key: cord- - d mz f authors: perkins, g.d.; handley, a.j.; koster, r.w.; castrén, m.; smyth, m.a.; olasveengen, t.; monsieurs, k.g.; raffay, v.; gräsner, j.-t.; wenzel, v.; ristagno, g.; soar, j. title: basismaßnahmen zur wiederbelebung erwachsener und verwendung automatisierter externer defibrillatoren: kapitel der leitlinien zur reanimation des european resuscitation council date: - - journal: notf rett med doi: . /s - - - sha: doc_id: cord_uid: d mz f nan für die erc-leitlinien wurde zusätzlich zu den ilcor-empfehlungen von den federführenden autoren die literatur zu den themenfeldern gesichtet, die bei ilcor keine berücksichtigung fanden. die leitlinien-verfasser waren sich bewusst, dass Änderungen gegenüber den empfehlungen von kosten und eventuell verunsicherung verursachen würden, und beschränkten sich daher auf Änderungen, die wirklich wichtig erschienen und durch neue evidenz belegt sind. die leitlinien wurden von den federführenden autoren konzipiert, von allen leitlinien-verfassern und den nationalen wiederbelebungsräten überarbeitet und schließlich vom erc-board verabschiedet. die leitlinien betonen die besondere bedeutung der interaktion des leitstellen-disponenten mit dem notfallzeugen, der mit der wiederbelebung beginnt, und der zeitnahen verfügbarkeit eines defibrillators. eine effektive, koordinierte gemeinsame aktion, die diese elemente zusammenführt, verbessert die Überlebenschancen des patienten nach einem kreislaufstillstand außerhalb eines krankenhauses (. abb. ). der leitstellendisponent spielt eine entscheidende rolle bei der frühzeitigen diagnose eines kreislaufstillstands, der leitstellengeführten reanimation (bekannt als telefonreanimation) und bei auffinden und einsetzen eines externen automatisierten defibrillators (aed). je früher der rettungsdienst alarmiert wird, desto eher wird eine adäquate behandlung begonnen und unterstützt. fertigkeiten, zutrauen und handlungsbereitschaft des ersthelfers hängen von den umständen des kreislaufstillstands, seinem trainingsstand und seinen vorkenntnissen ab. der erc empfiehlt dem notfallzeugen, der darin geschult und dazu in der lage ist, den zustand des patienten schnell zu beurteilen, indem er feststellt, ob der patient nicht ansprechbar ist und nicht normal atmet, und dann unmittelbar den rettungsdienst zu alarmieren. wenn irgend möglich, soll er währenddessen den patienten nicht verlassen. der patient, der nicht reagiert und nicht normal atmet, hat einen kreislaufstillstand und benötigt eine herz-lungen-wiederbelebung (cpr). unmittelbar nach dem kreislaufstillstand geht der blutfluss zum gehirn gegen null. das kann krampfanfälle auslösen, die möglicherweise mit einer epilepsie verwechselt werden. notfallzeugen und leitstellendisponenten sollen daher bei krampfenden patienten auch an einen kreislaufstillstand denken und sorgfältig klären, ob der patient normal atmet. die leitlinien-verfasser bekräftigen die ilcor-empfehlung, dass bei jeder wiederbelebung eine thoraxkompression durchgeführt werden soll. notfallzeugen, die ausgebildet und in der lage sind, eine atemspende durchzuführen, sollen herzdruckmassage und atemspende kombinieren. zusätzliche atemspenden können vorteilhaft für kinder bei asphyktischem kreislaufstillstand sein oder wenn sich das eintreffen des rettungsdienstes verzögert. da wir nicht davon überzeugt sind, dass eine wiederbelebung allein durch thoraxkompressionen einer standardwiederbelebung gleichwertig ist, empfehlen wir weiterhin die bisher praktizierte vorgehensweise. eine qualitativ hochwertige wiederbelebung ist entscheidend für eine verbesserung des ergebnisses (outcome). bei der herzdruckmassage soll eine adäquate drucktiefe sicher erreicht werden (etwa cm, jedoch nicht mehr als cm beim normalen erwachsenen), bei einer kompressionsfrequenz von − / min mit minimalen unterbrechungen. nach jeder kompression muss der brustkorb vollständig entlastet werden. atemspenden/beatmungen sollen eine sekunde dauern und zu einer deutlichen hebung des brustkorbs führen. das verhältnis von herzdruckmassage zu beatmung bleibt : . unterbrechen sie die thoraxkompressionen für die beatmung nicht länger als s. durch defibrillation innerhalb von − min nach dem kollaps können Überlebensraten von − % erreicht werden. eine frühzeitige defibrillation kann durch notfallzeugen unter verwendung von öffentlichen oder hauseigenen aeds durchgeführt werden. public-access-programme (öffentlicher zugang zu aeds) sollen an viel besuchten orten (flughäfen, bahn-oder busstationen, sportstätten, einkaufszentren, bürogebäuden und kasinos) etabliert werden. kreislaufstillstände an solchen orten werden häufig beobachtet, und ausgebildete helfer können schnell vor ort sein. das vorhalten eines aed gilt schon dann als kosteneffektiv, wenn sich an seinem standort alle jahre ein kreislaufstillstand ereignet, die kosten pro gewonnenes lebensjahr entsprechen denen anderer medizinischer interventionen. erfahrungen mit kreislaufstillständen in der vergangenheit und die art der umgebung können bei der wahl der aed-platzierung wegweisend sein. eine registrierung beim rettungsdienst ermöglicht es den disponenten, helfer zu einem nahe gelegenen aed zu führen und so die reaktionszeit zu verbessern. der ablauf der wiederbelebungsmaßnahmen für erwachsene kann auch bei kindern, die nicht ansprechbar sind und nicht normal atmen, sicher verwendet werden. helfer mit einer entsprechenden ausbildung können bei kindern die wiederbelebungschance mit initialen beatmungen verbessern. für den eher seltenen fall, dass ein helfer auf sich allein gestellt ist, ist es bei kindern und ertrunkenen auch besser, erst aktiv zu werden und verzögert hilfe zu holen. thoraxkompressionen atemspenden, elektroschocks sowie analysen der beatmung und des herzrhythmus führen zu unterbrechungen der herzdruckmassage. pausen von weniger als s vor und nach der abgabe eines schocks und ein anteil der thoraxkompressionen von mehr als % sind mit besserem outcome verbunden [ - ]. unterbrechungen der thoraxkompressionen sollen minimiert werden, wobei erkannt werden muss, wie wichtig die aufmerksamkeit und das wechselspiel der helfer ist, die zusammenarbeiten. die mund-zu-nase-beatmung stellt eine akzeptable alternative zur mund-zu-mund-beatmung dar [ ] . sie kann erwogen werden, wenn der mund des patienten schwer verletzt ist oder nicht geöffnet werden kann, der patient sich im wasser befindet oder bei der mund-zu-mund-beatmung keine abdichtung erreicht werden kann. aeds sind sicher und effektiv, wenn sie durch laien mit wenig oder ohne training verwendet werden [ ] . aeds ermöglichen eine defibrillation viele minuten, bevor professionelle hilfe eintrifft. helfer sollen thoraxkompressionen mit minimalen unterbrechungen durchführen, während der aed angelegt und verwendet wird. die helfer sollen sich darauf konzentrieren, der sprachführung unmittelbar zu folgen, insbesondere die herzdruckmassage sofort wieder aufzunehmen, wenn dazu aufgefordert wird, und unterbrechungen der thoraxkompressionen zu minimieren. pausen vor und nach einem schock sollten so kurz wie nur möglich sein [ , , , ]. standard-aeds können schon für kinder ab jahren verwendet werden [ ] [ ] [ ] . für kinder zwischen und jahren sollen spezielle klebeelektroden für kinder verwendet werden, wenn möglich mit einem kinderprogramm. stehen sie nicht zur verfügung, soll der defibrillator verwendet werden, wie er ist. die verwendung des aed wird nicht für kinder unter einem jahr empfohlen, obwohl es berichte über einen erfolgreichen einsatz in dieser altersgruppe gibt [ , ] . abgesehen von herzkranken kleinkindern ist eine defibrillierbare rhythmusstörung bei kleinkindern extrem selten [ ] [ ] [ ] [ ] [ ] [ ] [ ] . ist in diesen wenigen fällen ein aed der einzige verfügbare defibrillator, sollte sein einsatz erwogen werden (vorzugsweise mit verringerter dosis). die bedeutung unmittelbarer defibrillation wurde immer in leitlinien und ausbildung betont, ihr wird großer ein-fluss auf das Überleben nach kammerflimmern zugesprochen. wurde dieses konzept infrage gestellt, da evidenz dafür vorlag, dass thoraxkompressionen von bis zu s vor einer defibrillation das Überleben verbessern können, wenn der rettungsdienst erst nach mehr als − min eintrifft [ , ] . drei jüngere studien konnten diesen vorteil nicht bestätigen [ ] [ ] [ ] . die analyse einer randomisierten studie deutete auf eine verschlechterung des Überlebens bis zur krankenhausentlassung durch eine längere periode cpr (reanimation ohne beatmung länger als s) mit dadurch verzögerter defibrillation eines defibrillierbaren rhythmus hin [ ] . allerdings war in rettungsdienstbereichen mit einer hohen ausgangsüberlebensrate bei krankenhausentlassung (definiert als mehr als % der initial defibrillierbaren fälle) eine wiederbelebung über s vor der defibrillation erfolgreicher als eine wiederbelebung über eine kürzere zeit ( − s) [ ] . der erc empfiehlt, dass cpr fortgeführt werden soll, während ein defibrillator oder aed gebracht und angelegt wird, aber dann soll die defibrillation nicht weiter verzögert werden. in der praxis werden aeds meist von ausgebildeten helfern eingesetzt, sodass die aed-sprachführung grundsätzlich auf ein kompressions-ventilations-verhältnis von : eingestellt werden soll. wenn -ausnahmsweise -aeds an einem ort platziert werden, wo es unwahrscheinlich ist, dass ausgebildete helfer dazukommen, kann der betreiber die einstellung auf herzdruckmassage ohne beatmung ändern lassen. hat ein vollautomatischer aed einen defibrillierbaren rhythmus erkannt, gibt er den schock ohne weiteres zutun des helfers ab. in einer studie an Übungsphantomen konnte gezeigt werden, dass ungeschulte krankenpflegeschüler mit einem vollautomatischen aed weniger fehler machten als mit einem halbautomatischen [ ] . eine simulierte studie an phantomen ergab, dass die sicherheit nicht gefährdet war, wenn ungeübte laienhelfer einen vollautomatischen statt einen halbautomatischen aed benutzten [ ] . Über die anwendung an menschen in einem klinischen bereich liegen keine daten vor. defibrillatoren in der Öffentlichkeit ("public access defibrillation", pad) [ , ] . die registrierung der aed-standorte erleichtert es dem leitstellendisponenten, einen notfallhelfer zum nächstplatzierten aed zu führen und somit die hilfeleistung zu beschleunigen [ ] . die frühzeitige defibrillation mit einem aed vor ort kann möglicherweise auch krankenhauskosten reduzieren [ , ] . das volle potenzial von aeds ist noch nicht ausgeschöpft, da sie meist im öffentlichen raum zum einsatz kommen sich aber bis % der kreislaufstillstände zu hause ereignen. der anteil der patienten, die mit kammerflimmern aufgefunden werden, ist zu hause geringer als in der Öffentlichkeit, wohingegen die absolute zahl zu behandelnder patienten zu hause höher ist [ ] . selten profitieren patienten zu hause von öffentlichen aed-programmen [ ] . wenn ein patient kollabiert, muss schnell ein aed verfügbar sein: ein klares, einfaches symbol muss auf seinen standort und den schnellsten weg dorthin hinweisen. ilcor hat ein solches aed-symbol entwickelt, das weltweit verstanden wird; daher wird dieses empfohlen [ ] . viele notfallzeugen beginnen nicht mit der wiederbelebung, weil sie befürchten, dass thoraxkompressionen bei einem patienten, der keinen kreislaufstillstand hat, ernste schäden verursachen. drei untersuchungen befassten sich mit den risiken einer herzdruckmassage bei personen, die keinen kreislaufstillstand hatten [ ] [ ] [ ] . in den gepoolten daten dieser drei studien, also von patienten, fanden sich knochenbrüche (rippen und schlüsselbein) mit , % ( %-ci, , - , %), schmerzen an der stelle der herzdruckmasage mit , % ( %-ci, , - , %), aber keine relevanten verletzungen innerer organe. ersthelfer sollten keine bedenken haben, mit einer wiederbelebung zu beginnen, da es nur in extrem seltenen fällen zu ernsthaften verletzungen kommt, wenn ein patient keinen kreislaufstillstand hat und von einem notfallzeugen wiederbelebt wird. eine systematische Übersicht zu skelettverletzungen durch manuelle thoraxkompression berichtet von - % rippenbrüchen und von - % sternumfrakturen [ ] . organverletzungen (lunge, herz, bauchorgane) sind sehr viel seltener und kommen mit und ohne knochenverletzungen vor [ ] . sie treten häufiger auf, wenn beim normalen erwachsenen tiefer als cm gedrückt wird [ ]. beobachtungsstudien zur ausbildung und tatsächlichen durchführung von wiederbelebungsmaßnahmen sowie fallberichte dokumentieren nur selten muskelzerrungen, rückenbeschwerden, kurzatmigkeit, pneumothorax, brustschmerzen, herzinfarkt oder nervenschäden [ , ] . die häufigkeit solcher ereignisse ist niedrig, und die ausbildung in wiederbelebungsmaßnahmen und deren tatsächliche durchführung ist unter den meisten umständen sicher [ ] . teilnehmer von wiederbelebungsschulungen sollten über art und ausmaß der körperlichen belastung während des trainingsprogramms aufgeklärt werden. lernenden und helfern, die während des trainings signifikante symptome entwickeln (z. b. brustschmerz oder starke atemnot), soll zum trainingsabbruch geraten werden. mehrere studien am Übungsphantom haben nachgewiesen, dass die drucktiefe bereits weniger als min nach beginn der thoraxkompressionen abnimmt [ ] . eine krankenhauspatientenstudie zeigte, dass auch bei echtzeit-feedbacks die durchschnittliche tiefe der herzdruckmassage zwischen , und min nach beginn der cpr nachließ [ ] . es wird daher empfohlen, dass sich ersthelfer etwa alle min abwechseln, um eine verschlechterung der druckqualität infolge der ermüdung des helfers zu verhindern. beim wechsel der helfer soll die herzdruckmassage nicht unterbrochen werden. viele studien zu öffentlich zugänglichen defibrillatoren ("public access defibrillation", pad) zeigen, dass aeds von laien und professionellen ersthelfern (first respondern) sicher angewendet werden können [ ] . eine systematische metaanalyse fand publikationen, die insgesamt unerwünschte ereignisse bei der defibrillation auswiesen [ ] . ursache waren zufälliger oder vorsätzlicher missbrauch des defibrillators, gerätefehlfunktion und versehentliche entladung während des trainings oder der wartung. in einzelfallberichten kam es durch die entladung implantierter herzschrittmacher (implantierbarer kardioverter-defibrillator, icd) zu schocks an helfern, was in einem fall zu einer schädigung peripherer nerven führte. es gibt keine berichte über schädigungen der ersthelfer durch defibrillationsversuche in feuchter umgebung. obgleich verletzungen der helfer durch defibrillationen extrem selten sind, konnte gezeigt werden, dass chirurgische handschuhe keinen ausreichenden schutz bieten [ ] [ ] [ ] [ ] . daher sollen helfer während der schockabgabe die thoraxkompressionen nicht fortsetzen, und der patient soll während der icd-entladung nicht berührt werden. direkter kontakt zwischen dem helfer und dem patienten während der schockabgabe soll vermieden werden. eine große prospektive studie zu pad berichtete von wenigen negativen psychologischen effekten in verbindung mit einer wiederbelebung oder dem einsatz eines aed, die eine intervention erforderten [ ] . zwei große retrospektive fragebogenstudien zur wiederbelebung stellten fest, dass notfallzeugen ihre wiederbelebung als positive erfahrung einstuften [ , ] . auch familienangehörige, die zeugen von wiederbelebungsmaßnahmen werden, können psychologisch davon profitieren [ ] [ ] [ ] . das seltene auftreten von nachteiligen psychologischen auswirkungen bei ersthelfern nach einer wiederbelebung soll dennoch registriert und angemessen behandelt werden. das risiko einer krankheitsübertragung während des trainings und der tatsächlichen wiederbelebung ist extrem niedrig [ ] [ ] [ ] . das tragen von handschuhen während der wiederbelebung ist sinnvoll, aber die wiederbelebung soll nicht verzögert oder gar unterlassen werden, weil keine handschuhe verfügbar sind. drei studien zeigten unter kontrollierten laborbedingungen, dass beatmungsfolien oder -ventile die Übertragung von bakterien verringern [ , ] die verlegung der atemwege durch einen fremdkörper ist eine seltene, aber potenziell behandelbare todesursache [ ] . da die meisten atemwegsverlegungen beim essen entstehen, werden sie üblicherweise beobachtet. da die betroffenen anfangs bei bewusstsein sind und reagieren, besteht oft die möglichkeit zur frühzeitigen intervention, die lebensrettend sein kann. atemwegsverlegung durch fremdkörper. fremdkörper können eine milde oder eine schwere atemwegsverlegung verursachen. es ist wichtig, den ansprechbaren patienten zu fragen: "haben sie einen erstickungsanfall?" ein patient, der antwortet, hustet und atmet, hat eine milde obstruktion. kann er nicht sprechen, nur schwach husten, ringt er nach luft oder kann nicht atmen, so liegt eine schwere obstruktion vor. husten erzeugt einen hohen und anhaltenden atemwegsdruck und kann den fremdkörper ausstoßen. eine aggressive behandlung mit schlägen auf den rücken, oberbauch-und brustkorbkompressionen kann schäden hervorrufen und die atemwegsverlegung verschlimmern. diese soll patienten vorbehalten bleiben, die zeichen einer schweren atemwegsverlegung aufweisen. patienten mit einer milden verlegung des atemwegs sollen unter kontinuierlicher beobachtung bleiben, bis es ihnen besser geht, weil sich eine schwere verlegung noch entwickeln kann. klinische daten zum ersticken sind größtenteils retrospektiv und anekdotisch. bei erwachsenen und kindern über jahr, die bei bewusstsein sind und bei denen eine komplette atemwegsverlegung durch fremdkörper erfolgt ist, haben fallberichte die effektivität von schlägen auf den rücken sowie oberbauch-und brustkorbkompressionen gezeigt [ ] . in ungefähr % der fälle kann die atemwegsverlegung nicht durch eine einzige maßnahme beseitigt werden [ ] . die erfolgsaussichten steigen bei der kombination von schlägen auf den rücken, oberbauchund brustkorbkompressionen [ ] . eine randomisierte studie an leichen [ ] und zwei prospektive studien an an-ästhesierten freiwilligen [ , ] haben gezeigt, dass mit brustkorbkompressionen im vergleich zu oberbauchkompressionen ein höherer atemwegsdruck erzeugt werden kann. herzdruckmassagen bei bewusstlosen oder nicht ansprechbaren patienten mit einer atemwegsverlegung durch fremdkörper sind mit einem guten neurologischen outcome assoziiert (odds ratio, , ; %-ci, - . , p < , ) [ ] . daher soll sofort mit thoraxkompressionen begonnen werden, wenn der patient nicht mehr reagiert oder bewusstlos wird. nach kompressionen versuchen sie zweimal zu beatmen. führen sie die reanimation fort, bis sich der patient erholt und normal zu atmen beginnt. nach erfolgreicher beseitigung einer atemwegsverlegung durch fremdkörper können immer noch fremdkörper in den oberen oder unteren atemwegen verblieben sein und später zu komplikationen führen. patienten mit anhaltendem husten, schluckbeschwerden oder dem gefühl, dass immer noch etwas im hals steckt, 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authors: li, xingming; huang, jianshi; zhang, hui title: an analysis of hospital preparedness capacity for public health emergency in four regions of china: beijing, shandong, guangxi, and hainan date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: seass p background: hospital preparedness is critical for the early detection and management of public health emergency (phe). understanding the current status of phe preparedness is the first step in planning to enhance hospitals' capacities for emergency response. the objective of this study is to understand the current status of hospital phe preparedness in china. methods: four hundred hospitals in four city and provinces of china were surveyed using a standardized questionnaire. data related to hospital demographic data; phe preparation; response to phe in community; stockpiles of drugs and materials; detection and identification of phe; procedures for medical treatment; laboratory diagnosis and management; staff training; and risk communication were collected and analyzed. results: valid responses were received from ( . %) of the hospitals surveyed. of the valid responses, ( . %) hospitals had emergency plans; . % had command centres and personnel for phe; . % included community organisations during the training for phe; . % could transport needed medical staff to a phe; . % had evaluated stockpiles of drugs; . % had evaluated their supply systems; . % had developed surveillance systems; and . % could monitor the abnormity(see in appendix). physicians in . % of the analyzed hospitals reported up-to-date knowledge of their institution's phe protocol. of the respondents, . % followed strict laboratory regulations, however, only about . % had protocols for suspected samples. furthermore, only . % could isolate and identify salmonella and staphylococcus and less than % could isolate and identify human h n avian flu and sars. staff training or drill programs were reported in . % of the institutions; . % periodically assessed the efficacy of staff training; % had experts to provide psychological counselling; . % had provided training for their medical staff to assess phe-related stress. all of the above capacities related to the demographic characteristics of hospitals and will be discussed in-depth in this paper. conclusion: our survey suggested that, at the time of the survey, hospital preparedness for phe in china was at an early stage of development. comprehensive measures should be taken to enhance hospital capacity in the prevention and management of phe. public health emergency (phe) is an event or events that cause or may cause harm to the health of a community or nation [ ] . to prevent and/or minimize the harm caused by phe, early detection and management are necessary. as hospitals are the main location for phe surveillance and treatment, their preparedness is critical for phe's early detection and management [ ] . evaluating the current status of phe preparedness within the hospital system is the first step in improving a nation's preparedness for a phe. yet, there is no national data on china's hospital phe preparedness capacity aside from two studies that addressed the issues at local level [ , ] . to understand the current status of hospital phe preparedness in china, a sample survey of hospitals in four representative city/ provinces were conducted between november and march . the survey used a cross-sectional study design to survey hospitals in different regions of china. respondents were all secondary and tertiary hospitals(the detail of hospital classification see in appendix) in the city of beijing and provinces of shandong, guangxi, and hainan. the selection of hospitals in these four regions is intended to represent a variety of regional economic status. broadly speaking, beijing and shandong are economically well developed, hainan moderately developed, and guangxi developing [ ] . according to the hospital classification method issued by the national bureau of statistics of china, the surveyed hospitals included general hospitals, hospitals of traditional chinese medicine (tcm), hospitals of integrated traditional chinese medicine and western medicine (tcm-wm), specialized hospitals, community health center, and medical emergency center (the definition of community health center and medical emergency center see in appendix) [ ] . four hundred secondary and tertiary hospitals were surveyed. the study was approved by the institutional review board (irb) of the school of basic medicine, peking union medical college in beijing, china. based on a literature and government document review, a detailed methodological approach for research framework and questionnaire development was followed to inform the development of this study [ ] . an indicator system framework was created and questionnaire designed based on the framework. the questionnaire consists of sections and items. the questionnaire and the survey protocol (including field work manual and quality control procedures) were tested by a pilot study. for the purpose of this study, we analyzed the data focused on the following nine areas of interest: ( ) hospi-tal's demographic data (including region, sars crisis experience, teaching function, hospital type, and number of medical staff in related departments); ( ) hospital phe preparation (emergency plans, response initiating time, accessibility, and revision and implementation of emergency plan); ( ) response to a community phe (cooperation with local organizations, relationship with the community phe network, medical treatment, and rescue work in the community); ( ) stockpiles of drugs and materials (stockpiles of drugs and other resources and personal protective equipment); ( )phe detection and identification (syndrome surveillance); ( ) procedures for medical treatment (protocol for diagnosis, treatment, and transfer of phe victims); ( ) laboratory diagnosis and management (laboratory regulation and management system, sample disposal and evaluation system, collection and disposal of suspected samples, and diagnosis of pathogen/etiology); ( ) staff training (organization of phe training, current training of medical staff, curriculum development and training effectiveness assessment); and ( ) risk communication (organization for communication of risk psychological counseling to victim and medical staff, and communication with public). excluding aspect , items - (covering survey questions) represent types of phe preparedness capacities. each answered item was scored for "yes" and for "no" or "unknown". item scores were calculated by adding together "yes" answers. items scores were used as a proxy for measuring phe preparedness in an institution. a total item score was measured by calculating the score across all items. the higher the total item score, the better the hospital phe preparedness capacity. further analyses were conducted to understand the correlation between preparedness capacity and demographic information. the distribution of the related preparedness capacities across categories of phe [ ] and types of etiology was also assessed. a computerized questionnaire stored in a cd was sent to the targeted hospitals accompanied by an official letter from each of the four city and provincial health departments stating the importance of the survey and requiring that each hospital designates a department director to be responsible for coordinating the completion of the questionnaire. each returned questionnaire was carefully reviewed for its completeness and consistency. for those questionnaires with incomplete and/or inconsistent responses, one or two follow-up telephone calls were made to ensure completeness and consistency. the data from returned questionnaires were then transferred into a database for analysis. a database was set up using microsoft excel . data was checked, cleaned, and analyzed using spss software version . . ninety-five percent confidence interval of means ( % ci) was used to describe phe preparedness capacities. categorical variables were analyzed with frequency and percentage. comparisons of mean score of each of eight phe preparedness capacities among different types of hospitals were performed with p < . as statistical significance using parameter test (independent-samples t test (two-tailed) or one-way analysis of variance) and/or non-parameter test (mann-whitney test or kruskal-wallis test) based on data distribution characteristics and homogeneity. four hundred hospitals responded, with a response rate of %. however, seventy-seven questionnaires were excluded from analysis due to one of the following reasons: ( ) if less than % of items in the questionnaire were not answered, or ( ) hospital did not meet secondary and/or tertiary hospital standard according to the hos-pital classification system. therefore, the valid response rate was . %. of analyzed hospitals ( ), . % were in beijing, . % in shandong, . % in guangxi and . % in hainan. in terms of hospital type, . % were teaching hospitals. the mean number of physicians and nurses per hospital was . , and the mean number of total medical staff per hospital was . . the mean number of physicians and nurses in emergency department and infectious-disease department were . and . , respectively. table shows the demographic characteristics of the analyzed hospitals. of hospitals, ( . %) had an emergency plan. among the hospitals that had an emergency plan, . % reported that the institution possessed a protocol to initiate the emergency plan, . % had a classification system for different phe events, . % had evaluated and revised their emergency plan at least once, and . % reported that their emergency plan was accessible to all and table . of all analyzed respondents, . % were designated as the local emergency hospital for phe patient admissions and . % of them were the designated hospitals to provide medical rescue services during a national disaster. of all analyzed respondents, . % could promptly transport needed medical staff to the phe field, . % reported that they were prepared to respond to the needs of vulnerable people (including women, children, pregnant women and the disabled) during a phe, however, only . % had evaluated their ability to increase beds and equipment for phe. when performing a phe preparedness drill, . % of respondents reported that they would invite relevant community organizations to participate. with regard to capacity comparison, the statistics test showed: the total item score of hospitals in beijing( % ci: . , . ) was lower than that of hospitals in shandong ( % ci: . , . ) and guangxi( % ci: . , . ); the score of teaching hospitals( % ci: . , . ) was higher than that of non-teaching hospitals( % ci: . , . ); and the score of tertiary grade a ( % ci: . , . ) and b ( % ci: . , . ) hospitals was higher than that of secondary grade b ones( % ci: . , . ), respectively. among all types of hospitals, community health center scored highest on this aspect. our results revealed that . % of respondents had evaluated their stockpiles of drugs, and . % had established a relationship with suppliers to provide emergency drug- supplies, however, only . % had signed written contracts with suppliers. of all analyzed respondents, . % had drug-distribution plans, and . % knew where the national or local pharmacy distribution centers were located. in regards to other medical materials, . % had stockpiles of materials for responding to phe. as for the stockpiles of drugs for infectious diseases, about . %, . % and . % of responding hospitals had drug stockpiles for treating infectious diarrhea, influenza and botulismo toxin, respectively. when hospitals were compared on this item, statistical analysis showed that institutions in beijing ( % ci: . , . ) had a higher score than that of shandong ( % ci: . , . ). tertiary hospitals generally had a higher score than secondary ones. among all the respondents, . % reported that they had developed syndromic surveillance systems for certain diseases and . % required that physicians on duty should report any abnormity to the hospital's presidents (the definition of abnormity see in appendix). abnormity in admission diagnosis, routine microbiological tests, emergency room patients, and death with unknown causes were systematically monitored by . % of institutions and . % of hospitals shared their surveillance information with the local health authority. there were statistically significant differences between tertiary grade hospitals (grade a % ci: . , . ; grade b % ci: . , . ) and secondary grade b hospitals ( % ci: . , . ) for this capacity, with tertiary hospitals scoring higher on their ability to detect and identify a phe. physicians in . % of the responding institutions reported being familiarized with the latest treatment protocol for a phe, . % could transfer phe victims to corresponding medical agencies for appropriate treatment, and . % could provide training on the protocol system. however, only . % had specific procedures for patient transfer in a phe. as for infectious disease treatment protocol, . % had protocols for sars, but only . % for brucellosis. with regard to the capacity comparison among all the respondents, . % reported that they had a training program for the following medical staff: infection managers ( . %); emergency department physicians and nurses ( . %); and infectious disease ward physicians and nurses ( . %). staff training was supervised by a designated person in . % of institutions and . % had training curriculums, . % of which was updated regularly. effectiveness of phe training was periodically assessed in . % of respondents. for this capacity, statistical significance indicated that respondents in shandong ( % ci: . , . ) scored higher than participating institutions in guangxi ( % ci: . , . ). serious phe concerns were raised in china during the sars crisis when it became apparent that hospitals possessed poor emergency preparedness [ ] . even the upcoming olympics game in beijing and the . earthquake disaster in china have dramatically evoked the awareness of phe preparedness capacity for hospital. based on the experience of the sars pandemic, all hospitals should possess fundamental phe programs, including preparedness of drugs, equipment, staff, emergency education and staff training [ , , ] , coordination with relevant community bodies [ ], medical treatment [ ] , early detection and warning [ ] , laboratory diagnosis [ ] [ ] [ ] and psychological intervention [ ] . since the sars crisis, the central chinese government has become more active in the construction of public health system, especially in regards to the medical emergency response system [ ] . one major effort involved a . billion rmb investment in local governments to initiate the construction of regional phe medical treatment systems [ ] . in order to offer some insight into the development of hospital phe preparedness capacity, this study examined the current status of hospital preparedness in beijing, shandong, guangxi, and hainan. emergency preparedness refers to the processes involved in ensuring an institution: ( ) has complied with the preventive measures; ( ) is in a state of readiness to contain the effects of a forecasted disastrous event in order to minimize loss of life, injury, and damage to property; ( ) can provide rescue, relief, rehabilitation, and other services in the aftermath of the disaster; and ( ) holds the capability and resources to continue to sustain its essential functions during a phe [ ] . an emergency preparedness systems primarily composed of emergency plans and organizational structures and lays the foundation for dealing with phe [ ] . emergency plans establish the protocol for operation under a phe [ ] . for a hospital to mobilize all phe resources in a short period of time, contingency plans must be issued in advance [ ] . in addition, periodic review and updating of emergency plans enhance an institution's emergency response capacity [ ] . our study showed that most hospitals had emergency plans and that these plans focused on infectious diseases control with less attention to preparedness for biological, nuclear radiation and other terrorism attacks. most of the hospitals had phe command departments and emergency response teams, however, only . % of hospitals with emergency plans reported they had evaluated and revised their phe systems. overall, tertiary hospitals performed better in phe preparation than secondary hospitals. meanwhile, no statistical significance was found between hospitals that had admitted sars patients and those that had not, suggesting that after the sars crisis, all hospitals raised awareness of emergency plans and implementation. no hospital or medical system can manage a public health emergency without community networks and public involvement. therefore, hospitals need to communicate and cooperate with other local health agencies, functioning as a networked public health provider. problems like lack of communication and coordination between hospital departments and inter-agency networks hinder the availability of resources in a community and limit timely forecasting, public communication and effective regulation of a phe [ ]. our survey revealed that if a phe occurred, most of hospitals reported that they could take responsibility for phe rescue service, transport the medical staff in a timely manner, and provide priority health services to vulnerable populations. yet, less than one third of respondents attended regulation and revision workshops for emergency plans for infectious epidemic control held by local agencies. this lack of cross-institutional interaction indicated that the ability of hospitals to coordinate with community agencies in preparation for, or in the event of a phe was generally poor. the survey showed that among all the types of respondents community health center were best able to respond to phe and the respondents with multiple functions performed better suggesting that communication and coordination between hospitals and community agencies should be strengthened. characteristics of a phe include suddenness and unpredictability [ ] . for most hospitals, medicine storage may be in great demand when faced with a sudden increase in patients. therefore, hospitals must have programs to ensure appropriate levels of emergency supplies including drugs, medical equipment, electricity, water and oxygen, disinfectant, etc. our survey suggested that most of the hospitals could establish an emergency-drug-supply system for most of the infectious diseases we addressed in the questionnaire except anthrax, brucellosis, botulism toxin poisoning and tetramine poisoning. for most of surveyed hospitals possessed emergency resource reserves, but less than half of them had corresponding drug distribution programs. in addition, hospital capacity was affected by economic level and classification of the hospital, suggesting that the importance of local economic development strengthens hospital ability to provide phe. early detection and identification of a phe are amongst the most important objectives for prompt and effective public health response to a phe [ ] as well as an essential precondition for selecting appropriate prevention and treatment measures. this study showed that most of the hospitals could regularly train medical staff on how to report and identify suspicious phe and that the institutions possessed surveillance systems to monitor various aspects of abnormity. approximately half of the respondents could share surveillance information with the local health authorities. there were statistically significant differences among various classification of the respondents, which demonstrated that after the sars crisis, hospitals at all levels attached high importance to phe monitoring and early warning system, however, the capacity was affected by the comprehensive strength of hospital. phe happens suddenly and its incidence rate is relatively low, which leaves most medical staff inexperienced and unprepared [ ] . therefore, it is important that hospitals develop emergency plans for phe treatment programs. in this survey, more than half of respondents showed that their physicians were aware of current phe protocols. most hospitals had transfer and treating procedures for infectious diseases, including sars, influenza, and infectious diarrhea, but less held these procedures for biochemical incidents, leakage of nuclear, and terrorist attacks. because they are easily used as biological terrorist attacks materials [ ] , therefore, the prevention and control of these emergencies become very important. our statistical analyses showed that tertiary-grade, teaching and tcm-wm hospitals performed better on medical treatment procedures preparedness, which might reflect the fact that different types of hospitals have different functions and mission in the community, however, for this capacity, the statistical significance among different regions showed the important role that economic factor plays. hospital laboratories not only have the task of clinical diagnosis, but take some responsibility in the surveillance of public health [ , ] . therefore, laboratory informa-tion plays an important role in detection of the phe [ , ] . detecting phe related pathogen/etiology can not only confirm clinical diagnosis, but also identify newly emerging infectious diseases [ , ] . the presence of sars in china in , and the slow response to its emergence, revealed that china's public health laboratory systems were weak [ ] . this survey indicated that many of the hospitals did not report adequate laboratory diagnostic capacities. although hospital laboratory regulations seemed relatively good, only one-third of hospital laboratories had programs for dealing with suspicious samples collecting, disposal and delivery. [ ] . when phe occurs, hospital medical staff are usually the first responders and information providers, therefore, education and training are key measures to enhance phe response [ ] . our survey suggested that after sars crisis, most hospitals re-evaluated the importance of medical staff training for phe. the majority of respondents offered training programs to their related medical staff. however, the effectiveness of these training programs needs to be periodically evaluated. phe can cause psychological as well as physical problems for the public and medical staff attending to victims [ , ] . in a public health crisis or emergency, effective risk communication can help people cope, make decisions, and return their lives to normal. crisis communication, as an important part of a phe response [ ] , is key to ensuring complete, transparent and prompt information exchange, and to help hospitals make timely responses and reduce the serious consequences [ ] . the results of this survey revealed that medical staff in . % of the hospitals underwent training for evaluation of phe-related stress and only one-third of respondents had specific programs and spokespersons for communicating critical messages and information to the media, public, governments and stakeholders. these results indicated that most of the surveyed hospitals do not understand the importance of psychological care in a phe emergency, do not have the resources to deal with it, or presume that it is not their place to do so. indeed, this capacity evaluation revealed that when a phe occurred, most hospitals' response plans focused on physiological medical treatment, but health education, psychological counseling, and crisis communication plans were rare. however, for this capacity, the statistical significance among different regions and levels showed the important role that economic factor and comprehensive level play. the study has several limitations. first of all, the surveyed hospitals were restricted to four city and provinces, even some types of hospitals were rare (the number of the surveyed community health center and emergency center was just one, respectively), therefore, the results may not fully represent the phe capacity of all hospitals in china. secondly, because of self-report method there may be a respondent reporting bias. the inclusion of official documents from respective health bureaus, for example, may have encouraged respondents to complete survey but have also been interpreted as an official assessment of capacity leading some hospital representatives to overestimate phe capacity. thirdly, only quantitative data were collected to measure certain capacities of phe preparedness. most questions required a "yes" "no" or "unknown" answer which restricts the collated data to these three categories. finally, this data set is not complete as some hospitals did not respond and others had to be excluded on the basis of incomplete answers or for ineligibility for hospital classification. to a certain extent, this loss of respondents caused a loss of information. after several years of construction and development, the capability of hospitals in china to deal with phe, in particular infectious diseases control, has improved greatly [ , ] . nevertheless, this research suggests that china has more progress to make before phe preparedness is satisfactory. to enhance hospital preparation for dealing with phe, governments at all levels should increase investment in the construction of infrastructure to create and sustain appropriate phe capacity. on the other hand, hospitals at all levels should enhance their management, including updating and revising of emergency plans; strengthening communication and cooperation with other local agencies; enhancing the capacity of abnormity monitoring and laboratory diagnostic capability for infectious diseases; improving the treatment program for various phe scenarios; and strengthening psychological intervention and risk communication capabilities. finally phe preparedness in relation to terrorism caused by nuclear radiation and biochemical substance was low in this study and should be further assessed for areas of need and improvement. the regulations on emergency public health events, decree no. the location of medical institutes in public health emergency response system an analysis of the current status of hospital emergency preparedness for infectious disease outbreaks in beijing an analysis of the current hospital emergency responding capacity in the province of heilongjiang c: health statistic yearbook of china in . beijing, peking union medical college press; . . national bureau statistics of china: hospital classification method accessed on mechanism of public health emergency response at the eighth meeting of the standing committee of the tenth national people's congress. gazette of the standing committee of the national people's congress of the people's republic of china song rl: the statute of public health emergency and procedures for infectious atypical pneumonia prevention. beijing: china legal publishing house national development and reform commission and ministry of health of the p.r.c: planing for construction of medical treatment system accessed on september meeting the challenge of bio-terrorism: lessons learned from west nile virus and anthrax the role that symptom surveillance plays in coping with public health emergency zhang hw: the survey for current status of public health laboratory of part provinces in china medical examiners and bio-terrorism the laboratory network building of infectious diseases surveillance. the journal of diseases surveillance draft capacity assessment guidelines & the program approach social development department of national development and reform commission of the people's republic of china: national debt project of medical treatment system business dictionary web site: the definition of emergency preparedness assessing levels of hospital emergency preparedness a manual for health emergency preparedness. beijing: people's medical publishing house bio-terrorism: implications for the clinical microbiologist which public health respond system should be built in china from sars crisis assessing hospital preparedness using an instrument based on the mass casualty disaster plan checklist: results of a statewide survey education is the key to defense against bio-terrorism who: community emergency preparedness: a manual for managers and policy-makers beijing. beijing, people's military medical publishing house hospital management. beijing, people's health publishing house we appreciate all hospitals who participated in this survey. specifically we would extend our thanks to the following persons who offered great assistants in the process of data collection, data analysis, and manuscript drafting. they are peng lv (beijing); lixin ma (shandong); faqing chen (guangxi); and wenli pan (hainan). abnormity: abnormity means the rapid increase of emergency room patients with acute asthma, flu, fever of unknown causes.hospital classification: according to "the hospital classification system" of the ministry of health of people's republic of china, all hospitals in china are classified into primary, secondary, and tertiary hospitals based on their functions in providing medical care, medical education, and conducting medical research. a secondary hospital is defined as a regional hospital that provides comprehensive medical care, medical education, and medical research for the region. a tertiary hospital is defined as cross-regional, providing comprehensive and specialized medical care with a high level of medical education and research functions. secondary and tertiary hospitals are further classified into subgroups: grade a, grade b, and grade c according to their service levels, size, medical technology, medical equipment, and management and medical quality [ ] .community health center: community health center is a kind of primary health care delivery in china, most of which are transferred from secondary grade hospitals, and provide preventive, curative care, maternal and child care, rehabilitation and health education to local inhabitants by general practitioners, community nurses and public health workers.medical emergency center: medical emergency center (first aid station) is a kind of emergency health care delivery in china, which provide emergency care, first aid, monitoring and treatment for all those patients with prehospital emergencies. the authors declare that they have no competing interests. jsh designed the study and developed the tools. hzh participated in design of the study and development of the tools, and supervised the data collection and data entry. xml performed data checkup, data analysis and drafted the manuscript. all authors participated in discussion, revision and approved of the final manuscript. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /pre pub key: cord- - b vjhgn authors: hick, john l.; christian, michael d.; sprung, charles l. title: chapter . surge capacity and infrastructure considerations for mass critical care date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: b vjhgn purpose: to provide recommendations and standard operating procedures for intensive care unit (icu) and hospital preparations for a mass disaster or influenza epidemic with a specific focus on surge capacity and infrastructure considerations. methods: based on a literature review and expert opinion, a delphi process was used to define the essential topics including surge capacity and infrastructure considerations. results: key recommendations include: ( ) hospitals should increase their icu beds to the maximal extent by expanding icu capacity and expanding icus into other areas; ( ) hospitals should have appropriate beds and monitors for these expansion areas; hospitals should develop contingency plans at the facility and government (local, state, provincial, national) levels to provide additional ventilators; ( ) hospitals should develop a phased staffing plan (nursing and physician) for icus that provides sufficient patient care supervision during contingency and crisis situations; ( ) hospitals should provide expert input to the emergency management personnel at the hospital both during planning for surge capacity as well as during response; ( ) hospitals should assure that adequate infrastructure support is present to support critical care activities; ( ) hospitals should prioritize locations for expansion by expanding existing icus, using postanesthesia care units and emergency departments to capacity, then step-down units, large procedure suites, telemetry units and finally hospital wards. conclusions: judicious planning and adoption of protocols for surge capacity and infrastructure considerations are necessary to optimize outcomes during a pandemic. abstract purpose: to provide recommendations and standard operating procedures for intensive care unit (icu) and hospital preparations for a mass disaster or influenza epidemic with a specific focus on surge capacity and infrastructure considerations. methods: based on a literature review and expert opinion, a delphi process was used to define the essential topics including surge capacity and infrastructure considerations. results: key recommendations include: ( ) hospitals should increase their icu beds to the maximal extent by expanding icu capacity and expanding icus into other areas; ( ) hospitals should have appropriate beds and monitors for these expansion areas; hospitals should develop contingency plans at the facility and government (local, state, provincial, national) levels to provide additional ventilators; ( ) hospitals should develop a phased staffing plan (nursing and physician) for icus that provides sufficient patient care supervision during contingency and crisis situations; ( ) hospitals should provide expert input to the emergency management personnel at the hospital both during planning for surge capacity as well as during response; ( ) hospitals should assure that adequate infrastructure support is present to support critical care activities; ( ) hospitals should prioritize locations for expansion by expanding existing icus, using postanesthesia care units and emergency departments to capacity, then stepdown units, large procedure suites, telemetry units and finally hospital wards. conclusions: judicious planning and adoption of protocols for surge capacity and infrastructure considerations are necessary to optimize outcomes during a pandemic. the type of the mass casualty event (mce) is a major determinant of the demands on a hospital. for h n influenza, the impact on icu services varied considerably. the proportion of icu beds occupied by patients with h n peaked at - % in australia and new zealand [ ] , but icu services in mexico were overwhelmed, and many patients required ventilation outside icus [ ] . used for events of any scale and for both sudden (e.g., bomb detonation) or gradual events (e.g., pandemic influenza). . scope: using examples and general recommendations, provide templates for intensive care unit (icu) and isolation area expansion including consideration of central system capacity expansion (such as oxygen). recent recommendations have called for institutions to prepare for at least a % increase in icu capacity beyond baseline during a pandemic or catastrophic disaster [ ] . this level of expansion of space and services is not achievable without significant prior planning/preparedness activities. institutions should define their own capacities and capabilities. defining specific limitations (e.g., shortage of available ventilators), sources to mitigate these shortfalls (e.g., national stockpile, institutional cache) and a strategy for accepting/using outside resources to expand capacity is critical to response success. this document cannot account for operational planning details at individual institutions, but aims to provide a brief, general overview of key issues to be addressed during events requiring critical care surge capacity generation. hospitals should create their own specific plans according to hospital size, role in the community and the hazards recognized in the community. hospitals may refer to recent articles for surge capacity frameworks [ , ] and crisis patient care decision frameworks [ , ] . . goals and objectives: describe the basis for institutional standard operating procedures (sop) for icu and isolation space expansion using templates. provide recommendations for expansion of oxygen capacity and continuity of infrastructure operation. . mass casualty event: an event generating a large number of victims that does not generate demand exceeding the facility or community resources. . disaster: an event generating large numbers of victims that exceed usual hospital and/or community resources and requires changes in the usual practices to meet demand (usually short term). usually implies temporary communications and resource shortfalls and a temporary lack of situational awareness. note that a mce is not equivalent to a disaster, and increased capacity and preparedness increase facility surge capacity for larger patient volumes before a mce becomes a disaster. . crisis standard of care: a substantial change in usual health care operations and the level of care it is possible to deliver, made necessary by a pervasive (e.g., pandemic influenza) or catastrophic (e.g., earthquake, hurricane) disaster. this change in the level of care delivered is justified by specific circumstances and is formally declared by government entities. the formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protections for health care providers in the necessary tasks of allocating and using scarce medical resources [ ]. . surge capacity: three functional components of surge capacity exist (fig. ) [ , ] . a. conventional: using usual patient care spaces, resources and practices. b. contingency: using adapted areas of the facility for icu services (procedure areas, post-anesthesia care, operative suites, stepdown units) including adaptations to standard staffing and resource practices to provide functionally equivalent medical care, with minimal increase in risk to the patient. c. crisis: providing sufficient care under the circumstances with significant changes to standard staffing and resource practices (e.g., using an oxygen-saturation monitor with high/low rate alarms instead of usual cardiac and other monitors, tiered staffing so one nurse/physician with critical care expertise supervises several staff with lesser degrees of training that provide the bedside care) that may significantly impact patient morbidity and mortality. . an incident management system (hospital incident command system or alternative nationally compliant system) [ , ] is in place at the facility. this assures that in addition to using appropriate incident command positions and terminology that the process of management by objectives and utilization of formal and practiced planning cycles to generate incident action plans (iap) for the next operational period is followed. the hospital emergency executive control group coordinates these activities (see chap. : coordination and collaboration of interface units). . coordination agreements and systems with neighboring/regional health care facilities are put in place [ ] by the local, regional or national emergency executive control group (see chap. : coordination and collaboration of interface units). these may cross jurisdictional and even national boundaries. the importance of resource-balancing across multiple institutions cannot be overemphasized. during a single-site event, expedient patient transfer to those facilities with resources provides the best care possible, and during a pervasive event (such as a pandemic), s inter-facility coordination assures a consistent standard of care across a given region. 'regions' are usually defined functionally for hospitals rather than geographically (as is the case for emergency management), and planning should include usual referral partners regardless of geographic boundaries. . the hospital has an icu, operating rooms, postanesthesia care, stepdown/intermediate care units and procedure areas (may include respiratory/gastrointestinal procedure rooms or outpatient surgery/procedure areas) [ ] [ ] [ ] . the hospital has prepared for mces including stockpiling equipment, medications and basic supplies [ , ] . this should include planning for special populations regardless of the hospital's role in the community (for example, a hospital that does not usually provide burn or pediatric care may have to provide care for these patients during an incident that overwhelms or damages usual community resources). . the hospital has one ventilator per critical care bed [ ] but can obtain limited additional ventilators within - h. lines of authority . the hospital incident manager [ ] has overall decisionmaking authority to implement surge capacity or any other systematic decisions involved in the response. depending on the organization of the system, the hospital incident manager optimally may answer to (or at least coordinate with) an over-arching governmental entity and be providing institutional direction informed by higher level situational awareness and objectives. critical care staff (unit nursing supervisor or physician depending on availability) at hospitals should be prepared to act within their authority to: a. inform the incident manager about the status and capacity of icu services and their resource needs. these updates should occur as soon as possible after event declaration and be updated every few hours until the influx of patients has stabilized (after a no-notice event) at which point twice-daily reporting is likely to be sufficient unless specific circumstances require an update. unless temporary, requires state empowerment, clinical guidance, and protection for triage decisions and authorization for alternate care sites/techniques. once situational awareness has been achieved, triage decisions should be as systematic and integrated into institutional process, review and documentation as possible. institutions consider impact on the community of resource use (consider ''greatest good'' versus individual patient needs, e.g., conserve resources when possible), but patient-centered decision making is still the focus. institutions (and providers) should make triage decisions balancing the availability of resources to others and the individual patient's needs-shift to community-centered decision making s e. change staffing patterns and hours to provide the most appropriate coverage based on the demands of the incident. . critical care surge capacity-critical care is expanded across a continuum of physical space reflected below from conventional to crisis capacity. the institutional plan should provide for a phased expansion of critical care appropriate to the incident demands. hospitals should be able to increase their icu beds to the maximal extent by expanding icus and other areas with appropriate beds and monitors. increases beyond % over usual capacity are unlikely with the current h n virus. future mutations, outbreaks or mce may require maximum feasible expansion of capacity. this maximal feasible number will vary between institutions and countries, and be determined by the number of excess icu patients, the usual icu bed proportion of the total population and the maximum feasible expansion. as noted above, one group recommended a % expansion target, but many facilities may not be able to reach this target [ ] and should consider phased expansion to double capacity. a. conventional: involves spaces usually used for critical care. occupancy and staffing of existing beds is request additional staffing as needed for post-anesthesia care ( beds), pre-induction ( beds) and special procedures/outpatient surgery unit ( beds up to beds) . move stable icu patients to step-down units, move step-down and rule-outs to non-monitored beds as appropriate . transfer patients from monitored to non-monitored beds as appropriate . staff gastroenterology laboratory and cardiac outpatient area if required . move cots to pre-designated discharge holding area/waiting areas for holding patients pending transfers and clearing rooms . assess with planning chief need to activate regional transfer plan and for additional/follow-on staff and material resources crisis care . add cots or stretchers, transfer stable critical care patients with less resource demand to medicine floors (medical units are preferred by location to surgery, neurology, pediatric floor beds due to location) according to demand based on surge capacity worksheet . note additional beds created in units and halls do not have dedicated monitoring systems. call bioelectronics for any additional spares and ask that they pull accident & emergency (a&e) orthopedic area monitors, crash cart monitors, and depending on needs may move portable monitors from surgery/procedure areas. may need to make request to other facilities or discontinue cardiac/invasive monitoring to decrease demand. can also use saturation monitor for high/low rate alarm-respiratory care can assist re-allocation of saturation monitors . assess situation with planning section chief-as above-if internal/external transfers will not allow patients to move off cots within h then: decompression/demobilization in conjunction with incident manager prepare patient lists for transfer-focus on those that are stable or with resource needs that are difficult to meet in the current environment but do not preclude transfer. as more resources and staff become available and transfers are made to other institutions, transition critical care back to contingency and then conventional locations, restoring normal operations and care locations note that these represent a small portion of an overall surge capacity plan (which itself is a portion of the institutional emergency operations plan) and should be tailored to the needs of the facility maximized, including moving appropriate patients to step-down care from icu (facilitated by having preexisting 'bump lists'), increasing staffing through callbacks and holding staff as needed. this should be coupled with hospital-wide implementation of the same strategies of maximal bed use including 'surge discharge' that prioritize floor patients for early discharge or movement to other holding areas/hall beds per unit protocol so that adequate space can be created for icu patient transfers [ , ] . discharge holding areas should be pre-identified, and processes for patient assessment and rapid discharge should be in place if patients are to move efficiently between the emergency department (ed)/accident and emergency (a&e), operating suites, icus and inpatient floors. for example, a lounge or waiting area may be designated as an area where patients designated for early discharge can be moved while awaiting final orders, medications and transportation in order to more quickly make these beds available for incoming patients. this is of particular utility in a 'no-notice' or sudden event. during a more prolonged event, selective admission and surgical strategies (deferring elective procedures and selective scheduling of other procedures) will be of prominent value in maintaining maximal critical care resources. b. contingency: utilizes spaces that can provide comparable services to true icu beds with supervising staff that have critical care skills. this would include use of pre-and post-anesthesia care units (pacu), operating suites (especially in procedure areas), procedure rooms [gastroenterology (gi), respiratory, interventional radiology], step-down units/monitored units and potentially emergency department beds (though competing priorities for use will impact incident manager decisions about which spaces to use). the overall objective is to concentrate care for the least stable and most critically ill in the conventional critical care areas and move those that are more stable or with lower resource requirements to other areas of care. key infrastructure features include the ability to provide usual cardiac and oxygen saturation monitoring, intravenous medications and drips and mechanical ventilation [ ] [ ] [ ] . in preparing hospitals for a crisis, locations should be prioritized in the following order: expanding existing icus, postanesthesia care units and emergency departments to capacity, then step-down units, large procedure suites, telemetry units and finally hospital wards [ ] . infection control personnel should create a phased plan to accommodate larger numbers of patients with highly infectious diseases as this may be different than planning for patients that do not require isolation. hospitals should balance icu needs and the potential decreasing benefits of increasing icu capacity (because of excess workload) with other hospital needs that may suffer more as services are depleted. staff for these areas (anesthesia, surgery, critical care, emergency) should have a high degree of comfort managing the critically ill, at least on a short-term basis. hospital incident 'worksheets' should be developed that map and prioritize care areas for use based on ability to monitor the patient rooms, proximity to existing critical care or step-down units, and institution-specific factors (for example, pacu and pre-anesthesia care first, followed by conversion of step-down unit to icu level care, etc.) ( table ) . staff and equipment considerations should be pre-planned so that critical care staff can supervise overall care for critical patients while reducing their hands-on patient care responsibilities ('increasing the altitude of supervision' to oversee a larger number of patients) [ , ] . ventilators are expensive and difficult to stockpile, but contingency plans at the facility and government (local, state, provincial, national) levels should provide for some additional ventilators. planned criteria for re-distribution of equipment (use of oxygen saturation monitors restricted to those that are on ventilators or on high-flow oxygen, for example, with spot checks for others) or conservation of equipment (what medications should be given by pumps vs. those that can safely be given by gravity flow) may facilitate implementation during an event [ , ] . prioritization of support services (minimizing tests ordered, laboratory and radiology restricting services to essential tests and diagnostics, use of alternative diagnostics-for example, ultrasound rather than computed tomography for abdominal imaging) is also required and should be institution-wide. restrictions on utilization of diagnostics (laboratory, radiology) should increase with demand in pre-planned phases. the phased response for h n may last several weeks [ , ] . c. crisis: provision of 'sufficient' critical care in areas that are not designed for high-intensity care, for example, using floor beds with an oxygen saturation monitor (with high/low rate and low saturation alarms) for a patient on a ventilator and using staff that do not have significant training in critical care to provide basic care (basic nursing care, vital signs monitoring, etc.) with an even higher 'altitude' of the critical care nurses and physicians supervising these providers (e.g., critical care nursing and physician staff round on the patients at scheduled intervals to provide guidance to the primary nursing and physician staff and are available for consultation/questions). should demand exceed resource capacity for specific equipment (e.g., ventilators, extra-corporeal membrane oxygenation equipment), with no resources expected and no transfers possible [ , ] , triage processes should be implemented that have been pre-planned to the extent possible and are consistent with the community standard of care and any state, provincial or national guidance. central system considerations . oxygen a. remodeling or building projects at a hospital should consider incorporating oxygen ports (or extra ports) into patient rooms, meeting rooms, etc., to facilitate conversion to patient care areas or the accommodation of additional beds in usual areas. however, safety considerations are paramount, as these systems may not be used often and yet still require regular inspection and testing. multi-patient regulators are available that can serve multiple patients on variable oxygen flow rates from a single wall port, and these may be useful for providing cohort care, particularly in flat-space areas such as meeting rooms, etc. though this does not provide critical care, it can open beds up that can be used for critical care and thus is a valuable part of planning. b. hospitals should carefully consider limitations of the oxygen supply. even if enough ventilators or oxygen flow meters are available such that every bed in the hospital would have one, the oxygen systems for most hospitals were not designed to provide such a supply and maintain pressure within the system. continued supply and re-supply of liquid oxygen may be another limiting factor. hospitals should examine their oxygen delivery and storage systems for vulnerabilities. often, there are many potential points of failure within these systems with little redundancy or recovery. it may be to the institution's advantage to duplicate liquid oxygen systems, ideally separated geographically, or at least equipped to allow an interface with a trailerbased liquid oxygen system should the primary fixed delivery system fail. . suction/compressed air: suction and compressed air lines are a lower priority for incorporation into congregate care spaces (those providing low acuity non-ambulatory patient care); however, at least compressed air (and ideally suction) should be available for any spaces where mechanical ventilation is a consideration (i.e., patient rooms). hand-held and battery-operated suction units are available and may have utility, though the availability of wall suction is far preferable because of superior performance. . utilities a. electricity: emergency generators at most hospitals do not have the capacity to power outlets in all patient rooms sufficiently for the monitors, ventilators and pumps necessary for critical care. further, heating, air conditioning and ventilation systems (including negative flow systems) may not be included or adequately powered with emergency power circuits. critical care staff should identify which systems and outlets are included in emergency power, which are not and what the maximum load is (just because outlets are marked for emergency use does not mean that the generators can support the electrical draw if many of these outlets are used at once). the hospital should plan with jurisdictional emergency management the types and quantities of generators necessary to effectively run the facility should primary power fail and have the necessary adaptors available to wire temporary generators into the hospital system [ ] . b. water: clean water is required for many health care activities, including large volumes for hemodialysis. hospital planners may be unaware of the water needs for critical care activities and should work with critical care to forecast needs and identify suppliers and an operating procedure. c. continuity of operational planning: the ability of the institution to provide critical care depends on the maintenance of the operating infrastructure. water and utilities are separated from these because of the specific considerations above, but the availability of lighting, communications, information technology, fire suppression, heating/ventilation/air conditioning, nutrition services, laboratory, radiology and many other support and infrastructure services is not assured and critical care planners should be familiar with planning for maintaining general hospital operations during outages and other incidents [ , ] . functional roles and responsibilities of the internal personnel and interface agencies or sectors (these should be defined prior to the event and the specific actions to be taken listed in job action sheets or other resources that the care providers and incident management team can reference during an event) with resource acquisition (particularly for non-medical supplies such as security personnel for traffic control, etc.), coordinates the response on the jurisdictional level, and depending on the regional construct may assist with arranging patient transfers. this group assists with emergency medical services and other patient transportation resources. b. health care systems: provide mutual aid including resources and staff to disproportionately affected hospitals. depending on regional constructs, these systems ideally have a coordinating entity that establishes priorities of response and resource assignments, coordinates patient transfers, and works with other stakeholder agencies to obtain necessary staff, resources and emergency declarations. hospital personnel should understand how these systems work in their area and practice using them prior to an event [ , ] . logistics support and requirements necessary for the effective implementation of the sop incident management framework, institutional mobilization (disaster) plan, pre-existing phased implementation plans for capacity expansion, materials and resources appropriate to the plans (scope determined by institutional commitment and financial resources) and mechanism for monitoring, requesting and receiving resources [ ] [ ] [ ] are required. development/adaptation of facility plans should include administrative and critical care stakeholders, review and vetting with other affected department staff [accident facilities should establish temporary anteroom/changing area off hallway ( h). facilities should isolate ventilation to unit and change to % supply, % exhaust. step-down care may be provided in micu prior to transfer to floor negative pressure rooms . open surgery and procedure center as isolation stepdown/critical care isolation area in consultation with incident manager if necessary ([ patients or more anticipated). ventilation is already exhausted from this area; elective surgical volumes should be reduced during event. use locker rooms as clean/infectious transition zones for ppe donning/doffing. may use operating suites for icu level care in cooperation with anesthesia. capacity beds including in waiting/recovery and operating room/procedure rooms . ppe used by staff continuously in infectious area crisis patient care (catastrophic event, e.g., pandemic influenza) . using the standard surge capacity worksheet as a tool, determine with incident management which patient care areas to use as infectious patient cohort care depending on the current and anticipated event scope. cohort areas to may expand and contract during the course of the event . facilities should assist with construction of temporary anterooms for ppe changing adjacent to each cohort area and assure exhaust ventilation for these areas. supply may not be able to be manipulated for large areas . hospital should implement access control and staff screening/monitoring plans . ppe used by staff continuously in infectious/cohort area, potentially hospital-wide depending on scope of the event and transmissibility sample core infectious disease critical care capacity elements for 'city hospital.' note that this plan reflects specific adaptations for the facility and that each facility should identify a phased approach to these patients. space concerns are only one element of an overall infectious disease response plan and guidance for specific disease management, infection control, staff screening, behavioral health, visitor and access control policies, emergency department screening and cohorting, and patient transport planning (use of elevators, etc.) policies all should be included in the institutional plan city hospital sop for critical care management of a special pathogen: this guideline applies only to pathogens that are transmitted by airborne or suspected airborne routes and have a high likelihood of transmission and severe morbidity/mortality (may include sars, pandemic influenza, some hemorrhagic fevers). these patients require careful and comprehensive use of personal protective equipment (ppe) by staff caregivers s & emergency (a&e), operating room, stepdown units, and procedure areas, laboratory and radiology services, etc.], and preparedness activities supporting the sop (materials acquisition, planning). the initial development of the critical care surge plan should include a draft, with discussion, revision and a feedback cycle to the facility stakeholders. once a draft plan is complete, a tabletop exercise should test basic assumptions of the plan with revision as needed. initial orientation and training of staff on procedures should follow, and the plans should then be tested as realistically as possible in a functional exercise. after each exercise or event, an after-action review should identify areas for improvement and corrective actions. the sop should be redrafted as needed based on the experiences, or additional preparedness/planning activities may need to occur. education on these changes is conducted, and the plan exercised again. too often hospital disaster exercises stop with the patients being processed through the ed/a&e and do not require inpatient decision-making. effective augmentation of critical care services at a hospital requires substantial planning prior to the event, with integration of planning efforts across multiple services at the hospital and the engagement of community and government partners. development of a phased critical care expansion plan addressing staff, space and supplies in conjunction with hospital administration and emergency management personnel should be a priority with the ongoing h n influenza pandemic. conflict of interest none. critical care services and h n influenza in australia and new zealand critically ill patients with influenza a(h n ) in mexico task force for mass critical care. definitive care for the critically ill during a disaster: a framework for optimizing critical care surge capacity: from a task force for mass critical care summit meeting surge capacity concepts for health care facilities: the co-s-tr model for initial incident assessment refining surge capacity: conventional, contingency, and crisis capacity providing mass medical care with scarce resources: a community planning guide. prepared by health systems research, inc., under contract no. - - . ahrq publication no. - . agency for healthcare research and quality federal emergency management agency-department of homeland security medical surge capacity and capability: a management system for integrating medical and health resources during large-scale emergencies augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations of the working group on emergency mass critical care task force for mass critical care. definitive care for the critically ill during a disaster: medical resources for surge capacity: from a task force for mass critical care summit meeting healthcare facility and community strategies for patient care surge capacity hospital bed surge capacity in the event of a mass-casualty incident inpatient disposition classification for the creation of hospital surge capacity: a multiphase study patient care strategies for scarce resource situations task force for mass critical care. definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care: from a task force for mass critical care summit meeting electrical blackouts in hospitals and the need for reassessment of the electrical infrastructure and more powerful standby generation continuity of operations (coop) programs continuity of operations planning for public health and medical services. national disaster medical system training summit airborne infectious disease management: methods for temporary negative pressure isolation association for healthcare resource and materials management, health industry distributors association, health industry group purchasing association ( ) medical-surgical supply formulary by disaster scenario standards and guidelines for healthcare surge during emergencies-hospital operational tools manual key: cord- -aj nxi x authors: wang, chen yu; calfee, carolyn s.; paul, devon w.; janz, david r.; may, addison k.; zhuo, hanjing; bernard, gordon r.; matthay, michael a.; ware, lorraine b.; kangelaris, kirsten neudoerffer title: one-year mortality and predictors of death among hospital survivors of acute respiratory distress syndrome date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: aj nxi x purpose: advances in supportive care and ventilator management for acute respiratory distress syndrome (ards) have resulted in declines in short-term mortality, but risks of death after survival to hospital discharge have not been well described. our objective was to quantify the difference between short-term and long-term mortality in ards and to identify risk factors for death and causes of death at year among hospital survivors. methods: this multi-intensive care unit, prospective cohort included patients with ards enrolled between january and february . we determined the clinical characteristics associated with in-hospital and -year mortality among hospital survivors and utilized death certificate data to identify causes of death. results: of patients hospitalized with ards, mortality at year was substantially higher ( %, % ci – %) than in-hospital mortality ( %, % ci – %), p < . . among patients who survived to hospital discharge, the ( %) who died in the subsequent year were older (p < . ) and more likely to have been discharged to a nursing home, other hospital, or hospice compared to patients alive at year (p < . ). important predictors of death among hospital survivors were comorbidities present at the time of ards, and not living at home prior to admission. ards-related measures of severity of illness did not emerge as independent predictors of mortality in hospital survivors. conclusions: despite improvements in short-term ards outcomes, -year mortality is high, mostly because of the large burden of comorbidities, which are prevalent in patients with ards. electronic supplementary material: the online version of this article (doi: . /s - - - ) contains supplementary material, which is available to authorized users. abstract purpose: advances in supportive care and ventilator management for acute respiratory distress syndrome (ards) have resulted in declines in short-term mortality, but risks of death after survival to hospital discharge have not been well described. our objective was to quantify the difference between shortterm and long-term mortality in ards and to identify risk factors for death and causes of death at year among hospital survivors. methods: this multi-intensive care unit, prospective cohort included patients with ards enrolled between january and february . we determined the clinical characteristics associated with in-hospital and -year mortality among hospital survivors and utilized death certificate data to identify causes of death. results: of patients hospitalized with ards, mortality at year was substantially higher ( %, % ci - %) than in-hospital mortality ( %, % ci - %), p \ . . among patients who survived to hospital discharge, the ( %) who died in the subsequent year were older (p \ . ) and more likely to have been discharged to a nursing home, other hospital, or hospice compared to patients alive at year (p \ . ). important predictors of death among hospital survivors were comorbidities present at the time of ards, and not living at home prior to admission. ards-related measures of severity of illness did not emerge as independent predictors of mortality in hospital survivors. conclusions: despite improvements in short-term ards outcomes, -year mortality is high, mostly because of the large burden of comorbidities, which are prevalent in patients with ards. the last decade has seen many advancements in care for patients with acute respiratory distress syndrome (ards) including improvements in ventilator management [ , ] , noninvasive mechanical ventilation strategies [ ] [ ] [ ] , sepsis management [ ] , and intensive care unit system changes [ , ] . more patients with ards are now surviving to hospital discharge, a phenomenon that has been reported in both observational studies and randomized trials [ ] [ ] [ ] . for example, -day mortality decreased from % in the traditional tidal volume arm of the ards network arma study published in to % in the most recent ards network trial published in , in spite of increased severity of illness and more comorbidities in the more recent trial [ , ] . however, less is known about the epidemiology of long-term survival in ards, particularly in the context of increasing severity of illness and comorbidities among icu patients today [ ] . initial studies of long-term outcomes in ards found that in-hospital survival from ards provided a good estimate of long-term survival [ ] [ ] [ ] [ ] ; however, these populations are not reflective of ards patients in modern practice. in-hospital mortality in these studies was higher at - %, as these cohorts predated widespread implementation of low tidal volume ventilation. furthermore, patients who survived to hospital discharge and were selected for these studies were young (mean age mid- s), had few coexisting conditions, and lower severity of illness on presentation. more recent data demonstrate a widening difference between ards survival at discharge and long-term follow-up [ , , ] . this ''survival gap'' suggests that while modern icu interventions have resulted in short-term improvements in ards survival, the overall survival after ards may not have improved. temporal changes in icu patient characteristics including increased severity of illness and more comorbid illnesses may explain some of the changes in trajectory of illness following discharge [ ] . although factors that predict short-term mortality have been well described [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , a better understanding of predictors of long-term mortality in ards is required for improved prognostication and a better understanding of the effects of icu interventions on long-term outcomes [ ] . a small study predating low tidal volume ventilation found that comorbidities, ards risk factor, and age were most highly associated with mortality months following ards diagnosis [ ] , but the influence of increased severity of illness over time has not been assessed. a more recent study found that the survival benefits of adherence to low tidal volume ventilation persisted at years follow-up, suggesting that modern changes in clinical practice may provide long-standing improvements in survival [ ] . however, this study excluded sicker patients with cancer or life-limiting diseasediagnoses that are frequent in patients presenting with ards. the predictors and causes of death in a broad sample of patients surviving to hospital discharge with ards are not known. the purpose of the current study was to ( ) quantify the gap between in-hospital and -year ards mortality in modern practice, ( ) identify the most influential risk factors for death at year among hospital survivors in a large, multi-icu prospective cohort study of patients with ards, and ( ) examine causes of death among patients dying in the year after diagnosis of ards. some of these data have previously been presented in the form of an abstract [ ] . the study subjects were drawn from the validation of biomarkers in acute lung injury diagnosis (valid) study, an ongoing prospective, multi-icu cohort study of critically ill patients at vanderbilt university medical center, a tertiary medical center in nashville, tn. the inclusion criteria and exclusion criteria of valid have been reported previously and are described in the supplemental appendix [ ] . specifically, patients with severe chronic lung disease were excluded, but patients with other underlying comorbidities including advanced cancer and hiv were not excluded. the study was approved by the vanderbilt university institutional review board. for this analysis, we included patients enrolled between january and february who had or developed acute lung injury (ali)/ards during the first days after admission to the icu. during the study period, there were a total of , total patients enrolled in valid of whom, , had at least one risk factor for ards. of these, the current study focused on the who met the american european consensus conference (aecc) criteria for ali/ards [ ] . data collection and definitions have been described previously [ ] . diagnosis of ali/ards was defined by the aecc definition (pao /fio b mmhg for ali and pao /fio b mmhg for ards) [ ] , and could be established at any time during the first days in the icu. both mechanically ventilated (defined as invasive mechanical ventilation within days of aecc ali/ ards diagnosis) and not mechanically ventilated patients meeting aecc criteria were included in our primary analysis. in a sensitivity analysis, we also considered the berlin definition for ards [ , ] . berlin severity levels were defined as mild ( mmhg \pao / fio b mmhg with peep or cpap c cmh o), moderate ( mmhg \pao /fio b mmhg with peep c cmh o), and severe (pao /fio b mmhg with peep c cmh o). for both aecc and berlin definitions, the ratio of pulse oximetric saturation to fraction of inspired oxygen (spo /fio ) was used as a validated surrogate for pao /fio among patients without an arterial blood gas measurement at the time of ali/ ards diagnosis: spo /fio = ? . (pao / fio ) [ ] . the discharge location for patients who survived hospitalization was categorized as home, rehabilitation hospital, nursing home, hospice, or other acute care hospital. the lung injury score [ ] , brussels organ failure [ ] , and definitions for sepsis, pneumonia, aspiration, and trauma are included in the supplemental appendix. all patients were followed until death or for at least year after study enrollment. short-term mortality was defined as all-cause mortality during hospitalization. long-term mortality was defined as all-cause mortality year following enrollment in valid in patients who survived to hospital discharge. patient deaths were identified by medical record review and query of the social security death index (ssdi) [ ] . causes of death were determined by review of death certificate data obtained from the tennessee vital records office of the tennessee department of health. underlying causes of death were categorized as infection, malignancy (primary, metastatic, or hematologic), cardiovascular, respiratory, gastrointestinal/hepatic, trauma, or other causes (listed in supplemental appendix) based on icd- coding of the primary cause of death on the death certificate. we used t tests, chi-squared tests, and fisher's exact tests as appropriate to compare baseline demographics and clinical risk factors across groups. descriptive statistics and mcnemar's were used to compare in-hospital and -year mortality. since all events were accounted for over the year of follow-up, logistic regression was used to analyze associations between candidate risk factors and mortality. kaplan-meier survival plots demonstrate the time from discharge to death in hospital survivors and the log-rank test was used to estimate differences according to discharge location. clinical characteristics associated with -year mortality with p \ . on bivariable analysis were entered into a stepwise elimination model to retain potential risk factors if they remained associated at a p value of less than . . because of the modest number of outcomes, the forward stepwise elimination was used to maintain model parsimony. in a sensitivity analysis, we analyzed only patients meeting the berlin definition of ards [ ] . analyses were performed using stata version (stata corp, college station, tx). statistical significance was defined as a two-tailed p \ . for all analyses. among patients with ali/ards, the proportion of patients who died increased from % (n = , % ci - %) during hospitalization to % (n = , % ci - %) during the year after discharge (p \ . ). one-year mortality was higher than inhospital mortality regardless of ali/ards etiology (supplemental fig. ). in the subset of patients with -year outcomes available (n = , %), the -year cumulative incidence of death was % (n = , % ci - %, p = . ). in a sensitivity analysis of patients meeting the berlin definition of ards [ ] (excluded patients: non-mechanically ventilated in first days of enrollment; two patients with missing peep; two patients with peep \ cmh o; and four patients not meeting hypoxemia criteria on day otherwise meeting all berlin criteria) we found similar rates of hospital and -year mortality (supplemental table ). severity of ards defined by berlin levels (mild, moderate, severe) was associated with in-hospital mortality but not with mortality at -year among hospital survivors. comparison of baseline characteristics by hospital and -year outcomes demographics, comorbidities, and initial clinical characteristics did not differ substantially between those who died early (in hospital) and those who died over the subsequent year (table ) . patients who died in the hospital (n = ) were more likely to have a hematologic malignancy and less likely to have copd or metastatic cancer than patients who died after surviving hospitalization but were otherwise demographically similar. in addition, there was no difference in underlying cause of ali/ards although patients who died during hospitalization had a lower p/f ratio and a higher incidence of hepatic failure compared to those dying after hospitalization. by contrast, compared to patients who died in the year following hospital discharge (n = ), survivors at year (n = ) were younger, were more likely to have been admitted through the emergency department and had substantially fewer comorbidities such as copd, hiv, diabetes, chronic heart failure, chronic kidney disease, or malignancy (table ). in addition, patients who were alive at year were more likely to have trauma and less likely to have sepsis as the cause of ali/ards. increased severity of illness on presentation was associated with higher -year mortality among patients who survived hospitalization: respiratory rate, apache ii score, presence of coagulation failure, renal failure, and circulatory failure were all significantly associated with death after discharge ( table ) . comparison of hospital course between hospital survivors who were dead or alive at year among patients with ali/ards who survived hospitalization, those who survived to year had significantly shorter time from hospital admission to icu admission, lower creatinine at discharge, and were more likely to be discharged home or to a rehabilitation facility and less likely to be discharged to a nursing home or hospice facility (table ) . specifically, discharge destination among hospital survivors was strongly associated with long-term mortality (fig. ) (p \ . ). there were no differences in icu length of stay (p = . ) or duration of mechanical ventilation (p = . ) between hospital survivors that died and survived at -year follow-up. stepwise elimination identified several baseline characteristics as independent predictors of mortality among hospital survivors. these included age and severe comorbidities: hiv, metastatic cancer, hematologic malignancy, non-metastatic cancer, and chronic renal disease (table ) . trauma as a cause of ards and living at home prior to hospitalization were strong independent predictors of decreased odds of mortality at year. increased length of hospital stay was the only characteristic of hospitalization that was independently associated with increased odds of death at year among hospital survivors. severity of illness measures including lis, apache ii, organ failure, and pao /fio did not emerge as independent predictors of mortality in survivors. the c-statistic for the final adjusted model was . . predictors of -year mortality among survivors were similar after excluding patients discharged to hospice, and characteristics associated with -year mortality among those surviving the hospitalization were similar to those associated with overall -year mortality (data not shown). death certificate data was available for ( %) of the patients who died within year of enrollment. overall, the most common underlying cause of death both in the hospital and among hospital survivors was malignancy (fig. ) . seventy-two percent of patients with known malignancy at the time of ards were found to have malignancy as the underlying cause of death at year. there were no significant differences in underlying cause of death between patients who died in the hospital and patients who died after discharge. short-term mortality in ards has declined over the last decade owing to improvements in supportive care and of the use of protective ventilator strategies [ , ] . we sought to quantify the survival gap between short-and long-term ards mortality and identify risk factors for death and causes of death at year for hospital survivors. in this study of a broad, heterogeneous cohort of critically ill patients with ali/ards, overall hospital mortality was %, concordant with short-term mortality rates of ali/ards mortality reported in the era of low tidal volume ventilation [ , ] , and -year mortality was substantially higher at %, consistent with other recent studies [ , , ] . this finding did not vary according to etiology of ards or in the presence of sepsis. furthermore, in a large subgroup of patients followed for years, we found that more than half of the patients with ali/ ards had died. disposition after hospitalization was highly associated with -year mortality, suggesting that functional status after discharge may be an important contributing factor to long-term mortality after ards. the independent predictors of death at year were age, living somewhere other than home prior to admission, and serious comorbidities. although several measures of severity of illness and characteristics of hospital course were associated with long-term mortality among hospital survivors, only length of hospital stay remained an independent predictor of long-term mortality in a stepwise elimination model. restriction of the analysis to patients meeting the berlin definition for ards did not change the findings, and berlin level of severity of ards did not predict long-term mortality in hospital survivors. this study provides several insights into recent reports of declines in ards mortality. although short-term mortality in ards has decreased in the last decade, our findings expand upon other recent studies demonstrating a widening survival gap between ards survival at discharge and long-term follow-up [ , , ] . this gap suggests that while modern icu interventions have improved short-term outcomes in ards, other factors contribute to a persistently high long-term mortality in ards. one possible explanation is the temporal changes in characteristics of icu patients over the last several decades. large studies have demonstrated that older age, the number of comorbidities, and the severity of illness have increased both in the general icu population and in ards patients specifically [ , ] . icu treatment cannot address the underlying comorbidities and increasing age that ultimately contribute to high long-term mortality in icu patients today. although a recent study found that adherence to low tidal volume ventilation in ards was associated with a survival benefit up to years following hospitalization, these conclusions may only be generalizable to the most healthy of ards patients because those with significant comorbidities, poor social status, and life-limiting illnesses were excluded from enrollment in the observational study [ ] . our findings are consistent with prior studies focusing on long-term mortality in general critically ill patients, a finding that supports the hypothesis that long-term outcomes in ards are more related to the medical conditions and age of patients requiring icu care in general rather than the development of ards specifically [ ] . in a recent study of medicare patients, icu survivors had higher -year mortality than non-icu hospital survivors or non-hospitalized controls, and a separate study showed that critically ill patients have decreased ards acute respiratory distress syndrome, hiv human immunodeficiency virus, sd standard deviation, apache acute physiology and chronic health evaluation, lis lung injury score * p value compares values in patients who died in the hospital to those who survived hospitalization but died in the first year p value compares values in hospital survivors who died at year versus those alive at year a leukemia including chronic, acute, and following stem cell transplant b pao /fio missing in patients; spo /fio used as surrogate survival for up to years compared to age-and sexmatched population controls [ , ] . furthermore, predictors of long-term outcomes for critically ill patients are similar to those we observed in ards, with comorbidities as top predictors for subsequent re-hospitalization and death [ ] . one possible explanation for the persistently high risk of death in patients with critical illness includes a persistent pro-inflammatory state that may exacerbate or trigger other underlying inflammatory disorders including cardiovascular disease, recurrent infection, cancer, and renal failure-all common causes of death among patients in our study who survived to hospital discharge. this study has several strengths including the large sample size, broad patient population with few exclusion criteria, and the careful prospective phenotyping for ali/ ards, sepsis, and other important clinical variables. because there were very few exclusion criteria for enrollment in valid, the findings are likely to be generalizable. the study also has some limitations. first, it is a single-center study. however, this is counterbalanced by the broad spectrum of heterogeneous critically ill patients from four different intensive care units included. second, it is possible that we underestimated the -year mortality rate of ards survivors; although the ssdi has been shown to be a valuable tool for determining long-term outcomes [ ] , some patients without social security numbers may not be included. third, mortality does not capture the full burden of disease. long-term sequelae of ards, including impaired pulmonary function, neuromuscular weakness, and neuropsychiatric are well described [ , [ ] [ ] [ ] [ ] . however, these limitations would have led us to underestimate rather than overestimate the differences in survival across groups are statistically significant (p \ . ) driven by significantly increased -year mortality among patients discharged to hospice (p \ . ), nursing home (p \ . ), and other hospital (p = . ) compared to discharge to home long-term mortality is substantially higher than shortterm mortality in a broad sample of patients with ards. in spite of improvements in supportive care and significantly improved short-term outcomes, long-term outcomes remain poor. the top predictors of -year mortality in hospital survivors include non-modifiable factors including age and comorbidities, and the most common causes of death are malignancy and infection. these results underscore the importance of considering the interaction between comorbid illness and ards on the trajectory of long-term outcomes in hospital survivors of ards for testing new interventions and providing prognoses. researchers must measure whether effects of interventions can influence the overall trajectory of survival in ards patients who do and do not have major comorbidities. possible clinical applications of such research include improved guidance of initial discussions of prognosis and the benefits of full resuscitation for highrisk patients. for clinical trials, it is perhaps more realistic to target shorter-term endpoints such as -to -day mortality, since -year mortality will be driven primarily by comorbidities that cannot be reversed or influenced by treatments for increasing survival from ards such as lung protective or prone ventilation. this study, along with others, demonstrates that premorbid illnesses are the top predictors of long-term outcomes after ards in critically ill patients today. acknowledgments we thank all the patients who participated in the study and the research staff who assisted with the study. we are grateful to dr. underlying causes of death in patients with ali/ards who died during the hospital stay (gray bars) and those who survived hospitalization but died during the year following enrollment (black bars). in both groups, the most common cause of death was underlying malignancy. no difference is statistically significant ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome deadspace ventilation: a waste of breath! a multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome non-invasive ventilation in community-acquired pneumonia and severe acute respiratory failure neurally adjusted ventilatory assist (nava) improves patient-ventilator interaction during non-invasive ventilation delivered by face mask early goaldirected therapy in the treatment of severe sepsis and septic shock interventions to reduce mortality among patients treated in intensive care units recommendations on basic requirements for intensive care units: structural and organizational aspects mortality rates for patients with acute lung injury/ards have decreased over time recent trends in acute lung injury mortality acute respiratory distress syndrome: nationwide changes in incidence, treatment and mortality over years randomized, placebo-controlled clinical trial of an aerosolized beta- agonist for treatment of acute lung injury changes in hospital mortality for united states intensive care unit admissions from quality-adjusted survival in the first year after the acute respiratory distress syndrome one-year outcomes in survivors of the acute respiratory distress syndrome twoyear outcomes, health care use, and costs of survivors of acute respiratory distress syndrome survivors of acute respiratory distress 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in acute lung injury a simple classification model for hospital mortality in patients with acute lung injury managed with lung protective ventilation spanish initiative for epidemiology s, therapies for an ( ) a universal definition of ards: the pao /fio ratio under a standard ventilatory setting-a prospective, multicenter validation study the effect of acute respiratory distress syndrome on long-term survival long term mortality in clinical acute lung injury is dramatically higher than hospital mortality (abstract) urine neutrophil gelatinase-associated lipocalin moderately predicts acute kidney injury in critically ill adults the american-european consensus conference on ards: definitions, mechanisms, relevant outcomes, and clinical trial coordination acute respiratory distress syndrome: the berlin definition the berlin definition of ards: an expanded rationale, justification, and supplementary material comparison of the spo /fio ratio and the pao /fio ratio in patients with acute lung injury or ards an expanded definition of the adult respiratory distress syndrome a trial of antioxidants nacetylcysteine and procysteine in ards. the antioxidant in ards study group validation of the social security death index (ssdi): an important readily-available outcomes database for researchers three-year outcomes for medicare beneficiaries who survive intensive care determinants of longterm survival after intensive care neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome one-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study functional disability years after acute respiratory distress syndrome long-term outcomes in survivors of acute respiratory distress syndrome ventilated in supine or prone position key: cord- -w esk authors: moreno, gerard; rodríguez, alejandro; reyes, luis f.; gomez, josep; sole-violan, jordi; díaz, emili; bodí, maría; trefler, sandra; guardiola, juan; yébenes, juan c.; soriano, alex; garnacho-montero, josé; socias, lorenzo; del valle ortíz, maría; correig, eudald; marín-corral, judith; vallverdú-vidal, montserrat; restrepo, marcos i.; torres, antoni; martín-loeches, ignacio title: corticosteroid treatment in critically ill patients with severe influenza pneumonia: a propensity score matching study date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: w esk purpose: to determine clinical predictors associated with corticosteroid administration and its association with icu mortality in critically ill patients with severe influenza pneumonia. methods: secondary analysis of a prospective cohort study of critically ill patients with confirmed influenza pneumonia admitted to icus in spain between june and april . patients who received corticosteroid treatment for causes other than viral pneumonia (e.g., refractory septic shock and asthma or chronic obstructive pulmonary disease [copd] exacerbation) were excluded. patients with corticosteroid therapy were compared with those without corticosteroid therapy. we use a propensity score (ps) matching analysis to reduce confounding factors. the primary outcome was icu mortality. cox proportional hazards and competing risks analysis was performed to assess the impact of corticosteroids on icu mortality. results: a total of patients with primary influenza pneumonia were enrolled. corticosteroids were administered in ( . %) patients, with methylprednisolone the most frequently used corticosteroid ( / [ . %]). the median daily dose was equivalent to mg of methylprednisolone (iqr – ) for a median duration of days (iqr – ). asthma, copd, hematological disease, and the need for mechanical ventilation were independently associated with corticosteroid use. crude icu mortality was higher in patients who received corticosteroids ( . %) than in patients who did not receive corticosteroids ( . %, p < . ). after ps matching, corticosteroid use was associated with icu mortality in the cox (hr = . [ % ci . – . ], p < . ) and competing risks analysis (shr = . [ % ci . – . ], p = . ). conclusion: administration of corticosteroids in patients with severe influenza pneumonia is associated with increased icu mortality, and these agents should not be used as co-adjuvant therapy. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. pneumonia caused by the influenza a(h n )pdm virus infection may lead to life-threatening acute respiratory failure (arf) and acute respiratory distress syndrome (ards). antiviral therapy is the cornerstone of treatment for influenza pneumonia [ ] [ ] [ ] ; in addition, intravenous corticosteroids have been used as co-adjuvant therapy in patients with arf/ards to modulate lung inflammation and improve clinical outcomes [ ] [ ] [ ] [ ] [ ] . however, no randomized clinical trials have investigated the potential benefit or harm of corticosteroid therapy for arf/ards due to acute influenza pneumonia. during the h n pandemic, corticosteroids were widely used despite contradictory [ , ] , unfavorable [ , [ ] [ ] [ ] , or inconclusive [ , ] available data. a recent cochrane review [ ] concluded that co-adjuvant corticosteroid therapy was associated with increased mortality in patients with influenza pneumonia. however, the data were derived from observational studies of very low quality and with several methodological limitations, including other clinical indications of corticosteroids as a major potential concern. thus, it is impossible to be sure that patients who were treated with corticosteroids did not have other corticosteroid indications or were not more severely ill in the first place. we have previously reported that corticosteroid therapy does not improve survival in patients with primary viral pneumonia [ ] . however, in that observational study, we assessed the effects of corticosteroid therapy on survival between patients who were and were not treated, but we did not apply a statistical method that would have balanced all the variables between the two groups. therefore, the aim of the present study was to identify the factors associated with corticosteroid use and its impact on intensive care unit (icu) mortality using propensity score (ps) matching analysis in icu patients with influenza pneumonia. preliminary results of this analysis were presented in the th international symposium on intensive care and emergency medicine [ ] . this was a secondary analysis of prospective and observational cohorts of critically ill subjects admitted to icus in spain (which represents approximately % of the country's icus) between june and april . data were obtained from a voluntary registry created by semicyuc (sociedad española de medicina intensiva, crítica y unidades coronarias). all consecutive cases admitted to the icu were collected. the study was approved by the joan xxiii university hospital ethics committee (irb# ). patient identity remained anonymous, and the requirement for informed consent was waived due to the observational nature of the study, as reported elsewhere [ , [ ] [ ] [ ] [ ] [ ] . inclusion criteria participants included patients admitted with fever (> °c); respiratory symptoms consistent with cough, sore throat, myalgia, or influenza-like illness; acute respiratory failure requiring icu admission; and microbiological confirmation of viral a, b, or c infection identified by reverse transcription polymerase chain reaction (rt-pcr) at icu admission. data were reported by the attending physician reviewing medical charts and radiological and laboratory records. the attending physician ordered all tests and procedures related to patient care. exclusion criteria patients receiving corticosteroids as rescue therapy (due to shock) or due to chronic obstructive pulmonary disease (copd)/asthma exacerbation were excluded (see definition below). children < years old were not enrolled in the study. patients with non-pulmonary influenza infection and those with healthcareassociated pneumonia were also excluded. the following variables were recorded at icu admission: demographic data, comorbidities, time from illness onset to hospital admission, time to first dose of antiviral delivery, microbiological findings, and laboratory and chest radiological findings at icu admission (all the collected variables are reported in e- table of the supplementary material). to determine illness severity, the acute physiology and chronic health evaluation (apache) ii score [ ] was estimated for all patients within h of icu admission. organ failure was assessed using the sequential organ failure assessment (sofa) scoring system [ ] , also at icu admission. the indication of corticosteroid treatment was clearly reported in the case report form and was confirmed by the medical records. community-acquired pneumonia (cap) was defined in accordance with current american thoracic society and infectious diseases society of america guidelines (ats/ idsa) [ ] . the rt-pcr test for influenza was carried out in accordance with the guidelines of the centers for disease control and prevention (cdc) [ ] . primary viral pneumonia was defined as acute respiratory failure and unequivocal alveolar opacities involving two or more lobes, with negative respiratory and blood bacterial cultures during the acute phase of influenza virus infection at icu admission [ ] . systemic corticosteroids have been widely used as co-adjuvant therapy in patients arf/ards due to influenza pneumonia to modulate lung inflammation, despite controversy on clinical outcomes. our findings provide solid evidence to support the association of corticosteroids administration with increased icu mortality in critically ill patients with influenza pneumonia. copd "exacerbation" was defined according to copd exacerbation guidelines of the european respiratory society/ats [ ] as increased respiratory symptoms, particularly dyspnea, cough, and increased sputum purulence without pulmonary infiltrates in chest x-ray. copd patients with pulmonary infiltrates in chest x-ray were considered as cap and were included in the present analysis. asthma exacerbation was defined as acute or subacute episodes characterized by a progressive increase in one or more typical asthmatic symptoms (dyspnea, coughing, wheezing, and tightness of the chest [ ] without infiltrates in the chest x-ray. asthmatic patients with pulmonary infiltrates in chest x-ray were considered as cap and were included in the present analysis. community-acquired respiratory co-infection (carc) was considered in patients with confirmation of influenza virus infection showing recurrence of fever, increase in cough and production of purulent sputum plus positive bacterial/fungal respiratory or blood cultures at icu admission [ , ] . refractory septic shock was defined in accordance with the surviving sepsis campaign guidelines [ ] ; that is, patients in whom adequate fluid resuscitation and vasopressor therapy are unable to restore hemodynamic stability. ventilator-associated pneumonia was defined according to the new ats/idsa guidelines [ ] among icu patients who developed a new pneumonic event while mechanically ventilated for at least h after clinical presentation. corticosteroid treatment: we considered the primary indication recorded by the treating physician as coadjuvant treatment for viral pneumonia. corticosteroid therapy was defined as corticosteroid administration at icu admission (within the first h). patients receiving corticosteroids as rescue therapy (due to shock) or due to copd/asthma exacerbation were excluded (see exclusion criteria). obese patients were defined as those with a body mass index (bmi) of > kg/m . the icu admission criteria and treatment decisions for all patients, including the decision to intubate and type of antibiotic, antiviral, or corticosteroid therapy administered, were not standardized between centers and were left to the discretion of the attending physician, according to the spanish society of intensive care recommendations [ ] . primary to determine whether corticosteroid use was associated with icu mortality. in addition, the primary outcome was examined in eight pre-specified subgroups defined according to the following baseline characteristics: ( ) severity of illness (apache score < vs. ≥ ), ( ) intensity of organ dysfunction (sofa < vs. ≥ ), ( ) presence of shock upon icu (yes vs. no), ( ) need for mechanical ventilation (mv) upon icu admission (yes vs. no), ( ) inflammatory response to c-reactive protein (crp < vs. ≥ mg/dl), ( ) presence of bacterial coinfection (yes vs. no), ( ) chronic lung disease such as copd (yes vs. no), and ( ) asthma (yes vs. no). the cutoff for continuous variables was determined according to our population median value. secondary to determine risk factors associated with corticosteroid use. icu length of stay (los) and mv days were also examined in survivors between groups receiving and not receiving corticosteroid therapy. discrete variables were expressed as counts (percentage) and continuous variables as means with standard deviation (sd) or medians and interquartile range - % (iqr). for patient demographics and clinical characteristics, differences between groups were assessed using the chi-squared test and fisher's exact test for categorical variables, and the student t test or the mann-whitney u test for continuous variables. to investigate the association between baseline (icu admission) variables and corticosteroid use, a multivariate analysis (binary logistic regression) was performed. the multivariate model comprised factors of clinical interest and all significant covariates in the univariate analysis. the results are presented as odds ratios (or) and % confidence intervals (ci). model integrity was examined using standard diagnostic statistics and plots and goodness of fit for each model for all outcomes, and was assessed with the hosmer-lemeshow test. after this first approach, we generated a full-matching ps analysis in order to minimize the effect of a corticosteroid treatment selection bias and to control for potential confounding factors (additional information about the ps full-matching analysis can be found in the electronic supplementary material) [ ] . this allowed us to study two comparable (almost identical) cohorts: ( ) the corticosteroid-treated group and ( ) the control group, comprising patients who did not receive corticosteroid treatment. ps matching analysis attempts to compare outcomes between patients who have a similar distribution of all the covariates measured. an attractive feature of this approach is that it uses the entire sample. using the ps methodology, all patients were assigned a weight between and ; this propensity-matched cohort was generated by choosing the best weight balance. this method optimizes the post-weighting balance of covariates between groups and, in this way, approximates the conditions of random site-of-treatment assignment. to assess our ps adjustment, we checked for adequate overlap in propensity scores between groups with a crossvalidation model. to do so, we divided the patients in the database into two subsets: (a) a "training set" with patients ( %), and (b) a "validation set" with patients ( %). after the matching, a kaplan-meier survival plot was generated to track icu mortality over time for corticosteroid-treated and untreated patients. in addition, cox proportional hazards regression models were fitted to assess the impact of corticosteroids on icu mortality. the results are presented as hazard ratios (hr) and % ci and adjusted survival plots. because cox hazard survival analysis is not satisfactory for describing icu patient mortality over time [ ] , we performed a competing risks analysis to confirm our results. first, we computed the cumulative incidence function (cif) of death over time. at time t, the cif defines the probability of dying in the icu by that time t when the population can be discharged alive. the cif was estimated from the data using the cmprsk package developed by gray [ ] . we used the fine and gray model [ ] , which extends the cox model to competing risks data by considering the sub-distribution hazard (for instance, the hazard function associated with the cif). the strength of the association between each variable and the outcome was assessed using the sub-hazard ratio (shr), which is the ratio of hazards associated with the cif in the presence of and in the absence of a prognostic factor. in order to avoid spurious associations, the variables that we entered in the regression models were those with a relationship in the univariate analysis (p < . ) or a plausible relationship with the dependent variable. data analysis was performed using spss for windows version . (ibm corp., armonk, ny, usa). mixed-effects models were performed with r (cran.r-project.org). a total of patients with confirmed influenza pneumonia were enrolled at icus in spain during the study period ( ) ( ) ( ) ( ) ( ) ( ) . of these, ( . %) met the inclusion criteria and were included in the study (fig. ) . among patients with corticosteroid therapy, ( . %) received methylprednisolone, ( . %) prednisolone, and three ( . %) dexamethasone. for all patients who received therapy with corticosteroids due to pneumonia, this was initiated within the first h of icu admission. patients received a median (interquartile range [iqr]) daily dose equivalent to ( - ) mg of methylprednisolone, and the median duration of corticosteroid treatment was ( - ) days. the frequency of corticosteroid treatment by study period was . % in , . % in , % in , and . % in . considering the period as baseline, we observed that only in was there a significant reduction (p = . ) in the indication of corticosteroid treatment as co-adjuvant therapy for pneumonia. no differences in the rate of ventilator-associated pneumonia were observed between patients with (n = , . %) and without (n = , . %) corticosteroid therapy. clinical characteristics of patients and their distribution in the two groups are shown in table fig. flowchart of all excluded and included patients who received corticosteroid therapy were sicker according to the apache ii score, more obese, and more likely to have asthma, copd, and hematological diseases than those who did not receive treatment. mv use, serum procalcitonin concentrations, and icu mortality rate were higher in patients who received corticosteroids. there were no significant differences between groups regarding icu los or mv days. no other differences were found between the groups. overall mortality was . % ( / ). to determine factors associated with corticosteroid use, a stepwise logistic regression model was performed. apache ii score, asthma, copd, obesity, hematological disease, and mv were the independent variables included in the model. as shown in table , mv (or = . ), asthma (or = . ), copd (or = . ), and hematological disease (or = . ) were independently associated with corticosteroid use. table , supplementary material). ps matching was applied, and control and treated patients were matched. the summaries of balance for unmatched and matched data are shown in table (and e- fig. in the supplementary material). the apache ii score, sofa score, delay at icu admission, number of quadrants infiltrated in chest x-ray, serum lactate dehydrogenase (ldh), white blood cell (wbc) count, continuous renal replacement therapy (crrt), serum crp, mv, shock, chronic heart disease, human immunodeficiency virus (hiv/aids), primary viral pneumonia, bacterial co-infection, and corticosteroid use were the variables included in the logistic regression analysis of the ps model. the discriminatory power of the model (e- fig. , supplementary material) was good, with an area under the receiver operating characteristic curve of . ( % ci . - . , p < . ). the accuracy of the predictive model (training set) with respect to the validation set was . . e- figure (supplementary material) shows the kaplan-meier estimates of the mortality rate during icu admission, differentiating between patients with and without corticosteroid use. the cumulative survival was lower in patients with corticosteroid therapy than in untreated patients (log-rank test . , p < . ). when we excluded patients with carc, the results were similar (log-rank test . , p = . ; supplementary material) . however, in patients with carc, only a trend towards higher mortality related to corticosteroid treatment was observed p = . ; supplementary material) . finally, to determine the impact of corticosteroid use on icu mortality, a cox regression analysis adjusted for apache ii and potential confounding factors (see e- fig. in supplementary material) was performed. the survival plot (fig. ) showed that the use of corticosteroids was significantly associated with a higher icu mortality rate (hr . [ % ci . - . ], p < . ). when a multivariate fine and gray regression model was used (fig. and e- table in the supplementary material), corticosteroid use remained as a factor associated with mortality (shr = . [ % ci . - . ], p < . ). our results strongly suggest that administration of corticosteroids as co-adjuvant therapy to standard antiviral treatment in critically ill patients with severe influenza pneumonia is associated with increased icu mortality. this negative effect was evident in all subgroups considered and after careful adjustments, including a ps matching analysis. to assess the potential effects of corticosteroids on these severely ill patients, we limited our analysis to a well-defined cohort of icu patients with severe influenza pneumonia, and excluded those with other indications for corticosteroid use. the effect analysis of corticosteroids was restricted to early administration (within the first h of icu admission) in order to avoid the inclusion of patients receiving rescue therapy and to reduce the effects of time-dependent confounders. we found that mv, asthma, copd, and hematological disease were independently associated with corticosteroid use. severe acute lung injury following influenza infection is characterized by uncontrolled local and systemic inflammation [ ] [ ] [ ] . this damage is caused by an excessive host innate response with exaggerated migration of macrophages, neutrophils, and pro-inflammatory cytokines, leading to classic exudative diffuse alveolar damage, severe necrotizing bronchiolitis with predominantly neutrophilic inflammation, and intense alveolar hemorrhage [ ] . corticosteroids have several anti-inflammatory, immunomodulatory, and vascular properties, including inhibition of pro-inflammatory cytokines, reduction of leukocyte trafficking, stimulation of apoptosis in t-lymphocytes, and maintenance of endothelial integrity and vascular permeability. therefore, they may represent an option for adjunctive therapy; however, although they are frequently prescribed in critically ill patients with influenza pneumonia, their potential benefits and harms are controversial [ , , , , ] . three recent systematic reviews and meta-analyses [ ] [ ] [ ] concluded that corticosteroid therapy is significantly associated with mortality, even in the subgroup of patients with influenza hospitalized in or outside the icu. these systematic reviews recognize similar limitations such as the heterogeneity of the studies, lack of sufficient data on indication for corticosteroids, dosage, therapy timing, type of corticosteroid use, and severity of illness. a recent cochrane review [ ] reported an association between corticosteroid therapy and increased mortality. however, all studies included were observational (only seven studies included patients admitted to the icu) and of very low quality due to confounding by indication. therefore, it was impossible to determine whether additional corticosteroid therapy is indeed harmful in patients with influenza infection. several observational studies have evaluated the impact of corticosteroids on mortality in patients with influenza infection [ - , , , , - ] , and have offered conflicting perspectives. observational studies are potentially susceptible to bias and do not provide robust results. despite these weaknesses, however, observational data are representative of current clinical practice, and applying modern methods such as ps matching may help in evaluating the effects of certain interventions in clinical settings and may help to guide decision-making. to the best of our knowledge, only one study has used an analysis similar to ours in patients with influenza infection. in critically ill patients, kim et al. [ ] analyzed the effect of corticosteroid treatment on -day mortality with a similar methodology to ours, applying multivariate adjustment (controlling for variables that differed between the two groups and incorporating the ps) and ps matching ( : ). sixty-five pairs were generated, and the -day mortality rate was higher in the corticosteroid group ( % vs. %, p = . ). these data are in concordance with our results; however, the mortality rate in our patients was substantially lower. this discrepancy might be due to several factors, including differences in severity of illness, endpoint observational period (icu mortality vs. -day mortality), and early recognition vs. standard of care. interestingly, kim et al. reported that half of the patients treated with corticosteroids received hydrocortisone, a non-standard co-adjuvant treatment of pneumonia. the authors did not report the treatment indication for corticosteroid therapy; thus many patients in this cohort may have received corticosteroids for a reason other than influenza-induced acute lung injury. in contrast, our population comprised only patients treated with corticosteroids as an co-adjuvant therapy for severe viral pneumonia, excluding patients with other indications for corticosteroids (such as shock). therefore, with a homogeneous group of critically ill patients, and after carefully controlling for important confounders through a ps matching analysis and competing risks analysis, we provide robust evidence to support the association between corticosteroid administration and increased mortality. interestingly, the subgroup analysis showed that, in contrast to patients with asthma, copd patients treated with corticosteroids had a higher risk of icu mortality than those without corticosteroid therapy. we are not able to explain this finding using our database because we did not collect data on the degree of copd severity. copd patients may be at an advanced stage of disease. this condition, and other uncontrolled confounding factors, may explain the higher mortality among copd patients even after excluding patients with copd exacerbation. the main strengths of this study are the homogeneous and uniform population, the high number of critically ill patients included in our multicenter study, data regarding the kind/indication of corticosteroid treatment, and the carefully executed analysis to resolve confounding factors including the presence of competing risks. however, we recognize some limitations. first, our results were obtained in a homogeneous population of patients with influenza pneumonia and cannot be extrapolated to other populations. second, we did not review the duration of viral shedding or appearance of drug-resistant virus in either group. third, ps matching analysis may also be a limitation, because this method may not reflect the possible biases in observational studies, and some residual confounding may persist. however, as ps matching analysis can balance the population and reduces observational bias, it is the best evidence available for physicians. fourth, data on mv of patients were not recorded. lung-protective ventilation is the standard of care for patients with acute lung injury/ards because of the evidence that it decreases mortality. although we did not provide data regarding ventilation of patients, it is broadly accepted in this country that applying protective ventilation improves results and is one of the national quality indicators. finally, we did not record data about muscle weakness or metabolic alterations related to corticosteroid treatment. in a homogeneous group of critically ill patients with severe influenza pneumonia, after adequate adjustment by ps matching and competing risks, co-adjuvant corticosteroid therapy was significantly associated with increased icu mortality. our data strongly suggest that corticosteroids should not be used as co-adjuvant therapy in patients with influenza pneumonia. the online version of this article (https ://doi.org/ . /s - - - ) contains supplementary material, which is available to authorized users. higinio martín hernández hospital nuestra señora del andaluz ojeda anzález hospital virgen vega, salamanca) nicolás hidalgo andrés cataluña: rosa mª catalán (hospital general de joaquim ramón cervelló hospital dos leonel lagunes (hospital vall angels pascual diago (hospital verge de la cinta hospital san camil carmen lomas fernández, josé julián berrade (hospital m. broggi hospital virgen del puerto galicia: mª lourdes cordero complejo hospitalario de madrid: frutos del nogal sáez, m blasco navalpotro, ricardo díaz abad, josé luis flordelis lasierra josé mª molina (hospital nuestra señora de miriam díaz cámara eduardo morales fdez. de la reguera (hospital central de la defensa murcia: sofía martínez (hospital isabel cremades navalon, martín vigil velis (hospital universitario reina sofía noemí llamas fernández (hospital general universitario rafael méndez navarra: enrique maraví-poma, i jimenez urra, laura macaya redin, a tellería (hospital virgen del camino noelia artesero garcia, laura macaya (complejo hospitalario navarra-uci a) complejo hospitalario navarra uci b) tomás rodríguez (hospital de basurto iratí garrido santos (hospital de higinio martín hernández (hospital galdakao valencia: josé blanquer, nieves carbonell, josé ferreres franco abilio arrascaeta llanes hospital de la ribera, valencia) andorra: antoli ribas (hospital nuestra señora de meritxell effectiveness of neuraminidase inhibitors in reducing mortality in patients admitted to hospital with influenza a h n pdm virus infection: a meta-analysis of individual participant data impact of neuraminidase inhibitors on influenza a(h n ) pdm -related pneumonia: an ipd meta-analysis impact of early oseltamivir treatment on outcome in critically ill patients with pandemic influenza a the illegitimate crusade against corticosteroids for severe h n pneumonia adjuvant corticosteroid treatment in adults with influenza a (h n ) viral pneumonia* impact of corticosteroid treatment and antiviral therapy on clinical outcomes in hematopoietic cell transplant patients infected with influenza virus early corticosteroids in severe influenza a/h n pneumonia and acute respiratory distress syndrome methylprednisolone infusion for life-threatening h n -virus infection corticosteroid therapy in intensive care unit patients with pcrconfirmed influenza a (h n ) infection in finland h n influenza a virus-associated acute lung injury: response to combination oseltamivir and prolonged corticosteroid treatment corticosteroid treatment in critically ill patients with pandemic influenza a/h n infection analytic strategy using propensity scores corticosteroid therapy in patients with primary viral pneumonia due to pandemic (h n ) influenza use of early corticosteroid therapy on icu admission in patients affected by severe pandemic (h n )v influenza a infection corticosteroids as adjunctive therapy in the treatment of influenza (review) corticosteroid treatment in patients with severe influenza pneumonia: a propensity score matching analysis characteristics of patients with hospital-acquired influenza a (h n )pdm virus admitted to the intensive care unit impact of obesity in patients infected with influenza a(h n ) patients with influenza a (h n )pdm admitted to the icu. impact of the recommendations of the semicyuc pandemic and post-pandemic influenza a (h n ) infection in critically ill patients severe pandemic (h n )v influenza a infection: report on the first deaths in spain apache ii: a severity of disease classification system the sofa (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. on behalf of the working group on sepsis-related problems of the european society of intensive care medicine infectious diseases society of america/american thoracic society consensus guidelines on the management of communityacquired pneumonia in adults world heal organization asthma exacerbations: origin, effect, and prevention increased incidence of co-infection in critically ill patients with influenza community-acquired respiratory coinfection in critically iii patients with pandemic influenza a(h n ) virus surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock management of adults with hospital-acquired and ventilatorassociated pneumonia: clinical practice guidelines by the infectious diseases society of america and the recommendations of the infectious diseases work group (gtei) of the spanish society of intensive and critical care medicine and coronary units (semicyuc) and the infections in critically ill patients study group (geipc) of the spanish society of infectiou optimal full matching for survival outcomes: a method that merits more widespread use evaluating mortality in intensive care units: contribution of competing risks analyses a proportional hazards model for the subdistribution of a competing risk organizing pneumonia in patients with severe respiratory failure due to novel a (h n ) influenza clinical aspects and cytokine response in severe h n influenza a virus infection h n : viral pneumonia as a cause of acute respiratory distress syndrome glucocorticosteroid in treatment of severe pneumonia early use of glucocorticoids was a risk factor for critical disease and death from ph n infection effect of corticosteroid therapy on influenza-related mortality: a systematic review and meta-analysis do corticosteroids reduce the mortality of influenza a (h n ) infection? a meta-analysis corticosteroids for the treatment of human infection with influenza virus: a systematic review and meta-analysis early corticosteroid treatment for severe pneumonia caused by h n influenza virus systemic corticosteroids and early administration of antiviral agents for pneumonia with acute wheezing due to influenza a (h n ) pdm in japan effect of low-tomoderate-dose corticosteroids on mortality of hospitalized adolescents and adults with influenza a (h n ) pdm viral pneumonia the authors are grateful to michael maudsley for language editing and eudald correig for the statistical analysis.getgag (grupo español de trabajo gripe a grave) study group investigators. andalucía: pedro cobo (hospital punta de europa, algeciras); javier martins (hospital santa ana motril, granada); cecilia carbayo (hospital torrecardenas, almería); emilio robles-musso, antonio cárdenas, javier fierro author contributions gm, ar, jsv, iml, ed and at conceived and designed the study. all authors, apart from mr, lfr, jg, and as, contributed to the acquisition and local preparation of the constituent database. gm, ar, ec, st, iml, ed, jgm, ls, and jcy contributed to database creation and standardization, design of statistical analyses, and data analysis. gm, ar, lfr, jg, jsv, ed, mb, st, jg, jcy, as, jgm, ls, mvo, jmc, mvv, mir, at, and iml made important intellectual contributions and actively participated in the interpretation of the data and wrote the paper. all authors contributed to critical examination of the paper for important intellectual content and approval of the final manuscript. this study was supported in part by grants from semicyuc (spanish society of critical care) and the ricardo barri casanovas foundation. the study sponsors had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. the corresponding authors (ar/gm) had full access to all the data in the study and final responsibility for the decision to submit for publication. all named authors declare that they have no conflicting interests. the institutional review board of joan xxiii hospital approved the original study (irbref# ). key: cord- - p ug authors: mcgeer, allison title: let him who desires peace prepare for war: united states hospitals and severe acute respiratory syndrome preparedness date: - - journal: clin infect dis doi: . / sha: doc_id: cord_uid: p ug nan on march , the world health organization (who) first posted a worldwide alert concerning an outbreak of severe acute respiratory syndrome in vietnam, hong kong, and guandong province, china [ ] . in june , the centers for disease control and prevention (cdc) surveyed members of the infectious disease society of america emerging infections network (ein) about sars preparedness in their hospitals. it is a measure of the rapid globalization of both the outbreak and the outbreak response that, ! months after the outbreak was recognized, % of responding members of the ein reported that their hospital had cared for a patient meeting the case definition of sars and that % had plans in place to address sars [ ] . the major characteristics of the plans were remarkably uniform, given the very short time for their development and the rapidly changing data. it is a credit to who, cdc, and the outbreak management teams in each country that as much information flowed as rapidly as it did. the variability in the plans illustrates both the uncertainties inherent in the data available at the time of the survey and the significant challenges in sars preparedness. the most important and most difficult component of sars preparedness programs is the identification of infected patients. sars is a febrile respiratory illness that is often clinically indistinguishable from other causes of fever and pulmonary infiltrates [ ] [ ] [ ] . identification of cases depends on prompt recognition of epidemiological risk and clustered infections. of the ein members responding to the survey in this issue of clinical infectious diseases [ ] , ( %) reported that patients with respiratory symptoms in their emergency department (ed) would be screened for a travel history. routine screening in the ed is a substantial investment for most hospitals and one that some may judge to be of dubious benefit, given that only laboratory-confirmed cases of sars were diagnosed in the united states [ ] . on the other hand, the hospitals of % of respondents that have not implemented screening are dependent on their admitting physicians to consider sars in the differential diagnosis and to order appropriate precautions. this latter system has been shown to repeatedly fail to identify tuberculosis, another cause of acute respiratory disease [ , ] . sars is much more likely than tuberculosis to be transmitted and to result in disease. in the event of another outbreak of sars, systematic screening of ed patients, at least those who are to be admitted to the hospital, should be part of every plan. some aspects of the plans from june will likely now have changed. for instance, the relatively low percentage of plans ( %) that incorporated follow-up of exposed patients and visitors reflected the focus on health care worker infections early in the outbreak. documentation indicating that exposed visitors and patients who became ill were the major source of transmission should result in the incorporation of prompt patient and visitor follow-up into all plans [ , ] . similarly, at the height of the outbreak, uncertainties about transmission led many institutions to impose quarantine on returning travelers (and led some travelers to self-impose quarantine). however, transmission of sars was almost invariably linked to households and hospitals and did not occur before the onset of symptoms [ ] [ ] [ ] . thus, quarantine of travelers is not a necessary measure. recognizing the power of denial, however, some hospitals may continue to require daily checks of returning workers until the full incubation period has passed. as noted by srinivasan et al. [ ] , the survey also highlights more-general issues in infection control in hospitals. it may still be possible to manage sars safely in the significant minority of hospitals ( %) and eds ( %) that lack airborne isolation rooms. however, it is not possible to manage chickenpox, measles, or tuberculosis without appropriate airborne isolation precautions. because % of the responding hospitals admitted a traveler from an area of sars endemicity despite travel restrictions, it seems unlikely that they can avoid caring for all diseases spread by the airborne route. the issue of whether protection from sars requires airborne precautions will continue to generate controversy. a careful assessment of exposures in sars outbreaks, particularly those due to superspreading events and transmission despite compliance with isolation precautions, is needed to determine whether airborne spread occurs [ , [ ] [ ] [ ] . in addition, continued work on the science of health care worker respiratory protection is clearly needed. national standards vary widely in the developed world. in the united states, the standards of the occupational safety and health association recommend annual fit testing for n respirators [ ] . the results of this survey suggest that compliance with this recommendation is the exception rather than the rule. in canada, the canadian standards association, in the absence of data, has made no recommendation for protection against infectious agents [ ] . in some countries of the european union, fit testing is required before use but is not required annually; in others, fit testing of individuals is not currently recommended [ ] . the issue of how best to assure protection for each ward nurse in the middle of a weekend night is real. so is the fear that the logistical problems associated with always having a supply of fit-tested masks for all health care workers will push in-vestigators to downplay the risk of airborne spread. at least issues of importance in hospital preparedness for sars were not touched on in the survey reported by srinivasan et al. [ ] . disaster preparedness plans allow most facilities to contact all staff rapidly at the beginning of an emergency. outbreaks of disease, however, require plans for regular (sometimes twice daily) information updates for hospital staff, patients, visitors, and related medical service professionals. preparedness for sars also requires clear delineation of the roles and responsibilities of hospitals and government agencies in many areas of outbreak management. for instance, it is essential before outbreaks to determine who will set hospital policy (e.g., restrictions on hospital admissions, requirements for managing infected patients, and decisions as to which hospitals will admit patients with sars), who will establish work restriction policies for exposed health care workers, and who is responsible for follow-up of exposed patients, staff, and visitors. a number of ein members surveyed expressed concerns about health care worker compliance with precautions. at least analyses of risks associated with health care worker infection despite the use of precautions now identify that h of infection-control training and confidence that precautions would be protective are associated with substantial reductions in the risk of infection (toronto sars hospital investigation, unpublished data; lau et al. [ ] ). management personnel at all hospitals should now be asking themselves how confident they are that clinical staff clearly understand infectioncontrol precautions and how they can be sure that, if sars should reemerge, all health care workers have the training necessary to comply with precautions. one challenge for hospitals is to maintain the impetus to integrate the rapidly expanding new knowledge about sars into the best prevention programs. a second is to reassess the management of ex-posure to droplet-spread pathogens in hospitals. the cdc is currently recommending that all hospitals consider offering masks to all coughing patients and using droplet precautions (placing patients for whom such precautions are required in a private room, if possible; masking health care workers within m of such patients or upon room entry; and limiting the movement of such patients outside of their room), in addition to standard precautions, for all patients with symptoms of respiratory infections [ ] . although, as srinivasan et al. [ ] suggest, these isolation precautions may have benefits that extend to situations beyond sars outbreaks, it is also true that isolation may have risks, as recently demonstrated by redelmeier et al. [ ] . as life returns to a "new normal" after sars, we urgently need a better understanding of how to minimize the risk of transmission of viral respiratory diseases without creating adverse events associated with additional infection-control precautions. world health organization. cases of severe respiratory illness may spread to hospital staff. released hospital preparedness for severe acute respiratory syndrome in the united states: views from a national survey of infectious diseases consultants discriminative ability of laboratory parameters in severe acute respiratory syndrome (sars) analysis of deaths during the severe acute respiratory syndrome (sars) epidemic in singapore: challenges in determining a sars diagnosis council of state and territorial epidemiologists. sars investigative team, cdc. revised u.s. surveillance case definition for severe acute respiratory syndrome (sars) and update on sars cases-united states and worldwide environmental infection control of tuberculosis nosocomial transmission of multidrug-resistant mycobacterium tuberculosis sars transmission and hospital containment investigation of a nosocomial outbreak of severe acute respiratory syndrome (sars) in toronto, canada. hospital outbreak investigation team epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in hong kong clinical features and short-term outcomes of patients with sars in the greater toronto area possible sars coronavirus transmission during cardiopulmonary resuscitation superspreading sars events cluster of sars in medical students exposed to a single patient institute for occupational safety and health. tb respiratory protection program in health care facilities: administrator's guide. september selection, use and care of respirators. document severe acute respiratory syndrome (sars) sars transmission among hospital workers in hong kong public health guidance for community-level preparedness and response to severe acute respiratory syndrome (sars) safety of patients isolated for infection control key: cord- - va yyit authors: nan title: its asm date: - - journal: ir j med sci doi: . /s - - -z sha: doc_id: cord_uid: va yyit nan it is my great pleasure to welcome you to limerick, host city to the irish thoracic society annual scientific meeting. we look forward to a very exciting program, offering the best of original research and state of the art guest lectures against the backdrop of warmth and conviviality for which the meeting is known. thank you to all those who submitted abstracts and case studies this year-we received over for presentation, reflecting the high quality and innovative work taking place in research centres throughout the island and further afield. i would also like to thank the abstract review committee and judges for their time and expertise in what is never an easy task due to the increasingly high standard of submissions received. special features of the meeting include guest lectures on 'asthma genomics and the respiratory biome', 'use of niv in acute respiratory failure' and 'the role of nasal electrophysiology in the difficult cf diagnosis' as well as a symposium on 'chronic respiratory failure'. i am delighted to welcome distinguished guest speakers from the uk and usa who will share their expertise on these topics. welcome also to the patient and professional organisations represented. networking and sharing information on the wealth of activities taking place across the respiratory healthcare community has become an integral part of the meeting. i would like to extend a particular welcome to the exhibitors and sponsors of this year's meeting. we are very grateful for their continued support, without which the meeting would not be possible. we present the case of an -year-old gentleman who had an inflammatory neuropathy secondary to a thymoma. he underwent a vats thymectomy, the first case in ireland. the surgery involved a cm transverse incision above the supra-sternal notch, partial mobilization of the thymus, and -port placement with full thymic mobilization and excision. the advantages of a vats approach include lower blood loss ( vs. mls), lower post-operative ventilation rates ( . vs. . %), shorter lengths of hospitalisation ( . vs. . days), and improved cosmesis. the patient made an excellent recovery, discharged to home on post-operative day . we report a case of pleural giant b cell lymphoma in a year old man induced by immunosuppressive therapy for rheumatoid arthritis (ra). despite adequate control of his ra with anti-tnf treatment, this was substituted with leflunomide and prednisolone after a myocardial infarction. he subsequently developed recurrent bloody exudative pleural effusions containing a lymphomatous cell population. prolonged remission was obtained with the anti cd antibody therapy, rituximab. although the attribution of lymphoma with anti-tnf therapy and immunosuppressive treatment remains controversial [ ] [ ] , the association is more than spurious [ ] . despite a low risk of lymphoma from biological therapies, continued vigilance is warranted. pericardial atresia is a rare cardiothoracic malformation. it is mostly diagnosed incidentally, on surgery, or autopsy. it usually has benign symptoms, but herniation of the heart through a partial defect can be fatal. we describe an unusual case of years old zimbabwean lady who presented with severe headache, syncope, bradycardia and orthostatic hypotension. she was also noted to have elevated d-dimers and was hypoxic on room air. a chest x-ray reported cardiomegaly. a ct pulmonary angiogram demonstrated no embolism, but did show features consistent with absence of the pericardium. further cardiac mri confirmed this finding in addition to left ward rotation of heart into left thoracic cavity and four chamber dilatation. a review of the available literature on clinical presentation, diagnostic assessment and therapeutic options is presented. and soft tissue, including primitive neuroectodermal tumors (pnets). it responds relatively well to a combination of surgical resection, chemotherapy and radiation therapy. we describe a years old polish girl who presented with year history of right scapular, paraspinal and anterior chest wall pain. imaging confirmed . . cm mixed solid and cystic mass in right lung apex invading into supraclavicular muscles and neural foramen. the biopsy and immunotyping revealed small round ''blue cells'' soft tissue tumour equivalent of ees/pnet. she had neoadjuvant chemotherapy followed by surgical resection of the tumour with a good result and further planned to continue chemotherapy and evaluate treatment response. a year old man with known kartagener's associated bronchiectasis presented with increased cough and sputum production associated with pyrexia. radiologically, he had a right lower lobe infiltrate but sputum culture and urinary legionella antigen were negative. however, he failed to improve on a penicillin. bronchoscopy was performed and lavage specimens grew legionella pneumophila serogroup . he recovered following treatment with levofloxacin. there was no history of foreign travel but he did sleep in a camper van. there are known subgroups of legionella pneumophila and only serogroup is detected by urinary antigen. culture remains the gold standard. a year old lady was referred to the haematology service with a relapse of follicular lymphoma grade a. following salvage chemotherapy and pre transplant conditioning with alemtuzumab, she had a non myeloablative allogenic stem cell transplant. as part of the investigation for recurrent lower respiratory tract infections a bronchoscopy revealed a large exophytic tumour occluding the anterior orifice of the left upper lobe. biopsy and culture confirmed mycobacterium kansasii. the patient had an excellent clinical, microbiological and radiological response to treatment with resolution of the tumour at bronchoscopy. our case demonstrates an unusual presentation of mycobacterium kansasii. atypical mycobacterial infections although rare must be considered in this patient group. a -year-old woman presented in symptomatic hypercapnic respiratory failure. proximal muscle and neck flexor weakness was noted on examination. pulmonary function testing revealed restrictive physiology. creatinine kinase and serological testing were normal and acid-maltase deficiency was excluded. deltoid muscle biopsy was consistent with myofibrillar myopathy. myofibrillar myopathies are rare, encompassing a heterogenous group of sporadic and familial neuromuscular disorders characterised by slowly progressive muscular weakness. cardiac and respiratory muscles are involved in only a small subset of people. our patient has improved with non-invasive ventilation. further molecular genetic analysis is pending. a -year-old lady presented with dysphagia. she had a right lower lobe pneumonectomy for a t nomo non-small cell bronchial carcinoma years previously. a computed tomography scan of the thorax showed oesophageal dilatation, accounting for the presenting complaint, and an incidental thrombus in the pulmonary artery stump (pas). the formation of a pas thrombus is a common radiological finding following pneumonectomy [ ] . there is no strong evidence to suggest anticoagulation is beneficial in this group of patients. as no respiratory symptoms were present, anticoagulation could not be justified. a -month interval scan showed no thrombus propagation and the patient remained asymptomatic. department of respiratory medicine, beaumont hospital, dublin , ireland a year old gentleman presented to the respiratory clinic with a / history of progressive dyspnoea on exertion associated with cough. he reported longstanding lower limb weakness, progressing to involve his upper limbs. arterial blood gas demonstrated partially compensated hypercapnoeic respiratory failure whilst pfts showed a classic restrictive pattern. electromyography was abnormal and a muscle biopsy confirmed a diagnosis of nemaline myopathy. he was commenced on nocturnal non-invasive ventilation and his respiratory function improved significantly. nemaline rod myopathy is a rare congenital myopathy that typically presents in childhood. presentation in adulthood with respiratory difficulties is highly unusual. jo- positive polymyositis is an inflammatory myopathy and commonly presents with progressive muscle weakness and basal predominant interstitial lung disease. this is a case report of two women with different clinical presentations of jo- positive polymyositis who had bibasal interstitial lung disease on high resolution ct thorax. they both had worsening pulmonary function studies and one of them required icu admission and intubation for management of severe respiratory distress. they both responded to different regimens of iv cyclophosphamide and long term oral immunosuppressants. these cases illustrate the respiratory manifestations of jo- positive polymyositis and its treatment. year old male with a recent history of travelling abroad presented with week history of dry cough and day history of progressive sob on exertion and one episode of haemoptysis. cxr showed rul consolidation and rll effusion, ctpa was negative for pe. subsequently he developed recurrent spikes of temperature and septic screen was negative. he had three different antibiotics regime with no improvement. thereafter multiple blood cultures, vasculitic, typical and atypical microorganism, hiv, tb screen and bronchial washings came back as negative. repeat ctpa and serial cxr confirmed persistent bilateral consolidation. on day of admission he developed new systolic murmur, a-fib and type respiratory failure. tte and subsequent toe confirmed severe mr with mitral valve vegetation and prolapse treated with mitral valve replacement. dublin , ireland years old male admitted year ago with mesenteric ischaemia diagnosed& nstemi, had emergency small bowel resection with right hemicolectomy. admission has been complicated over year by wound infection, multiple pneumonias, multiple line infections, multiple admissions to itu, later diagnosed with short bowel syndrome, and c difficile colitis; and thrombosis of superficial venous system. due to difficult iv access and low albumin. recently admitted to itu deteriorated due to acute electrolyte disturbance. had transhepatic line (tipss) inserted by ir due to difficult iv access and low albumin. day became acutely sob, cxr complete opacification of right lung. chest drain inserted had drained litres of milky fluid, tubogram confirmed leak through diaphragm into pleura. a. mohamed, r. smyth, j.j. gilmartin university college hospital galway, co galway, ireland a year old man presented with a year history of progressive dyspnea. physical examination revealed a right pleural effusion. a chest radiograph and ct scan confirmed the presence of an effusion with thoracic lymphadenopathy and large mesenteric and para-aortic masses. a pleural aspiration was performed and litre of milky white fluid was removed. pleural fluid analysis noted a protein concentration of g/l and a triglyceride level of mg/dl. cytology revealed a wbc count of /ml with % of these being mononuclear. subsequent lymph node and bone marrow biopsy confirmed the diagnosis of chylothorax with small lymphocytic lymphoma. a -year-old gentleman presented with sub-acute onset of dyspnea associated with diffuse bilateral infiltrates on chest radiograph. his respiratory failure worsened despite broad spectrum antibiotics and he required intubation. he had recent type diabetes mellitus that was well controlled on oral hypoglycaemics. bronchial washings were positive for pcp on silver stain. despite extensive testing a cause for immunological deficiency could not be identified. he developed ards related fibrosis and died. pcp is the most common opportunistic infection in aids patients [ ] , it has been rarely reported in previously well, immunocompetent patients. an year old non-smoking female presented to the er with a week history of progressive dyspnoea and cough. the patient also recounted difficulty reclining at night to the point where she slept in a sitting position. examination revealed mild expiratory wheeze and hypoxemia on room air. initial clinical impression was of an infective exacerbation of late onset asthmatic bronchitis. cxr demonstrated a large hiatus hernia. pulmonary function studies showed a mixed obstructive and restrictive pattern. ct thorax revealed large diaphragmatic hernia with evidence of compression of the main bronchi. bronchoscopy showed dynamic airway collapse with complete obstruction of the left and right main stem bronchi and distal trachea on coughing. this represents an unusual cause of dynamic airway collapse and the imaging and literature are reviewed. a year old lifelong non-smoker with asthma presented to er with a days history of worsening breathlessness. on examination he was unable to complete sentences and reduced air entry through out chest.cxr showed right middle lobe consolidation. he had been treated as infective exacerbation of asthma. but unfortunately he deteriorated later on that day progressing to respiratory and circulatory failure and subsequently to disseminated intravascular coagulation. although having best of icu care he passed away the following day. all of his investigations including blood culture, atypical pneumonia screen, h n serology were came back negative. his post mortem examination hasn't revealed any cause other than right sided pneumonia contributing to his death. this represents a shocking but mysterious case of pneumonia as the cause of death. a year old gentleman was referred to the rapid access lung cancer service with a week history of progressive sob and new pleural effusion. of note, he had recently presented to his general practitioner with two soft tissue lesions on the right flank. on examination, axillary lymphadenopathy was palpable with a noted interval increase in the size of the cutaneous lesions. trucut biopsy of the skin lesion and pleural aspiration revealed a histological diagnosis of mantle cell lymphoma. subsequent radiology showed extensive systemic disease and chemotherapy was offered. our case illustrates the extranodal involvement that can occur in mantle cell lymphoma, however, patients rarely present with initial cutaneous involvement as in our case. a year old gentleman was referred to our lung cancer clinic with abnormal chest x-ray and palpable supraclavicular node. a staging ct thorax suggested lung primary with mediastinal and supraclavicular nodes. a biopsy of the palpable node showed hodgkin's disease (hd). a ct-guided biopsy of the lung lesion favoured lung primary and mediastinal nodal sampling revealed hd. he proceeded to lobectomy for excision of the primary lung lesion and the pathology returned a non hodgkins lymphoma. this case illustrates a presentation of dual pathologies: both hodgkins and non hodgkins lymphoma in the same patient mimicking locally advanced lung cancer. a -year-old man presented with a -month history of back pain and cough. he had a normal chest radiograph and was reassured. subsequent haemoptysis in this patient prompted ct imaging which showed a large left lower lobe mass that was concealed by the cardiac shadow. further mri imaging revealed extensive spinal metastases and thus stage iv disease. we wish to present a case series of five patients with benignappearing single plane chest radiography. further imaging revealed advanced stage lung cancer in these patients. these cases illustrate limitations of single plane radiography and identify anatomical areas where tumours may be missed such as behind the heart. they emphasise the importance of obtaining lateral films and ct imaging in patients with a reassuring single plane chest radiograph where clinical suspicion persists. a year old latvian security guard with a background of relapsing polychondritis and recurrent escherichia coli lrti's, represented to hospital with recurrent haemoptysis and pyrexia of unknown origin. hrct thorax revealed innumerable randomly distributed pulmonary micronodularity. bronchoscopy and bal were unremarkable. fresh sputum cytology confirmed the diagnosis of pulmonary nematodes consistent with strongyloides stercoralis. the patient was treated with high dose ivermectin, resulting in complete resolution of the pulmonary micronodularity. this case report discusses the diagnostic criteria for relapsing polychondritis, the international issues of pulmonary nematodes and the importance of understanding the three radiological subtypes of pulmonary micronodularity (random, centrilobular and peri-lymphatic). a year old gentleman with severe autism spectrum disorder (asd) presented acutely to the emergency department with behavioural disturbance. his prior history was notable for a right lower lobe infiltrate on chest radiography identified year prior to admission. his behavioural disturbance manifested by self harm, and had previously precluded in-hospital investigation. ct thorax confirmed right lower lobe consolidation and flexible bronchoscopy identified a . cm tree branch within a segmental bronchus of the right lower lobe. this case highlights the importance of flexible bronchoscopy and the difficulties of access to appropriate care for those patients with asd. a year old male was admitted with pleuritic chest pain after knee replacement. routine bloods, including liver function tests were normal. a chest radiograph showed right upper quadrant calcification. ct pulmonary angiography was normal but a ct abdomen showed an area of calcification in segment of the liver with low attenuation centrally consistent with a hydatid cyst. hydatid disease is caused by ingestion of the dog tapeworm echinococcus granulosus. it is uncommon within ireland. treatment includes monitoring of chronic cysts, medical therapy with antibiotics in combination with either surgery of percutaneous drainage. a year old female smoker was admitted with right sided pleuritic chest pain. ct thorax showed extensive right lung consolidation and bronchiectasis. bronchoscopy showed unexpected thickening and nodularity of the upper trachea. biopsies confirmed tracheal amyloidosis and immunohistochemical staining of the deposits was negative for serum amyloid a protein, transthyretin, and kappa and lambda immunoglobulin light chains, indicating amyloid of non-aa type. there was no evidence of amyloid at any other location. patients with tracheobronchial amyloidosis may be asymptomatic or present with dyspnoea, cough, haemoptysis or recurrent pneumonia. department of respiratory medicine, beaumont hospital, dublin , ireland a -year old male presented to beaumont hospital with dyspnoea, cough and haemoptysis due to alveolar haemorrhage, requiring icu admission for high frequency oscillatory ventilation and iv cyclophosphamide. originally diagnosed with a pauci-immune vasculitis, a lung biopsy confirmed a diagnosis of pulmonary capillaritis requiring escalating treatment with pulsed iv steroids and immunosuppression. while initially clinically stable, he has had multiple icu admissions, and during an exacerbation presents with symptoms of dyspnoea, a dropping haemoglobin and bilateral infiltrates on chest radiograph. he is now managed by an adult respiratory service with specialist advice, with iv steroids, iv ig and rituximab. we discuss a minimally invasive approach with video assisted thoracoscopic surgery (vats) in performing thymectomy procedures for cases of myasthenia gravis. a year old female was referred with a background history of myasthenia gravis. despite optimal medical therapy m.n. still experiences persistent symptoms and occasional hospitilization for iv immunoglobulins. a ct thorax showed an enlarged thymus. using a three port vats technique the thymectomy was completed and she was discharged days post operation. this case illustrates the possible benefits of minimally invasive approach to thymectomy and avoidance of sternotomy for cases of myasthenia gravis. we report the case of a y.o man who presented with classical pancoast syndrome symptoms caused by a large apical ewing's sarcoma of the chest wall. neoadjuvant chemotherapy localized the tumour to the first rib. complete enbloc surgical resection of the mm residual mass (entire first rib, partial second rib and sublobar lung) was accomplished by a combined anterior hemiclamshell and posterior approach. ypt . the c nerve root was spared and this led to a complete resolution of symptoms. we report the case of an y.o. who underwent curative resection by right sided lobectomy for a pt an adenocarcinoma. she developed this uncommon syndrome of intracardiac shunting of blood immediately post extubation. this syndrome causes profound dyspnoea as a result of arterial hypoxia which is accentuated by the upright position and relieved by recumbency. echocardiography based on clinical suspicion was diagnostic. this was successfully treated by the placement of an occluder device the patent foramen ovale. the case of a year old male smoker with a week history of haemoptysis, night sweats and dyspnoea on exertion is presented. chest radiography confirmed a right upper lobe thick-walled cavity with adjacent nodularity. both transbronchial and percutaneous biopsy sampling was non-diagnostic and microbiological testing was negative. following an episode of large volume haemoptysis he underwent emergency lobectomy. final histopathologic examination confirmed an anaplastic lymphoma kinase (alk)-negative pulmonary anaplastic lymphoma, an extremely rare cause of pulmonary cavitation. we report a g d homozygote: fev % predicted, oxygendependent with recurrent exacerbations ( in months) awaiting transplant assessment, started on ivacaftor through a named patient program. within weeks transplant assessment was deferred, fev had increased to % predicted, continuous oxygen was discontinued, sweat chloride had fallen from to mmol/l and exacerbation rate decreased to in months prospectively. a year old lady presented with headache and cough. neuroimaging raised the possibilitiy of cns mycobacterial infection. pansensitive mycobacterium tuberculosis was cultured from bronchoalveolar lavage. the patient experienced a type hypersensitivity reaction following the first dose of intravenous rifampicin. the patient was commenced therefore on iv amikacin, oral moxifloxacin and ethambutol. intravenous desensitisation to rifampicin was carried out using a day protocol. this was successful allowing the patient to return to oral therapy for the duration of her treatment. ipf and panca-positivity predating vasculitis is known but not widely appreciated. we describe two cases of ipf, initially anca-negative who became anca-positive with associated vasculitis. a -year-old, house-wife diagnosed with ipf in was anca-negative. in she was more breathless with borderlinepositive panca (repeat negative). in , she developed acute mononeuritis multiplex, with a highly positive panca, responsive to immunosuppression. ipf remained stable throughout. a -year-old male, with established ipf (anca-negative), presented acutely with alveolar haemorrhage, renal failure and now panca-positive, responsive to plasma exchange, haemodialysis and immunosuppression. these cases support the rationale for serial anca measurements in ipf. bronchoscopy in a year old female months after radical chemoradiotherapy and oesophageal stent insertion demonstrated stent erosion into the proximal trachea with recurrent oesophageal scc obstructing the carina. a mm covered ultraflex tracheal stent was deployed, with an oesophageal stent telescoped proximally into the displaced oesophageal stent. imaging out ruled a leak facilitating oral intake. six weeks later, staged cryotherapy and stenting of the carinal obstruction was successfully performed. cork university hospital, wilton, cork, ireland, mercy university hospital, cork a -year-old male was reviewed with increasing shortness of breath, hoarseness and stridor. his past medical history was remarkable for supraglottic amyloidosis. these lesions were thermally ablated in . he was followed up routinely. a ct thorax and subsequent bronchoscopy and biopsy was undertaken. at bronchoscopy he was found to have two large nodular protrusions that were biopsied. pulmonary amyloidosis is rare and manifestations include tracheobronchial infiltration, parenchymal infiltration (amyloidomas) persistent pleural effusions and pulmonary hypertension. symptoms of tracheobronchial amyloidosis can include hoarseness, stridor, dyspnoea and overt airway obstruction [ ] . treatment involves invasive bronchoscopic therapies such argon photocoagulation (apc) and occasionally surgery [ ] . we present two mushroom workers with bird fancier's lung. workers presented with progressive dyspnoea, cough and sweats, with features of hypersensitivity pneumonitis on hrct, pfts and bal/tbbx. serological studies to aspergillus fumigatus, saccharopolyspora rectivirgula, thermophilic actinomyces were negative but positive for avian proteins. workplace process analysis revealed chicken litter as fundamental in mushroom compost production. both workers received corticosteroids with symptomatic and radiological improvement. workplace relocation resulted in complete resolution of symptoms in one worker. the second worker remains exposed, wearing appropriate ppe with ongoing medical surveillance. detailed workplace analysis may be required in proper diagnosis of work-related respiratory diseases. wheeze is a continuous musical sound that lasts longer than ms [ ] . upper airway obstruction is commonly misdiagnosed as asthma. we describe four cases presenting with upper airway obstruction of different aetiologies. a -year-old female was referred with 'poorly controlled asthma'. inspiratory stridor was noted on physical exam and spirometric flow volume loops showed variable extrathoracic airway obstruction. laryngobronchoscopy confirmed paradoxical vocal cord movement. ir j med sci ( ) (suppl ):s -s a -year-old female was referred with 'poorly controlled asthma'. physical exam revealed inspiratory stridor and spirometric flow volume loops showed fixed upper airway obstruction. larynogbronchoscopy revealed subglottic stenosis. a -year-old male with a -pack-year history of smoking was referred with worsening wheeze. physical exam and investigations revealed subtotal tracheal compression secondary to a retrosternal goitre which was successfully resected with resolution of symptoms. a -year-old male was referred with wheeze, fatigue and intermittent apnoea while sleeping on his left side. physical exam revealed inspiratory stridor and spirometric flow volume loops showed fixed upper airway obstruction. ct thorax and bronchoscopy revealed a congenital double aortic arch, splitting to come around the trachea (see fig. ) causing tracheal compression. the four cases show the importance of considering misdiagnosed upper airway obstruction in the assessment of wheeze. a year male smoker with gastro oesophageal adenocarcinoma developed dyspnoea on treatment with epirubicin, oxaliplatin, and capecitabine, raynaud's phenomenon was noted and hrct showed bilateral interstitial infiltrates. scl antibodies were positive and thoracoscopic lung biopsy confirmed scleroderma-associated interstitial lung disease. patients receiving pneumotoxic agents should be assessed thoroughly for other causes before a diagnosis of drug-induced interstitial lung disease is considered. mid-western regional hospital limerick, limerick, ireland a year old woman presented with recurrent lower respiratory tract infections and weight loss of over a stone over the last months. she was a smoker of pack year. ct showed diffusely abnormalities in both lungs. there was ill-defined pulmonary nodules with small cavitating lung lesions. specimens taken from vats showed numerous airway-centred and airway-destructive nodules composed of eosinophils and large histiocytes with vesicular chromatin that are cd a positive. this is consistent with langerhans cell histiocytosis. she was advised on smoking cessation which she adhered to. follow-up cxr showed complete resolution of the multi-focal interstitial infiltrates several studies reported relationship between anca-associated vasculitides and malignancies (pre-existing or developed during patients follow up), bringing to discussion the putative role of tumor antigen in driving the auto-immune response. we describe the case of years old male with e-cadherin genetic mutation, mandibular cementoma, horse shoe kidney, alopecia and nails dystrophy who presented with haemoptysis and bilateral pulmonary infiltrates years after his first asthma diagnosis. bronchial washings demonstrated pigment laden cells consistent with alveolar haemorrhages. serological tests showed positive c-anca. there was no renal involvement. he was successfully treated with high dose of corticosteroids. we present an interesting case of endobronchial tb in patient who lacked normal host immunity. a gentleman ( years) presented with haemoptysis on a background of ulcerative colitis managed with mesalanine and azathioprine. bronchoscopy demonstrated a mass partially occluding the left main bronchus. pan-sensitive mtb was isolated and he was treated for months. four months following presentation an endobronchial resection was performed. however, repeat bronchoscopy following nine months of treatment demonstrated a persistent lesion in the left main bronchus and a new lesion in the trachea. the recurring lesion was characterised by the persistent afb, that were stainable, but did not grow. conclusion: the immune derangement, characteristic of inflammatory bowel disease patients, contributed to his aberrant persisting host response to dead organism. [ ] . in these two cases dipnech was diagnosed along side carcinoid tumour via lobectomy and mediastinal lymph node sampling. one patient was symptomatic for at least months prior to diagnosis complaining of episodic wheeze, flushing and diarrhoea. this patient was treated with a somatostatin analogue post operatively. dipnech has rarely been described and its prognosis and management have varied from several different case reports [ ] . these two cases highlight, that although a rare entity, it needs to be considered in cases of symptomatic cough and wheeze with radiological findings suggestive of discrete pulmonary nodules. in march , the first case of a subsequent outbreak of pansensitive mycobacterium tuberculosis, beijing strain, was diagnosed in a man from an irish prison. last year, the first patients in this sequence were presented. herein we discuss eight further cases connected to this outbreak. all cases, but one, are males of european origin aged between and years. clinical presentations ranged from classical symptoms of night sweats and weight loss to acute abdomen. four of the pulmonary tb cases had, on initial presentation, acid fast bacilli positive sputum on microscopy and culture. the radiological disease was primarily consolidation or cavitating lesion in the upper to mid zones. more than a year later, this case series continues to highlight the ongoing and mounting difficulties of managing this irish prison outbreak. a year-old irish male presented with a month history of dyspnoea, unsteady gait, numbness over both flanks and weight loss. he attended months earlier at another centre with swollen painful right testes. cxr demonstrated bilateral hilar lymphadenopathy, and rightsided pleural effusion. ct tap revealed marked mediastinal lymphadenopathy with right sided pleural effusion, mild splenomegaly, ill-defined right testes, and bilateral inguinal lymphadenopathy. serum ldh and ace were elevated. thoracentesis revealed serosanguinous exudative fluid. transbronchial and inguinal lymph node biopsy revealed evidence of non-caseating granulomas. mri spine revealed abnormal cystic areas throughout thoracic and lumbar spine. a diagnosis of sarcoidosis with multisystem involvement was made and high dose steroids were commenced with good clinical response. pleural and spinal cord sarcoidosis is a rare and interesting presentation. histology showed chronic inflammatory change and ulceration of the bronchi with no evidence of vasculitis or granuloma. no malignancy was evident. pulmonary changes similar to this have been described in patients with uc. alpha- antitrypsin deficiency (aatd) is an autosomal co-dominant genetic disorder associated with a substantially increased risk for the development of chronic obstructive pulmonary disease (copd) and liver disease. ats/ers guidelines recommend testing of all individuals with copd and poorly controlled asthma. the objective of the study was to investigate the diagnostic experiences of zz aatd individuals in ireland. a total of zz aatd individuals completed a questionnaire at an alpha- clinic in relation to their diagnostic experiences and clinical presentation. the mean age of symptom onset was . ± . years (range . - ); mean age of diagnosis was . ± . years (range . - ). the interval between onset of symptoms and aatd diagnosis was years. the smoking history analysis revealed % were past smokers, % never smokers and % were currently smoking. for the past smokers cohort % stopped smoking within the first months of a diagnosis of aatd; % stopped smoking after the first months of a diagnosis of aatd and % had stopped smoking prior to a diagnosis of aatd. our results further underline the need for increased awareness and early detection of symptomatic aatd individuals in the irish population, especially among the copd population. aat deficiency (aatd) results from mutations in the serpina gene, classically presenting with early-onset emphysema and/or liver disease. the most common mutation causing aatd is the z mutation, with the s mutation weakly associated with lung disease. aat deficiency is under-diagnosed and prolonged delays in diagnosis are common. ats/ers guidelines advocate screening all copd, poorlycontrolled asthma, and cryptogenic liver disease patients, as well as first degree relatives of known aatd patients. over , individuals have been screened to date following ats/ ers guidelines in the national targeted detection programme. sequencing of the serpina gene was performed to identify rare mutations. we have identified zz, sz, ss, mz, ms, and over individuals with clinically significant rare phenotypes (e.g. iz, fz, is, null, mmalton). this yields gene frequencies of . and . for s and z, respectively, in this targeted population. a number of rare and novel serpina mutations have also been identified. our results underline the need for increased awareness and early detection of aatd. all copd patients should be tested for aatd as per ats/ers guidelines. our data demonstrates that aatd in ireland is not a rare disease but a disease that is rarely diagnosed. rationale: alpha- antitrypsin (aat) deficiency (aatd) is genetic disease that results in low levels of aat and predisposes individuals to developing chronic obstructive pulmonary disease (copd). the z-allele is responsible for [ % cases of aatd. key studies have demonstrated that excessive infiltration of neutrophils into the lung and neutrophil derived proteins play a pathological role in aatd lung disease. in particular a key cytokine associated with copd disease progression is tnf-alpha which is also the cause of many problems associated with autoimmune diseases. the aim of this study was to determine if there is a novel autoimmune element driving inflammation in aatd and examine aat impact on this. methods: plasma and neutrophils were isolated from mm controls, asymptomatic zz aatd and aatd patients receiving augmentation therapy. tnf-alpha was quantified by a sandwich elisa. evaluation of neutrophil degranulation was carried out by western blot analysis of neutrophil supernatants for markers of tertiary (mmp- ) and secondary granules (lactoferrin) and via flow cytometry. autoantibodies against neutrophil granule proteins were quantified in plasma by elisa. results: our results demonstrate that there are high levels of tnfalpha in aatd plasma compared to controls (p = . ). in vitro, tnf-alpha caused an increase in the rate of degranulation of tertiary and secondary granules from zz aatd neutrophils compared to mm cells (p \ . ). analysis of autoantibodies against major neutrophil granule proteins revealed a high titer of anti-lactoferrin igg autoantibodies present in patients with zz aatd. treatment of aatd patients with aat augmentation therapy resulted in a decrease in the plasma levels of neutrophil granule proteins while also reducing the titer of anti-lactoferrin igg autoantibodies (p \ . ). conclusion: this study has uncovered that tnf-alpha inflammatory signaling pathway can result in the development of an autoimmune element in aatd. furthermore it highlights aat therapy can impact on neutrophil degranulation and thereby reduce development of novel anti-lactoferrin autoantibodies. chronic hypoxia (ch) exposure induces diaphragmatic remodelling similar to chronic obstructive pulmonary disease (copd). elucidating the underlying mechanisms may inform therapeutic strategies to combat muscle dysfunction in copd. this study investigates the effects of ch on redox homeostasis in mouse diaphragm muscle. c bl j mice were exposed to one and weeks of ch ( % f i o ) or normoxia. following treatment, excised muscles were homogenised and incubated with carbonyl-or thiol-reactive fluorophores before gel electrophoresis and fluorescence scanning. optical density (od) of fluorescence was normalised to total protein, determined by colloidal coomassie staining. a nine-fold increase in free thiol groups was observed after week of ch ( . ± . vs. . ± . ; mean od ± sem, ch v normoxia, n = per group; p = . , student's unpaired t test), while there was a significant decrease after weeks. a significant increase in carbonylation was observed after weeks of ch ( . ± . vs. . ± . ; mean od ± sem, ch vs. normoxia, n = per group; p \ . ). we have demonstrated that despite a reduction in oxygen tension and a large, initial increase in free thiol groups, weeks of ch significantly increases oxidative stress in mouse diaphragm muscle. changes in redox homeostasis are likely to affect redox-malleable proteins that are central to muscle performance. a- antitrypsin (aat) is a -kda glycosylated-protein synthesised in the liver which functions as a serine protease inhibitor. the pizz variant is associated with early onset emphysema. we hypothesize that a difference in the number of isoforms and the n-glycosylation pattern of pimm and pizz aat protein exists. the aim of this study was to compare the isoform composition of aat from pimm controls with that of pizz individuals. aat from pimm and pizz individuals was extracted and purified from plasma using alpha- -antitrypsin select-affinity chromatography medium. isoelectric-focussing of purified aat was performed followed by d-page. gels were stained with coomassie brilliant blue and were immuno-blotted for aat. eight and six isoforms of pimm and pizz-aat were identified by d-page, respectively. densitometric analysis demonstrated higher protein expression of pimm-aat compared to pizz-aat. the pi range of pimm-aat was . - . and the range for pizz-aat was . - . . the pizz-aat demonstrated a . - . pi cathodal shift of all bands, supporting the hypothesis that the pizz-aat protein is differentially n-glycosylated. this study confirms the presence of multiple isoforms of pimm-aat and demonstrates at least different isoforms of pizz-aat. this requires further investigation to establish differences in n-glycan groups and possible functional consequences. understand the therapeutic potential of alpha- antitrypsin alpha- antitrypsin (aat) is a glycosylated protease inhibitor found in human plasma. aat deficiency predisposes individuals to early onset emphysema and treatment currently consists of weekly intravenous infusions of purified plasma aat. although aat has previously been shown to exert anti-inflammatory properties by binding interleukin- and apolipoprotein b- , the latter being implicating in atherogenesis, hypothesized that aat may have multiple binding partners and that these complexes are involved in additional regulatory and anti-inflammatory pathways. the aim of this study is to identify all proteins that interact with aat as it circulates throughout the body in order to fully understand its therapeutic potential. to examine aat's interaction with potential linker proteins, permeation chromatography of plasma through su-perose / gl was performed. protein profiles were visualized by coommassie blue staining of sds-page gels and western blotting. immuno-bands were quantified by densitometry. aat eluted with molecular masses of approximately and kda indicating multiple binding partners, with the remainder eluting at the predicted molecular mass of kda. protein identification by mass spectrometry (lc ms/ms) is required to identity novel binding partners. identification of all proteins that bind to aat will progress our understanding of the molecular mechanisms by which aat regulates inflammation. ultimately identification of new functions of aat may be utilised to develop novel treatment options for chronic inflammatory diseases including cystic fibrosis, copd and severe asthma. no potential conflict of interest is reported. transthoracic echocardiography, neurocognitive/psychological assessments were also performed. on follow-up, all patients had normal renal function. two of seven had reduced respiratory and cardiac functions. had slightly reduced neurocognitive functions and had decreased feeling of well-being, and from depression. in this small follow up study of a cohort of severe h n patients, there was good recovery. given the initial severity of their respiratory decline i.e., requiring ventilation, this group did not seem to suffer severe chronic respiratory functional limitation. cryptogenic organising pneumonina (cop) is a disease of unknown cause, which can occur in the context of connective tissue disease. a more aggressive variant termed rapidly-progressive cop follows a fulminant course, leading to respiratory failure, and has high mortality [ ] . a -year-old gentleman with a history of dermatomyositis presented with dry cough and dyspnoea on exertion of -months duration. computed tomography (ct) of the chest revealed subpleural patchy ground glass opacities involving both lungs. bronchoalveolar lavage (bal) showed benign bronchial epithelial cells with % macrophages, % neutrophils, % lymphocytes and % eosinophils. staphylococcus and hemophilus were isolated on culture. broad-spectrum antibiotics and steroids were commenced. there was evident improvement clinically, and on pulmonary function tests, however, no significant change on ct chest neccesitated vats biopsy.histopathologic findings were consistent with cop. h after vats biopsy patient developed acute onset dyspnoea with respiratory failure requiring mechanical ventilation and intensivecare-unit admission. ct chest (see fig. ) showed diffuse worsening of ground glass appearance and left lung consolidation. despite best efforts to rescuscitate the patient he passed away h later. this represent a fatal case of rapidly progressive cop resistant to steroids. rapid deterioration resulted in poor prognosis with no lea way of trial of immunosupressive therapy. over a week period thirty seven patients were admitted by nchds to cork university hospital with clinical diagnosis of community acquired pneumonia. an audit was performed on the choice of antibiotic by nchd in comparison to the local antimicrobial guidelines based on a patients curb- score. this audit also compared the admitting nchd's interpretation of a chest x-ray and this was compared to the formal report given by the radiology department. the audit highlighted that antimicrobial prescribing in adherence with local guidelines weakened with an increasing curb- score. in total . % of patients were prescribed antibiotics according to the local guidelines. this fell to . % for a curb- score of / . approximately % of nchds incorrectly diagnosed an infiltrate on chest x-ray which was later refuted by the formal radiology report. antibiotic resistance is a growing global concern and adherence to selected local and regional guidelines for prescription of antibiotics is paramount in reducing the spread of resistance pathogenic bacteria [ ] . reference: rapid administration of guidelines-compliant empiric antibiotic therapy in emergency department (ed) can reduce mortality in patients admitted with community-acquired pneumonia (cap) [ ] . a -week prospective audit was conducted in january to assess adherence to local guidelines and use of curb- score in treatment of such patients. all patients admitted via ed during acute medical take with symptoms and signs of chest infection and new localising radiological shadowing were included. there were relevant admissions ( males, age - years, mean . ). curb- was calculated in ( . %) patients. seven patients ( . %) received antibiotics according to guidelines. in patients without curb- estimation adherence to guidelines was . % vs . % in those with curb- . the results of the audit were presented at hospital grand rounds and new copies of guidelines were circulated to each ward and ed. a laminated copy was placed in a prominent position in ed. a week prospective re-audit was conducted in april ( admissions, males, age - , mean . years) and demonstrated an increase in appropriate antimicrobial prescribing to . % vs . % in the original audit. appropriate antibiotics prescribing was again higher when curb- was calculated. medicine is an evolving field with increased pressure to produce an optimally functioning health care system within budget constraints. there is a current vogue of specialisation, with medical practitioners moving further from general medicine, to condition specific delivery of services. our key concern was whether the case mix breakdown warranted further stratification of the general respiratory outpatient clinic based on conditions. data of patients attending a respiratory clinic was collected for year. the primary diagnosis was coded using international classification of diseases ( th revision) coding scheme and analysed using a statistical analysis package (spss). asthma (n = , . %), copd (n = , . %) and sarcoidosis (n = , . %) accounted for . % of patients and the remainder of the top fifteen conditions were all respiratory in nature. . % (n = ) of attendances were for non-respiratory diseases as the clinic also provides follow-up for general medical patients post hospital admission. the gender mix was male (n = ) . %; female (n = ) . %. the mean age was . years (sd = . ). the difference in mean age for asthma ( . sd . ) and copd ( . sd . ) was significant at . (p = . ). the above analysis reveals a strong case for the creation of three specialist outpatient clinics, for asthma, copd and sarcoidosis. the single breath method to measure diffusion capacity requires a subject to inspire a gas mixture followed by a s (s) breath hold. we sought to determine if breath hold time reduction had a significant effect on measured lung diffusion for carbon monoxide (dlco) values. forced spirometry and co diffusion by the single breath method (dlcosb) were performed in duplicate with breath hold for s, s and s in controls (fev ± . % predicted), severe copd patients (fev . ± . % predicted), and patients with interstitial lung disease (ild) (fev . ± . % predicted). there was no significant difference between dlcosb and dlco(va) measured at , and s in the control (p = . ) and interstitial lung disease (ild) groups (p = . ). however, there was a significant difference between dlcosb (p = . ) and dlco(va) (p = . ) measured at , and s in the chronic obstructive pulmonary disease (copd) group. in the presence of severe airway obstruction the dlco decreases with breath hold time reduction. however, in healthy controls and patients with ild, there was no significant change in the dlco when breath hold time is reduced from to s. this could allow for a reduction in breath hold time when measuring the dlco in patients with advanced ild who are unable to breath hold for s. current guidelines recommend mechanical insufflation-exsufflation (mi-e) for airway clearance [ ] . the aim of this study was to determine the current use of mi-e in neurological conditions by physiotherapists in the uk. a questionnaire was sent to relevant members of the exercise has been shown to improve quality of life in respiratory patients. through exercise, pulmonary rehabilitation operated on the concept of encouraging people with chronic obstructive pulmonary disease (copd) to improve their exercise capacity and subsequently reducing the incidence of copd exacerbation and admissions to hospital. methods: this cross sectional study was conducted between january and february at the mid-western regional hospital, limerick, ireland. all patients attending our respiratory clinic over a period of weeks were invited to complete a questionnaire on arrival at the clinic. findings: the total number of participants was seventy-eight. asthma was the most frequently listed respiratory illness (n = ).fifty-two patients said they exercised ( . % of the study population). higher levels of exercise participation were seen in the younger age groups (p = . introduction: respiratory diseases, largely represented by copd, are the third most common cause of acute hospital admission.our aim was to audit the prescribing habits of inhaled, nebulised medication and oxygen by doctors in a general hospital. methods: all adult patients admitted medically with chronic respiratory diseases that were on inhaled or nebulised medication were included prospectively (jan to june ) in this study. a proforma was used to collect data from the patients. results: there were patients ( % male). the mean age was . patients ( %) had a diagnosis of copd and the others had asthma and pulmonary fibrosis. seven patients ( %) were currently smoking. four patients ( %) were on long term oxygen treatment. in only % of patients the correct dose of inhaler was prescribed. patients ( %) had the correct inhaler device charted. none of the patients had their inhaler technique checked on admission. in only % the dose of nebulised medication was charted. patients were given oxygen of which only was prescribed ( %). conclusion: this audit proves that our prescribing habits of inhaled, nebulised drugs and oxygen are not good. we intend to present this data to our colleagues and reaudit again. adherence to inhaled medications is difficult to assess. a prospective, observational study on patient inhaler usage while in hospital was carried out. the hypothesis was as inhalers are left at the bedside and not administered directly, doses are being missed. a device was designed that makes an acoustic record each time an inhaler was used. the drug prescription sheets on medical wards were screened to identify patients who were prescribed fluticasone/salmeterol via diskus. patients were then approached and asked to participate. the devices were analysed by two independent investigators. doses were classified as early if \ h and late if [ h were between doses. errors were classified as not priming the device correctly, blowing into the device, insufficient inhalation, inadequate breath hold. among patients, taking doses, ( %) doses were taken too early, while separately ( %) doses were missed. in addition, patients blew into the inhaler ( %) times and inadequately inhaled or failed to hold breath ( %). overall, ( %) had an error either in timing or technique. none of these irregularities were documented in the drug prescription sheet. in conclusion, administration of inhalers should be directly supervised by staff, documented and an action plan for patients that are unable to use inhalers be drawn up. results: patients participated in the audit. % knew the names of their respiratory medication, and % knew the general indication for their respiratory medication. % understood the specific indication for their preventer inhaler, % for their reliever inhaler, and % for the combination inhaler. % of patients knew the correct frequency of use of their inhaler, with % of patients demonstrating adequate inhaler technique. % of participants had previously being reviewed and educated by a respiratory nurse. conclusion: a significant percentage of respiratory patients lack adequate knowledge of their respiratory medication; this is despite a majority having previously been educated on this medication. recommendations: ongoing education and regular assessment of respiratory patients needs to occur. ir j med sci ( ) hcws are a cohort at risk of mycobacterium tb infection. qft-g, a lab based assay, is free of the bias and errors of tst placement or reading with the need for - h follow-up for interpretation eliminated. . % of our cohort had a false positive tst, which calls the sensitivity of this test into question. qft-g has been proven to approach % sensitivity [ ] and % specificity [ ] and is therefore a suitable replacement for tst in hcw screening. while there has been an increased recognition of non-tuberculous mycobacteria (ntm) as a clinical problem, much of this experience has come from specialised population such as cystic fibrosis patients. we evaluated our experience in a general respiratory service. positive non tuberculous mycobacterial culture results in st. vincent's university hospital from january to july were reviewed. patients with a known diagnosis of cystic fibrosis were excluded. fifty-six patients were identified with positive cultures for nontuberculous mycobacteria. thirty-eight isolates were from the respiratory tract, of which fourteen samples were sputum samples, thirteen samples were from both bronchial lavage and sputum and nine samples were bronchial lavage. the medical records of thirteen patients (seven female, six male) with probable disease were reviewed. the most frequent isolated ntm in our institution are mycobacterium avium (n = ). two patients had mycobacterium szulgai. mean age was . ± . years; all except one patient had underlying respiratory disease. five of the thirteen patients received some treatment for ntm but only three completed a full course due to intolerability to the medications and also side-effects. our studies confirm that ntm primarily affects patients with chronic lung disease and that the treatment for this disorder is poorly tolerated. lymphopenia in active mycobacterium tuberculosis (mtb) infection is a common and well-documented finding. rather than being an epiphenomenon, this effect likely contributes to pathogen persistence in the host and the lack of a meaningful response during chronic mtb infection. our study was designed to determine the baseline and post-treatment values of total lymphocyte count and its subsets in hiv-negative patients diagnosed with active pulmonary mtb. we prospectively recruited hiv-negative patients diagnosed with pulmonary mtb infection over a -month period. pre and post treatment analysis of total lymphocyte count and its subsets were performed at baseline and after months of tb chemotherapy. a control group comprising of patients with community acquired pneumonia also had pre-treatment lymphocyte counts performed. ten patients with active mtb infection and seven comparable controls were recruited over a -month period. baseline total lymphocyte count was lower in the study group ( . ± . ) compared to control ( . ± . ). treatment was associated with significant improvements in total lymphocyte, b-cells, cd , cd (p \ . ) and nk cell (p \ . ) counts. recovery of total lymphocyte count in the control group was not significant (p = . ). our study demonstrates treatment of active mtb in hiv-negative patients is associated with significant improvements in total lymphocyte count and its major subsets. pleural tuberculosis is a diagnostic challenge. ada is a biomarker that has been proposed to diagnose tuberculous pleurisy but not routinely used [ ] . we aim to evaluate the sensitivity and specificity of ada in the diagnosis of tuberculous effusions and to improve current practice. we prospectively examined ada levels from patients with pleural effusions and followed the clinical course to establish the final diagnosis via culture, histology and clinical diagnosis. data were analysed using mann-whitney u test. there were cases of tuberculous effusions with mean ada levels of ± . iu/l (ci . - iu/l) while the mean ada of non-tuberculous effusions were . ± iu/l (ci . - . iu/l, p value = . *). true positive rate was / and true negative rate was / . false positive rate was / while false negative rate / . if iu/l is taken as cut value, the specificity is % and the sensitivity is %. we describe four cases of tb occurring during pregnancy and post partum. in all cases the women were non-nationals with a mean age of years. in two cases the tb presented as vertebral osteomyelitis, in one case tb lymphadenitis and in one case as miliary pulmonary tb. the diagnosis and treatment of tb in pregnancy presents many challenges. the cases discussed highlight some of the complexities which we encountered. these included dealing with language and cultural barriers, multi-disciplinary management of tb osteomyelitis in a pregnant woman; involving close collaboration with the obstetric and orthopaedic teams and managing adverse effects of anti-tuberculous medications in the pregnant patient. most samples tested showed no evidence of mycobacteria, indicating need for improved case selection prior to testing. median time to zn testing is as recommended by guidelines, though there is room for improvement. in an unselected population, likelihood of negative results is high after weeks of negative cultures. however, clinical suspicion should remain high until culture negativity is declared at weeks, particularly when there is a high clinical probability of mycobacterial disease. background: a number of patients with bronchiectasis have a middle lobe/lingula predominant radiological pattern. other than an association with non-tuberculous mycobacteria there is a paucity of published data on this subgroup of patients. methods: we retrospectively analysed data from all patients with non-cf bronchiectasis who underwent bronchoscopy with bal in a university hospital over a month period. radiological features, demographic data and microbiology were reviewed. results: patients with bronchiectasis were assessed. ( %) had predominant middle lobe/lingular bronchiectasis. in this group ( %) patients were females compared to ( %) (p = . ) of other patients and mean age was ± compared to ± years (p = . ). bal microbiology in the middle lobe/lingular group revealed no growth in ( %), h influenzae in ( %), s aureus in ( %), mac in ( %) and other ( %). conclusion: middle lobe/lingula predominant bronchiectasis is a common radiological pattern particularly in females and only a minority have ntm infection. cystic fibrosis (cf) is characterised by neutrophil-dominated airway inflammation, in part attributable to the potent chemotactic agent leukotriene b (ltb ). the aim of this study was to investigate the ability of exogenous alpha- antitrypsin (aat) to inhibit ltb signaling. the biological consequence of the described aat induced inhibition was investigated at the level of neutrophil released proteolytic enzymes. circulating neutrophils isolated from healthy control volunteers (n = ) were stimulated with ltb ( - nm/ ) in the presence and absence of aat ( . - . lm) for increasing increments of time ( , , and min). the level of degranulated proteins in surrounding supernatants was determined by western blot analysis. the ability of aat to bind ltb was assessed specrophometrically with uv spectra recorded on a jenway spectrophotometer at °c. our in vitro data has shown that levels of degranulated mpo, ll- and mmp- (markers of primary, secondary and tertiary granule release, respectively) were significantly decreased in the presence of aat (p \ . ). the mechanism of inhibition involved direct binding of aat to ltb as reduced vibrational fine structure of the ltb / aat uv absorbance spectrum indicated complexation of the two molecules. the results of this study indicate that aat can inhibit ltb signaling thereby reducing the proteolytic activity of neutrophils and propose aat aerosolized augmentation therapy as an effective treatment for ltb associated pulmonary diseases including cystic fibrosis and severe asthma. the modified-shuttle-walk-test (mswt) is increasingly used in cystic fibrosis (cf) patients. however, few studies have correlated mswt with severity of disease or assessed the prognostic value of these tests. the aim of this study was to see if a correlation existed between mswt and forced expiratory volume in -s (fev ) and/or cf-able score. a total of mswt assessments were analysed. correlations (spearman) among fev , cf-able-score, percentage predicted distance travelled and percentage predicted distance travelled to desaturation were calculated. nine out of mswt showed desaturation. the mean distance travelled was , m; . % of predicted, and mean distance to desaturation was . m; . % predicted. there was a significant correlation between distance travelled and fev (r = . /p \ . ) ir j med sci ( ) (suppl ):s -s and inverse correlation with cf-able-score (r = - . /p \ . ). there was a significant but poor correlation between distance to desaturation with fev (r = . /p \ . ) and cf-able-score (r = - . /p = . ). however, the presence of desaturation during testing did not correlate with fev (r = - . /p = . ) or correlate significantly with cf-able-score (r = . /p = . ). in conclusion there is significant correlation between total distance walked and both fev and cf-able-score, however, the absence of a correlation with the presence of desaturation during testing highlights the usefulness of mswt as a possible independent predictive measure, with further study needed. prolonged antibiotic therapy for cystic fibrosis (cf) exacerbations leads to increased picc (peripheral inserted central catheter) use. consequently incidence of venous thromboembolism (vte) has risen. rates of picc induced thrombosis in adults are . % [ ] . we aimed to ascertain prevalence of picc induced thrombosis in adult cf patients. a retrospective review of radiology was conducted on patients who had picc insertion for antibiotics for cf exacerbations from january to december . we analyzed patients with confirmed vte on doppler ultrasound and recorded patient demographics, size of picc and site of insertion. piccs were inserted, ( . %) had vte. ( . %) were female and ( . %) were male with symptomatic vte, presenting with arm swelling and pain. further complications were ( . %) with superior vena-cava syndrome, ( . %) with pulmonary embolism. of these, were treated with months anticoagulation therapy, and were anticoagulated for months once repeat doppler ultrasound confirmed no thrombosis. our rate of vte was . %, lower than in existing studies. piccinduced thrombosis depends on the population studied, as well as acquired thrombophilia secondary to inflammation, or deficiencies of anticoagulant proteins (protein c and s) due to vitamin k deficiency and/or liver dysfunction. studies have documented very poor real-life adherence to nebulised antibiotic therapies [ ] . no data exists on real-life experience with inhaled antibiotics. consecutive adult cf patients commencing inhaled antibiotic therapy (tip) were recruited over a -month period. a questionnaire recording safety, efficacy, lung function and adherence at time of recruitment, assessed traditional nebulised treatment (tis) versus new inhaled therapy (tip) at , and months. wilcoxons rank test and paired sample t-tests were employed for statistical analysis. patients have been enrolled to date. patient died (unrelated to the drug). patient received a lung transplant. / ( %) discontinued tip; due to cough/bronchospasm and due to refractory oral candidiasis. / ( %) were intolerant of tis prior to enrolment, with / ( %) subsequently tolerating tip. there was a significant increase in mean adherence score from . in the tis group to . in the tip group (p value . ). there was no significant difference in cough, lung function, or adverse events between the groups. in a real-life clinical setting with new inhaled antibiotic therapy (tip) we demonstrate, improved tolerability, adherence, lower discontinuation rates and stable clinical phenotype. also subgroup analysis supports a trial of this in those who failed traditional nebulised treatment. aim to assess the clinical utility of a hand-held nno analyser to differentiate between pcd, respiratory disease and healthy subjects. clinically stable patients were recruited over a -month period. each subject completed compatible pcd phenotype proforma, nno analysis (niox mino Ò ), and one nasal brushing for electron microscopy (em) analysis. nno was measured using passive sampling at a flow rate of ml/s during tidal breathing. em images will be reviewed internally and externally at an international centre of excellence (unc chapel hill). independent t-tests were used to compare mean nno values between groups. subjects were recruited (n = pcd, n = cf, n = non-cf/ non-pcd bronchiectasis, n = copd, n = healthy subjects). mean nno levels (ppb ± sd) were ± . (pcd), ± (cf), ± (non-cf/non-pcd bronchiectasis), ± (copd) and ± (healthy control). although nno levels were reduced in pcd when compared to copd (p = . ) and healthy subjects (p \ . ), there was no statistically significant difference between nno levels in pcd and cf (p value . ). results of em analysis are pending. in this study, the hand-held niox mino Ò nno analyser distinguished patients with pcd and cf from patients with copd and healthy subjects but not cf from pcd. ir j med sci ( ) studies suggest that incorrect usage of inhalers impacts negatively on asthma control. the aim of this study was to evaluate inhaler technique and symptom control in patients with severe asthma. patients referred to a newly established clinic in cork university hospital were consecutively recruited over a month period. inhaler technique was assessed using a validated scoring system and instruction on correct usage given if scores were suboptimal. patients completed a validated asthma control questionnaire (acq) and asthma quality of life questionnaire (aqlq). at a follow-up clinic months later technique was reassessed and acq repeated. results at baseline and follow-up were compared using standard statistical methods. patients were recruited (female = %), and / were followed up. mean[sd] fev % predicted at baseline = . % ( . ). % of patients were classified as incorrect inhaler users initially, decreasing to % at follow up, indicating a significant improvement in inhaler usage post-training (p = . ). acq scores improved significantly from median (range) . ( . - . ) to . ( - . ), p = . . the aqlq results indicated that patients' qol is moderately affected by asthma; median (range) score of . ( . - . ). this study demonstrates the importance of formally assessing inhaler technique in patients with severe, long-standing asthma as part of their clinical review. asthma is a chronic airway disease characterized by airway inflammation, bronchial hyperresponsiveness and airflow obstruction. patients with persistent symptoms despite maximum treatment as per gina guidelines are considered to have severe persistent asthma. omalizumab is a recombinant humanized monoclonal antibody licensed as an add-on therapy in these patients. the aim of this study is to assess the clinical benefit amongst responders to omalizumab therapy at a tertiary referral centre. this was a retrospective audit assessing the effects on asthma control, frequency of exacerbation and hospitalisation rates over months before and after therapy. the study included responders ( females). there was a reduction in exacerbation and hospitalization rates following initiation of omalizumab, and %, respectively (p value . ). the number of exacerbations decreased from . ± . to . ± . and the mean number of admissions from . ± . to . ± . over the study duration (p \ . ). there was % reduction in the weekly need for rescue salbutamol with mean of . ± . puffs to . ± . puffs after omalizumab (p \ . ). seventy-nine percent of patients were able to reduce their maintenance oral corticosteroid. in summary, responders to omalizumab therapy are less likely to experience an asthma exacerbation and hospitalisation. they were also more likely to reduce maintenance corticosteroid therapy as well as the need for rescue reliever therapy. these data suggest that omalizumab has proven effective in improving health outcomes for a cohort of carefully selected patients with severe allergic asthma in ireland. bronchial thermoplasty (bt) is a bronchoscopic procedure aimed at reducing the mass of airway smooth muscle and attenuating bronchoconstriction in severe asthmatic patients failing medical therapy. we report our experience with the first four patients treated with bt. between december and august , four patients with severe asthma per gina guidelines, underwent three sessions of bronchial thermoplasty, weeks apart. stringent entry criteria were required, including ongoing symptoms despite optimal medical management with the use of ics and laba's. two patients had a limited response to omalizumab. thus far, four patients met study entry criteria. three females and male. the mean age was years (sd . ). the frequency of severe asthma exacerbations was - per year. the mean fev and fev /fvc prior to procedure was . and . %, respectively. the mean fev and fev /fvc after the procedure was . and . %, respectively. patients reported a subjective strong improvement in quality of life post bt with more symptom-free days and less use of rescue inhalers. this emerging data relating to bt in an irish population is consistent with international data sets. bronchial thermoplasty is an additional treatment option for patients with severe asthma. approximately - % of patients with asthma have gastrooesophageal reflux (gor) and it has been postulated that this may worsen asthma severity. this study was undertaken to examine the incidence of gor in an irish steroid-dependent severe asthma cohort. patients with severe asthma were recruited into this descriptive study from the severe asthma clinic in cork university hospital. our cohorts mean age was years. the mean (sd) fev was . ( . ) l ( % predicted). the mean time from asthma diagnosis was . ( . ) years with the patients being steroid dependent on oral steroid therapy for mean . ( . ) years with a mean dose of . mg prednisolone. ( %) reported symptoms of gor; with being concomitantly treated with proton pump inhibitor. ten patients had undergone a barium swallow with five demonstrating gor radiological evidence. a further patient previously had undergone fundoplicative surgery. there was no association between gor and cumulative systemic steroid dose or fev in a subgroup analysis. in our study of steroid dependent asthmatics, % of those formally assessed were found to have evidence of gor on barium swallow, which is consistent with reported research [ ] . the incidence of gor did not depend on cumulative steroid exposure or fev . introduction: incorrect inhaler usage is a significant problem in asthma management, resulting in poor control of asthma symptoms. the ability of patients to correctly use their inhaler might be directly linked to inhaler technique education. education may result in better inhalation technique, improved compliance and asthma control. the economic burden of asthma is very substantial and is one of the highest among chronic diseases. in the united states of america, approximately - billion dollars is wasted because of inhaler misuse per year (fink, ) . research question: ''what is the impact of a nurse-led education programme in promoting compliance with inhaler use in patients with asthma''. methodology: this is a quantitative study engaging a quasi-experimental pre-test and post-test design. a cohort of patients who met the inclusion criteria were recruited from the out-patient department over a period of six months. during each stage, the patient was asked to demonstrate how they take their inhaler. any errors in technique were identified and rectified. their demonstration was measured through observation and the use of an inhaler proficiency schedule (ips). the participant was also asked a series of specific questions in relation to their condition, confidence level with self-administration of their inhaler, and adherence to prescribed frequency of use. the findings in this study show that inhaler education improves technique, promotes compliance and increases participant confidence levels in taking an inhaler, and as a result asthma symptoms improve. it also emerged that participants believed they were taking their inhaler correctly and so assumed that education drives were not targeted at them. % ( ) felt that the service provider had assisted in their success with therapy. overall, respondents use their devices as prescribed, keep in contact with their hospital department and service provider, and most feel their quality of life has improved as a result of starting treatment with cpap. obstructive sleep apnoea syndrome (osas) is characterized by repetitive upper airway (ua) obstruction during sleep. alcohol consumption increases osas severity by diminishing ua muscle tone, aggravating snoring and osas-related daytime symptoms. we hypothesized that behavioural adaptation could lead to reduced alcohol consumption in subjects with more severe osas. the influence of anthropometric, social and demographic variables, along with osas severity on alcohol consumption among subjects undergoing inpatient sleep studies was examined. regression analyses were utilised to identify independent predictors of alcohol consumption, and generate odds ratios (aor) for excessive alcohol consumption by osas severity. subjects were assessed; . % were female, . % in paid employment, and . % married. . % had no osas [apnoeahypopnoea index (ahi) \ ] and . % severe osas (ahi [ ). alcohol consumption was . (± . ) u/week, with . % exceeding recommended limits. stepwise regression revealed male gender and employment status, but not ahi, as independent predictors of increased alcohol use. no difference in adjusted mean alcohol intake by osas severity class was observed. severe osas patients tended towards increased odds of excess alcohol consumption compared to those without (aor . ; % ci . - . ; p = . ). increasing osas severity is not associated with lower alcohol consumption; rather, the reverse may be more likely. in our sleep clinic, ess is a poor predictor of ahi, sacs did not perform as expected, and a combined measure is of limited utility. following polysomnography diagnosis, untreated osas cases were assessed. cpap compliant subjects were re-assessed * weeks later. body composition was assessed by bio-electrical impedence analysis. sensewear armband Ò (swa) measured free-living ee. swa data was included if average weartime was [ %. subjects ( male) (mean age, . years) were included. restrained-eating score was inversely associated with osas severity ( . , . , . in mild, moderate and severe, respectively). conversely, both uncontrolled eating score ( . , . , . ) and emotional eating score ( . , . , . ) were positively associated with osas severity. bmi (p = . ) and fat % (p = . ) were significantly higher in severe versus mild osas. cognitive-restraint was inversely associated with bmi and fat %, whereas both uncontrolledand emotional-eating were positively associated with these parameters. among this sample, more severe disease was associated with adverse eating behaviors. nutritional counseling targeting specific eating behaviors may be beneficial in osas. significant osa (ahi [ ) was present in % of the clinical group and % of the screened group. no correlation of clinical significance was proven between ahi and ess in either group. ess provides useful information on subjective sleepiness but this study might suggest that it is not a reliable predictor of the presence of osa or its severity. decreased energy expenditure (ee) contributes to overweight. we investigated free-living ee and body composition in obstructive sleep apnoea syndrome (osas). following polysomnography (psg) diagnosis, untreated osas cases wore the sensewear armband Ò (swa) for * days, including weekend days. swa quantifies free-living ee and physical activity (pa). data was included if weartime was [ %. body composition was assessed with bio-electrical impedance analysis. upper airway muscle dysfunction is implicated in the pathophysiology of obstructive sleep apnoea syndrome (osas). pharyngeal dilator muscle inotropes may serve as adjunct therapies. we hypothesized that tempol, a superoxide scavenger, would increase sternohyoid muscle power under conditions of oxidative stress (hypoxia). excised sternohyoid muscles from adult male wistar rats, were connected to a dual-mode force transducer, between stimulating electrodes, in a bath of krebs solution at °c, in either high oxygen (control) or low oxygen (hypoxia) ± mm tempol. stress and shortening were measured in muscles contracting from zero up to isometric load under tetanic conditions. peak power was determined. sternohyoid peak power was . ± . and . ± . w/cm in control and hypoxic conditions (drug-free), respectively, and . ± . and . ± . w/cm in control and hypoxic conditions (+tempol), respectively. two-way anova revealed that hypoxia (p \ . ) and tempol (p = . ) were significant factors without drug-gas interaction. tempol increased the power-load relationship over the early ( - %) portion of the load step test and this was significant under hypoxic conditions. we conclude that tempol increases sternohyoid muscle power under control and hypoxic conditions. our results suggest that antioxidant therapy may be useful in the treatment of osas and other muscle weakness disorders. r. lee obstructive sleep apnoea syndrome (osas) is reported as common among ipf patients [ ] . we determined the prevalence of the disorder in a cohort of ipf patients not on long term oxygen therapy and medically stable, excluding patients with active coronary disease and diabetes mellitus. patients with ipf patients attending a specialized clinic underwent overnight polysomnography following a night of acclimatization. a quality of life questionnaire (sf- ) and epworth sleepiness score (ess) were also completed. statistical analysis was by student-t and man-whitney u-testing. of the patients were male and mean age was . ± . (sd). % were current or ex-smoker. only % of the patients received steroids at some time in their treatment. patients had significant sleep-disordered breathing (sdb) based on the standard definition of ahi c /h but only were sleepy (ess c ), thus having osas. bmi correlated positively with ahi (r = . , p = . ). bmi was . ± . kg/m but higher in the osas/sdb group (p = . ). no difference in quality of life was evident between those with or without sdb or osas. we conclude that sdb and osas are as prevalent in ipf as a similar general population and bmi is the principal predictor of ahi in these patients. studies to date reveal wide variability ( - %) in the prevalence of fungus in the cf airway using culture-based methods. this study profiles the fungal microbiota of the cf airway using high-throughput-sequencing, and correlates this with standard culture-based methods and clinical phenotype. clinically stable adult cf patients were prospectively recruited, donating one or more sputum samples. culture-based methods were employed at time of sampling. high-throughput bar-coded sequencing targeting the internal transcribed spacer (its) and small sub-unit (ssu) regions was used to profile the fungal microbiota, with subsequent sequencing on a genome sequencer flx platform. baseline fev % predicted, genotype, gender, bmi and pseudomonas status, were recorded by retrospective review of medical notes. in a total of samples, culture-based methods detected fungus (aspergillus spp. and candida spp. only) in patients. highthroughput-sequencing identified rich fungal communities in greater than % of the patient sputum samples, with over % of the species found not detected by culture. fungi detected included c. albicans, c. dubliniensis saccharomyces cerevisiae, malassezia spp., fuscoporia ferrea, fusarium culmorum, acremonium strictum, thanatephorus cucumeris and cladosporium spp. a comparison of patient status with diversity and species richness of fungal microbiota identified that lower fungal diversity associates with decreased lung function. aim: to identify common anaerobes and their proteases and assess their ability to cleave natural host innate human antiproteases such as alpha one antitrypsin (aat). method: we prospectively recruited patients at our site in beaumont hospital. we obtained both sputum and bronchoalveolar lavage fluid (balf) at both stable and pre and post exacerbation timepoints. all samples were processed using both anaerobic bacteriologic techniques and s r rna sequencing methods. supernatants from p. melaninogenica were cultured in luria-bertani broth (lb) broth, (sigma l - tab) and basal anaerobic media (bam) broth under strict anaerobic conditions in an anaerobic cabinet (davidson & hardy). protease production was measured using sensolyte red protease assay (anaspec). this assay measures matrix metalloproteinase (mmp) activity in broth. the days with highest protease production were recorded. native aat was incubated for selected time points with supernatant and cleavage products visualised by sds-page electrophoresis and western blotting analysis using specific antibodies raised against the antiproteases. results: using sputum and broncheoalvelar lavage from patients with cf, prevotella species accounts for % of anaerobic samples identified from our group and p melaninogenica is the most common anaerobe grown from this group. the sensolyte red protease assay showed p. melaninogenica cultures produced the highest levels of active proteases on day , and . the western blot analysis demonstrated that when day and supernatants were incubated with aat, this antiprotease was degraded to give a distinct cleavage pattern. conclusion: this study is examining for the first time the pathogenicity of anaerobic bacteria found in cf lung and shows that the proteases produced by anaerobic bacteria are destroying host defense mechanisms and that this may impact other natural host innate antiproteases in the cf lung and play a role in inflammation. cf is a genetic disease with a high prevalence in ireland. in cf lungs chronic bacterial infection contributes to progressive respiratory failure. in particular, pseudomonas aeruginosa (pa), forms biofilms in the lungs which significantly contributes to antibiotic resistance. we have previously published on the importance of mif as a key inflammatory mediator in cf [ , ] . building on this work, we hypothesised that mif enhances biofilm formation in the cf lung contributing to enhanced antibiotic resistance. using in vitro biofilm formation methods and qpcr we examined the effects of mif ( ng/ml) on the growth, antibiotic resistance and gene expression of pa (strain pao ). our results to date have shown that mif significantly enhances biofilm formation of the pao strain of pa (p \ . ). in addition we have found a significant earlier induction of specific quorum sensing genes in response to mif. mif in pa cultures is associated with significantly less bacterial killing following antibiotic treatment. this raises the possibility of mif as an adjunct therapy with antibiotics by significantly this supports our hypothesis of mif inhibitors as an adjunct therapy improving the antibacterial effectiveness of antibiotics. macrophage migration inhibitory factor (mif) was one of the first cytokines to be discovered. mif is produced by a wide variety of tumours and is thought to play an important role in tumour progression. mif possesses a unique enzymatic activity linked to this role in cancer. to investigate this further we designed and evaluated a panel of small molecular weight inhibitors of mif and looked at their ability to block mif activity in vitro and in vivo. the small molecules were found to specifically inhibit the enzyme activity of mif when co-incubated with recombinant mif and its substrate. the inhibitors also significantly reduced cellular proliferation induced by treatment with recombinant mif (proliferation reduced by [ %, p \ . ) and significantly inhibited lpsinduced tnf-a production (tnf-a reduced by [ %, p \ . ). in vivo, the inhibitors were found to reduce tumour growth in a subcutaneous model of lewis cell carcinoma (tumour volume reduced by [ %, p \ . ). here we present data describing a number of novel small molecular weight inhibitors of mif found to be effective in vitro and in vivo. these inhibitors have the potential to be developed for therapeutic use in a cancer setting. idiopathic pulmonary fibrosis (ipf) is a progressive disease characterized by fibrosis. il- is a proinflammatory cytokine that has been shown to play a role in many fibrotic diseases including ipf. il- also induces the expression of, and binds to, one of its receptors, il- ra , which has been thought to function as a non-signaling decoy receptor. the cxc chemokine receptor (cxcr ) and its ligands-cxcl , cxcl , and cxcl -have been implicated in vascular remodeling and fibroblast motility during the development of the disease. in this study, cultured pulmonary fibroblasts from wild type and cxcr -deficient mice were treated with various cytokines, and the expression levels of il- ra and cxcr were measured. we demonstrate for the first time the expression of cxcr in cultured pulmonary fibroblasts from mice. also, il- was shown to downregulate basal and ligand-induced cxcr expression in fibroblasts. using wild-type and cxcr -deficient animals, cxcr was found to be necessary for the il- mediated upregulation of il- ra , and blocking cxcr significantly reduced the basal expression of il- ra . manipulation of the cxcr -mediated regulation of il- ra or the il- mediated downregulation of cxcr may represent novel therapeutic modalities in cases of acute lung injury or chronic inflammation that may progress to fibrosis. epithelial cell to mesenchymal transition (emt), whereby epithelial cells undergo transition to a mesenchymal phenotype, giving rise to fibroblasts and myofibroblasts has been implicated in the pathogenesis of idiopathic pulmonary fibrosis (ipf). alveolar epithelial cells (aec) are recognised to undergo emt in response to various stimuli including transforming growth factor-b (tgf-b ). comparison of gene expression, migration and chemokine secretion in normal and transitioned aec with primary pulmonary fibroblasts derived from normal and ipf patients was performed. a cells underwent h (h) serum starvation followed by h treatment with tgf-b ng/ml. total rna was extracted from a cells and primary human pulmonary normal and ipf fibroblasts. changes in expression of a panel of tgf-b target genes was determined by real time polymerase chain reaction array with subsequent validation. migration studies of the various cell types in response to serum and enzyme-linked immunosorbent assay (elisa) of cxcl , cxcl and il- levels in cell supernatants were performed. transitioned aec assumed a mesenchymal phenotype, exhibiting a marked reduction in differential gene expression when compared to fibroblasts. migration in response to serum by transitioned aec was increased significantly compared to normal or ipf fibroblasts as was production of cxcl and cxcl . background: aatd disease is a hereditary disorder leading to the development of emphysema. our group has published first evidence of upr activation within the endoplasmic reticulum (er) of zz monocytes. here we study mirna regulation of upr in healthy and emphysematous zz monocytes. method: monocytes mirnas were profiled using nanostring technologies. mirdip portal and kegg database identified mirna targets and gene networks. transfections with nm anti-mir were performed using siport-neofx. mrna, mirna and protein were measured by qrt-pcr, taqman mirna assay and western blotting. results: sixty mirnas were differentially expressed in zz versus mm monocytes. mir- a- p is overexpressed by [ -fold and predicted to target multiple genes which are enriched for pathways in the er stress response. emphysematous versus healthy zz patients have decreased mir- a- p expression. mir- a- p inhibition increased expression of two arms of the upr; grp and atf . conclusion: mirnas are differentially expressed in zz monocytes and may play a role in the upr. mir- a- p, predicted to target upr genes, is overexpressed in healthy zz monocytes, and negatively regulates the upr. emphysematous zz patients may have lost this protective mirna regulation leading to increased er stress in monocytes, contributing to the inflammatory milieu of aatd lung disease. . alpha- antitrypsin augmentation therapy is associated with decreased neutrophil adam- activity, plasma tnf-a levels and normalisation of neutrophil apoptosis alpha- antitrypsin deficiency (aatd) is characterised by neutrophil driven lung destruction and early emphysema in a low alpha- antitrypsin (aat) and high neutrophil elastase (ne) environment in the lungs of affected individuals. timely and effective neutrophil programmed cell death is essential for the resolution of inflammation and we have previously shown that neutrophils apoptosis is accelerated in aatd individuals. endoplasmic reticulum (er) stress is associated with the release of the pro-apoptotic cytokine tnf-a and, on the cell surface the activity of the sheddase adam- leads to the release of tnf-a from its membrane bound to its soluble form. the aim of our study was to determine if aat augmentation therapy can normalise the accelerated neutrophil apoptosis seen in aatd through inhibition of adam- activity and resultant tnf-a release. neutrophils were isolated from aatd individuals receiving aat augmentation therapy pre and post treatment. the kinetics of apoptosis were measured by caspase- cleavage utilising western blotting and cd b expression by facs analysis. adam- activity measured using a fluorogenic peptide substrate. plasma tnf-a levels were measured by elisa. er stress was determined using the er stress marker grp- . adam- activity was increased in individuals with aatd. in addition, adam- activity, plasma tnf-a levels and caspase- cleavage were reduced after augmentation therapy (p \ . ). cd b expression was increased after therapy indicating normalisation of apoptosis. grp- expression was unchanged. from our data we have demonstrated that aat augmentation therapy can normalise neutrophil apoptosis by ameliorating adam- activity and resultant tnf-a release. the observed normalisation of neutrophil apoptosis may lead to reduced inflammation and a reduction in recurrent infections which characterises patients with aatd. to identify lung-selective mirnas, extracted rna was probed to mirna microarrays (mra- ; , human mirnas), and results confirmed by taqman analysis. in silico analysis using targetscan and microrna.org identified genes targeted by identified mirnas. using a subtractive mirna strategy, lung-selective hypoxic responsive mirnas were identified (anova p \ . ); including mir- a- p and mir- . in silico analysis predicted that mir- a- p targets erythropoietin, which has a well-documented role to play in endothelial repair and angiogenesis. furthermore, mir- targets cullin , which has previously been shown to stabilize hypoxia-inducible factor-a and promote angiogenesis. we conclude that hypoxia, typical of that encountered in pulmonary disease, causes lung-selective alterations in mirna expression. mir- a- p and mir- may play important roles in pulmonary vascular remodelling and angiogenesis. further studies of these mirnas may uncover novel treatment strategies for hypoxic lung disease. this research project is funded by science foundation ireland. to assess whether mal plays a role in killing of intracellular mtb, we infected murine wild-type and mal knockout macrophages with virulent (h rv) mtb. we found that mal deficient cells were unable to kill mycobacteria. human macrophage cell lines transfected with sirna against mal showed the same deficiency in killing mycobacteria. we then proceeded to evaluate key macrophage mechanisms of killing mycobacteria. we found that phagolysosomal maturation and autophagy were mal-dependent in murine and human macrophages. pro-inflammatory cytokine production was also mal dependent. we then sought to determine the effect of the common mal s l polymorphism on macrophage responses to mtb. primary bone marrow derived macrophages from mice with the sl and ll polymorphisms displayed impaired mycobactericidal activity and phagolysosomal maturation. mal plays a critical role in determining macrophage responses to mtb through a pathway culminating in phagolysosomal maturation and killing of intracellular bacteria. asthma has been linked to the vitamin d deficient (vdd) state. we investigated whether vdd was associated with impaired lung function and inflammation. patients with respiratory symptoms (asthmatic and non-asthmatic) underwent spirometry and had serum analyzed for total immunoglobulin e (ige), high sensitive c-reactive protein (hscrp), eosinophil cationic protein (ecp), and -hydroxyvitamin d we examined caucasians (mean age years; mean bmi kg/m , mean fev = . % predicted). mean (oh)d was . nmol/l. % of recruits were vdd, % were insufficient, while only % were vitamin d sufficient. vitamin d levels were positively associated with fev (r = . , p = . ). % of patients with airway obstruction (fev \ % predicted) were vdd. ecp, hscrp and ige were non-significantly elevated in the vdd state compared to sufficiency. however, all patients with ige doctors' education about inhaled respiratory medication is extremely important in management of copd and asthma. while exercise-induced oxygen desaturation is a widely used clinical measure in ipf, data on sleep-related desaturation are lacking. we compared gas exchange during sleep and exercise in a cohort of ipf patients attending a specialized clinic not on long term oxygen therapy and medically stable, excluding patients with active coronary disease and diabetes mellitus. ipf patients underwent overnight polysomnography, including transcutaneous carbon dioxide (p tc co ) measurement, after a night of acclimatization. cardiopulmonary exercise testing was performed by incremental cycle ergometer. pulmonary function and awake arterial blood gases were also measured. statistical analysis included student-t and man-whitney u-testing. patients had significant sleep-disordered breathing (sdb) based on an apnoea-hypopnoea index (ahi) [ . fev was . ± . % (sd) and diffusion (dlco) . ± . % predicted. pao was . ± . kpa and paco . ± . kpa. p tc co rose by . ± . kpa during sleep (p \ . ) consistent with hypoventilation. the minimum oxygen saturation during sleep was lower than exercise ( ± . vs. . ± %), p = . and the fall in oxygen saturation was also greater during sleep ( . ± . vs. . ± . , p \ . ). we conclude that ipf patients desaturate more during sleep than exercise and suggest that nocturnal oxymetry be considered part of the clinical assessment of such patients. diabetes mellitus (t dm) causes increased risk of cardiovascular death, while glycosylated hemoglobin (hba c) level predicts longterm cardiovascular mortality in non-diabetics. while obstructive sleep apnoea syndrome (osas) is associated with adverse cardiometabolic outcomes, it remains unclear if this effect is independent of obesity and other confounders. we examined the relationship of osas severity with t dm prevalence and hba c levels in a large european population. subjects attending university-affiliated sleep laboratories across countries were prospectively assessed. all underwent overnight sleep studies, with bloods drawn to assess glycaemic health. the relationship of osas severity with t dm prevalence, and hba c levels in non-diabetics was examined with regression models adjusting for confounding factors, including obesity. , subjects were assessed, . % male, . % obese, and % with an apnoea-hypopnoea index (ahi)[ events/h. following adjustment for confounding factors, moderate and severe osas remained significant predictors of t dm (adjusted odds ratio . ; %ci . - . ; p = . ). in non-diabetics ahi (standardized b . ; p \ . ), and mean spo (standardized b - . ; p \ . ) were significant independent predictors of elevated hba c levels. osas severity and nocturnal hypoxaemia predict both prevalent t dm and hba c levels even after rigorous adjustment for confounding variables including obesity, which may contribute to excess mortality in osas populations. background: portable devices that determine tst may act as an adjunct to level diagnostic tests for osa. the swa is such and measures tst using a proprietary algorithm. calculation of tst could improve the accuracy of a level diagnostic device. aim: correlation of tst by swa and npsg, in a population with and without sleep apnoea. consecutive patients undergoing npsg because of a suspicion of osa wore an swa on the same night. patients were stratified by the presence and severity of osa. correlation coefficient for tst were determined between swa and npsg for all subjects and in the osa subgroups. results: the prevalence of a normal psg, mild moderate and severe osa was ( . %), ( . %), ( . %) and ( . %) of subjects. and the respective correlation coefficients were r = . , . , . and . . clinically important differences are presented with bland-altman plots (figs. , ) . correlation of tst between the two methods was weakest in those with severe osa. conclusion: the determination of tst by swa in a population with severe osa is likely to be unreliable. npsg remains the gold standard for determination of tst. the relationship between lung cancer and pulmonary fibrosis remains poorly understood. the aim of this study was to conduct a descriptive analysis of clinical data collected from a cuh cohort of patients with both ild and lung cancer. a database of patients with a histological diagnosis of lung cancer between august and december was reviewed. patients with established ild on ct scan were identified. data from clinical notes and radiology patterns were reviewed and analysed. the male to female ratio was . : . all were smokers. % of carcinomas in these patients were non-small cell lung cancer (nsclc). % of patients had usual interstitial pneumonia pattern, % had non-specific fibrosis, and % had asbestosis. the overall median survival was months (sem . ; % ci . to . ). median survival for patients with early stage disease who underwent surgery (n = ) was months, followed by those who received chemo-radiotherapy ( months), those who received no intervention ( months), and those who received radiotherapy alone ( months). survival for patients with lung cancer and ild was lower than published figures for patients with lung cancer alone. surgical candidates had the best survival though the survival benefit was very modest, while patients who received no intervention or radiotherapy alone faired very poorly. pleural ultrasound has a number of advantages over traditional imaging modalities with regard to visualisation of pleural pathology, in particular, pleural effusions. these include portability, the absence of radiation, dynamic imaging as well as increased sensitivity versus computed tomography scans in terms of differentiating between pleural fluid, thickening and masses [ , ] . we present a case series of patients who underwent pleural ultrasound under the care of respiratory physicians trained in this technique in our hospital from january to august . in total, ultrasound scans were carried out in the month period on a total of patients using a portable ultrasound machine. the average patient age was . years (range - years) and % were male. based on ultrasound findings, the physician proceeded directly to aspiration on occasions ( %) and a total of chest drains were inserted ( %). of those that were aspirated, the vast majority were exudative in nature (n = , . %). ( %) of the aspirates were due to malignant effusions. no procedure-related complications occurred. this case series highlights that imaging at the bedside is a feasible and, with the proper training, very safe method for managing pleural effusions. this audit shows that the vast majority of patients with mesothelioma are male with a poor prognosis regardless of therapeutic approach. approximately % die in the hospital/hospice setting. finally, more patients with mesothelioma should be considered for clinical trials. aat deficiency (aatd) results from mutations in the serpina gene, classically presenting with copd and liver disease. the most common mutation causing aatd is the z mutation, with the s mutation weakly associated with lung disease. aat deficiency is under-diagnosed and prolonged delays in diagnosis are common. ats/ers guidelines advocate screening all copd, poorly-controlled asthma, and cryptogenic liver disease patients, as well as relatives of known aatd individuals. over , individuals have been screened following ats/ers guidelines as part of the national aatd targeted detection programme. rare and novel mutations were identified by dna sequencing of the serpina gene. a number of rare serpina mutations including i, f, x christchurch , z bristol , and m malton were identified. the i mutation (arg cys) was present at a relatively high frequency ( . ) with over cases identified. the f mutation (arg cys) was found in cases. in addition, novel null mutations were identified, q dublin and q cork. current testing of suspected aatd cases is often limited and can miss rare and novel clinically significant serpina mutations. our findings underline the need for a comprehensive diagnostic work up of all patients with low aat levels including phenotyping, genotyping and if necessary, dna sequencing of the serpina gene. we previously observed that weaning-failure patients experience increased intensity of dyspnea (ajrccm ; :a ). we also observed that patients reported different qualitative sensations suggesting that more than one mechanism may contribute to dyspnea. the purpose of this study is to determine whether dyspnea experienced in weaning-failure patients is related to changes in pco or increase in respiratory effort or both. methods: tracheostomized patients who were being weaned from prolonged mechanical ventilation at a specialized facility were enrolled. dyspnea, transdiaphragmatic pressure-time product (ptpdi), minute ventilation, and transcutaneous pco (ptcco ) were measured during a -h trial of spontaneous breathing. patients who developed respiratory distress during the trial were considered weaning failures. patients who tolerated the trial and continued to breathe unassisted for at least h after the trial without signs of distress were considered weaning successes. results: patients were studied; were women; age, + (se) years; duration of ventilation before the study, + days. fourteen patients were weaning successes; patients were weaning failures. in the failures, dyspnea score increased from . + . at the start to . + . at the end of the trial (p \ . ). the increase in dyspnea in the failures was accompanied by increases in minute ventilation (p \ . ) and ptcco (p \ . ); ptpdi, an index of patient effort, remained unchanged during the trial. in the successes, dyspnea, minute ventilation and ptcco did not increase during the trial; ptpdi, however, decreased from the start to the end of the trial (p = . ). these findings suggest that an increase in pco , a major driver of minute ventilation, contributes to an increase in dyspnea during weaning failure. that the increase in dyspnea in the failures was not accompanied by an increase in ptpdi together with the successes exhibiting a decrease in ptpdi without any change in dyspnea suggests that effort is not a major determinant of dyspnea during weaning failure. conclusion: dyspnea increases in weaning-failure patients but not in weaning-success patients and the increase in dyspnea is accompanied by increase in pco and minute ventilation but not by an increase in respiratory effort. background: respiratory disease constitutes one of ireland's greatest public health challenges. patients with respiratory disease are often undiagnosed despite symptoms and risk factors for lung disease. the purpose of this study was to determine the prevalence of respiratory symptoms and disease in a targeted population screening program. study design: subjects were asked to complete a questionnaire on respiratory symptoms and risk factors as part of well-publicised free spirometry testing on world spirometry day. multiple linear regression analysis was performed to identify factors contributing to variation in population fev . logistic regression was used to identify predictors of airflow obstruction (fev /fvc \ %) followed by predictive model development and roc curve analysis to determine model diagnostic accuracy. results: ten centers throughout ireland participated in the study. analysis was limited to an initial discovery cohort of patients ( % female; age = years (range - ); fev = % predicted(range - %). factors associated with reduced population ir j med sci ( ) (suppl ):s -s fev (% predicted) were smoking history, male gender, lower educational status and history of existing lung disease. in those with no history of lung disease (n = ), % had abnormal spirometry with % demonstrating airflow obstruction. predictors of airflow obstruction were age, presence of cough and number of pack-years of smoking. presence of cough, age [ years and exposure [ pack years were associated with highest sensitivity and specificity for identifying airflow obstruction although predictive ability was only fair (roc auc = . ). conclusions: demographic and socioeconomic factors influence lung health in ireland. undiagnosed respiratory disease is common, particularly airflow obstruction and targeted screening is justified to identify patients with respiratory disease early. bronchiolitis affects one-third of babies in their first year of life. half of those hospitalised will have persistent cough and wheeze. to map this epidemic, we investigated all bronchiolitis admissions to tallaght hospital in the last years. this will aid future planning of the service and provide an insight into the epidemic in the irish population. from until , , children were admitted to tallaght hospital due to bronchiolitis. we analysed these on the basis of time of year of admission, length of stay, gender and age and compared them to national and international data. the busiest month was december, with . % of admissions. however, there was a significant increase in the incidence of bronchiolitis in the early spring of and (more than doubled) compared to previous years. the average length of stay is . days, male sex had % dominance and average age was . weeks, in keeping with international data. there has been in a significant shift in the timing and incidence of bronchiolitis in tallaght hospital in the last years. we explored the reasons for this, with special attention to rsv incidence, possible climate causes, vaccine programs and exposure risk. we identified children, males and females. mean weight was . kg (range . - kg). mean age was . months (range days- months). stridor was the commonest presenting symptom %. diagnosis was confirmed by micro-laryngobroncoscopy and supplemented by ct in %. % had complete tracheal ring stenosis and % had concurrent cardiac anomalies. two patients had bronchus suis. extracorporeal life support (ecls) was utilized in one patient preoperatively. cardio pulmonary bypass (cpb) or ecls was utilised for the repair. laryngeal release was required in / patients. patients underwent end-end anastomosis, slide and double slide tracheoplasty. a polydiaxanone suture was used for all anastomosis. mean (cpb) time was . min (range - min). mean cross clamp time was . min (range - min). mean length of ventilation was days (range . - days). mean icu length of stay was . days (range - days). there were two hospital mortalities. one patient only required re-intervention with balloon dilation. % were symptom free on a mean follow up of . months (range weeks- years). distal tracheal stenosis can be managed effectively utilizing cpb that also allows concurrent correction of congenital heart anomalies. mayo general hospital, midlands regional hospital background and aim: attempting to reduce unnecessary attendances of well patients at outpatient clinics is prudent. this study evaluated the asthma control test (act)t and respiratory proforma, with feedback through mobile texts, in children with asthma, to determine attendance at clinic or not. methods: patients between and years with a diagnosis of asthma were eligible for inclusion. the parent was surveyed, by post, weeks prior to the clinic date and asked to complete the asthma control test (act) and a respiratory proforma which assessed uacs symptoms, medication usage inclusive of intensification episodes and medical concerns. mobile telephone numbers were requested. parents mailed their responses in a supplied stamped envelope supplied. respondents were divided into two categories (a) act score greater than and a non concerning respiratory proforma, who were texted not to attend the clinic but supplied with another outpatient appointment and (b) the remainder were texted to attend the clinic. results: over clinics the parents of eligible children were surveyed. one hundred and forty-one ( %) replied of whom ( %) were well and did not attend the clinic but rebooked. of who attended, had new symptoms of uacs and had pneumonia. of who did not reply, forgot to reply, came to clinic with completed questionnaires, had good control. thirty-five did not attend the clinic of whom were discharged to the family doctor. conclusion: asthma care through postal survey with mobile text feedback is an option in the outpatient setting. background and aims: asthma is common in paediatrics with the most difficult to manage being those less than years. this study evaluated the impact of a nurse delivered education program developed for parents of children under years in terms of knowledge gained and parental empowerment. methods: twenty parents of children age - years were invited to attend five h educational sessions which related to asthma pathophysiology, signs and symptoms, clinical assessment and medication use. a specific educational program was developed. prior to enrollment each parent was administered two surveys; ( ) a previously tested asthma questionnaire containing statements, and ( ) a survey of parental concerns related to asthma. one month after the program was completed parents asthma knowledge and perceptions of empowerment were reassessed. results: while parents were enrolled data sets for were available for analysis. the pre-intervention mean knowledge level was . ( %) (range - ) and post knowledge level was mean . ( %) (range - , paired t test 
). the parental survey identified asthma recognition and poor coping skills as major themes which the educational program addressed. conclusion: a targeted asthma educational program improves parental knowledge and enhances parental empowerment. written action plans (w.a.p.) are recommended in international guidelines for the management of asthma [ ] . despite this, uptake remains poor [ ] . a qualitative prospective study of parents of children attending the paediatric asthma out-patient clinic at cork university hospital was performed to examine if; ( ) written action plans are valued by parents. ( ) they assist in recognition of symptoms. ( ) parents commence appropriate treatment at home and identify when to seek medical advice as a result of w.a.p. ( ) parents feel assured by possession of w.a.p. thirty parents of children aged - years were interviewed by the paediatric asthma nurse specialist to assess level of asthma control, knowledge of treatment and level of concern. parents were provided with a colour coded w.a.p. and all aspects of treatment were discussed. a follow up telephone interview was performed months later. in the pre intervention group only / felt they had enough information to manage their child's asthma; this increased to / post intervention (p \ . ). / knew the location of their w.a.p.s. there were no incorrect responses regarding dose/frequency of medication. / subjects had dropped a level of concern regarding their child's asthma (p \ . ). with sufficient written information and education, the anxiety and concern that many parents undergo while managing a child with asthma, can be reduced. eight patients ( male) underwent respiratory (ecls). there were -preterm, -term neonates, -infant and -child. indications included, congenital diaphragmatic hernia- , bronchiolitis- , primary pulmonary hypertension- , pertussis- and complete tracheal ring stenosis- . % of patients were transferred to sweden or uk. eight children ( males) underwent (ecpr) runs, with a mean age of . years (range weeks- years). / had underlying congenital heart disease, of which had univentricular pathology. mean conventional (cpr) time before initiation of (ecpr) was min (range - min). in the respiratory (ecls) cohort mortality was . %. the only survivor was treated in ireland. in the (ecpr) cohort our survival rate of % exceeded the international extracorporeal life support organization published results of %. all ecpr patients were treated in ireland. currently there is no funding for pediatric respiratory (ecls) in ireland. patients are being treated abroad at significant expense, family inconvenience and mortality. these results would suggest a change in health policy is overdue! recent evidence has confirmed a high prevalence of bronchiectasis and impaired lung function in school aged children with cf despite little in the way of symptoms of lung disease in this group in preschool years. if we are to significantly improve long term outcomes in cf we must gain a greater understanding of lung disease in the preschool years and intervene earlier with disease modifying treatments before irreversible lung disease occurs. the key to understanding early lung disease in greater detail lies in the design of robust, comprehensive, well powered longitudinal studies. shield cf was established in with these requirements in mind and is a framework through which we can start to answer some important questions. shield cf is centred around the annual cf bal surveillance programmes in our institutions. currently the shield cf programme includes: • bal-immediately processed, aliquoted and biobanked • whole blood-immediately processed, aliquoted and biobanked • oropharyngeal swab-processed for rna extraction • clinical information-baseline and ongoing information related to lung health entered onto online database from individual centres. in the future we plan to include: • lung function measured by lung clearance index (lci) • lung structure determined by chest ct to date patients have been recruited with a total of samples (n = cf, n = control). shield cf has contributed samples to different international multicentre studies. table below summarises key baseline findings within shield cf to date. within the next year shield cf will incorporate preschool children between the three centres. aim of our study was to audit hospitalization for copd exacerbations with respect to patient characteristics, diagnosis and standards of care. all patients admitted to roscommon hospital with a diagnosis of aecopd from july st to december st were included. medical notes were reviewed for data collection. patients were included in the study. there was a frequent failure to objectively confirm the diagnosis of copd by spirometry. only ( . %) patients had spirometry performed at any stage. patients were current smokers. inhaler technique was assessed in only patients. ( %) patients received chest physiotherapy. out of current smokers had documented smoking cessation advice, and received smoking cessation pharmacotherapy. ( %) patients were treated with antibiotics. management of aecopd in our hospital is frequently suboptimal, and may be managed better with respiratory physician involvement. there should be more frequent spirometric confirmation of diagnosis, more conservative use of antibiotics, better screening for ltot and improvement in smoking cessation service. many copd patients return for review at the respiratory outpatient department when clinically stable. they are often reviewed by less experienced nchds who may lack the knowledge and confidence to discharge them. furthermore many beneficial clinical and lifestyle interventions are not commenced. through a series of pdsas, a checklist was developed and implemented to ensure that copd patients received appropriate interventions and highlight which patients could be safely discharged to the care of their general practitioner. this combined a checklist of criteria for optimisation of copd patient management devised in the respiratory department as well as both the validated copd assessment test (cat) and modified medical research council dyspnoea scale. discharged patients had a cat score of b and no significant outstanding treatment modifications. the checklist was completed in copd patients of whom ( %) were suitable for discharge. interventions such as optimised pharmacological therapy, assessment of inhaler technique and vaccination education were not instituted in , and % of patients, respectively. we conclude that an opd discharge checklist is an appropriate intervention to improve quality of care for patients with copd and facilitate the discharge of stable patients from a respiratory opd. pulmonary rehabilitation (pr) is a multidisciplinary approach to improving the exercise capacity and symptoms of people with copd and ild. however, compliance is often suboptimal. this study investigated whether the education and literacy level of patients may affect attendance and completion of pr. patients were divided into two groups based on diagnosis; copd or ild. nine factors were studied: sex, age, baseline activity level, education, literacy, social isolation, transport to programme, oxygen requirements and anxiety and depression scores. completion of pr was defined as attending [ % of the classes. our findings demonstrated that % of copd patients failed the literacy test compared to % of ild patients. % of copd patients had only primary level education in contrast to % of ild patients. % of copd patients completed third level education compared to % of ild patients. % of copd patients travelled to pr in their own car in contrast to % of ild patients. % of copd patients got public transport to pr compared to % of ild patients. % of copd patients and % of ild patients completed pr. although there were significant differences in educational achievements between groups, this did not affect their compliance in completing pr. osteoporosis has not been fully evaluated in copd patients. the development of osteoporosis among copd patients is multifactorial. the objectives of this study were: ( ) to explore the prevalence of osteoporosis among copd patients, ( ) to observe any correlations between t-scores and different disease related variables. copd patients attending respiratory clinics were randomly assigned for dexa scanning. pts were excluded because of the coexistence asthma, age [ years and early menopause. the mean age of the studied patients was (range - ) years, and % were female. mean fev of these patients was %. seventy-two percent had osteoporosis, and % had osteopenia. mean t-score was - . (male - . , female - . ). t-score was noted to have positive correlation with age (r = . , p = . ), but no correlation with bmi (r = . , p = . ) and fev (r = - . , p = . ) was noted. statistical difference in t-score was observed between patients with normal/reduced mobility vs. poor mobility (p = . ) but no difference was observed among patients with steroids inhalers alone (over the last years) or in combinations with oral steroids (p = . ). very high prevalence of osteoporosis was noted among our cohort of copd patients. surprisingly, there was no association of bmd with fev , bmi and corticosteroid exposure. the aim of this study was to determine the benefits of standardised reassessment of long term oxygen therapy (ltot) patients. long-term oxygen therapy (ltot) is the treatment proven to improve survival in chronic obstructive pulmonary disease (copd) patients with chronic respiratory failure. this study was prompted by an absence of any formal or regular assessment of ltot after initial prescription. the patient's oxygen requirements were assessed carrying out abg analysis after the patient had been taken off oxygen for thirty minutes. the patient then participated in a six minute walk test ( mwt) to determine the need for ambulatory oxygen. of the patients contacted attended for ltot reassessment. % patients no longer met the criteria for ltot i.e. pao [ . kpa. % required a decrease in their static oxygen requirements. . % required an increase in their ambulatory oxygen requirements. . % needed a prescription for ambulatory oxygen. % had a sub therapeutic oxygen prescription. in total % of participants required a change to their oxygen prescription. current procedures for the assessment of ltot result in a large proportion of recipients not having appropriate prescription. there is a need for the initiation of standardised regular reassessment of all ltot patients. with increased ambulatory treatment of copd exacerbation, there is a need for opd assessment of blood gases and ph. we looked at the correlation between arterial blood gas (abg) and capillary blood gas (cbg) in a stable population of opd patients with copd. patients attending for oxygen assessment had a capillary blood sample taken from the fingertip pulp. this was analysed using the epoc Ò point of care analysis system. an arterial blood sample was obtained from the radial artery and analysed using a radiometer blood analyser. patients attended for oxygen assessment. we used pearson's correlation to compare the results of abg and cbg. it showed a moderately high correlation of pco at % (p = . ). a correlation of % with po (p = . ). the hco and base excess correlations were extremely high at % (p = . ) and % (p = . ), respectively. independent sample t tests were used to look at the agreement between abg and cbg values. it showed that cbg could be useful in predicting ph, hco and base excess but not very useful clinically in predicting pco and po . cbg could be used in the opd setting to monitor blood ph and may be useful in copd outreach assessments. identifying lung disease early is very important and can be done with spirometry testing. early detection of these diseases can greatly improve outcomes and quality of life for patients. members of the public were given the opportunity to have their lung function tested for free, as part of the world spirometry day campaign. spirometry was performed by respiratory scientists. access to smoking cessation advice, inhaler technique and the benefits of exercise to maintain healthy lungs were also provided. patients were tested. % (n = ) were male and % (n = ) were female. % (n = ) were under years. % (n = ) were [ years. % (n = ) reported that they had a previous lung function test. % (n = ) reported they never had a lung function test performed. % (n = ) did not answer. % (n = ) of those previously tested reported a history of known lung disease. % (n = ) who were never tested reported a history of lung disease. % (n = ) were non-smokers, % (n = ) were current smokers, % (n = ) were ex-smokers and % (n = ) unknown smoking status. % (n = ) achieved normal spirometry. % (n = ) results were abnormal. % (n = ) results were unreliable. of the abnormal results; % (n = ) demonstrated obstructive lung disease, % (n = ) restrictive lung disease & % (n = ) mixed lung disease. implementing and evaluating palliative care responses for patients with advanced respiratory disease. this multi-site action research project used mixed methods data collection strategies including qualitative interviews with patients and families, expert focus groups and quantitative methods such as education surveys, evaluation and chart audits. study findings demonstrate that palliative care interventions can be implemented within respiratory services for those patients with advanced disease. the study methodology of action research ensured that all key stakeholders in the service delivery across several sites contributed to sustainable organisational change which delivered measurable care improvements for patients throughout the research process. interventions that have developed include; shared training and education across sites, multi-disciplinary team meetings, pulmonary rehabilitation session on coping, death reviews and the development of a respiratory palliative care pathway for patients. palliative care interventions are feasible within care delivery models for patients with advanced respiratory disease. referral links and a care pathway between the hospital and hospice settings are at the cornerstone of this care delivery model. half of all patients admitted with copd in ireland are either dead ( %) or re-admitted to hospital ( %) within days [ ] . variation in the management of copd patients may contribute to this. implementation of care pathways has been suggested to improve outcomes such as mortality, admission rates and length of stay. the acmb was introduced as a sticker in the healthcare record in feb . a cross-sectional audit reviewed staff practice prebundle implementation, post-bundle and following an educational drive. % of patients in the pre-bundle group received nebulised bronchodilators within min of presentation, in comparison to[ % in the post-education group. prescription of oral corticosteroids improved with a corresponding decrease in patients receiving none. there is ongoing use of intravenous corticosteroids ([ %). the use of intravenous antibiotics was unchanged at approximately % although over % of patients received an antibiotic recommended in the acmb. % of pre-bundle patients received an abg, % within min; following the educational drive this increased to % with % within the timeframe. further education may be required to decrease the frequency of intravenous medications along with examination of barriers to managing patients within the acmb timeframe. the recent ers audit of irish patients with exacerbations of copd was the first nationwide assessment of survival and readmission rates for this patient cohort. it showed an average length of stay of days, a day readmission rate of % and mortality rate of . %. our copd outreach provides supported or pre-emptive discharge as an alternative to hospital treatment for copd exacerbations. we undertook an audit of patients treated by the outreach team over years to compare rates of these values with those from the ers audit. among patients who died in this period ( %) died in the day period from discharge and ( %) were readmitted. of those that died, % were readmitted within days and % died in hospital within a short period of readmission. of overall readmissions ( ) % were from early discharge programme, ( %) assisted and ( %) prevent readmissions. of note % of prevent readmission patients died within days. the median length of stay was days. these data indicate that survival and readmission rates are the same whether patients are treated in hospital or by outreach teams, however, with shorter lengths of stay the later is associated with substantively lower costs. future research will need to focus on identifying the factors that contribute to the high readmission rates. the central purpose of pulmonary rehabilitation is to reduce morbidity by improving functional capacity through exercise. it is still unknown if improvements in functional capacity are maintained in the long-term and lead to increased physical activity levels. the hypothesis of this study was that pulmonary rehabilitation would lead to a sustained increase in standard outcome measures and in daily physical activity. a prospective study of subjects with copd was performed, registered at clinicaltrials.gov (clinical trial number nct ). the primary outcome was a maintained improvement in standard outcome measures with a secondary aim of an increase in daily physical activity. a convenient sample of the cohort (n = ) was re-evaluated at a third time point at year. a weeks hospital based outpatient pulmonary rehabilitation programme led to a significant reduction in total energy expenditure (p \ . ) and breathlessness (borg, p \ . ) and improved exer- these findings show that while pulmonary rehabilitation increased exercise capacity this was not transmitted into increased daily physical activity. alternative methods to alter/affect behavioural change may need to be addressed. the national clinical programme for chronic obstructive pulmonary disease (copd) aims to improve quality, access and cost of care for patients with copd. pulmonary rehabilitation (pr) has been proven to meet these aims. the purpose of this study was to audit pr throughout ireland. hospitals and all local health areas (lha) were surveyed about prp in their catchment areas -ongoing programmes, length of and numbers on waiting lists, and enrolments in prp in the first months of . those without access to prp were asked about barriers to setting up such programmes. descriptive statistics were used. all hospitals (n = ) and lha (n = ) responded re access. % of hospitals (n = ) and % of lha (n = ) have access to pr. hospital settings have mean waiting lists . months( , ), mean numbers waiting ( , ) and mean number enrolled ( , ), (respondents = ). respondents (n = ) from the community showed waiting lists of and months, numbers waiting and and numbers enrolled and . 'black spots' with no access were identified. barriers that may be amenable to intervention include increased support for primary care teams, facilitation of appropriate referrals and the development of spirometry services in the community. patients were selected as per gold guidelines. the duration of the study was weeks. four primary care centres were selected, one each in longford, athlone, tullamore and mountmellick. one spirometry clinic was held every week on a rotational basis with the intention of accommodating patients per clinic. it was free service and intended for patients who had not previously undergone spirometry testing. the gp practise booked patients directly into the spirometry clinic. a total of patients were booked across the spirometry clinics. of the patients booked, % did not attend and % cancelled their appointment. out of the clinics utilized all available slots with one clinic utilizing only % of available slots. a total of patients were tested. out of these, had normal spirometry, had gold stage mild copd, had stage moderate copd, had stage severe copd and had stage very severe copd, had possible restrictive lung disease and unreliable data. success and efficiency of this type of service is heavily dependent on spirometry clinics being gp driven. a number of advantages, disadvantages and recommendations arose out of this study. . an audit of steroid and antibiotic therapy for acute exacerbations of copd in a cork hospital sought to determine compliance with these guidelines in the mercy university hospital, cork. a retrospective review was conducted on patients admitted with exacerbations of copd from st june to st august . forty-six patients attended the ed with exacerbations of copd. thirty-three charts were available for review. of the patients, ( . %) were prescribed iv hydrocortisone, despite being able to take oral prednisolone, ( . %) were prescribed oral prednisolone and ( . %) were not prescribed steroids. eight patients were prescribed co-amoxiclav alone, patient was prescribed clarithromycin alone and no patients were prescribed doxycycline alone. four were treated with piperacillin/tazobactam, patient with piperacillin/tazobactam and linezolid, patients with co-amoxiclav and clarithromycin, one patient with moxifloxacin, patients with ciproxin and for patients, antibiotics were not prescribed. of the patients prescribed co-amoxiclav and clarithromycin, had infiltrates on cxr. the prescription of antibiotics and steroids in the muh in patients with acute exacerbations of copd did not meet guidelines as per the national copd acute management bundle. though niv significantly improves outcomes in acute copd patient care, there is no compulsory niv training programme for nchds. we assessed nchd's knowledge of the use of niv in copd using a questionnaire, based on bts guidelines, with reliability assessment in a subset of nchds. experience level, knowledge of niv contraindications and settings were examined. questionnaires were completed. inter-rater agreement was good (kappa . , se . , % ci . - . ). % had previously worked in respiratory medicine. % had commenced patients on niv and/or titrated settings on call. % had received training in the use of niv. % adjusted niv settings incorrectly for hypercapneic acidemia. % used epap incorrectly. those with respiratory work experience had greater niv titration experience (p = . ) and superior knowledge of niv settings (p = . ). though % of interns had previously titrated settings, their confidence tended to be lower (p = . ) and their knowledge of niv settings was significantly inferior to more experienced doctors (p = . ). though niv is widely used by nchds of all grades, the present study shows training and knowledge deficiencies, especially among interns and those not in a respiratory post. there is a need for structured training in this key skillset among nchds. table . conclusions: approximately one-third of the patients in who presented to the ralc were classified as asymptomatic. approximately / of asymptomatic and only / of symptomatic patients had early stage cancer ( and ) which was a statistically significant difference. there was no difference in smoking history gender, tissue type and ecog status at presentation between symptomatic and asymptomatic patients. lung cancer is the most common cause of cancer death in ireland. a recent large screening trial demonstrated a % survival advantage with low-dose ct over chest x-ray [ ] . however, the false positive rate of . % for screening detected nodules is a major drawback. a lung cancer biomarker would lead to improved specificity, reduced costs and a reduction in unnecessary procedures for patients with ct-detected pulmonary nodules. biomarkers would also be useful for monitoring response to therapy or disease progression and may reveal the molecular mechanisms underlying cancer development. proteomics represents an important tool for identifying novel cancer biomarkers. recent advances in mass spectrometry allow rapid and accurate analysis of several thousand proteins in a single study [ ] . we prospectively recruited patients presenting to beaumont hospital rapid access lung clinic between april and july . paired bronchoalveolar lavage (bal) and serum samples were obtained. patients were subsequently grouped after clinical and mdt follow-up into ( ) benign, ( ) possible (for surveillance), and ( ) confirmed lung cancer. samples were then analysed by orbitrap mass spectrometry and candidate lung cancer biomarkers identified based on the clinical and histological characterisation. principal components analysis (pca) of the peptides found to be differentially expressed between control bal and cancer bal was performed to determine any outliers in the data and also to identify group clustering as per diagnosis. leave-one-out cross validation (loocv) of a protein plasma combination demonstrated an accuracy of * . % (auc: . ) for distinguishing benign conditions of the lung from cancer (sclc/ nsclc) (fig. ) . further analysis and validation is underway. trapped lung after malignant pleural fluid drainage is a contra-indication to talc pleurodesis. vats identifying patients amenable to talc may be prohibited by co-morbidities. initial experience with a miniinvasive alternative is described in three patients, two transferred with debilitating dyspnoea and previous multiple admissions for drainage procedures. ultrasound was performed and pleurx Ó insertion under la (single in patient, bilateral in ), with palliation of symptoms facilitating discharge in all three. a rapid access lung cancer clinic (rac) with radiological support was recently introduced aiming to both decrease the time to diagnosis of patients, whether negative or positive, and also to decide the most appropriate investigation for each patient with on-site radiologist support. in this observational study, we used a historical cohort of the last fifty red flag patients assessed at the respiratory clinic before the introduction of the rac, and compared it with the first thirty-five patients seen at the rac. time to diagnosis and the number of invasive investigations [bronchoscopy/fine needle aspiration (fna)] were compared as outcome measures. continuous variables were compared using mann-whitney u test and categorical variables using fischer's exact test. patients were similar in terms of demographics. there was a statistically significant reduction in the time to diagnosis (p \ . , mann-whitney u), whether negative or positive, following the introduction of the rac (fig. ) . there was also a statistically significant reduction in the number of bronchoscopies (p \ . , fischer's exact test) carried out after the introduction of the rac. these results demonstrate that the rac with radiological support decreases both the time to diagnosis and the number of invasive investigations that may not have yielded a diagnosis. tbna has been widely available for sampling mediastinal lymph nodes (ln) for over two decades. unfortunately, blind tbna has low sensitivity and limited access to only certain ln stations. ebus-tbna has revolutionised ln sampling demonstrated in many prospective multicentre trails. over a -month period, patients with evidence of lymphadenopathy on chest ct, underwent ebus-tbna. procedures were performed on patients ( males, mean age of . years). diagnostic yield, and sensitivity were calculated by reviewing clinical notes, radiological imaging, cytology, transbronchial/endobronchial biopsy, bal, and mediastinoscopy reports, and redo ebus-tbna reports from another centre. in % of procedures, ln were sampled. . % of ebus-tbna samples were diagnostic ( cases for sarcoid, and for lung cancer). diagnostic yield was compared in st . -month period versus nd and returned versus . %. sensitivities for sarcoidosis and lung cancer were calculated at and . %, respectively. review of current data shows diagnostic yield and sensitivities varies significantly, however, our results were below current published standards. radiologically guided lung biopsy is a relatively safe procedure to reach a histological diagnosis for suspicious lung lesions. we audited the performance of university hospital galway against the bts guidelines. this was a cross-sectional study. all patients who had radiologically guided percutaneous lung biopsies between january and october were included. primary outcome was the ability to reach a histological diagnosis. secondary outcome was development of pneumothorax or other complications. biopsies were performed. were males and were females. mean age was . years. mean lesion size was . ± . cm. the procedure was done under ct-guidance in patients ( . %), fluoroscopy in patients ( . %) and ultrasound in patients ( . %). the overall diagnostic rate for benign and malignant causes was . %. malignancy was diagnosed on biopsies ( %). sensitivity for detection of malignancy for lesions [ cm in size was ( . %). the procedure was complicated by pneumothorax in patients ( . %). only patients ( . %) required chest tube insertion. we achieved a higher diagnostic rate than the level set by the bts but pneumothorax rate was slightly higher. this could be because the majority of our samples were taken using large bore cutting needles. sarcoidosis is a systemic granulomatous disease of unknown aetiology that primarily affects the lung. several reports have suggested that analysis of cd +/cd + lymphocytes can be used to differentiate sarcoidosis from other causes of interstitial lung disease. the aim of this study was to evaluate the diagnostic utility of bal fluid cd /cd ratio in diagnosing pulmonary sarcoidosis. this was a retrospective cohort study. study population included all patients who had bal fluid obtained during fibre-optic bronchoscopy in university hospital galway between november and june . outcome variable was cd +/cd + ratio as calculated on flow-cytometry performed on bal fluid. patients got bal fluid analysed. ( . %) were found suitable for analysis by flow-cytometry. had a transbronchial biopsy performed. out of patients with histological evidence of sarcoidosis, only patients had bal fluid suitable for analysis. ( . %) of them had a cd /cd ratio higher than . . sensitivity of cd /cd ratio [ . in diagnosing pulmonary sarcoidosis was % with a specificity of %. positive predictive value was % and a negative predictive value was . %. the distribution of cd /cd ratios in patients with biopsy-proven sarcoidosis suggests that substitution of bronchoalveolar lavage cellular analysis for transbronchial biopsy is not advisable. we previously reported that smoking cessation (sc) services are available but lacked uniformity or consistency countrywide [ ] . we found that ( %) of service providers (sp) were collecting and analysing data on pregnancy status but % did not analyse it and % did not collect any data on pregnancy. we aimed to look at outcomes of sc in pregnancy, provide evidence based data to improve services for this vulnerable population and aid their evaluation and effectiveness. using a census of all known smoking cessation programmes throughout ireland [ ] , sps were asked to pilot a treatment database for a month period. many different data were entered including pregnancy status and treatment outcomes. the data were returned to tfri for analysis using a statistical package spss. a database was piloted over a month period by sps. a convenience sample of , patients was recruited while attending sc service throughout ireland and their data were entered into the database. a total of pregnant women attended the smoking cessation services during this period which represents . % of the females treated. they achieved a quit rate of . % at weeks and . % at months compared with . and . % of the rest of the female population treated in the same time period. the poor outcomes may be a result of the paucity of services in ireland for this population group. the findings will facilitate planning and delivery of effective sc programmes to pregnant women ensuring equity in service provision. maternal smoking in pregnancy is an important risk factor for low birth weight (lbw) (\ , g) and prematurity (\ weeks gestation) [ ] . the purpose of this study was to examine smoking rates and prevalence of associated adverse birth outcomes in the coombe women and infants university hospital, dublin over a year period - . a cross-sectional observational study was conducted using routinely collected data from the euroking k maternity system from january -december (n = , ). smoking prevalence declined significantly from . to . % over the period. rates in teenage mothers remained very high ( . % in ). smoking prevalence was almost twice as high in mothers of lbw compared to normal birthweight babies, one and a half times higher in mothers of preterm babies compared to full term and more than twice as high in mothers of small for gestational age (sga) babies compared to non sga. a statistically significant decline was seen in the prevalence of sga babies in the period. no statistically significant change was seen in the prevalence of lbw or preterm babies. prevalence rates in pregnancy are high in ireland compared with other developed countries. increased focussed efforts are needed to reduce smoking rates. smoking-related diseases account for over , admissions per year in ireland. % of all smokers will die of smoking-related disease, and smokers on average die years younger than non-smokers. the aim of this project was to assess attitudes and beliefs in smokers and ex-smokers. patients who were smokers or ex-smokers were interviewed using a standardised questionnaire. candidates were recruited from respiratory clinics and general-inpatient wards in beaumont hospital. data regarding underlying medical history was acquired from medical records. patients were included, ex-smokers and smokers. there were no differences in gender or medical history. ex-smokers had a mean age of . years compared to . years in smokers (p = . ). smokers had longer smoking history; . years compared to . years (p = . ). smokers reported lower expectations regarding the benefits of smoking-cessation than the exsmokers; only % believed there would be short-term health benefit and only % believed quitting was worthwhile compared to . and . %, respectively, in the ex-smoking group (p = . /p = . ) there is significant variation amongst smokers and ex-smokers regarding attitudes to smoking-cessation; this is despite receiving the same smoking-cessation advice and having low fagerstrom-scores. of note current-smokers were younger but had longer smoking histories and smoked from an earlier age. results: a total of patients have been referred, . % (n = ) male and . % (n = ) females. the mean age at referral was . years. . % of patients admitted to being current smokers, of these . % were male and . % were female. . % had a previous history of smoking . % of patients were referred from their gp, . % were referred from another consultant based with the mwrh and . % from another centre. a total of patients referred to the clinic subsequently had a diagnosis of cancer. patients had a diagnosis of lung cancer (adenocarcinoma = , scc = , other nsclc = and small cell = ). patients were diagnosed with a malignancy other then lung cancer, the most common being lymphoma, or metastatic lung disease. male patients accounted for . % (n = ) and female . % (n = ) of those diagnosed with cancer, with a mean age across both genders of . years. conclusions: the results of the audit would suggest that the ralc clinic is in line with national trends as regards smoking prevalence and age. the referral pathway needs to be the focus for the future facilitated by early referral from gp's. this will enable the ralc clinic to prioritise prompt investigations and treatments to optimise survival. sarcoidosis. we aimed to assess the diagnostic accuracy of ebus- [ ] . twenty ipf patients attending a specialized clinic were recruited. their blood samples were collected. full pulmonary function and awake arterial blood gas, high resolution computed tomography of chest (hrct) were performed. ccl was quantified using a enzyme-linked immunosorbent assay. ccl levels are presented as median ± interquartile range. correlations were analysed using pearson and simple regression. median concentration of ccl was higher in ipf patients [ , . pg/ml ( , . - , . )] compared to healthy controls [ , pg/ml ( , - , ), p = . ] [ ] . ccl levels were inversely correlated with diffusing capacity for carbon monoxide (dlco) (r = - . , p = . )* and awake carbon dioxide (co ) tension (r = - . , p = . *). positive correlations were observed between a-a gradient and ccl concentration (r = . , p = . *) and co rise during sleep (r = . , p = . *) but no relationship between ccl and fibrosis score, mean reticulation score or mean ground glass score on hrct. ccl levels correlate with physiological marker of fibrosis. we found significant correlation between ccl and markers of daytime hyperventilation and nocturnal hypoventilation. ccl may be a useful marker of disease activity in ipf. were reviewed. patients with normal cxr who had ctpa performed were included in study. in patients who had no pe but incidental findings (n = ), further review was done to see if these findings would account for presentation. in patients with normal cxr and negative ctpa, an alternative diagnosis directed by incidental findings was able to account for presentation in . % (n = ) of cases. of these, respiratory causes accounted for % (n = ), with pneumonia being the commonest overall cause at . %. other causes included atelectasis %, emphysema %, effusion %, collapse %, lesion % and pneumothorax %. ctpa is able to offer an alternative diagnosis in patients who had initial normal cxr and negative ct pa. our study is suggestive of high incidence of pneumonia in patients scanned for suspected pe. ctpa is the investigation of choice for suspected pulmonary embolism (pe). determining pretest probability for risk of pe using risk assessment scores and d-dimer is an important step in diagnosis. to establish positive predictive value of clinical and lab-based risk assessment for diagnosis of pe and to determine whether or not there was an overuse of ctpa in our service. a retrospective audit identified patients (n = ) who had ctpa performed from january -march . patients were classified as being low, intermediate or high risk for pe, based on wells criteria [ ] . cases were reviewed to establish if pretest assessments were used correctly in predicting probability of pe and need for ctpa. in high risk group (wells score [ ) (n = ), there were diagnosed pes (ppv . %). in intermediate risk group (wells score c b ) (n = ), there were pes (ppv . %). in low risk group (wells score b ) (n = ) there were pes (npv . %). in our sample, wells scores had reasonable predictive value for diagnosis of pe in high risk patients. positive predictive value in intermediate group was significantly lower and ctpa may be overused in this group. negative predictive value for low risk group was very high. therapeutic thoracentesis: the role of ultrasound and pleural manometry ultrasound-guided thoracentesis the utilization of endobronchial ultrasound for sampling of primary lung we performed a retrospective audit of mesothelioma patients diagnosed in the whsct between and and compared our practice against guidelines. patients ( male, female) were diagnosed-mean age . years, range - years. asbestos exposure was documented in patients ( . %). patients ( %) had right-sided chest disease with ( %) having left-sided disease /hospice. patients are still alive. all patients were known to a lung cancer specialist nurse pilcher alfred hospital intensive care, melbourne, australia we examined the use of bronchoscopy in a bed icu/hdu over a month period. our aim was to establish the number of procedures done, the indications and complications. we also performed an audit of procedure documentation and set-up. procedures were identified over the period in question. % patients were male and ages ranged from to with a mean of years. various indications were documented with infection ( %), tracheostomy insertion ( %) and difficulties with oxygenation ( %) being the most common interstitial lung disease and pulmonary vascular disease chairs d. o'callaghan, mater misericordiae university hospital we now characterize potential mechanisms associated this b cell phenotype in sarcoidosis. serum was collected from treatment-naive, sarcoidosis patients and control patients. b cell activating factor (baff; r&d systems) and soluble (s) cd (ebioscience) levels were measured by elisa. expression of b cells in sarcoidosis granulomas were assessed using standard immunohistochemistry. all subjects signed an informed consent prior to participation. b cells were detected in sarcoid granulomas, but using serial sections no cd positive b cells were identified with respect to reduced cd b cells in sarcoidosis, we found no evidence that these cells are sequestered in sarcoid granulomas and that the key critical b cell cytokine, baff is appropriately elevated. scd is increased raising the possibility that the phenotype in this population reflects shedding of cd from the surface of memory b cells the diagnosis of sarcoidosis required the presence of non-caseating granulomata with negative ziehl-neelson stain and fungal stain plus negative culture for mycobacterium tuberculosis (tb), other bacteria and fungi. results: patients were tested. / ( . %) had positive tblb. / had negative tblb ( . %). of the negative tblb group, / ( %) had positive ebb. tb cultures on all tblb biopsy samples were negative and bal was negative for bacterial and fungal growth in all cases. no patient suffered complications secondary to the procedure. conclusion: tblb remains a useful diagnostic test in the diagnosis of sarcoidosis serum fibroblastic growth factor- in acute sarcoidosis p other serum biochemical markers measured included calcium, phosphate, h urinary calcium, parathyroid hormone (ipth) and -hydoroxy vitamin d . results: subjects were male and were female. mean (sd) ipth was . ( ) ng/l, serum calcium . ( . ) mmol/l, serum phosphate . ( . ) mmol/l, serum -hydroxy vitamin d ( . ) nmol/l, and h urinary calcium excretion was . ( . , . ) mmol/l. fgf- was detectible only in those patients who also had hypercalciuria and was elevated in all those with hypercalcaemia. after adjusting for covariates using stepwise multivariate linear regression fgf- was independently associated with serum calcium conclusions: this study describes the distribution and determinants of serum fgf- in acute sarcoidosis for the first time. evidence is accumulating that fgf- may have a pathogenic role in adverse cardiovascular outcome, whether this applies to patients with sarcoidosis and normal kidney function merits further investigation convex probe endoscopic and endobronchial ultrasound (eus/ebus) for the diagnosis of sarcoidosis ebus and eus guided lymph node aspiration is a minimally invasive procedure widely used for diagnosis and staging of lung cancer. there has been increasing interest in utilising these modalities for the diagnosis of benign conditions including pirfenidone is an emerging therapy for limited ipf mcnicholas department of respiratory medicine, st. vincent's university hospital, dublin idiopathic pulmonary fibrosis (ipf) patients have reduced exercise capacity [ ], which correlates with parameters of pulmonary function and arterial oxygen tension resting pulmonary function testing and arterial blood gases were recorded. statistical analyses included student-t and mann-whitney u testing. maximal work load was reduced at . ± . % predicted corrected for sex, age and height. vo max was moderately reduced at . ± . % predicted. mean pre and post exercise borg score was and . a positive correlation was observed between vo max and fvc (r = exercise testing in the evaluation of diffuse interstitial lung disease pathophysiology of activity limitation in patients with interstitial lung disease diagnostic serum biomarkers to distinguish idiopathic pulmonary fibrosis from scleroderma-associated lung disease and healthy controls b. kennedy , p. branagan cork idiopathic pulmonary fibrosis (ipf) may be difficult to differentiate from scleroderma-associated interstitial lung disease potential biomarkers were measured by elisa or biochip immunoassay. differences between groups were calculated by unpaired t-tests. data are presented as mean ± sem. mean serum levels of kl- ( ± vs. . ± ng/ml elevated serum sp-d may help differentiate ipf from ssc-ild and healthy controls. the elevated serum sp-d in ipf compared to ssc-ild may reflect increased leakage from pulmonary capillaries arising from more extensive alveolar injury bone marrow and peripheral blood derived cd + cells as agents of tissue remodelling in idiopathic pulmonary fibrosis b cd + cells originate in bone marrow, circulate and then migrate to tissue where they may differentiate into macrophages. we investigated extrapulmonary cd + cells as a source of mediators of tissue remodelling in ipf. peripheral blood (pb) and bone marrow (bm) were obtained from /ml, p = . ) cd + cells. ipfs and controls did not differ significantly in ccl , ccl , tgf-b , ccl , mmp , mmp or timp expression in either pb or bm cd + cells. ipfs and controls do not demonstrate any quantitative differences in the expression of mediators of tissue remodelling in pb or bm cd + cells. nevertheless ccl as an indicator of pulmonary fibrotic activity in idiopathic interstitial pneumonias and systemic sclerosis circulating levels of the chemokine ccl but not cxcl are elevated and correlate with disease activity in rheumatoid arthritis diffusing capacity of carbon monoxide (dlco) are the physiologic characteristics mostly correlated with hrct findings. high fibrosis score and extent of the reticulation and honeycombing on ct are associated with increased the risk of death [ ]. we aim to investigate the correlations between radiological and physiological features of ipf. patients with ipf were recruited from our database. full pulmonary function testing and awake arterial blood gas were performed. survival data were collected after a period of follow up. hrct was scored by a core radiologist on-site. data was analysed using linear regression and spearman correlation high-resolution computed tomography in idiopathic pulmonary fibrosis: diagnosis and prognosis ct features of lung disease in patients with systemic sclerosis: comparison with idiopathic pulmonary fibrosis and nonspecific interstitial pneumonia incidental abnormalities found on negative ct pulmonary angiograms performed on patients for suspected acute pulmonary embolism and with normal chest x-ray primary chest wall tumours and lung cancer invasion of the chest wall are the usual indications for chest wall resection and reconstruction. we evaluated all patients who underwent chest wall resection ± reconstruction in our unit from february to july . patients were identified. reconstruction was completed using either a composite of marlex mesh and methyl-metacrylate or a goretex sheet. reconstruction of the chest wall prevents post operative complications and restores the respiratory dynamics by avoiding paradoxical or harmful movements. in the majority of cases, it was possible to approximate the soft tissue over the reconstruction. in selected cases, our plastic surgical colleagues used a variety of flaps to approximate the defect.we looked at mean length of stay, histological types, morbidity and survival. there were no intra-operative mortalities. day mortality was . %.chest wall resection is not a common procedure but may be performed in high volume centres with low morbidity and mortality. in those with primary chest wall tumours, a wide resection margin is associated with low recurrence rates. in patients with nsclc (t ) involving the chest wall, en bloc lung and chest wall resection has a proven curative benefit with excellent year survival. fibreoptic bronchoscopy is considered a safe diagnostic tool [ ] . it is suggested, however, that post-bronchoscopy complication rate increases with age [ ] . we decided to study the complication rate and the outcomes of bronchoscopy in patients over years in our institution. a retrospective review of case notes of patients over years who underwent bronchoscopy between september and november was performed. data on complications experienced during and after bronchoscopy and the influence of the results on subsequent management were collated and analysed.ninety-six patients were included. mean age was . years (sd . ). thirty subjects ( . %) had a documented lung disease. fifty-nine patients ( . %) were current or ex-smokers. indications for bronchoscopy were; to evaluate for malignancy ( . %) and to evaluate for tb ( . %). post bronchoscopy complications were noted in eight ( . %) cases including hypoxia ( . %), infection ( . %), tachycardia ( %) haemoptysis ( %) and pneumothorax ( %). six patients required post bronchoscopy treatment for complications. malignancy was diagnosed in twenty cases ( . %) and infection was detected in six ( . %). as a result of bronchoscopy, management was altered in fifty-one patients.in conclusion, bronchoscopy is relatively safe and has good diagnostic utility in patients aged more than eighty years. the introduction of an ebus-tbna program more than halved the numbers of endobronchial brushings without a statistically significant change in the number of combined bals and washings or biopsies. we plan to investigate the impact of ebus-tbna on the diagnostic yield of brushings biopsies bal and washings. the use of fibreoptic bronchoscopy in an intensive care unit tbna and eus-fna in patients with suspected sarcoidosis after its implementation at a university hospital. methods: we retrospectively analysed data on all patients with suspected sarcoidosis who underwent ebus/eus since the start of the service. sensitivity and diagnostic yield were calculated based on cytology results and further invasive diagnostics for negative samples. resuts: over months patients ( males females) with a mean age of ± were assessed. % had stage i disease. underwent ebus and eus. lymph nodes (lns) were sampled in total with a mean of . /patient. diagnostic yield was . % with patients diagnosed with sarcoidosis and patient with tuberculosis. there were false negatives yielding a sensitivity for detecting sarcoidosis of %. tumour necrosis factor alpha (tnf-a) inhibitors have had a huge impact on the treatment of inflammatory arthritis, inflammatory bowel disease and psoriasis. there is also much interest in the use of tnf-a inhibitors in the treatment of refractory sarcoidosis [ ] . paradoxically sarcoidosis in response to tnf-a inhibitors is increasingly recognised with over cases reported to date [ ] . we report a series of three cases of sarcoidosis that developed on tnf-a inhibitors.a year old lady with a history of severe crohn's disease developed a right upper lobe consolidation and respiratory failure following two doses of adalimumab. investigations for tuberculosis were negative. a ct guided biopsy of a persistent right upper lobe infiltrate confirmed non caseating granulomas consistent with sarcoidosis.a year old gentleman on etanercept for ankylosing spondylitis presented with dyspnoea and a dry cough. cxr showed diffuse fibrotic change. ct findings and a transbronchial biopsy showing multinucleated giant cells led to a diagnosis of sarcoidosis.a year old man on adalimumab for rheumatoid arthritis was admitted with cough and purulent sputum. cxr and ct thorax confirmed mediastinal and hilar adenopathy. investigations were negative for tuberculosis. endobronchial ultrasound guided needle aspiration showed non caseating granulomas consistent with sarcoidosis.sarcoidosis in response to tnf-a inhibitors is a rare but increasingly recognised condition. following exclusion of tuberculosis a high index of clinical suspicion is needed to prevent a delay in diagnosis. the distribution of cd /cd ratios in patients with biopsy-proven sarcoidosis suggests that substitution of bronchoalveolar lavage cellular analysis for transbronchial biopsy is not advisable. pirfenidone has been approved for the treatment of mild to moderate ipf in europe. pirfenidone regulates the activity of tgf-b and tnfa. we evaluated a single centre experience with pirfenidone.a retrospective cohort design was used to study ipf patients prescribed pirfenidone. a titrating dose of pirfenidone was commenced on patients with an fvc[ % predicted and dlco[ %. primary outcome was change in percentage predicted forced vital capacity (fvc). secondary outcome was change in percentage predicted transfer factor (dlco). symptomatic patients were prescribed pirfendione. the mean age was . years. patient died due to an exacerbation of ipf, others discontinued pirfenidone secondary to adverse-events. patients reached target dose. subjects continued pirfenidone at a reduced dose. participants reported side effects likely related to pirfenidone. the most commonly reported side effects were gastrointestinal disturbance and photosensitivity. no significant decline in fvc or dlco was noted in patients who continued pirfenidone in . weeks follow up. key: cord- -i q gsu authors: nan title: (th) european congress of trauma and emergency surgery: may – , antalya, turkey date: - - journal: eur j trauma emerg surg doi: . /s - - -z sha: doc_id: cord_uid: i q gsu nan introduction and aims: although liver is well protected by the thoracic cage, it is a frequently injured organ especially by penetrating traumas and also rarely by blunt traumas. retroperitoneally located pancreas and duodenum injury with or without liver injury occur rarely but they are seriously life threatening injuries. for these reasons we aimed to investigate the traumatic liver, duodenum and pancreas injuries as a whole. materials and methods: cases of blunt and penetrating traumas occured in our district are included in this study. in these patients parameters of sex, age, etiology, admission time, stability and physical status on admission, concurrent organ injury, operation type, gradings of injuries, were investigated. results: cases ( , %) suffered from liver injury, while cases ( , %) suffered from hepaticopancreaticoduodenal injury. cases ( %) were caused by penetrating injuries. cases of liver injury group had isolated liver injury whereas cases of the group has additional thoracic injury, cases had great vessel injury, case had orthopedic injury and lastly case had head injury in addition to the liver injury. in the combined hepatic injury group mortality rate was , %. conclusions . in hepatoduodenopancreatic injury group blunt and penetrating injury rates are equal. . duodenum-pancreas injuries occur rarely. liver,with injury rates of cases in this study, is the most frequently injured organ. . mortality rate is higher in the subgroups of patients who admitted to hospital late, and who had concurrent thoracic, orthopedic, and head trauma. background: the incidence of blunt bowel and mesenteric injury (bbmi) has increased recently in blunt abdominal trauma and this is possibly due to an increasing number of high speed motor accidents and the use of seat belts. objective: in this study we sought to identify the factors determining the time of surgical intervention and how they affect the outcome of the patient with bbmi. this was achieved by reviewing our experience as a major victorian trauma service in the management of bowel and mesenteric injuries and how this compares to current literature. methods: a retrospective study reviewing consecutive patients who presented to the alfred trauma centre with blunt bowel and mesenteric injuries over years. results: of the patients with bbmi % were male, % were female. % of the patients underwent a laparotomy, % of patients were treated conservatively and % were diagnosed post-mortem. the times from admission to laparotomy were: - h %, - h %, - h %, - h %, - h %, more than h %, respectively. fast (focused abdominal sonography for trauma) was done in and % of this group had a positive fast. while % of patients had a negative fast and % of patients had an equivocal fast. % overall group did not have a fast. computerised tomography (ct) scans were undertaken preoperatively in % of the patients and showed: free gas ( %), bowel wall thickening ( %), fat and mesenteric stranding or hematoma ( %) and free fluid with no solid organ injury ( %). conclusion: the timing of surgical intervention is mostly determined by the clinical examination and the helical ct scan findings in bbmi. fast lacks in sensitivity and specificity in identifying bowel and mesenteric trauma. delayed diagnosis of more than h has significantly higher bowel related morbidity but not mortality. predictors for the selection of patients for abdominal ct after blunt trauma: a proposal for a diagnostic algorithm introduction and objectives: gastrointestinal and mesenteric injuries (gimi) are not common in trauma, and their diagnosis is frequently delayed. our aims were to determine the reliability of ct scan and to assess the clinical significance of a delayed diagnosis. methods: retrospective analysis of cases confirmed at laparotomy. patients were identified at the severe trauma registry of our hospital, between and . results: we found ( , %) gimi out of patients with abdominal trauma, in a registry with . severe trauma cases included. the mean iss and niss were of and , respectively. mortality was of ( , %) patients, of them unexpected. a ct scan was performed in ( %) cases, and only in were there signs suggestive of a gimi. surgery was delayed for more than h in ( %) patients, the most common reason being a false negative result in the ct scan. there was no significant increase of morbidity or mortality in the delayed diagnosis group. conclusion: the overall incidence of gimi was high in our registry ( % in penetrating and . % in blunt trauma). several factors such as the initial lack of symptoms, a low diagnostic sensitivity of the ct ( % false negatives), and the nonoperative management of solid organ injuries, have contributed to a delayed diagnosis in one of every five patients in our series, but this has not led to a significant increase in septic complications in this group. author to editor: ct scan diagnosis of gastrointestinal injuries continues to be a matter of concern. there is controversy on the clinical significance of a delayed diagnosis of small bowel injuries management of rectal injury: reappraisal of old techniques introduction and objectives: due to immunological functions, conservation of injured spleen following abdominal trauma is very important. for this reason nonoperative management (nom) in the last years has been accepted as the ideal treatment in those patents who are hemodynamically stable and do not require a laparotomy; however in case of multiple abdominal solid organ injuries (soi) nom is controversial. methods: we report on a case of a -years-old patient with spleen and renal injury subsequent to blunt abdominal trauma. ct scan revealed a ois iv injury (third degree in graz classification) and an ois iv renal injury. since chances for successful spleen angioembolization were judged poor by radiologist, a laparotomy and partial spleen resection with preservation of one-third of the spleen was performed. immediately after surgery, angioembolization of the renal injury was successfully performed. results: a contrast enhanced ultrasound (ceus) performed on day and day after trauma revealed a hypertrophy of the residual spleen with diffuse distribution of contrast agent in the spleen parenchyma, confirming functional activity of the organ. morphological and functional evolution of left kidney was normal. conclusions: sequential treatment (surgical preservation of the most injured organ followed by immediate angiographic embolization) could be a valid option in case of multiple abdominal soi; furthermore, ceus is an interesting new tool to determine functional activity of residual spleen. introduction: precise timing of cholecystectomy procedure after biliary pancreatitis is still controversial. the major drawback of interval cholecystectomy is the recurrence of pancreatitis within the interval of - weeks. early cholecystectomy (performed prior to discharge), however, have the disadvantages of increased technical difficulty and conversion rates. methods: we reviewed patients with recurrent biliary pancreatitis among a total number of cases of biliary pancreatitis in-between january and january . results: the mean age was . (range - ), and male-to-female ratio was . ( : ). seventeen patients (% ) had a history of previous cholecystectomy. of these patients, (% ) have had early cholecystectomy, and (% ) have had interval cholecystectomy. the rest of the patients (% , n = ) consists of those who have been scheduled for interval cholecystectomy but have had a recurrent episode during the -week interval (% , n = ) or after the -week interval (% , n = ). conclusion: the majority of patients with biliary pancreatitis do not have any recurrent episodes even if they do not have a surgical or an endoscopic treatment. according to our data, however, an influenced percentage of recurrent pancreatitis develops in patients who do not have early cholecystectomy. therefore, we prefer early cholecystectomy in means of reducing the risk of recurrent pancreatitis during or after the -week interval. introduction and aim: nonoperative management (nom) of splenic injury is currently the most common management strategy in hemodynamically stable trauma patients. aim of this study was to asses if the success rates of - % described, mainly in the north-american literature could be confirmed. methods: we conducted a retrospective study of all patients older than year with blunt splenic injury who were admitted to a level i trauma center. a total of patients were identified with blunt splenic injury during the -year study period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results: the majority were young men; mean age was years. thirty-three ( %) patients underwent immediate surgical management. sixty-seven ( %) patients were treated with planned nom and ( %) patients underwent angiography and embolization (a&e). we did not encounter early complications following a&e. fourteen patients failed observation due to ongoing bleeding. of these, were treated with splenectomy and three with a&e. the splenic salvage rate after observation was %. the splenic salvage rate after a&e was %. four of the five patients with a rebleeding after initially a&e underwent splenectomy and one patient was treated with reembolization. the overall mortality rate was . %. none of the patients died as a result of splenic injury treatment failure. conclusion: nonoperative management in blunt splenic injuries in our trauma center is a well-tolerated treatment with a success rate of %. the splenic salvage and mortality rate is comparable with the literature which is mainly based on north-american studies. mannheim peritonitis index (mpi) is a scoring system with prognostic significance. we applied mpi to patients with perforative peritonitis (on patients in sri ramachandra medical college) to validate the scoring method. it is a specific score with accuracy and allows prediction of prognosis. aim of the study ( ) to study the incidence and aetiology of perforative peritonitis. ( ) to study the demographics of the study population. ( ) to analyse if mannheim peritonitis index (mpi) is a valid scoring method. p-possum (p < . ) scores in the index surgery. malignancy was the most frequent initial diagnosis in patients with spp and benign diseases in tp. there were no differences on the interval between operations ( ± days tp vs. . ± days spp; p = . ) neither in the number of previous laparotomies (p = . ). tp was associated to emergency index surgery (p = . ) and icu hospitalization (p < . ), mechanical ventilation (p = . ) and vasoactive drugs (p = . ). there were no differences in any of the clinical and biochemical parameters analyzed, neither in sirs (p = . ) or p-possum scores after relaparotomy (p = . ). we found no differences regarding mean hospital stay ( days tp vs. days spp; p = . ) and mortality rate ( % in spp vs. % in tp; p = . ). conclusions: although certain differences exist, the clinical course of postoperative peritonitis seems to depend more on factors other than their secondary or tertiary origin. background and aim: patients with primary acs will often develop a secondary acute respiratory distress syndrome (ards). mechanic pressure is mainly responsibe in pulmonary findings in acs. we aimed the role of aspiration of gastric contents into lower airways in pulmonary complications of acs. methods: the rats were initially divided into five groups (group i-v), and then these groups were divided again into two groups if they are unfed (group ia-va) or fed (group ib-vb). in animals in group i-v intraperitoneal pressure (iap) was applied as follows: , , and cm h o by instillation of isotonic saline solution. results: total scores of lung histopathologic findings were concordant with the degree of iab. when the total scores of histopathologic findings in lungs were compared for each applied iab with control group, the scores were higher in fed animals than unfed animals. histopathologic findings in lungs were observed when increased-iap to mmhg ( cmh o) which was accepted as cut-off value. the comparison of the scores of histopathologic findings in two groups in which the applied iab was lower then the cut-off value were not significantly different from the control group. however comparison of the scores of histopathologic findings equal to or above mmhg were significantly higher then the control group. conclusion: our results show that that pulmonary aspiration related with passive regurgitation in acs has a substantial influence on histopathologic findings seen in this disorder. editor to self: secilmiş bildiri emergency surgery and delayed abdominal closure: results in cases carlos mesquita, marco serô dio, francisco castro-sousa emergency and general surgery departments, coimbra university hospital, coimbra, portugal delayed abdominal closure (dac), in emergency surgery, must be economical, fast to execute and easy to maintain, allowing second look and definitive closure, with minimal prejudices to the abdominal wall. as an alternative to the vacuum closure systems, the aa have been utilising the rotondo and schwab technique (iatsic-dstc course), by the interposition of a plastic towel between abdominal contents and wall. dac has been utilised in patients ( male, female, - ) , median age of ( - ). in five, after abdominopelvic packing for hypovolemic shock conditions. in , after mediastinal and peritoneal decontamination procedures and lavage for septic situations with actual or potential compartment syndrome: three from acute necrotizing pancreatitis, six from dehiscent digestive sutures and two from strangulated hernias. four patients died in the open abdomen situation, one from pancreatitis and three from dehiscent sutures. primary abdominal closure has been possible in : in the cases of packing and in of the of the cases of sepsis. in one case of pancreatitis it has been possible a secondary closure. dac is now accepted like a safe procedure in damage control and compartment syndrome conditions which contributes to ameliorate the results in life threatening situations. than %. this report describes our experience with vacuum assisted closure (vac-)therapy in the management of efs in an oa. materials and methods: nine patients with seventeen high output efs in an oa were treated with vac-therapy from january till january . the abdominal wound was covered with fatty gauzes. small efs were covered with a patch of hydrophilic polyvinylalcohol foam. the entire abdominal wound was covered with polyurethane foam which promotes granulation and seals of the oa preventing further spillage of enteric contents. continuous negative pressure at - mm hg was applied. for large fistulas with protruding mucosa a hole was cut within the polyurethane foam and an ostomy bag was placed over the fistula mouth. surgery with enterectomy was planned - weeks later. results: the vac-dressing was changed every days. three efs closed spontaneously. time between onset of fistulisation and surgery was days (median days). no additional fistulas occured. one patient died postoperatively. conclusions: although previously considered a contraindication to vac-therapy, the oa with efs can be managed with vac-therapy. a taylored application of the foam and a reduced negative pressure seem to allow a safe and reliable way to manage efs. partial enterectomy and abdominall closure is possible after several weeks. introduction: it was the aim of the study to analyze the potential value of microdialysis in the rectus abdominis muscle (ram) compared with conventional monitoring parameters currently in clinical use for the detection of the abdominal compartment syndrome (acs). methods: pigs were anaesthesized, mechanically ventilated and continuously monitored. microdialysis was performed in different abdominal organs, the ram and cervical muscle (distant reference) for glucose, lactate, lactate-pyruvate ratio (lpr) and glycerol. iah was maintained for h. three groups were analysed: control (a), iah mmhg (b) and mmhg (c).cardiopulmonary parameters, urinary output, blood gas analysis and venous lactate were recorded. results: mean arterial pressure and abdominal perfusion pressure remained above clinically defined thresholds during the experiments for groups a and b. in contrast, group c demonstrated a persistent decrease below these thresholds. significant reduction of urinary output was only seen in group c. lactate levels also remained within physiological range in all groups. in contrast, microdialysis revealed a significant increase of lpr in all monitored organs in groups b and c, indicating ischemia and energy failure. of interest, lpr in the ram showed a significant increase already after h of iah in group b. conclusion: microdialysis of the ram detected local metabolic derangements in animals with iah of mmhg while clinically established monitoring tools failed to show organ dysfunction/tissue ischemia. our data suggest that continuous microdialysis in the ram may represent a promising tool for early detecting iah-induced metabolic derangements before manifestation of clinically apparent acs. introduction: to avoid morbidity associated with open abdomen, subcutaneous linea alba fasciotomy (slaf) was introduced for management of abdominal compartment syndrome (acp) in severe acute pancreatitis (sap). we analyzed the efficacy and safety of slaf as a surgical decompressive technique. methods: a retrospective study of a -year period identified patients with sap and acs undergoing slaf. mean age was (range - ) years, were male and had alcohol-induced sap. slaf was performed - days post-admission, in / cases within h. results: the mean (range) preoperative intra-abdominal pressure (iap) was ( - ) mmhg and immediate postoperative iap ( - ) mmhg. the mean decrease was ( - ) mmhg and the decompressive effect was considered sufficient in / cases. two of these developed recurrent acs and required completion laparotomy, as did the with insufficient effect ( - days post-slaf). the mean preoperative sofa score was ( - ) and ( - ) - days postoperatively, the decrease was > in patients with successful slaf. eventually four patients underwent necrosectomy, two following sufficient slaf. the overall mortality and morbidity rates were / and / , no complications were attributed to slaf itself. mean hospital stay was ( - ) days. of the survivors, fascial closure was achieved in two, and planned hernia in four (two with split-thickness skin graft and two with post-slaf hernia). conclusion: slaf is a safe decompressive technique in sap-related acs. it is effective in about - % of cases, but some require completion laparotomy and/or necrosectomy later on. methods: between march and december , patients were managed with vac technique (kci, san antonio). the mean age was . ( - ) , and m/f sex ratio was / . indications were severe abdominal sepsis in patients, mechanical obstruction due to colorectal cancer in patients, pancreatitis in patients, posttraumatic abdominal compartment syndrome patients, evisseration in patients, enterocutaneous fistule in patients. results: as morbidity there were fistulaes and intraabdominal abscess in all patients. four of the patients were died with concomitant disease. there was no mortality related using vac system. thirty five patients ( %) was underwent a delayed primary closure, five underwent secondary healing by granulation, and four underwent split thickness skin grafting. surgical outcomes of severe hepatic injury were retrospectively reviewed. (methods) among patients with hepatic injury treated between and , patients who underwent surgery were included. the study period was divided into early ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , middle ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and late ( ) ( ) ( ) ( ) ( ) phases, and type of injury, surgical procedure performed and patients' outcome were retrospectively reviewed. (results) ( ) percentage of patients undergoing surgery: % ( / ) underwent surgery in the early phase, % ( / ) in middle and % ( / ) in late phase. ( ) timing of surgery: the numbers of patients underwent laparotomy in er, urgent laparotomy in or, and delayed laparotomy (after h) were ( %), ( %) and ( %) in early phase; ( %), ( %) and ( %) in middle; and ( %), ( %) and in late phase, respectively. ( ) surgical procedures performed: for type iiib (jast grading) cases, hepatectomy was performed in % and hepatorrhaphy was performed in %, giving a mortality rate of % in early phase, . % in middle and % in the late phase. for iiib + ivc/hv cases, hepatectomy was performed in all patients, giving a mortality rate of % in early phase, % in middle and . % in late phase. (discussion) with the increase in nonsurgical management, surgical treatment for hepatic injury is performed preferably in patients requiring immediate response, such as laparotomy in er. the surgical outcome of hepatic injury has been improving, with a survival rate of approximately % for type iiib cases and % for iiib + ivc/hv cases. rifat tokyay, tolga taymaz amerikan hastanesi, istanbul, turkey objective: the aim of this study was to assess the unexpected returns (ur) within month of the adult patients and the pediatric trauma patients initially seen in the _ istanbul american hospital emergency department. design: all urs between . . - . . were recorded. initial diagnosis, final diagnosis, initial treatment, final treatment, reason for readmission, and last medical condition were noted. results: eighty eight urs were recorded. final diagnosis of of these patients were surgical. forty one of these surgical patients had ur due to error in diagnosis and five due to error in treatment. fifty two of these patients returned on the same day or the next day, between nd and rd days, between th and th days and between th and th days. male to female ratio was to . three of the patients were pediatric trauma patients, were between - years, and were over . missed final diagnosis were: acute cholecystitis ( ), acute appendicitis ( ), missed fractures ( ), pneumothorax ( ) liver mass ( ), urethral stone ( ), ectopic pregnancy ( ), diverticulitis ( ), subarachnoid bleeding ( ), others ( ). conclusions: acute cholecystitis, acute appendicitis, and missed fractures were the most frequent surgical causes of urs after emergency department discharges. liberal utilization of abdominal sonography and abdominal ct scan may reduce missed acute abdomen in abdominal pain patients and appropriate radiological imaging and meticulous evaluation of the x-rays may reduce unnoticed spinal, pelvic and facial fractures in trauma patients. editor to self: seçilmiş bildiri olabilir introduction and aim: bacteremia sepsis and septic shock might develop rapidly for the patients with infection in bile path. early diagnosis, surgical treatment and antibiotherapy decrease mortality. in this study, the relation between choledocholithiasis, cholangitis and pancreatitis and treatment methods have been evaluated. method: the demographic features, the treatments, the intensity of the illness and mortality rate of the patients in afyon kocatepe university general surgery clinic between the years background: enterocutaneous fistula continues to be a serious surgical problem. they are related with major electrolyte imbalances, malnutrition and delayed tissue healing. our recent experience with enterocutaneous fistulas is reviewed hereby. methods: we analyzed the charts of all patients with enterocutaneous fistula from january to december . fistulas were assessed for localization, type, output, etiology, use of somatostatin analog and fibrin glue, nutritional support, type of surgical intervention, wound vac, and endoscopic findings. results: we identified patients. fistulas were localized as gastroduodenal in five patients, jejuno-ileal in seven, and colonic in eight. there were enterocutaneous and entero-atmospheric fistulas. endoscopy was performed in patients. output was low (< ml) in , whereas high (> ) in patients. seventeen patients developed fistulas due to iatrogenic reasons, six patients had an underlying malignancy, and three patients developed fistulas after pancreatitis. somatostatin analogs were used in patients. conservative treatment was performed in patients, primary surgical intervention in patients, and secondary surgical intervention in patients. fibrin glue was used in patients and was of benefit to . healing was achieved in patients ( %) after mean . days (range - ). two ( %) patients were died. conclusion: there appears to be no strict rule for treatment of enterocutaneous fistulas. liberal use of endoscopy, fibrin glue as well as restorative surgical intervention all play a major role, and should be employed selectively on an individual basis in the management of enterocutaneous fistulas. aim: in this study we aimed to evaluate the patients whose admitted to neurosurgery and anesthesiology intensive care unit (naicu) between and . matherial and methods: the patients whose admitted to naicu between january and january evaluated retrospectively. diagnosis, age, gender, mortality rate, staying day in icu of the all patients were determined. head traumas were obtained in trauma and multitrauma patients. results: total number of the patients those are admitted to naicu were , and of them because of head trauma ( . %). of the cases were pure head traumas ( . %) or politraumas accompanied with head traumas (ht).the rate of ht was . % of all traumas.there were men, women. mean age of men were . and women were . . staying icu were obtained as . days. the mortality rate was found as . % ( cases). operated cases were ( . %) and the cases followed without any operation were ( . %). mortality rate between operated cases were . % ( ) and nonoperated cases were . % ( ) . ht cases were evaluated by glascow coma scale (gcs) as severe (gcs £ ),intermediate ,moderate (gcs ‡ ).the cases which had gcs £ were ( . %). operated cases were ( . %) and of them dead ( . %). the mortality rate of operated cases ( cases) which had gcs = - were . % ( cases). the number of cases were which had gcs ‡ and the mortality rate of operated cases ( cases) were . % ( cases) at this group. the mortality rate of nonoperated cases ( cases) were . % ( cases). conclusion: the higher rate was ht cases when the trauma patients evaluated and mortality rate of nonoperated trauma patients were higher then operated trauma cases. author to editor: this study send for giving knowledge about traumas which admitted to kocatepe university school fo medicine at a period of months. introduction and aim: this study has been carried out to compare conservative and surgical treatment for the acute pancreatic. method: the treatment processes and radiologic outlook of the patients with acute pancreatitis in afyon kocatepe university general surgery clinic between the years and have been observed retrospectively. results: the average age of the patients with acute pancreatic is and . % of them were women. while conservative treatment was applied on patients, surgical treatment was applied on patients. while the etiologic reason was based on a known source for the . % of the patients, no reason was found for the . % of the patients. ercp was applied for six patients within the scope of conservative treatment. necrotizing pancreatitis existed in five patients. surgical debritment and abdominal washing were applied for four of the patients. acute pancreatitis were diagnosed for the . % of the patients after tomography. one of the patients which had surgical treatment died ( . %). there was no mortality for the patients having conservative treatment. there was not a substantial distinction between the two treatment methods in terms of mortality. ten of the patients had laparoscopic cholecystectomy, ten of the patients had open cholecystectomy (one of the patients with abdominal washing), one of the patients had choledochal exploration with t tube drainage and open abdomen. conclusion: the conservative treatment should be prefered though the treatment ways of acute pancreatitis under discussion. there is not a distinction between the tow methohds in terms of mortality. mü nevver moran, emre gundogdu, ismail bilgiç, hayrettin dizen, mehmet mahir Ö zmen department of surgery, ankara numune teaching and research hospital, ankara, turkey our aim was to compare to efficiancy of different scoring systems as a prognostic indicator in acute pancreatitis. medical records of patients ( female) with mean (range) age of ( - ) years who are diagnosed as acute pancreatitis during years were evaluated according to age, sex, etiologic factors, sirs, apache ii, balthazar scores and ranson scores at admission and at h in order to evaluate the correlation with mortality. the commonest cause was gallstone seen in ( %) cases followed by idiopathic in ( %), alcohol in ( %) and other in ( %). there were ( , %) cases with mortality and ( %) patients underwent operation. in survivors mean (sd) age was ( ) years, sirs score was . ( ) , ranson scores at admission was . ( . ) , ranson scores at h was . ( . ), apache ii score was . ( . ), balthazar scores was . ( . ). in the nonsurvivors group of ( , %) cases, the mean age (sd) was ( ). admission sirs score was . ( . ), apache ii score was ( . ), ranson score was . ( . ), ranson scores at h was . ( . ). when both groups were compared sirs score, apache ii score at the admission and ranson score at h were found to be statistically significant (p < . , p = . , and p = . , respectively), and no differences observed in reference to balthazarscore, hospital stay and icu stay (p > . ). although admission sirs score, apache-score and h ranson score were all found to be important prognostic indicators, sirs seems better and most promising indicator as it is easy to use and not requires sophisticated tests. normal in patients ( %). the appendix was divided by endo-loop in %, intracorporeal suturing in % and endo gia in % of the patients. the meso-appendix division was performed by endoclip ( %), ligasure ( %) and bipolar cautery ( %) . conversion to open procedure rate was ( %). mean operating time was min ( - ). mean hospital stay was . days . major complications were as follows: right iliac artery injury (n = ), bladder injury (n = ), post operative bleeding (n = ), intraabdominal abscess (n = ), appendiceal stump leakage (n = ). minor complications were trocar site infection (n = ) and mechanical bowel obstruction (n = ).there was no mortality. conclusion: la is associated with considerably decreased morbidity and might be considered as the treatment of choice in aa. hakan yanar, cemalettin ertekin, korhan taviloglu, ali fuat kaan gö k, emre sivrikö z, gü lay sarıçam, recep gü loglu trauma and emergency surgery service, istanbul university, istanbul faculty of mediine, istanbul, turkey background: gastrointestinal stenting is increasingly employed to relieve passage. it provides a palliation in inoperable cases or anastomotic strictures. in left-sided colonic and rectal obstruction, it allows decompression for a definitive surgery to be performed. methods: between may and december , patients with acute mechanical intestinal obstruction were treated with endoscopic stenting. localization of malignancy, stenting complications, and surgical interventions were assessed. results: there were a total of patients undergoing gastrointestinal stenting. sixteen patients received gastroscopic stents, four patients with esophageal, eight patients with gastric, four patients with duodenal tumors. stenting failed in five patients ( %), and surgery was required in four patients. nine patients were referred to adjuvant oncologic treatment. fourteen patients received colonoscopic stents; in one patient with a left-colon, in nine patients with sigmoid colon, and in four patients with rectal tumors. stenting failed in seven patients ( %), and six patients were operated emergently with a need for stoma in two patients. ten patients were referred to adjuvant oncologic treatment. no patient was died related with procedure. conclusion: gastrointestinal stenting is a useful adjunct in the treatment of patients presenting with acute mechanical intestinal obstruction for palliation as well as for decompression before definitive surgical therapy. introduction and objectives: internal hernia (ih) is a rare entity which occurs due to the protrusion of an intraabdominal viscus through a normal or abnormal mesenteric or peritoneal aperture. ih can either be acquired through a trauma or surgical procedure, or constitutional and related to congenital peritoneal defects. intestinal obstruction due to ih is very dangerous and lethal because it may be silent, and delay in diagnosis may cause severe abdominal conditions. in this report, we aimed to present patients with ih. methods: seventeen patients who were admitted to our clinic with the diagnosis of ih between january and january were included. patients' demographic data, type of the hernias, type of surgical procedures, length of hospital stay, and prognosis of the patients are evaluated retrospectively. results: there were nine male, eight female patients. mean age of the patients was . years ( - ) . postsurgical ih were seen in eight, paraduodenal in four, transomental in one, sigmoid mesocolon hernia in one patient, and the remaining three hernias were not classified. laparotomy was performed in patients, laparoscopy in and conversion to open surgery in patient. small bowel perforation was found in three patients. seven patients underwent intestinal resection and anastomosis. mean length of postoperative hospital stay was . days ( - ). there was no mortality. conclusion: ih is a rare cause of small bowel obstruction in adults and often present with complications. a high index of suspicion may lead to early surgical intervention and reduce morbidity and mortality. introduction: esophageal perforation is a serious surgical condition in which delay for surgery results in high mortality. application of covered stents is an alternative for emergency surgery. the aim of this study is to analyze the results of esophageal stent application retrospectively. the clinical data and outcome of patients diagnosed and treated for esophageal perforation by endoscopic stent application between february and december were evaluated. results: the mean age of these patients was ( - ) and male to female ratio was / . causes of perforation was mediastinal abscess (n ¼ ), metal stent application (n ¼ ), and balloon dilatation (n ¼ ). stents were applied immediately after perforation in three patients. remained three patients were referred from other institutions and the mean time of delay was h ( - ). perforations were at proximal (n ¼ ) middle (n ¼ ) and distal esophagus (n ¼ ). self expanding covered metal stents were applied in an appropriate position to bridge perforation area in a fashion to cover minimally cm distal and proximal normal esophageal mucosa to all patients under fluoroscopic control. no contrast leak was observed immediately after application and h later. patients were interned and observed under intravenous fluid and antibiotic therapy. except one patient developing transient subcutaneous emphysema no complication was observed. all perforations were closed and the stents were removed at the end of fourth week. conclusion: at the early phase of esophageal perforations covered esophageal stent application can be a better alternative to surgery. introduction: upper gi bleedings are serious conditions which may be life threatening. in seriously bleeding cases the failure of the endoscopic interventions makes surgical intervention necessary. the aim of this study is to present the success rate of endoscopic interventions for upper gi bleeding performed by surgeons. methods: clinical data and the outcome of endoscopic interventions made to of , upper gi bleeding patients admitted to a large community hospitals single surgical endoscopy center between january and september were analyzed retrospectively. results: hemostasis with endoscopic interventions was achieved in ( . %) at initial (n ¼ ) or at second endoscopy (n ¼ ). patients underwent emerging surgery. there was no mortality at the patients treated by endoscopic interventions where as seven patients died after surgery ( . %). conclusion: the outcome of surgery is poor in upper gi bleeding. thus maximum effort should be given to achieve homeostasis by endoscopy. the success rate of endoscopic interventions in this study performed by surgeons is extremely high and satisfying. naomi beks, mariëlle van gameren, sander ten raa, armand van kanten, gert roukema emergency department, maasstad ziekenhuis, rotterdam, the netherlands analgesia use at the emergency department, how evidence-based do we work when dealing with patient with acute abdominal pain? based on a pilot at our emergency department we concluded that it is still common practice to withheld a patient with acute abdominal pain from analgesia till examined by a surgeon or resident. this in contrary to evidence presented in literature which show no negative effect of analgesia use on accuracy of diagnosis in patients with acute abdominal pain. a total of inquiries were send to nurses, physicians and surgeons working at the emergency department of teaching hospitals in the netherlands. we questioned their standard policy on analgesia use in acute abdominal pain. a total of completed inquiries were retrieved, resulting in a response rate of %. there is a difference between the response of nurses and doctors, versus %, respectively. compared to nurses, doctors are more optimistic about the moment analgesia is given. remarkable is the result that % of patients do not receive any analgesia even after examination by a surgical resident and % of the patients have to wait till they are examined by a surgeon is outshining. patients are still withheld from analgesia till a resident or surgeon examines them even though this is not evidence-based medicine. there is no consensus in the netherlands on analgesia use in patients with acute abdominal pain in the emergency department setting. a national guideline for patients with acute abdominal pain is recommended. introduction and objectives: the benefits of laparoscopic appendectomy remain debated in literature. methods: this is a monocentric, retrospective study to evaluate the differences between open and laparoscopic appendectomy for length of hospital stay, wound infection, major complications. retrospective surgical site infection rate evaluation has been possible only for in hospital stay, no further clinical data has been collected regarding outpatient follow-up. results: from january to october we reviewed patients undergoing surgery for acute appendicitis. patients underwent laparoscopic appendectomy ( . %) (group a), patients open appendectomy ( . %) (group b). two different surgical teams, one for laparoscopy and one for laparotomy, performed the procedures. complicated (perforated or gangrenous) appendicitis were in group a ( . %) and in group b ( . %). mean hospital stay group a was . days, . (p = n.s.) group b. mean hospital stay in complicated appendicitis group (a + b) was . days, in uncomplicated (a + b) was . days (p < . ). laparoscopic appendectomy was associated with lower wound infection rate (group a . % vs. group b . %) (p < . ). infection rate in complicated appendicitis (a + b) was . %, in uncomplicated cases (a + b) was . % (p < . ). no mortality in both groups has been observed. one conversion in laparoscopic group was reported. no cases of deep surgical site infection have been observed. conclusions: laparoscopic appendectomy seems to be associated to a lower rate of wound infection. length of hospital stay and rate of major complication seems to be related to gangrenous or perforated appendicitis and not to the surgical technique. significantly lower on postoperative third and seventh day, respectively. conclusions: in this model of general peritonitis, mb significantly reduced adhesion formation. mb is blocking the tnf alpha early postoperative days. early blocking of the activity of tnf-alpha after peritonitis resulted in lower rates of adhesion formation macroscopically. the tnf-alpha can be an important factor for postoperative adhesion formation. results: laparoscopic surgery was performed in patients due to peptic ulcer perforation. seventy-five patients ( %) underwent laparoscopic repair alone or laparoscopic repair with omentoplasty. in the remaining patients ( %), the procedure was converted to laparotomy. amongst ( men / women) patients who were included into the study, the mean age was . ( - ) . in patients ( %, / ) preoperative diagnosis was unclear and the patients were taken to operating theater due to acute abdomen. in all patients, but one, the duodenal defect was repaired by primary suturing; in one patient, simply intra-abdominal lavage and drainage were performed because the omentum was found to seal the defect. omentoplasty was performed in ( %) patients. one and two abdominal drains were used in ( %) and ( %), respectively. mean hospital stay was . ( - ) days. morbidity was % (n = ). early morbidity included bile leakage in three patients, postoperative intra-abdominal bleeding in one. one patient had trocar site hernia. one patient ( -year-old female) died on postoperative day due to sepsis in the intensive care unit. conclusion: laparoscopic primary repair is a safe and efficient method in peptic ulcer perforation. akın tarım, sedat yıldırım, cem aydogan, gö khan moray, mehmet haberal department of general surgery, baş kent university, ankara, turkey introduction: approximately % of multiple trauma patients sustain concomitant burns. complicated management issues arise in these patients as burn and trauma care often conflict. the purpose of this study was to describe the different types of burn injuries seen in burn patients with additional forms of trauma, and to report the survival rate for this patient group. methods: in this retrospective study, patients were admitted to our center with concomitant burns and trauma from - . this study retrospectively analyzed the types of burn injury, extent of burns, types of other trauma associated with the burns, and outcomes. results: of this study group, were male. average age was . ± . . mechanisms included motor vehicle collisions, electrocutions with subsequent falls, one plane crashes, lpg or oxygen tube explosions and other type of explosions. average burn size was . ± . %. the most common traumatic injury was fracture and head injury ( ). management of fractures in burn patients and resuscitation in head injured burn patient represented the most common conflicts in patient care. there were deaths in this series. conclusion: burns are a rare but significant complication in the trauma patient. outcomes are dependent on rapid trauma evaluation as well as effective resuscitation and wound management. given the complexities of their problems, these patients necessitate a balanced multidisciplinary approach to maximize their potential for full recovery. thoughtful compromise between trauma and burn priorities is frequently necessary. introduction: fournier's gangrene (fg) is a rapidly progressive, polymicrobial, synergistic necrotizing fasciitis. in this study we aimed to determine the risk factors effective on the prognosis of the disease. methods: the files of consecutive patients operated for fg during - were investigated retrospectively. the surviving and mortal groups of patients were compared for demographic data, etiological factors and treatment modality besides length of hospital stay and treatment cost. results: the mean age of the patients was . years and female/ male ratio was / . mortality was seen in ( . ) patients and significantly high in female ( . %) (p = . ). the most frequent comorbid disease was diabetes ( . %), etiological factor was perianal abscess ( . %) and etiological source was anorectal region ( . %); and they did not affect the mortality. the most frequent cultivated microorganism e.coli ( . %) was significantly high in the mortal group (p = . ). imipenem was the antibiotic used in all of the patients. the mean number of debridements was , and intestinal diversion was utilized for . % of the patients. fecal decontamination ( . %) of the patients was performed by surgical ( ) and nonsurgical ( ) methods. the length of hospital stay in surviving group ( . days) was higher than the mortal group ( . days) (p = . ). there was no difference between two groups of patients for the length of hospital stay (p > . ). conclusion: female gender, duration of complaint prior to treatment, fournier gangrene severity point and cultivated microorganism (e.coli) were the factors affecting the mortality. aim: post-traumatic coronary aneurysms (ptca) are extremely rare. we report an asymptomatic ptca in a young patient. case: -year-old male, with no significant previous history. admitted intubated and ventilated after a car runover. he had cerebral, thoracic, abdominal, pelvic and lower extremity trauma. initial assessment disclosed eight left fractured ribs with associated pneumothorax; fast was negative, head ct normal. thoracic ct reveled small bilateral hemothoraces and pulmonary contusion, with no evidence of vascular lesions. he also had a fibular, clavicle, and pelvis fracture. control angio-ct at day showed pleural and pericardial effusions and raised the suspicion of left descending ptca, subsequently confirmed with mri. the patient remained asymptomatic with normal ekg and cardiac enzymes throughout this period. a coronariogram confirmed the ptca, that had undergone spontaneous thrombosis, with no further treatment required. discussion: coronary aneurysms (true or false) may occur after blunt thoracic trauma. ptca normally result from controlled rupture post myocardial infarction or cardiac contusion, with gradual wall rupture. although in this patient the diagnosis was made without any clinical manifestation, suspicion is the main key for diagnosis. aneurysms must be considered as a differential diagnosis in patients with thoracic trauma history associated with arterial emboli, congestive heart failure, arrhythmia, chest pain or dyspnea. conclusion: every trauma victim must be exhaustively evaluated. in any case a careful follow-up must be made in thoracic and abdominal trauma victims to decrease the possibility of missing injuries. aim: acute mesenteric ischemia (aim) continues to be highly morbid cause of emergency. early diagnosis and treatment may reduce severity of the disease. the aim of this study is to investigate causes for morbidity and mortality in ami patients. materials and methods: this retrospective study has patients of ami. the patients were classified according to their age, sex, clinical and laboratory findings, comorbidity, etiology, operative procedures, complications. and effect of these causes on mortality and survival was investigated. the results were statistically evaluated. results: of patients were male and were female. mean age was . for females and . for males. the most common symptom was abdominal pain. only one third of patients had diagnosed correctly before operation. amylase was high in % of patients. plain abdominal graphy showed air-fluid levels in all patients. mortality rate was high in patients aging over years (p < . ). there were no relationship between mortality and gender. the patients those who had massive small bowel and colon resection developed high mortality rates ( %). resection of ileocaecal valve also increased the mortality. five patients all of whom developed perforation died. majority of survivors had surgical intervention during first h of ischemic attack. the patients those died due to perforation had delayed surgical intervention. • there is no benefit of routine laboratory findings in early diagnosis of ami. • massive intestinal resection, absence of ileocaecal valve and stomal procedure increased mortality rate. • delay in diagnosis and treatment also caused high mortality. cem aydogan , yahya ekici , ebru sakallıoglu , sedat belli , mahir kırnap , emin tü rk , mehmet haberal department of generel surgery, baş kent university, ankra, turkey institute of burn, fire and natural disaster, baş kent university, ankara, turkey introduction: more than % of all burn patients can be managed on an ambulatory basis. appropriate management of minor burns minimizes further damage. methods: the epidemiology, demographics, and outcomes of ambulatory acute burn patients were reviewed at our center between and . patients who were in aba referral criteria were excluded from the study. results: the patients' mean age was . ± . years (range, - years) . the percentage of patients whose first admission was to our center was . %; the percentage of those referred from another center was . %. scald burns were the most frequently reported cause of burns ( . %). the house was the most frequently reported place at which the burns occurred ( . %). the percentage of stoverelated burns was . %. the upper extremities ( %) and lower extremities ( %) were the most frequently reported places on which the burns occurred. mean tbsa affected and superficial partial thickness burned area were . ± . % and . ± . %. the mean follow-up and the mean number of dressings applied to the burns were . ± . days (range - days) and . ± . (range - ). four patients ( . %) needed skin grafting, and two patients ( . %) were hospitalized for debridement without grafting. conclusions: close follow-up is important in minor burns to minimize further damage. burn centers must play an active role in the care of all burns. the devastating effects of burns can be prevented and decreased by educational programs. stove-related burns remain a problem in turkey. results: mean age was . ± . years. the percentage of the male patients was . %. the mean tbsa affected was . ± . %. the percentages of high voltage electricity injury, lightning injury, and lowvoltage current injury were . , . , and . %, respectively. place of employments ( . %) and outdoors ( . %) were the most frequently reported places at which the burns occurred. the burns mostly occurred in urban areas ( . %).upper and lower extremities were the most frequently affected regions. the percentages of the patients who underwent debridement, grafting, amputation and fasciotomy were . , . , . , and , %, respectively. the percentage of patients who had additional trauma other than electric burn injury was . %. mean hospital stay of patients was . ± . days. the mortality rate was . %. majority of the patients died from septic complications ( . %) conclusion: aggressive multidisciplinary treatment modalities and early debridment, grafting and/or flaps are very important. special considerations are required for public education about electricity and its hazardous effects. governmental supports are needed both in prevention and in therapy. ahmet erkilic, harun analay, sabri mehmet barazi, halil Ç eliksö z, bayram rü zgar burn center, av.cengiz gö kçek general hospital, gaziantep, turkey early staged excision and autogenous skin grafting or temporarily wound coverage with biologic dressing or allograft until autogenous donor sites are available is now conventional treatment for fullthickness burns. typically, tangential excision is performed with a handheld knife thus it may be difficult to control bleeding from the wound bed and difficult to assess the suitability of underlying for accepting a graft. a hydrosurgery system -versajet Ò is available that can be used for tangential burn wound excision. this device offers an easy and more precise way of excising eschar and is particularly useful excising nonviable tissue from the concave surfaces of hands and feet, as well as the eyelids and ears. totally, hydrosurgical tangential excision (hte) were performed for patients with burn, in our burn center in one and half year. several times performing were needed . % of patients (n = ). wounds of patients with - % total burned body surface were covered autogenous skin grafts subsequent to hte. more extensive wounds were covered with biologic dressings temporarily and wounds as soon as suitable autogenous skin grafting was performed. at this interval, burn wounds were shrunk average - % and donor skin poverty was increased. frequently, delaying to excision and coverage of burn wounds may be awful. early excision and early coverage of the burn wounds must be a golden standard for the current treatment of the burns. also hte is becoming a candidate to golden standard at burn treatment. introduction: in our previous study, we examined the treatment results of burn patients older than years, and found a significant increase in mortality with increasing age groups. the aim of the present study was to reevaluate this patient group and also compare these results with the previous study period of to . patients and methods: one-hundred and fifteen patients older than years were admitted to our burn unit during the last years. these patients were divided to three groups with respect to their ages (group a: - years, group b: - years, and group c: older than years). demographic properties of patients, etiology, and extend of burn injury, co-morbidity, length of hospital stay, and mortality rates were recorded. results: during the last years, demographic properties and etiology of burn injury did not changed significantly. however overall survival rate increased from . to % and ld values for burn injury are significantly increased in all age groups. length of hospital stay is significantly decreased in all age groups, especially in group b (from . to . days). co-morbidities did not change over time and sepsis is the leading cause of death in patients ( %). conclusion: in our burn unit, treatment results in patients older than years showed a significant improvement during the last years. introduction and objectives: patients who has weakness of mental and motor functions are under more risk than normal burned injured population. we would like to focus on burn injured cases that have co-exiting morbidities. methods: comorbid patients who applied to burn unit due to burn between january and july were taken into evaluation. comorbid etiologies were seizures ( case), mental retardation ( case) and down syndrome ( case), respectively. results: during follow-up period, one of the cases had aggrevated petit mal convulsion due to devastating effect of burn injury. in one case there was grade pressure sore and urethral infection who was paraplegic patient. weight loss was observed on a geriatric case that had seizure due to insufficient nutrition. conclusion: burn injured cases that have comorbidity, special care, and additional measures should be taken. psychological, neurological or geriatric causes are the factors that affect the recovery of burn defects and success of operation. detailed evaluation of coexisting disorder and additional care are the key points of the comorbid burn patient. aim: the present study was aimed to evaluate the gender differences of burned children in clinical course and outcome. methods: children (aged - ) admitted to our burn center between august and january were retrospectively evaluated. total burn surface area (tbsa), levels of some acute phase markers, grafting need, and hospitalization time were analyzed. results: sixty three patients [ ( . %) males, ( . %) females] were included in this study. the mean age was respectively . ± . years and . ± . years in males and females (p = . ). the mean tbsa burned respectively . ± . % and . ± . % in males and females (p = . ). the mean wbc count in admission was significantly higher in males than females ( . ± . x - /l vs. . ± . x - /l, p < . ), but there was not any significant difference between females and males in crp count. (p = . ). skin graft operation was performed in ( . %) of males and in ( . %) of females (p = . ) and also, we did not find any significant difference between males and females in hospitalization time ( . ± . days vs. . ± . days, p = . ). conclusion: although many studies have showed that critically ill females have a better outcome than critically ill males, any significant difference was not observed between burned male children and burned female children in most of the clinical parameters, except white blood cell counts. introduction and objectives: the goal of our study was to evaluate the preparedness of hospital physicians, emergency physicians and paramedics in the eu and the usa for a mass casualty incident. methods: an online survey which contained questions was sent to the head of the department of trauma-surgery, emergency medicine and to paramedics by e-mail. among other things we questioned: existence of a hospital emergency-and disaster plan and the yearly exercise of the plan. coordination with the local rescue service as well as existence of decontamination facilities were asked for. replies were analysed statistically with the one-way analysis of variance (anova) test and the turkey-kramer multiple comparisons test. results: altogether, assistant and emergency doctors as well as paramedics answered. % were not conscious of the details of the disaster plan of her hospital while % did not know the plan at all. % of the interviewed doctors did not know her area of responsibility in the case of an internal emergency. % of the interviewed know what to do in case of an mci. % of the interviewed doctors and % of the paramedics did not know her area of responsibility at the treatment of patients contaminated chemically, nuclearly or biologically. conclusions: the preparedness for doctors and paramedics in hospitals and in the preclinical rescue service in the eu and the usa on a mci (mass casualty incident) are insufficient. the emergency medical education of doctors and paramedics should be adapted to the terrorist threats disaster preparedness of chief physicians and hospitals in germany, the eu and the usa for a mass casualty incident introduction and objectives: the goal of our study was to evaluate the preparedness of hospitals in the eu and the usa for a mass casualty incident. methods: an online survey which contained questions was sent to the chief physician of hospitals by e-mail. things we questioned: existence of a hospital disaster plan and the yearly exercise. coordination with the local rescue service as well as existence of decontamination facilities. replies were analysed statistically. results: altogether, senior consultants, of this senior consultants from germany as well as senior consultants from the usa and the eu, answered. all people claimed to have a hospital disaster plan. % of the german hospitals made an exercise of the plan with tabletop exercises. however, % of chief physicians in the usa and the eu made an exercise of the plan regularly with table top exercises. % of the hospitals in the brd did not have any decontamination possibility of nbc (nuclear, biological, chemical) contaminated patients, while % of the hospitals had this possibility on the spot in the eu and the usa. conclusions: the exercise of the hospital disaster plan in germany is insufficient, compared with the hospitals in the eu and the usa. furthermore the german hospitals are badly equipped in the worldwide comparison to decontaminate patients on the spot. we demand for an increase of the ''exercises'' of the hospital disaster plan (also by tabletop exercises) as well as an improved equipment for the decontamination of the injured. in the two big earthquakes that occurred in the north-west of turkey in in short intervals within less than months there were approximately , cases of death and around , were injured. there were several other deadly earthquakes in the whole world the same year. main survival factors in the post-disaster period are prevention from injuries as well as detecting the location of the survivors and the rescued. the reality of the situation of persons who lost their lives in such traps, the severely injured, and the ones who survived must be analyzed. rational prevention methods against possible crush injuries due to collapsing buildings have been con-sidered in the light of the field and simulation experience we gained and suggestions have been presented to reduce mortality and morbidity. our work has been conducted with the aid of medicine based on proof, appropriate observation as well as sampling and experimental methods. a global approach concerning worst case scenario led by earthquakes has been proposed taking into consideration the different models of behavior in different countries and societies to increase the chance of survival to a maximum and to reduce injuries to a minimum level. due to unlimited possibilities of travelling nowadays, it is not possible to estimate the place, the country or the circumstances under which a person could experience a disaster. carlos alberto godinho cordeiro mesquita ordem dos mé dicos, colé gio de competê ncia em emergê ncia mé dica, lisbon, portugal in portugal there are three official ways to differentiate: specialty (vertical), subspecialty (vertical) and competence (transversal). doctors may access to a subspecialty or a competence as a second step, after a specialty. portuguese medical association (ordem dos mé dicos, om) is the official entity that regulates all the medical and surgical activities in portugal, being his duty to protect the public interest. doctors must be registered with to practise medicine or surgery. om also sets the standards and outcomes for basic medical education. after graduating from medical school and completing their foundation training, doctors usually complete a third and even a fourth stage of postgraduate training, whose standards are set by the colleges. these are responsible for promoting the development of postgraduate medical education and training for all, establishing standards and requirements and making sure they are met across the country. emergency medicine exists as a competence since and goes behind the prehospital acute care. this college is strongly interested in the development of an autonomous college of competence on emergency surgery (trauma surgery included) and it exists, since , an official national working group on emergency surgery education (grupo de trabalho para a formaçã o específica em cirurgia de emergê ncia), with representatives of general surgery ( ), neurosurgery ( ), orthopaedics ( ), thoracic ( ), vascular ( ) , urological ( ) and paediatric surgery ( ) . the general surgeons, iatsic members and dstc instructors, also integrate and lead the national steering committee for dstc, after a recently signed memorandum of understanding. author to editor: the point of the situation, from an organisational point of view, about trauma and emergency surgery education in portugal and the importance for the relationship with portuguese speaking doctors around the world introduction and objectives: practical training in emergency medicine should be an important part of undergraduate education, as every physician should be able to handle medical emergencies. however, adequate practical training is time and personal consuming. this work seeks to determine whether medical students (peer to peer education) can be trained as course instructors in emergency medicine training and if there are differences in the training outcome. methods: the undergraduate training consists of both basic life support (bls) and advanced cardiac life support (acls) courses. after both courses, students have to pass a multiple choice test and have to complete a course evaluation. during the instructor training, all candidates, students and physicians were trained together with theoretical and practical training and were furthermore supervised during their first courses. results: until now, bls and acls trainings were conducted of which % (bls) and % (acls) were run by medical students. there were no significant differences in the written examinations nor in the course evaluations ( = very good to = unsatisfactory) between courses by staff ( . for bls and . for acls) or medical students as trainers ( . for bls and . for acls, respectively). conclusions: peer to peer education can be a useful tool in the manpower consuming practical training in emergency medicine without influencing the learning outcomes or the evaluation. background: non-invasive pelvic ring stabilization (pelvic binding, pb) in shocked patients is recommended by state and institutional guidelines regardless the fracture pattern. the purpose of this study was to determine the adherence to the guidelines, radiological efficacy of the technique, and identification of potential adverse effects associated. methods: analysis of the prospective database of a level trauma center on high-energy unstable pelvic fractures. collected data included patient demographics, physiology, fracture classification, application, and timing of pb, associated injuries and outcomes. pre and post-pb radiographs were compared to evaluate the changes in fracture position. the potential effects of pb on soft tissue complications were assessed by independent experts. results: during the -month study period a total of pb was performed on patients with high-energy unstable pelvic ring injuries. stable patients were less likely to get pb ( %) than shocked patients ( %). the adherence to guidelines was %. analyzing fracture types (ao/ota classification) of shocked patients the adherence was: b %, b %, b %, c %, c %, c %. better radiological appearance was detected in b %, c %, c %, c % types. one femoral artery, four bladder and three rectum injuries were identified in patients with pb applied. there were no association between the complications and the pb. introduction and objectives: in our country, the vast majority of circumsicion is stil not done by physicians. in this study, we evaluated the patients who treated for circumsicion complications in our clinic. methods: a total of children who treated for cicumsicion complication in our clinic between and were evaluated. results: mean age during circumsicion was . months ( - years). out of had not been circumsiced by physicians. complication was bleeding in patients, burred penis in , complete glanular amputation in , and urethral fistula in patient. one suture was enough to control bleeding for the majority of patients with this complications, while general anesthesia required for treating other complications. conclusions: significant number of children still undergo circumsicion between and years old (fallic period) in our country. the vast majority of complications occur when circumsicion is not done by physicians; significant number of these complications require revision under general anesthesia. as a result, circumsicion is still a challenging both public and social problem in our country, and results in high morbidity because the majority is not done by experienced hand. arda demirkan , salih ekinci , onur polat , serdar gü rler , mü ge gü nalp , semih baskan department of emergency, ankara university, ankara, turkey department of general surgery, ankara university, ankara, turkey objective: multiple trauma involves at least two systems of body which abdomen, extremities, chest and head-neck. the aim of this study is to show relationship between the severity of injury and electrolyte changes in multiple trauma patients. method: this is a prospective study which adult multiple trauma patients ( male and female) were studied. the median age was . (range - ) . in all cases, serum sodium, potassium and calcium levels and injury severity score (iss) were obtained on admission to emergency department after trauma. severity of injury was estimated with iss. degree of association between variables was evaluated by spearman's correlation coefficient test. results: the mean sodium levels was . mmol/l, the mean potassium levels was . mmol/l, the mean calcium levels was mg/ dl. there was a negative correlation between calcium and iss, and this is statistically significant (p = . ). while other serum electrolytes (sodium and potassium) did not change according to iss. conclusion: electrolyte abnormalities often occurs in critical ill patients, this imbalance has a prognostic importance particularly in multiple trauma patients. electrolyte changes determinated in early period and appropriate resuscitation is indispensable. we suggest that low calcium levels can be considered for the severe injury. this condition may be related to interrupted calcium mechanism in critical trauma patients. introduction and objectives: preparation is essential to meet the challenge of optimal care for a sudden unexpected surge of casualties due to a major incident. by definition, requirements exceed standard care facilities in qualitative and or quantitative respect and interfere with regular patient care. to meet the growing demand for disasterpreparedness a permanent facility to provide structured, prepared relief in such situations was developed. we describe this facility. objectives: the aim of this study is to find out the effects of melatonin on the erythrocyte and kidney malodyaldehyde (mda) and superoxide dismutase (sod) levels in radiocontrast nephropathy. methods: in this study, new zealand type rabbits were included. the test subjects were divided into four groups six rabbits in each (control, sham, hydration and melatonin groups). blood samples of all subjects were taken in beginning of study. renal tissue was obtained in the control group. the rest received ml diatrizoat sodium intravenously. hydration group was given ml/kg/day iv bolus . % nacl. melatonin group was given mg/kg iv melatonin four times with the same dose isotonic. it was blood and renal tissue samples were taken at the th and nd hours. mda levels were determined with ohkawa method, sod enzyme activity was studied with ransod (randox,uk) superoxide dismutase assay kit. results: the mean renal sod value of the melatonin group ( . ± . nmol/g) was significantly higher than in the sham ( . ± . nmol/g), control ( . ± . nmol/g) and hydration groups ( . ± . nmol/g) (respectively p = . , . , . ). the mean renal mda value of melatonin group ( . ± . nmol/g) was significantly lower than sham ( . ± . nmol/g) and hydration groups ( . ± . nmol/g) (p = . , . respectively). conclusion: melatonin has a curative effect on the lipid peroxidation caused by the contrast substance in the kidney. in preventing nephropathy resulting from contrast substance, giving melatonin together with hydration can be more effective than giving hydration alone in the clinic. in addition, all datasets entered with voice recognition were complete and available in the system as soon as the patient left the trauma bay. compared to the retrospective cohort % of the patients had incomplete data concerning the vital parameters. conclusion: the introduction of voice recognition technology real time produces more accurate data more quickly. we are convinced that high tech technology will increasingly assist the trauma surgeon and if we are correct it looks like the prediction of don trunkey will come true viz: ''the current possibilities for using digital resources within medical care are merely limited by our own imagination'' introduction and aims: despite the improvements in the diagnosis and treatment, mortality rates are still high following urgent operation for perforated peptic ulcer (ppu). in this study, we analyzed the factors affecting the survival of the patients operated for ppu. materials and methods: the records of the patients operated due to ppu between january and january were analyzed. age, sex, american society of anesthesiology (asa) score, alcohol consumption, smoking, nonsteroidal antiinflammatory drug (nsaid) usage, the time passed from the onset of symptoms to operation, history of previous peptic ulcer disease, diameter and localisation of the ulcer, surgical technique, length of stay, postoperative complications and mortality rates were determined. results: the mean age was and asa score was . primary suture and omentoplasty was the selected procedure in patients while gastrostomy was added to primary suture to another patients. twenty nine patients received primary suture, truncal vagotomy and gastroenterostomy and seven underwent resection. the mean length of stay was days. three patients suffered from atelectasis and pneumonia, one from empyema, eight from surgical site infection and four from leakage. twenty three of the patients experienced respiratory failure and died of multi organ deficiency ( . %). age and asa score were found as factors significantly affecting survival. abdominal cocoon (idiopatic sclerosing encapsulating peritonitis) is a rare disease of the peritoneum which refers to a condition where there is a total or partial encasement of the small bowel by a dense fibrous membrane. the abdominal cocoon is probably a developmental abnormality, largely asymptomatic, and is found incidentally at laparotomy or autopsy. it is an unusual cause of intestinal obstruction. pre-operative diagnosis cannot be often made correctly. complete recovery is expected after removal of the membrane surgically. a -year-old man presented with abdominal pain, swelling and vomiting of two day's duration. there was no history of peritonitis, abdominal surgery or tuberculosis. physical examination of the abdomen revealed a distended abdomen, hypoactive bowel sounds, tenderness and rigidity in the whole abdomen. a tender lump was palpated in the right lower quadrant. routine laboratory workup revealed a total leukocyte count of cells/ml, and normal serum chemistry. pa x-ray of the chest normal. plain abdominal x-ray showed few air-fluid levels. contrast-enhanced abdomen-pelvis computed tomography showed a dilatation up to . cm in small intestine. emergency laparotomy was performed through a right paramedian incision. in exploration, small bowel was observed to be dilated, its mesentery was edematous and the whole small and large bowel was covered by a dense whitish and approximately mm thick membrane. the membrane was partially removed, and adhesiolisis of the intestinal loops was performed without bowel resection. after surgery, the patient was tolerated diet without any complication and was discharged, on hospital day . methods: the data of al-ain hospital trauma registry were prospectively collected over a period of years ( ) ( ) ( ) ( ) . all trauma patients who were admitted to intensive care unit (icu) were included in the study. univariate analysis was used to compare gender, age, nationality, mechanism of injury, systolic blood pressure and gcs on arrival, the need for ventilation, presence of head or chest injuries, ais for both the chest and head injuries and the iss. significant factors were then entered into a direct logistic regression. results: there were patients ( males). mean (range) age was year. . % were uae nationals. the two most common mechanisms of injury were road traffic collisions ( . %) followed by fall from height ( . %). the median (range) iss was . the mean (sd) icu stay was . ( . ) days while the mean (sd) hospital stay was . ( ). the overall mortality was . %. significant factors that have affected mortality included gcs (p < . ), mechanism of injury (p = . ), age (p = . ) and iss (p = . ). the best gcs that predicted mortality was . while the best iss that predicted mortality was . conclusions: rta is the most common cause of serious trauma in uae followed by falls. gcs is the most significant factor that predicted mortality in icu trauma patients. introduction: glutamine is an antioxidant which enhance glutathione levels. in this study our goal is to assess the safety and efficacy of parenteral glutamine on antioxidant capacity and organ dysfunction in septic patients. methods: prospective, randomized study of the septic patients admitted to the surgical intensive care unit (icu). patients were randomized to receive either glutamine (group glu, n = ) or glutamine + n-acetylcysteine (group nac, n = ) or a control supplement-placebo (group pla, n = ) parenterally up to days. organ dysfunction and clinical outcomes were assessed by daily total sequential organ failure assessment (sofa) score over the -day study period. serum total antioxidant capacity (tac) was measured by cuprac method. also we evaluated procalcitonin (prc) and c-reactive protein (crp) levels as infection markers on days , , , and . results: there was no significant differences between the patients' ages, apache ii, sofa scores and infection markers on the day of admission. group glu and nac showed a significant decline of daily total sofa score (glu: p < . , nac: p < . , pla: p = . ) and crp levels (glu: p < . , nac: p < . , pla: p < . ). but prc levels decreased significantly over time just in group glu (glu: p < . , nac: p = . , pla: p = . ). on the other hand, serum tac measurements were not significant. the mean icu length of stay were glu: ± . , nac: . ± . , pla: . ± . (glu/nac: p < . , glu/pla: p < . ), but in group glu the overall mortality was significantly lower than nac and pla groups (glu: %, nac: %, pla: %). conclusion: in septic patients, parenteral supplementation with glutamine results in significantly better recovery of organ function compared with nac and pla. we coud not find any significant relationship between tac levels and clinical outcomes. background: acute renal failure (arf) requiring renal replacement therapy in icu setting is related to high mortality. the purpose of the study is to assess any indicators of improved survival. materıal and methods: retrospective study of trauma patients, who underwent haemodialysis over a period of years (patients with penetrating, blunt trauma and burns). information on pre-hospital and in-hospital resuscitation, trauma scores and physiological scores and daily icu records were collected. the majority of patients were initially dialysed with cvvhd and later on with sled. results: of the patients, died and overall mortality was . %. this was highest in the group of burn patients ( %). survival in all patients irrespective of mechanism of injury was unrelated to rts, iss, apache ii and triss. the duration of haemodialysis be-tween the three different trauma mechanism groups was not significantly different. age is not a significant predictor of survival. patients with polyuria at time of initiation of haemodialysis had not a better outcome than those who were oliguric/anuric/normouric. conclusions: arf in trauma patients has a low survival rate. controversial conclusions have been presented in the literature. in our study, none of the parameters reported in previous publications to affect survival was proven as correct, although our number of patients was comparable to that of other studies. as we are still at an early stage of understanding the predictors and the behaviour of renal failure in the trauma patients there is a need for the planning multicentric prospective studies. weaning from mechanical ventilation constitutes a dynamic process, and represents one of the most challenging decisions in the management of critically ill patients. success of weaning depends on multiple factors, and wrong decisions result either in prolonged mechanical ventilation, or reintubation and nosocomial pneumonia. many mathematical indexes have been described and used for decision making with varying successes. we have developed a multiparameter fuzzy-logic decision support system for prediction of success of weaning from mechanical ventilator. after fuzzifying relevant numerical variables, this system evaluates the appropriateness of perfusion, arterial blood gases, mechanical properties, and gas exchange, and converts these to a weaning probability. system has been designed using jfuzzylogic package and uses mamdani center of gravity algorithm for defuzzification. after optimization system has been tested over a software that creates random clinical scenarios within a range that can represent challenging patients. for each scenario jabour' weaning index, rapid shallow breathing index (rsbi) and pressure time index have also been calculated and compared with fuzzy-logic system. results indicate that currently used indexes and especially rsbi, disregard many important parameters and shown a potential to fail in many critical scenarios (in % of simulations). additionally we would like to discuss the potential of fuzzy-logic in clinical decision support, and design and optimization issues. trauma scoring systems used for uniform reporting and evaluation of trauma outcomes include physiologic, anatomic and combined systems. these systems have already been evaluated and shown to have accurate performance. we proposed a possible effect of response to resuscitation on the performance of trauma scoring. data necessary for calculation of iss, rts, triss and ascot systems have been retrospectively collected from the records of last consecutive trauma patients admitted to our surgical critical care unit. score and mortality prediction calculations have been performed over a software developed in our department, at three time points, at admission to er, after h of resuscitation, and at icu admission. additionally a fuzzy-logic inference system which uses physiologic variables as input has been designed for trauma related mortality prediction and applied to the same dataset. performances of scoring systems and fuzzy-logic inference system have been evaluated. results indicated that all systems have good discrimination, but variable calibration characteristics. for all systems evaluated response to resuscitation has effected system performance and scores and predicted mortality values calculated after resuscitation have shown better discrimination. fuzzy-logic inference system designed has shown discrimination characteristics comparable but not better then the other systems, which indicate the importance of inclusion of specific organ injuries in trauma scoring and mortality prediction. daily monitoring of immune/inflammatory status is a fundamental procedure in the icu. in small animal disease models such a surveillance is challenging given the limited blood volume available. to validate a new method for daily immuno-inflammatory monitoring in critically ill (septic) mice, we followed their short/longterm survival, organ function and inflammatory status. furthermore, the reliability of complete blood count (cbc) differential was tested in re-suspended blood cell pellet. female of- and cd- mice were subjected to cecal ligation and puncture (clp). ll blood samples were collected (facial vein puncture) from half of each strain daily for days or on day only. additionally, ll (diluted : ) volume was collected (of- only) and divided to compare cbcs in whole versus resuspended blood. there were no differences in / -day clp mortality. for both strains, changes in circulating interleukin- and chemical parameters (alt, ldh, bun, glucose) were comparable between sampled subgroups. ll sampling in of- mice caused a decrease of % in rbc and % in hb (both p < . ). in cd- animals, both rbc and hb showed a similar decrease of % (p > . ). platelet and wbc counts were unaffected. cbc comparison displayed a high correlation for all cell types (r > . , slope > . ) except lymphocytes (r > . ,slope > . ). this was reproduced in non-clp mice. the results indicate the minimal biological effect of daily sampling upon septic mice. cbc differential from resuspended pellet is highly reliable. this newly validated facial vein punture sampling protocol allows multi-directional monitoring in mouse models of critical illness such as acute peritonitis. introduction: a comparison of the amount of procalcitonin (pct) with that of c-reactive protein (crp) during various types of and severities of multiple trauma., and their relation to trauma-related complications, was performed. the aim of this study was to describe the amount of and the time course of pct and crp induction in patients with various types of and severities of high-velocity trauma. background: to provide a score to predict the risk of early mortality after single craniocerebral gunshot wound (gsw) based on three clinical parameters. methods: all patients admitted to baragwanath hospital, johannesburg, south africa, between october and may for an isolated single craniocerebral gsw were retrospectively evaluated for the documentation of (a) blood pressure on admission, (b) inspection of the bullet entry and exit site, and (c) initial consciousness (n = ). results: conscious gsw victims had an early mortality risk of . %, unconscious patients a more than fourfold higher risk ( . %). patients with a systolic blood pressure between and mmhg had a . % risk of mortality. hypotension (< mmhg) doubled this risk ( . %) and severe hypertension ( mmhg) was associated with an even higher mortality rate of . %. patients without brain spilling out of the wound (''non-oozer'') exhibited a mortality of . %, whereas it was twice as high ( . %) in patients with brain spill (''oozer''). by logistic regression a prognostic index (pi) for each variant of the evaluated parameters could be established: non-oozer: , oozer: , conscious: , unconscious: , £rrsys < mmhg: , rrsys < mmhg: , rrsys mmhg: . this resulted in a score ( - ), by which the individual risk of early mortality after gsw can be anticipated. conclusions: three immediately obtainable clinical parameters were evaluated and a score for predicting the risk of early mortality after a single craniocerebral gsw was established. gunshot wounds to the head are associated with poor outcome. we reviewed data to identify prognostic factors. we performed a retrospective study of all patients admitted to a level trauma center with isolated gunshot injury to the head during six and half years. data collected included demographics, mechanism of injury, prehospital and resuscitation room data, and initial ct scan characteristics. the primary outcome measure was the glasgow outcome scale (gos). seventy-two patients with isolated gunshot wounds to the head were admitted. overall mortality was %. the mortality for patients with an initial gcs of < was versus % for those with initial gcs > (p < . ). fifty percent had pupillary abnormalities on arrival at the emergency department. mortality in this group was versus % in those with normal pupillary reflexes (p = . ). elevated plasma lactate was associated with nonsurvival. thirteen percent of survivors were assessed as able to live independently after their injury. civilian gunshot injury to the head is related to high mortality. indicators of outcome are the admission gcs score, pupillary abnormality, metabolic acidosis, and ct pattern of severe injury. introduction and objectives: the aim of this study is to compare the effects of the mannitol and melatonin on the levels of blood and brain malondialdehyde (mda). methods: in the study, new zealand type rabbits were used. the test subjects were divided into four groups; sham (n = ), control (n = ), mannitol (n = ) and melatonin (n = ) groups. blood cerebrum tissue samples were taken to research for mda in the control group. head trauma was applied with feeney method to the rabbits in the other groups. venose blood samples were taken before and after trauma to observe mda. mg/kg melatonin was given to the melatonin group, and g/kg mannitol was given to mannitol ( %), between and in ( . %), and between and in patients ( . %). mortality rate was % (n = ). patients who died had significantly higher iss (p < . ), lower gcs, (p < . ), and higher head ais (p < . ). conclusions: road traffic collision is the leading cause of head injury in our setting. in this study population, head injury was severe, more than one fifth of the cases were admitted to the icu, and gcs was below in %. patients who died had significantly higher iss, lower gcs, and higher head ais. backgrounds and objectives: benefits of emergency burr-hole craniotomy (or evacuation) for patients with critical head trauma remained unclear. our study objective is to compare the effectiveness of burr-hole craniotomy to decompressive craniotomy using data from a large-scaled, multicenter and nationwide registry of hospitalized trauma patients in japan. materials and methods: among a total of records registered in japan trauma data bank, we selected patients with critical head trauma which were scored as ais (critical injury on the abbreviated injury scale) on head and underwent either of burr-hole craniotomy or decompressive craniotomy. parameters of the trauma injury severity score (triss) were used to adjust the baseline trauma severity. univariate analysis and multivariate logistic regression analysis estimated the relative risk of inhospital death. results: a total of zygomatic and/or orbital fractures were identified with subtarsal ( %), subciliary ( %), transconjunctival ( %) incisions, and laceration ( %). the risk of ectropion was highest in subciliary incisions ( . %, p = . ), however, only one case required operative management. entropion was found in two cases after transconjunctival incisions (p = . ); both required operative management. lid edema was present in . % of subtarsal and . % of subciliary incisions (p = . ). one hypertrophic scar was seen with the subtarsal and two cases with the subciliary approach (p = . ). conclusions: lower eyelid malposition occurs after any lower eyelid incisions for facial fracture repair. ectropion is most commonly seen in subciliary incisions, while entropion is rare. a subtarsal incision has a low risk of malposition, however is associated with hypertrophic scars. although choice of incision can be based on surgeon preference, a thorough patient discussion must include potential complications with each approach. in traumatology things happen quickly, data are often incomplete and therefore misleading and there is also pressure for quick decision. in dealing with the matter we distinct among wrong decisions based on insufficient data and errors due to systemic faults or individual incompetence or negligence. possible systemic faults are at every level of treatment: taking history, clinical examination, diagnostics, decision making, treatment procedures and even rehabilitation. most analysed errors occured when patient was handed over to another team or another level of treatment. haste and insufficient or inadequate report leads to wrong assumptions and -if that is not discovered in time -to wrong treatment. on personal level usual mistake was being satisfied when one injury was found and others were missed to insufficient exam or diagnostics. dealing with unfamiliar drugs lead to overdosage and sometimes death of the patient. to avoid such disasters extra training was added to medical school and medical students systematically approach the subject. at the emergency department adherence to protocols is encouraged, especially in cases of unresponsive patients. on hospital level enough time should be provided for attending physicians to make thorough rounds. this should provide much needed redundancy in the age of maximum efficiency. unfortunately we feel it is still not possible to implement measures of self-reporting as known by the airline industry due to inadequate law regulation! author to editor: measures for preventing medical errors in trauma department is showed. background and aim: missed injuries adversely affect patient outcome and damage physician, as well as institutional, credibility. autopsies are useful in uncovering missed injuries or undiagnosed conditions that contribute to death after injury. the aim of this paper is to analyze and compare medical documentation and autopsies findings in searching for missing injuries in trauma fatalities treated in our hospital. patients and methods: we analyzed data for patients died after trauma in years period (january st, -december st, introduction: immune suppression is a compensatory mechanism in acute inflammation e.g. following trauma. multiple mechanisms underlying this phenomenon include decreased cytokine production, shifts in cytokine balance and unresponsive adaptive immunity. we show in a model of acute inflammation that neutrophils, apart from their established pro-inflammatory characteristics, possess multiple mechanisms mediating immune suppression. methods: healthy male volunteers were given ng/kg e. coli lipopolysaccharides intravenously. blood was taken at various time points. neutrophils were stained with antibodies and isolated by facs. neutrophil receptor-expression, phagocytosis and oxidase were measured. lymphocytes were cultured in the presence of neutrophil subsets and cd /cd or pha. proliferation was measured by incorporation of h. results: distinct neutrophil subsets were identified. - h after administration of lps % of neutrophils displayed a two to threefold decreased expression in innate immune receptors, decreased phagocytosis and oxidase production. another neutrophil subset ( %) inhibited lymphocyte proliferation by % (in the presence of cd /cd or pha) in a : ratio independent of il- , tgfb, arginase or indoleamine - . instead direct delivery of h o appeared to be the mechanism of immune suppression. conclusion: in acute inflammation neutrophils utilize multiple mechanisms mediating immune suppression. firstly refractory neutrophils appear in the circulation. secondly another population of circulating neutrophils effectively suppresses adaptive immunity. these observations dictate an important role for neutrophil-mediated immune suppression following conditions such as trauma, contributing to the susceptibility to infections seen in these patients. sham-group) received a single intraperitoneal injection of either zinc protoporphyrin (znpp), an ho inhibitor, hemin, an ho- inducer, or vehicle. h later, rats were anesthetized and subjected to hts, including bleeding, laparatomy, and reperfusion (inadequate and adequate phase) and were sacrificed h later. ho- mrna was determined by real-time pcr and ho activity was determined in liver homogenate. free iron was measured by electron paramagnetic resonance spectroscopy in nonhomogenized liver tissue. ho- mrna was elevated only in the hts-group pretreated with znpp versus the sham-group. ho activity was increased in all hts groups compared to sham groups, with the most distinctive increase seen in the hemin pretreated groups. plasma bilirubin values showed a similar increase in the groups pretreated with hemin. no significant difference was found in free iron concentration among all groups. our data show that changes of ho activity prior to hts are not associated with elevated free iron, late after reperfusion, suggesting that free iron released from ho is efficiently deactivated. introduction: cells of the innate immune system are essential in the development of inflammatory complications. the activation status of this system can be determined by analyzing expression activation markers on neutrophils in peripheral blood. our research group previously showed that a combination of these receptors, the 'priming score', reflected the inflammatory status of individual patients. hypothesis: systemic activation of the innate immune system attracts functional neutrophils into damaged tissues. dysfunctional neutrophils stay behind in the circulation, causing a paralyzed innate immune system and increased susceptibility to late onset sepsis (> days objectives: our study objective is to stratify risk factors of the second (within hours) and third peak (within days) of trauma death independently. materials and methods: , records from japan trauma data bank were retrospectively analyzed. as outcomes for the analysis, we defined the early and delayed death as deaths within days and those after days, respectively. based on the framework of trauma injury severity score (triss), coded glasgow coma scale (cgcs), coded systolic blood pressure (csbp), coded respiratory rate (crr), injury severity score (iss) and coded age (cage) were used as independent variables to determine the outcomes using proportional hazard analysis. conclusions: in our observation, statistically-significant risk factors of early and delayed trauma death differed. physiological severity largely affected the second peak. in contrast, the third peak mainly correlated to anatomical severity and elderly in age compared to risk for the second peak. especially, an initial hypotension might no longer affect the third peak of trauma death independently. regression analysis including all the parameters of rts as explanatory variables showed the odds ratios of categorical sbp variables predicting the inhospital death. results: a total of , records matched the inclusion criteria. score- , , , , a and b in sbp subcategory consisted of , , , , , , and patients, respectively. inhospital mortality of score- , , , , a and b were , , , , and %, respectively. after adjustment for rts, the odds ratios for the inhospital death of score- , , , , a and b were . , . , . , . , . (reference) and . , respectively. isolated head trauma were more frequent in score- b compared to score- a ( vs. %, p < . ). conclusion: a trauma patient with systolic hypertension ‡ mmhg is scored points in sbp category under rts rule, however, exposed to higher mortality rate similar to patients with points in sbp subcategory and maybe related to isolated head trauma. author to editor: to whom it may concern: we have received a e-mail replied from abstractagent.com which alert the exceed in limitations of abstract submission. the e-mail noticed us, the presenting author of this abstract (akira endo) posted or more abstract as a presenting author, however, the authors of ''increased mortality in trauma patients with systolic hypertension'' believed that akira endo in department of accdm, tmdu, japan surely posted this abstract only. the name ''akira endo'' is common in japan. we suppose that ''akira endo'' of the other institutes were doublecounted. editor to self: seçilmiş bildiri background: the united arab emirates (uae) is developing rapidly, with many foreign construction, farm, and industrial workers at risk of injury. aims: to assess external causes, risk factors, severity, and anatomical region of work-related injuries using a trauma registry. methods: surgical admissions / to / were recorded in the registry at the main trauma hospital in al-ain region, population , . prevention-related variables were analyzed using spss and severity quantified by injury severity scores (iss). results: there were work-related injury hospitalisations, equating to an incidence of about / , workers/year. males accounted for %, ages - years %, and nonnationals %, with % of workers from the indian sub-continent. external causes included falls %, falling objects %, powered machines %, animals %, burns %, and other %. at least % of falls were from relatively high levels. median iss was for all six main external causes. extremities were most frequently injured. mean hospitalisation was . days. % (n = ) were admitted to the intensive care unit and % (n = ) died after admission. conclusions: main external causes were proportionately much more frequent than in industrialised countries, and admissions prolonged. priorities include effective countermeasures for falls from height and falling objects, and for machinery injuries. improved work injury data, access to occupational health services, specific regulations and frequent inspections at all construction sites, workshops, and farms, together with appropriate penalties for safety violations, are essential to reduce incidence and severity of occupational injury among vulnerable migrant workers in the uae. introduction and objectives: immobilization of the spine in trauma patients at risk of spinal damage is performed using a rigid long spineboard or vacuum mattress both during pre-hospital and inhospital care. however, disadvantages of these immobilization devices in terms of discomfort and tissue-interface pressures have guided the development of a new soft-layered long spineboard. we compared tissue-interface pressure and degree of comfort during immobilization on a rigid spineboard, a vacuum mattress and a newly developed soft-layered long spineboard. methods: in this randomized cross-over trial, volunteers were immobilized sequentially on all three devices for min per device. tissue-interface pressures were measured using an xsensor pressure mapping device, including the peak pressure and the peak pressure index (ppi). comfort was rated on a visual analogue scale (vas) after min and after min of immobilization. results: tissue-interface pressures were significantly higher on the standard long spineboard and the vacuum mattress than on the softlayered long spineboard. ppi for the sacrum on the soft-layered long spineboard was significantly lower than on both other devices, with an average ppi close to normal diastolic blood pressures. the participants reported significantly more comfort on the soft-layered long spineboard compared to the rigid long spineboard, both after and min (p < . ). conclusion: using the soft-layered long spineboard, which imposes less pressure on the tissue and provides better comfort than the standard long spineboard and the vacuum mattress, means buying time to optimize the patient's treatment while minimizing tissue damage. background: trauma and emergency surgery models differ all across europe. no definitive model was accepted and work and surgical emergency load are different in each region. we performed a cohort study to analyze the impact of emergency (including trauma) surgery in the general surgical practice at a portuguese university hospital. methods: data on emergency surgical cases and admissions to the surgical service over a -month period were collected and analyzed; this included patient demographics, referral sources, diagnosis, operation, and length of stay (los conclusion: emergency workload represents a significant part of the work for the general surgeons. the emergency surgical cases and admissions had a significant impact in the mortality rates of the general surgery admissions. resource planning and training should be based on more comprehensive, prospective data such as these. background: the long-term health outcomes and costs of helicopter emergency medical services (hems) assistance remain uncertain. the aim of this study was to investigate the cost-effectiveness of hems assistance versus emergency medical services (ems). methods: a prospective cohort study was performed at a level i trauma centre. quality of life measurements were obtained at year after trauma, using the euroqol- d as generic measure. health outcomes and costs were combined into costs per quality-adjusted life year (qaly). results: the study population receiving hems assistance was more severely injured than that receiving ems assistance only. the incremental costs for intramural care were e , for hems treated patients compared with patients treated by ems only, which was mainly determined by the costs of the intensive care stay and the used diagnostics. finally, the costs for hems assistance instead of ems assistance were e , per qaly. the sensitivity analysis showed a cost-effectiveness ratio between e , and e , . conclusion: the costs per qaly for helicopter emergency medical services in the netherlands remain below the acceptance threshold. therefore, hems should be considered as cost-effective. author to editor: this study describes the long-term health outcomes and costs of helicopter emergency medical services (hems) assistance. it investigates the cost-effectiveness of hems assistance versus emergency medical services (ems), and may serve as a reference for future quality of life and cost-effectiveness studies on the subject of hems and severely injured patients introduction: in usual multi-trauma care (utc) each partner has its own ''autonomous'' treatment perspective. clinical evidence, however, suggests that an integrated multi-trauma rehabilitation approach ('supported fast-track multi-trauma rehabilitation service': sftrs), featuring earlier transfer to a specialised trauma rehabilitation unit; earlier start of 'non-weight-bearing' training and multidisciplinary treatment; early individual goal-setting; co-ordination of treatment between trauma-surgeon and physiatrist, may be more (cost-)effective. the feasibility of a multi-centre trial examining the (cost-)effectiveness of sftrs was assessed. methods: data from multi-trauma patients (iss ‡ , complex multiple extremity injuries or complex pelvic fractures) were inventoried. patient characteristics, trauma severity, quality of life, health status, anxiety and depression, and cognitive functioning were assessed in two dutch trauma centres providing utc or sftrs. results: no differences in patient characteristics', trauma severity or discharge destination were found between sftrs and utc. discharge destination was 'home' ( . %), 'rehabilitation clinic' ( . %), 'nursing home' ( . %), 'other hospital' ( . %), 'unknown' ( . %). . % of patients died. however, hospital length-of-stay differed: . (sd: . ) days (sftrs) and . (sd: . ) days (utc). conclusion: adequate patient numbers may be recruited, baseline patient characteristics did not differ between collaborating centres, hospital length-of-stay was reduced in sftrs and adequate patient follow-up is possible. based hereupon, a nonrandomised multi-centre clinical trial started. (isrctn ). the trauma-region of north-west netherlands has consensus criteria for mobile medical team (mmt) scene dispatch. the mmt can be dispatched by the ems-dispatch centre or by the on-scene ambulance crew and is transported by helicopter or ground transport. although much attention has been paid to improve the dispatch criteria, the mmt is often cancelled after being dispatched. the aim of this study was to assess the cancellation rate and the noncompliant dispatches of our mmt, and to identify factors associated with this form of primary overtriage. methods: we conducted a retrospective case review of consecutive mmt-dispatches during a months period. by means of chart review, data pertinent to prehospital triage, patient's condition onscene and hospital course were collected and analyzed. all dispatches were evaluated by using the mmt-dispatch and mission appropriateness criteria results: median age was . years and . % of the patients was male. of these, patients were trauma victims ( . % blunt trauma). after being dispatched, the mmt was cancelled times ( . %). statistically significant differences between assists and cancellations were found for overall mortality, mean rts, gcs, and iss, mean hospitalization and amount of icu admissions (p < . ). almost % of all dispatches were neither appropriate, nor met the dispatch criteria. fourteen ( %) missions were appropriate, but did not meet the dispatch criteria. conclusions: nearly a half of mmt-dispatches were cancelled and almost % did not meet the dispatch criteria. dispatch criteria for the mobile medical team in our trauma-region need further refinement and compliance. the ''traumax Ò '' hip screw plate is a new device that allows the treatment the fractures both of the neck and the trochanteric area of the femur, expected subtrochanteric area. this plate conserves the characteristics of a dynamic hip screw (compression of the fracture site, good positioning of the pieces of bone, integrity of gluteus muscles) more specific characteristics: this device is modular, allows to choose the length of the barrel adapted to the length of the head screw, the diaphysal screws are locked by a tech nut according to the patented ''surfix'' system. the locked screw gives a good stability even if the bone has a poor density and allows to use a short plate that preserves the piercing lateral vessels of the femur. this short modular screw plate can be implanted by a cm minimal invasive approach using a particular instrumental pipe. during the presentation we will report the results of a prospective study colligating cases of ten french hospitals. a preliminary study of consecutives cases gives prominence to a few blooding with an average of ml, a operative time of an average of mn, a xr exposing time of an average of s. healing bone has been obtained in all cases. the head screw has been placed at the center or just below in %. no complication dues to the plate has been reported; in all cases only one approach has been used. aim: to assess moderate-term outcomes of silastic joint replacements of the first metatarsophalangeal joint. methods: the patients ( feet) that had silastic implants inserted were reviewed at an average of years and months (ranging months to years and months). the mean patient age was years. these patients answered a subjective questionnaire, had their feet examined clinically and radiographically and a pre-operative and post-operative aofas score was calculated for each. results: the questionnaire revealed that every patient described that their pain had decreased after surgery and feet ( %) were completely pain free. there was a significant improvement in patients' subjective pain scores after surgery (t value £ . ). preoperatively, the mean pain score for all feet was . , whereas post-operative the mean pain score was . . the mean aofas score before surgery was . . this increased to a mean score of . after surgery (p £ . ). this again is a significant improvement. no patient was dissatisfied with the outcome with their surgery. conclusion: these moderate term results are encouraging, with good subjective and objective results. however, long-term follow-up will be required to assess the longevity of this implant • theatre staff should be trained for proper application and cleaning of the exsanguinators • alcohol wipes are good alternative to current practice and should be used for decontamination • we must wash our hands before and after its use • we should use plastic bag over the limb first before using the exsanguinators it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator developed by the author. there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanically. in clinical use it has been applied to , patients in treatment of femoral fractures. the age of patients was from to years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. this reduction device provides possibility of reduction with minimal using of fluoroscopy or even, after more experience without using of any imaging technique as fluoroscopy, ultrasound or computer navigation. received clinical results are promising, as it has been shown early callus formation and radiological union within the - months. it has been allowed to patients early full weight bearing. during the treatment it has been confirmed working of self-dynamisation concept, which probably all together with d configuration resulted in unexpectedly quick fracture healing. follow up was months ( - ). according to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site. it can be used as primary method or soon after external fixation if damaging control concept used. ( ) ( ) ( ) ( ) ( ) and followed-up for a minimum of years formed the study population. a retrospective review of data from electronic patient record (epr), clinical coding, clinic and gp letters was made. age, residential placement, garden's classification of fracture, mode of injury, associated comorbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected. an indepth study was conducted to look into delays for surgery, length of stay in hospital, complications and treatment of these complications. reasons for re-admissions, re-operations and comorbidities developing as a result of these interventions was critically analysed. results: the mean age of patients was years (range - years). the incidence of non-union was % and avascular necrosis at year was %. revision surgery was performed in ( %) cases. complications were more principally in patients who had end-stage renal failure ( %), diabetes mellitus ( %), osteoporosis ( %), and steroid use ( %). conclusion: the complications and revision surgery rate was high in patients with particular co-morbidities despite being undisplaced. comorbidities and patient's age were also strong predictors of healing in addition to fracture configuration. outcome of hip fractures is influenced by complex interplay of multiple factors and not only by radiographic appearance. methods: this is a -year of retrospective study. we had included patients to our study ( females and males) with the average age of . . we used bryan and morrey classification system and included type i and type iii fractures. results: there were type i and three type iii fractures. associated injuries were two dislocations with one mcl injury and two radial nerve symptoms. all the patients had orif with screw and two patients had supplementation of fixation with wires. most patients were mobilized early in weeks time. nine of them treated with miniacutrak screw fixation, four with herbert screws and one lag screw (ao miniscrew). the approach was mainly postero-lateral but for five patients, it was antero-lateral. all patients were clinically and radiologically assessed. average time for radiological union was weeks. on the other hand, one patient had revision fixation because of failure of metalwork. additionally, one patient had capsular release for contraction and another one had removal of screw for prominence of metalwork. average follow-up was . months ( - months). mayo elbow score was excellent for seven patients, good for three patients, and fair for three patients. one patient could not be fully scored due to learning difficulties. we recommend open reduction and internal fixation for all type and type fractures so that function can be regained early. objectives: to report the outcome and comparison of calcaneum fracture managements for intra-articular fractures. methods: a prospective study of the patients with intra-articular calcaneum fractures in the foot&ankle unit of a busy trauma hospital. all the patients were followed up with the calcaneal fracture score. we compared the outcome of surgical management sanders type (group a) and type (group b) fractures with conservative treatment (group c) at years and assessed the medium term outcomes of groups a and b. group c were a consecutive series of patients recruited to the study later than a and b, hence the smaller number in that group. results: patients were included in our study. there were in group a, in group b, and in group c. mean follow-ups for the groups were a = years, b = . years, and c = . years. mean -year scores for the groups were a = . , b = . , and c = . , with statistically significant differences between groups a and c (p = . ), and between groups b and c (p = . ), but no significant difference between groups a and b. at medium-term follow-up (> years), the scores for group a and b were . and . , respectively. there were deep, superficial infections and metalwork removals in total. conclusion: on comparing the medium term outcome to the -year one, group a showed some improvement and group b stayed the same. in this series, contrary to published articles, there was a better outcome at years with surgical treatment than conservative treatment. author to editor: all the authors have agreed with content of the abstract. there was not any conflict of interest for this study. objective: to assess the effectiveness of mobile angiography with a digital subtraction angiography (dsa) technology directly into the emergency room (er) for blunt trauma patients with pelvic injury. materials-methods: this is a retrospective review of a cohort of blunt trauma patients with pelvic injury treated after the direct availability of mobile angiography by trained trauma surgeons into the er for resuscitation. data was collected including demographics, hemodynamic variables, resuscitation intervals form admission through completion of hemostasis, metabolic factors (ph and body core temperature), mortality and transcatheter arterial embolization (tae) related complications. results: twenty-nine patients underwent tae in the er. mean age, shock index, and injury severity score were ± years old, . ± . , and ± , respectively. the interval from the decision to perform tae through initiation of tae and the interval from the decision to perform tae through completion of tae were ± min and ± min, respectively. the mean dbody core temperature (bt) from admission through completion of tae was - . ± . °c. and the mean dph from admission through completion of tae was . ± . . there were clinically significant correlations between dbt and resuscitation interval, and between dph and resuscitation interval. tae was successfully performed in all cases and mortality was %. no tae-related complications were observed. conclusion: immediate availability of mobile angiography into the er by trained trauma surgeons was effective to shorten the time required to restore normal physiology of trauma patients with pelvic injury without leaving the er for resuscitation. introduction: tgf-b is a regulatory protein, involved in fracture healing. the purpose of this study was to investigate the role of tgf-b in human fracture healing, and to verify whether tgf-b is a reliable marker of nonunion. methods: serum samples of patients with long bone fractures were collected over a period of months. patients were assigned to groups: first group contained patients with physiological fracture healing. eleven patients with nonunions formed the second group. healthy volunteers served as controls. results: in patients with physiological healing serum concentrations were initially high. serum concentrations then decreased rapidly after weeks and reached a plateau between weeks and . thereafter, another continuous slight increase of the concentrations was observed between weeks and . in patients with impaired fracture healing tgf-b serum concentrations were initially similar to those with normal healing. a significant increase of the concentration was observed between weeks and , followed by a continuous decline of the serum levels for the remainder of the observation period. significant differences between the concentrations in both groups were observed at weeks and . tgf-b as marker would have detected patients with nonunions at weeks after fracture with a sensitivity of % and a specificity of %. distal metaphyseal radial fractures are extremely common fractures in children (% , ). high rates of displacement occurs during conservative treatment. the aim of this study was to determine the effect of kirschner wire application after closed reduction of radial metaphyseal fractures with high risk of redisplacement. in this retrospective study cases were studied in two groups. in group (n = ), k-wire applied after closed reduction. in group (n = ), only cast was applied following closed reduction. the mean follow-up was months. the compared clinical and radiological parameters were; pain, limb deformity, range of motion of the wrist, angulation of the fracture site, radial distal epiphyseal angle and severity of translation. redisplacement rate was % in group and % in group . this shows, kirschner wire fixation had a positive effect in continuity of the initial reduction (p = . ). age (p = . ), gender (p = . ), reduction quality (p = . ) had no effect on redisplacement. concerning the severity of translation, the risk of redisplacement increases in stage ( - %) and stage (> %) fractures (p = . ). concomitant complete ulnar fracture had also redisplacement risk (p = . ). redisplacement risk increases when the distance of fracture line to epiphyseal line was between and mm (p = . ). there was no significant difference between two groups after last evaluation based on radiological parameters and clinical results (p > . ). as a conclusion; this study shows that kirschner wire fixation prevents redisplacement in early follow-up of first weeks but there is no superiority after months follow-up in distal metaphyseal fractures of children. patients in group c showed the best functional results, the greatest ankle range of motion, the fastest full bearing, the fastest walking on toes and heels, and the shortest duration of physical limitations (walking on uneven ground and sports activities) (p < . for all). in group b, there were two reruptures, in group c one, and in group a there were no reruptures. good functional results and a relatively small number of postsurgical complications advocate the usage of surgical techniques. the best and fastest functional recovery was attained in the group treated with the original technique of percutaneous fixation with two embracing and crossed loops. open surgical reconstruction is indicated only in the case of rerupture after percutaneous suturing. introduction: there are different techniques for arthrodesis of endstage arthrosis of the ankle-joint. internal fixation is the favoured method in many institutions. we retrospectively examined the technique and clinical results of external fixation in a triangular frame. patients/methods: from to a consecutive series of patients with end-stage arthritis of the ankle joint was treated. mean age at the index-procedure was . years, patients were male ( . %). via a bilateral approach the malleoli and the joint-surfaces were resected. an ao-fixator was applied with steinmann-nails. follow-up examination at mean . years included a standardised questionnaire and a clinical examination including the criteria of the aofas-score and radiographs. results: in two cases, due to contracture a pes equinus position had to be accepted. in two cases a further bone transplant was performed at and weeks for unsatisfactory bony union. after mean . weeks, radiographs confirmed satisfactory union and the fixator was removed. in four patients a nonunion of the anklearthrodesis developed ( . %). the mean aofas score improved from . to . points. statistical analysis of the insurance status showed that patients insured under a workers injury compensation scheme had a mean score of . compared to . for the remaining (p = . ). discussion: nonunion rates and clinical results of arthrodesis by triangular external fixation of the ankle joint do not differ to internal fixation methods in literature comparison. the complication rate and the reduced patient comfort reserve this method mainly for infected arthritis and complicated soft tissue situations. implants with multidirectional locked screws have theoretical advantages in the treatment of periprosthetic fractures. in osteoporotic bone they provide a high stability. we concluded a retrospective study of a consecutive series of the outcome of vancouver b and c femoral injuries using two specific locked-implants. from to we treated patients with a periprosthetic fracture of the femur with a locked plate. the mean age at the index procedure was . years, patients were female ( %). in cases ( . %) we saw a hip endoprosthesis, in cases ( . %) a knee endoprosthesis and in cases both ( . %). outcome measures were intra-and postoperative complications, bony union, degree of mobility and social status, barthel-mobility-index and ''stand-up&go'' test. union occurred in cases ( . %) after the index procedure. twice the implant failed, we saw four general complications. the mean duration until full weight bearing status in these patients was . weeks. at follow-up patients ( %) had maintained the same social status as before the fracture. regarding the mobility status patients ( %) had regained their previous level, patients walking without aid before now required a cane and patients a walking frame. the mean barthel-index was points of . the mean stand-up&go time was measured as seconds. conclusion: overall failure rates of osteosynthesis after periprosthetic fractures of up to % are reported ( ). with . % implant related failures and % general complications, the presented methods achieve bony union and mobility in a high percentage of cases. arthroscopic-assisted percutaneous figure introduction: we describe a new arthroscopic-assisted reduction and percutaneous tension band wiring technique for patella fractures that combines the advantages of minimally invasive surgery and stable internal fixation. surgical technique: we reduce the fracture percutaneously by towel clips with the patient in the supine position. we insert two . mm kirschner (k) wires in a caudocranial direction under arthroscopic control. we do four stab incisions to assign the inferolateral (il) and inferomedial (im), superolateral (sl) and superomedial (sm) portals besides the k wire tips. we insert a trocar with its cannula from sl portal to sm portal under the k wires. we take the trocar out and leave the cannula inside. we run -gauge cerclage wire through the cannula in sl to sm direction. we take out the cannula. we perform exactly the same steps directed from sm portal to il portal, from il portal to im portal, and from im portal to sl portal, respectively. finally near the sl portal, wires are secured with a single knot. we check the fixation by c scope. results: radiographic consolidation was achieved in all five patients at an average of months. all patients returned to the activity level previous to fracture. conclusion: this technique presents advantages over open techniques. it is minimally invasive and cosmetically pleasing, permits visualization of reduction and stability, allows concomitant intraarticular pathology to be exposed, and facilitates early rehabilitation. although we did not attempted yet, we believe that even comminuted fractures can be fixed with this technique. ( ) timing of the procedure, ( ) accurate technique, ( ) stable implants for early mobilisation. in this study we present our experience in the treatment of ftp with locking plates trying to define the role of a medial plate. materials and methods: from to we treated patients with a ao c ftp by orif with locking plates. indications for a medial plate were: involvement of the medial joint surface, coronal fracture of the medial plateau and irreducible dislocated medial condyle. all the patients have been followed up clinically with the lysholm and rasmussen scores and radiographically until consolidation. results: all fractures united. one patient underwent knee amputation for septic complication. the mean lysholm score was ''fair'' while the rasmussen score was ''good'', that means that the subjective result was worse than the objective one. patients treated by double plating had a worse clinical result that was not dependent on the quality of reduction. we had three cases of malalignment, one rsd, two superficial infections, two transient nerve palsy. conclusion: complications in our series were frequent and the clinical results not particularly good. the right timing and an accurate surgical technique are essential for a good reduction, newer implants control effectively the fragments but the high energy of the trauma remains the major determinant of the bad outcome of these fractures. introduction: the high percentage of failure of fixation systems in periprosthetic fractures depends on the technical difficulty of the procedure, the presence of the cement mantle and the poor quality of the remaining bone. the lcp system offers an enhanced stability that reduce the implant mobilization, and preserves the bone vascularity, fastening the healing time. we present our results in the treatment of periprosthetic fractures with lcp. materials and methods: consecutive patients with vancouver b fractures were operated on using . lcp. a standard open reduction of the fracture through a lateral approach was used. patients were evaluated clinically and radiologically for a mean follow up time of . months. results: all the fractures united except two where a narrow . plate and too many cerclage wires around the fracture were used. all the patients showed at fu an hhs over points. the anatomical reduction of the fracture led to a faster healing. conclusions: the effect of the position of screws and cerclages in relation to the plate and fracture are discussed. the authors conclude that lcp system, has to be considered the golden standard in the osteosynthesis of vancouver type b periprosthetic hip fractures, permitting early weight bearing and healing in physiological time. it is better to avoid narrow . plates and cerclages at the fracture site. suggestions on the plate length and screw and cerclages position are given depending on the fracture type and length. the role of the anatomical prosthesis in the treatment of proximal humeral fractures ló ránt bardó cz, jános csotye pá ndy ká lmá n county hospital, gyula, hungary, traumatology introduction and objectives: we would like to present the results of the treatment of proximal humeral fractures with endoprosthesis. methods: between and we operated patients with endoprosthesis for proximal humeral fractures. were delta prosthesis, the results of these operations are the subject of an other presentation. patients were treated with anatomical shoulder prosthesis. the results of these were controlled by personal examination (constant score, x-ray) and by the base of the clinical documentation. was hemi-and total endoprosthesis. in cases the operation was acute and in cases for chronic cases. the average follow up time was . month. we categorized our patients in different groups, based on the fracture type and the time of the surgery. results: we compared the cs of the operated shoulder with the contralateral one in each patient group. we have to accentuate the importance of patient cathegorization, because the results can be analyzed properly only on base of these. on the x-rays the prosthesis were in good place, we found no evidence of losening. conclusions: when the indication is good, the prosthetic procedure is the choice for acute or chronic fractures of the proximal hunerus, and the results are good. we confirmed the statistically significancy of the efficacy of the treatment methods between the same analyzed groups. aim: to discover if how often lateral x-ray change the management of fracture neck of femur fractures as an adjunct to the standard ap film. method: orthopaedic consultants and registrar grade orthopaedic surgeons were asked to decide the management of neck of femur fracture solely from an ap film. at a second sitting the same films were shown in a different order in conjunction with the associated lateral hip x-ray. the surgeons were asked to comment on the adequacy of the lateral x-ray and their choice of management using the both films to make a decision. results: less than half of the lateral hip x-ray were adequate when reviewed on the monitors and very few operative decisions were changed with the addition of the lateral x-ray. conclusion: a standard ap film is usually sufficient to plan management in a fractured neck of femur fracture and the additional time, money, and discomfort of obtaining lateral films does not seem justified in these circumstances. an sermon, stefaan nijs, barbara bosch, paul broos department of traumatology, university hospitals gasthuisberg, leuven, belgium introduction: humeral head fractures extending into the shaft often are a challenge to the surgeon. although they are a rather rare entity, they often occur in osteoporotic bone and are difficult to stabilize. however, because of their intra-articular extension, a perfect reduction and stable osteosynthesis is needed. methods: between august and august , patients with a combined shaft and humeral head fracture were operated in our department. a long philos plate was used in all cases through an extended deltopectoral approach. postoperatively, immediate mobilization was allowed. mean follow-up time was months. results: there were three preoperatively existing radial nerve palsies of which two completely and one partially recuperated postoperatively. there occurred no radial nerve palsies which did not exist preoperatively. revision surgery was necessary in two patients because of hardware failure and secondary fracture displacement within the first week after surgery. in both cases, again a long philos plate was used. all fractures were radiographically healed within months; there were no cases of avascular necrosis of the humeral head. most of the patients were subjectively satisfied with the functional result although mobilization of the shoulder was only moderate in nearly half of the cases. conclusion: in conclusion we can say the use of long philos-plates for the treatment of combined shaft and humeral head fractures gives good results when carried out by experienced hands. osteosynthesis with the use of locked nails is an efficacious method for the treatment of long bone fractures and nonunions of extremities. however, it is contraindicated in case of infection. one way to obviate this problem is to coat implants with antibiotic-loaded bone cement. the objective of this work was to evaluate the efficiency of antibiotic cement-coated interlocking nails for osteosynthesis of long bones in case of infection (infected nonunions) or at high risk of its development (severe open fractures). in - , nails with antibacterial cement coating were used to treat patients including ones with severe open long bone fractures (gustilo-anderson type iiia-iiib). these fixators were employed both at admittance of the patients (with an isolated injury) and within - days after it (in case of polytrauma). patients of this group underwent one-step surgery combining osteosynthesis and the closure of soft-tissue defects with local muscular flaps. in patients with infected nonunions of long bones, osteosynthesis was performed after seeding fistula discharge for microflora. none of the patients in the group with severe bone fractures suffered deep suppuration and all achieved consolidation of fractures. one case of recurrent infection associated with extensive necrosis of bone was documented in the group of patients with infected nonunions. the remaining patients had resolution of signs of infectious process, and their nonunions consolidated. the use of antibiotic cementcoated interlocking nails is a promising method for osteosynthesis of long bones in case of infection and at high risk of its development. author to editor: severe open fractures and infected nonunions are one of the most difficult problems in trauma orthopedic surgery. we had only one treatment option for this pathology down to resent times. it was an external fixator, but it has many disadvantages. in we start using antibiotic cement-coated interlocking nail, and we have promising first results. this results we would like to present in eurotrauma . hawar akrawi, david gordon hargreaves department of trauma and orthopaedics, southampton university hospitals nhs trust, southampton, the united kingdom introduction: we describe our clinical experience with a new posterior approach for reconstruction of distal intercondylar fractures of humerus. the maserati approach comprises of a midline proximal triceps split in conjunction with elevation of medial and lateral edges of triceps from the condylar ridges. this approach gives adequate access for accurate reduction and internal fixation of distal and intraarticular humeral fractures. methods: a single consultant series of patients with distal humerus fractures (ao grade -a to -c) were treated using the maserati approach and distal humeral locking plates over -year period at level trauma centre. all cases were reviewed. there were female and male patients with age range from to year. average follow-up was months. these patients were assessed for: . accuracy of reduction of fracture fragments. . complications i.e. infection, triceps weakness, triceps lag and fracture union. . elbow function as per the mayo elbow performance score (meps). results: nine patients had anatomical reduction. no cases of infection or nonunion. one case of delayed union. none of the patients exhibited triceps lag or weakness. the meps was - (mean ). discussion: the maserati approach is a safe approach that provides good access to the articular surface of elbow without compromising the triceps muscle. triceps continuity is preserved, allowing early rehabilitation without the possible co-morbidities associated with other posterior elbow approaches (non-union of olecranon, triceps weakness or triceps lag). author to editor: dear sir/madam, i will be very grateful if you could offer me the opportunity to give a podium presentation about this innovative approach. patients with distal humeral fractures are difficult to manage and with oral presentation, i will be able to demonstrate clearly, with media presentation, the full advantage of this new approach. results: improvement of the neurological deficit was observed in cases. ct control at least of years follow up shows good bone integration of the iliac crest bone in majority of the cases. two patients experienced temporary neurological symptoms, which showed complete remission. the endoscopic procedure for reconstruction of the anterior load-bearing spinal column developed to a standard concept in trauma management. the minimal morbidity of the operative approach, good visualisation of the operative field and angle stable implant make it possible to restore the anterior column on a safe technique. full weight bearing (painless) ranged (un) - (ø ) and (rn) - (ø ) weeks. x-ray healing ranged (un) - (ø ) and (rn) - (ø ) weeks. there was one patient with delay union( weeks) in un group. there were any infection; loss of reduction; re-operation and nonunion in both groups. discussion: we started this study because many studies before preferred reamed nailing but we have long term experience with undreamed nail with the comparable results (retrospective analyze). our hypothesis is that the biological advantages of undreamed nail should display if the perfect technical performance is done. conclusion: there are no significant differences between un and rn groups in our study in this time. we expect recruiting more than patients by the year end and during next years we will be able evidence the data completely. this work was supported by the research project moofvz septic arthritis following acl reconstruction péter frö hlich zentralinstitution for sportsmedicine, budapest, hungary infection after arthroscopic anterior cruciate ligament reconstruction is an uncommon complication, which could be a danger not only for joint function, but also for the joint integrity. we have to differentiate by the clinical recognition of this complication from swelling caused by other conditions (for example suffusion). there is no standardized opinion and method in the field of arthroscopic or open procedure, or necessity of aggressive graft removing. from a consecutive case series of , patients, who underwent anterior cruciate ligament reconstruction between and . we report on patients with postoperative septic complication. of these were extraarticular, and intraarticular manifestation. our protocol is based on infection severity classification modified by gä chter. reliability and significance level of diagnostic criteria (clinical evaluation, laboratory tests, synovial fluid analysis, and bacterial culture) were analyzed. the outcome was determined by early recognition and consequent treatment. there is only one patient, whose acl tendon graft has to be removed. the ikdc score shows the following result: a: , b: , c: , d: , it proved to be similar to the multicenter studies. in the last years we have no more postoperative infection following acl reconstruction by the application our protocol. we will review this protocol. introduction: early fixation of long bone fractures in the multiple injured patient has been recognized as beneficial in minimizing secondary lung and remote organ failure. although early fracture fixation is expedient in px with multiple injury etc may be associated with post-traumatic systemic complication. in this study all pz from a consecutive series of trauma patients with truama team activation admitted between / and / to department of emergency of niguarda hospital in milan were included when they fulfilled all of the following criteria: directly admitted, iss of more than , and survival of more than h. patients with fracture of long bones and/or pelvis with a clear indication for operative treatment and the necessity of immediate fracture stabilization where treat according with dco. all other patients fulfilling the inclusion criteria with minor fracture or thus not requiring immediate fixation formed the control group. iss, rts and ps was calculated at the admission and reevaluated later by the trauma leader. all injury was classified with ao and gustilo classification conclusion: the goals of dco include stopping ongoing injury including local soft-tissue injury and remote organ injury secondary to local release of inflammatory mediators further thought to prevent pulmonary complications by allowing patients to avoid the enforced supine position. this study was conducted retrospectively to evacuate the effectiveness of the trauma team organization and to evaluate the concept of dco by immediate external fracture fixation and consecutive conversion osteosynthesis with regards to time saving, effectiveness and safety. introduction: injury of the soft tissue results in a release of numerous cytokines, which activate fibroblasts of the surrounding tissue to proliferate and to undergo a phenotypic transdifferentiation into contractile myofibroblasts (mfs). in this study we analyzed the hypothesis, that human joint capsule mfs are specifically regulated by the cytokine ifn-c via the modulation of alpha-smooth muscle actin (a-sma) which is responsible for the contractile phenotype. methods: joint capsules were obtained from patients undergoing orthopaedic surgeries. to investigate the functional effect of ifn-c, we cultured mfs in a three-dimensional ( d)-collagen gel contraction model. an alamarblue assay in combination with the collagen gels was established to analyze the viability and the proliferative capacity of mfs upon ifn-c treatment. the effect of ifn-c stimulation on the gene expression levels of the specific mf markers a-sma and collagen i is going to be determined by real-time pcr (rt-pcr). this part of the study is in progress. results: mfs cultured in the presence of ifn-c show a reduced proliferative capacity. moreover, the addition of ifn-c reveals a dose-dependent decrease of collagen gel contraction. these effects were specifically blocked by a neutralizing ifn-c antibody. first results of rt-pcr analysis show an inhibition of a-sma and collagen i gene expression by ifn-c. conclusions: ifn-c reduces mf viability and contractility in a dosedependent way, presumably by down-regulating mf specific genes. this study suggests that ifn-c might be effective in attenuating the contraction of soft tissue in fibrocontractive disorders. with an average age of . years old were included and a retrospective database study was performed. the outcome parameters we analysed were the radiological outcome, the functional outcome and the prevalence of complications. results: the fracture healed in an accurate anatomical position in all patients treated with esin ( %). seven patients ( , %) suffered from irritation around the entrance opening and in four patients ( . %) the pen migrated medially. in eight cases ( , %), this resulted in a reoperation, consisting of remodelling, reposition or removal of the pen. in two cases we saw a refracture after removing the pen. the overall complication rate was . %. dash scores showed an average functional outcome of . points (range: - ) at . months follow-up. conclusion: operative treatment with esin in dislocated midclavicular fractures offers good mid-term radiological results and a good dash score. the overall prevalence of complications was . % and in . % a re-operation was required. the results found in the available literature showed a re-intervention rate of %. prospective randomised research is required in order to determine the right surgical indications and to find out what the long-term results of this relatively new method of fixation are. aim: our main aim was to find out whether there is a place for nonoperative treatment as a definitive primary option in patients with significant medical co-morbidity. methods: we did this audit in collating information on , hip fracture patients across nhs hospitals in england. out of , ( . %) patients were treated conservatively. results: there were males and females patients managed conservatively in our study. during hospitalisation, became bedridden and died. among these patients, were deemed physically unfit for surgery by anaesthetists and by medical consultants. the decision was made by orthopaedic consultants in ten cases and by multidisciplinary team in four cases. five patients refused surgery and five patients were palliative due to terminal illnesses. patients who did not proceed to surgery had significantly higher mortality rates (overall mortality rate %) suggesting that they were physiologically much worse group of patients. conclusion: as the average life span of our population increases, some hip fractures are now treated nonoperatively because of the possibility of severe or fatal complications due to surgery. often, refusal of surgery by the patient or the patients' family obligates the need for nonoperative treatment. it might be acceptable not to opt for the surgery if the patients are medically very high risk because of these reasons (e.g. acute cardiac event, severe aortic stenosis, multiorgan failure etc). the burden of patients with pubic rami fractures seems to be increasing. more patients with pubic rami fractures are admitted to hospital due to the absolute increase in the number of elderly people. although pubic ramus fractures are generally considered a benign fracture for its inherent stability experience indicated that this fracture is accompanied with a high morbidity and mortality. in a case-control study patients aged over years old with an isolated single fracture of the pubic rami admitted to the hospital were compared for morbidity and mortality to age-and gender matched hospitalized patients without fractures. data was acquired by the patient files. during years patients, with a median age of . (range: - ) years, were admitted with a median length of stay of days (range: - ). the mortality rates of patients with isolated pubic rami fractures at , , and years were significantly higher in the patient group compared to our control group, being: . , . and . %, respectively (p < . ). one third of the mortality is explained by cardiovascular events. during hospital admission a complication rate of . % was found, which was mainly caused by infectious diseases, including urinary tract infection and pneumonia. thirty-three percent of the patients (temporarily) went to a nursing home, because of the incapability to mobilise independently. in conclusion, patients admitted to the hospital for an isolated pubic ramus fracture have significant morbidity and mortality both during hospital admission and during -year follow-up. purpose: comminute fractures of the radial head are challenging to treat with open reduction and internal fixation. radial head arthroplasty is an alternative treatment. the purpose of this study was evaluating our results of a closely followed cohort of patients in whom an unreconstructible radial head fracture had been treated with modular pyrocarbon/metallic prosthesis. methods: from may to september , patients were operated for traumatic injuries in elbow. there were female and male with mean age ( - years). the follow-up was a mean of months ( - months). fractures of the radial head have been classified by mason with a subsequent modification by johnston. the indication for a radial head replacement are comminuted type iii fractures in cases, type iv in cases, and monteggia variant with olecranon and radial head fractures in cases. results: by using the mayo elbow score, patients had good/ excellent results, with fair and poor outcomes. patients showed an average arc of motion from - º to º. complications were three implant dislocations, needed to remove the implant. asymptomatic radiographic heterotopic ossification in elbow was showed in one case and bone lucencies were found in seven cases. we had not seen persistent instability, infection, synostosis, loosening, severe degenerative changes or impingement. conclusion: the treatment of unreconstructible comminute radial head fracture with noncemented pyrocarbon radial head implant usually gives an optimal result depending on the severity of the initial injury and the presence of associated injuries. methods: this retrospective clinical study is a follow-up examination of bony avulsion fractures of the intercondyloid eminence in adults and adolescents treated in our hospital in the last years. after the medical history was recorded, the course of the accident and type of injury was documented (classification according to meyers and mckeever) . also the type of treatment (conservative, arthroscopic surgery or open surgery) and accompanying injuries were analysed. the clinical follow-up examination took place after more than months after the trauma. during the face-to-face interview, physical and radiological examination, the knee function, and especially the stability of the knee-joint were assessed. furthermore the clinical outcome was determined using the lachmann-test and the lysholm-knee-score. results: the patient group consisted of male and female patients aged - years. the patients showed subjective and functionally predominant good to very good results. despite subjective stability and absence of pain, in some patients remained a mild hyperlaxity of the anterior cruciate ligament. conclusion: fractures of the intercondyloid eminence are a rare but serious injury of the knee. the correct diagnosis, classification, and curative treatment of the fracture is indispensable for the flawless function and stability. an individual approach is necessary in every patient. distal radius fractures are typical and frequent fracture of elderly woman with reduced bone density. the angle stable plate, often also multidirectional is today the most common stabilisation device. because of the introduction of bulky and bended implants as the micronail or targon dr we decided to test the xs radius nail witch is a , mm or , mm straight nail and witch is introduced after guide wire placement and over drilling with a cannulated drill of the same diameter. it is locked parallel to the joint in different directions with angular stability with threaded wires. methods: radius sawbones were osteotomised corresponding to a a fracture and stabilised with a angle stable plate ( ) and xs nail ( ). , alternating load cycles from - n were performed and the deformation was registered. also a fe analysis with the msc patran/marc software were performed. both types of osteosynthesis showed good stability. the deformation of the xs group however was % lower. also the calculated deformation in the fe study was % lower. also deformation amplitude was lower with . mm compared to . mm in the plate group. the differences however were not significant. both devices show good biomechanical results. the xs nail has the advantage of mainly intraosseus position, simple operation technique with introduction over a guide wire from the proc. styloideus radii and over drilling with a cannulated drill of the same size. the exposure of the n rad.superf. must be performed. first clinical evaluation is presented. angioembolization in severe pelvic fractures: experience of a tertiary centre in united arab emirates results: twelve patients (all males) having a median (range) age of ( - ) years were studied. five were vehicle drivers, four passengers, two pedestrians, and one fall from height. seven had abdominal tenderness while four had abdominal guarding. median (range) systolic blood pressure before angioembolization was ( - ) mmhg and ( - ) mmhg after embolization. nine patients had unilateral internal iliac artery embolization, one had embolization of the pubic bone artery, one had pudendal artery embolization, and one had bilateral iliac embolization and liver embolization. six patients had external fixation of the pelvis after the angioembolization. three patients had a laparotomy, the first had intraperitoneal urinary bladder rupture which was repaired, the second had pelvic packing and diverting colostomy for a severe perineal wound, the third had a liver injury and died on the table. one patient had a thoracotomy with interposition aortic thoracic graft. eleven were admitted to the icu having a median (range) icu stay of ( - ) days. the overall median (range) hospital stay was ( - ) days. only one patient died ( . %). conclusions: angioembolization of severe pelvic fractures with haemorrhage was successful in % of cases and played an important role in the initial management of severe pelvic fractures with haemorrhage. there were nine female and eight male patients passed with a mean age of . years. the knees were assessed at regular intervals and the mean follow-up period was . months (range - ). after initial assessment to confirm absence of trochlear dysplasia, the technique involves plication of the medial retinaculum with a nonabsorbable suture passed percutaneously using a long curved needle under arthroscopic vision and a small incision to bury the knot from the plication. post operative rehabilitation was done with flexion restricted to °for the first weeks followed by a gradual return to normal range of movements with vastus medialis obliquus strengthening exercises. results: patients reported good outcomes with no further episodes of dislocations. one patient who had persistent patellar instability requiring further distal bony-realignment procedure to achieve stability. none of the patients had major complications. conclusion: we report good results with this relatively simple technique of medial retinacular plication and would advocate it as an effectiveless invasive surgical option for patients with recurrent patellar instability in the absence of major trochlear abnormality or significant mal alignment. in a lateral (group a) and in a prone position (group b) with no significant difference in age ( . / . years) as well as pre-and insurgery parameters; no patients were excluded. the complication rate was analyzed by medical records, the radiographic outcome by plain x-rays and ct scans after an average of months postoperatively. comparison of the two patient groups utilized t-tests or chisquare testing of pearson as determined by number of data points for each variable assessed. results: the adequacy of fracture reduction had significantly poorer findings according to matta in a (p = . ), resulting in a significantly higher post-traumatic arthrosis rate (p = . ) defined as helfet iii or iv. no revision surgery was needed; no infection was detected in any group whereas iatrogenic nerve damages ( temporary, persistent) were found only in a. there was no significant difference concerning extensive blood loss, femoral head necrosis, epstein grades, heterotopic ossification classified by brooker and secondary surgery needed. conclusions: due to gravity the femoral head in the lateral position may constrain reduction leading to an inferior radiographic outcome. purpose: the incidence of fracture neck of femur (nof) has been increasing worldwide, due to an aging population. the commonest forms of analgesia are opioids and in some units regional blockade. but regional block is skill dependent and opiates are known to have many side effects. paracetamol is an analgesia that is safe and has an excellent side-effect profile within standard doses. intravenous paracetamol has a far higher predictable bio-availability than oral, within standard dosage. this study is to assess the suitability of using intravenous paracetamol as an alternative. method: prospective study: a change in protocol resulted in all nof's admitted under the care of the senior author being prescribed regular intra-venous paracetamol within standard dosage. prn opioids were available for breakthrough pain. nof's admitted under the care of other consultants remained on the established protocol. opioid usage and pain scores ( - ) were measured. results: results of patients were collected, in intravenous paracetamol group and in the original protocol group. there is a % reduction in opiate usage in the intravenous paracetamol group (p value = . ). there is only a . difference in average pain score between groups (p value = . ). conclusion: the use of regular intra-venous paracetamol results in a significant reduction in the need for opioid analgesia. the pain relief within this group was comparable to that in the control group. a simple change in analgesia protocol to a safer, more predictive agent can result in an improved pre/postoperative period. author to editor: funding: the study received no funding from any source. external fixation has already became on the end of last century as routine temporarily method of fracture bone fixation, especially in the light of damage control. but out of damage control, external fixation has been accepted in many developed countries as routine temporarily method in treatment of complex articular fractures (knee, ankle, elbow). the main reason was absence (night time, weekend) of experienced surgeon who can treat these complex particular fractures, as during the night. sometimes, the skin problem can prolong such fixation for three or more weeks. however, external fixation of tibia and distal radius can be method of choose for definitive treatment not only in open but in closed fractures as well. it becomes justified when high mobile and relatively simple external fixation devices have been developed allowing addition correction of reduction. in this paper, we want to present possibility of using already applied, external fixation device as temporarily method. about week after external fixation done (on femur or tibia) we developed technique existing external fixator to be used as a reduction device. once, desirable fracture reduction achieved, internal fixation is very easy and we do not need fluoroscopy control for reduction, just for internal device fixation by minimally invasive method. using this method, we already treated patients with femur fractures and with tibia fractures. from results obtained it can be concluded that external fixator developed by mitkovic is suitable to function as accurate fracture reduction device providing condition for simple minimally invasive internal fixation. results: with the antegrade nailing technique the mean postoperative constant score was . (flexion . °m abduction . °, pain . ). the elbow extension was free in . %. a correct axial alignment was found in %, in % we found a varus deviation of °- °. in % the nail perforated. in complications there was one prolonged bone healing, one pseudarthrosis and one infection. two thirds of the patients were very satisfied with the outcome. in the retrograde nailing technique the mean postoperative constant score was . (flexion . °, abduction . °, pain . ). the elbow extension was free in . %. only % of the patients showed a mild discomfort at the operative approach at the elbow. a correct axial alignment was found in %, in % we found a varus deviation of °- °. in % patients showed a postoperatively detected fracture in the supracondyle region. . % of the patients were very satisfied with their outcome. conclusion: the retrograde nailing technique is a save and sufficient method for treating humeral shaft fractures, especially because the rotator cuff is not disturbed. introduction and objectives: the bony bankart lesion is an avulsion fracture of the glenoid that usually occurs after anterior shoulder dislocation. this injury is frequently missed and often creates shoulder instability. therefore, open reduction and internal fixation (orif) of the fragment is recommended. in this study we looked at shoulder function, instability and pain after this operation. postoperative x-rays were reviewed on anatomical reduction. patients and methods: between and , bankart fractures were operated. they were classified according to ideberg. sixteen patients had an ideberg type b fracture and three a type . these patients received questionnaires with a number of validated scoring systems. we used the ases, rowe shoulder score and the dash questionnaire. results: the response was %. all respondents did get a stable shoulder after surgery. two patients regularly experience mild pain. the average rowe score was . (range - ). the average ases score for adl was (maximum score , adl unlimited). the median dash score on the quality of life was . (where means no loss of quality of life). there was a clear positive relationship between the radiological postoperative congruency of the joint, the shoulder function and quality of life. introduction: traumatic dislocation is the most severe form of ligament injury of knee.the purpose of this study is to report our cases in past years. methods: between and , knees in men and women; patients were treated for traumatic knee dislocation in our trauma center. the mean age was ( - ) years at the time of injury. the mechanism of injury were motor vehicle accident in , fall from high in and industrial accidents in patients. patients had additional extremity trauma. vascular injury detected in knees who required immediate reconstruction by vascular surgeons. the orthopaedic stabilization of the initial injury was bridging external fixation in knees included all vascular injuries. patients had fibular nerve palsy. in knees medial collateral ligament, in knees lateral collateral ligament, in knees anterior cruciate ligament, in knees posterior cruciate ligament and in knees posterol ateral corner lesions were diagnosed. one had tuberositas tibia avulsion. multiligament reconstruction was performed on a delayed basis in patients for a minimum of ( - ) month after the injury all patients had functional rehabilitation for a mean ( - ) weeks. results: at an average follow-up of . ( - ) years they were examined for stability and range of motion. all knees having multiligament reconstruction and of the patients in whom nonsurgical treatment was undertaken were stable. patients having multiligament reconstruction had slightly lower knee range of motion hypothesis: computed tomography (ct) is more accurate than bone scintigraphy for diagnosis of a radiographically occult scaphoid fracture. methods: in a study period of year, consecutive patients with a suspected scaphoid fracture but no fracture on scaphoid radiographs were evaluated with ct within h of injury and bone scintigraphy between and days after injury. the reference standard for a true (radiographic occult) scaphoid fracture was either ( ) diagnosis of fracture on both ct and bone scintigraphy, or ( ) in case of discrepancy, clinical and/or radiographic evidence of a fracture. results: ct showed scaphoid and other fractures. bone scintigraphy showed scaphoid and other fractures. according to the reference standard there were nine scaphoid fractures. the prevalence of true scaphoid fractures among suspected fractures was therefore %. ct had a sensitivity of %, specificity of %, accuracy of %, a positive predictive value (ppv) of % and a negative predictive value (npv) of %. the prevalence corrected ppv was % and the prevalence corrected npv was %. bone scintigraphy had a sensitivity of %, specificity of %, accuracy of %, a positive predictive value of % and a negative predictive value of %. the prevalence corrected ppv was % and the prevalence corrected npv was %. summary: this study could not confirm that early ct imaging is superior to bone scintigraphy for suspected scaphoid fractures. bone scintigraphy remains a highly sensitive and reasonably specific study for the diagnosis of an occult scaphoid fracture introduction: the therapeutic management of scaphoid fractures is still surrounded by controversy. immobilisation for non-or minimal displaced scaphoid fractures results in a union rate of more than %. functional outcome is often measured using clinical examination and radiological consolidation. however, the indication of how successful the treatment has been is the functional outcome of the patient. functional outcome of upper-extremity fractures can be measured reliably using the dash (disabilities of the arm shoulder and hand) outcome measure. materials-methods: consecutive patients with non-or minimally displaced scaphoid fractures, treated conservatively, were included. the trauma mechanism, treatment modality, diagnostic modalities, duration of cast immobilization and complications were analysed for all patients. functional outcome was measured using the dash outcome measure. results: patients showed good clinical and radiologic outcome after weeks of cast immobilization with a mean dash of . . six patients consolidated within weeks with a mean dash of . . three patients with four fractures took more than weeks to achieve clinical and radiologic consolidation and had a mean dash of . . the dash questionnaires showed statistically significant differences between patient age, fracture location and duration of cast immobilization. conclusion: conservative treatment of non-or minimally displaced scaphoid fractures results in good functional outcome after weeks of cast immobilization, particularly in young patients with distal or waist scaphoid fractures. objective: pedicle screw instrumentation is the most common procedure in stabilizing fractures of the throracolumbar spine, but yields an immanent potential for iatrogenic damage due to malpositioned pedicle screws. methods-materials: patients undergoing posterior instrumentations were included. preoparative ct scans were used to determine fracture level and classification. postoperative ct scan were evaluated for screw positions of all pedicle screws. cobb angles were compared to calculate the degree of reduction. the position of all pedicle screws was determined according to the classification proposed by zdichavsky. results: pedicle screws were assessed. pedicle screws were classified as optimal (ia, %), ib, iia, iib, iiia and iiib. malpositions were more often the more cranial pedicle instrumentation was performed ( % increase per level, p < . ). malpositions (ib-iiib) occurred more often on the right side of the patient (p < . ). the mean reduction was °. discussion: this study confirms the hitherto felt but unproven suspicion that malpositioning occurs more often in the upper thoracic spine. even more remarkably is the side-dependency in malpositioning. we attribute the higher rate of malpositioned screws on the right side of the patient to the circumstance that the surgeon usually stands on the left side of the patient and visual control of the direction of the pedicle screw during insertion is probably more difficult on the opponent side. we recommend envisioning this fact and -if navigation is not used -changing the position during the procedure. background: u-shaped sacral fractures are rare and highly unstable pelvic ring injuries. surgical stabilization may facilitate early mobilization and reduce mortality. however, limited evidence has prevented the development of a standard treatment algorithm. furthermore, little is known about the quality of life in these patients. purpose: to assess the injury characteristics, choice of treatment and quality of life of patients with u-shaped sacral fractures. methods: eight patients with u-shaped sacral fractures were identified over a -year period. neurological outcome was classified by gibbons' criteria. quality of life was evaluated using the euroqol- d questionnaire. results: there were five women and three men; the median age was years. the injury severity score ranged from to . definitive internal fixation was established after to days. percutaneous iliosacral screws were used in two patients with relatively stable fractures. transsacral plate osteosynthesis was used in one patient with minor displacement. triangular osteosynthesis with transsacral plating was used in four patients with multilevel sacral fractures, highly unstable fractures or traumatic spondylolysis l -s . one patient with an associated l fracture received a triangular osteosynthesis without transsacral plating. early partial weight bearing was encouraged whenever possible. follow-up ranged from to months (median months). four patients kept severe bowel and/ or bladder dysfunction. in the euroqol- d, pain, mood disorders and mobility problems prevailed. conclusion: u-shaped sacral fractures are rare and complex injuries. operative stabilization is tailor-made on the individual fracture characteristics. outcome is dominated by neurological deficits, pain, mood disorders and mobility problems. background: traumatic amputations are important causes of acute stress disorder and post-traumatic stress disorder. in this study, we aimed to present traumatic amputated patients needed more psychiatric support than the other trauma patients during the hospitalization period in the orthopaedics and traumatology clinic and in the later periods more post-traumatic stress disorder could be observed in this patient group. patients and methods: twenty-two traumatic amputated patients who have been treated in our clinic were evaluated retrospectively. during the early post-traumatic period, between the nd and th day, it was observed whether they needed any psychiatric support treatment. after the th month of the trauma, the patients were referred to the psychiatry department, and it was evaluated whether they needed any psychiatric support treatment by measuring the 'post-traumatic stress disorder scale' (tssb-Ö ). results: twenty-one (% . ) of twenty-two patients were male, one (% . ) of them was female. introduction: intramedullary nailing is challenging in proximal tibia fractures, associated with high rates of malalignment. to date, no studies report the potential of lateral tibia nail insertion to correct primary valgus malalignment, commonly seen in proximal quarter fractures. materials and methods: fresh-frozen cadaver lower extremities were used to simulate an ao/ota -a fracture. six nails (expert tibial nailing system, synthes, salzburg, austria) were inserted at the lateral third, six nails at the middle third and six nails at the medial third of the lateral tibia plateau. after nail insertion, alignment in the coronal plane was recorded. results: mean varus malalignment was dependent on the entry point at the lateral tibia plateau. mean varus malalignment was °if nails were inserted at the lateral third, °at the middle third and °after nail insertion at the medial third. if nails were inserted from the medial third, valgus malalignment was recorded in two specimens. discussion: the effect of correction of coronal malalignment in proximal tibia fractures is dependent on the point of nail entry at the lateral plateau. primary valgus deformation up to °can be corrected by inserting tibia nails at the lateral third of the lateral tibia plateau. surgeons should be aware of possible varus deformity and valgus malalignment despite lateral nail insertion. introduction: treatment of patients with distal radial fractures is primarily based on radiologic parameters. however, correlation between these parameters and functional outcome is questionable. objective: determine the value of radiological parameters for the appropriate treatment of patients with distal radial fractures. methods: a retrospective analysis was performed for a consecutive series of patients with conservatively treated distal radial fractures. axial radial shortening, radial displacement, radial angle, dorsal angle, and dorsal displacement were measured on the postero-anterior and lateral x-rays. functional outcome was measured using the quick dash-score (qds). minimal follow up was months. the radiological findings of patients who met the criteria for conservative treatment were compared to those of patients that met the current criteria for operative treatment (dorsal angulation > °, radial angle > °, radial displacement > mm, radial shortening > mm and step off > mm) but who had been treated conservatively instead. results: in a -year period patients were treated conservatively for a distal radial fracture. the qds was performed in ( %) patients. male female ratio was : , the average age was years (range - ). the mean qds was (sd ± ; range - ). age and female sex associated negatively with the qds. none of the radiologic findings was associated with the qds. half of the patients met the current criteria for operative treatment. the qds of this group corresponded however with that of the correctly conservatively treated patients. introduction: conservative treatment is generally preferred for simple elbow dislocations. in this study, the clinical and radiological results of conservative treatment are retrospectively evaluated. the patients were treated with closed reduction, plaster splint and brace. methods: dislocations of all patients were towards posterior and the average length of immobilization was . days ( - days) after closed reduction. the patients were assessed clinically for range of motion, instability, and atrophy after . months of mean follow up. mayo elbow performance score (meps) was used to evaluate functional outcome. standard elbow x-rays were evaluated for degeneration, heterotopic ossification, and concentric reduction. results: the average age of the patients was . ( - ) years. none of the patients had muscular atrophy. four patients ( . %) reported mild pain with heavy activity. six patients ( . %) had neurological complaints related with ulnar nerve. the average flexion arc and average rotational arc were °and °, respectively. the differences between the contralateral elbow motions were . °for flexion arc and . °for rotational arc. four patients ( %) had minimal residual instability. three patients ( . %) had mild radiographic signs of arthrosis and patients ( . %) showed minimal-mild degree of heterotopic ossification. an average score of . was obtained using meps. only four patients ( %) considered themselves fully recovered. conclusion: closed reduction and immobilization is a universal method for simple elbow dislocations. however, although functional scores were excellent, most of the patients did not consider themselves fully recovered. anterior odontoid screw fixation (aosf) is a valuable treatment after of, reported union rates in the elderly vary between and % when assessed on plain radiographs. in this study union-rates in of treated with aosf in patients aged ‡ years were revisited and risk factors for non-union analyzed. retrospective data review of a prospectively gathered c -fracture patients treated with aosf for of and age ‡ years were included for study. asides demographics and common injury characteristics, injury radiographs and ct-scans were assessed for fracture displacement, type, atlantodental osteoarthritis and particularly focussing on the square surface of of. follow-up ct-scans were assessed for technical failures, odontoid union, number of screws in aosf, square surface of screws used and the related healing surface. there were male ( . %) and female ( . %) patients with a mean age of . ± . years at injury ( - y). mean follow-up with ct-scans was . ± . months ( . - . mo). intervall injury to aosf was . ± . days ( - days). mean square surface of fractures was . ± . mm ( . - . mm ) and mean osseus healing surface was . ± . % ( . - . %). ct-based analysis revealed osseus union in nine ( %), while the remaining nine patients ( %) revealed non-union. in two patients, symptomatic non-union indicated posterior fusion of c - . union-rate significantly correlated with increased fracture surface (p = . ). observable was the trend that using two screws for aosf correlated with increased fusion-rate compared to one screw (p = . ). lifethreathening hemorrhage is often seen in pelvic ring fractures. efficient treatment of this hemorrhage is critical for survival in these patients. the purpose was to analyse the causes of death in hemodynamically unstable patients with a pelvic ring fracture and to determine if standardized treatment will reduce mortality. retrospectively, all data were reviewed of hemodynamically unstable patients with a pelvic ring fracture in the period / / till / / . of all patients, the pathway of treatment was analysed and compared with the standardized treatment protocol in our clinic. all injuries were categorized in injuries in airway, breathing, circulation and disability according to atls Ò principles. death was classified as directly related to the pelvic fracture if the patient required massive transfusions, died within h after admission and had no other body area injury with ais ‡ responsible for persistent hemorrhagic shock. we reviewed the data of patients. / patients died ( %). these patients were significant older and had a significant higher iss and shock class than survivors. two patients died of pulmonary trauma ( %), patients ( %) died of exsanguination(c) and patients ( %) died due to major head trauma. in patients ( %) there was a combination of injuries, which caused death. thus, overall hypovolemic shock contributed to mortality in cases. only in three patients death could be directly related to hemorrhage from the pelvis. two nonsurviving patients ( %) were not treated according to our standardized treatment protocol. in the survivor group this was only one patient. there is no consensus on the treatment of the acute total achilles tendon rupture. treatment modality is chosen on the basis of patient characteristics or the preference of the attending surgeon. using ultrasound, the distance between the two tendon ends in equinus position can be measured. this could form the basis for decision making between conservative-and surgical treatment. this cohort study consists of consecutive patients, between january and january . using ultrasound, patients were assigned to a surgicalor conservative treatment group. a gap of more than mm in maximal equines position was an indication for surgical treatment. seventy-two patients, men and women, received a conservative treatment. in patients the achilles tendon was primarily sutured. in the surgical group the post operative treatment was identical to the conservative treatment. the male-female ratio did not differ significantly (p = . ). the average age was years. sports caused % (n = ) of all injuries. the surgical group showed six re-ruptures versus nine in the conservative group (p = . ). on average, a rerupture occurs after days. no significant difference in major and minor complications (p = . ). outpatient treatment was needed days for the surgical treatment group versus days for the conservative treatment group (p = . ). ultrasound measured distance between the two ends of the achilles tendon in equinus in an acute total rupture can be used as a selection method in making a decision between surgical and conservative treatment. introduction: missile wounds induced by aviation bomb splinters pertain to grave injuries, due to large wound area and high risk of complications. material-methods: patients with large defects, in of casescombined with long bone fractures caused by missile injuries were treated by us in the period of august-november in . every cases were subjected to radical primary debridement with complete drainage. after relevant preparation for soft tissue plastic repair (involving primary radical debridement, primary external fixation, complex drug therapy and repetitive regular debridement) the following repair procedures were undertaken: in four cases, soft tissue defects were covered via rotation of local flaps. in three cases, defects were covered through transplantation of free skin grafts. in four cases, large soft tissue defects were overlayed by vascularized thoraco-dorsal (ld flap). in two of these, bone defect repair was simultaneously performed applying avascular graft taken from hip bone crista. results: in seven cases, transplanted flaps adhered perfectly, without trophic or infective complications. in one case, rotated local flap necrotized due to interrupted perfusion, which was subsequently replaced by free skin transplant. in five cases, fracture consolidation was completed in - months. in remaining two cases (after bone defect repair), consolidation process still proceeds with satisfying rate. conclusion: transplantation of vascularized thoraco-dorsal flap is especially effective for covering large soft tissular defects. soft tissular plastic repair has the double advantage of defect reconstructive ability and prevention from secondary infections, with additional stimulation of bone tissue regeneration. introduction: shoulder arthroplasty remains a valuable treatment for complex fractures of the proximal humerus. however the success of anatomical arthroplasty is mainly dependent of anatomical healing of the tuberosities. even with specific prostheses and fixation techniques in - % of cases anatomical healing is not achieved. using a nonfracture specific trauma prosthesis we achieved better elevation and abduction; however endorotation, exorotation, subjective shoulder rating and complication rate did score poorer than in anatomical arthroplasty. we assumed that the impossibility to refixate the lesser and greater tuberosity fragment, and subsequently the subscapularis and infraspinatus-teres minor tendons, are the main cause for this observation material-methods: we developed a fracture specific reversed shoulder prosthesis allowing for anatomical refixation of the tuberosities. we included patients in the reversed fracture arthroplasty group. function is scored using the constant murley-score. radiographically we evaluate for evidence of scapular notching. complications are recorded. we compare our results to an historical series of delta iii prostheses. results: at months the mean constant score is . points. there was no case of notching. there was one complication, an early infect. the mean constant score in the delta group was points. there was notching present in % of cases. in the delta group there were five reoperations in three patients because of dislocation. conclusion: there is a strong trend to better functional outcome using the fracture specific design. there are less complications and less notching. the possibility to refixate the tuberosities leads to better results. introduction: as fractures of the femur are severe injuries and patients mostly suffer from extensive pain they quickly attract the physician's attention in the emergency room. the literature has shown that injuries to the ipsilateral knee can occur accompanying such injuries. in most cases, these injuries though were diagnosed on delay. excluding cases in which a knee injury was apparent already on admission, we sought to investigate the number and severity of initially undetected lesions to the knee accompanying a femoral shaft fracture and give an overview of the literature. methods: charts and x-rays of patients treated for a femoral shaft fracture from january until december were reviewed. patients, in whom any other injury of the affected limb apart from a midshaft femoral fracture was initially diagnosed, were excluded. also patients, in whom an injury to the knee had been diagnosed on admission, were excluded. results: fifty-three patients with midshaft femoral fractures were available for analysis. an injury to the knee was diagnosed in cases ( %). there was one partial tear of the posterior cruciate ligament and two grade lesions of the medial meniscus. all lesions were conservatively treated. the shoulder is the most mobile joint of the human body. it has a great range of movement that takes place in all three cartesian planes. this is a complex phenomenon. there is considerable controversy over an ideal method for the functional assessment of shoulder joint complex. various methods have been used but they are often inaccurate and unreliable. thus, a better technique, that is reliable as well as repeatable, is required to measure the movements. the aim of this study is to assess the shoulder movement by fastrak Ò and vicon Ò systems and to compare their repeatability. methods-materials: the functional movement of the shoulder joint was assessed by fastrak Ò and vicon Ò systems. a difference between the two systems was determined and a comparison of repeatability was carried out. a population of healthy male volunteers were asked to perform six different tasks that covered all the movements occurring at the shoulder. these tasks were repeated twice on each side on two different days. the measurements were recorded and a custom-made programme, prepared for each system separately, calculated the angles. results: the recorded data was analysed using repeated measure analysis of variance. it was found that the coefficient of repeatability of fastrak Ò was better than the vicon Ò system for each task and there was no significant difference (p < . ) between the two sides. conclusion: the fastrak Ò system is better than the vicon Ò system for assessing shoulder movements. it can be used in clinical practice. ( - ). we applied sarmiento cast without any padding or little padding immediately. we encouraged the patients moving their arms. the treatment ends upon the presence of a bone callus and absence of pain at the fracture site. during the whole therapy the skin condition is monitored and emphasis is put on the prevention of reflex sympathetic dystrophy. we evaluate the result of the treatment with a focus on the any restriction of the range of motion of joints and the presenting any angulation of the humeral shaft. average follow up time was months ( - ). all fractures were healed without any major problem and we did not face any nonunion and no major angulations axis of the humerus. average union time was months ( - ). the results of nonsurgical treatment of the humerus mid and distal thirds shaft fractures are reported as a less complicated way and have a higher rate of union. this method is practical, efficient, cheap, and safe, if a good cooperation with patients is established and close observation is done. ( ). the aim of this study is to evaluate the surgical anatomical aspects of the minimally invasive hip surgery procedure in cadavers. methods: the mis approach was performed on four specially embalmed cadavers. all cadavers had a normal 'range of motion' of the hip joint. the difference in muscle length and work space were measured in all leg positions. additionally the difference in muscle tension in anterior and posterior luxation was compared with regard to the accessibility of the femoral shaft. results: the length of the medial-and minimal gluteal muscles is reduced in abduction. a difference of more than cm was found between °to °abduction and full abduction. the working space ( . · cm), is limited in the maximum ( °) abduction position. posterior luxation gives a better femoral shaft approach and less/ none muscle tension/damage compared to anterior luxation. the optimal approach to the femoral neck during mis of the hip is achieved during °- °abduction of the ipsilateral leg combined with °retroflexion. the best femoral shaft approach for prosthesis insertion is the posterior luxation. no additional damage, excluding the skin and fascia incision, was seen during posterior luxation. posterior luxation and exorotation of the leg enables straight and direct access to the femoral shaft compared to the access obtained during anterior leg luxation. background: it has been stated that acromial morphology plays an important role in the etiology of rotator cuff pathology. the system most widely used to describe the morphology is the bigliani classification. recently nyfeller introduced the acromial index. we wanted to examine whether there is a correlation between these two parameters and the presence of a rotator cuff tear or an impingement syndrome. methods: we assessed both parameters in four groups of patients each. the first group consisted of patients with operatively treated rotator cuff tears (average age . years) and the second group of patients known with impingement syndrome but documented intact rotator cuff (average age . ). for both groups, an age and gender matched control group was constructed. results: type three acromions were significantly more prevalent in the rotator cuff tear group than in the control group (p < . ). the average acromial index was . + . in the rotator cuff tear group and . + . in the rotator cuff control group, which is not statistically significant (p = . ). in the impingement group, the acromial index was . + . and . + . in the impingement control group. this difference was found to be statistically significant (p < . ). conclusions: patients with a rotator cuff tear appear to have more frequently bigliani type three acromion than age and gender matched, asymptomatic patients. there is no correlation between acromial index and acromial type or age. objective: extracorporeal membrane oxygenation (ecmo) is rarely used successfully in trauma. transfusion related acute lung injury (trali) is also rare in plasma containing blood product transfusion. methods: this is a case report of a trauma patient with life-threatening trali following trauma that was rescued successfully using ecmo. a year old patient was struck by an automobile and suffered a grade ii splenic injury, grade iv-v right renal injury as well as multiple orthopedic injuries. an attempt at angiographic embolization failed as the patient required multiple transfusions and became progressively hypotensive. the patient underwent emergent nephrectomy but rapidly became hypoxic with the pao becoming less than mmhg for over an hour. despite aggressive attempts at ventilation and oxygenation, the endotracheal tube was filled with fluid and hypoxia pursued despite low right heart filling volumes. rescue ecmo was instituted with successful oxygenation. after h the patient recovered from trali and was able to have ecmo discontinued. the patient was weaned off the ventilator within days and the patient had full recovery. the patient did not suffer any hypoxic brain insult. conclusions: although it is often thought that ecmo is unsuccessful in trauma patients, this case demonstrates its potential use in trauma patients. author to editor: will also present as poster findings: a total number of patients (all male; . ± . ) were found. injuries were resulting from gun shot fires (n = ; . %) or stab wounds (n = ; . %). injury sites within the heart were the right atrium (n = ; . %), the right ventricle (n = ; . %), the left atrium (n = ; . %), and the left ventricle (n = ; . %) (more than one site was observed in patients). the accompanying injuries were observed in the spleen (n = ; . %), the lung (n = ; . %), the liver (n = ; . %), and the stomach (n = ; . %). in ( . %) patients emergent thoracotomy was clinically decided with suspicious findings of hypovolemic shock or cardiac injury including low blood pressure, jugular fullness, deeply heard heart sounds, filiform pulse, narrowing of pulse pressure. the rest patients (n = ; . %) were operated after major blood drainage from tube thoracostomy. all the injuries were repaired with sutures, and pericardial fenestration was done in all. mortality was observed in two cases ( . %). patients with penetrating regional wounds should be suspected for penetrating cardiac injuries, since immediate surgical intervention may decrease the risk of mortality. introduction: the use of ''pan-ct'' is discouraged in settings of high imaging demand. this study compared clinical and plain chest film findings to determine need for, and results of, chest ct. methods: during recent month period, patients sustained blunt chest injury either isolated or in setting of multisystem trauma. data was tabulated by a combination of prospective and retrospective analysis. initial injury assessment followed atls protocol. supine chest film, followed by chest ct, were performed in all patients and compared with clinical findings. results: significant clinical findings were defined as tachypnea, decreased air entry, chest wall tenderness and initial oxygen saturation less than %. the presence of two or more of these clinical findings occurred in patients ( %). ct findings in this group included multiple rib fractures ± flail chest, sternal fractures, pneumothoraces, hemthoraces, and pulmonary contusions. higher ais and need for interventions occurred in this group. the co-existence of tachypnea and desaturation correlated with the need for tube thoracostomy in / patients( %) - pre-ct, post ct. conclusions: in patients with blunt chest injury, the presence of two or more of the clinical signs -tachypnea, decreased air entry, chest wall tenderness, oxygen saturation < % -is associated with: ( ) significant chest injury demonstrated on chest ct; ( ) higher correlation with ct findings than plain films alone; and ( ) introduction: complex regional pain syndrome (crps) sustained after trauma has a great negative impact on rehabilitation and activities of daily living. treatment is most often unrewarding. aim: to analyze prospectively the efficacy of endoscopic thoracic sympathectomy (ets) in reducing pain and disability associated with crps. patient and methods: over a -year period, patients ( females and males; mean age . ± . ) with posttraumatic crps underwent unilateral ets. the median duration of crps symptoms before ets was . months (range: . - ) . the sympathetic chain was resected from the second to fifth rib. mean postoperative follow-up was . ± . months (range: - . ). pain was assessed, at rest (passive) and during movement (active), using a visual analogue scale (vas) from to . results: one patient ( . %) had a hydrothorax and three patients ( %) complained about contralateral compensatory hyperhydrosis. at month (n = ), months (n = ), months (n = ) and year (n = ) after ets, there was a significant decrease in passive and active vas (p < . ). ten out of patients ( , %) needed less analgesics after surgery, and seven ( %) did not need analgesics at all. the mean sleep duration improved significant from . ± . h preoperatively to . ± . h postoperatively (p < . ). overall, patient satisfaction was % ( out of patients). conclusion: ets is efficient for decreasing pain and improving quality of life, and therefore should be considered in the treatment of crps. author to editor: complex regional pain syndrome (also known as sudeck or reflex sympathetic dystrophy) is a complex disease that trauma surgeons frequently encounter in the post-traumatic period. endoscopic thoracic sympathectomy is not well known among trauma surgeon, although it is an good option in relieving the pain and improving the quality of life. monitoring is accomplished with chest x-ray (cxr), but ultrasound (us) is nowadays established as more sensitive than cxr in detection of ptx. patients and methods: from october , thoracic views for detection of ptx are systematically included in the efast protocol during primary survey for every trauma patients (pts) admitted to our level i trauma center. among hospitalized pts, a selective usguided aspiration for small ptx was applied in three pts (two with a slow reabsorption time, one in a pt requiring hyperbaric oxygen therapy for a soft tissue infection of the leg). in supine position, delimitation of the area of anterior ptx was done with a linear probe, searching for lung points in adjacent intercostal spaces. under local anesthesia, a fr catheter was inserted in the ptx and aspiration monitored in real time by us, until restoration of sliding lung. the day after, after confirmation of normal gliding lung, two pts were discharged and one deemed suitable for hyperbaric oxygen therapy. discussion: small traumatic ptx is generally monitored without treatment. in some pts, drainage is however required, but the procedure is blind if performed on the basis of cxr findings. us allows to precisely define the site and the limits of ptx, insert a small catheter in the right area, monitoring reexpansion of the lung and complete aspiration of ptx and shortening recovery. background and objectives: occult diaphragmatic injuries are associated with significant mortality, if the diagnosis is delayed. we report our experience in diagnostic and therapeutic thoracoscopy in a selected group of patients with penetrating thoracoabdominal injuries. methods: the patients who underwent thoracoscopic management of thoracoabdominal stab injuries between june and june were included into the study. the data were retrospectively analyzed. results: eighteen selected patients with thoracoabdominal stab injuries were managed by thoracoscopy. the procedures were performed under general (n = ) or local anesthesia (n = ). diaphragmatic injuries were repaired by intracorporeal sutures in seven cases and bleeding was controlled in another two cases by electrocautery coagulation. the procedures were simply diagnostic in nine patients. the mean operating time and hospital stay were . min and . days, respectively. there was neither intraoperative or early postoperative complication, nor mortality. in a patient who had intra thoracic adhesions due to prior tuberculosis, unmentioned by the patient preoperatively, adequate exploration could not be achieved during thoracoscopy. the procedure was converted to laparoscopy and laparoscopic gastric and diaphragmatic repairs were performed. conclusion: thoracoscopy seems to be a safe, quick and efficient method in the diagnosis and treatment of diaphragmatic wounds, due to thoracoabdominal penetrating injuries. the nonoperative management is gradually more used in abdominal stab injuries and surgeons can resort to thoracoscopy and laparoscopy as a minimally invasive, diagnostic and therapeutic tool. trauma surgeons should be aware of the benefits of thoracoscopy and must have sufficient skills to carry out this technique. summary: generating acute lung injury by smoke inhalation and analyzing a method to pursuit standardized smoke. methods: a standardized glass, measures of cm width, cm length and cm height used as a closed area. we established a valf system under the glass which allows air inside but does not let it outside. with a hole above the glass, we attached the system to pomp with a hose. and the pomp was attached to a cm radial length balloon by another hose. we put a four ampere electricity owen in to glass and put g cotton to the oven. we burned the cotton for s in the closed area and we fullfilled the balloon with smoke by the pomp in s. rabbits were entubated after being anestesized. we waited seconds for the smoke to reduce down to room tempe rature to avoid thermal damage. after that, we seperated the balloon from the pomp and put it right through rabbits by ambulant air flow and inhalated in min.this procedure repeated for each rabbit. after the procedure ended,the entubation tubes were pulled away and the rabbits were left to spontaneous respiration. rabbits were allowed to standart rabbit bait and water at the th hour. results: we think we used a standardized smoke inhalation model in this study. methods: ten wistar rats were anesthetized and heparinised before the femoral artery was pierced to initiate bleeding. rats were than randomized to control and study groups. mph was poured into the bleeding site and a mass was placed on it. after s, the mass was removed and assessment of hemostasis was done. if bleeding ceased the test was scored as ''passed at s''. if not, additional dose of mph and compression was reapplied for an additional s. if bleeding has stopped after the second application, the test was scored as ''passed at s''. if not, the same procedure was repeated for the last additional s. if bleeding stopped now test was scored as passed at s. similar sequence of trials was done in the control group but without mph. the difference between bleeding periods in two groups was observed. results: application of mph resulted in complete cessation of bleeding in four of five and one of five rats at and s, respectively. in the control group hemostasis could not be achieved in all five rats, even at s. the statistical difference between the groups was significant (p < . ( . - . year) with supracondylar humeral fractures were treated operatively. according to gartland ( %) were type-ii, ( %) were type-iii. at the time of arrival at emergency department, four ( %) children sustained vascular impairment with pink pulseless extremity persisting after reduction. in three cases, a cubital approach was performed. two arteries showed a major lesion (one direct suture, one saphenus vein graft), and one artery showed an entrapment. all lesions showed a normal postoperative pulsation. another three ( %) children sustained a complete paralysis of the radial nerve. these cases were conservatively treated with complete neural restitution. conclusions: urgent anatomical reduction and fixation are crucial. in persisting vascular impairment after reduction, surgical exploration for the restoration of arterial patency should be performed, even in the presence of a pink hand. conversion to open surgical repair was needed in one case due to retroperitoneal bleeding from the iliac arteries. early postoperative mortality was observed in ( %) patients; due to massive coagulation disorder and hemodynamic instabiliy in postop st day and th day. mean follow-up was months (range - months). late mortality was not observed. overall reintervention rate was % (n = ); proksimal re-stenting was needed due to type endoleak in one patient. embolectomy for crossfemoral bypass was needed in one other patient after stenting for aneurysmal abdominal aortic rupture, this patient underwent re-crossfemoral bypass surgery later on. introduction: dislocations of and fractures around the knee are accompanied by injuries of the regional vessels to a certain extent. in any case of suspicion at the scene of accident an immediate transport to an adequate trauma center is the precondition for successful limb salvage. methods: between and , patients with arterial injury after dislocation of or fractures around the knee have been treated. retrospective analysis was performed in order to acquire epidemiologic data. furthermore we investigated the sufficiency of preoperative management and diagnostics. we explored peri-and postoperative complications, such as compartment syndrome, secondary thrombosis, infection and number of revision surgeries and related the data to the final follow up after and months. results: arterial injury was found in four cases of knee dislocation, in seven cases of proximal tibial fracture, and in nine cases of distal femur fracture. seven patients underwent acute angiography, since the year all patients were assessed with cta. seventeen cases were treated with venous interposition, one with a venous patch, and two with direct suture. fasciotomy was performed in all cases. limb salvage was successful in cases. in seven cases secondary amputation was necessary, six of these patients were polytraumatized. discussion: sufficient time management is crucial for the survival of vessel injured extremities, as the time of ischaemia must not exceed h. perfect interdisciplinary coordination and the establishment of specific algorithms are needed in order to decrease the risk of complications and amputations of lower extremities. the survey on the epidemiology of car-motor related accidents in children in kashan, iran iman ghaffarpasand, maneli dorudian tehrani department of surgery, kashan medical university, kashan, iran introduction: the most common cause of death in children is accident and reinforced a lot of taxes on the society. kashan has the second position in trauma ranking of iran so we studied this important issue in the children. methods and material: in this descriptive study, data has been gathered by trained hospital nurses during month in traumatic patients refered to -bed teaching hospital, kashan. the main method is questionnaire filling by direct interviewing. findings: among cases of trauna ( . %) of them was children below years old that cases ( . %) were due to car accident, cases ( . %) were due to motor accident and rest of them ( . %) were pedestrian accident. boys involved . times as girls the most injuries happened was head-injury ( . %). conclusion: these finding suggest that we have to pay more attention to this age group specially - because of the high rate of their involvement. finally as you see the last but not the least, these findings emphasise on protective cap wearing for every persons. managing blunt splenic injury in a level ii trauma center: the laparoscopic option background: the past decades treatment modality of blunt splenic trauma was a point of discussion. where nowadays explorative laparotomy remains the standard of care for hemodynamic unstable patients, treatment of hemodynamic stable patients is less uniform. in this stable population maximum conservative approach seems preferable, though level evidence is still absent. failure of the conservative pathway is backed up by percutanous angioembolisation or laparoscopic salvation. the evolution to minimal invasive access makes laparotomy as a primary care for hemodynamic stable isolated splenic injury superfluous. methods: this paper discusses the initiation of explorative laparoscopy and successive splenectomy in two patients scoring a grade iii posttraumatic splenic injury. grading was based on ct scan imaging using the spleen injury scale defined by the american association for the surgery of trauma (aast). conservative treatment was abandoned because of moderate hemoperitoneum and continuing need for transfusion. results: an uncomplicated laparoscopic splenectomy was performed in both patients. perioperative spleen preserving measures failed because of the extent of the parenchymal lesion. conclusion: performing laparoscopic splenectomy seems a good procedure when conservative treatment for splenic injury fails. this accounts for a rural level ii trauma center where the accommodation to perform safe angioembolisation is missing, knowing that laparoscopic splenectomy is not a straight forward procedure but is made easier because of the growing skills of our surgeons. hepatic portal venous gas (hpvg) is often associated with serious intra-abdominal pathology like ischaemic bowel disease and necrotizing enterocolitis, with reported mortality rates above %, with most requiring urgent operation. however, hpvg has been reported seen on ultrasound or computed tomography (ct) scans immediately after blunt trauma, followed by spontaneous resolution. gastric pneumatosis (gp) has rarely been reported as a trauma-related entity. the combination of hpvg and gp after blunt trauma has been described in very few patients. we report the case of a -year-old woman who presented with an edh requiring craniotomy and an initial abdominal ct scan showing only an ois grade liver injury. a transient increase in serum amylase combined with abdominal distension led to a repeat abdominal ct scan h post injury to rule out pancreatic and duodenal injuries, revealing gp and hpvg. endoscopy demonstrated mucosal erythema of the posterior gastric wall from the fundus to the pylorus. however, the clinical status of the patient was benign, and did not mandate surgical intervention. the patient was treated nonoperatively with nasogastric decompression and antibiotic coverage, and underwent a successful recovery with no abdominal complications. to our knowledge, only one other adult patient has been described with hpvg and gp occurring after an initial normal abdominal ct scan. a gastric resection was performed, and operative treatment was recommended for this combination of entities in trauma patients. our patient shows that treatment strategies in these cases probably should be guided by the clinical status of the patient. introduction and aims: while the number of colorectal injuries due to penetrating trauma are increasing, increased traffic accident rates also cause the number of blunt rectal injuries associated with trauma in traffic accidents to be increased. rectal injuries occur rarely. because of post operative septic complications, morbidity and mortality rates are high. early admission, stability, operation type all play important roles in the fate of the patient. we aimed to investigate these criteria in our patients who have colorectal injuries. material-method: cases who had penetrating or blunt trauma in our district during last years were included in this study. aim of this study is to present three cases with torsion of omentum, that often resemble acute cholecystitis or appendicitis, and the diagnosis is made at the time of exploratory laparotomy. case description: the first case, a -year-old men, presented with a -day history of right hypocondrial abdominal pain, fever and vomiting. the pain increasing in severity while the patient is standing and relieved in supine position. laboratory findings were normal, except for mild leucocytosis ( , /cc). the patient underwent u/s examination, which showed an encysted mass in the right abdomen. a mass, originating from the omentum, was revealed after laparotomy. the mass was excised and an appendectomy was also performed. the second patient, a -year-old female, was admitted in our department with abdominal pain, associated with vomitus. a mild leucocytosis ( , /cc) was observed. an u/s was carried out, which revealed a mass · cm lying besides a stone-free gallbladder. the patient underwent diagnostic laparoscopy and a cystic mass, which was twisted, was resected using bipolar forceps. sixteen of all laparotomies did not reveal any internal organ lesion. of these laparotomies with negative findings, had been operated for stabbing injury and had been operated for gunshot injury. twenty-one cases had single organ injury; whereas, multiple organs were affected in cases. frequencies of organ injuries were as follows: small intestine, colon, stomach, liver, diaphragm, spleen, kidney, and pancreas. the mean duration of hospitalization was . ± days. after surgery, four cases needed intensive care unit; therefore, they were referred to a higher-level healthcare center. among cases whom the treatment was completed in our institution, had complication. conclusion: penetrating abdominal injuries mostly occurred in young males and stabbing injuries were more common. most penetrating injuries can be treated at secondary care centers. however, they should be referred to a higher-level institution after the initial intervention, when necessary. background: both nonoperative management (nom) of blunt hepatic trauma and the damage control laparotomy are significant advances in the management of massively injured trauma victims. methods: this study is a retrospective evaluation of patients admitted with liver trauma during . of them required early surgical procedures, damage control surgery and followed nom. patients were stratified by age, mechanism of injury, ais, initial blood pressure, heart rates, and blood transfusion volume. initial outcome data included major complications, intensive care unit and hospital length of stay, and mortality. readmission data including the number of admissions, surgical procedures, and hospital length of stay were then analyzed. the average age of the study group was , years. almost all of these patients were males ( , %) and car crash was the main mechanism involved ( , %). liver injuries were frequently an element of multiple trauma and was associated with cranio-cerebral trauma ( , %) and spleen lesion ( , %). the overall mortality during the first admission was , %, yet . % attributable to the liver trauma and only . % after damage control. conclusions: damage control surgery offers a simple effective alternative to the traditional surgical management of complex or multiple injuries. phase i can be done at a local hospital before transfer to a major trauma center for resuscitation and definitive repair. reasonable surgical procedures based on classification of liver injuries and damage control principles increase the survival rate of severe liver trauma. background: at our department, a simple scoring system based on three criteria (blood pressure below , be below - . and body temperature below °c) has been used to determine the suitability of individual patients as candidates for dcs. objectives: the present study was undertaken to establish a valid strategy for the treatment of severe pancreatic injury and to test the validity of the scoring system used at our department for identifying suitable candidates for dcs. subjects and methods: the subjects of the study were patients with the grater and equal of grade iii (organ injury scale (ois))pancreatic injury treated surgically (type iii in cases and iv or v in cases). results: resection of the pancreatic body and tail was performed in both the groups to treat type iii injury, and all of the cases with type iii injury had favorable outcomes. among the cases with type iv or v injury, all of those patients satisfying two or fewer than two of the criteria of the dcs scoring system survived dcs, while two patients satisfying all the three criteria of the dcs scoring system died after dcs. the two patients who underwent pancreatic duct-forming surgery needed prolonged hospitalization. discussion: our results suggest that dcs should be selected in cases where at least one of the three criteria of the dcs scoring system is satisfied. as a procedure for radical operation, resection of the distal pancreas may be recommended for type iii, and pancreatoduodenectomy for type iv or v. author to editor: our results suggest that dcs should be selected in cases where at least one of the three criteria (systolic pressure below , severe hypothermia with body temperature below °c, and acidosis with be below - . ) of the dcs scoring system is satisfied. this dcs score is accords with the score of another abstract (abs ref ). we did not show the details of the score in another abstract ( ). please refer in our another abstract (ref iatrogenic and traumatic lesions involving common hepatic duct and duodenum can be treated with a primary and contemporary reconstruction, at the condition of hemodynamic stability. we propose a technique which include the following steps: cholecystectomy with intraoperative cholangiography; transection of the common bile duct above the tear, oversewing its distal part; kocherization of the duodenum; a cm long roux-en-y jejunal loop is constructed and brought up retrocolically in the right sub-hepatic space, orientating its antimesenteric side towards the corresponding duodenal wall; termino-lateral hepatico-jejunostomy with a transanastomotic temporary stent in case of small biliary duct's size; a side-to-side jejuno-duodenostomy performed cm distally; a feeding jejunostomy. we remark the following advantages of this procedure: ( ) the rouxen-y biliary diversion reduces the risks of stenosis and cholangitis, frequent after a direct repair of the common bile duct; ( ) an adequate distance between the biliary and duodenal anastomosis prevent entero-biliary reflux; ( ) the duodeno-jejunal anastomosis appears more appropriate, considering the complications after direct repair of large duodenal tears. more aggressive options, such as duodeno-cephalo-pancreatectomy, pancreas-preserving-duodenectomy and segmental duodenal resection, must be considered more risk solutions. introduction: the liver is the most commonly affected organ in abdominal trauma. in our department, the majority of traumatic liver injuries are treated conservatively. this option involves the monitoring of possible complications, such as late rupture, hemobilia, arterio-venous fistula, pseudo-aneurysm, biloma and abscess formation. case: a year-old patient was admitted after a m fall. established diagnoses were: multiple facial fractures, right pneumothorax with pulmonary contusion, right renal artery thrombosis and grade hepatic laceration. the patient was discharged on the st post-trauma day (ptd), after an uneventful course. on the st ptd, he was readmitted for abdominal pain. thoracoabdominal ct revealed an intra-hepatic arterio-venous fistula. angiographic superselective embolization was performed, and the patient was discharged following a control abdominal ct scan that showed resolution of the fistula. he was again readmitted on the th ptd, with abdominal pain, jaundice and gastrointestinal bleeding. an abdominal ultrasound raised the possibility of hemobilia, confirmed by upper endoscopy. a new angiography did not reveal any active bleeding, and an abdominal ct showed satisfactory evolution of the liver lesion. the patient was discharged on the th ptd, asymptomatic. at month follow-up, the patient presents no complaints, other than a new-onset arterial hypertension of renovascular origin. conclusion: arteriovenous fistulae and hemobilia are relatively uncommon sequelae of abdominal trauma. however, these diagnoses should be actively sought in the presence of abdominal pain, especially when associated with jaundice and gastrointestinal bleeding. a multidisciplinary approach is essential for a successful treatment. diaphragmatic hernias constitute frequent complications after thoracic and abdominal trauma ( . - %), especially on the left side ( %) and the diagnosis is frequently delayed. clinical presentation is variable and may include respiratory distress and abdominal pain, frequently attributed to intestinal obstruction, pancreatitis, biliary colic or peptic disease. the authors present a case report of a right diaphragmatic hernia diagnosed years after a thoracoabdominal blunt trauma. the male patient, years old, was admitted in the emergency room with epigastric pain, bloating, slight abdominal distension with months of evolution and recent worsening. he suffered a previous thoracoabdominal trauma years ago, consecutive to a downfall of about eight meters high with lumbar vertebrae fracture (l ) and was submitted to conservative treatment in an orthopaedic ward; x-ray signs of diaphragmatic hernia were unrecognized. actual chest x-ray revealed an elevated right hemidiaphragm and presence of abdominal content in the right hemithorax. mr demonstrated a right hemidiaphragmatic rupture and the presence of abdominal content in the thoracic cavity. patient was operated by laparoscopic approach; a diaphragmatic hernia grade iii (a.a.s.t. classification) was observed and submitted to prosthetic repair. postoperative period was uneventful. patient remains asymptomatic with no signs of recurrence after years. this case is paradigmatic of the difficulty of immediate diagnosis of diaphragmatic hernias, especially at the right hemidiaphragm. high index of clinical suspicion is needed for its early recognition in context of blunt trauma. laparoscopic treatment revealed to be safe and efficient, with the known advantages of minimally invasive procedures. results: their ages were between and , were male and were female. the type of injury was penetrating in , blunt in and blunt and penetrating in patient. in patients, the left kidney was injured, in the injury was at right kidney and in injuries was bilateral. the average transport time to hospital was min ( min- days). one hundred and seventeen out of patients were explored immediately as they hemodynamically unstable position. remaining patients were evaluated with ultrasonography, intravenous urography and computerised tomography. sixty four of these patients were followed conservatively. the injuries in patients followed conservatively were in patient's grade , in grade , in grade . renal units of patients were operated. nephrectomy was done in , nephropathy was done in and renal artery repairing was done in patient. conclusion: nephrectomy and mortality were high because of the long transport time, frequent high grade and high rate of associated organ injuries. rojnoveanu gheorghe sigmoid volvulus is seen more frequently at elderly ages and early diagnosis and treatment decreases its mortality and morbidity rate. we reviewed sigmoid volvulus cases treated in our clinic. patients hospitalized and treated due to diagnosis ofsigmoid colonic volvulus in dr. lü tfi kırdar kartal education and training hospital during - were analysed. treatment modalities, morbidity and mortality rates were analysed. patients were male, were female. mean age was ( - ). sigmoid colon resection and end colostomy was done to patients, sigmoid colon resection and end to end anastomosis was done to patients and nonoperative colonoskopic decompression was applied to patients with sistemic illness and they were prepared for elective sigmoid colon resection and end to end anastomosis. in one patient with anastomosis, anastomotic leakage was detected and end colostomy was applied. two emergently operated patients with sistemic illness died. mortality rate was% . in conclusion, sigmoid volvulus patients with sistemic illness should be prepared to elective surgery with colonic decompression. we think that the best treatment for early diagnosed cases is sigmoid colonic resection and end to end anastomosis. introduction: onset of world war ii, the report concerning diverting colostomy declared reduced mortality rates for colon injury, compared to world war i. in spite that nearly years has passed away, although all therapeutic options, this method -used for the management for colon injury -still include some controversial points. methods: ninety-five patient's characteristics were compared in two groups (patients with or without diverting stoma). clinical findings and patient's characteristics, injury mechanism, localisation of the wound, blood transfusion requirements, fecal contamination, colon injury score (cis), penetrating abdominal trauma index (pati score), evidence of shock, morbidity rate, mean hospital stay, main and additional surgical procedures of patients who admitted to our clinic from to were reviewed retrospectively. results: we have no mortality in both groups, except the first postoperative h. diversion colostomy was performed in patients and primary repair in patients. median hospital stay for primary repair and diversion groups were and days, respectively, (p < . ). respiratory system, septic complications, clinical anastamosis leakage and other complications were similar in both groups. conclusions: although all articles that prompt primary repair, this approach includes some inconvenient points. it is acceptable in military or war originated injuries. diversion mostly is necessary in wounds, related to highly potent and energic fragments. nevertheless, nearly all of the civilian colonic injuries can be treatment with primary repair without diversion since the mechanism of the wound is different than war injuries. dogan gö nü llü , oguz Ç atal , nilü fer yazgan yıldırım , tayfun yucel , ferda nihat kö ksoy taksim trainig and research hospital, _ istanbul, turkey background: the management of haemodynamic stable penetrating injuries of the flank has not been well defined; laparoscopic exploration, closed abdominal examination and triple contrast computed tomography (ct) are alternative modalities. our aims are to explain our experiences in these cases. methods: we reviewed the patients with isolated penetrating flank trauma admitted between and . the flank was defined as area between the anterior and posterior axillary lines, inferior to the fifth intercostal space superior to the iliac crest. results: there were haemodynamic stable patients ( gunshot and stab injuries). there were three patient groups: laparotomy (g ) (n = ), laparoscopy (g ) (n = ) and only closed clinical observation with triple contrast ct scan (g ) (n = ). patients in the g were gunshot injuries; the other two gunshot injuries were tangential and were included in the g . in the g there were four left diaphragmatic injuries, all repaired laparoscopically. one patient with splenic laceration and another with small bowel injury were converted to an open exploration. there were eight negative laparoscopies ( / ).two patients of g ( / ) with negative tomography were submitted to laparotomy after day of closed observation. the mean length of hospitalization in the groups was respectively . , . and . days. introduction: intra and retro abdominal hemorrhage are common following blind and penetrating abdominal trauma. liver, spleen and kidneys are known to be prone to injury and to bleed after an abdominal trauma. hepatocellular carcinoma is a well known disease. however, a renal mass from a primary origin in the liver is rare. this paper presents a patient, who was treated with right nephrectomy for traumatic bleeding from a ruptured renal mass. end diagnosis was metastatic hepatocellular carcinoma. case: the patient was -years-old man. he had no positive medical and surgical history, and no complaint. he was referred to emergency service after traffic accident. during his initial assessment abdominal rigidity and tenderness were found, which were accompanied with tachycardia and hypotension even after fluid resuscitation. fast revealed that there was free fluid in his abdomen, so we decided to operate him. at laparotomy we observed a bleeding tumoral mass in the right kidney and in his liver. he was treated with right nephrectomy and irregular hepatectomy. pathologic examination demonstrated a metastatic hepatocellular carcinoma. conclusion: hepatocellular carcinoma is a well known disease with its common acute complications such as rupture and bleeding. in this case, we observed hcc metastasis to the right kidney although the patient had no medical and surgical history including hcc. bleeding was induced after a blind trauma, was treated with resection. gall bladder (gb) injuries either following penetrating or blunt abdominal trauma is a rare entity and usually misdiagnosed with a delay in diagnosis. the incidence of gb injury is reported to range between . and . % among the surgically treated patients following abdominal trauma. cholecystectomy is the definitive treatment even in severe contusion of a nonperforated gb. simple suture repair or cholecystostomy are also advocated as alternative surgical interventions by some authors. gb is afforded significant anatomic protection from external trauma, since it is partially embedded in the relatively massive liver parenchyme, cushioned by the surrounding omentum and intestines, and shielded by ribcage. clinical symptoms may be minimal or nil initially but gradual clinical deterioration, related to spillage of bile into the peritoneal cavity, can follow. bilous fluid taken by paracentesis or diagnostic peritoneal lavage can only be helpful after a delay as abdominal computed tomography. an year-old male was admitted to our emergency department for the fifth time because of penetrating abdominal trauma of at the right upper quadrant by a knife in a -day-period. he was hospitalized in three of them and operated on at last, because of acute abdomen, since paracentesis revealed bile coloured free abdominal fluid in addition to abdominal guarding, leucocytosis( , /mm ), and fever.the ultimate ultrasonography and computed tomography revealed large amount of free fluid (bile) and minimal intrahepatic hematoma. at laparotomy; full-cut hepatic and cholecystic perforation (both anterior and posterior surfaces) resulted in cholecystectomy. he was discharged on the fourth postoperative day. since almost all reports about the delayed rupture of gb are usually unrecognized gb perforations,a diagnostic delay can only be avoided by a high clinical index of suspicion. sixty-three patients were treated conservatively, whereas patients had laparotomy and patients underwent angiography. of patients transported by ambulance or helicopter, % arrived at the emergency unit within min after prehospital alert. in % the time on scene were longer than min. in this group only % were diagnosed by ct within min after arrival to the emergency unit. conclusion: low volume in trauma care results in substandard handling time. in hospitals with a low volume exposure to trauma, the prehospital response teams and surgeons achieves limited experience, especially in penetrating trauma. exchange programs must be emphasised. author to editor: this study describes the complete workload in primary handled trauma patients in a typical nothern european universtyhospital with very low incidence of penetrating trauma and low volume of blunt trauma. our trauma registry covers % of patients admitted to the hosptial. it is the only hospital in the area, and patients do not bypass the system and are treated elsewhere. the study will point out that prehosptial responsetime and inhosptial procedures are is acceptable, but emergencyroom handlingtime is to long, due to lack of practice. national or european exchange programs for surgical trauma care must be practiced. introduction: explosives create and energize particles that act as projectiles prone to further fragmentation in the body. these fragments may result in secondary injuries. this has been repeatedly described in the orthopedic and neurosurgical literature. in this paper we demonstrate that such a process is also possible for abdominal injuries during or after fascial penetration. material-method: in all abdominal wall injuries, despite negative physical examination of conscious and alert patients we used local wound exploration as a standard approach. finding a full thickness fascial defect, we assumed an intraperitoneal injury and performed laparotomy. result: using this method, we found hollow organ injuries in of ( . %) patients. in ( . %) of these patients at laparotomy, we found multiple, projectile induced injuries in a sprayed distribution. these injuries were found far from the trajectory, in the absence of bone fragmentation. the mean number of peritoneal defects was . , however, for each peritoneal defect, we found an average of . intraabdominal injuries when through and through injuries were excluded. conclusion: local wound exploration is an accurate indicator of possible intraabdominal injuries. although fragments of projectiles would be expected to be distributed along the trajectory, meticulous exploration of abdomen is mandatory because this is not always true. despite a single peritoneal defect, there may be multiple intraperitoneal injuries due to further fragmentation of the projectile. introduction and objectives: nonoperative management of penetrating abdominal stab wounds has been established as standard care recently. it decreased negative laparotomy rate without any increase in morbidity and mortality. in this study we evaluated the outcome of patients managed due to penetrating abdominal stab wounds. intraabdominal injury due to blunt abdominal trauma usually presents acutely. in the absence of peritoneal irritation findings or shock the patients may be treated conservatively. delayed small bowel obstruction after blunt trauma is very rare clinical entity. it may be caused by subclinical bowel perforation, localized bowel ischemia or mesenteric vascular injury. we present a years old man of blunt abdominal trauma that was treated nonoperatively. despite the success medical treatment, months later, the patient presented with abdominal pain and vomiting. the radiologic studies suggested a mechanical intestinal obstruction. at the operation a conglomerated terminal ileal segment causing obstruction was found and the patient is treated by a resection and primary anastomosis. the operative findings may be explained by a subclinical perforation at the time of the trauma. this kind of complication should be suspected in patients with post traumatic patients which presents with signs of intestinal obstruction in weeks after the trauma. nevin kanan, ayfer Ö zbaş department of surgical nursing, istanbul university, florence nightingale school of nursing, ankara, turkey with traumatic injury, kidneys can be thrust against the lower ribs, resulting in contusion and rupture. up to % of patients with renal trauma have associated injuries of other internal organs. injuries may be blunt (automobile and motorcycle crashes, falls) or penetrating (gunshot wounds). approximately - % of all renal trauma cases are blunt trauma injuries; penetrating renal trauma accounts for the remaining - %. blunt renal trauma is classified into one of four groups which are contusion, minö r laceration, majö r laceration and vascular injury. • with a contusion of kidney, healing may take place with conservative measures (i.e. bed rest) • if minö r laceration is present, the patient is hospitalized and kept on bed rest until the hematuria clears. • depending on the patient's condition and the nature of the injury, major lacerations may be treated through surgical intervention or conservatively (bed rest, no surgery) • vascular injuries require immediate exploratory surgery because of the high incidence of involvement of other organ systems and the serious complications that may result if these injuries are untreated. the patient is often in shock and requires aggressive fluid resuscitation. for the management of patient with renal trauma, nursing diagnoses are: • inefective tissue perfusion (renal) related to interruption of arterial flow • anxiety related to physical injury • acute pain related to physical injury • impaired urinary elimination related to renal damage and shock background: penetrating abdominal buckshot wounds are believed to necessitate emergent laparotomy to rule out any hollow or solid organ injury. recently, nonoperative management has been suggested in selected patients. this paper aims to present two cases with penetrating abdominal buckshot wounds, treated nonoperatively. materials-methods: a chart review has been conducted for patients operated in our institution for abdominal buckshot wounds. demographics, evaluation tools and follow-up parameters has been analyzed and documented. results: a total number of two patients (both male; and years old) were found. both were shot on their left thoracolumbar regions. left and bilateral chest tubes were necessitated after initial examinations, but both denied any abdominal tenderness, although computed tomography showed multiple abdominally located pellets. gastroscopy (n = ), echocardiography (n = ), intravenous pyelography (n = ) were necessitated for further evaluation, but showed no abnormality. the patients were followed up with routine abdominal examinations, vital signs and routine laboratory tests and discharged from the hospital on days and after uneventful recovery periods. discussion: patients with penetrating abdominal buckshot wounds may be followed with nonoperative management instead of routine laparotomy. objective: treatment procedures in cases who were operated due to colon injuries were investigated in this study. material-methods: thirty-two cases who were operated due to colon injuries in our clinic between and were investigated retrospectively. cases were investigated with regard to age, sex, type of trauma, hemodynamic condition, interval between injury and surgery, additional organ injury, transfusion volume, injury site and severity, faecal contamination, surgical procedures, postoperational complications and mortality and factors affecting morbidity and mortality were determined. colonic injury severity scale (ciss), abdominal trauma index (ati) and flint classification were used for evaluating severity of colon injury,severity of additional organ injury and faecal contamination, respectively. systolic blood pressure less than mmhg on admission was referred to as ''shock''. results: males comprised out of cases and mean age was . (range: - ) years. twenty-five cases were injured due to penetrating trauma and left colon injury was the most common ( cases) type of injury. additional intraabdominal organ injury and extraabdominal injury were observed in and cases, respectively. mean interval between injury and surgery was . (range . - ) h. fifteen cases received blood transfusion. five cases had shock on admission. seven cases received stoma surgery while all cases with flint grade more than iii or ati score higher than received colostomy. only cases with high ciss score received resection and anastomosis surgery. complications were observed in cases while mortality occurred in two cases due to hemorrhagic shock. conclusion: routine primary repair cannot always be performed in colon injuries since many factors affect the decision for type of surgery. primary repair may be performed safely in hemodynamicallystable cases with ati score less than and flint grade i-ii. seat belt syndrome is defined as a seatbelt sign associated with lumber spine fracture and bowel perforation. an isolated rectal perforation due to seatbelt syndrome is extremely rare. there is only one case reported in the danish literature and non in the english literature. hereby, we report a -years old male who was a front seat restrained passenger involved in a head-on collision. he has presented with lower abdominal and back pain. seat belt mark was seen transversely across the lower abdomen. initial trauma ct scan was normal except for burst fracture of l vertebra which was operated by internal fixation on the same day of admission. the patient continued to have abdominal pain and distention which became clear on the third day. repeated abdominal ct scan on the third day has shown free intraperitoneal air. exploratory laparotomy has revealed a perforation of the proximal part of the rectum below the recto sigmoid junction. hartmann's procedure was performed with end colostomy. the abdomen was left open and temporarily closed using saline iv bags sandwiched between layers of steri-drape. peritoneal toileting was performed four times under general anesthesia with gradual closure of the abdominal fascia over a period of weeks. postoperatively, the patient had urinary retention due to a quada equina injury although he could walk. the presence of seat belt sign and a lumber fracture should rise to the possibility of a bowel injury. author to editor: seat belt syndrome is defined as a seatbelt sign associated with lumber spine fracture and bowel perforation. an isolated rectal perforation due to seatbelt syndrome is extremely rare. there is only one case reported in the danish literature and non in the english literature. hereby, we report such a case. fuat ipekçi, muharrem karaoglan, hü seyin toptay, hasan Ş ahin department of general surgery, tepecik education hospital, izmir, turkey introduction and aims: meckel's diverticulum results from incomplete degeneration of omphalomesenteric duct. it is usually diagnosed incidentally during appendectomy; however, sometimes perforation or bleeding may lead the surgeon to the diagnosis. we aimed to investigate the frequency of meckel's diverticulum during emergency laparotomy performed for acute appendicitis and clinical and pathological characteristics of the patients with meckel's diverticulitis and appendicitis. material-method: the material consisted of , patients who admitted to our hospital and treated by appendectomy during a -year interval between the years and . of these patients ( , %) were male and remaining ( , %) were female. all patients were investigated for meckel's diverticulum weather they have acute appendicitis or not. results: meckel's diverticulum was found during out of , appendectomies ( . %). of the cases, were asymptomatic but four patients were symptomatic with inflamed diverticulitis. of these four patients two have normal appendix and other two have secondary appendicitis due to meckel's diverticulitis. all four symptomatic cases were treated by diverticulectomy and appendectomy. all asymptomatic cases were treated by appendectomy alone. no mortality or major morbidity was detected. conclusions: despite of its rarity ( . % in our appendectomy series), meckel's diverticulum must be searched weather the appendix is normal or inflamed. introduction: illegal drug smuggling is a widespread problem. drug packs carried inside body cavities may leak its contents and be dissolved inside the body and signs of toxicity (aka. body packer syndrome) become evident. this case was reported to represent the very first proven patient in turkey. case: a year-old man were brought in the emergency department (ed) from the airport because of severe tremor, palpitation, restlessness associated with hypertension and tachycardia. the patient was cooperative and oriented. on examination, his blood pressure (bp) was / mmhg, pulse rate /bpm, whereas other systems were unremarkable. he was put on cardiac monitor and infusion of glycerol trinitrate was instituted ( mcg/min). urinary toxicologic screen was positive for cocaine and benzodiazepine. after admission to the ed he complained of epigastric distension and abdominal pain and admitted that he had swallowed cocaine packs. his abdominal xrays showed gas-fluid levels and opaque round-shaped mass images. a nasogastric catheter was inserted and gastric contents (approximately , ml) were drained. he was consulted with surgery clinic with a diagnosis of an ileus due to swallowed packs. he was hospitalized in the surgical ward. after supportive treatment and repeated enema applications he excreted cocaine packs in days. he was discharged following clinical stabilization and abdominal x-rays were repeatedly normal. conclusion: toxicologic analysis must be employed in patients who are suspected to have intoxication, to identify life-threatening drugs and vasoactive substances. advanced imaging methods must be exercised to exclude bowel obstruction in these patients. background: pseudoaneurysm is a well recognized complication of pancreatitis. angioembolization is considered to be the first option of treatment. to our knowledge, the case we hereby report is the first one with successful re-angioembolization. case: a -year-old man, with aids, history of cns toxoplasmosis, chronic pancreatitis with pseudocyst secondary to alcohol abuse, was hospitalized for pneumonia. during his hospitalization, he developed abdominal pain and hypotension. after resuscitation, ct angiogram of the abdomen revealed active bleeding into a pseudo-aneurysm, near the head of the pancreas, measuring . x . cm and arising from superior and inferior pancreaticoduodenal arteries. this was confirmed by angiogram. angioembolization distal and proximal to the bleeding area was performed using coils. eight days later, the patient became hypotensive and dropped his hemoglobin again. he was taken for an emergency laparotomy which revealed a cm pancreatic pseudocyst with hemorrhage. the pseudocyst was opened through the medial wall of the duodenum, ligation of the bleeding intracystic vessels, and cysto-doudenostomy were performed. his postoperative course was uneventful and he was discharged home on postoperative day . five days later he was readmitted with hematemsis and anemia. celiac angiogram revealed bleeding from the gastrodoudenal artery which was embolized. he died months later due to hiv nephropathy without any evidence of re-bleeding. objectives: any sort of discomfort in the abdominal cavity that lasts less than week is defined as acute abdominal pain. the purpose of the study was to evaluate the outcome of hospitalized patients with unspecified acute abdominal pain following initial clinical and laboratory evaluation. method: from january to december , patients with acute unspecified abdominal pain were admitted to surgery department. gender, age, definite diagnosis, time from hospitalization to surgery and hospital length of stay were retrospectively reviewed. results: fifty-six of the patients with acute unspecified abdominal pain were females ( %) and were males ( %), median age was years (range - ). while definite diagnosis was confirmed in patients ( %), the initial diagnosis was not changed in patients ( %). distribution of new diagnoses were appendicitis (n = ), gastroenteritis (n = ), genitourinary disorder (n = ), familial mediterranean fever (n = ), inflammatory bowel disease (n = ), mesenteric adenitis (n = ), peptic ulcus perforation (n = ), constipation (n = ), diverticular disease (n = ), pneumatosis intestinalis (n = ), hepatobilier disease (n = ) and intra abdominal tumor (n = ). depending on the cause of abdominal discomfort, patients ( %) required surgical intervention. median time from hospitalization to surgery was h (range - the use of temporary skin substitutes (tss) is a useful technique in the treatment of full-and partial thickness burn wounds affecting a large body surface area. early excision of the eschar is mandatory. but if we cannot find sufficient donor site, tss using seems to best choice. the ideal tss must be has some properties: adherence, control of water loss, safety, flexibility, stability on wound surfaces, bacterial barrier, and ease of application, ease storage and cost effectiveness. case report: a -year-old girl was admitted to our burn center with deep flame burns affecting face, thorax, upper and lower extremity ( %). she underwent an early burn excision on day post-burn day. the whole area excised with hydrosurgically was covered with biobrane Ò and compressive dressing. seven days after we removed biobrane from the upper and lower extremities and grafted the wound bed. face healed spontaneously under the tss and tss covering the thorax was rest intact. after days thoracic tss was removed and grafted and we covered the thorax with biobrane Ò over the grafts again. after days a second grafting was needed. patient was discharged from the hospital th post-burn day. the use of biobrane Ò as a tss after burn wound excision was satisfactory, because it enabled us to delay auto grafting until we were sure of good conditions in the wound bed. also it proved to be a good dressing over the meshed autografts. it reduces the healing time and improved the quality of grafts. introduction: endoscopic examination of the colon during the diagnostic or treatment purposes, perforation incidence is reported between . and . %. determination of risk factors may decrease the incidence with early recognition of the serious complications of surgery may reduce interference. method: we have examined retrospectively the patients in whom colon perforation appeared due to endoscopic analysis of colon carried out at endoscopy unit between january and december . results: total colonoscopy and rectosigmoidoscopy were applied to , patients. in patients ( . %) perforation was observed. the median age was . ( - ), m/f: / . all colonoscopys were made for diagnosis; anemia in two, hemorrhodial disease in one, subileus in two, anal prolapsus in one, right colon tumor suspation in one patients. one sigmoid polypectomy was applied, diverticulosis disease of the colon in two patients, dolichocolon in one, one previous pelvic surgery were observed. perforation zone was observed in sigmoid colon in all patients. four patients were diagnosed in the process of colonoscopy ( . %), were diagnosed in - h ( . %), was diagnosed days later. laparotomy was applied to all patients. perforation zones of patients were fixed primarily and these patients were discharged as cured. one patient who was applied to diversionary ostomy was reoperated due to abdomen collection. no mortality was observed. conclusion: colonoscopic perforation is a rare, serious complication. sigmoid colon is the location where the perforations are mostly observed. although primary fixation is generally efficient in cases of early diagnosis, morbidity increases seriously due to late diagnosis. with more than one stomas. eleven patients were discharged with planned ventral hernias. primary abdominal closure succeeded in four patients. fasciitis due to severe peritonitis and stomas prevented primary closure. eighteen of patient died during treatment, were discharged. sixteen of patients with more than one bag were died, five survived (mortality . %). conclusions: morbidity and mortality were higher in patients with more than one stoma than patients with single stoma. second stoma has a negative effect on primary fascial closure. fasciitis due to severe peritonitis also prevents fascial closure. acute diaphragmatic hernia after minimally invasive esophagectomy the aim of this study was to evaluate the disease profile and mortality ratio of patients presenting with acute abdomen. four hundred fifty eight patients who underwent surgery with the diagnosis of acute abdomen were analyzed retrospectively. the effects of age, sex, american society of anesthesiology (asa) class, accompany disease, admission time after the onset of the symptoms, follow up interval before the operation on mortality and length of hospital stay were evaluated. male/female ratio was . , and mean age was . . main causes were biliary system disease ( . %), intestinal obstruction ( . %), peptic ulcer perforation ( %) and acute appendicitis ( . %). median asa class was and . % of the patients had at least one preexisting disease. mortality ratio was . %. asa class, age, preexisting diseases other than malignity, period between the onset of symptoms and admission, follow-up time was significantly effective on mortality. background: resveratrol is a strong antioxidant with antiinflammatory effects. we aimed to investigate the effects of resveratrol on oxidative injury, histopathology and bacterial translocation in induced i/r injury in rats. methods: female wistar-albino rats were randomly allocated into four groups; sham-operated group(laparotomy without i/r injury), i/ r group (laparotomy plus min of ischemia followed by min of reperfusion), alcohol group (only . % ethyl alcohole . ml/day intraperitoneally for both days before surgery and min before ischemia), resveratrol group ( mg/kg resveratrol intraperitoneally both days before surgery and min before ischemia. intestinal tissue samples were obtained for investigation of tissue levels of malondialdehyde (mda), nitric oxide (no), superoxide dismutase (sod), myeloperoxidase (mpo) and histopathologic evaluation bacteriological translocation (bt) in mesenteric lymph node (mln), liver and spleen was also studied. results: resveratrol significantly decreased mda, no and mpo levels in i/r injury (p < . ). sod activity of resveratrol-treated group was significantly lower than sham group and significantly higher than i/r and i/r + alcohol groups (p < . ). histopathologically, the median intestinal injury score in i/r and i/r + alcohol groups was significantly higher than in sham and resveratrol-treatment groups (p < . and p < . , respectively). the incidence of bt differred between the groups i/r and i/r + alcohol in mlm, spleen and liver (p < . ). nevertheless, the treatment with resveratrol reduced bt to mln, spleen and liver, compared to other i/ r groups (p < . gastrointestinal stromal tumors (gists) represent rare neoplasms of the gastrointestinal tract. here we describe a case with gist and thrombocytosis presenting as an acute abdomen. our knowledge, the co-existence of gist and thrombocytosis has not been reported so far. case: a -year old female was admitted to the emergency room with epigastric pain and vomiting over duration of days. physical examination showed abdominal distension, rebound tenderness, and a palpable rlq mass. the laboratory findings were, wbc: . /l, plt · - /l and c-reactive protein . mg/l. a computed tomography scan of the abdomen showed conglomerate of small bowel. the abdominal exploration showed that a · · cm mass was located on small intestine. the mass was completely resected and enteroenterostomy was performed. the histological examination demonstrated whirling sheets of spindle cells which were stained positively for cd (c-kit) and cd , mitotic index > / hpf, while smooth muscle actin and vimentin were focally positive, and keratine, desmin, s- protein were negative. this specific immunophenotype characterized gist. during the post operative follow up, platelets were above normal levels · - /l. therefore, bone marrow biopsy was performed. hiperplasia in megakaryocytes were found. the patient was negative for bcr-abl and philadelphia chromosome. discussion: here we describe a case with gist and thrombocytosis presenting as an acute abdomen. ten percent to % of these tumors are biologically aggressive; signs of malignant potential are metastases and invasion. the current treatment for localized disease is surgical resection. co-existence of thrombocytosis and gist has never been reported. laboratory tests showed no abnormality except white blood cell count of /ll.plain abdominal x-ray and ct did not show any abnormal findings including free air (fig. ) . endoscopic examination of the stomach revealed an ingested toothpick protruding from the prepyloric antrum (fig. ) . the toothpick was deeply fixed into the antral wall. the whole toothpick . cm in length was removed using a loop without damage to the gastrointestinal wall, bleeding or any other complication. after endoscopic removal of the toothpick, her epigastralgia resolved. on the second hospital day, the patient was asymptomatic. medical therapy with proton pump inhibitor was stopped and she was discharged on the third hospital day. conclusion: accidental ingestion of foreign bodies is common and in general harmless. a perforation of the gastrointestinal tract by ingested foreign bodies is rare, occurring in less than % of ingested bodies like toothpicks are involved in less than . %. occasionally, the passage of the swallowed item may stop at one of the anatomic bottlenecks of the gastrointestinal tract, which may lead to perforations that may require operative or endoscopic interventions. results: we analyzed the number, causes and rates of emergency operations. the total number of emergency operations was , and , , for the first and second groups, respectively. we observed an % decrease in number of emergency operations for the second group. we also observed that the cause of majority ( % for the first group, % for the second) of the emergency operations was acute abdomen and the rate between the groups did not change. lower extremity amputation and strangulation hernia operations decreased and %, respectively. the number of operations which are caused by ileus and acute cholecystitis increased and %, respectively. conclusions: difference in distribution of emergency operations between two groups was statistically insignificant. however, we observed both an increase and a decrease in small numbers of some subgroups. it is believed that this is related to the change in patient profile and technological improvements in surgery. aim: we hypothesized that one of the most widely used anesthetic agents, propofol, may reduce inflammatory processes, and organ injury induced with cecal and ligation puncture study design: bacterial peritonitis was induced in rats by cecal ligation and puncture. the rats were randomly assigned to three groups. group (n = ) received propofol, group (n = ) received intralipid, group (n = ) was control, which did not receive any injection. all animals were killed days later so we could assess the adhesion score. tissue antioxidant levels were measured in -g tissue samples taken from the abdominal wall. results: the adhesion score was significantly lower in the propofol group than in the control group (p < . ). the catalase levels were higher in the intralipid and control groups than the propofol groups. conclusions: intraperitoneal propofol reduced the formation of postoperative intra-abdominal adhesions without compromising wound healing in this bacterial peritonitis rat model. propofol also decreased the oxidative stress during peritonitis approximately, min after the onset of the operation, a sudden decrease in end-tidal carbon dioxide from to mmhg was noticed. soon after, both systolic arterial pressure and heart rate decreased dramatically. arterial blood gas measurements showed that pco was mmhg at that moment. surgery and insufflation of gas was stopped, ephedrine mg was given intravenously and ventilation with % o was started. trendelenburg position was achieved immediately. a catheter was introduced through the right juguler vein to the right atrium rapidly and - ml gas bubble was withdrawn. soon, hemodynamic measures were recovered. since substantial amount of blood in the peritoneum was noticed, conversion to laparotomy with subcostal incision was performed. at exploration, through and through tear of mm in inferior vena cava was detected. the defect was sutured with / polypropylene. anesthesiologist and surgeon must be aware of this dangerous complication. the emphasis is given to the prevention and prompt recognition of this event to the use of available tools in the management of cardiovascular complications. aim: obstructive jaundice, develops accompanied with high morbidity and mortality rates. the absence of bile in bowels leads to bacterial translocation and ultimately to endotoxemia and septice-mia. _ in our study, observing changes on bowel level during obstructive jaundice and examining its contribution to bacterial translocation have been aimed. material-methods: the study has been carried out at _ istanbul university _ istanbul faculty of medicine experimental medical research center (detam) with approval of _ istanbul university _ istanbul faculty of medicine ethical board for animals. two groups out of male wistar albino rats have been formed. one hour after injecting d-xylose to first group the rats were put to sleep (anesthetized) and specimens of tissue (liver, spleen, mesenteric lymph nodes) and blood were taken for microbiological and biochemical examinations. in the second group an obstructive jaundice has been established by ligation of common bile ducts. the same specimens were obtained after days. findings: in the first group no proliferation on tissue and blood cultures were detected. an obstructive jaundice has been shown in biochemical investigation of blood. d-xylose was found to be . ± . mg/dl. in the second group, proliferation, of mainly e. coli, were detected on cultures and d-xylose was found to be . ± . mg/dl. statistically significant increases were assigned between groups, between tissue and blood cultures (p < . ) and d-xylose values (p < . ). results: detecting statistically significant increases in d-xylose levels in the second group leads to the conclusion that increases in bowel permeability plays an important role in bacterial translocation. conclusions: while wound infections were higher in open appendectomy procedure group, surgical time was higher in laparoscopic procedure group. the achievement of optimal results will be based on increasing surgical laparoscopic experience. objectives: intraabdominal hypertension (iht) in intensive care units is a common problem. investigation of the effects of dexmedetomidine on respiratory system in rats with iht was aimed. patients and methods: adult wistar-albino male rats were anaesthetized by rata ''ksalazin/ketamin'' combination. experimental model of iht( - mmhg) was induced via pressure cuff. rats were left to spontaneous respiration for h prior to randomly division into four groups. the first group underwent no process (control group). in sf group; cc of . % nacl,in the third group; . lg/kg dxmt and in the last, . lg/kg dxmt were intravenously administered. thereafter min passed to observe the effects of dxmt. the rats were killed via cervical dislocation prior to surgery. lung tissues were fixed in % formalin and stained with he. whereas the other cross sections were stained with tunel method,the rest were stained with anti-caspase , , and anti-fas/fasl antibodies for immunohistochemical analysis. results: histological changes in group were the less. there were no atalectatic changes in the same group. pnl infiltration and interalveolar thickness were higher in the . lg/kg dxmt group than others. in indirect immunohistochemical studies, in the . lg/kg dxmt group, immunoreactivity of caspase and were increased. however, the caspase- immunoreactivity was less than caspase- . these results supported that . lg/kg dxmt administration led apoptosis, even though to be delayed, to start and showed that extrinsic pathways was used through apoptotic pathways. it was concluded that low dose of dxmt caused to delay in apoptosis in the lungs. results: a total of microorganisms were responsible for the cris, of which ( . %) were gram-positive bacteria, ( , %) were gram-negative bacteria and ( . %) were candida species. isolated from the microorganisms were: klebsiella pneumoniae ( %), acinetobacter ( . %), enterobacter ( . %), rroteas mirabilis ( . %) pseudomonas aeroginosa ( %), staphylococcus ( . %). patients ( . %) developed crbsis and in patients with positive blood cultures cris were negative. in our study, femoral venous access was associated with a significantly higher incidence of cri and crbsi than jugular and subclavian access; and jugular access was associated with a significantly higher incidence of cri and crbsi than subclavian access conclusion our results suggest that the order for punction, to minimize the cvc-related infection risk, should be subclavian (first order), jugular (second) and femoral vein (third). introduction and objectives: undescended testis is a risk factor for the testicular carcinoma, especially a seminoma. seminoma can be seen at any age, but it is considerably rare in elderly patients. we describe a patient who presented with acute abdomen secondary to an ileum perforation due to the involvement of seminoma. case: a year-old man complaining with right lower abdominal pain and a palpabl mass with a -week history was evaluated. an abdominal computed tomography was showed a large, solid, welldefined intraabdominal mass, measured about · ·x cm in right quadrant of lower abdomen. an exploratory laparotomy was adjudged to perform. whilst the preoperative investigations for surgery were continued, the patient admitted to the emergency service with acute abdomen symptoms, which was started suddenly. he had peritoneal irritation signs. he underwent an urgent laparotomy and a large mass located on terminal ileum mesenter through the retroperiton was detected. dilated ileum segments with omentum wrapped along the antimesenteric border of the distal ileum was found. on separating omentum from ileum, perforation along the antimesenteric border was noted. extended right hemicolectomy and an end ileostomy was performed. histopathologic examination revealed a classical seminoma with extensive tumor necrosis and showed evidence of vascular invasion. conclusions: undescended testes should be considered in men with an intraabdominal groin mass and should be aware of its potential complications. department with diagnosis of acute cholecystitis and on exploration giant gallbladder with giant stone and gallbladder adenocarcinoma. case: a years old female was applied to emergency department with abdominal pain, nausea and vomiting. on physical examination, right upper quadrant tenderness and defence were detected. murphy sing was positive and gallbladder was palpable on subcostal space. in laboratory tests, white blood cell count was , /mm , glucose was mg/dl and liver function tests were minimally elevated. in hepatobiliary ultrasonography, the gallbladder was hidropic ( · cm) and there was a stone ( cm in diameter) and a mass ( · cm) in the gallbladder.cholecystectomy operation was performed. acute cholecystitis + cholelithiasis + adenocarcinoma were reported in the histopathological evaluation. conclusion: the carcinomas of the gallbladder were associated with gall stones in - % of the patients. we concluded that the presence of the symptoms in our patient was delayed due to the magnitude of the gallstone and the excessive size of the gallbladder. perforation of the gallbladder by trans-gastric migration of a sewing needle _ ingestion of foreign bodies is a common problem, especially in the elderly, pediatric, and psychiatric population, but fortunately, most of them pass spontaneously and uneventfully within week.the perforation and migration of ingested foreign objects into the abdominal cavity is very rare and usually leads to a laparotomy. perforation of the stomach by sewing needle with migration to the gallbladder is extremely rare, and none cases have been reported in the literature. a -year-old woman was admitted because of abdominal pain and a history of a swallowed sewing needle month ago. she had been followed-up at her local hospital and referred to our hospital because of the failure of progression of the foreign body. physical examination showed right upper quadrant tenderness, guarding, and a positive murphy's sign. blood analysis showed increased white blood count. she was submitted to abdominal plain x-rays, which revealed a radio-opaque objects in the liver area with the form of the sewing needles. the patient was clinically stable, and a semi-urgent laparotomy was planned. at laparotomy the needle was in the gallbladder and that the end of the needle could be palpated and the site of gastric perforation. removal of the intra gallbladder needle did not cause any problem. we was performed cholecystectomy and primary gastroraphy. the postoperative period was uneventful and the patient was discharged on seventh day of the operation. if there is a history of sewing needle ingestion and failure of progression and also signs of an acute abdomen, the surgeon must carefully evaluate gallbladder. introduction: sigmoid volvulus is an unusual intestinal obstruction form ( ) . it is most common in the middle aged, elderly, institutionalized or neuropsychiatric patients ( ). patients and methods: twenty-one sigmoid volvulus patients were reviewed retrospectively between and .the recorded data were age,gender,admission symptoms,physical examination,radiological, and operative findings, surgical procedure, postoperative complications, mortality, and hospital stay.there were male and female patients. the mean ages of the patients was . years ( - ).the most common symptoms in acute abdomen patients were pain, and tenderness. abdominal distension were the most recorded sign in patient without peritonitis. the mean admission time was . days ( - ). five patients had a history of sigmoid volvulus ( %). leukocytosis and high fever were found in ( %) patients. radiological evaluation of the patients revealed sign of intestinal obstruction (n = , %),frimann-dahl sign (n = , %) and bilateral free air under diaphragm due to perforation of the twisted sigmoid colon (n = , . %). no patient underwent contrast enema examination of the colon. the mean hospital stay was . days ( - days) . two patients without signs of peritonitis were treated by sigmoidoscopy and operated on elective course.patients with signs of acute abdomen were operated urgently. the patients had several associated diseases such as atherosclerotic heart disease, diabetes mellitus, hypertansion, chronic obstructive pulmonary disease, cerebrovascular disease. eight patients ( %) died due to sepsis. morbidity rate was %. wound infection, evisseration pneumonia, and acute renal failure were found in ( %) patients. the principal strategy in treatment of sigmoid volvulus is early nonoperative detorsion followed by elective surgery consist of colectomy and anastomosis on well-hydrated patient. urgent laparotomy is indicated in case of peritonitis. sigmoidopexy is an alternative option but it is usually ineffective and has high recurrence rate. results: ten men and four (six) female were enrolled in the study. mean age was years (range - ). e.coli and acinetobacter were the common organisms cultured. all patients were treated with a common approach of resuscitation, broad spectrum antibiotics, and wide surgical excision. objectıves: acute appendicitis is one of the most common nonobstetric surgical pathology. clinical symptoms and findings are masked due to anatomical and physiological changes of peregnancy, so diagnose and treatment of acute appendicitis in pregnancy generally late. the curent study reported the cases which were diagnosed acute appendicitis in pregnancy and promptly operated in our general surgery clinic. material-methods: we evaluated sixteen cases' data between october and october who admitted to emergencey department with abdominal pain, vomiting, nausea and anorexia complaints and diagnosed as acute appendicitis in pregnancy and operated. results: the average of the cases were . (range - ) and thirteen of them were second, two of them were third and one of them was in the first trimester. the time interval between the onset of the complaints and operation was . (range - ) days. upon physical examination, there were rebound tenderness present in cases, muscular rigitide in three cases, right lower quadrant pain in nine cases and widely irration of all abdominal guadrant in four cases. there were not any maternal mortality and morbity after operation, however in only one case fetal mortality was observed inevitable abortion due to vaginal bleeding. conclusion: in our cases acute appendicitis was diagnosed frequently in the second of the pregnancy with abdominal pain symptoms and rebound tenderness findings. recognition is important because early diagnose and prompt surgical intervention can reduce maternal and fetal mortality and morbity in acute appendicitis. introduction and objectives: conservative management of penetrating trauma has been mainly advocated in centres with a high incidence and large experience with those injuries. our aim was to assess the preventable death rate in our patient population, and the failure rate of conservative management. introduction and objectives: the data about role of amelogenin that is an extracellular matrix protein, during the healing process of the gastrointestinal anastomosis is lacking. in this study, the effects of amelogenin treatment on normal and ischemic colon anastomosis were evaluated. methods: adult male wistar albino rats weighing - g, were divided into four weight-matched groups: normal colon anastomosis group (n = ); amelogenin treated normal colon anastomosis group (n = ); ischemic colon anastomosis group (n = ); amelogenin treated ischemic colon anstomosis group (n = ). sufficient equal volume of amelogenin to entirely cover the anastomosis area had been applied. all animals were killed on postoperative day . bursting pressure levels were measured. peri anastomotic colon tissue hydroxyproline, catalase (cat), cu-zn superoxide dismutase (sod), glutathione (gsh), malondialdehyde (mda) and nitric oxide (no) levels were assessed to evaluate oxidative stress. results: bursting pressure levels of the ischemic colon anastomosis group is significantly lower than the normal colon anastomosis, the amelogenin treated normal colon anastomosis and the amelogenin treated ischemic colon anastomosis groups respectively (p = . , p = . , p = . ). hydroxyproline level of the amelogenin treated normal colon anastomosis group is significantly lower than the normal colon anastomosis and the ischemic colon anastomosis groups respectively (p = . , p = . ). gsh level of the ischemic colon anastomosis significantly lower than the amelogenin treated normal colon anastomosis group and the amelogenin treated ischemic colon anstomosis group respectively (p = . , p = . ). conclusions: amelogenin treatment could support the physical strength of ischemic colon anastomosis and effect oxidant/antioxidant response positively. introduction: meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, occuring in - % of the population. in the majority of patients, meckel's diverticulum is asymptomatic. we report our experience with the management of complicated meckel's diverticulum in adults. methods: between april and january , the data of seven patients ( males and females) aged - years who underwent surgery due to complications of mechel's diverticulum was retrospectively evaluated. results: of the seven patients, three presented with acute surgical abdomen, two had abdominal pain mimicking acute appendicitis, one had incarcerated incissional hernia, and one had intussusception. intraoperative diagnoses were as follows; littre's hernia in one, ileoileal intussusception due to meckel's diveticulum in one, diverticulitis in two, perforation of the diverticulum in three patients. while diverticulectomies were performed in five patients, two had small bowel resections. in addition to, appendectomy was performed in four patient. all the patient had an uneventful recovery except one, who experienced a postoperative wound infection. the hospital stay was - days. ectopic gastric mucosa was found in two cases. in one case, neuroendocrine tumor was detected in the appendix. conclusions: meckel's diverticulum is an uncommon cause of acute abdominal disease in adults. meckel's diverticulum presents distinctive challenges to a clinician, as it is prone to varied complications such as intestinal obstruction, diverticulitis, perforation. the diagnosis of meckel's diverticulum is difficult to establish preoperatively, and index of suspicion is necessary in patients with an acute abdominal illness. introduction: pneumatosis cystoides intestinalis is a pathologhy which is rarely incidentally seen and is characterised with submucosal or subserosal air cysts. there is no surgical indication in asymptomatic cases. surgical treatment is needed in the development of complication or the possibility of risk. a patient who is hospitalized with diagnosis of pyloric stenosis and is detected pneumatosis cystoides intestinalis incidentally at the operation is presented. case: year old male was admitted our emergency department with vomiting weight loss complaints. pyloric stenosis was diagnosed by radiologic and endoscopic examination. he was hospitalized and acute abdominal signs developed. free air was detected in radiologic examination. surgery was performed. pyloric stenosis and pneumotosis cystoides intestinalis in jejenum were diagnosed. biopsy specimen was obtained from the cysts in jejunal serosa. subtotal gastrectomy, gastrojejunostomy and bilateral truncal vagotomy were performed for the pyloric stenosis. result and discussion: there is no surgical indication in asymptomatic cases. pneumotosis cystoides intestinalis commonly accompony pyloric stenosis and perforation of the cysts may bring out acute abdominal symptoms. knowing this pathology, we may avoid unnecessary emercent laparotomies. aim: in urgent surgical procedures for peptic ulcer perforation, there is considerable postoperative morbidity and mortality. this study aimed to describe and analyze the risk factors that determine beforehand morbidity and mortality in cases with perforated peptic ulcer. materıals-methods: age, sex, co-morbid diseases, symptom duration, abdominal air, amount of intra-abdominal liquid, location and diameter of perforation, operation, and the mannheim peritonitis index (mpi) score were prospectively analyzed in cases. significant risk factors that cause morbidity and mortality were determined through a statistical study. results: the study sample consisted of a total of cases ( males and females) with a mean age of (range - ). duodenum and stomach perforations were detected in and . % of the cases. in cases ( . %), a total of complications were detected. the mortality rate was . %. statistical analyses revealed significant relationships between morbidity and > age (p = . ), co-morbid disease (p = . ), perforation location (p = . ), type of operation (p = . ), and mpi score (p = . ). the factors significant for mortality included > age (p = . ), co-morbid disease (p = . ), > h of symptom duration (p = . ), > cc intra-abdominal liquid (p = . ), a perforation diameter of > . cm (p = . ), omentopexy (p = . ), and a mpi score of > (p = . ). conclusion: factors such as age, co-morbid disease, prolonged perforation duration, amount of intra-abdominal liquid, perforation diameter, type of surgical operation, and mpi score were significant for mortality. the present study found that primary suture is a safe procedure for cases with peptic ulcer perforation. introduction: the presence of foreign objects in the rectum is a rare encountered situation. these objects are usually inserted transanally or swallowed as foreign objects. this study was conducted to investigate the results of patients admitted to our clinic with a rectal foreign body. methods: data of patients who admitted to our clinic between and were evaluated retrospectively results: mean age of the population was . . the foreign object was taken out in the proctological position in patients. in patients these methods failed and laparatomy was performed and the objects were taken out transanally without colotomy. in three patients symptoms and signs of peritonitis were significant at admission and all of them were lost because of rectum perforation followed by septic shock. distribution of foreign objects was: six deodorant lids, five glass bottles, two aubergine, a glass, a salt cellar, a piece of plastic pipe, a vibrator, a plastic cover, a chocolate cover, a chicken bone, a fish bone, needles, a spiral, coins and key, a piece of thermometer, teeth prosthesis and soap. mortality was seen in three patients. the presence of foreign objects in the rectum is a rare encountered situation which should always be kept in mind for differential diagnosis. most of these objects can be taken out transanally. if this fails, all efforts must be shown to take it out without opening the colonic lumen. because of potential complications, the surgeon must be careful during intervention. median age of the alive was . median leukocyte number at the moment of appliance was . , median debridement . and median inpatient stay were determined as days. median age of the dead . median leukocyte number at the moment of appliance was . , median debridement . and median inpatient stay were determined as days. the most common reason of the aetiology was determined as perinal abscess. diversionary ostomy was applied to six patients. chronic kidney failure, and type diabetes was exist in four patients of dead-group. in addition, in one patient type diabetes and hypertension was observed. conclusion: chronic kidney failure related to hemodialysis and high level of lekucyte number at the moment of appliance are the important prognastic factors of deaths related to fg. computed tomography (ct) has become the mainstream of evaluating all hemodynamically stable patients with acute problems when the attending doctor, is urging for diagnosis. basing a diagnosis solely on radiological data sometimes ignoring medical history and physical examination may lead to unexpected errors. wrong interpretation of radiological images or images with equivocal findings which may delude the radiologist and technical errors (artifacts) are all potential sources of mistakes. the aim of this study is to draw attention to the danger of the modern imaging diagnostic modalities to misguide the treatment of patients who need emergency care. we present some cases we faced in our clinic where radiological images showed pathologic entities which in fact did not exist (false positive errors) but forced us to inappropriate treatment. two patients underwent negative laparatomies with imaging diagnosis of a ruptured gallbladder in one case and free air under the diaphragm in the other. a patient with a severe head injury and a ct scanning showing pneumocephalous was transferred to a tertiary centre to be proved on repeated images that initial diagnosis was mistaken due to a wrong calibration of the gantry. imaging findings do not necessarily represent reality. almost always surgeons rely on ct scans for treatment decisions. it is a hard task for a surgeon to question or ignore the pictures to treat a patient based on medical history and physical examination. experience of radiologist is essential and close cooperation with the attending surgeon is needed to avoid radiological misfindings in emergency cases. author to editor: to be presented as a poster. a full text is available on demand. intentional own insertion of rectal foreign bodies in a married, claimed to be straight male, using antidepressive medicaments because of sexual orientation disorder, resulted in resurgery with the same reason of mechanical intestinal obstruction after years in the same surgery clinic by the same surgery team as an emergency intervention. failure of the nonoperative measures under local, spinal and general anesthesia led to the surgical treatment of the -year-old patient in and , who is now years old during the second event. large bottles were removed through laparotomies and colotomies followed by primary repair to reverse the ongoing ileus, which resolved on the th postoperative days in both events. a surgeon who is called to see a patient with retained foreign body should answer whether the patient had rectal perforation and whether the foreign body could be removed transanally without regional or general anesthesia with or without surgical intervention. in case of children; habitually self inserting objects in her vagina or sexually aggressive behaviour with others, e.g. for a boy ''humping'' toys in sexual positions can be a behavioural indicator of child sexual abuse or assault. hence message is: if in a patient perforation of sigmoid colon or rectum history after anal insertion of foreign body in an otherwise healthy adult becomes habitual,the patient should be send to psychiatric counselling. discussion of the nonoperative measures to remove rectally inserted objects is also an utmost important opportunity constituting the largest part of the report of the present case. necrotizing fasciitis is a highly morbid and mortal condition. as a result of aggressive debridement, wide tissue defects occur. wound cleaning from infective material, granulation process and grafting of wound requires a long time. recently, a vacuum assisted therapy system has begun to use for this kind of wounds. this study discuss the treatment result of vacuum assisted therapy (vac Ò therapy tm ) in two patients with giant abdominal wall defect in view of current literature. case : a years old man had an operation because of an accident on railway. at the time of admission there was a wide defect with necrotizing fasciitis on the right lombar region and anterior abdominal wall. there was a full thickness defect about · cm after an aggressive debridement. it was successfully treated with vac and the patient has been discharged after tissue grafting on the postoperative day . case : a years old man had an operation because of an accident. he was admitted at postoperative day . he underwent an aggressive debridement because of necrotizing fasciitis. the skin, rectus abdominus, transversus abdominus, internal and external oblique muscles and some part of quadriceps femoris on the left side was excised. the sacroiliac joint was also broken and pubis was separated. vac abdomen has been applied on two different sites and the wound has become available for grafting after days of therapy. as a conclusion, vacuum assisted therapy provides safe and accelerated wound healing, improves proper tissue granulation in patients with giant abdominal defect. introduction: bogota bag (bb) is a device used for the temporary closure of the abdominal wall (aw). despite its potential benefits, their use is not widespread and remains controversial in the present. aım: to describe our experience in its management for the temporary closure of the aw in emergency situations. methods: for a period of years, bb has been used in patients (pts), with an average age of . years. six had a secondary peritonitis, one tertiary peritonitis, two haemoperitoneum and one a compartment syndrome established. the technique consisted of the placement of a bag of sterile serum, stitched to the skin with nonabsorbable material. results: the average of bags placed by year was . . no morbidity was associated with the placement and/or replacement of bb. the average time of hospitalization was . days and the average time of income in the icu was . days. in pts, the bag was replacement one or more times. the average number of surgical interventions by patient during the income was . . the average time of permanence of the patient with the bag was . days. sixty percent of patients are alive today. objectıves: the aim of the current study is to assess the role of ultrasonography in the management of acute appendicitis. methods: ultrasonography was performed to patients with acute appendicitis suspicion between and . appendectomy was performed to patients with acute appendicitis diagnosis according to clinical examination after ultrasonography. patients who had a diagnosis different from acute appendicitis with clinical examination were observed. the histopathological findings of patients with appendectomy were compared with their usg findings. results: of patients had acute appendicitis diagnosis by ultrasonography. hystopathological examination showed acute appendicitis in of these patients. patients did not have acute appendicitis. usg showed that patients did not have acute appendicitis. ten of these patients showed gynecological pathology, and six of them showed urinary pathology, and they were all treated appropriately. in eight patients the appendicitis findings became evident in clinical observation; resulting in appendectomy, and histopathological examination showed acute appendicitis. forty patients showed improvement at follow up. no spesific treatment was needed. misdiagnosis rate was determined as . %. the sensitivity, specificity, positive predictive value, negative predictive value and accuracy percentage of ultrasonography in the diagnosis of acute appendicitis was . , . , . , . and . %, respectively. conclusion: ultrasonography has a high degree of accuracy in the diagnosis of acute appendicitis. however, we also conclude that ultrasonography results should always be interpreted in combination with clinical findings. background: hydatid cyst disease is frequent in some regions of the world, including our country turkey, and is most commonly located in the liver and lungs. the hydatid cysts may rupture spontaneously or as a result of trauma. herein, we describe a rare case of retrovesical hydatid cyst which was resulted from rupture of spontaneous rupture of liver hydatic cyst intraperitoneally. case: fifty-four years old male was admitted to emergency department with complaints of frequent urination and abdominal pain lasting for days. there was general abdominal tenderness on physical examination. there was no history of trauma or operation. in his abdominal ultrasonography and tomography there were primary cyst ( · cm), ruptured cyst ( · cm) and retrovesically located cyst ( · cm). indirect hemagglutination test was positive for echinococcus granulosus ( / , ) . laparotomy was performed and all the cysts were excised by partial cystectomy. there was no postoperative complication. the patient was externalized on postoperative th day with albendazol treatment. conclusion: retrovesical localization of hydatic cyst is a very rare. these cysts mostly occur as a result of surgical inoculation caused by inadequate surgery or free intraperitoneal rupture of primary hydatic cyst. in endemic regions, possibility of hydatic cyst should be kept in mind in differential diagnosis of intrapelvic cysts and masses. background: wegener's granulomatosis (wg) is a systemic necrotizing vasculitis of unknown etiology characterized mainly by involvement of the upper airways, lungs, kidneys and may rarely involve the gastrointestinal tract. intestinal involvement may be asymptomatic. we herein report a wg with massive lower gastrointestinal hemorrhage due to colonic involvement. case: the patient complained of dyspnea which started months ago, fatigue, generalized arthralgia and myalgia together with loss of sensation on right upper extremity was applied to emergency and hospitalized by internal medicine department. physical examination revealed a very ill-looking patient, there were positive lung findings for wg and c-anca was positive. we consulted the patient because of hematochesia with abrupt drop of hemoglobin and platelet count. on colonoscopy whole mucosa was full with fresh blood from sigmoid to anal canal. on angiography multiple foci of bleeding were demonstrated on descending and sigmoid colon. embolectomy was not performed because of multiple foci. hemoglobin decrease continued and his clinical condition deteriorated; an explorative laparotomy and total left colectomy was performed. his melena persisted for days but hemoglobin was maintained at after units transfusion after operation. conclusion: we herein report a case with clinical wg who developed a gastrointestinal hemorrhage and treated by surgery. the uremic state and cytotoxic agents given to patients may detoriated the gastrointestinal bleeding. immunosuppressive therapy might exacerbate gastrointestinal complications. the clinicians should be aware of this situation, therefore treatment of these must be performed in centers where angiography and endoscopy are available. background: the aim of this study is to determine the strength and proceeded efficiency of mda, sod, and catalase levels that are indicators of oxidative stress in generalized peritonitis. material-methods: this study was conducted as prospective and randomized with patients who applied at dicle university, department of general surgery between march-september . patients were composed as group (n = ); generalized peritonitis, group (n = ); laparotomy under elective conditions and not present peritonitis; group (n = ) as control group. in order to measure limits of mda, sod, crp and catalase, blood samples were drawn from the patients in group and group on before operation day (bod), st and rd days. the mda values of group on before operation day, st and rd days were compared to group and , the difference were found statistically meaningful. statistical differences noticed between group and mda values on bod, st and rd days. statistical differences were noticed between catalase values measured bod and rd days when group and values compared to group . the sod values of group and group on day were compared to group , meaningful statistical difference was found. statistically meaningful difference was found between the sod values group and on st day. conclusion: values of sod, mda and catalase were noticed usable parameters for the following and detection of severity of generalized peritonitis sinan cumhur karakoç, gü rkan yetkin, _ ismail ethem akgü n, mehmet uludag, bü lent Ç itgez, hamdi Ö zş ahin, cabbar kartal general surgery departmet, Ş iş li etfal training hospital, istanbul, turkey objectıve: we aimed to evaluate the effects of early cholecystectomy on morbidity and patient comfort in patients with acute biliary pancreatitis. methods: patients who underwent cholecystectomy for acute biliary pancreatitis in our clinic between and were evaluated retrospectively. the patients were divided into three groups as early, late and elective cholecystectomy cases. fındıngs: patients who had undergone cholecystectomy operation in the first days until the administration to hospital were classified as the first group (early cholecystectomy). patients who had undergone cholecystectomy between the nd and th weeks until the administration to hospital were classified as the second group (late cholecystectomy). patients who had undergone cholecystectomy after weeks were classified as the third group (elective cholecystectomy). in group , no patient had pancreatitis attacks; of patients in group had recurrent pancreatitis attack in the preoperative period and treated in our clinic. in order of these data, age, height, weight, gender, sgot, sgpt, amylase, bilirubin and the time for waiting for the operation were compared and evaluated statistically. the time for waiting for the operation was found to be p > . , and it was shown to be significant. results: there is a tendency to perform cholecystectomy in patients with acute biliary pancreatitis, after the acute attack is resolved. we believe that the early cholecystectomy prevents the patient from the additional morbidity in patients with acute biliary pancreatitis, by showing this with a statistically significant result in our study. traumatic right sided diaphragmatic hernia is clinically rare and may present with complications in a later period. on the right side presence of liver is thought to be a protective factor for both development of diaphragmatic injury itself and for its complications. we present a case of right sided diaphragmatic hernia due to blunt trauma, which was asymptomatic for years and has been presented with intestinal obstruction. the patient, years of male, has presented with intestinal obstruction and abdominal pain which has been relieved after nasogastric decompression. despite conservative treatment patient has not shown further improvement and has been operated on a semi-elective basis. significant part of small and large bowel, distal portion of stomach, and almost whole of liver had been herniated and reduced by right thoracoabdominal approach. cm wide defect in diaphragm has been repaired with prolene mesh, laparotomy has not been closed and bogota bag has been applied. in the early postoperative period transaminase levels have increased , u, and ct-angiography has revealed patchy areas of low per-fusion in both lobes of liver. after therapeutic anticoagulation liver function has recovered completely, abdomen is closed and oral feeding commenced. at the th postoperative day respiratory insufficiency has occured after witnessed aspiration of gastric contents, followed by multiple organ failure. this case represents a quite late presentation of right sided traumatic diaphragmatic hernia, for which treatment was complicated. this case clearly shows the importance of detailed evaluation and timely treatment of all traumatic diaphragmatic hernias. cem ibis, dogan albayrak, fedayi calta, eren taskin, mehmet ali yagci, ahmet hatipoglu, irfan coskun department of general surgery, medical faculty, trakya university edirne, turkey introduction: amyand hernia is first described by claduis amyand in london in an year old male. it is a rare condition and described as appendix vermiformis in the hernia sac. we present a case of an incarcerated inguinal hernia with appendix vermiformis inside. case: sixty nine years old male with bulging and pain in the right inguinal region is evaluated. right inguinal hernia was detected. after opening the hernia sac, the appendix and ceacum were observed. lichtenstein procedure was performed. the patient was discharged in the second postoperative day. discussion: although the incidence of appendix vermiformis in the hernia sac is . - %, the incidence of acute appendicitis in the hernia sac is . - . % in various reports. the treatment of amyand hernia is related to the appendix found inside. the application of appendectomy to normal appendix in routine hernia repair procedure is controversial due to infection risk. we do not routinely perform prophylactic appendectomy in such patients. we thought that a patient tailored approach is more acceptable. introduction and objectives: hydatid disease is typically asymptomatic. it can become symptomatic due to expansion, rupture or pyogenic infection. rupture of the cyst is the most common complication, followed by secondary infection, jaundice, and anaphylaxis. methods: in this study, we analyzed demographic and clinical characteristics of the cyst hydatic patients who admitted the emergency service due to complications of the cyst hydatic. the medical records of patients, with a final diagnosis of complicated cyst hydatic were reviewed for demographic information, admission symptoms, laboratory findings, evaluation techniques, and outcome. results: ten patients ( men, women) with final diagnosis of complicated ce (cystic echinococcosis) included the study. all of the patients had abdominal pain. while the pain was diffuse in the entire abdomen in seven patients, it was located in the right upper quadrant in three patients. patient's complaints were nausea, vomiting, jaundice, ileus and urticaria. the clinical signs and symptoms of hc rupture are not always severe, but hydatid fluid can irritate, which can cause peritonitis as occurred in our series of patients, all of whom had acute abdominal signs. in this study, % of the patients with ruptured ce had abdominal pain. thus, the clinical presentation of ce rupture is not always silent. the severe clinical presentation and infrequency of ce perforation has been held partially responsible for the misdiagnosis by the surgeon. conclusion: in conclusion; complicated hc may be admitted to emergency service with different clinical pictures especially in endemic regions and must be considered in differential diagnosis. background: to evalute the changes in the pattern of iatrogenıc bılıary injury and consequentıal effects on treatment strategy and outcome. methods: seventy-three patıents treated for iatrogenıc bılıary injury (ibi) between july and november at a tertıary care center in izmir, turkey were retrospectıvely analysed. results: underlyıng diseases were; missed tumor (n: , . %), biliary surgery (n: , %) and hydatıc dısease (n: , , %). in recent years wıth a gradual increase in the avaılabılıty of endoscopıc and radiologial expertise the majorıty of patıents underwent extensıve preoperatıve diagnostic and therapeutıc procodures includıng endoscopıc retrograd panceratography for cases( . %) and percutaneus transhepatıc cholangıography for cases( %). defınıtıve surgery was performed in all patıents except ( . %) of them. roux-en-y hepatıco-jejunostomy was the primary reconstructıon technıque and performed for cases ( %). there was only one ( . %) hospıtal mortalıty. restenosıs developed in ( . %) cases and was reoperated. percutaneus baloon dilatation was faıled in three patıents as a fırst treatment optıon. none of patıents died of dısease related causes durıng the follow-up perıod. conclusion: increased experınece in laparoscopıc biliary surgery might be caused to attempt more challengıng cases and increased bılary tract injurıes. tolga kafadar, ercan gedik, sadullah girgin, bilsel baç, _ ibrahim halil taçyıldız department of general surgery, dicle university, diyarbakir, turkey the aim our study was to determine the independent risk factors affecting patients with upper gastrointestinal hemorrhage who underwent surgery. materials and methods: the medical records of patients with upper gastrointestinal hemorrhage who underwent operation were reviewed for variables including age, gender, shock, association with co-morbidity, pulse rate, hemoglobin levels, white blood cell count, serum urea, creatinine, sodium and potassium levels, time of opera-tion, number unit of blood transfusion, rockall risk score and length of hospital stay. in order to determine the independent risk factors mortality and morbidity, we carried out entered logistic regression analysis. results: morbidity and mortality rate were . % ( patients) and . % ( patients), respectively. the independent risk factors affecting morbidity were serum albumin level [odds ratio (or) = . , % confidence interval (ci) = . - . , p = . ] and rockall score ‡ (or = . , ci = . - . , p = . ), and the independent risk factors affecting mortality were advanced age (or = . , ci = . - . , p = . ), and high rockall score (or = . , ci = . - . , p = . ). conclusion: to decrease the postoperative morbidity and mortality rates in patients with ugih requiring surgery, patients preoperative risk factors should be demonstrated. we believe that establishment of interventional indication on time and evaluation of intraoperative surgical region and technique in combination with the patient-and disease-related factors in patients requiring surgery would help reduce morbidity and mortality rates. blunt thoracic trauma leads to various clinical conditions, such as hemothorax, pneumothorax, pulmonary contusion, and respiratory tract hemorrhage. especially, respiratory tract hemorrhage resulting from pulmonary contusion is so critical to require a clinical challenge. of our experienced survivors, trauma victims (male / , - years old) with blunt thoracic trauma associated with motorcycle accident were transferred to our emergency departments. they similarly suffered respiratory failure (average respiratory rate of ) and hypotension (average shock index of . ) on arrival. immediate after the rapid-developing respiratory failure in relation to lung contusion and endobronchial bleeding, bronchial blockade device and extracorporeal membrane oxygenation (ecmo) were urgently introduced at an average of and min, respectively, and achieved rapid resolution of their respiratory crisis. all of them withdraw from ecmo within days. pulmonary contusion sometimes follows fatal progress, and we consider that quick bronchus blockade and ecmo introduction is the key of survival. emergency departments (ed) in greece are incorporated to the departments of the hospital and are divided in two major areas: one for internal medicine and one for general surgery. every patient has free access to the (ed). the workload and the conditions treated in ed in greece are geographically and social -economically depended. the national health system is represented by one hospital for each prefecture. the general hospital of trikala, is categorized as an urban hospital, with beds, and is covering a population of approximately , people, living in the town and in villages situated in the surrounding mountain area. the department of general surgery is stuffed by general surgeon specialists and seven residences. during , , patients were examined in the surgical ed. in this study we analyze the characteristics of the patients, the number and causes of admissions in the various departments of our hospital and also the transferals to a tertiary center. aim: pneumotosis cystoides intestinalis is a rare entity, and may be associated with pyloric stenosis. materıals-methods: data of a patient operated for pyloric stenosis and pneumotosis cystoides intestinalis in our institution are presented. results: patient was a year-old addicted male, and his body mass index was . kg/m . he had been suffering from nausea/vomiting, bloating and constipation for a few months. a gastroscopic examination revealed atonic gastric dilatation, duodenal ulcer and related pyloric stenosis, and positive serology for helicobacter pylori. an eradication treatment in conjunction with long term proton pomp inhibitors were given, however the patient readmitted to our department with worsening symptoms including vomiting, pain and weight loss after months. repeated gastroscopies and gastric meal x-ray examination revealed pyloric stenosis and the patient decided to have an operation instead of repeated medical treatment. during laparotomy, subserosal foamy air bubbles were observed on the serosal wall of ileum. a partial resection of ileum was necessitated for the suspicion of perforation. vagotomy with finney pyloroplasty was performed in order to cure the pyloric stenosis. the postoperative period was uneventful and the patient was discharged from the hospital on day . the patient has not have a recurrence, gained weight and have no problem since years postoperatively. conclusion: pneumocytosis cystoides intestinalis may be observed in the presence of a pyloric stenosis and necessitates resection if any doubt for perforation is present. granulosus. in this study, a rare appearance of the disease is presented as an abscess located in the retroperitoneal space. results: the patient was years-old male with several comorbidities admitted to our emergency department with fever and left lumbar pain. he had had operated for hepatic hydatid disease years before the admission. physical examination revealed local tenderness and slight hyperemia on his left lumbar region. his laboratory findings showed leucocytosis, and a computed tomography demonstrated a huge retroperitoneal abscess located between spleen and pelvic entrance and denied any pathological finding regarding to the left kidney or adrenal gland. since the general condition of the patient did not allow an operation under general anesthesia, the abscess was drained through a cm long incision located on the hyperemic area under local anesthesia. after complete removal of the abscess and daughter cysts, a drain was left behind, and removed on day . the patient was discharged out of hospital on day , after an uneventful recovery period. discussion: to best to our knowledge, this is the first hydatid disease case presented as a retroperitoneal abscess in the literature. hydatid disease may be kept in mind as a differential diagnosis in the presence of a cystic retroperitoneal mass in endemic regions. ali uzunkö y , zekeriya sayın harran university school of medicine department of general surgery, sanliurfa, turkey osm ortadogu hospital, sanliurfa, turkey introduction and objectives: giant true splenic artery aneurism is rare lesions. these aneurisms have risk of rupture and bleeding. we have performed a giant true splenic artery aneurism. case: the case is a year old female patient. she applied to hospital with complaints of abdominal pain. at the physical examination, there were a moderate splenomegaly and a pulsatile mass in the left upper abdomen. it was shown a giant splenic aneurism at the abdominal computed tomography and colour doppler ultrasonography. colour-doppler abdominal ultrasonography showed about mm splenic artery aneurism. computed abdominal tomography showed a hypo dense mass situated anterior and superior to the pancreas tall and corpus extending up to the splenic helium. the diagnosis was confirmed by ct angiography. the patient was performed with general anaesthesia and left subcostal incision. at the exploration, splenic arterial dilatation and aneurismal sac was shown and aneurysmectomy with splenectomy was performed. there was no complication intraoperatively and postoperatively. the patient was discharged at the postoperative fifth day. there was no complaint at the control examination at the fifteenth day after discharging. conclusions: although giant splenic artery aneurism is rare, but they have risk of rupture and bleeding. there are two options for treatment of these lesions. one of them is aneurysmectomy. it is frequently performed with splenectomy. other option is embolisation. in our opinion, surgery for giant splenic artery aneurism is performed successfully without important complication. author to editor: saved by lookus introduction: an association between the administration of paracetamol and relative hypotension in critically ill patients has been reported by the staff working in the surgical and trauma intensive care unit of istanbul faculty of medicine. methods: a prospective, observational study was undertaken to investigate the effect of paracetamol on systemic blood pressure in two groups of critically ill patients. a dose of mg of paracetamol was administered intravenously to both groups in min time. blood pressure, heart rate were recorded at baseline, at the end of infusion and then at , , min after administration. the differences occured over the observation period was measured by friedman analyse. results: twenty-eight patients with sepsis, were enrolled to group- (anti-pyretic effect) and postoperative patients were enrolled to group- (analgesic effect). analysis of data from all patients showed that systolic arterial pressure (sap) and mean arterial pressure (map) were reduced significantly over the observation period in both groups (sap:p < . for both, map:group- p < . , group- p < . ). sap and map in group- and group- decreased by an average of approximately and % respectively. however, no significant decrease in dap was noted in group- . conclusions: utilization of the intravenous paracetamol for febrile and/or postoperative patients caused a significant decrease in systemic blood pressure after administration. this drug-induced hypotension was clinically relevant to control the required blood pressure. thus, clinicians should be aware of this potential effect, especially in critically ill patients. yazile sayın faculty of health, surgical nursing division, cumhuriyet university, sivas, turkey background: pain is considered one of the most important symptoms which guide diagnosis, treatment and nursing care in the emergency departments. aım: to discuss pain evaluation by nurses in emergency departments and to attract attention towards nurses' responsibility for pain evaluation. methods: qualitative and quantitative data from studies on pain evaluation by nurses were evaluated. results: all studies reviewed showed that about three fourths of the nurses in the emergency departments did not make pain evaluation based on the standards (using pain rating scales, reporting the conditions likely to affect pain evaluation etc.). the nurses included in studies assigned significantly lower scores for pain than the researchers(p < . ;p < . ). all studies revealed the following reasons why triage nurses did not play an effective role in pain evaluation: insufficient knowledge, the idea that doctors are responsible for pain evaluation, doctors not appreciating the value of pain data provided by nurses, insufficient cooperation among members of the health staff, work overload, time constraints, errors in reporting data on pain evaluation and conflicting attitudes and beliefs concerning pain evaluation. it has been reported that only - % of the patients presenting with pain to emergency departments received effective pain management. the most important reason for this low rate has been shown to be deficiencies in pain evaluation due to insufficient multidisciplinary cooperation. conclusion: it can be concluded that nurses in emergency departments are not efficient enough to use interventions which help to evaluate pain for effective pain management. introduction: diverticulosis of the colon is a common condition. complications of diverticulitis often require surgery. perforated diverticulitis may rarely present with spreading superficial sepsis. case: male, years, history of chronic depression. admitted in the emergency department after a -day history of abdominal pain in the left lower quadrant (llq), associated with asthenia, anorexia and weight loss, without diarrhea, constipation or fever. the patient examination showed edema and thickening of the abdominal wall with swelling and redness in the llq. blood chemistry revealed leukocytosis with neutrophilia and elevated c-reactive protein. a diabetic ketoacidosis was diagnosed. the abdominal ct confirmed abdominal necrotizing fasciitis with an abscess, without other intra-abdominal changes. the patient was then submitted to emergency surgery with debridement of the necrotising fasciitis and drainage of the abscess. he was admitted to the icu. further debridement was necessary h later. at d , fecal contamination of the wound was detected, leading to a subsequent laparotomy with identification of a sigmoid inflammatory mass attached to the site of the fistula's external orifice. a hartmannprocedure was performed (histology confirmed the diagnosis of perforated diverticulitis). the patient developed a sirs complicated with a right-side necrotizing pneumonia requiring multiple antibiotic treatment and pulmonary decortication. death occurred at the th hospitalization day. conclusion: necrotising fasciitis as a consequence of perforated diverticulitis is an uncommon but potentially lethal condition requiring prompt surgical intervention. when accessing an abdominal necrotising fasciitis without recognisable source, an elevated index of suspicion is necessary to link it to complicated diverticulitis. fatih baş ak, kü rş ad Ö ztü rk tc sb bozkir community hospital introduction: care of trauma patients may be difficult in small community hospitals. these hospitals are usually staffed by a small number of general practitioners and, perhaps, a general surgeon, and a significant number of trauma cases are brought to them. the records of minor and major trauma patients who admitted to bozkir community hospital between june and december were evaluated. mortality and transfer rate were recorded. general surgeon was not present in first months. the rates of last months when general surgeon has been present were calculated separately. results: trauma patients were admitted in first months ( . %) of these were transferred to larger centers. treatment of remaining ( . %) patients continued in our hospital. mortality rate of first months was . %. three patients requiring immediate surgery died because of absence of general surgeon. patients were admitted in last months. ( . %) of these were transferred to larger centers. mortality rate of last months was . %. three gunshot wound and one penetrating cardiac wound patients were saved with emergent surgery. conclusions: regardless of the sophisticated techniques for dealing with trauma that exist in larger centers, it is the staff of smaller hospitals that often shoulder the initial burden of trauma care. transfer rate is between and % of all trauma cases. our hospital is . h away from larger centers. presence of general surgeon in last months mainly affected the care of patients that requiring immediate surgical attention. metin kement, hakan acar, ilhami soykan barlas, uygar dü zci, cem gezen burn center, kartal education and research hospital, istanbul, turkey aim: fecal contamination which may result in septicemia, graft loss and wound healing delay is the most serious problem for burns in perineal, gluteal and upper thigh regions. temporary fecal containment devices can be used for diverting feaces from burned area. the aim of this study was to evaluate early results of using of these devices in our burn center. methods: twelve patients, who were applied temporary fecal containment devices in our burn center, were retrospectively evaluated in this study. results: ( . %) of the patients were male.the mean age was . ± . year.the mean tbsa burned was . ± . %. ( %) of the patients had burn in all three regions (perine, gluteus and upper thigh). three ( %) of the patients had burn in upper thigh. and ( %) of the patients had burn in gluteal region. the devices were placed intra-rectally on the first admission days of all patients.the mean application time was . ± . days. except minimal fecal leakage in ( . %) patients, any complication was not observed in our cases. local infection confirmed by tissue culture was observed in ( . %) patients including two patients with fecal leakage. besides, in one of these four patients, septicemia was developed and managed successfully with antibiotics and supportive treatment in intensive care unit of our center.one patient with % burn was died on days of application due to multiple organ failure. conclusion: temporary fecal containment devices aim to protect patients' wounds from fecal contamination by diverting feaces. if the safety of these device is proved in further studies, they may reduce the necessities of diverting stoma operation in burn patient. metin kement, ilhami soykan barlas, uygar dü zci, hakan acar, cem fazlı gezen burn center, kartal education and research hospital, istanbul, turkey aım: reactive thrombocytosis which develops secondary to infection, trauma, malignancy or surgery is the most common ethiology of thrombocytosis. although thrombocytosis is a benign and self-limiting condition in most cases, it may result in some thrombotic and hemorrhagic complications. the aim of this study was to evaluate the reactive thorombocytosis in burn patients. material: thrombocyte counts was retrospectively evaluated in consequent burn patients admitted to our burn center between august and january . the correlations between thrombocyte counts and demographic data, total body surface area burned (tbsa), hospitalization time and levels of some acute phase markers also analysed. results: the mean thrombocyte counts were respectively . ± . /mm , . ± . /mm on admission day and second day (p < . ). the number of patients with thrombocytosis was ( . %) in admission, ( %) of them were children. the rate of thrombocytosis was / ( . %) in children,whereas the rate of thrombocytosis was only / ( . %) in adults (p < . ). the mean thrombocyte counts in children and adults were respectively . ± . /mm , . ± . /mm in admission (p < . ). the mean wbc count was significantly higher in patients with thrombocytosis than patients with normal thrombocyte count (p < . ), but there was not any significant difference in crp count (p = . ). and also,we did not find any significant difference between patients with thrombocytosis and patients with normal thrombocyte count in tbsa and hospitalization time (p = . and . , respectively) conclusion: reactive thrombocytosis is seen more frequently in burned children than burned adults and mostly unrelated to degree of burn. background: electrical injuries are related with multiple organ dysfunction as well as high morbidity and mortality. pulmonary compromise is rare, if compared to other organ dysfunctions related with electrical injuries. in this study, we presented a case with pulmonary hemorrhage associated with electrical injury. case: a -year-old previously health man was brought to our emergency department (ed), h following the accident, with electrical injury. initial examination findings were blood pressure / mmhg, heart rate /min, respiratory rate breath /min. glasgow coma score was . decreased breath sounds, bilateral rales and wheezing were determined. there were small necrotic wounds (typical contact injury) on the first finger of left hand and under the right foot of patient. there was no trauma in thoracic wall. blood gas analysis revealed respiratory and metabolic acidosis. the inr and platelet levels were normal. when chest radiograph and thoracic computed tomography were assessed, air bronchograms and symmetric consolidations were determined in the both lungs. patient was intubated and fresh blood was aspirated from endotracheal tube. mechanical ventilatory support was performed the patient due to lung hemorrhage and respiratory failure. patient died after h of admission in the ed. conclusion: multiple organ dysfunction and necrotic skin lesions could be occurred in electrical injuries. electrical injuries on the chest may cause lung infarction because of the direct effect of the electrical current and vascular embolism. possibility of lung injury should be investigated after electrical injury especially in patients with respiratory failure. nebahat yıldız , aysel gü rkan , _ imren aş ar , ayş e hale uysal trauma and emergency surgery service,istanbul university, istanbul faculty of mediine, istanbul, turkey health science of faculty marmara universty, istanbul, turkey introduction and objectıve: the outcome of burn treatment is measured not only by mortality and morbidity, but also by post-burn psychological factors. the purpose of this study was to investigate whether difference in length of hospitalization exist between burn patients with and without mental health problems and if so, why. methods: the descriptive study was retrospective review of patient with burn injuries who had received care at one burn unit in the istanbul from october to december . socio-demographic features of patients, burn criteria (kind, depth, size, location), duration of hospital stay, and psychological problems were tabulated. results: psychological impairment was found in of hospitalized burn patient. there were acute stress disorder in fifteen patient, anxiety in nine, adjustment disorder together with anxiety in eight, depression in seven, post-traumatic stress disorder in six patient. fortyone ( . %) patient had burns which were between i and ii degree and ( . %) patient had burns which were between ii and iii degree. in patient, burned area has been % or more. patients with psychologocal impairment were longer hospital stay and intensive care unit than patients without psychologocal impairment. sixty-four ( . %) patients with psychologocal impairment had been discharge either getting better or recovering completely but unfortunately ( . %) patients died. conclusion: the presence of psychological problems in burn patients have an impact on their burn care. psychological interventions can contribute towards successful outcomes. introduction and objectives: major burns can cause disseminated intravascular coagulation (dic) and is a serious clinical problem. we would like to present dic cases whose burn rate is % according to total body surface area (tbsa) which developed after late postoperative period. methods: two cases over %, nd and rd degree burn injury admitted to our facility. first case who was year old female developed s. aureus and second case was years old female developed p. aeruginosa sepsis which was confirmed by blood culture. in first case dic developed at postburn day and in second case at postburn day. in both cases dic developed after postsurgery day . results: on patients, bleeding points, as leaking, were detected on all over burn areas. at the same period thrombocyte values decreased sharply ( . k/ul). increase in prothrombin time (pt) ( . second) and active partial thromboplastin time (aptt) ( second) values, decrease in fibrinogen levels was observed. cases were discharged from hospital in th day, without any problem. patient was taken for iu erythrocyte suspension and iu platelet suspension in this time totally. conclusion: dic occurs in early period of burning; but it can be formed in later periods, even after defects were recovered by operation. rapid establishment of dic table just before the discharging term from hospital is an unusual and interesting situation. the patients in our study can be accepted as an example of the necessity of observing coagulation parameters in every periods of burn damage. methods: sphere project handbook reviewed by experts in the field of each section, the terms of our country's adaptation has been made. within the framework of the project dissemination, sphere workshops have been organized in various provinces. the ppt slides were adapted to turkey's needs. the project's outcomes have been observed through the pre-post tests and the workshop evaluation forms. results: expert review and the end of the first study, with a high risk of disaster in our country, the handbook was understood to be necessary and useful. in addition to this, the control lists in details but useful and also, the summary tables are useful to take a decision in emergencies. it is also understood that preliminary results from the project is compatible with literatur data. conclusions: developed in each country is adapting to the local experience of the sphere, significant experience with disasters in our country the right to contribute are welcome. indeed, the first application of the new approach by the sphere project's coordination center is monitored with interest. introduction: ( ) initial assessment of trauma patients is a period with a high frequency of treatment protocol deviations and an elevated number of avoidable complications. ( ) the majority of medical errors are diagnostic or cognitive, whereas operative technical complications accounted for less than %, and ( ) general surgery residents (gsr) do not feel well-trained on the management of major trauma patients. aim: describe initial experience with one approach to foster quality improvement in trauma care modifying the method by which we train surgeons. methods: we integrated in the gsr program, simulation based training sessions with other educational tools as lectures and workshops. the scenario objectives were based on research data indicating major deficiencies in trauma care (tc). we incorporated team training and crisis resource management sessions. to review trauma life support diagnostic and therapeutic standardized protocols we run scenarios to train initial assessment, and head, thoracic and abdominal trauma. after every clinical case, residents participated in a video assisted debriefing session leaded by a specialized instructor. an evaluation interview was made after the course. results: all resident viewed the experience as a ''very good'' training modality. many of them felt their time was better spent in the simulator session than in the operating room, and wanted to do it more often or in a scheduled way. some of them complained about evaluating the mannequin and the equipment when compared to the one in their actual work setting. conclusions: integrating patient simulation with traditional surgical training may strength the approach to tc education. introduction: pulmonary embolism is a life-threatening condition and its diagnosis is generally based on clinical suspicion. case: a years old male had been admitted to another hospital with acute dyspnea and syncope and after initial evaluation he had immediately been undergone an operation due to epidural hematoma. he was referred to our emergency department with early diagnosis of acute coronary syndrome after operation because intraoperative and postoperative tachycardia could not be controlled. in his physical examination gcs: , arterial blood pressure / mmhg, heart rate /min and breath rate /min. ecg, echocardiogram and thorax ct findings complied with pulmonary embolism. venous doppler ultrasonograpy findings complied with chronic deep venous thrombosis. thrombolytic or antiaggregant medication could not be started because of epidural hematoma operation. at postoperative h low molecular weight heparin and at h warfarin was administered. in follow-up period his symptoms regressed and there was no complication due to epidural hematoma surgery. he discharged from hospital at day . conclusion: in trauma patients, one of the important issues that have to be considered during clinical evaluation is the primary reason leading to trauma. in this case, the investigation for syncope etiology revealed the haemorrhage and thrombus diagnosis concomitantly. these two diagnoses have opposite treatment strategies and due to this condition we had difficulty in management of the patient. although there are intracranial haemorrhage cases due to pulmonary embolism treatment (thrombolytic or antiaggregant), a similar case report cannot be found in the available literature. introduction and objectives: different societies have different type of snake bites. _ in our actually series, two patient from u.k. and seven patients from south-eastern part of turkey presented with lıke compartment syndrome result of was bitten by a snake to their fingers. methods: four of nine patients applied to our clinic at the day of event, the other five were referred to us after the emergency treatments have been done. all bites were over or distally to the pip joint. after being bitten by snake, patients admitted to our accident and emergency department because they had like as compartment syndrome on the forearm. two of the patients were referred to us very late stage and one of them had partial necrosis and the other had total necrosis already. none of patients had signs of systemic envenoming. results: two patients with local swelling and no other symptoms were discharged. coverage of the defects were performed with full thickness skin grafting in two patients, cross-finger flap in one patient, reverse dorsal digital arter flap in one patient and dorsal interosseous metacarpal flap in two patients. one patient had amputation. none of patients had fasciotomy. conclusions: this study represents the clinical effects and current approaches for the treatment of snake bites to distal finger. all patients presented with compartment syndrome like symptoms on the hand or forearm. these patients should be followed-up very closely. final wounds should be closed either with skin grafts or local flaps. simultaneously, systemic envenoming should be considered. the aim was to evaluate the geriatric patient with abdominal pain in emergency department (ed). methods: the preliminary retrospective study included the period between january and june , , ankara. data were achieved from registration notebooks, manually. the patients separated within age to three groups as - , - , and over. the finalization of management, hospitalization, operation rate, mortality were studied. results: there were ( . %, annually) patients. the mean age was . ± . ( - ), the mean hospitalization duration was days ( - ). the sex and the age of patients can be seen in table . . % (n = ) of them discharged from ed. abdominal ct and usg usage were . % (n = ), . % (n = ) in ed. . % (n = ) patients had both ct and usg. abdominal ct and usg results are showed in tables , . finalization of patient management was demonstrated in table . the operation rate for all patients was . % (n = ). general surgery hospitalization and operation rate were . and . % (n = , n = ). the mortality rate was . % (n = ) in admission. there were not any significant difference between the groups of - and - according to sex, finalization, ct, usg utilization, operation rate (p = . , p = . , p = . , p = . , p = . ) with spss x test, while the number of advanced geriatrics was unsuitable for statistics. conclusions: females and the - age group were common with a complaint of abdominal pain in ed. most of them had hospitalization indications and the primary yard was general surgery with brid ileus. mortality rate was lower than % introduction: nontraumatic epigastric and left upper caudran pain is a common complaint in emergency department. it can include lifethreatened various reasons as cardiac, respiratory, and serious gastrointestinal problems, rarely. case: a year old man had an emesis with recurrent epigastric and left upper caudran pain admitted as second turn to ed in h. physical examination except a slight epigastric sensitiveness, ekg, urine test and biochemical tests, complet abdominal ultrasonography, x-rays were nonspesific on the first day. wbc was . on cbc. his complaints relieved with semptomatic treatment with an mg ranitidine, mg metoclopramide, serum sale on his observation and discharged with suggestions. in second admission with nonspecific physical examination findings, computerized tomography (ct) revealed splenic unenhanced parenchymal areas consistent with splenic infarcts. computerized tomography angiography (cta) showed a small aneurysm of the celiac trunk, a characteristic pattern of caliber irregularities and arterial wall thickening of the splanchnic arteriesincluding splenic artery, common hepatic, right and left hepatic arteries-, suggesting splanchnic arterial mediolysis (figures and are presented with permission of patient's written consent). he was hospitalized to general surgery and started low molecular weight heparin. as clinical and radiologic findings were degrated, he was discharged without an operation. conclusions: splanchnic (segmental) arterial mediolysis is a rare noninflammatory vascular disease of the abdominal splanchnic arteries with slight symptoms. ct for vasculary and internal organs should be performed to diagnose in recurrent complaints beside observing the physical findings. introduction: it is well documented that healing of peptic ulcer perforation (pup) is possible with conservative therapy in selected cases. thus a spontaneously closed pup diagnosed at exploration may not require surgical repair. methods: study included three patients in which diagnostic laparoscopy suggested spontaneously closed pup between and . suggestion criteria were; fibrin cloth on duodenum with or without subhepatic fluid collection, no visible perforation, otherwise normal exploratory findings. omentum minus was dissected and cautiously observed. the stomach was filled with ml diluted methylene blue fluid via nasogastric tube, operation table was tilted to right and up, a gentle pressure on the stomach was made with the shaft of laparoscopic irrigator to fasciculate the passage while the descending section of duodenum was compressed with the shaft of a grasper. duodenum was cautiously observed for min to detect dye leakage in all patients. if no leak was observed, operation was terminated after abdominal irrigation and inserting a catheter to the subhepatic area. therapy for pup was given postoperatively. results: all patients were male and the mean age was ( - ), no leak of dye was observed at operation. nasogastric tube was removed and food intake was allowed at postoperative second day. all patients were discharged on third day. conclusion: although the perforation site is almost always identified at operation, to meet a spontaneously closed pup is also possible. irrigation and drainage alone may be sufficient for these cases after blue dye test as described in this study. the complicated appendix with/without abscess was delivered through the umbilical incision for an open technique safely. this gave our patients the maximum benefits of the minimally invasive surgery with better visualization, reducing equipment needs, less postoperative pain, rapid discharge, no postoperative infections, and excellent cosmetic results. all patients were quite satisfied during follow-up. conclusions: it is concluded that hybrid appendectomy seems to be feasible and reliable for children with complicated appendicitis not suitable for conventional laparoscopic technique. vata was successfully accomplished with obvious advantages, and avoided conversion to the open fashion. background: appendicectomy remains the most frequent emergency operation. the management of these patients varies between surgeons and hospitals. at our centre, it was a routine to review post operative children at months. aims: is to evaluate the need for a routine follow up in children who had appendicectomy. methods: it is a retrospective observational study for consecutive patients between and . a parallel questionnaire was sent to the parents of all the children. results: the average age was . years. % of the patients were found to have normal appendices. % of the patients were discharged within days. % of the patient had intravenous antibiotics for day and % were discharged with oral antibiotics. % had a routine follow up appointment in months time. in % of cases there was no change in the management. on the questionnaire % of the parents thought they were given enough information regarding the procedure. in terms of routine follow ups, % of the parents found it very useful while % found it a little or not useful. conclusion: this study shows that there is no change of the management or a clinical need for the routine follow up. however the patients and their families like to keep a follow up appointment. it is more convenient for the patients and their family to arrange other sorts of follow up like a phone call conversation or a general practitioner follow up. yavuz savaş koca, mustafa ugur, celal Ç erçi, recep Ç etin department of general surgery, sü leyman demirel university, isparta,turkey the aim of this study was to evaluate the disease profile and mortality ratio of patients presenting with acute abdomen. four hundred fifty eight patients who underwent surgery with the diagnosis of acute abdomen were analyzed retrospectively. the effects of age, sex, american society of anesthesiology (asa) class, accompany disease, admission time after the onset of the symptoms, follow up interval before the operation on mortality and length of hospital stay were evaluated. male/female ratio was . , and mean age was . . main causes were biliary system disease ( . %), intestinal obstruction ( . %), peptic ulcer perforation ( %) and acute appendicitis ( . %). median asa class was and . % of the patients had at least one preexisting disease. mortality ratio was . %. asa class, age, preexisting diseases other than malignity, period between the onset of symptoms and admission, follow-up time was significantly efective on mortality. reliability of ultrasonography for diagnosing acute appendicitis aylin hande gö kçe , acar aren , feridun suat gö kçe , hakan Ö zkan , alper dursun Ş agban , _ ibrahim aydın , gü rhan Ç elik , gü rol kö roglu s.b. _ istanbul eg itim ve araş tırma hastanesi, istanbul, turkey balıklı rum hastanesi, istanbul, turkey purpose: abdominal ultrasonography is the most commonly used diagnostic tool for diagnosing acute appendicitis,which is one of the most common causes of acute surgical abdomen. _ in this study, we examined the reliability of ultrasonography for diagnosing acute appendicitis. in this prospective study we performed abdominal ultrasonography on patients admitted to our surgical emergency department and diagnosed as acute surgical abdomen according to the physical examination and laboratory findings during . these patients were surgically treated by appendectomy and the materials were pathologically examined. results: patients were admitted to this study. of these patients ( . %) were diagnosed as acute appendicitis, and ( . %) of them diagnosed differently. ( . %) of patients diagnosed as acute appendicitis on ultrasonography examinations were reported as acute appendicitis on histopatological examination. ( . %) of patients diagnosed differently on ultrasonography examination were reported as acute appendicitis on histopathological examination. conclusion: the sensivity of abdominal ultrasonography for diagnosing acute appendicitis is high ( %), but the specificity is low (p = . ). we calculated that the specificity is . , positive predictive value is . , negative predictive value . , accuracy is . . abdominal ultrasonography is a helpful diagnostic tool for diagnosing acute appendicitis.however, it should not be seen superior to anamnesis and physical examination findings. poisoning: a case report background: mushroom poisoning is an important clinical problem which may cause serious complications and death. acute pancreatitis is a rare complication of mushroom poisoning. in this study, we presented a case that developed liver damage and acute pancreatitis following wild mushroom ingestion. case: sixty-six years old women admitted to emergency department with complaints of nausea, vomiting and abdominal pain. it was learned that patient was ingested wild mushroom before h of admittance and her complaints were started after - h of ingestion. in initial examination, general appearance and vital signs of patients were normal and there was epigastric discomfort. laboratory findings were leukocyte , /ll ( . - . ), aspartate aminotransferase u/l ( - ), alanine aminotransferase u/l ( - ), amylase u/l ( - ), lipase , u/l ( - ) on admission. liver and pancreas was determined as normal in abdomen ultrasonographic examination. computerized tomography of the abdomen showed minimal peripancreatic fluid. the patient was observed in emergency intensive care unit and symptomatic therapy was performed. hepatic transaminases and pancreatic enzymes were decreased progressively during the observation. the patient was discharged from the hospital after days clinical course, without complication. conclusion: mushroom poisoning and acute pancreatitis have similar gastrointestinal symptoms and sings. therefore, possibility of acute pancreatitis as well as other organ dysfunctions should be investi-gated in patients with mushroom poisoning. early recognition and appropriate therapy for acute pancreatitis and mushroom poisoning may lead to an improved prognosis and complications. mehmet mustafa altıntaş , , ayhan Ç evik , , yekin Ö zcabı , , gü lay dalkılıç , , hü seyin ekinci , , nejdet bildik , dr. lü tfi kırdar kartal education and training hospital, istanbul, turkey general surgery clinic, istanbul, turkey diagnostic emergency laparoscopy is very helpful in diagnosing acute abdomen and evaluating abdominal trauma. parallel to developments in laparoscopic techniques, its emergency applications are increasing. we reviewed our diagnostic emergency laparoscopy procedures applied to patients with acute abdomen and could not be diagnosed after h of follow-up. we applied diagnostic emergency laparoscopy to patients in dr. lü tfi kırdar kartal education and training hospital during - . in patients laparoscopy indication was undiagnosed acute abdomen. there were four acute appendicitis, two peptic ulcus perforation, two small bowel necrosis, one perforated hepatic hydatid cysts, one iatrogenic urinary bladder perforation, one postlaparoscopic cholecystectomy bile fistula and non-surgical adnexial pathologies. diagnostic emergency laparoscopy was performed in five patients with penetrating abdominal injury. there were small bowel injury in two patients, colonic injury in two patients and no injury in one patient. diagnostic emergency laparoscopy was performed in four patients with blunt abdominal injury. there were grade splenic laceration in two patients, grade liver injury in one patients and intraabdominal bleeding in one patient. in conclusion, diagnostic emergency laparoscopy is a suitable technique in undiagnosed acute abdomen patients which could not be diagnosed after physical examination, laboratory, radiology and follow-up and helps surgeon to diagnose the disease. also diagnostic emergency laparoscopy performed by experienced surgeons prevents negative laparotomy especially in abdominal trauma patients. mehmet ali yagcı, atakan sezer, ahmet rahmi hatipoglu, irfan coskun, zeki hoscoskun, aydın altan department of general surgery, trakya university school of medicine, edirne, turkey introduction: appendectomy is known as the most common nonobstetrical operative procedure in pregnant women with an estimated frequency of / , of all pregnancies.pregnancy continues to obscure the accurate diagnosis of acute appendicitis due to gestational physiological changes.diagnostic delay increases the incidence of perforation, hence increasing maternal and fetal morbidity and mortality. patients and results: four patients of appendicitis during pregnancy were concluded in study between to may ( table ). the mean age was (range - ). three patients presented during three trimester and one in first trimester.the mean time interval of symptoms to the admission is h (range - ).abdominal pain, vomiting, and nausea are the most common complaints.rebound was the main sign observed in all patients.fever was noted in two patients. mean value of wbc count was , per l (range , - , ). ultrasonographic examination was performed to all patients with the diagnosis of acute appendicitis.three patients were operated under general anesthesia and one under regional anesthesia. paramedian incision was applied to three patients and mcburney to the other one. the exploration findings were two perforated, one phlegmonous appendicitis and a normal appendix. no maternal or fetal mortality occured. cesarean section was performed on -week pregnancy during appendectomy due to early onset contractions. adhesiolysis was performed in same case because of postoperative ileus. conclusion: the accurate diagnosis of appendicitis during pregnancy requires a high level of suspicion and clinical skills. delay of operation correlates to more inflammatory changes in the appendix and to higher maternal and fetal complication rates. early laparotomy with appropriate preoperative diagnosis will reduce the fetal and maternal morbidity and mortality. introduction: paraesophageal hernias occur most commonly in elderly and account for % in all hiatal hernias [ ] . although the fundus or corpus of the stomach are most commonly the contents of a paraesophageal hernia, we reported a case in which the gastric fundus and corpus incarcerated in the paraesophageal space, followed by perforation. case: -year-old woman admitted to state hospital following sudden onset of abdominal pain.previously she was diagnosed as esophageal hiatal hernia. on physical examination, abdominal distension with mild tenderness was recognized. pulse rate and blood pressure were per min and / mmhg. the initial laboratory investigations revealed wbc , per ml, urea mg/ dl, creatinine . mg/dl. chest graphy revealed unusual gas shadow in the left thorax (fig. ) . ct demonstrated intraperitoneal free air, ascites, and the prolapsed stomach in the left thorax (fig. ). an urgent laparotomy was performed revealing dirty ascites.the gastric fundus and corpus were incarcerated in paraesophageal space (fig. ) . a perforation mm in size was recognized in the fundus. the perforation was sutured primary and cruroraphy was performed. the patient required respiratory support and died on the th postoperative day due to multiple organ failure and septic shock. conclusion: the contents of paraesophageal hernia commonly include the gastric fundus or corpus. paraesophageal hernias can cause lethal complications, including gastric obstruction, strangulation, perforation, and hemorrhage. paraesophageal hernias can usually be repaired easily, even using the most recent laparoscopic technique ( ). thus, because of the very serious potential complications inherent in cases such as ours that can result from an untreated paraesophageal hernia, we recommend that elective repair be carried out, even in asymptomatic patients. introduction and objectives: the solitary fibrous tumor (sft) of peritoneum, especially arising in lesser omentum is extremely rare. we report a case of lesser omentum soliter fibrous tumor, causing pain and abdominal fullness with its mass effect. case: a -year-old male was admitted to our hospital, due to an intraabdominal mass lesion, epigastric pain, abdominal fullness and vomiting episodes. on physical examination, a hard, non-tender mass was palpated in the epigastric region. computed tomography (ct) showed, an approximate . · . · . cm sized solid mass with fibrous capsula between left liver lobe and stomach. at laparotomy, a yellowish brown solid tumor with hard consistency was found on the lesser omentum. the tumor was not adhered to the adjacent structures and could be resected completely. postoperative course was uneventful and no recurrence was determined during follow up. results: histopathologic examination diagnosed the mass as a sft. the tumoral cells were spindle-shaped and did not present mitotic activity or atipies and showed very low proliferation index with ki (< %) and immunohistochemical positivity for cd and negativity for c-kit (cd ), actin, and s- . conclusion: although sft are rare, especially in the abdomen of adults, are generally benign but malignant cases have been reported. in our case, the tumor has a benign character shows neither mitotic activity nor nuclear atypical. this is the third case of soliter fibrous tumor of the lesser omentum described in the english literature. introduction and aims: a single hamartomatous adenoma of stomach is rare. gastric hamartomatous polyps are usually multiple, familial and assosciated with other syndromes. they are also associated with chronic helicobacter pylori infection, acid hypersecretion and predisposition to gastric cancer. this is the first case of gastric hamartoma which is coexistent with duodenal ulcer perforation. case: a -year old male admitted to our hospital with complaints of stomach ache, nausea and vomitting. because there was free air under right subdiaphragmatic surface on chest x-ray, an emergency operation was performed. there was a perforated ulcer on the first part of duodenum and a large quantity of bile mixed with blood in the abdominal cavity. on further exploration a tumoral mass which was about cm in diameter was found on the stomach corpus. because of possibility of malignancy, a subtotal gastrectomy including the perforation zone was performed. histologically the tumor was well circumscribed and it consisted of uniform, clear cells. at first, it was thought to be metastatic lesion from kidneys or other organs. in this context, all body was scanned however no pathology has been identified. later on, the tumor was approved to be hamartomatous adenoma and helicobacter pylori was positive. postoperative course was entirely uneventful. objectıve: the aim of this work is to determine the level of apoptosis, which is believed to hold an important role in septicemia process that affects mortality and morbidity in obstructive jaundice, in lingers of rats that were experimentally subjected to obstructive jaundice. materials and methods: the experimentals were separated into two goups of eight. choledoch was isolated in each group and while surgery was ended at this level in the control group, choledoch was tied with - silk from two different places and cut between ligatures full fold. experiment animals were operated for the second time in the postoperative seventh day for liver sampling and sacrificationaimed histological analysis through the old incision with anaesthesia provided. to exhibit the p expression immunohistochemically, anti-p clone do- was used as the primer antibody and hrp as the secondary antibody. samples taken for the determination of apoptosis were painted by the tunel method. fındıngs: in the evaluation of apoptotic cells in liver cells, apoptotic cells were observed to widely exist in the liver tissue and it was determined that they exhibited dense accumulation in some regions. in the immunohistochemical evaluation made for evaluation of p expression in hepatocytes, p -positive hepatocytes were determined to exist quite widely in the tissue samples taken from the livers of rats in the experiment group. result: consequently, in this study we determined that in the obstructive jaundice group, both apoptotic index and, as a result of the immunohistochemical studies, p expression increases in the liver. introduction: the risk of leakage from an anastomosis is higher in large intestine. in emergent colon operations primary anastomosis is avoided especially on the left colon, and multi-step procedures are preferred if there is a dirty abdomen. the aim of this experimental study was to compare different suture materials in left colonic anastomosis in presence of peritonitis. metods: this study was conducted on wistar-albino rats by dividing them in groups of equal numbers. after median laparotomy, the whole layer of left colon was cut cm over the pelvic peritoneum and fecal contamination was performed. one day later, the abdomen was opened again under general anesthesia. the abdomen was washed with sf before starting colonic anastomosis. for colonic anastomosis; vicryl + silk was used in the st group rats, pds was used in the nd group rats, and coated vicryl plus antibacterial suture and silk was used in the rd group rats. results: tissue hydroksiproline, anastomosis bursting pressures and histopathologic findings on the anastomosis line were evaluated on the th postoperative day. the highest anastomosis bursting pressure was found in group iii (p < . ). the highest tissue hydroksiproline level was found in group iii (p < . group i-iii, group ii-iii). when histopathologic findings were evaluated by comparing three groups, the healing of the intestine tissue score was found to be highest in group iii (p < . , groups i-iii). conclusion: consequently, it was observed that using antibacterial suture increased resection safety in the presence of peritonitis and anastomosis safety in primary anastomosis. introduction and objectives: the chance of finding the vermiform appendix within an inguinal hernia occurs in approximately one percent of the cases, and is known as amyand's hernia. appendicitis within an inguinal hernial sac is rare. materials and methods: we present two amyand's hernia cases: one with a vermiform appendix and one with a perforated appendicitis. case : an -years-old man presented with a years history of bilateral inguinal mass. ultrasound examination described a hernia which contains mobile bowel segments inside, on the right side. the appendix was obsereved edematous and hyperemic in the hernial sac. an appendicectomy was done. further exploration of the bowels revealed a meckel diverticulitis which was managed by a wedge resection. case : a -years-old woman presented with one week history of an inguinal mass, pain and anorexia. abdominal computerized tomography demonstrated an incarcerated right-sided inguinal hernia.the hernia sac was filled with the perforated appendix. appendicectomy was carried out. results: postoperative recovery was uncomplicated, the patients were discharged without any complication. discussion: acute appendicitis or perforation of the appendix within the hernia sac simulates perforation of the intestine, and does not have specific symptoms or signs. preoperative clinical diagnosis is very difficult and the diagnosis is made intraoperatively. since the absence of any pathognomonic radiological features, the value of preoperative computed tomography is limited. treatment of hernial appendicitis is an appendicectomy with suture hernial repair. the management of a non-inflamed appendix is debatable. the usual practice covers reduction of the appendix, and mesh repair. in the immediate post-operative period the patient had a high output jejunostomy and was dependent on total parenteral nutritional support. a bishop-koop procedure was performed on day and by day , the patient was completely independent of any adjuvant nutritional therapy. five months from primary surgery colostomy was closed. introduction and objectives: the management of pancreatic pseudocysts which occur after blunt abdominal trauma in children is still controversial. in this study, we present our experience therapeutic approach of pancreatic pseudocysts that occur after trauma. methods: we evaluated patients with traumatic pancreatic pseudocysts who admitted to our clinic between and . we performed ultrasonography, computerize tomography (ct) and blood amylase level for all patients. results: there were eight males and one female. the average age was . years (range - years). the mechanism of injury was bicycle handle bar injury in four, falls in three, assault in one and motor vehicle accident in one patient. abdominal pain was the most common symptom. the median size of cysts was . cm (range - cm). the time interval between trauma and pancreatic pseudocysts was days (range - days). of the nine patients, four ( . %) occurred in less than weeks. all patients were initially followed up conservatively. three patients ( %) were successfully treated conservatively, while patients ( %) required intervention either by percutaneous radiological drainage ( ), cystogastrostomy ( ) and external drainage with laparotomy ( ). complication developed in two patients (septic shock, persistent hyperamylasemia). no patient died. conclusion: traumatic pancreatic pseudocysts may occur short after traumatic injury in children. all patients with traumatic pancreatic pseudocysts should be managed by conservative approach initially. however, if the cyst is cause of gastric outlet obstruction or the size of cyst is bigger than cm, interventional management may be required. introduction: splenic abscess is a rare entity,with a frequency of . - . % in autopsy series.mortality rate is still high, up to %, and can potentially reach % among patients who do not receive antibiotic treatment. case : year-old woman presented with fever and left upper abdominal pain for days. hepatomegaly and tender splenomegaly were present.ct of the abdomen revealed · cm hypoechoic lesion in the spleen (fig. ) . initial laparoscopic approach was performed but failed due to inappropriate anatomy. conventional splenectomy was done and at exploration there was · cm abscess in spleen. the patient was dischared on the eighth day of operation. case : yearold woman admitted with femoral artery thrombosis.thromboembolectomy and leg amputation was performed by cardiovascular surgeons.she was consultated with fever and left upper abdominal pain on the second day of operation. ct of the abdomen revealed a · cm mass with air fluid levels in the spleen (fig. ) . splenectomy was performed and a · cm abscess was observed in spleen.the patient died on the second day of operation due to sepsis. a proximal stoma after resection of the perforated small bowel and colon, closure of the distal stump in case of severe generalized peritonitis without the possibility to perform a primary anastomosis. a loop ileostomy to prevent bacterial translocation in case of pancreatitis. retrospective analysis of clinical data of patients admitted between and for emergency operation requiring laparotomy and the construction of one or more small-bowel stomas. patients had ileostomies created for temporary fecal diversion after emergency surgery including bowel obstruction was the most frequent cause of peritonitis ( cases),followed by anastomotic leakage and peritonitis ( ), acute mesenteric infarction ( cases), intestinal perforation ( cases), strangulated incisional hernia ( cases), acute abdomen of crohn disease ( cases), peritonitis carcinomatosa and frosen pelvis ( cases), mean age was . years (range - ), being males and females. overall mortality was % ( patients). patients died on the first days postoperatively. indications, morbidity, mortality and problems involving the ileostomies in emergency abdominal surgery urgency are herein discussed. in the majority of patients with acute abdomen doing ileostomies,lacking of vital capacity of bowel wall as well as insufficiency of previously laid sutures were revealed, which forced a surgeon to resort to resection; in such cases the method of choice for decompression should be the application of ileostomy. postoperative jaundice is often multifactorial. a precipitating or causative factor may be identified but seldom can a specific therapy be offered. the late complications were mainly presented by the biliary ducts cicatricial stricture, the jaundice and cholangitis recurrency. in this report, we described an extremely rare case of a -year-old woman presenting with pain in the right upper quadrant, jaundice, and weight loss in whom a whipple procedure was performed. usg and mr cholangiography showed that dilatation of intrahepatic and extrahepatic bile ducts and hepaticojejunostomy line. mrcp also showed that, there was a closed jejunal loop related with hepaticojejunostomy. obstruction by local tumor recurrence and infiltration of the efferent jejunal conduit between the proximal hepaticojejunostomy and the duodenojejunostomy led to closed loop syndrome and jaundice. frozen sections by direct incisional biopsy revealed a recurrent tumor invasion. a previously unreported late complication after whipple resection of the head of the pancreas was recognized as ''closed efferent loop syndrome'' mimicking obstructive jaundice. the case was accepted as inoperable because of tumor invasion to the jejunum, transverse colon, and surrounding tissue. roux-en y type jejunojejunostomy was performed. the patient had an uneventful postoperative course. introduction: the form of mechanical asphyxia where respiration is prevented by the external pressure on the body: a large weight compressing the chest or abdomen, wedging of the body within a narrow space death in large crowds is traumatic asphyxia. case: a -year-old man was found compressed by a motorboat in the garage while he was working for installation of the boat. the face, neck and upper part of the chest were congested and many petechiae were observed on the conjunctivae. ecchymotic bruises were observed on the right cervical, lower chest, upper abdominal regions and open fracture of the right humerus, ecchymotic abrasion on right anterior superior iliac spine line were detected. subcutaneous haemorrhages in the chest wall and bleeding without subcutaneous haemorrhage in the inferior part of the right sternocleidomastoid region were observed during the internal examination. fractures of the right third and fifth ribs which were accompanied by bleeding in the surrounding soft tissues and muscles, and ecchymoses over the right sixth rib without any fracture were also observed. macroscopic examination of the lungs revealed congestion, subpleural superficial bleeding areas and histopathological examination showed hemorrhagic alveolar oedema. all the internal organs and big vessels were intact. there was no hemorrhage in the thoracal and abdominal cavity. toxicological analysis was negative. conclusions: in the presented case, the impact cause of the chest compression was distinctly determined by the autopsy and criminal investigation. death was reported as asphyxia by the thorax compression without other lethal factors. purpose: the purpose of this prospective study was to evaluate safety of early surgical interventions in the repairment of animal bites with tissue injuries. materials and methods: tissue repairment and/or reconstruction were done, total in patients. of them were dogs', of them were horses' or donkeys' biting between the years - . wound sterilization and debridement were made before repairment. rabies and tetanus prophylaxis were done for all patients. tissue repairments after animal biting were made early and promptly. patients having animal injuries, apart from biting were not included in the study. results: of the patients were male and of them were female. the minimum age of the patient was . and the maximum was , and the average age was . in cases head-neck, in eight cases extremities and in two cases body were biting areas. horses' or donkeys' bitings were seen particulary in ears. in these animals' biting tissue lose was emphased. we prefered primary saturation in cases, skin greft in ten cases and repairment with flap in five cases. finger amputation was required in one of the patients. total ear reconstruction was done gradually in a patient. no infections observed in patients after the surgical interventions. conclusion: we concluded that, early tissue repairments may done after wound sterilization and debridement, safely. treatment plan. multidetector computed tomography (mdct) imaging is an improving and being a widely used method recently in many areas of medicine. it is possible to evaluate the peripheric vascular structures, anatomic variations or vascular pathologies with mdct angiography (mdcta). methods: the arcuate foramen is an anatomical variant of the atlas vertebra: anterior and posterior osseous bridges or ponticles can arch over the vertebral artery, to a greater or lesser degree, transforming the arterial groove into a canal. dissection of the vertebral artery leading to thrombotic occlusion or ischaemia from narrowing of the arterial lumen has been described in trauma. there are fistula between a dural branch of the spinal ramus of a radicular artery and an intradural medullary vein in spinal vascular malformations. mdct angiography is feasible and is an alternative technique in diagnosis spinal vaskü ler malformations. the craniovertebral junction (cvj) is a funnel-shaped structure comprised of the clivus and foramen magnum and the upper two cervical vertebrae. the most frequent neoplastic lesions of the craniovertebral junction are meningiomas, neurinomas, chordomas, paragangliomas, epidermoids, dermoids and chondrosarcomas. conclusion: in this presentation, pathologies seen in craniocervical junction (congenital variation, trauma, vascular malformation and tumor) were discussed with figures and compared with the literature. introduction and objectıves:small bowel obstruction (sbo) is very rare. although the diagnosis is straightforward, some patients with intermittant and low-degree symptoms could be misdiagnosed as psychiatric disease. we presented here a patient with intermittant symptoms of ileus treated as psychiatric disease case: a year old male patient was referred from phsyiciatry clinic to our department with complaints of weight loss, nausea and malnutrition. his medical history revealed a laparoscopic appendectomy months ago. he emphasized that his complaints started shortly after the operation and increasingly got worse. he was admitted to hospital days after operation with symptoms of ileus and managed conservatively. the intermittant abdominal pain and nausea continued. since the pain was intensified after meals, patient refused eating. during the period of months he lost kg of weight. after numerous radiological and endoscopic investigations patient was referred to psychiatry due to persistent anorexia. after short psychiatric medication, he was referred to our surgical unit. multislice abdominal computerized tomography and and enteroclysis of small bowel clearly demonstrated an obstruction in the jejunal segment of the intestine. at laparotomy, small bowel obstruction was detected and segmental resection was performed. postoperative period was uneventful and patient was discharged from hospital on postoperative day . conclusions: the diagnosis of anorexia and nausea due to sbo is relatively difficult. the patients were sometimes misdiagndosed as having psychiatric disease. before starting psychiatric medication, they must be reevaluated for all putative causes of sbo. introduction: endoscopically placed biliary stents are a well-established procedure for the treatment of benign and malignant biliary disease. duodenal perforation may occur at the time of insertion of a biliary endoprosthesis or following endoscopic manipulation of such a stent. methods: we report a case of duodenal perforation complicating stenting for biliary fistula in surgery for hepatic hydatid cyst. case: a -year-old man was admitted to a local hospital following the sudden onset of abdominal pain,distension with nausea and vomiting. he developed a biliary fistula after surgery for hepatic hydatid cyst months ago. endoscopically placed biliary stent was performed for the treatment of biliary fistula at the same hospital months ago.on examination, marked abdominal distension with mild tenderness was recognized. his pulse rate and blood pressure were /min and / mmhg, respectively. abdominal x-ray showed two foreign body images and subdiaphragmatic free air. emergency laparotomy revealed dirty ascites and perforation of the third portion of the duodenum by the plastic stents. the second stent was found at pericecal area. after extraction the plastic stents and irrigation with isotonic sodium chloride solution, the site of perforation in the duodenum was primary reparing and triple tube placement performed. conclusion: endoscopic retrograde cholangiopancreatography (ercp) is considered to be the most difficult endoscopic procedure in gastrointestinal endoscopy, and is associated with potentially severe and sometimes life-threatening complications such as duodenal perforation. surgical statistics indicate the importance of early diagnosis and treatment for duodenal perforation. introduction and objectives: ticks play an important role in transmitting several infectious agents, such as viruses, bacteria, spirochetes, rickettsia, and parasites. in this study, we analysed the demographic and clinic characteristics of the patients who admitted to emergency service due to tick bite. methods: in this study, patients were selected from cases of tick bite admitted to the department of emergency medicine of ankara numune hospital during the - periods. detailed histories and some blood tests of patients were taken, and the body of the tick grasped gently avoiding to inject more salivary toxins. results: totally patients admitted to hospital in this period. the most frequent symptoms at administration were malaise, myalgia, and fatigue. hemorrhagic manifestations were observed in patients and bleeding was from multiple sites in patients. other symptoms were watery diarrhoea, skin eruption, macular rash, and petechia-ecchymosis. in the comparison of the clinical features and laboratory results of the surviving and the patients who died, we found that the rates of fever during hospitalization, confusion, neck stiffness, bleeding from multiple sites and presence of petechia/ecchymosis were higher in the patients who died than in the surviving ones. additionally, the mean values of alt, ast, lhd, ck, ptt, international normalized ratio (inr), and urea were also higher and mean plt counts were lower in the patients who died. conclusion: the acute tick-bite reactions show special histologic features, which are unquestionably related to the particular morphology and physiology of the mouthparts of these arthropods. results: totally patients ( men and women) were evaluated. the mean age was . ( - ) years and the mean follow up period was ( - ) months. the localization of the hernias were as follows: inguinal hernias, seven femoral hernias, two umblical hernias, two paraumblical hernias, one epigastric hernia and one inguinal + femoral hernia. all of these strangulated hernias were treated with prosthetic graft repairing. in addition to these hernia repairs, in the same operation sessions three hydrocele repairs, three omentum resections, two partial small intestine resection and anastomosis, one lymphadenectomy, one orchiectomy and one laparotomy were done when necessary. in the early post operative period four patients died because of other diseases not related with the surgical procedures or hernia itself. wound infections were observed in three patients and they were treated with antibiotics and anti inflammatory drugs. we report a rare case of ileal perforation caused by an ingested cm long fork. a -year-old man presented to the emergency department with exhaustion, weight loss and abdominal pain. he had been having pain in the abdomen, nausea and vomiting for the previous days. the patient had received psychiatric treatment, and started to experience weight loss and exhaustion - months previously. no conclusions could be drawn from physical examination for abdominal tenderness and defence. direct x-ray showed an appearance conforming to a fork in the intestine and subdiaphragmatic free gas. the patient was sent for emergency surgery, with a diagnosis of ileal perforation and foreign-body ingestion. most of the ingested foreign bodies that reach the stomach pass through the alimentary tract without complication. perforation occurs in, % of all cases of foreign-body ingestion, usually in the oesophagus. other sites where perforation can occur are the pylorus, the duodenum, the duodenojejunal flexure, the ileocaecal region and any site of congenital anomalies. long, thin or sharp objects, as seen in our case causing ileal perforation. foreign-body ingestion is a possibility to be borne in mind at presentations to the emergency department, especially those with symptoms described in psychiatric cases. appendicectomy is a common emergency operation, its major complications are uncommon. most complications of appendicectomy occur in the early postoperative period and easy amenable to treatment with conservative medical therapy. appendicitis, usually a benign disease, can have its prognosis worsened in case of postoperative fistula. the latter occurs rarely after open appendicectomy but accounts for % of the morbidity rate. schloffer tumor (inflamatory granuloma or abscess in the abdominal wall at the operative scar) is rare complication that usually develop months to years postoperatively and late postoperative enterocutaneous fistula has been described in literature as a rare complication of acute appendicitis. we describe one such case where the patient presented with a tender mass under the incision site six months later after appendicectomy. findings of computed tomography were demonstrated thickening in the abdominal wall and abdominal wall abscess like schloffer tumor. abscess was drained. there were not produced any microorganisms in the wound culture. after conservative therapy healing was completed in a short period. one year later, the patient was admitted with complaints. on the examination, passage of undigested food particles through a sore in the appendicectomy incision site. computed tomography were demonstrated fistula tract extending from appendicectomy site to skin. enterocutanous fistula was occured at the appendicectomy incision year later after operation and successfully treated with en-block fistulectomy and right hemicolectomy. postoperative course was uneventfull. patient discharged from hospital at seventh day after operation. objective: vascular insufficiency may lead to hypoxic injury in intestines. the lesions in the colon are called ischemic colitis. mesenteric ischemia is more prevalent in patients getting hemodialysis. in this study we report hemodialysis patients admitted to the emergency department because of acute abdominal symptoms. case year old woman was chronic hemodialysis patient admitted to the emergency room with acute onset abdominal pain.the initial diagnosis was acute appendicitis and she underwent laparotomy. peroperatively isolated cecum necrosis was seen. right hemicolectomy and ileotransversostomy was performed. she died days after surgery because of sepsis. case year old man was chronic hemodialsysis patient admitted to the er because of abdominal pain persisting for h. with an initial diagnosis of acute abdomen a median incision was performed. peropertively widespread peritoneal adherences and isolated cecum necrosis were seen. cecum was resected and side to end ileocolostomy was performed.he died days after his first operation. case year old man was chronic hemodialysis patient admitted to the er with pain localizing to right inferior abdomen. with an initial diagnosis of acute appendicitis laporotomy through a mc burney incision was performed. there was · cm cecum necrosis. cecum resection and end colostomy and ileostomy was performed. the patient was discharged days after the operation without any problem. discussion: ischemic necrosis of cecum is a rare variant of ischemic colitis. in hemodialysis patients requiring colon resection due to ischemic colitis, primary anastamosis should be avoided, diversion stomies should be preferred. agitation is a non-specific constellation of comparatively unrelated behaviours that possess a risk to the safety of the patient or caregiver, impedes the process of care giving or impairs a person's function. the management of agitated trauma patient contains hospital, prehospital, in emergency department and inside of the hospital transports. the reasons of the agitation hypoxia, hypoglycemia, hypovolemia, pain, traumatic brain injury, anxiety disorder, drug and alcohol abuse, psychiatric disorders. pain management has had a limited role in the management of trauma patients, primarily because of the concern that side effects (decreased ventilatory drive and vasodilatation) of narcotics may aggravate preexisting hypoxia and hypotension. health professionals should monitor pulse oxymetry and serial vital signs if any narcotics are administered to a trauma patient. small doses of benzodiazapine sedatives should be titrated cautiously because of the potential side effects of hypotension and ventilatory depression. to control agitated patients with traumatic brain injury include haloperidol, midazolam, and propofol. in the emergency setting, they are most often indicated to control agitated or psychotic behavior that constitutes an imminent danger to the patient or others. to control agitated patients should be a part of the trauma management. we present a protocol for trauma team. there were males ( . %) and females ( . ). eighty percent of the patients were between and years of age. the overall mortality was . % ( patients). eighty percent of deaths occured in comatose patients (p < . ). comatose state, precence of focal motor signs, respiratory irregularities and hypertansion-bradycardia, pupillary changes were determined as the bad prognostic factors. a midline shift greater than mm, hematoma volume greater than ml, accompanying intracerebral and extracranial traumatic pathologies significantly increased the mortality rate. there was no significant statistical correlation between the outcome and the age, sex of the patient, trauma-to-operation interval, thickness, localization and origin of edh and aetiology. results: the primary factor on outcome is glasgow coma scale scores of the patients at the time of surgery. therefore early surgery is crucial in the management of edh which is a dynamic process. introduction: in this study, we have evaluated the incidence and clinical characteristics of the patients for traumatic brain injury (tbi)-associated coagulopathy after tbi retrospectively. methods: retrospective study of all patients admitted to the trauma and emergency surgery intensive care unit (icu) from january through december with tbi. criteria for tbi-coagulopathy (tbi-c) included a clinical condition consistent with coagulopathy in conjunction with a platelet count < , mm and/or international normalized ratio (inr) > . and/or activated partial thromboplastin time (aptt) > s and/or prothrombin time (pt) > . s. the following potential risk factors were included to identify independent risk factors for tbi-c and its association with mortality, age, mechanism of injury (blunt (b) or penetrating (p)), glasgow coma scale (gcs), injury severity scale (iss), presence of polytrauma, icu length of stay (icu-los). results: a total of patients met study criteria. tbi-c occured in . % (n: ) of all patients (b: . %, p: . %). in patients with tbi-c, mean age was . ± . years. the averages of gcs was . ± . , iss was . ± . , icu-los was . ± . days, polytrauma was considered . % (n: ) and the overall mortality was . %(n: ) in patients with tbi-c. conclusions: in our study, tbi-c occured more frequently among patients sustaining blunt versus penetrating injuries. to our knowledge, tbi patients are at considerable risk of developing coagulopathy and anesthesiologists should be aware of this life-threatening syndrome, especially in tbi patients with blunt injuries. erythropoietin (epo), glycoprotein hormone, is a mainly produced by the kidney that stimulates proliferation, growth and differentiation of erythroid precursors in the bone marrow. recently, anti-inflammatory, neuroprotective, antiapopitotic, angiogenic and vasodilatator effects of epo have been also determinated. the purpose of this study was to investigate the effects of rhuepo in reducing the severity of experimental spinal cord injury (sci). ninety adult sprague-dowley rats weighted g (± ) were used for the study. through a dorsal incision, t - laminectomies performed in prone position and clip compression had made for ischemic injury as tator method. the rats divided in three groups. systemic l ( , u/kg) rhuepo had given h before the trauma in the first group, min. later after the injury in the second group and the third was the control group. the rats were killed with high dose intraperitoneal ketamin h later after the injury. the histological examination of injured spinal cord specimens for the potential neuroprotective effects of rhuepo was done. further more the axial spine sections stained with ttc (triphenyl tetrazolium chloride). the ischemic areas were evaluated with a imaging calculation program. we use wet-dry method for determination of ischemic tissue edema. we concluded that administrating a single dose rhuepo ( , u/ kg) has potential neuroprotective effect on experimental spine injury by reducing severity of inflammation and tissue edema in the secondary ischemic area. it has known both early surgery and high dose steroid treatment prevents the neurological function and viability caused of the traumatic secondary spine injury. we present surgically treated a traumatic rotation-compression spinal cord injury caused by a motor vehicle accident. the patient referred to our clinic h after the injury. at the time of admission, he had a localized pain at the thoracic - vertebrae level, loss motor and sensorial function under the level t classified as asia grade a. he was incontinent. in the radiological evaluation we found loss of height at the thoracic th and th vertebrae body, serious spinal column injury include t - burst fracture, laminas and facet joints fractures with three colon damage (denis f). we detected the spinal instability criteria in . we did not see penetrating injury or primary spinal cord injury signs but spinal canal tightness for percent in ct and mri scans. we took the patient to surgery in unusual classical surgery timing. first, decompressing surgery applied to the t - laminas and posterior stabilization with transpedicular screw-rot system. one day after the first operation, t and t corpectomy applied for anterior stabilization with cage-screw system. mega dose steroid had given also before the first surgery. postoperatively early neurological evaluation, he had asia grade c, after second month asia grade d without incontinence. in our opinion the decompressing surgery that applied in h in the patients without complete primary spine injury, has a positive neurological feedback. introduction: it is a rare occurrence with the rate of % in the subjects with spinal infestation cyst hydatic echinococcus granulosus. intradural hydatic cyst is relatively rare when compared with other spinal hydatic cysts. we are presenting here a -year-old female case who applied to emergency service with backache and paralysed legs and was diagnosed with spinal intradural extramedullary hydatic cyst. case: a -year-old female patient applied to emergency service with complaints of a backache started two days ago, paralyses in both legs and being unable to walk. in her neurological examination, a complete motor power loss in the lower extremities and bilateral sensation loss compatible with t dermatoma were detected. in the torako-lomber spinal magnetic resonance imaging (mri), multiple cystic characterized nodular lesions having peripheral contrast with regular contour including right neural foramen and paravertebral zone at the level of t -t and l in the intradural distance were determined. the patient was diagnosed with common spinal intradural extramedullary hydatic cyst exhibiting bone involvement. as the lesion was very broad had paraplegia, we did not consider operation. conclusions: hydatic cyst infestation is a benign disease. if it is not diagnosed early and treated when it involves in some systems rarely as it did in this study, the results can be serious. diagnosis should be confirmed quickly with increasingly common advanced radiological diagnosis methods. the aim in these cases is to eradicate the cysts surgically, however, chemo-therapy and percutaneous drain methods have become more significant recently. introductıon: several guidelines advocate multiple chest radiographs during primary resuscitation of trauma patients. several local hospital protocols include a repeat radiograph before leaving the trauma resuscitation room (tr). the purpose of this study was to determine the value of routine repeat radiograph. methods: one year data of all radiological imaging in our tr were prospectively collected for all patients presented to the tr of the hospital. we counted and assessed the radiographs and classified our findings as either 'new injury detected', 'presence of intervention equipment', or 'deterioration of previously detected injury'. results: in total, patients were included. more than % had two radiographs. eight ( . %) new injuries without clinical relevance were found on the repeat radiograph after an initial normal radiograph. in total patients ( %), had a repeat radiograph to verify the effect of an intervention or position of equipment. in patients ( %) with two abnormal radiographs, newly diagnosed injuries (n = ) or deterioration of known injuries (n = ) were found. in patients ( %) the results of the repeat radiograph had no clinical consequences. conclusıon: our study supports a strategy of omitting a routine repeat radiograph in trauma patients whose initial radiograph is normal. introduction and objective: the neck region is affected in only about - % of all trauma cases, and isolated neck injuries, especially from a blunt mechanism, is even more rare. our objective was to assess the incidence, disability from spinal cord injuries, and preventable deaths in our patients with isolated neck trauma. material and methods: patients were identified at the severe trauma registry of our hospital, between and . the triss method was used to assess preventable deaths. results: we found ( . %) patients with neck injuries out of . patients included in our registry, ( %) from blunt (bnt) and ( %) from penetrating trauma (pnt). only ( %) bnt and ( %) pnt were isolated. the mean iss of the bnt and pnt groups was of ± and ± . , respectively. in the bnt group, ( %) patients had spinal fractures (with spinal cord injuries with permanent disability), had airway injuries and a vascular injury. in the pnt group, patient had a spinal fracture, had vascular injuries and airway injuries. overall mortality was of ( %) patients, in each group, and only one of them was deemed preventable. conclusions: isolated neck trauma is a rare cause of disability and preventable death in our area. most penetrating injuries have a lowto-moderate degree of anatomic severity (ais £ ). for each group. however about applications increased gradually with a peak at o'clock in all groups. patients treated at ed were mostly stricken ( . %) and the busy period was between - h with two peaks at and o'clock. totally, patients were hospitalized mostly in group iii ( . %) regardless of cause (p < . ). patients referred to another hospital were frequently in group iii ( . %) and also in group iv ( . %). mortality was slightly high in group iii. however higher rate ( . %) was seen among patients in group ii. conclusion: midnight hours seemed safe in terms of mortality and severity of trauma. whether the reason for a higher transportation rate at night hours is the severity of trauma or sedation of ed staff is not clear. introductıon: in this study we aimed to investigate and compare the features of child and adult injuries due to bicycle accidents admitted to our emergency department. patients and methods: the study was carried out retrospectively by searching the files of patients admitted to the emergency department due to bicycle accidents, in the emergency department and archive records between the dates of january and december . the patients were divided into two groups as adults and children. age and sex of patients, season or month of injuries, place and mechanism of injury, injury site of the body, diagnosis and treatment modalities, discharge and hospitalization rates were evaluated. results: totally patients were included in the study. % of the patients were in child age group, % were adults. it was determined that number of accidents increased especially in the summer months. . % of accidents concerning children and all of adult accidents occurred in the streets. falling down from the bicycle was the most common injury mechanism in children ( %) and adults ( %). head and neck region was the most common body site subjected to the injury both in children ( %) and adults ( %). % of child patients and % of adult patients were discharged after emergency department follow up and treatment. there was a significant difference between two groups with respect to injury severity. conclusıon: as a conclusion most of the injuries due to bicycle accidents happen in children, in the streets, in summer months and school vacations. conclusıons: road traffic collision is a major cause of trauma and death in al-ain city. seatbelt compliance is alarmingly low and should be enforced. introduction and objectives: the controversy between the ''scoop and run'' versus the ''stay and play'' approach in severely injured trauma patients has been an ongoing issue for decades. the present study was undertaken to investigate whether changes in prehospital care for patients with severe traumatic brain injury in the netherlands, have improved outcome. methods: in this retrospective study, files were analysed for all patients admitted to one of six hospitals in the limburg region in the netherlands with a gcs < on admittance over the period january -december . all patients had proven traumatic brain damage on ct or mri. relevant prehospital and clinical data from a similar study conducted years ago were compared to data from the present cohort. the main outcome was mortality. results: the two research groups had similar characteristics. in the historic cohort, basic life support (bls) and the 'scoop and run' method in patients with major traumatic brain injury (tbi) was common, with an average time on scene of . min. nowadays, prehospital care is performed mainly on the level of prehospital advanced life support (als), with average time on scene about four times as long as in the historic cohort. however, the overall mortality rate for the current cohort compared to years ago has not decreased. conclusion: despite more on-site als in major tbi nowadays, there was no reduction in mortality. the team is provided to be ready all the time by making monthly and yearly national education exercises. these exercises are planned with two methods: ( ) as demonstration during education ( ) by creating extraordinary condition simulations aim: _ interpret the support of exercises plans on umke operational agility and to accomplish next plans through this way. material -method: umke teams are divided into two parts after geting their basic educations. first group is planned to exercise in education room with demonstrations. the second is planned to exercise the extraordinary situation simulations in which people(not from the groups) made up and acted as injured and moulage is also used in this group. after the exercises, results are compared according to the criteria for assessment. in the first group's demonstrations it is worked by giving roles to team members in the education atmosphere with existing equipments (chair, table, ladder…). in the second group, worked with the moulaged volunteers and extraordinary situation simulations just like the real(wreck, avalanche, fire…) the results are considered statistically by t test. findings: according to the assessment criterias the first group's average point is . and the second is found as . . (p < . ). discussion and result: exercises in a form of extraordinary situations effected team's performance, operational success and involvement positively. planning the exercises with this data will increase the quality of the educations which planned in the future. nurhan babaoglu, tayfun cucioglu, gö khan akbulut national medical rescue team, ministery of health, afyonkarahisar, turkey entry: umke designed as serving medical rescue in extraordinary circumstances. they carries their approaching skills to the top by managing regional and national exercises. the teams in different cities coordinate and share their knowledge and agility by this exercises. aim: after the workshop oriented educations, criteria are needed to improve and decide the affect of the exercises as numerical which supplies standardization of the teams. material-method: teams are evaluated according to criteria and graded from to . after the exercises, results and the importance of criteria shared with teams. month later same teams evaluated again in exercises. criteria: ( ) equipment ( ) team accordance and work discipline ( ) security and to define work risks ( ) approach to the injured ( ) evaluate the injured people ( ) convert the theory to practise ( ) usage of materials correctly and in proper place ( ) packaging ( ) taking out the injured safely ( ) cleanness of the materials and control of medical bag findings: after antalya umke basic education, team's evaluated and average score was . . this results shared with teams and in next exercises in isparta mean score founded as . . (p < . ) discussion and result: when the evaluation criteria and results shared with the teams, it is confirmed that the teams react better in ongoing situations. it is considered that it will also increase the quality and effectiveness of the education. the criteria for evaluation going to help standardization which can be used by all medical rescue teams will provide a common manner between the groups. hasan Ç elik, gö khan akbulut, nurhan babaoglu, tayfun cucioglu national medical rescue team, ministry of health, afyonkarahisar, turkey umke teams are established in in cities in order to act in disasters and extraordinary circumstances as a medical rescue team. members are chosen among the volunteered medical crew. the team's mission is to support the search and rescue teams medically in extraordinary circumstances. team starts with the first intervention and maintain the stabilization of the injured person before the transport so that prevents the second insult. working principles was not obvious during the establishment phase and this caused chaos at the beginning. by designating the teams responsibilities work distribution reached to the standard. national medical rescue team is consisting of medical personnel who are named as leader, logistic, pigeon, squirrel and courier. the team leader who is chosen from doctors who has experienced in disaster medicine and have knowledge about leadership, provides a common manner and motivation among the team. also directs the intervention to the injured person and coordinates with search and rescue teams just after the fast arrive in extraordinary circumstances. squirrel communicates with injured at first and starts his intervention with the direction of the leader. logistic is responsible for all equipment (spin board, medical bags…). courier provides the equipment transportation between logistic and squirrel. pigeon is responsible for photographing, recording and communicating with the center. this organization type performed in regional and national practises from to and also in train accident in kü tahya. _ it helped maintaining standardization and acquired successful results. author to editor: bu yazıyı ulusal medikal kurtarma ekiplerini (umke) tanıtmak amacıyla hazırladık. eg er uygun gö rü rseniz, umke yi tanıtıcı bir stand açıp medikal çantamızı ve dig er kullandıg ımız malzemeleri tanıtabiliriz. ayrıca bu gü ne kadar katıldıg ımız (pakistan depremi, isparta uçak kazası, kü tahya tren kazası) afet, tatbikat ve eg itimlerimizi(ameliyathane konteynırımızı) power point olarak sunabiliriz. helicopter use as a part of trauma care introductıon: rapid transport and persistence of prehospital care is crucial to decrease the mortalities and morbidities of combat related injuries. hence, helicopters are effectively used by the military although they are austere environments that offer limited space, equipment and resources for the crew and requires higher level of skills for prehospital trauma care. materıal-method: the data were collected from consequent casualties, by the helicopter medical team (a surgeon, anesthesiology technician and a paramedic). during the flight, we triaged the casualties according to wound characteristics (severity, mechanism, location), physiological parameters, and provided basic life support stated by trauma resuscitation course (trk). we transmitted these findings to the military trauma center to provide hospital preparedness. result: injury mechanisms were % explosives and % highvelocity weapons. time to hospital admittance was < min after the injury. most frequent sites of injury (ais - ) were extremities ( %) and thorax ( . %); the frequency of ‡ anatomical site injury was %. capillary refill rates were; < seconds . %, > seconds . %. mean sao , gcs, hr, respiratory rate values were . ± . , . ± . , . ± . , . ± . , respectively. during uninterrupted care, ( %) intubations were performed and % of casualties were operated upon admittance without any onboard mortalities. conclusion: the high energy and lethality of the wounding agents in combat render the helicopter evacuations indispensible. additionally, civilian major trauma patients may benefit from expeditious transport to the closest trauma centers or from rural inaccessible areas within the 'golden hour of trauma'. the most important steps for the treatment of the combat injury causalities are to stop or reduce bleeding and to start fluid resuscitation. peripheral intravenous (iv) line placement is one of the most important procedure in the battlefield conditions. most of the time, fluid resuscitation would be the only available medical treatment for the injured combatant because of the prolonged evacuation period in the battlefield. also, this procedure would be very difficult and time consuming especially under hostile gunfire. excessive blood loss and hypotension may cause the peripheral venous collapse and makes the procedure more difficult. here we described a simple method to make this procedure easier. we offer the forward medical team personal to perform the upper extremity peripheral venous mapping of the combatant before the operation. the medical providers (doctor or paramedic) who would perform the first medical intervention would examine the upper extremities of baddy just before the operation. the medical care provider should determine the suitable situations for the iv line placement. then he should remark the both site of the appropriate vein by camouflage paintings, leaving the probable angiocath insertion sites non-painted. we believe that this method would make the peripheral iv line placement easier and faster for the forward medical team personal in the war conditions. one probable disadvantages of this method is the negative psychological effect on the combatant that makes them to estimate the risk of wounded in a few hours. introduction and objectives: ambulance and emergency care technicians are the key personnel for pre-hospital care of trauma. this study reviews the work anxiety states of some of the students in ambulance and emergency care technicians department, vocational school of health services, marmara university by comparing it with those of the students in radiology department of the same school. methods: this study was developed as a sectional type of study and was conducted on volunteer students from the above mentioned departments. the data were analyzed using the spss . software and employing the frequency distribution, t-test for individual groups, and unidirectional variance analysis methods. results: the study group of subjects was . % female and . % male. . % of the subjects expressed anxiety over their employment in the future; . % of them expressed no work anxiety. the work anxiety points of the subjects were compared in terms of their genders, academic years and departments, and said comparison did not reveal any statistically significant difference (p > . ). conclusions: the work anxiety state is one of the major factors having an impact on professional success, and is a negative state having an impact on one's performance, success and, in turn, psychological state. it would be proper to study the issue of work anxiety by obtaining psychological support, and to cooperate with the actors in this sector to develop solutions. it is concluded that further studies should be conducted on work anxiety and its reasons. in general, emergency patients should be transported to the closest appropriate hospital. if the emergency medical services have identified a specific hospital with better resources to treat seriously injured patients, the patient should be transported to that institution, bypassing closer hospitals. the cooperation is expected between the hospitals, and the development of formal transfer agreements, describing all of the legal, economic, and medical aspects of the relationship are encouraged. ideally, the entire trauma system in a city should be designed on the basis of need and existing resources, with all affected parties involved in the planning, development, and implementation. the goal of the system is to match the needs of an injured patient to the resources of the available facilities so that optimal and cost-effective care is achieved. we conduct six essential questions for the preparation of trauma. is there a legal authority to formally designate hospital's trauma response in your city? what sources were used as a basis for standards of the trauma response in your service area? were the number of hospitals identified for your service area limited based on the results of needs assessment? what type of transport practice occurs in your service area when a field assessment identifies a trauma patient with severe injuries that threaten loss of life or limb? is a trauma registry present in your service area? is there a designated trauma advisory committee that evaluates the performance of trauma care delivery within your service area? we evaluated the role of primary hip arthroplasty (consisting of both total hip replacements and hemiarthroplasty) in these comminuted, osteoporotic or neglected fractures. these patients at-risk were in need of a single definitive surgical plan for early ambulation and preventing complications. typically these patients were elderly with poor mobility and had multiple other medical condition to be able to withstand multiple surgeries. there was a need to obtain the best results with the single, rapid procedure for pain relief and early ambulation. excellent to very good results were obtained in about % of these patients. good results were obtained in about % of these patients and poor results in about %. most of the poor results were the outcomes of complicated medical conditions rather than the failure of the orthopaedic procedure itself. we advocate arthroplasty in neglected, osteoporotic or severely comminuted per-trochanteric fractures for immediate mobilization and optimising outcomes. the role of intra-articular steroids or hyaluronic acid injections in early arthritis may be warranted and perhaps safe. but for patients waiting for a knee replacement these can prove positively dangerous. a meta-analysis has revealed that intra-articular injections given in patients waiting for a knee replacement procedure is fraught with dangers. apart from a high risk of post-operative infection and failure of the procedure, several other side-effects or complications make this risky. there is a higher-than-average chance of quadriceps tendon rupture, delayed wound healing, superficial infections and slower rehabilitation. in comparison hyaluronic injections have been found efficacious in the short term and do not contribute to complications normally attributed to steroids. thus intra-articular injections should be used with caution, repeated injections are best avoided and are certainly contraindicated if a procedure is anticipated to be performed within six months. introduction: pediatric forearm fractures are common. the majority has satisfactory outcome. but poor results do occur and malunion can compromise rotation. we belief that the angulation of the fracture depends on the action of the body and that we can reduce the fracture by completing the action. this way we can perceive a stable anatomic reduction without internal fixation. methods: we undertook a prospective study of distal forearm fractures in children. we included children with a non-displaced angulated metaphyseal distal forearm fracture. the angulation was between °and °.we all reduced them by completing the action of the body. this means a volar angulated fracture is reduced by pronation of the hand and a dorsal angulated fracture is reduced by supination. after the reduction they were casted in an upper-arm cast in pronation or supination depending of the reduction manoeuvre. afterwards the all received weeks of upper-arm cast and weeks of lower-arm cast. results: they all healed without loss of reduction and without further treatment. they all had full recovery of function. conclusıon: non-displaced angulated metaphyseal distal forearm fractures in children can be treated conservatively by closed reduction and plaster cast. background: vascular endothelial growth factor (vegf) plays an important role in the bone repair process as a potent mediator of angiogenesis and influences directly the osteoblast differentiation. inhibiting vegf suppresses angiogenesis and callus mineralization in animals. however, no data exist on systemic expression of vegf with regard to delayed or failed fracture healing in humans so far. methods: one hundred fourteen patients with long bone fractures were included into the study. serum samples were collected over a period of months following a standardized time schedule. vegf serum concentrations were measured. patients were assigned to groups according to their course of fracture healing. the first group contained patients with physiological fracture healing. eleven patients with delayed-or non-unions formed the second group of the study. in addition, healthy volunteers served as controls. results: an increase of vegf serum concentration within the first weeks after fracture in both groups with a following decrease within months after trauma was observed. serum vegf concentrations in patients with impaired fracture healing were higher compared to the patients with physiological healing during the entire observation period. however, statistically significant differences were not observed at any time point between both groups. vegf concentrations in both groups were significantly higher than those in controls. conclusıon: the present results show significantly elevated serum concentrations of vegf in patients after fracture of long bones especially at the initial healing phase indicating the importance of vegf in the process of fracture healing in humans. first, dsbls is applied to . cm proximal to most prominent point of medial malleol of tibia. the dsbls was inserted parallel to the joint surface in frontal and horizontal plane. after the dsbls is applied the selected nail is inserted. reamed imn is used for the tibias with narrow isthmus ( ). the success of di is checked following the insertion of nail with set screw on the dslbs. the unsuccessful attempts are repeated after the reason is removed. the di of tibias were successful and were unsuccessful at the first attempt. in unsuccessful cases, the nails were at the posterior ( ), anterior ( ) and lateral ( ) collum femoris fractures accounts . - % of all fractures. however it is very rare in children ( %). in this study we evaluated pediatric patients who were operated due to collum femoris fracture in terms of avascular necrosis and functional outcome. age of the patients ranged from to . there were seven girls and five boys. two of the patients were admitted to the emergency department due to a fall from height, therefore they had multi system trauma. the remaining ten patients had isolated collum femoris fracture. fractures was classified according to delbet classificaion; seven transcervical and five cervicothrochanteric. locking plate-screw fixation was applied to one patient, other fractures were fixed with two or three cannulated screws. open reduction was applied to four patients and closed reduction to eight. five of the cases were operated in the first h of the fracture, however the remaining seven patients were operated after the first h ( - days) due to late admission. range of motion of the hip joint was limited in only one patient who had polytrauma and operated after the first h. there were three avascular necrosis as acomplication. all of them operated after the first h and all the fracture types were cervicotrochanteric. open reduction was applied to two patients and closed reduction to one. pediatric collum femoris fractures are rarely seen in children but treatment is challenging and open to complications. fracture type, surgical methods, did not effect the outcome, but timing of surgery did. author to editor: in this study we discussed the outcome of pediatric collum femoris fractures, which is a very rare fracture in orthopaedic experience. surgical management of humerus shaft fractures is an increasing interest nowadays. we want to discuss the outcome of conservative, open reduction and internal plate fixation (or _ if) and intramedullary nailing (imn) methods in adults ( - years old). patients had conservative treatment with modified custom made sarmiento brace and of them had union with °- °of malunion. none of the nine have complains and the avarage union duration is weeks ( - ). one patients did not tolerate bracing and undergone surgery. patients had or _ if and had gone second operation for nonunion and had elonged wound drainage. all the fractures healed eventually with in weeks ( - ). no neurovascular complication was observed. patients had imn treatment and had delayed union up to months, had undergone reoperation with or _ if for non-union, had intraoperative fracture of elbow and had shoulder problems with impingement and rotatory cuff problems. avarage union duration was found weeks ( - ). surgical treatment is getting more popular for long bones nowadays. early return of work and social life, anatomic reduction, using no sling or such devices and easy follow up protocols are the facts that popularising the surgical management. but in our series, we had seen multiple types complications that are as high as they are mentioned in literature. with the experience of those patients that had been treated with in this year, conservative treatment methods have to be conserned firstly in suitable and tolerable patients for us. intoduction and objectives: correction of sagittal deformity is important in thoracolumbar burst fractures. the clinical maneuvers needed for reduction and the assessment of correction of the fractured vertebra is not well described. in this prospective series we used the length of the interspinous ligaments as reduction parameter. our aim was to evaluate the efficacy of this assessment technique in achieving good correction. methods: from to patients (m/f / , mean age . ) with unstable thoracolumbar burst fractures were treated by posterior fusion with a standard construct by a single surgeon. all patients were treated with segmental posterior instrumentation with two levels above and two levels below the fracture level fixation by means of pre-contoured rods and distraction technique. with these maneuvers the length of the injured level was tried to be equalized to the mean of upper and lower levels. anterior column was assessed by radioscopy. preoperative and postoperative radiographs were analyzed and local kyphosis (lk), farcy's sagittal index (fsi) and compression percentage (cp) were measured. results: the preoperative lk decreased from . °to . °, fsi decreased from . °to . °and cp decreased from to . . after a minimum follow-up time of years all patients continue to do well with no statistically significant decrease in these parameters. conclusions: assessment of thoracolumbar burst fracture reduction with pre-contoured rods and distraction technique can be made safely by intraoperative measurement of the length of the interspinous ligaments. case: an -year old lady was admitted in our emergency department with a neer -part fracture of the right proximal humerus caused by a fall. she was operated on and received a shoulder hemiarthroplasty. during cementation of the stem the patient became bradycard and acute respiratory arrest occurred. she was resuscitated, but eventually died h postoperatively. postmortem examination revealed embolic bone marrow occluding the pulmonary capillaries. comment: pulmonary embolus after upper extremity surgery is a rare complication. fatal pulmonary embolus is even more rare. when reviewing literature there is no previous case of fatal pulmonary embolus caused by fat emboli described. fat embolism syndrome was first described by zenker in , but its frequency today is still unclear. usually it presents as a multisystem disorder. the most often and most seriously affected organs are the lung, brain, cardiovascular system and skin. it is a self-limiting disease, therefore treatment should be mainly supportive. purpose: lack of knee flexion is a possible complication in severe femur fractures. two different techniques for the treatment of this problem were applied. materıals-methods: from to , patients with severely arthrofibrotic knees were managed with two different operative techniques. the mean age of the patients at the time of the operation was years. we recorded the clinical outcome of patient using judet quadricepsplasty with a follow-up of months, and of two patients using extra-articular mini-invasive quadricepsplasty and intra-articular arthroscopic lysis of adhesions during the same anesthesia session with a mean follow-up of months. all patients were evaluated according to the criteria of judet and the hospital for special surgery knee-rating system. results: the average maximum degree of flexion increased from °p reoperatively to °at the time of the most recent follow-up. according to the criteria of judet, the result was good for knees, and fair for one. the average hospital for special surgery knee score improved from points preoperatively to points at the time of the most recent follow-up. a superficial wound infection occured in one patient. conclusions: if you select the appropriate cases, the judet procedure and mini-invasive operation for the severely arthrofibrotic knee can be used to increase the range of motion and enhance functional outcome. purpose: floating knee and elbow injuries are complex injuries. the types of fractures, soft tissue and associated injuries make this a challenging problem to manage. we present the outcome of these injuries after surgical management. materials and methods: two patients with floating knee injuries(classified by blake and mcbryde) and one patient with floating elbow injuries were managed over an average of months. both fractures of the floating knee injury and the three fractures of the elbow injury were surgically fixed using different modalities. the associated injuries were managed appropriately. assessment of the end result used the karlströ m criteria after bony union. results: mechanism of injury was road traffic accidents in two patients (floating knee) and falling from height for one patient (floating elbow). there were associated injuries, patient was tipiia, patient was tipiib. both these patients had intramedullary nailing for femur fractures. patient had ilizarov external fixation for segmenter tibia fractures, patient had a proximal medial plate for proximal tibia fracture. patient had plates afıxed to all fractures.complications were knee stiffness and delayed union of femur in a patient (second operation required). the bony union time average from weeks for femur fractures, weeks for tibia, weeks for upper extremities. according to the karlstom criteria the end results was acceptable. the average elbow score was / (good). patients with tibial bio-screw fixation there is insufficient evidence from randomized trials to determine the optimal intervention in patients with displaced four-part fractures of the proximal humerus: head preserving surgery with problem to obtain and maintain reduction until bone healing, implant failure, avn of the head, ha with > % tuberosities related complications-resorption, displacement, rsa with high complication rate, moderate function due to restricted rotation and insufficient long-time follow-up. in our presentation we will discuss: • new rsa designs, which improve function and lessen complication rates • question of tuberosities fixation to rsa in proximal humeral fractures • literature overlook of rsa in proximal humeral fractures the goal of rsa is to minimize shoulder immobilization and to start functional rehabilitation immediately. indications are same as for ha + tuberosity osteoporosis and comminution + week or absent rc. decision for if, ha or rsa is often intraoperative. tuberosities fixation is debatable (prolonged immobilization, prosthesis dislocation). functional results are more consistent than in ha, but complication rate is higher (it may be lowered by new prosthesis designs). frequent ct scanning due to incomplete -view x-ray imaging of the cervical spine background: conventional c-spine imaging is still widely used, despite increasing replacement by ct scanning. the aim of this study was to analyze the frequency of incomplete c-spine x-rays ( -view series) in blunt trauma patients. methods: during a -year period we analyzed the frequency and value of -view series of the c-spine. secondary we assessed the reasons for subsequent ct scanning after the -view series according to the following classification: inevaluability, incomplete -view series, evaluation of findings on -view series or for unexplained, persistent clinical symptoms. furthermore we evaluated predictors for incompleteness. results: c-spine injuries were diagnosed in blunt trauma patients ( . %). patients ( %) had their c-spine cleared based on the nexus criteria. patients were primarily evaluated with view series and patients primarily with ct scanning. within the population with primarily -view series ( %) were repeatedly incomplete and ( %) were inevaluable. in the major part of the incomplete -view series no apparent reason could be determined. however, the presence of clavicular fractures (resulting in incomplete radiographs in vs. % without a fracture; p < . ) and rib fractures ( vs. %; p = . ) were associated with incomplete -view series. conclusion: in more than a third of the patients primarily assessed with -view series, the results are incomplete or inevaluable necessitating ct scanning. therefore, the diagnostic value of -view series is questionable. in patients with clavicular and rib fractures -view series can be omitted and primary ct scanning is advised. the treatment of open distal tibia fractures is still discussed controversially and they are a great challenge for surgeons. it is still not clear if there should be initial stabilization with an external fixator or primary osteosynthesis with an intramedullary nail or plate. we retrospectively examined patients with ii°and iiia°open distal tibia fractures which were treated during the last years in our level one trauma center. we treated male and female patients with an average age of years. ten patients were treated with an external fixator and patients were treated with an intramedullary nail or plate osteosynthesis in acute surgery. the patients, firstly treated with an external fixator, were stabilized with reamed intramedullary nailing in eight cases and with locked plating in two cases after wound closure. there was no difference in the duration until bony union in any groups. fewer unplaned revisions (n = ) and no deep osseous infections were found in those patients treated with an external fixator in the acute phase of the injury. patients treated with a definitive osteosynthesis underwent unplaned revisions in six cases and developed deep osseous wound infections in four cases. we therefore recommend that initial treatment with an external fixator should be preferred and after consolidation of the soft tissue, the definitive stabilization should be done with a stabile osteosynthesis system. author to editor: this topic remains of a high interest among trauma surgeons, especially now, that angle stable intramedullary fixation systems run the market. fractures of the clavicle shaft are common and have been typically addressed to nonoperative treatment. but favorable results with the precontured anatomic plates are facilitating surgeons for primary surgical treatment. this study reports the surgical results of adult clavicle shaft fractured patients (age range - ) that had been operated with in last months. all fractures were displaced and none of them was open nor had neurovascular injury. avarege healing time was found weeks ( - weeks). all patients had anatomic reduction postoperatively. of the patients fracture site was grafted with dbm. of patients had sterile wound drainage which was lasted for weeks postoperatively (all were grafted with dbm), of them re-operated ( of them for early implant failure and early implant removal for plate disturbance) and one patient was operated for times ( of them was in another center) for early implant failure, nonunion,wound problems and neurovascular complications. of was healed eventually. of patients were satisfied with the treatment and had a full range of motion at final follow-up and were able to return to pre-injury occupational and activity levels. nonoperative treatment of displaced shaft fractures may be associated with a higher rate of nonunion and functional deficits. however, our study shows that surgical treatment also has high complication rates. there is currently considerable debate about the benefits of primary operative treatment of these injuries because it remains difficult to predict which patients will have these complications. platelet rich plasma (prp) is applied in orthopaedic, maxillofacial and plastic surgery with variable outcome. different growth factors and cytokines are stored in platelets, including platelet derived growth factor (pdgf), contributing to the potential positive effects of prp. the aim of our study was to investigate the properties of pdgf administered locally in a rat femoral non-union model. in our experiment a critical sized osteotomy was performed in the rat femur, which was filled with a spacer, inhibiting bone formation for a period of weeks. in a second operation this spacer was removed and the test item was applied into the defect. we compared the pdgf group (d = ng, c = lg/ml of pdgf in fibrin matrix) with the fibrin alone and blank control groups. four weeks after the second operation, specimens were analysed by x-ray, lct imaging and histology. in group pdgf we found a lct confirmed union in of specimens and the lct evaluated bone volume was median . mm (q = . / q = . ). in the control groups there was a bony bridge in of fibrin and in of blank specimens. the bone volumes were median . mm (q = . /q = . ) fibrin and median . mm (q = . /q = . ) blank, respectively. we did not find a strong tendency for new bone formation in the group treated with pdgf. in our model we observed even a tendency to inhibit bone regeneration for pdgf. introduction and objectıves: hand traumas are one of the most common encountered complex traumas. closing the defects on either dorsal or palmar side of the hand is sometime difficult because of limited local tissue and to provide a tissue the tendon glides underneath. in spite of high risk of donor side morbidity and sacrificing a major artery of the hand, radial forearm flap is the most frequent choice to close the defects at this region. method: in a year time, five patients with severe hand traumas who admitted to our clinic, treated with perforator based three radial artery and two ulnar artery adipose-fascial forearm flaps. the adipose-fascial island flap was raised on one or two of these perforators without sacrificing a major vessel.the flap was transposed to defect region and covered with stsg. in all five patients' donor side was closed primarily. results: the biggest flap size was · cm. there was no flap loss except one patient who had partial flap necrosis and it healed secondarily. the donor side was healed uneventfully in all the patients. there was no tendon adhesion. conclusıon: perforator based radial or ulnar artery adipose-fascial flap is a safe and reliable method for closing defects on the hand. it has both less donor side deformity and fascial component of the flap provides better tendon gliding and less tendon adhesion. however, it requires more experience to raise adipose-fascial flap. introduction and objectıves: one of the most common causes of the lower extremity defect in adult is a road traffic accident. the most challenging issues is to close the defect on the / of lower extremity because local tissue is very limited and mostly damaged due to high energy injury. we investigated the difficulties of how we close the defect on one third of the lower extremity particularly in children, in our unit. method: in a year time, patients under years old admitted to our unit. all patients had gustillo iiib injury and the biggest size of the defect was · cm. one patient had different lesions on the heel the other was on the anterior aspect of tibia. after radical debridement, the wound closed with alt free flap with in first week of admission. different defects on a lower extremity were closed with alt and vastus lateralis muscle free flap with a single pedicle. result: the biggest flap size was · cm. an average pedicule length was . cm and the diameter of the vessel was . cm the average operation time was h min. one flap had partial necrosis and healed secondarily. they had uneventful recovery and discharged on average postoperative days. conclusıon: in children even less than years age, one of the good and suitable options for closing the defect on the one third of the lower extremity is alt as a free flap. stable odontoid fractures can be treated with external immobilization using, e.g., a philadelphia collar (pc) or a halo thoracic vest (htv). it is important to delineate the capacity of both orthoses, halo and philly, for immobilization of the atlantoaxial complex (aac), e.g., for their use in odontoid fracture care. in this in-vivo biomechanical comparison volunteers (mean age = . ± . ) were subjected to flexion-extension radiographs immobilized in a modified htv and a pc. radiographs were analyzed for the segmental rotation angle of c - in sagittal plane (sra c - ) and the absolute rotation angle of c - (ara c - ). separation angles (rsra c - and rara c - ) were calculated from flexion-extension views. concerning restriction of subaxial sagittal plane motion, the htv was more effective than the pc. the difference for the rara c - between the pc (mean . °) and htv (mean . °) yielded significance (p = . ). but, concerning restriction of flexion-extension at the aac, there was no statistical significant difference for the rsra c - between the pc and htv (p = . ). pc (mean . °) was superior to the htv (mean . °) in restricting sagittal motion at c - . in comparison to normals atlantoaxial motion was restricted by . % (pc) and . % (htv). the current study demonstrated that there was no significant difference in restriction of sagittal motion at c - between the pc and htv. in light of the current biomechanical data and a selected review of literature it is concluded that the use of a pc is sufficient for the treatment of stable odontoid fractures. introductıon: although most ankle injuries are associated ligamentous structures, some types of fractures mimic to ligamentous sprain and misdiagnosed as well. most of the ankle sprains undergo radiographic examination and some of type fractures easily are missed even x-ray. the aim of this study is to evaluate the missed talar neck fractures and to emphasize the missed fractures. materıals-methods: misdiagnosed cases were included in the study. average age at the time of trauma was ( - ). all cases evaluated prospectively. if the patients had ankle sprain and their initial x-rays show no evident of fracture, they were involved in the study. the diagnosis of the fracture was figured out by control x-ray, ct scan and mri (except case). all patients were evaluated by the scoring system of american orthopaedic foot and ankle society (aofas introductıon and objectıves: treatment of proximal humeral fractures remains controversial, because of complexity of this kind of fractures. the purpose of this study is to present our first experience using angular stable fixation in and part proximal humeral fractures method: in last mounts we treated patients with this method, men and women (mean age ). anterior approach was performed in every case (mis technique in two cases), and every patients underwent to early rehabilitation. periodical clinical and radiographic control were performed. results: short term results are good with satisfaction of the patient, no pain and acceptable range of motion. we have case of deep infection that need revision surgery and antibiotic treatment. preoperative diagnosis of appendiceal diverticulitis is rare. the incidence of appendiceal diverticulitis ranges from . to . %. % of the diverticulitis of colon cases appear above years of age, and they are mostly in the left colon. case: a year-old male, who had a -year history of episodic right lower quadrant abdominal pain was admitted to the surgical emergency department for worsening of his complaints. the physical examination was only notable for right lower quadrant abdominal tenderness. laboratory findings was normal. on ultrasonography examination signs of acute appendicitis was noted. as the radiological findings did not match with the clinical status of the patient, he was followed up. later, acute abdominal symptoms appeared, and the patient was admitted to the operating theatre. two cm long nodules were seen on the appendix preoperatively. appendectomy was done. the patient was discharged on the first postoperative day. the histopatological examination revealed acute appendicitis signs and two mm long diverticula one of which is inflamed in the middle and the other in the distal part of the specimen were reported. conclusıon: the most common cause of acute appendicitis in adult population is fecaloid. lymphoid hyperplasia, carsinoid tumors, mucosel, parasites, fruit and vegetable seeds are other causes. although appendiceal diverticulitis is rare, clinicians should be aware of its occurrence and tendency for appendiceal perforation. introduction and objective: traumatic intracranial hematoma is the most common complication of the head injury requiring emergency intervention. as most of them are located supratentorially, they can be seen less frequently in the posterior fossa. this study aims to evaluates the clinical, radiological and surgical aspects of traumatic posterior fossa hematomas in patients who were treated at our center. methods: the records of patients with of traumatic posterior fossa hematomas that had been treated at our center between and were reviewed. results: of the cases, had cerebellar hematomas and had epidural hematomas. fall was the most common cause, followed by animal kick, assault and traffic accident. diagnosis and management decisions were determined by cranial computed tomography scans. surgical intervention was performed in cases. the outcome was good in patients. three patients died who had low gcs at admission and additional cranial lesion. conclusions: patients with occipital trauma should be evaluated immediately using cranial computed tomography scans. early diagnosis of traumatic hematomas and prompt surgical intervention in those having mass effect provide good results. introduction: transcranial stab wounds made with a knife mostly produce a classic slot skull fracture and underlying tract hematoma, and often cause severe neurological deficits. an unusual case with combined pareses of oculomotor and trochlear nerves due to penetrating stab wound to the brain is presented. methods: a -year-old boy was admitted to our clinic after an altercation that resulted in the patient sustaining stub wound to his head. results: he was conscious. neuro-ophthalmic examination showed that the left eye had limited adduction, supraduction, and infraduction, incomplete convergence and left sided ptosis with dilated pupil. an emergency computed tomographic scan of his brain was obtained, which revealed a left slot fracture at the squamous portion of the temporal bone of the anterior cranial fossa and a frontotemporal intracerebral stub tract hematoma. he underwent emergent surgery. fractured bone pieces and lacerated brain tissue were removed. neurological deficits remained unchanged at months follow-up. conclusions: cranial nerve injury related to the knife wound to the brain is very rare. the penetration site, depth of penetration and trajectory of the object are important in occurring of this injury. prognosis seems to be poor in these cases. introductıon: large number of knee x-rays are done incidentally for patients presenting with knee trauma in accident and emergency. using only one lateral view knee x-ray as a screening tool would reduce the cost by % as per a. verma et al., an interesting proposition. method: we investigated the validity of lateral view knee x-rays alone as a screening tool for detecting fractures around the knee in acute knee trauma. randomly picked x-rays were reviewed. the ap and lateral views were interpreted by a consultant radiologist and the findings used as gold standard for the study. the lateral views alone were independently interpreted on two different occasions by the (a) radiographer (b) emergency nurse practitioner accident & emergency (c) middle grade doctor accident and emergency (d) consultant orthopaedic surgeon. results: there was significant inter observer variation in sensitivity which ranged from to % with the highest sensitivity being achieved by the radiographer. the specificity was generally high with a range from to %. though there was a high validity in the case of the radiographer the sensitivity for the other observers was low. conclusıon: though there could be a significant saving in terms of resources and unnecessary radiation by doing lateral views alone as opposed to the routine ap & lateral views as first line x-rays, we do not recommend using the lateral views alone as a safe screening tool in knee trauma because of high inter observer variation in sensitivity. tk gullett, charalambous p. charalambous, ajay sahu, matt j. ravenscroft stepping hill hospital, stockport, uk introductıon: in distal biceps tendon ruptures, re-attachment to the radial tuberosity should ensure an adequate tendon to bone surface contact to achieve a sound repair and fast tendon to bone healing. method and technique: we are describing a l-configuration reattachment of distal biceps tendon rupture, using a single anterior transverse incision at the cubital fossa crease. each pair of sutures from the most distal anchor is passed through the distal part of the tendon. one strand of each pair is passed in a zig zag fashion through the tendon whilst the other strand is simply passed straight through the tendon in a posterior to anterior direction. the four strands of the proximal anchor are passed so that they form two mattress sutures through the proximal part of the tendon. tightening is then performed in a specific sequence with initially pulling on strand a and b to bring the tendon down to bone and then tightening these to the corresponding suture strand of their pair. the two pairs of sutures are then tied to each other. this second anchor tightening ensures that the tendon is brought down onto the bone in an l configuration increasing the contact surface area between tendon and bone. results: we have used this technique in patients till now with excellent results and no re-ruptures. discussion: our technique is simple to perform and provides a sound repair with a large surface area of contact between tendon and bone. results: out of a % (n = ) response rate, respondents ( male, female) were included in the study. we excluded people with previous hip, knee or back problems. in our study, the symptom scores that is lysholm, oxford and visual analogue scale for pain and function did not show any significant decline with age. on the other hand, the scores measuring activity levels that is tegner and ucla scales declined significantly with increasing age. our normal scores were far ahead of age-matched post operative scores following total knee replacement. there was no difference between males and females. the symptom scores declined with increase in medical problems. conclusıon: our age matched scores were superior to post operative total knee replacement (tkr) scores from the njr. this furthered our motive to create a set of reference knee scores in the normal population which could be used by other studies to compare their results and help improve postoperative outcomes. mesenchymal stem cells (mscs) are multipotent stromal cells that have extensive proliferative potential and the ability to undergo multilineage differentiation. traditionally, osteogenic differentiation of mesenchymal stem cells has been studied in cells isolated from bone marrow and iliac crest. however, these harvest techniques are associated with several problems, including donor morbidity, pain, and limited amount of cells. only a few years ago, adipose tissue has been identified as another source of mulitpotent mscs, which are referred to as adipose derived stem cells (adscs). the aim of our study was to provide a comparative analysis of primary osteoblasts from the iliac crest and osteogenic differentiated mscs from adipose tissue, using osteoblast-specific protein expression. in patients the cells were differentiated into the osteoblast lineage using osteogenic medium (adobs). primary osteoblasts were isolated from iliac crest specimens in patients undergoing osteosynthesis with spongioplasty (female: , male: , mean age ± . ). phenotype marker expression of osteoblast-specific proteins osteocalcin, alkaline phosphase, type i collagen, and cbfa- (runx- ) was analyzed up to days following incubation using rt-pcr, western blot, and immunocytochemistry. additionaly, the following surface proteins of adscs were analyzed: nucleostemin, cd , cd , cd , cd , cd , and cd . rt-pcr analysis revealed that the non-differentiated adscs contained different types of stromal cells with a large variety of cd marker expression. surface protein expression (cd) did not differ significantly in cells isolated from either fat tissue or bone. author to editor: saved by lookus. background: at our department, classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (dcs) scoring system have been used to determine the efficacy of the treatment strategy in trauma patients. cases and methods: we examined out of hepatic injury patients, excluding cardiopulmonary arrest cases. the present study was undertaken to establish a valid strategy for the treatment of hepatic injury, and further improvement of the survival rate was evaluated based on the grater and equal of grade iv [organ injury scale (ois)] hepatic injury necessitating emergency room laparotomy. result: interventional radiology (ivr) treatment cases were all stable or responder patients and all survived with effective hemostasis. transient responder or non responder patients that needed hemostasis were treated by emergency laparotomy, and all the cases that eventually expired needed dcs. the mean injury severity score (iss) was . and the mean probability of survival (ps) was . , and hemostasis treatment was started within a mean of . min, yielding a survival rate of . % in the cases with grater and equal grade iv (ois) liver injury that needed emergency room laparotomy. conclusion: our criteria for deciding the therapeutic strategy based on the response to the initial fluid resuscitation seemed to be useful from the viewpoint of hemostasis for liver injury. the key to securing quality regional trauma care is to designate a trauma care hospital as a trauma center and to transport severely injured patients to the center as rapidly as possible. author to editor: we show that our classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (dcs) scoring system is very effective for liver injury strategy. fractures of the proximal femur are, more than ever, an important challenge in the field of traumatology. the gamma-nail, a combination of advantages of the sliding screw with the intramedullary nail, represents an efficient technique in the management of these fractures. a series of fractures of the proximal femur in which this nail was used is reported. the average age of patients was . years (range - years). . % ( patients) of the cases were female. the average duration of the operation recorded was min. in all cases closed reduction was achieved. the mean healing time was . weeks in . % of the cases. there were two cases of delayed consolidation but no pseudarthroses. postoperative complications occurred in cases ( . %). one case of migration of the proximal screw was the most important complication. the most frequent complications ( cases) were seromas and hematomas of the surgical wound, which resolved satisfactorily in all cases. superficial infections ( cases) also evolved favorably, once the appropriate antibiotic treatment had been instituted. no breakages or failures due to implant fatigue were seen. the patient's recovery after suffering the fracture and the operation was evaluated and the % ( patients) recovered their previous walking ability. the overall mortality was . % ( patients) with of the deaths occurring while in hospital. in conclusion, this preliminary study has shown that gamma-nail can be safely used by the average surgeon in the average hospital to treat a common and sometimes difficult fracture. valerio ranieri, loris trenti, aldo rossi, antonio manenti departement of general surgery, university of modena and reggio emilia, modena, italy a years old nigerian woman, at the end of the nd pregnancy, was submitted to a caesarean section for uterine atony. post-operative thrombo-prophylaxis was given. from pod , fever, abdominal pain and increasing tenderness in the right lower quadrant with leucocytosis appeared. ultrasonography showed only small amount of fluid in the douglas pouch, while a contrast-enhanced ct and a rmn revealed a dishomogeneus cylindrical mass of . cm in diameter extending from the right parauterine space towards the duodenum, suggestive of thrombosis of the ovarian vein. laparotomy followed: uterus, ovaries, appendix and bowels were normal. after mobilizing the right colon the ovarian pedicle appeared enlarged and firm; it was dissected, starting from the vena cava, and completely excised preserving the adnexa. post-operative course was uneventful. histology confirmed a suppurative thrombophlebitis; the haematological study ruled out any coagulation abnormality. the patient completed a months low-molecular-weight-heparin treatment. ovarian vein suppurative thrombophlebitis can seriously complicate a caesarean section, till to require a surgical treatment. the imaging is essential for a prompt diagnosis. purpose: to prospectively study the mechanism, distribution of injury, and outcome of patients hospitalized with camel bite injury. methodology: all patients admitted to al-ain hospital with a camel bite were prospectively studied over years (october -october . mechanism of injury including behavior of the camel, distribution and severity of injury, patient's demography, and outcome were studied. results: all patients were males having a median (range) age of ( - ). almost half of them were pakistani. twenty-five were camel caregivers while five were camel riders. seven patients were raised up by the camel's mouth and thrown to the ground while the other patients were only bitten. majority of the injuries were in the upper limb ( ) followed by the head and neck ( ). / upper limb injuries had associated fractures. two patients who were bitten at the neck were admitted to the icu. one of them died due to massive left-brain infarction and the other had complete quadriplegia due to spinal cord injury. the median hospital stay was days. one patient died ( %). conclusıon: the behavior of the camel is occasionally unpredictable and the canine teeth of the camel, which are long, can cause severe penetrating trauma despite the small puncture on the skin. care should be taken when handling the camel. author to editor: dear colleague: this is the only prospective clinical study of camel bites in the literature that took us years to collect. the data is very unique and is of great interest. fikri abu-zidan gastrointestinal cytomegalavirus infections occurs predominantly in immunocompromised patients.involvement of the gastrointestinal tract in acquired immunodeficiency syndrome (aids) patients is frequent. however the prevalence of cytomegalovirus appendicitis is exceedingly rare. case: a year-old male infected with the human immunodeficiency virus, who had chronic abdominal pain with subsequent development of acute right lower quadrant tenderness was admitted to the surgical emergency department. his physical examination revealed no other finding than a mass in the right lower quadrant. his abdominal ultrasonography and abdominal ct revealed a plastron appendicitis. so he was hospitalized for medical treatment and discharged after days of treatment. his control abdominal ultrasonography and ct at the second month showed that plastron appendicitis persisted, therefore the patient was rehospitalized. he was discharged after days of medical treatment. after months the patient experienced severe abdominal pain. appendectomy was performed and histopathogic examination revealed a cytomegalovirus infection. the problems related to diagnose cytomegalovirus appendicitis and therapeutic management of cytomegalovirus infections are discussed. conclusion: aggressive use of ultrasound and abdominal computed tomographic scanning, along with early surgical intervention, is recommended. introduction: spontaneous intramural hematoma of intestine due to anticoagulan therapy is an unusual reason for acute abdomen. the first symptom is usually severe abdominal pain, nausea and vomiting. the most useful radiographic methods is computed tomography. the treatment approach is conservative and surgical. we present four patients treated our clinics due to intramural hematom. two patients are treated surgically and two patients are treated conservatively. material and method: we carried out four patients diagnosed and treated for intramural hematoma of small intestine between and years in haydarpasa numune training and research hospital second surgery department. we examine in this patients age, sex, etiologcy, hematologic parameters, the treatment approach (conservative and surgery), hospitalization times. results: the mean age of the patients was . years (range - ). all patients were male. the etiological factor was warfarin treatment due to aort valve replacement in three patient and ischemic cerebral disease in one patient. laboratuary parameters were elevated leukocyte counts in all patients. two patients was treated by surgical treatment due to intestinal obstriction and ishemia two patient was treated conservatively (nasogastric decompression and total parenteral nutrition). median hospitalization time was . day ( - ). discussion: when patients using anticoagulan therapy applied to emergency unit with abdominal pain, physicians must remember intramural hematoma as reason of acute abdomen. first choice is conservative treatment however cases of acute abdomen with intestinal obstriction and ischemia require surgical intervention. introductıon: motorcycle accidents continue to be a source of severe injury. the joy and exhilaration of riding motorcycles brings with it the risk of morbidity and mortality associated with these accidents. case: it concerns a -year-old man that in / / entered the emergency room after suffering a motorcycle accident. at the admission he had pain, swelling and deformity of the left knee. radiographs showed tibial plateau fracture type vi of schatzker. he was submitted to surgical treatment with open reduction and ostheosynthesis with liss plate and was orientated to rehabilitation. six months after, the fracture was healed in correct alignment, had normal gait, normal knee range of motion and returned to work. eight months after surgery he suffered another motorcycle accident with left leg trauma, radiographs showed a supracondylar femoral fracture type .a ao-asif and diaphyseal tibial fracture below the plate. he underwent surgical treatment with open reduction and osteosynthesis of the supracondilyan femoral fracture with lcp plate, extraction of the liss plate and ostheosynthesis with diaphyseal lcp plate. eleven weeks postoperatively, he was able to walk without crutches. five months after had normal range of motion of the left limb and was working. conclusıon: tibial plateau fractures are serious injuries and stable fixation without compromising the soft-tissue envelope is often difficult but with the liss plate we can achieve fixation of an associated metaphyseal/diaphyseal fracture component with minimal approach. multiple consecutive fractures are an important source of limb deformity and impairment, which we could prevent in this case. introduction: the optimum management of non-united humeral diaphyseal fractures remains unclear. a number of implants are available utilising varying operative philosophies and balancing operative complication risks. we present two cases of humeral shaft non-union treated with an intramedullary compression nail, a technique which is previously unreported. cases: case : a year old male with a closed fracture of the humeral diaphysis ( -a ). initial failed open reduction and internal fixation with an anterior placed . mm dynamic compression plate (dcp) was subsequently revised to a posterior . mm dcp plus bone graft months later. one year post revision, the fracture had failed to unite and was referred to the senior author. he underwent a stage reconstruction with the t humeral intramedullary nail in compression mode. at month review the fracture had united and at years postoperatively he had full range, pain free shoulder and elbow movement. case : a year old female with a closed diaphyseal humerus fracture ( -a ) treated conservatively in a u slab and functional brace developed a mobile, painful non-union. she underwent the same procedure as above and at months the fracture had united. she was pain free and had full range of elbow movement. shoulder movement was restricted due to co-existing glenohumeral osteoarthritis. conclusion: key tenets of fracture and non-union surgery include the ability to obtain stability and compression. this paper describes the first reported use of an intramedullary nail in compression mode for humeral diaphyseal non-union. fingertip amputations are the most common type of amputation injury in the upper extremity and they are important because of an often disproportionately long period of convalescence. different surgical procedures are available for reconstruction, but none is absolutely satisfactory. twenty-two cases ( patients) of fingertip amputation have been treated by primary skin closure using the v-y plasty (tranquilli-leali). there were men and women. the average age was . years. the procedure was carried out under regional anaesthesia using a tourniquet. all devitalized tissue was excised and the bone was smoothed. a triangular flap with a distal base was developed. the width of the base should be the same as the amputated edge of the nail or the nailbed, and the length should be a little longer than the width. the flap was mobilized and sutured to the nail or the nailbed. finally the volar gap was closed. the average follow-up period was months, ranging from to months. all of the flaps survived and achieved normal or adequate two-point discrimination. two patients had some loss of distal interphalangeal joint extension and five patients had cold hypersensitivity. rapid return to work was possible in most cases. the technique is simple and presents an excellent method for fingertip reconstruction in allen type i, ii and iii injuries. bilateral anterior shoulder dislocation is rare, and his aetiology is via various traumatic insults, atraumatic occurrences, and through extreme muscular contractions like epilepsy. in epileptic seizures is more common to occur posterior bilateral dislocation. the aim of this work is to describe a rare case of anterior bilateral shoulder dislocation after a convulsive crisis. it concerns a case of a -year-old male, with alcoholism history, who entered the emergency room in / / with a generalized tonic-clonic seizure. after, he had bilateral shoulder deformity and swelling. radiographs demonstrated a bilateral anterior shoulder luxation and bilateral greater tuberosity fracture. the dislocation was reduced and both shoulders were immobilized. month later, radiographs showed bilateral reduction maintenance and bilateral greater tuberosity fracture deviation. the patient had extremely restriction of active and passive ranges of motion in both shoulders: in the left had º of active external rotation and º of abduction; in the right º of active external rotation and º of abduction. at this moment surgical procedure was done with bilateral open reduction and osteosynthesis with ''phylus'' plate and was orientated to physical rehabilitation. at the month follow up, he had significantly improved both shoulders range of motion, and returned to the normal daily activities and months later returned to work. displaced fractures of the greater tuber-osities after shoulder dislocation may result in motion limitation and functional disability. open reduction and stable fixation allows for early passive motion of the joint and early return to activities of daily living. introduction and objectıves: direct inoculation, hematogenous spread or underlying medical illness which can predispose a patient easily for osteomyelitis are the causes of a vertebral infection. this case report represents a vertebral osteomyelitis of a patient seen after spine trauma. case: an year-old girl was admitted to our out-patient clinic with a history of progressive back pain. her inflammatory markers were high, physical examination revealed only spinous tenderness to palpation and she had a spine trauma history when she was at nine. radiological evaluation demonstrated lumbar and mild anterior compression, an incomplete intervertebral fusion and endplate irregularities with an intact spinal cord. bilateral sequential transpedicular drainage from l vertebra was performed without any complication. she has a pain free course of months with negative inflammatory markers. conclusions: the management of vertebral osteomyelitis is often challenging and in case of continuing pain and progressive kyphosis, surgical treatment is indicated. beside aggressive surgical procedures, minimally invasive techniques can be an option for the treatment of such cases. . instead of standard screws with diameter of mm using screws with diameter of . mm . instead of , diameter cannulated tunnel using , mm cannulated tunnel results: in use of this new modified method the time of surgery is shorter, the percutaneous surgical technique is simplified, the blooded lose is minimalizied, the surgery can be performed by two persons: the surgeon and the scrub nurse and few special instruments required. conclusion: based on our results we recommend this modified minimal invasive percutaneous osteosynthesis in case of garden iii femoral neck fractures, in garden iv one, especially immobile patients and patients with poor general conditions (asa score iv). introduction: pelvic fracture is one of the serious skeletal injuries, resulting in substantial mortality. the large amount of kinetic energy necessary to fracture the bony pelvis often leads to concomitant thoracoabdominal injury. pelvic fracture and combined injuries need effective initial resuscitation. however, it is hard to predict the mortality due to the complexity of multiple injuries. therefore, the introduction and objectıves: in this study, we aimed to investigate the distribution of the diagnosis in patients who underwent urgent surgical intervention in the operating room. methods: distribution of the diagnosis in patients who underwent an orthopaedic urgent intervention in the year are evaluated retrospectively from the medical records. results: patients with orthopaedic complaints [ male, female; mean age . ( - ) years] were operated on urgently in the year . patients ( shoulder, hip and lisfranc dislocations) had traumatic acute joint dislocation in which closed reduction was unsuccessful without general anestesia, one had supracondylar humeral fracture, one had distal femoral epiphyseal type ii fracture, one had isolated radial shaft fracture with neurovascular injury, one had t spinal fracture dislocation with paraplegia, one had type iii acromiaclavicular ligament rupture, one had quadriceps muscle laceration due to knife wound, one had tendo calcaneus rupture and one had patellar tendon rupture with medial meniscal injury due to knife injury. the mean time from admission to operation was found . h (range - ). conclusıon: it was concluded that the closed reduction of joint dislocations under general anestesia were the major group in orthopaedic urgent intervention. why ankle should be reduced urgently? shahzad sadiq, tariq mahmood worcester acute hospital, worcester, uk fracture dislocation of ankle is common orthopaedic emergency. it is paramount that to avoid soft tissue damage, the ankle is reduced as soon as possible. despite all efforts ankle dislocations could lead to significant blister formation. we reviewed a case series in which ankle joint was reduced with external fixator until skin healing methods: the cases who were admitted to our emergency department between august and and were exposed to traumatic extremity amputation were studied. the medical records such as age, sex, education level, occupation, the way trauma occurred, the affected anatomic zones, performed interventions and hospitalization duration parameters were evaluated. results: the data of subjects were evaluated in this study. mean age was , the rate of female/male was / . . there was a reverse correlation between the education level and occurrence prevalence. . % of the cases were laborers, . % various free self employed and . % were farmers. according to their occurrences, industrial accidents . %, pinching finger in the doorway . % and home accidents . % formed the first three rank. hand finger amputation was . %, toe amputation . % and others were . %. while cases were treated at the emergency service and discharged, cases were referred to related clinics. five cases were referred to other centers and two subjects willingly left our clinic. the mean length of stay was . days. conclusıons: traumatic amputation concerns particularly the young and the people in active work life. since the majority of the cases have hand injuries, they are striking because they cause workforce lose in addition to cosmetic and functional defects. introduction: distal radius fractures are one of the most common injuries regardless of age group. due to their localization they pose a serious threat to the fine wrist movements. for most of the patients the perfect functional result is of a vital importance. open reduction and stable osteosynthesis may help to produces desired outcome. methods: we have compared distal radius radius fractures treated with open reduction and stabilization with . mm synthes lcp and treated with synthes , mm lcp. we have compared the functional results, neurological damage and patient comfort with questionare form. measurements from x-rays were also compared. we have included patients of age between and years, with distal radius fracture. of them with intraarticular fracture. results: intraarticular fractures of distal radius treated with synthes . mm lcp show better functional results compared to synthes . mm lcp. there is no relevant difference depending on used material in extraarticular fractures. conclusıons: we recommend the use of synthes . lcp for intraarticula distal radius fractures for its greater diversity and abillity to stabilize even a small fragments. introduction and objectives: surgical treatment of fractures by using resorbable implants is not too expanded alternative to classical steel or titanium implants. indication for using are intraarticular and periarticular fractures at first of all. the most advantage is no necessary of implants extraction. another one is propagation of load callus during the degradation of material. possibility of making profitable ct and nmr is indispensable.in this paper author presents experiences with using of resorbable screws. methods: at our department there are resorbable cortical screws . , . and . mm bionx made from polyamide polymer with minimal stronghold for weeks and total absorption after years. this screws are determinated for cancellous bones in periarticular areas. we are using them in cases of fracture posterior wall of acetabulum, distal humeral intraarticular fractures, radial head. it can be used for treatment children¢s fractures too. the follow up is same like in ''classical'' osteosynthesis. results: there were no infection's complications, no malfunction screws in our group of patients. the postoperative and ambulatory treatment including physiotherapy was same like in group with classical osteosynthesis. the only one failure was during surgery -we have wraped screw four times because of insufficient pre-drilling and using too much power during insertion. we could recommend resorbable screws as suitable alternative in some type of surgical treatment intraarticular fractures at most. the indication have to be well look over and way of using has to be well understand as well as careful manipulation during surgery. the benefits are no metal material, no extraction in future and profitable ct and nmr. heart valve lesions in blunt cardiac trauma -mechanism, diagnosis and treatment robert lipovec, granc gregorcic department of cardiac surgery, university clinical center maribor, maribor, slovenia because of the variation in diagnostic criteria, cardiac involvement in blunt chest trauma is estimated at approximately %. in contrast to cardiac contusion which is often difficult to validate, traumatic valvular lesions are usually associated with some degree of hemodynamic impairment. patients with positive findings on clinical examination, ecg, cxr and troponine should be screened for valvular lesions by transthoracic echocardiography. blunt injury to cardiac valves can lead to progressive ventricular failure often requiring surgical management. patients with structural damage to the left sided heart valves usually require immediate surgical repair, while right sided valvular lesions can be managed in a delayed fashion. the management is based on type of structural injury and hemodynamic compromise. valvular reconstruction is usually attempted, if possible. the paper outlines historical perspective, mechanisms of injury as well as our experience with diagnosis and treatment of traumatic valvular lesions. two case reports are presented. one patient had a traumatic mitral chords rupture and the other had a tricuspid papillary muscle rupture. both cases were diagnosed immediately and surgically corrected. the ruptured mitral valve was urgently replaced. the tricuspid valve was repaired by delayed surgery. patients in al-ain city, united arab emirates . %, respectively. only the difference between group iia and iib was found to be statistically significant. dıscussıon: rib fractures increase the pain and have a negative effect on breathing during postoperative course. ineffective breathing may cause athelectasis, fever and infection which is associated with increased morbidity. the incidence of rib fractures are higher in anatomical resections in whom the thoracic cavity should be opened widely. a longer incision and step to step opening of the thoracic cavity may decrease the incidence of this undesirable complication. objectıve: this case report describes a surgical method to treat multiple rib fractures by using arch bars. case: a year old male patient was admitted to emergency unit with bilateral flail chest, bilateral multiple rib fractures, bilateral hemopneumothorax and pulmonary contusion. the patient was initially tachypneic and had a shallow breathing. because of the respiratory arrest he was intubated. physical examination revealed crepitation from subcutaneous and oseeous tissues especially on the left hemithorax. after left sided tube thoracostomy cc hemorrhagical drainage and massive air leak was observed. ct scan showed bilateral rib fractures extending from the first to the eleventh ribs, bilateral hemopneumothorax and bilateral pulmonary contusion (picture , ). therefore tube thoracostomy was also administered on the right hemithorax and cc hemorrhagical drainage and air leak occured. because of the thoracic deformity, persistant hemorrhagical drainage and air leak from the left hemithorax, the patient underwent exploratris thoracotomy and damaged pulmonary parenchyma was repaired. multiple rib fractures which damaged the thoracic wall stability severely were fixed by using arch bars (picture ). the patient required mechanical ventilation for days postoperatively. the latest ct scans of pulmonary parenchyma and thoracic wall after arch bar application are seen in pictures and . conclusıon: in this case the conventional rib fixation procedures with kirschner wires or plate plaques could not applied because of multiple small fractured segments. despite various materials suggested in literature, the use of arch bars to repair flail segments with multiple small pieces are not mentioned. tariq siddiqui, kimball maull the trauma center at hamad, hamad general hospital, doha, qatar introductıon: intrathoracic fluid following blunt chest trauma is almost always blood, and derangement in the patient's cardiorespiratory status is directly related to the volume of blood accumulated in the pleural space and the associated compression of pulmaonary parenchyma. tension chylothorax in the setting of bilateral chylothoraces is a rare cause for such a condition. a year old man fell from a height of three meters and presented with back pain. examination disclosed abrasion and tenderness over the right paraspinal area. he was discharged home. four days later, he returned in severe respiratory distress -hypertensive, with rapid pulse, tachypneic and with peripheral cyanosis. there were no breath sounds on the right side and decreased air entry on the left, and bedside ultrasound showed fluid in the right chest. chest x-ray confirmed complete opacification of the right hemithorax and loss of the costo-phrenic angle on the left side. a right tube thoracostomy yielded , ccs of pinkish-white fluid with immediate improvement in cardiorespiratory status. computed tomography disclosed bilateral th and th rib fractures, spinous process fracture of the th thoracic vertebra and bilateral effusions. a left chest tube brought back ccs of additional similar fluid. diliatation of the cisterna chyli in the abdomen with collapse of the thoracic duct were confirmed by mri. conclusıons: post-traumatic tension chylothorax causing cardiorepiratory compromise is rare. in this report, the patient responded to chest tube decompression and dietary measures without complication. author to editor: this report is complimented by excellent illustrations, including ct and mri findings, showing the anatomy of the injury… conducive to poster display. introduction: blast lung injury (bli) is a unique injury rarely seen in the civilian population. our objective was to assess its severity, prognosis and associated injuries as compared to victims with chest wall trauma following explosions. material and methods: retrospective study of victims of the march terrorist bombings in madrid who were treated at the closest hospital. we compared the group with pure bli (bilateral infiltrates in a butterfly pattern, and absence of chest wall fractures) (group i) with that of patients with peripheral infiltrates and chest wall fractures (group ii). results: of patients included in the registry, ( %) had thoracic injuries. ( %) were included in group i, and ( %) in group ii. the mean iss in groups i and ii was of . ± and . ± . , respectively. among the critical patient population in both groups (n = ), those belonging to group ii were in need of a longer period of ventilatory support and had more ventilator-associated pneumonias. in group i, the most frequent associated injuries were tympanic perforation ( . %), º- º burns ( . %) and abdominal trauma ( %). in group ii, º- º burns ( %), followed by tympanic perforation ( %) and skeletal trauma ( %). one patient died in each group ( . vs. . %). conclusions: pure bli patients had a greater degree of anatomic severity, had more severe burns and abdominal trauma than patients with lung infiltrates and thoracic wall fractures. overall prognosis was excellent in both groups. aım: aim of the study was to determine the rate of injuries detectable by ultrasonography in patients suffering from blunt thoracic trauma. materıals-methods: this study include the patients suffering from blunt thoracic trauma who have not any pathological findings in routine radiological diagnostic procedures. ultrasonography of the thorax was prospectively performed in patients with blunt chest trauma additionally to the routine radiological diagnostic procedures. ultrasound findings referring to the rate of detection of fractures, pneumothorax, pleural effusions, lung contusions, haematomas of the lung and chest wall was performed. results: we studied consecutive patients suffering from blunt thoracic trauma who has any pathological findings in routine radiological diagnostic procedures. the findings detectable by ultrasonography were the following: pleural effusion %, haemopneumothorax %, haematoma of the chest wall %, contusion of the lung %. conclusıon: rib fractures and pleural effusions are commonly diagnosed by ultrasonography in patients with blunt thoracic trauma. this study showed that ultrasonography may have superiority to chest-x-ray in diagnosis of rib fractures, pneumothorax, haemothorax, haematomas of the chest wall and pulmonary contusions in blunt thoracic trauma patients. Ş adiye emircan , Ö zlem kö ksal , fatma Ö zdemir , halil Ö zgü ç department of emergency medicine, uludag university, bursa, turkey department of general surgery, uludag university, bursa, turkey aım: the purpose of this study is to define the epidemiologic properties of patients that have been subject to thorax injuries and general body traumas, analyze their condition when they are brought to our emergency department, to determine the correlation of physiological and anatomical risk factors with the mortality rate, and to ensure early diagnosis of severe trauma. methods: trauma cases that had been subject to general body trauma have been retrospectively examined in this study. epidemiological properties of the cases have been determined, their initial condition during initial admission to emergency department have been analyzed, and cases have been assessed in terms of mortality developments. survival probabilities and unexpected mortality rates have been computed using trauma revised score-injury severity score (triss) methodology. results: mortality rates was . %. univariance analysis revealed that hypotension, age, pathologic respiration pattern, blunt injury, accompanying injury, abdominal trauma, high injury severity score (iss), low glascow coma scale (gcs), revised trauma score (rts), triss were the factors affecting mortality. in logistic regression analysis, presence of blunt injuries, triss < , iss > and gcs < have been found independent prognostic factors. strongest factor indicating mortality has found to be triss. in presence of factors affecting mortality, patients with thorax trauma should be evaluated as being of high risk group and therefore diagnosis and treatment strategies must be aggressive. case analysis based on triss model shall further reveal the mistakes that may be made in patient care and may improve patient care. introductıon: penetrating thoracal and cardiac wounds are asssociated with high mortality. we aimed to present our experience in such cases. materıals-method: twenty three patients with penetrating thoracal stab injury, between and , were investigated retrospectively. gender, age, injured areas, extent of thoracal damage, accompanying organ damages and outcomes of these patients were evaluated. results: all patients, except one, were male with a mean age of . years (between and years). in patients penetrating abdominal injury accompanied thorax trauma and one of these patients died peripoeratively. patients out of thoracal trauma had an additional cardiac stab wound and half of them were only pericardial injury. one of these cases went into emergency coronary artery bypass surgery due to lad injury. only four patients required intensive care postoperatively and four patients were lost perioperatively all of which had additional cardiac injury. conclusıon: the overall mortality rate was %, but mortality of patients with additional cardiac stab injury was higher, with a rate of %. suspect of cardiac injury should be considered in patients who are injured close around cardiac area and one should intervene quickly both in diagnosis and treatment. introduction: abdomen and thorax blunt and penetrating injuries, common cases of emergency surgery, cause less complication with proper analysis and surgical intervention. material and method: we retrospectively evaluated patients operated due to thoraco-abdominal blunt and penetrating trauma in _ istanbul training and research hospital last year. results: median age was . ( - ) and all were male. patients were operated due to blunt abdomen in , penetrating abdomen injury in , abdomen and thorax penetrating injury in by general surgeons. abdominal exploration in ( . %) were negative laparotomy. background: we described a patient with dysfunctions of all the nerves and ruptured brachial artery and vein due to closed injury caused by spontaneously reduced dislocation of the elbow. case: a -year-old man fallen down onto his left elbow with small skin erosion and a large area with ecchymosis on the elbow presented. left radial and ulnar pulses were nonpalpable but no sign of acute ischemia was noticed. he had drop hand and could minimally make flexion, opposition, abduction and adduction of fingers. strength of fingers, wrist flexion and thumb adduction were weak. radiography was normal. emergent surgical exploration was performed with prediagnosis of severe closed soft tissue injury and vascular damage. brachial artery and vein had complete disruption with rupture of brachial muscle and the anterior joint capsule. elbow joint could be posteriorly dislocated. artery and vein were repaired with saphenous vein graft. median and ulnar nerves had normal appearance. at postoperative th hour nerve injuries showed complete recovery. he could have normal range of motion in the wrist and hand. sensorial examination was normal. he had a well perfused arm. conclusıon: spontaneously reduced dislocations of the elbow can be sometimes missed. large hematoma and neurologic dysfunction in closed injury of the elbow indicate severe trauma of joint also in case of normal bone structure in radiography. immediate diagnosis and operative treatment of brachial artery injury is mandatory. closed elbow dislocation and multiple nerve injuries may have good results with conservative treatment. we present the case of a y male, with his left lower limb severely damaged by a caterpillar vehicle. he was admitted in the er about min after the accident. he presented with exposed fractures of the femur and leg bones, extensive soft tissue and muscle damage, class iii shock, and an umbilical clamp in the exteriorized femoral artery in the thigh, placed by a fireman in site. the mess (mangled extremity severity score) calculated for this patient was . after the initial assessment in the er the patient was transfered to the or. he had a complete transection of the femoral artery and vein with a severe ischemic foot. despite the mess score, a vascular and bone repairs have been considered. two temporary shunts were placed in both femoral vessels (artery and vein) followed by external fixation of the femur and leg fractures. the definitive vascular repair of the artery and vein was made with autologous saphenous vein after the bone fixation. some damaged skin and necrotic soft tissues were removed, and the reminder skin was only proximated. the limb was functionally and anatomically preserved, with no obvious neurologic deficit, despite subsequent debridements and skin grafts. the authors concluded that in similar cases: introductıon: trauma is responsible for . million of death, % of them in young people. vascular injuries of the upper extremity represent % of all peripheral vascular lesions, the majority of them at the braquial artery. objectıve: report a case of chemical injury of braquial artery. methods: -year-old man was admitted in the emergency room with third degree sulphuric acid burn in the middle third of arm ( % of total body surface area). the radial and ulnar artery pulses were palpable. at the th day after injury, haemorrhage was noted and disruption of braquial artery was clear. a braquial-radial reversed long saphenous vein interposition graft was performed. after surgery palpable radial and ulnar pulses were present, without evidence of nerve injury. results: the chemical burns severity depends on the concentration, properties of the agent and the duration of skin contact. sulphuric acid causes coagulation necroses, with thrombus formation in the microvasculature. its corrosive properties are accentuated by exothermic reaction with water. its burns are more serious than those compared with strong acids, and, as observed in this case, it causes frequently third-degree injuries. besides this, it has the ability to cause continuing tissue destruction, from th hour to th day after injury. this fact could explain why there was no artery lesion at the admission but at the th day. conclusıon: sulphuric acid burn is potential devastating and tend to be prolonged in time, obliging to a continuous monitoring and multidisciplinary approach. introduction and objectıves: the medicolegal studies show that the most frequent mechanisms of the lethal major vascular injuries were stab wounds followed by gunshot wounds and blunt trauma. during the blunt traumas, simple lethal major vascular injuries without any fracture are seen rarely. we experienced a case of common femoral artery and vein transection as a cause of death without any femoral fractures which were caused by blunt trauma. case: during the transportation of wood blocks, a wooden log fell from the truck over the forester, -year-old man. he sustained a crush injury and died in the emergency service on the same day of the trauma. it was learnt that no medical intervention was performed on the case. ecchymotic bruises on the left abdominal-pelvic, femoral, right inguinal, genital region, deformation under the right knee were observed during the autopsy. it was determined that there was a traumatic transection on the left common femoral artery and vein, which was accompanied by massive bleeding in surrounding soft tissues and muscles without any fracture of the left femur. all the internal organs were intact and showed paleness. death was due to internal hemorrhage caused by the transection of the femoral artery and vein. conclusıons: during the examination of the cases who were exposed to the blunt trauma, peripheral vascular injury must be investigated without any delay. if vascular injury was determined in the early times after the trauma, surgical and medical treatment could be performed successfully and the case could survive. introductıon: traumatic internal carotid artery dissection is a rare and grave cause of embolic strokes occurred especially in young age group. if it is not diagnosed early and required treatment is not given, thrombosis can be a serious trouble with permanent neurological deficit and high mortality rate up to %. case: we presented a delayed diagnosed traumatic carotid artery dissection in a year-old female case. there were no ischemic infarct findings in the cerebral ct on admission, but there were cerebral infarct findings in the cerebral ct taken twice because of the left hemiplegia noticed days later when the patient regained her consciousness. we made the diagnosis of the case, forwarded to our emergency service with acute cerebral infarct diagnosis, certain through arterial doppler ultrasonography, cerebral mri, diffusion mri and mr angiography. we did not consider invasive treatment since the neurological damage was permanent and dissection grade was iv according to angiography findings. we did not administrate anticoagulant treatment considering that the patient can turn her ischemic infarct into hemorrhagic infarct. the case was discharged within a week and advised physiotherapy. conclusıon: although the advances in diagnostic methods, diagnosis with traumatic carotid artery dissection is still missed out or delayed as in the case we presented. early diagnosis enables permanent neurological damage to be decreased or vanished. however, the vital factors for early diagnosis are the obtained anamnesis to direct to radiological examinations, detailed physical examination and high clinical doubts. introduction: acute arterial occlusion is a serious clinical condition resulting death of patient or related organs. these are usually older patients with a lot of comorbid conditions. method: _ in our clinic, we retrospectively examined the records of patients who underwent surgical treatment for acute arterial occlusion between january and december . mean age of patients was . years. ( %) of these patients were female, and ( %) were male. embolic occlusions were found in an upper extremity in ( %) patients and in a lower extremity in ( %). the most common source of these emboli was cardiac origin. atherosclerosis, trauma and arterial catheters were the other causes of emboli. ( %) of patients were admitted less than h preoperatively, ( %) were admitted - h preoperatively, ( %) were admitted after a delay of longer than h preoperatively. ( %) of patients were in sinus rythm, ( %) were in atrial fibrillation preoperatively. motor dysfunction of extremity was found in ( %) of patients preoperatively. diagnosis was based on the findings of physical examinations and emergent doppler ultrasonography. any other invasive evaluation was not performed to decrease acute occlusive ischemic period. surgical intervention had performed immediately results: the overall mortalıty rate was % ( ). _ in ( . %) of patients, after setting of demarcation line, amputation was performed. conclusıon: early diagnosis, catheter embolectomy and use of anticoagulation are very important therapeutic modalities for limb salvage and reduction of morbidity and mortality. there was a comorbidity in all patients and cardiac disease and hypertension were the most common ones. the most common laboratory abnormalities were leukocytosis, hypoalbuminemia, hyperamylasemia. there was superiory vasculary necrosis in patients, inferior vasculary necrosis in one patient.one patient had nonocclusive mesenteric ischemia. segmentery resection was performed to patients. abdominoperineal resection was performed to the patient with inferior mesenter artery occlusion. we performed duodenotransversostomy on two patients and only laparotomy on two patients. reoperation was required in five patients. causes of death was multiorgan insufficiency in seven cases, cardiac death in two cases.one patient died due to short intestine syndrome. results: the patient was discharged on postoperative th hours without any complications. conclusıon: single incision laparoscopic appendectomy is a safe and effective technique that can be performed in well experienced centers success. jorge pereira, luis filipe pinheiro surgery department, sã o teotó nio hospital, viseu, portugal trauma represents one of the most important causes of death and disability of today. the exponential growth of the major cities, the continuous building of roads and the uprising of terrorism, foresee that trauma will keep is importance as a major cause of disease. recently, the management of the trauma patient as been modified, with the introduction of the atls method. this fact has produced great improvement, proven and reproducible, decreasing mortality and morbidity of trauma. the teaching of this new method, albeit its good results, has not seen many changes over the years. however, in recent days, we have seen the introduction of new computer technologies in teaching. this methods use simulation, e-learning and even interaction as learning techniques. taking advantage of the mentioned techniques, the authors produced an animated video, using computer-animated drawings that allow demonstrations difficult to reproduce in real life. using simple software and computer video editing, the authors invite you to watch a trauma patient in the emergency room, since his arrival to the end of the primary survey, watching demonstrations of life saving techniques and the stabilization of the patient. the authors present a video of a young male, years of age, ± kg victim of a motorcycle crash, with a fall over cut branches of trees, min before his admission in the e.r. he sustained an impalement with a stick in the fourth right anterior para-sternal space. at admission he was conscious, gcs = , bp = / , hr = /m, sato = %, hemodynamically normal. breath sounds slightly diminished in the left. a left anterolateral thoracotomy as been done, as well a left subcostal lararotomy, since the stick also had penetrated the left hemidiaphragm. the patient had no significant thoracic or abdominal injuries despite the violence of the trauma mechanism. the ''foreign body'' was successfully removed by combined abdominal and thoracic route, and a left chest tube was put in place. the patient recovered very well and was discharged in the eighth day. author to editor: ''english'' corrections are welcome, please! berker bü yü kgü ral, mehmet bekerecioglu al-marashda , amgad elsherif , hani o. eid , fikri m univariate analysis was used to compare patients who died and those who survived. significant factors were then entered into a backward stepwise likelihood ratio logistic regression. results: out of , patients of the registry, patients ( . %) had chest trauma with a mean (sd) age of . ( . ) years. ( %) were males . ( . %) got injured in the street or highway, ( . %) at work place, and ( . %) at home. the main mechanism of injury was road traffic collision in ( %) fall from height in ( . %). ( . %) were admitted to icu. the median (range) iss was ( - ). ( . ) of patients got isolated chest injury, ( . %) had head injury, ( %) lower limb injury, ( . %) upper limb injury iatrogenic rib fractures during thoracotomy: comparision of posterolateral and anterolateral thoracotomies operations for thoracic trauma, extended lung resections and re-thoracotomies were excluded. posterolateral thoracotomy incision was performed for group i ( patients; . %), and anterolateral thoracotomy incision for group ii ( patients; . %). groups were also divided into two groups for the type of resection the percentages for rib fractures for group ia, ib, iia, and iib were . , . , . , and . damage control principles can a be used in all surgical fields . general surgeons must have experience in vascular repair skills . the reperfusion of the limb joão filipe coutinho vasconcelos , sandrina braga , pedro brandão , daniel brandão , miguel maia , joana ferreira , paulo barreto , vítor martins , a. guedes vaz , leonor rios vila nova de gaia, portugal department of plastic surgery rectal prolapse describes the protruding of the entire rectum or some parts of the rectum from anus. it is caused by the weakening of the ligaments and muscles that hold the rectum in place.it is associated with advanced age, long term constipation or diarrhea, childbirth, previous surgery, and sphincter paralysis. trauma may cause sphincter paralysis and can be associated with rectal prolapse. it usually begins with prolapse of the rectum during defecation or val salva movement and usually progresses to a chronic stage. long term prolapse can cause ulcerations, bleeding and in some cases perforation if not reducted. a -year-old male presented with rectal prolapse, bleeding, abdominal pain. he stated that he could not replace the prolapsed segment for days and has been suffering for years since after he fell from a tree and he had massive bleeding during the last h. physical examination revealed that a cm segment of the rectum was prolapsed with the whole layers. there were ischemic and necrotic areas and active bleeding from the mucosa. reduction trial was not successfull. emergent laparotomy was performed. bimanual reduction failed.thus transanal intervention, with sigmoid resection was performed. end colostomy was preferred. no complications occurred the following months and colorectal anastomosis was performed with a preventive ileostomy. although rectal prolapse is usually a benign condition it may cause fatal complications such as perforation, necrosis if not reduced for a long time and surgery should be performed promptly in these cases.ing to the age, diagnosis, treatment results, mortality rates between the years of and . results: summarised in the table .in conclusion, the most of our multitrauma cases caused by traffical accidents, were young. the mortality rate % for multitrauma cases, the percentage of multitrauma cases were . % of all intensive care patients. preventing the accidents is as much important as treatment strategies for multitrauma cases. arif tü rkmen, ertan gü nal, mehmet bekerecioglu, berker bü yü kgü ral department of plastic and reconstructive surgery, gaziantep university school of medicine, gaziantep, turkeyintroduction and objectıves: as personal problems dealing with health, jobs, financial status and the family problems increasing, more suicide attempt subjects are consulted in emergency rooms day-byday. although gunshots to the oro-facial region form - % of the total victims, it is important that seconder deformities resulted with aesthetic, functional and psychological problems were usually encountered after primary surgery. this study reviews cases of self-inflinct gunshot injuries of face and our experiences in early and late managements over a -year period.methods: this study is based on subjects who attempted suicide resulting in extensive facial deformities, not in death between and . demographic details, mechanism and direction of injury, early and late management and seconder deformities were recorded. results: after establishing the airway control and completing the primary survey, all patients underwent debridement and bleeding control. reconstruction of maxillofacial fractures were performed in patients on the day of admission and the remaining within days of injury. following procedures as scar revisions, rhinoplasty, mandible reconstruction, ectropion operations or coverage of palatal defects etc. were performed after earliest months from primary operation.conclusıons: after stabilization of life-threatening injuries, the goals of early management are regenerate of anatomic form and function to include dental occlusion and mouth opening to prevent scarring, contractures of mobile structures and ankylosis. seconder operations required for aesthetic and functional problems should be performed earliest after month from primary operation that all the scar formations and wound healing's were completed. background: injuries of maxillofacial region in patients with polytrauma are frequent but are rarely treated primarily. in order to achieve satisfactory treatment results trauma treatment team must include a maxillofacial surgeon.materıal-methods: the study shows treatment results of polytraumatized patients with maxillofacial injuries. dominant trauma was: maxillofacial in %, craniocerebral in %, locomotor in %, thoracic in % and abdominal in % of cases. treatment of maxillofacial trauma was in % of cases surgical and in % conservative. treatment of other traumas was operative in % and conservative in % of patients. results: early mortality rate was %. four exitus were recorded during the first h, exitus on the th day and exitus on the th post-trauma day. dominant trauma was in exitus craniocerebral, in exitus thoracic and in exitus severe locomotor. long-term treatment results in remaining patients were: for maxillofacial regiongood in patients ( %), satisfactory in patients ( %) and poor in patients ( %); for other regions -good in patients ( %), satisfactory in patient ( %) and poor in patients ( %). conclusıon: existing maxillofacial trauma in polytraumatized patients usually directs treatment toward conservative methods.reasons for this are insufficient number of maxillofacial surgeons in trauma teams and delay of surgical treatment of other present traumas due to difficult anesthesia application. unfortunately, conservative treatment approach induces inadequate treatment results from both functional and esthetic point of view. however, as revealed by hospitalization, transportation, and mortality data, women were exposed to more severe trauma. in addition, poisoning and fall caused more death. the rate of mortality of women seems to be less when compared to literature. conclusıon: bicyclists in non-fatal frontal crashes with cars suffered the most serious injuries from the impact to bonnet and windshield, likely due to highest energy transformation. bicycle helmets, collision mitigation system that alerts the driver or automatically brakes the car, and external airbags protecting the bicyclists from hitting bonnet and windshield, may reduce injuries.author to editor: this is a complete analysis of mechanism of injury in crashes carfront versus bicyclist. journals were completed with traffic notes from police at scene, patents own history of the crash from the injury database and furthermore interview. the catch area is welldefined with no other hospitals in the area and total cover of all injuries in the database. this gives a good picture of the dynamics of the the crash and mechanism of injury. or street ( ais +). third impact in patients gave injuries ( head/neck) at windshield ( ais +) or street ( ais +). thirteen persons, who hit the street as the fourth impact point, sustained three injuries (zero ais +) as contusions of the pelvis and lower back. conclusıon: pedestrians in non-fatal frontal crashes with a car suffered the most serious head injuries at second impact in bonnet, windshield or street. safer passageways for pedestrians might preclude the crash. mechanisms preventing the pedestrian of hitting the bonnet and windshield, may reduce the injuries. author to editor: this is a complete analysis of mechanism of injury in crashes carfront versus pedestrian. journals were completed with traffic notes from police at scene, patients own history of the crash from the injury database and furthermore interview. the catch area is welldefined with no other hospitals in the area and total cover of all injuries in the database. this gives a good picture of the dynamics of the the crash and mechanism of injury. one of the primary characteristics which professions possess is to make the members of a profession have autonomy in decision making and practice. nursing practice is evaluated in relation to professional practice standards and guidelines, rules, etc… application of professional standards requires that nurses use critical thinking for the good of individuals or groups. critical thinking also requires the use of scientifically based and practiced-based criteria for making clinical judgments. these criteria may be practice based on standards developed by clinical practice guidelines developed by individual clinical agencies. for example, intensive care units (icus) are designed to meet the special needs of acutely and critically ill patients. a patient is generally admitted to the icu for one of three reasons. the patient may be physiologically unstable, at risk for serious complications and require intensive and complicated nursing support. despite the emphasis on caring for the patient who can survive death is common in icu patients. it is reported that % of patients admitted to icus will die, and another % may leave the icu but will not survive to discharge. this suggests a need for caution and coordination of care when transferring patients from icus to general units. in this article, the practice guideline which titled ''patient appropriateness for adult icu admissions and discharge'' will be discussed. the terminology for pelvic fractures and its recent modifiers are confusion to the trainee to say the least. we surveyed orthopaedic trainees in the latter part of their surgical rotations. the same set of radiographs were shown to all trainees and their classifications recorded. the same set of radiographs were shown to the trainees again after a period of days. we found significant inter-observer variability ( %) and wide intra-observer variability ( %). though trainees were adept at identifying basic fractures patterns and identifying individual column or lip/wall fractures the complex fracture patterns seems to generate different answers from the same observer at different times. the ct scan was the most effective tool identified for accuracy of the fractured fragments but the more complex assignments resulted in the trainees grouping them differently. results: twenty-one fractures ( . %) healed without complication including five fractures where external fixation was converted into internal one. the mean time to union was . ( - ) months. there were two pin-track infections, two deep infections, and only one nonunion. the femur length was equal to the healthy side in cases, and was shorter by - cm in five cases. mean active knee flexion was °. knee flexion was more than °in patients. conclusions: external fixation is a useful technique for the stabilization of severe open and close highly comminuted femoral shaft fractures. it is safe procedure to achieve temporary rigid stabilization of femur fracture in critical polytraumatized patients before delayed internal fixation (damage control orthopedics). purpose of this study was to determine the factors predicting mortality.methods: a retrospective study was performed on cases of pelvic fracture who visited to emergency department from january to june . data were collected regarding demographic characteristics, mechanism of injury, injury severity score (iss), abbreviated injury score (ais), simplified acute physiologic score ii (saps ii), transfusion requirements, fluid requirements, the finding of angiography, hemoglobin, platelet, prothrombin time ( fractures were managed by using an intraarticular, chevron-shaped olecranon osteotomy in all patients. methods: the mean age was . years. a straight posterior surgical incision was performed. a thin oscillating saw was used to begin the olecranon osteotomy. a small osteotome was then inserted and the osteotomy was completed through the subchondral bone. the posterior elbow capsule was incised. the olecranon fragment and the triceps muscle were reflected proximally to expose the distal humeral articular surface. osteotomy fixations were performed with two intramedullary kirschner wires and dorsal tension band in patients. in four patients, an intramedullary screw and a tension band were used for fixation. results: at the final control, the jupiter classification system was used for the evaluation of the patients. eighty one percent of the patients revealed good and excellent results at the long-term followup. none of the patients showed osteotomy nonunion. the most frequent complication was skin problem due to subcutaneous prominence of the implants.conclusions: the goals of treatment of distal humerus fractures are anatomic articular restoration and rigid fixation. olecranon osteotomy provides good visualization for rigid fixation especially in type c distal humeral articular fractures. this is a useful method for excellent anatomic reduction of the articular surface. conclusions: there could be some steps during primary treatment for discussion. but real mistake was vacillation and delay of reosteosynthesis and spongioplasty even it was cause by risk for infection and possible failure of flap. our case demonstrate that sometimes too much care could be hurtful. introductıon: the population who applied to the public emergency services due to the injuries related to butchering the sacrificial animals during the feast of sacrifice were evaluated. materıals-method: eighty-nine patients who admitted to the emergency services in kirikkale during the feast of sacrifice in were evaluated according to age, sex, application day and time, state of experience, type and mechanism of injury and medical treatment. results: the age average was ± and % of them were male. eighty-eight percent of the patients admitted in the first day. seventy percent of the injuries were penetrating injuries and % of them were blunt. the average time passed after the trauma was min. almost half of the cases were wounded with a knife, % were wounded unintentionally by the others and % of the cases were due to hit of animals. fifty-seven percent of the patients had butchering experience before. ninety-one percent of the cases were hand injuries. thirty percent of the cases had fractures. nine percent of all cases had tendon injury, % of the cases were treated primarily skin suturation. conclusıon: the injuries related to butchering of the sacrificial animals sometimes can be serious. in extremity injuries, the number of tendon cuts and bone fractures can not be underestimated. both equipments and medical staff support for the injured people should be provided and preliminary arrangements should be done during the feast of sacrifice. every butchering job in this period should be given to professionals. introduction: osteoporotic fractures of the trochanteric area are often treated with a gamma-nail or similar implants utilizing a screw applied into the femoral head. one of the main problems of these techniques is the cut out in the femoral head. we biomechanically evaluated a novel technique of cement augmentation of the bed of the screw in a standardised osteoporotic bone model and its capability to reduce the cut out rate. material and methods: utilizing a polyurethane-foam osteoporotic model that has been previously described (specific gravity . g/cm ), a biomechanical testing of a neck of femur screw (tgn, stryker, duisburg, germany) was performed. the screw was implanted according to manufacturers instruction, the migration characteristics were then biomechanically tested (zwick testing machine) with a static stepwise load increase ( n). first these tests were performed without, in a second series with the augmentation of a fast hardening biopolymer (corthoss, orthovita, usa). each series was repeated five times. the transfer from a stable to an unstable condition was biomechanically determined. results: on average the applied load at the moment of failure with critical cut out was n for the non-augmented screws. with augmentation, the average load was , n, the difference was statistically significant.discussion: it appears in biomechanical testing that augmentation of the femoral head can improve the load bearing capabilities and thereby possibly reduce the rate of cut-out failure in osteoporotic bone. we proceed now with further biomechanical testing, grant of the local ethics committee for human testing has been applied for. introductions and objectıves: the aim of this study was to examine the relationship between childs' favourite cartoon stars who can fly and falling down from a high place in two cases. methods: in this paper we presented two similar cases who were seen with a history of falling down from a high place. the first case was a -year old girl who fell down from the third floor of their apartment. on her examination it was learned that she wanted to fly like her favourite magical cartoon star girls. the second case was a -year old boy who fell down from the second floor. while falling down he was screaming to his friends that he was flying.results: on the physical examination of the first case, deformity and crepitation in right femur were found. x-rays showed right femur distal epiphysis salter harris type iv fracture. she was hospitalized due to the pneumothrax in pediatric surgery intensive care unit. the procedure of closed reduction and fixation with multiple kirschner wires was performed under general anestesia. closed body fracture in the left femur was found in case ii. introductıon: the purpose of this study was to compare the biomechanical properties of different possibilities of screw placement in multidirectional palmar fixed-angle plate in distal radius osteotomy cadaver model under loading conditions. methods: an extra-articular fracture was created in pairs of fresh frozen human cadaver radii. the specimens were randomized into four groups. all radii were plated with a volar fixed-angle plate. there were different possibilities of screw placement in the distal fragment:group a: screws were used in the distal row of the plate. group b: screws were used alternately in the distal and proximal row. group c: screws were used in the proximal row. group d: screws were used filling all screws holes in the distal and proximal row of the plate.the proximal fragment was fixed with screws each. the specimens were loaded with n under dorsal and volar bending and with n axial loading. results: group d had the highest stiffness of n/mm under axial compression and was statistically significant stiffer than the other groups. group b had a stiffness of n/mm followed by group a with n/mm. group c showed only a stiffness of n/mm. there were no statistically significant differences under dorsal and volar bending.conclusıons: occupying all screw holes in the distal fragment offered the highest stability. using only the proximal row with screws showed an unstable situation. it is therefore recommended to use at least screws in the distal fragment. perilunate dislocations are the most common type of carpal dislocation. they can be produced by high-energy injuries. the population primarily at risk is male young adults. in perilunate dislocations, the proximal articular surface of the lunate retains contact with the distal radius. the dorsal-perilunate/volar-lunate dislocation is more common. we performed a retrospective study of perilunate dislocations from to . a total of were reviewed. mean age of the patients was . (range - ). all the patients were male. the trauma mechanism was fall from height in and motor vehicle accident in . all the dislocations were dorsal-perilunate/volar-lunate dislocations. all the dislocations were together with ipsilateral scaphoid fractures. all were closed injuries and all were reduced by closed reduction maneuvers. percutaneous pinning was applied for the dislocation and scaphoid fractures. mean follow-up time was months (range - months). when compared with the non-injured wrist, there was limited range of movement in only one patient.no limitation of range of motion in the other patients could be obtained. the patients did not have pain and instability. radiologically no arthrosis of the wrist could be obtained but in all patients there was scaphoid pseudoarthrosis. functional range of motion of the wrist after a perilunate dislocation is independent of the concomitant scaphoid fractures. bostjan sluga, tomaz malovrh traumatology department, university clinical centre, ljubljana, sloveniainfective complications of tibia fractures result in nonunion, bone defects and soft tissue envelope impairment. several methods of treatment have been described to deal with bone defect including callus distraction, fibula transfer, muscle flap and bone grafting. there are many possibilities to encourage bone healing; bone morphogenic proteins, platelet rich plasma, electrical, ultrasound or shockwave stimulation and hyperbaric oxygen therapy. a patient with both tibias infected nonunion is presented. high energy trauma primarily and inadequate debridement secondarily were probably the cause of the healing complications. a middle-age man was injured in a gas explosion and suffered comminuted closed fractures of both distal tibias. after an immediate external fixation we operated him on the th day after the injury, anatomical reduction and internal fixation on both sides was done. an infection developed after weeks. ankle joint arthrodesis was necessary on one side and implant removal, repetitive debridement with bone grafting on the other. we could not cure the infection and the fracture did not heal. after years, operations, days of ciprofloxacin, days of gentamicin, days of vancomycin, days of implanted gentamicin antibiotic beds and the use of cultivated autogenous steam cells clinically evident nonunion was still present. surgery was performed again, a resection of cm of bone and callus distraction with an unilateral frame. despite a fast progress in knowledge and improvement of methods, a radical debridement, preservation or reconstruction of soft tissue coverage, systemic and local antibiotic therapy and appropriate stabilization is still a keystone in infected nonunion treatment. some people who live in some regions of our country trust in bonesetter's skills more than these ones of professional orthopaedist in the hospitals. the fact that some bonesetter's particular skills to cure the non-operative back pain seems to make them credible on closed reduction too. in this case report, right humerus proximal body fractures due to falling were discussed. the case was -year-old male. in the treatment of this case, velpau bandage, closed reduction and plaster cast-splint has been applied after that he was called to the clinic control, but he did not come to control. the parents of the case were aware of the fact he cannot raise enough the right upper extremity and he was taken along to the hospital. from his anamnesis, it has been learnt that the bonesetter has removed the castsplint and, tried to perform closed reduction. actual physical examination showed that there was an arm pain, crepitation and deformity. a diagnose has been made: there was an union right humerus proximal body fractures, so he has to be hospitalised. under general anaesthesia, closed reduction and bandage velpeau were applied. on the rd day of the hospitalisation, the case was externed and was advised to come for a polyclinic control. because of the importance of epiphysis lines of bones and of other complications from the upper extremities fractures, the treatments have to be performed by the orthopaedists or in accordance with them. about this medical issue, families should be made conscious by healthy authorities. there were women and men. the mean age was . years (range - years) and mean follow-up period was months (range - months). posterior kocher-langenbeck approach was used at patients and ilioinguinal approach was used at two patients.results: there were both column, posterior column with posterior wall, transverse with posterior wall and posterior wall fractures. anatomic reduction was obtained at patients and adequate reduction at patients according to matta criterias. harris scoring system revealed excellent at , good at , moderate at and bad at patients. over % of these patients had satisfactory function. there were any pulmonary embolism, deep infection or nonunion detected. one of four patients whom had developed osteoarthritis, managed with total arthroplasty. postoperative sciatic nerve injury was developed at one patient. conclusıon: secondary arthrosis, nonanatomic reduction, unstable fixation and nerve injuries were associated with poor results. our clinical experience for acetabulum fractures were similar to that reported previously at the literature with over % of satisfactory results sedat kocak, birsen ertekin, esma erdemir, abdullah sadik girisgin, basar cander introduction and objectives: quadriceps muscle tears are usually seen in middle-aged and older people. particularly people with chronic diseases (such as diabetes mellitus, renal failure and gout) are prone to develop quadriceps muscle ruptures. we present a case of partial rupture of the quadriceps muscle in a -year-old girl after intramuscular injections. we thought that this patient could be the youngest patient reported with a quadriceps muscle rupture. methods: patient presented to our clinic with left knee pain, limitation in knee flexion and a localized palpable swelling at the anterolateral side of thigh. there was no blunt trauma but it happened while she jumping on the sofa. in her detailed history we learnt that she had a serious upper tract respiratory infection a week ago and used some parenteral antibiotics (twice a day, intramuscular clindamycine for days).results: plain radiographies were normal. mri showed a partial tear of the vastus lateralis muscle matching with the injection sites. the patient was placed in a long leg half-cast which was maintained for weeks. she treated with conservative treatment successfully.conclusions: mr imaging is useful to diagnose and differentiate in this pathology. multiple intramuscular injections may contribute to damage muscles and make them prone to tears with muscle contractions. quadriceps muscle ruptures in children can be treated successfully with conservative treatment. twenty year old female attempted suicide by jumping from a four story high building, resulting in multiple fractures of the limbs and a complex fracture of the body of the fourth lumbar vertebra (l ) resulting in paralysis of the inferior limbs. the l fracture was treated by a neurosurgeon with the extraction of the body of the vertebra, insertion of a cage device and arthrodeses of the third and fifth vertebras using a metal plate and screws, thereby stabilizing the affected segment and decompressing the medullar channel. the approach was achieved by a general surgeon using the technique of localio, that consists in a paramedian incision of the abdomen and the dissection of the retroperitoneal space without entering the abdominal cavity, dissecting and isolating the left ureter and the main vascular structures (iliac vessels and the left iliolumbar vein) in order to allow a good exposure of the three vertebra bodies involved. the patient recovered the complete function and control over the limbs, resulting no neurological sequelae from the fracture. it is of major importance that this procedure be performed by a multidisciplinary team of surgeons, involving a neurosurgeon and a general surgeon, in this way achieving a better result and a lower risk of complications. josef märz department of surgery, regional hospital karlovy vary, czech republicabdominal ultrasonography or ct were applied to ( . %) patients with blunt trauma and ( . %) patients with penetrating trauma. one ( . %) negative laparotomy was applied to patients with blunt trauma. to splenic injuries was splenectomy. sigmoid perforation, diaphragm rupture, bladder rupture were observed and were fixed primarily. one patient died during surgery due to liver and vena cava injuries. patients with penetrating injury were operated due to firearm injury in ( %) and stab wound in ( %), mortality was not. negative laparotomy was applied to ( . %) patients. multiorgan injury was observed in patients. tube thoracostomy was inserted to patients. of the intestine injuries and stomach injury was fixed primarily. two resection and anastomose and three diversionary ostomy were done. conclusion: proper examination must be considered according to the formation of trauma. _ imaging methods have been used less in penetrating trauma, and negative laparotomy is reported to be applied more than in cases of blunt traumas introductıon: chest tube insertion is frequently used by thoracoabdominal surgeons in urgent conditions. occasionally, this invasive procedure may be associated with lethal complications in inexperienced hands. in this study, we analyzed patients with visceral and/or diaphragmatic injuries due to chest tube insertions. methods: six patients with diaphragmatic and visceral injuries subsequent to chest tube insertions between and were evaluated. the diagnosis was established with roentgenogram, biochemistry of the fluid drained from the chest tube and confirmed with computerized tomography in all patients. results: pleural effusion accompanying respiratory distress was the main indication for chest tube insertion in all patients. in five patients, coexistent gastric perforations with diaphragmatic ruptures were detected, also the esophagus was additionally perforated in one patient. partial gastrectomies were performed in three patients, whereas total gastrectomy in one and primary repair required in two patients respectively. five of the patients died from septic complications. the only survived patients with early diagnosis and primary repair was discharged from the hospital on the th day. conclusıon: penetration of a drainage tube through viscera is a wellrecognized but seldom reported phenomenon. in the majority of patients with diaphragmatic rupture, abnormalities can be found at initial chest radiography. if transdiaphragmatic herniation is missing, diaphragmatic rupture is difficult to diagnose by chest radiography alone. computed tomography is often necessary to reveal the correct diagnosis. early diagnosis and treatment are extremely important in the management of these patients. bronchobiliary fistula is a rare condition, arising as a complication of hydatid disease of the liver, hepatic tuberculosis, hepatic malignancy, chronic pancreatitis, hepatic trauma or surgery. conservative treatment is directed at non-surgical approaches of relieving biliary obstruction to allow for normal flow of bile into the duodenum via endoscopy or percutaneous routes. however in complicated cases which failed conservative non-surgical therapy, surgical intervention is usually required. we report a -year-old man who presented with bilioptysis from a bronchobiliary fistula resulting from firearm injury after days. for his current admission, the patient reported a -day history of cough productive of yellow-green sputum coupled with fevers and malaise.this was successfully treated surgically with a right medial lobectomy and t-tube drainage. paget-von schroetter syndrome(pss) refers to spontaneous thrombosis of the subclavian vein and constitutes . - % of all venous thromboses. it is prevalent among young and healthy adult males who engage in sports. a -year-old male presented with pain and swelling of the left arm after a sequence of intense, repetitive weight lifting exercises. upon questioning, he disclosed that he had been engaged with weight lifting for a long time and had complaints for a while. bases on these findings, upper-extremity effort thrombosis was suspected. contrast-enhanced mr angiography revealed near-complete occlusion of the proximal left subclavian vein and collateral formations in the distal were observed. color doppler us showed a heterogeneous thrombotic mass that filled almost the entire proximal segment of the left subclavian vein thrombosis extended into the proximal segment of the left internal jugular vein. furthermore, extensive venous collateral formations were present the left proximal cervical localization. both mr angiographic and sonographic findings were consistent with pss. as the patient had already developed extensive venous collaterals, no surgical intervention was performed. instead, treatment with lowmolecular weight heparin and anticoagulants, was initiated and was continued along with the follow-up for bleeding parameters. as of years clinical follow-up the patient is doing well, and treatment is continued with oral anticoagulants and acetylsalicylic. pss should be considered in the differential diagnosis of effort induced upper extremity pain and swelling. conservative non-operative treatment is acceptable and can be successfully used with favorable long-term outcomes. although, blunt trauma of the extremities is a common diagnosis in emergency clinics, compartment syndrome associated with vascular injury following blunt trauma may be difficult to diagnose. urgent diagnosis and treatment of compartment syndrome is of particular importance for limb salvage or even to save the patients' life. years old male patient was referred to emergency clinic due to blunt trauma of the right lower extremity. right thigh was echimotic and swollen. pallor, coldness and severe pain were present at the lower part of the trauma level. distal pulses were not palpable. acute compartment syndrome of the right thigh was diagnosed that led to an emergent operation. intraoperatively, popliteal artery rupture was diagnosed and repaired with end-to-end anastomosis. fasciotomies were performed at the anteromedial and anterolateral portions of the right leg and anteromedial part of the thigh for the treatment of compartment syndrome. in early postoperative period, distal pulses were palpable. preoperatively present pallor and coldness improved in the first few h. fasciotomies were closed with skin grafts at the th postoperative day. patient was discharged at the th postoperative day with palpable distal pulses and failure of dorsal flexion of the right ankle representing mild neurological injury. possible vascular injury should be kept in mind in a patient with compartment syndrome following blunt trauma of extremities. success of surgical repair depends on the early diagnosis and treatment. late repair may result in neurological complications or even the loss of extremities.conclusıon: acute mesenteric ischemia is highly mortal emergency which should always be suspected in elderly patients with cardiac disease suffering from abdominal pain. acute ischemia of the lower member after injury by firearm -case report patient with years, male sex, admitted at the urgency department after injury of the left lower member by firearm. at the admission presented loss of substance and hemorrhage in the medial and lateral faces of left leg and foot with signs of ischemia. an arteriography of the member was carried out showing infrapopliteal arterial lesions of the three axes. during surgery, fracture and losses of peroneum substance was observed with macroscopic tibial and peroneal common nerves integrities. he was submitted to tibial interposition grafts with subsequent reversed contralateral internal saphena vein bypass.in the th postoperative day it was carried out surgical debridement and plastia with partial skin graft. he presented good cicatricial evolution, with hospital discharge days after, oriented to external consultations of vascular surgery, plastic surgery, physical/ rehabilitation medicine and pain consult. five months after surgery, pain was controlled with the medication instituted, with improvement of the left lower member limitations with physiotherapy, good cicatricial evolution and posterior tibial and dorsalis pedis pulses palpables. dıscussıon: the incidence of arterial wounds following penetrating injury of the members is %. the vascular trauma occurs more frequently in the lower extremities, being the most common clinical presentation acute isquemia. the most frequent causes are vehicle accidents, falls and firearm wounds. in the united states, injuries by firearm represents the first cause of death in young individuals of male sex. the arterial bellow-knee injuries by firearm remain like a challenge, with an associated rate of amputation of to %. jorge pereira, luis filipe pinheiro surgery department, sã o teotó nio hospital, viseu, portugaltrauma represents one of the most important causes of death and disability of today. the exponential growth of the major cities, the continuous building of roads and the uprising of terrorism, foresee that trauma will keep is importance as a major cause of disease.recently, the management of the trauma patient as been modified, with the introduction of the atls method. this fact has produced great improvement, proven and reproducible, decreasing mortality and morbidity of trauma. the next stage of treatment implies surgery. the dstc course, and other similar ones, allow the teaching of surgical damage control to surgeons. in this courses, the surgeon not only learns the theoretical basis of the surgical techniques but also acquires the skills to perform them. more importantly, he learns trauma pathophysiology, so he can perform the difficult task of surgical decision-making. using the same computer-animated drawing technique as in a previous video (primary survey), the authors continue to present a trauma patient, after the stabilization of the primary survey, at the operating room. the patient has a severe abdominal trauma and needs damage control of his lesions, for he is already suffering from the deadly triad: hypocoagulation, acidosis and hypothermia. a year-old male patient was admitted to our hospital for severe abdominal pain. thoracoabdominopelvic ct scan demonstrated incarcerated bowel loops in the right hemithorax. strangulated transverse colon segment and omentum through the defect at the dome of right diaphragma was found at diagnostic laparoscopy. diaphragmatic hernia was primarily repaired with endostitches, and supported with a polipropylene mesh fixed with endotuckers subsequent to reduction of strangulated organs to the abdomen. resection of necrotic intrabdominal organs and a side-to-side stapled colocolonic anastomosis was performed through a subcostal minilaparotomy. drainage of right hemithorax was provided with a tube thoracostomy. the patient was discharged on the th post-operative day without any major complications. introduction and objectıves: single incision laparoscopic procedures are accepted as a step towards pure natural orifice transluminal endoscopic surgery. however, loss of requirement of any perforation of visceral organ and an endoscopic equipment make this technique more popular and easily performable. here in we report our first appendectomy case who was performed with single incision laparoscopic surgery (sils) technique. methods: years old male patient with the diagnosis of acute appendisitis underwent single incision laparoscopic appendectomy. a key: cord- -h eqnzn authors: kao, hui-yun; ko, hai-yun; guo, peng; chen, chang-hsun; chou, su-mei title: taiwan's experience in hospital preparedness and response for emerging infectious diseases date: - - journal: health secur doi: . /hs. . sha: doc_id: cord_uid: h eqnzn the communicable disease control medical network (cdcmn), established in after the sars outbreak in taiwan, has undergone several phases of modification in structure and activation. the main organizing principles of the cdcmn are centralized isolation of patients with severe highly infectious diseases and centralization of medical resources, as well as a network of designated regional hospitals like those in other countries. the cdcmn is made up of a command system, responding hospitals, and supporting hospitals. it was tested and activated in response to the h n influenza pandemic in - and the ebola outbreak in west africa in - , and it demonstrated high-level functioning and robust capacity. in this article, the history, structure, and operation of the cdcmn is introduced globally for the first time, and the advantages and challenges of this system are discussed. the taiwanese experience shows an example of a collaboration between the public health system and the medical system that may help other public health authorities plan management and hospital preparedness for highly infectious diseases. u nder the global health security agenda, hospital preparedness for highly infectious diseases is regarded as a critical strategy for disease control and prevention. hospital preparedness is particularly important to protect healthcare workers and reduce transmission of diseases within hospitals. following the anthrax attacks in the united states in , the sars outbreak in , and decades of medical system reforms, a number of countries have adopted an approach that designates specific responding hospitals at the national, regional, and/or local levels to centralize resources, build capacity, and train special medical staff. in japan, patients diagnosed with category i communicable diseases are referred to designated infection hospitals. , in singapore, its largest hospital, tan tock seng hospital, was appointed as the screening and treatment center for sars and other emerging infectious diseases. , the hong kong health authority established hospital clusters for resource sharing and a continuum of quality care. the european commission founded the european network of infectious diseases (enid), including setting up high-level isolation units (hlius). the us government made a new tiered hospital program in response to a domestic ebola outbreak, designating regional treatment centers and state treatment centers for the management of patients with ebola and other emerging infectious diseases. [ ] [ ] [ ] after the sars outbreak in in taiwan, where a series of nosocomial outbreaks resulted in the collapse of hospital operations, a new medical network for highly infectious diseases, named the communicable diseases control medical network (cdcmn), was established. it was funded through government mid-and long-term plans and had been modified in terms of the command system, how it is activated, and responding hospital criteria. in , additional changes were made to enhance response effectiveness and coordination with regional and local medical facilities. this article describes the establishment and history of the cdcmn, the framework of the medical network, responses to the h n pandemic and ebola in west africa, identification of its strengths and challenges, and how the system changed over time. an overview of taiwan's hospital preparedness efforts is provided to help public health authorities in countries with similar programs or plans to improve hospital preparedness for highly infectious diseases. during the sars outbreak in taiwan, several hospitals were forced to close because of nosocomial clusters of infections. some hospitals started to refuse to take in patients with similar and suspected syndromes. meanwhile, the public lost confidence in the medical system, and many people avoided seeking medical attention despite developing symptoms. it is estimated that outpatient visits were reduced by % in total and by % in public hospitals, indicating that public hospitals bore the brunt of this loss of trust. furthermore, because of patient referral procedures at that time, the referral system was disorganized, which may have expanded possible transmission to other hospitals, making the situation even worse. the department of health (now the ministry of health and welfare) established a sars coordination center to integrate resources and coordinate the academic, medical, and private sectors to combat sars. under the command structure, an infection prevention network was organized, comprised of designated sars treatment hospitals located in northern, central, southern, and eastern regions. a funded infection prevention network with regions (taipei, north, central, south, kao-ping, and east) was approved and incorporated into the plans for post-sars reconstruction and the - biological defense against emerging infections, establishing a permanent strategy of graded medical treatment. in each region, a commander and a deputy commander were selected to oversee the coordination and operation of responding hospitals (at the time they were called infectious disease hospitals), and a consulting committee composed of epidemiologists, lab researchers, medical workers, hospital managers, and jurists was set up to advise on policy formulation. a command center would be activated depending on the epidemic emergency and would be staffed by the local health bureaus, medical centers, and other coordinating organizations. from to , the number of responding hospitals varied from to in regions, with another supporting hospitals serving as backup for medical resources and manpower. nearly negative pressure isolation wards and nearly isolation wards were ready for patients with emerging infectious diseases. in terms of the activation mechanism, reforms were implemented in phases (table ). in phase ( july -march ), responding hospitals-initially based on the designated sars treatment hospitals and other public health hospitals affiliated with the department of health-were divided into categories based on disease and hospital capacity, and they were responsible for patient management of specific communicable diseases. in addition, based on different scenarios of outbreak scale and disease type, some of the hospitals could be activated for additional diseases. during phases and , the selection of the responding hospital candidates was handed over to local health authorities, who took into consideration factors such as local geography and traffic when designating responding hospitals. in phase (april -december ), the categorization framework was modified to a tiered approach of responding hospitals, including national treatment hospitals, regional hospitals, and local hospitals. in phase , starting in and continuing through the present, the tiered approach was adjusted to incorporate cross-regional cooperation. in accordance with cross-regional activation, during an epidemic regions in the network are activated depending on the outbreak location, and then they coordinate with and support one another with medical resource allocation since the completion of phase , taiwan has continued to adjust the number and composition of its responding hospitals. in , the responding hospitals were no longer categorized as national, regional, and local, because in the event of cross-regional activation it is more efficient and flexible to launch a responding hospital where an epidemic occurs, as shown by the h n influenza pandemic. in addition, considering the continuously improving healthcare system in taiwan, all the responding hospitals were able to take in patients with highly infectious diseases and rapidly activate the emergency response plan, regardless of the category level. the tiered system of responding hospitals was determined to be impractical and was abandoned. soon after a system review in , an expert consultation meeting held by taiwan cdc decided to gradually adjust the operation and the reimbursement scheme of cdcmn. in , the number of responding hospitals decreased to based on improved hospital capacity and readiness for highly infectious diseases and national-level budget constraints. in , the number of regional responding hospitals was further decreased to ( per region); however, taiwan's hospital preparedness and response hospitals that were no longer regional responding hospitals could be designated as local responding hospitals and funded by the local public health bureaus. in , the infection prevention network was formalized and renamed the communicable disease control medical network. this ensured that the activation of a command center, the assignment of a commander and a deputy commander, the selection process of responding hospitals (renamed from infectious disease hospitals), the allocation of resources and staffing, and the hospital response and preparedness work are regulated to effectively act to ensure disease control and patient treatment. the current elements of cdcmn are described below. since , the cdcmn has gradually adjusted the number of responding hospitals. in addition, the operation and reimbursement scheme was decided by a comprehensive review and discussion meeting that included attendees from local health bureaus, commanders and deputy commanders in each region, and policy officers from taiwan cdc in . now core elements comprise the medical network: ( ) a command system, ( ) responding hospitals, and ( ) supporting hospitals ( figure ). the network is divided into regions, and responding hospital and supporting hospital are designated in each region. one commander and deputy commander are assigned by the ministry of health and welfare in each network region. they review relevant plans of communicable disease control, and they supervise and provide consultation to local health bureaus. during an outbreak, the command center leads case investigation; infection control and patient transport in medical facilities; coordination; expropriation; requisition; and allocation of hospitals, hospital beds, and manpower. at the local level, public health bureaus may designate isolation hospitals based on the specific condition, distribution of medical care facilities, and hospital capacities. from these, local responding hospital is designated for specific disease control needs. currently there are isolation hospitals, including local responding hospitals. at the national level, taiwan cdc designates regional responding hospitals in regions based on the isolation hospital list and a swot (strengths, weaknesses, opportunities, and threats) analysis of candidates. in addition, other local responding hospitals in off-island areas receive funds from the taiwan cdc to tackle health discrepancies in demographic distribution and insufficient medical resources. table shows general groups of the regional responding hospitals, supporting hospitals, and the number of local responding hospitals in each region. the central and local responding hospitals may receive subsidies from the taiwan cdc and public health bureaus, respectively, on personnel training and drills and procurement and maintenance costs for facilities and equipment of isolation wards. the regional and local hospitals are responsible for taking in patients with category i and v communicable diseases (eg, smallpox, plague, rabies, novel influenza, mers, a in phases and , the total numbers of responding hospitals are and separately in administrative districts, with treatment center designated as both national and regional responding hospital. among administrative districts, districts in phase and district in phase did not have responding hospitals and instead coordinated with neighboring responding hospitals for geographic and traffic factors. ebola, and other hemorrhagic fevers). each regional responding hospital has qualified negative pressure isolation wards, with to beds per million population and beds in off-island areas. this is standard practice in line with japan, singapore, and hong kong. facilities and negative pressure equipment in regional responding hospitals are inspected and validated annually. every responding hospital is required to formulate an emergency response plan for emerging infectious diseases. plans should include the structure of the command and response task force, reporting procedures and information management, patient transport and care, medical personnel safety measures, environment maintenance, infection control, and risk assessment. drills and training courses are held to strengthen knowledge and clinical skills of healthcare workers and disease control personnel. in each region, supporting hospital is designated from regional medical centers. supporting hospitals are responsible for offering medical consultations to support the responding hospitals and serve as a back-up for manpower and medical resources during the period of outbreak. healthcare workers in supporting hospitals offer profes-sional consultations during ordinary times, while during an outbreak they are dispatched by the regional commander for medical care assistance. depending on the scale of the outbreak, a tiered activation process of a regional responding hospital is further defined as the initial launch of isolation wards (including negative pressure wards), the floor evacuation, the building evacuation, and the whole hospital evacuation (figure ). once the evacuation is activated, patients without the outbreak disease will be evacuated and transferred to other hospitals to allow the responding hospital to take in patients with category i and v communicable diseases. if the outbreak expands further, the commander may appoint isolation hospitals or requisition medical facilities at various levels to take in priority patients with emergency or outbreak diseases. the regional commander may request cross-regional assistance as well. upon the order of the regional commander, medical facilities transfer infected patients to the regional responding hospital or other appointed isolation hospitals. for off-island areas, patient transport is divided into options to be decided by the commander, based on the evaluation of the case status, the outbreak situation, hospital capacity, risk of transport, and other administrative factors. one option is to dispatch the support workforce to the local responding hospital in off-island areas where a patient could be treated directly. the other option is to transfer the patient by airplane to a regional responding hospital. however, the former option would be costly for the transport of the support team, and the latter option could increase the risk of transmission en route. therefore, the patient's status and the need for the patient's advanced medical care are major factors that the commander evaluates and decides for best patient care. in addition to healthcare workers in responding and supporting hospitals, a list of support healthcare workers, including physicians, nurses, respiratory therapists, radiographers, psychiatrists, medical technologists, and pharmacists, is made and updated regularly by local health bureaus. the support workforce in each region should be equivalent to % of the healthcare staffing in responding hospitals. this ensures that in the event of an outbreak, surge capacity is available. furthermore, frontline healthcare workers from local health centers or clinics may be requisitioned to expand workforce capacity. all healthcare workers on the support list are required to participate in training courses, personal protective equipment (ppe) donning and doffing exercises, and annual simulation drills held by responding and supporting hospitals to ensure safety and enhance willingness to serve. as h n influenza emerged in mexico and the united states in late april and the who announced a phase global influenza pandemic, the central epidemic command center (cecc) for h n influenza was established at the level of executive yuan. , h n novel influenza was listed as a category i notifiable disease, which meant that all patients under investigation for h n were prioritized to be treated in responding hospitals. , in the early phase, responding hospitals were notified to be ''ready for response.'' these hospitals were required to figure . activation procedure of a regional responding hospital taiwan's hospital preparedness and response report back to the cecc on the results of inspections of negative pressure isolation wards, manpower mobilization, training and drill plans, ppe stockpile status, and transport procedures. as the epidemic developed, the regional commanders were authorized to coordinate and organize isolation hospitals and negative pressure isolation wards in regulating regions. in late may , soon after several domestic cases were reported, the cecc commander decided to launch responding hospitals (at the activation level of building evacuation) to admit and treat patients confirmed with h n influenza. , as the who announced that the pandemic was of moderate severity, and the major strategy changed from containment to mitigation, the cecc decided to remove h n novel influenza from the notifiable disease list, and patients were no longer placed under compulsory isolation. they could also seek medical attention at clinics or emergency departments and directly receive treatment. in july , the cecc integrated the emergency medical services, the cdcmn, and medical institutions contracted with national health insurance. the regional commanders of cdcmn were further authorized to mobilize medical resources in the integrated system and to provide complicated cases with adequate treatment. [ ] [ ] [ ] during the h n pandemic, the average utilization rate of negative pressure isolation beds was around . %. the mortality of h n influenza in taiwan was . per million. this was the third lowest mortality rate compared to other organization for economic co-operation and development (oecd) members ( figure ) and onefifth of that in the united states, , indicating the epidemic was well controlled and the medical network operated robustly. in the early phase of the ebola outbreak in west africa, regional responding hospitals were instructed to be aware of patients who had a travel history to ebola-affected countries and to enhance infection prevention and control measures. as soon as the who declared the ebola outbreak a public health emergency of international concern (pheic) on august , , the taiwan cdc consulted with regional commanders and deputy commanders to establish an emergency response task force and strengthen areas: health education, quarantine control, hospital preparedness, and international cooperation. , in light of reported ebola cases among healthcare workers in spain and the united states, all regional-level hospitals, medical centers, and responding hospitals in the cdcmn were requested to hold training and drills on proper donning and doffing of ppe. furthermore, a series of conference calls were held by the taiwan cdc, covering ( ) the emergency response plan for managing a patient with ebola and other response efforts with medical directors in regional responding hospitals; ( ) public health measures with local health bureaus; and ( ) issues of healthcare personnel safety with relevant medical associations. meanwhile regional and off-island responding hospitals were prioritized to receive specific types of ppe procured by the taiwan cdc, in accordance with the who and the us cdc's guidance. no-notice inspections were also performed in regional hospitals and medical centers to understand current infection control measures and collection of travel kao et al history, occupation, contact history, and cluster information in emergency departments. the inspection showed rapid patient management and transfer flow; good infection control, with physicians and other medical staff dressed in full ppe; and timely reporting to local health authorities. other areas, such as the waiting time to access isolation wards, and collection of travel history, occupation, contact history, and cluster information in emergency departments, needed improvement. in total, suspected cases (none confirmed) were reported in taiwan before the who announced the ebola outbreak over. after american nurses contracted ebola from an imported case in a hospital in texas, the us cdc and the secretary for preparedness and response (aspr) of the department of health and human services (hhs) recognized that not all hospitals have the same capacity to manage ebola patients. a -year -tiered hospital program for ebola and other highly infectious diseases was announced in december . , in addition, the national ebola training and education center (netec) was established in , which recruits professionals with ebola experience to develop training courses and assess the preparedness of designated hospitals. , this new system shares many elements with the cdcmn in taiwan. for instance, both use a centralized patient isolation approach and designate hospitals with stronger capacity, personnel training, and adequate facility and resources. in addition, the center for infectious disease control and prevention in taiwan was established in as an avenue for training and drills in public health, medicine, disease control, and anti-bioterrorism, which is similar to the netec. the communicable disease control medical network has been tested and demonstrated to be flexible and have robust capacity in responding to epidemics over the past several years. the structure and activation mechanism has evolved over time. in , a comprehensive review of the operation of the cdcmn was conducted. this system has several strengths, which should be maintained. the command system as well as the responding and supporting hospitals, are empowered legally to effectively activate and coordinate isolation wards, medical resources, and manpower as needed during the early phase of an outbreak. in addition, the command structure connects public health authorities and the medical system to integrate medical resources and share information with coordinating partners. after the sars outbreak, awareness of healthcare workers' safety was raised. currently, most healthcare workers exercise good infection preven-tion and control practices. furthermore, emergency response plans in responding hospitals are in place, and the inspection of negative pressure isolation wards is conducted annually. in terms of the enhancement of healthcare workers' knowledge and clinical skills, systematic health personnel training and drills have been regularly performed in responding hospitals. there are other areas of challenges where improvement is needed. first, the role of the local public health authorities in the cdcmn is ambiguous in the command system, and their responsibilities should be further clarified. second, the government funds for cdcmn have been reduced, even though facilities and equipment need to be renewed and replaced after years of operation. also, since there are only a few confirmed cases with highly infectious disease treated in negative pressure isolation wards, the wards have rarely been used. however, maintenance of the negative pressure isolation wards is costly. as a result, economic factors may have reduced responding hospitals' willingness to be in the network. in a post-ebola time, training programs of comprehensive core clinical and infection control skills, such as hands-on practices while wearing ppe and mental health and behavior changes, should be further developed with reference to the who and other countries' guidance in response to future emerging disease epidemics. in addition, strategies are needed to incentivize participation of frontline medical workers to ensure a robust response team. further, fair risk compensation payments for caring for highly infectious diseases by healthcare workers is still a topic of debate despite existing regulations governing the operation procedures and compensation for requisitioned health personnel. however, these have not been reviewed since the sars outbreak. as discussed previously, the number of responding hospitals evolved over time. the challenges of identifying a role for local public health bureaus in the cdcmn, using negative pressure isolation wards during nonemergency operations, and operating within a decreasing cdcmn budget resulted in a change in the number of regional responding hospitals, from hospitals in to hospitals in to hospitals in . this alteration enhanced the local public health bureaus' role in the hospital preparedness efforts by allowing them to identify and coordinate local responding hospitals and enabled local hospitals to use negative pressure isolation rooms during daily operations, which better justified the investment required to maintain them. in addition, the regional responding hospitals received more cdcmn resources (previously diverted to hospitals) to maximize the effectiveness. the changes create a more cost-effective network that still maintains flexibility taiwan's hospital preparedness and response and surge capacity during an epidemic. although changes from to date showed improvement in the operation and budget allocation, current challenges, such as the cost for renewal and replacement of the medical equipment in responding hospitals, the development of integrated and comprehensive training courses of core skills for healthcare workers, and risk compensation payments, need the taiwanese government's ongoing commitment and collaboration with medical partners to continue efforts in enhancing a more solid and effective system. this is the first time that the taiwan cdc has shared its experience in constructing and operating the communicable disease control medical network. the framework has been further empowered since its legislation in , with an overarching structure divided into a command system, responding hospitals, and supporting hospitals. over the past years, the control strategies of the cdcmn have been tested during the h n influenza pandemic, the h n epidemic, ebola in west africa, and other outbreaks, demonstrating a high level of functioning and robust capacity. the command system also bridges the public health and medical systems to improve allocation of manpower and resources at the national and local levels. the taiwan cdc will continue to maintain the key elements of the cdcmn and resolve challenges through continued work with hospitals, local health bureaus, medical associations, and other cooperating partners, in order to protect people from emerging infectious disease threats. as national and global progress is made toward building a safe and secure network to respond to infectious diseases, hospital preparedness work highlights the critical functions needed to identify, isolate, and respond rapidly and coordinate smoothly. at the international level, countries could help each other to strengthen and build a more resilient healthcare system. it would be of great value for the cdcmn partner in global alliance to develop a strong international partnership with other similar designated hospital frameworks in japan, europe, and the united states. in this way, information exchange, health and safety issues of medical workers, technical and clinical skills, the response team framework, response workforce and logistics, and other key topics can be discussed and reviewed by experienced professionals across the world. this could help hospital preparedness networks to become more efficient while maintaining core capacities in preparing for the next emerging health threat. designated medical institutions for specific infectious disease public health challenges and legacies of japan's response to the ebola virus disease outbreak in west africa sars transmission and hospital containment public health measures implemented during the sars outbreak in singapore clusters, hospitals & institutions framework for the design and operation of high-level isolation units: consensus of the european network of infectious diseases us department of human health and services. hhs selects nine regional ebola and other special pathogen treatment centers us department of human health and services. hhs selects regional ebola treatment center for southwestern us interim guidance for u.s. hospital preparedness for patients under investigation (puis) or with confirmed ebola virus disease (evd): a framework for a tiered approach post-sars reconstruction plan: research project of social and economic impacts in the sars outbreak. the evaluation of activation mechanisms of different medical systems in responding to the sars crisis prevention and control of sars in taiwan infection disease prevention network (idpn) a decade after sars-lessons learned and preparedness. taipei: center for disease control, ministry of health and welfare, r.o.c. (taiwan) promotion plan of strategy adjustment on responding hospitals of communicable disease control medical network principal of the activation of responding hospitals and operation of support workforce in communicable disease control medical network taiwan's response to the h n influenza pandemic. taipei: center for disease control, department of health, r.o.c. (taiwan) response measures of the communicable disease control medical network to h n novel influenza focus h n pandemic preparedness and response statement on the st meeting of the ihr emergency committee on the ebola outbreak in west africa the current ebola outbreak in west africa and the response measures in taiwan emerging infectious diseases (eid) response a no-notice drill of hospital preparedness in responding to ebola virus disease in taiwan early identification and prevention of the spread of ebola-united states addressing infection prevention and control in the first u.s. community hospital to care for patients with ebola virus disease: context for national recommendations and future strategies key: cord- -e g lns authors: nan title: poster sessions - date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: e g lns nan the improvement in p/f ratio in the hfov group compared to cmv was statistically significant [at hours (p= . ) and hours (p= . )] and this trend continued through the study period. though the fio was higher in the hfov group at baseline, by , and hours this was significantly lower as compared to cmv group(p< . and p< . and p< . respectively)and again this trend continued over the study period. we studied patients with heatstroke admitted in icu during the august heat wave in france. plasma samples were available at the admission for all patients and during the course of the disease in patients. to assess the extent of the inflammatory response in the patients, plasma concentration of cytokines was studied by elisa. leucocyte activation was evaluated by the expression of eta integrins and l-selectin by flow cytometry using specific moabs; reactive oxygen production (ros) by chemoluminescence and metalloproteases mmp and mmp by gelatin zymography. as markers of cell activation and/or apoptosis, microparticles (mp) isolated from plasma were double-stained with annexinv (av) and cell specific moabs against platelets (cd ) or granulocytes (cd ) and analyzed by flow cytometry. microparticles procoagulant phospholipids were measured by prothrombinase assay. whole blood and microparticles tf was determined by a specific clotting assay. increased levels of il , il and il -ra were observed whereas il , il -eta and tnflpha were normal or undetectable (table) . blood leucocyte activation was demonstrated by:-an up-regulation of eta -integrin expression, -a down-regulation of l-selectin expression, -an increased ros production. moreover, pro-mmp and , possibly released by activated granulocytes were increased in the tested patients with presence of active mmp in three. markers of dic (thrombocytopenia, decreased fvii and fv levels, presence of soluble fibrin and increased levels of tat) were observed in / patients. whole blood tf was increased in all patients ( ± pg/ml, mean ±sd) vs controls (< pg/ml). compared to healthy controls, the number of av positive mps was not increased, but the cellular origin was different, with a significant decrease in platelet mps (p< . ) and a significant increase in granulocyte mps (p< . ). furthermore, mps tf was increased and contributed for a large part to the high procoagulant state. high levels of inflammatory cytokines play a crucial role in leucocyte activation leading to down regulation of l-selectin, ros production and active mmp . our results suggest a major role of mps of granulocyte origin in the tf-dependent procoagulant state that correlates with the severity of the disease. kalenka a , münch e , fiedler f departement of anesthesiology and critical care medicine, faculty of clinical medicine mannheim, university of heidelberg, mannheim, germany introduction: recombinant factor viia (rfviia; novoseven, novo nordisk, agsvaerd, denmark) has been approved for prevention and treatment of bleeding in patients suffering from hemophilia with inhibitors. numerous case reports and retrospective studies submitted to a webbased drug surveillance have been published, that record the sucessfull use of rfviia to treat lifethreatening haemorrhage in patients without pre-existing coagulation disorders. however, it is unknown whether rfviia induces hemostasis in septic patients with disseminated intravascular coagulation. therefore, the objective of this study was to investigate clinical efficacy of rfviia in septic and non-septic patients with bleeding complications methods: between / and / , adult patients with life-threatening haemorrhage without pre-existing coagulopathy were entered into the study retrospectively. out of patients with severe sepsis and dic (known infection and at least organ dysfunction) and non-septic patients with severe bleeding complications due to different reasons, we reviewed coagulation parameters and the amount of transfused blood products prior to and hours after application of rfviia. the patients´s underlying diseases and dosages of administered rfviia are illustrated in table . relevant thromboembolic complications were recorded results: prior to administration of rfviia, . ± . (mean ± standard error of the mean) units of red blood cells (rbc), . ± . units of fresh frozen plasma (ffp) and . ± . units pooled platelets (plt) were substituted to the non-septic patients. after administration of rfviia, significantly less rbc . ± . (p< . ), ffp . ± . (p< . ) and plt . ± . (p< . ) were transfused. coagulation analysis demonstrated normalisation of international normal ratio ( . ± . versus . ± . ; p< . ) and partial thromboplastin time ( ± . s vs. ± . s; p< . ) after administration of rfviia. no differences were detected concerning the platelet count. in the septic-group administration of rfviia neither resulted in a reduction of transfused blood products nor in a reversed coagulopathy. three thromboembolic complications were observed in the non-septic patients. mortality rate was % in the non-septic group vs. % in the septic group (p= . ) marsilia p f , imperatore f , munciello f , scarpelli m , teodori r , de cristofaro m , occhiochiuso l unit of anaesthesia and intensive care, department of emergency, a. cardarelli hospital, naples, italy introduction: acute septic descending mediastinitis (asdm) has been defined as the mediastinum infection which results from the spreading of oropharyngeal infections, or deep neck structures ( ). drotrecogin-alpha (activated) or recombinant human activated protein c (rhapc) is the only biological agent approved for use in severe sepsis syndrome that has demonstrated efficacy in reducing -day all-cause mortality and new data suggests a trend towards longer term survival( ). very few data in literature report the use of rhapc in the treatment of asdm. aim of this study is to report our experience of cases of asdm complicated by a severe sepsis-induced multiple organ failure syndrome (mofs) and successfully treated with the infusion of rhapc. four male and three female patients were admitted to our intensive care unit for asdm due to oropharyngeal infection and complicated by a severe sepsis-induced mofs. all patients were undertaken to combined cervicotomy and thoracotomy surgical operation with toilette and drainage of infection. moreover the infusion of rhapc at gamma/kg/min for hours was given together with all other certain established procedure. respiratory failure was managed with sedation, orotracheal intubation and invasive mechanical ventilation. cardiac failure was managed with invasive arterial and central venous pressure monitoring together with the infusion of catecholamines up to standard doses; while renal failure was managed with continuos venous-venous haemodiafiltration. antibiotics were given first empirically and then according to lab test results. in cardiac surgery, more than in any other type of surgery, in early postoperative period can occur low cardiac output syndromes due to hypovolemia or to myocardial failure. our objective is to evaluate the accuracy of the systolic pressure variations (spv) and of its negative component ∆ down under mechanical ventilation in predicting the response to volume loading and to diagnose hypovolemia. in a group of patients who underwent cabg surgery, in the early postoperative period we monitored: co/ci, cvp, pcwp, bp (s/d/m), vps and ∆ down. the including criteria were: sinus rhythm, ci ≤ . l x min- x m-?, pcp < mm hg. all the patients underwent a fluid challenge ( ml of colloids in min). according to the ci variation the patients were then divided in two groups: group a ( pts) with a raise of ci > %, and group b ( pts) with a ci variation < %. we analyzed the variations of the parameters mentioned above due to fluid loading and the differences between the two groups. in the following table are the data obtained. all parameters are measured in mm hg and are expressed as the average value ± standard deviation (*p< . ).statistical analysis shows significant differences between the two groups regarding only the initial value of spv ( . ± . mm hg in group a, . ± . mm hg in group b, p< . ) and ∆ down ( . ± . mm hg in group a, . ± , mm hg in group b, p< . ). there also significant differences of the values before and after the fluid challenge only in group a and for the same parameters: spv (from . ± . mm hg to . ± . , p < . ) and ∆ down (from . ± . mm hg to . ± . mm hg, p< . ). in predicting a significant raise of ci after volume loading a spv > mm hg the new parameters of preload dependency tend to replace the classic pressure parameters in hemodynamic assessment, being more accurate as predictor of ci response to volume loading and as detector of hypovolemia ( ). the low costs and accuracy of the spv method advocate for using it in critical care settings, even in cardiac surgery. marangoni e , volta c a , alvisi v , bertacchini s , ragazzi r , orlando a , alvisi r anesthesia and intensive care, university of ferrara, ferrara, italy several studies provide compelling evidence on the clinical role played by fluid optimization. till now, the assessment of the intravascular volume has been based on data derived by pulmonary-artery catheter. however, some studies suggest that the use pulmonaryartery catheter is associated with an increased mortality and hence the central venous pressure (cvp) remains the only parameter to be used. nine patients undergoing mechanical ventilation were enrolled. cvp was determined while patients were breathing spontaneously (sb) and during assisted control ventilation (acv) at different peepe levels ( - - - cmh o). patients clinical characteristics are (mean±sd): age (yr) ± ; weight (kg): ± ; tidal volume (ml, acv): ± ; respiratory rate (b.min- , acv): ± ; static compliance of the respiratory system (ml.cmh o- , acv): ± . the following parameters were determined: mean airway pressure (acv), mean systemic blood pressure (map), cvp. the most dramatic increase of cvp was registered when the patients were ventilated in acv compared to spontaneous ventilation ( fig. ) . surprisingly, cvp values were much less influenced by progressive rise of mean airway pressure obtained by different peepe level. moreover, map variations were closely linked to those of cvp. our data shows that cvp monitoring is useful for assessing the intravascular volume in patients requiring high peepe level. however, the cvp values obtained during acv are very different from those calculated during sb and hence, when possible, it is advisable to determine cvp during sb. pottecher j , bouyges s , caron s , moreau x , beydon l dept of anesthesia, hôpital larrey, angers, france routine use of pulmonary artery catheters (pac) measuring continuous cardiac output but not svo is controversial in cardiac surgery. oxygenation derived variables like arteriovenous oxygen difference (avdo ) could better reflect supply-demand balance than cardiac index (ci). moreover, bedside, respiratory changes in arterial pulse pressure (deltapp) are a more reliable indicator of fluid responsiveness than pressures obtained from pac (cvp and pcwp). the goal of our study was to compare two hemodynamic assessment methods: one based on pac derived variables, the other taking avdo and dpp into account. fifty consecutive mechanically ventilated patients emerging from cardiac surgery in a university hospital icu were included without informed consent since pac insertion is systematic in our institution.an independent observer simltaneously recorded pac variables (cvp, pcpw, ci) (first set, s ), avdo and deltadpp (second set, s ). initially, the caring physiscian could get the first set of value, was asked about volemia, inotropism and vasomotor tone and gave a therapeutic option. then he had access to the second set of value, answered the same questions and was able to maintain or to change his opinion. patients were divided in four categories, according to deltapp (< or >= ) and avdo (< or >= ) and discrepancies between the two sets of answers were analysed. based on s data, new drugs or therapeutic were introduced ( % of patients): inotropic drug, fluid loading, diuretic, vasodilatator, vasopressor. after knowing s , in patients ( %) we challenged the initial decision. deltapp did not correlate with cvp nor with pcpw. similarly, ci did not correlate with avdo . according to table: case : therapies decided knowing s challenged by s : all should not have been fluid loaded; case : therapies decided knowing s challenged by s : they should have received a fluid load; case : therapies decided knowing s challenged by s : should not have been fluid loaded and should have received inotropes; case : therapies decided knowing s challenged by s : should have been fluid loaded and should not have received inotropes. deltapp >= (n) deltapp >= (n) avdo < ( ) case ( ) case avdo >= ( ) case ( ) case conclusion: conventional pac measurements do not allow optimal therapeutic guidance, postoperatively in cardiac surgery. indeed, ci does not reflect metabolic requirements at best measured by avdo . also, cvp and pcpw do not reflect hypovolemia contrarily to deltapp. the association all data provided by s albers j , heggemann f , kayhan n , bahner m , vahl c f abt. herzchirurgie, icu, abt. radiodiagnostik, chirurg. universit, heidelberg, germany noninvasive imaging of coronary artery disease (cad) using multidetector computer tomography (mdct) provides theoretically additional information to the classical d coronary angiography. the objective was to determine: ( ) how accurate is the d imaging compared to the d method? ( ) is it feasible to profit from the additional d information in the clinical setting? methods: study population consisted of consecutive patients with diagnosis of -vessel-cad (n = ).every patient underwent both, d coronary angiography and mdct scanning (siemens somatom plus vz, slice thickness . or . mm, pitch . , contrast medium ml). retrospective gating was used. d visualization was performed using raytracing. comparison of d and d imaging was performed in a blinded manner, blinded investigators scored applicability of the coronary segments (cs) for aortocoronary bypass grafting (acb) (necessary/not necessary) and stenosis (stenosis < %/ - %/ - %/ - %). ( ) agreement in applicability for acb was (cs number/% agreement) / . , / . , / . , / . , / . , / . , / . , / . , / . , / . . cs rarely being object to acb, showed poor agreement: / . , / . , / . , / . , / . . agreement in quantification of stenosis was: . % for the right coronary artery, . % for the left anterior descendent and . % for the circumflex coronary artery. ( ) d volume data were acquired in a single breathhold. temporal resolution was ms (reconstruction time min/image) enabling calculation of stroke volume. d visualization showed distribution of coronary calcifications together with non-calcified lesions. severe cad was identified noninvasively in all cases studied. ( ) accuracy of the d method was sufficient for bypass planning purposes. however, quantification of stenosis was not acceptable. ( ) data acquisition was quick, safe and provided additional data superior to conventional d (calcification, soft plaques, d quantification of stroke volume). in conclusion, patients with severe cad can be diagnosed with high accuracy using noninvasive imaging. boulo m , fleyfel m , robin e , lebuffe g , lecoutre h , onimus j , tavernier b , vallet b anesthesiology and intensive care medicine, university hospital, lille, france aortic surgery can be taken as a model of fluid and blood losses leading to volume status variation and hemodynamic impairment. these variations together with aortic clamping may compromise tissue perfusion. in intubated and ventilated operated patients, respiratory pulse pressure variation (∆pp) reflects ventricular preload dependency ( ). ∆pp is a good predicting marker of increase in stroke volume index (svi) after a fluid challenge (fc) ( ). the aim of this study was to evaluate whether preload dependency as assessed by ∆pp measurement was associated with impaired tissue perfusion. after approval from the local ethics committee, patients undergoing aortic surgery were prospectively enrolled. intraoperative hypovolemia was suspected when heart rate increased and/or systolic blood pressure dropped more than % from baseline. a ml colloidal fc was then systematically performed. automated gastric tonometry (tonocap, datex-ohmeda, finland) was used to assess pgco -petco before and after fc (co gap- ,co gap- ) . an increased co gap larger than mmhg can be taken as a threshold value of decreased tissue perfusion. an increased svi larger than % was identified as responder (r) and fc was repeated until svi did not increase more than % again. an increase in svi of less than % was identified as non-responder (nr conclusion: increased production of gut wall lactate was previously shown to be associated with increased leakage of macromolecules across the gut wall due to gut barrier dysfunction ( ). in this study we were able to show that even short and uncomplicated cpb leads to increased gut wall lactate detected by gut luminal microdialysis, indicating gut barrier dysfunction. simultaneous tonometry proved to be insensitive to these changes. we propose that gut luminal microdialysis in the rectum may be a good method to estimate markers of metabolism and gut barrier dysfunction during surgery and in the critically ill patient. matamis d , tsagourias m , vakalos a , synefaki e , kareklas m icu, papageorgiou general hospital, thessaloniki, greece introduction: copd patients are often aged, smokers and may suffer from right ventricular (rv) failure. moreover, they may have smoking and age -related diseases of the left heart, as ischemic heart disease or valvulopathies. left ventricular (lv) failure may induce hypercapnic respiratory failure (hrf) and mimic the clinical picture of copd, especially in patients with heavy smoking history. the aim of our study was to identify, in patients with hrf leading to mechanical ventilation (mv), the prevalence of rv, lv, or biventricular failure, the presence of severe valvulopathies and the impact of the targeted cardiac treatment (according to echo findings) on the mv days and mortality. over a period of seven years patients ( m and f) with a mean age of ± years and a mean apache score of ± included in the study. heart function was assessed with echo within the first hours from intubation. patients were divided in three groups (rv failure, lv failure and normal heart group) according to echo criteria. cardiac treatment was given according to echo findings. respiratory treatment and weaning process was identical in all patients. anova and chi square test were used for statistical analysis. the objective of this study was to measure the cost-effectiveness of an igm enriched immunoglobulin preparation in adult patients treated for severe sepsis and septic shock. we performed a meta-analysis followed by an economic analysis conducted from the hospital perspective in germany. effectiveness data from a meta-analysis of eight randomised trials (n= ) was used to assign probabilities in a decision model to estimate cost-effectiveness of igm enriched immunoglobulin preparation and its comparator standard therapy. analysis of effectiveness data used all cause hospital mortality as the primary outcome and intensive care (icu) length of stay (los) as a secondary outcome. benefit was expressed as lives saved (ls). published icu treatment cost data was applied to assess differences in treatment costs. cost-effectiveness was calculated as the incremental cost per ls. we develop a systematic data collection of all the admitted patients in our icu through a home-made software and database leading to a broad description of the population and activities of the icu during the last five years; this was correlated with the classical scoring systems of icu patients. the system was utilisator friendly made by automatically generating hospitalisation icu reports which guaranteed the use of the database and its completion. at the end of each year and after a data validation period standard reports were generated with classical parameters: mean age of the population, mean length of stay, mortality rate, readmission rate, daily repartition of all the icu admissions ... and correlated with the severity of the icu population. the following observations were noted during this five years period: non significant elevation of the mean age and of the mean icu length of stay, but significant reduction of the global mortality while the mean icu scores remain stable. in the same period the number of icu technical procedures (right catheterisation days, artificial ventilatory days, cvvhdf days...) was also significantly higher but without significant influence on nosocomial infection rate. interesting management data were also available: more than thirty procent of the icu patients were admitted during the night shifts (between pm and am) which can be an important data to discuss the staffing problems (during the night shifts for example). the use of antibiotics was also significantly reduced during the same period. a five years data collection period of standard icu indicators correlated with the use of severity scores can be an interesting icu management tool to promote quality of care (and communication procedures inside and outside the icu) and to reduce mortality and morbidity in icu populations. further studies are necessary to confirm these interesting observations. the national intensive care evaluation (nice) registry (www.stichtingnice.nl) aims to analyse and improve the quality of dutch intensive care. the nice registry contains data items for each patient admitted to one of the participating icus. to support the individual icus in comparing their population and performance to several standards nice has introduced an internet application, nice online. users of nice online compose their own data analyses by selecting a)functions, b)split-elements, c)comparisons, d)subpopulations. figure (left side) shows an example of a request for a graph which presents the mean length of stay (function) for survivors and nonsurvivors (split-element) of the user's own icu and of all participating icus together (comparison). readmissions to the icu are excluded (subpopulation). results of analyses, presented in graphs or tables, can easily be copied, e.g. to management reports. privacy of patients and of icus is ensured by )login and password, )encryption of transferred data, )using a copy of the original nice database without patient-or icu-identifying information, )disabling combinations of functions and comparisons which may lead to identifiable information. in figure transport of the critically ill patient between hospitals or intrahospital remains an hazardous road trip where the patient is exposed to less controlled circumstances outside the icu. to gain more insight in the incidence of complications, circulatory-and respiratory instability (ci/ri) related to intrahospital transport, we investigated transports from our surgical icu. all data concerning transports from the surgical icu to the department of radiology from - were retrospectively reviewed. clinical relevant circulatory instability (ci) was defined as the necessity to start vasoactive medication(vam)or to change the existing dosage of vam during or directly after transport to maintain a map ≥ . clinically relevant respiratory instability (ri) was defined as the need to change the settings of the mechanical ventilator (fio , peep, minute volume) during or directly after transport. we also evaluated the administration additional opiates and sedatives (aos) prior to or during transport and the possible impact of i.v. administration of contrast fluid jopromide (ultravist ®) on renal function. sedation and analgesia are essential components of patient care in the intensive care unit (icu). "bottom up" costing of intensive care is more accurate but more labour intensive and difficult to perform compared to "top down" costing ( ). "bottom up" cost of sedative, analgesic and neuromuscular blockade drugs have not been reported. we therefore performed an audit of the cost of these drugs in our icu using the "bottom up" costing approach. over a month period, we prospectively recorded the daily amount of sedative, analgesic and neuromuscular blockade drugs administered to patients in a -bedded icu and multiplied the amounts by the cost of drug per milligram using pharmacy costing figures. patients were divided into groups that corresponded, roughly, to the length of stay quartile marks. out of patients admitted during the study period, data were collected for ( %). we also collected data for % ( days) of icu patient days. table shows cost of sedation per group, patient and icu day. around % of the cost was on drugs administered to the % of patients who stayed in icu for more than hours. propofol and alfentanil were the commonest drugs used (administered to % and % of patients respectively) and the most expensive ( , and , respectively). total cost was , which was % of the pharmacy ("top down") cost. cost of sedation per group. several medical specialities have conducted surveys among their residents during their training, in order obtain a feed back and assess possible improvement issues. at our knowledge, not such a survey has been conducted in europe. in france, icu specialisation can be obtained by two separate trainings: either specifically in medical icus or jointly to the anaesthesia training which is followed by the majority of future icu practitioners. a shortage in icu doctors is expected, urging raised efforts to make this training as attractive as possible. this inquiry was intended as a first step in this purpose. a question questionnaire was mailed to the first year residents (y ) whereas a question one was sent to the forth year residents (y ) registered to the joint icu-anaesthesia training program (lasting years) in france. anonymity of answers was insured. a total of questionnaires were received ( %) for y and ( %) for y . main y answers were: age: ± year, ( % female). they chose icu for good job opportunities ( %), a clinical ( %) and dynamic ( %) speciality. they had discovered icu-anesthesia during medical studies ( %). night shifts were: not disturbing ( %), are shared by many other specialities ( %), and are more interesting that non-specialised night wards ( %). a % of them hesitated before starting this specialisation. half of them changed geographical region for specialisation. medical english was spoken and red: %. a computer was owned personally: %. main y answers were: ± year, ( % female), their -year training was judged for theory: excellent ( %), good ( %), fair ( %); for practical teaching: excellent ( %), good ( %), fair ( %). medical english was spoken and red: %. only % had a position at the end of their training. they wished to join public institutions: %, private: %. research was a professional issue for %. future practice restricted to icu was aimed by %, whereas % preferred anaesthesia and % emergency medicine and pain clinics. they had published in french at least once during training: %, in english: %. additional degrees (mainly in infectiology and as sub-specialisation in some icu techniques) were obtained by % during specialisation. periods spent in non-academic hospitals (one year) were rated as excellent: %, good: %, fair: %; and medical supervision was judged excellent-good in %. they spent an average euros/year for medical furniture (books, computer). a computer was owned personally: %. finally, % did not regret choosing icu (and anaesthesia) as a speciality. training in icu (and anaesthesia) was judged as good especially for practical aspects by most of residents. about a third aimed at working exclusively in icu. more efforts should be performed to improve formal job offer at the end of the training. conclusion: diagnostic and imaging testing represents a significant amount of hospitalization costs in our icu due to the high number of tests performed per patient per day and especially for abg analysis. thus, a better control of lab tests ordering will result in costs reduction and a cost containment policy is becoming mandatory. kanevetci b n a c i , dosemeci l , y?lmaz m , cengiz m , ramazanoglu a anesthesiology and reanimation, akdeniz university, antalya, turkey the common problem arising in the icu's is the use of the beds for the patients who are expected not to benefit from icu treatment. in this prospective study, we aimed to determine the proportion, costs, length of icu stay and prognosis of those patients who were expected to die according to our clinical experiences. one hundred and forty five patients over year of age admitted to our -bed icu between march and february and expected not to benefit from icu treatment according to the experiences of the physicians working in icu. the apache ii, saps ii and gcs scores were noted and according to those scores, the estimated mortality rates were determined by the formulas. also icu stay, icu beds occupied by those patients, icu and hospital discharge mortality and morbidity and costs were determined. we didn't change the treatment strategies of those patients. the patients who had high risk of mortality but could possibly recover completely after given therapy were not included in the study. the mean age was . ± . . the most common underlying diseases were nontravmatic intracerebral hemorrhage ( % . ), cerebrovascular accident ( % . ), head injury ( % . ), metastatic tumors and vascular diseases of gastro-intestinal tract ( % . ), cardiac arrest ( % . ), lung cancer and end-stage lung diseases ( % . ) and the others ( % . ). the mean gcs, apache ii, saps ii scores were . ± . , . ± . , . this represents a % increase in activity with no change in the number of beds available or alteration to admission criteria. in both time periods bed occupancy was > %.length of icu stay decreased from a mean of . days to . days (p< . )and the length of ventilation decreased from . days to . days (p< . ). this reduction was observed across all specialites excluding neurosurgery. the use of information technology to provide iterative feed back has reinforced the adoption of the ventilator and euglycaemia carebundles making the desired elements of the care bundle the default mode within the intensive care unit. the culture of the icu has changed enabling more reflective practice ready for the adoption of the sepsis care bundle and other packages of evidence based treatment. papadopoulos a c , karakoulas k k , vassilakos d , filippidou m , skourtis c t h , giala m m anaesthesiology and intensive care, ahepa university hospital, aristotle university of thessaloniki, thessaloniki, greece proper heparinization is perhaps the most important aspect of sampling technique for arterial blood gas and ph analysis. ( ) the aim of our study was to evaluate two sampling techniques for arterial blood gases and ph measurements and their possible cost implications. we obtained paired samples from postoperative spontaneously breathing patients in icu having an indwelling arterial line. body temperature and blood hb of patients were within normal ranges. commercially available preheparinized (quik a.b.g.tm, marquest medical products, co, usa) and self-prepared with liquid sodium heparin syringes were used. ( ) the pao , paco and ph values were obtained from the same analyzer within minutes of sampling. the cost of each sampling technique was also estimated. data were analyzed by bland and altman analysis. the mean differences (+/-sd) between the results of the sampling techniques were - . (+/- . ) mmhg for pao , . (+/- . ) mmhg for paco , and - . (+/- . ) for ph. the % confidence interval was . - . for pao , . - . for paco , and . - . for ph. the correlation coeffiecient (r) between measurements from the two syringes was r= . for pao , r= . for paco , and r= . for ph. the cost of each sampling technique was . euros for preheparinized and . euros for self-prepared syringes, per sample. our data demonstrated a relationship between the results of the two sampling techniques, close enough, to justify the use of self-prepared heparinized syringes for arterial blood gas and ph measurements. a significant -fold cost reduction would result by the routine use of this latter technique. we checked the performance degree of the following measures in two stages, pre and post intervention: prophylaxis of pulmonary embolism (pe), elevation of the head of the bed to > degrees, intensive insulin therapy, lower tidal volumes in acute lung injury, daily trial of spontaneous breathing, daily withdrawal of sedation, stress ulcer prophylaxis and use of nimodipine in subarachnoid hemorrhage.the intervention consisted in the handing over of written information and talk on the therapeutics measures to the medical staff and to the nursing. conclusion: with only one diagnose, the system is unable to identifie the complex cases. the stay and most of the icu procedures, do not interfere nor modify the weight of the drg. dias f s , nagel f , wawrzeniak i , fonseca c , guerreiro m , froemming j , canabarro m general icu, hospital são lucas da pucrs, porto alegre, brazil there is no information regarding the impact of the resident in critical care medicine on the outcome of critically ill patients in our environment. we performed a comparative study between two periods in an icu, the first without ccmsp (pi) and the second with ccmsp (pii). we collected prospectively the following data: gender, age, apache ii and mods in days (d ), (d ) and (d ), prevalence of sepsis/septic shock, duration of mechanical ventilation (mv), use or renal replacement therapy and icu survival. between january and june , there were icu admissions, of which in the pi period ( ) ( ) and in the pii ( ) ( ) ( ) ( ) . after the implementation of a ccmsp, despite an increase in organ dysfunction in d and in prevalence of sepsis/septic shock, there was a significant reduction in the utilization of renal replacement therapy and mortality. these findings suggest that, the participation of a ccmsp medical resident was an important factor in the support of septic patients, reduction in renal replacement therapy and mortality. pachl j , haninec p , tencer t , tomas r , mizner p anaesthesiology and ccm, dept. of neurosurgery, charles university, rd school of medicine, prague, czech republic introduction: delayed cerebral ischemia due to vasospasm is a major cause of death and disability in patients after subarachnoidal hemorrhage (sah). the outcomes of several experimental studies designed to investigate an effect of nitric oxide donors on the treatment and prevention of this life-threatening condition appear controversial [ , ] . the purpose of our study was: ) to specify the influence of prophylactic subarachnoidal administration of sodium nitropruside (snp) on the incidence of vasospasm ) to determine the role of brain tissue monitoring-pbtio , pbtico and phbti, measured in the area of high risk of vasospasm, for management of snp administration. prospective observational study on patients with non-traumatic sah (hunt-hess grade i-iv) with secured ruptured aneurysma. in postoperative period all patients underwent triple-h protocol with calcium channel blocker. subarachnoidal preventive snp was administred in initial dose of mg by catheter which was inserted to basal cisterns during neurosurgical procedure. the timing of following dosage (period of or hrs) was directed by the changes of pbtio , pbtico and phbti after snp administration. snp administration did not exceed a period of postoperative days. the brain tissue respiratory values were estimated by codman neurotrend multiparameter sensor®. the blood flow velocity was simultaneously measured on circuit of willis by transcranial doppler sonography (tcd). in case of detected signs of vasospasm the dosage of snp was increased and maintained by monitoring modalities (tcd and values of pbtio , pbtico , phbti). : patients were enrolled. no brain infarction was developed in the studied group. all patients survived. the vasospasm was identified in two patients by tcd and simultaneously by changes of tissue respiratory values.these patients arrived at hospital with delay of several days from the beginning of symptoms. the overall outcome was good in out of patients including patients with vasospasm. preventive subarachnoidal administration of snp controled by tcd and brain tissue multiparameter sensor might increase the effect of triple-h protocol with calcium channel blocker. multimodal brain tissue monitoring could be the way to maintain titratable prophylactic snp administration. the therapeutical intervention requires considerable raise in doses frequency and its effect cannot be evaluated until now. basílio c , rio e , barbosa s , paiva j , mota a department of anesthesiology and critical care, department of neurology, hospital s. joão, porto, portugal the search for drugs to minimize neuronal lesions after prolonged seizures has been the goal of treatment of patients with status epilepticus. topiramate is a new anticonvulsant with multiple mechanisms of action: potenciation of gaba, blockade of glutamate receptors (ampa), inhibition of sodium and calcium channels. recent studies state that topiramate is effective in treating refractory status epilepticus and may reduce post-status epilepticus neuronal lesions. description of two clinical cases of patients, admitted in the icu, with status epilepticus refractory to conventional therapy were treated with topiramate. case : woman, years old, with a history of alcohol abuse and psychiatric disease was admitted with encephalitis and tonic-clonic seizures. the patient was treated during days with hidantin, valproate sodium and thiopental. despite this, the eeg showed a periodic epileptiform activity. topiramate ( mg daily) was added to valproate with clinical improvement and an absence of ictal discharges on eeg after days. case : male, years old, admitted with hematemesis, shock and eventual cardiopulmonary arrest. admitted in the icu for postoperative care of duodenal ulcer surgery. two days later, the patient developed partial status epilepticus. he was treated with midazolam, clonazepam and phenytoin. the eeg showed bilateral periodic epileptiform discharges with no recent cerebral lesions in the cerebral ct scan. pentobarbital coma was induced for seven days. status epilepticus persisted despite appropriate measures and on the th day topiramate ( mg daily) was added to clonazepam. after days, there was clinical improvement and eeg showed periodic generalized slow wave activity with motor response to painful stimulus wich was a prediction for a better outcome. in both cases, topiramate was able to induce clinical improvement and disappearance of ictal discharges in the eeg in case . however, in case the pattern of eeg persisted with signs of better prognostic. it needs further investigation with larger prospective series to better confirm the results. van tulder l , chioléro r , regli l , revelly j , berger m surgical intensive care unit, neurosurgical, university -chuv, lausanne, switzerland hypovolemia is deleterious in patients developing a vasospasm after subarachnoid haemorrhage (sah). fluid resuscitation to induce hypervolemia is considered by many as the cornerstone of management. the efficacy of this approach is however not established.the aim was to assess the effect of fluid resuscitation on blood volume and fluid balance during the initial phase of icu management for cerebral vasospasm after sah retrospective analysis of the database of a clinical information system (metavision, imd soft). patients with the diagnosis of vasospasm after sah (angiography) were studied. cardiac index (ci) and intra-thoracic blood volume (itbv) measured with transthoracic thermodilution (picco, pulsion) were determined as part of the clinical management. fluid supply consisted of isotonic saline. the value of mean arterial pressure (map), ci, itbv, as well as fluid supply and fluid balance at time , , , and hours were analysed (presented as mean±sd). comparisons between these time-points were performed with one-way analysis of variance for repeated measurements. p< . was considered significant. results: ten patients were studied. fluid supply amounted to . ± . l at h, . ± . at h, and . ± . at h (p< . ). initial map was ± mmhg, ci . ± . l/min/m^ , and itbv ± ml/m^ . there was no significant change over time for these variables, although itbv increased to ± at h, and decreased to ± ml/m^ at h. cumulative fluid balance amounted to . ± . l at h, . ± . at h, and minus . ± . at h (not significant), due to a diuresis. despite aggressive volume loading with normal saline, the fluid balance of patients with vasospasm was not significantly altered over the first hours of icu admission. these preliminary data suggest that, these patients may become rapidly resistant to fluid loading due to induced natriuresis. this escape phenomenon, may contribute to the absence of documented benefit of fluid expansion in vasospasm this was a prospective study design. all cases of sah(n= )of ages between to years which were admitted over a period of thirteen monthswere included in this study. aneurysm detection criterion was digital substraction angiography or ct angiography. mean hunt-hess grading in coiling group was , whereas in clipping group it was . .fisher grade was > in all patients clipped and between - in patients coiled. exclusion criteria included cases witha-v malformation, preexisting neurological deficit or where no intervention was done. outcome analysis was done using modified rankins scale (mrs) and world federation of neurologicalsurgeons gradingwfns).stastisticallyanalysed using chi-square and standard error of difference between two means-tests results: % aneurysms (n= ) were coiled and %(n= ) were clipped. there were no significant differences in age race, gender, but there was a significant difference in the hunt-hess grading ( ajderian s stepan , petrov n department of anesthesiology and icu, military medical academy, sofia, bulgaria background: the modulation of the intracranial pressure in patients with head injuries is important precondition in the optimizing of the therapeutic management. the goal of the authors is to study the influence of the hypocapnea over intracranial pressure as a part of complex treatment of the head injuries methods: : there are encompassed patients with head injury ct-scan data for brain contusion and perifocal edema who assessed according glasgow comma scale under pct. all patients had ventricle drainage placed in one of the lateral brain ventricles in order to measure intracranial pressure and received standard therapy. the patients divided in two groups: i -in patients we applied controlled hypocapnea with ???? value between - mm hg and ii group - patients with ???? values between - mm hg. statistical program was used -sd, tcriteria and p-value. we received significantly dropping of the intracranial pressure in patients set at artificial ventilation with moderate hypocapnea. in first group the mean value of intracranial pressure was . mm hg. in this group ( %) patients died. botsis p , litis d , nikolopoulou i , chatzivasiliadis h , ioannidou h icu, kat hospital athens greece, athens, greece acute pancreatitis and acute acalculus cholecystitis are frequent and serious complications in severely head traumatized patients. the aim of this study is to find if the early administration of somatostatin plays a role in the prevention of these complications. methods: brain injured icu patients ( men and women), with no abdominal or thoracic trauma, were entered the study. age +/- , apache ii score ≤ , gc +/- on admission, with no signs of preexisting gallstones in the u/s of the upper abdomen. surgical on conservative therapy for the brain injury, with drugs known not to interfere with the pancreatic and biliary system and early e.n. via nasogastric tube, was performed. after the admission in icu they were divided into two groups: a) at group a ( patients) somatostatin ( ?g/h) was added in the standard therapy for the next days. b) at group b ( patients), the standard therapy was continued, as planned. daily laboratory tests for: temperature, blood type, bilirubin, blood sugar, ca, alkaline phosphatase, serum-urine amylase, serum-lipase and daily clinical examination as well for: pain and tenderness of the abdomen, vomiting, distention, decreased bowel sounds. every second day an u/s of the upper abdomen was performed. at patients of group b ( %) and at patient of group a ( %) acute pancreatitis was developed the th day-of-stay in icu. at patients of group b ( %) and at patients of group a ( %) acute acalculus cholecystitis was developed as well at the same day. diagnosis of both complications was based on clinical and laboratory findings. early administration of somatostatin in brain injured icu patients diminishes the possibility of development of acute pancreatitis, but does not influence the development of acute acalculus cholecystitis in these patients. rijnsburger e r , girbes a r , spijkstra j j , peerdeman s m , polderman k h department of intensive care, department of neurosurgery, vu university medical center, amsterdam, netherlands hypothermia is widely used to improve neurological outcome in various types of neurological injury; however, this has not yet been well studied in patients with subarachnoid haemorrhage (sah), where cooling has been used mainly to prevent or treat vasospasms [ ] . hypothermia has been used to treat refractory intracranial hypertension in patients with tbi and severe stroke; however, its potential to treat cerebral oedema in patients with sah has not been well studied [ ] . only one small feasibility study dealing with this issue has been published, but here various interventions (such as induction of barbiturate coma and mild hypothermia) were applied simultaneously [ ] . thus it remains to be determined whether induction of hypothermia per se can decrease icp in patients with sah. methods: patients admitted with sah and refractory intracranial hypertension (icp> mmhg lasting longer than minutes despite prevention of hypovolemia or induction of hypervolemia, induction of hypertension, and treatment with nimodipine, mannitol and hypertonic saline, and following coiling or clipping of the cerebral aneurysm) were treated with induced hypothermia ( - oc) according to a protocol guided by icp. hypothermia was induced using cooling blankets and infusion of refrigerated fluids. target temperatures were achieved within (range - ) minutes. icp decreased from . ± . to . ± . (normal value: < mmhg). icp< mmhg was achieved in / patients; in / patients icp decreased but remained at levels between - . hypothermia was maintained until normal icp had been observed for hours, after which patients were slowly rewarmed (again guided by icp). hypothermia was maintained for an average of ± hours. no patients died during treatment with hypothermia. two patients ( . %) died in the icu after hypothermia was discontinued; ( . %) died in the subsequent months. good functional outcome at months (glasgow outcome score - ) was achieved in patients ( . %). previous studies had reported a high incidence of side effects such as pneumonia in patients treated with hypothermia. we observed no increase in infectious problems, perhaps because our patients were treated with sdd. conclusion: induced hypothermia can be safely and effectively used to treat refractory intracranial hypertension in patients with sah. vasospasms and intracranial hypertension are thought to be the two key factors in the development of additional brain injury in sah; however, it remains to be determined whether this treatment also improves neurological outcome and survival in these patients. to evaluate the usefulness of magnetic resonance images (mri) in patients suffering from severe brain injury, unfavourable clinical progress and marshall brain scans types i and ii. fifteen patients with severe brain injury were retrospectively studied, considering their age, gender, initial gcs initial head scans and mri upon admission to intensive cares unit (icu), their outcome (gos) at discharge form icu. mri level i was defined as being when the subcortical white matter was affected, mri level ii being level i plus affectation of the corpus callosum, and mri level iii was defined as being mri-ii as well as damage to the brain stem and spinal cord. gos was also evaluated, defining gos i-ii as positive and gos iii, iv and v as negative. the average age of the patients studied was . years old. nine ( %) were males and six ( %) were females. the average gcs on admission was . . five patients ( %) had and initial marshall scan type i and ten ( %) had marshall scan type ii. two patients ( . %) showed mri-i, five ( %) mri-ii and eight ( . %) mri-iii. in the two patients with mri-i their initial gcs was . and both progressed favourably and were discharged from intensive care unit. the five patients with mri-ii had an initial gcs of . three of these ( %) did not progress well. in the eight patients with mri-iii, the initial gcs was . . seven of these ( . %) progressed unfavourably when discharged from intensive care. magnetic resonance images are related to the severity of head damage and have a high diagnostical and prognostical value for use with patients suffering from diffuse axonal lesions. pakulski c , badowicz b , bak p , kwiecieñ k , mikulski k , surudo t department of emergency medicine, pomeranian medical university, szczecin, poland, intensive care unit, regional hospital, pasewalk, germany, traumacentre, pomeranian medical university, szczecin, poland the management of patients with severe head injury should include monitoring of mean arterial pressure (map) and intracranial pressure (icp), cerebral perfusion pressure (cpp) and levels of jugular bulb oxygen saturation (sjo ). the aim of the study is to present the outcome in patients with severe central nervous system injuries treated in the traumacentre, pomeranian medical university. this retrospective study evaluates the methods of treatment in patients with severe brain injury treated between july st, and december st, in the our traumacentre. these patients were admitted to our institution directly from the accident sites or from the referring hospitals during the first post-injury day. glasgow coma score of or less was the inclusion criterion. in all patients map and icp values were monitored, cpp values were calculated, and additionally in patients sjo values were measured. the initial treatment protocol was always the same: analgosedation (fentanyl, midazolam), normoventilation, osmotic diuretics (mannitol , - , g/kg/day in doses and furosemide , - , mg/kg/dose in doses), supine position. the protocol was modified with regard to map, icp and sjo values (brain ischemia or brain hyperemia). the patients with increased icp values resistant to osmotic diuresis were scheduled for unilateral or bilateral decompressive craniectomy. the results of treatment were evaluated with glasgow outcome classification after months following the injury. the mortality in our ample was , % - deaths out of treated patients. isolated brain injury was the cause of death in patients, and in patients-multi-organ injury. sixty seven ( , %) patients were transferred from the trauma icu for further treatment to other wards. out of the patients discharged from the trauma icu patients died -goc ( , %), none of the patients were in the neurovegetative state -goc ( %), patients with persistent aphasia or hemiparesis were classified as goc ( , %), patients with mild neurological deficits that didn't impair their social life were classified as goc ( , %), and finally patients without any neurological sequelae were classified as goc ( , %). out of patients with treatment modified according to sjo values patients survived. brain hyperemia was found in non-survivors and severe brain ischemia was found in non-survivors. the outcomes in our patients treated with the protocol based on monitoring of cpp and sjo are encouraging. monitoring of sjo is a significant element of the modern treatment protocol for patients with brain injury and the best method of diagnosing both hyperemic and ischemic episodes. anastasiou e , tsaousi g , giannakou m , efthimiou k , geka e , albanèse j , boyadjiev i , chaabane w , antonini f , leone m , martin c intensive care and trauma center, hopital nord, marseille, france in severely head-injured patients, it is often needed to add vasopressive amines to maintain adequate cerebral perfusion pressure (cpp). norepinephrine (n) and dopamine ((d) are proposed, but their vasoconstrictive effects may be deleterious for regional circulations.objective is to compare the effects of d and n on cerebral, splanchnic, and renal circulations when used to raise cpp after severe head injury. prospective, randomized, cross-over study including patients with head trauma, requiring intracranial pressure (icp) monitoring and vasopressor therapy. after and min of administration of d or n, were studied : systemic hemodynamics (mean arterial pressure (map), cardiac index (ci), central venous oxygen saturation (svo ), cerebral circulation (icp, cpp, transcranial doppler : mean velocity in the middle cerebral arterey (vmca)), splanchnic circulation (gastric intramucosal ph (phi)), renal circulation (urin flow (uf), creatinine clearance (clcreat) and metabolic data (energy expenditure) (es), oxygen consumption (vo ), and lactate (lac)). the wilcoxon signe test was used with p< . considered significant. they are presented in table . no significant differences were observed in systemic hemodynamics when the two drugs were compared. none of the studied local circulation were altered with any of the studied drugs. vakalos a , doukelis p , kareklas m , setzis d , matamis d i.c.u, papageorgiou general hospital, thessaloniki, greece in patients with severe head injury the main complication is cerebral edema and intracranial hypertension that may cause cerebral ischemia, disability and in certain cases brain death. transcranial doppler (tcd) is a non-invasive, bedside technique which detects the blood flow velocities in the great intracranial arteries. the aim of our study was to investigate if there is a relationship between tcd findings and the outcome of patients with severe head injury. methods: patients with severe head injury (gcs< ) were included in our study. from these patients were males and females. their mean age was . years, with a range from to years. among these patients died in the icu ( . %). in each tcd examination we measured the maximum, mean and the end diastolic velocity (vmax, vmean and vmin respectively), and we calculated the pulsatility index (pi). the patient's outcome was recorded at the disharge from the icu according the glasgow outcome scale as following: good recovery (gr), moderate disability (md), severe disability (sd), persistent vegetative state (pvs) and death. the patient's outcome was compared with the cerebral flow velocities and the pi index. there was a statistically significant difference in the mean values of all velocities between the outcome categories of the patients. we found the stronger difference in the mean values of vmax and vmin between the death and the categories pvs and sd, and in the mean values of vmean between the death and the categories pvs, sd and md. inter-hospital transfers of the critically ill patient raises important medical and ethical dilemmas . in a transfer questionnaire assessed the views of intensivists in scotland, regarding the problem, that when no intensive care bed is available, is it ever acceptable to transfer an existing patient to another facility to create a bed for a new referral . % of scottish consultants would not transfer a stable patients to create space for a new patient under any circumstances. reasons given included no intrinsic benefit to the current patient and that there was a designated transfer team who were experienced in transferring critically ill patients and providing critical care without walls. this time the questionnaire was repeated among intensivists in south thames to determine any regional variation. the questionnaire was sent to consultants in intensive care units (icus). consultants were asked if they would ever consider transfer of an existing patient to another hospital in order to admit a new referral and if so what would they consider the most compelling reasons for doing so.we also asked whether or not formal consent was sought prior to undertaking a transfer and what risks, if any, were explained to the patient and their family. prior knowledge of their wishes regarding this form of therapy is essential in order to preserve their autonomy. objective: to examine the knowledge of copd patients related to the illness, about mechanical ventilation as a potential treatment and their wish to participate in the health care decision-making process and advanced care planning. methods: a qualitative research of an intentional sampling of homogeneous subgroups with copd outpatients (ii and iii by gold score) was performed between november and march in an ambulatory setting by means of semistructurated interviews and later content analysis with a sample size defined by saturation criteria. : male outpatients with copd were interviewed (age range from to years). they feel to be correctly informed and trust their respiratory physician or family doctor, but in most cases there have not been prior discussions with the health care team concerning mv as a potential treatment of their disease. they consider themselves to have a good quality of life although their health is not good. they are interested in participating in the health care decisionmaking process. in case of treatments and cares as mv or admittance to an intensive care unit they accept any option that keeps their usual quality of life at the same level. this sample of copd patients are in favour of advanced care planning and show the aim to shape their own specific advanced directives. conclusion: patients with copd do not have enough information to take autonomous decisions. although mv is a potential treatment for copd patients with acute exacerbations, most of them were unaware of mv as a possible treatment option for them because discussions about this topic occur infrequently between physicians and patients. they are in favour of participating in health care decision-making with physicians and accepting any therapy that makes them able to keep their quality of life. the patients consider advanced directives as an opportunity to express their preferences in order to be considered when they are not able to communicate with the health care team. conclusion: wh/wd in ireland is common ( %) and similar to european practice( %). there was no sdp although the prevalence was % in europe. the increased use of sedation ( %) in association with wd suggests an awareness of patient comfort. despite only one advance directive, patient wishes were known in %. icu physicians were the primary initiators of eol discussion ( %) suggesting their important role in icm practice. the majority ( % v %) of eol decisions were taken during 'office hours'. this is finding warrants further study; it may represent the inexperience of on call personnel or may reflect the complexity of the decision. despite popular opinion extubation is infrequent and comfort measures tend to be continued. an anonymous questionnaire including questions was sent out to all staff mebers including medical staff, nurses and physiotherapists. questions included potential benefits to staff and patients and concerns regarding the use of restraint. of the questionnaires sent out, were returned completed. most respondents ( , %) felt that sedative drugs are used as a form of restraint in care of the patients. most ( , %) thought there is a place for physical restraint in critical care and that it might benefit patients, ( %) believed it might benefit staff but ( %) of responders had concerns regarding the use of physical restraint. a majority ( %) stated that concerns would be answered if undertaken as part of a clear unit policy. responders ( %) would be happy to use physical restraint with sedation to ensure patient's safety, but only ( %) would agree to its use if they were a patient. the majority of responders ( %) felt that some form of physical restraint may be appropriate. practice should be re-examined and consideration given to the use of some physical restraint in addition to sedative drugs. in some patients shock is so severe that extremely high doses are needed to elevate their blood pressures. studies show that % of icu physicians withhold or withdraw vasopressor administration because patients did not respond to "maximal" therapy. however the "maximal" dosage of vasopressors is not defined so each physician has his/her own limit as to the highest dose of adrenaline or noradrenalin that he/she will administer to a patient. many icus physicians order doses of up to mg of adrenaline or noreadrenalin per hour ( mg/kg/hour) we hypothesize that this dose is futile. following helsinki approval, all intensive care charts from were reviewed ( patient charts patient days) patients were found to have received a vasopressor. demographic data as well as apache ii scores, icu days and total hospital days, biochemistry, liver functions, blood gases, diagnoses and secondary complications were recorded. vasopressors, adrenaline and noradrenalin, maximal doses , initial dose, number of days/hours patient received all subsequent doses, and mortality were recorded. the data showed that all patients who received more than microgram per kilogram per minute of adrenaline or noradrenalin died. (p value < . ). the length of time that the patients received vasopressors had no influence on survival. these data showed a direct correlation between the number of days a patient received vasopressors and the length of hospitalization. the length of time a patient received low dose of vasopressors had no significance on mortality, but the vasopressor dose had an indirect association with survival. there was no significance difference in age between survivors and non-survivors. the elderly (over years of age) and the young had the same of survival rates when receiving vasopressors. patients who received more than microgram per kilogram per minute of noreadrenaline or adrenaline died. it thus appears that therapy with such high doses is futile. th annual congress -berlin, germany - - october s ehrmann s , mercier e , bertrand p , dequin p medical intensive care unit, department of biostatistics, bretonneau university hospital, tours, france to carry on indefinite invasive treatments in the intensive care unit for patients with a high probability of death in the short term, is ethically objectionable. on the individual level it extends the agony and suffering of the patient and on the community level it consumes precious limited resources. as there is no tool that can objectively and reliably help the physician to make ethical decisions of therapeutic limitations, we examined whether the absolute change of the lod score between the day of admission to the icu and the third day of unlimited treatment could be predictive of death in the icu. methods: consecutive patients admitted to the icu were prospectively included during a three-month period. for all of these patients the simplified acute physiologic score ii (saps ii) and the lod score (lod ) were calculated on the day of admission. the lod score was calculated again between the nd and the th hour in the icu (lod ) for the remaining patients ( patients left the icu before the nd hour, of whom died) without exclusion criterions ( therapeutic limitations before the nd hour). the endpoint was death in the icu. the performance of the deltalod = lod -lod index to predict death was examined through univariated and multivariated analysis and through calculation of the positive predictive value of death (ppv) for different cut-offs. after hours of unlimited treatment in the icu, deltalod appears to be a good predictor of death in the icu, independent of the initial severity of disease. the ppv is not high enough even for high cut-offs to assist with making individual therapeutic limitation decisions. accordingly to the bayes theorem, the performance of deltalod deserves to be evaluated in a population of patients exhibiting greater severity of disease. developed as an answer to the stressful everyday practice. indeed, in icu, the caregivers are under a great pressure induced by several factors: the explicit urgency to act, the implicit burden to face patients and families in critical situations and the requirement of a high level of technicity. such a creative workshop was set up for physicians and nurses in our unit, in order to give the opportunity to express the "unspoken", to share the experiences, explore the patient's perspectives. methods: sessions of hours were planned. at the first session, the participants were proposed to imagine a situation starting from one of pictures of icu patient. they were invited to write as "i" or "you" in order to take the patient's or the relative's place through their imagination. the written texts were distributed to all participants and discussed at the second session. the workshop was organized and moderated by a senior specialist in intensive care medicine and the person in charge of the medical humanities teaching program. the participation to the workshop was optional. : physicians ( m, f) and nurses (all f) and ( f, m) medical students participated to workshops. one month later, they answered a questionnaire. all participants gave a positive global appreciation and underlined the importance of the discussion which allowed the sharing of their experiences. felt encouraged to adopt the patient's perspective, were reassured about their feelings of their practice. the relevant themes of the texts were the behaviour of the caregivers, the abrupt change of worlds, a strange perception of time, the importance of noises in the icu environment. despite the similarity of the themes, the way the narrators shaped the story was very different. the author's selection of words, details, and literary devices confers the personal touch of his/her experience. none of them considered the writing as an obstacle to their expression, even if they first felt difficult to step in the writing process. all of them were satisfied with the workshop and with the sharing of their experiences. the most important point reported was the awareness that the others, either physician or nurses, had the same preoccupations and feelings. the fact that this workshop did not give any concrete recipe for the resolution of problems induced some frustration among icu caregivers. there have been few studies to investigate how well the results obtained by co rebreeding to assay cardiac output (co) ( - ). a reliable non-invasive co monitor could enhance patient safety and reduce risk. this study evaluates a nico measurement and calculated derived parameters from co. co was based on differential from of the co fick equation. twenty three co measurements with derived parameters were obtained from male patients admitted to a medical intensive care unit, st vincent hospital, medellín, colombia, . the nico monitor (novametrix medical systems inc) was connected between the ventilator circuit and tracheotomy tube. previously, multilumen swan-ganz thermodilution catheters, edwards labs were placed into the external jugular vein via an introducer sheath. co was calculated from pulmonary blood flow by correcting for shunt. the difference between consecutive thermodilution and nico measurements was calculated. also, calculated derived parameters from s-g catheter such as ci, svri, lvswi, rvswi, and svi were compared to measurements derived from nico. on nico measurements, central venous pressure replaces the value of pcwp. correlation between the two methods was determined by pearson´s correlation. a bland-altman analysis was used to compare the bias and precision of the two methods, and a difference > % was considered as a limit of accuracy. significance was assessed at the % confidence interval. twenty-three matched pairs of consecutive changes in co and calculated derived parameters measurements were recorded in three critically ill patients. with a mean (±sd) age of , y. relationship between changes in thermodilution and nico co measurements was significant (r = . , p = . ). none of calculated derived parameters (ci, svri, lvswi, rvswi, and svi) were considered significant. only co and rvswi showed difference between means to compare the degree of agreement measurements (co . % and rvswi . %% respectively). the results of the current study agree with those from previous studies where is suggested that nico monitor would provide a good alternative to invasive co measurements on critically ill patients. however, nico cannot be a substitute to get calculated derived parameters when pulmonary artery occlusion pressure is a necessary value. (std) has been demonstrated to be sufficiently accurate for estimation of intrathoracic blood volume (itbv) and evlw when compared with the clinical standard, i.e., transpulmonary thermo-dye dilution (tdd) [ ] . in this study, we examined the reliability of std for estimation of itbv and evlw with respect to several influencing factors. we retrospectively analyzed data of critically ill patients patients ( male, female; age - , mean ± years) who underwent extended hemodynamic monitoring by the transpulmonary thermo-dye dilution technique. the agreement between itbvstd/ itbvtdd and evlwstd / evlwtdd was determined as mean bias and standard deviation (sd) within different categories (level of peep, pao /fio ratio and evlw). linear regression analysis was applied to compare overall bias between evlwstd and evlwtdd with the different factors. : mean bias ± sd within the different categories are shown in the clinical judgement of an adequate volume status in critically ill patients remains a challenge. current clinical parameters to assess the adequacy of resuscitation often do not adequately reflect the volume status of the patient. therefore additional information about the adequacy of circulating blood volume in critically ill patients could be of great value. on occasions in critically ill patients on a surgical intensive care unit the adequacy of circulating blood volume (bv) was clinically judged by the parameters central venous pressure, mean arterial blood pressure, heart rate, and urine production. clinically estimated blood volume was compared with measured blood volumes using pulse dye densitometry with indocyanine green (ddg- a/k, nihon kohden, japan). obtained bv measurements were categorized in low blood volume (lbv), normal blood volume (nbv), and high blood volume (hbv) using reference values for men and women - ml/kg and - ml/kg respectively( ). clinical judgements led to hypovolemic (hv) versus not hypovolemic (nhv) cases. there was no statically significant relation between the clinical judgement of volume status and measured bv. in hv patients no lbv was measured and in clinically nhv patients lbv as well as hbv were measured. no significant correlation between measured bv and calculated fluid balances was found. conclusion: there seems to be a discrepancy between the clinical judgement of circulating blood volume and the measured circulating blood volume in critically ill icu patients. these results emphasize the difficulty of judging the volume status by current clinical parameters in critically ill patients. schütz n , romand j a , stotz m , gerard i , bendjelid k apsic, geneva university hospitals, geneva- , switzerland we recently demonstrated the accuracy of a new miniaturized transcutaneous sensor (tosca monitor, switzerland) to monitor non invasively paco (tcpco ) in white skinned patients [ ] . the objective of the present study is to analyse the same accuracy in a subgroup of dark skinned patients. eight post operative patients (mean ± ) were included. tcpco sensor was applied at the ear lobe. the simultaneously obtained tcpco and paco values (measured using a blood gas analyser) were compared by linear regression analysis. the difference between paco and tcpco values were compared using the method of bland and altman. : paired measurements were correlated. tcpco correlated with paco (r = . , p< . ) in the paco range . to . kpa. the mean bias between the two methods was . ± . %. our results demonstrate that skin pigmentation affects slightly the accuracy of the sensor. ( ). in critically ill patients it is difficult to gain knowledge of the intravascular volume using the conventional clinical parameters such as mean arterial blood pressure, central venous pressure (cvp), heart rate and urine production. new insights in the assessment of hemodynamics such as central venous saturation (svo ) and blood volume (bv) monitoring may give additional information of a patient's intravascular volume status. methods: blood volume measurements were performed in critically ill icu patients on occasions using pulse dye densitometry with indocyanine green (icg)(ddg- a/k, nihon kohden, japan). blood volume measurements were compared with the parameters svo and cvp in assessing the patient's intravascular volume status. also the relation between bv and albumine and colloid oncotic pressure (cop) was investigated. th annual congress -berlin, germany - - october s hofmann d , sakka s g anesthesiology and intensive care medicine, friedrich schiller university, jena, germany introduction: patient management guided by extravascular lung water (evlw) is associated with reduced mortality of patients with pulmonary edema [ ] . recently, single transpulmonary thermodilution (std) has been demonstrated to be sufficiently accurate for estimation of intrathoracic blood volume (itbv) and evlw when compared with the clinical standard, i.e., transpulmonary thermo-dye dilution (tdd) [ ] . in this study, we examined the reliability of std for estimation of itbv and evlw with respect to several factors of pulmonary function. we retrospectively analyzed data of critically ill patients patients ( male, female; age - , mean ± years) who underwent extended hemodynamic monitoring by the transpulmonary thermo-dye dilution technique. the agreement between itbv std / itbv tdd and evlw std / evlw tdd was determined as mean bias and standard deviation (sd) within different categories (level of peep, pao /fio ratio and evlw). linear regression analysis was applied to compare overall bias between evlw std and evlw tdd with the different factors. mean bias ± sd within the different categories are shown in acute-on-chronic (aoc) liver failure but data on the use of this procedure is yet scarce. we communicate our experience after centralizing all the procedures of our centre in the icu data of all treatments performed in our centre (liver transplant program; icu with continuous renal replacement therapies -crrt-experience; a unique protocol for surgery, hepatology and icu patients and a prospective registry). alf patients stay in the icu but aoc patients are admitted every other day for the procedure. mars is performed with a prisma monitor and sessions are aimed for a length of al least hours if feasible (in alf continuously with h changes). we analysed clearance, metabolic control, tolerability and technical and clinical complications. we used pearson correlation coefficient and linear regression analyses to detect relation between hours of treatment and clearance capabilities electrical impedance tomography (eit) is a promising technique to assess continuously respiratory function with high temporal resolution . changes in thoracic gas volume lead to corresponding changes in thoracic impedance. the aim of this study was to evaluate air distribution during volume controlled mechanical ventilation. five adult patients undergoing elective thoracic surgery with single lung ventilation were included. eit data were collected during ventilation of both lungs (tidal volume (tv): ml), left lung (tv: ml), and right lung (tv: ml), respectively. eit was performed using electrodes placed around the thorax. data are presented as percent of impedance change of both lungs (normalized electrical impedance (nei)). during one lung ventilation nei was reduced to . ± . in right lung and . ± . in left lung compared with both lungs with a clear separation between ventilated and nonventilated lung. in addition we found an imbalance of distribution of ventilation along the vertical axis in favor of the ventral part of the lungs (fig. ) . conclusion: eit seems to be a sensitive non-invasive method for monitoring distribution of ventilation. the use of pet in adults with tma has dramatically improved outcome. resistance to pet, which is observed in / of such patients and may affect mortality, remains however incompletely understood. we retrospectively studied adults with tma treated by pet in our unit to evaluate the short and long term outcome and to identify predictive factors of mortality and of resistance to pet. all records of adults with tma treated by pet between and were reviewed. tma associated with bone marrow transplantation were excluded from the study. age, sex, cause of tma were collected. glasgow and sofa scores were estimated at the admission. clinical data including: neuroligical or pulmonary disorders with mechanical ventilation (mv), renal failure, and therapeutic delay (td) to pet; biological data including: hemoglobinemia, platelet count, and ldh; plasmatic volume exchange per procedure and number of plasmapheresis sessions were also collected. mortality was assessed at one month and at one year follow-up. all data were analyzed and compared between survived/deceaded and between responders/nonresponders (r/nr) patients. : females and males were included. mean age: . ± . yo, mean glasgow coma score: ± , mean sofa score: . ± . . etiologies of tma: post-immunologic , post-infectious , post-neoplastic , drugs associated , idiopathic . two patients were in mv, underwent hemodialysis and had at least two organ dysfunction. the mean td for pet was . ± . days and the mean plasmatic volume exchange per procedure was . ± . ml/kg. patients ( %) partially or fully responded to pet. patients ( %) survived after one month and ( %) after one year follw-up. the comparison between survived and deceaded patients showed that response to pet ( / vs / responders respectively) was the only significant determinant parameter. the comparison between r and nr showed that a longest td ( . ± . vs . ± . ) and neoplastic cause of tma ( / vs / ) were significantly discriminant for a non-response to pet. almost all of the r patients ( %) exhibited a positive response to pet before the tenth plasmapheresis session. in a median follow-up period of , ( - ) months, relapses episodes occured in patients ( %). adults with tma, characterized by a mild to important severity, treated by pet have a relatively good outcome since survival reached % at month and was maintained at % after year follow-up. among the parameters studied, lack of response to pet was the only predictive factor of mortality. two factors were predictive of resistance to pet: neoplastic etiology of tma and a longer td to pet. adult with tma non-responding to pet after the tenth plasmapheresis session could be considered as totally non-responder and should benefit shortly from another therapy. ) . additional in-formation can be gained by visual conditioning of large data sets. we report a novel approach on data inter-pretation by visualizing the gastric tonometry values in a case of necrotizing pancreatitis and septic shock and the correlating clinical events ( ( y., male, apache ii score , measurements, days running). pgco was measured every min. with a gastric tube (trip, ngs catheter) and an automatic gas analyzer (tonocap, finland). we recorded these values continuously and calculated the frequency distribution in an h interval and in an area between and mmhg (increment ). this histogram was displayed as a contour-plot. in that kind of visualization the frequency is displayed as colour in the area and not as third axis in a graph. our form of data processing provides additional information on pathological patterns at an early stage. in context with other parameters, this can be helpful in guiding treatment, e.g. volume substitution, catecholamines or blood transfusion. in this case we can see episodes of normal tonometric values as well as periods of pathological patterns like periods of septic shock (t , t ), daily abdominal lavage in a period of severe sepsis (t ), major abdominal surgery (t ), unsuccessful trials of enteral feeding (t ), successful enteral feeding (t ), weaning period and extubation (t ). the graphical presentation of the frequency distribution of a large number of data easily allows to conceive the information of the data. the aim of future activities has to be the development of a real-time bedside display of the progress of changes in the measurement of pgco -values. our study population consisted of patients undergoing elective cardiac surgery (n= ). blood samples for tnf alpha mrna were taken preoperatively (baseline), hr and hrs postoperatively. total rna was extracted from purified peripheral blood mononuclear cells (rneasy, qiagen). we utilised real time rt-pcr to quantify tnf alpha gene expression after cardiac surgery using abi prism sequence detection system and normalised against an endogenous reference gapdh. the patients were divided into two groups: group a: eighteen patients who developed complications post surgery as defined by i) hypotension requiring inotropes (n= ) ± intra-aortic balloon pump counterpulsation (n= ) and /or ii) lactate > mmol/l (n= ). group b: control group of patients with an uneventful postoperative course (n= ). statistical analysis was performed using the kruskal-wallis test. ischaemia of the colon is a recognised but infrequent complication following cardiac surgery. colonic ischaemia is thought to lead to a disruption in the intestinal barrier and this has been implicated in the progression to the systemic inflammatory response syndrome (sirs) with some patients going on to develop multi-organ dysfunction syndrome (mods). little is known of the early pathophysiological processes occurring in the colon during cardiac surgery. thus, the aim of this study was to investigate the early histological changes within colonic mucosa and cytokine release during cabg surgery. methods: patients undergoing coronary artery bypass surgery ( on-pump, off-pump) were prospectively recruited. mucosal biopsies of the sigmoid colon were obtained after induction of anaesthesia and immediately at the end of the procedure. microscopic examination was performed using haematoxylin and eosin staining. peripheral blood was assayed intraoperatively for cytokines il- and il- and for up to hours post-operatively. on-pump surgery produced a . -fold increase in columnar epithelium apoptosis. no other histological changes occurred. there was a -fold rise in il- in both two groups intraoperatively. post-operatively, il- continued to rise to -times baseline levels in contrast with the off-pump group which remained at intra-operative levels. il- did not change significantly in the off-pump group. in the on-pump group there was a fold increase in il- associated with initiation of cardiopulmonary bypass (p< . student's t-test). post-operatively, il- levels returned to baseline levels. apoptosis of colonic mucosa occurs during on-pump cabg but not in offpump cabg. this precedes the inflammatory process. thus, we identify apoptosis, rather than necrosis, as the principal mode of cell death following on pump cabg surgery. further elucidation of this process may identify targets for pharmaceutical prevention colonic mucosal apoptosis. cabello b , rubio o , delgado m , vera p , mancebo j intensive care, hospital sant pau, barcelona, spain liberation from mechanical ventilation can be interfered by the development of congestive heart failure (chf). this issue has been poorly studied as a cause of weaning failure. we designed a clinical-physiologic study to analize the mangnitude of the problem and its physiological characteristics. during a two months period we daily screened all the intubated mechanically ventilated patients in our -bed icu looking for those who meet usual weaning criteria. these patients went on a t-piece trial (sb) during minutes. patients who presented respiratory distress were studied with esophageal-gastric balloon and a swan-ganz catheter. hemodynamic and respiratory measurements were collected in assist control ventilation (acv), pressure support (ps) of cm h with peep of and again sb. we defined chf when the pulmonary wedge pressure (pcwp)was normal during acv and above mm hg during sb. unsuccessful extubation in copd patients is associated with increased morbidity and hospital mortality, and accurate prediction of post-extubation acute respiratory failure (arf) is potentially important. our hypothesis was that two parameters i.e., the airway occlusion pressure at . s (p . ) and the expiratory flow limitation (efl) determined by applying a negative expiratory pressure (nep) during tidal breathing, both recorded repeatedly after extubation, could be good indicators of postextubation arf in copd patients. copd patients were included prospectively after extubation. a specially devised system (micro ; medisoft , dinan, belgium) was used to measure efl and p . . each patient was placed in half sitting position and breathed spontaneously. after stabilization of the patient, a nep of - cm h o was applied at the beginning of expiration and maintained throughout the ensuing expiration. the test breath was the breath during which the nep was applied, and the preceding expiration served as control. five test breath separated by periods of quiet breathing were recorded. the expiratory flow-volume loops generated with nep were compared by superimposition with those obtained during the immediately preceding breaths. the portion of the tidal expiration over which there was no appreciable change in flow with nep was considered as flow-limited and was expressed as a percentage of the expired control tidal volume (%vt). the module of nep was replaced by that allowing to measure the p . . five measurements of p . were made, spaced by at least seconds. gas exchange, p . and efl under nep were measured at the st , th, th and th hour following extubation. if a limitation of flow was evidenced at a given time, the subsequent measurements were not carried out. post-extubation arf was defined by a respiratory rate of more than per min, a respiratory acidosis with a paco > . mmhg and a ph lower than . without metabolic acidosis. to date, patients have been included. heighteen of them ( %) presented a elf at ± hours following extubation. nine patients presented an arf at ± hours in post extubation. these patients had a elf and a p . significantly higher than those without postextubation arf (respectively . ± . % vs. . ± . %; and . ± . cm h o vs. . ± . cm h o; p < , ). seven patients ( %) did not have elf and did not present arf in post extubation. conclusion: elf by nep and p . are easily measured in the period following extubation in copd patients. this preliminary report seems to demonstrate that p . and efl, measured precociously then repeatedly after extubation, could be good indicators of postextubation arf in copd patients. serebriysky i i , galstian g m , gorodetsky v m . intensive care unit, national centre of hematology, moscow, russian federation acute respiratory failure (arf) is the most frequent and serious complication in patients (pts) with hematological malignancies. respiratory insufficiency in this group of patients can be caused by a combination of increased vascular permeability, heart failure and liquid overload. the aim of this study was to analyze the effects of colloid replacement therapy in pts with hematological malignancies and arf. we examined pts with acute leukemia, complicated by sepsis and arf (bilateral radiographic infiltrates, pao /fio = ± ). three of them had pawp> mmhg, respectively , and mmhg. all the patients received infusions of % albumin (a.). the first infusion of ml was carried out during minutes, later the speed was ml/ min. we measured extravascular lung water index (elwi), pulmonary vascular permeability index (pvpi) by picco-plus (pulsion, germany), central hemodynamics parameters by swan-ganz catheter. in the first group that received a. in doses of . ml/kg ( pts) there were no significant changes in ci, pawp, elwi, pvpi, apart from pt ( st pt, see should critical illness polyneuropathy (cip) itself prolongs mechanical ventilation or whether this prolongation is the effect of concurrent risk factors for weaning failure is a matter of debate. our primary objective was to evaluate the impact of cip on the length of mechanical ventilation after controlling for coexisting risk factors for weaning failure. we also set out to assess the impact of cip on the length of the stay as well as to determine the costs associated with this neurological complication. a prospective cohort study. setting: icu of a tertiary hospital. patients: all patients with severe sepsis or septic shock that required mechanical ventilation for at least days who were considered ready to discontinue mechanical ventilation. patients underwent a neurophysiologic evaluation at onset of weaning from mechanical ventilation. gianesello l , pavoni v , paparella l , gritti g dept. of critical-medical surgical area, section of anaesthesia and intensive care, florence, italy extubation failure (ef) has an important effect on length of icu and hospital stay,icu and hospital mortality( ).ef can occur secondary to upper airway obstruction or to an inability to manage respiratory secretions a cause of laryngeal dysfunction (ld) and ineffective cough.ld can result from depressed mental status or local trauma after intubation.pre-admission functional status can also delay post-estubation swallowing impairment in critically ill elderly patients( ). over a -month period patients who needed reintubation after successful trial of weaning and planned extubation, in a polyvalent intensive care unit (icu) were identified.data including clinical features (age, sex, saps ii on admission, glasgow coma score (gcs) on day of extubation, type of patient, length of intubation and mechanical ventilation (mv) before extubation, length of icu stay (los), icu and hospital mortality) were collected.moreover we considered two parameters that asses airway patency and protection like predictors of ef:cough strength and suctioning frequency after extubation.cough strength on command was measured with a semiobjective scale of to ( = weak cough, = strong cough). ( / )( . %), pulmonary embolism( / )( . %)and severe sepsis( / )( . %).seven of patients who received reintubation a cause of defective airway manage needed at least one suctioning every two hours; moreover the same patients and other three with alteration in neurological function had weak cough (grade to ).the los of ef patients was ± . days, their icu and hospital mortality were . % and . %, respectively, both higher when compared with not reintubated patients.results of logistic regression showed that saps ii is the only independent risk-factor of reintubation (odds ratio . , sig. . ),while age, type of admission,length of intubation and gcs seem to do not influence ef.data were analysed using the spss . for windows. conclusion: ef can depend from defective airway protective mechanisms due to alteration in consciousness or glottic incompetence.this event influences negatively los and outcome.severity of illness is the only independent risk-factor. over a year-period, patients with dild ( males; age: ± years; saps ii: ± ) were retrospectively studied. among them, patients were immunocompromised and patients sustained complications attributable to the procedure: airleak (n= ), pneumothorax (n= ). the median duration of the chest tube drainage was ± days (range: to days). both the pao /fio ratio and mean level of peep were comparable before and hours after the olb (table ) . no patient died in the perioperative period. olb allowed to establish a diagnosis in patients ( %). in patients ( %), the dild was idiopathic (table ) . in patients, histologic diagnoses obtained from olb were not suspected clinically or by radiological investigations: invasive pulmonary aspergillosis, diffuse amyloidosis, methotrexate lung toxicity. ± ± peep level (cm h o) ± ± idiopathic interstitial pneumonia diagnosis uip aip* boop n. of patients *: acute interstitial pneumonia (ards) conclusion: in ventilated patients, olb can be performed with acceptable morbidity at bedside in the icu. in this study, olb established a definite diagnosis in % of patients and corrected the clinical and radiological diagnosis in % of the cases. fonsato v , mariano f , triolo g , camussi g , nederlof b , tetta c laboratory of renal immunopathology, university of turin, unit of nephrology and dialysis, cto hospital, turin, italy, department of research, fresenius medical care, bad homburg, germany introduction: high porosity membranes may enhance cytokine elimination by convection and also diffusion. however, there is need to balance the high permeability between cytokine removal and a clinically acceptable loss of plasma proteins. here,we studied the sieving coefficients (sc)and clearances of different cytokines (tnfa; il- b;, il- , il- , il- ra) and protein permeability profile (albumin, cystatin c, igg)in an ex vivo hemofiltration (hf), hemodiafiltration (hdf)and hemodialysis (hd)circuit of nanostructured high porosity polysulfone membranes with different albumin permeabilities of %(type a)and %(type b). three hundred ml of fresh normal human blood was incubated with endotoxin ( mg, e. coli, sigma, °c, hr and overnight at room temperature). we set up the three circuits under the following conditions: i) post dilutional hf, at three different blood flow rates ( , or ml/min) and with a fixed ( %) ultrafiltration rate (ufr: . , . and . l/hour, respectively). the circuit operated at zero balance. samples for scs and clearances were obtained conventionally at , , , , , and min; ii) hd, at a dialysate flow rate of l/h and l/h; iii) hdf, dialysate flow rate of l/h and l/h included . l/h of ultrafiltrate. both hd and hdf were conducted always at blood flow rate of ml/min. cytokines were determined by commercially available kits, albumin, cystacin c and igg by nephelometry (beckman). median sc was nearly up to for il- b and il- ra, at about . for il- , . for il- and . for tnfa (type a vs b, p > . ). despite similar high cytokine clearance ( and mil/min), permeability profile showed a higher sc for albumin, cystacin c and igg for type b than for type a (p< . ). sc for all cytokines was significantly reduced in hd (at both l/hr and l/hr) as compared with hf and hdf. it was of interest that in hdf sc of il- and il- at l/h were overlapping those obtained in hf. however, sc of il- b, il -ra and tnfa in hdf were about half of those obtained with hf. in addition, increasing dialysate flow (from l/h up to l/h) in hd and hdf at a constant blood flow of ml/min led to decrease sc of il- , il- , tnfa and albumin. albumin clearance was . ± . and . ± . ml/min in hdf and hd, respectively. our data show that high cut-off polysulfone membrane are associated with high clearances of cytokines independently from blood flow rate and ufr. tailoring membrane porosity on the basis not only of cytokine clearances but also on ex vivo plasma protein permeability was instructive to formulate their clinical application in mixed convective-diffusive treatments rather than in pure convective or diffusive modes. nunomiya s , momose k , ohtake k division of intensive care, dept of anesthesiology and intensive care med, jichi medical school, minamikawachi, japan introduction: several clinical and experimental studies have reported recently that direct hemoperfusion using a polymyxin b immobilized fiber column (pmx-dph) is effective for septic ards and improves pulmonary oxygenation. unfortunately, however, little is known about the exact mechanism in such effects. therefore, we studied the role of circulating leukocytes activities in endotoxemic pigs undergoing pmx-dph. eleven anesthetized pigs were received endotoxin infusion (etx) to develop ards state and submitted to either pmx-dph group or ctrl group. ards state was defined when pao /fio ratio decreased to the level less than % compared to the point before etx. extracorporeal circulations (ecc) were done for hours in both groups. blood samples were obtained at points; the time before etx (t- ), ards state (t ), hour (t ) and hours (t ) after the start of ecc. leukocyte activities were measured as the abilities of oxygen radical productions from leukocytes using chemiluminescence assay. one was dead within hour and another was dead within hours after the start of ecc in ctrl group, whereas no animals were dead in pmx-dph group during the study period. time courses of pao /fio ratio and leukocyte activities in both groups are shown in tables. changes in p/f ratio compared to t- cotogni p , muzio g , trombetta a , canuto r , trompeo a , viale a , ranieri m anestesia e rianimazione, patologia generale, university of turin, turin, italy in the early phase of ards, intense inflammatory reactions occur in the alveolar space. in this setting, the balance between pro-and anti-inflammatory cytokines may be a critical component for prognosis. evidence is accumulating that n- /n- polyunsaturated fatty acids (pufa) ratio may influence inflammation, since the eicosanoids formed from n- pufa and those developed from n- pufa have opposite effects upon inflammatory mediators production. in standard artificial nutrition -both in parenteral and in enteral formulas -n- /n- pufa ratio is quite low (between : and : ), since most nutrients are richer in n- than in n- pufa. though, the most favourable n- /n- pufa ratio is not yet defined. our study tested the hypothesis that n- /n- pufa ratio may modulate inflammatory cytokines production in a cell culture of human pneumocytes exposed to lipopolysaccharide (lps). a cells, a human pulmonary cell line with type ii pneumocyte properties, were cultured ( /cm ) in ham f- k medium. in all cultures but in controls, lps was added hours after seeding, to obtain a final concentration of mug/ml. three hours after lps, pufa were added as docosahexaenoic acid (dha) (n- ) and arachidonic acid (aa) (n- ) in different n- /n- ratios. four hours later, all culture supernatants were collected to determine the release of tnfalpha, il- , il- , and il- (elisa). pro-inflammatory cytokines production was significantly reduced by a : ratio of n- /n- pufa, but increased by a : ratio. a higher ratio ( : ) was not associated with further cytokines reduction (table ) . *n- /n- conclusion: in a human pulmonary cell culture stimulated with lps, inflammation can be modulated by pufa, through appropriate changes of n- /n- ratio. high doses of selenium could be a promising way for septic shock treatment. however, selenium (se) toxicity is supposed to be related to oxidative stress through a reaction with thiols. in the situation of an oxidative stress such as severe sepsis, it is to be feared that selenium toxicity could be increase, despite the fact that preliminary results are in favor of two different pathways for lipopolysaccharide (lps) and se toxicity. after approval by the crssa ethical committee, wistar male rats were studied. rats were quarantined for days. then, lipopolysaccharide (lps) followed one hour later by selenium, as sodium selenite (lps-se group) or se alone, as sodium selenite, (se group) were administered intraperitoneally. in ten rat lps-se groups, lps were administered at the dose of mg/kg followed by se at increasing doses from . to mg/kg. in ten rat se groups, se was administered with increasing doses from . to . mg/kg. mortality rate was observed at hours. surviving animals were sacrificed under anesthesia by halothane. blood samples were taken on two surviving rats of each group. plasma selenium concentration was measured using electrothermal atomic absorption. mortality related to se appears for lower doses in lps-se groups than in rats receiving se alone. mortality rate of rats receiving mg/kg lps alone was % ( / ). for doses of more than . , septic rats died in respiratory distress in less than one day. for lps alone or followed by se at the dose of . mg/kg, rats were rapidly sick. they rolled up into a ball. their fur was dull, and stood on end. they were asthenic and had diarrhea. se rats developed an encephalopathy the first day and later recovered, except rats with extremely high doses of se, according to the literature on selenium acute toxicity. mortality related to se (mg/kg) mg/kg . . . . lps-se / / / / / not do se / / / / / / conclusion: in a % mortality non reanimated lps rat model, mortality related to selenium administration appears at lower doses those administred in healthy rats. mortality was related to respiratory distress in lps followed by se rats. doses of . mg/kg, presently considered as the maximum selenium level administration, seems not to modify the spontaneous evolution of sepsis in this model. zimmermann t department of visceral-, thoracic-and vascular surgery, technical university dresden, dresden, germany selenium plays a dual role in the regulation of the inflammatory response in mononuclear blood cells. first, selenium enzymes (gpx , trr) are essentiel for the physiological regulation of the redoxsensitive transcription factor nf-kb (key role in inflammation). second, selenium is capable to inhibit the activity of nf kb. another transcription factor (ap- ) is being specific activated via the subunits (c-jun,c-fos) by means of selenium. the authors investigated patients with severe sepsis within the sic-study (selenium in intensive care). mononuclear blood cells: nf-kb-and ap- binding activity, p /p (nf-kb)-protein concentration in the nucleus and cytoplasm. mrna-expression of ikb, tnf, tissue factor, mif, gpx- and trr (selenoenzymes), intracellular synthesis of mif and ikb. ros in whole blood. blood was taken on the ., ., ., ., ., . day of sepsis. septic patients with supplementation of selenium showed a increase of the nf-kband a strong increase of the ap- binding activity during the course of the sepsis. in the same time a rigorous reduction of the mrna-expression of ikb (inactivator of nf-kb) and mif could be observed. the mrna-expression of the tissue factor and tnf was not influenced. supplementation of selenium lead to a amplified translocation of p /p (nf-kb) within the nucleus, whereas in the placebo group this effect was not shown. in contrary to septic patients, only the nf-kb bindung activity was strongly suppressed in healthy controls. selenium seems to possess a regulatory role in der inflammatory response of mononuclear blood cells. the positive effect of selenium in septic patients could be dependent on the time point of the supplementation, within the inflammatory (anti-or hyperinflammatory) response. this could be one explanation of "non-responders" of selenium supplementation. high dose of selenium (se) could be a promising way for septic shock treatment. however, selenium toxicity is supposed to be related to oxidative stress through a reaction with thiols. in the situation of an oxidative stress such as severe sepsis, it is to be feared that selenium toxicity could be increased. presently human administration of sodium selenite of more than µg per dose must be avoided, outside carefully conducted study. however preliminary results are in favor of two different pathways for lipopolysaccharide (lps) and se toxicity, which leads to think that selenium, especially as sodium selenite, could be a new way of treatment. after approval by the crssa ethical committee, wistar rats were studied. rats were quarantined for days. sixty four rats received mg/kg of lps intraperitoneally, followed one hour later by milliliters of saline water (placebo) (n = ), or . mg/kg selenium as sodium selenite (n= ) corresponding to around mg for a kg man, or . mg/kg selenium as sodium selenite (n= ). mortality rate was observed at hours. videos were performed during the -hour course. surviving animals were sacrificed under anesthesia by halothane. blood samples were taken on two surviving rats of each group. there is a tendency of the mortality decrease in this post-treatment septic rat model. moreover, rats receiving lps alone or supplemented by . mg/kg sodium selenite were rapidly sick. they rolled up into a ball. their fur was dull, and stood on end. they were asthenic and had diarrhea. lps non-surviving rats died in an asthenic syndrome, and surviving lps alone rats remain very asthenic at hours. on opposite, surviving lps followed by se rats were much more dynamic, even quite normal. th annual congress -berlin, germany - - october s kepa l , oczko-grzesik b department of infectious diseases, silesian university medical school, bytom, poland cytokines and neutrophiles play an important role in pathogenesis of bacterial sepsis with purulent meningoencephalitis (bs-pme). experimental studies in animals revealed that pentoxyfiline (pf) exerted inhibitory influence of cytokines on these cells with beneficial outcome of the disease. the aim of the presented study was the estimation of pf influence on clinical course and outcome of bs-pme in adults. between - bs-pme was recognized in patients treated in our centre. neisseria meningitidis and streptococcus pneumoniae were etiological agents in subsequently % and % of cases. in the remaining % of subjects the etiology was not elucidated. all patients were divided at random way into two groups: i - patients (mean age yrs.) treated with antibiotics, symptomatic drugs and pf ( mg/kg/day) beginning from the first day of treatment, ii - patients (mean age yrs.) treated only with antibiotics and symptomatic drugs. cerebrospinal fluid (csf) samples were taken on the st, th and th day of therapy with estimation of pleocytosis and protein, glucose, lactic acid, tnf-alpha, il- beta and crp concentrations. mean periods of consciousness impairment, fever persisting as well as hospitalization were comparable in both groups of patients. faster normalization of csf protein, glucose, lactic acid and crp concentrations were recorded in patients of group i, who survived, compared to subjects of group ii, but the differences were not statistically significant. csf parameters remained abnormal in fatal cases. most frequent sequeles of bs-pme were: partial deafness, deafness, paresis and paralysis. side efects of pf were not observed. death sequels group i ( %) ( %) ( %) group ii ( %) ( %) ( %) conclusion: pentoxyfiline used as adjunctive therapy in adult patients with bacterial sepsis and purulent meningoencephalitis did not reveal evident beneficial influence on clinical course and outcome of the disease. zahorec r , setvak d , cintula d , blaskova a , belovicova c of anesthesia and icu, st. elizabeths cancer institute, bratislava, slovakia sepsis is a common cause of acute renal failure (arf). arf in early phase of severe sepsis occurred in - % septic patients and is associated with significant influence on sepsis mortality. the aim of this observational study was to measure the incidence of arf syndrome and to evaluate the efficacy of noradrenaline and furosemide infusion (martin et al. (martin et al. , for the treatment arf in early phase of severe sepsis. an observational study of consecutive critically ill cancer patients with severe sepsis ( ) and septic shock( ). acute renal injury/arf syndrome was detected according bellomo et al ( ) criteria. the surrogate markers of renal dysfunction involve serum urea, serum creatinine and urine output (diuresis per hour). we measured creatinine clearance and excretion fraction of sodium from collected urine.the severity of severe sepsis was measured by apache ii and sofa score during the first - hrs of icu stay. we monitored in all pts invasive sap,map,cvp,temperature, pulse oximetry, urine flow per hour and per day.blood sampling were done every hrs for wbc counts, platelets count, procalcitonin, crp, urea, creatinine and lactate. : severe septic patients with mods (initial sofa score were , and , p., and apache ii score , and , )received full intensive therapy. severe sepsis was documented by proven infection and high serum levels of procalcitonin (mean , ng/ml) and crp(mean mg/l). acute renal injury ( pts) and arf( pts) syndrome was detected in patients ( %) out of septic cancer pts. we used the combination of noradrenaline infusion ( , - , mcg/kg/min) and furosemide infusion( - mg/hr) for hemodynamic and renal support. we induced polyuria and reverse ari/arf to nonoliguric arf in pts ( %) from severe septic pts. we used no renal replacement therapy.we recorded % hospital mortality. acute renal injury and acute renal failure syndrome occurred in % of severe septic patients. criteria for ari/arf syndrome diagnosis are very simple and useful in early detection of renal dysfunction. renal rescue protocol (combination of noradrenaline and furosemide infusion) seems to be very effective modality in the treatment for ari/arf syndrome in early phase of severe sepsis, when it is instituted very early with low/moderate dosage of noradrenaline and furosemide. the purpose of the present study was to evaluate the effects of intravenous lornoxicam on hemodynamic and biochemical parameters, serum cytokine levels, patients' outcome in humans suffering from severe sepsis methods: patients were included to the study. after applying, lornoxicam mg was administered intravenously every hrs for six doses vs placebo. hemodynamic parameters (heart rate,mean arterial pressure), nasopharyngeal body temperature, arterial blood gas changes (ph, po , pco ), plasma cytokin levels (interleukin -b, interleukin -r, interleukin , interleukin , tumor necrosis factor-a), biochemical parameters (lactat, leucocyt, trombocyt, creatinin, total billirubin, serum glutamat oxalat transaminase), staying time in the intensive care unit, time of mechanical ventilation support, mortality, with the control group were recorded. all measurements were obtained at baseline (before start of the study) and were repeated immediately at th , th and th h. after lornoxicam. no differences were found differences in major cytokines, duration of ventilation and icu stay, and fi / pa intravenous lornoxicam vs placebo (p> . ). we found that the effect of intravenously lornoxicam did not effect hemodynamic and biochemical parameters, or cytokine levels or in patients' outcome in severe sepsis in humans. because of the limited number of patients in our study and the short period of observation, our findings need to be confirmed by larger clinical trials of intravenously lornoxicam in a dose-titrated manner bernard gr, wheeler ap, russell ja, et al: n engl j med , : - . bubenek-turconi s s t , sefu f , stelian e , boros c , miclea i , timofiev l , moldovan h , iliescu v st cardiovascular anaesthesia and intensive care dept., st cardiac surgery dept., institute of cardiovascular diseases c. c. iliescu, bucharest, romania severe systemic inflammation with a vasodilatory syndrome occurs in about one third of all patients after cardiac surgery with cardio-pulmonary bypass (cpb). we studied the effects of early continuous veno-venous hemofiltration (cvvh) on the course and outcome of the patients with severe systemic inflammatory response syndrome (sirs) after cardiac surgery. a group of patients with severe sirs [fulfilling the criteria of accp/sccm consensus committee ( )] in early postoperative period after cardiac surgery with cpb was divided in two subgroups: a - patients receiving conventional therapy and b - patients who received cvvh for a period of h. criteria for receiving cvvh was a severe cardiovascular dysfunction (catcholamine support required in large amounts, norepinephfrine or epinephrine > . ?g x kg- x min- , for maintaining a map > mm hg or a svr > dyne x sec x cm- ). of those patients had also a severe respiratory dysfunction with pao /fio < . there were no significant diferences regarding demographic data and type of surgery between the two groups. the patients from group b had a dramatic improvment of the cardiovascular function, the catecholamine support being tapered off faster than in group a even the initial dose was very much higher in group b. also the patients with respiratory dysfunction from group b were extubated earlier than those from group a, with the same amendament regarding the severity of the dysfunction. the result are sumarized in the following ricci z , salvatori g , bordoni v , bonello m , ratanarat r , d'intini v , ronco c nephrology dialysis and transplantation, ospedale civile s.bortolo, vicenza, italy sepsis and mods are associated with a disruption of normal homeostasis and alteration of biological systems. the accumulation of pro-apoptotic factors in plasma may contribute to organ dysfunction. removal of such factors by extracorporeal blood purification techniques may help to re-establish homeostasis and cell function. we investigated the effect of treatment dose comparing standard and high volume hemofiltration. in a prospective, randomised, cross over study two hemofiltration regimes in two consecutive days were administered to anuric septic patients: we studied hours high volume hemofiltration (hvhf: l/h) followed by hours standard hemofiltration (cvvh: l/h) and viceversa. replacement solution was administered pre filter and performed by m polysulfone membranes. blood flow rate was ml/min. routine laboratory and clinical data were collected including illness severity scores. prefilter plasma and ultrafiltrate were collected at treatment start, at hour, at hour, for each hemofiltration regimen. plasma samples and ultrafiltrate were frozen at - °c. samples were close labelled. samples from normal human blood were used as control. samples were studied for apoptosis using a u monocyte cell line. a quantitative analysis of the apoptotic u cells in culture was carried out by fluorescence microscopy at hours. u cells were also assayed for caspase , activation. during the sequence hvhf/cvvh cell apoptosis significantly decreased after hour of l/h treatment start (p< , ); after hours of l/h treatment apoptosis rate continued to decrease significantly (p< , ). after passing to l/h regime the percentage of apoptosis remained constant. the fold-increase of caspase- measured at hr correlated with the above findings (r= , ). similarly when the inverse sequence (cvvh/hvhf) was studied cell apoptosis did not show a decrement in the first hours, while after switching hemofiltration dose to l/h apoptosis was significantly decreased either at the first and at the fifth hour (p< , ; correlation between apoptosis and caspase- fold increase: r= , ). the results where independent from the administration sequence. conclusion: high hemofiltration rates seem to correlate with a decrease in plasma apoptotic pattern during crrt in anuric septic patients. the clinical relevance of such findings may contribute to explore new therapeutic options in septic patients. epinephrine (e). we conducted a casenote review of patients with septic shock. the unit icnarc/midas database was searched for all patients admitted over a two year period with septic shock. the icu notes and charts were then retrieved and data found on physiology, choice and dose of catecholamine given. : patients were identified, of whom were treated with ne and with e. there were notable differences in outcome between the two vasopressors commonly used. patients receiving either drug were seen to have an increased mortality in association with higher doses used. no patient survived to hospital discharge who was treated with a dose of e above . micrograms/ kg/ min or ne above . micrograms / kg/ min. conclusion: there is an increased mortality seen in patients with septic shock receiving e. whilst they may be older, with worse apache scores and calculated risk of death; this doesn't explain the degree of the problem. some of the answer may lie in their worse glucose metabolism. there was also an increasing mortality seen with increasing dose of vasopressor given. this was independant of apache score and as such may repesent a drug effect rather than a marker of illness severity. (vili) .but positive end expiratory pressure with or without low tidal volume is protective against lung injury. in this study we investigated the effect of different inspiratory times on vili. methods: sprague dawley rats were used. all were started to ventilate on pressure controlled ventilation mode, after anesthetized and tracheostomized, with the parameters of cmh o peak inspiratory pressure (pip), cmh o peep, fio : . , breaths/min and i/e: / . after minutes stabilization period baseline blood samples were taken for blood gas and cytokine analysis, then the rats were randomized into groups due to their peak inspiratory pressure, peep and inspiratory/expiratory ratios as follows: other ventilator settings were kept as baseline values. the rats were ventilated with these parameters for two hours. at the end of experiment before sacrification of rats, blood samples were obtained for blood gas and cytokine analysis. then the lungs were taken out and the left lung was used for measurement of wet weight/dry weight ratio (ww/dw). there were no differences in baseline ph, pao , paco , map values among groups. as compared to baseline values pao decreased in lp / , hp / , / , / groups and hpp / , / groups but significant differences was found only in hp / group(p= . ). at the end of experiment map decreased in all hp groups and hpp / group. ww/dw ratio was found lower in hpp groups when compared to hp groups (p< . ). il- level was found higher in hp groups than lp and hpp groups at end of experiment. high pip caused lung injury with deterioration of oxygenation and increase in ww/dw ratio. while application of peep was protecting lungs from vili changing inspiration expiration ratio did not. dragazis i , mariatou v , kopteridis p , kapetanakis t h , karidis n , balanika m , michalia m , armaganidis a nd critical care department, athens university medical school, athens, greece our purpose was to investigate whether temperature modulates ventilatorinduced lung injury (vili). we perfused (constant flow ml/min) isolated sets of normal rabbit lungs and ventilated them using different perfusate temperatures and two different ventilatory settings ( groups). after initial stabilization all preparations were ventilated for min using pressure controlled ventilation [pcv] with peep cm h o and pcv cm h o above peep. following the results of randomisation the necessary adjustments were made during this period to obtain in the perfusate: ) a ph . with a partial pressure of co mm hg and ) a perfusate temperature of oc, oc or , oc. two groups of preparations were tested at each temperature level: a control or low pressure (lp) group ventilated with peep cm h o and pcv cm h o above peep for min and a high pressure (hp) group, in which a pcv = cm h o above peep (= cm h o) was applied for min. the weight gain (deltawg in g/min) observed in each group during this period, as well as changes in ultrafiltration coefficient (kf in gr/min/ cm h o/ g) were used to assess vili (indexes of pulmonary edema and of vascular permeability respectively). our results are summarized in table . deltawg in hyperthermic isolated, perfused lungs was significantly higher than deltawg in any other group. significant kf changes were observed only in hp groups, with a significantly higher deltakf in the hp_ . group (p= . ). there were no important differences between normothermic and hypothermic preparations. methods: sprague-dawley rats were anaesthetized, paralyzed and mechanically ventilated. rats were ventilated similarly (vt= ml/kg, rr= bpm, fio . ), but were randomized to peep , or cmh o (n= per group). the abdomen was then inflated stepwise with helium up to mmhg of abdominal pressure (iap, intra-peritoneal direct measurement). airway pressure (paw), esophageal (pes) and gastric (pga) pressure were also measured, together with invasive blood pressure. data were simultaneously recorded and digitally stored for subsequent analysis. this allowed to consider end-expiratory (pes exp), mean (pes m) values of pes and the difference between pes at end-inspiration and end-expiration (dpes). data are presented as mean±sd. we conclude that in our study study the closed tracheal suctioning system did not decrease the incidence of ventilator-associated pneumonia, not even the exogenous pneumonias. we believe that the respiratory secretions suction may be done with guarantee with an open tracheal suctioning system if it is performed with suitable asepsis measures. and we think also that it is not necessary the high cost that the routine use of a closed tracheal suctioning system represents. however the closed tracheal suctioning system may be recommended in patients with severe impairment of gaseous exchange. in order to avoid decrease in bacterial count due to empiric ab before sampling, we evaluated the feasability of delaying the cultures of broncho-alveolar lavage (bal) frozen at - °c et - °c for hours. the results from these delayed processing were compared with those from immediate ones. a total of bals were performed on icu patients suspected of nosocomial or community-acquired bacterial pneumonia. each sample was divided in three, one for immediate culture (h ), the nd and rd for a delayed processing after storage at - °c and - °c for hours (h ) respectively. all negative h samples (n= ) were also negative at h except for one sample that yielded and cfu/ml of streptococcus sp on - °and - °h culturing respectively. seventy seven bals yielded one or more microorganisms, with a total of microorganisms in one or both samples. h and h (- °& - °) hájek r , nìmec p , zezula r , fluger i , rù?ièková j cardiac surgery, university hospital, olomouc, czech republic introduction: thrombelastography (teg)is a method frequently used in perioperative assessment of haemostasis in cardiac surgery. this bedside examination can reveal some specific disorders of haemostasis especially hypercoagulation and fibrinolysis. one hundred fourteen consecutive patients with acquired heart desease were assessed. all the patients were operated electively and the cardiopulmonary bypass was used. standard laboratory perioperative assessment of coagulation was performed. these results were compared with teg performed afer indtroduction of anaesthesia, after minutes of cpb and immediately after admission on icu after operation. preoperative anticoagulation therapy, blood loss and the necessity of transfusion were evaluated. only patients nad no anticoagulation medication preoperatively. in laboratory assessment all the patients had normal results preoperatively, patients had coagulation disorder and patients thrombocytopenia postoperatively. teg examination revealed hypercoagulation status in patients and hypocoagulation in patients preoperatively. during operation increased fibrinolysis was found out in , % patients ( , % during operation, , % after operation and , % both during and after operation), only in % of them aprotinin was used because of increased bleeding. thrombocytopatia was revealed in , % patient and only in of them thrombocyte infusion was required. in patients the residual high level of heparin was confirmed. the average blood loss during operation was ml and during first hours was ml. no patient was reoperated because of bleeding. correction of hypocoagulation was made with ffp in average dose tu ( case with normal postoperative teg tracings versus cases with pathological teg). conclusion: teg revealed hypercoagulation status in many patient preoperatively, which was not confirmed by standard laboratory tests. during operation mainly fibrinolysis and thrombocytes dysfunction was present but any specific therapy was usually not necessary. the use of blood products depends more on clinical status of the patient than on the teg results. clinicians are facing the challenge to differentiate between postoperative inflammation a condition considered to be benign and early signs of infection. the aim of our study was to define the timecourse of sirs and severe sirs after cardiac and thoracic surgery. we utilised a structured data mining process to the prospectively collected data within the patient-data-management-system (picis caresuite v. . ) from the cardiothoracic icu of a university hospital between january and may . data from all monitoring device are collected in intervals of minutes, laboratory data and blood gas analysis was done according to institutional standards. in this data mining process we determined in a first step the fulfillment of each individual item of the sirs criteria (accp/sccm consensus conference) during a minimum of one hour. in the second step we identified the first occurrence of simultaneous fullfillmment of at least criteria as the starting point for sirs. severe sirs was defined as sirs with at least two criteria for organ dysfunction as defined in the sofa score. we used three categories sirs, sirs with low blood pressure (sirs low bp) and severe sirs with additinal organ dysfunction (sirs severe). a total of patients were admitted during the observation period. sirs was present in ( . %), sirs with hypotension in ( . %) and sirs with additional signs of organ dysfunction in ( %). the timepoints of first fullfillment are given in the table. the timeprofile with very early fullfillemtn was not changed by censoring the first hours after admission since the identified state persistent for a prolonged period. timepoint of first sirs fullfillment: in this large cohort of patients after cardaic and thoracic surgery we found dystinct profiles for sirs with additional signs of organ dysfunction. in the majority of the patients the three different sirs categories occurred within the first hours. further research is necessary to determine whether any of these categories are indicative of a changed outcome depending on the starting point. th annual congress -berlin, germany - - october s samalavicius r , misiurine i , norkiene i , juozaitis m , urbonas k , bubulis r , baublys a anaesthesiology and intensive care, vilnius university hospital santariskiu clinics, vilnius, lithuania introduction: preoperative risk stratification for predicting mortality and morbidity is widely used in cardiac surgery. the goal of this study was to assess the value of serum lactate level in predicting mortality and morbidity following coronary artery bypass grafting (cabg) procedures. methods: consecutive cabg patients, operated on from . . to . . , were included in this prospective observational study. all patients were operated using cardiopulmonary bypass. serume lactate levels were measured before cardiopulmonary bypass, before declamping of the aorta, after heparin neutralisation and at the icu admission. : lactate level greater than mmol/l was found in . % of patients during cardiopulmonary bypass, in . % of patients shortly after weaning from cpb and in . % of patients at icu admission. mortality rate of patients, with hyperlactemia at icu admission was . % and morbidity . %. mortality rate of patients without hyperlactemia was . % and mobidity - . %. lactate levels on icu admission were raised in non survivors (median . +/- . , range . - . mmol/l)compared with survivors (median . +/- . , range . - . ). conclusion: increased serum lactate levels following coronary artery bypass grafting allows to identify a group of patients with increased risk of postoperative mortality and morbidity. since the year , we have been studying prognosis in cardiac surgery (cs) and noticed the lack of models with similar populations in the literature. the objective this study is create a predictive score (rio score-pre) of in-hospital mortality in patients (pts) undergoing cs based on preoperative variables. classical cohort with data of pts, of whom undergoing valvular surgery (vs) and admitted to intensive care units (icu), public and private, consecutively selected between june and february . all variables were previously defined. the data underwent univariate analysis with the chi-square, student t, mann-whitney, and pearson tests, followed by logistic regression, and stepwise (likelihood ratio), with the chi-square linear tendency test and a classification table. the score created (appendix) allows the following prediction: from to -low risk; from to -medium risk; and from to -high risk. pérez-vela j , renes e , escribá a , alonso m , corres m , garcía a , perales n intensive care unit, hospital de octubre, spain, spain vital parameters monitorization is an usual practice in the management of critically ill patients. cardiac index (ci) is one of more important perfusion parameters used. picco system is a device that offer the quantification of intermittent ci by transpulmonary thermodilution (citp) and in a continuous manner by arterial pulse contour analysis. objective: to compare the agreement between the standard thermodilution monitorization system (citd) with the transpulmonary system. also, we analysed the complications secondary to the picco system. prospective study, in patients in the immediate postoperative period after cardiac surgery with cardiopulmonary bypass. ci by standard themodilution was measured with pulmonary artery catheter abott optiq svo /ccoâ. we made a transpulmonary thermodilution with ml physiologic fluid injection with a temperature less than celsius degrees, through a central venous line, and we analysed the thermodilution in the femoral artery catheter thermistor (a -fr gauge, cm long arterial with a thermistor embedded in its wall: pulsiocath pv l) using the picco system from pulsion medical system (munich; germany). we calculated ci (both methods) after inserting the picco system, one hour later and then, every two hours. also we measured parameters when staff considered appropriate to value the results of a therapeutic attitude. results between techniques were compared by lineal regression analysis and the bland-altman method. we analysed a total of pair of data obtained in patients, male and female, in the immediate postoperative period of valvular replacements ( mitral, aortic and one both), aortic grafts, myocardial revascularizations, mixoma and pericardiectomy. mean age: ± . years, mean citd . ± . and citp . ± . l/m. the range of measured ci: . a . l/m/m . in comparison we obtained a r= . and a bias of - . ± . . in tables we have the realised statistic analysis. we did not have complications attributed to the system. both ci measurement methods are comparable, showing a good agreement between systems, indicating that citp is as reliable and precise as standard thermodilution. this suggests that picco is a monitorization system applicable to clinical routine in critically ill patients. we did not observe complications attributed to the system. gomes r v , rouge a , nogueira p m m , fernandes m a o , olival s a , campos l a a , dohmann h f r , santos m surgical intensive care unit, hospital pró-cardíaco -procep, surgical intensive care unit, instituto nacional cardiologia laranjeiras, rio de janeiro, brazil the left ventricular ejection fraction (lvef) has been extensively studied as a prognostic marker in cardiac surgery (cs); our group, however, has found a correlation between left atrial diameter (lad) and several outcomes in cs. the objectives this study is show the importance of lad as a prognostic marker by assessing the following outcomes: in-hospital mortality (hm), surgical intensive care unit length of stay (siculos), pneumonia (pn), and need for hemodialysis (nhd). compilation of data collected in the databank of several cohorts with patients (pts) of sicu from june/ to february/ . the variables studied underwent uni-and multivariate statistical analysis. the few reports exist about lad on echocardiography as a risk marker for cs; in our studies, however, lad has reached greater significance than the subjective analysis of lv function. the great prevalence of valvular surgery (vs - %) might be another possibility. these findings should be validated in a cohort with other centers. conclusion: amylase level > un/ml and bilirubin concentration of mg/dl in duodenal aspirated fluid has a high positive predictive value. position of the feeding tube within the gastrointestinal tract can be determined objectively by using simple ph and bilirubin reagent strips. webb i , gibbs t , beale r , jones a . department of intensive care medicine, guy's and st thomas' hospital, london, united kingdom septic shock may be accompanied by dysfunction of the hypothalamic-pituitaryadrenal axis (hpa). in a recent multi-center randomized controlled clinical trial, treatment with hydrocortisone and fludrocortisone significantly reduced the risk of death in patients with septic shock and relative adrenal insufficiency (as determined by acth stimulation) but not in patients with an adequate adrenal response ( ). subsequently it has become accepted practice to start corticosteroid replacement in patients with septic shock following an acth stimulation test to determine the presence (non-responder-nr) or absence (responder-r) of "adrenal insufficiency". in those patients with "adequate" adrenal function, corticosteroids are withheld or withdrawn. it is known that in patients who recover, this "adrenal insufficiency" is temporary. however, less is known about the temporal changes in hpa function within the period of critical illness. methods: our clinical information system (carevue, philips medical systems, uk) was interrogated to find all patients with septic shock who underwent repeated acth stimulation ( \mug) testing in an month period. baseline cortisol, nr/r status (\deltacortisol < \mug/dl), vasopressor requirements and use of hydrocortisone were identified. we identified patients who underwent repeated acth stimulation testing within a single episode of septic shock, who received no or limited steroid replacement therapy. in subjects ( , , the recognition that hpa abnormalities exist in sepsis and that exogenous steroids are beneficial in some individuals has changed practice over recent years. however, the best indicator of which patients would benefit from corticosteroid replacement remains unclear. in addition, this preliminary data suggests that an individual patient's response to acth stimulation may change during an episode of septic shock. of particular concern are patients who are initially "responders" who would not recieve beneficial therapy if only single estimates of adrenal dysfunction are used. twenty four neonates with tof were divided into two groups after getting parents consent and local ethical commitee approval into two groups ( each); group i : after general anaesthesia they had continous thoracic paravertebral block with a catheter placed at right fifth space with continous infusion of . ml/kg of . % ropivacaine every minutes to be maintained post operatively in nicu this. group ii :had balanced general anesthesia. measurements: -number of neonates required post operative ventillatory support in both groups. -mean total dose of opioids required for analgesia in both groups. -days of stay in nicu in both groups. -mortality in both groups results: -there was statistically significant less need for ventilatory support in group i ( %) in comparison to group ii ( %). -mean total dose of opioid analgesia was higher in group ii -more days of stay in group ii. -three cases of mortality in group ii ,while one case of mortality in group i. conclusion: picu mortality was relative high, partly due to high prism scores and the high proportion of mv pts. mortality continues to increase up to y and stayed the same thereafter. the majority of our pts reached their preadmission cognitive status (pcpc) at two y. on the other hand they didn't reach their overall functional status (popc) even after two y mainly due to the high proportion of pts with mild disability, popc , which is however compatible with near normal and independent life. s -s . .jalan r, williams r. blood pruif predictors of transfusion requirements for cardiac surgical procedures at a blood conservation center references: maillet jm grant acknowledgement: chris stoutenbeek foundation references: .debra henry fiser ( , ) ( , ) ( , ) ( ) e coli ( , ) ( , ) ( , ) ( , ) s pneum+ ( , ) ( , ) ( , ) ( . ) others**+ ( , ) ( , ) ( , ) ( , ) *p= . g / g ; **p< . g /g ,+all groups conclusion: in our country, late-onset vap showed important variations in aetiology considering th and th days and that should influence antimicrobial prescribing practices. nosocomial pneumonia represents a significant cause of morbidity and mortality in intensive care units (icu). the high incidence of nosocomial pneumonia among icu patients can be attributable to dysregulation of lung immune responses elicited by systemic inflammation. in a previous study with endotoxin-challenged mice, defects of lung adaptive immunity were heralded by reduced numbers of lung-resident cd + t-lymphocytes. the depletion of cd + t-lymphocytes was associated with a higher susceptibility to lung infection caused by staphylococcus aureus in some clinical and experimental studies. the aim of our study was to evaluate the mechanism by which endotoxemia reduces the number of lung-resident cd + t-lymphocytes and increases susceptibility to s. aureus in the lungs. experimental systemic inflammation was initiated in balb/c mice (n= ) with \mug of endotoxin (lps) given intraperitoneally; hrs after this challenge, the animals were anesthetized and x cfu of s. aureus (s.a.) were administered into the trachea. for the control group, mice were challenged only with s. aureus (n= ). mice were sacrificed hrs after the challenge with s. aureus. lung-resident lymphocyte subsets were obtained by enzymatic digestion of lung tissue. lung-derived and circulating total t-(cd +) and b-(cd +) lymphocytes, cd + and cd + t-lymphocytes as well as nk cells were enumerated with monoclonal antibodies, single platform method and cytometric analysis. colony forming units (cfu) of s. aureus were obtained from lung tissue homogenates using a plate dilution method. the differences between groups of animals were evaluated by one-way anova with a level of significance p< . . data are presented as mean standard ± error. results are shown in the table (number of cells is expressed as cellsx /ml for the blood and cellsx lobe for the lung). conclusion: our results demonstrate that mice challenged with endotoxin and s. aureus have reduced recruitment of cd + t-lymphocytes to the lungs when compared to animals infected only with s. aureus. despite this finding, the susceptibility to secondary lung infection due to s. aureus was significantly decreased after endotoxin challenge indicating its protective effect against staphylococcal infection. aranha f g , rouge a , gomes r v , dessen m , nogueira p m m , fernandes m a o , campos l a a , dohmann h f r surgical intensive care unit, hospital pró-cardíaco -procep, rio de janeiro, brazil the need for dialytic support (hd) in the po period of cs relates to a significant increase in costs and length of hospitalization, in addition to high rates of morbidity and mortality.the objective this study is assess the incidence of hd and its association with mortality in adult patients (pts) undergoing cs. historical cohort with data of pts undergoing cs collected from june/ to january/ . the pts were divided into groups as follows: ) group i, pts who did not undergo hd; and group ii, pts who required hd, accounting for . % of the sample. their mean age was . years, . % were males, . % were diabetic, and % of the cs were elective. the mean aha mortality score was . ± . , and the mean euroscore was . ± . . analysis of frequency and the chi-square test were used for comparing mortality. fifty-six ( . %) pts died in the hospital, ( . %) in group i, and ( %) in group ii. thirty-nine ( . %) pts died within days, of whom ( . %) were in group ii. an important statistical significance (p< . ) was observed between both groups. the po intensive care unit length of stay was significantly longer in group ii, in which % of the pts remained hospitalized for more than days (p< . ). the po intensive care unit length of stay and mortality were significantly greater in the group of pts undergoing hd in the po period of cs. a high percentage of patients underwent hd ( . % of the sample), which may be explained by the profile of the population studied. in group ii, in-hospital mortality was %, and mortality in days was . %. in the entire sample, these indices were . % and . %, respectively, and the euroscore predicted a mortality rate greater than . %. the conventional choice for type-b aortic dissection has been medical treatment. surgical repair has been kept for cases presenting complications. both treatments are associated with high mortality rates. endovascular stent-graft placement opens up new perspectives in the controversial treatment of thoracic aorta dissections. the objective of this paper is to describe our experience in the post-operative handling of type b aortic dissections treated with endovascular stent grafting. twelve patients admitted to an all-purpose icu from january to march treated with endovascular stent grafting. ten patients with acute type b dissection and one patient with traumatic rupture of thoracic aorta. the pre-operative study included transesophagic ecography and ct to evaluate the extent of the dissection, the relation with the left subclavian exit, true and false lumen size, and vascular complications. placement of the endovascular stent-graft (talent type) was successful in all cases. three patients died within the first days, two of them in the icu, with a mortality rate of %. complications: one patient had retroperitoneal hematoma, and another presented perioperative ami. two cases were observed of paraplegia, and one case of perioperative acute cerebellar ischemia in relation with type a retrograde dissection of the thoracic aorta. the mean stay in the icu was . days. mean mechanical ventilation time was . days. five patients ( %) presented nosocomial infection: four infections by catheter ( %), one episode of urine infection ( %) and one episode of pneumonia associated with mechanical ventilation ( %). four patients presented acute kidney collapse ( %), without the need for hemodialisis in any case.conclusion: endovascular stent-graft placement can be an alternative to open surgery in the treatment of type b aortic dissection. preliminary results on post-operative morbimortality are promising. randomized and controlled studies are needed to assess the therapeutic potential. durand m , gardelin m , bertet m , tessier gonthier-maurin y , bouzat p , girardet p anaesthesia, chu de grenoble, grenoble, france global tissue hypoxia is associated with a poor outcome after cardiac surgery [ ] . the best predictor of anaerobic metabolism in septic patient seemed to be the ratio of venoarterial co difference (dpco )/arteriovenous o (ca-vo ) content [ ] . the aim of the present study was to verify if this ratio had the same predictive value after cardiac surgery. we performed a retrospective analysis of patients with simultaneous measurements of arterial and venous blood gases and arterial lactate levels during the first hours after surgery. we tested the predictive value of heart rate (hr), cardiac index (ic), mixed venous oxygen saturation (svo ), dpco , ca-vo , dpco /ca-vo and oxygen consumption (vo ) to predict anaerobic metabolism (lactate > mmol/l). the area under roc curves was calculated for the main parameters. results are expressed as mean +/-sd. : results of lactate were below mmo/l (gr ), were above (gr ). dpco (kpa) was significantly higher in gr than in gr ( numerous prospective, randomized studies in critically ill patients indicated that enteral feeding is superior to parenteral feeding and that early enteral feeding, compared with delayed enteral feeding, improves patient outcome as measured by length of stay or complication rates. ideally, tube insertion would be inexpensive and would require minimal time and technical expertise. we inspected a simple bedside technique for positioning the feeding tube. all included patients received a polyurethane feeding tube with a flexible wire stylet ( - silk enteral feeding tube, corpack, wheeling, il).one size cm - fr of feeding tubes was used in this study. feeding tube position was confirmed by an abdominal radiograph. each radiograph was reviewed by a radiologist. equipment to measure ph and bilirubin consisted of color -coded paper (multistic sc bauer corp.usa), amylase and bilirubin (second test) were measured in the central clinical laboratory. successful aspiration of duodenal fluid was performed in ( %) patients. median time for perform bilirubin and ph by color -coded paper (multistic sc bauer corp.usa) -up to seconds. median time for perform bilirubin and amylase analysis in duodenal fluid in central laboratory was . ( + . ) hours. koulenti d , mis m , myrianthefs p , tsigou e , ioannidis c , gavala a , grigoriou p , baltopoulos g icu, kat hospital, athens, greece introduction: liver dysfunction is very common in critically ill patients due to a variety of reasons including trauma, sepsis, congestive heart failure, gall stones, hemorrhagic shock, transfusions, and drug hepatotoxicity. the purpose of the study was to investigate the characteristics of liver dysfunction in icu patients. we prospectively collected data concerning demographic characteristics and liver biochemistry in critically ill patients for a total period of months. liver dysfunction was defined as an increase in liver enzymes by twofold times including sgot, sgpt, alkaline phosphatase, gamma-gt, and bilirubin. during the study period, patients were admitted in our icu. mean age was . ± . , saps ii was . ± . , apache ii was . ± . and mods was . ± . . icu los was . ± . . forty-five patients ( . %) developed liver dysfunction. five of them ( . %) had more than one episodes of liver dysfunction. mean peak values of liver enzymes in patients developing liver dysfunction were sgot . ± . , sgpt . ± . , alp . ± . , gamma-gt . ± . , total bilirubin . ± . , and direct bilirubin . ± . . mean duration of liver dysfunction was . ± . days. mean day of liver dysfunction developed was on . ± . day. confirmed aetiology of liver dysfunction included sepsis ( pts), trauma-rhabdomyolysis ( pts), cholestasis ( pts) and drugs ( pts). we found statistically significant differences (p< . ) between the patients developing liver dysfunction and those who did not concerning los ( . ± . vs. . ± . days), saps ii score ( . ± . vs. . ± . ), apache ii . ± . vs. . ± . and mods score . ± . vs. . ± . . mortality was also significantly higher in patients developing liver dysfunction ( . vs. . %). half of the critically ill patients may develop liver dysfunction during icu hospitalization due to a variety of reasons which may be related to increased los, increased illness severity and other organs dysfunction and worst outcomes. hoeksema m , wester jp , bosman rj , oudemans-van straten hm , van der spoel ji , haak eaf , leyte a , zandstra df intensive care unit, clinical pharmacy, clinical chemistry, olvg, amsterdam, netherlands in critically ill patients with multiple organ dysfunction (mods), thrombocytopenia is frequently observed. heparin-induced thrombocytopenia (hit) accounts for - % of all causes of thrombocytopenia. as hit may be complicated by arterial and venous thrombosis (hitt), alternative anticoagulation is indicated. fondaparinux sodium (arixtra®) is a newly developed synthetic pentasaccharide and acts by selective antithrombin-mediated indirect factor xa inhibition resulting in subsequent thrombin inhibition. fondaparinux sodium has no cross-reactivity to heparin and has not induced an immune-mediated thrombocytopenia in non-icu patients. the elimination is almost exclusively renal. its major drawback is the increased risk of bleeding, to which patients with mods are prone. data on treatment schedules in critically ill patients are non-existent. we describe our experience with fondaparinux anticoagulation in the treatment of hit. we have treated patients with mods and laboratory-proven hit with fondaparinux sodium between december and february . treatment with unfractionated heparin or nadroparin calcium was stopped and laboratory tests for hit were performed with the hit-antibody elisa test. awaiting the test results, fondaparinux sodium (arixtra®, sanofi-synthelabo, the netherlands) was administered as a once daily subcutaneously injection or a continuous infusion of . - . mg/day without loading dose. study endpoints were increase of platelet counts, thrombo-embolic and bleeding complications, and need of transfusion. one female and two male patients, aged between and years, with apache ii scores between and , were diagnosed of hit due to concomitant nadroparin calcium anticoagulation. minimum platelet counts varied from to g/l. hit-antibodies were present in all patients. all patients suffered acute renal failure and were treated with continuous venovenous hemofiltration. treatment with fondaparinux sodium varied from to days. platelet counts improved during fondaparinux sodium. one patient died and autopsy revealed a new myocardial infarction. in another patient recurrent major bleeding resulting in acute tamponade and hematothorax occurred under treatment of both unfractionated heparin and nadroparin as well as under fondaparinux. the third patient suffered a minor bleeding complication. totally, units of erythrocyte concentrates, units of plasma, and units of platelet concentrates were transfused during treatment days.conclusion: treatment with low-dose fondaparinux sodium in patients with mods and hit may be an alternative to treatment with direct thrombin inhibitors. the efficacy and safety need to be determined. caballero zirena a , cortés díaz s , Álvarez terrero a intensive care unit, hospital virgen de la concha, intensive care unit, "virgen de la concha" hospital., zamora, spain introduction: acute pancreatitis is an "acute inflamatory process of the pancreas with variable involvement of other regional tissues or remote organ systems". the definitions of severe pancreatitis accepted generally are: acute physiology and chronic health evaluation (apache ii) score greater than , three or more ranson´s criteria and ct grading system of balthazar. predicting severity of pancreatitis early in the course of disease is very important to prevent and minimize organ dysfunction and complications. from to a total of patients were hospitalized with the diagnosis of acute pancreatitis. of these, patients ( %) were admitted to the intensive care unit. the aim of this study was to compare apache ii score, ranson´s criteria and ct grading system of balthazar for predicting severity and fatal outcome in severe pancreatitis. : patients were identified. there were men and women. the mean age was years (range - ). the most common cause of severe acute pancreatitis were gallstones ( %) and alcoholism ( %). the mean of apache ii score at the admission was , (range - ). most of the patients had higher ct score. all of them had more than three ranson´s criteria. the overall mortality was % ( patients). the intensive care unit length of stay ranged from to days ( mean days). high apache ii or ranson´score at admission significantly determined survival. ranson criterium has the disadvantage of delay. apache ii score is useful in organ failure prediction. balthazar score is superior in predicting pancreatitic necrosis. none of the parameters tested achieved sufficient predictability when used alone. claessens y e , marque s , chiche j d , mira j p , dhainaut j f , cariou a emergency medicine, icu, icu and emergency medicine, cochin hospital, paris, france introduction: saving red pack cell (rpc) transfusion is an important goal in critical care management. the need for rpc transfusion after icu discharge has never been evaluated. prospective monocentric study in critically ill patients admitted between july and december in the medical icu of a teaching hospital. data collected: demographics; saps and lod (d & discharge) ; comorbidity; diagnosis, treatments, icu and hospital lenght of stay ; hb level at icu admission and discharge ; rpc transfusion in icu and during the days following icu discharge with hb threshold and active haemorrhage. information letter was given to patients and families results: population: consecutive pts ( ( ) yrs, saps ( ), (med(sd)). icu mortality %. hb at admission . ( . ) g/dl. . % needed rpc transfusion, threshold . ( . ) g/dl) ; % mortality among rpc transfused pts. , however, with unknown impact on the pituitary-glucocorticoid axis (key mediators: acth / cortisol, affected key metabolite: serum glucose). both, the acth / cortisol system [ ] and blood glucose levels [ ] are increasingly regarded important in intensive care medicine. since the effects of levo on this system may depend on the state of consciousness, we studied respective endocrine effect of levo both in the awake and anesthetized state. we compared respective effects of levo with those of established inotropes, milrinone and dobutamine. awake and anesthetized ( . mac sevoflurane, ventilated) dogs (total: experiments) randomly received levo ( µg/kg plus steps: . - . µg/kg/min), mil ( . µg/kg plus . - µg/kg/min) or dob ( . - µg/kg/min). under steady state conditions (each dose: min) we measured arterial acth-, cortisol-and glucose-levels. statistics: data presented as mean±sem, wilcoxon test, p< . , alpha-adjusted for multiple testing. : levo preserved the levels of acth both in the awake state ( . ± . vs. . ± . pg/ml, baseline and highest drug dose) and during anesthesia ( . ± . to . ± . pg/ml). levo dose-dependently -but insignificantly-increased cortisol under both conditions (awake state: ± , ± , ± and ± ng/ml; anesthesia: ± , ± , ± and ± ng/ml). levo preserved (as did mil and dob) arterial glucose at ~ - mg/dl under all conditions. mil maintained acth in the awake state ( . ± . to . ± . pg/ml) and during anesthesia ( . ± . to . ± . pg/ml), also cortisol ( ± to ± ; ± to ± ng/ml). dob maintained acth in the awake ( . ± to . ± pg/ml) and anesthetized state ( . ± . to . ± . pg/ml), and caused insignificant increases in cortisol ( ± to ± ; ± to ± ng/ml). hfov is an ideal method of ventilation to minimize vili. however, there is limited data regarding outcome in children treated with hfov. we therefore report our experience with hfov at our picu. we retrospectively analysed the chartrecords of all children treated with hfov after failure on cmv between - . the following were recorded: demografic variables, admission diagnosis, pim ii scores, and oi and aado at several timepoints before and after transition to hfov. end points included survival at days post-admission to picu and total number of ventilation days (cmv and hfov). twenty-four children aged day to . years were treated with hfo. seven died and seventeen children survived. non-survivors had a significant higher pim score ( . vs . ), shorter duration of pre-cmv ( vs h). the oi and aado between non-survivors and survivors were . vs . and vs , respectively. both oi and aado did not decrease over time in the non-survivors. total ventilation days were lower in the non-survivors ( vs h).conclusion: hfov was associated with a high survival percentage ( %)in a selected group of children were cmv failed. olsen p , rasmussen m , tønnesen e , zhu w , stefano g deptartment of anaesthesia, Århus university hospital, Århus, denmark, neuroscience research institute, state university of new york, new york, united states exogenously administered morphine has immune modulating effects. the discovery of endogenously synthesised morphine and increased synthesis in response to surgical stress ( , ) and endotoxin infusion imparts a role to endogenous morphine in the immune response. morphine may also affect cancer progression. however, in vitro and xenograft experimental studies illuminating morphine's role in carcinogenesis show conflicting results. the aim of the present study was to analyse human gliomas for the content of endogenous morphine. the study was approved by the regional ethical committee on human research.twelve gliomas were extracted during craniotomy and frozen instantaneously in liquid hydrogen. patients did not receive morphine intra-or postoperatively. pathological analyses confirmed the diagnoses glioma. upon preparation samples were analysed for morphine content with radioimmunoassay (ria) and specificity was confirmed with mass spectrometry. all tumours contained endogenous morphine with concentrations ranging from , ng/g - , ng/g. the identity of morphine was subsequently confirmed by mass spectrometry. the demonstration of endogenous morphine in gliomas suggests its potentially role in carcinogenesis either as an inherent protective measure or as a result of neoplastic transformation. however, it remains to be clarified where the endogenous morphine production takes place. it is also unknown whether the presence of morphine is a pan-cerebral phenomenon or specific to cancerous tissue. the present study revealed a high content of endogenous morphine in human gliomas, providing further support to the idea of potential influence of endogenous morphine in cancer growth. . the majority of infections were exogenous, i.e., the bacterium was introduced into a normally sterile organ, directly from the picu environment. one quarter of the infections were primary endogenous, i.e., the child developed an infection due to a micro-organism present in the admission flora. the death of one child was unrelated to infection. this study shows an infection and mortality rate of % and %, respectively. low level pathogens caused practically all infections which were mainly exogenous following breaches of hygiene. sdd was effective as endogenous infection due to agnb was controlled. scale (gcs),hypotension (systolic blood pressure < mmhg) and hypoxia (cyanosis or pulse oximetry < %)on admission, other traumatisms, head computed tomography (ct) based on marshall's classification (tcdb), intracranial pressure (icp) monitoring,jugular bulb oxygen saturation (sjo ), transcranial doppler (tcd), intracranial hypertension (htic) defined as icp> mmhg.brain edema treatment,length of stay in critical care unit (icu) and hospital,gcs at icu and hospital discharge, and mortality. we also studied hemodinamic and respiratory (pao /fio < ) complications, fever (axilar temperature > , ºc) and electrolytic disorders (sodium < mmol/l or > mmol/l). lewejohann j c , hansen m , zimmermann c , muhl e , bruch h p surgery-icu, universitätsklinikum schleswig-holstein-campus lübeck, lübeck, germany propofol infusion syndrome (pris) is a very rare and often fatal syndrome in critically ill patients undergoing long-term propofol infusion at high doses. until today cases of pris in adults have been described in the literature and of them died. the aim of our representation is to demonstrate the clinical course of a patient with severe rhabdomyolysis subsequent to a multiple trauma and sedation with propofol and to make obvious the importance of this life-threatening syndrome. a year old multiple trauma patient of about kg bodyweight was admitted to our surgical-icu at a university hospital. he had a severe head trauma, a fracture of the cervical vertebra, an ards, multiple rip fractures, severe lower leg fractures with severe vascular damage and the nead of amputation h after admission, fractures of the femora, pericardial effusion and hematoma of the spleen. he received from the beginning on high doses of catecholamnies (norepinephrine, epinephrine), hemofiltration because of renal failure. after resection of his right lower leg one day after admission he received propofol % in a dose range between to ml/h over a time period of days. an initial myoglobin level of µg/l as a result of the multiple trauma on admission decreased to µg/l when the propofol infusion was started with ml/h at first. myoglobin level decreased to µg/l after h. propofol infusion then was increased to ml/h and after h to ml/h. in the following h we saw a dramatic increase of the myoglobin level to a peak level of µg/l. the propofol infusion was stopped then because of the severe rhabdomyolysis and because we thougt about the recently publihed review about the propofol infusion syndrome. soon after removal of propofol myoglobin level decreased rapidly and the patient survived later on. the propofol infusion syndrome is a very rare complication subsequent to propofol use. our patient was severe head injured and received high doses of catecholamines as triggering factors like the patients described in literature. rhabdomyolysis decreased rapidly after stopping the propofol infusion.conclusion: think about the propofol infusion syndrome in patients with severe rhabdomyolysis receiving high dose propofol long-term sedation and consider alternative sedative agents. in northern ireland the process of co-ordinating appropriate and timely therapeutic intervention for severe traumatic brain injury (stbi) is somewhat fragmented. the objectives of the audit were to obtain baseline epidemiological data for stbi in northern ireland and to review current regional critical care management. this was a month prospective audit. stbi patients were identified for inclusion through referrals made to the regional neurosurgical unit (rnsu). during the audit period adult patients were referred to the rnsu. patients were admitted to the regional icu (ricu). % of these patients were male and mostly in the - year age group. % of the injuries were due to falls, . % road traffic accidents and . % assaults. alcohol was detected in % of the patients. icp monitoring was utilised in % of cases, and on day of admission intracranial hypertension (icp > mmhg) was diagnosed in %. this figure fell to % by day . muscle relaxants were used for icp control in % of patients on day and in % on day . over % of individuals developed a ventilator-associated pneumonia (vap) during their ricu stay. this significantly increased the length of stay, but did not increase individual mortality. % of patients required a tracheostomy prior to discharge. there was a high incidence of vap in stbi patients in northern ireland. this may be related to the increased frequency of alcohol intoxication in these patients. heavy reliance on muscle relaxants for icp control may be a further contributing factor. in light of these findings new critical care management guidelines for stbi are being considered.pradl r , chytra i , kasal e , bosman r , ?idková a , ?tepán m dept. of anaesthesia and intensive care medicine, charles university hospital, plzen, czech republic transesophageal doppler was confirmed as useful non-invasive tool for hemodynamic optimisation in group of elective surgery patients. the aim of prospective randomized study was to evaluate the efficacy of early hemodynamic optimisation in multiple trauma patients using transesophageal doppler in comparison with traditionally used basic hemodynamic monitoring (arterial blood pressure, heart rate, central venous pressure). patients with multiple trauma and expected blood loss more than ml admitted and mechanically ventilated on interdisciplinary icu of university hospital in were randomized in protocol group (doppler) and control group (control). hemodynamics of doppler group patients were immediately after admission to icu managed according to the protocol based on data obtained by transesophageal doppler. hemodynamics of control group patients was aimed at generally used resuscitation endpoints -mean arterial pressure (map), central venous pressure, heart rate (hr), urine output and skin perfusion. the age, the apache ii score and injury severity score (iss) were assessed. map, hr and blood lactate level (lact) were evaluated at the time of icu admission (map- , hr- , lact- ) and after hours of icu stay (map- , hr- , lact- ). mann-whitney, wilcoxon, unpaired and paired t-test were used accordingly; p< , was considered statistically significant. a total of patients ( men and women) were enrolled and randomized in doppler (n= ) and control (n= ) group. no differences between doppler and control group in age ( , ± , vs , ± , ), apache ii score ( , ± , vs , ± , ) and iss ( , ± , vs , ± , ) were found. no differences between both groups in map- , map- , hr- , hr- , lact- and lact- were detected, however significant differences between map and blood lactate level at the admission to icu and after hours of icu stay were observed in doppler group (see table) .map- mm hg map- mm hg p lact- mmol/l lact- mmol/l p doppler , ± , , ± , * , ± , , ± , * control , ± , , ± , n.s. , ± , , ± , n.s. n.s. -non-significant, * -p < , conclusion: we conclude that early hemodynamic optimisation by transesophageal doppler in multiple trauma patients can contribute to better tissue perfusion and elimination of oxygen debt. the study is supported by a research grant iga mz cr nd/ - fotouhi ghiam a , abootalebi s , tavana r neurology unit, internal medicine department, al-zahra hospital, bushehr university of medical sciences, bushehr, shiraz university of medical sciences, shiraz ,iran introduction: awareness of the relative prevalence of diseases causing loss of consciousness (loc) in a particular geographic locality could greatly facilitate the approach to patient management. so this study has established to determine the etiologies responsible for nontraumatic loc and hospital outcome in an emergency ward (ew).methods: patients older than twelve years old who present with loc were enrolled in this cross sectional study during the -month period in the ew of the al-zahra teaching hospital. loc was defined as a clinical state manifested by any decrease in level of consciousness ranging from confusion to deep coma. these numbers of patients (accounting for % of the ew patient volume) were identified with a mean age of . years ( . % men). etiology was metabolic in . % , structural in . % and infective in % of patients. it remained unknown in % despite extensive investigation. the most prevalent causes in subgroups were cerebrovascular accidents ( . %) , drug intoxication ( . %), and hypoxic-anoxic conditions ( . %) respectively. the history taking and physical examination were most useful in diagnosis. computed tomography (ct) scan plays an important role in diagnosis of structural causes. lateralizing signs ( %) and nausea/vomiting ( . %) were particularly evident in the presenting symptoms. prognosis is highly dependent on etiology. the admission glasgow coma scale significantly correlated with outcome (p < . ). overall series hospital mortality was . %. most of the patients have been referred to center in less than hours after loc onset. metabolic causes were the commonest overall etiology. the number of undiagnosed cases are significantly higher than other similar domestic and foreign (usa , europe , asia , africa) studies, so emphasis on educating the medical staff to approach to loc and establish cpr committee in ew should be considered. poor outcome was associated with low gcs score. endobronchial blockade represents an alternative to a double-lumen tube (dlt)( ). the wire-guided arndt endobronchial blocker (web, cook inc) can be coupled to a fiberscope and directed as a unit through an endotracheal tube into the area to be blocked. this is of particular interest in patients with a difficult airway in whom intubation with a dlt is contraindicated( ). in contrast to a dlt, that results in complete blockade of either the left or right lung, the web can be positioned in almost any portion of the airway, thereby allowing to isolate a single lobe. we report on the use of the web in a patient with bronchopleural fistula and pulmonary hemorrhage. a yr-old male was admitted after being hit by a truck. orotracheal intubation had been performed at the scene. ct scan revealed fractured ribs, severe bilateral lung contusion, bilateral pneumothorax, pneumomediastinum and -percardium. chest tubes placed in the right thoracic cavity were suggestive of bronchopleural fistula. bronchoscopy revealed a tear in the right lower lobe bronchus and significant bleeding into the airway. due to massive leakage, selective ventilation of the left lung was decided. because of severe mediastinal emphysema, the risk of airway loss during tube exchange seemed high. we decided to perform selective blockade using the web. the web was inserted through the endotracheal tube together with the fiberscope and endoscopically directed into the right lower lobe bronchus with its cuff proximal to the bronchial tear. once the cuff was inflated, the bronchopleural fistula closed, and ventilation improved to normal within minutes. the web was left in place for hrs, and the fistula did not reccur thereafter. the patient's trachea was extubated on day , and he was transferred to a peripheral ward on day in good condition. the web for use in single-lung ventilation with single-lumen intubation proved to be an appropriate tool in an emergency situation caused by severe bronchopleural fistula. intubation with a dlt was considered a high-risk maneuver because of severe mediastinal emphysema and difficult airway. with the web inserted through the endotracheal tube it was possible to isolate the injured right lower lobe from ventilation, to prevent spread of hemorrhage, and to avoid the risk of airway loss during tube exchange. because the web is fixed to the fiberscope with a wire loop, both fiberscope and blocker can be navigated through the tracheobronchial tree as one unit, the web released as soon as in place. our expercience with the web prompts us to recommend this device as a highly practicable alternative to a dlt whenever one-lung ventilation or lobe isolation is required. ( ) campos jh, kernstine kh. anesth analg ; : - .( ) arndt ga, et al., acta anaesthesiol scand ; : - . chaparro m , prieto m , aragonés r , muñoz j , curiel e , arias d , delgado m , ruíz m . intensive care unit, hospital materno-infantil, málaga, spain postpartum haemorrhage is one of the most common causes of maternal morbidity and the primary cause of maternal mortality. only a few case reports have shown that recombinant activated fvii (rfviia) successfully controlled intractable obstetric bleeding ( ). three obstetric patients with massive bleeding and clinical and analytical repercussion, without previous coagulopathy are presented. the use of rfviia in three consecutive obstetric patients with unresponsive lifethreatening haemorrhage admitted to our intensive care unit within the last six months is reported. demographic data, rfviia doses, timing of treatment and diagnosis, among other variables are presented in the floros j , maratheftis n , kolliass , vletsas c , roussos c icu, neurosurgery, evangelismos, athens, greece cerebral microdialysis is a relatively new technique for measuring the levels of brain extracellular chemicals, which to date has predominantly been used as a research tool. there are many reports which emphasize the importance microdialysis to monitor patients with head injury. we describe a significant relation lactate/pyruvate ratio and icp in ten severely head injured patients admitted in the icu in the perioperative period. microdialysis catheters inserted via a bolt fixation device together with the icp catheter. the catheters implanted into the brain to reflect changes in the penumbra of a lesion under computed tomographic control. we used the standardized equipment (cma microdialysis oma ). the lactate/pyruvate ratio is a better marker of ischemia in these patients. there is a strong difference between the values (repeated measured anova) l/p (p< . ) and icp (p< . ) in tracking secondary ischaemic and edema events. the lactate/pyruvate ratio was increased in all ten patients - hours before any change in the ct scan. the lactate/pyruvate ratio is also a better marker of ischemia (p< . ) than lactate alone (p< . ).conclusion: .microdialysis is an effective tool for studying extracellular chemistry and, thus, has great potential for exploring the pathophysiology of secondary brain damage. . the sensitivity and specificity of microdialysis for ischemia and secondary damage are better than icp. . there are data to confirm that microdialysis can be used to direct therapy and influence outcome. moriwaki y , sugiyama m , toyoda h , fujita s , yamagishi s , kanaya k , hasegawa s , kosuge t critical care and emergency center, yokohama city university medical center, yokohama, japan recently, most of trauma patients can be non-operatively treated. one of the most important issues is a few chances of experience of surgery for trauma patients (on-jobtraining). many training courses (off-job-training) for initial trauma care are held frequently, which training course obtain good results in many country. however, it is obvious that on-jobtraining is more effective training method. the objective of this study is to clarify the hourly incidence of trauma patients and surgery for them in one typical urban emergency center and how surgeons are effectively trained for initial care of trauma patients in this center in the education of surgical specialty. our city yokohama is one of the biggest city in japan and has of third level emergency center, including our center, for , people. we examined , of trauma patients treated mainly by surgeons (neck-chest-abdominal trauma cases and polytrauma cases) in our emergency department (ed) including cardiopulmonary arrest (cpa) patients, and of them including cpa who underwent emergency operation. the planning of training in the education of surgical specialty was discussed from a viewpoint of an hourly incidence of trauma patients and surgery for them. trauma patients were mainly transferred during the night shift: . of non-cpa trauma patients ( . %) were transferred during the day shift and . during the night shift per months. surgeries for them were also performed mainly during the night shift: . of non-cpa patients ( . %) and . of all trauma patients (including cpa) underwent surgery during the day shift and . and . patients, respectively, during the night shift per months. we conclude that trainee for surgeon in japan can have adequate opportunity of the initial care and surgery for trauma patients if they belong to the emergency center as an exclusive staff and are on frequent night duty. key: cord- -lcgeingz authors: nan title: th international symposium on intensive care and emergency medicine: brussels, belgium, - march date: - - journal: crit care doi: . /s - - - sha: doc_id: cord_uid: lcgeingz nan introduction: increasing evidence supports a central role for "immunosuppression" in sepsis. it is necessary to develop biomarkers of immune dysfunction that could help to identify patients at risk of poor outcomes [ ] . the decreased expression of human leucocyte antigen (hla)-dra is proposed as a major feature of immunodepression and its persistent decrease is associated with mortality in sepsis [ ] . in a previous study, we evidenced that fcer a (fc fragment of ige receptor ia) is the gene showing the lowest expression levels of the entire transcriptome in sepsis [ ] . here we studied the association between fcer a expression and mortality in infected surgical patients. methods: fcer a and hla-dra expression levels were quantified by droplet digital pcr in blood of infected surgical patients. patients died within days ( . %). spearman test was used to evaluate the association between gene expression and the sequential organ failure assessment (sofa) score. areas under receiver operating curves (auroc) were used to determine the gene expression cut-off values predicting mortality. kaplan-meier survival curves were obtained and differences in survival between groups were evaluated using the log rank test. cox regression was employed to assess mortality risk at days. results: gene expression levels of fcer a and hla-dra correlated inversely with patients' severity (r: - . p< . ; r: - . , p< . respectively). both genes showed significant aurocs to predict survival, but fcer a showed the best accuracy (fig. ) . patients with introduction: severe pulmonary and renal conditions such as acute respiratory distress syndrome (ards), respiratory failure, and deterioration in kidney function often occur in patients with nosocomial pneumonia (np). the emergence and course of infection is genetically determined, hence host genetic landscape may influence an ability to resist infection. methods: variants for genotyping were selected using the phewas catalog which presents genotypic data for caucasian patients, phenotypes and single nucleotide polymorphisms (snps) with p < . [ ] . snps with the lowest p-values for phenotypes with both, respiratory and renal manifestations were selected: intergenic variants rs and rs , rs (edil ) and rs (cyp a ). cyp a gene was associated with pneumonia and ards in our previous investigations, so we included in our analysis three sites of cyp a gene (rs , rs and rs ) studied on a smaller sample. genotyping was performed on sites for a sample results: allele rs -g of the cyp a gene was protective against ards and an increase in creatinine level (fig. ) . the rs -g allele was associated with lung complications and with the development of severe respiratory insufficiency (fig. ) . conclusions: the snps rs and rs can influence the aggravation of pulmonary and renal symptoms through genetically mediated response to infection. introduction: an uncontrolled inflammatory response plays a major role in the sepsis related organ dysfunction. mesenchymal stem cells(mscs) can improve survival of sepsis experimental models by modulating the inflammatory response. macrophages have been considered as important immune effector cells and their polarization imbalance aggravates the disordered inflammation reaction. the project aims to identify the effects of mscs on macrophages polarization against dysregulated inflammatory response. methods: raw . cells were plated in the lower chambers of transwell system in the presence or absence of lipopolysaccharide (lps). then, mscs were seeded in the upper chambers and incubation for different time. finally, transforming growth factor beta (tgfβ) receptor (tgf-βr) inhibitor was added in transwell system. the phenotype of raw . cells were analyzed by flow cytometry, the levels of inflammatory cytokines were detected by enzyme-linked immunosorbent assay (elisa). results: our data showed that lps increased the level of interleukin (il)- in raw . cells (p< . ) (fig. ). in line with il- expression, lps induced the expression of m macrophage (p< . ). moreover, lps stimulated raw . cells co-culture with mscs in transwell system, mscs inhibited the expression of il- and m macrophages, while increased m macrophages (p< . ). compared with lps group, the concentration of tgf-Β was obviously increased in mscs treatment groups (p< . ), furthermore, there were no significantly difference between mscs directed and indicted groups. more significantly, tgf-βr inhibitor abolished the impact of mscs on lps stimulated raw . cells (p< . ) (fig. ) . conclusions: mscs polarized m macrophages into m macrophages and decreased pro-inflammatory cytokine levels by paracrining tgf-β. introduction: sepsis is dysregulated response to an infection, which can lead to progressive microcirculatory dysfunction, release of reactive oxygen intermediates (roi) and life-threatening organ dysfunction. our aim was to investigate the relationship between organ damage -characterized by the sequential organ failure assessment (sofa) scores, microcirculatory failure and roi production, in a large animal model of experimental sepsis. methods: fecal peritonitis was induced in anesthetized minipigs (n= ; . g/kg autfeces containing - x cfu bacteria i.p.), control animals (n= ) received sterile saline i.p. invasive hemodynamic monitoring and blood gas analyses were performed between - hrs, the signs for failure of circulatory, respiratory and urinary systems were evaluated in accordance with the sofa score. the microcirculatory perfusion rate in the sublingual region was measured by orthogonal polarization spectral imaging technique (cytoscan a/r). the leukocyte-origin roi production was determined by lucigenine (mostly o -. ) and luminol-based (h o ) chemiluminescence methods. results: between - hrs after induction the sofa score indicated moderate organ failure in animals (m: . ; p: . , p: . ) and the change was statistically significantly higher in pigs, suggesting severe organ dysfunction (m: . ; p: . , p: . ). the microcirculation was significantly deteriorated in all cases, independently of sofa score data. the h o production was significantly lower in septic animals as compared to controls, while the lucigenine enhanced roi production correlated with the sofa score-indicated moderate and severe organ dysfunction. conclusions: sublingual microcirculatory parameters are not correlating with the severity of sofa score-indicated organ dysfunction in abdominal sepsis. the measurement of roi production of the whole blood seems to be better biomarker for the detection of the progression of events from moderate to severe organ damages. introduction: the purpose of this study was to characterize differences in sepsis management in patients with and without left ventricular (lv) dysfunction. septic patients with lv dysfunction have higher mortality, and limited guidance exists for sepsis management of patients with lv dysfunction. the possibility exists that the cornerstones of sepsis management may contribute to these poor outcomes. methods: a retrospective chart review was conducted from may -january at two centers. adult patients who had a diagnosis of sepsis, were treated with vasopressors for > hours, and had an echocardiogram within months were included. patients were divided into two groups: reduced ejection fraction (ef) of < % and preserved ef defined as ef ≥ %. information about patient outcomes and sepsis management were collected. the primary outcome was the need for mechanical ventilation (mv). categorical and continuous data were analyzed using the chi-squared and mann-whitney u tests, respectively. the irb has approved this project. results: a total of patients with ef < % and patients with ef ≥ % were included. no significant differences in fluid management, vasoactive agent maximum rate or duration, or steroid use were observed. net fluid balance between low and preserved ef was positive . liters vs. . liters (p = . ), respectively. the number of patients that needed mv was higher in the low ef cohort ( % vs. %, p = . ), and this cohort had fewer mv-free days ( , iqr - vs. (iqr - ), p= . . conclusions: no significant differences were observed with regard to sepsis management, reflecting current guidelines. the significantly increased need for mv is a provocative result. a potential mechanism is the inability of a patient with reduced lv dysfunction to maintain appropriate cardiac and respiratory function in the face of fluid overload. prospective analysis of the role of fluid balance in septic patients with lv dysfunction is warranted. introduction: the relationship between myocardial injury and systemic inflammation in sepsis response is not well understood [ ] . it´s proposed to evaluate the association between myocardial injury biomarkers, high-sensitive troponin t (hs-ctnt) and n-terminal pro-brain natriuretic peptide (nt-probnp), with inflammatory mediators (il- , il- Β , il- , il- , il- / il- p , il a, il- and tnf-α ) and biomarkers, c protein reactive (cpr) and procalcitonin (pct), in septic patients methods: this was a prospective cohort study performed in three intensive care units, from september to september enrolling patients with sepsis (infection associated with organ dysfunction), and septic shock (hypotension refractory by fluids infusion requiring vasopressor). blood samples were collected up to h after the development of first organ dysfunction (d ) and on the th day after inclusion in the study (d ) results: ninety-five patients were enrolled, with median age years (interquatile? - ), apache ii: median ( - ), sofa: median ( - ); . % were admitted in icu with sepsis and . % with septic shock. hospital mortality was . %. in d , nt-probnp correlated with il- (r = . , p < . ) and il- (r = . , p < . ). in d , hs-ctnt and nt-probnp correlated with pct (r = . , p < . and r = . , p < . ; respectively). nt-probnp d was higher in nonsurvivors than in survivors on mortality in seventh day (p = . ) and in-hospital mortality (p = . ). hs-ctnt d (p = . ) and nt-probnp d (p < . ) were significantly higher in non-survivors on in-hospital mortality. nt-probnp d (or . ; ic % . - . , p= , ) and hs-ctnt d (or , ; ic % . - . , p= , ) were independently associated with in-hospital mortality conclusions: nt-probnp plasma levels at d correlated with il- and il- , and both nt-probnp and hs-ctnt at d correlated with pct. in addition, nt-probnp has been shown to be an important predictor of mortality introduction: heparin-binding protein (hbp) acts proinflammatory on immune cells and induces vascular leakage through cytoskeletal rearrangement and cell contraction in the endothelium and is a promising novel prognostic biomarker in sepsis and septic shock. however, studies on repeated measures of hbp are lacking. our objective was to describe the kinetics of plasma hbp during septic shock and correlate it to hemodynamic parameters. methods: we included patients with septic shock (sepsis- ) on admission to helsingborg hospital's intensive care unit (icu) during september to february . patients were sampled from icu admission and every hours for hours or until death or icu discharge. the plasma samples were analyzed for hbp and converted using the natural log (lnhbp) for normality. lnhbp was then evaluated against mean arterial pressure (map) as primary analysis and against systemic vascular resistance index (svri) as a secondary analysis, using mixed-effects linear regression models, treating patient id as a random intercept and adjusting for hemodynamic parameters. results: a total of patients were included with median age years, females ( %), surgical admissions ( %), median sofa-score points on day one and deaths from all causes within days ( %). plasma hbp ranged from to ng/ml with a median of ng/ml (lnhbp range . to . , median: . ). an increase lnhbp was significantly associated with a decrease in map (coef. - . mmhg, % ci: - . to - . , p= . , n= ), when adjusting for heart rate (hr), noradrenaline (na), vasopressin (vp), dobutamine (dbt) and levosimendan (ls). in a secondary subgroup analysis, an increase in lnhbp was also significantly associated with a decrease in svri (coef. - . dyne*s*cm- *m- , % ci: - . to - . , p= . , n= ), when adjusting for map, hr, na, vp, dbt, ls and cardiac index. conclusions: repeated measures of plasma hbp during septic shock were correlated with important hemodynamic parameters in this small pilot study. introduction: mid-regional pro-adrenomedullin (mr-proadm) comes from the synthesis of the hormone adrenomedullin (adm), which is overexpressed during inflammation and progression from sepsis to septic shock. thus, mr-proadm can be a useful biomarker for the clinical management of septic patients [ ] . the aim of our study was to understand the ability of mr-proadm to predict -day ( -d) mortality and to find a correlation between mr-proadm and sequential organ failure assessment (sofa) score in the first hours from intensive care unit (icu) admission. methods: we evaluated consecutive septic shock patients according to sepsis iii definitions. clinical data from the medical records included demographics, comorbidities, laboratories, microbiology and biomarker levels. whole blood samples for biomarker profiling were collected at , and hours from icu admission. mr-proadm measurement was detected in edta plasma using a sandwich immunoassay by trace® (time resolved amplified cryptate emission) technology (kryptor thermo fischer scientific brahms). results: overall -d mortality rate was . %. mr-proadm [odds ratio (or) = . ], sofa score (or = . ) and lactate (lac) levels (or = . ) in the first hours were associated with -d mortality in univariate logistic analysis (p value < . , table ). -d mortality rate was not associated with procalcitonin (pct) levels (or = . ). further linear regression analysis showed significant correlation between mr-proadm and sofa score at hours from icu admission (p value< . , fig. , table ). conclusions: mr-proadm demonstrated superior accuracy to predict -d mortality compared to pct levels and is directly linked to sofa score at hours from admission. mr-proadm may aid early identification of poor prognosis septic patients who could benefit a more intensive management. introduction: study of the expression of cell free dna (cfdna) in the search for new biomarkers for infection, sepsis and septic shock. methods: the population studied was all patients included in the sepsis protocol from march to january , hospitalized patients of a federal public hospital. plasma samples were collected for quantification of cfdna, which after centrifugation were stored at - °c and then thawed and analyzed by fluorescence using a varioskan flash fluorometer). cfdna values were expressed as ng/ml. the patients were divided into groups: infection and sepsis/septic shock. we analyzed mortality, sequential organ failure assessment score (sofa score), qsofa (quick sofa), comorbidities, cfdna and laboratory parameters of patients. results: among the patients, % were classified as infection and % sepsis/septic shock. overall lethality was %, infection . %, and sepsis/septic shock . % (p< . ). the mean of cfdna, sofa and lactate was higher according to the classification of infection and sepsis/septic shock: cfdna ( . ± . and . ± . , p= . ), sofa ( . ± . and . ± . , p< . ), qsofa (positive in % and %, lactate ( . ± . and . ± . , p< . ). we analyzed leukocytes, creatinine, crp (c reactive protein), inr (international normalized ratio), as predictors of severity and only crp showed no association with disease severity (p= . ). levels of cfdna and qsofa showed worse prognostic utility as a predictor of sepsis / septic shock when compared to lactate and sofa: or . ( % ci . - . ), p= . for cfdna, or . ( % ci . - . ), p= . for sofa and or . ( % ci . - . ), p= . for lactate. negelkerke r square was , for cfdna. in addition, area under the curve for cfdna mortality was . ( % ci . - . ) and sofa . ci % . - . ). conclusions: our study suggests that cfdna and qsofa have worse prognostic accuracy when compared to lactate and sofa, variables already used in clinical practice and easily measured. introduction: the aim of this study is to develop a "molecular equivalent" to sequential organ failure assessment (sofa) score, which could identify organ failure in an easier, faster and more objective manner, based on the evaluation of lipocalin- (lcn /ngal) expression levels by using droplet digital pcr (ddpcr). sepsis has been classically defined as the exuberant, harmful, pro-inflammatory response to infection. this concept is changing [ ] and the presence of a life-threatening organ dysfunction caused by a dysregulated host response to infection is now considered a central event in the pathogenesis of sepsis [ ] . methods: lcn expression levels were quantified by ddpcr in blood of a total of surgical patients with a diagnosis of infection. spearman analysis was used to evaluate if lcn correlated in a significant manner with sofa score. area under the receiver operating curve (auroc) analysis and multivariate regression analysis were employed to test the ability of lcn to identify organ failure and mortality risk. results: spearman analysis showed that there was a positive, significant correlation between lcn expression levels and sofa score (fig. ) . aurocs analysis showed that lcn presents a good diagnostic accuracy to detect organ failure and mortality risk (fig ) . in the multivariate regression analysis, patients showing lcn expression levels over the optimal operating points (oops) identified in the aurocs showed a higher risk of developing organ failure (table ) and a higher mortality risk (table ) . conclusions: quantifying lcn expression levels by ddpcr is a promising approach to improve organ failure detection and mortality risk in surgical patients with infection. introduction: sepsis is an inflammatory state due to an exacerbated immune response against infection. in cancer patients, sepsis presents a -fold higher mortality than in general population and leads to longer intensive care unit (icu) and hospital lengths of stay. it has been shown that reduced levels of circulating immunoglobulins (ig) might be a surrogate marker of unfavorable outcome in sepsis [ ] . the aim of this study was to evaluate the association between ig levels in plasma and -day mortality rate in cancer patients with septic shock. methods: from december to november , we conducted a prospective study in the intensive care unit (icu) of cancer institute of state of sao paulo, an -bed icu linked to university of sao paulo. patients ≥ years old with cancer and septic shock were enrolled. descriptive statistics were computed for demographic and outcome variables. laboratory data and ig levels were collected at icu admission and at days , and . a multivariate analysis was performed to evaluate predictors of -day mortality. results: a total of patients were included in the study. the -day and -day mortality were . % and . %, respectively. no significant differences in igm and igg levels were observed between survivors and non-survivors. in both groups, the median igm levels were low and the median igg levels were normal. in the multivariate analysis for -day mortality, a favorable status performance measured by the eastern cooperative oncology group (ecog) was associated with better survival; metastatic disease, higher sequential organ failure assessment (sofa) score at admission and higher levels of initial lactate were associated with increased mortality. conclusions: low levels of serum endogenous immunoglobulins are not predictors of -day mortality in cancer patients with septic shock. introduction: cytovale has developed a rapid biophysical assay of the host immune response which can serve as a rapid and reliable indicator of sepsis. neutrophils and monocytes undergo characteristic structural and morphologic changes in response to infection. one type of response is the generation of neutrophil extracellular traps (nets), these have been proposed as potential mediators for widespread tissue damage. during netosis there is a fundamental reorganization of a cell's chromatin structurea signal that we have shown is sensitively measured by the cytovale cytometer. we hypothesized that quantification of plasticity (deformability) of leukocytes in the peripheral blood provides an early indicator of sepsis. the cytovale assay uses microfluidic cytometry to measure the plasticity of up to , white blood cells from edta-anticoagulated, peripherally-collected whole blood and provides a result in minutes. methods: in two prospective studies conducted in two academic medical centers in baton rouge, la, the cytovale test was performed on peripheral blood samples obtained from patients who presented to the emergency department with signs or symptoms suggestive of infection. the two studies included high acuity patients ( patient study) and low acuity patients ( patient study). an adjudicated reference diagnosis of sepsis or no sepsis was established for each subject, using consensus definitions, by review of the complete medical records. results: the receiver operator curve (roc) performance of the cytovale assay for both studies demonstrated an area under the curve (auc) greater than . (fig. ) . conclusions: measurement of neutrophil and monocyte plasticity by a novel assay provides an accurate and rapid indication of sepsis in patients who present to an emergency room with signs or symptoms of infection. plasma hepatocyte growth factor in sepsis and its association with mortality: a prospective observational study introduction: sepsis and septic shock are commonly associated with endothelial cell injury. hepatocyte growth factor (hgf) is a multifunctional protein involved in endothelial cell injury and plays a pivotal role in sepsis. this study assesses its correlation with relevant endothelial cell injury parameters and prognostic value in patients with sepsis. methods: a prospective, observational cohort study was conducted in patients with sepsis admitted to the department of critical care medicine at the zhongda hospital from november to march . the plasma hgf level was collected on the first h after admission (day ) and day , then was measured by enzyme-linked immunosorbent assay. the primary endpoint was defined as all-cause -day mortality. furthermore, we analyzed the correlation of hgf with relevant endothelial cell injury markers. results: eighty-six patients admitted with sepsis were included. hgf levels of non-survivors were elevated upon day ( . ± . pg/ml vs. . ± . pg/ml; p = . ) and day ( . ± . pg/ml vs. . ± . pg/ml; p = . ) compared with that in survivors, and showed a strong correlation with von willebrand factor (r = . , p < . ), lactate (r = . , p = . ), pulmonary vascular permeability index (r = . , p = . ), first h fluid administration (r = . , p < . ) and sequential organ failure assessment score (r = . , p = . ) (fig. ) . plasma levels were able to discriminate prognostic significantly on day (auc: . , %ci: . - . ) and day (auc: . , %ci: . - . ) (fig. ) . conclusions: hgf levels are associated with sepsis and are correlated with established markers of endothelial cell injury. elevated hgf level in sepsis patients is a predictor of mortality. methods: adult patients with septic shock by the sepsis- classification due to lung infection or primary bacteremia or acute cholangitis are screened using two consecutive measurements of ferritin and of hla-dr/cd co-expression for mals (ferritin above , ng/ml) or immunosuppression (hla-dr/cd less than %) and randomized into immunotherapy with either anakinra (targeting mals) or recombinant ifnγ (targeting immunosuppression) and into placebo treatment. main exclusion criteria are primary and secondary immunodeficiencies and solid and hematologic malignancies. results: patients have been screened so far. most common infections are community-acquired pneumonia ( . %), hospitalacquired pneumonia ( . %) and primary bacteremia ( . %). mean +/-sd sofa score is . +/- . and charlson's comorbidity index . +/- . ; patients have mals ( . %); two immunosuppression ( %); the majority remain unclassified for immune state. conclusions: current screening suggests greater frequency of mals than recognized so far in a setting of septic shock due to lung infection or primary bacteremia or acute cholangitis. development of an algorithm to predict mortality in patients with sepsis and coagulopathy d hoppensteadt , a walborn , m rondina , j fareed study was to develop an equation incorporating biomarker levels at icu admission to predict mortality in patients with sepsis, to test the hypothesis that using a combination of biomarkers of multiple systems would improve predictive value. methods: plasma samples were collected from patients with sepsis at the time of icu admission. biomarker levels were measured using commercially available, elisa methods. clinical data, including the isth dic score, sofa score, and apache ii score were also collected. -day mortality was used as the primary endpoint. stepwise linear regression modeling was performed to generate a predictive equation for mortality. results: differences in biomarker levels between survivors were quantified and using the mann-whitney test and the area under the receiver operating curve (auc) was used to describe predictive ability. significant differences (p< . ) were observed between survivors and non-survivors for pai- (auc= . ), procalcitonin (auc= . ), hmgb- (auc= . ), il- (auc= . ), il- (auc= . ), protein c (auc= . ), angiopoietin- (auc= . ), endocan (auc= . ), and platelet factor (auc= . ). a predictive equation for mortality was generated using stepwise linear regression modeling. this model incorporated procalcitonin, vegf, the il- :il- ratio, endocan, and pf , and demonstrated a better predictive value for patient outcome than any individual biomarker (auc= . ). conclusions: the use of a mathematical modeling approach resulted in the development of a predictive equation for sepsis-associated mortality with performance than any individual biomarker or clinical scoring system. furthermore, this equation incorporated biomarkers representative of multiple physiological systems that are involved in the pathogenesis of sepsis. the effects of biomarker clearances as markers of improvement of severity in abdominal septic shock during blood purification t taniguchi , k sato , m okajima introduction: sepsis associated coagulopathy (sac) is commonly seen in patients which leads to dysfunctional hemostasis. the purpose of this study is to determine the thrombin generation potential of baseline blood samples obtained from sac patients and demonstrate their relevance to thrombin generation markers. methods: baseline citrated blood samples were prospectively collected from patients with sac at the university of utah clinic. citrated normal controls (n= ) were obtained from george king biomedical (overland park, ks). thrombin generation studies were carried out using a flourogenic substrate method. tat and f . were measured using elisa methods (seimens, indianapolis, in). functional antithrombin levels were measured using a chromogenic substrate method. results: the peak thrombin levels were lower ( ± nm) in the dic patients in comparison to higher levels observed in the normal plasma ( ± nm). the auc was lower ( ± ) in the dic group in comparison to the normals ( ± ). the dic group showed much longer lag time ( . ± . ) in comparison to the normal group ( . ± . ). wide variations in the results were observed in these parameters in the dic group. the f . levels in the dic group were much higher ( ± pmol) in comparison to the normal ( ± pmol). the tat levels also increased in the dic group ( . ± . ng/ml) in comparison to the normal ( . ± . ng/ml). the functional antithrombin levels were decreased in the dic group ( ± %). conclusions: these results validate that thrombin generation such as f . and tat are elevated in patients with dic. however thrombin generation parameters are significantly decreased in this group in comparison to normals. this may be due to the consumption of prothrombin due to the activation of the coagulation system. the decreased functional at levels observed in the dic group are due to the formation of the complex between generated thrombin and antithrombin. introduction: sepsis-associated disseminated intravascular coagulation (dic) is a complex clinical scenario involving derangement of many processes, including hemostasis. assessment of markers including inflammation, endothelial function, and endogenous anticoagulants may provide insight into dic pathophysiology and lead to improved methods for assessment of patient condition and response to treatment. methods: citrated plasma samples were collected from patients with sepsis and suspected dic at icu admission and on days and . dic score was determined using the isth scoring algorithm (e.g. platelet count, pt/inr, fibrinogen and d-dimer). cd ligand (cd l), plasminogen inhibitor (pai- ), nucleosomes, procalcitonin (pct), microparticle tissue factor (mp-tf) and prothrombin . (f . ) were measured using commercially available elisa kits. protein c activity was measured using a clot-based assay. interleukin (il- ), interleukin (il- ), interleukin (il- ), tumor necrosis factor alpha (tnfα), and monocyte chemoattractant protein (mcp- ) were measured using biochip technology. results: significant differences in levels of protein c (p= . ), pct (p= . ), il- (p= . ), il- (p= . ), pai- (p= . ), were observed between survivors and non-survivors. significant variation of protein c (p= . ), nucleosomes (p= . ), pct (p< . ), il- (p= . ), il- (p= . ), il- (p= . ), tnfα (p= . ) and mcp- (p= . ) were observed based on severity of dic score. conclusions: markers from multiple systems perturbed in dic were associated with mortality, suggesting that while these systems may not be routinely evaluated in the normal course of patient care, dysfunction of these systems contributes significantly to mortality. in addition, numerous inflammatory cytokines showed an association with dic score. this suggests that the measurement of additional markers in sepsis-associated dic may be of value in the prediction of mortality and may be helpful in guiding treatment for these patients. introduction: the endotoxin activity assay (eaa) is a rapid immunodiagnostic test based on chemiluminescence. it was approved by the fda in as a diagnostic reagent for risk assessment of severe sepsis in the icu. ascertaining endotoxin levels in the bloodstream is important in targeting patients and determining the appropriate timing for initiation of treatment. it has high sensitivity and specificity for endotoxin, and is considered to be useful in predicting clinical symptoms and determining prognosis. the usefulness of the eaa has yet to be fully clarified. methods: a total of patients admitted to the icu between january and june with suspected sepsis or sepsis were enrolled. the eaa was conducted within hr after admission. patient characteristics were determined, together with levels of il- , procalcitonin, presepsin, and pao /fio . thereafter, the patients were classified into groups depending on their eaa value: ) < . ; ) from ≤ . to < . ; ) from ≤ . to < . ; ) from ≤ . to < . ; and ) ≤ . ). the transition of various markers was also examined. the spearman rank correlation, wilcoxon rank sum test, and a nonrepeated anova were used for the statistical analysis. a p-value of < . was considered statistically significant. the eaa values showed a positive correlation with both the apache ii (r= . ) and sofa scores (r= . )(p< . ), although that with the latter was stronger. a significant correlation was also observed with levels of procalcitonin (r= . ) and presepsin (r= . early diagnosis is important to allow early intervention. the current clinical methods are insufficient for early detection. we hypothesized that intraperitoneal microdialysis allows detection of peritonitis prior to changes in standard clinical parameters in a pig model. methods: bacterial peritonitis was induced in pigs by bowel perforation and intraperitoneal fecal instillation, one pig underwent sham surgery. intraperitoneal microdialysis catheters were placed in each abdominal quadrant. the observation time was hours. results: in peritonitis pigs the intraperitoneal lactate increased during the first two hours and remained elevated throughout the observation time (table ) , whereas the arterial lactate remained within reference range (< . mm). intraperitoneal glucose decreased significantly. hemodynamics were hardly influenced during the first two hours, and decreased thereafter. sham surgery did not influence in any of the parameters. conclusions: a rapid and pronounced increase in intraperitoneal lactate and decrease in intraperitoneal glucose was observed after instillation of intraabdominal feces. systemic lactate increase was absent, and the hemodynamic response was delayed. postoperative intraperitoneal microdialysis is applicable in detecting peritonitis earlier than standard clinical monitoring and should be evaluated in a clinical study in order to explore if early intervention based on md data will reduce icu length of stay, morbidity and mortality. introduction: procalcitonin (pct) is a serum biomarker suggested by the surviving sepsis campaign to aid in determination of the appropriate duration of therapy in septic patients. trauma patients have a high prevalence of septic complications, often difficult to distinguish from inflammatory response. pct values typically declined after h from trauma and increased only during secondary systemic bacterial infections. the aims of the study are to evaluate reliability and usefulness of pct serum concentration in trauma. methods: we retrospectively analyzed data from trauma patients admitted to icu at bufalini hospital -cesena, from july to august . we collected data about antimicrobial therapy, injury severity score (iss), first arterial lactate in emergency room, sofa score and sepsis severity. plasma pct concentration was measured using an automate analyzer (modular e-brahms) on st day of antimicrobial therapy and every h hours. antimicrobial therapy was stopped according to a local protocol; however medical judgment was considered the overriding point for therapeutic decision. results: median iss of patients was . , inter quartile range (iqr) . . pct mean concentration at the starting of antimicrobial treatment was . μg/l (d.s . ), median . (iqr . ). no significative correlation (spearman´s rho test) was found between pct at day of antimicrobial therapy and iss (rho - . ), between first arterial lactate in er and pct (rho . ). daily course of pct was not related to distance from trauma (rho - . ). in of patients ( . %) pct measurement led physician to save days of antimicrobial therapy compared with standard clinical practice. we couldn´t find any cut off value. conclusions: our experience suggests that pct could help physician to optimize duration of antimicrobial therapy in trauma patients. no standard approach can be recommended at present. introduction: long duration of antimicrobial treatment may predispose to colonization and subsequent infections by multidrugresistant organisms (mdro) and clostridium difficile. progress (clinicaltrials.gov registration nct ) is an on-going trial aiming to use pct for the restraining of this calamity. methods: adult patients with sepsis by the sepsis- classification and any of five infections (pneumonia community-acquired; hospital-acquired or ventilator-associated; acute pyelonephritis; primary bacteremia) are randomized to pct-guided treatment or standard of care (soc) treatment. in the pct arm antibiotics are discontinued when pct on or after day is decreased by more than % of the baseline or remains below . ng/ml; in the soc arm antibiotics are discontinued at the discretion of the attending physician. patients are followed for six months. primary endpoint is the rate of infections by mdro and/or c.difficile or death. serial stool samples are cultured for mdro and screened for glutamate dehydrogenase antigen and toxins of c.difficile. results: patients have been enrolled so far. mean ± sd sofa score is . ± . . most common diagnoses are community-acquired the progress trial is the first trial assessing the probable benefit from pct guidance to reduce ecological sequelae from long-term antibiotic exposure. analysis of baseline patient characteristics indicates that progress is a real-world trial so that results can have major clinical impact. prospective multi-site validation of -gene host response signature for influenza diagnosis s thair , s schaffert , m shojaei , t sweeney there are no blood-based diagnostics able to identify influenza infection and distinguish it from other infections. we have previously described a blood-based -gene influenza meta-signature (ims) score to differentiate influenza from bacterial and other viral respiratory infections. methods: we prospectively validated the ims in a multi-site validation study by recruiting individuals ( patients with suspected influenza, healthy controls) in community or hospital clinics across australia. we assayed the ims and genes from viral genome of influenza strains to generate the blood flu score (bfs) as a measure of viremia using nanostring from whole blood rna. results: using clinically determined phenotypes, the ims score distinguished patients with influenza from healthy (auc= . ), non-infected (auc= . ), bacterial (auc= . ), other viruses (auc= . ) ( figure a) . interestingly, probes of bfs were found in all phenotypic groups (non-infected, bacterial, and other viral infections) to varying degrees, and positively correlate with the ims score (r= . ). ims aurocs improve when the bfs is used to inform the phenotypic groups: healthy (auc= . ), non-infected (auc= . ), bacterial (auc= . ), other viruses (auc= . ) ( figure b ). patients who were clinically influenza negative but had a high ims and bfs were admitted less often, yet had~ -fold higher mortality than those who were clinically influenza negative with low ims and no bfs (table ) . conclusions: collectively, our prospective multi-center validation of the ims demonstrates its potential in diagnosis of influenza infections. introduction: previous findings of our group suggest that patients with gram-negative hospital-acquired severe sepsis have better prognosis when sepsis is developing after recent multiple trauma through stimulation of favorable interleukin (il)- responses [ ] . under a similar rationale, we investigated if preceding osteomyelitis may affect experimental osteomyelitis. methods: sham or experimental osteomyelitis was induced in male new zealand white rabbits after drilling a hole at the upper metaphysis of the left tibia and implementing diluent or log of staphylococcus aureus using foreign body. after three weeks, the foreign body was removed and experimental pyelonephritis or sham surgery was induced after ligation of the right pelvo-ureteral junction and instillation of log of escherichia coli in the renal pelvis. survival was recorded and circulating mononuclear cells were isolated and stimulated for the production of tumour necrosis factor-alpha (tnfa) and il- . at death or sacrifice, tissue outgrowth and myeloperoxidase (mpo) were measured. results: four sham-operated rabbits (s), rabbits subject to sham surgery and then pyelonephritis (sp) and rabbits subject to osteomyelitis and then pyelonephritis (op) were studied. survival after days of group sp was . % and of group op % (log-rank . ; p: . ). lab findings are shown in figure . il- production was blunted. negative correlation between e. coli outgrowth and tissue mpo was found at the right kidney of the op group (rs: - . , p: . ) but not of the sp group (rs: - . , p: . ). conclusions: preceding staphylococcal osteomyelitis provides survival benefit to subsequent experimental osteomyelitis through downregulation of innate immune responses leading to efficient phagocytosis. introduction: activation of neutrophils is a mandatory step and a sensitive marker of a systemic inflammatory response syndrome (sirs) which is closely related to development of multiple organ failure. the search for drugs that can prevent sirs and reduce mortality in critically ill patients remains significant. the aim of this study was to study the anti-inflammatory effect of the synthetic analogue of leu-enkephalin (dalargin) on human neutrophils. methods: the study was conducted on isolated from the blood of healthy donors neutrophils. their activation was assessed by fluorescent antibodies to markers of degranulation cd b and cd b (sd b-fitc and cd b-alexafluor (bd biosciences, usa). as inductors of inflammation lipopolysaccharide (lps) and the peptide formyl met-leu-pro (fmlp) were used. mkm fmlp and dalargin in concentrations of and μ g / ml were added to neutrophils at a concentration of ppm / ml and incubated for min at °c; then antibodies were added and incubated for min on ice; then fluorescence was assessed by flow cyto flow meter beckman-coulter fc . non-parametric criteria were used; data were presented as a median and %- % interquartile intervals. the statistical significance was estimated using mann-whitney test. the difference was considered statistically significant at p< . results: synthetic analogue of leu-enkephalin in various concentrations has an anti-inflammatory effect on both intact and preactivated with bacterial components neutrophils, reducing their activation and degranulation in a dose-dependent manner (figs. , ) . conclusions: synthetic analogue of leu-enkephalin prevents neutrophil activation by bacterial compounds. this has a potential of translation into clinical practice for sepsis treatment. introduction: the endothelin system plays important roles in circulatory regulation through vasoconstrictor et-a and et-b receptors and vasodilator et-b receptors (etar; etbr, respectively). tissue hypoxia during the progression of sepsis is associated with microcirculatory and mitochondrial disturbances. our aim was to investigate the possible influence of etar antagonist, etbr agonist or combined treatments on oxygen dynamics, microcirculatory and mitochondrial respiration parameters in experimental sepsis. methods: male sprague-dawley rats (n= /group) were subjected to faecal peritonitis ( . g/kg faeces ip) or sham-operation. septic animals were treated with sterile saline solution, or received the etar antagonist etr-p /fl peptide ( nmol/kg iv), etbr agonist irl- ( . nmol/kg iv) or same doses as combination therapy, hr after sepsis induction. invasive hemodynamic monitoring and blood gas analyses were performed during a -min observational window. introduction: sepsis often induces immunosuppression, which is associated with high mortality rates. nivolumab is a human igg- antibody directed against the programmed cell death (pd- ) immunecheckpoint inhibitor, which disrupts pd- -mediated signaling and restores antitumor immunity. nivolumab is an approved anti-cancer drug that may have the potential to improve sepsis-induced immunosuppression. methods: this multicenter, open-label study investigated the safety, pharmacokinetics and pharmacodynamics of a single intravenous infusion of or mg nivolumab in japanese patients with immunosuppressive sepsis (lymphocytes ≤ /μl). the dosing of nivolumab was set using the predicted steady state concentration of nivolumab at mg/kg every weeks (q w), which was the approved dosage for cancer patients at the time of planning. results: five and eight patients were assigned to the and mg groups, respectively. the mean (standard deviation) peak serum drug concentration in the mg group was comparable to the predicted median concentration ( % pi [prediction (figures and ). adverse events (aes) were observed in four patients in each group. drug related-aes were observed in only one patient in the mg group (table ) . no deaths related to nivolumab occurred. conclusions: a single dose of mg nivolumab appeared to be well tolerated and sufficient to maintain nivolumab blood concentration in patients with sepsis. results suggest both and mg nivolumab therapy could improve relevant immune indices. introduction: the systemic inflammatory response syndrome (sirs) accompanies tissue trauma and infection and, when severe or dysregulated, contributes to multiple organ failure and critical illness. observational studies in man and animal have shown that low-dose acetyl-salicylic acid promotes resolution of inflammation and might attenuate excessive inflammation by increasing the synthesis of specialised pro-resolving lipid mediators (spms). methods: we randomly assigned patients with sirs who were expected to stay in icu for more than hours to receive enteral aspirin ( mg per day) or placebo for days or until death or discharge from the icu, whichever came first. the primary outcome was il- serum concentration at h after randomisation. the secondary outcomes included safety and feasibility outcomes. in one center, additional blood samples were taken during the first three days for exploratory analysis of spms using reversed-phase highperformance liquid chromatography -tandem mass spectrometry (rp-hplc-ms/ms). results: from march through december a total of patients across four general icus in australia underwent randomization (table ) . compared to placebo patients, il- serum concentration after h in aspirin-treated patients was not significantly lower ( [ - ] pg/ml vs [ . - ] pg/ml; p= . ). there were no significant differences for control vs. aspirin-treated patients in the change of pro-resolving/anti-inflammatory lipids between the time points (figure , ). there were no between-group differences with respect to icu or hospital mortality, number of bleeding episodes or requirements for red cell transfusions (table ) . conclusions: in patients admitted to the icu with sirs, low-dose aspirin did not result in a decreased concentration of inflammatory biomarkers compared with placebo. introduction: sepsis is associated with excessive ros production, nf-kb, inos and inflammatory mediators overexpression. vitamin c is a cellular antioxidant, it increases enos and decreases nf-kb; it has several immune-enhancing effects and is crucial for endogenous vasopressors synthesis. vitamin c reserves in sepsis are often as poor as in scurvy [ ] . in recent studies, intravenous high vitamin c dose seems to reduce organ failure and improve outcome in septic shock. methods: we treated all septic shock patients admitted to our icu in months (from / to / ) with intravenous vitamin c . g/ h and thiamine mg/ h (for its synergistic effects) [ ] as adjunctive therapy for consecutive days and we compared data to septic shock patients admitted in the previous months period. we enrolled patients: received vitamins supplementation, standard of care. we analysed -days mortality, sofa at and hours, pct variation from baseline in first days, vasoactive therapy length and daf (days alive and free from vasopressors, mechanical ventilation and rrt in days follow up). patients with end stage kidney disease were ruled out. we analysed data with mann-whitney and wilcoxon tests. results: vit c group showed lower -days mortality ( % vs . %: ns); sofa improvement at (- . ± . vs - . ± . : p= . ) and hours (- . ± vs - . ± : p< . ) was higher in vit c group; vit c patients had faster pct reduction without statistical significance. mean vasoactive therapy length was quite similar. daf was . (± . ) days in vit c group and . (± . ) in controls (p= . ). control patients needed rrt, none in vit c group. conclusions: despite small study size, we found that vit c has positive effects on survival and improves sofa score (fig. ) and daf (fig. ) in septic shock. no vit c patient developed oxalate nephropathy nor worsened renal function. introduction: toxin-producing gram-positive organisms cause some of the most severe forms of septic shock [ , ] . adjunctive therapies such as intravenous immunoglobulins (ivig) have been proposed for these patients [ , ] . however, at patient presentation, the presence of a toxin-producing organism is most often unknown. methods: we reviewed the use of ivig in our patients requiring extracorporeal membrane oxygenation (ecmo) in a -year period between february and march . results: in % ( / ) of the patients that received ivig for presumed toxin-mediated shock, group a streptococcus or panton-valentine leukocidin producing s. aureus was isolated, but the clinical characteristics of these patients were not significantly different from the ones with other final diagnoses, except for a predisposing influenza infection and the presence of an often very high procalcitonin level. these patients were extremely unwell at presentation with a sofa score of ± , high lactate levels ( . ± . mmol/l) and need for vasopressors (equivalent norepinephrine dose of . ± . μ g/kg/min). they had very high inflammatory parameters with a procalcitonin ≥ ng/ml in more than half of patients ( / ). ivig use in these patients was generally safe, with only possible transfusion reaction. the mortality of % ( / ) was lower than predicted based on the sofa scores. conclusions: ivig administration can be considered in a selected group of patients presenting with acute and very severe septic shock, as part of a multimodal approach [ ] . introduction: extra corporeal treatments are used in septic patients to decrease the inflammatory mediators, but definitive conclusions are lacking . more over in many studies the effect of aki isn't evaluated and this may be an important bias. . the aim of this study is to evaluate in septic patients with aki: the effect of the adsorbing membrane oxiris on the immunological response -the different response in survivors and non survivors methods: from our local data base we analyzed retrospectively septic shock patients with aki (kdigo classification) submitted to crrt with the adsorbing membrane oxiris (baxter, usa ) . at basal time ( t ) and at the end of the treatment ( t ) we evaluated the following variables: il il procalcitonin endotoxin (eaa). all data are expressed as mean ±sd or median and iqr. student t test or mann-whitney was used to compare values changes. p < . was considered statistically significant. results: thirty patients with sepsis /septic shock and aki were enrolled in this study. patients had aki , patients aki , patients aki . the duration of treatment was ± hours. patients had citrate as anticoagulation and heparine continous ev. at table are shown the main results of this study in all the patients. survivors vs non survivors had a significant decrease of il , procalcitonin and eaa. conclusions: data of this study confirm on clinical ground previous study "in vitro" [ ] that the adsorbing membrane oxiris has important immunological effect during septic shock with aki. this must be confirmed in a rct. introduction: sepsis is common and often fatal, representing a major public health problem. hemoadsorption (cytosorb) therapy aims to reduce cytokines and stabilise the overall immune response in septic shock patients. methods: a prospective, multi-centre, investigator initiated study to evaluate hemoadsorption (cytosorb) therapy in septic shock patients admitted to a tertiary icu's in india during to . all centres followed a common protocol and received ethics committee approval. results: a total of patients were administered cytosorb in addition to standard of care. a total of patients ( %) survived out of patients. among survival group, patients ( %) were administered cytosorb within hours of icu admission resulting in significant reduction in sepsis scores, apache ii ( . vs . ) and sofa ( . vs . ) post cytosorb therapy. also there was reduction in inflammatory markers like cytokines il in most of the patients. all patients in survivor group showed a significant improvement in map ( . vs . ) and reduction in vasopressors (epinephrine . to . mcg/kg/min, nor-epinephrine . to . mcg/kg/min) after cytosorb therapy. no device related adverse effect was observed in any of the patients. among the non-survivor group, ( patients, %) we observed that cytosorb was administered after hours of icu admission. although a few patients showed improvement in sofa score, majority did not show a significant improvement with map ( . vs . mm of hg) and required increased demand in vasopressors. conclusions: in this multi-centered prospective iis study, we could observe clinical benefits of hemoadsorption (cytosorb) therapy in septic shock patients if the therapy was initiated early. larger randomised study are required to establish the above clinical benefits in larger patient population. a single centre experience with hemoadsorption (cytosorb) in varied causes of sepsis and mods y mehta , c mehta , a kumar , j george , a gupta , s nanda , g kochar , a raizada introduction: sepsis and the multiorgan failure is a leading cause of mortality in the intensive care unit. promising new therapies continue to be investigated for the management of septic shock. we tried to evaluate a novel hemoadsorption therapy (cytosorb) through a retrospective evaluation of patient's data in our centre. we used it as an adjuvant therapy in our patients with sepsis due to varied causes. methods: we retrospectively analysed data of introduction: septic shock is a life-threatening multiple organ dysfunction that has high morbidity and mortality in critically ill patients, due to a dysregulated host response to infection. the aim of this study was to evaluate the efficacy of therapeutic cytokine removal (cytosorb®) in the management of patients with septic shock. methods: we retrospectively analyzed patients admitted to icu with septic shock between june and november . patients included in the study were diagnosed according to the third international consensus definitions for sepsis and septic shock (sepsis- ), received maximal supportive care including continuous veno-venous hemodiafiltration (cvvhdf) for acute kidney injury and cytosorb® haemoadsorption column was added to return limb of the cvvhdf circuit. demographic data, procalcitonin and leukocyte levels before and after therapeutic cytokine removal and duration of cytosorb® haemoadsorption column application and apache ii scores were recorded. results: the mean age of patients included in the study was ± . years ( % male) and the mean body mass index was . ± . . the mean apache ii score was . with an expected and actual mortality rates of % and %, respectively. % of the patients were admitted with sepsis and % of them with septic shock. . % (n= ) of the cases were solid organ transplant recipients. cvvhdf was applied in all patients during therapeutic cytokine removal. treatment was combined with ecmo in patients. while the mean duration of cvvhdf was . hours, the duration of cytosorb® haemoadsorption column application was . ± . hours. procalcitonin ( . ± ng/ml vs ± ng/ml) and leucocyte levels ( ± / mm vs ± mm ) after therapeutic cytokine removal were found significantly lower than the pretreatment values (respectively p= . , p= . ). conclusions: therapeutic cytokine removal applied with cvvhdf in septic shock patients have positive contributions to biochemical parameters and provide survival advantage. introduction: recent studies have focused on demonstrating the potential benefits of immunomodulation in the management of septic patients. the aim of our study was to assess the effects of a hemoadsorption column (cytosorb®) in critical ill septic patients. methods: after ethical approval was obtained, we prospectively included patients admitted to the general icu of fundeni clinical institute. three consecutive sessions of renal replacement therapy (continuous venovenous hemodiafiltration) in combination with cytosorb® were applied after icu admission. clinical (heart rate, arterial pressure, temperature, glasgow coma scale) and paraclinical data (pao , serum bilirubin and creatinine, platelet count, white blood cell count, ph, c-reactive protein and procalcitonine), vasopressor support and need for mechanical ventilation were recorded before and after the three sessions. results: the mean age in the study group was ± years. median number of organ dysfunction at the time of icu admission was [ ] [ ] [ ] [ ] [ ] and the mean sofa score was . ± . . the use of cytosorb® was associated with a non-significant increase in pao /fio ratio from ± to ± (p= , ) and creatinine levels from . ± . to . ± . mg/dl (p= . ). although we observed a non-significant increase in c-reactive protein levels from ± mg/l to ± mg/ l (p= . ), we noted a significant decrease in procalcitonine levels from a median of . [ . , . ] ng/dl to a median of . [ . , . ] ng/dl (p= . ). a significant decrease in platelet count was also noted from ± /mm to ± /mm (p= . ). mean sofa score decreased non-significantly from . ± . to . ± . (p= . ). conclusions: the use of cytosorb was associated with a slight nonsignificant improvement in organ function and a decrease of procalcitonine levels. thrombocytopenia remains one of the most important complications of renal replacement therapy. introduction: circulating cell-free neutrophil extracellular traps (nets) would induce a microcirculatory disturbance of sepsis. the removal of nets remnants from the circulation could reduce nets-dependent tissue injury. to address this issue, we evaluated the effect of hemoperfusion with a polymyxin b cartridge (pmx-dhp; toray, japan), which was originally developed for the treatment in patients with gram-negative bacterial infection, on circulating cell-free nets in patients with septic shock and in phorbol myristate acetate (pma)-stimulated neutrophils obtained from healthy volunteer. methods: ex vivo closed loop hemoperfusion was performed through a circuit formed by connecting the small pmx module to a tube and a peristalsis pump. whole blood from healthy volunteers incubated with or without pma or from septic shock patients were applied to circuit and perfused. blood was collected at , and hr after perfusion. circulating cell-free nets were assessed by myeloperoxidase (mpo)-, neutrophil elastase (ne)-, and cell free (cf)-dna. results: plasma mpo-dna, ne-dna and cf-dna levels were significantly increased at hr after pma stimulation when compared with plasma levels without pma. when either blood from septic shock patients or pma-stimulated neutrophils obtained from volunteers were applied to circuit, circulating mpo-dna, ne-dna and cf-dna were significantly reduced in perfusion with pmx filter than in perfusion without pmx filter at times and hr. conclusions: in the ex vivo experiments, mpo-dna, ne-dna and cf-dna were found to decrease after ex vivo perfusion through pmx filters. selective removal of circulating components of nets may improve the remote organ damage in patients with septic shock. a retrospective study of septic shock patients who were treated with direct hemoperfusion with polymyxin b-immobilized fibers based on the levels of endotoxin activity assay s sekine, h imaizumi, i saiki, a okita, h uchino tokyo medical university, anesthesiology/icu, tokyo, japan critical care , (suppl ):p introduction: the purpose of this study was to evaluate the outcomes for septic shock patients with direct hemoperfusion with polymyxin b-immobilized fibers (pmx-dhp) and endotoxin activity assay (eaa). methods: according to the levels of eaa, patients were classified for three groups (low group (gl); eaa < . , intermediate group (gm); eaa > . or eaa < . , high group (gh); eaa > . ). in order to evaluate the severity of illness, acute physiology and chronic health eva-luationii (apache ii) score, the sequential organ failure assessment (sofa) score, catecholamine index (cai) were recorded. and the presence of pmx-dhp treatments were also recorded. blood samples were obtained to measure eaa levels, inflammatory markers (procalcitonin (pct), c-reactive protein (crp), and white blood cell count (wbc)), serum lactate level as an indicator of tissue hypoxia, and for blood culture. apache ii score, sofa score, cai, inflammatory markers, serum lactate levels (lac) and blood culture results were examined for diagnosis of septic shock and prognosis of -days mortality. each values were also compared to eaa levels. results: septic shock patients were included (gl/ gm/ gh: / / ). in gh, apache ii and sofa score was significantly higher than that in gl (p< . ). eaa levels were significantly increased in gramnegative bacteremia patients compared to the patients with grampositive bacteremia or fungemia. there was no relationship between eaa levels and other inflammation markers, cai, and lac. in gm, days mortality in patient with pmx-dhp treatments was lower than that of without pmx-dhp treatments ( . ( / ) vs . ( / ), p= . ). in gh, -days mortality in patient with pmx-dhp treatments was same as that of without pmx-dhp treatments ( . ( / ) vs . ( / ), p= . ). conclusions: these results of this study suggest pmx-dhp treatment may improve the outcome of septic shock patients with intermediate eaa levels. introduction: numerous inconclusive randomized clinical trials (rcts) in sepsis in the past years suggest a need to re-think trial design to improve resource allocation and facilitate policy adoption decisions. the inclass study (clinicaltrials.gov nct: ) is an ongoing rct evaluating clarithromycin as an immune modulator in high-risk septic patients with clinical and cost-effectiveness outcomes. we aim to compare the original one-shot trial with an alternative sequential design that balances trial costs and value of information. methods: adult patients with sepsis, respiratory failure and total sofa score of at least , are randomized to receive intravenous clarithromycin or placebo adjunctive to standard-of-care therapy. for the cost-effectiveness study, efficacy is measured in quality-adjusted life years (qalys) by eq- d- l questionnaire at days. the endpoint is the incremental net monetary benefit (inmb) of clarithromycin compared to placebo, defined as wtp x (increment in qaly) -(increment in costs), where wtp is willingness to pay per qaly gained. fixed and variable costs of trial execution (including administrative, insurance, supplies, tests) are calculated; hospitalization cost is extracted from patient records; medical care beyond day is recorded; cost of adoption in the general population is estimated. previous data from rcts using clarithromycin are used to form a prior belief about the inmb. known incidence of sepsis with respiratory failure allows estimation of the population to benefit from trial decision. a bayesian model is used to determine the sequential design that maximizes trial value. results: we will compare the performance of the sequential trial design with the one-shot design of inclass trial in terms of sample size, cost, social-welfare, and probability of correctly identifying the best treatment. conclusions: in this protocol we validate a bayesian model for sequential clinical trials and assess the benefits for the patient population and health care system. the effect on the outcome of critically ill patients with catecholamine resistant septic shock and acute renal failure through implementation of adsorption therapy g schittek introduction: cytosorb-adsorption has been described as an effective way for hemodynamic stabilisation in septic shock [ ] . aim of this study was to examine whether the adsorption-therapy could influence patient-outcome with catecholamine resistant septic shock (crss) and acute renal failure(arv). furhtermore we tried to identify clinical constellations that would predict an effective use of adsorbers [ , ] . initial il- in patients with catecholamine-reduction through adsorption was non-significantly different to those with no reduction ( ng/l [ , ] vs. ng/l [ , ]). mortality did not differ significantly between the groups ( % vs %). length of intensive care unit stay (los) did differ significantly ( days [ , ] vs days [ , ] ). conclusions: il- can be reduced with adsorption. patients with catecholamine-reduction did not differ in regard to their initial il- . los was shorter for patients treated with adsorption. according to our experience adsorption can be taken into consideration when crss is beginning. introduction: in our intensive care unit (icu), we have already started expanded application to the contact precautions. applied patients are; ) emergency admission, ) patients who had already had bacteria* that are required to contact precautions, ) scheduled surgical patients with prolonged icu stay, although we have not yet decided the started period of expanded application exactly. *detected bacteria(db);mrsa, cd, mdrp, esbl, pseudomonas a, pisp, prsp, vrsa. the aim of this study was to determine the adequate starting period of expanded application to the contact precautions in the scheduled surgical patients in the mixed icu. methods: we performed retrospective observational study on patients who were admitted to our icu after planed surgery from may to dec. . we detected the patients who acquired bd newly and investigated the relation to the length of icu stay. the relationship between detection rate and categorized date was also analyzed using logistic regression adjusted for age, gender, apache , and sofa score. using youden´s index and roc curve, we also calculated cutoff point of the duration of icu stay related to detection rate. finally, we made the logistic regression model of each cutoff day(day to ) and compared odds ratio(or) and auc of each models using stata. results: category day or more, especially day or more had significantly higher detection rate of db compared to day ( results: pao /fio was lower than mmhg in ( %) patients. compared to patients in group , patients in group were less severely ill at admission but presented a higher sofa and cpis score and a greater incidence of ards and shock at pneumonia onset (fig ) . ( %) patients in group had a microbiological diagnosis of pneumonia, compared to patients ( %) in group (p= . ). pao /fio ≤ mmhg was associated with less probability of having microbiological diagnosis of pneumonia (or . , % ci . to . , p= . ). when adjusted for other variables significantly associated with positive microbiology, pao /fio ≤ mmhg remained significantly associated with less probability of a microbiological diagnosis (adjusted or . , % ci . to . , p= . ). hospital mortality was significantly higher in patients in group compared to group ( % vs %, p= . ). however, no difference was found in non-response to treatment, icu and hospital stay, icu mortality (table ) and -days survival (fig ) . conclusions: a significant higher number of patients with vap didn't have a definitive etiological diagnosis when using the proposed threshold criteria of pao /fio ≤ mmhg. pao /fio ratio does not seem a good predictor of etiology in patients with vap. introduction: immunological dysfunction is common in critically ill patients but the optimal method to measure it and its clinical significance are unknown. levels of tumor necrosis factor alpha (tnf-α) after ex-vivo whole blood stimulation with lipopolysaccharide has been proposed as a possible method to quantitate immunological function. we hypothesized that patients with a lower post-stimulation tnf-α level would have increased rates of nosocomial infections (nis) and worse clinical outcomes. methods: a secondary analysis of a phase randomized, multicentre, double-blinded placebo controlled trial [ ] . there were no differences in allocation groups; all the patients were analyzed as one cohort. on enrolment, whole blood was incubated with lps ex-vivo and tnf-α level was measured. patients were grouped in tertiles according to delta and peak tnf-α level. the primary outcome was the development of nis; secondary outcomes included -day mortality. results: data was available for patients. baseline characteristics and outcomes are reported in tables and . patients in the highest tertile for post lps stimulation delta tnf-α compared to the lowest tertile were younger, had a lower acuity of illness and had lower baseline tnf-α. when grouped according to peak post-stimulation tnf-α levels, patients in the highest tertile had higher serum tnf-α at baseline. both comparisons showed no difference between nis and clinical outcomes between tertiles. in multi-variate analysis peak or delta tnf-α were not associated with the occurrence of nis. conclusions: admission ex-vivo stimulated tnf-a level is not associated with the occurrence of nis or clinical outcomes. further study is required to evaluate the ability of this assay to quantify immune function over the course of critical illness. results: sanitary and epidemiological examination revealed the connection between infection and intravenous infusion of dexamethasone performed concurrently with chemotherapy. in patients fever with chills and hypertension developed within hours after infusion of the infected drug; empirical intravenous antibiotic therapy started immediately after collecting blood culture. in patients fever appeared after - days outpatiently, so they received antibiotics per os. all these patients had permanent vascular access, and bsi was detected either the next chemotherapy course when fever reappeared ( pts) while using vascular access, or as a result of a specific examination ( pts). in all cases empirical antibiotic therapy started on the first day of fever, drug correction was performed in patients according to results of bacteriological research. septic shock developed in patient, pneumonia in patients. permanent vascular access was preserved only in case. all patients were cured and continued to receive antitumor treatment. conclusions: detection of more than case of b. cenocepacia bsi should be the reason for sanitary and epidemiological examination. a favorable outcome of bsi treatment is associated with the early start of antibiotic therapy and its correction after microbiological examination. emerging conclusions: implementation of asp in hospital allows to decrease incidence of eskape-bacteremia and candidemia, which may lead to improved clinical outcomes in icu's patients (fig ) . association of multi-drug resistant (mdr), extended-drug resistant (xdr) and pan-drug resistant (pdr) gram negative bacteria and mortality in an intensive care unit(icu) s chatterjee , s sinha , a bhakta , t bera , t chatterjee , s introduction: colistin-resistant klebsiella pneumoniae (cr-kp) is increasingly reported around the world. it is worrying to note emergence of resistance to last line of defence against mdr gram negative infections in regions endemic to carbapenem resistance. we report the first outbreak of cr-kp co-producing carbapenemases in an adult intensive care unit (icu) from south india. methods: retrospective analysis of all patients with carbapenem resistant klebsiella pneumoniae blood stream infection (bsi) was done between january and december . microbiological and clinical variables along with outcomes were analysed. results: seven patients had cr-kp with no prior exposure to colistin. all seven were modified hodge test (mht) negative making probability of blakpc unlikely. in resource limited setting, analysis beyond mht could only be performed for cr-kp samples. / samples belonging to cr-kp isolates produced the blandm- whilst / cr-kp isolates did not produce either blakpc or blandm carbapenemases prompting hypothesis of blaoxa- or blavim as the causative factor. compared to carbapenem resistance only group, cr-kp group had higher apache ii, icu length of stay and mechanical ventilation duration. day mortality was noted to be . % for carbapenem resistant and % for cr-kp groups. aggressive infection control measures were undertaken with successful containment of cr-kp strains along with reduction in overall bsi. conclusions: infection control measures form the backbone of patient care in centres showing endemicity for carbapenem resistant klebsiella to prevent colistin resistance and also to reduce occurrence of overall blood stream infections. rapid diagnosis of carbapenem resistance: experience of a tertiary care cancer center with multiplex pcr s mukherjee tata medical center, critical care medicine, kolkata, india critical care , (suppl ):p introduction: sepsis due to carbapenem resistant organisms has high mortality; inappropriate empirical antibiotic is one of the main causes of this poor outcome. on the contrary, "too much" broad spectrum empiric antibiotics will increase drug resistance, even in community, because of selection pressure. so, early diagnosis of resistance pattern (carbapenemase genes) is crucial. aim of this study is to compare rapid diagnostic test like polymerase chain reaction (pcr) with conventional culture sensitivity (c/s) to identify carbapenem resistance. methods: this is a prospective observational study done in tata medical center, kolkata, india. real time multiplex pcr technique has been developed "in house" in our microbiology lab and can identify ndm, ndm , kpc, oxa - , oxa - , oxa - & vim carbapenemase genes. blood cultures were sent as per clinical & laboratory diagnosis of sepsis in icu patients. culture positive samples had been used for conventional c/s by vitek system along with pcr study to identify carbapenemase genes. result of pcr technique was been compared with conventional c/s method. results: multiplex pcr results were available within - hours of positive blood culture compared to conventional c/s method that takes - days. among positive blood cultures, samples were positive for carbapenemase genes. most common gene identified was oxa - ( %), followed by ndm ( %). our pcr technique has very high sensitivity, specificity, positive & negative predictive value ( . %, . %, . % & . % respectively) while comparing with final c/s report by vitek system (table ) . there was only one false negative diagnosis for carbapenem resistance. conclusions: real time multiplex pcr for carbapenemase gene can be helpful for early diagnosis of carbapenem resistance and can help us to choose / modify antibiotics or to use 'targeted therapy'. it is more practical to "rule -in" infection rather than "rule -out" by this technique. carbapenemase producing enterobacteriaceae colonization in an icu: risk factors and clinical outcomes m miranda, jp baptista, j janeiro, p martins centro hospitalar e universitário de coimbra, intensive care unit, coimbra, portugal critical care , (suppl ):p introduction: carbapenemase-producing enterobacteriaceae (cpe) colonization has been increasingly reported in intensive care units (icus) since their first identification more than years ago. colonization with cpe seems to constitute a risk factor for mortality. the aim of our study was to identify associated risk factors and clinical outcomes among patients with fecal colonization by cpe admitted to a portuguese tertiary hospital icu. methods: a -year retrospective study was performed in patients with previous unknown cpe status (colonization or infection), admitted to our icu. rectal swabs were performed and analyzed using real-time polymerase chain reaction testing. clinical records were reviewed to obtain demographic and clinical data. results: of patients admitted, ( . %) harbored cpe, ( . %) were colonized at admission and ( . %) acquired cpe colonization during icu stay. the most frequent carbapenemase genes detected were kpc ( . %) and vim ( . %). cpe carriers had high rates of hospitalization (previous or ongoing), invasive procedures (mainly intraabdominal surgery), malignancy (hematopoietic or solid tumor), introduction: gram-negative pathogens-particularly pseudomonas aeruginosa and enterobacteriaceae-predominate in nosocomial pneumonia (np) and ciai both. these infections are becoming difficult to treat with available treatment options due to growing antimicrobial resistance in india. ceftazidimeavibactam has in-vitro activity against gram-negative organisms producing class a, class c and some class d beta-lactamases. we carried out a qualitative analysis to assess the safety and efficacy outcomes of the indian population cohorts involved in the re-prove and reclaim trials. methods: in line with the global reprove protocol, indian patients enrolled in the study with np, were randomly assigned ( : ) to mg ceftazidime and mg avibactam or mg meropenem. in the reclaim study, indian patients with a diagnosis of ciai were enrolled in the study and were randomly assigned ( : ) to receive either ceftazidime-avibactam ( mg of ceftazidime and mg of avibactam) followed by metronidazole ( mg); or meropenem ( mg). the primary efficacy outcome measure in the reprove and reclaim studies was clinical cure rate of caz-avi compared with that of meropenem at toc (test-of-cure) visit in pre-defined analysis sets. in both studies, non-inferiority was concluded if the lower limit of the twosided % ci for the treatment difference was greater than - · % in the primary analysis sets. as the indian subset study was not statistically powered to detect a difference in the subgroup, we descriptively analysed the efficacy results in the indian population and compared them with the overall results in the global trial. in addition, the study also analysed the safety of caz-avi in the indian patients by monitoring the number and severity of adverse events. introduction: early administration of effective intravenous antimicrobials is recommended for the management of the patients with sepsis. although meropenem (mepm) is one of the first-line drugs in patients with sepsis because of its broad spectrum, the optimal dose in the critical care settings especially during continuous renal replacement therapy (crrt) has not been established since therapeutic drug monitoring of mepm has not been popular. methods: eighteen critically ill patients who received crrt were enrolled in this study. one gram of mepm was administered over hour, every hours, and blood samples at , , , and hours after administration were collected on day , and . all samples were stored at - °c until analysis. the measurement of the blood concentration of mepm was performed using high performance liquid chromatography with ultraviolet detection (hplc-uv introduction: meningitis is one of the complications of severe traumatic brain injury, and it is often associated with encephalitis (incidence from . - . % to - %). the aim of the investigation was to study the dynamics of the concentration of meropenem in serum and cerebrospinal fluid (csf) with intravenous and intrathecal administration of meropenem. methods: in eight patients with bacterial meningoencephalitis blood serum and csf were studied prior to the administration of meropenem and - min, , . and hrs after it. antibiotic regimen: mg of vancomycin ( mg bid) and meropenem ( mg tid diluted in ml of saline iv + mg bid diluted in ml of saline bolus slowly intrathecally). meropenem infusion was carried out for minutes, mins after it ml of blood and ml of csf were sampled. prior to antibiotics administration blood and csf were taken for microbiological examination. to determine the concentration of antibiotics iquid chromatography/mass spectrometry was used. the samples were analyzed on an agilent infinity liquid chromatograph coupled to a sciex qtrap mass detector (sciex, us introduction: the prophylactic use of probiotics has emerged as a promising alternative to current strategies viewing to control nosocomial infections in a critically-ill setting. however, their beneficial role in vap prevention remains inconclusive. our aim was to delineate the efficacy of probiotics for both vap prophylaxis and restriction of icu-acquired infections in multi-trauma patients. methods: randomized, placebo-controlled study enrolling multitrauma patients, requiring mechanical ventilation for > days. participants were randomly assigned to receive either probiotic (n= ) or placebo (n= ) treatment. a four-probiotic formula was applied and each patient received two capsules per day from day to day post icu admission. the content of one capsule was given as an aqueous suspension by nasogastric tube, while the other one was spread to the oropharynx after being mixed up with water-based lubricant. the follow-up period was days, while icu stay and mortality were also assessed. ], while no difference in -day mortality rate was identified between groups ( . % probiotics vs . % placebo). conclusions: the prophylactic administration of probiotics exerted a positive effect on the incidence of vap or other icu-acquired infections and icu stay in a critically-ill subpopulation being notorious for its high susceptibility to infections, namely multi-trauma patients. use of a c-reactive protein-based protocol to guide the duration of antibiotic therapy in critically ill patients: a randomized controlled trial i borges introduction: the rational use of antibiotics is one of the main strategies to limit the development of bacterial resistance. in this study we aimed to evaluate the effectiveness of a c reactive protein (crp) based protocol in reducing antibiotic treatment time in critically ill patients. methods: an open randomized clinical trial was conducted in two adult intensive care units of a university hospital in brazil (clini-caltrials.gov: nct ). patients were randomly allocated to: i) intervention -duration of antibiotic therapy guided by crp levels, and ii) control -duration of therapy based on best in the intention to treat analysis, the median (q -q ) duration of antibiotic therapy for the index infection episode was . ( . - . ) days in the crp group and . ( . - . ) days in the control group (p= . ). in the cumulative suspension curve of antibiotics, a significant difference in the exposure time between the two groups was identified, with less exposure in the crp group (p= . ). in the pre-specified per protocol analysis, with patients allocated in each group, the median duration of antibiotics was . ( . - . ) days in the crp group and . ( . - . ) days in the control group (p= . ). mortality and relapse rates were similar between groups. conclusions: daily levels of crp may aid in reducing the time of antibiotic therapy in critically ill patients, even in a scenario of judicious use of these drugs. introduction: the macrophage activation syndrome (mas) or hemophagocytic lymphohistiocytosis(hlh) is a life threatening complication characterized by pancytopenia, liver failure, coagulopathy and neurologic symptoms and is thought to be caused by the activation and uncontrolled proliferation of t lymphocytes and well differentiated macrophages, leading to widespread hemophagocytosis and cytokine overproduction [ , ] .the etiology is unknown, but is considered to have an infectious trigger.the aim of our study is to evaluate the impact of hlh in our beds infectious diseases icu, during months period ( - ). methods: a retrospective study based on electronic databases, including all patients admitted in our icu, that have matched at least out of criteria for hlh diagnosis ( ):fever; hepatosplenomegaly; > cytopenia (hb < g/dl, plt</dl, pmn -n< /mmc); hypertriglyceridemia> mg/dl, fibrinogen< mg/dl; hemophagocytosis-bone marrow, spleen, and/or lymphnodes; nk activity reduced/ absent; ferritin level> ui/l; cd > . we have evaluated the etiology established with cultures, serology, and molecular methods, treatment with corticosteroids, iv immunoglobuline, cyclosporine, etoposide and outcome ( ) . results: patients were admitted to icu, patients( . %) met the criteria for hlh. the average length of stay in icu was days; patients died ( %) without relation with the followed treatment. conclusions: hlh is not a rare condition in infectious diseases icu. the etiology is more frequent established compared with literature data. treatment (corticosteroids, immunoglobuline, cyclosporine, etoposide) is not associated with increased survival forecasting hemorrhagic shock using patterns of physiologic response to routine pre-operative blood draws introduction: irreversible hemorrhagic shock (ihs), a critical condition associated with significant blood loss and poor response to fluid resuscitation, can induce multiple organ failures and rapid death [ ] . determining the patients who are likely to develop ihs in surgeries could greatly help preoperative assessment of patient outcomes and allocation of clinical resources. methods: machine learning model of ihs is developed and validated via porcine induced bleed experiment. healthy sedated yorkshire pigs first had one ml rapid blood draw during a stable period, and then were bled at ml/min to mean arterial pressure (map) of mmhg. subjects had ihs defined as map< mmhg. arterial, central venous and airway pressures collected at hz during the blood draw [ fig ] were used to extract characteristic sequential patterns using graphs of temporal constraints (gtc) methodology [ ] , and a decision forest (df) model was trained on these patterns to determine subjects at high risk of impending ihs. results: in a leave-one-subject-out cross-validation, our method confidently identifies % ( % ci [ . %, . %]) of the subjects who are likely to experience ihs when subject to substantial bleeding, while only giving on average false alarm in , such predictions. this method outperforms logistic regression and random forest models trained on statistically featurized data [tab , fig ] . conclusions: our results suggest that by leveraging sequential patterns in hemodynamic waveform data observed in preoperative blood draws, it is possible to predict who are prone to develop ihs resulting from blood loss in the course of surgery. future work includes validating the proposed method on data collected from human subjects, and developing a clinically useful screening tool with our investigations. work partially funded by nih gm . introduction: the h s and oxytocin(oxy) systems are reported to interact with one another [ ] . h s plays a major role in the hypothalamic control of oxy release during hemorrhage [ ] . there is scarce information about oxy receptor(oxyr) expression in the brain in general and what is there is ambivalent. oxyr has been immunohistochemically(ihc) detected in the human hypothalamus but not in the hippocampus, in contrast to rodents [ ] , which underscores the need for additional characterization in relevant animal models. thus the aim of this study is to map the expression of the oxy and h s systems in the porcine brain in a clinically relevant model of hemorrhagic shock (hs). methods: anesthesized atherosclerotic pigs (n= ) underwent h of hs (map +/- mmhg) [ ] , followed by h resuscitation. ihc detection of oxy, oxyr, the h s producing enzymes cystathionine-γ -lyase (cse) and cystathionine-β -synthase(cbs) was performed on formalin fixed brain paraffin sections. results: oxy, oxyr, cse and cbs were localized in the porcine brain. proteins were differentially expressed in the hypothalamus (fig ) , parietal cortex and cerebellum (fig ) . cell types positively identified were: magnocellular neurons of the hypothalamus, cerebellar purkinje cells and granular neurons, and hippocampal pyramidal and granular neurons of the dentate fascia. arteries and microvasculature were also positive for oxyr and cse. conclusions: our results confirm the presence of oxy and oxyr in the hypothalamus similarly to the human brain. novel findings were: oxyr in the cerebellum and cse expression in the hypothalamus and cerebellum. the coexpression of oxyr and cse may link and help better understand neurochemical systems and physiological coping in hemorrhagic shock. funding: crc introduction: septic shock is one of the main causes of intensive care unit (icu) admission, leading to mortality up to % of patients. acute kidney injury (aki) frequently occurs and is associated to great morbidity and mortality. hemodynamic optimization may reduce the incidence of aki, but the use of vasopressors to increase mean arterial pressure (map) could have deleterious effect on renal perfusion. we aimed at investigating the effect of map and norepinephrine (ne) on the incidence of aki in septic shock patients methods: retrospective study based on prospectively collected data on digital medical records (digistat) at our icu. introduction: in patients with distributive shock, increasing mean arterial pressure (map) to a target of > mmhg can improve tissue perfusion. patients unable to achieve the target map of > mmhg despite adequate fluid resuscitation as well as catecholamines and vasopressin standard care (sc), may benefit from the noncatecholamine vasopressor angiotensin ii to increase map. this posthoc analysis examined whether patients from the athos- study with a baseline (bl) map < mmhg and treated with sc plus either angiotensin ii (ang ii) or placebo achieved a map of > mmhg for consecutive hours, without increasing the dose of sc therapy. methods: patients were assigned in a : ratio to receive ang ii or placebo, plus sc. randomization was stratified according to map (< or > mmhg) at screening. in patients with bl map < mmhg, we evaluated whether patients achieved a map of > mmhg for the first hours after initiation (map measurements taken at hours , , and ), without an increase in the dose of sc. results: among treated patients, had bl map < mmhg (ang ii, ; placebo, ). median bl map (iqr) was ( - ) and ( - ) mmhg for placebo and ang ii groups, respectively. patients with bl map < mmhg who were treated with ang ii were more likely to achieve map ≥ mmhg for consecutive hours after initiation without an increase in sc dose ( %, %ci - ), compared with placebo-treated patients ( %, %ci - , or= . , p< . ). conclusions: in this post-hoc analysis of patients with bl map < mmhg, patients receiving ang ii plus sc were significantly more likely to achieve a map > mmhg for the first consecutive hours after initiation than patients receiving sc only. this suggests that administering ang ii may help patients with catecholamine-resistant distributive shock to achieve the consensus standard target map. norepinephrine synergistically increases the efficacy of volume expansion on venous return in septic shock i adda, c lai, jl teboul, l guerin, f gavelli, c richard, x monnet hôpitaux universitaires paris-sud, hôpital de bicêtre, aphp, service de médecine intensive-réanimation, le kremlin-bicêtre, france critical care , (suppl ):p introduction: through reduction in venous capacitance, norepinephrine (ne) increases the mean systemic pressure (psm) and increases cardiac preload. this effect may be added to the ones of fluids when both are administered in septic shock. nevertheless, it could be imagined that ne potentiates in a synergetic way the efficacy of volume expansion on venous return by reducing venous capacitance, reducing the distribution volume of fluids and enhancing the induced increase in stressed blood volume. the purpose of this study was to test if the increase in psm induced by a preload challenge were enhanced by ne. methods: this prospective study had included septic shock adults. to reversibly reproduce a volume expansion and preload increase at different doses of ne, we mimicked fluid infusion through a passive leg raising (plr). in patients in which the decrease of ne was planned, we estimated psm (using respiratory occlusions) at baseline and during a plr test (plr high ). the dose of ne was then decreased and psm was estimated again before and during a second plr (plr low ). . the increase in cardiac index induced by plr low was significantly greater than that induced by plr high (p< . ). Δ psmhigh -Δ psmlow was moderately correlated with the diastolic arterial pressure at baseline-high (p= . , r= . ) and with the ne-induced change in mean arterial pressure (p= . , r= . ). conclusions: ne enhances the increase in psm induced by a plr, which mimics a fluid infusion. this suggests that it may potentiate the effects of fluid in a synergetic way in septic shock patients. this may decrease the amount of administered fluids and contribute to decrease the cumulative fluid balance. introduction: arginine vasopressin (avp) can be used in addition to norepinephrine (ne) for ne-resistant septic shock. however, a subgroup who will response to avp is unknown. the purpose of this study was to determine factors which could predict the response to avp in patients with ne-resistant hypotension. methods: this was a single-center, retrospective analysis of patients who administered avp for ne-resistant hypotension in our intensive care units (icus). eligible patients were adult patients who administered avp in addition to ne due to hypotension (mean arterial pressure (map) < ) in our icus between august and december . we divided all patients into two groups by response to avp; responders and non-responders. the responders were defined as an increase of map ≥ mmhg at h after avp initiation. we conducted univariate and multivariate logistic regression analysis to evaluate the effect of variables on avp response. results: a total of patients were included; responders ( %), non-responders ( %). there was no significant difference for map at the time of avp initiation ( vs mmhg; p = . ), initiation dose of avp ( . vs . u/min; p = . ), and dose of ne at the time of avp initiation ( . vs . μ g/kg/min; p = . ). map at h after avp initiation was significantly higher in responders than non-responders ( vs mmhg; p < . ). responders were older ( vs ; p = . ) and had lower heart rate (hr) ( vs. ; p = . ) and lactate ( . vs. . mmol/l; p = . ) at the time of avp initiation. the multivariate logistic analysis revealed that hr ≤ (or . , % ci . - . , p < . ), lactate ≤ (or . , % ci . - . , p < . ) and age ≥ (or . , % ci . - . , p = . ) were significantly associated with the response to avp. conclusions: hr, lactate levels and age before avp initiation can predict the response to avp in icu patients with ne-resistant hypotension. the maximum norepinephrine dosage of initial hours predicts early death in septic shock d kasugai , a hirakawa , n jinguji , k uenishi nagoya university gtaduate school of medicine, department of emergency and critical care, nagoya, aichi, japan; fujita health university, department of disaster and traumatology, fujita health university, toyoake, japan; fujita health university hospital, department of emergency and general internal medicine, fujita health university hospital, toyoake, japan critical care , (suppl ):p introduction: the mortality of septic shock refractory to norepinephrine remains high. to improve the management of this subgroup, the knowledge of early indicator is needed. we hypothesize that maximum norepinephrine dosage on the initial day of treatment is useful to predict early death in septic shock. methods: in this retrospective single-center observational study, septic shock patients admitted to the emergency intensive care unit (icu) of an academic medical center between april and march were included. cardiac arrest before icu admission and those with do-not-resuscitate orders before admission were excluded. the maximum dosage of norepinephrine initial hours of icu admission (md ) was used to assess -day mortality. results: one-hundred-fifty-two patients were included in this study. median sofa score was ( - ), and median md was . ( . - . ) mcg/kg/min. vasopressin and steroid were administered in ( %) and ( %) cases. nineteen patients ( %) died within a week. non-survivors had higher md , higher sofa score, and higher rate of vasopressin use. the higher md predicted -day mortality (area under curve . , threshold . mcg/kg/min, sensitivity %, specificity %). after adjustment of inverse probability of treatment weighing method using propensity scoring, md higher than . mcg/kg/min was independently associated with -day mortality (or: . , %ci: . - . , p < . ). conclusions: the maximum dosage of norepinephrine higher than . mcg/kg/min initial hours was significantly associated with day mortality in septic shock, and may be useful in the selection of higher severity subgroup. the impact of norepinephrine on right ventricular function and pulmonary haemodynamics in patients with septic shock -a strain echocardiography study k dalla sahlgrenska university hospital mölndal, göteborg, sweden critical care , (suppl ):p introduction: septic shock is characterized by myocardial depression and severe vasoplegia. right ventricle performance could be impaired in sepsis. the effects of norepinephrine on rv performance and afterload in septic shock are not immediately evident. the aim of the present study was to investigate the effects of norepinephrine on rv systolic function, rv afterload and pulmonary haemodynamics. methods: eleven, volume-resuscitated and mechanically ventilated patients with norepinephrine-dependent septic shock were included. infusion of norepinephrine was randomly and sequentially titrated to target mean arterial pressures (map) of , and mmhg. at each target map, strain-and conventional echocardiographic were performed. the pulmonary haemodynamic variables were measured by using a pulmonary artery thermodilution catheter. the rv afterload was assessed by calculating the effective pulmonary arterial elastance (epa) and pulmonary vascular resistance index (pvri). results: the norepinephrine-induced elevation of map increased central venous pressure ( %, p< . ), stroke volume index ( %, p< ), mean pulmonary artery pressure ( %, p< . ) and rv stroke work ( %, p= . ), while neither pulmonary vascular resistance index nor epa was affected. increasing doses of norepinephrine improved rv free wall strain from - % to - % ( %, p= . ), tricuspid annular plane systolic excursion ( %, p= . ) and tricuspid annular systolic velocity ( %, p= . ). there was a trend for an increase in cardiac index assessed by both thermodilution (p= . ) and echocardiography (p= . ). conclusions: the rv function was improved by increasing doses of norepinephrine, as assessed both by strain-and conventional echocardiography. this is explained by an increase of rv preload. pulmonary vascular resistance is not affected by increased doses of norepinephrine. peripheral perfusion versus lactate-targeted fluid resuscitation in septic shock: the andromeda shock physiology study. preliminary report g hernandez , r castro , l alegría , s bravo , d soto , e valenzuela , m vera , v oviedo , c santis , g ferri , m cid , b astudillo , p riquelme , r pairumani , g ospina- tascón table . conclusions: this preliminary results suggest that using crt as a target for fr in septic shock appears to be feasible, and not associated with impairment of tissue perfusion-related parameters as compared to lactate-targeted fr. grant fondecyt chile introduction: shock patients often become resistant to catecholamines which often require the addition of a non-catecholamine vasopressor. preclinical studies suggest that in the presence of aadrenoceptor antagonism, the renin-angiotensin aldosterone system exerts the major vasopressor influence. we sought to determine the effects of angii or lypressin (lyp [porcine vasopressin]) on blood pressure in a norepinephrine (ne)-resistant hypotension pig model. methods: phentolamine (phn), a reversible α-blocker that antagonizes the vasoconstriction by ne, was continuously infused to induce hypotension. after ne-resistant hypotension was established, lyp or angii was then co-infused with phn. mean arterial pressure (map) and heart rate were continuously recorded (fig. ) . results: as shown in fig. conclusions: in a background of α-adrenoceptor blockade, at clinically comparable doses, the vasopressor effect of ang ii was maintained while those of ne and lyp were attenuated. these data suggest that the blood pressure effect of vasopressin-like peptides may require a functioning α-adrenoceptor. patients with shock who are resistant to increasing doses of catecholamines may also have vasopressin resistance potentially making angiotensin ii a preferred vasopressor for these patients. introduction: resuscitative endovascular balloon occlusion of the aorta (reboa) has been increasingly used for the management of both traumatic and non-traumatic hemorrhagic shock. however, there is limited evidence for its use in gastrointestinal bleeding (gib), especially in the icu setting. we successfully treated a patient with massive gib using reboa in the icu. we will discuss the difficulty performing the procedure and its countermeasure. methods: a case report. results: an -year-old woman was transferred to our hospital with shock. coffee grounds material was found in a nasogastric aspirate after intubation and upper gastrointestinal endoscopy identified a pulsating large duodenum ulcer without active bleeding, for which an elective procedure was planned. she was admitted to our icu, responded to initial resuscitation, and thereafter extubated. her systolic blood pressure (sbp) suddenly dropped to mmhg with massive hematochezia at that night, and did not increase despite resuscitation with blood products, crystalloid and norepinephrine. to buy time until measures for stop bleeding, we planned to place reboa in the icu. following the placement of a sheath in the left femoral artery, we tried to place a fr intra-aortic balloon occlusion catheter, which unintentionally and repeatedly went into the right common iliac artery because her left femoral artery was tortuous. after compressing the right lower abdomen, we managed to introduce reboa in zone . it took approximately minutes to successfully place the catheter. the patient's sbp increased immediately after the balloon inflation and bleeding was endoscopically controlled. introduction: the natural components of the pomegranate fruit may provide additional benefits for endothelial function and microcirculation. we hypothesized that chronic supplementation with pomegranate extract might improve glycocalyx properties and microcirculation during anaerobic condition. methods: eighteen healthy and physically active male volunteers aged - years were recruited randomly to the pomegranate and control groups ( in each group). the pomegranate group was supplemented with pomegranate extract for two weeks. at the beginning and end of the experiment, the participants completed a high intensity sprint interval cycling-exercise (anaerobic exercise) protocol. the systemic hemodynamics, microcirculation flow and density parameters, glycocalyx markers, and lactate and glucose levels were evaluated before and after the two exercise bouts. results: no significant differences in the microcirculation or glycocalyx were found over the course of the study. the lactate levels were significantly higher in both groups after the first and repeated exercise bouts, and were significantly higher in the pomegranate group relative to the control group after the repeated bout: . ( . - . ) vs. . ( . - . ) mmol/l, p = . . conclusions: chronic supplementation with pomegranate extract has no impact on changes to the microcirculation and glycocalyx during anaerobic exercise, although an unexplained increase in blood lactate concentration was observed. introduction: extracorporeal membrane oxygenation in adults in accompanied by high mortality. our ability to predict who will benefit from ecmo based on currently available clinical and laboratory measures is limited. the advent of single cell sequencing approaches has created the opportunity to identify cell populations and pathophysiological pathways that are associated with mortality without bias from a priori cell type classifications. identification of such cell populations would provide both an important prognostic markers and key insight into immune response mechanisms and therefore a possibility for advanced drug matching that may impact clinical response to ecmo in these patients. methods: whole genome transcriptomic profiles were generated from a total of , peripheral blood monocytes obtained from patients at the time of cannulation for ecmo (fig ) . differential gene expression analysis was performed with the monocle package for the r statistical analysis framework. time-to-event data were analyzed in a survival analysis with a log-rank test for differences. results: genes encoding several members of the heat shock family of proteins were up-regulated in cells from non-survivors. notably, these genes were expressed by a small fraction of cells ( . % on average). nevertheless, the proportion of cells expressing these genes was a significant predictor of survival to days (p = . by log rank test), with a particularly pronounced effect in the first days after initiation of ecmo support (fig ) . conclusions: the proportion of cells expressing genes encoding members of the heat shock proteins is predictive of survival on ecmo. majority of pt ( %) had no known predisposing conditions, followed by immobility ( %) and cancer ( %). in ecg analysis tachycardia and v -v t wave inversion were the most common findings whereas hypoxemia± hypocapnia were the most prominent features in abg analysis. pt ( %) had bleeding complications (none intracranial), ( . %) during rtpa, ( . %) in the first h and only pt required transfusion. mortality rate was %: % directly due to pe (all during cpr) and % due to late complications (newly diagnosed cancer and infections). conclusions: in our experience, fibrinolytic therapy is safe and effective but in submassive pe should be applied after thorough assessment of risks and benefits on individual basis aiming to patient tailored precision medicine. [ ] trials evaluated the role of levosimendan in preventing low cardiac output syndrome in patients undergoing cardiac surgery. the studies were similar in their design and recruited patients with preoperatively low lvef undergoing either isolated cabg or valve surgery combined with cabg (table ). in both, a -hour levosimendan infusion was started at induction of anesthesia. neither study met the primary efficacy composite enpoints, but both showed a clear tendency for better outcome in patients undergoing a cabg compared to a valve procedure. we are currently evaluating the solidity of a co-analysis based on shared end-points. we are planning a shared analysed of the data related to the cabg settings and analyze the aggregated mortality data for both studies at and months by cochran-mantel-haenszel odds ratio. data from individual studies would be analysed as fixed effect and breslow-day test was used to evaluate homogeneity of the odds ratios results: in the placebo groups of the two studies, the mortality is similar; . % ( / ) in levo-cts and . % ( / ) in licorn, corroborating the working hypothesis that the two studies can be coanalysed. in a preliminary combined analysis (fig ) , -day mortality was . % ( / ) in the placebo group and . % ( / ) in the levosimendan group. odds ratio was significantly in favor of levosimendan ( . ; % confidence interval . - . ; p= . , fig. ) conclusions: the levo-cts and licorn trials can be co-analysed in their sub-setting of patients requiring isolated cabg surgery for mortality at and months. a preliminary analysis on mortality reinforce the hypothesis that, in isolated cabg surgery, levosimendan lowers post-operative mortality significantly both at and months, when started at the induction of anesthesia introduction: emergency medical system (ems) -based st elevation myocardial infarction (stemi) networks allows not only stemi diagnosis in the pre-hospital phase but also reduces treatment delays; treat your fatal complications and the immediate activation of the catheterization laboratory. the aim of study was to investigate the effect of out-of-hospital by mobile intensive care (micu) versus hospital beginning treatment in hospitalization length and survival of patients with stemi diagnosis introduction: contrast induced nephropathy (cin) is a complex acute renal failure syndrome, which can occur after primary percutaneous coronary intervention (pci) and is an important cause of morbidity and mortality in this subgroup of patients. the aim of our study was to establish the incidence and predictors of cin after primary pci. we performed a retrospective analysis of stemi patients treated with primary pci in the period from january until september of . cin was defined as an absolute increase in baseline serum creatinine of ≥ . mg/dl ( μmol/l) or > % relative rise within hours after primary pci. we analyzed demographic characteristics, risk factors, clinical status at hospital admission, laboratory parameters, left ventricle ejection fraction and data regarding pci procedure. results: the study included patients, with an average age of . ± . years, . % of the patients were males. an average of . ± . ml of contrast medium per patient was utilized. cin developed in ( . %) patients and overall intra-hospital mortality was . %. in multivariate analysis, the independent predictors of cin were age> years ( introduction: left main coronary artery (lmca) disease is a disease of the main coronary branch that gives more than % of blood supply to the left ventricle, it carries high mortality without surgical intervention; [ ] however the influence of lmca surgery on morbidity icu measures needs to be explored. we aim to determine whether lmca is definitive risk factor for prolonged icu stay as a primary outcome and whether lmca is definitive risk factor for early morbidity methods: retrospective descriptive study with purposive sampling analyzing patients underwent isolated coronary artery bypass surgeries (cabg). patients were divided into groups those with lmca disease as group ( patients) and those with coronary arty disease requiring surgery but without lmca disease as group ( patients) then we will correlate with icu outcome parameters including icu stay length, postoperative atrial fibrillation, acute kidney injury, re-exploration, perioperative myocardial infarction, post operative bleeding and early mortality. results: patients with lms had significantly higher diabetes prevalence ( . % vs %, p= . ). however, we did not find a statistical significant difference regarding icu stay, or other morbidity and mortality outcome measures conclusions: diabetes was more prevalent in patients with lms. the latter group showed similar outcome as those without lms in this study these findings may help in guiding decision making for future practice and stratifying the patients care. introduction: multimorbidity in patients admitted for acute myocardial infarction [ami] is associated with higher risk for in-hospital mortality and adverse clinical outcomes. we investigated to what extent an increasing number of comorbidities affects the age-stratified excess risk of death and other clinical outcomes among patients with myocardial infarction. methods: we analyzed nationwide administrative data of ` admissions for an acute myocardial infarction between and . we calculated multivariate regression models to study the association of four comorbidities (chronic kidney disease [ckd], diabetes mellitus, heart failure [hf], and atrial fibrillation) and excess risk of in-hospital mortality, length of hospital stay [los] , and -day readmission and stratified the analysis for different age categories. results: the incidence of admissions for ami increased continuously during the observed decade without an increase in in-hospital mortality, los, and -day readmission. among admitted patients with ami, there was a stepwise increase in risk for adverse outcomes for each comorbidity. compared to patients with no comorbidity, patients with comorbidities had -fold increased risk for mortality (adjusted odds ratio [or] . , % confidence interval [ci] . to . ) and a similar risk for readmission (or . , ci . to . ). the los was . days (ci . to . ) in patients with no comorbidity and increased by . days (ci . to . ) with each additional comorbidity. these associations were stronger in younger compared to older patients. ckd was the strongest predictor of in-hospital mortality and los, while hf was the strongest predictor of -day readmission. conclusions: this study of nationwide admitted patients with ami found a stepwise increase in the risk for adverse outcome with increasing number of comorbidities, particularly in the younger patient population. younger, multimorbid patients may thus have the largest benefits from multidisciplinary treatments. introduction: certified cardiac arrest centers, sophisticated post cardiac arrest care and prehospital ecls teams aim to increase survivor rates with a preferable neurological outcome after cardiac arrest. centers also provide emergency ecls and ecls pick ups for cardiogenic shock patients before arresting. few data answer the question of the long-term quality of life after ecls therapy. methods: in a retrospective single center register we included patients after emergency ecls (ecpr and cardiogenic shock) between / and / discharged alive and performed a follow-up after years on average at / . in our center criteria to initiate ecls therapy in cardiogenic shock or under cardiac arrest are an observed collaps, shockable rhythm, absence of frailty and severe comorbidities. all patients were requested to take part in a telephone interview. thus, we analyzed survival, cpc scores and sf scores. results: patients with hospital survival after ecls were screened. % (n= ) had survived until / ; patients were not accessible; had ceased. survivors (mean±sd; min-max; ± ; - years, women) answered sf questionaires ± ; - months after ecls ( % cardiogenic shock, % ecpr with shockable rhythm in %). the participantsĆ pc scores were in median . the results of the sf were physical functioning ± , physical role functioning ± , bodily pain ± , general health ± , vitality ± , social role functioning ± , emotional role functioning ± and mental health ± . survivors who did not take part at the sf had a cpc score of in median (n= , personally signed refusals, language barriers, vegetative states). conclusions: after emergency ecls therapy and hospital survival % of our patients survived the following years up to over years with a preferable neurological outcome and a general mentally and physically satisfactory quality of life. a vague outcome in % limits the results of our study. introduction: successful weaning from va-ecmo requires the restoration of a sufficient cardiac function to ensure an adequate tissue perfusion. skin blood flow (sbf) is among the first to deteriorate during circulatory shock and the last to be restored after resuscitation. sbf would be a good predictor of successful weaning from va-ecmo. methods: patients with va-ecmo, who required a first weaning attempt, were included. weaning procedure (wp) was performed by a reduction of va-ecmo blood flow to l/min for minutes. the weaning criterion was an aortic velocity-time integral (vti) > cm. successful weaning from va-ecmo was defined as hemodynamic stabilization and without the need to increase the vasopressor dose during the next hours. sbf, assessed by skin laser doppler (peri-flux , perimed, right index finger); perfusion unit: pu), together with global hemodynamic parameters were obtained before and after min of weaning. receiver operating characteristic curves (roc) were generated to assess the ability and reliability of baseline parameters to predict a successful weaning. results: we studied wps in patients with va-ecmo for pulmonary embolism (n = ), post cardiotomy (n = ), acute coronary syndrome (n = ), myocarditis (n = ). these were successful (sw) in and unsuccessful (nsw) in . at baseline, hemodynamic variables, lactate, ecmo blood flow were similar in both groups (table ). sbf was greater in sw than nsw patients (table ). during wp, ci rose from baseline and was similar in sw and nsw (p= . ) ( table ). vtis were higher in sw than nsw ( ( - ) vs ( - ), respectively, p= . ). sbf decreased in sw and remained low in nsw (table ) . from the roc curves analyses, baseline sbf had the highest area under the roc curve with a cut off ≥ pu (sensitivity %, specificity %) (figure ). conclusions: sbf is a good predictor of successful weaning from va-ecmo introduction: postoperative cognitive dysfunction (pocd) is defined as a temporarily decline in cognition associated with surgery. long-term pocd ( months after surgery) occurs in - % of cardiac patients and is associated with a higher morbidity and mortality. endo-cabg is a new minimally invasive endoscopic coronary artery bypass grafting (cabg) technique that requires retrograde arterial perfusion which may be associated with a higher incidence of neurological complications. the aim of this study is to assess the incidence of pocd after endo-cabg. methods: sixty consecutive patients undergoing an endo-cabg were enrolled. pocd was assessed following the recommendations of the " statement of consensus on assessment of neurobehavioral outcomes after cardiac surgery". a comparative group of patients undergoing percutaneous coronary intervention (pci) and a control group of healthy volunteers were also enrolled. additional tests included the digit span test and digit symbol-coding test. patients were tested at baseline and at month follow-up. pocd is defined as a reliable change index (rci) ≤ - . (significance level %), or z-score ≤ - . in at least two different tests. results: after enrolling patients in each group, respectively in the endo-cabg-group, in the pci-group and healthy controls were analysed. patients suffering from a cva within three months after their procedure were automatically classified as having pocd (pci: n= ; endo-cabg: n= ). the total incidence of pocd was not different between groups (pci: n= ; endo-cabg: n= , p= . ). conclusions: our results suggest that the risk of pocd after endo-cabg is low and comparable with the risk of pocd after pci. introduction: rhabdomyolysis ( rml) post aortic surgery probably affects the renal outcome adversely [ , ] . there is no robust data regarding the same in literature. methods: retrospective single center data review; prior approval from institutional review board. patients were divided to two groups group -with rml ( ck above cut off levels u/litre) and group without rml. the determinants of rml and the impact of the same on outcome; predominantly renal function was evaluated. chi-square tests are performed for categorical variables whereas, student t tests (un-paired ) are performed with continuous variables. correlation is performed between creatine kinase and creatinine rise. p value . (two tailed) is considered for statistical significant level. results: out of patients, patients ( . %) developed rhabdomyolysis ( group rml) and did not( group non rml). demographic and intraoperative factors had no significant impact on the incidence of rml. there was a significantly higher incidence of renal complications including new postoperative dialysis in the rml group. other morbidity parameters were also higher in the rml group. conclusions: there is high prevalence of rml after aortic dissection surgery -identification of risk factor and early intervention might help to mitigate the severity of renal failure introduction: we investigate whether central venous pressure (cvp) pressure waveform signal can be informative in detection of slow bleeding in post-surgical patients. we apply a novel machine learning method to analyze cvp datasets to characterize bleeding in a porcine model of fixed rate blood loss. methods: thirty-eight pigs were anesthetized, instrumented with catheters, kept stable for minutes, and bled at a constant rate of ml/min to mean arterial pressure of mmhg. cvp waveforms were extracted from inspiration and expiration phases of respiration and statistically featurized. the proposed machine learning method, canonical least squares (cls) clustering, identifies correlation structures that differ between subsets of observations. we extend it to supervised classification. both clustering and classification methods yield human-interpretable models that reflect distinctive patterns of correlations within cvp waveforms. results: we conducted three experiments to discover structure in the physiological response to bleeding. first, we clustered respiration cycles with full knowledge of blood loss. the color-coded cluster assignments are shown in the figure . they are consistent with escalation of bleeding. second, we deployed clustering on only cvp features without blood loss. temporal structure was complemented with some subject-specific clusters (fig ) . third, we ran cls classification to decide whether an observation came from before or after the onset of bleeding (performance shown in the results: over the last decade, the number of patients with hlhs who underwent norwood has increased. interstage mortality has decreased, and is currently - %. significant morbidity was not seen at a rate higher than in the international literature. discharge planning, and community access to allied health professional services remained a concern. conclusions: the paediatric congenital cardiac surgical service in the united arab emirates is relatively new (compared to some services around the world). interstage mortality in hlhs is improving as a result of programme development, surgical progress and postoperative care. in the interstage period, there is currently no home monitoring programme in place. some patients were found to have had very extended hospital admissions. improved community support may reduce interstage mortality further, as well as improve the social situation of many of these patients. postoperative complications were observed in ( . %) patients. we lined out the prevalence of cardiac complications, such as heart failure and rhythm disturbances, observed in ( . %) and ( . %) patients respectively. hospital mortality rate was . % ( / ). the cause of mortality in all cases was acute heart failure, due to the initial severity of the disease, and in ( . %) cases an acute myocardial infarction was diagnosed. duration of postoperative period was . ± . days. conclusions: off-pump coronary artery bypass grafting can be safely performed with relatively low incidence of mortality and postoperative morbidity. prognostic value of mid-regional pro-adrenomedullin and midregional pro-atrial natriuretic peptide as predictors of multiple organ dysfunction development and icu length of stay after cardiac surgery with cardiopulmonary bypass in adults introduction: one of the most harmful complications after cardiac surgery with cardiopulmonary bypass is a syndrome of multiple organ dysfunction (mods). we consider that mid-regional proadrenomedullin (mr-proadm) and mid-regional pro-atrial natriuretic peptide (mr-proanp) plasma concentrations can be used as predictors of mods development and los in icu. methods: thirty six adult patients (mean age years, male) with cardiovascular diseases undervent cardiac surgery with cardiopulmonary bypass (heart valve(s) replacement - ( . %) patients, aorta and it`s branch surgery - ( . %) patients, valvular surgery and coronary artery grafting - ( . %) patients). nyha heart failure class ii was in ( . %) patients, iiiin ( %) patients, ivin ( . %) patients. in the dynamics levels of mr-proadm and mr-proanp were measured in the venous blood with the kryptor compact plus analyzer (thermo fisher scientific, germany) before day and on the st and th days after surgery. all patients were divided into subgroups according to the lengths of stay in the icu and the development of mod in the postoperative period. the data are shown as median and th and th percentiles. the data were compared by mann-whitney u-test, pvalue of < . was considered statistically significant. results: levels of mr-proanp did not significantly change at the study stages and did not have a significant difference between subgroups. the levels of mr-proadm increased in the first postoperative day and remained elevated for days. this increase was significantly higher in subgroups of increased los in icu and with mods. the data are shown in the table . conclusions: mr-proadm can be used as predictor of mods and los in the icu for adult patients underwent cardiac surgery with cardiopulmonary bypass. introduction: prolonged intensive care unit (icu) stay after cardiac surgery is associated with increased mortality and cost .the aim of this study was to investigate factors influencing prolonged icu stay. methods: consecutive patients who underwent cardiac surgery from june to october in our cardiothoracic department, were retrospectively investigated. group a consisted of pts with prolonged stay defined as more than days and group b the rest of the cohort. the following characteristics and perioperative factors were compared between the groups: smoking, diabetes, copd, redo(re-operation), ejection fraction (ef)< %, emergent procedure, cardiopulmonary bypass time (cpb)> min, low cardiac output syndrome (lcos), acute kidney injury(kdigo) and mortalitychi square test was used for the statistical analysis. introduction: hemorrhagic complications of extracorporeal membrane oxygenation (ecmo) pose a major morbidity and mortality. optimal anticoagulation strategies balancing risks of bleeding and thrombosis in children are poorly understood. we aimed to identify factors associated with non-surgical bleeding in the first ecmo hours. methods: we evaluated all pediatric (< yrs) post-cardiotomy patients requiring ecmo between dec -july stratifying them by presence/absence of surgical bleeding. non-surgical bleeding was defined as chest tube output > cc/kg/hr during the first -hours not requiring reoperation. patient characteristics and coagulation parameters at various time points after ecmo initiation were compared between groups, and receiver operator characteristic (roc) curves were constructed to identify models and thresholds with optimal predictive performance. figure . conclusions: deranged coagulation parameters, particularly kaolin rtime may predict non-operative bleeding in pediatric ecmo patients. these findings may guide therapeutic anticoagulation while avoiding hemorrhagic sequelae in at risk patients. introduction: elevated cardiac troponin (ctn) level in patients (pts) admitted in the intensive care unit (icu) is multifactorial and has been associated with a worse prognosis. the aim of the study was to review the frequency and the main cause of ctn elevation and to calculate a discriminating index. methods: we retrospectively assessed all pts admitted in our eightbed general icu during a -month period with at least one measurement of ctn during their icu stay. we recorded clinical characteristics, the level of ctn on admission, the maximum ctn during icu stay and the possible causes of elevation. variables are expressed as mean ± sd or as median and interquartile ratio (ir), according to the normality of their distribution. student´s Ô test or the mann whitney u tests were used to compare the group of elevated ctn with the group of normal ctn. the prognostic performance of elevated ctn was evaluated by the receiver operating characteristics (roc) curve. statistical analysis was performed using spss version . (spss, inc., chicago, illinois). results: in out of pts that ctn was measured at least once, abnormal levels (> . pg/ml) were found in ( %) of them, and the maximum ctn value was ( . ) pg/ml. the clinical characteristics of the pts are depicted in table . sepsis was the main cause of troponin elevation, which complicated by acute kidney injury (aki) in pts ( %). maximum ctn, aki and the difference of maximum -admission ctn (Äctn) differed significantly between pts who survived and pts who died (p= . and . , respectively). the area under the curve (auc) was . and the optimal prognostic cut-off value of Äctn was pg/ml with a sensitivity of . and a specificity of . conclusions: raised cardiac troponin values is a frequent finding in icu pts and sepsis is the driving cause. aki and the difference between maximum and admission ctn measurements differ significantly between pts who survive and pts who die. an elevation of ctn during icu hospitalization > pg/ml seems to be a threshold indicating poor prognosis regarding both mortality and aki. the prognostic role of nt-pro-bnp in septic patients with elevated troponin t level introduction: sepsis is frequently accompanied with release of cardiac troponin t (tnt) and nt-pro-bnp, but the clinical significance of this myocardial injury and cardiac dysfunction remains unclear [ ] . tnt is known to be an independent predictor of mortality, whereas the prognostic role of nt-pro-bnp is uncertain. methods: here, we report data of va-ecmo-patients, treated with dobutamine, levosimendan, suprarenin or no inotropic agens, in respect of -day survival. all data were collected retrospectively ( / to / ) at a single center, all patients with a survival below hours were excluded. while treatment of va-ecmo patients is strongly guided by standard operation procedures at our institution, no recommendation on positive inotropic therapy could be made. results: a total of va-ecmo patients were evaluated, of which patients were treated with levosimendan within hours after cannulation. day survival in the whole cohort was . %. a total of patients did not receive any positive inotropic therapy at hours after implantation (survival . %). survival was best in the levosimendan plus dobutamine group %, followed by dobutamine mono-therapy . % and levosimendan mono . %. survival with suprarenin mono was . %, suprarenin plus levosimendan . % and suprarenin plus dobutamine , %. pooling data, we found no evidence that levosimendan and/or dobutamine (survival . %, n= , p= . ) improves survival over no inotropic therapy (fig ) . therapy with any combination including suprarenin however resulted in poor survival ( . %, n= , p= . ). adjustment for lactate levels or ecpr did not change the results. conclusions: this retrospective analysis of va-ecmo patients shows no evidence that early inotropic therapy improves outcomes in va-ecmo patients. this conclusion is obviously biased by retrospective design. until randomized data are available, suprarenin however should be avoided. survey of non-resuscitation fluids in septic shock a linden-sonderso introduction: positive fluid balance is associated with poor outcome in septic shock. the objective of the present study was to characterize non-resuscitation fluids in early septic shock. methods: consecutive patients > years of age were screened for inclusion criteria during a -month period in icus in sweden and in canada. inclusion criteria were septic shock per sepsis- definition within hrs of icu admission. a maximum of patients per center were included. type, indication and volume of non-resuscitation fluids were recorded during the first days of admission. fluids other than colloids, blood products and crystalloids given at rate > ml/kg/h were considered to be non-resuscitation fluids. the study was registered on clini-caltrials.gov (nct ). data are presented as median (interquartile range). results: a total of patients were included between march st and june th (see table for demographics). patients received ( - ) milliliters (ml) of non-resuscitation fluids introduction: we aimed to ascertain the extent and make-up of fluid overload in critically ill patients and to identify whether delivery of more concentrated medications could reduce this. positive fluid balance is associated with increased mortality [ ] . a recent study has shown that the predominant component of fluid overload was from iv medications and maintenance fluid [ ] . methods: we reviewed sequential patients admitted to our icu with an apache ii score of greater than and a length of stay (los) greater than hours. the patients' electronic admission summary was interrogated to establish: length of stay (los) fluid balance at hours, total volume administered as iv medications, total volume administered as maintenance fluid and total fluid administered introduction: in children less than kilograms, maintenance fluids are routinely added to the resuscitation requirements calculated using parkland's or other formulae. the contribution of this component for fluid resuscitation in children can add a significant quantity to total estimated fluid requirements. for example, in a child who is kilograms with a % burn, the maintenance fluid requirement is mls per hours and the resuscitation component per parkland's will be x x %= mls. hence, the maintenance requirement can exceed the resuscitation requirement in this child if the burn surface area is less than a % burn. the contribution of maintenance fluids to the total fluid requirements in small children with thermal injuries is under-recognised and not frequently studied. methods: to understand the contribution of maintenance fluids to the total fluid requirements in children less than kilograms who need resuscitation for thermal injuries of different sizes, we numerically simulated . children who had similar weights but different burn sizes and . children with similar burn size but different weights. the results are as shown in fig introduction: accurate quantification of fluid in resuscitation of thermal injuries is important for benchmarking, comparing and improving outcomes. in adults, it is usually expressed as mls/kg/%tbsa. in children, maintenance fluids are added to the resuscitation requirements. this is kept constant and the resuscitation component is titrated to meet pre-defined end points-usually urine output. maintenance fluids are not uniformly stratified across the weight ranges. we propose that quantification of fluids in mls/ kg/%tbsa in children does not accurately capture fluid needs for resuscitation due to the maintenance component of the fluid requirement. methods: we conducted this retrospective study in children admitted to a single-center burns intensive care unit (bicu) between january and december . children ≤ kilograms with tbsa ≥ % admitted within hours of their injury were included. oe (observed to expected ratio) and fluid in mls/kg/% tbsa were calculated as shown in figure . results: there were children in the cohort with half requiring invasive mechanical ventilation in the bitu and nearly a quarter requiring inotropic support. the demographic details are as shown in table . the oe ratio at the end of hours in the cohort was . ( . - . ). the total fluid given was . ( . , ) mls/kg/ % tbsa. the titrated resuscitation component was . ( . , . ) mls/kg/tbsa. total fluid (which included the maintenance fluid) had a poor correlation with oe ratio r = . (fig ) . exclusion of the maintenance fluid had a better correlation with the oe ratio r = . conclusions: to capture differences in the titratable resuscitation component rather than differences in the maintenance requirements, fluid should be quantified in children by excluding the maintenance component when expressed as mls/kg/%tbsa. dynamic arterial elastance for predicting mean arterial pressure responsiveness after fluid challenges in acute respiratory distress syndrome patients p luetrakool , s morakul , v tangsujaritvijit introduction: dynamic arterial elastance (eadyn; pulse pressure variation/stroke volume variation; ppv/svv) is a dynamic parameter of arterial load that can be continuously monitored. previous study proposed that eadyn was able to predict mean arterial pressure (map) responsiveness after fluid challenge [ ] [ ] [ ] [ ] [ ] . the objective of this study was to assess whether the eadyn was able to predict map responsiveness in acute respiratory distress syndrome (ards) patients ventilated with low tidal volume. methods: we performed a prospective study of diagnostic test accuracy in adult ards patients with acute circulatory failure and fluid responsiveness. all patients are continuously monitored blood pressure via arterial line connected with flotrac® transducer and vigileo® monitor. once the attending physicians decided to load intravenous fluid, we recorded ppv/svv and also other hemodynamic parameters before and after fluid bolus. map responsiveness was defined as an increase in map ≥ % from baseline after fluid challenge. results: twenty-three events were included. nine events ( . %) were map-responsive. cardiac output, heart rate and stroke volume were similar in both map-responder and map-nonresponder group. baseline map, diastolic blood pressure (dbp) and pulse pressure (pp) were significantly different after fluid challenge in map-responder group. eadyn of preinfusion phase was failed to predict map conclusions: one of the arterial load parameters such as eadyn derived from non-calibrated pulse contour analysis method was unable to predict map responsiveness in ards patients with low tidal volume ventilation. the our aim is to test the hypothesis that in fr septic shock patients, fluid load will determine a significant increase in pmsf but not in cvp. we prospectively included all mechanically ventilated patients with diagnosis of septic shock with invasive hemodynamic monitoring (transpulmonary thermodilution volumeview-ev ed-wards©). we collected hemodynamic and metabolic data and pmsf with the inspiratory holds technique, before and after a fluid challenge (fc) of ml of ringer lactate in minutes). fr was defined as an increase in cardiac output (co)> %. results: measures were obtained in patients. in case we observed fr. we found a significant increase in pmsf after a fc (mean difference(md) . ± . mmhg, p=. ). cvp increased significantly (md . ± . mmhg, p=. ). pmsf increased significantly in non-fr (md ± mmhg, p=. ) but not in fr while cvp was higher after fc only in fr (md . ± . mmhg, p=. ). venous return gradient (pmsf-cvp) globally increased after fc (md ± mmhg, p=. ), but only in non-fr such increase was significant (md ± mmhg, p=. ). no correlation was found between the variation co and venous return gradient. we did not find any improvement in metabolic parameters after the fluid challenge. conclusions: pmsf and combined cvp variations do not correlate with fr in our cohort of septic shock patients. inspiratory holds may not be adequate to infer pmsf in such context. further studies are warranted to investigate the effect of fc on pmsf in this field. evaluation of pre-load dependence over time in patients with septic shock i douglas , p alapat , k corl , m exline , l forni , a holder , d kaufman , a khan , m levy , g martin , j sahatjian , w self , e seeley , j weingarten , m williams , c winterbottom , d hansell is an effective method to predict fluid responsiveness (fr) or cardiac response to preload expansion. we have previously shown that fluid responsiveness is a dynamic state, changing frequently over a hour monitoring period. methods: fresh is a currently enrolling prospective randomized controlled study, evaluating the incidence of fr and patient centered outcomes in critically ill patients with sepsis or septic shock (nct ). patients randomized to plr guided resuscitation were evaluated every - hours over the first hours of care and classified as fr if the sv increased > % when measured with non-invasive bioreactance (starling sv, cheetah medical). the time of first fr was noted. results: a total of plr assessments were performed in patients over a hour monitoring period. % were female, and the average age was years. plrs were evaluated over time, with time representing initial fluid resuscitation ( figure ). when individual subjects were evaluated over time, % of subjects who became fr only after hours showed evidence of lv/rv dysfunction ( figure ). conclusions: fluid responsiveness or preload dependence frequently changes for septic shock patients over the first hours of care. evidence suggests it is beneficial to periodically perform an assessment of preload responsiveness to guide fluid administration, as preload dependence is a dynamic and changing state. preload dependence provides additional information beyond fluid responsiveness. those patients who remain primarily fluid non-responsive (preload independent) are more likely to demonstrate echo confirmed lv/rv dysfunction, as the delay in return to cardiac function may be related to underlying cardiac deficits. further evaluation may be indicated in preload independent patients. introduction: hydroxyethyl starch (hes), a synthetic colloid, has been used as a volume expander, and is associated with renal impairment in patients with sepsis. however, a small dose of hes ( %, / . ) has sometimes been used in acute ischemic stroke. therefore, we investigated whether a small dose of hes was linked with renal deterioration in patients with acute ischemic stroke. methods: a consecutive patients with acute ischemic stroke within days from onset were included between january and may (fig ) . we collected admission serum creatinine (scr), estimated glomerular filtration rate (egfr), and renal function was assessed using kdigo definition of acute kidney injury on hospital days to as to patient's hospitalization period. is crucial for venous return and volaemic status, and as such it is a useful parameter in physiology and clinical settings alike. we tested whether: near infra-red spectroscopy (nirs) could be effective at measuring msfp both in healthy individuals and in conditions with a rise in interstitial pressures; after an occlusion pressure is relieved, the decrease in venular blood volume could allow calculation of τ (time constant) and thus venous resistances (rv). in order to verify these hypotheses we used a forearm nirs probe on healthy individuals at rest and during different degrees of maximal voluntary contraction (mvc). methods: healthy subjects volunteered in the study that took place at sant'andrea hospital in rome (italy). all subjects had venular pressures and volumes assessed via a nirs probe positioned on the forearm using a pressure-cuff in steps of mmhg from to mmhg, at rest and at % and % mvc. for each patient msfp, unstressed volume (vu) and stressed volume (vs) were measured. a temporary mmhg occlusion was obtained and volume time course was calculated upon release, to derive τ . results: p-v relationship was found to have a -slopes shape reflecting venular network changes. we measured vu, vs, and obtained msfp values of . ± . mmhg, p< . ; during exercise no changes in vu and vs were noted but msfp values rose; value was found to be . ± . sec at rest and . ± . sec after exercise, reflecting a reduction in rv. conclusions: nirs measurements on healthy subject may have implications in the clinical assessment of critical care patients where changes in interstitial pressure are possible. introduction: in the pathogenesis of multiple organ dysfunction syndrome (mods) important role plays the development of hepatic dysfunction. a known method for assessing hepatic blood flow is reohepatography (rhg). however, it requires the analysis of a large number of parameters of the rheogram curve. the aim of this study was to develop a method for assessing arterial hepatic blood flow based on the rhg in patients with mods after abdominal surgery. methods: patients in the department of anesthesiology and intensive care unit were included in a prospective study ( men and women, age . ± . years, weight . ± . kg.). all patients were divided into two groups: group -patients after orthopedic and trauma surgery (n = ), group -patients after abdominal surgery with mods (n = ). patients in the groups did not have statistical differences by sex, age, body weight, height. rhg was carried out using the "reo-spectr" (russian federation). we have compared the rhg indicators between the groups ( table ) . we have developed a method for assessing hepatic arterial blood flow, which consists in determining the area under the arterial part of rhg curve using the simpson's rule. its normal values range from . mΩ *s to . mΩ *s. the method is non-invasive, can be applied at the patient´s bed. its advantage is simplicity, it can be used for rapid diagnosis and monitoring the effectiveness of treatment. area under the rhg curve in the group were . ± . mΩ *s and . ± . mΩ *s in the group (p < . ). conclusions: patients after abdominal surgery with mods have impaired hepatic blood flow, which may be associated with liver pathology caused by main surgical disease (obstructive jaundice) and hemodynamic disorders caused by acute cardiovascular failure. the method we developed allows us to determine disorders of hepatic arterial blood flow in the early stages before signs of liver dysfunction appear. comparison of pulse oximetry hemoglobin with laboratory measurement of arterial and central- results: patients: % male, median years ( - ); p:f ratio ( - ); peep ( - ); apache iii . ( ); median ventilation time days ( - ). fair agreement was seen in subjective assessment vs objective measures with binary assessment of rv size and function. ordinal data analysis showed poor agreement with rvfws ( figure ) and rv dimensions. if onestep disagreement was allowed the agreement was good ( table , ). significant overestimation of severity of abnormalities was seen comparing subjective assessment with rv eda and tapse, s' and fac. there was no difference in agreement values when accounting for clinician echo experience, perceived expertise (at level of cardiologist) or type of qualifications. conclusions: relatively low levels of agreement were seen with subjective assessment vs objective measures of rv size and function assessed by echo. it seems prudent to avoid subjective rv assessment in isolation and a combination of objective and subjective measures should be used. introduction: even short periods of hypotension are associated with increased morbidity and mortality. using high-density numerical physiologic data, we developed a machine learning (ml) model to predict hypotension episodes, and further characterized risk trajectories leading to hypotension. methods: a subset of subjects with / hz physiological data was extracted from mimic , a richly annotated multigranular database. hypotension was defined as > measurements of systolic blood pressure ≤ mmhg and mean arterial pressure ≤ mmhg, within a -minute window. derived features using raw measurements of heart rate, respiratory rate, oxygen saturation, and blood pressure were computed. random forest (rf), k-nearest neighbors (knn), and logistic regression models were trained with -fold cross validation to predict instantaneous risk of hypotension using features extracted from the data leading to the first episode of hypotension (cases) or icu discharge in subjects never experiencing hypotension (controls). for a given subject, risk trajectory was computed from the collation of instantaneous risks. results: from a source population of subjects, subjects met our definition of hypotension, and subjects without hypotension comprised the control group. features were generated from the four vital signs. the area under the curve (auc) for random forest classifier was . , out-performing logistic regression (auc . ) or k-nearest neighbors (auc . ) (fig ) . risk trajectories analysis showed average controls risk scores < . (< % risk of future hypotension), while the hypotension group had a rising risk score ( . to . ) in the hours leading to the first hypotension episode, and significantly higher scores leading into subsequent episodes (fig ) . conclusions: hypotension episodes can be predicted from vital sign time series using supervised ml. subjects developed hypotension have an increased risk compared to controls at least hours prior to the episode. introduction: in critically ill patients or in patients undergoing major surgery, monitoring of co is recommended [ ] [ ] [ ] . less-invasive advanced hemodynamic monitoring with pwa is increasingly used in perioperative and critical care medicine. in this study, we evaluate the measurement performance of an uncalibrated pulse wave analysis (pwa) device (mostcareup, vygon, ecouen, france) compared with cardiac output (co) assessment by pulmonary artery thermodilution (patd) in patients after cardiac surgery. methods: in patients after cardiac surgery, we performed seven sets of patd measurements to assess patd-co. simultaneously, we recorded the pwa-co and compared it to the corresponding patd-co. to describe the agreement between pwa-co and patd-co we used bland-altman analysis showing the mean of the differences and %-limits of agreement and calculated the percentage error. results: we included patients in the analysis. the bias between pwa-co and patd-co was . l*min- . upper and lower % limits of agreement were + . l*min- and - . l*min- . the percentage error was . %. conclusions: pwa-co estimated with using the mostcareup device shows good agreement with pulmonary artery thermodilutionderived co in patients after cardiac surgery. introduction: non-invasive continuous blood pressure monitoring devices have been investigated, however, these devices did not have sufficient accuracy and precision. we developed a continuous monitor using the photoplethysmographic technique and tested the accuracy and precision of this system to ensure it was comparable to conventional continuous monitoring methods used for critically ill patients. methods: the study device was developed to measure blood pressure, pulse rate, respiratory rate, and oxygen saturation, continuously with a single sensor using the photoplethysmographic technique. patients who were monitored with arterial pressure lines in the icu were enrolled. the physiological parameters were measured continuously for minutes at -minute intervals using the study device and the conventional methods. the primary outcome variable was blood pressure. results: pearson fs correlation coefficient between the conventional method and photoplethysmography device were . for systolic blood pressure, . for diastolic blood pressure, . for mean blood pressure, . for pulse rate, . for respiratory rate, and . for oxygen saturation. percent errors for systolic, diastolic and mean blood pressures were . % and . % and . %, respectively. percent errors for pulse rate, respiratory rate and oxygen saturation were . %, . % and . %, respectively. conclusions: the non-invasive, continuous, multi-parameter monitoring device presented high level of agreement with the invasive arterial blood pressure monitoring, along with sufficient accuracy and precision in the measurements of pulse rate, respiratory rate, and oxygen saturation. conclusions: stroke volume measurement using bioreactance technique had strong correlation with odm while pwtt had moderate correlation. both devices had small bias with wide limits of agreement and percentage error compared with odm. therefore, these devices are not interchangeable with odm. however, using trends in stroke volume to guide treatment might still be acceptable. introduction: hemorrhage is the most common cause of trauma deaths and the most frequent complication of major surgery. it is difficult to identify until profound blood loss has already occurred. we aim at detecting hemorrhage early and reliably using waveform vital sign data routinely collected before, during, and after surgery. methods: we use waveform vital sign data collected at hz during a controlled transition from a stable (non-bleeding) to a fixed bleeding state of pigs. these vital signs include airway, arterial, central venous and pulmonary arterial pressures, venous oxygen saturation (svo ), pulse oximetry pleth and ecg heartrate, continuous co, and stroke volume variation (lidco). we used gated recurrent units (gru), long short-term memory (lstm) and dilated, causal, one-dimensional convolutional neural (table ) . however, outside of the very low fpr range (cf. rocs in fig. and ), our models appear inferior to a referenced random forest (rf) classifier. conclusions: our work demonstrates the applicability of deep learning models to diagnose hemorrhage based on raw, waveform vital signs. future work will address why the rf classifier can address the greater homogeneity of subjects when they bleed compared to an apparently wide dispersion of their statuses when being stable. this work is partially supported by nih gm . can myocardial perfusion imaging with echo contrast help recognise type acute myocardial infarction in the critically ill? introduction: many instances of significant bleeding may not occur in highly monitored environment, contribution in the delay in recognition and intervention. we therefore proposed a noninvasive monitoring for early bleeding detection using photoplethysmography (ppg). methods: fifty-two yorkshire pigs were anesthetized, stabilized and bled to hemorrhagic shock, and their invasive arterial blood pressure (abp), and ppg data were collected [ ] . time series of vital signs were divided into data frames of minute updated every seconds and beat to beat features were computed. the final feature matrix contained abp features and ppg features. a supervised machine-learning framework using least absolute shrinkage and selection operator regularized logistic regression model was constructed to score the probabilities for hemorrhage of each data frame. data in stabilization was set as negative and data in bleeding was set as positive. model performance was evaluated by receiver operating characteristic (roc) area under the curve (auc) with leave-one-out cross validation, and its precision was assessed with activity monitoring operative characteristic (amoc). results: two different models were proposed using abp and ppg features separately. figure showed the ppg model could classify the hemorrhage with auc = . , where the auc of abp model was . . figure showed the ppg model could detect the hemorrhage on average . minutes (equals to ml blood loss) if the false alarm rate of / was tolerated, whereas the average detection time of abp model were . minutes at same threshold of false alarm rate. conclusions: we proposed a novel non-invasive bleeding detection approach using ppg signals only. this method potentially can improve the identification of hemorrhage with in patients and environments where invasive monitoring is unavailable. table , catheter and procedure characteristics are shown in table . the median angle of bed position was °. no patients were positioned in neutral or tp. all procedures were successful with a mean of . punctures per patient, and a maximum of . the median procedure time was . minutes. no major complications occurred in any of our patients. conclusions: central venous catheterisation in moderate upright position is feasible and can be done safely when using realtime ultrasound by well-trained physicians. we recommend performing clinical assessment and pre-procedural ultrasound to choose the optimal puncture site and position in order to attain an optimal ultrasound visualisation of the vessel and patient comfort. methods: a retrospective analysis of patients presenting to tertiary-care emergency department who required cvc for vasopressor administration was carried out. all central venous cannulation into the right brachiocephalic vein was performed with ultrasound guidance using the high frequency linear probe. right brachiocephalic vein was visualised in its long axis. the needle was positioned just beside the centre of ultrasound probe degrees below the coronal plane and degrees angle to the ultrasound probe and advanced just behind the clavicle. results: the mean puncture time taken to perform this procedure, calculated from the needle piercing the skin until to the aspiration of blood from the brachiocephalic vein through the needle, was ± . s. no procedure-related complications were detected. conclusions: the oblique needle trajectory of right brachiocephalic vein cvc in adult is feasible and able to visualised well the anatomical structure, hence avoid complications. introduction: central venous cannulation, a routine procedure on intensive care units, is associated with a low complication rate. as a consequence, the routine use of chest x-ray (cxr) or ultrasound (us) to assess these complications is under discussion. our aim was to identify risk factors for central venous catheter (cvc) placement associated complications that can help decide whether or not follow-up using cxr and/or us is indicated. methods: multicenter prospective, observational study. consecutive critically ill adult patients who underwent cvc placement. either the internal jugular vein or subclavian vein was cannulated. complication rates were determined. predicting factors were obtained through a questionnaire filled in by physicians after placing a cvc. if the questionnaire was incomplete or data was missing, analyses were performed using the available data. patient characteristics were duplicated if a patient recieved more than one cvc. outcomes were iatrogenic pneumothorax and malposition. pneumothorax was detected using us, whereas cxr was used to determine cvc malposition. table . usguidance, insertion site, and setting were predictive for complications. the overall cvc placement associated complication rate is low and multiple risk factors associated with the occurrence complications were identified. a complication rate this low, strongly suggests that routine post-procedural diagnostics is superfluous. therefore, we suggest, provided that uneventful execution of the procedure is assured, post-procedural diagnostics are only necessary in selected cases with (multiple) risk factors. introduction: the use of ultrasound for subclavian vein cannulation (scv) has developed poorly due to the difficulty of visualizing this vein via the classical infraclavicular approach. we explored the feasibility of ultrasound-guided subclavian vein catheterization via a supraclavicular approach methods: prospective study conducted over six-month period in intensive care unit. after approval of the ethics committee, we included patients over years of age and requiring central venous access. exclusion criteria were: hemostasis disorders, puncture area infections and cervico-thoracic vascular malformations the procedure consisted of catheterization of the vsc with a supraclavicular approach under ultrasound guidance using an ultrasound in plane approach (fig and ). data collection included clinical and ultrasound data: scv depth, diameter and length, catheterization time, number of needle redirection, cannulation success and complications. results: thirty four patients were included. age: ± (mean ± sd), % of whom were male. the success rate of scv catheterization was % (one failure). the depth of the scv was ± . mm and its diameter was ± . mm. the puncturable length of the scv was ± mm and the puncture angle was ± °. the time required to obtain an adequate ultrasound image was ± seconds. the interval between the beginning of the puncture and the insertion of the guidewire into the vein was ± sec. the total catheterization time was ± seconds. the number of needle redirection . +/- . redirects. the quality of the ultrasound image was excellent or good in . % of cases. an arterial puncture was observed in two patients conclusions: this preliminary study demonstrated the feasibility of the subclavian vein cannulation via the supraclavicular approach. more study are required to confirm its safety and to compare this approach to the infraclavicular acces using ultrasound. introduction: lung ultrasound b-lines, a comet-like reverberation artefacts arising from water-thickened interlobular septa, indicate extravascular lung water which is a key variable in heart failure management and prognosis. aim of this study is to measure the correlation between lung ultrasound b-lines and nyha functional classification. methods: this is a months prospective study on congestive heart failure patients conducted in urban emergency departments in malaysia. following enrolment, patients had their functional capacity categorised based on nyha classification, followed by point of care ultrasound (pocus) lung scan using a mhz linear probe. the scanning was performed by trained emergency physicians. the longitudinal scan done at the recommended zones of both left and right lungs and the total number of b-lines identified were summed up as the comet score. comet score of , , and were categorised based on amount of blines of less than , - , - and more than b-lines respectively. results: hundred and twenty-two patients were analysed ( males( . %) and females( . %)) ranging from to years old. comet score of , and were found to be statistically significant with presence of paroxysmal nocturnal dyspnoea, elevated jugular venous pressure, lung crackles, bilateral pitting oedema and chest radiographic findings. a moderate correlation between nyha classes with comet score , and (rs= . (p< . )) was documented. conclusions: our study demonstrated a moderate correlation between nyha classes and lung ultrasound b-lines. lung ultrasound may be a potential tool to objectively determine the functional capacity in patients with congestive heart failure and monitor its changes in response to treatment and disease progression. the introduction: point of care ultrasound (pocus) is a tool of increasing utility in the management of the critically ill patient. guidelines exist for training and accreditation in pocus [ , ] however the widespread use of pocus has been hampered by a lack of mentors. online communication with end-to-end security, such as whatsapp ™ are increasingly used in medicine as a communication aid [ ] . some individuals are using such communications to share pocus images for review-the overall sentiment around these tools is unknown. methods: an online survey of pocus users was conducted via twitter ™. the question was "in situations where an expert opinion on an ultrasound is not immediately available, is it acceptable to get an expert review via an online medium such as whatsapp, and would you be happy to be that expert?" results: votes were received. voters were a mix of pocus users from the usa, europe, and australia. % said the medium was acceptable, and that they would be happy to provide expertise. % voted "no", with % voting "other" (fig ) . conclusions: in this international survey of pocus users, % were happy to provide and receive mentorship using remote software such as whatsapp. distance mentorship for pocus training should be explored. [ ] . a description of the development and refinement of insight -a feasibility and clinical effectiveness randomized controlled trial. methods: a modified delphi exercise was used to select the most beneficial ultrasound windows and imaging questions to ask for each window in scheduled inter-professional ultrasound. nurses, doctors and physiotherapists from critical care were given the same information regarding potential utility of each window. the windows and associated questions were individually ranked; each window and question tested against three further criteria; and filtered by ease of training to level standard; clinical usefulness; time of practical delivery and applicability across an inter-professional group. results: the modified delphi exercises and prioritization exercise ranked ease of adoption by training; feasibility within the time frame and clinical usefulness to develop a core insight scan of domains, each with set binary questions (tables and ) conclusions: we have developed a research intervention that will allow us to test the effectiveness of inter-professional scheduled whole body assessment of critically ill patients by ultrasound. we now plan to conduct a clinical effectiveness trial with an internal pilot to confirm feasibility. to search for optimal pressing time, the plots from the color sensor during nail bed compression were analyzed. we found two phases in the color sensor plots. in the initial part of compression, the plots changes rapidly (rapid phase) and then the slope of plots reduces (slow phase). the pressure release during the rapid phase could destabilize the measurement. the longest period of the rapid phase was . s among all the study subjects. thus, a pressing time of s seems to be needed to obtain stable crt measurements. conclusions: on our study for the investigation of standard pressing time and strength for crt measurements, pressing the nail bed with - n and s appears to be optimal. detection of pancreas ischemia with microdialysis and co sensors in a porcine model introduction: pancreas transplantation is associated with a high rate of early graft thrombosis. current postoperative monitoring lack tools for early detection of ischemia, which could precipitate a graft-saving intervention. we are currently exploring the possibility of ischemia detection with microdialysis and co -sensors in the organ tissue or on the surface in a porcine model. methods: in anesthetized pigs, co -sensors and microdialysis catheters are inserted into the parenchyma or attached to the surface of the pancreas. pco is measured continuously and lactate is sampled with microdialysis every min. ischemia is induced by sequential arterial and venous occlusions for minutes, with minutes of reperfusion in between. results: pco increased and decreased in response to ischemia and reperfusion within minutes. lactate increased and decreased with the same pattern, but with a considerable delay as compared to pco . an example is depicted in figure . the values are presented in introduction: reliable automated handheld vital microscopy (hvm) image sequence analysis is a prerequisite for use of sublingual microcirculation measurements at the point-of care according to the current consensus statement. we aim to validate a recently developed advanced computer vision algorithm [ ] versus manual analysis in a wide spectrum of populations and contexts. methods: our collaborators were invited to contribute raw data of published or ongoing institutional review board approved work. inclusion criteria were use of the cytocam hvm device, manual analysis with the ava software, and image quality as independently assessed by massey score of < in > % of recordings in a random subset of each study. subjects from studies were included, covering clinical and experimental populations, major shock forms and interventions to recruit the microcirculation (table ) . results: , , red blood cells were tracked by the algorithm across , frames in measurements in real time. a good to excellent correlation was found between algorithm-determined and manual capillary density (p< . , r . - . , figure ). capillary perfusion was classified using space-time diagram derived red blood cell velocity (rbcv), yielding good correlation with manual analysis for functional capillary density und proportion of perfused vessels. microcirculatory alterations during disease and interventions were equally detected by the algorithm and manual analysis. change in flow short of severe abnormality was reflected in absolute rbcv but not microcirculatory flow index. conclusions: we demonstrate the validity of automated software for hvm image sequence analysis across broad populations, disease conditions and interventions. thus, microcirculatory assessment at the bedside may finally complement point-of-care evaluation of disease severity and treatment response in critically ill patients and during surgery. introduction: in , naumann et al introduced the poem score as a real-time, point-of-care score to assess sublingual microcirculation [ ] . our study aimed to determine the reproducibility of the poem score. methods: two expert operators used a sidestream darkfield (sdf) videomicroscope (cytocam, braedius, netherlands) to separately acquire four high-quality video clips and assign a poem score to each image in adult mechanically ventilated patients. each operator was blinded to the other's images and analysis. video clip scores and acquisition times were recorded. results: of the patients enrolled in this study, % (n= ) required vasopressors. we categorized poem scores - as "normal" and poem scores - as "impaired." (fig ) . with only one instance of interrater disagreement (i.e., a single image scored as versus ), cohen's kappa ( . ) confirmed a strong correlation between interpreters. the mean time to complete a study session was minutes. conclusions: the present inability to quickly characterize the quality of sublingual microcirculation as either normal or impaired at the point of care limits real-world clinical application of this resuscitative endpoint. the rapidly obtained poem score appears to be reproducible between bedside interpreters. future studies should assess the effect of poem score-guided resuscitation. . sublingual microcirculatory images were obtained using a cytocam-idf device (braedius medical, huizen, the netherlands) and analyzed using standardized published recommendations. results: the median age of participants was years. we found no significant difference in proportions of hemodynamic responders before and after marathon ( % vs %, p= . ). also we did not find differences between plr induced changes of total vessel density (tvd) and proportion of perfused vessels (ppv) of small vessels before and after marathon. correlations between changes of sroke volume and changes of tvd or ppv of small vessels during plr were not significant. conclusions: marathon running did not change microcirculatory responsiveness. introduction: clinical measurement of mitochondrial oxygen tension (mitopo ) has become available with the comet system [ ] . a question with any novel technique is whether it is feasible to use in clinical practice and provides additional information. in elective cardiac surgery patients we measured cutaneous mitopo and tissue oxygenation (sto ). methods: institutional research board approved observational study in patients undergoing cardiopulmonary bypass (cpb). mitopo measurements were performed on the left upper arm (comet, photonics healthcare b.v.) by oxygen-dependent delayed fluorescence of aminolevulinic acid (ala)-induced protoporphyrin ix [ ] . priming of the skin was done with ala (alacare, photonamic gmbh) applied the evening before surgery. sto measurements (invos, medtronic) were done in close proximity to the comet sensor. results: at the time of writing of patients were enrolled and mitopo measurements were feasible in this clinical setting. mitopo appeared sensitive with a high dynamic range. for example, highdose vasopressor therapy decreased mitopo and blood transfusion increased a low mitopo but not a high mitopo . in the example in figure , mitopo is clearly dependent on cpb flow and the restored cardiac circulation is able to maintain good cutaneous oxygenation after cpb even before returning of cellsaver blood. sto had the tendency to provide relatively stable values within a small bandwidth and little response to even major hemodynamic changes. conclusions: mitopo shows the effect of interventions on mitochondrial oxygenation and provides additional information compared to standard monitoring and sto . introduction: traumatic asphyxia is a rare condition in which breathing and venous return is impaired due to a strong compression to the upper abdomen or chest region, and induces swelling, purplish red appearance, and petechiae around the face and neck. to our knowledge, there are no reports describing details of traumatic asphyxia including the clinical course and the therapeutic reactivity from cardiac arrest. we focused on cardiac arrest among all traumatic asphyxia patients treated at our hospital, and investigated their clinical features and therapeutic reactivity. methods: sixteen cases of traumatic asphyxia involved with our hospital between april and march were reviewed by using the pre-hospital activity record, medical record, and hyogo prefectural inspection record. these patients were divided into three groups. the first group had already cardiac arrest at the time of rescue from the trapped place (group a; cases). the second group became cardiac arrest after the rescue (group b; cases). the third group did not experience cardiac arrest (group c; cases). results: all cases had abnormal findings in skin or conjunctiva (table ) . total mortality rate reached %, but among cases of group a and b who resulted in cardiac arrest, there were cases with injury severity score or more and abbreviated injury scale in the chest or more. they had pneumothorax, flail chest, pericardial hematoma. seven of them restored spontaneous circulation, and two cases achieved neurologically full recovery. conclusions: there are some cases of traumatic asphyxia whose therapeutic reactivity is very good even after cardiac arrest, so it is important not to spare efforts for life support in such cases. rhythm and % witnessed arrest, five hundred ten ( %) patients had a good functional outcome at -months. physiological derangements were each negatively associated with outcome in bivariate analysis at the p < . level. a summary score of physiological derangements was included with potential confounders in the final regression model, and was independently associated with outcome with the chance of a good outcome decreasing by % for each increase of one physiologic derangement ( % ci . - . ). conclusions: uncorrected physiological derangements are independently and cumulatively associated with worse outcome after cardiac arrest. although causality cannot be established, it is reasonable to consider that the correction of physiological parameters may be an important step in the chain of survival after resuscitation. characteristics introduction: glan clwyd hospital (gch) was recently designated one of three cardiac arrest centres for wales. it has offered a / percutaneous coronary angiography (pci) service to a geographically dispersed north wales population of approximately , since june . prior to this, urgent coronary angiography was available on a more limited basis to patients requiring pci. the aim of this study was to investigate factors associated with hospital mortality after critical care admission following cardiac arrest. methods: retrospective review of the ward watcher critical care database at gch to identify patients who had undergone cpr in the hours prior to critical care admission in - . patients likely to have sustained ooha of cardiac aetiology (ooha-c) were identified from primary and secondary diagnoses and free text entry. data were subsequently analysed using excel and spss. the project was registered as a service evaluation with gch audit department. results: there were cardiac arrest admissions over this period, increasing from in - to in - . of these were ooha, of which were considered ooha-c. although ooha-c hospital mortality appeared to decrease over the time period ( %% to %), this was not statistically significant (p= . ). factors associated with survival to hospital discharge are presented in the tables below. on logistic regression, only pci and low ph within the first hours of critical care remained statistically significant (p= . and p< . respectively). conclusions: although we have been unable to make a distinction between patients presenting following stemi and nstemi, and appreciating a potential influence of selection bias, the significant association between pci and survival to hospital discharge supports the introduction of clinical pathways enabling pci access following ooha-c [ ] . chest radiography. [ ] here, we aimed to derive and validate rules to estimate p_max.lv using anteroposterior chest radiography (ches-t_ap), which is performed for critically-ill patients urgently needing determination of personalised p_max.lv. methods: a retrospective, cross-sectional study was performed with non-cardiac arrest adults who underwent chest_ap and computed tomography (ct) within h (derivation:validation= : ). on chest_ap, we defined cd (cardiac diameter), rb (distance from right cardiac border to midline) and ch (cardiac height, from carina to uppermost point of left hemi-diaphragm) (fig , ) . [ ] setting p_zero ( , ) at the midpoint of xiphisternal joint and designating leftward and upward directions as positive on x and y axes, we located p_max.lv (x_max.lv, y_max.lv). the coefficients of the following mathematically-inferred rules were sought: x_max.lv=a *cd-rb; y_max.lv=ß *ch+γ . (a : mean of (x_max.lv+rb)/cd; ß , γ : representative coefficient and constant of linear regression model, respectively ) . conclusions: evaluable echocardiographic records were reached in most of the patients. etco positively correlated with all parameters under consideration, while the strongest correlation was found between cimax and etco . therefore, cimax is a candidate parameter for real-time monitoring of haemodynamic efficacy of chest compressions during cpr. introduction: the uk resuscitation council has set out guidelines for management of patients post cardiac arrest [ ] . this is in line with european resuscitation council guideline. we set out to find if we are following the guideline. methods: we did a retrospective audit over the course of years looking at the data of patients who had in hospital and/or out of hospital cardiac arrest and after the return of spontaneous circulation were admitted to the intensive care unit (icu). we focused on whether the care they received was as per the standards set by the uk resuscitation council. results: we had in the hospital and out of hospital cardiac arrests; patients had less than minutes of cpr, had more than minutes cpr and patients the data was not recorded; patients needed more than minutes to reach from the site of arrest to the icu. the partial pressure of carbon dioxide was > . kpa in patients at two or more occasions. target map was not documented in patients; blood sugar target was not documented in patients and was not maintained within limits in patients. target temperature was not documented in patients. the withdrawal of treatment was not delayed for hours in patient out of . in patients neurological tests were not documented. multimodal assessment tools were not used in patient. electroencephalography and serum neuron specific enolase were not used to diagnose brain deaths as they were not available at our trust. patients were discharged, died in the icu and died in hospital after discharge from icu. conclusions: the audit reflected our local practice and showed that our mortality was in line with the acceptable limits; poor documentation of plan of care which posed problems in analyzing the care that these patients received; some of the parameters were not being maintained as set by uk resuscitation guideline. introduction: high-quality chest compressions (cc) with minimized interruptions are one of the most essential prerequisites for an optimal outcome of resuscitation. therapy of reversible causes of cardiac arrest often requires intra-hospital transportation (iht) during ongoing cpr. the present study investigated cc quality during transportation depending on the position of the provider. methods: paramedics were enrolled into a manikin study with four groups: a reference group with the provider kneeling beside manikin on the floor (group ), and groups performing cc during a simulated iht of meters: walking next to the bed (group ), kneeling beside the patient in bed (group , fig. ) or squatting above the patient in bed (group , figure ). indicators of cc quality were measured as defined in the erc guidelines (pressure point and depth, compression frequency, complete relief, sufficient pressure depth) [ ] . all paramedics performed cc during each scenario (group - ). results: there were no statistical differences in quality of cc between groups , and . notably, group performed significantly worse in respect to the proportion of cc with correct pressure point (p = . vs group ), correct cc depth (p= . vs. group , p= . vs. group , p= . vs. group ). the results are shown in table . conclusions: carrying out guideline-compliant cc [ ] during iht is feasible with multiple provider positions. based on the present results, kneeling or squatting position next to the patient ( figure and ) is recommended, whereas "walking next to the bed" while performing cc should be avoided. methods: a retrospective review of clinical notes was undertaken for patients admitted to icu following return of spontaneous circulation but whom remained comatose. this audit encompassed three-month periods before and after introduction of the care bundle in october . audit standards were assigned from target parameters documented in the bundle and reflected guidance from the cheshire and merseyside critical care network. results: patients were included in our audit; admitted prior to and admitted following implementation of the care bundle. in patients whom targeted temperature management was indicated, improved adherence to thermoregulation between - °c was observed ( vs %). significant improvements were since in the observance to target values for oxygen saturation ( vs . %, p= . ) and mean arterial pressure ( vs . %, p< . ) following the introduction of the care bundle. improved observance of ventilation targets was also seen; maintenance of p a co > . kpa ( vs %, p= . ) and tidal volumes < ml/kg ideal body weight ( to . %, p= . ). conclusions: the introduction of a post-cardiac arrest care bundle in our icu has improved care by providing discrete physiological targets to guide nursing staff and standardising management between clinicians. variations in care are associated with poorer patient outcomes [ ] and introduction of this bundle has reduced disparities in practice. array of cardiac diseases and reported survival rate is low in spite of advances in resuscitation and ems services. methods: single-centre retrospective study analyzed outcomes of ohca patients admitted to cardiac icu between .- . we studied demographic data, initial rhythm, type of cpr, comorbidities and various post admission diagnostic findings in order to identify their impact on survival. results: ohca comprised , % of all admissions. mean los was . days ( - ). mean age was , y ( - ), m: f ratio : and bystander cpr was performed in only % ohca patients. the most common initial rhythm was vf ( . %), followed by vt ( . %), pea was found in , % and asystole in . % of pt more than half of pt received adrenalin ( %) and defibrillation ( %) and only % required a temporary pacemaker. % of pt had an ecg consistent with mi after rosc, % underwent coronary angiography resulting in pci in % of cases. in pt ( %) therapeutic hypothermia protocol was performed. most ohca pt had hypertension ( %) and hyperlipidaemia ( %) as the most common risk factors followed by cardiomyopathy ( %), diabetes ( %) and cad ( %). only % had a preexisting significant valvular disease and the rest were extracardial comorbidities: chronic renal disease ( %), copd ( %) and cerebrovascular disease ( %). patients survived ( %) and gcs on admission was the only significant impact factor on survival along with comorbidities (mean gsc was in survivors vs. in deceased). interestingly, age, initial rhythm, troponin i level, ph and therapeutic hypothermia had no impact on survival. conclusions: our data demonstrate the importance of early onsite resuscitation as the most important factor of neuroprotection and outcome and puts an emphasis on the importance of cpr education for layman population. prediction of acute coronary ischaemia and angiographic findings in patients with out-of-hospital cardiac arrest j higny , a guédès , c hanet , v dangoisse , l gabriel , j jamart introduction: coronary artery disease (cad) is the leading cause of out-of-hospital cardiac arrest (ohca). however, diagnosis of acute coronary ischaemia (aci) remains challenging, particularly in patients without st-segment elevation on the post-resuscitation ecg. in this regard, a consensus statement recommends the implementation of a work-up strategy in the emergency room (er) to exclude noncoronary causes of collapse within hours. methods: retrospective single-centre study performed on consecutive patients with resuscitated ohca who underwent a diagnostic coronary angiography (ca). we present data on coronary angiograms for patients who underwent cardiac catheterization after resuscitation. afterwards, we sought to identify parameters associated with aci. results: st-segment elevation was noted in patients ( %). stsegment depression or t-wave abnormalities were noted in patients ( %). invasive coronary strategy allowed to identify an acute culprit lesion in cases ( %). patients with st-segment elevation underwent an immediate angioplasty for an acute coronary occlusion. patients without st-segment elevation underwent an ad hoc percutaneous coronary intervention for a critical lesion. stable cad was found in cases ( %) and a normal angiogram was found in only cases ( %) (figure ). conclusions: aci was the leading precipitant of collapse. stsegment elevation was highly predictive of coronary occlusion. in addition, a culprit coronary lesion was identified in nearly % of patients undergoing ca despite the lack of stsegment elevation. finally, our findings suggest that the identification of risk criteria may help to improve the recognition of aci after ohca. the prediction of outcome for in-hospital cardiac arrest (pihca) score e piscator , k göransson , s forsberg , m bottai , m ebell , j herlitz , t djärv figure. predictive value for classification into < % likelihood of favorable neurologic survival was . %. false classification into < % likelihood of favorable neurologic survival was . %. the phica score has potential to be used as an aid for objective prearrest assessment of the chance of favorable neurologic survival after ihca, as part of decision making for a dnar order. introduction: prognosis of survival in patients with cardiac arrest remains poor. during and after cardiopulmonary resuscitation, pathophysiological disturbances in relation with a cytokine storm, are described as "post-resuscitation" disease like a combination of cardiogenic and vasodilatory shocks. veno-arterial extracorporeal membrane oxygenation (va ecmo) allows to restore adequate perfusion but little is known about its effect on left ventricular (lv) function and about the role of cytokines. methods: this study was performed in an experimental model of cardiac arrest performed in groups of anesthetized and mechanically ventilated pigs. cardiac arrest was obtained by application of electrical current to epicardium inducing ventricular fibrillation. after a no-flow period of minutes, medical resuscitation with catecholamines and vasopressors was performed in "control" group while va ecmo was started in "ecmo" group and va ecmo in combination with cytosorb (extracorporeal blood purification therapy designed to reduce excessive levels of inflammatory mediators such as cytokines) was started in "ecmo-cyto" group. lv function was assessed with transthoracic echocardiography and arterial pressure with aortic pressure catheter. results: hemodynamic stability was obtained after ± and ± minutes in ecmo and ecmo-cyto groups, respectively. no return of spontaneous circulation was observed in control group. at minutes following cardiac arrest, lv area fractional change on short axis was normalized in ecmo and ecmo-cyto groups ( ± and ± %, respectively). vasopressor requirements were significantly lower in ecmo-cyto group than in ecmo group. conclusions: after cardiac arrest (no-flow) of minutes duration, va ecmo allowed complete lv recovery and hemodynamic stability within minutes of "post-resuscitation" disease. cytosorb added to va ecmo could contribute to reduce post-resuscitation vasodilatation. impact of rapid response car system on ecmo in out-of-hospital cardiac arrest: a retrospective cohort study m nasu , r sato , k takahashi introduction: extracorporeal life support (ecls) has been reported to be more effective than conventional cardio-pulmonary resuscitation (cpr). in ecls, a shorter time from arrival to implantation of extracorporeal membrane oxygenation (ecmo; door-to-ecmo) time has been reported to be associated with better survival rates. this study aimed to examine the impact of the physician-based emergency medical services (p-ems) using a rapid response car (rrc) on door-to-ecmo time in patients with out-of-hospital cardiac arrest (ohca to study the interest and the educational contribution in the short and medium term of medical simulation compared to a classical training. methods: cohort, prospective, observational, single-center, randomized study with control group including residents ( in anesthesia resuscitation and in emergency medicine). all benefited from a theoretical training with a reminder of the latest recommendations on the management of cardiac arrest and anaphylactic shock. they were randomized into groups and received practical training on a high-fidelity simulator for the management of either cardiac arrest (acc group) or anaphylactic shock (ca group). each group was evaluated at weeks (t ) and at months on two scenarios: refractory ventricular fibrillation (fv) scored on points and grade anaphylactic reaction (ra ) scored on points. each group served as the control group for the pathology in which they did not receive specific simulator training. the results are expressed on average with their standard deviations with "p" < . . introduction: simulation is a tool for improving the quality and safety of care, and its recognized as an essential method of evidence-based education. emergency medicine is a discipline in which there is a constant concern for the safety of patients. the emergency physician is often called upon to take charge of critical situations that use knowledge, know-how and knowledge as skills that must be mastered and whose theoretical learning alone is insufficient. methods: it´s a prospective study including residents in emergency medicine performing their specialty courses in emergency services and emergency medical assistance in the region of sousse from january to june . they were randomized into two groups: the one benefiting from a traditional education and the other from an education based on simulation sessions. the chosen scenario was the management of a cardiac arrest. a pre-test and a post-test were performed in both groups. results: we included emergency residents who did not receive specialized training in the management of cardiac arrest, there was a female predominance with an average age of , there was no significant difference regarding the pretest between the two groups with . there was no significant difference with respect to the pre-test score between the two groups . ± . / for the control group versus . ± . / for the simulation group. there was a significant progression after the course with an average posttest score of . ± . in the simulation group while this score was . ± . in the control group with a statistically significant difference (p < . ). conclusions: simulation learning has led to a better acquisition of cognitive knowledge by learners. the simulation is not intended to replace bed-based teaching, nor theoretical or faculty teaching, but it is an essential complement . in tunisia, the simulation must continue its current integration in the initial and continuous training of doctors. introduction: recent studies have shown that obesity and its related metabolic dysfunction exacerbates outcomes of ischemic brain injuries in some brain areas, such as the hippocampus and cerebral cortex when subjected to transient global cerebral ischemia (tgci). however, the impact of obesity in the striatum after tgci has not yet been addressed. the objective of this study was to investigate the effects of obesity on tgci-induced neuronal damage and inflammation in the striatum and to examine the role of mtor which is involved in the pathogenesis of metabolic and neurological diseases. methods: gerbils were fed with a normal diet (nd) or high-fat diet (hfd) for weeks and then subjected to min of tgci. hfd-fed gerbils showed the significant increase in body weight, blood glucose level, serum triglycerides, total cholesterol, and low-density lipoprotein cholesterol without affecting food intake. results: in hfd-fed gerbils, neuronal loss occurred in the dorsolateral striatum days after tgci and increased neuronal loss were observed cholesterol days after tgci; however, no neuronal loss was the in ndfed gerbils after tgci, as assessed by neuronal nuclear antigen immunohistochemistry and fluoro-jade b histofluorescence staining. the hfd-fed gerbils also showed severe activated microglia and further increased immunoreactivities and protein levels of tumor necrosis factor-alpha, interukin- beta, mammalian target of rapamycin (mtor) and phosphorylated-mtor in the striatum during pre-and postischemic conditions compared with the nd-fed gerbils. in addition, we found that treatment with rapamycin, a mtor inhibitor, in the hfd-fed gerbils significantly attenuated hfd-induced striatal neuronal death without changing physiological parameters. conclusions: these findings reveal that chronic hfd-induced obesity results in severe neuroinflammation and significant increase of mtor activation, which could contribute to neuronal death in the stratum following tgci. abnormal mtor activation might play a key role. associations between partial pressure of oxygen and neurological outcome in out-of-hospital cardiac arrest patients introduction: exposure to hyperoxemia and hypoxemia is common in out-of-hospital cardiac arrest (ohca) patients following return of spontaneous circulation (rosc) but its effects on neurological outcome are uncertain and study results are inconsistent. methods: exploratory post-hoc substudy of the target temperature management (ttm) trial [ ] , including patients after ohca with rosc. the association between serial arterial partial pressures of oxygen (pao ) during hours following rosc and neurological outcome at months, evaluated by cerebral performance category (cpc), dichotomized to good (cpc - ) and poor (cpc - ), was investigated. in our analyses, we tested the association of hyperoxemia pao > kpa and hypoxemia pao < kpa, time weighted mean pao , (twm-pao ) (fig ) , maximum pao difference (Δ pao ) and gradually increasing pao levels ( . - . kpa) with poor neurological outcome. a subsequent analysis investigated the association between pao and a biomarker of brain injury, peak serum tau levels. results: patients were eligible for analysis. patients ( %) were exposed to hyperoxemia or hypoxemia after rosc (table ) . our analyses did not reveal a significant association between hyperoxemia, hypoxemia, twm-pao exposure or Δ pao and poor neurological outcome at -month follow-up after correction for co-variates (all analyses p= . - . ) (fig ) . we were not able to define a pao level associated with the onset of poor neurological outcome. peak serum tau levels at either or hours after rosc were not associated with pao . conclusions: hyperoxemia or hypoxemia exposure occurred in one third of the patients during the first hours of hospitalization and was not significantly associated with poor neurological outcome after months or with the peak s-tau levels at either or hours after rosc. introduction: cerebral hypoperfusion may aggravate the developing neurological damage after cardiac arrest. near-infrared spectroscopy (nirs) provides information on cerebral oxygenation but its clinical relevance during post-resuscitation care is undefined. we wanted to assess the possible association between cerebral oxygenation and clinical outcome after out-of-hospital cardiac arrest (ohca). methods: we performed a post hoc analysis of a randomised clinical trial (comacare) where both moderate hyperoxia and high-normal arterial carbon dioxide tension (paco ) increased regional cerebral oxygen saturation (rso ) as compared with normoxia and low-normal paco , respectively. rso was measured from ohca patients with nirs during the first h of intensive care and neurological outcome was assessed using the cerebral performance category (cpc) scale at months after cardiac arrest. we calculated the median rso for patients with good (cpc - ) and poor (cpc - ) outcome and compared the results using the mann-whitney u test. we compared the rso over time with outcome using a generalised mixed model. finally, we added median rso to a binary logistic regression model to control for the effects of possible confounding factors. results: the median (interquartile range [iqr]) rso during the first h of intensive care was . % ( . - . %) in patients with good outcome compared to . % ( . - . %) in patients with poor outcome, p = . . we did not find significant association between rso over time and neurological outcome ( figure ). in the binary logistic regression model rso was not a statistically significant predictor of good outcome (or . , % ci . - . , p = . ). conclusions: we did not find any association between cerebral oxygenation during the first h of post-resuscitation intensive care and neurological outcome at months after cardiac arrest. fig. introduction: near-infrared spectroscopy (nirs) provides a noninvasive means to assess cerebral oxygenation during postresuscitation care but its clinical value is unclear. we determined the possible association between cerebral oxygenation and the magnitude of brain injury assessed with neuron-specific enolase (nse) serum concentration at h after out-of-hospital cardiac arrest (ohca). methods: we performed a post hoc analysis of a randomised clinical trial (comacare) comparing two different levels of carbon dioxide, oxygen and arterial pressure after ohca and successful resuscitation. we measured rso continuously with nirs from patients during the first h of intensive care. we determined the nse concentrations at h after cardiac arrest from serum samples using an electrochemiluminescent immunoassay kit. the samples were tested for haemolysis and all samples with a haemolysis index > mg of free haemoglobin per litre (n = ) were excluded from the analyses. we calculated the median rso for all patients and used a scatterplot and spearman's rank-order correlation to assess the possible relationship between median rso and nse at h. in addition, we compared the nse concentrations at h after cardiac arrest in patients with good (cerebral performance category scale [cpc] - ) and poor (cpc - ) neurological outcome at months using the mann-whitney u test. results: we did not find significant correlation between median rso and serum nse concentration at h after cardiac arrest, rs = - . , p = . (figure ). the median (iqr) nse concentration at h was . ( . - . ) μg/l and . ( . - . ) μg/l in patients with good and poor outcome, respectively, p < . . conclusions: we did not find any association between cerebral oxygenation during the first h of post-resuscitation intensive care and nse serum concentrations at h after cardiac arrest. the association between lactate, cerebral oxygenation and brain damage in post-cardiac arrest patients introduction: patients admitted to the intensive care unit (icu) after being successfully resuscitated from a cardiac arrest (ca) have a large cerebral penumbra at risk for secondary ischemic damage in case of suboptimal brain oxygenation. therefore, resuscitation during icu stay should be guided by parameters that adequately predict cerebral hypoxia. the value of lactate as resuscitation parameter may be questioned in post-ca patients since the brain critically depends on aerobic metabolism. we aimed to investigate the relationship between arterial lactate, cerebral cortex tissue oxygenation (scto ) by near infrared spectroscopy (foresight) and unfavorable neurological outcome at days (cpc score - ) methods: subanalysis from the neuroprotect post-ca trial. lactate values and scto were recorded hourly in post-ca patients during hours ttm and subsequent rewarming. results: in total paired lactate/ scto measurements were analysed. we found no correlation between paired lactate and scto² (fig. ) . moreover, temporary trends in lactate did not correlate with corresponding trends in scto during the same one-hour time interval (r²= . ) (fig ) . if lactate values above . mmol/l are considered to be abnormal, lactate could not adequately detect clinical important brain ischemia (scto < %): sensitivity % and specificity % (table , ). nevertheless, time weighted lactate at h (or . ; p . ), h (or . , p . ), h (or . ; p . ) and h (or . ; p . ) were inversely correlated with unfavorable neurological outcome at days (fig , ) . conclusions: although lactate was a marker of prognosis in post-ca patients, it should not be used to guide resuscitation since lactate values were not correlated with scto and changes in lactate do not correspond with changes in scto during the same time interval. simplified introduction: the aim of the study was to investigate whether simplified continuous eeg monitoring (ceeg) [ ] post-cardiac arrest can be reliably interpreted by icu physicians after a short structured training, and whether acceptable interrater agreement compared to an eeg-expert can be achieved. methods: five icu physicians received training in interpretation of simplified ceeg (fig ) consisting of lectures, hands-on ceeginterpretation, and a video tutorial -total training duration day. the icu physicians then interpreted simplified ceeg recordings. basic eeg background patterns and presence of epileptiform discharges or seizure activity were assessed on -grade rank-ordered scales based on a standardized eeg terminology [ ] . an experienced eeg-expert was used as reference. results: there was substantial agreement (κ . ) for eeg background patterns and moderate agreement (κ . ) for epileptiform discharges between icu physicians and the eeg-expert. sensitivity for detecting seizure activity by the icu physicians was limited ( %), but with high specificity ( %). among icu physicians interrater agreement was substantial (κ . ) for eeg background pattern and moderate (κ . ) for epileptiform discharges. conclusions: after a one-day educational effort clinically relevant agreement was achieved for basic eeg background patterns after cardiac arrest. assessment of epileptiform patterns was less reliable, but bedside screening by the icu physician may still be clinically useful for early detection of seizures. interpretation of simplified ceeg requires awareness of its limitations and support from an eeg-expert when clinically indicated. introduction: hypoxic-ischemic injury on head computed tomography (ct), which manifests with varying degrees of cerebral edema and loss of gray-white matter differentiation, is a poor prognostic sign after resuscitated out-of-hospital cardiac arrest that may influence early clinical decision-making. agreement among physicians on the presence of hypoxic-ischemic injury on early head ct is unknown. methods: we recruited faculty physician participants ( emergency medicine, critical care, neurocritical care, and general radiology; average . years of practice) across academic medical centers each with > admissions for resuscitated out-of-hospital cardiac arrest each year. participants, blinded to clinical context, reviewed unique head cts obtained within hours of cardiac arrest that were randomly selected from a local registry. a blinded neuroradiologist also reviewed all scans (gold standard). participants determined if hypoxic-ischemic injury was present on each ct, and agreement was determined using multi-and dual-rater kappa statistics with % confidence intervals. results: overall agreement among physicians regarding the presence of hypoxic-ischemic injury on head ct was fair (kappa . ; % ci, . - . ) with agreement consistent across most specialties (table ) . when compared to the neuroradiologist, individual physician agreement ranged widely, from poor (kappa . ) to substantial (kappa . ), with of physicians having fair or worse agreement compared to the gold standard interpretation. conclusions: the finding of hypoxic-ischemic injury on early head ct after cardiac arrest had high interobserver variability as interpreted by acute care physicians and general radiologists. pending the development of objective diagnostic criteria, clinicians should bear in mind the subjectivity and subtlety of cerebral edema or loss of graywhite matter differentiation soon after return of spontaneous circulation in these patients. figure ). baseline characteristics and differences between the wlst and no-wlst groups are shown in table . utilization of neuro-prognostication tests is shown in table . while ct and eeg were commonly employed, ssep and mri were used less frequently. basic multimodal neuroprognostication (arbitrarily defined as at least one ct or mri, plus eeg, plus ssep) was performed only in . % of all patients undergoing wlst but the rate increased significantly over six years (p< . ) and was higher in the time period after , compared to the one prior to ( figure ). this association remained significant after adjustment for confounders such as age, arrest rhythm, downtime, targeted temperature management, apache ii score and organ failure in a logistic regression model (p= . ). in an institution with access to a wide range of imaging and neurophysiology tests, mri and ssep remained underutilized but the rate of basic multimodal neuro-prognostication increased significantly over the study period, especially in the period after . introduction: although multiple reports using animal models have confirmed that melatonin appears to promote neuroprotective effects following ischemia/reperfusion-induced brain injury, the relationship between its protective effects and the activation of autophagy in cerebellar purkinje cells following the asphyxial cardiac arrest and cardiopulmonary resuscitation (ca/cpr) remains unclear. methods: rats used in this study were randomly assigned to groups as follows; vehicle-treated sham-operated group, vehicletreated asphyxial ca/cpr-operated group, melatonin-treated shamoperated group, melatonin-treated asphyxial ca/cpr-operated group, melatonin plus (+) p-pdot (the mt melatonin receptor antagonist)-treated sham-operated group and melatonin+ p-pdot-treated asphyxial ca/cpr-operated group. results: our results demonstrate that melatonin ( mg/kg, ip, time before ca and times after ca) significantly improved the survival rates and neurological deficits compared with the vehicle-treated asphyxial ca/cpr rats (survival rates ≥ % vs %). we also demonstrate that melatonin exhibited the protective effect against asphyxial ca/cpr-induced purkinje cell death. the protective effect of melatonin in the purkinje cell death following asphyxial ca/cpr paralleled a dramatic reduction in superoxide anion radical (o ·-), intense enhancements of cuzn superoxide dismutase (sod ) and mnsod (sod ) expressions, as well as a remarkable attenuation of autophagic activation (lc and beclin- ), which is mt melatonin receptor-associated. furthermore, the protective effect of melatonin was notably reversed by treatment with p-pdot. conclusions: this study shows that melatonin conferred neuroprotection against asphyxial ca/cpr-induced cerebellar purkinje cell death by inhibiting autophagic activation by reducing expressions of ros, while increasing of antioxidative enzymes, and suggests that mt is involved in the neuroprotective effect of melatonin in cerebellar purkinje cell death induced by asphyxial ca/cpr. introduction: fucoidan is a sulfated polysaccharide derived from brown algae and possesses various beneficial activities, such as antiinflammatory and antioxidant properties. previous studies have shown that fucoidan displays protective effect against ischemiareperfusion injury in some organs. however, few studies have been reported regarding the protective effect of fucoidan against cerebral ischemic injury and its related mechanisms. methods: therefore, in this study, we examined the neuroprotective effect of fucoidan against cerebral ischemic injury, as well as underlying mechanisms using a gerbil model of transient global cerebral ischemia (tgci) which shows loss of pyramidal neurons in the hippocampal cornu ammonis (ca ) area. fucoidan ( and mg/kg) was intraperitoneally administered once daily for days before tgci. results: pretreatment with mg/kg of fucoidan, not mg/kg fucoidan, attenuated tgci-induced hyperactivity and protected ca pyramidal neurons from ischemic injury following tgci. in addition, pretreatment with mg/kg of fucoidan inhibited activations of resident astrocytes and microglia in the ischemic ca area. furthermore, pretreatment with mg/kg of fucoidan significantly reduced the increased -hydroxy- -noneal and superoxide anion radical production in the ischemic ca area after tgci and significantly increased expressions of superoxide dismutase (sod ) and sod in the ca pyramidal neurons compared with the vehicle-treated-group. we found that treatment with diethyldithiocarbamate (an inhibitor of sods) to the fucoidan-treated-group notably abolished the fucoidanmediated neuroprotection in the ischemic ca area following tgci. conclusions: these results indicate that fucoidan can effectively protect neurons from tgci-induced ischemic injury through attenuation of activated resident glial cells and reduction of oxidative stress following increasing sods. thus, we strongly suggest that fucoidan can be used as a useful preventive agent in cerebral ischemia. the effects of cold fluids for induction of therapeutic hypothermia on reaching target temperature and complications-a sub-study of the tth study a holm , m skrifvars , fs taccone ). there was no difference in early bleeding incidences (fig ) . during late observation, ttm patients had fewer minor bleeding ( . % vs. %) and more intracranial bleeding ( . % vs. %; fig ) . adjusted calculated risk ratio for major bleeding (including intracranial) for ttm was . ( %ci . - . ) at baseline and . ( %ci . - . ) over time. conclusions: bleeding complications were common. although the risk ratio for major bleeding increased over time in ttm patients, residual and unmeasured confounding in addition to selection and detection bias may limit the clinical relevance of this finding. methods: patients with neurological deficit > by nhiss were included. the t°of the brain was recorded non-invasively using radiothermometer rtm- -res (russia). we measured t°in symmetric regions of left & right hemispheres, calculated the average t°of brain, fig. (abstract p ) . temperature of patients given and not given pre-icu fluids (table ) . conclusions: observed moderate brain t°heterogenecity in hp, marked increase brain t°heterogenecity in is & sharp decline of t°h eterogenecity in cci. supposedly, correcting the impairment of cerebral tb (increase or decrease t°) through physical (selective cerebral hypothermia, magnetic stimulation etc.) or pharmacological (sedation) can contribute to positive therapeutic results in is & cci. nonivasive radiothermometry of the brain can be an objective method of patients' condition evaluation & their rehabilitation potential. introduction: basilar artery stroke has a multitude of different presentations and may not be captured on plain computed tomography (ct). it can progress to severe disability, locked in syndrome and death [ ] . with the advent of thrombolytic and endovascular therapies, prompt diagnosis can change the outcome. we present a case of basilar artery stroke, which was heralded by tongue spasticity and dysarthria, indicative of pseudobulbar palsy. methods: case reviewed with consent. a literature search was conducted using pubmed and medline. results: a -year-old presented with pulmonary oedema and hypertension. he was transferred to our intensive care unit for treatment of a suspected anaphylaxis. his marked lingual swelling was associated with dysarthria. glyceryl-trinitrate and labetalol infusions were started for hypertension. he developed left sided weakness and deteriorated over several days to the point that he could only move his right foot (table ) . magnetic resonance imaging (mri) showed midbrain ischaemia and angiogram showed no flow in the basilar artery (fig , ) . conclusions: common presenting features of basilar artery occlusion include dysarthria, vertigo, vomiting, headache and motor defects; these may evolve gradually or be intermittent [ , ] . presentation with pseudobulbar palsy is described in early literature [ ] . delayed recognition of the stroke led to aggressive treatment of hypertension, potentially compromising perfusion to the penumbral area [ , ] . this case highlights the need for a wide index of suspicion with posterior strokes. consent: informed consent to publish has been obtained from the patient prognosis is related to gcs < or = on admission (p = . ) and to malignant cerebral edema (p = . ). conclusions: our study has shown some predictive factors closely related to mortality and morbidity in patients with acute ischemic stroke. gcs at admittance < or = and onset of malignant cerebral edema lead to a worst prognosis at discharge from nicu. coherence analysis of cerebral oxygenation using multichannel functional near-infrared spectroscopy evaluates cerebral perfusion in hemodynamic stroke tj kim table ). in addition, severe stroke patients were more likely to have higher phase coherence in interval iii (p = . ). conclusions: our results demonstrated that the higher phase coherence of oxyhb in myogenic signal, which was originated locally from smooth muscle cells in brain was related to impaired cerebral perfusion. this suggests that monitoring cerebral oxygenation using fnirs could be a useful noninvasive measuring tool for evaluating impaired cerebral autoregulation in stroke patients. is esmolol associated with worse outcome at the acute phase of ischemic stroke that receives thrombolysis? introduction: ischemic stroke patients experienced frequent early neurological deterioration (end) events. since ischemic stroke has also been shown as inflammatory disease, the neutrophil-tolymphocyte ratio (nlr) may associated with end events. however, the direct study regarding this association has not been addressed. poor grade sah, use of vasopressors, mechanical ventilation, intracranial pressure monitoring, external ventricular drainage, blood transfusions and renal replacement therapy were all more frequent among nonsurvivors (all p< . ). mortality was also higher with initial lactate above mmol/l, in those admitted to public hospitals and when admission to icu was delayed more than hours after ictus. after adjusting for common predictors (age, gender and wfns) saps non-neuro, sofa non-neuro, early vasopressor use and admission to a public hospital were independently associated with hospital mortality. moreover, the area under the curve for prediction of mortality with saps , sofa and wfns was . ( figure ). hospital, austria. the association of intensity and duration of intracranial hypertension episodes with -month glasgow outcome score (gos) was visualized using the methodology introduced by güiza et al. [ ] . results: in both cohorts, it could be demonstrated that the combination of duration and intensity defined the tolerance to intracranial hypertension, and that a semi-exponential curve separated episodes associated with better outcomes from those associated with worse outcomes. the association with worse outcomes occurred at a lower pressure-time burden than what has been previously observed in patients with tbi. nevertheless, the percentage of monitoring time spent by every patient in the zone associated with poor gos was independently associated with worse -month neurological outcome, even after correcting for age and fisher score ( introduction: apnea test is an essential component in the clinical determination of brain death, but it may incur a significant risk of complications such as hypotension, hypoxia and even cardiac arrest [ ] . we analyzed the risk factors associated with failed apnea test during brain death assessment in order to predict and avoid these adverse events. methods: medical records of apnea tests performed for brain-dead donor between january and january in our institution, were reviewed retrospectively. age, gender, etiology of brain death, use of catecholamine and results of arterial bleed gas analysis (abga), systolic/diastolic blood pressure (sbp/dbp), mean arterial pressure (map) and central venous pressure (cvp) prior to apnea test initiation were collected as variables. a-a gradient and pao /fio were calculated for more precise assessment of the respiratory system. in total, cases were divided into a group which was completed apnea test and the other which was failed the test. introduction: tunisia has already suffered recurrent outbreaks since . outbreak started relatively earlier this year. we were interpellated by the frequency of neuroinvasive presentation of the disease. methods: we report a case series of patients presented to icu with niwnd. results: we report cases of niwnd with different severe presentations overlapping neurological manifestation including encephalitis (n= / ), meningitis (n= / ) and flaccid paralysis (n= / ). almost all patients live in the locality of sousse. six patients presented a long course of isolated fever before developing neurological signs. cerebrospinal fluid was consistent with encephalitis within the patients. cerebromedullar mri identified brain lesions (n= / ), myelitis (n= / ) and polyradiculoneuritis (n= / ).three patients had electromyography for flaccid paralysis showed diffuse axonal polyneuropathy with motoneuron involvement. ten cases had a positive wnv igm antibody and nine had a positive wnv igg antibody in serum. urine polymerase chain reaction was positive for wnv in / patients. ten patients were mechanically ventilated. all patients were managed symptomatically. two received high doses of methylprednisolone for days, one patient received polyclonal immunoglobulin intravenous and one patient had plasmapheresis. two patients died consecutive to brainstem lesions. two patients recovered significantly and discharged with no complications. five other patients evolved to persistent flaccid paralysis with a minimal consciousness state and weaning difficulties requiring tracheostomy. the last remaining patient is still evolving. conclusions: modification of the regional climatic conditions accounted probably for the early outbreak of niwnd. this initial case series displays the severity and the poor outcomes of niwnd with higher incidence compared to past epidemics. noninvasive estimation of intracranial pressure with transcranial doppler: a prospective multicenter validation study c robba , c fig. ], mean bias was - . mmhg (limits of agreement are ± sd . mmhg). . % measures were outside the limit of agreement in the overall population. however, when icp was high, % of measures were out of the limit of agreement. the auc [ fig. introduction: surgical treatment of aortic aneurysm needs extracorporeal circulation (ecc), aorta clamp and hypothermia, and it is often related to poor systemic perfusion and blood flow velocity. one of the main concerns of intensive care team is to prevent secondary neurological injury after long time without blood flow pulsatility, such as brain edema and seizure. the most common parameters for neuromonitoring would be intracranial pressure and eeg, however, for non-neurological patients this information is unusual and prevents optimal management. methods: we aimed to assess brain compliance and neurological condition of icu patients on immediate post-operative recovery of bentall-de bono procedure and/or other aortic aneurysm surgical treatment using a novel non-invasive intracranial pressure (icp) device. this device uses mechanical displacement sensor capturing extracranial continuous volumetric variation of the skull and this information proportionally reflects intracranial dynamic [ ] . results: twenty patients were included in this study. ecc mean time was minutes for patients and only one did not need it. eleven presented altered icp curves with poor brain compliance (p /p ratio > . ) assessed by icp curve morphology analysis. volemic optimization and neuroprotective measures were taken based on this icp information for acute case management. among these patients with altered icp curves, eight were discharged from icu with good clinical condition and glasgow coma scale of . overall mortality rate was six out of twenty ( %) and three of these had altered icp curves. conclusions: brain monitoring of cardiovascular post-operative patients is important to prevent secondary neurological complications and can be a helpful tool for neuroprotective acute management on icu. the technique supplies electrical current to muscle, combined with passive cycling. prior to a clinical trial, we first investigated the effects of one session of fes in healthy volunteers. methods: healthy male volunteers (n= ) were recruited. the participants had their postural sway assessed on a pressure sensitive board, and measurement of maximal inspiratory pressure (mip). ultrasounds were taken assessing thickness of the quadriceps and rectus abdominis. they performed minutes of supine passive cycling, with fes supplying the lower limbs and abdomen. after a minute rest, the tests were repeated. a further participants performed just the initial baseline tests, to help assess muscular factors affecting balance and sway. results: the current needed for palpable contraction was significantly correlated to weight in the abdomen (r= . , p< . ) and quadriceps (r= . , p< . ). current required to stimulate the abdominal muscles was also correlated to depth of the subcutaneous fat layer (r= . , p< . ) and echogenicity of the muscle (r= . , p= . ). pre-cycling, left and right vastus lateralis thickness inversely correlated to postural sway in the antero-posterior (r=- . , p< . ) plane. compared to pre-cycling, postural sway in the antero-posterior and lateral planes increased significantly after cycling. there was a significant decrease in mip after cycling and greater reductions in mip were found in participants who had thinner rectus abdomni. conclusions: sway at baseline is related to quadriceps thickness, which atrophies during critical illness, and could worsen balance. mip is reduced during fes and the severity of reduction is related to the thickness of the abdominal wall muscles at baseline, suggesting that fes can fatigue the diaphragm and abdominal muscles. in awake healthy volunteers, fes is a safe, comfortable technique. introduction: in most cases postoperative cognitive dysfunction (pocd) is transient, but still some patients suffer from persistent cognitive impairment which is associated with increased length of hospital stay, early withdrawal from labor market and higher mortality. available data on the prevalence of pocd after cardiac surgery is very diverse from % to % upon discharge and up % months after surgery. we aimed to investigate the prevalence of short-term and long-term pocd after off-pump coronary artery bypass grafting (cabg) surgery. methods: psychometric testing was performed in (mean age . ± . ) patients before, days and months after the surgery. we used following tests to assess cognitive capacity: auditory verbal learning test (avlt), digit span test (dst), digit-letter substitution test (dlst), stroop's test and trail making test (tmt). a decline in comparison to preoperative test results for % or more in two or more tests was declared as pocd. results: the prevalence of pocd after days was . % ( patients) and . % ( patients) after months. when comparing patients who developed pocd with those who did not we found the former were older ( . ± . vs . ± . years; p< . ), had lower education level ( . ± . vs . ± . years; p< . ) and had longer surgery duration ( . ± . vs . ± . minutes; p< . ). the most affected cognitive domains were long term memory (avlt) and executive function (tmt) and least affectedworking memory (dst) and selective attention (stroop's test). conclusions: in our prospective study the prevalence of long-term pocd after cardiac surgery was slightly less ( . %) in comparison to available data (from % to %). it might be due differences in psychometric testing and interpretation of its results among authors. advanced age, low cognitive reserve and long duration surgeries are linked with higher incidences of pocd. introduction: postoperative cognitive dysfunction (pocd) is a common and widely described phenomenon in surgical patients. advanced age, major surgery, certain general anesthetics, genetic factors, sleep deprivation and other factors were described as contributing factors to pocd. the hospital stay itself is a major 'social' trauma for patients; social isolation, sleep deprivation and changes in daily regimen may effect neurocognitive behavior of patients. in this trial we tried to assess the link between pocd and the length of hospital stay in cardiac surgery patients. methods: patients who underwent 'off-pump' coronary artery bypass grafting (cabg) surgery selected for this trial. neuropsychological testing was performed prior to the operation and upon discharge. we used auditory verbal learning test (avlt), digit span test (dst), digit-letter substitution test (dlst), stroop test and trail making test (tmt). a % or more decline in two or more tests in comparison to preoperative test results was declared as pocd. patients were allocated into two groups according to the length of hospital stay: the short-stay group (group ) included patients (n= ) who were discharged on the th day after surgery or earlier and the long-stay (group ) group consisted of patients (n= ) who were discharged on the th day after surgery or later. patients received similar anesthesia, postoperative care and were operated by the same surgical team. reasons for prolonged duration of hospital stay were mainly surgical. results: patients ( . %) in group and patients ( . %) in group had pocd upon discharge (p< . ). mean length of hospital stay were ± . and ± . days in group and group patients respectively (p< . ). conclusions: prolonged length of hospital stay increased the prevalence of pocd in our trial. studies with various types of surgical procedures and larger patient populations needed to further understand the effect of length of hospital stay to pocd. the influence of multiple trauma with head trauma on posttraumatic meningitis: a nation-wide study with hospital-based trauma registry in japan introduction: posttraumatic meningitis is one of severe complications and results in increased mortality and longer hospital stay among head trauma patients. however, it remains unclear whether there is a difference in the incidence of post-traumatic meningitis due to single traumatic brain injury (tbi) and multiple trauma including head injury. methods: this study was a retrospective observational study during years we included trauma patients registered in japanese trauma data bank whose head ais score was > in this study. multivariable logistic regression analysis was used to assess potential factors associated with posttraumatic meningitis such as csf fistula, skull base fracture, type of injury that divided into single tbi and multiple trauma. introduction: the aim of this study was to determine if regional cerebral oxygenation (rsco ) can be used as an indicator of tissue perfusion in icu patients with tbi [ , ] , and to determine the prognostic value of cerebral oxygenation rsco in survival prediction. methods: patients were enrolled retrospectively from january through july in the icu of derince kocaeli training hospital. patients with trauma patients and traumatic braine injury patients who were admitted to the icu from the emergency room were included in the study. the sedation levels of the patients were followed up with bis. the rsco , bis was taken as well as blood lactate level, mean arterial blood pressure and cardiac output at baseline time, , , , and hours. results: no significant difference was also detected between the value of rsco in all patients . it was average sco (right) . ± . and average rsco (left) . ± . . conclusions: cerebral regional oxygen saturation might be helpful as one of the perfusion parameters in patients with tbi but it could have no prognostic value in mortality prediction. however, further studies with larger sample size are still needed to validate these results. introduction: tbi in elderly is an increasingly cause of admission in icu. data regarding management and prognosis of these patients are lacking. validated prognostic models refer to younger patients and do not adequately consider the influence of pre-injury functional status, which often compromises with aging. frailty has been defined as a state age-related of increased vulnerability and decline in autonomy of daily life activity. aim of the study is to evaluate the impact of frailty on outcome in tbi elderly patients. methods: moderate and severe tbi patients > years, admitted in neuroicu from january to may , were prospectively enrolled. data of age, comorbidity, glasgow coma scale (gcs), pupils' reactivity, ct scan characteristics, neurosurgical intervention and gose (extended glasgow outcome scale) at -months were collected. frailty status was measured by clinical frailty scale (cfs) [ ] and patients were divided as frail (cfs> ) and not frail (cfs< ). bad outcome was defined as gose< . results: ( %) of the studied patients were frail. frailty was not related to age. frail patients had more comorbidities and worse pupils' reactivity at admission (table ) . other variables did not differ between groups. in univariate analysis neurological diseases, gcs, tsah (traumatic subarachnoid haemorrhage), compressed/absent basal cisterns, non-reactive pupils and cfs were significantly associated to bad outcome. in multivariate analysis only gcs and cfs remained associated to bad outcome ( table ) . conclusions: pre-injury frailty is strongly associated to outcome in tbi elderly patients. the age of the patients was . ± . years. patients were operated on for intracranial traumatic ( cases) and non-traumatic hematomas ( ), brain tumors ( ) and the need for plastic of postoperative skull defects ( ). general endotracheal total intravenous anesthesia with fentanyl, propofol, rocuronium, or tracrium was used. after tracheal intubation, - nerves were blocked (e.g., supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, great auricular, greater and lesser occipital nerves), depending on the surgical site. . - . % ropivacaine was used. for blockade of one nerve used . - . ml of local anesthetic. fentanyl was applied on section of a periosteum, dura matter and at inefficiency of blockade of nerves. anesthesiology monitoring included hr, ecg, spo , nib, respiratory parameters, eeg (csi), body temperature, blood glucose and lactate levels. in and - hours post-surgery, the intensity of pain was ranked by alert patients using vas. results: the volume of local anesthetic for blockade in one patient was . ± . ml. in ( . %) from patients, an additional fentanyl injection was required to skin incision due to an increase in blood pressure and heart rate by % of the baseline values, and an increase in csi until un. patients available to productive contact in hours post-surgery ranked the pain by vas at ( ; ) point, and in - hours post-surgery ranked it at ( ; ) p. conclusions: at patients with craniotomies scalpe-block with lowvolumes of a ropivacaine showed high efficiency ( . %). were transferred to hospital ward or ( . %) to the center of intensive nursing care; ( . %) went to the surgical recovery room. acute renal failure, hypernatremia and hyperphosphatemia were independent predictors of mortality as described in table . conclusions: hypernatremia and hyperphosphatemia were independent predictors of mortality in critically ill patients. introduction: the strong ion difference (sid) is essential for the assessment of acid-base equilibrium, thus requiring an accurate measurement of plasma electrolytes. currently there is no gold standard for electrolyte measurements and sid computation. differences in electrolyte values obtained with point-of-care (poc) and central laboratory (lab) analyzers have been reported [ , ] . in previous studies [ , ] we have shown that changes in pco induce electrolyte shifts from red blood cells to plasma (and vice versa), yielding variations in sid. aim of the present in-vitro study was to induce sid changes through acute changes in pco and compare values of electrolytes and sid obtained with poc and lab techniques. methods: blood samples from healthy volunteers were tonometered (equilibrator, rna medical) with gas mixtures at fractions of co (fco ) of , , and %. electrolytes were measured quasisimultaneously with a poc analyzer (abl flex, radiometer) and a routine lab method (cobas ise, roche). for both techniques a simplified sid was computed as sodium + potassiumchloride. results: bland-altman analysis of sid calculated with poc and lab showed a proportional bias (slope = . , r = . , p < . ), indicating a variable agreement between methods according to the average sid value (fig. ) . sid values measured with poc and lab at different fco differed significantly (p< . , fig. ) . a similar discrepancy was observed for chloride (p < . , fig. ), while sodium (p= . ) and potassium (p= . ) were similar. conclusions: sid measured with poc and lab differed significantly, mainly due to a variable discrepancy in chloride. our findings suggest that our poc analyzer is superior to the lab in measuring electrolytes and thus compute sid. introduction: this study evaluated the safety of half dose insulin (hdi) versus standard dose insulin (sdi) for the treatment of hyperkalemia in a medical intensive care unit (micu) population with renal insufficiency. recent emergency medicine data demonstrated a lower incidence of hypoglycemia in patients with renal insufficiency when hdi was used for the treatment of hyperkalemia [ ] . there is limited data describing the safety of hdi in a micu population with renal insufficiency. methods: this was a retrospective, chart review of patients admitted to the micu with a diagnosis of aki and/or ckd stage - with a serum potassium ≥ . meq/l from january to september . sdi is defined as units of regular iv insulin and hdi as units. the primary outcome was the incidence of hypoglycemia within hours of insulin administration. secondary outcomes included severe hypoglycemia and change of serum potassium after insulin administration. results: a total of patients were screened and were included for analysis. the incidence of hypoglycemia occurred in / patients ( . %) and / patients ( . %) who received sdi and hdi, respectively. one patient in the sdi group and two patients in the hdi group developed severe hypoglycemia. the mean decrease in serum potassium after insulin administration was . meq/l in both groups. patients in the hdi group who were re-dosed with units of regular insulin did not have any hypoglycemic events. conclusions: in a micu population with renal insufficiency, sdi and hdi regimens appear safe and effective for the treatment of hyperkalemia. introduction: sepsis and septic shock are common causes of admission in the intensive care unit with a high mortality rate [ , ] . hence, electrolyte disturbances are common in this group of patients. acute hypernatremia is one of the multiple features of homeostasis disturbances and available data in the literature suggest that its incidence can reach % [ , ] . (fig , ) . the main source of sepsis was pneumonia with affected patients ( . %). conclusions: hypernatremia is significantly associated with higher mortality in septic patients. (abstract p ) . the outcome versus the sodium levels higher in the group - % vs . % (p= . ). there were no significant differences between the groups in length of stay in the icu. in group , there was an increase of serum phosphorus level and in the group the tendency to decrease. however, statistically significant differences were obtained only on the nd day after surgery . ± . mmol/l (group ) vs . ± . mmol/l (group ) (p= . ). the roc curve was constructed to assess the predictive significance of serum phosphorus levels (fig. ) . auc was . ; % ci . - . ; p= . ; sensitivity . %, specificity . %. the kaplan-meier survival analysis (fig. ) introduction: the rate of extubation failure might be higher in obese patients than in non-obese patients. effect of obesity on mortality is controversial [ , ] (obesity paradox). several pathophysiological changes contribute to an increase of respiratory complications [ ] . we sought to identify incidence of extubation failure in obese and non-obese patients. methods: the primary endpoint of this post-hoc analysis of a prospective, observational, multicenter study [ ] performed in intensive care units was extubation failure, defined as the need for reintubation within hours following extubation. only patients with body mass index (bmi) recorded were included. results: between december , and may , , among the patients with bmi available undergoing extubation, obese patients ( %) and non-obese patients ( %) were enrolled. extubation-failure rate was . % ( / ) in obese patients, and . % ( / ) in non-obese patients (p= . ). delay of reintubation did not differ between obese and nonobese patients (figure ). length of intubation > days was significantly more frequent in obese patients ( / , %) than in non-obese patients ( / , %, p< . ). precautions to anticipate extubation failure were more often taken in obese patients ( / , %) than in non-obese patients ( / , %, p< . ). spontaneous breathing trial (sbt) characteristics differed between obese and non-obese patients (table ) . physiotherapy was more often used in obese patients ( / , %) than in non-obese patients ( / , %, p= . ). conclusions: incidence of extubation failure did not differ between obese and non-obese patients. in obese patients, clinicians anticipate more a possible extubation failure, delaying the moment of extubation, performing more physiotherapy and providing an optimal sbt. introduction: in the acute phase of critical illness, growth hormone (gh) resistance develops, reflected by increased gh and decreased insulin-like growth factor-i (igf-i), mimicking fasting in health. the epanic rct observed fewer complications such as muscle weakness and faster recovery with accepting a macronutrient deficit in the first icu week, as compared with early full feeding [ , ] . we characterized its impact on the gh axis in relation to the risk of acquiring muscle weakness. methods: in this epanic rct sub-analysis, for matched patients per group, and all patients assessed for muscle weakness (n= ), serum gh, igf-i, igf binding protein (igfbp ) and igfbp were measured upon icu admission and at day or the last icu day for patients with shorter icu stay (d /ld). for matched patients per group, gh was quantified every min between pm and am, and deconvolved to estimate gh secretion. groups were compared with wilcoxon test or repeated-measures anova. associations between changes from baseline to d /ld and muscle weakness were assessed with logistic regression analysis, adjusted for baseline risk factors, baseline hormone concentrations and randomization. results: in the fully fed group gh, igf-i and igfbp increased, whereas igfbp decreased from admission to d /ld (all p< . ). accepting an early macronutrient deficit prevented the rise in gh and igf-i and the decrease in igfbp (all p< . ) but did not affect igfbp , whereas basal, but not pulsatile, gh secretion was lowered (p= . ). a stronger rise in gh and igf-i was independently associated with a lower risk of acquiring muscle weakness (or ( %ci) per ng/ml change . ( . - . ) for gh; . ( . - . ) for igf-i). conclusions: accepting an early macronutrient deficit suppressed basal gh secretion and reduced igf-i bioavailability during critical illness, which may counteract its protection against muscle weakness. introduction: aim of the study was to relate hypokalemia (hypok) and hypoglycemia as diabetic ketoacidosis (dka) treatment complications and precocious insulin interruption also use of sodium bicarbonate with length of stay (los) in intensive care unit (icu). methods: analysis of retrospective cohort study data of patient (pt) treated for dka at icu of hospital kaunas clinics of lithuanian university of health sciences during - has been carried out. serum kalemia, glycaemia; rate of episodes of hypok, hypoglycaemia and precocious insulin interruption; use of sodium bicarbonate, in relation with los in icu were analysed. spss . was used for statistic calculations. traits evaluated as significant at p< . . results: at the beginning of dka treatment hypok ( . ± . mmol/l) was recorded in / ( %) pt. due to disregarding of blood ph ( . - . ( . ± . ) kalemia was falsely misinterpreted as "normo-" or "hyperkalemia" . - . ( . ± . mmol/l) in of ( %) pt, as normo-and hyperkalemia thus not treated and complicated by hypok additionally in / ( %) pt. in hypok los in icu was . ± . vs . ± . h, p< . . insulin use has caused hypoglycaemia ( . - . ( . ± . mmol/l)) in / ( %) pt, los in icu . ± . vs . ± . h, p< . . insulin use was interrupted in case of normo -and hypoglycaemia with still persisting ketoacidosis in / ( %) pt, los in icu was found to be . ± . vs . ± . h, p< . . sodium bicarbonate was given for symptomatic treatment of acidosis during the first h of dka in / ( %) pt with stable hemodynamic: hco buffer has increased ( . ± . - . ± . mmol/l), p< . , but ketoacidosis has still persisted, los in icu was . ± . vs . ± . h, p< . . conclusions: hypok ( %), hypoglycemia ( %), precocious interruption of insulin use ( %) have prolonged los in icu almost twice. symptomatic treatment of ketoacidosis with sodium bicarbonate ( / pt) didn't control it and has prolonged los in icu. introduction: cystathionine-γ -lyase (cse), a regulator of glucocorticoid (gc)-induced gluconeogenesis [ ] , correlates with endogenous glucose production in septic shock [ ] . the hyperglycemic stress response to noradrenaline (noa) is mediated by the kidney [ ] and less pronounced with low cse [ ] . gc receptor (gr)-mediated gene expression is differentially regulated: the gr monomer is considered to repress inflammation, and gc side effects are attributed to the gr dimer; recent reports challenge this view [ ] . gc-induced gluconeogenic gene expression is reduced in gr dimerization deficient (grdim) mice [ ] . the aim of this study is to investigate renal cse expression and systemic metabolism in grdim and grwt mice in a resuscitated model of lps-induced endotoxic shock. methods: anesthetized grdim (n= ) and grwt (n= ) mice were surgically instrumented, monitored, resuscitated and challenged with lps. noa was administered to maintain map and c glucose was continuously infused. h after lps, cse expression was determined via immunohistochemistry of formalin-fixed paraffin sections (n= p.gr.). results: grdim required . -fold more noa than grwt and had . fold higher glucose and . -fold higher lactate h after lps. this was concomitant with elevated endogenous glucose production ( -fold), % lower glucose oxidation and . -fold higher renal cse expression in grdim. conclusions: increased cse expression together with higher glucose production (confirming [ , ] ) and glucose levels in grdim mice suggest an association that may link cse to gc signaling. the higher noa administration in grdim mice could contribute to these effects. introduction: to achieve safe glycemic control in critically ill patients frequent blood glucose (bg) measurements and according titration of insulin infusion rates are required. automated systems can help to reduce increased workload associated with diabetes management. this bi-centric pilot study combined for the first time an intraarterial glucose sensor with a decision support system for insulin dosing (sgcplus system) in critically ill patients with hyperglycemia. methods: twenty-two patients ( females, males, with preexisting diabetes mellitus, age . ± . years, bmi . ± . kg/ m , creatinine level . ± . mg/dl, saps (simplified acute physiology score) . ± . , tiss- (therapeutic intervention scoring system) . ± . who were equipped with an arterial line and required iv insulin therapy were managed by the sgcplus system during their medical treatment at the intensive care unit. results: sgcplus-based bg determinations were performed and . ± . sensor calibrations per day were required. sensor glucose readings correlated well with reference bg (figure ). mean treatment duration was . ± . days. time to target was ± min ( - mg/dl) and ± min ( - mg/dl). mean blood glucose was ± mg/dl with seven blood glucose values < mg/dl. mean daily insulin dose was ± u and mean daily carbohydrate intake ± g /day (enteral nutrition) and ± g/day (parenteral nutrition). acceptance of sgcplus suggestions was high (> %). the novel intraarterial glucose sensor demonstrated to be highly accurate. the sgcplus system can be safely applied in critically ill patients with hyperglycemia and enables good glycemic control. introduction: we aimed to assess the effect of frailty as assessed by clinical frailty scale (cfs) and karnofsky performance score (kps) on critical care (cc) and hospital mortality in this group at a nonspecialist tertiary critical care unit. methods: patients admitted to critical care were identified from our electronic database by screening for liver disease or cirrhosis in the admission diagnoses. those with an aetiology of liver disease other than alcoholic liver disease (ald) were excluded. data was collected on patient demographics, length of stay, status at discharge from critical care and hospital and cfs. kps was also calculated where sufficient in-formation was available in the medical record. data was analysed using logistic regression multivariate analysis with stata software. [ ] . results: tg diagnosis criteria and severity grading criteria for acute cholangitis and acute cholecystitis were judged from numerous validation studies as useful indicators in clinical practice and adopted as tg diagnostic criteria and severity grading without any modification. provide initial treatment, such as sufficient fluid replacement, electrolyte compensation, and intravenous administration of analgesics and full-dose antimicrobial agents, as soon as a diagnosis has been made. in new flowchart for the treatment of acute cholecystitis (ac) in the tg , grade iii ac was indicated for gallbladder drainage, but some grade iii ac can be treated by laparoscopic cholecystectomy (lap-c) at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. we also redefine the management bundles for acute cholangitis and cholecystitis. introduction: c-acetate breath tests provide a non-invasive assessment of gastric emptying [ ] and could, hence, be used to judge tolerance to enteral nutrition. result values like t (time for % absorption) correlate with scintigraphic measurements. the data evaluation is based on model equations like the β -exponential function (bex) [ ] . it considers a mono-phasic breath gas response. this may not be the case during critical illness, which could reduce precision too low for a reliable personalized assessment [ ] . methods: we recently developed an evaluation of irregular gastric emptying patterns, which separates absorption from post-absorptive distribution and retention of tracer and from the terminal respiratory release of the oxidized tracer [ ] . using breath test data of icu patients (mean saps +/- ) the precision of this approach was compared with a bex analysis to explore how often an extended analysis is warranted and whether it improves the reliability of estimates. results: patients had a release profile consisting of series of peaks with a periodicity of - min. a first dominant peak carries about % of the released moiety, as reported [ ] for controls. for these patients the precision in t for the bex approach was +/- % of that observed for the new approach. for the other patients, the secondary peaks had a similar periodicity but were more pronounced, indicating persisting peristaltis, which has been linked to tolerance to enteral nutrition [ ] . the bex approach achieved a precision of +/- % relative to the new one, challenging its applicability for these patients. introduction: clinical scoring systems used to prognosticate the severity of acute pancreatitis (ap), such as apache ii, are cumbersome and usually require hours or more after presentation to become accurate, at which time the window for early therapeutic intervention has likely passed. sirs at presentation is sensitive but poorly specific for severe ap. we postulated that sirs and accompanying hypoxemia would specify at presentation patients with ap who have severe inflammation and are at risk for clinically severe disease. methods: patients with ap who had sirs and hypoxemia at presentation were enrolled in an open-label study evaluating the safety and efficacy of cm -ie, a calcium release-activated calcium (crac) channel inhibitor (nct ). hypoxemia was defined as an estimated pao < mm hg calculated using a log-linear equation and the spo on room air at the time of presentation. a contrastenhanced computed tomography (cect) was performed at presentation and a cbc with differential, d-dimer and crp were analyzed daily. the cect was read by a blinded central reader who assessed the degree of inflammation using the balthazar scoring system (table ) . results: patients, seven men and six women, have been randomized in the study. the mean estimated pao at presentation was mm hg. patients had sirs criteria present and the other patients had sirs criteria present. the median value for age was . (iqr - ), initial neutrophil-lymphocyte ratio (nlr) . ( . introduction: to investigate whether circulating immune profiles were able to serve as early biomarkers in predicting persistent organ failure (pof methods: thirty-nine patients with predicted severe acute pancreatitis (psap) and healthy control subjects were prospectively enrolled in our study. we measured the expression of monocytic human leukocyte antigen-dr (mhla-dr), the proportions of dendritic cells (dc) and its subtypes (including myeloid dendritic cell (mdc) and plasmacytoid dendritic cell (pdc)), the different cytokineproducing cd + t helper (th) cells and regular t (treg) cells. plasma crp and several inflammatory mediators levels were measured by elisa. results: compared with healthy controls, there is a significant decrease in the expression of mhla-dr, the frequencies of total circulating dcs and its subsets, and percentage of th cells in patients with psap. however, we found significantly higher frequencies of th cells, higher proportion of treg cells than healthy subjects. of interest, we observed that there was a significant decrease in the positive percentage and mean fluorescence intensity (mfi) of mhla-dr, the proportions of total dcs and pdc, and th cells in patients with pof compared with transient organ failure (tof). besides, there is a significantly higher frequency of th cells in pof than those in tof. area under the receiver-operating characteristic curve analysis showed that disease severity scores had a moderate discriminative power for predicting pof in patients with psap. more importantly, the expression of mhla-dr and the percentage of dcs and pdc had a significantly higher auroc and thus, better predictive ability than disease severity in patients with psap. conclusions: circulating immune profile show multiple aberrations in patients with psap who have developed pof. both the expression of mhla-dr and the percentage of total dc and pdc may be early good biomarkers for predicting risk of pof in patients with psap. introduction: pancreatic fistula (popf) due to anastomosis insufficiency is a common ( - %) complication after pancreaticoduodenectomy and often discovered with delay, causing severe morbidity, icu stay and deaths. microdialysis (md) catheters have been shown to detect inflammation and ischemia in several postoperative conditions and organs. the aim was to investigate if md catheter monitoring could facilitate earlier detection of popf than current standard of care. methods: in a prospective, observational study patients ( to years) were investigated. a md catheter was fixed to the pancreaticojejunal anastomosis. samples for analysis of glucose, lactate, pyruvate and glycerol were acquired hourly during the first hours, then every - hours to discharge. popf was defined according to the international study group of pancreatic fistula update definition. results: patients who developed popf (n= ) had significantly higher glycerol levels (p< . ) in microdialysate than did patients without popf (n= ) during the first h. thereafter, the difference diminished. a glycerol concentration > μmol/l during the first h detected patients who later developed popf with a sensitivity of % and a specificity of %. lactate and lactate to pyruvate ratio were significantly higher (p< . ) and glucose was significantly lower (p< . ) in patients with popf from about h. fig. shows microdialysis measurements in patients with (red lines) and without (blue lines) popf. conclusions: a high level of glycerol in microdialysate is an early (first hours) indicator of popf. glucose, lactate and lactate to pyruvate ratio are indicators of peritonitis caused by the leakage. thus, md monitoring detects popf several days earlier than current methods and may play an important clinical tool in the future. we are currently conducting a rct to explore if md monitoring will improve prognosis in these patients the phenomenon of total impaired of metabolic activity of gut microbiota in critically ill septic patients introduction: during a critical condition, dramatic disturbances occur not only in the change of species diversity, but in gut microbiota metabolism as well, that might lead to nonreversible breakdowns of host homeostasis and death [ ] . metabolic activity of microbes can be assessed by the measurement of the levels of aromatic microbial metabolite (amm) in blood serum, which are associated with the severity and mortality of icu patients. critically ill patients are characterized by the totally different sfs profile than in healthy people, particularly by the absence of phpa; but dominated by p-hphaa and p-hphla [ ] . the purpose of our study is to assess the gut metabolic activity via amm in sepsis. methods: in this study simultaneously serum and fecal samples (sfs) were taken from icu patients: -with sepsis, -chronic critical ill (cci) patients and control - sfs from healthy people. after liquid-liquid extraction from serum and fecal samples, phenylcarboxylic acids (amm) were measured using gc/ms (thermo scientific). results: the sum of the level of most relevant amm in serum samples were higher in patients with sepsis (median - . μm) than in cci patients ( . μm) and healthy people ( . μm). at the same time the opposite pattern was observed in the fecal samples - . , . and . μm, respectively. the ratios of sums amm gut/serum were higher in healthy people than icu patients (fig. ) introduction: the aim of this study is to describe the characteristic of bioelectric impedance vector analysis (biva) and muscular ultrasound during the first week after admission in the icu, and their correlation with indices of metabolic support. biva is a commonly used approach for body composition measurements [ ] . muscular ultrasound represents a valid tool to provide qualitative and quantitative details about muscle disease [ ] . methods: consecutive patients admitted to icu and expected to require mechanical ventilation for at least hours were enrolled in the study. within the first hours of icu admission (t ), patients were evaluated with muscular ultrasonography comprehensive of diaphragm thickness (dth) and rectus femoris cross-sectional area (csa). at the same time, biva and biochemical analysis. all the same measures were repeated at day (t ) and (t ) (figure (table ) . dividing the patients in two groups based on prealbumine changes (t vs t : increase, anabolic vs decrease, catabolic), those in which prealbumine increased had a higher reduction in muscle mass ( figure ). conclusions: this study showed how the pa tends to be reduced in the first week of icu stay. it is correlated with a concomitant introduction: the modified nutrition risk in critically ill (mnutric) has been developed in order to identify critically ill patients who may receive benefit from nutrition support [ ] . several evidences showed the association between the mnutric score and clinical outcomes [ , ] , however there are no data in thai critically ill patients. the purpose of this study was to find the association between mnu-tric score and -day mortality in medical intensive care unit (icu) patients, ramathibodi hospital. methods: we retrospectively reviewed the medical patient records from june to january . a mnutric score of each patient was calculated to evaluate the risk of malnutrition. statistical analysis of the association between mnutric score and -day mortality, length of stay in icu and hospital were performed. results: a total of critically ill patients were included in the study. the -day mortality was . % in patients with high mnutric score ( - ) and . % in patients with low mnutric score ( - ). modified nutric score was significantly correlated with day mortality (r = . , p< . ), length of stay in icu (r = . , p< . ) and length of stay in hospital(r = . , p< . ). in the receiver operating characteristic (roc) curve analysis, the auc of mnutric score and -day mortality was . ( % confidence interval (ci), . - . ) (fig ) . optimal cut-off value of showed sensitivity of . % and specificity of . % in mortality prediction (youden's index, . ). additionally, patients who received adequate nutrition supplement within days was . % for calorie and . % for protein. there was no association between nutrition support and -day mortality. conclusions: in thai medical intensive care population, the mnutric score was associated with -day mortality in critically ill patients. fig. (abstract p ) . within the first hours of icu admission (t ), patients will be evaluated with muscular ultrasonography comprehensive of diaphragm thickness and rectus femoris (medial vastus) cross-sectional area. at the same time, anthropometric measure will be collected (such as body height, ideal body weight, real body weight declared, right arm circumference) as well as biva measure (xc, r, pa, lean body weight and % of extracellular body weight) and biochemical analysis (inclusive albumin, pre-albumin, blood count, lymphocyte count, magnesium, phosphorus, reticulocytes, renal and hepatic function test). the day after, the fluid balance will be calculated as well as the nitrogen balance. all the same measures will be repeated at day (t ) and days (t ) introduction: ultrasonography is an essential imaging modality in critical care to diagnose and guide for therapeutic management of shock, multiple organ failure, etc. enteral tube feed intolerance occurs frequently in hospitalized patients and more so in critically ill patients. in present study, we consider that nursing staff may be able to use bedside ultrasound as an alternative to standard aspiration protocol or radiographic studies to assess gastric volume and nasogastric (ng) tube in patients with enteral feed intolerance. methods: in present prospective, single-center study, we performed ultrasound residual stomach volume and ng tube placement assessments of adult critically ill patients (figure ) compared to standard protocol of stomach volume assessment (routine daily shift -ml syringe aspirations) and ng (nasogastric) tube placement verified by abdominal x ray. we used an abdominal (linear ultrasound transducer) probe ( - mhz). the residual volume was calculated according to formula: gv (ml) = + . x right-lateral csa- . x age). results: hundred simultaneous double (ten critically ill patients) ultrasound measurements sessions were performed by nursing staff of our intensive care (icu) (fig ) . double simultaneous measurements of the ultrasound assessments were compared to standard nurse icu protocol for assessment of residual volume of stomach. the new ultrasound assessment method demonstrated excellent intra-class reliability (icc- . ( . - . , p< . ) and strong correlation with standard residual volume assessment method (icc- . ( . - . , p< . ). ng tube placement was successfully verified by ultrasound measurements in all ten critically ill patients and, thereafter, confirmed by abdominal x-rays. conclusions: preliminary results of our study demonstrated good correlations between both methods of ng tube placement and residual stomach volume: standard icu nurse protocol and ultrasound assessment. evaluating the documentation of nasogastric tube insertion and adherence to safety checking l roberts introduction: enteral feeding into a misplaced nasogastric (ng) tube is recognised by the national patient safety agency as a never event. ng tubes are commonly indicated in level / patients, thus we set out to evaluate current practice in critical care. the aim was to evaluate: documentation of insertion, adherence to safety guidance pertaining to checking safe use, chest x-ray interpretation. methods: this prospective cohort study was based on inpatients in critical care who had insertion of ng tubes over four weeks; there were insertions. data was analysed from patients' medical notes and the hospital's imaging system. results: % of insertions were documented using proformas. . % of proforma documentations included or more details: type of tube, tube length at the nostril, nex measurement, aspirate adequacy, chest x-ray adequacy, whether it was safe to feed. only . % of hand-written documentations included or more details. % of initial aspirates were obtained on insertion, of these, % had an appropriate ph between and . . this led to % of patients having chest x-rays to confirm initial placement of the ng tube. only % of chest x-rays adequately satisfied the four criteria. written documentation in medical notes stating if it was safe to feed was completed in % of cases. conclusions: we found that proformas ensure a higher level of detail and uniformity in the documentation of ng tube insertions. there was a high incidence of chest x-rays performed to confirm correct placement of tubes due to difficulties in obtaining aspirates and failure to follow guidelines. a need for a uniform, ward-specific proforma on ng tube insertion has been identified, as well as a teaching session on chest x-ray interpretation and on techniques to aid obtaining aspirates. we have established critical care's shortcomings in ng tube insertion documentation and tube safety checking. introduction: pressure ulcers(pu) are considered as important types of public health problems, due to high mortality and cost. we aimed to investigate the efficiency of curcumin and fish oil on prevention and treatment of pu using a feasible mice model. methods: mice were randomly divided into control(group ), curcumin(group ), fish oil(group ), curcumin and fish oil(group ) groups. mm skin bridge between two gauss magnets was formed on the back of mice, followed by ischemia reperfusion cycles as hours of rest after hours of magnet placement [ ] . a single dose of curcumin and fish oil was injected intraperitoneally. tissue samples had taken th day of first compression, rates of pu, inflammation, reepithelisation, neovascularisation and granulation were examined histopathologically. the data analyzed by pearson chi-square test. results: third degree pu were observed in all groups.there was no significant difference between groups in terms of inflammation.the formation of reepithelisation showed a significant difference between groups.partial reepithelisation ratios in group and group was elevated.there was significant difference between groups in terms of neovascularisation, the highest rate as % was observed in group .formation of granulation was observed at maximum rate as . % at group . conclusions: depending on positive results of curcumin, fish oil, cur-cumin+fish oil on wound healing it may be advised to use them in treatment of acute pu.after similar rate of pu with control group we consider that it should be beneficial to evaluate the effect of these therapies with more studies by changing the mode of administration, time of initiation and duration of therapy. introduction: inflammation is a key driver of malnutrition during acute illness and has different metabolic effects including insulin resistance and reduction of appetite. whether inflammation influences the response to nutritional therapy in patients with disease-related malnutrition remains undefined. we examined whether the effect of nutritional support on the risk of mortality differs based on the inflammatory status of patients. methods: this is a secondary analysis of a multicentre trial in eight swiss hospitals, where patients with a nutritional risk score (nrs) of ≥ upon hospital admission were randomly assigned to receive protocol-guided individualized nutritional support according to nutrition guidelines (intervention group) or a control group. the inflammatory status was defined based on admission crp levels as low inflammation (cpr < mg/dl), moderate inflammation (crp - mg/dl) and high inflammation (crp > mg/dl). results: we included a total of , patients of which . %, . % and . % had low, moderate and high inflammation levels on admission. while overall there was a significant reduction in day mortality associated with nutritional support (adjusted or in the overall cohort . , %ci . - . ), the subgroup of patients with high inflammation did not show reduced mortality (adjusted or . , %ci . - . , p for interaction = . ). there was no difference in other secondary endpoints when stratified based on inflammation. nutritional support did not affect crp levels over time (kinetics). conclusions: this secondary analysis of a multicentre randomized trial provides evidence, that the inflammatory status of patients influences their response to nutritional support. these findings may help to better individualize nutritional therapy based on patients initial presentation. introduction: low plasma glutamine levels have been associated with unfavourable outcomes in critically ill patients. this study aimed to measure plasma glutamine levels in critically ill patients and to correlate glutamine levels with biomarkers and severity of illness. methods: we enrolled critically ill patients admitted to three icus in south africa, excluding those receiving glutamine supplementation prior to admission. we collected clinical, biochemical and dietary data. plasma glutamine levels were determined within hours of admission, using liquid chromatography mass spectrometry and categorized as low (< μmol/l), normal ( - μmol/l) and high (> μmol/l). results: of the patients (average age . ± . years, % male), % were mechanically ventilated, with a mean apache ii score of . ± . and a mean sofa score of . ± . . plasma glutamine levels were low in . % (median plasma glutamine of . μmol/l). baseline plasma glutamine correlated inversely with crp (r=- . , p< . ) and serum urea (r=- . , p< . ), and positively with serum bilirubin (r= . , p< . ) and serum alt (r= . , p= . ). significantly more patients with low admission glutamine levels required mechanical ventilation (chi = . , p< . ) and had higher apache scores (p= . ), higher sofa scores (p= . ), higher crp values (p< . ), higher serum urea (p= . ), higher serum creatinine (p= . ), lower serum albumin (p< . ) and lower bilirubin levels (p= . ). using multiple logistic regression analysis, apache score (odds ratio, [or] . , p= . ), sofa score (or . , p= . ) and crp (or . , p< . ) were significant predictors of low plasma glutamine levels. roc curve analysis revealed a crp threshold value of . mg/l to be indicative of low plasma glutamine levels (auc . , p< . ). conclusions: . % of critically ill patients had low plasma glutamine levels on admission to icu. this was associated with increased disease severity and higher crp. introduction: the east of england deanery operational delivery network in the united kingdom came together as a group of intensive care units to comply an evidence-based care bundle. one of the branches of this care bundle is on parenteral nutrition and states: 'parenteral nutrition should not be given to adequately nourished, critically ill patients in the first seven days of an icu stay.' this is based on evidence [ ] [ ] [ ] that showed that 'in patients who are adequately nourished prior to icu admission, parental nutrition initiated within the first seven days has been associated with harm, or at best no benefit, in terms of survival and length of stay in icu.´the objective of this second cycle was to assess whether or not we are adhering to the guidelines, last year we were failing to hit targets and after some action i reassessed how we performed in the year compared to . methods: a retrospective audit of the whole year of for all patients admitted to icu who had parenteral nutrition started at any point during their stay. results: there is a significant improvement in the percentage of patients who are being started incorrectly on tpn before days ( % compared to %) (fig , ) . i also found a total reduction in the number of patients prescribed tpn, a reduction in the number of bags being used and a reduction in length of hospital stays. conclusions: as we have recently switched over to an electronic icu programme for all documentation and prescriptions, as part of our plan and act in the pdsa cycle we are organising for several things to be put in place on the new system on prescription: pharmacy authorisation, links to guidelines and alert/justification boxes. i will do a further cycle in another year. jg and mpc contributed equally. introduction: recent rcts revealed clinical benefit of early macronutrient restriction in critical illness, which may be explained by enhanced autophagy, an evolutionary conserved process for intracellular damage elimination [ ] . however, in the absence of specific and safe autophagy-activating drugs, enhancing autophagy through prolonged starvation may produce harmful side effects. a fasting-mimicking diet (fmd) may activate autophagy while avoiding harm of prolonged starvation, which also improved biomarkers of age-related diseases in an experimental study [ ] . we evaluated if short-term interruption of continuous feeding can induce a metabolic fasting response in prolonged critically ill patients. methods: in a randomized cross-over design, prolonged critically ill patients receiving artificial feeding were randomized to be fasted for hours, followed by hours full enteral and/or parenteral feeding, or vice versa. patients were included at day in icu and blood glucose was maintained in the normal range. at the start and after and hours, we quantified total bilirubin, urea, insulin-like growth factor-i (igf-i) and beta-hydroxybutyrate (boh) in arterial blood. insulin requirements were extracted from patient files. changes over time were analyzed by repeated-measures anova after square root transformation. results: as compared to hours of full feeding, hours of fasting decreased bilirubin (- . ± . mg/dl; p= . ) and igf-i (- . ± . ng/ml; p< . ), and increased boh (+ . ± . mmol/l; p< . ), without affecting urea concentrations (fig ) . fasting reduced insulin requirements (- . ± . iu/hour; p< . ). conclusions: short-term fasting induces a metabolic fasting response in prolonged critically ill patients, which provides perspectives for the design of a fmd, aimed at activating autophagy and ultimately at improving outcome of critically ill patients. introduction: recent evidence has led to changed feeding guidelines for critically ill patients, with a shift towards lower feeding targets during the acute phase [ ] . when micronutrients are not provided separately, prolonged hypocaloric feeding could induce micronutrient deficiencies and increase risk of refeeding syndrome once full feeding is restarted, which are both potentially lethal complications [ ] . since there is limited evidence how to optimize micronutrient provision in order to avoid deficiencies, we hypothesized that there is a great variation in current practice. methods: within the men section of the european society of intensive care medicine (esicm), we designed a questionnaire to gain insight in the current practice of micronutrient administration. in email blasts, invitations were sent to all esicm members, with currently more than respondents. the survey will be closed at december , . results: first, we will describe demographic characteristics of the respondents, including geographical location, icu and hospital type, and function. second, we will describe some aspects of the current practice of micronutrient administration. we will identify the proportion of respondents having a protocol, on which evidence such protocol is based and whether it takes into account the stability and daylight sensitivity of micronutrients. next, bearing refeeding syndrome in mind, we will identify whether there are respondents who never measure and/or separately administer micronutrients and phosphate. finally, we will make a top of the most measured and most supplemented micronutrients. conclusions: this survey will deliver more insight in the current practice of micronutrient provision across different types of icus and may identify areas for future research. furthermore, we will evaluate whether there is need to increase awareness for refeeding syndrome. introduction: large gastric residual volumes (grvs) have been used as surrogate markers of delayed gastric motility to define enteral feeding intolerance (efi). recent studies have challenged the definition of efi. study objectives: ) investigate the potential relationship between grvs and clinically outcomes, ) develop an algorithm for early identification of patients at increased risk of mortality due to efi. methods: a retrospective study of inpatient encounters from electronic health record charts within the dascena clinical database. , patients were included in the study; patients had efi. eight vital signs (diastolic/systolic bp, heart rate, temperature, respiratory rate, grv, glasgow coma scale, and feeding rate) and their trends were input to the classifier. machine learning classifiers were created using the xgboost gradient boosted tree method with -fold cross validation. results: rate of change in grv (Δ grv) was measured over a -day period, beginning at the time of efi onset (figure a) . figure b shows a high likelihood of mortality for patients with none or modest grv reduction. patients with an increase in grv over the five-day period after efi onset had the highest mortality likelihood. a stratification algorithm was developed to identify efi patients who died inhospital despite grv reduction at , , and hours in advance of efi onset. area under the receiver operating characteristic (auroc) curves demonstrated high sensitivity and specificity of algorithm predictions of in-hospital death up to hours in advance of efi onset (table ) . conclusions: the analysis suggests an association between grv and mortality, especially in patients with persistent grv increase over the -day period after efi onset and the potential of algorithmic models to predict efi development. prospective validation of these fig. (abstract p ) . changes in metabolic markers of fasting over time for both randomization groups algorithms may assist in clinical trial design to develop treatments for patients at highest risk of experiencing serious outcomes due to efi. a quality improvement project to improve the daily calorific target delivery via the enteral route in critically ill patients in a mixed surgical and medical intensive care unit (icu) b johnston, d long, r wenstone royal liverpool and broadgreen university hospital trust, critical care, liverpool, united kingdom critical care , (suppl ):p introduction: 'iatrogenic underfeeding' is widespread with the calo-ries study reporting only %- % of prescribed daily kcal was actually delivered to patients [ ] . in the present project, quality improvement methodology was utilised with the aim of delivering greater calories by implementing -hour volume-based feeding and allowing increased feeding rates for, 'catch up' of missed daily feed volume. methods: baseline data assessing the percentage of daily kcal delivered to ventilated patients was collected in september . data was presented and new intervention guidelines agreed based upon the pepup protocol [ ] . nurse champions were identified and were responsible for cascade training of the pepup protocol. educational tools to help determine daily calorific requirement and volume of feed required were provided. repeat data was collected at months (cycle ) after pepup implementation. results: ten patients were included in cycle . during cycle the percentage of kcal achieved via enteral feeding was %. following intervention this increased to % (p< . ) during cycle . this increased further to . % of daily kcal when calories obtained from propofol were included. conclusions: a -hour volume-based feeding regimen is a simple and cost-effective method of improving enteral feeding targets. through the use of quality improvement methodology, we demonstrated that this approach is achievable. the success of this project has led to the adoption of the protocol in other icu units in a regional critical care network. effect of non-nutritional calories on the calory/protein ratio in icu patients s jakob, j takala university hospital bern, dept of intensive care medicine, bern, switzerland critical care , (suppl ):p introduction: nutritional diets are composed to match the needs of critically ill patients. while effective calory needs can be measured or calculated, the needs of proteins are more controversial. we aimed to calculate non-nutritional calories and assess how they influence the ratio of calories to protein delivered to the patients. methods: in this retrospective analysis, nutritional and nonnutritional calories and protein delivery were calculated in consecutive icu patients receiving enteral nutrition in . introduction: marked protein catabolism is common in neurocritical patients. optimal nutritional monitoring and protein nutritional adequacy could be associated with outcome in neurointensive care unit (ncu) patients. we aimed to evaluate the impact of monitoring and optimal support of protein using nitrogen balance on outcome in neurocritical patients. methods: a consecutive patients who were admitted to ncu were included between july and february . nitrogen balance was calculated using excreted urine urea nitrogen during icu admission. follow-up nitrogen balance monitoring was performed in patients. we divided patients into two groups based on the results of nitrogen balance (positive balance and negative balance). moreover, we evaluated improvement of nitrogen balance in patients. we assessed the outcome as length of stay in hospital, length of stay in ncu, and in-hospital mortality. we compared the clinical characteristics and outcome according to nitrogen balance. results: among the included patients (age, . ; and male. . %), ( . %) patients had negative nitrogen balance. the negative balance group was more likely to have lower glasgow coma scale (gcs), longer length of stay in hospital, and longer length of stay in ncu. in patients with follow-up nitrogen balance monitoring, improvement of nitrogen balance group had lower in-hospital mortality ( . % vs. . %, p = . ), and received adequate protein intake ( . g/kg/day vs. . g/kg/day, p = . ) compared to no change group (table ) . there was no significant difference in baseline nitrogen balance, baseline body mass index, and gcs between two groups. conclusions: this study demonstrated that critical illness patients in ncu are underfeeding using nitrogen balance, however, adequate provision of protein was associated improvement of nitrogen balance and outcome. this suggests that adequate nutrition monitoring and support could be an important factor for prognosis in neurocritical patients. increased protein delivery within a hypocaloric protocol may be associated with lower -day mortality in critically ill patients introduction: to test the hypothesis, using real world evidence that increasing protein delivery and decreasing carbohydrates (cho) may improve clinical outcomes. methods: retrospective analysis of existing electronic medical records (emr) of patients admitted to the intensive care units (icu) at the geisinger health system. logistic regression analysis was used to determine correlation between protein delivered (which was proportional to the concentration of protein in the formula utilized) and clinical outcomes. results: medical encounters for a total number of , icu days were collected and analyzed. average age was . years ( . % male) and . % were obese and overweight. primary diagnoses included sepsis or septic shock, acute and/or chronic respiratory failure (or illness), cardiovascular diseases, stroke and cerebrovascular diseases among others. median hospital los was . days, . days in the icu, median days of invasive mechanical ventilation of . -day readmission rate among patients discharged alive was . %. patients in the high protein group received lower amounts of chos (data not shown). unadjusted -day post-discharge mortality was inversely proportional to the amount of protein delivered (table ) . conclusions: a significant improvement in mortality is observed with increased protein delivery while decreasing carbohydrate loads. prospective randomized trials are warranted to establish causality. introduction: acute kidney injury (aki) is associated with high mortality. the risk increases with severity of aki. our aim was to identify risk factors for development and subsequent progression of aki in critically ill patients. methods: we analysed patients without end-stage renal disease who were admitted to the icu in a tertiary care centre between january to december and did not have aki on admission. we identified risk factors for development and non-recovery of aki as defined by the kdigo criteria. results: the incidence of new aki in days was % (aki i %, aki ii %, aki iii %). multivariate analysis revealed bmi, sofa score, chronic kidney disease (ckd) and cumulative fluid balance as independent risk factors for development of aki. among patients who developed aki in icu, % had full renal recovery, % partial recovery and % had no recovery of renal function by day . aki patients without renal recovery in days had significantly higher hospital mortality ( %) compared to the other groups. independent risk factors for non-recovery of renal function were ckd, mechanical ventilation, diuretic use and extreme fluid balance before and after first day of aki. (table ) the association between cumulative fluid balance before aki and hours after aki with risk of aki non-recovery are shown in figure and . conclusions: aki is common and mortality is highest in those who do not recover renal function. cumulative fluid accumulation impacts chances of aki development and progression. (table ). all were in r . / ( %) of those with an admission ck> had aki or . all ( %) patients who required crrt for aki associated with rm were at risk for aki regardless of initial ck: vascular surgery ( / ), multi-organ dysfunction ( / ), and/or pre-existing renal disease ( / ). conclusions: raised ck is common in icu but its cause is multi factorial thus an isolated measure > does not require immediate high output treatment for rm aki. aki is more common in patients who have more than ck> on sequential days or those whose first ck was > as rm may be contributing. a single ck> in patients with a clear reason to develop rm should also start treatment. surgical outcomes of end-stage kidney disease patients who underwent major surgery p petchmak , y wongmahisorn , k trongtrakul introduction: acute kidney injury (aki) occurs in more than % of successfully resuscitated out-of-hospital cardiac arrest patients treated with targeted temperature management (ttm) [ ] . the effect of the duration of cooling on aki has not been well studied. in this post-hoc analysis of the tth randomized controlled trial that compared vs -hours of ttm ( °c) after cardiac arrest [ ] , we studied the impact of ttm length on the development of aki. fig. . duration of ttm had a significant impact on the development of creatinine values during the first days in the icu, p< . . this was primarily driven by an increase in creatinine during rewarming on day for the hour and day for the -hour group (fig ) . conclusions: in a trial of vs hours of ttm after out-of-hospital cardiac arrest, the length of ttm did not affect the incidence of aki. fig. (abstract p ) . creatinine over time patients [ ] , but there are no published data on longer-term renal outcomes in adult patients. the purpose of this study was to assess longer-term trends in serum creatinine in this cohort. methods: a retrospective study was conducted of all patients admitted to an adult regional referral centre for ecmo at a uk university hospital between and . those who survived for > months were included. demographics, baseline serum creatinine, presence of aki during icu admission, and serum creatinine at hospital discharge were determined. serum creatinine and dependence on renal replacement therapy (rrt) were assessed at and months post ecmo. results: patients had a complete (or near-complete) data-set available. the mean age was . years, % of whom were male. / had aki during their critical care admission. none were dependent on rrt at or months post ecmo. most patients had lower serum creatinine results at hospital discharge compared to their pre-hospitalisation baseline, but creatinine concentrations at and months post ecmo tended to be higher than at hospital discharge ( figure ) . conclusions: in this cohort of ecmo patients who were discharged from hospital alive, serum creatinine tended to be lower at hospital discharge compared to baseline and rose again in the following months. decreased creatinine production due to deconditioning and muscle wasting may offer a biological rationale for the lower creatinine results at hospital discharge [ ] . therefore, caution should be exercised in the use of serum creatinine at hospital discharge to assess renal dysfunction -further research is warranted. introduction: aki complicates more than half of icu admissions [ , ] and is associated with development of chronic kidney disease (ckd), need for renal replacement therapy (rrt) and increased mortality [ ] . we prospectively evaluated all icu admissions during a one-year period in order to determine incidence, etiology and timing of aki as well relevant clinical outcomes. methods: prospective observational study of all patients admitted from jan to dec to a multidisciplinary icu in greece. patients with end-stage renal disease and anticipated icu stay less than hrs were excluded. aki diagnosis and classification was based on kdigo criteria [ ] . lowest creatinine level within months before admission or first creatinine after icu admission served as reference. (fig ) . conclusions: although aki alert does not include urine output criterion or aki risk factors, it remains a helpful tool to point out patients with aki. education and diagnostic algorithms are still needed to early diagnose and treat aki patients. influence of severity of illness on urinary neutrophil gelatinaseassociated lipocalin in critically ill patients: a prospective observational study c mitaka, c ishibashi, i kawagoe, d satoh, e inada untendo university, anesthesiology and pain medicine, tokyo, japan critical care , (suppl ):p introduction: neutrophil gelatinase-associated lipocalin (ngal) is a diagnostic marker for acute kidney injury (aki). ngal expression is highly induced not only in kidney injury, but also in epithelial inflammation of intestine, bacterial infection, and cancer. however, the relationship between ungal and severity of critically ill patients has not been well understood. the purpose of this study was to elucidate whether ungal is associated with severity of illness and organ failure in critically ill patients. methods: we prospectively enrolled patients with sepsis (n= ) and patients who underwent esophagectomy with gastric reconstruction for esophageal cancer (n= ). sepsis was defined according to sepsis- . ungal levels were measured on icu day , , , and . ungal levels and aki rate in patients with sepsis were compared with those in patients who underwent esophagectomy. aki was defined according to kdigo. acute physiology and chronic health evaluation (apache) ii score and sequential organ failure assessment (sofa) score were calculated. results: median ungal level ( ng/mg creatinine) was significantly higher in patients with sepsis than that ( ng/mg creatinine) in patients who underwent esophagectomy on day . median apache ii score and median sofa score in patients with sepsis were significantly higher than those in patients who underwent esophagectomy. four patients with sepsis developed aki, and out of them underwent continuous renal replacement therapy, whereas no patients who underwent esophagectomy developed aki. ungal levels were positively correlated with apache ii score and sofa score in patients with sepsis. ungal levels were remarkably elevated (> ng/mg creatinine) in urinary tract infection (n= ), loops enteritis (n= ), and obstructive jaundice due to cholangiocarcinoma (n= ). conclusions: these findings suggest that ungal level is associated with severity of illness and organ failure in patients with sepsis. ungal levels might be influenced by severity of illness and inflammation. to assess the quality of the course us renal images had to be evaluated in "post-renal obstruction" (p-ro) or "no p-ro". the rate of correctness (roc farius ) was determined. in we, once again, contacted the students to attend a web-based online "follow-up". this online survey was created with "google formular". new and unknown us images were presented and rated in "p-ro" or "no p-ro" (roc fup introduction: septic-induced kidney injury worsen the patient's prognosis [ ] . renal resistance index (rri) is correlated with an increased mortality in septic patients [ ] . the aim of this study was to describe the evolution of rri in a rat sepsis model. methods: the local ethics committee approved the study (apa-fis# - ). sepsis was induced in -month-old male rats by caecal ligation and puncture (clp) [ ] . the rri was assessed before and h after clp by pulse doppler on the left renal artery (rri=(peak systolic velocityend diastolic peak)/ peak systolic values expressed as % per column. abbreviations in alphabetical order: aki acute kidney injury; akin acute kidney injury network definition; ckd chronic kidney disease. there were statistical differences between subgroups with and without aki for the subgroups of patients with previous ckd (p = . *), sepsis at admission (p = . **), hypotension (p= . ***) fig. (abstract p b) . target comparing accuracy and precision of aki alert and actual aki diagnoses velocity) (fig ) . rri were compared by a paired wilcoxon test (r software v. . . ). a p value < . was considered significant. results: rats were included. hours after sepsis induction, all rats were in septic shock with cardiac dysfunction. the rri increased after sepsis induction compared to baseline ( . ± . vs . ± . , p< . ) and mean renal artery velocity decreased ( . ± . vs . ± . , p< . ) (fig ) . systolic and diastolic peaks velocity of the renal artery were unchanged. conclusions: sepsis induced changes in rri and mean velocity on the left renal artery whereas no changes in systolic or diastolic velocities were seen. these results are consistent with available clinical datas. the rri could be an additional tool to assess renal failure in septic rats. further studies are needed to confirm the validity of this marker during sepsis. kidney failure is one of the most common organ dysfunction during sepsis. the rri could be an additional tool in small animals to assess the effects of potential therapeutic targets on renal function induced by sepsis. (fig ) . the egfr improved more with the heparin group ( % vs %; p= . ) (fig ) . interruptions of the filter circuit were as expected less with the citrate group ( mins vs mins; p= . ). finally, inotropic requirements increased following therapy interruptions, more so with patients receiving citrate ( . % vs . %; p= . ). conclusions: our analysis suggests that using citrate anticoagulation for rrt results in a monitoring cost saving of approximately £ per hours, alongside the other conferred savings previously reported. furthermore, results demonstrate the efficacies of both systems are similar in the initial hours, although there is a suggestion that heparin systems improves renal parameters more quickly. finally, interruptions and 'filter downtime' caused an increase in the patient's inotropic requirements, however results suggestive that this is greater in the citrate group. mmol/l respectively. demographic characteristics of the study group and the main parameters of the procedure were presented in fig . conclusions: regional citrate is a safe and effective anticoagulation method for crrt in children, when it is applied following a protocol. it significantly prolongs circuit survival time and thereby should increase crrt efficiency. we did not find any serious adverse effects of regional citrate anticoagulation. - ) , deceased at year n= ( %). the mdrd trend is more indicative than creatinine of decline of renal function in the post operative period (fig ) . crrt was used in . % ( pts) and was associated to a greater los and mortality (fig ) . preoperative bilirubin, bun and creatinine are among the greatest risk factors for its use ( table . at year follow up n= pts ( . %) were on hemodialysis. conclusions: aki requiring crrt in after lt is associated with higher mortality and los. identify patients at risk and adopt preventive strategies in the perioperative period is mandatory. introduction: we developed a new co removal system, which has a high efficiency of co removal at a low blood flow. to evaluate this system, we conducted in vivo studies using experimental swine model. methods: six anesthetized and mechanically ventilated healthy swine were connected to the new system which is comprised of acid infusion, membrane lung, continuous hemodiafiltration and alkaline infusion. in vivo experiments consist of four protocols of one hour; baseline= hemodiafiltration only (no o gas flow of membrane lung); membrane lung = "baseline" plus o gas flow of membrane lung; "acid infusion" = "membrane lung" plus continuous acid infusion; "final protocol" = "acid infusion" plus continuous alkaline infusion. we provided an interval period of one hour between each protocol. we changed the respiratory rate of the mechanical ventilation to maintain pco at - mmhg during the experiment. results: the amount of co eliminated by the membrane lung (vco ml) significantly increased by . times in the acid infusion protocol and our final protocol compared to the conventional membrane lung protocol, while there was statistically no significant difference observed in the levels of ph, hco -, and base excess between each study protocol. minute ventilation in the "final protocol" significantly decreased by . times compared with the hemodiafiltration only protocol (p < . ), the membrane lung (p= . ) and acid infusion protocol (p= . ). we developed a novel ecco r system which efficiently removed co and is easy-to-setup to permit clinical application. this new system significantly reduced minute ventilation, while maintaining acid-base balance within the normal range. further studies are needed for the clinical application of this easy setup system comprising of the materials typically used in a clinical setting. , and psychomotor agitation ( %) while the most common symptoms of hypertensive emergency were chest pain ( . %), dyspnea ( . %) and neurological deficit ( %). clinical manifestations of hypertensive emergency were cerebral infarction ( . %), acute pulmonary edema ( . %), hypertensive encephalopathy ( . %), acute coronary syndromes ( . %), cerebral hemorrhage ( ,. %), congestive heart failure ( %), aortic dissection ( . %), preeclampsia and eclampsia ( . %). conclusions: hypertensive urgencies were significantly more common than emergencies ( . % vs. . %, p< . ). there was no statistically significant difference in the number of patients with hypertensive urgency and emergency in relation to age, gender, duration of hypertension, except for the - age group, where urgency was statistically significantly higher (p= . ). introduction: emergency department (ed) crowding is a major public health concern. it delays treatment and possible icu admission, which can negatively affect patient outcomes. the aim of this study was to investigate whether ed to icu time (ed-icu time) is associated with icu and hospital mortality. methods: we conducted an observational cohort study using data from the dutch nice registry. adult patients admitted to the icu directly from the ed in academic centers, between and , were eligible for inclusion. for these patients nice data were retrospectively extended with ed admission date and time. ed-icu time was divided in quintiles. the data were analyzed using a logistic regression model. we estimated crude and adjusted (for disease severity; apache iv probability) odds ratios of mortality for ed-icu time. in addition, we assessed whether the apache iv probability (divided into quartiles) modified the effect of ed-icu time on mortality. results: a total of , patients were included. baseline characteristics are shown in table . the median ed-icu time was . [iqr . - . ] hours. icu and hospital mortality were . and . %, respectively. the crude data showed that an increased ed-icu time was associated with a decreased icu and hospital mortality (both p< . , figure a ). however, after adjustment for disease severity, an increased ed-icu time was independently associated with increased hospital mortality (p< . , figure b ). figure shows that only in the sickest patients (apache iv probability > . %), the association between increased ed-icu time and hospital mortality was significant (p= . , figure d ). we found similar results with respect to icu mortality. conclusions: this study shows that a prolonged ed-icu time is associated with increased icu and hospital mortality in patients with higher apache iv probabilities. strategies aiming at rapid identification and transfer of the sickest patients to the icu might reduce inhospital mortality. reliability and validity of the salomon algorithm: -year experience of nurse telephone triage for out-of-hours primary care calls e brasseur, a gilbert, a ghuysen, v d´orio chu liege, emergency departement, liège, belgium critical care , (suppl ):p introduction: due to the persistent primary care physicians (pcp) shortage and their substantial increased workload, the organization of pcp calls during out-of-hours periods has been under debate. the salomon (système algorithmique liégeois d'orientation pour la médecine omnipraticienne nocturne) algorithm is an original nursing telephone triage tool allowing to dispatch patients to the best level of care according to their conditions [ ] . we aimed to test its reliability and validity under real life conditions. methods: this was a -year retrospective study. out-of-hours pc calls were triaged into categories according to the level of care needed: emergency medical services (amu), emergency department visit (maph), urgent pcp visit (upcp), delayed pcp visit (dpcp). data recorded included patients' triage category, resources and potential redirections. more precisely, patients included into the upcp + dpcp cohort were classified under-triaged if they had to be redirected to an emergency department. patients from the amu+maph cohort were considered over-triaged if they did not spend at least resources, emergency specific treatment or any hospitalization. results: calls were actually triaged using the salomon tool, of which . % were classified as amu, . % as maph, . % as upcp and . % as dpcp (fig ) . as concerns the amu+maph cohort, the triage was appropriate in . % of the calls, with an over-triage rate of . %. as concerns the upcp + dpcp cohort, . % of the calls were accurately triaged and only . % were under-triaged. sal-omon sensitivity reached . % and its specificity . %. these results indicate that salomon algorithm is a reliable and valid nurse telephone triage tool that has the potential to improve the organization of pcp out-of-hours work. introduction: inappropriate visits to the emergency department (ed), such as patients manageable by a primary care physician (pcp), have been reported to play some role in the ed crowding [ ] . indeed, non-urgent patients directly managed by pcps could reduce ed workload [ ] . triage and diversion to alternative care facilities, eventually co-located within the ed, could offer a solution [ ] provided fig. (abstract p ) . distribution of different calls, their triage using the salomon algorithm and the inappropriate triages (over and undertriages) based on the preselected criteria the availability of a reliable triage tool for their early identification. we created a new triage algorithm, persee (protocoles d'evaluation pour la réorientation vers un service efficient extrahospitalier) and tested its feasibility, performance and safety. methods: after initial evaluation with a -level ed triage scale [ ] , ambulatory self-referred patients classified as level or below benefited from a simulated triage with persee identifying categories of patients: ed ambulatory patients and primary care (pc) treatable patients. we collected patients data and resources. patients requiring less than resources, no specific emergency treatment and no hospitalization were considered as manageable in a pc facility. results: patients were included in the study of whom . % were self-referred (fig ) . among those self-referrals, . % were triaged as level or below. . % patients were triaged as ambulatory patients of whom % were as pc treatable. we noted a redirection rate of % of the global visits or % of the self-referrals, an error rate of %, a sensitivity of . % and specificity of . %. conclusions: using advanced ed triage algorithm in addition to classical ed triage might offer interesting perspectives to safely divert self-referrals to pc facilities and, potentially, reduce ed workload. introduction: generally, prehospital medical provider should minimize staying prehospital scene to reach the patient to definitive care as soon as possible in prehospital medical activity. in addition, some textbook and report saids that medical provider minimize the number of procedure or limit minimum requirement procedure because unnecessary procedure may extend the staying time in prehospital scene. however, there are few studies evaluating this hypothesis and that this "extension is significant or not. therefore, we perform this study. methods: we evaluated the operated air ambulance(doctor-heli) case from st april to st march , in gifu university hospital using our mission record. we evaluated about time from landing to ready for taking off(activity time), operation doctor, mission category (i.e. trauma), number of procedure in the each activity and work load. we only focused on prehospital care and exclude transportation from hospital to hospital . in addition, we exclude the case which are not suitable for analysis. results: cases were operated in these period. cases were suitable for analysis. average activity time in prehospital scene was . ± . . there was weak correlation between the number of procedure and activity time. (r= . ) the length of the activity time did not depend on mission category. if the doctor perform and over procedures, staying time was minutes longer, this was significantly longer than that of under and under procedures. conclusions: we confirmed that we have to minimize the number of procedure or limit minimum requirement procedure in prehospital scene. and our result suggest we may have to limit appropriate number of procedures. introduction: organ failure is a critical condition, but the prevalence is largely unknown among unselected emergency department (ed) patients. knowledge of demographics and risk factors could improve identification, quality of treatment, and thereby improve the prognosis. the aim was to describe prevalence and all-cause mortality of organ failure upon arrival to the ed. methods: this was a cohort-study at the ed at odense university hospital, denmark, from april , to march , . we included all adult patients, except minor trauma. organ failure was defined as a modified sofa-score > within six possible organ systems: cerebral, circulatory, renal, respiratory, hepatic, and coagulation. the first recorded vital, and laboratory values were extracted from the electronic patient files. primary outcome was prevalence of organ failure; secondary outcomes were - -day and - -day mortality. results: of , contacts . % were female and median age (iqr - ) years. the prevalence of new organ failure was . %, individual organ failures; respiratory . %, circulatory . %, cerebral . %, renal . %, hepatic . %, and coagulation . %. the - -day and - -day all-cause mortality was . % ( % ci: . - . ) and . % ( % ci: . - . ), respectively, if the patient had new organ failures at first contact in the observation period, compared to . % ( % ci: . - . ) and . % ( % ci: . - . ) for patients without. seven-day mortality ranged from hepatic failure, . % ( % ci: . - . ) to cerebral failure, . % ( % ci: . - . ), and the - -day mortality from cerebral failure, . % ( % ci: . - . to renal failure, . % ( % ci: . - . ). conclusions: new organ failure is frequent and serious, with a prevalence of . % and a one-year mortality of % with wide variation according to type of organ failure. results: we proceeded to a descriptive study that showed that % of patients were male and % of them were female with a sex ratio of . .the average age of patients was years old and ranged between and years old.we found that patients of our population had medical background, dominated by diabetes in cases, high blood pressure in cases and asthma in cases.the results also showed that . % of patients had a history of abdominal surgery while % of them had history of other types of surgery.the patients were oriented according to their severity level as following: % care unit of emergency department, . % close monitoring room .the vaspi score was ranged between and with an average of ± . it was higher than in . % of cases.the results of physical examination found an isolated pain in , % of cases, a reactionnal pain syndrom in % of cases, a peritoneal syndrome in % of cases and an occlusive syndrome in % of cases.the final diagnosis was mostly represented by the following causes: . % of gastroenteritis . % of constipation and % of ulcer disease.the final orientation of patients according to the diagnosis led to hospitalization in % of cases and to outpatient clinic in % of cases while % of them did not need any more care. conclusions: appropriate diagnostic evaluation and decision for or against hospitalization is a challenge in the patient who comes to the emergency department with acute abdominal pain it need an adequate evaluation and management. introduction: we assessed patients' impressions of a selfadministrated automated history-taking device (tablet) to gather information concerning emergency department (ed) patients prior to physicians' contact. the quality of communication was compared with the traditional history-taking. methods: the algorithm content was developed by two emergency physicians and two emergency nurses through an iterative process. item-content validity index (i-cvi) was measured by five experts rating the relevance of each item (from : not relevant to : highly relevant) [ ] . next, quality control was realized by research team. to assess the feasibility, we used a computerized randomization. low acuity, ambulatory adult patients presenting to the ed were assigned either to a control group (cg, n= ) beneficiating form a traditional history-taking process or to the experimental group (eg, n= ) assigned to use the tablet with further history-taking by the ed physician. communication was analyzed by the health communication assessment tool [ ] and satisfaction assessed by questionnaires. results: after two rounds, validity was excellent for each item (i-cvi > . ). the universal agreement method was of . . refusals (n= ) to participate were analyzed: they fear using an electronic device or the experimentation. content satisfaction revealed that % of patients understood the questions. % of patients indicated that the device was easy to hold and use. medical communication was not affected by the device (p= . ). we noticed that, among the subsections, physicians significantly introduced themselves better in the eg (p= . ). conclusions: in this feasibility study, patients were highly satisfied. the use of a self-administrated automated history-taking device does not generate miscommunications and allow physicians better introduce themselves. . a positive point we have established is the possibility for the detorsion of a twisted retention ovarian cyst after its transvaginal aspiration. we used this method only in cases when the onset of torsion did not exceed hours. . % of all emergency conditions associated with retention cysts were recurred by conservative therapy, and . % of patients with the retention cysts rupture were successfully treated in this way. conservative management is possible in the case of a small loss of blood (up to . - . ml), hemodynamic stability and the absence of signs of continuing bleeding. the detorsion and resection of the cyst when torsion is not more than °and even longer than hours, in most cases did not reveal necrosis in the appendages. conclusions: improvement of organs of preservation and reproduction in women. criteria for admission to an intensive care unit of a tertiary hospital: analysis of the decisions of the outreach intensivist and day in-hospital mortality introduction: the aim of this study was the analysis of icu admission criteria and evaluation of in-hospital mortality of patients assessed by our critical care outreach team. criteria for admission to the icu should be defined to identify the patients most likely to benefit from icu admission. this triage process is complex, associated with several factors, including clinical characteristics of the patients, but also subjective factors because it depends on the judgment of the intensivist who decides whether to admit or not the patient and is obviously conditioned to the structure and size of the icu. methods: the outreach intensivist records the patient observation in a form with questions (reversibility of acute illness, objective of admission in icu, comorbidities, functional reserve and intuitive prognosis of the doctor). analysis of months (january through june , ) of admission decisions in icu, mean delay, icu mortality, and day in-hospital mortality ( hm). results: the intervention of the intensivist in "outreach" was requested on occasions. the main places of observation were the emergency room ( . %) and the wards ( . %). the hm increased with the degree of comorbidity decompensation. functional reserve also influenced hm, reaching . % in partially dependent patients and . % in totally dependent patients. there was agreement between the mortality and the physician´s intuitive prognosis in % of the cases. conclusions: a larger sample is needed to draw sustainable conclusions, however, the evaluation algorithm correlated well with hospital mortality. decompensated comorbidities and low functional reserve have a negative impact on prognosis, regardless of acute disease. there was agreement between mortality and the physician´s intuitive prognosis. electrochemical methods for diagnosing the severity of patients with multiple trauma introduction: multiple trauma is one of the leading causes of death worldwide [ ] . timely diagnosis and treatment is crucial in this state. one of the promising areas is the use of new electrochemical methods they are simple, flexible, efficient and of low cost. among these methods, attention is paid to the measurement of open circuit potential (ocp) of the platinum electrode and cyclic voltammetry (cva). the ocp is a reflection of the balance of pro-and antioxidants in the body, and the amount of electricity (q) determined by cva is proportional to the antioxidant activity of the biological environment. methods: a total of patients with severe multiple trauma ( . ± . y.o., men and women) were enrolled; apacheii . ± . ; iss . ± . ; blood loss ± ml. blood plasma was collected from patients. measurement of the ocp was carried out according to [ ] , cva analysis -according to the original method on a platinum working electrode. results: a shift in the ocp towards more positive potential values (fig. ) , while the antioxidant activity of blood plasma decreased (fig. ) . a more significant change of ocp, as compared to the q values, may indicate not only a deficiency in the components of the antioxidant defense system of the body, but also an increase in the concentration of prooxidants (e.g., reactive oxygen species), which are involved in oxidative stress. who underwent surgical fixation). information was collected from tarn, icnarc and surgical team databases. our primary outcome was itu resource utilisation (itu los and mechanical ventilation days). our secondary outcomes were morbidity and mortality (hospital los, infection burden, inotrope use and death before discharge). data was collected and analysed in microsoft excel and r. results: patients were included (group = , group = , group = ). mortality was significantly higher when comparing the post groups undergoing conservative ( %, / ) vs. surgical fixation ( %, / ), p-value = . . regarding potential temporal changes, there was no significant difference in mortality between the non surgical groups; pre- (group : / ) and post (group ), p-value . . group patients did spend more time mechanically ventilated (p-value . ) and used more antimicrobials (p-value . ) ( table ) . conclusions: patients undergoing surgical rib fixation at the rlh had significantly improved mortality with more days spent mechanically ventilated. pilot study on ultrasound evaluation of epiglottis thickness in normal adult a osman introduction: as the prevalence of epiglottitis is decreasing due to immunization, the difficulty in early detection remained. the aim of this study is to determine the thickness of epiglottis in normal adult with the utilization of bedside ultrasound. methods: this was a prospective observational study of convenience selection among healthy staff in emergency department, university malaya medical centre. the identification and measurement of epiglottis were performed using a mhz linear transducer by trained emergency physicians and registrars in em. subjects were scanned in either standing or upright seated position with the neck neutral or mildly extended. the epiglottis, thyroid cartilage and vocal cord were visualized and the epiglottis anteroposterior(ap) diameter was measured. difference in categorical parameters were analyzed by independent-sample t-test. the relationship between height, weight and epiglottic size was analyzed using pearson's correlation. results: fifty-six subjects were analyzed with males and females age ranging from to years old. the epiglottis ap diameter ranged from . cm to . cm, with average of . cm. there was significant difference in epiglottic ap diameter between male (m= . cm, sd= . ) and female (m= . cm, sd= . ; t( )= . , p=< . , twotailed). moderate positive correlation between height and epiglottic ap diameter (r= . ) and weight (r= . ) was documented. conclusions: our study demonstrated the identification and visualization of epiglottis was feasible and easy with the use of bedside upper airway ultrasonography. there was a little variation in the ap diameter of epiglottis in adults. indoor vs. outdoor occurrence in mortality of accidental hypothermia in japan y fujimoto , t matsuyama , k takashina introduction: the impact of location of accidental hypothermia (ah) occurrence has not been sufficiently investigated so far. thus we aimed to evaluate the differences between indoor and outdoor occurrence about baselines, occurrence place, mortality, and length of icu stay and hospital stay. methods: this was a multicenter retrospective study of patients with a body temperature ≤ °c taken to the emergency department of hospitals in japan between april and march . we divided the included patients into the following two group according to the location of occurrence of ah (indoor versus outdoor). the primary outcome of this study was in-hospital death. secondary outcomes were the length of icu stay, and hospital stay. results: a total of patients were enrolled in our hypothermia database. there were and patients with the outdoor and indoor occurrence. the indoor group was older ( versus . years-old, p< . ) and worse in adl than the outdoor group. the proportion of in-hospital death was higher in the indoor group than the outdoor group ( . % [ / ] versus . % [ / ], p< . ). the multivariable logistic regression analysis demonstrated that adjusted odds ratio of the indoor group over the outdoor group was . ( %ci; . to . ) ( table ) . as for secondary outcomes, both of the length of icu stay and hospital stay in survivors were longer in the indoor group than the outdoor group. conclusions: our multicenter study indicated that indoor occurrence hypothermia accounts for about % of the total in this study, and the proportion of in-hospital death was higher in the indoor group. we have to raise an alert over the indoor onset accidental hypothermia and need to take countermeasures for prevention and early recognition of ah in indoor location. conclusions: during acute asthmatic attack, arterial hyperlactatemia is frequently present at ed arrival. nevertheless, the plasma lactate level was no significant difference between ed admission and hr after treatment. the introduction: this is a case series of traumatic aortic injury (tai) which was diagnosed by transesophageal echocardiography (tee) in the emergency department. the number of patients with blunt thoracic aorta injury arriving at emergency department is on the rise and survival rate is time-dependent on early diagnosis. tee offers several advantages over transthorasic echocardiography (tte) including reliability, continuous image acquisition and superior image quality. methods: all trauma patients who presented to emergency department from st january until th november at hospital raja permaisuri bainun, perak, malaysia with suspected tai were evaluated with transesophageal echocardiography. over the years period, tee was performed in patients. patients had positive findings suggestive of tai. results: the first case was an old lady who presented after a deceleration injury in a car accident. tee was performed due to hemodynamic instability and found an intimal flap along the ascending aorta. the second case, a stanford type a (figure ) , was complicated with pericardial tamponade. the intimal flap was visualised from the aortic arch extending to the descending aorta by tee. the third case was a case of intramural haematoma involving distal aortic arch extending to the descending aorta which survived until corrective surgery. in the fourth case, tee revealed a motion artefact which mimicked an intimal flap in the ascending aorta. in the fifth case, tee showed intimal flap at aortic isthmus which was not detected by tte. in the last case, a traumatic aortic dissection was complicated by aortic regurgitation (figure ) . conclusions: tee can be a useful point of care tool use by emergency and critical care physicians for early diagnosis of blunt traumatic aorta injury. introduction: reboa is an endovascular intervention intended to preserve central perfusion in the context of shock due to noncompressible torso haemorrhage. more so, it is less invasive than the traditional approach of resuscitative thoracotomy (rt) and aortic crossclamping. though its use dates back to the korean war, it has not been widely adopted in trauma management, as evidence demonstrating clear benefit compared with conventional rt is lacking [ ] . we aimed to evaluate feasibility, outcomes and complications after reboa for haemorrhagic shock and traumatic cardiac arrest. methods: we performed a systematic literature review, searching scopus and pubmed databases using relevant terms (july ). we included studies enrolling patients with haemorrhagic shock or cardiac arrest after civilian trauma who had undergone reboa and reported hospital mortality (our primary outcome). abstract-only studies and single-patient case reports were excluded. we collated and analysed data using review manager v . . the newcastle-ottawa scale was used to assess risk of bias. results: sixteen in-hospital studies met inclusion criteria (n= ). ten were case series and six were cohort studies comparing reboa outcomes with those of rt. there were wide differences between studies' inclusion criteria, case-mix (including cardiac arrest), injury severity, insertion details, and reported outcomes. overall hospital mortality post-reboa was . %. meta-analysis of cohort studies indicated notably lower mortality in patients undergoing reboa (or . , . - . ) than rt with low statistical heterogeneity between studies (i = %), shown in fig . conclusions: whilst our findings are limited by methodological differences and biases in the included studies, almost % of patients undergoing reboa for haemorrhagic shock and/or cardiac arrest survived to discharge. furthermore, reboa appeared to offer a consistent mortality benefit compared with rt. introduction: trauma related coagulopathy remains a primary contributor to mortality on battlefields and in civilian trauma centres. fibrinogen is considered to be the first to drop below critical level and correspondingly compromised coagulation process. however, it is unclear if fibrinogen concentrate at a very early stage is feasible and effective to prevent from coagulopathy. methods: a total of acutely injured patients in austria, germany and czech republic were screened and enrolled in this controlled, prospective randomized placebo controlled double blinded multicentre and multinational trial. upon the completion of randomization, fibrinogen concentrate ( mg/kg, fgtw©, lfb france) or placebo was reconstituted and given to the patients at the scene or during helicopter transportation from the scene to nearby hospitals. blood samples were taken at baseline (scene of accident before study drug administration), at the emergency room, three hours, nine hours and twentyfour hours after admission to the hospital as well as after three and seven days after admission, for measurements of blood gases and coagulation, together with clinical data and outcome records. results: the demographic and injury characteristics and the estimated blood loss, iss, and gcs at the scene were similar in both groups. in the placebo group, fibrinogen concentration dropped from mg/dl at injury site to mg/dl () at er admission and clot stability reduced from . mm ( , mm) to mm (p= . ) (fig ) . fibrinogen concentrate administration prevented the drop of fibrinogen level (baseline of mg/dl to mg/dl and improved clot stability from mm at baseline to mm at er. conclusions: pre-hospital administration of fibrinogen concentrate in traumatic bleeding patients is feasible and effective in preventing the development of coagulopathy. data from this study support the use of fibrinogen to prevent trauma related coagulopathy. fibrinogen concentrate vs cryoprecipitate in pseudomyxoma peritonei surgery: results from a prospective, randomised, controlled phase study results: the per-protocol set included pts (hfc, n= ; cryo, n= ). the mean total intraoperative dose of hfc was . g vs . pools of cryo (containing approx . g of fibrinogen). median duration of surgery was . h. overall haemostatic efficacy of hfc was non-inferior to cryo and was rated excellent or good for % of pts receiving hfc and cryo, with similar blood loss. intraoperatively, only red blood cells were transfused (median: unit). intraoperative efficacy is shown in table . infusions were initiated . h earlier with hfc than cryo due to faster product availability. preemptive hfc led to a greater mean increase vs cryo in fibtem a ( figure ) and plasma fibrinogen (figure ). there were serious adverse events (saes) in the hfc group and in the cryo group, including thromboembolic events (tees; deep vein thromboses, pulmonary embolisms). no aes or saes were deemed related to the study drug. conclusions: hfc was efficacious for treatment of bleeding in pts undergoing surgery for pmp. no related aes and no tees occurred in pts treated with hfc. fig. (abstract p ) . fib mcf t to t with % ci fig. (abstract p ) . fibtem a prior to and following the preemptive dose of hfc/cryoprecipitate introduction: patients in the intensive care unit often suffer from thrombocytopenia. in dealing with this problem, we need to figure out not only the cause of thrombocytopenia but also the risk of bleeding. however, there is no reliable method for evaluating bleeding risk. methods: in this preliminary study, four thrombocytopenic patients who required platelet transfusion before undergoing invasive procedure were enrolled. written informed consent was obtained from all patients for participation in the study. bleeding was graded using the who bleeding scale. thrombogenic activity was evaluated using total thrombus-formation analysis system (t-tas), rotational thromboelastometry (rotem), and multiplate impedance aggregometry. for t-tas analysis, we prepared a novel microchip, named hd chip, which is suited for analyzing low platelet samples rather than those with normal platelet counts. , key patient groups in which it was wasted and the use of standard laboratory tests (slts) to guide its use. the purpose was to assess the potential benefit a point of care viscoelastic haemostatic assay (vha) could have on ffp transfusion and waste. the national blood transfusion committee and nhs blood and transplant committee have published data showing that up to % of ffp is transfused inappropriately [ ] . methods: blood bank data was obtained evaluating haemorrhaging patients in whom ffp was requested across a nine-month period in . patient bleeds were categorised by speciality. the mean time ffp dispensed and wasted was recorded, as were timings of slt requests. where available, the inr result was recorded. results: patients were identified. transfusions were requested. table shows that the highest transfusion requirements are for acute medical emergencies and major trauma. % of transfusion were surgical specialities, it would be expected that these patients would have anaesthetic or critical care input. units were wasted. acute medical emergencies wasted the highest amount of ffp ( units). table demonstrates that . % of transfusions had an inr available one hour prior to ffp being dispensed. conclusions: we conclude that use of slts to guide ffp transfusion is low. this suggests transfusion decisions are being made clinically. a point of care vha could give treating physicians better access to timely haemostatic data. introduction: we developed the process for the out-of-hospital packed red blood cells (prbc) transfusion in the hems of castilla-la mancha clm according to criteria of medical indications, security, monitoring and tracking. haemorrhage is a preventable cause of death among population suffering accidents or bleeding injuries in regions with low population density where health services should reach people in remote areas. hems of clm is the first out-ofhospital emergency service in spain that provides prbc transfusion there where the accident takes place. this program has been developed jointly between hematologists of the center for transfusions ct and the hems team. methods: observational retrospective study with data collected from june to august . the medical helicopter was provided with two prbc o rh(d) negative (fig ) . shock index was selected as indication for transfusion. to achieve feasibility and preservation of the prbc it was established a prospective monitoring and microbiological culture for both groups: case group for the prbc kept in the hems and control group in the hospital (fig ) . controls and comparison of hematologic analysis were performed immediately and days after collection. statistics used spss . (signification p< . ). results: prbc were evaluated, case - control. analyses were tested days and after collection. hemolysis was not observed. all cultures were negative. results obtained of the prbc after days transported in the hems related to monitoring parameters were not different than those observed on prbc conserved in the ct. prbc were transfused to patients in out-of-hospital assistance. neither post-transfusional reactions or undesirable events have been registered. prbc units are changed every days. conclusions: the process designed (collection, conservation, tracking and tests) to make prbc available in the medical helicopter has demonstrated to keep the standard conditions and properties to be transfused in critically ill patients out-of-hospital. outcomes in patients with a haematological malignancy admitted to a general intensive care unit a corner east sussex healthcare nhs trust, intensive care, eastbourne, united kingdom critical care , (suppl ):p introduction: recent published data have challenged the view that critically ill patients with a haematological malignancy have a poor prognosis [ ] . reports have largely originated from tertiary centres. the aim of this audit was to evaluate the intensive care unit (icu), in hospital and one year mortality for a cohort of patients admitted to a mixed medical and surgical icu in a district general hospital. methods: details were obtained for all patients with a haematological malignancy admitted to eastbourne and hastings icu between march and august . patient characteristics, type of malignancy, reason for admission, degree of organ support and survival rates at icu discharge, hospital discharge and year postadmission were collected. results: patients, % male, were identified. median (interquartile range, iqr) age was ( - ) years. % had neutropenia. the commonest malignancies were acute leukaemia %, lymphoma % and myeloma %. reasons for admission were respiratory %, cardiac % and renal %. organ supports used were noradrenaline %, intubation and mechanical ventilation %, renal replacement therapy (rrt) % and dobutamine %. overall survival rates are shown in figure . patients were discharged from hospital following a period of mechanical ventilation. for these patients, median (range) age was ( - ) years. all were male. median (iqr) time in hospital prior to admission was ( - ) days, / patients required vasoactive support, / required rrt, median icu length of stay was ( - ) days. / were admitted following surgery for an unrelated condition. to date, only / patient has survived years post icu admission. conclusions: although survival rates were disappointing, particularly in those patients requiring mechanical ventilation, selected patients have the potential for a good outcome. these results outcomes have been presented to our haematology department to aid patient counselling. analyses. cox regression was used for the survival analysis. organ failure was defined as the occurrence of renal failure based on acute kidney injury network (akin)-creatinine or need for; vasopressors, invasive ventilation or continuous renal replacement therapy (crrt) the first days after admission. length of stay was only analysed in survivors. results: the study included unique patients. prolonged aptt was associated with mortality with a % confidence interval (ci) of hazard ratio . - . . prolonged aptt correlated also with the occurrence of renal failure and the need for vasopressor and crrt with % ci of odds ratio (or) . - . , . - . and . - . (fig ) . increased pt-inr was associated with the need for vasopressors and invasive ventilation with % ci of or . - . and . - . . both aptt and pt-inr correlated with length of stay with % ci of or . - . and . - . . conclusions: activated partial thromboplastin time on admission to the icu is independently associated with mortality. both aptt and pt-inr are independently associated with length of stay and the need of organ support. all regression models were adjusted for saps score which means that aptt prolongation and pt-inr increase on admission represent morbidity that is not accounted for in saps . introduction: the goal was to assess if daily venous thromboembolism (vte) assessment was being done in our critical care (cc) unit, and if not, what changes could be made. a mortality review showed the need for a dynamic vte assessment in cc patients, who are subject to daily changes influencing vte risk. a daily risk assessment was introduced, and a 'tab' on our clinical information system, metavision(r)(mv) was created. recently published national institute for health and care excellence guidelines on vte risk assessment in cc provided us cause to assess our compliance [ ] . methods: data was collected from mv. review of daily vte assessment was made and a percentage completion of daily vteassessments was calculated per patient.interventions were done using standard improvement methods through pdsa cycles. results: baseline data, of patients, was collected in july, .compliance with daily vte assessment was %. the results were presented at the clinical governance forum(cgf), and posters were displayed in cc. the second cycle, of patients, was collected in october. compliance had increased to %.following discussion from presenting results at the cgf, the vte tool was appropriately modified.the responsibility of vte assessment was also shifted to becoming more shared, including all clinical staff, rather than mainly consultants. the third cycle, of patients, was collected in november. compliance had increased to %.introducing a nursing care bundle with vte is in progress. conclusions: despite the identification of a risk in our clinical practice and the development of an appropriate it tool to facilitate improved practice, the advent of new national guidance revealed poor compliance with agreed standards. this shows the difficulties with achieving practice change in complex multiprofessional clinical environments. a sustained effort is required focusing on dissemination and engagement across the whole team. introduction: we describe the changes in anti factor xa (afxa) activity, thrombin generation and thromboelastography (teg) in critically ill patients with and without acute kidney injury (aki) following routine administration of tinzaparin as part of venous thromboembolism (vte) prophylaxis. methods: pilot prospective observational study. patients divided into those with and without aki were administered tinzaparin by subcutaneous injection as per established local guidelines. patients who did not receive tinzaparin were recruited as a 'control'. plasma afxa activity and thrombin generation were measured at intervals over a hour period. teg parameters were collected at t and t . results: afxa activity: results are shown in figure . / patients failed to achieve a prophylactic afxa level of > . at any point. / patients achieved a level of > . however in all cases this was at the lower end of the prophylactic range and was achieved for only a short time (median . hours). / achieved a level of > . for the whole h period. there was no difference between the aki and no aki groups. endogenous thrombin generation: there is no significant difference in thrombin generation between the aki and no aki groups. there is a significant decrease in thrombin generation between h and h (p< . ) and a significant increase between h and h (p< . ) (figure ). there is no significant difference between h and h (p= . ). teg: all teg parameters for all patients were within normal range conclusions: standard vte prophylactic dose tinzaparin rarely achieves an afxa range that has been suggested for vte prophylaxis. however, as assessed by thrombin generation, a hypo-coagulable state is generated in response to lmwh. there is no difference between critically ill patients with or without aki that would suggest the need for dose reduction in this context. (abstract p ) . thrombin generation at h, h and h. t = time of tinzaparin administration, with the sample taken just prior to administration. patients from aki group shown with dotted line and from no aki shown with solid line % which takes the third place between cpb-associated complications . current data demonstrates the importance of researching of changes in haemostatic system in paediatric patiens after cpb. provided below data is an intermediate result of our research. methods: patients in age up to mohth days (median age - , months, youngest age - days after birth, oldest - months days), who underwent cardiac surgery with cpb to treat congenital heart diseases, were enrolled in this study. all patients were divided into two groups: stwithout tc, ndwith tc. protein c (pc) and fibrin-monomer (fm) plasma levels were assessed in there points: before surgery, -hours and hours after surgery. thrombotic cases were provided by doppler ultrasound or mri. results: thrombotic complications were diagnosed in chidren ( %). between all tc ischemic strokes were diagnosed in % ( cases), arterial thrombosis in % ( cases), intracardiac thrombus in % ( cases). in group with tc fm-mean values in points , and respectively were . ; and mcg/ml, meamwhile in group without thrombosis - . ; . and . mcg/ml .pc-mean value in st groupwere ; and %, in the nd group - ; and % respectively in the points , and . statistically significant differences between groups in rd point (p< . ) and correlation between pc and fm (r=- . ; p< . ) were detected. conclusions: cpb causes hypercoagulation with increasing of pc consumtion and fm level. moreover, cp associated with a high risk of tc on the rd day after cardiac surgery. further studies to investigate prognostic values of fm and pc in thrombosis are required. these studies would help to asses fm and pc as markers of tc and possibility of pc-prescribing for prevention and treatment of these complications. introduction: thrombocytopenia is a common condition in critically ill patients and an independent predictor of mortality. the relevance of a supranormal platelet count remains unclear. septic patients with disseminated intravascular coagulation (dic) are also known to have a high mortality, but the influence of sepsis on mortality rates in coagulopathic patients is less well characterised. our objectives were to: ) evaluate mortality amongst patients with sepsis and nonsepsis associated dic. ) assess incidence of dic during the first days of admission. ) assess the relationship between platelet count and mortality. methods: records of adult critical care patients admitted to the royal liverpool university hospital between - were retrospectively reviewed. the presence of sepsis (using the definition of sirs with infection), coagulopathy, degree of thrombocytopenia and day mortality were noted. modified isth dic score was used to define dic. results: the overall mortality rate was %. patients were identified as having sepsis ( %) and non septic patients ( %). mortality rates of patients with sepsis were significantly higher than without sepsis ( % vs % respectively, p< . ). in patients with dic, their dic scores tended to be 'positive' for the first days of admission. fibrin-related markers were often not available for dic scoring. mortality rates amongst patients with sepsis-associated dic were greater than patients with non-sepsis related dic. thrombocytopenia severity was associated with mortality, and patients with platelets above the upper limit of normal had lower mortality rates ( % when platelets > x ^ /l, % when platelets < x ^ /l). conclusions: sepsis-associated coagulopathy is associated with a higher mortality rate than non-sepsis associated coagulopathy. supranormal platelet counts may be associated with a mortality benefit. introduction: deep vein thrombosis (dvt) is a major problem in icu and affects overall lethality. dvt is widespread complication in icu, especially in elderly patients, when early activisation may not be achieved. aim of this study is comparison of haemostatic potential and analgesia methods of elderly patients who underwent major urological surgery during their stay in icu. methods: a cross-sectional study was employed. participants were ≥ y.o., underwent major urological surgery, have had normal initial hemocoagulation data (thromboelastography was performed to all of them), had received analgesia with epidural catheter or iv by opioids use and were treated in icu > days due to non-coagulopathy states, were included. data were collected from october till october . the patients were examined with thromboelastograph "mednord" for thromboelastogramm (teg) and with esaote usg for thrombi occurrence in lower limb deep veins. the anticoagulants were prescribed under the esa guidelines . results: participants (n= ) were divided in two groups -non-opioid analgesia with epidural catheter (n= ) and opioid analgesia (n= ). we received moderate decrease in anticoagulants dosage to the patients with epidural analgesia with the same teg goals compared to the patients with opioid analgesia. other factors as comorbidities may provoke dvt events, but was not evaluated in this study. the dvt events were monitored by expert with the use of usg to locate thrombi in the vein. conclusions: use of epidural catheter analgesia provides moderate decrease of anticoagulants dosage compared to opioid analgesia patients; however strict control of teg data must be presented. comorbidity need to be monitored for early detection and prevention of dvt events. introduction: patients with morbid obesity (mo) have a high risk of thromboembolic events. in patients with a bmi > , the hypercoagulable state is due to impairment of all parts of the blood coagulation as well as anticoagulation mechanisms by obesity. methods: the hemostasis system was studied in patients with a bmi> kg/m with various pathologies that were admitted to icu. all patients were divided into groups depending on the type of therapy: group (n= ) received monotherapy with enoxaparin sodium . % . ml sc times a day every h; group (n= ) received combination therapy with enoxaparin sodium . % . ml sc times a day every h and pentoxifylline mg times a day every h. to study the hemostasis system, we used lpteg immediately after hospitalization, on , , days. results: in both groups, prior to treatment: contact coagulation intensity (icc) was increased by . %, intensity of coagulation drive (icd) -by more than . %, clot maximum density (ma) -by . %, index of retraction and clot lysis (ircl) - . % above normal. patients of the st group: icc increased by . %, icd was close to normal values, ma increased by . %, ircl was increased by . %. patients of the nd group on the th day: icc decreased by . % compared with the norm; the coagulation and fibrinolysis parameters were close to normal values and the decrease in fibrinolysis activity reaches to normal. conclusions: combined therapy of thromboembolic complications in patients with obesity sodium enoxaparin sodium and pentoxifylline is more effective than enoxaparin sodium monotherapy because it affects all parts of the hemostatic system. introduction: a laryngeal injury secondary to blunt neck trauma can lead to life-threatening upper airway obstruction [ , ] . ultrasound enables us to identify important sonoanatomy of the upper airway [ ] . the purpose of this report is to discuss role of pocus airway in blunt neck trauma and to determine airway management based on standard schaefer subgroups classification. methods: three cases of blunt neck trauma presented to our centre with either subtle or significant clinical signs and symptoms. standard airway management was performed prior to pocus airway using mhz linear transducer and it findings were later compared to flexible fibreoptic laryngoscopy and computed tomography (ct). results: pocus airway had identified one out of cases to have schaefer and the remaining as schaefer . all pocus airway findings were confirmed with flexible fibreoptic laryngoscopy and ct scan (figs , ) . based on schaefer, supportive care and early steroid administration are advisable for group and . for groups to , immediate open surgical repair is deemed necessary due to extension of injuries.all cases were intubated using glidescope.all including those presented with schaefer were managed conservatively and discharge well with proper follow-up. conclusions: upper airway ultrasound is a valuable, non-invasive and portable for evaluation of airway management even in anatomy distorted by pathology or trauma. an organised approach using pocus airway as an adjunct can expedite care and prevent early and long term complications in facilities without flexible laryngoscope and ct. introduction: high-flow nasal oxygen (hfno) and helmet noninvasive ventilation (hniv) are increasingly used for the early management of acute hypoxemic respiratory failure (ahrf). we compared the physiological effects of hfno and hniv during ahrf. methods: in this randomized cross-over study, we enrolled patients with acute-onset (< days), non-cardiogenic respiratory distress (respiratory rate> /min), pulmonary infiltrates at the chest-x-ray and hypoxemia (spo < % while breathing on room air). all patients received hniv (peep cmh o, pressure support adjusted to achieve a peak inspiratory flow of l/min) and hfno (flow l/min) for one hour each, in a randomized cross-over manner. at the end of each period, arterial blood gases, inspiratory effort (esophageal pressure) and respiratory rate were recorded. self-assessment of dyspnea and device-related discomfort ( [ ] [ ] [ ] [ ] [ ] ). conclusions: as compared to hfno among critically ill patients with ahrf, hniv ameliorates oxygenation, limits inspiratory effort and relieves dyspnea, without affecting paco , respiratory rate and comfort. introduction: pre-intubation hypoxemia is a predictor of negative patient outcomes including in-hospital mortality. while successful first intubation attempt is also an important factor of patient outcomes, little is known about whether physicians achieve successful first intubation attempt for the hypoxemic patients in the emergency department (ed). the aim of this study is to investigate the first-pass success for patients with pre-intubation hypoxemia in the ed. methods: this is an analysis of the data from the second japanese emergency airway network study (jean- study)a multicenter, prospective, observational study of eds in japan. we included all patients who underwent intubation in the ed from through . we excluded patients ) aged < years and ) patients who underwent intubation for cardiac arrest. we grouped pre-intubation hypoxemia as follows: non-hypoxemia (oxygen saturation [spo ], ≥ %), moderate-hypoxemia (spo , %- %), and severehypoxemia (spo , < %). primary outcome was the first-pass success rate. to demonstrate the association between pre-intubation hypoxemia and the first-pass success in the real-world setting, we fit two unadjusted logistic regression models ) using grouped preintubation hypoxemia as a categorical variable and ) using the preintubation spo as a continuous variable. results: among , patients who underwent intubation in the ed (capture rate, %), , patients were eligible for the analysis. compared to the non-hypoxemia, the first-pass success rate was low in moderate-hypoxemia ( % vs %; or= . [ %ci, . - . ]) and severe-hypoxemia ( % vs %, or= . [ %ci, . - . ]). additionally, there was a linear association between pre-spo and lower first-pass success rate (or for the success, per one pre-spo decrease, . [ %ci, . - . ]). conclusions: based on the large, multicenter data, the first-pass success rate was low in hypoxemic patients compared to nonhypoxemic patients in the ed. introduction of rapid-sequence induction guideline to reduce drug-associated hypotension in critically unwell patients introduction: the aim of this project was to assess whether the introduction of a rapid sequence induction (rsi) agent guideline changed drug choice and the incidence of peri-intubation vasopressor use at st john's hospital, livingston. it is well documented that emergency airway management in the critically ill can be a source of significant morbidity and mortality [ , ] and the choice of induction agent matters [ ] . methods: an rsi agent guideline was instituted for all critically ill patients being intubated in icu and the ed [ figure ]. following this, we set up an intubation registry to collect data from all intubation events. this data was then compared to a previous audit of intubations completed in . results: the choice of agent used pre-and post-intervention are summarized in figure . forty-five intubation events were included in the initial audit in , of which, ( %) required vasopressor support immediately following intubation. of the intubation events following the guideline's introduction, ( %) required vasopressors. ketamine use changed from % to %, propofol use from % to % and midazolam from % to %. thirty-eight of these intubation events ( %) were compliant with the guideline. conclusions: the introduction of the rsi guideline dramatically affected the choice of induction agent and reduced the incidence of significant hypotension requiring vasopressors ( % versus %). overall compliance with the guideline was excellent ( %). introduction: the purpose is to test the feasibility of using the i-gel® device for airway maintenance during bronchoscopic-guided percutaneous dilatational tracheostomy (pdt). usually pdt is accomplished via the tracheal tube. failure to position the endotracheal tube correctly can result in further complications during the procedure. the alternative implies extubation and reinsertion of an i-gel® airway device. methods: the pdt was performed using the blue dolphin method in patients in intensive care unit. before undertaking bronchoscopicguided percutaneous dilatational tracheostomy (pdt), the patient's tracheal tube (et) was exchanged for i-gel®, as a ventilatory device for airway maintenance. the insertion of the i-gel®, the quality of ventilation, the blood gas values, the view of the tracheal puncture site, and the view of the balloon dilatation were rated as follows: very good ( ), good ( ), barely acceptable ( ), poor ( ), and very poor ( ) [ ] . results: the i-gel® successfully maintained the airway and allowed adequate ventilation during percutaneous tracheostomy in all patients. the ratings were or in % of cases with regards to ventilation and to blood gas analysis, for identification of relevant structures and tracheal puncture site, and for the view inside the trachea during pdt. conclusions: the i-gel® successfully maintained the airway and allowed adequate ventilation during percutaneous tracheostomy in all patients. the ratings were or in % of cases with regards to ventilation and to blood gas analysis, for identification of relevant structures and tracheal puncture site, and for the view inside the trachea during pdt. no damages to the bronchoscope, reports of gastric aspiration or technical problems were detected. the bronchoscopic view obtained via an i-gel® seems to be better than that obtained through an endotracheal tube (et) or through traditional laryngeal mask [ ] . introduction: the purpose of this study was to investigate the efficiency of nasal airway inserted in the oral airway (on airway) in securing the airway patency during mask ventilation [ ] (fig ) . methods: fifty eight patients undergoing general anesthesia were randomly assigned to either oral airway group (group o) or on airway group (group n). in both group, mg/kg of propofol was infused intravenously and mask ventilation was performed in the sniffing position without head extension or jaw thrust. the patients were ventilated with a volume-controlled ventilator with o flow of l/min, tidal volume of ml/kg (ibw), and respiratory rate of /min. before the start of mask ventilation, airway was placed in the oral cavity. oral airway was used in group o and on airway was used in group n. peak inspiratory pressure (pip), tidal volume and etco were compared between the two groups. the location of airway tip was graded by fiberoptic bronchoscope as; : airway obstructed by tongue, : epiglottis visible, : airway touches epiglottis tip, : airway passes beyond epiglottis tip [ ] . methods: a prospective uncontrolled observational study in - in ukrainian hospitals. sma-pts from - mo were involved. all pts. ready for extubation: afebrile, no infiltrations on chest x-ray, normal wbc. however, each sma-pts. failed sbt (t-tube or psv). we evaluated: extubation success (no reintubation in hours), icu los, one year survival. three pts. were excluded: two pts. by staff decision, family have choosen tracheostomy. sma-pts. included. a cuff leakage test performed -with a negative, dexamethazone mg iv was administered. after extubation niv was started by ventilogik ls in st mode via nasal mask giraffe. the epap and ipap settings were titrated to reach the chest excursion and target levels of spo ( - %) and etco ( - mmhg). a sputum was draining by mechanical insufflation-excuflation (mie) and aspirator results: all pts, were extubated successful. the mean icu los was . days ( - days), one year survival rate was %, respiratory failure fully compensated by niv, there was no icu admission. every sma-pts. are in good condition, gaining weight introduction: aerosol delivery has previously been assessed during simulated adult hfnt, delivered by various stand-alone humidification systems [ ] . the objective of this study was to evaluate aerosol delivery during simulated hfnt delivered by a mechanical ventilator, across three clinically relevant gas flow rates. methods: ml of mg/ml salbutamol was nebulised using an aerogen solo nebuliser (aerogen, ireland). an adult head model was connected to a breathing simulator (asl , ingmar, us), vt ml, bpm and i: e, : (fig ) . hfnt was supplied via the servo-u ventilator (maquet, getinge, sweden), using the integrated nebulisation option. tracheal dose was recorded at two nebuliser positions; a (after the humidification chamber) or b (before of the cannula), at three gas flow rates ( lpm, lpm and lpm) (n= ). the mass of drug captured on a filter placed distal to the trachea (tracheal dose) was quantified using uv spectroscopy at nm. results: presented in table . conclusions: to our knowledge, this is the first study to successfully demonstrate aerosol delivery during simulated hfnt, delivered by a mechanical ventilator. increasing gas flow rate was associated with a reduced tracheal dose (p= < . ). at lpm, a significantly greater tracheal dose was observed when the nebuliser was positioned before the nasal cannula (p= < . ). at lpm, a greater tracheal dose was yielded when the nebuliser was positioned after the humidifier (p= < . ). introduction: tracheotomies are often performed in critically ill patients who are in need of prolonged mechanical ventilation and respiratory care. our aim was to evaluate the possible effect of percutaneous and surgical tracheotomies on thyroid hormone levels. methods: eighty seven adult patients were included in our study from january to september . patients were in need of prolonged mechanical ventilation and tracheotomies were performed after consent was taken. we have excluded patients with preexisting thyroid diseases. forty five patients were undergone percutaneous tracheotomies and forty two patients were undergone for surgical. thirty eight female patients and forty nine male, age range - . we studied tsh, t and ft serum levels using chemiluminescence immunoassay method before either procedure and hours post each procedure.: statistical analysis was performed using spss . significance was estimated at the level of p< . results: tsh levels were increased in surgical group compared to percutaneous group at hours post procedure but the difference was not found statistically significant (p> . ). the rise in post operative levels of t compared to preoperative was found statistically significant for surgical tracheotomy group (p< . ).elevated ft levels for both groups have shown statistically significant difference between preoperative and postoperative period for the surgical tracheotomy group (p< . ) conclusions: we analyzed the effect of surgical versus percutaneous tracheotomy on thyroid hormones and it was found that both introduction: insertion of a tracheostomy for weaning purposes is associated with prolonged critical length of stay (los) and several adverse patient outcomes [ ] . previous work has suggested that protocolised weaning may reduce weaning times [ ] . we aimed to assess the impact of protocolised weaning on los following introduction of a standardised weaning protocol in . conclusions: introduction of a standardised weaning protocol for patients with a tracheostomy in our unit has had a beneficial effect on several patient outcomes, notably duration of weaning and length of critical care admission. introduction: delirium is a relatively frequent neurologic complication in liver transplantation (lt) recipients, which is an important cause of increased morbidity, mortality, extended icu stay, and increased cost of medical care. extubation of the endotracheal tube at an appropriate timing is an essential part of intensive care after lt, suggested to improve graft perfusion and systemic oxygenation, and thus decrease intensive care unit (icu) stay and positively affect prognosis. the aim of this study was to compare the incidence of delirium between early and late extubation groups after lt. methods: medical records from patients who received lt from january to july in a single university hospital were retrospectively reviewed. patients were divided into groups: those who underwent early extubation after lt (group e, n = ) and those who underwent extubation within few hours of icu admission after surgery (group c, n = ). the data of patients´demographics, perioperative management, and postoperative complications were collected. early extubation was defined as performing extubation in the operating room after lt. a propensity score matching analysis was performed to minimize the effects of selection bias. results: postoperative delirium occurred in / ( . %) in group e and / ( . %) in group c, respectively (p = . ). after propensity score matching, there was no difference in icu stay (p = . ), time to discharge after surgery (p = . ), and incidence of delirium between groups (p = . ). conclusions: although this study is retrospective in nature, limited by small sample size, early extubation did not affect the incidence of delirium after lt. further prospective studies on this area are required. weight estimation and its impact on mechanical ventilation settings in queen elizabeth hospital intensive care unit a nasr, a iasniuk, a roshdy queen elizabeth hospital, icu, london, united kingdom critical care , (suppl ):p introduction: documented weight in the intensive care unit (icu) can be the total, ideal, adjusted or predicted body weight (pbw). lung protective ventilation depends on tidal volume (vt) delivery which is based on accurate calculation of patients´weight [ ] . the weight is most probably documented on admission to the icu using estimation or one of many available equations. the aim of this study is to assess the documented versus the pbw and its impact on tidal volume delivery for mechanically ventilated patients in queen elizabeth hospital icu. methods: data was collected prospectively from all ventilated patients over a period of weeks in june . vt delivered in the first hour was calculated for each patient. documented body weight and height of each patient was obtained from the nursing chart. pbw was calculated and compared with the documented weight. the difference in vt attributable to the difference in weight has been subsequently calculated. results: ventilated patients were included ( males). the mean tidal volume delivered according to the documented body weight was . ml/kg versus . ml/kg based on pbw. vt more than ml/ kg was delivered in % of patients based on documented weight versus % when correcting the weight according to the pbw equation. conclusions: inaccuracy in documenting weight on patients´admission to the icu is a potential cause of delivering unsafe tidal volume [ ] . the harm can extend to drug dosage, nutrition provision and renal replacement therapy. introduction: ventilator-associated pneumonia (vap) is the leading cause of death among mechanically ventilated critically ill patients [ ] . chest radiography (cxr) is essential in the diagnosis of vap. in the past decade lung ultrasonography has proven to be a valuable tool in the diagnosis and monitoring of lung diseases. the aim of the study is to assess sensitivity and correlation between cxr, lung ultrasound and clinical pulmonary infection score (cpis). methods: in this retrospective, non-randomized study seven patients with proved vap were enrolled. in all patients cpis and lung ultrasound score (lus) [ ] were assessed. comparison of patients that had lus≥ and cpis≥ points was performed. the correlation between lus and cxr was done using the pearson model. results: we found significant difference between positive cxr patients with lus≥ and cpis≥ ( % vs %, p< . ). there is a very high correlation between cxr and lus. these results render lung ultrasound as a highly sensitive tool in the diagnosis of vap. conclusions: our study shows that lung ultrasonography could be used as a reliable supplementary method in the diagnosis of vap. the benefits of lung ultrasound include the ability to perform it at the patient´s bed without need for transportation, no radiation exposure and repeatability. the high correlation between cxr and lung ultrasound makes echography a valuable adjunct in the diagnosis of vap. color introduction: it is difficult to differentiate between pneumonia and atelectasis as cause of lung consolidation in intensive care unit patients. tools like the clinical pulmonary infection score are of little help (sensitivity % and specificity % for detecting pneumonia) [ ] . the objective of this study was to determine the accuracy of ultrasound assessed vascular flow within the consolidation to distinguish these causes. methods: adult patients with pulmonary symptoms and lung consolidation on lung ultrasound that were scheduled for chest-ct were included. vascular flow was analyzed with color doppler imaging (flow velocity scale was chosen at . m/sec.). the final diagnosis made by the treating physician was regarded as the gold standard. results: patients were included of which nine ( %) were diagnosed with pneumonia. vascular flow in the consolidation was present in seven ( %) out of nine patients with pneumonia, compared to three out of ( %) patients with atelectasis (p = . ). the diagnostic accuracy in differentiating between pneumonia and atelectasis was %. the sensitivity and specificity were % and % respectively. the positive predictive value was % while the negative predictive value was %. conclusions: vascular flow in lung consolidations assessed by lung ultrasound in icu patients aids in differentiating between pneumonia and atelectasis. it outperforms the frequently used clinical pulmonary infection score. methods: three intubated patients for various causes of respiratory distress undergoing mechanical ventilation were subjected to tee. at the level of mid-esophagus, the descending aorta short-axis view ( °) the imaging plane is directed through the transverse axis of the descending aorta. sector depth was increased to image the left pleural space beneath the aorta. for the right lung, the tee is rotated to the right at the level of atria until lung is seen or until the image of the liver is seen and the probe was withdrawn until the right lung is seen. recruitment manoeuvres were performed after identifying pbl atelectasis. atelectatic lungs were visually observed to open up during and after the recruitment manoeuvres. results: the time to acquire the image of pbl atelectasis from the time of insertion by tee is short. the images of posterior lung and the effect of lung recruitments is successfully viewed (fig ) . no immediate complication seen. conclusions: tee provides an excellent view of pbl atelectasis and able to directly monitor the success and failures of recruitment manoeuvres. introduction: high respiratory driving pressure (Δ prs) is strongly associated with increased risk of lung injury and increased mortality during mechanical ventilation. Δ prs consists of the pressure required to distend the lung the transpulmonary driving pressure (Δ pl) and the pressure required to distend the chest wall. Δ pl is the pressure that increases the risk of lung injury. data on Δ pl is limited because its measurement requires an esophageal catheter. we aimed to assess changes in Δ prs and Δ pl during proportional assist ventilation (pav+) at different experimental conditions. methods: we retrospectively analyzed patients ventilated with pav+ who had esophageal pressure measurements before and after dead space or chest load addition. we calculated end-inspiratory plateau pressure (pplateau), Δ prs, respiratory system compliance (crs) and Δ pl during occluded breaths in pav+ (figure ). data were compared with wilcoxon signed rank test and p value< . was considered significant. results: patients were analyzed. dead space increase ( patients) did not affect the studied parameters. chest load ( patients) significantly increased pplateau (p= . ) and Δ prs (p= . ) and decreased crs (p= . ) but Δ pl remained the same (p= . ). median (iqr) changes were . ml/cmh o ( . - . ) for crs, . cmh o ( . - . ) introduction: particle flow in exhaled air from mechanically ventilated patient's mirrors the opening and closing of small airways and can be detect by optical particle counter [ ] . we hypothesized that this particle flow is affected by cardiac function. methods: exhaled air from mechanically ventilated patients was analyzed using a customized optical particle counter pexa, figure . introduction: we assessed the diagnostic accuracy of mechanical power (mp) and driving pressure (dp) alone and combined with stress index (si) to identify ventilator settings likely to produce ventilator induced lung injury caused by tidal hyperinflation [ ] [ ] [ ] . methods: secondary analysis of a previous database of ards patients [ ] . computerized tomography markers of tidal hyperinflation (were used as a "reference standard". analysis of the area under the receiver-operating characteristics curve (auc) was used using a two-fold cross-validation. results: in a cluster of patients, a "training set" of not hyperinflated patients was compared with a "validation set" of hyperinflated patients. (figure - ) . conclusions: si seems to be more accurate than mp and dp in identifying tidal hyperinflation in patients with ards. specificity and sensibility were not improved combining si with mp or dp. the introduction: the pao /fio (p/f) ratio is widely used to assess the severity of lung injury. conceptually, the p/f ratio should be independent of the fio and solely depend on the pulmonary condition. however, effect of fio modulation on the p/f ratio has not been well characterized in ventilated intensive care (icu) patients. the purpose of the present study was to investigate the relationship between fio and the p/f ratio in icu patients on mechanical ventilation. methods: in a prospective, interventional study patients with a swan ganz catheter in situ were included. the p/f ratio was calculated at fio levels ranging from . to . with minute intervals. during the study other ventilator settings were not modulated. to understand the physiological effects of fio modulation on gas exchange and hemodynamics, mixed venous oxygen saturation and cardiac output were assessed. shunt fraction was calculated as described by west [ ] . results: patient characteristics and ventilator settings are reported in table . all patients were admitted to the icu after elective cardiac surgery. modulation of fio did have a significant effect on the p/f ratio, following a u-shaped pattern (p < . ) (figure ). the shunt fraction varied with altering fio levels, also exhibiting a u-shaped pattern (p < . ) (figure ). cardiac output was not affected by fio . conclusions: in contrast to current thinking, the p/f ratio varied substantially with altering fio levels in mechanically ventilated icu patients. this is an important novel physiological observation. in addition, it demonstrates that the assessment of the severity of respiratory failure by using the p/f ratio should be standardized to a fixed fio level. conclusions: in patients undergoing prolonged mechanical ventilation, we must take into account all the factors that may affect our patients. the assessment of diaphragmatic dysfunction is key to preventing weaning failure. an optimal level of consciousness as well as a good management of secretions are key to a successful weaning. prognostic value of the minute ventilation to co production ratio as a marker of ventilatory inefficiency in the icu r lopez , r pérez , Á salazar , i caviedes , j graf introduction: ventilatory inefficiency for co clearance may provide better severity stratification in acute respiratory failure than oxygenation [ ] . ventilatory inefficiency (vi) is best assessed by the bohr-enghoff physiological dead space [ ] . we recently reported that the minute ventilation to co production ratio (ve/vco ), a simplified vi index from exercise testing that obviates the paco measurement, correlates better than other vi indices to physiological dead space in mechanically ventilated patients [ ] . here we report the prognostic performance of this index using a survival analysis. mean±sem ve/vco was higher in patients who died than those who survived ( ± vs ± , p< . , figure ). we found a ve/ vco cutoff value of . mortality was higher in patients with high-ve/vco (≥ ) as compared to those with low-ve/vco ( % vs %, p= . ) with an odds ratio of . [ %-ci . - . ]. cumulative mortality was higher in the high-ve/vco than in the low-ve/vco group (log-rank p= . , figure ). conclusions: in this unselected cohort of mechanically ventilated patients an early high ve/vco ratio was associated to -days mortality. the ve/vco ratio may be a simple and non-invasive vi index with prognostic value in this population. introduction: sodium thiosulfate (sts) is a clinically relevant and safe hydrogen sulfide donor that improved acute lung injury (ali) and brain ischemia/reperfusion injury in previous studies [ , ] . methods: in a prospective, controlled, randomized, and doubleblinded trial, twenty adult, anesthetized, mechanically ventilated and surgically instrumented swine with preexisting coronary artery disease [ ] underwent h of hemorrhagic shock (hs; removal of % of the calculated blood volume and subsequent titration of mean arterial pressure to mmhg). post-shock resuscitation ( h) comprised re-transfusion of shed blood, crystalloids, and norepinephrine. animals were randomly assigned to "placebo" or "sts" ( . g·kg - ·h - for h). before, at the end of and every h after shock, hemodynamics, blood gases, and lung function were recorded. results: survival rates did not differ between groups. sts-infusion attenuated the hs-induced impairment of lung mechanics and pulmonary gas exchange (table , ), resulting in a significantly higher horovitz/peep-ratio ( figure ). conclusions: sts during acute resuscitation from hs may protect comorbid swine against hs-induced ali. introduction: alveolar epithelial cell (aec) death is a main mechanism of severe respiratory failure in acute respiratory distress syndrome (ards). classically, cell death is classified into necrosis or apoptosis. recent studies have reported that not only apoptosis but also certain types of necrosis are molecularly regulated and that these regulated necrosis can be therapeutic targets for various diseases. however, the relative contribution of necrosis and apoptosis to aec death in ards has not been elucidated. our study aimed to elucidate which type of cell death is dominant in aec death and to evaluate whether the regulated necrosis is involved in lps-induced experimental ards. methods: we established ards model by instilling μ g of lps intratracheally to mice. to estimate the relative proportion of apoptosis and necrosis in aec death, we measured cytokeratin m level (total cell death marker) and m level (apoptosis maker) in bronchoalveolar lavage fluid (balf) by elisa, and quantified propidium iodide-positive necrotic cells and tunel-positive apoptotic cells in the lung sections. moreover, we performed pathway enrichment analysis of gene expression data from pcr array to evaluate whether regulated necrosis pathway is associated with the ards model. results: both m and m levels were increased in the ards mice. the m /m ratio (an indicator of the proportion of apoptosis to total cell death) in the ards mice was significantly lower than that of healthy controls. moreover, the number of propidium iodidepositive necrotic cells was significantly higher than that of tunelpositive apoptotic cells in ards mice. in the pathway enrichment analysis, the necroptosis pathway, a regulated necrosis pathway, was associated with lps-induced experimental ards. conclusions: aec necrosis is more dominant than apoptosis in lpsinduced ards model. moreover, necroptosis may contribute to ards pathogenesis. aec necrosis including necroptosis is a potential therapeutic target for ards. clinical ards diagnosis is not associated with a unique circulating neutrophil cell surface phenotype t craven , s duncan , s johnston , c haslett , k dhaliwal , t introduction: acute respiratory distress syndrome (ards) is a form of non-cardiogenic oedema due to alveolar injury secondary to an inflammatory process. the clinical diagnosis is defined by the berlin criteria but this may not reflect the underlying biological process. the activated neutrophil is central to the pathogenesis of ards, characterised by altered cell surface markers. methods: three cohorts of seven participants were recruited. the first cohort suffered from mild, moderate or severe ards as defined by the berlin criteria [ ] . the second cohort was composed of ventilated patients on the intensive care unit with acute inflammatory lung disease (diagnosis of clinical suspicion) but did not meet the berlin criteria for ards. a third cohort was composed of age and sex matched healthy volunteers. procurement of human tissue was approved by a regional ethics committee ( /ss/ or /s / or amrec: -hv- ) and with the informed consent of the participant or their personal legal representative. patients were excluded if aged under or over years of age, were expected to survive for less than hours, if the attending physician refused, due to the absence of suitable indwelling vascular catheter, if the haemoglobin concentration was below . g/dl, or if the patient was enrolled in a trial of novel anti-inflammatory agent. whole blood (lysed erytocytes) underwent flow cytometry to determine cd b, , b, , l and . results: a description of the enrolled cohorts can be found in table . there were no significant differences between the mechanically ventilated, critically ill cohorts for any cell surface molecule in the multiplicity adjusted p values (fig ) . the results support the conjecture that clinical diagnostic criteria should not be used as a surrogate to stratify patients according to biological changes, with implications for the testing of biological therapies. introduction: aim of the present study was to compare the global and regional diagnostic accuracy of lung ultrasound (lus) compared to lung computed tomography (ct) scan in patients with the acute respiratory distress syndrome (ards). ards is characterized by a diffuse, inhomogeneous, inflammatory pulmonary edema. lung ct scan is the reference imaging technique, but requires transportation outside the intensive care and exposes patients to x-rays. lung ultrasound (lus) is a promising, inexpensive, radiation-free, tool for bedside imaging. methods: lung ct scan and lus were performed at peep cmh o. lus was performed using a standardized assessment of regions per hemithorax: superior and inferior; anterior, lateral and posterior. each region was classified for the presence of normally aerated, alveolar-interstitial syndrome, consolidation regions and pleural effusion. agreement between the two techniques was calculated, and diagnostic parameters were assessed for lus using lung ct as a reference. both a global and a regional analysis were performed. results: thirty-two sedated and paralyzed ards patients (age ± years, bmi . ± . kg/m and pao /fio ± ) were enrolled. global agreement between lus and ct was . ± . . the overall sensitivity and specificity of lus are shown in table . similar results were found with regional analysis (anterior/lateral/posterior lung regions is a common practice in our icu. during the interruption eit belt was positioned. when the presence of spontaneous breathing activity was evident by clinical assessment and ventilator traces analysis, nmba were administered to reach full paralysis, in accordance with the treating physician. eit tracing were analyzed offline and the change in eeli after nmba bolus, as compared to before nmba administration, was measured. respiratory mechanics and arterial blood gas (abg) data were collected results: we enrolled ards patients, undergoing controlled mechanical ventilation with muscle paralysis. baseline respiratory mechanics and abg data are shown in table . in out of patient the bolus of nmba led to an increase of eeli. in case, the nmb administration led to no changes in eeli. the mean change in eeli was ± ml conclusions: in our small population of ards patients, the administration of a bolus of nmba after the regain of spontaneous breathing activity led to an increase in eeli in out of patients. further study are needed to ) correlate this increase to global and regional respiratory system compliance and ) correlate this increase to the time needed to wean the patient from nmba introduction: to analyze the use of the orthostatic board as an auxiliary device for the treatment of severe ards by assessing its risks and benefits. methods: we selected patients, females and males, hospitalized in a neurological icu, between june and july , in a physiotherapeutic follow-up with diagnosis of severe ards. the patients were submitted to orthotics assisted for to minutes and monitored hr, pam, fr, sato at °and °of inclination and the pao / fio ratio after the procedure. the mean number of sessions per patient was . . all patients were undergoing anticoagulation in rass - , in the treatment of the cause of ards. the mean time of mechanical ventilation was . days. results: among the patients selected, . % presented tachycardia above bpm, requiring intervention in . % and interruption of the procedure in . %. pam arterial hypotension < mmhg was observed in . %, requiring intervention (increase of vasopressor dose and / or change of plank angulation) in % and interruption of the procedure in . %. hypoxemia sato < % was observed in . %, without interruption, but an improvement in pao / fio was observed in only . % of the patients. conclusions: assisted orthostatism as an auxiliary device for the treatment of severe ards was shown to be an alternative, with improvement of pao / fio in . % of the patients, safe and without significant hemodynamic repercussions that could lead to interruption of the procedure. introduction: the eolia trial found that vvecmo compared to conventional mechanical ventilation (cmv) did not improve mortality in patients with severe ards [ ] . the cmv strategy consisted of airway pressures below cmh o. in patients with severe ards higher airway pressures are required to maintain lung aeration. grasso et al. measured the transpulmonary pressure (p l ) in patients with severe ards and increased peep until p l was cmh o, accepting airway pressures above cmh o. fifty percent of patients responded to an increase in airway pressure and did not require vvecmo [ ] . we hypothesized that a p l guided open lung concept (olc) improves oxygenation and prevents conversion to vvecmo in patients with severe ards. methods: a retrospective study was conducted in a tertiary referral icu. the records of patients referred to our icu for advanced medical care were reviewed. inclusion criteria were severe ards according to the berlin definition and the eolia trial inclusion criteria for vvecmo. results: mechanical ventilation was limited to a p l of < cmh o instead of plateau pressures below cmh o. the p l guided olc resulted in an increase in p/f ratio and none of the patients required vvecmo. during the first hours peak airway pressure was increased, but was reduced within hours while peep was maintained ( fig. ). at hours both peak airway pressures and peep were reduced to baseline values while p/f ratio remained stable. only one patient ( . %) died of disseminated invasive aspergillosis. conclusions: the p l guided olc improved oxygenation and none of the patients required vvecmo. these findings support a ventilation strategy guided by transpulmonary pressures instead of plateau pressures in patients with severe ards. introduction: the mortality benefit conferred by early prone positioning in the treatment of acute respiratory distress syndrome (ards) has been well established. we also know that aprv improves oxygenation, and more recently has been shown to reduce ventilator dependent days and icu length of stay [ , ] . however, controlled ventilation remains the mainstay mode of ventilation used during prone position. literature looking at combined aprv and prone positioning is scarce. we aim to explore and report our institutional experience with respect to feasibility and outcomes in combining aprv and prone positioning, and perform a literature review in this area. methods: we undertook a single-centre retrospective cohort study within a surgical icu of a tertiary hospital in singapore between jan -oct . patients with ards who received combined prone positioning and aprv were reviewed retrospectively. a literature review of patients with ards who received combined intervention was also performed. results: adult patients aged - years old diagnosed with ards received a combination of aprv and prone positioning for a duration of - h ( table ). all the patients tolerated aprv with prone positioning well. our patients saw an improvement of p:f ratio ranging from - upon completion of combination therapy. out of patients were extubated within hours of turning supine, was weaned to tracheostomy mask after days and died while on the ventilator. only case report and randomized clinical trial were found on this topic upon literature review, which corroborated our findings. conclusions: in our experience, aprv is a practical and feasible alternative mode of ventilation that can be employed in the prone position, yielding significant p:f ratio improvements. the synergistic effects on improving oxygenation herald potential, especially in the subset of severe ards patients with refractory hypoxemia, where extracorporeal membrane oxygenation is unsuitable or unavailable. introduction: the recirculation during veno-venous extracorporeal membrane oxygenation (vv ecmo) had been a drawback, which could limit sufficient oxygenation. purpose of this study is to compare the short-term oxygenation in acute respiratory distress syndrome (ards) patients under vv ecmo according to their cannula configurations, especially in the national environment of the absence of newly developed double-lumen, single cannula. introduction: vv-ecmo is most commonly used in severe potentially reversible respiratory failure. this report looks at two patients in whom vv-ecmo was used to facilitate surgical airway stenting. methods: case -a -year-old with recurrent respiratory arrests, on a background of neurofibromatosis type and kyphoscoliosis. he had complex airway pathology, including, airway neurofibromas and granulation tissue, tracheobronchomalacia, severe kyphoscoliosis and a permanent tracheostomy tube. rigid bronchoscopy was performed and following debridement of granulation tissue, a trouser-leg stent was deployed. case -a -year-old with progressive stridor due to recurrence of a malignant melanoma, which was causing mid-lower tracheal compression. three tracheal stents were deployed via a rigid bronchoscope. in both cases, percutaneous bi-femoral vv-ecmo was established prior to general anaesthesia and decannulation took place the following day. results: in these cases, vv-ecmo provided stable extracorporeal gas exchange without conventional tracheal intubation. cardiopulmonary bypass and veno-arterial ecmo have been described in patients at risk of compression of the heart and distal airway [ ] . however, if the major threat is airway collapse, vv-ecmo can provide cardio-respiratory support without the problems associated with arterial cannulation and with lower anticoagulation requirements. introduction: ecco r facilitates the use of low tidal volumes during protective or ultraprotective mechanical ventilation when managing patients with acute respiratory distress syndrome (ards); however, the rate of ecco r required to avoid hypercapnia remains unclear. methods: we determined ecco r requirements to maintain arterial partial pressure of carbon dioxide or co (paco ) at clinically desirable levels in ventilated ards patients using a six-compartment mathematical model of co and oxygen (o ) biochemistry [ ] and whole-body transport [ ] with the addition of an ecco r device for extracorporeal veno-venous removal of co . the model assumes steady state conditions and is comprehensive from both biochemical and physiological perspectives. o consumption and co production rates were assumed proportional to predicted body weight (pbw) and adjusted to achieve pao and paco levels at a tidal volume of . ml/(kg of pbw) as reported in lung safe [ ] . clinically desirable paco levels during mechanical ventilation were targeted at mm hg for a ventilation frequency of . /min as previously reported [ ] . results: model simulated paco levels without and with an ecco r device at various tidal volumes are tabulated in tables and , respectively. table shows a substantial increase in paco at a tidal volume of ml/(kg of pbw) that is more pronounced when further reducing the tidal volume. additional simulations showed that predicted ecco r rates were significantly influenced by ventilation frequency. conclusions: the current mathematical model predicts that ecco r rates that achieve clinically acceptable paco levels at tidal volumes of - ml/(kg of pbw) can likely be achieved with current technologies; achieving such paco levels with ultraprotective tidal volumes of - ml/(kg of pbw) may be challenging. figure a ). pulmonary infections for each subtype of immunosuppression are shown in figure b . conclusions: ards vv-ecmo patients with underlying immunosuppression have higher mortality rates and higher rates of ecmo weaning failure. immunosuppressed patients suffer from a different spectrum of pulmonary infections in comparison to not immunosuppressed patients. introduction: acute asthma attack in children is a life-threatening emergency that requires urgent medical intervention. in the present study, we aim to clarify the effect of non-invasive ventilation (niv) on the heart rate (hr), respiratory rate (rr), and fraction of inspired oxygen (fio ) in children with acute severe asthma (asa) who failed to respond to standard medical treatment; and to evaluate the associated complications and length of stay (los) at the pediatric intensive care unit (picu). methods: this is a retrospective descriptive study of prospectively collected data. it was carried at the picu of a tertiary university hospital, saudi arabia. the study included children ≤ years old with asa admitted to the picu from november to november and required niv. outcome measures include the effect of niv on the hr, rr, fio , and los. the study included children with asa and ( %) of them required niv. of those patients, ( %) were excluded due to incomplete data, and ( %) patients were included in the final analysis. they were ( %) male and ( %) female with a mean age of months and a median pediatric index of mortality (pim ) score of . %. of them, ( %) had moderate asthma scores (≥ - ) and ( %) had severe asthma scores (≥ ). the median duration of niv was hours and the median los in the picu was three days. at hours, only rr showed a significant decrease compared to initiation of niv (p-value < . ) (fig ) ; while hr, rr, and fio were significantly improved at hours from initiation of niv (p-value < . ) (fig ) . conclusions: non-invasive ventilation, in association with standard medical treatment, was associated with clinical improvement in children with asa not responding to standard medical treatment alone. niv was not associated with significant complications or side effects. neurally adjusted ventilatory assist (nava) is a partial support ventilatory mode which triggers and tailors the level of assistance delivered by the ventilator to the electrical activity of the diaphragm. the objective of this study was to compare nava and pressure support ventilation (psv) in patients who were difficult to wean. methods: a total of difficult-to-wean patients who were able to sustained psv in the critical care medicine unit (icu) of the zhongda hospital, southeast university were enrolled in the study (fig ) . patients were classified according to the reason for weaning failure and were randomly assigned to receive nava or psv during weaning ( table ). the primary outcome was the duration of weaning. secondary outcomes included the proportion of successful weaning and patient-ventilator asynchrony. results: there were % ( / ) and % ( / ) patients in the psv and in the nava group never weaned from mechanical ventilation (p = . ). the duration of weaning was significantly shorter in the nava group [ . ( . - . ) days], than in that in the psv group [ . ( . - . ) days] (p = . ). the proportion of patients with successful weaning was % (n= / ) in nava group which was much higher than that in psv group ( %, n= / ) ( table ) . compared with psv, nava improved the rate of successful weaning in patients with single reason ( % vs. %, p = . ) but not in patients with multiple reasons for difficult weaning ( % vs. %, p = . ). nava decreased ineffective efforts and improved the trigger and cycling-off delays when compared with psv. mortality was similar in the two groups (fig ) . in patients who were difficult to wean, nava decreased duration of weaning and increased the probability of successful weaning. nava which improved patient-ventilator asynchrony, is safe, feasible and effective over a prolonged period of time during weaning. conclusions: only mrc score is independently associated with sbt failure and difficult or prolonged weaning. hgs is also associated with these two outcomes related to mv weaning and may serve as a simple tool to identify icuamw. introduction: there is evidence to support that in patients with hypoxemic respiratory failure (ahrf) under non invasive ventilation (niv), high tidal volume (tv) and high respiratory rate (rr) are associated with niv failure and possibly poor prognosis. we postulated that high minute ventilation (mv); or tv x rr; is associated with mortality in ahrf, when niv is initiated. methods: single-center, prospective and observational study. we included consecutives ahrf adults requiring niv. ahrf was defined as acute dyspnea with new pulmonary infiltrates on chest radiography and paco below or equal to mmhg. we registered demographic and clinical parameters (including rr, mv, arterial blood gases, heart rate and blood pressure) at baseline and after hours of first session of niv, apache ii score, diagnosis, need for intubation and icu mortality. we performed a multivariate analysis to assess independent factors associated with mortality and roc . ) and (auc = . ; p = . ), respectively for mortality, future exacerbations and readmissions. the optimal cut-off point for the mwt ratio to predict mortality was . and to predict future exacerbations and readmissions was . . the mwt ratio performed at icu discharge reveals interesting discriminative properties to predict early mortality, future exacerbations and readmissions in ae/copd patients. diffuse alveolar haemorrhage in an intensive care unit -search and you will find m matias , e ribeiro , j baptista , p martins introduction: the incidence of diaphragmatic ruptures after thoracoabdominal traumas is . - % [ ] and up to % diaphragmatic hernias present late [ ] when there is a complication. we report two cases of delayed traumatic diaphragm rupture to highlight the diagnostic difficulties. methods: case (image ) presented left diaphragmatic hernia containing the stomach, spleen, bowel and pancreas. the patient reported a motor vehicle accident dating months. he had thoracoabdominal trauma with several broken ribs on the left side. he then reported occasional pain in his left shoulder and occasional dyspnoea. case (image ) showed right diaphragmatic hernia containing right hemicolon, right hepatic lobe and gallbladder, he reported occasional dyspnoea and recent right chest pain. he had a years car accident in which three ribs broke on the right side. results: almost % of the patients with delayed diaphragmatic rupture presented with complications between and months after trauma, singh [ ] reported a diaphragmatic rupture presenting years after the traumatic event. the physical examination is often not helpful. conclusions: those cases emphasizes on the delayed presentation, patients may be asymptomatic or produce only mild, nonspecific symptoms, such as vague abdominal pain, chest pain or recurrent dyspnoea for months or years. the best tool to guide the clinician toward the appropriate diagnosis is a high index of suspicion whenever there is a history of high velocity trauma, regardless of how remote. factors associated with asynchronies in pressure support ventilation (psv), a bench study introduction: critically ill patients frequently have increased risk of ocular surface disorders (osds) due to poor eyelid closure and reduced tear production due to sedation during mechanical ventilation. we conducted a study to look at the incidence of osds in our icu with the current eye care practices and the impact of a protocolised eye care on the incidence and outcome and to determine the correlation of risk factors with the incidence of osds methods: this study was done in our mixed medical surgical icu. it had a prospective cohort design and was done as before and after study in two phases (phase i and phase ii). in phase i existing eye care practices were continued. in phase ii protocolised eye care was implemented and incidence of osds was noted in both phases. introduction: both fentanyl and morphine are known as opioid analgesics, which blocks the brain from receiving pain signals, the route of administration and the adverse effects affect their use. we compare the efficacy of intranasal fentanyl versus intravenous morphine adults population presenting to an emergency department (ed) with acute post traumatic severe pain. methods: we conducted a prospective, randomized, double-blind, placebo-controlled, clinical trial in a tertiary emergency department between october and june . adults with severe post traumatic was included to receive either active intravenous morphine ( mg immediately and then mg every min if persistence of severe pain maximum mg) and intranasal placebo or active intranasal concentrated fentanyl ( μ g /kg maximum μ g) and intravenous placebo. exclusion criteria: significant head injury, allergy to opiates, nasal blockage, or inability to perform pain scoring, pain scores were rated by using a digital scale at , , , and minutes. routine clinical observations and adverse events were recorded. conclusions: iscs were related to k over-use in our bicu. burnt patients are at risk of hepatic injury [ ] , but k related hepatic injury likely occurred. its not clearly understood mechanisms may involve a cumulative dose effect. although involvement of concomitant medications is being investigated, k restriction policy seemed to contain hepatic disorders. introduction: in november , our institution switched from using alfentanil to fentanyl for analgesia and sedation in adult patients receiving ecmo. there is no published evidence comparing the clinical use of alfentanil vs fentanyl for sedation in ecmo patients, although some reported increased fentanyl sequestration into the circuit [ ] . for these reasons, we conducted a retrospective observational study to explore whether there were any significant differences in patient outcome or adjunctive sedation before and after the switch. methods: outcome data and total daily doses of alfentanil or fentanyl as well as adjunctive sedation/analgesia for each patient where obtained from our clinical information system (philips icca®). data was included from ecmo patients who were sedated with alfentanil or fentanyl from / / to / / until ecmo decannulation. patients not requiring either opiate or who were switched between the two during ecmo therapy were excluded. all medicines prescribed for the management of sedation or agitation were included. for each patient an average total daily dose of each drug, was calculated. data was analysed using stata®. results: both groups were found to be statistically equivalent for mode of ecmo, age, apache score and charlson score (p= . ) except for bmi (p= . ). no difference in patient outcomes were found between groups (table ) . patients in the alfentanil group were found to have received significantly higher median average total daily dose of quetiapine and midazolam (table ) . conclusions: no differences in patient outcomes were found between patients sedated with alfentanil compared to fentanyl. we introduction: the european society of intensive care medicine consensus statement recommends that for comatose survivors of cardiac arrest hours without sedation is the minimum acceptable before neurological assessment. they highlighted the need to investigate the pharmacokinetics of opioid drugs in post-cardiac arrest patients, especially those treated with controlled temperature [ ] . methods: following approval by research ethics committee, we measured the blood concentration of fentanyl in post-cardiac arrest patients treated with ttm following cessation of continuous infusion. the fentanyl was discontinued when the patients were rewarmed to a temperature of . degrees celsius and a blood sample taken hours later. the blood was analysed using a commercial elisa kit (neogen corporation). using the total dose of fentanyl administered, the half-life of fentanyl was calculated for each patient. patient physiological data, cyp a and abcb polymorphism and drug history were compared with half-life. results: the median fentanyl concentration at hours was . mcg/l with a very wide range ( . - . mcg/l). the results for calculated half lives are shown in figure . there was no correlation between fentanyl level and bmi, illness severity (saps ll), creatinine clearance, transaminase or lactate level. there was no correlation between co-administration of drugs of metabolised by the cyp a and abcb enzyme systems or genotype. conclusions: there is marked variation in the concentration of fentanyl at hours in patients managed with ttm following cessation of fentanyl infusion. the calculated clearance of fentanyl in some patients is greater than hours and a hour cut off is not safe. introduction: objective of this study was to compare the effects of three analgesic regimens, one opioid and two multimodal ones, on cardiovascular stability and pain intensity in patients undergoing elective surgery under general endotracheal anesthesia during the h postoperative period. methods: sixty elderly patients, asa ii, undergoing elective knee sugary were assigned to receive ) morphine or mg iv q h, depending on body weight, and paracetamol g iv q h (mp group), or multimodal nerve block: ) femoral nerve block, single shot (fnb group) or ) fascia iliaca compartment nerve block single shot (ficnb group). measurement of pain intensity was performed with numerical introduction: opioids are frequently used in the intensive care unit (icu) to relieve pain and facilitate tolerance of life-support technologies. when discontinued abruptly, patients may develop a cluster of symptoms known as opioid-associated iatrogenic withdrawal syndrome (oiws). this phenomenon is poorly described in critically ill adults although it is associated with unfavourable outcomes, such as prolonged icu stay. the objective of this study was to describe the signs and symptoms of oiws in adult icu patients. methods: a prospective observational study was conducted in two tertiary care centres in patients requiring mechanical ventilation and regular opioids for more than hours. after an opioid dose reduction of at least %, patients were assessed daily for signs and symptoms of withdrawal using a standardized form. concomitantly, the presence of oiws was assessed daily by a physician using modified dsm- criteria. all physician evaluations were blinded and performed independently. inter-rater reliability for dsm- evaluations was assessed with the kappa coefficient. results: a total of patients were screened and twenty-nine enrolled. the majority were male ( . %) with a median age of . the median apache ii score was . withdrawal occurred in . % of patient within a median of three days (iqr to days) from opioid weaning. according to investigator assessment, restlessness, agitation, anxiety, hallucinations, insomnia/sleep disturbance, mydriasis and elevated blood pressure were more prevalent in oiws-positive patients. dsm- evaluations identified dysphoric mood, muscle aches, lacrimation/rhinorrhea, pupillary dilation/piloerection/sweating, diarrhea and yawning more frequently in oiws-positive patients. the kappa coefficient showed good agreement ( . ). conclusions: oiws in critically ill adults presents with a large spectrum of signs and symptoms that occur within a median of three days from onset of opioid weaning. further studies are needed to confirm these preliminary findings. withdrawal reactions after discontinuation or rate reduction of fentanyl infusion in ventilated critically ill adults s taesotikul introduction: propofol is a well-known sedative, commonly used in intensive care units (icu s), that on rare occasions has been reported to cause green urine and has also been associated with pink or transient white urine discoloration. it can cause several adverse effects, such as low blood pressure, pain on injection, apnea, hypertriglyceridemia and when administered in high doses it may lead to the "propofol infusion syndrome". methods: we present two examples of interesting urine discolorations observed unexpectedly in our icu in patients under propofol sedation requiring mechanical ventilation. results: dark green urine discoloration as presented in fig. is the result of a phenolic metabolite of propofol that is produced in the liver and is subsequently excreted in the urine, thus changing its color. it is considered a reversible phenomenon that resolves after propofol discontinuation.respectively, pink urine discoloration as presented in fig. can also be the result of propofol infusion. the increase in urine excretion of uric acid caused by propofol, in combination with a low urinary ph can lead to the formation of uric acid crystals and turn the urine pink. discontinuation of propofol and urine alkalization can reverse the phenomenon. conclusions: green or pink urine discoloration due to propofol is generally a benign, reversible condition. its presence should not compel the physician in charge to perform unnecessary testing, although other causes of discoloration should be considered. as far as green urine discoloration is concerned, other factors such as drugs, dyes, certain nutritional supplements or even a pseudomonas urinary tract infection may be at fault. on the other hand, pink urine syndrome due to propofol infusion seems to be even rarer. although its presentation is not alarming, it may well increase the risk of uric acid lithiasis, a fact that the physician in charge should always keep in mind. conclusions: hepatic changes related to propofol are frequently observed and should be systematically monitored to ensure patient safety. fig. (abstract p ) . dark green urine discoloration introduction: clevidipine (clev) and propofol (prop) are lipid-based medications used in the intensive care unit (icu) for hypertension and sedation, respectively. no data exists regarding potential adverse effects of concurrent therapy with this combination. this study aims to evaluate the incidence of hypertriglyceridemia (htg) and pancreatitis in icu patients using concurrent clev and prop. methods: this was a single-center, retrospective chart review in patients utilizing clev and prop concurrently from february to november . patients were included if they were years and older, on clev and prop concurrently for at least hours with no more than hours of interruption at a time, had at least one triglyceride (tg) level during concurrent therapy, and admitted to the medical or surgical icu. the incidence of htg (defined as tg equal to or greater than mg/dl) and pancreatitis (provider assessment based on american college of gastroenterology guidelines) was evaluated. patients with and without htg were compared to identify risk factors for the development of htg. results: of patients screened, patients were included which comprised observations. the incidence of htg was . % with no patients developing pancreatitis. patients with htg had a higher median age compared to without htg ( . vs. ), p= . . in patients with htg the median dose of clev and prop were mg/h and . mcg/kg/min, respectively, which was higher but not statistically significant when compared to patients without htg. cumulative lipid load (g/kg/d) was non-significantly higher in patients with htg ( . vs. . ), p= . . conclusions: the incidence of htg was comparable to what is cited in literature for prop alone. patients with htg were older, had higher median clev and prop doses, and a larger cumulative lipid load compared to patients without htg. introduction: the society of critical care medicine guidelines for pain, agitation and delirium suggested use of nonbenzodiazepine sedatives like dexmedetomidine which is associated with a reduced duration of mechanical ventilation, shorter length of hospital stay and a lower incidence of delirium [ ] . enteral clonidine represents a potentially less costly alternative for agitated patients with prolonged dexmedetomidine infusion. limited literature exists examining this transition for management of agitation [ ] . methods: the critical care management initiated an action plan on the transition of patients with prolonged dexmedetomidine infusion to oral clonidine. a protocol was prepared with clinical pharmacist's assistance. risk factors were assessed and inclusion criteria were applied as per protocol. dexmedetomidine infusion rate was reduced gradually with oral clonidine administration in selected patients. other rescue managements were implemented as per protocol. oral clonidine was then tapered down by reducing frequency of administration over few days. results: post intervention data in showed significant decrease of dispensed doses and cost of the injections compared to . the annual cost saving was % equating to , usd (table , figure ). conclusions: transitioning to clonidine may be safe and less costly method of managing agitated critically ill patients on prolonged dexmedetomidine infusion. more studies are needed to evaluate the efficacy and safety of this practice. incidence of dexmedetomidine associated fever at a level trauma center na beaupre, jt jancik hennepin county medical center, pharmacy department, minneapolis, united states critical care , (suppl ):p introduction: we evaluated the incidence of dexmedetomidine associated fever (daf) in a level trauma center's medical intensive care unit (micu). hypotension and bradycardia are the most commonly reported adverse effects associated with dexmedetomidine (dex) infusion. case reports suggest dex can cause fevers and the clinical trials that led to the approval of dex demonstrated fever rate to be - % [ ] . methods: this was a single-center, retrospective chart review of patients admitted to the micu at hennepin county medical center between march and july of that were started on a dex infusion. patients were included if they were years and older, on a dex infusion for at least hours, and had temperature data available. fever was defined as > . c and other causes of fever including infections, medications, withdrawal, recent surgery, thromboembolic disease, thyroid disorders and seizures were excluded from analysis. results: of the patients screened, were included. the mean age was years and . % were males. of all the patients included, the mean change in temperature after initiation of dex infusion was + . c from baseline. the mean initial dose was . mcg/kg/hr. four of patients ( . %) had a daf. of those that had a daf, the median initial dose was . mcg/kg/hr; the median time of infusion was . hours; and the median cumulative dose was . mcg/kg/hr. the median time to fever after initiation of dex was hours, with a range of to hours. the median time to fever cessation after discontinuation of dex was hours. conclusions: in our population, the incidence of dexmedetomidine associated fever was relatively rare at . % and similar to current literature rates. the results obtained showed a statistically significant fact that fewer points on the test, from to points, received older patients who underwent an urgent surgical procedure, over years of age, of which % . also statistically significant data were obtained that patients who used a higher amount of sedatives during emergency surgery, % had a worse test result than under points due to increased preoperative anxiety. the older population is more susceptible to postoperative delirium, especially in emergency surgery situations, which they carry, unpreparedness for surgery, increased use of medication for fig. (abstract p ) . flowchart of enrolled patients calm, unpredictability of the duration of surgery, and therefore anesthesia as well the use of anticholinergics, which is sometimes impossible to avoid in operative procedures such as gall bladder surgery. the results of the study suggest that in cases of emergency surgery, the use of protocols for postoperative delirium should be planned regularly to prevent or at least mitigate the clinical picture of delirium that can lead to complications postoperatively. introduction: delirium is a serious and often underestimated condition with implications for morbidity, mortality and healthcare costs. as it presents in a wide range of settings from admission to discharge, early prediction and risk assessment are essential. e-pre-deliric is a delirium prediction score which has been validated in itu patients but not in other populations, and we conducted a quality improvement project using this score to assess its utility in other settings. methods: data was gathered from three patient categories: those undergoing elective surgery (es), admissions to the emergency observation unit (eou) in the a&e, and patients with fractured neck of femur (nof). clinical notes were reviewed to collect data to calculate e-pre-deliric score at admission, along with a number of other clinical variables including incidence of delirium, and statistical analysis performed. results: a total of patients were included, with in the es group, in the eou group, and in the nof group respectively, with an overall average e-pre-deliric score of . %. es had a . % average e-pre-deliric score, a mean age of and no cases of delirium. the eou group had an average age of , a . % average e-pre-deliric score and no incidence of delirium. the nof group had a mean age of and an average e-pre-deliric score calculated on admission of . %. this was the only group in which patients developed delirium. a % cut off was demonstrated to be the most accurate to predict delirium in this population with a sensitivity of . and a specificity of . . conclusions: despite the limitation of a small sample size, this project has shown that e-pre-deliric score could be a useful tool to predict patients at high risk of delirium in a non-itu setting, with a % cut off in hip fracture patients. further investigation should be conducted into the potential use of e-pre-deliric in non-itu patients. comparison of long-term mortality between patients with and without delirium during admission in medical intensive care units in a university hospital n kongpolprom king chulalongkorn memorial hospital, pulmonary unit, bangkok, thailand critical care , (suppl ):p that delirium is linked with preoperatory comorbidities. the complexity of surgery has a big influence on the development of delirium, especially in the cases of aortic dissection. delirium was associated with intraoperatory blood transfusions. finally, our data point to a bridge between postoperatory electrolytic disturbances, as well as inflammation as factors potentially triggering delirium onset. introduction: we did a retrospective case note study of mortality due to sepsis of our unit over three months as observational study in which we noted the causes of deaths, origin of sepsis, organism, patient characteristics and icnarc physiology scores and icnarc h model predicted risk of acute hospital mortality percentage. methods: icnarc data base was used to gather the data and coding was used to identify the patients with sepsis for three months. patients mortality attributed to sepsis were identified from mortality list.causes of death were noted from patients notes and death certificates.cyber lab was used to access the data and case note were ordered for review.patients characteristics were noted including dnacpr orders and treatment withdrawal orders. scores (apache scores, icnarc physiology scores, icnarc h predicted risk models of acute hospital mortality percentage) were noted. results: mortality percentage was found to be % as per codig which was reduced to % as % deaths were attributed to other causes. % patient had dnacpr in first hrs. average length of stay was . days with median of . days.median age was yrs in surviving age group and years in other. icnarc physiology score with predicted risk of . %. commonest cause was found pneumonia % followed by urine tract infection. % patients were with no source identification. conclusions: conclusion was made that we do need to improve the coding as significant percentage was mentioned as sepsis as cause of death where clinicians differed. pneumonia was found to be the commonest killer in critical care followed by urine tract infection. it was pointed to be useful to carry out further audit targeting pneumonia .review of icnarc case mix program, development of icnarc physiology score, which provides excellent local use with downside of lacking international comparison was done also. introduction: hospitals vary widely in the quality of care they provide for septic patients. since many septic patients present to their nearest hospital, local variations in care quality may lead to geographic disparities in access to optimal sepsis care. we sought to better understand geographic access to high quality sepsis care, taking advantage of publicly reported data on sepsis management and outcomes in a large us state. methods: we performed a cross-sectional analysis of geographic access to high quality sepsis care, taking advantage of a new york state initiative that mandates public reporting of sepsis quality data to the state government. we linked these data to the locations of hospitals in new york state from the us centers for medicare and medicaid services and population data from the us census bureau for . we defined hospital sepsis performance using self-reported risk-adjusted mortality rates (ramr) and defined high-performing hospitals as those with a ramr < %, which represents the lower end of short-term mortality typically observed in sepsis. we used arcgis to generate drive-time estimates and assess population access to high performing acute care hospitals for sepsis care. results: hospitals publicly reported treating , cases of sepsis from a population of , , persons. overall access to an acute care hospital was excellent at the -minute drive threshold ( . %), good at the -minute threshold ( . %), and marginal at the -minute threshold ( . %). we classified hospitals ( . %) as high-performing based on a ramr < %. high-performing hospitals reported , ( . %) of the total sepsis cases. high-performing hospitals were geographically dispersed across the state, although population access diminished substantially with increasing drive times ( . % at -minutes, . % at -minutes, and . % at minutes; figure ). conclusions: one in six people do not have timely access to a high performing hospital for sepsis care using a -minute threshold. [ ] . this poses a significant safety risk. a previous study found that the implementation of a multidisciplinary medication safety group in intensive care increased reporting of errors and near misses [ ] . the purpose of our work was to set up a multidisciplinary group to provide a forum to review and improve medication safety at all stages of the process. here we discuss some of the initiatives and outcomes implemented in the last months. methods: ccmsg was formed in , under the leadership of the critical care pharmacy team, with representation from medical and nursing disciplines. the group meet fortnightly to analyse trends in medication errors, implement changes to local practice and review outcomes to improve patient safety. the cohesive, multidisciplinary nature of the group allows medication safety initiatives to be delivered in the most effective way. results: on average, ccmsg reviewed medication errors per month. the most common high risk drug classes involved are seen in table . medication safety initiatives implemented were based on these trends and included writing guidelines and policies, bedside education, teaching and training, informatics optimisation and operational changes. examples are seen in table . conclusions: initiation of a ccmsg provides a cohesive approach to facilitate the implementation of targeted safety initiatives, which are proven to reduce some of the most common medication errors in critical care. in addition, these often result in optimisation of operational and financial inefficiencies. introduction: cis/hospital electronic medical records downtime can cause major disruptions to workflow, patient care, key communication and information continuity [ ] . here we describe the consequences of deploying a business continuity plan (bcp) designed to support a critical care clinical informatics system (cis) failure, during an -hour unplanned downtime in a large central london icu. the institutional bcp was developed through an iterative process based on cis provider recommendations and internal workflow knowledge. it consisted of a web offline chart (woc) that is accessible at every computer connected to the network (in the event of a cis server fault), and via hard copy from designated back up computers connected to a printer (in the event of whole network loss). operational and clinical consequences were recorded during informal and formal debrief of the informatics team. the decision making around´drop-to-paper´was reviewed. -the bcp permitted´drop-to-paper´, service continuity and controlled uptime -patchy network loss and lack of a general institutional bcp delayed initial system failure diagnosis (network vs primary server); reduced reliability of´read-only´data and delayedd rop-to-paper-day-to-night handover during downtime led to loss ofḿ emory´of key patient data/events, and should have accelerated decision to´drop-to-paper-transfer of prescriptions was time consuming, distracting (occupied cis team) and prone to error conclusions: previous end-to-end testing of the bcp had not identified many of the observations and recommendations that came from the analysis of an actual period of unplanned downtime. we recommend sharing of similar experiences and scheduled high-fidelity simulated downtime in other institutions to replicate real world conditions, particularly in a critical care setting. . ) were predictors of icu transfer. we developed a simple score to predicting icu transfer from previous variables and performed analysis of auc of roc, which was compared to that of apa-che ii. the result showed the auc of roc of a new score was slightly higher than the apache ii, namely . vs. . respectively. conclusions: the immunocompromised patients take two times higher risk than the immunocompetent ones regarding icu transfer. the other risk factors are lower gcs, lower sbp, and higher rr. a newly developed score may be a promising tool for predicting and triaging site of care in patients who require imcu admission. introduction: this research aims to explore the role of situation awareness in the decision-making of patient discharge from the intensive care unit (icu). the discharge of these patients is a complex and, moreover, a challenging transition of care. readmissions are undesirable given the association with a more extended hospital stay and a possible chance of higher mortality. little is known on how the decision-making process takes place and accordingly, the role of situation awareness of patient discharge from the icu. in order to improve the quality of care of patient discharge from the icu, further research is necessary. methods: this research concerns a qualitative study in which various health care providers, working in an icu adults of a large teaching hospital, were interviewed. through purposive sampling, six nurses, two physician assistants, two intensivists and a physiotherapist were included. on the obtained data a thematic analysis was applied, based on the principles of the grounded theory. results: the discharge decision of icu patients seems mainly based on the team´s situation awareness, with the initiating role of the intensivist and the guiding role of the nurse. furthermore, there is an additional role for the physician-assistant and a consultative role for physiotherapy in the process of the decisionmaking. worries of patients and family seem not to affect the decision-making directly. in the decision-making process, the well-being of the patients and the possibility to provide the most suitable and best possible care were central. organizational factors, such as an urgent demand for icu beds do count but seem not to push the decision to transfer patients from the icu to the regular hospital ward. conclusions: the decision to dismiss icu patients is a complex process with different disciplines and a variety of factors involved. obtained knowledge and insights into the role of situation awareness provide starting points for improving the quality of the discharge process of icu patients. conclusions: despite the fact that older people was more severe illnes, and similar frequency of respiratory failure, the use of mechanical ventilation, the use of central venous catheter and arterial catheter was less frequent. the addition of a simulation fellow within the intensive care team and introduction of in situ simulation n bhalla, d hepburn, g phillips royal gwent hospital, intensive care unit, newport, united kingdom critical care , (suppl ):p introduction: traditionally, simulation based medical education has been carried out in off site simulation centres, however, we trialled the addition of a simulation fellow, within our intensive care team, to run an in situ simulation (iss) program on our intensive care unit over a month period. methods: our multi-disciplinary iss program, led by a simulation fellow, incorporated participants, observers and facilitators including doctors (junior trainees up to consultants of varying medical specialties), nursing staff, healthcare support workers, operating department practitioners, physiotherapists and medical students. we ran simulated emergency scenarios and technical skills sessions. with every scenario, we collected data on participant and observer feedback using the world health organisation participant feedback form and conducted a satisfaction survey at the end of our trial period. results: our results, highlighted in table , show participants found iss led by a simulation fellow realistic, well structured and organised. it was useful for testing and understanding our response systems, fig. (abstract p ) . patient journey of group : those patients discharged home days after step down from critical care identifying strengths and gaps and establishing individual roles/functions within emergencies; overall leaving us feeling better prepared for critical care emergencies. from our satisfaction survey, % of participants found the simulation fellow a useful addition to the intensive care team and expressed the need for more in situ simulation. conclusions: the addition of a simulation fellow allowed for numerous disciplines within the critical care team to be involved in challenging emergency scenarios (fig , ) , with the additional realism of being on the intensive care unit playing the role they would in real life; as well as having opportunity for spontaneous discussion and learning. from this they reported great benefit and satisfaction. following our initial success with this program, we plan to have a simulation fellow as an ongoing role within our critical care team. impact of multidisciplinary team in readmission in a brazilian cardiac intensive care unit c bosso , p introduction: the aim of this study is to determine the importance of the multidisciplinary team at readmission rates in a cardiac intensive care unit (cicu). methods: retrospective study with analysis of patients in a cicu of a medium size brazilian hospital. the years of and represent the reduced team (physician, nurse and physiotherapist) and and the complete multidisciplinary team (additional presence of phonoaudiologist, psychologist, pharmacist, dentist and nutritional professional). the risk of mortality was determined by saps score. in order to compare the teams, it was utilized odd ratio of a logistical sample to the discrete data, and t-student test to the continuous data. the data analysis was executed from the software rstudio ( . . ), and the significance level adopted was %. results: the number of patients was of n= ( from the reduced team and from the multidisciplinary team). the age, sex and bmi didn`t present significant difference between groups. the average age of the sample was ± years old (p= . ). the male sex represented % (p= . ), and the bmi was around . ± . (p= . ). the main diagnoses were similar in both groups -coronary angiography with stent ( %), unstable angina and non st elevation myocardial infarction ( %). table shows the average, standard deviation, p-value to t-student test to saps score and lengh of stay (days), according to both reduced and multidisciplinary teams. table exposes the mortality rate and readmission for both teams. the figure shows the odds ratio and its ic % to the comparison of the mortality, readmission, hours readmission and hours readmission rates between the teams. conclusions: the multidisciplinary team performance reduced the number of hospital readmissions in and hours in a cicu. methods: during the initial audit hours' worth of waste from one itu bed was manually divided into the categories above. results: based on these figures it was estimated that a saving of £ per year would be made (£ . per bed space) over the course of a year should domestic waste bins be placed across the bed icu/hdu. a business case was made, and every bay had a domestic waste bin installed with poster signs for explanation.the reaudit in which all domestic waste across the unit was weighed produced an even greater figure of a saving of £ per bed space (£ ) per year. conclusions: introducing a domestic waste bin may save approximately £ per year per bed. in a typical itu such as lewisham ( itu beds/ hdu beds) that may mean a saving of £ per year (with % capacity). there are also environmental benefits, burning of plastics releases harmful dioxins. the authors wish to make intensive care units and indeed all areas of the hospital aware of the cost and environmental impact associated with disposing of waste in incorrect categories. we hope that our quality improvement project demonstrates how easily money may be saved and environmental footprint reduced. association between resilience and level of experience in intensive care doctors in india j gopaldas, a siyal manipal hospital, bangalore, critical care medicine, bangalore, india critical care , (suppl ):p introduction: attrition of doctors in intensive care unit (icu) is one of the highest amongst all medical specialities globally, and is strongly associated with stress and burn out syndrome (bos). factors that contribute to bos are low pre-morbid resilience and low level of icu experience. studies from india have shown high levels of stress in intensive care doctors (> %), but there are no published studies measuring pre-morbid resilience and risk of burnout in relation to years of experience amongst icu doctors. our main aim was to measure cross sectional resilience levels in icu doctors compared between those with less than years of experience to those with years or more. a secondary aim was to assess the impact of other factors that may contribute to low scores. methods: an anonymised survey was conducted involving doctors in icus across different states in india, using the connor-davidson resilience scale (cd-risc ), which is validated in indian population. results: a statistically significant correlation was found between low levels of resilience in icu doctors with under years of experience . ) , and the significance level adopted was %. a logistic regression model was used to test the difference between the mortality and readmission rates in < and ≥ groups, which enabled the calculation of odds ratios. chi-square test was used to evaluate categorical variables and t-student test to some quantitative variables. the roc curve was constructed to verify the sensitivity of prediction of mortality through different saps scores. results: among the < and ≥ groups, respectively % and % was male (p = . ). mean weight of the> years was ± kg and < years was ± (p < . ). odds values indicated a significant difference only for the mortality rate, which was more than double among ≥ . readmissions in any time, h and h as well the mortality is shown in table and odds in figure . there was a significant difference in saps points between groups ( table ). the ≥ group presented an average of points higher on the severity scale when compared with those in the < group. there was no significant difference in lengh of stay. the highest amount provided by saps scores was % and a specificity of % for hospital mortality not group < years. in ≥ group the highest sensitivity was % and the specificity was %. roc curve for saps is shown in figure . conclusions: the extremely elderly patients of a cicu is more severe, with higher mortality and have the same lengh of stay and readmission rates. introduction: the purpose was to assess the prevalence and impact of non-urgent interruptions (nui) within critical care (cc).a root cause analysis of a never event in our cc discussed nui as a contributory factor, paralleled by learning from serious incidents.the negative impact of nui is well evidenced, resulting in delayed task completion, increased stress, and affecting patient safety. methods: any nui during a consultant ward round (cwr) or invasive procedure (ip), not relating directly to the current clinical episode, was included. qualitative data was collected by a survey, assessing the cc multidisciplinary teams(mdt) perception of nui. results: one third of reviews during the cwr, and %of ips, had a nui. adverse effects included prescription omissions, delayed cwr, near-miss with a cvc, and failed picc insertion. overall, % of staff considered nui a problem; % had experienced nui that led to distraction in train of thought. % felt that nui had led to an error: % of doctors, versus % of nurses. % overall felt nui contributed to stress at work. reasons for interruptions included: feeling overloaded, needing to resolve concerns before forgetting/being distracted, unable to prioritise, and to shift responsibility.lack of leadership or clinical supervision providing a point of contact for problems during shifts was mentioned as contributory. senior staff raised that whilst attempts have been made to level hierarchy, allowing a voice for all to express concerns contributes to interruptions. potential solutions included awareness on impact of nui, jobs book,´sterile cockpitd uring ips, and increased clinical supervision during shifts. conclusions: we have demonstrated the prevalence and consequences of nui within cc is significant.the impact on staff is significant, both for contribution to errors and also the negative impact on stress in the workplace. identified potential solution will be implemented. the impact of an education package on the knowledge, skills and self-rated confidence of medical and nursing staff managing airway & tracheostomy/laryngectomy emergencies in critical care l o´connor , k rimmer , c welsh methods: the factors affecting the delivery of intensive care was elucidated by a comprehensive review of the intensive care literature. a further understanding of intensive care delivery in south africa was obtained by "making sense of the mess" with eight workshops and interviews using a systems approach. systemic intervention served as the meta-methodology and methods and techniques from interactive planning, critical systems heuristics, soft systems methodology and the viable system model were employed. results: making sense of the mess emphasised the complexity of intensive care delivery, on both a situational and a cognitive level. it became clear that a single methodology would not suffice, but that a pluralist methodology was required to guide improvement in intensive care delivery. based on this understanding, nine principles were formulated to guide the development of a framework. systemic intervention was again used as the meta-methodology. interactive planning was identified as the key methodology, incorporating methods and techniques used in the making sense of the mess phase to build a systemic framework for the improvement of intensive care delivery. embedded in the proposed framework are matters relating to systemicity, complexity, flexibility, empowerment, and transformation of intensive care delivery. the proposed framework allows for multiple-perspectives, including that of marginalised stakeholders, the mitigation of multivested interests and power relationships (fig ) . it is both flexible and adaptable to promote learning about the complex problems of intensive care delivery and it accommodates the strengths of various relevant approaches to complex problem solving. conclusions: the proposed framework aims to facilitate sustainable improvement of intensive care delivery and to ensure the "just-use" of resources to foster distributive justice. the perioperative management of adult renal transplantation across the united kingdom: a survey of practice c morkane , j fabes , n banga , p berry , c kirwan introduction: there is a limited evidence base to guide perioperative management of patients undergoing renal transplantation and no national consensus in the uk. we developed an electronic survey to provide an overview of uk-wide renal transplant perioperative practice and determine the need for future guidelines on patient management. methods: a -question survey was developed to encompass the entire renal transplant perioperative pathway with input from clinicians with expertise from renal transplant surgery, anaesthesia, nephrology and intensive care. the survey was sent to lead renal anaesthetists at each of the transplant centres across the uk. results: twenty-two centres ( %) returned complete responses. there was limited evidence of guideline-based approaches to preoperative work-up, with marked variety in modality of preoperative cardiorespiratory function testing performed. questions regarding intraoperative fluid management (fig ) , blood pressure targets and vasopressor administration (fig ) identified a broad range of practice. of note, the routine use of goal-directed fluid therapy based on cardiac-output estimation was reported in six ( %) centres whilst nine centres ( %) continue to target a specific central venous pressure (cvp) intra-operatively. a dedicated renal ward was the most common postoperative destination for renal transplant recipients ( % of centres), whilst a renal or transplant-specific hdu provided postoperative care in ( %) centres. the need for care in an icu setting was decided on a case-by-case basis. conclusions: this questionnaire highlighted a high degree of heterogeneity in current uk practice as regards the perioperative management of renal transplant recipients. development of evidence-based national consensus guidelines to standardise the perioperative care of these patients is recommended. fig. (abstract p ) . framework for the improvement of intensive care delivery introduction: postoperative care of high risk patients in the icu used to be considered the gold standard of care in terms of reducing perioperative mortality [ ] . new evidence comes to question this practice [ ] . the primary objective of our study was to detect any benefit of postoperative icu care after elective surgery in terms of patient's outcome, length of hospital stay, complications and cost. methods: a -month retrospective analysis of high perioperative risk patients who were about to be subjected into an elective operation were included into the study. subsequently they were allocated into two groups. group i patients were those admitted into the icu for postoperative care while those admitted into the standard ward consisted group ii. demographic data, length of hospital stay, outcome, need of mechanical ventilation, complications and total cost were recorded. results: a total of patients were recorded, in each group. there was no statistical difference regarding the demographic data between the two study groups. seven patients died before hospital discharge ( in group i and in group ii, p> . ). there was no impact of icu admission on length of hospital stay (p= . ) which is primarily affected by the need of mechanical ventilation (p= . ) and reoperation (p< . ). the total cost and the postoperative cost of hospital care did not statistically differ among study groups. conclusions: according to our study the need of postoperative care of high risk patients in the icu is rather questionable in terms of perioperative mortality, length of hospital stay and cost of care. introduction: tivap is a preferred vascular access device for patients with solid tumors and radiological-guided insertion is a standard of care. however, many hospitals have no access to interventional radiology service. our study aimed to determine whether it is safe to place tivaps in icu for immediate administration of chemotherapy. methods: we analysed prospectively maintained database of our department and collected data for adult pts with tivaps implanted between / and / . the median age was (range - ) years, % were women. all procedures were performed by trained physicians with experience in ultrasound (us). puncture technique was used and tip location was controlled with electrocardiographic (ecg) and us with subsequent chest x-ray confirmation. pts were followed up for at least days after the procedure for complications, functioning of tivap and surgical wound healing. results: all tivaps were successfully implanted in pts. infraclavicular route was used in cases ( . %). difficulties with indwelling guide wire were observed in ( . %) pts but did not precluded implantation. placement complications included pneumothorax (n = ), catheter malposition (n = ) and artery bleeding (n = ). these complications required additional therapy but were managed successfully and resolved without consequences. in the rest cases internal jugular vein (jv) was used. complications were not observed. ecg and us navigation provided optimal tip location control in these situations. surgical wound healed after - days and chemotherapy initiation did not affect healing. all tivaps had adequate functioning days after placement. conclusions: it is feasible to implant tivaps in icu. these devices can be used on the implantation day without jeopardizing patient safety. jv catheterization seems to be optimal approach and us navigation and ecg are sufficient methods for placement control. introduction: there is increasing use of clinical information systems to improve patient safety and quality of care in critical care. with all these systems, a rigorous business continuity access (bca) plan needs to be in place so patient safety is not compromised [ ] and ensure continuity of care. here we evaluate the types of medication errors that occurred during a period of unscheduled downtime; potential contributory factors [ ] and the number of errors involving critical medicines [ ] were analysed. methods: during the unscheduled downtime, all prescribing and administration of medicines were transferred to a paper based system using the patients' web offline chart (woc -philips healthcare). pharmacists at the time double checked the paper charts that were transcribed, to mitigate errors but this was not consistent due to the timing of the event. we retrospectively compared the paper drug charts against the electronic prescriptions and noted all errors for patients. results: in total medication errors were identified & allergy omission ( table ) . pharmacists double checked % of the paper charts. conclusions: our data highlights the risks associated with unscheduled electronic patient management system downtime and the heterogeneity of the types of errors & potential contributory factors. it underscores the need for robust local bca plan implementation, critical review of the woc document and regular staff training around potential unscheduled system downtime. introduction: the transfer of patient care (toc) between the intensive care unit (icu) and hospital ward is associated with a high risk of medical errors [ ] .according to uk national data between - % of patients have an error or unintentional medication change made when moving between care settings [ ] . currently different prescribing systems without interoperability are used between icu areas & ward settings in our institution, resulting in medications needing to be re-prescribed on transfer. we aimed to evaluate the time delay in medication re-prescribing, number of unintentional omissions of drug doses and reasons, as well as percentage of critical medicines [ ] omitted in the first h following discharge. methods: over a month period, discharged patients ( % of all discharges) from two icu units were included. the icu discharge letter which contained the medication list on transfer was compared against the ward based electronic drug chart to identify all unintentional omitted medication doses during the first hours. the starting time point was when the patient physically left icu. results: / ( %) of patients had their medication prescribed more than hours post discharge. there were a total of / , ( %) unintentional omitted doses (table ) . of these / ( %) were considered critical medicines ( table ) . conclusions: this data confirms the risk associated with toc especially around medicines. the need of interoperable electronic prescribing systems is one solution and could improve patient safety by streamlining the process. introduction: staff perceptions of safety may contribute to workforce stress and be organisationally important [ ] . this study explored the feasibility of capturing perceptions of safety with a bedside professional reported (bpr) shift safety score, and explored relationships between bpr and measures of staffing and workload. methods: uk health research authority approval was obtained (id ). data were collected for consecutive days at imperial college healthcare trust ( general critical care beds on sites).the bpr asked all icu staff to rate each shift as "safe, unsafe, or very unsafe". responses were described and correlated with data on organisational staffing (care hours per patient day chppd) and nursing intensity (total number of organs in failure/ total number of nurses). results: a total of bpr scores were recorded (response rate %). we noted heterogenous responses between sites and days, and within shifts, only % of shifts were unanimously rated. whilst % of shifts were rated by staff as "unsafe" or "very unsafe", organisational metrics recorded only % as 'unsafe'. we did not find a correlation between measures of staffing (chppd) and perceptions of safety ( figure ). preliminary analyses suggest that staff perceptions of safety are not well correlated with nursing intensity (figure ), although these numbers commonly inform staffing metrics. conclusions: completing the bpr tool was feasible and acceptable to staff. responses showed variations in perceptions of safety and a gap between organisational metrics and individual perceptions. introduction: delivery of intensive care (icu) is complex because of multiple stakeholders with varied perspectives and conflicting goals that interact and are interdependent. to inform the development of a framework for the improvement of icu delivery in south africa, it was essential to first understand icu delivery or "make sense of the mess". a systemic approach such as systems thinking is required to holistically explore and understand the complexity of icu. no methodology is perfect and methodological pluralism as proposed by systemic intervention, a systems thinking approach, was used for a more flexible and responsive intervention. the methods used was the making sense of the mess phase of interactive planning, stakeholder analysis as describe by critical systems heuristics, rich pictures from soft systems thinking and viable systems model diagnosis. making sense of the mess was done in phases: first the mess was formulated with rich pictures generated in workshops and interviews. the discussions of the rich pictures by the respective stakeholders were transcribed and analysed using braun and clark's thematic analysis. secondly, based on the data generated from phase a diagnosis of the viability of the icu system was made. results: the data from the phases were very rich and complex and themes emerged (figure ). these themes were interdependent and resulted in disorganised icu delivery with limited opportunities for learning to improve icu delivery with dichotomies that existed at various levels of icu. it was a problem to present the complex data in the traditional linear manner due to the interdependence of the themes. the analysis is presented as stories, a known approach in the complexity discipline, where the themes of the analyses are portrayed. the making-sense-of-the-mess phase confirmed the complexity of icu delivery, at both a situational and a cognitive level and with this understanding a framework for the improvement of icu delivery could be developed. introduction: improving prescribing practice involves changing prescriber behaviour. education is assumed to change behaviour but other approaches may be more effective (figure ) [ ] . changes to the presentation of information and the configuration of choices have potential to rectify common prescribing errors through subtle 'nudges' [ ] . the implementation of clinical information systems (cis), including electronic prescribing, provides an opportunity to deploy strategies such as standard orders, dose limits, and product level prescribing. with an infinite number of configuration options available, clinical leaders need to know which interventions are most effective. we evaluated several of these strategies in a before and after observation study methods: interventions, utilising cis nudges, were chosen to improve four areas of prescribing practice in a tertiary critical care unit using methods matched to the top levels of the hierarchy. data were collected for months before and after interventions to map changes in compliance with a pre-defined standard except for the standardisation intervention where months' data were collected due to low prescription numbers. no education on changes was given during the baseline data collection so any change in performance after the go-live date is entirely attributable to the intervention. results: the change in performance for each level ranks the intervention levels in the order (highest first) forced function, automation and standardisation ( table ). the use of point of prescribing reminders was not associated with a significant difference in performance. conclusions: the effectiveness of intervention levels seen in practice is consistent with that of the model. further studies could be undertaken to strengthen these conclusions but in the meantime the approach to changing practice using cis nudges should focus on standardisation or above. introduction: intensive care unit (icu) sound pressure levels (spl) are persistently above world health organisation recommendations for clinical areas [ ] . this may impact patient recovery. standard spl monitoring records single values for each h period (laeq ). we hypothesise this reporting rate is unsuitable for icu. methods: we measured spl october -may , logging frequency (hz), spl (db), and loudness (perception of sound) every second [ ] . the resulting dataset was of a size that conventional statistics programs would require computational resources not easily obtainable on standard university commodity hardware. we processed the full dataset without sampling by using distributed task dispatching, parallelism and scheduling of a cluster computing framework (apache spark). we created a system consisting of a single workstation ( cores; gb ram) running ubuntu . lts, oracle java . , apache spark . , scala . , r core . , r studio . and sparklyr . . . we utilised the sparklyr library in r studio to run arbitrary r code using the dplyr library. we analysed aggregate data in r core & used ggplot (v ) to create visuals. results: we achieved more complex analysis than standard spl reporting with relatively modest computing resources. specifically we identified lower spl peaks in the early hours & loudness levels considerably higher than parallel spl. conclusions: simple laeq do not facilitate reflection on practice thus impetus for change is limited. loudness data highlight the patient experience of spl in the icu is more intrusive than laeq indicates due to high sensitivity to sounds~ - khz, a common frequency range for alarms. higher fidelity increases understanding of spl which can lead to targeted interventions to reduce patient disturbance. introduction: survivors of critical illness face significant long term impairments in mental and physical function. early mobilisation (em) in the intensive care unit has been suggested to improve functional outcomes and reduce delirium in the icu. we hypothesized that implementing a protocol for em in the icu would improve mobilisation rates while remaining safe. methods: design: prospective non-blinded observational cohort study, based on a quality improvement project. data was collected conclusions: only of variables in boyd criteria were significant associated with morbidity or mortality. the physiologic score and operative score were significant higher in the patient on mortality and morbidity after sicu admission. effects of structural hospital characteristics on risk-adjusted hospital mortality in patients with severe sepsisanalysis of german national administrative data d schwarzkopf introduction: the quick sequential organ failure assessment (qsofa) score is a simple tool used to identify severe patients with infection. as this score is calculated from three variables that can be measured at the scene of trauma-systolic blood pressure, respiratory rate and consciousness-the prehospital qsofa score may also be a good predictor of mortality in trauma patients. so we evaluated the discriminative ability of the prehospital qsofa score in patients with trauma for in-hospital mortality. methods: this is a retrospective multicenter study using the data from nationwide trauma registry in japan. we included patients with trauma aged ≥ years old transferred to hospitals from scene. primary outcome is in-hospital mortality. results: the mean age was . ± . years old and patients ( %) were male. in-hospital mortality occurred in patients ( %). in-hospital mortality in each qsofa score was / ( . %), / ( %), / ( %) and / ( %) in qsofa score , , and , respectively (p< . for trend). area under receiver operating characteristics curve (auroc) of the aqsofa score for inhospital mortality was . ( % confidence interval . - . ). if we use the cutoff ≥ , sensitivity and specificity of the qsofa score were . and . . conclusions: in patients with trauma, the prehospital qsofa score was strongly associated with in-hospital mortality. we can identify patients with very low risk of death by using the cutoff ≥ of the prehospital qsofa score. introduction: only one prospective study is available of the validation of the diagnostic and prognostic role of qsofa (quick sofa score) in the emergency department (ed). a prospective study was conducted in greek eds. methods: the prompt study (clinicaltrials.gov nct ) run in the ed of six hospitals in greece among patients with suspected infection and presence of at least one of fever, hypothermia, tachycardia, tachypnea and chills. clinical data were collected and the -day outcome was recorded. sepsis was defined by the sepsis- criteria. results: the sensitivity and the specificity of at least signs of qsofa for the diagnosis of sepsis was . % and . % respectively and for the prognosis of -day mortality . % and . % respectively. the odds ratio for -day mortality when qsofa was equal to or more than was . among patients with charlson's comorbidity index (cci) equal to or less than ; this was . among patients with cci more than (p: . between the two ors by the breslow-day's test; p: . by the tarone's test). conclusions: data validated the sensitivity of qsofa for the diagnosis of sepsis. cci was an independent predictor of severity. qsofa could better predict unfavorable outcome among patients with low cci. comparative accuracy between two sepsis severity scores in predicting hospital mortality among sepsis patients admitted to intensive care unit n sathaporn, b khwannimit prince of songkla university, internal medicine, hat yai, thailand critical care , (suppl ):p introduction: recently, the new york sepsis severity score (nysss) was developed to predict hospital mortality in sepsis patients. the aim of this study was to compare the accuracy of nysss with the sepsis severity score (sss) and other standard severity scores for predicting hospital mortality in sepsis patients. methods: a retrospective analysis was conducted in a medical intensive care unit of a tertiary university hospital. the performance of severity scores was evaluated by discrimination, calibration, and overall performance. the primary outcome was in-hospital mortality. results: overall , sepsis patients were enrolled, patients ( . %) were classified to septic shock by sepsis- definition. hospital mortality rate was . %. the nysss predicted hospital mortality . +/- . %, which underestimated prediction with smr . ( %ci . - . ) . however, the sss predicted hospital mortality +/- . %, which slightly overestimated mortality prediction with smr . ( %ci . - . ). the nysss had the moderate discrimination with an auc of . ( % ci . - . ), in contrast to the sss presented good discrimination with an auc of . ( %ci . - . ). the auc of sss was statistically higher than that of nysss (p< . ). nevertheless the apache iv and saps ii showed the best discrimination with auc of . . the auc of the nysss and sss was significant lower than that of apache ii, iii, iv, saps ii and saps ( figure ). the calibration of all severity scores was poor with the hosmer-lemeshow goodness-of-fit h test < . . the nysss was the lowest overall performance with brier score . . the apache iv present the best overall performance with brier scores . . conclusions: the sss indicated better discrimination and overall performance than the nysss. however the calibration of both sepsis severity scores and another severity score were poor. furthermore, specific severity score for sepsis mortality prediction needs to be modified or customized to improve the performance. introduction: metabolic markers, especially lactate, have been shown to predict mortality in acutely unwell patients. we hypothesised that early changes in metabolic markers over time would better predict mortality and length of stay, with patients who correct their metabolic derangement having lower risk of death and reduced length of stay (los). methods: single centre, retrospective cohort study in a bed icu. we included all patients who had an arterial measurement of lactate, paco , base excess (be) and ph on admission and at hours after admission to icu between / / and / / . the 'clearance' of these markers was calculated using the equation ((value at admissionvalue at hours)/value at admission). clearance calculations only included those patients with deranged results on admission (lactate> mmol/l, be<- mmol/l, ph< . , paco > . kpa). roc analysis was used to predict in-hospital mortality and length of stay, using both the initial admission values, and using the clearance value, as well as icnarc and apache ii scores for comparison. if a patient was admitted twice in the time period, only the first admission was included. results: patients were included (sex ratio . , mean age . ). table ). none of the values tested had a auc greater than . for predicting length of stay. conclusions: the clearances of metabolic markers over the initial hours after icu admission does not provide better prognostic information than the value at admission. initial lactate level was the best predictor of mortality, but compared poorly to icnarc score. metabolic markers do not accurately predict length of stay. . - . ) vs . (iiq . - . ), p= . ]. the other hemogram parameters did not differ between groups (table ) . when adjusted for severity score, in patients submitted to emergent surgery, the mpv value was still independently associated with mortality (or . ci . - . , p= . ), and its roc curve (auc) was . to mortality (figure ). conclusions: mpv is a cheap and easily accessible marker which can add prognostic value in this specific population. in the future, we will validate it in a larger cohort of cancer pts admitted to intensive care. haematological malignancy in critical care: outcomes and risk factors c denny introduction: about % of patients admitted to hospital with a haematological malignancy will become critically ill [ ] . life expectancy in these patients is poor with a month mortality of % or more in specialist units [ ] . in contrast, patients without critical illness can expect a year survival rate exceeding % for many cancers. this disparity results in differences of opinion on the best strategy for such patients among haematologists and critical care physicians. we conducted a local quality improvement project to quantify mortality and risk factors in critically ill patients with a haematological malignancy in our hospital. methods: patients admitted to the critical care unit of broomfield hospital, a district general hospital with tertiary specialist services, from january to december with haematological malignancy were included in the analysis. patients in remission for more than years and patients admitted following elective surgery were excluded from analysis. death in critical care or in hospital after critical care discharge were the primary outcomes. mortality was correlated with demographic data using simple statistical measures and regression analysis. results: patients were included in the analysis. overall mortality was %(n= ). survivors tended to be younger ( vs years) but had similar clinical frailty scores. early critical care admission (within hours) was associated with better survival ( . vs . %). nonsurvivors had a greater incidence of sepsis and respiratory failure, and required more ventilatory and vasopressor support. mortality was higher in patients requiring more than one organ support. conclusions: the overall mortality in our data is lesser than previously published data but supports the conclusion that mortality is determined primarily by the number of organs supported with the effects of malignancy playing a secondary role. (figure ). increasing levels of frailty were associated with increasing risks of death at year (p< . ) (figure ). frailty significantly increased -year mortality hazards in unadjusted analyses (hr . ; %ci; . - . ; p< . ) and covariate-adjusted analyses (hr . ; %ci . - . ; p= . ) ( table ) . conclusions: frailty was common and associated with greater age, more severe illness and female gender. frailty was significantly associated with heightened mortality risks in both unadjusted and covariateadjusted analyses. frailty scoring may encapsulate variables affecting mortality which are omitted in current predictive systems, making it a promising risk stratification and decision-making tool in icu. fig. (abstract p ) . unadjusted survival curves stratified by frailty status. frail patients were statistically significantly less likely to survive to year plateau at day = , delta peak= and hpr= . . were assigned respectively a point value of , , and to these predictors based on their beta coefficient in the predictive model. the score yielded a roc-auc: (auc= . ; %ci, [ . - . ]; p= . ). using the validation data set (n= ), the score had an roc-auc= . and similar estimated probabilities for mortality. conclusions: the paw-mps seems to demonstrate interesting discriminative properties to predict mortality. what is the role of the pulmonary embolism severity index (pesi) and rv/lv ratio as clinical risk assessment tools for patients undergoing ultrasound-assisted catheter-directed thrombolysis (uacdt)? introduction: to evaluate if the pulmonary embolism severity index (pesi) score correlates with rv/lv ratio, biomarkers of cardiac injury, fibrinogen and length of stay(los). also to evaluate the correlation between rv/lv ratio with biomarkers of cardiac injury, fibrinogen and los for patients who underwent uacdt. methods: a retrospective review of patients with sub-massive pulmonary embolism (pe) who underwent ultrasound-assisted catheterdirected thrombolysis (uacdt) was performed. pesi score, rv/lv ratio, length of stay(los), fibrinogen levels, troponin levesl, and brain natriuretic peptide(bnp) levels, were calculated and collected prior to uacdt. spearman's rank correlation coefficient was calculated for all non-parametric variables. results: patients, males and females, were included in the study. the mean (±sd) age was ± years. the mean pesi score was ± . mean rv/lv ratio was . ± . . a significant correlation between the rv/lv ratio and both fibrinogen and troponin level (p= . , p= . ) was noted. no significant correlation existed between pesi score and rv/lv (p= . ). no significant correlation existed between both rv/lv ratio and pesi score with length of stay (p= . ) after uacdt. there were no noted mortality or complications. conclusions: pesi score is used as a prognostic factor for the patients with pe, however, our study shows that pesi score does not correlate with rv/lv ratio or length of stay after the uacdt. there was inverse correlation between rv/lv ratio and fibrinogen. there was also positive correlation between rv/lv ratio and troponin for patients with and without heart failure. according to our data, there may be limited use of pesi score and rv/lv ratio for risk stratification of pe patients undergoing uacdt. introduction: conventional scores for prediction of risk and outcome, such as sapsii and sofa, have not been validated for patients admitted to level ii critical care units (intermediate level or imcus). we compared the performance of sapsii and sofa scores with the intermediate care unit severity score (imcuss) in a general population admitted to imcu. methods: we conducted a prospective observational cohort study in a -bed level ii-iii icu from a university-affiliated hospital, during a three-month period. we applied sapsii, sofa day one and imcuss to all patients admitted during that period. primary outcome was a composite of hospital mortality and need to increase level of care. additionally, we tested the relevance of each variable within each score to predict the outcome. results: we included patients with a mean age of . ± . years. patients were considered "step-down" (transferred from our level iii beds), and the remaining originated from the emergency conclusions: months after completion, the primary care management intervention had no effect on mental health-related quality of life and physical function among survivors of sepsis. increase in ptsd symptoms in the control group may suggest a possible protective effect of the intervention. introduction: critically ill patients and their families are often confronted with an overwhelming amount of clinical information shortly after hospital admission. their reliance on internet resources for additional information is increasing, particularly for unfamiliar medical terminology. yet, little is known about whether these online resources meet the recommended reading level and complexity appropriate for the average reader. methods: an online search of websites containing four common critical care diagnoses in the icu (respiratory failure, renal failure, sepsis and delirium) was performed. a total of readability formulas were used. the flesch-kincaid grade reading level (grl) and flesch reading ease (fre) were used in the final analysis. document complexity was evaluated using the pmose/ikirsch formula. results: websites on respiratory failure were written at the th grl with fre of . . renal failure resources had a th grl with fre of . . sepsis websites had an th grl with fre of . . delirium websites had a th grl with fre of . . when comparing website types (government, non-profit and private), anova showed a difference in fre across all groups and government websites had a conclusions: online resources used by intensive care unit patients and families tend to be written at higher than the recommended th grl, with government sites better meeting this target than nonprofit and private organizations. online resources should be improved to lower this unfortunate barrier to patient education. introduction: the recent enactment of the data protection act , the general data protection regulations, and a series of data breaches in the healthcare sector, have renewed interest in how our patients' information is collected, used and shared. the complex framework of laws and regulations governing the use and disclosure of personal data may lead to professional and financial consequences if information is disclosed inappropriately. disclosures to the police when they concern incapacitous patients are particularly challenging, as the disclosure may have no direct benefit to the patient and may cause the patient considerable harm. methods: we have reviewed the relevant laws and regulations to identify the circumstances in which doctors must release information regarding incapacitous patients to the police. the laws and regulations are examined to identify the extent of the disclosure required, and any requirements for the disclosure to be lawful. we have also identified laws which confer a power to disclose information about incapacitous patients, and the circumstances in which these powers can be used. results: in conjunction with a local police constabulary we have developed an information request form which makes it easier for those requesting and disclosing information to understand the legal basis of the disclosure. we have also developed guidelines to allow practitioners to understand where a disclosure is obligatory or discretionary. conclusions: the next stage of the project is to audit disclosures of information in the intensive care unit, and identify whether information is being released lawfully and following the correct procedure. introduction: family members are affected both physically and psychologically when their relative is admitted to icu. there is limited knowledge describing their experiences and structured interventions that might support them during their relative's critical illness. the aim of this review is to describe published literature on the needs and experiences of relatives of adult critically ill patients and interventions to improve family satisfaction and psychological well-being. methods: design: scoping review. standardised processes of study identification, data extraction on study design, sample size, sample characteristics and outcomes measured (figure ) . results: from references, studies were identified for inclusion four key themes were identified: ) different perspectives on meeting family needs ) family satisfaction with icu care ) factors impacting on family health and well-being and capacity to cope ) psychosocial interventions conclusions: family members of patients in icu experience unmet information and assurance needs which impacts on their physical and mental health. structured written as well as oral information show some effect in improving satisfaction and reducing psychological burden. icu's who are able to support interventions based on meeting family information needs, in addition to reducing psychological burden and increasing satisfaction will enable each family to provide more support to their relative within the icu. introduction: unmet informational needs lead to dissatisfaction with care and psychological distress. identifying interventions to help meet specific needs is a crucial and necessary step in providing family centred care in icu. we aimed to implement and evaluate the impact of delivering a structured communication strategy on levels of anxiety, uncertainty and satisfaction with care and decision making in families of critically ill adults. methods: a quasi experimental study with pre and post test design. a convenience sample of family members were recruited from july to february . the intervention group (n= ) received both oral and printed information to guide them in preparing for a structured family meeting. the control group (n= ) received usual fig. (abstract p ) . article selection process for scoping review routine care and existing family informational support. anxiety, uncertainty and family satisfaction were measured in the two groups on icu admission and icu discharge. results: mean anxiety, uncertainty and satisfaction with care and decision making scores pre and post intervention were compared. there were no significant differences in mean anxiety, uncertainty or satisfaction scores between the two groups before the intervention (p> . ). mean scores on anxiety ( . vs . ), and uncertainty ( . vs . ) were lower post intervention, but not significantly so ( figure & ). total satisfaction, satisfaction with care and satisfaction with decision making mean scores were similar in both groups before and after the intervention (p. . ). conclusions: providing relatives with a combination of targeted written and oral information delivered by nursing and medical staff reduced anxiety and uncertainty with this reduction being evident through to discharge from icu. although not statistically significant, there was what may be seen as a suggestion of a clinically significant drop in anxiety and uncertainty following the intervention introduction: clinical studies in intensive care unit (icu) patients are warranted in order to improve healthcare. the aim of this study was to analyse barriers and challenges in the process of achieving informed consent from icu patients. methods: we analysed patients considered for inclusion in a prospective observational study of venous thromboembolism in the icu, i.e. the norwegian intensive care unit dalteparin effect (norides) study. data were collected from the screening log, consent forms and associated research notes of the norides study. results: we observed that of ( %) eligible patients according to inclusion and exclusion criteria were omitted from the nor-ides study due to barriers and challenges in the process of receiving informed consent. were categorized as psychiatric diseases consisting of known psychosis or recent suicide attempt, likely or actual treatment withdrawals and due to language barriers among non-norwegians. among the patients included in the norides study, ( %) consents were from patients and ( %) obtained from their next of kind. from the patient consents, ( %) consents were oral and ( %) were written. patients were physically unable to sign, and patients did not recognize their own signature. the study further pointed at some specific challenges in the process of consent, herein questionable competence to give consent, failure to remember being asked/included, inability to separate research from treatment etc. there were also difficulties in evaluating who was next of kin and how to reach them. conclusions: barriers and challenges in obtaining informed consent from icu patients led to exclusion of one fifth of the eligible patients in our study. informed consent directly from patients was obtained from less than half of the included patients. obstacles in the process of achieving informed consent were practical, medical, ethical and/or legal. determinants of end-of-life decision-making in the intensive care unit p eiben, c brathwaite-shirley, s canestrini king´s college hospital nhs foundation trust, london, united kingdom critical care , (suppl ):p introduction: although the majority of intensive care unit (icu) deaths follow the decision to forgo life sustaining treatment (lst), variability in patterns is commonly observed [ , ] . we reviewed end of life (eol) practice at our institution in order to explore: (i) patient characteristics affecting eol decision-making, (ii) communication among surrogate decision-makers, and (iii) eol management. methods: we retrospectively analyzed data from consecutive patients who died in our ten-bed icu over months (study period). patient demographics, apache ii, functional status, diagnosis on admission, icu length of stay (los) were collected; family/next-of-kin (nok) involvement and rationale for lst limitation were recorded ( conclusions: our analysis shows that in our institution eol deliberations follow a shared decision-making process. lack of family/nok involvement and incomplete documentation was exceptional. the significant difference in los between w-group and nw-group, in the face of similar apache ii, warrants further investigation. vae calculator rheumatology review . van der jagt m. crit care consensus on circulatory shock and hemodynamic monitoring. task force of the european society of intensive care medicine cardiac output monitoring: how to choose the optimal method for the individual patient perioperative cardiovascular monitoring of highrisk patients: a consensus of guidelines for nutrition support therapy in the adult critically ill patient references . nice guideline for aki: prevention, detection and management serial creatinine results pre-and post ecmo references . polit et al. research in nursing & health reference . sherliker et al national blood transfusion committee, nhs blood and transplant arch otolaryngol head neck surg fig. (abstract p ). rsi agent guideline references . nuckton tj nejm icm baseline characteristics reference elso guidelines for cardiopulmonary extracorporeal life support s -leitlinie invasive beatmung und einsatz extrakorporaler verfahren bei akuter respiratorischer insuffizienz .auflage p handgrip strength does not predict spontaneous breathing trial failure or difficult or prolonged weaning of critically ill patients g friedman total burn care introduction: we aimed to evaluate safety and efficacy of light sedation with dexmedetomidine (dex-ls) in acute brain injury (abi) patients. methods: retrospective analysis on icu patients with traumatic/medical abi, out of the neuroprotection window and undergoing dex-ls. data of pre-infusion and infusion periods were compared. results: patients (age ± , males . %) were included. traurespectively. conclusions: dex-ls among icu patients affected by abi turned out to be feasible and safe. it enabled discontinuation from mv and maintenance of spontaneous breathing in the majority of cases %) delirious patients and of ( . %) non-delirious patients could be discharged from the hospital. we evaluated the -year mortality in the hospital survivors. results: totally, patients participated in our study. the majority of them ( . %) were male with the median age of [ , . ] years and the median apache ii score on the first day of icu admission of risk of delirium was associated with preoperatory euroscore ii (p= . ) and history of previous cardiac surgery (p= . ). moreover, in the intraoperatory period the risk of delirium was associated with red blood cell transfusion, intervention for aortic dissection (p= . ), hypothermic circulatory arrest (hca) with anterograde cerebral perfusion (acp) (p= . ) (table ). in the postoperatory period risk of delirium was associated with levels of creatinine clearance (p= . ) and c-reactive protein (crp) (p= . ). conclusions: delirium is relatively frequent in the cardiac surgical icu patient journey of group : those patients discharged directly home from critical care unit poor compliance with co-signing in icca ( %, n= ) compared to paper ( %, n= ) (figure ) and the reported difficulty in co-signing ( %, n= ) reveals significant usability concerns and potential safety issues. % (n= ) found icca intuitive, though % (n= ) found navigating the interface difficult and reported concerns with losing saved work ( %, n= ). conclusions: this study highlights important usability issues that may impact staff satisfaction th national audit project of the royal college of anaesthetists and the difficult airway society. major complications of airway management references . guidelines for provision for intensive care services (gpics), version medicines optimisation: the safe and effective use of medicines reducing harm from omitted and delayed medicines. a tool to support local implementation p understanding the delivery of intensive care in south p mobilising ventilated patients early with interdisciplinary teams (move it) singapore general hospital, department of respiratory and critical care p validation of boyd criteria and possum-score on mortality and morbidity in general surgical intensive care unit k chittawatanarat, y chatsrisuwan faculty of medicine pts with central nervous system neoplasms or submitted to elective surgeries were excluded. descriptive analysis and χ test, pearson´s, wilcoxon rank-sum, uni and multivariate logistic regressions were used when appropriate. results: from a total of pts identified, . % (n= ) were admitted after emergent surgery and . % (n= ) for medical reasons. global icu mortality was . % (n= ). in comparison to survivors, the patients that died had a similar age were recorded data regarding demographics, clinical variables, paw (at admission and at day ), high pressure ratio (hpr = number of days with high pressures: peak ≥ and/or plateau ≥ ; and/or driving pressure ≥ ; and/or auto-peep ≥ ; divided by los), trends of paw (paw at day -paw at admission) and outcomes. the patients were divided into two groups: a construction group (n= ) and a validation group(n= ). the paw-mps was developed and validated by analyzing in a multivariate regression model the different paw ± . ; pco , ± mmhg paw were respectively for peak, plateau, driving, and auto-peep at admission: ± , . ± , . ± and three independent mortality risk factors were identified centro hospitalar do porto p five-year mortality and morbidity impact of prolonged icu stay n van aerde , g hermans laboratory of cellular and molecular medicine we investigated differences in mortality and morbidity after short (< days) and prolonged (≥ days) icu-stay. methods: prospective, -year follow-up study of former epanicpatients (clinicaltrials.gov:nct , n= ). mortality was assessed in all. for morbidity analyses, all long-stay and a random sample ( %) of short-stay survivors were contacted. primary outcomes were total and post- -day -year mortality in multivariable cox regression analysis, icu-risk factors comprised hypoglycaemia, corticosteroids, nmba, benzodiazepines, mechanical ventilation, new dialysis, new infection, liver dysfunction, whereas clonidine may be protective. among long-and short-stay -year survivors hgf, mwd and pf sf- were lower in long-stayers mwd: % ( %ci: %- %) vs % ( %ci: %- %) multivariable regression identified associations with benzodiazepines (hgf and pf-sf ), vasopressors (pf-sf ) and opioids ( mwd) ptsd related symptoms were accessed with the post traumatic stress syndrome questions inventory (ptss- ) at the post icu follow up clinic, six months after the acute stress event. the post icu consultation was carry out by an icu doctor and an icu nurse. exclusion criteria: previous severe psiquiatric disorders, not able to respond the questionnaire medical %, surgical % and trauma %. patients ( %) were on imv and the median ventilation days was . ptsd scores ranged from to . delusional memories were conclusions: in this study the rate of ptsd was lower . % and related with a lower saps ii and the presence of memories of the icu stay. no relation was found with delusional memories, imv or superior icu length of stay. patients with lower illness severity and without imv, should be elective to the follow up-clinics. p long-term effects of a sepsis aftercare intervention k schmidt united states; jena university hospital patras general university hospital, intensive care unit, patras, greece; patras general university hospital, division of infectious diseases results: ( . %) patients were readmitted within hours and ( . %) in to days. the two groups didn't differ in age, gender, charlson comorbidity index and length of stay on both admissions. elective surgery was the most common type of admission ( . %) followed by medical ( . %), emergency surgery ( %) and trauma ( . %). the mean time to readmission in the late group was . (± . ) days. patients in the late group had higher apache ii score on their first and second admission, ( . ± . vs . ± . ; p= . ) and ( . ± . vs . ± . ; p= . ) respectively. respiratory insufficiency was the most common cause of readmission in both groups followed by sepsis and cardiac arrest. finally in the early group p introduction: in intensive care units, perceived inappropriate treatments (pit) have been associated with negative impact on caregivers univariate analysis revealed that burn-out, pit and intention to leave were greater in units where nurses´teams included no activity in the icu, compared to "shared" work in icu and idtcu. in multivariate analysis, perception of non beneficial treatment of patients with life support witholding was associated with: bad collaboration with other units p profile of intensive care unit (icu) patients on whom life-sustaining medical treatment were withdrawn or withheld s chatterjee variables collected-age, sex, apa-che iv score, diagnostic-category and co-morbidities. primary outcomes were icu and hospital mortality. secondary outcomes included icu and hospital length of stay(los) female sex, n (%) ( . %) diagnosis on admission: medical, n (%) rrt at time of wlst, n (%) ( . %) dnr order, n (%) ( . %) organ donation services involved, n (%) ( . %) introduction: high flow nasal cannula(hfnc) is a new modality in respiratory failure management [ ] . this study objectively held to compare the physiological outcomes in the non-invasive ventilation(niv) treatment of cardiogenic acute pulmonary oedema(apo) patient in the emergency department(ed) delivered by helmet cpap(hcpap) and hfnc. methods: single-centre randomized controlled trial on patients presenting with cardiogenic apo. primary endpoint was a heart rate reduction.secondary endpoints included: improvement in subjective dyspnoea scales, respiratory rate, blood oxygenation, intubation rate and days mortality rate. results: patients were enrolled and randomized ( patients to hcpap; to hfnc) ( to . ± . ). intubation rate was lower in hcpap ( . % for hcpap versus . % for hfnc) and days mortality rate is lower in hcpap ( . % for hcpap versus . % for hfnc). conclusions: both hcpap and hfnc significantly improved patient condition in patient presenting to the ed with cardiogenic apo. however, hcpap was better than hfnc in improving physiology outcomes, lower intubation rate and mortality rate in patient introduction: the aim of the study was to compare the confusing assessment method of the intensive care unit (cam-icu) and the nursing delirium scoring scale (nu-desc) for assessment of delirium in the icu. furthermore we wanted to test the interpersonal variation of the nu-desc. delirium is proved to be associated with increased mortality [ ] . nu-desc is an observational five-item scale that does not require patient participation and is adapted to the fluctuating nature of delirium. each item can be scored from to . delirium is defined with a score > . the nu-desc has recently been translated into danish (nu-desc dk) but has not been validated.methods: icu patients, who met the inclusion-criteria for the cam-icu were scored with both cam-icu and nu-desc dk. patients were scored of two independent nurses at approximately the same time every day.results: a total of patients were enrolled, and comparisons between cam-icu and nu-desc dk were registered ( figure ).there was agreement between nu-desc and cam-icu in of registrations (hereof registrations were delirium negative). in interpersonal variation, registrations were made. the conclusion was identical in % of registrations, but only % agreed in all scoring-scale items (all negative).conclusions: a high agreement between nu-desc and cam-icu was found however the comparison was based on predominately patients with negative delirium score. the interpersonal variation of nu-desc scoring was substantial. a future validation of the nu-desc dk as a screening tool in the icu requires thorough training and instructions to minimize interpersonal variation. introduction: an increasing number of patients are being discharged directly home from critical care units and this is currently viewed as a negative quality indicator [ ] . the purpose of this audit was to characterise a cohort of patients who can be safely discharged directly home from adult critical care at st thomas´hospital (sth). methods: retrospective observational study of two groups of patients; ) those discharged directly home from critical care, ) those discharged within two days of step down to a ward from critical care (admissions st june- st october ). the clinical notes of these patients were reviewed via online systems. results: baseline demographics of the patients in group and patients in group were similar (mean age of years, versus years, p= . ); average length of stay in critical care was also similar ( . days versus . days respectively p= . ). in group , of icu days were after considered fit for step down versus of days in group , p= . (fig , ) . in group , drug related presentations were more common ( % versus % p= . ), fewer patients had specialist follow up post discharge ( % versus %, p< . ). in group , patients ( %) were readmitted within days, to critical care. in group , patients ( %) were readmitted, to critical care (p= . and . respectively); none of these readmissions were felt to have been preventable.conclusions: there is a cohort of patients suitable for discharge directly home from critical care who did not spend significantly longer in icu awaiting discharge than those who were stepped down to the ward. identifying these patients early, potentially by their diagnosis, and creating a pathway including access to specialist follow up clinic could allow prompt discharge directly from critical care, thus improving patient satisfaction and reducing hospital-acquired morbidity healthcare costs [ ] . the evaluation of the usability of a critical care information system ( introduction: critical care information systems (ccis) support clinical processes by storing and managing data, but poor usability can lead to staff dissatisfaction and increased workload, promoting workarounds that may compromise patient safety [ ] . the purpose of the study was to evaluate the usability of a philips intellispace critical care and anaesthesia (icca) ccis, recently implemented in beds across three critical care units of a large uk teaching hospital. methods: a prospective, mixed method observational study conducted in may , comprising of ( ) an audit assessing the ease of linking bedside devices to icca, ( ) an audit assessing the usability of co-signing medications in icca compared with a non-icca paper factors that commonly drive workforce metrics may not correlate with staff perceptions of safety. the bpr is a pragmatic, staff driven, tool to augment other measures of safety and is applicable to various icu settings. further research is needed to explore staff perceptions in order to understand the importance of this organisationally, and for staff stress. ventilator-free duration in icu, central venous catheter duration, urinary catheter duration, rates of deep vein thrombosis (dvt) and stress ulcer prophylaxis, rates of de-escalation antibiotic therapy, dvt prophylaxis duration, stress ulcer prophylaxis duration, icu and hospital mortality, -day mortality, rate of central venous catheter infection, length of stay in icu and hospital between two groups were analyzed. results: rate and duration of dvt prophylaxis in the intervention group were . % and ( , ) days respectively, in the control group were . % and ( , ) days, the differences between two groups were statistically significant(p< . ) ( table ). there were no differences in ventilator-free duration in icu, central venous catheter duration, urinary catheter duration, rate of stress ulcer prophylaxis, rates of de-escalation antibiotic therapy, stress ulcer prophylaxis duration, icu and hospital mortality, -day mortality, rate of central venous catheter(cvc) infection, length of stay in icu and hospital between two groups ( table ) . conclusions: electronic checklist in ward rounds can increase the rate of dvt prophylaxis and reduce the duration, but it cannot improve the prognosis of critically ill patients. introduction: the goal of the project "i see you" is family-centeredcare based on family meetings that improve the experience of the patient´s family members during hospitalization in the icu. the meetings focus on relaying information, raising knowledge and addressing the social and emotional needs of families. providing support along with information was found to be the strongest predictor of family satisfaction and could lead to improve cooperation between family and staff [ ] .methods: meetings and questionnaire: family meetings consist of a multidisciplinary team, a group facilitator and combined with a multimedia presentation about the unit and equipment. in addition, they focus on social and emotional needs: managing daily routine, sharing problems, fears and anxieties and more. at the end of the session a questionnaire was given to assess the impact of the intervention. sharing data: at the end of the first quarter, the data from meeting was summarized and sent to the staff alongside tools for effective communication.results: the project began in february . to date, family members of patients have attended the sessions. the topics discussed by the participants include: contact with the patient, prevention of infections, procedures, visits, conversations with doctors, medical confidentiality; guardianship; tracheotomy and social issues (fig ) . a sample of questionnaires was transferred to participants report satisfaction at a very high level.conclusions: the meeting received a very positive feedback from the participants. the project has achieved its goals and therefore it has been decided to be continued.introduction: possum score and boyd criteria are used to predict the outcome for high risk surgical patients. the aim of this study was to validation of these two measurement tools on mortality and morbidity in a university-based surgical intensive care unit (sicu) in thailand.methods: nine hundred and fifty two patients were enrolled onto this prospective review. all patients who had been admitted to sicu in a university-based hospital were included. all patients were collected for boyd criteria and possum score and outcomes and morbidity during sicu admission and discharge. introduction: aromatic microbial metabolites (amm), such as phenyllactic (phla), p-hydroxyphenylacetic (p-hphaa), and phydroxyphenyllactic (p-hphla) are involved in the pathogenesis of septic shock and are associated with mortality [ ] . according to previous studies, amm have a high prognostic value in patients with abdominal infection [ , ] . we hypothesize that amm have the prognostic value in patients with pneumonia in icu. methods: data of patients with community-acquired pneumonia was obtained on admission to icu. the levels of amm (phla, p-hphla and p-hphaa) were measured in blood serum using gas chromatography with flame ionization detector and compared in groups of patients: with favorable and with lethal outcome (mann-whitney utest). spearman's correlations between amm and clinical and laboratory data were calculated. using method of logistic regression and roc analysis, we measured the prognostic value of amm. (table ) . it was revealed, that some amm have similar prognostic characteristics in comparison with sofa and curb- scales; high level of amm is associated with high risk of death (roc-analysis - fig. ) .conclusions: serum concentrations of amm can be used as independent and practical criteria for the assessing of prognosis in patients with infection in icu. introduction: frailty in the critically ill is associated with increased morbidity and mortality but the optimal timing of frailty assessment, how to best measure frailty, reasons for adverse outcomes and how critical illness impacts frailty are unknown [ ] . in preparation for a multi-center study designed to address these knowledge gaps, we conducted a pilot study whose aim was to assess feasibility as determined by recruitment rates, ability to assess frailty at icu admission and hospital discharge, ability to measure icu and hospital processes of care and ability to conduct -month assessments. conclusions: a multi-center study is feasible but follow-up losses due to mortality and inability to return for assessment will require sample size adjustment. frailty characterization is method dependent, can be done on hospital discharge but varies with time of assessment. these findings will need to be confirmed in our larger study currently in progress. introduction: given the ageing of the world´s population, the demands of critical care resources for elderly patients has increased during the past decade. however, little is known about quality of life and outcomes of elderly icu survivors. the aim of the study is to assess outcomes of elderly icu survivors at least months after discharge: quality of life and mortality. methods: it is a retrospective study performed in a medical adult icu between january to december . the study included all elderly survivors ( ≥ years) after icu admission. outcomes were assessed by telephone interviews at least months after icu discharge. the primary outcome was assessing the quality of life after icu stay, measured by euro qol d questionnaire. the eq- d descriptive system contains five dimensions (mobility, self-care, usual activities, pain and discomfort, and anxiety and depression). for each dimension, there are five levels (no problems, slight problems, moderate problems, severe problems and unable to/extreme problems figure . conclusions: most elderly survivors patients showed a good health related quality of life using the euroqol d- l after icu discharge. fig. (abstract p ) . quality of life (euroqol d) scores after icu discharge introduction: sepsis survivors face mental and physical sequelae even years after discharge from the intensive care unit (icu). effects of a primary care management intervention in sepsis aftercare were tested. exploratory analyses suggest better functional outcomes within the intervention group compared to the control group at six and months after icu discharge. longer term effects of the intervention have not been reported. methods: a randomized controlled trial was conducted, enrolling patients who survived sepsis (including septic shock), recruited from nine german icus. participants were randomized to usual care (n= ) or to a -months intervention (n= ). the intervention included training of patients and their primary care physicians (pcp) in evidence-based post-sepsis care, case management provided by trained nurses and clinical decision support for pcps by consulting physicians. usual care was provided by pcps in the control group. the primary outcome of the trial was the change in mental healthrelated quality at -months after icu discharge. secondary outcomes included measures of mental and physical health. data were collected by telephone interviews using validated questionnaires at the -months follow-up ( months after the -year intervention).results: [ . %, intervention, control] of patients completed the -months follow-up. unlike the intervention group, the control group showed a significant increase of posttraumatic symptoms (diff. ptss- to baseline, mean (sd) . ( . ) control vs.- . ( . ) intervention; p= . ). there were no significant differences in the mcs and all other secondary outcomes between intervention and control group.introduction: survivors of sepsis often show symptoms of posttraumatic stress disorder (ptsd). only few studies report on courses of more than month after discharge from the icu. the aim of this study was to identify predictors for changes in ptsd symptoms over time up to month. methods: follow-up data of the smooth triala rct to evaluate a primary care management intervention on sepsis survivorswere analyzed. included patients were surveyed by phone for ptsdsymptoms at one, , and months after discharge from icu using the post-traumatic-stress-scale (ptss- ). scores changes between follow-up periods were analyzed using latent-change scores in structural equation models. predictors were clinical and sociodemographic baseline characteristics as well as physical, cognitive and functional sepsis sequelae assessed by validated questionnaires.results: patients were included of which participated in the month follow-up. a decrease of ptsd symptoms between and months was predicted by higher education (b=- . , p= . ), while higher pain intensity at one month predicted an increase (b= . , p= . ). increasing ptsd symptoms between and months were predicted by reporting more than two traumatic memories at one month (b= . , p= . ), more sleep problems (b= . , p= . ) and worse cognitive performance at months (b=- . , p= . ) as well as more neuropathic symptoms at months (b= . , p= . ).conclusions: sepsis patients that suffer from physical, cognitive and functional impairments after icu discharge may be at increased risk for developing late-onset ptsd. these predictors need to be replicated by future studies. early versus late readmission to the intensive care unit: a ten-year retrospective study v karamouzos , n ntoulias , d aretha , a solomou , c sklavou , d logothetis , t vrettos , m papadimitriou-olivgieris , d velissaris , f fligou conclusions: icu patients whose life-sustaining treatment was withdrawn or withheld had higher illness-severity scores, were older, had longer icu los and higher mortality than those in active-treatment group. healthcare introduction: caring for the critically ill patient is a complex task and becomes tougher when a death process takes place. a number of needs and coping strategies emerge from the healthcare providers before these issues but are mostly displayed out of individual skills and intuition. if those approaches are unappropriate and the needs are not met, patients' death process may be burdensome for caregivers. this could affect the quality of care for patients and families during the whole end-of-life care process. the aim of our study was to explore the different needs and coping strategies used by icu healthcare providers when facing patients in the dying process. methods: qualitative and collective case study. ten semi-structured interviews were conducted in icu personnel ( physicians and nursing professionals). a thematic analysis was done using nvivo software. local ethics committee approved the study. results: respondents were % women, had . ± . years-old and . ± . years of icu experience. main needs identified in icu healthcare providers refer to a lack of tools for doing emotional containment when delivering bad news to families, handling personal mourning, the need to perceive consistency regarding end-of-life care management across the icu team, and a wish of having regular training from a psychologist. main identified coping strategies included closing rituals, finding quiet spaces to spend time, and asking for counselling with more expert colleagues. a need for systematic, although basic training on these issues from qualified professionals is demanded. conclusions: usually, basic needs from patients and families in the process of dying are well addressed, but healthcare providers' needs are underrecognized and coping strategies mostly unknown. visibilization of those needs and basic but formal training in emotional containment, self-care and coping strategies are greatly desired. introduction: in the intensive care unit (icu), patients often exhibit cognitive impairments that prevent them from participating in decisions related to therapeutic options at the end of life. consequently, their families are often asked to speak for them when difficult decisions must be made. the main of this study was to determine the frequence in wich family want to share in end of life decisions and factors associated with this desire.methods: a prospective study was conducted in one mixed icu in montevideo. relatives of patients were invited to participate in this study after hours in the icu and completed a survey that included the hospital anxiety and depression scale. results: we analized relatives from patients hospitalized in the intensive care unit. the relationship with the patient was as follows: % spouses, % siblings, % grown children, % parents, and % other family members and friends. of them, . % reported a desire to share in end of life decisions. anxiety and depression symtoms were present in % and % respectively. factors asociated with the desire of involvment in end of life decisions by bivariate analysis were: female sex ( % vs %, p= . ), presence of anxiety ( % vs %, p= . ) and patient ecog - ( % vs %, p= . ). multivariate analysis shows that the presence of anxiety is the only independent factor associated with the desire to participate in end of life decisions (or . , ic % . - . ; p= . ). conclusions: have a loved one in icu is often associated with anxiety and depression after hours of admission. only % of the relatives want to participate in end of life decisions. the presence of anxiety is independently associated with the want to share in decisions making process. introduction: intensive care aims to treat failure of vital organ systems. sometimes, a patient's condition is of such a degree that intensive care is no longer beneficial, and decisions to withdraw or withhold intensive care are made. this means that life-sustaining treatments are terminated or not initiated. we aimed to identify variables that are independent factors for the decision to withdraw or withhold intensive care. methods: registry study using extracted data from a national quality registry the swedish intensive care registry (sir) - . data are delivered to the registry by nurses and doctors daily, during each patients' stay in the intensive care unit (icu). a total of , intensive care cases reported to the sir from - . results: data regarding each patient´s age, sex, diagnoses, condition at admission (expressed as simplified acute physiology score version , saps ), comorbidities and registered decisions to withdraw or withhold intensive care were analyzed. of the , cases reported, . % were women and . % men, and . % were - years old. a total of . % received a decision to withdraw or withhold intensive care, accounting for . % of all women and . % of all men, p< . . independent variables associated with increased odds of receiving a decision to withdraw or withhold intensive care were older age, worse condition at admission, and female sex. female sex was associated with an increased odds of receiving a decision to withdraw or withhold intensive care by % (ci . - . %) after adjustments for condition at admission and age. conclusions: older age, worse condition at admission and female sex was found to be independent variables associated with an increased odds to receive a decision to withdraw or withhold intensive care.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -j rogzm authors: stefan, mihaela s.; pekow, penelope s.; shea, christopher m.; hughes, ashley m.; hill, nicholas s.; steingrub, jay s.; lindenauer, peter k. title: protocol for two-arm pragmatic cluster randomized hybrid implementation-effectiveness trial comparing two education strategies for improving the uptake of noninvasive ventilation in patients with severe copd exacerbation date: - - journal: implement sci commun doi: . /s - - - sha: doc_id: cord_uid: j rogzm background: copd is the fourth leading cause of death in the us, and copd exacerbations result in approximately , hospitalizations annually. patients with acute respiratory failure due to severe copd exacerbation are treated with invasive (imv) or noninvasive mechanical ventilation (niv). although imv reverses hypercapnia/hypoxia, it causes significant morbidity and mortality. there is strong evidence that patients treated with niv have better outcomes, and niv is recommended as first line therapy in these patients. yet, several studies have demonstrated substantial variation in the use of niv across hospitals, leading to preventable morbidity and mortality. through a series of mixed-methods studies, we have found that successful implementation of niv requires physicians, respiratory therapists (rts), and nurses to communicate and collaborate effectively, suggesting that efforts to increase the use of niv in copd need to account for the complex and interdisciplinary nature of niv delivery and the need for team coordination. therefore, we propose to compare two educational strategies: online education (ole) and interprofessional education (ipe) which targets complex team-based care in niv delivery. methods and design: twenty hospitals with low baseline rates of niv use will be randomized to either the ole or ipe study arm. the primary outcome of the trial is change in the hospital rate of niv use among patients with copd requiring ventilatory support. in aim , we will compare the uptake change over time of niv use among patients with copd in hospitals enrolled in the two arms. in aim , we will explore mediators’ role (respiratory therapist autonomy and team functionality) on the relationship between the implementation strategies and implementation effectiveness. finally, in aim , through interviews with providers, we will assess acceptability and feasibility of the educational training. discussions: this study will be among the first to carefully test the impact of ipe in the inpatient setting. this work promises to change practice by offering approaches to facilitate greater uptake of niv and may generalize to other interventions directed to seriously-ill patients. trial registration: name of registry: clinicaltrials.gov trial registration number: nct date of registration: december , chronic obstructive pulmonary disease (copd) is the fourth leading cause of death in the us, and copd exacerbations result in approximately , hospitalizations annually [ , ] . patients who do not respond to pharmacotherapy are placed on invasive (imv) or noninvasive mechanical ventilation (niv). while invasive mechanical ventilation (imv) administered through an endotracheal tube is an effective method of treating acute respiratory, it requires treatment in an intensive care unit, and places patients at risk for a wide range of complications, including ventilator-associated pneumonia. niv (continuous positive airway pressure, cpap or bilevel positive airway pressure, bipap) provides positive pressure ventilation via a face mask without the need for intubation. multiple randomized controlled trials [ , ] , meta-analysis [ , ] , and analyses of real-world data [ , ] have demonstrated that treatment with niv, when added to usual care, reduces the risk of intubation, lowers the incidence of ventilator associated complications, and results in better short-term survival. based on this evidence, niv receives a grade a recommendation in current global initiative for chronic obstructive lung disease (gold) guidelines [ ] . furthermore, the european respiratory society and american thoracic society joint guidelines [ ] as well as british thoracic society guidelines [ ] make a strong recommendation for the use of niv as a first-line treatment for patients with copd exacerbation and acute respiratory failure. although the evidence supporting the use of niv is compelling, prior research has demonstrated substantial variation in the use of niv in routine clinical settings, highlighting a persistent gap in niv adoption. in a recent study of more than , patients with copd cared for at us hospitals, median hospital percentage of niv use among ventilated patients was . % (range . - . %) and the bottom % of hospitals offered a trial of niv to less than half of ventilated patients [ ] . more importantly, institutions with higher rates of niv had lower imv use and better clinical outcomes. thus, low hospital rates of niv in patients admitted for severe copd represents an evidence practice gap and a missed opportunity to improve the outcomes among this vulnerable population. appropriate delivery of niv is a complex, multicomponent intervention that requires timely recognition, and effective communication, and coordination across multiple disciplines. figure depicts the flow for a patient who comes to the emergency department with severe copd exacerbation and each clinician's responsibilities in the process of niv initiation and monitoring. only few studies have tested strategies for supporting niv implementation. a single site, before-after study from canada found that multidisciplinary guidelines for the use of niv in patients with stefan acute respiratory failure (arf) were associated with greater niv utilization but included only patients in the intensive care unit [ ] . for this study, we used the intervention mapping process model to develop and select implementation strategies to increase the uptake of niv [ ] . figure summarizes the steps in the development of our implementation strategy to increase the use of niv in severe copd exacerbation. in step (formative evaluation), we conducted semistructured interviews with key informants in a sample of hospitals with high rates of niv and good copd outcomes (low mortality and niv failure rates). the analysis of the interviews revealed different professional identities and roles in niv delivery: physicians, respiratory therapists (rts), and nurses. although several clinicians' tasks are distinct, fig. shows the connections between physicians, nurses, and rts indicating the need for coordination to ensure optimal patient outcomes. the three groups encounter significant professional boundary issues with regards to their work responsibilities and priorities. for example, nurses were concerned about patient's inability to eat or take medications while on niv. rts considered that nurses do not have a good understanding of the vital role of niv. however, the two professions agreed that when there was a shared understanding of the treatment plan and when the concerns from both sides were openly addressed, the collaboration was considerably improved. rts perceived themselves as experts in initiating and managing niv; in some institutions, there was a strained relation between the rts and physicians, with rts complaining about a lack of autonomy and the need to wait for physicians when niv was immediately indicated. we identified the following contextual factors and strategies associated with successful niv implementation: provider buy-in, respiratory therapists (rt) autonomy to deliver niv independently, interdisciplinary teamwork, collegial, trusting relationships between rts, physicians, and nurses, and ongoing staff education [ ] . in step , we organized the specific types of determinants that influence niv delivery using the theoretical domain framework (tdf) [ ] . the tdf was used as a guiding theory for this project because the desired behavior change is primarily at the individual level, e.g., convincing providers to consider niv in any patient with severe copd exacerbation. we summarized the barriers in the tdf domains with an eye toward choosing an implementation strategy which could overcome several of the identified barriers. eight of the domains (knowledge, skills, professional roles and identity, beliefs about capabilities, beliefs about consequences, environmental context and resources, social influences, and emotion) were present in the existing literature and our research. interdisciplinary teamwork, on-going education, providers buy-in, and rts autonomy were found as the top four determinants for successful niv delivery in copd exacerbations. these findings suggest that to succeed, implementation strategies need to account for the complex and interdisciplinary nature of niv therapy and the need for team coordination. step : to guide the selection of implementation strategies, we used the expert recommendations for implementing change (eric) [ ] . the main themes that emerged from the qualitative analysis and literature review mapped to the tdf domains and the implementation strategies most likely to address those barriers are shown in table . systematic analysis of the barriers suggested that to succeed, implementation strategies for knowledge transfer need to account for the complex and interdisciplinary nature of the niv therapy and the need for team coordination; however, these hypotheses need to be carefully tested. interprofessional, dynamic team training for physicians, rts, and nurses was the implementation strategy selected as targeting several key determinants [ , , ] . niv is delivered in high acuity environments by teams in which membership is dynamic, decisions must be made quickly, and members are not always face-to-face (asynchronously taking care of patients). this creates a critical need for effective communication, conflict management, and shared mental model [ ] skills that are well suited to ipe approaches [ ] [ ] [ ] . by contrast, conventional education regarding niv is administered to individual clinicians or groups of clinicians of the same discipline via lectures or online modules. educating individual care providers in silos does not address the interprofessional collaboration inherent to niv delivery. on the other hand, ipe competencies emphasize the importance of establishing awareness and knowledge regarding interprofessional team roles. in this way, leveraging an ipe platform enables learning via interaction between two or more professions who learn from, with, and about each other's roles and responsibilities (in this case, in regards to niv) [ , ] . the overall objective of this study is to conduct a pragmatic, parallel, -arm randomized cluster trial to compare the effectiveness of two implementation strategies: on-line education (ole) and interprofessional education (ipe) on the uptake of niv. the central hypothesis is that ipe will outperform conventional education, and that rt autonomy and/or team functionality will act as mediators. we will accomplish this goal by completing three specific aims. aim : to compare the effectiveness of ole and ipe for increasing the delivery of niv in appropriate patients hospitalized with copd exacerbation. aim : to examine the effect of ole and ipe on rt autonomy and team functionality as potential mediators of niv uptake. aim : to evaluate the acceptability and feasibility of the ole and ipe strategies to inform further refinement of the strategies. in this cluster randomized controlled -arm parallel trial, hospitals will be randomized to ope or to ipe. patients and clinicians are clustered within the hospitals because the ipe encourage facility-level change in clinicians' communication and care coordination. the study will be conducted in hospitals with riskadjusted niv proportion below median that have at least eligible copd admissions in an -month period. potential eligible hospitals are those participating with data in premier database, a voluntary, fee-supported database containing highly detailed hospital billing data pooled from more than geographically and structurally diverse hospitals whose makeup closely resembles that of us hospitals. hospitals that demonstrate interest in participating in the study will be asked to commit to form a copd-niv team composed of one physician, one rt, and one nurse that will be in close contact with the investigators and are responsible for delivering the educational intervention in their institution. eligible hospitals will be contacted in a random order until the sample of hospitals is achieved. to assess for potential participation bias, we will compare participating and refusing hospitals using available data such as size, ownership, teaching status, and location. the overall study design is shown in fig. . the explanatory continuum indicator summary (pre-cis) framework was used to assess the pragmatism of the trial (fig. ) . we will randomly allocate hospitals to one of the study arms, stratified by the baseline niv proportion and hospital bed size. a researcher not involved in the study and blinded to the identity of the hospitals will use a computer-generated randomization scheme. the randomization scheme will be concealed to the investigators. due to the character of the intervention, it will not be possible to blind participants or investigators providing the educational program; however, the investigators will not be aware of the results of the study by intervention arm until the analysis is finalized. the trial will compare two implementation strategies: one active control consisting of traditional, online education (ole) learning and a strategy of in-person interactive inter-professional education (ipe). consent for participation in the educational strategies will be sought as a waiver of consent via an email sent to all potential participants after the randomization period and prior to the implementation at each site. participants in the copd-niv teams and the training will be physicians, rts, and nurses who are involved in treating patients with severe copd exacerbation. the following domains will be targeted in the educational training interventions: the hospital-based copd-niv teams will be responsible throughout the trial period for encouraging clinicians from each specialty to complete the courses. the investigators will have a conference call with the copd- niv team after the institutions have been randomized to discuss recruitment and surveys' delivery. (e.g., rt autonomy, team functionality, and organizational readiness for implementing change). conference calls between the investigators and the individual copd-niv team will continue every quarter for the duration of the months of active implementation period with a follow-up call at the end of the study. active control group: online education (ole) sites will be given access to free continuing education modules customized for each discipline; rt and nurse online education training will be approximately min long, and physician's online education training will be about h. the modules will be delivered online through a secure website that will allow us to count the number of providers completing the course. we will use traditional powerpoint presentations with embedded whiteboard animation videos. we selected an active control instead of usual care, because it will allow stronger inferences about the benefits of ipe when compared to more traditional learning approaches. the online modules will be offered for the entire period of the study for all the new staff. it will consist of a -minute in-person interprofessional educational workshop. training of the facilitators we will organized a one day in-person training for all the niv-copd teams. the training will consist of modules: ( ) niv knowledge and skills: delivered by niv experts and ( ) ipe: delivered by an expert in ipe and team training. the didactic training regarding niv use in copd will include a review of the evidence supporting the benefits of niv, advantages of niv as compared to invasive mechanical ventilation (imv), selection of patients, contraindications to niv, and management of patients while on niv including monitoring, ventilator settings, attention to patient comfort, weaning from niv, and decision about niv failure and need for intubation. the didactic module will emphasize the importance of early initiation of niv in patients with severe copd. the second half of the training will concentrate on teaching interprofessional collaboration. specifically, the interprofessional education collaborative (ipec) recommends four key competencies in successful ipe, which include roles and responsibilities, teams and teamwork, values and ethics, and interprofessional communication [ ] . we selected the following core competencies for our interactive ipe. professional roles and identity: each team member learns about abilities, tasks, duties, responsibilities, and concerns of their fellows' team members; values/ethics: work with individuals of other professions to maintain a climate of mutual respect and shared values; teams/teamwork: apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to deliver patient-center care that is safe, timely, effective, and efficient [ ] . given the demands for team coordination in niv delivery and findings in our qualitative work, we anticipate that ipe will contribute to greater rt, physician, and nurse understanding of each other's roles, increase team communication and functionality, and stimulate the development of shared mental models which facilitate coordination for niv. we will use positional clarification which involves verbally presenting team members with information about their teammates' jobs through discussion [ ] . psychological safety and speaking up will be encouraged and facilitated. for example, an rt may assume that physicians have more knowledge about niv delivery for a particular patient than they do (because physicians are generally more knowledgeable about treatments) and remain quiet; when in fact, the rt has important information about how the patient may respond (cognitive bias) [ ] . the sessions will be recorded, so that participants will have ongoing access to the content. we anticipate that the members of the copd-niv team who will become the training facilitators at their hospital will not be subject matter experts in the training context, especially the ipe. therefore, a special instructor script will be written and will be paired with the presentation. delivery of the ipe sessions at institutions randomized to ipe training sessions for clinicians at ipe sites will be led by the copd-niv teams and will include information (e.g., -min lecture), demonstration (providers will be provided with contextualized examples), and practice ( min, action-based approach with guided practice). it will contain a scenario of a patient with severe copd coming to the emergency room with shortness of breath. they will review the guidelines for patient selection and monitoring and niv settings and management. each participant will be able to try the niv mask and understand the importance of appropriate settings and attending to patient comfort. the three core competencies for interprofessional collaboration and how they apply to the niv delivery will be explained. the ipe sessions will be offered up to twice a month for months-the number will vary by institution depending on the number of providers that need to be trained. for the entire period of the study, we will continue to have every other monthly breakfast/lunch meetings where cases of patients with copd in need of niv will be presented with emphasis on interprofessional work structure, rt autonomy, and team functionality. full ipe sessions will be offered once a month every months for the new staff, as part of on-boarding. table outlines the implementation and effectiveness outcomes at the cluster (hospital) level, their implementation timing, how they will be measured, and the source of data collection. to compare the effectiveness of ole and ipe for increasing the delivery of niv in appropriate patients hospitalized with copd exacerbation. primary outcome hospital-level risk-standardized (rs) initial niv proportion among patients hospitalized with a copd exacerbation that were ventilated with niv or imv is assessed via administrative records of patients discharged from participating premier hospital who were years or older and received a principal diagnosis of copd, or a principal diagnosis of acute respiratory failure paired with a secondary diagnosis of copd. we will use a previously validated set of icd- -cm codes that achieve a reasonable balance of sensitivity and specificity while minimizing potential biases [ ] . secondary outcomes rs hospital rates of niv failure (imv after a trial of niv), mortality, length of stay, and -day readmission among all patients with copd. all outcomes will be measured at the hospital level: ( ) at baseline using prior months of data, ( ) at months post-implementation to assess immediate/short term impact, and the following months to assess sustainability. the -month assessment period is necessary to have adequate numbers of eligible copd admissions for assessing hospital rates of niv utilization. the time from randomization to the completion of the educational sessions with an expected duration of months will not be included in the calculation of rs-niv post-intervention. to examine penetration, we will measure providers' exposure to educational training using participation logs. patient and hospital information demographics, comorbidities, prior year number of admissions for copd, prior year use of niv or imv, and outcomes will be identified from icd- procedure codes and billing codes. for each participating hospital, we will record the number of beds, the annual number of admissions for copd, teaching status, geographic region, and whether it serves an urban or rural population. we will also collect information about staffing: number of rts, hospitalists, emergency room physicians, and nurses. we will record if hospitals use protocols for niv initiation and management, and if niv can be delivered on the regular medical floor or only in an intensive care unit. these factors will be used to describe participant hospitals and evaluated as potential confounders or effect modifiers. noninvasive and invasive ventilation for each patient, we will examine standardized charge codes generated daily by respiratory therapists as well as dated icd- procedure codes to determine whether or not they were treated with assisted ventilation, and, if so, whether ventilation was niv or imv. we define the primary method of ventilation as the first method by date and distinguish between patients treated with niv as an initial strategy from those in whom niv use follow exposure to invasive mechanical ventilation (imv). we have previously validated the niv icd procedure codes and respiratory therapy charge codes by retrospective medical chart review. using icd- -cm codes alone yielded a sensitivity of % ( % ci, - %) and specificity of % ( % ci, - %). the approach of using icd- -cm procedure codes and/or respiratory therapist charges increased sensitivity to % ( % ci, - %) without reducing specificity ( %, % ci, - %) [ ] . statistical analysis of aim we will generate descriptive statistics overall, by hospital and educational strategy, including counts and percentages for categorical data, means, standard deviations, and percentile distributions for continuous data. we will compare characteristics of hospitals, including staffing characteristics, in the two study arms via chi-square tests and t tests or wilcoxon tests. characteristics of patients in the enrolled hospitals in the two arms will be compared via gee models accounting for clustering by hospital. we will calculate the percentage of patients treated according to each of the primary ventilatory strategies: no assisted ventilation, niv, and imv. we will then calculate the proportion of patients initially treated with niv among those who received assisted ventilation. we will estimate a risk-standardized proportion of ventilated patients initially treated with niv (rs-niv) for each hospital and for each data collection period (baseline period, months post-intervention, and between to months post-intervention). we will use hierarchical logistic regression with a random hospital effect to model initial use of niv among patients started on ventilation, adjusting for demographics, and comorbidities. from the model, a predicted niv percentage for each hospital will be computed as the niv percentage that would be anticipated at a particular hospital by using its hospital random effect, given the patient case mix. the expected niv percentage will be computed as the rate that would be expected if the same patient mix were treated at an "average" hospital, using the average hospital effect. the rs-niv percentage is then computed as the ratio of predicted to expected niv percentage standardized by the overall unadjusted mean niv percentage for all admissions in our model. risk standardization has key advantages: it adjusts for differences in patient mix, which may impact the suitability of niv; it also provides more stabilized estimates based upon bayesian shrinkage towards the overall mean among hospitals with small numbers of ventilated patients [ , ] . the mean and median rs-niv rates of the two arms will be computed for each study period. the primary analysis will use an analysis of variance model to compare ipe to ole on change in rs-niv rates from baseline to months post-intervention. additional analyses will adjust for hospital characteristics that are unbalanced between the study arms. a secondary analysis will compare the post-intervention levels, adjusting for baseline rs-niv. to assess sustainability, similar models will be used to compare level of rs-niv after an additional months have passed. for the secondary outcomes, our analysis will calculate hospital rs-rates of niv failure, mortality, -day readmission, and length of stay among ventilated patients, as well as all copd admissions for each study period. we will compare outcomes of ole and ipe hospitals using models described above. although we assume that the patients treated in ipe hospitals will have better clinical outcomes, we do not expect it to be able to detect an effect of these strategies on secondary outcomes due to overall low outcome rate, the small projected change, and relatively small number of clusters. organizational readiness the implementation of the educational strategies to increase the use of niv in copd exacerbations will require the coordinated action of many organizational members (e.g., physicians, rts, and nurses). the organizational readiness for implementing change (oric) survey can assess this construct at the supra-individual level (team, department, or organization) [ ] . when organizational readiness is low, clinicians at these hospitals are likely to see the implementation (educational strategies) for the intervention (niv use in copd exacerbations) as undesirable and potentially avoid or resist planning for the implementation or participating in the implementation [ , ] . the oric will allow us to identify the difference between organizations resisting the change (increasing niv utilization) and sites that are unable to implement the educational strategies due to difficulties inherent in organizing and conducting the educational strategies at their hospital. to assess the readiness of the organization to implement the change, we will use a item survey adapted from the original -item organizational readiness for implementing change (oric) [ ] . this survey will measure change commitment and change efficacy of the organization towards increasing the rate of niv use for copd exacerbations. power and sample size for aim the minimal number of hospitals participating in the trial was based on the analysis of premier - data. hospital rs-niv proportions were calculated for the hospitals with at least eligible copd admissions. the median rs-niv rate among this group of hospitals was % (iqr - %). we then selected the hospitals with rs-niv proportion less than %, based on the clinical impression that these hospitals would have sufficient room for improvement, as potentially eligible sites. among these hospitals, the median number of eligible copd patients was over a -month period, ranging from to patients. the number of ventilated patients per hospital ranged from to , with a median of . to achieve stability in estimation of hospital level rs-niv, we will assess our primary endpoint at months post-intervention expecting a minimum of ventilated patients per hospital in which to assess niv rates. power analysis was conducted to determine the number of hospitals needed to assess the primary outcome of difference between the study arms in change in the hospital level risk-standardized proportion of ventilator starts that are niv (rs-niv). using a type i error rate of . , and standard deviation of change in rates over time derived from our prior work with the premier data base, a total sample of hospitals, in each arm will give % power to detect difference of % in change (e.g., % increase among ole hospitals, vs. % increase among ipe hospitals). power is > % to detect a % difference in change between the intervention groups. to examine the effect of ole and ipe on rt autonomy and team functionality as potential mediators of niv uptake. study design to complete this aim, we will survey clinicians at baseline, year, and end of the study period. participants and settings we will select a random sample of rts for the rt survey and providers ( from each discipline) for team functionality and organizational readiness for change surveys. a waiver of consent will be sent to all potential participants via email, the survey link will be included at the end of the email. to maximize participation, we will provide $ incentives to participants. rt autonomy job autonomy is defined as the degree of perceived control that an employee has over how they perform tasks and the degree to which they operate independently. prior studies showed that it mediates the relationship between employment status, work attitude, and performance [ , ] . in our previous study, indepth interviews with key stakeholders from a sample of hospitals with high use of niv suggested that rt autonomy is critical to achieving timely initiation of niv, often facilitated by the use of protocols [ ] . these results are in line with prior literature [ ] that supports the benefits of autonomous rt practice for weaning from imv [ , ] . factors identified by the interviewees to contribute to rt autonomy were rt-driven protocols, rt expertise, and collegial relationship between rt and physicians. we assume that ipe will increase the physicians trust in rts by allowing them to learn about their abilities and duties and concerns, and that ipe will facilitate team member recognition of their own knowledge with rts being more likely to "speak up" (e.g., to suggest niv use instead of intubation). to assess rt autonomy, we adapted a survey from the -item job autonomy measure from aarons et al [ ] . team functionality the iom and quality chasm reports brought widespread attention to clinical teamwork as a means of improving safety and quality in healthcare [ ] . engagement in training-related activities designed to disseminate knowledge, skills, and attitudes for teamwork (such as ipe) is one way to acquire attitudes and behaviors consistent with teamwork and improve downstream impact on care quality and safety for patients [ ] [ ] [ ] . get all clinicians (physicians, rts, and nurses) involved in the delivery of niv with the goal of promoting mutual trust and effective communication which will improve team functionality and hopefully promote niv use. to assess team functionality, we adapted questions from the -point likert scale assessment of collaborative environment survey (ace- ), a -item questionnaire which measures the perception of interprofessional "teamness" [ ] . we created an -item questionnaire that has been divided into two parts: the first is the -item measure team functionality in managing patients with copd exacerbation and the second is the -item measure team functionality in initiating niv. statistical analysis we will develop a series of models evaluating associations among the intervention, mediators, and outcome, including a structural equation model (sem) to estimate the role of mediators as well as the direct effect of intervention on the outcome [ ] [ ] [ ] [ ] . first, to evaluate the impact of educational intervention on the mediators rt autonomy and team functionality to implement change, multi-level models will be fit, clustering on hospital. additional models will adjust for hospital and practitioner characteristics. next, models for the primary rs-niv outcome will be fit, with these potential mediators as the primary predictors. main effects and interaction models will be evaluated. then, the mediators will also be included as covariates in multi-level models including intervention, to evaluate whether rt autonomy and team functionality have effects on outcome, and after controlling for intervention. finally, multi-level structural equation modeling will then be employed to estimate the indirect effect of the educational intervention on rs-niv in the presence of mediators. analysis will be performed using stata's gsem. this model will allow estimation of the direct effect of ipe intervention relative to ole, in addition to the impact through the mediators (fig. ). power and sample size for aim for aim analyses, power was assessed for educational mode impact on job autonomy for respiratory rt measured by aaron's job autonomy survey (ajas), and team functionality measured by the ace- tool. estimating sample size to achieve % power, using a type i error rate of . , a sample of rt's per hospital, will allow us to detect a moderate (cohen's d = . ) difference in ajas at a -year post-intervention. this is accounting for clustering on hospital with intraclass correlation (icc) in the range of . -. . based upon data from local area hospitals, we estimate staffing of - rts per beds. for a few smaller hospitals, we will hope to include all rts and may fall short of . similarly, for the ace- , a sample size of clinicians ( each of rts, rns, and mds) will achieve % power to detect a moderate effect size difference, accounting for clustering within hospitals, with icc in the range of . -. [ ] . to evaluate the acceptability and feasibility of the ipe and ole strategies and to inform further refinement of the strategies. study design to achieve this aim, we will perform a qualitative study using semi-structured interviews with providers to assess relative importance of various barriers and determinants on the implementation of the two strategies. participants and settings we will recruit a random sample of nurses, physicians, and rts. as it is typical in qualitative research, the total sample is not fixed; depending of the size of the program, we will select - individuals from each profession in each hospital and expect to enroll approximately - providers enabling us to reach thematic saturation. potential participants will be contacted via email by the study research assistant and invited to conduct an interview. a waiver of consent will be included in the body of the email prior to the contact information for the interview. those who are interested in participating will be contacted by telephone to arrange an interview time over the telephone. to maximize participation, we will provide $ incentives and schedule sessions at a time convenient to the participants. data collection we anticipate that interviews will last approximately min. all interviews will be audio recorded and transcribed verbatim. the interview team will consist of one research associate who will be trained by the investigator. the focus of the interviews will be to explore the implementation process-the acceptability and feasibility of the educational training strategies, participation in the training sessions, barriers to participation, adaptation made to the training sessions, and how the niv protocol was incorporated into the clinical workflow. expected outcomes this qualitative analysis will allow us to gain a broader perspective on the process of implementation from the perspective of the participants. we expect to understand and identify barriers and facilitators and their relative importance for this implementation strategy to be the most successful. the knowledge gained from this aim will be important for further application and refinement of ipe for other therapies/interventions directed to the critically ill patients. data analysis transcripts will be reviewed by the interviewer for accuracy. qualitative data management and analysis software (nvivo) will be used to organize and code the data [ ] . the nature of the interviewee role and the setting in which they work will be summarized and reported by location. we will use directed qualitative content methods to analyze interview content, beginning with a coding framework based on our prior work [ , ] . coding will occur concurrently with the interviews to ensure that the interview guide is eliciting data related to the domains of interest. two team members will be primarily responsible for coding and will be supervised by one co-investigator proficient in qualitative analysis. the first interviews will be read by each researcher with the goal of agreeing on the use of the domains and or constructs. this codebook will be used for all interviews going forward, with the team meeting periodically to discuss the emergence of any new codes or to clarify the relevance of domains and constructs to the text. each transcript will be coded twice, once by each researcher. discrepancies will be discussed until consensus is reached. through regular investigators meetings, we will generate overarching themes. the investigation will collect the following information to calculate the costs to initiate the intervention: ( ) cost of the training of the copd-niv team in the ipe arm of the study and inclusive of salary/fringe costs of the implementation specialists travel to the one day training session, ( ) cost of webinars inclusive of speaker costs and video recording costs, and ( ) cost of the continuing educational credits provided to the clinicians attending the ipe sessions at their hospitals and to the copd-niv team for their attendance of the -day session and for teaching the copd-niv-ipe course at their hospital. we propose the following strategies for dissemination: ( ) after study completion, we will host webinars to share the results with the participant hospitals; ( ) we will develop a one-page information sheet with the results and conclusion of the study and distribute it on the premier inc. website; ( ) we will develop a toolkit and implementation manual with step-by-step guidance to help other institutions implement the ipe strategy; ( ) publications and presentations at national and international respiratory and d&i conferences; and ( ) we will work with society of hospital medicine and copd foundation to share the finding of the study to their members. table present the proposed timeline for the study. potential limitation and rational for key decisions why study only education? we have carefully considered other implementation strategies such as audit and feedback, which is an electronic medical records decision support tool and academic detailing. when mapping the barriers within eric compilation of implementation strategies, we found that ipe covered several of identified barriers. additionally, we were concern that using multiple strategies would complicate our attempt to understand the educational intervention impact. interprofessional care is essential to the management of seriously ill patients and in the absence of robust studies to determine if ipe indeed impact patient outcomes, it is critical to be able to assess it in randomized controlled trial. for this pragmatic clinical trial, we need to be able to calculate hospitals' niv rates and identify low performing hospitals to be able to invite them to participate in the trial and determine the rates after the implementation period. our intention was to have these rates calculated directly from the administrative or electronic data without a need for data collection. we did not come across any other database which provides the needs for this trial. still, if the trial shows that ipe is effective in improving the niv rates, individual hospitals will be able to calculate their own rates and decide if they want to implement the ipe strategy. this study will be among the first to carefully test the impact of ipe in the inpatient setting. over the last years, there have been increasing interest in linking ipe with interprofessional collaboration and team-based care [ , ] ; however, only recently have researchers begun to look beyond the classroom and beyond learning outcomes on such issues as patient safety, patient and provider satisfaction or quality, and cost of care. consequently, the institute of medicine report "measuring the impact of interprofessional education on collaborative practice and patient outcomes" questions calls for purposeful, well-designed, robust studies to understand the link between ipe and patient and health systems outcomes [ ] . 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and starting values in lisrel maximum likelihood estimation the robustness of lisrel modeling revisited sample size requirements for structural equation models: an evaluation of power, bias, and solution propriety three approaches to qualitative content analysis basics of qualitative research: techniques and procedures for developing grounded theory core competencies for interprofessional collaborative practice board on global health, institute of medicine. measuring the impact of interprofessional education on collaborative practice and patient outcomes springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations karen riska acted as a research coordinator and participated in manuscript revisions. taylar clark acted as a research assistant and completed literature review activities and provided editorial feedback on manuscript drafts. authors' contributions ms designed the protocol, wrote the first draft of the manuscript, and provided senior-level conceptual feedback on manuscript revisions. pkl, psp, jss, amh, and cms acted as co-i during the implementation, participated in the design of the protocol, and provided senior-level editorial feedback on manuscript preparations. all authors read and approved the final manuscript. sources of funding: this study protocol has been approved and funded by the nhlbi (nih), r hl .availability of data and materials not applicable for this section ethics approval and consent to participate baystate irb has approved this study and deemed it ethical. baystate irb has also declared that this study is minimal risk, and therefore approved our waiver of consent for the participants of this study. key: cord- - tlp yr authors: perkins, g.d.; handley, a.j.; koster, r.w.; castrén, m.; smyth, m.a.; olasveengen, t.; monsieurs, k.g.; raffay, v.; gräsner, j.-t.; wenzel, v.; ristagno, g.; soar, j. title: basismaßnahmen zur wiederbelebung erwachsener und verwendung automatisierter externer defibrillatoren: kapitel der leitlinien zur reanimation des european resuscitation council date: - - journal: notf rett med doi: . /s - - - sha: doc_id: cord_uid: tlp yr nan für die erc-leitlinien wurde zusätzlich zu den ilcor-empfehlungen von den federführenden autoren die literatur zu den themenfeldern gesichtet, die bei ilcor keine berücksichtigung fanden. die leitlinien-verfasser waren sich bewusst, dass Änderungen gegenüber den empfehlungen von kosten und eventuell verunsicherung verursachen würden, und beschränkten sich daher auf Änderungen, die wirklich wichtig erschienen und durch neue evidenz belegt sind. die leitlinien wurden von den federführenden autoren konzipiert, von allen leitlinien-verfassern und den nationalen wiederbelebungsräten überarbeitet und schließlich vom erc-board verabschiedet. gemeinsame aktion, die diese elemente zusammenführt, verbessert die Überlebenschancen des patienten nach einem kreislaufstillstand außerhalb eines krankenhauses (. abb. ). der leitstellendisponent spielt eine entscheidende rolle bei der frühzeitigen diagnose eines kreislaufstillstands, der leitstellengeführten reanimation (bekannt als telefonreanimation) und bei auffinden und einsetzen eines externen automatisierten defibrillators (aed). je früher der rettungsdienst alarmiert wird, desto eher wird eine adäquate behandlung begonnen und unterstützt. fertigkeiten, zutrauen und handlungsbereitschaft des ersthelfers hängen von den umständen des kreislaufstillstands, seinem trainingsstand und seinen vorkenntnissen ab. der erc empfiehlt dem notfallzeugen, der darin geschult und dazu in der lage ist, den zustand des patienten schnell zu beurteilen, indem er feststellt, gemeinsame reaktion rettet leben abb. interaktion zwischen leitstellendisponent, helfer und einsatz eines automatisierten externen defibrillators ob der patient nicht ansprechbar ist und nicht normal atmet, und dann unmittelbar den rettungsdienst zu alarmieren. wenn irgend möglich, soll er währenddessen den patienten nicht verlassen. der patient, der nicht reagiert und nicht normal atmet, hat einen kreislaufstillstand und benötigt eine herz-lungen-wiederbelebung (cpr). unmittelbar nach dem kreislaufstillstand geht der blutfluss zum gehirn gegen null. das kann krampfanfälle auslösen, die möglicherweise mit einer epilepsie verwechselt werden. notfallzeugen und leitstellendisponenten sollen daher bei krampfenden patienten auch an einen kreislaufstillstand denken und sorgfältig klären, ob der patient normal atmet. die leitlinien-verfasser bekräftigen die ilcor-empfehlung, dass bei jeder wiederbelebung eine thoraxkompression durchgeführt werden soll. notfallzeugen, die ausgebildet und in der lage sind, eine atemspende durchzuführen, sollen herzdruckmassage und atemspende kombinieren. zusätzliche atemspenden können vorteilhaft für kinder bei asphyktischem kreislaufstillstand sein oder wenn sich das eintreffen des rettungsdienstes verzögert. da wir nicht davon überzeugt sind, dass eine wiederbelebung allein durch thoraxkompressionen einer standardwiederbelebung gleichwertig ist, empfehlen wir weiterhin die bisher praktizierte vorgehensweise. eine qualitativ hochwertige wiederbelebung ist entscheidend für eine verbesserung des ergebnisses (outcome). bei der herzdruckmassage soll eine adäquate drucktiefe sicher erreicht werden (etwa cm, jedoch nicht mehr als cm beim normalen erwachsenen), bei einer kompressionsfrequenz von - /min mit minimalen unterbrechungen. nach jeder kompression muss der brustkorb vollständig entlastet werden. atemspenden/beatmungen sollen eine sekunde dauern und zu einer deutlichen hebung des brustkorbs führen. das verhältnis von herzdruckmassage zu beatmung bleibt : . unterbrechen sie die thoraxkompressionen für die beatmung nicht länger als s. durch defibrillation innerhalb von - min nach dem kollaps können Überlebensraten von - % erreicht werden. eine frühzeitige defibrillation kann durch notfallzeugen unter verwendung von öffentlichen oder hauseigenen aeds durchgeführt werden. public-access-programme (öffentlicher zugang zu aeds) sollen an viel besuchten orten (flughäfen, bahn-oder busstationen, sportstätten, einkaufszentren, bürogebäuden und kasinos) etabliert werden. kreislaufstillstände an solchen orten werden häufig beobachtet, und ausgebildete helfer können schnell vor ort sein. das vorhalten eines aed gilt schon dann als kosteneffektiv, wenn sich an seinem standort alle jahre ein kreislaufstillstand ereignet, die kosten pro gewonnenes lebensjahr entsprechen denen wenn möglich bitten sie jemanden den rettungsdienst anzurufen ( ) sonst rufen sie selbst an verlassen sie den patienten nur, wenn es keine andere möglichkeit gibt. schalten sie ihr telefon auf "freisprechen" um leichter mit dem leitstellendisponenten sprechen zu können. schicken sie jemand los, einen aed zu holen. sind sie allein, verlassen sie den patienten nicht, beginnen sie cpr. die angst, etwas falsch zu machen, erschöpfung und mangelnde muskelkraft führen häufig dazu, dass helfer bei der thoraxkompression nicht so tief drücken wie empfohlen. nach den leitlinien von zeigten vier beobachtungsstudien, dass eine drucktiefe von , - , cm bei erwachsenen zu besseren ergebnissen führte, als alle anderen angewandten drucktiefen [ ] [ ] [ ] [ ] . in einer untersuchung an patienten waren drucktiefen von , bis , cm mit einem maximum von , cm mit den höchsten Überlebensraten assoziiert [ ] . eine beobachtungsstudie beweist ferner, dass eine drucktiefe von mehr als cm bei der thoraxkompression bei erwachsenen zu mehr schäden führt, als mit drucktiefen von - cm [ ] . der erc schließt sich der ilcor-empfehlung an, dass es bei einem durchschnittlich großen erwachsenen sinnvoll ist, eine drucktiefe von -bis maximal cm anzustreben. der erc ist sich bei dieser empfehlung bewusst, dass es schwierig sein kann, die drucktiefe einzuschätzen, und dass zu geringe drucktiefen eher schaden als zu tiefe. im training soll kontinuierlich die bedeutung einer adäquaten drucktiefe betont werden. die kompressionsfrequenz ist definiert als die aktuelle frequenz der thoraxkompressionen, die in einem umschriebenen zeitraum durchgeführt werden. sie unterscheidet sich von der zahl der herzdruckmassagen in einem spezifischen zeitraum, die auch die unterbrechungen berücksichtigt. zwei studien an insgesamt . patienten fanden eine höhere Überlebensrate bei patienten, die thoraxkompressionen mit einer frequenz von - /min erhielten, verglichen mit > /min, - /min, < /min oder - /min. sehr hohe kompressionsfrequenzen führten zu einer zu geringen drucktiefe [ , ] . daher empfiehlt der erc die kompressionsfrequenz von - /min. atemspenden, elektroschocks sowie analysen der beatmung und des herzrhythmus führen zu unterbrechungen der herzdruckmassage. pausen von weniger als s vor und nach der abgabe eines schocks und ein anteil der thoraxkompressionen von mehr als % sind mit besserem outcome verbunden [ ] [ ] [ ] [ ] [ ] . unterbrechungen der thoraxkompressionen sollen minimiert werden, wobei erkannt werden muss, wie wichtig die aufmerksamkeit und das wechselspiel der helfer ist, die zusammenarbeiten. wann immer möglich soll die thoraxkompression auf einer harten unterlage erfolgen. luftgefüllte matratzen müssen entlüftet werden [ ] . die evidenz für den nutzen von rückenbrettern ist zweifelhaft [ ] [ ] [ ] [ ] [ ] . wenn sie verwendet werden, geben sie acht, dass es nicht zu unterbrechungen der thoraxkompression und zur dislokation von atemwegsund gefäßzugängen kommt. während der herzdruckmassage lehnt sich der helfer häufig auf den brustkorb, sodass sich dieser nicht wieder vollständig ausdehnen kann [ , ] . kann sich die brustwand nach jeder kompression wieder komplett ausdehnen, führt dies jedoch zu einem besseren rückfluss des blutes zum herzen, und das kann den erfolg der herzdruckmassage verbessern [ , [ ] [ ] [ ] . helfer sollen also darauf achten, sich nicht auf dem brustkorb abzustützen. der optimale kompressionsablauf (verhältnis von kompressionszeit zur gesamtzeit von kompression und entlastung) wurde an tiermodellen und mit mathematischen simulationen mit uneinheitlichen ergebnissen untersucht [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . eine beobachtungsstudie an menschen hat jüngst das bislang empfohlene verhältnis von : infrage gestellt, sie kommt zu dem schluss, dass kompressionsphasen von mehr als % eines zyklus nicht machbar seien und zu einer zu geringeren drucktiefe führen könnten [ ] . für den helfer ist das verhältnis schwer zu korrigieren, es wird stark durch andere parameter der thoraxkompression beeinflusst. der erc räumt ein, dass es wenig evidenz dafür gibt, ein spezifisches verhältnis zu empfehlen, folglich genügt die evidenz nicht, das bisher empfohlenen verhältnisses von : zu zu ändern. die verwendung von geräten zu feedback-und sprachführung soll in der klinischen praxis die qualität der wieder-belebung verbessern, indem die chancen auf rosc ("return of spontaneous circulation" -rückkehr des spontankreislaufs) und damit auf ein Überleben erhöht werden [ , ] . die art des feedbacks schließt sprachanweisungen, metronome, anzeigen, displays, wellendarstellungen, schriftliche anweisungen und optische alarme ein. der effekt solcher maßnahmen wurde in randomisierten [ , ] und beobachtungsstudien untersucht [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . keine dieser studien zeigt mit feedback ein verbessertes Überleben zum zeitpunkt der entlassung aus dem krankenhaus, und nur eine untersuchung fand eine signifikant höhere rosc-häufigkeit. in dieser studie wurde es allerdings dem behandelnden arzt überlassen, wann er ein solches gerät einsetzt, und über die gründe, wann ein gerät eingesetzt wurde oder nicht, sagt die studie nichts aus [ ] . der einsatz eines feedback-geräts bei der wiederbelebung sollte als teil einer umfassenden qualitätssteigerungsinitiative zur wiederbelebung betrachtet werden [ , ] , nicht als isolierte maßnahme. bei nicht relaxierten schweinen mit schnappatmung, mit ungesichertem, aber freiem atemweg, führt kontinuierliche thoraxkompression ohne beatmung zu einem verbesserten outcome [ ] . zu beginn eines kreislaufstillstands hat ein drittel der menschen eine schnappatmung, die den gasaustausch erleichtert [ ] . thoraxkompressionen führen aber beim intubierten patienten nur zu einem atemhubvolumen von ml, nicht ausreichend für eine adäquate ventilation [ ] . beim beobachteten kreislaufstillstand im kammerflimmern verdreifachte sofortige kontinuierliche thoraxkompression das Überleben [ ] . dementsprechend mag sie besonders in der frühen (elektrischen) und zirkulatorischen phase der wiederbelebung vorteilhaft sein, während in der späteren (metabolischen) phase eine zusätzliche beatmung an bedeutung gewinnt [ ] . während der herzdruckmassage ist der systemische blutfluss und damit der blutzufluss zur lunge deutlich re-duziert, folglich halten ein niedrigeres atemhubvolumen und eine niedrigere atemfrequenz als normal eine effektive sauerstoffversorgung und ventilation aufrecht [ ] [ ] [ ] [ ] . bei ungesicherten atemwegen führt ein atemhubvolumen von ml häufiger zur magenüberblähung als ein hubvolumen von ml [ ] . eine beatmungszeit von s ist ohne übermäßige magenblähung machbar [ ] . während einer wiederbelebung kann es zu einer unbemerkten hyperventilation kommen, besonders bei der beutel-masken-beatmung eines patienten mit gesichertem atemweg (intubation, supraglottische atemwegshilfen). obwohl dies zu einem erhöhten intrathorakalen druck [ ] und erhöhten atemwegsdruckspitzen [ ] führt, fanden sich in einer sorgfältig kontrollierten tierstudie keine negativen effekte [ ] . auf der basis der vorhandenen evidenz empfiehlt der erc für die beatmung eines erwachsenen bei der wiederbelebung ein hubvolumen von bis ml ( bis ml/kg). in der praxis führt dies zu einem sichtbaren heben des brustkorbs [ ] . notfallhelfer sollen eine beatmungsdauer von s anstreben, sodass sich der brustkorb hebt, aber eine zu schnelle und zu heftige beatmung vermieden wird. für beatmungen sollen die thoraxkompressionen nicht länger als s unterbrochen werden [ ] . diese empfehlung gilt für alle formen der beatmung während einer wiederbelebung, einschließlich mund-zu-mundund beutel-masken-beatmung mit oder ohne sauerstoffgabe. die mund-zu-nase-beatmung stellt eine akzeptable alternative zur mund-zu-mund-beatmung dar [ ] . sie kann erwogen werden, wenn der mund des patienten schwer verletzt ist oder nicht geöffnet werden kann, der patient sich im wasser befindet oder bei der mundzu-mund-beatmung keine abdichtung erreicht werden kann. ein patient der eine trachealkanüle oder ein trachealstoma trägt, kann im notfall mund-zu-tracheostoma beatmet werden [ ] . daten aus tierversuchen sprechen dafür, dass das verhältnis thoraxkompression zu ventilation größer als : sein sollte [ ] [ ] [ ] . nach einem mathematischen modell bietet ein verhältnis : den besten kompromiss, was blutfluss und sauerstoffversorgung angeht [ , ] . in den leitlinien und wurde dem auf sich allein gestellten helfer ein verhältnis : bei der wiederbelebung eines erwachsenen empfohlen. so werden unterbrechungen der thoraxkompression und damit die zeiten ohne blutfluss ("no flow fraction") [ , ] sowie die wahrscheinlichkeit einer hyperventilation reduziert [ , ] . mehrere beoabachtungsstudien berichten von einer leichten verbesserung beim outcome der patienten, nachdem die leitlinienänderung von : auf : eingeführt worden war [ , , , ] . der erc bleibt daher bei seiner empfehlung für ein kompressions-ventilations-verhältnis von : . reanimation ohne beatmung ("compression-only cpr") tierversuche zeigten, dass eine wiederbelebung nur durch thoraxkompression in den ersten wenigen minuten nach einem nicht asphyktischen kreislaufstillstand genauso effektiv sein kann wie eine kombination aus herzdruckmassagen und beatmungen [ , ] . tierversuche und mathematische modelle haben aber auch gezeigt, dass die sauerstoffvorräte nach - min erschöpft sind [ , ] aeds sind sicher und effektiv, wenn sie durch laien mit wenig oder ohne training verwendet werden [ ] . aeds ermöglichen eine defibrillation viele minuten, bevor professionelle hilfe eintrifft. helfer sollen thoraxkompressionen mit minimalen unterbrechungen durchführen, während der aed angelegt und verwendet wird. die helfer sollen sich darauf konzentrieren, der sprachführung unmittelbar zu folgen, insbesondere die herzdruckmassage sofort wieder aufzunehmen, wenn dazu aufgefordert wird, und unterbrechungen der thoraxkompressionen zu minimieren. pausen vor und nach einem schock sollten so kurz wie nur möglich sein [ , , , ] . standard-aeds können schon für kinder ab jahren verwendet werden [ ] [ ] [ ] . für kinder zwischen und jahren sollen spezielle klebeelektroden für kinder verwendet werden, wenn möglich mit einem kinderprogramm. stehen sie nicht zur verfügung, soll der defibrillator verwendet werden, wie er ist. die verwendung des aed wird nicht für kinder unter einem jahr empfohlen, obwohl es berichte über einen erfolgreichen einsatz in dieser altersgruppe gibt [ , ] . abgesehen von herzkran-ken kleinkindern ist eine defibrillierbare rhythmusstörung bei kleinkindern extrem selten [ ] [ ] [ ] [ ] [ ] [ ] [ ] . ist in diesen wenigen fällen ein aed der einzige verfügbare defibrillator, sollte sein einsatz erwogen werden (vorzugsweise mit verringerter dosis). die bedeutung unmittelbarer defibrillation wurde immer in leitlinien und ausbildung betont, ihr wird großer einfluss auf das Überleben nach kammerflimmern zugesprochen. wurde dieses konzept infrage gestellt, da evidenz dafür vorlag, dass thoraxkompressionen von bis zu s vor einer defibrillation das Überleben verbessern können, wenn der rettungsdienst erst nach mehr als - min eintrifft [ , ] . drei jüngere studien konnten diesen vorteil nicht bestätigen [ ] [ ] [ ] . die analyse einer randomisierten studie deutete auf eine verschlechterung des Überlebens bis zur krankenhausentlassung durch eine längere periode cpr (reanimation ohne beatmung länger als s) mit dadurch verzögerter defibrillation eines defibrillierbaren rhythmus hin [ ] . allerdings war in rettungsdienstbereichen mit einer hohen ausgangsüberlebensrate bei krankenhausentlassung (definiert als mehr als % der initial defibrillierbaren fälle) eine wiederbelebung über s vor der defibrillation erfolgreicher als eine wiederbelebung über eine kürzere zeit ( - s) [ ] . der erc empfiehlt, dass cpr fortgeführt werden soll, während ein defibrillator oder aed gebracht und angelegt wird, aber dann soll die defibrillation nicht weiter verzögert werden. in der praxis werden aeds meist von ausgebildeten helfern eingesetzt, sodass die aed-sprachführung grundsätzlich auf ein kompressions-ventilations-verhältnis von : eingestellt werden soll. wenn -ausnahmsweise -aeds an einem ort platziert werden, wo es unwahrscheinlich ist, dass ausgebildete helfer dazukommen, kann der betreiber die einstellung auf herzdruckmassage ohne beatmung ändern lassen. hat ein vollautomatischer aed einen defibrillierbaren rhythmus erkannt, gibt er den schock ohne weiteres zutun des helfers ab. in einer studie an Übungs-phantomen konnte gezeigt werden, dass ungeschulte krankenpflegeschüler mit einem vollautomatischen aed weniger fehler machten als mit einem halbautomatischen [ ] . eine simulierte studie an phantomen ergab, dass die sicherheit nicht gefährdet war, wenn ungeübte laienhelfer einen vollautomatischen statt einen halbautomatischen aed benutzten [ ] . Über die anwendung an menschen in einem klinischen bereich liegen keine daten vor. defibrillatoren in der Öffentlichkeit ("public access defibrillation", pad) [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . für den häuslichen bereich können erfahrungen aus der vergangenheit und die art der nachbarschaft bei der entscheidung, wo ein aed stationiert sein soll, helfen [ , ] . die registrierung der aed-standorte erleichtert es dem leitstellendisponenten, einen notfallhelfer zum nächstplatzierten aed zu führen und somit die hilfeleistung zu beschleunigen [ ] . die frühzeitige defibrillation mit einem aed vor ort kann möglicherweise auch krankenhauskosten reduzieren [ , ] . das volle potenzial von aeds ist noch nicht ausgeschöpft, da sie meist im öffentlichen raum zum einsatz kommen sich aber bis % der kreislaufstillstände zu hause ereignen. der anteil der patienten, die mit kammerflimmern aufgefunden werden, ist zu hause geringer als in der Öffentlichkeit, wohingegen die absolute zahl zu behandelnder patienten zu hause höher ist [ ] . selten profitierenpatientenzuhause vonöffentlichen aed-programmen [ ] [ ] . das kap. "besondere umstände" liefertdie evidenz, die die erc-empfehlung untermauert, dass an bord aller kommerziellen flugzeuge in europa bindend aeds vorgehalten werden sollen, auch bei regionallinien und sog. "billigfliegern" [ ] . [ , ] . eine jüngere beobachtungsstudie konnte zeigen, dass ein aed erfolgreich eingesetzt werden konnte, bevor das innerklinische wiederbelebungsteam eintraf [ ] . drei beobachtungsstudien zeigten beim vergleich von aed-einsatz mit manueller defibrillation keine verbesserung beim Überleben bis zur krankenhausentlassung [ ] [ ] [ ] . in einer dieser studien [ ] überlebten in der aed-gruppe weniger patienten mit nicht defibrillierbarem rhythmus bis zur krankenhausentlassung als in der gruppe mit manueller defibrillation ( vs. %; p = , ). eine andere große beobachtungsstudie mit . patienten in krankenhäusern zeigte auch, dass der aed im krankenhaus mit einer niedrigeren Überlebensrate assoziiert war als ohne aed ( , vs. , %; adjusted rate ratio, rr, , ; %-konfidenzintervall, ci, , - , ; p < , [ ] viele notfallzeugen beginnen nicht mit der wiederbelebung, weil sie befürchten, dass thoraxkompressionen bei einem patienten, der keinen kreislaufstillstand hat, ernste schäden verursachen. drei untersuchungen befassten sich mit den risiken einer herzdruckmassage bei personen, die keinen kreislaufstillstand hatten [ ] [ ] [ ] .indengepooltendaten dieser drei studien, also von patienten, fanden sich knochenbrüche (rippen und schlüsselbein) mit , % ( %-ci, , - , %), schmerzen an der stelle der herzdruckmasage mit , % ( %-ci, , - , %), aber keine relevanten verletzungen innerer organe. ersthelfer sollten keine bedenken haben, mit einer wiederbelebung zu beginnen, da es nur in extrem seltenen fällen zu ernsthaften verletzungen kommt, wenn ein patient keinen kreislaufstillstand hat und von einem notfallzeugen wiederbelebt wird. eine systematische Übersicht zu skelettverletzungen durch manuelle thoraxkompression berichtet von - % rippenbrüchen und von - % sternumfrakturen [ ] . organverletzungen (lunge, herz, bauchorgane) sind sehr viel seltener und kommen mit und ohne knochenverletzungen vor [ ] . sie treten häufiger auf, wenn beim normalen erwachsenen tiefer als cm gedrückt wird [ ] . beobachtungsstudien zur ausbildung und tatsächlichen durchführung von wiederbelebungsmaßnahmen sowie fallberichte dokumentieren nur selten muskelzerrungen, rückenbeschwerden, kurzatmigkeit, pneumothorax, brustschmerzen, herzinfarkt oder nervenschäden [ , ] . die häufigkeit solcher ereignisse ist niedrig, und die ausbildung in wiederbelebungsmaßnahmen und deren tatsächliche durchführung ist unter den meisten umständen sicher [ ] . teilnehmer von wiederbelebungsschulungen sollten über art und ausmaß der körperlichen belastung während des trainingsprogramms aufgeklärt werden. lernenden und helfern, die während des trainings signifikante symptome entwickeln (z. b. brustschmerz oder starke atemnot), soll zum trainingsabbruch geraten werden. mehrere studien am Übungsphantom haben nachgewiesen, dass die drucktiefe bereits weniger als min nach beginn der thoraxkompressionen abnimmt [ ] . eine krankenhauspatientenstudie zeigte, dass auch bei echtzeit-feedbacks die durchschnittliche tiefe der herzdruckmassage zwischen , und min nach beginn der cpr nachließ [ ] . es wird daher empfohlen, dass sich ersthelfer etwa alle min abwechseln, um eine verschlechterung der druckqualität infolge der ermüdung des helfers zu verhindern. beim wechsel der helfer soll die herzdruckmassage nicht unterbrochen werden. viele studien zu öffentlich zugänglichen defibrillatoren ("public access defibrillation", pad) zeigen, dass aeds von laien und professionellen ersthelfern (first respondern) sicher angewendet werden können [ ] . eine systematische metaanalyse fand publikationen, die insgesamt unerwünschte ereignisse bei der defibrillation auswiesen [ ] . ursache waren zufälliger oder vorsätzlicher missbrauch des defibrillators, gerätefehlfunktion und versehentliche entladung während des trainings oder der wartung. in einzelfallberichten kam es durch die entladung implantierter herzschrittmacher (implantierbarer kardioverter-defibrillator, icd) zu schocks an helfern, was in einem fall zu einer schädigung peripherer nerven führte. es gibt keine berichte über schädigungen der ersthelfer durch defibrillationsversuche in feuchter umgebung. obgleich verletzungen der helfer durch defibrillationen extrem selten sind, konnte gezeigt werden, dass chirurgische handschuhe keinen ausreichenden schutz bieten [ ] [ ] [ ] [ ] . daher sollen helfer während der schockabgabe die thoraxkompressionen nicht fortsetzen, und der patient soll während der icd-entladung nicht berührt werden. direkter kontakt zwischen dem helfer und dem patienten während der schockabgabe soll vermieden werden. eine große prospektive studie zu pad berichtete von wenigen negativen psychologischen effekten in verbindung mit einer wiederbelebung oder dem einsatz eines aed, die eine intervention erforderten [ ] . zwei große retrospektive fragebogenstudien zur wiederbelebung stellten fest, dass notfallzeugen ihre wiederbelebung als positive erfahrung einstuften [ , ] . auch familienangehörige, die zeugen von wiederbelebungsmaßnahmen werden, können psychologisch davon profitieren [ ] [ ] [ ] . das seltene auftreten von nachteiligen psychologischen auswirkungen bei ersthel-fern nach einer wiederbelebung soll dennoch registriert und angemessen behandelt werden. das risiko einer krankheitsübertragung während des trainings und der tatsächlichen wiederbelebung ist extrem niedrig [ ] [ ] [ ] . das tragen von handschuhen während der wiederbelebung ist sinnvoll, aber die wiederbelebung soll nicht verzögert oder gar unterlassen werden, weil keine handschuhe verfügbar sind. drei studien zeigten unter kontrollierten laborbedingungen, dass beatmungsfolien oder -ventile die Übertragung von bakterien verringern [ , ] . es konnten keine studien gefunden werden, die die sicherheit und effektivität solcher hilfsmittel (beatmungstücher, taschenmasken), die den direkten kontakt mit dem patienten verhindern sollen, untersuchten. wenn man weiß, dass der patient eine schwerwiegende infektion hat (z. b. hiv, tuberkulose, hepatitis-b-virus, sars), wird ein infektionsschutz empfohlen. wird eine solche infektionsbarriere verwendet, ist dafür sorge zu tragen, dass es dadurch nicht zu unnötigen unterbrechungen der wiederbelebung kommt. studien an Übungsphantomen haben gezeigt, dass die qualität einer wiederbelebung besser ist, wenn eine taschenmaske verwendet wird, als wenn beutel-masken-beatmung oder ein gesichtstuch zur anwendung kommt [ ] [ ] [ ] . die verlegung der atemwege durch einen fremdkörper ist eine seltene, aber potenziell behandelbare todesursache [ ] . da die meisten atemwegsverlegungen beim essen entstehen, werden sie üblicherweise beobachtet. da die betroffenen anfangs bei bewusstsein sind und reagieren, besteht oft die möglichkeit zur frühzeitigen intervention, die lebensrettend sein kann. s notfall + rettungsmedizin · suppl · [ ] . . abb. zeigt den behandlungsalgorithmus bei einem erwachsenen mit atemwegsverlegungdurchfremdkörper. fremdkörper können eine milde oder eine schwere atemwegsverlegung verursachen. es ist wichtig, den ansprechbaren patienten zu fragen: "haben sie einen erstickungsanfall?" ein patient, der antwortet, hustet und atmet, hat eine milde obstruktion. kann er nicht sprechen, nur schwach husten, ringt er nach luft oder kann nicht atmen, so liegt eine schwere obstruktion vor. husten erzeugt einen hohen und anhaltenden atemwegsdruck und kann den fremdkörper ausstoßen. eine aggressive behandlung mit schlägen auf den rücken, oberbauch-und brustkorbkompressionen kann schäden hervorrufen und die atemwegsverlegung verschlimmern. diese soll patienten vorbehalten bleiben, die zeichen einer schweren atemwegsverlegung aufweisen. patienten mit einer milden verlegung des atemwegs sollen unter kontinuierlicher beobachtung bleiben, bis es ihnen besser geht, weil sich eine schwere verlegung noch entwickeln kann. klinische daten zum ersticken sind größtenteils retrospektiv und anekdotisch. bei erwachsenen und kindern über jahr, die bei bewusstsein sind und bei denen eine komplette atemwegsverlegung durch fremdkörper erfolgt ist, haben fallberichte die effektivität von schlägen auf den rücken sowie oberbauch-und brustkorbkompressionen gezeigt [ ] . in ungefähr % der fälle kann die atemwegsverlegung nicht durch eine einzige maßnahme beseitigt werden [ ] . die erfolgsaussichten steigen bei der kombination von schlägen auf den rücken, oberbauch-und brustkorbkompressionen [ ]. eine randomisierte studie an leichen [ ] und zwei prospektive studien an anästhesierten freiwilligen [ , ] haben gezeigt, dass mit brustkorbkompressionen im vergleich zu oberbauchkompressionen ein höherer atemwegsdruck erzeugt werden kann. herzdruckmassagen bei bewusstlosen oder nicht ansprechbaren patienten mit einer atemwegsverlegung durch fremdkörper sind mit einem guten neurologischen outcome assoziiert (odds ratio, , ; %-ci, - . , p < , ) [ ] . daher soll sofort mit thoraxkompressionen begonnen werden, wenn der patient nicht mehr reagiert oder bewusstlos 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gloves provide adequate electrical insulation for safe handson defibrillation? i: resistive properties of nitrile gloves do clinical examination gloves provide adequate electrical insulation for safe hands-on defibrillation? ii: material integrity following exposure to defibrillation waveforms bystander-initiated cardiopulmonary resuscitation out-of-hospital. a first description of the bystanders and their experiences factors surrounding cardiopulmonary resuscitation influencing bystanders' psychological reactions family presence during cardiopulmonary resuscitation offering the opportunity for family to be present during cardiopulmonary resuscitation: -year assessment presence during cardiopulmonary resuscitation is beneficial to familymembersintheout-of-hospitalsetting basic-cpr and aids: are volunteer life-savers prepared for a storm infections acquired during cardiopulmonary resuscitation: estimating the risk and defining strategies for prevention ethical and practical considerations in providing critical care to patients with ebola virus disease prevention of transmission of infection during mouth-to-mouth resuscitation prevention of oral bacterial flora transmission by using mouth-to-mask ventilation during cpr arandomisedcrossover comparison of mouth-to-face-shield ventilation and mouth-to-pocket-mask ventilation by surf lifeguards in a manikin mouth-tomouth ventilation is superior to mouth-to-pocket mask and bag-valve-mask ventilation during lifeguard cpr: a randomized study comparison of mouth-to-mouth, mouth-to-mask and mouth-to-face-shield ventilation by lay persons international comparative analysis of injury mortality. findings from the ice on injury statistics. international collaborative effort on injury statistics cardiac arrest following foreign-body aspiration the choking controversy: critique of evidence on the heimlich maneuver airway pressure with chest compressions versus heimlich manoeuvre in recently dead adults with complete airway obstruction airway obstructed by foreign material: the heimlich maneuver the treatment of food-choking relationships between pre-hospital characteristics and outcome in victims of foreign body airway obstruction during meals key: cord- -zpn h mt authors: chaffee, mary w.; oster, neill s. title: the role of hospitals in disaster date: - - journal: disaster medicine doi: . /b - - - - . - sha: doc_id: cord_uid: zpn h mt nan when the first rain began to fall in houston,texas, in june , did hospital staff know they would soon be providing care for hundreds of patients without electrical power or running water in flooded hospital buildings? on april , , did the emergency department staff arriving for the day shift at oklahoma city hospitals know that a former soldier was driving a rented van filled with pounds of ammonium nitrate toward the murrah federal building and that they would soon be faced with bombing victims? in , did restaurant patrons in wasco county, ore., have any idea, as they selected food from salad bars, that they would soon be evaluated in hospitals for profuse, watery diarrhea from intentional food contamination by a religious cult? in march , did the toronto healthcare workers who were caring for patients with respiratory symptoms know they would soon become infected with severe acute respiratory syndrome (sars) ? we can be quite certain that none of them knew. the capricious nature of disaster implies victims and responders are generally caught unaware. but we do know some things. we know there will be hurricanes, typhoons, tornadoes, earthquakes, mudslides, fires, and blizzards this year. we know people will pick up firearms, make bombs, and inflict pain and suffering on others. we know there will be casualties from train accidents, cars crumpled in chain reactions, building collapses, and explosions.we know infectious diseases will do what they do best: spread, sicken, and kill. we know terrorists have not given up their violent assaults. we know there will be mental health symptoms in accident survivors and the caregivers who respond to their needs. it is the hospital, at the heart of the health system, that will receive the injured, infected, bleeding, broken, and terrified from these events. we know the victims will seek life-saving care, comfort, and relief at hospitals, but many u.s. hospitals continue to prepare for disaster as though it will not happen to them. there are more than hospitals in the united states that form a diverse patchwork of healthcare services. u.s. hospitals vary greatly by geographic location (urban, suburban, and rural); financial and management structure (for profit, not-for-profit, private, public); type of care (general medical services or specialty care, such as psychiatric or pediatric); and government affiliation (department of defense,veterans health administration, or public health service). any of these hospitals may be called on to respond to the next disaster or may be the victim of a disaster. many experts believe that these hospitals are not adequately prepared to respond effectively ( the hospital was of little significance in american healthcare before the civil war. only hospitals existed in when the first survey was conducted-a time when no proper gentleman or lady would venture into a hospital by choice. the murky medical practices of the s offered little that couldn't be found in homes, and physicians had little in their armamentarium to change the course of disease and injury. however, discovery and scientific advance changed that. effective anesthesia, surgical antisepsis, antibiotics, the x-ray, and other advances turned the hospital into a place of comfort, hope, and healing. the th-century hospital became a sophisticated financial institution, the core of medical education, and the site of dazzling technological display. medical advances offered aid not only to the chronically ill but offered hope to those who suffered acute trauma or medical or psychiatric emergency. past events illuminate the variety and complexity of demands placed on a hospital in a disaster: the potential impact of disaster is staggering. the release of tons of methyl isocyanate from the union carbide factory in bhopal, india, in december exposed more than , to the deadly gas and killed about in the first week after the release. in september , workers scavenging a dismantled cancer clinic in goiania, brazil, took home a source containing cesium- . they sold it to a junkman who showed the glowing item to friends and neighbors. once radiation exposure victims presented to hospitals, and the release became well known, hospitals were overwhelmed. although were actually exposed and showed signs of radiation sickness, , people were evaluated. when the aum shinri kyo cult placed sarin on five trains in the tokyo subway system on march , , people made their own way to hospitals, were transported by authorities, and hospital staff and rescue personnel were contaminated due to poor or nonexistent decontamination procedures. on sept. , , when u.s. hospitals and healthcare professionals were confronted with the worst attack on american soil, and again during the anthrax attacks along the eastern seaboard, individuals and organizations responded heroically. a powerful change in thinking, also called a paradigm shift, occurred after the terror attacks: the health system came to be viewed as a foundation of national security. another perspective has changed as well. in the event of a disaster, emergency medical services (ems), police, and fire have long been recognized as first responders. however, just recently, hospitals also have been designated as first responders-and first receivers. the value of the hospital in national security has been increased, and hospitals are recognized as safe havens in communities, the public expects hospitals to be prepared to care for their needs, and the hospital is now recognized as a first responder in emergencies. however, hospitals remain significantly underprepared to respond as effectively as the public expects. most importantly, preparedness is at direct odds with productivity. daily operating requirements stretch most hospitals' resources. allocating funds to improve emergency response capabilities that may never be used could be viewed as foolhardy. community integration is now seen as necessary, but hospitals (other than those in networks or that are government facilities) have had few reasons to build healthy relationships with other hospitals in their communities. to meet the needs of communities in a disaster, business competitors must work as partners. hospitals play a vital role in the health,social structure,and economic life of a community. patients expect hospitals, and health system workers, to be available to provide care for them in all circumstances. a level of preparedness that was viewed as adequate in the past is no longer seen as acceptable. to be more highly prepared and to be able to respond effectively, hospitals must make substantial investment in equipment, training, facilities improvements, and supplies. hospitals depend on public trust; poor performance during a disaster could be financially crippling to a facility. rubin writes that hospitals are expected to handle whatever they receive and do it right the first time. hospitals are vulnerable to the stresses of disaster responses due to a number of inherent characteristics: • complexity of services: hospitals are facilities that provide healthcare but must also function as laundromats, hotels, office buildings, laboratories, restaurants, and warehouses. • dependence on lifelines: hospitals are completely dependent on basic public services: water, sewer, power, medical gases, communications, fuel, and waste collection. • hazardous materials: the hospital environment contains toxic agents and poisonous liquids and gases. • dangerous objects: heavy medical equipment, storage shelves, and supplies can fall or shift during an event such as an earthquake. multiple forces have placed hospitals in a precarious preparedness posture. the capacity of the health system has been scaled down to a bare minimum to cut operating costs. emergency departments are crowded with the uninsured and the underinsured who have no other access to care. the nursing workforce has withered, and physicians have left practice due to uncontrolled liability insurance costs. many hospitals determine their surge capacity by the number of patients they could comfortably care for using standard spaces, quality care standards, and additional teams of personnel to help. in reality, a disaster is not going to comply with the limits of hospital capacity. if bombing victims arrive at a -bed community hospital, spaces will need to be converted and used that planners may have never imagined, such as chapels, hallways, and offices. nurses accustomed to a certain nurseto-patient ratio may find the ratio in a disaster much higher and have to adapt practice accordingly. surge capacity must not be viewed only as the number of beds or spaces that can be allotted to care for patients, but it must include all supporting hospital services that are involved in patient care. if hospital services fail during a disaster, the hospital fails the population depending on it. the population includes not just the victims of the disaster, but the others presenting for needed care-women preparing to give birth, patients with chronic disease exacerbation, and children with lacerations that need sutures. a vital hospital emergency management program acts as an insurance policy that increases the chances of continued operations under difficult circumstances. an effective hospital emergency management program guides the development and execution of activities that mitigate, prepare for, respond to, and recover from incidents that disrupt the normal provision of care. the program should include the following components: • emergency manager: the emergency manager is the primary point of leadership in the development, improvement, exercise, and execution of the hospital's emergency management plan. • emergency management plan: the plan identifies the hospital's response to internal and external emergencies. deliberate (advance) planning permits the development of strategies while the organization is not under pressure to react. • executive leadership: hospital executive leadership charts the course for an organization. a hospital that lacks executive leadership committed to emergency preparedness will be significantly hampered in its efforts. • strategic planning: the hospital's strategic plan is the blueprint that guides all efforts to achieve its mission. it is critical that emergency management and preparedness efforts are woven into strategic planning. • emergency management committee: extremely broad membership is desired to ensure all hospital operations that will be stressed in a disaster are integrated and well prepared. • hazard vulnerability analysis (hva): the hva is a tool used to assess the risks in a specific environment. the emergency management plan can be tailored to address the hazards most likely to affect hospital operations. • vulnerability analysis: every aspect of hospital operations that will be depended on in a disaster should be assessed to determine whether there are weaknesses present that fail when stressed. hospitals in the u.s. navy medical department and a number of civilian hospitals in new york have had their level of preparedness assessed using the hospital emergency analysis tool (heat). the heat examines more than factors that contribute to effective emergency preparedness and response. after the systematic analysis by a team of experts, the hospital receives an after-action report that documents strengths and weaknesses and permits the development of a strategic plan to improve preparedness. • staff training, exercise, and continuous improvement: the joint commission on accreditation of healthcare organizations requires hospital staff members involved in the execution of the emergency management plan to receive orientation and education relative to their role in an emergency. exercise of the emergency plan is also required. lessons learned should be integrated into plans to continuously revise them. a commitment to the following philosophies will enhance hospital emergency preparedness: • imagine the unimaginable: when flood waters rise in a community, when a tornado touches down and demolishes an elementary school, when a disgruntled hospital employee opens fire with an automatic weapon in the emergency department, when a passing train derails and spills toxic chemicals, or when a wildfire closes in, it is too late to update an old plan, train staff to respond effectively, check phone numbers, and stock disaster supplies. disaster complacencybelieving a problem won't happen to you or your hospital-is a significant threat to effective planning and response. • protect the staff: only a true obsession with self-protection will ensure that staff members are not injured or become ill during disaster response. adequate stockpiles of gloves, masks, and other equipment must be available, along with training and leadership commitment to self-protection policies. • build in redundancy: expect the primary plan to fail and build in alternatives to every emergency measure. • rely on standard procedures whenever possible: people perform best in unusual situations when they perform activities that closely mirror what they do under normal conditions. • maintain records: patient care records are critical to obtaining reimbursement for disaster care provided. • plan to degrade services: normal levels of services cannot be maintained during disaster response. identify services, such as elective surgery, that can be temporarily curtailed or minimized so that personnel and resources can be reassigned. the federal government has implemented programs to augment local and state capabilities when they are overwhelmed. the united states has a well-established emergency medical safety net: the national disaster medical system (ndms). the ndms has two primary capabilities designed to enhance disaster medical response. the first is specialized disaster response teams who augment the medical emergency response at the site of disaster. the second ndms capability is a plan to share the inpatient bed capacity of the civilian and federal health systems in the event either system is overwhelmed with patients requiring inpatient care. ndms federal coordinating centers (fccs) play a regional role in maintaining a supply of ndms hospital members and providing training and exercises. when the ndms is activated, fccs coordinate patient reception and distribution of patients being evacuated. hospitals enter into a voluntary agreement to participate in the ndms. they must be accredited and generally have more than beds. the agreement commits a hospital to provide a certain number of acute care beds to ndms patients; however, it is recognized that hospitals may or may not be able to provide the agreedupon number of beds. hospitals that receive ndms patients are reimbursed for care by the federal government. the strategic national stockpile the strategic national stockpile (sns) was established in as the national pharmaceutical stockpile. it is now managed by the u.s. department of homeland security and serves as a national repository of antibiotics, chemical antidotes, antitoxins, intravenous therapy, airway management equipment, and medical/surgical items. the stockpile is designed to supplement local agencies that are overwhelmed by a health emergency. the noble training center in anniston,ala., (on the site of the former fort mcclellan army base) is the only hospital facility in the united states that trains healthcare professionals in disaster preparedness and response. the department of homeland security operates the noble training center, which offers a variety of training programs, including one for hospital leadership. more information is available online at: http://training.fema. gov/emiweb/ntc/. even though the federal government has many emergency response assets that can help in the response to an emergency, experience has shown that hospitals must be prepared to be self-sufficient for to hours after an event. a comprehensive hospital emergency management program must address a number of critical elements to adequately protect patients and staff and permit the facility to continue to operate. these are discussed in the following. just as one team leader is necessary for a controlled response to a cardiac arrest, an organized approach is essential to a successful hospital-wide emergency response. the hospital emergency incident command system (heics) is designed to provide that coordination. developed and tested in orange county, calif., in , it provides structure to response. heics uses: • a reproducible, predictable chain of command • a flexible organizational design that can be scaled to the scope of the problem • checklists for each position to simplify response and carefully define each task • a common language that permits communication with outside agencies the eoc will serve as the command post for operations during an emergency response. it should be fully operational and integrated into local and county emergency operations (box - ). hospital disaster drills have often been treated as annoyances and are planned in ways to render them futile. exercises are generally announced (unlike actual events), planned during regular business hours, and rarely include all hospital operations that will be affected by an actual event. hospitals are encouraged to drill individual units-frequently and during nights and weekends-and then build up to full, functional exercises involving management of moulaged "casualties." community participation is critical to identify elements that work or that need fine-tuning. only through exercise will the plan be adequately stressed so that failure points are identified. the facility's structural integrity and essential services are an often overlooked part of preparedness. box - recommended equipment and supplies for a hospital eoc (hvac) system so that it can be shut down and, ideally, so that specific zones can be manipulated to control airflow in the building in case of contamination • maintain a fuel source for full-load demand for to days' duration • develop a plan for the management and disposal of increased volumes of contaminated waste maintaining the physical security of the structure is important on a daily basis but becomes more of a challenge during a disaster. to ensure that the environment remains safe, egress must be controlled. additional elements of the physical security plan should include the following: • a security force with full-time security responsibilities; the force should have undergone criminal background checks and professional law enforcement training. • all entrances and exits should be controlled, monitored, and capable of being locked. • the hospital should be able to perform perimeter security protection ("lockdown") within minutes of notification. • hospital staff should be trained and drilled on the performance of lockdown. • hospital leadership should know what triggers the execution of a lockdown procedure. • a plan should exist for supplementing security staff in a disaster. it is critical that a hospital be able to rapidly assess the impact of a disaster on its operations and communicate the status to leadership in a situation report (often referred to as a "sitrep"), or a rapid needs assessment (ran). the assessment should, at a minimum, include the following: • the extent and magnitude of the disaster and the scope and nature of casualties • the status of operations and any disrupted critical services • the impact of disruptions on operations and the ability to sustain operations hospital staff must be able to receive timely and accurate notifications in a disaster, including when and where to report and for how long and other essential information. contact information for all staff members must be continuously updated and tested. additionally, the facility must be able to receive warnings and notifications from external agencies and be able to send warnings. triage is performed daily in emergency departments, where the most critical are treated first. but during a dis-aster, triage procedures must adapt to become like what is used on the battlefield, where the greatest good is offered to the greatest number. multiple disaster triage systems exist, including start (simple triage and rapid treatment), id-me (immediate, delayed, minimal, expectant), and mass (move, assess, sort, and send). it is important that a hospital use a system that is consistent with what is being used by services delivering patients to the facility. whatever system is selected, there must be predisaster training and exercises. when casualties present to an emergency department in numbers that overwhelm the facility, an alternative area must be available to manage overflow. the alternative triage area should be lit so that it can be used at night, weatherproofed, and temperature-controlled. a plan for working with the media will be needed. it is not recommended that media personnel be permitted access to a hospital during a disaster, but rather be provided regular, factual updates on activities and the status of the facility at a predetermined meeting place. risk communications involve using credible experts to deliver carefully worded messages to communicate most effectively in a high-stress, low-trust environment, such as a disaster. preparing hospital leaders in risk communications principles will ensure that they are able to communicate effectively to the public via the media. there is conflicting evidence about the value of certain types of mental health services in the wake of disaster, but it is clear that every disaster creates emotional trauma victims. primary victims are those who have been directly affected by the disaster. secondary victims are rescue workers in whom symptoms develop, and tertiary victims are relatives, friends, and others who have been affected. the critical incident disrupts a victim's sense of control as daily life is abruptly changed. hospitals must plan for providing mental health services to disaster victims but must also consider the needs-acute and long-term-of the hospital staff who attempt to respond to an overwhelming event. it is recommended that hospitals have trained crisis intervention teams that are well integrated into the emergency management plan. in the event of an intentional act that results in mass casualties, not only must a hospital care for the victims, but it has a critical role in bringing perpetrators to justice. hospital staff members require training in proper management of potential evidence-in both collection and preservation. evidence collection containers, including -gallon drums for patient decontamination run-off, should be available as well as bags to preserve other types of evidence. law enforcement agencies and forensic departments can provide training and guidance. staff members should be familiar with and follow procedures for maintaining chain of custody for evidence that is collected during patient care activities. a disaster will place significant demands on the food service system of a hospital. the adequacy of food supplies for patients and staff should be evaluated. because a hospital may need to be self-sufficient for several days in a disaster, a -to -day supply of food products is advisable. food service personnel should be included in disaster exercises. volunteers may or may not be of assistance, depending on their relationship with the hospital and their background. a volunteer pool that consists of individuals who serve regularly at the facility, are familiar with standard procedures, and participate in exercises can add valuable manpower to a disaster response effort. on the other hand,disasters will draw volunteers who wish to assist,a phenomenon known as "convergent volunteerism," in which unexpected and uninvited healthcare workers arrive and wish to render assistance at a large-scale incident. these "freelancers" may cause problems or may even be impostors. despite "just-in-time" supply schedules and empty warehouses, hospitals should maintain dedicated disaster supplies and arrangements for rapid resupply in the event of a disaster. disaster response will rapidly deplete critical supplies-administrative as well as clinical. conducting realistic exercises will help with the determination of the adequacy of stock and can be done without opening actual supplies so they can be restocked. disaster supplies can be rotated into the daily-use stream to ensure stock does not expire. experience with disasters has demonstrated a number of predictable pitfalls that occur in hospital disaster response. because immediate on-scene control of a disaster is chaotic and communication is often problematic, patients will present to the closest hospital available. this often leaves other nearby facilities with capacity and personnel that go unused. hospital personnel must be experts in protecting themselves, or they will become part of the problem and fur-ther stress the facility. some controversy exists over the level of protection needed in certain environments, but it is clear that masks (n ) and gloves (latex or nonlatex) will prevent transmission of biological agents. communications failure has often been identified as a predictable failure in disaster response. hospitals need to examine both internal communications systems (with staff and patients) and with external agencies. multiple layers of redundancy are essential to deal with expected failures and include the use of -mhz radios, dedicated trunk lines in the emergency operations center, two-way communications for hospital units and essential personnel, communications-on-wheels (cows), and access to amateur radio (ham) operators. the last resort is using runners who carry messages. hospitals must be able to identify and decontaminate patients who have been exposed to radiation or a compound that poses a threat to the patient's health and the safety of the facility. if the hospital depends on an external agency or has decontamination equipment that requires time to set up, an immediate alternative must be in place, such as a hose and hose bib outside of the emergency department. consideration should be given to patient privacy, managing patient valuables and clothes, and handling weapons brought into the hospital. a trained, exercised, and well-equipped team will be the foundation of successful efforts. hospitals will benefit from having a plan to care for children and other dependents of staff. in a disaster, staff will be called on to work extended hours, and usual family care arrangements may be unavailable. the creation of emergency patient admission packs that are maintained with disaster equipment will facilitate the admission of a large number of patients. if an automated patient tracking system is used, a back-up manual system should be available. all systems should be able to manage unidentified (john and jane doe) patients. many hospitals have wholly inadequate or nonexistent plans to manage mass fatalities. morgue space is generally limited in most facilities, so additional surge capacity must be identified in advance. arrangements for refrigerated storage trucks, refrigerator space, and other alternatives, including ice rinks, should be addressed with socially sensitive plans. complex cultural and religious issues may come into play in the event that there are contaminated remains and should be examined in advance. emergency drugs must be available at the point of care. often they are secured in pharmacy departments or warehouses, resulting in precious minutes of life-saving time being lost as personnel try to locate and obtain critical medications. in addition to drugs needed to respond quickly to nerve agents and other emergency situations, stockpiles of antibiotics should be maintained to provide prophylaxis to patients and staff. in a disaster, patients converge on the place they know they can obtain care-the hospital-and they arrive using any means possible. furthermore, with the victims of disaster, come their families, loved ones, and the media-all who have very important needs that must be addressed. hospitals can no longer approach disaster planning with a minimalist attitude that relies heavily on luck and belief that it will be someplace else that gets hit by the disaster. the hospital that received the most patients from the rhode island nightclub fire got lucky-the victims began arriving during a change of shift so there were two shifts of nursing staff available. however, the hospital also attributes its effective response to having drilled critical departments and procedures. emergency planning is the backbone of preparedness, but events will occur in each disaster that demand creative responses under pressure. this ability to respond flexibly is known as planned innovation. good plans will use general "all hazards" templates for disaster management but will permit independent initiative and a tailored response to a specific situation. the u.s. health system appears to be emerging from the dark ages of emergency planning. a minimalist attitude of preparedness was acceptable in the past despite the regular occurrence of natural disasters. the threat of terrorism and the resulting health system impact have stimulated investment in research, a resurgence of disaster training in nursing and medical schools, and visionary projects such as er one. er one is a national prototype for a next-generation emergency department. located in washington, d.c., it is developing new approaches to the medical consequences of terrorist attacks, natural disasters, and emerging illnesses. more information is available online at: http://er .org. the next phase of hospital emergency management will be a renaissance if creative planning prevails over naysayers, if resources are applied to priority preparedness activities, and if healthcare leaders are committed to ensuring that all who depend on hospitals will receive the care they need in a disaster (box - ). the care of strangers-the rise of america's hospital system combined external and internal hospital disaster: impact and response in a houston trauma center intensive care unit implications of hospital evacuation after the northridge, california, earthquake lessons learned from the activation of a disaster plan: / two new york city hospitals' surgical response to the a test of preparedness and spirit emergency department impact of the oklahoma city terrorist bombing tragedy and response-the rhode island nightclub fire the station nightclub fire and disaster preparedness in rhode island mass decontamination: why re-invent the wheel? meeting new challenges and fulfilling the public trust: resources needed for hospital emergency preparedness recurring pitfalls in hospital preparedness and response pan american health organization. principles of disaster mitigation in health facilities health care at the crossroads-strategies for creating and • auf der heide e. principles of hospital disaster planning department of health and human services. (includes recommendations on prehospital and hospital care preparing for the psychological consequences of terrorism-a public health strategy. this publication of the national academies of science includes an examination of current infrastructure and response strategies guide to emergency management planning in health care regional care model for bioterrorist events • the hospital emergency incident command system • the international critical incident stress foundation box - hospital preparedness and response resources sustaining community-wide emergency preparedness systems dvatex: navy medicine's pioneering approach to improving hospital emergency preparedness advanced disaster medical response-manual for providers. boston: harvard medical international trauma and disaster institute critical incident stress making room for outside the box thinking in emergency management and preparedness key: cord- - ai chbu authors: andersen, bjørg marit title: background information: isolation routines date: - - journal: prevention and control of infections in hospitals doi: . / - - - - _ sha: doc_id: cord_uid: ai chbu the isolation of patients with suspected or documented infections—to not spread to others—has been discussed for hundreds of years. guidelines are many, methods are different, attitudes show vide variations, routines and procedures are still changing, regulations by law may be absent, and some healthcare professionals may be afraid of adverse outcomes of isolation [ – ]. microbes that are spread in the environment, on the hands and equipment are invisible. the invisible agent does not call on attention before the infection; clinical disease, hospital infection or nosocomial infection is a factum that can be registered [ , , , – ]. how to stop the transmission is often “to believe and not believe” in infection control. like luster in sogn and glitre in akershus or in separate isolation buildings at the hospital, like epidemic buildings at ullevål hospital. despite academic controversy about "infection or not" from the late s to the s, the isolation treatment was used for presumably "infectious diseases" like typhoid, cholera, scarlet fever, diphtheria, smallpox, plague, etc. patients were isolated in hospital, at home or in own local epidemic houses in the country. chronic carriers of typhoid bacteria (salmonella typhi) were isolated alone at home or at the counties epidemic house by themselves (smitteborg, "infection castle" in skreia, norway, is still a local name). the epidemic houses had access control and were monitored by the healthcare board mayor. hygiene and infection control were very important since they had few curative agents. it was prepared vaccines and carried out partly or complete mass vaccinations against some infections. pulmonary tuberculosis was treated at sanatoriums in the mountains or at coast hospitals. the patient did not come home until he was free from infection. during outbreaks of typhoid fever, diphtheria or scarlet fever, the patients were isolated in separate sick barracks or at home. to be a carrier of an infectious disease could lead to work prohibition and isolation. schools were closed intermittently during outbreaks, and posters were put on houses with infectious disease as a warning. disinfection of houses, clothing and all of its contents was completed after the termination of the isolation period, using chlorine and sulphur smoke. carbolic acid and hydrochloric acid were also used where sulphur fumes treatment failed. bedding, clothing and fixtures that could not be washed or disinfected were often burned, with a financial compensation for this "outlay." patients who broke the isolation routines could be penalized and committed to further isolation. the society's need went first before each individual's needs [ ] . during the years from to , among approximately . million inhabitants in norway, there were a total of , , cases of acute laryngitis and bronchitis, , with acute gastroenteritis, , with "croup pneumonia," , cases of diphtheria, , with scarlet fever, , with rheumatic fever, , with typhoid and paratyphoid fever, with poliomyelitis and with dysentery! [ ] knowledge of infection, sanitation and housing conditions (less overcrowded), clean water, good personal hygiene, vaccinations and nutritional status were factors mitigating epidemic outbreaks beginning of the twentieth century. this demonstrates that most infectious diseases can be prevented and controlled, even without antibiotics. in , before the breakthrough of the penicillin, there were the most important precautions against infectious diseases in norway: [ ] isolation of the source of infection, [ ] disinfection, [ ] vaccination, [ ] quarantine, [ ] food hygiene and [ ] eradication of insects [ ] . airborne infection was estimated as "the most important form of spreading infections" which may be correct even today [ , ] . the last years of isolation treatment carried out in norway have been in separate houses and buildings until ca. when most infectious diseases were integrated into appropriate wards for the underlying diseases. in there was still isolate buildings where all kinds of infections were taken care of and with good routines. today, this type of isolation is gone, with exception of some buildings in preparedness for strict isolation. in each third to fifth hospital bed, there is an infected patient, and each third patient is treated with resistance-driving antibiotics today [ , , , ] . isolation units are therefore of great need. in norway with . million inhabitants, ca. , patients are treated annually in hospitals and about , receive hospital infections, resulting in at least , extra days in hospitals because of infection. hospital infections with staphylococcus aureus occur in % of the patients [ , ] . isolation treatment is laborious and expensive (ca. , nkr or usd per day). out of the , somatic beds in norway in , hospital infections charged ca. % of these, which would generate a need for ca. infection beds. however, the somatic bed capacity in norway is steadily being reduced, which creates several problems in the healthcare. there is an increased need of isolates for patients with infections, especially due to pulmonary tuberculosis, mrsa, vre, clostridium difficile (cd), multiresistant gram-negative bacteria and other "multidrug-resistant organisms" (mdro) [ , , , , [ ] [ ] [ ] [ ] . global incidence of entero-pathogenic bacteria and imported resistant agents increases, and there is an ongoing microbial spread via food, animals, fish, water, supplies and the environment [ , ] . new knowledge of transmission, robustness and ability to survive in the environment may reinforce the methods for isolation. cd, originally defined as contact transmission, may also spread through the air [ ] . cd problem increases, particularly in the united states where half a million patients are infected each year and , of them died in [ ] . a special dangerous cd type (nap ) is detected [ ] . the incidence of new respiratory viruses like human metapneumovirus, bocavirus, human coronavirus, etc. increases. for the first time in more than years, a highly pathogenic virus as ebola has been introduced to norway and to other countries in europe. pandemic-actual viruses such as sars, mers, different types of bird flu, new outbreaks of ebola and other viral haemorrhagic fevers show the need for isolation and emergency preparedness [ ] [ ] [ ] [ ] [ ] . children's diseases, who disappeared with vaccinations, like whooping cough, mumps, rubella and measles, are now increasing with outbreaks in areas with high vaccination rate in america and europe [ ] . from to , europe had more than , measles cases [ ] . by hospitalization, these need airborne infection isolation units. noro-, rota-and sapoviruses and other types of virus gastroenteritis are highly infectious with vomiting and producing of aerosols, i.e. airborne infection. growing global outbreaks of norovirus may cause fast and widely spread of gastroenteritis among patients and personnel in health institutions and cause inactivity and stop of new admissions [ , ] . the closure of wards or hospitals. outbreaks often end with the closure of the ward, as shown in one study, median in days [ ] . geriatric wards are usually closed during outbreaks. the most frequent cause is outbreaks of norovirus, %, p < . and influenza/parainfluenza, . %, p < . [ ] . intensive care units (icu) are often particularly vulnerable to infection. crosscontamination between such patients is normal [ ] . in a -bed icu for adults, patients were followed for patient days and cross-transmission was followed by genetic typing of the microbes [ ] . a total of episodes of cross-transmission was demonstrated and dominated by pseudomonas aeruginosa, other gram-negative bacilli and s aureus. cross-transmission was associated with understaffing, use of nasogastric tube, ventilator and other multiple patient-to-nurse contacts and immune-compromised patients [ ] . patients treated at understaffed icus were three times more likely to be infected; immunosuppressed had four times greater risk, and bronchoscopy-treated patients led five times higher risk [ ] . intensive units often have no isolates, and if they have, they are not so much used because of staff shortages. airborne infection isolation units will quickly be economic by more control over the spread of infection, fewer extra days in hospitals and fewer sick leave for personnel, as was demonstrated during the sars epidemic [ ] . the larger outbreaks of infectious childhood diseases require more isolation for airborne infections [ ] . the same goes for whooping cough which years ago was an unknown phenomenon in norway and now in widespread child and adult disease [ ] . imported infections are increasing, and hospital infections like wound infections, respiratory tract infections and antibiotic-associated diseases are also increasing. in the s, the state board of health in norway recommended that the number of isolation beds should be % of the hospital's total bed numbers and the icu % [ ] . at ullevål hospital, % of the beds were airborne infection isolates, and % contact isolates in [ , , ]. in , a european investigation was done as regards the number of "high-level isolation rooms" (hirs), i.e. airborne infection isolation units with negative pressure (not defined) with at least air changes per hour and sluice (anteroom) [ ] . this is a unit intended for high-risk infections like haemorrhagic viral infection, sars, the starting phase of pandemic influenza, xdr (extended drug-resistant) tuberculosis, anthrax, plague, biological terrorism, etc. [ ] in all, european network countries (eunid) with hospitals and about isolation beds participated. many of these had fewer than air changes per hour [ ] . the total proportion of airborne infection isolates (hir) per country were calculated per million inhabitants. the largest proportion of these isolation units were detected in luxemburg, . per million; followed by finland, [ ] . most countries used hepa filter for air extraction from the isolates ( out of ). among countries, had localized airborne isolates (hir) to own buildings or wards, in was hir in the same ward as other patient rooms, and in both solutions were adopted [ ] . a total of hirs were equipped for intensive care, most in italy ( beds) and in denmark ( portable beds) [ ] . after year , hirs have been used in europe to approximately imported haemorrhagic fever cases and confirmed sars cases. in the united states, there are three "high-level isolation units" (hliu), placed at the same level as laboratory with biosafety level (bsl) and , in separate buildings, with limited and controlled access, negative air pressure and special treatment of sewage and garbage [ ] . isolates rely on "evidence-based design," i.e. knowledge of the construction, design, materials, equipment, furnishing, standards, etc., which are considered as core elements of the infection prevention [ ] . solid evidence of the spread of infection is used to control good environmental measures, disinfection and proper use of the isolates [ ] [ ] [ ] . infection isolation involves admittance of the patient to a separate room with disinfection/bathroom, sluice or anteroom (see fig. . ). it is always an advantage with some negative pressure of infection isolates-even for contact infection-to avoid spread of infections outside the isolate. a contact isolate has sluice, patient room and disinfection/bathroom, about. m . the sluice should be at least m with room for bed or stretcher and wash basin. it shall have a defined clean side, space for clean clothes and unused ppe and a dirty side, for infectious waste and infectious waste bags or containers. patient room should be at least m , with the head end against the wall and about m free zone on both long sides and from the foot end, to avoid too close contact with the patient. disinfection room, combined with bathroom, - m , contains shower, toilet and wash basin, with plenty of space to be able to help the patient as needed. it should also be equipped with decontaminator, preferably a well-sealed, throughput decontaminator from disinfection room to the sluice. in throughput decontaminators (or autoclaves), infected equipment can be put in from the disinfection room and removed decontaminated in the sluice. all throughput systems should be assured with complete sealing against air leakage. it should only be opened from one side at the time, i.e. interlock. avoid throughput cabinets between the sluice and disinfection room. all isolation unit surfaces must be smooth, robust and withstand disinfectants, both liquid and dry gaseous form. avoid tiles, gaps and joints where dirt can form the basis for growth and biofilms of microbes which may prevent effect of disinfection. there should be at least eight air changes per hour (> six air changes [ ] ), which is important to remove the infectious agent in the room air. incoming air must enter on the wall or ceiling; air extraction shall go out by the floor ( cm above), preferably in the disinfection room. the isolate should have separate ventilation system so korridor ute dekont. that the infection does not come across to other patients by setbacks in joint ventilation ducts. intake air should be a certain distance from the air outlet. hepa filters should be set on air outlet, and procedures for maintenance and control should be established. airborne infection isolate is provided and formed as for a contact isolate. the isolate should be organized for direct access from outside. in addition, the controlled and defined negative pressure is graded down from the sluice to the disinfection-bathroom compartment [ ] . pressure is usually, − to − pascal relative to the corridor and the adjacent rooms. in the sluice there is - pascal, in the patient room − to − pascal and disinfection room − pascal. the air will then be drawn from the cleanest room (sluice) to the dirtiest room (disinfection room), if the doors are closed. the most stable, controlled negative pressure may be made by doors opened outwards from the patient room to the sluice and further from the sluice to the corridor (see fig. . ). the vacuum will suck the door even tighter to the door frame to hinder air leakage. interlocked doors should be used so that only one door at a time may be opened into the patient room. the stability is dependent on the number of air changes per hour. the minimum and most stabile is air changes per hour ( ) ( ) ( ) ( ) ( ) ( ) ( ) [ , , ] . each air exchange reduces the pathogenic agents in the air substantially. all air expelled exits at the floor ( cm above) and is gathered into an outgoing ventilation channel from the disinfection compartment. avoid "shortcuts" of the air circulation. as for contact isolates, airborne infection isolates should have separate ventilation systems with no setbacks in ventilation ducts; external intake of air over the roof should be well away from the external air outlet over the roof, and all air from the unit is hepa filtrated. procedures for maintenance, disinfection and control of filters and ducts should be established. cohort isolation of several patients with the same infectious agent may be appropriate. it is a good initiative during pandemics. the sars epidemic released a rapid learning process where the chinese built-within a week-a dedicated sars hospital for patients in beijing [ ] . in a study from brazil, all patients with proven mdros (multidrug-resistant organisms) were transferred to a -bed unit for isolation treatment by a trained personnel, where personnel, patients and family were weekly taught about how to handle mdro's by a special team [ ] . after the intervention, the mdro rate was significantly reduced, specially by the reduction of vre. isolated patients had at least the same good treatment quality as not isolated patients [ ] . in norway, cohort isolation was utilized in trondheim during the first national outbreak of mrsa ( ) ( ) ( ) ( ) ( ) . a total of patients were infected (including personnel), and died ( . %) directly or indirectly from the hospital epidemic [ ] . the control of the outbreak came first when infected patients and personnel were cohort isolated in a separate isolation ward [ ] . barrier care of one infectious patient among other patients without infections on the same bedroom in dormitory is not recommended. a good standard of patient isolates depends on good daily cleaning and a thorough disinfection by termination of the isolation. long-time surviving bacteria, viruses and fungi should not be a risk for the next patient to be isolated, which may happen [ , ] . mrsa, multiresistant acinetobacter baumannii and other mdros are contaminating bedding, bed and environment for months, if not removed [ ] . disinfection of rooms and isolates are often not well enough done [ ] . the terminal disinfection, removal and disinfection of all equipment in the room and disinfecting of all surfaces are important. disinfectants (liquid) that are effective against all microbial agents are chloramine %, household bleach % or peracetic acid for h. treatment with hot water (> °c) for min is a very effective disinfection of equipment and textiles. different types of gas or steam disinfection (hydrogen-peroxide dry gas, chlorine gas, formaldehyde gas) may be effective for equipment and room disinfection [ ] [ ] [ ] [ ] . note that there is yet no gas treatment that is documented to kill mycobacteria [ ] . the isolates are often used incorrectly. in the same ward and at the same time, patients without infection are placed on the isolates while infectious patients are not isolated. although defined isolate treatment is determined and ppe used, it turns out that the patient is walking freely around in the ward, not really isolated. knowledge and practices increases understanding of disease control measures. some patients that are both prone to infection and have serious infections, like cystic fibrosis patients, should be treated in isolates [ ] . depression, anxiety and anger get less visits and information by health professionals; more often fall injuries or other injuries, inferior care, etc. are claimed to be side effects of isolation [ , ] . however, patients previously depressed and anxious at admission suffer no more under an isolation stay [ ] . there is not shown differences between isolated and non-isolated patient, according to the patient's view of treatment, on the contrary [ ] . but the patient satisfaction is the highest among those who are well informed [ ] . most studies show that contact time with the medical doctor is approximately equal for isolated and non-isolated patients and approximately equally frequent [ , ] . although mrsa or vre infected patients, in one study, had more frequent falls and pressure ulcers, this was not reduced by removing the contact isolation, so that it was likely other factors which could contribute to such complications [ ] . outbreaks are very costly and take up significant resources and healthcare for other patients [ ] . a patient infected with mrsa was at ullevål university hospital, norway, estimated to generate an additional charge of , nkr (ca. $ , ), including extended length, spread to a hospital employee, screening tests and antibacterial treatment in [ ] . in , in connection with a mrsa outbreak in neonatal ward at ullevål, the calculated additional costs were , nkr (ca. $ , ) per mrsa-positive patient, including isolation expenditure, disinfection and cleaning, screening and extra days in the hospital [ ] . active screening and isolation of patients with mrsa are significantly and markedly cheaper for the healthcare than uncontrolled transmission which can result in serious infection and death [ ] . anchoring isolation procedures in laws is essential to the implementation of isolation. norway has several laws, regulations and guidance to control infections in healthcare facilities [ ] [ ] [ ] [ ] [ ] [ ] . international studies have laid the basis for the norwegian isolation measures and techniques [ - , - , ] . a number of studies regarding the design and function of isolation units exist [ , , [ ] [ ] [ ] [ ] . simply to place patients in single rooms provides noticeable improvement in the spread of infection [ ] . the implementation of good isolation measures and compliance is often weakened by confusion, lack of written procedures, lack of training, competence and understaffing. a number of other factors also influence the attitude of healthcare professionals with regard to follow the hospital's infection control procedures, not least professional disagreement about the procedures. • in emergency wards in the united states, only % of the wards used contact protection (gloves and gown) upon receipt of patients with diarrhoea or faecal incontinence, % for suspected cd, % for purulent skin infections, % for suspected mrsa and % by multiresistant gram-negative rods [ ] . • it may be a big difference between what staff and others say they do and what happens in reality [ ] . among persons who entered isolates, the compliance was higher by strict isolation infections ( %) than with other infectious conditions [ ] . visitors followed the measures better than personnel ( % versus %) [ ] . the compliance with isolation procedures increased significantly when more time was spent with the patient, being a visitor, and when the patient was on a strict isolation [ ] . the study pointed out the danger of increased demands for doctors and nurses due to savings can result in adverse effects such as reduced compliance with key routines as isolation [ ] . morgan et al. observed visits of a healthcare professional to isolated and non-isolated patients. patients on contact isolation had % fewer visits and % less contact, and there were fewer visitors than non-isolated patients [ ] . however, the staff implemented significantly more frequent handwashing after visit in isolates, %, than by visits with non-isolated patients, % [ ] . • during the mrsa outbreak with ca patients in trondheim, norway, - , kvittingen et al. described problems that may occur during epidemic and endemic conditions as "doctors more or less wholehearted support and scepticism to the measures made by the hygiene committee, discussions concerning the virulence and resistance development, what to do when a local outbreak paralyzes the department completely, information problems, lack of qualified personnel, etc." [ , ] . they stressed that "larger hospitals should dispose well-planned isolation opportunities, both for patients who are infectious spreaders and perhaps equally important, to protect patients with reduced infection defence," and that "personnel in management positions (should) provide effective and loyal support for infection control personnel" [ ] . • this was a very important observation done for more than years ago. it is still causing major problems during outbreaks and endemic situations when there may be a choice between shortcut thoughts about "economy" and infection control. still, impression and experience is that staff working directly with the patients have great respect for contact and airborne routines, at least in norway. isolation regimes and interpretation of these are an almost perpetual discussion which changes with endemic and epidemic conditions, economy and guesswork. although isolation of patients with infectious diseases has been used for hundreds of years, there is little evidence in terms of endemic conditions [ ] [ ] [ ] [ ] . the norwegian isolation regimes are based mostly on guidelines from cdc [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . in addition, an increasing number of guidelines are focusing on special isolation factors [ , - , - , ]. cdc's isolation guideline is graded from high evidence, highly recommended as the ia, to no recommendation and unresolved questions or professional disagreement [ ] . category ic is included in the legislation for patients and caregivers [ ] . classification into categories is essential for the most important infection control measures in hospitals. "these recommendations are designed to prevent transmission of infectious agents among patients and healthcare personnel in all settings where healthcare is delivered. as in other cdc/hicpac guidelines, each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability and, when possible, economic impact" [ ] . the cdc recommendations are changed over time [ ] [ ] [ ] [ ] [ ] [ ] [ ] . cdc/hicpac system recommendations in categories in correspondence with investigations, theory and economic possibility; quoted [ ] . cdc's isolation guideline refers to the administrative responsibility around isolation treatment [ ] . the hospital's management is responsible for ensuring the implementation of good practical measures and to be the driving force in the hospital's infection control preparedness. this should particularly be done with regard to isolate patients, an extra burden, and also for the economy. enough isolate capacity is to be provided in relation to citizens, patient categories, type of hospital activity and endemic/epidemic conditions. the isolates must be of good quality and design, and it should be enough airborne infection isolation units [ ] . some of the cdc-recommended administrative responsibilities are quoted here: [ ] citation: "healthcare organization administrators should ensure the implementation of recommendations in this section: transmission-based precautions), establish processes to monitor adherence to those performance measures and provide feedback to staff members. category ib" [ ] . citation ended. a good and active hospital management is of major importance to stop the outbreak [ , , , , , , , ] . ransjø et al. attached the importance to the activity of the hospital management during outbreaks of multidrug-resistant microbes in sweden [ ] . in norway, an outbreak of vre by a dialysis department spring , at ullevål university hospital, was expected from the department's critical building condition [ ] . after great effort from the staff, the outbreak stopped within days [ ] . a structural rehabilitation started then, with expansion of bed numbers, assisted by the hospital management. one year later, all patients were vre negative [ ] . a number of outbreaks at ullevål's premature intensive care unit during years have been linked to chronic understaffing, overcrowding, part-time work, lack of infection control practices and isolates, lack of information and a lack of management responsibilities [ , ] . the responsibility of the hospital management to prevent and combat outbreaks of infection should be clearly stated in the hospital's infection control program. cdc defines contact isolation, using gown and gloves when in contact with patients infected with resistant bacteria like mrsa and other mdros (multidrug-resistant organisms), and single rooms are recommended [ ] . direct contact contamination occurs when microbes are transmitted from an infected person to another without the "intermediate stage" in the environment. microbes transferred to the hands can further spread to the own mouth, nose, hair, ears, clothing, etc. [ ] healthcare personnel is likely to be a "source, vector or a victim" of infections like mrsa [ , ] . patients bring their own microbes into the hospital, with often large contact before a known infection [ ] [ ] [ ] [ ] [ ] . therefore, rapid tests are recommended where possible to detect pathogens [ , ] . indirect contact contamination happens when the microbes are transferred to an object in the environment and from there transmitted to other objects or people. infectious patients themselves will have the agent on the body and clothes and transmit it to the environment. the undetected microbes can spread quietly and calmly in many directions via equipment, rooms, surfaces and missing/incorrect procedures [ ] . this is often a large and persistent environmental problem and a threat to other patients [ , , , , , , [ ] [ ] [ ] [ ] [ ] ] . the most typical spread occurs when people with contaminated hands are depositing microbes on equipment, machinery, knobs, door handles, uniforms, other textiles, furniture, toys, etc. [ ] [ ] [ ] fellow-patients on the same room are highly susceptible to infection [ , , , , , , [ ] [ ] [ ] [ ] . infection can be spread further via equipment (bp apparatus, stethoscope, medicine tray, blood sugar test equipment, journal, etc.) and the personnel's uniform. it is often brought to the ward office, to service rooms and to other personnel or patients. a long "domino" chain of infections may follow infectious agents not stopped by simple hygienic measures and isolation [ ] . contact infection may also be an airborne infection from patients coughing and sneezing by certain aerosol procedures, when cleaning the surfaces, by bedding and by strong air currents (e.g. by rapidly opening and closing doors) which dislodges dust from the lamps, shelves, etc. [ , , , , [ ] [ ] [ ] therefore, a daily good housekeeping and good routines for final disinfection in isolates is very important to reduce the burden and risk of pathogenic microbes [ , ] . contact infection prevention (cp)-recommended by cdc [ ] . some citations selected from siegel et al. ; cdc guideline for isolation, where recommendations are in categories where ia is strongest recommendation. selected citations: [ ] " . in acute care hospitals, place patients who require cp in a single-patient room when available. category ib. . when single-patient rooms are in short supply, apply the following principles for making decisions on patient placement: ----place together in the same room (cohort) patients who are infected or colonized with the same pathogen--. category ib. in close proximity to the patient (e.g., medical equipment, bed rails). don gloves upon entry into the room or cubicle. category ib. . wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. don gown upon entry into the room or cubicle. remove gown and observe hand hygiene before leaving the patient-care environment. category ib. . patient transport. in acute care hospitals and long-term care and other residential settings, limit transport and movement of patients outside of the room to medically-necessary purposes. category ii. . when transport or movement in any healthcare setting is necessary, ensure that infected or colonized areas of the patient's body are contained and covered. category ii. . remove and dispose of contaminated ppe and perform hand hygiene prior to transporting patients on cp. category ii. . don clean ppe to handle the patient at the transport destination. category ii. precautions. category ib/ic. . in acute care hospitals and long-term care and other residential settings, use disposable noncritical patient-care equipment (e.g., blood pressure cuffs) or implement patient-dedicated use of such equipment. if common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. category ib [ ] ." selected citation ended. spread of pathogenic infectious agents through the air and droplets requires a defined negative pressure ventilation isolate and a system which reduces airborne infection in the patient's room. it is best done by air replacement - times an hour [ , ] . the cause of airborne, pathogenic microbes may include: and the urinary tract. . by rapid removal of the bandage from pus and discharging wounds. . by raise up of infected dust, skin cells and other contaminants by activities that create air currents, often in poorly cleaned rooms [ ] . . re-aerosolized pathogens from used textiles and equipment in the patient room or where these contaminated items are brought, for instance, to the ward's disinfection room or to the laundry. by massive contamination and poor routines for washing equipment and hospital textiles, this may cause a special problem of re-aerosols [ ] . . construction activity of all types without measures against airborne infection is influencing the airborne spread of bacteria, virus and fungi. this must be taken into account when rebuilding and repairing buildings and ventilation ducts etc. [ , ] . if ignored, it may cause large problems like the outbreak of bacillus cereus among patients, most with sepsis, during months of a large construction project next to the hospital [ ] . air samples showed growth of large quantities of bacillus inside the hospital, the units and also isolates, and hospital textiles were heavily contaminated [ ] . on a daily basis, the human inhales , particles or more via airways; many of these are bacteria, viruses and fungi but mostly come up again without causing disease. a solid documentation shows that airborne infection may occur at a variety of infectious diseases [ , , , , , , , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . rooms with mrsa-infected cases may have larger numbers of mrsa bacteria in air samples than in samples from surfaces [ , ] . mrsa may even be spread to nearby located rooms, to patients not infected [ , ] . the few existing units for airborne infection isolation mean that most patients, except for pulmonary tuberculosis, most often are admitted to contact isolation or single-patient rooms, with the use of ppe corresponding to airborne infection: gloves, infection-protecting gown, cap and surgical mask and sometimes room-bound shoes [ ] . airborne precautions (ap)-recommended by cdc [ ] . an aiir directly to the outside, the air may be returned to the air-handling system or adjacent spaces if all air is directed through hepa filters. (c) whenever an aiir is in use for a patient on airborne precautions, monitor air pressure daily with visual indicators (e.g., smoke tubes, flutter strips), regardless of the presence of differential pressure sensing devices (e.g., manometers). (d) keep the aiir door closed when not required for entry and exit. . when an aiir is not available, transfer the patient to a facility that has an available aiir. category ii. . in the event of an outbreak or exposure involving large numbers of patients who require airborne precautions: (a) consult infection control professionals before patient placement to determine the safety of alternative room that do not meet engineering requirements for an aiir. (b) place together (cohort) patients who are presumed to have the same infection(based on clinical presentation and diagnosis when known) in areas of the facility that are away from other patients, especially patients who are at increased risk for infection (e.g., immune-compromised patients). (c) use temporary portable solutions (e.g., exhaust fan) to create a negative pressure environment in the converted area of the facility. discharge air directly to the outside, away from people and air intakes, or direct all the air through hepa filters before it is introduced to other air spaces. category ii. . place the patient in an aiir as soon as possible. if an aiir is not available, place a surgical mask on the patient and place him/her in an examination room. once the patient leaves, the room should remain vacant for the appropriate time, generally h, to allow for a full exchange of air. category ib/ic. instruct patients with a known or suspected airborne infection to wear a surgical mask and observe respiratory hygiene/cough etiquette. once in an aiir, the mask may be removed; the mask should remain on if the patient is not in an aiir. category ib/ic. . restrict susceptible healthcare personnel from entering the rooms of patients known or suspected to have measles (rubeola), varicella (chickenpox), disseminated zoster, or smallpox if other immune healthcare personnel are available. category ib. . wear a fit-tested niosh-approved n or higher level respirator for respiratory protection when entering the room or home of a patient when the following diseases are suspected or confirmed: (a) infectious pulmonary or laryngeal tuberculosis or when infectious tuberculosis skin lesions are present and procedures that would aerosolize viable organisms (e.g., irrigation, incision and drainage, whirlpool treatments) are performed. category ib. (b) smallpox (vaccinated and unvaccinated) ---category ii. (c) no recommendation is made regarding the type of personal protective equipment (i.e., surgical mask or respiratory protection with a n or higher respirator) to be worn by susceptible healthcare personnel who must have contact with patients with known or suspected measles, chickenpox or disseminated herpes zoster. unresolved issue. . in acute care hospitals and long-term care and other residential settings, limit transport and movement of patients outside of the room to medically-necessary purposes. category ii. . if transport or movement outside an aiir is necessary, instruct patients to wear a surgical mask, if possible, and observe respiratory hygiene/cough etiquette. category ii. . for patients with skin lesions associated with varicella or smallpox or draining skin lesions caused by m. tuberculosis, cover the affected areas to prevent aerosolization or contact with the infectious agent in skin lesions. category ib. . healthcare personnel transporting patients who are on airborne precautions do not need to wear a mask or respirator during transport if the patient is wearing a mask and infectious skin lesions are covered. category ii. . exposure management immunize or provide the appropriate immune globulin to susceptible persons as soon as possible following unprotected contact (i.e., exposed) to a patient with measles, varicella or smallpox: category ia. (a) administer measles vaccine to exposed susceptible persons within h after the exposure or administer immune globulin within days of the exposure event for high-risk persons in whom vaccine is contraindicated. (b) administer varicella vaccine to exposed susceptible persons within h after the exposure or administer varicella immune globulin (vzig or alternative product), when available, within h for high-risk persons in whom vaccine is contraindicated (e.g., immune compromised patients, pregnant women, newborns whose mother's varicella onset was < days before or within h after delivery. (c) administer smallpox vaccine to exposed susceptible persons within days after exposure." citation ended. "--the environmental recommendations in these guidelines may be applied to patients with other infections that require airborne precautions". selected citation ended. particularly dangerous or unknown infectious agents with high mortality need special treatment in high-risk isolates with separately, controlled ventilation and disinfection of air extraction/waste/water, etc. or in buildings separated from other patients and without common ventilation [ , [ ] [ ] [ ] [ ] [ ] . during the ebola epidemic from march , health professionals and patients were not protected well enough since the who recommended procedures for close contact/droplet infection [ ] . the who excluded risk of airborne transmission of ebola, even though it was documented to be transferred via air to primates [ , ] . the uncertain infection control procedures of who were upgraded from september to october by the who and cdc, from contact/droplet infection metre from the patient to strict isolation, but still without measures against airborne infection [ , ] . the principle of "prevention is better than cure" was not in use. the same happened in connection with sars in where who was recommending a low infection control level, contact/droplets metre from the patient, and had to raise the disease control level up to strict isolation ca. months later on [ ] . high-risk infections are recorded almost daily around the world, like the pneumonic plague in madagascar, outbreaks (partly nosocomial) of multidrug-resistant tuberculosis in all parts of the world and nosocomial outbreaks of crimean-congo haemorrhagic fever in germany after import of ill us soldier from afghanistan [ ] [ ] [ ] . nearly each day, there are reported new cases of avian influenza, mers, various haemorrhagic viruses or other dangerous microbes [ , [ ] [ ] [ ] [ ] . since , there has been no need for strict isolation in norway, with the exception of the imported healthcare professionals with ebola in autumn . risk of infection may occur when patients with greatly reduced infection defence are coming into contact with infected equipment, textiles or other patients, staff or visitors who have infection or are carriers of possible pathogenic microbes [ , , ] . the following conditions are particularly vulnerable to contamination, agranulocytosis, neutropenia; < . in granulocytes or rapidly decreasing number < , severe burns, patients with severely weakened immune system due to the treatment with immunosuppressive, chemotherapy or radiation (transplants, cancer or leukaemia). this heterogeneous group is growing due to a more advanced treatment and more cancer and transplant cases. they should be protected against infection from "outside" by treatment in protective isolation in a clean room with anteroom or sluice and with hepa-filtered air in a positive pressure room [ , , [ ] [ ] [ ] [ ] [ ] [ ] . cdc recommends that by allogeneic haematopoietic stem cell transplantation (hsct), the patients should be treated in protective isolation, especially to protect against fungal infections such as aspergillus; category ib. [ ] "as defined by the american institute of architecture, air quality for hsct patients is improved through a combination of environmental controls that include [ ] hepa filtration of incoming air, [ ] directed room air flow, [ ] positive room air pressure relative to the corridor, [ ] well-sealed rooms (including sealed walls, floors, ceilings, windows, electrical outlets) to prevent flow of air from the outside, [ ] ventilation to provide ≥ air changes per hour, [ ] strategies to minimize dust (e.g., scrub-able surfaces rather than upholstery and carpet, and routinely cleaning crevices and sprinkler heads), and [ ] prohibiting dried and fresh flowers and potted plants in the rooms of hsct patients. the latter is based on molecular typing studies that have found indistinguishable strains of aspergillus terreus in patients with haematologic malignancies and in potted plants in the vicinity of the patients" [ ] . • in protective isolate should intake air be hepa filtered which removes . % of particles larger than or equal . μm in diameter; category ib. [ ] • the room should be at positive pressure relative to the corridor with a pressure difference of . pascal or more; category ib. [ ] • the pressure should be monitored visually every day; category ia [ ] . • the room must be sealed so that no outside air to seep in; category ib. [ ] • there should be a minimum of air changes per hour; category ib. [ ] • use smooth surfaces, avoiding textile furniture and the like, and perform good cleaning; category ii [ ] . • do not use carpeting in corridors or rooms in the area; category ib. [ ] • the patient should be at least possible out of the room, the necessary examinations, etc., to be implemented in the shortest possible time; category ib. [ , , , , ] • if necessary, use respiratory protection if out of isolation; category ii [ , ] . • staff are using adequate infection control equipment if the patient has infection; category ia/ib. [ ] • patients with respiratory infection-at the same time they need protective isolation-should be transferred to a defined airborne isolate. if hepa filters are lacking on the air intake to the airborne infection isolation units, a portable system of the hepa filter may be used in the room to remove fungal spores and bacteria; category ii [ ] . avoid transfers outside the isolate [ , ] . a retrospective, case-control study of immunocompromised patients in switzerland showed that when invasive fungal infection occurred, the mortality was over % [ ] . an outbreak of fungal infection among patients on a haematological department showed that the more often . protective isolation the patient was transferred to other departments/was outside the isolate, the more frequently he was infected with invasive fungi [ ] . with more than five patient transfers outside protective isolates, the risk of fungal infection was sixfold higher than if staying in protective isolation. if the patient was transferred during neutropenia, the risk increased by nearly sevenfold [ ] . building activities. fungal spores are always released during construction activity and may become airborne also in risk areas where severely immunocompromised patients are located [ , , ] . infectious agents may be spread via air, textiles and equipment with deposition of fungal spores and other microbes during the construction period. fungal spores follow air currents far away [ ] . construction activity must therefore be coordinated with appropriate departments and wards so that the patient area is shielded. air from construction places should not leak into patient areas and be taken out directly from the building in such a way that it does not re-enter through the systems for intake of air. leakage of water in buildings. fungal growth in patient room walls is due to neglected maintenance of buildings for many years and usually comes from water leakage from the old pipes, roof leaks or poorly maintained bathrooms. patients should not stay in rooms with suspected fungal growth and decay! control of fungi should be implemented in protective isolates and storages for such isolates once a year or more frequently when suspected water leaks and rot. the requirement is fungal spores per litres of air using the sas-slit sampler. patients must be protected against infections during care and treatment [ , , [ ] [ ] [ ] . cleaning and disinfection of rooms, surfaces and equipment between infection susceptible patients must be extra careful since many-at the same time-have serious infections, including resistant bacteria. despite a good cleaning, abundant amounts of microbes may be detected in the environment and the equipment after cleaning [ , ] . healthcare professionals who treat infectious patients may be highly exposed to infection, although they really should be protected [ , - , , , , ] . at the beginning of the sars epidemic in , % of sars patients were the hospital personnel who had taken care of the first sars patients [ ] . during the ebola outbreak in , healthcare workers were again severely attacked by the disease and death in the first phase, until a more protective personal protective equipment system was in place [ , [ ] [ ] [ ] . there is still a great variety in international guidelines in terms of personal protection equipment (ppe) by ebola virus for healthcare workers [ ] . the who, united kingdom and cdc defined ebola as non-airborne infection in and still does the same in [ ] . none of these recommended respiratory protection for suspected ebola infection in august-september , at least half a year after the start of the epidemic. only the united kingdom recommended respirator mask for confirmed ebola. there was no covering of the head or neck, not either during aerosol-generating procedures! in october , the cdc upgraded the ppe measures to strict isolation measures for proven ebola infection, while the earlier ppe measures were recommended for suspected ebola infection (table . ) [ ] [ ] [ ] . during the pandemic flu in , norwegian health authorities did not allow the staff at hospitals to use respirator masks (p masks) when taking care of the flu patients; they should use surgical masks [ ] . exceptions were for aerosol-generating procedures. the same health authorities went public and said that surgical masks did not have any protective effect! [ ] recurrent problems are that the health authorities are not able to see the importance in protecting health professionals who are-and will always be-the frontline workers, even at the most serious infectious diseases [ ] . governments that are not willing to take care of their healthcare employees create unnecessary fear and reluctance to make a good contribution during outbreaks. if the disease is not as dangerous as sars and ebola, a highly contagious pandemic influenza or a large norovirus outbreak could paralyse the healthcare system when a high number of the staff get sick at the same time. by preventing disease transmission to health professionals, the hospital can be operatively enough to handle properly other serious diseases such as traffic accidents, myocardial infarction, stroke, etc., even at largescale epidemics. in spite of problems concerning isolation and prevention of spread of emerging and new serious infections, new guidelines are now appearing, which works with reduction of infection control in severely affected countries with endemic infections [ , ] . 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methicillin-resistant staphylococcus aureus before results of polymerase chain reaction at hospital admission become available what may be lurking in the hospital undergrowth? inapparent cross-transmission of extended-spectrum beta-lactamase-producing klebsiella pneumoniae the exposure to hospital roommates as a risk factor for healthcare-associated infection evaluation of bedmaking-related airborne and surface methicillin-resistant staphylococcus aureus contamination effect of floor cleaning bacteria and organic materials in patient floor cleaning: effect on bacteria and organic materials in hospital rooms air quality and microbiological contamination in operating theaters with and without laminar air flow occlusive scrub suits in operating theaters during cataract surgery hot and steamy: outbreak of bacillus cereus in singapore associated with construction work and laundry practices the airborne transmission of infection in hospital buildings: fact or fiction? role of ventilation in airborne transmission of infectious agents in the built environment-a multi-disiplinary systematic review virus diffusion in isolation rooms an outbreak of influenza abroad a commercial airliner review of aerosol transmission of influenza a virus detection of bordetella pertussis and respiratory syncytial virus in air samples from hospital rooms airborne dispersal as a novel transmission route of coagulase-negative staphylococci, interaction between coagulase-negative staphylococci and rhinovirus infection aerial dispersal of methicillin-resistant staphylococcus aureus in hospital rooms by infected and colonised patients air and surface contamination patterns of methicillinresistant staphylococcus aureus on eight acute hospital wards air contamination around patients colonized with multidrug-resistant organisms protecting staff against airborne viral particles: in vivo efficiency of laser masks association of private isolation rooms with ventilator-associated acinetobacter baumannii pneumonia in surgical intensive-care unit droplet fate in indoor environments, or can we prevent the spread of infection environmental survey to assess viral contamination of air and surfaces in hospital settings international infection control guidelines may not protect against ebola. hospital health care guidelines does not protect against ebola. bit's th annual wold congress of microbes - (wcm ) pneumonic plague outbreak multi drug-resistant tuberculosis outbreak in gaming centres health care response to cchf in us soldier and nosocomial transmission to health care providers incidence of, and risk factors for, nosocomial infections among haematopoietic stem cell transplantation recipients, with impact on procedure-related mortality ventilation systems for hospital rooms devoted two immune compromised and/or infectious patients invasive aspergillosis in severely neutropenic patients over years: impact of intranasal amphotericin b and hepa filtration hospital infection control in haematopoietic stem cell transplant recipients masking of neutropenic patients transport from hospital rooms is associated with a decrease in nosocomial aspergillosis during construction in-hospital transfer is a risk factor for invasive filamentous fungal infection among hospitalized patients with haematological malignancies: a matched case-control study rikshospitalet: daily work in protective isolation rikshospitalet: for you to be a stem cell transplant. guideline for adult patients and their families protective isolation. in: handbook of hygiene and infection control for hospitals. oslo: ullevål university hospital risk factors for acquiring vancomycin-resistant enterococcus and methicillin-resistant staphylococcus aureus on a burn surgery step-down unit residual viral and bacterial contamination of surfaces after cleaning and disinfection protecting the frontline: designing an infection prevention platform for preventing emerging respiratory viral illness in healthcare personnel in: handbook of hygiene and infection control in hospitals. part microbiology and infection control reconsidering contact precautions for endemic methicillin-resistant staphylococcus aureus and vancomycin-resistant enterococcus duration of contact precautions for acute-care settings comparing the recommended ppe equipment by ebola infection in guidelines from the who, united kingdom and cdc in [ ] [ ] [ ] who key: cord- -r tl kq authors: nan title: dublin pathology . th joint meeting of the british division of the international academy of pathology and the pathological society of great britain & ireland date: - - journal: j pathol doi: . /path. sha: doc_id: cord_uid: r tl kq nan the christie nhs foundation trust, manchester, uk one controversy in preparing the rcpath "dataset for tumours of the urinary collecting system [ nd edition])", april was which who grading scheme ( or ) to use for urothelial carcinoma. since there is a split within grade ( ) between low grade & high grade, use of both schemes in parallel was recommended. this has the advantage of better indicating where a particular patient lies in the grading continuum & minimises the consequences of 'grading error' for cases close to the threshold between low & high grade in the scheme, (a critical distinction for management if who grading is used in isolation). the nice guidance on bladder cancer (http://www.nice.org.uk/guidance/ ng ) incorporates risk stratification tables for ta/t bladder cancer utilizing this parallel who grading recommendation in a multiparameter formula that also considers tumour size, pt classification and the presence/absence of cis or aggressive subtype(s). amongst the more aggressive bladder cancer subtypes is invasive micropapillary urothelial carcinoma and the nested variant. a bladder origin can be difficult to recognise at metastatic sites, especially for micropapillary and discohesive/plasmacytoid subtypes. uroplakin ii has recently become available, is more sensitive than uroplakin iii & may assist within a panel. spindle cell lesions of the bladder are often difficult & loss of cytokeratin expression is common in sarcomatoid carcinoma. there is potential to mistake inflammatory myofibroblastic tumour for a malignant tumour. two molecular pathways for bladder cancer are recognised. fgfr at p is the most frequently mutated oncogene in bladder cancer & is prevalent in low grade papillary tumours. p loss of function mutations and loss of rb are prevalent in cis. no prognostic molecular test is currently validated for clinical use in bladder cancer, though some (e.g. fish) are in use as an adjunct in diagnosis. indiana university school of medicine, indianapolis, usa some dogmas in testicular pathology do not hold up to scrutiny. the belief that all pure, postpubertal teratomas are malignant is invalid. within this group there is a small subset that is benign; these may be divided into dermoid and non-dermoid types that, however, share features that distinguish them from the usual teratoma of adults. these include absence of: atypia, regressive parenchymal changes, intratubular germ cell neoplasia, and i( p). also they usually show organoid arrangements, and prominence of ciliated epithelium, squamous cysts and smooth muscle. patients do not need further intervention beyond excision sufficient to establish the diagnosis. cases often interpreted as isolated testicular polyarteritis nodosa because of the presence of fibrinoid vascular necrosis are mostly attributable to chronic, intermittent torsion. they usually present as pain-associated, palpable or ultrasound-detected masses, with the "mass" corresponding to infarct and/or hemorrhage. there are associated chronic vascular changes, with frequent marked intimal hyperplasia of arteries, mural fibrosis of veins, dilated venules and arteriolar hyalinization, consistent with torsion-induced venous outflow obstruction and secondary arterial hypertension. these patients do not develop systemic vasculitis on follow-up. many "sarcomas" in patients with germ cell tumours, especially after chemotherapy, are more correctly regarded as sarcomatoid yolk sac tumours. they are reactive for cytokeratin and glypican . they often show characteristic features: nodular growth, myxoid and fibrous stroma, spindled and epithelioid cells, abrupt changes in cellularity, and tumor "ringlets." most are high grade and aggressive. most regressed germ cell tumours can be recognized through a combination of findings, although the only diagnostic ones are a scar with coarse intratubular calcifications or with intratubular germ cell neoplasia. alcohol consumption has doubled in ireland and the uk in the last years. the causes of this increase include increased affordability of alcohol and its widespread availability. as a consequence, the health harms associated with alcohol have dramatically increased. binge drinking and alcohol consumption among by women have risen especially dramatically. for example, the mortality from cirrhosis has doubled in the last years in both men and women. in response to this, the medical profession on both islands have led informal and later formal campaigns to encourage policy change regarding alcohol at a national level. in ireland, this was driven by rcpi. the involvement of the medical profession has had a powerful influence, as doctors do not have a conflict of interest in this matter, in contrast to the alcohol industry. the policy changes advocated include particularly minimum unit pricing (mup), which has been shown to be effective in reducing alcohol consumption, alcohol-related admission to hospital and crime in canada. modelling of the data suggests it would have similar benefits in uk and ireland. this is regarded as the single most important first step. other steps which will help include actions around alcohol labelling, availability and breaking the link between alcohol and sports and leisure promotion. turning off the tap of cheap alcohol will hopefully soon reduce alcohol health harms in uk and ireland  barrett's oesophagus: an evolving challenge for the gastroenterologist p dot o'toole cost-effective surveillance programmes for barrett's oesophagus (bo) needs to be focused at risk groups. it is not only a question of identifying more individuals with bo (initial screening) but screening and subsequent surveillance has to identify at-risk individuals with bo who can benefit most from surveillance or therapy. advances in endoscopic imaging (high resolution endoscopy ([hre] with dye-based chromoendoscopy, electronic chromoendoscopy, and autofluorescence,...) certainly prove beneficial in better detecting dysplasia within known bo and can guide sampling and subsequent therapy. dysplasia can be patchy and easily missed during routine biopsy sampling of bo and adequate training with high resolution instruments is needed to increase detection rates. once dysplasia is detected, endoscopic ablation is recommended. until recently, the standard treatment for hgd was oesophagectomy but endoscopic resection and ablation techniques are now available to eradicate dysplasia and mucosal adenocarcinomas. resecting visible lesions (using endoscopic mucosal resection [emr] or endoscopic submucosal dissection techniques) allows full pathological t staging. when invasive cancer is eliminated at multidisciplinary review (i.e., purely mucosal neoplasia confirmed with a nodal risk < %), further endotherapy to ablate residual metaplasia in bo can be performed using radiofrequency ablation (raf). in a tertiary centre use of staging emr is frequently necessary (> %) in patients referred for endotherapy and expert endoscopy is required to ensure safe and complete oncological resection. conversely pt submucosal cancers detected following emr are confidently triaged for oesophagectomy. combination of emr and rfa in expert groups exceeds > % for eradication of neoplasia and metaplasia. adverse events are quite low (stricture form healing, %; self-limited haemorrhage, very rare perforations ...) and recurrence of bo is also low (< % at years). careful follow-up endoscopies is necessary at to months initially; intervals theerafter probably yearly.  the pathologist's role in the diagnosis and management of neoplasia in barrett's oesophagus p c muldoon st. james's hospital, dublin, ireland the last decade has seen a revolution in the management of neoplasia in barrett's oesophagus. more detailed biopsy protocols, along with the advent of sophisticated local resection and ablation techniques, have radically altered the management of this expanding cohort of patients. these new treatment modalities, coupled with a massive increase in the numbers of cases of barrett's being diagnosed, have significantly altered the demands placed upon pathologists involved in this area. these changes have presented pathologists with an opportunity to challenge our existing practices, to improve the reproducibility of our analysis and to increase the clinical relevance of the way in which we report neoplasia in this setting, where the pathologist plays a critical role in the multidisciplinary management approach. this talk aims to outline a practical approach to the handling of these specimens and to provide clear guidelines as to how to report them in the most clinically useful way.  modern management in ibd p mwr vieth ; h neumann klinikum bayreuth, pathology, bayreuth, germany; university hospital erlangen, medical clinic i, erlangen, germany ulcerative colitis and crohn's make a distinct histological picture. around % of an ibd diagnosis is the clinical information and about % derives from histology, only. for routine purposes it is recommendable in case of a first manifestation of an ibd to make a diagnosis such as: "picture of ulcerative colitis or picture of crohn's disease" and to recommend a follow-up endoscopy with biopsies not prior to weeks after the first endoscopy and than confirm the diagnosis later to exclude mimickers of ibd. in crohn's disease it is helpful to take biopsies from the upper gi-tract to get further hints of crohn's disease. in case of neoplasia, the guidelines leave some room for local endoscopic treatment of low grade dysplasia whereas high grade dysplasia is still seen as an indication for operation since there is a high probability of detecting a carcinoma in the operation specimen afterwards. operation means on normal complete proctocolectomy. this has been indivdually questioned in the last time. there are exceptions for discussing the indication of an operation in ibd: cases with numerous pseudopolyps that cannot be searched for neoplasia, low grade lesions that cannot be completely removed, multiple neoplastic lesions and unresponsiveness to medical treatment.operation and endoscopic specimen in ibd need a subtile search for neoplastic lesions. a microscope with reverse light may help to identify suspicous lesions and may help to decide where exactely to cut a specimen. in conclusion a tight cooperation between clinical and histopathological partners is recommended to reach a high standard for patient care. second opinions may help to achieve and fuel the own learning process esp. in an institution with a lower number of ibd patients during the year. colorectal or bowel cancer screening (bcs) is commonplace and organised national screening programmes have been developed in many countries, most notably in western europe. traditionally, faecal occult blood (fob) detection has been the screening method of choice, those testing positive being selected for subsequent colonoscopy, but this is changing, with alternative or additional screening tests gaining favour. most of the problems in bcs pathology practice are particularly related to fob-based screening programmes, as these are enriched for large, bleeding sigmoid adenomas, in comparison to programmes utilising endoscopy as the primary screening modality. experience within the closely related uk bcs programmes to date has yielded several recurring problems: the diagnosis of stage pt or 'polyp' cancers, in particular distinguishing common epithelial misplacement from 'true' invasion; the management of stage pt cancers, in relation to indications for surgical intervention after such a diagnosis; and the minimum criteria for a biopsy diagnosis of colorectal adenocarcinoma. these issues will be discussed with illustrative examples, along with the somewhat more mundane but highly important practical issue of measuring various parameters related to bcs pathology. the importance of quality assurance measures to ensure high standards within bcs pathology is emphasised. with the introduction of colorectal cancer screening in various countries of the eu there is a sharp increase in the incidence of early colorectal cancer. a significant part of these early tumours presents in a pedunculated polyp. in most cases, these carcinomas are already completely removed by polypectomy. classic risk factors that suggest a high risk for lymph node metastases include haggitt level , positive resection margins, poor differentiation and lymphatic or vascular invasion. however, the evidence is rather thin. most pt studies are performed on sessile polyps. risk factors are more firmly established and include differentiation grade, lymphatic invasion, kikuchi level sm or the presence of budding. however, for a clinical useful decision model, we will need an integrated approach, and both specificity and sensitivity of the various factors should be taken into account. radical surgery seems overtreatment for a large number of polyp cancers. leeds university, leeds, uk minimum datasets have changed cancer reporting. this talk will explain the decision making processes behind the latest datasets both for cancer reporting and bowel cancer screening. it will also look at where we may be going in the future for staging and molecular reporting. the intestines play host to a broad spectrum of infective organisms ranging from viruses, through bacteria , fungi and unicellular parasites to worms. the spectrum of infections seen varies with geographical location, due to socioeconomic factors and due to changes in human behaviour. immunocompromisation due to infections (in particular hiv), malignancy (especially haematological tumours) and the use of immunosuppressive drugs also has an important role in determining the infections commonly seen in the gi tract. the typical pathological features of intestinal infections will be discussed together with suggestions on how to optimise the diagnosis of such pathologies. erasme university hospital, brussels, belgium pathologists are confronted with different types of colitis, most commonly infectious colitis and inflammatory bowel disease (ibd) followed by microscopic colitis and ischaemic colitis. several other forms of colitis, however, exist and might be underrecognised; these diseases include segmental colitis associated with diverticulosis, diversion colitis, eosinophilic colitis and behcet's colitis. clinical presentations of these rare types of colitis vary, and laboratory data are often non-specific; mucosal biopsy is essential in establishing the diagnosis. segmental colitis associated with diverticulosis (scad) is mainly characterised by the involvement of the sigmoid colon with sparing of the rectum and proximal colon. scad often mimics ibd at endoscopic and histological examination; since scad has a self-limited course that resolves without further recurrence or need for treatment, the implications of an inaccurate diagnosis are obvious. diversion colitis is a non-specific colonic inflammation following surgical diversion of the faecal stream. is is characterised by a chronic lymphoplasmacytic infiltrate, and the existence of lymphoid follicular hyperplasia is considered to be a hallmark feature. the development of diversion colitis is attributed to a lack of short chain fatty acids. eosinophilic colitis is etiologically obscure and can be associated with involvement of other sections of the gastrointestinal tract. an infiltrate of eosinophilic granulocytes is found to varying degrees in all wall layers. a history of food intolerance or allergy is present in most of the patients, and peripheral eosinophilia is present in % of cases. gastrointestinal involvement has been reported in up to % of patients with behcet's disease. in cases with ileocolonic involvement, it is often difficult to distinguish behcet's disease from other inflammatory bowel diseases. the diagnosis, therefore, often depends on clinical manifestations and intestinal ulcerative lesions. s·  how to write a paper and get it published p cs herrington ; p dm berney university of edinburgh, edinburgh, uk; barts health nhs trust, london, uk scientific papers have a predetermined structure, and writing in this way requires practice. most journals accept only a small fraction of submitted papers and it is important that any paper has something specific to say; and says it in a clear and concise way that can be understood by editors, reviewers and readers, all of whom play a role in assessment of its contribution. editors look for novelty and significance in the context of the aims and scope of their journal; and scientific rigour, which expert reviewers help them to assess. writing a paper and having it assessed by a journal is an iterative process. during the writing phase, the scientific rigour of the argument can be refined; and following submission and peer review, reviewers and editors often make constructive comments that help to improve it still further. the peer review process therefore acts not only as a quality filter but also as a mechanism for quality improvement. writing papers and submitting them for publication is therefore generally a positive experience, particularly if one remembers that the process is iterative and (inevitably) not all papers will be accepted for publication by the first journal that they are sent to.  large-scale routine diagnostics using whole-slide imaging in sweden -the linköping experience p c lundström cmiv, linköping university, linköping, sweden this presentation will describe the large-scale routine usage of wsi at linköping university hospital, sweden. since all histology slides are scanned, amounting to more than half a million slides to date. to a significant extent the digital images are used for primary review. the initial implementation led to several of the benefits foreseen with digital pathology, but it could also be concluded that further development was needed to unlock the full potential, in particular within the it solutions. therefore, a consortium led by cmiv, linköping university was formed in to create innovations for a new generation of digital pathology. this triple helix consortium also includes industry and more than half of sweden's health care providers, an engagement that reflects the dominating view in swedish pathology that large-scale adoption of wsi practice is possible and desirable. this talk covers the experiences made during the initial digitization, including laboratory process adjustments, and the later additions to the digital pathology toolbox accomplished by the ongoing innovation project. apart from obvious targets such as the pathologists' workstation, the developments also touch upon other areas including grossing and enterprise image management.  digital pathology -are we there yet? p sm hewitt national cancer institute, bethesda, maryland, usa the implementation of whole slide imaging for diagnostic histopathology is far more complex than connecting an instrument to a server, and placing a computer on a pathologist's desk. the technology is additive to the histology workflow, with additional cost beyond the current practice of review with a microscope. the adoption of digital pathology for histomorphologic diagnosis requires the restructuring of the workflow, additional technology advances beyond the imaging instrument, and development of new tools to assist the pathologist. the end goal is to improve pathologist's productivity and provide additional diagnostic information. digital pathology, to succeed must become a value-added proposition. the adoption of digital pathology requires: )improvements in scanner performance as measured by defined quality metrics. )advancement in server and networks to distribute images to the desktop efficiently. )software to facilitate review and diagnosis, beyond presenting only and image of the slide. evolution of the current technologies is required to provide an economic impetus for widespread adoption and use of digital pathology in the diagnostic setting. to a significant extent, the distinction between melanocytic naevi and malignant melanomas is based on tissue architecture. amongst the best known architectural features pointing to malignancy are absence of lesional symmetry and maturation, and presence of melanocyte ascent. however, each of these three features has significant pitfalls. as a rule, naevi are 'roughly symmetrical' and melanomas are not, but there are asymmetrical naevi (traumatized naevi, most larger congenital naevi; some combined naevi; some large acral and genital naevi) and symmetrical melanomas (including many small melanomas, especially small nodular melanomas; some spitzoid melanomas). in addition, it is not always clear whether a lesion should be considered 'roughly symmetrical' or not. i suspect that not uncommonly, a diagnosis is reached first, and the verdict regarding symmetry is adjusted according to that diagnosis. similar caveats relate to absence of maturation as an indicator of malignancy. it is seen in blue naevi and all its variants; deep penetrating naevi; some bap naevi. melanomas not uncommonly feature smaller cells in their deeper parts, or there may be an underlying naevus remnant with smaller cells. naevi with ascent include many spitz naevi; reed naevi; some naevi in early infancy; traumatized naevi; naevi of acral skin. over-interpretation of ascent may result from inexperience with melan-a and some other immune stains. melanomas devoid of ascending melanoma cells comprise a wide variety of subtypes including, desmoplastic melanomas and, vexingly, some spitzoid melanomas. these architectural features must, therefore, be evaluated in the context of all other findings, and with a 'splitter's' mind set, taking into account the individual characteristics of the specific naevus and melanoma variants that are of relevance to the case under study. most melanomas are fairly easy to diagnose on histological grounds. however, melanoma is a tumour that can histologically mimic almost any other tumour including epithelial and mesenchymal neoplasms. pathologists need to familiarize with the wide histological appearances of melanoma to avoid serious misdiagnoses. of crucial importance is the knowledge that a number of melanomas can closely mimic benign naevi. some variants of melanoma represent distinctive clinicopathological entities and these include desmoplastic melanoma, "malignant" blue naevus, pigment synthethizing melanoma, naevoid melanoma, spitzoid melanoma and epidermotropic metastatic melanoma. tumoral melanosis refers to complete regression of a melanoma, a diagnosis that it is often missed because of the absence of tumour cells within the regressed area. a small percentage of melanomas display focal or extensive histological changes that closely mimic other neoplasms and often a combination of histological features with immunohistochemistry is necessary to arrive to the correct diagnosis. microscopic variants of melanoma include adenoid (pseudoglandular), angiotropic and angiomatoid, signet ring cell, balloon cell, clear cell, rhabdoid and follicular (with exclusive involvement of hair follicles). some melanomas display heterologous differentiation also known as transdifferentiation. the latter should not be confused with the so-called collision tumour in which a melanoma co-exists with a neoplasm of different lineage. a wide variety of heterologous differentiation has been described in melanoma including osteosarcomatous and chondrosarcomatous (mainly seen in acral melanomas), meiomysarcomatous, rhabdomyosarcomatous, neuroendocrine, ganglioneuromatous and even epithelial. except for desmoplastic and pigment synthetizing melanoma, all other variants of the tumour have the same behaviour as ordinary melanomas. melanocytic tumours with spitzoid features represent one of the most challenging and controversial areas in dermatopathology. what is currently known as spitz naevus was initially reported as "juvenile melanoma" by sophie spitz on . she recognized the relatively indolent but somewhat unpredictable behaviour of these distinctive melanocytic lesions that are particularly common in young children. over the years, the histological spectrum of these tumours was expanded, and it has become clear that classical spitz naevi follow an entirely indolent disease course. the prognosis of tumours with atypical histological features remains somewhat unpredictable. this presentation will give an overview of the morphological spectrum of spitzoid melanocytic tumours, their behaviour and recent advances of their molecular characteristics. optimisation is a core tenet in radiography and involves the radiographer ensuring that images of diagnostic quality are produced with minimum radiation dose burden to patient and staff [ , ] . in paediatric practice this is particularly important due to the more radiosensitive nature of the child [ ] . in alignment with the isrrt world radiography day theme 'radiographers optimise dose', radiography students in an institution submitted clinical case study coursework that focused on paediatric radiation dose optimisation. the purpose of the current study was to analyse these case studies as examples of prevailing radiographic practice and to compare students' perception of optimisation with the evidence within each case. the evidence of optimisation was established through independent and objective image analysis along with thematic analysis of the case commentaries. the case study evidence demonstrated that optimised techniques were generally well implemented. the exception was collimation, which was sub-optimal in % (n= ) of the examinations, and on average irradiating an area % larger than necessary. students were generally able to correctly identify techniques as optimal or not. however, when appraising exposure, positioning and collimation, between % and % of students were inaccurate in their assessment of what is optimal. overall the study reflects positively on current irish paediatric radiography with regard to dose optimisation, although more accurate collimation needs to be practised. similarly student perceptions show good understanding of optimal techniques, although appreciation of exposure, positioning and collimation errors could be improved. the aim of this project was to design and prototype immobilisation devices for children who are unable to independently maintain upright sitting posture during radiographic investigations. while current market devices exist, they are seldom used by radiographers -particularly in europe as their methods of restraint have been deemed 'culturally unacceptable' with some claiming that they are in violation of the human rights of the child [ ] . the design challenge was to create devices that were functional (fit for purpose [ ], radio-lucent, compliant with infection control and easy to use) while minimising discomfort and intimidation. a search of the literature, prior art, patent landscape and current market devices was performed in order to identify product requirements. triz methodologies -a problem solving, analysis and forecasting tool derived from the study of patterns of invention in the global patent literature were used to identify the physical contradictions underlying the design challenge and generate potential solutions. eight unique concept designs were identified from these methods. these were then evaluated using pugh criteria -a ranking system of the relative merits of each concept based on design requirements identified. four of the eight concepts were chosen to be prototyped: a -d printed seat, a swing based template, an acrylic-based support and an adaptable wheelchair. the prototypes were made in collaboration with the ucd school of engineering and tested using paediatric phantoms in ucd radiography department. the final prototypes will be trialled in crumlin children's hospital with a view to future use and development. thrombotic microangiopathy (tma) is a pathology that results in thrombosis of capillaries and arterioles due to endothelial injury. it is usually characterized by an atypical haemolytic syndrome (ahus) or thrombotic thrombocytopaenic purpura (ttp). tma is considered to be caused by infections, drugs, autoimmunity, tumours, pregnancy, transplants and inherited abnormalities involving the alternate complement pathway. this presentation describes the pathology of tma. it includes a retrospective year study ( - ) of all renal biopsies reported by one pathologist. all renal biopsy request forms and reports, where cases included light (lm), fluorescence(fm) and electron microscopy(em), were reviewed. cases without all modalities (lm, fm, and em) were excluded. biopsies were reported in the study period ( in ( in to in . were transplant biopsies. biopsies were insufficient (lm, fm and em all not possible. this resulted in native renal biopsies as the study group. following review of the reports cases were reported as tma. were associated with thin membrane nephropathy, with minimal change disease and with plasma cell dyscrasia/ b cell malignancy. this resulted in cases with tma as the only pathology reported which represents % of all adequate native medical renal biopsies. clinical indications included proteinuria in %, nephrotic syndrome in %, increased creatinine in %, increased blood pressure in % and haematuria in % of the cases. acute renal failure was described in % and hus in just % of the cases. pathological changes were predominently arteriolar sclerosis and glomerular double contours on lm with chronic subendothelial injury on em. the conclusions of this presentation are . tma is overwhelmingly a chronic lesion as seen in renal biopsy pathology. . it is a very common pattern of injury. . it is not usually associated with clinical hus or ttp features at presentation. the era of targeted cancer therapeutics has brought forth new challenges for molecular diagnostic laboratories. the list of genes, and indeed specific mutations, that predict drug responses keeps growing, and with it grows the demand for molecular sub-classification of tumors. in colorectal carcinoma, for example, recent studies support expanding testing beyond kras to include nras and braf in predicting resistance to egfr-targeted therapies. similarly, in non-small cell lung carcinoma standard screening for egfr mutations and alk gene fusions may be insufficient when actionable alterations involving ros , ret, her , met, braf and other genes are being targeted (successfully) in ongoing clinical trials. fortunately, the introduction of next-generation sequencing (ngs) into the clinical laboratory is meeting the demand. due to its quantitative output, ngs not only provides precise mutant allele ratios, but it can also be used to detect gene gains and losses. furthermore, when applied to rna, ngs supports the detection of gene fusions and serves in assessing gene expression levels. while ngs is a powerful tool for molecularly characterizing solid tumors, the quality of the results in large part rests on the selection of appropriate input material; therefore, review by a pathologist prior to testing remains a cornerstone to success. other growing uses of ngs include monitoring minimal residual disease in the setting of hematologic malignancies, and in the detection of targetable mutations in cell-free dna within the plasma. the advent of next generation sequencing has ushered in an era of tremendous potential for identifying the molecular causation of simple and complex disorders, both rare and common. the successes of next generation sequencing reflect the combined interpretive skills of geneticists, bioinformaticians and clinicians working in close collaboration. in the realm of muscle disease, we have witnessed both the strengths and the weaknesses of next generation sequencing technologies. the use of exome sequencing in patients with rare muscle disease who have been carefully phenotyped has proven to be a successful strategy for identifying causative variants in new genes as well as in known genes. in fact, exome sequencing has significantly expanded both the clinical and the histological phenotypic spectra of muscle conditions associated with causative variants in known genes. in the absence of careful phenotyping or large genetic reference data sets for identifying variants of interest, causative variants may be missed, however. the use of rna sequencing-using rna extracted from muscle biopsy specimens-has proven to be a powerful tool for finding causative variants affecting gene splicing or expression, which may be missed with next generation sequencing. muscle pathology plays an essential role in complementing next generation sequencing. the deep phenotyping of patients with muscle disease relies heavily on muscle histological and immunohistochemical findings in combination with muscle imaging, clinical history and neuromuscular examination findings. examples of how next generation sequencing coupled with careful clinical and histological phenotyping has uncovered causative variants in new genes as well as in known genes will be discussed in this talk. medicine, diagnostic pathology, technology, and diagnostic tests are evolving at an extremely rapid pace. drug developers and diagnostic developers each face unique challenges. companion diagnostic development is a key component of pharma drug development strategy. we will discuss the importance of companion diagnostics in the success of personalized medicine, the fda position on companion diagnostics, and the role, advantages and disadvantages of tissue based companion diagnostics. other technologies, such as next gen sequencing, will increasingly be utilized in a complementary fashion along with traditional slide based immunohistochemical and in situ hybridization. the scope and limitations of available technologies will be reviewed. diagnostic technologies of all types will complement each other to provide the most accurate diagnostic information for clinicians and patients. following the who classification of haematological malignancies there has been a greater emphasis on the integration of molecular information with clinical and morphological data not just for diagnostic purposes but also to help convey both prognostic and therapeutic information. this talk will concentrate on routine testing in the work-up of common haematological malignancies focusing specifically on clonality and translocation analysis in lymphoproliferations and mutational testing in bcr-abl negative myeloproliferative neoplasms. using case studies to illustrate common indications for testing this talk will also highlight some of the practical points and pitfalls in the interpretation of these tests. beaumont hospital, dublin, ireland "should i keep the brain?" is one of the most frequent questions addressed to neuropathologists by surgical pathology colleagues. fears relating to inappropriate organ retention coupled with decreasing availability of expert neuropathology opinion and the widely held belief that advances in neuroimaging have replaced the brain autopsy, have all contributed to a decline in the post mortem study of human brain tissue. leaving aside the critical relevance of neuropathology to forensic medicine, the vital role played by careful examination of the post mortem brain extends far beyond pathology and has contributed greatly to science and medicine. in general, prolonged retention of entire brains may be avoided. in hospital practice it is uncommon for a patient to die without brain imaging. access to pre-mortem brain imaging will guide the surgical pathologist in careful and appropriate sampling of calvarial, dural, meningeal, vascular and parenchymal central nervous system components. spinal cord examination requires prior experience in spinal cord removal but most post mortem technologists are expert in cord extraction. sampling and appropriate processing of nerve and muscle requires prior experience or neuropathology advice. high quality photography obtained at all phases of post mortem brain examination including the coronally sectioned individual cerebral hemispheres, with retention of blocks from each of the brain lobes together with cerebellum, brain stem, vessels and dura -meninges will ensure that in the event of a neuropathology opinion benign required -that opinion will not be compromised. specific issues which will be addressed will include the death of patients with epilepsy, dementia, stroke and undiagnosed neurological disease. the key learning objective will be to ensure that pathology trainees approach post mortem examination of the nervous system with interest and excitement. following several high profile misdiagnoses in ireland a national quality assurance (qa) programme for cellular pathology in was initiated with a vision of establishing a patientcentred pathologist-led framework that would enhance the quality of patient care with timely, accurate and complete pathological diagnoses and reporting. national qa guidelines were developed based on key quality activities generating a total of key quality indicators (kqi). examples of the quality activities include turnaround time, monitoring of amended reports, frozen section correlation and various elements of peer review. all cellular pathology departments in the public state-funded hospitals participate in the programme in addition to laboratories within privately-run hospitals. each laboratory enters codes on individual cases designed to capture the relevant kqi and the anonymised encrypted qa data is then electronically extracted from the laboratory information system to a national database. this national central database is managed by a novel information technology system, the national quality assurance intelligence system (nqais)-histopathology, that was designed to process and display the qa data so that each individual laboratory can analyse their own data and also compare their performance to the national average for each kqi. since complete national data has been inputted into the nqais system and in initial qa targets were agreed for turnaround time, frozen section correlation and rate of intra-departmental consultation (idc). in additional targets for autopsy icd, frozen section deferral rate and turnaround time have been added. to our knowledge this programme has enabled ireland to be the first country to publically report national metrics on the quality of their pathology services.  the politics of eqa: the nhs england qa review and its consequences p de hughes in , a review of external quality assessment processes was carried out on behalf of nhs england. the main recommendations of this review related to the strengthening of governance of eqa, both nationally and within pathology provider organisations. recommendations specifically affecting cellular pathology were: (i) professional bodies, led by rcpath, should develop methodologies for assessing the performance of individuals in eqa schemes. (ii) all pathologists reporting pathology results and providing clinical advice should be participate in eqa schemes relevant to their practice, should achieve levels of performance determined by the professional bodies and this performance should be noted at annual appraisal. (iii) where a need to improve performance is identified, additional remedial training should be carried out, or practice in the area of concern should be stopped until appropriate retraining has been undertaken and revalidation achieved. this process should supported and resourced by the employing organisation, as should eqa scheme participation. (iv) interpretative eqa schemes are designed to assess and improve individual performance, and attempts at collusion are considered matters of professional probity. the professional response to these recommendations is expected to be led by the rcpath under the guidance of a newly-established national oversight group working on behalf of nhs england and should be more clear at the time of the pathsoc conference. a key part of this response will be to separately consider the implications of this review for technical schemes, affecting laboratories, and interpretative schemes, affecting individual practitioners. roche tissue diagnostics, tucson, arizona, usa tumour samples to guide treatment decisions have become of increasing significance. most importantly the results of companion diagnostic testing directly influences the management of individual patients as more drugs are approved for treatment of specific molecular distinct subgroups. reporting suboptimal quality test results may be harmful to the patient and cause the mismanagement of a prescribed companion drug. the consequences of unsatisfactory performance and measures for improvement are the responsibility of the laboratory. presently, there are number of eqa schemes for molecular testing available in europe however, their results clearly indicate the need for eqa since %- % of laboratories do not carry out according to the standard set by the eqa provider or utilize standardized procedures. continual improvement programs, internal quality control and validation program assist laboratories however; by using standardized quality practices such as iso and the use of external quality assurance schemes can provide essential feedback to the laboratory to assure accurate molecular testing results.  how to run a histopathology eqa in the digital age p nj mayer ;p jd oxley cork university hospital, cork, ireland; southmead hospital, bristol, uk interpretative eqa schemes in histopathology were first introduced in the uk in the mid- s, well before the advent of the internet and high resolution digital images. in this lecture we will outline key developments, as eqa schemes have evolved into the digital era, with particular emphasis on the national urological eqa scheme, which we have run since . we will outline the main practical issues involved in running an eqa scheme and share our personal experience of the development and introduction of the web-based eqalite software, which is being utilised by increasing numbers of schemes. we will address the pros and cons of traditional glass slide-based circulations versus virtual circulations using scanned digital images and show how the digital archive generated from old eqa circulations has become a valuable educational and teaching resource. we will also briefly explore, from an organiser's perspective, the major issues facing eqa schemes in the future, as eqa performance becomes more embedded into revalidation and fitness to practice.  molecular pathology: the future? p cs herrington molecular pathology is already central to stratified medicine. and the ability of pathologists to understand disease phenotype is essential for interpretation of the current explosion in '-omics' data. moreover, the future of stratified medicine will require integration of information from different sources, in the context of disease phenotype, to inform patient management: pathologists are ideally placed to lead this integration. this applies not only to data derived from ex vivo cells and tissues but also to molecular imaging data, which require accurate correlation with cell and tissue phenotype for accurate interpretation. molecular pathology is key to the future of pathology; and this future extends beyond the traditional light microscope the following plenary, oral and poster abstracts have been subjected to peer review. hypothesis: suppressor of cytokine signalling (socs) family members play a vital role in the activation of the jak/stat signalling pathway via a negative feedback loop and have been implicated in the development of cancers. in breast cancer (bc), socs mrna has been correlated with oestrogen receptor (er) positive tumours favouring a good prognosis (bmc cancer , : ) . this study aimed to determine whether socs at the protein level correlates with tumour morphology and low grade in bc. methods: differential expression analysis between tubular and grade matched nsts were undertaken in the metabric cohort. primary breast cancer tissue microarrays (n= ) were immuno-stained for socs and expression patterns correlated with clinico-pathological and molecular variables including outcome. results: differential gene expression analysis on the metabric data identified socs as the top gene with a significant overexpression in the tubular type as compared to low grade nsts (adjusted p value= . ). immunohistochemistry on the tenovus series showed positive nuclear socs expression to correlate with tumours of low grade (p< . ), low proliferation (ki p< . ), er/pr positive (p< . ) phenotype and tubular morphology (p< . ); as well as negative her status (p= . ) and non-triple negative status (p< . ). survival analysis revealed significant associations with long term breast cancer specific survival (p= . ). positive socs correlations were also observed with the expression of androgen receptor (ar) (p< . ) and stat (p= . ), further indicating its role in these two signalling pathways. conclusions: results from this study suggest socs to be a marker of favourable prognosis: identifying low grade, er positive breast tumours with particular correlations to the tubular histological tumour type. background: ovarian cancer is the fifth leading cause of cancer in women and has poor long-term survival, in part, due to chemoresistance. tumour hypoxia is associated with chemoresistance in ovarian cancer. however, relatively little is known about the genes activated in ovarian cancer which cause chemoresistance due to hypoxia. this study aimed to firstly identify genes whose expression is associated with hypoxia-induced chemoresistance, and secondly select hypoxia-associated biomarkers and evaluate their expression in ovarian tumours. methods: cisplatin-sensitive (a ) and cisplatin-resistant (a cis) ovarian cancer cell lines were exposed to combinations of hypoxia and/or cisplatin as part of a matrix designed to reflect clinically relevant scenarios. rna was extracted and interrogated on affymetrix human gene arrays. differential gene expression was analysed for cells exposed to hypoxia and/or treated with cisplatin. potential markers of chemoresistance were selected for evaluation in a cohort of ovarian tumour samples by rt-pcr. results: a wide range of genes associated with chemoresistance were differentially expressed in cells exposed to hypoxia and/or cisplatin. selected genes [angptl , her and hif- α] were chosen for further validation in a cohort of ovarian tumour samples, n= . high expression of angptl trended towards reduced progression-free and overall survival. high expression of her trended to increased progression-free but reduced overall survival, while high expression of hif- α trended towards reduced progression-free and increased overall survival. conclusion: this study has further characterized the relationship between hypoxia and chemoresistance in an ovarian cancer model. we have also identified many potential biomarkers of hypoxia and platinum resistance and provide initial validation of a subset of these markers in ovarian cancer tissues. methods: analysis of affymetrix™ human exon . st microarray data revealed differentially expressed genes (degs) between a bc group and a control non-bc group. ingenuity pathway analysis (ipa; bioinformatics software) was used to identify networks of the degs. the expression of a micro-network was validated using immunohistochemistry. double immunofluorescence was undertaken to identify the lineage of cells expressing components of the network. results: we identified a network of interacting genes that were upregulated in fcdiib compared to normally formed cortex or fcd without balloon cells (fcdiia). some components of this network were expressed in bcs but others were expressed in novel cell populations. double immunofluorescence identified a cell with the phenotype of a glial progenitor that was only present in fcdiib but not in normally formed cortex. conclusions: we have identified a novel population of glial progenitors found frequently adjacent to bcs in fcdiib. paracrine signaling between bcs and the novel chi l positive cells is likely to be involved in the pathogenesis in fcdiib. further investigations into the role of these cells would give us a better understanding of the molecular abnormalities underlying fcd and possibly provide novel therapeutic targets. excellent anatomical knowledge of the anal sphincter complex (asc) is essential for the treatment and understanding of low rectal and anal pathology. some of the current descriptions of the asc are contradictory. in this study, the three-dimensional ( d) anatomy of the asc is described with relevance to low rectal and anal surgical pathology. six human adult cadaveric specimens (three males, three females) were obtained from the leeds gift research tissue programme. paraffin embedded mega-blocks containing the asc were serially sectioned at µm intervals. sections were stained with haematoxylin & eosin, masson's trichrome and millers' elastin, from which d reconstructions were developed. the asc is a complex structure, varying between individuals in the size and distribution of its layers with intermingling of fibres and inconsistency of the longitudinal smooth muscle affecting the creation of the surgical intersphincteric plane. longitudinal fibres penetrate the internal and external anal sphincter to anchor in the submucosa and ischiorectal fossa. striated muscle fibres from the external sphincter were identified in the submucosa in four of six specimens. the asc is highly complex due to the degree of variation in its structure and intermingling of smooth and striated muscle fibres and their penetration of major structures. this creates potential tissue planes for the spread of infection, fistula extension and tumour spread. the complex anatomy of the asc also impacts on the staging of low rectal cancers in this region, which requires further investigation. p h thorpe; a asiri; m akhlaq; d jackson; m ilyas cten is upregulated in a number of tumour types and in colorectal cancer expression is associated with advanced dukes stage, poor prognosis and distant metastasis. cten is localised at focal adhesions and regulates cell motility but knowledge of underlying signalling mechanisms is sparse. epithelial to mesenchymal transition (emt) is a process whereby cells acquire an invasive phenotype to aid cell migration and is found to occur in a number of biological processes including cancer metastasis. we investigated whether cten increases cell migration through emt pathways in colorectal cancer. cten was forcibly expressed in colorectal cell lines and snail expression determined by qpcr and western blot. the cycloheximide pulse chase assay was used to assess any changes in snail protein stability. further to this, the transwell migration assay was performed to investigate changes in cell motility. forced expression of cten was shown to increase snail protein expression in hct and caco cell lines. there was no change in the level of snail mrna suggesting that cten regulates snail at a post transcriptional level. inhibition of protein synthesis confirmed this and showed that cten regulates the stability of snail protein. simultaneous forced expression of cten and knockdown of snail demonstrated that this relationship was functionally active. forced expression of cten increased cell migration (p< . ) which was subsequently lost when snail was knocked down (p< . ). we are the first to identify snail as a downstream target of cten signalling. this finding advances the understanding of cancer cell motility regulatory networks and further highlights cten as a potential therapeutic target in colorectal cancer. work supported by a pathological society grant. treatment strategies for patients with advanced colorectal cancer p sd richman ; gj hemmings ; p chambers ; m taylor ; hm wood ; e tinkler-hundal ; k southward ; jm foster ; a ouime ; kg spink ; p quirke leeds institute of cancer and pathology, leeds, uk; affymetrix, high wycombe, uk treatment for advanced colorectal cancer is moving to combination therapies, targeting multiple signalling pathways. indeed, mrc focus has been designed to assess this. we determined pten protein expression, and assessed this in relation to other biomarkers associated with signalling downstream of the epidermal growth factor receptor. tissue microarrays were constructed from advanced colorectal cancer (acrc) clinical trials (focus and piccolo) for immunohistochemistry (ihc). mutation status of kras, nras, pik ca and braf was assessed by pyrosequencing. copy number variation was assessed on oncoscan® ffpe assay kit (affymetrix inc.). pten protein expression was correlated with mutation status, mmr status, primary tumour location and copy number. pten protein expression for patients showed complete loss of expression in / ( . %) -focus and / ( . %) -piccolo. braf mutation status was significantly different between the pten negative and pten positive populations (p< . ), with significantly more pten negative tumours having the braf v e mutation. loss of pten expression correlated with genomic deletions involving the pten gene. / ( %) of pten negative tumours exhibited loss of the pten region ( q), half of which were focal deletions. only / ( . %) pten positive tumours showed deletions of this region, and none were focal events. there was no significant difference in either primary tumour site or mmr status (p= . ) between the pten negative and pten positive populations. signalling pathways do not stand in isolation; they are interlinked in a complex signalling network. current treatment interventions must target the correct pathway combinations if patients are to benefit from targeted therapy. our data suggests a subset of patients may require dual akt and mek pathway inhibition, in addition to anti-egfr monoclonal antibody therapy and inhibition of braf. zonal differences in pd expression in centre of tumour versus periphery in microsatellite stable and unstable colorectal cancer p gm o'kane ; m lynch ; j aird ; s hooper ; c muldoon ; n mulligan ; c loscher ; dj gallagher st. james's hospital, dublin, ireland; dublin city university, dublin, ireland; mater misericordiae university hospital, dublin, ireland colorectal cancers (crc) that show evidence of microsatellite instability (msi-h) are marked by a high tumour infiltrating lymphocyte (til) population which is thought to be prognostic. programmed cell death (pd- ) is a negative regulator of the immune system and targeting the interaction with its ligand pd-l offers a potential therapeutic target. we aimed to characterize cd and pd- expression in both the tumour centre (ct) and tumour periphery (pt) of microsatellite stable (mss) and unstable crc. methods: paraffin-embedded tumour blocks were cut at um, prepared and stained using specific antibodies for cd and pd- . the pt was defined as the area within a x high power field (hpf) from the outline of the tumor. the ct was defined as the area at least one x hpf apart from the tumor outline toward centre of the tumor. images were taken at x, x, x and x. positive cells were averaged across high power fields and classified as high or low positivity. results: forty-two specimens have been analysed to date including msi-h and mss tumours. sixty-eight percent of msi-h were stage ii and % of mss were stage iii. in the msi-h group, a high cd count in the ct and pt correlated with and earlier tumour size and stage. pd- positivity was seen in % of msi-h ct compared to % positivity in the ct of mss tumours. the periphery of both mss and msi-h specimens showed significant pd- expression with % and % of samples showing positivity respectively. there was no association between high or low densities of staining and stage. conclusions: zonal differences exist in the expression of cd and pd- in microsatellite stable and unstable tumours. a high proportion of msi-h tumours show pd- activity in the centre of the tumour despite an improved prognosis. further profiling of other t cell populations may help to further understand this expression which may act as a biomarker or provide a therapeutic target biomarkers that are able to distinguish stage ii and iii colon cancer patients at high risk of developing disease recurrence, who may benefit from adjuvant chemotherapy, are still lacking. genome-wide profiling of somatic aberrations, including gene point mutations, dna copy number aberrations (cna) and structural variants (sv), is expected to provide better insight into the molecular pathology of tumour progression and clinical outcome. genome-wide analysis of cnas was performed using high-resolution comparative genomic hybridization for microsatellite stable (mss) stage ii and iii primary colon cancer samples (n= ). in addition, the prevalence of genes suffering from cna-associated chromosomal breaks, indicative for svs, was determined. the mutation status of commonly affected apc, tp , kras, pik ca, fbxw , smad , braf and nras genes was examined for samples using targeted massive parallel sequencing. associations of genomic aberrations with disease-free survival (dfs) rates were explored by log-rank tests using , permutations. disease recurrence and dfs rates differed significantly for several cna-regions (p< . ). a total of genes were recurrently affected by cna-associated chromosomal breaks (fdr< . ), among which genes ( %) that were also identified in a previously analysed cohort of metastatic colorectal cancers. gene point mutation frequencies were in concordance with literature. in a univariate analysis, none of the individual mutated genes appeared to be significantly associated with dfs. in summary, several associations are found between highly prevalent genomic cnas and disease recurrence in this cohort of mss stage ii and iii colon cancers. further in-depth analysis is required to unravel underlying biology that contributes to disease recurrence. km sutton ; d bottomley ; d morton ; p quirke ; p np west accurate and reliable methods for assessing the molecular profile of clinical tumour samples are important for the delivery of personalised medicine. when adopting a targeted amplicon sequencing method in combination with next generation sequencing (ngs), it is ideal to call mutations against a control sample to enable artefacts to be removed from the analysis. blood is considered the gold standard control but may not always be available. we compared the use of histologically normal mucosa to blood as a control in colon cancer. we examined mutations in colon cancers from the ncri foxtrot trial using the fluidigm access array for ngs library preparation. we assessed the use of both blood and normal colonic mucosa as a control for assessing mutations in genes. all samples were tested in duplicate. the work was partly funded by a pathsoc career development fellowship and is presented on behalf of the foxtrot collaborative group. mutation calls made using normal mucosa as a control compared to blood were in good agreement; a mathew's correlation coefficient above . was seen for all of the genes where agreement could be assessed. we found that false positive mutations were due to poorer amplification of the normal mucosa samples and false negatives were due to mutation calls in the normal mucosa. overall we found that when assessing mutations in hotspot oncogenes, testing in duplicate and the use of a normal control tissue is not required to make mutation calls. however, where a normal control is required, normal mucosa from the resection margin is a suitable alternative to blood where it is not available. we report a series of four unusual ovarian or extraovarian neoplasms composed of an admixture of adenosarcoma and a predominant component comprising a sex cord tumour. the neoplasms occurred in women aged to . three cases arose within the ovary and one was extraovarian (pelvis and abdomen) in location. in all four cases, there were minor areas with morphological features of adenosarcoma with a phyllodes-like architecture and periglandular increased cellularity with mitotic figures. in two cases, the stromal component was morphologically in keeping with a juvenile granulosa cell tumour. in one case, the stromal component had some features of both adult granulosa cell tumour and sertoli cell tumour within a fibromatous background. the fourth case morphologically could not be categorised as any of the usual types of ovarian sex cord tumour and was categorised as an unclassifiable sex cord tumour. in all four cases, there was immunohistochemical evidence of sex cord differentiation. in each case, we propose that the sex cord tumour arose from a pre-existing adenosarcoma thus representing an unusual form of sarcomatous overgrowth of sex cord elements which can occur within adenosarcomas. this phenomenon is not well described in the literature. background: human epididymis protein (he ) is a secreted protein that is overexpressed in some cancers. he is emerging as a useful biomarker in diagnosis and follow-up of endometrial cancers. the aim of this study was to evaluate the potential role of serum he in the diagnosis and management of endometrial cancer. methods: patients undergoing surgery for endometrial disease were recruited into this study and had pre-operative serum samples taken, n= . demographic, clinical, radiological and laboratory data were reviewed. he and ca serum levels were analysed using the fujirebio diagnostic elisa kits and results correlated with clinicopathological details. standard cut-off points of pmol/l for he and u/ml for ca were used. results: he showed a sensitivity of % and specificity of . % for detection of endometrial cancer. ca had a very low sensitivity of % for endometrial cancer diagnosis. he was elevated in all stages of endometrial cancer and demonstrated the ability to distinguish between benign and malignant groups. he also provided information about myometrial space invasion. conclusion: he has a role in endometrial cancer diagnosis and prognosis and has the potential to be used in a screening setting or as a triage marker in the primary care setting. for women diagnosed with endometrial cancer, he has the potential to stratify them into treatment regimens where the most appropriate treatment can be delivered resulting in improved quality of life and outcome for endometrial cancer patients. platelets drive metastatic changes in ovarian cancer cells p cd spillane ; nm cooke ; s o'toole ; d kenny ; o sheils ; jj o'leary histopathology department, trinity college dublin, dublin, ireland; department of molecular and cellular therapeutics, rcsi, dublin, ireland; department of obstetrics and gynaecology, trinity college dublin, dublin, ireland background: ovarian cancer is the th leading cause of cancer related deaths in women. previously we described a dynamic interaction between ovarian cancer cells and platelets in vitro, involving platelet adhesion, activation and induction of pro-survival and pro-angiogenic signals in the cancer cells. this study looked to further investigate this phenomenon in ovarian cancer cells by assessing the molecular changes it induced. methods: cell lines m and skov were used as in vitro models of metastatic ovarian cancer. platelet cloaking of cells was quantified by flow cytometry. cells co-cultured with/ without platelets for hrs were examined by rt-pcr for emt related changes and by affymetrix gene . st arrays for whole transcriptome changes. results: significantly more platelets adhered to skov cells than m cells. while there were different rates of adhesion, the platelets induced similar changes in emt related genes in both. there was a significant loss in expression of epithelial genes and an increase in mesenchymal genes, indicating the induction of emt. whole transcriptome analysis showed that there were a greater number of gene expression changes occurring in skov cells compared to m cells, correlating with the adhesion data. a gene panel of commonly affected genes in both cell lines was identified, many of which form part of an interlinking pathway that is regulated by tgfβ and associated with cell adhesion/ecm remodelling. though only genes overlapped, the biological processes affected in both cell lines were very similar, with of the processes enriched in the m data set also seen in the skov data set. conclusion: this study shows that platelets can enhance the metastatic potential of ovarian cancer cells through the induction of emt and ecm changes. in addition, it has identified a set of genes that hold potential to be in vivo markers of this interaction. background: during the metastatic cascade, circulating tumour cells rapidly and efficiently adopt a platelet cloak. platelet cloaking of tumour cells promotes metastatic disease by promoting cellular proliferation, angiogenesis and emt while inhibiting autophagy and apoptosis. the aim of this study is to examine whether the platelet cloak contributes to tumour cell evasion of nk cell mediated immune surveillance. methods: freshly isolated pbmcs were harvested from healthy donors and stimulated for hours with il- ( u/ml). pbmcs were co-incubated with ovarian ( m and skov ), melanoma (sk-mel- ) and cml (k ) cell lines that were either uncloaked, or cloaked with washed platelets from healthy donors. the nk-tumour cell receptor ligand systems, nkg d-mica/micb and cd /cd -cd were examined using nk cell cd a expression and interferon-gamma production to quantify nk cell mediated recognition and 'killing' of cancer cells. results: we first demonstrated that ovarian and melanoma cancer cell lines when cloaked with washed platelets strongly inhibited nk cell antitumor reactivity. platelet cloaking induced down-regulation of the stress ligands mica and micb on the tumour cell coupled with their release into the microenvironment, a known nk cell immune decoy strategy. in addition, platelets significantly down-regulated both cd (nk cell) and cd (tumour cell), inhibiting nk cell activity. both mechanisms occur in tandem to comprehensively incapacitate nk cells and promote tumour immune evasion. conclusions: ovarian and melanoma tumour cells are efficiently cloaked by platelets, which facilitates immune evasion by actively suppressing nk cell cytotoxicity and cytokine production. purpose of the study: glioblastomas (gbm) are the most common and most aggressive primary malignant brain tumours in adults. one of their histopathological hallmarks is the microvascular proliferation; these tumours are among the most angiogenic of malignancies by displaying the highest degree of microvascular proliferation. igfiir/man- -p is a receptor that belongs to the insulin-like growth factor (igf) system. the involvement of igf-iir/man- -p in the process of angiogenesis has been postulated in rare earlier studies. to our knowledge, the role of igf-iir/man- -p in the neovascularisation of human gbm has never been studied. methods: igf-iir/man- -p expression was evaluated in the vascular compartment from human gbm and from normal adult brain samples by means of quantitative immunohistochemistry on tissue microarray sections. in vitro cell line experiments were carried out in order to characterise the igfiir/man- -p role in angiogenesis. summary of results: igf-iir/man- -p was strongly expressed in the cytoplasm of endothelial cells in hyperplastic vessels and exhibited a dot-staining pattern. we found a higher expression of igf-iir/man- -p in gbm vessels compared to normal brain vessels (p= . ). furthermore, preliminary in vitro experiments suggest a role of igf-iir/man- -p in tube formation but not in growth of the ea.hy endothelial cell line. conclusions: this work shows a possible role of igfiir/man- -p in the process of neovascularisation of gbm angiogenesis. additional investigations are required to confirm the role of this receptor as a direct actor of angiogenesis in gbm. purpose of the study: vasa vasorum (vv) are microvessels which supply vessels that cannot be nourished by diffusion from their own lumina. vv are believed to be a key element in the pathogenesis of vascular diseases. a number of different imaging methods have been used to study the vv but there is still no definitive consensus on their structure. the aim was to describe the normal microvessel anatomy of temporal arteries. methods: human temporal artery, obtained following routine biopsy with ethical approval and patient consent. samples were embedded into paraffin blocks and serially sectioned at micron intervals. alternate sections were stained with h&e and scanned to create virtual slides. the slides were aligned, vv were segmented (annotated) and iso-surfaced to generate d reconstructions. summary of results: the reconstruction shows the structural arrangement of the vv as a complex plexus. no connection to the vascular lumen was visualised. in this segment a hierarchical branching structure was not observed. vv were almost exclusively restricted to the adventitia of the vessel wall. mean ± sd area of the vv (n = ) is . µm (± . ). the mean ± sd number of vessels per slide is . (± . ). these metrics are based on one arterial specimen. conclusion: this method allows us to study the three-dimensional spatial relationships of microvessels within arterial specimens. furthermore, metric data generated in the process can support the d images to study the microvasculature. this method will be applied to diseased arteries in future to generate novel hypotheses about the inflammatory process. acknowledgements: this research was supported by a pathsoc intercalated studentship. purpose of the study: it is controversial whether mesothelioma can be diagnosed with confidence in effusion cytology and therefore an ancillary marker of malignant mesothelial cells would be clinically valuable. brca- associated protein (bap ) is a tumour suppressor gene which shows biallelic inactivation in approximately half of all mesotheliomas. bap expression is commonly lost in mesothelioma. we investigated whether loss of bap expression can be used to support a diagnosis of mesothelioma in effusion cytology. methods: immunohistochemistry (ihc) for bap was performed on cell blocks from effusions associated with confirmed mesothelioma cases, effusions containing mesothelial cell atypia, benign effusions, and effusions from patients with lung adenocarcinoma. results: ihc for bap was performed on cases of confirmed mesothelioma. ( . %) showed negative staining in the presence of an internal positive control. in effusions considered to have atypical mesothelial cells in the absence of definitive diagnosis of mesothelioma, cases demonstrated negative staining for bap . on follow up, of these patients received a definitive diagnosis of mesothelioma in the subsequent months ( were lost to follow up immediately). only of consecutive benign effusions were interpreted as bap negative. patients with confirmed adenocarcinoma demonstrated positive staining for bap . conclusion: we conclude that loss of bap expression in effusion cytology is quite specific for mesothelioma. whilst it is not definitive, it can be used to support the diagnosis of mesothelioma in atypical effusions. we caution that interpretation of bap ihc on cell block may be difficult and that convincing positive staining in non-neoplastic cells is required before atypical cells are considered negative. we also note that bap loss is not a sensitive test and cannot be used to exclude mesothelioma. the south-east of scotland experience on the molecular detection of egfr, kras and alk mutations in lung adenocarcinomas p y kheng ; l williams ; k walsh ; j fairley ; s camus ; l gilroy ; k gilmour ; d stirling ; w wallace ; d harrison ; a oniscu royal infirmary of edinburgh, edinburgh, uk; the university of edinburgh, edinburgh, uk the approval of novel targeted treatments for egfr-positive and alk-positive non-small cell lung cancer (nsclc) has led to the increased requirement for mutation testing services in south east of scotland. egfr mutations are typically found in females, asians and never smokers whereas kras mutations are associated with smoking. alk rearrangements are commonly found in younger patients and never smokers. this study aimed to determine the prevalence of egfr, kras and alk mutations in south east of scotland and to evaluate our experience in testing of alk with ihc and fish. data of all patients tested were collected retrospectively from clinical records. from january to may , we reported mutation rates of egfr, kras and alk to be . % ( / ), . % ( / ) and . % ( / ) respectively. in our cohort, an increase in one pack years of smoking resulted in a decrease in the odds ratio of egfr-positivity (or . , % ci . - . , p< . ). kras-positivity was associated with a history of smoking, with rates in both former (or . , % ci . - . , p= . ) and current smokers (or . , % ci . - . , p= . ) significantly higher than in non-smokers. the number of smoking pack years had no influence on the rates of kras-positivity. alk-rearrangements were found to be associated with never smokers (p< . ) and younger patients (≤ years old) (p< . ). to date, no false positives were reported for parallel testing of alk with ihc and fish. we observed % sensitivity ( ihc+/ fish+) and . % specificity ( ihc-/ fish-) when comparing ihc with fish. in conclusion, the prevalence of egfr mutation in south east of scotland has reflected mutation rates reported in west of scotland. our findings further support the use of alk-ihc as a diagnostic screening tool. purpose of the study: the molecular mechanisms of metastasis and progression of penile squamous cell carcinoma (pscc) are unclear. nobody, to our knowledge, has investigated the expression of cell-cycle proteins in advanced or metastatic pscc. we aimed to determine the extent of hpv infection in patients with advanced pscc and its effect on the expression of the key cell-cycle proteins p , p ink a and retinoblastoma (rb). methods: archival paraffin embedded blocks were obtained from primary penile cancers, all patients having developed locally-advanced or metastatic disease. all patients were treated in the phase ii trial of docetaxel, cisplatin & -fluorouracil (tpf) chemotherapy cruk/ / (nicholson et al. bjc ; : - ) . samples were analysed immunohistochemically for p ink a, p and rb protein expression on a tissue microarray. all tumours were hpv typed using pcr. summary of results: hpv dna was detected in / ( %) with hpv present in / ( %). cases were not suitable for analysis. no association was found between hpv and expression of either p ink a (p= . ), p (p= . ) or rb (p= ) using fisher's exact test. conclusions: hpv dna is detected in less than half of progressive pscc, suggesting either the loss of hpv in advanced disease or that non-hpv related cancers progress more commonly. the lack of correlation between hpv and these cell-cycle proteins suggests that they may undergo somatic mutation that is not driven by hpv, leading to increased growth and invasiveness. treatment strategies may be hampered by this genetic diversity, which requires further investigation. prostate cancer is the second most common form of cancer in males, and the incidence of this disease is predicted to double globally by . more than . million new cases of prostate cancer are diagnosed each year and two thirds of these patients are from the western world. current diagnostic tests for prostate cancer are limited in both sensitivity and accuracy, and a method for accurate prognosis in these patients is yet to be developed; therefore, there is a need for a sensitive and specific prostate cancer test to implement early and appropriate therapy. the recent discovery of altered endosomal-lysosomal biogenesis in prostate cancer cells has identified a fundamental change in the cell biology of this cancer that holds great promise for the identification of novel biomarkers that can predict disease outcomes. investigation of the endosome compartment and endosome biogenesis revealed elevated gene and expression of critical machinery components that are required for endosome biogenesis and endocytosis. here we demonstrate significantly altered expression of endosomal and lysosomal genes in mrna microarrays of prostate cancer tissue compared to non-malignant tissue, and that specific endosomal and lysosomal genes are predictive of patient outcomes. two endosomal tri-gene signatures were identified that had a significant capacity to stratify patient outcomes. changes in the expression of these genes was further ascertained by qpcr in fresh-frozen prostate tissue specimens, which further implicated altered endosome biology during disease progression, with significant changes in expression observed between aggressive prostate cancer and indolent disease or normal prostate tissue. these findings support the initiation of a retrospective trial to determine if these new biomarkers can accurately predict clinical progression in prostate cancer patients. m craze; c joseph; c nolan; a green; ea rakha; io ellis; p a mukherjee university of nottingham, nottingham, uk introduction: lymphovascular invasion (lvi) is an important step in the metastatic cascade. identification of a molecular signature for the lvi positive phenotype will help identify relevant drivers and pathways. this study aimed to investigate determinants of lvi from a biomarker database. methods: biomarkers (n > ) from a well annotated series (n= ) were analysed for correlations with lvi [clinical/ihc (d - ) supplemented]. proteins with significant associations with lvi were interrogated for pathway enrichment analysis [corrected for false discovery rate (fdr)], using the string . platform incorporating gene ontology (go), kegg and nci. results: biomarker analysis related to both clinical/ihc determined lvi identified positively associated markers, in both clinical and ihc categories (e.g. ada , cd , foxp , kpna ). a further markers were negatively associated, in both categories (e.g. bcl , brca , mage and sox ). significant pathways (p< . ) unifying the positively associated proteins include metabolism, immune responses (t-cell regulation and differentiation), cell activation and transcription [go] ; t-cell receptor signalling pathways and pathways in cancer and haematopoietic cell lineages [kegg] . for negatively associated proteins, the following were significant: ubiquitination processes, regulation of the mitosis [go]; p pathways [kegg] and apoptotic and cell cycle pathways [go & kegg] . on cross-validating a subset included in the metabric cohort, there were overlapping enrichments for immune response regulation (go) and haematopoietic cell lineages (kegg). conclusions: these preliminary findings are the first to unify biomarkers for lvi pathway analysis in bc, using protein based data. within the constraints of selection bias, data mining from immunohistochemistry of multiple biomarkers in relation to biological processes hold promise. *am supported by the nihr and the academy of medical sciences abstracts s· assessment of her status on needle core biopsy of breast cancer: impact of histopathological concordance p m pigera; ahs lee; io ellis; ea rakha; z hodi nottingham city hospital, nottingham, uk one of the key recommendations introduced in the asco/cap update guideline recommendation on her testing is the novel concept of "histopathological concordance." it is proposed that certain tumour morphological features such as histologic type and grade should trigger repeating a molecular test in cases of "discordance". in this study we have we have reviewed breast cancer cases consecutively reported in routine practice in nottingham in the last years. data on her status was collected and cases with her assessed on resection specimens (rs) were analysed in details. results: of all cases, patients ( %) had her status assessed on core biopsy and the corresponding tumour rs. the main reasons for a repeat were tumour multifocality and morphologically different or heterogeneous tumours. a few cases were repeated because of borderline negative fish results or neoadjuvant therapy. cases were repeated due to insufficient tumour in the core biopsy. in this study the her status of the index tumour was changed in cases and both were in the borderline result category. her testing of different tumour foci of multifocal or morphological heterogeneous tumours was consistent with that of the index tumour assessed on the core biopsy apart from two cases; one positive and one negative. tumours were upgraded from grade on core to grade on excision and her status did not change. no contribution of hormone receptor or tumour type was identified. conclusion: there is excellent agreement between her assessed in core biopsy and rs. histopathological discordance seems to play a minor role which does not justify test repeat in routine practice. tamoxifen prevents breast cancer in a sub-set of high-risk women in a mechanism that appears to be dependent on reduction of md. animal model studies suggest that tamoxifen remodels the mammary stroma to a tumour-inhibitory phenotype. this study aims to analyse the effect of tamoxifen on breast fibroblast function and identify potential protumourigenic pathways contributing to density-associated risk. methods: primary human breast fibroblasts were treated with hydroxytamoxifen ( nm- µm). fibroblast function was analysed by measuring: proliferation; expression of stromal proteins fibronectin (fn), lox and collagen ; effects on tgf-β signalling via smad phosphorylation and upregulation of the myofibroblast marker sma. genome wide analysis was performed using rna-seq. summary of results: fibroblasts from patients were treated with tamoxifen. all patients showed reduced proliferation with treatment. in % of patients tamoxifen treatment resulted in reduced expression of fn. tgf-β-mediated upregulation of sma and fn were consistently inhibited by tamoxifen, as was fibroblast contraction of collagen gels. rna-seq analysis revealed modulation of a number of metabolic pathways by tamoxifen, including significant upregulation of dhcr , part of the microsomal antioestrogen binding site (aebs). conclusions:these data indicate that tamoxifen can directly remodel the stromal microenvironment, generating a less 'reactive' stroma. modulation of aebs activity has been proposed to be anti-tumourigenic, and also is implicated as a suppressor of hedgehog signalling. thus, tamoxifen impacts on multiple pathways to create a tumour inhibitory phenotype. this work was supported by the pathsoc small grant scheme. purpose of the study: the phenotypic features of basal like (bl) breast cancer (bc) resemble those occurring in brca -germline mutation carriers. several lines of evidence suggesting the overall tendency of basal-like/triple negative bc to spread through vascular rather than lymphatic routes. the latter has recently been attributed to the activation of cadherin switch, an emt-like phenomenon, in blbc. this study aims at studying the cadherin switch expression profile tgfb , a key emt-trigger, expression in brca mutated compared to sporadic bc. the expression of e-cadherin, n-cadherin and tgfb were studied in a subset of germline brca mutated bc (n= ) compared to non-selected cohorts of non-lobular sporadic invasive blbc (n= ) and non-basal bc (n= ) using ihc and tma. summary of results: compared to sporadic bc, brca mutated cases were of younger age, more grade , with more medullary-like tumours, and more lvi positive. e-cad was significantly less expressed in brca cases than in the sporadic non-basal and in the blbc. however, n-cad was not significantly expressed in brca , non-basal, and blbc. tgfb was significantly less expressed in sporadic bc, both non-basal blbc than brca mutated bc. e-cad/n-cad combinatorial expression phenotypes were significantly different between brca mutated and non-basal and blbc. higher proportions e-cad-/n-cad+ were significantly observed blbc than non-basal bc. brca mutated cases displayed the least e-cad+ expression and the highest e-cad-/n-cad+ in the studied series. conclusions: despite the known similarities between brca mutated and blbc, results of this study demonstrate the more occurrence of cadherin switch in brca mutated breast cancer. e-cad repression appears to contribute more than n-cad gain in blbc than non-basal bc. exploring molecular mechanisms underlying lymphovascular invasion in breast cancer p sn sonbul ; a mukherjee ; r russell ; om rueda ; m aleskandarany ; ar green ; e provenzano ; c caldas ; io ellis ; ea rakha the development of tamoxifen resistance (tr) in oestrogen-dependent breast cancer (bc) is a therapeutic challenge. insulin-like growth factor binding proteins (igfbps) may play a role in this process. we have investigated the role of igfbp proteins in tr bc. igf axis genes were evaluated in mcf- (wt) cells and tamoxifen-resistant (tamr) variants using qrt-pcr and confirmed by elisa, western, and ligand blotting. igfbp- & - were knocked down by shrna transfection, and subsequent sensitivity to -hydroxytamoxifen ( -ht) was determined via wst- . cell migration was investigated by using the incucyte system. igfbp- expression was evaluated in bc cases by tma immunohistochemistry. five out of genes of the igf axis (igf-ir, igf- r, igfbp- , - and - ) had the highest expression levels by both parental wt and tamr cells. igfbp- was down-regulated by ~ -fold while igfbp- was up-regulated by ~ -fold in tamr versus wt cells (mrna and protein levels). significantly, a knockdown of igfbp- in tamr cells restored sensitivity to ( -ht), reduced erα expression to ± . % and enhanced cell migration. expression of igfbp- was significantly (p< . ) associated with survival advantage in tr patients. igfbp- and igfpb- are reciprocally regulated in the acquisition of tr by mcf- cells. igfbp- may play a role in the development of tr in vitro and its high levels in clinical samples may predict tr. purpose of the study: several lines of evidence are currently suggesting that the morphologic heterogeneity of breast cancer is mirrored at the genetic level. understanding the molecular genetic evolution of bc would contribute further insights into the molecular derangements driving disease progression. moreover, varied clinical outcome and response to similar therapeutic regimen is attributed, at least in-part to intratumoural heterogeneity. ngs can reliably study the genetic events using miniscule amounts of genomic dna. methods: gdna was extracted from ffpe tissue sections from a case of invasive duct carcinoma ( primary tumour samples and samples from positive axillary lymph node metastases). sample preparation and exome enrichment was performed using nextera rapid capture exome kits (illumina, fc- - ). exome sequencing was performed using illumina miseq with x depth of coverage (following adapter/barcode trimming). exploratory analyses and data mining were executed regarding variant (s) concordance/ discordance between primary tumour samples and their respective metastatic variants. summary of results: initial findings revealed candidate indels common to all three axillary lymph node samples yet absent from the three primary tumour samples. several genes have been identified as having frameshift mutations caused by indels. molecular players previously linked to anti-angiogenesis are amongst the genes affected by indel mutations in their coding sequences that may lead to potential abrogation of protein function. conclusions: these initial findings provide the framework for detailed molecular analyses for assessing molecular evolutionary events in primary breast cancer and their corresponding metastases. c-myc is amplified in approximately % of breast cancers (bc) and is associated with poor outcome. c-myc protein is multi-faceted and participates in many aspects of cellular function and is linked with therapeutic response in bc. we hypothesised that the functional role of c-myc differs between molecular subtypes of bc. we therefore investigated the correlation between c-myc protein expression and other proteins involved in cell cycle control, proliferation, apoptosis and dna damage together with clinicopathological parameters, outcome and treatments in early invasive primary bc (n= , ) using immunuohistochemistry. the metabric bc cohort (n= , ) was evaluated for c-myc mrna expression. in whole series, there was significant association between c-myc protein expression with higher tumour grade, lymph node(ln) positivity and medullary-like tumours. c-myc showed differential association with other proteins in the molecular classes. in luminal a tumours, c-myc was associated with atm (p= . ), cyclin b (p= . ), pik ca (p= . ) and ki (p< . ). in contrast, in basal-like tumours, c-myc showed positive associated with cyclin e (p= . ) and p (p= . ) expression. c-myc was an independent predictor of a shorter distant metastases free survival in luminal a ln+ tumours treated with endocrine therapy (et; p= . ). c-myc expression did not predict patient outcome in the other molecular subtypes with respect to adjuvant treatment. high c-myc mrna expression was associated with higher grade and basal phenotype (p< . ). in luminal tumours treated with et, c-myc mrna expression was associated with bc specific survival (p= . ). c-myc function is associated with specific molecular subtypes of bc and confers resistance to et. the diverse mechanisms of c-myc function, particularly in luminal a bc, warrants further investigation. metasin axillary predictive score (maps): a measure of axillary nodal disease prediction to provide an informed choice for breast cancer patients and surgeons p pp gopinath ; d george ; p sai-giridhar ; s jader ; e arkoumani ; s holt ; g francis ; c yiangou ; s al ramadhani ; s el sheikh ; n agrawal ; v sundaresan purpose of study: intra-operative sentinel lymph node sampling and molecular analysis empowers the surgeon to carry out axillary clearance as a one-step process. we have recently completed the clinical validation of metasin, an intraoperative molecular assay for sentinel lymph node analysis in breast cancer patients ( cases). method: the assay uses positive predictive markers and is quantitative, enabling the prediction of tumour volume using markers ck and mammaglobin. in this study group, patients had positive sentinel nodes and cases underwent axillary clearance. of the axillary clearance cases, % contained positive lymph nodes. % were sentinel node (snb) macrometastases, % were snb micrometastases and % were snb negative or contained isolated tumour cells. informative data was available for sentinel nodes from positive cases. results: using the qpcr values (from metasin assays using standardised pre-mixes) and clinical axillary clearance data, the cases have been stratified on the basis of the involvement of other axillary nodes. we have shown a three-tiered predictive grouping exists: group a includes low tumour volume disease with a nodal positivity of % within the axilla (n= ): group b with a % positivity of other nodal involvement (n= ) and group c with positivity of % of axillary clearances (n= ). the clustering of the metasin data is dependent on the qpcr results and shows that the cases can be sub-grouped to provide a probability basis for prediction of axillary nodal involvement; dependent on the qpcr cut offs. this gives the patient and surgeon a statistical basis for determining the likelihood of other axillary nodal disease. sequencing of the brca and brca genes has long been used in genetics laboratories to identify cases of familial breast and ovarian cancer. however, the advent of chemotherapy for ovarian cancer based on parp inhibitors, which requires the presence of a brca or brca mutation, is turning this specialist test into a commonly-applied companion diagnostic. at the same time, the introduction of new dna sequencing technologies is posing challenges even for experienced genetics laboratories. emqn has been providing eqa of brca and brca gene sequencing world-wide for years. the rate of serious diagnostic errors has varied from year to year, but the mean has hovered stubbornly around %. in eqa, just samples per year are sent out, and the quality and experience of participating laboratories varies greatly. we recently carried out a collaborative study to measure the quality of brca gene sequencing by traditional and new methods in experienced, expert laboratories from countries. ten dna samples ( with pathogenic mutations, with normal dna sequence) were sent to each laboratory. ten labs used next-generation sequencing (ngs) alone, used sanger sequencing alone, and the others used combinations of sanger sequencing, ngs, mlpa and other technologies. seventeen ( %) of labs identified all clinically-significant variants on all samples. four false negative results were reported by labs. two were due to deficiencies in the bioinformatics pipeline of the ngs process, while were attributed to a sample swap, and incorrect interpretation of a melting profile. no significant trend was identified with respect to the genotyping accuracy of the different methodologies used. the observed error rate of % amongst expert laboratories indicates the complex and challenging nature of this kind of testing. caution will be required when applying these technologies to sub-optimal ffpe samples in pathology laboratories. p n wolstenholme ; sj patton ; z deans ; s abbs ; j coxhead ; k brugger ; p westwood ; k thomson ; h scheffer next generation sequencing (ngs) is increasingly being introduced into clinical diagnostic laboratories worldwide. the huge amount of data generated by ngs cannot be duplicated by alternative methods for laboratories to internally validate all results, therefore external assessment of data is required. the uk national external quality assessment scheme (ukneqas) for molecular genetics and the european molecular genetics quality network (emqn) have developed a joint eqa scheme for ngs, with the aims to: (a) assess and improve quality; (b) enable laboratories to benchmark their ngs service against others and against best practice; (c) work towards consistency of reporting clinical results generated by ngs; and (d) contribute towards best practice. emqn and ukneqas offer numerous disease-specific, molecular pathology and technical eqa schemes. the objectives for developing ngs eqa were to make it generic (independent of genes, diseases, platforms, and testing context (e.g,. somatic, germline etc)) and applicable all users. two pilot eqas have been run and labs from countries participated. these labs were sent a genomic dna sample and asked to sequence either their smallest gene panel or largest single gene which the lab tested, submit technical details, and genotypes at known snps. the results were compared against a "consensus eqa genome" established by multiple validations of the dna. different genes were tested. most labs are using small panel of - genes. % of all variants were detected by every lab which tested for them. a detailed summary of the key findings will be presented. both pilots have proved to be challenging to meet our objectives, however the results have enabled clinical diagnostic labs to start to address the quality of their ngs testing. tumours invade the vasculature, which transports circulating tumour cells (ctcs) to distant sites enabling growth of secondary tumours. ctcs hold the potential to monitor: therapeutic response, emergent mutations and act as a screening tool for the early detection of cancer. there are numerous methods to isolate ctcs. once isolated, epcam and/or panck positivity and cd negativity are used to verify ctc status. however, due to the metastasis associated process of epithelial-mesenchymal transition, epithelial markers may be ineffective at identifying all ctcs. to overcome such protein marker based limitations, we have developed a novel staining pipeline (ctc- ) that combines histochemical staining (giemsa) with immunofluorescene (dapi, epcam/panck, her and cd ) staining and whole slide imaging for robust identification, enumeration and characterisation of ctcs from cancer patients. ctcs are isolated from whole blood using screencell cyto devices. cyto devices are then slide mounted, giemsa stained and digitised. giemsa staining is washed out and slides are immunofluorescently stained for epcam/panck, cd , her and counter stained with dapi. fluorescently stained slides are digitised. giemsa stained and four colour immunofluorescent digital slides are processed in silico generating a single z-stacked digital slide for pathological assessment. the ctc- staining pipeline has been experimentally validated via ctc characterisation of peripheral blood from lung, breast and ovarian cancer patients, with respect to healthy donor and spiked-in controls. the ctc- pipeline overcomes recognised weaknesses in ctc characterisation. histochemical staining is added to the current gold standard of epcam/panck and cd staining, while also preserving a fluorescent channel for assessment of biomarker status (e.g. her , apoptosis or platelet cloaking). such advancements enable robust pathological assessment of ctcs in the clinic. thorough interrogation of diseased tissue requires the use of multiple biomarkers in order to investigate biological pathways. unless fluorescent technology is used, multiple sections are required from each tissue block as each section can only be tested for a limited number of markers. histogenic molecular mapping (hmm) is a technique which used digitized images to evaluate multiple biomarkers. although each section cut from a block is slightly different from the immediately preceding section, the similarity is sufficient to allow non-linear registration of images of successive sections. if the order is known, multiple sections can be mapped onto each other by registering each with the immediately preceding section. this allows several biomarkers to be mapped into a single "composite" section thereby giving a representation of the pathways activated/expressed in the tissue. we used hmm to investigate the mismatch repair pathway in colorectal cancer. sequential tissue sections were stained for mlh , pms , msh and msh and then scanned. bespoke computational algorithms were used for image registration and composite images were binned as either "mismatch repair proficient" or "mismatch repair deficient". validation of each category could be obtained by quantification of pixels in binarized images or pixel distribution using stereology. our data show that hmm can be used for interrogating biological pathways in tissue sections and, ultimately, automated diagnosis of disease states. personalising whilst pre-operative radiotherapy is the standard of care in locally advanced rectal cancer (larc), only half of patients respond. individualised treatment based on a predictive test could avoid unnecessary radiation exposure in poor responders. macrophages in the tumour microenvironment with tumoricidal m and tumour protective m phenotypes could be modulating this response. this study investigated the possible predictive value of m and m subpopulations in identifying the response to short-course radiotherapy (scrt). pre-treatment biopsies and post-treatment resection samples were taken from patients with larc given scrt. dual-staining immunohistochemistry was performed with cd , hla-dr (m marker), and cd (m marker). samples were scored for hot-and-random spots by nuance software (version . . ) and compared with tumour response measured by reduction in tumour-cell density. the work was partly funded by a pathsoc career development fellowship. samples showing a low score for hla-dr positive m macrophages exhibited a better response to scrt with a median % reduction in tumour cell density (iqr to ). those with a high score exhibited a poor response with only a % reduction (iqr to , p= · ). no such trends were observed for cd + m macrophages. the ratio of hla-dr+ to cd + macrophages for biopsy and resection samples was significantly different showing a drop in the hla-dr positive macrophages in the resection samples (biopsy median · , iqr . to . ; resection median · , iqr . to . ; p= · ). assessment of macrophage subpopulations in pre-treatment biopsies appears to predict the degree of response to scrt in larc. further investigation to validate these findings is now required prior to developing a predictive test for use in routine clinical practice. patients with a poor predicted response could avoid toxic and costly radiotherapy and undergo alternative strategies including chemotherapy. next-generation sequencing technologies (e.g. s profiling) are increasingly used to investigate complex bacterial communities. they have advantages over classical methods, as a significant proportion of bacteria are 'non-culturable'. however, they do not distinguish 'viable' and 'non-viable' populations, which may skew results, particularly following antibiotic exposure. here we report culture and s data from a clinically reflective human gut model, describing changes in the gut microbiota following exposure to multiple antibiotics. a triple-stage chemostat model was inoculated with pooled human faeces from healthy volunteers to establish gut microbiota populations. the model was sequentially exposed to clindamycin ( . mg/l, qds, days), vancomycin ( mg/l, qds, days) and fidaxomicin ( mg/l, bd, days). specific bacterial populations were enumerated daily on selective agars. periodically, s profiling of gut model samples was performed; dna was extracted on a qiaxtractor, s v pcr products were sequenced on an illumina miseq, and resulting data were analysed using qiime. both culture and s profiling demonstrated marked alterations in gut microbiota populations following antibiotic exposure. for many populations, notably bifidobacteria and enterobacteria, changes seen by culture correlated with s profiling. however, as culture describes numerical changes in populations, and s profiling describes proportional changes, results are not always directly comparable. s profiling greatly increased microbiome coverage, particularly for clostridia. population diversity (number of observed species and shannon index) decreased with sequential antibiotic exposure. use of culture and molecular methods in tandem can greatly increase understanding of changes occurring in complex microbial populations. barrett's oesophagus is the erosive replacement of the normal squamous oesophageal lining with a glandular epithelium and is the major precursor of oesophageal adenocarcinoma. barrett's patients are enrolled into active surveillance programmes in order to detect and treat oesophageal cancer at an early stage. surveillance however is costly and burdening to patients. to improve screening efficacy there is an acute need for accurate biomarkers of cancer progression risk in barrett's patients. understanding the pattern and pace of clonal evolution that occurs within the barrett's segment is a key step towards achieving this goal. opinion is divided over whether goblet cells (intestinal metaplasia) on oesophageal biopsy are required for a diagnosis of barrett's oesophagus. this is based on the unproven assumption that goblet cell differentiation marks increased cancer risk in barrett's oesophagus patients. we have investigated the clonal structure of non-dysplastic and neoplastic barrett's oesophagus by combining state-of-the-art d modeling and genetic lineage tracing. by tracing the clonal origin of an early oesophageal adenocarcinoma through whole-exome sequencing and mitochondrial dna sequencing, we find that this cancer developed from non-goblet columnar epithelium, whereas the adjacent goblet-bearing mucosa was free of oncogenic mutations. our results have important implications for the harmonization of the clinical diagnosis of barrett's oesophagus. long-course chemoradiotherapy (crt) is used to down-stage locally-advanced rectal cancer (larc) prior to resection. an interval period prior to surgery allows for tumour shrinkage to facilitate surgical removal. the optimal time interval remains unclear, with little high-quality evidence to guide clinical decisions about when to operate. this study explores the pathological outcomes from a pilot randomised controlled trial comparing an interval of weeks versus weeks between crt and surgery. thirty one patients were recruited from seven uk centres between june and may . photographs were taken of the specimens and assessed by a blinded histopathologist for the quality of the mesorectal dissection. rates of pathological complete response (pcr), down-staging, and circumferential resection margin (crm) involvement were determined. response was also assessed using novel tumour cell density (tcd) assessment where the slides from the resected specimen and baseline biopsy were scanned at x magnification, the tumour area selected and to data-points analysed by a blinded expert to describe the percentage of different tissue components. the work was partly funded by a pathsoc career development fellowship and is presented on behalf of the starrcat trial investigators. twenty three patients underwent surgery ( from the -week arm and from the -week arm). the mesorectal fascial plane was intact in specimens from the -week arm ( %) and from the -week arm ( %). three patients at -weeks and two patients at -weeks showed a pcr. only one patient (from the -week arm) had an involved crm. tcd was . % for the -week arm and . % for the week arm (p= . ). in this small randomised trial, rates of mesorectal quality, crm status, pcr and tcd were similar following either a or week interval after crt. further studies are now needed to clarify whether a longer interval does facilitate on going down-staging. the role of tissue factor pathway inhibitor (tfpi) in liver injury p g petts ; h kudo ; a dorling ; m thursz ; r goldin imperial college london, london, uk; kings college london, london, uk introduction: studies have demonstrated that inhibition of the coagulant cascade is associated with less advanced liver fibrosis and better outcome in acute liver injury. tfpi is a serine protease inhibitor that acts as a homeostatic inhibitor of the coagulation cascade and may be a target to modify outcome in liver disease. methods: transgenic mice carrying a genetic modification that allows cells expressing a-smooth muscle actin (asma; e.g. activated hepatic stellate cells) to simultaneously express tfpi were used in models of chronic liver injury (carbon tetrachloride, ccl ) or acute liver injury (paracetamol) and culled at set time points after dosing. results:chronic liver injury: at hours after the last dose of ccl the transgenic mice had significantly decreased asma expression and tissue inhibitor of metalloproteinase (timp) - gene expression but no difference in matrix metalloproteinase (mmp) - and - gene expression compared to wild types. this suggested a microenvironment that would promote fibrosis resolution. however after hours this difference was lost. at all time points there was no significant difference between fibrosis in transgenic and wild type mice as demonstrated by sirius red staining, hydroxyproline assay and collagen a gene expression. acute liver injury: in paracetamol induced liver injury there was a significant difference in parenchymal necrosis in transgenic mice compared to wild types at and hours after dosing ( hours: mean necrosis % vs. % respectively, mann-whitney test p= . . hours: mean necrosis % vs. % respectively, mann-whitney test p= . ). conclusion: these results suggest that tfpi is an unlikely therapeutic target in chronic liver injury. however in acute paracetamol induced liver injury tfpi appears to rescue the injured liver in a sustained manner from hours after the initial insult and suggests a role for tfpi in managing acute liver injury. (research funded by the pathological society). analysis of adenocarcinoma and non-small cell lung cancer (nos) for egfr mutations now forms part of the royal college of pathologists' lung cancer dataset. identification of patients harbouring these mutations facilitates delivery of targeted therapies with superior efficacy. testing of these tumours for alk has also been introduced in our centre. we assessed our compliance with the college guidelines in this area for and . in those tumours positive for egfr or alk mutations, we examined the original sections to assess any correlation between mutation status and morphological subtype. of the appropriate cases ( %) diagnosed histologically in were sent for egfr mutation analysis, increasing to / ( %) in . of the cases over this time ( %) were positive for an egfr mutation. of these, showed an acinar growth pattern, were solid, lepidic, papillary and micropapillary. it was not possible to characterise the growth pattern in two of the cases analysed as cell blocks. the most common mutation, a missense mutation at codon of exon , was most frequently associated with an acinar growth pattern. of the cases, ( %) were sent for alk mutation analysis, compared with ( %) in . both of the two cases with an alk translocation ( p rearrangement) showed an acinar growth pattern. our compliance with college guidelines in sending appropriate lung specimens for mutation analysis is improving. the correlations between mutation status and morphological subtype add to, and are in keeping with, the current body of evidence in this area. primary synovial sarcoma of the heart -an interesting case report and review of literature p s venkatesan ; p sloan ; s kendall ; m giles royal victoria infirmary, newcastle, uk; james cook university hospital, middlesbrough, uk seventy five percent of primary cardiac tumours are reported to be benign atrial myxomas. the remaining are malignant tumours with most of them being sarcoma, particularly angiosarcoma and malignant fibrous histiocytoma. synovial sarcoma of the heart is a very rare malignancy accounting for less than % of all primary cardiac tumours. most of them arise from the pericardium and the right side of the heart and is considered to be highly aggressive with reduced survival rates. diagnosis in these rare locations is also challenging. we report a -year-old gentleman who presented to us with productive cough, chest pain and paroxysmal nocturnal dyspnea. echocardiography revealed a calcified left atrial mass arising from the posterior leaflet of the mitral valve and radiologically was thought to be a benign atrial myxoma. excision was planned with histology showing a malignant biphasic spindle cell tumour exhibiting marked cellular atypia and numerous mitoses. on immunohistochemistry, the glandular component expressed diffuse positive staining for bcl- and ema with focal positive staining for pancytokeratins. the spindle cell component expressed cd and ema and was found to be negative for cd , s , desmin, melan-a and hmb- . cytogenetic testing revealed ss -ssx / gene fusion with ss rearrangement confirming the diagnosis of synovial sarcoma in this rare location. a postoperative computed tomography was performed which showed no evidence of metastasis or primary lesions elsewhere. there was excellent postoperative surgical recovery and adjuvant chemotherapy was considered in the multi disciplinary meeting. primary cardiac synovial sarcoma is an extremely rare malignancy especially when arising from the left atrium posing diagnostic difficulty mimicking atrial myxoma. in contrast to the poor prognosis mentioned in the literatures, there was excellent recovery in this gentleman. swyer-james-macleod syndrome (sjmls) is a rare lung condition that manifests radiologically as unilateral hemithorax lucency as a result of post-infectious obliterative bronchiolitis, leading to small airways obstruction and secondary emphysema. the histological features of sjmls are poorly and infrequently described. we present three cases of the syndrome that underwent lobectomies in our institution from to , in three women, aged, , and years, presenting with recurrent lower respiratory tract infection, shortness of breath and pleuritic chest pain. two underwent left upper lobectomies, one left lower lobectomy. the first case demonstrated hyperlucency of the affected lobe with markedly reduced blood vessel attenuation. the radiological findings of the second case were of extensive bronchiectasis, hyperlucency, mucus plugging and hypervascularity. the radiological findings of the third case were of an apical bulla and upper lobe cavitating lesion with lobar hypolucency and hypoperfusion. the main histological findings were bronchiolar changes with bronchiolectasis, mucus plugging, constrictive / obliterative bronchiolitis and various degree of peribronchiolar inflammation. emphysema was mild and diagnosed as loss of attachment of alveolar walls. in addition, case had dystrophic, hypoplastic or absent branches of the pulmonary arteries. case showed prominent bronchial arterioles and abnormal tortuous dilated pulmonary arteries and veins. case had established bronchiolar scars in the bronchovascular bundles, pleural arteries showed medial hypertrophy and the interlobular septa contained dilated prominent veins, as well as cystically dilated inflamed peripheral bronchus. these cases highlight the importance of vascular changes in sjmls, likely secondary to the bronchiolar inflammation and destruction leading to capillary bed destruction from secondary emphysema and reactive pulmonary and arterial changes. mediastinal nodal staging with ebus is recommended for patients with resectable non-small cell lung cancer and has emerged as a safe tool to establish granulomatous pathology in suspected sarcoidosis. we conducted a retrospective analysis of the outcomes of ebus performed in a large teaching university hospital with a rapid access lung clinic over a month period and correlation with endobronchial and ct guided biopsies, and surgical resections, when available, and compared the adequacy of ebus when performed with and without rapid on-site evaluation (rose background and aims: in interstitial lung disease (ild), when an aetiological factor appears absent and clinical-radiological correlation is non-contributory, histology is required. the traditional surgical lung biopsy (slb) is not without risks. cryotechnically obtained specimens contain more alveolated lung tissue and less crush artefact than conventional transbronchial biopsies and may offer an alternative to slb in selected cases. we aimed at studying the complications of cryoprobe transbronchial lung biopsy (cpbx) and the quality and pathological characteristics of the tissue obtained. methods: this is a prospective study of patients who were selected for cpbx including cases of possible/probable idiopathic pulmonary fibrosis (ipf). complications of the procedure as well as the quality and pathological characteristics of the tissue are studied. results: twenty-seven procedures were performed in patients, of which were radiologically ipf. a total of biopsies were obtained (average . biopsies per procedure). only one was inadequate initially. fibroblast foci and features consistent with usual interstitial pneumonia (uip) pattern were present in biopsies from patients ( . % of total; % of suspected ipf cases). granulomas were identified in patients ( . %), of which were radiologically suspected ipf ( % of suspected ipf cases). two patients ( . %) had organizing pneumonia; both were inconsistent with ipf radiologically. the findings in the remaining patients were nonspecific; two of these were radiologically ipf ( % of ipf cases). seven patients ( . % of procedures) developed pneumothorax, only of them ( . %) required chest tube drainage. five patients ( . %) developed bleeding (moderate in ( . %) and mild in ( . %)). conclusion: cpbx was useful in this cohort at potentially identifying features not typical of ipf and displayed an acceptable complication rate. cardiomyopathy zj van der klooster ; s sepehrkhouy ; m harakalova ; r goldschmeding ; n de jonge ; ajh suurmeijer ; ra de weger ; f asselbergs ; p a vink introduction: genetic dilated cardiomyopathy is a heterogenous group of diseases caused by mutations in various genes. several types of cardiomyocyte cell death have been implicated in dilated cardiomyopathy: (macro)autophagy-related cell death, apoptosis, necroptosis and oncosis. one plausible mechanism of genetic cardiomyopathy is proteotoxicity of accumulated protein aggregates. we investigated the association of such aggregates as sign of autophagy-related cardiomyocyte cell death with specific pathogenic mutations. methods: hearts from patients with a genetic dilated cardiomyopathy or a combined phenotype of dilated and arrhythmogenic cardiomyopathy were included. microscopic slices from regions were immunohistochemically stained for p , a marker for aggregated proteins destined for autophagy. results: sporadic p positive cells were seen in control hearts ( . % of cardiomyocytes, range . - . %). troponin mutations (tnnt and tnni ; . %, range . - . %, n= ) showed hardly any increase in p . titin ( . %, range . - . % ,n= ) and lamin a/c ( . %, range . - . %, n= ) mutations showed a threefold increase in p staining. a tenfold positive staining was found in desmosomal mutations (pkp and dsp; . %, range . - . %, n= ) and myosin mutations (myh and mybpc ; , % range . - . %, n= ). phospholamban mutations ( . %, range . - %, n= ) and desminopathies (desmin and alpha-b crystallin; % of cardiomyocytes, range . - %, n= ) showed the highest number of p positive cells. conclusion: accumulation of p positive protein aggregates is associated with the type of mutation underlying the dilated cardiomyopathy. titin, lamin a/c and troponin mutations revealed little protein aggregation, whereas desminopathies, phospholamban, desmosomal and myosin mutations show abundant aggregates. this suggests that the type of mutation plays an important role in determining distinct mechanisms of cardiomyocyte cell death. major trauma centre status and its impact on the department of cellular and anatomical pathology in a large tertiary referral centre p ra hadden background: major trauma has been centralised into major trauma centres which act as the focus of major trauma networks. in april , derriford hospital in plymouth, devon became operational as the regional major trauma centre for the south west peninsula. as a result, there was potential for an increased number of trauma-related deaths to be referred to the local coroner, as well as surgical specimens, potentially increasing the work load on pathologists. the case mix could include post-operative cases, neurosurgical cases, polytrauma cases and forensic cases. methods: on admission, all eligible trauma patients are recorded onto the trauma audit & research network (tarn) database. the tarn data was retrospectively analysed and cross referenced with the department of cellular and anatomical pathologies database to determine how many patients had died, how many had post-mortem examinations were performed and how many surgical specimens were sent, on patients from outside the region or transferred from smaller major trauma units. results: over the first two years, there was a small increase in workload from patients who, prior to trauma centre status would have gone to other centres. conclusions: in recieveing patients from elsewhere in the region, there was an increase in workload for both autopsy and non-autopsy work. this excluded some neurosurgical cases, which traditionally would have been referred (as derriford is the neurosurgical centre). there are several areas for implication including, apt time, mortuary space and non-autopsy surgical work. although the workload increase is small, at a time when services are being stretched it is important to ensure any increase in work will not be the "straw that broke the camels back" and can be dealt with accordingly. derriford hospital, plymouth, uk to attempt to streamline general pathologist's approach to the investigation of potentially asbestos-related deaths methods turnaround times, tissue sampling protocol and frequency with which samples were sent for formal fibre counts was investigated for consecutive coronial autopsies at the author's institution. colleagues at other institutions were questioned about their own practice when investigating cases of potential asbestosis, lung cancer or mesothelioma. the author found no consensus in opinion on methods of sampling of the lungs in potential asbestosis, lung cancer or mesothelioma. the most common indication for samples to be sent for asbestos fibre counts was for malignant mesothelioma. sending tissue for fibre counts led to considerable delays in the authorisation of postmortem reports and to significant cost implications. the author presents a pragmatic algorithmic guide to approaching potentially asbestosis-related deaths with suggestions for sampling the lungs and tumour in all cases. in general terms, malignant mesothelioma previously confirmed premortem with histology and immunohistochemistry should not require extensive postmortem histological sampling. lung cancer and asbestosis require widespread sampling of lung tissue to determine amphibole count according to helsinki criteria in the former, and in the latter, assessment of the distribution and degree of fibrosis in addition to fibre count. one or more of these tissue blocks can be sent for formal counts in equivocal cases after following the algorithmic approach. conclusions although predominantly intended as a pragmatic approach to assist the busy practicing autopsy pathologist, the author believes that the algorithm presented will help departments streamline their approach to these cases and help the relative of the deceased gain access to compensation when appropriate in a more timely fashion. purpose of the study: this is a case report of a three year old girl who died suddenly at home. an autopsy was performed in order to determine the cause of death. method: an autopsy was conducted which showed no gross abnormalities. microscopy of the main organs and microbiological samples were taken for further assessment. results: histological assessment of the heart showed multiple small foci of lymphocytes around vessels and within the interstitum of the epicardium, myocardium and subendocardium. these lymphoid aggregates consisted of - lymphocytes up to larger numbers of lymphocytes collectively. several foci were present within virtually all of the sections taken in both right and left ventricles. there was no evidence of myocyte necrosis. immunohistochemistry confirmed they were of t lymphocyte cell origin admixed with smaller numbers of macrophages. histology from the respiratory system showed a diffuse subepithelial lymphocytic infiltrate in the larynx and trachea, and the nasopharyngeal samples detected coronavirus, adenovirus and two types of parainfluenza virus. however, viral polymerase chain reaction (pcr) from the cardiac tissue was negative. conclusion: an unequivocal diagnosis of a myocarditis could not be made in this case due to the lack of myocyte necrosis and the absence of viral dna within the cardiac tissue. genetic testing was strongly advised as splenic material had been taken at autopsy and following molecular genetic techniques a mutation was detected in the sodium channel indicating an inherited ion channelopathy. further genetic counselling and testing of the remaining siblings and family members is being performed. varicose veins affect a third of the uk population. isolated case reports and small series of fatalities resulting from varicose vein haemorrhage appear in the literature infrequently. some of the earliest reports of fatality we have found appear in british medical journal ( ) and the lancet ( ), more recently they have appeared in journals of forensic pathology. our purpose is to establish and bring attention to the rarity of fatality resulting from varicose vein haemorrhage and the importance of the scene of death and autopsy findings. a literature review was undertaken, we obtained relevant office of national statistics (ons) mortality data for the years - , and reviewed our own post-mortem records for demographic, clinical and scene of death information in cases we have encountered. our findings confirm that fatality resulting from varicose veins remains a rare cause of death. some of these deaths are preventable and in nice (national institute of health and care excellence, uk) issued guidelines in which haemorrhage from varicose veins constitute a vascular emergency. importantly emphasis on first aid is required, simply elevating the limb stops bleeding and is life saving, whereas direct pressure and tourniquets do not. pathologists should be aware of potential findings at autopsy in these cases. in particular, awareness that even obscure minor injury to a varicose vein could have resulted in significant blood loss leading to death. blood lost at the scene will not be apparent at autopsy, and details of blood loss could be variably recorded on the scene of death information provided, therefore vigilance is required. histopathologists practice in an era of ever advancing medical treatments for a wide variety of oncological, neurological, haematological and rheumatological diseases. immune modulating therapies are taking a more prominent place in clinical practice. however, with such great advances in therapy comes great risk, with the potential of life threatening opportunistic infections in our patients. we present a series of immunosuppressed patients who acquired such infections and in whom the diagnoses were made by histopathological examination. the spectrum of these pathogens ranges from viral (cmv, ebv, herpes), parasitic (strongyloides) to fungal (p. jirovecii, cryptococcus), and the range of infections is diverse. our series includes males and females, with an age range of - (mean age = years). unsuspected infectious diagnoses were made at post mortem in of the cases. organs affected included lung (n = ), brain (n = ) and haematological system (n = ). in one case both colon and lung were affected (n= ) and in a further case both liver and lung were affected (n= ). immunohistochemistry and/or histochemistry was invaluable in making the diagnoses and was used in all cases (n= ). treatments leading to immunosuppression included chemotherapeutic agents, monoclonal antibodies, steroids and methotrexate. we believe that with the ever increasing use of immunosuppressive therapies (both new and old) for a wider number of disorders, vigilance should be paid to their potential to cause life threatening side effects. histopathologists play a pivotal role in the recognition of this risk and in the diagnosis of these diseases. audit of hospital-based adult autopsy practice in a university hospital from july - p d abu-sinn; f macsweeney the contribution of hospital-based autopsy practice to improvements in patient care is substantial; however, there remains a void in the processes of audit and raising quality of standards in autopsy services. we aim to assess the current autopsy practice compared to rcpath guidelines and identify areas for achieving a high quality autopsy service. all adult autopsy cases performed at a university hospital mortuary between july and were reviewed. a total of adult autopsies were performed by consultant histopathologists. ninety nine percent were coroners' cases. the median turnaround time was . days, with a range of - days, excluding outlier cases (complex timeconsuming cases). there was considerable variation in turnaround times in complex cases and between the various reporting pathologists. eighty five percent of cases were compliant with rcpath minimum dataset for autopsy practice. the remainder were lacking clinical information only. histology and toxicology contributed to cause of death in . % and . % respectively. no organs were retained. further review of the cases not compliant with rcpath guidelines ( %), identified that the possible reasons were the inaccuracy, and sometimes irrelevance to the cause of death, of the information received by the pathologists. in many instances, the clinical information given to the pathologist may be controversial, and a certain degree of caution needs to be implemented to avoid including misleading information in the autopsy report. the turnaround times could be improved if a preliminary report is issued within a set time frame, to be followed by the complete report when the histology and toxicology results are available. however, this practice is not acceptable to some coroners who prefer one complete final report. variations in autopsy practice are to be expected as each autopsy involves substantial case-specific information to which a case-specific answer to the cause of death is expected. prostate cancer is the second most common form of cancer in males, and the incidence of this disease is predicted to double globally by . more than . million new cases of prostate cancer are diagnosed each year and two thirds of these patients are from the western world. the current psa-based test for the diagnosis of prostate cancer lacks specificity, results in missed-diagnoses, over-diagnosis and unnecessary biopsies/treatment. there is an urgent need for a method that enables early accurate detection of prostate cancer. endosomes and lysosomes are cellular compartments that degrade and turnover macromolecules in order to maintain cellular homeostasis. these organelles are directly involved in the critical processes of energy metabolism, cell division, and intracellular signalling, which are all hallmarks of cancer pathogenesis. endosomes have a critical role in controlling the secretion of proteins into extracellular fluids, making them an ideal system to identify new biomarkers that are released from cancer cells. we have discovered that endosome biogenesis (formation and function of endosomes) is altered in prostate cancer. there were significant changes in the gene and protein expression for endosomal proteins and differential distribution of endosome subsets in prostate cancer cell lines. there were also changes to the endosomal traffic and signalling of the transferrin receptor in prostate cancer cells. these fundamental changes in the cell biology of prostate cancer have allowed us to identify a specific set of endosomal proteins that have diagnostic potential. we are developing elisa's to quantify these endosomal proteins in patient samples and antibodies for immune histology applications. the objective for this project is to develop an effective method for the early and specific diagnosis of prostate cancer, which is important as this will have a major impact on patient outcome and survival. the incidence of malignant melanoma has rapidly increased in recent times and melanoma currently represents the second most common cancer diagnosed in young adults. diagnosis is based predominantly on histological assessment; however, due to the wide spectrum of morphological characteristics and lack of firm diagnostic criteria, accurate diagnosis can be challenging. some atypical melanocytic lesions do not display clear-cut morphological features to allow distinction of benign from malignant tumours, making diagnosis and treatment difficult. among these atypical melanocytic lesions blue nevi, spitz nevi and dysplastic lesions are common. from histological features alone, it can be difficult to exclude a diagnosis of melanoma and therefore aggressive surgical strategies may be employed in cases were they are unnecessary, highlighting the need for improved diagnostic techniques. both mrna and mirna profiling have been shown to be able to distinguish benign nevi and primary melanoma tumours. studying mirna expression levels is an attractive strategy as mirnas are highly resistant to degradation and can be easily analysed in ffpe samples. we have studied mirna expression levels in a cohort of benign, blue, spitz and dysplastic nevi versus primary melanoma tumours and their derived metastases. expression levels of key melanoma mirnas, including mirna , mirna , mirna and mirna c can be used to distinguish between nevi and malignant melanomas. we propose an easy to implement, simple and robust molecular method based on mirna expression ratio that, in combination with histological assessment, allows diagnosis of difficult to classify atypical melanocytic lesions. background: diagnosis of lynch syndrome (ls) traditionally relies on clinical criteria to guide diagnostic genetic testing. mmr status of the patient's tumour can help detect lynch syndrome families as well as having other recognised applications for the patient's management including prognostic and predictive significance. as such, the 'dataset for colorectal cancer histopathology report' recommendations from the royal college of pathologists were updated in july to include screening of colorectal cancer patients under the age of and molecular testing for abnormalities in the mismatch repair genes. in south-east of scotland we introduced molecular testing to identify individuals at risk of ls. to widen our screening in line with revised guidelines set by european experts, we expanded our cohort criteria to include those between the age of and . methods: molecular analysis was carried out on individuals: via 'reflex testing' (newly diagnosed colorectal carcinoma ≤ yrs, or clinical/ pathological features associated with mmr defects, such as pre-menopausal endometrial carcinoma, multiple tumours and medullary-type carcinomas) and via 'request testing' (clinical criteria and referral dependent). 'molecular-positive' profiles for ls were identified for genetic pre-testing counselling/diagnostic testing. results: patients with potential ls were identified, ( . %) underwent genetic counselling/testing and cases were confirmed ls with germline pathogenic mutations in the mmr genes. eight of these were identified using reflex testing. conclusion: this is the first uk study to show that screening for ls in patients with colorectal cancer under the age of is effective at identifying families with ls. the testing protocol is in line with the recent recommendations. the human microbiome is rich and diverse, especially in the oral cavity and gastro-intestinal tract, where it has been shown to be more stable in adults, although various factors such as diet and antibiotics mays influence its composition. this pilot study aimed to examine and compare the oral and gut microbial composition in four individuals using a culture-independent approach. methods: saliva and faecal samples were collected from volunteers within the same day on two separate occasions. the v region of the s rrna gene was amplified in all samples and pcr products sequenced on an illumina miseq. unique barcodes were used to sequence multiplexed libraries together. the data were analysed using the quantitative insights into microbial ecology (qiime) software. a second series of samples of faeces from individuals were run to investigate consistency over time. operational taxonomic units (otus) were assessed and showed major phyla represented in the saliva samples: firmicutes, proteobacteria, bacteroidetes, fusobacteria and actinobacteria. similar phyla except forfusobacteria, were found in the stool samples. the weighted unifrac pcoa analysis displayed a clear separation of the sample groups, and also showed a more disperse bacterial profile for the saliva samples, based on population sizes, whereas rarefaction curves and unweighted analysis indicated higher bacterial diversity in the stool samples. each individual could be distinguished either by oral or faecal microbiome. one volunteer who had had previous radiotherapy to the mouth displayed a particularly distinct oral microbiota. the microbial community profiles of saliva and faecal samples of four individuals were found to be distinct from each other, despite sharing similar phyla. analysis of multiple samples from each volunteer clearly separated each sample by volunteer and by sample type. are current automated approaches for determining the phylogeny of multiple deposits capable of interpreting the complexity of cancer evolution? p tg palmer; hm wood; m taylor; w fateen; im carr; p quirke tumour heterogeneity is central to chemotherapy resistance and disease progression in advanced malignancy. this heterogeneity arises due to the evolution of clones within the tumour cell population; the advent of high throughput sequencing has allowed the detection of different tumour cell clones within and between primary tumours and their metastases, potentially allowing mapping of tumour evolution. several, automated bioinformatic approaches have been devised for determining tumour phylogeny from changes in genomic copy number (cn); either by the overall similarity of genomic changes between tumour deposits or by examining the occurrence of shared breakpoints. we have compared these automated approaches with a manual determination of phylogeny based upon shared breakpoints identified from four cases of metastatic colorectal cancer consisting of between and deposits. we illustrate several recurrent issues identified with the use of automated systems for the determination of tumour phylogeny associated with an inability to correctly identify and interpret changes in ploidy, an inability to identify heterogeneity within tumour deposits, the masking of smaller events by larger ones, overinterpretation of convergent, but unrelated events, over calling sequencing artefacts as changes in cn, and non-calling of genuine cn changes due to low tumour cell content or low sequencing depth. we conclude that manual interpretation of bioinformatics data is still required to determine the phylogeny of metastatic cancer within an individual. results: levels of agreement between each sample size and the 'gold standard' were evaluated using bland-altman plots. separate pairwise comparisons were performed. some small sample sizes were shown to have small mean difference and narrow limit of agreement. the ki- pis were then translated into grades and similar comparisons were performed by calculating the kappa score for categorical variables. additionally, the interobserver variation between the two independent researchers were calculated. conclusion: smaller sample sizes (below ) tend to overestimate the ki- pis, possibly due to the effect of concentric counting starting from the center of the hotspot. however, the ki- pis do start to stabilise closer to (e.g. ). the interpretation of whether a lower sample size can replace the current standard would be a subjective decision, but the kappa score gives a rough idea of how much it affects the clinical grading. updated data will be presented. purpose of the study: targeting the stem cell properties of tumor-initiating cells is an avenue through which cancer treatment may be improved. before this can be achieved, so-called cancer stem cell (csc) models must be developed and characterized in specific malignancies. methods: in this study, holoclone formation assays were used to characterize stem-like molecular signatures for prostate cancer (pca) cells. summary of results: lncap and pc parent cells were capable of responding to stem cell differentiation morphogen retinoic acid (ra), suggesting the presence of inherent stemlike properties. lncap cells, which represent early, androgen-responsive disease, formed holoclones after twenty six days. pc cells, which represent advanced, metastatic, castrationresistant disease, formed holoclones after only six days. holoclones displayed decreased expression of ra-genes, suggesting a more immature, less differentiated phenotype. gene and mircorna arrays demonstrated that holoclones downregulated a number of stem cell differentiation regulators while displaying enhanced regulation of g to m transition and the mitotic spindle checkpoint components of the cell cycle. pc holoclones displayed pronounced downregulation of known regulators of osteoblast differentiation from mesenchymal stem cells and epithelial mesenchymal transition. conclusion: our results suggest that some pca cells retain the ability to transition to a more immature state in which differentiation and metastatic mechanisms are changed. the highlighting of osteoblast differentiation regulators in this mechanism is particularly notable, considering the propensity of pca to metastasize to bone. we examined by flow cytometetry the interaction in vitro between platelets and human cancer cell lines of different origin and metastatic potential. the emt profile of cells hr post platelet exposure was assessed by morphology and gene expression analysis (rt-pcr). here we showed that platelet cloaking of cancer cells is universal, occurring across all tumour types examined. however, it is heterogeneous with adhesion rates varying both across and within tumour types, from % (pc -metastatic prostate cancer) to % (skmes -metastatic lung cancer). changes indicative of emt were seen in all cell lines. however, again they were heterogeneous in nature; with morphology changes akin to emt observed at varying degrees across the cancer types. also, there was no consistent pattern to the emt-like gene expression changes seen, with one exception a significant increase in the expression of plasminogen activator inhibitor (pai- )was observed in % of the cell lines examined. in this study we describe the universal nature of platelet cloaking and that even though the interaction is not inducing precisely the same molecular changes in all the cancer cells; overall it is driving these cells into a mesenchymal phenotype. giant cell tumours of bone (gct) are primary locally aggressive bone tumours with a recurrence rate of up to ~ %. the tumour is characterised by numerous osteoclasts and neoplastic stromal cells. making a diagnosis can be challenging because the differential diagnosis incudes an array of benign osteoclast-rich tumours but also osteoclast-rich osteosarcoma. recently the occurrence of h f a p.gly try (g w) and g l mutations was reported in % of gct, the latter occurring rarely. these mutations occur in less than % of > other benign and malignant bone tumours. it has been emphasised that a diagnosis of gct should be made with caution in the absence of detection of g w substitution. given the diagnostic importance of g w mutation in gct, we have developed a simple, quick and cost-efficient diagnostic test to detect this recurrent alteration in ffpe dna using droplet digital pcr (ddpcr). the ddpcr data from dna of > gct have been compared with previous 'genotype' data generated using sanger sequencing, and a number of next generation sequencing approaches (whole exome, whole genome and targeted panels). the g w and g l can both be detected in a single assay. we have demonstrated the sensitivity, specificity, repeatability and robustness of the test to be very high with a turnaround time of no more than working days. as ~ % of gct recur locally following curettage a blood test would be valuable to monitor patients. to this end the ddpcr test also shows that the mutation can be detected in plasma. typically resistant to chemotherapy and radiotherapy, high grade disease has been treated by surgery for more than years. it has recently been shown that idh and idh mutations are present ab initio in ~ % of chondrosarcoma cases and that these are retained throughout disease progression. this has opened up a number of new potential diagnostic, biomarker and therapeutic options. digital pcr is currently the most sensitive and accurate method for detecting and quantifying mutant dna molecules. the biorad qx digital pcr platform is also both cost effective and scalable. using the qx platform, we have developed assays for the common idh mutations and the common idh mutation. we have developed the idh assays both in singleplex and multiplex. we have optimised and validated all assays in tissue samples demonstrating both high sensitivity and specificity when compared to previously genotypes samples. we have demonstrated that the assays are quantitative over orders of magnitude and in high quality dna we can detect idh mutations at below mutant molecule in , wild type molecules. in a pilot study, we have used digital pcr to analyse circulating tumour dna levels in plasma taken pre-surgery from patients whose chondrosarcoma harbour an idh mutation. it was possible to detect idh mutant molecules in plasma of all grade iii samples, % of grade ii and none of the grade i samples. in of these cases where the ctdna was also measured post-operatively, the levels of ctdna dropped dramatically. tumour necrosis factor receptor, cd , gene functions as an oncogene and promotes cell proliferation in colorectal cancer cell lines p haa almasmoum; h thorpe; m ilyas introduction: cd is a tumour necrosis factor (tnf) receptor which regulates a range of cellular responses. cd is activated by its ligand cd l and may promote tumourigenesis in haematological cancers. however, cd functions as a tumour suppressor in solid cancers. cd maps to chromosome q , a region which is amplified in - % of colorectal cancer (crc). the functional activities of cd were tested in crc cell lines for cell proliferation and motility. methods: expression of cd was screened in crc cell lines by western blot. to define the role of cd in human crc, we knocked down cd using small interfering rna (sirna) and the knockdown was confirmed by qpcr and western blot. the prestoblue assay was used to study proliferation in colorectal cell lines, and flow cytometry to study the cell cycle. transwell migration and wound healing assays were performed to investigate the effect of cd on cell motility in crc. result: cd was expressed in crc cell lines hct , rko, dld and ht , and not expressed in sw and sw cell lines. knockdown of cd reduced cellular proliferation in hct (p= . ) and dld (p= . ) cell lines. knockdown of cd showed a higher number of cells in the sub g phase (dead cells) in the cell cycle analysis compared to the control. however, knockdown of cd in hct did not have an effect on cell motility in both the transwell migration (hct = p= . ) and wound healing assays. discussion: cd exhibited oncogenic activity in crc cell lines. cd enhanced cell proliferation but not cell motility in crc cell lines. the expression of cd (common leucocyte antigen) and cytokeratin is thought to be mutually exclusive with cd expression largely restricted to haematological malignancies and cytokeratin expression largely restricted to carcinomas. we report two clinically relevant cases. the first case is a urinary bladder biopsy showing a high grade malignant tumour with cells that had scanty cytoplasm, hyperchromatic stippled nuclei and high mitotic activity. nuclear molding was present. the tumour cells showed focal strong positivity for ck and diffuse positivity for cd and synaptophysin. focal positivity for cd was present and confirmed on repeat staining. the morphology and immunoprofile was consistent with a small cell carcinoma showing aberrant cd expression. the second case is a maxillary tumour biopsy composed of medium/large atypical lymphoid cells with hyperchromatic nuclei, small nucleoli and scanty cytoplasm. mitoses and apoptotic cells were noted. immunohistochemistry showed the atypical cells to express cd , cd a, bcl and mum but not cd , cd , cd , cyclin d , cd , tdt, alk , cd , cd , neuroendocrine or melanocytic markers. a high ki proliferation fraction was present. the appearances were consistent with a diffuse large b-cell lymphoma. the above cases highlight the possibility of aberrant expression as well as loss of expression of immunohistochemical markers by neoplastic cells in undifferentiated malignancies. attention to tumour morphology may provide diagnostic clues. interpretation of immunohistochemistry in the context of tumour morphology as well as awareness of aberrant expression/loss of expression can help avoid diagnostic error. accurate, timely diagnosis is the ultimate aim in surgical pathology. numerous histological pitfalls and lesional mimics exist, with the need to maintain an awareness of such entities vital if potentially serious misdiagnoses are to be avoided. this case report describes two distinct lesions within the same lymph node, both of which are potential mimics of each other. a year old female presented with a three week history of a left breast lump. she had no known previous breast disease or any associated risk factors. a needle core biopsy of this clinically and radiologically suspicious mass yielded a diagnosis of grade invasive lobular carcinoma. left axillary sentinel node biopsy was thus undertaken. two hot and blue sentinel lymph nodes were excised. one was free of neoplasia, the second contained benign naevus cell inclusions within the capsule together with a micrometastasis. immunocytochemistry confirmed the presence of two distinct cell populations; the benign naevus inclusion cells stained positively for s but not for ae / , the reverse pattern was observed in the invasive lobular carcinoma cells. heterotrophic benign inclusions within lymph nodes are an infrequent yet well recognised entity. ridolfi et al reviewed the lymph nodes from axillary surgery patients and found . % of lymph nodes contained benign naevus cell inclusions. small benign naevus cells within the capsule of a lymph node can resemble the 'indian file' pattern of classic invasive lobular carcinoma. this case is unusual in that both metastatic carcinoma and benign naevus inclusion cells were present within the same lymph node, enabling a clear comparison of the cytomorphology and immunoprofile of these two distinct lesions. an awareness of benign inclusions within lymph nodes helps to avoid the potential for misdiagnosis. the judicious use of immunocytochemistry can be useful in distinguishing benign inclusions from carcinoma. recently there has been increasing recognition of distinct breast cancer phenotypes. of these, basal phenotype breast cancer (bbc) has attracted particular interest since the majority are triple negative (tn); have an aggressive natural history and can be associated with brca germline mutation. this area is mired in difficulty, as a precise unifying definition of bbc remains elusive. several morphological features more prevalent in bbc have been identified. in our practise we noticed variable use of 'basal' in reports. given this, whilst no specific therapies to bbc currently exist, we felt it necessary to understand how accurate our designations have been and whether this is a worthwhile practise. method: the diagnostic database was searched for all malignant tn breast resections or reports containing the word 'basal' within -months. tn was defined as allred score er - / , pr - / and her , + or + negative on fish. for completeness, we considered including all breast cancers, but pragmatically this was not possible. we carried out ck and ck staining on all cases where not performed. results: of the invasive breast cancers, cases ( %) were identified, of which % were tn and % were designated bbc in the report. % were both tn and bbc. where a diagnosis of bbc was made, % of cases had additional markers requested. preliminary results showed % were ck + and ck +. this is higher than other studies, implying specificity but not sensitivity in suspecting bbc amongst reporting pathologists. discussion: a limitation of this review is that it cannot identify the rare non-tn bbc not diagnosed as such. it also represents current practise in a single institute and may not reflect national practise. we identified patchy use of the designation bbc, with overall under-reporting of this subtype. we recommend that if it becomes necessary to distinguish bbc lesions, additional markers studies, such as ck and be consistently performed. purpose: neoadjuvant chemotherapy (nact) is increasingly used for the management of large but operable, inflammatory, and locally advanced breast cancer (labc). little is known about predictors of response/survival following nact. the topoisomerase iiα (top a ) gene, a key regulator of dna repair and modelling, is thought to be target for anthracyclin and other chemotherapeutic agents. the aim of this study is to assess the role of top a as marker for response/resistance to nact and patient outcome. methods: patients who underwent nact, predominantly anthracyclin, for primary and operable invasive carcinoma or labc in the period between to at a single large tertiary referral breast unit were identified. comprehensive data on chemotherapy regimen, surgical treatment, pathological response and survival were collected. pre-treatment tumour samples were stained for standard predictive and prognostic markers and top a. results were correlated with pathological response (pr) and patient survival. results: patients fulfilled inclusion criteria. mean age was . ys. complete pr was achieved in . %. the mean expression level of top a in pre-treatment core biopsies was . %, range - %. there was significantly higher expression in high grade tumours (p= . ) and positive correlation with ki expression (r= . , p< . ). there was no correlation with nodal status, pr or her expression. cases with high expression (> %), had significantly worse overall survival (mean vs months, p= . ). this was also identified in the endocrine non responsive group (er allred score≤ ), mean vs months, p= . . on multivariate analysis, top a was not an independent factor for overall survival. conclusions: top a protein is expressed in high grade breast carcinoma with high ki proliferation index. its expression in pre-treatment biopsies predicted patient outcome in the neoadjuvant setting. this strong adverse effect on survival warrents further prospective investigation as a marker of outcome in nact patients. the risk of circumferential resection margin (crm) involvement is confined to tumours of the rectum with the risk of peritoneal involvement increasing the further a tumour is located above the peritoneal reflection. there is no internationally accepted definition of the upper limit of the rectum, and the term 'rectosigmoid' is frequently applied to tumours in this area leading to confusion around the risks and whether radiotherapy can be given. the photographs from abdominoperineal excision specimens were available for quantitation using aperio imagescope. both fresh and fixed specimen images were included where available. the position of the anal verge, top of the sphincters, anterior peritoneal reflection, mesorectal apex (defining the limit of the mesorectum) and high vascular tie were identified and the distances between each point measured. the work was supported by a pathsoc bursary. there was wide variation in the length of the mesorectum in both fresh (median mm, iqr to mm) and fixed ( mm, to mm) specimens. the length of the anal canal also showed variation (fresh mm, to mm; fixed mm, to mm). the height of the anterior peritoneal reflection was lower in females compared to males (fresh vs. mm, p= . ; fixed vs. mm, p= . ). there is marked variability in the anatomy of the rectum between individuals and genders. this potentially affects the risk of either crm or peritoneal involvement and whether radiotherapy could be offered. a fixed definition of the upper limit of the rectum for all patients is not helpful. this should be determined for individual patients on the basis of the mri findings. the term 'rectosigmoid' should be abolished and more accurate definitions based on the position of the mesorectal apex and commencement of the sigmoid mesentery should be used to define the boundaries of the rectum and sigmoid colon and determine subsequent risks to the patient. pre-operative chemoradiotherapy (crt) with anti-egfr antibodies may change the status of egfr pathway mutations. we assessed the mutational status of a number of egfr pathway genes before and after crt in the nwcog excite trial. patients with mri-threatened surgical margins were given pelvic radiotherapy ( gy) with capecitabine, irinotecan and cetuximab followed by surgery after weeks. dna was retrospectively extracted from the pre-treatment biopsy and resection specimen by macrodissecting areas of greatest residual tumour. the mutational status of kras (codons / / / ), nras ( / / ), pik ca ( / / / ) and braf (v e hotspot) were determined by pyrosequencing. the work is presented on behalf of the nwcog excite trial investigators and was part-funded by a pathsoc fellowship. patients commenced treatment and underwent surgery with pathological complete response in ( %) and near-complete in ( %). pre-treatment testing (n= ) detected mutations in kras (n= ), braf (n= ), nras (n= ) and pik ca (n= ). any egfr pathway mutation was detected in %. following crt, cases with residual tumour able to be tested (n= ) showed mutations in patients ( %). there was a discrepancy compared to pre-treatment biopsy in cases ( %): from wild-type (wt) to mutant (mut) in , from mut to different mut in and from mut to wt in . one patient changed in codons (mut to wt in kras /pik ca and wt to mut in kras ). in patients ( %) this changed their overall egfr pathway status ( x wt to mut and x mut to wt). intratumour heterogeneity may explain some of the differences in egfr pathway mutations reported between biopsies and resections presenting a challenge to personalised medicine. however, cetuximab may also drive the growth of undetectable mutant clones to detectable levels on pyrosequencing. further assessment using more sensitive sequencing technologies is currently being employed to investigate these differences. there is a vast amount of historical ffpe material held in archives, but due to variations in fixation and processing this presents several challenges when applying newer genomic technologies to it. in this study we compared the genomic information obtained with the oncoscan® ffpe assay kit (oncoscan) and next generation sequencing (ngs). samples from patients were obtained from centres taking part in the mrc cr trial of short course radiotherapy versus selective long course chemoradiotherapy in rectal cancer. dna was prepared using agilent sureselect kits and sequenced using illumina platforms in parallel to analysis using the oncoscan assay. for both methods, quality control (qc) data was generated and the sample classified as a 'pass' if it fell within the pre-defined qc boundaries. for the oncoscan assay, copy number (cn) and somatic mutation (sm) data was further investigated. this study was part funded by a pathsoc fellowship. in total, cases ( %) passed the ngs qc and ( %) passed the oncoscan qc. a total of ( %) passed qc on both platforms with marked variability in sample pass rates between the centres for the ngs (range % to %) and oncoscan (ranges % to %). when assessed manually, the oncoscan sm data was considered acceptable for cases ( %), which included initially classified as 'failed' by the qc data. similarly, the oncoscan cnv data was interpretable for the majority of cases. this study has shown that whilst historical dna held in the ffpe blocks of archival clinical trials like mrc cr can present challenges when using new genomic technologies, a large proportion of samples can still yield valuable genomic data. marked variation exists in the quality of genomic material between centres confirming that differences in specimen handling affect dna quality. prospective trials must address this by standardising fixation and processing protocols. the plane of colon cancer resection has recently been shown to predict survival. complete mesocolic excision (cme) with central vascular ligation (cvl) produces an oncologically superior specimen and appears to be related to optimal outcomes. we aimed to assess whether a regional educational programme in cme with cvl led to an improvement in the quality of colon cancer specimens. following a regional educational programme in cme with cvl in the capital and zealand areas of denmark, cases of primary colon cancer resected across six hospitals were assessed by grading the plane of surgery and undertaking tissue morphometry. these were compared to specimens resected prior to the educational programme. this work was partly supported by a pathsoc undergraduate bursary. across the region, the mesocolic plane resection rate improved from % to % (p< . ). hillerød hospital had implemented cme with cvl as standard prior to the educational programme and continued to produce optimal specimens. three of the other hospitals showed a significant improvement in the plane of surgical resection. hillerød specimens continued to be more radical with a greater distance between the tumour and the high tie, area of mesentery and lymph node yield compared to the other five hospitals. a multidisciplinary regional educational programme in cme with cvl has improved the oncological quality of colon cancer specimens as assessed by mesocolic planes, however, there has been no significant effect on the amount of tissue resected. surgeons at hillerød continue to produce more radical specimens suggesting that such educational programmes are not alone sufficient to increase the amount of tissue resected around the tumour. hillerød have recently published their long term outcomes with survivals being % higher when compared to other hospitals across the region. further engagement is now necessary to ensure that optimal outcomes are achieved across the region. investigating the faecal microbiome in formalin fixed paraffin embedded (ffpe) material p itr jobling ; m taylor ; c young ; hm wood ; p quirke university of leeds, leeds, uk; leeds institute of cancer and pathology, leeds, uk purpose: research into the faecal microbiome has shown a diverse population with a high level of variability between individuals. altered faecal microbiomes are present in a range of diseases but work remains to understand their role in gastrointestinal disease. current research into the microbiome makes use of fresh or frozen faecal samples. this restricts researchers to predominantly prospective study designs. one potential method for rapidly increasing and diversifying research is the retrospective study of ffpe material. we aimed to investigate the feasibility of typing the microbiome in ffpe faecal samples using next generation sequencing (ngs) technology. methods: material from six faecal samples was divided and stored as frozen or fixed and paraffin embedded creating two matched sub-groups. to assess assay sensitivity one sample was diluted to eight different concentrations before fixing and embedding. the v and v regions of the s rrna gene were amplified. primer pairs created approximately bp and bp targets in e.coli respectively. pcr products were multiplexed and sequenced on an illumina miseq. qiime software was used for analysis. results: analysis of alpha (within sample) diversity showed a significant difference between sub-groups when targeting v (p= . ) but not v . analysis of beta (between sample) diversity showed a significant difference between sub-groups when targeting v (p= . ) while the v region showed a reduced, but still significant (p= . ) difference. the sensitivity assay showed comparable results down to . % concentration levels. conclusion: to our knowledge this is the first feasibility study generating ngs data on the microbiome from ffpe faecal material. variation between matched frozen and ffpe faecal material was less when targeting v compared to v . we hypothesise this may be due to the shorter amplicon undergoing less dna fragmentation in ffpe material. there are several platforms available for dna mutation detection in formalin-fixed paraffin-embedded (ffpe) material, all with their relative strengths and weaknesses. we investigated the oncoscan® ffpe assay kit (oncoscan) in comparison to pyrosequencing in patients with operable colon cancer recruited to the phase ii component of the ncri foxtrot trial of pre-operative vs. post-operative chemotherapy. ffpe samples of tumour from the resection specimens of cases were tested for kras / / and braf v e mutations using pyrosequencing. the oncoscan assay allows for the interrogation of mutations across nine genes. pre-extracted dna was analysed on the oncoscan assay and quality control (qc) scores generated, indicating confidence in mutation calling results. the mutational status of all samples was automatically assessed in the affymetrix sm viewer, and then manually confirmed. this work is presented on behalf of the foxtrot collaborative and was part funded by a pathsoc fellowship. out of samples, failed oncoscan qc thresholds, however, only of these were deemed inconclusive by manual interrogation. samples were interpretable by pyrosequencing. of the samples that produced conclusive results on both platforms, the concordance rate was very high at . % when calling a mutated versus non-mutated kras/braf status. mutations were 'missed' by pyrosequencing in only case ( . %) and by oncoscan in cases ( . %). in addition, the oncoscan assay provides mutational data in additional genes along with copy number (cn) and loss of heterozygosity (loh) information. in patients with colon cancer recruited to the ncri foxtrot trial, the oncoscan ffpe assay shows good correlation with pyrosequencing when determining the mutational status of kras/braf. although pyrosequencing has a slightly lower failure rate, the oncoscan has the added advantage of targeting more mutations, producing genome wide cn, and loh information in one assay. excellent anatomical knowledge of the rectum and surrounding structures is essential for total mesorectal excision (tme). denonvilliers' fascia (dvf) has been frequently studied, though the optimal anterior plane in tme is still disputed. the relationship of the lateral edge of dvf to the autonomic nerves is also unclear. we studied whole-mount microscopic sections of en-bloc cadaveric pelvic exenteration specimens and describe implications for tme. four human adult cadaveric specimens (two males, two females) were obtained from the leeds gift research tissue programme. paraffin-embedded mega-blocks were produced and serially sectioned at and µm intervals. sections were stained with haematoxylin & eosin, masson's trichrome and millers' elastin. additionally, a developmental series of eleven human fetal pelvic specimens (embryonic age of - weeks) were studied. dvf consisted of multiple fascial condensations of collagen and smooth muscle fibres and was indistinguishable from the anterior mesorectal fascia and the capsule of the prostate or posterior vaginal wall. the lateral edges of dvf appeared fan-shaped, and the most posterior part was continuous with the mesorectal fascia. peri-rectal fasciae were not identified in fetal specimens. dvf is adherent to and continuous with the mesorectal fascia. optimal surgical dissection during tme should be carried out anterior to dvf to ensure radical removal, particularly for anterior tumours. autonomic nerves are at risk, but can be preserved by following the mesorectal fascia along the anterolateral mesorectum. the lack of evident fasciae in fetal specimens suggests that these might be formed in later developmental stages. the perineal body (pb) is poorly understood. in abdominoperineal excision (ape), there is no natural dissection plane through the pb. knowledge of the pb is essential to avoid straying in to incorrect planes leading to tumour perforation and unnecessary urogenital and anorectal injuries. this study describes the anatomy of the pb and the implications for ape. six human adult cadaveric specimens (three males, three females) were obtained from the leeds gift research tissue programme. paraffin-embedded mega-blocks containing the pb were produced and serially sectioned at and µm intervals. sections were stained to reveal collagen and elastin, and with an antibody against α-smooth muscle actin. the pb is formed of a fibromuscular mass, which was thicker and wider in female specimens compared to males, extending from the external anal sphincter to the rectogenital septum. muscles from the urogenital diaphragm and anterior rectal wall anchored into the pb. the longitudinal muscle (lm) of the rectal muscularis propria extended in anterolateral directions and intertwined with the somatic pelvic floor muscles to create strong fixation of the anorectum. the lm plays a dominant role in the formation of the pb. surgeons should be aware of the complex course of the lm through the pb to prevent injuries to the urogenital organs and perforation of the anterior rectal wall. the perineal phase of an ape starts with excellent exposure followed by proper tension on the pb to allow safe dissection through the densely-packed fibromuscular mass. introduction: ki is a proliferation marker that is exclusively present in dividing cells and absent in resting cells. its expression has already been studied in different cancers and used to understand the cellular organisation of barrett's epithelium (lavery ). however, very little is known about the cellular organisation based on ki expression patterns in upper gi sequence. this study aims to examine the cellular organisation as defined by ki expression patterns in upper gi cancer sequence. methods: ki expression within barrett's crypts was assessed in cases (nbde , lgd , hgd ) . the barrett's crypts were divided into three equal regions: crypt base (bottom third), middle region and the surface (upper third), respectively. ki was scored using the allred system and analysed using one-way anova with bonferroni post-hoc analysis. results: one-way anova showed significant difference across the three groups (p < . ). bonferroni post-hoc analysis showed significant difference in the surface architecture between nbde and hgd (p < . ) and lgd and hgd (p < . ). for the middle region, although there was no statistical significance between the groups, nbde and lgd and lgd and hgd showed statistical trends (p = . and p = . respectively). for the basal compartment there was significant difference between nbde and lgd (p = . ). this study showed for the first time a significant difference in the ki expression between nbde, lgd and hgd in the basal and surface regions. middle compartments showed trends but additional ndbe, lgd and hgd groups need to be analysed to increase the statistical power. the results warrant further molecular analysis between the various groups and show a clear role for proliferation in the maintenance of the cellular architecture and organisation across the upper gi groups which might help in the understanding of the origin and development of oac. • frequency of serosal involvement in rectal cancers (suggested contributing factors for this include effect of pre-operative therapy, tumour regression and recent changes in surgical practice). • turnaround times: suggested contributing factors include increased departmental workload, retirements and reduced reporting capacity. the following action plan was implemented to improve compliance with standards: • ensure all pathologists are aware of results via presentation/dissemination of audit report • identify issues affecting turn-around times and improvement strategies • support recruitment to increase reporting capacity. • maintain awareness of the need to recognise serosal involvement in rectal excisions. • re-audit in year. the design and maintenance of a pilot online digital archive of archetype colorectal polyps and gastrointestinal (gi) teaching cases for the national bowl screening programme (bowelscreen) in the republic of ireland. methods: suitable internal and referral cases were identified by bowelscreen consultants at saint vincent's university hospital. these cases were subject to both internal and external review, by the mater misericordiae university hospital, and represented typical examples of lesions seen in a national bowel cancer screening programmes (e.g adenomas, ssls, adenomas with misplacement, tsas). representative slides, including immunohistochemistry, were anonymised and digitised using the hamamatsu nanozoomer digital pathology (ndp) whole slide scanner platform and associated software packages (ndp scan and view). whole slide images (wsi) were uploaded to secure cloud storage using a generic file transfer protocol program. wsi were collated into cases and accessible via the pathxl gateway (pathxl.co.uk) by approved users via an online case referral and reporting system. users were notified of pending cases via email and the viewing of wsi occurred within the user's web browser utilising an online version of ndp view program and did not require local use of propriety software. each case was referred across the two participating sites and scored in four areas; diagnosis concordance, quality of wsi, web interface and the online referral and reporting system. conclusion: with the maturation of technology involved in digital microscopy a digital archive program is now a feasible approach to the standardisation of diagnosis and a useful adjunct to traditional optical microscopy in education within the national bowel screening programme. conclusions: a committed and conscientious bms can learn how to report histopathology cases. however, if this is to be achieved, the department in which he or she works must also be committed and supportive. carcinoid tumour of the appendix: a case report p aae shalaby; p aae shalaby a case of a years male operated on for acute appendicitis and an incidental finding of a carcinoid tumour at the tip is reported. the tumour was less than cm in greatest dimension but it infiltrates through the wall of the appendix into the surrounding fat. it stains positive for the neuroendocrine markers. carcinoid tumour of the appendix is unusual, but it has to be looked for during examination of appendectomy specimens done for appendicitis ( . %). women are more frequently affected than men ( : ) and the tumour is usually small less than cm in diameter and frequently located at the tip. it is usually diagnosed incidentally after an operation for acute appendicitis and sometimes during other procedures (colectomy, cholecystectomy and others). the tumour rarely metastasis to the liver and this is usually related to the tumour diameter) and can cause a "carcinoid syndrome": flush, diarrhea bronchoconstriction, cardiac valve disease. diagnosis is made by the pathologist and staging by conventional radiologic procedures (tac, us), dosage of neuroendocrine mediators such as hours urinary -hiaa. simple appendectomy is adequate treatment for appendicular carcinoids less than cm in diameter. adequate treatment for tumours greater than cm is right hemicolectomy. the mangement of tumours to cm range is controverisal, but generally, appendectomy alone is sufficient except when meso-appendix is invaded. carcinoid tumour of the appendix has a good prognosis with a -year-survival rate, of - %. the prevalence of epithelial changes in helicobacter pylori-associated gastritis in oman: a retrospective study p aae shalaby; a al saadi there is strong association between h. pylori gastric infection and epithelial changes and progression to cancer. it has been shown that h pylori infection is strongly associated with high proliferative activity and it could be a risk of initial step of gastric carcinogenesis. the aim of this study was to examine the association between epithelial changes in the gastric mucosa and gastric h pylori infection in oman by retrospective examination of the gastric biopsies for patients presented to sultan qaboos university hospital (squh) in . a total of biopsies were studied with a prevalence of h pylori infection in % with about % showing epithelial changes, mainly intestinal metaplasia in % out of the h pylori positive cases, a few cases with low grade dysplasia and reactive atypia. in cocnlusion intestinal metaplasia was the main epithelial change that was related to h pylori infection. further studues are required to investigate the relation between h pylori infection and the progression to gastric carcinoma. purpose of the study: low rectal carcinoma may require abdomino-perineal excision of the rectum (aper), which has been associated with higher rates of tumour perforation and circumferential margin (crm) involvement than anterior resection. this increases the risk of local recurrence and may necessitate adjuvant treatment. the extralevator abdominoperineal excision of rectum (elape) in the prone position has been found to improve these outcomes and has been encouraged by the low rectal cancer national development programme (lorec). we aimed to assess the effect of increasing the practice of elape on the histological and oncological outcomes in these cases in the mid-yorkshire nhs trust, a large district general hospital. in the number of surgeons routinely performing aper was reduced and all those performing the procedure had been trained in the cylindrical resection technique. joint operating and laparoscopic procedures were encouraged. a retrospective review of case notes and histological reports between and was performed (before and after sub-specialisation). patient demographics, histological findings and complications including local recurrence were recorded. summary of results: between and , apers were performed, with tumour perforation in ( %) and crm involvement in ( %) of cases. after sub-specialisation, were performed. none were perforated and cases ( %) showed margin involvement. local recurrence occurred in two cases before specialisation and none after at the time of follow-up. joint operating and subspecialisation increased the number of cases performed by each surgeon, and the number performed laparoscopically. conclusions: elape in conjunction with departmental restructuring significantly improves immediate oncological outcomes in a dgh setting, with no effect on day mortality. the technique may reduce local recurrence, although longer follow-up would be required. background: systems biology uses computational and simulation approaches to interrogate gene expression datasets and explore biological pathways. by employing systems biology and data mining tools we can identify new biomarkers. our objective was to ascertain the utility of a novel panel of systems biology derived biomarkers in cervical pre-cancer for more accurate grading and stratification of cin disease. methods: this project is conducted within the framework of an fp funded programme "systemcerv". gene pathways were analysed using matlab and sirene. along with accessing keggs online database for gene prediction and david for gene functional classification, we identified a novel panel of biomarkers. gephi software was used to visualise communities of genes related to cervical pre-cancer and cancer progression. clinical validation was performed by immunohistochemistry on a range of cervical lletz specimens (normal, cin , cin and cin ). all patients gave written informed consent. in parallel, p ihc was performed on all specimens as a benchmark stain. the mortality associated with cervical cancer can be reduced if the disease is detected at the early stages of development or at the pre-malignant stage. the pap smear is the current screening method, but is highly subjective and can often exhibit low specificity and sensitivity. for this reason, either a replacement or supportive technique is necessary to improve the quality of cervical cancer screening. raman spectroscopy is a powerful tool that can generate a biochemical fingerprint of a sample in a rapid and non-destructive manner. in this study, raman spectroscopy has been applied to the investigation of cervical cells from preservcyt specimens. raman measurements were taken from the nuclei of cervical cells from normal, cin , and cin samples. these spectra were processed, analysed and used to define a spectral signature for each grade of cervical disease. principal component analysis (pca) was used to discriminate between the two data sets. distinct raman spectral differences were detected between normal, cin and cin cells. notably, it was possible to observe spectral peak shifts representing fluctuations in guanine (dna/rna), ch deformation in proteins and carbohydrates, carbon-carbon double bonds in phenylalanine, tyrosine and tryptophan, and amide i. the pca showed an excellent discrimination between the data sets. this study has shown that raman spectroscopy can detect subtle changes between cervical cells, and may be a powerful tool for improved diagnosis of cervical dysplasia. background: myd and mad are two potential prognostic biomarkers that have been investigated in ovarian cancer. high myd and low mad ihc staining is associated with reduced pfs, both markers are also linked to paclitaxel chemoresistance. the main objective of this study was to assess the in vitro relationship between mad and myd , through alteration of mad , myd or its receptor tlr in two ovarian cancer cell lines using sirna targeting mad , tlr or myd and a myd overexpression plasmid vector. following overexpression/sirna knockdown procedures, myd , tlr and mad expression was assessed through qpcr and western blot analysis. mir- , mir- and mir- a gene expression was also assessed by qpcr. furthermore the effect of tlr / myd knockdown on chemoresponse was assessed in skov- cells using the cck- assay. results/discussion: it was found that knockdown or overexpression of myd in skov- or a cells respectively or knockdown of tlr in skov- cells had no effect on mad expression or the expression of mir- , mir- and mir- a. interestingly however knockdown of mad in both cell lines induced a fold increase in tlr expression, furthermore knockdown of tlr in skov- cells was shown to restore chemosensitivity to paclitaxel. the results demonstrate a potential in vitro link between tlr and mad and support a role for tlr in paclitaxel chemoresistance. background: the prognosis of epithelial ovarian cancer is poor in part due to the high frequency of chemoresistance. recent evidence points to the toll-like receptor- (tlr ), and particularly its adaptor protein myd , as one potential mediator of this resistance. downregulation of mad , a key component of the spindle assembly checkpoint complex, has also been linked with paclitaxel resistance . both markers have individually been shown to be associated with poor outcome in ovarian cancer. high myd and low mad immunohistochemical staining is associated with reduced progression free survival. the main objective of this study was to assess the combined utility of mad and myd in predicting patient prognosis. methods: two tissue microarrays composed of cores from high grade serous epithelial ovarian cancers patients were constructed and stained for mad and myd . staining was scored based on previously derived scoring schemes for myd or mad staining. the mean overall score from triplicate cores was then used to classify patients into high and low staining categories. results: a trend towards reduced progression free and overall survival was observed in patients with high myd and low mad expression. the results demonstrate the combined utility of mad and myd as predictors of prognosis in ovarian cancer. purpose: ovarian cancer is characterised by high rates of terminal, chemoresistant recurrence. although chemoresistance is known to be a property of cancer stem cells (cscs), the mechanism is poorly understood. we have previously identified a novel four-member csc stem-progenitor cell hierarchy for ovarian cancer. the aim of this study was to characterise the contribution of each member of the ovarian csc hierarchy to chemoresistance. methods: the csc hierarchy was assessed for tolerance to chemotherapy drug cisplatin (mtt assay) both as components of the parent population (a cell line) and as isolated cell types. the hierarchy was additionally assessed in the long-term cisplatin-adapted 'a cis' cell line. cell types were analysed and isolated via flow cytometry and assessed for stem cell characteristic via single-cell asymmetric division and murine xenograft tumourigenicity assays, and molecularly characterised (whole transcriptome arrays). results: cisplain dose-response assays from a -derived csc sub-populations indicated that only one of the four populations within the hierarchy had a high cisplatin-tolerance (ic = um) compared to the other populations (ic = um). this was notable as the relative cisplatin ic s for the a and a cis parent cell lines are um and um respectively. treatment of the parent a cell line with the ic ( hours) resulted in a proportional % loss in each of the four cell types, suggesting that this specific csc subpopulation adapts to cisplatin over a longer period of time. conclusion: although cscs are known to be chemoresistant, the mechanism though which this is achieved is poorly understood. our data indicates that only some members of a csc hierarchy are responsible for chemoresistance. notably, this sub-population appears to possess inherent chemoresistance in pre-treatmentcells. as such, it should be possible to target these cscs in the primary malignancy to prevent chemoresistant recurrence. mixed sex cord-stromal tumours of the ovary are very rare. we report a case of mixed sex cord -stromal tumour (also referred to as gynandroblastoma) containing both sertoli-leydig cell tumour and adult granulosa cell tumour in a female years old who presented with postmenopausal bleeding. on histology, the majority of the tumour represented an unsual form of well differentiated sertoli-leydig cell tumour with a pseudoendometrioid appearance. minor foci of classic adult granulosa cell tumour were present. on immunohistochemistry, the tumour was diffusely positive for inhibin and sf and focally for calretinin, er and cd . ema, pax and ck were negative. as far as we are aware, this is the first report of an ovarian mixed sex cord-stromal tumour containing a component of pseudoendometrioid sertoli-leydig cell tumour. a year old female patient presented with bilateral painful warty lesions on the labia majora. the patient had had hiv for a long time and was on highly active antiretroviral therapy. she also suffered chronic renal failure requiring haemodialysis three times weekly. clinically, the lesions were highly suspicious of vulval cancer. the lesions increased significantly in size over a short period of time ( months) requiring surgical resection under general anaesthesia. histological examinations revealed polypoid lesions with prominent pseudoepitheliomatous hyperplasia and dense inflammatory infiltrate, composed mainly of lymphocytes and plasma cells, extending to the hypodermis. numerous abscesses with large numbers of eosinophils were present withinin the hyperplastic epithelium. the typical intranuclear inclusions of herpes simplex virus (hsv) were identified. hsv immunohistochemistry was positive. this is a rare case of vulval hsv warts mimicking cancer. oral acyclovir was administered following surgery and resulted in good control. literature review shows only previously described cases of verrucous hsv, types and , simulating neoplasia in patients with aids on antiretroviral therapy. primary mucinous eccrine adenocarcinoma of the skin is a rare adnexal neoplasm, typically involving the head and neck region in the elderly population. here we present a case of primary mucinous eccrine adenocarcinoma of the vulva; occurrence at this site is extremely rare, with only five cases published in english literature. a year old female presented with a mm vulval lesion, clinically suspected to be an inclusion cyst. the lesion was removed and sent for histopathological assessment. histological examination revealed a well circumscribed, partly encapsulated tumour composed of rounded and irregular nests of polygonal epithelial cells with scattered lumina, suspended in pools of extracellular mucin. the epithelial cell nuclei displayed a uniform chromatin pattern with small distinct nucleoli. the mucin pools stained positive for alcian blue and dpas. immunohistochemical staining demonstrated positivity for cea, ck , gcdfp, oestrogen receptor, progesterone receptor, synaptophysin and chromogranin. immunostaining was negative for ck , cdx , ca- , ttf- , ch / , ck , her- , wt- , cd and s . ki- proliferation fraction was approximately %. overall, the findings were those of a mucinous eccrine adenocarcinoma with neuroendocrine differentiation. following multidisciplinary discussion, and negative imaging of the breasts and gastrointestinal tract, a diagnosis of primary mucinous eccrine adenocarcinoma of the vulva was reached. only a handful of cases of primary mucinous eccrine adenocarcinoma of the vulva have been reported. metastatic disease, particularly from breast and colon, must be excluded. follow up data from patients with primary mucinous eccrine adenocarcinoma of the skin suggests a high local recurrence rate ( . %), necessitating close follow-up. however, risk of metastasis is low ( . %). royal shrewsbury hospital, shrewsbury, uk introduction: primary extraskeletal myxoid chondrosaroma (emc) of the vulva is a rare mesenchymal neoplasm. the myxoid tumour differential diagnosis on a core biopsy can be quite challinging. to date, few cases have been reported in the literature. case report: a -year old woman noticed a swelling on the right side of the labia, thought to be a bartholin's cyst in . she was managed conservatively. she had drainage and marsupialization under general anaesthesia. this resulted in extreme bruising of the vulva. this was managed with antibiotics and non-steroidal anti-inflammatory medication, and it resolved after weeks. six months later, the patient presented again with a persistent vulval mass. a biopsy was obtained under general anaesthesia, and it showed a myxoid tumour with differential diagnosis of low grade chondroid tumour. an mri was performed to assess the extent of the disease. the tumour was excised. at surgery, a x cm lobulated, extremely vascular vulval tumour was found. the tumour was inseparable from the inferior pubic ramus of the pelvic bone. a complete macroscopic resection was obtained. histology confirmed low grade myxoid chondrosarcoma. conculsion: vulval lesions with unusual characteristics or insidious evolution in the labia majora or bartholin's glands area should be carefully and promptly investigated. differential diagnosis of myxoid tumours in the vulva should include myxoid chondrosarcoma amongst other diagnoses. (fish) showed the presence of a bcl rearrangement in a proportion of cells. therefore this case is best regarded as a composite lymphoma of diffuse large b cell lymphoma with hairy cell leukemia rather than blastic transformation of hairy cell leukemia. to the best of our knowledge, simultaneous occurrence of diffuse large b cell lymphoma and hairy cell leukemia in a lymph node has not yet been reported in the literature. bone marrow examination by aspirate and trephine biopsy is an important haematological investigation. ideally, aspirate findings should inform examination of the trephine biopsy, but if the two modalities are separate the aspirate report can be delayed and histopathologists may assess the trephine biopsy without being aware of the aspirate findings. we audited the availability of aspirate results to the histopathologist examining trephine biopsies, over the period in which our department implemented an integrated haematopathology reporting system. the effects on diagnostic concordance, turnaround times and immunohistochemistry requesting were also assessed. the setting was a regional specialist haematopathology centre. prior to integration, a prospective audit of consecutive trephine biopsies received by a senior haematopathologist was carried out, against standards set by the international committee for standardisation in haematology. data were collected from hospital computer systems. the move to integrated reporting involved the installation of new software (hilis) to specifically handle integrated haematopathology data. ten months later, a retrospective analysis of a further cases was performed using hilis data. prior to integration, % of aspirates were reported within days, and access to the aspirate report was available at time of examination for % of trephine biopsies. after integration, % of aspirates were reported within days, and reports were available at time of examination for % of trephine biopsies. diagnostic concordance was % initially, and % after integration. the mean number of immunostains requested per case was unchanged ( . vs . ). our findings show integrated reporting has markedly increased the availability of aspirate reports to the histopathologist, and improved diagnostic concordance. this new model benefits the haematologist, histopathologist and patient. introduction: clonality studies are carried out when the diagnosis of lymphoma is particularly challenging. the detection of clonality in lymphoproliferative lesions suspicious for lymphoma can be a valuable supplementary tool as it has a high positive predictive value. clonal studies can also help to distinguish recurrent or residual disease from reactive inflammation. however false positive and negatives are common and can be attributable to several factors, including poor dna quality. methods: cases reported over a six month period (jun-nov ) were retrospectively reviewed, % of which were referral cases. we investigated various aspects of clonality studies; including dna quality, fixation method, clinical information provided and correlation between the morphological/immunophenotypical findings and clonality results using euroclonality/biomed- primers (igh, igk, tcr-Β and gamma-delta). results: ( %) had adequate dna quality, ( %) poor dna and ( %) had inadequate dna quality. external cases had better dna quality in the majority of cases. clinical information was provided in % of local cases and % of external cases. in % of cases clonality results supported the initial histological report. cases showed clonal expansion despite a benign process on histology. suspected cases lymphoma ( b-nhl and t-nhl) showed no clonality, of which yielded poor dna quality. skin cases although had good dna quality, usually had low number of neoplastic cells resulting in poor pcr products. conclusions: dna quality is very variable and clinical information is often not provided precluding adequate assessment of clonality findings. dna was worse locally (decalcified marrow trephines using formic acid and peloris system with high temperatures that can cause dna degradation). standardisation of fixation methods and interpretation of peaks/ bands in the clinical context of the patient is essential for clonality to be informative. kikuchi-fujimoto disease: a novel diagnosis by transbronchial biopsy of mediastinal lymphadenopathy p pm ellery; n archard; a ramsay ucl hospitals nhs foundation trust, london, uk objectives: kikuchi-fujimoto disease (kfd) is a rare, self-limiting form of necrotising lymphadenitis that most commonly affects young asian women, and classically presents with fever, malaise and lymphadenopathy. the cervical lymph nodes are involved in around % of cases, with other sites rarely involved. we report an unusual case in which an unexpected diagnosis of kfd was made via transbronchial biopsy of mediastinal lymph nodes. a year old boy of pakistani origin presented with a month history of lethargy, neck stiffness and weight loss, with fever (up to °c) and night sweats. chest x-ray, mantoux test, blood cultures and viral pcr were negative. lumbar puncture was normal, with no acid fast-bacilli. ct showed enlargement of the deep cervical lymph nodes (petpositive on further imaging), and mediastinal lymphadenopathy. he was transferred to our hospital for further management, with a differential diagnosis of tb, lymphoma, rare infection or autoimmune disease. he underwent transbronchial biopsy of the mediastinal lymph nodes. results: his biopsy showed blood clot and cores of lymph node, with focal collections of crescentic macrophages, admixed lymphocytes and prominent apoptotic debris. immunohistochemistry demonstrated a population of cd -positive plasmacytoid dendritic cells and granular mpo positivity in macrophage cytoplasm. the background lymphocytes were mainly cd -positive t-cells. the features were those of kfd. conclusion: involvement of deep lymph nodes is unusual in kfd, and to our knowledge, this is the first case diagnosed via transbronchial biopsy. such biopsies often produce scanty diagnostic material, and here the detection of the characteristic immunoprofile of kfd helped confirm the diagnosis. this case highlights that kfd should be considered at sites other than the cervical lymph nodes, and demonstrates the value of immunohistochemistry in reaching a definitive diagnosis. we describe a benign intravascular proliferation of atypical polytypic cd positive t cells, co-expressing follicular t helper cell lineage markers coincidental to local sepsis of the buttock. a year old female presented with a x cm buttock abscess at the site of a longstanding palpable lump. peripheral blood showed only a neutrophilic leucocytosis. immunohistological examination showed large aggregates of atypical cd positive, alk negative lymphoid cells expressing a pan t helper phenotype with cd partially downregulated. podoplanin proved that the atypical t cells were primarily, but not exclusively, localised within lymphatic channels. a t cell receptor clone was not detected using pcr. to find intravascular concentrations of atypical lymphoid cells is uncommon in skin biopsies and raises the possibility of leukaemia or intravascular lymphoma. intravascular lymphoma is a rare variant of non hodgkin lymphoma with a minority possessing t or nk cell lineage but frequently involving skin. cd is a transmembrane glycoprotein and a member of the tnf superfamily involved in regulating proliferation. it is considered a reliable marker of lymphoma. primary cutaneous cd positive tlpds encompass a spectrum of biological aggressiveness and include primary cutaneous anaplastic large-cell lymphoma and lymphomatoid papulosis (lyp). cd can also be up regulated in activated b and t cells and it has been proposed that cd positive ivtlpds are equivalent to an intravascular form of lyp. intravascular proliferations of atypical cd positive t cells have been linked with chronic inflammation and abscess formation. furthermore atypical cd positive tlpd expressing a cd positive t helper phenotype and exhibiting an indolent clinical course have been reported in the arm, trunk, neck and prepuce. ultimately ivtlpd may require follow up based upon clinical features and natural progression due to overlapping diagnostic features. p g laing; s craig; l moss; c crichton; p johnston the investigation of lymphoid neoplasia requires multiple sections, in our practice consisting of twelve antibodies and thirteen single stained slides. by selecting particular antibodies for double staining, spatial relationships between cell types and overall tissue organisation can be more easily visualised. this pilot study aimed to optimise the staining intensity and specificity to provide accurate diagnostic information, reduce slide number, material and consumables costs, preparation time in the laboratory and storage space to enhance costbenefit. twelve antibodies were chosen and paired: kappa/lambda, cd /cd , mum- /cd , cyclin d /cd , bcl- /cd and cd /pax- . firstly, these combinations were applied to normal tissue and then known tumours to optimise technique. once the staining protocols were finalised they were run on eleven consecutive cases with conventionally stained non-hodgkin lymphoma (nhl) panel requests. the slides were then reviewed by the lymphoma team for quality and diagnostic accuracy compared to the standard single stained slides. the results demonstrate that double staining is possible in the diagnosis of nhl. the combinations chosen have proved successful and have provided interpretable results; for example, the relationship of light chain staining in plasma cells, mum- and cd positive cells in diffuse large b-cell lymphoma proves positive. we feel time will be saved cutting sections to improve efficiency in lymphoma investigation and reduce panel storage space by around %. in conclusion the outcomes from this pilot study have been positive for medical and scientific staff, has shown that double staining in the diagnosis of nhl is possible and that optimising this protocol with a view to live diagnosis is worthwhile. in an age in which novel therapies are not necessarily defined by their ability to kill malignant cells, understanding the biology of malignant cells after treatment is extremely important. this is particularly true of ibrutinib (pcl- ) therapy in chronic lymphocytic leukaemia which is characterised by lymphocytosis. imagej/fiji image analysis software could therefore be used to analyse cell shape and grouping characteristics. we used a novel assay in which chronic lymphocytic leukaemia cells, cultured for days, were seeded onto fibronectin coated glass coverslips and then had their b cell receptors ligated with goat anti human igm. they were compared with cells simultaneously inhibited with ibrutinib. we tested multiple staining techniques and found that using either rose bengal or texas red phalloidin staining produced the most reproducibly analysable data when using imagej/ fiji. we demonstrated, using the assumption that the outline of interacting cells would be larger than cells which were alone that homotypic interactions were increased after b cell receptor cross linking ( groups larger than cells against group larger than cells per nm x nm field (p= . )). nuclei were also significantly larger when cross linked. (mean . (+- . ) pixels without cross linking and . (+- . ) (p=≤ . )) suggesting increased nuclear spreading. these effects were reversed by the addition of ibrutinib with groups larger than cells per the same field(p= . compared with cross linked sells) and nuclear size mean being . (p≤ . compared with cross linked cells). this study demonstrates a novel, easily reproducible assay to assess a variety of cellular responses to ibrutinib therapy and suggests a method of quantifying activity both when stimulated and inhibited. this technique could easily be scaled up to further investigate cellular behaviour following ibrutinib therapy. purpose: gliomas represent % of all solid intracranial tumours and are associated with a poor prognosis. recent studies indicated that the human cytosolic branched chain aminotransferase protein (hbcatc), which metabolises the branched chain amino acids (bcaa), was significantly upregulated in idh / wild type (wt) glioblastomas, correlated with methylation patterns in the bcat promoter and is associated with a worse prognosis compared with idh mutant gliomas. the diagnostic and prognostic significance of markers of bcaa metabolism is currently under investigation. methods: glioma tumour samples were compared for hbcatc, hbcatm and bckdc expression using western blotting and immunohistochemistry. dna was extracted from fresh frozen tissue. sanger sequencing of the p.arg region of idh and p.arg region of idh was undertaken using a dna analyser (applied bio-systems). summary: in idh wt tumours, like hbcatc (p= . ), the expression of the mitochondrial isoform (hbcatm) is significantly (p= . ) expressed relative to idh mutant gliomas. hbcatm additionally shows a more significant correlation with patient survival than hbcatc on kaplan-meier analysis. in idh wt tumours, low hbcatm expression is a positive prognostic factor (p = . ). hbcatm expression additionally correlated with who grade. although previous reports indicate that increased hbcatc occurs exclusively in idh-wt tumours, our studies demonstrate that % of idh mutant tumours express comparable levels of hbcatc. although hbcatc alone has been suggested as a putative therapeutic target, it is important to evaluate the expression of hbcatm in glioblastomas as its expression may impact the efficacy of new treatments targeting hbcatc. conclusions: idh wt high grade gliomas traditionally have a poor prognosis. however we demonstrate for the first time that relatively low hbcatm may select for a better performing clinical cohort and may be a possible candidate target for drug therapy. a year old female presented with an occipital mass, presumed to be a lymph node and underwent fine needle aspiration of the lesion. fna yielded two air dried slides, upon which a diagnosis of mesenchymal neoplasm was made. the patient underwent a subsequent incisional biopsy allowing a formal histological diagnosis of myxoinflammatory fibroblastic sarcoma to be made. myxoinflammatory fibroblastic sarcoma is a low-grade neoplasm usually occuring on the distal extremities and only rarely presents as a head and neck neoplasm. fna is a useful tool in the diagnosis and subsequent management of head and neck neoplasia and we describe here the cytological features and subsequent histological diagnosis of myxoinflammatory fibroblastic sarcoma occuring in the occipital scalp. objective: presentation of giant cell fibroblastoma (gcf). because of it has a dilemma of microscopic appearances; it is mandatory to differentiating it from atypical dermatofibroma (adf), fibrous hamartoma of infancy (fhi) and vascular lesions. methods: eighteen month-male egyptian child presented with painless slowly expanding subcutaneous back swelling at the left scapular area. results: histologically, the lesion is poorly circumscribed and range from cellular to myxoid in a dense to loose collagenous stroma. the tumours composed of mixture of spindle shaped or stellate cells admixed with multinucleated giant cells with occasional pleomorphism and very low mitotic index (< per high-power fields). these cells infiltrate around adnexal structures and through subcutaneous fat. a distinctive finding is cracking artifact of the stroma simulating angiectoid spaces. these pseudovascular spaces are lacking a true endothelial lining and lined by discontinuous layer of enlarged multinucleated giant cells. immunostains, including factor viii, cd , cd a, sma, s and cd were negative. ki labeling index is very low. all the cellular components show positive immunoreactivity for cd . conclusions: first case of gcf reported in egypt. we recommend a wide scaled study to categorize this tumour with molecularly similar lesions. the royal county sussex hospital, brighton, uk a year old man being investigated for obstructive hydronephrosis was incidentally found to have a . cm splenic mass on computed tomography (ct). no lymphadenopathy was present and the mass remained stable on sequential ct and ultrasound scans. on positron emission tomography (pet) the lesion had a low signal with moderate uptake. all haematological investigations were within normal limits including a negative epstein barr virus (ebv) test. his past medical history included previous immunosuppressive therapy for inflammatory bowel disease. a core biopsy under ct guidance was performed. the cores showed a paucicellular spindle cell lesion with bland, blunt ended nuclei, no cytological atypia and a sparse chronic inflammatory infiltrate. there was no necrosis. the spindle cells stained positive for smooth muscle actin (sma) and h-caldesmon indicating this to be a splenic leiomyoma. splenic lesions are uncommon and within their differential include, lymphoma, inflammatory pseudotumour, harmatomas and leiomyomas. ( ) a splenic leiomyoma is an unusual and rare benign smooth muscle tumour with an unknown pathogenesis. they are thought to arise from the capsule and blood vessel walls of organs. ( ) they have been documented in immunosuppressed states (constitutional or acquired), in those with ebv infection and in children with ataxia-telangiectasia. ( ) leiomyomas within the spleen are rarely reported in the literature, especially in those patients over the age of eighteen. in this case there was historical immunosuppression, however leiomyomas should be considered in the differential diagnosis of well-defined solitary splenic lesions purpose of the study: the zucker diabetic fatty (zdf) rat is extensively used as a model of diabetic kidney disease (dkd) associated with obesity and progressive insulin resistance ('diabesity'). this study aimed to validate qualitative ultrastructural parameters of glomerular injury in the zdf animal model and apply these criteria to an interventional study investigating the effects of roux-en-y gastric bypass (rygb) on dkd. methods: superficial renal cortices were immersion-fixed in . % glutaraldehyde, post-fixed in % osmium tetroxide, processed and embedded in epoxy resin prior viewing under a technai transmission electron microscope. glomerular basement membrane (gbm) thickness, podocyte foot process diameter (pfpd) and podocyte foot process frequency (pfpf) per unit length of gbm were determined for each group (sham and rygb operated zdf fa/fa diabetic animals vs non-operated non-diabetic zdf fa/+ lean controls). statistical analysis was performed using a mann whitney u test and an unpaired t-test where appropriate. summary of results: selected tem parameters (gbm thickness, pfpd and pfpf) demonstrated significant differences between specified sham-operated zdf fa/fa vs fa/+ samples, p= . . analysis of rygb interventional study samples still in progress. early post-operative glucose measurements showed a significant improvement in glucose homeostasis in the rygb group (rygb vs sham, p= . ) occurring independently of weight loss. urinary albumin:creatinine ratios were lower in the rygb group vs sham operated positive controls (p= . ) and were comparable with age-matched lean control fa/+ samples. conclusions: preliminary findings support a beneficial role for rygb in an animal model of 'diabesity'. validated ultrastructural parameters should assist in elucidating changes in podocyte activation and differentiation as mediators of the observed remission of albuminuria following rygb surgery. nottingham university hospital, nottingham, uk spitz naevus is a benign melanocytic lesion that shares many histological features with malignant melanoma. although the morphological criteria differentiating the two entities are well established however, some cases can be challenging. many isolated markers have been proposed to help in differentiating spitz naevus from melanoma, albeit none has been shown to be definitive. aim: this is a preliminary study looking at the immunohistochemical expression of markers that are known to have important role in cell cycle regulation, proliferation and melanocytic differentiation (p , ki , and hmb ). the aim is provide to a combination of proteins that can help in differentiating spitz naevus from malignant melanoma. the study included cases of spitz naevi, benign compound naevi and cases of malignant melanoma. immunohistochemical expression of p , ki , and hmb has been accessed and compared with the morphological features of these lesions. results: it is noted the mean p expression is higher in compound and spitz naevi than melanoma ( , , and respectively). proliferation activity as measured by ki index is higher in melanoma in comparison with compound and spitz naevi ( . , . , and . respectively). hmb shows only junctional positivity in out of cases of spitz naevi while in the other two it shows week dermal component. hmb is constantly positive at the deep dermal component of melanoma, albeit the staining intensity is variable. the immunoprofile of spitz naevus is different from that of a malignant melanoma. a combination of biological markers as (p , ki , and hmb ), can provide a potential tool to differentiate between the two entities. nevertheless, expanding the biomarker repertoire on a large number of cases is necessary to further establish a reliable panel to differentiate among difficult cases. direct immunofluorescence in a tertiary referral centre: an audit of local guidelines and usage p lj lumsden; l motta; r green salford royal hospital, salford, uk direct immunofluorescence (dif) forms an important and costly adjunct to conventional haematoxylin and eosin (h&e) histology in dermatopathology, particularly in bullous diseases and other immune-mediated diseases. we aim to assess the usage and diagnostic yield of dif in our dermatopathology department. requests for dif on skin biopsies received over a month period met the inclusion criteria. each individual report was assessed with regard to the indication for dif, whether dif was deemed to be indicated or not indicated on assessment of the clinical history supplied on the request card, the results of dif and whether dif was contributory to the final diagnosis. we also collected data on the usage of dif over the last years to assess changes in practice. all requests for dif were granted in line with current departmental policy. the indication categories were divided as follows: bullous , alopecia , lupus , vasculitis , dermatitis herpetiformis (dh) and 'other' . all requests for dif were deemed to be indicated in both the bullous and dh categories by our panel, but indicated requests varied from . % to % in the remaining categories. in . % ( out of ) of cases dif was deemed to be contributory to the final diagnosis. our analysis also showed that usage of dif in our department is escalating, with a . % increase in requests from to . our departmental policy with regard to dif is inclusive and operates solely on the basis of clinician request. with the increasing usage of dif, established departmental guidelines and/or a protocol for dif usage should be mutually agreed with dermatology colleagues in order to ensure effective use of this expensive test. overview of merkel cell carcinoma in an irish population p a cooper ; j thorne royal college of surgeons in ireland, dublin, ireland; beaumont hospital, dublin, ireland purpose of study: merkel cell carcinoma (mcc) is an uncommon but highly aggressive primary cutaneous malignancy of neuroendocrine cells with a propensity for regional and distal metastases. due to it's rarity, information relating to it's epidemiology in an irish population is limited, mainly owing to difficulty in gathering large patient series. our aim was to identify all cases of mcc in our institution in a defined year period and review the patient demographics compared to internationally available data. a search was carried out on the hospital laboratory system to identify all cases of mcc from / / to / / . all histology reports were reviewed and any information pertaining to patient demographics was recorded in an excel spreadsheet. a literature review was performed relating to the patient profile of mcc internationally and the results were compared. results: a total of reports pertaining to individual patients were recovered. all patients were of caucasian irish ethnicity. the incidence of mcc was higher in men ( % of cases, n= ) than women. the median age at diagnosis was years (range - ). men presented at an earlier age (median years) than women (median years). regarding the anatomic site of the tumours, % (n= ) were on the head or face, % (n= ) were on the lower limb and % (n= ) were on the upper limb. all were on sun-exposed sites. of note, the majority of tumours in the male population were on the head ( . %, n= ), while the female population showed an equal distribution between the head and the lower limbs ( %, n= for each sub-site). the subset of patients we identified show demographics consistent with published literature for us, australian and other european cohorts. merkel cell carcinoma is a disease of the elderly affecting sun-exposed sites. we note some variation in the dominant anatomic sites between genders and conclude this is due to differing environmental exposure. background: a novel cell-dispensing instrument referred to as a single cell manipulator (scm) device was developed with the following features: i) rapid optical and fluorescent detection of single cells ii) generation of picoliter sized droplets encapsulating the isolated single cell and iii) printing of the single cell in an "ink-jet" like manner onto a chosen substrate. this technology was used to isolate cells of interest from i) heterogeneous mixed populations of cells, ii) co-cultures of cells and iii) clinical patient samples for subsequent downstream biological analysis. methods: cells were injected into a reusable silicon dispenser chip that was coupled to a live cell camera for image capture and display of cells approaching the chip's exit nozzle. an optical detection mechanism determined the presence of single, fluorescent cells within the selected region of interest close to the chip exit nozzle. a sorting algorithm ensured that only droplets containing the single cells of interest were selected for printing to the prescribed location and user-chosen substrate. results: fluorescently labelled hpv caski cervical cells were spiked into a cervical liquid based cytology sample and printed onto a glass slide using the scm. undifferentiated ntera human embryonal cancer stem cells were isolated from a mixture of differentiated and undifferentiated cells based on fluorescent tagging of the cell surface receptor, stagespecific embryonal antigen (ssea ). the thyroid stimulating hormone receptor (tshr) was expressed in anaplastic v e mutated thyroid cancer cell lines that were treated with the mek inhibitor pd . treated cells were isolated using the scm. the scm pasca technology allows isolation of single cells from heterogeneous populations of cells and clinical samples for downstream analysis at a single cell level. this study aims at quantifying immunohistochemistry (ihc) stained human cell lines for protein biomarkers by manual pathologist review. staining analyses are used to calibrate tissue microarrays of tumour cores, against quantitative protein concentration allowing a systems-based data analysis. as a proof of concept, ffpe human cell line pellets (n= ) were ihc stained for smac protein and analysed using aperio image analysis software. staining quantification manually performed by pathologists provided parameters including average staining intensity, percent total cell positivity and h-score. these data were enriched by qualitative parameters pointing out possible histological artefacts. a calibration curve was plotted using h-score data and protein concentrations, previously determined by western blotting. the panel of cell lines provided a range of strong and weak/absent ihc staining using a highly specific smac antibody. the calibration curve showed a strong correlation between absolute protein concentrations and manual h-scores. expression amounts in cell lines correlate with ihc staining intensities determined by pathologist review. the linear correlation between manual h-score and absolute protein values provides an avenue to indirectly determine protein expression. further analysis will be performed on additional antigens and analysis outcomes will be then compared to digital results. this data will provide the basis for deterministic systems-biological data analysis approaches. purpose of the study: 'lean' is a management framework for maximising value and minimising waste. it originated in the automotive manufacturing industry and has been utilised successfully in non-manufacturing processes. one such application in our department was the 'leaning' of the molecular test requesting process using a smart-phone app. this study will look at the potential utility of this application within the national health service (nhs), wherein approximately twenty different molecular test request forms are currently in use. a mobile application to facilitate molecular test requesting was developed using xcode and the objective c programming language. the application was built around an email based system. patient anonymity was paramount in the design; nhs numbers are used as identifiers. the application generates a molecular test request form and can also generate a national cancer drugs fund application form for each request. administrative staff use colour coded flags to represent the progress of each email request through the workflow process to facilitate tracking. the app reduced the administrative staff workload by reducing the number of steps and paperwork involved in the molecular test requesting process. a threefold reduction in time taken by clinicians to request molecular tests was noted. a survey of staff involved with molecular test requesting revealed a % reduction in 'lost requests' after the introduction of the application. we present a 'lean' method for requesting molecular tests using a smart-phone app. this application can be used to standardise molecular test request forms within the nhs along with automatic generation of a national cancer drugs fund application form for each request. purpose of study: automated approaches for quantitative digital image analysis (dia) of tissues are becoming increasingly popular in pathology due to advances in whole slide scanning hardware and digital imaging technology. it is essential that dia is standardised to ensure accuracy and reproducibility of results. very limited published data exists on the effect of scanner hardware variations on the accuracy and reproducibility of dia results.the aim of this study was to test the following variables: variation in light source intensity during the day; presnap calibration & white balance of scanned images; variation in dia due to debris on peripheral parts of the section or coverslip edges. methods: immunohistochemistry stained sections from patient samples were scanned on the same aperio cs scanner, hourly, for consecutive days to generate scanned images of each sample, representing images in total. all scanned images were run through aperio software using a macro to quantify positive cell counts. for a subset of images, a region of interest was drawn around the tissue to exclude any debris/coverslip edges from peripheral parts of the slide in the subsequent dia. statistical analysis was performed to calculate the coefficient of variation between dia results from scans on different days. results: variation in light source intensity accounted for . % to . % variation in cell counts between repeat scans of the same slide. exclusion of debris/coverslip edges accounted for - % variation in cell counts between repeat scans of the same slide. subjective analysis revealed no significant difference in appearance of different scans of the same slide. conclusion: variation in light source intensity, presnap calibration and overall white balance, plus debris in peripheral areas of the section account for minimal variation in resultant dia results. technical advances in scanner hardware have reduced variability in scanning operations. further investigations are ongoing. the complexity of ovarian cancer resistance mechanisms: a novel, clinically relevant, in-vitro investigation p s busschots g blackshields ; bt hennessy novel carboplatin and taxol resistant cell lines were developed from upn oc cells in a clinically relevant selection strategy to better understand resistant mechanisms in oc. upn - c models carboplatin resistance and upn - t models taxol resistance. upn - calt and upn - talt were exposed to alternating treatments of both agents during development. affymetrix arrays were used to characterise gene/mirna signatures linked with the development of chemoresistance in oc cell lines upn - c and upn - t. bioconductor software, david v . and mirna-target interactions (mtis) analysis was carried out to identify de-regulated genes/mirnas, gene pathways and gene/mirna interactions involved in resistance. upn sublines developed using taxol were significantly resistant to taxol, vinblastine and olaparib (p-gp substrates), and reversible with elacridar (p-gp inhibitor) treatment. significant up-regulation abcb was seen in upn - t which was reflected at the protein level. srpx was highly up-regulated in upn - t. gli and ccl were up/down-regulated respectively in upn - c. gli had a validated interaction with mir- down-regulated in upn - c. lin b was highly deregulated in upn - c and upn - t and had a validated interaction with let- i, down-regulated in upn - c. p-gp over-expression is a dominant mechanism for taxol resistance in our cell lines. mechanisms for carboplatin resistance are more complicated. the top deregulated genes are involved in numerous pathways including apoptosis, cellular transformation, signal transduction, and cell migration cervical glandular neoplasia: the influence of excision procedure on margin status although cold knife cones (ckc) have been traditionally advocated for treatment of adenocarcinoma in situ (ais), large loop excisions of the transformation zone (lletz) are increasingly used. we analysed excisions from patients where ais was confirmed prior to procedure over years to assess the influence of excision procedure on final margin status. we tabulated whether margins were involved, close (lesional tissue less than mm from margin) or excised. results: lletzs were performed in % ( of patients), ckc excision in % ( of ). women who had lletzs were younger than those having ckc excision ( . years versus . years). positive margins were present in % ( of ) and close margins in % ( of ) lletz cases. for ckc, margins were positive in % of cases ( of ) and close in % ( of ) conclusion: although complete excision is more frequently observed when ckc is performed, compared to lletz, for the treatment of ais %) patients, discordant low-grade lymphoma was identified in the bone marrow during staging investigations. were classified as follicular lymphoma, marginal zone lymphoma, chronic lymphocytic lymphoma, lymphoplasmacytic lymphoma, non cll -like monoclonal b-cell lymphocytosis. five had an accompanying a low-grade component that could not be classified. none of the transformed high-grade lymphoma cases were ebv positive. in our cohort, we did not observe statistically significant difference in survival between the transformed and non-transformed cases. an equal proportion of cases transformed from follicular lymphoma and marginal zone lymphoma. . % of transformed patients had a previous history of another cancer, compared to . % of non-transformed cases. age, gender and a history of autoimmune disease were not associated with transformation. transformed chronic lymphocytic lymphoma an investigation into the presentation and nature of diffuse large b cell lymphoma within a large patient cohort p hr freer t cell/histoiocyte-rich large b cell lymphoma ( . %) was the next most common subtype, followed by primary dlbcl of the cns ( . %). a modified r-ipi (the patient performance score was unknown) was used to stratify the patients into four risk groups and was found to be predictive of patient outcome. the average ldh level was . iu/l, well above , the upper limit of the normal range. of the cohort of patients, . % achieved remission, . % were alive with disease at the end of the study and . % are now deceased. the majority of patients that did die did so within a year of diagnosis. in addition, bcl- negative patients were identified, with a mean age at diagnosis of . years. of these patients were female and male. the mean ldh level was some researchers included additional clinical features that were common when there was malignancy in the asymmetrical tonsils. in this study we aim to evaluate the cancer detection rate in this setting including those who possess high risk clinical features such as age (> ), pain and history of smoking. methodology: in total, consecutive tonsillectomy cases, clinically labelled as asymmetrical tonsils were analysed. out of these, cases (group ) were additionally labelled with investigation for unknown primary, obvious lesion or suspicious ulcer seen. the remaining cases with a sole clinical indication of asymmetry were stratified as group . results: in the first group, cases had a histological confirmation of tonsillar primary ( %). while, in the second group, the histological analysis showed cases with benign reactive pathology ( %) while, one case was diagnosed as malignant lymphoma ( %), cases with mild dysplasia ( %) conclusion: our results do correlate with the considerable agreement amongst otolaryngologists that the appearance of an asymmetrically enlarged tonsil in the presence of associated risk factors is considered an indication for tonsillectomy and histological examination given the significant rate of tonsillar malignancies in this group. anatomical difference in the depth of tonsillar fossa and asymmetry of the anterior tonsillar pillar may give a false impression of a clinically asymmetrical or unilateral enlarged tonsil metastatic adenoid cystic carcinoma to the lung and kidney: a single case report p rm doyle the tumour has three prognostically significant subtypes which form the basis for tumour grading; cribriform, most frequent, tubular and solid, associated with a more aggressive clinical course and metastasis. in the majority of cases ( %) the tumour has an insidious onset and patients have locally invasive disease at first presentation, which coupled with adjacent, important anatomical structures means a complete primary surgical resection is often not feasible. distant metastases are frequent and predominately involve the lung and bone with renal metastasis a rare occurrence. an optimal treatment regime for acc has yet to be established and while local management with combination surgery and adjuvant radiotherapy is currently favoured there is conflicting evidence regarding the use of radiotherapy and no formal surveillance guidance for local and regional recurrence or distant metastasis exists. we report a single case of a year old male who presented in with an asymptomatic right neck mass and underwent right radical neck dissection and adjuvant radiotherapy for acc. the patient represented in with aspiration pneumonia on a seven month history of dysphagia and dyspnea. xray and subsequent computed tomography (ct) imaging identified large, multiple right sided lung lesions, maximum cm, and a . cm left renal upper pole mass. ct guided biopsy of the right lung lesion and ultrasound guided biopsy of the renal mass were reported as metastatic adenoid cystic carcinoma regan ; cm martin ; cv timon cytokeratin (ck ) is a junctional biomarker with a seqika fragment which stabilises hpv- e transcripts. we assessed the expression pattern of ck protein in tumour specimens from patients diagnosed with oropharyngeal squamous cell carcinoma (scc) presenting at two major irish head and neck centres, within the last years. methods: archived tumour specimens together with epidemiological data were collected from patients presenting with new primary oropharyngeal scc at two main head and neck centres in ireland, within the last years. briefly, dna was extracted from tissue blocks and hpv testing carried out using spf hpv pcr immunohistochemical staining for ck [clone sp , ventana] was performed on tissue blocks following optimisation on the ventana benchmark ultra immunostainer. slides were analysed by light microscopy and scored using the h scoring system with % of these identified as hpv- subtype. ck expression was observed in the tonsillar crypt epithelium of both normal tonsils and tumour specimens. % of cases were positive for ck , with % of cases demonstrating h score of > . ck expression in the tumour cells was significantly linked to hpv status and our results suggest that the expression of ck in normal tonsillar crypt epithelial cells provides a selective advantage to hpv-related carcinogenesis at this site, possible due to the unique propensity of ck to bind and stabilise hpv- e transcripts regan ; cm martin ; cv timon methods: archived hpv-positive tumour specimens and epidemiological data were collected from patients presenting with new primary oropharyngeal scc at two head and neck centres in ireland over a one year period. briefly, dna was extracted from tissue blocks and hpv testing carried out using spf hpv pcr. the inno-lipa hpv genotyping extra test [fujirebio] was used to determine genotype. immunohistochemical staining for ck , gda, mmp- , agr- , pd- and pd-l was performed following optimisation. slides were analysed by light microscopy and scored using the h scoring system (junctional biomarkers) frozen section reporting of necrotising granuloma of the liver following percutaneous instrumentation of the biliary tree: a case series eh hadjimichael; p df fielding; mi ilyas; az zaitoun; dl lobo; pk kaye nottingham university hospital, nottingham, uk percutaneous transhepatic cholangiography (ptc) is an interventional radiological technique for both diagnostic imaging and therapeutic decompression of the proximal biliary tract in malignant distal obstruction when retrograde techniques fail. recognised complications of ptc include sepsis, haemorrhage and pneumothorax. we describe four cases where necrotising granuloma, apparently secondary to previous ptc, has resulted in frozen section examination at the time of subsequent planned cancer resection, to exclude tumour metastasis. four cases of necrotising granuloma in the liver have been identified between january and february . all cases were planned whipple's procedures for pancreatic cancer where initial intraoperative evaluation revealed solitary subcapsular liver lesions. biopsy and intraoperative frozen section examination were performed to exclude metastatic disease. all frozen sections except one were reported as showing benign necrotizing granuloma formation. the first case was initially reported as malignant and the operation was abandoned. a benign diagnosis was confirmed on paraffin sections in all four cases with the first patient undergoing successful surgical resection at a later date. to the best of our knowledge these are the first reported cases of necrotising granuloma in the liver secondary to prior instrumentation of the liver and leading to intraoperative histological assessment. we highlight this as a potential pitfall in frozen section interpretation undertaken ahead of planned potentially curative surgery which can lead to overstaging of otherwise resectable disease or to the interpretation of a potential diagnosis of tuberculosis. these risks can be reduced with greater surgical and pathological awareness of this entity. inclusion body fibromatosis, also known as infantile digital fibroma, is a benign, predominantly myofibroblastic tumour primarily found on the digits of infants. clinically, these lesions present as asymptomatic cutaneous nodules, rarely larger than cm in size, classically on the dorsal or dorsolateral aspect of the second, third and forth digits. they have a high recurrence rate, reported as between and %, although this can be reduced by undertaking complete wide local excision. we report a case of inclusion body fibromatosis in an month-old boy, presenting with an enlarging, firm lesion on his left second toe. following surgical excision, the lesion showed classical histological features of inclusion body fibromatosis -spindle cells arranged in interlacing fascicles in collagenous stroma and numerous pink intracytoplasmic inclusions. the lesion appeared incompletely excised and the patient will be kept under review on account of the high risk of recurrence.decreased expression of the mitochondrial bcat protein correlates with improved patient survival in idh wild-type gliomas me conway ; j hull ; m el hindy ; sc taylor ; f el amraoui ; c paton-thomas ; p white ; m williams ; p hr haynes ; sm hutson ; km kurian key: cord- - rvfsx p authors: nan title: ps - date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: rvfsx p nan as a base line, we retrospectively reviewed patient characteristics (time ventilated and icu mortality) of all patients ventilated > days over months. over the following months, we determined the impact of the long term care plans on patients ventilated > days. those who failed > weaning attempts from mechanical ventilation were assessed by the mdt for suitability for long term weaning plans. not all were accepted by the mdt team due to resource limitations. both groups were similar with regard to age, gender and apache ii. in the second group, patients adhered mdt weaning plans; all survived to icu discharge. the introduction of the mdt plan was associated with a significant reduction in mortality for all patients ventilated > days (p< . ), with the most significant difference seen in those patients ventilated > days (p< . ). the duration of mechanical ventilation was greater following the introduction of the long term plans. conclusion. we demonstrated the feasibility of applying a long term mdt weaning approach to patients receiving prolonged mechanical ventilation across different consultant weeks. our preliminary data suggests that this approach did not lead to harm and was in fact associated with a significant reduction in icu mortality. the increase in median time to wean requires further investigation. multidisciplinary team involvement with this difficult patient group was essential to enable a change in practice to occur and led to a culture shift within the unit. conclusion. the inclusion of plasmatic levels of transthyretin as an a additional variable improves the predictive ability of the severity scales and indicators of organ failure. . early administration of aas in the acute coronary syndrome, during the months of the study we diagnosed a total of patients with acs, all of them received aas in the first hours which results in a % compliance for this indicator. . semi-upright positioning of patients with invasive mechanical ventilation (imv), during the period of monitoring we attended patients with imv > hours, which made a total of days of imv, we complied to the indicator of semi-upright position % . prevention of tromboembolic events, in the days of monitoring we attended to a total of patients with a stay over hours and we achieved profylaxis of deep venous thrombosis in , which leads to a compliance of %. . pneumonia associated with mechanical ventilation, during the months of monitoring we recorded a total of days of imv in a total of patients and pneumonias associated with imv, which comes down to a total of per episodes. . profylaxis of gastrointestinal hemorrhage in patients with invasive mechanical ventilation, during the days of the study we attended a total of patients with imv > hours with a compliance to the indicator of %. conclusion. discussion. in our unit the indicators have a high percentage of compliance, the only divergence being the pneumonia associated with mechanical ventilation which is due to the small number of patients with imv. due to the characteristics of our unit, with the private setting and the high number of admissions of post surgical patients ( %), imv > hours constitudes a low percentage of our patients. we also have to stress the fact that there where non-labour days during the time of the study. conclusions. in our unit the indicators of quality of the critical patient have a high compliance rate. the use of imv > hours in our unit has a low occurance rate. grant acknowledgement. work group of quality indicators of the semicyuc. drug-drug interactions can cause adverse drug events (ades) and affect icu patient care. a pharmacist on rounds decreases the number of preventable order-writing ades and positively impacts patient safety, outcome and drug costs. the aim of this study is to describe the frequency of drug-drug interactions and its implications on patient outcome. from august to february our clinical pharmacist, present on daily rounds, conducted an active screening of all icu physician orders searching for drug-drug interactions (epocrates rx ® drug reference). these interactions were classified in seven different groups according to potential adverse effects: neurological, cardiovascular, gastrointestinal, renal / metabolic, pharmacokinetic, hematological and others. once an interaction was identified the icu team was warned to detect and report any possible ade and the pharmacist could make interventions judged necessary like a recommendation of an alternative therapy or dose adjustments. physicians , acceptance rate of these interventions and incidence of ades were recorded. we analyzed orders with prescribed items. there were drug-drug interactions identified ( interaction per prescribed items) and these interactions were present in orders ( %). neurological was the leading group with . % (n= ) followed by cardiovascular . % (n= ), gastrointestinal . % (n= ), renal/metabolic . % (n= ), pharmacokinetic . % (n= ), hematological . % (n= ) and others . % (n= ). a great variety of therapies was involved in these interactions. the clinical pharmacist made interventions in order to change the prescribed drug therapy and acceptance rate was %. the incidence of order-writing ades was . per patient days. there was not ades-associated mortality rate during the study period. conclusion. drug-drug interactions are frequent and involve the majority of routinely prescribed items in icu environment. neurological and cardiovascular are the most common affected systems. these interactions can adversely affect patient outcome and a clinical pharmacist integrating the multiprofessional icu team can help to identify and minimize its effects. patients with severe and persistent bleeding have high mortality rates despite standard therapy. recombinant activated factor vii (rfviia) must be considered as a pharmacological complementary treatment for critical ill patients suffering from acute bleeding (acbl). the aim of this report is to evaluate the role of rfviia in the management of severe bleeding refractory to other treatments following a regular protocol for its administration in our icu. during a one year period (february -february ) a protocol of rfviia was applied to patients who were admitted with acbl diagnosis in our icu. the protocol was developed by a commission of experts according to the recommendations of use of rfviia indicated by martinowitz et al ( ). indication: any salvageable patient suffering from massive uncontrolled bleeding that fails to respond to appropiate surgical measures and blood component therapy. preconditions: fibrinogen > mg/dl, platelets > xmm , ph > , , no hypothermia. results. patients with acbl fulfilled the criteria of the protocol. etiology of the bleeding: surgical and obstetric. the average of age was . mean apacheii was . in all cases only one dose of rfviia of mcgr/kg was given. transfusion requirements: red blood concentrates (rbc), fresh frozen plasma (ffp), cryoprecipitate (cry) and platelets (plt) decreased significantly. in addition, prothrombin time (pt) and activated partial thromboplastin time (aptt) improved. patients survived and were discharged from hospital, one patient died due to nosocomial pneumonia. there were no adverse events. before an after rfviia administration before-after pt (s) case . - . - . - . following an agreed protocol model, the use of rfviia may have an important role in achievement of an adequate hemostasis, reduces blood requirements and the adverse events in patients with acbl. intensive care units (icus) provide intensive observation and treatment for critically ill patients, but the total hospital mortality is high at . %. this is according to statistics from the intensive care national audit and research centre (icnarc) case mix programme database. most of the deaths occur in icu itself ( . %), rather than after discharge from icu ( . %). the purpose of this study was to see if the deaths in the lister hospital icu were related to the initial clinical insult or caused by a complication that developed during the icu stay. methods. this retrospective study included all patients admitted to the lister hospital icu over a -year period from april to march . for all patients who died in icu, an icu consultant classified the cause of death into the following three categories: ( ) initial reason for admission; ( ) co-morbidity -e.g. myocardial infarction that occurred after icu admission on a background of ischaemic heart disease in a patient who was admitted after having had major surgery; or ( ) complication that developed because the patient was in icu -e.g. line sepsis or ventilator-associated pneumonia. results. there were admissions to lister icu over the -year period. some were repeat admissions, leaving individual patients to study. the total hospital mortality was . %. patients ( . %) died in icu, patients ( . %) died after discharge from icu but prior to hospital discharge and patients ( . %) survived to hospital discharge.we were able to obtain medical notes for of the patients who died in icu. of these patients, patients ( . %) died due to initial reason for admission, patients ( . %) died due to co-morbidity, and patients ( . %) died due to a complication that developed because the patient was in icu. of the patients for whom we could not obtain medical notes, patients stayed in icu for day, patients stayed for days and patient stayed for days before dying in icu. the short lengths of stay for these patients suggest that they died due to initial reason for admission. our study reveals that most of the deaths in icu were related to the initial clinical insult for which they were admitted. less than a third of the deaths were related to a complication that developed during their icu stay, whether the complication was related to co-morbidity or being in the icu environment. this is surprising, as icu admissions are for patients who suffer an acute deterioration that is potentially recoverable. therefore, deaths that occur in icu should be related to complications that subsequently develop rather than the initial clinical insult. our finding that the converse is true could imply that we may be too unrealistic in our assessment of whether the acute clinical problem is potentially recoverable or not. the practise of withdrawal of treatment varies from unit to unit. if it is carried out properly it could decrease the amount of suffering the patients and the relatives undergo and it would also save valuable resources, which could be utilised more constructively. there was a relative's complaint on unnecessary prolongation of treatment and this lead to this prospective study. we proposed to study the frequency, reasons, documentation, delays and the process of withdrawal of treatment. the study was carried out at the new cross hospital, wolverhampton uk over a period of months may and june . the critical care unit has itu and hdu beds. a proforma was prepared after obtaining the suggestions from the consultants and the nursing staff working in this critical care unit. i was contacted when a decision to withdraw treatment was made. i went through the notes and the monitoring charts to fill in the details in my proforma. the patients were followed up from this point. . treatment was withdrawn on patients and there were admissions during the audit period. the commonest reason was 'unfavourable response in spite of aggressive treatment' followed by 'poor neurological condition'. out of patients suffered from multi organ failure while patients suffered irreversible neurological damage. the decision to withdraw was made by a single itu consultant in majority of the cases. withdrawal decision to death time ranged from minutes to hours. the commonest mode of withdrawal was by extubation. dnar forms were filled for patients only. quality of documentation varied from short and concise to long notes lacking relevant information. there was no documentation in one case. the documentation by the trainees was found to be sub standard. conclusion. partial withdrawal was associated with delay in death. complete withdrawal was associated with quicker death. documentation was sub optimal. inadequate information was provided when trainees did the documentation. majority of the patients suffered from multi organ failure. identification of variables correlated with predisposition p is an initial step. subsequent studies would then be needed to test the clinical efficacy of piro scoring system in the diagnosis and management of sepsis. grant acknowledgement. we acknowledge elililly for the access to the databases. we declare no financial support. to identify genetic markers of proc and proc c loci that may be associated with the susceptibility to develop sepsis, which may adversely affect the prognosis of patients. in the group of patients with severe sepsis and/or septic shock, there were statistically significant differences (p = . ) for the mean apache ii score in genotype cc of snps of proc c, without significant differences for the remaining variables (sofa h, prothrombin time, partial thromboplastin time). snp type groups or subgroups or % ci-p rs cases vs controls . . - . * . rs presence of shock . . - . . rs presence of mof . . - . . † or: odds ratio, ci: confidence interval, mof: multiple organ failure, *sasieni test, †homozygous test conclusion. genotype aa + ga vs gg of the proc gene (snps ) was found to be involved in a higher susceptibility to develop sepsis, genotype cc (snps ) to present multiple organ failure, and genotype gc to develop shock. genotype cc of proc c was related to a higher apache ii score. none of the snps studied seemed to affect the prognosis of patients. patients with sepsis, particularly those in septic shock often develop atrial fibrillation (af) ( , ). interestingly, incidence and prognostic impact of af in septic shock have scarcly been examined so far. the aim of the present study was to answer the following questions: . what is the incidence of newly diagnosed af on a surgical intensive care unit (icu)? . which percentage of patients suffering a septic shock eventually does develop af? . what is the impact of newly diagnosed af on mortality and length of icu stay in patients with septic shock? we prospectively recorded data of all patients who were newly diagnosed with af and all those with a septic shock on a surgical icu (no cardiac surgery) during a one year period according to the requirements of the local ethical committee. during the observation period patients were admitted to the icu. patients ( , %) newly developed af during their stay on the icu. patients ( , %) had a septic shock. of the patients with septic shock had chronic af. of the remaining septic patients, ( %) were newly diagnosed with af. those patients with septic shock who developed af, had a higher mortality as compared to septic patients without af ( % versus %). moreover the median length of stay in the icu of surviving patients was significantly longer in patients with newly diagnosed af as compared to those without af ( versus days). conclusion. according to our data, more than % of patients with septic shock develop af. those patients who do develop af during septic shock seem to have a considerably poorer prognosis compared to those without af. af is a clinically important complication in septic patients and might be a useful criterion in assessing the prognosis of patients with septic shock. to our knowledge this is the first study to describe the incidence and prognostic relevance of newly diagnosed af in septic shock. a. socias* , a. rodríguez salgado , l. gutiérrez , r. morales , a. villoslada , b. comas , m. borges intensive care unit, surgery department, internal medicine, emergency department, h. son llàtzer, palma de mallorca, spain our objective was to evaluate the utility of seriated lactate measurement as a part of a cpims to predict outcome in patients with sepsis. prospective study, conducted in a teaching hospital in patients with sepsis included in a cpims. it automatically produces an annotation on the medical chart and a serie of analytics forms when activated. plasmatic lactate levels were determined at the moment of activation and after and h. clinical and analitical variables, as well as severity scores were also collected. patients have been included fron january to january . statistical tests: chi-square, mann-whitney, anova, kruskal-wallis, spearman, logistic regression. roc curves were traced for all seriated lactate determinations and for lactate clearance at h [ ] . results. patients were included, ( %) had sepsis, ( , %) severe sepsis and ( , %) septic shock. eighty-five ( , %) patients deceased, of whom ( %) had sepsis, ( , %) severe sepsis and ( , %) septic shock at the moment of activation. mean lactate levels were , ( , ) mmol/l, , ( , ) mmol/l and , ( , ) mmol/l at the activation moment, at and a hour respectively. patients with septic shock had significantly higher lactate levels at every moment (p< , ). moreover those levels correlated with the number of organ failure (nof) for the first d (table ) and the sofa score for the first days (p< , ). using roc curves we established a cutoff of mmol/l for lactate levels and of % for lactate clearance. pacients with initial lactate > (p< , ), at h (p , ) or at h (p < , ) and those with a lactate clearance at h < % (p , ) had higher mortality. recently it was suggested that critically ill patients can tolerate hemoglobin levels as low as g/dl and a more "liberal" red blood cell (rbc) transfusion strategy may in fact lead to worse clinical outcomes. objective: to study the rbc transfusion practice in critically ill patients and to examine the relationship of rbc transfusion to clinical outcomes. prospective observational study of patients admitted in the icu between / / and / / . we excluded patients with active haemorrhage. data on demographics, comorbidities, length of icu stay and icu mortality were collected. . patients were enrolled. ( . %) were transfused. pre-transfusion hemoglobin was . ± . g/dl. related factors to transfusion in multivariate analysis (od (ic)): uci los . ( . - . ). mv . ( . - . ). rr ( . [ ] [ ] [ ] [ ] [ ] [ ] [ ] . chronic anemia ( - ). transfused patients had higher icu mortality ( % vs %, p < . ). however, in a multivariate analysis including saps , mv, rr and transfusion, only saps was significantly related to outcome. conclusion. our transfusional trigger was approximately gr/dl. rbc transfusion was related to chronic anemia (prior to icu admittance), the use of invasive supports and the icu los. in our group of patients, rbc transfusion was not related to icu mortality. w. huber* , m. neudeck , a. umgelter , w. reindl , m. franzen , c. lampart , m. hennig , r. schmid nd medical department, institute for medical statistics and epidemiology, klinikum rechts der isar,technical university of munich, munich, germany introduction. np still has a high mortality and the outcome is hard to predict in the individual patient. while in the last years non-surgical therapy of sterile necroses has become the standard of care, infected necroses are currently treated surgically in most centres. we here present the data of consecutive patients with np treated non-surgically regardless of the infection of the necroses. it was the aim of our study to find prognostic factors relevant for the outcome of patients with conservative therapy of np focussing on the relevance of the infection of pancreatic necrosis. methods. data analysis of consecutive patients with np proven by contrast-enhanced ct-scan admitted to a medical icu. patients were treated with with imipenem as first line antibiosis and ct-guided puncture or drainage if appropriate. surgery was restricted to complications of the puncture or fluid collections not accessible to radiological drainage (n= ). hemodynamic monitoring using picco or pac and monitoring of intra-abdominal pressure if appropriate. statistics: multiple regression analysis (backward selection); chi-square-test (comparison of survival); sas software. patients characteristics: n= ; female; male; age . +/- . years, maximum crp . +/- . mg/dl, max. apache-ii-score . +/- . , max. lipase +/- u/l; max. ldh +/- u/l. / ( %) of the patients required mechanical ventilation and / ( %) dialysis/hemofiltration. .) prognosis: the only independent risk factors at admission to the icu for an unfavourable outcome were the level of serum creatinine (p= . ) and old age (p= . ). the following parameters were not predictive: etiology of pancreatitis, blood/serum levels of lipase, calcium, glucose, leukocytes and hematocrit as well as the presence of a cullen-and/or a grey-turnersign. .) mortality: the overall mortality was / ( %). in patients puncture and drainage of the necroses was performed. the mortality of these patients ( / ; %) was not different compared to the patients without puncture/drainage ( / ; %). in / ( %) of the patients with puncture bacteria and/or fungi were cultured in the aspirates. the mortality of these patients ( / ; %) was not different compared to the patients with sterile necrosis ( / ; %). conclusion. .) the overall mortality of % was low with regard to the severity of np. .) infection of the necroses had no impact on the outcome. therefore, the presence of infected necrosis is no contraindication to conservative management of np. .) the most important predictors for the outcome were serum creatinine levels and old age. x. schmit*, j. vincent intensive care, erasme university hospital, brussels, belgium sepsis remains an increasingly common killer. although there are a lot of studies about sepsis, it is a clinical syndrome and uncertainties will remain in its clinical course. the patient populations are very heterogeneous. some patients will respond well to initial empirical antibiotic therapy while others do not improve and need an adaptation or even a procedure in order to contol the infection. our study addresses for the first time the value of a dynamic evaluation of blood crp concentrations in an icu heterogeneous population of septic patients. clinical an other biological variables were also studied. in critically ill patients with sepsis, enrolled in a prospective observational multicenter study, crp levels and standard clinical and biological variables were measured daily from the day of identification of sepsis until death, transfer to the regular floor, or the th day, whatever came first. patients were divided into three groups according to their clinical course: group -patients with a favourable response to the initial antibiotic therapy; group patients who required a change in antibiotic therapy (shift to or addition of another antibiotic class); group -patients who needed surgery or drainage to control the infection. the studied population, from two large institutions was similar to those found in most of the icu's, with a median age of years, a majority of male patients and the lungs as the most common infectious site, and about % of positive cultures. we found that an increase in crp of at least . mg/dl in the first hours was associated with an inadequate response to therapy with a sensitivity of % and a specificity of %. crp concentrations decreased more rapidly and more significantly in group than in group (p= . ). there is quite a significant variability in baseline crp levels but we show that the time course during therapy is meaningful. in contrast, no correlation was found between crp levels and any of the clinical or other biological studied variables. these variables may also vary in numerous other situations than sepsis. conclusion. changes in crp over the first hours of therapy can help to evaluate the response to therapy in septic patients. the daily dosage of crp is easily accessible, inexpensive to perform, and offers much information, aiding in the clinical course of sepsis and early adequate therapeutic attitudes. is it not our rescuer? in septic patients scoring systems such as acute physiology and chronic health evaluation ii (apache ii) as well as sequential organ failure assessment (sofa) on admission and during treatment quantify the disease severity and therefore stratify the risk of adverse outcome. predictive roles of certain in-hospital parameters such as hypoalbuminemia, increased serum creatinine, c-reactive protein (crp), lactate and serum blood glucose were studied in some prospective clinical studies, however, their independent predictive roles of outcome in septic patients remain uncertain. our aim was to evaluate the predictive role of admission apache ii, admission and total maximum sofa score, hypoalbuminemia, increased serum creatinine, c-reactive protein, lactate, and serum blood glucose for the -day mortality of septic patients admitted to medical icu. included were all consecutive patients admitted to our medical icu in with criteria for sepsis according to sccm/esicm/accp/ats/sis international sepsis definitions conference. the data were collected retrospectively and the predictive roles of variables were tested by univariate and multivariate regressional statistical method. in patients (mean age . +/- . years, . % men) mean admission apache ii was . +/- . , mean admission sofa score . +/- . and total maximum sofa score . +/- . . -day mortality was present in %. we observed significant differences between nonsurvivors and survivors in mean apache ii ( . +/- . versus . +/- . , p = . ), peak blood glucose ( +/- . mmol/l vs . +/- . mmol/l, p = . ) peak serum lactate ( . +/- . mmol/l vs . +/- . mmol/l, p < . ), minimum serum albumin ( . +/- . g/l vs . +/- . g/l, p < . ), peak serum creatinine ( . +/- . micromol/l vs . +/- . micromol/l, p < . ), admission sofa score ( . +/- . vs . +/- . , p < . ) and total maximum sofa score ( . +/- vs . +/- . , p < . ). according to regressional statistical analysis, minimal serum albumin level was the most significant independent predictor of the -day mortality of septic patients in medical icu (or . , hi-square . , p = . , % ci . to . ). serum hypoalbuminemia was the most significant independent predictor of the -day mortality in septic patients. conclusion. the early decrease in mhla-dr expression is related with mortality, but after the severity adjustment, it does not predict outcome globally or in septic subgroups. a flat trend curve of mhla-dr expression is associated with a high risk of ni, which increases the icu length of stay. reference(s). ( )v caille, shock ;( )monneret g icm grant acknowledgement. university paris (ea ), all investigators introduction. intravenous fluid therapy is a cornerstone in the management of severe sepsis and septic shock but the effects of rapid boluses of either crystalloids or colloids on septic-induced microcirculatory alterations are not well defined. we hypothesized that fluid administration may improve the microcirculation in the early phase of severe sepsis and septic shock. we used a sidestream dark-field (sdf) imaging device (microvision medical, amsterdam, the netherlands) to evaluate the sublingual microcirculation in patients with severe sepsis or septic shock during the first hours of resuscitation, in whom fluid challenge was indicated to improve tissue perfusion. hemodynamic and microcirculatory measurements were obtained before and after a fluid challenge with either ml of a % albumin solution or ml of crystalloid over min. at each assessment, sequences of seconds each were recorded and stored under a random number. an investigator blinded to the patient's clinical course and sequence order, analyzed the images semi-quantitatively. the vessels were separated into large and small using a cut-off value of µm in diameter and two microcirculatory variables were evaluated: percentage of perfused vessels and percentage of perfused small vessels. a student t-test was used and data are presented as mean ± sd. a p< . was considered as significant. while arterial pressure and vasopressor use remained unchanged, microcirculatory perfusion increased and lactate levels decreased during fluid challenge (table ) . before after p mean art p, mmhg , ± , , ± , , card outp, l/min (n) , ± , ( ) , ± , ( ) , scvo , % , ± , , ± , , lactate, mmol/l , ± , , ± , , % total perfus vessel , ± , , ± , < , % small perfus vessel , ± , , ± , < , these results suggest that fluid resuscitation can improve the sublingual microcirculation in the early phase of severe sepsis. sdf monitoring may become a new tool to guide fluid therapy in critically ill patients. the study was held in a bed multidisciplinary icu of a tertiary hospital. twenty four norepinephrine dependent (> . γ/kg/min) patients, fulfilling the criteria of septic shock, were enrolled in the study. patients were divided in groups according to the continuous administration of mg hydrocortisone for > days (group a: pts) or conventional treatment (group b: pts). end points of the study were, the within days vasopressors weaning, evolution of mods and -day as well as -day survival. mods was described by sofa score. statistics : statistical analysis was computed by using paired t-test and linear regression analysis. groups were similar regarding demographics ( + vs + y), initial sofa score ( + vs , + ), initial norepinephrine dose ( . + . vs . + . γ/kg/min) and mean elapsed time from the onset of shock ( . + . vs . + . days). an early and significant decrease in norepinephrine dose (p< . ), was observed in all group a pts, while no difference was detected in group b pts. this decrease was associated with hemodynamic stability. on days and mean abp was significantly higher in group a pts (p< . , p< . ). weaning from vasopressors within days was achieved in pts in group a ( . %) and pts in group b ( . %). seven day mortality was . % in group a vs % in group b while -day mortality was % and % respectively. in the treatment group a positive correlation between the within days shock reversal and survival (cor coeff = . , r = . , p= . ) was found. there was no relation between the time elapsed from the onset of shock to the steroid administration and survival (p= . ). oxygenation parameters (fio /po ), sofa score and creatinine did not differ between groups. wbc in group a pts were significantly higher (p< . ) only on day . no significant adverse effects were detected. in late septic shock patients with mods the administration of low doses of hydrocortisone is associated with decreased vasopressors requirements, hemodynamic improvement and beneficial effect on survival. the within days shock reversal was a good predictor of survival. prolonged sepsis is associated with the development of immunoparesis, a down-regulation of the immune system, the degree of which is associated with a poor outcome. little is known about its evolution during the septic process (including the recovery phase), particularly in terms of functionality of the different leukocyte populations. below are preliminary data from an ongoing study. after appropriate consent was obtained, ml blood samples were drawn from previously healthy patients with septic shock (n= ). associated demographic and clinical data (eg sofa score, steroid use etc) were also collected plus icu and hospital outcomes. samples from healthy volunteers acted as controls (n= ). total and differential counts were performed by coulter counter. flow cytometry was used to assess viability (dual staining annexin v/ propidium iodide to determine apoptosis and necrosis), and characterization of populations (surface molecule expression of characterising lymphocytes, monocytes, and neutrophils). functional assays were performed on the phagocyte cell population using phagotest (phagocytic activity assessed as % ingestion of opsonized fitc-labeled bacteria) and phagoburst (measure of oxidative burst activity in response to opsonized e coli, pma and the chemotactic peptide fmlp expressed as % positive cells vs non-stimulated controls, and the increase in median fluorescence intensity [mfi]) (kits from orpegen pharma). compared to controls, septic shock samples taken on icu day showed a wide range of functional responses with some having a reduced number of functionally phagocytic phagocytes while others retained their phagocytic capacity. changes in phagocytic capacity were not related to the respiratory burst. respiratory burst was generally suppressed in septic patients. the viability of the phagocytic population ranged between - % in all septic patients. the proportion of neutrophils of total leukocytes remained constant ( - %) whereas the monocyte population was more variable ( - %) . conclusion. phagocytic populations of septic patients differ from healthy controls. variable effects were seen in phagocytic activity and/or respiratory burst in different septic shock patients on day of admission. this may possibly relate to previous priming or to as yet unexplained immunoparetic mechanisms. further work will assess the evolution of leukocyte number and functionality, and any relationship to outcome. it has been established that raised procalcitonin (pct) levels > ng/ml in critical care patients are associated with an elevation of infection-related mortality risk . we have performed a study to assess the effect of drotrecogin alfa (activated)(daa) on outcome in patients with severe sepsis and very high procalcitonin levels > ng/ml. we examined the outcome data for consecutive patients with severe sepsis and two or more organ failures who had procalcitonin levels greater than ng/ml at the time of critical care admission. pct was measured using the brahms pct-q immunochromatographic test. patients were divided into groups depending on whether or not they received drotrecogin alfa (activated). for all patients we recorded age, sex, apache ii score, and outcome at days. risk of death and standardised mortality ratio (smr) were then calculated. between july and november a total of patients with severe sepsis and multiple organ failure had pct > ng/ml. fourty-seven were not given daa because of or more contraindication or because their prognosis was so poor. the results are shown in the table. the smr was lower in the group not given daa. in patients with very high pct > ng/ml there was no reduction in mortality associated with the administration of daa. it is known that mortality increases with elevated pct > ng/ml and there may be a point at which the physiological derangement is so severe that daa is less effective. given that this drug is expensive and has significant side effects it would be prudent to avoid its use under such circumstances. pct may be useful in selecting patients for this treatment if our results are repeated in a larger study. since adrenergic stress and catecholamine-induced myocardial stunning may contribute to the pathogenesis of septic cardiomyopathy we evaluated the effects of beta blockers in patients with septic cardiomyopathy and shock. twenty patients with septic shock requiring milrinone therapy who were treated with enteral metoprolol after stabilization of cardiovascular function and within hours after onset of shock were included into the retrospective study protocol. hemodynamic, laboratory and clnical data documentation was performed immediately before, , , , , , and hours after the first metoprolol dosage. the incidence of the following adverse events was evaluated during metoprolol therapy: symptomatic or asymptomatic bradycardia, decrease in mean arterial blood pressure, cardiac or stroke volume index, central venous oxygen saturation, and hypoglycemia. descriptive methods and a linear mixed effects model was used for statistical analysis. metoprolol therapy was started after cardiovascular function had been stabilized ( . ± . hrs after onset of shock) and was targeted to reduce heart rate to - bpm. hemodynamic data and laboratory parameters were documented immediately before, , , , , , and hours after the first metoprolol dosage. a linear mixed effects model was used for statistical analysis. heart rate (p< . ), central venous pressure (p= . ), norepinephrine (p< . ) and milrinone dosages (p= . ) significantly decreased during beta blocker therapy. cardiac, stroke volume and cardiac power index remained unchanged. metoprolol was discontinued in two patients because of asymptomatic bradycardia. norepinephrine and milrinone dosages had to be increased in seven and four patients, respectively. in none of the four patients with a decrease in cardiac index a decrease in central venous oxygen saturation occurred. arterial lactate levels (p< . ) and c-reactive protein serum concentrations (p= . ) decreased during the observation period. enteral metoprolol therapy in combination with phosphodiesterase inhibitors seems to be safe and may be beneficial in patients with septic cardiomyopathy and shock. further studies on the use of beta blockers for septic cardiomyopathy are warranted. septic shock represents the leading cause of mortality in critically ill patients worldwide. the cornerstone of therapy continues to be early recognition and prompt initiation of antibiotic plus hemodynamic support measures. continuous renal replacement therapies (crrt) seem to play an important role in the early management of septic patients with acute renal failure, based on classical depuration properties and mediator clearance capacity. different crrt include: -convection techniques as high-volume hemofiltration (hvhf). -adsorption techniques as coupled plasma filtration adsorption (cpfa); introduced in recent years,it's a technique that separates plasma from the blood by means of a plasma filter. the plasma is then passed through a synthetic resin cartridge and returned to the blood. a second blood filter is used to remove excess fluid and small molecular weight toxins. the aim of this prospective and not randomized study was to analyze and compare the hemodynamic effects of both techniques(hvhf and cpfa). we studied twelve patients (n= ) with septic shock and acute renal failure. we initiated either of the two crrt when patients fullfilled renal depuration criteria. we analyzed the clinical effects by measuring main hemodynamic parameters and vasoactive drugs requirements during the first twelve hours. we started cpfa in four patients (mean age was years, % were male, and mean apache ii was ), and hvhf in eight patients (mean age was years, % were male, and mean apache ii was ). in table we represent the variation percentages in main hemodynamic parameters and norepinephrine requirements after the first twelve hours of crrt. no adverse effects due to crrt were registered. (up to %) . the aim of this study was to analyze the clinical presentation and to evaluate mortality associated factors (timing and accurancy of diagnosis, timing of surgery, severity score and organ failure, surgical and medical treatments). this study retrospectively investigated the medical records of patients (pts) diagnosed and treated for nf who were admitted to a -bed general icu from to . the pt characteristics are shown in table . the mean delay from onset of symptoms and hospital admission was . ± days. the provisional clinical diagnosis was incorrect in % pts. eighty % of pts was admitted with clinical signs of septic shock (ss). the mean time from diagnosis until surgery was ± , hrs. all pts underwent a mean of ± , surgical procedures related to necrotic tissue debridement. the wounds were sealed with a vacuum-assisted closure device which was exchanged every days until second intention healing. only pt required above-knee amputation. after surgery % of pts were submitted to hyperbaric oxygen therapy (n= - /pt). all pts received broad-spectrum antibiotics therapy which was changed according to the results of culture and sensitivity. mechanical ventilation was performed in all pts for respiratory failure (mean time= , ± days). two pts required surgical tracheostomy at admission for airways obstruction due to nf. all pts were in ss requiring vasopressor therapy for , ± days. thirty % of pts showed renal dysfunction (rifle class injury) and % were treated with high volume hemofiltration for anuric renal failure. disseminated intravascular coagulation was diagnosed in % of pts. low dose steroids were prescribed in % of pts and pts were treated with apc. the average lenght of icu and hospital stay were respectively of , ± and , ± days. overall mortality in our series was %. two pts died of severe ss and mof. in one case hyperkaliemia of unknown origin (after ss resolution) was fatal. sepsis is a common source of morbidity and mortality among critically ill patients. targeting measures to reduce the incidence and promote early recognition and treatment of sepsis is at the forefront of many critical care initiatives. advances in the management of severe sepsis have evolved over recent years in an attempt to combat the spiraling mortality trends. the "surviving sepsis campaign" (ssc) is a worldwide initiative promoting the evidence-based treatment of sepsis, with the explicit goal of reducing both the morbidity and mortality associated with sepsis. protocol watch (pw) was developed as a tool to assist clinicians at the bedside with the implementation and compliance of the ssc guidelines. participants were critically ill patients in -bed intensive care unit in a large university-affiliated teaching hospital in the northwestern united states. prior to the installation of pw, implementation of the ssc was done using a paper-based system of standing orders. base line data on compliance with the ssc guidelines were collected. protocol watch, which offers an electronic version of the guidelines and is resident on the bedside patient monitor, was then installed in all critical care beds. the post pw installation data collection is currently being completed. preliminary results show a significant improvement in both the early identification of sepsis as well as compliance with the ssc guidelines. in addition, the feedback from the clinical users has been extremely positive. if the final data analysis supports the preliminary findings, pw could emerge as an important method for assisting in the implementation of the ssc guidelines, thus making a valuable contribution in the care of critically ill patients with sepsis. hyperglycemia during acute brain injury such as ischemic stroke, cerebral hemorrhage, or head trauma is frequent and is associated with increased morbidity and mortality [ ] . there is also a profound increase in glucose utilization (hyperglycolysis) that can persist for up to one week after traumatic brain injury (tbi). however, little is known about the optimal glycolytic rate and about the influence of intensive insulin therapy on the tbi-induced changes in glucose metabolism [ ] . this study was designed to estimate the safety of routine versus intensive insulin therapy on the basis of hypoglycemic episodes defined as blood glucose concentration < . mmol/l (< mg/dl), in patients admitted to intensive care unit (icu) after severe tbi. in this prospective, single-blind, randomized clinical trial patients admitted after severe tbi, were enrolled and randomly assigned to one of two groups on the basis of the targeted levels of glycemia. insulin infusion was administered either at conventional rates, to maintain glycemia at . - . mmol/l ( - mg/dl), or intensive rates, to maintain glycemia at . - . mmol/l ( - mg/dl). hypoglycemic episodes, duration of icu stay, infections rate, mortality and neurologic outcome measured using the glasgow outcome scale (gos) at months follow-up, were recorded. in patients receiving intensive insulin therapy, hypoglycemic episodes were significantly higher ( . % vs . %, p< . ), duration of icu stay shorter ( . vs . days; p< . ), and infections rate lower ( . % vs. . %, p< . ) than in patients treated with conventional insulin therapy. mean gos and overall mortality at months were similar in the two groups ( . % vs. . %). intensive insulin therapy significantly increased the risk of hypoglycemic episodes. despite the shorter icu stay and lower infection rates, no differences were observed at months follow-up mortality and neurologic outcome. therefore, in tbi patients receiving intensive insulin infusion, whether to avoid episodes of hypoglycemia either with a stricter blood glucose monitoring or with a wider target blood glucose level needs further investigation. severe head injuries are a frequently encountered problem in intensive care medicine, and a cause of significant mortality and long term morbidity. various clinical features related to the initial trauma and secondary brain injuries are associated with adverse outcomes. [ ] we developed a head injury database, and investigated the management and outcome of head injured patients in our department, with particular emphasis on ventilation and haemodynamics in the pre-hospital and resuscitation phases. in this observational cohort study we collected data on head injured patients admitted to the icu at the royal london hospital (rlh) between march and november . demographic, clinical and outcome data was extracted from the patient notes and the icnarc database and then entered in a data collection proforma and subsequently in a ms excel spreadsheet for analysis. outcome measures were primarily mortality, and for survivors, the length of stay both in intensive care and in hospital were recorded. data was collected on head injured patients. the group of patients that died tended to be older, to have a lower gcs at the scene, a higher systolic blood pressure both at the scene and in the emergency department, and a lower pao in the emergency department although these results were still in the physiological range for the majority of patients. of the patients that had abg results recorded, only % had an initial paco < . in the emergency department. the lowest mortality ( . %) was associated with an initial a&e paco in the range . - . kpa. the mortality rate for patients brought directly to rlh was . % compared with . % for patients transported from other hospitals. ( , ) . we evaluated the association between bnp and the presence of sah, intracranial hypertension, hyponatremia, csws as well as water and salts balance in patients with severe traumatic brain injury (tbi). we examined patients with severe tbi coming from emergency ward. serum bnp was measured five times: t ( ˚- ˚day), t ( ˚- ˚day), t ( ˚- ˚day), t ( ˚- ˚day), t ( ˚- ˚day). daily and cumulative balance of water, sodium and potassium were calculated for all the patients. the presence of hyponatremic events, csws, intracranial hypertension episodes, sah (tc evidence) and the use of cathecolamines were notified, as well. seventeen male patients were included in the study (with a total of days of monitoring in icu and samplings of bnp). no association between bnp and the other observed variables (hyponatremia, csws, sah, the use of cathecolamines and intracranial hypertension) was observed. on the other hand, positive correlations between bnp levels and cumulative sodium balance (r= , ; p< , ) as well as between bnp and water balance (r= , ; p< , ) were observed. bnp level was higher in patients with positive cumulative sodium balance than in patients with negative balance: mean (sd) , ( ) pg/ml vs ( ) pg/ml (p= , ), respectively. bnp levels were also higher in patients with positive cumulative water balance: mean (sd) , ( , ) vs , ( , ) pg/ml (p= , ), respectively. our study does not confirm the role of bnp in the genesis of hyponatremia and csws. moreover, observing higher bnp levels in patients with positive sodium and water balance, we conclude that bnp in patients with severe tbi has a physiological role in the regulation of water and salts balance in order to avoid the excessive expansion of extracellular compartment. brain tissue oxygen monitoring plays important role in prevention of secondary brain injury. values of partial brain oxygen pressure (pbto ) in first hours after severe brain trauma should predict final patient's outcome. aim of this study is to analyze relationship between early values of brain oxygen in severe head trauma and the patient's outcome one year after this traumatic accident. study follows up our previous observation. we analyzed data of consecutive adult patients treated in our icu during time period of month for severe head trauma with glasgow coma scale (gcs) and less and with monitoring of intracranial pressure (icp) and partial brain oxygen pressure (pbto ). we placed sensor for pbto monitoring at the same time as icp sensor. all patients were treated according standard therapeutical protocol used in our department. target of our treatment was to avoid icp hypertension, to maintain cerebral perfussion pressure above mmhg and to reach optimal pbto levels. we compared data of first hours of the treatment in icu with neurological status using glasgow outcome scale (gos) in time intervals , and months after trauma in all patients. all this studied patients were already not at these times treated in our hospital. group with gos at the time of leaving icu had patients and initial values of pbto in first hours of treatment , mmhg (mean). group with gos had patients and initial valus of pbto , mmhg (mean). from this group patients died a one improved to gos . group with gos had patients, initial values of pbto , mmhg. from this group patients improved to gos and patients to gos , both in months. there were no changes in neurological status between and month after injury. group with gos had no patients. group with gos had patients and initial values of pbto , mmhg at a time of leaving icu. conclusion. there were found in our study no clear relationship between initial values of brain tissue oxygen and long term outcome. patients in vegetative state at a time of leaving of icu had in our group bad prognosis. all patient with severe dissability improved. values of brain tissue oxygen were in this group below mmhg. group with gos had values also relative low. we have no database of patients treated without brain tissue oxygen monitoring to make direct comparation and to evaluate real benefit of brain tissue oxygen monitoring. can protein s predict neurological deterioration after moderate or minor traumatic brain injury? p. bouzat* , p. jaffres , p. declety , j. brun , g. francony , j. c. renversez , a. kaddour , c. jacquot , j. f. payen department of anaesthesiology and critical care medicine, department of biochemistry, department of emergency medicine, albert michallon hospital, grenoble, france serum protein s "eta (ps ) is believed to reflect brain damage following traumatic brain injury (tbi). since patients with moderate tbi (glasgow coma scale, gcs, score - ) or minor tbi (gcs - ) may be at risk for subsequent neurological deterioration, we wondered whether the determination of serum ps on admission could be associated with the neurological outcome. methods. patients with moderate or minor tbi were prospectively studied. they had normal or moderate ct scan (trauma coma data bank, tcdb, classification i or ii, respectively) on admission. serum ps dosages were performed on admission within hours post-injury using a commercially available kit (elecsys s roche, detection limit . mathrmµg/l). neurological outcome was assessed up to days after trauma. secondary neurological deterioration was defined as a decrease in gcs score of points or more from the initial gsc score, or any treatment for neurological deterioration. two groups of patients were defined : group (absence of secondary neurological deterioration) and group (presence of neurological deterioration). data are expressed as median and range. univariate analysis (non parametric mann-whitney test, chi test) was used to identify factors related to the neurological outcome. . patients had a secondary neurological deterioration days after trauma (group ). they had significant higher gcs score and more injuries on ct than group . however, serum ps were not different between the groups (table) . ( - ) serum ps (µ µ µg/l) . ( . - . ) . ( . - . ) tcdb classification i/ii (n) / / ** gcs score on admission ( - ) ( - )** **p< . conclusion. serum ps cannot be viewed as a biological marker for detecting patients at risk for neurological deterioration after minor or moderate tbi. the contribution of this blood sampling is not as informative as a ct scan or the gcs. methods. seventy patients with traumatic brain injury (tbi) and stroke with glasgow coma scale (gsc) < were evaluated. thirty-degree head-up position was used during the study. icp was monitored during the following procedures: chest compression, vibration associated to chest compression, unilateral continuous chest compression, tracheal suction with open circuit and closed circuit, passive mobilization of arms and legs, hip rotation, scapular mobilization in lateral decubitus and lateral flexion of the lower trunk. wilcoxon test was used to evaluate changes on icp during the procedures. algorithm of intracranial hypertension (ich) therapy in patients with tbi should be modified on the base of the level of cerebral autoregulation (ca) impairment. the aim of the study was the application of the pressure reactivity index (prx) monitoring in the treatment of tbi patients. tbi patients with gcs< underwent the monitoring of the arterial blood pressure (abp), icp, prx. analog outputs from the monitors abp and icp were connected to the analog-to-digital converter (dt , data translation) installed into a laptop computer. data were sampled, digitized, and stored on the hard disk with the software for the waveform recording. digital signals were processed with software (icm plus, england). the therapeutic strategy modified on the base of results clinical evaluation and prx, abp and icp. all the patients were divided into two groups. patients had preserved ca with prx [- ; , ], gcs , +/- , ; icp , +/- ;cpp , +/- mmhg. in patients gos was favorable ( -with good recovery; -moderate disability) and unfavorable in patients ( -severe disability; -vegetative state). in this group we used iv infusion of colloids and vasopressors for cpp-protocol. in patients were determined "optimal" levels of cpp: in it was - mmhg, in - - mmhg, and in - - mmhg. in patients developed ca failure on the day after brain trauma and uncontrolled intracranial hypertension demanded decompressive craniotomy. second group included patients with impaired ca -prx [ , ;+ ], gcs , icp , +/- , , cpp , +/- mmhg. gos: both patient had unfavorable outcome (one-severe disability, other-vegetative state). conclusion. the monitoring of prx added to routine measuring of the abp and icp in tbi patients is helpful in choice of the best therapeutic strategy. grant acknowledgement. we thank dr. marek czosnyka and peter smielevski for their scientific support. a. raigal*, g. hernandez, l. marina intensive care unit, hospital virgen de la salud, toledo, spain severe traumatic brain injury (tbi) defined with a glasgow coma score (gcs) ≤ with normal or near normal craneal ct at hospital admission (type i-ii traumatic coma data bank classification) represents a common clinical dilemma about the real severity of cerebral lesions and neurological prognosis. the aim of the study was to relate some clinical factors with a higher probability of developing neurological complications (intracraneal hypertension) and bad neurological function on icu discharge defined as the presence of a motor component of gcs≤ . retrospective series of patients consecutively admitted for severe tbi in the general -bed icu of a tertiary trauma center during one year. we study patients with craneal ct admission classified as tcdb i-ii, after excluding those with another non traumatic cause of the coma and encephalic death on admission. after the admission ct the radiologic study was repeated in the first hours posterior to the trauma. icp was monitorised in all patients with tcdb> in the second ct or type i and confirmed gcs ≤ after transitory withdrawal of any sedative agent. the radiologic study was repeated after hours, on the th day and if the clinical evolution or icp required it. epidemiological, clinical and radiologic associated variables were also analysed and the gcs at icu discharge. a multivariant study was done adjusted by age, genre, initial gcs, radiologic lesion, associated trauma lesions and vital signs during the early phase of the traumatic injury (arterial oxygenation, blood pressure, etc). five patients ( %) had a poor gsc on discharge (m≤ ). those five patients showed an early damage of tcdb type at second ct and hypericp during icu admission. a sixth patient showed unfavorable outcome of the second ct with normal icp and gcs= on discharge. of the left over patients with a favorable neurologic evolution, showed hemodynamic and/or respiratory deterioration. the multivariant study displayed a relation between the early progression of lesions in the second craneal ct (or . , % ci: . - . ) with increase of icp or a poor gcs on icu discharge. also, the presence of systemic factors associated to admission was related to a good gcs on discharge (or . , % ci: . - . ). conclusion. . the early progression of type tcdb is related to hypericp and bad neurologic prognosis on icu discharge. . systemic factors in the initial phase of trauma (hypotension, hypoxia, etc) are related in these patients with a good final neurologic outcome, absence of both radiologic deterioration and intracraneal hypertension. the glasgow coma score on hospital admission has been shown to be correlated with outcome in patients with traumatic brain injury( ). however many patients who arrive at a neurosurgical referral centre have been sedated and intubated some time prior to transfer and so their glasgow coma score cannot be accurately recorded. an option in these cases is to use the last recorded score prior to sedation and intubation. this may be the glasgow coma score recorded in the accident and emergency department of the referring hospital, or in some cases that recorded on the ward after deterioration. in some cases the only available score is that recorded at the scene of the injury. in our study we examined the degree of correlation between these various glasgow coma scores and outcome at one year in order to assess the validity of using a surrogate for the admission glasgow coma score when this is not available. data were collected prospectively on all patients admitted to the queens medical centre from to with a recorded glasgow coma score of or less within hours of a traumatic brain injury. three glasgow coma score groups were identified. patients in group (certainty factor ) had a glasgow coma score recorded on admission to the queens medical centre. group (certainty factor ) was made up of patients in whom the last pre sedation and intubation glasgow coma scores was recorded at the referring hospital. in group (certainty factor ) the glasgow coma scores were recorded at the injury scene. for each group we looked at the strength of the association between the glasgow coma score and glasgow outcome score using linear regression analysis. results. data were available on patients. mean age years (range - ), % male and % victims of road traffic accidents. linear regression between the glasgow coma score and glasgow outcome score was highly significant in all three groups (p = < . for all three groups). the strength of the association was similar for groups and and superior to group (r = . for group , r = . for group , r = . for group ). we found a good correlation between the glasgow coma scores and outcome for all three groups. the best predictor of outcome is the glasgow coma score actually recorded on admission to the referral centre, but the pre-intubation glasgow coma score at the referring hospital provides an acceptable alternative. head injury remains a common cause of hospital admission, morbidity and mortality. uk recommendations are that all head injuries are managed either in the emergency department or the regional neurosciences centre. many patients are managed in local hospitals despite evidence that outcomes are improved by specialist care. we reviewed outcome data for all head-injured patients admitted to a regional centre over a -month period (sept -aug ). consecutive adult patients (> years) were studied prospectively. gcs following resuscitation, demographic data and surgical intervention were recorded. glasgow outcome scores were determined at discharge from the regional centre, and at and months following injury. whilst at the regional centre, patients were managed according to locally established protocols. . patients were admitted ( m, f). gcs following resuscitation was - in patients, - in , and < in . patients were aged - years, were - years and > years. patients had evacuation of an extradural haemorrhage, had evacuation of a subdural haemorrhage, had contusionectomies and patients required decompressive craniectomy. gos data were available for all patients at discharge, at months and at months (table ) . for patients with initial gcs < , gos was available for at discharge, at months and at months ( table ). mortality from head injury was % with only / patients with severe head injury dying. patients were discharged in a vegetative state with only remaining so at months. a bolus infusion of . % saline in % hydroxyethyl starch / . (hs) attenuates mean intracranial pressure (icp) in patients suffering from spontaneous subarachnoid hemorrhage (sah) ( ). it has been suggested that intracranial pulse pressure is more useful for prediction of intracranial compliance than mean icp alone ( ) . in this study, the effect of an infusion of hs on the parameter mean icp wave amplitude (i.e. intracranial pulse pressure) is compared with the effect on mean icp. prospectively collected data was retrospectively analyzed. all patients included were sedated and mechanically ventilated patients suffering from spontaneous sah. nine patients received infusions of hs, mean . (range . to . ) ml/kg. mean values of a minute period just prior to the infusion were compared with a -minute period after maximum effect was reached. results. the mean icp wave amplitude decreased . mmhg ( % confidence interval - . to - . ) from a baseline of . (sd . ) mmhg, p = . . mean icp decreased . mmhg ( % confidence interval - . to - . ) from . (sd . ) mmhg, p <. . comparing mean icp and mean icp wave amplitude, there was no statistically significant correlation for baseline values or change (table ). there was a stronger correlation between baseline values and change for mean icp wave amplitude than for mean icp (table ) . this study documents an effect of osmotherapy on intracranial pulsatility; mean icp wave amplitude was attenuated after infusion of hs. this reduction was strongly correlated to baseline mean icp wave amplitude. however, regarding the association between mean icp wave amplitude and mean icp, we found neither any correlation for baseline values nor for change after hs infusion. hence, monitoring of one parameter can not substitute the other. the value of mean icp wave amplitude in clinical practice should be further evaluated. hyponatraemia is an important electrolyte dysbalance in acute brain diseases. there are two known syndromes: the more frequent cerebral salt wasting (csw) syndrome due to natriuresis, and the less common syndrome of inappropriate secretion of antidiuretic hormone (siadh) caused by free water retention. differentiation between them can be made using renal function parameters, and is essential because each syndrome requires different therapy. we retrospectively analysed all patients (pts) with acute brain diseases admitted to our neurologic-neurosurgical care unit (nnicu) over a period of five years who developed hyponatraemia (serum sodium < ). first we divided them according to measured serum osmolality (normal values - mmol/kg) and then we evaluated the group with hypoosmolality (s osm < mmol/kg). the type of hyponatraemia was diagnosed using renal function parameters established in clinical practice in our nnicu. there were pts (mean age +/- yrs, m ) with days of hyponatraemia. the majority of pts had normal serum osmolality ( pts, days), some had hyperosmolality ( pts, days) and only pts ( days) had low plasma osmolality. osmolality was not measured for the remainder. pts in the hypoosmolal group (mean age +/- yrs, m ) were with the following diagnoses: subarachnoid haemorrhage , intracerebral haemorrhage , ischemic stroke , tumour , trauma , infection and others . the mean gcs at the start of hyponatraemia was . (range - ), the mean discharge gos was . (range - ). hyponatraemia lasted from to days (mean . days) and in patients was already present on the day of admisson. the mean value of hyponatraemie was . mmol/l (range - mmol/l, p< . ) and the mean value of serum osmolality was . mmol/kg (range - mmol/kg, p< . ). the mean increase of natraemia over hours was . mmol/l (range - mmol). no patients had central pontine myelinolysis. renal function parameters were examined in patients ( %), of whom patients were diagnosed csw syndrome (diuresis +/- ml/day; fu na+ . +/- . mmol/day, p< . ; c osm . +/- . ml/s, p< . ; c el . +/- . ml/s, p< . ; c na+ . +/- . ml/s, p< . ; ewc - . +/- . ml/s, p< . ; fe na+ . +/- . , p< . ), patients had other causes of hyponatraemia and no one siadh. renal function parameters are very useful to diagnose the type of hyponatraemia and available to put into clinical practice. hyponatraemia with hypoosmolality is not so frequent, and csw syndrome is more prevelant then siadh. microbial colonization of the respiratory and gastrointestinal tract (rt and gt) of a critically ill patient is an early event in the chain leading to invasive infection. systematic colonization surveillance permits monitoring of transmission dynamics, early detection of epidemics in the icu and possibly guidance for adequate empiric antimicrobial treatment in infectious episodes. we retrospectively analyzed the ability of colonization surveillance to predict microbial etiology of subsequent infections and permit adequate empiric therpay in septic episodes. the study was performed in a -bed general icu from november to december . infection control policy included weekly surveillance cultures of bronchial secretion and stool samples. all cases of ventilator-associated pneumonias (vap) and bloodstream infections (bsi) during the study period were recorded and the relationship between infectious etiology and most recent colonization was analyzed, based on species, antimicrobial susceptibility patterns and molecular typing by rep-pcr of selected isolates. in cases of new septic episodes, empiric treatment was determined, among other risk factors, by the antimicrobial susceptibility of most recent colonizers in either the rt or gt. during the three years of the study, we recorded vap and bsi cases ( catheter-related). pathogens isolated from vap cases correlated with bronchial or stool colonizers in %, with prior rt colonization being most important. in bsi cases, gram-negative pathogens were recent colonizers in % associated with both the gt and rt. no relationship was observed between gram-positive colonization and subsequent infection. rep-pcr techniques confirmed pathogen and colonizer concordance in all cases tested. systematic colonization surveillance use to determine empiric antimicrobial treatment in new vap episodes permitted % adequacy, compared to only % if the hellenic society of intensive care vap guidelines were used. empiric treatment for bsi cases was adequate % of the time. conclusion. rt and gt colonization is strongly related to microbial etiology of subsequent infection. systematic weekly colonization surveillance of rt and gt specimens could be helpful in implementing adequate antimicrobial therapy, especially for multidrug resistant gram (-) pathogens, in the icu. s. barbadillo* , m. olsina , a. leon intensive care unit, microbiology, capio hospital general de cataluña, sant cugat del vallés, spain production of extended-spectrum beta-lactamases (esbl) by enterobacteria is an important resistance mechanism against antimicrobial beta-lactamics. klebsiella pneumoniae and escherichia coli (esbls) strains had mostly been described but infection due to enterobacter producing extended-spectrum beta-lactamases (esbls) is a relatively uncommon clinical entity. this study was performed to investigate the risk factors associated with the acquisition of enterobacter-esbls strais infections in an intensive care unit (icu). this case-control study took place at a tertiary spanish hospital with a polyvalent icu beds from january to december . demographic data, underlying diseases, risk factors, length of icu stay and hospitalization and antimicrobial treatment were investigated by comparing infections due to enterobacter esbl-positive to cases due to esbl-negative strains. enterobacter were tested for esbl production by double disc diffusion synergy test (ddst) as well as by the mic reduction test. thirty-six enterobacter infections over a period of years were collected. ventilator associated pneumonia was the most frequent infection ( %). nine cases ( %) of esbl-producing eneterobacter isolates were compared to those infections with enterobacter non-esbl. days of mechanical ventilation, length of icu stay, tracheotomy, peripherical venous catheter and administration of cephalospin were all associated with esbl-enterobacter infections in the univariate analysis. there was not differences for sex, age, prognostic scores and mortaliy between groups. the multivariate analysis revealed the administration of broadspectrum cephalosporin as the unique risk factor for the presence of esbl-producing strains [odds ratio (or) . ; % confidence intervals (ci) . - . ; p= . ]. use of cephalosporines was associated with enterobacter esbl-positive isolates. thus, rational antimicrobial administration and antibiotic protocol regimens appears to be critical for control emergence of esbl production. to evaluate and characterize the ni in two intensive care units (icu) of a central portuguese hospital. a retrospective study of patients with ni, hospitalized in two icu (one medical and other surgical)between / / and / / identified by a computer-based program vigi@ct (biomerieux) and confirmed after. in the surgical icu we found episodes of ni. of this ( . %) were respiratory infections; ( . %) were surgical site infections and ( . %) bacteriemias. in the respiratory infections the most frequent agents were acinetobacter baumannii ( - . %) and pseudomonas aeruginosa ( - . %). enterococcus faecalis ( - . %) was the most frequent in surgical site. staphylococcus epidermidis ( - %) and acinetobacter baumannii ( - . %) the most frequent agents in bacteriemias. among all microrganisms . % of acinetobacter baumannii; . % of pseudomonas aeruginosa and . % of klebsiella pneumoniae were multiresistent bacteria (mrb). in the medical icu we found episodes of ni. half of these were due to respiratory infections ( - %), ( . %) were bacteriemia and ( . %) were urinary infections. pseudomonas aeruginosa was the most frequent microrganism ( - . %) among respiratory infections. in the bacteriemias coagulase negative staphylococcus (cns) (staphylococcus epidermidis and staphylococcus hominis) were the agents most frequently found ( - . %). escherichia coli was the bacteria most isolated in urinary infections ( - %). in medical icu we found mrb, among these were pseudomonas aeruginosa ( . %); were staphylococcus epidermidis ( . %) and ( . %) were acinetobacter baumannii. conclusion. ni is a significant problem in our icu's. we found more ni episodes in the surgical icu than in the medical. respiratory infection were the most common ni in both icu. as expected surgical site infection is also a serious occurence in the surgical icu as well bacteriemia. in the medical icu bacteriemia was also a considerable issue. gram negative bacteria and cns were predominat in this ni. acinetobacter baumannii was the most frequent mrb. we study retrospectively icu pts, men ( %), women ( %) who developed bacteremia. all had been operated at least once under general anaestesia. mean age: . ± . years, length of stay (los): . ± . days. all were mechanically ventilated and were divided in groups according to their age: group a ( . %) < and group b ( . %) ≥ years. in groups a and b we had respectively: mean age: . ± . and . ± . years. los: . ± . and . ± . days. underlying diseases: multiple trauma ( . %) and ( . %), complicated surgery ( . %) and ( . %), other ( . %) and ( . %). in groups a and b respectively: site of infection: pneumonia ( . %) and ( . %), intra-abdominal infection ( %) and ( . %), central venous catheter-related infections (cvc-ri) ( . %) and ( . %), other ( . %) and ( . %). invading microorganisms in single strain bacteremia: ps. aeruginosa ( . %) and ( . %), ac. baumannii ( . %) and ( . %), st. aureus ( . %) and ( . %), kl. pneumoniae ( . %) and ( . %), st. epidermidis ( . %) and ( . %), other and ( . %). mods occurred in ( . %) and ( . %). mortality rates (mr): / ( . %) and / ( . %). global mr: / ( . %). conclusion. ) cvc-ri appeared more frequently in elderly (p< . ), while all other sites of infection did not differ. ) invading organisms were similar in both groups except ac. baumannii which was isolated much more frequently in younger pts and very rarely in the elderly (p< . ). the resistance was similar in both groups. ) los was smaller in elderly (p< . ). ) elderly developed more frequently mods (p< . ) and had higher mr (p< . ), while the outcome of the infection was independent of the type of invading organism and its resistance. j. pavleas , a. skiada* , g. thomopoulos , i. stefanou , n. kouna , b. kaitanidi , a. salvari , p. tassiopoulou , a. papadopoulou , e. christofilou intensive care medicine, laikon general hospital, research laboratory for infectious diseases "g.l. daikos", athens university, microbiology laboratory, laikon general hospital, athens, greece nosocomial catheter-related bloodstream infections (cr-bsi) have been associated with increased morbidity and possibly increased mortality in critically ill patients. the aim of this study was to analyze the epidemiology of cr-bsis in our intensive care unit. prospective epidemiological study, in a mixed icu of a tertiary care hospital, of the incidence of cr-bsis, the responsible bacteria and the outcome of the episodes of bacteremia. the demographic and clinical characteristics of all patients admitted in the icu were recorded. each bacteremia recorded was classified as primary, catheter-related or secondary. the study took place in a tertiary care hospital, mixed icu, during a thirty-two months period. three hundred and thirty patients were admitted. their mean age was years and % of them were male. mean apache score was and the mean duration of stay in the icu was days. the total number of bloodstream infections (recorded in patients) was . of these, % were catheter-related. specifically, sixty-five cr-bsis occurred in catheter days ( . per catheter days). sixteen cr-bsis were due to gram-positive ( methicillin-resistant staphylococcus aureus, coagulase-negative staphylococci and enterococcus spp.) and to gram-negative bacteria ( acinetobacter baumanii, pseudomonas aeruginosa, klebsiella pneumoniae and one each of morganella morganii, enterobacter cloacae and serratia marcescens). of the gram-negative bacteria, % were multi-drug resistant, while % of the enterococci were vancomycin resistant. a positive outcome was noted in % of the catheter-related and in % of the other bacteremias. although cr-bsis have a better prognosis than the other bacteremias, they are still a serious cause of morbidity and mortality in the icu. since these infections are preventable, appropriate measures should be meticulously applied. opportunistic invasive aspergillosis in an immune compromised patient is being increasingly reported. however, this condition is thought to be rather rare in an immune competent host and therefore often unrecognized. we report two cases of invasive aspergillosis in patients without previous medical history of conditions leading to immune compromised status admitted to our intensive care unit. first case concerns a -year old woman who underwent an exploratory laparotomy because of acute abdomen without any significant findings. in the postoperative period, the patient developed sepsis with multiorgan failure necessitating ventilation, vasopressive and inotropic support and hemofiltration. early microbiologic analysis of the sputum showed an aspergillus fumigatus and patient was treated with voriconazol. the further evolution was unfavorable with hemodynamic instability and the patient died after two months of treatment. the autopsy revealed a severe tracheobronchitis and aspergillus endocarditis. the second patient, a -year old man admitted to our intensive care unit due to recurring arterial embolism and fever was diagnosed culture-negative endocarditis of the native mitralis valve on the transoesophageal echocardiography. subsequently, patient underwent a successful valve replacement. the culture of explanted valve revealed an aspergillus fumigatus infection and appropriate antimycotic treatment was started. in the postoperative period, the course was complicated by a sudden neurological condition with altered consciousness and patient eventually died of cerebral aspergillosis. in both patients, an exogenous infection possibly took place. the first patient was admitted to our hospital during the reconstruction work next to the intensive care unit. this may have led to her exposure to increased pathogen load during the early postoperative period. the second patient probably contracted the infection during the reconstruction work he was executing himself at his house before the admission to the hospital. invasive aspergillosis is a severe condition which is not only limited to patients with immune compromised status. alertness of the physicians ensuing in early diagnosis may be crucial for determining the individual patient prognosis. k. clabault* , f. soulis , m. tavolacci , g. beduneau , f. tamion , g. bonmarchand , j. richard medical intensive care unit, epidemiology and public health, rouen university hospital, rouen, france introduction. surgical hand rubbing (sr) has been proved to be an efficient alternative to traditional hand scrubbing. we tested an educational program based on continuous direct observing practice in order to implement this technique in a medical icu. residents and medical students benefit from an educational program included a ten minutes video demonstration of the sr presented by the infection control practionner. results of each observation was immediatly feed back to residents. medical students were encouraged to complete a form for each sr occuring h activity. data collection were due to sr (in emergency or not), duration of sr procedure, quantity of alcohol hand based (ahr) rub used. two successive groups of residents and groups of students participated to the study. two hundred and twenty-five observations were performed during a month period. the mean of the procedure time was s (sd . ). time expected according to the institutionnal protocol was s. . % of sr was inferior to mn , . % between mn and mn , . % superior to mn . time of sr did not differ between emergency or planned procedure ( s vs s, p= . ). cumulative volume of ahr was significantly correlated with duration of the procedure (r= . ,p< - ). our study suggest that implement of a new procedure of surgical hand disinfection in a icu is feasible on result on good adhesion of educated residents. the original method based on a audit performed by medical students may allow both hand hygiene education and adherence to an infection control program of future practionnners. infection surveillance: it is based in the unit not in the patient, using the envin-helics tool. this information from the patients was gathered: age, diagnosis on admission, apache ii, exposure and use to invasive devices (mechanical ventilation, central venous and urinary catheter). a multidisciplinary team from microbiology, preventive and intensive care units composed the team. the criteria for infection diagnosis were those from the cdc. incidence rates were calculated. handwashing surveillance: it was recorded in two periods: january-march (p ) and october-december (p ); each observation period lasted minutes. we observed the opportunity, defined as every time in which an indication for handwashing exists. . patients were enrolled, , % male, mean age ± ; more frequence of patients with medical pathology ( , %) with a media ± standard deviation of , ± , . apache ii . ± , . overall mortality rate was , %. a greater incidence of infections were found in the traumatic group. there is a large number of central venous catheter (use rate , %, , %:coronary patients). infections were detected as acquired in our unit ( , % and , %o patient-day). the respiratory tract infections and bactraemias were the most frequent localizations, with ventilator-associated pneumonia (vap) as the predominant nosocomial infection ( . % over total infections; , % in intubated patients, an incidence rate of , %o). there were two outbreaks of methicillin resistant staphylococcus aureus (mrsa). thus, the most frequent were pseudomona aeruginosa ( , %), escherichia coli ( , %) and staphylococcus aureus ( , %); acinetobacter baumanii and methicillin resistant staphylococcus aureus were quite very infrequent ( , % and , % repectively). opportunities of handwashing were detected (p : , p : ). the compliance increased from , % in p to , % in p . conclusion. )nosocomial infections affected to one out of five of the admitted patients. the vap was the most frequent infection. )we had a large rate of vap but similar to spanish standard ( , / days of use of mechanical ventilation). )the microbiology was similar to other critical care units, with a predominance of pseudomona aeruginosa. there were two outbreaks by mrsa. ) despite an increase in handwashing compliance, the rate of vap did not was lowered. m. karvouniaris* , s. xitsas , p. kasviki , d. lagonidis , m. stougianni , a. tefas icu, microbiology lab, general hospital of giannitsa, giannitsa, greece introduction. icu physicians are nowadays faced with the formidable task of dealing with bacteria that can hardly treat. multidrug resistant gram(-) bacteria are usually isolated from brocheal aspirates and associated with the development of vap , while their presence increases the risk of death. sometimes the only option for treating them is colistin , which was until recently an obsolete antibiotic of questionable efficacy. methods. patients with at least a -day stay in our icu had the following characteristics : men ( . %) , median age years ( interquartile range years) , median icu stay days (interquartile range days) , a mean apache ii score of . ( % confidence interval . - . ) these patients where retrospectively divided in two groups. the first one included patients with at least one brocheal culture positive for panresistant gram ( -) bacteria and the second one consisted of patients carrying bacteria sensitive to colistin only. a comparison was made according to days of stay in the icu , survival in months , age and apache ii score. statistical analysis was made using mann-witney analysis and a kaplan-maier analysis for survival. the patients in the group with the panresistant bacteria spend more days in the icu (p< . ) , while tended to live longer ( mantel-cox pairwise , p< . ). multidrug resistant bacteria are poorly responsive to colistin which failed to make an impact in survival. introduction. aids is a increasing chronic disease , with a great impact in medical costs. objective: to analyze incidence and epidemiological factors and outcome in aids patients (with previous or actual diagnosis) admitted to a general adult icu, comparing them with non-aids patients. retrospective cohort comparative study made in a general adult -bed icu of a university hospital, in a -month period. it were analyzed all patients admitted during this period. it was made descriptive statistics, analysis of variance and t-test. during studied period, there were patients admitted with a previous or actual diagnosis of aids. most common admission cause in these patients was sepsis by community pneumonia ( patients) and neurological diseases ( cases). there were patients with association with pulmonary tuberculosis, and patient with coexistent pulmonary paracoccidioidomycosis. among most frequent complications, ( . %) had acute renal failure (arf), ( . %) plaquetopenia (of these, had associated leucopenia), and ( . %) ards (all secondary to pneumonia). conclusion. in this study, aids patients admitted to icu were younger, mainly male, more severe and with a higher icu and hospital mortality. systemic complications were frequent, and commonest admission cause was community pneumonia with sepsis. it is emphasized the association with tuberculosis and paracoccidioidomycosis. grant acknowledgement. this study was not supported by any companies. th esicm annual congress -berlin, germany - - october a. sencan* , t. adanir , h. er , m. aksun , g. aran , n. karahan anesthesiology and icu, infection deseases, anesthesiology, izmir ataturk training and research hospital, izmir, turkey acinetobacter baumanii is a gram-negative coccobacillus that is normally a commensal pathogen but can be a nosocomial pathogen which is responsible for severe icuacquired infection, mainly pneumonia and bacteraemia. the aim of this study was to determine the risk factors and mortality rate of acinetobacter baumanii infections in icu patients. in this retrospective study, we analyzed acinetobacter baumanii infections developing in all patients who were admitted into our icu between january , and december , . a comparison of data was collected from the patients' record cards. age, gender, mortality ratio, apache ii and sofa values, length of mechanic ventilation (lomv) and length of icu stay (loicus) up to determination of infection, total length of mechanical ventilation (tlomv) and icu stay (tloicus), region of culture from which the infectious agent was obtained, existence of another microorganism together with acinetobacter baumanii (eamo), tracheotomy, intubation tube, central catheter, urinary catheter and nasogastric tube days up to the determination of infection and the feeding route were evaluated. these characteristics were compared between living and dead patients. during that time period, cases of acinetobacter infection were found in our clinic. the mortality ratio was %. the comparison of living and deceased cases is shown in the following table. we observed that this nosocomial infection was seen in the - year-old age group and in the first week of mechanical ventilation. mortality was greater in patients with high sofa scores and the infection prolonged the length of total icu stay. if the infection was located in the lungs, the mortality rate could be higher. there were cases of a baumanii nosocomial pneumonia and of them died. in addition, the rate of female patients dying was greater ( of female patients died). r. e. farah* , a. kondratov , r. michelis , n. makhoul internal medicine, intensive care unit, eliachar research laboratory, nahariya hospital, nahariya, israel community-acquired pneumonia, that requires hospitalization, is a severe illness with high mortality rates, especially, in the cases of delay of appropriate treatment. at times, the correct diagnosis of the disease is difficult due to equivocal clinical picture or chest film, accompanying diseases that could mask or simulate the pneumonia. the aims of our study were: .follow-up levels of scd and oxidized fibrinogen (of) throughout hospitalization in the group of patients admitted to the hospital due to pneumonia and pulmonary edema of non-infectious origin; .an estimation opportunity using them as possible new markers for diagnosis of pneumonia and for following response to treatment. three groups of patients were studied: a group of patients admitted due to pneumonia, a group of patients admitted due to pulmonary edema, and a control group - healthy subjects. the blood samples for white blood cells count, erythrocyte sedimentation rates, levels of fibrinogen, c-reactive protein, albumin, scd , oxidized fibrinogen were taken for each patient on admission, and hours following admission and on discharge day. the received dates were compared using student t-test. the levels of scd were higher, but still in the normal ranges, on admission in the patients with pneumonia and pulmonary edema in comparison with control group (p< . for both groups), with gradual declining throughout hospitalization period (p> . for both groups in discharge day). the comparison of scd levels between groups of patients with pneumonia and pulmonary edema did not reveal statistically significant results (p> . ). the rates of oxidized fibrinogen were in the normal ranges (< . nmol/mg) throughout hospitalization period in both groups of patients, but surprisingly higher in the control group (p< . ). oxidized fibrinogen and scd can't be used as reliable markers neither for primary diagnosing of pneumonia or differential diagnosis from pulmonary edema, nor for patient follow-up throughout hospitalization period. the finding of elevated levels of of in the group of healthy persons demands additional studies for discovering other factors that cause changes in fibrinogen oxidation rates. appearance of myocardial infarction and stroke during the same hospitalization is rare and has great mortality ratio. it was expected these events to take place more often during winter and in connection with infection. we have retrospectively analyzed data of patients with diagnose of acute myocardial infarction and stroke during the same hospitalization, treated in our internal intensive care unit from january to december . none of these patients were subjugated to thrombolytic therapy, percutaneus coronary intervention or coronary artery bypass graft. all included were caucasians (who were maked . % of total number of hospitalised patients during that period), ( %) males,and ( %) females. age of patiens was between and years, mean ± . (ci - ). six patients have survived ( %), and died ( %) ( males and females). the average age of deceased males was ± . years (ci - ), and females was ± . (ci - ). mean apache ii score was ± (ci - ), and mean gcs was ± (ci - ). most of the patients ( patients or %) were admitted during the winter, six in autumn ( %), five in spring ( %) and in summer only one patient ( %). in patients ( %) ( males and females) we found connection between current state with recent infection (within last month) or signs of infection on admission in icu. respiratory infection was found in patients, urinary infection in , and in cases we have found some other source of infection. also we found significant connection between current state (myocardial infarction and stroke during same hospitalization) and infection during winter (p= . ) and positive correlation between infection and mortality of these patients (r= . , p< . ). although exact mechanisms are still unknown. we can expect these events more often during winter period when are respiratory infection are more frequent. introduction. vap is the most frequently occurring nosocomial infection among patients requiring mechanical ventilation in the icu and is associated with increased morbidity and mortality. the major route of acquiring vap is oropharyngeal colonization by the endogenous flora or by pathogens acquired from the icu environment. oral decontamination with hexetidine , % reduces the risk for vap according the results of many reported studies and is the most common oral antiseptic in greek icus. our aim was to determinate the effect of oral decontamination with hexexidine , % on development of oropharyngeal colonization and vap. methods. patients admitted to the icu and received mechanical ventilation for more than days. were males ( , %) and ( , %) females. mean apache ii score on admission was , ± , . we excluded patients with multiple icu admissions. only the first admission was considered for analysis. we excluded also all patients with a diagnosis of pneumonia on or before the first day of mechanical ventilation, so that the sample would include only patients who had hospital-acquired pneumonia develop while receiving mechanical ventilation. all patients were randomized to hexetidine . % applied every hrs into the mouth, beginning hrs after admission. oropharyngeal sample cultures were obtained on admission on the nd and on the th day of hospitalisation and analyzed for gram positive, gram negative microorganisms and fungi. all patients were examined daily for the presence of vap with clinical criteria and chest x-rays. the most common isolates were: pseudomonas aeruginosa , %,klebsiella pneumoniae , %,s.aureus %,enterococcus faecium % ,acinetobacter %,e.coli , %,proteas mirabilis , % and candida species , %. coupled plasma filtration adsorption (cpfa), using a sorbent once the separation between plasma and blood has been obtained with a plasma filter, has been designed to non-selectively remove inflammatory mediators released in sepsis and septic shock. the aim of this study was to test whether cpfa is beneficial in septic shock. fourteen h-fasted, anesthetized, invasively monitored, mechanically ventilated female sheep ( . ± . kg) received . g/kg body weight of feces s lactate (rl)+ hydroxyethyl into the abdominal cavity to induce sepsis. ringer starch (voluven) (volume ratio= : ) was titrated to maintain cardiac filling pressures at baseline levels throughout the experimental period. four hours after feces injection, animals were randomized to two groups: cpfa treatment (n= ) or control (n= ). a four-pump hemofiltration machine (lynda, bellco, mirandola, italy) was used for the study. although mean arterial pressure and cardiac index were significantly lower in the cpfa group compared to the control group (p= . and p= . , respectively) and blood lactate concentrations tended to be higher in the cpfa treated group (p= . ), survival time tended to be longer in the cpfa than in the control group ( . ± . vs . ± . hours, log rank p= . ). in this clinically relevant septic shock model, cpfa treatment tended to prolong survival time. acute severe liver failure (alf) is a clinical syndrome that results from rapid loss of the major liver functions. despite improvements in the treatment of these patients, including liver transplantation, mortality rates remains high. a liver support system capable of removing endogenous toxins may be useful in alf patient's management. the aim of this study was to assess the efficacy of the extracorporeal liver assist device mars ® (molecular adsorbent recirculating system) in patients with alf unresponsive to intensive medical therapy. the study was performed in a medical-surgical intensive care unit of a tertiary referral hospital with multi-organ transplant program. a prospective clinical case-control study was designed. patients with severe alf of any etiology admitted to icu were included if mods was present and an indication for liver transplantation was done. standard treatment measures were applied in all cases according to patient's clinical condition. patients received mars ® treatment after this therapy was introduced in our icu. patients without mars treatment were the control group. outcome parameters were the main variables for comparison between groups. complications related with mars treatment were also analyzed. methods. in a previously-described test set-up, a l jar serving as a dummy lung was ventilated through a heated water-filled reservoir placed on a weighing scales so that gain or loss of water from it could be detected. the ventilator was a viasys sensormedics b using a fisher/paykel mr humidifier the ventilator was set to maximum power at a frequency of hz. three investigations were performed with humidifier temperatures of . ˚c, . ˚c and . ˚c. weight gain or loss over - hours was recorded and calculated in g/h. four measurements were made at . ˚c, four at . ˚c and two at . ˚c. previous spirometry studies suggested - % tracheal stenosis following percutaneous tracheostomy(pt) based on techniques that involved either the original ciaglia serial dilatation or griggs modified forceps blunt dilatation of the trachea. subjective voice changes and hoarseness has been reported at an incidence of % following pt by the blue rhino single dilator technique. aim of this study was to assess upper airway narrowing effects based on spirometry and symptoms following pt by blue rhino technique. invitations were sent to patients(identified from the liver database) who underwent pt during their intensive care stay and were attending liver clinic beyond months after the procedure. all participants underwent formal pulmonary function tests and filled in a standardized questionnaire on symptoms (pain, dysphonia, dyspnoea, cough, throat tightness, dysphagia) and scar appearance. flow volume loops were recorded using a jaegar master-lab . pneumotachograph, and best values for forced vital capacity(fvc),forced expiratory volumes at . and second(fev . ,fev ),peak expiratory flow rate(pefr),forced inspiratory flow at %vital capacity(fif ),forced expiratory flow at %vital capacity(fef )and peak inspiratory flow(pif) recorded. values for fev /pefr,fef /fif and fev /fev . ratios were then calculated. during august to january , patients underwent pt, of whom survived. of the outpatient attendants participated in the study. median age was . years ( - y) and m:f ratio was : . of the current or past smokers had obstructive airway disease based on fev /fvc ratio. median interval between pt and review was months ( - mth,n= ; - mth,n= ; - mth,n= , beyond y,n= ). median apache ii score on day of pt procedure day was . nine patients had failed extubation, and one patient underwent pt procedures during the same hospital stay. median duration of translaryngeal intubation prior to pt and from pt placement to decannulation were days ( - d) and days ( - d) respectively. moderate/severe dyspnoea was reported by patients (mild,n= ) and cough by patients (mild,n= ). patients reported voice changes and patient with hoarseness. assessment of scars at the time of review showed patient with keloid scar and patient with an ugly indurated scar (at and months respectively); all others were good to barely visible. satisfactory flow-volume loops were obtained for patients. patients had evidence of extrathoracic tracheomalacia based on the fef /fif ratio > ( with symptoms), however fev /pefr ratio did not suggest obstruction in any of them. dyspnoea and cough were the most common symptoms, notably in smokers. late complications were uncommon, other than one patient with indurated scar, hoarseness and possible tracheomalacia. leonard rc. chest fikkers bg. anaesthesia j. dellamonica*, a. lyazidi, f. vargas, l. brochard medical icu, henri mondor hospital, creteil, france high frequency percussive ventilation (hfpv) is a technique that delivers small bursts of gas with frequency higher than hz (usually - hz). intrapulmonary percussive ventilation using hfpv has been used during spontaneous breathing, but is also proposed superimposed to conventional ventilation (cv). airway humidification during hfpv has not been studied, however, and is generally provided with an aerosol. a poor airway humidification could lead to secretion thickening and atelectasis. we therefore performed a bench study to assess hygrometry provided by different devices when hfpv is added to cv. methods. circuits have been tested: . a heater humidifier (hh) (fisher & paykel mr ) placed on the inspiratory line of the cv. .& . heat and moisture exchanger (hme) and active hme (ahme) were tested placed at the y piece. for these circuits, hfpv was connected to a branches y piece with inspiratory and expiratory lines of the cv. . hh was connected between hfpv and y piece. all circuits were tested with the aerosol provided by the manufacturer. hygrometry (relative and absolute humidity rh and ah) was measured using psychometric method at y piece. hygrometry provided was compared with non parametric test. p< , was considered significant. conclusion. the minimal level of humidity recommended during prolonged mechanical ventilation is mgh o /l, and the fourth circuit was the only one to provide sufficient ah. temperature drop due to gas acceleration and large admission of gas during hfpv may explain the lack of efficacy of the other devices. coagulation abnormalities are very frequent in critical illness. these, often secondary to sepsis and dic, significantly contribute to mortality in the intensive care unit (icu). thrombelastography (teg ® ), a cell-based whole blood analysis, enables global evaluation of the haemostatic system and the purpose of the present study was to evaluate whether the haemostatic competence on admission to the icu, evaluated by teg ® was associated with mortality in critical ill patients. blood samples were prospectively obtained upon arrival from consecutive patients admitted to a multidisciplinary tertiary icu. teg ® analysis was performed (teg ® haemostasis analyzer, haemoscope corporation, niles il, usa), measuring clot formation,stability and degradation in whole blood. the teg ® parameters r time, angle, and the maximal amplitude ma were evaluated. the r time represents the initiation of the coagulation process (normal reference - min), the ma represents maximal clot strength mainly dependent on the platelet function (normal reference - mm), and angle represents the clot build up, involving fibrinogen function (normal reference - ˚). the primary endpoint of the study was defined as death within days. data are presented as mean (sd). mann-whitney's u-test and fischer's exact test were applied with a p value < . considered statistically significant. the age was . ( ) years in a cohort of . % medical (n= ) and surgical (n= ) patients of whom were male ( . %). length of stay in the icu was . ( . ) days and the apache ii score was . ( . ). thirty-one patients died ( . %). r time ( . ( . ) min vs. . ( . ), respectively; p= . ), ma ( . ( . ) mm vs. . ( . ), respectively; p= . ) and angle was significantly lower in non-survivors than in survivors ( . ( . )v s. . ( . ), respectively; p= . ). patients with a normal teg did receive less cvvhdf ( . % vs. . % (p< . )and had a lower mortality rate ( . % vs. . (p< . ) than patients with not-normal teg. a compromised haemostatic competence on admission to the icu as evaluated by the teg ® r time, angle, and ma are associated with increased -day mortality in un-selected critically ill patients. this finding is consistent with the hypothesis that a dysfunctional haemostatic system could be a central part of developing organ failure and, hence, mortality. this prognostic tool may be useful as a rapid, point-of-care assessment. the possibility of goal-directed haemostatic intervention should be investigated in a randomized controlled trial. n. komitopoulos* , a. kanavou , a. giakoumaki , i. ioannidis , a. komitopoulou , e. varsamis nd internal medicine dpt, biochemistry lab, konstantopoulion general hospital, athens, greece introduction. brain natriuretic peptide (bnp) is a -amino-acid polypeptide mainly secreted by the ventricles of the heart in response to excessive stretching of myocytes. cardiac dysfunction, characterized by reduced ejection fraction, biventricular dilatation and decreased response to resuscitation with fluids, is often present in patients with sepsis. the myocardial depression is probably due to tumour necrosis factor-α and interleukin- β acting in synergy. the aim of the study was to determine whether bnp levels in elderly septic patients are related to the severity of the disease. in patients ( males) with sepsis of various origin, aged ± years, hospitalized in the internal medicine department, bnp serum levels (direct immunochemiluminescence, centaur, bayer) and apache ii score were measured within hours after hospital admission. sepsis was determined according to the criteria of the consensus of the american college of chest physicians and the society of critical care medicine ( ) . patients with acute myocardial infarction were excluded from the study. the mean bnp value (pg/ml) in our subjects was ( - ). the bnp levels in the subgroup of individuals with chronic heart failure (n: ) were higher than those of the rest of the patients [ ( - ) vs ( - ), p= . , mann-whitney test]. a statistical significant difference was also found in bnp levels of the patients with apache ii score ≥ as compared to those of lower score [ ( - ) vs ( - ), p= . , mann-whitney test]. patients who succumbed (n: , %) had extremely high bnp levels [mean: ( - ) ]. a positive correlation was observed between bnp values and apache ii score (linear regression analysis , r= . , p< . ). in conclusion, brain natriuretic peptide was found to be correlated with the severity of sepsis in elderly patients and thus it might be used as a useful prognostic marker in septic process. prometheus ® is a newly developed extracorporeal liver support that combines fractionated plasma separation and adsorption (fpsa) with high-flux hemodialysis. clearance of albumin-bind and water-soluble toxins are achieved in several steps. here we present our results in applications. thirteen patients ( patients with viral hepatitis acute on chronic liver failure, three mushroom intoxication, one liver failure after metastatectomy and one cittrullinemi) have undergone ( . ± . [ - ] ) times fpsa with high flux hemodialysis between june till march in our icu. inclusion criteria were hyperbilirubinemia (total bilirubin > mg/dl), or hepatic encephalopathy (grade ), or inr > . during a six-hours period of application, a variety of clinical and biochemical parameters were assessed; and data before and after the procedure were recorded. seven of the patients survived. one patient has undergone liver transplantation; six survived without liver transplantation. there was a decrease of ± % in total bilirubin per application (from . ± , mg/dl to . ± . mg/dl; p< . ), blood urea nitrogen (bun) was decreased from ± gr /dl, to , ± , gr/dl (p< . ), white blood cell (wbc) increased from , ± , mm to ± , mm (p< . ), albumin decreased from , ± , gr/dl to , ± , gr/dl (p< . ). consequent applications have led to additional decreases in bilirubin. regarding the hemodynamic parameters, there were no significant changes during the procedure. conclusion. fpsa obtained decreases in bilirubin and bun (but also in albumin levels). there can be an increase in white blood cell count. this procedure can be considered a bridge therapy for liver transplantation: it can increase the tolerance time until the liver transplantation or can improve the clinical status achieving a treatment without an organ donation. at present orthotopic liver transplantation is the only treatment modality that provides significant improvement in outcome of hepatic liver failure; but the availability of transplantation is hindered by organ shortage resulting in extended wainting list. extracorporeal liver support devices are effective therapies to overcome periods of descompensation or to bridge until transplantation. although its main therapeutic indication is hepatic failure, the possibility of removing metabolits opens new therapeutics options for other entities. we reports clinical cases where patients were treated with prometheus as a bridge to transplant or to treat refractory pruritus. several analytics results like bilirubin, platelets, creatinine, urea were measured before and after each treatment. extracorporeal liver support devices have recently attracted increasing interest. although its role in liver failure and other conditions with toxin accumulation is yet to be better characterized, we believe that its use may be advantageous and life saving in selected patients. thrombocytopenia is a common problem in the icu and cardiovascular patients. it has been considered to play a role in worsening the prognosis of icu patients. especially patients submitted to cardiac surgery may be exposed to high dose of unfractionated heparin (ufh) infusions, mainly during extra-corporeal circulation. after open-heart surgery, as opposed to other surgical procedures, the platelet count falls, primarily due to platelet damage and destruction in the bypass circuit and hemodilution. heparin is the most common drug to be implicated in thrombocytopenia in icu patients. determining the etiology for the low platelet count is important for the implementation of appropriate management. the use of a direct thrombin inhibitor in treatment should be considered early (< hours) if a diagnosis of heparin-induced thrombocytopenia is possible( ). the aim of the study is to present one case of heparin-induced thrombocytopenia after a mitral valve replacement surgery and to compare the rotational thromboelastometry (rotem) and coagulation tests before and after argatroban administration. an -year-old female patient was hospitalized because of acute mitral regurgitation secondary to chordal rupture and submitted to a mitral valve replacement. past medical history included hypertension, diabetes, chronic atrial fibrillation and mild renal failure. before the surgery, a coronary angiography was performed and revealed normal coronary arteries and a normal left function. after four days using ufh, the platelet count dropped % and the anticoagulation was changed from ufh to low molecular weight heparin. postoperatively, the patient presented in shock, acute renal failure and signs of peripheral hypo perfusion and increased abdominal pressure. seven days after the surgery, the suspicion of hit was confirmed by elisa test for pf -heparin antibodies. heparin was stopped and argatroban was initiated. the patient died from multiple organ failure week later. we evaluate the rotem and coagulation tests (platelets; ptt; tat; pai; ptn-c; fibrinogen; d-dimer and antithrombin-iii) before and after the argatroban use. conclusion. comments: in this case the roteg was as good as a wide coagulation profile test to evaluate the effects of anticoagulation using argatroban in a hit patient. the objective of this study is to evaluate the efficacy and safety of this technique in a multidisciplinary icu environment following a procedures' protocol. it was created a fiberoptic bronchoscopy protocol to implement in a routine basis, and we are testing it in this study. we applied it, in a prospective manner, in every patient undergoing fiberoptic bronchoscopy from january to march , to evaluate the indications, risk factors, the use of drugs (sedatives, analgesics and muscle relaxants) and monitoring (ecg, bp, spo , etco , plateau pressure and blood gas analysis), complications and results of this technique. our sample included patients (medical, surgical and trauma patients), with a median saps ii of ( - ). ten patients had criteria of severe respiratory failure (pao /fio < ). twenty four fbo were done in the study period; for diagnostic reasons ( pulmonary infiltrates, hemoptysis and stridor), for therapeutic reasons (bronchial toilet) and to assist percutaneus tracheostomy. seventeen of our patients had risk factors for this procedure (bronchodilator therapy in patients, pao /fio < in patients, peep > cmh o in patient, platelet count < /mm in patient and altered coagulation screen in another). all exams were successfully concluded. the median procedure time was minutes ( - minutes). beyond sedation, exams were done with topical anaesthesia and with muscle relaxants. concerning safety, the exam was interrupted due to hypoxemia in one patient and due to episodic tachycardia in another patient, both concluded without major problems. two patients showed new pulmonary infiltrates in x-ray evaluation hours after the technique. no significant variation of the pao and paco were noticed during the first hour after the procedure. concerning efficacy, from broncho-alveolar lavage samples, were microbiology positive. one small-cell lung carcinoma was diagnosed by a bronchial biopsy. all these findings have therapeutic relevance. full pulmonary reexpansion was achieved after fbo in cases of lobar atelectasis. conclusion. implementation of a protocol and an individual risk assessment policy may improve safety of bfo in ventilated patients in icu. fbo contributes to valuable diagnostic information and is useful for therapeutic purposes. n. markou* , p. malamos , p. myrianthefs , i. alamanos icu-b, athens university school of nursing icu, kat hospital, athens, greece there is a scarcity of data on the effects on oxygenation of the position of the mixing tube relative to the t-piece and the venturi mask. some data show that while a mixing chamber positioned between the venturi mask and the t-piece is associated with improved oxygenation, positioning of the t-piece between the mixing chamber and the venturi mask has no effect on patients' pao ( ). yet there are no data on an alternative arrangement, with two mixing chambers, one at each end of the t-piece. we relate our experience with this arrangement. we studied critically ill patients who were either intubated or on tracheostomy and who although clinically stable and spontaneously breathing on a t-piece for at least hours could not be extubated. the patients initially (t- ) had one mixing chamber that was positioned between the t-piece and the venturi mask. after sampling of arterial blood gases, a second mixing chamber was inserted at the other limb of the t-piece and arterial blood gases measured again after a further minutes (t- ). patients in whom interruption of these arrangements (for administration of nebulized drugs or for endotracheal suction) was needed at the time period starting at minutes before t- and up to t- , were excluded from the study. during this time period fio for all patients was , . in all patients ( intubated and on tracheostomy) were studied. results are expressed as median and interquartile range. statistical analysis was performed with wilcoxon signed-rank test. there was a significant increase in pao from t- (median mmhg, %- % range - mmhg) to t- (median mmhg, %- % range - mmhg) (p = , ), with no significant change in paco , breathing frequency, arterial blood pressure or heart rate. a second mixing chamber adjusted to the limb of the t-piece opposite to the venturi mask is associated with significant improvements in oxygenation. presumably the second mixing chamber acts as a reservoir with high-content oxygen mixture, and this might be beneficial, especially in patients with higher peak inspiratory flows. percutaneous dilatational tracheotomy (pdt) is one of the procedures more frequently performed at the patient bedside in icu. airway control is usually maintained through an endotracheal tube (ett) but a laryngeal mask airway (lma) can be successfully used as well ( , ). lma ensures a high quality fiberoptic view of laryngotracheal structures; furthermore mechanical ventilation is easier and more uniform with lma than with an ett withheld at vocal folds level. potential disadvantages of lma are the risk of inhalation and a failed ventilation in case of oedematous airway. methods. icu patients were scheduled for pdt in the last three years. all pts were admitted to pdt after a - hours fast time from enteral nutrition. predictive anatomic and anthropometric parameters or history of difficult airway were considered. in case of suspected difficulties in airway management, an evaluation laryngoscopy was made. if tube removal was considered possible, a lma, proportional to body weight, was positioned. the following parameters were registered: • classification of fiberoptic laryngeal view through lma • uniformity of inspired/expired tidal volumes during mechanical ventilation • trends of pco and po during whole procedure by seriated blood gas analysis • need of lma repositioning or its substitution with an ett during the procedure • suspect or clinical evidence of airway inhalation • chest x-ray after pdt results. in patients lma positioning was unsuccessful; in patients lma did not allow an adequate ventilation due to a increasing laryngeal oedema evident at fob endoscopy. in these cases the ett was soon repositioned. in other patients ventilation was maintained thorough lma but an increase in pco higher than % was registered during procedure. in all the other patients we had no problem neither in lma positioning nor in mechanical ventilation. in all our population we did not have any difficulty in airway management. no cases of airway inhalation were registered. conclusion. in our experience lma is an effective and successful ventilatory device during pdt. it improves the quality of endoscopic view, makes easier tracheal puncture and allows a more uniform ventilation. it is important to remember that, before removing ett, we must always evaluate the risks related to full stomach and to the presence of a difficult airway. single dilator technique is increasingly used for percutaneous tracheostomy ( ). although complications have shown a decreasing trend, there remains a concern that the posterior tracheal wall damage can occur during tracheostomy tube placement over a loading dilator. the lip between the loading dilator and the tracheostomy tube tip often causes an obstruction requiring greater force which may be responsible for posterior tracheal wall damage. the percutan tracheostomy set ( tracoe medical, gmbh, frankfurt) claims to overcome this problem by having a tracheostomy tube-loading dilator assembly with a collapsible silicone sleeve covering the tip of the tracheostomy tube. we were interested to evaluate this in practice. a total of patients scheduled for elective pdt were enrolled in this open prospective observational clinical trial. assent was obtained from the immediate relatives. patients were excluded if they had unidentifiable anatomy, severe coagulopathy, a history of difficult tracheal intubation or required significant levels of ventilatory support ( fio > . or peep > cmh o). experienced operators conversant with pdt techniques performed the procedures whilst the airway and bronchoscopy were maintained by an anaesthertist. the trachea was punctured in all cases between the nd and rd tracheal rings and dilated using the percutan single rhino dilator. the tracheostomy tube-loading dilator assembly was then inserted. the ease of tracheostomy tube insertion was graded by the operator on a scale of - , being extremely difficult and extremely easy. all complications were recorded during the procedure. a total male and female patients aged ± years (mean±sd) were enrolled. patients were ventilated for . ± . days (range - days) before tracheostomy. the operating time was . ± . minutes (range - minutes). stoma dilatation and placement of a size tracheostomy tube was successful patients. other two cases required a second dilatation before tracheostomy tube placement. average grade of tracheostomy tube placement was median (range - ). the operators stated that the force required to place the tracheostomy tube was less than that required with other single dilator manufacturers kit. there were no serious perioperative complications and blood loss was estimated for all cases between - ml except in one patient surgical ligation of a venous bleed was required. no significant difference was seen in pre and post tracheostomy arterial blood gases. this study suggests that the percutan tracheostomy set allows a single step dilation of tracheal stoma and relatively easier placement of tracheostomy tube. further randomised controlled trials are warranted to assess its advantages over the other singe dilator techniques. nebulizers designed for use with oxygen or air require high flows of heliox to create aerosol in the respirable range. this aerosol is not well characterized for standard nebulizers and the high flow of heliox is costly. the objective of this study was to characterize the performance of a new breath enhanced nebulizer designed for use with heliox ( / ) gas and compare it to an industry standard breath enhanced nebulizer. using a malvern spraytec laser difractor we measured the aerosol particle size (vmd), total output rate (tor), respiratory fraction (rf) and calculated the respiratory drug delivery rate (rddr = tor x rf). heliox flows of and lpm were used and normal saline was nebulized. we performed trials with each flow. a pari lc plus reusuable breath enhanced nebulizer was used for comparison at lpm source gas flow. table . a novel active humidification system has been developed which can heat and humidify dry therapeutic gases during mechanical ventilation. this study measures the ability of this in-line humidification device (pari hydrate , pari respiratory equipment, midlothian, va, usa) to heat and humidify gas during mechanical ventilation. the new technology (c-force ; pari respiratory equipment) produces water vapor from an in-line, small device placed proximal to the circuit 'wye' in the inspiratory line. a controller allows precise water vaporization and heating directed into the gas flow. this study was performed to determine the performance of this humidification device for mechanical ventilation. we used a puritan bennett mechanical ventilator under various settings to produce minute ventilation volumes of , , , . , and . litres. our test lung (quick lung, ingmar medical, pittsburg, pa, usa) was set to normal lung settings to simulate cp= . l/cm h o and ra= cm h o/l/s. the disposable c-force was inserted into the ventilator circuit inches proximal to the patient wye. gas temp and relative humidity (rh) were recorded at the patient wye using an electronic thermometer and hygrometer. the source gas was dry medical air; measured at % rh and oc. ambient temperature was . oc and relative humidity was . %. although the amount of water and the temperature are adjustable with this device we used a constant temperature setting of oc and the calculated water setting that would saturate the volume of gas using minute ventilation. no attempt was made to optimize the temperature and humidification of the gas beyond these settings. patients were similar in terms of demographics,type of admission and reason for intubation. the overall incidence of severe life-threatening complications was significantly lower in the after group than in the before group ( % vs. , p< . ) (fig ). the implementation of eti management protocol permitted to decrease the incidence of severe life-threatening complications in icu patients. ( , ) . the aim of this study was to review the tracheostomy practice and to determine if either technique was associated with better outcomes in the setting of an inner city general hospital. we identified patients who had had tracheostomies over a / year period (may -dec ) by using our institution's icnarc (intensive care national audit and research centre) database. the case notes of these patients were examined in detail. we divided the patients into two groups (st and pt) depending on method of tracheostomy insertion. patient age, sex, weight and apache score were recorded. we collected figures on icu length of stay (los) and icu & hospital mortality. we also compared the following data: duration from intubation to tracheostomy, time from clinical decision to actual procedure, size of tracheostomy tube inserted and number of tracheostomy days. high flow gas therapy is a new therapy which has been shown to reduce intubations, ventilator days and non-invasive ventilation. the purpose of this study is to determine the efficacy of a novel humidification device (pari hydrate tm g) for high flow gas therapy and compare it to current high flow oxygen humidification devices. we compared aquinox (smiths medical ), mr (fisher & paykel), i (vapotherm) and pari hydrate (pari respiratory equipment). each device was setup as per manufacturer's instructions to heat and humidify medical air at flow of lpm. temperature settings were adjusted to c. we recorded warm-up time from "on" to highest stable temperature when set at c, exiting gas temperature, maximum device surface temperature, and water condensate. water condensate was obtained from a condensation tube connected to outlet side of the devices and measured after minutes. temperature of the condensate tube water was set at c. ( ) suggest that, in patients liberated from mechanical ventilation (mv), the persistence of the tracheostomy tube at discharge from icu to the ward may increase the post-icu mortality rate. our objective was the confirmation of this hypothesis with close attention to selection biases as confounding by indication, patients characteristics and the prognosis at icu-discharge ( ). prospective observational study in the general -bed icu of a tertiary hospital without a step-down unit. inclusion criteria: patients tracheostomized in our icu during a -month period without neurological damage. exclusion criteria: patients tracheostomized before icu-admission, tracheostomies for difficult to control airway, and patients with "do-not-resucitate" orders. data collection: age, gender, comorbidities, severity of illness at icu admission, admission category, indication for tracheostomy, length of icu and hospital stays, length of mv, need for aspiration and characteristics of respiratory secretions, and glasgow coma scale (gcs) at icu-discharge. patients with tracheostomy tube were discharged only to wards with specific "tracheostomy care protocols" with a nurse-to-patient ratio of : - . statistical analysis: multivariate logistic regression analysis adjusted for age, gender, body-mass index (bmi), severity of illness and diagnosis at icu-admission, indication for tracheostomy, duration of mv, glasgow coma scale, need for aspiration and characteristics of respiratory secretions at icu-discharge. lung recruitment (rm) can be considered as an adyuvant for lung protection in the ventilatory support of ards patients. the recruitment pressures needed to achieve full lung recruitment in these patients are generally above cmh o. however little is known about the hemodynamic effects of the brief application of pressures beyond this level in ards patients when using a sequential cycling recruitment maneuver. we , ) that were± mmhg; lis , ±present six ards patients (pao /fio managed with a global lung protective ventilation (lpv) strategy. we used trans-esophageal echocardiography (tee) to assess the effects of a rm using increasing levels of pressure. after confirming hemodynamic stability with predefined criteria, patients were submitted to a cycling sequential rm in pressure controlled ventilation that included three consecutive pip/peep levels of / , / and / cmh o each one of them maintained for min and followed by a min period of pressure reduction to / cmh o before the next pressure level was explored ( ). data were collected during the second minute of each recrutiment step. after rm, lpv was reinstituted: vt - ml/kg and a peep level adjusted to a level immediately above maximum dynamic compliance obtained during a decremental peep trial after recruitment ( ). all patients could be mmhg). no significant decreases in mean±fully recruited (pao + paco systemic arterial pressure (less than % during maximal intrathoracic pressure) and in heart rate were observed. tee measured left (lv) and right (rv) cardiac output (co) and systolic volume (sv) decreased significantly only at rm pressures of and cmh o (around and % respectively). recovery to baseline levels occurred within minutes after reducing the airway pressures (table) . central venous pressure increased progressively to a maximum of % of the baseline value at maximal rm pressures. we hypothesized that patients in acute (arf) on chronic respiratory failure (crf) have complex acid-base disorders and that stewart's quantitative approach may be useful to make the situation clearer. in this approach, plasma ph is dependent on independent variables: strong ion dissociation (sid), total weak acid negative charge (atot) and paco . in a prospective observational study, arterial plasma from consecutive patients with crf, obstructive and restrictive, admitted to our medical icu in arf between november , and april , were studied. they were compared with those from patients with ards admitted to our icu in the same period. in addition, values in patients were compared with those in normal subjects from the literature( ). the plasma values were taken from the samples obtained at icu admission (d ), d and d . arterial blood gas, electrolytes, lactate and albumin were measured and the following variables computed: sid = hco − + albuminate (alb-) + phosphate (pi-)) from reference ( ), strong ion gap (sig) computed from reference ( ), atot= (alb-)+(pi-). the values (mean±sd) were compared using anova (table ) . there was no effect of time on the variables and, therefore, the values in table correspond to icu admission. for statistical similar ph between crf and ards, paco was higher in obstructive crf than ards. sid was not different between crf and normal subjects but greater in crf than in ards, as was sig. atot was lower in ards than in obstructive crf. in crf patients, low ph mostly resulted from hypercapnia without metabolic alkalosis on average. in ards patients, acidemia is mostly metabolic. the positive sig expresses accumulation of unmeasured anions. ( ) open lung approach has been based on a lower inflection point (lip) and an upper inflection point (uip) of the pressure-volume (p-v) curve. but we cannot always find out them, so we examined the method to get maximal compliance point in stead of uip and lip from static compliance curve. in ten patients with ards(ards group) and twelve non-ards patients (control group), we found a maximal compliance point by the static compliance curve induced by differentiation of the pressure volume curve led by polynomial approximation of scattergram of plateau pressure and tidal volume. in the ards group the compliance at the range from to cmh o were smaller than that of the control group (p< . ). but there was no difference between the maximal compliance point of the ards group and that of the control group ( . ml/cmh o at . cmh o vs. . ml/cmh o at . cmh o). we conclude that maximal compliance points were detected in all patients by this method and there was difference of the compliance between the ards group and the control group in low pressure range. p. kopterides* , i. i. siempos , a. armaganidis critical care department, attikon university hospital, department of experimental surgery, "evangelismos" hospital, critical care department, "attikon" university hospital, athens, greece prone positioning is increasingly used to improve oxygenation in patients with hypoxemic respiratory failure, especially those with acute respiratory distress syndromeacute lung injury. however, its benefits in regard to clinical outcomes are uncertain. we performed a systematic review and meta-analysis of the pertinent randomized controlled clinical trials to assess at what extent prone positioning has an effect on mortality and various clinical outcomes in patients with hrf. we conducted a systematic literature search of medline, current contents, and cochrane central register of controlled trials (from inception to january ). we included only rcts(in which prone positioning was the applied intervention and supine positioning the control treatment) that reported clinical outcomes in patients with hrf. there were no language restrictions. four trials met our inclusion criteria, including patients randomized to prone and patients to supine ventilation. data were extracted independently to assess intention to treat intensive care unit (icu) and hospital mortality, days of mechanical ventilation, length of stay, incidence of ventilator-associated pneumonia and pneumothorax, and associated complications of the implemented intervention. data were also collected to assess the quality of the included studies. the pooled odds ratio (or) for the icu mortality in the intention-to-treat analysis was . (confidence interval . - . ), for the comparison between prone and supine ventilated patients. interestingly, the pooled or for the icu mortality in the selected group of the more severely ill patients favored prone positioning (or . ; ci . - . ). the duration of mechanical ventilation and the incidence of pneumothorax were not different between the two groups. the incidence of ventilator-associated pneumonia was lower, but not statistically significant, in patients treated prone compared with patients treated supine (or . ; ci, . - . ). however, prone positioning was associated with a higher risk for development of pressure sores (or . ; ci, . - . ) and a trend for more complications related to the endotracheal tube (or . ; ci, . - . ). despite the limitations of the meta-analysis (ie the included studies were heterogeneous in terms of design, case mix, report of outcomes etc), the available evidence suggests that prone positioning has no discernible effect on mortality in the general population of patients with hypoxemic respiratory failure. it may decrease the incidence of ventilatorassociated pneumonia at the expense of more pressure sores and complications related to the endotracheal tube. however, some data imply that the more severely ill patients may benefit most from the intervention and await confirmation from adequately powered and designed clinical trials. in severe acute respiratory distress syndrome (ards), short-term high frequency oscillation (hfo) and tracheal gas insufflation (tgi) improves oxygenation relative to both standard hfo and ards network conventional mechanical ventilation (cmv)( ). we hypothesized that hfo-tgi may improve pulmonary function indices relative to cmv, if repeatedly employed on a daily basis. thirty adult patients with severe ards {pao /inspired o fraction (fio ) < mm hg at peep > cm h o}were randomized to receive either low tidal volume cmv ( - ml/kg predicted body weight) alone or in combination with daily, - -h-lasting hfo-tgi until resolution of severe ards or death. primary end-points were the time courses of gas exchange, respiratory mechanics, and hemodynamics. survival to days following randomization was also evaluated. data from all patients were analyzed. patient clinical profiles were similar. median hfo-tgi use was h/day for days. within the first eight days following randomization, study (hfo-tgi) group patients vs. controls had higher pao /fio ( . - . ± . - . mm hg vs. . - . ± . - . mm hg; p < . - . ) and quasistatic respiratory system compliance, and lower oxygenation index ( . - . ± . - . vs. . - . ± . - . ; p < . - . ), shunt fraction, and plateau and mean airway pressures. hemodynamics were not significantly affected by hfo-tgi. there was a trend toward improved -day survival in the study group vs. control ( / vs. / , p = . by fisher's exact test). in severe ards, the systematic daily use of hfo-tgi substantially improves gas exchange and respiratory mechanics. pressure-volume (pv) curve could help knowing which patient can benefit from a recruitment manoeuvre (rm). this study has been design to compare the hys of the quasi-static pv curve and the volume recruited by a rm. after ethical approval and relatives informed consent, early onset (< h) ards patients were investigated (igs ii = [ - ], lis = , [ , [ ] [ ] [ ] ] ). patients were sedated and paralyzed throughout the study. a to cmh o pv curve (pv tool, hamilton medical) was realized to measure hys i.e. the surface between the inflation and deflation curve measured between and cmh o. after min of ventilation, a rm consisting of a seconds pause at cmh o was realized using the pv tool. the volume recruited during the seconds/ cmh o rm was obtained by integration of the flow signal necessary to maintain the pressure of cmh o. no correlation was found between the lower/upper inflection points and the point of de-recruitment on the deflation limb of the pv curve. the volume recruited during a pause at the end of the inflation curve was well correlated with hys (r = , ; p = , ) (figure). in the early course of ards, the hys of the pv curve may be an indicator of how much the lung can be recruited by a seconds/ cmh o rm. treating acute respiratory failure (ali/ards) in the icu often requires mechanical ventilation, which carries a risk of vili. it is now commonly accepted that these patients should be ventilated "gently", i.e. reducing transpulmonary pressure fluctuations during ventilation. it is however still much debated as to how peep should be applied. methods to identify "best peep" are based upon descriptions of respiratory mechanics. however, only little is known as to how changes in peep modify pulmonary gas exchange. pulmonary gas exchange is usually described by arterial blood gas analysis or over-simplifying models such as the pao /fio ratio, the alveolar-arterial oxygen difference or the effective shunt. we describe the use of a more complex two-parameter model ( ) describing the effects of a peep-change using routine icu equipment. this method has potential for non-invasive use and may be incorporated in standard respiratory monitoring. eleven adult patients with acute respiratory failure on mechanical ventilation were included in the study. the patients were studied at two different levels of peep, i.e. either increasing or decreasing peep with cmh o. on each occasion the fio was varied in - steps to achieve values of sao ranging from - %. at each fio level measurements were taken of ventilation and arterial acid base and oxygenation status. these data were then used to estimate pulmonary shunt (shunt) and a measure of ventilation/perfusion mismatch, i.e. deltapo . upon increasing peep shunt decreased significantly by % (median) in patients, whereas deltapo improved in patients by kpa (median). as assessed by the p/f ratio oxygenation improved in patients by kpa (median). the increase in p/f ratio was, however, in cases explained by decreased deltapo not shunt. in patients where p/f-ratio was unchanged the value of shunt decreased significantly. the results suggest that by describing gas exchange by shunt and deltapo additional information can be obtained. these information may enable improved assessment of potential for recruitment and/or peep optimization. further studies are warranted. optimal peep avoids ventilator induced lung injury. this study determined the value of the elimination time-constant for co (tau-co ) to assess optimal peep. methods. pigs received lung lavage and hrs of injurious mechanical ventilation. a recruitment maneuver (rm) was performed for ' at / cmh o of peep/plateau pressure. the open lung peep (ol-peep) was defined as the level of peep after rm that kept the lung free from collapse. ol-peep was determined by respiratory dynamic compliance (cdyn), during a peep titration trial using the open lung tool ® (maquet, sweden), which was performed in vcv at a vt of ml/kg while decreasing peep from to cmh o in steps of cmh o every ' ( ). thereafter, we randomly assigned six ' periods at diff. peeps: ol-peep and peep either cmh o above or below it both, in recruited and non-recruited conditions. baseline ventilation was applied between study periods. we recorded dynamic lung mechanics and volumetric capnography data on a breath-by-breath basis (nico, respironics, usa). abg data were collected at the end of each period. paco was added to volumetric capnography to perform a complete dead space analysis using the standard bohr-enghoff formula. tau-co was calculated multiplying the respiratory time constant (cdyn x raw) by the amount of co eliminated per breath (vtco ,br). lung mechanics and gas exchange were best at ol-peep after rm. tau-co was longest at this moment due to an increase in both, cdyn and vtco ,br. the increase in cdyn and the decrement in raw slowed down peak expiratory flow during ol-peep ventilation. a reduction in vdalv/vtalv after rm and ol-peep indicated an increased ventilatory efficiency ( ) . vdalv/vtalv was more sensitive for determining ventilatory efficiency than the classical vd/vt. positive pressure ventilation in patients suffering from acute lung injury (ali) affects both, the distribution of ventilation (v) and perfusion (q) within the lungs. the aim of this work was to study the effect of lung recruitment and peep on v/q as assessed by multiple inert gas elimination technique (miget). a recruitment maneuver (rm) was performed for ' at / cmh o of peep/plateau pressure. the open lung peep (ol-peep) was defined as the level of peep after rm that kept the lung free from collapse. ol-peep was determined by respiratory dynamic compliance (cdyn), during a peep titration trial using the open lung tool ® (maquet, sweden), which was performed in volume control at a vt of ml/kg while decreasing peep from to cmh o in steps of cmh o every ' ( ). thereafter, we randomly assigned six 'periods at diff. peep levels: ol-peep and peep either cmh o above or below it both, in recruited and non-recruited conditions. baseline ventilation was applied between study periods to standardize lung volume history. we recorded dynamic lung mechanics on a breath-by-breath basis. hemodynamic data were recorded continuously and discont. by the picco monitor (pulsion, munich, germany). miget and abg data were collected at the end of each study period. ventilation at ol-peep after a rm resulted in better oxygenation and lung mechanics, lower shunt and lower amounts of areas with a high v/q as compared to the other periods studied (table) . recruited lungs ventilated at ol-peep showed better gas exchange and ventilatory condition than any other condition studied. these findings show that rm in conjunction with ol-peep make ventilation and perfusion more homogeneously distributed within the lungs and lead to an adequate matching of both. the onset mechanism of ali/ards and subsequent tissue injury are considered to be associated with neutrophil elastase, and the main two causes( direct lung injury: group d. and indirect lung injury: group i) of ali/ards are considered to be pneumonia ( bacterial, fungal, viral et al), aspiration pneumonia and sepsis. in japan, sivelestat sodium hydrate, a selective elastase inhibitor, was approved in for ali/ards accompanied by sirs, and this medicine has been evaluated in clinical situation. in this study, we performed a retrospective comparison of the sivelestat sodium hydrate administration between two groups of patients: group d, consisting of patients ( males and females, aged ± years old) , and group i, consisting of patients ( males and females, aged ± years old) with ali/ards accompanied by sirs who were treated with sivelestat sodium hydrate at a dose of . mg/kg/hour for hours or more in the icu. il- , il- , elam- (endothelial leukocyte adhesion melucule- ), pai- (plasminogen activator inhibitor- ) and pct (procalcitonin) were measured every hours. elisa and eia methods were used for the measurement of il- , pai- and elam- , respectively, and icl method was used for pct. the apache ?scores of group d and group i were ± and ± , and the lung injury score(lis) were . ± . and . ± . , respectively, with no significant differences between the groups. sofa scores of group d and group i were ± and ± , which was significantly higher than that of group d (p< . ). the pao /fio ratios under mechanical ventilation management , and hours after the beginning of drug administration were ± , ± , and ± mmhg in group d, and ± , ± , and ± mmhg in group i. furthermore, the survival rate after days was significantly higher in group d than in group i (group d: . %, group i: . %, p< . ). these results suggest that sivelestat sodium hydrate is a good option as a treatment strategy for neutrophil elastase-associated direct lung injuries accompanied by sirs. grant acknowledgement. no disclosure pulmonary edema significantly contributes to ventilation-perfusion mismatching and hypoxemia in ards. while inhaled nitric oxide (ino) has been shown to lower pulmonary pressures and edema accumulation in experimental acute lung injury (ali)( ), its clinical use has been questioned because of a lack of improvement in outcome, rebound phenomena and potential toxicity. we investigated the effects of aerosolized iloprost, a stable prostacyclin analogue, compared to ino on pulmonary pressures and lung edema in oleic acid lung injury. the most effective dose of iloprost in this setting was determined in healthy animals prior to the experiment. the anesthetized and ventilated sheep received a central venous oleic acid infusion ( . ml/kg) and were continuously infused with ringer's lactate to achieve a positive fluid balance ( ml/kg/h). in the ino group (n= ), inhaled nitric oxide ( ppm) was then administered continuously for hours, while animals in the iloprost group (n= ) received aerosolized iloprost ( µg every hours). animals in the control group (n= ) had no further intervention. pulmonary edema was measured by transpulmonary thermodilution (extravascular lung water). oleic acid infusion was associated with impaired oxygenation, pulmonary hypertension, and lung edema in all groups. while ino significantly decreased pulmonary vascular resistance index (pvri), effective pulmonary capillary pressure (pceff), and extravascular lung water index (evlwi), both parameters were unaffected by iloprost. oxygenation index (pao /fio ) increased significantly both during no and iloprost inhalation but also tended to improve in the control group over time. conclusion. this is the first study directly comparing the effects of inhaled nitric oxide and aerosolized iloprost on pulmonary hemodynamics and lung edema in experimental lung injury. in contrast to ino, µg iloprost inhaled every hours was ineffective to reduce pulmonary pressures and extravascular lung water. these findings partly contradict previous investigations, and may be best explained by dissolution of the highly water soluble iloprost in alveolar edema, which is a common finding in oleic acid lung injury. much higher doses of iloprost may thus be required to achieve a reduction of pulmonary pressures and fluid filtration when alveolar edema is present. while inhaled nitric oxide (ino) may be used in the management of ards, data would suggest that its benefits pertain to a short-term improvement in oxygenation with no significant beneficial effect on mortality . we performed a retrospective audit on the use of ino in our mixed medical and surgical intensive care unit. the following data were collected; age, apache ii score, length of icu stay, duration and cost of ino therapy, percentage change in pao /fio ratio, icu mortality. patients were sub-divided into responders/non-responders and survivors/non-survivors. a response to ino was defined as > % increase in pao /fio ratio . results are displayed in the table below. five responders survived to icu discharge ( . %), while non-responders survived ( . %). this difference did not reach statistical significance (p = . , chi-square). the total group costs of ino for responders, non-responders, survivors and non-survivors were £ , , £ , , £ , and £ , respectively. responders only accounted for % of the total ino expenditure in our icu. conclusion. ino is an expensive therapy. in this small retrospective audit we were unable to show any significant benefit of ino on outcome. the use of ino within our icu needs to be reappraised, especially in those ards patients classified as non-responders. the pvm tool of the respirator was easy to use. we observed no clinically evident haemodynamic complication. as a consequence of the pvm peep was increased in patients from ± to ± cm h o and decreased in patients from ± to ± cm h o. peep was not changed in two patients. there was a significant increase in pao /fi o ratio from ± to ± (p= . ) ( figure) while the change in paco was not significant ( ± versus ± ; p= . ). changes in peep did not correlate with changes in paco (r = . ; p= . ). after the implementation of the pvm into commercially available respirators, this manoeuvre can be performed safely and quickly. the setting of peep according to the results of the pvm lead to an improved oxygenation of the patients. we conclude that patients with ali/ards may profit from a routinely performed pvm. introduction. ards is a common syndrome with a high mortality rate in intensive care units. several pharmacological therapies have been proposed but none of them improved survival up to now. pulmonary hypertension occurs already in early stages of the disease and its magnitude has been shown to be associated with poor outcome. the phosphodiesterase type inhibitor sildenafil selectively dilates pulmonary vessels and has been approved for treatment of pulmonary arterial hypertension.. we investigated the effects of oral sildenafil in combination with inhaled prostacyclins in five patients with ards and septic shock. five patients with severe ards were investigated. underlying diseases were: copd (n= ), small airway disease (n= ), idiopathic fibrosing alveolitis (n= ), as well as cardiac insufficiency (n= ). four patients showed severe obesity, mean bmi was , ( ± , ). all patients fulfilled criteria of septic shock, three of them developed acute renal failure requiring continuous venovenous hemofiltration. all patients were monitored by a pulmonary artery catheter. mechanical ventilation was carried out according to recommendations of the ards-network. prone positioning (at intervals of hours) was instituted if possible. inhaled prostacylins (iloprost) were given times daily (max. concentration µg/d). if no persistent improvement of oxygenation could be achieved, sildenafil was added per os ( x mg/d). the combination of oral sildenafil ( x mg/d) and inhaled prostacylins resulted in a significant decrease of the mean pulmonary arterial pressure (pap-m). on the third day of therapy pulmonary arterial pressure was reduced by about % of the initial value (table ) . within a week a % improvement of the horowitz indices could be achieved. administration of sildenafil was continued in four patients until they could successfully be weaned from mechanical ventilation. these four patients left hospital alive. one patient died because of cardiogenic shock. , ± , * * significant difference from day (p < , ) conclusion. sildenafil in combination with inhaled prostacyclins causes significant reduction of pulmonary arterial hypertension as well as significant improvement of oxygenation in patients with ards and septic shock. increasingly the mouse has become the experimental animal of choice in immunological research because of the large set of immunological tools that is available. this is of particular interest in the area of inflammatory and immunological response to mechanical ventilation. most available rodent ventilators only ventilate one mouse at a time. in order to expedite the results of interventions, larger series of mice must be ventilated in a short period of time. therefore, we developed a method to ventilate mice simultaneously using a conventional ventilator. twelve mice were anesthetised, tracheotomised and subsequently connected to a servo ventilator c with a distribution system allowing simultaneous ventilation of six mice. a canula was inserted into the carotid artery for bloodsampling. for consecutive hours the mice were ventilated in a pressure-controlled, time-cycled mode, pip cm h o, peep cm h o, i/e ratio of : , fio . and a frequency of /min. during the hours of ventilation, arterial bloodgasses were collected after various periods of ventilation, with a maximum of bloodsamples per individual mouse. (n= ) not only demonstrated normocapnia (paco . ± . ) but also a normal ph (ph . ± . ) and adequate oxygenation (pao . ± . ). six mice can be ventilated simultaneously using a servo ventilator c with a distribution system, thereby decreasing the number of days spent to the experimental procedure and expediting experimental time. pulmonary vascular permeability increases in response to lung overstretching. phosphoinositide -kinase gamma (pi k gamma) is activated by mechanical stretch. akt, a major downstream signal molecule of pi k gamma, induces nitric oxide (no) production. we investigated the contribution of pi k gamma to acute alveolar edema formation by mechanical stretch. in wild type (wt) and knock-out (ko) pi k gamma mice, lungs were ventilated and perfused with two settings: eip - cmh o and eep cmh o (stress) or eip - cmh o and eep - cmh o (no stress). at the end of each experiment histological alveolar edema, lung elastance, pulmonary expression of erk, akt, enos, nitrate/nitrite (nox) on pulmonary perfusate were measured. see table . data are mean ± sd. during high stress ventilation vascular permeability changes were pi kgamma, akt, enos mediated. the lack of pi k gamma activity protected from alveolar edema increases. recent experimental data suggest that intrapulmonary cxc chemokine release, neutrophil infiltration and myeloperoxidase activity is considerably increased in aged individuals [ ] . years represented the best age threshold value that discriminated survival in mechanically ventilated patients [ ] and, we speculated that inflammatory responses may differ considering this age threshold. in patients bronchoalveolar lavage (bal) was performed with aliquots of ml . % saline on initial hospital presentation within hours after multiple trauma. cytokines were quantified using a sandwich immunoassay and neutrophil secretion products were determined with immunoluminometric assays. bal-phospholipids were determined with electrospray ionization mass spectrometric analysis. we compared older (> years, n= ) with younger patients (< pg/ml) (n= ) using the mann-whitnes-u-test or fisher's exact test and used the spearman rank correlation to assess relations between inflammatory parameters and age. older patients (mean±sd, . ± . years) had similar injury severity scores, thoraxtrauma severity and pao /fio -values as compared to younger patients ( . ± . years) (p> . ). of the older and of the younger patients developed ards (p> . ). only one patient died days after trauma. he was years old and developed ards due to sepsis weeks after trauma. intraalveolar il- release and both pulmonary and systemic neutrophil activation as reflected by myeloperoxidase and lactoferrin concentrations were reduced in older compared to younger patients (p< . ). pulmonary inflammatory parameters decreased significantly with increasing age: bal-neutrophils (rho=- . , p= . ), the inflammatory cell membrane phospholipid phosphatitylinositol : / : (rho=- , , p= . ), bal-lactoferrin (rho=- . , p= . ) and bal-il- (rho=- . , p< . ). in contrast to experimental data proinflammatory responses were reduced in aged individuals. it is tending to speculate that reduced immune competence instead of exacerbated inflammation may contribute to worse prognosis seen in the aged given an inflammatory insult. design: prospective, randomized controlled study. setting: medical and surgical intensive care units in a university tertiary care centerpatients: a total of patients with localized ards ready for recruitment maneuver (rm) were included. intervention: patients were randomized to receive mechanical ventilation (mv) in supine (smv, control group) or in prone position (ppmv, study group). both groups were ventilated with protective lung strategy (tidal volume to ml/kg). an rm was applied using a pressure control mode (pcv) with a cm h o and a cm h o peep for s. peep was subsequently reduced by cm h o increments until a decrease in compliance was observed. a second rm was then performed and peep was set one step above the level at which compliance declined. pcv level was kept at cm h o during the determination of optimal peep. results: bronchoalveolar lavages (bal) and blood samples were collected before randomization and at hours to determine the concentrations of interleukine (il- ), interleukine (il- ), interleukine (il- ) and tumor necrotic factor (tnf-±), pao / fio . pao /fio was improved and paco was lower in ppmv when compared with smv with statistic significance. at hours after rm, il- ( p = . ), il- ( p = . ) and il- ( p = . ) in bal was lower in the ppmv group than smv group. the serum level of il- ( p = . ) and tnf-± ( p = . ) were reduced with statistic significance and il- was reduced also (p = . ) for the ppmv group. conclusion. ppmv may improve oxygenation and reduce pco than in the smv position in patients with the localized ards during rm. the pro-inflammatory cytokines can be reduced during ppmv, which indicates attenuation of vili during pcv with peep recruitment maneuver for these patients. grant acknowledgement. this research is sponsored by the grants of vghnsu - . inflammatory cytokines have been found to be elevated in bronchoalveolar lavage fluids (balf) of ards patients. mediators formed from n- fatty acids (fa) and those developed from n- fa have opposite influences upon inflammatory processes. the aim of this study was to investigate whether n- fa may modulate inflammatory cytokines release in a cell culture of human pneumocytes exposed to balf of ards patients. thirty-one patients ( males, ± yr, sapsii ± ) with ards (as defined by the american-european consensus conference) requiring mechanical ventilation were included in the study. the p. were divided into those with pulmonary ards [ardsp, pneumonia (pn) n= ], and those with extrapulmonary ards (ardsexp, sepsis n= ; other n= ) without pn. all p. were examined by bal for clinical purposes within h after intubation. tnf-alpha, il- beta, il- and il- levels were measured in balf. we exposed a cells, a human pulmonary cell line with type ii pneumocyte properties, to the collected balf. after h, fa were added as docosahexaenoic acid (n- ) and arachidonic acid (n- ) in two different n- /n- ratios ( : and : ). h later, culture supernatants were collected to evaluate cytokine and prostaglandin (pg)e release. the fa percentage content was determined in phospholipids of a cells. level of peroxisome proliferator-activated receptor (ppar)gamma and nf-kb binding activity were determined. cytokine levels in balf were found higher in ardsp than ardsexp (p<. ). the baseline n- /n- fa ratio of : in a cell phospholipids approximately dropped to : and raised to : after : n- /n- ratio and : ratio incubation, respectively. we found that pge levels were significantly lower in a cells treated with the : ratio than those with : (p<. ). the release of cytokines from a cells was reduced by the : ratio (p<. ), but increased by the : (p<. ). nf-kb activity was induced in a cells by balf. addition of : ratio to the cells resulted in an increased expression of ppargamma, whereas nf-kb activity was more inhibited compared to : (p<. ). our results showed that increasing the n- share in n- /n- fa ratio induces a significant reduction of pro-inflammatory mediator (cytokines,pge ) release in stimulated a cells, whereas the administration of an n- fa predominance increases their release. although different cytokine levels in ardsp vs. ardsexp, the cause of ards did not influence the effect of n- addition. fa are ligands for ppargamma. our results suggested that n- fa might exert their anti-inflammatory effects through direct actions on the intracellular signaling pathways which lead to activation of ppargamma and inhibition of nf-kb activity. inflammatory response in a cells exposed to balf can be modulated by n- fa, due to their incorporation into membrane phospholipid pools that modifies lipid-related intracellular signaling events. th esicm annual congress -berlin, germany - - october s type plasminogen activator inhibitor (pai- ) is one of the primary regulators of fibrinolysis in vivo. a - g- g sequence polymorphism in the promoter of the pai- gene has been described as response polymorphism, since its release is regulated by various inflammatory factors. elevation of pai- levels after stressful events is much more pronounced in patients with the g allele. thus, the formation of microthrombi is no longer counteracted by the fibrinolytic system, resulting in impaired microcirculation, multiple organ dysfunction and poor outcome. our aim was to study the impact of the g allele on the survival rate of ali-ards patients. methods. ali-ards ( ali) due to sepsis ( ), pneumonia( ), aspiration ( ), severe trauma ( ), cardiac surgery ( ), pancreatitis ( ) and pulmonary embolism ( ) were studied. the mean apache ii score was ± . identification of the g- g polymorphism was based on polymerase chain reaction and reverse-hybridization. the comparison of the death rates between the two polymorphism groups ( g g versus non- g g group) was done by means of a logistic regression model, with survival as the dependent variable and the polymorphism, as well as the apache score, as the independent variables. . patients died (mortality . %). patients had a genotype g- g, patients were g- g heterozygous, while were g- g homozygous. apache scores were not significantly different between subgroups. the death rate among the g- g patients was %, while in the non- g- g patients was %. the univariate analysis showed that the g- g patients had % higher odds of dying compared to the non- g- g patients (odds ratio = . , % ci: . to . , p-value= . ). in the multivariate analysis the g- g patients had approximately . times higher odds of dying compared to the non- g- g patients (odds ratio = . , % ci: . to . , p-value= . ). however results were not statistically significant. our findings suggest a negative effect of this polymorphism on the survival odds of ali-ards patients. however, the small number of patients limited our power to detect a statistically significant difference regarding its influence on the prognosis of ali-ards patients with disorders triggering the coagulation cascade. our data might support further research on the relation between g- g polymorphism and outcome of ali-ards patients. excessive production of nitric oxide by neuronal nitric oxide synthase (nnos, nos- ) is one major factor in the pathogenesis of acute lung injury and systemic inflammation after burn and smoke inhalation injury. we hypothesized that the use of the selective nnos inhibitor -nitroindazole ( -ni) will block molecular mechanisms in ovine acute lung injury. adult ewes (n= ) were chronically instrumented to determine cardiopulmonary hemodynamics and pulmonary transvascular fluid flux. after seven days of recovery, sheep were randomly allocated to either an injured untreated control group (n= ), or an injury group treated with -ni (n= ). the injury consisted of a % total body surface area flame burn and breaths of cotton smoke. -ni ( mg/kg/h) was continuously infused from h post injury to the end of the -h study period. this double hit injury was associated with oxidative stress, severe pulmonary derangements and systemic inflammation, as evidenced by a . -fold increase in plasma nitrite/nitrate (nox) levels, as well as -fold, -fold, -fold and -fold increases in interleukin- (il- ), myeloperoxidase (mpo), malondialdehyde (mda) and poly-adp-ribose-polymerase (parp) lung tissue concentrations, respectively. compared to untreated controls, -ni significantly reduced nox plasma levels ( . ± vs. ± µmol/l) and decreased il- , mpo ( . ± . vs. . ± . u/g tissue), mda ( . ± . vs. . ± . nmol/mg protein) and parp lung tissue content ( . ± . vs. . ± . ), thereby decreasing pulmonary obstruction ( . ± . vs. . ± . obstruction score) and increasing pao /fio ratio ( ± vs. ± , each p< . ). these data show that nnos-derived no plays a pivotal role in the pathophysiology of combined burn and smoke inhalation injury and suggest selective nnos inhibition as a useful approach to attenuate pulmonary injury. h. qiu*, p. li, y. yang department of critical care medicine, nanjing zhong-da hospital, nanjing, china hpmecs were cultured, and used lps with a gradient concentration ( ng/ml, ng/ml, ng/ml, and ng/ml) to stimulate the cells for h, h, h, and h. subsequently, the experiments below were carried out. total ribonucleic acid was extracted from the cells for reverse transcription polymerase chain reaction (rt-pcr) to identify the expression level of angii receptor mrna. the total protein was extracted from the adhere cells for western blot to identify the protein expression of the at receptor. radioreceptor assay (rra) was used to obverse the affinity (kd) and maximum receptor binding (bmax) of angii with its receptor after lps stimulation. rt-pcr demonstrated that angiotensinii type (at ) receptor mrna level escalated after varying concentrations lps stimulating in h, h, h and h. there was obvious time-dependent increase in ng/ml group. the level of the at receptor mrna in ng/ml and ng/ml groups have not time-dependent increase. irrespective of lps stimulating or not, hpmecs didn't express mrna of angiotensinii type receptor (at ). western bolt presented that the protein level of at receptor had a predominant increase followed the lps treat compared with control group ( ng/ml). after stimulated for h, the level of at receptor protein reached to the peak value in ng/ml group, and no notable difference was defined at every time after that. the significant dose-dependence was showed in every stimulating time, but the time-dependence was defined just in ng/ml and ng/ml groups. rra was confirmed that there was no striking statistics difference between each group for kd. as far as bmax is concerned, bmax of the three groups ( ng/ml, ng/ml, and ng/ml) had a significant increase compared with the control group. the groups of ng/ml and ng/ml had peak value at h and h respectively, and had a significant decrease after respective peak value time. the bmax of the ng/ml group escalated to the peak value and demonstrated a notable time-dependence. lung ischemia and reperfusion in the pulmonary vascular compartment is an unavoidable consequence of transplantation. it is associated with release of inflammatory mediators promoting chemotaxis and adherence of neutrophils, which finally disrupt endothelial cell layer and increase permeability, possibly leading to acute lung injury ( ). rare data exist about similar mechanisms in the upper and lower respiratory compartment with tracheobronchial (tbec) and alveolar epithelial cells (aec). purpose of this study was to evaluate the effect of hypoxia/re-oxygenation (h/r) regarding the inflammatory response in the respiratory compartment. aec and tbec were placed in a hypoxic incubator with % oxygen for hours and re-oxygenated at % oxygen during , , and hours. for each time point, control cells were left at % oxygen. supernatants were analyzed performing a sandwich enzymelinked immunosorbent assay (elisa) for mcp- and cinc- (pharmingen, san diego, ca). caspase- and ldh measurements were performed. statistical significance was assessed by student's t-test. (values: mean ±sem). protein expression of mcp- and cinc- in aec was decreased upon h/r: at h hypoxia with h re-oxygenation mcp- decreased fromm ± pg/ml to ± pg/ml (p< . ), cinc- from ± pg/ml to ± pg/ml (p< . ). at h/ h h/r no difference in mcp- and cinc- expression could be observed in comparison to control cells. interestingly, inflammatory mediators released from tbec did not show any differences upon stimulation compared to control cells. caspase- activity in stimulated and unstimulated aec was similar. in tbec, however, caspase- activity was decreased by % at h/ h h/r, at h/ h by %, and at h/ h by % (p< . ). ldh values did not differ in stimulated and unstimulated aec and tbec, indicating that no process of necrosis is involved. upon h/r the lower respiratory compartment with aec reacts with decreased production of inflammatory mediators, while the upper compartment with tbec shows diminished apoptosis rate. biological significance of this attenuation of epithelial injury upon h/r has to be further investigated. , . : - grant acknowledgement. société suisse d'anesthésiologie et de réanimation schweizerische gesellschaft für anästhesiologie und reanimation: ssar/sgar methods. ards was induced in healthy pigs ( ± kg) by repeated saline lung lavage until pao decreased to less than mmhg. after a stabilisation period, the animals were randomly assigned to two groups: cmv: fio = . , vt = ml/kg, and hfov/av-ecla: fio = . , frequency = - hz. after lung recruitment, the peep in the cmv group and the mean airway pressure (mpaw) in the hfov/av-ecla group was set cmh o above the lower inflection point (lip) of the p/v-curve. gas exchange and hemodynamic data were determined hourly. after h, mrna expression of tnf-alpha, il- -beta, il- , il- and il- in lung tissue was quantified by real time pcr. histopathologic analysis from the lungs was performed using a four point semi-quantitative severity based scoring system. ( ). h s also exerts a variety of cytoprotective effects in vitro and in vivo ( ) . therefore, we tested the potential cytoprotective effect of infusing the h s-donor nahs during porcine thoracic aortic occlusion-induced ischemia/reperfusion(i/r)-injury. methods. after random assignment to either nahs (n= ); mg/kgxh started h before and continued until h after aortic occlusion) or vehicle (n= ) anesthetized, ventilated and instrumented pigs underwent min of aortic occlusion using inflatable balloons placed immediately downstream the a.subclavia and upstream the aortic bifurcation. during aortic occlusion, mean arterial pressure (map) was maintained between - % of the baseline levels using continuous i.v. esmolol, nitroglycerine and atp. during the reperfusion continuous i.v. noradrenaline (na) was titrated to maintain map> % of the baseline level. dna damage in blood samples was evaluated with single cell gel electrophoresis (tail moment in the comet assay). data are median (range), within group effects over time were analyzed using a friedman anova on ranks, intergroup differences with an unpaired rank sum test. results. infusing nahs resulted in significantly lower heart rate and cardiac output, while map and stroke volume remained unchanged. nahs significantly reduced the na requirements needed to achieve the hemodynamic targets, significantly decreased glucose turnover, and completely blunted the i/r-induced dna damage (see septic shock is associated with increased oxidative stress, which in turn depresses mitochondrial activity. the key antioxidant enzyme superoxide dismutase (sod) was reported to restore mitochondrial function ( ). since glucose oxidation represents the most effective energy generating process, we investigated the effect of genetic cuzn-superoxide dismutase overexpression on glucose oxidation in a clinically relevant model of murine septic shock ( ) . h after sepsis induction by cecal ligation and puncture (clp) or sham-operation heterozygous (he), homozygous (ho) sod overexpressing and wildtype (wt) mice were anesthetized, mechanically ventilated and instrumented. in the clp groups normotensive, hyperdynamic hemodynamics were achieved with colloid fluid resuscitation and intravenous noradrenaline (na) titrated to maintain mean arterial pressure (map) > mmhg. glucose oxidation rate was calculated from simultaneous determination of co enrichment and co concentration (gas chromatography/mass spectrometry) in the expired gas during continuous i.v. stable-isotope , , , , , - c -glucose infusion. measurements were recorded , and h after clp. within group effects over time were analyzed using a friedman anova on ranks, intergroup differences with an unpaired rank sum test. all parameters of gut and liver macro-and microcirculatory perfusion and oxygenation were well maintained. na infusion rates did not differ between clp groups. glucose oxidation (percentage of the infused c -glucose) did not differ between groups nor over time. liver sod-activity prior to anesthesia and surgery was . -fold and -fold higher in he and ho mice, respectively. while it decreased by about % in the septic he and ho mice, sod activity was not significantly affected in the wt animals. given the comparable parameters of macro-and microcirculatory perfusion and oxygenation, the lacking na-induced increase in glucose oxidation rate confirms the sepsis-related defect in energy metabolism. the higher tissue sod-activity did not restore the impaired carbohydrate utilisation, possibly due to a sepsis-related loss of tissue sod and/or catalase activity. anemia is frequent in icu and involved both functional and true iron deficiency due to inflammation and blood loss. hepcidin (hepc) is a negative regulator of iron recycling by macrophages. its synthesis is highly inducible by inflammation and repressed by iron deficiency and stimulation of erythropoiesis. we explored iron metabolism and hepc gene expression in this complex situation of icu anemia. we developed a model of inflammation in c bl/ mice, by ip injections of zymosan (z), combined or not with repeated blood withdrawals (w). we followed blood numeration and tissue iron concentrations. using qrt-pcr, we quantified hepc and il- mrna in the liver as well as erythropoietin (epo) mrna in the kidney (normalised to s mrna and expressed as a ratio to controls (c)). hepatic ferroportin protein concentrations were assessed by western-blot. kruskal-wallis or anova were used for comparisons of mean±sd. p< . significant. anemia was found already days after zymosan injection, and was more severe blood withdrawals, either alone (w) or following z (z+w). at day , epo mrna expression was stimulated in both w ( . ± ) and z+w ( ± . ), as compared to c( ± . ) or z ( . ± . )(p< . ). as expected, z injection induced il- mrna expression ( . ± . for z; . ± . for z+w). interestingly, hepc mrna was induced following z injection ( ± . ) but the combination of inflammation and w repressed hepc mrna expression ( . ± . ). to confirm that it was due to erythropoiesis stimulation, we injected epo on consecutive days following z and found that it prevented activation of hepc mrna( . ± . ). in mice undergoing w or epo injections, spleen iron was reduced, as opposed to c and z ( ± , ± , ± , ± vs ± and ± µg/g for z+w, w, z+epo, epo, c and z). ferroportin was reduced in z and increased by w and epo (western-blot). conclusion. in this mouse model of inflammation, induction of hepc gene expression is prevented by repeated w or epo ip. it seems that the signalling pathway which represses hepc expression in response to activation of erythropoiesis dominates over the pro-inflammatory signal. furthermore iron exporter ferroportin is also induced. these results raise the possibility that iron supplementation might be proposed for critical care patients' anemia. studies examining the effect of glutamine supplementation in critical illness have demonstrated significant beneficial effects in animals and man although the mechanisms by which this protection occurs are not understood. we aimed to examine the effect of various glutamine concentrations on the ability of c c myoblasts to differentiate and its effect on heat shock protein expression (hsp). methods. c c myoblasts were raised under standard conditions. differentiation to multinuclear myotubes was induced by replacing fcs with % horse serum. cells were supplemented with glutamine at concentrations between and mm throughout and this was replaced every other day. photographs were taken at day of differentiation. hsp content of cells was determined using western blotting as described previously (maglara et al, ) . at low levels of glutamine ( - mm), cell survival was greatly impaired and differentiation was reduced. however hsp content of cells grown in media of . m and m glutamine showed an increased hsp response compared with cells grown and differentiated in physiological glutamine concentrations. no effect of higher glutamine concentrations (between . - mm) on cell viability or hsc and hsp content was evident. conclusion. glutamine supplementation affects heat shock protein (hsp) expression in various cell types. several authors have suggested that exposure of cells to relatively high concentrations of glutamine results in increased hsp expression and an enhanced cell survival (wischmeyer et al. ) skeletal muscle degeneration occurs following a number of insults and muscle repair is reliant upon activation and differentiation of stem cells or myoblasts to form mature multinucleated muscle. transgenic studies in our laboratory have demonstrated that the ability of skeletal muscle cells to produce hsps during stress and development is crucial to the correct maturation and functioning of these cells (mcardle et al, ) . our data suggests that the glutamine concentration for optimal myoblast proliferation and differentiation is ∼ mm. reduction below this value resulted in reduced cell viability and modified hsp although levels higher than physiological had little effect on cell growth and differentiation. this might suggest that reduced glutamine concentrations in it self acts as a stressful stimulus. further reduction however renders the cell unable to respond at all. in addition g regulation might be linked to other stress hormones, such as cortisol (c) and prolactin, in rats and humans in physiological conditions. our aim is to study the circadian variations of cortisol and ghrelin plasma levels in patients with acute coronary syndrome (acs) admitted to the intensive care unit. eight male ( ± years old) patients with acs were studied. seven showing non-st-elevation and one with st-elevation. within the first hours of admission, blood samples were taken every hours (nine samples) in all acs patients. patients were kept nothing per os during the sample drawing period. eight patients admitted in the department of internal medicine in a stable clinical situation were studied on the day before being discharge, as control group. g and c levels were measured in all samples using specific ria (phoenix pharm. usa). control subjects showed a cortisol circadian rhythm with peak values at : a.m. ( , ± , mcg/dl) and nadir values around : p.m. ( , ± , mcg/dl). in this patients g levels also present circadian variations, with peak values at : a.m. ( , ± , pg/ml) and nadir values at : p.m. ( ± , pg/ml). in contrast, patients with acs showed a very demised c circadian rhythm, and the amplitude of the circadian variations of g levels is markedly reduced, showing a shift of the peak values to : p.m.( , ± , pg/ml ) and nadir values around : a.m. ( , ± , pg/ml). there is a circadian rhythm of ghrelin with a peak ranging from : a.m. to : a.m. in hospitalized subjects. those variations are o shifted in phase respect to cortisol rhythm. opposite, in patients with acs the circadian variations of ghrelin levels are lost. the results of lft of patients admitted to the general intensive care unit of a large teaching hospital in south london, between st december and th february were obtained from the chemical pathology department. mortality statistics were obtained from the hospital electronic patient record. lft of patients who were readmitted were excluded. a total of patients had a first admission to the general icu during the three months studied. the average age was . yrs (sd . ), % were male and the mean length of stay was . days (range - ). mortality rate at days was % ( / ). at the time of admission only ( %) patients had entirely normal lft. patients with cholestatic lft above the normal range on admission were more likely to be female (akp odds ratio: . ( . - . ), gammagt or: . ( . - . )). abnormalities in alt, akp and gammagt on admission, were associated with a higher likelihood of death at days (table). average length of stay was greater in those with abnormal lft but only reached statistical significance with akp above the normal range (table) . conclusion. abnormality of liver function tests is common in the critically ill patient admitted to the general intensive care unit. even relatively minor elevations of lft are associated with an increased risk of death within days. the cause of these abnormalities is likely to be multifactorial and further studies are needed to elucidate the cause. myxedema coma with extreme hypothermia: a case report e. brands* intensive care, academisch ziekenhuis maastricht, maastricht, netherlands a patient is presented with an undiagnosed hypothyroidism which progressed to myxedema coma with extreme hypothermia, bradycardia, anaemia and somnolence. a year old male patient, with a history of hypertension and a cerebral vascular accident, was admitted to the emergency room after a collapse. during several months he showed progressive disability due to fatigue, unstable gait and chilliness. the last weeks his condition worsened leading to muscle weakness, dysarthria, dysphagia, cognitive dysfunction and somnolence. upon physical examination we saw a somnolent patient with a gcs (glasgow coma scale) of - - , with hyporeflexia and pareses of the lower extremities. respiratory rate of per minute. blood pressure was / with a heart rate of beats per minute. the patients temperature was . oc. the patients gcs decreased to - - upon which an endotracheal tube was placed and mechanical ventilation instituted. laboratory tests showed a haemoglobin . normal adrenal function test. one day after thyroid hormone substitution ( µgr t intravenously on day one, followed by µgr t once a day, µgr t orally every hours on day one only), the patients regained consciousness. his heart rate increased to beats per minute after normalisation of body temperature. gastroscopical evaluation showed an ulcus duodeni. despite of a ventilator associated pneumonia the patient recovered well. hypothyroidism may lead to a variety of symptoms ranging from malaise and fatigue to specific organ related complaints. especially in the elderly the symptoms may be mistakenly attributed to the physiological aging process, psychiatric, neurological illnesses or even dementia. numerous precipitating factors can evolve untreated hypothyroidism to myxedema coma. in our patient infection, cold exposure, gastro intestinal bleeding or iron deficiency could have played a role. the elderly patient is already prone to hypothermia due to physiological changes, in myxedema this may lead to an extreme low temperature. myxedema in its classical, full clinical presentation is a rare occurence in present times. especially in the elderly patient it can cause pronounced hypothermia. according with surviving sepsis guidelines we must control blood glucose levels to a less than mg/dl after h of admission to an icu. objectives: to evaluate the results obtain with the use of an intensive insulin treatment (iit) in a polyvalent intensive care unit. we conducted a prospective cohort study in a -bed polyvalent icu in a portuguese university hospital. adult patients who were assumed to require at least days of intensive care were eligible for inclusion. the study was carried out during months. capillary blood glucose (cbg) levels were measured on admission and subsequently every two or four hours in all patients during days. with the iit, insulin infusion was started when the blood glucose level exceeded mg per decilitre. we enrolled patients, age: , ± , ( , ), sapsii: , ± , ( , ), sofa: , ± , ( , ), length of stay in icu: , ± , ( , ), mortality rate: . %. , % of the patients were diabetes. incidence of hypoglycemia - , %. to examine the effect of central venous catheter (cvc)location on the incidence of catheter related blood stream infection (crbsi) in a total parenteral nutrition (tpn) population over a -year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . . bed university hospital. tpn population includes all medical and surgical patients hospital-wide referred for tpn. service based in intensive care. tpn committee meets quarterly to examine prospectively collected data. . cvcs were included. we compared incidence in different anatomical locations(figure). femoral cvcs were rarely used for tpn and so were excluded. subclavian cvc insertion was associated with a peak incidence of crbsi of per cvc days in which dropped to in . peak incidence of crbsi in internal jugular cvcs was per cvc days in , per cvc days in . this study prospectively examines the effect of anatomical location on crbsi. crbsi in subclavian cvcs remains almost consistently lower than internal jugular throughout study. this correlates with published data in the literature and cdc recommendations for use of subclavian site in preference for cvc insertion . patients after urgent abdominal surgery require adequate nutritional support. we aimed to assess the effectiveness of parenteral nutrition (pn) by "all-in-one" system with adding of glutamine to eliminate metabolic disturbances in patients after small bowel obstruction surgery. methods. patients after small bowel obstruction surgery (mean age . ± . years) was divided into groups. control group (n= ) received standard basic intensive therapy including pn by "all-in-one" system "oliclinomel" in first hours after an operation. glutamine group patients (n= ) received additional glutamine (dipeptiven - ml/kg/day). plasma whole protein and its fractions, amino acids spectrum, transferrin concentration, glucose and insulin levels, as well as standard laboratory and instrumental data were assessed before, at rd and th day of pn. in all patients metabolic disturbances with protein status shifts was revealed. dynamic analysis of data showed faster compensation of these disturbances in glutamine group. in both groups whole protein and albumin/protein ratio decreased gradually while amino acid sum, essential and nonessential amino acid concentration, glucose and insulin levels remained normal. by th day glutamine group showed faster increasing of transferrin concentration ( . ± . g/l vs. . ± . g/l) and fisher index ( restoration of metabolic activities confirms adequate nutritional support in both groups but glutamine adding provides faster improvement of protein disturbances and helps to avoid glutamine deficiency. y. kang* , h. jiang , x. qiang , x. jin , q. yi icu, general surgery, respiratory, west china hospital of sichuan university, chengdu, china to investigate the effect of supplementation with alanyl-glutamine dipeptide on insulin resistance and outcome in critically ill copd and respiratory failure patients. prospective, randomized and controlled study. patients who were admitted to west china hospital icu between jan and feb were selected and randomized into two groups which were given the similitude nutrition support protocol. two groups' nonprotein calorie were kcal/kgd, % were provided by fat emulsion. the nitrogen supply were . g/kg in each group. in treatment group %- % of nitrogen was given from the parenteral nutrition by the alanyl-glutamine dipeptide, the rest was the equilibrium amino acids. in the rd and th day, blood glucose clamp were performed in both groups, and blood glucose was rigidly controlled between . to . mmol/l. daily blood gas, glucose and insulin dosage and th day mortality , length of stay (los) in hospital and in icu, duration of mechanical ventilation (dmv) and the costs of icu and hospital were measured respectively. . patients completed the research. there was no difference in blood gas between two groups, but pao rose gradually. compared with control group, the five day's blood glucose level have a decreasing trend in treatment group. during the five days, the average insulin dosage have an obviously decreasing in treatment group. there were no difference between two groups in th day mortality, los in hospital and the costs of hospital. but the los in icu and dmv have a decreasing trend in treatment group. alanyl-glutamine dipeptide have not improved pulmonary function in critically ill patients with copd and respiratory failure. however, alanyl-glutamine dipeptide have contained certain function at attenuated insulin resistance and stabilized the level of blood glucose. alanyl-glutamine dipeptide did not reveal the effect of improving outcome in critically ill patients with copd and respiratory failure, the th day mortality, los in hospital and the costs of hospital. but the the los in icu and dmv have a decreasing trend in treatment group. adrenocortical dysfunction is a common finding in severe illness. however, it remains currently unclear whether adrenocortical responses predict outcome in acute critically ill patients. to investigate this, ( men) acute critically ill patients, with a median age of years were studied. admission diagnoses included multiple trauma (n= ), medical (n= ) or surgical (n= ) critical conditions. within hours of icu admission, a morning blood sample was obtained to measure baseline cortisol, corticotropin (acth), and dehydropiandrosterone sulphate (dheas). subsequently, a low-dose ( mcg) acth test was performed to determine stimulated cortisol. the incremental rise in cortisol was defined as stimulated -baseline cortisol. overall, patients survived and patients died. non-survivors were older and in a more severe critical state, as reflected by the higher sofa and apache ii scores. furthermore, non-survivors had a lower incremental rise in cortisol ( . vs. . mcg/dl, p< . ) along with lower dheas than survivors ( vs. ng/ml, p= . ). the two groups had similar baseline and stimulated cortisol. multivariate logistic regression analysis revealed that age (odds ratio= . , % c.i. . - . , p= . ), sofa score (odds ratio= . , % c.i. . - . , p< . ), and the incremental rise in cortisol (odds ratio= . , % c.i. . - . , p= . ) were independent outcome predictors. in mixed critically ill patients a blunted cortisol response to acth within hours of icu admission is an independent predictor for poor outcome. in contrast, baseline cortisol or adrenal androgens are not of prognostic significance. teicoplanin is a gycopeptitide antibiotic for treatment of highly resistant gram-positive bacteria such as methicillin resistant staphylococci and enterococcus faecalis. it is eliminated unchanged by the kidneys. in renal impairment the maintenance dose has to be reduced. data on pharmacokinetics of teicoplanin in patients requiring continuous veno-venous haemofiltration (cvvh) are sparse. therefore teicoplanin pharmacokinetics was assessed in critically ill patients during on cvvh. teicoplanin serum levels were measured in adult critically ill patients requiring cvvh for acute renal failure after the first dose and at approximate steady state conditions (day - of therapy). cvvh was performed using . m polyetersulfone membranes; blood flow was ml/min and the ultrafiltration rate amounted ml/kg body weight. a loading dose of , mg of teicoplanin was administered (infusion time h). subsequently the dosage was guided by serum levels and reduced to an average daily dose of ± mg per day. samples were drawn , , , , and h after start of infusion. teicoplanin was measured by a fluorescence polarisation immunoassay in serum and ultrafiltrate. pharmacokinetics was calculated using a non-compartmental model by kinetica . concentration time profiles of patients were determined after the first dose and of patients during steady state. the teicoplanin peak concentration was . ± . µg/ml (mean sd) after the first dose and . ± . µg/ml at steady state. trough levels amounted . ± . µg/ml and . ± . µg/ml, respectively. the half-life increased from . ± . h after the first dose to . ± . h at steady state, whereas the clearance declined from . ± . l/h to . ± . l/h. the apparent volume of distribution decreased from ± to ± l. the sieving coefficient of teicoplanin amounted . after the first dose and . after repeated administration. a loading dose of , mg of teicoplanin followed by a maintenance dose of about , mg per day appears to result in adequate serum levels in a majority adult critically ill patients on cvvh. however, because of a considerable variability of teicoplanin pharmacokinetics in this group of patients, therapeutic drug monitoring is recommended to warrant safety and efficacy of treatment. although heparin is the most frequently used anticoagulant in cvvh, alternatives to heparin are needed in case of heparin induced thrombocytopenia (hit). argatroban, a direct thrombin inhibitor approved for hit is primarily metabolized by the liver, thus, should not accumulate in renal failure. however, there is only limited data regarding its use in continuous venovenous hemofiltration (cvvh). we report a patient with acute renal failure where anticoagulation by argatroban appears to be influenced by cvvh. a years old woman was admitted to the icu department with septic shock and acute renal failure. bilateral infected crural ulcers could be identified as focus and therefore both calves had to be amputated. after days of cvvh with heparin as anticoagulant a rapid drop in platelet count of more than % occurred, a suspected hit was confirmed by heparin-pf antibodies (elisa). although there was no hepatic failure argatroban was started at mg/h ( , µg/kg/min) because of cholestatic cholecystitis and severe sepsis. results. aptt increased from to seconds after hours of argatroban infusion and further to sec after hours (figure ). at the same time pt fell from % to %. therefore argatroban dose was reduced by % to , mg/h. after h cvvh had to be stopped for h. after discontinuation of argatroban a decrease in aptt from to sec, as well as an increase in pt from to % was observed. h after argatroban was restarted at , mg/h, cvvh was stopped again for , hours without discontinuing argatroban. shortly after cvvh was halted aptt increased from to sec and pt decreased from to % within hours. this trend continued even after stepwise reduction of the dose of argatroban to , mg/h. the trend could not be reversed until the dose was further reduced to , mg/h and argatroban was stopped. after restarting cvvh without argatroban infusion a further decline in aptt as well as an increase in pt was observed. conclusion. this case demonstrates that argatroban may be influenced by cvvh and that dose may have to be substantially reduced in these patients. regional citrate anticoagulation (rca) is the recommended strategy when risk of bleeding is increased in continuous venovenous hemofiltration. we evaluated the feasibility and the safety of this method in high volume hemofiltration (hvhf) in critically ill patients with severe coagulopathy. methods. patients ( ± years, saps ii ± , sofa . ± . , septic shocks and sirs) have been retrospectively studied between january, and december, . continuous renal replacement therapy, daily limited to hours, was performed with a frésénius hdftm generator. blood flow was ml/min. the generated replacement fluid, calcium free, was used in pre-dilution. a citrate solution (acdar-fréséniustm) was infused to target a prefilter ionised calcium level below . mmol/l whereas systemic calcium perfusion maintained normal plasmatic calcium level. hemofiltration characteristics, filters lifetime and metabolic complications were the main collected data. . hfhv days ( filters needed) were analysed. mean hemofiltration volume was ml/kg per hour (about l per hour or l per day). percent of the prescribed hfhv dose could be carried out. mean filters lifetime was . hours. percent of them prematurely clotted. citrate and calcium perfusion flow respectively needed to be modified an average of and , time per day. metabolic alkalosis (ph> . ), hypocalcemia (ca++< . mmol/l), hypercalcemia (ca++> . mmol/l), hypernatremia (na+> mmol/l) and one citrate intoxication (total to ionised calcium ratio> , ) occurred. none of these events lead us to modify the anticoagulation strategy. prefilter ionised calcium level in non clotting filters was , ± , mmol/l versus , ± , mmol/l in clotting filters (p= , ). % of the patients died in hospital whereas predicted mortality was %. conclusion. rca is a reliable and simple method for hvhf with high hemorrhagic risk patients. frequent minor metabolic complications require a narrow biological monitoring. to improve our practices, prefilter ionized calcium levels should be decreased. continuous venovenous hemofiltration(cvvh) or hemodiafiltration (cvvhd) are the commonest renal replacement therapies(rrt) prescribed to the patients with the septic shock having renal failure. each cvvh session for hours costs around e in india as against intermittent hemodialysis(ihd),which costs around e per to hour session. hence ihd is still the commonest form of rrt in indian icus. major concern of ihd in septic shock patients is hemodynamic instability. whether stringent hemodynamic monitoring and maintaining preset goals would reduce these instabilities & deliver optimal rrt is not clear. we undertook a prospective study to evaluate this concept. we attempted to achieve preset goals of keeping mean arterial pressure (map) > mm, cardiac output (co) > lit./min & cardiac index (ci) > . lit./min/m throughout the session by following the protocol in the given sequence-: ) fluid boluses ) increase in vasopressor or inotrope dose ) adjustment in ultra filtration rate between - ml/hr and )adjustment in blood flow rate between - ml/min on hemodialysis machine. dopamine, norepinephrine, vasopressin and dobutamine were used alone or in combination to achieve these goals. hemodynamic monitoring & data collection was done with flotrac-vigileo monitoring systemtm (edwards lifesciences,irvine,ca,usa) and intellivue mp (philips,germany). . ihd sessions of patients with septic shock needing vasopressor were monitored and managed in icu. base line apache ii score was . ± . and all patients had at least organ failure. average duration of ihd was . ± . hrs and net negative fluid balance achieved per ihd session was . ± . ml. table showing hemodynamic parameters before ihd and during ihd preset goals were maintained without any intervention in sessions, with fluids alone in sessions, fluids and escalation of vasopressor in sessions and fluid bolus plus vasopressor escalation plus reduction in ultra filtration & blood flow in sessions. only / sessions were terminated at & min. due to development of new myocardial infarction in one and persistent hypotension in the other. additional cost of c. o. and c.i. monitoring was aboute per session. continuous veno-venous haemofiltration (cvvh) clears solutes and improves acidosis in critically ill patients with renal failure and sepsis. we studied solute clearance and filtration quantity prospectively in the first hours of patients requiring cvvh on two teaching hospital intensive care units. data collected included demographic data, reason for starting cvvh, blood biochemistry prior and after starting cvvh as well as duration of cvvh, including reasons for any interruptions. blood tests were collected once in a -hour period. data was collected for the entire period that patients required cvvh. solute clearance on cvvh within the first hours was expressed as a percentage change of urea and creatinine levels compared with levels prior to cvvh. quantity of haemofiltration was calculated over the interval between the first two blood tests and expressed in relation to bodyweight. data from patients is presented ( patients died before blood samples on cvvh was taken). the main indication for commencing cvvh was sepsis/acidosis in patients and renal failure in patients. the values for urea and creatinine on admission differed considerably between both groups. patients with sepsis/acidosis received a median cvvh-dose of . mls/kg/hr, whereas patients with renal failure were treated with a median cvvh-dose of . mls/kg/hr. table shows the respective median values for urea and creatinine prior to cvvh and from the first sample on cvvh, as well as the median (interquartile range;iqr) cvvh dose delivered in the period between the two samples. ( ) . we therefore studied the effect of anticoagulation on cvvh delivery. over a four month period data from patients across adult intensive care units was recorded. the number and reasons of interruptions and subsequent time lost as well as the type of anticoagulation was documented. infusion of heparin into the circuit was the primary form of anti-coagulation. heparin was started at units/kg/hr and adjusted according to local protocol to achieve a target heparin ratio (aptr) of . - . . aptrs taken from the circuit within the previous hours were defined to represent the degree of heparinisation at the time of a filter clotting off. a total of . patient hours of cvvh was delivered. filter clotting was implicated in of interruptions ( %). table shows the various forms of anticoagulants used, the number of interruptions and total time lost due to filter clotting. in the heparin group, aptrs were recorded. only % of these were therapeutic and % were sub-therapeutic. aptrs were recorded within the hours prior to filter clotting, representing % of all clotting events occurring on heparin. clotting events occurred with a therapeutic aptr, with recorded subtherapeutic ratios (relative risk . ), and event with an aptr > . filter clotting is by far the most common cause for interruptions in cvvh delivery ( %). adequate anticoagulation of cvvh circuits with heparin is problematic and failure to achieve the terget aptr carries a considerable risk of filter clotting. % of ap-trs were subtherapeutic despite use of a written protocol, suggesting that many patients are exposed to an increased risk of filter clotting regardless of other causative factors. whilst we recognise that the aetiology behind filter clotting is multifactorial, reducing these interruptions with adequate anticoagulation is important and may have positive effects on patient outcome. during continuous renal replacement therapy (crrt) anticoagulation of the extracorporeal circuit is generally required to prevent clotting of the circuit, preserve filter performance, optimize circuit survival, and prevent blood loss due to circuit clotting. unfractionated heparin (ufh) and low molecular weight heparin (lmwh) are generally used to perform this strategy. however, this anticoagulation may cause dangerous bleeding especially in acute renal critical patients. in these patients, it's very difficult to predict bleeding or thrombosis correctly during crrt. to asses the safety and efficacy of the use of an enoxiparin dose protocol based on anti-xa activity in crrt. methods. consecutive patients with acs was admitted to a coronary care unit of terciary hospital between [ ] [ ] patients presented heart failure during their hospitalization. clinical, ecg, echocardiographic, features were prospectively investigated. we also took blood samples in the first hours of their admittance to the ccu for a complete hemogram, levels of total cholesterol, hdl cholesterol, ldl cholesterol, triglycerides, creatinine, clearance of creatinine (mdrd equation), glucose, hbac , high sensibility-c reactive protein (hs-crp) and a follow up of levels of troponine, ck and ck-mb. we determined the presence of microalbuminuria (ma) (> mg/dl in a -hour urine sample). all patients were submitted to a coronary angiography in the first hours. we defined rd if the clearance of creatinine < ml/min/ . m . non-st segment elevation myocardial infarct (nstemi) was the most frequent cause of heart failure ( . %). the rd was present % of hf. the patients of this group was oldest, more diabetes mellitus, more previous myocardial infarct more anterior descendent occlusion. moreover, the patients with hf and rd had a lowest hematocrit ( % vs %), troponin i peak concentration ( . ng/ml vs ng/ml) and had higher of creatinine ( . mg/ml vs . mg/ml), ma, admission glycemia ( mg/dl vs mg/dl), nt probnp ( pg/ml vs pg/ml) and cystatin c ( . vs . ). both group present similar reduced ejection fraction ( % vs %). this group presented higher incidence of post infarct angina ( %; p= . ). in-hospital mortality was in patients with hf and rd % vs % in hf without rd (p= . ). in the follow-up (median days) the mortality of patients with hf and rd was % (p= . ). the mortality of the group with rd and treatment with ace-inhibitors was % vs % without ace-inhibitors (p= . ). the multivariate analysis identified the rd was a independent predictor of mortality in the patients with heart failure ( . ; p= . ) and the impact negative of rd was reduced by ace-inhibitors (or= . , ci % . - . ; p= . ). conclusion. the rd is common and a strong predictor of mortality in patients with hf complicating acute coronary syndrome. it is associated with a worse risk profile. ace-inhibitors improve the prognosis this group of patients. acute renal failure is a very frequent problem in the critically ill patients and contributes to their high mortality. the most frequent cause is sepsis,usually in the context of multiple organ dysfunction. the more prevalent admission cause in our arf patient were medical illness and pos-operative urgent surgery. the arf patients presented higher saps ii and initial sofa scores. the most common risk factor was shock;other factors frequently seen were sepsis,mod and rhabdomyolysis. the mortality rate measured was lower than that referred in the literature. following a needs-assesment, realistic acute-care simulations were designed using a modified delphi approach. didactic instruction was given regarding crm strategies including "the three c's of communication": clear instructions, citing names, closing the loop (eliciting feedback following instructions). teams of four: two physicians (a leader and an assistant);a pre-briefed critical-care nurse (rn) and critical-care respiratory therapist(rt), then responded to standardized simulation scenarios, delivered using a laerdal high-fidelity mannequin in a working critical care unit. we found insufficient crm skills on the first simulation (suggesting poor retention from didactic instruction alone) with gradual improvement following the three simulations (suggesting simulation offers a supplementary technique but may still be insufficient). we therefore made the team perform a fourth resuscitation, but with the physician-leader blindfolded. we found immediate/marked improvement in crm skills: physicians elicited help sooner and ensured instructions were completed. other members were quicker to volunteer changes in vital signs. debriefing confirmed that this novel approach was well received and participants reported enhanced understanding of the importance of teamwork. in the early stages of undifferentiated shock we are essentially "blind" to the diagnosis, and hence must rely on others. this strategy is also useful for trainees whose first language is not english: blindfolding forces them to focus on communication, with the result of increasing their confidence and reassuring supervisors. this technique allowed us to emphasize crm principles. we now expectat senior trainees to perform at least one blindfolded simulated-resuscitation. it is no longer an exaggeration to say our teams are "good enough to resuscitate blindfolded"! in current spanish population around % of people are over years of age. in our country, life expectancy is years. it is obvius that this population aging has modified some approachs in organs donation and transplantation process, forcing to include older people in waiting lists. the increase in the organs demand for transplantation has conditionated changes in the donor profile, therefore the evaluation, acceptance and rejection criteria of donors have been changing. the acceptance for older donors with associated comorbidity provide transplantations with acceptable results getting to reduce tranplant waiting lists and mortality. the consequence that arise from it is the concept of expanded criteria donor (ecd). we studied retrospectively donors from a hospital with no neurosurgery service from january to december , comparing donation potential between over and under years of age donors. . four of the donors younger than years (n: ) were not appropriate ( , %) whereas older than years (n: ) were ( , %) (p-ns). donors older than years provided kidneys and livers available for transplantation ( , % and , % of total organs, respectively) whereas younger than years group obtained kidneys and livers available ( , % and , % of total organs, respectively). number of useful organs per donors was , and , for younger and older than years donors, respectively (p: , ). conclusion. in our serie, age was not a predictor variable for hepatic usefulness whereas it was for renal usefulness. nowadays dce are indispensable and age can not be an exclusive factor in this donors evaluation. pct has many indications in icu patients, mainly prolonged mechanical ventilation / weaning difficulties and airway protection in comatose patients. the consensus conference on artificial airways in patients receiving mechanical ventilation recommended translaryngeal intubation for an anticipated need of up to days and a tracheostomy if an artificial airway for more than days is anticipated. however this decision should be individualized. the aim of this study is to analyse the indications and timing pct in our icu patients, and icu and hospital survival. we conducted a retrospective study, analysing patients submitted to pct, in months: since the technique was implemented in our icu in december , until march . we reviewed their age, gender, apache ii score, length of icu stay, ventilation time before and after pct, icu and hospital survival. patients were stratified in groups, based on the indication for the pct: prolonged mechanical ventilation (n= ) and airway protection in comatose patients (n= ). data was treated in spss programme, using the mann whitney test. the results presented are in mean values. conclusion. )the indications for pct in our icu were prolonged mechanical ventilation (n= ) and airway protection in comatose patients (n= ), a reduced sample size to analyse. )there was no significant difference in age ( years), gender, apache ii ( , ) and saps ii ( , ) scores. )comatose patients submitted to pct for airway protection had less ventilation days prior ( , vs , p= , ) and after ( , vs , p= , ) tracheostomy. their length in icu was shorter ( , vs , p= , ) . they had a lower hospital survival rate ( % vs , % p= , ), although there was no significant difference in icu survival. ) , % of patients submitted to pct due to prolonged mechanical ventilation were discharged alive from our icu, but only , % were discharged alive from hospital. recent literature suggests that early pct (in - days) could have had an influence on this high mortality hospital rate. )overall icu survival rate is %, but hospital survival is only % -a high mortality rate is seen after discharge from icu, in hospital wards. t. van galen*, o. p. groenendijk recovery room -high care, vu university medical center, amsterdam, netherlands introduction. the vu university medical centre (vumc) has chosen to integrate competence management (cm) within the human resource structure. functioning as an health care professional is not only about performing medical or nursing interventions. cm explicates not only knowledge and skills, but also attitude. cm contributes in developing abilities to cope with complex medical and nursing situations. cm is about managing professional behavior for reaching personal and organizational objectives. cm also contributes to an organization wide understanding of achieving the mission statement objectives. after introducing cm to the high care (hc) nursing staff, the set of (chosen) competences was integrated within the unit's mission statement (september ) . during team sessions competences were described to fit into the daily organizational and professional practice (october ) . personalizing cm is performed during an (competence based) assessment (december ) . strengths and weaknesses are determined. personal objectives are integrated within a defined educational and development structure guided by the clinical supervisor educator. although cm is relatively new in our organization and the return on investment is hard to determine, some results are clear. with cm observable behaviors were defined and thereby manageable, next to the set of nursing skills definitions (already defined as part of the primary training course and daily practice). increased employee responsibilities led to % more (non mandatory) training course attendance. during the hc nurse attended full training course hours. in the training course attendance increased to full hours for each hc nurse. with cm the relation between organizational and individual performance objectives is more clear. a prismant survey proclaimed decreasing sickness absence when cm is implemented. this result was confirmed on our ward. sickness absence decreased from > % to < %. because most of the personal development targets were easy to combine, the educational/training course budget was not exceeded. cm provides more different development levels, thereby individual talents are easier to discriminate. the employee satisfaction with cm is growing. conclusion. cm was successfully implemented on our hc unit within a month period. starting with a manageable package of competences the rollout strategy was easy to cope with for the hc supervisor and nursing staff. there are a few conditions the organization has to facilitate. cm must be integrated in the organization mission statement and adopted by hospital management. nursing supervising staff, including the clinical supervisor educator, must be capable to apply and practice cm. span of control and educational/training budgets must be fitted for applying cm. cm is a well manageable and applicable tool to increase and improve nursing outcomes. [ ] have shown immune modulatory effects. the alpha agonist dexmedetomidine produces sedation more analogous to nrem sleep compared to traditional agents [ ] . obstructive sleep apnoea and depression are known to alter both sleep architecture and immune function. we postulated that immune modulation could be produced by pharmacologically altered sleep pathways. methods. pvg hooded lister rats (harlan)were randomly allocated to midazolam, dexmedetomidine or sham infusions. all animals were instrumented with implanted telemetry week, and jugular lines day prior to the infusions. infusion rates were targeted to maintain deep sedation, mg/kg/hr for midazolam and . - mcg/kg/min for dexmedetomidine. infusions were commenced at am, and continued for hrs during the sleep phase, and recommenced hours later for a further hrs. animals were then given mg/kg ultrapure e.coli lps at am the following day. blood was taken every mins for facs and cytokine analysis. at mins post lps animals were sacrificed and their brains and lungs harvested. lungs were macerated and the samples were stained for ox and cd b and analysed by facs. there was no statistical significance difference between the groups at any time points for serum tnf,il- ,il- , crp, total blood pmn and monocytes, platelet-leukocyte aggregates. there was a non-significant trend to lower monocyte/neutrophil margination into the lung bed in the dexmedetomidine group. conclusion. in this underpowered study pharmacological manipulation of sleep does not produce immunoparesis in a rat model of icu sedation and sub-lethal endotoxaemia. from these data animals in each group would be required to detect a true difference. gut microbiota is a stable community with high biodiversity index and plays a key role in maintenance of health status. several factors of gut ecology alteration occur during the critical patients(pts) care:luminal hypoxia/hypercarbia, gastric-secretions inhibitors, vasoactive, sedation, nutrient/fiber scarcity, antibiotics, sepsis/injury, digestive surgery. ecological balance disruption of gut microbial community often results in reduced protection against pathogens,including opportunistic ones. we studied faecal microbiota changes in critical pts during icu stay. consecutive pts expected to need mechanical ventilation (mv) for> days were enrolled. exclusion criteria: hospital stay and/or antibiotic treatment before icu admission, opportunistic/autoimmune diseases, cancer/steroid therapy. faeces were collected at icu admission(t ) then weekly(t ,t ,t ). pts were excluded if t or t samples could not be harvested. total bacterial dna pattern analysis was performed by denaturing gradient gel electrophoresis (dgge). the % of similarity between the t -dgge profile and the following ones in each pt was used as index of microbiota modification. a similarity value > median at t versus t was defined as index of microbiota biodiversity preservation. new dominant dna bands were analyzed to identify bacteria species. . pts ( peritonitis, lung infections, cellulitis, meningitis, trauma) were enrolled. pts ( alive) were discharged before t , pts ( alive) before t , and pts ( alive methods. rfviia was used in adult patients aged between - (mean ± ) years average bmi . ± . underwent massive perioperative haemorrhage. all patients were admitted to icu with the diagnosis of sepsis or severe sepsis. all septic patients has been received da therapy within - hrs of icu admission. the following diseases were diagnosed: post abdominal surgery bleeding (severe sepsis after surgery: laparoscopic cholecystecomy, laparotomy due to peritonitis) - pts, gastrointestinal bleeding (severe sepsis in acute pancreatitis ) - pts, postpartum bleeding (septic shock in the course pyelonephritis and right hydronephrosis) - pts, intracranial bleeding (septic shock in pregnancy) - pts. we used the questioners of novo nordisk to asses the indications and effectiveness of treatment. we compared haemoglobin level, haematocrit, number of platelets and laboratory coagulation profile parameters before treatment, hours and hours after treatment. the dosage of rfviia was . ± . µg/kg. continuous iv mg infusion is effective for spasticity due to tetanus. compared to previous reports, our case series contributes meaningful additional data, as mg therapy was applied effectively for up to days without major toxicity, and all pts had good outcome. iv mg therapy has been proposed as first-line treatment for tetanus ( ), but the optimal dose and maximum duration of therapy are unknown. we believe that iv mg is a promising treatment option but, until more data are available, it should be reserved for carefully selected tetanus cases. observational, prospective, multicenter study in which patients admitted to the icu during the periods of the envin study for the years and were included. the following rates as markers of quality were defined: ) rate of amc use, ) rate of directed treatments, ) overall rate of changes in the amc used for therapy, ) rate of amc change due to inappropriate treatment, ) rate of amc change due to adjustment of treatment or deescalating therapy, ) rates of use of selective digestive decontamination (sdd), and ) duration of prophylaxis of cefazolin, amoxicillin-clavulanate, and cefuroxime. data of all variables in and are compared. high rate of use of antimicrobials in the icu. twenty-five percent of antimicrobial agents were used as directed therapies and in % of cases, antimicrobials were changed. changes for inappropriate treatment decreased, whereas changes for adjustment of treatment increased. there was an increase in the use of sdd. duration of prophylaxis with antimicrobials was is longer than the length of days prescribed. [ , ] . our goal was to evaluate this marker in critically ill patients with severe sepsis and sirs. methods. patients with severe sepsis and patients after coronary artery bypass grafting (cabg) have been included in this pilot study. plasma samples have been collected daily in the sepsis group or on day after surgery in the cabg-group. bg was measured with the turbidometric assay (wako pure chemical ind.) with a cut-off of pg/ml. results. bg levels were elevated after uncomplicated cabg and differed to the sepsis group. median concentrations were in the normal range in sepsis patients but fraction of elevated beta-glucan levels tend to increase with length of stay and were higher in nonsurvivors. this first observational study demonstrated consistent results of higher bg levels in different populations of critically ill patients. while bacterial translocation has been suspected as reason for sirs after cabg, this has never been associated with fungemia. this finding and higher bg levels in nonsurvivors with sepsis warrants further research. reference(s a prospective, observational and multicenter study in which an analysis was made of antimicrobials used in patients admitted to the spanish icu during the time periods of the envin study. the present report includes data for the years to . reasons for the use of antimicrobials included community-acquired infection, extra-icu nosocomial infection, and as a prophylactic measure. empirical or directed treatments were also differentiated. the antimicrobial drugs most frequently used for each indication as well as the mode of therapy are described. rate of antimicrobial use is expressed as percentage of patients in which one or more drugs were administered. descriptive statistics are presented. of a total of , patients admitted to the icu during the study period, , ( %) received , antimicrobials. changes in the number of antimicrobials and rates of antibiotic use are shown in table . table shows the distribution of antimicrobials according to reasons of prescription and modes of use antimicrobial agents most frequently used in the -year study period were amoxicillin-clavulanic acid, piperacillin-tazobactam, cefazolin, and vancomycin. data of the drugs most frequently used in each category are available. candidemia is a major cause of morbidity and mortality in modern icus. candidemia rates and patterns in icu appear to be changing over time. non-albicans spp, especially c. tropicalis and c. glabrata may be associated with higher mortality ( ). we describe the epidemiology and outcome of candidemia caused by candida albicans and non-albicans spp. from to , consecutive cases of candidemia in a general medical-surgical icu were identified from the computerized microbiology database. apache ii scores, demographic and clinical data were abstracted from clinical records. antibiotic usage was retrieved from the pharmacy database. . cases of candedemia were identified, giving an incidence of ( %ci - ) per patient-days. candidemia rates (per patient days) increased, with non-albicans making up a greater proportion over time ( fig. ). antibiotic use did not change significantly over time. non-albicans species made up % of isolates -c. tropicalis ( . %), c. glabrata ( . %), c. parapsilosis ( %), c. krusei ( . %), c. guillermondi ( . %). risk factors more commonly present in non-albicans species were: haematological neoplasm (p= . ) and neutropenia (p= . ). c. albicans was associated with diabetes (p= . ) and male sex (p= . ). baseline apache ii scores for non-albicans vs c. albicans (median, iqr , ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) were similar, however patients with non-albicans had a higher icu mortality ( % vs %, p= . ), and a trend towards higher hospital mortality ( % vs %, p= . ). despite stable antibiotic usage, candidemia rates are progressively increasing over time, with non-albicans making up a higher proportion of cases. mortality rates were higher than generally reported, but may be partly related to the high baseline illness severity. the comparatively higher mortality of non-albicans candidemia may be related to the high incidence of c. tropicalis and c. glabrata, which made up > % of non-albicans spp. risk factors associated non-albicans were identified and could help guide early empiric therapy in this group. previous studies have investigated the role of diabetes mellitus(dm) as risk factor for infections. tight glycemic control has recently been proved to reduce morbidity in icu patients. the aim of our study was to assess the association of prior dm history with bsi in icu patients. we prospectively studied medical patients admitted to a -bed general icu, during a -month period. history of dm, age and apache ii at admission were recorded. all patients were under tight glycemic control and were followed up for the development of bsi during icu stay. cox proportional hazards regression models were fitted for each consecutive bsi episode. statistical significance was set at p< . . although myocardial systolic dysfunction is common in sepsis/sirs, its time course over longer periods in severely ill patients is not well investigated. the aim of this project is to investigate the time course of left ventricular (lv) systolic function over a period of days in patients with severe sepsis/sirs using transthoracic echocardiography (tte), and to evaluate the adequacy of different tte methods. methods. patients with severe sepsis/sirs with circulatory failure despite adequate fluid resuscitation were included. tte examinations were performed daily for a total of days. lv systolic function was assessed by eyeballing ejection fraction (eb), simpson's biplane method in the chamber view, atrioventricular plane displacement (avpd) with m-mode in the septal, lateral, anterior and inferior view, tissue velocity imaging (tvi) in the mitral annulus and stroke volume in the left ventricular outflow tract (sv-lvot). data were analysed for differences over time using anova. systolic function was impaired and there were statistically significant changes with time in the measured parameters except tvi. table . avpd, eb, tvi, sv-lvot and simpson's were obtained in %, %, %, % and % respectively of all possible measurements. conclusion. lv systolic function was impaired in this heterogeneous group of patients as expected . all parameters improved significantly throughout the observation period reaching normal values by day . simpson's biplane method was difficult to perform due to poor imaging quality. the eb method was inconclusive in several patients due to hyperdynamic status. the fact that tvi was not significantly improved was unexpected and may be due to small sample size, wall filter settings and variations in sampling volume. the avpd method was easy to obtain and seemed the most consistent marker of systolic function in this group of patients. the small sample size of this study precludes subgroup analysis however it would be relevant to study differences, eg. between survivors and non-survivors. in view of the adverse consequence of af "chronic or paroxysmal" comprising hemodynamic deterioration, risk of thromboembolic complications, and the intolerable fast palpitation, etc., cardioverting af to sinus rhythm seems an ideal goal. there had been some controversy concerning the effects of af on atrial and ventricular dimensions as well as functions. the present work addresses the latter issue through trial of cardioverting patients( females and males) with a mean age of . years (range from to years). underlying cardiac examination revealed rheumatic heart disease in pts, hypertension in , ischemic heart disease in , and lone af in pts. only one pt had cardiomyopathy and one pt had thyrotoxicosis. prior to cardioversion, all pts were subjected to clinical evaluation, and transthoracic echocardiography (tte). transesophageal echocardiography (tee) was done only in cases with heparin or warfarin anticoagulation for at least days. standard m-mode, cross sectional and pulsed doppler echocardiography were obtained using hewlett-packard sonos echocardiograph. echo parameters measured before cardioversion comprised left ventricular end diastolic diameter (lvedd), left ventricular end systolic diameter (lvesd), fractional shortening (fs), and left atrial dimensions (length, diameter and volume by planimetry). left atrial function after cardioversion was expressed as atrial ejection force (aef) and doppler a-wave, with aef defined as the force that the atrium exerts to propel blood into the lv and expressed as aef= . *mitral orifice area*(peak a velocity) . effective mechanical atrial function (emaf) was defined as a-wave more . m/s. the presences of la thrombus or spontaneous echo contrast (sec) were studied by tte or tee. measures were recorded weeks after cardioversion to avoid la stunning. a questionnaire was sent to the lead clinicians of itus in germany inviting them to describe their current practice for the management of new-onset af. the questionnaire sought to establish the type of hospital and unit in which the intensivist practiced, whether there was a protocol in place for the management of af, satisfaction with current management strategies, and opinions about the immediate goals of treatment. in addition, colleagues were asked to identify and rank their choice of medical treatment. there were responses, with describing their units as mixed medical-surgical, as medical, surgical and cardiothoracic. thirty were teaching hospitals, district hospitals, and the remainder specialist or unstated. sixty-seven had no protocol for treatment of af in itu patients, but only expressed dissatisfaction with their current approach. those who did use a guideline cited the european society of cardiology guideline most commonly. for reversion to sinus rhythm was the goal of treatment, whilst for ventricular rate control was satisfactory. for hemodynamically unstable af in the itu, considered electrical cardioversion to sinus rhythm to be optimal treatment, would use medication with the aim of reversion to sinus rhythm, and for ventricular rate control with medication was sufficient. when medication was thought appropriate, the ranked choice of drugs is given in the table (findings for uk practice are given in parentheses, and percentages are used for easier comparison). conclusion. the lack of a uniform approach to the management of new-onset atrial fibrillation in the itu is common to both uk and germany. however, both consider amiodarone to be the first choice drug, while β-blockers and calcium channel blockers feature more prominently in germany. the use of magnesium appears to be far more emphasised in the uk. we suggest a pan-european consensus to manage this prevalent problem. atrial fibrillation is a common problem in the intensive care population, with a reported incidence between % and %. it is associated with an increased mortality, but there is some question whether this represents a true mortality increase, or whether it occurs in a group with a higher risk of dying. few studies have defined the extent of the problem in the mixed medical-surgical intensive care population. all patients admitted to our intensive care unit for more than hours were enrolled into the study over a six month period, with the exclusion of children and those who had an existent or treated tachyarrhythmia. they were then followed up prospectively for days, with various parameters recorded, including the development of atrial fibrillation, the presence of sepsis, apache ii score, treatments and interventions, and outcome at days. the population studied were divided into those who developed new-onset atrial fibrillation (new-onset af) and those that did not (no af). data from the two groups were then compared to determine any significant associations. two hundred and twenty-eight patients were admitted over a six month period, with one hundred and twenty-two meeting the inclusion criteria (excluded were for duration of stay less than hours; who already had af or a pacemaker; and who were children). twenty-eight patients developed new-onset af ( %). of the patients who had sepsis, ( %) developed af, as opposed to out of ( %) in the non-septic group. the af group tended to be older (mean age vs ) and more ill (mean apache vs ), with a higher mortality rate ( % vs %). when the mortality rate was standardised (observed/predicted mortality), the af group still appeared to have a worse outcome (smr . vs . ). this result is in contrast with a recent finding that showed smr to be similar in the two groups . our study found no association with low serum potassium or magnesium levels. findings are summarised in the table. conclusion. the rate of new-onset af in our mixed medical-surgical intensive care unit is %. there is a strong association with sepsis, with over one third of septic patients developing af ( %). our findings of older age and greater degree of illness being independent risk factors for af concur with other studies, but we have also shown an increased standardised mortality rate associated with af, suggesting that the arrhythmia confers a higher risk of death. after myocardial infarction, venous lactate levels as determined in the central laboratory are known to be increased. the relationship between systemic lactate levels and hemodynamic parameters at presentation is largely unknown. we hypothesized that arterial lactate immediately measured in the catheterization laboratory provides optimal information to study this relation. we determined arterial lactate with a point-of-care analyzer (poc) in patients with st-elevation myocardial infarction (stemi) prior to primary percutaneous intervention (pci), and investigated if lactate was related with blood flow in the involved coronary vessel. we prospectively measured arterial lactate levels (reference values , - , mmol/l) in patients with stemi directly before treatment with primary pci. patients on mechanical ventilation were excluded. all blood samples were analyzed within minutes from sampling. thrombolysis in myocardial infarction (timi-)flow in the infarct-related vessel at first angiogram was recorded for all cases and dichotomized as timi - (inadequate) and - (adequate). additional data was taken from the medical chart. lactate levels were analyzed after lognormal transformation. . with multivariate analysis, shock, body mass index, tachycardia, smoking and especially timi-flow were independently related with lactate levels. the relation of timi-flow with lactate was more pronounced than the relation of timi-flow with heart rate and blood pressure. in patients with myocardial infarction, systemic arterial lactate measured before revascularisation with a poc-device allowed detection of a strong relation between poor timi-flow and elevated arterial lactate levels. there are few echocardiographic investigations of myocardial dysfunction in sirs and sepsis. the aim of this project was to investigate left ventricular diastolic function over a period of days in patients with sirs/sepsis and circulatory shock using transthoracic echocardiography (tte). methods. patients with severe sepsis/sirs were included. tte examinations were performed daily for days. diastolic function was assessed by transmitral pulsed doppler with e/a ratio, deceleration time(dt), and tissue velocity imaging (tvi) in the mitral annulus. patients were subdivided into < and > years of age. changes in these parameters over time were analyzed using anova. median values for dt, e/a, e/É andÉ for all patients were calculated. there were no differences with time for all parameters exceptÉ (table ). in patients < y.o., subnormal values for e/É andÉ were seen ( table ) . reliable continuous hemodynamic monitoring of critically ill patients is essential for effective volume management and adequate administration of vasoactive drugs. the picco-system (pulsion, germany) allows continuous measurement of cardiac index (ci) using arterial pulse contour analysis. calibration of this system by transpulmonary thermodilution is recommended every hours. in this study we examined the reliability of the continuous measurement of the cardiac index using the arterial pulse contour analysis (cipc) compared to the cardiac index acquired by the transpulmonary thermodilution (citd) when calibrating the system. our study includes measurements in critically ill patients ( male, female, age - years, mean . ± . ) requiring hemodynamic monitoring with the picco-system. patients had an infection, hepatorenal syndrome, gastrointestinal bleeding, acute pancreatitis and were admitted to the icu for other reasons. first the cipc was recorded immediately before the next calibration and afterwards the citd was measured times what resulted in a simultaneous calibration of the pulse contour algorithm of the picco-system. we performed a mean of . ± . measurements per patient ( - ). the time-lag between the measurements was h min ± h min ( min- h min). the comparison of cipc immediately before calibration and the calibration-derived citd resulted in a correlation coefficient of . with a p-value of < . . in mean the aberration between cipc and citd was . ± . l/min*m . in the bland-altman-analysis the cipc was in mean . l/min/m lower than the mean of citd and cipc. the standard deviation was . l/min/m . there was no correlation of the time-lag between the calibrations and the difference of cipc and citd (r= . ; p= . ). there was an increase of the aberration of cipc and citd in low and high cipc values. reliable cipc values with an aberration from citd less than . l/min*m can be obtained with a cipc in-between and l/min*m . ) the picco-system allows a reliable continuous measurement of the ci using the pulse contour analysis. ) in our study we could not find an increased difference of cipc and citd even with longer time periods in-between the calibrations using transpulmonary thermodilution. ) reliable ci values using the pulse contour analysis can be obtained in-between and l/min*m . ) because calibration is easy to achieve and additional data for the intrathoracic blood volume and the extravascular lung water are obtained a - hours period in-between the calibrations is reasonable. n. zoremba* , g. schälte , j. bickenbach , b. krauss , r. rossaint , r. kuhlen intensive care medicine, anaesthesiology, university hospital rwth aachen, aachen, intensive care medicine, helios klinikum, berlin-buch, germany cardiac function monitoring in patients at risk for cardiac failure is a very useful tool to recognize and treat cardiac dysfunctions. the objective of this study was to compare a new method of non-invasive determination of cardiac output (ev-co) based on electrical velocimetry with invasive cardiac output measurements performed with a pulmonary artery catheter (pa-co). methods. twenty-five patients ( male, female) were included into the study during a three month period. the non-invasive measurements of cardiac output (co) were obtained with a new cardiovascular monitor (aesculon eletrical velocimetry, osypka medical gmbh, berlin, germany). simultaneous invasive measurements of co were made by injection of iced . % saline and the recording of thermodilution curves with a pulmonary artery catheter (baxter swan-ganz catheter, . french, edwards life sciences, irvine, usa). the analysis of the data was performed based on statistical methods recommended by bland and altman for evaluation studies( ). in all patients invasive and non-invasive co values could be obtained. the analysis of co showed a strong linear correlation (r= . ) between ev-co and pa-co (fig. a) . the mean difference between ev-co and pa-co was - . ± . litre*min − (mean±sd). the lower and upper limits of agreement for the comparison of ev-co with pa-co were - . litre*min- and . litre*min − and are defined as the mean difference± sd (fig. b) . the percentage error between ev-co and pa-co was . %. in this present study we found a good correlation between the haemodynamic values measured by electrical velocimetry and those obtained from pulmonary artery catheter measurements. therefore, electrical velocimetry, a new icg algorithm, is a suitable method to evaluate haemodynamic parameters with clinically acceptable accuracy. reference(s). ) bland jm, altman dg: statistical methods for assessing agreement between two methods of clinical measurement. the pulmonary artery catheter (pac) is still used to assess the hemodynamic status in cardiac patients, because it allows the measurement of pulmonary artery occluded pressure (paop), an indirect marker of left ventricular function. we studied the relationship between the cardiac function variables derived from pac and those provided by the transpulmonary thermodilution technique (picco) in patients with acute heart failure (hf) and severe sepsis or septic shock. twenty-one patients with circulatory failure requiring invasive hemodynamic monitoring were included. icu diagnosis was hf in and severe sepsis or septic shock in patients. all patients were monitored with a pac (edwards lifesciences, usa) and a picco catheter (pulsion medical system, germany). the following parameters were simultaneously assessed during the first day in each patient: cardiac index by either method (ci-pac, ci-picco), paop, cardiac function index (cfi), global ejection fraction (gef), and global end-diastolic volume index (gedvi). pearson correlation, bland-altman analysis and nonparametric mann-whitney u test were performed, as appropriate. results are given as median (interquartile range, iqr). a total of simultaneous measurements were performed during the first hours after icu admission ( measurements in each patient). the overall correlation showed a pearson correlation coefficient between ci-picco and ci-pac of . (p< . ). bland-altman analysis showed a mean bias of . l/min/m and limits of agreement (± two standard deviations) - . to + . l/min/m . using the pac the median (iqr) ci in hf and septic patients was . ( . - . ) and . ( . - . ) l/min/m (p< . ), respectively. the paop was ( - ) in hf and ( - ) mmhg in septic patients (p= . ). the gedvi in hf and septic patients was ( - ) and ( - ) ml/m (p= . ), respectively. in hf patients the cfi was . ( . - . ) and in those with sepsis . ( . - . ) min- (p< . ), and the gef was ( - ) versus ( - ) % (p< . ), respectively. in critically ill medical patients, assessment of cardiac function using transpulmonary thermodilution technique is a valuable alternative to the more invasive pulmonary artery catheter. cardiac output and cardiac function index better discriminate between patients with and without impaired cardiac function than pulmonary artery occluded pressure. endotoxin (lipopolysaccharide, lps) tolerance is characterized by a reduced sensitivity to subsequent challenge of lps. in animal models lps tolerance is closely associated with marked, unbalanced production of pro-and anti-inflammatory cytokines as several animal studies have shown a decrease in proinflammatory cytokines and an increase in il- (anti-inflammatory cytokine). the presence and mechanism of lps tolerance in humans is unclear. the aim of this study was to test whether -day administration of endotoxin leads to lps tolerance by an enhanced anti-inflammatory response and a suppressed proinflammatory response. methods. healthy volunteers received iv bolus injections of ng/kg escherichia coli lps on consecutive days. blood samples (tnfα, il- , il- β, ifnγ and il- ) were drawn before (t= ) and after (t= , , min, , , and hrs) administration of lps on day and and on t= hrs on day till . symptom scores were obtained including nausea, vomiting, headache, muscleache, backache and shivering. the volunteers were asked to score above mentioned complaints ranging from 'nihil' (score ) up to 'severe'(score ) every half hour after administration of lps on five consecutive days. both tnfα (proinflammatory cytokine) and il- (anti-inflammatory cytokine) showed a peak level the first day which was almost completely abolished on the fifth day (anova repeated measures between day and : p< . , figure ). all volunteers experienced the expected and transient influenza-like symptoms on the first day, at t= . hrs after the administration of±maximum clinical symptom score . . (p±lps. the symptom score on day was . < . )(figure ). conclusion. endotoxin tolerance developed after consecutive days of lps administration as demonstrated by the attenuated release of proinflammatory cytokines on the fifth day. in contrast to animal studies, the attenuated cytokine response was not limited to the proinflammatory response, but also the anti-inflammatory response was diminished. this human endotoxin tolerance model appears to be useful in exploring the possible beneficial effects of endotoxin tolerance, for example, in ischemia-reperfusion damage. t. eduardo* , f. alvarez , j. gomez-hererras , s. florez , s. soria , c. lajo anaesthesiology and reanimation, university hospital, pharmacology and therapeutics, faculty of medicine, university of valladolid, valladolid, spain systemic inflammatory response occurs frequently after coronary artery bypass surgery, and it is strongly correlated with the risk of postoperative morbidity and mortality. we have analysed the effects of gelatin priming versus ringer's lactate priming on cytokine release and during the inflammatory state following coronary artery bypass surgery with cardiopulmonary bypass. a prospective, randomized study was designed. forty four patients undergoing elective coronary artery bypass grafting were allocated randomly to one of two groups: patients with ringer's lactate prime and patients with gelatine containing prime during coronary artery bypass surgery. the study protocol was approved by the ethics committee of the 'clinico' hospital of valladolid. written informed consent was obtained from each patient. plasma levels of interleukin il- , il- , tnf-alpha, c-reactive protein (crp), complement (c ), and sris score were measured along the surgery and within the first postoperative hours at various time points. cytokine levels were measured by enzyme-linked immunosorbent assay from plasma sample obtained. the spss program (version ) was used for the statistical analysis of the data. differences from baseline and between the groups were evaluated by two-way analysis of variance for repeated measurements (anova, followed by scheffe's test). correlation analysis between variables was calculated using pearson's correlation coefficient. a probability value of p < . was considered significant. there were no significant differences between the groups regarding pre-operative data. patients were similar with regard to type of procedure, bypass time, aortic cross-clamp time and number of grafts. in both groups the serum levels of the proinflamatory cytokines (il- , il- , tnf-alpha), sris score, c , crp, and leukocytes increased significantly over baseline, with no difference between either the colloid or crystalloid group. the operation time, blood loss, need for inotropic support, extubation time, and length of intensive care unit stay did not differ significantly between the two groups. priming with gelatin versus ringer's lactate produces no significant differences in the inflammatory response in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. a prerequisite to evaluate resuscitation from hemorrhagic shock is a reproducible experimental model, which leads to a predictable outcome. in order to evaluate the best predictor of death, blood lactate was compared to mean arterial pressure in hypotensive animals submitted to severe controlled hemorrhage. forty immature pigs were anesthetized with ketamine, atropine and halothane, intubated and maintained breathing spontaneously with atmospheric air and halothane. pulmonary, femoral and jugular vein catheters, were inserted in order to measure cardiac output, mean arterial pressure (map), blood gases and blood lactate. group i (n= ) was hemorrhaged to a map of mmhg breathing room air with halothane . %. group ii (n= ) remained as control of group i, breathing room air with halothane . % and no bleeding. group iii (n= ) was hemorrhaged to a map of mmhg breathing room air with . % halothane. finally, group iv (n= ) remained as control of group iii breathing room air with halothane . % and no bleeding. variables were recorded every ten minutes with no further intervention for minutes, when anesthesia was discontinued in the surviving animals. death of the animals was registered up to twenty four hours after the experiment. all animals in group i died. all animals in group iii survived, despite the fact that both groups had equal degree of hypotension (map = mmhg). however, only group i exhibited high levels of blood lactate. receiver operating characteristic (roc) curve analysis with death of the animals as the variable of interest, demonstrated that only blood lactate exhibited % sensitivity, % specificity and a roc curve area of . . mean arterial pressure was less accurate in predicting the death of the animals. tissue oxygen tension (tpo ) represents the balance between local supply and demand and may be a useful monitoring modality. we previously reported that lipopolysaccharide infusion produced different responses in four organ beds studied ( ). in the present study we sought to compare peripheral tpo measurements (bladder, muscle) against those measured in more vital organs (liver, renal cortex) during acute hypoxaemia. under isoflurane anaesthesia, male wistar rats (approx g weight) underwent left common carotid and right jugular venous cannulation for blood sampling/bp monitoring and fluid administration, respectively. flow in the descending aorta (abf) and left renal artery (rbf) were monitored by ultrasonic flow probes (transonic systems, usa). arterial po was measured using a blood gas analyser (radiometer, copenhagen, denmark). tissue po was determined using oxylite probes (oxford optronix, uk) placed in thigh muscle, between the right and left lobes of the liver, in the left renal cortex and within the bladder lumen. after a -min stabilisation period, fluid-resuscitated rats ( ml/kg/h, n-saline) were subjected to progressive increases in hypoxaemia ( , . and % inspired oxygen). comparisons were made to time-matched controls breathing room air. statistics were performed using two-way rm-anova and post-hoc tukey's test. results. data shown as mean (± se), *p< . between control (c; n= ) & hypoxaemia (h; n= ); $ p< . between timepoint & baseline. ( ) ( ) conclusion. patients with erd have higher severity and more frequently immunodepression and medical pathology. they needed more invasive procedures and antibiotic therapy so infection rates and resistance patterns are superior to the rest of icu patients. conclusion. an improvement of the methods of regulation and of the monitoring of treatments are essential if we take into account the increasing bacterial resistance. if glycopeptides are still the initial standard treatment of serious infections, new therapeutic strategies should be emerging, depending on the confirmation of presented innovations. prospective observational cohort study, performed in a -bed icu. all copd patients with ae who required intubation and mechanical ventilation were eligible. at icu admission, information on endotracheal aspirate purulence, and hyperthermia was collected. in all patients, gram stain and quantitative endotracheal aspirate culture (positive at cfu/ml) were performed. in addition, leucocytes count, c-reactive protein (crp), and procalcitonin (pct) levels were measured. univariate and multivariate analyses were used to determine variables associated with bacterial severe aecopd. positive predictive value and negative predictive value were calculated for variables independently associated with bacterial severe aecopd. . severe aecopd were diagnosed in patients. bacteria were isolated at significant threshold in exacerbations. s. pneumoniae ( %), methicillin-sensitive s. aureus ( %), and h. influenzae ( %) were the most frequently isolated bacteria. age ( ± vs ± ), male gender ( % vs %), saps ii ( ± vs ± ), duration of mechanical ventilation ( ± vs ± d), and mortality ( % vs %) were similar in patients with bacterial severe aecopd and those with nonbacterial severe aecopd. rate of patients who received prior antibiotic treatment was significantly lower in patients with bacterial severe aecopd than in patients with nonbacterial severe aecopd ( % vs %, p = . ). no significant difference was found in rates of patients with hyperthermia ( % vs %), purulent endotracheal aspirate ( % vs %), and leucocytosis ( % vs %) between the two groups. although leucocytes, crp and pct levels were similar in the two groups, rates of patients with pct > . ng/ml ( % vs %, p = . ), and patients with positive gram stain of endotracheal aspirate ( % vs %, p< . ) were higher in patients with bacterial severe aecopd than in patients with nonbactrerial severe aecopd. pct > . ng/ml (or [ % ci] = . [ . - ], p = . ), and positive gram stain of endotracheal aspirate ( [ - ], p < . ) were independently associated with bacterial severe aecopd. conclusion. positive gram stain of endotracheal aspirate, and pct > . ng/ml are independently associated with bacterial severe aecopd. these results could be helpful for future interventional studies aiming at reducing antibiotic use in these patients. systemic inflammatory response (sir) in patients with infection clearly influences outcome. the aims were to study the sir in icu-acquired infection (i-icu) according to the source and etiology and evaluate outcome impact. multicentre prospective study from april to july in ucis of hospitals. the number of patients admitted to icu> h until icu discharge or a -day period. i-icu diagnosed according to the cdc's criteria, source, etiology and sir were analyzed. conclusion. % of the i-icu worsen in sepsis severe/septic shock. vap and bacteriemias had more severe sirs and uti less frequent. septic shock presented a high mortality (> %) without significant differences in infection sites. c albicans, a baumannii and p aeruginosa developed the worst sir. conclusion. this analysis confirms that a small percentage of long stay patients occupy a large proportion of icu patient-days. the mortality is higher in this group than the overall unit, but the survival rate of . % could justify the extra resources required to treat these patients. age does not appear to influence length of stay in this study. the patients who are most likely to have a prolonged length of stay are re-admissions, patients who are peri-transplant or have ventricular assist devices. editorial: safe use of cricoid pressure cricoid pressure: knowledge and performance amongst anaesthetic assistants assessment of the ml syringe as a simple training aid in the application of cricoid pressure reference(s). possum and portsmouth-possum for predicting mortality possum scoring for patients with fractured neck of femur this study would not have been possible without the contribution of all icu team and the following people: wagner fontes, marilia calipo ferreira and ivy dantas gangiredddy ch admission of older patients to intensive care units is a controversial issue. the outcome of elderly patients with critical illness in india has not been previously studied. retrospective chart review of males > years & female > years from may till november . data collected included age, gender, disease category, comorbidities, mechanical ventilation days, length of stay in icu and hospital, apache ii, sofa, premorbid functional state and mortality. in admissions to micu, were critically ill elderly [ ( . %) males, ( . %) females]. premorbid functional state assessment showed: independent ( . %), partially dependent ( . %) and wholly dependent ( . %). at admission, organ involvement was respiratory [ ( . %) ], renal [ ( . %)], neurology ( . %), metabolic ( . %) and cardiac ( . %). mean apache ii and sofa scores were . + . (median ). and . + . (median . ) respectively. mean length of stay (los) in icu was . days + . and . days + . in hospital. mean icu stay was . + . & in hospital was . + . in - year age group, vs . + . and . + . in the over group [ . ] . total mechanical ventilation days were (range - ). died ( %) of which [ / ( %) ] were in - yrs and / ( . %) in > yrs [ns] . decisions to limit life support were taken in / cases ( . %), dnr in ( %) and withholding in ( %). apache score > correlated with mortality ( deaths in score> ; death in score < (chi square test . ). there was no correlation between premorbid functional status and mortality. respiratory involvement was the predominant cause of admission. the hospital mortality for the elderly was only %. apache ii score correlated with mortality. the sample size was too small to detect any significant differences between age groups in terms of los and mv days. % of the deaths were preceded by eol decisions. introduction. the phenomenon of increased intra-abdominal pressure and the resultant physiologic compromise were first described in the late s. acs has been defined as the cardiovascular, pulmonary, renal, splanchic, abdominal wall and intracranial disturbances resulting from elevated iap. korn and associates first used the term acs in . malbrain et al found during one day point prevalence study in icus had . % of patients has acs. intra abdominal pressure (iap) was measured in consecutive patients (age range - ; males: females) who were admitted to the micu with diverse clinical problems. iap was routinely measured using the transurethral measurement of urinary bladder pressure using a foley's catheter. abdominal compartment syndrome (defined as > cm h o) was found in patients (age range - , males; females). of these patients had primary acs, had secondary and had recurrent acs. the mean apache ii score was and sofa score was . in the acs group; the apache ii score was . the sofa score was . the group without acs. ( p value not significant) out of , patient with acs had a surgical intervention to reduce iap (pd catheter in , decompressive celiotomy in ). the indications for intervention were unexplained respiratory deterioration seen as in increase in plateau pressure or fio , fall in urine output despite adequate map and fluid resuscitation and iap> cm of water. / in the intervention group died ( . %). patients in the raised iap group managed conservatively with fluid restriction and diuretics. the mortality in the patients without acs was . %. in addition, increased iap alone gave a clue to the need for surgical intervention in / patients; these would have otherwise been managed conservatively. our study suggests that routine iap measurement of patients in the icu is beneficial because of the presence of unsuspected acs in a significant proportion of patients ( %) irrespective of the primary disease. acs may cause renal, hemodynamic and respiratory compromise that can be improved by judicious and timely intervention. further, raised iap alone may sometimes give a clue to the need for a surgical intervention, which may beneficially affect the clinical course. a. lorx* , b. szabó , m. hercsuth , z. hantos anesthesiology and intensive therapy, semmelweis university, budapest, medical informatics and engineering, university of szeged, szeged, hungary introduction. the low-frequency respiratory impedance (zrs) has been shown to reflect the respective contributions of the airway and tissue mechanical properties accurately in healthy subjects. little information is available, however, on the values of airway and tissue parameters derived from low-frequency zrs data in ali patients before and after bronchodilator therapy. zrs was measured with small-amplitude forced oscillations between . and hz at three peep levels ( , and hpa) before and after nebulised berodual in mechanically ventilated patients including with severe pneumonia and with postoperative respiratory failure, without any previous pulmonary disease. airway resistance (raw) and inertance (iaw), and constant-phase tissue damping (g) and elastance (h) were estimated from zrs spectra by model fitting. raw decreased with peep, and on the administration of berodual in both groups. in the postoperative patients, g decreased with peep, and g and h decreased following berodual inhalation; this indicates that bronchodilation was accompanied by recruitment of previously closed regions of the lungs. there was no change in iaw and hysteresivity (g/h), suggesting that the peripheral airway inhomogeneity was not markedly affected by the intervention. the decreases in raw reflect the presence of reversibly elevated airway resistance in all patients. the decreasing g/h in the pneumonia patients after berodual indicates improved homogeneity in the mechanical properties of the peripheral lung with consequent improvement in ventilation, although the changes did not reach the level of statistical significance. berodual inhalation results in improved tissue properties of the respiratory system, i.e. decreases in elastance and tissue damping, which is associated with the bronchodilator effect. overall, the low-frequency oscillation technique proves to be an informative and accurate method for bedside monitoring of critically ill patients. dialysis disequilibrium syndrome -report of cases n. shaikh* , m. kettern , y. hanssens anesthesia and intensive care, pharmacy, hamad medical corporation, doha, qatar introduction. dialysis disequilibrium syndrome (dds) is a central nervous system disorder occurring in pts (pt), either during or within hours of dialysis. dds is unknown in pt who are on dialysis for some time and no case had been reported in ventilated pts. report of cases of fatal dds in ventilated pts with acute renal failure (arf) on haemodialysis (hd) for more than a week. case : a year old male pt victim of motor vehicle accident, spleenic and bowel injury. ct head normal, gcs / . he underwent spleenectomy, hartman's procedure and abdominal packing. post-op, he was in dic and haemorrhagic shock. he remained hypotensive, adrenaline and noradrenaline were started. pt was oliguric and developed arf on day , daily hd was started over hours, normal bath and heparin free. on day , pt was trying to obey commands. on day , pt developed sepsis and meropenem was started. on day , pt underwent hd, became unresponsive after hour and pupils fixed-dilated. ct brain showed severe oedema and herniation. eeg was flat and brain stem reflexes absent. diagnosed as brain dead on day and expired same evening. case : a year old male pt fell from height, on arrival gcs was / . he had severe chest trauma and liver laceration,underwent laprotomy, haemostasis and packing of abdominal cavity. on day , pt developed arf, started on slow hd ( - hours) , low sodium, potassium and heparin free. ct brain on day was normal. on day pt developed septic shock, started vancomycin and ciprofloxacin. pt required noradrenaline. on day , during hd (increased potassium, heparin free), pt developed hypotension, pupils became dilated and fixed. hd was stopped, mannitol was given and pt was hyperventilated. ct brain showed severe oedema and herniation of brain. brain stem functions were absent. eeg was flat and heart stopped after hours. tioxidant capacity, as well as the detection of oxidized biological markers. the direct, in vivo quantitative measurement of the production of superoxide radical, an important parameter of the oxidative load, is difficult due to its low concentration and a short half life ( ) . in this study, the effect of h/s and resuscitation on the oxidative state in vital organs (gut, liver, lungs, kidneys) was estimated for the first time by measurement of the production of superoxide radical in vivo, using a new superoxide assay.methods. male wistar rats were divided in two groups (n= ): sham and h/s group. h/s was induced by withdrawal of blood targeting to a mean arterial blood pressure of - mmhg, which was maintained for minutes. at the end of the shock period, rats were resuscitated with re-injection of the removed shed blood volume. tissue samples were collected hours after resuscitation and the oxidative load was assessed by a new superoxide assay which directly measures the production of superoxide radical and an established lipid peroxidation assay which measures the production of organic hydroperoxides. statistical analysis was performed using anova. animals that underwent h/s exhibited a statistically significant increase in the production of organic hydroperoxides in the gut (p< . ), liver (p< . ) and lung (p< . ) tissues, whereas no change was observed in the kidneys. the rate of production of superoxide radical increased more in the gut and the liver (p< . respectively) and to a lesser extent in the lungs (p < . ), while kidneys were not affected as well.conclusion. this study demonstrates an increase in oxidative load in the gut, the liver and the lungs after h/s-resuscitation, which was estimated by two different methods. moreover, and for the first time in a model of h/s, the new superoxide assay directly and more precisely estimates oxidative stress in vivo, since the formation of superoxide radical seems to play a pivotal role in the cataract of reactions that lead to the oxidation of biological structures. these results suggest that predominantly the gut and the liver, and to a lesser extent the lungs, but not the kidneys are the organs primarily affected by h/s in this model. reference(s). . biasi f, et al.: free radic. biol. med. ; : - . . georgiou cd, et al.: anal. biochem. ; : - . g. luckner* , s. jochberger , v. d. mayr , v. wenzel , h. ulmer, in this retrospective analysis, we examined if a low-dose avp infusion ( iu/h) can reverse isolated postoperative vasodilatory hypotension and prolonged vasopressor requirements (> hrs) in fifteen patients under chronic ace inhibitor treatment. hemodynamic and laboratory parameters were recorded , , hrs, and immediately before start of avp therapy, , , , and hrs after start of avp, as well as , , and hrs after cessation of avp infusion. the primary endpoint was to evaluate hemodynamic effects and changes in phenylephrine dosages during avp infusion. the secondary endpoint was to evaluate changes in laboratory parameters during avp. . avp infusion did not show any significant effects on hemodynamic variables. only mild, non-significant effects on map (+ . %, p= . ) and phenylephrine (- . %, p= . ) dosages were observed during the first hrs after avp infusion. there were no changes in laboratory parameters during avp infusion. a supplementary, low-dose avp infusion proved to be ineffective to improve hemodynamic function and reverse vasopressor dependency in patients with chronic ace inhibitor therapy and prolonged postoperative hypotension. results. drotaa was administered in patients [ ± years old, simplified acute physiology score (sapsii): ± ]. a community acquired infection was the causal infection in % of cases. patients had > organ failures before the drotaa onset (hemodynamic failure in patients,respiratory in ). all patients received hydrocortisone (started ± hours before the onset of drotaa) and patients received hemofiltration (started ± hours before the onset of drotaa). serious bleeding events occurred in patients. interestingly, the icu mortality was % while mortality predicted from saps ii was %. we observed a significant improvement in the pao /fio ratio and in the blood lactate level after the onset of drotaa (h ) ( table ). in patients treated with norepinephrine (n= ), we also observed a rapid decrease in the vasopressor dose after drotaa onset while the mean arterial pressure was maintained stable in the same period ( figure) . in this observational study, we evidenced significant improvement in the hemodynamic and respiratory failures and a decrease in blood lactate after the onset of drotaa administration. in the past few years new insights in the role of microcirculatory alterations during sepsis have been elucidated by means of orthogonal polarization spectral (ops) imaging. persistent alterations appeared to have prognostic value. several other techniques, such as near infra red spectroscopy, laser doppler and peripheral temperature have been used to asses peripheral circulation. however there is unclarity about relation between peripheral and microcirculation during sepsis. aim of this study was to evaluate the relation between peripheral and microcirculatory alterations during sepsis. we performed a single centre observational study in patients with < h severe sepsis/septic shock. ops imaging of the sublingual region and semi-quantitative analysis were performed as described in detail elsewhere . skin perfusion was measured as central-to-toe temperature difference (deltat). non-parametric rank correlation is expressed as spearman's rho(rs). , ( , - , ) , ( , - , ) , serratia marcescens (n= ) , ( , - , ) , ( , - , ) , acinetobacter baum (n= ) , ( , - , ) , ( , - , ) , klebsiella pneumoniae (n= ) , ( , - , ) , ( , - , ) , all pathogens (n= ) , ( , - , ) , ( , - , ) , msc -meropenem serum concentration, mic -minimum inhibitory concentration conclusion. we conclude that continuous infusion of meropenem in dose g per hours in critically ill patients provides reliable serum meropenem concentrations in relation to mics of meropenem sensitive pathogens. grant acknowledgement. this study is supported by the czech ministry of education (project msm ) s. boyes* , g. l. thomas speech and language therapy, salford primary care trust, intensive care unit, hope hospital, salford, united kingdom although several key documents recommend that slt should be integral to the multidisciplinary care of critically ill patients , , , these services are often not funded. without this input there is increased risk of nosocomial pneumonia, malnutrition and dehydration. antibiotic prescription and length of stay may increase with higher dependency and a slower transition through levels of care. communication difficulties may also impact on the patient experience. as per royal college of speech & language therapists guidelines our project explored unmet need and defined the potential role of slt at hope hospital, a regional neuroscience centre. slt provided daily input to critical care patients for a month period. prospective data were collected detailing referrals and slt management, and were compared with retrospective data from months prior to the project. stakeholder evaluation was carried out using pre and post project staff questionnaires, and by collecting anecdotal evidence from patients and staff.results. referrals to slt increased by % ( pre-project versus during the project). pre project, % referrals( ) were inappropriate and % ( ) transferred before asessment. % referrals ( ) during the project were appropriate and assessed. % of pre-project referrals were seen on the day of referral compared to % during the project. pre-project slt intervention focused on assessment and advice alone. the project promoted earlier identification of needs, early management of clinical risk and contributed to multidisciplinary care. major training and education needs were identified. stakeholder evaluation was overwhelmingly positive, demonstrating slt contribution to multidisciplinary care and the patient experience.conclusion. dedicated slt input in critical care increased referrals to slt. the number of inappropriate referrals and the time to slt assessment decreased. input promoted the identification of clinical risk, facilitating early intervention and rehabilitation. training needs and additional roles for slt (weaning, decannulation and risk management) were identified. stakeholder evaluation demonstrated improved patient experience. these findings form the basis of a business case to expand slt resources in critical care. whereas several studies established cefotaxime, or other rd generation cephalosporins, amoxicillin/clavulanic acid and oral quinolones as effective first-line antibiotic regimens in community-acquired cases, little is known about the spectrum of antimicrobial resistance, impact of an effective initial antibiotic regimen on survival and the spectrum of causative micro-organisms in hospital acquired cases. all cases of sbp diagnosed in a university hospital between january and august were retrospectively analysed. . cases ( m, f) were retrieved. mean (± sd) age was (± ) years. meld-score was . (± . ) at the time of the diagnostic tap. in patients the infection was community acquired, in patients hospital acquired. patients ( . %) died in the hospital. the initial antibiotic regimen was a third generation cephalosporin in , an ampicillin/sulbactam in and a quinolone in cases. cases (all hospital-acquired infections) were initially treated with a carbapenem and vancomycin had been added in cases. in patients the antibiotic regimen had to be changed during the course of treatment. survival was not worse in hospital-acquired cases than in community-acquired cases, but hospital-acquired cases were more often treated with broader antibiotic regimens at the onset of therapy. patients in whom the initial antibiotic treatment had to be modified had a higher mortality than patients in whom the initial treatment was continued ( % vs. %; p= . ). in patients with positive culture results, an effective first-line antibiotic regimen was associated with lower mortality ( % vs. %; p= . ). binary logistic regression analysis found meld-score at diagnosis (p= . , % confidence interval (ci) . - . ), ascitic fluid cell count (tsd) (p= . , % ci . - . ) and an escalation of antibiotic therapy (p= . , % ci . - . ) to be independently associated with mortality. the most commonly cultured micro-organism was e. coli (n= ), followed by enterococcus faecium (n= ). among culture positive cases the causative micro-organism was resistant to ceftriaxone in ( %), to ampicillin/sulbactam in ( %) and to ciprofloxacin in ( %).conclusion. the incidence of resistance to one of the recommended standard regimens is high in hospital-acquired and community-acquired cases of sbp. failure of the initial antibiotic regimen is associated with higher mortality. broader antibiotic regimens should be considered as initial approach. the multidrug-resistance (mdr) of gram (-) strains in the icu is a severely growing problem, so colistin has been recently reintroduced in clinical practice. colistin had fallen out of favour after due to nephrotoxicity, neurotoxicity and poor pharmacokinetics in lung tissue. the aim of this clinical trial is to study the efficacy and safety of colistin in mdr gram (-) nosocomial infections (ni) in the icu during the last months. we enrolled retrospectively icu patients (pts), men ( %) and women ( %), who developed a mdr gram (-) ni. mean age: . ± . years, mean stay: . ± . days. underlying diseases: multiple trauma , complicated surgery , other . the pts were treated ( courses) with intravenous (iv) colistin . . iu x daily (adjusted for creatinine clearance) in combination with carbapenems or b-lactamase inhibitors. in pts aerosolized colistin ( . iu x daily) was added to iv colistin. the ni treated were: pneumonia ( . %), central venous catheter-related infection ( %), peritonitis ( %), central nervous system infection (cnsi) ( . %). pts with cnsi additionally received colistin intrathecally. the responsible bacteria were: ac. baumannii ( . %), ps. aeruginosa ( . %) and kl. pneumoniae ( . %), with double pathogen in episodes of ni. clinical success (important lessening of the signs and symptoms of ni) occurred in ni ( . %); microbiological success (eradication of the pathogen in cultures of blood, peritoneal fluid, bronchial secretions or celebrospinal fluid) was obtained in ( . %). nephrotoxicity was observed in pts ( . %); it was reversible. mortality rates: / = . %.conclusion. ) colistin in combination with other antibiotics is an effective treatment of severe mdr gram (-) ni in the icu. ) the incidence of adverse events is low; a close surveillance of renal function is needed. ) when aerosolized colistin was included in treatment, microbiological success was accelerated (p< . ). ) pneumonia was the ni best corresponded to colistin than other sites of ni, but not statistically significantly (p< . ). ) prognosis was independent of type of invading gram (-) microorganism. introduction. the biggest concern in infection epidemiology in intensive care is the emergence of multidrug-resistant gram-negative (pseudomonas aeruginosa, klebsiella pneumoniae and acinetobacter baumannii) and gram-positive (staphylococcus aureus) organisms. two periods of six months were analyzed for each icu: in the first six months (from mar/ to aug/ ) no infectious disease advice was given in any; in the following six months (sep/ the fev/ ) infectious disease consultation was given in icu when requested, as opposed to icu , where it was continuously provided by an infectious disease consultant with degree in intensive care. the number of multi-resistant organisms grown was then compared. a t-test for two independent samples was used in statistics. the species distribution of the pathogens evaluated in icu is summarized in table . there was reduction in the occurrence of p.aeruginosa % ( - , %), a.baumannii % ( , - %) and s.aureus % ( , - , %), with significant p value for p.aeruginosa, the most common microorganism.* k.pneumoniae percentage of increase = , %. table summarizes the results in icu , where the decrease in growth of the multi-resistant stains was higher: % for p.aeruginosa ( , - , %), , %for k.pneumoniae ( , %- , %) and % for s.aureus ( , - %) also with significant p value for p.aeruginosa. introduction. intravascular catheter related infections are very critical in icu environment, with elevated morbi-mortality and impact on costs. in our unit, according to a quality political, it had established standards on prevention, diagnosis and treatment of nosocomial infections, with a periodic review of the ours rates. we will describe the managerial model chosen when we noticed an increase of the catheter related infections incidence: outcome management. in december it was created a multi-professional work group ( doctors, nurses and respiratory therapists) who performed a weekly meeting with the brainstorm technique. all the infections data were reviewed. the group identified main risk factors related to the problem using a diagram cause-effect. then, it had established corrective measures, deadlines and ways for execution. measures chosen: team for catheter insertion; using full-barrier precautions for insertion of central venous catheters; using of semipermeable and transparent dressings; avoiding the jugular and the femoral sites; routine replacement of the catheters after ten days insertion; removal of the unnecessary catheters. target was return of catheter related infection rate to level of the previous year. in the first three months after the intervention, we noticed a reduction of the median rate of catheter-related bloodstream infection per catheter-days: , infections to , . catheter-related bloodstream infection is the nosocomial infection par excellence: costly, common, and frequently fatal. efforts to improve patient safety must focus on simple and inexpensive interventions and prevention measures. the managerial tool showed us main causes of the problem and caused the adhesion of all staff around the catheter related infections and the correct measures to solve it. limited data suggest that vancomycin when given by intermittent injection may not be as affective as linezolid for the treatment of ventilator acquired pneumonia and this inferiority may be negated by administering vancomycin by continuous infusion ( ). administration in this fashion may improve the drug's tissue penetration and is easier to control but a double blind randomised controlled trial has not been carried out. the way in which vancomycin was administered in our icus was changed in may so that any patient with central venous access was given vancomycin by continuous infusion according to a strict protocol ( ) . data from our electronic prescribing system was correlated with icnarc data for mortality. we conducted a retrospective audit from december to october comparing icu outcome in patients who were treated with one agent only. patients who received both linezolid and vancomycin or were on a bd and infusion regiment were excluded. . patients were treated with vancomycin infusion, of whom . % died. this was not significantly different from the mortality for vancomycin when given by intermittent injection of . %. interestingly the mortality for those treated with linezolid in an unmatched group of patients was . % (p< . ). conclusion. contrary to previous audits, our data suggest that vancomycin is not inferior to linezolid for icu mortality. the mode by which vancomycin is administered does not affect mortality. the increased mortality found in patients treated with linezolid has yet to be explained. further analysis is required. there are recommendations for control and prevention of methicillin-resistant staphylococcus aureus (mrsa) ( ); surveillance reduction in antibiotics use, screening, nasal and skin decolonization, handwashing, isolation, decontamination of clinical areas, adequate staffing. these recommendations however, are frequently based on large series and case reports rather than randomised trials ( ) . of those recommendations, only two (handwashing and adequate staffing) are reliably carried out in our icu. even conventional 'deep cleaning' has been shown to be unreliable ( ). all patients admitted to itu at university hospital birmingham between june and may were retrospectively studied so that any microbiological sample that was positive for mrsa was correlated with the date of icu admission. conclusion. there has been a steady decline in the number of primary mrsa infection occurring in our icu whilst the number of cases admitted has remained constant. colonisation pressure from patients admitted to icu is independent of mrsa acquisition. the reasons for our decline in mrsa infection remain unclear as full recommendations to inhibit mrsa spread can not be implemented. in our tertiary surgical icu, antibiotic policy restricts prescription of meropenem to ) the empirical treatment of suspected bacterial severe sepsis in patients with risk factors for antimicrobial resistance or with documented colonisation with multiresistant gram negative (mrgn) organisms, or ) the directed treatment of infections caused by mrgn organisms. to evaluate compliance with these restrictions, the indications for meropenem use were reviewed, and the feasibility of a de-escalation strategy in case of empirical meropenem prescription was evaluated. we performed a retrospective study of all meropenem prescriptions in the surgical icu from / / to / / . patients who received more than one dose of meropenem were included in the analysis. age, apache ii, prior length of stay, duration of meropenem administration, antibiotic prescription other than meropenem, microbial etiology and site of infection were recorded. the presence of risk factors for antimicrobial resistance, i.e. either previous exposure to broad spectrum antibiotics or a hospital stay for longer than days prior to infection were documented. data are presented as mean (standard deviation). data from hundred and thirteen meropenem prescriptions were available for analysis. mean age of the patients was ( . ), and the mean apache ii score was ( . ). pulmonary ( %) and intraabdominal ( %) infections were the most frequent sites of infection. meropenem was prescribed according to the restricted indications in / patients ( %). in patients it was initiated empirically with both risk factors for antimicrobial resistance present, and in patients it was used because of documented colonisation with mrgn organisms prior to the current infection; in cases it was used after identification of a mrgn organism as the causative organism of the infection. in the other patients (n= ), meropenem was started empirically with no or only risk factor for resistance and without documented colonisation with mrgn organisms. empirical prescription of meropenem was de-escalated in patients ( %). reasons for not de-escalating were the identification of mrgn organisms or uncontrolled polymicrobial infections. compliance with the restricted indications for meropenem in our icu was high. empirical prescription of meropenem was de-escalated upon culture results in half of the cases. d. r. goldhill , a. badasconyi* , a. a. goldhill , c. waldmann anaesthetic department, the royal national orthopaedic hospital, stanmore, anaesthetic department, the whittington hospital, medical school, kings college london, london, anaesthetic department, the royal berkshire hospital, reading, united kingdom patient position in icu is important for preventing complications such as pneumonia [ ] . two hourly turning is a common standard of care [ ] . evidence suggests that patients may not be turned this frequently [ ] . we therefore conducted a prospective observational study of patient position and turning in icu and the factors that may affect the frequency of turns. forty eight of uk icus contacted agreed to participate in this study. the position of each icu patient was recorded every hour over two hour periods, one midweek and one weekend. the patient age, gender, estimated height and weight, diagnosis, whether intubated and ventilated, hourly sedation score, nurse:patient ratio and number of patients on the unit were also recorded. patients could be on their back, front, left or right side. a turn was defined as a change from one of these positions to another. the degree of rotation and whether patients were flat, head down or head up was also noted. analysis of the relationship between the average time between turns and factors that may be associated with this was performed using multiple regression on the log transformed dependent variables. . sets of observations were analysed. patients were prone at some time. other positions are in the table. the average time between turns was . hours, median . (range . - ; interquartile range - . ). there was no significant association between the average time between turns and age, gender, respiratory tract-related diagnosis, intubated and ventilated, sedation score, day of week or nurse:patient ratio. there were significant differences between hospitals in the frequency with which they turned patients on their unit. patients are rarely nursed flat. some patients go for prolonged periods without a change in their position. there was no association between the average frequency of turns and the patient and organisational factors we examined. however there are differences between hospitals in the practice of turning patients. introduction. this study compares the incidence of vap in traumatic patients receiving mechanical ventilation for > hours with a endotrachealtube with a dorsal lumen for intermitent drainage of subglotic secretions with others that received mechanical ventilation with a conventional endotracheal tube. traumatic patients admitted to the reanimation unit of the complexo hospitalario de ourense from march to august that received mechanical ventilation for at least hours were eligible for study. the follow-up period consisted of the patients remaining stay in the reanimation unit. demographic and clinical characteristics of patients were collected on admission. vap was suspectted in patients with a clinical pulmonary infection score or more. the diagnosis was done by tracheal aspiration and protected specimen brush. the bacteriologic examination was done by cuantitative and cualitative methods. patients were included inthe study ( that received intermitent drainage of subglotic secretions and in group control). there were not early-onset pneumonia on patients with intermitent drainage of subglotic secretions. there were not significative stadistycal differencies in incidence, duration of ventilation, reanimation length of stay or mortality.conclusion. this study didn't find statystical differences between the two groups because of the short number of patients; but it is important that inthe group wich received intermitent drainage of subglotic secretions there weren't eppisodies of early-onset pneumonia. f. lambiotte* , t. levent , x. lemaire , m. castro , l. gaybor , w. joos , t. ngheim intensive care, chsa, maubeuge, infectious disease, tourcoing, france to analyze the indications and the quality of the prescription of glycopeptides (gp) in an intensive care unit of beds. a -months retrospective study. the treatment was indicated if it answered the recommendations were selected. it was correct if:correct initial dose,corrects glycopeptides concentrations,serum dose obtained with fixed levels, antibiogram justifying the prescription of a gp in the event of bacteriological documentation. . saps ii , (± , ), age years (± , ),gender (m/f) , . , % of the patients presented a renal insufficiency. treated pathology: pneumoniae( %), septic shock( %), intra-abdominal infections ( %), blood stream infections, hyperthermia of unknown origin ( %), infections of the skin ( %), pyelonephritis ( %). frequency of organism recovery was: coag-neg staphylococci (including oxa-r), staphylococci aureus (including mrsa), entérococcus (including ampi-r),others : . the indications of regulation were largely respected but the methods of use of the gp were failing. even when the regulation was correct (n= ), the fixed serum rate was reached only in % of the cases. there is no difference between this patients in septic shock and other patients. taking into account the profile of the patients of intensive care unit, it seems difficult to predict that a treatment will be effective and that sub-inhibiting serum concentrations will be avoided even if the recommendations were respected. the situation becomes more and more delicate because of the increasing bacterial resistance. nosocomial pneumonia (np) continues to be an important cause of morbidity and mortality in the icu. the type of icu (medical, md or surgical, sg) has been described as an important factor to influence their etiology. prospective, observational study conducted between / and / in specialized icus of a tertiary hospital. all patienst who fulfilled clinical criteria ( of ) of np were included. epidemiological and microbiological features were registered. the patients were grouped according their origin from a md or sg icu. we included patients (md, n= and sg n= ). age ± yrs. icu admisión apache ii . ± . the distribution of infections between icus was for md and sg respectively: ventilator-associated pneumonia (vap) % vs %, ventilator-associated tracheobronchitis (vat) % vs %, and np % vs %. we could not find significant differences in epidemiological characteristics (except age ± vs ± , p= . ), risk factors for nn and blood test between the groups. patients ( %) had microbiological diagnosis (md= vs sg= ). the most frequent microorganism producing pneumonia in these patients were mrsa and mssa (same distribution: , % vs , %, p= . ), followed by p. aeruginosa ( , % vs %, p= . ). the inadequate initial ab therapy was slightly higher in sg patients ( % vs %, p= . ) and the mortality rate was not influenced by this variable. the icu and hospital los were alike and hospital mortality rate was significant higher in md than sg icu patients ( , % vs , %, p= . ). for a predicted mortality of % and %. we find some differences in this small cohort of md and sg icu patients with np. the microbiology profile showed important differences between the groups. the main limitation of this study is the small sample size. renal insufficiency is a frequent complication of septic shock. aminoglycosides are highly potent bactericidal antibiotics that together with beta-lactam antibiotics will result in a broad antibacterial coverage. yet, the use of these antibiotics in the treatment of early gram-negative septic shock has been hampered by the assumption that aminoglycosides may be nephrotoxic even in short term therapy. as this is very difficult to investigate in the clinical setting, an experimental study was set up, the aim of which was to evaluate whether the addition of tobramycin further deteriorates kidney function in pigs with endotoxin-induced renal damage. the animals were anaesthetised, catheterized, mechanically ventilated and randomised to groups. groups i (n= ) and ii (n= ) received endotoxin infusion in a dose of mcg x kg- x h- for h, whereas groups iii (n= ) and iv (n= ) received corresponding amounts of saline. groups i and iii received a -min infusion of tobramycin sulphate in a dose of mg x kg- starting minutes after the initiation of the endotoxin infusion, whereas groups ii and iv received corresponding amounts of saline. in parallel with the tobramycin/saline infusions, a cefuroxime infusion in a dose of mg x kg- was given to all pigs. renal function was evaluated by cefuroxime clearance, creatinine clearance, plasma cystatin c, plasma urea, urine output and urine nag (n-acetyl-beta-d-glucoaminidase) excretion. there was no significant difference in physiological baseline variables between the groups of pigs. the elimination rate of cefuroxime - h decreased in both endotoxemic groups whereas it was constant in the non-endotoxemic groups. at h cefuroxime concentration and cystatin c were higher in endotoxemic vs. non-endotoxemic pigs (p< . and p< . , respectively), whereas urine output and creatinine clearance were lower (p< . for both). however, there were no differences between groups i and ii or iii and iv in cefuroxime elimination, urine production, cystatin c or creatinine clearance. plasma urea and urine nag did not differ between any of the groups. endotoxin in the dose administered caused a significant renal dysfunction in this porcine model. the results indicate that the addition of a high single dose of tobramycin seems not to further aggravate the endotoxin-induced renal injury.grant acknowledgement. this work was financed by grants from the nielsen-olinder foundation. the overall nosocomial infection rate was decreased in the chx-treated patients by % ( / vs / ; p< . ). we also noted a % reduction in the incidence of total respiratory tract infections in the chx-treated group ( / vs / ; p< . ). gram-negative organisms were involved in significantly less (p< . ) of the nosocomial infections and total respiratory tract infections by % and %, respectively. no change in bacterial antibiotic resistance patterns in either group was observed. a reduction in mortality in the chx-treated group was also noted ( / : . % vs / : . %). inexpensive and easily applied oropharyngeal decontamination with chx oral rinse reduces the total nosocomial respiratory infection rate in patients undergoing off pump cabg surgery. this results in significant cost savings for those patients. staphylococcus aureus (mrsa) has sparked development of alternative anti-microbial strategies. one such approach involves the use of light-activated antimicrobial agents (photosensitisers), termed photodynamic therapy (pdt). following excitation of the photosensitiser by light of an appropriate wavelength, singlet oxygen and free radicals are generated locally which directly attack the plasma membrane and lead to bacteriolysis. although pdt is well established as an oncological treatment, its use in the treatment of wound infections, in particular those involving resistant strains of bacteria, has yet to be established. after anaesthesia and depilation, week old female c black mice received either a single excisional wound or a superficial scarified wound that were immediately inoculated with an emrsa- bacterial suspension ( cfu/wound) and treated after hour with pdt using methylene blue (mb) as the photosensitiser and laser light with a wavelength of nm to a dose of j.cm − per wound. at the end of treatment, the wounds were excised and processed to assess the total number of viable bacteria per wound. two further experiments investigated the heating effect of pdt and possible collateral damage caused by pdt. three control groups were used to sequentially test the effect of mb alone, light alone and an untreated group which received neither mb nor light illumination. pdt treatment resulted in at least a log reduction (p< . mann whitney-u test) in the number of viable bacteria isolated from the wounds (figure) . there were no obvious histological differences between pdt-treated and untreated wounds. the temperature of the treated wounds rose by an average of . ˚c (± . ˚c) at the end of the treatment.conclusion. pdt is effective in reducing the total number of viable mrsa in an inoculated wound and this effect is not due to local heat generation. there were no gross histological changes apparent between pdt-treated and untreated inoculated wounds. candida species have become the third most common nosocomial bloodstream isolates worldwide. an early adequate treatment is undoubtedly a major prognostic factor. on the basis of efficacy and cost considerations, the empirical treatment often consists in fluconazole administration. yet, given the ever increasing incidence of potentially azoleresistant species such as candida glabrata (which currently accounts for one fourth of cases), this therapeutic option may be ineffective and result in subsequent poor prognosis. moreover, definite identification of candida glabrata may take up to five days, thus delaying modification of initial antifungal therapy and further impairing prognosis. the purpose of this study was to identify early risk factors for candida glabrata candidemia, likely to guide and improve the efficacy of the empirical treatment. all non neutropenic patients with blood culture-confirmed candidemia were included in this prospective study, performed in five french icus. for each patient, baseline characteristics and potential risk factors for candida glabrata candidemia available at candidemia diagnosis were collected. comparisons between patients with and those without candida glabrata candidemia were based on student's t-tests or chi-square tests, as appropriate.variables with a p value < . were entered into a multiple logistic regression model to determine independent risk factors for candida glabrata candidemia. of the patients included over a -year period, had a candida glabrata candidemia. independent risk factors for candida glabrata candidemia were: age > yrs (odds ratio -or- . , p < . ), recent abdominal surgery (or . , p < . ), recent use of cephalosporins (or . , p < . ), solid tumor (or . , p = . ), and diabetes mellitus (or . , p = . ). the model showed satisfying goodness of fit (hosmer-lemeshow statistic = . ) and discrimination (auc = . ). we found early available and easy-to-identify risk factors for candida glabrata candidemia. when these factors are present, alternatives to fluconazole for the empirical treatment should be considered. ventilator-associated pneumonia (vap) is an airways infection that must have developed more than hours after the patient was intubated. vap is the leading cause of death amongst hospital-acquired infections, exceeding the rate of death due to central line infections, severe sepsis, and respiratory tract infections in the non-intubated patient. hospital mortality of ventilated patients who develop vap is percent compared to percent for ventilated patients who do not develop vap.[ ] reducing mortality due to ventilator-associated pneumonia requires an organized process that guarantees early recognition of pneumonia and consistent application of the best evidence-based practices. the ventilator bundle is a series of interventions related to ventilator care that, when implemented together, will achieve significantly better outcomes than when implemented individually. to evaluate the implementation effect of a vap bundle in a general intensive care unit (icu), with the utilization of a software house made designed for this goal.(http://www.bundles.com.br) in a bed general icu, implementation of the bundle was done over months beginning on january . the key components of vap bundle are: elevation of the head of the bed; daily "sedation vacations"; ventilation tube with subglotic aspiration system; peptic ulcer disease prophylaxis; deep venous thrombosis prophylaxis; oral feeding tube instead of nasal feeding tube and oral hygiene with chlorexidine twice a day. we compared the incidence density rate from april to december to the same period in (software stata . ). the vap incidence rate reduced from , / to , / mechanical ventilation days (p< , ) -incidence rate ratio , (ci: % , - , ). after months, the rate of vap was zero. this period was the lowest incidence of vap ever registered in the icu. the incidence of multi-resistant gram-negative bacteria infections was also the lower than before bundle implementation. after five months of a vap bundle implementation with the aid of software house-made to help clinicians follow the results in daily basis, has demonstrated an important reduction in the incidence of vap in our icu. the impact of this system implementation for longer period should be followed. amphotericin b desoxycholate (ampho b) has been nebulized in transplant patients to prevent aspergillus infections, but also as part of selective digestive decontamination (sdd) to decrease fungal colonization and infection in critically ill patients. severe adverse effects of ampho b after systemic administration, particularly nephrotoxicity, led to its substitution by less toxic antimycotics. however, it is still unknown whether even small amounts of ampho b found systemically after inhalation therapy ( ) may be associated with organ dysfunction and increased mortality in critically ill patients subjected to sdd prophylaxis. topical (polymyxin, tobramycin, ampho b) and systemic (cefotaxime for days) antimicrobial chemotherapeutics were routinely administered to ventilated surgical patients who were expected to remain in the icu for more than hrs. a prospective observational study was conducted to accompany the change in sdd regimen ( months of data collection with nebulization of ampho b ( mg every hrs) and months without). conclusion. the use of nebulised amphotericin b as part of a sdd prophylaxis was associated with an increased incidence of renal failure and increased mortality in this study. in the view of the nephrotoxic properties of ampho b, this finding may be potentially explained by systemic effects after prolonged drug inhalation in predisposed critically ill patients. however, in the ampho b group, there were a slightly higher percentage of patients suffering from pre-existing diabetes and renal insufficiency, and potentially nephrotoxic antibiotic regimens were administered more frequently in the study period. drainage for septic focus is the most important process in the management for severe sepsis and septic shock. however, there is no reliable evidence concerning the drainage technique, because the condition is usually so complexed and various that there can not be managed with the uniform standard technique. we have preferred double luminal drain with continuous high pressure aspiration method (dld-chpa) in patients with these conditions. the aim of this study is to clarify the effectiveness and safetiness of dld-chpa by clinical experience.methods. dld-chpa was performed for septic foci. the effectiveness of drainage was examined before and after dld-chpa. the structure of dld is same as that of aspiration device used during surgery which consists of outer tube with multiple pore and inner tube directly connected with high pressure aspirating central vacuum system. the aim of dld-chpa is rapid and continuous removing of discharge and pus, to maintaining dry condition of the abscess and fistula, and stimulating granulation; which leads (a) to quickening the closure of the abscess and fistula and (b) prevention of worsening of local condition of localized abscess and leaking point of injured intestine until definitive surgery. mean grade of discharge soaking in gauze, a wash recovered in intermittent lavage, local inflammation of skin surrounding drain (dld) improved after dld-chpa. mean volume of discharge from wound and drain other than dld was depressed after dld-chpa. the sum of volume of discharge and aspirated material after dld-chpa is smaller than before dld-chpa. the frequency of dressing change was decreased. in all cases, we could perform definitive surgery without worsening of local inflammation, especially inflammation of skin around drain. there was no complication with dld-chpa.conclusion. dld-chpa is useful and safe procedure for managing septic foci by draining mucinous purulent fluid effectively, which can prevent worsening of local condition of localized abscess, and keeping the local condition good until definitive surgery, if definitive surgery is necessary. to evaluate pre-dialysis full-dose aminoglycoside administration in septic anuric critically ill patients. in a prospective observational study, all septic patients with anuria received fulldose gentamycin (g), tobramycin (t) or amikacin (a) consisting in a mg/kg (g/t) or mg/kg (a) dose, infused hours before daily dialysis. the pharmacokinetic study of serum dosages was compared to that of septic patients with normal renal function. dosages were compared to that of patients with normal renal function who received infusions and served as controls. anuric patients' demographic data were as follow: mean age [iqr - ], mean saps ii [iqr - ], former renal failure %, respiratory tract infection %, nosocomial infection %, icu mortality %. pre-determinated aminoglycoside peak concentration targets for g/t ( - mg/l) and a ( - mg/l) were achieved in respectively % and . % of anuric patients versus and % of controls. compared to target (theoretically non-toxic) trough mg/l for a), trough concentrations in≤ mg/l for g/t and ≤concentrations ( anuric patients were higher (g/t : median . mg/l; a: median . mg/l) than in normorenal patients (g/t : median . mg/l; a: median . mg/l). with aminoglycoside clearance due to intensive dialysis (median kt/v . / session), delay in aminoglycoside infusion was reduced to hours with an observed half-life of . hours.conclusion. this pilot study supports the feasibility of a new aminoglycoside dosing schedule consistent with full-dose administration three hours before dialysis in anuric septic critically ill patients. the prerequisite is that hemodialysis should be performed daily, using high efficacy membranes. further randomised controlled trials are needed to confirm these results. conclusion. mortality in gram negative nosocomial infection remains high but the impact is greatest for nf-gnb due to their intrinsic resistance to many antibioitics, making selection and optimal therapy difficult. in our population, bsi due to nf-gnb was not associated with significantly increased mortality. this could be explained by older age in f-gnb cf nf-gnb. our study highlights the importance of risk stratification to identify patients at risk. empirical combination antimicrobial therapy (ecat) has been recommended for bacteraemia due to gram positive microorganisms during many years, especially for streptococcus pneumoniae, although its use still remains controversial. the aims of this study were to determine the prevalence of ecat in icu patients with gram positive bacteremia (gpb), to describe the main clinical, epidemiological and microbiological features of such patients comparing with monotherapy treatment and to know the impact of this strategy on related mortality to gpb in critically ill patients. during a ten years and a half period, from to , icu-patients with gpb were prospectively evaluated. empirically antibiotic combination or monotherapy regimen was administrated until the agent of infection was identified following the patient's physician criteria. the administration of two or more antibiotic with activity against gram positive microorganism was defined as ecat. clinical and microbiological variables were recorded. logistic regression analysis was performed to deterrmine the impact of this strategy on related mortality to gpb. there is evidence that current practice could be improved. to achieve this, teaching and assessment techniques that are acceptable to both consultants and trainees must be developed. in other specialities video is used to teach communication skills, although its application to intensive care training has not been widely studied. after obtaining ethics approval, specialists in intensive care at general hospitals in the north-east of england were invited to take part in the study. participants were given a written scenario describing the admission to the icu of an elderly woman with pneumonia. data was included which suggested deterioration despite treatment and progression toward multi-organ failure. the consultants were then videoed conducting an initial meeting with the patient's closest relative (played by an actress). questionnaires were used to record previous experience of communication skills training and reaction to the video exercise. . consultants gave written, informed consent to take part. only half of the participants had previous, limited experience of audio or video recording to teach communication skills. none felt 'significantly experienced' in this area or had used the technique with trainees. most had developed their communication skills by sitting-in as an observer when colleagues were talking to relatives. participants stated they had never had any formal teaching in communication skills either through lectures, workshops or role-play. the plausibility of the scenario and actress were rated highly by all the participants. despite individuals choosing to agree with the statement 'i was anxious and uncomfortable throughout the video exercise', none of the respondents disagreed with the statement 'i managed to settle into the normal style i use when speaking to relatives'. only participants did not support the statement 'overall i feel happy with the way the consultation went'. of the participants disagreed or strongly disagreed with the statement 'i feel the video does not represent my normal practice of speaking to relatives.'conclusion. this study shows that video techniques can be used to reproduce realistic intensive care scenarios. the format was well received by a majority of specialists and despite no previous experience of being filmed, participants felt that the simulation closely replicated their normal practice. teaching-training would be required to introduce these techniques as current specialists have received little formal training in communication skills. during a two-month period, consecutive adult icu patients (sapsii score: ± ; ventilated patients) requiring a transthoracic echocardiography were prospectively studied. after a curriculum including a -hour training course and hours of hands-on, one of noncardiologist residents and an intensivist experienced in ultrasound subsequently performed hand-held echocardiography (hhe), independently and in random order. assessable "rule in, rule out" clinical questions were purposely limited to easily identifiable conditions by the sole use of two-dimensional imaging. cricoid pressure should be applied lightly ( n) before induction of anaesthesia and while the patient is still awake. once the patient is unconscious the force should be increased to n (vanner & asai, ) . a simple training aid using an air filled, capped ml syringe has been described (ruth et al., ) , but a lack of knowledge and poor technique amongst anaesthetic assistants has already been highlighted (meek et al., ) . the aim of this study was to investigate knowledge and skills of a group of intensive care unit nurses in performing cricoid pressure, using a structured interview questionnaire and simple practical test. we asked intensive care nurses from queen elizabeth hospital, birmingham uk to participate in a structured interview. volunteers were asked about their own experience, training and knowledge of cricoid pressure in a questionnaire conducted by one of the authors. each subject was then asked to apply the force that they would normally use in clinical practice to the plunger of a plastipak (b-d) ml syringe filled with air. the destination of the plunger was recorded (ml). the subjects were then informed of the recommendations stated above and allowed to practice the application of n on the syringe ( . ml standard destination). they were than asked if they thought a simulator would be useful for training. . % respondents (n= ) were staff nurse with to years experience, and % performed cricoid pressure less than monthly. only % nurses had formal training and % described their training as 'totally inadequate'. . - % nurses applied and released cricoid pressure only on instruction by anaesthetist and . % respondents did not know the optimum force to use. on simulation, the mean force applied was nearer n than n (mean plunger destination . ml, less than . ml standard. s.d = +/- . , variance = . ). of ( . %) respondents thought simulation training would be useful. intensive care nurses perform this procedure infrequently and become deskilled. this study also highlights the inadequacy of training they receive. using a readily available training aid such as a ml syringe is reliable and may improve staff confidence, performance and patient safety. j. m. boles* , g. prat , a. berthouloux , b. seys , a. renault réanimation médicale, hôpital de la cavale blanche -chu, psychothérapie, société civile alternatives, brest, france the policy of our -bed medical icu includes helping members of the staff to cope with the burden of job stress. our university hospital agreed to finance a focus group to help staff relieve their stress. we performed an evaluation months after. a first non-anonymous survey was conducted in / amongst the staff to know who was willing to attend a focus group. an independant family therapy psychologist was selected out of candidates. a focus group was set up in / open to any volunteer; -hour monthly reunions were conducted by the psychologist. an anonymous questionnaire was sent to all staff members in / . initial survey: mds/ , daytime nurses/ ( night nurses/ ), / auxiliary nurses,the secretary and the chief nurses agreed to attend = , % of the daytime staff. the group held reunions, attended respectively by , , and members of the staff. the group was then suspended. anonymous evaluation: / staff members answered = , %. conclusion. ) in a two hour icu oriëntation in the undergraduate curriculum the icu nursing staff was as successful as the medical staff in improving understanding of the icu organization as well as in improving the ability to recognize vital organ functions and principles of the monitoring of critically ill patiënts. this study suggests that icu nursing staff can enhance learning the basic practical monitoring of undergraduates and can be successfully integrated into undergraduate medical education. in meeting the needs of increasing numbers of medical students there is a potential for this role to be to developed. ) interest to qualify as an intensivist increased significantly when the intensivist was the teacher. guidelines for cpr teach us to do chest compression per minute and to ventilate for a minimum time. however, paramedics tended to do chest compression more quickly and to do ventilation more slowly. in japan, prehospital cpr has been performed by emergency life support techniciens (elst), who belongs to the fire department. in this study, we tried to clarify the actual condition concerning prehospital cpr. japanese elsts are licensed after hours of lecture and , hours of experience, and they are trained repeatedly. in yokohama, one supporting medical doctors is working in the central operation center of the fire department. they can detect the frequency of chest compression and ventilation during cpr in the ambulance. we recorded these frequency for and evaluate the quality of cpr by elst.results. in our system, elst performed chest compression times per . sec, that meant times per minute. they perfom ventilations for . sec. we should train elsts more frequently and repeatedly and should use metronome, voice guide or aed with voice guide during cpr in the ambulance. tracheostomy is often required in icu patients to prevent the consequences of long term translaryngeal intubation, indicated in prolonged mechanical ventilation and long term airway maintenance. it has lots of benefits like increasing patient comfort, less need for sedation, improving oral and bronchial hygiene, allowing oral nutrition, and ease the process of weaning from mechanical ventilation. percutaneous tracheostomy (pct) as opposed to surgical tracheostomy (st) has many advantages: it can be made at bedside (and be performed immediately once the decision is made), being safe and easy, with less operative time, and less intra and early postoperative complications (reduced stomal bleeding and infection, due to the tamponade effect of the tightly fitting tracheostomy tube). it is also associated with lower costs and has better cosmetic results than st. the aim of this study is to compare the timing and outcomes of tracheostomies in our icu, and hospital mortality of these patients. we conducted a retrospective comparative study in distinct periods: and , when all patients in our icu were submitted to st (n= ); and and when patients were preferentially submitted to pct (n= ). we reviewed their indications for tracheostomy, age, gender, apache ii and saps ii score, days to tracheostomy, length of icu stay, ventilation time before and after tracheostomy, icu and hospital mortality. the results presented are in mean values. conclusion. )there was no significant difference in indications for tracheostomy (prolonged mechanical ventilation and airway protection in comatose patients), age( ), gender, mean ventilation days prior to( , ) and after ( , ) tracheostomy. )pct was performed sooner ( , vs , day), and these patients had a sooner icu discharge ( , vs days). )patients submitted to st had higher apache ii( , vs , ) and sapsii( , vs , )scores; higher icu( % vs , %) and hospital mortality ( % vs , %). reported here. the study was carried out in finland. the expert panel was formed of intensive and critical care nurses and physicians of five university hospitals and four central hospitals. altogether (=n) experts participated in first round. the experts completed a questionnaire which consisted of demographics and one essee question. text were analysed according to research questions by content analysis. competence requirements in intensive and critical care nursing can be described as five main domains: specific ) knowledge base, ) skill base, ) attitude and value base and ) experience base of intensive and critical care nursing. additionally competence can be described as several ) personal attributes of competent intensive care nurse. competence requirements can be divided into clinical and professional competence requirements. the sub domains of clinical competence requirements are implementation of principles of nursing care, implementation of clinical guidelines and implementation of nursing interventions. the sub domains of professional competence requirements are then ethical activity, decision making, development work and collaboration.conclusion. competent nurse in intensive and critical care nursing has to have specific knowledge base, skill base, attitude and value base and experience base that differs from overall competence in nursing. additionally competent intensive and critical care nurse has to have spesific personal attributes.grant acknowledgement. we would like to thank the experts of university and central hospitals who participated in this study. to define examine catheter related bloodstream infections (crbsi) over a -year period ( - ) , and compare three expressions of incidence.methods. -bed tertiary referral centre. hospital-wide, total parenteral nutrition(tpn) service based at department of intensive care. quarterly meetings of tpn committee analyse prospectively collected data to examine crbsi incidence. effect of introduction of education protocols and appointment of dedicated tpn nurse were assessed. . patients, cvcs were included. a consistent decline in incidence was observed, % of patients in to % in (figure) . incidence may also be expressed as percentage of cvcs infected, decreasing from % of cvcs to % . finally, incidence is expressed per cvc days which peaked at / cvc days dropping to / cvc days .conclusion. crbsi occurs commonly in tpn populations, but published data remains limited. irrespective of means of expression, our data demonstrates a falling incidence in crbsi, which we attribute to the appointment of a tpn nurse, ongoing education protocols regarding cvc insertion and maintenance. this data supports the pronovost paper that an intervention may result in a sustained decline in the incidence of crbsi. dimension and course of cognitive ability change after elective coronary bypass (cabg) or valvular replacement (vr) interventions are discussed controversely. the aim of our study was ( ) to measure the difference of cognitive abilities concerning attention, memory and fluid intelligence before and after cardiosurgery, ( ) to investigate the outcome difference between cabg-and vr-patients and ( ) to investigate the relevance of duration of bypass-and aortic-clamping as well as duration of anesthesia as predictors of cognitive outcome. subjects: consecutive patients; cabg, vr; timepoints of measurement: t : - days before intervention, t : days and t : - days after intervention: cognitive assessment instruments: d -test (selective attention), rbmt (memory), cft- (fluid intelligence). a significant decline of all measured cognitive functions at t compared to t could be demonstrated for the cabg-(d : p< . ; cft : p< . ; rbmt: p< . ) as well as for the vr-sample (d : p< . ; cft and rbmt: p< . ). both groups showed a remission at t concerning memory and intelligence scores, only vr-patients had persistent deficits in selective attention (p< . ). there were no significant differences between cabgand vr-samples at any time of measurement. no parameter of surgery reached significance as predictor for cognitive outcome in regression analysis. in the early postacute phase ( days) after cabg-and vr-surgery we could show deficits in various areas (attention, memory, fluid intelligence) of cognitive performance as well as rapid remission within one week. despite expectations there were no significant differences between cabg-and vr-samples. abdominal complications in postoperative cardiac population are not frequent but may be catastrophic. non-occlusive mesenteric ischemia appears when there is a mismatch between perfusion and metabolic demands. the symptoms and signs are not incontrovertible and the suspicion of this complication may improve prognosis. indocyanine green plasma disappearance rate (icg-pdr) has been proposed as a tool for the assessment of liver perfusion and function ( , ) so that it may help in diagnosis and to optimize treatment. a prospective study was conducted in cardiac surgery patients. icg-pdr values were measured hours and hours after icu admission transcutaneously by a commercially available system (limon; pulsion medical systems, munich, germany). icg-pdr values and other postoperative data were compared between patients suffering and not suffering from abdominal complications. mann-whitney and wilcoxon tests were applied for statistics. significance was considered when p < . . . patients were analysed but we did not find major abdominal complications. minor abdominal complications were suspected in because they suffer abdominal pain, ileus and higher serum amylase values. this group of patients were older ( ± vs ± , p= . ) and suffer from more hypertension (p= , ). their preoperative risk (numeric eu-roscore) was higher(es num ± vs ± , p= . ) and so was the apache ii score ( ± vs ± , p= , ). twelve hours after icu admission icg-pdr values were lower ( . ± vs ± ,p= . ) and normalized at hours. length of stay (los) was longer (icu-los was ± vs ± , p= . and hosp-los was ± vs ± , p= . ). they had associated more complications : cardiovascular (p= . ), renal (p= . ), neurolgical disorders (p= . ) and infectious (p= . ). procalcitonine (pct) values were also higher(p= . ). they suffer from higher preoperative pulmonary hypertension (pap de ± vs ± , p= . ). cardiac index values were lower hours after admission (ic- . ± . vs ± . , p= . ). serum amylase values were higher in first postoperative day (amy- was ± vs ± , p= . and amy- was ± vs ± , p= . ). and so were aspartate amino-transpherasa (ast) values hours after admission (p= . ). the incidence of gastrointestinal hemorrhage was also higher (p= . ).conclusion. . patients suffering from minor abdominal complications had worse icg-pdr values hours after admission. . they were were older and their preoperative risk and apache ii score were higher. . they suffer more complications and their los was longer. . serum amylase, ast, pct, pap and cardiac index values were worse in these patients. deployment of an intraaortic balloon pump is a technique that is used and recommended in high-risk surgical patients. this group includes patients with haemodynamically significant stenosis of the left coronary artery trunk and ejection fraction minor %, preoperative unstable angina, and intraoperative and postoperative cardiogenic shock. we examined the pre-and post-operative use of an intraaortic balloon pump in our surgical series and its association with morbidity and survival. we undertook a prospective, observational, cohort study of patients who underwent cardiac surgery with extracorporeal circulation between january -june who were admitted to the polyvalent intensive care unit of our third-level hospital. the data collected were analysed statistically with spss . . the study included patients, with a mean age of . ± . years and % were men. the incidence of iabp were: preoperative . %, intraoperative . %, postoperative . %, technically imposible . % and no need of iabp . %. % had some degree of surgical morbidity (including atrial fibrillation). the overall mortality was % and the mean stay was . ± . days (range, - days). the indication were: ejection fraction %, unstable angina %, vessel disease %. after an univariate analysis iabp and postoperative complications there was relation with low output or shock (the indication of iabp, p< . ). the others postoperative complications (mechanical ventilation > h, kidney failure, important haemorrhage and perioperative infarction) were no relationed and has the same incidence as the moderate-low risk interventions.conclusion. the intraaortic balloon pump is a commonly used technique in high-risk patients, reducing the incidence of postoperative complications to the limits of those in moderateor low-risk patients. mecc is a new approach to cardio-pulmonary bypass (cpb). the system differs from conventional bypass (cpb) as follows: minimal priming volume (< ml); no venous reservoir (closed system); active venous drainage; no cardiotomy suction; heparin coating (tip-tip). practical advantages of mecc include: minimal haemodilution; no blood-air interface; reduced foreign-body contact; less haemolysis; reduced heparin given. potential improvements in clinical outcome in icu as a result include: reduced requirement for inotropes; fewer blood transfusions; less systemic inflammation; reduced coagulopathy; improved endorgan function. these factors combine [ ] to significantly reduce prbc transfusion (u/patient) requirements with mecc ( . ± . ) compared with cpb ( . ± . ), or opcab surgery ( . ± . ). mecc has recently been introduced in the swcc for routine cabg surgery. intraoperative data were collected for quality control purposes (n= ), compared with historical controls (same surgeon and anaesthetist) but with cpb (n= ). conclusion. an improved haematological profile (seen here with hb, but theoretically reflected in other blood components) with mecc may reduce postoperative coagulopathy, costs and risks associated with blood and other blood product transfusion, and improved oxygen delivery and therefore end-organ function. g. satkurunath*, p. wilton intensive care and anaesthesia, harefield hospital, harefield, united kingdom cardiothoracic units have high usage of intensive care unit (icu) beds and patient flow-through affects their continued productivity and cost-effectiveness. prolonged icu stay patients are a small percentage but consume a disproportionate amount of resources and have a higher mortality. our aim was to determine the type and the outcome of icu patients requiring prolonged stays at our institution to determine if resources were used appropriately on patients with a reasonable chance of survival. our institution is a cardiothoracic hospital specializing in adult cardiothoracic surgery and transplantation. a retrospective analysis of the institution icu database was performed and all admissions with a duration ≥ days from april to march were identified. the medical records of these patients were reviewed to determine individual risk factors for prolonged icu stay. this data was compared to the overall icu outcome audit data for that year. there were a total of icu admissions of which ( . %, patients) were ≥ days. the median icu length of stay in the study group was . days (range - ). the patients had a cumulative total of bed days which was . % of the total icu bed days ( ). icu mortality was . times greater than the overall unit mortality ( . % versus . %). mean and median age was similar to that of the overall unit. the percentage of readmissions in the study group was . times greater than the overall percentage ( . % versus . %). in the prolonged stay group patients ( . %) survived the hospital admission: were discharged home and were transferred to another hospital for further rehabilitation. cardiac surgery necessitating cardiopulmonary bypass involves periods of ischaemia followed by reperfusion. reperfusion of previously ischaemic tissue may itself result in tissue damage through the activation of neutrophils, production of oxygen free radicals and endothelial damage. this phenomenon has been termed ischaemia reperfusion injury (iri). the consequences of iri may be observed locally in the form of reversible cellular dysfunction or more remotely with effects observed in the lung, liver and cardiovascular system. ultimately, a systemic inflammatory response syndrome (sirs) may develop with the potential to progress to multiple organ failure in the most extreme cases. remote ischaemic preconditioning (ripc) is a technique which provides protection against experimental iri in humans. we performed a randomised controlled trial to investigate the effect of ripc on patients with triple vessel coronary artery disease undergoing cabg surgery (n = ). ripc was induced by cycles of minutes of inflation ( mmhg) and deflation of a blood pressure cuff around the upper arm hours prior to surgery. patients were assessed post operatively for the development of sirs. blood samples were collected up to hours post operatively. myeloperoxidase (mpo), interleukin- (il- ), c-reactive protein (crp), and von willebrand factor (vwf) were measured as biochemical markers of neutrophil activation and endothelial damage.results. sirs developed in % of patients who had undergone ripc compared to % in the control group (p = . ). mpo, il- , (table ) crp, and vwf (table ) were elevated post operatively but no protection was observed in patients pre-treated with ripc. of note, the study was not powered to measure these variables as the primary outcome and thus it is possible that a protective effect may be observed in a larger study population. gender differences in the coronary bypass surgery have been the focus of numerous publications in recent years. compared to men, women undergoing coronary artery bypass grafting appear to have a higher morbidity and mortality, particular in the perioperative period. the aim of this study was to analyze which clinical parameter and laboratories data effect on gender differences in postoperative course. . to the end of december .,all patients on whom were performed elective coronary bypass surgery were included in this retrospective study. age,ef,euroscore,numbers of days in jil,total numbers of day in hospital stay, troponin t (t - hours after addmision,t - hours after addmision in jil),lactate (l ,l ),cardiac output,cardiac index were observed. for all variables was made descriptive statistics. we used student-t test and mann-whitney u test. . patients ( m and f)were observed. analyzing age, ef,euroscore,cardiac output and cardiac index we did not find statistical important differences man versus female. analyzing troponin t, level of lactate (particulary l )we found statisticaly important higher levels in women group. women needed longer support with inotropes and are more likely to spend longer time in the hospital. fortunately, the last decade has produced a surge of public interest and scientific research in womens health, including gender issues related to cabg. it is now well accepted that there are major differences in the risk profile of man compared to the profile of woman undergoing cabg procedures. even when both genders share a common risk factors, the relative impact of risk factor is often quite different in man as compared to woman. w. baulig* , v. hinselmann , m. lachat , k. rentsch , e. schmid devision of cardiac anaesthesia, department of cardiac surgery, institute of clinical chemics, university hospital zurich, zurich, switzerland reports regarding the benefit of continuous local analgesia after various surgical procedures are conflicting ( ). the aim of this prospective, randomized, double-blind study was to investigate the efficacy of continuous local anaesthesia using the pain relief system (i-flow corp, usa) in patients after abdominal aortic surgery. after closing the peritoneum, two multi-hole catheters (length cm) were placed in the opposite direction of the skin incision. following skin closure, both catheters were connected to the elastomeric pump filled with ml of an unknown solution (either sodium chloride [nacl] . % or ropivacaine . %) and a continuous infusion of ml.h- was started through each catheter. every hours until h after surgery combined visual analog pain scale (vas) and numeric rating scale (nrs), partial oxygen (pao ) and partial carbon dioxide pressure (paco ), arterial oxygen saturation (sao ), pulse rate, and mean arterial pressure were recorded. the serum concentration of ropivacaine, free ropivacaine and alpha- -acid glucoprotein were measured daily. the total amount of intravenous morphine sulphate and nonsteroidal analgetics, ventilation time, length of stay in the icu, and the condition of the removed catheters were documented. sixteen patients were enrolled, but one patient had to be excluded because of accidental catheter removal at icu arrival. demographic and surgical data were not different between groups. ropivacaine was applied in , nacl . % in patients. vas/nrs was lower in the ropivacaine group during the first postoperative hours ( . ± . ) than in the control group ( . ± . ), but this difference did not reach statistical significance. no significant intergroup differences were found with regard to morphine sulphate, metamizole and paracetamole consumption, pao , paco , sao , ventilation time and length of stay in the icu. serum concentrations of free ropivacaine ( . ± . µmol/l) were well below toxic levels ( . ± . µmol/l). in two thirds of the removed catheters > % of the holes were closed. . ± . . ± . metamizole (g) . ± . . ± . continuous infusion of ropivacaine . % ml.h- using two multi-hole catheters at the surgical site in patients after abdominal aortic surgery did not reduce the consumption of intravenous morphine and nonsteroidal analgetic drugs. introduction. prognostic scores have been developed for assessing patients's risk of complications or death and are useful to identify high risk patients allowing specific interventions. surgical scores have been developed but it is still not clear if they offer any benefit compared to general icu scores. the aim of this study was to compare the accuracy of the scores apache ii, apache iii and p-possum in a brazilian surgical intensive care unit. consecutive surgical patients admitted in the surgical unit were included prospectively from august to march . cardiac and neurosurgery, age < and length of stay in the icu < h were excluded. after exclusion, the scores were applied in patients. we compared actual in-hospital mortality with those predicted by the apache ii, apache iii and p-possum scoring systems applying receiver operating characteristic (roc) curve analysis by integrated methods using r-system . . . the physiological parameters of p-possum score were obtained in the postoperative period. the operative parameters in orthopedic surgery were adapted. the most common surgeries were: abdominal surgery ( . %), orthopedic ( . %), urologic ( . %), vascular ( . %), bariatric ( %) and thoracic ( . %). procedures done before h of hospital admission were and before h of admission were . the average number of days in icu was . (+- . ) and the mean number of postoperative days before discharge was . (+- . ). the rate of icu readmission in days was . %. the median age was years. overall hospital mortality was . %. the mean absolute values of apache ii, apache iii and p-possum were . (+- . ), . (+- . ), . (+- . ) and mean predicted in-hospital mortality were . %, . % and . %. respectively. the area under the curve from receiver operator characteristic curve analysis for apache ii was . , for apache iii was . and for p-possum was . . these data suggest that p-possum may provide a better estimate of the risk of mortality than apache ii and is at least as accurate as apache iii. p-possum requires fewer individual patient parameters to be calculated and is thus easier than apache iii to be generated. preeclampsia is a multisistemic disease that may occur in pregnancy or in the immediate post-partum period. the incidence of pregnancy induced hypertensive disease is observed in . % in spain. we analise the mortality and the clinical profile of this entity in our icu. the study comprise prospectively women admitted in icu with the diagnose of severe gestosis, from january to october . we define preeclampsia, eclampsia and hellp syndrome as used by the american college of obstetric and gynecology. we consider hellp as a different disease as its mortality rises up to a %. cualitative variables are shown as percentage and cuantitative variables as mean ± standard deviation or median and range in asymmetric variables. we used chi square test, t-test and multivariant testing for statistical analysis of the data. we report data from women admitted in icu in the period january . we didn't find significant difference on systolic pressure between preeclampsia, eclampsia or hellp nor in uric acid levels. there were significant differences in aminotransferase enzymes and platelet count between preeclampsia-eclampsia and hellp. gestational age was significantly lower in preeclampsia than in eclampsia or hellp (p< , ) and, additionally, the weight of newborn were significantly lower in preeclampsia versus eclampsia and hellp. fetal death is associated with a birth weight below gr (p< . ), or . , ci % ( . - . )). maternal death is associated with renal failure, heart failure or coagulopathy (p< . ) or . (ci % . - . ). multivariant analysis show that primiparity appears as a protection versus mortality, p< . or . (ci % . - . ) and pulmonary oedema as a risk factor p< . or . (ci % . - . ). fetal mortality is associated in multivariant analysis with gestational age and consequently with low weight (p< . ) and (p< . ) respectively, or . , ci % . - . and or . ci % ci . - . respectively. women admitted to the icu are mostly years old, in the week gestational age of their first pregnancy. in our environment, delivery mostly occurs in the following to days of admission. maternal mortality is low but not so fetal mortality that rises up to , %. maternal mortality is associated with multiparity and complications such as pulmonary oedema, and fetal mortality mostly with gestational age and low birth weight. in order to reduce postoperative morbidity and mortality following liver resection due to hepatic failure it is important to carefully monitor liver function. as lactate is mainly cleared by the liver, it has the potential to be a good indicator of liver performance. many factors may determine liver function, such as the extent of the liver resection, pre-existent liver conditions, the amount of blood loss, and other patient and operation characteristics. we assessed the value of fast and inexpensive point-of-care lactate measurements as an indicator for liver function next to prothrombin time which is the current standard. in a retrospective observational study we included all patients admitted to the surgical icu after liver resection between april and march . lactate levels were frequently measured in arterial blood with a point-of-care device (abl radiometer). maximal lactate during the first hours after icu admission were determined. extent of liver resection, preoperative liver condition and red blood cell transfusions were recorded. . patients were studied ( males, females) with a median age of years (range - ). abnormal liver parenchyma was present in ( %) patients. in patients, more than % of the liver was resected (major resection). red blood cells were administered in patients with a mean of . (± . ) packed cells. lactate measurements were performed during the first postoperative day. multivariate analysis with the parameters volume percentage resected, peri-operative blood loss, age, gender, preexistent liver condition, showed that the extent of liver resection was significantly associated with lactate levels (p= . ). mean lactate levels were respectively . for major resections and . for minor resections. blood lactate levels were significantly correlated to pt (pearson's r= . ; p< . ).conclusion. the extent of liver resection was an independent predictor of lactate levels. age, gender, amount of blood loss and preexistent liver disease were not associated with lactate levels. lactate levels were clearly correlated with prothrombin time. phaeochromocytoma is a rare chromaffin cell tumour predominantly arising in the adrenal medulla. following pharmacological control, elective surgical excision is performed ( ). postoperative admission to itu is standard as cardio-respiratory, renal and metabolic complications (hypertension, hypotension, pulmonary oedema and hypoglycaemia) may occur ( ) . the aim of this study was to identify postoperative complications following adrenalectomy, requiring critical care support. the data collected would allow us to evaluate the statement that, 'not every patient following adrenalectomy for phaeochromocytoma requires itu admission'. over years, adrenalectomy patients with a clinical, laboratory and histological diagnosis of phaeochromocytoma, were studied retrospectively. twenty three patients were identified from clinical databases and data collection followed a review of the perioperative records.results. % of the adrenalectomies were open, the remainder were laparoscopic ( were converted to open). multiple anaesthetic techniques were used by four anaesthetists. % arrived on itu intubated, but extubation followed within to hours. with a map between and mmhg, % received postoperative inotropic support (noradrenaline . to . mg/h) for to hours. one patient ( %) required inotropic support for hours and remained intubated for hours. six developed postoperative respiratory infections ( % were open adrenalectomies); one of which required reintubation, ventilation and inotropic support. all of those that developed respiratory infections had morphine infusions or pca for analgesia. although the difference between the preinduction and peak intraoperative blood pressures (systolic and mean) were smaller in those receiving remifentanil, it was not statistically significant.conclusion. ) following adrenalectomy for phaeochromocytoma, few patients experienced significant perioperative morbidity and the traditional practice of electively admitting all patients to the itu, should be reviewed. ) an experienced team approach ( ) is more likely to limit perioperative complications than using surgical duration, tumour size and urinary catecholamine concentration to predict postoperative complications ( ). ) standardising the anaesthetic technique could increase the 'in theatre' extubation rate. ) the routine use of epidural analgesia may reduce the incidence of postoperative respiratory infections and may influence the incidence of reintubation. ) the role of remifentanil requires further investigation but prior to venous ligation of the tumour, it appears to improve intraoperative haemodynamic stability. thoracoabdominal aortic aneurysm (t(a)aa) repair is associated with major blood loss exceeding the intravascular volume and complex perioperative coagulopathies requiring transfusion of blood products. there have been three reports evaluating bloodproducts needs in t(a)aa repair. the combination of surgery induced tissue damage and massive blood products transfusion may enhance post operative organ dysfunction and infections. mortality in cabg surgery is associated with number of bloodproduct transfusions. in t(a)aa surgery this relation has not been studied. this question might be of clinical importance as elective t(a)aa repair is associated with considerable mortality ( - %) and morbidity (e.g. respiratory failure - %). in this retrospective single centre study we identified all consecutive patients with taa(a) surgery during the period - . patients records in an icu database and transfusion database were combined and evaluated. baseline characteristics, apache ii score, respiratory failure (ventilator support > hours), transfusion and mortality data were collected. association between variables was determined with multivariate regression analysis. in all patients cellsaver was used. results. patients underwent t(a)aa surgery in the study period. patients ( ( . %) male and ( . %) female) were identified in both databases. the mean age was . ± . years. in hospital mortality was . %. mean apache ii score in the first hours was ± . rbc transfusion results in an significantly increased mortality risk (or . ( %ci . - . )). rbc transfusion was significantly associated with respiratory failure (or . ( %ci . - . )). increased post operative apache ii score results in significantly more rbc infusion (p< . ). these findings could not be demonstrated for ffp and platelets infusion. we did not find a significant difference in blood transfusions and extent of aneurysm, as found by others. our quantity of blood transfusion is much less than reported previously (with and without cellsaver use). conclusion. large volume of blood transfusion may be necessary during and after t(a)aa surgery. rbc transfusion is associated with increased mortality rates. as apache ii score is related to rbc transfusions, peri operative optimalisation might contribute to less blood transfusions. blood transfusion in our population is less than reported previously. cardiac surgery is occasionally complicated by refractory postcardiotomy bleeding, leading to increased mortality and morbidity. recombinant activated factor vii is being increasingly used as rescue therapy in such cases. we report our experience with the use of rfviia in our -bed csicu. all patients who received rfviia as rescue therapy for intractable bleeding during or after cardiac surgery over a -year period was analyzed. we assessed and compared the use of blood products (rbc, ffp, plt), coagulation indicators (international normalized patio [inr] , activated partial thromboplastin [aptt], and fibrinogen), and platelet levels before and after rfviia administration. results. patients (mean age, , +/- , years) received a single dose of rfviia ( , +/- , microg/kg). surgical procedures were aortic surgery (n= ), double valve operation (n= ) and left ventricular assist device (n= ). the men time between icu admission and rfviia administration was hours while patient received it intraoperatively. the mean blood product usage prior and after the administration of rfviia was the following: packed rbc, , versus , u; ffp, , versus u; platelets versus , u; bleeding stopped in all cases and no patient needed reoperation. the mean coagulation results were ptt, , +/- . versus , +/- , seconds; p= , ; inr, , +/- , versus , +/- , ; p< , . in all cases, blood loss decreased considerably after rfviia administration almost eliminating the need for additional blood products, and the prolonged prothrombin time normalized. no side effects of rfviia treatment were noted. there were no thrombotic complications, cardiac ischemic events or deaths. our results support the use of rfviia as rescue therapy in severe, uncontrollable, nonsurgical, postoperative hemorrhage after cardiac surgery as efficacious and safe. however the data are still limited, and further studies are necessary to determine the safety and efficacy of this new hemostatic agent. coumarin oral anticoagulants are widely used to prevent thromboembolic complications in patients at risk for such events. rapid reversal of anticoagulant effects may be required in cases of severe bleeding or emergency surgery and the use of prothrombin complex concentrate (pcc) is recommended. as a surrogate marker international normalised ratio (inr) is used to evaluate the effective use of treatment with pcc. however, a clear correlation between correction of inr and improved haemostasis has not yet been established. this study intended to validate the correlation between the correction of inr, shortening of time to haemostasis, and reduction of blood loss in anticoagulated rats. four groups of female wistar rats were used in the study. rats in groups to were anticoagulated with . mg/kg body mass of phenprocoumon on occasions ( and hours), group , the control group, received isotonic saline. approximately hours after the second treatment, ml/kg body mass isotonic saline was administered intravenously (iv) in groups and . groups and received and iu octaplex ® /kg body mass. fifteen minutes after treatment blood samples were taken. the tail tip was cut off and the tail immersed in isotonic saline at + ˚c. bleeding time and haemoglobin concentration in the saline were measured subsequently. mean bleeding time in group was ± s. in groups and , the maximum observation time of minutes was recorded (except of one which died after minutes). in group mean bleeding time was ± s, complete cessation of bleeding was observed in out of animals. one animal died before minutes and in the remaining clotting was noted with markedly reduced bleeding. haemoglobin concentrations in groups and ( , µg/ml and , µg/ml) were significantly higher (p < . ) than in group ( µg/ml). no statistically significant difference was found between group ( µg/ml) and group . pulmonary thromboembolism (pe) is a critical complication after general surgery with an incidence ranging between , % and % and a mortality rate up to %. systemic thombolytic therapy is the core treatment of submassive and massive pe but may be associated with severe bleeding complications after major surgery. we report a case series of four postoperative patients with suspected (n= ) or proven (n= ) massive, life threatening pulmonary thromboembolism. diagnostic and therapeutic measures as well as decision-finding pro and contra thrombolytic therapy are discussed. one female and three male patients (age to years) presented with acute hypoxemia and severe cardiogenic shock (n= ) or cardiac arrest (n= ) on postoperative day to day following major surgery. pe was suspected in all cases and confirmed by a computer tomography pulmonary angiography (ctpa) in two patients. thrombolytic therapy with mg alteplase (actilyse ® ) was indicated in one patient under cardiopulmonary resuscitation and in two patients by severely impaired right ventricular ejection fraction, and was waived in one patient with moderately impaired right ventricular function. immediate thrombolysis lead to successful resuscitation and to a marked improvement in right heart function and gas exchange within min after administration. bleeding complications following alteplase injection occurred in all patients within the following hours requiring transfusion of - units packed red cells as well as minor surgical revision in two patients. three patients survived in good conditions and one patient died from progressive therapy-refractory right heart failure. we carried out a single-centre, prospective, randomized, double-blind trial with the aim of assessing the efficacy of postoperative prophylactic treatment. this prospective study examines the relationship of haemoviscoelastography (hvg) mednord (ukraine co analyser), a viscoelastic test, measures clot formation and includes information on the cellular, as well as the plasmatic coagulation, system and serum anti-xa concentration in patients treated with enoxaparin. patients scheduled for open prostatectomy using epidural anesthesia were enrolled. epidural catheters were removed the morning after surgery before the commencement of subcutaneous enoxaparin mg once daily. venous blood samples were obtained at: ) the induction of anesthesia (baseline), ) immediately before the third dose of enoxaparin operatively; ) h after the third dose postoperatively, and ) immediately before the fifth dose postoperatively. whole blood samples were obtained for haemoviscoelasthgraphy (hvg), activated clotting time, and anti-xa level analyses at each of the four time intervals. at the four sample intervals, the r time (mean ± sem) ( , ± , ; , ± , ; , ± , min) and the κ time ( , ± , ; , ± , ; ± , ± , min) of the hvg were significantly correlated with the expected peak and trough levels of lmwh and serum anti-xa levels (p < . ). after fifth dose immediately, hvg r times exceeded the normal range in of patients ( %). prolongation of r time and κ time on postoperative day may indicate an exaggerated response to lmwh. lowfrequency haemoviscoelastography is a test that could potentially correlate with the degree of anticoagulation produced by low molecular weight heparin enoxaparin. lowfrequency haemoviscoelastography mednord (ukraine co analyser), a viscoelastic test, measures clot formation and includes information on the cellular, as well as the plasmatic coagulation system is a test that could potentially correlate with the degree of anticoagulation produced by lmwh. the r time from the haemoviscogram correlates with serum anti-xa concentration. hvg is a convenient test to measure the degree of anticoagulation from lmwh. despite the evidence of perioperative hypercoagulability in cancer patients, there are no consistent data evaluating the extent, duration, and specific contribution of platelets and procoagulatory proteins by in vitro testing. this study compared efficacy of haemoviscoelastography versus thromboelasthgraphy for monitoring of coagulation imbalance. patients undergoing open surgery for abdominal cancer received mednord (ukraine co analyser) analysis (hvg), a viscoelastic test, measures clot formation and includes information on the cellular, as well as the plasmatic coagulation system. we examined the efficacy of a variety of coagulation tests. a complete coagulation screen, activated clotting time (act), thromboelasthgraphy (teg) and haemoviscoelastography (hvg) were performed before surgery, at the end of surgery, and enoxaparin anticoagulation monitoring on postoperative days , , , and . there were analyzed for the reaction time and the maximal amplitude (ma). we calculated the elastic shear modulus of standard ma (gt) and hvg ma (gh), which reflect total clot strength and procoagulatory protein component, respectively. the difference was an estimate of the platelet component (gp). there was a % perioperative increase of standard ma, corresponding to a % increase of gt (p < . ) and an %- % contribution of the calculated gp to gt. we conclude that serial standard thromboelas-tography and hvg viscoelastic test may reveal the independent contribution of platelets and procoagulatory proteins to clot strength. using multiple linear regression, all coagulation, teg and hvg variabities were used to model postoperative hypercoagulation. results showed that some components of the teg failed to identify hypercoagulation (r < . , p > . ). however, three components of the routine coagulation assay, including bleeding time, prothrombin time, and platelet count could be modeled to show prolonged postoperative hypercoagulability (p < . ). we conclude that all components of the hvg test reflect postoperative coagulopaties, these results suggests that it may be usefull in determining the coagulation status of cancer patients perioperatively. postoperative hypercoagulability, occurring for at least week after major cancer abdominal surgery, may be demonstrated hvg viscoelastotest. hypercoagulability is not reflected completely by standard coagulation monitoring and teg and seems to be predominantly caused by increased platelet reactivity. hvg provides a fast and easy to perform bedside test to quantify in vitro coagulation, may be usefull in determining the coagulation status of cancer patients perioperatively. in the epidural anaesthesia group (n = ), haemoviscoelasthography (hvg) was performed after crystalloid preloading and during the immediate postanaesthesia course. in the general anaesthesia group (n = ) hvg was performed before induction and during the immediate postanaesthesia course. hvg were repeated postoperativly at , and h. [kk] in the preanaesthesia period were similar in both groups. intraoperative blood loss was not significantly different between between the epidural and general anesthesia groups. there was no significant difference in measured coagulation variables between both groups, but there were significant differences in postoperative r, t and f variables (p < , ). in the postanaesthesia period r and t significantly decreased (p < , ), and ar and f increased (p < , ) in general anaesthesia group. the total blood loss after open prostatectomy was correlated (r = , ; p < , ) with the prostatic tissue weight. when the tissue weight resected exceeded g, blood loss was in excess of the linea correlation shown with the weight of resected prostatic tissue. ( , %) patients has significantly increased f (fibrinilytic activity) and h postoperatively. thromboelastography (teg) provides information on patients' coagulation status within minutes. the value of the teg has not been established in general icu patients. we present cases of critically ill patients with bleeding tendency in whom clinical decisions based on conventional laboratory results were modified by teg. we started implementing routine use of teg (haemoscope,usa). we describe patients in whom teg results changed clinical decisions that were taken before information from teg was available. case - y. o parturient admitted with massive pulmonary hemorrhage of unknown etiology. because of concern of a bronchial tear and bronchial arterial source bleeding, angiography with embolization was performed. despite this, bleeding recurred. there were no coagulation abnormalities and the patient was not thrombocytopenic. teg showed significant early thrombolysis and therefore treatment with tranexamic acid begun. within few hours bleeding stopped and did not recur. case - y. o man with autoimmune vasculitis presented with acute on chronic renal failure and epistaxis. after dialysis which was performed without heparin,the patient became hemodynamic unstable,was intubated and ventilated due to massive pulmonary hemorrhage. blood samples showed inr . ,prolonged ptt,normal fibrinogen level,thrombocytopenia and hemoglobin . g/dl. teg showed no primary fibrinolysis. repeated teg with heparinase showed normalization of the teg tracing. it thus evident that the patient did receive heparin during dialysis and the diagnosis of dic was negated. the patient was treated with packed red cells only,and further bleeding was not demonstrated. case - y.o man with status epilepticus due to an a-v malformation and brain edema,developed left arm compartment syndrome secondary to thrombophlebitis. the patient's platelet count was , . he was operated uneventfully without correcting the thrombocytopenia. a few hours later there was bleeding from the operative site. a teg test showed normal parameters. therefore,despite an initial assessment by the surgical team that the reason for bleeding is a coagulopathy,the patient was taken for a re-exploration of the wound. an arterial bleeder was found which was coagulated.conclusion. laboratory abnormalities are critical for making decisions in critically ill patients. occasionally, the clinical setting of bleeding with mild coagulation and platelet count abnormalities, preclude the patient from receiving invasive procedures prior to correction of the abnormality. thromboelastography can identify alteration in platelet number and function and abnormalities in the coagulation system. in our cases teg tracings were performed in addition to other coagulation tests. we found that in some patients as demonstrated here, the information provided by teg is different from that derived from conventional coagulation tests and leads to a change in clinical decisions. candida airway colonization is common in mechanically ventilated icu patients but the implications of this finding are not well appreciated. fluconazole prophylaxis is a reasonable approach to decrease fungal infections in critically ill surgical patients and is routinely administered in all of our cardiac surgery patients that stay in sicu for more than days. the present study was undertaken to evaluate the incidence and clinical significance of positive bronchial secretion cultures (bsc) for candida in mechanically ventilated cardiac surgery patients, who were febrile (t> c) after the first h in sicu. positive bsc for candida developed in . % of our general sicu population ( . % after cabg, . % after vr, . % after cabg+vr and % in others). the average time for candida airway colonization of sputum was . ± d. the vast majority ( %) of patients developed positive bsc prior to initiation of fluconazole prophylaxis ( pts within - d, pts within - d and pts after d of sicu stay). the icu stay ( ± d), hospital stay ( ± d) and mortality ( %) were significantly higher in patients with positive bsc for candida, compared to the general sicu population (icu stay . ± . d, hospital stay . ± d, mortality . %). candida airway colonization of febrile cardiac surgery patients after the first h in sicu is associated with a grave prognosis and could be a marker of compromised immune response. this colonization appears early in the course of icu stay and therefore the initiation of earlier fluconazole prophylaxis may be necessary. the current incidence of ie is estimated as cases per . population per year and continues to increase. the prognosis is significantly influenced by proper diagnosis and adequate therapy. cardiac surgery for active ie is established as a cornerstone therapy as it is required in % of patients but remains a challenging and high-risk procedure. the purpose of this study was to analyze the clinical characteristics of the patients underwent cardiac surgery for active ie in our center for a -month period. to evaluate principal indications for cardiac surgery and assess the major causes of surgical morbidity and mortality in ie patients. retrospective review of ie cases who underwent cardiac surgery from december to november in our -bed csicu. we collected age, gender, site of endocarditis, native or prosthetic, microbiological agent, indication of surgery, postoperative complications, icu stay and mortality. . patients with ie underwent surgical intervention in acute phase of infection. their ages ranged from to years (mean , ) and % were males. the causative agents were: streptococci-enterococci ( %), staphylococci ( %), candida spp ( %), pseudomonas aeruginosa ( %). the principal indications for cardiac surgery were development of heart failure due to severe heart valve defects or prosthetic valve dysfunction and intracardiac abscess. all patients had positive blood culture endocarditis but only two were still positive before operation. cases of aortic valve involvement were the most frequent, followed by cases of mitral valve endocarditis. native valve endocarditis prevailed over the prosthetic ones versus . surgery was performed using a mechanical prosthesis of the infected valve. in patients the procedure was complemented with tricuspid valve annuloplasty. patients underwent bentall procedure. the mean icu stay was , days (range to ). thirty-days mortality of patients undergone surgery for ie was %, patients died in the icu. operation for active ie carries a relatively higher mortality in comparison with elective surgery. an indication of surgery depends on several clinical variables but the main indication remains heart failure due to severe heart valve defect or prosthetic valve dysfunction. a high degree of clinical suspicion, at an early diagnosis, and indication of surgical treatment prior to deterioration of ventricular function and installation of generalized sepsis may improve prognosis. severe sepsis is a major cause of morbidity and mortality following major surgery. factors that are associated with an increased risk of sepsis following surgery include emergency surgery, patient comorbidities and degree of surgical insult. the risk of developing severe sepsis following major surgery for cancer has been shown to relate to the charlson comorbidity score , with a higher score predicting a greater risk of developing severe sepsis .we conducted a prospective observational study in order to investigate whether the charlson score could be correlated to the risk of developing sepsis following elective major general surgery in patients without cancer. we collected data on patients undergoing elective major surgery in a large teaching hospital. the charlson comorbidity index was calculated preoperatively for each patient. the patients were followed up for days postoperatively, and signs of the systemic inflammatory response syndrome (sirs), sepsis and septic shock were documented each day. the source of sepsis was recorded, if present. admission to critical care bed was also documented. . data was complete on patients, ( . %) were male, and ( . %) had cancer. the median age of the patients was years. mean operation time was hours, and mean transfusion requirement intraoperatively was . units. the median charlson score was . ( . %) patients were admitted to a critical care bed for reasons other than routine postoperative care. ( . %) patients developed sirs postoperatively. ( . %) patients developed sepsis postoperatively, and ( . %) of these went on to develop septic shock. there was a progressive, but non-significant difference in charlson score in those patients who developed septic shock or sepsis and those who did not. those patients who developed septic shock had a mean charlson score of . , while those with sepsis had a mean charlson score of . . those patients who did not develop sepsis had a mean charlson score of . . sepsis and septic shock are common after elective major surgery, but the charlson comorbidity index was not a useful predictor of the likelihood of developing sepsis in our population of cancer and non-cancer patients. rate of neurological complications after central nerve blockade is < . % ( ) and spinal epidural abscess vary from : to : ( ) . we audited the complications following epidural analgesia in postoperative patients admitted to our critical care unit with sepsis. we performed a retrospective case note review of all septic patients who had epidural analgesia for postoperative pain relief or for weaning from mechanical ventilation. all patients who had a major laparotomy and sepsis were included. we looked into the complications of epidural during insertion, usage and after removal of epidural catheter. patients were followed up by the critical care outreach and acute pain teams on discharge from the critical care unit. data are presented as mean and standard deviation. in a year period there were septic patients who had epidural analgesia. of these were commenced immediately prior to the laparotomy and were inserted in itu to enable weaning from mechanical ventilation. the male: female ratio was : with an average age of . ( . ). there were patients with or more organ failure. only ( . %) patients had positive blood cultures during the period of epidural analgesia. multiple attempts at epidural insertion were found in patients. mean duration of epidural catheter was . ( . ) there were survivors and non-survivors in this group. of the nonsurvivors died during the period epidural analgesia. the other nonsurvivors were followed up for an average period of . days and a median duration of days after the epidural catheter was removed. none of the patients developed any complications attributable to the epidural. the serious complications of epidural analgesia like epidural abscess and nerve injuries, although rare, are reported in case series( ). we did not note any adverse complications of epidural analgesia in this high risk group of septic patients admitted to the critical care unit. key: cord- -n f xupw authors: nan title: ps - date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: n f xupw nan bronchoscopy bronchoalveolar lavage (bal) may be followed by a systemic inflammatory response which clinical effects in critical patients are unknown. we designed this study to examine the effects of fiberoptic bronchoscopy (fob) with and without bal on body temperature, systemic arterial pressure, heart rate and supportive therapies requirements in mechanically ventilated patients. methods. consecutive mechanically ventilated patients were prospectively enrolled. fob with bal ( ml of isotonic saline instilled by aliquots of ml) was performed in patients and without bal in . heart rate and mean arterial pressure were recorded hrs before (time ), at the beginning (time ), and (time ) and hrs after the procedure (time ). body temperature, vasopressors, urine output and fluid balance were registered during hrs before and after fob. there were not changes in hemodynamic parameters, body temperature nor supportive therapies (p: n.s.) in fob patients without bal. on the contrary, in patients with bal, there was a significant decrease in mean arterial pressure hrs after the procedure (table). fluid balance and urine output remained unchanged (p: n.s.), but number of patients on vasopressor therapy and mean vasopressors dosage increased after bal (from . ± . µg/kg/min to . ± . µg/kg/min; p < . ); body temperature did not change (p: n.s.). conclusion. global tests may better reflect physiological haemostasis than standard screens or individual factor assays in critically ill patients with sepsis. studies that involve clinically relevant endpoints of bleeding are required. abizanda r , reig-valero r , bisbal-andres e , mas-font s , sánchez-morán f , madero-peréz j , iranzo-velasco j intensive care department, hospital universitario asociado general de castello, castello, spain to limit therapeutic effort (let) is a reasonable acceptable medical and ethical attitude that must be offered to those cases where the evolution of patients is no good in spite appropiate treatment. our aim has been to look into the let decisions and in the participation of patients and surrogates in them. retrospective analysis of decision making processes about let attitudes in a multidisciplinary beds icu during and , as compared to practices registered during and . since , a consensus attitudes form has been fulfilled between the attending medical team and the surrogates of patients to whom let was proposed (by any part). the agreement offered differentiated possibilities of let (no cpr, no increases in fio , no use of vasoactive drugs, no use of extracorporeal renal depurative techniques, and so on). existing agreement for each individual patient was reviewed every time that the attending team or the surrogates ask for that. during the analyzed years, let attitudes were performed ( in and in ) over a whole in icu mortality of patients ( and ). in patients in whom let was decided, age, severity of illness, risk of death, nursing workload and icu length of stay, were significantly higher than in patients not subjected to let. agreement on let attitudes, between the attending medical team and the patient's representatives was present in % of cases, and in the % the let was decided only on professional-technical reasons. in those cases, medical decision was also informed to relatives. the number of patients being discharged from the icu in whom let was established was ( %). withholding approaches were more than three times higher than withdrawing indications. shorten of death process, was performed in patients ( % of let). these observational data agree with the theoretical approaches established by our group in . no claim was presented by relatives or patients against medical attitudes. conclusion. an increasing transparency in decision making about let does not meet refusal from the patient's representatives, and, by the contrary, it favours that the decision becomes a collegiate one and makes more easy the implementation of non futile attitudes. rubulotta f m , gullo a , levy m m , ramsay g intensive care, gasthuisberg uz, leuven, belgium, intensive care, cattinara, trieste, italy, intensive care, brown, providence, united states, hospital director, atrium, heerlen, netherlands the objective of this study is to assess the end-of-life decision-making process in different countries. questionnaire administered by the same interviewer to north american physicians after an end-of-life discussion with proxies of patients admitted to a medical intensive care unit (micu). questionnaire administered by the same interviewer to italian icu physicians during a regional meeting. physicians in both countries were asked, using a five point linkert scale, to indicate their percentage of responsibility in the decision making process. . usa physicians reported a % of responsibility in the end-of life decision-making process in the micu. italian physicians claimed % of responsibility in the end of life decision making process. physicians have different percentage of responsibility in the end-of-life decision making process according to their culture and working environment ( ) . decision to withhold or withdraw of life-sustaining treatment for an incapacitated brain-damaged patient raises complex issues regarding legal or medical concerns. it is the main question how a "clear and convincing" evidence based decision can be constituted or who has the right to make decision in end of life for a patient living in persistent vegetative state. here we present the care of a woman who was left in a persistent vegetative state after having a cardiac arrest. in , the case of n.u. had a cardiac arrest triggered by a delivery with severe abruption placentae. hypoxic-ischemic encephalopathy developed after a poor response to resuscitation. after one-year stay in icu, she was discharged from hospital without a ventilatory support but still required tracheotomy cannula, gastrostomy tube and urinary catheter. nursing homes caring for incapable patients are not under the cover of health insurance policy in turkey. so the sole solution for caring ms. u was being nourished at own home. to both improve and supply a constant care for ms. u, her sister and her husband agreed on to 'err on the side of life': the final decision was a marriage between mr. u and sister-in-low. it perhaps seems like a moral disturbing solution at first sight, but we do not have to forget that the families commonly disagree over how best to care for a loved one. those unfortunate circumstances need stronger bond shared by each family member, rather than a familial dispute. participation of sibling into the care of ms. u, of course, did not improve the neurological outcome or any cognitive function, but resulted in nearly uninterrupted care, which could be so hard to ensure in a different manner. furthermore since , artificial nutrition and hydration delivered by family without a nurse support, surprisingly maintain normal levels of hematological and biochemical parameters, measured periodically. we believe that the acceptance of diagnosis by all family members that her condition was irreversible, and then they had submitted to her unfortunate destiny. nevertheless, it is difficult to analyze underlying factors, which cause perhaps a compulsive marriage. this profound decision, whether reflects what the patient would want for herself or what the family would want for their incapacitated loved one, is rather debatable. in order to help relieve conscious patients and family members from the burden of an icu stay, we introduced in our icu non-professional hospice volunteers (hv), trained to intervene in palliative care settings. we performed an evaluation after one year. after an agreement was signed with the hv association, hv's role and hours of presence were defined and adapted between the hv women and the icu staff. an hv was on duty one afternoon every weeks from / to / and every week from to / . hv met patients and family members either upon request or suggestion by the staff. a special logbook could be consulted to transmit information. evaluation was performed using questionnaires for staff and hv. these results clearly indicate that introducing hv in an icu is considered by a large majority of the medical and nursing staff as useful and appropriate, though some expressed reluctance to share informations with the hv. satisfaction of patients and family members is being evaluated. a working group has proposed improvements. italy has icus. these include adult and pediatric units. we contacted icus selected at random all over the country. local icu regulations allow family members one visit a day in % of cases. only one family member can enter inside the icu after wearing gloves, mask and gown in % of cases, two family members wearing the same protection in % of cases, and more than two people in % of icus. icu physicians meet the family members at admission and once a day in % of cases. reasons given for adopting these rules include-in % of cases a lack of physical space to receive relatives longer than minutes, in % of cases a lack of icu staff, in % of cases concern about an increased risk of infection, and in % of cases other reasons. all units have special rules for caring for families of terminal patients. the communication between physicians and families in italy could be improved first of all by more space inside the unit, second by dedicating more staff time. families seem to be adequately supported by the icu staff in terminal or difficult situations. masnou n , pont t , gracia r , salamero p transplant coordination, hospital vall d'hebron, bcn, spain the aim of the study is to compare tissue donation refusal between organ donors and potential tissue donors. methods. prospective and descriptive study of all family interviews from to , through specifically designed protocol. this included epidemiological data, the manner of comunication to transplant coordinator (tc), interview features and perceived family attitude. there were deaths in this period. we evaluated as potential tissue donnors patients. a tc carried out the interviews with these families, % ( ) refused donation. over % were actual tissue donors.we followed patients in brain death in this period. only could be organ donors, % of these families didn't consent to tissue donation; so only % of patients could give tissue. we did interviews ; % of families were familiar with spanish law about transplant and presumed consent, and only % of people carry donor cards or have made a living will. regarding the family ties to the deceased, in the case of organ donation the parents refused in % of cases, the partner in % ,the children in %, siblings in % and % in the case of more distant relatives.in the case of tissue donors the refusal was from the parents in % of cases,the partner in %, the children in %, siblings in % and other relatives in % of cases.these differences were due, in part, to the advanced age of the tissue donors. if we relate the cultural level of the interviewed people with the refusals we find the following results: mo low cultural level %, average % and high % while in the tissue group , low %, average % and high % (ns). the reasons for family refusal were as follows (mo-mt %): deceased had expressed negative attitude / , family opposition / , resentment of the health system / , difficulties with image of the corpse / , deceased's will unknown / , contrary religious beliefs / ,flat refusals / , others / .regarding reversed refusals in mo, consent was obtained in % of cases and in % of mt. tissue donation is still the war horse for tc.this is due to a general lack of awareness of every aspect of this subject.there remains to carry out the lengthy task of social education in this area. methods. this is a descriptive study on the level of satisfaction of students who received these classes.it was carried out with th year students( y)and th( y).we used a post-course questionnaire, which included:level of interest,clarity and usefulness of explanation, students'environtment.it was agreed by the professionals working on this project not to use audiovisuals.the lesson was structured in six parts: introduction,donation rate, difference between organs and tissues,characteristics of the waiting list,conditions to become an organ donnor(brain death),discussion on transplant law and personal experiences.sometimes,kidney receptors participated and explained their experiences. we considered the experience useful and satisfying.both the institutions and the students supported the presentation in over % of cases.the teachers considered the course enjoyable and accessible.we feel that we need to evaluate the level of comprehension and therefore we have designed a new study with two questionnaires, one prior and one a week after the course so as to evaluate the changes in the students' sensivity and perceptions. organ transplantation activities are dependent on legislation, attitudes of the general public and health care professionals, and the organization of transplantation. reports from countries throughout the world have emphasized the importance of positive attitudes in health workers on organ donation and transplantation, yet there is a lack of studies on this subject. even in spain, the leading country in organ donation rates, there is also an existing shortage of these studies. however, donation rates have not kept pace with demand, resulting in a critical deficit of available healthy organs. it has been suggested that the attitudes of medical personnel regarding organ retrieval is a key success factor to improve organ donation. the aim of this study is to examine attitudes towards organ donation in health care workers. we analysed a long survey, which evaluates attitudes, knowledge, roles and experience towards organ, and tissue donation and transplantation. this survey was administered to all participants before and after the post graduate courses ( and ) in organ donation. we studied this changes in term of prognosis (glasgow outcome scale). we prospectly studied patients the first hours after sah. patients with chronic cardiac disease or brain death were excluded. clinical characteristics (glasgow scale, heart rate, systolic blood pressure), cardiac enzymes (troponin i, total serum creatine kinase and myocardial isoenzyme, myoglobin), ecg changes (st-t changes, prolonged qt and corrected qt intervals), echocardiographic assessment of cardiac function (left ventricular ejection fraction, hypokinesia) were studied on the day of the admission. data are shown in the table. only systolic blood pressure bpm were found to be independent factors of poor outcome. measurements of myocardial specific enzymes and echocardiographic assessment of cardiac function have no prognosis impact in this study. )the more the patient sleeps during the day, the more likely to have poor quality sleep at night. )sleep disruption in icu is related to the degree of illness-severity and length of stay in the unit. )actigraphy is a simple method of assessing sleep that is well tolerated by patients and doesn't interfere with nursing activities. it is well-known that the ischemia-reperfusion injury in patients resuscitated from cardiopulmonary arrest (cpa) severely damages the brain. some recent studies have been reported that neuron-specific enolase (nse) is an useful marker for outcome prediction. the aim of this study was to compare the prognosis of patients resuscitated from cpa with levels of s protein and nse in serum and cerebrospinal fluid (csf). twenty four patients resuscitated from cpa were eligible in this study. patients were divided into two groups according to the glasgow outcome scale (gos) at three months after the initiation of therapy. group g had the favorable neurological outcome and group p had the poor outcome, evaluated by gos. the blood and csf samples were taken within hours after resuscitation and the levels of s protein and nse were compared between the two groups. jugular bulb oxygen saturation levels were measured when hemodynamics were stabilized. mann-whitney's u test was used for continuous variables. correlations were tested using spearman's rank correlation test. a p-value less than . was considered statistically significant. six patients in group g had favorable neurological outcome and eighteen patients in group p had poor outcome. the levels of s protein in serum and csf (median, . and . ng/ml, respectively) in group p were significantly higher than those (median, . and . pg/ml, respectively) in group g. the levels of nse in serum and csf (median, . and . ng/ml, respectively) in group p were significantly higher than those (median, . and . ng/ml, respectively) in group g. jugular bulb oxygen saturation levels in group p were significantly higher than those in group g. the levels of s protein in serum correlated well with those of nse in serum (σ= . , p< . ). the outcome and jugular bulb oxygen saturation levels correlated with the levels of s protein in serum (σ= . , p< . , and σ= . , p< . , respectively). the levels of s protein in serum and csf correlated well with nse and their neurological outcome, so that s protein would be an excellent biological predictor in patients resuscitated from cpa. grant acknowledgement. this work was supported by the grant from the japan society for the promotion of science, japan. wright k , munasinge a critical care and emergency medicine, royal surrey county hospital, guildford, united kingdom injury to the cervical spine occurs in - % of blunt multisystem trauma. spinal immobilisation consists of a hard collar, headblocks and tape immobisation.this immobilisation is maintained until the cervical spine can be cleared of injury. often this relies on the patient being able to co-operate with a neurological examination. following head trauma some patients may never regain sufficient neurological ability to co-operate with an examination. others may remain obtunded for some time. until the spine is cleared the patient needs to be log-rolled and turned in accordance with spinal care bundles. complications such as pressure sores can ensue if this is not followed. evidence has also shown that removal of the cervical spine collar in head injured patients improves venous drainage from the head and so is beneficial in managing intracranial pressure .we therefore need an approach to clearing the spine in obtunded multisystem trauma patients. literature review study leading to institutional protocol. a safe clearence protocol is suggested. a protocol guided approach will allow the rapid removal of cervical spine precautions in multisystem injured patients. patients who have a spinal injury demonstrated are excluded from this approach and are managed in accordance with the spinal service guidance. hypothalamic-pituitary-adrenal (hpa) function has been recently studied in patients with traumatic brain injury (tbi), but few studies have shown its relationship with outcome. the aim of this study was to analyze hpa response and its relationship to intensive care unit (icu) survival in patients with isolated tbi. we studied consecutive patients ( male) with isolated tbi. norepinephrine (ne) was used to maintain cerebral pressure perfusion over mmhg when necessary. at - hours following tbi, we recorded values for plasma acth, baseline serum cortisol and stimulated cortisol at and minutes after performing high-dose corticotropin stimulation test (hdcst). mean and sd are reported. chi-square and logistic regression analysis were done. age was . ± . years. iss . ± . ; apache ii . ± . ; gcs score after resuscitation . ± . . plasma acth was . ± . ng/ml (normal values - ng/ml). baseline cortisol was . ± . ug/dl, stimulated cortisol at minutes . ± . ug/dl and at minutes . ± . ug/dl. all patients increased at least ug/dl after hdcst or had a stimulated value greater than ug/dl. overall survival was . % ( patients). univariate analysis of variables related to icu survival showed: age < years (p= . ),apache ii < (p= . ),acth < ng/ml (p= . ),baseline cortisol < ug/dl (p= . ),use of ne (p= . ),second-tier measures to control icp (p= . ), gcs > (p= . ). logistic regression analysis revealed that no need of second-tier measures to control icp (or . ci % . to . ) and plasma acth lower than ng/ml (or . ci % . to . ) were significant independent predictors of icu survival. conclusion. )adrenal gland function, assessed by hdcst, is not impaired at early stage of tbi. ) tbi patients with low levels of plasma acth had a high icu survival. paramythiotou e , katsarelis n , papakonstantinou k , stathopoulos g , varveri m , fousfoukis s , roussos a , karabinis a icu, george gennimatas general hospital, athens, greece aspiration of foreign bodies during trauma is a known com-plication. it usually concerns teeth, pieces of food etc and for their removal several procedures, invasive or not -like bronchoscopy or thoracotomy -must be underta-ken. we describe three patients with foreign body aspira-tion in our icu. a year -old male was admitted in our icu with face trauma, a broken mandible and a broken femoral bone. a foreign body was observed in the left lower bronchus on the chest x -ray. an attempt to retrieve it with the flexi-ble bronchoscope failed and the foreign body moved to the right lower bronchus. a rigid bronchoscope was then used with success and the foreign body was removed. it was a part of the broken mandible. the patient was discharged after two weeks. case . a year -old male was admit-ted after a road accident suffering from a severe cerebral injury, a pneumothorax and a broken lower mandible. a fo-reign body (piece of a broken tooth) was aspirated in the right upper bronchus. it was retrieved with a flexible bronchoscope. he remained in a "vegetative" situation for a long time and finally died because of a septic shock. case . a yearold patient was admitted with cerebral injury and a low glascow coma scale, a pneumothorax and acute respiratory failure. a foreign body was present in his right upper bronchus. the flexible bronchoscope and a basket were used in order to retrieve it. it was a large tooth. his neurological situation never ameliorated and the patient developed a septic shock and a multiorgan fai-lure and died. severe cerebral injury may result in foreign body aspira-tion especially when it is accompanied by facial trauma. for comatose patients, x -ray of the chest and thorax c/t scan are the main diagnostic tools for this situation. retrieval of the foreign bodies is necessary to avoid further complications such as atelectasis, pneumoniae etc. flexible bronchoscope used through the endotracheal tube is very effective in their removal. medical personnel dealing with trauma patients must have a high index of suspicion for the presence of foreign bodies in the tracheobronchial tree. flexible bronchoscopy or use of the rigid bronchoscope in case of failure, are very use-ful and safe techniques for the removal of these foreign bodies. mandila c , koukoulitsios g , stathopoulos g , paramythiotou e , theodoropoulos g , karabinis a icu, general hospital of athens ''g gennimatas'', athens, greece we report angiographic detection of vertebral artery dissection (vad) in two sedated patients in the intensive care unit (icu). in both cases vad was suspected solely by the presence of ischemic lesions evident on cervical spine and brain magnetic resonance imaging (mri). two patients were intubated, sedated, and admitted to the icu with glascow coma scores < after having suffered blunt head and neck injuries due to motor vehicle accidents. in the first patient computed tomography (ct) of the brain and cervical spine revealed traumatic subarachnoid haemorrhage, anterior atlas arc fracture, axis fracture, and a c body fracture. in addition, brain and cervical spine mri depicted a medullar contusion at the c level, an increased interarticular space c -c , and a left cerebellar hemisphere infarct. based on these findings carotid and vertebral angiography was performed, which showed complete left vertebral artery occlusion at the c level with incomplete distal filling due to a hypoplastic right vertebral artery. in the second patient brain ct was normal, while cervical spine ct revealed c -c dislocation with accompanying posterior sliding of c , and a subdural haematoma at the c -c level on the right. cervical mri showed dislocation with spinal cord dissection at the c -c level, and a large ischemic right occipital brain lobe lesion that was ascribed to putative right vertebral artery thrombosis/dissection. carotid and vertebral angiography revealed bilateral vad at the c -c level with distal reopacification by collateral perfusion. anticoagulant therapy was not administered due to coexisting contraindications (subarachnoid haemorrhage, hemorrhagic contusions, subdural hematoma). the level of consciousness increased step-wise in both patients. while the second patient suffered bilateral vad, his recovery was more complete than that of the first patient. in patients with brain and cervical trauma, the coexistence of cerebral lesions due to accompanying vad is probable. mri can prompt further investigation by depicting ischemia of vertebral artery-dependent areas. the impact of vad largely depends on the efficiency of collateral flow to the affected parenchyma. maintaining of normal cerebral oxygenation is the main goal of intensive care of patients with severe head injury. it can be achieved by different methods. one of them is hyperoxya. in this study we investigated the influence of different fractions of inspired oxygen (fio ) on cerebral oxygenation and intracranial pressure (icp). two patients with traumatic brain injury (tbi) with glasgow coma scale on admission enrolled in the study. patients had one-side lesions and underwent decompressive craniotomy. we compared fio with icp (n= ), cerebral oxymetry in non-lesioned hemisphere rso (nl) (n= ), oxygen partial pressure in cerebral tissue (ptio ) in lesioned (les) (n= ) and nonlesioned (nl) hemisphere (n= ), pao (n= ), jugular bulb saturation (sjo ) (n= ), o extraction ratio (o er) (n= ), arterio-venous o difference (avdo ) (n= ) and lactate concentration in jugular bulb (lac(v)) (n= ). plasma osmolality, cardiac output, invasive mean arterial blood pressure, paco and blood temperature were stable during investigation. fio changing from to , leaded to decrease in pao (m±sd) ( , ± , vs , ± , torr ((p< , )), sjo ( , ± % vs , ± , % (p< , )), rso (nl) ( , ± % vs ± , % (p< , )), ptio (les) ( , ± , vs , ± , torr (p< , )) and non-significant changes in ptio (nl) ( , ± , vs , ± , torr), lac(v) ( , ± , mmol/l vs , ± , mmol/l), icp ( , ± , vs , ± , torr), o er ( , ± , vs , ± , ) and avdo ( , ± , vol% vs , ± , vol%).we found good correlation between fio and pao (r= , (p< , )), sjo (r= , (p< , )), rso (nl) (r= , (p< , )), ptio (nl) (r= , (p< , )) and ptio (les) (r= , (p< , )).during comparing of different methods of cerebral oxygenation assessment we found good correlation between sjo and ptio (nl) (r= , (p< , )) and no correlation between sjo and ptio (les) (r= , (p= , )), rso (nl) and ptio (nl) (r= , (p= , )), rso (nl) and ptio (les) (r= , (p= , )). fio increasing is effective and quick method of cerebral oxygenation improving.icp is not influenced by fio changes.fio must be noticed during interpretation of high levels of sjo and rso . jugular oxymetry reflects the oxygenation mostly of the non-lesioned brain hemisphere. cerebral oxygenation monitoring can be improved by combination of sjo and ptio methods. nijboer j m m , van der horst i c c , hendriks h g d , ten duis h j , nijsten m w n surgery, cardiology, anesthesiology, university medical center groningen, groningen, netherlands there is a longstanding belief that in trauma patients hematocrit(ht) is more sensitive than hemoglobin(hb) in detecting blood loss. this association of ht with trauma is reflected by numerous references in medline. we studied the relation between hb and ht in trauma patients. trauma patients with an iss> from to were included. all blood samples taken during the first week in which hb and ht were both measured, were analysed. in patients (mean age ± yrs; % male) paired hb and ht values were available. the mean hb was . ± . mmol/l with a range from . to . mmol/l. the mean ht was . ± . , ranging from . to . . hb and ht had a pearson r of . (figure) . in a large series of trauma patients hb and ht behaved as identical parameters. the idea that ht is different from or superior to hb is a misconception and there is no reason for determining both hb and ht in trauma patients. paramythiotou e , papakonstantinou k , tsirantonaki m , kalogeromitros a , noulas n , pedonomos m , apostolakou h , karabinis a icu, george gennimatas general hospital, athens, greece introduction. propofol is often used as a sedative in icu patients. unfortunately large doses may be needed sometimes causing propofol infusion syndrome (pris). we are presenting a patient with this syndrome followed by manifestations compatible with a catastrophic antiphospholipid syndrome (caps). a year old female was admitted to our icu with a multiple trauma. she had many skull fractures, a subarachnoid hemorrhage and a small acute subdural hematoma. she was put to sedation with propofol. large propofol doses were used to keep her sedated ( - ml/h of propofol infusion %) along with noradrenaline and corticosteroids to maintain a normal arter. pressure. three days later she developed high fever, cpk rose to . µg/l and a multiple organ failure followed including renal and right heart failure. a cvvhd was immediately started. she was also put on broad spectrum antibiotics and the propofol infusion was interrupted. a week later her situation had become stable, she was free from vasoactive agents and her renal and cardiac functions were reestablished. the blood cultures taken did not prove the presence of bacteremia, though the simultaneous presence of an infection could not be excluded. thirty -two days after her admission she presented a status epilepticus. a brain c/t and mri were performed, revealing the presence of multiple hypodense areas not following a vessel distribution. an anticardiolipinantibody titer igg ( st u, nd > u ) gave us the hint for a probable caps. after a combined therapy with plasma exchange and immunoglobulins she recovered and survived later on. propofol infusion is very popular in icus hospitalizing patients with cerebral injuries permitting physicians to perform regularly a neurological examination. large propo-fol doses and concomitant use of corticosteroids and catecholamines with or without sepsis could precipitate pris as in our case. our patient's condition was complicated by the neurological manifestations attributed to probable catastrophic antiphospholipid syndrome. the question aroused is if pris could have triggered such an autoimmune disorder. conclusion. attention must be paid to propofol doses used for sedation of patients with craniocerebral injuries especially adolescents. alternative sedation or combination with other sedative and/or analgesics must be considered. tsarenko s v , petrikov s s , huseynova k t , krylov v v neurosurgical icu, neurosurgery, sklifosovsky scientific research institute of emergency medicine, moscow, russian federation invasive measurement of the intracranial pressure (icp) is known as the best method of intracranial hypertension evaluation. unfortunately it is associated with high equipment costs and risk of infection complications. we compared non-invasive methods of intracranial hypertension assessment with invasive icp measurement. methods. patients enrolled in the study (severe head injury (n= ), arterial aneurism rupture (n= ), hemorrhagic stroke (n= ), arterio-venous malformation (n= ). average age (m±sd) ± . m/f ratio was / . all patients were operated ( underwent decompressive craniotomy, boneplastic craniotomy and -insertion of icp sensor only). all patients received invasive icp monitoring (average time , ± days). we used codman intracranial pressure microsensors or ventricular icp monitoring systems (hanni-set, smith medical). average preoperative glasgo coma scale (gcs) was , ± , . all patients had head ct scan and neurological examination on admission, and dynamically in postoperative period. we compared icp values with ct scan data (volume of zones with high and low density, signs of lateral and axial dislocation), gcs and neurological signs of brain stem dislocation. analyses of all data showed correlation between icp and gcs (r= - , ; p< , ; n= ), neurological signs of brain stem dislocation (r= , ; p< , ; n= ), volume of zones with high and low density (r= , ; p= , ; n= ) and lateral dislocation on head ct scan (r= , ; p= , ; n= ). then icp values obtained before the mass lesion evacuation were compared with preoperative head ct scan and neurological signs of brain stem dislocation. we found good correlation between icp and signs of axial (r= , ; p< , ; n= ) and lateral dislocation (r= , ; p= , ; n= ) on head ct scan. we did not find correlation between icp values and gcs (r=- , ; p= , ; n= ), neurological signs of brain stem dislocation (r= , ; p= , ; n= ) and volume of zones with high and low density on ct scan (r= , ; p= , ; n= ). we found that invasive icp monitoring is the best method of intracranial hypertension assessment. neurological examination or ct scan data can not reflect all cases of icp changes but they can be used as screening methods of intracranial hypertension estimation. markogiannakis h , sanidas e , messaris e , tsiftsis d st department of propaedeutic surgery, hippocration hospital, athens medical school, university of athens, athens, department of surgical oncology, herakleion university hospital, herkleion medical school, university of crete, herakleion, greece nonoperative management (nom) is considered to be the treatment of choice for carefully selected blunt hepatic trauma patients. the objective of this study is to identify and evaluate the factors that can safely predict nom of these patients. our study is a retrospective analysis of trauma registry data of all consecutive adult blunt hepatic trauma patients admitted in a greek level i trauma center over a -year period. factors that were included in the analysis were: sex, age, mechanism of injury, initial vital signs, grade of liver injury, concomitant injuries, and injury scoring systems used for total injury severity estimation. nineteen patients ( %) were immediately operated, whereas ( %) were initially selected for nom. concomitant abdominal, pelvic and spinal cord trauma, high injury severity score (iss), low international classification of diseases - th revision injury severity score (iciss), and low probability of survival (ps) were predictive factors for operative management of these patients. immediately operated patients suffered statistically significantly more frequently concomitant abdominal ( . % vs . %, p= . ), pelvic ( . % vs . %, p= . ), and spinal cord injuries ( . % vs . %, p= . ) than conservatively treated patients. additionally, immediately operated patients with blunt liver injury were significantly more severely totally injured than those treated with nom as expressed by higher iss ( . ± . vs ± . , p= . ), lower iciss ( . ± . vs . ± . , p= . ), and lower ps ( . ± . vs . ± . , p= . ). moreover, the percentage of patients that were admitted in the icu and mortality rate were significantly lower in patients treated with nom than those treated with immediate operation ( . % vs . %, p= . and . % vs %, p= . , respectively). thirty-three patients that were initially selected for nom were successfully treated conservatively; thus, the rate of success of nom was %. conclusion. nom of blunt hepatic trauma patients is safe and efficient resulting in significant reduction of icu admission and mortality. concomitant abdominal, pelvic and spinal cord trauma, iss, iciss, and ps are predictive factors for operative or nonoperative management of these patients. ruler van o , lamme b , reitsma j b , gouma d j , boermeester m a surgery, epidemiology and biostatistics, academic medical center, amsterdam, netherlands the decision when to perform a relaparotomy for secondary peritonitis is largely subjective and experience-based. to date there is no reliable scoring system that aids the decisional process by predicting relaparotomy outcome. our aim was to identify variables predictive of a positive outcome of relaparotomy in the acute phase of the disease. the study population was derived from a retrospective cohort of secondary peritonitis patients(n= ). patients with a positive relaparotomy (n= ) were compared to patients undergoing a negative relaparotomy (n= ) and patients undergoing an index laparotomy only (n= ). a prediction model was build from a logistic regression model by the addition of patient, peritonitis, operative and postoperative variables. a stepwise build-up of predictive models incorporating the chronology in which information is achieved in clinical practice was used. variables entered were assessed on clinical judgment and statistical analysis. accounting for chronology of information, postoperative variables are most predictive for positive relaparotomy. this implicates that information on the clinical course after the index laparotomy is required to predict who will need a relaparotomy. further adjustment and external validation of this model and development of a prediction rule is needed in a prospective, cross-sectional series of patients with secondary peritonitis. schöniger-hekele a , klingbacher e , hiesmayr m department of cardiac thoracic vascular anaesthesia and intensive care, department of cardiothoracic anaesthesia and intensive care medicine, medical university of vienna, vienna, austria in general icu-patients nasal carriage of staphylococcus aureus was associated with a higher risk of developing staphylococcal infections and death. the aim of this study was to determine the impact of mssa-colonisation on postoperative infections and los in elective cardiac surgery patients. we prospectively collected all data for the analysis. the cohort consisted of patients, that underwent routine preoperative nasal swab one week before surgery. only patients with mrsa were treated topically with mupirocin. before surgery patients ( , %) were identified as staphylococcal aureus nasal carriers, while , % were free of nasal colonization. compared to the non-carriers the mssa-carriers did not have a significant difference of the total and staphylococcus aureus infection rate. other indicators of infection and inflammation parameters(crp, leukocytes)did not show significant differences. data-mining searched publications from common languages for randomised clinical trials that supplemented with impact® before and/or after major elective surgery. infectious complications, mortality, and hospital stay were primary outcomes. seventeen studies (n= ) were analyzed, and (n= ) described patients undergoing elective gi surgery. studies were conducted in countries, however, the clinical effects of impact® treatment were homogenous across the set of trials. impact® use significantly reduced postoperative infections overall (p < . ), and anastomotic leaks in gi surgical patients (p = . ). furthermore, impact® use shortened the average hospital stay by . d (p < . ), and a trend was observed towards reduced risk of mortality. considerable differences in country-specific operation modalities were noted. in a chinese trial, nosocomial infection prevalence was unusually low, % when supplemented with a control formula vs. % with impact®. in all other trials, nosocomial rates were - % with control feeds vs. - % with impact®. in germany and switzerland, hospital stays were extended for gi surgical patients. there, average stays were d for the impact® group and d for the control group vs. d and d, respectively, in all other countries. conclusion. impact® specialized nutrition support, as a component of infection control during surgery, is valuable for all methods practiced worldwide. to determine the incidence of nosocomial infection in critically ill patients with brain trauma. it is a prospective study performed during months of the patients with brain trauma admitted in a -beds medical-surgical icu of a -beds university hospital. infections were diagnosed according to cdc criteria. infections were classified bassed on the onset moment as early onset and late onset: early onset (eo) were those developed during the first days of icu-stay; and late onset (lo) were those developed days after icu-admission. the statistical analysis was performed using spss . program. continuous variables are reported as means and standard deviation, and categoric variables as percentages. turkmen a , turgut n , altan a , medetoglu a , gökkaya s department of anaesthesiology and reanimation, okmeydani training hospital, istanbul, turkey airway suctioning is classically performed with disconnection of the patient from the ventilator and the introduction of suction catheter into endotracheal tube. several authors suggest that application of closed suction catheters (csc)in intubated patients for more than h is safe and can reduce the costs associated with mechanical ventilation. therefore, we evaluated the possible role of prolonged application of csc in causing enhanced colonization of the lower respiratory tract. the prospective, randomized study included mechanically ventilated patients. the csc tips, tracheobronchial aspirates of each patient were examined for microbial growth. we analyzed the data with the student's t test for paired samples and fisher exact test. application for h significantly enhanced the microbial growth on the csc tips (table) . to decrease vap incidence in the icu is necessary to implement infection control policies. nevertheless that implementation is not always simple and requires effort by the icu workers. new infection control policies were applied in our icu in . those recommendations were adapted from the published guidelines concerning the prevention of vap and adapted to our icu. particular concern was made on the handwashing and contact isolation precautions. to analysed the impact of these measures the incidence of vap was analysed before and after that implementation. prospective study of all patients admitted in the icu for more than hours, between and . patients data collected included the number of ventilation days, the date of the vap diagnosis with or without microbiological confirmation. the vap diagnosis was made by new radiographic infiltrate for at least h and at least two of the following criteria: fever > . °c or < . °c; leukocytes > , /µl or < , /µl, purulent sputum, or isolation of pathogenic bacteria from lower respiratory tract. the microbiological samples were collected by proximal or distal bronchial aspirated. the vap diagnosis was made on the patients receiving mechanical ventilation, , and patients during the study period. theodorakopoulou m , lignos m , diamantakis a , zoupa p , stelliou a , karabekiou i , armaganidis a icu, nursing icu, attiko university hospital, athens, greece hand hygiene is the most important action to control spread of nosocomial infections.hand washing compliance among health care workers remains low.the objective of this study was to assess compliance of hygiene in our icu. a month prospective study on a bed icu of a university hospital.antiseptic solution were placed at the bottom side of each bed and one hand washing facility exists within the unit. well instructed observers recorded opportunities of hand washing, and actual performance of hand washing or hand disinfection. observation time was set at hrs. it was performed on morning and afternoon shifts all days of the week.every observer monitored beds.the staff was not informed of the study.staff was classified according to their work status (doctors, nurses etc.). . hrs of observations were recorded in sessions. a total of opportunities for hand hygiene were observed. see table for hand washing opportunities and actual hand washing compliance among the staff. the average hand washing opportunities were . opp/pt/hr and the average actual hand washing was . act.wash/pt/hr.hand washing compliance was similar for doctors,nurses and nursing assistants.medics, physiotherap, and visiting doctors showed significant difference in actual hand washing compliance.the overall compliance rate was / ( . %). it is a prospective study during months of the patients admitted in icu during hours o more. were taken throat swab, tracheal aspirate and urine on admission and twice weekly. were registered the colonization and infection by pseudomonas. the infections were diagnosed according to cdc criteria. the infections were classified bassed on thorat flora as: primary endogenous (pe) when they were caused by germs that were already colonizing the throat on the icu admission; secondary endogenous (se) when they were caused by germs that were not colonizing the throat on the icu admission but were acquired during the stay in icu; exogenous (ex) when they were caused by germs which were not colonizing the throat. the infections were classified bassed on the onset moment as: early onset (eo) were those developed during the first days of icu-stay; late onset (lo) were those developed days after icu-admission. conclusion. in our serie, the most of infections caused by pseudomonas were pneumonias, had a late onset and were secundary endogenous. prolonged critical illness is characterized by feeding-resistant wasting of lean body mass. this catabolic state is due to an impaired activity of the thyroid and gh axes, since restoration of physiological levels of igf- and thyroid hormones by continuous infusion of trh+ghrp- is capable to induce anabolism [ ] . whereas the cause of hyposomatropism during prolonged critical illness is mainly located within the hypothalamus, concomitant changes in peripheral thyroid hormone metabolism are involved in the low t syndrome. the aim of this study was to examine these peripheral changes into more detail in an animal model of prolonged critical [ ] . burn-injured, parenterally fed, new zealand white rabbits ( x n= ) were randomized to receive -d treatment with saline, trh ( \mug/kg/h) ,ghrp- ( \mug/kg/h), or trh+ghrp- . blood glucose was maintained below mg/dl by continuous insulin infusion. endocrine and biochemical organ system markers were studied. animals were sacrificed for assay of deiodinase activity in snap frozen samples. infusion of trh+ghrp- and trh increased hepatic activity of type deiodinase (d ) versus the saline group (p= . and . resp.), restoring tt levels within physiological range. only combined infusion of trh+ghrp- induced a significant increase in igf- levels into the range observed in healthy rabbits. administration of trh alone resulted in a further decline of serum igf- levels. ( ) infusion of ghrp- +trh is able to restore peripheral thyroid hormone and serum igf- levels within the physiological range, mainly due to re-activation of d . ( ) d activity during critical illness is regulated via alterations in the thyroid axis. ( ) reactivation of the thyroid axis in prolonged critical illness, without concomitant reactivation of the gh-axis, might worsen catabolism. and strong ion difference (sid) approach, to our knowledge is still not available a systematic comparison. the approach to sid may be more or less rigorous: we can calculate the apparent sid (the difference between strong ions, sidapp) or the effective sid (the sum of weak anions, sideff); moreover, when computing the sid variation (Äsid) the reference value of sid can be considered fixed ( meq/l) or variable (the expected sid) as a function of total non volatile weak acids concentration. the aim of this study was to suggest how the computation of Äsid should be sophisticated in order to obtain a good correspondence with be in icu patients. conclusion. the rigorous computation of the corrected Äsid seems to be necessary in the icu population, because of non-neglectable concentration of unmeasured anions and of diffuse and serious hypoalbuminemia in these patients. moreover, Äsid is a measure of plasma buffer base variation, so it should be compared with an equivalent be formulation, that is plasma be. leditschke i a , southcott e , gissane j , enslin a , hickman p e , potter j m intensive care unit, act pathology, australian national university medical school, the canberra hospital, canberra, australia recently it has been shown that total plasma cortisol measured by immunoassay may not detect elevations in plasma free cortisol in hypoproteinaemic critically ill patients( ). we investigated the relationship between urinary free cortisol and total serum cortisol in a group of critically ill patients. methods. patients were studied within hours of icu admission. patients with neurotrauma or oliguria were excluded. hourly total plasma cortisol and -hourly urinary cortisol were measured for hours using routine immunoassay for the plasma samples and high performance liquid chromatography for the urine samples. statistical analysis was performed using graphpad instat software. summary results for total plasma cortisol at the mid point of the urine collection and urinary free cortisol are shown in table . using a non parametric (spearman r) test of correlation, urinary free cortisol was found to correlate moderately well with total plasma cortisol; spearman r = . , % confidence intervals . to . , p to further investigate this topic, we conducted a prospective study of patients admitted to a general adult icu. morning blood samples were taken within hours of icu admission to measure plasma cortisol, corticotropin (acth), dehydroepiandrosterone sulphate (dheas), free thyroxine (ft ), tri-iodothyronine (t ), thyroid-stimulating hormone (tsh) and prolactin (prl). . critically ill patients ( males) with diverse underlying diagnoses, having a median age of years (range - years) were enrolled. their median apache ii and sofa scores were and respectively. there were no differences between survivors and non-survivors in plasma cortisol, acth, ft , and t . in contrast, survivors had higher median values for tsh ( . mciu/l vs. . mciu/l, p= . ), dheas ( ng/dl vs. ng/dl, p= . ) and prl ( ng/ml vs. ng/ml, p= . ) compared to non-survivors. our data indicate that hormone concentrations differ between survivors and nonsurvivors acutely ill patients. further studies are required to investigate whether endocrine measurements are helpful in predicting clinical outcome. mekontso-dessap a , lellouche n , brochard l , brun-buisson c , dubois-randé j medical intensive care unit, coronary care unit, henri mondor hospital, créteil, france relative adrenal insufficiency has been demonstrated to be associated with increased mortality in septic shock patients. cardiogenic shock (cs) induces a stress response involving the adrenal cortex, but functional hypoadrenalism has never been investigated in this setting. the aim of the present study was to prospectively evaluate adrenal function in patients admitted to intensive and coronary care unit for cardiogenic shock. methods. consecutive patients ( men) admitted for cs, with a mean age of ± years were included. patients submitted to any steroid therapy or etomidate were excluded. patients needed mechanical ventilation and patients were equipped with an intraaortic balloon pump. causes of cs included acute myocardial infarction (n= ), cardiomyopathy (n= ), arrrythmia (n= ), and others (n= ). patients underwent a high dose short corticotrophin test (sct) and relative adrenocortical insufficiency (nonresponders) was defined by a rise in cortisol less than microg/l after stimulation. . ( . %) patients were classified as nonresponders and ( . %) as responders. no significant difference was evidenced between responders and nonresponders concerning clinical characteristics and outcome (table ) . in contrast to international guidelines, it is common practice in some icu's in the netherlands to treat septic critically ill patients with high dose dexamethason on admission. increase in mortality might be associated with the induction of adrenal failure. we compared adrenal function in patients with high, single dose ( mg) dexamethason (dexa) with patients receiving no steroids during the study period. we studied ventilated patients with mods admitted for emergency reasons. excluded were patients after elective surgery, with an expected short stay or steroid use. cortisol (co) was measured day and at . am. at day the co response and minutes after mcgr synthetic acth was determined. the patients did not receive corticosteroids, other than dexa on admission if they were included in the dexa+ group. all / patients ( %) with dexa had baseline co levels on day below . mmol/l, compared to / ( %) in the control group (ns). however, adequate co response (rise in co of more than . mmol/l, min after mcg synthetic acth iv) was % in patients with dexa and % ( / ) for patients without dexa. in a case control analysis apache score was not a determinant. neutrophils are believed to occupy a prominent position in the pathogenesis of organ failure that arises from the systemic inflammatory response syndrome (sirs). the epidermal growth factor-like -transmembrane (egf-tm ) family of molecules are a group of glycoproteins whose structure suggests a dual role in cell adhesion and intracellular signaling. two members of this family, hcd and the egf molecule-containing mucin-like hormone receptor (emr ) are expressed on human monocytes and macrophages. the aim of this study was to examine the expression of hcd and emr on neutrophils from patients with sirs and ascertain if they were associated with sepsis or the clinical course of disease. we analysed erythropoietin, interleukin- (il- ), interleukin- (il- ), and interleukin- p (il- p ) in the blood of patients (controls n= ) with circulating nrbcs. in-hospital mortality of nrbc-negative and nrbc-positive patients was . % ( / ) and . % ( / ; p< . ), respectively. in-hospital mortality increased with the nrbc concentration ( figure ). . % ( / ) of patients with more than nrbcs/µl in the peripheral blood died. multiple logistic regression revealed a significant association between the appearance of nrbcs in the blood and age (odds ratio . ; . - . ; p< . ), erythropoietin (odds ratio . ; . - . ; p< . ), il- (odds ratio . ; . - . ; p< . ), and il- (odds ratio . ; . - . ; p< . ), respectively. gender and il- p were not significantly associated with the appearance of nrbcs in the blood to estimate the red blood cell production in the bone marrow the increase in the reticulocyte concentration in blood was measured. the reticulocyte concentration in nrbc-positive patients was ± /nl, being significantly higher than in nrbc-negative patients ( ± /nl; p< . ). furthermore, in the course of hospitalization the increase in the reticulocyte concentration in nrbc-positive patients was significantly higher ( ± /nl; n= ) than in nrbc-negative patients ( ± /nl; n= ; p< . ). conclusion. an association of the appearance of nrbcs were found with increased levels of erythropoietin, il- , and il- , respectively. therefore, nrbcs in the circulation could be an indicator which summarises hypoxic and inflammatory injuries. thus, generally the appearance of nrbcs in blood is a valid parameter to identify patients at high mortal risk. moreover, the increased number of reticulocytes in the blood of nrbc-positive patients may indicate that the appearance of nrbcs is not associated with disturbed bone marrow function as far as the erythropoiesis is concerned. grant acknowledgement. sysmex europe corp. macrophage migration inhibitory factor (mif) was originally described as a tlymphocyte derived cytokine that inhibits the migration of the macrophages at the site of inflammation( ).subsequently it was also identified as a stress induced hormone released from the anterior lobe of the pituitary in response to some pro-inflammatory stimuli ( ) .the glucocorticoid counterbalancing proinflammatory actions of mif have been thoroughly documented. our study compared postoperative changes in serum mif levels of patients undergoing bowel and liver resections. patients were recruited in our descriptive study.patients in the first group (a) underwent only hepatic resection without surgically opening the bowel. the other group (b) comprised of patients who have had bowel resection with surgical bowel opening. mif, il- β, il- , prealbumin, albumin, α fibrinogen and c-reactive protein levels were measured before and immediately after the operations and also for three consecutive days. to evaluate organ functions the mods-test was used. statistical analysis was carried out by means of spss for windows, applying the mann-whitney test. a higher level of mif ( pg/ml / - /) was found in group a as compared to that of group b immediately after the operations, that proved to be significant. other parameters monitored in this study were not statistically different between the two sets of patients. higher elevations in mif levels with liver resections compared to bowel resections might be attributable to mif release from damaged liver cells. the presumably minimal endotoxin exposure during the bowel surgery was either insufficient or inefficient to induce relevant mif elevations in our patients. chromogranins are prohormones, precursors of numerous peptides displaying various biological activities. some even have antifungal and antibacterial properties. as catecholamines, they result from secretory granules of the chromaffin cells in adrenal medulla. aims of the study: to analyze the physiological secretion of cgb and its derivatives in healthy subjects; and to compare its characteristics with those of patients undergoing the stress of septic shock. methods. healthy voluntaries and patients with septic shock were included. samples of serums were taken at several times to establish a kinetic of secretion. serum proteins were studied by mono and two-dimensional electrophoresis with anti-cgb specific immunodetection, using polyclonal antibodies; and by chromatography (rp-hplc) with specific immuno-detection of each eluted sample, and then by mass spectrometry (maldi tof) and antimicrobial tests. the healthy subjects' electrophoretic profiles are identical. we did not find fragments of molecular weights (mw) lower than kda. but patients' profiles show a great number of short fragments. there were no qualitative modifications of monodimensional electrophoresis profile over time in healthy subjects, whereas for patients, we observed the disappearance of a kda band and of short fragments of weak mw. this modification occurs hours after the end of the infusion of norepinephrine. rp-hplc chromatograms show strong similarities between controls and patients. however the peaks of albumin (hsa) and transferrin are higher in healthy controls. for the whole population, we observe at the end of the chromatogram, immonreactive peaks: the peak of hsa (immunoreactive zone which corresponds to an association of cgb and hsa); and an isolated peak after hsa peak. conclusion. this is the first study of cgb secretion in human serum. we show noticeable differences between healthy controls and patients with septic shock. the clinical improvement of a patient corresponds to the modifications of the electrophoretic profile (backwards to the profile of a healthy control). for the first time, an association is also shown between the hsa and the cgb. in septic shock, the free cgb seems to be more abundant. patients with septic shock or non infectious sirs within hours of admission were included and allocated to the following groups according to usual criteria : group (surgical patients with septic shock), group (surgical patients with sirs), group (medical patients with septic shock) and group (medical patients with sirs). pct at study entry was compared between groups and and between groups and to determine the diagnostic cutoff value for septic shock in surgical and in medical patients respectively. identifying sepsis in intensive care unit (icu) can be difficult. we assessed the utility of the biphasic aptt waveform (bpw) and procalcitonin (pct) determinations, alone or combined, for the diagnosis of sepsis in icu patients. this prospective observational study included adult patients admitted to a -bed university hospital medical-surgical icu during a -month period. the presence of sepsis, severe sepsis or septic shock was determined on the day of admission by standard clinical and laboratory criteria, without knowledge of aptt or pct. aptt transmittance waveforms (biomérieux mda system) and pct levels (brahms pct lumitest) were determined on the day of admission. threshold values for the prediction of any form of sepsis were assessed by receiver operating characteristic (roc) curves. the bpw was detected when the slope of the pre-coagulation phase (slope_ ) exceeded the threshold value (i.e., became more negative). the combined assessment of aptt transmittance waveforms and pct levels provides a rapid means of identifying septic patients on icu admission. van nuffelen m , abraham a , zakariah a , vincent j l intensive care medecine, erasme university hospital, brussels, belgium both c-reactive protein (crp) and procalcitonin (pct) concentrations have been proposed to monitor sepsis in acutely ill patients. the aim of this study was to study their time course in septic icu patients. the study included infectious episodes (mean age: years, ratio m/f: / ), as defined by standard cdc criteria. patients were divided into two groups, depending on their evolution: favorable (clinical and white blood cell count) or unfavorable (need for additional procedure and/or change in antibiotic regimen). crp was measured daily by direct immunoturbimetry and pct by immuno luminometric assay. and pct were as follows(median values): where day represents the day where antibiotics were started. conclusion. crp and pct kinetics in septic patients show no significant trend in patients who respond favorably to therapy. however, an increase in these variables indicates a poor response. percutaneous tracheotomy (pt) is frequent in the icu to help wean patients from mv. we compared the effectiveness and airway management of laryngeal mask-airway (lma) vs endotracheal intubation (ei) we included consecutive intubated adult patients in the icu who required pt, randomized into two groups of . one group had a proseal lma and the other underwent laryngoscope-assisted partial withdrawal of the endotracheal tube. ventilator settings in both groups were: volume-control ventilation, fio , minute volume . l, peep . arterial blood gas pressure was measured before the start of each pt and before insertion of the tracheotomy tube. data were recorded concerning the duration of the procedure from commencing airway manipulation to insertion of tracheotomy tube and airway complications results. % of patients were men (median age years). reasons for tracheotomy were a low level of consciousness( %), lung disease ( %), neuromuscular disease ( %) and airway obstruction ( %). no significant changes were seen in duration, ph, p or pc . complications included six accidental extubation, four tube cuff tears, four guidewire bends and four difficulty to insert the tracheotomy tube. three patients planned for lma required ei because of impossibility to place correctly the pro-seal laryngeal mask-airway. no other complications arose in this group the differential diagnosis between sepsis and sirs is of considerable importance in burn patients. delay in the initial adequate treatment increases the mortality rate. the aim of this study was to assess whether plasma procalcitonin (pct) level was related to sepsis, burn size and organ failure in severely burned patients over the entire clinical course. methods. forty one patients, mean age ± (sd), (range - year), mean burn size . ± (sd) % of body surface area (bsa), (range % - % bsa) were included in our study. all patients were classified daily in one of the following three categories: negative, sirs, sepsis according to the definitions of the accp/sccm. a total of patient days were evaluated: negative (n: ), sirs (n: ), sepsis (n: ). measurement of pct levels and evaluation of organ function by sofa score were performed daily until discharge from icu. admission pct levels were significantly higher in patients with burn size > % of bsa than in those with burn of less than % of bsa ( . ng/ml vs . ng/ml, p= . ). pct plasma concentrations differed among the three diagnostic classes and were higher in sepsis than in sirs ( table ) . a statistically significant correlation was observed between pct levels and sofa score (r= . , p< . (pearson' bivariate correlation)). the optimal timing of tracheotomy in critically ill patients requiring prolonged mechanical ventilation (mv) is debated. recent studies suggest that early tracheotomy could substantially reduce both infectious morbidity and mortality. in a prospective, randomized, study we compared early tracheotomy with prolonged endotracheal intubation in icu patients needing prolonged ventilatory support. patients projected to need ventilatory support for > days were prospectively randomized to either early (open or percutaneous) tracheotomy within days (et) or prolonged intubation (pi) with or without delayed tracheostomy. the primary end-points were: days mortality and cumulated incidence of nosocomial pneumonia, and number of ventilatory free days between day and . time in the icu and on mv, days mortality, number of septic episodes, accidental extubation and amount of sedation were recorded as secondary end-points. a sample size of patients was determined for a reduction of the days mortality from % to %¨(two-sided, power= . ). the study was prematurely closed because of poor accrual, after patients (et= , pi= )have been included. no difference was found between the groups for any of the primary (table ) or secondary end-points. in addition, laryngeal or tracheal damage and time for resuming oral nutrition did not differ between the groups. early pdt has several advantages when long-term mechanical ventilation is adamant. however, in patients suffering from tbi, one major concern are increased intracranial pressures (icp´s). during pdt, decrease of venous return and hypercapnia might seriously comprise icp. therefore, changes in icp´s during videobronchoscopic guided pdt were measured. methods. patient with tbi,treated at our neurosurgical intensive care unit, required long-term (> days) mechanical ventilation due to intracranial lesions. indication and feasibility to perform pdt were evaluated in patients treated with severe tbi from the day after admission on a daily routine. icp levels below mmhg (over at least hours) without extended icp treatment and no icp increase > mmhg during neck extension was considered to be a safe timepoint for pdt. videobronchoscopic guided, single-step pdt with modified ciaglia technique (blue rhino, cook, germany) was performed in patients, in two patients pdt had do be aborted for anatomic reasons. as operation time we defined begin of videobronchoscopy until the intra-tracheal position of the tracheostoma was confirmed. icp´s were recorded either through intraparenchymal catheters (n= ) or by external ventricular catheters (n= ). methods. an anonymous questionnaire was distributed among croatian anaesthesiologists at three universities (zagreb, split, rieka) and during two anaesthesia meetings (split, dubrovnik) between sept. and may . . completed forms were returned which was % of the anaesthesiologists in croatia. male and female respondents were % and %, respectively, with a mean age of . years. they had been practicing anesthesia from to years with % practicing in an academic center, and % in a community hospital. % completed a difficult airway course, receiving training at their hospital or at a meeting such as the european society of anaesthesiology. per respondent per year, an average of anesthetics were performed, with patients having endotracheal intubation. the most frequently preferred laryngoscope blade was macintosh ( %) followed by miller ( %) and mccoy ( %). % indicated they rarely failed an intubation using a conventional laryngoscope. in difficult airway situations, following laryngoscopy, the technique of choice was the laryngeal mask airway followed by the gum elastic bougie. for anticipated difficult intubations, % performed sedated awake intubation, and % used the flexible bronchoscope. while the asa difficult airway algorithm was used by % of respondents, % stated that they used an internally developed difficult airway protocol. croatia. laryngoscopy and sedated awake intubation are used more frequently than fiberoptic bronchoscopy. the asa difficult airway algorithm was used by % of the anaesthesiologists surveyed. in a randomized crossover trial, special forces (sf)-medics of the royal netherlands army and residents in anesthesiology performed cricothyrotomies using two different emergency airway devices on larynges from freshly slaughtered pigs ( ) . we compared the quicktrach with the portex emergency cricothyroidotomy kit. all data were analyzed using spps version . (wilcoxon test for non-normal distributed -paired comparison and mcnemar test for nominal values). the quicktrach-technique was done significant faster than the portex-technique in both groups. intratracheal placement of the cannula was achieved by ( %) sf-medics and ( %) residents using the portex-technique and using the quicktrach-technique by ( %) sf-medics and ( %) residents. despite the fact that it was a procedure performed in very critically ill patients, tracheostomy was associated with very few minor complications in this sample. we hipothetized that this low rate of complications is due in part to the very high expertise of the operators involved in the realization of conventional tracheostomies in the two centers. grant acknowledgement. the authors are indebted with dr. ederlon a. c. rezende for his support and suggestions. kiessling a h , isgro f , skuras j , lehmann a , pieper s , saggau w klinikum ludwigshafen, cardiac surgery, klinikum ludwigshafen, anaesthesiology, ludwigshafen, germany tracheotomies are routinely performed for severely ill patients with respiratory failure. the procedure facilitates the weaning procedures by reducing dead space and decreasing airway resistance, by improving secretion clearance and by decreasing the risk of aspiration. this intervention is correlated with a poor survival rate. the aim of the investigation was the evaluation of the quality of life scores (qof) and outcome after cardiac surgical procedures. the retrospective, non-randomized follow up study was performed in a single surgical intensive care unit in patients after cardiac procedures and surgical tracheotomy. preoperative data and items were collected and outcomes analyzed after a mean follow up period of . years. a written questionnaire for the documentation of the sf score and beck depression scale were used. in addition to the test battery, healing outcome and vocal function were components of the questioning. overinflation of the endotracheal tube cuff (> mmhg) may cause tracheal damage and complications such as tracheal stenosis and tracheo-oesophageal fistula. we have surveyed the practice of tracheal cuff pressure measurement in our medical-surgical intensive care unit (icu) and evaluate the impact of a regular cuff pressure monitoring program (cpmp) on reducing cuff overinflation. cuff pressure have been evaluated over three periods (p = before cpmp, p = months after cpmp and p = years after cpmp) obtained in measurements in - patients each period. the cpmp consists of regular cuff pressure monitoring twice a day. comparing to the first period, mean cuff-pressure decreased in the second period from ± mmhg to ± mmhg (p< . ) and the rate of overinflated cuffs from % to % (p< . ). in the third period, mean pressure was in the normal range ( ± mmhg) but there was a significant increase in underinflated cuffs. however, in these patients, the operator hasn't noticed any leakage around the tube cuffs. a regular cuff pressure monitoring program can reduce significantly the overinflation of tracheal cuffs in icu and this may lead to prevent subsequent complications. icu medical stuff may also maintain this protocol by a regular education of the nurse team in order to always keep endotracheal tube cuff pressures in the normal range preventing over (tracheal damage) and underinflation side effects (nosocomial pneumonia). further studies are needed to evaluate this educational procedure on the outcome of the icu patients. forty-three patients ( men, women) with a mean age of . and a mean simplified acute physiologic score (saps) ii of . were studied. three patients were excluded because of insufficient data. ts was done because of traumatic brain injury with persistent glasgow coma score < (nineteen patients), unsuccessful weaning -failure of spontaneous breathing trial in or more occasions ( patients), hypoxic encephalopathy ( patients) and prolonged invasive ventilation ( patients). in the subgroup of patients with unsuccessful weaning, spontaneous breathing could be achieved in seven patients by day to day (mean of . days) after ts. in patients, ts has been considered an adjunctive intervention for the weaning process, and in these patients, spontaneous breathing was achieved in patients and bipap ventilation in patients. thirty nine patients could be discharged from icu (mean of . days after ts) in spontaneous breathing ( patients) or bipap ventilation ( patients). mortality analysis revealed a total of deaths (four in the icu, during hospital stay and after hospital discharge at six months). in patients with hypoxic encephalopathy ( ), five deaths were observed during hospital stay. complication rate was low, with local haemorrhage in seven patients. our study revealed that ts was useful as an adjunctive therapy in the weaning process in the majority of patients and could reduce icu stay; however, the subgroup of patients with hypoxic encephalopathy did not benefit from ts and should be considered for alternative strategies of airway protection. zgoda we report a prospective case series of successful percutaneous tracheostomy procedures in the critically ill without complication. the balloon-tracheostomy tube apparatus (image ) was placed overwire then inflated to form the stoma, then deflated. the tracheostomy tube followed the deflated balloon into the airway. almost no anterior tracheal compression took place. the average procedure time from puncture to tube placement was - minutes. ten icu patients underwent bfpt. six of the patients had a successful tube placement after only balloon dilation. the rest had successful tracheostomy placement after a second dilation. one of these patients had a previous tracheostomy and the procedure was successful with balloon dilation attempts at the site of the previous tracheostomy. two were coagulopathic with inr> and/or platelet count(s) of less than k. the average estimated blood loss was less than ml. one patient had an obvious tracheal ring fracture without immediate clinical significance. there was no posterior tracheal wall damage, no pneumothorax, and no obvious damage to the anterior neck. thus far, there have been consecutive tracheostomy tubes placed without bleeding complications, or damage to the posterior tracheal wall but more study is needed. bfpt is an easy and effective means of placing an elective tracheostomy tube at the bedside in the icu. despite surgical percutaneous emphysema is a recognised complication following percutaneous tracheostomy [ ] ,it is not usually reported with a fenestrated trachesotomy tube as the direct cause [ ] .the rationale to use a fenestrated tube when performing percutaneous tracheostomy is to eliminate the need to change the tube when the patient is weaned from mechanical ventilation. report of a cluster of complications associated with fenestrated tracheostomy tubes placed percutaneously. in our trust ( hospitals) within a week period patients developed subcutaneous emphysema (one with an associated pneumothorax). the cases were performed by experienced doctors. all using portex blue rhino kits, with the insertion of tracoe-twist fenestrated tracheostomy tubes (using the non-fenestrated inner cannula); bronchoscopic guidance was used in all of the cases.we also have performed a bench top study on the fenestrated tubes to find the source of leak. eight patients developed subcutaneous emphysema (one with an associated pneumothorax).the emphysema was immediate in some, but only becoming apparent several hours after insertion in the majority.in at least two,the emphysema was so extensive that it compromised the patients' airway making exchanging the tracheostomy impossible and oral endotracheal intubation very difficult. fortunately there were no directly attributable deaths or hypoxic injuries. the bench top study revealed air can track between the inner and outer cannulae at quite low pressures. surgical percutaneous emphysema is a complication following percutaneous tracheostomy using fenesterated tubes which can lead to pneumothorax and airway compromise.it seems that the fenestrations can remain in the pre-tracheal fascia with air tracking between the inner and outer cannula leading to the development of subcutaneous emphysema.we have now changed our practice to insert only non-fenestrated tubes for percutaneous tracheostomies. therapeutic hypothermia (th) improves outcome after cardiac arrest (ca) due to ventricular fibrillation (vf). however, due to lack of protocols and to technical difficulties inherent to its practical application, this treatment has not been widely implemented in daily practice. we evaluated whether th could be effectively introduced in icu practice and assessed its impact on patient outcome. we retrospectively analyzed comatose patients resuscitated from out-of-hospital ca due to vf and non-vf rhythms (asystole or pulseless electrical activity in patients with circulatory shock before initiating the treatment, th was also beneficial ( / patients had good outcome vs / patients treated with sr, p= . ). in contrast, th had no impact on the outcome of survivors of ca due non-vf rhythms ( / patients in the th group survived with good neurological outcome vs / in the sr group). conclusion. therapeutic hypothermia can be safely and effeciently introduced in icu practice for the treatment of all comatose patients resuscitated from cardiac arrest with a major impact on the outcome of patients resuscitated from ca due to vf, independently from their hemodynamic status. in contrast, our data do not support the use of therapeutic hypothermia after cardiac arrest due to asystole or pulseless electrical activity. lavery g g , hickland b , caddell p , dillon m , northern, ireland intensive care society audit group regional intensive care unit, royal hospitals trust, belfast, united kingdom since october , a centralized service has facilitated the interhospital transfer (iht) of over critically-ill adult patients using a standard ambulance and mobile icu equipment. quality of escort is an important factor in the transport of all potentially unstable patients ( , ) and so all ihts are performed by an experienced icu team ( doctor and nurse) . the aim of this project was to assess the use and the quality of this service. information regarding the indications for, and conduct of, iht was recorded prospectively for all patients transferred by the service over yr ( / - / ). icus prospectively collected data including admission apache ii score and icu (and hospital) outcomes. all data were entered on a central database (ms access). molnar t , köszegi t , bogar l , szakmany t anesthesiology and intensive therapy, institute of laboratory medicine, university of pecs, pecs, hungary it has been proposed, that procalcitonin (pct) might be used as a prognostic factor for outcome after cardiac arrest ( ) . to date no studies addressed the question whether pct levels are different after vf and pea induced in-hospital cardiac arrest. methods. consecutive patients were studied following cardiac arrest. pct levels were measured on icu admission (t ), then on the first (t ) and third day (t ) post-arrest. for statistical analysis mann-whitney u test and chi-square test were used with spss . . data are presented as median and interquartile range. out of the patients suffered pea and vf arrest. there was no significant difference between the groups regarding age, male/female ratio and anoxic time and time to rosc. mortality was % vs. . % in the pea and vf groups, respectively, p< . . serum pct levels were significantly higher in the pea group (table ) . s b levels did not differ significantly between the two groups. serum pct: . ( . - . ) vs. . ( . - . ) and s b: . ( . - . ) vs. . ( . - . ) were significantly higher at t among non-survivors in the pea group, p< . respectively, whereas in the vf group no such difference was observed. conclusion. significantly lower inflammatory response was detected in patients initially in vf arrest, with significantly better survival compared to pea arrest, although anoxic time and time to rosc was similar in the two groups as reflected by nearly identical s b levels. however, patients with pea arrest often have long, undetected hypoxic period, which may trigger the release of inflammatory markers such as pct. the significantly higher pct and s b values in the nonsurvivor group of pea patients may indicate the potential prognostic value of such measurements. horn j , zandbergen e j g , vos p e , verlooy p , van dijk g w , vroom m b , hijdra a ic, amc, amsterdam, neurology, rijnstate, arnhem, neurology, umc, nijmegen, neurology, olvg, amsterdam, neurology, umcu, utrecht, neurology, amc, amsterdam, netherlands after cardiopulmonary resuscitation (cpr) many patients develop post-anoxic encephalopathy (pae) often accompanied by myoclonic seizures or epilepsy.( , )treatment is often difficult, several strategies have been advocated. ( , ) in this study we investigated the medication used in these patients. from the database of the propac study, a prospective cohort study in pae patients, we selected patients with myoclonic or epileptic seizures. medication used to treat these conditions was extracted from the records. in patients, showed myoclonic seizures or epilepsy. records of patients could be retrieved. differentiation between myoclonus and epilepsy was difficult, we used the description as found in the records. eleven patients received no medication. treatment was started in patients ( %): in ( %)a benzodiazepine, in ( %) another antiepileptic drug, in a combination of both. clonazepam was used most often ( patients, %). valprioc acid was used in patients ( %), phenytoin in . seventeen patients (out of ) received propofol and in patients a second benzodiazepine was administered. outcome after month: had died ( %), were in coma, vegetative state or severely handicapped ( %) and were moderately handicapped or completely recovered. conclusion. dutch neurologists prefer benzodiazepines in patients with seizures in post-anoxic encephalopathy, often combined with an antiepileptic drug. myoclonic status reacts poorly to medication, however, treatment is often started because of problems in daily care or mechanical ventilation. in this study we found that the different types of seizures were often not specified in the records, despite the consequences on prognosis. we suggest to use the definition proposed by wijdicks et al for myoclonus status. in this study epileptic or myoclonic seizures in patients with post-anoxic encephalopathy seemed to be related to poor outcome, as % had a poor outcome. we conducted an etiologic study among parturients presenting a cerebrovascular stroke. the aim was to determine the frequency of the various types of vascular accident and their moment of arisen,to underline the factors of risk and to estimate the prognosis of vascular accidents in this population(p-values < , were considered to be statiscally signifiant). among our patients, had an ischemic accident, of which had venous origin, an arterial origin and had an hemorragic accident .the majority of damage occurs in the rd quarter of pregancy or in the post-partum. five of our patients had no risk factor and had several risk factors.as for the arterial accident , the etiologic inquiry was not decisive for four patients.they had however several risk factors of thrombosis vascular. five patient with an ischemia died and three of the patients having a bleeding died. uni-varieted logistic regression did not find statiscally-significant result concerning mortality in relation with the age,the term gestationnel or the type of accident . conclusion. cerebrovascular strokes complicating the evolution of a pregnancy remain an unknown entity. they can cause sequela and have fatal issues.studies including a larger number of patients are requested in order to decrease the incidence and the important morbi-mortality. they are also meant to find out all risk factors,take them in to consideration and therefore work on their mechanism. bubnova i d , dobrinin i n , astakhov a a anaesthesiology and reanimatology, ural postgraduate medical academy, chelyabinsk, russian federation one of the ways for the cerebral perfusion support in severe brain trauma (sbt) patients is the cardiac output optimization. but we must know whether the decreasing of hypovolemia range be better for brain protection or not in each case. this study we tried to reveal if the the topic level of central haemodynamic regulation disturbances (chrd) can determine the response on the volume load (vl). in the previous works we showed that the patients with sbt may have different types of the haemodynamic regulation due to interfere of the humoral and the autonomic nervous stimulus. this study we examined patients with main regulatory types. all patients were under artificial ventilation and had and less gcs. for the estimation of the type and topic level of chrd we compared the absolute data and the variability (spectral power (sp) in - . hz band) of blood pressure (bp), heart rate (hr), peripheral vessels pulse (pvp), and stroke volume (sv), determined by the bioimpedans method. also we determined the variability of eeg amplitude in the alone biparietal channel. all comparisons were made before and after infusion of , ml of % stabisol. especial attention were paid to the p ( . - . hz) and p ( . - . hz) bands of sv, which reflect the hormonal, more often adh activity (p ) and predominantly connect with patients breathing (p ). last findings showed it may be used as a marker of hypovolemia. the patients with the worst type of regulation (a result of brain stem dysfunction) responded on the vl by the sv increasing in , % cases. but they showed a decreasing sp of p only in , %, and sp of p increased in , %. in cases of hypothalamic dysfunction (type ) the sv grew in % patients, sp of p decreased in , % and p increased in %. the patients with the best adaptive type of regulation (type ) responded on the volume load only in , %, but had sp of p decreasing in , % and low growth of p ( , %). surprisingly, in some cases we revealed the great decreasing of variability of hr, bp, pvp and eeg amplitude as a transformation from type or to after infusion. in sbt the vl partly compensates hypovolemia, but creates an exertion in regulatory system, especially in case of significant chrd. so we need to find out the predictive marker of response on the vl in different level of brain damage. engström m , schött u , reinstrup p anaesthesia and intensive care, lund university hospital, lund, sweden acidosis has been found to be a predictor of worse outcome in trauma patients suffering from exsanguination. it has, however, not been studied if acidosis may be a causal factor in the development of coagulopathy. rotational thromboelastography (roteg) is a coagulation monitoring tool that is gaining increasing popularity as it seems to be more sensitive and specific than routine coagulation tests in detecting defects of the coagulation system. clot formation time (cft) and alpha angle are roteg parameters primarily dependent on the rate of fibrin formation and the platelet activity. methods. blood samples of ml each were obtained from healthy volunteers. one sample was studied without any additions. three samples were adjusted to ph . , . and . by the addition of , and µl of m hydrochloric acid (hcl). the last sample was first adjusted to a ph of . by the addition of µl of hcl and then reversed to a ph of . by addition of µl of tromethamol (tham) . mmol/ml. after adaptation of the ph to the desired level roteg was performed to study the coagulation system. we found a strong correlation between decreasing ph levels and an impairment of the coagulation (p< . ) (figure ). the impairment of the coagulation caused by the acidosis was reversible after addition of the buffer tham. in subarachnoid haemorrhage (sah), old age and high clinical grade at presentation are poor prognostic factors. treatment for these patients has been largely conservative. with endovascular coil embolisation a less invasive treatment option has become available( ). this study focuses on elderly and high grade patients admitted to the nicu. retrospective analysis of patients with aneurysmal sah. demographic features, wfns grade at presentation (low grade: & ), fisher grade, data for aneurysm site and mode of intervention were recorded. outcome at three months coded according to the modified rankin score (good outcome: rankin - ). conclusion. our data suggest that favourable outcomes (rankin score - ) can be achieved in elderly patients with high grade (wfns - ) sah. % of high grade patients > years made a good recovery. this may be due to the less invasive nature of coil embolisation and careful patient selection. gama r x , oller a m , bortoletto t c , almeida c r m , gurgel a p a , henrique l m p , zanini a a , faintuch j central pharmacy, hospital alemao oswaldo cruz, sao paulo, brazil lipid-based parenteral nutrition (tpn) mixtures are deemed safer than glucosebased preparations as regards possibility of hyperglycemia, but few comparative studies are available. aiming to determine glucose concentrations during such therapy, a clinical study was done. stable septic patients submitted to tpn (n= ) during a -month period were investigated on the st and the th day of therapy. both glucose-based (group i, n= , . ± . % of total calories as fat) and lipid-based (group ii, n= , . ± . % of calories as fat) programs were employed. groups were comparable regarding age ( . ± . vs . ± . years , ns), gender ( . % females in both groups) and features of septic problems . energy intake was slightly higher in the lipid-based preparations, but without statistical difference ( ± vs ± kcal/day ). conclusion. ) glucose-based tpn was associated with moderate hyperglycemia when compared to a lipid-containing prescription in this septic population; ) no clinically significant hyper or hypoglycemia was registered. guidelines for blood transfusion (bt) are based on plasmatic haemoglobin value (hb) and on clinical state. apart cardiac and septic patients, the threshold value of hb for bt is g/dl. the aim of the study was to evaluate the central venous oxygen saturation (scvo ) as a guide for bt decision. methods. patients of general and urologic surgery for whose a bt was discussed were included. scvo (%) and hb (g/dl) were measured before and after bt. the following parameters were registered: age, history of cardiovascular disease (cv), presence of sepsis, number of blood units. patients were retrospectively divided into groups according to scvo before bt < or > %. overall, demographic characteristics were similar. bt provided a significant increase of hb for each patient while scvo value rose significantly only in patients with scvo before bt < % (table ) . results are given in median (range). * wilcoxon test for values before vs after bt; # mann-whitney test or chi- for scvo < vs > %; significance for p< . . . ( . - . ) hb after bt . * ( . - . ) . * ( . - . ) . * ( . - . ) conclusion. among the patients studied, only those with a low scvo before bt had a better tissue oxygenation by hb increase. scvo might be an interesting parameter to help the clinician in his decision of postoperative bt. szakmany t , dodd m , dempsey g , lowe d , rogers s n department of anaesthesia, regional maxillofacial unit, university hospital aintree, liverpool, united kingdom perioperative blood transfusion is reported to be related to cancer recurrence and reduced survival . to date, little is know about the effects of blood transfusion on outcome in oropharyngeal cancer. we undertook this study to test the hypothesis that perioperative blood transfusion has an adverse effect on survival of patients with oropharyngeal cancer. methods. patients undergoing oropharyngeal cancer resection were evaluated from jan to december . transfusion rate, units of blood transfused and tumour stage were recorded. the primary outcome measure was oropharyngeal cancer death within two years. cox logistic regression was used to assess the association between cancer death and blood transfusion. data are presented as median (interquartile range). overall transfusion rate was % ( / ), units of blood transfused ( ) ( ) ( ) ( ) ( ) . mortality was . % ( / ). mortality was significantly higher in the transfused group (table .) however, in the cox regression analysis only tumour size, stage and clear resection margins were predictive of survival. after stratification of patients for these predictors, transfusion did not affect disease specific survival. in patients who are supported by mechanical ventilation with tracheostomy and who undergo neck surgery because of the neck trauma or neck infection, there is some risk of dislocation of the tracheostomy tube, contamination of the fixation device during daily surgical wound management and daily nursing care. the object of this study is to clarify the usefulness and safety of our technique of easily detachable fixation of tracheostomy tube with small clip in these patients. methods. patients who underwent this technique were examined. we detach the clip fixing the tracheostomy tube during daily surgical wound management and attached it as soon as finishing wound management. we did not experienced dislocation of the tube during daily surgical management and daily nursing care in all cases. we easily protected contamination of fixation device of the tracheotomy tube during surgical wound management. our technique of fixing the tracheostomy tube using detachable small clip is useful and safe in patients who are supported by mechanical ventilation with tracheostomy and who undergo neck surgery because of the neck trauma or neck infection. schachtrupp a , toens c , afify m , lawong g , schumpelick v surgery, rwth aachen, aachen, surgery, marien hospital, dusseldorf, germany in the presence of abdominal compartment syndrome (acs) the increased intraabdominal pressure (iap) leads to organ damage and reduced cardiac output (co). decompression is of utmost importance but occasionally circulatory collapse occurred. moreover, it is unknown whether reperfusion will increase organ damage. aim of the underlying study was to determine the influence of decompression on circulation and organ damage in a porcine model of the acs. we investigated pigs (dl, kg). in two groups (each n= ), iap was increased to mmhg for h using co . in one group a period of decompression lasting for a period of h followed. in the control group, iap remained unchanged for h. all animals received a basic volume substitution of ml/kg. additionally, ml of kristalloids were given whenever the continuously monitored co was lower than the control reading of ml/min x kg. heart rate (hr), mean arterial pressure (map), central venous pressure (cvp) and urine output (uo) were recorded. at the end of the experiment, specimen from the lung, liver, kidney and bowel were taken for histological examination. moreover, liver tissue was examined for the expression of icam- displaying leukocyte sticking. statistical analysis was done using analysis of variance as well as paired and unpaired ttesting. a p< . was considered significant. in case of repeated pairwise testing, level of significance was adjusted. results. co did not differ between groups but additional volume was needed in study groups. hr, map and uo did not differ. cvp was significantly increased. after decompression, hemodynamic parameters remained stable, uo increased significantly. medium grade histological was found after h of increased iap. reperfusion did not increase organ damage. the highest expression of icam- was found after h of increased iap without reperfusion. conclusion. in this model, administration of additional volume was sufficient to preserve co despite the presence of an iap of mmhg. decompression did not lead to circulatory collapse. nonetheless, organ damage was present which was not increased by decompression. these results imply, that in the presence of critically increased iap, adequate volume substitution is needed together with an immediate decompression in order to avoid organ damage. there were episodes of ventilator associated pneumonia in patients of total admitted patients ( . %) and patients who required mechanical ventilation support ( . %). the mean ventilator associated pneumonia rate was . / ventilator days. leading causative agents detected in our picu patients were pseudomonas aeruginosa ( . %),enterococcus ( . %) and staphilococcus aureus ( / %). all patients with ventilatory associated pneumonia survived. ventilator associated pneumonia occurs at significant rates among mechanically ventilated picu patients. ultrasonic guided pleural aspiration is a safe ed accurate method of obtaining fluid in pleural effusion, caused by several mechanisms (pneumonia, cancer, congestive heart failure etc). drainage could improve pulmonary ventilation and allow the laboratory examination of the fluid, useful for the differential diagnosis. pneumothorax (pnx)is the principal complication of thoracentesis. for this reason, five years ago, the emergency department of this hospital, adopted the plastic catheter (pc)in use for iv infusion in order to perform a pleural drainage. the aim of this study was to evaluate the effectivness of this method compared with the more common metallic needle (mn)contents in the set for thoracentesis. where insert the needle. after a local injection of anesthetic lidocaine, one of the two needles was chosen. in particular, for the pc, after the inserction, the metallic core was removed and only the plastic tube was left in place and connected to the drainage system. pleural aspiration was removed when the patient had thoracic pain, cough or fluid flow ceased. by ultrasonography, at the point of drainage, was measured the space between the two pleural layers and this was considered a parameter of drainage entity: the lower the space, the greater the drainage. results were analised on a statistical manner by t test of student for impaired data. patients who underwent thoracentesis by pc had more complete thoracic drainage (pleuric space , +/- , cm vs , +/- , cm; p < , )without case of pnx ( vs ). ultrasound is more accurate than plain chest radiography for estimating pleural fluid volume and aids thoracentesis. chest drainage by plastic catheter increases efficacy and safety. prospective randomized study included enterally fed patients with an expected mechanical ventilation period of at least days. the diagnosis of vap was based on clinical, radiological and bacteriological criteria. qualitative and quantitative bacteriological study of microorganisms isolated from gastric content as well as from upper and lower respiratory tract was carried out on the st, th and th day of the therapy. material from lower respiratory tract was taken by protected specimen brush (psb) using bronchoscope. introduction. vap is a frequent nosocomial infection. since delayed appropiate antimicrobial therapy worsens prognosis, broad-spectrum antibiotics are frequently administered. early clues on potential microorganisms involved could help select a more focused antimicrobial therapy. the known relation between vap and upper airways colonization prompted us to determine if uas at the time of icu admission (day ) could accurately identify microbial agents involved in early vap (within the first days following tracheal intubation). consecutive icu patients who had a clinical pulmonary infection score (cpis) consistent with the diagnosis of vap between and were retrospectively analyzed. uas (nose and throat) were obtained at day for all patients, and specific pathogens (other than normal oropharyngeal flora) were cultured. pulmonary plugged specimen (pps) were obtained whenever vap was suspected and were considered positive beyond cfu/ml. the concordance between uas at day and the first pps was analyzed. in level i(unit-based), . %( % ci . - . )of patients stayin > d, acquired at least one episode of iapn. the percentage varied strongly according to the country ( . to . %),type of icu ( . % in mixed, . % in medical and . % in surgical icus) and percentage of intubation. incidence density (id)per patient-days was . ( . - . )in icus with < % of intubation, . ( . - . ) in icu with - % intubation and . ( . - . ) in > % of intubation, p< . ). the median n of days from admission to iapn were . ( . - . ). the most frequently isolated were p aeruginosa ( . %) and s aureus ( . %), with large variations between countries.gp cocci were isolated in . %, gnb-enterobacteriaceae in . %,gnb non-enterobacteriaceae . % and fungi/parasites . %. table shows the distribution of micro-organism according to the time of onset of iapn. in level ii surveillance (patient-based) intubation utilisation ratio was . ( . - . ) and deviceadjusted indicator: . iapn* / intubation days ( . - . ). % of all general critical care patients were transferred for their care. these patients accounted for % of all bed days in the network. transferred patients had a mean icu stay of days, days longer than non-transferred patients (p= . ) together with a slightly longer hospital stay. there was also a small ( . %) increase in hospital mortality associated with transfer which was not statistically significant. there is a large number of level patients who are at risk of deterioration or have stepped down from higher levels of care.these patients can be looked after on an acute ward with additional support from the critical care/outreach team the critical care network has level beds and the audit identified level patients. ( . %)of these patients(at the time of the audit) could not access a level /hdu bed despite their condition warranting care in an hdu area. the care delivered to this group of patients is therefore by staff trained for a level / area.with level beds, capacity for level patients was appropriate on this day with beds available. the networks patient transfer activity for was non clinical transfers and clinical transfers. sepsis is one of the leading causes of death in intensive care medicine (icm). the rapid diagnosis and management of sepsis is critical to successful treatment. since we have integrated diagnostic and treatment feature of severe sepsis into our berlin simulation training in order to optimize team functions. lectures and interactive simulation scenarios are combined and discussed. participants are postgraduates with differing professional experience in icm (pe). to evaluate the structure, content and impact of those courses participants of four simulation courses in were given anonymised questionnaires both in advance and immediately after the course. pairs of items were defined to measure the acquirement of knowledge in sepsis and the impact of several teaching methods. participants were also asked whether the course content should have been given earlier or later during their postgraduate training. answers were given on a five point scale (likert-like) and results are given as median and interquartile range (iqr). participants' pe in icm varied from two months to years. all participants expressed benefits from the course. both lectures and scenarios were evaluated helpful to identify sepsis patients earlier. most of the participants thought that the course was at a right point of time during their postgraduate training (pt) (n= , median of icm/pe . a, iqr - a) and participants thought that this course would have been even more helpful if had been given earlier during their pt [n= , pe . a ( . - . a)]. "the course was being helpful concerning future identification of sepsis patients" - ( - ). "the lectures were being helpful concerning future identification of sepsis patients" - ( . - ) "the scenarios were being helpful concerning future identification of sepsis patients" - ( . - ) "the scenarios were realistic" - ( - ) and "i enjoyed the course" - ( - ) conclusion. simulation courses to train early identification and timely treatment of septic patients are very helpful and appreciated at every stage of pe in icm. simulation courses should be integrated as early as possible. jermin s p , kapila i , dyson m critical care, south manchester university hospital, manchester, united kingdom there is a recognised shortage of icu beds in the uk.critical care outreach services help reduce pressures on critical care by providing clinical support, increasing staff skills and by providing educational support( ). early identification of sick patients may lead to a reduction in number of admissions to icu, length of in hospital and icu stay ( ) . this study aims to compare the level of care of all inpatients on a normal 'in hours'working day(tuesday) with those of all in patients on an average winter 'out of hours' day(sunday) data was collected from every inpatient in the hospital(excluding psychiatric,paediatric and long term rehabilitation patients) on an average tuesday in april between the hours of - and then on a sunday in january between the hours - . data consisted of levels of care(using uk intensive care society definitions)( ) during both periods but also included demographic details for the second period.presence of respiratory rate(used as an index of deterioration) recording was also noted for the second period. conclusion. the current complement of level and beds in the hospital is and (dependant on staffing levels)respectively.despite some flexibilty in using level beds for level patients and assuming an % bed occupancy, there is a considerable need for more level capacity particularly during the winter period.extension of the current theatre recovery area into a bedded post-operative hdu could provide additional beds .outreach services would also need to be vastly extended. abizanda r , nicolás-picó j , mateu-campos l , carregui-tusón r , sánchez-morán f , mas-font s , ferrándiz-sellés a intensive care department, hospital universitario asociado general de castelló, castellÓ, spain when no icu specific analytical accounting is available, the only indicators of direct costs are the number of icu stays per patient, and pharmacy costs. it is usually accepted that these pharmacy costs represent between and % of total costs, and that they are very much influenced by therapeutic attitudes of the attending teams and the introduction of new pharmacological options or the change in the already existing ones. our aim is to analyze the changes in pharmacy costs occurred during the interval between and . methods. this is a retrospective analysis performed on a multidisciplinary beds icu activity, in a teaching referral hospital. the analysis has been performed through data coming from the managerial departments and the pharmacy service, and costs have been classify as related to therapeutic group (pharmacy instructions from the spanish national health system) and to individual active drugs. the analysis collects information raised from the icu daily patients chart. pharmacy costs amount ranged between , % in and , % in . since then a slight increment in pharmacy costs has been detected up to , %. the reasons for cost decrements are linked to the progressive control on albumin use and antibiotic policies. by the contrary, increasing percentages are associated to the introduction of new sepsis therapeutic approaches (drotecogin) and the routine introduction of antiplatelet agents in non elevated st coronary syndromes. the "top twenty" drugs cost evolution is presented, and in a constant fashion the two firs places represent the use of sedatives (propofol) and fibrinolytic agents in ami (tecneplase). factors that allow or avoid to keep the stability of what pharmacy costs represent are strictly linked to changes in physician attitudes (abandon of non demonstrable efficacy of certain agents -albumin -, the incorporation of new options -drotrecogin, antiplatelets -and the maintenance of consolidated practices -fibrinolytic agents, sedatives, nutritional strategies. physician teams are obliged to keep this information "alive" in order to avoid unnecessary raises in direct costs. cotogni p , bini r , forno g , porta c , aliffi s , ranieri v m , pittiruti m anestesia e rianimazione, chirurgia d'urgenza, school of nursing, university of turin, turin, chirurgia generale, catholic university, rome, italy enteral nutrition (en) is the preferred method for nutrient delivery in icu critically ill patients. nonetheless, there is always a significant gap between prescribed and delivered feed. this is partly due to 'patient-related' problems, e.g. gastrointestinal (gi) intolerance to en, but also by logistic 'management-related' events which imply transient nutrient delivery interruptions, which are often mandatory but sometimes avoidable. the aims of this study (prospective, descriptive study of en delivery in teaching hospital icus) were (a) to analyze the causes for en transient interruptions; (b) to assess whether a specific nurse training might be associated with better nutrient delivery. in two icus (group a), all nurses had been previously trained in en through a h education module, while nurses of other icus (group b) had not. over a period of months, we studied all icu pts receiving en (either alone or combined to parenteral nutrition). pts receiving en for < days were excluded. en was administered as a continuous ( / h) intragastric infusion of a standard polymeric diet. we recorded any transient interruption of nutrient delivery lasting more than min, noting the duration and the cause. we examined pts fed by en accounting for en days ( . + . days/pt). in the groups, patient populations were similar in saps, diagnosis on admission to icu, complications, days of mechanical ventilation and mortality. the main causes of transient en delivery discontinuation were mechanical ( %), or secondary to diagnostic and therapeutic procedures ( %), or related to true gi intolerance to en ( %). comparing groups, we found that group a was characterized by a lower incidence of discontinuations for mechanical causes (p<. ), as well as by a shorter duration of interruption due to mechanical causes (p<. ), to procedures (p<. ), or to intolerance (p<. ). also, the difference between prescribed and delivered feed was significantly lower in group a (p<. ). our study shows that (a) the majority of discontinuations of en delivery is secondary to 'management-related' causes and not to patient's intolerance; (b) a specific training in artificial nutrition of the icu nurses may be effective in increasing nutrient delivery by reducing incidence and duration of those en discontinuations which are not 'patient-related'. saura p , ortiz d , prat r , fernández r , artigas a critical care center, hospital de sabadell, sabadell, spain, critical care center, hospital de sabadell, sabadell, the role of icu staff on cost containment is a matter of debate being drugs consumption, diagnostic test and fungible the main able to be improved. we hypothesised that these items could have the major impact in cost variability per patient in the icu. our objective was to prospectively evaluate the relative role of these variables compared with other classical items as length of stay, quality of life, age, severity of illness. design: prospective cohort study setting: -bed intensive care unit patients: consecutive patients with a length of stay longer than hours. measurements: we prospectively recorded: demographic data, spas ii score and diagnostic related group on admission, length of icu stay, health-related quality of life (euroqol d), and consumption of fungible, pharmaceutical and diagnostic procedures. the costs of the fungible, pharmaceutical and diagnostic tests were recorded from the hospital administrative database as cost per unit. we elaborated a multivariate linear predictive model in order to analyse the variables causing the variability of the cost per patient. patient transfer between hospitals is associated with increased mortality ( ), and patients transferred from intensive care unit (icu) to icu have also been shown to have increased mortality ( ) . the aim of our analysis was to compare our mortality figures with those of published data. . a retrospective analysis of , patients admitted to a -bedded unit in a university teaching hospital over a -year period. we compared those patients admitted from our own hospital (internal) with patients transferred from other icus (external icu) and those transferred from other hospitals from an area outside icu (external other). we compared icu mortality with apache ii predicted mortality and calculated the standardized mortality ratio (smr). results. over the year period, , patients were admitted into the icu. forty-nine( %)were transferred from another icu, ( %)were transferred from areas outside the icu in other hospitals and ( %) were admitted from our own hospital. mortality figures are shown in the table. conclusion. lipid solutions enriched with w- fatty acids are safe, well tolerated in patients with ards, and without changes in the hemodynamic or gas exchange of these patients. cdc defintions for nosocomial infections nosocomial infections in pediatric intensive care units in united states nosocomial respiratory infections picu ventilator-associated pneumonia nosocomial pneumonia in the picu (abstract k- ) pediatric ventlator-associated pneumonia last's anatomy the impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis incidence of nutritional risk and causes of inadequate nutritional care in hospitals nutritional risk screening (nrs ): a new method based on an analysis of controlled clinical trials r:an update on perioperative management of diabetes intensive insulin therapy in critically ill patients introduction. the objective of this study was to evaluate the use of human resources in icu comparing the planned level with the operative level. prospective study involving all the patients admitted in the icu between and . simplified therapeutic intervention scoring system (tiss ) was used to assess nurse workload in the icu. provision of resources was measured as the number of nurses per icu bed (patient nurse ratio -p/n). the operative level of care was calculated dividing the measured tiss points equivalent to the nursing activities of one nurse per shift. the efficiency in the use of nursing manpower was based on the number of available nurses, the amount of work that one nurse can perform per shift and the level of tiss during the study. the work utilization ratio was calculated. severity of illness was evaluated by the apache ii score. conclusion. the apache ii score remained elevated through the study period. the measured tiss was higher than planned and as a result the work utilization ration was above %. nevertheless the number of patients admitted increased every year and the mortality remained lower that the expected by the apache ii score. adverse drug reactions (adr) are common in hospitalised patients, but few empirical data are avalaible regarding patients with serious adr requiring intensive medical care. as morbidity linked to adr remain underappreciated, delay for diagnosis may contribute to organ failure requiring artificial life support. the aim of this study was to determined the proportion of admissions related to serious adr and potential avoidability. we have prospectively included all adults patients coming from university hospital admitted in a -bed medical intensive care unit (icu) in a french university hospital in bordeaux, france, during a -month period. for each patient, we have determined if serious adr have contributed to organ(s) failure(s) requiring admission by follow-up and with independant clinical pharmacologists. clinical pharmacologists have estimated the strenght of relationship between drug(s) prescribed in hospital and potential avoidable adr as the cause of organ failure.results. of patients admitted from medical icu between may and october , ( , %) were hospitalised because of almost one organ failure related to adr, % of cases adr were potentially avoidable. coma, seizures with acute respiratory failure and metabolic life-threatening disorders were the most frequently avoidable adr and linked to drugs prescribed in a short delay before admission. artificial life support was required in % of cases.vasopressives drugs were prescribed in cases , hemodialysis in , non invasive ventilation in , and mechanical ventilation was needed in cases.the mean of simplified acute physiologic score ii of work load omega score, of length of stay and the rate of mortality were not significantly different between patients with or without adr. serious adr were a frequent reason of admission ( , %) and were often potentially avoidable if cautions of prescriptions would have been taken into account. measures are needed to improve adr detection and reduce drug-induced morbidity. performing every interventional procedure strictly lege artis is of significant importance not only to the patient, but also to the medical personnel. ensuring the maximum alertness to stay strict to the rules and performing by book leads to minimal complications, more wise decisions and reduction of the cost as it minimizes the single use material waste. : in our polyvalent six bed icu we installed cameras providing full surveillance of each bed. all of the cameras were in use for two weeks registering every interventional procedure on hour basis. medical and nursing stuff were aware of the registration process. the whole medical team reviewed the collected videos every five days. we totally registered central vein catheterizations, oro-tracheal intubations, three tracheostomy operations, radial artery catheterizations, rhinogastric tube insertions, urinary bladder catheterizations, pulmonary artery catheterizations bronchoscopies, and six chest drainage procedures. all procedures were graded on to scale, in respect with asepsia,, antisepsia ,speed of performance, material waste and complications. procedure days - days - days - central veins access radial artery access pulmonary artery access tracheal intubations bladder catheteriasations levin tube insertion bronchoscopy tracheostomy bulau insertion conclusion. increased stress among the medical personnel was noted due to the presence of the cameras, although procedures were more exact as the time advanced in spite of the fact that the duration in time of each procedure seemed to be longer. complication rates were constant. [ ] , thereby increasing providers' financial risk considerably [ ] . in future, reimbursement in germany will be based on a special procedure (ops ) which may be quantified through a specific, patientdependent cost predictor score. the aim of this study was to develop and validate such a score capable of predicting the total direct costs of intensive care services in large teaching hospitals. individualized clinical as well as economic information was collected for all consecutive patients across mostly surgical icus in university hospitals across germany during a month period. resource consumption covered hotel and personnel costs, medication, laboratory tests, diagnostic and invasive procedures. resources were valued with local costs through bottom up costing. an "icu cost predictor score" (icu-cps) was devised by combining a routine measure of severity of illness (daily saps ii score without gcs) with a daily measure of selected medical interventions ( highly rated parameters of tiss- : mechanical ventilation, multiple catecholamines, > l daily fluid replacement, peripheral artery catheter, pulmonary artery catheter, haemofiltration, intracranial pressure measurement, alkalosis/acidosis treatment, special interventions, actions outside icu) during the entire icu stay. based on a preliminary analysis of patients from icus, the icu-cps demonstrated a strong positive correlation of . (p < . , -tailed) with total icu costs. this coefficient varied from . to . between icus. the correlation of the icu-cps score with costs was better than that of saps ii (without gcs) ( . ; p< . , -tailed). the mean icu-cps per day was ± (mean ± sd). average costs per day were € , ± , . on average, each score point of the icu-cps thus corresponded to a cost of . the preliminary results of this study indicate that intensive care services may be adequately reimbursed on the basis of the icu-cps predictor score, taking into account patients' acute severity of illness as well as required medical interventions. the aim of our study was to analyse variable cost determinants of severe sepsis treated in intensive care units in hungary. we selected a non-random sample of intensive care units. each unit identified patient retrospectively, who were treated with severe sepsis. the resource use of variable costs were collected on a daily basis (for day - ) from medical and nursing documents. these costs were divided into disposables, radiology, biochemistry, blood products and drugs&fluids. personnel costs were calculated from annual salary report and the indirect costs were calculated by the financial directors. the mortality of severe sepsis in our sample (n= ) was found to be . %, with average lenght of stay . (sd . ). mean icu cost per day of severe sepsis was euro. there were no differences found between day - cost of radiology, biochemistry and blood products, however, disposables had much higher cost on day (p= . ). drugs&fluids costs were higher on day only for those patients who did not survive. analysing drugs&fluids by grouping them into categories, we found that colloid use was significantly higher on day in those, who died later ( ml vs. ml, p= . ). there was no correlation found between apache ii scores and any cost components. egdt has shown significant reduction in mortality and health care resource consumption and is recommended by the surviving sepsis campaign . this study assessed data from severe sepsis and septic shock patients prior to implementation of an egdt program and projected the potential impact on resource utilization at our hospital. we queried the clinical data repository and found emergency department(ed)patients admitted from jan -dec meeting search criteria including: patients > years, hospital admission from the ed with documented infection, antibiotic treatment and requiring vasopressors (day , ), ventilator assistance (day , ), new dialysis (day - ) or a serum lactate > mmol/l. exclusion criteria were admission gi bleed or traumatic injury. based on resource utilization data from the henry ford health systems corporate data stores, percent differences between egdt and non-egdt groups were calculated and applied. assuming constant mortality, the projected impact on hospital resource consumption and costs was assessed. cost savings was assoicated with survivors. increased costs were noted in non-survivors. cost benefit favored egdt. . four consecutive tptd measurements were performed with ice-cold saline. the volume of the injectate varied between and ml depending on bodyweight. the mean of consecutive measurements with a normal td curve and injectate temperature lower than °celsius was considered as the gold standard. a total of quadruple measurements fulfilled the quality control criteria. mean cardiac index (ci) was , l/min/m (sd , ). the mean coefficient of variation (percentage of the sd of the mean) for quadruple tptd measurements of ci was , % (sd , ). the table shows the differences between measurement, the mean of and the mean of measurements in comparison with the mean of measurements. measurements were performed at our catheterisation laboratory in seven children with a bodyweight of - , kg. evlw was measured with the cold system (cold, pulsion medical systems) incorporating both tptd and tpdd techniques. ice-cold indocyanine green was injected close to the right atrium. changes in temperature and dye concentration were measured using a special catheter located in the distal aorta. mean cardiac index (ci) was , l/min/m (sd , ) and mean evlw-tpdd was , ml/kg ( , - , ). repeatability ( . x sd of the difference between repeated measurements) for ci, evlwi-tptd and evlwi-tpdd were , l/min/m , , ml/kg and , ml/kg respectively. the bias between the two methods is - , ml/kg with a precision of , .conclusion. transpulmonary thermodilution appears to be an adequate method to measure evlw in children. children may have higher normal values of evlw compared to adults. loh t f children intensive care unit, kk hospital, sin, singapore a common approach for insertion of central venous catheter is to access the subclavian vein via subclavian approach. this approach is associated with arterial puncture and air leak , . local pressure is difficult to apply as the vein runs under the clavicle. we describe an axillary approach to access the subclavian vein in paediatric patients. patients were selected for this approach when conventional approaches for central venous access were exhausted or contraindicated. the patient's arm is kept abducted with slight external rotation perpendicular to the thorax with the dorsum of the palm flat to the bed. head is turned to the contralateral side. the axillary artery is palpated and followed as it inserts into the apex of the axilla lateral to the teres minor when it becomes the subclavian artery. the axilla vein runs medial to the artery becoming anterior to the artery as it enters the axilla apex to become the subclavian vein . a puncture is made medial to the artery at the base of axilla and directed towards the axilla apex. the needle is punctured - degrees to the skin and limited to the apex of the axilla. confirmation of venous access is made by free flow of blood. the catheter is inserted using the seldinger technique and secured. chest xr done to confirm placement. . paediatric patients were selected for this approach. arterial puncture was made in one patient and hemostasis secured with direct local pressure and subsequent insertion was successful. access required a mean of . attempts. one patient hand was swollen days after the line inserted but doppler study did not reveal any venous thrombosis and the line left in situ. routine limb neuromuscular and vascular assessments were made. no malposition or air leak was seen on cxr.no local or line related infections were documented. catheters were removed after . days. follow up (mean of weeks) after the catheter was removed showed normal hand power and movement in all patients. axillary approach maybe a novel alternative to central venous catheter insertion in paediatric patients when conventional approaches are not possible. change was recorded on capnography in all tests performed. radiographs confirmed correct placement of ngt throughout study period. in the subgroup of children(n= )who had an endotracheal placement the time to complete capnograph colour change was ≤ seconds, (median ( - )) in all cases. in critically ill children sufficient gastric aspirate can be obtained for ph testing and capnography rapidly discriminates between ngt placed correctly from those passed in to the trachea. a one year prospective & observational study included all admissions (n= ) until h after discharge. cultures for bacteria and fungi and antibiotic sensitivity tests ( antibiotic using bauer-kirby disc diffusion method) were obtained on admission [ blood, stool, urine & cerebrospinal fluid (if needed)] and repeated on suspicion of nis .all cannulae, endotracheal tube (et) aspirates & tips, nasogastric tubes & different catheters were cultured. all picu health care workers (hcws) were subjected to throat & under-finger nails culture as well as inanimate objects , both on bimonthly basis. the referral place (ward or emergency), prism iii score, length of stay (los) & fate, were recorded. reports of the dutch society of pediatrics concerning transport and stabilizing critically ill children, resulted in a reorganization of the transport of critically ill children in the netherlands. as of february , all children in the northwestern region of the netherlands requiring mechanical ventilation were transported by pediatric intensive care teams of the vu and amc university medical centers. these teams consist of a pediatric intensivist or anesthesiologist (in training) and pediatric intensive care unit (picu) nurse and were on call hours, days per week. the objective is to report the first year results and to compare an experienced (amc) and a novice (vumc) center. demographic data, diagnosis at admission and severity of illness score (prism) and duration of transport (preparation, travel time, intervention in other hospital and complications during transport) were prospectively collected. all data were analyzed per center and in total in order to identify any difference between both picu-teams. transport frequency was divided according to picu-capacity ( % vumc and % amc). statistic analysis included student t-test for continuous variables and chi test for dichotomous variables. in total patients were transported by either picu-team. half of the transports took place during the evening or night. demographics, prism-score and admission diagnosis were comparable. mean transport time was hours and minutes. there was a significant difference in preparation time . results concerning other transportation variables are similar for both clinics. neither picu-team reported complications during transport. a continuous picu transport system carried out by two specialized centers is feasible and efficient. apart from a difference in preparation time, which may be influenced by a multitude of factors, there were no differences concerning other transport variables between an experienced and inexperienced team. after cardiac surgery it is not uncommon that a solitary collapse of a lobe, e.g., the left lower lobe develops. it has been difficult to experimentally study therapeutic interventions for lobar atelectasis due to lack of suitable animal models. the aim of this study was therefore to develop a reproducible model in pigs.methods. anesthetized pigs were tracheotomized and ventilated vcv, fio . , peep cmh o, vt ml/kg. this ventilation was maintained under the experiment except during the lung recruitment maneuver (lrm). a bronchial blocker (cook c-aebs- . ) was inserted in the right lower lobe (about cm from the et-tube opening) by the use of a fiberoptic bronchoscope. to ensure a correct position, the balloon of the blocker was inflated shortly and thereafter deflated under inspection via the bronchoscope. thereafter, a lrm (pcv with peak pressure of cmh o, peep cmh o, i:e : and rr of /min during min) was performed to optimize the lung volume history after which end-expiratory lung volume (eelv), quasistatic compliance of the respiratory system (crs) were measured and blood gases (mixed venous and arterial) were obtained. the balloon of the bronchial blocker was inflated, the air of the isolated lobe exsufflated and measured ("lobe volume"). thereafter the lobe was selectively lavaged (with a "lobe volume" of °c . % nacl) using a syringe times or until no frothing of the lavaged fluid was seen. eelv, crs and blood gases were obtained. in one pig ct thorax was done and another pig was thoracotomized and the lungs were inspected. statistics:wilcoxon. the "lobe volume" was ± ml (mean±sd). after the selective lobe lavage, eelv decreased from ± to ± (p< . ), pao from ± to ± (p< . )and crs decreased from ± to ± (p< . ).both ct and the inspection of the lung showed atelectasis of the right lower lobe. a reproducible experimental lobe atelectasis can be obtained by selective lobe lavage in pigs. this method may be used experimentally for studying methods treating atelectasis. garcia-hernandez r , perez-vela j l , corres m a , hernandez-sanchez e , renes e , gutierrez j , arribas p , perales n postoperativecardiac unit, hospital doce de octubre, madrid, spain in the literature donor´s norepinephrine (ne) usage was considered high vasoactive support and leads to refuse heart graft implantation.the sortage of available donor hearts limits cardiac transplantation and nowadays some authors point that vasoactive drugs (vad) could be useful to improve donors hemodynamics and so graft function in the recipient. objetive: to assess graft function and icu evolution in patients who underwent cardiac transplantation depending on donor´s ne dose. retrospective study from until of intrahospital donors and theirs recipients two groups were set: low ne dose: donors who received < . mcg/kg/min or no ne; high ne dose: donors who received >/= . mcg/kg/min. we assessed in the donors: number, type, length and dosage of vad; volume intake and clamp time; in the recipients: presurgical left ventricular eyection fraction (lvef); extracorporeal circulation (ecc) time; incidende of ventricular disfunction, cardiogenic shock, primary graft failure (pgf); mortality and others icu evolution parameters (incidence of acute renal failure-arf-, acute lung injury/respiratory distress -ali/ards-, sepsis, length of dva usage, mechanical ventilation and icu admission, etc...). statistical analysis was done with t-student´s test and chi( ) (using yates´ or fisher´s modification when indicated). conclusion. in our serie, the donor´s ne dose did not have an influence on the heart graft disfunction or in the others items assessed. the ne use for hemodynamic management on heart donors could not worsen the recipients evolution, but new studies with high number of patiemts should be developed in order to set a clear limit in the dosage used. jacquet l , rubay j , vancaenegem o , laarbaui f , lovat r , noirhomme p cardio-vascular intensive care, cardio-vascular surgery, saint-luc university hospital, brussels, belgium many patients with complex congenital heart disease,the majority having been operated on during their first years of live, are now adults and pose unusual problems for cardiologists, surgeons and intensivists caring for adult patients. we have reviewed the charts of patients > years old who were admitted in our cardiovascular icu after operation for guch from january to december in order to describe their specific outcome. during this years period, data from pts ( males, females and xxyy karyotype) were collected. the mean age was y (rang - ).among these, had tetralogy of fallot and had been already operated before, having had previous surgical procedures. the main indication for surgery was pulmonary insufficiency and pts received a pulmonary homograft. retrospective review of all echo examinations in this setting over a one-year period (jan -jan ) we performed echo in patients ( % of ). echos were carried out during the first hours in % and on the next day in %. sixty-eight percent were performed during the first postop days. echo was performed as urgent in %, semi-urgent (> hours) in % and for control in % of cases ( % tte, % tee). % were carried out by cardiologists and % by anesthesiologists. however, % of the urgent echos were performed by anesthesiologists. indications were: hemodynamic instability ( %), cardiac transplantation follow-up ( %), cardiac ischemia ( %), cardiac function follow-up ( %), and suspected cardiac tamponade ( %). findings were left ventricular dysfunction ( %), hyperdynamic left ventricle ( %), right ventricle dysfunction ( %), new segmental wall motion abnormalities ( %) and hypovolemia/vasodilation ( %). % were normal or similar to previous echos. new myocardial infarction was diagnosed in %. echo induced changes in patient management in %: resternotomy ( %), medical therapy ( %) and others ( %)(iabp insertion/removal, anti-rejection therapy). main changes in therapy were: inotropic agents ( % increase, % decrease) and iv fluid administration ( %). in % echo findings were unexpected/unrelated to the symptoms. % of patients were also managed with a pulmonary artery catheter(pac). in % of these there was no agreement between two techniques. number of echo carried out by the anesthesiologists increased from % in the first four months of the study to % in the second four months and to % during the last four months. in this study, echo provided important diagnostic and therapeutic data on postoperative cardiac surgical patients. findings led to management changes in % of patients. echo should be included in training of physicians working in csicu. is . %. the mean age is ± years. the mean bmi is ± . kg/m . patients with normal bmi ( - kg/m ) and patients with more than normal weight(above bmi) had a similar outcome. (fig. ) we ruled out that younger age compensates for a possible higher mortality in heavier patients.however, the age turned out to be similar in the different bmi groups and cannot be held accountable for lack of increased mortality in patients with more than normal weight. (fig. ) .conclusion. bmi does not show to increase mortality in cardiac surgical patients, despite of possible increased comorbidities. samalavicius r , misiuriene i , norkiene i , juozaitis m , baublys a department of cardiac anaesthesia, vilnius university hospital, vilnius, lithuania obesity is one of the risk factors for adverse outcomes of major surgery. we assesed the influence of obesity on outcomes of cabg in our institution. the data of consecutive patients, who underwent coronary artery bypass grafting at vilnius university heart surgery clinic between january , and december , were analysed. obesity was defined as body mass index > . kg/m . obese patients (n= ) were compared to remaining group of patients. preoperative risk factors, postoperative outcomes, mortality rates were analysed. associations between obesity and postoperative outcomes were analysed. in a prospective observational study we assesed nutritional status of consecutive cardiac surgery patients with a nutritional risk screening form, which contained bmi, food intake, weight lost and stress factor. we evaluated mortality, icu stay and frequency of impaired healing in the groups in nutritional risk and with normal nutrition. we identified from ( , %) patients as in nutritional risk. both groups did not significantly differ in age, bmi, left ventricle function, preoperative serum albumin level, prevalence of chronic renal failure or perifery vascular disease. there were significantly more diabetics ( , % vs. , %, p< , ) and patients with copd ( , % vs. , %, p< , ) in risk group. we found out the rate of complicated wound healing , % (all sites and grades). there was significantly higher rate of complicated wound healing ( , % vs. % p< , ) and longer icu stay ( , vs. , hrs., p< , ) in group in risk compared to group without risk. there was trend to higher mortality in risk group, statisticaly nonsignificant( , % vs. , %). we identified diabetes, copd and nutritional risk as to be preoperative independent risk factors of impaired healing in elective cardiac surgery by multivariate analysis.conclusion. cardiac surgery patients have a similar prevalence of nutritional risk as general population of patients. simple screening form is able to identify group of patients in increased risk of impaired healing. maximum sofa during first three days (maxsofa d) and deltasofa between first and third postoperative days (deltasofa ) revealed to have strongest correlation to mortality (p= . , roc area . and p= . , roc area . respectively). the maxsofa d of points corresponded to mortality with sensitivity of . and specificity of . . maxsofa d correlated to the icu stay (p= . ).conclusion. the sequential assessment of organ dysfunction during the first three days postoperatively is an independent predictor of mortality and morbidity in cardiac surgery patients. hájek r , rùžièková j , zezula r , fluger i , nìmec p , jarkovský j , nemethová d cardiac surgery, university hospital olomouc, olomouc, center of biostatistics, masaryk university, brno, czech republic introduction. thromboleastography (teg) is reliable and extensively used method of haemostasis monitoring. using teg as a bed-side method, we are able to detect a coagulation disorders, especially hypercoagulation and fibrinolysis methods. in prospective randomized study two groups of elective cardiac surgery patients were compared. patients of group a (n= ) were monitored both conventional lab tests and simultaneously with teg. the following teg measurements were performed: st -baseline after the anesthesia induction, th-at rewarming on cpb (with heparinase) and th-immediately after icu admission (both nativ and heparinase). patients of group b (n= ) were monitored only using lab tests. pre and postoperative coagulation status, incidence of thrombocytopenia, fibrinolysis,blood loss , transfusion therapy, surgical reexploration were evaluated. changes of hemostatic profile using teg diagnostic algorithm and also changes of pre-and postop.lab tests were evaluated results. both groups were comparable by age ( , / , ) , male gender ( %, / , %) and surgery type. the lab coagulation tests including platelet count were within normal range in both groups before surgery. no diference between both groups were recorded in : average blood loss during and postoperative, incidence of surgical reexploration because of bleednig , red blood cell, fresh frozen plasma and platelet transfusion and using of aprotinin. in both groups lab values of quick test, platelet count and fibrinogen were lower and aptt and tt were higher after surgery. the changes of teg parameters characterised by coagulation index : ci >ci , ci <ci . frequency of coagulagulation patterns: teg : enzymatic hypercoaguability , %, platelet hypercoag. , %, sec.fibrinolysis , %. teg : low platelet function , %, primary fibrinolysis , %, low clotting factors , %. teg (heparinase): enzymatic hypercoag.. , %, platelet hypercoag. , %, low platelet function , %. only one parameter-quick test value(%) correlated with ecc duration (r- , , p< , )in both groups. this study shows no diference of therapy between groups monitored with teg compared with conventional lab tests. most of patients in teg group showed the signs of hypercoagulation on teg before and after elective surgery. . to achieve a better glucose control in diabetic cardiac surgery patients a three to five-fold increase of basal insuline dose has been suggested. ( ) .our objective was to determine wether three or five-fold increase in basal insulin-dose during hypothermic cpb makes a better glycemic control without risks.methods. type ii diabetes patients were included in this prospective study. two hours before surgery a continuous endovenous insulin infusion was started to achieve the target glucose level results. (median+/-sd) pts were excluded due to off-pump surgery. one due to continuous hypoglycemia .itg showed lower blood glucose levels( +/ mgdl- )than cg( +/- mgdl- ) during intraoperative period (p< . ). % of itg and % of cg patients presented at least one blood glucose level.mean time with blood glucose levels conclusion. -in type ii diabetic patients sheduled to cardiac surgery a five-fold increase in insulin dose at the begining of cpb achived intraoperatively safe and better glycemic control than three-fold increase;. -patients with better glycemic control had less infections and shorter hospital stay as it was also demonstrated by others ( ) .this results give support to stablish insulin protocols that allow a tight glycemic control in the perioperative setting. giuliano k k patient monitoring, philips medical systems, andover, united states introduction. the purpose of this research was to develop a predictive model for the early identification of sepsis using the currently recommended physiologic parameters that are continuously or frequently monitored in the critical care setting. data from the project impact ® international dataset were used to assess whether a combination of the physiologic parameters of heart rate, mean arterial blood pressure, body temperature and respiratory rate could distinguish between critically ill adult patients with a diagnosis of sepsis and those without a diagnosis of sepsis in the first hours of intensive care unit admission. all four predictor variables used in the analyses (respiratory rate, heart rate, mean arterial blood pressure, and temperature) differed significantly between the septic and nonseptic patient groups. however, using logistic regression, only two out of the four predictor variables (mean arterial blood pressure and temperature) were independently associated with being septic. according to hosmer and lemeshow goodness-of-fit tests, the logistic regression model was a good fit and explained between . % and . % of the variance. using the significant predictors of temperature and mean arterial blood pressure, the odds ratio for having sepsis was . for patients with a temperature of oc or higher and . for patients with a mean arterial blood pressure of less than mmhg. in addition, the odds of having sepsis were . times greater if the patient had both of these physiologic conditions present. the results of this research provide support for the use of some of the currently recommended clinical monitoring guidelines for patients with sepsis. however, the results also underscore the limitations of using these variables for sepsis monitoring, since this group of variables alone was not sufficient for discriminating between critically ill patients with and without sepsis. more work needs to be done to see if these variables would perform better if different cut-off values were used. zubani f , de peri e , rasulo f , candiani a , latronico n intensive care unit, spedali civili, university hospital of brescia, brescia, italy introduction. more than percent of patients with sepsis syndrome or septic shock present altered mental status manifested by decreasing attention, disorientation, agitation, obtundation and in worst cases profound stupor and coma (septic encephalopathy). we don't know the exact physiopathological mechanism which cause se, but many clinical studies have shown that cerebral blood flow (cbf) is reduced in these patients. the current study was performed to evaluate the behaviour of cerebrovascular autoregulation during systemic inflammatory response syndrome (sirs), sepsis syndrome, septic shock and multiple organ failure (mof). we have studied all patients with se admitted into the intensive care unit of the spedali civili university hospital of brescia from january to september . cerebral autoregulation has been evaluated bilaterally in the mca territory with thetransient hyperemic response test (thrt). twelve patients were included in this study and thrt have been totally performed. cerebral autoregulation was impaired in % of thrt: the two conditions most associated with worst cerebrovascular response are sepsis ( , %) and mof ( %); patients with septic shock have shown unexpectedly the best autoregulatory response. in patients with infections caused by gramnegative organisms cerebral autoregulation was impaired in % of measurements: there are many evidences in literature about endotoxin's ability to influence cerebral blood flow. another important factor able to influence the behaviour of cerebral blood-vessels is paco : the effect of hypercapnia is more evident in patients with septic shock and with mof, particularly, the share of patients with septic shock with cerebral autoregulation completely impaired, was hypercapnic in % of measurements. cerebral autoregulation was impaired in the most part of measurements. gramnegative organisms and hypercapnia play a fundamentally roll in the loss of this mechanism. conclusion. platelet transfusion is associated with longer icu stay and % increased risk of death. rudiger a , fischler m , harpes p , gasser s , hornemann t , von eckardstein a , maggiorini m wolfson institute of biomedical research, university college london, london, united kingdom, medical icu, university hospital, department of biostatistics, university, zurich, medicine, regional hospital, zofingen, clinical chemistry, university hospital, zurich, switzerland introduction. b-type natriuretic peptide (bnp) and its n-terminal portion (nt-probnp) may be useful in the assessment of cardiac preload in patients with chronic heart failure. however, it remains controversial whether or not this option is still valid in critically ill patients. to resolve this question we sought to establish the relationship between natriuretic peptide levels and surrogates of cardiac preload and inflammation in this kind of population.methods. this retrospective study included critically ill patients with heart failure and/or refractory shock, all monitored with a pulmonary artery catheter (pac). linear correlations between hemodynamic and laboratory parameters were performed using relative differences and described by the pearson correlation coefficient (r). a mixed linear model for repeated measurement was used to control for repeated effects. the analysis included measurements from patients with heart failure (n= ) and septic shock (n= ). mean (sd) age was ( ) years, and % were men. icu-and hospital mortalities of the population were % and %. bnp and nt-probnp correlated (p< . ) well with c-reactive protein (r= . and r= . ), to a lesser extent with leukocyte count (r= . and r= . ) and central venous pressure (r= . and r= . ), but not (p> . ) with the pulmonary artery occlusion pressure (r= . and r= . ). these relationships were confirmed in mixed linear model analyses for repeated measurements. supported by other clinical observations and evidence from laboratory studies, our results suggest that inflammation is a important stimulus for bnp and nt-probnp elevations in humans. natriuretic peptide levels may therefore not be used as surrogates of cardiac preload in critically ill patients with heart failure or shock. animal studies suggest that melatonin plays an adjunctive role in defence mechanisms to overcome severe illness and, accordingly, melatonin seem to affect morbidity and mortality.we report on correlations between nocturnal melatonin serum levels and measures of illness severity in patients consecutively admitted to a medical intensive care unit. on the day of admittance at : h am blood for the determination of serum melatonin levels was obtained and illness severity was assessed according to the acute physiology and chronic health evaluation score (apache) and the therapeutic intervention scoring system (tiss). for the entire study group there was a weak negative correlation between tiss and nocturnal melatonin concentration (r = - . , p< . ) while such correlation was not observed for melatonin and apache. subgroup analysis revealed that in patients with sepsis both apache and tiss scores correlated negatively with nocturnal melatonin concentrations (n = , apache: r = - . , p< . ; tiss: r = - . , p< . ). such correlation did not occur in other disease entities like coronary syndromes or intoxications. our study indicates that melatonin is specifically affected by serious infectious disease and low melatonin levels may contribute to the adverse outcome of sepsis. baykara n , aydemir e , solak m , toker k anesthesiology and reanimation, university of kocaeli, school of medicine, kocaeli, turkey the purpose of the present study to assess changes in antidiuretic hormone (adh), growth hormone(gh) levels and hemodynamic response during a standart weaning protocol in patients with copd. this study was carried out in patients undergoing ventilatory treatment with synchronized intermittent mandatory ventilation (simv)+peep for respiratory failure due to copd. their durations of mechanical ventilation (mv) were between - days. exclusion criteria were:abnormal left or right ventricular function,abnormal liver or renal function,diabetes mellitus,cns disease or mv exceeding one week. weaning was carried out in stages of min each, from / of the initial rate of simv (simv / ) +peep, to continuous positive airway pressure (cpap), to spontaneous breathing. systolic blood pressure, diastolic blood pressure,heart rate,central venous pressure,pulmonary capillary wedge pressure,cardiac output,hourly urine output,plasma osmolality and adh, gh were measured during at each ventilatory condition. hemodynamic parameters did not change significantly among the ventilatory conditions. adh concentrations during simv+ peep and simv i / +peep were similar and were significantly higher than during spontaneous breathing. adh concentration during cpap was not significantly different from spontaneous breathing. even though statisticallyinsignificant,hourly urine output was higher during cpap and spontaneus breathing than during simv+peep and simv / +peep modes. gh level did not change significantly among ventilatory conditions. accordingly, weaning appears to be well tolerated from a hemodynamic standpoint in copd patients with normal cardiac function after short term mv. cpap is the ventilator mode causing the least adh secretion in patients with copd. jukes a l , saayman a g critical care directorate, university hospital of wales, cardiff, united kingdom enteral feeding is the preferred method of nutritional support in the critically ill patient (jolliett et.al., ) . the enteral feeding protocol within our unit advocates prompt replacement of wide-bore tubes with fine-bore feeding tubes once enteral tube feeding is established to maximise patient comfort and safety. the aim of this review was to compare the current fine-bore feeding tube used within the critical care directorate (ccd), medicina (entrafeed, fg or eng) with that manufactured by merck, (corflo, fg or cng). it was hypothesised that as a result of the specific features of the cng tube, it would be easier to aspirate; reduce the incidence of occlusions; and have increased radio opacity when compared with the eng.methods. an audit proforma was completed for patients who had a fine-bore feeding tube placed within the ccd: (eng); (cng) placed. the patients were followed until feeding was stopped due to a complication, or no longer required. chest x-rays were reviewed by a consultant at the end of the study, unaware of ng type. all nasogastric feeding tubes were placed by medical staff. very few measured the tube length required to insert prior to placement. auscultation, was used in % of tubes placed. aspiration of gastric contents was attempted in % of tubes but only obtained in ( %)tubes ( eng, cng). only of these had a ph of or less, confirming gastric placement. all patients received a chest x-ray, visibility comparable ( eng and cng clearly visible on x-ray). there were occlusions ( eng, cng). many tubes were accidentally displaced or pulled out by patients ( eng, cng). the majority of tubes ( %) remained insitu for days or less ( eng, cng). the results of the review did not warrant a change in the type of nasogastric feeding tube used within the ccd. it has highlighted that education and training of doctors is required within the ccd regarding the placement, and appropriate methods used to confirm correct ng position. radiological confirmation of ng tube position is advised on initial placement in critically ill patients. however, attempts should be made to aspiration and ph test to assist subsequent confirmation, avoiding unnecessary x-rays. administration of lipid solutions to critically ill patients may be associated with changes in laboratory and gas exchange parameters. lipid solution composure may impact in these changes. methods. investigate gas exchange and hemodynamic changes in patients with ards treated with a lipid solution enriched with w- fat acids. prospective, randomise, double blind study of parallel groups. sixteen patients with ards within hours of diagnosis were randomised in two groups. group a (n= ) received lipid solution lipoplus® % b.braun medical ( % mct, % lct, % w- ) and group b (n= ) intralipid® % ( % lct). lipid solution was given over hour at . mg/kg/h. hemodymanic and gas exchange parameters were analysed before treatment and at and h of lipid solution infusion. statistics: bmdp, wilcoxon and sign tests. the following table shows the percentage of change after lipid solution infusions compared with baseline levels. no side effects were observed with both lipid solutions in the patients studied. immunonutrition is a balanced nutritional support containing immune enhancing substances like arginine and omega- -fatty acids. the aim of this study is to find out if immunonutrition can reduce the number of blood transfusions and blood loss in cardiac patients. in this prospective and double-blind study we randomised patients who either received immunonutrition or an isocaloric placebo. comparison of the group was done with repeatedmeasures anova. we could not find a difference concerning postoperative blood loss and blood transfusions. ± ± (mean ± sd) number of blood transfusions , ± , ± , per patient (mean ± sd) infection rate (%) length of stay (hospital) ± ± (median ± sd) conclusion. we could not prove a significant advantage of immunonutrition as reported in the literature. ( ) . the objective was to apply rifle in the postoperative cardiac population and to analyze outcome, length of icu stay (los) and mortality for each subgroup. we stratified patients according to their preoperative plasmatic creatinine (ppc in mg/dl). theoretic plasmatic creatinine is obtained according to simplified formula mdrd (modification of diet in renal disease) ( ) . the expected mortality was calculated using logistic euroscore (european system for cardiac operative risk evaluation) ( ). we evaluated patients: with ppc < ; with ppc < ' ; and patients were classified according to "r" (ppc ' - ), "i" (ppc - ), "f" (> without renal replacement therapy (rrt)), "fo" (oliguria treated by rrt). "fo" subgroup suffered major complications than non-oliguria subgroups (p< ' ). conclusion. . mortality was equal in "i" and "f" patients, but higher than "r" group (p < ' ) and lower than "fo" (p < ' ). . los was similar in "rif". . "fo" los was longer than "rif" los. . "fo" group suffered more severe complications and developed acute renal failure as a part of multi-organ dysfunction syndrome (mods), which needed multiple organ support therapy (most). standard hemofiltration is reported to improve hemodynamics and survival in animal models of septic or endotoxic shock. in humans, despite the lack of convincing data, hemofiltration is thought to be the gold standard to treat acute renal failure (arf) in case of septic shock. we compared survival of septic arf treated with ihd or continuous veno-venous hemodiafiltration (cvvhdf) in the prospective randomised hemodiafe study. we performed post-hoc analysis of data from a prospective, multicenter ( centers) randomised study. patients with arf (urea > mmol/l or serum creatinine > micromol/l or oliguria) associated with mods (lod > ) and needing renal replacement therapy were enrolled. they were randomised to receive ihd or cvvhdf performed with the same membrane (polyacrylonitrile, an ) and a bicarbonate based buffer. guidelines to improve hemodynamic tolerance and efficiency were provided. primary endpoint was -day survival evaluated in an intention-to-treat analysis. septic arf was defined if any sepsis was diagnosed before the occurrence of arf. data are presented as mean±sem among the patients enrolled in hemodiafe, the overall septic population consisted of pts ( ± y.o., m /f , saps ii ± , lod score . ± . ) randomised in the ihd (n= ) or in the cvvhdf group (n= ). eighty-nine percent of patients had septic shock and % were under mechanical ventilation. mean serum urea and mean serum creatinine were respectively . ± mmol/l and ± micromol/l just before the first session. the -day survival in the whole population of the study was % with no significant difference between the two groups (respectively , % and , % in cvvhdf and ihd). survival was significantly lower in septic patients compared to non septic ( , % versus , % p = , ). in septic patients, we found no significant difference in survival between the two treatment groups (respectively , % versus , % in cvvhdf and ihd p = , ). standard cvvhdf does not offer any survival benefit compared to ihd to treat septic arf associated with mods. methods for evaluation of glomerular filtration rate -gfr-( -hours creatinine clearance - hcrcl-or cockcroft-gault formula -cg-) are not well suited for critically ill patients: hcrcl requires a steady state and cg has not been completely validated. shorter time crcl can be used but this method has not been evaluated in unstable patients. we intend to demonstrate that hours crcl ( hcrcl) is similar to hcrcl even in unstable patients prospective study on adult icu patients. we calculate hcrcl, hcrcl and cg estimate. hcrcl was measured at the beginning of the hcrcl interval. age, sex, weight and diagnosis were recorded and for the hours period registered sofa, nutrition, diuretics, nephrotoxics, hypotension or hypoxemia, use of vasopressors and regularity of urine flow. we defined groups: patients recently admitted (less than hours) and in stable condition and expected stable renal function. statistical analysis: paired t-test, pearson correlation coefficient and partial correlation coefficients results. patients, ( . %) on admission and ( . %) in stable condition. in cases ( . %) hcrcl was lost and in ( . %) hcrcl because methodological problems. patients completed the protocol ( stable and on admission) and were included for analysis. no differences were detected in both groups. mean hcrcl was . ± . and hcrcl . ± . ml/min with a mean difference of . ± . (p . ). hcrcl correlated well with hcrcl (coefficient . , p< . ) and less well with cg formula (coefficient . , p< . ). these coefficients were not affected by group of patient, antecedents, sex, age, sofa score, and use of diuretics, nutrition or nephrotoxic drugs, hypotensive episodes, hypoxemia, use of vasopressors and irregular urine flow. we observed less aggregation for values in the high range of clearance; analysing only patients with crcl below (n= ) the correlation was even higher ( . , p< . )conclusion. hclcr correlates well with hcrcl, is easier to obtain, is most reproducible and eliminates unnecessary delays and methodological problems complicating hcrcl. hcrcl can be a good estimate of gfr in icu, even in unstable patients key: cord- -bbae nam authors: gougelet, robert m. title: disaster mitigation date: - - journal: disaster medicine doi: . /b - - - - . - sha: doc_id: cord_uid: bbae nam nan c h a p t e r the definition of mitigation includes a wide variety of measures taken before an event occurs that will prevent illness, injury, and death and limit the loss of property. mitigation planning commonly includes the following areas: • the ability to maintain function • building design • locating buildings outside of hazard zones (e.g., flood plains) • essential building utilities • protection of building contents • insurance • public education • surveillance • warning • evacuation it is of critical importance that emergency planners incorporate the basic elements of mitigation and have the authority and resources to incorporate these changes into their organization/facility/community. emergency planners should have a basic idea of the concepts of mitigation through their use in natural disasters over the years. the recent federally mandated transition to the all-hazards approach in disaster emergency response has also given a new perspective on mitigation. although it is not necessary to redefine mitigation, it is essential to understand how the scope and complexity of mitigation and risk reduction strategies have evolved as the united states adapts to new threats. for example, what measures can be taken in advance to protect the population and infrastructure from an earthquake, flood, ice storm, or terrorist attack? as with each mass casualty event, the answers to this question are location-specific and heavily dependent on the circumstances surrounding the event. however, a common understanding of the goals and concepts of mitigation along with knowledge of its policy history and current practices will help a community develop mitigation plans that are both locally effective and economically sustainable. this chapter illustrates how mitigation strategies have evolved, outlines key historical elements of u.s. mitigation policy, highlights critical current mitigation practices, and describes common pitfalls that can hamper mitigation efforts. the realm of mitigation planning is far reaching and complex, and, therefore, the emphasis of this chapter is on the continuity of medical care during a mass casualty event within a community. in the simplest of terms, mitigation means to lessen the possibility that a mass casualty event can cause harm to people or property. however, this simple definition covers a broad range of possible activities. for example, an effort to ensure that essential utilities, such as electricity and phone service, continue to be available throughout a natural disaster is very different from efforts to minimize the economic damage of postdisaster recovery from a major flood or attempts to educate the public on how to reduce their risk of exposure during a dirtybomb incident. mitigation strategies can range from focusing exclusively on "hardening" to focusing more on resiliency. hardening of targets is best described as measures that are taken to physically protect a facility, such as bolting down equipment, securing power and communications lines, installing backup generators, placing blast walls, or physically locking down and securing a facility. mitigation through hardening has only limited use in systems or facilities such as hospitals where open access to the surrounding community is the hallmark of their operations. in these circumstances, a resilient system capable of flexing to accommodate damage and the ability to maintain or even expand current operations will make that system ultimately more secure. mitigation through resiliency also has limitations. in many cases, hardening structures is most appropriate, particularly when many citizens may be quickly affected without prior notice or warning. this may include hardening structures in earthquake zones, physically protecting and monitoring the food chain and drinking water systems, and physically securing and protecting nuclear power plants. in these cases, resiliency may come too late to prevent illness and death in large numbers of patients, and planners should target hardening to whatever degree is practically and financially feasible. the threats of nuclear, radiological, chemical, and biological attacks present new challenges for emergency planners. the potentially covert nature of the attack, the wide variety of possible agents (including contagious agents), and soft civilian targets make planning efforts exponentially more difficult than in the past. this complexity has also eroded the distinction between mitigation and response activities. although it is never possible to mitigate or to plan responses for all contingencies, we do know, however, that there is a basic common response framework. this framework includes coordination, communication to enable inter-agency information sharing, and flexibility to rapidly adapt emergency plans to different sitvations. traditionally, mitigation in the united states has focused on natural disasters; however, early mitigation planning against manmade disasters included civilian fallout shelters and the evacuation of target cities if a nuclear attack was eminent. the federal emergency management agency (fema) states : mitigation is the cornerstone of emergency management. it's the ongoing effort to lessen the impact disasters have on people's lives and property through damage prevention and flood insurance. through measures such as; zoning restrictions to prevent building in hazard zones (e.g. flood plains, earthquake fault lines), engineering buildings and infrastructures to withstand earthquakes: and creating and enforcing effective building codes to protect property from floods, hurricanes and other natural hazards, the impact on lives and communities is lessened. mitigation begins with local communities assessing their risks from recurring problems and making a plan for creating solutions to these problems and reducing the vulnerability of their citizens and property to risk. however, since the mid- s, mitigation planning has become increasingly more complex. terrorist attacks, industrial accidents, and new or reemerging infectious diseases are just a few of the threats that have started to consume more planning time and resources. the growing scope of threats that must be addressed in mitigation strategies challenges all aspects of planning and response at all levels of government. [ ] [ ] [ ] the importance of sharing intelligence information at the earliest possible stage of a terrorist attack, especially a bioterrorism event, is now recognized in national policy as a critical mitigation asset. theoretically, if there were the slightest indication of a contagious biological attack occurring within the united states, then early recognition triggered by intelligence alerts followed by appropriate local responses could allow for isolation, treatment, and containment of a potentially widespread event. this intelligence sharing must become a large part of mitigation efforts aimed at limiting the effectiveness of manmade disasters. a similar analogy can be made with the early warning given to the medical community when a surveillance system picks up an unusual cluster of illnesses, long before the initial diagnosis may be made at a physician's office or healthcare facility. the new national incident management system (nims) states that intelligence must be shared within the incident management structure and states that a sixth functional area, or incident command system section, covering intelligence functions may be established during the time of an emergency. the elevated status of intelligence within nims establishes the importance of early and effective intelligence sharing. the challenge is to establish these sharing relationships before the disaster by incorporating them into an ongoing hazard monitoring process and by integrating them into drills, exercises, and day-to-day activities to ensure that this critical resource is operational when needed to mitigate the consequences of a disaster. the disaster mitigation act of (dma- ) elevated the importance of mitigation planning within communities by authorizing the funding of certain mitigation programs and by involving the office of the president. under dma- , the president may authorize funds to communities or states that have identified natural disasters within their borders and have demonstrated public-private natural disaster mitigation partnerships. dma- provides economic incentives through promoting awareness and education to prioritize the following objectives for federal assistance to states, local communities, and indian tribes: • forming effective community-based partnerships for hazard mitigation purposes • implementing effective hazard mitigation measures that reduce the potential damage from natural disasters • ensuring continued functionality of critical services • leveraging additional nonfederal resources in meeting natural disaster resistance goals • making commitments to long-term hazard mitigation efforts to be applied to new and existing structures this important legislation sought to identify and assess the risks to states and local governments (including indian tribes) from natural disasters. the funding would be used to implement adequate measures to reduce losses from natural disasters and to ensure that the critical services and facilities of communities would continue to function after a natural disaster. further evidence of the expanding complexity of mitigation efforts can be found in the terrorism insurance risk act of . this act fills a gap within the insurance industry, which typically does not provide insurance coverage for large-scale terrorist events. the federal government, in the wake of the sept. , , attacks, promptly passed this act, addressing concerns about the potential widespread impact on the economy. the act provides a transparent shared public-private program that compensates insured losses as a result of acts of terrorism. the purpose is to "protect consumers by addressing market disruptions and ensure the continued widespread availability and affordability of property and casualty insurance for terrorism risk; and to allow for a transitional period for the private markets to stabilize, resume pricing of such insurance, and build capacity to absorb any future losses, while preserving state insurance regulation and consumer protections." , effective mitigation planning now is expected to include many different aspects of private industry. private industry is a critical partner; its involvement may range from being a potential risk to the community, such as a chemical plant, to providing assistance in responding to an event. this is especially true in the area of healthcare; most healthcare in the united states is provided by the private sector. it is important to note that the national fire protection association (nfpa) recently released nfpa ,standard on disaster/emergency management and business continuity programs, edition. this standard establishes a common set of criteria for disaster management, emergency management, and business continuity. planners may use these criteria to assess or develop programs or to respond to and recover from a disaster. although mitigation planning has become an essential feature of nearly every industry and institution in the wake of sept. , , healthcare settings are disproportionately affected by new challenges and complexities in mitigation. the severe acute respiratory syndrome (sars) outbreak shook the foundation of mitigation and prevention in healthcare when healthcare workers and first responders in china and canada died in after caring for patients with the sars virus. access to several toronto area hospitals was significantly limited for several months because of illness, quarantined staff, and concerns about contamination. the economic costs to the city of toronto were in the billions of dollars. hospitals and their communities were thrown into a complex mitigation and prevention crisis. the association of state and health officials (astho) has come out with specific guidelines and checklists to help prepare states and communities prepare for a possible outbreak. pan-influenza planning closely parallels sars planning, with considerable effort toward preventive vaccination of the population and emphasis on protecting healthcare workers. effective strategies were learned during the toronto sars outbreak, although it was definitely a "learn-as-you-go-along" situation. the most effective mitigation strategies to prepare for the consequences of an outbreak would be to plan for the home quarantine of patients, establish public information strategies to reduce public concern, to close affected facilities until the knowledge base permitted their safe reopening, plan for a coordinated information and command and control center, and have preestablished protocols and procedures in place to protect the health of healthcare workers and first responders. vaccination is an essential component of hospital and community mitigation planning. during the fall of , the u.s. government requested that all states prepare for a smallpox attack. the preparations called for each state to present a plan within days to vaccinate all persons within the state, starting with healthcare workers. each facility and community needs to look at the risk of a disease, the effect of vaccination on healthcare workers, and the ability to maintain continuity of care. if properly informed, healthcare workers could respond and treat patients without risk to themselves or their families. the availability of a vaccination and the ability to mass vaccinate the majority of the population should be considered in all community response plans. the plans for both sars and paninfluenza now need to address the availability and possible stockpiling of antiviral agents as well as procedures for mass vaccination of the population, if a vaccine were to become available. we have learned much from the many earthquakes, tornadoes, hurricanes, fires, and floods that the united states has experienced, but it is extremely difficult to plan for terrorist and natural events that can quickly overwhelm communities, states, or even the whole nation. these historical events, policy developments, and shifts in public attention have created a very complex planning and operating environment. the next section of this chapter addresses some of the key current practices that mitigation strategists should consider. current mitigation strategies are as varied as the circumstances in which they are formed. this section illustrates the impact of mitigation through a comparison of responses to two earthquakes that were broadly separated in geography and community preparedness. these examples are followed by a discussion of critical elements of mitigation and risk reduction practice in three broad categories: coordination with other organizations and jurisdictions, hospital concerns, and mitigation strategies based in community health promotion and surveillance. the first step for protecting communities and their critical facilities against earthquakes is a comprehensive risk assessment based on current seismic hazard mapping. this determination of location should also include the assessment of underlying soil conditions, the potential for landslide, and other potential hazards. communities located on seismic fault lines must also develop and enforce strict building codes. after the bam, iran, earthquake, a large section of the city, at first glance, looked like a burned forest with only the bare trees left standing. it soon became clear that these were steel vertical beams standing upright in mounds of concrete rubble. in comparison, after the northridge, calif., earthquake many of the buildings were structurally compromised but did not collapse on their occupants. undoubtedly, this was the result of the strict building codes and enforcement throughout the state of california. to the victims of the bam earthquake, the most important lifesaving measures may have been the development and enforcement of strict building codes. building codes are minimum standards that protect people from injury and loss of life from structural collapse. they do not ensure that normal community functioning might continue after a significant event. structural protection of facilities requires the active role of qualified and experienced structural engineers during planning, construction, remodeling, and retrofitting. the immediate response of a structural engineer after a disaster is to assess building damage and to assist in determining the need for evacuation and the measures needed to ensure continuity of function. extensive analysis of seismic data taken during an earthquake that are compared with subsequent building damage has given structural engineers valuable information on structural failures of buildings. this information allows communities to rebuild with better and stronger facilities. the following measures to protect the structural integrity of a facility should be in place before an incident : • a contract with a structural engineering firm to participate in planning, construction, retrofitting, and remodeling • a contractual agreement guaranteeing the response, after an event, of a structural engineer (with appropriate redundancy) to ensure structural stability, to assess the need for evacuation, and to take additional measures to ensure the continuity of essential functions • inventory and classify all buildings • conduct a vulnerability assessment • ensure code compliance • determine public safety risks • determine structural reinforcement needs, and prioritize them • prepare lists of vulnerable structures for use in evacuation and damage assessment extensive resources and technical assistance for structural earthquake protection are available on the internet. fema's web site itemizes these resources into three major categories: earthquake engineering research centers and national earthquake hazards reduction program-funded centers, earthquake engineering and architectural organizations, and codes and standards organizations. fema has released the risk management series publications, which provide very specific guidance to architects and engineers about protecting buildings against terrorist attacks. the institute for business and home safety is also an excellent source of incident-specific information for both businesses and homes. the protection of facilities from earthquake damage also involves protecting the facility's nonstructural elements. these nonstructural elements do not comprise the fundamental structure of the building (box - ). primary damage to nonstructural elements may be the result of overturning, swaying, sliding, falling, deforming, and internal vibration of sensitive instruments. relatively simple measures, which do not require a structural engineer, may be taken to prevent damage to or from nonstructural elements. these measures may include fastening loose items and structures, anchoring top-heavy items, tethering large equipment, or using spring mounts. other elements, such as stabilizing a generator from vibration damage by placing it on spring mounts or from sliding damage by having slack in attached fuel and power lines, may require the assistance of an engineer. hospitals and other medical care facilities are especially vulnerable to damage from nonstructural elements. consider the placement of routine medical care items such as intravenous poles, monitors/defibrillators, and pharmaceutical agents and medical supplies on shelves. loss of emergency power to key services, such as computed tomography scanners, laboratory equipment, and dialysis units, may also significantly affect the continuity of medical care (e. aur der heide, personal communication, february ). loss of generator power may be due to failure of crossover switches, loss of cooling, or loss of connection of power and fuels lines. a process for the continual review of the power needs of new and critical equipment should be a part of a hospital's emergency planning process. cooperating with the federal government and understanding the resources, structure, and timeframe in which the federal resources are available are critical to appropriate mitigation planning. nims and the national response plan are described elsewhere in this book. each document describes in detail the organizational structure and response authority of the federal government in the time of a disaster. , healthcare organizations, communities, and states are mandated to ensure that their strategies for mitigation, response, and recovery are developed in coordination with these national models. presidential decision directive homeland security presidential directive (hspd) # mandates that by fiscal year ,"the secretary shall develop standards and guidelines for determining whether a state or local entity has adopted the nims, " and all mitigation and risk reductions strategies should be designed accordingly. in addition to efforts to coordinate with federal plans, mitigation strategists must also build functional partnerships within communities and across jurisdictional lines. this point has been emphasized in several recently published planning guides. , [ ] [ ] [ ] these guides help hospitals and their communities plan for mass casualty events by incorporating key features of planning, risk assessment, exercises, communications, and command and control issues into functional and operational programs. hospitals also present special challenges. presidential decision directive hspd # specifies that hospitals qualify as first responders. as such, they have important mitigation activities to consider. what does mitigation mean for a hospital? in the current threat environment, it means minimizing the impact of an event on the institution and ensuring continuity of care. accessibility to the public -hours a day, seven days a week has been a hallmark of hospital emergency care. however, one of the most important mitigation strategies a hospital can adopt is the ability to limit and control access to patients and families during the time of a mass casualty or a hazardous materials event. additionally, facilities must have plans and the ability to decontaminate patients, protect essential staff and their families, handle a surge of patients with complimentary plans for the forward movement of patients to surrounding areas, set up alternative treatment facilities within the community, to train staff in early recognition and treatment of illness or injury related to weapons of mass destruction, and ensure continuity of care and financial stability during and after an event. although hospitals will always form the cornerstone for medical treatment of patients during mass casualty events, best practices for hospitals must now also incorporate healthcare resources within the community. hospitals will have to work with other first responders within the community to conduct drills and exercises that realistically test the whole hospital's ability to respond to a mass casualty event. hospitals also will have to ensure that staff members have the proper training to complete hazard vulnerability assessments and to set up and staff outpatient treatment facilities to ensure continuity of care. , even with very careful planning, most communities will be overwhelmed for the first minutes to hours or possibly days after a massive event, until an effective and prolonged response can occur. communities must also look at the continuity of medical care as a communitywide issue and not just emphasize the hospital or emergency medical services aspects of medical care. the loss of community-based clinics, private medical offices, nursing homes, dialysis units, pharmacies, and visiting nurse services can significantly increase the number of patients seeking care at hospitals during a mass casualty event. risk communication and education, specifically aimed at protecting the affected population, can help prevent surges of medical patients. hospitals now have enormous community responsibilities in terms of preparing for and mitigating mass casualty events. hospitals in hurricane, flood, earthquake, and tornado zones have prepared for many years against these threats. however, a pattern of repeated systems failures within hospitals continues and includes communications and power loss, with additional physical damage to the facility. to prevent such failures, hospitals need to recognize that mitigation and risk reduction planning must approach the level of detail and logistical support that parallels military planning. surveillance is another key mitigation strategy for health emergencies. early recognition of sentinel cases in biological events can significantly affect the outcome, particularly in contagious events. states are funded and required to participate in the surveillance programs mandated in cdc and health resources and services administration guidelines. , the earlier an event is recognized, especially if it involves a contagious disease, the earlier treatment can begin and preventive measures can be taken to prevent the spread of illness to healthcare workers and responders, as well as the rest of the community. public health departments are critical to establishing relationships between local providers and their communities. local, state, and federal public health agencies must ensure that effective surveillance at the community level occurs. these agencies can also assist in awareness-level and personal protection training for hospital staff, emergency medical service employees, and law enforcement first responders. motivating healthcare facilities to take part in mitigation is one of the largest challenges in disaster medicine. it is always best to take measures beforehand to minimize property damage and prevent injury and death. in the case of hospitals, some preliminary research indicates that four factors affect an institution's motivation to mitigate: influence of legislation and regulation, economic considerations, the role of "champions" within the institution, and the impact of disasters and imminent threats on agenda-setting and policy making. it was discovered during this research that "mitigation measures were found to be most common when proactive mitigation measures were mandated by regulatory agencies and legislation." tax incentives, government assistance grants, and building code and insurance requirements may also serve to motivate administrators and decision makers to put the necessary time and effort into mitigation planning. extensive mitigation activities are a necessary prerequisite for the response and recovery activities that must follow a large-scale mass casualty event. we have never seen the number of casualties in the united states we are preparing for today. we do have the threat of an enemy who will strike within the united states with the purpose of inflicting mass numbers of casualties on the civilian population. we must maintain the perspective that even the smallest chance of such an incredibly devastating event, whether manmade or natural, warrants our full attention. if there is no other motivating factor, the possibly such an event must suffice. principles of hospital disaster planning smallpox response plan and guidelines (version . ) severe acute respiratory syndrome (sars) biological and chemical terrorism: strategic plan for preparedness and response. recommendations of the cdc strategic planning workgroup federal emergency management agency. the disaster mitigation act of terrorism risk insurance act of insuring against terror? nfpa standard on disaster/ emergency management and business continuity programs association of state and territorial health officials and national association of county and city health officials. state and local health official epidemic sars checklist association of state and territorial health officials. preparedness planning for state health officials sars transmission and hospital containment. emerg infect dis federal management emergency agency. mitigation ideas: possible mitigation measures by hazard type, a mitigation planning tool for communities personal observations during deployment: dmat nm#- northridge earthquake community medical disaster planning and evaluation guide: an interrogatory format. am coll emerg physicians data acquisition for earthquake hazard mitigationabstract. presented at: international workshop on earthquake injury epidemiology for mitigation and response governor's office of emergency services. hospital and earthquake preparedness guidelines federal emergency management agency, national earthquake hazards reduction program. publications and resources federal emergency management agency, mitigation division institute for business and home safety technical guidelines for earthquake protection of nonstructural items in communication facilities. bay area regional earthquake preparedness project (barepp) federal emergency management agency, response and recovery. a guide to the disaster declaration process and federal disaster assistance national incident management system homeland security presidential directive/hspd- : management of domestic incidents it takes a community: the army's integrated bioterrorism response model. frontline first responder medical disaster conference. coordination draft: conference report improving local and state agency response to terrorist incidents involving biological weapons homeland security presidential directive/ hspd- : national preparedness joint commission on accreditation of healthcare organizations. health care at the crossroads: strategies for creating and sustaining community-wide emergency preparedness systems revised environment of care standards for the comprehensive accreditation manual of hospitals analyzing your vulnerability to hazards acute care center: a mass casualty care strategy for biological terrorism incidents neighborhood emergency help center pamphlet: a mass casualty care strategy for biological terrorism incidents. available at hospital responses to acute-onset disasters: a review. prehospital disaster med department of health and human services,health resources and services administration. national bioterrorism hospital preparedness program continuation guidance for cooperative agreement on public health preparedness and response for bioterrorism-budget year five disaster mitigation in hospitals: factors influencing decision-making on hazard loss reduction guidelines for vulnerability reduction in the design of new health care facilities principles of disaster mitigation in health facilities protecting new health care facilities from disasters key: cord- -gp urb authors: bonadonna, lucia; briancesco, rossella; coccia, anna maria title: analysis of microorganisms in hospital environments and potential risks date: - - journal: indoor air quality in healthcare facilities doi: . / - - - - _ sha: doc_id: cord_uid: gp urb this report provides information on indoor air quality and on associated potential risks in hospitals. spread and persistence of microbial communities in hospital environments are of huge interest to public health. hospitals are characterized by high infective risk, firstly cause of the compromised immunologic conditions of the patients that make them vulnerable to bacterial, viral, parasitological and fungal opportunistic infections. evidence suggests that microbial agents spread through air, surfaces, aerosol and hands. if surfaces may act as a reservoir for some pathogens, hands are an important transmission route. airborne and aerosolized waterborne microorganisms are taken into consideration, and their presence into the hospital environments is reviewed. the term hospital environment includes hospital buildings and healthcare settings with all indoor components that differentiate them: occupying people (sick people, visitors and hospital staff), indoor air, surfaces, medical equipment, drugs, medical devices, food and wastes (bottero et al. ; capolongo et al. ) . all these components may potentially support survival and growth of biological agents. how microbial communities persist and change in indoor environments is of great concern to public health. in fact, recent studies demonstrated that when humans occupy a space, human being there alters the microbiota of that space (smith et al. ; capolongo et al. b) . within hospitals, people can be exposed to bioaerosols, particles of biological origin suspended in the air, and the potential for contracting a microbial pathogen is high. the human exposure to pathogens may be associated with a wide range of major public health issues, such as infectious diseases, acute toxic effects and allergies. hospital environments are characterized by high infective risk, firstly cause of the compromised immunologic conditions of the patients that make them vulnerable to bacterial, viral, parasitological and fungal opportunistic infections (d'alessandro et al. ) . the potential transmission of biological matter during surgery operations and medical treatments of infected individuals makes hospital environments strongly designated to become easily contaminated with spread of pathogens among patients (baglioni and capolongo ) . furthermore, in the last decades, if the use of antibiotics has been an excellent tool into preventing nosocomial infections, the extensive employ of these drugs has inevitably conducted to the insurgence of antibiotic resistance events. hospital buildings may be considered as dynamic environments affected by several factors that actively contribute to define the infective risk for patients. aspects that have to be considered are represented by the number of occupants (in addition to patients, medical employees and visitors), their effective state of health, hygienic habits and activity occurring at any time in the hospital (capolongo et al. a; astley et al. ) . hygienic conditions of sites and rooms, building materials and equipment, furnishings also influence the microbial community composition (signorelli et al. ). in addition, technological devices such as hydraulic, heating and air-conditioning systems may represent a potential source of bacteria, fungi (moulds), virus and other organisms if not adequately designed and submitted to a planned preventive maintenance. microclimatic conditions and accidental events can support microbial and fungal growth (water infiltration and condensation) causing harmful indoor conditions (buffoli et al. ). outdoor microbial load and seasonal climatic characteristics also affect the microbiological quality of the hospital indoor air. hospital-acquired infections are emerging as important cause of morbidity and mortality in immunocompromised patients and severe underlying illnesses. each year, million patients suffer from hospital-acquired infections and nearly , of them die (klevens et al. ) . data from the world health organization show that on hospitalized patients, - are expected to contract, at least, one healthcare-associated infection (who ). however, the real burden is unknown because of the difficulty to gather reliable data. in fact, the diagnosis of nosocomial infections is complex and based on multiple criteria and not on a single laboratory test. in healthcare facilities, the main sources of infection are the patients and the healthcare employees, although the environment plays also an important role. in fact, environment may act as a reservoir for potential infective microorganisms and may contribute to their dissemination. consequently, bacteria are also common on inanimate surfaces, equipment and indoor air. infected patients spread microorganisms in the hospital sites through the release of expectorate drops, fluids from infected wounds, excrements, urine, blood, other corporeal fluids, but also through clothes and blankets. in addition to pathogenic microorganisms, the patients' endogenous flora could be a consistent source of microbes. microbial spread occurs mostly via large droplets, direct contact with infectious material or through contact with inanimate objects contaminated by infectious material. the direct contact between patients is rare; hands of clinical personnel can spread infective microorganisms and represent the most frequent vehicle of nosocomial infections. thus, hand hygiene is recognized as the primary measure to reduce infections. even healthy people and staff may act as carriers when infected or colonized. pathogens such as staphylococcus aureus, staphylococcus pyogenes, neisseria meningitidis, corynebacterium diphtheriae, hepatitis b virus, cytomegalovirus can be transmitted by symptomless carriers. pathogens and opportunistic pathogens may be present in water distribution systems and in aerosol released by water-cooling systems (e.g. legionella sp., mycobacterium sp.). microbial contamination can also occur in pharmaceuticals during the distribution among patients and in improperly processed food. in addition, hospital wastes not rightly and quickly eliminated can become a harmful contamination source. microorganisms that can be spread by contact include those associated with impetigo, abscess, diarrhoeal diseases, scabies and antibiotic-resistant organisms (methicillin-resistant staphylococcus aureus and vancomycin-resistant enterococci). vectorborne transmission is limited to areas in which insects, arthropods and parasites are widespread. water and aqueous solutions used in healthcare facilities are often associated with the hospital-acquired infections. despite water treatment and chlorination, water entering in the hospital distribution systems may contain low concentrations of various autochthonous microorganisms such as pseudomonas sp., legionella sp., nontuberculous mycobacteria, acinetobacter sp., aeromonas sp., sphingomonas sp., enterobacter sp., aspergillus sp. and amoebae, which may cause clinically important opportunistic infections. remaining embedded in a matrix of extracellular organic polymers combined with nonorganic particles, these microorganisms can induce the development of biofilms in the plumbing system of healthcare facilities, hot water tanks, air-conditioning cooling towers, sinks, shower heads and faucet aerators. in addition to own each group characteristics, the biofilm constitutes a barrier, thus preventing both the complete cleaning of the environment that the total elimination of the microorganisms, with the consequent presence of survivors that, in the same time, can develop resistance to biocides and transmit this resistance, whether genetic, even in microorganisms of other species. some biofilm-forming bacteria such as legionella, klebsiella, pantoea agglomerans, acinetobacter baumannii and enterobacter cloacae can cause hospital infections and are more resistant to disinfectants and antibiotics than their planktonic states. biofilm can act as microbial reservoir that constantly releases viable microbes into the water stream. tap water may then contaminate surfaces, medical devices and instruments as well as endoscopes, dialysis machines, nebulizers, humidifiers and ventilators (exner et al. ) . the routes of transmission of waterborne pathogens include direct contact, ingestion of water, indirect contact and inhalation of bioaerosols. pseudomonas aeruginosa and legionella pneumophila are the most significant waterborne pathogens in healthcare facilities. p. aeruginosa is an environmental common microorganism. it is frequently associated with nosocomial infections, particularly among mechanically ventilated or immunocompromised patients in intensive care units. the major reservoir of p. aeruginosa is considered the patients' endogenous flora, and horizontal transmissions among patients have long been considered the most frequent source of p. aeruginosa infections. other studies have shown patient-to-patient spread via hands of healthcare workers, or via fomites. however, during the last years, the application of molecular typing methods made it possible to identify tap water supplied by intensive care units as a significant source of exogenous p. aeruginosa isolates. a review of prospective studies showed that between . and % of infection/colonization episodes in patients were due to genotypes found in intensive care unit water (trautmann et al. ) . l. pneumophila has been recognized as the first emerging waterborne pathogen transmitted by inhalation. its transmission represents a considerable risk for patients with chronic lung disease and those who undergo general anaesthesia. in hospitals, the immunosuppressive status of patients and other risk factors induce not only a higher risk of infection but also a higher incidence of lethality than in other settings. from to % of notified legionellosis are of healthcare-associated origin (exner et al. ) . in healthcare settings, not only humidifiers, respiratory devices and cooling towers, but also showers and taps are specific reservoirs of legionella (joly and alary ; who ; ansi/ashrae ) . nontuberculous mycobacteria (ntm), even called environmental mycobacteria, are also responsible for healthcare-associated infection by inhalation route and direct contact. the structure of their cellular wall particularly rich of long-chain lipids and the ability to form biofilms contribute to their resistance to chemicals and support their persistence. indeed, ntm are frequently found in water distribution systems and can be aerosolized through showers and taps. a microbiological survey carried out by the authors confirmed ntm presence in the water plumbing of a hospital after the occurrence of some cases of atypical mycobacteriosis in a hospital wards. the ntm load ranged between × and × cfu/l and human pathogenic opportunistic nmt species (m. intracellulare, m. chelonae, m. llatzerense and m. gordonae) were found in addiction to other harmless environmental species (briancesco et al. ) . since the risk resulting from the presence of ntm in water is not controllable by classical water disinfection procedures, filters at the point-of-use are now recommended to be the best option for minimizing the risk. moreover, water distribution systems may be potential indoor reservoirs of moulds such as aspergillus sp., zygomycetes, fusarium sp. and other fungi. showers and taps can be the sources of risk for aerosolization of fungal spores (anaissie et al. ) . moulds are ubiquitous in nature and grow almost anywhere indoors or outdoors. persons can be exposed to mould through skin contact, inhalation or ingestion. because of the ubiquity of mould in the environment, some level of exposure is inevitable. inhalation is usually presumed to be the most important mechanism of exposure to viable (live) or nonviable (dead) fungi, fungal fragments or components. the majority of fungal spores have aerodynamic diameters of - µm, which are in the size range that allow particles to be deposited in the upper and lower respiratory tract. inhalation exposure to a fungal spore requires that the spore be initially aerosolized at the site of growth. in general, persons with impaired host defences suffer the most severe types of fungal infections. airborne hospital microorganisms are apparently harmless to healthy people. nevertheless, they can cause adverse health effects in immunocompromised individuals. the hospital itself and its technological systems can offer detrimental sources to the indoor air quality. air-conditioning systems and aeraulic plants can become contaminated over time and trap various contaminants such as dust and biological organisms. moisture from them can condense within the ducts and support microbial growth. thus in hospitals, special air handling and ventilation are required to prevent airborne transmission (ansi/ashrae ). inadequate ventilation is implicated in the airborne transmission of bacteria (obbard and fang ) . bioaerosol spread through the air cover in a wide size range. droplets are larger than μm and their source is primarily the act of coughing, sneezing or talking. in hospitals, particular medical performances such as suctioning and bronchoscopy spread particles of this size. among droplet-transmitted infections, smallpox, measles, chickenpox, tuberculosis, meningococcal disease, pneumonia caused by mycoplasma, sars and flu are the most relevant. small particles residual from evaporated droplets ( μm or smaller in size) and dust particles containing infectious agents may remain suspended in air for a long time. in this way, microorganisms can be dispersed widely by air currents over a longer distance from the source. the airborne transmission of infections regards only microorganisms spread in large number into the air with low infective dose. key factors influencing the level of airborne microbial burden are the occupant density and dampness depending on the particular location within the hospital. in hospital indoor air quality moulds are frequently recovered, especially during the construction/repair activities. fungal spores have low settling velocities remaining in the air for a long time. the hospitalized weakened patients are more susceptible to infections from naturally occurring mesophilic fungi, and in last decades, high mortality rates have been reported in transplant patients and leukaemia patients (taccone et al. ) . in a survey study that followed the occurrence of numerous post-surgery infections at a transplant centre of a hospital in rome, the levels of bacteria and fungi occurring in air and surface samples from an operating block (operating rooms, intensive care units, surgery recovery rooms and annexes corridors) were assessed. low concentrations of fungi were found in air and surface samples (ranging from to cfu/m and from to cfu/cm , respectively). other than numerous pathogenic opportunistic species were isolated (alternaria infectoria, alternaria tenuissima, epicoccum nigrum, purpureocillum lilacinum, cryptococcus laurentii), many other environmental opportunistic fungi belonging to the genera penicillum, aspergillus, cladosporium, mucor, stemphylium, conidiobolus and trichoderma were found. bacterial densities in bioaerosol ranged from to cfu/m with the highest values characterizing an emergency room. staphylococcus aureus and other opportunistic staphylococcus species were isolated in many areas. several bacterial opportunistic species were also recovered (leclercia adecarboxylata, enterobacter cloacae, bacillus cereus and kokuria varians). in general, a moderate microbial pollution affected the examined surfaces with the exception of a massive bacterial density (> × cfu/cm ) observed on a drug carriage where pseudomonas stutzeri, opportunistic pathogenic bacteria, was isolated as prevalent microbial species (bonadonna et al. ) . although recommendations exist, there is a regulatory lack of a referential standard for microbiological parameters of indoor air quality in healthcare facilities because of the deficiency in the relationship between microbiological survey data and their epidemiological implications. in hospital rooms, the surfaces are frequently contaminated with pathogens able to survive for a long time on room surfaces (beds, sheets, floors, walls and furniture) and medical equipment (de oliveira and damasceno ; capolongo et al. ) . biological agents may be transmitted to the patients by personnel gloves and visitor hands or through dust that, once deposited on the surfaces, may be contaminated and then resuspended by natural convection or conditioning air systems. hospitalization in a room in which the previous patient had been colonized or infected with methicillin-resistant staphylococcus aureus (mrsa), vancomycinresistant enterococci (vre), clostridium difficile, multidrug-resistant acinetobacter, multidrug-resistant pseudomonas or yeasts as candida auris can represent an additional risk factor for the next patient admitted to the room. the most relevant nosocomial pathogens persisting on dry inanimate surfaces and the duration of their persistence are reported in how long do nosocomial pathogens persist on inanimate surfaces? a systematic review by kramer et al. ( ) . gram-negative bacteria persist longer than gram-positive bacteria. moisture improves the persistence for several types of bacteria (e.g. chlamydia trachomatis, listeria monocytogenes, salmonella typhimurium, pseudomonas aeruginosa and escherichia coli) while only staphylococcus aureus persists longer at low dampness. no health-based standards or exposure limits for indoor biological agents exist. differences in season; climatic and meteorological conditions; type, construction, age and use of the building and ventilation systems; and differences in measurement protocols used in the various studies (e.g. viable versus nonviable microorganism sampling, sampler type and analysis) make it difficult to interpret sampling data relative to information from the medical literature (alfonsi et al. ) . these difficulties are exacerbated in hospitals where the patient health status, the activities that take place and the potential spread of pathogenic biological agents increase the level of complexity respect to other indoor environments. moreover, the global burden of healthcare-associated infection is unknown because of the difficulty of gathering reliable diagnostic data. the definition of the role that the environment has on the acquisition of hospital infections is highlighted by the need for multiple strategies to control the dissemination of pathogenic microorganisms and the adoption of prevention measures. because nearly skin flakes containing viable microorganisms are shed daily from normal skin, it is not unexpected that patients-through gowns, bed linen, bedside furniture and other objects close to them-become contaminated with other patient flora. the clarification of the role that surfaces have in the spread of infections could provide support to increase adherence to control measures. improving and intensifying the cleaning routine may reduce the dissemination of pathogens. more attention should be given to the adequacy of the length, the frequency and specific care when cleaning surfaces, because removing dirt helps to reduce biofilms. the spread of pathogens could be prevented by using engineering and environment control strategies. thus, in addiction to cleaning and disinfection standard procedures, the maintenance of appropriate hygienic targets may be obtained by employment of durable antimicrobial materials, such as copper and copper alloys (brasses and bronzes), especially for high-touch surfaces. antimicrobial copper touch surfaces can lower the number of microbes on surfaces, reducing the risk and preventing the transfer of antibiotic resistance between bacterial species (michels et al. ; gião et al. ) . cause of microbial biocide multiresistance issue, in recent years new sanitation procedures, based on the use of probiotic products, have been studied. this technique connoted as biostabilization is based on the principle of competitive microbial exclusion and does not imply a biocidal action. surfaces sanitizing probiotic products containing vegetative and spore forms of bacillus species, in association with good hygienic practices, seem to provide - % reduction of pathogenic agents and more than % reduction of infection events (mazzacane et al. ; caselli et al. ) . in order to avoid infections caused by airborne microorganisms, it is very important to maintain protective barriers that control the microbiological quality of the air. for aerosolized waterborne pathogens, faucets are easily accessible for preventive measures, and the installation of single-use filters on hospital water outlets appears to be an effective concept to reduce water-to-patient transmissions of nosocomial pathogens. infection control programs have been defined by who and the centres for disease control. the improvement of the surveillance systems for hospital infections and the implementation of standard procedures for reduction of microbial spread represent the main commitments (who ; cdc ) . evidence based design and healthcare: an unconventional approach to hospital design pathogenic molds (including aspergillus species) in hospital water distribution systems-a -year prospective study and clinical implication for patients with hematologic malignancies legionellosis: risk management for building water systems ventilation for acceptable indoor air quality operative and design adaptability in healthcare facilities ergonomics in planning and reconstruction workshop la qualità dell'aria indoor: attuale situazione nazionale e comunitaria. l'esperienza del gruppo di studio nazionale sull'inquinamento indoor. istituto superiore di sanità. roma, maggio . atti. roma: istituto superiore di sanità improving sustainability during hospital design and operation: a multidisciplinary evaluation tool nontuberculous mycobacteria: an emerging risk in engineered environmental habitats project, natural lighting and comfort indoor improving sustainability during hospital design and operation: a multidisciplinary evaluation tool improving sustainability during hospital design and operation: a multidisciplinary evaluation tool measuring hygiene and health performance of buildings: a multidimensional approach social sustainability in healthcare facilities: a rating tool for analyzing and improving social aspects in environments of care impact of a probiotic-based cleaning intervention on the microbiota ecosystem of the hospital surfaces: focus on the resistome remodulation guidelines for environmental infection control in health-care facilities. recommendations of cdc and the healthcare infection control practices advisory committee (hicpac) water use and water saving in italian hospitals. a preliminary investigation surfaces of the hospital environment as possible deposits of resistant bacteria: a review prevention and control of health care-associated waterborne infections in health care facilities influence of copper surfaces on biofilm formation by legionella pneumophila in potable water occurrence of nosocomial legionnaires' disease in hospitals with contaminated potable water supply estimating health care-associated infections and deaths in u.s. hospitals how long do nosocomial pathogens persist on inanimate surfaces? a systematic review the sanification of hospital stays: new strategies for the reduction on hais. health management from laboratory research to a clinical trial: copper alloy surfaces kill bacteria and reduce hospital-acquired infections airborne concentrations of bacteria in a hospital environment in singapore italian society of hygiene (siti) recommendations for a healthy, safe and sustainable housing the hospital microbiome project: meeting report for the st hospital microbiome project workshop on sampling design and building science measurements epidemiology of invasive aspergillosis in critically ill patients: clinical presentation, underlying conditions and outcomes on behalf of the aspicu study investigators ecology of pseudomonas aeruginosa in the intensive care unit and the evolving role of water outlets as a reservoir of the organism legionella and the prevention of legionellosis. copenhagen: who report on the burden of endemic health care-associated infection worldwide. copenhagen: who key: cord- -rqlrt ke authors: lloyd-smith, mckenzie title: the covid- pandemic: resilient organisational response to a low-chance, high-impact event date: - - journal: nan doi: . /leader- - sha: doc_id: cord_uid: rqlrt ke the global healthcare sector is currently in the midst of the covid- pandemic, a ‘low-chance, high-impact’ event which will require healthcare systems, and the organisations within them, to maintain organisational resilience in order to respond effectively. however, contrary to the instinctive reaction to tighten control, the quality of response depends on healthcare systems’ capacity to loosen control and, subsequently, enhance improvisation. three factors critical to enhancing an organisation’s capacity for improvisation are highlighted; increasing autonomy, maintaining structure and creating a shared understanding. by drawing on the case of christchurch hospital’s response to a major earthquake, this paper demonstrates the vital role that improvisation can play within a clinical setting, when responding to a low-chance, high-impact event. at the time of writing, the cumulative global number of covid- cases sits at , a growth of over cases in a single day-the second largest yet-with no sign of growth abating soon. rather than routine emergencies, the global healthcare sector is currently dealing with a 'lowchance, high-impact' event. one which creates an urgent threat to social and life-sustaining systems, creates deep uncertainty and requires international governmental intervention. in order to respond effectively, healthcare systems and organisations within them need to 'proactively adapt to and recover from' this pandemic, which falls outside the range of expected disturbances; we call this 'organisational resilience'. however, in low-chance, high-impact events, evidence suggests that plans often fail, communications falter and commandand-control systems do not work as expected. contrary to the natural reaction to tighten control in the face of such events, organisational resilience often depends on the ability of an organisation's leadership to loosen control which, in turn, increases the capacity for improvisation. when responding to routine emergencies, rapid response benefits from hierarchical decision-making and formal coordination with clear lines of authority and command. in emergency medical care, as with firefighting and police response, these organisational features are pre-existing and well used which allows for seamless rapid response to commonly faced situations. however, when low-chance, high-impact events occur, conditions change from routine to novel and represent a fundamental shift to an organisation's environment. in such circumstances, the context in which decisions are being made and action unfolds is often changing, unexpected and unforeseen. thus, response requires flexibility, on-the-spot decision-making and informal coordination. as conditions shift from routine to novel, such as those being experienced within healthcare systems responding to covid- , rigidly clinging onto pre-existing routines and control structures is likely to undermine resilience and backfire with tragic consequences. instead, organisations are required to creatively use existing resources, structures and processes, and enable their recombination to extend the range of alternative solutions to problems arising from the event. rather than attempting to provide a comprehensive review of resilience or improvisation, the focus of this paper is on highlighting the role that improvisation plays within resilience. i start by highlighting key findings regarding an organisation's capacity for improvisation during the handling of low-chance, high-impact events. by drawing on the case of christchurch hospital's response to a major earthquake, i show the vital role that improvisation can play within a clinical setting facing a novel and deeply uncertain situation. i subsequently review three enabling factors for increasing an organisation's capacity for improvisation: increasing autonomy; maintaining structure, and; creating a shared understanding. i conclude with a brief discussion of the risks and challenges associated with improvisation. organisational improvisation: creating order from chaos regardless of how well prepared an organisation is, it can never predict all potentialities, due to the cognitive limitations which stop us from anticipating all possible situations and consequences. it would be impossible to anticipate and prepare for every event in advance and, therefore, unexpected situations will inevitably occur. during such situations, including those induced by low-chance, high-impact events, the optimal deployment of resources is made difficult, if not impossible, as little or no time is available to allow for the conventional sequence of planning, formulating and implementing. organisational improvisation, defined as 'the conception of action as it unfolds, by an organisation and/or its members, drawing on available material, cognitive, affective and social resources', occurs when this conventional sequence is replaced by cognition and action occurring simultaneously. improvisation is a creative act, at the intersection of intuition and spontaneity. individuals who successfully improvise remain creative under pressure by pulling order out of chaotic conditions, so that, when a novel situation occurs which renders translating research and evidence existing operating procedures and control structures inadequate, the improvisor is able to replace traditional order with an improvised one. if resilience is embodied in making do with the resources you have to recover from larger than expected disturbances, which are neither fully controlled nor completely understood, improvisation is the spontaneous and creative act of finding solutions. in contrast, refusing to make decisions in the absence of complete and accurate information, or attempting to optimise resources before deployment will inevitably lead to avoidable failure. this ability to creatively respond within uncertain conditions makes improvisation during a low-chance, high-impact event not only possible, but critically important for a resilient organisational response. take the example of new zealand's christchurch hospital which, on february , was struck by a magnitude . earthquake, causing damage which led to a % loss of total in-patient capacity. the acute medical wards were not structurally damaged but their function was compromised by water leaks and loss of utilities, including communications, water and electricity. ongoing seismic activity meant staff were unable to stand unsupported, yet the acute ward staff maintained their responsibility of providing patient care, while attempting to make the immediate environment safe by identifying and reporting damage. ground tremors continued for days and utilities failed for weeks. in this low-chance, high-impact event, had the clinical team waited for the reinstatement of traditional order, or complete information about the situation-thereby allowing them to follow their standard operating procedurespatients would have received delayed care, potentially resulting in suffering or death. instead, the team abandoned traditional order, rapidly constituted a new situation, and improvised solutions to ensure the safety and uninterrupted care of patients. subsequent to the immediate response, a decision was made to evacuate patients and permanently close the three acute medical wards. within week of the earthquake, a new ward was to be created in a nearby hospital and patients relocated. the hospital to which the acute wards were to be relocated did not have an acute-admitting facility nor emergency department services. this meant that the team faced complex problems while establishing a fully viable acute ward, including a lack of proper infrastructure and the inability to maintain existing operational procedures, while the split of acute services across two hospitals posed additional risk to patient safety by potentially limiting continuity of care and disrupting the existing model of care delivery. to sustain uninterrupted acute care the team adopted creative and critical thinking, developing workarounds to overcome hindrances, and gradually incorporated these workarounds into daily operations. infrastructure was quickly installed, new operational procedures established, policies modified, technology adopted and a new model of care delivery implemented almost immediately. the acute medical team had no training in responding to this type of low-chance, highimpact event, yet rapidly responded to the situation without the benefit of prior planning. the present challenge for clinical leaders in the midst of the covid- pandemic is to loosen control, in order to increase organisational capacity for improvisation. however, this loosening of control is counterintuitive within the healthcare context, in which resilience is traditionally synonymous with enforcing compliance, increasing bureaucratic constraints and reducing procedural deviations. evidence shows, however, that improvisation neither requires nor benefits from anarchical organisation. instead, research reveals that improvisations are already successfully used within clinical settings, especially those characterised by uncertainty, such as trauma units. this paper subsequently introduces three factors which are critical to enhancing an organisation's capacity for improvisation; autonomy, structure and shared understanding. the role played by each factor is analysed within the case of christchurch hospital to understand its importance in responding to a novel and deeply uncertain situation. while tight structuring, hierarchical decision-making and formal coordination are important for rapid organising and efficient functioning in routine conditions, these become increasingly vulnerable as conditions shift from routine to uncertain, often becoming entirely inappropriate in novel conditions. the first phase of a low-chance, high-impact event is inevitably marked by novelty, caused by a lack of information, communication and coordination. in such circumstances, it would be impossible to control every action made at the operational level, such as front-line clinicians, and attempts by leadership to do so would quickly result in a bottleneck in decision-making, slowing down response and impeding both flexibility and local initiative. in addition, those in front-line roles are likely to know more about the current situation than those within more centralised roles, allowing them to take more appropriate action based on immediate needs. the marginalisation of front-line staff during a low-chance, high-impact event leads to an inefficient response and a suboptimal outcome. in contrast, teams and organisations which consistently operate error-free in highly uncertain conditions display the tendency to push decision-making to the frontline, to those with the most expertise and/or specific knowledge about the situation, regardless of rank or seniority. by increasing autonomy and allowing decision rights to migrate, leaders encourage improvisation by enabling front-line staff to act spontaneously, guided by intuition, which increases the likelihood that challenges will be overcome. the migration of authority encourages faster response, and has been shown to be successful in clinical settings. for example, the loma linda university children's hospital, california, operates a paediatric intensive care unit (picu) that has been designed around this principle. due to the complexity and pace of change occurring within a picu setting, the unit accommodates the likely scenario that decisions will have to be made without perfect information. rather than relying on strict protocols and hierarchical decisions regarding patient care, decisions within the picu are migrated down to the staff with the best knowledge of the situation, regardless of rank or seniority. by designing for autonomy, clinical leaders enable flexibility and on-the-spot decision-making by those most informed, allowing front-line staff to deliver patient care more effectively, and earning the hospital consistently high patient care results. in the case of christchurch hospital, had front-line staff waited for instructions from clinical leaders, rather than acting immediately in the initial response to the earthquake, patients would have received delayed care. by acting autonomously, front-line staff relied on expertise, intuition and specific knowledge of their circumstances which generated faster, more informed decisions and thus a more resilient response. the second enabling factor for improvisation is the maintenance of a structure with clear lines of communication and coordination. despite the need for loosened control, improvisation neither requires, nor benefits from, total anarchy. rather translating research and evidence than materialising 'out of thin air', improvisation comes from adjustments to, and recombinations of, already existing resources. continuing to maintain some structure provides a 'common frame' around which adjustments can occur. to ensure autonomy is preserved, this structure may be absent of explicit rules, freeing up individuals to respond as required. but guidelines with a high degree of flexibility support creative adjustments, while helping strike a balance between control and autonomy. further, resilient response to low-chance, highimpact events requires collective behaviour rather than solo acts. maintaining structure supports collective behaviour by enabling coordination via communication. maintaining coordination while increasing autonomy actively enables front-line staff to improvise, by allowing individuals to effectively and continuously integrate their behaviours with others. as a result, an organisation is able to remain stable while becoming exceptionally flexible to the demands of the situation. healthcare systems are in the advantageous position of being able to rely on pre-existing role structures, providing front-line staff with an expectation of how their behaviours will integrate with others. reflecting on christchurch hospital's response to the earthquake, accounts highlight that self-organising behaviour, 'out of the box' thinking and problem-solving occurred between frontline clinical staff attempting to establish a fully viable acute medical ward in less than week. this rapid, autonomous response was underpinned by a coordination meeting between senior clinicians from different departments and the establishment of a hospital control room. members of different medical teams cooperated in a shared decision-making process which acted to coordinate activities based on existing roles, while debrief exercises were used to communicate new protocols and procedures. by melding the existing role structure with autonomy-enhancing processes, christchurch hospital was able to enhance and sustain organisational resilience, enabling their effective response. when tasks are complex and organisations large, such as those within healthcare systems, it is difficult for individuals to be fully aware of the interdependencies of their actions. this is further exacerbated in highly demanding situations, such as low-chance, high-impact events, during which individuals may be unable to maintain holistic awareness of the situation. however, as we have already established, resilient organisational response requires collective behaviour rather than individual acts. therefore, creating a shared understanding of a situation helps teams improvise solutions to problems found within the complex and uncertain conditions produced by such events. traditionally created by plans, rules and familiarity, in novel situations a shared understanding is produced through direct information sharing. the monitoring of activities and frequent updating of progress within groups allows interdependent tasks to be coordinated, while liaising between groups allows for coordination across an organisation. this timely sharing of information, supported by a structure, allows individuals to create and sustain a 'big picture' of the situation at any one moment. while the initial phase of a low-chance, high-impact event is often characterised by failure of communication, the subsequent establishment of a shared understanding of the situation enables front-line operators to remain sensitive to operations, and aware of how their decisions and actions potentially impact others; a vital process in uncertain and rapidly changing conditions. further, by creating a shared understanding of the situation, individuals become aware of how their efforts fit together with others to achieve the desired outcome. in contrast, a lack of shared understanding has been shown to produce less effective responses to such events. in the aftermath of the earthquake, christchurch hospital's communication systems ceased to function due to the main power and backup generators failing. the hospital received little information about the impact of the earthquake, leaving them unable to predict the number of casualties or when they would arrive. however, a shared understanding of the situation was quickly enabled by the provision of communication technologies including radiotelephones and mobile phones to key staff, while direct information sharing occurred via a loudspeaker system which communicated updates. this development of shared understanding was supported by the senior clinician coordination meeting. by creating a shared understanding of the unfolding situation and facilitating communication throughout the response, christchurch hospital's leadership enabled frontline staff to coordinate under novel circumstances, allowing individuals to improvise solutions to problems and understand how their actions and decisions were embedded within a larger operation. when responding to low-chance, high-impact events, organisations are forced to cope with novel situations which are likely to be both unexpected and deeply uncertain. resilience will be necessary for organisations to cope with, and recover from, such disturbances. due to the non-routine nature of such circumstances, existing routines and processes will no longer apply, as unvarying practices cannot handle what they do not anticipate. the rapid response required for handling low-chance, high-impact events forces the conventional sequence of planning, formulating and implementing to be supplanted by the simultaneous occurrence of cognition and action, resulting in organisational improvisation. by replacing traditional order with an improvised one, an organisation increases its chances of recovering from a larger than expected disturbance, which is neither fully controlled nor completely understood. there is, however, variability in both 'the quality of improvisational action and its suitability under various conditions' and, therefore, the potential negative implications of improvisation are worth acknowledging. by adopting improvisation, an organisation is unable to centrally control the use of resources, and therefore deploy them optimally; potentially leading to their inefficient or ineffective use. in addition, improvisations are inherently unpredictable, and one aimed at solving a problem could accidentally escalate it. this can lead to the creation of a 'spiral of complexity' in which an improvisation to overcome one problem creates another unexpected problem, requiring further improvisation and leading to an escalating lack of control. most importantly for a clinical setting, improvisations should only be undertaken, and supported, on the condition that they fit with the organisational goals and are unlikely to cause harm to patients or staff. despite the potential disadvantages of enabling improvisation, the alternative is the maintenance of organisational rigidity. during a low-chance, high-impact event, mandating adherence to inflexible protocols, refusing to make or allow decisions in the absence of complete information, or attempting to optimise resources before deployment, will inevitably lead to avoidable failure. the covid- pandemic can be considered a low-chance, high-impact event. one which has caused urgent threat to life, created global conditions of deep uncertainty, and requires resilient response from healthcare systems and the organisations within them. however, while hierarchical decision-making and tight control is important for efficient functioning in routine conditions, these become inappropriate in the novel conditions currently being faced. therefore, contrary to the instinctive reaction to tighten control, the resilience of healthcare systems depends on the flexibility enabled by loosening control. in these novel circumstances, maintaining existing routines and processes is likely to backfire, as the order they wish to maintain no longer exists. instead, the construction of a new order is required, by creatively utilising existing resources, structures and processes, and enabling their recombination. without the benefit of time, preparation is superseded by improvisation. by increasing autonomy, maintaining structure and creating a shared understanding of the situation, clinical leaders are able to increase their organisation's capacity for improvisation. when these three factors are embraced, as they were within christchurch hospital's response to a major earthquake, an organisation is able to respond rapidly and flexibly to the new environment, remaining resilient despite the challenges. interactive dashboard of global covid- cases designing resilience: preparing for extreme events organizational response to adversity: fusing crisis management and resilience research streams predicting disaster response effectiveness organising for effective emergency management: lessons from research effective emergency management: reconsidering the bureaucratic approach organizational improvisation: what, when, how and why the incident command system: high-reliability organizing for complex and volatile task environments organizing for resilience coordination in fast-response organizations organizational improvisation we have a problem': anticipation and improvisation as sources of organizational resilience ambiguity and choice in organizations the difficulties of improvising in a crisis situation: a case study making sense of improvisation the collapse of sensemaking in organizations: the mann gulch disaster managing the unexpected: sustained performance in a complex world when disaster strikes: sustained resilience performance in an acute clinical setting resilience of the canterbury hospital system to the christchurch earthquake earthquake disaster response in dynamic delegation: shared, hierarchical, and deindividualized leadership in extreme action teams the initial health-system response to the earthquake in christchurch resilient health care: turning patient safety on its head workarounds in nursing practice in acute care: a case of a health care arms race? in: resilient health care introductory essay-improvisation as a mindset for organizational analysis managing the unexpected: resilient performance in an age of uncertainty the institutional context of crisis. a study of the police response during the july terror attacks in norway managing high reliability organizations organizing for high reliability: process of collective mindfulness must accidents happen? lessons from high-reliability organizations university children's hospital receives leapfrog top hospital award minimal structures: from jazz improvisation to product innovation disaster, organizing, and role enactment: a structural approach expecting the unexpected? how swat officers and film crews handle surprises a retrospective observational study of medical incident command and decision-making in the oslo bombing coordination in organizations: an integrative perspective coordinating mechanisms in care provider groups: relational coordination as a mediator and input uncertainty as a moderator of performance effects to the edge and beyond: how fast-response organizations adapt in rapidly changing crisis situations theatrical improvisation: lessons for organizations the author would like to thank amit nigam for motivating competing interests none declared. patient consent for publication not required.provenance and peer review not commissioned; externally peer reviewed.this article is made freely available for use in accordance with bmj's website terms and conditions for the duration of the covid- pandemic or until otherwise determined by bmj. you may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. mckenzie lloyd-smith http:// orcid. org/ - - - key: cord- -twsy oq authors: nan title: siu abstracts date: - - journal: world j urol doi: . /s - - - sha: doc_id: cord_uid: twsy oq nan introduction and objective: th e bladder is generally considered an organ for voiding and storage of urine, with the urothelium serving as an impermeable barrier. recent discovery of aquaporins in the bladder urothelium in rodents and later on also in human challenges this notion of impermeability. upregulation of aquaporins in response to dehydration or bladder outlet obstruction and downregulation following transitional cell carcinoma has been shown. th is emphasize the need to better understand the function and distribution of aquaporins, as well as their role in bladder diseases. th e present study aims at establishing basic knowledge about the expression of aquaporin (aqp ) in the porcine bladder, related to gender and gestational age. th ree pregnant sows at , or days of gestation were sacrifi ced. fetuses were removed and necropsied. th e bladder was rapidly removed and whole wall tissue samples from the bladder dome was snap frozen in liquid nitrogen and stored at - c. genetic gender determination was performed and fetuses with uncertain gender determination were excluded. aquaporin mrna expression was analyzed using qpcr and β-actin was used as the reference housekeeping gene. results were compared using two-way anova. results: a total of samples were analyzed. gestational age was either (n= ), (n= ) or days (n= ). aquaporin was expressed in all samples. aqp mrna expression was increased in the fetal porcine bladder with increasing gestational age (p< . ). however, there was no signifi cant diff erence in aqp mrna expression between genders (p= . ). conclusion: expression of aqp in fetal porcine bladder is demonstrated with increasing expression during gestation. to our knowledge aquaporins in the porcine bladder tissue have not previously been studied. th is exciting new discovery contributes to the ongoing discussion on reviewing the dogma that the lower urinary tract has an impermeable barrier function. improved contractility of the long term bladder outlet obstruction induced bladder underactivity using growth factor expressing mesenchymal stem cells introduction and objective: as the underactive bladder is diffi cult to manage, a new method of increasing bladder contractility in patients with underactive bladder is desired. mesenchymal stem cells (mscs) can serve as vehicles for the gene, proliferate and differentiate into bladder smooth muscle cells to repopulate damaged bladder. th e other is that the exogenous hepatocyte growth factor (hgf) gene can provide complementary functions as angiogenesis and inhibition of fi brosis. th is study was performed to examine the recovery of the decreased bladder contractility in the long term bladder outlet obstruction (boo) models of rats using transplantation of hgf expressing human mscs (hgf-hmscs) into the bladder wall. introduction and objective: suddenly dropping to low environmental temperature, cold stress exacerbates lower urinary tract symptoms (luts) such as urinary frequency and urgency. th is study determined if transient receptor potential ankyrin (trpa ) channels could mediate the cold-stress induced detrusor overactivity in rats. materials and methods: twenty-four female -weeks sprague dawley (sd) rats were used. th is th congress of the sociÉtÉ internationale d'urologie -siu abstract book study used hc (tocris bioscience) as trpa channel antagonist. th ree days prior to cystometric investigations, polyethylene catheters were inserted into the bladder and abdominal cavity. cystometric investigations of the unanesthetized rats were performed at room temperature (rt, ± °c) for min. following, the rats were intraperitoneally injected with vehicle, . -(low dose), or . -(high dose) mg/kg hc (n= , in each). aft er min, the treated rats were exposed to low temperature (lt, ± °c) for min. during the cystometric investigations, the micturition parameters were recorded. introduction and objective: hypoxia-inducible factors (hif , hif and hif ) play a critical role in cellular and systemic responses to hypoxia by inducing a range of diverse genes involved in cell survival, they have also been implicated in development of renal cell carcinoma. we aimed to assess the eff ect of zinc and cobalt on hypoxia-inducible factor expression in immortalized human kidney cells. to cells in mcl). esr at the observed patient aft er the seventh transfusion decreased from initial mm/ hour to mm/hour. aft er the fourth transfusion of mononuclear fraction of peripheral blood at the patient the increase in the content of the total testosterone that allowed to reduce a dose of % of dermal gel of testosterone from . ml per day to . ml per day was observed. aft er the seventh transfusion of mononuclear fraction of peripheral blood because of normalization of production of testosterone the restored number of own leydig's cells an androgen -replacement therapy was cancelled. introduction and objective: ketamine use as a recreational drug is on a rapid increase in young people. many reports have shown that long-term ketamine abuse is liable to lead to lower urinary tract symptoms that resemble interstitial cystitis (ic). ic is a disease characterised by severe and chronic pelvic pain with frequency, urinary urgency, and nocturia in the absence of bacterial infection or other diseases. th is study evaluated the therapeutic eff ect of human umbilical cord blood derived mesenchymal stem cells (ucb-mscs) in a ketamine induced cystitis (kc) rat model. for kc rat models -weekold, female sprague-dawley rats were used. sham treatment (n= ) rats were assigned to the control group. th e rats in the kc group (n= ) and kc+m-scs group (n= ) were intravenously injected with ketamine at a dose of mg/kg for days a week over a duration of weeks. aft er one week, x ucb-mscs were directly injected into the submucosal layer of the anterior wall and dome of the bladder in kc+mscs group. th e cystometric parameters and immunohistochemical results (toluidine-blue, masson trichrome, tunel staining) were measured at one week following the intervention. results: most rats in the kc group exhibited irregular voiding frequency and decreased inter-contraction interval in comparison with the control group ( . ± . vs. . ± . seconds, respectively; p< . ). th e kc+mscs group demonstrated improvement in most voiding parameters to normal levels within week. a single injection of ucb-mscs signifi cantly increased the inter-contraction interval ( . ± . , p< . ) ( figure ). in immunohistochemical analysis, the bladders in kc group were characterized by mast cell infi ltration in toluidine-blue staining, fibrosis in masson trichrome staining and apoptosis in tunel staining which were signifi cantly ameliorated in the bladders in the kc+mscs group ( figure ). conclusion: th e injection of ucb-mscs restored the damaged bladder and associated pathologies including mast cell infi ltration, fi brosis and apoptosis in the kc rat model. stem cell therapy could be valuable treatment option for painful bladder conditions such as ketamine induced interstitial cystitis. mp- . , figure . introduction and objective: currently no markers are available to predict intravesical bacillus calmette-guerin (bcg) response. among the various markers under study survivin has good sensitivity in detecting bladder cancer cases and there has been very limited number of studies regarding survivin as a prognostic marker and predictive marker. prospective evaluation of urinary survivin levels as a potential prognostic and predictive biomarker in non-muscle invasive bladder cancer cases on intravesical bcg therapy was planned in this study. from august to august a total intermediate and high risk group patients of nmibc age ranging from to yrs (mean ) planned for intravesical bcg instillation were enrolled. recurrence and progression score were calculated by using eortc genitourinary scoring system and risk table. patient's urinary samples were taken, pre and post [ (t ), (t ) and weeks (t )], intravesical bcg instillation. urinary survivin expression was studied by elisa technique. results: out of patients, ( . %) had complete remission at months th e mean survivin levels in remission group (group i) was . +/- . which was signifi cantly less than those in recurrence group (group ii) mean . +/- . . pre and post bcg, there was a signifi cant decrease in the urinary survivin levels in group i when compared to group ii where there was a signifi cant rise in pre and post bcg urinary survivin levels (p value< . ). conclusion: low pre bcg urinary survivin level can be used as a useful predictive marker for achieving complete remission in nmibc patients with on intravesical bcg immunotherapy. also pre and post bcg urinary survivin levels act as a useful prognostic marker and can be used as an adjunct to cystoscopy. introduction and objective: th e natural resistance-associated macrophage protein (nramp ) gene modulates macrophage activation in a myriad of infectious and autoimmune diseases. its single nucleotide polymorphisms (snps) have been identifi ed to infl uence susceptibility to tuberculosis and response to bcg therapy in murine models. in this study, we evaluate the predictive role of nramp snps in the oncological outcomes of asian patients receiving intravesical regimes of bcg for nmibc. a total of nmibc patients who underwent post-transurethral resection intravesical regimes of bcg ( mg or mg) or bcg ( mg) with interferon alfa from to and deemed intermediate to high risk by the european organisation for research and treatment of cancer risk tables, were prospectively recruited. from these patients and a group of healthy controls, peripheral blood samples were stored and genomic dna purifi ed. a total of nramp snps were evaluated using high resolution melt analysis. th e corresponding results were verifi ed by dna sequence analysis. kaplan-meier and cox regression methods were used to analyze the data. introduction and objective: microscopic hematuria can indicate presence of underlying urological conditions. aua guidelines recommend evaluation algorithms for microscopic hematuria. population-based studies have focused on risk pools such as heavy smokers and elderly men. we evaluated whether men interested in self-managing their lower urinary tract symptoms (luts) with an over-the-counter (otc) product should be screened for microscopic hematuria to detect undiagnosed signifi cant conditions (including urothelial malignancy) causing hematuria. materials and methods: urine dipstick testing was conducted in men who preferred to self-manage luts using an otc product. urologic assessment was conducted by a urologist to determine conditions causing/contributing to the urinary symptoms for: men < years; and men ≥ years who had traces of glucose, leukocyte, and/or blood in urine; or had an aua symptom index score ≥ . men experiencing complete urinary retention, dysuria, extreme thirst, gross hematuria, or urethral discharge ("do not use" symptoms in this study) were also assessed. men ≥ years of age who did not meet any of these criteria did not undergo urologic assessment. introduction and objective: th is fi rst experience, pilot study, was aimed to evaluate the outcome of en-bloc bladder tumor resection using the plasma-button electrode in cases of papillary non-muscle invasive bladder tumors (nmibt) from the perspectives of surgical safety and effi cacy, perioperative morbidity, histological assessment and short-term oncologic outcome. a total of patients previously diagnosed by abdominal ultrasound, contrast ct and fl exible cystoscopy with papillary bladder tumors over cm in diameter were included in the trial. th e exclusion criteria consisted in solid sessile tumors, lesions located in bladder neck area and tumors involving the ureteral orifi ce. en-bloc tumor resection using the plasma-button approach was applied in all enrolled cases. th e tumor base was subsequently biopsied by standard single-wire loop resection and followed by plasma-button coagulation. th e fi rst follow-up cystoscopy was completed at months. results: all procedures were successfully performed leading to visually complete tumor ablation. th e mean tumor diameter was . cm (range between and cm). no obturator nerve refl ex adverse events or cases of bladder wall perforation were encountered. no signifi cant postoperative hematuria and re-intervention requirements were encountered in this series. th e mean catheterization period was . days (range to . days) and the mean hospital stay was . days (range to days). th e pathological analysis confi rmed the presence of detrusor muscle in the resected biopsy specimens for all enrolled patients, thus enabling for a reliable tumor staging to be established (all nmibt histology diagnosed patients). a single case of other site residual lesion was found during the fi rst evaluation cystoscopy, while no orthotopic recurrences were described. to reduce the overdiagnosis and overtreatment of insignifi cant tumors there is an urgent need for a specifi c test to detect clinically signifi cant prostate cancer (pca). using gene expression profi ling specifi c pca-biomarkers were identifi ed. eight promising biomarkers were selected and the diagnostic accuracy was tested in urine of an intent-to-treat cohort. th e aim of this study was to clinically validate the four-gene biomarker panel (hoxc , dlx , tdrd and hoxc ) using an independent prospective multicenter study cohort. in two independent prospective, multicenter studies (cohort : n= en cohort : n= ) urine was collected aft er digital rectal examination (dre) from men undergoing prostate biopsies based on an elevated serum psa level (≥ . ng/ ml) and/or suspicious dre. klk , hoxc , hoxc , tdrd and dlx mrna levels were measured using rt-qpcr. th e assay was validated according to miqe criteria, hence the test is a standardized laboratory developed test (ldt). results from cohort were used to develop models with (combinations of) the four genes based on the comparative ct method. th e chosen model was validated in cohort , i.e. a fully independent validation cohort. results: pca was identifi ed in % ( / ) and % ( / ) of men from the studies respectively. th e model with the combination of hoxc /dlx resulted in the highest average auc ( . ) and specifi city ( %) at ≈ % sensitivity, based on cohort . furthermore, hoxc and dlx were signifi cant in the logistic regression, in % and % respectively. th is model was independently validated for the diagnosis of pca with gleason score ≥ in prostate biopsies. using roc curve analysis hoxc /dlx outperformed pca in both cohorts (cohort auc= . vs. . ; cohort auc= . vs. . ). adding serum psa to the hoxc /dlx model resulted in an auc of . and . , respectively. th is study showed the promising results of a new urine test for the early diagnosis of clini-cally signifi cant pca using a model which combines hoxc with dlx . th ese results demonstrate that this model could be used to assess the risk of pca with gleason score ≥ and therefore could reduce the amount of unnecessary prostate biopsies. introduction and objective: curcumin contains mul-introduction and objective: a family history of prostate cancer is a well-recognized high risk factor for this disease. various models for an inherited risk for prostate cancer have been described, but to date traditional linkage and association studies have only identifi ed a small number of rare tumor suppressor genes and snps involved in prostate cancer risk and development. we performed whole exome sequencing on multiple participants (n= ) with prostate cancer from families with a signifi cant history of prostate cancer to potentially identify new prostate cancer susceptibility variants. exome variants were fi ltered against a range of parameters with a subset of variants chosen for validation by sanger sequencing and segregation analysis within their respective families. each prostate cancer participant met the following criteria for inclusion if: (i) they had a verifi ed diagnosis of prostate cancer, (ii) there were multiple cases of prostate cancers in the family, iii) pathology, diagnostic and treatment notes were available, and (iv) they were classifi ed as brcax mutation status. results: essential splice site, missense and stop lost variants were fi ltered against a recently published candidate gene list, leaving shared truncating variants and shared missense variants to be genotyped through all prostate aff ected (n= ) and unaff ected male participants (n= ). th ree missense variants demonstrated complete segregation and one missense variant demonstrated partial segregation with the prostate cancers. th ree truncating variants demonstrated complete segregation and three truncation mutations demonstrated partial segregation with prostate cancer. no segregating variants between the three families were shared. conclusion: ten truncating or missense variants showed either complete or partial segregation in our three familial prostate cancer families. of interest, we detected a cyp a and parp variant in our multicase prostate cancer families. th ese two variants have previously been reported to occur in other familial associated prostate cancer families, thereby, potentially adding to the evidence that these two variants may have a role in the risk and development of prostate cancer. another eight novel variants were detected that segregated with disease and warrants further investigation. th congress of the sociÉtÉ internationale d'urologie -siu abstract book were recorded. patients with diabetes, hypertension or known cardiovascular disease were excluded. introduction and objective: traditional methods of prostate cancer diagnosis in males with an elevated or rising psa have relied on outpatient trus biopsy using local anaesthetic and taking between - biopsies. trus biopsy is painful, associated with rectal bleeding in %, uti in % and urosepsis in up to % of patients. it is also has a poor sensitivity (< %) low accuracy rates of < % and a poor specifi city of < %. from we changed to template guided prostatic biopsy (tgpb) carried out transperineally under a general anaesthetic. to date we have carried out tgpb in patients with a positive biopsy rate of % (accuracy of %; and specifi city of %). th e procedure is painless, utis occurred in %, no sepsis and no rectal bleeding. because of the large numbers of biopsies taken % of patients had transient retention. in patients who had a previous -ve trus biopsy % had a subsequent +ve tgbp and patients having tgbp on the fi rst occasion for an elevated psa ( . - ) % had a positive biopsy. results: with the advent of tesla mri and mri fusion technology we have now progressed to mri fusion biopsy using real time ultrasound imaging and fusing the abnormal mri image to perform the biopsy (biojet fusion, global prostate solutions) . th is allows for even greater accuracy of the biopsy without taking large numbers of samples. to date we have achieved a +ve biopsy rate of % with an accuracy of > % (in patients). to date there have been no cases of uti, sepsis or retention. to determine the suitability of circulating tumour cells (ctcs) as prognosticating indicator and biomarker for delivery of precision medicine. patients were recruited and screened (n= ) as a part of admet (androgen deprivation th erapy and adjuvant metformin) trial. five millilitres of whole blood was collected from patients for ctc enrichment, enumeration and propagation. enrichment was performed using cd negative selection kit (rosettesep™). ctcs were identifi ed using immunofl uorescence imaging with antibodies against prostate specifi c antigen, cytokeratin, cd and nucleus. cells were propagated in customized stem cell solution with hypoxic conditions. results: at screening, of patients demonstrated circulating tumour cells with the mean number of (range - , ± ) . in all of the enriched samples, cells could be propagated temporarily with the peak population being reached at . weeks. cells were cultured in both d and d conditions and temporary organoids could be developed from of patients. polymerase chain reaction and immunofl uorescence imaging at weeks aft er culturing demonstrated characteristics consistent with prostate cancer cells. conclusions: circulating tumour cell technology remains a viable option as a means of providing biomarker information and tumour activity indicator in delivering precision medicine. firstly, enumeration can be used to help determine the response to a treatment. secondly, temporary culture and progression into development of organoids may be used to allow for downstream analysis and therapeutic decision. transcriptionally-targeted retroviral replicating vectors: a novel strategy for gene therapy of prostate cancer introduction and objective: while hematospermia is mainly associated with genitourinary infl ammatory disorders, there are very few studies for prostatitis associated hematospermia (pah) via robust prostatitis evaluation methods. for this reason, we evaluated the incidence of pah with systematic evaluation methods for prostatitis. we evaluated hematospermia patients from a single hospital over fi ve years. we classifi ed the patients into pah versus he-matospermia without evidences of prostatitis (hwp) by using a nih-cpsi (chronic prostatitis symptom index) questionnaire and expressed prostatic secretion studies. th congress of the sociÉtÉ internationale d'urologie -siu abstract book cant diff erence in patient's the quality of life impact (table ) . introduction and objective: chronic prostatitis/ chronic pelvic pain syndrome is a chronic pain disease with high prevalence rates and substantial health care costs. chronic prostatitis syndrome is a common urological condition that many clinicians fi nd diffi cult to diagnose and treat eff ectively. th e signifi cance and diagnostic value of semen analysis in bacterial prostatitis has been extensively debated and remains controversial. our objective was to investigate the diagnostic accuracy of semen and urine culture in the diagnosis and treatment outcome of bacterial prostatitis. th e present study is based on a retrospective analysis of a database of over patients (age range - years) who met the consensus criteria for bacterial prostatitis, % of whom had dysuria, % perineal discomfort, % had obstructive luts, % infertility of unknown etiology, % erectile dysfunction and % recurrent infection of the partner. segmented urine cultures and semen culture, were performed in all patients. treatment were started as per the culture report and culture negative patients were treated empirically with quinolones group of antibiotics. patients were followed-up for year to rule out disease recurrence. results: of the patients, had positive semen culture and had positive urine culture; had negative culture for both semen and urine. of the positive cultures % of the bacteria was gram-negative microorganisms (escherichia coli was the commonest specimen isolated) and % had signifi cant positive cultures for gram-positive microorganisms. patients with positive semen culture had % response to antibiotics and full recovery was noted from the symptoms prospective aft er the full course of the antibiotic and recurrence of the disease were noted in % of the patient aft er year follow-up. patients with urine positive cultures, % had response to antibiotic, but % recurrence were noted in year. patients with negative cultures, % had symptomatic relieve but all of them had recurrence in year follow-up. conclusions: th e diagnosis of chronic prostatitis is diffi cult due to the absence of typical clinical symptoms and specifi c ultrasonographic signs. our data support the usefulness of semen analysis in the diagnostic work-up of prostatitis patients. semen culture positive patient responded well to medications and recurrence rate was very minimal compared to urine positive and culture negative patients. in our clinical work-up, semenculture are considered the only tests necessary to diagnose bacterial prostatitis and also guide us through the treatment. (rc) has been shown to be a predictor of poor outcomes in patients with bladder cancer. change in muscle volume during neoadjuvant chemotherapy (nac) administration has not been well studied. our objective was to assess for psoas muscle volume (pmv) change during the period of nac therapy and to assess if such a change was a predictor of pathologic response or survival. mp- . , figure . introduction and objective: alternative approach to the radical cystectomy for muscle-invasive bladder cancer is radical transurethral resection (tur), followed by chemotherapy/ radiotherapy. objectives: primary end points of the study were os (overall survival) and dss (disease-specifi c survival). secondary endpoint -oos survival aft er salvage cystectomy. materials and methods: sixty eight patients with t bladder cancer were treated by 'complete' tur fol-lowed by chemotherapy / radiotherapy. th e follow-up ended in june . all patients were subjected to "safety" resection. patients who had no tumor (t ), or had non-muscle-invasive (t ) tumor were given the option of follow-up with cystoscopy and adjuvant therapy or immediate cystectomy. mostly elder patients are candidates for bladder sparing. th ose with invasive tumor on the safety resection were subjected to cystectomy- patients (control group). we used spss : xi-square and kaplan-meier for statistical processing. results: five years overall survival (os) in the bladder spared group was % (n- ), and % of the cystectomy group (n- ) -p= . . th e disease specifi c survival (dss) was % and % for the bladder spared and cystectomy group respectively (p= . ). th irty four percent ( patients) with preserved bladder developed recurrent tumors. a repeated tur was conducted. fift een percent ( ) of them were with invasive tumor and the action taken was cystectomy. fift y percent ( ) of the salvage cystectomy group and % of the immediate cystectomy group survived years. of the preserved bladder patients, ( %) necessitated dj stenting and ( %) pns. pns in the cystectomy group were ( %). haematuria occurred in patients with preserved bladder and in of the cystectomy group. th e statistical diff erence between both groups according to complications is p = . . infl ammatory conditions were more common in the bladder sparing technique- orchiepididymitis, urosepsis, pyelonephritis, compared to urosepsis and pyelonephritis in the cystectomy group. conclusion: bladder conservation and radical cystectomy for muscle-invasive bladder cancer appear comparable regarding the dss until the th year. cystectomy continues to be standard of care. radical tur is successful bladder-sparing strategy in selected patients with no residual tumor on retur and lower life expectancy. introduction and objective: bladder cancer occurs commonly in the elderly patients. in some circumstance, uremic patients developed bladder cancer. we considered patients who are aged more than years old, end stage renal disease (esrd) or poor performance status (eastern cooperative oncology group, ecog >= ) as fragile patients for operation. we conducted this study to assess radical cystectomy (rc) outcomes and chemotherapy use including neoadjuvant and/or adjuvant chemotherapy in the fragile patients in routine practice. all patients undergoing rc for bladder urothelial cancer in china medical university hospital from to were enrolled. patients' basic characters, surgical and pathology reports and treatment records were retrospectively collected. patients were stratifi ed into fragile and non-fragile group. pearson's chi-square test and student t-test were used to assess parameters of these two groups. results: we identifi ed patients. th ere were patients aged more than years old, patient are uremic status and patients were performance ecog: . total patients were stratifi ed into fragile group. th e sex and pathological staging were no diff erence in these two groups. major perioperative complications defi ned as clavien-dino grade or more were . % in fragile group and only . % in non-fragile group (p= . ). chemotherapy use rate was . % and . % in fragile and non-fragile groups (p= . ). th e -day morbidity rate of non-fragile and fragile group was . % and . %, respectively. th e day morbidity was no signifi cant between these two groups ( . % of non-fragile and . % of fragile groups). in fragile group, -day mortality rate was . % and -day mortality rate was . %. th ere was no -day mortality in non-fragile group. half the patients died within months in fragile patients and fi ft y percent of patients lived aft er years in non-fragile patients. conclusions: fragile patients received radical cystectomy had higher perioperative major complications rate and higher -day mortality rate. we off ered complications and morbidity rate in these patients who received radical cystectomy. in elderly, esrd or ecog>= patients, we need more cautious care to decrease complication and morbidity rate. introduction and objective: primary management of muscle invasive bladder cancer (mibc) is cystectomy (cx). all traumas, including major surgery like cx, induce a stress response (sr), which plays an important role controlling the human immune system. a widely used parameter for systemic surgical sr is measurement of serum levels of c-reactive protein (crp). th is prospective study aims to compare the introduction and objective: several prognostic models predicting survival of patients with metastatic urothelial carcinoma (uc) have been developed, however, of them, the fi rst model by bajorin in is still the most representative and widely-used. th e aim of this study was to validate three major prognostic models constructed based on phase and trials, by using a cohort of real-world patients. we reviewed patients with metastatic uc who received fi rst-line chemotherapy at our fi ve affi liate institutions between and . using this multi-institutional cohort, we validated the following models: the "bajorin model", a model consisting of visceral metastasis and performance status (j clin oncol ; : ) ; the "apolo model", a nomogram including visceral metastasis, performance status, albumin and hemoglobin (j natl cancer inst ; : ) ; and the "galsky model", a nomogram including leukocyte count, number of sites of visceral metastases, site of primary tumor, performance status and lymph node metastasis (cancer ; : ) . cox proportional hazards regression model was used for multivariate analysis. harrell's c-index was calculated for each model. conclusion: all models were demonstrated to have high external validities in real-world patients, and of them, the "apolo model" achieved the highest c-index in the present population. further studies with larger populations are needed for establishment of the next standard model. the impact of female gender on bladder cancer specifi c death risk after radical cystectomy: a meta-analysis of patients liu s, yang t, na r, jiang h, ding q introduction and objective: bladder cancer was one of the most commonly diagnosed cancers in the world. up till now, there has been no study summarizing current studies on gender disparity and bladder cancer outcomes aft er radical cystectomy. to perform a fi rst meta-analysis on the association between female gender and cancer-specifi c death risk aft er radical cystectomy. a comprehensive literature search of the medline and embase databases was conducted for relevant studies published till november, th . th e primary goal of our study was to investigate the impact of gender disparity on cancer-specifi c death risk aft er radical cystectomy in urothelial bladder carcinoma population. th e meta-analysis was performed by estimating the odds ratios (or) and confi dence intervals (ci) through a random eff ect approach. results: a total of studies were included in the meta-analysis with a total population of patients. th e baseline characteristics of the studies were described in table . female gender was associated with a worse survival (pooled or: . , % confi dence interval . - . ) compared with male gender aft er radical cystectomy. signifi cant (q= . , p= . ) statistical between-study heterogeneity was present, with . % of variance secondary to between-study diff erences (i : . %). sub-group analysis found the correlation was signifi cant in north american, european studies (or: . , % ci . - . and or: . , % ci . - . , respectively) and studies from larger size of samples (or: . , % ci . - . ). we also found studies adjusted for the key elements (t stage, n stage and grade) obtained positive correlation (or: . , % ci . - . ). introduction and objective: pathologic response after neoadjuvant chemotherapy for muscle invasive bladder cancer is used widely as a surrogate endpoint for overall survival. controversy persists, however, whether the absence of residual cancer (pt ) or the presence of only non-muscle invasive residual cancer (pt , ptis, pta) is the optimal surrogate endpoint. we aimed to assess survival dependent on these pathologic responses in a large multicenter patient cohort. we retrospectively reviewed records of patients with urothelial cancer who received neoadjuvant chemotherapy and underwent cystectomy at contributing institutions from - . patients with ct - an m and eventual pn disease were selected for this analysis. estimated os was compared between pt and pt /pta/ptis patients. a multivariable cox proportional hazards regression model for overall mortality was generated to evaluate hazard ratios (hrs) for variables of interest (age, gender, number of cycles and type of chemotherapy regimen, surgical margin, and pt vs. pt /pta/ptis). conclusions: pt /pta/ptisn and pt n stage on the fi nal cystectomy specimen are strong predictors of survival in patients receiving nac and rc. we did not discern a statistically signifi cant diff erence in os when comparing these two endpoints. signifi cance of computer materials and methods: fift y patients were included in our study, of them presented with haematuria and a recent diagnosis of bladder carcinoma, and patients with a history of previous transurethral resection of superfi cial bladder cancer in their follow up period. th ey ranged in age years to years with a mean of . ; while male to female ratio was . : . th e main steps to perform virtual cyctoscopy incorporate proper bladder distention with air aft er draining the residual urine through foley's catheter and scanning the patient in both supine and prone positions. an excellent overview of the bladder masses was obtained in all cases and the results of virtual cyctoscopy and conventional one were comparable with excellent sensitivity rates of virtual cyctoscopy in detection, localization and morphology description of the bladder lesions at variable sizes. results: for detection of all lesions (n= ), virtual cyctoscopy alone showed sensitivity: . %, specifi ty: . % with two false positive and one false negative in comparison to conventional cyctoscopy which detected lesion while in axial ct alone the sensitivity: . %, specifi ty: % with false negative fi ndings. conclusion: ct virtual cystoscopy is a promising technique for use in bladder tumor detection of lesions larger than mm. optimal evaluation requires adequate bladder distention with the patient in both supine and prone positions and interpretation of both transverse and virtual images. is an evolving technique aiming to improve upon the diagnostic sensitivity of prostate biopsy for the diagnosis and local staging of prostate cancer (pca). diff erences in interpretation, expertise and application of mpmri may be responsible for the range of reported results. th is retrospective study aims to evaluate the diagnostic accuracy of mpmri in a cohort of patients from melbourne, australia, as compared to the gold standard of radical prostatectomy (rp). th is retrospective study was conducted in through the electronic patient records of a tertiary hospital and several private urology practices in melbourne, australia. patients having undergone rp had their records assessed for the presence of a pre-operative mri performed aft er st january which was then evaluated against the reference standard of a radical prostatectomy wholemount specimen. mri sequences typically included t weighted imaging, diff usion weighted imaging and dynamic contrast enhancement at t. mri reports were evaluated using the prostate imaging-reporting and data system (pi-rads) system. in our cohort the sensitivity and specifi city of mpmri for prostate cancer (pca) detection was found to be approximately - % and - % respectively. th e area under the curve for determining local stage was approximately . . conclusion: mpmri may have a useful role as an adjunct for prostate cancer diagnosis and directing management toward improving patient outcomes. staging information may be less reliable. a randomized prospective trial to assess the outcomes of mri/trus-guided prostate biopsy and traditional -core trus-guided prostate biopsy baco e , rud e , eri l , moen g , vlatkovic l , svindland a , eggesbø h , ukimura o introduction and objective: th e outcomes of magnetic resonance imaging (mri) and -dimensional transrectal ultrasound ( d-trus)-image-fusion-guided prostate targeted biopsy (mri-group) has not yet been compared with traditional -core trus-guided prostate biopsy (control-group) in a randomized control trial (rct) . th e aim of this study was to compare the prostate cancer (pca) detection rates (cdrs) and histopathological outcomes in the two groups. th is prospective rct included prostate biopsy (pb) naïve patients with suspicion for pca, where were randomized to mri-group and to control-group from / to / . in the mri-group, two tb of mri suspicious regions was followed by -core systematic random biopsy (rb). in the control-group, two tb towards palpable and/or trus-visible suspicious regions and -core systematic rb were performed. clinically signifi cant pca (cspca) on biopsy was defi ned as maximum cancer core length (mccl) ≥ mm of gleason score (gs) or any mccl of gs ≥ according to start criteria. cdr of all pca and cspca, and histopathological fi ndings were compared between the two groups. results: in the mri-and control-group cdrs were / ( %) and / ( %), (p= . ). cspca were detected in / ( %) in and / ( %) in control-group, (p= . ). tb (median cores/ patient) detected cspca in / ( %) in mri-and / ( %) in control-group (p= . ), respectively. concordance of gs on biopsy and radical prostatectomy specimen was / ( %, k = . ) in mri-and / ( %, k = . ) in the control-group (p< . ). upgrading of gs biopsy vs. gs-rp specimen was % in mri-group and % in control-group (p< . ). since the present study had a restricted cohort size, this may limit the generalizability of the results. no signifi cant diff erence in cdrs was found between the two groups. pca diagnosis can be achieved with few mri/trus-fusion guided prostate biopsy. gleason score on targeted biopsy was more accurate in the mri-group. introduction and objective: infection is a complication of trus prostate biopsy, despite the use of antibiotic prophylaxis. worryingly the rate of infectious complications following trus biopsy has been shown to be increasing. we aimed to determine the rate, severity, risk factors and microbiology resistance patterns associated with trus biopsy sepsis. as well the standard patterns of care surrounding trus prostate biopsy. a retrospective case-control study was conducted. using electronic coding all patients who presented to cabrini hospital with sepsis following a trus biopsy from to were identifi ed. validated cases were matched to controls in a ratio of : . eligible controls were required to have undergone a trus biopsy at the same surgical institution as the case and in the closest period of time. demographic, procedural and patient related data-points were recorded for all patients using hospital and urologist records. univariate logistic regression models were constructed and used to determine risk factors associated with infection. results: seventy-one cases developed sepsis following trus biopsy and were matched to controls. th e average rate of sepsis over the -year study period was . %. a sofa score ≥ was identifi ed in % of cases. we found a high prevalence of antibiotic resistant e. coli, with % of blood culture isolates classifi ed as multidrug resistant organisms. eight diff erent prophylactic antibiotic regimens were identifi ed. statistically signifi cant risk factors included previous antibiotic use and prior international travel within the six months prior to biopsy. th e addition of a penicillin antibiotic to standard fl uoroquinolone antibiotic prophylaxis was protective. conclusions: trus biopsy is an elective procedure and as such needs to be associated with minimal morbidity. th e patterns of care surrounding periprocedural variables for trus biopsies were non-uniform and diverse. a wide variety of diff erent prophylaxis regimens and bowel preparation routines were recorded. patients with risk factors for sepsis may represent a better target population for intervention with alternative preventative strategies. alternative preventative options include augmented prophylaxis, tailored prophylaxis or the tp biopsy approach either as a fi rst line biopsy modality or based on epidemiological risk factors. psa level) and pathological data was collected for all patients undergoing fi rst-time prostate biopsy with at least months follow-up, at music practices. from this overall cohort we identifi ed all patients whose pathology revealed multi-focal hgpin and/or asap (pre-malignant pathology) . for this subgroup, we examined the frequency of repeat biopsy across music practices and cancer detection outcomes. introduction and objective: nowadays overtreatment is recognisable challenge in pca management. overdiagnosis is possible reason for further overtreat-ment. we hypothesised that repeated prostate biopsies could not only help to cure but also harm patients with pca. consecutive patients who underwent biopsy for suspicious pca following at least one rebiopsy at single tertiary medical centre in - were included. age, initial and subsequent psa, drv, histology and biopsy features were recorded along with characteristics of subsequently diagnosed pca and chosen treatment approach. descriptive statistical methods were used for further analysis. results: basic characteristics were (mean±sd or frequency): age at initial biopsy ( . ± . years), time between initial/fi nal biopsy ( . ± . months), initial/ fi nal psa ( . ± . and . ± . ng/ml), drv (normal/suspicious . %/ . %), and number of initial/fi nal biopsy cores ( . ± . and . ± . ). initial/ fi nal histology was bph in ( . %)/ ( . %), infl ammation in ( . %)/ ( . %) and premalignant lesions in ( . %)/ ( . %) cases. finally, ( . %) pca were diagnosed ( by biopsy, by turp) performing biopsies aft er all. mean number of biopsies per patient was . in total and . to reach cancer positive histology; turp was performed in ( . %) patients. in ( . %) patients ≤ biopsy cores were cancer positive and in ( . %) patients gleason score was ≤ . gleason score ≥ was found in ( . %) cases. treatment with curative intention was held in cases (rrp , external radiotherapy ), no treatment (as/ww) in and hormonal therapy in patients. fourteen patients with minimal low grade cancer (≤ positive cores, gleason score ≤ ) underwent rrp ( % of all surgery cases). conclusion: repeated biopsy is important approach in pca diagnosis. however, based on our results we cannot exclude the risk of overdiagnosis and subsequent overtreatment with signifi cant impact on patients' quality of life, including radical surgery for low risk disease and early hormonal therapy in non-metastatic low-intermediate risk disease. th e study is retrospective, but potential bias became the advantage, since we could exclude prospective "self-control" within treatment decision making process. (siemens, munich, germany) and images were interpreted visually to evaluate uptake in biopsy districts of prostate gland. th e lesions suspicious for pca were submitted to additional targeted biopsies. introduction and objective: multiparametric mri (mpmri) and mri/trus-fusion-guided biopsy (tb) are advocated to detect index lesions and signifi cant prostate cancer (pc) within the prostate more exactly than systematic biopsies (sb) . th e aim of this study was to evaluate the detection accuracy of tumor foci by mp-mri and tb on radical prostatectomy (rp) specimen. we selected consecutive patients who were treated with rp for localized pc diagnosed by tb and/or transperineal saturation sb. on mpmri, all lesions were scored according to pirads. all lesions with pirads≥ underwent tb. on rp specimen, index lesion was defi ned as highest gleason score (gs) or highest tumor volume (tv). gs= + and tv≥ . ml or gs≥ + and tv≥ . ml were considered signifi cant. we performed spearmans correlation coeffi cient between mpmri and rp specimen and fisher's test between mpmri, tb and sb. introduction and objective: prostate biopsy is evolving to pre-biopsy multi-parametric mri (mp-mri), followed by systematic biopsy (sb) ± targeted biopsy (tb). mp-mri combined with trus-guided tb may increase detection rates of prostate cancer (pca), especially clinically signifi cant pca (cspca). however, few studies compare the detection rate of sb versus tb in the same cohort of men, as recommended by the standards of reporting for mri-targeted biopsy studies (start) consensus panel. th is study compares the diagnostic yield of sb and tb in a single cohort. th irty-three patients had a pre-biopsy mp-mri that identifi ed a target lesion. each patient then had a trus-guided sb and tb. th e cognitive fusion technique was used to perform the tb. results: among the patients, mean age was years; mean psa was . ng/ml. th e positivity rate for pca was % (n= ) for both sb and tb. th e positivity rate for cspca was % (n= ) for sb and % (n= ) for tb (p= . ). sb underdiagnosed cases ( %) of cspca that were detected through tb; tb underdiagnosed cases ( %) of cspca (p= . ) . th e positivity rate for sb and tb combined was % (n= ) for cspca (p= . ). conclusion: detection rates for pca using sb and tb were equal, but sb had a higher detection rate for cspca. combining tb with sb increased the rate of detection for cspca by %. tb alone was % more introduction and objective: active surveillance (as) has gained popularity with the intention of avoiding or postponing interventions in subjects with pca of low biological potential. unfortunately, several inclusion criteria have been proposed but many doubts still persist about their performance in predicting favorable disease. we aimed to assess the added value of biopsy factors, like maximum cancer length in a core (mcl), cumulative cancer length (ccl), cumulative length of positive cores (clpc), and percentage of cancer involvement in positive cores (cipc), to the prias criteria in patients who underwent radical prostatectomy (rp) but eligible for active surveillance (as). from january to december , consecutive subjects underwent rp. we identifi ed ( . %) patients who were eligible for as based on prias criteria: clinical stage t c or t , psa level of ≤ ng/ml, gleason score ≤ , psa-d of < . ng/ml and one or two positive biopsy cores. we calculated the diagnostic accuracy of biopsy factors in determining pathological confi rmed unfavorable disease. decision curve analysis (dca) were performed. explored, we examine the feasibility of monitoring low volume gleason sum (gs) + disease compared to gs + disease. introduction and objective: th e selection of prostate cancer patients for active surveillance (as) is based on the criteria for low risk according to protocols such as the national comprehensive cancer network (nccn) or european association of urology (eau) guidelines. we aim to compare pathological upgrading and upstaging rates between prostate cancer patients who met the above guidelines but underwent radical prostatectomy. we also aim to refi ne the selection criteria for our local population. a total of men were treated with rp at our tertiary center from to . seventy-three patients met the nccn criteria for active surveillance: ct -t a, prostate-specifi c antigen (psa) less than ng/ml, and biopsy gleason sum to . th irty-fi ve met the eau guidelines, which had additional criteria of: or less biopsy cores positive and % or less ca detected per core. results: of the patients who met the nccn criteria, ( . %) showed pathological upgrading (gleason > ) while ( . %) were upstaged (pt ). upgrading and upstaging fi gures for the patients meeting the eau guidelines were ( . %) and ( . %) respectively. analyzing the patients who met the nccn criteria, those who had % or more of the number of biopsy cores positive for prostate cancer had a far greater upgrading rate of . %, which was more than the . % (p = . ) seen in the other patients. psa density or percentage of individual core did not show any statistical diff erence in upgrading or upstaging. conclusion: a lower percentage of upgrading was seen in patients meeting the eau. upstaging fi gures were relatively the same. when counseling patients for active surveillance using the nccn criteria for low risk, we should exercise strong caution in patients with % or more of the number of biopsy cores positive for prostate cancer. biochemical recurrence rates in active surveillance candidates and the role of improving gleason grading introduction and objective: to evaluate prospectively the role of prostate-specifi c antigen (psa) density to predict gleason score upgrade in prostate cancer patients eligible for active surveillance (t /t , biopsy gleason score ≤ and psa ≤ ng/ml and ≤ positive biopsy cores). between january and november , among the patients who underwent more than core trans-rectal ultrasound guided biopsy, patients eligible for active surveillance under-went radical prostatectomy. using the modifi ed gleason criteria, tumor grade of the surgical specimens was examined and compared to the biopsy results. results: a tumor upgrade was noticed in ( . %) patients. extra-capsular disease and positive surgical margin was found in ( . %) and ( . %) patients, respectively. a statistical signifi cant correlation between the psa density and postoperative upgrade was found (p= . ); this is in contrast to the other studied parameters which failed to reach signifi cance, including psa, prostate volume, number of biopsy cores and number of positive cores. tumor upgrade was also highly associated with extra-capsular cancer extension (p= . ). th e estimated optimal cutoff value of psa density was . ng/ml , obtained by roc analysis (area under the curve . , p= . , % ci . - . ). conclusions: psa density represents a strong predictor for gleason score upgrade aft er radical prostatectomy in patients eligible for active surveillance. since tumor upgrade increases the potential for postoperative pathological adverse fi ndings and prognosis, psa density should be considered when treating and consulting patients eligible for active surveillance. surgical outcomes of south australian patients who have discontinued active surveillance plagakis s , o'callaghan m , , , moretti k , , foreman d , introduction and objective: active surveillance (as) is a recognized management pathway for patients with low risk prostate cancer (pca). diff ering protocols exist to identify suitable patients and manage their follow up. our study compares surgical pathology outcomes between patients who were initiated on, but discontinued, as and underwent radical prostatectomy (rp) with patients who received surgery immediately at the time of diagnosis. we also explore predictors of as discontinuation. our cohort comprised men diagnosed with pca from the south australian prostate cancer clinical outcomes collaborative database between - , aged - years, gleason score ≤ and psa ≤ . patients were stratifi ed into an immediate treatment group and an as group. to assess if as derivation rules aff ected outcomes, patients were sub-categorised according to enrolment criteria of university of toronto, prias and royal marsden protocols (with psa and gleason adjustment accordingly). all patients had a minimum of two years follow up. chi squared, logistic regression and cox proportional hazards modelling were used to compare outcomes between groups. results: forty-three ( %) patients in the as group underwent rp, compared with in the immediate treatment group. extra capsular extension and upgrading of histology at rp were more common in those managed by as compared to those receiving im-mediate surgery. th ese associations were supported by sensitivity analysis using prias and toronto criteria but not royal marsden selection criteria. as trended to being associated with unfavourable surgical pathology in multi-variable analysis, but this was only statistically signifi cant for prias ), p= . ). in all patients managed by as, sensitivity analysis suggested that the percentage of core positive at diagnosis is a signifi cant predictor of as discontinuation in those meeting the university of toronto selection criteria (hr . ( . - . ), p= . ). to determine if prias has increased rates of active surveillance (as) for patients with low-risk prostate cancer (pca). secondly, to determine whether urologists are operating on greater proportions of high-grade pca as a result of increasing as and what eff ect this has on surgical practice. prospective data was collected on patients from - (cohorts - , - ) who underwent trus biopsy by a urologist in geelong (n= ). positive trus biopsies (n= ) in both the pre and post prias cohorts were assessed to see if they met prias eligibility and whether they received as or active treatment (at). at patients were risk stratifi ed by gleason score and d' amico risk. data on post-prostatectomy staging, margin status and nerve-sparing techniques were collected. chi-squared test were used to calculate statistical signifi cance between cohorts. results: as increased between cohorts ( %, %, p= . ). before prias % ( / ) of patients eligible for as by prias criteria opted to undergo as compared with % ( / ) aft er the introduction of prias (p=< . ). th e relative proportion of high-grade pca (gleason score ≥ and d' amico high-risk) undergoing at increased from to % (p= . ) and to % (p= . introduction and objective: renal trauma is predominantly managed conservatively. trauma nephrectomy is reserved for patients who fail conservative or alternative management options. nephron sparing surgery is the cornerstone of renal preservation. our objective was to review the management of renal trauma at three tertiary facilities in queensland over a year period and compare these outcomes with current literature. a retrospective analysis was performed to fi nd the total number of renal traumas presenting to the princess alexandra hospital, royal brisbane and women's hospital and gold coast hospital, in queensland, australia. renal trauma patients were identifi ed using icd- codes (s . - ) and operative databases. patients requiring angioembolisation were obtained from radiological databases. we accessed the number of conservatively managed patients, trauma nephrectomies and angioembolisations for renal trauma. results: a total of renal traumas were identifi ed from june to june . six hundred and sixteen injuries were managed conservatively. th irty-three patients warranted acute exploration due to haemodynamic instability and resulted in nephrectomy in all cases. a trauma or general surgeon was the primary operator. fift een patients underwent angioembolisation for blunt renal trauma and patients for penetrating injuries. two patients proceeded to delayed nephrectomy for ongoing bleeding and for a ureteric stricture requiring nephrectomy aft er failed auto transplantation. th ese were performed by an urologist. th ere were further devascularised atrophic kidneys. seventeen of renal units were spared and of patients remained with functioning kidneys. all treated patients with angioembolisation were followed up with either mag renogram or ct triple phase and had functional kidneys at . years. conclusion: renal trauma is managed conservatively in most cases, consistent with the current literature. angioembolisation is an eff ective management option in selected patients with renal trauma. th is may prevent the need for trauma nephrectomy. in our cohort, patients requiring a trauma nephrectomy had predominantly grade iv and v injuries. general or trauma surgeons performed trauma nephrectomies in the acute setting of haemodynamic instability with rapid transfer to theatre. delayed nephrectomies were performed primarily by urologists in this cohort. introduction and objective: to review the contemporary management of traumatic extra-peritoneal bladder ruptures at an australian level one trauma centre. patients presenting with bladder injuries from july through to june were identifi ed using the traumanet database. th is was cross-linked with medical records and only patients with extra-peritoneal bladder rupture were included in the study. clinico-pathological data were collected from the database, medical records and health information services coding data. results: over the twelve-year study period, multi-trauma patients sustained an extra-peritoneal bladder rupture. of these patients, . % had a concurrent pelvic fracture and . % had co-existing intra-abdominal injury. a total of patients underwent operative repair for the bladder rupture and patients were managed conservatively with catheter drainage. of the patients managed operatively, % of cases were done at the time of another general surgical or orthopaedic operation and only two cases were done as a stand-alone repair. conclusion: extra-peritoneal bladder ruptures can be managed both conservatively and with operative repair. if operative repair is performed, it is usually done at the time of another operation for concomitant injury. management outcomes of major renal injuries following blunt trauma: changing concepts over years results: a total of / ( . %) of group i, and / ( . %) of group ii were treated non-operatively. diagnosis and grading in group i depended mainly on u/s, ivp and in some cases ct scan, while u/s and enhanced ct scan were mainly used for most of the group ii cases. in the total cohort, grade iii, iv and v renal injury were seen in ( . %), ( . %) and ( . %) patients respectively. open exploration was followed in ( . %) and ( . %) patients of group i and ii, with an overall exploration rate in / ( . %) of grade iv and v injury. th e incidence of nephrectomy have decreased from cases ( . %) in group i to cases ( %) only in group ii ( / kidneys were pathologic). double-j stenting and percutaneous drainage of urinoma was done in and cases, and chest-tube drainage to one patient with traumatic urinothorax in the conservatively managed group. outcomes were excellent, however in the non-operatively managed (grade iv-v) cases, / ( . %) normotensive patients had a non-functioning kidney within one year of follow up. conclusion: non-surgical management of high grade blunt renal injury can be safely undertaken and also recommended unless the patient is haemodynamically unstable. accurate grading is sometimes imprecise in multi-trauma patients, where instability is not always due to renal injury. drainage of extravasation is necessary to reduce morbidity. abdominal exploration does not mandate concomitant renal exploration, which is indicated in selected instances, otherwise it is an aggressive decision with a triple incidence nephrectomy rate. management of grade iv renal trauma: a revision of the aast renal injury grading scale is mandatory chiron p , hornez e , , boddaert g , dusaud m , bayoud y , molimard b , desfemmes f , durand x introduction and objective: th e aast (american association for the surgery of trauma) injury grading scale for renal trauma is currently the most important variable predicting the need for kidney repair or removal, for morbidity and mortality aft er blunt or penetrating injuries of the kidney. th e revision included the renal pelvis, the uretero pelvic junction and the segmental vascular injuries as grade iv, limiting grade v to severe hilar injuries. however, this revision does not permit the identifi cation of the group of patients who will require surgery because of hemodynamic instability due to grade iv renal injuries. th is study aims to propose an add-on for the grade iv of aast renal injury scale, in order to improve the management of these patients. we searched the following electronic databases: medline and scopus database. searches were not restricted by date, language or publication status. searches were last conducted in september . paediatric studies were excluded. results: seventy-one articles were found, were pertinent, including directly related to the topic. th ree risk factors were identifi ed to be associated with surgery for hemodynamic instability: peri-renal hematoma > . cm, intravascular contrast extravasation, medial renal laceration. presence of two or more of these criteria has been validated by others studies to predict the need for intervention. patients with > % devascularized fragments also present a poor prognosis and should be treated more aggressively. conclusion: th ese data should be incorporated into a future reassessment of the classifi cation, in order to better determine the need and time for surgery in grade iv renal traumas, generally leading to a nephrectomy. single panurethral reconstruction can be a surgical challenge. techniques include staged urethroplasty, augmented anastomosis with buccal mucosa graft (bmg) onlay via penile and/or transperineal, skin fl aps, or combinations of these. we report our experience of single stage modifi ed transperineal urethroplasty using a dorsal bmg in treatment of panurethral stricture. aft er obtaining irb approval, we performed a retrospective review of our urethral stricture database and identifi ed patients having undergone single stage transperineal urethroplasty using dorsal bmg as treatment of pan-anterior urethral stricture. patient characteristics, operative, and post-operative outcomes were studied. failure was defi ned as a need to any intervention during the follow-up period. results: th irteen patients underwent complete anterior urethra dorsal urethrotomy with dorsal bmg onlay between september and january . mean age was . years (sd: +/- . ). urethral stricture etiology was lichen sclerosis in patients ( . %), idiopathic in ( . %), hypospadias in ( . %) and infection in ( . %). previous treatments of dilatation and dviu were noted in patients ( . %) and previous urethroplasty in ( . %). mean operative time was . minutes (sd: +/- . ). mean estimated blood loss was . cc (sd: +/- . ). th ere were no intraoperative complications. early postoperative complications were buccal donor site bleed in patients ( . %) one treated with digital compression and other with hemostatic stitch, one patient ( . %) presented a perineal abscess and secondary urethroperineal fi stula. late complications was observed in patients who had postoperatory dribbling ( %). at mean follow up of . +/- . months, had recurrence ( . %) requiring dviu without new recurrence aft er a mean follow-up of . months (range - ) and one had meatal stenosis treated with dilatation ( . %) without recurrence aft er . month of follow-up. conclusion: in this small cohort, reconstruction of panurethral strictures may be safely and eff ective-introduction and objective: we present a novel technique for reconstruction of bulbo-membranous urethral strictures aft er surgery for bph with external sphincter sparing to preserve continence. anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue. by meticulous dissection of this sheath we separated the muscle from the urethral wall preserving the sphincteric function. patients with bulbo-membranous strictures aft er turp or open prostatectomy (op) who failed dilation and/or internal urethrotomy were reconstructed with a bulbo-prostatic anastomosis with preservation of the fi bers of the external sphincter. th e bulbo-membranous junction is approached dorsally, the inter-crural space is opened on the midline and the bulb is mobilized only from one side, without detachment from the perineal body. th e bulbo-membranous junction and membranous urethra are exposed and secured with vessel loops. th e membranous urethra sheath is opened circumferentially, carefully refl ecting the circular muscle fibers until exposure of the urethral wall. gentle blunt proximal dissection allows separating the muscle away from the urethra up to the prostatic apex, where healthy urethra is found to perform the anastomosis. results: from january to march we operated patients ( aft er turp and aft er op). all had membranous or bulbo-membranous strictures; bladder neck contractions were excluded. mean age was years ( - ). fourteen patients have been treated with either dilation and/or dviu; seven were with a suprapubic tube. mean length of stricture was cm ( - . ) , mean time from surgery to reconstruction was months ( - ) and mean follow-up was months ( - ) . two patients were not evaluable due to insuffi cient follow up. of the remaining , twelve were completely dry or using one security pad ( . % success). th ere were two clavien complications (both scrotal hematomas) and no stricture recurrence. conclusion: excision and bulbo-prostatic anastomosis with sphincter sparing for strictures aft er surgery for bph is feasible and safe. our technique allows preserving continence in most patients. to our knowledge this technique has not been described before. a larger series and reproduction in other centers will help to validate its therapeutic role. introduction and objective: panurethral strictures are complex and extensive strictures that involve the penile and bulbar urethra. management of these patients is challenging. in the last two decades, oral mucosal graft s have gained widespread popularity as the most versatile substitute tissue for urethral reconstruction. th e aim of this paper to present the shortterm outcome of our experience in the use of oral mucosal graft s in one-stage urethroplasty in patients with panurethral strictures. materials and methods: between april and october , men were evaluated and had one-stage oral mucosa urethroplasty for panurethral strictures. results: th ere were patients age range of - years with a mean of . years. aetiological factors identifi ed were poorly treated urethritis ( . %), post-urethral catheterization ( %) and lichen sclerosis ( . %). th e commonest cause of catheter-associated panurethral strictures was part of intra-operative patient monitoring in ( %), following spinal cord injury ( %). preliminary suprapubic cystostomy was done in patients ( . %). graft length ranged from - cm with a mean of . cm. oral mucosa donor sites were buccal in ( . %), labial ( . %), combined buccal and labial ( . %) and ( . %) for combined buccal/lingual and buccal/labial/penile skin fl ap respectively. twenty eight patients ( . %) had satisfactory voiding on removal of the urethral catheter and subsequent follow-up whereas patients ( . %) experienced diffi culty. of these , one patient had bladder outlet obstruction due to benign prostatic hyperplasia which was the reason for previous repeated urethral catheterization that had resulted in the stricture. oral mucosa donor site complications were present in patients ( . %) and consisted mainly pain and numbness in the mouth. duration of follow-up ranged from - months and there was no mortality among the patients. conclusion: panurethral strictures are common in our practice mainly resulting as complication of prolonged urethral catheterization. urethral reconstruction by one-stage oral mucosa graft urethroplasty is feasible, has good outcome though it may be associated with minor donor site complications. larger number of patients and longer-term follow-up are needed to assess durability of the procedure. missed and delayed ureteral injuries in hasan sadikin hospital, bandung, indonesia introduction and objective: to review our experience with delayed and missed traumatic ureteral injuries. materials and methods: genitourinary trauma database was retrospectively reviewed from - . variables such as time to diagnosis, imaging modalitites, location of missed or delay injuries, management, duration of operation, length of stay and complications were noted. introduction and objective: traumatic urethral stricture as the result of straddle injury or pelvic fracture urethral injury (pfui) is associated with long term morbidity and reduce the quality of life. most patients will end with long life urethral dilatation even aft er endoscopic treatment. anastomotic urethroplasty at present is the answer of defi nitive treatment. general principles of urethroplasty are to defi ne healthy urethra above and below the site of surrounding fi brosis and to perform a spatulated end-to-end anastomosis. prior to the year of , most urethral stricture cases including traumatic anterior and posterior urethral stricture was managed mostly with direct vision internal urethrotomy (dviu) in our institution. we present our experience with transperineal anastomotic urethroplasty. to our knowledge this is the fi rst indonesian local centre report of the changing defi nitive treatment of traumatic urethral stricture in a series of patients. we retrospectively reviewed traumatic urethral stricture due to straddle injury and pfui that had been treated with urethral reconstructive surgery by transperineal anastomotic urethroplasty approach. th e data cases from january -december were analyzed; which were the age of patients, location, length of gap, previous operations, and treatments. th e clinical outcome was evaluated with urofl owmetry aft er , , , and months aft er the surgery. results: a total of patients came with traumatic urethral stricture to hasan sadikin hospital during , which consist of patients with pfui and patients with traumatic anterior urethral stricture due to straddle injury. th e median age was . and . for pfui and straddle injury, respectively. twenty four percent of pfui patients had distraction length > cm and % had distraction length < cm. meanwhile, % of straddle injuries had stricture length < cm and % had distraction length > cm. in order to achieve tension free of anastomotic urethroplasty, % of pfui patients underwent crural separation, % patients underwent inferior pubectomy and only one patient for supracrural re-routing. sixteen percent of patient of pfui are redo case urethroplasty. success rate aft er transperineal anastomotic urethroplasty of pfui cases was %, % for redo case pfui and % for straddle injury cases. mean q max rates at , , , and months aft er catheter removal of pfui patients was , , , and ml/s whereas for straddle injury patients was , , , and . conclusions: in short term follow up, transperineal anastomotic urethroplasty achieved a signifi cant good result for traumatic urethral stricture treatment at our institution. recurrence after urethroplasty in a tertiary care centre in sub-saharan africa: an analysis of preoperative factors introduction and objective: urethral strictures disease remains very common in sub-saharan africa but despite this, there are no available reconstructive urology trainings / fellowships outside the formal urology residency programmes of the region. we reviewed the outcomes of urethroplasties at a tertiary urology centre in nigeria, sub-saharan africa which typically off ers general urology service. preoperative independent predictors of recurrence post-urethroplasty were determined. th e records of a total of men who had urethroplasty for proven anterior urethral stricture disease between february and january were retrospectively analyzed. age, social status, aetiology of strictures, stricture location, length of strictures and type of urethroplasty were assessed. appropriate inferential statistics were performed to determine independent predictors of stricture recurrence. results: mean patient age was years (range to ) and majority of the patients were of low income status ( . %). iatrogenic strictures due to urethral instrumentations and catheterization ( . %) and post infl ammatory strictures ( . %) were more common. isolated penile and long segment peno-bulbar strictures accounted for over two-thirds of all patients ( . %). mean stricture length was . cm (range to cm). most patients had quartey's urethroplasty ( . %), others had buccal mucosal graft ( . %), orandi ( . %) and anastomotic bulbar urethroplasty ( . %). for a mean follow up of . ± months, the overall recurrence rate was . % with mean time to recurrence of . months. of the evaluated preoperative factors (age, p= . ; social status, p= . ; aetiology, p= . ; stricture location, p= . ; type of urethroplasty, p= . ; stric-ture length, p= . ), only stricture length (p= . ) was a signifi cant predictor of recurrence. roc analysis was done and stricture length > cm signifi cantly predicted recurrence (auc of . , p= . ). conclusion: stricture length > cm are a signifi cant cause of recurrence following urethroplasty in the setting of prevalent general urology practice in sub-saharan africa. th e introduction of formal reconstructive urology fellowship or training may help improve skills and outcomes. introduction and objective: males with hypospadias are likely at increased risk for future urologic complications as adults. however, it is unclear how childhood surgery modifi es this risk. th e purpose of this study is to describe the spectrum of adult presentations with hypospadias-related complications and examine the eff ect of childhood surgery on these complications. a retrospective chart review over a year period, from august -december , demonstrated adult patients who presented to an adult reconstructive urologist with urologic complications related to hypospadias. patients were divided into two groups: those with no prior hypospadias surgery (group , n= ) and those who underwent surgical correction as a child (group , n= ). charts were reviewed for age at presentation, initial complaints, history of repair, and surgical intervention required. results: overall, the mean age at presentation was . years old. meatal location was not statistically diff erent between groups and , respectively: glans ( . % vs. . %), subcoronal ( . % vs. . %), coronal ( . % vs. . %), distal penile ( . % vs. . %), midshaft ( . % vs. . %), and penoscrotal ( . % vs. . %). overall, luts ( . %) was the most common presenting complaint, followed by spraying ( . %), urethrocutaneous fi stula ( . %), recurrent uti's ( . %), and chordee ( %). comparison demonstrated group patients were more likely to present with luts ( . % vs. . %, p= . ) and recurrent uti's ( . % vs. %, p= . ). contrastingly, group patients presented more commonly with cosmetic dissatisfaction ( . % vs. . %, p= . ). urethral stricture disease was demonstrated in more patients who had previous hypospadias repair, than those who had not ( . % vs. . % p= . ). of these, strictures were signifi cantly longer in the previous surgery group ( . cm vs. . cm, p= . ). surgical intervention was required in . % of group and . % of group (p= . ). conclusion: correction of hypospadias as a child likely increases the future risk of urethral stricture, recurrent uti's, and subsequent luts, but improves patient satisfaction with cosmesis. follow-up of hypospadias repair patients should extend into adulthood, as a signifi cant portion of adult presentations ultimately require surgical intervention. introduction and objective: during male to female gender confi rming surgery with vaginoplasty, a space is created for the neovagina within the potential space between the prostate anteriorly, and denonvillier's fascia and rectum posteriorly. entry to this plane is challenging, and to date, the only surgical approaches to this space describe blunt and sharp dissection along the ventral surface of the urethra. th e likely trauma to perirectal vasculature muscle-laden connective associated with this approach may account for the observed recto-vaginal fi stula rate associated with vaginoplasty. we describe an alternative, never before published approach using a male urethral sound upon the apex of the prostate to enter this plane with sharp dissection in a reliable and effi cient fashion. we describe our surgical technique, wherein we use a male urethral sound during the dissection to help expose denonvillier's fascia over the apex of the prostate. we dissected a block of tissue containing prostate, denonvillier's fascia and rectum from human cadavers, to describe (using ihc) the location and relative abundance of blood vessels (factor viii ab.), nerves (nf & s- ab.), and connective tissue (h&e and masson's trichrome), to support the sharp surgical approach we describe over the traditional approach to this plane. we describe clinical outcomes and the recto-neovaginal fi stula rate utilizing this approach in our institutions. results: immunohistochemistry results showed that the sharp dissection we describe is associated with incision through signifi cantly fewer blood vessels and sensory-motor nerves as compared to the traditional surgical approach. use of the sharp dissection we describe resulted in, at our institutions, a signifi cant decrease in recto-neovaginal fi stula in the peri-operative period. conclusion: th e surgical technique we describe for dissection of the plane between prostate and denonvillier's fascia during vaginoplasty is well supported by the anatomic studies we performed, and, is associated with lower morbidity. th is surgical approach and technique is also likely useful for gaining access to this same plane for repair of recto-vesical and recto-urethral fi stulas. introduction and objective: mitrofi noff procedure is commonly employed as bladder draining tool in patients who are unable to do clean intermittent self-catheterization through native urethera. it preserves renal function in small capacity and high pressure bladders and to improve quality of life. here we want to share our single centre experience of patients undergoing mitroffi noff procedure. a retrospective study of patients who underwent mitrofi noff procedure from january till december with a median age of (range = to ). twenty eight patients were males while female. indications for catheterizable stoma formation included neurogenic bladder in patients, small bladder in , bladder tumor in , uretheral stricture in one and interstitial cystitis in one patient. median follow-up was month to years. stoma was made from appendix in cases, from tapered ileum in cases and from ureter in cases. stoma location was lower right quadrant in cases, left lower quadrant in cases and at umbilicus in cases. augmentation accompanied by mitrofanoff was done in patients while mitrofanoff alone was done in patients. augmentation was done by using ileum in patients and cecum in one and illeocecum in one patient. data was entered from chart review and analyzed on spss. sixteen patients were analyzed in terms of complications and stoma revision. results: post-operative complications included uti in ( . %) patients, stones formed in ( . %), fistula was seen in ( . %) patient (augmentation cystoplasty + mitrofanoff ), stoma stenosis seen in ( . %), stoma revision done in ( . %). one female ( . %) patient had dribbling urine through urethera (incontinence), she underwent bladder neck closure. metabolic complications were not seen based on serum electrolytes follow-up records. we concluded that aft er mitrofanoff procedure renal function was preserved in most of the patients while no metabolic complications were seen in patients aft er undergoing mitrofanoff +bladder augmentation. stone risk was . % which was not very high. quality of patients was improved aft er mitrofanoff procedure. results: sesfm has higher porosity and larger pore size compared with bam (p< . ). at weeks, the presence of vesical calculus was evident in / rabbits. histological analysis showed that sesfm and bam promoted similar degree of urothelium regeneration (p> . ), and sesfm promoted a higher degree of smooth muscle and vessel regeneration compared to bam at each time point (p< . ). in addition, muscle strips supported by sesfm displayed higher contractile responses to carbachol, kcl, and phenylephrine compared with bam. at weeks, both matrices elicited similar mild acute and chronic infl ammatory reactions. conclusion: our results demonstrated that sesfm has greater ability to promote bladder tissue regeneration with structural and functional properties compared to bam, and with similar biocompatibility. introduction and objective: ureteral access sheaths (uas) can aid ureteroscopy by facilitating multiple passes of the ureteroscope, maximizing irrigation drainage, and reducing intra-renal pressures. however insertion of the access sheath may induce ureteral ischemia, cause iatrogenic ureteric injury, and could ultimately lead to ureteric stricture. in this study, we aim to evaluate the stricture rate following ureteroscopy both with and without the use of uas. we performed a retrospective chart review of consecutive ureteroscopies performed at our center (a tertiary referral center for endourology) between april and april to treat ureteric and renal calculi. th e primary outcome was the development of new hydronephrosis three months following successful ureteroscopy, not due to an obstructing stone. patients without follow-up renal ultrasound (us) or ct scan months post-ureteroscopy were excluded. data on age, sex, size of the stone, location of the stone, stone density, stone-free rate (sfr), time of the procedure, pre-op stenting, postop stenting, use of the uas, size of the uas, length of the uas, stone analysis, and imaging details were recorded. baseline and outcome variables were compared with anova and chi-square analysis where appropriate using spss statistical soft ware. results: a total of patients were eligible. a uas was used in ( . %) patients; ( . %) for renal stones and for proximal ureteric stones. th ere was no signifi cant diff erence in baseline or demographic data. none of the patients developed new hydronephrosis or developed a ureteric stricture, and none required endoureterotomy. conclusions: uas use during ureteroscopy for renal and ureteric stones is both safe and eff ective. even with routine use of . f and f uas, ureteric stricture rates are very low (zero in this series), suggesting that signifi cant ureteric injury is rare with proper technique and case selection. to evaluate the value of fl exible ureteroscopy for the treatment of the upper urinary tract calculi in children. a total of children, males and females, were identifi ed in this study. th e median age was . years, range months to years. among them, patients had the upper ureteral calculi ( with calculi in situ, with middle/fi stal ureteral calculi shift ing to upper ureteral aft er rigid ureteroscopic lithotripsy) and had renal calculi. ipsilateral mild to moderate hydronephrosis was found in all of the cases. four children had melamine-induced stones ( with upper ureteral calculi and with renal calculi). th e calculi were found on left side in cases, on right side in , and on both sides in (upper ureteral calculi). th e median stone size was . (range . to . ) cm. retrograde fl exible ureteroscopy and anterograde fl exible ureteroscopy in mini-percutaneous nephrolithotomy was performed. results: twenty eight cases were performed retrograde fl exible ureteroscopic procedure. one case was conversed to mini-percutaneous nephrolithotomy because the fl exible ureteroscope could not be inserted into the upper ureter. th e fl exible ureteral access sheath was failed to insert into the upper ureter in cases, and the fl exible ureteroscope was inserted into ureter directly. th e successful rate of stone search was % in cases. th irty cases were successfully performed in one stage. th e stones were successfully fragmented aft er two stages in two cases. th e success rate of stone fragmentation was . % with the holmium laser lithotripsy in one stage. th ree anterograde fl exible ureteroscopy with mini-percutaneous nephrolithotomy were successfully performed, and the stones were successfully found and fragmented aft er a single holmium laser lithotripsy. th e median operative time was (range to ) mins. th ere was no major perioperative complication. th e patients were discharged from hospital aft er a median of . days (range to ). double-j stent was removed aft er to weeks when no residual stones more than . mm in size were found. no recurred stones, no urethra stricture, no ureter stricture, no urinary incontinence and no vesicoureteral refl ux were found during the to -months follow-up. conclusion: flexible ureteroscopy is a safe and feasible method for the treatment of the upper urinary tract calculi in children. it is suitable for the stones in the pelvis and calyceal where the rigid ureteroscopy could not reach. introduction and objective: laparoscopic ureterolithotomy is an alternative to open ureterolithotomy for the primary treatment of large, impacted, proximal or mid ureteral stone. transperitoneal and retroperitoneal approaches are the basic techniques and each has its own advantages and disadvantages. th e aim of this study is to compare retroperitoneal versus transperitoneal laparoscopic ureterolithotomy in eff ectivity, pain scale and early complications. in this prospective comparison study from january to december , patients with proximal and mid ureteral stones underwent retroperitoneal laparoscopic ureterolithotomy or transperitoneal laparoscopic ureterolithotomy. th e randomization occurred on consecutive sampling on a : basis. groups and consisted of patients who underwent retroperitoneal laparoscopic ureterolithotomy and transperitoneal laparoscopic ureterolithotomy, respectively. demographic and clinical variable, operative time, length of stay, ureteral suturing, pain scale according to visual analog scale (vas) and early complications data were collected and analyzed. statistical analysis was performed with spss® version . using student t-test and mann-whitney u tests with p value< . considered statistically signifi cant. results: vas on day between the groups was statistically signifi cant, and was higher in group (p< . ). according to the clavien-dindo classification of surgical complication all the patients were in grade classifi cation. th e diff erences in operative time, length of stay, ureteral suturing, visual pain analog score on day , and early complications between the groups were not statistically signifi cant. ionising radiation is commonly used in urological practice in the form of fl ouroscopy. to date there is a relative dearth of information regarding patient exposure during the urological procedures and the subsequent risk of development of a lethal malignancy due to the radiation exposure. objectives: to determine the radiation exposure for a patient for the most commonly performed urological procedures and determine the lifetime additional risk of fatal cancer per procedure. data was collected prospectively in two institutions on endoscopic urological operations. procedures were classifi ed as retro-graphic, semi-rigid ureteroscopic (urs) and fl exible ureterorenscopic (furs). data collected included procure type and diffi culty, dose are product [dap (gy*cm )]). th e eff ective dose (ed) as measured in millisievert was determined from the dap by using the monte carlo calculation. results: a total of consecutive operations from two institutions were assessed. th e mean ed for all procedures in this study was . msev, irq ( . - . ). th e maximum ed was . msev. th e radiation exposure for all procedures was relatively small, for diagnostic retrographic procedures the median ed was . msev. for retrograde procedures that involved a stent insertion the median ed was . msev. th e median ed for all ureteroscopic surgeries was . msev, and the median ed for all furs procedures is . . th e fi ndings of this study are reassuring. endoscopic urological procedures appear to expose patients to relatively small radiation compared to other procedures requiring fl uoroscopy and a very low lifetime additional risk of fatal cancer per procedure. five during the follow no local recurrence was noted and two patients presented with distant metastasis. th e actual -year overall and cancer specifi c survival was . % and . %, respectively. on multivariable cox regression analysis, acci was the only factor associated with increased risk of overall mortality (hr . ; % ci ( . - . )). conclusion: rpn achieves excellent long-term oncological outcomes. age and comorbidities are associated with increased risk of overall mortality. to our knowledge, this is the fi rst series of long-term follow up aft er rpn reported to date. introduction and objective: partial nephrectomy provides equivalent oncologic and superior functional outcome compared with radical nephrectomy over the short and long term. with the development of laparoscopic techniques and increasing laparoscopic surgical experiences, laparoscopic partial nephrectomy (lpn) has become an acceptable alternative to radical nephrectomy for expert laparoscopic urologists to treat small renal mass. it was reported that using barbed suture can reduce warm ischemia time during lpn. we designed a single blind randomized controlled trial to fi nd whether the barbed suture can materials and methods: from july to march , forty-six patients with renal score less than were enrolled for this study. patients were randomized into two groups: control and v-loc group. all patients were evaluated before surgery including performance status, asa score, liver and renal function, abdominal ct, lung function, and cardiac function etc. during the surgeries, standard ports were placed. aft er the renal artery was clamped by bulldog, tumor resection was performed using a cold scissor. th en the inner layer deep vessels and collecting system, and outer layer were sutured with v-loctm respectively in v-loc group. in control group, inner layer was sutured with - absorbable sutures, and the outer layer renal parenchyma was sutured with absorbable sutures. operative characteristics and complications were compared between groups. results: laparoscopic partial nephrectomy was successfully completed in all forty-six patients without open conversion. control and v-loc groups were equivalent in demographic and tumor characteristics. no signifi cant diff erence was seen between control and v-loc groups in operative time ( vs. min, p = . ), estimated blood loss ( vs. , p = . ), warm ischemia time ( vs. min, p = . ), and complication rate ( % vs. . %, p = . ). conclusion: lpn with v-loc sutures for renorrhaphy is safe and feasible. however, using v-loc suture for renorrhaphy doesn't show any superiority in patients with low and moderate complexity renal tumors in our randomized control trial. small th e local recurrence free survival was signifi cantly better in the combined us/ct-guided group than in the us-guided group (p= . ). recurrences were found in % with us/ct-group and in % in usgroup. th e overall complication rate was similar (us/ ct % versus us %) in both groups. th e mean percentage decrease in the estimated glomerular fi ltration rate (egfr) aft er the treatment was . ± . % with us/ct, compared to . ± . % mean decrease in egfr aft er treatment in the us-guided group (p= . ). conclusion: th e use of combined us/ct-guidance when performing renal rfa resulted in superior primary and short term outcome compared to the use of us-guidance alone in patients treated at the same institution. increased experience with rfa treatment probably also contributed to the results. introduction and objective: to present our initial experience in female patients undergoing transvaginal notes-assisted laparoscopic partial nephrectomy (pn). between august and january , a prospective analysis of the initial ten patients who underwent transvaginal notes-assisted pn was entered into an institutional review board (irb)-approved database. th e procedure was performed using two umbilical trocars and one trocar through the vaginal wall. th e main renal artery clamping, segmental renal artery clamping and unclamped pn were performed depending on the circumstances of the tumour. some perioperative parameters including operative time, warm ischemic time, blood loss, and perioperative complications were recorded. sexual function was assessed with the female sexual function index (fsfi) questionnaire before and aft er surgery. th e cosmetic results were investigated by administering patient scar assessment questionnaire and scoring system (psaq). results: nine transvaginal notes-assisted pns were completed successfully. one patient with a right anterior upper-pole tumor was converted to radical nephrectomy because of persistent bleeding from the parenchymal defect. th e median (range) operating time was ( - ) mins and the median (range) estimated blood loss was ( - ) ml. th e median (range) warm ischaemia time (wit) was ( - ) mins. th e median (range) postoperative hospital stay was ( - ) days. all surgical margins were negative. eight patients completed the fsfi questionnaire, and analysis did not show diff erences in fsfi scores before and aft er surgery. th e better cosmesis results were confi rmed by the psaq score. transvaginal notes-assisted pn is a safe and feasible surgical procedure in the treatment of small renal mass with excellent cosmesis results. more prospective studies with long follow-up are needed to investigate the oncologic safety. introduction and objective: to analyze the complications of urologic transvaginal natural orifi ce transluminal endoscopic surgery (tv-notes), and to explore eff ective measures for its prevention and management. materials and methods: from may to february , a total of cases underwent tv-notes in our institute. intraoperative and postoperative complications were graded according to satava and clavien-dindo grade classifi cations system. th e major complications and their treatments were most importantly analyzed. results: among the tv-notes procedures, case conversion to open surgery and one case conversion to suprapubic-assisted laparoendoscopic single-site surgery (sa-less). th irty-one ( . %) patients had intraoperative complications, the minor and major was ( . %) and ( . %), respectively. th e intraoperative complications include cases of pneumoderm, cases of skin ecchymosis, cases of pleural damage, cases of liver injury, case of adrenal central vein injury, cases of spleen injury, cases of inferior vena cava injury, cases of renal veins injury, case of right iliac vein injury, case of bladder injury, case of renal collecting system injury, cases of colon injury, case of rectum injury. th e proportion of patients incurring minor and major postoperative complications undergoing tv-notes was . % (n = ) and . % (n = ), respectively. th e postoperative complications include case of adrenal crisis, cases of incision infection, cases of postoperative fever, cases of postoperative bleeding, case of the right external iliac artery thrombosis and case of urinary leakage. no intraoperative and postoperative deaths occurred. conclusion: tv-notes operation is safe and feasible surgical technique in urology, and does not increase the incidence of complications. but there is a potential risk of major complications occurring, which should be paid more attention to prevent. introduction and objective: knotless barbed suture, a relatively innovative type of suture, can eliminate knot tying, speed the placement of the sutures, and create the possibility of improved scar cosmoses. th e minimally invasive radical prostatectomy (mirp), as one of the earliest surgeries that adopted this advanced technique, was reported about diverse eff ects on the patients and the surgeons. our objective is to present the available evidence about the effi cacy and safety of barbed sutures in minimally invasive radical prostatectomy. we searched pubmed, em-base, and cochrane library for published studies and clinicaltrials.gov for additional information to identify randomized controlled trials (rcts) and cohort studies addressing the application of barbed and conventional sutures in mirp (until feb. ) . quality assessment was performed according to cochrane recommendations. th e data were analyzed using review manager (version . ), and sensitivity analysis was performed by sequentially omitting each study. hemi-pelvises, . % had the periprostatic plexus (ppp) as the largest vein of the dvc. th is was followed by the obturator vein (ov) ( . %), which originates from the lateral part of the plexus and runs laterally. next was the internal pudendal vein (ipv) ( . %), which originates lateral to the posterior part and runs postero-laterally. in the rp group, the dvc bunching stump was an average of . mm from the origin of the cavernous vein. no complications occurred while performing examinations. conclusion: d-ct pelvic venography depicted the dvc and its related veins in all cases. venous systems making up the dvc diff ered among patients. in . %, the main venous system was the ppp, which can be controlled by conventional dvc ligation technique. however, in the remaining % of hemi-pelvises, the ipv and the ov were the main venous systems. th ese will need wider ligation because of existing outside and to the back of pathways. we believe that a better understanding of dvc will lead to refi ned rp. introduction and objective: bladder pheochromocytoma and carcinoid tumors are rare neuroendocrine tumors of the bladder. presenting a series of cases of these rare bladder tumors which were managed laparoscopically. materials and methods: case was a years lady who presented with symptom of giddiness following micturition. ultrasound revealed a . cm bladder mass at the bladder base. twenty four hour urinary biochemical evaluation and mibg scan did not reveal any abnormalities. cystoscopy revealed a submucosal sessile mass above the trigone. on cystoscopic bladder distension a spike in blood pressure ( / ) was noticed which fell rapidly on emptying. patient underwent laparoscopic partial cystectomy aft er weeks of alpha blockade with phenoxybenzamine. case was a years old gentleman who presented with episodes of severe headache following micturition. despite antihypertensives his blood pressures were not under control. ultrasound revealed a cm bladder mass in the left lateral wall encroaching close to the left ureteric orifi ce. twenty four hour urinary biochemistry and mibg scan was suggestive of bladder pheochromocytoma. aft er weeks of alpha blockade he underwent cystoscopy followed by laparoscopic partial cystectomy with left ureteric reimplantation. case was a years old gentleman a hypertensive who underwent an attempted turbt and subsequent hypertensive crisis and bleeding for a bladder mass in a peripheral hospital. he was stabilized and referred to our center for further management. ultrasound revealed a cm anterior wall mass. twenty four hour urinary biochemistry and mibg scan was suggestive of bladder pheochromocytoma. aft er weeks of alpha blockade he underwent laparoscopic partial cystectomy. mri has shown to be accurate in diagnosing index tumours in prostate cancer. a variety of focal therapies has been explored in treating these lesions. th is study aims to compare the detection rate, grade and location of non-index lesions found in radical prostatectomy specimens with their initial mpmri. a prospective database of all men undergoing mpmri for suspicion of prostate cancer in our group practice was kept. ethics approval was obtained from epworth healthcare. of these men, all who had a -d summary diagram including pirads score for each mpmri and who then underwent radical prostatectomy were assessed. volumetric studies were performed for all prostatectomy specimens and compared to each corresponding mpmri -d summary diagram. analysis of non-index lesions was performed. conclusion: a signifi cant amount of patients who underwent radical prostatectomy in treatment for prostate cancer were identifi ed to have non-index tumours in their volumetric analysis. in our cohort of patients, the majority of low grade disease was undiagnosed on mpmri. however, a signifi cant amount of moderate grade non-index tumours were also missed on initial mpmri. th is questions the safety and appropriateness of focal therapy. ongoing research is warranted and we will continue to report our prospective mp-mri database as our experience with this modality grows. eligibility for active surveillance of prostate cancer and functional outcomes after prostatectomy shepherd a , , o'callaghan m , , introduction and objective: we aimed to compare the outcomes following radical prostatectomy (rp) of active surveillance (as) and non-as candidates. we hypothesised that as eligibility at diagnosis would be associated with favourable pathological, surgical and also functional outcomes. using a prospectively maintained database, all patients with a primary treatment of rp conducted prior to were identifi ed, including those who were initially eligible for as. men defi ned as eligible for as were those: diagnosed between and years of age; with gleason score ≤ ; psa ≤ ; clinical stage ≤ a; and with percentage of positive cores ≤ %. we compared the histopathological and functional outcomes of the two groups. results: of patients with a primary treatment of rp, met the criteria for as. pre-operative tumour characteristics of the patients meeting criteria for as were favourable compared with those ineligible (lower psas and less cancer in the biopsies; p< . ). functionally, the groups had similar pre-operative continence ( % vs. %) and potency rates ( % vs. %). histologic characteristics of the prostate specimen in patients qualifying for as were more favourable, with lower rates of positive surgical margins and extracapsular extension observed in this group (p< . ). following rp, at -, -and -month follow-up, there were no signifi cant diff erences in the proportion of men who were continent between as and non-as candidate groups ( months: % vs. %; months: % vs. %; months: % vs. %; p> . ). similarly, no signifi cant diff erences between groups were observed in the proportion of men who were potent at -and -month follow-up ( months: % vs. %; months: % vs. %; p> . ). aft er -month follow-up, however, potency appeared to be higher for the as candidates ( % vs. %; p= . ). were assessed pre-implant as well as at , , and months aft er seed implantation, and every months thereaft er. we evaluated clinical factors, including prostate volume (pv), neoadjuvant combined androgen blockade (cad), radiation dose to % of the prostate volume (d ), and to % of the urethral volume (ud ) to predict urinary disorders aft er brachytherapy using multivariate analysis. results: th e mean pre-implant ipss was . , with the greatest mean score of . at month aft er seed implantation. at , , , , and months, the mean ipss had decreased to . , . , . , . , . and, . respectively. th e mean pre-implant prostate volume (pv) was . g, followed by . g at months and . g at months aft er brachytherapy. in cases with pv more than g, d more than gy, and ud more than gy, ipss levels were signifi cantly high-er even years aft er treatment. on multivariate analysis, d more than gy (p< . ) and ud more than gy (p= . ) were independent predictors for ipss increases of more than points at years aft er brachytherapy. only d was an independent predictor at (p< . ) and years (p= . ) aft er brachytherapy. introduction and objective: metformin has been shown to be protective in prostate cancer (pc). we aimed to assess the eff ects of metformin on pc outcomes in men treated with external beam radiotherapy (ebrt) and/or androgen deprivation th erapy (adt). we also aimed to investigate the eff ects of metformin on the above outcome measures in type diabetic men with pc. th e outcome measures of time to biochemical failure (bf), metastasis, pc specifi c mortality and overall mortality were analysed in men on metformin using a competing risk model and a cox proportional regression model. a total of eligible cases, of whom were on metformin, were identifi ed with a median follow-up of . months. th ere were no diff erences in age, initial psa, gleason scores, t stage, d' amico risk or duration of adt between men who were on metformin and those not on metformin. treatment with metformin did not result in any apparent improvement in time to bf, time to metastases or overall survival but there was an increase of . fold in pc-specifi c deaths (p< . ) in men on metformin and adt when adjusted for cancer risk and co-morbidities. on a subgroup analysis of the men with type diabetes, similar fi ndings were seen with metformin being associated with a . fold increase in pc-specifi c deaths (p < . ). th ese adverse eff ects were lost in men on metformin and statins. conclusions: th e use of metformin did not improve time to metastases, time to bf or overall survival in men undergoing ebrt +/-adt for pc with curative intent. however, in type diabetic men on high doses of metformin there was an increased risk of pc-specifi c mortality. further studies are needed to investigate these fi ndings. th e objective of this study is to assess ire eff ects in prostate tissue and to correlate ire treatment planning with the d-histopathology of radical prostatectomy (rp) specimens that essential structures will be spared. sixteen patients, scheduled for rp, ire procedures were performed weeks before rp. ablation was performed according to two protocols: focal or extended ablation. th e electrode probes were inserted transperineally under ultrasound guidance. th e locations of the electrodes were used as input for the plannings soft ware. following rp, the specimens were processed into whole-mount sections, were histopathologically (pa) assessed and ablation zones were delineated. th e volumes of tissue alteration were determined by adding the delineated areas. th e planned and pa ablation volumes were compared using the pearson correlation coeffi cient. results: th e d volumes of the ablation zones follow the planned lesions volumes with a pearson correlation index r= . with a slope of . ( figure ). th e focally planned ablations results in a volumetric smaller histopathological ablation zone than predicted whereas the extended ablations result in volumetric larger ablation. pa showed sharply demarcated fi brotic and necrotic areas with mild infl ammation. th e urethra was aff ected by the ire treatment in nine mp- . , figure . correlation of ablation volumes t -weighted mri and ceus with h&e pathology (pa) mp- . , figure . scatterplot of planned ablation zone volumes compared with volumes in histopathology patients were observed throughout the neurovascular bundle in thirteen prostates and extended beyond the prostatic capsule in twelve cases. conclusion: ) ire in prostates results in sharply demarcated lesions with fi brotic and necrotic features, but may damage essential structures as urethra, capsule and nerves. ) th e actual ablation zones on d-histopathology follow reasonably the planned ablation zones. ) focal ablation protocols lead to a smaller ablation zone than extended ablation protocols. therapeutic all patients treated at our institution with primary pca t - , n , m were included provided they did not present with a long history of adt. patients were stratifi ed into groups according to their psa nadir occurring between - weeks following hifu. group a (n= : nadir < . ng/ml), group b (n= : nadir > . - ng/ml ng/ml), group c (n= : nadir > ng/ml). th e primary endpoint of our analysis was the onset of any salvage therapy other than hifu. repeat hifu can be performed without undue additional morbidity and is standardly not considered as salvage therapy but rather an adjuvant to the index hifu. multivariate analysis was performed to determine what predicts onset of salvage therapy. results: at inclusion: . % of patients were t and . % were t . outcomes are summarized in table . conclusion: group a (nadir < . ) showed % salvage treatment free survival without adt; preoperative high gleason, high initial psa and "no turp" were negative predictive factors for outcome; % of the patients had nd hifu treatments in follow-up; in case of salvage therapy most patients opted for adt. metastasis-free survival of % at and % at years excludes turp in pca as potential metastasis-inducing factor. combined "turp and hifu" showed its oncological effi cacy, postponing / avoiding classical salvage therapies (rad/adt) and their potential side eff ects. laparoscopic radical prostatectomy (lrp): changing trends in practice introduction and objective: we audited our lrp outcomes in order to evaluate outcomes and how our practice has evolved over the years. we evaluate pathological and margin status outcomes and determine whether there has been a shift towards treatment of higher risk disease and the impact of this practice on margin status. a total of patients underwent lrp performed by one surgeon at our institution from june to september . we divided the cohort into early period from - (group , n= ) and - (group , n= ). results: mean age was yrs. mean preoperative psa ( . ) and gleason score (gs, ) did not diff er between groups. however, preoperative stage ≥t c increased from ( %) to ( %) for groups and respectively. postoperatively, diagnosis of gs ≥ increased from ( %) in group to ( %) in group . similarly, % of group was staged as pt compared to % of group . th ere were more extracapsular extension in group ( %) compared to group ( %). overall positive surgical margin (psm) rate was % (group , % vs. group , %). when stratifi ed according to pathological stage, psm was identifi ed in more men with pt ( %) compared to pt ( %). th e commonest site of psm was at the apex. seminal vesicle invasion rate was similar ( %). results: mean operation time and length of hospital stay for rarp and lrp were . ± . min and . ± . min, and . ± . days and . ± . days, respectively (p = . and p = . ). aft er cases, the mean operation time for rarp was similar to lrp (less than h). positive surgical margins in localized cancer were seen in . % and . % of cases in rarp an lrp, respectively (p = . ). at postoperative months, sexual intercourse was reported in % and %, and pad-free continence in % and % in patients with rarp and lrp, respectively (p = . and p = . ). conclusion: previous large-volume experience of lrps may shorten the learning curve for rarp in terms of oncological outcome. additionally, previous experience with laparoscopy may improve the functional outcomes of rarp. introduction and objective: signifi cant prostate cancer is increasingly diagnosed in younger men. th is patient group has high expectations regarding oncological and functional outcomes at robotic radical prostatectomy (rarp). we reviewed a prospective database ( rarps) at a single tertiary referral centre and obtained erectile dysfunction rates/treatment and continence pre-and post-operatively, positive margins, metastases and death. median follow-up was years. male sprague-dawley rat aged weeks were used. a total of rats were divided into two groups. one group was used as a control and other group received intramuscular injections of testosterone propionate ( mg/kg) plus β-estradiol ( . mg/kg) for weeks to induce bph. th e prostate and genitourinary organ weights, histopathologic change and serum hormones were evaluated. we compared the eff ects of ldd ( mg/kg) with tamsulosin ( μg/kg) in intraurethral pressure responses induced by es of the hypogastric nerves. we performed western blotting for alpha a and d receptor of adrenergic nerve. results: bph-induced rats showed signifi cantly increased absolute prostate weight and prostatic index (prostate weight/body weight x ), increased testosterone, free testosterone and estradiol levels in the serum. histomorphology also showed that epithelial cell layers in the prostates of bph-induced rats were larger than control groups. ldd and tamsulosin signifi cantly inhibited the intraurethral pressure elevation induced by es of the hypogastric nerves. alpha d and alpha a adrenergic receptors in bph rat model were expressed more than control. ldd decreased expression of alpha d adrenergic receptor than control. conclusions: th is study suggested that ldd could be an alternative medicine to treat bph inducing lower urinary tract symptoms. does according to recent studies, atherosclerosis has a key role in the pathogenesis of bph. th erefore, we evaluate the correlation between prostate volume and intima-media thickness (imt) of carotid artery in diabetic bph. from january to august , patients with dm were analyzed, retrospectively. baseline characteristics and diabetic profi le were collected. mean intima-media thicknesses (imt) were collected using carotid doppler ultrasound. and prostate volume (pv) was measured by transrectal ultrasound. two groups were analyzed using lineal regression analysis. results: th e patients were classifi ed into group (n= , . %) and into group (n= , . %) based on the presence of bph. th ere were statistically signifi cant diff erences on bmi, waist circumference and hba c between the two groups (table ) . th ere is a signifi cant correlations between imt and pv and imt and transition zone (tz) (p= . , p= . , figure ). porting symptoms listed on the otc label as reasons for not using the product; traces of glucose, leukocyte, and/or blood in their urine; or an aua-si score ≥ . conclusion: pvp has demonstrated acceptable complication rates compared to traditional turp in treating bph in a cohort of men having a greater frequency of comorbidities and in those having to remain on oral anticoagulation. th is makes pvp an attractive alternative to turp in such men particularly if symptomatic relief and re-treatment rate in the longer term is demonstrated to be equivalent. prospective study of high-risk patients undergoing photovaporisation of prostate (pvp) without cessation of oral anticoagulants ow d , papa n , sengupta s , , lawrentschuk n , , , bolton d introduction and objective: greenlight laser photovaporisation of the prostate (pvp) is suggested to be safe to perform on high risk patients requiring surgical intervention in the management of benign prostatic hyperplasia (bph), where cessation of oral anticoagulation is not possible due to medical comorbidities. we prospectively evaluated the outcomes of patients who underwent pvp with ongoing oral anticoagulant therapy. materials and methods: between january and december , patients with ongoing oral anticoagulant therapy were treated with pvp. types of oral anticoagulants were recorded and perioperative outcomes were collected. th ese metrics included transfusion rate, duration of hospital stay and laser treatment variables. ninety-day readmissions also were recorded as were complications of treatment. results: sixty-two patients were treated by greenlight laser pvp while taking oral anticoagulants. out of this total, patients ( . %) were on warfarin while ( . %) had ongoing clopidogrel. th e remaining were either taking one or a combination of other (non-asprin) oral anticoagulants. nine out of ( . %) patients required readmission post pvp, and all of these readmissions were for management of complications related to haematuria. five of this group of patients ( . % of total cohort) had undergone pvp without cessation of warfarin, while of patients ( . % of total cohort) had undergone treatment without cessation of clopidogrel. th ree patients ( . %) required blood transfusion. conclusions: despite continuation of oral anticoagulants in these high risk patients, the readmission rate is low and transfusion rate is similar to what has previously been reported for conventional turp in patients without anticoagulation. greenlight laser pvp is a viable option for surgical management of bph in patients for whom cessation of oral anticoagulant therapy is contraindicated. introduction and objective: cystinuria is a rare, chronic condition characterised by recurrent urolithiasis. th e condition is due to a variety of genetic mutations in an amino acid transporter and accounts for between . - percent of urinary tract stones. cystine urolithiasis may be treated by preventative medical therapy or therapeutic urological intervention. it is the authors' experience that patients tend to shy away from long-term medical treatment, possibly due to a perceived lack of effi cacy or poorly tolerated side-eff ects. as with all chronic conditions, quality of life for cystinuric patients is expected to be diminished. sub-optimal medical therapy and the need for repeated urological intervention is expected to have a further impact on quality of life. th e authors seek to describe the natural history and quality of life in patients with cystine urolithiasis. th is in turn allows further improvements to the standard-of-care off ered to such patients. a cohort study was carried out involving participants recruited from a single surgeon's case mix. participants suff ering from cystinuria and related urolithiasis were invited to complete a questionnaire involving demographic information, use of medical treatment, surgical interventions and the sf- quality of life survey. attitudes towards the use of current and potential future medical treatments were also explored. results: fourteen participants completed the survey. th e sf- survey showed lower quality of life than the general public in of domains. th e mean interventional rate in patients with cystinuria was . procedures per patient. most patients reported previ-ous use of d-penicillamine and urinary alkalinisation medications, with most ceasing due to side-eff ects or lack of perceived effi cacy. conclusion: cystinuria is associated with a high rate of surgical intervention and lower quality of life than the general public. individuals with this condition report that medical management is either ineff ective or poorly tolerated. th ere is a need for further improvements in medical management of cystinuria, to reduce the rate of operative intervention. recommendations to guide clinical practice, based on patients' experience of cystinuria management can be made. dipstick results: a total patients were retrospectively reviewed for the ph results. th e mean diff erence in ph between spot urine value and the -hr collection values was . ± . ph. higher ph was associated with lower accuracy (p < . ). th e accuracy of spot urine samples to predict -hour ph values of < . was . %, . % for . to . and % for > . . samples taken more than days apart had only % the accuracy of more recent samples (p < . ). th e overall accuracy is lower than % (p < . ). infl uence of diurnal variation was not signifi cant (p = . ). conclusions: spot urine ph by dipstick is not an accurate method for evaluation of the patients with urolithiasis. patients with alkaline urine are more prone to error with reliance on spot urine ph. relationship is the fi rst lithotripter on the market with a unique design that allows for a dual focus system with the option of either a narrow or wide focal zone. ex vivo data on the slk-f lithotripter shows that the disintegration capacity and the renal vascular injury are independent of the focal diameter of the sw generator at the same peak positive pressure and disintegration power. th e objective of this study is to compare the single-treatment success rates of narrow and wide focal zones for the shock wave lithotripsy of renal stones. a total of patients with previously untreated radio-opaque solitary stone located within the renal collecting system, measuring at least mm, were randomized to receive narrow or wide focus lithotripsy while maintaining a constant overall energy level. patients were followed with kub x-rays and renal ultrasound at and weeks post lithotripsy to assess stone area and stone free status. urinary markers indicating the degree of renal cellular damage (microalbulin and beta microglobulin) were measured pre and post swl, hours post swl and days post-treatment. primary outcome was success rate, defi ned as stone-free or adequate fragmentation (sand and asymptomatic fragments <= mm) at months post-treatment. mp- . , figure . introduction and objective: despite being uncommon, infantile kidney stone remains a major health problem due to its higher recurrence rate and morbidity. th e parents usually notice that their infants have recurrent fever and failure to thrive of unknown origin. th ose patients comprise a big challenge for the urologist in management. th erefore, this study aimed to evaluate the outcome of shockwave lithotripsy (swl) in management of renal stones in infants. a retrospective analysis of prospectively collected data performed between january and december for infants underwent swl for single radio-opaque renal stones ≤ mm at a single stone center. swl was performed with dorneir s lithotripter with a maximum of shocks per session. a single session was indicated for each infant, but a second session was performed when satisfactory disintegration was not achieved. follow-up based on urinalysis, urine culture and sensitivity, plain x-ray kidney ureter bladder (kub) and abdominal ultrasonography (us) was carried out weeks post swl and monthly for successive months. multislice computed tomography (msct) was performed -months post-swl to confi rm the stone-free status. results: a total of infants, less than months of age were enrolled in this research. swl success was defi ned as absence of any residual fragments on msct months aft er the last session. stone free rate was . % aft er the fi rst swl session and reached % aft er the second session. rate of retreatment with second session of swl was . %. urinary tract infection (uti) was detected in . %, transient renal obstruction with low grade fever in . % of infants and no major complication had been recorded. conclusion: th e new generation of swl technology with a precise focal area seems to be safe and eff ective in management of kidney calculi in infants. stone introduction and objective: th e incidence of abdominal discomfort is frequent during pregnancy, but renal colic is infrequent. one of the main causes of renal colic during pregnancy is urolithiasis. managements of urolithiasis during pregnancy are hydration, antibiotics, ureteral stent insertion, percutaneous nephrostomy, and ureteroscopic stone removal. in this study, we assessed the reliability and stability of ureteral stent insertion to pregnant patients with renal colic. results: th e overall mean patient age ( years), male to female ratio ( . : ) and mean asa score ( . ) did not vary signifi cantly between years. admissions for elective renal stone procedures, adjusted for population, increased % over the study period. th is growth was entirely in the last years, corresponding with a -fold increase in the use of pyeloscopy (from to cases per year). from the fi rst to last year, there was a % reduction in eswl (from to cases per year) and a % increase in pcnl (from to cases per year). nephrolithotomy ranged from to cases per year. th ere has been an increase in the proportion of associated ureteric stent insertions from % to %. th e proportion of day-only admissions has decreased from % to %. th e average government assigned cost per admission has increased %. conclusion: victorian public hospitals have seen a rapid expansion in the use of pyeloscopy and laser for treatment of renal stones. th is corresponds with a signifi cant increase in admissions for elective renal stone treatment, relatively fewer day-case admissions, higher treatment costs and more associated stent isertions. introduction and objective: th is retrospective study assessed the semirigid ureteroscopy approach coupled with ballistic or ho:yag laser lithotripsy for the treatment of proximal ureteral stones. patients with a single lower calyceal stone with an evidence of a ct diameter between and cm were enrolled in this multicentric study. exclusion criteria were the presence of coagulation impairments, age less than or more than , presence of acute infection, presence of cardiovascular or pulmonary comorbidities. patients were randomized into three groups: group a: patients treated with swl; group b: patients treated with rirs; group c: patients treated with pcnl. patients were controlled with abdomen x-ray and ct scan aft er months. a negative x-ray or an asymptomatic patient with stone fragments less than mm big and a negative urinary colture were the criteria to assess the stone-free status. a statistical analysis was carried out to assess patients' data, success and complications rates, re-treatment rate and need for auxiliary treatment. radiotherapy is an eff ective and common treatment for the prostate cancer. however, there is still an historic deep rooted fear of its use due to the existence of late genitourinary toxicities such as the radiation cystitis. nowadays these toxicities may pose less of a threat due to the use of newer radiotherapy techniques and the reduction of radiation doses applied to the tissues adjacent to the tumor. th e objective of our study is to fi nd predictive factors and determine the cumulative incidence of overall and severe radiation cystitis. conclusion: radiation cystitis is a feared complication of the use of radiation therapy in prostate cancer which occurs infrequently, and the severe cases requiring hospitalization are very rare. th e characteristics of the tumor, purpose of radiotherapy used or radiation dose applied do not seem to infl uence the incidence of radiation cystitis. introduction and objective: th e aim of the study was to assess prognostic factors of biochemical and radiological disease progression (dp) in subgroup of lymph node (ln) positive prostate cancer (pc) pts. evaluation of detection rate of ga-psma pet/ct for biochemical recurrence after radical prostatectomy introduction and objective: prostate specifi c membrane antigen (psma) is overexpressed in more than % of all prostate cancers (pca). since the introduction of pet-imaging with gallium-labelled psma, this method is regarded as a signifi cant step forward in the diagnosis for recurrent pca. from the patients that were scanned for detection of recurrent pca aft er radical prostatectomy between august and december , were evaluable for retrospective analysis. patients underwent pet/ct aft er injection with the ga-hbed-psma. th e potential infl uence of psa-level, primary gleason score (gsc) and psa-doubling time (psa-dt) on the detection rate were evaluated. results: a total of ( %) patients had pathological fi ndings on the ga-psma pet/ct, with an average psa-level of . ng/ml (range . - ng/ ml). detection rates were %, %, % and % for psa-levels < . , . - , > - . and > . respectively. if recurrent pca was detected, oligometastatic disease ( metastasis or less) was most commonly seen ( %). th e detection effi cacy was signifi cantly infl uenced (p< . ) by higher gsc ( % and %, for gsc ≤ and ≥ respectively). for the patients that were evaluated for the infl uence of psa-dt on detection rate, no signifi cant diff erence was found (p= . ) for psa-dt < months and ≥ months (detection rate % and % respectively). conclusion: ga-psma pet/ct has a high detection rate compared to prior studies of conventional imaging modalities, especially in lower range psa-levels. further research is needed to determine to assess whether localization of small volume disease on ga-psma pet/ct can improve diagnostic algorithms and outcomes in patients with recurrent pca. introduction and objective: to assess long-term results of salvage pelvic lymph node dissection (plnd) in prostate cancer (pc) patients (pts) with biochemical recurrence aft er primary local treatment and confi rmed solitary lymph node (ln) metastases. results: a total of , abstracts were screened, full-text papers were considered, and articles were included ( rct, comparative studies, and case series). th is abstract focuses on the comparative studies. primary therapy was prostatectomy in , radiation therapy in , and studies included both therapies. diff erent defi nitions of recurrence were applied among mostly retrospective studies and the adt strategy oft en not specifi ed. factors associated with unfavorable outcomes (overall, pc-specifi c, or metastasis-free survival) included higher age, higher psa nadir, higher gleason score, higher psa-dt, and early start of adt at recurrence. contradictory results were reported on the role of the length of adt aft er ebrt, partly explained by a selection of high risk cases. most patients with disease relapse aft er primary therapy seem not to benefi t from adt while side eff ects are known to be harmful. selected highrisk patients (short psa doubling time, high gleason score) however may have benefi t, and early start of adt may be preferable in this group. an intermittent adt strategy in this setting may be feasible. a rct is indicated, although diffi cult to perform. a personalized approach is warranted, taking disease characteristics, side eff ects, and quality of life into account. adt may only be given in patients with pc recurrence who have high risk characteristics. introduction and objective: locally radio-recurrent prostate cancer (rr-pca) can off er a chance of cure albeit with potential morbidities. current salvage treatment options include radical surgery and minimally-invasive ablative modalities such as hifu and cryosurgery (s-cryo). current data suggests that s-cryo can achieve disease-free survival (dfs) rates up to % at years. however, the majority of data is based on retrospective analysis with mid-term follow-up and there is still paucity of data on longterm outcomes. th e aim of this study was to analyze morbidity and oncological outcomes, with median follow-up years, of s-cryo on rr-pca patients at an academic center. figure ). adverse events were similar between the treatment arms. figure . th ese analyses demonstrates that, during the fi rst year of treatment, men treated with degarelix had a reduced risk of disease-related adverse events. th ere was also a lower risk of death, likely due to the higher incidence of cv events in lhrh agonist patients. introduction and objective: androgen-deprivation therapy (adt) appears to increase cardiovascular (cv) morbidity and mortality in men with prostate cancer, particularly in those with a history of cv disease (cvd). however, the risk is lower with the gonadotropin-releasing hormone (gnrh) antagonist, degarelix, compared with lhrh agonists. here we evaluate regional diff erences in baseline cv status in men with prostate cancer treated with degarelix or lhrh agonists and their subsequent risk of cv events. th is was a pooled analysis of data from three phase studies with a duration > months. individual patient level data on baseline cv status and subsequent cv events over year were summarized by geographic region (usa/canada vs. europe). cv event data were compared using cumulative incidence functions (with all-cause mortality as the competing risk) and cox regression analyses. canada had more severe disease and a higher cv risk (p< . ) ( table ). in men with baseline cvd, cumulative incidence ( % ci) of a cv event was . ( . - . ) in usa/canada vs. . ( . - . ) in europe (p= . ). at baseline, cv status was similar in the degarelix and lhrh agonist groups (table ) . however, in those with baseline cvd, degarelix was associated with a lower risk of subsequent cv events vs. lhrh agonists in both regions (hazard ratio [ % ci]: . [ . - . ]; p= . ). conclusions: men in the usa/canada with prostate cancer and cvd and who were treated with adt were more likely to experience a cv event than their counterparts in europe. th is likely refl ects the greater severity of baseline cvd and higher cv risk in these patients. degarelix reduced the risk of cv events compared with lhrh agonists in both regions. introduction and objective: androgendeprivation therapy (adt) decreases bone mineral density and may increase skeletal complications in metastatic prostate cancer. however, lhrh agonists and gnrh antagonists have diff erential eff ects on follicle-stimulating hormone (fsh), which regulates bone resorption. th e current analysis compared the eff ect of lhrh agonists and the gnrh antagonist, degarelix, on serum alkaline phosphatase (salp), a marker of bone turnover, and the incidence of skeletal adverse events (aes). conclusions: degarelix suppressed s-alp more quickly and for longer than lhrh agonists. it also reduced bone pain and was associated with a lower incidence of fractures. collectively, these data indicate that degarelix provides better control of skeletal disease in men with metastatic prostate cancer, an eff ect that may be mediated by its diff erential eff ect on fsh. prognostic introduction and objective: testosterone (t) regulates nitric oxide synthase and is necessary to achieve an optimum response to pde inhibitors for erectile dysfunction. recently, tadalafi l was found to be eff ective for treating lower urinary tract symptoms (luts) secondary to benign prostatic hyperplasia (bph). we studied the relative importance of the t level in patients with luts and determined whether the t level predicts the response to tadalafi l mg once daily for luts/bph. aft er a -week washout period, men older than years without (n= , t level ≥ ng/dl) and with (n= , t level < ng/dl) hypogonadism were given tadalafi l mg once daily for weeks. we assessed its impact and the severity of luts/bph using the international prostate symptom score (ipss) and bph impact index (bii) and ipss quality-of-life (ipss-qol) subscores. safety was assessed using treatment-emergent adverse events. introduction and objective: diabetes has been reported as a major cause in patients who complain of erectile dysfunction and is frequent in the comorbidity of severe erectile dysfunction. also, patients with diabetes are oft en poor response to treatment for erectile dysfunction. in such patients, according to the mirodenafi l (mvix ) use of the odf (oral decomposition fi lm) mg and mg was to compare the therapeutic eff ects of the treatment period. of the patients with erectile dysfunction were enrolled in a patient with diabetes. and the patients were classifi ed into two groups by randomized double blind controlled trial. th e fi rst group was to take the mirodenafi l odf mg once a daily and the second group was to take a mg at least twice one week, depending on the need to have sexual intercourse. international index of erectile function- (iief- ), international prostate symptom score(ipss) were examined for each time of initial visit, weeks, weeks, weeks. th e questionnaire items of two groups were analyzed at each time point. total of patients were included in the study. th e patients who were taking once a daily were and the patients taking when needed were . th ere was no signifi cant diff erence between age, iief- score, and ipss of each groups on initial visit. ipss score and quality of life score was lowered gradually all aspects in the two groups. iief- score was a tendency to increase in all categories. in comparing the two groups at weeks, once a day group showed a signifi cantly higher score than the group taking when needed for the questionnaire of erection confi dence, erection times, iief- total score(p< . ). th ere was no diff erence between two groups at weeks, weeks. in addition, this study showed the similar therapeutic eff ect between the two groups at end point of continued treatment during the weeks. conclusion: aft er daily dose method weeks, at least twice weekly dosing method and daily dose method is determined to exhibit the same eff ect. th erefore, we think that it is possible to change the intermittent dosing from daily regimen aft er two months. introduction introduction and objective: phosphodiesterase inhibitors (pde i) are the established fi rst line therapy for most cases of erectile dysfunction(ed). it is estimated that - % of ed patients may drop out and discontinue the usage of these drugs. th is study aims to evaluate the patient perspective of discontinuation of on-demand tadalafi l mgm and switching to daily tadalafi l mgm for ed. th e study comprises men with median age years suff ering from ed of average . years duration. co-morbidities included: hypertension ( %), diabetes ( %), dyslipidemia ( %) and smoking ( %). th e primary indication for usage of on-demand tadalafi l mgm was ed. all the patients had used mgm tadalafi l on demand on more than occasions over the last months. results: th irty-eight out of men opted to discontinue on-demand mgm tadalafi l and switch to daily dose mgm tadalafi l. a detailed interview was conducted to identify the reasons for this switch over. th e salient factors were: ) unsatisfactory clinical response to on-demand dose ( %), ) adverse eff ects with on-demand dose ( %), ) concomitant improvement in luts ( %), ) economic factors-daily dose therapy is cheaper than on-demand ( %), ) freedom of spontaneous sexual activity with daily dose ( %), ) patient perception of daily dose as a long-term cure for ed ( %), ) combination of above factors ( %). overall % of patients planned to continue daily dose tadalafi l mgm. conclusion: daily dose tadalafi l mgm appears to be preferred by patients over on-demand mgm tadalafi l for ed treatment. and plateaued aft er two years. in % of men, iief-ef improved by category, in % by and in % by categories. five men remained within the same category despite slight improvements in score, man's score dropped from to changing from "no ed" to "mild ed". fift y six percent men achieved normal erectile function. conclusions: improvements in erectile function were clinically meaningful and signifi cant during the fi rst to years of t therapy and sustained during the full treatment duration. th ey were independent of obesity class. it may be necessary to continue t therapy for to years before an optimal response is achieved. hypogonadal conclusion: all changes were clinically meaningful and sustained for the full observation period, despite the fact that patients' age increased by years. t therapy seems to be highly eff ective in hypogonadal men with t dm, improving both erectile function and glycemic control. needle-free delivery of intracavernosal injections: proof of concept introduction and objective: intracavernosal injection is a well-established second line therapy for the treatment of erectile dysfunction (ed) and has shown very high success rates. despite this, intracavernosal injection is not a therapy suited to all patients for a number of reasons including needle phobia (trypanophobia), pain, and anxiety with self-needling. th e development of needle-free injectable devices has been heralded as a promising advance in the administration of certain vaccines and parenteral medications. initial research into the use of these devices in the delivery of intracavernosal injections however showed inferiority to needle-tipped injectors in terms of efficacy and pain scores. th e use of needle-free injection devices is not currently recognised for the administration of intracavernosal injections. it was the aim of our study to investigate the ability of contemporary needle-free injection devices to successfully deliver intracavernosal injections. two diff erent needle-free injection devices were used to inject . mls of methylene-blue solution into the corporal bodies of a number of australian brangus bullock penises; the bioject®ze-tajet™(spring-loaded fi ring system) and biojector® (pressurized co fi ring system) were used. both products are produced by bioject medical technologies inc., california, usa. all the available syringe depths were used for each device, and compared with the injection of the same volume of methylene-blue with an insulin syringe as a control. following injection, a cross-section of the penis was taken, and the depth of penetration observed macroscopically. results: despite the comparatively thicker and denser tunica albuginia of the bullock penis, the pressurized co device successfully delivered the solution into the corporal body, through the tunica. none of the syringes from the spring-loaded device penetrated the tunica. we have shown that contemporary needle-free injectable devices can in theory be used to administer intracavernosal injections successfully. th e bullock penis model may not be the ideal model for the human penis but we are currently in the process of performing human cadaveric experiments with these devices. needle-free injection devices may be very useful in the administration of intracavernosal injections in the future and extend the use of these therapies to a wider population of patients. penile linear shock wave therapy for poor responders to prior erectile dysfunction therapy ( ), ici with alprostadil ( ), vcd ( ) and muse ( ) . all these patients opted to discontinue these regimen due to unsatisfactory erectile improvement or side eff ects. th ese patients were treated with lswt by renova device with four weekly outpatient sessions without any analgesia or preparation. lswt was applied to four anatomical sites (right, left crura, and right, left corpus cavernosum) at shocks per minute, total shocks per session. patients were followed up at and months aft er the last session. results: at one month follow up statistically significant improvement in iief was recorded in patients ( %) from mean score of . at baseline to . .th e improvement was maintained at months .no side eff ect was noted. overall % patients expressed satisfaction with lswt irrespective of the clinical outcome. conclusion: lswt appears to be a safe and eff ective noninvasive, offi ce based therapy in the management of diffi cult to treat poor responders to prior treatment of ed. introduction and objective: hypogonadism and sexual dysfunction are common clinical presentation in male liver transplant candidate. th e aim of the study was to evaluate the eff ects of living donor liver transplantation (ldlt) on testosterone, sex hormone-binding globulin (shbg), free androgen index (fai) and erectile function in ldlt recipient. introduction and objective: penile size has been a source of major concern and anxiety to the male population since several years. diff erent methods for increasing penile size have been described in the literature, such as, pubopelvic liposuction, lipectomy, suspensory ligament dissection, z-plasty, v-yplasty and injections. combining some of these techniques may be more eff ective to improve the length of the penis. in this study, patients were underwent the combination of z-plasty and suprapubic lipectomy for increasing penile size. between and , patients who complained decreased penile size were underwent surgery. z plasty and suprapubic lipectomy were performed to each patient. informed consent was provided by all participants. th e outcomes were assessed based on the preoperative and postoperative penile length in the fl accid state at maximal stretch and patient-partner satisfaction. th e paired student t test was used for statistical analysis. results: median age of the patients was . ( - ) years. th e etiologies were congenital micropenis in ( %), concealed penis in ( %), previous penile surgery in ( %) and epispadias in ( %) patient. mean preoperative and postoperative penile lengths were . cm ( - cm) and . cm ( . - cm) respectively. th e mean increase in stretched penile length was . ± . cm (minimum . cm, maximum cm) (p< . ). th e patient and partner satisfaction rates were . % ( / ) and . % ( / ) respectively. only one postoperative complication was detected. th is was a wound infection at suprapubic incision site. conclusions: based on our results, the combining of the penoscrotal z-plasty and suprapubic lipectomy is a safety, eff ective and satisfactory procedure for lengthening of the penis in selected cases. corporal lengthening with infl atable penile implants : - ( ) ). recently, we have developed a new technique that combines key aspects of these approaches to create a minimally invasive, no-touch ("mint") technique for penile prosthesis insertion. we theorized that the mint technique would take advantage of the benefi ts that each of these established approaches off ered and therefore our aims were to assess feasibility, safety, post-operative hematoma and infection rate and percentage of patients cycling the prosthesis by weeks. th e principles of the mint technique involve a small infrapubic incision approach combined with a no-touch technique facilitated by using standard surgical drapes ( x clear non-adhesive drape and x ioban® drape) and an alexis® wound retractor. we present results for our fi rst consecutive patients undergoing primary prosthesis implantation from may -july with at least months follow-up. patients having revision surgery, or with complex surgery necessitating > incision were excluded. data was collected using a prospective database. results: average age (±sd) was . (± . ) years. median follow-up was . months. patients had one or more of the following etiologies for erectile dysfunction: vascular disease (n= ), post-radical prostatectomy (n= ), diabetes (n= ), peyronies disease (n= ), venous leak (n= ) and priapism fi brosis (n= ). seventy percent had used intracavernosal injections. implant used: coloplast titan (n= ), american medical systems (lgx; n = ), (cx; n = ). th e average (±sd) cylinder and rear tip extender length was . (± . ) and . (± . ) cms respectively. all operations were completed successfully and there were no peri-operative complications necessitating intervention or re-operation. th ere were post-operative hematomas (treated conservatively). sixty-fi ve percent could cycle prosthesis by weeks. th ere were no post-operative infections. conclusion: th e mint technique for penile implant surgery is a safe and feasible procedure with a zero infection rate in our fi rst patients. effi cacy and safety of botulinum th e initial number of patients to be recruited were twenty-six, but actual patient enrolment was eleven (six control and fi ve botulinum toxin a). all of the patients had a history of vulvar pain for more than six months despite proper medical treatments. patients were randomly assigned to two groups: control -saline injection, toxin -botulinum toxin a (meditoxin® injection, meditox, inc., korea). in both groups, areas of pain were mapped on the vestibule and injections were performed at fi ve sites to cover the entire painful area. th e dosage of each injection was - ml with a maximum cumulative total of ml. at baseline, two, four, and eight weeks aft er the injection, visual analogue scale (vas) and sf- questionnaires were scored. data was analyzed and p value was considered to be signifi cant at < . according to the mann-whitney test. results: th e mean age of patients was . ( - ) years old in the control group and . ( - ) years old in the toxin group. aft er breaking of the blinding, two of the toxin group had iu of botulinum injection, and the others had iu injections. two patients from the control group dropped out because of aggravated pain. th eir vas were and respectively at their drop-out point (baseline and , respectively). at week eight, vas was signifi cantly decreased in toxin group when compared with baseline (table ) . th ere were no drug related adverse reactions. introduction and objective: congenital anomalies of uro-genital system have increased globally as a consequence of higher maternal age at pregnancy and developments in assisted reproductive techniques in the last few decades. aim of the study was to determine the incidence of apparent congenital uro-genital anomalies in north indian newborns and factors associated with them. a prospective study was conducted to collect data of all newborns delivered at our institute between september and august . th e predetermined format included newborn's birth weight and gestational age, maternal age, parity and infertility treatment if any. newborns weighing less than gm or born before weeks of gestation were excluded from the study. results: th ere were , deliveries with , males and females. a total of apparent uro-genital congenital anomalies were recorded with an incidence of . per newborns. th e most common anomaly was cryptorchidism found in newborns, amongst others hypospadias was noted in , ambiguous genitalia in , congenital hernia/hydrocele in , exstrophy-epispadias complex in and prune belly syndrome in newborn. newborns weighing less than , grams had a higher proportion of anomalies ( . %) in comparison to those weighing over , grams having . % (p = . ). maternal age (> yrs), parity (> ) and infertility treatment were recorded in . %, . % and . % respectively and all were independently associated with increased risk of uro-genital anomalies (p= . ). conclusions: incidence of apparent congenital uro-genital anomalies was . %. infertility treatment, parity (> ) and maternal age (> years) were independently associated with increased risk of congenital uro-genital anomalies. comparison conclusions: double-breasting spongioplasty is very good method to decrease complications in hypospadias repair, so it is recommended an as interposing tissue in tipu. advantages of the double breasting spongioplasty are that avoiding of suture line and adding two layers of spongiosum over neourethra decreases the chances of urethral fi stula and gives cylindrical shape to neo-urethra. use stretched penile length (spl) is the standard measurement used in reconstructive penile surgery (rps), but is associated with high inter-rater variability, and is seldom reported. furthermore, ruler-based measurements require that all measurements be made intraoperatively; post-hoc measurements are diffi cult to impossible. we used a novel smartphone application to assess the correlation of post-op digital-photo based length measurements to intra-operative ruler measurements. th congress of the sociÉtÉ internationale d'urologie -siu abstract book materials and methods: intra-operative spl was measured in a consecutive series of pediatric patients undergoing rps who agreed to participate in this study. spl was measured intra-operatively (spl-io), and a picture was taken, with the ruler and from a true lateral view, as proof. a second digital picture was taken at the same time, with a reference object (obj) (object whose dimensions are known and constant). post-op, spl was later measured using the medmeasure! app for iphone and ios android, using the picture with obj, by two diff erent surgeons blinded to intra-op measurements. th e three diff erent measurements (intra-op spl (spl-io), and post-op using the app (spl-s -spl-s ) were then compared to assess overall correlation and correlation to ruler measurements using spss . statistical soft ware package. results: twenty consecutive patients underwent surgery for hypospadias (n= ), buried penis (n= ), epispadias (n= ) and circumcision accident (n= ). median age at surgery was months [ - ]. median penile spl-io was . cm [ . - . ]. when ruler-based measurements (spl-io) and app-photo based measurements were treated as independent measurements (students t test), there was no statistical diff erence between any of the three groups (p . - . ). even with spl-io measurements were treated as the gold standard, by bland-altman limits of agreement analysis, the correlation factor of spl-ip to spl-s & spl-s was > %. conclusions: when compared with intraoperative measurements, digital measurements using medmeasure! are reliable and precise, provided that the picture is taken from a true anterior-posterior or lateral view. because measurements are made based on captured images, a limitless number of length measurements (within the same plane as the reference object) can be made post-hoc. use of digital photography and this smartphone app has the potential to aid in surgical planning, improve documentation, and, facilitate clinical research. aseel's technique for distal penile and coronal hypospadius repair (simple, easy with less complications) introduction and objective: th is technique is modification of the old operation of arab that makes it very simple, easy to learn and even in cases of failure there will be no problem of redoing it or other operation because of the minimal tissue dissection. th is technique was applied in patients. first a transverse ventral incision is done parallel to the circumcision incision and cm proximal to the urethral meatus, figure ( ) . th en proximal and distal skin dissection is done, figure ( ). a longitudinal incision across the urethra plate extending through the meatus is done, figure ( ) and closed transversely that leads to urethral advancement, figure ( ). th en aided by skin hooks the distal skin edge is pulled downwards to create a roof for the advanced urethra, figure ( ) followed by closure of the skin incision, no catheter or stent is left , figure ( ). th is is a -minute operation and the patient is discharged as a day case. results: th irty-eight patients passed without complications and had loss of the skin stitches either partial in cases or complete in cases that were repaired by reapplication of the stitches, no meatal stenosis or fi stula were reported. th is is a very easy technique that can be applied as an outpatient or day case, and done in minutes, with no catheter or stent per urethra left or complications such as urethral meatus stenosis or fi stula formation. th e remained boys ( ) underwent transinguinal laparoscopy during ipsilateral herniorrhaphy. all data were collected prospectively. results: th e incidence of cppv confi rmed by transinguinal laparoscopy was . % ( / ). th e width of hernia sac and mother's age at birth were signifi cant risk factors in the univariate analysis. however, in the multivariate analysis the width of hernia (> cm) sac was only an independent risk factor for cppv (odds ratio . ; p= . ). th e laterality, type of hernia, age, preterm, low birth weight, twin, blood type, father's and mother's age at birth, and the type of delivery were insignifi cant. in this study the width of hernia sac was the independent risk factor for cppv. th is result suggests that the transinguinal laparoscopic examination is benefi cial for the detection of cppv in boys with this risk factor. however, it should be considered in the clinical practice that the one-third of boys with cppv has a narrowed width of hernia sac (< cm). low introduction and objective: traditionally bladder exstrophy complex is managed by staged repair, however now there is trend towards single stage repair. to achieve a satisfactory level of continence, secure abdominal wall closure and preservation of renal functions in patients with bladder exstrophy remains an elusive goal. objective of the study was to assess continence and functional outcome of single stage repair pediatric and adults. materials and methods: th irteen patients, boys and girls with classic bladder exstrophy were treated from to . aft er proper evaluation patients under went complete primary repair of exstrophy repair (ureteric re-implantation, bladder closure with or without cystoplasty, iliac osteotomy, neck reconstruction and epispadias repair). bladder and urethral plate was mobilized as single unit and bladder closure was done to create an adequate capacity bladder. epispadias repair was done by separating the two corpora; tubularization of urethral plate and ventral transposition of neo-urethra to create an orthotopic neomeatus. th en bilateral anterior iliac osteotomies were performed and external fi xators were applied to approximate the pubic symphysis which helps in sphincteroplasty. bladder neck was reconstructed using young dees technique and placed deep within the pelvis; sphincteroplasty was done followed by abdominal wall closure. voiding cysto-urethrography was obtained at months and at one year. continence was defi ned as dry intervals of hours or more. patients were followed-up at , , , months and annually. results: age of patients varied from days to years (mean . years). pre-operative symphyseal gap varied between - cm and post operatively the average diastasis was . cm with the range of cm to cm. in a follow-up period was months to years, patients had good results ( girl and boys) minor supra-pubic leak was present in patients which was managed conservatively, all being able to hold urine for - hours with no leaking at night. colo-cystoplasty was needed in cases with small bladder plate. overall continence rate was . % in single stage. two male incontinent patients were continent aft er second surgery. conclusions: single stage complete bladder exstrophy repair is safe and viable option for both pediatric and adult cases. augmentation enterocystoplasty is required in small bladder capacity cases. anterior iliac osteotomy with approximation of pubic symphysis improves continence and allows tension free closure of abdominal wall and sphincter. long wilms tumor (wt) represents approximately six to seven percent of all pediatric cancers and accounts for more than percent of all tumors of the kidney in the pediatric age group. recently some centers have explored the role of nephron sparing procedures in children with unilateral wilms tumors because of the concern about late occurrence of renal dysfunction aft er unilateral nephrectomy. we assessed the long-term renal functional outcome aft er parenchymal-sparing procedure for non-syndromic unilateral wilms tumor at our center. we retrospectively reviewed the records of all children with unilateral wilms tumor who had undergone nephron sparing surgery at our center. patient's long-term renal function, tumor recurrence, and survival, were determined from a review of each patient's medical record. results: a total of eight patients underwent partial nephrectomy (pn) and the remaining three with polar tumors underwent hemi-nephrectomy (hn) following chemotherapy. smaller tumor volumes were associated with not only preservation of renal function but also increase in egfr during the follow-up period. th e median preoperative egfr was ± . and median egfr at the last follow-up was . ± . . in properly selected children with non-syndromic unilateral wilms tumor, nephron sparing surgery provides excellent renal function preservation. introduction introduction and objective: hyperbaric oxygen (hbo) therapy, which increases the amount of oxygen dissolved in the blood and that carried to tissues, is used in the treatment of several disorders. hbo therapy may be a useful adjunctive treatment in the management of some of challenging conditions encountered in pediatric urology practice. in this paper, we report our experience on the use of hbo therapy in children with urologic problems. we reviewed our department's records to identify pediatric patients who received hbo therapy between and . all patients were evaluated at the department of underwater and hyperbaric medicine and informed consent was obtained from the patient or his parents. total number of hbo sessions was determined based on patient's clinical response to hbo therapy. results: eleven patients received hbo therapy during the study period. all of them were male. th e mean age was . ± . ( - years) . indications of hbo therapy were necrosis aft er hypospadias and epispadias repair, penile glans necrosis, circumcision caused penile skin necrosis, sickle cell crisis induced priapism, and testicular torsion. th e average number of hbo sessions was . ± . ( - ). nine patients ( %) healed aft er hbo therapy, but ( %) patients did not (table ) . . th e essential parameters of kegel exercise are duration of contraction and active relaxation, and, frequency of exercises. to date, exercise duration times could only be captured during in-clinic biofeedback. we hypothesized that a smartphone-based app that provides users biofeedback -and reports mean duration of contraction and relaxation, could help return to continence aft er rp. we designed/made a working prototype of such an app, and validated it. our novel app (ios) was programmed to allow users to record the duration of kegel active pfm contraction and relaxation. it also allows users to record urinary frequency, urgency, voiding, and leakage events, and number of pads used-on a daily basis. it contains a -q visual analog scale questionnaire that queries satisfaction (urinary, sexual, erectile), pain control, depression, sleep quality, and quality of life. data from the app can be "pushed" automatically by the user to a queryable custom database on a hipaa-secure server (ucsf). we provided the app to non-medical colleagues ( women/ men age - ) for evaluation. all completed mock kegel exercises using the app to measure contraction/relaxation duration, which were timed using a stopwatch. measured times were compared to duration times recorded in our database for each user. a -point likert scale was used to query the following items: ) user reported ease of use; ) privacy related anxiety related to use of such an app to submit study data wirelessly; and ) perceived usefulness of the app to improve kegel performance. results: th e pfm contraction and relaxation times recorded by the app within the wireless database disagreed with stop-watch measured duration times by mean +/-< second for all subjects. mean likert scores: . "overall ease of use" score = . (sd . ), "privacy related anxiety" score = . (sd . ), and "usefulness"= . (sd . ). conclusions: our novel smartphone app appears to allow users to accurately record key kegel exercise parameters: duration and progress. th e platform also allows collection of key patient data during daily life. a randomized controlled clinical study is warranted to further assess clinical utility, and, possible means to further enhance utility and research. safety and effi cacy of reduced dose of botulinum toxin-a for patients with detrusor overactivity place j, vyas l, watcyn-jones t, lupton b, miah s, darrad j, kumar v introduction and objective: th is prospective study was carried out to look at the response of a lower dose of botulinum toxin-a for treatment of symptoms of oab, its tolerability and side-eff ects. materials and methods: following due counselling and consenting, all newly diagnosed patients with confi rmed detrusor overactivity on uds (n= , with a mean age of . years (range= - )) were given iu of trigone-sparing, intra-detrusor botulinum toxin-a. of the total of patients, ( . %) were males and ( . %) were females. of this cohort, . % stopped anticholinergic medications because of lack of benefi t. th e rest ( . %) could not tolerate the side eff ects. th e procedure was performed in outpatient department using a fl exible cystoscope under local anaesthetic. th ese patients fi lled up a pre-treatment iciq-sf for oab as well as ui and follow-up scores at week , and . th e per-procedural pain score and follow-up urinary residual volumes were recorded. results: two ( . %) patients did not respond to the treatment at all. in the responders, average scores from the iciq-sf questionnaire fell from the pre-treatment level of . ( - ) to . ( - ) at week , . ( - ) at week and . ( - ) at week (p< . ). th e urgency incontinence scores fell from an average pre-treatment level of . ( - ) to . ( - ) at week follow-up. th e average daytime urinary frequency scores fell from . to . and nocturia scores fell from . to . . five patients went into urinary retention following intra-detrusor botulinum toxin-a injections. in the rest of the cohort, post void residuals remained largely unchanged with pre-procedure fi gure of . mls ( - ) to . mls ( - ) (p=ns). average pain score was . ( - ) on a scale of to . no symptomatic uti was found in post procedural patients. conclusions: th ese results albeit with a small number of cases, have suggested a signifi cant clinical response in over % patients with proven detrusor overactivity with a reduced dose of intra-detrusor botulinum toxin-a injections, thereby maintaining the clinical eff ectiveness of the drug and at the same time reducing the cost of delivery with possibly reduced incidence of urinary retention. prior to the initiation of intravesical onabotulinumtoxina treatment, all patients had an assessment of mid-stream urine for culture and sensitivity, renal tract ultrasound scan, subjective and objective assessments of symptoms (including iciq-ui and iciq-oab questionnaires) and conventional urodynamic study. all patients had proven overactive bladder. onabotulinumtoxina effi cacy and durability was assessed by subjective and objective assessments of symptoms. results: duration of effi cacy of onabotulinumtoxi-na injections is well maintained in the idoa group in comparison with noab group. th ese trends are shown in figure . four injections out of administered in total to the idoa group were unsuccessful ( . %) and brought no relief of symptoms to the patient. th ere were no unsuccessful treatments in the ndoa group ( / total injections administered). results: from the general practitioner's records, none of the non-traceable patients were on botulinum toxin-a treatment elsewhere. of the total number of traceable patients (n= ), ( %) stayed on mirabegron alone. of these % were satisfi ed ( / ). as a whole . % ( / ) were satisfi ed and continued with mirabegron only. one patient moved to combined mirabegron with an anticholinergic. of the patients on mirabegron iciq-sf scores fell from . ( - ) to . ( - ) at months. eighteen of ( %) patients progressed requiring botulinum toxin a treatment. side-eff ects included-palpitations ( ), vomiting ( ), rashes ( ), lethargy ( ) and yellow urine ( ) . th is study showed that % of patient with refractory oab symptoms awaiting fi rst or subsequent treatment with intra-detrusor botulinum toxin a injections will respond to mirabegron and % of these responders ( . % of total) are able to come off botulinum toxin a at months, reducing the burden of the waiting list; with a cost reduction mirabegron= £ vs cost of botulinum toxin a= £ /year/patient. th is is a small study but provides a medium-term option for patients on long waiting list for botulinum toxin a thereby helping to limit use of botulinum toxin-a for patients with detrusor overactivity. introduction and objective: patients that fail to achieve symptom improvements with sacral neuromodulation (snm) may benefi t from increased aff erent stimulation via tined lead placement at the pudendal nerve. we evaluated −year outcomes of chronic pudendal neuromodulation (cpn) in patients that had failed sacral neuromodulation (snm). adults enrolled in our prospective observational neuromodulation study that had a pudendal lead placed were evaluated. medical records were reviewed. outcomes were measured at , , and months with interstitial cystitis symptom/problem indices (icsi−pi), overactive bladder questionnaire (oabq) symptom severity (ss) and quality of life (qol), voiding diaries, and global response assessments (gra analysis of voiding dysfunction after transobturator tape procedure for stress urinary incontinence introduction and objective: voiding dysfunction is common complication of midurethral sling surgery (mus) for stress urinary incontinence. however, the defi nition of post-mus voiding dysfunction is inconsistent in the literature. subjective feeling of slow stream, signifi cant postvoid residual (pvr), additional procedure for bladder emptying, or objective fl ow rates can be a yardstick of voiding dysfunction. in this study we retrospectively investigated the risk factors for post transobturator tape procedure (tot) voiding dysfunction applying various defi nitions in one cohort. four hundred fi ft een patients were evaluated who underwent tot. preoperative urodynamic study were performed and urofl owmetry and international prostate symptom score questionnaire were investigated pre and post-operatively. several postoperatively parameters representing voiding dysfunction were adopted for analysis. acute urinary retention requiring catheterization (aur), subjective feeling of voiding diffi culty during follow-up (vd), and signifi cant postoperative pvr greater than ml or more than % of voided volume (pvr) were adopted for categorization of the defi nition of voiding dysfunction. results: sixteen patients ( . %) required catheterization, ( . %) experienced post-operative voiding diffi culty, ( . %) and ( . %) showed low fl ow rate and signifi cant pvr. in the aur and vd category, concomitant co-operation and general anesthesia were signifi cant parameters, especially anteroposterior repair of vagina. older and menopaused patients complained subjective voiding diffi culty. th e patients in vd category showed lower fl ow rates and larger pvrs. patients in pvr category had old age and low preoperative fl ow rates. th e patients with vd tend to be prescribed alpha blocker during postoperative follow-up period. th ere were no signifi cant urodynamic parameters attributing for various voiding dysfunction categories. with logistic regression analysis aur, vd and pvr category had concomitant co-operation and preoperative retention history as risk factors. conclusion: several factors including preoperative voiding symptoms and intraoperative parameters such as co-operation may aff ect postoperative voiding dysfunction. th e diversity in clinical presentation underscores the importance of a high clinical suspicion with an appropriate diagnostic evaluation. subjective and objective voiding dysfunction should be evaluated aft er midurethral sling operation. introduction and objective: some have hypothesized that patients with lower functional bladder capacity (fbc) experience less improvement in symptoms after staged neuromodulation procedures. th erefore, we evaluated the impact of baseline fbc on generator implant rate and symptom changes. adults enrolled in our prospective observational neuromodulation study were evaluated. functional bladder capacity (fbc) was defi ned as average volume per void on day voiding diary. data were collected from medical records, and validated interstitial cystitis symptom/problem indices (icsi−pi) and overactive bladder questionnaire (oabq) symptom severity and health related quality of life (hrqol) domains, and examined with descriptive statistics, wilcoxon rank sum tests, logistic regression, and spearman correlation coeffi cients. results: of patients (mean age . ± . years; % female), most had urinary urgency/frequency with or without urge incontinence ( %) and a sacral lead placed ( %); % had the lead placed at the pudendal nerve. mean fbc at baseline was . ± . ml. among the , ( %) had ≥ % improvement in overall symptoms aft er lead placement with subsequent generator implant. baseline fbc was similar between implanted/not implanted patients (p= . ), however implanted patients had a median . % increase in fbc aft er lead placement compared to explanted patients whose fbc decreased by median . % (p= . ). logistic regression identifi ed a strong relationship between percent change in fbc aft er lead placement and generator implant (p= . ) but there was no relationship between baseline fbc (ml) and subsequent generator implant. at months, a lower pre-implant fbc weakly predicted a greater improvement in oab-q hrqol from baseline (p= . ; r = - . ). fbc (ml) at baseline, or percent change in fbc aft er lead placement, had no relationship with achieving at least % improvement in icsi−pi or oab−q symptom severity scores at months. conclusions: lower baseline fbc should not be a contraindication to neuromodulation since there was no impact on outcomes. improved fbc aft er lead placement may have contributed to overall improvements in symptoms leading to generator implant. improvement in fbc was equal to or greater than that seen in medical treatment trials for oab. introduction and objective: to present our preliminary experience with the sars (sacral anterior root stimulator) in spinal cord-injury patients with hyperactive bladder at our center. th e sars is an implantable electronic device that allows patients with spinal cord injury to assume voluntary control of micturition, defecation and erectile function. it involves a s -s dorsal (sensitive) rhizotomy and placement of electrodes around those roots, which are connected to a subcutaneous receiver antenna. by transcutaneous radiofrequency stimulation of that antenna the patient can selectively use stimulation programs to activate the diff erent functions: program for micturition, program for defecation and program for erection. results: between january and november nine sars implants (eight men and one woman) were performed in patients with spinal cord injury-related overactive bladder refractory to standard conservative treatment. average age was years and mean follow-up was months (range - ). bladder function: eight of the nine patients exhibit an increase of the bladder capacity and use the device - times daily, voiding - cc with ≤ cc residual urine. one of these patients showed de-novo postoperative stress incontinence due to sphincter incompetence that was solved with placement of a suburethral sling. th e ninth case had a poor compliance and low capacity bladder; despite sars, he failed to increase capacity and persisted incontinent so aft er months he underwent a continent urinary reservoir. voiding objectives were therefore achieved in / patients ( % success). defecation: all patients use the device once a day. erectile function: of the eight male patients, seven achieved erection with sars. however, this erection was not always reliable for intercourse; patients associate sildenafi l and eventually requested a penile prosthesis implantation. complications: th ere were no postoperative complications or failure of the internal components. one patient showed a transient s neurapraxia, which resolved spontaneously aft er months. conclusion: in selected spinal cord injury patients, sars is an excellent option for urinary and defecatory control, being also useful for erectile function in some of them. how to determine the complication rate of urolastic (vinyl dimethyl polydimethylsiloxane, pdms), a bulking agent for female stress urinary incontinence. twenty-eight females with stress urinary incontinence were treated with pdms. th e group mainly consisted of secondary patients (n= ), with extensive comorbidity. six patients had one previous surgical procedure for sui; nine underwent two procedures and ten received three or more interventions. an amount of . - . ml of pdms was injected at - positions paraurethrally at the midurethra. procedures were performed on the outpatient department, with local anaesthesia. th e clavien dindo score was determined aft er months, to assess the severity of the complications encountered. results: aft er six months, % ( / ) of the patients reported a % improvement, % ( / ) a - % improvement and % ( / ) a - % improvement, % ( / ) reported % improvement and % ( / ) was % improved. six patients ( %) had no improvement aft er six months, four of which had also not shown initial improvement. in one patient the implants were removed during surgery, so no follow-up was available. of twenty-eight patients treated, % ( / ) had no complications. in % ( / ) complications were seen, which were classifi ed following the clavien dindo-classifi cation. a score of i was appointed to % ( / ) of the patients. reasons were: implant-exposure, minor pain, anti-emetics use or de novo retention. th ree patients had a score of ii, because of more severe complaints of pain or urge. th ey were treated pharmacologically. in % ( / ) one or more implants were removed, mostly due to exposure, erosion or pain. removal under local anaesthesia was performed in % ( / ) of the patients and this resulted in a iiia-score. th ree patients ( %) had a iiib-score, which meant the implant(s) were removed under general anaesthesia. in the fi rst twenty-eight diffi cult to treat patients receiving pdms, in ten cases a clavien dindo grade ii-iiib is scored, mainly because of surgical removal of implants. in spite of the seemingly high complication rate, this remains a useful therapeutical option for female stress urinary incontinence. magnetic stimulation for stress urinary incontinence: a randomized, double-blind, sham-controlled trial introduction and objective: we conducted a multicenter, randomized, double-blind, sham-controlled trial to evaluate the effi cacy of magnetic stimulation (ms) for stress urinary incontinence (sui). a total of sui subjects were randomized : to active or sham ms for eight weeks (twice weekly). th e primary criterion for response was a reduction of points or more in the international consultation on incontinence questionnaire for urinary incontinence-short form (iciq-ui sf). th e secondary outcomes included objective (leakage of less than gram on -hour pad test) and subjective cure (a 'never' response to 'how oft en do you leak urine?), incontinence diary, pelvic fl oor muscle strength, urofl owmetry, patient global impression of improvement (pgi-i) and international consultation on incontinence questionnaire-lower urinary tract symptoms quality of life (iciq-lutsqol). results: using the primary criterion, ( . %) of subjects were treatment responders in the active group compared to ( . %) of subjects in the sham group (relative risk (rr) . , % ci . - . , p< . ). based on objective cure, ( . %) subjects in the active group were dry versus ( . %) subjects in the sham group (rr . , % ci . - . , p< . ). nineteen ( . %) in the active group and ( %) subjects in the sham group perceived themselves as dry (rr . , % ci . - . , p< . ). th e active group had greater reductions (p< . ) in incontinence frequency than the sham group. changes in pelvic fl oor muscle strength and urofl owmetry parameters were not statistically signifi cant between groups (p> . ). th irty-nine ( %) subjects in the active group reported signifi cant benefi ts (much/very much better) for pgi-i rating compared to ( . %) subjects in the sham group (p< . ). all item scores in iciq-lutsqol were not statistically diff erent (p> . ) except 'eff ect on friends' , 'smell' , feeling of embarrassment' and 'overall impact' in the active group. of all evaluable subjects, ( . %) of subjects in the active group and ( . %) of subjects in the sham group experienced adverse events (p= . ). conclusions: modifi ed tvt abbrevo is a simple, safe and eff ective procedure with comparable short-midterm cure rates to standard tvt abbrevo. th e modifi cations of avoiding the tunnelling device and groin exit helped to minimize the groin pain and analgesic requirements. evaluation of standard practice for artifi cial urinary sphincter implantation auckland dhb, auckland, new zealand; ucd medical center, sacramento, usa introduction and objective: th e artifi cial urinary sphincter (aus) has been available since and over this time it has established itself as the gold standard in management of post prostatectomy incontinence. th e successes, failures and diffi culties are well documented, however little is published regarding the standard implantation practice of the aus. our objective was to review the standard practice for implantation of the aus within a group of high volume implanters. aft er obtaining institutional review board ethical approval a web-based questionnaire was designed using survey monkey soft ware. an email was sent to the current members of the society of genitourinary reconstructive surgeons (gurs) explaining the aims of the confi dential questionnaire with a web link to the aforementioned questionnaire. all results were collected via survey monkey and were then analyzed. results: one hundred and twenty gurs members were contacted by email, members replied. th is group averaged aus placements a year (range to ). pre-operative assessment utilized routinely included pad weights in . %, pad numbers in . % and urodynamic studies in % of participants. additionally % of participants surveyed would routinely perform a cystoscopy in the pre-operative assessment ninety four percent of those surveyed used greater than one pre-operative antibiotic; most commonly gentamicin with either vancomycin or cefazolin. th e antibiotic most commonly utilized alone was levofl oxacin. post-operatively % continue antibiotics anywhere between hours and month, with % continuing intravenous antibiotics for a minimum of days. intra-operatively % have aus componentry prepared on a separate set up stand. th e single cuff aus, size . and . cm cuff were the most commonly placed cuff s, with the - cm reservoirs. radio-opaque contrast is used by % of participants in the aus reservoir. only % of participants would recommend a medical alert bracelet in the post-operative period, and % encourage pump traction. conclusion: despite a uniform technique recommended for the implantation of the aus by american medical systems in order to improve success and decrease complications, there is great heterogeneity in pre-operative assessment, surgical placement and post-operative management of the aus in a cohort of high volume implanters. patients presenting to a multi-disciplinary stone clinic were administered a survey. th ey were asked to elect a treatment modality from shock wave lithotripsy (swl), ureteroscopy (urs) or percutaneous nephrolithotomy (pcnl) for a hypothetical mm kidney stone. th e success rates ( % swl, % urs and % pcnl), morbidity and the risks associated with each treatment options were explained. patients were also to elect whether personal or doctors' decision of treatment is most preferred and the most important variable in deciding a choice of treatment modality. results: of the respondents with mean age . ± . , female/male ratio was : ( figure ). majority of the subjects ( %) elected urs as their treatment choice (table ) . previous experience with urs (p= . ) and pcnl (p= . ) impacted the choice of urs. th e respondents were equally distributed in their primary concern being success rate ( %) versus risks ( %) associated with the procedure of choice (p= . ). age and gender has no infl uence on treatment choice (p= . and p= . ) and on whether the primary concern is success or risk (p= . and p= . respectively). majority ( %) of the surveyed population would prefer the physician recommend the appropriate treatment. conclusion: th ough patients prefer the physician to recommend the appropriate treatment for a medium-sized renal stone, it is important for the physician to consider the patient's priorities of minimizing risk versus maximizing success. as such, majority of patients selected ureteroscopy as a procedure with a balance of moderate risk and moderate success. solo introduction and objective: sonography has been brought in percutaneous nephrolithotripsy (pcnl) as an adjunct to x-ray to restrict radiation exposure. th is study was designed to respond this question that "is sonography proper enough to supersede x-ray in pcnl under spinal anesthesia?" moreover, we investigated possible predictors of success. tract infection were excluded from study. th e intraand post-operative surgical outcomes were evaluated. results: th e mean age of the patients was . ± . years. mean stone size was . ± . cm. mean access and operative time were . ± . and ± . minutes respectively. superior calyx was selected for access in % of patients. th e patients were categorized in following groups; history of more than one section previously open stone surgery ( %), horseshoe kidney ( %), major lumbosacral deformity ( %), failed standard pcnl ( %), children under years old ( %), pregnancy ( %). th e primary complete stone free rate was %, and aft er ancillary procedures (urs, swl), raised to %. th e mean hemoglobin drop was . ± . gr/dl. transfusion needs in patients. signifi cant prolonged or delay hemorrhage was not shown in any cases. pneumothorax was detected in one patient that managed with chest tube insertion. visceral or solid abdominal organ injury was not occurred. conclusion: with some attention, the outcomes of ultrasonography-guided pcnl for challenging renal stones are comparable with standard fl uoroscopic approach, and in some situation, fl ank position contain benefi ts rather than standard prone position. study of ten cases of p.c.n.l in "previously operated kidney stone with incisional hernia" conclusions: p.c.n.l in incision hernia patient is a safe procedure with excellent results. c.t. urogram is necessary tool for puncture. st puncture in virgin fi eld (out of incisional hernia site) and avoiding colonic gas shadow on fl uoroscopy is key point. bowel injury is the concern -which should be taken care during puncture. daycare pcnl: now a reality! introduction and objective: pcnl as a therapy for renal stones is an established modality. th e use of holmium laser has led to miniaturisation of instruments and sheaths and has thus made the procedure less morbid. a stage has come for the patient to now leave hospital on the same day of the procedure. materials and methods: all cases were done under spinal anaesthesia and prone position. aft er placing a retrograde ureteric catheter, pcs was accessed through the appropriate calyx, and a french sheath with suction capability was used. holmium laser was the energy used. aft er fragmentation, clearance was achieved by a combination of suction and retrograde wash and confi rmed radiologically and visually. clots were fl ushed out through the sheath which was then removed having retained the guide wire. finger pressure on the puncture site achieved haemostasis. th e guide wire and the retrograde catheter were fi nally removed. no urethral catheter was kept. a total tubeless procedure in the real sense. all patients were counselled about haematuria and pain. results: from january to march , a total of cases are included comprising renal and upper ureteric stones. stone size ranged from . to . cms. age ranged from to yrs. th e m/f ratio was : . operative time ranged from to mins. th ere was no signifi cant blood loss. all patients received dose of a parenteral analgesic hrs post procedure, were ambulant hours postopt and were allowed oral liquids. patient had leak at puncture site lasting for hours .all had haematuria which cleared completely within to hours. all were off ered discharge on the same day without any major event. one patient had clot retention on the th po day requiring clot evacuation. conclusion: pcnl as a day care procedure has been achieved by the above described method. patient acceptance is fair though most showed apprehension of going home the same day aft er a major procedure. whether it can be accepted universally remains to be seen. initial experience in ultraminiperc we have reviewed our initial experience of ultra-miniperc-ump in patients. between june and march , total patients underwent ultra-miniperc. puncture and dilatation were done under fl uoroscopy in prone position. we used and fr ump amplatz. stones were fragmented by holmium laser and removed by whirlpool eff ect. post-operative stone-free status was confi rmed by ultrasonography and x-ray aft er week. results: mean patient age was years ( to years) and male to female ratio was . : . in % the procedure was bilateral simultaneous and in % in solitary kidney. stone locations were lower calyx ( %); upper calyx ( %), middle calyx ( %), renal pelvis ( %), upper ureter ( %) and rest were at multiple sites. calyx punctures were lower ( %), upper ( %), middle ( %) and multiple in rest. eight punctures were supracostal. mean operative time from puncture to amplatz removal was minutes (range to minutes). signifi cant bleeding (hb drop more than . gm/dl) was in %. all were managed conservatively without transfusion. dj stents were kept in patients. nephrostomy-tube was not kept in any patient. eleven percent of patients had minor complications like pleural eff usion ( %), uti-fever ( %), and mild hematuria ( %). all were managed conservatively. one patient required conversion to miniperc- fr track due to intraoperative poor vision. mean hospital stay was days ( - days). th ree patients required readmission for fever or clot colic. stone-free rate was %. eight percent had small fragments that were treated by oral hydrotherapy. two patients were treated by eswl. introduction and objective: a prospective randomized controlled study was executed to compare minipercutaneous nephrolithotomy (miniperc) and retrograde intrarenal surgery (rirs) in the management of renal stones larger than mm in a single session. between june and february , patients presenting with renal stones > mm were randomized to a miniperc or a rirs group in a ratio of : . randomization was performed by a biostatistician and opened to the surgeon at the time of the patient's admission on the day before surgery. patient and stone characteristics, perioperative outcomes, and complications were compared between the two groups. th e primary end point was "stonefree", which was defi ned as no residual stone or stones < mm on computed tomography within months postoperatively. results: th irty-fi ve patients (miniperc) and (rirs) were included in the fi nal analysis. th ere were no statistically signifi cant diff erences in stone size ( . ± . versus . ± . mm, p= . ) and stone number ( . ± . versus . ± . , p= . ) between the miniperc and rirs groups. laterality, mean hounsfi eld units, stone location, presence of staghorn stone, and stone composition were similar between the both groups (p> . ). miniperc and rirs had stone free rates of . % and . %, respectively (p= . ). operation time ( . ± . versus . ± . minutes, p= . ), hemoglobin drop ( . ± . versus . ± . g/dl, p= . ), and hospital stay ( . ± . versus . ± . days, p= . ) were similar between the two groups. pain visual analogue score at hour postoperatively ( . ± . versus . ± . , p= . ) and analgesic requirement ( . % versus . %, p= . ) were lower in the miniperc group. two patients in the miniperc group and in the rirs group had minor pelvic or ureter perforation. one patient in each of both groups had hypertension and urinary tract infection. miniperc and rirs are safe and feasible surgical options for managing renal stones larger than mm. rirs had a little higher stone free rates, but more immediate postoperative pain and higher analgesic requirement compared with miniperc. colonic perforation during percutaneous nephrolithotomy darabi mahboub m, aslzare m, shakiba b introduction and objective: percutaneous nephrolithotomy (pcnl) is the treatment of choice for large, extracorporeal lithotripsy failure stones and those in the inferior calyx. despite the development of new techniques and the increasing experience in recent decades, complications may still occur. colonic perforation is one of the most dangerous and rare complications of pcnl, which may lead to peritonitis and sepsis. we present our -year experience on the diagnosis and management of colonic perforation during pcnl. we retrospectively reviewed the data of pcnl procedures performed between may and august . preoperative and operative factors, such as age, sex, history of previous ipsilateral stone intervention, stone side, stone location, site of skin puncture and punctured calyx, were reviewed in patients with colonic injury. results: colonic perforation was found in patients ( males and females) and the mean age was . ± . years (range: to ). all injuries were retroperitoneal. th e left side was aff ected in patients and the right side was injured in cases. conservative management was the treatment planned for all patients. it included withdrawal of the nephrostomy tube outside the kidney to the colon as a percutaneous colostomy, insertion of a double-j ureteral stent, intravenous broad-spectrum antibiotics, bowel rest and total parenteral nutrition. under this conservative management, complete healing of the colon was achieved in all patients. early diagnosis and conservative management of colonic perforation can minimize patient morbidity and mortality and result in excellent healing of the fi stulous tract without any serious complications. colon materials and methods: during ten years, pnl procedures performed in our center. extraperitoneal colonic perforation complicated procedures. all cases were managed without any tube in the colon. we took a retroperitoneal drain through pnl tract and a double-j stent inserted in all cases. we reported the results of our cases that managed without colostomy tube. results: male to female ratio was / . th e diagnosis was established aft er nephrostomy tract dilation and nephroscope insertion before lithotripsy in two cases and in other cases, at the end of nephrolithotomy during amplatz sheath removal. conservative treatment was successful in all cases. mean hospital stay was / days. th ere wasn't any fever or other major complication. conclusions: it seems that management of retroperitoneal colonic perforation when diagnosed intraoperatively during tubeless pnl without colostomy tube is safe and eff ective. does intercostals nerve block and peritubal nerve block with bupivacaine reduce post-operative pain after percutaneous nephrolithomy? introduction and objective: to fi nd the most eff ective post-operative analgesia method aft er percutaneous nephrolithotomy (pcnl). in a prospective, -months duration study all patients undergoing pcnl (tubeless or with -f nephrostomy) were divided into groups. group (pcnl in fi rst- -months) had no intervention; group (pcnl between and months) received intercostal block (icb) with . % bupivacaine; group (pcnl in last -months of study) had peritubal track infi ltration (pti) with . % bupivacaine at end of procedure. visual analog pain scores and rescue analgesia requirements at , , and hours in the arms were compared. results: see table . conclusions: peritubular tract infi ltration with bupivacaine established its superiority over both intercostal block and standard pcnl for post-operative analgesia and rescue analgesic requirements. the post-operative fever was defi ned as body temperature above . within hospital stay. relationship between clinical factors and sirs or post-operation fever was assessed using logistic regression analysis. results: a total of male ( . %) and female ( . %) were enrolled in our study (table ) . forty-fi ve cases ( . %) developed sirs and fever was observed in cases ( . %). shock was observed in ( . %) cases. in univariate analysis, stone size (p = . ) and urine wbc (p = . ) were found to be the predictors of sirs. in multivariate logistic analysis, stone size (or= . , p= . ) and urine wbc (or= . , p= . ) were signifi cantly related to the development of sirs (table ). in univariate analysis, post-operative fever was found to be associated with the location of stones (p= . ), stone size (p= . ), urine wbc (p< . ) and albumin (p= . ). by multivariate logistic regression analysis, only stone size (or= . , p= . ), urine wbc (or= . , p= . ) and serum albumin (or= . , p= . ) were associated with post-operative fever (table ) . conclusion: patients with larger stone size and urinary tract infection before surgery might have higher risk of developing sirs and fever, while a normal serum albumin was found to be the protective factors of fever development. introduction and objective: perioperative hemorrhage owing to high vascularity in bph is the fearsome complication of turp that leads to clot retention, reoperation and oft en requiring blood transfusion. finasteride, a type α-reductase inhibitor, by interacting with vascular endothelial growth factor (vegf), reduces prostatic angiogenesis. microvessel density (mvd) is a histological measurement of angiogenesis and thus a marker of bleeding. we aim to determine the eff ect of two weeks preoperative fi nasteride therapy in reducing prostate vascularity in terms of mean microvessel density (mvd) and expression of vegf in prostate urothelium among patients of bph by comparing with controls. trial has been conducted in department of urology at shifa international hospital islamabad from jan to jan . total patients of benign prostatic hyperplasia (bph) planned for transurethral resection of prostate (turp) having prostate sized of more than grams on trans-abdominal ultrasonography were randomized into two groups each group having patients. th e finasteride group (group a) was prescribed oral mg of fi nasteride daily for weeks before surgery. th e control group (group b) didn't receive any drug. aft er weeks, turp was performed and prostate chips were sent for histopathological determination of mvd and expression of vegf. results: mean age . ± . years, ranging from minimum of years to years. th e mean prostate gland size was comparable in both groups ( ± . grams vs. . ± . grams). mean mvd in fi nasteride group was . ± . whereas in control group mean mvd was . ± . . when compared the mean mvd in both group, the mean mvd was signifi cantly low in fi nasteride group as compared to control group with a p= < . . similarly mean expression of vegf was % in fi nasteride group compared to % in control group. th is expression of vegf was also signifi cantly lower in fi nasteride group as compared to control group (p= . ). also mean mvd was clearly correlated with size of prostate gland and the correlation was found statistically signifi cant on pearson correlation test ( -tailed) with p= . . conclusion: finasteride reduces microvessel density and hence prostate vascularity with only week therapy and the mean mvd is clearly correlated with size of prostate. characteristics -alpha reductase inhibitor induced prostate volume reductions yun j , yang h , kim d , jeon y , lee c introduction and objective: benign prostatic hyperplasia develops in the transition zone of the prostate and α-reductase inhibitors ( -aris) reduce prostate volume. we investigated whether oral treatment with the -aris dutasteride and fi nasteride more significantly aff ected volume reduction in the transition zone or in the entire prostate. total prostate and transition zone volumes (tpv and tzv) were measured at baseline using a transrectal ultrasound (trus) and then at yr aft er the commencement of dutasteride ( . mg) or fi nasteride ( . mg). th e ratio of tpv to tzv was used to determine the transition zone index (tzi). volume reduction (%) was calculated as the ratio of volume reduction to baseline prostate volume. additionally, serum prostate specifi c antigen (psa) concentrations were measured at baseline and then at yr aft er the -ari were commenced. results: all of the patients (mean age, . yr ± . ; range, - yr) with clinical lower urinary tract symptoms suggestive of benign prostatic hyperplasia and who were -ari naïve were prescribed dutasteride ( . mg, . %, / ) or fi nasteride ( . mg, . %, / ) for more than yr ( . ± . mos). at baseline, the mean tpv, tzv, and tzi values were . ± . cm , . ± . cm , and . ± . , respectively. at yr aft er the commencement of the -ari, the mean tpv, tzv, and tzi were . ± . cm , . ± . cm , and . ± . , respectively. th e tzi value is not signifi cantly diff erent at yr compared with baseline (p > . ), while the tpv and tzv reductions are . ± . % and . ± . %, respectively; there is no signifi cant diff erence between the tpv and tzv volume reductions (p> . ). conclusion: th ese results show that prostate volume reduction induced by -aris occurs in the entire prostate universally, rather than in the transition zone specifi cally. russo g, favilla v, privitera s, castelli t, fragalà e, cimino s, morgia g introduction and objective: combination therapy with of -alpha reductase inhibitors ( -ari) and alpha-blockers (ab) is the gold standard for the treatment of moderate-severe secondary to benign prostatic hyperplasia (bph). several clinical trials have already analyzed the overall impact of the medical treatment of luts/bph on sexual sphere, but any one investigated the overall impact on erectile dysfunction (ed) and libido alterations (la). th e aim of this this systematic review and meta-analysis was to evaluate the impact of combination therapy on ed and la from randomized clinical trial (rct). we performed a search of the cochrane central register of controlled trials, pubmed, embase, cochrane database of systematic review, and web of science, until december . we conducted a meta-analysis to determine the impact of combination therapy ( ari + ab) in determining the onset of ed or la. a p value < . was used to denote the presence of heterogeneity. of the studies reviewed, only fi ve rct were included, involving participants. th e overall prevalence of erectile dysfunction was of . %, . % and . % in patients treated with combination therapy, ari and ab respectively. th e overall prevalence of altered libido was of . %, . % and . % in patients treated with combination therapy, ari and ab respectively. combination therapy ari + ab was found to be associated with increased risk of ed (or = . ; p < . ) and la (or = : ; p = . ) compared to monotherapy with ab. th e combination therapy was found to increase the risk of ed (or = . ; p = . ) compared to monotherapy with ari, but not the risk of la (or = : ; p = . ). analyzing the individual monotherapies, therapy with alpha-blockers signifi cantly reduces the risk of ed (or = . ; p < . ) and la (or = . ; p = . ) compared to treatment with ari. conclusions: combination therapy ari + ab is associated with a higher risk of ed. in addition, ari monotherapy has the same risk of the combination of having la. th ese results could be taken into account during the counseling therapy in patients with luts/ bph. mladenov b, mariyanovski v introduction and objective: bph bleeding is one of the common causes of gross hematuria in older men. -alpha reductase inhibitor ( ari) treatment has been showed to reduce prostate tissue microvascularity and to prevent bph-associated hematuria. alpha-blockers are oft en prescribed, where their eff ect on hematuria is not well evaluated. th e aim of this study was to investigate the impact and effi cacy of the current used drugs for bph for treatment and prevention of bph-caused hematuria. a total of men with median age of were enrolled for a period of years. all were presented with bph-caused macrospopic hematuria, diagnosed according to an adopted investigation protocol. detailed history was obtained, including usage of alpha-blockers and/or -ari prior to the hematuria episode. patients were released or immediately hospitalized and catheterized according to their status. all patients were followed up for year for recurrent bleeding and were divided into groups -with an alpha-blocker, -ari, or without therapy. in this study patients were sent home and treated conservatively, other with severe bleeding and/or clot retention necessitated catheterization and hospitalization. from patients ( %) were taking alpha-blockers, ( %) -ari, and ( %) had no medications for the bph prior to the hematuria. patients were followed up for recurrent bleeding for year in medication groups. were given alpha-blockers, - -ari and were released without medication for the bph. within year bph-bleeding occur respectively in , , and cases. th ere was a statistically signifi cant diff erence between the group with -ari therapy and the group without therapy (p= . ). no statistically signifi cant diff erence (p= . ) was found between the groups with an alpha-blocker and without therapy. in all cases with medication the hematuria episodes were lighter according to blood loss and/or hospital stay (in days) than the initial one. conclusions: according to our study, bph-associated hematuria can be eff ectively controlled and reduced with ari. although as per our data alpha-blockers have a positive eff ect on the intensity of the recurrent hematuria, much more signifi cant results in treating and controlling bph-bleeding are shown with -ari. effi overactive bladder syndrome (oab) is a common condition with a negative impact on quality of life. botulinum toxin is commonly used. despite the favorable outcomes seen using botulinum toxin a, the method of injection and side eff ects still need to be solved. our aim is to use botulinium toxin with simple method and check its safety and effi cacy. a total of patients with refractory oab were included in this study. inclusion criteria was refractory non neurogenic oab not responding to conservative management for at least months. aft er written consent, patients were randomly divided into two groups. group a ( patients) received botulinium toxin a unit intravesical instillation diluted in cc normal saline, group b ( patients) received placebo in the form of cc normal saline by the same method. patients were evaluated initially by history, physical examination, overactive bladder symptom score (oabss), quality of life symptom score (qolss), urine analysis, routine laboratory investigations, kub, pelviabdominal ultrasound and urodynamics. patients were followed up at one, and two month post instillation for effi cacy and safety by oabss, qol score, side eff ects and postvoid residual urine. introduction and objective: th e authors evaluate the safety and effi cacy of the prostatic urethral lift when performed in conjunction with a second procedure. in this retrospective study, patients underwent the prostatic urethral lift between january and november . sixteen patients received the prostatic urethral lift as a single procedure and the mean patient age for this group was years (range to ). in the remaining patients, a second procedure was performed in conjunction with the prostatic urethral lift . th ese procedures were: th ulium laser enucleation of the middle lobe, optical urethrotomy and bladder neck incision. results: in patients who were treated with the prostatic urethral lift as a single procedure the mean international prostate symptom score was . (range to ) and mean maximum urine fl ow rate was . mls- (range to ). th e average prostate volume was cc (range to ) and mean quality of life rating was . points (range to ). at months aft er the procedure, the mean international prostate symptom score improved by . points ( %), mean maximum urine fl ow rate by . mls- ( %) and mean quality of life rating by . ( %). th e improvements achieved in the combined procedures were greater than the patients who underwent the prostatic urethral lift as a single procedure. th ere was one case ( %) of postoperative moderate pelvic pain which was managed conservatively with a nonsteroidal anti-infl ammatory drug. a urinary tract infection occurred in one case ( %) and resolved aft er treatment with an antibiotic. th ere were no complications in the combined procedure cases. no patients reported any decline in erectile function, retrograde ejaculation or dysejaculation. conclusion: th e prostatic urethral lift is a safe and eff ective treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia while preserving sexual function. in carefully selected patients, the performing the prostatic urethral lift in conjunction with a second procedure may achieve superior results with no major complications. evaluation . we sought to evaluate the effi cien-cy, safety and outcome parameters between green-light pvp and vit. data of xps cases were retrospectively collected from experienced surgeons at high volume greenlight xps centers. preoperative, operative and post-operative parameters were collected and compared between groups. pvp was defi ned as pure vaporization only while vit included techniques to incise into adenoma and allow tissue resection and removal. results: as summarized in table , men undergoing vit (n= ) had larger prostate size, higher ipss∕qol and retention preoperatively than those undergoing pvp (n= ). while vit allowed greater delivery of energy ( . vs. . kj∕g), operative time was longer and had greater need for > fi bres. th ere were no diff erences in intra and post-operative adverse events. while no diff erences were observed in ipss∕qol at months post-operatively, more favorable qmax and pvr were observed at months, along with greater psa reduction, in the vit group. preoperative patient characteristics introduction and objective: to prospectively evaluate at two years, the quality of life (qol) and satisfaction of subjects randomized to either gl-xps or turp for luts/bpo. a total of patients at sites in european countries who were candidates for surgical relief of bpo were randomised : to undergo gl-xps or turp. subjects had ipss scores > and prostate volumes < mls. multiple self-administered patient questionnaires were assessed from baseline to years via: ) a general health status eq- d- l questionnaire (index score and visual scale); ) physical and mental health (sf- physical health and sf- mental health scores); ) erectile function and ejaculatory status (iief- questionnaire); ) urinary continence via oabq-sf symptoms, oabq-sf health and iciq-ui sf; ) overall satisfaction: willingness to undergo the procedure gain or ) recommend to a friend. table and subject satisfaction at years is shown in figure . conclusions: th ere is a statistically similar improvement in qol with gl-xps and turp at years. erectile function is not aff ected by gl-xps or turp and both result in a % risk of retrograde ejaculation at years. functional introduction and objective: technology for photoselective vaporisation of the prostate (pvp) has evolved in recent years. we report our early experience of pvp with the greenlight™ -w xps and assess our institutional learning curve for this technique. we performed a retrospectively analysis of our fi rst patients undergoing pvp using the greenlight™ -w xps over a twoyear period. data was collected on demographics, prostate volume, length of stay, time to trial of void, and complications. complications were graded according to the clavien classifi cation system. th e operative learning curve was analysed via various intra-operative lasering variables including the total delivered energy, total vapourisation time (vt), and vapourisation time/operation time (vt/ot). th e study population was divided into three consecutive equal groups and the three groups were compared. results: mean age was . mean length of stay was . days. mean prostate volume was cc. twenty-fi ve percent were on some form of anticoagulation. twenty-one percent were in-dwelling catheter-dependent preoperatively. th e median duration to removal of in-dwelling catheter was day. seventy-six percent had a successful trial of void on day . th e overall complication rate was %, the vast majority of which were clavien grade i or ii. th ere were no statistically signifi cant diff erences between the groups in terms of age or prostate size. over time, there was a statistically signifi cant decrease in ot and increase in vt/ot but no diff erences in complication rates, time to trial of void or length of stay as experience increased. conclusion: greenlight laser pvp using the -w xps is a safe and effi cient treatment option for benign prostatic hyperplasia, with minimal bleeding and low complication rates. our data suggests that a learning curve exists for this procedure in terms of intra-operative lasering variables with no statistically signifi cant increase in post-operative complications or length of hospital stay during this period. tillou x, le gal s, chahwan c, oitchayomi a, doerfl er a introduction and objective: to compare results of pvp (photoselective vaporisation of the prostate) in elderly patients to those observed in younger male patients taking into account the presence of an indwelling bladder catheter. we performed a review of our prospectively maintained database between december and march . a total of patients were operated for luts related to hbp. th ree groups were fi rst established to compare results of pvp in elderly male patients. we then analyzed the impact of an indwelling bladder catheter by comparing two groups of patients under and above year-old. results: th ere were no diff erences between groups for bmi, neurological disorder or hypertension history, aspirin treatment, ipss, qol and preoperative pvr (post void residual). patients above years old had statistically more heart diseases (p= . ) and had more anticoagulant treatments (p= . ). prostate volume increased with aging (p= . ), which resulted in an increased procedure time (p= . ) and an increased amount of energy delivered (p= . ). for postoperative outcomes, there were no diff erences between groups for bladder catheter removal time, ipss, qol, pvr, and surgical complications. postoperative qmax was statistically lower for patients above years old (p= . ) but with a decreased diff erence compared to preoperative measurements (p= . ). in the group without an indwelling catheter, postoperative catheter time was signifi cantly longer in patients over years (p= . ) with a greater pvr (p= . ). urofl owmetry and ipss voiding were signifi cantly improved in both groups without diff erences. th ere was no diff erence for early or late postoperative complications. for patients with an indwelling catheter, for all parameters studied, no statistically signifi cant diff erences were found except higher post-operative pvr in patients older than year-old. conclusions: pvp is an effi cient and safe procedure in elderly male patients despite more heart diseases and anticoagulant treatments. with or without a previous indwelling bladder catheter, functional outcomes were identical whatever age. introduction and objective: th e procedure of holep has steep learning curve and more than cases are needed for overcoming the curve. th e objective of our study is for identifying the detailed steps in improving skills during learning curve. total patients who underwent holep in single center were included in the study. th e operation was performed by surgeons who were experienced tur-p more than cases. patients were divided into groups. groups were initial cases (group ), mid cases (group ), and later cases (group ) in each surgeons. th e enucleation time, morcellation time, the amount of energy use, diff erential count of hemoglobin between pre-and post-operation, post-operative urofl owmetry parameter were compared between each group. especially, enucleation time was divided into diff erent steps, which was action time that was actual use of laser energy or dissecting prostate tissue using cystoscopy and identifi cation time was time for identifying anatomical structure without any procedure. results: mean ages was . years old and mean bmi was . kg/m . mean psa was . ng/ml and mean prostate volume was . cc. th ere were no signifi cant diff erences in baseline characteristics in preoperative data. aft er cases (group ), there was less use of laser energy, less time consuming for morcellation and identifi cation compared to group . identifi cation time was signifi cantly improved than group and more shortening feature as cases added but had no signifi cant diff erence. aft er cases (in groups ), there was more signifi cant diff erence in all operative parameter. especially morcellation time was signifi cantly improved aft er cases. th ere was no signifi cant diff erence in post-operative urofl owmetric parameters. conclusion: in initial experience, it seemed to be overcoming one step about identifying surgical anatomy in learning curve aft er cases. especially, cases were optimal cases for overcoming learning curve for morcellation. aft er cases, we did not overcome the learning curve but all operative parameter was improved. transrectal ultrasound as an intraoperative tool in the identifi cation of the plane of dissection during holep procedure introduction and objective: holmium laser enuclation of the prostate (holep) has been named since as the potential gold standard of treatment for bladder outlet obstruction as a consequence of benign prostatic hiperplasia. one of the most important steps during procedure is to identify the plane of dissection between the adenoma and periferic zone. in this study we demonstrated the utility of transrectal ultrasound in the identifi cation of this surgical plane during ho-lep for novel surgeons. materials and methods: previews informed concerned, we preform transrectal ultrasound during holep of patients, using the proved of the flex focus ultrasound system of bk medical, obtaining images of the prostate as a method to simplify the identifi cation of the surgical plane. we preformed holep as a standard method with storz endoscopic instruments using fr resectoscope with a kunts element and with the watts holium laser power suite from lumenis, we obtained images of the fi ve patients in real time with axial and sagital planes simultaneously, clearly helping the surgeon to identify the surgical dissection plane between the adenoma and the peripherical zone. conclusions: transrectal ultrasound could be a useful tool during the training of novel surgeons in holep technique. introduction and objective: th e aristolochia family of herbaceous plants has been used worldwide for traditional medicinal purposes for more than two centuries. th ese plants contain aristolochic acid (aa), a powerful nephrotoxin and human carcinogen, which, in susceptible individuals, causes chronic kidney disease and/or upper urinary tract urothelial carcinoma (utuc). bioactivation of aa yields a reactive intermediate that binds covalently with dna to form aristolactam (al)-dna adducts. in the urothelium, these adducts give rise to a unique mutational signature. as there are several reports of renal dysfunction in japan associated with the use of aa-containing chinese herbs, we hypothesize that a fraction of utuc cases in this country may result from past use of aristolochia herbs. patients with histologically confi rmed utuc who underwent nephroureterectomy in kyushu university aft er august were eligible for this study. informed consent was provided by each participant prior to surgery. surgical specimens of tumor and renal cortex were snap-frozen following nephroureterectomy. dna was isolated from renal cortex and analyzed for the presence of al-dna adducts using either mass spectrometry or a p-postlabelling method. dna isolated from matched tumor samples was subjected to mutational analysis of the tumor suppressor gene tp . results: th irty three utuc patients were enrolled in this study between august and march , males and females, with a mean age of years. al-dna adducts were detected in of renal cortex samples ( . %) analyzed; adduct levels were . and . per deoxynucelotides. sequencing analysis of tp in tumor dna revealed the absence of the unique mutational signature associated with aa. conclusion: aa exposure was confi rmed in two utuc patients; however, in these two cases, the mutational profi le of tp in tumor dna was not consistent with aa-induced carcinogenesis. further accrual and analysis of utuc cases are needed to estimate the prevalence of aa exposure in japan, to evaluate the role of aa exposure to utuc in this country, and to confi rm the public health implications of these fi ndings. preoperative introduction and objective: our aims are to assess the association between upper urinary tract urothelial carcinoma (uutuc) development and the polymorphisms in the aurora kinase a (aurka) phe ile (rs ) and survivin rs c>t genes. a total of patients with uutuc and hospital controls with bladder stones were recruited in this study. clinical records, demographic data, and possible confounding factors were collected using a standardized questionnaire. genotyping was determined using a real-time polymerase chain reaction using taqman probe. results: signifi cantly more controls than patients with uutuc drank alcohol and tea, but there were no diff erences in the frequencies of cigarette smokers and coff ee drinkers. aurka phe ile gene polymorphisms, but not survivin rs c>t gene polymorphisms, were associated with uutuc development (χ test and multivariate logistic regression) (χ = . , p= . ; crude or= . , % ci= . - . ; adjusted or= . , % ci = . - . ). stratifi cation analysis and multivariate logistic regression analysis showed that only the association between aurka phe ile gene polymorphisms and uutuc development were diff erentiated between those with and without the habits of smoking, tea drinking, or coff ee drinking. conclusion: our major fi ndings supported that aur-ka phe ile gene polymorphisms, but not survivin rs c>t gene polymorphisms, increase genetic susceptibility to uutuc. metastatic and has thereaft er stabilized around %. th ere was a regional variation in the proportion of patients who underwent cn between % and %. th e relative survival at fi ve years was % aft er cn compared to % in patients who did not undergo cn (p< . ). th e median age of the m patients who underwent cn was years compared to years in patients who did not undergo cn. tumor recurrence, aft er initial treatment with curative intention in primary m patients, was % aft er fi ve years. th e location of the metastases were: lung %, bone %, lymph nodes %, liver %, adrenal % and brain metastases in % of the patients. th irteen percent of the patients suff ered local recurrence in the renal fossa aft er nephrectomy. th e most common treatment for patients with a recurrence was oncological medical treatment ( %). metastasectomy was performed in % of the patients with recurrence and in % of the patients the surgery had a curative intention. conclusions: th e incidence of metastases in renal cell carcinoma in sweden is decreasing and is lower than in historical materials. th e patients with synchronous metastases who undergo cn have a signifi cantly better survival than patients who do not undergo cn, but constitute a highly selected group. recurrence after initial treatment with curative intention is treated surgically in % and oncologically in %. immediate introduction and objective: pretreatment characterization of renal masses (rm) remain suboptimal with overtreatment being a signifi cant concern. we examined the ability of preoperative clinical characteristics to predict histological features of rms. in the global renal mass study conducted by the clinical research offi ce of endourology society (croes), data were collected for consecutive patients with renal masses who underwent surgery for clinical stage i renal mass between - . based on surgical histology, tumors were categorized as benign, low aggressiveness cancer, and high aggressiveness cancer. we assessed the ability of clinical (patient gender, age, smoking history, bmi), laboratory (preoperative hemoglobin and c-reactive protein) and radiographic (tumor diameter, location, exophytic rate and enhancement) characteristics to discriminate between benign and cancer (low + high aggressiveness) and between highly aggressive tumors and others (benign + low aggressiveness cancer). multivariate logistic regression was used to estimate the probability of the histological group by clinical and radiographic features in the entire cohort and a sub group of ct a tumor. th e performance of the models was consequently studied by calibration, nagelkerke's r , and discrimination (roc area under the curve). results: th e study cohort included patients with clinical stage i renal mass of which ( %) had ct a mass. benign lesions were found in ( . %), low aggressiveness tumors in ( %) and high aggressiveness tumors in ( . %). male gender, smoking history, increased tumor size, and lower exophytic rate were associated with malignancy and high aggressiveness features (all p-values < . ). models developed based on these characteristics had the ability to discriminate benign from malignant (bootstrap corrected c-index of . ) and high aggressiveness tumors from benign and low aggressiveness tumors (bootstrap corrected c-index of . ). similar results were achieved in the ct a subgroup. th e c-index of tumor diameter as a single predictor of malignancy and high aggressiveness tumors in the entire cohort was . and . , respectively. conclusions: although older age, male gender, smoking history, increased tumor diameter and reduced exophytic rate are associated with malignancy and high aggressiveness of renal mass, models incorporating these characteristics have modest discriminating power, slightly better than the predictive ability of tumor size alone in clinical stage i tumors. could surgery be prevented in the management of small renal masses? introduction and objective: th e diagnosis, characterization and management of small renal masses (srms) remains an important clinical issue. a proportion of srms may be benign or have low malignant potential. th ese lesions could arguably be managed non-operatively. strategies such as renal mass biopsy may be valuable in reducing the rate of unnecessary surgery. we evaluated a large contemporary surgical series of resected srms in a tertiary center with a very low biopsy rate to determine the number of procedures that could have been prevented for benign and low malignant potential lesions. conclusion: sbrt is a safe and effi cacious modality and appears to be well-tolerated at the dose fractionation we have used, and its use correlates with improved survival in this cohort of patients with rcc. cyberknife can deliver complex treatment plans to multiple lesions while minimizing irradiation to the surrounding healthy tissue, thereby decreasing the risk of complications. cyberknife has the potential to be an excellent treatment modality for renal cancer patients with renal cell carcinomas or patients with bilateral renal cell carcinoma who refuse surgery or are medically inoperable. introduction and objective: th e introduction of the robotic surgical systems has changed the way both surgeons and patients view urological surgical procedures. we tested the same theoretical and tangible benefi ts for partial nephrectomy with tele-lap alf-x system. we review our technique of robot-assisted laparoscopic partial nephrectomy performed using a new robotic telesurgical device (alf-x) on swine large white/landrace model. we set up an operating theatre to test alf-x on partial nephrectomy procedure to be performed on swine large white/landrace in total anesthesia. th e console incorporates the following main components: an ergonomic seat, the laparoscopic teleoperation master (ltm) with haptic handles, a d-hd monitor, an eye-tracking system (ets), a keyboard and a touchpad, and one foot pedal. th e ets is an infrared-based eye tracking system that detects which point the surgeon is looking at. th ere was one surgeon placed at computer-console and one surgeon placed at the surgical table. a random decision on the kidney to be tested is performed before the operation. once the trocars are placed and the kidney isolated a period of warm ischemia is due to perform the partial nephrectomy on the lower or upper pole (random choice). th e haptic sensation can be used for palpation, pushing or pulling to estimate elasticity and consistency of tissues and controlling the tensility of the sutures when tying. low-cost disposable or reusable instruments were used. results: to date, we performed partial nephrectomy with alf-x robot on swine large white/landrace (pigs) models. th ree robot's arms were used. five partial nephrectomies were on the right kidney, while were on the left one. th e mean surgical time was . minutes (range - min). th e mean warm ischemia time was . min (range . - min). th e mean blood loss was . ml (range - ml). conclusions: according to these experimental experiences on pig models, we may assume that robot-assisted laparoscopic partial nephrectomy, using tele-lap alf-x system, is safe, feasible and reproducible procedure. moreover it off ers a good perception when instruments touch each other avoiding collision between robotic arms. we believe that robot-assisted tele surgery approach could be reasonable an innovative contribution in the near future also in humans. it also off ers a reduction of costs per intervention. preoperative chronic kidney disease to reduce the eff ects of selection bias and potential confounding factors, patients in non-ckd group were selected by propensity score matching. results: th e median age of all patients was . years (range, - years) and the median follow-up was . months (range, - months). comparisons of the propensity score-matched cohorts showed that t and n stages were more advanced and the tumor size was larger in the ckd than in the non-ckd group (p < . each). kaplan-meier analyses showed that recurrence-free survival (rfs), cancer-specifi c survival (css), and overall survival (os) were signifi cantly lower in the ckd group (p < . each). multivariate regression analysis showed that preoperative ckd status was an independent predictor of css and os in patients with rcc (p < . each). conclusion: preoperative ckd may be associated with more aggressive features and poorer prognosis in patients with rcc. rcc patients with preoperative ckd should be followed up frequently and carefully aft er nephrectomy. . ) were independent prognostic factors. bone-modifying agents (zoledronic acid and denosumab) were not associated with os. th e median os of patients receiving molecular-targeted therapy aft er diagnosis of bone metastasis was signifi cantly better than that of those who did not receive targeted therapy ( . vs. . months, p= . ). our study suggests that molecular-targeted therapy prolongs survival of rcc patients with bone metastasis. th us, molecular-targeted therapy, nephrectomy and surgery for bone metastasis should be considered for these patients. introduction and objective: ureteric stenting for urinary tract obstruction secondary to malignancy may off er a survival benefi t and buy time for oncological management. since the introduction of the ureteral stent symptom questionnaire (ussq), studies have revealed that up to % of patients with ureteric stents for benign conditions experience stent related symptoms that interfere with daily activities and reduce quality of life. our aim was to evaluate stent symptoms in patients with malignant obstruction and their impact on health related quality of life. patients with indwelling ureteric stents for malignant obstruction were identifi ed from the departmental stent register during a march to june . telephone interviews and face to face interviews at the time of stent change were conducted using the validated ussq. results were analysed according to the questionnaire scoring system. results: twenty patients with a mean age of years completed the ussq. of these patients - % reported bothersome urinary symptoms that included storage symptoms, incontinence and haematuria. fifty percent of patients experienced stent related pain in the fl ank ( / ), suprapubic ( / ) and groin area ( / ). fift y percent of these patients required regular analgesia and - % experienced pain interfered with activities and daily life. seventy percent of patients experienced diffi culty in performing physical activities, with a negative impact on social life. one out of patients reported sexual dysfunction. eighty fi ve percent experienced urinary tract infection (uti) with % having a uti most or all of the time and % requiring admission to hospital. mortality within one year of stent insertion was %. conclusion: ureteric stents are associated with signifi cant debilitating symptoms and reduced quality of life in patients with malignant obstruction. th is has signifi cant implications for management of cancer patients and patient counselling. ureteric stenting can prevent death from malignant obstruction, but may result in prolonged suff ering due to stent symptoms without benefi t in overall survival. introduction and objective: management pheochromocytoma laparoscopic was initially controversial because of the possibility of adrenergic discharge with the generation of the pneumoperitoneum. th e work of a proper medical preparation and anesthetic precise control obvious that circumstance and allows more precise surgery and a better image as it gives the laparoscopy to get with much less aggressive surgical removal. our goal is to present the preparation and the key points in its approach. we present -year-old male with recent diagnosis prostate cancer and high pressure treated with drugs. discovery of left adrenal mass of cm. in ct and mri and scintography with mibg suggestive focus of pheochromocytoma in the adrenal gland. twenty-four-hours urine: total catecholamines: . ug/ ( - ) adrenaline: . ug/ hours ( d- ); normetanephrines ug/ ( - ), metanephrines: ug/ ( - ). vanilvandelico . ug/ ( - ). preparing medical / anaesthetic consisted: entry days before surgery and control alpha-blockers with doxazosin every hours. treatment with beta-blockers with propranolol. expansion of intravascular volume with intravenous fl uid therapy hours before surgery. and control of blood glucose levels. intraoperatively crisis were treated with nitroprusiate. results: aft er adrenalectomy laparoscopic left with a length of minutes and adequate control pressure intraoperative the pathology diagnosis was of pheochromocytoma. postoperative attended without incident (clavien i) and went out hospital to the hours. th e presence a pheochromocytoma should not be a contraindication to laparoscopic approach of the adrenal gland in services experienced laparoscopic, and must be an exhaustive control of anesthetic, as well as a careful dissection of the gland trying to avoid excessive manipulation of the same. robotic assisted "davinci" adrenalectomy al-ansari a, younes n, al-rumaihi k, al-jalham k, gul t, badawi a, kamkoum h introduction and objective: adrenal mass could be challenging, especially when it is large in size or cystic, adrenal had short and variable vasculature, in addition to functional adenoma, adrenal surgery require minimal handling. robotic assisted adrenalectomy (ra) had been proven to be safe and eff ective. objectives: to describe robotic adrenalectomy (ra), to ensure a safe and eff ective removal of complex adrenal mass. we reviewed the record of consecutive patients who underwent ra performed by a single surgeon, between january and january , fi ve were right and fi ve were left , were solid and were cystic, none were functional adenoma patients position and port placement were similar to renal surgery, aft er control of the renal vein the gland was dissected, small arteries were clipped and the gland were removed. results: patients were females and males, age range between to years mean tumor size was . cm range ( . - cm), mean hospital stay was days, no perioperative complications, all masses were intact, one postoperative addisonian crisis pathology was benign cyst, adenoma, ganglionuroma, neuroendocine, adrenal hyperplasia, adrenocortical neoplasm of low malignant potential. conclusion: robotic adrenalectomy is safe and feasible in the management of complex adrenal mass. robotic materials and methods: th e girl was in a good general health and came walking to our out-patients department. she was admitted and her investigations reviewed. she had a right renal mass with cavo-atrial extension with an isolated embolus in the pulmonary artery. she was planned for a complete excision under cardio-pulmonary bypass with deep hypothermic circulatory arrest. under general anaesthesia, aft er establishing complete monitoring, she was opened by long midline laparotomy and mid-sternotomy. mid-sternotomy extension was done up-front in-view of the pulmonary embolus. an incision was made in the posterior peritoneum medial to the inferior mesenteric vein. th e right renal artery was dissected posterior to the left renal vein, ligated and divided. suddenly her end tidal carbon-di-oxide fell. th e video demonstrates the trans-esophageal echo-cardiography confi rming fragmentation of the cavo-atrial thrombus and its migration into the right ventricle and main pulmonary artery. th e patient was immediately put on cardio-pulmonary bypass. initially the venous return was low. she was rapidly cooled to degrees centigrade and aorta cross clamped just above the diaphragm. arterial infl ow was reduced to litre per minute to main blood fl ow to the brain. th e video demonstrates opening, clearing and repairing of the right atrium, right ventricle and main pulmonary artery in a step by step approach. th e branches of the pulmonary artery were cleared with fogarty's catheter. right radical nephrectomy was completed and ivc cleared and repaired. th e total circulatory arrest time was minutes. she was slowly re-warmed and taken off cardio-pulmonary bypass. results: her post-op recovery was uneventful. th e fi nal histo-pathology report showed a primitive neuro-ectodermal tumor. she received adjuvant chemotherapy for cycles and is well at months of follow-up. in an appropriate case pulmonary artery embolectomy along with excision of cavo-atrial tumor thrombus is acceptable in experienced centers. an up-front mid-sternotomy should be contemplated in patients where the risk of embolisation of tumor thrombus is high. a total of consecutive patients who underwent a turbts were identifi ed from january to february by a single surgeon at our institution. we excluded patients as they had a known history of bladder cancer that previously underwent treatment. via rigid cystoscopy, tumors were resected en bloc using a polypectomy snare with electro-cautery and retrieved transurethrally. following turbts, the base of the tumor was either biopsied and fulgurize or a formal turbt was performed. results: nineteen consecutive patients (median age , range - ) underwent an initial turbts for the initial staging and management of bladder tumor. median number of tumors found was (range - ). median tumor size was cm (range cm- cm). median follow-up was months (range - months). tumors sites were: posterior wall, trigone, lateral wall, anterior wall. immediate aft er snaring of the tumor, patients underwent biopsy and fulguration while underwent a turbt in the same operative setting. patient from the turbt group experienced an obturator refl ex. muscle was visualized on of pathology specimens. patients required subsequent redo procedure to obtain muscle for tissue diagnosis and staging. recurrence occurred in patients (median . months, range . - months). conclusion: turbts is a feasible technique for pedunculated bladder tumors. it provides a bloodless fi eld with maximal visibility for the surgeon and may be an adjunct in turbt. dilep-diode laser ( nm technical aspects for overcoming the holep learning curve omori y, matsumoto s, matsumoto s introduction and objective: holep is an excellent surgical procedure and alternative to turp and open prostatectomy for bladder outlet obstruction due to benign prostatic hyperplasia. it has been widely accepted and performed, for its safety and eff ectiveness. however, it may not be considered an option for the majority of worldwide urologists, because of its steep learning curve. our objective is to help beginners and operators who are interested in learning holep to get familiarized with it, and feel confi dent about opting for this procedure. in this video we demonstrate a case of holep using watt holmium laser in a -year-old male with ml prostate. th e operative fl ow is described as follow: ) downward dissection of the left lobe and longitudinal incision; ) downward dissection of the right lobe and longitudinal incision; ) enucleation of the medium lobe; ) lateral side dissection of the both lobes; ) o' clock incision and bladder neck ablation at between and o' clock ) diagonal longitudinal incision of apical lobes; ) enucleation of the both lobes; ) hemostasis; ) morcellation. results: in this video operative time was min (enucleation time: min) and resected tissue weight was g. our procedure has some modifi cations compared to the surgical technique from original procedure of gilling, separating lobes and dissecting in a retrograde fashion. conclusion: holep is a safe and eff ective surgical procedure. we hope our procedure will become the reference for beginners and urologists who are wishing to master it, but are worried about methods and complications. and also we hope holep will become the new gold standard for the treatment of benign prostatic hyperplasia. to obliterate the circular fi bers of bladder neck to the level of proximal urethra, carefully avoiding the external striated sphincter. laser power is reduced to w to prior to vaporization of any pseudomembranous trigonitis, which is commonly found in pbno or recurrent cystitis cases. results: laser vaporization is successful in relieving voiding diffi culties. th is procedure opens the bladder neck and allows for optimal post-operative urine fl ow. th e patient had improvement in both objective and subjective voiding functions immediately aft er treatment. during -months follow-up urofl owmetry, the maximum fl ow rate increased from to ml/s. th e postvoid residual urine decreased from ml to less than ml. conclusion: primary bladder neck obstruction in female can be eff ectively and safely treated with laser photoselective vaporization of the bladder neck. bilateral retroperitoneal laparoscopic nephrectomy using mm instruments introduction and objective: laparoscopy has become the standard nephrectomy approach. it has been shown that th e retroperitoneal approach is comparable to the transperitoneal approach when it comes to safety and results, even more, it can present advantages in selected patients, as in patients with prior abdominal surgery. th e use of mm instruments is gaining acceptance as a safe way to improve aesthetic results and minimize abdominal wall trauma while maintaining the principles of standard laparoscopy. we present the case of a -year-old woman with a history of radical hysterectomy and radiotherapy, aft er which she presents: ) bilateral ureteral obstruction that produces terminal renal insuffi ciency, and, ) vesico-vaginal fi stula, refractory to conservative treatment. th e decision is made to perform a bilateral retroperitoneal laparoscopic radical nephrectomy as a defi nitive treatment of the vaginal fi stula and as preparation for the kidney transplant. results: th e right nephrectomy is performed fi rst. classic retroperitoneal technique is used, using mm trocars (with an mm trocar to create the retroperitoneal space). on the left side, a previously produced nephrostomy catheter tract is used to insert a mm trocar. no relevant intraoperatory complications were observed. preoperative haemoglobin was g/l and the postoperative was g/l aft er transfusion of one bag of packed red blood cells. th e only postoperative complication was the infection of the mm left side trocar tract (where the previous nephrostomy catheter was placed). th e total hospital stay was days. th e pathological anatomy for both kidneys was: chronic pyelonephritis with extended interstitial fi brosis and tubular atrophy. conclusions: retroperitoneal laparoscopic nephrectomy is an effi cient and safe approach, comparable to transperitoneal laparoscopic nephrectomy, and even superior to this one in patients with previous abdominal surgery. th e use of mm instruments (in this case in a combined fashion), allows performing the surgery in a safe way, with superior aesthetic results. pure aft er complete mobilization of the renal artery three hem-o-lok clips were applied and the artery was transected. th e ivc was isolated upwards as far as possible, and intraoperative laparoscopic ultrasound was employed to identify the extent of the thrombus. aft er the inferior vena cava ivc was blocked using tourniquet loops above and below the thrombus and the contralateral renal vein was blocked, the ivc was opened and the tumor thrombus was extracted entirely. th e ivc was stitched with a running - polypropylene suture. th e specimen was extracted in an endoscopic extraction bag through a gibson incision. results: from february to june , fi ve patients underwent pure conventional retroperitoneal laparoscopic nephrectomy and tumor thrombectomy. th e mean patient age was yr ( - yr). th e mean operative time was min ( - min), and the mean estimated blood loss was ml ( - ml). th e mean length of tumor thrombus was . cm ( - cm). with a mean follow-up of . mo ( - mo), one patient was identifi ed lung metastasis four months postoperatively. introduction and objective: partial nephrectomy provides equivalent oncologic and superior functional outcome compared with radical nephrectomy over the short-and long-term. with the development of laparoscopic techniques and increasing laparoscopic surgical experiences, laparoscopic partial nephrectomy has become an acceptable alternative to radical nephrectomy for expert laparoscopic urologists to treat small renal mass. however, higher complexity tumors are associated with more resection of normal tissue, a longer warm ischemia time, and postoperative morbidity, especially entirely endophytic hilar tumor. in order to reduce normal tissue resected during laparoscopic partial nephrectomy for entirely endophytic hilar tumor, we develop a novel technique to deal with the higher complexity tumors. subject is a -year-old female with t a clear cell carcinoma with a diameter of . cm. th e tumor is entirely endophytic hilar tumor. renal nephrometry score is . she underwent laparoscopic partial nephrectomy in retroperitoneal approach. standard ports were placed. th e surgeon opened gerota's fascia and dissects along the renal capsule mobilizing the kidney from within gerota's fascia. th e resection line was marked using the laparoscopic ultrasound probe. aft er the renal artery was clamped by bulldog, tumor enucleation was performed using a cold scissor. one incision above the tumor was made, and careful dissection was performed to approach the tumor. th e tumor was completely mobilized outside its margin. th en the inner layer renal parenchyma and collecting system was sutured with - absorbable sutures and the outer layer renal parenchyma was sutured with absorbable suture. results: th e procedure was successfully accomplished without open conversion and transfusion. th e operative time was min, and the estimated blood loss was ml. th e warm ischemia time was min. histology revealed that the tumor was chromophobe renal cell carcinoma, and the surgical margin was negative. conclusion: laparoscopic partial nephrectomy for entirely endophytic tumor is challenging. tumor enucleation with one resection line can reserve more normal renal tissue during the procedure. more cases are needed to evaluate the effi ciency of the technique. introduction and objective: laparoscopic adrenalectomy by posterior approach carries high recovery and shorter operative time. children with metastatic high risk neuroblastoma arising from the suprarenal gland should undergo local surgical excision of the primary tumor before further intensifi cation of chemotherapy and possible bone marrow transplantation. herein, we report a video of left laparoscopic adrenalectomy showing the diff erent steps of the procedure. th congress of the sociÉtÉ internationale d'urologie -siu abstract book materials and methods: a . -year-old boy with left metastatic suprarenal neuroblastoma, received chemotherapy according to high risk european protocol. child positioned in prone position, fi rst trocar at the tip of the last rib by open introduction, two mm trocars one in costovertebral angle and the other is lateral. balloon development of the space, gerota fascia opened, the upper pole of kidney identifi ed, mass dissected, suprarenal vein is clipped during dissection, extraction in bag. results: oral feeding is begun aft er hours, discharge from hospital in the second day postoperatively, rapid convalescence, rapid resumption of chemotherapy. conclusion: laparoscopic adrenalectomy using posterior approach gives direct access to the adrenal gland, no peritoneal violation, rapid intestinal movement recovery, short hospital stay and rapid recovery. all advantages that might facilitate the early start of adjuvant chemotherapy in children with neuroblastoma, however, oncological outcome should be proven by long-term follow-up, larger number of patients, and good selection of small tumor facilitates surgical extirpation. introduction and objective: robotic multiplex partial nephrectomy (rmxpnx) is minimally invasive partial nephrectomy for three or more tumors in a single kidney. rmxpnx has been previously shown feasible with excellent preservation of renal function. we present our technique of off -clamp robotic transperitoneal multiplex partial nephrectomy in the treatment of multifocal and hereditary renal tumors. a prospectively maintained database was retrospectively queried to identify all patients who underwent rmxpnx from to . rmxpnx is defi ned a resection of or more masses from a single kidney. patients underwent rmxpnx when the largest tumor reached cm in size. tumors were excised using enucleation techniques. from the data of eligible patients, a representative patient was identifi ed and surgical video was edited to demonstrate the important aspects of the surgical technique. results: th e patient is a -year-old white male with von hippel lindau diagnosed with bilateral multifocal renal tumors with several tumors > cm in size. he underwent bilateral robotic multiplex partial nephrectomy separated by weeks with no operative complications. th irty fi ve tumors were excised from the right kidney. fift y two lesions were then resected from the left kidney. his preoperative creatinine was . and at year postop from bilateral multiplex partial nephrectomies his creatinine is . . in the hands of an experienced surgeon, off -clamp robotic transperitoneal multiplex partial nephrectomy is feasible, safe and eff ective in the treatment of multifocal and hereditary renal tumors. th is technique provides exceptional renal functional preservation and decreases technical diffi culty of reoperation. louie-johnsun m introduction and objective: th e advantages of minimally invasive laparoscopic surgery are well documented. as there are few urological emergencies suitable for a laparoscopic approach, the increased use of robotic surgery for elective procedures that can be performed equally as well laparoscopically threatens the acquisition of skills that can be transferred from these elective procedures (e.g. laparoscopic radical prostatectomy, pyeloplasty and partial nephrectomy) to emergency cases. in emergency situations, a robotic approach may not be feasible or practical. we highlight this with three recent cases. materials and methods/results: a video presentation of three of our recent urological emergency cases managed successfully laparoscopically which includes: ( ) a -year-old girl with neurogenic bladder presenting with urinary peritonitis aft er spontaneous rupture of an augmentation cystoplasty: laparoscopic adhesolysis and repair of perforated augmented bladder. ( ) an -year-old woman with intraoperative mid ureteric injury during laparoscopic right hemicolectomy: laparoscopic ureteroureterostomy and insertion of ureteric stent. ( ) a -year-old woman with ureterovaginal fi stula post laparoscopic hysterectomy: laparoscopic ureteric reimplantation with psoas hitch and insertion of stent. conclusion: despite the increasing use of robotic surgery in urology we encourage the continued training and dissemination of advanced laparoscopic skills in the elective setting to allow for the advantages of laparoscopy to be transferred to the less common urological emergency setting. robotic ureteric catheter placement; ) port placement with patient in lateral position; ) bowel mobilization; ) localization of lower calyx by intra-operative ultra sound probe; ) lower segmental nephrectomy; ) anastomosis (ureterocalicostomy) with - v-lock sutures over a pre placed f ureteric catheter and drain placement; ) changing of ureteric catheter to dj-stent on rd day post-operatively. results: th e procedure was completed successfully without any intra operative complications in all the cases. mean operative time was ± minutes and analgesic requirement of ± milligram of tramadol. none of the patients required blood transfusion. urethral catheter was removed on th and drain on th post-operative day and stent aft er weeks. one patient had clavien grade (pyrexia) complication. conclusions: robot-assisted laparoscopic ureterocalicostomy for secondary upjo is safe and feasible in expert hands. apart from the short recovery times, early mobilization, decreased analgesic requirements; robotic approach provides the added advantage of technical ease and precision of suturing. laparoscopic dismembered pyeloplasty for upjo in pelvic ectopic kidney apollo bgs hospital, mysore, india introduction and objective: renal ectopia is a rare anomaly and may be associated with pelvic ureteric junction obstruction (pujo). we report such a case with an ectopic pelvic kidney (l-type) with pujo and its successful laparoscopic management. th rough this report we emphasize the importance of adequate preoperative imaging and intraoperative details to avoid mishaps. a -year-old male was admitted with complaints of right-side lower abdominal pain of a dull aching type lasting months. ultrasonography revealed left pelvic kidney. th ese fi ndings were confi rmed with an intravenous pyelogram, which showed the left kidney low lying in the pelvic region with features of hydronephrosis and upjo. ct angiography revealed no crossing vessel as the cause of pujo. results: th e patient was taken up for transperitoneal laparoscopic pyeloplasty under general anesthesia. aft er creation of the pneumoperitoneum and with the ports in place, dissection was started and the dilated pelvis could be visualized through the peritoneal window. th e peritoneum was incised and the dilated pelvis on the left side was reached. aft er further dissection, the classic anderson-hynes dismembered laparoscopic pyeloplasty was done by using - vicryl. minimal excision of the redundant pelvis was required and because the kidney was not mobilized, nephropexy was not required. care was taken to avoid injury to the right ureter, which was coursing in close proximity to the left renal pelvis. preoperatively placed stent was retained and repositioned during the pyeloplasty. estimated blood loss during the procedure was around ml, and the procedure was completed in minutes without any intraoperative complications. th e patient could tolerate oral feeding on the evening of the same day. conclusion: th e upjo in ectopic pelvic kidneys presents a large spectrum of presentation. th e laparoscopic approach provides good surgical exposure, and operative times are compared to those of laparoscopic procedure in anatomically normal kidneys. laparoscopic we present laparoscopic radical cystectomy (lrc) and intracorporeal orthotopic ileal neobladder with two isoperistaltic aff erent limbs. a -year-old male patient with recurrent urothelial bladder carcinoma. ct demonstrates bulky bladder tumor in right lateral wall. lrc and intracorporeal urinary diversion were performed. six trocars were used in the procedure. aft er lrc and extended pelvic lymph node dissection were accomplished, a cm ileal segment cm proximal to the ileocecum was harvested, of which a cm proximal ileal segment was moved to anastomose with the end of the harvested segment which was right isoperistaltic aff erent limb. th en cm ileal segment was detubularisated leaving cm intact proximal ileum for left isoperistaltic aff erent limb. th e harvested ileal segment was symmetrically folded with identical limb lengths. th e posterior wall of the neobladder was sutured, and ileoureteral stents were delivered into the two isoperistaltic limbs and passed up the ureter and coiled into the renal pelvis, and one foley catheter was delivered into the neobladder at the same time. bilateral ureteroileal anastomoses were performed in a continuous manner respectively. th e anterior wall of the neobladder was closed and the posterior urethra was anastomosed with the neobladder. we have performed cases with this technique. all procedures were completed without open conversion. th e mean operative time was min with a blood loss of ml. th e construction time of the neobladder was min. th e time to orally allow was postoperative day in all. th e mean hospital stay was d. foley catheter and dj stents were removed on postoperative day . no major complication was occurred. conclusion: laparoscopic radical cystectomy and intracorporeal orthotopic ileal neobladder with two isoperistaltic limbs were a safe and feasible for experienced laparoscopic surgeons. however, more cases and long follow-up were required to evaluate the function of the novel neobladder. all in this video, we wanted to share our robotics augmentation ileosistoplasty experience in -year-old male patient with a diagnosis of neurogenic bladder. an -year-old male patient treated with clean intermittent catheterization and anti-cholinergic therapy for neurogenic bladder. bladder capacity was detected cc, the irregularities in the bladder contour and left grade vur was detected in control video urodynamics. so we decided to implement robotic augmentation ileocystoplasty to the patients. results: th e transperitoneal approach is performed by using veress needle to access the peritoneal cavity. th e abdomen was insuffl ated using co and trocars placed under direct vision ( of camera port ( mm), of da vinci ports ( mm) was placed and of mm and of mm assistant ports were placed). a cm segment of ileum with mesentery was incised with about cm proximal from the ileocecal valve and this segment was suspended. intestinal anastomosis was performed with - vicril and - monocril sutures and created a u-shaped ileal pouch. th e bladder was released from the surrounding tissue. about cm, longitudinal incision was made to the bladder. a single-j catheters were placed to the left ureter and bladder for the left ureteral catheter and cystostomy. th e bowel prepared for bladder augmentation and it was sutured with . pds with wate tight anastomosis. operation was terminated by placing the drainage catheter. introduction and objective: although their numerous indications make double-j stents frequently preferred in the armamentarium of the urological practice, serious complications can arise, if they are not used correctly. in endourological surgeries, due to type and stuff of material the breakage or fracture risk of the equipment is more. th ere are various types of surgical procedures for the removal of the foreign bodies. shock wave lithotomy (swl) and ureteroscopy (urs) are the fi rst step in the removal encrusted ureteral stent. th is report presents a case of successful forgotten ureteral stent removal by means of fl exible ureterorenoscope (furs) and fl uoroscopic imaging. a -year-old male patient was admitted to our clinic with the complaint of recurrent urinary tract infection. in his medical history he said that he had an open kidney stone surgery in and aft er months d-j catheter removal had been performed. aft er radiologic imaging it is determined that there are two d-j catheter pieces in the right kidney collecting system. furs and removal of foreign body was performed successfully. postoperative fi rst day patient discharged with no complication. results: various materials and coatings have been developed to avoid ureteral stent complications such as encrustation and infections. th e incidence of encrustation increases with the duration that the stent remains in place. th ere are numerous types of removal techniques for foreign body removal, however furs seems to be the better one with the minimal postoperative rates. our technique was performed easily and in a short surgery time. conclusion: flexible urs modifi ed with fl uoroscopy has particular advantages for treating encrusted ureteral stents. th is procedure is least invasive and is thus considered to be most suitable surgery for encrusted ureteral stents or foreign body materials in the kidney. results: we outline strategies to prevent diffi culties with urethro-ileal anastomosis during rarc iucd neobladder formation. furthermore we off er some key technical points that can be benefi cial in overcoming challenging urethro-ileal anastomosis. conclusions: due to the technically complex nature of rarc icud neobladder formation, the awareness of potential pitfalls during each step of the process is essential. issues and solutions discussed in this video provide a valuable resource for clinicians performing this procedure. robotic in this video we present a patient presenting with concomitant renal neoplasm and a large calculus in the renal pelvis that what was managed with robotic pyelolithotomy at the time of partial nephrectomy. results: aft er exposure of kidney the ureter was identifi ed. th e renal pelvis was exposed and pyelolithotomy was performed. aft er this hilum was clamped and partial nephrectomy and renorrhaphy followed. th e warm ischemia time was minutes. th e procedure was completed without any complications. patient was discharged on the second postoperative day. conclusions: although uncommon, the presence of concomitant stone and renal neoplasm can make the decision of optimal patient care more challenging. using robotic platform simultaneous management of both conditions can be accomplished in appropriately selected cases. single introduction and objective: female epispadias is a rare congenital anomaly and is classifi ed, into vestibular, subsymphyseal, and retro-symphyseal. historically treatment consists of staged repairs with urethral and vulvar reconstruction in fi rst stage followed by bladder neck reconstruction at a later age. in addition, staged procedures require multiple sessions of surgery and anesthesia, and are associated with relatively higher morbidity. recently single stage perineal urethroplasty has been used for epispadias repair. objective of the study is to evaluate the results of single-stage perineal urethroplasty with double breasting of the urethra and bladder neck and sphincteroplasty in female epispadias. we treated patients with severe female epispadias since to . age varied from to years (mean years). perineal urethroplasty with double breasting, sphincteroplasty, and genitoplasty was done in cases. th e urethral plate and bladder neck was mobilized from the surrounding tissue till bladder neck. a urethral mucosal strip of about to mm was denuded from the bladder neck to the end of urethral plate on one lateral edge, and tubularized over a f catheter. urethroplasty was done with double breasting of the urethral muscle margins starting from inside the bladder neck downward to the neo-meatus with corporoplasty, sphincteroplasty, and genital reconstruction. results: all patients were satisfi ed and happy about cosmesis. of the patients, were fully continent with a dry interval of to hours, one of them had occasional night wetting was put on anticholinergic. one was partially continent with dry interval of hours required anticholinergic. conclusions: perineal urethroplasty with double breasting of urethra, from inside the bladder neck to the neomeatus, resulted in continence in most cases because it increased the urethral and bladder neck resistance, as well as bladder capacity, all were important factors in continence. we advocate this procedure as a fi rst choice in all patients with female epispadias, because it is simple, safe, and eff ective for continence. single we had partial penile disassembly to have the advantage of both technique. so objective of the study was to evaluate the functional and cosmetic outcome of single stage partial penile disassembly repair in isolated male epispadias. a retrospective analysis of cases of primary epispadias repair, performed during july to july at our institution. patients were classifi ed on the basis of type of epispadias, urinary incontinence, presence/degree of chordee and penile rotation. exstrophy epispadias complex and secondary repair were excluded. surgical technique: penile de-gloving with mobilization of urethral plate from ventral to dorsal aspect with preservation of blood supply at both ends, distally up to the level of midglans and proximally up to pubic symphysis with division of penopubic ligament to lengthen the penis and position the urethra ventrally. tubularization of urethral plate followed by spongioplasty, corporoplasty with medial rotation of corporeal bodies (without any corporotomy) and glanuloplasty with meatoplasty to bring the meatus ventrally. skin cover with rotation of ventral fl aps and z-plasty when required. results: age of the patients varied from months to years with a mean of years. forty patients ( %) had excellent cosmetic outcome while three patients ( %) had minimal residual chordee/torque but didn't require any surgery in a follow-up to - years. all seven partially incontinent patients in the study group achieved continence aft er surgery. none of the patients developed complications like fi stula or stricture. all the patients in the post pubertal group reported normal erections and successful ejaculations aft er the surgery. post-operative follow-up ranged from - years with a mean of years. conclusions: th e technique incorporates all the benefi ts of cantwell ransley repair, needs less extensive dissection than total penile disassembly. both functional and cosmetic results are good with low complication rate. spongioplasty reconstructs near normal urethra and corporoplasty with spongioplasty also helps in prevention of urethral fi stula. introduction and objective: to introduce a unique technique, single port laparoscopic assisted extraperitoneal closure of patent processus vaginalis using j shaped bended spinal needle. materials and methods: a . -mm -degree laparoscope was inserted through an umbilical incision. th e scope could view both inguinal ring. j shaped bended g spinal needle was inserted just mm lateral to the internal inguinal ring. th e needle was introduced to the extraperitoneal space over the vas deferens and spermatic vessels, injecting of saline for the preperitoneal hydrodilation. a - polyester suture was threaded through an g spinal needle. same - polyester suture was threaded through a g spinal needle from the tip. along the guidance of the suture and g needle, j shaped bended g spinal needle was reintroduced to extraperitoneal space. g spinal needle traveled through the upper margin of internal ring, g needle tip was pulled out of the initial g needle punctured opening. - polyester suture was pulled outside from the g needle tip and then g needle is also withdrawn. aft er all these procedure, internal inguinal ring was completely encircled and tied extracorporeally. th e knot was buried in the subcutaneous area within the punctured needle hole. results: sixteen children underwent laparoscopic transcutaneous extraperitoneal (lte) repair of hydrocele by using j shaped bended spinal needle. all patients were discharged on the same day aft er surgery without any complication. during a mean follow-up period of months (range - mo), no recurrence has been observed except fi rst cases. th is lte technique is simple, fast, safe and cosmetic procedure for pediatric hydrocele. robot assisted laparoscopic ureteral reimplantation for girl and boy patients: differences and similarities introduction and objective: nowadays robot assisted laparoscopic extravesical ureteral reimplantation is getting famous and in the literature is being an alternative for gold standard open surgery. in our clinic we have performed ralur procedures in our clinic for vesicoureteral refl ux and ureterovesical stricture and with this video-abstract we would like to share our experience on ralur in girl and boy patients; diff erences and similarities of procedure. we have performed ral-ur cases in our clinic between july -april for pediatric and adult patients. technique: all procedures have been performed under general anesthesia. nasogastric tube and urethral catheter placed to all patients. for all procedures -port confi guration is used: two robotic mm trocar, one mm camera trocar and one mm (including mm cover) assistant trocar. following docking robotic working arms of robot is placed. in all procedures one monopolar curved scissors, one needle holder and one maryland bipolar forceps is used as the working arms. all procedures performed transperitoneally and extravesically. in the working area of the procedure girls have more structures compared to boys. uterus, fallopian tubes and ovaries are the risky structures for girls while the vas deferens in boys. as seen in the video fallopian tubes, uterus and vas deferens are extraperitoneal organs, but ovary is intraperitoneal organ. we create a peritoneal window to reach the retroperioneal space and to dissect the ureter. dissecting the ureter we have been very careful not to harm vas deferens in boys and fallopian tubes in girls. protecting this structures we open one peritoneal window in boys and two windows in girls to fi nd and to work with the distal part of the ureter. vessel tape is used to hang the ureters. th e bladder is elevated with a - straight needle vicryl suture through the abdominal wall. aft er that the ureter was clipped with a hemoloc clip and sutured with a - vicryl suture in watertight fashion (if necessary). aft er suturing the distal ureter tailoring for the dilated distal rest ureter is performed (if necessary). following detrusorotomy, mucosa is cut for the anastomosis (if necessary). before the ureterovesical anastomosis f nelaton or a dj catheter was placed inside the ureter (if necessary). ureterovesical anastomosis is made with a - monocryl suture (if necessary). in the cases that ureter and mucosa are not cut, realignment suture is used. detrusorraphy is performed by a - barbed suture. following detrusorraphy we repaired the parietal peritoneum to close the peritoneal window one line and two lines in boys and girls, respectively. results: ralur procedure has been used successfully in girls and boys by considering the anatomical differences. bleeding was minimal in all patients. all patients discharged at the nd or rd postoperative days. conclusion: while using ralur procedures in pediatric patients, surgeon must be aware of the anatomy. mistakes during the procedure may damage the reproductive system components. performing this procedure in children, compared in adult patients, there are diffi culties due to the small size of the abdominal cavity. with the appropriate trocar placement this problem can be solved. robot assisted laparoscopic left ureteral reimplantation for ureterovesical stricture introduction and objective: extravesical robot-assisted laparoscopic ureteral reimplantation (ralur) for vesicoureteral refl ux (vur), ureterovesical strictures (uvs) and ureteral pathologies are alternative to the gold standard open repair in the literature. with this video presentation we want to share our initial experience with robot-assisted laparoscopic extravesical ureteral reimplantation using the ureteral advancement technique for a -year-old boy patient who is the youngest patient received this intervention in turkey. we have performed ral-ur procedure for adult and pediatric patients in our clinic. th is patient explained in the video was a -yearold boy who has had recurrent infections due to this condition. when the patient applied to our clinic he had already grade left ureterohydronephrosis. we performed left sided ralur procedure for this patient. technique: th e davinci si system was used via a transperitoneal approach. we used a port confi guration for the procedure; one -mm trochar for optic, two -mm trochars for robotic working arms and one -mm trochar for assistance. th e patient was placed in a modifi ed trendelenburg (approximately °) position. aft er docking the robotic arms, the ureter is identifi ed closed to the vas deferens. th e ureter is dissected distal to the vas and tented up with a tape. th e bladder is elevated with a - straight needle vicryl suture through the abdominal wall. a cm detrusorotomy is performed". aft er that left ureter was clipped with a hemoloc clip and sutured with a - vicryl suture in watertight fashion. aft er suturing the distal ureter tailoring for the dilated distal rest ureter is performed. before the ureterovesical anastomosis f nelaton catheter is placed thorough urethra and bladder inside the left tailored ureter. following this application nelaton catheter is binded to the urethral catheter. ureterovesical anastomosis is made with a - monocryl suture. detrusorraphy is performed by a - barbed suture. following detrusorraphy we repaired the parietal peritoneum and fi nished the procedure. foley catheter, nelaton catheter and drain are left at the end of the procedure. rectourethral fi stula is a morbid complication that can occur post trauma, radical prostatectomy, radiation, or pelvic surgery. th e management of these cases can be challenging and might require multiple procedures to achieve cure. th e use of omentum fl ap between the rectum and the urethra is recommended for its potential benefi ts in prevention of fi stula recurrence. we aim to illustrate the feasibility and safety of a new laparoscopic surgical technique for interposition of omentum in patients with complex pelvic fractures urethral injury (pfui) and rectourethral fi stula (ruf). we performed prospective case series of patients with pfui and ruf from september till october . th e initial approach is perineal with continued dissection until urethral transaction. laparoscopic team mobilises omentum and enters retroperitoneum lateral to bladder. a tvt needle is passed from perineum hugging the posterior wall of pubic symphysis and enters peritoneal cavity. th is tract is dilated and omentum transposed in to perineum. th is omentum is used as interposition between urethral anastomosis and rectum. th e clinical outcome was considered a failure when any instrumentation was needed or the recurrence of ruf. th congress of the sociÉtÉ internationale d'urologie -siu abstract book results: median age is years (range - ). all patients had complex pfui with ruf. th ey all had an attempt of perineal anastomotic urethroplasty with ruf repair that failed outside our center and were referred to us subsequently. all the patients had supra pubic catheters and of the three patients were passing urine through the rectum and the urethral meatus. one of the patients had a loop colostomy that was closed during the fi rst failed surgery. no intra-operative or post-operative complications occurred. patients were discharged home on post-operative day . all patients had the urethral catheter removed aft er weeks. th ree-month follow-up shows no fi stula recurrence with good urine fl ow. conclusion: using our new technique of laparoscopic omentoplasty for interposition of omentum in patients with ruf post pfui is a viable and safe option. th is allows us to perform a perineal surgery with the benefi t of omental interposition using a minimally invasive technique. further studies with larger number of patients as well as longer follow-up would be needed. introduction and objective: to test the hypothesis that a new surgical technique using elaborated perineal anastomotic urethroplasty combined with laparoscopic omentoplasty for patients with complex and prior failed pelvic fracture urethral defect repair was feasible, safe, and eff ective. we performed a prospective, observational, stage a study to observe treatment outcomes of combined perineal and laparoscopic approach for urethroplasty in patients with pelvic fracture urethral defect at a single center in pune, india, between january and february . complex and redo patients with pelvic fracture urethral defect occurring aft er pelvic fracture urethral injury were included in the study. anterior urethral strictures were excluded. th e primary study outcome was the success rate of the surgical technique, and the secondary outcome was to evaluate feasibility and safety of the procedure. th e clinical outcome was considered a failure when any postoperative instrumentation was needed. results: fift een male patients with a median age of years were included in the study. seven patients were adolescents ( - years) and patients ( . %) were adults ( - years). th e mean number of prior urethroplasties was . (range, - ). all patients underwent elaborated bulbomembranous anastomosis using a perineal approach with inferior pubectomy combined with laparoscopic mobilization of the omentum into the perineum to envelope the anastomosis and to fi ll the perineal dead space. of patients, ( . %) were successful and ( . %) failed. one adolescent boy years old developed a recurrent stricture months aft er the procedure and was managed using internal urethrotomy. median follow-up was months (range, - months). conclusion: combining a laparoscopic omentoplasty to a membranobulbar anastomosis for complex and redo pelvic fracture urethral injury is successful, feasible, safe, and with minimal additional morbidity to the patient. th e technique has the advantage of a perineal incision and the ability to use the omentum to support the anastomosis. dorsal results: buccal mucosal graft urethroplasty was done in all the patients with the graft being harvested from the buccal mucosa of the oral cavity. postoperative evaluation was done with voiding cystourethrogram at the time of catheter removal during the th postoperative week. mean peak urinary fl ow rate increased from . ml/sec to . ml/sec with normal fl ow curve stabilised at months to a mean of . ml/sec. patients were followed at , , and months in the fi rst year and then monthly thereaft er with urofl owmetry and ultrasonogram. mean follow-up period is around months. two patients required urethral dilatation for recurrence of symptoms. none of the patients developed stress urinary incontinence during follow-up. conclusions: female urethral stricture disease is under diagnosed and bmg urethroplasty is underutilised. our study adds to the limited evidence base, that bmg urethroplasty can be done safely with good results in females. a introduction and objective: ureteral fi stula's treatment oft en includes long and complex surgical and endoscopic therapies and represent a challenge for the urologist oft en with disappointing results. uventa® stent placement could represent a new option of conservative treatment for ureteral fi stulas. materials and methods: uventa® self-expanding ureteral stent are able to restore urinary fl ow in ureteral stenosis and to facilitate the closure of ureteral fi stulas thanks to its triple layer structure made of two layers of metal mesh with interposed a ptfe membrane. uventa® stents are available in diff erent lengths and diameters, and allow the coaxial overlap of the ends of multiple stents, providing a lumen of large caliber able to ensure the proper urinary fl ow and the possibility of further endoscopic procedures. we show the case of -year-old man that in september , undergone to pelvic surgery for an adenocarcinoma of the sigma in advanced stage. th e postoperative period revealed a urinary leakage, dealt initially in conservative way by the general surgeon. due to unsatisfactory results, the patient was then evaluated by the urologist and subjected to bilateral ascending pyelography highlighting the presence of a high fl ow left ureteral fi stula in pelvic tract; he case was managed immediately with bilateral ureteral stenting prior to placement of a uventa® stent. th e subsequent step was a retrograde pyelography through the left stent, used to identify the site of the ureteral fi stula. aft er hydrophilic guidewire positioning and mono-j stent removal, the delivery system of the uventa® stent is advanced coaxially to the guidewire under radiologia control. once reached the desired position the stent is released from its delivery system whit pull-back technique playing a uventa® stent fr x cm allowing its simultaneous self-expansion. th e next ureteroscopic control has shown the need to placement of an additional uventa® stent to complete fi stula's coverage. following the insertion of a hydrophilic nitinol guidewire a new uventa® stent fr x cm has been positioned further in order that the ends of the two stent's overlap for a length of at least cm. results: intraoperative retrograde pyelography showed that the stent have eff ectively excluded the fi stula. th e absence of contrast medium leakage was also documented by retrograde cystography performed after days from stents positioning. conclusions: in our experience, the application of uventa® stent has proven to be an eff ective option in the conservative treatment of minimally invasive ureteral fi stulas. robotic we performed fi ve robotic ureteroplasties using a buccal mucosal onlay between september and march . th e graft was procured by our otolaryngology colleague (jcl). th e graft onlay was performed using - pds suture and stent was placed robotically. stent was left in place for - weeks, and imaging repeated aft er removal. results: table describes each case and the outcomes observed. th e three patients who have undergone stent removal and reimaging had complete success and resolution of obstruction. th ere were post-operative complications, and none were higher than grade iii (table ) . table shows the demographic and perioperative variables of the patients undergoing this procedure. conclusion: our technique of robotic buccal mucosal ureteroplasty is safe and eff ective. we believe this is a relatively simple technique which is easily replicated. long-term data will be important to prove the validity of this procedure. primary endoscopic realignment of rupture urethra introduction and objective: pelvic fracture urethral injury (pfui) is more common in india and subcontinent. th ere is no consensus on the initial management of this injury. th ere are two schools of thoughts in all cases of suspected or confi rmed urethral rupture: a) initial supra-pubic catheterization (spc) followed by urethral reconstruction of inevitable stricture; and b) realignment of urethra. we demonstrate method of primary endoscopic realignment of rupture urethra and review the literature comparing these two procedures. a /m-presented with retention of urine and bleeding per urethra. he had sustained pelvic trauma when he was crushed between a tank and a wall. aft er initial resuscitation he had x ray pelvis, ct abdomen, rgu. he then underwent spc under ultrasound guidance. on th day aft er spc he underwent primary endoscopic realignment of the rupture urethra. we have shown a technique and reviewed the relevant literature emphasizing advantages of realignment. results: we used a two endoscopes technique one each from the spc route and per-urethral route. intra-operative contrast study was done to see extent of injury and also to see possible patency and continuity of the urethra. additionally methylene blue study was also done. a ptfe guide wire (gw) was passed from below. at the fi rst site of the gw from above it was apparent that further manoeuvers such as "going for light" would not be required. th e gw was carefully pulled in suprapubically. a silicon foley catheter ( f) was gently passed perurethrally over it. th e position of catheter was confi rmed suprapubically. patient had no major or minor complication. catheter was placed in for weeks and removed. post catheter removal patient voided well. th ese results correlated well with other studies in the literature. conclusion: ) technically not a challenging procedure. ) low risk and low complication rate. ) one failure of procedure does not preclude further attempts. ) adequate experience and instrumentation are essential. ) level evidence in favor of this approach over spc alone and further urethroplasty. neourethra with penile skin flap after total amputation of the penis kulkarni s, joshi p, batra v, sharour w, hunter c, surana s, kulkarni j introduction and objective: urethral carcinoma is a rare oncological entity. th e standard treatment for invasive urethral squamous cell carcinoma is radical penectomy, prostatectomy, cystectomy and ileal conduit. in our technique, we describe a palliative surgery that avoids the ileal diversion and perineal urethrostomy through the use of dorsal penile skin tubularization. th is video represents a detailed, step-by-step technique for retro auricular graft harvesting that we have found facilitates resident and general urologist teaching. ears were prepped and draped. th e grafted was areas were marked bilaterally. diluted lidocaine with epinephrine was injected subcutaneously. th e graft was harvested using sharp scissors. donor site was closed in two layers with minimal aesthetic changes. conclusions: our technique to harvest retroauricular graft is a simple and reproducible. it is useful in patients with lack of bmg. th is step-by-step video could be a useful resource for residents and general urologist who wish to learn an alternative graft . hand combined antegrade and retrograde intraureteric surgery in re-implanted ureter introduction and objective: we review a case of re-implanted ureter complicated with stricture and stone impaction. a -year-old gentleman was following the urology department at hmc. between the year until he was managed by the same urology team for his multiple urological complaints. diff erent open and endourological approaches were conducted. at the year of , this gentleman was complaining of colicky pain due to a cm impacted stone in the left lower ureter, sessions of eswl failed to break it. ivu showed left ureteric stricture, cystoscopy with trial of ureteroscopy was unsuccessful because the left ureteric orifi ce couldn't be identifi ed, so left percutaneous nephrostomy access inserted and followed by antegrade fl exible ureteroscopy, small opening found at the lower part of mid ureter and opened widely by laser, then followed by antegrade double j stenting. retrograde rigid ureteroscopy french identifi ed the stone at mid ureter in a later session and fragmented by laser. a double j stent was reinserted and removed later with smooth recovery. results: management of stones, in the male urethra, is a challenge, more so in a reconstructed urethra. th e dilemma always is whether it is worth incising an otherwise normal or reconstructed urethra, to extract a calculus, especially in this minimally invasive era. th e point to note is the 'painting' technique used to powder the stone, rather than fragmenting the stone into large fragments, which are then diffi cult to remove. high frequency and low energy laser setting is the order of the day. conclusion: laser lithotripsy using a high frequency low energy setting, is a good option for urethral calculi in a reconstructed urethra. retrograd introduction and objective: uretery duplication is a most common congenital anomaly of upper urinary system. th e incidence of it, in autopsy and intravenous pyelography (ivp) series, is . % and - % respectively. it is two-fold more frequent in women than men. retrograde intrarenal surgery (rirs) is a new technology in stone surgery with the fl exibility and most eff ective visualing. in patients who suff er from kidney or uretery with ureter duplication, rirs become the best surgery choice with its advantages. in this case, we present a patient who have the symptoms of kidney stone and ureter duplication. a -year-old male patient applied our clinic with the left fl ank pain. in his intravenous pyelography (ivp) and computerized tomography, it was clearly seen left ureter duplication of which both ureteropelvic junction and duplicated ureters obstructed by two kidney stones. other laboratory tests were normal. rirs surgery was performed the patient successfully. postoperative fi rst day patient was discharged without any complication. results: ureter duplication is a rare congenital anomaly of upper urinary system but the rarest thing is that the obstruction of both duplicated ureters with upj by kidney stones. in our case this kind of case successfully treated by rirs. in this surgery a new technique of access sheet entering for rirs was applied. to our knowledge it is the fi rst case in literature. surgical procedures in patients with urinary tract abnormalities are more diffi cult than the normal anatomy. th e development of new technologies is changing approach to such cases. rirs fi eld of use is gradually increasing in urologic practice. rirs in is a preferable method in duplicated ureter with stone formation. a introduction and objective: nephron-sparing surgery is now the standard of management of small renal mass and is increasingly performed for larger and more challenging lesions. th e aim of this study is to report our experience with robotic partial nephrectomy (rpn) and lapascopic partial nephrectomy (lpn) in patient's surgical outcome (blood loss, wit los renal function, complication). ( )) aml (rpn ( ) lpn ( )), oncocytoma (rpn ( ) lpn ( )) and simple cyst (lpn ( )). th e positive surgical margin rate were both % in rpn and lpn group. th e decline in glomerular fi ltration rate at the last available follow-up was similar in both groups. laparoscopy training at home guijarro a, ascencios j, morales s, huertas j, fernández b, navarro f, paniagua p introduction and objective: th e increasing use of laparoscopic surgery makes training fundamental to acquisition of the basics techniques of endourology. unfortunately, laparoscopic fi eld requires high ability and a long learning curve so it's needed simulators to practice. traditional pelvitrainers improve the laparoscopic skills of a trainee but don't simulate the real conditions of the human body. we present a homemade training surgical model that may help to achieve the skills needed and simulates the abdominal space. it is called simulated environment for laparoscopic training (selt). we have developed a laparoscopic training system based in a simulated environment. we modifi ed a dummy who represents a human trunk, this model it easy to fi nd in hardware stores. th en, we performed several orifi ces in order to place traditional laparoscopic ports in pelvic surgery disposition and two additional for our camera. inside the dummy we placed three screws and developed another hole for attaching a cork panel. also, we used a wardrobe fl ashlight as lighting system. as optical system we have used a inch tablet or a photographic camera linked to the tv. finally, for reproducing a vesicourethral model we use two balloons in order to create an anastomosis between them. final price for the selt model, excluding optical system and disposables (we used discarded ports) was euros, what is signifi cantly lower than the commercial pelvitrainers. time needed for installing all the devices is about minutes. results: th e level of simulation is high, it is more realistic, being harder and diffi cult than "traditional" pelvitrainers. th e degree of movements is limited by the real placement of the ports, distance until exercise is similar and we have to be able to work without results: nine patients underwent tmc left pyeloplasty. th ere were female and male patients with age ranging from - years .operating time ranged from - minutes with mean of minutes. per-operative blood loss was minimal ranging from - ml. return of bowel movement was within - days. all patients were discharged within days and drain removed with - days. two patients were discharged on nd day but drain was removed on rd day in outdoor. follow-up of patients showed improvement in their pain status and ivu showed no re-stricture or stenosis. our last patient is yet to come for the fi rst follow-up. conclusion: tranmesocolic approach for left puj obstruction is feasible and seems to have low morbidity with shorter hospital stay. comparison with colon-refl ecting pyeloplasty and larger number of cases are needed for better statistical evaluation. transperitoneal conclusion: th e overall cdr ( %) for our cohort was comparable to results from mri in-gantry biopsy. in volumes > cm , the cdr was % which was signifi cantly higher than that achieved by historical trus controls. th is study reinforces the benefi t of fusion biopsy in prostates in all volumes, but this utility is further enhanced in large volume glands without the potential toxicity associated with increased number of biopsies. fusion mim-transperineal fusion biopsy has the greatest impact in the biopsy naive population results: during the above mentioned period patients underwent radical prostatectomy. in ( . %) cases erp was preceded by mpmri and psm was detected in of them ( . %). in the majority of patients ( / ; . %) with positive margins pca was locally advanced or gleason score was greater than . th e margin was focal in ( . %) cases. th e most frequent location of psm was the prostate apex. it occurred in patients ( . %) and in of them the right side was involved. in ( . %) patients psm was detected in a location in which mpmri did not reveal the presence of pca. in of them, cancer invaded periprostatic tissues. macroscopic evaluation of the specimen performed directly aft er the erp indicated the possibility of psm presence only in patients but in both cases histological evaluation of the prostate specimen revealed extensive psm. the peri-prostate fat seen on mri. prostate volume was calculated using (height x width x length x π)/ . peri-prostatic fat density was then calculated using peri-prostatic fat volume/ (peri-prostatic fat volume + prostate volume). peri-prostatic fat ratio was calculated using (peri-prostatic fat volume / prostate volume). intervention includes cryoablation, brachytherapy, prostatectomy, external beam radiation with or without androgen deprivation therapy. results: a higher periprostatic fat density is signifi cantly associated with a higher gleason score, p= . , odds ratio . . a higher periprostatic fat ratio is also associated with a higher gleason score, p= . odds ratio . .patients with a higher prostate fat density (p= . , odds ratio . ) and higher peri-prostatic fat ratio (p= . , odds ratio . ) was also more likely to undergo intervention for prostate cancer (table ). psa has no correlation between periprostatic fat and periprostatic fat ratio. a higher prostate fat density and fat ratio is signifi cantly associated with a higher gleason score and a higher likelihood of patient undergoing an intervention for prostate cancer. peri-prostatic fat density and fat ratio may be an important risk factor in diagnosing patients higher grade prostate cancer. laparoscopic . th e mean urinary ph among the diabetics was . ± . and among the non-diabetics was . ± . , which was signifi cantly lower (p< . ). conclusions: th ere is a strong association between type diabetes and uric acid stone formation. th ere is also a strong association between diabetes mellitus, bmi, and also with lower urinary ph. the most patients ( %) were discharged on good condition while one patient died post-operatively. majority of patients ( %) stayed in the ward more than days post operation, the long-term post-operative outcome is yet to be assessed. conclusion: usd in our local setting seem to aff ect people of low social economic status whose daily activities in the fi elds, livestock keeping etc. mean survival; therefore longer stay in the hospital has a detrimental economic impact. outdated diagnostic, treatment equipment and technology lead to prolonged hospital stay. th ere is a need therefore for administrators and urologists in tanzania to improve quality of management of usd by acquiring aff ordable equipment and technologies. percutaneous nephrolithotomy in an ambulatory setting introduction and objective: percutaneous nephrolithotomy (pcnl) is the gold standard for the surgical management of large renal stones. various modifi cations have been done over a period of time to bring down the morbidity of this procedure. ambulatory pcnl (a-pcnl) aims at short hospital stay which is less than hours with faster recovery aft er pcnl. th is study aimed at exploring the feasibility and safety of short stay ambulatory pcnl. : th e number of pcnl procedure done at our institute annually ranges between - . hence, carefully selected patients with single renal calculus, size< cm, bmi < kg/m , favorable anatomy, no medical co-morbidities and moreover patients staying within a radius of km to the hospital with a supportive well informed family were given the option of a-pcnl. a total of patients underwent a-pcnl from april to june . all patients underwent totally tubeless pcnl with single puncture, amplatz size < f, minimal saline irrigation and puncture site infi ltration with . % bupivacaine. postoperatively narcotic analgesics were given; catheter was removed in the post-operative ward and patient was discharged within hrs. patients were explained regarding the complications of the procedure and need for homecare management. results: ten out of patients had insignifi cant post-operative period. one patient returned aft er hrs with loin pain which was evaluated and managed with injectable nsaid. another patient had hematuria which resolved aft er hours with conservative management. introduction and objective: chronic kidney disease (ckd) is associated with increased cardiovascular (cv) disease, independent of other risk factors. it is unclear whether anaemia develops in the setting of nephrectomy induced ckd, and whether it leads to an increased risk of cv morbidity. we assessed the impact nephrectomy has on renal function and evaluated our cohort for the presence of anaemia in relation to ckd stage and cardiac specifi c morbidity. pre-operative, post-operative, and yearly creatinine, hb and hct (up to years) was collected from nephrectomy patients between and . th e cohort was stratifi ed by cardiac risk factors and the prevalence of anaemia was stratifi ed by each ckd stage. we collected all-cause mortality and cv morbidity and mortality data. statistical tests were two-sided. where data was non-normally distributed median values and non-parametric tests were used. results: th e eff ect of nephrectomy on renal function is immediate (pre-operative vs. post-operative cr: p= . ) but not progressive (post-operative vs. -year cr: p= . ). elderly patients, patients with ≥ risk factors, bmi≥ or hypertension had signifi cantly higher post-operative cr (p= . ; p= . ; p= . ; p= . ). advanced age and mild ckd were important risk factors for ckd stage progression. th e prevalence of anaemia increased as ckd stage increased. at one year, the prevalence of anaemia was highest in ckd- patients ( . %), compared to ckd- ( . %) and ckd- ( . %) patients. fift een percent of patients experienced a new cv event; % of these patients were anaemic. conclusion: nephrectomy leads to immediate renal function deterioration but with no progression over time. th e clinical impact of nephrectomy is especially important in elderly patients and in patients with mild pre-operative renal impairment. th e prevalence of anaemia is more common in patients who have a higher ckd stage aft er nephrectomy, and may be a key risk factor for cv morbidity in nephrectomy patients. we believe that it is important to be able to predict who will progress to clinically signifi cant ckd, in order to optimise comorbidities and aggressively treat complications of ckd, such as anaemia. renal results: urological complication were observed in . % of all transplants. in an early phase we found that . % of patients showed problems related to the ureterovesical suture (loosening of the suture or attaching the double-j stent in the suture). suspicion of leakage with the formation of a urinoma was noted in . % of cases. more frequent were the late urological complications: hydronephrosis was seen in . % of cases. when further analyzing this group we discovered a distal ureteral stenosis in . % of all transplants. persistent hydronephrosis was resolved by reimplantation ( . %), permanent nephrostomy ( . %) or placement of a double-j stent ( . %). a large group of late complications consisted of infectious pathology. th us . % suff ered from complicated urinary tract infections which slightly more than a quarter of this population presenting with hydronephrosis. recurrent urinary tract infections without complications were found in . % of transplanted patients. conclusion: currently, the urological team mainly plays a role in the pre-and post-operative phase of renal transplantation. given the signifi cant compli-cations associated with the ureterimplantation performed during kidney transplantation, we advocate a place for the urologist in the perioperative phase as well. since the majority of the complications could be related to refl ux pathology, we propose a ureterimplantation with anti-refl ux mechanism. and october , patients were prospectively randomised into two groups. all patients presented with a simple renal cyst underwent ultrasonographic aspiration and injection of a sclerosing agent. in group , patients had the cyst injected with eo, and in group , were treated with ae. one injection was used in cysts of < ml and two injections were used in larger cysts. complete and partial success were defi ned as complete cyst ablation or a > % reduction in cyst volume with symptomatic relief, respectively. patients were followed up using semi-annual ultrasonography and computed tomography for years. results: sclerotherapy was technically successful in all patients. th ere was no signifi cant diff erence in cyst volume between the groups. aft er years of follow-up there was complete symptomatic relief in both groups, and the overall radiological success rate was % of both groups, at % complete and % partial in group , and % complete and % partial in group . th e frequency of transient complications in the form of microscopic haematuria was % and %, and of low-grade fever was % and % in groups and , respectively. a composite outcome parameter, known as "trifecta", has been recently proposed as measure of the surgical quality for partial nephrectomy (pn) procedures. we aim to validate the value of "trifecta" as a predictor of operated kidney functional preservation in a multi-institutional cohort of patients undergoing minimally invasive pn. we retrospectively reviewed records of consecutive cases of minimally invasive (laparoscopic and robotic) pn performed for ct renal masses in centres from usa and europe from to . inclusion criteria consisted of availability of a renal scan obtained within two weeks prior to surgery and follow-up renal scan - months aft er the surgery. trifecta was defi ned as a combination of negative surgical margin, zero perioperative complications and warm ischemia of less than minutes. th e primary endpoint of the study was to compare the degree of ipsilateral renal function preservation in relation to achievement of trifecta. renal function preservation was defi ned as a proportion of post-operative to pre-operative split renal function assessed by mag renal scan. a multivariable linear regression model was used to determine the independent value of several factors (surgical modality, charlson comorbidity score, achievement of trifecta, r.e.n.a.l score) to predict ipsilateral split function preservation. th e logic was that pnet is chemo-responsive and remaining are not. results: a total of patients were identifi ed. th e various histo-pathologies are shown in table . group had and group had patients. mean age in group was . yrs ( - yrs) with ( %) males and ( %) females. tumor was right-sided in ( %) and left -sided in ( %) cases. th e mean tumor size was . ( - ) cm. necrosis was noted in ( %). level of thrombus was level i in , level ii in , level iii in and level iv in . mean age in group was . yrs ( - yrs) with ( %) males and ( %) females. tumor was right-sided in ( . %) and left -sided in ( . %) cases. th e mean tumor size was . ( - ) cm. necrosis was noted in ( %). level of thrombus was level i in , level ii in , level iii in and level iv in . one of these was diagnosed pre-operatively by a biopsy and had received chemotherapy with partial tumor shrinkage. remaining received adjuvant chemotherapy. of relevance is that the youngest patient in group was years whereas the oldest patient in group was years. in patients with renal tumors and venous thrombus who are younger than years, pre-operative biopsy should be contemplated. in patients with a diagnosis of pnet, neo-adjuvant chemotherapy can be studied. introduction and objective: th e use of nephrectomy in emergency is increasingly rare due to the improved critical care urinary sepsis and development of radio-embolization. few series have been reported on this subject. th e aim of our study was to evaluate current indications, morbidity and mortality and results of nephrectomies performed in our hospital in emergency. a single-center retrospective study was conducted from january to december . twenty patients were operated in emergency from total nephrectomy. results: nine women and men with a mean age . ( . to . ) were treated for sepsis on emphysematous pyelonephritis or renal abscess, trauma with haemorrhagic shock, acute bleeding on renal tumours with haemorrhagic shock. one patient required critical care for multiple organ failure. th e time between the initial care and surgery was . days ( . - ). ten patients were referred to the emergency room by their physician and by a peripheral hospital. all these nephrectomies concerned native kidneys ( left kidneys). surgical approach was a lumbotomy for patients and a median laparotomy for patients. one patient died of multiple organ failure following urinary sepsis. one patient required dialysis following nephrectomy. th e mean follow-up aft er surgery was . months ( . to . ). conclusion: th e nephrectomy in emergency remains anecdotal. uncontrolled urinary sepsis were the main indications. th e identifi cation of populations at risk of progression to septic shock is essential for faster and reduced mortality in sepsis care. experiences of adrenalectomy for the incidentally discovered adrenal masses introduction and objective: a diagnosis of urinary tract obstruction (upjo) results in a functionally signifi cant impairment of the urinary transport from the renal pelvis to the ureter. options for the surgical management of upjo include ureteral stent placement, balloon dilation (antegrade, retrograde or cutting balloon), endopyelotomy, and open or laparoscopic pyeloplasty. however, in some cases, surgery is not eff ective, or too invasive for a particular patient. we herein report ten cases of treatment using bethanecol chloride. we retrospectively reviewed the record of patients, men and women, aged - years (mean . ) whose diagnosis was upjo ( cases of hydronephrosis on the left , on the right). th e chief complaints were back pain ( cases) and urinary tract infection ( cases). one patient had no complaint. all patients took mg of bethanecol chloride times a day for two weeks. aft er two weeks, kidney condition was evaluated using ultrasonography. results: five cases of hydronephrosis decreased or disappeared. five cases showed no improvement. among the latter, one had pyelonephritis, two had received laparoscopic pyeloplasty (one of whom had a non-functioning kidney and a pyelonephritis), and another had a non-functioning kidney. guzman martinez-valls p, sanchez rodriguez c, doñate iñiguez g, maluff torres a, honrubia vilchez b introduction and objective: we present man -yearold, hypertensive, diagnosed incidentally of intrathoracic renal ectopia during a constitutional syndrome study. intrathoracic renal ectopia is a very rare fi nd, with an incidence of less than of every , , which mainly aff ects left kidney since the liver protects the right diaphragm from pressure changes. a literature review of incidence, source, clinic, diagnostic and treatment of this type of renal ectopia occurs and we present the case diagnosed in our service. : chest x-ray shows a mass back in mediastinum so it was decided to ask for tomography computer (ct) that shows a hernia left postero-lateral difragmatic with promotion to the thoracic cavity of upper pole and half of the left kidney. since the patient is asymptomatic and the hernia is extrapleural does not need repairing surgical treatment. annual checks will be. intrathoracic renal ectopia is a very uncommon, usually asymptomatic, fi nding oft en diagnosed incidentally and which does not usually require treatment. surgical ( ), non-clamp zero ischemia ( ). th e average blood loss was ml (range ml - ml) and patients ( %) required blood transfusion. postoperatively patients ( %) had surgical complications: severe haemorrhage requiring emergency completion nephrectomy ( ), post-operative urinoma formation requiring ureteric stenting ( ), pneumothorax requiring tube thoracostomy ( ) . early day mortality occurred in one patient with pre-existing stage chronic kidney disease who died of acute on chronic renal failure. th e r.e.n.a.l. score of those with and without surgical complications was . and . respectively. th e complication rate of low (score - ), intermediate (score - ), and high (score - ) r.e.n.a.l. category was . %, . % and % respectively. statistically, blood loss, transfusion rate and surgical complication rate were not signifi cantly associated with medical co-morbidity, r.e.n.a.l. score or mode of ischemia, although more complex mass apparently resulted in more surgical complications. our study suggested that partial nephrectomy is a safe operation with acceptable bleeding risk and low complication rate. further larger scale study is needed to analyze the correlation of complications with renal mass complexity. introduction and objective: th e sound of running water has been eff ectively used for toilet training during the toddler period. however the eff ect of the sound of running water (srw) on voiding function for adult male with lower urinary tract symptoms (luts) has not been evaluated yet. to determine the eff ect of the srw on urination of male patients with luts, multiple voiding parameters of urofl owmetry with postvoid residual urine (pvr) were assessed according to the presence of the srw played by mobile application. a statistically pre-calculated numbers of consecutive male patients with luts were prospectively enrolled between march and april , excluding patients with hearing impairment, disability for movement, neurologic disease, urology deformity, and recent history of urinary tract infection or urethral stricture. urofl owmetry with pvr measured by bladder scan were randomly performed once a week for two consecutive weeks with and without srw in a completely sealed room away from exterior noise aft er pre-checking bladder volume scanned to be more than cc. th e srw was played with river water sound among relax melodies recorded in the smart-mobile application. results: th e mean age of enrolled patients and their mean ipss were . ± . years (range: - ) and . ± . . all patients have not been prescribed any medications including alpha-blocker or anti-muscarinic agents in the last three months. a signifi cant increase in mean peak fl ow rate (pfr) with srw was detected in comparison with pfr without srw ( . ml/s vs. . ml/s, p = . ). however, there were no diff erences in other urofl owmetric parameters including pvr. materials and methods: over a two-year period, men underwent lumbar spinal fusion by a single neurosurgeon. we excluded men with previous prostate or urethral surgery, a history of urinary retention, men taking alpha-blockers or fi ve alpha-reductase inhibitors, and men with prolonged hospital stay, leaving men evaluable. all men left the operating room with a foley catheter in place and were given a void trial on the day of anticipated discharge. twenty-three men were unable to void aft er eight hours and had their foley catheters replaced; they were discharged next day with an appointment for urologic follow-up. th ese men were compared to successful voiders with respect to comorbid medical conditions, age, surgical placement of hardware, operative time, lumbar level, multiple level fusion, and surgical approach. results: using multivariable analysis, successful postoperative voiders were compared with men who failed the initial voiding trial. only insulin-dependent diabetes mellitus (p-value less than . ) and multiple lumbar level surgery (p-value less than . ) were predictive of initial postoperative failure of voiding trial. conclusion: men scheduled to undergo lumbar fusion who have insulin-dependent diabetes or who will require multiple level intervention may benefi t from preoperative initiation of alpha blockade at the time of scheduling, as well as an inpatient postoperative urologic consultation. introduction and objective: heart rate variability (hrv) is a tool to measure autonomic nervous function, however there is no evidence that it is able to defi ne sympathetic hyperactivity in men with luts. we suppose that luts is diff erent between sympathetic hyperactive and hypoactive patients. th erefore we measured their hrv, divided luts patients into two groups, sympathetic hyperactive group and sympathetic hypoactive group according to the lf/hf ratio, and then compared their clinical situations. a total of symptomatic luts patients (ipss> ) and healthy volunteers were enrolled. all subjects had no disease which can aff ect autonomic nervous system, such as diabetes, hypertension and so on. electrocardiographic signals were obtained from subjects in resting state and calculated the hrv indices with spectral analyses. we divided luts patients into two groups by lf/hf ratio . which was mean value in healthy volunteer and compared the diff erence of clinical characteristics, ipss, psa and trus results. th e parameters were compared by independent sample t-test using spss version . results: th ere was no diff erence in age, serum psa and volume of prostate. th e comparative results of pa-rameters of hrv between groups (mean ± standard error) are in the table . conclusions: as most investigators believe that lf and hf represent sympathetic and parasympathetic nervous system activity, respectively, our results may suggest that luts patients with relatively sympathetic hypoactivity suff er from nocturia more than those with sympathetic hyperactivity. we suggest that the imbalance of the autonomic nervous system activity may be a factor that evokes varieties of symptoms in men with luts. introduction and objective: women presenting with urogenital pain oft en have lower urinary tract symptoms (luts). pelvic fl oor dysfunction and hypertonicity is thought to contribute to these symptoms. physical therapy and myofascial release are eff ective for both conditions, suggesting a common underlying pathophysiology. we aim to investigate the association among pelvic fl oor tone, luts, and pelvic organ distress. th ere was a tendency of lower hemoblobin decrease in ari group, however, this results was not statistically signifi cant. th ere were also no significant diff erences in improvement of ipss, qol and urodynamic fi ndings between the two groups. conclusion: preoperative use of ari does not compromise, but rather increase the effi ciency of surgery. th e use of ari is not a contraindication to th ulium laser vapoenucleation. age-specifi c relationships between lower urinary tract symptoms and late-onset hypogonadism symptoms in the japanese general population introduction and objective: aging is known to aff ect sexual, psychological and physiological functions including lower urinary tract symptoms (luts). recent data suggested that severity of luts was associated with that of late-onset hypogonadism (loh) in elderly men. however, information on the association in young adults is limited. in this study, we evaluated the relationship between luts and loh symptoms in young and middle-aged adults. results: th e mean ages of the patient and control groups were . ± . years and . ± . years, respectively (p= . ). th e mean ifsf-total and all of the ifsf sub scales (except pain) in the patient group were signifi cantly lower than those of the control group. th e mean udi- score of the patients was signifi cantly higher than the controls (p= . ). th e mean iiq- scores of the patients was higher than controls, however this increase was not statistically signifi cant (p= . ). introduction and objective: sav is one of the core components of hippo pathway, and this pathway plays a role for cell proliferation, apoptosis and migration through regulation of yes-associated protein (yap ). yap is known as an oncogenic protein in many human cancers, but only a few studies demonstrated that yap acts as an oncogene in renal cell carcinoma (rcc). in our previous study, we identifi ed sav was downregulated in high grade clear cell renal cell carcinoma (ccrcc) cases compared with low grade ccrcc cases and re-expression of sav inhibited rcc cell proliferation in vitro. to evaluate a role of sav in vivo, we created a murine xenograft model of human rcc. a total of -o cells with stable sav re-expression (sav - ) and control cells (control) were subcutaneously injected into the fl anks of mice, respectively. th ese two cell lines were also injected into subrenal capsule. tumor size, histological appearance and proliferation rate were evaluated. furthermore, transcriptome analysis was performed using a whole-genome microarray, in order to identify functional pathway by ingenuity pathway analysis (ipa) soft ware. to explore whether the identifi ed pathway was involved in hippo signaling pathway, western blotting was performed using antibodies against downstream proteins. in addition, the luciferase reporter assay was performed to explore whether the promoter activity is regulated by hippo signaling. results: tumors injected with sav - showed a decrease of tumor size and growth rate, compared with those of control. by immunohistochemical analysis, it was shown that re-expression of sav caused yap to localize in the cytoplasm. pathway analysis revealed that tgfβ signaling was found to be inhibited in tumors with sav - . in sav re-expression cells, protein levels of tgfβ were lower than those in control cells. when yap and tead were introduced, reporter activity of tgfβ promoter was increased. attached to a linear motion stage with a stepper motor. shaft buckling was determined by measuring the peak force to compress a cm section of the shaft a distance of cm. lubricity was measured by extracting each wire through simulated tissue at a constant speed, measuring average force over a second period. tip fl exibility was determined by isolating the distal cm portion of each guidewire and measuring the peak force required to compress a distance . cm while securing the tip in a small hole in a wooden block. perforation force was evaluated by stabilizing each wire in the dilator of a ureteral access sheath and measuring peak force required to perforate aluminum foil. up. , table . th e results showed that kh- protected tm cells against h o -induced oxdidative stress in a dose-dependent manner. it improved signifi cantly both the decline of semen parameters and decrease of testicular weight of androgen-defi cient rats at a dose of mg/kg. also it inhibited the activities of aromatase with and then increase the serum testosterone levels. conclusion: th ese results suggested that the aromatase inhibitory activity of kh- may contribute to the improvement of serum testosterone levels in androgen-defi cient male rats. introduction and objective: although several theories have been suggested, the pathophysiology of interstitial cystitis/bladder pain syndrome (ic/bps) is unclear. disruption of the bladder epithelial barrier is an important pathophysiologic theory of ic/bps, and uroplakin is known to have an important role in the bladder epithelial barrier. th e change in expression of uroplakin subtypes in the bladder could be related to ic/bps. we investigated the change in expression of uroplakin ib and iii in the bladders of patients with ulcerative ic/bps. bladder tissue samples were obtained from patients with ulcerative ic/bps who were treated with augmentation ileocystoplasty. samples for the control were obtained from normal bladder tissue apart from the malignant lesions of patients with bladder cancer who needed radical cystectomy. a voiding diary, the pain visual analogue scale (vas), and the o'leary-sant interstitial cystitis symptom index (icsi), and problem index (icpi) were used to assess patients with ic/bps before operation. expressions of uroplakin ib and iii were compared between the ulcerative ic/bps and control groups by immunofl uorescence staining and western blotting. results: in total, patients with ic/bps (mean age . ± . years, women and men) were evaluated. th e mean symptom duration was . ± . years. preoperative voiding frequency, nocturia, and functional bladder capacity documented in the voiding diary were . ± . , . ± . , and . ± . ml (mean ± sd), respectively. pain vas score, icsi, and icpi were . ± . , . ± . , and . ± . (mean ± sd), respectively. th e mean anesthetic bladder capacity was . ± . ml. immunofl uorescence staining showed that uroplakin ib and iii were localized in the urothelium. in western blot analysis, immunoreactive bands indicating expression of uroplakin iii were signifi cantly increased in the ic/bps group compared with the control group. however, uroplakin ib expression was not diff erent between the ic/bps and control groups. green fl uorescence protein cassette, and the infectivity of kshv was assessed using fl ow cytometry. to investigate viral replication, the levels of expression of representative kshv latent and lytic proteins were analyzed by immunofl uorescence assay. in addition, cell cycle and proliferation following kshv infection was analyzed. finally, cdna microarray was performed to identify gene changes by infection of kshv in bc. results: four bc cell lines, except rt , showed levels of infection similar to or higher than those of hu-vecs. infectivity of kshv in tccsup and huvec cells was similar, but t , , and ht- cells showed signifi cantly higher infectivity than huvec. our tested kshv-infected bc cells were latently infected by kshv. interestingly, a subset of kshv-infected bc cells showed higher brdu incorporation and proliferation rate than non-infected cells. furthermore, in soft agar colony formation assay, the numbers and sizes of colonies of kshv-infected cells were signifi cantly greater and larger, respectively, than non-infected cells. cdna microarray analysis showed that many proliferation and cancer development-related genes were simultaneously up-regulated in kshv-infected cells. introduction and objective: bladder cancer (bca) is the second common genitourinary tumor, and especially muscle-invasive bca (mibc) is poor prognosis. th erefore, it is important to clarify the mechanism of invasion in mibc is useful for the strategy of appropriate treatment. previously, we have showed hgf-met signaling is correlated with invasion in bca cells. here, we investigate the eff ects of met inhibitor, cabozantinib (xl ), in bca cells to investigate the significance of met upregulation in rt , , j , t , um-uc- cells, we conducted western blot analysis. next, we examined eff ect of cabozantinib on proliferation and invasion abilities using mtt and matrigel invasion assays. invasion assays were performed by the xcelligence system. moreover, to investigate biological function of hgf-met signaling, we analyzed gene expression profi le and real time pcr of cells which cultivated with or without hgf stimulation. . th e mechanical properties of scaff olds were measured to compare tensile strength between two types. for in vitro cell study, scaff olds were seeded with human fi broblast cell at x cells and were cultured for up to weeks. th e ability of these scaffolds to support fi broblast cell growth was also investigated in vitro. results: d strand-deposited scaff olds were characterized by sem images and porosity measurement. sem images showed the surface morphology of pcl scaff olds. th e young's modulus of °pcl was . ± . mpa, and °pcl was . ± . mpa, respectively. human fi broblast cells covered well the surface of the scaff olds. immunofl uorescent staining of α-er-tr on fi broblast cells/scaff olds confi rmed that the cells remained viable and proliferated throughout the time course of the culture. th is is a preliminary study to investigate the possibility of using d bioprinting technique for tissue engineered tunica albuginea. introduction and objective: aft er - years at people the decrease in a pool of pluripotent stem cells resulting in insuffi ciency of replenishment of cellular structure of cambial zones and, as a result, to incomplete replacement of the perishing old cells is observed. in reply surrounding epithelial and endothelial cells, and also the macrophages, attracted with death of old cells, stimulate cells division of growth zones by the cellular growth factors (pechersky a.v. et al., ) . to patients aged from till years with a cancer of a kidney, bladder, prostate gland of a stage of t -t the chemotherapy or target therapy was carried out. to patients of - years for restoration of regeneration it was carried out from to transfusions of mononuclear fraction of peripheral blood, same-gender and blood types with recipients. results: in month aft er carrying out chemotherapy or target therapy aft er development of a leukopenia in patients the level of the basic fi broblast growth factor (bfgf) increased on average by . times, at patients from them the increase in level of the human vascular-endothelial growth factor (human vegf-a) on average by . times was observed, the rd of them had an increase in the human epidermal growth factor (human egf) on average by . times. in - months aft er the last transfusion of mononuclear fraction of peripheral blood the maintenance of hemopoietic cells predecessors of cd + in peripheral blood increased on average by . times (at patients with to - cells in mcl). at patients the level of the basic fi broblast growth factor (bfgf) decreased on average by . times, at patients from them reduction of level of the human vascular-endothelial growth factor (human vegf-a) on average by . times was observed, the rd of them had a reduction an human epidermal growth factor (human egf) on average by . times. decrease in levels of cellular growth factors naturally brought at all patients in a buccal epithelium to decrease in an expression of p on average by . times, at the rd of them to decrease in an expression of bcl- on average by . times. excess stimulation of mitotic activity at people years are more senior it is possible to lower to normal level by means of restoration of number of a pool of pluripotent stem cells by transfusion of mononuclear fraction of the peripheral blood from young donors of - years of one with the recipient blood types and a sex. mashhadi r to compare the expression rate of sex steroid hormone receptors of estrogen (er), progesterone (pr) and androgen (ar) in normal urothelium and urothelial bladder cancer (ubc) and to evaluate the possible associations of these receptors expression with cancer progression and patient's survival. we evaluated the clinical data and tumor specimens of patients with patho-logically confi rmed primary ubc with normal healthy controls. both patients and controls selected from list of subjects who have been referred to sina urology clinic, and had a minimum of one year follow-up duration. data collected from medical cords. for evaluation of expression, immunohistochemistry was performed on paraffi n-embedded tissue sections using a monoclonal antibody for androgen, estrogen and progesterone receptors. presence of at least % positive cells defi ned as positive expression. results: none of the control subjects showed ar expression, while % of the patients were ar-positive. er/pr expressions were observed in . %/ and . % of the cases and in . % and . % of the controls, respectively. a statistically signifi cant correlation was found between ar expression and tumor stage and grade (p < . ). ar-positive patients showed a signifi cantly poorer prognosis than ar-negative cases (log-rank test, p = . , hazard ratio = . ; % confidence interval: . - . ). conclusion: ar expression was signifi cantly associated with higher grade and poorly diff erentiated tumors with unfavorable outcome. ar expression test might be useful as a diagnostic tool for determining the malignancy and outcome of ubc patients. park s, park w, yoon s introduction and objective: previous researchers consider interaction roles of ampk and ros as a regulator of cancer cell apoptosis and cancer invasiveness in hypoxia and oxidative stress. th e aim of this study was to fi nd out the other aspect of invasion and cell death mechanisms as a new treatment option in urothelial cancer. we performed western blot analysis to determine association between ampk regulator (compound c, aicar) and ros scavenger (nac and tempol) as cytotoxic eff ectors. using gelatin zymography to measure mmp- , activity, we evaluated the cancer invasion. pathway activation analysis was also determined by western blot. cell survival was investigated by mtt analysis. results: ros scavenger like nac and tempol treated cells showed no change of expressions of phospho-ampk. aicar, compound c and tempol treated cells showed no change of mmp- and mmp- expressions. however, nac treated cells showed decreased expressions of mmp- and mmp- . ai-car and compound c treated cells with or without added nac and tempol showed no change of mtor and phospho-mtor expressions. aicar treated cells only showed decreased expression of phospho-p s k. compound c and tempol treated cells did not showed statistically any change in cell counts. however, aicar and nac treated with or without added compound c and tempol showed increased cell death signifi cantly. conclusions: activator of ampk and ros scavenger like nac decrease t invasion activity and increase t cell death. so, we demonstrate that the cytotoxic mechanism of bladder cancer remains to be further investigated. epigenetic bladder cancer is still one of common human malignancies which some environmental agents play important role in the process of carcinogenesis, such as aromatic amines or chronic arsenism, and easy to be recurrent and progressive despite of therapy. it is continuing to search some novel genetic or epigenetic biomarkers and to investigate their signifi cance in bladder urothelial carcinoma. doc- /dab (diff erentially expressed in ovarian carcinoma- /disabled- ) interacting protein (dab ip), a novel family of ras gtpase-activating protein family, is a potent tumor suppressor gene. th e objectives of this study are to explore the prognostic values of dab ip expression and the possible regulatory mechanism in superfi cial bladder cancer. with irb consent and patient permit, eight human urothelial cancer cell lines and superfi cial bladder cancer tissues were available for exploring dab ip expression using western blotting and immunohistochemical staining, respectively. th e prognostic signifi cance of dab ip expression in term of recurrence and progression were analyzed with log-rank test. aft er treated with demethylizing agents trichostatin a (tsa) and -aza ' deoxycytidine (aza) separately and together, urothelial carcinoma cell lines were then tested with dab ip mrna expression using quantitative rtpcr. data mining was also done using published mrna diff erential array (dataset gse ). th irty patients with non-muscle invasive bladder cancer and agematched healthy controls were included in the study. peripheral blood samples were obtained from the patients before transurethral resection of bladder tumor (turbt), twenty days aft er the operation (fi rst control) and at the end of intravesical immunotherapy (second control). vegf- , mmp- , es and tsp- were measured by enzyme-linked immunosorbent assay (elisa). th e mean marker levels of the patients and controls were statistically compared. th e mean marker levels of the patients before turbt, in the fi rst and second control were also compared. results: th e mean age of the patients ( females and males) and controls ( females and males) were found to be . ± . and . ± . , respectively (p= . ). although the mean vegf and mmp levels in the patients before turbt were signifi cantly higher than the controls (p< . and p< . , respectively), there were no diff erences between the mean es and tps- levels (p= . and p= . , respectively). th e wegf- and mmp- levels signifi cantly decreased aft er turbt (p< . and p< . , respectively). th ese reductions continued aft er intravesical immunotherapy, but these diff erences between fi rst and second control were statistically insignifi cant. th is study showed that elevated angionenic factors in the patients with bladder cancer decreased aft er the treatment. we think that vegf and mmp may be used for the follow-up and therapy of non-muscle invasive bladder cancer. prognostic results: nitrose oxide level and bfgf expression were signifi cally elevated in patients with urothelial carcinoma associated with chronic bladder infection, normal urothelium showed low levels of no and low expression of bfgf. conclusion: th e association of elevated levels of nitrose oxide and over-expression of bfgf indicated that the angiogenic peptide bfgf had been modulated by nitrose oxide. th ese results would indicate an anti-angiogenisis target therapy in urothelial carcinoma associated with chronic bladder infection. the relationships between increase of serum creatinine and recurrence of nonmuscle invasive bladder cancer after transurethral resection of bladder tumor introduction and objective: while impaired renal function had a negative impact on the prognosis of invasive bladder cancer by infl uencing stage of tumor and selection of treatment modality, the relationships between the change of renal function and prognosis of non-muscle invasive bladder cancer (nmibc) have not yet been studied. preliminarily, we investigated the impact of increased serum creatinine and recurrence of nmibc. a total of patients who underwent transurethral resection of bladder tumor (turbt) with minimum follow-up of months were divided into two groups based on with (n= ) or without recurrence (n= ). th e changes of serum creatinine from the preoperative baseline to the time of recurrence were evaluated (Δ creatinine). for subjects without recurrence, serum creatinine was measured at months aft er turbt. th e impact of variables including characteristics of host (age, sex, past medical history, bmi, and smoking history), tumor (location, size, and grade), and laboratory data on recurrence of nmibc were then analyzed. tsai y , jou y , tsai y , liu b , lin h , wei c , chen s , tsai h , tzai t introduction and objective: bladder cancer is a common human malignancy and exhibits a life-long risk of disease recurrence and progression. it is continuing to search some simple, innovative biomarker to monitor the disease status in order to diminish the suff ering during cystoscopic follow-up. th e metabolite of tryptophan aft er indoleamine , -dioxygenase (ido) digestion, -hydroxyanthranilic acid ( -haa) is conventionally thought to be a potential biomarker for bladder cancer occurrence. th e aim to study is to investigate the diagnostic potential of an integrated a -haa-based biosensor for urothelial carcinoma of the upper tract and urinary bladder. human urothelial cancer cell lines and human urothelial carcinoma tissues as well as adjacent benign tissues were available for exploring ido expression, including western blotting and immunohistochemical staining. patients who received urological surgery were enrolled for urine -haa testing using an integrating biosensor for -haa. some of urine specimens were investigated with high performance liquid chromatography (hplc) assay. results: from western blotting assays, eight human urothelial carcinoma cell lines exhibited more ido expression than the immortalized cell sv-huc. both of urothelial carcinoma of urinary bladder and upper urinary tract exhibited more ido immunoreactivity than those of the adjacent benign bladder, ureteral or cortical tissues (chi-square test, p= . ). th ere is a moderate correlation for urine -haa measurement based on between hplc and the biosensor assays (r = . , p= . ). besides, the -haa content within the cultured media of tccsup and bftc measured with biosensors signifi cantly increased with incubation time (p < . ). finally, patients with urothelial carcinoma of bladder and upper tract have higher urine -haa levels than those without recurrence or benign urological disease, such as bph, or hernia (unpaired t-test, p= . ), except for urolithiasis. conclusion: th e integrated biosensor exhibited a modest accuracy in urine -haa detection. both of urothelial carcinoma of urinary bladder and upper tract exhibited higher ido expression and its metabolite -haa in urine. how a cancer spreads: public awareness of genitourinary cancer introduction and objective: patients' perceptions of disease can aff ect the diagnosis and treatment of the disease. it is diffi cult to give a defi nite answer to the questions; "can genitourinary cancers be spread around during coitus or in public bathtub?". doctors know that there is no evidence that cancers can be spread in this way, however many people don't know that. th e objective of this study was to investigate the public awareness of genitourinary cancer. one hundred and forty nine patients who have visited outpatient department of urology completed a self-administered questionnaire from june to july . th e questionnaires included epidemiologic information about age, gender, residential area, level of education and yearly income and the questions whether prostate cancer and bladder tumor could spread out during coitus or bathing. returned responses to questions were analyzed. results: a total of of ( %) patients completed the questionnaires. mean age was years, and ( %) men and ( %) women were included. th e residential area were metropolitan in ( %), urban in ( %), and suburban in ( %), respectively. th e level of education were middle school graduates in ( %), high school graduates in ( %), and college graduates in ( %), respectively. th e yearly incomes were under , dollars in ( %), , ~ , in ( %), and over , in ( %), respectively. seventeen ( %) and ( %) patients answered that they thought that bladder tumor could spread during coitus and bathing, respectively. likewise ( %) and ( %) patients answered that they believed that prostate cancer could spread during coitus and bathing, respectively. moreover, young patients (< years) reported that they have the opinions that coitus spreads prostate cancer ( %) and bladder tumor ( %). of college graduates, % and % reported that they thought coitus spreads prostate cancer and bladder tumor, respectively. conclusion: a signifi cant proportion of patients believed that prostate cancer and bladder tumor could spread during coitus. furthermore, even young and highly educated people also tended to have this misbelief. protoporphyrin we evaluated the feasibility of photodynamic diagnosis of bladder cancer by spectrophotometric analysis of voided urine samples aft er extracorporeal treatment with -aminolevulinic acid (ala). further, we investigate the protein that plays a key role in increased accumulation of protoporphyrin ix in bladder cancer cells. sixty-one patients with bladder cancer, confi rmed histologically aft er the transurethral resection of a bladder tumor, were recruited as the bladder cancer group, and outpatients without history of urothelial carcinoma were recruited as the control group. half of the voided urine sample was incubated with ala, and the rest was incubated without treatment. intensity of the samples at the excitation wavelength of nm was measured using a spectrophotometer. th e diff erence between the intensity of the ala-treated and ala-untreated samples at nm was calculated for photodynamic diagnosis of bladder cancer. immunohistochemistry was used to estimate the expression of peptide transporter , hydroxymethylbilane synthase, ferrochelatase, atp-binding cassette , and heme oxygenase- in samples from patients who underwent transurethral resection of bladder tumors. th e correlation between the expression of each protein in cells from resected bladder specimens and accumulated protoporphyrin ix in bladder cancer cells in voided urine was evaluated using pearson's correlation analysis. results: th e area under the curve was . . sensitivity and specifi city of the method were % and % respectively. th e expression of peptide transporter (p < . , r = . ), heme oxygenase- (p < . , r = . ), and ferrochelatase (p < . , r = . ) was correlated with the accumulation of protoporphyrin ix in bladder cancer cells in voided urine. we demonstrated that protoporphyrin ix levels in urinary cells treated with ala could be quantitatively detected by spectrophotometer in patients with bladder cancer. th e expression of ferrochelatase plays a key role in the accumulation of protoporphyrin ix in photodynamic diagnosis of bladder cancer. assessment of visual inspection as a tool to determine pelvic drain fluid type following radical cystectomy crozier j, papa n, lawrentschuk n introduction and objective: following radical cystectomy, patients generally spend a period of days under observation on a urology ward. during that time, staff closely monitor pelvic drain output to assess for the possibility of a urine leak. we aim to investigate the ability of medical and nursing staff to correctly identify pelvic drain fl uid type using visual inspection alone. investigators collected a series of de-identifi ed images showing pelvic drain fl uid in patients post radical cystectomy. th e fl uid type in each image was confi rmed by measuring creatinine level. investigators then attended a victorian public hospital urology meeting and a victorian gp conference. attendees were invited to participate in a study. present staff included consultant urologists, urology registrars, urology residents, urology nurses, medical oncologists, radiation oncologists, general practitioners and medical students. participants were then provided with a survey. th ey were asked to indicate their level of experience working on a urology ward, the number of years since graduation from their primary medical or nursing degree. participants were then shown the series of pelvic drain fl uid images on a project. th ey were asked to correctly identifying the fl uid type in each image. using the survey, participants had the option of choosing either urine or peritoneal fl uid. results: all groups poorly identifi ed fl uid type. no individual staff group was signifi cantly better at identifying fl uid type. level of experience on a urology ward and years since graduation do not infl uence ability to determine fl uid type. conclusion: visual inspection of pelvic drain fl uid is a poor determinant of fl uid type. chang y, hsiao p, chen g, lee s, huang c, wu h, yang c, chang c introduction and objective: muscle invasive bladder urothelial cell carcinoma occasionally mixed with squamous diff erentiation. we conducted this study to investigate the incidence and treatment outcome of bladder urothelial cell carcinoma with squamous component. we enrolled patients muscle invasion bladder cancer who received radical cystectomy with bilateral pelvic lymph node dissection during to . patients' characteristics, chemotherapy record, and pathological report were retrospectively reviewed. th e following endpoints were assessed: overall survival (os) and recurrence-free survival (rfs). response of neoadjuvant chemotherapy subgroup was also analyzed. all survival data were analyzed by the kaplan-meier method using a log-rank test and multivariate analysis was carried out using a cox proportional hazards regression model. results: it was very clear that more than one third of these cases coming from the south of saudi arabia ( . %). th e bilharzia infestation found in ( . %) of the cases most of them are the southern patients. th e t staging turn to be high in most of our cases ( . % are t b). squamous cells carcinomas was also a striking feature of our result and found in ( . %). lymph node involvement found in one fourth of these cases ( . %). a total of ( . %) had local or lymph node recurrence and ( . %) got distant metastasis. around % ( cases) of our result showing that these cases having high grade and around % ( cases) had a hydronephrosis upon presentation. bladder cancer as a cause of death because of its advancement or recurrence account for ( . %) of deaths happened in these cases. th e survival of these cases severely aff ected by the fact that cases ( . %) could not know there survival status because they stop to show up in our institute for follow-up in spite the fact that there are some of them followed for more than years. arabia showing that the bilharzia infestation is quit high especially in the south and the squamous cell cancer is not as low as we expected. finding of hydronephrosis, lymph node involvement, high t and high recurrence in high percentage of our cases indicating that the bladder cancer aggressiveness behavior is not changing over years. introduction and objective: th is is an observational retrospective study utilising long-term patient follow-up for years (ys). to determine the survival and quality of life in women with age range - years, who had been treated for carcinoma of the bladder with radical cystectomy with preservation of genital organs. materials and methods: study included women patients with invasive urothelial carcinoma of the bladder treated with genital sparring radical cystectomy during the period from to . th ey had orthotopic ileal neobladder. follow-up included recurrence-free survival, metastases-free survival, overall survival, continence, and sexual function. results: overall survival up to - ys was in / women ( . %). survivors up to ys were in / ( . %). survival from to ys was in / patients ( . %). tumours stage of t were / patients, t were / patients, and t a were / patients. tumour grade was g in / , g in / , and g in / . age range of - ys were patients, range of - ys was patients, range of - ys was patients. continence was good in / patients; three patients / needed cic. sexual function tested by fsfi over< - was ( . %). conclusion: th e study provide evidence of safety and effi cacy of radical cystectomy with sparing of genital organs in women aged to with low grade, low stage invasive urothelial carcinoma of the bladder. oncological outcome for - years was good; continence and sexual function were very good. th is procedure should be considered when surgical approach appears to be feasible. tan w, sherer b, nehra a, deane l introduction and objective: radical cystectomy for bladder cancer has been the surgical gold standard for decades. increasingly, experience with robotic assisted techniques has become more common in select centers. in the majority of instances, the urinary diversion has been performed extracorporeally and with the use of stents. herein, we report our center's initial experience with robotic radical cystectomy and stentless totally intracorporeal urinary diversion. a retrospective review of the medical records of all patients undergoing robotic cystectomy and intracorporeal diversion was conducted at rumc from - . specifi cally, attention was focused on perioperative parameters. results: a total of patients were identifi ed (male= , female= ) in the sample. four patients underwent intracorporeal ileal conduit reconstruction and one patient underwent totally intracorporeal ileal neobladder reconstruction. no patients received a pre op bowel preparation, post op pca or epidural and all were allowed oral intake early. no patient received a transfusion for operative blood loss. one patient was readmitted for dehydration. see table for details. conclusion: robotic assisted radical cystectomy with stentless intracorporeal diversion is safe and feasible. eliminating bowel preparation, pca and epidural, and incorporating early refeeding and ambulation may result in a shortened length of stay. a rigorous post-operative plan to optimize return of bowel function, permit rapid reintroduction of diet without restrictions and facilitate early ambulation is critical in improving outcomes for this patient population. computed up. , table . and hypermethylation of these two gene promoters. in order to investigate clinical usefulness for noninvasive bladder cancer detection, we further analyzed the methylation status in urine samples of bladder cancer patients. methylation of the tested genes in urine sediment dna was detected in the majority of cases that were hypermethylated in tumor samples ( . %) and the frequencies were . % . % and . % for apc, rarβ and survivin, respectively. our results indicate that methylation of apc, rarβ and survivin gene promoters is a common fi nding in patients with bladder carcinoma. th e ability to detect methylation not only in bladder tissue, but also in urine sediments, suggests that methylation markers are promising tools for noninvasive detection of bladder cancer. usefulness of the all cases were followed for over year. th e procedure is ) point marking; ) circular incision; ) level incision; and ) specimen retrieval using a needle electrode in accordance with the ukai's method. we investigated pathological fi ndings (margin situation), operation time, complications and recurrence. results: it is possible to diagnose the precise pathological fi ndings by turbo. we judged the width and depth ew in sequential section. th ere were few complications during and aft er the operation. operation time of turbo ( - min) was longer than conventional turbt. urethral catheter holding period and hospitalization period aft er turbo was the same as turbt. turbo is a relatively safe procedure even for beginners. twenty cases had a recurrence in cases. eleven cases had a recurrence in under year, but the same place recurrence was cases. th ere were few cases of same place recurrence in under year among margin-negative cases. th erefore we judged that ew-negative cases had no residual cancers. conclusion: turbo is a safe and useful procedure that provides precise pathological fi ndings with minimal complications. second tur is not necessary for turbo. turbo has a possibility to be gold standard of the treatment for non-muscle invasive bladder cancer (nmibc). the risks of bladder-preserving bacillus calmette-guérin therapy in high-grade non-muscle-invasive bladder cancer continuous physical activity has many eff ects on human body. it doesn't only strengthen the skeleton or muscles; it also affects cardiovascular system, nervous system and etc. in this research we wanted to fi gure out if continuous physical activity (cpa) eff ects the lower urinary tract symptoms in retired military offi cers or not. th is is a retrospective study. retired offi cers attending to urology clinic for annual prostate control and not using any drugs for prostate were enrolled in this study. aft er the patients' permission were taken for the study they were asked for cpa or not and their international prostate symptom scale (ipss) answers were compared. results: th ere were patients in cpa group and patients in non-cpa group. th e mean age is ( - ) in cpa group and . ( - ) in non-cpa group. answers of questions in ipss: incomplete emptying (p= . ), frequency (p= . ), urgency (p= . ), and straining (p= . ) were detected statistically rare in cpa group (table ) . although they were not statistically signifi cant, intermittency (p= . ), weak stream (p= . ) and nocturia (p= . ) were rare in cpa group too (table ) . in order to maintain a better lower urinary tract function, elderly men should continue their physical activity aft er retirement. conclusions: th e number of nocturia episodes was signifi cantly and linearly correlated with ipss total score, voiding, storage, qol and nih-cpsi voiding scores. however, other risk factors, including bmi, body fat percentage, blood pressure, bun, creatinine, lipid panel, ck, t , free t , prostate-specifi c antigen, serum testosterone levels, urine fl ow (assessed using urofl owmetry) and prostate size (assessed using transrectal ultrasound and digital rectal examinations) were not associated with the number of nocturia episodes, despite an a priori assumption that they all infl uence nocturia risk. risk results: symptom prevalence increased to . %, and the mean international prostate symptom score increased by . points during years. aft er adjusting for confounders, smoking history of ≥ pack-years was an independent risk factor for symptom deterioration and storage sub-symptoms, compared with non-smokers ( . and . odds, respectively). physical activity had a protective eff ect for voiding sub-symptoms. high daily protein intake exacerbated the storage symptoms. however, alcohol intake was not associated with symptom deterioration. conclusions: th e symptom prevalence among elderly men living in a suburban area increased to . %, and the international prostate symptom score increased by . points during years. smoking history, physical activity, and protein intake were associated with symptom deterioration. however, there was no signifi cant association with alcohol intake and symptom deterioration. russo g, castelli t, urzì d, privitera s, fragalà e, favilla v, cimino s, morgia g introduction and objective: a signifi cant amount of epidemiological evidences have underlined an emerging link between mets, benign prostatic enlargement (bpe) secondary to benign prostatic hyperplasia (bph) and related lower urinary tract symptoms (luts). we aimed to assess the connections between lower urinary tract symptoms (luts) related to benign prostatic enlargement (bpe) and metabolic syndrome (mets) with its components. is increased prostatic urethral angle related to lower urinary symptoms in male without prostatic obstruction? introduction and objective: th e prostatic urethra is a bent tube, and the clinical signifi cance of the prostatic urethral angle (pua) was recently reported. we investigated the statistical signifi cance of an increased pua on the international prostate symptom score (ipss), with luts/bph. a prospective analysis was made of patients ( . ± . years) with luts and/or bph. patient underwent an evaluation including the ipss, psa, transrectal ultrasonography, urofl owmetry, and measurement of post-void residual. pua were measured by cystourethroscopy ( figure ). in order to minimize the eff ect of prostate, patients with prostatic obstruction under cystourethroscopy were excluded. th e minimum pua degree of symptoms change was constructed as a predictor of the eff ect of medication. all patients received tamsulosin . mg during the fi rst weeks and . mg during the next weeks. results: th e psa, prostate volume and pua were . ± . ng/ml, . ± . ml and . ± . °, respectively. th e area under the roc curve was . at the degrees with a sensitivity of . % and a specifi city of . %. comparing a higher pua (over degree, group a) with a lower pua (under degree, group b), patient with a higher pua had a longer luts period (p= . ), an improvement of symptoms aft er medication (p= . ) and an increase of average fl ow rate (p= . ). however, there was no signifi cant diff erence in age, psa, post-voided volume between the two groups. conclusion: pua showed signifi cantly correlated with the improvement of ipss, the eff ect of medication, and urofl owmetry. our fi ndings suggest that pua under cystourethroscopy may be one method to assess the presence of luts in men and help in the treatment of individuals by better predicting their likely classifi cation from ipss, urofl owmetry, and prostate volume. however, further studies are needed to explore the mechanisms and the eff ects of pua under cystourethroscopy. introduction and objective: th e prevalence of lower urinary tract symptoms increased with age. it is known that irritable bladder symptoms such as urinary frequency, urgency, nocturia increased with age in many studies. recently it was reported that vascular calcifi cation was one of the cause of lower urinary tract symptoms. we studied to evaluate the association between lower urinary tract symptoms of vascular calcifi cation in the abdominal ct using by agar score. th e records were obtained from a retrospective database who underwent abdominal ct due abdominal pain, hematuria. sex, age, height, weight, prostatic size, calcifi cation of aorta and internal iliac artery, amount of subcutaneous fat and visceral fat in the umbilicus level, international prostate symptom score, overactive symptoms score and urofl owmetry were assessed. calcifi cation of aorta was estimated from renal artery bifurcation to iliac artery bifurcation level. and internal iliac artery calcifi cation was calculated from bifurcation of iliac artery to bladder. we scanned each subject of . cm interval on the ct scan. th e calcifi cation of blood vessels was measured as agar score using abdominal ct aft er our explaining about each contents of nih-cp-si and iief- , the paper was checked by volunteers in person, and then we collected it. th e subjects were limited to - s korean male. we analyzed the collected questionnaires, and considered men who have perineal and/or ejaculatory pain or discomfort and a total nih-cpsi pain score of ≥ as having prostatitis-like symptoms, and categorized to four groups by iief- score, mild ( - ), mild-moderate ( - ), moderate ( - ), severe ( - ). results: an average age of volunteers was years old ( - ). th e iief- category was divided to fi ve groups. among total volunteers, persons were chronic prostatitis like symptom patients ( . %), and whose nih-cpsi average of pain score, voiding score, quality of life score and total score were . ± . , . ± . , . ± . , and . ± . , respective-up. , figure . ly. th ere were a little correlations among pain score, voiding score, quality life score, but not signifi cant. an average of total iief- scores in chronic prostatitis like symptom patients was . ± . , it was signifi cantly lower than absent group. th ere were all negative correlations of between iief- and pain score (t=- . , r = . , p= . ), voiding score (t=- . , r = . , p= . ), qol score (t=- . , r = . , p= . ), and total score (t=- . , r = . , p= . ). conclusion: th e higher total nih-cpsi score, especially pain score plays a larger role, adversely aff ects erectile function of chronic prostatitis like symptom patients in - s korean male. a antimuscarinic agent is the mainstay of treatment, but it have side eff ects such as dry mouth, constipation. th ese eff ects resulted in cessation of medication in many cases. th e authors therefore assessed the impact of side eff ects on health-related quality of life (hr-qol) through an analysis of questionnaires. th is study was designed to investigate the patients' satisfaction by quality weight (utility weight) of health status as aff ected by the side eff ects of oab medications in tertiary hospitals in korea. patients who had oab symptoms lasting longer than months and side eff ects aft er any antimuscarinic treatment fi lled in the eq- d. th e questionnaire and vas score for two diff erent health statuses, presence or absence of side eff ects, were analyzed. quality weight was calculated using the score of ed- d health status. results: one hundred patients were enrolled. th e most prevalent side eff ect was dry mouth ( %), followed by constipation ( %). twenty-eight percent of the patients had dry mouth and constipation concurrently. most of the patients with side eff ects tried to overcome these side eff ects ( %), but % desired a change in medication, and % stopped medication altogether. fift y-fi ve patients replied that they consider side eff ects to be an important factor in deciding on the continuation of medication. th e quality weight of eq- d without side eff ects was . , while the quality weight with side eff ects was . (p= . ). th e vas score was in patient without side eff ects and in those with side eff ects, supporting the results of quality weight assessment. th e same trend was observed when stratifi ed according to age and sex. as for the overall distribution of ed- d, the patients with side eff ects were less healthy in terms of daily life, pain/discomfort, and anxiety/depression. introduction and objective: treatment of men with large prostates is challenging with greater risk of complication and retreatment. while photo-vaporization (pvp) has been well described for greenlight w-xps, vapor resection techniques have been described to help improve tissue resection, including vapour-incision techniques (vit). we sought to evaluate the effi ciency, safety and outcome parameters between greenlight pvp and vit specifi cally for men with prostate volumes > . among xps cases retrospectively collected from experienced surgeons at high-volume greenlight xps centers, had large prostates. preoperative, operative and post-operative parameters were collected and compared between groups. results: as summarized in table , men undergoing vit (n= ) had comparable preoperative parameters to those undergoing pvp (n= ). while vit allowed greater delivery of energy ( . vs . kj/g), operative time was longer and there was greater need for > fi bres. th ere were no diff erences in intra-and day post-operative adverse events. both vit and pvp demonstrated comparable marked improvements in ipss/qol at months post-operatively. however, despite greater urinary retention and pvr preoperatively, men with vit demonstrated signifi cantly lower post-operative pvr and greater qmax at moths. no signifi cant diff erence in retreatment rates was noted between vit and pvp follow-up. conclusions: both greenlight pvp and vit techniques can be safely used to treat men with large prostates. both techniques off er signifi cant and durable relief of symptom relief with comparable complication rates at years. longer follow-up is necessary to assess durability. open within two years, one-hundred patients were prospectively randomized into two equal groups. all patients underwent tvp whereas rb was used in group- . rb is a balloon fi xed to -way foley catheter tip by blaster strip making it air tight. we placed it in the rectum opposing prostate and infl ate (pressure controlled) for min. hemoglobin (hg) levels have been assessed pre-and postoperation. blood transfusion, amount of saline for irrigation, catheter duration, hospital stay, and rectal complain were recorded. follow-up was and -mo, postoperatively. results: enucleated adenoma weight was gm in g- and gm in g- . th ere is signifi cant diff erence between both group for hg-loss within fi rst h post-operative and total hg-loss . gm in g- and . gm in g- (p, . ) and . gm vs. gm (p, . ) respectively. also there is signifi cant diff erence between both group in relation to the saline/l for irrigation ( . vs. . l), catheter duration ( . vs. . day), and hospital stay ( . vs. . day), with favorable results to the rb group. blood transfusion was in g- and one in g- . th ere is no rectal complain. conclusion: rb infl ation post-tvp is simple and safe procedure without operative technique, reduces post-operative blood loss, blood transfusion incidence, saline for irrigation, and shortens the catheterization period and hospital stay, without rectal complication. conclusion: th ough this was not a head-to-head study and there were a number of dissimilarities in the study design, we demonstrated a non-inferiority of our study and a signifi cantly shorter median length of catheterization, time until stable health, and hospitalization relative to the goliath study. introduction and objective: th ulium laser enucleation of the prostate (th ulep) has been introduced as a minimally invasive treatment for benign prostatic obstruction (bpo). th e aim of the study is to assess what are the intraoperative key points and possible complications of the morcellation procedure aft er th ulep. to assess whether this events have any eff ect on hospitalization length. a cooperation between the university of milan and moscow was settled. prospective study that analyzes events that prolonged the morcellation process aft er completing thullium laser enucleation procedure in a group of consecutive patients was performed. events related to the morcellation procedure were recorded. patients' hospitalization length were evaluated aft er discharge only considering patients that were not re-admitted because of a surgical related issue. statistical analysis was performed by the student t and chi-square test and logistic regression analysis. for all statistical comparisons signifi cance was considered at p< . . results: mean age was . years. five groups of reasons for prolonged morcellation were recorded. bladder suction with wall damage, bleeding due to "ex vacuo" fast empting, suction problem, morcellation impairment and prolonged morcellation time due to enlarged prostate. each group of issues was related to a signifi cant prolonged operative time (p< . ). th e table shows the key points rate and their correlation with a prolonged hospital stay. a statistical significance between the event and the prolonged hospital stay found only for bladder suction. conclusions: issues related to the morcellation procedure aft er laser enucleation of the prostate (th ulep) causes prolonged hospitalization length only in the case of bladder suction. other events, even if related to a slower operative time, do not mean a prolonged hospitalization. suprapubic cystostomy makes turp more effective and safer introduction and objective: a recent survey found turp the commonest performed procedure in bph, despite the rising popularity of laser prostatectomy. th e reasons for popularity in laser are ease of performance, lesser complications, and good results. it is the complications factor that makes it look attractive. th e onus is therefore to make turp safer. th is is more applicable in india, where the cost of laser excludes - % of patients. numerous innovative procedures have been tried to make turp safer. continuous outfl ow has been described as innovation, the means to achieve it not described. introduction and objective: prophylactic peri-vesical drain placement during suprapubic prostatectomy remains a widespread surgical practice. however the surgical technique of suprapubic prostatectomy has signifi cantly improved and as such the contemporary role of prophylactic surgical drains needs reevaluation. it has been traditionally assumed that prophylactic drains helps prevent fl uid collection (blood, serum, urine) which if not drained can lead to surgical wound complications. th is paper investigates the incidence of surgical wound complications aft er a series of suprapubic prostatectomy done without placement of surgical drains but in the context of modifi cations to the surgical technique. prostatic hyperplasia (bph) were operated upon between and -all using a modifi ed suprapubic prostatectomy technique that includes meticulous dissection, hemostatic suturing that covers the main areas of anatomic distribution of the urethral arterial branches of the inferior vesical artery, non-placement of drains and suprapubic catheter, and also routine irrigation of the surgical wound with normal saline among other modifi cations. pre-and post-operative blood hemoglobin levels, prostate specimen weights and presence of surgical wound complications if any were recorded. th e main outcome measure was to determine the presence of early surgical wound complication defi ned as clinical evidence of hematoma/ seroma, infection, drainage or wound dehiscence. results: th e mean age of the patients was . (range of to years). th e mean prostate weight was . gm-(range of to gm). th e mean hemoglobin diff erence was . mg/dl (range of . mg/dl to . mg/dl). on a minimum days observation of the surgical wounds, there was only one case of superficial wound infection ( . %) that healed with wound dressing. th ere was no mortality and none of the patients received blood transfusion. in the context of an improved surgical technique, suprapubic prostatectomy for bph can be safely performed without the placement of prophylactic peri-vesical drain. non-placement of prophylactic surgical drains in this series was not associated with increased wound complication rate. effects of detrusor underactivity conclusions: according to detrusor activity, there were not diff erent in diff erences between preoperative or postoperative ipss. abnormal detrusor contractility (esp. dua) cannot be a contraindication for tur-p, and turp should be a defi nite therapeutic option in abnormal detrusor activity. geavlete p, dragutescu m, multescu r, georgescu d, geavlete p introduction and objective: th is long-term retrospective study aimed to analyze the re-intervention necessities aft er bipolar plasma vaporization of the prostate (bpvp) in patients with medium sized benign prostatic hyperplasia (bph). materials and methods: th ere were followed patients who underwent bpvp for prostates sized between and ml. th e re-intervention rates were analyzed during a follow-up period of at least months. results: additional interventions consisted of immediate reoperation for secondary hematuria, endoscopic re-intervention for urethral stricture or blad-der neck sclerosis and transurethral resection of the prostate (turp) for residual bph bulk. endoscopic hemostasis during hospitalization was required in cases ( . %) and in discharged patients in other cases ( . %). during the follow-up period, patients ( . %) with bladder neck sclerosis underwent the plasma vaporization approach. urethral stricture was diagnosed in patients ( . %), of them receiving internal optical urethrotomy while urethroplasty was performed in cases. residual adenoma was present in patients ( . %), thus requiring and secondary turp. conclusion: bpvp is a valuable endoscopic treatment alternative for medium size bph cases with higher effi ciency and a satisfactory rate of reoperation. diode laser nm for the treatment of bph: long-term comparison of the enucleation vs. vaporization introduction and objective: to report -years follow-up results of clinical trial comparing diode laser enucleation of the prostate (dilep) with diode laser vaporisation of the prostate (dlvap). a total of consecutive patients were included in the prospective study who had received laser treatment for bph. patients were assigned to two groups based on the type of procedure: to dilep group and to dlvap group. patients with a history of neurogenic bladder dysfunction, chronic prostatitis or bladder cancer were excluded from evaluation. standard follow-up examinations were performed in both study groups in predefi ned time points (in the perioperative period, at month and month , and month , and then every year). primary endpoints included: lower urinary tract symptoms (luts) as measured by the international prostate symptom score (ipss), urinary fl ow rates and post-void residual urinary volume. complications were assessed. an additional endpoint was to review video records to precisely determine the timeframes for individual surgical procedures and to plot the learning curve. results: all the remaining patients had undergone the -year follow-up assessment. measurements were performed at , , , , , , and months. th ere were no statistically signifi cant differences in baseline characteristics between the two groups. no signifi cant intraoperative and early postoperative bleeding was observed. hospital stay aft er surgical intervention covered day that was equal to average time of urethral catheter indwelling. th e improvement rates, calculated based on the ipss scores at years aft er surgery, were . % and . % in the dilep and dlvap group, respectively. th e results indicate signifi cant decrease in severity of luts. th e sustained treatment eff ect was in favor of dilep intervention group. also treatment effi cacy was better in the dilep group compared to the dvlap group, as regards the maximum urinary fl ow rate (qmax). th e diff erence was statistically signifi cant. conclusions: diode laser enucleation and vaporisation of the prostate are low-risk minimally-invasive treatment option of treatment of patients with bph. both methods may be safely performed even in high risk and patients on ongoing oral anticoagulation. treatment eff ects are better and more sustained with laser enucleation than with laser vaporization of the prostate. dilep is a true endourological alternative to turp. changes in urination according to the sound of running water using a mobile phone application introduction and objective: th e sound of running water (srw) has been eff ectively used for toilet training during toddlerhood. however, the eff ect of srw on voiding functions in adult males with lower urinary tract symptoms (luts) has not been evaluated. to determine the eff ect of srw on urination in male patients with luts, multiple voiding parameters of urofl owmetry with postvoid residual urine (pvr) were assessed according to the presence of srw played by a mobile application. eighteen consecutive male patients with luts were prospectively enrolled between march and april . urofl owmetry with pvr measured by a bladder scan was randomly performed once weekly for two consecutive weeks with and without srw in a completely sealed room aft er pre-checked bladder volume was scanned to be more than cc. srw was played with river water sounds amongst relaxed melodies from a smartphone mobile application. results: th e mean age of enrolled patients and their mean international prostate symptom score (ipss) were . ± . years (range: - ) and . ± . , respectively. all patients had not been prescribed any medications, including alpha-blockers or anti-muscarinic agents, in the last months. th ere was a signifi cant increase in mean peak fl ow rate (pfr) with srw in comparison to without srw ( . ml/s vs. . ml/s, respectively, p = . ). however, there were no diff erences in other urofl owmetric parameters, including pvr. th e study showed that srw from a mobile phone application may be helpful in facilitating voiding functions by increasing pfr in male luts patients. th is study aims to analyse how bladder outlet obstruction index (booi) and bladder contractility index (bci) aff ect surgical outcome for bph patients who were treated homium laser enucleation of the prostate (holep). we classifi ed the patients, who were treated holep and observed more than months, into group i (booi≥ and bci≥ , n= ), group ii (booi≥ and bci< , n= ), group iii ( <booi< and bci≥ , n= ) and group iv ( <booi< and bci< , n= ) based on urodynamic study result. patient's characteristics including volume of prostate, psa, ipss, maximum urinary fl ow rate and residual urine volume compared in each group. and we also compared ipss, maximum urinary fl ow rate, residual urine volume before and months aft er surgery. results: th ere was no signifi cant diff erence comparing age, psa, ipss, maximum urinary fl ow rate and residual urine volume among each group. th e prostate volume, ranked in ascending order of group, are as follows: . ± . ml, . ± . ml, . ± . ml and . ± . ml, it had signifi cantly disparity between group i and iii (p= . ), group i and iv (p= . ), and group ii and iv p= . ). using repeated measure anova, we found that ipss, maximum urinary fl ow rate and residual urine volume were signifi cantly improved within group in each group aft er surgery except ipss storage subscore between group ii and group iii and residual urine volume. and the degree of improvement among each group was not diff erent (table ) . th e incidence of aur ( . %) and bph-related surgery ( . %) were low in ct group. in comparison of baseline age, psa, and pv according to switch of medical therapy, baseline pv was signifi cant diff erence in both groups, respectively (p= . , p= . ). conclusion: th ere was more mt than ct in initial treatment. however, there was more switch of medical treatment type in initial mt in real-world clinical practice over -year follow-up. th e incidence of bph progression events was high in initial mt group. th e initial use of ct is recommended in patients with luts and bph. relationship between bladder wall thickness and lower urinary board the antarctic research vessel "shirase" on their way home and approximately two months aft er returning to japan. we analyzed the data of members of the winter party who had responded to the questionnaires more than times before departure and during their stays in antarctica. results: compared to before departure, the mean scores for all of the questionnaires decreased during their stays in antarctica, from . to . points for ipss, from . to . points for oabss, and from . to . points for psqi, but the mean volume voided per micturition increased from to ml. in regard to the amount of change in ipss scores over the same period, a signifi cant diff erence was noted between members with a pre-departure score ≥ points and members with a pre-departure score < points (- . vs. . , p = . ). th is study is the fi rst to report the urinary status of people in a polar environment investigated with questionnaires and voiding logs. we initiated this study under the assumption that one's urinary status would deteriorate in a polar environment, but our fi ndings indicated that urination and sleep tend to improve in antarctica. management of male luts: a southeast asia regional survey on practice patterns and perspectives results: responses were obtained from urologists from centres with size ranging from to patients per week. referral patterns diff er across the region -in hong kong, singapore and malaysia, patients prefer or are required to consult a general practitioner before seeking urologist care. common investigations that respondents proposed included urofl owmetry ± post-void residual volume measurement ( %), psa ( %), urinalysis ( %), voiding diary ( %), physical examination ( %) and trus-biopsy ( %). however, only urinalysis and symptom scores are essential investigations recommended consistently in major international guidelines. whether urofl owmetry should become an essential investigation in sea remains debatable. luts secondary to bph/bpo ( %) and oab ( %) were the two most common diagnoses for the case scenario, and correspondingly, alpha-blocker ( %) and antimuscarinics ( %) were the two predominant treatments suggested by respondents. nocturnal polyuria is a common cause of nocturia especially amongst elderly, yet relatively few urologists ( %) considered this condition as a main diagnosis. respondents felt that there was a paucity of large-scale epidemiology studies on luts in sea, and on the natural history of the disease. more education on the proper evaluation and diagnosis of luts is needed for both gps and urologists in the region. results from this sea survey revealed variations in urologists' practice patterns and guideline recommendations, and pointed to the needs for further research and education in luts. female urethral prolapse: bhalla v , attri a , bhalla s introduction and objective: urethral prolapse means the protrusion of the distal urethra through the external urethral meatus. female urethral prolapse is a rare condition that has bimodal distribution aff ecting postmenopausal women and prepubertal girls. female urethra has two layers of smooth muscles inner longitudinal layer and outer circular which remain adherent to each other by strong connective tissue. separation of these two layers with episodic increase in intra-abdominal pressure leads to complete urethral prolapse. birth trauma during prolonged vaginal delivery, perineal tears, debility, malnutrition and periurethral bulking agent injections have been implicated in postmenopausal group. we present two postmenopausal female patients of urethral prolapse having similar clinical presentation aged years and years respectively. th ey presented with symptoms of blood spotting of undergarments and voiding diffi culty with dysuria of acute onset. on physical examination a doughnut-shaped erythematous infl amed mass was seen protruding from external urethral opening. th e evaluated parameters included pop-q grade, international prostatic symptom score (ipss), overactive bladder questionnaire (oab-q), international consultation on incontinence questionnaires short form (iciq-sf), maximum fl ow rate (q-max), and residual urine volume (ru). we evaluated them before and , , year aft er surgery. results: pop-q grade before surgery tended to be high in elderly group without signifi cance. anatomical cure at year aft er surgery (%) of non-elderly and elderly was and %, respectively. a tendency to having poor scores was observed in elderly group concerning preoperative ipss, iciq-sf and oabss; however they did not attain signifi cance. th ese three parameters improved in both groups aft er surgery; however, the percent improvement was signifi cantly poor in elderly group. th e maximum fl ow rate before surgery was signifi cantly low in elderly group and was still low aft er surgery. th e residual urine volume did not show signifi cant diff erence in each group before and aft er surgery. in the observation period of year, de novo oab and mesh extrusion were observed in elderly group with a signifi cant frequency. conclusions: th ough the anatomical cure was not age specifi c, age apparently aff ected on the outcome of tvm especially in the percent improvement of luts. autologous materials and methods: ten women with sever and complicated stress urinary incontinence secondary to the bladder neck and urethral trauma or congenital epispadias (with or without extrophy) underwent transurethral injection of autologous muscle derived cells. a second injection was performed according to the assessment of patients, months aft er the fi rst treatment session. all patients were followed at one week, , and months aft er injection by physical examination (cough stress tests), one hour pad test and iiq- score. multi-channel urodynamic study and maximal urethral closure profi lometry (mucp) was performed before and months aft er the last treatment session. cough stress test, one hour pad test and urofl owmetry were repeated at months aft er the last injection. in each visit the severity and incidence of complications was recorded. results: all patients completed the study and were followed for months. th ree patients were cured; four and three of patients were improved and failed to the treatment respectively. th ere were no major adverse events related to the treatment. conclusions: according to our clinical results, in a limited number of female patients, muscle derived cell therapy is a minimally invasive and safe procedure in the treatment of patients with severe and complicated sui. th e cure rate is not high, though it may be considered as an option beside other treatment modality. are we evaluated the eff ect of patient position and bladder fi lling status on the q-tip angle for urethral hypermobility. we measured the q-tip angle in the supine position and at a ° angle in a reclining position in patients during bladder emptying and then repeated the measurements while fi lling the bladder, usually - ml. we defi ned urethral hypermobility as the urethral angle straining or coughing minus that at rest > °. results: all female patients (mean age, ± years; range, - ) who complained of urinary incontinence were assessed using the q-tip angle. th e pelvic organ prolapse quantifi cation stages of all patients were ≤ stage . mean q-tip angle with an empty bladder was . ± . ° in the supine position and . ± . ° in the ° reclining position (p = . ). mean q-tip angle during the fi lling bladder state was . ± . ° in the supine position and . ± . ° in the ° reclining position (p = . ). th e urethral hypermobility rate during the bladder emptying state was . % ( / ) in the supine position and . % ( / ) in the ° reclining position. th e relative positive ratio of the reclining to the supine position is . . th e urethral hypermobility rate during the bladder fi lling state was . % ( / ) in the supine position and . % ( / ) in the ° reclining position. th e positive rate was higher in the ° reclining position during bladder emptying than that in the other position during bladder fi lling. conclusion: th e outcome of the q-tip angle measurement and the rate of urethral hypermobility changed in relation to patient position. th e reclining position during bladder emptying increased the q-tip angle, resulting in positive urethral hypermobility. rotational th ere was no mortality from the surgical procedure, whereas pain and catheter blockage was main complication. all patients were followed at , , and weeks respectively. our success rate was %. vesicovaginal fi stula is the most common urogenital fi stula. obstructed labor and its complications are still the leading cause of its development, whereas iatrogenic fi stula is also up-coming warning for all health care professional. the effi cacy of combination therapy of alpha blocker with anticholinergic in adult women with overactive bladder introduction and objective: overactive bladder (oab) is associated with symptoms including urgency, with or without urge incontinence, usually with frequency and nocturia. anticholinergics are mainly used for the treatment of patients with oab, especially women. other than anticholinergics, alpha blockers have been shown in several clinical reports to be useful in treating detrusor overactivity caused by neurological diseases. th e aim of the study is to evaluate the effi cacy of alpha blocker in combination with anticholinergics to treat women suff ering from oab. th is prospective study enrolled female patients with oab. patients have been randomised into two groups. th e interventions for the -week treatment period included solifenacin daily for the group and combination of both solifenacin and tamsulosin daily for the group . at baseline and weeks aft er treatment, patients completed a -day bladder diary, international prostate symptom score (ipss), quality of life (qol) index, overactive bladder symptom score (oabss), maximum fl ow rate (qmax) and postvoid residual urine volume (pvr). results: a total of women were randomised and completed this study (group ; , group ; ). statistically signifi cant improvements in terms of urgency and frequency were observed in both groups at weeks aft er treatment as compared with baseline (p< . and < . ), while no inter-group diff erence was observed between the two groups. although group showed improvement of ipss voiding subscore, qol and qmax than group but not statistically signifi cant (p= . , p= . , p= . ) . no signifi cant diff erence was observed in terms of toxic events between the two groups. conclusion: th e combination of alpha blocker and anticholinergic for weeks was noninferior to anticholinergic alone in effi cacy, and there was no evidence of benefi t of alpha blocker in treating female oab. further studies are needed to assess the role of combined therapy of alpha blocker and anticholinergic in the treatment of female oab. conclusion: advancement of cystoscopy will continue undoubtedly. th is report emphasizes the key people whom contributions will always be a corner stone in the fi eld of urology. "gleason" in a nutshell unusual urogenital disorders introduction and objective: to present some aspects of unusual urogenital disorders, congenital malformations, and syndromes, sometimes occurring in eminent personalities or having been described by famous scientists. th e review of historical sources and biographies of famous suff erers and the study of modern medical literature about all these rare urogenital diseases. results: penile deformities such as hypospadias (the most known representative was henry ii of france - , suff ering also from chordee) and the rare epispadias (respectively the most known was the byzantine emperor heraclius, - ) were recorded by historians because of the infertility consequences or the bizarre urination habits (heraclius needed protective measures to avoid getting wet). historians also were attracted by spectacular and dramatic urological emergencies, such as fournier gangrene, known by the case of the prominent suff erer herod. referring to famous researchers, françois gigot de la peyronie ( - ), founder of the royal academy of surgery of france, described the homonymous disorder ( ), consisting of penile deformity due to induration of the corpora cavernosa of the penis. th e above disease, called also induratio penis plastica (ipp) is one of the extraordinary urogenital problems together with the strongly psychologically and non-physically induced syndromes koro (genital retraction syndrome) and castration anxiety (the latter described by freud). belief that genitals have disappear and fear of damage or loss of the penis characterize them both. much of the research has been done on the two above topics, although still relevant today. conclusions: unusual urological disorders are broadly known when happening on famous personalities or when described by famous physicians or when attract the common opinion as extraordinary events (called mirabilia by historians). koutsiaris e , drettas p , oikonomou a , poulakou-rebelakou e , rempelakos a introduction and objective: th e loss of a testis represents a psychologically traumatic experience in males of any age. testicular loss is commonly the result of torsion, trauma, infection or malignancy. th e patients who experience orchiectomy request the implantation of an artifi cial testis for psychological or cosmetic reasons. testicular prostheses are one of the most commonly implanted devices and we present the evolution of these devices. review of the medical literature regarding the history of testicular prostheses and the various materials that have been used during the decades. results: th e fi rst testicular prosthesis was an alloy of molybdenium, cobalt and chromium and was used in . during the s, other materials were used such as plexiglass and polyethylene without much success. it was then suggested by the scientifi c community that the ideal testicular prosthesis should not produce any infl ammatory reaction and that should be also made by a proven non carcinogen material. it was also suggested that the material of the prosthesis should also resist mechanical press and take and hold the desired form. as a result, solid silicone rubber prostheses were introduced and used in the s. th e demand for more natural feeling implants lead to gel fi lled silicone devices appearing in . in , fi rmer silicone coated prosthesis became the "gold" standard. in the us in , the food and drug administration (fda) halted the use of gel fi lled breast implants due to the risks of autoimmune disorders and the possibility of tumor development. as a consequence, in there was a voluntary withdrawal of silicone gel fi lled testicular prostheses and replacement with saline fi lled prostheses. nowadays both silicone and saline fi lled testicular implants are used worldwide which are safe and eff ective. conclusions: testicular prostheses reduce the psychological impact that results from loss or absence of a testicle and should be off ered to male patients of any age. introduction and objective: we investigated population-based management trends of urinary stone disease in the use of extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy during the recent years in a korean population. we conducted this retrospective study by reviewing the medical records of patients diagnosed with acute ureteric colic in the emergency room and in the urology outpatient from january to december . nine hundred patients were diagnosed with ureteric stone and all of them underwent ultrasound as the primary imaging modality. sensitivity, specifi city, positive and negative predictive value in determining the size, position of the stone in the ureter by ultrasound has been documented. results: out of patients, there were males ( %) and females ( %). age range was - years. our study found that color doppler ultrasound with twinkling sign, diagnosis was made with confi dence in cases ( . %). sixty-fi ve patients who failed the ultrasound, the stones were confi rmed by helical ct, failure to detect the stone was mainly due to poor visualization (due to bowel gases and obesity) and smaller size of stone. right side stones were seen in ( . %) patients while left side stones were seen in ( . %). stones were detected bilaterally in cases ( . %). th e range of stones size was - . mm. th ere were ( . %), ( . %) and ( . %) upper, middle and lower ureteral stones. conclusion: th ere is no doubt that spiral ct is superior in the demonstrating of ureteral calculi. th e present study emphasized that utilization of color doppler ultrasound with twinkling in trained hands can provide an excellent alternative modality with high sensitivity and specifi city in diagnosis of acute ureteric colic and with confi dence can be used as fi rst imaging modality, hence we could avoid high cost, higher radiation dose and high workload. contemporary imaging practice patterns following ureteroscopy for stone disease cleveland clinic, cleveland, usa introduction and objective: routine imaging following ureteroscopy for treatment of renal/ureteral calculi continues to be a topic of debate. however, with the increasing focus on healthcare costs and quality, judicious use of diagnostic imaging to optimize outcomes while minimizing resource utilization is a priority. we sought to identify post-ureteroscopy imaging practices amongst experienced urologists. a redcap questionnaire was sent to urologists in north america. th e questionnaire surveyed demographic data, clinical volume, and imaging preferences post-ureteroscopy. additionally, we surveyed the extent to which stone, anatomic, and procedure-related factors infl uenced these preferences. th e likelihood of altering clinical practice and the desire for specifi c imaging guidelines were also assessed. th e interquartile range (iqr) was utilized as a measure of median consensus, with a lower iqr denoting increased agreement. results: th ree hundred twenty two urologists completed the questionnaire. th e mean number of years in practice was ± ; % of respondents performed more than ureteroscopic stone procedures monthly. routine postoperative imaging was obtained by % of participants as follows: us ( %), kub ( %), ct ( %), ivp ( %), and kub + us ( %). urologists who did not routinely image patients were more concerned about cost ( % vs. %, p= < . ), radiation exposure ( % vs. %, p= < . ), and diagnostic inaccuracy of us ( % vs. %, p= < . ). th ese urologists were also less likely to have completed an endourology fellowship ( % vs. %, p= < . ). th e most compelling predictors of obtaining postoperative imaging were post-op pain and fever (median , iqr ), residual stones (median , iqr ), ureteral perforation (median , iqr ), and presence of a solitary kidney (median . , iqr ). conclusions: currently, about % of urologists who regularly perform ureteroscopic stone procedures obtain post-op imaging. imaging preferences were guided by the presence of residual fragments, ureteral perforation, solitary kidney, and postoperative pain or fever. introduction and objective: ct scans expose patients to ionizing radiation which is associated with risks of secondary malignancy. we sought to evaluate the performance of reduced dose ct scans in patients evaluated for renal colic in the emergency room. up. , figure . introduction and objective: intraoperative exposure to ionizing radiation is a growing concern for the safety of both patient and or staff . eff orts to reduce the amount of radiation during ureteroscopic procedures oft en result in decreased image quality. lessray™ is a device used to digitally enhance images obtained from a c-arm using a low-dose pulse setting allowing for reduction in radiation dose while maintaining image quality. a randomized prospective trial of patients was performed comparing ureteroscopic cases for unilateral obstructing ureteral stones using standard fl uoroscopy compared to lessray™. patient demographics, stone parameters, and operative characteristics were recorded in addition to total radiation dose, total fl uoroscopy time and images obtained ( (table ) . a statistically signifi cant reduction in radiation exposure to the surgeon was also noted (p = . ). image quality was not compromised and no conversion from less-ray™ to standard fl uoroscopy was needed in any case. a nearly threefold reduction in patient radiation exposure was achieved using the lessray™ digital enhancement device compared to standard fl uoroscopy. th is novel technology has not previously been used in urologic surgery and off ers a promising alternative to standard fl uoroscopy while ameliorating risks to both the patient and surgeon. bilateral results: in the cases of cn patients, accepted retroperitoneal laparoscopic cyst unroofi ng, accepted retroperitoneal laparoscopic partial nephrectomy, patient with a preoperative diagnosis of cystic renal cell carcinoma, the maximum diameter of cm and located in the center of the kidney got retroperitoneal laparoscopic radical nephrectomy. one patient recurred yrs later aft er retroperitoneal laparoscopic cyst unroofi ng, and underwent open partial nephrectomy at last. six mestk patients underwent retroperitoneal laparoscopic radical nephrectomy and accepted retroperitoneal laparoscopic partial nephrectomy. twelve cases were followed up for months to years, no recurrence. conclusion: cn and mestk are rare benign tumors of the kidney. preoperative misdiagnosis is high. multi-cystic lesions with no mural nodules should take cn/mestk into consideration, especially when the lesions convex to the pelvis, should be highly suspected for cn diagnosis, and to assess the possibility of partial nephrectomy. cyst unroofi ng for cn has recurrence risk. the value of -t multiparametric mri for detecting prostate cancer of t stage introduction and objective: th e objective of this study was to prospectively determine the value of -t multiparametric (mp) mri with pelvic -phased array coil for prostate cancer of t stage. december , patients underwent -t mpm-ri with pelvic -phased array coil, transrectal ultrasound-guided biopsy and radical prostatectomy for adenocarcinoma. mr images were evaluated by three experienced radiologists with regard to extracapsular extension and seminal vesicle involvement and compared with whole-mount histopathological sections as a gold standard. we estimated the sensitivity, specifi city, positive, and negative predictive value and overall accuracy of mpmri for t disease. introduction and objective: prostate cancer (pca) imaging has undergone a revolution in the past fi ve years with the rise of multiparametric magnetic resonance imaging (mri) for cancer detection and the evolution of positron emission tomography-computed tomography (pet-ct) for staging. initially, choline pet-ct was considered the new standard for detecting metastatic disease where biochemical recurrence (bcr) occurs aft er primary treatment, but a newer agent based on prostate-specifi c membrane antigen (psma) has emerged. despite the reported promising results with this novel imaging modality few reports correlating psma pet-ct with pca histology have been documented. we present the case of a fi t year old gentleman, where psma pet-ct was used to accurately detect pca pelvic lymph node (ln) metastasis in the setting of bcr following primary radiation treatment. results: th e positive psma pet result was confi rmed with histological examination of the involved pelvic lns following robotic-assisted laparoscopic pelvic ln dissection (plnd). larger studies are required to document accurately the role of psma pet-ct but it is likely it will usher in a new era of surgical and even radiation treatment of oligometastatic disease, aiming for cure or prolonged deferring of systemic treatment. introduction and objective: imaged guided radiotherapy has been shown to improve the outcome of pelvic radiotherapy, notably with prostate gold seed fi ducials. lipiodol has been utilized for radiotherapy bladder fi ducials, but can be technically diffi cult to inject as discrete fi ducial markers, particularly in the post-prostatectomy setting. th e objective is to investigate contrast agent/tissue glue mixtures as radiotherapy bladder fi ducials with respect to deliverability and visualisation for radiotherapy verifi cation. two radiopaque contrast agents, lipiodol and urograffi n were investigated. th ese were mixed with a three tissue glues: histoac-ryl™, tisseel™ and glubran™. to simulate the clinical procedure, the mixtures were injected ex-vivo into the submucosa of fl uid fi lled pigs' bladders using a cystoscope and williams needle. th e aim was to produce a small, medium and large fi ducial. th e bladders were transferred to a pigs' pelvis to provide realistic tissue densities for radiotherapy imaging. visualisation of the pelvis was performed in accordance with radiotherapy procedures. th e initial imaging was done on a radiotherapy ct simulator. radiotherapy verifi cation was performed by radiation therapists using widely accepted protocols including cone beam ct (cbct) and kilovoltage (kv) & megavoltage (mv) d planar images. results: delivery: urograffi n glue mixtures were diffi cult to deliver as it polymerized rapidly in the catheter. consequently it was only possible to produce a single fi ducial. th e lipiodol glue combinations were all deliverable. visibility: th e urograffi n glue combinations were only able to produce a single fi ducial that was visible on ct and cbct but were not visible with kv or mv verifi cation. all of the lipiodol glue combinations produced multiple fi ducials that could be satisfactorily visualised on ct and cbct. lipiodol with either hystoacryl or glubran produced visible fi ducials on kv imaging, however the lipiodol tisseel combinations could not be seen. no combination produced suffi cient contrast with mv planar imaging. introduction and objective: th e fl exible urethrocystoscopy is a procedure that is performed routinely in urology for monitoring bladder tumors and diagnosis in patients with lower urinary tract symptoms and hematuria. th e aim of this study is to analyze whether the use or not of antibiotic prophylaxis is indicated in this outpatient procedure. prospective nonrandomized observational study in which patients were divided into two groups: -group : patients with prophylaxis with ciprofl oxacin mg h before urethrocystoscopy; -group : patients without antibiotic prophylaxis. prior to inclusion in the study absence of urinary tract infection is checked by urine culture obtained three days before the procedure. indication of cystoscopy, cystoscopy results, presence of comorbidities, urine culture aft er days, urinary symptoms over the next seven days were analyzed. statistical analysis with spss . with signifi cance diff erences p≤ . . results: th e mean age of patients in group was . ± . years versus . ± . years in group (p= . ). no diff erences in the percentage of men / women included among the groups. fourteen percent of patients in group had bacteriuria compared with % in group , no signifi cant diff erence. in the multivariate analysis, it appears that neither age, diabetes, smoking, lower urinary tract symptoms or immunosuppression were associated with the onset of bacteriuria between groups. conclusion: th e use of ciprofl oxacin prophylaxis in fl exible cystoscopy is not indicated in our health area, because does not diminish the presence of urinary tract infection or bacteriuria. minimal inhibitory concentrations for a novel anti-bacterial peptide eluting urethral catheter introduction and objective: catheter associated urinary tract infection is a serious prevalent medical problem. several strategies have been developed to suppress the seemingly inevitable ascent of foreign pathogens through the urethra. th e primary strategy has been to coat the surface of the catheter with repellant agents, such as silver alloy hydrogels or anti-biotics. anti-bacterial peptides, such as human beta defensing (hbd- ) or cathelicidine are naturally produced peptides from the urothelium, acting to inhibit bacterial attachment and infi ltration as part of the innate immunity of the host. we have recently been able to engineer anti-bacterial peptide elution through gelatin coated catheters. th is study investigates the effi cacy of this strategy in deterring common uti pathogens. materials and methods: e. coli and p. aeruginosa, bacteria commonly associated with uti, were inoculated in tryptic soy broth, and then were aliquoted into each well of plates. anti-bacterial peptides, either recombinant hbd- or cathelicidine, were diluted and added to each well at increasing concentrations, where microorganisms were exposed for hours or for the indicated times following antimicrobial challenge and determination of the planktonic mics. bacteria were then enumerated by serial dilution plating. time-kill studies were performed. bactericidal activities of the antimicrobial agents were defi ned as a log decrease in the cfu/ml over hours relative to cell counts in the starting inoculum. results: th e standard inoculant of e. coli and p. aeruginosa commonly required an mic of μg/ml hbd- , and μg/ml for cathelicidine. time kill studies estimated bactericidal eff ect for hbd- on e. coli and p. aeruginosa both at hours, while for cathelicidine it was and hours, respectively. conclusion: th e current study demonstrates the efficacy and feasibility of a controlled release elution of anti-bacterial peptides, hbd- and cathelicidine, in inhibiting growth of common uti pathogens. the conclusion: co-infections of ng with ct appear less frequently. and mpcr method is rapid and accurate for identifi cation of stp. th e mpcr should be conducted in advance prior to antibiotic treatment as well as it will be better to give suitable antibiotics rather than empirical combination antibiotics for ng with ct in patient with urethritis. introduction and objective: th e prevalence of multi-drug resistant extended-spectrum beta-lactamase-producing (esbl) bacteria in normal gut fl ora in the australian community is increasing. current prophylactic antibiotic regimes for trans-rectal ultrasound (trus) prostate biopsies do not have activity against esbl organisms leaving some men at risk of esbl sepsis. our objective is to determine the prevalence of esbl in gut fl ora in northern tasmanian men and to identify risk factors for colonisation. patients were recruited into two groups. group were volunteers from the urology pre-operative clinic or the general community. group were men undergoing trus prostate biopsies. all patients were assessed via an enrolment questionnaire for the presence of known esbl risk factors. further procedural data were collected for those who had trus biopsies. all patients were assessed for esbl via a faecal culture, prior to any antibiotic prophylaxis. fisher's two-tailed test was used for comparative analysis. patients with ic/pbs were assessed with the o'leary-sant interstitial cystitis index score and global response assessment questionnaire prior to commencing treatment. assessment with these questionnaires was performed aft er treatments ( weeks) and again aft er treatments ( weeks). assessment end points were pain, urgency, symptom score and problem score. results: data was collected on patients, female and male. six patients had failed rimso- dimethyl sulphoxide (dmso) % w/w treatment prior. at baseline the mean pain score was . , urgency score . , symptom score . and problem score . . aft er weeks the mean pain score fell to . , urgency score to . , symptom score to . and problem score to . . at weeks the global response to treatment was %. nocturia was the fi rst symptom to improve with urgency and pain following. no side eff ects were noted no was reported during instillation and all patients tolerated the treatments. conclusion: ic is a diffi cult disease to treat. it requires a multimodal approach. we found that intravesical chondroitin sulphate reduced pain, urgency and o'leary-sant symptom and problem scores in patients with ic/pbs. all patients tolerated the treatment and no side eff ects were reported. introduction and objective: extended spectrum beta-lactamase (esbl) producing enterobacteriaceae are an increasing concern in an era of antibiotic resistance as they cause infections ranging from community acquired urinary tract infection (uti) to life threatening sepsis. we retrospectively reviewed the incidence and antibiotic susceptibility profi le of all esbl producing enterobacteriaceae at a university hospital in the united kingdom. patient gender, age and catheter specimen were assessed as risk factors. patient age, gender and specimen type were recorded in the database. urine samples received from outside our institution (including community isolates) were excluded from the analysis. urine was processed by calibrated loop sampling on to chromogenic clear media (oxoid ltd, basingstoke, uk). a positive culture was defi ned as ≥ cfu/ml except for samples from children and pregnant women where a cut-off value of > cfu/ml was used. susceptibility testing was performed by bsac (british society of antimicrobial chemotherapy) disc diff usion testing and reported for ampicillin, co-amoxiclav, piperacillin-tazobactam, carbapenems (ertapenem, meropenem), nitrofurantoin, pivmecillinam, trimethoprim, cephalexin, fosfomycin, third generation cephalosporins (ceft riaxone, ceft azidime) quinolones (norfl oxacin or ciprofl oxacin), aminoglycosides (gentamicin, amikacin) and others. cultures of more than two organisms (heavy mixed growth) were considered contamination and excluded. other exclusion criteria included missing data such as gender, age or susceptibility results, age < years old or an unusual specimen type such as an ileal conduit, nephrostomy, prostatic secretion, bag specimen or a suprapubic aspirate. results: our initial database included , samples which was reduced to , samples from , unique patients aft er exclusion criteria were applied. causative organisms were found to predominantly be e. coli, enterococcus, klebsiella, pseudomonas and proteus species. th e proportion of causative organisms was largely stable across the ten year period. antibiotic resistance was demonstrated to have increased, particularly across fi rst line agents. male gender and catheter use were associated with multi-resistance. in the modern era of antibiotic resistance we demonstrate that antibiotic resistance in hospital urinary tract infections is increasing. our results may be used to guide empirical treatment of hospital urinary tract infection. chronic pyelonephritis is a risk factor for renal dysfunction after urinary diversion in bladder cancer uehara s , , murao w , otsuki h , shimizu t , yoshioka t , , fujio k okayama university, okayama, japan; abiko toho hospital, abiko, japan introduction and objective: several reports showed that acute pyelonephritis is a risk factor for renal dysfunction in bladder cancer aft er urinary diversion, but the impact of chronic pyelonephritis fer renal dysfunction was unclear. materials and methods: from to , patients underwent radical cystectomy in our institute. among those patients, who showed hydronephrosis (more than grade ) or did not have enough data were excluded in this retrospective study. finally patients were enrolled. th e urinary diversions were divided into types: ileal neobladder (ib), ileal conduit (ic), ureterocutaneostomy without stent (uc) and ureterocutaneostomy with stent (ucws). ureteral stents were indwelled because of the ureteral stenosis aft er ureterocutaneostomy. because the cases of ucws generally showed pyuria and bacteriuria, ucws was determined as the chronic pyelonephritis model, and the estimated serum creatinine-based glomerular fi ltration rate (egfr) was calculated and compared with other urinary diversion. results: median follow-up period was . months (range - months) and median egfr was . ml/ min/ . m before surgery and . ml/min/ . m at the last follow-up. th e median decrease of egfr during the period between pre-surgery and the last follow-up in ib, ic, uc and ucws was . , . , . and . ml/min/ . m respectively. renal function was signifi cantly impaired in ucws cases than other urinay diversion. conclusion: chronic pyelonephritis may be a risk factor for renal dysfunction aft er urinary diversion. to avoid the renal dysfunction, ureteral stents should not be indwelled permanently. comparison of antibiotic susceptibility of escherichia coli between community-acquired and post-biopsy acute prostatitis introduction and objective: th e etiology of acute prostatitis aft er transrectal-ultrasound-guided-prostate-biopsy (pbx-ap) seems to be diff erent from that of community-acquired acute prostatitis (ca-ap). recent studies suggested that pbx-ap should be considered a separate category of prostatitis, distinct from spontaneous acute prostatitis. th us, we aimed to compare antibiotic susceptibility of escherichia coli between ca-ap and pbx-ap. of , patients who underwent transrectal-ultrasound-guided-prostate-biopsy, a total of patients had pbx-ap. in among these, escherichia coli was isolated on urine or blood culture. in of the patients with ca-ap, escherichia coli was identifi ed on urine or blood culture test. th us, a total of patients with ca-ap (n = ) or pbx-ap (n = ) caused by escherichia coli were included in this retrospective study. we compared demographic variables, data on clinical laboratory tests or transrectal ultrasound and antibiotic sensitivity data between the two types of prostatitis. results: in comparison to the ca-ap group, the pbx-ap group showed signifi cantly higher incidence of bacteremia and lower count of white blood cell. th ere was no signifi cant diff erence between the two, regarding to other clinical or laboratory parameters including age, body mass index, serum psa, prostate volume and percentage of patients with ebsl-positive escherichia coli. th e percentages of patients with quinolone-resistant escherichia coli in the ca-ap and pbx-ap groups were . % and . %, respectively, while those with nd or rd cephalosporin-resistant escherichia coli were . % - . % and . % - . %, respectively (table ). in both groups, the percentage of patients with amikacin-resistant escherichia coli were . %. our data suggest that a combination therapy of cephalosporin and amikacin can be recommended for treatment of pbx-ap while quinolone alone may be a feasible treatment option for ca-ap. the effectiveness of prostatic massage in treating chronic prostatitis (cp) tanabalan c, panah a, kabir m, masood j, pati j, nargund v introduction and objective: we review the eff ectiveness of prostatic massage under general anaesthesia (ga) for persistent symptoms aft er failure of antibiotic therapy. th e mainstay of treating cp is empirical antibacterial therapy with varying results. prostatic massage has been used to treat cp with mixed results. retrospective study of patients that were seen in urology outpatient clinics from june to july with symptoms of chronic prostatitis. all patients had a full clinical evaluation and urinary samples were sent for culture/microscopy on their visit. patients were treated initially with a course of -aminoquinolone and doxycycline in combination with lifestyle advice. if initial antibiotic therapy failed and no abnormal results detected in the work-up, a prostatic massage was off ered. th is involved a rigid cystoscopy followed by a -minute prostatic massage under anaesthesia. post-operatively patients received a further course of antibiotics. patients were followed up aft er the procedure and were assessed for improvement in symptoms. a total of patients ( %) commented on an improvement in some or all of their cp symptoms for a mean length of time of . (range . to . weeks). mean psa was . (range . to . ). one bladder tumour and one urethral stricture were detected on cystoscopy with one prostate cancer following prostate biopsies. if voiding urinary symptoms present men were given an alpha-blocker, there was no signifi cant improvement in pain symptoms post-operatively between the two groups (p= . ). th ere were no adverse eff ects from having the procedure with no complications noted. prostatic massage under ga is a safe and eff ective therapy in the treatment of refractory cp in select patients. th e issues of long-term surveillance and assessment of response to treatment remains a challenge. th ere seems little role for alpha-blockers, psa testing and mri prostate in the management of cp. oral antibiotic therapy and lifestyle modifi cations should remain as a fi rst-line treatment option. th e eff ect of stress, lifestyle and ethnicity has not been demonstrated in this study and further research will need to be undertaken. intravesical hyaluronic acid and chondroitin sulfate therapy for interstitial cystitis and painful bladder syndrome shin b, hwang e, chung h, kim s, jung s, kang t, park k, kwon d introduction and objective: damage to the urothelial glycosaminoglycan (gag) barrier layer may underlie the pathogenesis of several chronic bladder pathologies, including interstitial cystitis/painful bladder syndrome (ic/pbs). th is study evaluated the eff ect of intravesical hyaluronic acid (ha) in ic/pbs. twenty patients received intravesical ha mg and chondroitin sulfate (cs) g (ialuril®) in ml saline solutions once weekly for weeks, once every weeks for the next month, then once every month for the next months. results: a signifi cant improvement in urinary symptoms was evident on voiding diaries (number of voids and mean void volume; p= . and . , respectively). th e interstitial cystitis symptom index and interstitial cystitis problem index resulted in a significant improvement in both scores (p= . and . , respectively). th e storage symptom score (ipps) decreased from . to . (p= . ). th e quality of life to urinary symptom reduced from . to . (p= . ). th ere was no statistical signifi cant change in the voiding symptom score of ipps aft er ialuril instillation (p= . ). conclusions: th is promising experience seems to offer an additional therapeutic option in patients with refractory ic/pbs. prevention of surgical site infection: new approach alexander e , , hulda t , edna d introduction and objective: until the middle of the th century, when ignaz semmelweis and joseph lister became the pioneers of infection control by introducing antiseptic surgery, most wounds became infected. in cases of deep or extensive infection this resulted in a mortality rate of - %. most surgical site infections (ssi) are superfi cial, but even so they contribute greatly to the morbidity and mortality associated with surgery. th e aim of this study is to fi nd out rate of surgical site infection by single change of wound dressing. th e study is prospective in two hospitals (ba regional hospital, tophill hospital in kumasi). surgically clean cases are selected for operation. wounds are not opened till the seventh day or when soaked. window is left for wound inspection. results: results are shown in table . table , patients with diff erent surgical conditions were operated. average post-surgery change of dressing was days. ssi= / ( . %). single post-surgery change of dressing is eff ective ssi prevention method. effects of semen cuscutae on the fertilization ability in varicocele-induced rat introduction and objective: th ere is no specifi c medication to improve the sperm motility and count yet. th is study aimed to evaluate the favorable eff ects of purifi ed fl avonoid, semen cuscutae extract (sce) against oxidative stress injuries and other homeostatic imbalances in reproductive organs in adolescent rat with varicocele and to develop the new herbal medication to treat the male fertility. materials and methods: seventy-two rats were divided into groups: control (ctr) + hydroxypropyl-methyl cellulose (hpmc) (ctr + hpmc), ctr + mg/kg sce and ctr + mg/kg sce, varicocele (vc) + hpmc, vc + mg/kg sce and vc + mg/kg sce. in ctr group, they were started with medication for days from weeks aft er environmental stabilization. for the vc groups, they were given medications for days aft er weeks of operation. blood was collected before sacrifi ce for the testosterone test. sperm motility, daily sperm production (dsp), sperm count, and sperm transit time were calculated. th e seminiferous tubules were graded according to johnsen scoring. th e mrna expression of glutathione peroxidase (gpx ) and . nmol/mg protein, respectively) than vc group ( . ± . u/mg protein and . ± . nmol/mg protein, respectively). also, the testosterone, johnsen score were signifi cantly increased in the dose of mg/kg sce group than other groups. th ese results suggest that purifi ed fl avonoid semen cuscutae extract could be an alternative medicine for the infertility patients by inhibition of oxidative stress by favorable mechanisms. the relationship between pregnancy rate and semen quality improvement after varicocelectomy varicocele is the most common cause of male infertility and is generally correctable via surgery. in some reports, pregnancy rates were improved aft er varicocelectomy in male patients with poor semen quality. th e aim of this study was to determine the relationship between semen improvement and pregnancy rate. patients who underwent microsurgical varicocelectomy from jan. to jun. were enrolled. all patients had history of infertility (> year) and confi rmed varicocele on physical examination. th e abnormality of semen analysis results was based on who guidelines. varicocelectomy was performed in patients with poor semen quality in a series of two semen analysis where the female partner was normal in spontaneous pregnancy, as evaluated gynecologically. microsurgical varicocelectomy was performed by single surgeon. follow-up semen analysis was performed months aft er operation. improvement in semen quality was defi ned as > % improvement in total motile sperm compared with pre-operation semen analysis. pregnancy rate, method of pregnancy, and time to pregnancy were investigated. results: a total of male patients were included in this study, ( . %) in the improvement group (ig) and ( . %) in the non-improvement (nig). th e pregnancy rate was % ( / ) in the ig group and % ( / ) in the nig group; there was no significant diff erence between groups. pregnancy methods between the two groups were similar (table ) . introduction and objective: to review the learning curve, complications and outcomes of the fi rst cases of microsurgical vasectomy reversal performed in a developing country. th e fi rst dedicated service in male infertility microsurgery in south africa was established in . between january and december , a total of patients underwent microsurgical vasectomy reversal by a single surgeon (amir d zarrabi). mean patient age was years (range to ), mean age at vasectomy years (range to ), mean number of children for the male partner . and mean age of the female partner years (range to ). th e mean time interval between vasectomy and reversal was . years (range . to . ). five patients had previous failed vasectomy reversals and in patients the indication for reversal was post-vasectomy pain syndrome. a total of % of patients travelled from other countries for their surgery. results: mean surgical time per testicular unit was . minutes (range to ) and total operative time minutes (range to ). sperm motility (intra-operative light microscopy) was good in . %, average in . % and poor in . %. vasovasostomy was required in . % of testicular units and vaso-epididymostomy in . %. in patients sperm was harvested at the time of reversal for cryopreservation. complications occurred in % of patients and were managed conservatively in all but , who required an additional surgical procedure. for patients with adequate follow-up the overall surgical success rate was %. mean post-operative sperm count was . million. nine pregnancies and live births have been recorded during the limited follow-up. comparing the fi rst cases with the last cases revealed no signifi cant diff erences in surgical time, complications or patency rates. th e mean post-operative sperm count was % higher for the last cases. although microsurgical vasectomy reversal is technically demanding and requires specialized equipment and instruments, it can be successfully implemented in a developing country. infl uence of unilateral iatrogenic torsin on contralateral testis in rat, prepubertal and postpubertal introduction and objective: th e present study was conducted to investigate the infl uence of hemicastration and age at hemicastration on the subsequent contralateral testis. sixty-four wistar-derived male rats divided randomly in groups. group named immature intervention, group immature control, group mature intervention and group mature control. in group , rats hemicastrated at days of age (prepubertal). in group , sham surgery (midscrotal incision) was done at same age. in group , rats hemicastrated at days of age (postpubertal) and in group sham surgery was done at same age. twenty days aft er fi rst surgery, in intervention groups contralateral orchiectomy was done and in control groups random orchiectomy (left or right) was done. blood sampling for evaluation of serum testosterone was performed just before second surgery. results: testis weight and the mean testicular weight per g of body weight was greater in hemicastrated rats. th ese parameters was greater in prepubertal group than postpubertal hemicastrated rats. th ere was no appreciable diff erence in serum testosterone levels in groups. our research demonstrated that hemicastration resulted in compensatory hypertrophy of the remaining testis and it decreased as the animals aged. hemicastration does not lead to reduction in serum testosterone levels and remaining testis can retrieve a normal serum testosterone level. role of antibiotic in the treatment of semen hyperviscosity: a single institution study introduction and objective: th e prevalence of semen hyperviscosity is estimated to be between - % and can lead to male factor infertility both in vivo and in vitro. semen is composed of fl uids secreted by the male accessory glands, which contain proteins essential to the coagulation and liquefaction of semen. hypofunction of the prostate or seminal vesicles causes' abnormal viscosity of seminal fl uid. hyperviscosity can impair normal sperm movement in the female reproductive tract, and can lead to decreased sperm count. multiple factors have been predicated which result in the development of semen hyperviscosity, of this infection is considered to be one of the main contributor. aim of the study was to predict the eff ect of antibiotic in the treatment of hyperviscosity. th is is a single institution study, patients (age range - years) were recruited who were diagnosed with semen hyperviscosity (failure to liquefy aft er min). medical, sexual, and family history were documented. all the patients semen were kept for culture and they all got levofl oxacin for days and patient who had positive culture were changed to appropriate antibiotics. all the patients underwent repeat semen analysis aft er weeks. results: seventy seven percent patient had previous history of prostatitis, % patient had past history of sexual transmitted diseases. seventy fi ve percent patient are suff ering from infertility, of this % patient had a family history. th irty seven percent patients had positive culture and of this only % patient had liquefaction post treatment. culture negative patients, % patient had liquefaction post treatment. conclusions: semen hyperviscosity is associated with infertility and exact cause is considered to be multifactorial, of this infection is considered to be the main factor. in our study we did found that most of the patients has infection but antibiotic treatment even for culture positive patients showed minimal eff ect. treatment with antibiotic along to treat hyperviscosity cannot be considered curative since in our study the eff ect was only %. further research is needed to better understand the contributors to semen hyperviscosity and the treatments that can be used for infertile males with hyperviscous semen. modifi ed microsurgical subinguinal varicocelectomy: bundle ligation technique hong y, lee s, choi k, park d, hong j introduction and objective: microsurgical varicocelectomy has become the gold standard because of low recurrence and postoperative complication rate. during the procedure, isvs should be carefully dissected, cut and suture-ligated one by one. however, it is not easy to divide all isvs in a horizontal line, which can result in some uncertainty whether every single isv was divided or the same vein was unnecessarily divided multiple times. th erefore, we have developed a modifi ed technique, so called bundle ligation technique (blt), to make the procedure more reliable and simpler. a total of cases of microsurgical subinguinal varicocelectomy performed from to were grouped as conventional varicocelectomy (cv, n= , age: ± . ) and blt (n= , age: ± . ). mean follow-up time was . ± . months. blt is a simpler procedure because isvs are ligated as a whole, however, it is possible only aft er dissecting and securing the testicular artery fi rst. we compared operation time, resolution of palpable varicocele or pain, recurrence rate and complications. results: mean operation time was . ± . in cv group and . ± . in blt group (p= . ). resolution rates months aft er surgery were . % (cv) and . % (blt) in each group. recurrence aft er surgery during the mean follow-up time was . % (cv) and . % (blt). th e aim of the study is to evaluate the eff ect of hbo on the level of sperm dnaf and on the content of reactive oxygen species (ros) in semen. th e study included men with idiopathic infertility, the level of sperm dnaf was above % and the content of ros in the sperm was above . mv/sec. in the main group (n= ) sessions of hbo were performed and in vitro fertilization (ivf) was carried out months later. in the control group (n= ) ivf was performed without preceding hbo. th e age of patients ranged from to years (median - . years). sperm dnaf was determined by tunel, the level of ros in semen was studied by chemiluminescence. th e assessment was made at the time of entry into the study and aft er months (in the main group - months aft er hbo). in the main group, average sperm dnaf aft er hbo decreased from . ± . % to . ± . % (p< . ), the median level of ros in semen decreased from . mv/sec to . mv/sec (p< . ), whereas in the control group of patients these fi gures have remained almost at the same level - . ± . % and . ± . % (p> . ), . mv/sec and . mv/sec (p> . ). pregnancy resulting from ivf occurred in . % ( / ) of the cases in the study group and in . % ( / ) -in the control group (p< . ). conclusion: hbo is an eff ective method to reduce the number of sperm with dnaf, which can potentially lead to an increased fertility in patients with idiopathic male infertility. to evaluate the natural history and growth kinetics between sporadic clear cell renal cell carcinoma (ccrcc) and ccrcc in von hippel-lindau disease (vhl). we reviewed patients with sporadic ccrccs and patients with vhl ccrccs all confi rmed by delayed surgery aft er at least months active surveillance. th e growth rate was calculated. th e growth kinetics between sporadic and vhl ccrcc were compared. th e initial tumor diameter and pathological grade were reviewed, and their correlation with the growth rate were analyzed. results: th e mean growth rate of sporadic ccrcc was . cm/yr (range, - . cm/yr). th e mean growth rate of vhl ccrcc was . cm/yr (range, . - . cm/yr). th e growth rate of vhl ccrcc was lower than that of sporadic ccrcc (p= . ). for vhl ccrcc, the initial tumor diameter aff ect the growth rate (r= . , p< . ), while the pathological grade not (p= . ). for sporadic ccrcc, the pathological grade aff ect the growth rate (p< . ), while the initial tumor diameter not (r=- . , p= . ). conclusion: th e growth kinetics of vhl ccrcc is more indolent than that of sporadic ccrcc. for ccrcc with aggressive growth kinetics, its growth rate might correlates with the pathological grade, for those with slow growth kinetics, the growth rate might correlates with the initial tumor diameter. effects of trpm silencing on the proliferation, migration, and invasiveness of renal cell carcinoma (rcc) cells proliferation, migration, and invasiveness of human rcc following trpm knockdown. we constructed sirna sequences targeting the trpm gene and then transfected them into rcc cells mediated by liposome. th e potency of nm trpm sirnas was detected trpm mrna measurement by rt-pcr. th e eff ect of trpm sirna on cell viability was determined by wst- assay. cell motility and invasiveness were evaluated by wound healing assays and a matrigel migration and invasion assay. transfected rcc cells were cultured in eagle's minimum essential media supplemented with % fetal bovine serum. all measurements were done hours aft er trpm blocking. results: trpm sirna weakly inhibited the gene transcription of trpm . it was for nothing in the proliferation of human rcc cells. compared with vehicle control, the migration and invasion of human rcc cells were suppressed signifi cantly by trpm sirna until aft er hours. in addition, although protein levels of mmp- were not changed signifi cantly, we found that the protein levels of matrix metalloproteinase (mmp)- were diminished markedly by trpm sirna. th ese results suggest that trpm may have a role in the rcc progression including migration and invasion through upregulation of mmp . role of tnf-and cd in resistance to sunitinib treatment in clear cell renal cell carcinomas introduction and objective: tumor necrosis factor-α (tnf-α) was originally reported as a cytokine to induce apoptotic cell death and cachexia. recent studies have indicated that tnf-α also enhances tumor progression by inducing epithelial-mesenchymal transition (emt). tnf-α is also known as a modulator of cd expression, which belongs to cancer stem cell marker in several cancers. in this study we clarifi ed the signifi cance of tnf-α as well as cd in clear cell renal cell carcinomas (ccrccs). protein expression of tnf-α and cd was examined by immunohistochemistry in primary ccrccs, untreated metastatic ccrccs, and metastatic ccrccs treated with sunitinib, and its association with the clinicopathological parameters and prognosis was analyzed. involvement of tnf-α in emt and induction of cd was analyzed by comparing expression of emt-related genes and cd , and migration and invasion in cultured ccrcc cell lines. results: tnf-α and cd were predominantly expressed in carcinoma cells of high-grade ccrccs with positive correlations with primary tumor stage and distant metastasis. th ere was a positive correlation between tnf-α and cd expression, and elevated expression of tnf-α and cd was a poor predictor of prognosis. tnf-α enhanced migration and invasion of ccrcc cells together with down-regulation of e-cadherin expression and up-regulation of matrix metalloproteinase and cd expression. tnf-α also up-regulated the expression of tnf-α itself in ccrcc cells. twenty-fi ve patients were treated with sunitinib for metastasis, and the patients with cd -high tumors showed a shorter time to treatment failure compared to those with cd -low tumors. furthermore, residual carcinoma cells in the sunitinib-treated metastatic ccrccs were strongly positive for cd , and the cd expression was signifi cantly higher in tumors from the sunitinib-treated patients than in those from untreated ones. conclusions: tnf-α seemed to play an important role in progression of ccrccs by inducing emt, and suggested that tnf-α-induced cd might be involved in the resistance to sunitinib treatment. although further experimental studies on the relations between cd expression and cancer stem cells in ccrccs are needed, our data suggest that therapy targeting tnf-α and/or cd may provide a clue for improving the prognosis of patients with sunitinib-resistant ccrcc. introduction and objective: th e aim of this study was to investigate the relationship between the immunohistochemical expression of hypoxia-inducible factor- α (hif- α) with histological parameters such as tumor size; presence of tumor necrosis and hemorrhage; nuclear grade and pathological stage in patients with clear cell renal cell carcinoma (ccrcc). specimens from cases of rcc patients treated with radical prostatectomy were formalin-fi xed, paraffi n embedded, and stained with h&e. additional sections from each case were stained for hif- α. hif- α immunohistochemical expression was estimated as negative ( ), weak positive (+ ), moderate positive (+ ), and intense positive (+ ). th e statistical package "in stat " was used for data processing. results: immunohistochemical expression of hif- α in crcc was signifi cantly higher than in normal kidney tissue at statistically signifi cant level (hif- α: x -test = . , p= . ). a positive non-signifi cant correlation was found between hif- α and the tumor nuclear grade (r= . , p= . ); between hif- α and presence of hemorrhage (r= . , p= . ); whereas, a negative non-signifi cant correlation of a very weak scale was observed comparing hif- α and tumor size (r = - . , p= . ); hif- α and pathological stage (r=- . , p= . ), as well as hif- α and tumor necrosis (r=- . , p= . ). conclusion: our data showed heterogeneity in angiogenic activity, which might have an impact on biological behavior and anti-angiogenic, anti-vegf therapy of ccrcc patients. th is study suggests that there should be taken more than one tissue biomarkers into the consideration in predicting the biological behavior of ccrcc. introduction and objective: clear cell renal carcinoma (ccrcc) is the most frequent rcc subtype and is characterized by high mortality of %, due to late diagnosis and distant metastases found in % of rcc patients. although the involvement of vhl (von hippel-lindau), hif a (hypoxia-inducible factor -alpha) and vegf-a (vascular endothelial growth factor a) genes in development and progression of ccrcc is widely analyzed, our objective was to perform the common study of those factors in clinical samples of matched tumor-normal kidney biopsies of ccrcc cases. materials and methods: vhl, hif a and vegf-a mrna levels in samples were assessed by quantitative polymerase chain reaction (qpcr); rna was extracted from matched tumor-normal (t, c) kidney samples of ccrcc patients (mean age . ± . , median age ); ccrcc cases were characterized by local or distant metastasis; sunitinib was administrated to patients. vhl, hif α and vegf-a proteins were localized in matched tumor-kidney tissue of patients with the use of immunohistochemistry (ihc). molecular data was statistically calculated with clinical and follow-up data. introduction and objective: to identify tissue biomarker that are predictive of the therapeutic eff ect of sunitinib in treatment of metastatic clear cell renal cell carcinoma (mcrcc). our study included patients with mcrcc; these were selected from patients who received sunitinib in our hospital between the years - according to inclusion criteria of the study. patients were stratifi ed into two groups based on their response to sunitinib treatment; non-responders (progression), and responders (stable disease, regression). th e eff ect of treatment was measured by comparing imaging studies performed before the initiation of treatment with those done between rd and th months of treatment. histological samples of tumour tissue and healthy renal parenchyma, acquired during surgery of the primary tumour, were examined with immunohistochemistry to detect tissue biomarkers (mtor, p , vegf, hif , hif , caix). th e comparison between the two groups of patients was based on comparing the average levels of biomarker expression in both tumour tissue, as well as in healthy renal parenchyma. results were evaluated using student's t-test. results: when considering the results of the group of responders, statistically signifi cant diff erences in marker expression in tumour tissue versus healthy parenchyma were found for mtor ( %/ . %;p= . ), p ( %/ . %;p= . ), vegf ( . %/ %;p= . ) and caix ( %/ . %;p= . ). as for the group without response (non-responders), a statistically signifi cant diff erence was also evident in p a vegf expression in tumour versus healthy tissue ( %/ . %;p= . resp. . %/ %;p= . ). in the responders, a further signifi cant diff erence was found in the frequency of high expression (more than %) between tumour tissue and healthy parenchyma in vegf ( %/ %;p= . ) and caix ( %/ %;p= . ). caix shows high levels of expression in the tumour tissue, in both of the evaluated groups. when comparing the expression levels in the same type of tissue, between the group of responders and non-responders, no signifi cant diff erence in any biomarker was found. conclusion: a signifi cantly higher expression of vegf in crcc in comparison to healthy parenchyma, can predict a better response to sunitinib. on the other hand, the high expression of vegf in healthy renal parenchyma can predict worse response to treatment. the impact of preoperative retrograde pyelography before radical nephroureterectomy for upper urinary tract urothelial carcinoma on intravesical tumor recurrence song p , ko y , choi j , moon k , jung h , kim t introduction and objective: despite its diagnostic role in identifi cation of upper urinary tract urothelial carcinoma (uut-uc), approach to ipsilateral ureteral potentially aggravates spread of tumor, as reported in preoperative ureteroscopy before nephroureterectomy. we thus assessed the impact of preoperative retrograde pyelography (rgp) on intravesical recurrence aft er radical nephroureterectomy for uut-uc. of a total of patients who underwent nephroureterectomy for uut-uc from january to june in our institution, patients who did not undergo preoperative ureteroscopy were selectively enrolled. computed tomography and urine cytology as a basic diagnostic modality were performed in all subjects. th e impact of preoperative rgp and the other variables (age, sex, operating time, clinicopathological factors, and hematological factors) on intravesical recurrence were analyzed by multivariate cox regression model. during a mean follow-up period of . months, ( . %) patients had intravesical recurrence aft er rnu, and subjects ( . %) underwent preoperative rgp. th e mean duration from preoperative rgp to rnu was . ± . days and mean interval of intravesical recurrence was . ± . months. multivariable analysis showed that rgp and pathologic stage over t were independent factors for intravesical tumor recurrence (p= . and p= . , respectively, table ). regarding the duration from preoperative rgp to rnu, no signifi cant diff erence was observed between the recurrence group and the non-recurrence group (p> . ). as with preoperative ureteroscopy, our data demonstrated that preoperative rgp is an independent factor associated with intravesical recurrence of uut-uc aft er rnu. introduction and objective: axitinib which is tyrosine kinase inhibitor is standard nd-line treatment for metastatic renal cell carcinoma (mrcc). th e neutrophil-to-lymphocyte ratio (nlr), an index of systemic infl ammation, is associated with outcome in several cancer types. to assess the relation of pretreatment nlr with progression-free survival (pfs) and overall survival (os) of patients treated with axitinib. twenty-two patients with mrcc were treated with axitinib between october and january . patients were stratifi ed in two groups with nlr > (group a: n= ) vs. < (group b: n= ). pfs and os were estimated using kaplan-meier method. results: median os and pfs were . and . months, respectively. median os was . and . months in group a and group b, respectively (p= . ). median pfs was . and . months in group a and group b, respectively (p< . ). multivariate analysis showed that nlr > was an independent predictor of os (hr . . ; p= . ). in patients with mrcc treated with axitinib, pretreatment nlr might be an independent predictor for the outcome. th e aim of this study was to evaluate whether preoperative neutrophil-to-lymphocyte ratio (nlr) predict the prognosis in patients with upper urinary tract urothelial carcinoma (uu-tuc). a cohort of patients diagnosed with uutuc from to at tokyo metropolitan tama medical center was enrolled in this retrospective study. log-rank test and cox proportional hazards regression models were used for univariate and multivariate analyses. results: on univariate analysis, pathologic t stage, grade, lymphovascular invasion, c-reactive protein (crp) level, and nlr were signifi cantly associated with recurrence-free survival (rfs) and cancer-specifi c survival (css). th e rfs rates for an nlr < . and for one ≥ . at years were . % and . %, respectively. th e css rates for an nlr < . and for one ≥ . at years were . % and . %, respectively. th e multivariate cox proportional hazards regression models showed that the nlr could be an independent predictor for rfs and css. based on the results of multivariate analysis, the scoring model was developed. rfs and css rates at years were as follows: risk factor, . % and . %, respectively; risk factor, . % and . %, respectively; risk factors, . % and . %, respectively; risk factors, . % and . %, respectively; and risk factors, . % and . %, respectively. conclusion: th e preoperative nlr is an independent prognostic predictor. th e model based on the nlr and pathologic factors can be useful in clinical practice. clinicopathological outcome of small cell carcinoma of upper urinary tract: one starting point, diverging paths lu k, wang h, lin v, yu t introduction and objective: primary small cell carcinoma of upper urinary tract (uut-scc) is an extremely rare disease entity with distinct histological and biological behavior, representing less than . % of urinary tract tumor. th e rarity of these neoplasms poses a diagnostic and therapeutic challenge. little is known about uut-scc and the current knowledge of this disease is based on case reports or small series. our aim of study was to characterize the patients with uut-scc and to evaluate patient outcomes with the available treatment modalities. th is was a single-institute retrospective observational cohort study of patients with small cell carcinoma of upper urinary tract followed at e-da hospital, kaohsiung city, taiwan be-tween january , and october , . patient and tumor data were analyzed using descriptive statistical methods. results: six patients with primary uut-scc were identifi ed, consisting of arising from renal pelvis and from upper ureter. th e median age at diagnosis was years with male-to-female ration of : . th e most common presenting symptoms were painless gross hematuria, followed by fl ank pain. th e morphological appearance of the tumor cells and their immunohistochemical reactivity for neuroendocrine markers and cytokeratin helped establish the diagnosis. in of cases, scc coexisted with urothelial carcinoma. surgery was standard treatment given to all patients. of all cases, of patients received chemotherapy, including one receiving neoadjuvant chemotherapy and administering adjuvant chemotherapy. overall median survival was months. conclusion: primary small cell carcinoma of the upper urinary tract is characterized by an aggressive clinical course with early metastatic spread and relatively short overall survival. although high response rate to cytotoxic chemotherapy, its duration of response is limited and the prognosis remains dismal. as there is no standard of care for patients with uut-scc, further eff orts should be directed at its early detection and made to develop more eff ective therapeutic approach for this high-risk lethal disease. prognostic introduction and objective: th e aim of this study was to evaluate the impact of body mass index (bmi) on survival in patients with non-metastatic renal cell carcinoma (rcc) treated with radical or partial nephrectomy. between june and july , patients with rcc underwent radical or partial nephrectomy at two hospitals. among these patients, patients with lymph node or distant metastasis were excluded. th us, the medical records of the remaining patients ( men and women, mean age of . years) were retrospectively reviewed. th e median follow-up duration was months (range to months). th e patients were classifi ed into groups according to their bmi based on the asia-pacifi c criteria for obesity: normal ( . to < kg/m ), overweight ( to < kg/m ), and obese (≥ kg/ m ). th e prognostic signifi cance of various clinicopathological variables including bmi was analyzed using univariate and multivariate analysis. results: of the total patients, patients ( . %) were categorized as normal, ( . %) as overweight, and ( . %) as obese. forty-six patients ( . %) developed local recurrence or distant metastasis and patients ( . %) died of disease during the follow-up period. in the univariate analysis, bmi, tumor size, t stage, fuhrman's nuclear grade, coag-ulative tumor necrosis, and lymphovascular invasion were signifi cant predictors of recurrence-free survival. also, bmi, tumor size, t stage, fuhrman's nuclear grade, and lymphovascular invasion were signifi cant predictors of cancer-specifi c survival. in the multivariate analysis, bmi (p= . ), tumor size (p= . ), t stage (p< . ), fuhrman's nuclear grade (p= . ), and lymphovascular invasion (p= . ) were independent predictors of recurrence-free survival. also, bmi (p= . ), tumor size (p= . ), t stage (p= . ), and lymphovascular invasion (p= . ) were independent predictors of cancer-specifi c survival. our results suggest that bmi is an independent prognostic factor for recurrence-free and cancer-specifi c survival in patients with non-metastatic rcc treated with radical or partial nephrectomy. th ese fi ndings indicate that bmi could be an eff ective tool for predicting recurrence or survival in patients undergoing nephrectomy for non-metastatic rcc. phase i/ii study of multipeptide-based cancer vaccine ima after single-dose cyclophosphamide in japanese patients with advanced renal cell cancer hongo f , ueda t , nakamura t , naya y , okihara k , tamada s , schoor o , singh-jasuja h , nakatani t , miki t introduction and objective: ima is the fi rst therapeutic vaccine for renal cell cancer (rcc) consisting of multiple tumor-associated peptides (tumaps) confi rmed to be naturally presented in human cancer tissue. objective was to assess the safety and tolerability of ima vaccination. in this phase i/ii study in japan, we treated a total of japanese patients with advanced rcc with human leukocyte antigen a (hla-a)* + subjects in - . each of the vaccinations consisted of an i.d. injection of gm-csf ( μg) followed within - minutes by an i.d. injection of ima ( μg of each peptide). th e vaccine therapy was a monotherapy, i.e. no other anti-tumor therapies were concomitantly administered during the study course. no treatment with either anti-cancer agents or immunosuppressants was allowed within weeks before entering the trial. patients were to receive vaccinations in the fi rst weeks of treatment (induction period) followed by further vaccinations at weeks intervals for up to weeks (maintenance period). th e primary endpoint was safety and tolerability. th e secondary endpoints were pfs, os, immunogenicity. results: no treatment-related serious adverse events (saes) or deaths were observed during the study period. at follow-up at months, all cases were assessed for treatment response. ten percent of patients had partial response (pr), % with stable disease (sd), % of patients had progressive disease (pd). median pfs was . months and median os was . months. among all patients analyzed for t-cell response, fi ve showed vaccine-induced (vi) t-cell responses against at least one hla class i-restricted tumap and two patients with responses to multiple tumaps. interestingly, two of the immune responders were of hla-a* phenotype, a hla suballele rarely occurring in europe and us but common in japan. we evaluate the patients who underwent robot-assisted laparoscopic partial nephrectomy (ralpn), laparoscopic partial nephrectomy (lapn), or open partial nephrectomy (opn) in terms of perioperative outcomes. all patients with ct a renal masses who underwent ralpn (n= ), lapn (n= ), or opn (n= ) between november and may at our institute were compared in terms of perioperative outcomes, including the mean operative time, ischemia time, estimated blood loss, change in the estimated glomerular fi ltration rate (egfr), surgical margins, and complications. intraoperative and early postoperative data were collected retrospectively. conclusion: ralpn was signifi cantly associated with shorter ischemia time. any methods of partial nephrectomy preserved renal function at three months postoperatively and showed good oncological outcomes. laparoscopic nephrectomy: does patient obesity affect outcome? introduction and objective: th e prevalence of obesity worldwide is increasing, up to % of men and % of women are now obese. th ere are various means to assess obesity, waist circumference (wc) has emerged as a superior determinant of obesity and then body mass index (bmi). th is study evaluates wc on the outcome of laparoscopic nephrectomy. data was obtained on consecutive patients. a wc of > cm for women and > cm for men is considered obese. data collected includes age, gender, asa score, wc, anaesthetic duration, operative approach, surgery duration, blood loss, renal function, complication rate and duration of hospital stay. overall, patients underwent laparoscopic nephrectomy, were male and female. seventy three ( . %) patients had wc above normal for their gender. mean anaesthetic duration was longer in obese patients . minutes vs. . minutes, (p= . ). operative duration in obese patients was also longer, . minutes vs. . minutes, (p= . ). th ere was no diff erence between groups for conversion, number of ports, intra-operative complications, blood loss, or post-operative complications. however, obese patients had a longer in-patient stay; . days versus . days. conclusion: laparoscopic nephrectomy is safe in obese patients. however, obese patients should be warned that their obesity may be associated with increased anaesthetic and surgical ties and prolonged recovery. the long-term oncologic results of radiofrequency ablation for small renal tumors sung g , bae y , kim s introduction and objective: th e aim of this study was to retrospectively evaluate the long-term oncologic results of radiofrequency ablation (rfa) of small renal masses (srms). : th e patients who had been followed over years aft er percutaneous or laparoscopic rfa for small renal mass were included in this study. a total of patients and renal tumors were included. th e follow-up study included physical examination, chest radiography, creatinine, and contrast-enhanced ct or mri. recurrence was defi ned as contrast enhancement aft er months or lesion growth at subsequent imaging or viable cancer cells on follow-up biopsy. results: th e mean tumor size was . cm and the mean follow-up period was . months. technical success was achieved in / renal tumors ( . %). repeated rfa was necessary in tumors due to incomplete ablation. th e overall complication (oc) occurred in . % of which the low-grade complications accounted for . % of oc. a relevant deterioration of renal function aft er rfa was very rare. th e -year local recurrence-free survival rates, cancer-specific survival rates, and overall survival rates are %, . %, and . % respectively. conclusion: rfa is considered useful treatment for selected patients with srms and also for nephron-sparing. our long-term follow-up results suggest excellent therapeutic outcome with rfa, while achieving eff ective local tumor control. introduction and objective: endoscopic approach of the terminal ureter was proposed as a complementary fi rst step in nephroureterectomy with perimetal cystectomy in order to obviate the low abdominal incision. we aimed to establish the value of a novel method of endoscopic distal ureteral management: pluck technique using bipolar plasma vaporization. during the last years, we performed nephroureterectomy involving plasma-button uretreal desinsertion by bipolar vaporization in upper urinary tract transitional cell carcinoma (uuttcc) cases (pta - cases; pt - cases; pt - cases; pt - cases). th e tumor was pyelocaliceal in cases, ureteral in cases and both ureteral and pyelocaliceal in cases. th e follow-up protocol included cystoscopy with urinary cytology, abdominal ultrasound and ct. th e mean follow-up period was months (range to months). results: all procedures were successfully completed. th e mean duration of the endoscopic procedure was minutes. in cases, aft er the completion of the nephroureterectomy, endoscopic haemostasis of the desinsetion area and margins was necessary. th e postoperative complications' rate was . %: cases of hematuria, one imposing endoscopic approach and another treated conservatively. during the follow-up period, patients presented bladder recurrences, had renal fossa tumor and had secondary lymphnode invasion. th e disease-specifi c mortality rate was %. conclusion: th e endoscopic detachment of the terminal ureter using bipolar plasma vaporization as part of one-step nephroureterectomy is a safe and eff ective method. mid-term evaluation demonstrated good oncologic outcomes. th congress of the sociÉtÉ internationale d'urologie -siu abstract book introduction and objective: we thought that combining open and laparoscopic surgery for partial nephrectomy would be less invasive than open method, easier and expend shorter time to clamp renal artery than pure laparoscopic approach. and combining approach would lead to introduce pure laparoscopic approach safely from open method. we reviewed the records of patients with renal mass treated with partial nephrectomy from to at our hospital. a total of patients underwent partial nephrectomy. of these, patients underwent pure laparoscopic procedures. seventy-seven patients underwent combining method, and two patients of these with solitary kidney and one patient with chronic nephritis were excluded. we compared these two groups in terms of perioperative outcomes, including the mean operative time, ischemic time, change in the glomerulofi ltration rate (egfr), and adverse events. conclusion: th is nonrandomized, comparative study suggests that pure laparoscopic approach had longer cold ischemic time but lower postoperative egfr change. complication rates were almost equivalent for both approaches. th erefore, we might shift safely to pure laparoscopic approach through the combined approach in the way of partial nephrectomy. nephron th irty-four ( . %) had bilateral suspected malignant tumors and were used as material for this study. twenty-fi ve were men and were women. results: eighteen patients ( %) had the same type of tumor in both kidneys. ten of them had clear cell carcinoma and had papillary renal cell cancer. four patients had bilateral oncocytomas. in patients ( %) the lesions diff ered between the kidneys (table ). in all patients only one kidney was operated on one occasion. in two patients treated with radical nephrectomy (rn) over years ago for renal cancer the subtype of the fi rst tumor was unknown. ten patients were treated with nss -nss, with rn -nss, with nss -rn, with nss -observation and with nss -radiofrequency ablation. two of the patients had von hippel-lindaus disease and one had birt-hogg-dubé syndrome. conclusion: bilateral renal masses were found in % of the patients in a material of patients treated with nss. over % of them had the same type of tumor on both sides but % of these were benign. th e combination of diff erent malignant and benign lesions occurred in %. th ese fi ndings are strong arguments for tumor biopsy before surgery is decided. preoperative oita red cross hospital, oita, japan introduction and objective: approximately % to % of patients who underwent total nephroureterectomy for upper urinary tract (uut) urothelial carcinoma (uc) developed recurrence in the bladder during the follow-up period. last year, we presented a risk factor for intravesical recurrence aft er laparoscopic radical nephroureterectomy (lrnu) in patients with uut-uc in siu congress. th is time, we will report the result of analysis of a multi-center study. a total of patients with uut-uc received lrnu between january and december in oita university hospital and affi liated institutions that were enrolled in this study. patients with concomitant bladder cancer or a history of bladder cancer were excluded from this study. postoperative cystoscopy and urine cytology were performed every months for to years, and postoperative intravesical recurrence was evaluated pathologically. th e signifi cance of each variable was analyzed univariately by log-rank test. multivariate analyses by cox proportion hazards regression model was used to estimate simultaneous eff ects of multiple risk factors. statistical signifi cance was defi ned as a p value of < . . results: median follow-up aft er lrnu was months (range - ). of the patients, postoperative intravesical recurrences were shown in / ( %). average time to fi rst intravesical recurrence was . months. in univariate analysis, there were two signifi cant risk factors of intravesical recurrences. one was for patients who did not receive postoperative adjuvant chemotherapy (p= . ). th e other was for patients with preoperative positive urine cytology indicating class iv and v (p= . ). multivarite analysis revealed that preoperative positive urine cytology indicating class iv and class v was a signifi cant risk factor for intravesical recurrence (hr . % ci . - . p= . ). in this multi-center retrospective study, preoperative positive urine cytology was a significant risk factor for intravesical recurrence. th erefore, adjuvant chemotherapy such as intravesical instillation therapy can be eff ective to prevent intravesical recurrence in patients with preoperative positive urine cytology. retroperitoneal laparoscopic nephron-sparing surgery for complicated renal cysts introduction and objective: to evaluate the feasibility, effi cacy and safety of laparoscopic partial nephrectomy for complex renal cystic lesions. a retrospective cohort study on clinical data of patients with complex renal cystic lesions treated by laparoscopic partial nephrectomy from may to april in peking university th ird hospital. according to the bosniak classifi cation, cases were lesions of grade iif, were grade iii, and were grade iv. th e mean diameter of cystic lesions was ( . ± . ) cm, and lesions were larger than . cm. results: all procedures were performed through retroperitoneal approach and successful. th e mean operative time was ( . ± . ) min, ranged from min to min, and the mean renal warm ischemia time was ( . ± . ) min, ranged from min to min. blood loss in operations was from ml to ml, and the mean was ( . ± . ) ml. th e postoperative hospital stay was ~ days, and the mean was ( . ± . ) day. postoperative pathological results included simple renal cysts ( . %), cases of adult cystic nephroma ( . %), mixed epithelial and stromal tumor ( . %), cases of renal cell carcinoma with cystic change ( . %), and multilocular cystic renal cell carcinoma ( . %). th e results showed . % of cystic lesions of grade iif, . % of grade iii and . % of grade iv were malignant. in the follow-up ranged from to months (median months), there was no case of recurrence. conclusion: th e diff erentiation between benign and malignant renal cystic lesions before surgery remains diffi cult. according to the bosniak classifi cation, radiological diagnostic fi ndings are standard but still limit to the accuracy to determine the dignity of pathological entity. laparoscopic partial nephrectomy is feasible to treat complex renal cystic lesions, and is a safe and eff ective minimally invasive option. introduction and objective: th e aim of the study was to evaluate the value of metastasectomy in patients with metastatic renal cell carcinoma (mrcc) in the targeted therapy era. we reviewed the medical records of patients who presented with mrcc and received no systemic therapy before enrollment. of them, underwent complete metastasectomy followed by targeted therapy (complete metastasectomy group), underwent partial metastasectomy followed by targeted therapy (partial metastasectomy group), and treated with targeted therapy alone (non-metastasectomy group). we estimated progression-free and overall survival using kaplan-meier curves. a cox proportional hazards regression model was used to estimate the prognostic signifi cance of metastasectomy. results: clinicopathological variables did not diff er among the groups except for history of nephrectomy, bone metastasis, number of metastatic sites, and time from diagnosis to treatment. th e median progression-free survival was . , . , and . months in the complete, partial, and non-metastasectomy groups (p = . ). karnofsky performance status (hr . , p < . ), cell type (hr . , p = . ), sarcomatoid or rhabdoid features (hr . , p < . ), retroperitoneal lymphadenopathy (hr . , p < . ), number of metastatic sites (hr . , p = . ), lactate dehydrogenase (hr . , p = . ), and time from diagnosis to treatment (hr . , p = . ) were independent predictors of progression-free survival. th e median overall survival was . , . , and . months in the complete, partial, and non-metastasectomy groups (p < . ). complete metastasectomy (hr . , p = . ) was an independent predictor of overall survival, along with age (hr . , p = . ), karnofsky performance status (hr . , p < . ), sarcomatoid or rhabdoid features (hr . , p = . ), bone metastasis (hr . , p = . ), retroperitoneal lymphadenopathy (hr . , p < . ), number of metastatic sites (hr . , p = . ), hemoglobin (hr . , p = . ), neutrophil (hr . , p = . ), corrected calcium (hr . , p = . ), and time from diagnosis to treatment (hr . , p = . ). conclusion: complete metastasectomy performed before targeted therapy signifi cantly increased overall survival in patients with mrcc. if surgically resectable, aggressive metastasectomy should be considered. guideline results: prominent international guidelines and strategies varied signifi cantly in relation to follow-up practice. th e mode and frequency of radiological imaging was signifi cantly diff erent across the guidelines for low and intermediate risk disease. although there is currently no consensus within the literature regarding surveillance protocols, various guidelines and strategies have been developed using both patient and tumour characteristics. th is information raises questions regarding the follow-up practice in australia due to both the lack of guidelines and the fi nancial. introduction and objective: nephrectomy is the cornerstone therapy for renal cell carcinoma (rcc) and its continued refi nement through research may enhance patient outcomes. medical registries are used domestically and internationally to aid research, assess trends and help guide future practice of many medical disciplines. th ere is currently no national australian nephrectomy registry. th is review aimed to explore possible defi ciencies within the australian rcc nephrectomy fi eld and through assessment of literature from established registries, determine if a national nephrectomy registry is appropriate and justifi ed to address these issues. a pubmed search identifi ed records pertaining to rcc nephrectomy in australia. a similar search identifi ed records relating to established nephrectomy registries internationally as well as other surgical registries of clinical importance. th ese records were reviewed to address the stated aims of this article. results: australian rcc nephrectomy fi eld lacks population-based data: resulting key issues identifi ed ) diffi culty benchmarking individual and institutional outcomes; ) small sample sizes and reduced power of studies; ) assessment of regional and nationwide outcome trends: diffi cult to achieve and oft en done years in retrospect with no ongoing monitoring; ) care centralisation debate: can small volume centres provide comparable outcomes to high volume centres? ) best practice guidelines: patterns of adherence to existing protocols is uncertain; and ) limited platform for large scale prospective studies -restricting potential research. review of established international registries demonstrated the registry model can eff ectively address issues comparable to those identifi ed in the australian literature. a centrally held, de-identifi ed national nephrectomy registry could provide a means of ad-dressing defi ciencies identifi ed in the australian rcc nephrectomy fi eld. th e model is supported by evidence from comparable international examples and will provide population-based data needed for studies at the institutional, regional and national level. th e development of a confi dential and non-threatening escalation policy to be implemented should trends in the data emerge is a future possibility. scope exists for possible integration with current or future registries/ databases to develop a more encompassing urological, cancer or surgical registry. need remains for continued exploration of the feasibility and practicalities of initiating such a registry. new technologies of identifi cation of renal artery in retroperitoneal laparoscopic renal surgery hao y, xiao c, liu y, ma l introduction and objective: th e objective of this study was to evaluate the feasibility of a new method to identify renal vessels during retroperitoneal laparoscopic nephrectomy. a total of patients underwent transperitoneal radical laparoscopic nephrectomies from january to august . in the fi rst consecutive patients (group ) we located renal artery with the standard technique; in the last consecutive patients (group ) the medial arcuate ligament (mal)-psoas muscle fat complex was used as an anatomic landmark to identify renal vessels. comparative analysis was carried out between the two groups, including mean hilar exposure time, mean blood loss, duration of hospital stay, conversion rate and complication rate. no diff erences were noted in gender, age, mean body mass index, tumor side and size of the lesions in the two groups (p> . ). mean hilar exposure times were . ± . minutes in group versus . ± . minutes in group (p< . ). mean blood loss was . ± . ml in group versus . ± . ml in group (p< . ). no signifi cant diff erences were detected regarding duration of hospital stay, complication rate and conversion rate between the two groups (p > . ). no complications and no recurrence of disease at ct evaluation were recorded neither in group nor in group . conclusion: radical laparoscopic nephrectomy in use of the mal-psoas muscle fat complex as an anatomic landmark is technically feasible and safe. in conclusion, the mal-psoas muscle fat complex can serve as an objective and belt-and-braces anatomic landmark for the identifi cation of the renal vessels in retroperitoneal laparoscopies. kalpinskiy a, alekseev b, kaprin a, nyushko k, vorobyev n, vokach d introduction and objective: th e aim of our study is to evaluate the results of percutaneous radiofrequency ablation (rfa) of renal tumors in elderly patients with severe comorbidities and a high risk of surgical intervention. th e aim of this study was to evaluate the expression of cd and microvessel density (mvd) in clear cell renal cell carcinoma (ccrcc) as well as the relationship between mvd and possible prognostic markers like tumor size, degree of tumor necrosis and degree of tumor hemorrhage. expression of cd was detected in patients with ccrcc and cases with benign kidney tissue using immunohistochemical staining. th e mvd was studied by weidner's method. results: th e expression of cd in the clear cell renal cell carcinoma (ccrcc) ( . (ds± . ), varied from to .) were signifi cantly higher than the expression of cd in the benign kidney tissue, as the control group, was . (ds± . ) (u= , p< . ). th e mvd values marked by cd were negatively correlated with degree of tumor necrosis (r=- . , p= . ), tumor size (r=- . , p= . ), but no association was found between mvd values and degree of tumor hemorrhage (r=- . , p= . ) in crcc. our results show that mvd in crcc were signifi cantly higher than mvd in the benign kidney tissue. th ere was a negative non signifi cant correlation between the mvd and presence of tumor necrosis as well as between mvd and tumor size. on the other hand, there was no correlation between mvd and degree of tumor hemorrhage in ccrcc. conclusion: expression of hif- α and vegf in crcc was signifi cantly higher than in normal kidney tissue. th e expression of hif- α and vegf may be responsible for angiogenesis in ccrcc, however these angiogenic factors play an important role in the prognosis of ccrcc patients. transvaginal hybrid notes nephrectomy in a low resource setting firaza p, lorenzo e, bardelosa j, reyes e, patron n introduction and objective: hybrid notes decreases the invasiveness of conventional laparoscopic surgery and overcomes the limitation of pure notes especially in the absence of angulated instruments. th e patients are , and -year-old females with complaints of recurrent fl ank pain and urinary tract infection due to an obstructed non-functioning kidney. materials and methods: materials used include standard laparoscopic instrumentations and a endoscope. under general anesthesia the patient was placed in a lithotomy position with the aff ected side up at degrees. veress needle was initially inserted thru the umbilicus and was later replaced with a mm laparoscopic port with additional mm port also inserted at the aff ected lower quadrant site. pa-tient was then positioned in a steep trendelenberg and mm port was inserted thru the posterior vaginal wall under direct vision from the abdominal cavity that was later used for the endoscope. nephrectomy proceeded despite noted severe adhesions and the kidney was placed in the specimen retrieval bag. th e vaginal port site was enlarged to cm for extraction of the specimen. th e vaginal wound was repaired using running - absorbable sutures. results: th ree cases of transvaginal hybrid notes nephrectomy were successfully completed. th e median operative time was minutes (range: - ). th e mean estimated blood loss was ml for the three cases. median renal dimensions (cm) were as follows: craniocaudal . (range: . - ), laterolateral . (range: - . ), and anteroposterior . (range: . - . ). th e patient resumed regular diet as early as day post operatively. drain was removed prior to discharge. th e mean date of discharge was rd day post-operatively. th ere were no noted surgical complications according to clavien-dindo grading system. conclusion: hybrid notes transvaginal nephrectomy is a feasible and reproducible procedure in selected patients regardless of laterality for better cosmesis, reduced post-operative pain and early recovery. however, the view was challenging because it was from the pelvis. th e left side procedure proved to be more diffi cult due to the gonadal vein obstructing the view, which is usually larger in young females. introduction and objective: to summarize our clinical experiences of laparoendoscopic single-site surgery (less) in urology. results: all procedure underwent successfully using single trocar x cone (storz) without any major complications. early recovery with minimal scar is the hallmark of less surgery. duration of time ( - mns), blood loss ( - ml), mobilization ( - hrs), hospital stay ( - days). no intraoperative complication without any conversion to other surgery (multi port laparoscopic surgery) and uneventful post-operative period was the fi nal outcome. introduction and objective: th e use of fl exible cystoscopy to study bladder is usually perform in urology departments using diff erent types of lubricant to reduce pain. th e objective is to compare the use of lubricant gel with lidocaine versus lubricant gel without anesthetic in fl exible cystoscopy in terms of pain and tolerability. materials and methods: seventy two patients are divided in two groups in this observational not randomized study. group : patients with lidocaine gel % and group : patients with lubricant gel without anesthetic. th e main variables analyzed are score in visual analogue scale (vas) and score in spanish pain questionnaire (spq). t-student test and chi-square test are used to compare diff erences using spss program and signifi cant statistical diff erences is considered p≤ . . results: mean age of patients in group is . ± . years and . ± . years in group (p= . ). th e distribution according to sex was men: women in group and men: women in group (p= . ). th e main pain score in vas was . ± . in group versus . ± . in group (p= . ). in the spq, the current intensity value was . ± . in group versus . ± . in group (p= . ), and the total intensity value was . ± . in group versus . ± . in group (p= . ). th e cost of gel with lidocaine is . euro and gel without anaesthetic . euro. conclusion: th e use of lidocaine gel do not produce benefi t in the fl exible cystoscopy and expensive the procedure. new laparoscopic surgery using water filled laparo-endoscopic surgery systems introduction and objective: urologist usual operated under water fi lled condition, such as transurethral surgery, percutaneous renal surgery. however, laparoscopic surgery was done under co . water fi lled condition has several merits. water pressure is suppressing venous bleeding and prevent from co embolism in venous injury condition. to keep water temperature as same as body temperature was useful to avoid low body temperature. simultaneous observation of ultrasound image from the surface of the body and laparoscopic view is possible during surgery. th us we conduct to develop the water fi lled laparo-endoscopic surgery systems (wafles). first problem is dispersion of blood aft er bleeding. it interrupts the laparoscopic view. we solved this problem to control the fl ow of irrigation, aff ording the continuous observation of bleeding point and it is easy to control the bleeding by vessel sealing system or coagulation. second problem is managing fl oating organs such as intestine or nets. th ese are disturbed the operating view and space. to keep the operating space, we use sheath and single port devices. however, obtaining wide view was still hard in the water because fl oating organs disturb the fi eld. to solve this problem, we use -d tracking navigation system. results: using young male pig, we performed partial nephrectomy and radical cystectomy using this new system. wafles is now developing. we will be present the update of this research soon. comparison of safety, effi cacy and cosmetic outcomes between standard laparoscopic live donor nephrectomy and mini-laparoscopic donor nephrectomy: a randomized clinical trial introduction and objective: th is study was conducted to compare safety, effi cacy and cosmetic outcome between standard laparoscopic live donor nephrectomy (sldn) and mini-laparoscopic donor nephrectomy (mldn) in a randomized clinical trial. from march to june , consecutive kidney donors were randomly assigned to two equal groups for laparoscopic donor nephrectomy. from march to june , consecutive kidney donors were randomly assigned to two equal groups for laparoscopic donor nephrectomy. mldn: six to eight centimeters pfannenstiel incision was made slightly above pubis symphysis and millimeters trocar was fi xed through exposed fascia using open technique. five mm port was placed under direct vision at the umbilicus for camera insertion and two . mm ports were placed in subxiphoid and paraumbilical area. sldn: ten mm port was placed at umbilicus using open access technique for camera insertion. five mm trocar for grasping and mm trocar for vascular clipping were placed at subxiphoid and paraumbilical areas under direct vision, respectively. th e second mm trocar was placed in suprapubic area. cosmetic appearance was assessed three months aft er surgery by using the modifi ed patient scar assessment questionnaire (psaq). conclusion: our experience in this study revealed that peri and postoperative fi ndings were comparable between sldn and mldn but mldn has signifi cant better cosmetic appearance than standard laparoscopic approach. qiu m, ma l, lu j introduction and objective: to report our experience and outcomes with retroperitoneal laparoscopic anderson-hynes dismembered pyeloplasty for the repair of ureteropelvic junction obstruction (upjo). we performed retroperitoneal laparoscopic anderson-hynes dismembered pyeloplasty between june and december . ureter was found in the lower pole of the kidney psoas front, then ureteropelvic junction stenosis was dissociated. ureter was cut at about cm distal ureter beyond the part of stenosis, then stenosis was resected. posterior wall was continuous sutured, and double j tube was antegrade placed. at last, anterior wall was continuous sutured. patient characteristics and perioperative outcomes were analyzed. perioperative parameters including operative time, estimated blood loss, postoperative length of hospital stay, and complication. results: th e procedure was successfully accomplished in all patients, and no patient required conversion to open surgery. th e mean operation time was . min ( - min), mean estimated blood loss was ml ( - ml), mean postoperative length of hospital stay was . d ( - d), and mean time of keep drainage tube was . d ( - d) . patients were followed up for ~ months (average . months). eighteen cases were followed up in years, and an- renal cyst ( ) other patients were followed up for - years. th e total remission rate was . %. conclusion: retroperitoneal laparoscopic dismembered pyeloplasty is a safe and effi cacious procedure for upjo in a long time follow-up. positioning-related complications of robot-assisted radical prostatectomy (rarp) in a steep trendelenberg position with physique fixation appliance by the negative pressure takeda h, nakano y, narita h introduction and objective: because of recent advances in minimally invasive surgical techniques, robot-assisted radical prostatectomy (rarp) has become the primary treatment option in prostate cancer. rarp, however, necessitates patients to be placed in a steep trendelenberg position, which presents multiple opportunities for complications relating to the positioning of the patient. our study aims to study the prevalence and demographic predictors of these positioning complications. we included patients who underwent rp from to using data extracted from our hospital database. all patients (n= ) had trendelenberg position with physique fi xation appliance by the negative pressure, hug-u-vac and film dressings. positioning complications (skin, eye, nerve, compartment syndrome/rhabdomyolysis) were identifi ed using patient-level diagnosis and procedural international classifi cation of disease, th edition, clinical modifi cation codes. we analyzed body pressure by portable interface pressure sensor. results: positioning complications occurred in . % of cases with shoulder complications contributing the most to this frequency. rubefaction occurred in cases, without bedsore. having positioning complications not increased a patient's odds of having increased age, bmi, operation time, body pressure, insignifi cantly. conclusion: th e steep trendelenberg position used in rarp was not shown to be associated with patient positioning-related complications in this sample. physique fi xation appliance by the negative pressure is safety and useful. evaluation of nasogastric tube (ngt) suction for evacuation of large bladder blood clot introduction and objective: blood clot formation in the urinary bladder can be caused by many etiologies such as postoperative bleeding, tumor bleeding, radiation cystitis and etc. acute urinary retention may disclose and a large three way catheter with irrigation is placed conventionally to prevent further formation of blood clot and manually remove the blood clot. when this failed an endoscopic procedure takes place to con-trol the bleeding and to relief the bladder. urologists may fi nd it diffi cult to remove a large, thick and bulky clot using ellik evacuator. here we introduce using nasogastric tube as an alternative to procure a safe and effi cient way to remove these bothersome clots. aim: to introduce a novel method to successfully remove large, troublesome blood clots during cystoscopy. we prospectively perform blood clot evacuation on patients within month (september -february ) in hasan sadikin hospital. th e patient, preoperatively have at least ½ of bladder volume with blood clot using ultrasonography. a fr ngt inserted into the bladder through the resectoscope sheath fr and connected to suction unit with a mmhg negative pressure. a calibration of the ngt tip does not exceed more than cm from the cystoscopy beak was made. backward and forward movement was set in motion during the procedure to facilitate blood clot removal. cystoscopy evaluation was performed in the end of the procedure to evaluate any complication. a total cystoscopy time, ngt suction time, and the volume of blood clot were documented. results: a total patients was all successfully managed with this method without any complications such as bladder laceration/perforation. th e mean age was years old with male predominance. most common etiologies of blood clots retention were postoperative bleeding ( %). th e average time for clot removal time was ( - ) minutes. th e average volume of blood clots removed was grams. conclusion: evacuation using ngt suction is eff ective, safe and an effi cient way to remove of large bothersome clot. learning curve assessment of robot-assisted radical prostatectomy in the oncological and functional outcomes takeda h, nakano y, narita h introduction and objective: th is study aims to compare the oncological, safety and functional outcomes between fi rst-step rarp and second-step rarp. th e study was conducted on a total of patients having undergone robot-assisted radical prostatectomy from to . th e fi rst patients (group ) were compared with the second (group ) to evaluate the learning curve eff ects. results: both groups were similar with respect to age, prostate-specifi c antigen level, body mass index, gleason score, and distribution of the clinical stage. th e operative time was minutes for group , and minutes for group (p= . ). individual times of various stages of the procedure (dissection of the seminal vesicles, entering the extraperitoneal space and dissection of the endopelvic fascia, incision of the bladder neck, division of the prostatic pedicles and preservation of the neurovascular bundle, and urethrovesical anastomosis) decreased signifi cantly over time. estimated blood loss was ml for group , ml for group . th e length of stay was . days for group , . days for group . positive surgical margin rates were % for group , % for group . while one patient in group had biochemical recur-rence, no patient in group had biochemical recurrence. continence rates at months were . %, and . % in groups and . conclusion: surgical, oncologic, and functional outcomes of rarp improve with increasing experience. outcomes similar to the published series by high-volume centers could be achieved aft er to rarp cases. possibility of d modeling and intraoperative navigation during procedures in the retroperitoneal space introduction and objective: application of d modeling allows you to get more information about the spatial imaging of the disease. intraoperative navigation in the retroperitoneal space is an innovative minimally invasive procedure, the surgeon improves orientation in retroperitoneal space. we present the method of intraoperative navigation based on virtual simulation during videoendoscopic partial nephrectomy for kidney's tumors. special computer program has been developed, that created three-dimensional image of operative space on the basis of preoperational tomographic data of a concrete patient. we used hardware-soft ware complex (hsc) for virtual modeling of the surgery zone. th e complex consists of a pc, original soft ware and mechanical d digitizer. th e hsc allowing to form virtual d model of a patient according to the results of tomography examination. th e original method of matching the system of coordinates of a virtual model with the patient was off ered. th e procedure was conducted under the conditions warm ischemia, aft er mobilization of the kidney, partial nephrectomy was performed by observing the image of d organ model agreed with the video image of the kidney tumor. th e method was originally performed for the patients with small renal tumors, who needed in surgical treatment, their average age was . (in the range from to ) years, men - ( . %), women - ( . %). size of the tumors were . ( . - . ) cm, they were located in the lower poles of the kidneys. average time of an operation performed with the use of the computerized choice of the surgical approach was . ( - ) minutes. warm ischemia time was . ( - min). th ere were no complications during the operation and in the post-operative period. th ere were no cases of positive surgical margins. conclusions: usage of the introduced computer program allows the surgeon to determine compliance with the contours of the d models of the body shown in the video monitor. th e technique provides additional possibilities for the surgeon in selecting borders in partial nephrectomy. th is method is particularly perspective for teaching beginner surgeons, it can help them acquire skills in minimally invasive surgery. possible impact of continuous drainage after minimally invasive partial nephrectomy introduction and objective: postoperative management of partial nephrectomy without drain placement is common, but the specifi c eff ects on patients are unclear. we investigated the impact of no drain placement aft er minimally invasive partial nephrectomy (mipn). we retrospectively studied consecutive patients who underwent laparoscopic and robotic partial nephrectomy at a single academic center. th e study group included evaluable patients without drain placement. th e quantity of postoperative fl uid collection in the perirenal space was calculated using computed tomography. th e pre-and postoperative serum concentrations of total protein and albumin, in addition to neutrophils, lymphocytes, monocytes numbers and c-reactive protein (crp) levels in the blood were compared. results: drain was placed in ( . %) patients who underwent mipn. th e remaining ( . %) patients were not provided with drain placement. although the average total quantity of fl uid discharged from the drain was ml, the average fl uid remaining in the perirenal space was not signifi cantly diff erent with or without drain placement ( . ml vs. . ml, p= . ). decrease in serum total protein and albumin with drain placement was signifi cantly greater than without drain placement (total protein; . % vs. . % p< . and albumin; . % vs. % p= . ). no drain placement also caused markedly greater decreases in lymphocytes and monocytes than drain placement, while neutrophils and crp were not different. a mipn population was necessary by design, which may limit the ability to generalize these results. conclusion: analysis of the quantity of fl uid collection showed little need for routine drain placement. no drain aft er mipn prevents serum protein loss and might aff ect wound-healing immune responses. initial experiences of laparoscopic radical cystectomy introduction and objective: simultaneous treatment of bilateral lesions is an interesting application of laparoscopy. our goal was to present our experience with simultaneous bilateral laparoscopic pyeloplasty using three midline ports in two adult patients. two adult patients (one male and one female) underwent bilateral laparoscopic dismembered pyeloplasty in one session. one of the patients had horseshoe kidneys. a -mm trocar was placed through the umbilicus, and two -mm trocars were placed midline - cm superior and inferior to the umbilicus. results: intra-and postoperative periods were uneventful. operation time was and minutes in the fi rst and second patient, respectively. obstruction was relieved in both patients bilaterally on a -month follow-up. conclusions: simultaneous bilateral laparoscopic pyeloplasty using three midline ports is safe and feasible in adult patients with bilateral ureteropelvic junction obstruction. introduction and objective: radical cystectomy is considered to be the most eff ective treatment for patients with muscle-invasive bladder cancer. most urinary diversions are performed extracorporeally because of complex procedure time consuming. however, with the development of minimally invasive radical cystectomy techniques, increasing attention has been focused on intracorporeal urinary diversions, including both ileal conduit and orthotopic neobladder. we reviewed cases of laparoscopic radical cystectomy with intracorporeal ileal conduit in our medical center. ten patients with bladder cancer who underwent laparoscopic radical cystectomy and intracorporeal ileal conduit were retrospectively reviewed. with the cystoprostatectomy and lymphadenectomy completed, a - cm segment of ileum was identifi ed cm from the ileocecal junction. division of the isolated segment of bowel and the mesentery was performed using the endo-gia stapler. ileo-ileal continuity was reestablished by creating a generous side-to-side anastomosis with endo-gia stapler. th e left ureter was passed to the right side of the abdomen. aft er placement of single-j stent, the ureters were spatulated and the ureteroileal anastomis was performed with a running suture. results: laparoscopic radical cystectomy and intracorporeal ileal conduit were performed successfully in all ten patients from jan to dec . th e mean operating time was min ( - min), and the mean ileal conduit construction time was min ( - min). th e mean blood loss was ml ( - ml), and no patient received transfusion. th e time to orally allow was postoperative day ( - ). th e mean hospital stay was d. no major complication occurred. results: all the procedures were successfully completed without additional trocars except for one patient who was immediately converted to suprapubic-assisted laparoendoscopic single-site surgery (sa-less) nephrectomy for rectal injury during the placement of the zou-port. in our initial cases, tri-port was used. in the subsequent procedures, zou-port was used. th ere were no other intraoperative complications occurred. postoperative complications included a right external iliac artery thrombosis in one patient who underwent pure transvaginal notes simple nephrectomy. th e mean operative time was (range to ) mins and the mean estimated blood loss was (range to ) ml for pure transvaginal notes renal cyst decortication. th e mean operative time was (range to ) mins and the mean estimated blood loss was (range to ) ml for pure transvaginal notes nephrectomy. th e mean visual analog scale (vas) pain score was . (range - ) on postoperative day . th e mean time for ambulation was . (range - ) d. th e mean time for oral feeding was . (range ~ ) d. th e mean postoperative hospitalization stay was . (range ~ ) d. during the to -month follow-up period, all the patients were in good condition. th e posterior colpotomy incision healed well. th ere was no scar on the abdominal wall. th ere was no retrograde infection of pelvic and abdominal cavity, umbilical hernia, or uterine prolapse. conclusion: th e application of zou-port in pure notes transvaginal eff ectively reduces the diffi culty of operation and avoids the abdominal and pelvic organ injury, which is worthy of clinical application. lower ureter stricture. all the cases presented only one abdominal scar before surgery, including cases with the history of caesarean section, cases with the history of birth control surgery, cases with the history of appendectomy, cases with the history of inguinal hernia repair, cases with the history of ureterolithotomy, one case with the history of bladder lithotomy, and cases with the history of laparotomy surgery. th e mean length of scar is . ( . to . ) cm. under general anesthesia, the patients were positioned in lithotomy with aff ected side elevated at °. two trocars ( mm or mm) were introduced into abdominal cavity from the incisions at the right and left medial margin of umbilicus. a -or -mm trocar was inserted into the abdominal cavity through the abdominal scar under the direct vision. our technique for the transabdominal scar-assisted u-less is similar to that of standard laparoscopy, using conventional operating apparatus placed in the umbilical trocars, under direct vision achieved by a fl exible-tip ° laparoscope placed through the trocar at the abdominal scar. th e specimen was placed inside a homemade bag and removed under direct vision through an extended incision at the abdominal scar. to explore the application of three-dimensional ( d) laparoscopic technique in hybrid transvaginal notes nephrectomy. a total of female patients underwent hybrid transvaginal notes nephrectomy using d laparoscopy system. th ose included cases of hydronephrosis, cases of renal empyema, and cases of renal atrophy. th e median age was (range to ) years, and body mass index was . ( . ~ . ) kg/m . all patients were with unilateral disease and normal contralateral kidney. th e perioperative data including operative time, estimated blood loss, and surgical outcome were analyzed. results: th e procedures were successfully completed. th e median operative time was ( to ) mins. th e median estimated blood loss was ( to ) ml. th e patients were recover ambulation on postoperative day to , and tolerated diet on postoperative day to . th e patients were discharged on postoperative day to . th ere were no intraoperative or postoperative complications. during the -to -month follow-up period, all the patients were in good condition. th e posterior colpotomy incision healed up well. th ere were two hidden umbilicus scars. and p= . , respectively). mean incision length was shorter ( . vs. . cm, p< . ) and the scar satisfaction score was higher ( . vs. . , p= . ) in ldn with fl ank incision group. th e postoperative pain scores were higher (p= . ) in ldn with fl ank incision group but analgesic requirements were similar in both groups (p= . ). conclusion: ldn with fl ank incision had cosmetic satisfaction and comparable graft function, although challenging to the surgeon with longer warm ischemia time and higher postoperative pain. the effect of caudal block on postoperative analgesia in robotic assisted laparoscopic prostatectomy: a prospective study in a national referral centre introduction and objective: caudal block is widely used in paediatric surgery. it provides satisfactory postoperative pain relief in lower abdominal operations with minimal complications. th is pilot study explores its eff ect on postoperative pain control and its safety in patients who underwent robotic assisted laparoscopic prostatectomy (ralp). from to , consecutive patients were randomised into groups of patients. th e intervention group received caudal block using ropivacaine immediately aft er operation, while the control group only received analgesia consisting of paracetamol, nsaids, and opioids. both groups were assessed using verbalised pain scores in recovery room, and , , , , hours aft er the operation. additional analgesic requirements were recorded in the intervention group. opioid-related adverse events and the time to passage of fl atus were also recorded. introduction and objective: th e dorsal venous complex (dvc) ligation and vesicourethral anastomosis (vua) are the most challenging parts during laparoscopic radical prostatectomy (lrp). th is study will introduce a unique technique without any knots for the dvc ligation and vua using the unidirectional single running self-retaining suture. th is study is to examine the eff ectiveness of our knotless laparoscopic radical prostatectomy compared with the conventional technique. materials and methods: from december to december , lrp were separated into groups: group of knotless lrp and group of conventional single-knot lrp. during knotless lrp, the dvc is sutured using a - / circle self-retaining suture with bites at the same place, and the vua is performed with a -cm - / circle barbed self-retaining suture with one needle driver. retroperitonoscopic pyeloplasty is a feasible approach in the management of pelviureteric junction obstruction with a crossing vessel. anterior transposition using the posterior approach demands a good experience. herein, we present a case with complex vascular anatomy representing a real surgical challenge for a retroperitonoscopic approach. in the period from - , cases with a crossing vessel were operated by a single surgeon using both transperitoneal and retroperitoneal approaches. we report here a y old girl with left sided pelviureteric junction obstruction presenting with recurrent loin pain. lateral retroperitoneal laparoscopic approach was used with trocars; mm optic trocar and two mm working trocars. th e pelviureteric junction was tightly pushed anteriorly and close proximity to complex crossing vessels. dissection from the crossing vessels was performed followed by anterior transposition of the pelviureteric junction and a diffi cult anastomosis was performed with antegrade dj insertion. smooth postoperative recovery, no leakage, dj is removed aft er . month; follow-up ultrasound revealed decompression of the pelvis with no recurrence of the symptoms during the follow-up period. conclusion: retroperitonoscopic lateral approach is feasible for the management of pelviureteric junction obstruction with crossing vessel even in the most diffi cult cases in well trained hands. robotic assisted laparoscopic reimplantation for iatrogenic ureteral injury franklin a, jones c, pokala n, cummings j introduction and objective: ureteral injuries are a source of morbidity in pelvic surgery. robotic approaches to these injuries have been proposed. we reviewed our experience with this approach to examine the outcomes in patients undergoing robotic assisted laparoscopic reimplantation (ralr) for iatrogenic ureteral injury. oncological outcomes of robotic prostatectomy in the victorian public sector basto m , , sathianathen n , te marvelde l , landau a , , graves r , , everaerts w , , birch e , lawrentchuk n , goad j , moon d , murphy d , , , , introduction and objective: following the installation of the davinci s at peter maccallum cancer centre in , we aim to report medium-term oncological outcomes of patients undergoing robot-assisted radical prostatectomy (rarp) and to identify factors that act as predictors for biochemical recurrence (bcr) and oncological failure (of). a prospective cohort of consecutive men who underwent rarp in a single victorian public hospital were followed up for a median time of . and . months for bcr and of respectively. of was defi ned as bcr (psa≥ . ng/ml) or the start of adjuvant therapy. however, longer-term data is still required to better evaluate oncological success. functional outcomes of robotic prostatectomy: the victorian public sector experience basto m , , sathianathen n , te marvelde l , landau a , , graves r , , everaerts w , , birch e , lawrentchuk n , goad j , moon d , declan murphy d , , , , introduction and objective: to report medium-term functional outcomes of men aft er undergoing robotic assisted radical prostatectomy (rarp). furthermore, the impact of the procedure on quality of life will also be analysed. a cohort of consecutive men who underwent rarp in a single victorian public institution was assessed post-operatively for continence and potency status. a 'prostate cancer research survey' that was distributed pre-operatively and at , , , and months post-rarp, in combination with hospital medical records were utilized to collect data. th e following validated questionnaires were included in the survey: expanded prostate cancer index composite for clinical practice (epic-cp), sexual health inventory for men (shim) and prostate cancer related quality of life scale (pcar-qols). th e latter primarily evaluated the impact of surgery on quality of life. results: utilising hospital medical records, of the ( %) men that had follow-up post-operatively, % ( / ) were fully continent at months using a zero pad defi nition and % ( / ) were continent using a zero or security pad defi nition. of those who completed the epic-cp questionnaire, preoperatively (n= responders), . % and . % were continent using a zero and security pad defi nition respectively. at -months (n= responders), . % of patients were fully continent using zero pads per day and . % of patients were continent using none or security pad per day. regarding erectile function, shim scores were available for men pre-rarp, of which % were considered to be potent. of this subset of men, only %, % and % are considered post-operatively potent at , and -months. none of the patients that were pre-operatively impotent regained their erectile function at months. sexual confi dence was the facet of life that was most impacted by rarp. other quality of life subdomains showed no signifi cant diff erences aft er robotic prostatectomy. conclusion: th ere has been satisfactory recovery of continence post-rarp, however, erectile dysfunction still remains an important adverse sequela of surgery. overall, robotic prostatectomy has been successfully implemented in the victorian public sector with satis-introduction and objective: to compare patterns of care and perioperative outcomes of robotic prostatectomy to other surgical approaches, and create an economic model to assess the viability of robotic prostatectomy in the case-mix public health funding system. we retrospectively reviewed all radical prostatectomies (rp) performed for localised prostate cancer in victoria, australia, between july and april from the victorian admitted episode dataset (vaed), a large administrative database that records all hospital inpatient episodes in victoria, australia's second most populous state. patterns of care, length of hospital stay (los) and blood transfusion rates (btr) were compared by surgical approach. we then created an economic model to evaluate the incremental cost of robotic assisted radical prostatectomy (rarp) over open radical prostatectomy (orp) and laparoscopic radical prostatectomy (lrp) incorporating the cost off set from diff erences in length of hospital stay and blood transfusion rates. th e economic model constructs estimates of the diagnosis related group (drg) costs of orp and lrp, adds the gross cost of the surgical robot (capital, consumables, maintenance and repairs), and manipulates these drg costs to obtain a drg cost per day which can be used to estimate the cost off set associated with rarp in comparison with orp and lrp. economic modelling was performed around a base-case scenario, assuming a -year robot lifespan and robotic cases performed per fi nancial year, and one and twoway sensitivity analyses performed for the -arm da vinci shd, si and si dual surgical systems (intuitive surgical ltd, sunnyvale, ca, usa). both situations present a challenge to the surgeon contemplating a radical prostatectomy for prostate cancer, due to surgical access and anomalous vascular and ureteric anatomy. open radical prostatectomy has been reported in transplant recipients, but very little has been described using a robot-assisted laparoscopic approach. a case series will be described, illustrating the challenges and techniques required to successfully perform transperitoneal robot-assisted radical prostatectomy in patients with a congenital pelvic kidney or renal transplant within the pelvis. operations were performed using the da-vinci surgical system. we will describe a series of patients between and who underwent transperitoneal ro-bot-assisted radical prostatectomy, including patients with a congenital pelvic kidney and a redo renal transplant within the pelvis. prostatectomy was performed using a partial nerve spare in all cases, and pelvic lymph node dissection was not performed. th ere was a mean console time of minutes with a mean estimated blood loss of ml. histopathology confi rmed gleason sum - disease confi ned to the prostate with no extraprostatic extension or seminal vesicle invasion (pt c), and surgical margins were free of tumour in all cases. th e tumour volume ranged from . to . cubic centimetres. th e psa became undetectable postoperatively and remained undetectable without further therapy. careful perioperative review of imaging and placement of ports under direct vision was essential in avoiding complications. stay suture is applied at glans. circumcision incision is applied leaving at least mm tissue of inner mucosal collar. penile skin is denuded down to the penoscrotal junction. minor degree of chordee is corrected by this procedure. a fr feeding tube in the urethra adds to identify the distal urethra which is just underneath the skin in these case, which removed at the end of procedure. mucosa is defi cient ventrally and is replaced by a triangular patch of skin. th is skin patch is excised and mucosal edges are approximated in the midline. th is simple maneuver gives glans penis an upward tilt and meatus appears almost on the tip of glans. redundant preputial skin is excised and mucocutaneous approximation is done with / pds. no dressing is required. we operated cases of glanular hypospadias between december and january . mean age of children was . ± . years. all cases were day cases. th ere was no need for catheterization and dressing. we used temporary dressing for mild bleeding immediate post op in cases only which were removed in recovery room. th ere was no immediate post-operative complication like urinary retention, severe pain, fever or urinary tract infection. th ere was no complication of meatal stenosis in follow-up ( - month follow-up). urine stream was good and cosmesis was satisfactory to parents. we had low complications in our set up and success of glanular hypospadias by our technique was good in terms of good urine stream and cosmesis. conclusions: th e goal of modern hypospadias surgery is a functional neourethra that appears to be normally circumcised penis. tubularized incised plate urethroplasty is a widely applicable technique for distal hypospadias repair. but our current series shows that modifi ed tubularized incised plate technique has low complication rate and excellent cosmetic results superior to tubularized incised plate urethroplasty for primary distal hypospadias repair. however, these results must be further evaluated by comparison study of large series. the impact (catalona, ) was performed in patients. occult metastatic disease was found in two patients ( groins) at the time of diagnosis and subsequently developed in patients during follow-up. th erefore, a total of ( %) of the patients developed metastatic disease. conclusions: current management protocols place moderately diff erentiated t penile scc without vascular invasion in a low risk group for lymph node metastases. for this reason a primary option for these patients expectant approach is currently recommended. our experience has shown that patients in this group are really at higher risk for metastatic disease, and we suggest early modifi ed groin dissection instead of expectant observation. introduction and objective: penile cancers are rare. in ghana, they account for less than % of all genitourinary cancers. data on penile cancers in ghana is scanty. we report on cases of penile cancers seen over the last years at the komfo anokye teaching hospital (kath). th e aim of the study was to describe the clinicopathological presentation and the mode of treatment of penile cancers in our setting. th is was a retrospective study of histologically confi rmed cases of penile cancers seen at kath from january to december . information gathered included age, the clinicopathological features and mode of treatment using a structured proforma. results: th ere were cases of histologically confi rmed penile cancers over the period. th e age range was from - years with a median age of years. eight were uncircumcised and were married. in only one did the lesion not originate from the glans penis rather aff ecting the base and upper part of the left of hemi-scrotum. in patients, the lesion was restricted to the glans penis, it had involved the distal penis in , midshaft in , proximal penile in and base of penis in one of whom had auto amputation. all were squamous cell carcinoma with majority being moderately well diff erentiated ( %). seven had ulcerative lesions and were caulifl ower-like. majority were advanced (t ) involving the corpora ( %). only one patient reported with a t lesion. eleven patients ( . %) had lymph node involvement and two had distant metastasis at presentation. only one patient had a penile sparing surgery with of them having partial penectomy at various levels with ure-throstomy at the stump ends. one had total penectomy with suprapubic urinary diversion whiles the one with auto amputation had radiotherapy as the primary treatment. eleven of the patients had lymph node dissection. four had adjuvant radiotherapy. conclusion: most patients present with advanced disease making any hope of achieving a functional and cosmetically acceptable penis aft er treatment impossible. further education is needed to ensure early detection and treatment. how does partial penectomy due to penile cancer affect the sexual life? even though the high incidence of penile cancer in brazil, the sexual life of its patients, as well as their partners, has never been evaluated before. th e aim of this study is to evaluate erectile function in patients who underwent partial penectomy due to penile cancer, describe the socio-demographic and clinical data as well as to assess the patient's partners' sexual function. we performed a prospective analysis in patients between and at pernambuco state cancer hospital in brazil. th e sample consisted of patients who were submitted to partial penectomy for the treatment of penile cancer. control group included volunteer couples from the general population with similar socio-demographic features. th e assessment of erectile function and female sexual dysfunction were evaluated with iief- and fsfi respectively. results: th e prevalence of erectile dysfunction (ed) in the group of individuals subjected to partial penectomy was . %, including severe ed in %, moderate ed in %, mild-to-moderate in %, mild ed in . %, and no ed in . % of the participants. th e prevalence of ed in men of the control group was . % and was typically characterized as mild ed (p < . ). between partners of partial penectomy and control groups, % and % reported sexual dysfunction, respectively (p = . ). a comparative analysis of the risk factors for the ed showed that there were not diff erences between both groups (body mass index (bmi); tabagism; diabetes; hypertension; dyslipidemia and hypogonadism). conclusion: th e actual incidence of erectile dysfunction in patients submitted to partial penectomy for penile cancer is . %. comparative analysis between patients who underwent partial penectomy and general population showed a higher dysfunction rate in addition to more severe ed. in despite of that, their partner's sexual function was similar between the analysed groups. the introduction and objective: androgens are essential for the development and growth of the genitalia. th ey regulate the erectile physiology by multiple mechanisms. several studies have examined associations among sex hormones' serum levels, erectile function and sex drive. we sought to identify a protocol for using testosterone in men with erectile dysfunction and late-onset hypogonadism (loh). during a -month period, men with erectile dysfunction who presented to the andrology clinic were selected. th ey underwent a complete physical examination and fi lled out the international index of erectile function- questionnaire. serum luteinizing hormone (lh) and testosterone levels were evaluated. patients received a single intramuscular injection of mg testosterone. th ereaft er, serum levels of lh and testosterone were measured weeks later. results: th e mean age was years old. aft er treating patients with testosterone, ( %) showed improvement in loh symptoms including libido, loss of energy, irritability and quality of life. th e mean international index of erectile function was and . , prior to and aft er treatment respectively. mean serum testosterone levels before and aft er treatment were . and . ng ml_ respectively (p = . ). mean serum lh revealed a signifi cant decrease aft er the study (p = . ) ( . and . ng ml_ , before and aft er the study respectively). our fi ndings suggested that testosterone replacement therapy improves libido and loh symptoms in individuals with almost normal or lower limit normal value of serum testosterone levels. does l-carnitine therapy add any extra benefi t to standard inguinal varicocelectomy in terms of deoxyribonucleic acid damage or sperm quality factor indices: a randomized study to evaluate if addition of l-carnitine therapy to standard varicocelectomy adds any extra benefi t in terms of improvement in semen parameters or deoxyribonucleic acid (dna) damage. one hundred patients enrolled in this study and were randomly divided into groups ( patients in each group). in group , standard inguinal varicocelectomy and, in group , standard inguinal varicocelectomy plus oral antioxidant therapy (oral l-carnitine, mg times a day) were performed for months. for all patients, routine semen analysis and dna damage test of spermatozoa (by methods of terminal deoxynucleotidyl transferase dutp nick end labeling and protamine damage assay) were performed at baseline and at and months postoperatively. results: in both groups, the improvement in semen analysis parameters and dna damage was observed, but there was not any statistically signifi cant diff erence between the groups in these parameters, although the slope of improvement in dna damage was slightly better in group (that was not statistically signifi cant). we observed that addition of mg of l-carnitine orally daily to standard inguinal varicocelectomy does not add any extra benefi t in terms of improvement in semen analysis parameters or dna damage. serum uric acid as a risk predictor for erectile dysfunction introduction and objective: testicular torsion is one of the few urological emergencies that require prompt diagnosis and treatment, since its delay leads to testicular ischemia inevitably leads to testicular necrosis and atrophy. we aimed to determine the pattern of presentation and early outcome of patients with testicular torsion managed at kcmc. th is was a hospital based descriptive retrospective and prospective study involving patients who were managed for testicular torsion between january and january . eighty three ( %) were at the age of years with a mean . and a standard deviation of . . results: left side was more aff ected by . %. th irty two ( . %) patients arrived at kcmc within six hours from the onset of symptoms. scrotal pain was the main complaint. seventy two ( %) patients were misdiagnosed at the peripheral health facilities and treated empirically with antibiotics. ninety six point nine percent of those with more than degrees of rotation and duration of arrival to kcmc beyond six hours were found with missed torsion compared to . % of those with a degree of rotation less than and less than six hours on arrival to kcmc (p-value . ). orchiectomy of the aff ected testis and fi xation of the viable was the mostly adopted treatment option by . %. eighty four percent of our clients had fi rm and smooth testis at follow-up of three months with % having atrophic testis at three months in both groups (retrospective and prospective arms). conclusion: testicular torsion aff ects more young adolescent males. all patients with testicular torsion presented with scrotal pain. most patients arrived to kcmc hospital beyond six hours majority of them being treated empirically with antibiotics at the peripheral health facilities. missed torsion is a common sequel to our patients outcome at three months is promising by having viable testis. ho:yag laser ablation for ulcerative interstitial cystitis tokyo women's medical university aoyama hospital, tokyo, japan introduction and objective: in cases of ulcerative interstitial cystitis are usually treated by tur or by electrocautery, resulting in improvement of pain. efficacy of electrocautery using laser remains unclear because of a very few number of case reports. we treated this time ulcers of interstitial cystitis by cautery using ho:yag laser to evaluate its effi cacy as well as safety. materials and methods: eight cases with hunner's ulcers whose pains were hardly controlled aft er drug therapy and/or hydrodistention were treated with ho:yag laser. patients were evaluated with interstitial cystitis symptom index (icsi), interstitial cystitis problem index (icpi), international prostate symptom score (ipss), quality of life (qol) index and a visual analog pain scale (vas) at base line, one, three and six months post operatively. statistical analysis was performed using the paired t test, in which p< . was considered statistically signifi cant. results: patients were all females aged to years. half of them were treated more than two times. scores obtained by the questionnaire survey were improved aft er the laser therapy. scores of icsi, icpi, ipss, qol index and vas were statistically signifi cantly decreased at one and three months. only vas was statistically signifi cantly decreased at six months. th ere was no severe complication associated by the therapy. conclusion: ho:yag laser therapy for ulcerative interstitial cystitis is effi cacious at least for three months. also this treatment is safe for aged patients. introduction and objective: th e use of methylene blue (mb) to highlight anatomic structures in urology is a well-established practice. a narrow urethral plate can be diffi cult to properly locate intraoperatively, particularly in panurethral strictures. our objective is to assess the value of intraurethral injection of mb during urethroplasty. th ere is cc of mb ( mg/ ml) diluted in cc of normal saline. th e mb is gently injected retrograde into the urethra. a penile clamp is applied for minutes to increase the contact time of the mb with the urethra. th e urethroplasty commenced and the urethra was opened. th e impact of the mb on the anatomy of the urethra was by subjective assessment of a single surgeon (s.b.k.). results: a total of consecutive cases were prospectively evaluated from - . precise staining of the narrow lumen was successfully observed in ( %). in these cases, the diseased urethral strictured portion of the urethra was subjectively stained blue with mb. th e grossly normal appearing urothelium remained pink and did not take up signifi cant mb stain. in ( %) cases minimal or no staining was observed. extravasation in to the spongiosa was seen in ( %) cases. in ( %) cases there was dense staining distal to the narrow lumen. th ere were no known allergic complications. conclusion: normal urothelium does not appear to be stained by mb. mb readily stains diseased and strictured urotheilum. intraurethral injection of mb is a useful tool in urethroplasty. it helps in delineation of stricture and identifying lumen. it guides us to the exact area of urethra to be augmented. it is a simple, non-costly and non-invasive tool. in our high volume tertiary referral unit, it is now standard to inject methylene blue in urethra immediately prior to urethroplasty. demography, preoperative imaging and surgical outcome in penile fracture results: condition was occurred in . % of patients during an abnormal sex such as masturbation, aggressive sex and also taghaandan. all patients except one that refused intervention were treated surgically. only four cases involved bilateral corporal injury. two involved unilateral corporal injury with an associated urethral injury, and one involved bilateral corporal injury with an associated urethral injury that all were repaired primary. urine analysis was performed for . % of patients. gross hematuria was seen in one and microscopic in two patients of urethral injury and did not see in others. retrograde urethrogram were not taken of patients with urethral injuries. diagnostic cavernosography or magnetic resonance imaging was not used in any of the patients. cystoscopy was performed in case of gross hematuria with complete urethral transection. no complications occurred in the patients in early follow-up. we are interested in that report entire result of this study such as longterm surgical outcome at congress. conclusion: based on islam promotion for early and inexpensive marriage, avoiding from abnormal sex can signifi cantly decrease penile fracture. in addition, we recommended immediate surgical exploration and repair of tunica albuginea without any preoperative diagnostic imaging. introduction and objective: cowper's glands are two exocrine glands, which are located in the perineal pouch between the fascia layers of the urogenital diaphragm. th ey excrete pre-ejaculate into the urethra to lubricate it and neutralize acid to enable sperm to pass through the urethra. th e glands form two ducts that are . to cm long. although anatomic variations exist, the majority of ducts combine to make one confl uent passage that opens at the posterior part of the bulbar urethra. cowper's gland collecting ducts dilatation is called syringocele, an uncommon and under-diagnosed anomaly in adults. in pediatric patients there are . % and . % found on autopsy studies. we are presenting case of an adult -year-old male, whose symptoms were unrecognized by many physicians, even experienced urologists. th e patient had diff erent treatments with antibiotics and other diff erent medications without success. results: th e patient's chief complaint was dribbling aft er voiding few drops of urine when smiling, coughing, sneezing, crouching and any kind of eff ort. he received treatment as an outpatient by family physician and dermatologist. a bulging on the perineum was found by palpation, hard to elastic consistency, walnut size formation in the corpus spongiosum, easily movable from the perineal skin. urethroscopy was performed and the fi nding in the bulbar urethra was a cystic formation, gray to white color with very thin blood vessels. it fi lled the lumen of the bulbar urethra, but with pressure very easily passed the urethra and verumontanum to the bladder. voiding and retrograde urethrography showed fi lling defects in the bulbar urethra. th is cystic formation was fi xed to the fl oor of the urethra. an incision and deroofi ng of the cystic wall by resection was done. th e patient aft er this procedure was without dribbling aft er voiding. introduction and objective: th e use of methylene blue (mb) to highlight anatomic structures in urology is a well-established practice. th ere are diff ering opinions regarding the management of short atraumatic bulbar strictures. some favor augmentation with buccal mucosal graft (bmg) while others favor excision and primary anastamosis (epa). th e divergence of opinion is unifi ed toward epa in the face of signifi cant spongiofi brosis. our objective is to determine if mb can be used to assess the degree of spongiofi brosis in short atraumatic bulbar strictures. we term the procedure methylene blue spongiography. five cc of methylene blue ( mg/ml) is diluted in cc of normal saline. th e dissection for the urethroplasty continues until the bulbar urethra is exposed. th e location of the stricture is identifi ed. insulin needles are inserted in three locations. one needle is placed in the sponge proximal to the stricture. another needle is placed in the sponge at level of stricture. th e third needle is placed in the sponge distal to the stricture. large atraumatic clamp is place at the most proximal extent of the bulb to limit the confounding blood fl ow from the bulbar artery. methylene blue is gently injected via distal needle. th e two remaining needles are then observed for mb effl ux. presence of mb effl ux in needle proximal to stricture implies a defi ciency of signifi cant spongiofi brosis and urethral transection with epa is not performed. absence of effl ux of methylene blue in proximal needle implies signifi cant spongiofibrosis and epa is performed. we performed mb spongiosography in short bulbar idiopathic strictures. mean length of the stricture was . (range to . ). in ( %) cases methylene blue was seen across the stricture and transecting urethra was avoided. in ( %) cases where no mb went across primary excision and anastomosis was performed. no patients had adverse reaction or complication of methylene blue. conclusions: methylene blue spongiography can be performed to guide the method of urethroplasty performed. it is a simple, cost eff ective, and time effi cient method to further evaluate the degree of spongiofibrosis. effi . th e allium bulbar urethral stent is a fully covered, self-expandable, large caliber metal stent, specially designed for the treatment of bulbar urethral strictures. th e indwelling time for the stents was planned to be months. all men underwent an internal uretrotomy procedure followed by an endoscopic stent placement. progressive decreasing of the urinary peak fl ow rate, recurrent urinary infection and stent migration were the early removal criteria. th e success criteria aft er the stent removal were: no evidence of stricture on urethrogram or endoscopy, urinary peak fl ow greater than ml/sec and no recurrent urinary tract infection. results: five stents were replaced since very early migration not more than one month period. none of the patients reported discomfort at the stent site. five patients complained of mild urinary incontinence which was resolved aft er stent explantation. all stents were removed very easily without any complication to months (mean . months) aft er implantation. follow-up period was meanly months ( to ) after stent explantation. clinical success was achieved in patients ( %). conclusion: based on our results, temporary placement of allium bulbar urethral stent, for management of the recurrent urethral strictures, is noninvasive, safe and eff ective procedure. the impact of testicular loss on the psychopathology we also compared the results of long-term treatment group and short-term treatment group. th is study showed that cases of long-term continuous administration of doc consisting of or more cycles among patients of castration-resistant prostate cancer (crpc) treated with doc from october to september at our institution, retrospectively. nineteen patients who had treated with doc or less cycles were defi ned as short-term dose group, and both groups were compared. doc was administered every to weeks at to mg/m , and was treated with prednisolone at mg/day as a general. results: th e median number of treatment cycles was (range to ), and the median age of patients was (range to ) years old. th e median psa levels at start of doc based chemotherapy was . (range . to . ) ng/ml. th irteen cases ( %) showed a decrease in psa levels and cases ( %) showed a decrease in psa levels of % or more, the -year survival rate of long-term dose and short-term dose group were % and %. adverse eff ects of grade or lower consisted of leukocytopenia in % and thrombocytopenia in %, stomatitis and general fatigue in some cases, however, grade or higher were not observed in long-term dose group. in multivariable analysis of parameters, long-term treatment was related to psa levels at start of treatment and alp levels. pattern of use of androgen deprivation therapy in prostate cancer: an italian multicenter cross-sectional analysis introduction and objective: androgen deprivation therapy (adt) for prostate cancer (pca) is widely used with diff erent indications, however, some discrepancies exist between clinical practice and the recommendations of the international guidelines. th e aim of this cross-sectional study was to evaluate patterns of use of adt in patients with pca in italy. we also aimed to measure the adherence of adt prescriptions to the recommendations of the eau guidelines. materials and methods: th e choice study was an italian multicenter cross-sectional studying conducted from december to january on patients treated with adt for pca (fi rst prescription or renewal of therapy). th e project involved radiotherapy departments and urology centers. inclusion criteria were: age ≥ years, previous diagnosis of pca and current adt. at baseline all the following information were included: charlson comorbidity index (cci), clinical stage, psa level at the time of the diagnosis, total prostate volume and gleason score; gleason score and pathological stage from radical prostatectomy (rp) when available. we subdivided the cohort into three risk categories for each treatment group, based on d' amico classifi cation. patients were categorized according to primary treatment into rp, radiotherapy (rt), rp + rt and adt only. radiotherapy comprised external beam therapy and brachytherapy. adt included bilateral orchiectomy, gnrh agonists or anti-androgens. th ree geographical areas were considered: northern, central and southern italy. adt change (adt-c) was defi ned as any modifi cation of therapy between previous adt and treatment prescribed aft er enrolment. the prevalence and outcomes of pt disease after neoadjuvant hormonal therapy plus radical prostatectomy in high-risk prostate cancer introduction and objective: to identify the prevalence and clinical outcomes of pt disease following neoadjuvant hormonal therapy (nht) and radical prostatectomy (rp) in high-risk prostate cancer. we retrospectively included patients who had received nht and rp for the treatment of high-risk prostate cancer. we classifi ed the patients into two groups, the pt group and the non-pt group depending on whether a residual tumor was observed or not. we identifi ed cases ( . %) with pt disease aft er reviewing all slides of the patients. th ere was no recurrence of disease in the pt group during a median follow-up of months. among the patients in the non-pt group, biochemical recurrence (bcr) developed in patients ( . %), with the median time to bcr being months. conclusions: among the patients with high-risk prostate cancer, we found cases that showed a pathologic complete response aft er nht and no recurrence of disease during the follow-up, which means that the androgen-deprivation therapy could potentially eradicate high-risk prostate cancer. th is is one of the largest studies demonstrating the prevalence of pt disease and its outcomes aft er nht among patients with high-risk prostate cancer. introduction and objective: in metastatic castration-resistant prostate cancer (mcrpc), data are limited regarding optimal combinatorial or sequential use of available treatments. p - (stride; nct ) is an ongoing, randomized, open-label, phase study evaluating concurrent vs. sequential administration of the androgen receptor inhibitor enzalutamide (enz) with the autologous cellular immunotherapy sipuleucel (sip-t). fift y-two patients (pts) with asymptomatic or minimally symptomatic mcrpc were randomized : to receive sip-t infusions with enz starting weeks before (n= , concurrent arm a) or weeks aft er (n= , sequential arm b) sip-t initiation. th e primary endpoint is peripheral t cell proliferation response to pa , the sip-t immunizing antigen. secondary endpoints include interferon (ifn)-γ elispot and humoral immune responses to pa and prostatic acid phosphatase (pap), product release parameters (total nucleated cell count, cd + cell counts, and antigen presenting cell activation [as measured by cd upregulation]), cytokine production, and adverse events (aes). results through week are described. results: pa -specifi c t cell proliferative response was signifi cantly elevated at all post-baseline time points (p< . ) and was sustained through week , including a > -fold increase at week in both arms. th is pa -specifi c response was observed in nearly all pts, . % in arm a vs. . % in arm b. both arms showed a signifi cant and sustained increase in humoral responses to pa and pap as well as ifn-γ elispot response to pa . sip-t product parameters were similar between arms. cytokines indicative of immune activation (such as ifn-γ, interleukin- , and tumor necrosis factor-α) were also elevated in both arms. aes were observed in % (arm a) and % (arm b) of pts. th e incidence of grade ≥ aes was similar between arms. materials and methods: tur specimens without hormonal use ( cases), specimens aft er three weeks of chlormadinone acetate (cma) ( cases), specimens aft er average six months of dutasteride ( cases), and specimens two weeks aft er initial use of degarelix ( cases) were studied using he and immunohistochemical staining with prostate specifi c antigen (psa), prostatic stem cell markers such as cd , cd , and vimentin. results: specimens treated with cma showed acinar dilatation and atrophy of glandular cells. specimens treated with dutasteride showed marked decrease of gland and increase of fi bromuscular tissue. specimens treated with degarelix showed prominent decrease of gland and glandular cells. psa was stained all of the prostatic glandular cells in all specimens. cd was stained at basal cells in normal prostatic tissue without hormones, however in hormone treated specimens, basal cells elongate and some glandular cells were also stained by cd , especially in cma treated specimens. cd was stained in many glandular cells without special patterns. vimentin was stained in all mesenchymal interstitial cells and a part of basal cells, and not stained in glandular cells. conclusion: elongation of basal cells and increased sensitivity to cd in glandular cells, especially treated with cma, were thought to the result of emt of prostatic glandular cells. th ree weeks use of cma might be a good model to observe emt of prostatic cells among these three hormone models, presumably because six months use of dutasteride is long enough to alter the structure of prostatic tissue, and degarelix has strong apoptotic activity to prostate cells in a short period. aryl plays an important role in normal physiologic responses such as development, cell cycle regulation, and immune function in various tissues. th e strong nuclear ahr expression was observed in the invasive phenotype and an elevated nuclear ahr expression was associated with a poor prognosis of human prostate. on the other hand, the ahr defi ciency results in a smaller volume and in increased susceptibility to prostate tumors in mouse model. in the present study, we investigated ahr expression and its role in the growth and invasiveness of human prostate cancer cells. we checked ahr proteins expression in prostate cancer cell lines and in human prostate cancer specimens by immunoblotting and immunohistochemistry respectively. we used a small interfering rna targeting ahr, constitutive active ahr expression vector, and ahr agonist and antagonist were used to moderate its expression and signaling to examine growth and invasion in prostate cancer cells. introduction and objective: androgen deprivation therapy (adt) has been increasingly used in patient with prostate cancer (pca). it has been considered that adt is associated with greater risk of incident cardiovascular disease (cvd). th e one of the reason is that hyperlipidemia was caused by adt may contribute to greater cvd risk. but the evidence remains inconclusive and sometimes contradictory. in our present study, we investigated an eff ect of adt on arterial atherosclerotic changes assessed by cardio-ankle vascular index (cavi) in pca patients. th e present study was participated in patients with prostate cancer before initiate adt. we recorded and statistically analyzed the data of the patients before adt and at months, months, and months aft er adt. and the patients' arterial atherosclerotic changes was evaluated by cavi at baseline. correlation between the degree of infl ammation and gleason score in prostate cancer patients alexandrescu e, geavlete p, georgescu d, geavlete b introduction and objective: hypothesis regarding the involvement of infl ammatory processes in prostate cancer has been the subject of several recent studies. chronic infl ammation generates the appearance of morphological changes of atrophic type, lesions located predominantly in the periphery of the gland, as well as prostate cancer (pca). th e aim of the study was to assess the possible infl uence of associated infl ammation on the gleason score in pca patients. results: th e gleason score - was detected in patients ( . %), score - in patients ( . %) and score - in patients ( . %). cases of aggressive disease (gleason score - ) were detected by prostate biopsy, while high-grade infl ammation has been mostly associated with pca cases incidentally detected by turp. no signifi cant correlations were found between the presence and degree of histologically proved infl ammation and the gleason score or the presence of pca. identifi cation of n -methyladenosine methylated mrnas in prostate cancer pang k , , cumberbatch m , , catto j , introduction and objective: rna methylation is a common epigenetic event in oncogenesis, and the most common form is the methylation of n -adenosine (m a). th e recent identifi cation of > , m a-methylated human mrnas from > human genes point towards novel epigenetic mechanisms. however, the distribution of m a in the prostate transcriptome is unknown. we aimed to predict the mrnas susceptible to m a-methyation in primary prostate cancer (pca) and castrate-resistant pca (crpc), and identify the functions of these mrnas. th e aim of this study was to assess the contribution of multiparametric mri and pca in pre-decision of initial biopsy in patients with serum psa level - ng/ml and normal digital rectal examination. th e study is planned as prospective and single-centered. patients whose serum psa level - ng/ml with normal digital rectal examination scheduled for initial prostate biopsy were included in the study between february and march . each patient underwent multiparametric mri (diff usion, spectroscopy, dynamic-contrast, t ) one week prior to biopsy. th e lesion seen at least in two mri was accepted as multiparametric mri lesion. twenty to thirty ml initial urine samples were taken aft er minutes prostate massage for pca examination before biopsy. pca score over was considered as signifi cant. guided biopsies were taken according to lesions seen in multiparametric mri. patients with high psa levels were separated into two groups as high pca scores and normal pca scores. each group, then, was separated into two groups due to mri results as lesion positive and negative. tumor incidence and positive predictive values were calculated in patients with high psa and pca scores with positive multiparametric mri lesion. tumor incidence and negative predictive value were also calculated in patients with high psa level but low pca score with negative multiparametric mri lesion. up. , figure . a biopsy-induced hemorrhage was defi ned as a case in which a subject complained of bleeding from the rectum and excretion of blood clots was confi rmed. we categorized signifi cant rectal bleeding into two grades for hemostasis management, including mild and severe. when the bleeding was classifi ed as mild, we inserted the gelatin sponge into the participants in either group b or reinserted it into those participants in group a. if the bleeding could not be stopped by this approach, we additionally used index fi nger pressure for ten minutes or more to promote hemostasis. in the severe cases, an endoscopic clipping was performed to control the bleeding because arterial bleeding was suspected. a blood test and a questionnaire survey, and pain related to biopsy was performed before and aft er biopsy. th e diff erence in background factors between groups a and b was assessed. to identify the independent predictive factors for rectal bleeding for all participants, background factors, including insertion of a gelatin sponge into the rectum were analyzed by logistic regression analysis. results: signifi cantly fewer patients in group a required hemostasis aft er biopsy compared to group b ( ( . %) vs. ( . %), p= . ). th e results of blood tests performed before and aft er biopsy and the results from the questionnaire did not diff er signifi cantly between the two groups. in multivariate analysis, only "insertion of a gelatin sponge into the rectum" emerged as a signifi cant predictor of hemostasis. our results suggest that the tissue elastic modulus of prostate cancer may increase with an increase in the gleason score and that the diff erence in the stiff ness between low-grade lesions and prostate hyperplasia may be slight. th ese basic fi ndings will contribute to the development of quantitative elastography technique. the results: th e median ipss was , the mean psa was . ng/ml; the mean size of prostate was . cc. of the total subjects, prostate cancer was detected in ( . %) patients. among subscores refl ecting specific luts, the nocturia was only symptom score predict the cancer detection. th e detection rate of patient with nocturia more than time a day was . %, but the cancer detection rate of patient without nocturia was only . %. at multivariate analysis adjusting infl uence of covariate of age, psa, prostate size and transitional zone size, frequency and nocturia scores were the two only factor predicting cancer detection. at the roc curve analysis measuring the benefi t of the additional consideration of the severity of nocturia and frequency, the additional consideration induced . % prediction accuracy elevation (from . to . ). conclusions: men with frequency or nocturia have lesser chance of prostate cancer detection rate than the men without luts. however, the infl uence of these storage symptoms seems not strong enough to change current consensus of indication to biopsy the prostate. routine in the discontinuing group were %, %, - . %, - . % and - . %, respectively (p= . ). th e median Δegfr at baseline, , , and months in the continuing group were %, %, - . %, - . % and - . %, respectively (p= . ). th e continuing group decreased months later. however, the renal function in the discontinuing group had a tendency to improve at months aft er treatment insignifi cantly. th ere was not statistical signifi cant diff erence in various factors between discontinuing group and continuing group. conclusions: it was possible that the recovery of testosterone was associated with the improvement of the renal function. it has been reported that the discontinuation of adt recovered the level of testosterone. namely, the discontinuation of adt for prostate cancer might revive the renal function. th erefore, it was suggested that intermittent adt might recover the renal function. introduction and objective: as more and more patients are getting diagnosed as carcinoma of prostate (cap), we would like to look into how prostate cancers are presented at the early age of forties and how they were treated. as cap is more popularised in the media, more and more people are asking gps for psa measurements. introduction and objective: irreversible electroporation (ire) is a novel ablative therapy for prostate cancer, with reported advantages of sparing surrounding essential structures. th ese properties could potentially help to reduce or avoid side eff ects. th e objective is to determine quality of life outcomes (qol) and side-eff ects of ire treatment. sixteen patients planned for radical prostatectomy (rp), were asked to participate in the study. all patients underwent an ire treatment one month before rp, using a focal or extended ablation protocol. th e safety was measured by the number of adverse events graded by the common terminology criteria for adverse events (ctcae). to determine qol validated questionnaires (expanded prostate cancer index composite (epic), the fi ve-item version of the international index of erectile function (iief- ) and international prostate symptom score (ipss)) were used. results: five developed a urinary retention (ctcae grade ) solved by an indwelling catheter or self-catheterisation. two patients developed a urinary tract infection (ctcae grade ), one progressed to urosepsis (ctcae grade ), both resolved without sequelae. mild haematuria (ctcae grade ) was noted in ten patients, spontaneously resolved within days. five patients experienced temporary incontinence with duration of - days, three suff ered from total incontinence and needed pads and pelvic fl oor training (ctcae grade ). two patients reported mild hematospermia, lasting one and thirty days. ipss showed no signifi cant diff erence between baseline (average of (avg) ± ) and four weeks postoperatively (avg ± ). iief showed no signifi cant diff erence between baseline (avg ± ) and four weeks postoperatively (avg ± ). epic outcomes, shown in figure , were not signifi cantly diff erent at baseline, one and four weeks aft er ire, regardless of the used ablation protocol. conclusion: ire treatment for prostate cancer is safe and shows only adverse events that lie within the range of what was expected and shows promising rates of genito-urinary functional preservation. introduction and objective: mri-guided transurethral ultrasound ablation (tulsa) is a novel minimally-invasive technology for treatment of prostate cancer aiming to provide local disease control with low morbidity. th e ultrasound device generates conformal volume of thermal ablation, shaped precisely to the prostate using real-time mri thermometry feedback control. aim of this prospective, multi-national phase i study is to determine safety and feasibility of mri-guided tulsa. biochemical recurrence (bcr) was defi ned using phoenix criteria (psa nadir + ng/dl) and positive biopsy in the treated area was considered recurrence. we compared the perioperative and oncologic outcomes following fc in patients with gs vs. gs ( + ) at initial trus biopsy. th e complications were reported using the clavien-dindo classifi cation. we found patients with gs and with gs ( + ). clinical and operative characteristics were similar (table ) . th e mean follow-up was . (± . ) months. th ere was no signifi cant diff erence noted between gs vs. gs in the biopsy recurrence ( % vs. %, p= . ) and bcr rates. th ere were complications in ( . %) patients. all were low grade, except two patients who had iii b complications (table ) . conclusion: th e perioperative and oncologic outcomes of fc -hemiablation for unilateral, organ confi ned pca appears to similar between gs and gs ( + ) disease. pentafecta in the evaluation of surgical results after open radical prostatectomy de la rosa h, rios s, martinez n introduction and objective: "pentafecta" has been used to evaluate the oncological and functional results in patients with prostate cancer treated with minimal invasive radical surgical techniques. in this study we evaluate, with this quality tool, the outcomes in a group of patients undergoing open radical prostatectomy. we analyzed retrospectively the database of surgeries performed at the urology department of the military hospital of guadalajara and the clinical fi les of patients with localized prostate cancer treated with radical prostatectomy. we describe the patients' characteristics including the charlson comorbidity index (cci) and identify the parameters that conform pentafecta as well as the variables that can infl uence the oncological and functional results using the fisher´s exact test. results: fift y four patients were treated with radical prostatectomy between and , fi nding in their fi les a minimum of months of follow-up. seven patients were discarded of the study because they undergo laparoscopic radical prostatectomy, and more because missing information at their fi les. th e average age was ( - ) and the cci average was . ( . - . ). mean operative time was min ( - ) and intraoperative bleeding cc ( - ). th e presence of potency, continence, biochemical recurrence-free survival, negative surgical margins and no perioperative complications were %, %, %, % and % respectively. seven ( %) patients achieved pentafecta, and patients ( %) failed to achieve. statistical analysis confi rmed the surgeon's experience as the only factor associated with achieving pentafecta. conclusions: th e fi rst cause of failure to achieve pentafecta in our study group was impotence, second were positive surgical margins and third surgical complications mainly intraoperative bleeding. pentafecta is a useful tool for objective assessment of oncological and functional outcomes of patients treated with open radical prostatectomy. plasma introduction and objective: hepatocyte growth factor (hgf) is a well-known multifunctional growth factor, the amount of evidence has accumulated suggesting that the hgf/met (hgf receptor) signaling axis is involved in cancer progression. macrophage stimulating protein (msp) is also known as a growth factor which activates not only macrophages but also cancer cells and osteoclasts through the activation of the specifi c receptor d' origine nantais (ron). hgf and msp are secreted as an inactive single-chain precursor (pro-hgf, pro-msp), which lacks biological activity and, therefore, requires proteolytic activation for conversion to an active two-chain form by hgf activator (hgfa). although, there have been reported a lot of study for hgf/met signaling with castration-resistant (cr) pc and bone metastasis, the report for examination of plasma protein is rare. in addition, msp/ron signaling axis is not well evaluated in pc. here, we analyzed the associations between pc progression and plasma levels of hgf and a closely related molecule, msp. conclusion: dehydroepiandrosterone (dhea) concentrations in blood were examined by newly developed ultra-sensitive quantifying method, lc-ms/ms. we confi rmed that low serum dhea levels in men with prostate were related to high gleason score and advanced clinical stage. th ese results suggest that serum dhea level may be useful as a prognostic factor in men with prostate cancer. introduction and objective: androgen/androgen receptor (ar) signal is known as a powerful driver of prostate cancer (pca) progression. previously we reported the limitation of prostate-specifi c antigen (psa), which is an ar-regulated protein, at diagnosis as a prognostic biomarker of pca. paradoxically pca patients with low psa < . ng/ml had a more advanced stage of cancer compared with those with psa between . and ng/ml. although serum total testosterone (tt) has also been reported as a pca prognostic biomarker, its usability is still controversial. we examine the potential and the character of tt as a biomarker, comparing to psa. serum tt level of patients who underwent prostate biopsy at kanazawa university hospital between and were measured and pca-specifi c survival (pcass), overall survival (os), and the correlation between tnm stage and tt level were analyzed. results: of total biopsied patients, were diagnosed with pca. median tt was . ng/ml (range: . - . ). when patients were divided into groups according to their tt at diagnosis, patients with tt < and ≥ ng/ml had worse pcass than those with ≤ tt < , ≤ tt < , and ≤ tt < ng/ml. os in patients with tt < and ≥ ng/ml also was worse than that in other groups. moreover, tt < and ≥ ng/ml showed worse pcass even in patients with advanced stage (t or n or m ). higher tnm stage was observed in patients with tt < and ≥ ng/ml than those with ≤ tt < ng/ml. low tt level has been reported as a predictive biomarker indicating worse outcomes in pca patients. th is study showed not only low but also high tt level may indicate poor prognosis. th ese data are consistent with our previous studies showing low psa (< . ng/ml) also might indicate poor prognosis as well as high psa. although poor prognosis of high tt and high psa strongly depends on androgen/ar signal, poor prognosis of low tt and low psa patients may be due to other signals than androgen/ar. usefulness of psa as a marker of prostate cancer in men treated with dutasteride takeda h, nakano y, narita h introduction and objective: to analyse whether the use of treatment-specifi c criteria for repeat biopsy maintains the usefulness of prostate-specifi c antigen (psa) level for detecting prostate cancers. th is study was a retrospective investigation to assess the eff ects of dutasteride on psa in asymptomatic men aft er negative st biopsy and on repeat prostate biopsy decision. th e usefulness of psa was evaluated using biopsy thresholds defi ned by three times consecutive rises and . ng/ml up in psa from nadir (the lowest psa level achieved while in the study) in the dutasteride group. prostate cancer pathological characteristics were compared. results: of men, (dutasteride) underwent at least one prostate biopsy during the study and were included in the analysis. mean follow-up (month) was . , ipsa was . ng/ml, mean prostate volume(cc) was . , psad was . ng/ml/cc. nine of ( %) were detected prostate cancer, % ( / ) of gleason and % ( / ) of gleason - cancers were detected in the dutasteride group. in the study, the incidence of gleason and gleason - cancers generally increased with greater rises in psa. sensitivity of psa kinetics with dutasteride was high as usual. conclusion: using treatment-specifi c biopsy thresholds, the present study shows that the ability of psa kinetics to detect prostate cancer is maintained with dutasteride in men with a previous negative biopsy. biopsy decisions based on three times consecutive increased and . ng/ml psa measurement from nadir in the dutasteride group are useful, indicating the importance of confi rmation of psa measurements. our goal was to develop a fi t-for-purpose assay that could be performed on rna from diagnostic needle biopsies, and provide improved risk stratifi cation in early-stage pca. to date, development and validation studies have included > , patients from four academic centers. in these studies, archival tissues were assayed following prospectively designed protocols with pre-specifi ed methods and statistical analysis plans. results: feasibility and development studies confi rmed gene expression and identifi ed genes whose expression was predictive of clinical recurrence, biochemical recurrence (bcr), prostate cancer death, and adverse pathology (ap) at surgery in the face of tumor heterogeneity and multifocality. analytic validation studies showed that the assay provided robust, reproducible results over a wide range of rna inputs, diff erent operators, instruments, and reagent lots. th e fi rst clinical validation study established gps as an independent predictor of ap in men with nccn verylow to intermediate-risk pca. exploratory analyses showed that gps is a robust predictor of ap despite inter-observer diff erences in pathologic grade and stage assessment. a second clinical validation study in a racially diverse population confi rmed the assay as a predictor of ap and validated the assay as a strong predictor of bcr (hr/ gps units= . ; p< . ). gps was also signifi cantly associated with metastatic disease (hr/ units= . ; p= . ). other exploratory analyses showed that the assay can predict ) likelihood of clinical recurrence aft er bcr, regardless of salvage therapy, and ) tumor aggressiveness when assessed in adjacent normal-appearing tissue. all four gene groups contribute to the predictive value of the assay. conclusions: th e development program for the assay addressed challenges of small sample size, tumor heterogeneity, multifocality, and biopsy under-sampling. validation in two large contemporary cohorts of men with pca in two prospectively designed studies provides level ib clinical evidence for gps as a predictor of ap. clinical and therapeutic implications of neuroendocrine prostate cancer: a long winding road to cure lu k, wang h, lin v, yu t introduction and objective: primary neuroendocrine cancer of prostate is an extremely rare variant of prostate cancer, comprising . % to % of prostate malignancies. th is entity encompasses various clinical contexts, ranging from the de novo small cell carcinoma (scc) to a treatment-emergent transformed phenotype that arising from typical adenocarcinoma (ad) of the prostate. th e rarity of these neoplasms poses a diagnostic and therapeutic challenge. little is known about neuroendocrine prostate cancer and the current knowledge of this disease is based on case reports or small series. our purpose was to characterize the cases treated at a tertiary academic center and to evaluate patient outcomes with the available treatment modalities. th is was a single-institute retrospective observational cohort study of patients with neuroendocrine prostate cancer followed at e-da hospital, kaohsiung city, taiwan between january , and october , . patient and tumor data were analyzed using descriptive statistical methods. results: among prostate cancers, six patients were identifi ed with primary neuroendocrine prostate cancer, comprising from de novo mixed variety (scc and ad) and from transformed phenotype (pure scc). th e median age at diagnosis was . years. th e most common presenting symptoms were obstructive symptoms (weak stream, incomplete empty and urine retention). th e morphological appearance of the tumor cells and their immunohistochemical reactivity for neuroendocrine markers, and prostate specifi c antigen (psa) helped establish the diagnosis. overall median survival was months from diagnosis of neuroendocrine prostate cancer/ prostate small cell carcinoma. conclusion: primary neuroendocrine prostate cancer is characterized by an aggressive clinical course with relatively short lifespan. although high response rate to cytotoxic chemotherapy, overall prognosis is poor. as there is no standard of care for patients with neuroendocrine prostate cancer, further eff orts should be directed at its early detection and made to develop more eff ective therapeutic strategy. association th e mean duration for the side eff ect to occur was months (range - months), the mean duration between the onset of side eff ect and beginning of hbo therapy was months (range - months). th e patient with both hemorrhagic proctitis and cystitis completely recovered, and the remaining patients had improvement of side-eff ects. conclusion: hbo therapy can be a choice of treatment for radiation induced side-eff ects. a treatment trend of the prostate cancer in japanese provincial hospital introduction and objective: th e prostate cancer patients can choose various treatment options for cancer. however, the choice is limited by a diff erence in the scale and/or the location of each medical institution. we examined a treatment trend of the prostate cancer in our japanese provincial hospital. we evaluated patients who had a diagnosis of prostate cancer between and . th ey were classifi ed four groups, cases of the middle-aged generation (range - years old), cases of the early advanced-aged generation (range - ), cases of the middle advanced-aged generation (range - ) and cases of the latter advanced-aged generation (range -). we sorted each groups using the d' amico risk classifi cation system. in the middle-aged generation, patients, except for metastatic cases, underwent radical prostatectomy or radiotherapy. in the early advanced-aged generation, of low-very high risk group patients ( %) chose radical prostatectomy or radiotherapy. on the other hand, in the same generation, of intermediate risk group cases ( %) were treated with hormonal therapy. in the middle advanced-aged generation, only of low-very high risk group patients ( %) underwent radical prostatectomy or radiotherapy, which was fewer compared with the early advanced-aged generation. th at means, they oft en chose hormonal therapy. in the latter advanced-aged generation, all patients, except for cases, were treated with hormonal therapy. th e cases belong to the low-intermediate risk group, chose watchful waiting (psa monitoring). introduction and objective: robot-assisted radical prostatectomy (rarp) has emerged as an excellent treatment option for men with localised prostate cancer. as with other surgical treatment options, urinary incontinence remains a signifi cant side eff ect of the procedure and has been associated with weak pelvic fl oor muscle (pfm) strength. we aimed to assess pfm strength preand post-rarp, its relevance to incontinence and relevant predictors of poor outcomes post-op. we conducted a retrospective analysis of a prospectively collected database of men undergoing rarp by urologists over a -month period. each man had a pelvic fl oor strength assessment pre-operatively and at week and weeks post-operatively. pfm strength was recorded as strong (grade ), moderate (grade ) or weak (grade ). continence rates were recorded at weeks post-op, with continence defi ned as no requirement for pads or continence aids. basic demographic data and histological data were also collected. introduction and objective: urethral trauma is reported to occur in . % of patients undergoing catheterisation but, in practice, seems to be more common than this. we have investigated its incidence retrospectively and prospectively and have evaluated a new approach to catheterisation to reduce the incidence of catheter-related trauma and its consequences, which has led to the development of a novel urethral catheterisation device (ucd) produced by urethrotech™. a total of patients being catheterised for cardiac surgery were reviewed retrospectively and studied prospectively to determine the incidence of urethral trauma due to urethral catheterisation. one hundred similar patients were then studied prospectively to trial a ucd to see if it reduced the incidence of trauma. ( ) lavh ( ) myomectomy ( ) lap. ovarian cyst excision ( ) ( ) nephrectomy ( ) ileal ureter substitution ( ) ureterolithotomy ( ) angioembolization ( ) urs c d-j stent ( ) ureteroneocystostomy ( ) ureteroureterostomy ( ) . hospitalization ( notes. none had documented consent and none had been counselled about potential complications. one hundred and forty-six were successfully catheterised. four ( . %) required a suprapubic catheter for traumatic and unsuccessful urethral catheterisation. no other adverse events were recorded. seventy-four consecutive patients were studied prospectively aft er counselling and consenting. th e incidence of urethral trauma was out of ( . %). five had urethral or perineal pain and urethral bleeding ( . %) and ( . %) additionally required a suprapubic catheter. having developed a practice of passing a urethral catheter over a guide wire in patients undergoing reconstructive urethral surgery in our unit we subsequently trialled the urethrotech™ ucd for routine urethral catheterisation. th is ucd was used for catheterisation in consecutive patients without complications. we conclude that urethral catheterisation has a signifi cant risk of trauma -ten times the reported incidence -and to reduce that risk the catheter should be passed over a guide wire, as with the ure-throtech™ ucd, as is the practice for passing catheters and similar tubes into other anatomical structures. th is should particularly apply in high risk patients, such as those being catheterised for cardiac surgery who are about to be heparinised, and in higher risk circumstances such as when catheterisation is being performed by junior medical or nursing staff . results: mean age at the time of transplantation was . ± . years with male to female ratio of . : . etiology of esrd included renal parenchymal diseases ( %), o vesicoureteric refl ux ( %) and o vesicoureteric refl ux due to posterior urethral valve ( %), urolithiasis ( %) and neurogenic bladder ( %). pre-transplant bilateral nephroureterectomies were performed in patients, augmentation ileocystoplasty with mitrofanoff conduit in patients while posterior urethral valve fulguration in patients. mean serum creatinine post-transplantation was . mg/dl and . mg/dl at week and months respectively. surgical complications occurred only in two patients; one developed lymphocele while other presented with febrile uti due to ureteric refl ux in the early postoperative period and was managed by doing a new ureteral reimplantation. th e mean graft and patient survival rates at one year were % and % respectively. one patient lost her graft at months which was turned out case of hyperoxaluria. acute rejection was seen in ( %) patients. all of these were successfully reversed with pulse therapy. none of the patients developed cytomegalovirus (cmv) infections or lympho-proliferative disease. symptomatic urinary tract infections aft er transplantation occurred in ( %) patients including pyelonephritis in ( . %) patients. two of these patients with pyelonephritis had prior bladder augmentation. ureteric stenosis is a well recognised major urological complication of renal transplantation. following initial antegrade decompression, defi nitive treatment options include long-term ureteric stenting, endoscopic stricture dilatation/division or ureteric re-implantation. th ere is minimal current data in the literature to help guide patient choice. we aimed to characterise the outcomes following management of ureteric stenosis at a large european regional transplant centre. a retrospective cohort study was performed for all patients following renal transplantation who required treatment for ureteric stenosis between august and august . case identifi cation was via a prospectively maintained database on all renal transplant patients and international classifi cation of disease procedure codes. results: of renal transplants performed during the study time period, patients developed ureteric stenosis requiring intervention ( . %). eleven patients underwent initial open ureteric re-implantation, had endoscopic management and had longterm ureteric stents. mean length of time between elective stent changes was . months (range - months). one patient opted for open re-implantation aft er a period of stenting with a good outcome. one experienced graft failure due to non-compliance with immunosuppression, otherwise renal function was preserved. of the patients having open re-implantation only one experienced re-stenosis -managed with long-term ureteric stenting and . % had satisfactory renal function at follow-up. two patients received successful balloon dilatation and patient had upper tract stenosis managed with pyeloureteroplasty. all patients have experienced no decline in graft function since. endoscopic, open reconstruction and long-term stenting can all provide satisfactory outcomes for the majority of renal transplant patients aff ected by this problem. medium-term graft function was well preserved. in recent years approximately half of patients have proceeded to open re-implantation. surgical and clinical factors impact the choice of treatment. however, patient choice also plays a significant role. th is study has provided up to date information to aid counselling patients. further prospective study is warranted to assess what variables infl uence patient choice and cost effi ciency of open re-implantation versus long-term ureteric stenting. the angiogenic mechanisms of endothelial progenitor cells in kidney transplantation patients introduction and objective: th e blood fl ow blocking during kidney transplantation oft en results in renal ischemic injury. in this process, endothelial cells and endothelial progenitor cells (epcs) are activated to participate in angiogenesis. epcs and endothelial cells participate in angiogenesis and tissue repair through diff erent signaling pathway. prostaglandin e (pge ) is a kind of metabolites of arachidonic acid, and is a mediator of infl ammation and ischemia. pge took part in angiogenesis and epcs diff erentiation according to our previous study. in this study we will demonstrate the angiogenic function of epcs of kidney transplantation patients and reveal the molecular mechanisms of angiogenesis. materials and methods: epcs from peripheral blood aft er kidney transplantation were isolated by density-gradient centrifugation. facs was used to identify the epcs. th e aa metabolites pge in epcs cultured medium was measured by liquid chromatography-tandem mass spectrometry (lc-ms/ms). q-pcr and wb were used to detect the expression of endothelial markers in human umbilical vein endothelial cells (huvecs) cultured with epcs conditional medium. tube formation assay was performed to elucidate the angiogenic ability of huvecs. results: epcs from kidney transplantation expressed c-kit and cd by facs analysis. multiple types of aa metabolites was detected in the conditional medium by lc-ms/ms and pge was increased to more than -fold aft er kidney transplantation. huvecs cultured with conditional medium highly expressed cd and ve-cadherin and also formed more tubes compared with control. huvecs given pge had the same biological characteristics like the conditional culture. conclusion: pge paracrine of epcs from kidney transplantation enhanced the capacity of angiogenesis in huvecs. graft survival, proteinuria and kidney growth: challenges between pediatric and adult deceased kidney donation basiri a , , , zare s introduction and objective: th e presence of widening discrepancy between supply and demand of donor and recipient in the fi eld of renal transplantation, has led us to compare the graft and patient survivals, post transplantation complications, rate and severity of proteinuria secondary to hyperfi ltration injury and the kidney growth of recipients who underwent transplantation from pediatric (group ) and adult deceased donors (group ). each groups contains patients. outcome measures included, patient and graft survivals, quality of graft function as assessed by serum creatinine (scr) and estimated gfr (egfr), surgical complications, proteinuria that was detected by routine urinalysis and then confi rmed by a -h urine protein > mg, and kidney length that measured by early and following ultrasonography. results: th e mean donor age in groups and were . (range . to y/o) and ( to y/o) respectively. th e nine kidneys ( %) from pediatric donors (group ) were off ered en-block. mean follow-up was month (range to ). th ere were no statistical differences in the incidence of dgf between two groups ( % versus %) (p= . ). group had a slightly higher incidence of acute rejection than group ( versus %), but the diff erence was not statistically signifi cant (p= . ). one year's graft survival were similar between two groups ( % and %). serum cre-atinine (scr) and estimated gfr (egfr) th ere were no statistically diff erences between two groups ( . versus . mg/dl and versus cc/min respectively) (p= . ). th e incidences of surgical complications that required surgical intervention (urinary leakage, ureteral stenosis, lymphocele, vascular thrombosis) were similar in both groups ( versus %) (p= . ). development of proteinuria was not diff erent between two groups ( % versus %) (p= . ). early kidney length within one week was signifi cantly lower in group than in group ( ± mm versus ± mm) (p< . ), but the rate of increase of kidney length in group was signifi cantly greater than group ( ± mm versus ± mm) (p< . ) under follow-up period. conclusion: although in this study, median-term outcomes and complications of single and en-block kidney transplantation from pediatric donors are acceptable and same as those from older donors. but assessment of functional and hemodynamic adaptation of small pediatric kidneys in adult recipients and subsequent hyperfi ltration eff ects requires the study with more cases and greater follow-up periods. george a, singh c, devasia a introduction and objective: th e need for vascular access for hemodialysis (hd) increases with the increasing number of patients with end stage renal disease (esrd) requiring hd, with increasing life span, and with more available facilities especially in developing countries. when the usual accesses (radiocephalic and brachiocephalic) have been utilised or failed, a ptfe graft is usually considered. we present here a 'bridging' option of a basilic vein transposition, as a doable, cost eff ective procedure before av graft ing. patients with end stage renal disease were included. th ey all either had poor cephalic veins at the wrist and cubital fossa, or had previously used and failed fi stulae. anasthesia: regional block (local anaesthetic). technique: th e basilic vein was exposed using three small incisions: cm above cubital fossa, mid arm (medial aspect), and upper arm (medial aspect up to axilla). th e vein was completely freed off surrounding structures, tributaries tied, distal end ligated, patency ensured and vein delivered out of the uppermost incision. using a tunneller, the vein was rerouted subcutaneously, anteriorly to reach the cubital fossa incision. th e brachial artery was identifi ed and looped. arteriovenous anastomosis was done using 'o' prolene, continuous sutures. (images in the poster). results: out of a total of venous access surgeries done during the study period, seven basilic vein transpositions were done. all had pre-operative doppler evaluation to assess size and patency of veins. all fi stulae created were functional at the time of discharge. th e fi stula is used for hemodialysis at - weeks, when the fi stula matures (arterialization of the vein implying good/suffi cient fl ow for dialysis). one patient needed exploration for a venous thrombus, hours later, which was removed with a venotomy and th congress of the sociÉtÉ internationale d'urologie -siu abstract book using a fogarty catheter. subsequently with anticoagulation for hours, the fi stula continued to function and is being used for access. th e second patient had exploration on the th post-operative day for evacuating a subcutaneous hematoma. th e fi stula is patent and will be used once it has matured. five of the seven done were uneventful and are being used for hemodialysis access. conclusion: basilic vein transposition, is the preferred option of vascular access over a ptfe graft , as it is cost eff ective, autologous and doable under regional anaesthesia. retrospective results: a total of renal transplants have been performed since . th e transplants were performed via an extraperitoneal approach with a modifi ed lich-gregoir ureteric anastamosis in most cases. jj-stents were not routinely used. th irty two urological complications were noted in transplants ( %). th ere were boys and girls with ages ranging from . to . yrs (mean . ). th e most common complication was vesico-ureteric refl ux (vur) occurring in patients ( %). all those with vur presented with recurrent urinary tract infections and bladder dysfunction was present in % (none were augmented). vur was managed successfully with reimplant in six and submucosal injection of defl ux in three; eight patients were managed conservatively. post-operative urine leaks occurred in patients ( %) and were managed with reimplant in two, uretero-ureterostomy in one, jj-stent in one and conservatively in two. ureteric stenoses presented in patients ( %) with hydronephrosis and worsening renal function and were managed initially with either percutaneous nephrostomy or jj-stent placement. surgical management was performed in four patients (three reimplants and one uretero-ureterostomy); two patients were managed conservatively with transient jj-stent placement. th ree patients ( %) developed unexplained hydronephrosis -one with worsening renal function due to chronic rejection and two with stable renal function. loss of graft occurred in patients ( %) as a direct result of their urological complication. th ere were deaths -two due to chronic rejection and one due to overwhelming sepsis immediately post uretero-ureterostomy for ureteric stenosis. conclusion: urological complications following paediatric renal transplantation are common and can cause signifi cant morbidity and even mortality. vur was the most frequently observed and, if presenting with recurrent utis, can be managed successfully with surgery. other urological complications observed included urine leaks, ureteric stenoses and unexplained hydronephrosis. kidney transplantation in abnormal bladder: analysis of outcome kumar a, gulia a, chauhan u, sharma a, yadav r, dassi v introduction and objective: kidney transplantation in abnormal bladder is a challenging situation and associated with poor outcome. we have analyzed outcome of our data of last years. materials and methods: from to , patients who had abnormal bladder had undergone kidney tx. average age at the time of transplant was years. average age at bladder reconstruction was years. four patients had neurogenic bladder who were practicing cic, using native urethra and one had appendix as a mirofenof procedure. two patients had bilateral nephrectomy for grade vur and their lower ureters were used for augmentation and other two had ileocystoplasty. four patients of grade vur refl ux had subsequent transplant in the bladder. four patients with puv had bladder augmentation and mitrofenof procedure due to poor compliance. one child with puv had augmentation by stomach patch when he was year old. one patient had cystectomy in the past and ileal conduit reconstruction where transplant ureter was implanted. all patients had very trabeculated and thick bladder during ureteric reimplantations. all patients had extravesical ureteroneocystostomy with stents. urethral catheter was kept on average of days. no patients had any ureteric leak or stricture in postoperative period. all four patients with cic through native urethra had recurrent uti in the postoperative period and required long-term chemoprophylaxis. one patient who had ileocystoplasty before transplant, died due to sepsis just before his transplant. incidence of uti was % in this group. six patients also had pyelonephritis, which was controlled by injectable antibiotic. rejection rate was % in this group in fi rst month which was higher than our normal bladder group. average serum creatinine was . mg% at months and . mg% at year which was high than normal bladder population. average follow-up is . years where serum creatine was . mg%. mean hospital admission was . times. conclusion: kidney transplant in abnormal bladder is a good option but long-term results are inferior. recurrent uti and pyelonephritis are still a troublesome problem. various techniques and procedures are required to overcome these diffi cult situations. analysis of results: th e mean operative time, warm ischemia time and blood loos were minutes, . minutes. ml respectively. th ere were major complications including hemorrhage and injury to organs like bowel, spleen and pancreas. fourteen of these patients required exploration to control bleeding or repair. two patients were explored for adhesive obstruction. th ere were minor complications which were managed conservatively. one patient died in immediate postoperative period due to slippage of a single hemolock clip. all patients have adequate vascular and ureteric length. th ere were cases of multiple vessels. th ere were two urinary fi stulae and one ureteric obstruction. mild atn was noticed in patients. no graft was lost. hospital stay was . days. operative time has also come down to from minutes. th e average cost of the laparoscopic donor nephrectomy is us$ . conclusion: lap donor nephrectomy is a safe and minimally invasive procedure. it is a cost eff ective procedures even for the developing country. prostate carcinoma in solid organ transplant recipients tillou x , guleryuz k , bouvier n , belin a , chiche l , bensadoun h , doerfl er a introduction and objective: improvements in immunosuppression and anti-infection drugs in solid organ transplantation have led to a signifi cant survival increase for patients and graft s. prostate cancer (pc), being the most common tumor in men and given the increasing number of old male recipients, should show an increasing incidence in solid organ transplant recipients (sotr). th e aim of this study was to analyze retrospectively our liver (ltr), kidney (ktr) and cardiac transplant recipients (ctr) treated for a pc. between january and december , we found pc in male sotr ( %): pc in ltr, in ktr and in ctr. a ge at diagnosis was . ± . ( . - . ) years old and the interval from transplantation to diagnosis was . ± . ( . - . ) months. mean psa level was . ± . ( . - ) ng/ml. clinical stages were t , t and t in respectively , and patients. diagnosis was suspected during screening, because of prostatitis or bone pain in respectively , and patients. th ree pc were discovered aft er prostate transurethral resection. results: th irty-one patients ( ktr and ltr) with a localized disease underwent radical prostatectomy (rp). histological fi ndings were pt c and pt tumors, with positive surgical margins. gleason score (gs) was in case, in cases, in cases and in case. one patient with positive pelvic lymph nodes was given hormonotherapy. another had a biochemical recurrence at months and was treated with salvage radiotherapy. with a mean follow-up of . ± . ( . - . ) months, two ktr died from kp, and years aft er hormonotherapy and rp respectively. conclusions: prevalence of pc in sotr remains controversial, even though a signifi cant increase can be expected in the coming decades. it is therefore recommended to systematically screen male transplant recipients aft er years of age because outcome is much better if pc is diagnosed and treated early. radical prostatectomy is feasible in ktr as well as in ltr. conservative introduction and objective: conservative surgery results in the transplanted population remain unknown because they are only presented in small series or case reports. our objective was to study renal conservative surgery for kidney graft renal cell carcinomas (rcc) in a multicenter cohort. nephron sparing surgery (nss), radiofrequency ablation (rf) and cryoablation (ca) were studied. iiib) . none of the patients treated by radiofrequency ablation or cryoablation had complications. th e mean time of follow-up was . months ( . - ). fift y-nine ( . %) patients had a functional kidney graft , without dialysis and no long-term complications. specifi c survival was % at the last time of follow-up. conclusion: nss has proven its effi ciency for treatment of small tumors of transplanted kidneys with good long-term functional and oncological outcomes, which prevent patients from returning to dialysis. cryoablation and radiofrequency ablation seem to be alternative therapies that can be chosen with good results, in selected patients. ureteric implantation into introduction and objective: conventional technique recommends ureteric anastomosis to the bladder during kidney transplantation in patients with bladder augmentation. we report our experience of kidney transplantation in augmented bladders with the transplant ureter implanted into the bowel portion of the cystoplasty. a total of patients (mean age, . years (range - years), female, deceased donors) with augmented cystoplasty and subsequent kidney transplantation by a single surgeon between and was reviewed. following standard arterial and venous anastomosis and reperfusion of the transplanted kidney, ureteric implantation involved continuous pds / anastomosis between the spatulated ureter and full thickness bowel portion of the cystoplasty over a size fr dj stent. a second layer of bowel plication was performed around the anastomosis to prevent refl ux using interrupted / vicryl sutures. chart review was performed to evaluate the short-term urological and kidney function outcomes. results: th e cause of renal failure was bilateral vesicoureteric refl ux in patients, posterior urethral valve with refl ux nephropathy in patients, tuberculosis of the urinary tract with infl ammatory ureteric stricture in patient, and lumbosacral agenesis with neurogenic bladder in patient. bladder reconstruction was performed at a median duration of months ( - months) before transplantation. gastrocystoplasty was performed in patients, while the colon and/or ileum were used in the remaining patients. all reconstructed bladders except had a mitrofanoff created for clean intermittent self-catheter drainage aft er transplantation between to x / day. aft er surgery, th e dose fi nding study, toxicokinetics of human bone marrow-derived mesenchymal stem cells, and study deciding timing and number of cell injection were conducted in order. results: from the dose fi nding study, × was selected as dose per an injection of human bone marrow-derived mesenchymal stem cells. from the toxicokinetics of human bone marrow-derived mesenchymal stem cells, days was selected as interval between repeat treatments. in the third study, the ratio of maximal intracavernous pressure to mean arterial pressure was signifi cantly lower in the control group than in the sham group ( . % vs. . %, p< . ). immediate single injection of human bone marrow-derived mesenchymal stem cells ( . %, p= . ) signifi cantly improved erectile function compared to that in the control group, whereas delayed single injection ( . %, p= . ) showed marginally signifi cant improvement. all histomorphometric changes were signifi cantly improved in the up. , figure . immediate or delayed single injection groups than in the control group. repeat treatments did not provide any incremental eff ect on recovery of erectile function and histomorphometric changes. conclusion: intracavernous injection of × human bone marrow-derived mesenchymal stem cells results in recovery of penile erection along with histomorphometric changes in a rat model of cavernous nerve injury, even when treatment was delayed by weeks following cavernous nerve injury. any incremental eff ect aff orded by repeat treatments remains to be undefi ned. relationship between metabolic syndrome, erectile dysfunction and hypogonadism abou farha m, el-abd s, el-gharbawy m, abou farha o introduction and objective: a strong association between erectile dysfunction (ed) and metabolic syndrome (ms) and hypogonadism was determined. aim of the work: to investigate the relationship between (ms), (ed) and the incidence of hypogonadism. th e correlation between hypogonadism and the metabolic risk factors was also determined. a total of patients with ed were included in the study, patients meet the criteria of ms were estimated. ed was classifi ed based on iief- domain score and the relation between severity of symptoms and the number of metabolic risk factors was determined. th e incidence of hypogonadism in ms patients was determined and the correlation between hypogonadism and metabolic risk factors was identifi ed. introduction and objective: peyronie's disease (pd) is a fi brotic disorder aff ecting the tunica albuginea of the corpora cavernosa. erectile dysfunction (ed) due to pd may be secondary to the penile deformity and the resultant changes in the hemodynamic parameters. th e aim of this study is to defi ne color doppler duplex ultrasound (cddu) characteristics in pd, with specifi c attention to describing the presence and etiology of ed in these patients. introduction and objective: th e cause of peyronie's disease (pd) is unknown. th e most accepted causative theory is trauma to tunica albuginea. because prevalence varies ( . - %), the potential for contributory cofactors have been proposed. we hypothesized that metabolic syndrome and other comorbidities may be found at higher rates in pd. retrospective chart review of patients presenting to a men's health clinic with a variety of complaints: erectile dysfunction (ed), premature ejaculation (pe), premarital checkup, small penis, decreased libido, lower urinary tract symptoms (luts) were screened for pd. variables collected: presence/absence of diabetes mellitus (dm), hypertension(htn), dyslipidemia (dl), body mass index (bmi), total testosterone (t), penile peak systolic velocity (psv) and end diastolic volume (edv), smoking, and glycosolated hemoglobin level (a c) in patients with dm. results: a total of patients, with a mean age of years (range - ) were analyzed. pd incidence ranged widely within individual clinics ( - %, average %). hypertension, bmi, t level, total number of comorbidities, low psv, abnormal edv, and mean a c were not associated with the presence of pd. th congress of the sociÉtÉ internationale d'urologie -siu abstract book diabetes was associated with pd (p= . ) and dm patients had a % higher incidence. patients with the highest a c levels (> . ) had an increased incidence of pd [or . (p= . , ci . - . )]. increased age was correlated with pd (p= . ); for each year of life, the likelihood increases by an or of . (~ % per year) (p= . , ci . - . ). dyslipidemia (p= . ) and smoking (p= . ) were associated with - % lower incidences of pd. conclusion: peyronies disease is found in about % of patients seen for other complaints. diabetes, particularly poorly controlled diabetes, is associated with an increased incidence. several other clinical factors appeared noncontributory. a decreased incidence of pd in smokers and patients with dyslipidemia is seen, but does not necessarily refl ect a protective role, but likely increased levels of erectile dysfunction in these groups--patients with inability to achieve erection are unlikely to complain of peyronies' disease. further research into the interaction of pd and dm are warranted. kim j, park j, chae j, oh m, park h, kim j, moon d introduction and objective: limited data are available concerning sexual behavior of korean men. th is study aimed to perform the national sex survey and to collect the basic data for establishment of the prevention strategies of sexually transmitted infections (stis) and hiv/aids. th is is a national survey performed on a sample of , individuals ( , men and , women) aged - years old. th e online surveys were carried out on a national scale in south korea. subjects were randomly selected from resident registration. a structured questionnaire was developed which elicited information concerning: demographic information, information on their sexual behavior, sexual identity, prostitution, experience of stis, and experience of sex education. results: th e majority of the subjects were either married or living with a partner. mean number of sexual intercourse is . ± . times a month. mean sexual satisfaction score using visual analog scale is . ± . . eighty-four percent had a fi xed sex partner; . % ( . % of men; . % of women) had experience through a speed dating or prostitution; . % of men and . % of women were sexually attracted to the same gender only, . % of men and . % of women were sexually attracted to both gender; . % of participants had the experience of the stis. only . % of the respondents had received sex education in the past year. we performed the national sex survey according to the nationwide distribution of population. it would be useful for establishment of the prevention strategies of stis and hiv/aids. to control stis and hiv/aids, powerful policies containing sex education and medical services will be needed. the introduction and objective: erectile function evaluated by international index of erectile function- (iief- ) tends to decrease in aging, obesity and hypogonadism, but the importance of body composition is unclear. in the present study, we evaluated associations between iief- , body composition and testosterone level (tt) in middle-aged men. design was a population-based cross-sectional study in middle-aged men. between march and september , police officers aged - years who had participated in a health examination were included. total , men underwent a detailed clinical evaluation using the validated international index of erectile function- (iief- ) questionnaires and body composition (measured by bioelectrical impedance analysis). weight, body mass index (bmi), waist-hip ratio (whr), and serum testosterone level were also established. results: data from men were analyzed. th e median age was . years, and median value of iief- score was . th e iief- score was inversely associated with age, whr, and body fat percentage (bfp) (r=- . ; p< . , r=- . ; p< . , r=- . ; p= . , respectively), and positively associated with body muscle percentage (bmp) and body skeletal muscle percentage (bsp) (r=- . ; p= . , r=- . ; p= . , respectively). testosterone level had no correlation with iief- score (p= . ). using logistic regression analyses, age, whr, bfp, and bsp predict moderate to severe erectile dysfunction (ed) in univariate analysis. age, whr, and bfp were independent predictive factors for moderate to severe ed in multivariate analysis (p< . , or . , % ci . - . ; p= . , or . , % ci . - . ; p= . , or . , % ci . - . , respectively). our data showed that erectile function in middle-aged men was closely associated with whr and bfp than with testosterone level and body muscle percentage. however, whr was identifi ed as a negative predictive factor for ed. further studies for the unique form of obesity pattern in korean men will be needed. in order to estimate the magnitude and outline the main components of adult male genital organs "dysmorphophobia" in greece, we surveyed the beliefs of men about parameters potentially aff ecting their sexual performance and activity as they relate with self-perceptions regarding adequacy of their external genitalia image. herein, we present preliminary results of this questionnaire based cross-sectional study. a specially designed self-administered questionnaire, consisting of demographic characteristics and main outcome measure questions aiming at defi ning whether and how beliefs regarding men's sexual image adequacy aff ect their sexual confi dence and function (answers scored - ), was fi lled in by males (aged - ) who consulted a single urology clinical setting, for symptoms unrelated to genital area pathology. statistical analysis was performed using spss- , p< . . results: th e majority of subjects ( . %) were highly satisfi ed of their sex organs image, while only one in seven ( . %) reported moderate to low levels of satisfaction. small penile size in the fl accid state was the most frequent ( . %) complaint followed by small erect penis dimensions ( %). in one out of two men ( . %), sex image inadequacy impression was based on self-assessment, in . % on sexual partner comments and in only . % on expert medical examination. nine out of ten men ( . %) considered external genitalia appearance the most signifi cant determinant of a man's sexual confi dence with . % believing they strongly fulfi l this requirement, while most of them ( . %) were highly satisfi ed with their whole body image. in only one in ten men ( . %) the impression of the sexual partner regarding sex image aff ects signifi cantly his sexual performance. most men ( . %) argued against resorting to surgical techniques to improve their sex image, % considered this option imperative for their well-being, while one in four ( . %) would consider surgery if a spectacular cosmetic result was guaranteed. various statistically signifi cant correlations between demographic and main outcome measures variables were recorded. conclusions: symptoms of genital organs dysmorphophobia, are expressed by one in seven men of the general population, in most cases complaints focus mainly at small penile size, while most frequently impression of inadequate sex image originates from self-assessment and negative sexual partner's comments. th e majority of men consider genital image a strong determining factor for sexual performance, while very few experience sexual relationships difficulties due to feelings of genital inadequacy. only a small minority of men would be strongly willing to undergo external genitalia surgery, which they consider imperative treatment for sexual image inadequacy. abou farha m, el-abd s, el-gharbawy m, abou farha o introduction and objective: metabolic syndrome is a public health problem associated with increased incidence of erectile dysfunction (ed). erectile dysfunction in patients with metabolic syndrome is diffi cult introduction and objective: erectile dysfunction (ed) and lower urinary tract symptom/ benign prostatic hyperplasia (luts/bph) has common pathophysiology. and phosphodiesterase type inhibitor (pde -i) partially reverses the prostatic tissue contraction, and increases cyclic guanosine monophos- phate to show antiproliferative eff ects in the prostatic smooth muscle cells and consequently, voiding symptoms were suggested to be improved. however, there was no defi nite mechanism of the eff ectiveness of pde -i on luts/bph. some previous study has reported the hypothesis which is pde -i improve the blood fl ow rate of prostate and it may improve the luts. in present study, by transrectal ultrasonography (trus), evaluated the change of blood fl ow rate of prostate aft er pde -i administration. materials and methods: total patients were included in this study. among enrolled patients, patients had once daily administrated mirodenafi l (mvix®, sk chemical, korea) mg for week, other patients had administrated placebo daily. peak systolic velocity (psv) and end diastolic velocity (edv) were estimated by trus at before medication and a day aft er last administration. results: baseline characteristics were no signifi cant diff erence between two groups. in mirodenafi l group showed . cm/sec increase of psv and placebo group showed . cm/sec increase of psv (p= . ). moreover, mirodenafi l group showed . cm/sec increase of edv and placebo group showed . cm/sec decrease of edv (p= . ). once daily administration of mirodenafi l mg showed improvement of blood fl ow rate of prostate. factors predicting outcomes of penile rehabilitation with udenafi l mg following radical prostatectomy introduction and objective: udenafi l is a selective phosphodiesterase type inhibitor (pde i) made available in recent years for the treatment of erectile dysfunction (ed). penile rehabilitation using pde is following radical prostatectomy (rp) has been advocated; however, there are no previous reports on the role of udenafi l for potency recovery aft er rp. herein, we evaluated independent predictors of potency recovery in rp patients who underwent penile rehabilitation with udenafi l mg. between january and december , a total of patients underwent rp at a single institute. among them, men were enrolled in a penile rehabilitation program using udenafi l mg every other day. uni-and multivariable cox regression analyses were used to determine independent predictive factors for potency recovery. results: th e overall potency rate was . % during the mean follow-up of . months. on the multivariate cox analyses, preoperative international index of erectile function (iief)- scores (hazard ratio [hr], . ; p = . ), alcohol consumption (hr, . ; p = . ), and gleason biopsy score (hr, . ; p = . ) were independent preoperative predictors for potency recovery. among post-rp variables, the use of robotic procedures (hr, . ; p = . ) and pathologic stage (hr, . ; p = . ) were significantly associated with potency recovery. conclusion: th is study identifi ed predictive factors for the recovery of potency in patients undergoing penile rehabilitation with udenafi l following rp. our results provide physicians with useful information for counseling rp patients and selecting optimal candidates for penile rehabilitation. introduction and objective: androgen replacement therapy (art) effi cacy on late-onset hypogonadism (loh) has been widely investigated in western countries; however, it remains controversial whether art can improve health and prolong active lifestyles. we prospectively assessed long-term art eff ects on the physical and mental statuses of aging men with loh in japan. of volunteers eligible patients > years with loh were randomly assigned to either the art (n= ) or the control groups (n= ). art was conducted with intramuscular injection of testosterone enanthate mg each time every four weeks up to times. th e primary endpoint was health-related quality of life assessed by questionnaires. secondary endpoints included glycemic control, lipid parameters, blood pressure, waist circumference, body mass index (bmi), body composition, muscular strength, bone mineral density (bmd), international prostate symptom scores (ipss), international index of erectile function (iief)- scores, and serum prostate-specifi c antigen levels. th e safety and tolerability of long-term art were also examined in these populations. results: fift y-two weeks aft er the initial treatment, art signifi cantly aff ected the role physical subdomain of the short form- health survey (sf- ) scale (p = . ). art was also associated with signifi cant decreases in waist circumstance (p = . ) and serum triglyceride (tg) (p = . ) and with signifi cant increases in whole-body and leg muscle mass volumes (p = . and . , respectively), serum hemoglobin (p < . ), ipss voiding subscore (p = . ), and the second question on iief- (p = . ). th ere was no signifi cant deference between the groups in terms of bmi, bmd, isometric handgrip strength, serum fasting blood sugar and hemoglobin a c, serum psa, and the incidence of sever adverse events. conclusion: long-term art for patients with loh have the benefi cial eff ects on role physical subdomain of the sf- scale, serum tg, waist circumstance, muscle mass volume, voiding subscore of ipss, and the second question of iief- . we hope our study will contribute to the future development of this area. introduction and objective: hyperoxaluria is characterised by a high urinary oxalate level. super-saturation of urine with oxalate will lead to nucleation, aggregation and the formation of calcium oxalate crystals leading to renal calculi. patients with hyperoxaluria are at increased risk of recurrent urolithiasis. objectives: to analysis the interventions and outcomes of new patients with enteric and dietary hyperoxaluria referred to a metabolic stone clinic. an analysis of patients with hyperoxaluria was performed. data examined included; age, sex, metabolic abnormalities, malabsorptive syndromes, previous treatments, stone composition, medical and life style interventions. all patients had or more hr collections of urine performed at median of months apart. twenty-four-month follow-up was performed to assess need of further stone treatment. results: a total of patients were identifi ed for study. twenty-fi ve were male, were female. th e median age is years, iqr ( - ). first median urinary oxalate level is . mm, iqr ( . - . ). patients that reduced their oxalate intake and increased their fl uid intake were signifi cantly less likely to need further long-term stone treatment. th e arr of increased urinary output and decreased urinary oxalate on the need for further stone surgery is th congress of the sociÉtÉ internationale d'urologie -siu abstract book . %, ci (- . - . ) . th e rrr for the need of stone surgery is . %, ci (- . - . ) . th e nnt to prevent one patient needed further stone treatment is . , ci ( . -- . ) . conclusion: hyperoxaluria is important cause of recurrent stone formation that requires management in a dedicated metabolic stone clinic. compliance with fl uid, dietary and medical management is limited. in compliant patients, urine parameters and stone recurrence rates can be altered. clinical using specifi c diagnosis codes from billing data, patients were identifi ed that met criteria for urosepsis secondary to an obstructive ureteral calculi. data was analyzed in the following areas: demographics, admitting hospital of origin, duration of admission before transfer, need for higher level of care, need for invasive procedures, and length of hospital stay. results: using the screening criteria patients were identifi ed. th e average age was ; % were female versus % male. patients transferred from an outside hospital made up % of the patients and overall hospital admission lasted . days. of the patients transferred % went to the icu for an average duration of . days. of the transferred patients % needed vasopressor/ionotropic therapy, and % required intubation. overall, over % needed urologic intervention; % had ureteral stent placement and % underwent nephrostomy tube placement. patients admitted from the ed made up % of the patients and had an average admission of . days. of these patients % went to the icu for an average of . days. only % and % needed vasopressor/ionotropic therapy and intubation respectively. also, % had ureteral stent placement and only % had a nephrostomy tube placed. conclusion: urospesis in the setting of an obstructive ureteral stone is a medical emergency that merits urgent relief of the obstruction. once this condition is identifi ed, any facility without the resources for prompt intervention should transfer these patients immediately to a center with these capabilities. th is is supported by our data, as transferred patients on average had a longer icu and hospital stay, and needed more aggressive interventions. clinical signifi cance of ureteral wall thickness adjacent to the stone in abdomen-pelvis ct in the patients treated with extracorporeal shock wave lithotripsy park m, yeo j, cho d introduction and objective: although, ivp was standard diagnostic tool for years, the use of abdomen-pelvis ct (apct) without contrast, particularly in an acute setting, is becoming increasingly common. th is study was planned to know the clinical signifi cance of ureteral wall thickness adjacent to the stone in apct in the patients treated with extracorporeal shock wave lithotripsy (eswl). : th e data of patients who took ap-ct to diagnose ureter stone and were treated with eswl was reviewed. aft er maximum zoom of the ap-ct image showing the longest diameter of stone, the ureteral wall thickness adjacent to the stone was measured by same physician. th e baseline characteristics of patients, the parameters related to ureter stone and effi cacy of eswl were investigated. th e correlation between ureteral wall thickness and those parameters was statistically analyzed. th en, the patients were divided into two groups by the median value of ureteral wall thickness and the diff erence of those parameters between two groups was also investigated. additionally, cut-off value of ureteral wall thickness contributing to the diff erence in the effi cacy of eswl was determined. in simple correlation analysis, bmi, stone length at kub, stone diameter in ct, number of eswl, and time to stone removal showed signifi cant positive correlation with ureteral wall thickness. th e median value of ureteral wall thickness was . mm and the patients were divided into two groups. in comparison of baseline characteristics between two groups, group ii showed more incidence of pyuria than group i and stone burden at kub and ct also showed statistical diff erence between two groups. in comparison of effi cacy of eswl, group ii showed more number of eswl and longer time to stone removal than group i. th e cut off value of ureteral wall thickness contributing to the diff erence in the effi cacy of eswl was . mm. conclusions: in addition to actual size of stone, ureteral wall thickness of ct also aff ects the treatment effi cacy of eswl. especially, the ureteral wall thickness greater than . mm has an impact on the results of the eswl. the introduction and objective: th e treatment of large volume bladder stones by current equipment continues to be a management problem in both developing and developed countries. ah- stone removal system (srs) invented by us is primarily used to crush and retrieve bladder stones. th is study evaluated the safety and effi ciency of transurethral cystolitholapaxy with srs to treat the large volume bladder stone. materials and methods: srs, which was invented by aihua li in , composed by endoscope, continuous-fl ow component, a jaw for stone handling and retrieving, lithotripsy tube, handle, inner sheath and outer sheath. a total of patients with bladder stones were performed by transurethral cystolitholapaxy with srs since . th ese patients were divided into four groups by the stone size. fift y nine patients with stone size < cm were in group a, patients with stone size from to . cm were in group b, patients with stone size from to . cm were in group c, and patients with stone size ≥ cm were in group d and the largest stone was . cm. results: characteristics of patients and stone removal time in variable size were evaluated. to patients with single stone, stone size was . ± . cm and the operating time was . ± . min in group a. stone introduction and objective: eswl has emerged as a primary modality of treatment for solitary renal calculi in modern era. th e size of calculus is a major factor for consideration before subjecting a patient to eswl procedure. stone size less than two centimetre is considered ideal for eswl. other factors like obesity, position of calculus, renal infundibular anatomy and stone composition etc. also determine clearance rates. given a choice patients in india still prefer one time clearance by pcnl than multiple eswl sittings for similar sized calculus. our study reiterates the benefi ts of eswl in developing world with multivariate data supporting it. th e objective of this study was to evaluate the feasibility and safety of minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy for upper urethral calculus aft er radical cystectomy urinary diversion. a total of patients underwent minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy from january to august . th ere were cases that were diagnosed urinary stones aft er bricker urinary diversion of radical cystectomy, case of studer orthotopic ileal neobladder, and case of cutaneous ureterostomy. th ere were cases with left side calculi and cases with right side ones, including renal calculus, ureteral calculus and ureterointestinal anastomotic calculus. th e upper urethral calculi were identifi ed by urinary tract ultrasound and the multiplanar ct. all of cases underwent minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy. th e ureteral stent was indwelled for weeks routinely. th e kidney ureter and bladder x-ray or a ct scan was examined weeks aft er the procedure to evaluate the clinical outcomes. any residual calculus larger than mm was taken as signifi cant. results: th e combined lithotripsy was carried out successfully in all the cases. th e mean operative time was ( ± . ) min. th e nephrostomic catheter was removed days aft er the surgery. th e average blood loss was less than ml. no residual calculus was found during the weeks' follow-up. th e average follow-up was months. one case had recurrent calculus months aft er the fi rst procedure, which was successfully managed by the fl exible ureteroscopy again. minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy for upper urethral calculus secondary to urinary diversion aft er radical cystectomy is technically feasible introduction and objective: th e main goal of any intervention for urolithiasis is complete stone removal in order to achieve a stone free status. complete stone removal assures resolution of the immediate adverse outcomes of the stone disease, and prevents possible long-term complications such as pain, obstruction and stone growth. percutaneous nephrolithotomy is an eff ective procedure which is being considered as the gold standard in the treatment of large/complex renal calculi. reported stone free rates are up to %, probably refl ecting the level of experience, stone properties and equipment employed in the procedure. it is well established that higher incidence of residual fragments increases the complication rates and needs further interventions. th e main reason for failure of complete radiolucent stone clearance is inability to visualize the residual stones either by nephroscope or by fl uoroscopy. th e use of intraoperative ultrasound for assessment of residual radiolucent stones during percutaneous nephrolithotomy, will help to increase stone free rate. materials and methods: between sept. and sept. intraoperative ultrasound was used in cases of large complex radiolucent renal stones. results: it showed stone free rate % in patients, false negative in patients ( %) and there was diffi cult scanning in patients ( %). conclusions: th e use of intraoperative ultrasound for assessment of residual radiolucent stones during percutaneous nephrolithotomy, it will help to increase stone free rate. intravenous acetaminophen decreases sedation requirements during extracorporeal shockwave lithotripsy conclusion: th ere is benefi t in pre-operative administration of intravenous acetaminophen in reducing the dose requirements of sedative analgesic for satisfactory pain control during the procedure of swl under conscious sedation. introduction and objective: while most of the bleeding associated with pcnl can be managed conservatively, few need angioembolisation. th ere are diff erent technical methods of embolisation with risk of varying degree of parenchymal damage. we present case of ultrasonography guided embolisation. materials and methods: right lower calyx pcnl was performed successfully in year female with mm renal stone in solitary kidney. she came back on th postoperative day with gross hematuria, with cm by cm clot in renal pelvis and mm arterio-venous fi stula at pcnl puncture site. patient was managed with iv higher antibiotics, strict bed rest, blood transfusion and iv tranexamic acid. but her renal function deteriorated (creatinine- . mg/dl). one haemodialysis was done and patient was explored by sub costal approach, with idea of removal of blood clots and suture ligation of av fi stula. renal pelvis was opened and clots were removed. during operation av fi stula was located with doppler usg and deep suture by - vicryl was attempted to close av fi stula, but due to oedematous kidney suture closure was not possible. so under usg guidance gauze lumber puncture needle was inserted into av fi stula, its position was confi rmed by saline jet on real time usg and cc histoacryl tissue adhesive (monomeric n-butyl- -cyanoacrylate) was injected into av fi stula. intraoperative embolisation of av fi stula was confi rmed by colour doppler. results: renal functions became normal in hours and patient was discharged on th postoperative day. aft er days ivp was done which demonstrated normally excreting whole kidney, showing successful superselective embolisation in solitary kidney. conclusions: usg guided procedure avoids the side eff ects of contrast media in case of acute renal failure. it avoids hazards of radiation and complications of angiographic catheterisation. th e main importance of this procedure is preserving maximum renal tissue, especially in case of renal insuffi ciency and in solitary kidney. th is procedure gives a new vision to do percutaneous usg guided embolisation by thin gauze needle without need of angiography, iv contrast, radiation and minimum morbidity. ultrasound th ree pregnant women in the th, th and th week of pregnancy presented with a symptomatic large renal stone in the fi rst and multiple renal stones in the second and third which were unresponsive to conventional medical therapy. th ey required defi nitive stone treatment. th e operations were done in nov , jun and feb . data was gathered prospectively. all steps of gaining access to the pyelocalyceal system including needle insertion, tract dilation, and amplatz sheath placement were performed under ultrasonography guidance. tract was dilated with single shot technique. th e fi rst two procedures were performed in supine position and the third procedure was performed in lateral fl ank position. results: two patients were stone-free postoperatively and one patient had only an asymptomatic mm residual stone. th ey were discharged on the nd postoperative day and had an uneventful postoperative course. no fever, bleeding or renal colic was noticed during postoperative hospitalization. th e fi rst two patients delivered their fetuses at term without any abnormality reported by the examining pediatric specialist aft er their birth. th e third patient was followed until week of pregnancy without any obstetric complication. conclusion: ultrasonography can be used as an imaging modality guiding all steps of obtaining percutaneous access in pregnant women. supine or fl ank ultrasound guided percutaneous nephrolithotomy can be off ered to pregnant women in whom conservative measures fail to the patient's well-being. introduction and objective: acute ureteral obstruction in pregnancy may result in severe pain, hematuria and serious complications like upper urinary track infection with consecutive sepsis. th e ureteral stenting has been usual in recent years. we evaluated the usefulness of ureteral stenting for ureteral obstruction with symptoms in pregnancy. fift y-three pregnant women participated in this study. abdominal ultrasonography, serum creatinine levels, white blood cell (wbc) counts, urinalysis and urine culture were done in all patients. of these pregnant women, women were treated by ureteral stenting because of not improving with conservative management (positioning, analgesia, antibiotics, etc.). th ey were completely followed-up to removal of ureteral stent. results: of these pregnant women, women who were treated by ureteral stenting, experienced signifi cant relief of pain at least for days. in abdominal ultrasound, patients ( %) had resolution of hydronephrosis. twelve of patients ( %) continued to have problems post-therapeutically irritative voiding symptoms with dysuria, urgency, frequency, and hematuria, but patients experienced relief of symptoms for days. a patient was taken remove of stent due to continuous complaint irritative voiding symptoms. aft er delivery, patients were taken ivp. of patients, were normal fi nding with ivp. four patients were diagnosed ureter stone (upper , mid , lower ). th ree patients were treated by extracoporeal shock-wave lithotripsy for the stone in upper and lower urinary tract. a patient was treated ureteroscopic lithotripsy. conclusions: since the ureteral stents were usually placed without any major problems and well tolerated with only minor and short post-therapeutic discomfort. we concluded that the ureteral stenting was a simple, safe and eff ective method of internal upper tract drainage in case of symptomatic ureteral obstruction during pregnancy. safety introduction and objective: to evaluate objective and subjective outcomes of retrograde intrarenal surgery (rirs) for the treatment of radiopaque - mm renal calculi. a retrospective analysis was performed for patients who underwent rirs to treat renal calculi sized with - mm between april and december . operative and postoperative data were collected for each patient such as stone burden, stone location, number of sessions, and auxiliary procedures. th e term of follow-up was one year at least. surgery was usually performed under general anaesthesia. flexible ureteroscopy with ureteral access sheath and holmium-yag laser were employed. patients were evaluated with simple radiography, abdominal ultrasonography, or ct without contrast. surgery success was determined as stone free rate (sfr) at three months aft er last session. re-treatment rates were also calculated. results: mean age was . ± . years old. th e highest-frequency location was pelvis ( %). single stones were described in % of patients although multiple urolithiasis were detected in the %, mainly located in the lower calyceal. average surgery time was . ± . min. th e auxiliary procedure rate and the re-treatment rate were . % and . %, respectively. th e overall sfr and sfr aft er a single session were . % and . %, respectively. although no serious complications were noted in all of patients (above clavien-dindo classifi cation level iii), clavien level i to ii complications were identifi ed in two-patients ( . %). all these patients were successfully treated conservatively. conclusion: our fi nding suggest that rirs represents a valuable treatment option of - mm radiopaque renal calculi for selected patients. rirs would be also a good therapeutic alternative to extracorporeal shock wave lithotripsy (eswl) and percutaneous nephrolithotomy (pnl). rirs should be considered as fi rst line treatment. prospective analysis is required to be corroborated these fi ndings. ureteroscopic lithotripsy for extremely old patients yoshioka t , uehara s , otsuki h , shimizu t , murao w , fujio k , kikuchi h , fujio k , wada k , araki m , ebara s , watanabe t , nasu y introduction and objective: one of the biggest problems in st century is an aging society. in , the number of old people (≥ years old) in japan was , , . th at is about % of all japanese population. japanese society is becoming not an "aging" society, but an "aged" society, and we have to prepare for this society. on the other hand, upper urinary stone is a common disease, and oft en occurs not only young people but also aged people. however, there are no standard treatments for aged patients of upper urinary stones, especially extremely old patients who are more than years old. in this study, we investigate the safety and effi cacy of ureteroscopic lithotripsy of upper urinary calculi for these patients. between january and october , ureteroscopic lithotripsy (urs) underwent in abiko toho hospital. of these cases, cases are for the extremely old patients (≥ years old). we retrospectively reviewed gender, age, body mass index (bmi), american society of anesthesiology (asa) physical score, stone size, reasons for operation (whether symptomatic or not), operative duration, and stone free rate (sfr) of all cases. all data were reviewed by one urologist, and asa physical scores were evaluated by one anesthesiologist. results: all cases were bedridden female. mean age was . (range to ), bmi was . kg/ m^ (range . to . ), asa physical score was . (range to ). cases had preoperative complicated pyelonephritis, and out of these cases were indwelled preoperative unilateral ureteral catheters. mean stone size was . mm (range . to . ), and operative duration was . minutes (range to ). postoperative complication was pyelonephritis (clavien grade ), and sfr was % ( / cases). in all cases, postoperative unilateral ureteral catheters were indwelled, and were withdrawn weeks later. th ere have been no recurrent stones and/or pyelonephritis (median observation time: . months). conclusion: although sfr was low, urs for extremely old patients can prevent recurrent complicated pyelonephritis even on infected stones. th ere were . % of patients who had a single urinary stone and . % (n = ) had or more. one hundred and nine stones were treated. sixty-three percent of stones were intrarenal. th ere were ( . %) postoperative complications: two stage clavien classifi cation infections (prostatitis at day and two pyelonephritis hours aft er the procedure); three stage b complications (two renal colics requiring ureteral stenting hours aft er discharge and symptomatic perirenal urinoma hours aft er discharge). th ere was one intraoperative complication ( . %): a ureteral wound with contrast leakage. th e rate of transfer to conventional hospitalization was . %. stone size infl uenced the stone-free status and the need for more than one sessions (p < . ). th ere was a signifi cant correlation between operative time and stone size above mm (p= . ). conclusions: flexible and rigid ureteroscopy are safe and effi cient procedures for upper urinary tract stones, and can easily be carried out in an outpatient introduction and objective: renal stone disease is one of commonest urological disorders. pakistan is located in stone belt region with high incidence of urolithiasis. th ere have been innovations and improvement in stone treatment modalities. eswl is one of them. here we share experience of single centre in terms of stone free rate and effi cacy in adults. a retrospective study in which we included adults (age above years old) who underwent eswl from january to december . eswl was done by standard technique. we used modulith sl x lithotripter th generation storz medical. number of shocks per session for kidney and for ureter. energy level for kidney is set at and for ureter at . rate of shock wave delivery is shocks/minute. we followed patients for to months aft er last eswl session done. stone free status was defi ned as residual stone not more than mm in size. we reviewed data charts of patients for diff erent variables mentioned in results. introduction and objective: yolk-sac tumor (yst) is formed almost % germ cell tumors of infant and children. yst is the most common type of testis tumors in prepubertal period, but adult pure yst is extremely rare. in this case we aim to share our surgical experience with an adult pure yst in the right testis. a year-old man was referred to our clinic from cardiovascular surgery department for right testicular mass which is detected during the evaluation of his deep vein thrombosis. th e patient stated having a slowly progressive increase in size of his right gonad. th ere is no history about testicular trauma or epididymoorchitis. physical examination revealed a painful right testis which was uniformly increased in size and presented a smooth surface. usg showed a volumetric increase in the right testis. mass size was detected as . x . x cm, which was characterized by cystic components in heterogeneous echogenicity. serum chemistry revealed a marked increase in afp while β-hcg and ldh levels were within the normal limits. results: a right radical inguinal orchiectomy was performed. during the orchiectomy, because of the invasion to scrotum skin, scrotum skin was removed. th e surgical specimen was rigid, its surface was smooth and necrotic areas were observed ( figure ). pathologic examination revealed a pure yst with positive spermatic cord, tunica albugea, tunica vaginalis and scrotum skin invasion and in light microscopy tumor cells with large hyperchromatic nuclei arranging concentrically around a small vessel were seen (schiller-duval or glomeruloid body). metastasis of lung adenocarcinoma to the testis is an extremely rare occurrence and very few cases have been reported to date. th e authors aim to review the current literature in regard to incidence, clinical manifestation, sources of primary tumour and mechanism of metastasis, in addition to retrospective ten year review of testicular pathology at a single institution. we report an unusual case of a -year-old non-smoking australian gentleman who presented with a six month history of cough and dyspnoea. a physical examination, complete laboratory and radiological work up was performed. a palpable left testicular mass was identifi ed, ct scan revealed multiple bilateral lung nodules and mediastinal lymphadenopathy, however testicular tumour markers were negative. th e patient underwent a radical left inguinal orchidectomy and endobronchial hilar lymph node biopsy with bronchial washings. medical records and pathology results for patients undergoing radical orchidectomy over the past ten years at our institution were obtained and analysed. results: histopathological examination of the left testis and lung biopsy revealed features of a moderately to poorly diff erentiated adenocarcinoma, with morphological and immunohistochemical appearances consistent with lung origin. th e prognosis is extremely poor. a total of patients underwent radical orchidectomy at our institution between january and february . th e mean patient age was ( - ). histopathology is summarised in table . cur-up. , figure . th congress of the sociÉtÉ internationale d'urologie -siu abstract book rent literature review confi rms testicular metastases are rare and may be discovered incidentally at autopsy or following diagnostic orchidectomy. autopsy series revealed testicular metastases in . to . % of specimens. th e most common primaries, excluding lymphoma and leukaemia, include prostate, melanoma, sarcoma, gastrointestinal tract, kidney and lung, with most testicular metastases being a fi nal manifestation of widespread tumours. conclusions: testicular metastases from lung adenocarcinoma origin are scarcely encountered in clinical practice and may create a diagnostic dilemma by mimicking primary testicular neoplasms. extensive pathologic evaluation and specifi c immunohistochemical staining is essential. in patients presenting with a testicular mass, the diff erential diagnosis must include metastatic carcinoma. by . on average compared to only . by non-users (p= . ). many of these fi ndings were only present with recent vge; heavy users from high school and middle school did not show similar trends (table ; figure ). conclusion: th is study shows that subjects with heavy vge perform better on the da vinci skills simulator than subjects who report no vge. th e improvements seen with recent vge are not apparent if stratifying for frequency of use during high school and middle school. th ese fi ndings may have important implications for the future of surgical training. 'virtual urology clinic': a feasibility study in a busy uk teaching hospital introduction and objective: urology is an advancing surgical specialty with a parallel increase in demands from health service commissioners to meet national targets and patients' needs. th is has been refl ected on the outpatient urology service with a rising burden and delays in patients' outpatients' assessments. in our busy tertiary unit, we estimated a total of overdue outpatient appointment (by months or more). th us we designed this virtual clinic feasibility study aiming to: prioritise patients according to their clini- cal needs, enhance their care and decrease the burden by assigning patients to our novel computer based follow-up models. we used the hospital information system to identify one urologist overdue appointments (by months or more). all included cases had thorough review of their medical notes, investigations and treatment before being stratifi ed according to their diagnosis then assigned one of outcomes: urology, cancer nurse specialist (cns) and gp follow-up. results: a total of cases were reviewed in this virtual clinic over a period equivalent to full working days. even though they were all waiting to see one urology cancer surgeon, only % had a primary diagnosis of cancer with the rest being diagnosed with a benign urological condition. th e clinical investigator recommended for only % of all patients to have a urology follow-up with % and % discharged to the gp and computer based follow-up respectively. all patients received a letter explaining the procedure of this clinic along with a tailored management plan. th ere was an evident gap between the dynamic changes in service provision with new available tools and our current practice. th is virtual clinic allowed bridging this gap by categorising the urological priorities and utilising existing resources such as our novel computer based follow-up models. over the last year more than patients' visits have been registered on our computer based clinic which is potentially a cost eff ective model. patients' perspectives of accessibility introduction and objective: patients undergoing major lower abdo/pelvic operations are oft en catheterised (idc) at the start of the procedure to monitor urine output and decompress the bladder to avoid bladder injury. early removal of urinary catheters aft er surgery has been associated with a decrease in urinary tract infections though increasing failure of trial of void (tov), thus being discharged with idc or prolonged admissions. th e aim of this study is to determine the optimal time for tov. th is is a retrospective study looking at patients undergoing abdominal or pelvic procedures due to colorectal/pelvic pathology in the townsville base hospital surgical unit from jan -dec . pre-procedure idc and the deceased were excluded. data was collected from the operating theatre database (ormis). results: out of the total, were female while male, abdominal and pelvic procedures. sixteen male patients had documented prostatic history which include bph, prostate cancer and prostatitis post radiation. four were discharged with an idc failing tov. fift y-seven percent of the patients had their catheters removed on day post-op; . % on day , % on day , . % on day and % > days. th ree patients developed a urinary tract infec-tion (uti) ( . %). patients with good pre morbid function and female tend to pass their trial of void on day post op for pelvic procedures. th e majority of patients had comorbidities and failed tov on day . th ere was no signifi cant diff erence between day and day in uti rates (increasing day onwards). conclusions: idc's should be removed in a timely manner to reduce complications, balanced with monitoring fl uid balance. we proposed that patients should have tov on day , due to increased rates of failed tov day in patients with comorbidities and no diff erence in uti rates between days and . th e limitation of this study is the lack of documentation of preoperative urinary function. to further this study, we can analyse the data to state diff erences between bladder dysfunction as well as tov in groups with various comorbidities. international urology journal club on twitter: a growing educational forum introduction and objective: urologists use urinary and thoracostomy drainage collection systems regularly. pleural and urine fl uid pools at the bottom of dependent loops of both thoracostomy and urinary drainage tubing systems, respectively. we hypothesized that fl uid pooled in a dependent loop ) diminishes the expected negative pressure-head delivered to the pleural space by a chest-tube, and ) obstructs antegrade catheterized urine drainage. we created an ex-vivo thocacostomy tube model, and, performed two separate clinical trials to test our hypothesis. a pleur-evac chest drainage system was connected to - cmh o wall-suction. a digital pressure transducer was connected to the drainage tubing close to the insertion of connection to a chest-tube. model: to simulate dependent loops observed in hospital patients, we created , , and cm-high dependent loops (distance between the bottom of loop and the highest-point en-route to the drainage box). th e pressure close to the (blind-ending) chest-tube was measured as the drainage tube was fi lled in ml. increments. fitted linear regression of pressure and loop-height was performed. clinical trials # . pressure within the drainage tube was measured in six icu patients with thoracostomy tubes in place following cabg surgery. clinical trial # : we performed early-morning hospital icu bedside bladder-scan us on patients with an indwelling urinary catheter and clear urine, to assess for un-drained residual urine. results: with an empty dependent loop, thoracostomy tube pressure equaled the suction pressure (- cm h o). pooled of fl uid within the dependent loop diminished proximal negative pressure (p< . ) in a volume (i.e. loop-height) dependent fashion. th e net range of proximal drainage tube pressure ranged from - to + cmh o. in icu patients, an identical relationship between loops and chest-tube pressure was observed. bladder scan of catheterized ward patients revealed high urine residuals (mean ml) with a dependent loop present, and ~zero residual when no loop present. conclusions: th oracostomy-tube negative-pressure is steadily diminished as a dependent loop fi lls with fl uid. th e resulting air-lock opposes antegrade drainage. th e weight of the fl uid column accounts for positive thoracic pressures, and could account for why many patients fail water seal trials. similarly, urinary tubing dependent-loops result in air-locks that prevent gravity dependent drainage. th oracostomy and urinary drainage tubing should always be positioned without dependent loops. single incision mid-urethral sling (miniarctm) and tension-free vaginal tape (tvt) procedure in women with stress urinary incontinence (sui) at months. a total women with sui were randomized to receive miniarc and tvt. th e primary outcomes were objective and subjective cure rates at a -month follow-up visit. objective and subjective cure of sui were defi ned as a negative cough stress test and absence of self-reported sui symptoms. cure rates of the two groups were compared at -month follow-up. results: a total of ( %) of women originally included in the study (miniarc: , tvt: ) were evaluated at -month follow-up. th ere were no signifi cant diff erences found in demographic and clinical preoperative parameters. objective cure rates for miniarc and tvt groups were % and % while subjective cure rates were % and %. th ere was no statistically signifi cant diff erence between groups (p> . ). conclusions: our -month randomized clinical trial showed that miniarc single incision sling is not inferior to tvt procedure with respect to objective and subjective cures at -month follow-up. introduction and objective: male sui is a debilitating and challenging problem to manage. insertion of transobturator sling off ers less invasive treatment than aus insertion. published data demonstrate cure rates of % but are limited by short follow-up. th e aim of our study was to report long-term outcomes for male transobturator slings for sui with a mean year (minimum year) follow-up. a single-centre retrospective audit of outcomes in male patients who underwent transobturator sling insertion for sui. follow-up was conducted via telephone or in outpatient clinic. incontinence was classifi ed as mild (≤ pads/day), moderate ( - pads/day) or severe (≥ pads/day). classifications post-surgery were: cured -dry; improved -≤ pads/day and ≥ % less pad use; failure -no change or worsened. results: in patients with mild/moderate incontinence, / patients (= . %) were cured/improved with tot. success rates were poor in severely incontinent patients, regardless of radiotherapy history ( %; n= ). of 'cured'/'improved' patients, ( . %) maintained that degree of continence for the duration of follow-up. one patient was lost to follow-up. th ree patients reported a later decline in continence; patients had had previous pelvic radiotherapy. one patient had progression of underlying prostate cancer. conclusion: durable success rates of . % are achievable in men with mild/moderate sui who have not had pelvic radiotherapy. pelvic radiotherapy may play a role in delayed failure of tots with % of patients with mild/moderate sui who were initially cured/improved declining in the second or third year aft er surgery. the mesh wallstent (urolume) in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury dept. of surgery, div. of urology, king saud university faculty of medicine, riyadh, saudi arabia introduction and objective: to evaluate the longterm effi cacy and safety of the urolume stent for the treatment of detrusor sphincter dyssynergia (dsd) in spinal cord injured (sci) patients. twenty-four spinal cord injured patients with neurogenic bladder and dsd associated with high detrusor pressures and incomplete emptying on pre-operative video-cystometrograms (vcmg) were retrospectively reviewed. twenty-one patients had cervical level injury whilst had a thoracic injury. eleven patients were on clean intermittent catheterization (cic) and with indwelling foley's catheter. all patients underwent urolume stent insertion according to standardized protocol. follow-up assessment included blood chemistry, ultrasound scan (upper tracts and residual urine) at one and three months aft er insertion, and a follow-up vcmg at six months. residual urine volume, autonomic dysrefl exia, catheter need, and presence of bladder stones and hydronephrosis were compared before and aft er treatment. post-operative patient and physician satisfaction, complications and re-obstruction rates were also analyzed. paired t-test is used and p value < . was taken as signifi cant. results: th e twenty-four patients had a mean (range) follow-up of . ( . - ) years. th e mean age was introduction and objective: at present, sacral neuromodulation (snm) with interstim® therapy is indicated for non obstructive urinary retention and overactive bladder, including urinary urge incontinence and signifi cant symptoms of urgency-frequency alone or in combination, in subjects who have failed or could not tolerate more conservative treatments and do not have any neurological disorder. th ere are also reports of the use of interstim® in the treatment of chronic pelvic pain and other conditions. we report our experience with the use of this device in patients with post-traumatic brain injury damage without anatomical anomalies and with severe urinary voiding dysfunction who had failed intensive medical and behavioral therapies. materials and methods: from november to november , patients underwent interstim® placement ( male and female). all had severe voiding dysfunction secondary to post-traumatic brain injury damage; ten of them had also defecatory disturbances ( a chronic constipation and fecal incontinence). th e main goal was to evaluate the improvement of the urinary symptoms and the second goal the improvement of the intestinal symptoms. success was defi ned as a ≥ % improvement in any of the two variables evaluated. results: with a mean follow-up of months, / patients reported ≥ % improvement in their urinary voiding symptoms ( %), in these patients urinary frequency decreased from to episodes per day, mean voided volume increased from cc to cc, incontinence disappeared in of patients and urgency disappeared in all patients. of patients with intestinal disturbances, showed a signifi cant improvement ( %). one patient showed a clavien iii complication (seroma and partial dehiscence of the surgical wound managed with conservative surgical treatment). conclusion: snm in post-traumatic brain injury patients is an eff ective and safe option for urinary and defecatory dysfunction when other conservative therapies have failed. to our knowledge the use of inters-tim® in this scenario has not been reported previously. a larger series and a longer follow-up are needed to validate this indication. introduction and objective: th ere were some reports that in the patients who have stress incontinence (sui) with detrusor underactivity, voiding symptoms aggravated aft er mid-urethral sling operation (mus). we report our experiences of mus cases on the patients who have sui with detrusor underactivity. conclusion: urethral sphincter and bladder function worsen immediately aft er rarp and recover over time. th e bladder storage function aft er rarp returns to almost the same level before rarp, the voiding function improves compared with the condition inserted into the rabbit bladder through the urethra and saline solution is infused using a disposable syringe into the bladder through the end cap. conventional cystometry was performed and the intravesical pressure was measured by prototype intravesical pressure sensor at the same time. we also evaluated the biocompatibility of ecofl ex® by checking changes in the levels of macrophages, macrophage migratory inhibitory factor, and infl ammatory cytokines in the bladder tissue and urine. cape town, south africa th congress of the sociÉtÉ internationale d'urologie -siu abstract book and urgency incontinence are signifi cantly detected luts in children with vur the -gene genomic prostate score assay: initial commercial experience of , patients th congress of the sociÉtÉ internationale d'urologie -siu abstract book th congress of the sociÉtÉ internationale d'urologie -siu abstract book pelvic strength physiotherapy percutaneous treatment of bladder stones in children: -year experience; is blind access safe? extirpative treatment of upper urinary tract urothelial carcinoma: an -year comprehensive review paik l th e overall complication rate was %. no hydronephrosis were seen thought the follow-up period. stricture rate was low, only one patient ( %) at one year, and none at years had urethral stricture. patients ( %) required re-stenting due to stent migration ( patients, %), or stricture ( patient, %), all of which happened during the fi rst year of surgery. patients ( %) required alpha-blockers to control bladder neck dyssynergia post operatively. stents ( %) were removed due to exacerbation of autonomic dysrefl exia symptoms (n = ); encrustation and stone formation (n = ). overall, % of patients and % of physicians felt there was improvement in urination at year. conclusions: th e treatment of detrusor sphincter dyssynergia in spinal cord injured patients with urolome stent is safe and eff ective sacral neuromodulation with interstim® therapy for urinary voiding dysfunctions in post-traumatic brain injury patients: a new therapeutic indication? hospital pablo tobon uribe, medellin, colombia th congress of the sociÉtÉ internationale d'urologie -siu abstract book between pre-and post-operative qmax abstract book before rarp; however, the urethral sphincter func male ( . %) ( %) . ** introduction and objective: we evaluated the clinical eff ect of alternative fl utamide therapy for metastatic prostate cancer that relapsed aft er initial maximum androgen blockade (mab), and investigated the relationship between the eff ectiveness of alternative fl utamide therapy and the eff ectiveness of initial mab. and december , patients with metastatic prostate cancer that relapsed aft er initial surgical or medical castration along with bicalutamide for mab were treated with fl utamide therapy ( mg daily). importantly, patients who had discontinued bicalutamide because of adverse events were excluded.results: of the patients treated with alternative fl utamide therapy, prostate-specifi c antigen (psa) levels decreased by > % (group a) in patients ( %), by - % (group b) in patients ( %), and by - % (group c) in patients ( %), but increased by > % in patients ( %). th e median duration of response was . , . , and . months for groups a, b and c, respectively. th e duration of response for patients ( %) was more than months. aft er alternative fl utamide therapy, decreased psa levels of > % were achieved in of patients ( %) with mab nadir psa levels of < . ng/ ml, in of patients ( %) with mab nadir psa levels of . to ng/ml, and in of patients ( %) with mab nadir psa levels of > ng/ml. during the observation period there were no severe side eff ects.conclusion: approximately % of patients with metastatic prostate cancer who relapsed aft er mab with bicalutamide achieved a decrease in their psa level with no severe side eff ects. th e nadir psa level during mab, however, was not a predictor for the eff ectiveness of alternative fl utamide therapy. th us, alternative fl utamide therapy is a reasonable treatment option for metastatic castration resistant prostate cancer. nevertheless, changing to another therapy should be considered in patients who achieve decreases in psa levels of < % with alternative fl utamide therapy, as the duration of response was relatively short in these patients. association of renal function and androgen deprivation therapy with prostate cancermasuda h, kanesaka m, sugiura m, hou k, araki k, kojima s, naya y introduction and objective: we evaluated the change of renal function by androgen deprivation therapy (adt) and examined the association of the occurrence of renal dysfunction and concomitant diseases. between january and april , patients who could measure estimated glomerular fi ltration rate (egfr) at pretreatment, , and months were evaluated retrospectively. all of them were diagnosed prostate cancer by prostate biopsy pathologically and had taken adt for at least months. we assessed the renal function of prostate cancer patients by using the egfr and investigated the time-independent change rate of the egfr (Δegfr) aft er adt. th e Δegfr was calculated by (post treatment egfr-pretreatment egfr)/pretreatment egfr × ). univariate and multivariate logistic analyses were carried out to identify clinical covariates signifi cantly associated with the risk factors for renal dysfunction at months later.results: th e incidence of the renal dysfunction at months was % ( / ). th e mean Δegfr at , , months were - . %, - . % and - . %, respectively (p= . ). th e incidence of the renal dysfunction at months was signifi cantly associated with the renal dysfunction at month (p< . ), at months (p< . ), hypertension (p= . ) and dyslipidemia (p= . ). th e renal dysfunction at pretreatment with adt did not aff ect the renal function months later (p= . ). th e renal dysfunction at months (odds ratio [or] . , p= . ), renal dysfunction at months ([or] . , p= . ), hypertension ([or] . , p= . ) and hyperlipidemia ([or] . , p= . ) were independent predictors of the renal dysfunction at months in the multivariate analysis.conclusions: it was suggested that the renal dysfunction with adt occurred relatively early. th e earlier renal dysfunction may cause the renal dysfunction at months later. so, when the treatment of adt began, it was thought that an examination of periodical renal function was necessary. th e present results suggested that it was necessary to control the blood pressure and lipid for receiving adt with prostate cancer. immune (pc) and isolated lymph node metastases aft er curative therapy are usually treated with an anti-androgen therapy. th e choline pet-ct is the method of choice in diagnostic of the recurrent psa. controver-sial in the latest debate is the oncological eff ectiveness of the local salvage therapy of isolated lymph node metastases. th e aim of this study is to compare the oncologic outcome of the salvage lymphadenectomy (la) alone versus the la in combination with adjuvant radiotherapy (ar) and androgen deprivation therapy (adt).materials and methods: th erefore we randomized patients with biochemical recurrence of a pc (psa: ≥ , ng/ml) aft er curative local therapy and detection of at least one lymph node metastasis. we applied two treatment arms. a (n= ): single la; b (n= ): la plus ar/adt (bicalutamide) over years. we determined the biochemical recurrence-free survival (bfs) and the time-to-treat (ttt) until complete androgen blockade. conclusion: compared for both treatment arms, the combination of la plus adt/ar is superior to la alone. however, both methods are to be seen as individual decisions in highly selected patients. th e oncological long-term eff ectiveness is questionable. stem cell transformation of prostatic cells after hormonal therapy we reviewed consecutive patients who underwent transperineal mri-trus fusion target biopsy followed by conventional transrectal systematic core biopsy between july and mar in our institution. in all patients, t low region was detected by prostate mri image and target biopsy was conducted for region of interest (roi) of the mri image utilizing biojet system. baseline characteristics and pathological outcome were analyzed.results: in analyzed cohort, mean age was . ± . years, median initial psa was . ng/ml (range, . - . ), median prostate volume (pv) was . ml (range, . - . ) , and median volume of roi was . ml (range . - . ). of patients, prostate cancer was detected in ( %) patients by target biopsy and ( %) patients by systematic biopsy. patients with positive biopsy was likely to be higher psa than men with negative biopsy (p= . ). median roi/pv was not signifi cant between them ( . vs. . : positive vs. negative, p= . ). cancer detection rates per core between target and systematic biopsy were . and . %, respectively (p= . ).regarding pathological results, mean gleason score of target biopsy was . compared with . of systematic biopsy, although which is not statistically signifi cant (p= . ).conclusion: mri-trus fusion target biopsy is gradually spreading in japan, since its higher cancer detection rate compared with conventional systematic biopsy. in our institution, substantial detection ability of prostate cancer by mri-trus fusion target biopsy was confi rmed, which encouraged future clinical trial for prostate focal therapy. multiparametric introduction and objective: sepsis has always been a concern in the traditional transrectal ultrasound (trus) guided biopsy of the prostate. however, rates of sepsis following trus biopsy have shown to be increasing around the world in addition to the emergence of multiresistant organisms found in rec-tal fl ora. as a result, our practice of seven urologists has switched to transperineal (tp) biopsy. we aim to determine the rate of hospital re-admission in our patients undergoing tp biopsy. an ethics approved prospective database of all men undergoing tp biopsy at our practice has been kept including antibiotics used as well as re-admission for infection. introduction and objective: robot-assisted radical prostatectomy (rarp) has become one of standard treatments for localized prostate cancer. however, a feasibility of rarp in elderly patients has not been clear yet. we performed a comparative analysis of peri-surgical / oncological outcomes for younger and elder patients underwent rarp. we reviewed and compared our initial consecutive patients who underwent rarp from / to / for peri-surgical outcomes, including surgical times, blood loss, complications, pathological fi ndings, continence recovery, and oncological outcomes stratifi ed by age less than and over years.results: in our cohort, men were age less than and men were ≥ . preoperative parameters (age, psa, gleason score) were similar in both younger and elder groups. operative time (mean: vs. minutes) and estimated blood loss were similar in both groups. one of elder patients ( . %) needed transfusion. peri/post-operative complications in both groups appeared to be minimal with no cases of intra-operative open conversion. one of younger patients needed a surgical settlement for port site herniation. surgical positive margin rates in organ-confi ned (pt ) disease were also similar ( . %, younger vs. . %, elder). continence at months was % in elder patients as opposed to % in younger patients. biochemical recurrences in short follow-up period (median vs. months) were observed . % in elder patients as opposed . % in younger patients.conclusions: in our study, although urinary continence recovery in elderly patients might show a short delay, rarp in elderly patients was relatively safe and yielded good oncologic results. rarp is feasible eve in elderly patients. quality in the fi rst study, community-based urologists ordering at least assays from / to / participated. clinicopathologic data, the gps and treatment were abstracted from medical records of gps patients and a clinically similar baseline group. th e proportion of men recommended and pursuing active surveillance (as) before and aft er the availability of the gps were computed. in the second prospective study, urologists at centers (academic and community) recorded tr on pre-and post-gps questionnaires, including changes in treatment intensity.results: fift een urologists completed the chart review study on men ( gps; baseline). th e relative increase in tr for as was %, ( % baseline, % gps; absolute diff erence of %). gps pts chose as more than baseline pts ( % gps; % baseline, absolute increase of %, relative increase of %). of men recommended as, % of gps and % of baseline pts chose it. in men in the prospective study, the relative increase in recommendation for as was % and absolute tr increase for as was also % ( % to %). % of tr changed post-gps and tr modality and/or intensity occurred in % of men ( decreased; increased; equivocal).conclusions: both studies, conducted with diff erent methodologies, demonstrate that use of gps provides meaningful change in tr and decisions in men with newly diagnosed pca and results in a net increase in recommendation and/or adoption of as. in the chart review study, tr changes appear to underestimate changes in actual treatment received and more gps patients than baseline patients were assigned to as supporting the clinical utility of gps in the initial assessment and management of men with low risk pca. comparison we prospectively evaluated in patients with clinically localized prostate cancer, the possible association between hce (≥ . mmol/l) and aggressive prostate cancer. pre-operative serum cholesterol levels (ch), triglycerides (tr), were prospectively assessed in men treated consecutively with radical prostatectomy from feb. to oct. . th e results were related to patient specifi c and clinico-pathologic data.results: patients with hce (n= ) had a more aggressive grade gleason score (gs) ≥ b, p< . )), a locally more advanced stage (≥pt a, p< . ), and lymph node metastasis (n+, p< . ). hce was also associated more frequent with a positive surgical resection margin (r , p< . ). in multivariate regression analysis hce is associated with a high-risk pc (hr . , % ci . to . , p < . ) -adjusted for psa, dre, age and poor biopsy score (gs ≥ ).conclusion: th e results indicate that hca is associated with high-grade and metastatic disease in men diagnosed with clinically localized pc. our fi ndings suggest that ch can be used as an additional predictive marker in therapy. conclusion: th e incidence of bs-positive tumours is low in men being staged for radical treatment except in high-risk disease. pelvic/prostate mpmri alone cannot be relied upon to exclude bone metastases in this group. hyperbaric oxygen therapy for radiation induced side-effects introduction and objective: to evaluate the effi cacy of hyperbaric oxygen (hbo) th erapy for prostate conclusions: in our japanese provincial hospital, the comparatively young patients chose a treatment according to treatment algorithm. however, according to aging, the patients tended to choose hormonal therapy regardless of algorithm. as for one of the reasons, it is thought as follows: even if the patients chose operation or radiotherapy, it may be diffi cult to visit the institutions that have such a treatment because public transport does not develop in our prefecture. nurse-led telephone follow-up for prostate cancer surveillanceturner b, tanabalan c, nargund v, pati j, wells p introduction and objective: we review the patients' experience of a nurse-led, telephone follow-up service for men with 'stable' prostate cancer, to measure satisfaction and quality. th e telephone follow-up service is based on the premise that psa measurement can be used as a surrogate for outpatient attendance. telephone follow-up service serves to reduce the number of patients attending hospital appointments. th is has led to increased clinic capacity and reduced waiting times, ensuring urgent care is available for patients who need it. a nurse-led, protocol based telephone follow-up service was set up for patients deemed to have 'stable' disease. questionnaires were sent to all patients. survey was voluntary and anonymous. we addressed a variety of aspects of the service, including time, duration and content of the telephone appointments, patients' preference for type of follow-up (telephone vs. hospital follow-up) and overall satisfaction with the service.results: response rate of %. reported high satisfaction with telephone follow-up ( % were either satisfi ed or very satisfi ed). majority of patients found the length of the conversations to be 'just right' ( %) with a lesser majority expressing that the calls were always at times convenient to them ( %) and that they were always called when they were told they would be called ( %). patients felt that the information given to them over the phone was always easy enough to understand ( %) and the majority felt that they always had the opportunity to ask questions during the conversations ( %). when asked whether they would prefer telephone follow-up or hospital follow-up, % of respondents reported that they would prefer telephone follow-up, citing convenience, time and privacy as the reasons for their preference. twenty-one percent of patients would prefer hospital follow-up, reporting ease of understanding, not liking the telephone and preference for face to face contact.conclusions: telephone follow-up relieves pressure on the outpatient department, increases capacity, reduces waiting times and brings care closer to home. patients perceive the service as a valuable addition to their care and report high levels of satisfaction with the service. prostate ' th e target sample sizes of australasian trials 'currently recruiting' ranged from to men (median= ), the majority of trials investigating medical and radiation oncological interventions. five of the trials 'currently recruiting' were recorded as single-centre studies in new south wales, victoria and queensland. of the remaining trials, % (n= ) were recorded as international, industry sponsored, multi-centre studies with australian and/ or new zealand recruitment sites.conclusion: australasian prostate cancer clinical trial activity (though likely under-recognised in this study, due to trial registration limitations) represents a relatively small fraction of international eff ort. continued investment will ensure that the talented and world-leading scientists and medical professionals across both nations can tackle the big challenges in prostate cancer through working collaboratively. assessment modifi ed laparoscopic intravesical nonrefl uxing ureteral reimplantation with psoas hitch using a submucosal tunneling introduction and objective: we aimed to study the safety and effi cacy of the cystoscopy-assisted nonrefl uxing ureteral reimplantation technique using sub-mucosal tunneling during laparoscopic ureteroneocystostomy (unc) with a psoas hitch in patients with distal ureter stricture aft er gynecologic surgery. we reviewed six female patients who underwent gynecological surgeries. all patients showed persistent postoperative distal ureter stricture or obstruction. th ese patients underwent laparoscopic nonrefl uxing unc with a psoas hitch using a submucosal tunneling technique combined with cystoscopy at our institute.results: th ey had corrective surgery at an average of . weeks aft er ureteral injury. th e short-term success was confi rmed either by voiding cystourethrography (vcu) or by diuretic isotope renal scan (mag- ) conducted months aft er the operation. none of the patients showed evidence of postoperative stricture at the reimplanted site and refl ux on either mag- renal scan or vcu. none of the patients showed major or minor complications during follow-up. it is safe and feasible to perform the laparoscopic nonrefl uxing unc with a psoas hitch using a submucosal tunneling technique combined with cystoscopy for ureteral stricture. upper ureteral injuries were more frequent in the urological surgery group than in the non-urological surgery group ( % vs. . %). complications or serious injuries were more frequent in the urological surgery group. th ere were no signifi cant diff erences in the mean durations of hospitalization and indwelling times between the groups. conclusion: th e occurrence of a ureteral injury during urological surgery is an infrequent but serious complication may occur. urologists should pay attention to the potential for ureteral injury, especially during a ureteroscopic ureterolithotomy for the treatment of an upper ureter stone. reducing the risks of trauma due to urethral catheterisation mundy a, yim i, tamini a, roberts n conclusion: isolated ureteric trauma can be managed successfully using minimally invasive endoscopic and radiological approach. a pcn initially helps in minimizing extravasation and ureteral wall edema subsequently facilitating stent placement. medium-and long- university of sydney, sydney, australia introduction and objective: urethral stricture is a common urological presentation for obstructive lower urinary tract symptoms. th e treatment of choice for a durable outcome is usually substitution urethroplasty using buccal mucosal graft . graft failure is not uncommonly encountered. we present the mediumand long-term outcomes of ventral buccal mucosal graft urethroplasty using spongio fl ap technique. a retrospective review of a single surgeons experience was reviewed for a period of years. data was collected from medical records, surgeon's notes and operation reports. inclusion criteria included reconstruction of anterior urethral stricture using bm graft positioned ventrally and graft support using spongio fl ap technique. patients who were lost to follow-up were excluded from analysis. graft patency was defi ned as having a lumen greater than fr. th is was assessed via cystoscopic examinations at , and months intervals post procedure.results: a total of male patients identifi ed with age ranging from to years and mean age of years. average length of bm graft used was . cm. total of ( %) achieved long-term successful outcome. of these ( . %) patients had successful outcomes with no further interventions, and ( . %) required gentle urethral dilatation at fi rst cystoscopy and subsequently achieved long-term patency. sixteen ( . %) of this cohort formed recurrent stricture at initial cystoscopy, and ( . %) of patients formed urethral stricture formed delayed stricture, despite the initial cystoscopic examination and urethral dilatation.conclusion: ventral buccal mucosal graft urethroplasty using spongio fl ap technique has very good short-term and long-term graft patency outcomes. outcome of paediatric kidney transplantation: single center experience nawaz g, jamil i, athar khawaja m, muhammad s, shohab d, ur rehman a, ali khan i, khan a, hussain i, akhter s introduction and objective: renal transplantation is the treatment of choice for children with end-stage renal disease (esrd) because in addition to making them off dialysis it also improves growth and development of the child. about - % of children have a lower urinary tract dysfunction due to congenital or acquired genitourinary anomaly as the etiology of esrd and they need a diversion or augmentation procedure prior to transplantation. we aim to deter-mine the outcome of paediatric renal transplant at year in term of graft survival and complications. we retrospectively reviewed the record of consecutive children underwent living related renal transplant between jan to jan . all were primary renal transplants and had living related renal donors. patient characteristics, causes of esrd and pre transplant surgical procedure were recorded. patients with lower tract abnormalities as cause of renal failure underwent reconstructive procedure prior to transplant. induction immunosuppression consisted of triple therapy with antithymocytic globulin (atg), prednisone and mycophenolate mofetil (mmf). cyclosporine was introduced when creatinine came down to > % of normal. all patients were treated as cmv positive with either acyclovir or ganciclovir and received daily dose of trimethoprim-sulfamethoxazole as prophylaxis for pneumocystis carnii pneumonia aft er transplantation. post transplant surgical and medical complication, graft and patient survival were recorded.conclusion: ureteric implantation into the bowel portion of augmented bladders appears safe in this population of patients with previously reported increased risk of ureteric complications and urinary tract infections aft er transplantation. transition of cavernous function after radical prostatectomy materials and methods: study subjects were ed patients with a history of rp (median age: ). intervals between rp and examination diff ered among patients (range: to months). we also performed doppler penile ultrasound examination using intracavernous injection of micrograms of prostaglandin e . we adopted an infusion rate of less than ml/min at mmhg of intracavernous pressure as the normal cavernous function limit for dicc.results: arterial velocity in ultrasonic examinations showed a tendency to decrease. cavernous function aft er rp clearly diff erentiated according to phospho-diesterase inhibitors (pde is) response ( figure ). in the pde is responder patient group ( cases), the rate of normal cavernous function was % at month, months, and months, but the rate increased to % at months, and % at months. a diff erent transition was seen in the pde is non-responder patient group ( cases). in this group, the rate of normal cavernous function was also % at month. however, from here, the rate increased to % at months, and then aft er this point, it decreased to % at months. sixteen -week-old sprague-dawley rats were induced diabetes by a onetime intraperitoneal injection of streptozocin ( mg/ kg). one week later, the diabetic rats were randomly divided into groups including a normal control, dm control and two uu treated group ( , and mg/kg/d). th e latter rats were fed uu by intragastric administration for weeks. aft er weeks, penile hemodynamic function was evaluated by measuring the intracavernosal pressure aft er electrostimulating cavernous nerve. we measured nitric oxide (no) and cyclic guanosine monophosphate (cgmp) activity. endothelial nitric oxide synthase (enos) and neuronal nos (nnos) protein expression was determined by western blot. masson's trichrome staining was also assessed.results: serum glucose level in dm +uu group was signifi cant lower than in that of the dm control groups. maximum intracavernosal pressure in dm control rats decreased signifi cantly compared to normal control rats and increased signifi cantly compared to untreated dm rats aft er uu supplementation. dm + uu group had signifi cantly increased no and cgmp level compared with the dm control group. decreased activity and expression enos and nnos were found in the dm groups compare with normal control group. decreased enos and nnos in diabetic rats were improved by uu administration. decreased the cavernous smooth muscle to collagen ratio was improved in dm + uu groups in the masson's trichrome staining.conclusions: uu eff ectively ameliorated erectile function in a streptozocin induced diabetic rat model of erectile dysfunction. you d , jung s , jang m , kim b , lee c , song g , choi k , shin h , suh n , kim y , ahn t , kim c the etiology and management of erectile dysfunction (ed) in patients with metabolic syndrome (ms). eighty-six patients suff ering from erectile dysfunction and metabolic syndrome were included in the study, patients were classifi ed based on iief- domain into three groups: mild ed (n= ), moderate ed (n= ) and severe ed (n= ). th ese patients were treated using upgraded regimen protocol (changing of the life style for months, on demand use of pde- inhibitors for months, chronic dosing with long acting pde- inhibitors for months and combination therapy of pde- inhibitors and intracavernosal injection for months) re-evaluation of the patients was done at the end of each stage by (iief-ef, waist circumference and laboratory investigations).results: aft er months of lifestyle modifi cation there was increase in the iief-ef but this change was not signifi cant the overall improvement was ( %), aft er on demand pde- inhibitors for months( . %) of patients with mild ed were improved, ( %) with moderate ed and ( . %) with severe ed were improved. non-improved patients in each group aft er on demand pde- inhibitors received pde- inhibitors chronic dosing for another months then re-evaluated ( . %) of patients with mild ed were improved, ( . %) with moderate ed and ( . %) with severe ed were improved, combination therapy in the form of tadalafi l mg daily and pge μg on demand were off ered to patient whom reported failure of pde- inhibitors chronic dosing patients with mild symptoms reported the maximum improvement ( %), patients with moderate symptoms reported fair improvement ( . %); however patient with severe symptoms reported no improvement at all.conclusion: pde inhibitors should be considered as the fi rst line phamaco-therapy in treatment of ed in metabolic syndrome patients. non-responders to pde inhibitors may have a benefi t from daily dosing of long acting pde- inhibitors. combination therapy of pde- inhibitors chronic dosing associated with intracavernosal injection of pge may play a role as a salvage therapy aft er failure of monotherapy. following this upgraded regimen case with ms and ed can have overall successful results in . %. comorbidity of premature ejaculation and erectile dysfunction: are they inseparable in chinese adult men?tang y, yang j, jiang x introduction and objective: premature ejaculation (pe) and erectile dysfunction (ed) are usually regarded as a symbol of incompetence. but in china for the inconsistent defi nitions of pe, some of them cannot correctly distinguish pe from ed. th erefore, to fi nd out the real relationship between pe and ed, a detailed investigation was implemented. were enrolled. all the subjects were evaluated by the face-to-face questionnaires of premature ejaculation diagnostic tool (pedt) and the international index of erectile function (iief- ). a professional urologist was invited to measure their lengths of penis and volumes of testes. all the data were analyzed by spss version . soft ware.results: a total of men aged from to years ( . ± . ) were categorized into lifelong pe (lpe) ( men), acquired premature ejaculation (ape) ( men), variable pe (vpe) ( men) and subjective pe (spe) ( men), respectively. th ere was no signifi cant diff erence among the four pe subtypes except for the ielts and the iief- . th e self-estimated ielt of spe was signifi cant longer than that of other subtypes, and the similar case could be seen in iief- . th e highest percentage was found in ape ( . %) for chronic prostatitis (cp) and in lpe ( . %) for ed.conclusion: vpe was the most common subtype, next ape, thirdly spe and the least one is lpe. consistent with the previous reports, we found that the incidence of cp in ape was the highest among all the four subtypes of pe, and cp was a signifi cant risk factor of ape but not for other subtypes. th ere has always been controversial about the relationship between pe and ed. th e results from our multinomial logistic regression analysis showed that ed was not only associated with pe, but also could be regarded as a risk factor of pe. introduction and objective: depression oft en overlapped with late-onset hypogonadism (loh) syndrome. clinically, many loh patients who have depressive symptom were treated with testosterone replacement therapy (trt). however, treatment efficacy of trt for these patients is unclear. in this study, we aimed to identify characteristics of loh patients on trt who had medical history of ongoing mental health treatment for depression syndrome. we reviewed consecutive patients who visited men's health clinic and underwent trt in our institution during june and december . prior to trt, patients received a physical examination and full hormonal evaluation including free testosterone (ft), lutenzing hormone (lh), and follicle-stimulating hormone (fsh). th e aging males' symptoms (ams) score was also evaluated. trt was conducted by mg monthly testosterone injection. effi cacy of trt was noted when diff erential of ams score between pre-and post-treatment was more than points. in the entire cohort of patients, the mean age was . ± . years and pre-trt ams score was . ± . . pre-trt ft, lh, and fsh were . ± . ng/ml, . ± . miu/ml, and . ± . miu/ml, respectively. of total patients, cases ( . %) had diagnosis of depression by psychiatrist and ongoing mental health treatment. patients with positive medical history of mental health treatment were found to be younger ( . vs. . years, p = . ), higher pre-trt ams score ( . vs. . , p < . ), lower lh ( . vs. . %, p = . ), and lower fsh ( . vs. . %, p = . ) compared to patients with negative medical history of mental health treatment. effi cacy of trt was greater in men who have mental treatment history ( . vs. . %, p = . ) based on ams improvements. while, there were no signifi cant diff erence in ft ( . vs. . ng/ml, p = . ), trt duration ( vs. days, p = . ), and trt discontinuation rate ( . vs. . %, p = . ) between two groups.conclusion: even though, loh patients who had diagnosis of depression and underwent medical treatment such as antidepressant, trt can be feasible approach for those patients. majority of those loh patients underwent mental health treatment at the same moment with trt, which may not harm treatment effi cacy of trt. the effect on blood flow rate of prostate in daily administration of mirodenafi l mg for benign prostatic hyperplasia patients: randomized paroxetine is the most eff ective ssris. in few studies, tramadol has been used to treat pe. considering the high incidence of pe in men and lack of consensus on its treatment, we decided to compare the therapeutic eff ects of tramadol, paroxetine and placebo in the treatment of primary pe. in this randomized, double-blind, placebo-controlled clinical trial, patients were randomly divided into groups. one group was treated with tramadol mg, the other group took paroxetine mg and the third group was treated with placebo. before starting treatment and aft er weeks, patients were asked to measure their average intravaginal ejaculation latency time (ielt) and fi ll the pep (premature ejaculation profi le) questionnaire. aft er collecting the data, they were recorded in spss version and were analyzed.results: patients in the groups in baseline characteristics, including mean age, ielt and pep were similar at the beginning of the study and there was no clinically signifi cant diff erence in the groups (p> . ). a total of patients completed the study period. at the end of the th week, the mean ielt and average of pep scores increased in all groups. th ese changes in tramadol group were signifi cantly higher than the paroxetine and placebo groups (p< . ). th ere were no signifi cant diff erences in terms of side eff ects between the groups. th e results showed that despite an increase in mean ielt and pep scores in all groups, the rate of improvement in tramadol group was considerably more than the other groups. th us, tramadol may be considered as an appropriate alternative therapeutic for long-life pe. the effi cacy and safety of tadalafi l mg once daily for the treatment of erectile dysfunction related to the vascular causes after robot-assisted radical prostatectomy: -year follow-updong-a university hospital, busan, south korea; jeil hospital, ulsan, south korea introduction and objective: to evaluate the effi cacy and safety of tadalafi l mg once daily use in the treatment of erectile dysfunction (ed) based on the vascular cause aft er robot-assisted radical prostatectomy (rarp). th e study retrospectively evaluated patients who underwent rarp and had a penile rehabilitation by tadalafi l mg once daily use at our medical center. th e patients were surveyed based on the abridged fi ve-item version of the international index of erectile function (iief- ) questionnaire, which was self-administered before the surgery, and at months, year and years aft er the surgery. th e patients were classifi ed into the tadalafi l group (n= ) and the non-tadalafi l group (n= ). each group was then classifi ed depending on the nerve-sparing (ns) procedure: bilateral ns and unilateral ns. additionally, patients who underwent a penile color-duplex u/s study to evaluate the cause of erectile dysfunction were also analysed.results: at months, year, and years, the total iief score of the tadalafi l group and that of the non-tadalafi l group were . ± . vs. . ± . , . ± . vs. . ± . , and . ± . vs. . ± . , respectively. statistically signifi cant improvements (p< . ) were observed in the tadalafi l group for all domains of iief- score, while in the non-tadalafi l group there was no signifi cant improvement in any of the domains at and years. fift y three patients had a penile color-duplex u/s study. arteriogenic and venogenic ed was seen in patients ( . %) and patients ( . %). fift een patients ( . %) showed unremarkable fi ndings. venogenic ed patients had little response compared to arteriogeinc ed patients by tadalafi l mg once daily use ( % vs. . %). th e overall side eff ects were hot fl ushing in . %, headache in . %, and dizziness in . %. in ed patients aft er ns ralp, a once daily dosage of tadalafi l mg was well tolerated and signifi cantly improved ef compared with the non-tadalafi l group until two years. but in the venogenic ed patients, response to a once daily dosage of tadalafi l mg was relatively limited compared to the arteriogenic ed patients. effects of long-term androgen replacement therapy on the physical and mental statuses of aging males with late-onset hypogonadism (earth): a randomized phase trial in japan introduction and objective: to determine the role of stone density and skin-to-stone distance (ssd) by non-contrast computed tomography of the kidneys, ureters and bladder (ct-kub) in predicting the success of extracorporeal shock wave lithotripsy (eswl). we evaluated patients who received eswl for renal and upper ureteric calculi measuring - mm, over a month period. mean stone density in hounsfi eld units (hu) and mean ssd in millimeters (mm) was determined on pre-treatment ct-kub at the ct workstation. eswl was successful if post-treatment residual stone fragments were ≤ mm.results: e wl success was observed in . % of the patients. mean stone densities were ± and ± hu in e wl successful and failure groups, respectively; this was statistically signifi cant (p < . , student's t-test). mean ssd were . ± . and . ± . cm in eswl successful and failure groups, respectively, this was not statistically signifi cant.conclusions: th is study shows that stone density can help in predicting the out-come of eswl. we propose that stone densities < hu are highly likely to result in successful eswl. conversely, stone densities > hu are less likely to do . th is should be accounted for when considering eswl. assessment th is prospective study was conducted upon children with mean age . ± . years. patients underwent retrograde intrarenal surgery (rirs) under general anesthesia as monotherapy. th e procedure was initially started by the semi-rigid ureteroscope (storz . f) and holmium laser and was completed by the fl exible ureterorenoscope (fl ex x ) for other parts of the stone which were not accessible by the semi-rigid ureteroscope. ureteral access sheath was not used and only hydrodilation was performed. patients were evaluated preoperatively by ultrasound and plain x-ray of the abdomen and pelvis. pre-intervention sterilization of urine was performed in all patients using culture guided antibiotics. follow-up lasted for months.results: stone-free rate aft er a single session treatment was % and % aft er second session. mean operative time was . ± . minutes. th e mean fl uoroscopy exposure time was . ± . seconds. mean hospital stay was . ± . days. all patients had jj stent inserted. no major complications (clavien iii-v) occurred. none of the children received blood transfusion. th ree patients needed a second session of rirs, patient required a pnl session.conclusions: retrograde intra renal surgery using combined semi-rigid and fl exible ureteroscope off ers eff ective and safe option for treatment of medium sized renal stones children with comparable results to shock wave lithotripsy (swl) and percutaneous nephrolithotomy (pnl). introduction and objective: calcium stones are associated with osteoporosis and manifested mainly by elevated fasting urinary calcium/creatinine ratio. th e objective of this study is to demonstrate the presence of abnormal metabolism of calcium and calciuria in women with osteoporotic fracture with no previous-ly known renal lithiasis compared to women without osteoporosis and without renal lithiasis. eighty-seven women were included in the study and divided into two groups: group : postmenopausal women with osteoporotic fracture and without renal lithiasis; group : postmenopausal women without osteoporosis and without history of renal lithiasis. th e following parameters of phospho-calcium metabolism were analyzed: calciuria h, oxaluria h, uricosuria h and citraturia h. th e presence of hypercalciuria, hyperoxaluria, hyperuricosuria and hypocitraturia was compared between the two groups. statistical signifi cance was determined as p≤ . . results: th e mean age was . ± . years in group and . ± . years in group (p = . ). women in group had higher levels of serum alkaline phosphatise (p< . ) and fasting urinary calcium/ creatinine ratio (p< . ) than women in group . th e percentage of women with hypercalciuria in group ( %) was higher compared to women in group ( . %) and statistically signifi cant (p = . ). th ere were no statistically signifi cant diff erences in the percentage of hyperoxaluria, hyperuricosuria and hypocitraturia between the two groups. th is paper has the limitations of cross sectional study in a unique center and with a low number of patients. dept. of urology, ulster hospital, dundonald, uk introduction and objective: bladder stones are more common found in children from developing countries. open cystolithotomy or transurethral cystolithalopaxy are the traditional treatment but a percutaneous approach has been advocated. we present our experience with percutaneous cystolithotomy in children with bladder stones without any ultrasonic or fl uoroscopic guidance. from april to october , a total of children ( boys and girls) with a mean (range) age of . ( - . ) years underwent percutaneous cystolithotripsy (pccl). th e mean (range) stone diameter was . ( . - ) cm. one hundred thirty-eight children ( %) had a solitary stone while nine ( %) had more than one stone. th e main component of the stones were calcium oxalate in patients ( . %).results: all children were stone-free aft er one pccl; no recurrent stones developed. th e mean (range) pccl procedure time was . ( to ) min and intraoperative blood loss was scant. perioperative complications were few. th e mean (range) hospital stay was . ( - ) days.conclusions: blind access pccl (without any ultrasonic or fl uoroscopic guidance) is a facile and safe approach for removing stones in the pediatric bladder stones. advantages include the lack of ionizing radiation, no need for opacifi cation by iodine contrast media and low relative cost. we recommend this minimally invasive technique for management of large bladder stones (larger than cm) in children. to our knowledge, this is the largest single center series re-ported on percutaneous cystolithotripsy of endemic bladder stones in children. retrograde intrarenal surgery (rirs) in an unusual kidney ( ), polycystic kidney ( )]; who underwent rirs for stone management was evaluated. stone size was less than mm in all the cases. bleeding being the commonest complication, hemoglobin drop was measured to fi nd out the blood loss. all patients were assessed by x-ray and usg on the fi rst postoperative day and month follow-up. th e other parameter of focus was operative time, hospital stay, stone free rate and the auxiliary procedure. th e auxiliary procedure was divided as (staged, follow-up ( month) or other-pcnl/swl) so that stone free was the main target for the patients. conclusion: urolithiasis occurs in an abnormal kidney, indeed challenging, but rirs can also be performed successfully. proper handling of instrument can increase the longevity of the instrument for cost eff ectiveness. although complete stone clearance cannot be achieved, but meritorious achievement is less morbidity, early recovery, minimal bleeding with less complication. th us, rirs can be performed effi ciently, effi caciously and successfully in an unusual kidney with prior exposure of rirs. value of intraoperative ultrasound in decreasing of the risk of residual radiolucent stone post-pcnl al shareef j, aboelmagd m introduction and objective: hemorrhage is the most concerning complication aft er tubeless percutaneous nephrolithotomy (pcnl). we compressed the access tract of the kidney with oxidized regenerated cellulose (surgicele) aft er pcnl to facilitate homeostasis for tubeless pcnl. since april to september , pcnl was performed at our hospital. all patients received one stage procedure with metal dilator. aft er the end of stone extraction, the access tract was cauterized and an f foley catheter was inserted to the renal pelvis through the working sheath then infl ated and gently retracted. th e working sheath was withdrawn to the renal capsule and the access tract of the renal parenchyma was packed with surgicele and compressed with small sized dilators through the working sheath for minutes. a bloodless tract usually could be obtained in nearly every patient and all patients underwent tubeless modifi cation. th e results of these patients were analyzed with retrospective chart review.results: th e age of these patients ranged from to (mean . ) years old. th e average stone size was . ( . - . ) cm and the average operation time was . ( - ) minutes. th e target stones had been removed in all patients and the overall stone free rate was . %. th e postoperative blood transfusion rate was . % with no patient underwent angiographic intervention or other management for severe hemorrhage. postoperative fever was noted in . % patients and sepsis was noted in . % patients. th is study was designed to evaluate the adverse eff ects of swl on the metal devices for spine fi xation and the hemoclips for hemostasis. a total of cases who underwent swl for treatment of upper ureteral and renal stones were investigated. th eir ages were from ~ years (mean . ± . ). male patient was one and female patients were . th e piezolith (wolf, germany) was used as the lithotripter. th e metal devices were hemoclips for cholecystectomy in one, and pedicle screw in fi ve patients and bone cement (polymethylmethacrylate) in one patient for spinal fi xation through l to s . th e locations of the stones were the kidneys in and the upper ureter in patients and their sizes were from . cm to . cm (mean, . ± . ) . th e numbers of the swl were . ~ . times (median, ) . th e distances between the stones and metal devices were . ~ . cm (mean, . ± . ). th ey were followed-up for . ~ . months ( . ± . ). th e complications were investigated in terms of pain, fever, damage of the devices (change of morphology and location in simple x-ray fi lm and their function). no patient showed fever and pain in sites of the devices requiring medication, injection or other management during or aft er swl. one patient was admitted for acute colick fl ank pain with tenderness in costovertebral angle caused by acute ureteral obstruction by a crumbled small piece of the stone. th ere was no complication concerning with the eff ect of the swl on metal devices. even though swl is one of the safe treatment modality in various clinical fi elds, it can't be said that swl is always safe without complication. however, it can be said that it would be safe when it being done following the instruction. a prospective study to identify risk factors of pleural injury during percutaneous nephrolithotomy a total of patients with renal/upper ureteric stones, undergoing pcnl between january and june were evaluated for pleural injury. an erect chest x-ray antero-posterior view on inspiration was done within -hours of pcnl. th e patients were divided into groups a and b depending on whether they developed or did not develop pleural injury. patient-, stone-, renal-and procedure-related factors were compared between the two groups. patients with any known disease of lungs or pleura, patients undergoing simultaneous bilateral pcnl, relook nephroscopy, concomitant other procedures such as endo-pyelotomy or retrograde ureterorenoscopy were excluded from study. tract dilatation up to -f was done using alken metal dilators and an amplatz sheath was placed into system. nephroscopy was done with rigid nephroscope and stones were fragmented with pneumatic lithoclast.results: pleural complications occurred in patients ( %). out of patients, had supra-costal puncture and ( . %) developed pleural injury; patients had infra-costal puncture and pleural injury occurred in ( % on multivariate analysis, only low bmi and mean age < -years was associated with higher risk of pleural injury. th e limitation is the small number of patients (as pleural injury is not common a very large number is needed to show signifi cance).conclusions: higher incidence of pleural injury was noted in patients with low bmi and younger age. large multicenter study can provide a true picture. flexible and rigid ureteroscopy in th e success rate was defi ned as radiopacities less than mm on plain fi lm at one month follow-up aft er the fl exible ureteronoscopic procedure. our tips included: tip , moving technique, refers to move the lower pole stones to the upper pole or middle pole depending on the convenient site for fragmenting the stones with the escape basket. if the stones were large or the lower pole orifi ce is narrow, we fragmented the stones into two or more pieces, trapped and moved the stones into the convenient pole. tip , holding technique, refers to hold the stones in the renal pelvis and insert a laser fi ber through the escape to fragment the stones. tip , sheath technique, refers to extract the large stones and pull the stones to the sheath distal side, the stone was too large to pull out, a laser fi ber was inserted though the escape, fragmented the stones. all the videos were recorded.results: overall success rate was . %. th e success rate in the renal pelvis stone, upper pole, middle pole and lower pole was %, . %, . %, . % respectively. th e operating time was . minutes on the average. th ree patients had fever over °c aft er the procedures. no urosepsis occurred.conclusion: our tips are feasible in the treatment of kidney stones with fl exible ureteronoscopy. satisfactory success rate, shortening operating time, less fl exible ureteronoscopy consuming and less complication were obtained in the procedures of fl exible ureteronoscopy with escape. ureteroscopic introduction and objective: patients with underlying diseases, especially in old-aged, the urinary tract obstruction with the ureter stone would progress to the severe condition like renal failure or sepsis. prompt urinary diversion like percutaneous nephrostomy or removal of the stone via ureteroscope is necessary for these patients. however, most of them have poor general conditions to endure regional or general an-esthesia. so, we tried to implement the ureteroscopic removal of stone (urs) without anesthesia for the patients with ureter stone who were in septic conditions or severe urinary tract infections (uti). fift een patients ( males and females) included this study and all of them had serious problems like sepsis, heart problems or lung problems which were diffi cult to endure anesthesia. most of them were inserted pre-operative percutaneous nephrostomy catheter (pcn) due to impending septic shock. all of the stones were impacted in the ureter and urs were successfully performed with painkiller like pethidine mg iv. success rate of stone removal, pain perception during operation using a visual analog pain scale were done. results: th e mean age of the patients was . (± . ). th e position of the stones was as follows; upper ureter, mid-ureter and lower ureter stones. and there was no patient that had to stop the operation because of intolerable pain. th e mean of vas (visual analogue pain scale) was . (± . ). overall success rate was %. however, % of cases were unable to fi nd the impacted calculi but stone debris and blood clots. th e general condition of the patients except one was improved quickly aft er operation and discharged aft er . (± . ) days.conclusion: most obstructive uropathy due to calculi was in serious conditions to need immediate procedures and urs were safely and successfully performed under intravenous analgesics. in some of female patients, urs is well-tolerated even without analgesics. prompt urs procedure with intravenous analgesics can recover these conditions with minimal morbidity. geavlete p, georgescu d, multescu r, geavlete b introduction and objective: percutaneous nephrolithotomy (pcnl) is nowadays a widely practiced procedure. despite the good stone-free rates, it still has a specifi c morbidity. our goal was to describe the complications of this method on a signifi cant series of patients. between january and january , patients (age between and years) underwent pcnl ( procedures). we used f rigid nephroscopes and f fl exible ones ( procedures). th e mean follow-up period was months (range to months).results: intraoperative incidents were encountered during procedures ( . %): losing the percutaneous traject ( cases), poor visibility due to bleeding and imposing the termination of the procedure ( cases) and descendant stone fragments' migration imposing antegrade ureteroscopic removal ( cases). th e overall complications' rate was % ( cases): signifi cant bleeding requiring blood transfusions ( cases), emobolisation ( cases) nephrectomy ( cases) or open surgical hemostasis ( cases), sepsis ( cases), fever ( cases), pyelocaliceal perforations ( cases), hemoperitoneum ( case), persistent lumbar uri-nary fi stulae requiring retrograde jj ureteral stenting ( cases) and extra-renal stone fragments migration ( cases). however, the majority of these complications were minor. th e mortality rate related to pcnl procedures was %.conclusion: according to our experience, pcnl is a safe and eff ective technique. most of the intraoperative incidents or complications are minor and easy to solve. however, an adequate training is imperative in order to reduce the associated morbidity. is spinal anesthesia adequate for percutaneous nephrolithotomy? introduction and objective: to evaluate the adequacy of spinal anesthesia in terms of patient and surgeon satisfaction and convenience during percutaneous nephrolithotomy. patients who were candidates for percutaneous nephrolithotomy and operated by two endourology fellows during july -september were enrolled. spinal anesthesia was performed using an injection of . mg/kg bupivacaine . % in the intrathecal space; no opium (fentanyl) agent was used. all procedures were performed with the patient in the prone position. access was achieved by fl uoroscopic guidance, and the tract was dilated using a single-stage technique. anestheisa duration was defi ned from injection of anesthetic medication to fi xation of nephrostomy tube. operation duration was defi ned from start of cystoscopy to fi xation of nephrostomy tube. patient pain and satisfaction during operation and surgeon satisfaction was measured by an ordinal likert-type scale and collected by an examiner blinded to the study objectives.results: a total of patients (mean±sd age, . ± . years; male) were enrolled during the study period. th e mean±sd of anesthesia and operation duration were . ± . and . ± . minutes respectively. severe pain causing signifi cant discomfort to the patient and surgeon was observed in patients ( %). in three patients the operation was prematurely terminated because of excessive pain and/ or agitation of the patient. mild-moderate pain was observed in eight patients ( %). vomiting and headache was observed in another two patients. the african : our experience of stenting ureters in outpatients without screening or ga introduction and objective: to review ureteric catheters/dj stents placed under local anaesthetic, with antibiotic coverage, without the use of screening, at groote schuur hospital (gsh) over the last years. a prospectively collected database exists from july until present. all patients signed informed consent and received pre-procedural oral antibiotics. a post-procedural abdominal kub radiograph was obtained to ensure correct placement. demographic data and variables (stent/catheter, indication, side, success/failure -including reasons for failure) were collected. patients were asked to subjectively rate the level of pain at the end of the procedure.th e data has been collected and tabulated into an ex-cel® worksheet.results: a total of procedures (average . per year) were performed with age range from to years (average: . years). th e average time taken was minutes (median: minutes). th e shortest procedure recorded was minutes, and longest was minutes (with a failure). th e failure rate totals . % and further inspection shows that . % of failures were with bilateral stents, . % right sided and . % left sided. stated diff erently, % ( / ) of bilateral stents failed, . % ( / ) of right sided stents failed, and . % ( / ) left sided stents failed. th ere was a success rate of . % with stenting under local anaesthetic. th e average subjective pain score was . , which is tolerable. sivalingam et al ( , urology : - ) showed the average cost for stenting under general anaesthetic was almost times more expensive than under local. th eir local group had a failure rate of . %, which was lower than our . %, but we had a larger group ( in years vs. in years).conclusion: flexible cystoscopy and stenting under local anaesthetic without screening is useful and feasible, with minimal morbidity, discomfort and failures. it can be practiced as a cost eff ective, offi ce-based procedure and is suitable for the third world environment. introduction and objective: urolithiasis is an ancient disease with global distribution and is an important health problem all over the world. th ere are diff erent results for stone clearance rate in diff erent renal and ureteric locations aft er eswl. here we share our experience of the comparison of stone free rates and complications in diff erent renal locations. a retrospective study in which we included adults (age above years old) who underwent eswl from january to december . eswl was done by standard technique. we used modulith sl x lithotripter th generation storz medical. we followed patients for to months aft er last eswl session done. stone free status was defi ned as residual stone not more than mm in size. we reviewed data charts of patients for diff erent variables mentioned in results. introduction and objective: tubeless percutaneous nephrolithotomy (pcnl) for staghorn calculi has been reported to be safe and eff ective in select patients. although outpatient pcnl has been recently been shown to be safe and eff ective in a series of patients, it requires further study before urologists embrace same day discharge following pcnl. th e objective of this study is to report our early experience in treating staghorn calculi with pcnl on a completely outpatient basis, assessing its safety and effi cacy. a review of all outpatient tubeless pcnl cases between march and may at two canadian centres was performed, including collection of preoperative, intraoperative and postoperative data. strict preoperative, intraoperative and postoperative criteria were used in the selection of candidates for outpatient pcnl: no intraoperative complications including signifi cant bleeding or collecting system perforation; postoperative hemodynamic stability; adequate pain control; reliable patient with supportive family.results: fift y patients underwent ambulatory pcnl during the study period. staghorn calculi were treated in patients including cases of bilateral staghorn calculi, resulting in a total of staghorn renal units treated by ambulatory pcnl. all patients were discharged home uneventfully - hours postoperatively. th ere were no major postoperative complications, emergency room visits, hospital readmissions or deaths. th e stone-free rate was %, with of the renal units being stone-free at follow-up.conclusion: th is small series represents the largest series of ambulatory pcnl for staghorn calculi to date. in very carefully selected patients, pcnl for staghorn calculi on a completely outpatient basis appears safe and may be feasible. further research on ambulatory pcnl for staghorn calculi is required prior to widespread adoption by urologists. introduction and objective: th e most diffi cult aspect of percutaneous nephrolithotomy (pcnl) is frequently the renal puncture. most are performed under fl uoroscopic control. parallax, the assessment of the displacement of an object when viewed along two lines of sight, is the concept which allows the surgeon to gauge the d relationship of the needle to the kidney from a d fl uoroscopic image. whilst most urologists appreciate successful access correlates with both kidney and stone images moving in unison on rotation of the c arm (or "reverse parallax"), confusion oft en arises with unsuccessful attempts in relating how to amend the puncture with the radiological fi ndings. we create a model to describe visual observation of parallax. by way of a short video we outline how it can be implemented seamlessly into routine pcnl.results: visualization of the theory followed by its application in theatre clearly demonstrates a failsafe technique to allow operators to reliably detect when their puncture needle is deep or superfi cial to the stone.conclusions: parallax, as an adjunct to routine fl uoroscopy during pcnl, allows the operating urologist to rapidly gauge depth of needle in relation to the collecting system in diffi cult access scenarios. familiarity with this technique is important to minimize radiation exposure, ensure satisfactory access to the collecting system and improve operating times. the signifi cance of non-enhanced compute tomography for renal colic has been overestimated in absence of pyuria kim t , ahn s , kang j , kim j , myung s , moon y , kim k , chang i introduction and objective: th e study was undertaken to compare clinical utility in patients undergoing non-enhanced computed tomography (nect) and intravenous urography (ivu) in patient with classic symptoms of renal colic without evidence of urine infection and to determine the clinical importance. th is was a retrospective observational analysis of all adult patients between and . all nect and ivu were reviewed and categorized as the cause of symptoms. non-urolithiasis cause were further categorized as "acutely important", "follow-up recommended", and "other unimportant cause". full record review blinding to imaging fi nding was underwent including demographics, diagnosis, and management. we compared stone characteristics on imaging study, and demographic, exact diagnosis, and management methods between nect and ivu groups.results: a total of , patients were available inclusion criteria and ( . %) patients were underwent ivu and patients were nect. th e incidence of nect was . % at , but . % at . nect group was older ( . ± . vs. . ± . years old, p< . ), less hematuria in urine analysis ( . vs. . %, p< . ) and more admit ( . vs. . %, p< . ) than ivu group. urinary stones were detected ( . %) patients. nect group showed higher proportion of renal stone, mid ureteral stone and multiple stones ( . vs. . %, p< . , . vs. . %, p< . , . vs. . %, p< . , respectively), and smaller stone ( . ± . vs. . ± . mm, p< . ), and more radiolucent stone ( . vs. . %, p< . ) comparing to ivu group. th e incidence of urolithiasis more than mm were no diff erence between nect and ivu groups ( . vs. . %, p= . on radiologic fi nding, and . vs. . %, p= . on full chart record). moreover, the incidence of "acutely important" among non-urolithiasis cause was similar between nect and ivu groups on full record review ( . vs. . %, p= . ) . th e incidence of the active management including surgery and extracorporal shock wave therapy (eswl) were not diff erence between nect and ivu group ( . vs. . %, p= . ).conclusions: nect is a rapid and accurate diagnosis test for suspected renal colic, and nowadays almost renal colic patients in our hospital underwent nect in ed. however, it did not show better advantage for the detection of clinically signifi cant urolithiasis and acutely signifi cant cause of renal colic in patient with renal colic and absence of pyuria. from january to july we reviewed the scrotal ultrasound images of all patients diagnosed with leydig cell tumor and treated with conservative surgery (group a). we considered only patients that were fi rst diagnosed at one of the participating centers. we create a random homogenous control group of patients (group b), in term of age and presentation, diff erent from the group a just for the defi nitive malignant histology. all the images were collected and we analyzed ultrasound features of the lesions classifi ed in terms of length, us lesion homogeneity, shape, presence of hypervascularization. th e collected data were analysed by an online regression (student's t-test, chi-square test, and logistic regression analysis).results: th irty fi ve patients with leydig cell tumor underwent conservative surgery at our centers. a random group b of patients was also considered. pa-tient mean age was . years (range to ) for the fi rst group and . years for the second one (range to ). patients presented either with a palpable testicular nodule ( patients group a, . % - patients . % group b) or a nodule diagnosed by ultrasound ( patients group a, . % - patients . % group b). mean ultrasound size was . cm and . cm for the two groups respectively (range . to . cm and . to cm). both groups had hypervascularization of the lesions with no signifi cant diff erences. patients presenting with lct (group a) had an homogenous ultrasound intralesional aspect and the shape is defi ned with an elliptic or spheroid mold while patients from group b had dis-homogenous intralesional aspect and non-defi ned margins (p> . ).conclusion: although most focal lesions will be malignant and require an orchiectomy, recognition of the benign entity may be challenging. in a small lesion mainly not palpable the presence of a well-defi ned shape with an homogenous intralesional ultrasound aspect do correlate with a lct. adult testicular pure yolk-sac tumor the association of torsion with testicular cancer: a retrospective study introduction and objective: testicular torsion is a medical emergency that usually requires surgical exploration of scrotum to allow reperfusion of the aff ected testis. nonetheless, such surgeries can be frequently resulted in orchiectomy due to tissue ischemia and necrosis. however, testicular malignancy has been anecdotally reported with the association of torsion in the surgical specimens and the literature remains scant on the association of torsion with testicular tumors. th is retrospective study was set to explore the association of torsion with testicular cancer in cases of testicular torsion undergoing orchiectomy during scrotal exploration. a chart review was performed for patients who admitted to our clinic and had a diagnosis of testicular torsion between january and february . data of patients' characteristics, the laterality of the torsion, time and type of intervention and pathological examination were recorded. results: overall, patients with a diagnosis of testicular torsion were identifi ed. th e mean age was . years (ranges from to years). all the patients had unilateral intravaginal testicular torsion aff ecting the left side in cases ( . %) and on the right side in cases ( . %). manual detorsion was successful in patients ( . %) all of whom underwent bilateral testicular fi xation surgery within hours via scrotal incision. twenty-six ( . %) patients underwent emergency surgery with a testicular detorsion and fi xation surgery in ( . %) cases (bilaterally in and right-sided in ) and orchiectomy in ( . %) cases ( in right side and in left side). th e type of incision was scrotal in cases, inguinal in cases and unspecifi ed in surgeries. pathological examination of specimens revealed ischemia and necrosis in cases, while patients underwent testicular removal via inguinal incision had malignancy including seminoma and malign mixed germ cell tumor.conclusion: our retrospective study, as the largest case series in the current literature, showed the association of intravaginal torsion with testicular cancer to be . %. further high-level evidences are needed to establish the optimal incision type in testicular torsion cases with surgical exploration to avoid scrotal violation resulted from suboptimal approaches. wong l , , dickson b , catton c , yap s , , alkasab t , van der kwast t , hamilton r , jewett m st vincent 's hospital, melbourne, australia; princess margaret hospital, toronto, canada; university of california davis, davis, usa introduction and objective: paratesticular sarcoma (pts) is an uncommon disease and the literature is mostly confi ned to small case series with short follow-up. herein we present an update on our institution's experience in the management of patients with pts. fift y-one men with pts at princess margaret cancer center, between and were identifi ed from retrospective chart review. important relevant clinical pathological variables were collected with study endpoints being local recurrence, metastasis and overall survival. univariate analysis of variables associated with survival end points was performed with cox proportional hazards regression.results: median follow-up of our cohort was . years (iqr . - . ) with a median overall survival of . years. at presentation . % (n= ) of men had localized disease. interval completion hemiscrotectomy (performed aft er initial unplanned diagnostic surgery) was done in men, in which % (n= ) had residual disease present. local recurrence (lr) occurred in patients ( . %). median time from diagnosis to lr was months. univariate analysis showed presence of positive margins at diagnostic surgery (hr . , p= . ) and upfront/ completion hemiscrotectomy (hr . , p= . ) to be signifi cant variables. at last follow-up, / men ( . %) with lr were alive and disease free, developed metastatic disease with pts-related mortalities, and deceased of other cancer type. metastasis was present in men ( . %), with median time to metastasis mo, and median to from metastasis to death . mo. at last follow-up, . % (n= ) of the patients were deceased with cases attributable to pts. on univariate analysis, there were no significant variables for metastatic disease, and age (hr . , ci . - . , p= . ) and non-localized disease at presentation (hr . , p= . ) were signifi cant for overall survival.conclusion: in our cohort of pts patients with median years follow-up, aggressive treatment of local recurrence ( . %) resulted in good disease free survival for of men. completion hemiscrotectomy, particularly for positive margin disease, may decrease local recurrence. a rare case of testicular metastasis from primary lung adenocarcinoma: case report and ten-year review of testicular pathology at a single institution demkiw s , jackett l , goad j , wong l introduction and objective: health care websites provide a valuable resource of health information to online consumers, especially patients. offi cial surgical and medical society websites should be a reliable fi rst point of contact. th e primary aim of this study was to quantitatively assess medical and surgical society websites for content and highlight the essential features required for a high-quality, user-friendly society website. twenty specialty association websites from each of the regions, australia, uk, canada, europe, and the usa were selected for a total of websites. medical and surgical specialities were consistent across each region. each website was systematically and critically analysed for content and usability.results: th e average points scored per website was . out of . of the total (n= ) websites, scored at least out of points and scored out of . as well, % ( . / ) of the websites had an infor-mation tab for patients on their respective homepages while % ( . / ) had download access to patient information. a minority of the websites included different forms of multimedia such as pictures and diagrams ( . / , %) and videos ( . / , %). we found that most society websites did not meet an adequate standard for delivery of information. half of the websites were not patient accessible, with the primary focus being for health professionals. as well, most required logins for information access. specialty health care societies should create patient-friendly websites that would be benefi cial to all online consumers. application materials and methods: students were selected by sampling in pbl group (n = ) and pbl-ebm group (n = ), and the two groups received clinical teaching of urology by pbl and pbl-ebm model respectively. at the end of the study, each student received objective and subjective evaluation.results: th ere was no signifi cant diff erence in results of the baseline on evidence-based medicine between two groups (p> . ), but the percentage of high-recommended-level research evidence obtained by the students in the pbl-ebm group was signifi cantly higher than that in pbl group (p< . ). and questionnaire showed more students in pbl-ebm group believed that this teaching model improved their ability of comprehensive analysis and application of medical evidence, and developed their skills in solving problem and obtaining information on various subjects (p< . ).conclusions: th e model of problem-based learning combined with evidence-based medicine is feasible and eff ective in clinical teaching of urology and optimize the outcomes from pbl education. by the pbl-ebm model teaching, students improve the ability to advantage in managing evidence from medical studies, analyzing and solving problem, obtaining and applying medical information. incidence (dvt) or pulmonary embolism (pe), is recognized as one of the most serious complications of surgery. in urologic surgery, this has not been well reported thus the objective of this study is to access the risk factors for the development of vte among patients undergoing major pelvic surgery for prostate and bladder cancer in an australian tertiary referral center. consecutive patients undergoing major pelvic uro-oncologic surgery, namely radical cystectomy and radical prostatectomy over a fi ve-year period ( - ) were identifi ed. patient variables, types of surgery, types of thromboprophylaxis (pharmacological and/or mechanical) used in this patient cohort were collected for analyses as predictive factors.results: an overall incidence of vte was . %. patients undergoing radical cystectomy were more likely to suff er a vte event compared to patients having radical prostatectomy. in this cohort, the risk factors for vte include, prolonged operative time of greater than hours, lymph node dissection (lnd) and patients requiring blood transfusions.conclusion: patient undergoing major pelvic uro-oncologic surgery have a % risk of developing vte. risk factors identifi ed in this study should be used to guide the use of early and prolonged thromboprophylaxis. optimal trial of void after idc insertion for pelvic surgery th am c , ho p introduction and objective: in , we pioneered the fi rst international twitter-based journal club (#urojc) to discuss urology articles on a monthly basis with diverse global participation. since that time, this model of an international twitter-based journal club has been adopted by several other medical specialties including general surgery, respiratory medicine and nephrology. th e objective of this study is to examine the development of the urology journal club into an innovative and thriving forum for exchange of ideas, information and opinions since its conception two years ago. monthly twitter analyses such as number of users, tweets and impressions for the journal club were obtained via a third-party service called symplur using the hashtag #urojc. qualitative analysis was also performed of each individual tweet to assess for relevance to the discussion. comparisons were made between data from the fi rst and second year of operation of the journal club, including the number and geographic location of participants, as well as the quantity and quality of tweets.results: see table for summary statistics. th e total number of unique users of #urojc almost doubled from year one to year two. th e mean number of total participants increased by seven per month, and mean number of total countries represented increased by three per month. while the number of tweets per month also increased from year one to year two, the proportion of content-relevant tweets remained stably high at approximately %. meanwhile, there was a greater degree of participation from authors of the study being discussed over time. journal club continues to draw robust participation from a global audience, and serves as a benchmark for twitter-based journal clubs in other specialties. th e majority of tweets are relevant to the content of the article, providing a novel forum to discuss new research fi ndings with a global audience. prognostic impact of perinephric fat stranding on computed tomography in ureteral urothelial carcinoma introduction and objective: ureteral urothelial carcinoma causes gradual ureteral obstruction. perinephric fat stranding is defi ned as linear areas of soft tissue attenuation in the perinephric space, which can result from any acute process or injury to the kidney. we analyzed the prognostic impact of perinephric fat standing as well as secondary signs of upper urinary obstruction on the oncologic outcomes of patients with ureteral urothleial carcinoma. a total of patients who were evaluated by abdominal-pelvic computed tomography (ct) preoperatively and were diagnosed with ureteral urothelial carcinoma aft er nephroureterectomy conducted between january and december were enrolled in this retrospective study. we analyzed the association between oncologic outcomes and clinical-pathologic fi ndings, including secondary signs of upper urinary obstruction on preoperative ct such as hydronephrosis grade, perinephric fat stranding, renal enlargement, kidney density diff erence, renal cortical thinning, periureteral fat stranding.results: preoperatively patients ( . %) had perinephric fat stranding on preoperative ct. multivariate analysis showed that perinephric fat stranding, higher pt stage (≥ t ), lymph node involvement of cancer, and positive surgical margin were independent prognostic factors of cancer-specifi c survival (p = . , p = . , p < . and p = . , respec-tively). and perinephric fat stranding, higher pt stage (≥ t ), lymphovascular invasion, and lymph node involvement of cancer were identifi ed as independent prognostic factors of recurrence-free survival in ureteral urothelial carcinoma (p = . , p = . , p = . and p = . , respectively).conclusion: perinephric fat stranding on preoperative ct in ureteral urothelial carcinoma was found to be an independent prognostic factor of disease recurrence and cancer-specifi c mortality. our fi ndings indicate that immediate radical surgery and adjuvant therapy should be considered in patients with perinephric fat stranding preoperatively. lower increased urinary tract malignancy in end-stage renal disease (esrd) has been reported. however, little is known in chronic kidney disease (ckd). th is study is designed to explore the association between ckd and upper urinary tract urothelial carcinoma (uut-uc). health insurance database, we included ckd patients between january and december . th e non-ckd controls were selected with the ratio : and frequency matched with gender, age group and index date. chi-square test and t-test were used to inspect sociodemographic information and comorbidities. logistic regression analysis was used to calculate hazard ratio (hr) and % confi dence interval (ci). a year-old man with a strong family history of various cancers presented with haematuria and was subsequently found to have a mass in the right pelviureteric junction suggestive of urothelial carcinoma. work-up confi rmed the diagnosis without evidence of metastatic disease and the patient went on to have an open transperitoneal nephroureterectomy. laparoscopic approach was initially attempted but abandoned due to dense adhesions thought secondary to previous open bowel resection for colorectal cancer. a fl ank incision was used; there were no specifi c operative complications and the specimen was easily retrieved without manipulation or rupture. post-operative recovery was unremarkable and histological analysis of the tumour revealed a non-invasive high-grade papillary urothelial carcinoma at the right pelviureteric junction with clear resection margins. approximately months post-operatively the patient re-presented with a rapidly enlarging mass at the fl ank incision. imaging demonstrated a circumscribed hypodense mass within the muscle layers at the site of the scar and biopsy revealed poorly diff erentiated carcinoma. surgery to excise the mass was subsequently performed and immunohistochemical analysis revealed a lack of staining for msh .results: abdominal wall metastasis following open nephroureterectomy for upper tract urothelial carcinoma is rare, with only one case reported previously. given patient's previous history of colorectal cancer, strong family history and immunohistochemical fi ndings are highly suggestive of lynch syndrome. incisional site tumour recurrence following surgery for urological malignancy is a very rare complication, with only a handful of case reports existing, mostly relating to port-site metastasis following laparoscopic surgery. wound recurrence following open surgery is an extremely uncommon but recognised event, more frequent in certain gynaecological and general surgical malignancies. ls involves inherited defects in the dna mismatch repair system, resulting in predisposition to a number of malignancies. urologists should consider the possibility of lynch syndrome in any patient with de-novo upper tract urothelial carcinoma, and strongly recommend genetic testing where patients meet the amsterdam ii criteria or are diagnosed under the age of . prognostic ) developed recurrent bladder cancer within years aft er nephroureterectomy, and the median interval between surgery and intravesical recurrence was . months (range to months). multifocal tumors, native aristolochic acid nephropathy and distal ureter invasion were determined as risk factors for intravesical recurrence by univariate analysis. however, by multivariate analyses, multifocality (hazard ratio = . , % ci = . - . , p = . ) and native aristolochic acid nephropathy (hazard ratio = . , % ci = . - . , p = . ) were identifi ed as independent predictors for the development of recurrent bladder cancer aft er surgery for uut-uc in renal transplant recipients.conclusions: th e incidence of intravesical recurrence aft er laparoscopic nephroureterectomy for uut-uc in renal transplant recipients is high, and most subsequent bladder cancers recur within years aft er surgery. tumor multifocality and native aristolochic acid nephropathy are signifi cant independent risk factors in developing initial intravesical recurrence aft er laparoscopic surgery for primary upper urinary tract urothelial carcinoma aft er renal transplantation.introduction and objective: transient urinary incontinence may occur in up to % of patients aft er holmium laser enucleation of the prostate (holep). however, there are few published data concerning the factors associated with de novo urinary incontinence (ui). th e aim of this study was to investigate the associated factors of de novo ui aft er holep. our study included patients who underwent holep. enrolled patients were divided into two groups according to the presence of ui. independent t test was used to compare between two groups. logistic regression was performed to analyze a correlation between de novo ui and other factors such as age, prostate volume, retrieved tissue weight, operative time, and the fi rst post-void residual (pvr) urine volume immediately aft er removing postoperative urethral catheter. urethral catheter was removed aft er bladder instillation with a ml normal saline via urethral catheter, and pvr urine volume was estimated immediately aft er the fi rst postoperative self-voiding. all defi nitions of ui corresponded to recommendations of the international continence society.results: aft er holep, patients ( . %) had de novo ui, most of which resolved within - months; had stress ui, had urgency ui, and had mixed ui. age and pvr urine volume were signifi cantly higher in ui group than non-ui group ( . ± . vs. . ± . years; p = . , . ± . vs. . ± . ml, p < . ). in a logistic linear regression analysis, only pvr urine volume was an independent predictor of de novo ui aft er holep. th e most optimal cut-off value of pvr urine volume for predicting de novo ui was defi ned as . ml in the receiver operating characteristics curve analysis (sensitivity, . %; specifi city, . %; auc, . ; p < . ).conclusion: about one-third of patients might undergo de novo ui following holep, and most of them might have been resolved within - months. high pvr urine volume aft er removal of postoperative urethral catheter is associated with de novo ui aft er holep, and could be used a practical tool to predict postoperative de novo ui. concomitant transurethral and introduction and objective: stress urinary incontinence is a common medical problem among women. th e urethral closure complex and/or the support mechanisms are responsible for incontinence in the majority of patients. several surgical procedures with diff erent degrees of invasiveness and outcomes have been reported to treat the problem. although many are reasonably eff ective, a general trend towards study of natural and biocompatible tissues is emerging over popular synthetic materials. here we report our experience with injection of autologous adipose-derived stem cells to the periurethral region as a new method of stress urinary incontinence treatment. ten women with symptoms of stress urinary incontinence were treated by injections of autologous adipose-derived stem cells into the periurethral region via transurethral and transvaginal approach under urethroscopic observation. th is report presents the short-term outcome of the patients. th e outcome measured by pad test results, iciq-sf scores and qmax.results: th e mean age of the participants was . ± . years. urinary incontinence signifi cantly decreased through the fi rst two, and weeks aft er the injection therapy. th e diff erence was signifi cant in pad test results (p< . ) and iciq-sf scores (p< . ), especially comparing results between and weeks and among and weeks, but not for and weeks compared to each other. surprisingly, qmax showed improvement aft er the study period (means . vs. . ; p= . ). th is study showed that injection of the autologous adipose-derived stem cells to periurethral region is a safe, yet shot-term eff ective treatment option for stress urinary incontinence. further studies with longer follow-up are needed to confi rm its longterm effi cacy. sparc sling system for treatment of female stress and mixed urinary incontinence in the elderly sung l, noh c, chung j, yoo j introduction and objective: th e aim of this study was to investigate the safety and effi cacy of the suprapubic arch (sparc) sling procedure for the management of urinary incontinence in elderly versus younger women. a total of women underwent the sparc procedure for female urinary incontinence. of these patients, were classifi ed younger women (sui, . mui, ) and (sui, . mui, ) were elderly (more than year). th e preoperative evaluations included a complete medical history, a female bladder questionnaires, urogynecological examination and urodynamic test with valsalva leak point pressure (vlpp). th e main outcome measures were perioperative morbidity, postoperative sui, persistent or de novo urge incontinence, postoperative complication and voiding dysfunction. th e objective and subjective success rate were evaluated by visual analogue score and global patient impression questionnaire at , , months. th e mean follow-up period was ± mo (range, - mo).results: th e incidence of sparc related morbidity was similar in both groups. for the operation outcome results, in younger group ( patients) there were cases of cure ( . %), cases of improvement ( . %), and cases of fail ( . %) and in elderly group ( patients) there were cases of cure ( . %), cases of improvement ( . %), a case of fail ( . %) (p> . ). th e operation satisfaction rate of patients was . % in the younger group and . % in the elderly group (p> . ). a total of patients ( . %) would like to recommend the sparc procedure to others. th e objective success rate and operation satisfaction rate of the younger group did not diff er from elderly group. no severe intraoperative or postoperative complications occurred in both groups.conclusions: th e sparc procedure is eff ective and off ers a satisfactory cure rate without signifi cant morbidity in elderly women. validity introduction and objective: urinary incontinence secondary to surgery or trauma is a debilitating condition for the patient, and for the urologist a diffi cult situation to manage. because of the complexity of reconstructive surgical techniques and the cost of the prosthetic devices used, there is a need for a simple procedure. aims: we here in report our experience in managing urinary incontinence secondary to sphincteric incompetence in patients using a modifi ed bulbar urethral sling procedure over a period of years. results: all patients were continent postoperatively, with only mild stress leakage in the erect posture in two patients, during a mean follow-up of . months (range - months) and required one or some time two pads per day to remain continent during the daytime. one patient required clean intermittent catheterization for a short period postoperatively. conclusions: th e male bulbourethral sling procedure using a polypropilene mesh is economical and safe but further experience is needed to establish this procedure as an alternative for the treatment of male urinary incontinence. investigation of a teikyo university, tokyo, japan; juntendou university, tokyo, japan introduction and objective: th is study compares the safety and benefi ts of administering anticholinergic agent propiverine hydrochloride in combination with adrenergic alpha- receptor antagonist silodosin (sp group) as therapy for patients diagnosed with benign prostatic hyperplasia with overactive bladder, as opposed to administering silodosin alone (s group). th is study included male patients aged or above who had an international prostate symptom score (i-pss) of or more, an overactive bladder, a qol index of or greater, an overactive bladder syndrome score (oabss) of or more along with an oabss urgency score of or greater, and a maximum urinary fl ow rate of < ml/s. at random, patients were assigned to the sp group, and to the s group. th e sp group was administered mg/day of silodosin along with mg/day of propiverine hydrochloride and the s group mg/day of silodosin only, for weeks respectively. i-pss, qol index, oabss urofl owmetry results, and residual urine were evaluated prior to therapy and , , and weeks post-therapy.results: th ere were no statistically signifi cant diff erences in patient background between the two groups. statistically signifi cant improvements were seen in i-pss total score, qol index, and oabss weeks post-therapy, but there were no statistically signifi cant diff erences between the two groups. both groups refl ected statistically signifi cant improvements in i-pss storage symptom scores and voiding symptom scores, but there were no diff erences between the two groups. analyzing by prostate volume, among those with lower prostate volume (average . ± . mm ), the sp group showed a statistically signifi cant improvement in i-pss total score and oabss as compared to the s "monotherapy" group. no serious side eff ects were shown in either group.conclusion: among benign prostatic hyperplasia patients with overactive bladder, those treated with silodosin alone showed statistically signifi cant improvements in both storage and voiding symptoms, as did those additionally treated with propiverine hydrochloride. results were even more benefi cial when both silodosin and propiverine hydrochloride treatment were used for patients with lower prostate volumes. the effi cacy and safety of fesoterodine in vulnerable elderly patients with overactive bladder takeda h, nakano y, narita h introduction and objective: we evaluated the efficacy and safety of fesoterodine in medically complex vulnerable elderly patients with overactive bladder. in this -week, patients were community dwelling men and women years old or older. patients with oab had scores of less or more on the ves- by nccn (vulnerable elders survey). we evaluated the changes of each parameter before and to weeks aft er the administration of fesoterodine mg per day. th e overactive bladder symptoms score (oabss), ipss were used as a subjective questionnaire for overactive bladder symptoms. we compare between vulnerable elderly group and no-vulnerable elderly groups. statistical comparisons before and aft er the administration were made using the wilcoxon signed-rank test. to examine the relation between oabss and ipss, spearman's testing was used for correlations between independent variables and p< . was considered statistically significant. safety evaluations included self-reported symptoms and post-void residual volume.results: a total of patients were enrolled (mean age . years, . % age years or greater). th e vulnerable elderly patients had high rates of comorbidities, polypharmacy and functional impairment. at week both group had insignifi cantly greater improvements in oabss (p= . ) and ipss (p= . ). adverse eff ects were generally similar.conclusions: fesoterodine improved overactive bladder symptoms not only in no-vulnerable elderly patients, but also in vulnerable elderly patients. the effectiveness and tolerability of fesoterodine mg in "real world" outpatient clinical settings the benefi cial effect of a combination of solifenacin and mirabegron on oab patients persu c, paraianu b, nita g, geavlete p introduction and objective: th e development of a new drug class intended for the treatment of oab patients opened a new and promising era for our patients. th e current study aims to evaluate the eff ects of a combination therapy using an antimuscarinic and mirabegron. we designed a prospective study including oab patients with or without wet episodes. treatment was started with two months of solifenacin mg, then mirabegron mg was added for the next two months. th e patients were evaluated using a bladder diary for three consecutive days at the end of each treatment period. we compared the total number of voidings, the number of urgency episodes and the number of urge incontinence episodes. th e statistical analysis included only the patients who fi nished the whole four month period. a total of fourteen female sprague-dawley® rats weighing - g were used, which were randomly divided into two groups. both the experimental group and the control group, fourteen rats were inserted intrathecal catheter in the spinal l -s segment. seven days later, all rats were catheterized through the bladder dome for saline-fi lling cystometry. in experimental group, seven rats were given intrathecal diff erent concentration ketanserin ( . - . mg/kg) dose-response curves for ketanserin were followed by doi ( . mg/kg) test.in control group, seven rats were given intrathecal normal saline. all rats were intravascularly perfused with % paraformaldehyde aft er the completion of the urodynamic recordings. th e l -s spinal cord were removed and pathological sections and immunohistochemical staining were made. meanwhile, we observed and recorded the distribution of -ht a receptors in the spinal motor neuron. results: th irty-four patients were included in the study. twenty-four of them completed the follow-up. twenty-one were female and were male with an average age of . years ( - years). detrusor sphincter dyssynegia was the most common abnormal urodynamic fi ndings in these patients. th ere was an improvement in bladder capacity, detrusor and sphincter action following de-tethering surgery.conclusion: urodynamics should be considered as a part of preoperative evaluation in all patients with primary tethered cord syndrome to decide the urological aspect of management. urinary bladder reinnervation with creation of a "somato-autonomic" refl ex pathway in rabbits -s ) and detrusor muscle (recipient, s -s ) were located. aft er their resection, intradural anastomosis of donor root to the recipient distal root stub was performed. th ose roots whose stimulation elicited the largest response were always selected. aft er - months (mean months), the artifi cial refl ex arc's function was examined (to date in rabbits). under general anaesthesia, skin segments l -s were peripherally stimulated and then the spinal root above the anastomosis was stimulated. detrusor response was measured using an emg strip electrode and intravesical pressure (pves) monitoring and sphincter response using an emg needle electrode. a root sample from under the anastomosis was resected for histology.results: electromyography confi rmed detrusor response to peripheral skin stimulation in ( %) animals and sphincter response in ( %). five ( %) animals displayed elevated intravesical pressure (pves) up to cm h o. root stimulation induced detrusor and sphincter emg response in ( %) and ( %) rabbits, respectively, and ( %) animals displayed increased pves up to cm h o. micturition was not induced in any animals. with confi rmed detrusor contraction (emg, elevated pves), external sphincter activity was never inhibited. somatic-to-autonomic anastomosis creation was histologically confi rmed in all samples. hind limb paresis occurred in ( %) animals and spinal lesion in ( %).conclusion: lumbar-to-sacral-nerve rerouting is a technically manageable method with donor root fibres verifi ably joining recipient roots. only in a limited percentage of cases, however, can the method achieve positive functional results, i.e. demonstrable detrusor contractions and elevated intravesical pressure. physiological micturition without detrusorsphincter dyssynergia as described in the literature did not occur in our experiment. development in this study, we evaluate the effi cacy of the prototype intravesical pressure sensor integrated into a catheter-like tube and in the rabbit and biocompatibility of ecofl ex® as a packing materials in the rats. th e catheter type wireless pressure sensor is manufactured by direct inserting the prototype sensor into the port split from the feeding tube between the sensor and the port so the tube could hold the bladder pressure. th e tip of the tube is results: th e measured resonance frequencies and the pressure data converted from those signals were compared to the reference pressure data obtained from a conventional cystometry. th e scale factor of the sensor to correlate the prototype sensor resonance frequencies to the reference pressure data is - . kpa/ mhz (=- . mhz/kpa), comparable to the result of its in-vitro measurement, a pressure responsivity of - . mhz/kpa. increased macrophage activity and mif in the bladder were revealed in the early phase aft er implantation of ecofl ex®. however, decreased macrophage activity and mif in the bladder were observed in the later aft er implantation. furthermore, decreased infl ammatory cytokines were also observed at that time. in this study, we demonstrated the feasibility of the catheter type which is non-invasive method and easy to apply to patients in actual examination. further investigation to overcome the limitation of the prototype intravesical pressure sensor is necessary for the application to the real life practice. in addition, ecofl ex is biocompatible materials for the implanted medical devices in the bladder. introduction and objective: urethral pressure profi le (upp) is a primary method for evaluating urethral continence function in human beings. however, upp recording in female rat, a widely used animal model, has been challenging because of the animal's small body size. th is study reports a novel method for recording upp in female rats. seventeen anesthetized female rats were studied. leak-point pressure (lpp) data of rats were included; the other rats were excluded due to animal die or abnormal urogenital organ. upp curves were recorded using a modifi ed method of water-perfusion catheter system, with the lateral hole facing -, -, -, -o' clock positions respectively in a randomized sequence. lpp, functional urethral length (ful), and maximum urethral close pressure (mucp) were the analysis parameters. in the era of aging society, an easy-to-use screening tool for voiding dysfunction refl ecting to activity of daily life is much-needed. bladder diary (frequency volume chart) is gold standard to check urine storage status, but diffi cult for elderly to measure and record all the time. urofl owmetry is useful to check voiding status, but limited to clinics or hospitals. we developed a portable device, p-urofl owdiary®, which records every urine fl ow with bladder diary at home. we elucidate the feasibility and the usefulness of this device. materials and methods: p-urofl owdiary® records voiding time and date, length of voiding, voided volume, fl ow rate and self-evaluation of every urination for a couple of days with gravimetric determination method. th e device consists of a disposable urine cup, a load cell and the circuit board on which microcomputer, clock, acceleration sensor, audio guidance, bluetooth and sd card mounted. self-evaluation of every urination is recorded by pushing one of the four buttons on the body-side, which represent "very good", "good", "bad" and "very bad". th e data in sd card are analyzed using the dedicated soft ware. accuracy of the measurement has been approved in a comparative study of the device and an existing urofl owmeter. th e infl uences of hand shaking are canceled by acceleration sensor and are smoothed by the soft ware.results: th e feasibility study were done under the approval of irb of nara medical university. first semester study in healthy volunteers focused on user-friendliness. th e results were almost acceptable except for female volunteers, especially in elderly. th e urine volume and peak fl ow rate as well as self-evaluation were linearly related in volunteers who measured multiple sessions. a clinical trial in patients with voiding dysfunction is in operation in seven institutions, and summarized data will be reported.conclusion: p-urofl owdiary® is light and small and easy-to-use at home even in elderly. although its practical usefulness as voiding diary have been proved, the usefulness as urofl owmetry and self-evaluation of every urination is not clarifi ed yet. however, p-urofl owdiary® seems to be a useful tool for screening of voiding dysfunction as well as assessment of therapeutic performance. to determine the continence position and the contributory factors in the female canine urethra. materials and methods: by using adult female dogs, we determined the continence function of each mm intervals of the urethra when we excluded these segments by progressively inserting a fr catheter and recording the abdominal leak-point pressure (alpp). th e urethral pressure profi le (upp) and alpp were determined before and min aft er occlusion of the abdominal aorta. each urethra specimen was split into segments averagely and the histological components were determined. th e relationship between the histological components and the urodynamic parameters were analyzed.results: th e striated muscle confi ned to the distal / urethra. th e anatomic structure of the proximal / urethra was found to be quite homogenous, which surrounded by circular smooth muscle. th e connective tissue constituted with abundant collagen fi bers and vascular plexus was most voluminous in the distal / urethra, and relatively richer near the bladder neck. upp had pressure zones: high pressure zone corresponding to the distal / urethra and low pressure zone corresponding to the proximal / urethra. alpp decreased sharply when exclusion progressed over the distal / urethra. alpp and mucp decreased about % and % aft er occlusion of aorta, respectively. th e distribution of the urethral pressure or pressure change is in accordance with the location of the striated muscle sphincter; there is no linear correlation with any other particular tissue component in the diff erent urethral segments.conclusion: th e strongest continence function locates at the distal / urethra with striated muscle layer; the remaining / proximal urethra lacking striated muscle has only weak continence function. striated muscle is the predominant contributory factor to continence and the other components like vascular sinusoids, smooth muscle, collagen fi bers are minor contributory factors. urodynamics in children: a -year experience persu c, mirciulescu v, geavlete p introduction and objective: urodynamics, in the modern defi nition of the term, developed rapidly from a state of the art gadget into an extremely useful tool in the armamentarium of the modern practitioner, who is no longer accepting the clinical exam as the mainstay of the diagnosis, but requires more and more in-depth data from paraclinical investigations.our study aims to review the particular aspects of the urodynamic examination in children. we retrospectively reviewed the data from our archive in patients aged less than years old, examined in our department in the last years. for analysis purposes, patients were divided into two groups, less than years old and more than years old, considering that compliance during the examination improves greatly with age. a total of children were evaluated, in the fi rst group and in the second. we noticed changes in the procedure over time, due to the lack of standardization.results: th e main conditions behind the urinary symptoms were spina bifi da, myelomeningocele, cerebral palsy, spinal cord injury, frontal dementia. children with chronic conditions showed a signifi cantly better compliance during the examination, providing "cleaner" traces and shorter examination times. in cases ( %), the results of the exam were considered unreliable. in the fi rst group, sensations are recorded in only cases ( %), the other traces are marked as pain or crying. in the second group, the sensations are reported by children ( %). in six cases ( %), more than one examination was available, and the intra-individual variability was higher than in adult patients. urodynamics in children is a challenging, yet useful investigation, which requires both a state-of-the-art equipment and dedicated and highly professional staff . th e main question when thinking about urodynamic testing in children is not whether it can be done, but if it is really needed for the management of the patient, keeping in mind not only the benefi ts but also the potential harm that it can do. the underactive bladder syndrome: a single center experience persu c, geavlete p introduction and objective: detrusor underactivity (uab syndrome) is defi ned as a contraction of reduced strength or duration, leading to obstructive symptoms of the lower urinary tract. our study aims to review our clinical experience with such cases. we reviewed the electronic fi les of the patients diagnosed with uab aft er urodynamics in the past years. our review focused on the referral diagnosis and other associated conditions, as well as on the symptoms reported by the patient during history taking or the examination itself. we tried to correlate symptoms with the parameters obtained during urodynamics. th e initial treatment offered was also recorded.results: a total of patients ( males, females) were analyzed. th e most common referral diagnosis was bladder outlet obstruction ( pts - %), followed by oab syndrome ( pts - %) and other conditions ( pts - %). most patients reported signifi cant dysuria ( pts - %), sensation of incomplete voiding ( pts - %) and the need for straining in order to void ( pts - %). other reported symptoms include recurrent utis ( pts - %), urgency ( pts - %), frequency ( pts - %) and urinary incontinence ( pts - %). th e initial treatment consisted of self-catheterization ( pts - %), α blockers ( pts - %), suprapubic cystostomy ( pts - %), double voiding ( pts - %) and neurostimulation ( pts - %).conclusion: th e most common causes for uab include neurogenic conditions and obstructive symptoms associated with aging. th ere are no specifi c symptoms to support this diagnosis but some might suggest it stronger than others. urodynamic evaluation is mandatory to assess the parameters of this condition. underactive bladder: clinical features, urodynamic parameters, and treatmenthoag n, gani j introduction and objective: underactive bladder is a complex clinical condition that remains poorly defi ned in the available literature. we aim to determine its prevalence among those with voiding dysfunction, presenting symptoms, risk factors, urodynamic fi ndings, and treatment undertaken. a retrospective chart review was conducted on consecutive urodynamic studies performed for voiding dysfunction between and , to identify patients with detrusor underactivity. underactive bladder was defi ned as bladder contractility index less than . charts and urodynamic tracing were examined for patient demographics, suspected risk factors, presenting symptoms, urodynamic parameters, and treatment undertaken.results: th e prevalence of underactive bladder in this series was % ( / ). average age was . (range - ). women represented . % ( / ) of patients. th e most common reported symptoms were: urinary urgency ( . %), weak stream ( . %), straining ( . %), nocturia ( . %), and urinary frequency ( . %). prior pelvic surgery and prior back surgery was noted in . % and . %, respectively. most common management was intermittent self-catheterization at . %, followed by observation/conservative treatment at . %, and sacral neuromodulation at . %.conclusion: underactive bladder is common, yet precise diagnosis and treatment remains nebulous. th ere exists signifi cant overlap in symptoms compared to other bladder disorders, and urodynamic evaluation is useful in determining those patients with impaired detrusor contractility. th is will help prevent mismanagement of these patients with surgery or medical therapy that may worsen their condition. th ere remains much work to be done to better understand this condition, and establish optimal management for patients. what is the relationship between the size of a patient's medical notes and their fitness?birring a, jelski j, burns-cox n introduction and objective: assessment of patients' co-morbidities is necessary when considering treatment options. comorbidity tools exist but aren't always used outside of studies. clinicians may infer a patient's fi tness from the size of their notes. th is is particularly apparent in multidisciplinary meetings when the patient, and sometimes the referring clinician, is absent. we aim to establish if any correlation exists between the thickness and weight of medical notes and patient comorbidity. th ickness and weight of medical notes was measured for consecutive patients admitted to a urology/surgical ward. comorbidity was assessed using the charlston comorbidity index (cci).results: mean (and range): age ( - ) years; thickness . ( . - . ) cm; weight ( - ) g; cci . ( - ). male to female ratio : . pearson's correlation (r) between thickness and cci was . (p= . ). th e correlation between weight and cci was . (p= . ). regression analysis showed, an . cm increase in thickness gives in a -point increase in cci (p= . ); and a g increase in weight gives a -point increase in cci (p= . ).conclusion: th ere is a statistically signifi cant relationship between the thickness and weight of a patient's notes and their cci (p= . ), but the strength of this relationship is extremely weak (r= . and . ). on average, an . cm or kg diff erence in size has only a -point diff erence in cci. th is change may reduce the -year survival of a patient by as little as %. size of notes is a highly misleading indicator of fi tness. patients should have a formal comorbidity assessment before deciding treatment options.did you know? siu academy... the endorsed event programme allows approved webcasts from high-quality meetings around the world to be presented and shared on the portal.off ers a wide range of content eligible for selflearning cme credits non-accredited content is eligible for self-learning credits. contact your national accreditation body to fi nd out how. navigate the portal to its full potential by using the top and bottom panels. this allows you to narrow down your search by selecting the type of content, topic, sub-topics and labels to fi nd exactly what you are looking for. what's trendingthe what's trending page gives you an overview of featured content and the most recent material at a glance. the "rate & comment" feature allows you to share your feedback on every piece of material available on the portal. share exciting new content with colleagues through facebook and twitter at the click of a button.www.siu-urology.orgregister today! siu academy reaches over , users.are you one of them?siu members span over countries and represent the full spectrum of clinicians and investigators from all the urological subspecialties, including established academic and non-academic urologists, as well as physicians undergoing full-time training in urology.siu membership gives you an equal voice in this influential organization. we believe that each member can contribute the knowledge and experience needed to forge valuable links between urologists, and between developed and developing nations. by working together, our members carry on the tradition of creating positive change in a changing world. as a new member, you will be a partner in the one urological association dedicated to creating sustainable educational projects and providing and improving urological resources worldwide.members are able to vote for siu leadership, organize siu-endorsed educational activities, become involved in the congress scientific programme, as well as contribute to various siu academy programmes. we strive to make each member feel valued, respected, and supported.the siu network, both virtual and live, is an unparalleled pool of global contacts. siu brings urologists together. key: cord- -qfnukav authors: nan title: irish thoracic society annual scientific meeting, ramada hotel, belfast: th– th november date: - - journal: ir j med sci doi: . /s - - -y sha: doc_id: cord_uid: qfnukav nan welcome to the irish thoracic society annual scientific meeting . we are delighted that the meeting has made a return to belfast this year and in honour of this we've put together a programme that we feel sure will make for a highly interesting and worthwhile experience. a central feature will be the presentation of original research in both oral and poster form, showcasing the wide range of important and innovative work being carried out throughout the island. the focus of this year's symposium is lung cancer and we are delighted to welcome a panel of leading international speakers who will share their knowledge and insights on this important topic. additional guest lectures on ciliary dyskinesia and asthma by distinguished specialists in both fields complete a varied and, we hope, highly stimulating programme. it is my pleasure to welcome you to the irish thoracic society annual scientific meeting . on behalf of the irish thoracic society i wish to thank dr. jackie rendall for her outstanding work in conjunction with the its office in organising this year's programme. thanks to her sterling efforts we look forward to a rewarding and stimulating meeting. has been a busy year for the irish thoracic society and i would like to take this opportunity to reflect on some of the highlights. february saw the publication of the inhale report, nd edition (ireland needs healthier airways and lungs -the evidence). compiled by the its in conjunction with dr neil brennan and dr terry o'connor, the report underlines the serious resource deficits that still exist in respiratory health-care. clearly a lot more work is needed in this area and the society will continue advocating for a respiratory strategy to tackle the imbalance. throughout the year the society has made representations on a broad range of issues including copd, tuberculosis, critical care services and lung cancer. with respect to the latter, the irish thoracic society lung cancer sub-committee has been working with the national cancer control programme towards the development of improved services for lung cancer care. the society has also been represented on the national copd strategy group and the national tb advisory committee and we look forward to the respective reports on this work. significant headway has been made in the area of education and research. the irish thoracic society boehringer ingelheim research fellowship, launched last year, has recently been awarded for a second time, promising valuable contributions to respiratory research from two very worthy projects in the coming years. our ability to communicate with members has improved dramatically thanks to a radical upgrade of the irish thoracic society website -www.irishthoracicsociety.com. this provides information on the society's activities and other relevant issues. many delegates will have become familiar with its facilities for on-line registration and submission of abstracts in the lead-up to the meeting and we trust they have proven convenient and user-friendly. password protected members areas are designed for more specialist interest content and we encourage members to help us develop these areas further as a resource for sharing information and discussion of issues. we recognise the important role our members continue to play in all these activities. in order to sustain our efforts, the continued support of members and the expansion of our membership base is vital. i would also like to take this opportunity to thank our partners in the pharmaceutical and medical equipment sectors. their support over the years has been central to the society's development and is now more important than ever -we look forward to continued collaboration in and beyond. dr. jj gilmartin, president, the irish thoracic society patient's with copd are known to have decreased levels of activity. this study looks at free-living activities as measured by the sense-ware armband to determine if there was a relationship with standard exercise field tests for this patient population. thirty one patients with copd were recruited: men (n = ), female (n = ). ethical approval and written consent was obtained. the senseware Ò armband was worn for seven consecutive days and distance on the shuttle walk test was measured. pearson's correlations were undertaken using spss version . the mean age of the study population was . yrs (± . ) with a mean fev % (± ). the shuttle walk test (swt) was m (± ). free-living activities as measured by; physical activity level (pal) of . patients low levels of activities in daily life as measured by the senseware Ò armband parameters correlates with the shuttle walk test making it a reliable outcome measure. the shuttle walk test can provide us with valuable insight into the patient's free-living activities and sleep pattern. international literature points to inequity in the provision of palliation in favour of patients with cancer despite the high mortality associated with copd. chronicity is associated with biographical disruption, loss and shifting relationships with healthcare professionals all of which may influence the nature of palliative care in advanced copd. a three phased project is underway aimed at developing palliative care for patients with copd. the purpose of phase one is to identify palliative care needs of these patients. a mixed method research design was employed for phase one involving health status measurement and qualitative interviews. inclusion criteria were those patients who were hospitalised for exacerbation of copd. the patient sample was mainly derived from one hospital over a one year period with a primary diagnosis of copd. gatekeepers were in place to protect confidentiality. data was collected using the st george's respiratory questionnaire(sgrq), hospital anxiety and depression scale (hads), and the medical research council (mrc) dyspnoea scale. in a nd round of interviews, the questions are open and semi-structured. interviews were undertaken in patients' homes. an integrated analysis is underway of data represented in different forms using spss and nvivo software. twenty six patients were interviewed. ages ranged from - yrs (mean = ). anxiety and depression scores averaged . and . respectively. scores of [ indicating moderate and severe levels were found in cases for anxiety and for depression. average sgrq scores = . indicating significant impact on quality of life. themes from qualitative data include a catastrophic diagnostic event along the illness trajectory, ambivalence towards opd visits and rigid daily routine to control breathlessness. issues emerged regarding recruitment, the construing of palliative care in copd and articulation of experiences of quality of care. conclusion: preliminary findings suggest significant disability and lay expertise; isolation; anxiety; impact on relationships and poorly articulated fears of the future. unmet palliative care needs are evident and challenge nursing to find appropriate ways of construing palliative care in copd. patients with severe copd are likely to have repeated exacerbations and early mortality. in ventilated patients herpes simplex virus- (hsv- ) is frequently identified and is associated with an increased mortality. we determined the frequency of hsv- in copd patients (stable and exacerbated) and if it was associated with disease severity and mortality. methods: stable and exacerbated copd patients were recruited. spirometry was performed. sputum was obtained and lysed by ddt. nucleic acids were extracted and specimens were tested for hsv- and gapdh using real-time pcr. results: one hundred and thirty six patients with exacerbations of copd and stable patients were recruited. hsv- was detected in % of copd patients during an exacerbation and % of stable copd patients. no significant differences in hsv- copy numbers were seen on comparison of these groups. detection of hsv- was associated with increasing copd disease severity, p \ . . the presence of hsv- during exacerbations was associated with increased mortality, p \ . , predominantly from respiratory causes, p = . . conclusion: hsv- is frequently detected in the sputum of copd patients. it is more commonly found in patients with severe airways disease and its presence during exacerbations is associated with increased mortality. pulmonary rehabilitation (pr) is associated with symptomatic and physiologic improvements in patients with copd. however, biologic effects on systemic inflammatory and profibrotic cytokines are unproven. thirty two patients with moderate or severe copd (age . ± . y, fev ± . % predicted) were recruited to a pr programme. cardiopulmonary exercise testing was performed before and after the programme. serum c-reactive protein (crp), tumour necrosis factor-alpha (tnf-a), interleukin- (il- ), transforming growth factor-beta (tgf-b) and oxidative burst were measured before exercise, at peak exercise and at recovery. there were statistically significant improvements in all domains of the st georges respiratory questionnaire, chronic respiratory disease questionnaire and hospital anxiety and depression questionnaire. there were no significant changes in crp or tnf-a associated with exercise or pulmonary rehabilitation. exercise was associated with a surge in oxidative burst. endurance exercise was associated with an increase in il- (p = . ) that was attenuated by pulmonary rehabilitation (p = . ). incremental exercise was associated with an increase in tgf-b (p = . ) that was attenuated by pulmonary rehabilitation (p = . ). demonstrating biological effects of pr has proved elusive to date. this is the first study to demonstrate modulation of both circulating inflammatory and profibrotic cytokines by pr in patients with copd. queen's university, royal victoria hospital, belfast city hospital, n. ireland beta cryptoxanthin is a pro-vitamin a carotenoid which is reported to be a good biomarker of fruit and vegetable intake. we hypothesised that levels of serum beta cryptoxanthin would be related to fev . in , men aged to years were recruited into the belfast arm of the prospective epidemiological study of myocardial infarction (prime). we describe the cross-sectional analysis of the men who had a valid spirometry trace and plasma sample at year follow-up. beta cryptoxanthin levels were measured using hplc analysis. fev values at years were modelled using simple linear regression, and adjusted for covariates. serum beta cryptoxanthin levels were positively correlated with fev (r = . , p \ . ). for each nanomole per litre increment in serum beta cryptoxanthin levels, fev was . mls greater. following adjustment for the covariates, for each nanomole per litre increment in serum beta cryptoxanthin levels, fev was . mls greater ( %ci . to . , p \ . ). serum beta cryptoxanthin levels are positively correlated with fev . this suggests that in this population a moderate increase in serum beta cryptoxanthin levels (achievable by a modest increase in dietary intake of fruit and vegetables) may have a protective effect on lung function. the study was undertaken to evaluate organ utilization in the republic of ireland. a retrospective review of potential donors from january to august was performed. donors organ were selected according to criteria set by the international society of heart and lung transplantation (ishlt), abo group compatibility and predicted tlc. this included a donor age \ years old, a satisfactory history, a normal chest radiogram, arterial blood gases (abg) of [ kpa ( mmhg) (fio of % and a peep of ). potential offers for organ donation occurred. the median donor age was years (range - ), the mean period of mechanical ventilation was days (range [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . sixty percent ( offers) were declined on the basis of ishlt criteria, % were declined because of age, % due to poor blood gases, % due to abnormal chest x-ray and % because of chest trauma. sixty-three offers were evaluated at the donor site. five percent ( offers) were excluded because of size and hla crossmatch constraints, these were offered to uk transplant. lungs ( . %) were successfully transplanted. organ donation in republic of ireland is high ( per million population), however lung utilisation is low. the pathway to increase number of lung transplantation may include a framework for optimising donor physiology. the use of endoscopic ultrasound with fine-needle aspiration (eus-fna) is well established in diagnosing and staging non-small cell lung cancer with positron emission tomography (pet) positive posterior mediastinal lymph nodes. the sensitivity of eus-fna ranges between and %. it is less invasive and has lower complication rates when compared to surgical staging of mediastinal nodes. this study aims to describe our initial experience of eus-fna in lung cancer. eus-fna was used prospectively for the assessment of pet positive mediastinal lymph nodes between january and july . when eus-fna did not show malignant invasion, a confirmatory mediastinoscopy was done. endpoints were performance of eus-fna, morbidity and length of hospital stay. patients underwent eus-fna during the study period for both diagnosis and staging. patients had positive lymph node invasion and had no evidence of malignant invasion on eus-fna. negative cytology on the latter was confirmed on mediastinoscopy giving eus-fna a sensitivity of % for the study period. it upstaged the disease in patients. eus-fna is reliable, non-surgical tool for mediastinal staging. it reduces the need for surgical staging procedures in lung cancer patients with suspected mediastinal involvement. the limitation of this study is the poor documentation of the lymph node stations that were sampled. the role played by the innate immune system in determining survival in non-small-cell lung cancer (nsclc) is unclear. the aim of this study was to investigate the prognostic significance of cytotoxic t-lymphoctye infiltration in nsclc. immunohistochemistry was used to detect cd + t-lymphocytes in the tumor islets and tumor stroma in patients with surgically resected nsclc. quantification of immune infiltration was performed using a novel automated image analysis algorithm. univariate cox regression analysis, kaplan-meier analysis and the log-rank test were used to illustrate differences in overall survival according to the expression of tumour to stroma lymphocyte infiltration ratio. lymphocytes were detected in both the tumour islets and stroma in all patients. we used the median of tumor:stroma cd + infiltration ratio as a threshold to dichotomise patients to either high or low infiltration rate. results showed that those with a higher intratumoral lymphocyte infiltration had a significantly better survival compared to those with a low tumour/stroma infiltration ratio (p \ . ). microlocalization of infiltrating cytotoxic t-lymphocytes is a powerful predictor of outcome from surgically resected nsclc. the biologic explanation for this and its implications for the use of adjunctive treatment require further evaluation. . ebus-tbna for lung cancer -initial irish experience accurate mediastinal staging is essential in lung cancer patients under consideration for surgical resection. compared to mediastinoscopy or l anterior mediastinotomy (the gold standard), ebus-tbna is less invasive and may be carried out during diagnostic bronchoscopy, offering the potential for one-stop diagnosis and staging. ebus commenced in sjh in mid . we retrospectively analysed the first cases, ( %) of whom had tbna. patients with known or suspected lung cancer had ebus-tbna of n glands. cytology was positive for malignancy in / ( %). in the patients where cytology was negative, had no further follow up. of the other , only were proven node positive, but were confirmed node negative at mediastinoscopy/surgery and had resolution of nodes at repeat ct. therefore, in these patients ebus-tbna had a negative predictive value of %, sensitivity % and overall accuracy %. in patients with primary paratracheal mass, ebus-tbna was positive in all . of a total lung cancer cases where ebus-tbna was positive, this was the only positive sample in ( %). in % of patients ebus-tbna obviated the need for more invasive sampling of the mediastinum-this is one-stop diagnosis and staging. the national patient safety agency (npsa) (may ) highlights the role of ultrasound guidance for pleural drain procedures. we review our practice from a district general hospital. pleural studies were identified from the hospital pas and the radiology database. case notes of those who had their effusions drained by catheter were studied. patients (m:f : ; age - [mean . ]) had drains placed in the period august through july . were in patients; electively admitted for the procedure and remained an outpatient. ( %) drains were sited under ultrasound guidance, ( %) placed on ward ( of these marked in ultrasound) and ( %) sited in ct. patients had single drain placement, had drains; had drains and patient had drains. ( %) drains were placed by career radiology staff, ( %) by ward based staff. consent was documented on ( %) occasions. ( %) drains were flushed regularly as instructed by radiologist. average time in situ was days (range - days). ( %) patients were discharged home with drains in situ. patients died with drains in place. drain removal was performed by hospital ward staff. we conclude that most drain placements conform to npsa recommendations. consent is poorly documented. this will be addressed by implementation of a chest drain management chart. protocol for the care of pleural-sited catheters has been written. ultrasound is more sensitive than clinical examination or chest x-ray for determining the presence of pleural fluid and helps guide thoracentesis. we report our initial experience with chest ultrasound examinations performed at the bedside by the respiratory consult service for assessment of pleural effusion. ( %) of referrals were from the oncology/haematology service, ( %) from other medical teams and patients from general surgery. on ( %) of ultrasound examinations pleural fluid was detected and drainage was performed. in / ( %) fluid was drained by aspiration alone and in the remaining ( %) a seldinger chest drain was placed. patients ( %) had malignant or paramalignant exudative effusions ( with lung primary; with metastatic cancer from other sites and with lymphoma), ( %) had parapneumonic effusions and there were transudates, hemothorax and unexplained exudates. the procedure was well tolerated by all patients. one patient had a small post-aspiration pneumothorax on chest x-ray that required no further intervention and there was one drain misplacement. ultrasound is safe, portable and sensitive for detection of pleural fluid. it can be used at the bedside by respiratory physicians to guide management of pleural effusion. in an effort to standardise treatment of primary spontaneous pneumothorax (psp) and secondary spontaneous pneumothorax (ssp), the british thoracic society (bts), in , published the first evidence based guidelines for management of this condition. the objective of this audit was to assess compliance with the bts guidelines in amnch. retrospective hipe data, chart and radiology review of all spontaneous pneumothoraces admitted to amnch during . there were spontaneous pneumothoraces admitted to hospital in the year studied ( psp's and ssp's). of the psp's: mean age was . years; male:female ratio was : ; were classified as large and as small; attempted aspiration; intercostal drains were inserted with an average drain time in situ of days; mean drain calibre was fr. of the ssp's: mean age was . years; male:female ratio was : ; underlying pulmonary disease was copd in and cystic fibrosis in ( patients); were classified as large and as small; none were aspirated; intercostal drains were inserted with an average drain time in situ of days; mean drain calibre was fr. conclusion: bts guidelines are not being adhered to in amnch. in particular, aspiration, which is the recommended first line treatment in psp, is an underutilised therapeutic procedure. on average, the calibre of intercostals drain used was too large and not in keeping with the guidelines which recommend initial placement of small calibre ( - fr) drains. it is important to note that our data reflects patients admitted to hospital, and does not include patients managed and discharged from the emergency department. penetrated chest trauma is potentially fatal if not promptly addressed. we aim to review the incidence, demographics and the outcome of patients with napct who attended a single level-iii trauma centre. we conducted a retrospective study of all napct's presented to cork university hospital between - .our definition of napct is non accidental injury of chest involving sharp objects penetrating skin and muscular layers with or without injury to deep structure above the level of the diaphragm requiring hospital admission. patients with napct wounds were admitted to c.u.h from january to december . there were females ( . %) and males ( . %) with a median age of years (range - ). the average length of stay in hospital was days.the highest incidence was . / population (n = ), which was in . there was a decreasing trend in the following nine years. the incidence in was . injuries / population (n = patients). the incidence of napct's was low and the annual incidence is decreasing over the last years. young men were the commonest victims. pleural infection is a difficult management issue with approximately % patients requiring surgical intervention and a % mortality rate. early diagnosis and appropriate therapy is vital to reducing morbidity, mortality and health care costs. this is an audit of the management of pleural infection in the ulster hospital from february to april as per bts guidelines. pleural infection was diagnosed as pleural fluid with ph \ . , ldh [ iu/l, glucose \ . mmol/l. eight patients were identified, ( . %) male with a mean (sd) age (± ) years. all patients had pleural fluid sampling within hours of suspected infection. all patients had chest drains inserted with median (iq range) duration of drainage ( - ) days. positive bacterial culture from pleural fluid was obtained in ( %) patients (haemophilus influenzae, enterococcus) and from sputum in ( . %) patients (h.influenzae, coliforms, klebsiella). antibiotic therapy was as per bts guidelines. median (iq range) hospital stay was ( - ) days while surgical intervention was required in ( . %) patients. one patient died at day from a non-respiratory complication. this audit demonstrates appropriate management of pleural infection but shows that pleural infection remains a difficult management problem with significant morbidity and mortality. twenty-two patients died awaiting lung transplantation. the highest mortality rate was among those patients with idiopathic pulmonary fibrosis n = . the mode of death was acute exacerbations of ipf. cf patients, emphysema patients and sarcoid patient, patient with bronchiectasis died awaiting lung transplantation. these data indicate that the mortality rate of patients awaiting lung transplantation is highest amongst patients with idiopathic pulmonary fibrosis suggesting that early referral on the basis of a gas transfer less that % predicted as per international guidelines should be considered. approximately lung cancers are diagnosed annually in northern ireland, however despite recent advances in the management of this disease little impact has been made on survival rates . the short interval from diagnosis to death and the complex problems that are a reality for many of these patients make it imperative that health care professionals gain a greater understanding of the experiences of those living with this disease. this qualitative study aimed to explore the experiences of patients and carers living with a lung cancer diagnosis within a northern ireland context. a secondary aim was to describe participants' experiences of service delivery in order to identify any areas for improvement. a semi-structured in depth interview process was used and a purposive sample of participants was identified, comprising patients with advanced lung cancer and carers. the central emerging theme of ''living with dying'' highlighted the struggle of dealing with a poor prognosis and the pervasive uncertainty associated with an unpredictable disease trajectory, whilst trying to maintain some quality of life and positivity. the findings confirm the need for effective support and information pathways that provide timely and responsive services which embrace the holistic needs of patients and carers. the total number of patients was and complete data was available on ( %) patients. the mean age was ( - ). there were ( %) male and ( %) female patients. the mean duration from first radiological investigation suspicious for lung cancer to first procedure, first diagnostic procedure and first treatment regardless of modality were , and days respectively. the mean interval from first procedure to first diagnostic procedure, and mean interval from first diagnostic procedure to first treatment were and days respectively. there were ( %) patients with confirmed cancer diagnosis and ( %) of them went for curative surgery. in conclusion, our practice in management of lung cancer is consistent with the bts guidelines. transbronchial needle aspiration (tbna) is a bronchoscopic technique that enhances the diagnosis and staging of patients with thoracic cancers and other diseases. while endobronchial ultrasound guided-tbna (eus-tbna) is the gold standard, many units do not have access to the technology and expertise required. this study explored the clinical utility of tbna in the diagnosis and staging of patients with thoracic cancer in a university hospital. we studied the yield of tbna in patients diagnosed with thoracic cancers in our institution from september st to august st . from patients with thoracic cancer, patients had tbna performed. eleven specimens ( %) were diagnostic ( from hilar nodes and from subcarinal nodes) and of the ( %) were the only positive diagnostic specimen, avoiding the need for further diagnostic procedures such as transthoracic needle biopsy and mediastinoscopy in these patients. three of the eleven cases were small cell lung carcinoma, were squamous cell carcinoma and were adenocarcinoma. while eus-tbna is the gold standard for the diagnosis and staging of patients with thoracic cancer, tbna provides a clinically useful alternative in units that are not equipped to provide this service. however, dedicated training in the use of tbna should preclude the routine use of this procedure in bronchoscopy units. types of cancers in our study are as follow: poorly differentiated small cell cancer (all smokers), squamouss cell cancer (all smokers), nonsmall cell ca ( nonsmokers), adenocarcinoma (all were smokers), nonclassified , wide spread metastasis , carcinoid tumour .and one patient presented with mesothelioma transformed to sarcomatous changes. among nonsmokers had nonsmall cell cancer, mesthelioma, metastatic lung cancer, was unclassified. patients underwent bronchoscopy, bronchoscopic biopsies, bronchial washings sent, patientst under went ct guided biopsies, had mediastinoscopy and lymph node biopsy to confirm diagnosis. patients were given chemotherapy and got radiotherapy. at the time of diagnosis patient were referred for surgery, among them had lobectomies, pneumonectomies, wedge resection, deemed unresectable perioperatively. patients were given chemotherapy and got radiotherapy. patients deemed unsuitable for treatment. majority of these patients referred by general practitioners and the early diagnosis determined the final out come of the patients. there needs to be high index suspicion for early patients refrall in the presence of risk factors for lung cancer. . audit of lung mass/nodule service regional hospital department of respiratory medicine, midland regional hospital mullingar a lung mass/nodule service was established in . service was provided by consultant respiratory physician and respiratory nurse specialist. we performed a retrospective audit on this service and held regular weekly mdt meetings involved oncology service in tullamore and st james's lung cancer service to monitor the progress of all possible lung cancers. aims of study: aim of the service is to provide prompt access to the patients, their investigations, management and proper follow up. in last five years patients were reviewed. ( %) were male. average age was (range - ). number of patients evaluated each year was in , in , in , in , and in (jan-aug). more detailed analysis was performed of a subgroup this population; all patients who presented from jan-june . total number of patients was . ( %) presented with lung mass, ( %) with pulmonary nodule, ( %) had associated pulmonary infiltrates, ( %) haemoptysis, ( %) enlarged mediastinal lymph nodes. ( %) had bronchoscopy, ( %) ct/us guided biopsy, ( %) thoracentesis, deemed unsuitable for further evaluation. ( %) were diagnosed with bronchogenic carcinoma ( non small cell cancer %, ( squamous cell cancer . %, adenocarcinoma . %, undifferentiated . %), small cell cancer . %, sarcoidosis ( . %), and had either an initial nondiagnostic evaluation or assigned to follow-up ct scan protocol (as per fleischner society guidelines ). of the lung cancer patients, ( %) were referred for chemotherapy/radiotherapy, ( %) for surgery, ( %) for palliative management. of the ( %) assigned to the follow-up protocol, was subsequently diagnosed with cancer. lung mass/nodule service facilitates early diagnosis of lung cancer and subsequent assignment to appropriate therapy; it also provides a coordinated careful follow-up of lung nodules. many patients with lung cancer are symptomatic from diagnosis, and quality of life (qol) may be maximised through use of specialist palliative care in parallel with other treatments. patients are at increased risk of psychological disorders such as depression and anxiety. this study explored anxiety, depression and qol of a small group of patients (n = ), predominantly male ( . %), mean age years, using the marie curie ''breathing space'' outpatient clinic over a four week period. ''breathing space'' is a nurse led multidisciplinary clinic using integrative, person-centred care to maximise qol of patients with lung cancer through weekly assessments and interventions to enhance breathing, stamina, relaxation, mood, independence and well-being. a prospective survey design incorporated qualitative and quantitative approaches using semi structured interviews at baseline and after four weeks. qualitative data explored patient expectations and experiences of clinic attendance. most reported preconceived fears about the clinic due to poor information which were later dispelled. anxiety, depression and quality of life scores improved for this small sample. the core elements of ''breathing space'' may contribute to improve qol for patients with lung cancer. further work is needed on a larger sample to confirm the effect on anxiety and depression. we performed a retrospective analysis of procedures done in the endoscopy/bronchoscopy unit in a dublin teaching hospital from to . since , all data in the unit has been entered live to an electronic patient record, replacing hand written reports. this excludes procedures carried out in areas other than the endoscopy unit, such as icu, hdu, bone marrow transplant unit etc. a total of procedures were carried out, which consisted of upper gi endoscopy , ( %), colonoscopy , ( %), bronchoscopy , ( . %), cystoscopy %, ercp %, sigmoidoscopy . %, trus biopsy . %, ileoscopy . %. during bronchoscopy, the following procedures were performed; tbbx ( %), endobronchial bx ( . %), tbna of mediastinal glands or peripheral lesions ( %). indications for bronchoscopy were; mass on the chest radiograph %, haemoptysis %, consolidation %, persistent symptoms with normal chest radiograph . %, pleural effusion %, recurrent infections %, hoarseness . %, stridor . %, others %. focal endobronchial tumours were present in ( %) cases, the vast majority of which were cancer. excessive haemorrhage occurred in ( . %), which was controlled in all cases with standard measures. the incidence of pneumothorax post transbronchial biopsy was \ %. mortality was zero. an electronic database provides a useful tool for audit of clinical practice. bronchoscopy is the third most common procedure performed in an endoscopy unit of a major teaching hospital in dublin. the most common pathological diagnosis in this unit is lung cancer. the workplace smoking ban protects adults from secondhand smoke (shs/ets) but there is now concern about the protection of children from (shs) in the home or in cars. we evaluated the levels of shs/ ets that might be experienced by a child in the back of a car, where the driver is smoking. a particle was located in the back of a car at the height of a child's car seat. measurements were recorded prior, during, and minutes after smoking had stopped. this was repeated with the drivers window open, and with it closed. these results show that particulate levels rise significantly with active smoking. the levels are significantly higher when the driver's window is closed during smoking, however even with the window open the levels are significantly elevated. post smoking levels are higher than the levels during smoking with the window open. these results are comparable with those reported from the us. children in the back seat of cars with the driver smoking are subject to very high levels of ets, which persist even after the smoking has stopped. having the driver's window open reduces the exposure, but it is still significantly higher than background levels. cells (gift from dieter c. gruenert, usf) were pretreated ± % cse and then stimulated with lps; cytomix (tnf-a, il- b, lps) or cytomix (tnf-a, il- b, ifn-c) and il- release measured. exposure to cse significantly reduced the stimulated il- release in all cases in the cfbe o-cells (cytomix : . ± . pg/ml, +cse . ± . pg/ml; cytomix : ± . pg/ml, +cse ± . pg/ml; lps-pa lg/ml . ± . pg/ml, +cse . ± . pg/ml; all p \ . ). however, il- release from hbe o-cells was only significantly inhibited basally and after stimulation with cytomix (cytomix ; ± . pg/ml, +cse ± . pg/ml; p \ . ). these data indicate that the response of the cf cell line to cse differs from that of the normal cell line. cse inhibits via tlr in a cells causing a reduction in both basal and lps stimulated il- release. this would provide a rationale for reduced responses to cytomix or lps. further studies will examine the effect of cse on tlr in our cell lines. previous studies have demonstrated improved lung health in bar workers, and reduction in cardiac morbidity following such bans. we sought to evaluate medical admissions before & following implementation of the ban, to assess for any impact on respiratory and cardiovascular admissions. data were obtained for all medical emergency admissions to our institution in the -month periods from january -december , and january -december using the hospital in-patient enquiry system. data were examined for trends in respiratory and cardiovascular disease between the study periods. medical admissions increased over the study period ( / n = ; / n = ). however, there was a decrease in the proportion of admissions due to pneumonia (rr . ), asthma (rr . ), spontaneous pneumothorax (rr . ), stroke (rr . ), and unstable angina (rr . ). admissions with copd increased (rr . ). these changes were seen in smokers & non-smokers. no significant mortality impact was observed. the proportion of medical admissions for respiratory and cardiovascular disease decreased in the years following the implementation of the smoking ban. any impact on chronic diseases may take many more years to become apparent. the ban on smoking in public places came into force in northern ireland on the th april . the objective was to look at the impact of the smoking ban on smoking prevalence in diabetic patients a year before and a year after the smoking ban. a retrospective analysis of smoking habit data held on a computerised data base (the diamond system) a year before and a year after the introduction of the smoking ban. the data of diabetic patients was analysed. there were % male and % female. type diabetics were % and % of the patients had type diabetes mellitus. a year before the smoking ban, ( %) were smokers- % male, % female. the prevalence of smoking in type male diabetic was % and in type female diabetic %. the prevalence of smoking in type male diabetics was % and in females %. one year after the smoking ban ( %) were smoking- % male and % female (p [ . ). to date, there has been no statistical difference in the number of patients with diabetes mellitus who smoke since the introduction of the smoking ban. the ban on smoking in public places came into force in northern ireland on the th april . our objective was to look at the impact of the smoking ban on blood pressure control in a group of patients with diabetes mellitus. a retrospective analysis of smoking habit data held on a computerised data base (the diamond system) was performed, one year before and one year after the introduction of smoking ban. the data of diabetic patients was analysed, % male and % female. type diabetics were % and % of the patients had type diabetes mellitus. mean blood pressure of the non-smokers was / mmhg before the smoking ban and / mmhg one year after the introduction of smoking ban. the mean blood pressure of smokers was / mmhg before and / mmhg a year after the ban (p [ . ). there was a small improvement in the blood pressure control of nonsmoking diabetic patients a year after the ban, however it was not statistically significant. overall, blood pressure control was at target. the law prohibiting workplace smoking improved the respiratory health of dublin bar workers. however, non-smoking bar workers living with a smoker are exposed to cigarette smoke at home. ( ) . for this study barworkers were studied. current smokers (n = ), and asthmatics (n = ) were excluded from analysis. ( %) lived with a smoker, and ( %) did not. all barworkers had similar baseline co levels, but those without exposure at home had a more significant reduction yr post ban. breathing symptoms in those without home exposure were lower at baseline, while ent symptoms were similar in both groups. fev remained constant in those not exposed to cigarette smoke at home, while it declined (not significantly) in those with home exposure. exposure to cigarette smoke in the home continues to put nonsmokers at increased risk of significant respiratory symptoms. smokefree homes would bring improved health. smoking adversely affects the health of patients with cf. study aims: to determine active and passive smoking exposure among adult irish cf patients. methods: cf patients attending cuh completed a questionnaire relating to personal smoking and second-hand smoke (shs) exposure, correlated with pulmonary function and exacerbation-rate data. results: patients ( male) completed the questionnaire (table ) . . % were currently smokers. . % admitted to having tried smoking at some time. in the never-smoked group (n = ), % were currently exposed to shs; mean duration of exposure was . pack-years ( %ci: . - . ), while % had previous shs exposure; mean duration of exposure was . pack-years. % were never exposed to shs. in those currently exposed, the source was from a parent in . % and a sibling in . %. anthropometric data and exacerbation rates were similar between groups, but smokers showed a trend towards better lung function. a large level of exposure to shs exists among irish cf patients, with a clinically relevant proportion actively smoking. this study identifies a need for more aggressive smoking cessation strategies for both patients and caregivers. supported by cfai. a non-probability sampling of self-identified glc was recruited using electronic and print media advertisements between december and march . , respondents completed the questionnaires. otc data for the same period was analysed (n = , respondents). appropriate statistical analyses were performed to compare the mean differences in smoking rates between these two surveyed populations across age, gender and socio-economic groups (ses). adjusted current rates in glc were % and . % in general population (p = . ) and ''heavy'' smoking prevalence was . % in glc and . % in general population (p = . ). upper ses glcs are ''heavy'' smokers compared to general population of similar ses group (p = . ). glcs (\ years) were ''heavy'' smokers compared to general population of same age-groups (p = . ). no significant gender differences were observed. more glc were ''heavy'' smokers than the general irish population, but current smoking rates among the glc in ireland were not significantly different from the general population. a sampling frame of post-primary schools was used to randomly select schools for the issac study. , children ( - years) completed the isaac questionnaire. smoking prevalence was based on children's self-reported answer to the question ''if you travel by car does anyone smoke cigarettes in the car [yes/no]? for part , we used ''upgreen counters'' for vantage points: a shopping car park (saturday - pm); near a school (monday - pm); a busy sub-traffic junction (monday - pm), and ''moving cameras'' for the th vantage point, the civic offices (monday - am). smoking prevalence in cars was . % in ireland. for the four vantage locations, the prevalence rates were: . % (n = / ), . % (n = / ), . % (n = / ), and . % (n = / ), respectively. smoking in cars is a public-health policy issue. our findings show that children are regularly exposed to second-hand-smoke in cars in ireland and this demands legislation. in march we performed a pilot study to determine the feasibility of a pulmonary outreach programme in the midlands area. there are currently two similar programmes in ireland, but this was the first in a rural setting. our programme has two pathways of care: patients discharged \ h received home visits on consecutive days and were followed up for days (early discharge programme, edp); if discharged [ h due to unsuitability for the edp, they were reviewed for the first two weeks by specialist respiratory support within the community (outreach programme op). all patients were subsequently enrolled into pulmonary rehab. to date, patients have been enrolled to pop. % were male; mean age years; majority had severe disease ( . % stage ii, . iii, . % iv). . % required ltot, % home-nppv. . % were active smokers. . % were readmitted within the first weeks. the mean length of inpatient stay was . d for the edp, and . d for op; the average los nationally is . days. overall there were substantial financial savings. thus, rural pulmonary outreach programmes are feasible as they lead to a reduction in hospital los, improved patient knowledge of their disease, and are cost effective. the physical and psychological symptom burden associated with patients with advanced copd has been compared to that of patients dying with cancer. traditionally palliative care services have focussed on people with cancer, however recently the american thoracic society have endorsed the concept that palliative care should be available to patients at all stages of their illness [ ] endorsing the who palliative care definition [ ] . the irish hospice foundation and hse undertook a study in examining how all levels of palliative care can be extended to people with copd. challenges identified for introducing palliative care for people with copd include the uncertainty of the copd disease trajectory, the tension between delivering hope and planning for the inevitable, the lack of comprehensive respiratory services and the need for further education and research. the development of a model of care for patients with stage iii / iv copd providing a clear pathway of access to all levels of palliative care, the production of information and educational material, the requirement that all palliative care services are accessible to copd patients as required and the need for further collaboration between respiratory and palliative care services are key recommendations in the report of the study. school of pharmacy, queen's university , and mater hospital , belfast introduction: self-management plans for copd is derived from success in asthma. patients may benefit from the early intervention following selfmanagement plan . methods: patients ( y; % females) with mod-severe copd, were randomly assigned to an intervention group ( ) and usual care ( ). a pharmacist delivered an education program on disease state, medications, home exercise and breathing techniques. a booklet and a customised action plan for acute exacerbations (antibiotics and steroids) were given. follow up was at three months by telephone and a six months scheduled visit. the eq- d health status and sgrq were administered to all patients. outcomes included admissions, a/e visits and quality of life. results: at months the intervention group had reduction in both admissions [ ( %) vs ( %); p = . ], and a/e visits [ ( %) vs s ( %); p \ . ]. on the sgrq there was improvement in the symptom (- . ; p = . ), impact (- . ; p = ). and total score (- . ; p = . ). physical activity scores did not improve. the difference in the eq- d scores improved both vas scale [ . vs . ; p = . ], and utility scale [ . vs . ; p = . ]. this ongoing study indicates that a clinical pharmacy led management programme can reduce the need for hospital care in patients with moderate-to-severe copd and improve aspects of their health related quality of life. copd is a leading cause of morbidity and mortality worldwide. exacerbations of copd result in frequent hospitalisation and account for % of the costs associated with the disease. our objective was to identify risk factors which predict relapse requiring readmission following an exacerbation of copd. from to , consecutive exacerbations of copd admitted to hospital were prospectively studied. baseline demographics, number of hospitalisations in the previous year, oxygen use and smoking history were assessed. breathlessness and quality of life scores were recorded and oxygen saturations and spirometry measured. rehospitalisation data was collected at day , weeks and months. during the follow up period, patients ( %) were readmitted by day , ( %) were admitted by six weeks and ( %) were admitted by three months. logistic regression analysis identified hospitalisation in previous months (p = . , or . , ci . - . ) and borg score or higher (p = . , or . , ci . - . ) predicted readmission in % of patients at day . home oxygen use (p = . , or . , ci . - . ), pack year [ (p = . , or . , ci . - . ) and borg score [ (p = . , or . , ci . - . ) predicted week admission in . %. admission in the previous year and borg score of c predict early relapse, while home oxygen use, pack-year history c and borg score of c predict later relapse following an acute exacerbation of moderate copd. aecopd is an inflammatory lung disease associated with systemic consequences. a systematic analysis was undertaken of alpha- antitrypsin (a at), c-reactive protein (crp) and procalcitonin (pct) in the serum of patients with aecopd and matched inflammatory controls (cellulitis), pre-and post-antibiotic therapy. a at and crp are acute phase proteins. pct, a serum calcitonin precursor, is also raised in bacterial infections. venous samples from patients were analysed in this prospective study. amongst the aecopd and controls (cellulitis), were males and females (aged to ). crp(mg/l) levels were elevated in cellulitis (mean ± std error, . ± . ) and aecopd ( . ± . ) patients prior to treatment. a at(lmol/l) levels were also significantly elevated in cellulitis ( . ± . ) and aecopd ( . ± . ) patients. following intravenous antibiotic therapy, crp levels fell in cellulitis ( . ± . ) and copd ( . ± . ) patients. similarly, a at values fell in cellulitis ( . ± . ) and in aecopd ( . ± . ) patients. pct (ng/ml) levels were not elevated in all individuals with either cellulitis ( / ) or aecopd ( / ), but did decrease significantly in those that were elevated following antibiotic therapy. crp and a at levels are significantly elevated during aecopd and cellulitis. both levels fell significantly post antibiotic treatment (p = . for crp and p = . for a at). pct levels, when elevated, were reduced post antibiotic therapy. these data suggest that aecopd elicits a systemic response similar to a non-respiratory infection and this response to treatment can be monitored using biomarkers. in copd there is a cytotoxic t-cell infiltrate in the airway mucosa. it has been suggested that a virus may be a co-factor. we have recently shown high levels of ebv in severe disease . we wanted to establish if it was present in early disease. we recruited smoking ( pack y) subjects ( y) with early copd with mean fev . ( %) and smoking ( pack y) unobstructed smokers ( y) with mean fev . ( %). none of the subjects had used inhaled or oral steroids. nose and throat swabs were taken. induced sputum was obtained using hypertonic saline. total nucleic acids were extracted, and ebv dna was detected using taqman quantitative pcr. results: ebv was detected more often in the copd ( / swabs and / sputum) than the control ( / swabs and / sputum). p = . and . for swabs and sputum respectively (fisher's exact test). there was a wide range of copy numbers which were not different among those who were positive. conclusion: ebv is present more frequently in early copd than in unobstructed smoking controls. ebv is known to be a cyclical herpes virus which comes and goes. it may have a role in the pathogenesis of copd. background and method: niv is a valuable treatment for hypercapnic respiratory failure. [ ] transcutaneous co monitors(tosca) has provided novel approach to monitor these patients.. we assessed niv service and the use of transcutaneous co monitors in our tertiary care center. charts of patients attended from july to dec were retrospectively evaluated. data was retrievable on from total of patients. there mean age was ± yrs. were female. copd was in %, decompensated obesity/hypoventilation was % and neuromuscular/chest wall deformity was %. fev (mean) was . % - . %. % had type and ( %) had type respiratory failure. their average-ph was ( . - . ). mean pco was ( . - . ). only % of patients had repeat blood gas analysis at - hour, tosca was used to monitor non-invasive ventilation in ( %) of patients. the average number of use per patient was . - . . there length of stay(avg) was . days. their mean ipap and epap were . and respectively. ( %) patients were commenced niv in hdu. ( %) died due to respiratory failure. conclusion: % of patients were successfully monitored with tosca. we conclude that tosca is a valuable tool for monitoring patients at ward level. respiratory assessment unit, crest directorate, st. james's hospital, dublin as part of its transformation programme, the hse established a group in september to develop a national strategy for the management of copd. the aim of this survey was to capture information regarding the availability and range of physiotherapy services for persons with copd in ireland and thus inform the report of the national copd strategy group. the survey was emailed to physiotherapy managers across care settings in november . the survey sought information relating to the range of physiotherapy services for persons with copd provided at each site, as well as perceived service deficits and existing/potential innovations in practice. data were analysed using descriptive statistics. fifty-seven sites responded to the survey. no formal joint services between acute hospitals and pccc were reported. pulmonary rehabilitation programmes (prps) were available in sites only. service deficits reported related to lack of appropriate treatment space, lack of specialised respiratory staff, the absence of prps, and lack of interaction between acute hospitals and community services. physiotherapy services for persons with copd vary greatly across sites and settings. prps are not widely available and are primarily hospital based. there is a need for wider availability of joint hospital/ community based initiatives such as copd outreach and prps. pulmonary rehabilitation has established efficacy, but patients often require follow-up care or maintenance. there are few studies that explore the patients' experience of pulmonary rehabilitation and maintenance. also, there are no guidelines for health professionals as to what constitutes effective maintenance for clients who complete pulmonary rehabilitation. the study aim was to explore patients' perceptions of pulmonary rehabilitation and the maintenance options provided to them. a qualitative, exploratory descriptive design used focus groups to collect data. the purposive sample (n = ), had a diagnosis of either copd or bronchiectasis, and had attended a pulmonary rehabilitation programme within the last year. a focus group schedule using open ended questions and prompts was designed. discussions were transcribed verbatim and burnard's ( ) thematic content analysis was used to guide data analysis. the dynamics of group participation and peer support were identified as important incentives for patients. increased confidence and personal achievement were described as outcomes. the reasons for non-participation in maintenance were also elucidated by patients. this study provides an important contribution in relation to the experience of patients and the findings enhance current quantitative studies. patients' experience of outcomes and expectations has the potential to influence future services. following recommendations from the hse transformation programme , a multidisciplinary committee was established to develop a national strategy for the management of copd. as a member of the committee representing anail, the author conducted a survey to establish the range of inpatient and outpatient services provided by respiratory nurses for persons with copd. a questionnaire was devised to gather information regarding the provision of services such as inhaler technique, oxygen assessments, copd outreach programmes, pulmonary rehabilitation programmes (prp's) and palliative care services for persons with end stage copd. thirty-five members of anail were surveyed in october . data were analysed using descriptive statistics. a response rate of % was achieved. inpatient and outpatient services such as respiratory nurse reviews, oxygen assessments, self management plans were provided by more than % of respondents. of those who replied % provided inhaler technique education, % can refer persons with copd for prp, % run an outreach programme and % providing limited palliative care services. a number of current innovations and deficits within the services provided by respiratory nurses were highlighted. the contribution made by specialist nurses to the acute and chronic respiratory service is reflected by this survey. the inspiratory fraction-inspiratory-to-total-lung capacity (ic/ tlc) is an independent risk factor for mortality in chronic obstructive pulmonary disease (copd) . ic/tlc b %predicted is associated with significantly shorter survival. little data exists about the effect of pulmonary rehabilitation (pr) on survival in copd . the purpose of this study is to examine the effect of pr on ic/tlc. patients (mean age . ± . ), with clinical evidence of copd (mean fev . ± %predicted, mean ic/tlc . ± . %predicted) were enrolled in an week pr programme, consisting of twice-weekly sessions of exercise and education. assessments/re-assessments consisted of lung function (spirometry, diffusion, sniff nasal inspiratory pressure, capacity), exercise tests (shuttle, treadmill) and quality-of life-questionnaires (qol). patients, re-assessed at months, demonstrated improvements in exercise and qol compared to baseline (p \ . ). these patients were divided into groups-group ic/tlc b % predicted (n = ), group ic/tlc [ % predicted (n = ) at baseline. there were no between-group differences in improvements in exercise or qol at months. group ic/tlc improved at / from baseline . % predicted to . % predicted, and group from . to . % predicted (not significant). although the results are not significant there appears to be a trend in improved ic/tlc following pr. this study should be repeated with a larger sample size. department of medicine, midland regional hospital, mullingar, ireland primary objective was to assess the appropriateness of our hospital admissions for copd exacerbations as per nice guidelines. we also assessed the quality of their outpatient copd medical care. all copd related admissions mar-may were prospectively reviewed. variables as per nice guidelines were considered with one point for each variable. a score of zero was considered an inappropriate admission while c was appropriate. patients were included. mean age was ( - ), ( %) were male. ( %) patients were admitted as per guidelines, ( %) patient met no criteria. commonest variables present were: poor level of activity ( %), significant co morbidities ( %), inability to cope at home ( %). least common variables were: impaired level of consciousness ( %), cyanosis ( %), acute confusion ( %). ( %) received antibiotics. ( %) had spirometry performed for diagnosis. out of smokers ( %) were offered cessation advice. ( %) were appropriately on inhaled steroids. out of an eligible ( %) were enrolled in pulmonary rehab. mean los was . days, and there was linear relationship between length of stay and guideline score. there was excellent compliance with nice guidelines for copd admissions. quality of outpatient care was good in the domains evaluated. up to % of copd hospital inpatients will be readmitted within weeks of discharged. specific predictive markers of readmission are not currently in routine clinical practice. in this study, we assessed a remote monitoring system for continuous readout of patients' pulse rate and o saturation (biancamed, ireland). a cohort of normal volunteers (n = ) and copd patients (n = ) were enrolled and full remote monitoring and psychological profiling (via a modified hospital anxiety and depression score (hads)) of patients' well being was performed. in controls and patients, mean percentage of recording time was % (range: %- %) and % (range: %- %) respectively. principal reasons for loss of recording were a) patients moving out of range of monitor, b) non-compliance due to impracticality and/or discomfort while wearing the device, and c) accidental slippage of the oximeter probe. analysis of time of o saturation below %, %, % and % per hour revealed significant improvement over time in % of patients. one patient subsequently readmitted showed a significant deterioration prior to admission. in conclusion, this system shows potential in the early identification of copd patients who clinically deteriorate at home. in , % of respiratory inpatient discharges related to copd. information on hospital services for copd patients was required for the development of a national strategy. a survey on relevant staffing, wards and diagnostic units, policies and practice and access to specialist services was distributed to acute hse hospitals via hospital networks. hospitals responded ( %). written policies are in place for management of copd ( %), non invasive ventilation (niv) ( %) and long term oxygen therapy ( %). niv is provided in the emergency department (ed) ( . %), medical assessment unit (mau) ( . %), icu ( . %), hdu ( . %), respiratory ward ( . %), all medical wards ( . %). in almost two thirds of hospitals, all inpatients with copd can access respiratory nurse specialists, smoking cessation officers and palliative care services. access by ed/mau patients is possible in %, % and % of hospitals respectively and by gp referral in %, % and %. ten hospitals have pulmonary rehabilitation programmes ( %), five have onward referral mechanisms and four were planning a programme. the waiting time for programmes is up to one year. three hospitals have outreach programmes in place. this survey highlights the variation in hospital based services for copd patients and opportunities for service development. in the health services executive established a steering group to develop a national strategy for the management of copd. this study aims to describe the range of services available to copd patients and ease of access from the primary care perspective. a postal survey was distributed to a random sample of gps by the icgp. data was analysed using excel. valid questionnaires were returned (response rate . %) from practices in counties. . % have access to spirometry within their own practice. a practice nurse usually conducts the test ( %) and a gp interprets the results ( %). patients are unable to access patient support groups ( . %), pulmonary rehabilitation ( . %), rapid access respiratory clinics ( . %) or community options for management of an exacerbation-home based ( . %) or local community unit/district hospital ( . %). waiting times are up to six months for physiotherapy and pulmonary function testing and up to one year for respiratory consultant review, long term oxygen therapy assessment and pulmonary rehabilitation. this survey highlights geographical variation and gaps to be addressed for a shift to occur towards a community-based, responsive, flexible service for copd patients. oxygen therapy is an important treatment option for patients with severe copd, as long term continuous therapy (ltot). information on relevant community resources for ltot was required for the development of a national copd strategy. a survey was distributed by e-mail via each local health office (lho) manager ( ), covering activity and costs of aids and appliances, policy and procedure. data was analysed using excel. twenty two responses were received from local health areas ( %). there were wide population differences in the rate of ltot between areas, from - / , . home oxygen can be prescribed by hospital consultant, gp, respiratory nurse specialist or physiotherapist. arrangements for follow-up of patients on long term home oxygen vary considerably. half of respondents have difficulty with the level of detail provided on home oxygen prescriptions. % have a policy on provision of portable oxygen cylinders. % are aware of arrangements for ongoing maintenance of oxygen appliances. cost of ltot in was estimated to be in excess of € million. long term oxygen is an important copd therapy but is costly and has potential for harm. standardised practices are required for its use in the community. spirometry is the gold standard for diagnosis of copd. additional pulmonary function tests (pfts) can also assist in management. details of respiratory diagnostic resources in ireland were required to inform the national copd strategy. a questionnaire was developed in conjunction with the irish association of respiratory scientists and circulated to members via email. questions focused on staffing, workload, waiting times, tests available, referral sources and educational activities. ten laboratories responded ( %). pft activity ranged from , to , . minimum waiting times ranged from days to weeks and maximum from four days to eight weeks. laboratories accepted referrals for basic pfts from respiratory consultants (all), other hospital consultants (all), respiratory nurse specialists ( %), emergency departments ( %), medical assessments units ( %) and gps ( %). tests confined to respiratory team/other consultant referrals included bronchial provocation, minute walk, long term oxygen therapy and fitness to fly assessments. five hospitals participated in training relevant to copd in the hospital and two in the community. additional copd services included participation in pulmonary rehabilitation and outreach programmes. respiratory diagnostic laboratories are predominantly resourced for hospital referrals. examples are provided where scientists also provide a service to the community, for diagnostic tests and education. patients with copd have higher blood levels of markers of inflammation such as tumour necorsis factor (tnf-a), interleukin (il- ) interleukin (il- ) and c-reactive protein (crp). these are independent risk factors for decreased lung function and are associated with increased symptoms such as shortness of breath and respiratory rate. recently, tools to measure activity have been developed which continuously record patient free living activity and sleep. we hypothesized that there may be a relationship between levels of systemic inflammation and measures of free-living activities. thirty one patients were recruited: men (n = ), female (n = ). ethical approval and written consent was obtained. venous blood samples were taken (il- , il- , tnf-a and crp which were logged for normal distribution). a senseware Ò activity monitor was worn for consecutive days and the st.george's respiratory questionnaire were measured. pearson's correlations were undertaken using spss version s mean age of . yrs (+/- . ) with an fev or (+/- ) and a mean smoke pack history of (+/- ). a medium negative correlation was found between lgcrp and physical activity duration [r = - . , n = , p = . ]. a large correlation was found between the lgcrp and the st. georges respiratory questionnaire [r = . , n , p = . ]. this was also reflected in the impact section of the questionnaire [r = . , n = , p = . ]. c-reactive protein blood levels appear to be inversely correlated to free-living activities and quality of life. these data suggest that the measure of crp may be an important factor to include in the assessment of the severity of copd. during the months of july and august , in a prospective study, patients were transferred from the adelaide and meath hospital within days of their acute admission with copd, to peamount hospital for airc. patients were enrolled: males with a mean age of . yrs and a mean fev of . l ( %). the mean length of stay (los) in the acute hospital was . days and the mean los in peamount hospital was . days, with a total mean hospital stay of days. we hypothesise that this extended hospital stay and targeted respiratory care will improve patients overall quality of life, breathlessness, and exercise capacity, and reduce their dependency on the acute hospital service and re-admission rates. these patients will be followed up over the next year as a continuation of this study. the miners' disability score (mds), developed during the compensation process for uk miners, utilises a ten-point scale. the medical research council(mrc) dyspnoea scale, previously validated using the incremental shuttle walking test(iswt), utilises a five-point scale which may be less discriminating. we aimed to validate the mds as a score of respiratory disability in copd patients. patient data (mds/iswt/endurance shuttle walking test(eswt)) from our pulmonary rehabilitation programme were initially analysed (n = ; median fev = . l; mean age = yrs). subsequently, inpatients (median fev = . l; mean age = . yrs) had baseline mrc dyspnoea grade, mds, and manchester respiratory activities of daily living score (mradl) determined. degree of association between variables was assessed using the spearman rank correlation. mds correlated well with iswt (rs = - . , %ci - . to - . ), but not with eswt. fev was not associated with mds grade. mds correlated well with mrc dyspnoea grade (rs = . , %ci . to . ). mrc grade and mds correlated well with mradl (mrc rs = .- . , %ci - . to - . ; mds rs = - . , %ci - . to - . ) score. the mds showed a more favourable association. the mds is a valid measure of respiratory disability that could be used to complement fev and may provide an accurate reflection of performance status and disability in patients with copd. copd is an unremitting disease that impacts negatively on quality of life. the aim of this study was to compare functional capacity (fc); a measure of weight distance over six minutes, with standard tools used in the assessment of patients with stable copd. forty one patients with severe copd: fev % ± % predicted were recruited: men (n = ), women (n = ). senseware Ò armbands were worn for seven days to quantify their average daily steps. ethical approval and written consent were obtained. pearson's and spearman's correlations were performed using spss version . functional capacity was significantly associated with mean daily steps: men (r = . , p = . ) women (r = . , p = . ), shuttle walk test: men (r = . , p = . ) women (r = . , p = . ) and fev in men only (r = . , p = . ). there was no relationship between fc and borg: men (r = . , p = . ) women (r = . , p = . ) or the saint-george respiratory questionnaire: men (r = - . , p = . ) women (r = . , p = . ). we found that quantifying ''free-living'' measures is an important dimension of functional status not ordinarily captured and that functional capacity is a reliable outcome measure for assessing stable copd. the only gender difference identified was in male fev . patients (n = , mean age ) admitted to castle hill hospital with acute exacerbation of copd were studied. patients were either treated with standard therapy plus mg erdosteine bd (n = ) or standard therapy alone. (n = ) and followed up at day five and day ten. there was no significant improvement in subjective measures of breathlessness. at day subjective cough frequency was reduced by % in the +erd group as compared with deterioration in the -erd group. fev increased by ml -erd group and ml in the +erd group. hacc hour recordings on nine patients revealed coughs on day one falling to coughs by day five. there was a % reduction in cough frequency on the +erd group and % reduction in the -erd group. cough counting may be a useful objective marker to judge the success or failure of treatment strategies in acute exacerbation. chronic obstructive pulmonary disease is a lung disease characterized by chronic airflow obstruction that is not fully reversible measured using spirometry. the aim of this audit was to assess use of spirometry in diagnosis of copd in primary care. two hundred questionnaires were sent to primary care practices, seventy nine were completed. questionnaires identified which practices used spirometry. information was obtained on who performed spirometry within the practice, what training had been received, what criteria for screening for copd was utilised and general information on management of copd. we found % of practices had a spirometer. the most common reasons for not were cost involved ( %) and lack of confidence in interpreting results ( %). spirometry was performed most commonly by practice nurses ( %), interpretation of results was largely done by general practitioners ( %). only % had received recognised training in spirometry. the largest group of patients screened were symptomatic smokers over years old, however only % of patients screened had spirometry performed. these data indicate that we need to promote training in the use of spirometry for the diagnosis and management of copd in primary care in ireland. physiological responses to pulmonary rehabilitation (pr) are measured using a variety of clinical exercise tests. we compared incremental with endurance cardiopulmonary exercise testing (cpet) in a series of patients attending a pr programme. thirty two patients with moderate or severe copd (age . ± . y, fev ± . % predicted) were recruited to an -week pr programme. exercise capacity was assessed using incremental cpet before and after pr in patients and endurance cpet (at % of the peak incremental cpet workload) before and after pr in patients. among the incremental exercise group, there were no significant differences in vo max (mls/min) (p = . ), vo max (mls/kg/min) (p = . ), vco max (mls/min) (p = . ) or maximum workload achieved (watts) (p = . ) before and after pr. among the endurance exercise group, there was a significant difference (p = . ) in exercise duration ( vs seconds), but no differences in vo max (mls/min) (p = . ), vo max (mls/kg/min) (p = . ) or vco max (p = . ) (mls/min) before and after pr. incremental cpet is a poor tool to measure physiological changes in exercise capacity associated with pr. endurance cpet is the more ideal test, demonstrating significant increases in endurance time associated with pr despite unchanged peak oxygen consumption and carbon dioxide production. cardiopulmonary exercise testing (cpet) provides a global assessment of the integrative exercise responses involving the pulmonary, cardiovascular, haematopoietic, neuropsychological, and skeletal muscle systems, which are not adequately reflected through the measurement of individual organ system function. this case report looks at how cpet makes the initial diagnosis of mcardle's syndrome. a year old man initially presented to the cardiologists complaining of muscle fatigue after a short period of sustained exertion. all his cardiac investigations were normal. deconditioning would have explained the young mans symptoms adequately. as such, he was sent for cardiopulmonary exercise testing (cpet) to differentiate between poor aerobic conditioning and a possible pathological aetiology. the patient managed to exercise for six minutes and the test was limited by muscle fatigue. there was early failure in the aerobic metabolic pathway with a significantly reduced vo max (oxygen uptake-aerobic metabolism) and the absence of a corresponding rise in the vco signalling a concurrent failure of the anaerobic pathway. these results pointed towards a rare muscle enzyme deficiency. diagnosis was confirmed in the conventional way using a muscle biopsy. this case represents a unique and non invasive way of diagnosing a rare and often under diagnosed enzyme deficiency and underlines the versatility and diagnostic value of cpet. non-invasive ventilation (niv) is increasingly provided at ward level with implications for skills and practice development, support and inter-professional decision-making. despite recommendations by the british thoracic society ( ) that niv can be provided outside of the intensive care unit, use of niv at ward level remains problematic, presenting particular contextual challenges to care. a qualitative research study was undertaken, involving focus group interviews with nursing staff (n = ) and individual semistructured interviews with doctors (n = ) from specialised (respiratory) and non-specialised units in a regional teaching hospital. a number of support issues were identified. niv was considered a time-consuming procedure, with a perception of inadequate staffing levels at ward level. access to experienced medical and nursing support was viewed as an integral part of niv service provision. knowledge gaps exist at local level specifically in relation to inadequate education and training. clinical practice guidelines for niv were recommended to guide practice. this research study sought to inform practice development, specifically the greater acceptance and use of niv at ward level, through examining care issues. the themes expressed in the findings point s towards the need for review of present service provision, particularly in the areas of education, training and guideline development. pulmonary function laboratories interface with all medical disciplines. there is anecdotal evidence that pulmonary function tests (pfts) are often requested inappropriately. an audit was undertaken in the pulmonary function laboratory, belfast city hospital to determine how many referrals were appropriate, the origin of each referral and the designation of the referrer. the audit randomly considered requests over a six-month period. requests were reviewed by a clinical scientist and a consultant chest physician. a request was deemed inappropriate if tests unlikely to contribute to the patient's management were sought, or if tests were omitted that should have been requested. the requests originated from the following main specialities: respiratory medicine ( %), general surgery ( %), general medicine ( %) and haematology ( %). sixty-seven percent of referrals were made by junior doctors (junior or senior house officers) and % of these were appropriate. thirteen percent of requests were made by consultants of which % were appropriate. only % of respiratory referrals were appropriate. overall % of requests were considered appropriate, however there was significant variability among disciplines ( %- %). the results indicate that many pft requests are inappropriate. additionally, the quality of respiratory referrals is not better than nonrespiratory referrals. consultant requesting does not guarantee correct referral. the findings have both resource and educational implications. a phenomenological approach enabled the researcher to gain an insight into the participants lived experiences and uncover their stories. the researcher is a respiratory nurse specialist and therefore has a particular interest in this area. a husserlian phenomenological approach with bracketing of preconceived ideas underpinned the chosen methodology. a total of seven interviews were transcribed by the researcher in this study. the participants were patients on long term non invasive ventilation. data was generated using unstructured interviews, which were tape-recorded. data was analysed using colaizzi's framework. beginning the therapy, process of adjustment to the therapy and gaining a new independence were the major themes identified within the study. this study is small however; the findings have implications for nursing practice, education and management locally and highlighted areas that require further research. dysregulation of pulmonary inflammation has been proposed as contributing to airways disease in cystic fibrosis (cf). the aim of this project was to compare two t helper- cytokines (interleukin (il)- and il- ) for their relative stability, activity and interaction with glycosaminoglycans (gags) which are highly abundant in the cf lung. bronchoalveolar lavage fluid (balf), serum and sputum pre-and post-nebulised hypertonic saline (hts) were collected from cf patients and compared to balf and serum from non-cf controls. western blots and elisas were used to visualize and quantify cytokine levels respectively. il- was undetectable within cf balf and was shown to be degraded by neutrophil elastase. as a biological consequence significantly reduced levels of il- were secreted by jurkat t lymphocytes (p = . ). il- was competitively displaced from gags by il- , which binds gags via electrostatic interactions. exposure of cf balf to hts or treatment of cf patients with hts displaced il- from gag matrices rendering the chemokine susceptible to proteolytic cleavage and reducing the chemoattractant capacity of cf sputum. in conclusion, gags possess the ability to influence the cytokine profile of the cf lung promoting a neutrophil dominated immune response and hts treatment may improve resolution of this inflammation. human cathelicidin, ll- , a amino acid antimicrobial peptide produced by neutrophils and respiratory epithelium has been shown to have antimicrobial activity as well as possess immunomodulatory properties. we have investigated this potential immunomodulatory effect of ll- using lps stimulated thp- monocytes. effects of ll- on the lps signalling pathway were investigated using western blot and elisa. ll- was shown to inhibit the degradation of ijba and ijbb during lps stimulation, whilst preventing the phosphorylation of ijba, ikk, stat- , akt, c-jun and atf- . cytokine data showed a partial reduction in lps induced il- and tnf-a with lg/ml ll- . further investigation revealed that lps induced cytokine production could be reduced to control levels when ng and ng of lps was used to challenge cells in the presence of lg/ml of ll- . washing of cells following pretreatment with ll- abolished ll- 's inhibitory effects on lps-induced il- production when compared to unwashed samples. results suggest that ll- is exerting its anti-inflammatory effect primarily by neutralising lps activity as nearly all these effects can be inhibited by higher ll- :lps ratios. exposure of bacteria such as p. aeruginosa, growing within a biofilm in the lungs of cf patients, to antibiotics during treatment of recurring pulmonary exacerbations, may result in the development of antibiotic resistance. the aim of this study was to compare biofilm formation and antibiotic susceptibility of matched p. aeruginosa isolates cultured from cf sputum before and after antibiotic treatment of an acute exacerbation of pulmonary infection. biofilm formation ( hours) by matched pairs of p. aeruginosa isolates, cultured from sputum samples prior to commencing and at the end of antibiotic treatment, was assessed by total viable count using the calgary biofilm device. all isolates formed biofilms with no differences in biofilm formation apparent between any of the matched pairs of isolates. prior to commencing antibiotic treatment, p. aeruginosa isolates from (caz), (tob), (pip/taz) and (mer) patients were susceptible. following antibiotic treatment, the susceptibility status of isolates changed from sensitive to resistant for (caz), (tob), (pip/taz) and (mer) patients. these results indicate that antibiotic treatment had no effect on the ability of p. aeruginosa isolates to form bacterial biofilms but in some patients resulted in the development of antibiotic resistance. cause of death. paradoxically, neutrophils are recruited into the lungs but fail to clear infections. the question that this project will address is; are cf neutrophils intrinsically abnormal? within this study we shall focus on neutrophil membrane proteins and present the first proteome study on normal and cf membranes. a pure neutrophil membrane fraction was prepared by sucrosedensity ultracentrifugation. the solubilizing power of nonionic and zwitterionic detergents as membrane protein solubilizers for twodimensional electrophoresis was investigated. ief was performed with immobilized ph gradients. optimized solubilization of membrane proteins was achieved by combining the zwitterionic detergent chaps ( %) or sb - ( %) with the nonionic detergent triton x- ( %). excellent reproducibility of protein-spots was observed on ph linear gradient strips ( - and - ), allowing for comparative studies. with our now optimized protocol we propose to screen circulating neutrophils from cf patients during periods of exacerbation, and to look for quantitative changes in membrane protein expression (up-regulation, down-regulation or post-translational changes) using a stable-isotope labeling approach. data arising from this project will identify candidate proteins that could be used as biomarkers and/or contribute to a better understanding of disease progression in cf. neutrophil dominated inflammation characterises acute lung injury, pneumonia, copd, cystic fibrosis and bronchiectasis. factors modulating neutrophil mediated inflammation may have important therapeutic potential in these conditions. the anti-inflammatory protein, secretory leukoprotease inhibitor (slpi), is a non-glycosylated molecule produced by epithelial cells, macrophages and neutrophils. this study aims to enhance our knowledge of the anti-inflammatory effects of slpi and to investigate the relationship between slpi and the human neutrophil. neutrophils were purified from whole blood and subcellular fractionation performed employing sucrose gradients and ultracentrifugation techniques. translocation of slpi to the outside of the cell post pma( ng/ml) or fmlp( - m) activation was assessed by western blot analysis. our experimental results confirm the findings of sallenave et al [ ] and demonstrate that slpi resides within the neutrophil cytosol. however, contrary to previously published data we have found that slpi does not co-localise with lactoferrin in the secondary granules [ ] (figure ). cytosolic spli migrated as a dimer on sds-page and upon cell activation translocated to the outside of the cell in predominantly monomeric form. our results may support the concept that slpi orchestrates diverse effects within the neutrophil, with monomer and dimer forms of the molecule possessing distinct anti-inflammatory modes of action. the primary cause of morbidity and mortality is infection by gramnegative bacteria such as pseudomonas aeruginosa, resulting in chronic airway inflammation characterized by release of interleukin (il)- . to avoid the innate immune system, p. aeruginosa can undergo genetic changes [ ] , such as modification of the lipid a component of the lipopolysaccharide (lps) structure [ ] . the aim of this study was to compare the pro-inflammatory response of various types of purified lps isolated from cf patients with that of commercially available lps. human (hte) and cf (cfte) tracheal epithelial cells at * % confluency were serum starved ( h), then stimulated with lps from sigma (laboratory stain) or isolates that differed in their lipid a structure: pak (mild cf), se (severe cf), se (infant cf), bronc (bronchiectasis) and il- release measured. in order to achieve similar il- release, sigma lps was required at -fold higher concentrations than cf lps isolates (ug/ml vs. ng/ml). there was a differential response to lps between hte and cfte cells: se and pak strains induce a higher response in cfte cells when compared to hte. in conclusion, the inflammatory response to p. aeruginosa is dependent upon strain and environment, which may be due to changing lipid a structures. we investigated the ability of secreted bacterial proteinases from three pathogens (burkholderia multivorans, burkholderia cenocepacia, and pseudomonas aeruginosa) involved in chronic bacterial infections in cystic fibrosis to degrade various host defence-related molecules. these included secretory leukocyte proteinase inhibitor (rhslpi), alpha- antitrypsin (aat), secretory iga (siga), igg, lactoferrin and lysozyme. host defence-related molecules were co-incubated with cell-free bacterial supernatants from hour biofilm cultures from all three pathogens under investigation. no degradation of aat, siga, igg, and lactoferrin was observed for any of the organisms. only one out of isolates tested demonstrated the ability to degrade lysozyme. all isolates of b. multivorans (n = ) and p. aeruginosa (n = ) were able to degrade rhslpi however, out of five bacterial isolates tested for b. cenocepacia only two demonstrated a limited ability to degrade the molecule with [ % of the protein band still remaining intact at the end of the experiment. this study demonstrates that the majority of the host defence molecules investigated are resistant to degradation by bacterial proteinases from b. multivorans, b.cenocepacia and p. aeruginosa when grown as a biofilm. however, rhslpi was vulnerable to significant degradation which could result in aberrant serine proteolysis in regions of the lungs containing biofilm growth. children are ten times more sensitive to radiation-induced cancer than adults. we aimed to determine the cumulative radiation exposure associated with imaging in a paediatric population with cf, to identify contributing factors and to suggest ways of reducing their lifetime radiation exposure. medical and radiology records were reviewed. effective radiation dose (msv) and cumulative lifetime radiation doses were calculated for each patient using national radiological protection board (uk)data files. patients, mean age . ( - . ) years with a total follow up time of person years, had chest radiographs, abdominal radiographs and computerized tomography (ct) scans, including thoracic ct scans. average cumulative radiation exposure per patient was . ( . - ) msv. radiation exposure increased with age (p = . ) and with increasing numbers of cts (p = . ). radiation dose was significantly increased in the subgroup who presented with meconium ileus (p = . , independent of age).radiation dose was not significantly related to lung disease severity (measured as forced expiratory volume in second (fev ). radiation exposure in our cf population compares favourably with other tertiary centres worldwide. radiation dose can be minimised by reducing frequency of scans and altering scanning technique. a number of mirna expression profiling studies have shown mir- to be highly expressed in rat and human lung. tom a predicted target of mir- has been shown to interact with tollip and proposed as a negative regulator of il- b and tnf-a signalling pathways. the aim of this study was to validate tom as a target of mir- and elucidate its role in tlr and il- signalling pathways in cystic fibrosis (cf) versus non-cf airway epithelial cells. expression of mir- and tom were evaluated by qpcr. overexpression of premir- was performed by reverse transfection and tom was subsequently detected by western blot. mir- was found to be down-regulated (p = . ) and tom mrna significantly up-regulated (p = . ) in cf bronchial cells when compared to their non-cf counterparts. overexpression of mir in cf cells led to a decrease in tom protein production. this data shows that mirna is differentially regulated in cf airway epithelial cells and that tom is a target of mir- and may have an important role in regulating innate immune responses in the cf lung. case : y.o. male with recurrent infective exacerbations was noted to experience more severe and longer exacerbations compared to other similar patients. common variable immunodeficiency (cvid) was diagnosed based on low iga, igm, igg , igg and lack of antibody response to pneumovax. treatment with ivig has commenced. case : y.o. male who experienced severe anxiety during transition to adult cf care. obsessive compulsive disorder was recognized as exemplified by patient using alcohol wipes weekly to clean himself. he has responded well to cognitive behavioural psychotherapy. we conclude that physicians should appreciate the spectrum of coexisting conditions that are separate to a diagnosis of cf and can contribute to morbidity and mortality. cfrd adversely affects pulmonary function however diabetic control did not significantly impact function any further. this finding warrants larger prospective studies to confirm that a diagnosis of cfrd impacts pulmonary function but that diabetic control may not. with improving cf survival, fertility issues emerge. this descriptive study assesses knowledge & approaches to fertility information provision in cf care. prospective anonymous questionnaires were mailed to a male cf cohort (n = ). sections included demographics, fertility knowledge, investigation & personal relationships. response rate was % (n = ). mean age years (range - , sd . ). all knew that cf affected fertility but only . % (n = ) were able to provide explanations. of this group, . % (n = ) provided the correct explanation. % (n = ) have discussed fertility with a healthcare professional and half (n = ) selfinitiated this. mean discussion age was . years (range - , sd . ). one third stated preference for earlier discussion. . % (n = ) who had discussions were satisfied with information provided. commonest first source where patients heard of infertility was written material ( . %, n = ). three-quarters of respondents (n = ) requested further fertility information. the preferred source was written material ( . %, n = ). . % (n = ) have had semen analysis & all remaining (n = ) would accept an opportunity for this if offered. all respondents were aware of infertility however most unaware of explanation. few have formally discussed fertility. the majority want further information (preferred method written material) & an opportunity for semen analysis. this study identifies significant gaps existing in sex education during provision of cf care. a. sahadevan, s.h. chotirmall, a.k. mann, p. branagan, c. gunaratnam, n.g. mcelvaney discovering predictors of mortality in cf within ireland has therapeutic implications. we aim to determine factors predicting mortality in an irish cf cohort. a retrospective analysis of clinical, microbiological and radiological parameters in deceased cf patients over an -year period ( - ) was conducted (n = ). this was age matched to a living cf cohort. spss version . was used-chi-squared and independent student t-testing applied. mean age . years (sd +/- . , range - ) [deceased group] and . years (sd +/- . , range - ) [living group]. % (n = ) and . % (n = ) were female in the deceased and living groups respectively. within the deceased cohort, . % (n = ) had abnormal liver function (p = . ), . % (n = ) grew pseudomonas (p = . ) and . % (n = ) had candida in sputum (p = . ). correspondingly, in the living cohort . % (n = ) had abnormal liver tests, . % (n = ) and . % (n = ) respectively grew sputum pseudomonas and candida species. the deceased had poorer lung function (p \ . ), weight (p \ . ) and bmi (p \ . ). mean fev was . litres and mean weight . kilograms less than that of the living cohort. poor pulmonary function (fev , fvc), abnormal liver function, sputum culture of pseudomonas and candida spp and suboptimal nutrition (weight, bmi) were all predictors of mortality in our cohort. abnormal lfts are common in cf. we aim to determine any relationship between abnormal lfts & pulmonary function in a cf cohort. cf patients were included during the -month study ( - ). serum bilirubin, alanine aminotransferase (alt), alkaline phosphatase (alkp) & international normalised ratio (inr) were obtained in the outpatient clinic when exacerbation free. lung function (fev ) was concurrently determined. spearman (nonparametric) correlation was applied where appropriate. mean bilirubin was . umol/l (range . - umol/l) and mean alt . iu/l (range - iu/l). . % (n = ) had both above average bilirubin and alt of which ( . %) and ( . %) respectively in the bilirubin and alt groups had fev abnormal liver function did not impact fev however inr showed negative correlation. this may relate to malabsorption of fat soluble vitamins or be explained by a residual coagulopathic state following recurrent pulmonary exacerbations. osteoporosis & vitamin malabsorption contribute to poor nutritional status in cf. we aim to determine the effect of vitamin d deficiency and bone fragility on pulmonary function. systematic random sampling of an outpatient cf cohort was studied. pulmonary function (fev ), vitamin d status (serum) and bone fragility (z-score on dexa) was determined. chi squared analysis was applied to results (spss version . ). patients were included in the study (age - ). . % (n = ) exhibited vitamin d deficiency. of these, a single patient had normal lung function (fev [ % predicted), reduced function (fev - % predicted), markedly reduced function (fev - % predicted) and patient fev \ % predicted (p = . ). vitamin d deficiency was commoner in males (n = ). within the cohort, patients had normal bmd (z-score [ - ), had osteopenia (z-score - - . ) & had osteoporosis (all male) (z-score [ - . ) (n = ). in those with vitamin d deficiency (n = ), patient had osteoporosis & a further osteopenia ( . %) (p = . ). vitamin d deficiency is characterized by lower fev & bmd (osteopenia) however osteoporosis was present in cases of normal vitamin d levels. our study suggests the role bone health plays in the cf ''gender gap'' may be overestimated. biopsy showed nodular glomerulosclerosis (ngs) occurring in the absence of diabetes mellitus, amyloidosis and any other known cause of ngs. a recent paper has suggested that the pathogenesis of ngs in normoglycaemic, non-diabetic cf patients is similar to that of classic diabetes induced ngs and may be mediated by the development of advanced glycosylation end products (age). in cf, chronic pulmonary infection/inflammation, in combination with reduced glutathione levels contribute to an oxidative state and increased levels of age and to s /calgranulin. it is postulated these ligands interacting with rage resulting in the formation of nodular glomerulosclerosis in patients with cystic fibrosis. we conclude that increasing life spans of cf patients may lead to an increased identification of proteinuric renal disease, the aetiology of which may include this newly described pathological process. this is the first case described in a european cystic fibrosis population and the fourth case worldwide. nebulised hypertonic saline is an effective and safe therapy for cf lung disease. however reports show over % of patients cannot tolerate this treatment, and up to % of patients are totally noncompliant when using standard nebuliser units. positive expiratory pressure nebulizer devices splint open the airways and have a more controlled rate of nebulisation. we tested if patients who had failed hypertonic saline via standard nebuliser units could tolerate this therapy via a pep nebulizer. we prospectively recruited adult cf patients over a month period, who had previously failed hypertonic saline trials and commenced them on hypertonic saline via a pep nebulizer. patients completed a questionnaire on tolerability of the new device. notes were examined retrospectively on mean time to intravenous antibiotic usage pre and post therapy and mean time to next exacerbations. there was a subjective reduction of over [ % noted in coughing, chest tightness and bad taste using the pep nebulizer, with all patients tolerating this form of treatment. in this small study we found an absolute reduction in antibiotic usage of % post hypertonic saline usage and a fold increase in time to next exacerbation post nebulized pep treatment. hypertonic saline administered via a pep nebulizer may be a novel therapeutic strategy for patients who cannot tolerate hypertonic saline through a standard nebulizer. chronic lung infection with p. aeruginosa is responsible for most of the morbidity and mortality in patients with cf. cross infection involving the epidemic strains liverpool (les), manchester (mes), midlands (mid ) and clone c has been documented. regular genotyping is recommended to assess distribution of genotypes. genotyping is not currently performed in the belfast trust. the aim of this study is to perform molecular typing of isolates. the results will inform future strategies for laboratory screening, and infection control. p.aeruginosa isolates collected during routine clinics were typed using pulsed field gel electrophoresis (pfge), restriction patterns were analysed using bionumerics. a multiplex pcr ( ) was used to type isolates. samples were typed by both methods and results compared. % of isolates were defined by pfge as the les genotype. . % of adult isolates were defined as clone c. no mes or mid isolates were reported. there was . % correlation between pfge and pcr results. this study reports prevalence of the les strain in the ni cf population. it is recommended that patients with cf infected by p.aeruginosa have all isolates of varying phenotypes genotyped. pcr detection of les isolates will be a useful tool for screening. having successfully derived a method to culture nasal epithelial cells (necs) from cystic fibrosis (cf) and non-cf subjects, the aim of this study was to characterise the electrophysiological responses of these cells. cells from f del/f del patients and non-cf controls were used for patch-clamp investigation. cultured cells were separated and plated on glass coverslips chambers. culture medium was replaced with standard external solution (ses) before establishing whole-cell configuration. membrane ion currents were recorded using patchclamp. once a stable current was achieved, amiloride and forskolin were applied to the cells to elicit their responses. the f del/ f del cells responded to amiloride by rapid reduction in wholecell current, when forskolin was added to the bath it had little or no effect on the cell current amplitude in the cf cells (n = ). in the non-cf cells however, there was a response to the addition of forskolin. these responses to both amiloride and forskolin were as expected and demonstrate that this cell model of nasal epithelial cells obtained from nasal brushings proves to be a very feasible model for future studies of cf and can be used as an ideal model for research into the nature of action of numerous cf drugs. it has been shown that females with cystic fibrosis (cf) have worse lung function compared with cf males. gender and bmi have been correlated with lung function in adults. we aimed to show a similar trend in a paediatric population. we studied children aged years and older attending our cf unit. fev , height and weight were measured at the clinic when patients were at their baseline. of patients, were males ( %) and were females ( %). of the males had fev [ % ( %), had fev - % ( %) and with fev \ % ( %). within the female subgroup, had fev [ % ( . %), had fev - % ( . %) and had fev \ % ( . %) (p = . ). bmi was divided into groups; \ th percentile indicating poor nutrition that may affect lung function and [ th percentile (table ) . no statistical difference was found (p = . ). there was no statistical difference between genders with regards to lung function although there was a trend in favour of males. in our group of well nourished patients, there was no correlation between bmi and fev . this is in contrast to adult data in a similar study. piperacillin-tazobactam induced fever is well documented in patients with cystic fibrosis. here, we report adverse reactions which occurred in three patients treated with piperacillin-tazobactam over a three month period. setting: tertiary care, academic medical centre (beaumont hospital, dublin, ireland). patients and methods: three patients were evaluated retrospectively for piperacillin-tazobactam induced fever and evidence of bone marrow suppression. results: two of our series had evidence of drug induced fever (using criteria by young et al.). both patients had a mean duration of piperacillin-tazobactam exposure of . days with an average temperature of . c. fever resolved in both patients within hours of discontinuation of the antibiotic. neither had evidence of a septic focus (determined by cxr, blood cultures, ivc tip analysis or msu). two of our series developed bone marrow suppression, one becoming pancytopenic requiring bone marrow biopsy, the other becoming transiently neutropenic. both recovered within hours of cessation of offending agent. components of the new iv piperacillin-tazobactam preparation (ph buffers or stabilising agents) may be involved in the development of these late reactions. objectives: cystic fibrosis patients suffer from chronic bacterial colonisation and repeated exacerbations. one of the most challenging elements of treating these patients is that they develop antibiotic resistance. the aim of this study was to assess if changes in antibiotic sensitivity were related to the number of exacerbations (noe). we compared the noe requiring intravenous antibiotics with respiratory cultures at the time. the sensitivities of pseudomonas to antibiotics were analysed from to . we correlated the changes in sensitivities with the noe they had in this period. a univarious analysis was performed using a non-parametric test. noe was used as a dependent variable. thirty-two patients were included. in the piperacillin/tazobactam group, % became resistant with a mean noe of . . (p = . ) no resistance developed with colomycin. % of patients developed resistance to gentamicin. % of patients developed resistance to ceftazidime with average noe of . . (p = . ) only % of patients developed resistance to ciprofloxacin. the findings of this study showed considerable variations with antibiotic sensitivities. twenty-one patients demonstrated some change in sensitivities, and eleven with none. those with antibiotics resistance had a higher noe compared to those with constant sensitivities. slpi is an anti-inflammatory antiprotease that negatively regulates tlr , , and . we examined the effect of the viral rna mimic polyic on cytokine production by evaluating responses it induced in airway epithelial cells; we then evaluated slpi's effect on these responses. we performed selective inhibition studies to identify the receptor by which polyic induces its effects. rna was isolated from cystic fibrosis (cf) and non-cf bronchial epithelial cells and used in quantitative rtpcr reactions with gene- fev \ % ( %) ( %) s specific primers to each receptor. cells were stimulated with polyic in time course and dose response experiments and il- and interferon (ifn)-beta production quantified by elisa. the effect of pre-treatment with slpi or receptor inhibitors was evaluated. polyic induced il- but not ifn beta production. il- production was inhibited by pretreatment with slpi but not by inhibitors to pkr, rig , or mda . further rtpcr experiments demonstrated deficiency of phosphatase shp- , important for interferon production. polyic induces expression of the proinflammatory cytokine il- via a mechanism involving tlr . slpi inhibits this effect. polyic does not induce ifn beta production in airway cells. shp- deficiency demonstrated is a proposed mechanism for this effect. objective: in cystic fibrosis the mechanisms that lead to initial bacterial colonization, the development of a sustained and predominantly neutrophilic inflammatory response, and the ultimate destruction of the lung over decades remains unclear. here we investigate whether humoral autoimmunity could play a role in pathogenesis of cystic fibrosis. circulating autoantibodies in plasma of cystic fibrosis patients (n = ) and of healthy controls (n = ) were studied using immunofluorescense using hep cells as a substrate. selected samples were studied using immunofluorescense on primary bronchial epithelial cells. eight out of cf patients presented igg autoantibodies against hep epithelial cell line and against primary bronchial epithelial cells. there was no apparent correlation between fluorescence intensity and autoantibody titers and the disease intensity. the fluorescence pattern was in all cases mixed (speckled and nucleolar). igg autoantibodies with avidity for bronchial epithelium are present in some patients with cystic fibrosis. this suggest that autoreactive adaptive responses directed against bronchial epithelium may be important in aetiology of the disease and warrant further investigations. the role of pulmonary rehabilitation (pr) has not been widely investigated in patients with diagnoses other than copd. the aim of this study was to investigate the effects of an week pr programme in patients with bronchiectasis. seventeen patients with a diagnosis of bronchiectasis were recruited from respiratory consultant clinics. all patients underwent an -week programme ( supervised sessions) of exercise training and education. subjects were assessed at baseline and on programme completion on measures of exercise capacity and quality of life. data were analysed using minitab version . thirteen patients ( female, male) completed the programmemean age . (sd = . ) years, mean %predicted fev . % (sd = . ). after eight weeks, there was a significant increase (p = . ) in the incremental shuttle walk test distance of . metres ( % ci: . to . m). there was a trend toward a statistically significant improvement (p = . ) in the st george's respiratory questionnaire impacts subscale although there was no statistically significant improvement in the overall score (p = . ). results of this observational study support the potential role of pr in patients with bronchiectasis. robust trials are necessary to assess the effect of such programmes on a range of outcomes, as well as the efficacy of individual programme components. pkcd genetically depleted mice had baseline capillary filtration coefficient (kfc) compared to their wild type counterparts. there was no difference between these groups.similarly, there was no difference between wet-to-dry ratio's at baseline or in response to hydrostatic challenge.however, pkcd knockout mice experienced a significant protective effect when challenged with lps for hours injected intraperitoneally compared to their wild type. this correlated with reduction in neutrophil recruitment to the lung as well as significant attenuation of histological evidence of lung injury. however, there was no significant difference in the respective cytokine profiles. pkcd plays a central role the development of acute lung injury following exposure to lps and may represent a potential therapeutic target in attenuating acute lung injury. the precise mechanisms remains to be elucidated, however it is likely mediated through impaired neutrophil response. mycobacterium tuberculosis (mtb) is responsible for almost million deaths annually (who). the success of the bacillus is largely due to its ability to evade the host immune response. mycobacteria survive s within macrophages by blocking fusion of phagosomes and lysosomes, thus avoiding exposure to antimicrobial peptides and enzymes present in lysosomes. il- inhibits the progression of phagosome maturation in murine macrophages, however little is known about the role of il- on phagosome maturation in human macrophages. pma-differentiated thp- cells were seeded at . x cells/ml on glass coverslips. monocyte derived macrophages (mdms) were isolated from buffy coats obtained from the irish blood transfusion board. cells were treated with anti-il- monoclonal or isotype control antibody, infected with live or killed gfp-bcg and pkh green-labeled m. tuberculosis h ra, and incubated with lamp- antibody and alexa fluorescent stain. the colocalisation of mycobacteria-containing phagosomes with lysosomes, as identified by lamp- , was determined by confocal microscopy. colocalisation of mycobacteria-containing phagosomes with acidified lysosomes was infrequent in untreated thp- cells, % ± . . however colocalisation increased when killed mycobacteria were internalised ( . % ± . ). similarly in cells treated with anti-il- colocalisation increased to % ± . . mdms treated with anti-il- and infected with gfp-bcg showed a significant increase in phagosome maturation compared to untreated mdms. this data suggests il- suppresses the ability of macrophages to proceed with phagosome maturation, favouring survival of mycobacteria within the host. the prevalence of tuberculosis (tb) in ireland is not decreasing and management is becoming more complex with a multi-cultural population and increased drug resistance. there are new presentations (e.g. tb associated with biological agents). shorter rotations for junior doctors may be associated with less familiarity with tb management. we reviewed the appropriateness of our practice by examining the management of randomly selected patients attending our clinic. there was an equal gender balance and % were non-nationals. forty-two percent had pulmonary tb. significant deficiencies in management and documentation were identified. bcg status was not recorded in cases. incomplete data was available on the patients' hiv status. while all patients received pyridoxine prophylaxis, % of patients receiving ethambutol did not have an ophthalmology review. only % of patients received ethambutol. one patient (with multi-drug resistant tb) was transferred to another centre for negative pressure isolation. of the patients who were treated, one did not complete their treatment. this review indicated a need for improved documentation of bcg, hiv status and attention to issues such as ophthalmology review. to achieve this we have developed a clinical care pathway for management of tb in our clinic. background: northern ireland has consistently had a low tb prevalence ( . / , ). however, there has been an increase in cases of mdr-tb admitted to the rvh since . retrospective chart review of mdrtb cases. six patients were admitted between - . five were suspected to have mdr-tb on admission based on epidemiological risks; two had prior tb treatment; one was a contact of mdrtb; two were from countries of high mdr prevalence. four patients had primary mdrtb. the rifampicin resistance probe was positive in all cases. susceptibility testing showed isolates to be resistant to a median of drugs. all were susceptible to second line injectable agents, and / were susceptible to quinolones. one patient was hiv co-infected. patients converted their sputum to culture negative in a median of weeks (range - ) and were considered for discharge when they had negative cultures month apart. hospital admissions were prolonged due to drug toxicities and/or social issues (median hospital stay months, range - ). discussion: due to globalisation, even countries with low tb prevalence need to manage mdrtb. management of these patients is complex, and significant toxicities were seen. prolonged isolation also has significant resource implications. a year old male was admitted from the local psychiatric unit with apparent pneumonia. a chronic schizophrenic and heavy smoker, he had spent some years in institutional care in various facilities. he was treated with high flow humidified oxygen and nebulised bronchodilators. hours later he was found to be sputum smear positive for aafb. he was isolated and the infection control team mobilised. he turned out to have a fully sensitive m.tb organism and responded well to treatment. bts tb guidelines were followed and all staff and patients in the same ward bay as the patient were informed and letters sent to all gps. one patient contact had oesophageal carcinoma and was a chronic alcoholic. he developed post operative pleural effusion (tb culture positive) some months post exposure. a second contact (also alcoholic) was investigated as possible lung cancer some months after exposure and was smear positive for aafb. both patients died on treatment for their tb. all tb isolates were identical. the index case is alive and well. this highlights the danger of even short delays in diagnosis and appropriate isolation of tb patients. streptococcus pneumonia is a leading cause of invasive diseases which will pose an important health problem in ireland. efficacy of pneumovax is between and % (ref ). the vaccination would prevent severe pneumococcal infections (ref ). the purpose of the audit was to determine the rate of update of pneumovax among the chronic respiratory group and to identify reasons why the vaccination may not have been administered. subsequently, address ways of improving current policy. patients who attended the respiratory outpatient clinic in st. james's hospital from july till jan were questioned whether they have the pneumovax given at any stage of the life and ever receive booster dose; and reasons why if they had not been vaccinated. a total of patients were interviewed. . % were male and . % were female. mean age of male was . and mean age of female was . . approx % of patient has obstructive airflow diseases. % has received pneumovax at some stage while % never received pneumovax. the main reason ( . %) is poor awareness of the importance of the vaccine. the main implication from the audit is to raise awareness of pneumovax via campaign, reminding gp; and the funded pneumovax clinic. nursing home acquired pneumonia (nhap) is an important subset of healthcare associated pneumonia. we have prospectively compared three different pneumonia severity scores: pneumonia severity index (psi), modified bts score and naughton score and several inflammatory markers including procalcitonin levels to determine their ability to predict fatality in nhap. this study was carried out on fifty patients presenting to our hospital over a two year period, july to june inclusive. the case fatality rate was %. the modified bts score most accurately identified fatal outcome ( n = ; n = ; n = ). psi and naughton scores were poor predictors with % of deaths characterized as psi category or . procalcitonin levels co-related well with disease severity as measured by the psi and modified bts scores. none of the inflammatory markers accurately predicted patients at low risk of death from nhap. we conclude that the different pneumonia severity scores and several commonly used inflammatory markers fail to accurately predict patients at low risk of death from nhap. the adelaide and meath hospital, tallaght opened in and celebrates its th anniversary this year. we sought to assess changes in the incidence, demographic characteristics, and microbiological profile of tb infection in our institution over this period. patients diagnosed with active tb in the years & were included. patients were identified using laboratory, public health, and hipe records. demographic, clinical, and microbiological data were obtained by retrospective chart review. there was marked growth in the incidence of tb over this period our data emphasizes the re-emergence of tb as a major public health issue in ireland, and highlights immigration as a major contributing factor. the emergence of resistant infection has not to date been seen in our institution, but can be anticipated in the near future. we report a case of a -year-old white male who presented with one month history of pleuritic chest pain. chest radiograph demonstrated left upper lobe cavitation. bronchoalveolar lavage was smear positive for acid-fast bacilli and culture grew pan-sensitive mycobacterium tuberculosis complex. standard anti-tuberculous treatment with rifater and ethambutol was instituted; however the patient developed a severe cutaneous reaction after weeks. skin biopsy demonstrated findings consistent with allergic dermatitis. the rash resolved after discontinuation of therapy; however it recurred after sequential re-exposure to rifampicin, ethambutol, isoniazid and moxifloxacin. the patient underwent desensitization to rifampicin; ethambutol and isoniazid using modified penicillin protocols. titration to target dosing with each individual drug was achieved allowing reinstitution of standard therapy with rifater and ethambutol. the sequential desensitisation processes were each complicated by the reoccurrence of a mild rash, which was controlled by oral prednisolone. to our knowledge this is the first reported case of hypersensitivity to four anti-tuberculosis agents with a favourable response to a strategy of sequential rapid oral desensitisation. introduction: tb is a major infectious disease. in n.ireland the incidence remains low but is increasing. in cases were notified, from the southern trust. a tb nurse was appointed in september . this audit was undertaken to review the tb clinic and optimise the service provided. a retrospective month case note audit. all aspects of the service were reviewed; nationality of those attending, use of interpreter services, the problem of missed appointments and the reason for failure to attend. contact tracing and mantoux testing were assessed as this is a new role for the tb nurse. compliance with treatment in the light of mdrtb cases. results: patients attended the tb clinic in the month period. ( . %) were not native of n.ireland. there have been cases of mdrtb in the trust in the last year which has posed particular operational problems. tb remains an active problem in the southern trust. patient attendance at the clinic may be optimized by having appointment letters in the patients own language and introducing services at peripheral sites. lack of negative pressure ventilation facilities is an ongoing problem. pharmacy dispensing of full treatment course has improved compliance. we sought to analyze differences between patients with latent, pleural and pulmonary tuberculosis (tb) attending a dedicated tb clinic in the mercy university hospital, cork from july to june . two hundred and sixty nine patients were referred to the clinic. one hundred twenty eight ( %) had active tuberculosis, ( %) had latent tuberculosis infection (ltbi), ( %) had an alternative diagnosis and ( %) had atypical mycobacterial infection. among those with active tuberculosis, ( %) had pulmonary tb and had extra pulmonary tb, of whom had pleural tb ( %). in this group of patients with tb infection, female sex and foreignborn status were more frequent in those with ltbi compared with those with pulmonary tb. in contrast, smoking was more prevalent in patients with pulmonary tb. % of patients with pulmonary tb were asymptomatic. mantoux induration was less in those with pleural tb compared with those with pulmonary tb and ltbi. directly observed therapy was implemented predominantly in patients with pulmonary tb and at a rate considerably short of world health organisation recommendations across all groups. the purpose of this study was to determine if the lysophospholipids sphingosine -phosphate (s p) and lysophosphatidic acid (lpa), which have been implicated in allergy, induce up-regulation of adhesion molecules and eosinophil chemoattractants in an in vitro cholinergic nerve cell model, imr- cells. s p and lpa act mainly via g-protein coupled receptors s p - and lpa - respectively. eosinophils accumulate at innervating cholinergic nerves in fatal asthma and in animal models of asthma and adhere to nerve cells in culture via intercellular adhesion molecule- (icam- ). the methods used were real-time pcr and western blotting. s p , s p , lpa , lpa and lpa were expressed on imr- cells. both s p and lpa induced erk phosphorylation and erkand g i -dependent up-regulation of icam- expression in imr- cells, with differing time courses. lpa also induced erk-and g i -dependent up-regulation of the eosinophil chemoattractant, ccl- . the eosinophil granule protein eosinophil peroxidase (epo) induced erk-dependent up-regulation of transcription of s p , lpa , lpa and lpa . thus s p and lpa, acting via g i -coupled nerve cell receptors, induce up-regulation of adhesion molecules and chemoattractants which stimulate eosinophil accumulation and adhesion to cholinergic nerve cells. in turn, epo induces up-regulation of s p and lpa receptors, potentially perpetuating s p-and lpa-induced effects. asthma and rhinitis are characterised by eosinophilic inflammation. however, recent studies indicate that eosinophils are not essential for clinical symptoms, but instead exert a remodelling effect on the local tissues. we propose that neural remodelling involving the bmp pathway, enhancing a cholinergic phenotype, is a potential mechanism of airway remodelling in asthma. imr cells behave like cholinergic neurons when cultured with sodium butyrate. we exposed imr cells to eosinophil granule proteins and to bone morphogenetic proteins & and harvested the cells. proteins were separated into fractions and western blot analysis was performed. rna was isolated, converted to copy dna, and analysed using quantitative pcr. we found that major basic protein, but not eosinophil peroxidase, produced a down-regulation of bmpreceptor a (bmpr a) gene expression ( % reduction at hrs, p = . ). mbp decreased bmpr a in membrane protein and increased bmpr a within the nuclear protein. co-incubation of bmp with mbp attenuated expression of the bmp pathway transcription target id and of choline acetyltransferase. co-incubation with bmp & mbp produced increased expression of id and choline acetyltransferase. these results indicate that eosinophil granule proteins change bmp receptor balance, producing a downstream effect on cholinergic gene expression and therefore on the cholinergic phenotype of cells. exercise-induced bronchoconstriction (eib) has a reported prevalence of - %. this study aimed to measure for the first time, the prevalence of eib and asthma in professional rugby players and to demonstrate the utility of a sport specific field-test as a screening tool in field-sport. prospectively a cohort of senior international rugby players underwent spirometry before and after a rugby-specific exercise challenge. exercise intensity levels were also assessed. a fall in forced expiratory volume in one second (fev ) c % from baseline after exercise challenge was considered diagnostic of eib. during analysis, players were divided into two groups: those with airflow obstruction (ao) and those without (nao). ao airflow obstruction, nao no airflow obstruction forty-two players were tested. table summarises the spirometric results. twelve players ( %) had a history of, or were diagnosed with, airflow obstruction (ao group). seven players had a previous diagnosis of asthma and were on inhaled treatment, of these; % (n = ) had eib after exercise despite regular inhaled therapy. five players ( %) were newly diagnosed with eib. eib is more prevalent in professional rugby players than in the general population. a pre-existing diagnosis of asthma with regular inhaled therapy does not preclude eib. sports-specific field-testing is a useful method of screening in players. ulster hospital, dundonald, regional immunology service, royal hospitals, belfast. asthma is a major risk factor of anaphylactic deaths in children with peanut allergy. peanut allergy is a lifelong condition but some children outgrow their coexistent asthma. it is currently not known whether children who have outgrown their asthma symptoms have ongoing eosinophilic airways inflammation. exhaled nitric oxide is recognised as a non-invasive marker of eosinophillic airways inflammation. the aim of our project was to examine the levels of exhaled nitric oxide in peanut allergic children. children with peanut allergy were recruited at the ulster hospital and royal belfast hospital for sick children, northern ireland. exhaled nitric oxide levels (eno) were measured using the niox mino in all children. results: children were enrolled over a month period, age range to years (median years). ( %) had no history of wheeze, ( %) had outgrown asthma, ( %) had current active asthma and ( %) had occasional wheeze within the last year but were not taking any regular asthma medication. levels of eno were significantly elevated in those with outgrown asthma and those with occasional wheeze but no regular asthma medication (p \ . ). exhaled nitric oxide levels were elevated in children with a history of asthma outgrown and those with current 'untreated' asthma. this would suggest ongoing allergic airways inflammation. our study gives a rationale for checking eno in children with peanut allergy. consideration should then be given to starting inhaled corticosteroid therapy in peanut allergic children with elevated exhaled nitric oxide levels. guideline-defined asthma control, physical activity and bmi omalizumab has been shown to be effective in severe persistent allergic. this study describes our local experience in a group of carefully selected asthmatic sufferers. a retrospective audit was performed on patients with severe persistent allergic asthma who fulfilled the criteria for omalizumab therapy. only those who were regarded as omalizumab-responders were included in this analysis (n = ). the primary outcome measures for the study were acute hospital admissions, exacerbation rates, reliever usage and change in fev . these data were analysed for the six month period prior to commencement of omalizumab and for the six months following. the results showed that as a group acute hospital admissions reduced by %, with a corresponding reduction in exacerbation rates of %. mean fev increased by ml and reliever usage was reduced by %.this is consistent with that reported in the literature. omalizumab has proven effective in our local population of carefully selected severe asthmatics. introduction: difficult to treat asthma (dta) is associated with frequent symptoms despite therapy with high dose inhaled corticosteroids (ics). adolescent asthma presents special difficulties given the associated development issues. we sought to determine objective features of dta in this group. methods: all patients ( - yrs) attending the adolescent asthma clinic were reviewed. clinical data was collected at referral. dta was defined as requiring high dose ics (bdp) of [ mcg/day (\ yr) or [ mcg/day ( - yrs). the dta group was compared with remainder on low dose ics. of a total of ( f: m) patients, ( %) had dta with a mean ics of mcg/day. there were no significant differences in steroid rescue, bmi, fev /fvc, serum ig or eosinophil level, dust mite responsiveness, eczema, rhinitis, or smoking. dta patients were more likely to have elevated eno ( vs. ; p = . ) and lower ige level ( vs. ; p = . ). co-existing conditions more likely in dta included grass allergy (p = . ), any food allergy (p = . ), gord (p = . ) and vcd (p = . ). conclusions: dta in adolescents was associated with higher eno and lower ige levels, grass and food allergy, gord and vcd. identification of these features early can potentially facilitate more comprehensive and effective management. omalizumab is a monoclonal ige antibody which reduces asthma exacerbations. it is only cost effective in severe asthmatics with recurrent exacerbations. to assess the outcome of omalizumab treatment in severe asthmatic patients in the respiratory department of connolly hospital. a retrospective chart review of asthmatic patients treated with omalizumab. baseline demographics, omalizumab dose and frequency, other asthma medications, fev , exacerbation rates, and side effects were reviewed. male to female ratio was : . mean age was . years. mean ige level prior to omalizumab was . u/ml. mean fev prior to treatment was . %. mean fev post treatment was . %. prior to omalizumab five patients were on step of gina treatment guidelines, patients were on step . four patients reduced their shortacting beta agonist requirements, one patient was weaned to a lower dose of steroid and patient increased their inhaled steroid dose during the treatment period. patients had recurrent exacerbations prior to treatment. mean number of exacerbations during year of treatment was . . the most common side effect experienced was joint pains. treatment with omalizumab reduced exacerbation rates in these severe poorly controlled asthmatics. airway sensory hyperreactivity (shr) is an important clinical feature in chronic cough and is characterised by bouts of coughing triggered by relatively innocuous stimuli including exposure to aerosols, scents and changes in air temperature. these abnormal sensory responses are often what distress a patient most about their condition . the aim of this study was to determine the prevalence and clinical features of shr in patients with chronic cough. we undertook a retrospective case review of sequential referrals to the belfast city hospital cough clinic. we defined shr + as those individuals reporting cough provoked by one or more of the following; ) change in air temperature (thermoactivation), ) exposure to aerosols, scents, odours (chemoactivation), ) talking, laughing or singing (mechanoactivation). we compared shr + with shr-patients across a range of variables using chi-square and analysis of variance as appropriate. charts were available for review. we identified shr + in ( %) with significantly more females in the shr + ( % versus %, p = . ). no other features including age, cough duration, cough aetiology, atopic status, preceding urti or pc reliably distinguished shr + from shr-patients. these preliminary results suggest shr is a common problem especially among females with chronic cough. omalizumab is a humanized monoclonal antibody to ige which prevents binding to fceri receptor. it is known to increase eosinophilic apoptosis and inhibit the th immune response culminating in a reduction in eosinophil recruitment, activation and tissue migration. omalizumab use in the management of css however has been reported in one case to ameliorate the asthmatic component of the disease and to significantly lower plasma eosinophil counts at three months. our patient, mb, a year old man diagnosed with css years ago manifesting with uncontrolled asthma, severe pan-sinusitis with recurrent nasal polyposis, eosinophilic gastoenteritis histologically confirmed with duodenal biopsy and subacute bowel obstruction. initial eosinophil count was . /l., with an elevated ige level of u/ml. autoantibodies were negative. mb's extrapulmonary symptoms were well contolled with oral steroids and azathioprine. efforts to minimize oral steroid doses were hampered by persistent asthma and rhinosinusitis as well as a relapse of eosinophilic gastroenteritis in . omalizumab was commenced in june . after weeks, apreciable improvements in asthmatic and sinusitis symptomes were noted. average peak flow improved from to l/m and a reduction in peripheral eosinophil count from . to . /l. a paediatric asthma telephone clinic (patc) was set up in our hospital to provide follow up for children with mild asthma. structured telephone interviews with children aged between and and their carers who received detailed asthma education, was conducted and subsequent appropriate clinical action initiated. the aim of this study is to assess the effectiveness of the patc for medical surveillance by the asthma nurse. a retrospective review of case notes of the children referred to the patc was conducted. unscheduled use of health care & use of antibiotics or steroids between time of the patc and the next out patient clinic were recorded. pulmonary function was compared pre and post the patc. descriptive statistics were carried out and a paired t test was used to detect any significant change in lung function. forty one patients were referred to the patc with asthma. only ( %) had an unscheduled visit to the gp and no patient presented to s the emergency department. there was no significant change in pulmonary function. routine follow up of children with mild asthma and their carers by an asthma nurse via a structured telephone consultation can be considered an alternative to face to face follow up. further evaluation comparing the patc to an outpatient clinic and assessment of child/ carer satisfaction could confirm this. approximately , ( . %) patients received inhaled shortacting beta agonists in combination with a regular standard-dose inhaled corticosteroid.. a further , ( . %) patients were also prescribed a regular inhaled long-acting beta agonist (salmeterol or formoterol). patients ( . %) on combination therapy were coprescribed four different asthmatic treatments inclusive of oral prednisolone. approximately ( . %) of the patients prescribed a respiratory drug were co-prescribed nicotine replacement therapy. in total there were , patients prescribed a mucolytic drug in combination with a respiratory drug b) there were significant levels of coprescribing of salbutamol with beta blocking agents at . % ( %ci: , . ). in addition . % ( %ci: . , . ) of the patients prescribed theophylline in were also prescribed ciprofloxacin. c) levels of co-prescribing with antibiotics was %. the antibiotics coprescribed were augmentin, clarithromycin, cephalosporins and ciprofloxacin. assessing changes in asthma control is difficult. peak flow diaries are not completed and history is subject to recall bias. with a view to developing an electronic asthma management system, we attempted to use breath acoustics to assess changes in respiratory status. spirometry and breath sounds were simultaneously recorded in asthmatic subjects during histamine challenge. breath sounds were recorded by a microphone over the trachea. data was collected from seven male and four female subjects with a mean age . yrs. acoustic features were extracted from the breath sounds and evaluated for a correlation with the percentage change in fev . the highest correlation occurred between the duration of exhalation and percentage change in fev (r = - . ). fev showed a correlation with number of wheezing episodes (r = - . ), median wheeze frequency (r = - . ), maximum wheeze duration (r = . ), frequency of maximum duration wheezing group (r = - . ) and mean frequency of the wheezes(r = - . ). using these features together (combined in a linear discriminant classifier) a % drop in fev was detected with a sensitivity of % and specificity of %. the results of this study suggest a strong relationship between duration of exhalation and fev .the study also showed that combining acoustic features can be beneficial in detecting a decrease in fev . the liver disease of alpha- antitrypsin deficiency (aatd) is associated with endoplasmic reticulum(er) stress. seps is a selenoprotein that through a chaperone activity decreases er stress. we aimed to determine the effect of seps on er stress in this condition by measuring activity of the grp promoter and levels of active atf as markers of the unfolded protein response in hepg cells transfected with zaat transgene. we investigated levels of nfjb activity, a marker of the er overload response. to determine the effect of selenium supplementation on the function of seps we investigated glutathione peroxidase activity, grp promoter and nfjb activity. we also investigated the anti-inflammatory effect of selenium through the -deoxy-d , -prostaglandin j pathway( d-pgj ) and checked selenium levels in a population of zz and mm phenotypes for aatd. seps reduced levels of active atf . overexpression of seps also inhibited grp promoter and nfjb activity and this effect was enhanced in the presence of selenium supplementation. increased d-pgj concentrations were found in selenium supplemented cells. we demonstrated serum selenium levels to be in the low normal range in the patients tested. this data demonstrates a role for seps in this conformational disease and suggests a possible therapeutic potential for selenium supplementation. alpha- antitrypsin (a at) is a glycoprotein synthesised chiefly in the liver and functions as the most important antiprotease in the lung and also demonstrates anti inflammatory properties. it has previously been demonstrated that a at is packaged along with neutrophil elastase within the primary granules of these cells [ ] . thus there remains a paradox as to why an enzyme and cognate inhibitor would simultaneously compartmentalize, potentially impeding protease antimicrobial activity. this aim of this study was to reevaluate the localisation of a at within the neutrophil. compartmentalisation of a at within the neutrophil was established by sub-cellular fractionation, western blot analysis and confocal immunofluorescence. our data clearly show that a at is a genuine outer membrane protein of neutrophils associated with cholesterol-and sphingolipidenriched membrane domains called lipid rafts. we have observed that treatment of neutrophil membranes with phosphatidylinositol-specific phospholipase c (piplc) or high nacl concentrations removed a at from the neutrophil membrane indicating that localization of a at in lipid rafts is mediated by electrostatic interactions to a glycosylphosphatidyl-inositol (gpi) linked membrane protein. further studies will address the relevance of neutrophil associated a at and may support the theory that the anti inflammatory effects of a at are not simply related to modulation of serine proteases activity. aat deficiency (aatd) is a hereditary disorder, resulting from mutations in the serpina gene, classically presenting with earlyonset emphysema and liver disease. the most common mutation associated with aat deficiency is the z mutation, with the s mutation also associated with lung disease. aat deficiency is under-diagnosed and prolonged delays in diagnosis are common. world health organisation guidelines advocate screening patients with copd, asthma, cryptogenic liver disease and first degree relatives of known aatd patients. zz aatd patients on the national alpha- registry (n = , . +/- . years, male, female) were compared to a cohort of mm copd patients (n = , . +/- . years, male, female). mean aat levels in the zz group were . +/- . g/l compared to . +/- . g/l in the mm copd cohort. the mean fev for all zz patients was . +/- . % compared to . +/- . % for mm copd patients. however, when zz cases identified by family screening were removed, the mean fev of the zz cohort was lower than the mm group ( +/- . %, p = . , compared to mm group). when mm and zz groups were stratified by smoking status, zz smokers had mean fev of . +/- . % compared to . +/- . % for never smokers, while mm smokers had mean fev of . +/- . % compared to . +/- . % for never smokers. these findings underline the clinical significance of the zz phenotype and smoking in the development of copd. ). in the present study we examined the immunomodulatory activity of aat and investigated whether nadph-oxidase activation via the g-protein coupled n-formyl-methionyl-leucyl-phenylalanine (fmlp) receptor was inhibited by aat. oxygen (o ) consumption was quantified using a clark-type oxygen electrode and o production was determined by superoxide dismutase (sod)-inhibitable reduction of cytochrome c. both the rate of o consumption and o production elicited by fmlp ( - m) was significantly inhibited in the presence of aat ( lm). in addition, inhibition of o production was dose dependent and almost completely inhibited by . lm aat. mechanisms of inhibition were investigated and found to be mediated through a decrease in intracellular camp. levels of camp at seconds post fmlp stimulation were elevated to . ± . pmol/ neutrophils, whilst co-treatment with aat ( . lm) reduced camp levels to . ± . pmol/ cells. in conclusion, the observed inhibition of neutrophil nadphoxidase activity by aat, is further evidence supporting a role for this molecule as an anti-inflammatory mediator. alpha- antitrypsin (aat) is a serum glycoprotein that inhibits proteases, and is produced mainly by hepatocytes. it is particularly important in dampening the action of neutrophil elastase, which can damage the lungs. aat deficiency results from both a qualitative and a quantitative deficiency of the protein which predisposes to the development of emphysema, chronic bronchitis, bronchiectasis, and liver disease. we investigated patients registered on the irish alpha- database as aat deficiency mz phenotype. the information gathered from the database was supplemented with chart reviews for clinical information and pulmonary function tests. mz patients had a mean fev % predicted of . +/- . %. we note that there is a negative correlation between cigarette pack years and fev % predicted (r = . ). the serum level of aat does not necessarily correlate negatively with fev (r = . ). nearly % of mz patients were detected by family screening of known aat deficient patients. it remains uncertain whether mz patients are predisposed to aat deficiency sequelae when compared to the general population. we aim to settle this uncertainty by comprehensively describing the characteristics of this cohort of patients. this may represent a change in the way mz patients are managed and could implicate earlier preventative measures to decrease the likelihood of developing emphysema. alpha- antitrypsin (aat) is produced by hepatocytes, and is the most important antiprotease in the lung. aat deficiency (aatd) is a hereditary disorder resulting from mutations in the aat gene, presenting with emphysema in adults and liver disease in childhood. who guidelines advocate a targeted strategy in screening copd, non-responsive asthma, and cryptogenic liver disease patients and also relatives of known aatd patients. the most common phenotype associated with disease is zz followed by sz. a chart review of aatd patients on the national alpha- registry was performed on zz (n = ) and sz (n = ) patients. the mean age at diagnosis for zz patients was . +/- . years for males and . +/- . years for females. we demonstrate that zz individuals identified as a result of family screening have significantly increased fev ( . +/- . %, . +/- . years) when compared to zz patients identified by targeted symptomatic screening ( . +/- . %, . +/- . , p = . ). zz and sz patients who smoked had significantly decreased lung function compared to nonsmoking zz and sz and that a positive correlation between pack years and fev exists. our results emphasize the need for increased awareness and early detection of asymptomatic aatd. identification of patients from a targeted detection programme should include aggressive family screening and allow the initiation of preventative measures before significant lung disease has occurred. thirty-three females age - mean and males, age - , mean underwent cpx. mean bmi in females was . ( . ) and . ( . ) in males. most tests were done because of unexplained dyspnoea ( ). other reasons for requesting cpx were: assessment for fitness for lung cancer surgery ( ); assessment of fitness in patients with sarcoid ( ); cardiac transplant assessment ( ); pre surgical assessment for other major surgical procedures ( ). the data on the patients who underwent cpx for unexplained dyspnoea was analysed. mean bmi was . . thirty-two of these patients had normal lung function. as a group these patients were extensively investigated before coming for cpx, had ct scans performed, had lung perfusion scanning, had echocardiography. forty-one of the patients had sub maximal tests with no evidence of cardiac or respiratory disease, the test being limited by reconditioning. in conclusion, cpx is a valuable tool in this district general hospital with various reasons for requesting the test. in patients with unexplained dyspnoea, it may be prudent to request cpx at an earlier stage in the investigative journey. sarcoidosis is a multisystemic disease of unknown aetiology. prognostic biomarkers are not part of routine clinical practice. our hypothesis is that enhanced activity for myofibroblast differentiation in sarcoidosis at the initial diagnosis and is associated with an adverse prognosis and the development of pulmonary fibrosis. in addition we investigate the role of tgf-b in this process. fifty patients with biopsy proven sarcoidosis (stage i n = , stageii n = , stage iii n = ) were enrolled. bronchoalveolar lavage (bal) samples were obtained at initial evaluation. primary lung fibroblasts (ccd- lu) were incubated with bal samples and a-smooth muscle actin (asma) mrna expression as a marker of myofibroblast differentiation was assessed via rt-pcr. asma mrna was significantly elevated up to % (above control) in patient's samples. we also found a significant correlation between asma mrna expression and progression of pulmonary disease in sarcoidosis, (p \ . ). to investigate the role of tgf-b contributing to this enhanced myofibroblast differentiation, we coincubated bal samples with saturating concentrations of anti-tgf-b antibody and found a % reduction in this biological activity, (p \ . ). in conclusion we demonstrate firstly enhanced capacity of bal samples to induce myofibroblast differentiation, secondly it is of prognostic significance and finally tgf-b is a significant contributor to this biological activity (fig. ). we present a case of cs seen recently at our hospital and the management undertaken for this yr old, the son of a tuberculosis specialist in south africa. his main symptom was exertional syncope with evidence of conduction abnormality on ecg, poor cardiac function on echocardiogram with normal coronary angiogram. an exercise stress test induced ventricular tachycardia. a dual chamber pacemaker and a defibrillator were placed. he had several hospital admissions over a year with ventricular tachycardia/ ventricular fibrillation. cardiac ablation followed electrophysiological studies. cardiac biopsies confirmed cs. there was no evidence of pulmonary or eye involvement. we discuss diagnostic tests and criteria and also treatment options. corticosteroids are believed to control the inflammation and fibrosis, preventing cardiac dysfunction. we closely follow his progress to assess long term effect of steroid treatment especially on his arrhythmia. idiopathic pulmonary fibrosis (ipf) is a progressive disease frequently associated with terminal respiratory failure. the insight patients with ipf have into their disease process and prognosis is unknown. this may lead to delayed communication regarding end-of-life issues. we studied insight into disease and attitudes towards invasive ventilation (iv) amongst a group of ipf patients and compared these outcomes with copd patients with a comparable severity of disease. ten patients with ipf and eight patients with copd were studied. spirometry, the minute walk test and arterial blood gas were recorded as markers of severity. patient insight into disease and attitudes towards iv were surveyed using a newly developed questionnaire. % of patients with ipf felt they had sufficient information about their illness compared to % of copd patients. % of ipf patients had discussed prognosis with their doctor, versus % with copd. if the need arose, % of ipf patients wanted iv compared with % of copd patients. only one patient felt that the issue of iv should not be discussed. there is a deficiency in knowledge regarding disease process and prognosis among ipf patients. end of life issues and iv should be carefully addressed with these patients. coeliac disease is a gluten sensitive enteropathy that results in a chronic malabsorptive disorder. the disorder is rarely associated with pulmonary conditions though the link between the gut and lung remains obscure. conditions include the rare association with pulmonary haemosiderosis (hamilton lane syndrome) and for the first time to the best of our knowledge, pulmonary alveolar microlithiasis(pam). we also describe a literature review of the pulmonary associations of coeliac disease. pulmonary haemosiderosis is a form of pulmonary haemorrhage syndrome progressing to pulmonary fibrosis. we describe pulmonary haemosiderosis and capillaritis in a year old female coeliac, an association known as hamilton lane syndrome. treatment involved corticosteroids and a gluten free diet with resolution of her symptoms. pam is a rare disease where minute calculi are found in alveoli resulting in progressive pulmonary fibrosis. no association with coeliac disease has previously been published. we describe a case of a year old female coeliac who over years developed pulmonary fibrosis secondary to pam. there is no effective treatment and individuals may progress to transplantation. coeliac disease should be considered in patients presenting with pulmonary haemorrhage/ haemoptysis and in patients with interstitial lung disease where histological findings are consistent with pam. the vdi at and months with pulmonary involvement were significantly higher (p = . , p \ . respectively), but not at month. a vdi [ has been associated with a fold increase in mortality. ( %) with pulmonary involvement had a vdi [ at initial presentation compared to ( %) (p \ . ) without pulmonary involvement. the percentage with vdi [ in the pulmonary patients reduced at and months ( % and % respectively, p = . ). ( %) of patients with pulmonary involvement at presentation had eu-vas criteria for generalised and severe subgroups compared to ( %) without pulmonary involvement (p \ . ). of patients died had pulmonary involvement; one was attributed to vasculitis. we conclude that pulmonary involvement at presentation is highly predictive of severe organ damage (vdi [ ) at initial presentation and year and more extensive disease activity (bvas (all stages) and euvas) in anca-associated vasculitis. background: levels of adenosine can be rapidly increased during settings of inflammation and acute lung injury. these increases in adenosine have been implicated in pathological progression of lung diseases, as well as, protection against acute lung injury. we tested the effects of elevated adenosine levels on endothelial barrier function in vivo and in vitro. methods: intracellular levels of adenosine were elevated in rodents through inhibition of adenosine deaminase with pentostatin, and lung edema was measured in models of acute lung injury caused by a-naphthylthiourea (antu). the degree of antu-induced lung edema, as measured by lung wet to dry weight ratios and filtration coefficients (k f ), was significantly diminished in the rodents given pentostatin either before or after the antu injury. in vitro analyses using pulmonary artery endothelial cells plated on a monolayer demonstrated that adenosine receptor a a and a b agonist, n-ethylcarboxamidoadenosine (neca), improved permeability. while no significant effects were noted with adenosine receptor a , a a , a b , or a inhibitors or adenosine transporter inhibitors alone, we noted a significant attenuation of the adenosineinduced barrier function enhancement in the presence of adenosine receptor a a and a b antagonists, and adenosine transporter inhibitor, nitrobenzylthioinosine (nbti). adenosine enhances the pulmonary endothelial barrier function in acute lung injury through interaction with a a and a b receptors. childhood interstitial lung disease (child) comprises a spectrum of heterogenous disorders characterised by tachypnoea, radiological diffuse pulmonary infiltrates and abnormal histology. pathologies largely unique to children presenting in the first two years of life are now appreciated and up to % of cases may be inborn errors of surfactant metabolism leading to surfactant dysfunction . we report our experience of child in infants presenting to the royal belfast hospital for sick children over years and describe the presentation, investigations and clinical outcome in this group. all children presented with chronic tachypnoea, hypoxaemia, crackles, indrawing and failure to thrive. differential diagnoses of cystic fibrosis, aspiration, immunodeficiency and cardiac disease were considered and excluded in all cases. nine children had a hrct scan, the commonest finding being a 'mosaic' or diffuse interstitial pattern and four underwent lung biopsy, none of which resulted in a definitive diagnosis. eleven children were treated with inhaled corticosteroids and three with additional systemic steroids and all have experienced clinical resolution over time. the recent identification of the genes responsible for surfactant dysfunction disorders may, in future, obviate the need for a lung biopsy and be diagnostic in approximately % of children. screening of patients with contrast echocardiography, thoracic computerised tomography (ct) and cerebral magnetic resonance imaging (mri) has identified patients with definite hht, ( %) of whom had epistaxis, ( %) had telangiectasia and ( %) had a first-degree relative with hht. contrast echocardiography and/or ct were performed in patients, identifying patients ( %) with pulmonary arteriovenous malformations (pavms). nineteen patients with single or multiple pavms had embolization procedures performed, with - pavms embolized per procedure. mri was performed in ( %) patients but no cerebral arteriovenous malformations (cavms) were diagnosed. hht incidence in ireland is thought to be in - , , suggesting that there are many more undiagnosed cases nationally. internationally published data suggest a prevalence of - % for pavms and - % for cavms in patients with hht. while the prevalence of pavms in our group is consistent with these data, the prevalence of cavms is not, suggesting that irish patients with hht may differ genotypically and phenotypically from those in other countries. atrial and c-type natriuretic peptides (anp, cnp) are known vasodilators in many vascular beds. the role of npr-c in natriuretic peptide (np) mediated pulmonary vasodilation remains unknown. furthermore the role of endothelium in mediating vasoactive effects of np is controversial. using isolated ventilated-perfused lungs to monitor pulmonary artery (pa) pressures upon exposure to increasing doses of angiotensin ii in the presence of vehicle or anp, cnp, or the selective npr-c ligand, canf. additionally, using isolated pa rings constricted with phenylephrine, concentration dependent relaxations were measured in response to nps in endothelium intact/denuded vessels. results: anp and cnp but not canf significantly attenuated the vasoconstrictive properties of angiotensin ii in isolated perfused lung. similarly, canf had no vasodilatory effect in constricted pa rings. anp and cnp both vasodilated the pa rings. however, only cnp had endothelium dependent vasodilation at doses higher than - m. the endothelium dependent vasodilation was completely abolished by pretreatment with l-name, no synthase inhibitor, and iberiotoxin, a k + channel blocker. pretreatment with a-glycyrrhetinic acid ( a-ga), a myoendothelial gap junction inhibitor, and indomethacin, a cyclo-oxygenase inhibitor, had no effect on endothelium dependent vasodilation. conclusion: npr-c plays limited role in np mediated pulmonary vasodilation. the endothelium dependent effect of cnp is mediated by no and bkca channels. pulmonary embolism with potential fatal consequences is common amongst acutely ill medical patients. it is recognised that venous thromboembolism (vte) prophylaxis is underutilised in this population. we postulated that an education campaign could increase its usage. we prospectively studied consecutive medical admissions for one month before and after an educational intervention to see if the rate of thromboprophylaxis prescribed increased in patients who warranted such prophylaxis as recommended by the american college of chest physicians (accp) guidelines. prior to an educational intervention, we studied ninety-nine consecutive medical admissions. thirty-six patients in this group met criteria for prophylaxis and had no contraindication to prophylaxis. nineteen ( . %) of these patients received prophylaxis and seventeen ( . %) did not receive prophylaxis. the data were presented to the medical staff and the guidelines were discussed (educational intervention). subsequently, of consecutive medical admissions, met the criteria for prophylaxis. thirty-six ( . %) of these patients received thromboprophylaxis. compliance with the accp guidelines therefore rose from . % to . % (p = . ; fisher's exact test) of those eligible following the educational intervention. our data supports the use of education to increase adherence to guidelines which may improve outcome in acutely ill medical patients. venous thromboembolic disease is a major cause of morbidity and mortality amongst medical inpatients. prophylactic therapy with low molecular weight heparin, unfractionated heparin, and graded compression stockings has been shown to significantly reduce risk of pe & dvt. we sought to assess compliance with current international guidelines in a medical inpatient population, as well as the impact of a simple, prominent educational poster at ward and emergency department level. data was collected using a proforma derived from current accp guidelines. collection was performed on dates, before and one month after intervention. patients were assessed on each date. at baseline, prophylaxis was indicated in % (n = ) of patients. of these % (n = ) received appropriate therapy. compliance was best among specialist disciplines such as stroke medicine. acute s medical teams fared less well. among the post-survey cohort, prophylaxis was indicated in % (n = ), and prescribed in (n = %) (p = . for comparison) of these. vted prophylaxis is under prescribed. our results suggest that simple educational measures can improve compliance with established international guidelines. however, more interactive methods may yield greater benefits. pulmonary arteriorovenous malformation (pavm), a rare cause of hypoxia, are familial in % manifesting as osler weber rendu (owr) syndrome and are associated with embolic stokes in % ( , ) . this report highlights a case of hypoxia secondary to pavm with a family history of embolic strokes not associated with owr. a year old man was admitted with dyspepsia. admission chest x-ray identified a left mid zone mass. he had no medical history. his mother died from a stroke aged and had an ''abnormality in her lung''. his brother died at age from an embolic stroke. shortly after admission, he complained of dyspnoea. physical exam revealed oxygen saturations of %, tachypnea and tachycardia. oxygen saturations improved to % on % oxygen. he had no telangectasia or other signs of owr syndrome. ct pulmonary angiogram displayed a large pavm in left lower lobe. a contrast echo identified a large extracardiac right to left shunt. endoscopy confirmed oesophagitis secondary to excessive alcohol intake. he was discharged on aspirin pending review by cardiothoracic surgery for definitive treatment of his pavm to prevent worsening of his symptomatic hypoxia and reduce his risk of an embolic stroke. it has been hypothesised that fatigue of the genioglossus muscle contributes to collapse of the upper airway in osas. in this study, fatigability of the genioglossus was compared in healthy control subjects (aged - ) and osas patients (aged - ; apnoea/ hypopnoea frequency - /hr) using surface electromyographic (emg) signals recorded with a novel intra-oral electrode. emg signals were recorded during sustained isometric tongue protrusion at % of maximum voluntary contraction. endurance time was the point at which force fell % below the target level. muscle fibre conduction velocity (cv), an index of fatigue, was estimated from two adjacent emg signals and the rate of muscle fibre cv decrease during each contraction was calculated. the mean endurance time was lower in patients ( . ± . secs) than controls ( . ± . secs). in addition, the mean rate of decrease of muscle fibre cv, when normalised to an initial value of one, was greater in patients ( . ± . percent per second) than in controls ( . ± . percent per second). together, these results suggest increased susceptibility to genioglossus fatigue in untreated osas patients. furthermore, this approach provides a means of examining the role of fatigue in the pathophysiology of osas. obstructive sleep aponea (osa) is characterised by recurrent collapse of the airway during sleep leading to reduced or complete cessation of airflow despite respiratory effort, causing fragmented sleep and excessive daytime sleepiness. sleep deprivation is thought to be responsible for up to % of road traffic accidents. we examined data on the occupation of consecutive patients treated for osa with continous positive airway pressure (cpap) in our institution. specifically the numbers driving vehicles as the primary part of their occupation. drivers made up % ( ) of the total. this included taxi drivers ( ), bus drivers ( ) and train drivers, delivery persons ( ) and drivers of other vehicles ( ) . this data is of major importance given that the rate of osa in the populaiton is estimated at - %, whilst drivers making up % of our diagnosed osa polulation. it has major implications for service provision, the safety of all road users and those legislating in this regard. to avoid expensive sleep laboratory diagnosis of osa, we provide a home-based monitoring service with overnight oximetry and/or five channel limited sleep study. we wished to review these studies to assess their usefulness in reaching a diagnosis and to look at practical difficulties that may arise. we reviewed all oximetries and sleep studies, in patients with suspected osa, requested by one consultant in months period in st. john's hospital limerick and the mid-west regional hospital. of the oximetries, . % were suggestive of mild, . % moderate and . % severe osa. % were normal, . % borderline and . % malfunctioned. patients did not attend their first appointment. % of patients were waiting less than weeks. of the limited sleep studies, . % were suggestive of mild, . % moderate and . % severe osa. . % were normal. patients ( . %) had prior non-diagnostic oximetries. there were a large number ( ) of non-attendants for sleep study; we attribute this to longer waiting time and lack of secretarial back-up. there was minimal damage to the equipment. patients were started on long term cpap, to date nearly % are persisting with this. this confirms that home diagnosis of osa is both feasible and practical. both conditions represent a significant burden to the health service in terms of diagnosis, treatment and management. volunteers agreed to undergo a home limited cardiopulmonary sleep study and to interview with questionnaires including the epworth score. studies were manually scored to determine the apnoea hypopnoea index. results: volunteers were recruited, were excluded due to incomplete studies and withdrew consent. subjects ( female) were analysed, mean age: yrs (range - ), mean bmi: (± . ). significant osahs (ahi [ ) was found in females ( %) and male ( %) subjects, % overall. conclusion: osahs is very common in this group of patients without being the primary reason for attendance. this would suggest that osahs remains under-diagnosed particularly in the context of cardiovascular disease. we suggest that there should be routine screening for osahs in this patient group. to assess newly diagnosed patients with osahs for cardiac dysfunction by echocardiography. background: osahs is a common condition occurring in approximately % of men and % of women. it is associated with an increased morbidity and mortality from cardiovascular disease. newly diagnosed patients (ahi [ ) attending the sleep clinic in st. james's hospital were sent for echo to determine evidence of early heart changes in this group. results: patients were scanned ( female). average age: years, (range - yrs) with average weight of kg (+/- ) evidence of diastolic dysfunction was found in female ( %) and of the male subjects ( % the nf-jb inflammatory pathway is selectively activated by intermittent hypoxia in vitro and in patients with obstructive sleep apnoea syndrome (osas). nitric oxide (no) acts as an important signalling molecule in several biological processes including inflammation. we hypothesise that no plays a critical role in regulating the microenvironment of intermittent hypoxia and in modulation of the associated nf-jb response. serum nitrite and nitrate levels were measured in osas patients with no other medical disorder and healthy controls (body mass index-and age-matched). levels in osas patients were remeasured following continuous positive airway pressure (cpap) therapy. we also investigated the effect of no on transcriptional events initiated by intermittent hypoxia in an in vitro model. serum nitrite and nitrate levels did not differ between osas patients and controls (p = . and p = . respectively). nitrite levels in osas patients increased significantly following cpap therapy ( . lm compared to . lm (p = . )), indicating increased endothelial nitric oxide synthase (nos) activity. in our translational in vitro model no increases oxygen bioavailability in hypoxia through mitochondrial inhibition and decreases intermittent hypoxia-induced nf-jb activity. conversely, nos inhibition increases nf-jb activity. the findings support a role for no in regulating the inflammatory response to intermittent hypoxia. continous positive pressure (cpap) is an effective therapy for obstructive sleep aponea (osa). it's efficacy is limited by several factors including variable compliance with therapy. compliance is defined as cpap usage of greater than hours more than % of nights. studies of predictors of compliance have shown conflicting results. data on patients with osa treated with cpap in our institution was examined including aponea-hyponea index (ahi), oxygen desaturation index (odi), minimum oxygen saturation, epworth sleepiness score (ess) and compliance rates. the overall compliance rate was found to be %, with overall compliance at weeks following initiation of therapy . %. this rate compared with compliance of . % at months. this suggests that week compliance rates are a good marker of longer-term compliance. obstructive sleep aponea (osa) is characterised by recurrent collapse of the airway during sleep leading to reduced or complete cessation of airflow despite respiratory effort. this leads to sleep fragmentation through multiple arousals with poor sleep and has been associated with major co-morbidities including impaired cognition, poor quality of life, and increased risk of accidents. evidence is emerging that osa is an independent risk factor for adverse cardiovascular outcomes. we treat over one hunderd patients for osa with continous positive airway pressure (cpap) in our institution. patient data including body mass index, neck circumference, aponea-hyponea index (ahi), oxygen desaturation index (odi), lowest oxygen (o ) saturation, epworth sleepiness score (ess) was collected. neck circumference was correlated with markers of disease severity and found to be a predictor of more severe disease as defined by higher ahi and lowest o saturation. no correlation was found with odi or ess. we propose that this is a useful and easily obtained marker of severity of osa. prompt management of exacerbations is a cornerstone of effective treatment of cystic fibrosis. it is therefore imperative that patients promptly report changes in symptoms to their physician/cf team. we sought to clarify which symptoms patients would report to the clinical team and when they would report them. an anonymous questionnaire was sent to a random sample of stable adult patients with cystic fibrosis ( male and female). predictors of early response were evaluated using logistic regression. % returned questionnaires that were suitable for analysis. for all symptoms a significant number of patients would not contact the medical team before their next routine out-patient appointment or even report it at all (table ). there was a wide variation in the time to alerting the clinical team between and within symptoms. females were significantly more likely to report a change in small volume haemoptysis or cough before their next out-patient appointment. younger patients were more likely to report small and large volume haemoptysis. delayed patient responsiveness to changes in respiratory symptoms is a barrier to prompt management of exacerbations in cf. supported by: health research board, cf association of ireland. bronchoalveolar lavage can be used to investigate pulmonary aspiration in children by measuring pepsin concentration, however, it is invasive. sputum induction is a potential non-invasive way of obtaining samples. we aimed to: ( ) assess safety and feasible of measuring pepsin in inducted sputum in children and ( ) determine whether the sputum induction procedure caused gastro-oesophageal reflux with refluxed pepsin contaminating samples. children with no respiratory or gastroesophageal symptoms were recruited (n = , range - years). following spirometry, sputum induction was carried out and pepsin concentration measured by an 'in house' elisa. spirometry was repeated and any complications noted. only one child (aged ) produced no sample, however two other year olds did complete sputum induction. no adverse effects were reported. one child required a sabutamol nebuliser following a % decrease in fev . of the sputum samples ( %) were positive for pepsin. sputum induction appeared a safe procedure in children. it is well tolerated by children and can be successfully carried out in children as young years of age. however, the analysis of pepsin in sputum obtained by induction is not useful in the investigation of respiratory associated gastroesophageal reflux disease as % asymptomatic children have positive samples. immunodeficiency may result in recurrent pulmonary infection leading to chronic lung damage and bronchiectasis. the aim of our study was to identify immunodeficiency in idiopathic bronchiectasis and the parameters that correlate with disease severity. patients with idiopathic bronchiectasis were assessed. patients were recruited over a one year period from the respiratory out-patient and in-patient service. serum immunoglobulins, igg subclasses and pneumococcal antibody levels were measured. clinical, physiological, microbiologic and radiologic data was obtained. patients with igg subclass deficiency (iggsd) were significantly more likely to be hospitalised with a respiratory exacerbation as compared with the immunocompetent group (p \ . ). iggsd was associated with lower fev (p \ . ), more severe obstructive airways disease (p \ . ) and persistent sputum purulence (p \ . ). iggsd correlated with low pneumococcal antibody levels. there was no significant difference in bronchiectasis severity or lobar involvement on high resolution ct. our findings support the hypothesis that patients with iggsd and documented bronchiectasis suffer more severe exacerbations even in the contaxt of radiologically mild disease. patients with evidence of bronchiectasis radiologically should have serum immunoglobulins and igg subclasses performed. this cohort is high risk for progressive lung damage in the setting of recurrent severe exacerbations and should be identified early to ensure optimal management. macrophages undergo apoptosis after infection with m. tuberculosis (mtb). this macrophage response deprives the bacillus of its niche cell, and supports the host response through better antigen presentation.virulent strains of mtb do not cause apoptosis at low multiplicities of infection (moi) which may contribute to this pathogen's ability to survive long-term in macrophages. we investigated the ability of mtb to cause macrophage cell death at a high moi ( - ) which is likely to represent the high bacillary burden seen in the later stages of infection. the mechanism of cell death was analysed by fluorescent microscopy and nucleosome elisa. macrophages infected with virulent (h rv) mtb displayed several features typical of apoptosis including dna fragmentation and exposure of phosphatidylserine. however, mitochondrial cytochrome c release and nuclear fragmentation were not observed, suggesting that mtb-induced cell death differs from classical apoptosis. cell death was significantly reduced (p \ . ) following treatment with serine protease inhibitors (aebsf and tpck) but was not effected by the caspase inhibitor zvad-fmk. in summary, mtb triggers a novel serine protease-dependent macrophage cell death pathway which may facilitate dissemination in the later stages of infection. a better understanding of this macrophage response may direct new vaccine and treatment options. patients had microbiological confirmation of tb, were culture positive and patients were pcr positive. the mean (sd) age was ( ). male:female ratio : . of the pulmonary cases, bronchoscopy (bronchial washings/ biopsy) was required to make a microbiological diagnosis in cases ( %). of the cases where sensitivity data was available, there were cases ( . %) of drug resistant tb. of these, ( %) were mono-resistant, ( %) were poly-resistant and ( %) were multidrug-resistant tb. various factors including the presence of a resistant organism determined duration of treatment and site of care. six patients had disease in multiple sites the high rate of drug resistant tb in this population has implications not only for the management of index cases but also for the management of contacts and the management of latent tb in the population as a whole. resource limitations have raised interest in portable monitoring systems that can be used to improve access to the diagnosis of obstructive sleep apnoea syndrome (osas). this prospective study compares a combined electrocardiogram and oximetry recorder (holter-oximeter) in an unattended home setting against attended polysomnography for detection of osas. subjects ( male: female) with suspected osas underwent attended polysomnography (psg) in hospital and subsequent unattended evaluation at home with a holter-oximeter (nemon dr +). an algorithm for estimation of the (apnoea-hypopnoea index) ahi using only a single lead of electrocardiograph (ecg) and the oximetry trace had previously been developed using a database of psg recordings. osas was defined as ahi c , non-osas as ahi \ , and b ahi \ as indeterminate. evaluation methodology was in accordance with the recommended american academy of sleep medicine guidelines (flemons et al. ) . sensitivity and specificity were %. positive and negative likelihood ratios were [ and respectively. estimated ahi agreed closely with psg ahi (r = . ; p \ . ). combined holter-oximeter monitoring compares well against polysomnography for identifying osas and is potentially a suitable device for home screening of sleep apnea in a population suspected of having osas. current international guidelines suggest the combined use of pre test probability scores, d dimers and ct pulmonary angiography (ctpa) for the management of suspected pulmonary embolism (pe). our aim was to audit adherance to international guidelines for the management of suspected pe in a teaching hospital. a retrospective audit was performed on all ctpa's carried out in merlin park hospital from the / / to the / / . patients had clinical notes available for analysis. only % of patients had a documented well's or geneva score. ctpa confirmed pe in % of cases overall. when a well's score was calculated in these patients, % were high risk, % were intermediate risk and % were low risk. a third of patients in the low and intermediate risk groups had no d dimers measured. half of patients in the high risk group had an inappropiate d dimers. no patient with a confirmed pulmonary embolism had a normal d-dimers. % of patients had d dimers measured and . % of these of were normal. all ctpa's in this subgroup were negative for pulmonary embolism. when a well's score was calculated, retrospectively, from clinical notes patients were in an low or intermediate risk group where ctpa was not indicated. we conclude that pre test probability scores are underutilised. it confirms that patients with low or intermediate risk of pe and negative ddimers should not require ctpa. it also highllights that d-dimers should be used appropriately in low or intermediate risk groups. common variable immunodeficiency (cvid) is a primary immunodeficiency syndrome characterised by diminished serum immunoglobulin levels and impaired antibody responses. cvid may present as granulomatous disease and masquerade as ''sarcoidosis''. we have previously described four patients referred to us with a diagnosis of sarcoidosis with granulomatous disease on biopsy who in fact had cvid. sarcoidosis is more typically associated with hypergammaglobulinaemia. we have evaluated serum immunoglobulin levels in patients with granulomatous disease on biopsy with clinical and radiological pattern compatible with sarcoidosis. thirty seven ( %) were male. mean age of presentation was . (sd +/- , range - ). % of patients demonstrated hypergammaglobulinaemia (n = ). % (n = ) demonstrated low igm levels. % (n = ) demonstrated an isolated low igg level. a single patient had low igg and igm levels and has been further evaluated for cvid. % of patients had low/ normal iga levels (n = ). in conclusion, hypergammaglobulinaemia was less common than anticipated in this cohort of patients with granulomatous disease believed to be secondary to sarcoidosis. patients with a putative diagnosis of sarcoidosis should have immunoglobulin levels determined to exclude cvid. in chronic asthma, goblet cell hyperplasia and decreased ciliogenesis are characteristic features which may be influenced by th cytokines (eg il- and il- ). in vitro basal mucociliary differentiation and differences in paediatric epithelial cells (normal & asthmatics) exposed to il- were studied. blind non-bronchoscopic bronchial brushings obtained from children were differentiated at air liquid interface for days. cells s were treated with ng/ml il- and ng/ml il- . transepithelial resistance (ter), number of ciliated (anti a -acetylated tubulin antibody) and goblet cells (muc ac + ) were assessed as a measure of tissue differentiation. both asthmatics and normal cell cultures formed well differentiated pseudostratified epithelium (ter [ x/cm ). asthmatic cultures expressed significantly more goblet cells ( . %, sd = . ) when compared with non-asthmatic cultures ( . %, sd = . ) under basal culture conditions (p = . ). significant more goblet cells are seen in asthmatic cultures when chronically exposed to il ( ng/ml and ng/ml) when compared with identically treated nonasthmatic cultures (p \ . ). asthmatic cultures expressed significantly less ciliated cells ( . %, sd = . ) when compared with nonasthmatic cultures ( . %, sd = . ) under basal culture conditions (p = . ). asthmatic cells differentiate at basal conditions with higher proportion of goblet cells and decreased number of ciliated cells when chronically exposed to il- . combining inhaled corticosteroids with long-acting b -agonists results in improved asthma symptom control and fewer asthma exacerbations compared to inhaled corticosteroids alone. however, there are limited data as to whether these beneficial effects are due to enhanced antiinflammatory actions, or whether such combination therapies impact on airway remodeling in asthma. we sought to determine the effects of inhaled budesonide/formoterol combination therapy, versus inhaled budesonide alone or inhaled placebo, on allergen-induced airway responses, airway inflammation and airway remodeling. fourteen asthmatic subjects with dual responses after allergen inhalation were included in this prospective randomized, double-blind, -period cross-over study. outcomes included asthmatic responses, changes in airway responsiveness and sputum eosinophilia, measured before and after allergen challenge, and numbers of airway submucosal myofibroblasts measured before and after study treatment. combination treatment attenuated the maximal early asthmatic responses and also resulted in a -doubling dose attenuation of allergen-induced airway hyperresponsiveness compared to budesonide or placebo treatment (p \ . ). allergen-induced increases in sputum eosinophils and in submucosal tissue myofibroblasts were significantly reduced by combination treatment (p \ . ), but not by budesonide alone when compared to placebo. inhaled budesonide/formoterol combination therapy attenuated allergen-induced airway responses and provided greater anti-inflammatory effects than either budesonide alone or placebo. combination therapy also attenuated the allergen-induced increases in submucosal myofibroblast numbers, suggesting that clinical benefits associated with such combination treatment may relate to effects on airway remodeling. the purpose of this study was to determine the effects of sub-cytotoxic concentrations of eosinophil peroxidase (epo) on expression and sub-cellular localisation of the linked cell growth and cell cycle mediators, focal adhesion kinase (fak), cyclin-dependent kinase inhibitor p kip and the epidermal growth factor receptors egfr and erbb . eosinophils exert many of their inflammatory effects in allergic disorders by degranulation and release of cationic granule proteins including epo. in sub-cytotoxic concentrations, eosinophil granule proteins increase transcriptional expression of various growth factors in airway cells. the methods used were real-time pcr, western blotting of membrane, nuclear and cytoplasmic cell fractions and immunoprecipitation. epo induced a concomitant time-dependent egress of fak and p kip from the cell nucleus to the cytoplasm. immunoprecipitation indicated a physical association between fak and p kip , implying that fak acts as a nuclear-cytoplasmic shuttle for p kip . epo also induced up-regulation of expression of egfr and erbb . our results imply that epo potentially induces cell proliferation, by up-regulating egfr and erbb and cell cycle, by driving p kip from the nucleus. this has implication for the role of eosinophils in tissue remodelling and turnover in conditions from asthma to cancer. alpha- antitrypsin (a at) deficiency predisposes individuals to early onset emphysema and is a debilitating disease in which neutrophils play a central role. it is becoming more evident that a at possess key anti inflammatory properties and the aim of this project was to examine the possible role of a at in modulating neutrophil chemotaxis. western blot and facs analysis was utilised to examine the effect of a at on release of cd b, a key molecule in chemotaxis and adhesion, from the neutrophil membrane. the effect of a at on neutrophil migration using il- ( - ng/ . cells) was quantified employing a multiwall chemotaxis chamber. our experimental results revealed that a at ( . lm) prevented the release of cd b from the neutrophil membrane. inhibition of il- chemotaxis was dose dependent and almost completely inhibited by . lm aat. in addition, neutrophils of a at deficient (zz) individuals displayed decreased levels of cd b. this study highlights the importance of serum levels of a at for modulating neutrophil activity and aims to evaluate whether infused a at possess the ability to bind and govern the activity of circulating neutrophils in vivo. aat deficiency (aatd) is a hereditary disorder, resulting from mutations in the serpina gene, and classically presents with earlyonset emphysema and liver disease. the most common mutation causing aatd is the z mutation, with the s mutation also associated with lung disease. aat deficiency is under-diagnosed and prolonged delays in diagnosis are common. the world health organisation advocates screening copd, poorly-controlled asthma, cryptogenic liver disease patients and first degree relatives of known aatd patients. , individuals with copd, asthma, or cryptogenic liver disease were screened in the national targeted detection programme. , healthy individuals from the tcd biobank were genotyped for s and z alleles. targeted screening identified zz, sz, ss, mz, ms, and mi individuals, yielding gene frequencies of . and . for s and z respectively. biobank screening of , healthy individuals identified ms, mz, sz and a single ss case, yielding gene frequencies of . and . for s and z. the allele frequencies for s and z in ireland were previously estimated at between . - . and . - . ( ). our pilot study shows s and z alleles occur at higher frequencies, suggesting , zz individuals and over , carriers on the island of ireland. the z mutation is more clinically significant with a higher penetrance than s in the groups we have evaluated. inspiratory-to-total lung capacity ratio predicts mortality in patients with chronic obstructive pulmonary disease joint accp/aacvpr evidence-based clinical practice guidelines sarcoidosis: clinical update hereditary hemorrhagic telangiectasia pulmonary arteriovenous malformations: techniques and long-term outcome of embolotherapy obstructive sleep apnoea in a patient with bilateral carotid body tumours, a unique case references obstructive sleep apnea caused by carotid body tumor: case report obstructive sleep apnea due to a carotid body paraganglioma continuous positive airway pressure therapy compliance rates across three sleep centres we present a unique case of a patient who presented with obstructed sleep apnoea (osa) caused by bilateral carotid body tumours.the patient was treated during a year period, during which time he required non-invasive ventilation at night via continuous positive airways pressure (cpap). he also underwent surgical resection of his right and left carotid body tumours sequentially while on cpap. during family screening his daughter was discovered to have a carotid body tumour but without osa.at presentation, his apnoea-hypopnoea index (ahi) was . , and his epworth score was out of possible . after resection of both carotid body tumours, his ahi score fell to . , and he was symptomatically improved and he was able to return to work.this unusual case highlights the need to investigate patients with osa for an underlying treatable cause. to our knowledge, this is the first report of bilateral familial carotid body tumours causing osa; to date osa has only been reported with unilateral carotid body tumours. , to determine long-term compliance rates for patients prescribed continuous positive airway pressure (cpap) therapy from three sleep centres. having 'limited study' devices now in use for - years now, we have the opportunity to compare cpap compliance rates between sleep centres using these, and established centres using full polysomnography (psg).a population-based analysis of patients prescribed cpap therapy over a -year period - , with compliant vs. non-compliant status determined in june .it is possible to achieve long-term compliance rates of [ % with limited study systems and correct follow-up care. however, factors such as patient education and follow up, along with a high level of home service, are vital. . is brain natriuretic peptide a good marker for obstructive sleep apnea and the efficacy of continuous positive airway pressure therapy in obstructive sleep apnea patients? the aim to assess natriuretic peptide levels n-terminal pro b-type and b natriuretic peptide in congestive heart failure (chf) patients with/without obstructive sleep apnea (sa). the effect of cpap on natriuretic peptides in a sleep apnea population was assessed.a blind study in a known population, sleep apnea status was unknown. biosyn triage measured bnp, roche measured nt bnp. both were measured in congestive heart failure patients ( female, male) with obstructive sleep apnea ( female, male) and normal patients ( female, male).bnp is a good marker for chf. nt probnp is a good marker for chf, it could distinguish chf patients from chf osa patients. cpap didn't reduce natriuretic peptide concentrations. aim: to show that osahs is a common feature in patients with metabolic syndrome. background: metabolic syndrome has been described as a constellation of risk factors for cardiovascular disease. the who places the incidence at % of the population. osahs occurs in - % of males and females. key: cord- -cts al z authors: kaplan, alan; o'neill, daniel title: covid- and healthcare's productivity shock date: - - journal: nejm catal innov care deliv doi: . /cat. . sha: doc_id: cord_uid: cts al z the covid- pandemic has highlighted the urgent need for health care providers to abandon volume-based payments in favor of models that give them financial stability in volatile times. in the u.s., covid- is colliding with the largest, most lucrative healthcare industry in the world. and yet, as patients shy away from hospitals and clinics, the crisis is challenging longstanding pillars of providers' revenue models, many of which focus on in-person visit volume, high-priced procedures, and profitable markups on drugs that physicians buy and bill to insurers and patients. while the shock may prove short-lived, it creates an opportunity for creative, forward-thinking organizations to reconsider purely transactional revenue streams and labor-intensive operating models. such changes could leave us with a more sustainable healthcare system, grounded in more streamlined and accessible care delivery enterprises. over the last years, as u.s. health spending swelled from % to % of gross domestic product, employment in healthcare also surged. between and , the number of staff working in physicians' offices rose three times as fast as economy-wide employment. in hospitals, headcount is up by almost a third since the late s. healthcare services are inherently labor-intensive, but they have become much more so in recent years. america's medical practices now employ more than eight full-time employees per , u.s. residents, up from just over six in . hospital staffing is approaching employees per , people, up from in the late s, despite a significant drop in admissions per capita and the average length of stay. the sheer magnitude of financial resources flowing into healthcare contributes to this marked hiring growth. u.s. hospital revenues, for example, have risen by an average of $ billion in each of the last ten years. in each of those years, hospitals hired almost , additional employees ( figure ). physicians' offices have hired almost as aggressively, adding more than , staff per year. contrary to common perception, the patient care and support roles account for the bulk of that hiring -from physicians and nurses to surgical technicians, health aides and social workers. combined, hospitals and practices added almost half a million employees in patient-facing roles from through , while the number of managerial, financial and administrative support staff actually declined ( figure ). hospitals, for example, cut office and administrative headcount by almost , over the last five years, while adding , physicians and surgeons, , nurse practitioners and physician assistants, and more than , registered nurses (rns). in physicians' offices, hiring emphasized advanced practice clinicians (nps, pas and crnas) and medical assistants. as hiring surged, wages for health workers also ticked up. in aggregate, through expanded headcount and higher pay rates, aggregate wage bills for hospitals and physicians' offices increased by roughly $ billion between and ( figure ). sixty percent of that increase accrued to physicians, advanced practices clinicians and rns, though these professions account for just a third of the employee base in these care settings. another % went to pharmacists, radiology techs, medical assistants and other clinical and patient support professionals. in contrast, managerial, financial and administrative staff form % of the hospital and practice workforce, but collected only % of incremental wage spending. hospitals and medical offices headed into the covid- crisis with much higher labor costs than they carried just a few years ago, and staff in patient-facing roles account for most of the extra expense. revenue growth, fee for service and healthcare's operating model this hiring pattern tracks the basic financial incentives that shape american healthcare: provider revenue growth stems from rising prices and increased service volume. face-to-face visits, procedures and drug infusion all require more patient-facing staff, which creates a clear business case to add these workers. meanwhile, submitting a claim for the same service but with a higher contracted price requires little additional work in business operations. and, as hospitals and physician groups have merged, they often consolidate billing operations, allowing provider organizations to reduce back office staffing even as patient service revenue continues to expand. research on hospital consolidation is consistent with this pattern, finding that merging hospitals consistently results in higher prices for patients and insurers (and hence revenue for the hospital), while potentially allowing some facilities to lower their own operating expenses, which would include administrative staff costs. that business model has produced decades of uninterrupted revenue growth for hospitals and other clinical enterprises. while most industries face periodic downturns, hospital revenue has grown by at least % in every year since , according to national health expenditure data from the centers for medicare and medicaid services. physician and other clinical services revenue also increased every year since the s, by at least % annually. this left an industry, with an increasingly labor-intensive and volume-driven revenue model, acutely vulnerable to a sudden drop in tests, procedures and other billable encounters -just as highly-leveraged airlines struggle with a dip in ticket sales. moreover, given an unbroken half century of growth, many healthcare leaders have little experience handling even short-lived contractions. finally, while healthcare is clearly less cyclical than many industries, it does contain a layer of low-value services -profitable for the provider, but of little use to the patient -which accounts for % to % of nationwide provider revenue, by some estimates. the covid- crisis is a severe shock to that model, simultaneously delaying many surgeries or screenings and encouraging patients to re-consider the necessity of some interventions. one recent analysis showed a drop of % to % in visit volume in the first week of april for specialties such as gastroenterology, urology and dermatology. visit volumes have since rebounded significantly, but remain below pre-crisis levels, as of mid-may. moreover, the crisis forced providers to embrace service channels, such as video consultations or asynchronous patient communication, which are less labor-intensive and so challenge prior expansion in patient-facing staff. physicians and nurse practitioners are just as critical when consults shift from the exam room to a video screen, but the daily tasks of a medical assistant or technician do not easily translate to virtual care. a urology example illustrates how the sudden shift to virtual care can reduce or postpone specialist cash flow, and may encourage more conservative care, lowering provider revenue over the course of an episode. pre-crisis, a man in his mid- s with difficulty urinating would generate practice revenue through a billable office visit, a blood draw to rule out prostate cancer, urinalysis to rule out infection and uroflowmetry to diagnose urinary obstruction. follow-up procedures would likely produce additional billings from cystoscopy to confirm benign prostatic hyperplasia (bph) and a minimally invasive surgical procedure to improve symptoms. the entire series of interventions could generate roughly $ at medicare rates, and would involve several office staff apart from the urologist. with in-person care limited by covid- , the same case might be managed through two virtual consults, with half as much revenue (even with virtual payment parity) and little need for staff beyond the physician. many patients will still need subsequent diagnostic and therapeutic interventions, so some of that revenue will accrue later, but others will choose to forego the surgical procedure altogether in favor of long-term medical management. in a similar way, covid- could require more conservative care for lower back pain, a notorious area for low-value care. pre-crisis, some patients and clinicians would opt for in-office epidural injections to relieve symptoms. covid- forces a delay in that billable intervention, and a month or two of conservative management through over-the-counter analgesics and physical therapy will likely obviate the need for some of these injections entirely, trimming provider revenue for an equivalent case. as covid- fears mounted, hospitals and clinics froze whatever operations they could and directed resources to essential care and pandemic preparation. that shift in emphasis has stressed a set of enterprises accustomed to steady annual revenue growth, through ever-higher prices and, for most services, fairly predictable volume. as with many crises, that economic shock creates important opportunities to evolve. while the demand for health services is likely to rebound, management of the epidemic may require recurring stay-at-home orders or sustained social distancing over the next to months, prompting some patients to avoid procedures they deem optional, and otherwise prefer virtual contact whenever possible. provider organizations that adapt quickly can build more resilient businesses and help nudge the broader health system onto a more sustainable and value-oriented path. an accelerated transition away from fee-for-service pricing will cushion provider revenues against volatility in volume for discretionary or elective spending." first, an accelerated transition away from fee-for-service pricing will cushion provider revenues against volatility in volume for discretionary or elective spending. primary care practices with capitated "per patient per month" contracts have seen little revenue erosion amidst the crisis. many specialist groups can and should explore similar population-based contracts. some clinical laboratories, for example, have long participated in managed care capitation, collecting a fixed monthly fee in exchange for handling all diagnostic testing in a given patient panel. specialists who conduct routine screenings (e.g., colonoscopies or mammograms) could develop similar arrangements, to replace some volume-dependent revenue with predictable, recurring cash flow. hospitals have historically favored episode and procedure-based pricing, given that continual price hikes for emergency room (er) visits, surgeries and admissions ensured steady revenue growth. however, with some chains seeing er volumes drop % to %, adding some populationbased revenue may become appealing. trauma centers, for example, carry high fixed operating costs, and are not inherently suited to competition for patients in any case. hospitals could strike per member per month (pmpm) contracts with local insurers, based on expected volumes. and certainly, volatile visit and procedure volumes make a compelling case for accelerated transition to some accountability for total cost of care. as travis broome and farzad mostashari have argued, the structure of shared savings acos -where medical groups earn bonuses based on performance relative to local market cost trends -inherently insulates those revenue streams amid system-wide volatility. many of these steps require new contracts with willing and flexible payers, but would also produce more predictable financials for health plans that are also worried about unpredictable covid- costs and the impact on next year's premiums. specialist practices, whose work is inherently more episodic, may be less suited to capitation than relationship-based primary care, but they have other options to revamp their revenue mix. some bundled payment models, for example, are structured around -day episodes of care, which could make revenue less sensitive to precise timing or delivery method in certain components of that episode. similarly, "buy-and-bill" economics can be very lucrative for oncologists, allergists and other specialists that administer drugs in a practice, charging the patient and insurer a markup on the wholesale price of those drugs. but when covid- fears halt in-office drug administration, those attractive markups evaporate. an alternative approach would pay the clinician for overseeing a course of therapy, irrespective of where or how the drugs are administered. such a model could " allow for home infusions when practice visits pose infection risks, and might have the side benefit of eliminating the financial conflict of interest for providers who earn larger margins when they administer more expensive drugs. finally, specialists could consider adding a new revenue stream by offering virtual "econsults" to capitated or at-risk primary care groups. this sort of revenue stream might grow as primary care practitioners try to care for patients unable to follow a typical referral path, offsetting lost revenue from in-person patient consults. several companies, including thea health, sitka and rubiconmd, offer tools to facilitate pcp-to-specialist consultations. state regulators and medical boards could facilitate these models by eliminating burdensome requirements for clinicians to be separately licensed in each jurisdiction, as some states have done on an emergency basis during the covid- crisis. second, hospitals and practices should revisit operating models that presume ever-rising revenues will fund ever-larger headcount. if physician practices could deliver care with six employees per , americans in the late s, before ubiquitous email and videoconferencing, it is unclear why they need eight employees per , today. in a matter of weeks, many practices shifted to telehealth, video-consults and asynchronous patient communication. for some, a higher virtualto-in-person visit ratio will allow for a lighter in-office footprint. fewer in-office visits may allow for gradual reduction in on-site nurses, medical assistants or nursing aides: jobs that account for % of incremental headcount in medical practices over the past five years. similarly, if states eliminate physician oversight requirements for nurse practitioners and physician assistants, it would remove administrative overhead costing $ , to $ , per nurse practitioner per year. if physician practices could deliver care with six employees per , americans in the late s, before ubiquitous email and videoconferencing, it is unclear why they need eight employees per , today." finally, fully implementing digital solutions for referrals and documentation would also boost practice efficiency. scribbling on a patient face sheet and passing it to a medical assistant, who then faxes a letter to a referring physician, inflates the practice's operating costs, creating financial vulnerability when revenues dip. most practices already use electronic health records and practice management systems that include tools for electronic referral management with little or no incremental cost. other systems, such as the econsult products mentioned above, may carry an incremental cost, typically in the range of $ , to $ , annually per physician. in contrast, an additional medical assistant or support technologist in a medical practice, would, on average, cost $ , to $ , annually in salary and benefits, a much higher figure, even if spread across multiple physicians. lighter support staffing, coupled with work-from-home arrangements for administrative employees, can shrink real estate needs, offering additional savings in the medium term. in recent decades, healthcare organizations have built an increasingly labor-intensive business model, hiring large numbers of patient-facing staff and boosting wages. covid- is a sudden, unfamiliar shock to that volume-driven model. it may also spur salutary change. hospitals and " practices that shift revenue away from pure fee-for-service pricing, while embracing virtual care delivery and eliminating unnecessary operational overhead could exit the crisis with more resilient businesses, while boosting the financial health of the system as a whole. hospital admissions, average length of stay, outpatient visits, and outpatient surgery, by type of ownership and size of hospital: united states, selected years health care cost and utilization report health care market concentration trends in the united states: evidence and policy responses. health aff (millwood) the impact of hospital consolidation. robert wood johnson foundation do hospital mergers reduce costs? eliminating waste in us health care the impact of the covid- pandemic on outpatient visits: a rebound emerges. commonwealth fund deep dive: how the mssp program is prepared for crises like covid- the potential national health cost impacts to consumers, employers and insurers due to the coronavirus (covid- ) california's nurse practitioners: how scope of practice laws impact care. california health care foundation key: cord- - p rwp authors: nan title: escp th european symposium on clinical pharmacy ‘implementing clinical pharmacy in community and hospital settings: sharing the experience’, istanbul, turkey – october ; abstracts date: - - journal: pharm world sci doi: . /s - - - sha: doc_id: cord_uid: p rwp nan pharmacy, groupe hospitalier pitié salpétrière, paris, france background and objective: strongyloides stercoralis infects each year millions of persons worldwide. in immunocompromised patients, this intestinal nematode can disseminate and cause a fulminant fatal illness: hyperinfection syndrome. oral ivermectin is the principal treatment. since one of the features of s. stercoralis hyperinfection is the development of an ileus and small bowel obstruction, the drug absorption is impaired and thus a reduced efficacy is noted. no parenteral antihelminthic drug is licensed for human use, but parenteral ivermectin is commonly used in veterinary medicine. we report two cases of s. stercoralis hyperinfection syndrome that were refractory to oral drugs and, as a life saving therapy, were treated with a veterinary formulation of parenteral ivermectin (ivomec Ò , merial) after agreement from the french drug administration (afssaps). design: case report. setting: pneumology and neurochirurgical intensive care units, university hospital, paris, france. main outcome measures: case report. results: patient a -year-old african man has been hospitalized in august for a degradation of his condition in neurosarcoidosis with hydrocephalus, associated with enterococcus faecalis meningitis. he underwent ventriculo-peritoneal shunt and was treated with corticosteroids (prednisone mg/day). his condition worsened on september , with the diagnosis of a disseminated strongyloidiasis with paralytic ileus. he was initially treated with ivermectin ( mg bid) via the nasogastric tube. antibiotics were added on day to control the sepsis. on day albendazole ( mg/day) was added. subcutaneous ivermectin was then obtained and administered on day ( lg/kg) in association with ivermectin via nasogastric tube while albendazole was discontinued. the patient's condition improved during the following days. he completed days of ivomec Ò and days of oral ivermectin. he returned home months later. patient a -year-old african man was hospitalized in november because of a kg weight loss. he was diagnosed with hiv, meningeal tuberculosis, urinary and pulmonary infections and s. stercoralis hyperinfection treated with oral ivermectin. on january he was admitted in pneumology intensive care unit with melena on severe immunodepression. on february he developed a septic shock with ards on an important bowel obstruction. therefore, among other antiinfectious therapies, a veterinary formulation of subcutaneous ivermectin was administered ( lg/kg/day). the sepsis was controlled, but on february he died of an acute haematological deterioration. conclusions: as the occurrence of malabsorption is a frequent complication of disseminated strongyloidiasis, a parenteral formulation of ivermectin would be really helpful, especially as the efficacy of the subcutaneous form has been proved in the literature. keywords: strongyloides stercoralis, hyperinfection, parenteral ivermectin • each pharmacy received three covert sp visits over six weeks. verbal and written feedback was provided to the pharmacy staff after each sp visit. no pharmacy was visited by the same sp more than once. each pharmacy was visited by the same pe throughout the study. background and objective: heart failure (hf) is a common disease with an estimated prevalence of . to % in europe. patients with hf have frequent episodes of exacerbation. non-compliance to medical and dietary advice is a significant clinical problem as is suboptimal treatment. one example of factors influencing the ability to comply with a treatment plan is impaired comprehension. the objectives were to construct a medication assessment tool and to establish face validity for its use in this project, to construct an interview schedule in order to identify non-compliance, poor patient comprehension and suboptimal treatment, to conduct a survey and to report the findings to the clinic. design: a cross-sectional study performed during april -may . setting: the emergency department and medical wards at malmö university hospital. main outcome measures: comparison of compliance, comprehension and optimal treatment on a population basis between men and women, younger (\ years) and elderly ([ years) patients, and patients in different new york heart association (nyha) classes, in order to assess if exacerbation could have been caused by any of these factors. results: of the patients included, % reported high compliance. in the subgroup analysis, women and elderly patients reported a significant higher compliance than men and younger patients. comprehension on self-care was poor. only % weighed themselves regularly and % did not limit the amount of fluids. no more than % reported they would contact a health care provider in case of experiencing more symptoms. suboptimal treatment was also found to be a great concern with only % being treated with angiotensinconverting enzyme inhibitors (acei) or angiotensin ii receptor blocker (arb), % with beta blockers, and % with aldosterone receptor antagonists, but no consideration to other co-morbidities has been taken into account. the majority treated with recommended agents had not achieved target dose as recommended in guidelines. conclusions: poor patient compliance and comprehension as well as suboptimal treatment could contribute to hf exacerbation and efforts should be made to improve these factors in order to reduce hf exacerbation. keywords: heart failure, compliance, sub-optimal treatment background and objective: adherence with inhaled corticosteroids has repeatedly been reported to be poor. poor adherence could lead to inadequate control of asthma complaints. monitoring of repeat prescriptions by a pharmacist could offer an opportunity to reach concordance with the patient and improve adherence. the objective of this study is was to improve asthma control by optimizing use of asthma medicines. design: retrospective follow up study. all pharmacy dispensing records concerning respiratory medication (r ) from st october to th september were collected. between st october to th september monitoring of repeat medication was conducted by a pharmacist. pharmacists discussed asthma complaints and use of asthma medicines with all patients calling for repeat prescriptions. when indicated the pharmacist proposed adjustments of asthma medicines to the gp after this telephone consultation. setting: community pharmacy and one gp practice ( gp's) in leiden, the netherlands, serving a community of . patients. main outcome measures: self-reported use of short-acting betaagonists (saba) by intervention patients. defined daily doses (ddds) of short-acting beta-agonists (saba), long-acting beta-agonists (laba) and inhaled corticosteroids (ics). results: consultations were registered for intervention patients. for patients more than consultation was registered. at the first consultation only of patients ( %) reported use of pharmaceutical sciences, strathclyde institute of pharmacy and biomedical sciences, university of strathclyde, glasgow, united kingdom background and objective: to test a method to quantify adherence of medication use to clinical guideline recommendations in a primary care setting. design: retrospective survey to field-test a -item instrument (mat-cvd) based on earlier studies of quality of medication use in cardiovascular disease (cvd) . setting: a database of patients [ % male, mean (sd) aged ( ) years] coded with circulatory system disease (read code 'g*') was drawn from computerised records of all patients receiving care from a single community pharmacist and general medical practitioner (gp) collaboration (n = , ). the pharmacist worked as a supplementary prescriber and had remote access to the electronic records of the gp. patients had diagnoses of diabetes (n = ), hypertension (htn; n = ), ischaemic heart disease (ihd; n = ), other ischaemic vascular disease (cerebrovascular n = ; peripheral vascular n = ), heart failure (hf; n = ), atrial fibrillation (af; n = ), were anticoagulated (warfarin, n = ) or otherwise identified as potential candidates for primary prevention of cvd (n = ). main outcome measures: adherence (%) to criteria based on guideline recommendations on primary and secondary prevention of cvd, treatment of htn, ihd, hf, af and warfarin therapy; overall applicability of criteria and quantification of insufficient data; interrater agreement of application of individual mat-cvd criteria and of the overall tool (cohen's r) results: a total of criteria were applicable and for ( %) of these there was insufficient data to apply the standard. the guideline adherence ( % ci) overall was ( - )%. highest adherence was to 'primary/secondary prevention of cvd' [ ( - )% adherence, n = criteria]. lowest adherence was to 'treatment of af' [ ( - )% adherence, n = criteria]. non-adherences were found to at least one criterion in ( %) and to c criteria in ( %) patients. inter-rater agreement was assessed on the application of the tool to all patients by two independent raters. all six sections and the overall tool were found to have inter-rater agreement r [ . and a percentage agreement [ %. among the ( %) of individual mat criteria that were applicable to c patients showed r [ . . in two of the remaining seven criteria the base-rate problem was responsible for r \ . and when taken into account the number of individual criteria with acceptable inter-rater agreement was ( %). conclusions: the application of the mat-cvd to routine primary care records in a scottish primary care setting is feasible and reliable; the tool has potential use in continuous quality improvement of prescribing in primary care. pc- self-management of complications in diabetic patients: a pharmaceutical care program in community pharmacies pharmacy, general medicine unit, university medical outpatient clinic, lausanne, switzerland background and objective: seamless care refers to continuity of patient care in the health system across caregivers. the objectives of the present study were ( ) to identify barriers to seamless information between a given hospital and an outpatient clinic in switzerland and ( ) to propose tools for improving pharmaceutical seamless care. design: this is a retrospective study with a convenient sample of patients for mapping the information flow network. the inclusion criteria were: ( ) at least one stay lasting more than hours in the hospital in , ( ) regular checkups with a gp in the outpatient clinic and ( ) medication delivered by the community pharmacy of the outpatient clinic months prior to months after the hospitalization. setting: both hospital and outpatient clinic are independent and run their own pharmacy. the hospital pharmacy is implied in drug production and distribution without generalized pharmaceutical care activities, and the community pharmacy delivers rx or otc medication for outpatients. geographic and computer proximity between both entities constitutes an ideal setting for seamless care projects. main outcome measures: ( ) to map medical or administrative information between community pharmacy, gp and hospital and ( ) to find opportunities to improve pharmaceutical seamless care. results: sixteen patients met inclusion criteria ( women, men, average years, mean visits/patient/year with gp: , and with community pharmacist: , i.e. -time more with pharmacist than gp). we observed that administrative information is computerized on a common database for both hospital and outpatient clinic. in contrast, clinical information is mainly handwritten and difficult to share between hospital and outpatient clinic caregivers. patient medication database is managed by a community pharmacy software not linked to medical information. however administrative information flows in one direction from the administrative to the community pharmacy database. we identified potential tools easily available to the community pharmacy to improve pharmaceutical seamless care in the center: ( ) an alarm through the administrative database connection if a patient is hospitalized to allow pharmacist to contact hospital physician for medication history and ( ) an access to patient discharge letter and lab results to improve rx validation process. conclusions: clinical information is not easily shared between caregivers of the hospital and the outpatient clinic. if global seamless care still remains a long term goal, initial actual steps promoted by community pharmacists can be easily implemented. keywords: seamless, information, community pk- implementation of a protocol for pharmacokinetic monitoring of high-dose methotrexate background and objective: to quantify the impact of the implementation of a protocol for the pharmacokinetic monitoring of patients receiving high-dose methotrexate. design: prospective experimental study, in which the hospital pharmacy department designed a specific protocol for the pharmacokinetics follow-up of these patients and for gathering the data required for a correct rescue. results were compared between three months before and three months after implementation of this new protocol. setting: -hr infusions of methotrexate at a dose of c g/m were evaluated in adult patients admitted to the oncohaematological area of a tertiary level hospital. main outcome measures: number of infusions started at the correct time, number of missed blood extractions, number of missed leucovorin doses, calculation of the elimination half-life, and measurement of the urinary ph (dichotomous variables). degree of compliance with the leucovorin rescue dosage protocol was measured on a scale of - points, with all items carrying the same score (correct loading dose, dosage as function of body surface area, and dosage as function of the concentrations of methotrexate obtained). results: the number of infusions started at the correct time increased from % to %. the number of missed blood extractions fell from . to . extractions per course; and missed leucovorin doses dropped from . to per course. the elimination half-life could be calculated in only % of courses in the first study period versus % of courses after protocol implementation. urinary ph changed from not being measured in any cycle to being measured in % of cycles. compliance with rescue dosage protocol was scored with . points before versus . points after implementation. background and objective: to quantitatively evaluate the safety of the current injectables medication process, from prescription to administration, in the paediatric and neonatal intensive care units. to compare the potential impact of safety measures on the risk. to classify these measures from a pharmacoeconomic point of view. design: assessment by a prospective risk analysis according to the failure modes, effects and criticality analysis (fmeca) method [ ] by a multidisciplinary team: one physician, two nurses, three pharmacists. three drugs chosen as models (gentamicin; morphine; dopamine). failure modes (fm) defined during brainstorming and criticality indexes calculated on the basis of their likelihood of occurrence, potential severity for the patients and detectability. impact of ten safety measures on the criticality indexes of the selected three drugs, extrapolation to all drugs injected daily and calculation for each measure of the investment in euros per year to improve the safety by quali (- point of criticality) per day. setting: university hospital, fifteen nicu beds and ten picu beds. main outcome measures: mean criticality indexes; gain in qualies per day; cost-efficacy ratios for each safety measure. results: in the current situation, the sum of mean criticality indexes of thirty-one identified fm was , for the selected three drugs. we gain , qualies ( , by extrapolation to all drugs injected daily) with civas (centralized intravenous additives services), , ( , ) with a clinical pharmacist, ( , ) with double check by nurses, ( , ) with cpoe (computerized physician order entry), ( , ) with in-line filters, ( , ) with vial of dilution, ( , ) with horizontal laminar airflow hood, ( , ) with intermediate dilution, ( , ) with simple additional measures of asepsis and ( ) with a drug planer. the best cost-efficacy ratios were obtained by a clinical pharmacist ( quali = . euros) or by double check by nurses ( quali = . euros) or by civas ( quali = . euros). the highest ratio was obtained with cpoe, due to the very high costs investment ( quali = . euros). conclusions: the use of a prospective risk analysis allowed us to quantitatively evaluate the relationship between the medication process of injectables and the paediatric patient safety and to build a strategy for continuous quality improvement, by selecting the most appropriate evolutions. based on the results of the pharmacoeconomic analysis, development of clinical pharmacy and civas for some drugs will be discussed with the paediatric department background and objective: studies show that up to % of patients starting treatment with antidepressants fill only a single prescription at the pharmacy, apparently not accepting treatment. the aim of this study was to determine characteristics and reasons associated with non-acceptance of ssri treatment. design: retrospective questionnaire study. patients presenting a gp prescription for a newly started ssri treatment to a community pharmacy were selected. 'non-accepters' were defined as those patients filling only a single ssri prescription, and patients who received at least three prescriptions were defined as 'accepters'. setting: community pharmacies in the netherlands. main outcome measures: characteristics evaluated included sociodemographic (e.g. level of education), disease (e.g. reason for use) and treatment (e.g. type of ssri) characteristics. 'non-accepters' were also asked for the reason not filling a second prescription. results: 'non-accepters' and 'accepters' were included in the analysis. 'non-acceptance' was more common among patients with a low level of education (or . ; ci . - . ) and in patients who reported aspecific symptoms like fatigue, stress and restlessness as the reason for ssri use (or . ; ci . - . ). in addition, there was a trend that 'non-acceptance' was more common among patients over years of age (or . ; ci . - . ) . of all 'non-accepters', . % (n = ) did not start ssri use, while . % (n = ) discontinued ssri use within two weeks. fear of side effects and the actual occurrence of side effects are main reasons for not accepting ssri treatment. in addition, a considerable number of 'non-accepters' indicated that they felt an aversion towards medicine use, were feeling better meanwhile or disagreed the gp's diagnosis. of the 'nonaccepters', . % discontinued treatment without informing the gp. conclusions: acceptance of ssri treatment is a decisive moment in compliance to treatment initiated by gps, and deserves more attention. gps and pharmacists should address issues related to the use of ssris especially in groups who are at risk for non-acceptance. keywords: antidepressants, discontinuation, nonadherence edu- pharmaceutical interventions by pharmacists working within surgery and medicine departments julie prince , stephanie diallo , eric grandsire , anne lecoeur , caroline fijalkowski , michelle lebas-certain , franck le mercier pharmacy, ambroise pare hospital ap-hp, boulogne-billancourt, france background and objective: since , our pharmacy department set up a nominative daily drug distribution system without computarization. in each pharmaceutical unit localized in clinical departments, the prescriptions are screened daily by a pharmacist, then the drugs are delivered by a technician. our objective was to compare the frequency and content of pharmaceutical interventions in surgery and medicine departments. pharmacy, haematology, nurses' management, cancer centre henri becquerel, rouen, france background and objective: while several studies have evaluated the frequency and the consequences of medication errors, few have explored their causes. in particular, knowledge of nurses regarding treatment of their patients has been scarcely studied. this survey has been carried out to determine how nurses master medications prescribed to the patients they care for, and how often they access drugs database. design: this work is a prospective study carried out from february to april . we have decided to focus on the clinical audit method, following french health authorities recommendations. a questionnaire has been elaborated and submitted to nurses during semistructured interviews. setting: french cancer centre: nurses from an oncology department and from a haematology department. main outcome measures: data collected were: nurses' profile (age, length of service, competencies' self-assessment), knowledge on drugs prescribed to their patients (usage, administration, side-effects, drug interactions…), use of existing tools (i.e. drugs database) and possible tools to be developed by the pharmacy ward to help them in their daily practice. results: twenty out of twenty six nurses (mean age: , mean length of service: years) consider their medical knowledge as intermediate level. % of pharmaceutical classes are quite well known ( % of the indications are known). only % of drugs' inn are given and more than half of the generic drugs' names are not mastered. administration conditions and conservation are known for respectively % and % of the products. however, side-effects ( %), contraindications ( %) and drug-drug interactions ( %) are not acquired. in their daily routine, nurses face problems mainly related to: drug administration ( %), drug conservation ( %), and dealing with generic drugs and therapeutic equivalence ( %). % of nurses refer to a drug database several times a week when only % more than once a day. pharmacy ward is considered to give information on drugs on a 'regular' basis. three tools have been identified for their potential to help nurses: summarized data on drugs (card format), drugs administration and conservation tables. conclusions: this study has helped to define nurses' difficulties regarding patients' treatment, and their needs for information on drugs. it is also useful for the pharmacy ward to improve its relationships with clinical wards and feedback on treatments. training sessions will shortly be organised to improve the above results. results: the aim of the vita (vienna transdanubia aging) study is the early detection of alzheimer dementia and the discovery of its risk factors. at basic examination, dementia was diagnosed in out of patients ( %) at an age of years. in % of these cases dementia was classified as alzheimer disease. in addition, a clinically relevant depression was diagnosed in % of patients at basic examination, but only % of them were treated accordingly. the first re-examination after . years included those patients, who showed no or only mild signs of cognitive disorders at basic examination. % of these patients developed dementia within the period of . years. the first reexamination also revealed a rapid increase of patients with depression ( % vs. %). the incidence for the development of dementia was % in patients, who have never suffered from depression. however, in patients with the diagnosis depression at basic examination, the risk for dementia was doubled. we aimed to prove whether there is a statistically significant correlation between long-term medication with selected drugs and the development of depression. eleven classes of drugs were investigated, including calcium channel blockers, beta-and alpha-blockers, corticoids, statines, non-steroidal anti-inflammatory drugs, h -blockers, neuroleptic drugs, benzodiazepines, levodopa and opiates. medication was documented from those patients pharm world sci ( ) : - ( male, female) without dementia and depression at basic examination, and without dementia at first re-examination. at first reexamination of them were depressive ( % male, % female), and had no depression (control group). for each class of drug, patients were divided into groups according to gender and duration of medication. a statistically significant (p \ . ) correlation was found between the treatment with benzodiazepines (c months) as well as beta-blockers (c months) and the development of depression in both male and female. conclusions: in elderly long-term therapy with benzodiazepines and beta-blockers can aggravate the development of depression. background and objective: pharmacogenomic studies aim to elucidate the genetic bases for interindividual differences and use such genetic information to predict the efficacy, response rate and safety of a selected drug. to date, the prognostic value of fccr polymorphisms as markers to predict treatment outcome in nhl is still being studied. our goal was to determine whether there is any correlation between fccriia polymorphisms and clinical response to rituximab in patients with nhl. design: in the present study we analysed fccriia polymorphisms in the genomic dna isolated from peripheral blood of patients with nhl who have undergone immunotherapy with rituximab. genotype analysis was based on a polymerase chain reaction (pcr) method followed by a restriction fragment length polymorphism (rflp) study. data were analysed using the computer software spss for windows (version . ) and treatment outcomes of the patients were compared using chi-square or fisher's exact test. a cut-off p-value of . was adopted for all the statistical analysis. survival estimates were calculated using the kaplan-meier method. the curves were examined by the log-rank test. setting: unit of molecular oncology of instituto português de oncologia, porto, portugal. main outcome measures: the response to therapeutics with rituximab was evaluated according to physical examination and computed tomography images. responses were scored according to international working group consensus. overall response rate (orr) was considered as complete response (cr), unconfirmed complete response (cru) and partial response (pr). overall survival (os) duration was defined as the period of time between st treatment with rituximab and either death or the last clinical evaluation of the patient. event-free survival (efs) was defined as the time interval between st treatment with rituximab and the occurrence of an event (recurrence or death) or the time of the last clinical evaluation of the patient. results: the orr for hh genotype was % and for r allele was % (p = . ). however, our results demonstrate that all patients carrying the hh genotype had complete responses to rituximab therapy. complete response rate for hh genotype was % and for r allele was % (p = . ). when comparing the fccriia genotypes, hh genotype or r allele does not have a significant impact on os at -year (p = . ) or on efs at -year (p = . ). conclusions: this study demonstrates that fccriia polymorphism is predictive of complete response to regimens containing rituximab in nhl patients, but is not predictive of overall or event-free survival. based on the current observation, rituximab has in some way an fccriia-dependent mechanism of action which is ameliorated in patients with hh genotype. we hypothesize that hh genotype increases affinity of fccriia receptor not only for naturally occurring igg , via antibody-dependent cellular cytotoxicity but also ameliorate connection with chimeric igg rituximab. keywords: non-hodgkin lymphoma, rituximab, pharmacogenomics pt- platinum salts, cancer and renal insufficiency. sub-group analysis of the irma study xavier pourrat , nicolas janus , stéphane oudard , isabelle ray-coquard , jean-philippe spano , jospeh gligorov , jean-françois morere , philippe beuzeboc , gilbert deray , vincent launay-vacher pharmacy, hôpital trousseau, tours, nephrology, gh pitié-salpêtrière, medical oncology, hôpital européen georges pompidou, paris, medical oncology, centre léon bérard, lyon, medical oncology, gh pitié-salpêtrière, medical oncology, hôpital tenon, paris, medical oncology, hôpital avicenne, bobigny, medical oncology, institut curie, paris, france background and objective: the irma study reported the high prevalence of renal insufficiency (ri) in solid tumour patients: mean age . , mean weight . kg ( . % between and kg), glomerular filtration rate (gfr) \ ml/min for - % [ ] . we present the results for irma patients who received a platinum salt (ps) as part of their chemotherapy. design: data were retrospectively collected for in and outpatients with cancer presenting over two periods in (february st- th and october st- th). setting: anticancer centers in france. main outcome measures: subgroup analysis of irma patients who received ps. data collected: sex, age, weight, serum creatinine (scr), type of tumor and anticancer drugs. the prevalence of scr [ lmol/l was assessed. gfr was estimated with cockcroft-gault (cg) [ ] and amdrd [ ] formulae. chi-square test was used to compare the prevalence of ri between patients who received ps and patients who did not. results: patients were included: mean age . and weight kg, men. the prevalence of scr [ lmol/l was . %. gfr \ ml/min was . % with cg and % with amdrd. the prevalence of ri was significantly higher in patients who received ps as compared to patients who did not receive ps (p = . ). there were prescriptions: . % carboplatin, . % cisplatin and . % oxaliplatin. . % of patients received carboplatin or cisplatin, the two drugs of this class needing dosage adjustment and being nephrotoxic. conclusions: ri is highly frequent in cancer patients receiving ps. appropriate evaluation of renal function necessitates cg or amdrd calculation. in addition, two third of those patients with pre-existing ri are at risk for iatrogenic acute renal failure still receive nephrotoxic ps. consequently, appropriate methods for the nephrotoxicity prevention of those drugs should be used as recommended for cisplatin by the escp special interest group on cancer care [ ] . [ ] prevalence of renal insufficiency in cancer patients and implications for anticancer drugs management: the irma study. cancer (in press). [ ] prediction of creatinine clearance from serum creatinine. nephron, ; : - . [ ] a simplified equation to predict glomerular filtration rate from serum creatinine [abstract] . j am soc nephrol ; : - . pharmacy, hospital la candelaria, tenerife, spain background and objective: to describe an quantify the pharmaceutical interventions in patients on total parenteral nutrition (tpn)and the drug related problems (drp)in patients on this type of nutritional support. to know the acceptance degree of the interventions and its relevance on patients' care and quality of life. design: prospective longitudinal study for four months (from january to april ). all patients on tpn were included. the registered data were: patients number, hospital departments, type of interventions and modifications on the tpn. setting: the pharmaceutical interventions were classified in: indication, effectiveness, safety and adherence according to the cipolle and cols methodology in order to identify de drp related to the tpn and/ or to the drugs. main outcome measures: all interventions were recorded both in the patient medical record and in a excel database in the pharmacy department. results: patients were evaluated and interventions were recorded. that means an average of interventions per patient and a duration average per nutrition of . ± . days. the drp were: indication . %, safety . %, effectiveness % and adherence . %, being the drp the most representative. the drp were listed in: nutritional assessment ( . %), monitoring ( . %) and individualized tpn ( . %). a total of patients ( . %) was favoured through some type of pharmaceutical intervention, being the most implicated hospital departments the neonatology and digestive surgery departments. a % of the interventions were focus on monitoring and optimization of nutritional support and % on drugs (diuretics, insulin, digoxine, enalaprile, and propofol). the acceptance degree of the interventions was %. conclusions: the individual monitoring of the patients with tpn represents an improvement of their clinical outcome and a lower incidence of drp. therefore, with this method we contribute to a lower hospital stay and it also may prevent the appearance of new adverse effects. main outcome measures: the number of interventions carried out and accepted, items concerned: regulation problems, nitrogenous and calorie intake, electrolytic intake, prescription omissions and eventually other fields. results: altogether, parenteral nutrition prescriptions were analyzed for one month in five pediatric units. the pharmaceutical analysis, which consumes hours a day for pharmacists, generated interventions for prescribers: % concerned electrolytic intake, more than half of which concerned potassium and sodium, the main dangerous electrolytes; % were prescriptions omissions; % about nitrogenous and calorie intake; % about other fields (weight error, incompatibility of lipids with divalent ions). of these interventions, which concern exactly prescriptions, were accepted by prescribers, that is %, leading to prescription modifications. conclusions: putting in place a systematic pharmaceutical analysis of parenteral nutrition prescriptions has ensured the detection and the correction of prescription errors. these errors concern mainly non adjustment of electrolytes to the biological results of the child. pharmaceutical interventions are important for safety of the patient and represent a privileged way to communicate with prescribers and their acceptance is, on the whole, satisfactory. background and objective: the number of elderly intensively increases and the fact that they consume a great amount of pom and otc drugs makes them a significant group of patients that need pharmacy care. unfortunately pharmacists often find their interaction with elderly clients very difficult and determined by many factors such as the sensory and physical limitations that accompany the aging process. to test the readiness of the elderly patients to communicate with the pharmacist, to assess the barriers that hinder the proper communication process and to provide a communication skills training in order to be improved the communication process. design: an experimental design involving two stages -assessment and education. setting: setting: the elderly patient center (hospice) and private community pharmacies both situated in the city of sofia, bulgaria. participants: patients aged + ( community pharmacy patients and patients from the elderly center). main outcome measures: an initial interview with the patients and questionnaire with the selected pharmacists to assess the level of communication and to clarify the hinders. communication skills training leaflets provided to the pharmacists. test of the newly received skills. final interview with the patients to be assessed the level of their satisfaction. results: the trained pharmacists that have passed the education process are more facilitated in providing pharmaceutical care that leads to the elderly patients' satisfaction (about %). additionally, the elderly patients obtained significantly more information from their pharmacists that leads to better care and avoidance of nearly half of the drug-related problems (drps) for this age. conclusions: pharmacist communication skills' training appears to be an effective means of enhancing the communication process in the pharmacy. background and objective: as the hospital has no pharmacists working in the multidisciplinary teams on the wards, we wanted to introduce and evaluate a clinical pharmacy service. design: a month prospective pilot study with three aims: . identify drug related problems (drps) (data collecting period of eight months). . design drug related information sheets and teach nurses. . evaluate the service by questionnaire. suggest cost-effective measures. setting: paediatric ward with beds, national university hospital. main outcome measures: the acceptance rate of the drps identified and suggested by the pharmacist, the number of drug information sheets introduced and lectures given to nurses. physicians' and nurses' views on the service. results: the pharmacist identified drps in ( %) of the charts that was screened. immediate action was taken in ( %) of the cases, the physician considered ( %) of the suggestion rational but no immediate action was taken due to various reasons, and ( %) of the suggestions were not approved by the physician. the most commented drp was ''dosage'' ( %), which included too low or too high dose, non-optimal administration time or inappropriate formulation. the pharmacist designed six drug information sheets and gave five lectures. cost-effective measures were suggested for drug handling and specific drugs. seven out of eight physicians and all nurses (n = ) considered the pharmacist a natural participant in the multidisciplinary team. conclusions: quality assurance of drug treatment may be performed by a clinical pharmacist, not only by the traditional way of identifying drps, but also by designing drug information sheets and teaching. the clinical pharmacist is also capable of suggesting cost-effective measures. physicians and nurses considered the clinical pharmacist a natural participant in the multidisciplinary team. as a result of this project, the clinical service will continue and also be introduced to one of the other paediatric wards. keywords: drp, paediatrics, quality assurance pc- iatrogeny and drug dispensations for outpatients: implication of a hospital pharmacy emilie degris , isabelle peyranne , anne laure sarda , nadine malric , brigitte bellon pharmacie, hôpital paule de viguier, chu toulouse, toulouse cedex , france background and objective: in france, some drugs are not available in community and outpatients have to go to hospital to obtain their treatment. our objective was to assess the role of the pharmacist in prevention of iatrogeny when dispensing drugs, in particular medication errors at high risk for the patient. design: a month retrospective study, from december to may setting: pharmacy of paule de viguier, teaching hospital of toulouse, france main outcome measures: each error encountered was recorded and analysed. first, we determined the number of errors avoided and the number of errors effective (divided into groups: non avoided and created by pharmacy). then, we quantified the frequency ( = once, = from twice to ten times, = more than ten times) and the severity ( = no risk, = weak, = moderate, = high) of each error. the multiplication of those two parameters gave us the level of the risk of error for the patient ( = no risk, to = weak risk, and = moderate risk, = high risk). finally, for each type of error we noted the actors. results: we made dispensations during the period of the study. we recorded errors ( . %): ( for dispensations) were avoided by the evaluation of the pharmacist, were not avoided ( for dispensations) and were created ( for dispensations). among the avoided errors, ( . for ) were at high risk ( ), ( for ) at moderate risk ( or ), ( . for ) at weak risk ( or ). the actor of of them was the prescriber (mainly lack of information on the prescription like no dosage). among the effective errors, ( . for ) were at moderate risk ( or ), ( . for ) at weak risk ( to ), ( . for ) had no risk ( ). the actor of of them was the pharmacy. conclusions: the errors for the activity ''retrocession'' are not numerous. the majority of them are stopped by the evaluation of the pharmacist, in particular those at high risk for the patient. we implemented curative and preventive measures to decrease the number of errors made both by prescribers and pharmacy. background and objective: despite improved treatments and guidelines, asthma control remains suboptimal. in a recent observational study, we described the asthma control test Ò (act) as an easy tool to measure asthma control of patients presenting at community pharmacies ( ) . the present randomised controlled trial was set up to study the hypothesis that a pharmacist intervention, focused on optimal use of asthma medication and tailor-made to the patient's current asthma control, would result in improved asthma control in adult patients. design: a -month randomised controlled trial in asthma patients: patients in the control group (c) and patients in the intervention group (i). patients in the control group received usual care. patients in the intervention group received a protocol defined pharmacist intervention, mainly focusing on inhaler technique and adherence to controller medication. setting: randomly selected community pharmacies in flanders (the dutch speaking part of belgium). main outcome measures: primary outcome was the level of asthma control, as measured by the asthma control test Ò . secondary outcomes included rescue medication use, night-time awakenings due to asthma, patients' peak expiratory flow, inhalation technique, adherence to controller medication, quality of life, knowledge on asthma and smoking behaviour. results: mean act scores did not change from baseline for both study groups (act at baseline for c: . , i: . -act at months for c: . , i: . ). however, a predefined subgroup analysis of patients having insufficiently controlled asthma at baseline showed that the intervention significantly increased act scores during the course of the study compared with usual care (p = . ). the intervention also significantly reduced reliever medication use (p = . ) and the frequency of night-time awakenings due to asthma (p = . ). inhalation technique (p = . ) and adherence to controller medication (p = . ) were significantly better in the intervention group. these findings suggest that the more effective use of asthma medication is responsible for the improvements in symptom control. there were no differences between control and intervention group in peak expiratory flow, quality of life, knowledge on asthma and smoking behaviour. conclusions: a pharmacist intervention can significantly improve outcomes for asthma patients (clinicaltrials.gov number nct ). background and objective: patients admitted to surgery departments receive multiple drugs before, during and after surgical procedures. drug-related problems (drp) are the most common cause of injury to hospitalized patients. in pharmacotherapeutic follow-up (ptf) a pharmacist is responsible for drug-related patient needs by detecting, preventing and solving drug-related problems (drp) aiming at specific results to improve patient quality of life. drp are pharmacotherapy negative outcomes leading to failed therapeutic goals or undesirable events. when a drp appears, it affects not only older hip fracture patient health, but also the effectiveness of hospital health care. the general objective of this study was to demonstrate that ptf improves the hip fracture assistential process quality, comparing some quality indicators of this process between patients in study group (sg) and control group (cg). design: cuasi-experimental study with control group. ptf was the intervention. setting: two traumatology wards in a large teaching hospital, ''hospital san cecilio'', granada, spain. the period of study was from january to july (sg) and the same period but in (cg). main outcome measures: incidence and types of drp; drp solved in sg; differences in lengh of stay, six-months mortality and threemonths readmissions between study and control groups. results: the incidence of drp was % in sg (n = ) and . % in cg (n = ). in sg, more than % of drp were resolved. in sg and cg the % and % of drp were related to medication need, % and % to effectiveness, and % and % to safety, respectively. mean length of stay was days in sg and . in cg. in general, patients with drp had a significative longer length of stay ( . d) than those without drp ( d); but in sg, patients in which drp were solved had the same length of stay than those without drp. sixmonths mortality was . % in sg and . % in cg, and readmissions was . % and . % respectively. . % (n = ) of patients reported an aspirin allergy that triggers their asthma attacks. . % (n = ) had never used aspirin before and did not know whether they had any sensitivity to aspirin. . % (n = ) of subjects could correctly describe and distinguish between preventor and releiver drugs. . % (n = ) confused the terms, while . % (n = ) had no idea about these terms. % (n = ) of asthmatics had received previous inhaler usage education from a specialist (doctor, nurse or pharmacist). of these patients had ineffective inhalator usage although they had ostensibly received education. the inhaler technique of the remaining who had been previously educated was accepted as successful. % (n = ) of the patients had never received inhaler usage education before a specialist. of these patients demonstrated successful technique but of failed. conclusions: the results of this pilot study indicate that some asthmatics are ignorant of their condition. in addition most of them seem to have no comprehension of the concepts of preventor or reliever therapy. despite prior education about half (n = ) were unable to demonstrate successful technique. furthermore cigarette smoking may be a detremental factor to the lives of asthmatic patients. this results of this study suggest the potential benefit of an innovative pharmacist led patient education service among asthmatic patients in turkey. background and objective: according to a recent meta-analysis, drug-related morbidity leads to . % of preventable hospital admissions causing enormous expenditures. in austria, there are only data on the incidence of adverse drug reactions (adrs) of psychiatric drugs. clinical pharmacy is not widely practised at hospital ward level. with this study, we aim to evaluate and document adrs leading to or occurring during hospital admissions. to improve the co-operation of doctors and pharmacists in an austrian hospital, to enhance doctors sensitivity in detecting drug-related morbidity, to increase patient safety and lower costs by reducing hospital admissions. design: two study nurses especially instructed about typical symptoms of adrs identify and document these cases prospectively in cooperation with doctors on selected internal wards for a period of three months. these cases are evaluated by a clinical pharmacist by means of a computer tool and data-base specialised on detecting causality and severity of adrs. results and outcomes form the basis for structured feedback to doctors. setting: university teaching hospital. main outcome measures: quantity and quality of adrs connected with hospital admission. results: during the first six weeks, patients were screened. sixty three adrs ( female) were identified ( . % of admissions). more than % of adrs occurred in patients more than years old. reasons: polypharmacy (mean number of drugs on admission . ) and reduced renal function (mean creatinine clearance . ml/min). diuretics, oral anticoagulants, nsaids, digoxin and antibiotics were most frequently associated with drug-related problems. water-electrolyte imbalance, overantigoagulation with or without bleeding, gastrointestinal problems and bradycardia are some of the most common problems. results concerning the severity of adrs will be available in september . conclusions: adrs are frequent in austria. incidences are comparable to numbers given in the literature. mainly older patients are affected. the impact on clinical practice is yet unknown. background and objective: adherence to cardiovascular treatment, particularly in the first year, is low and can result in serious complications. depression is associated with a fold increased risk of nonadherence with medical treatment. therefore, our aim was to investigate whether illness and treatment perceptions were associated to depressive symptoms in patients starting treatment for cardiovascular diseases. design: cross-sectional study with mailed questionnaire. setting: patients, who were dispensed at least a first prescription for a cardiovascular disease (anti-thrombotics excluded), were selected from pharmacies in the netherlands. main outcome measures: the questionnaire comprised the illness perception questionnaire-brief (ipq-b), beliefs about medicines questionnaire (bmq), the medication adherence report scale (mars) and the centre for epidemiological studies depression scale (ces-d). descriptive statistics and associations between depressive symptoms and the other study variables were assessed by bivariate correlations. results: sixty two ( . %) of eligible patients returned our questionnaire. the mean age was . yr ± . (range - ) and . % was female. patients reported to have hypertension ( . %), cardiac arrhythmia ( . %) and hypercholestereamia ( . %). the mean score on ces-d was . ± . and median self-reported adherence (mars) was . reports of depressive symptoms increased with emotional response (ipq-b emotional response, r = . ), the perceived consequences (ipq-b consequences, r = . ) and increased experience of symptoms (ipq-b identity, r = . ) attributed to their cardiovascular disease. depressive symptoms correlated with concerns about medication (bmq, r = . ), but not with self-reported adherence. adherence was relatively high, as . % of the sample had the maximum mars score of . conclusions: in patients who started cardiovascular treatment, perceptions about cardiovascular disease and concerns about medication are associated with report of depressive symptoms. depressive symptoms did not correlate with self-reported adherence. the majority of patients reported excellent medication taking behaviour, which might reflect their awareness of the importance of adherence or reluctance to report deviant behaviour rather than their actual behaviour. further research is needed to clarify this finding. results: fifteen nurses completed the questionnaire. % of the nurses were aware of the purpose of controlled release formulations. pharmaceutical codes added to brand names such as uno, zok, la and ocas related to prolonged activity were not recognised in % of cases. in contrast, retard and cr were linked to slow release by % of the responders. the purpose of enteric coated (ec) drugs was only known by %. in general, the nursing staff did not pay a lot of attention towards the prevention of drug-nutrient and/or drug-tube interactions. the recommended time interval between administration of enteral feeding and drugs was not respected. % of the responders would crush drugs together (in the same mortar) when multiple drugs are prescribed. based on the results of the survey, an intervention plan has been developed. this consisted of information rounds, a poster related to the topic and implementation of the use of a website dedicated to crushing medication developed by the flemish association of hospital pharmacists. background and objective: the detection and solution of drugrelated problems is an important activity within pharmaceutical care. this study focused on drug-related problems (drps) detected during dispensing of new prescriptions in community pharmacies and aimed to explore frequency as well as nature and the pharmacist's management of them. design: during their pharmacy internships fifth-year pharmacy students collected consecutively hospital discharge and primary care prescriptions. after training, they documented drps and interventions on an adapted pcne classification form. inclusion criteria were: age over , at least one new medication, at least prescribed drugs. setting: swiss community pharmacies affording the opportunity of internships for fifth year pharmacy students. main outcome measures: prevalence, nature and management of drps in community pharmacies assessed with an adapted pcne classification form. results: the patient's median age was years (iqr ) and they received a median of (iqr ; range - ) different drugs. prescriptions of patients ( ( . %) discharged from hospital) were analysed. in ( . %) of all prescriptions at least one drp was detected. the most frequent drps were potential interactions ( . %), wrong/improper application or time of drug intake ( . %), inappropriate drug ( . %) or inappropriate drug form for indication ( . %), no clear indication for drug use ( . %) and too high or too low dosage ( . %). these drps led to a total of interventions (multiple answers): patient counselling ( ); request of information from prescriber ( ); change of drug ( ; there from after consultation with physician), drug form ( ), dosage ( ), instruction for application ( ) or deliverable drug amount ( ); drug stopped ( ); start with new drug ( ); referral to a physician ( ); others ( ). out of all interventions . % could be managed by the pharmacist without any contact to the prescriber. there were no differences between hospital discharge and primary care prescriptions. conclusions: in the delivery process of new prescribed drugs drps are frequently observed prompting many interventions. most drps can be managed by the pharmacy. further studies are needed to analyse relevance of the problems and impact of according interventions. the main selection criteria were clinical relevancy (patient centred initiatives) reproducibility of clinical and economical outcome, outcome indicators and multidisciplinary approach. an approval by the hospital board and medical council must underline the willingness to integrate the clinical pharmacy in the patient care team. results: projects has submitted (on a total of hospitals). a total number of hospitals were selected to receive funding for clinical pharmacy activities. projects were quoted for a full time equivalent and projects for a half time clinical pharmacist. the projects described different fields or a combination of different aspects of pharmaceutical care like e.g. the transfer of information on medication use on admission and discharge conclusions: the funding of the belgian health authorities triggered a very high response rate, which proves the increasing attitude from the belgian hospitals to the positive impact of clinical pharmacy. the funding was complementary to other national projects to improve overall safety of medical treatment. also, many hospital administrators took the opportunity to enhance more economical and rational use of drugs. financial support by the belgian authorities of clinical pharmacy and the results of the projects could trigger a further integration of the hospital pharmacies into a patient care team. background and objective: the task of assisting patients in selfmedication practice is an important component of pharmaceutical care in spain. in order to provide appropriate self-medication counselling pharmacist should be able to distinguish between a minor ailment and one that it is not, and should, consequently, refer patients as necessary to gps. nevertheless, there are no criteria for referral to gp in spain. the objectives were:( )to identify the most relevant minor ailments, agreeing on the specific criteria for referral to the gp.( )to select the non-prescription drugs, with evidence of safety and effectiveness, for the treatment of the identified minor ailments design: qualitative study with an expert panel which was made up of primary care physician from semfyc and six community pharmacists (two members of sefac and four members of giaf-ugr). the expert panel held two meetings, of five hours each. it was established which minor ailments were considered most relevant within the framework of community pharmacy in spain. subsequently, the expert panel, reach an agreement on the general content that should be included in the protocols for the management of each selected minor ailment. finally, a working team composed of gps and three community pharmacists prepared the protocols, which were compiled into a guide for self-medication counselling. setting: university of granada, spain during . main outcome measures: identified minor ailments, content of the protocols for each minor ailment, non prescription drugs selected. results: it was selected minor ailments, allocated as follows; respiratory (rhinitis, cough, cold, flu), pain (period pains, sore throat, headache, backache, toothache), gastrointestinal (heartburn, diarrhea, constipation, vomiting, hemorrhoids), skin and mucous membrane (aphthae, acne vulgaris, cutaneous wounds, burns, stings, urticaria, herpes labialis, eczema lesions) and others (vaginitis, varicose veins, fever, conjunctivitis, insomnia). the following sections were specified in each protocol: banal and serious reasons or conditions that can lead to the symptom (including drugs); referral criteria according to the duration of the symptom and associated signs; drug treatment and non-pharmacologic therapies. it was selected a total of different non prescription drugs. conclusions: a total of minor ailments were identified as the most frequently demanded in community pharmacies in spain. referral criteria were based mainly in the duration of the symptom and other associated symptoms that are indicative of illness. for the treatment of these minor ailments, different non prescription drugs were selected. keywords: non-prescription drugs, minor ailment, community pharmacy services mareike kunkel , matthias ganso , irene kraemer pharmacy, johannes-gutenberg-university hospital, mainz, germany background and objective: in clinical pharmacy service was implemented in three surgical clinics (inclusive icu). drug related problems (drp) were identified by medication review and discussed with the physicians. from january to june all pharmaceutical interventions (pi) from pharmacists ( fte) were recorded (paper based) and classified according to drp (with the pi-doc Ò -system, which was modified to comply the requirements for hospital use ), intervention type, outcome and clinical relevance. the pis were documented and evaluated with an access Ò database. design: retrospective study of pis in surgical patients, identification of drp by medication review. setting: departments of neurosurgery, accident surgery and general/abdominal surgery ( , and beds, respectively), university hospital. main outcome measures: drp, intervention type, outcome, clinical relevance, drugs and admission diagnoses being at risk for drps. results: within six month patients were admitted. drps were identified in % (n = ) of the patients. patients with drps were older (mean = y sd ± vs. y sd ± ) and had an increased length of stay (mean = d sd ± vs. d sd ± ). pis were made. the acceptance by the physicians was . %. pis were classified to the outcome subcategory patient safety and clinical relevance was estimated as major (n = ) or moderate (n = ) by pharmacists. further data are based on these pis. the most often addressed drps categories were overdose ( %), no or insufficient drug monitoring, when necessary ( %), untreated indication ( %) and increased risk of an adverse drug reaction ( %). the type of recommended intervention varied: change dose/time of application ( %), stop drug ( %) and conduct drug monitoring ( %). drps related with the outcome patient safety and at least moderate clinical relevance were caused by drugs ( %). the most affected drugs were vancomycin ( %), diclofenac ( %), potassium ( %), acetaminophen ( %), digitoxin ( %), phenytoin ( %) and theophylline ( %). the incidence of the most frequently admission diagnoses of patients with relevant drp differed from the incidence of diagnoses of all admitted patients (incidence icd- (cost-)effectiveness has started to emerge ( ) . a literature review was carried out that a) summarized the findings of pharmaco-economic studies; b) evaluated the methodology employed by studies; and c) suggested how future research has to be designed to meet the requirements of a pharmaco-economic analysis. design: studies to be included are identified by searching electronic databases. due to limited relevance of older studies, the scope is limited to studies published between and . mainly three techniques can be used to conduct an economic evaluation: costeffectiveness analysis, cost-utility analysis and cost-benefit analysis. ( ) all studies are reviewed regarding results and methodological quality. nineteen out of studies met our eligible criteria. setting: clinical pharmacy services provided in a hospital setting. main outcome measures: results were analyzed in terms of number of preventable adverse drug events (ade), length of stay (los) and financial savings. methodological quality was assessed with respect to perspective, scope and measurement of costs and consequences, sources of data on costs and consequences, and application of an incremental analysis. results: a) nearly all studies conclude a financial benefit based on direct cost saving and estimated cost avoidance as a measure of prevented ade or shortened los. b) methodologically there are a number of shortcomings: e.g. not including the wage of the personnel, lack of control groups, use of expert panels to estimate savings and costs, possible selection bias, no valorization of health effects. c) a methodology for conducting a prospective economic evaluation of an observational study is proposed. conclusions: it is not obvious to calculate the net savings of a clinical pharmacy program or to compare different programs because there are no common guidelines for this type of assessment. the ideal protocol is hard to achieve, so best practice will be more realistic. addition of direct cost saving, labor cost and economic value of prevented ade and shorter los results in a lucrative service. these savings are higher for specific inverventions (like preventing ade, switch therapy) or disciplines (e.g. intensive care unit versus geriatrics background and objective: the contribution of pharmacists to the delivery of public health in scotland is recognised in national pol-icy , . the new community pharmacy contract with its emphasis on public health will provide a new framework in which the contribution of community pharmacy to improving health in scotland can be delivered. the objective was to define the core public health competencies applicable to community pharmacy practise, using the 'skills for health public health practice competency framework' . design: a web based delphi methodology was used to achieve consensus on which competencies, from the 'skills for health public health practice competency framework', should be met or aspired to by practising community pharmacists using a multidisciplinary group of expert stakeholders. two rounds took place. setting: primary and secondary healthcare and academia. main outcome measures: panel members rated their extent of agreement/disagreement that each community pharmacist should achieve or be striving to achieve that particular competency. consensus was defined as c % rating a competency as strongly agree/ agree. results: ten organisations ( % of those invited) and organisation members ( % of those invited) agreed to participate. responses were received from ( %) individuals in round and ( %) in round . consensus was achieved for / ( %) competencies in round and a further / ( %) in round . competencies achieving consensus predominantly focused on health improvement activities at individual and local community levels and ethical management of self, rather than those relating to surveillance and assessment, strategic leadership or research and development. conclusions: this research has identified that many of the competencies in the 'skills for health' document can be applied to community pharmacy. research has since been carried out, using focus group and questionnaire methodology, to investigate the views of practising community pharmacists. background and objective: in spain, off-label drug utilization (nonapproved indications, patient population, doses, administration route, association), must be derived to compassionate use, which requires a prior national health authorities (nha) approval and a monitoring plan and follow up information provided to them. request to nha includes circumstances of case and patient protection measures, including: physician assessment, informed consent and institutional clearance. the objective of this study is to analyse the strength of recommendation, strength of evidence and clinical efficacy of drugs prescribed outside the terms of product licence (off-label) in paediatric patients of our hospital. design: literature review to evaluate the evidence level: micromedex healthcare series, cochrane library, pub-med, embase, expert opinion or consensus. sample: % off-label drugs used in at least paediatric patients (prior spanish nha treatment approval required for every patient). years, retrospective observational study ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . setting: paediatric hospital ( beds) and pharmacy department ( pharmacist) in a large general teaching hospital ( beds, pharmacists). main outcome measures: categorisation of evidence-based medicine according to thomson ratings of recommendation (class i-iii), evidence (category a-c) and efficacy (class i-iii). results: paediatric patients ( % total patients: adults and paediatrics) used off-label drugs ( % total drugs: adults and paediatrics). out of this off-label drugs, % ( / ) only approved for adults, % ( / ) outside of license in terms of indication for adults and paediatric patients and % ( / ) both causes. off-label drugs for indications were used in at least paediatric patients: % anti-infective agents, % haematopoietic growth factors, % cytokines, % hormone therapy, % antiarrhythmics, % other therapeutic groups. the categorisation according to evidence-based medicine was: a) strength of recommendation class: % i, % iia; % iib, % iii and % indeterminant; b) strength of evidence category: % a, % b, % c and % no evidence; c) clinical efficacy class: % i, % iia, % iib and % indeterminant. conclusions: a higher proportion of off-label prescriptions is observed among paediatric patients, most of them related to nonapproved indications in this population. there is a broad range of therapeutic groups involved. the evidence of most off-label therapies are based on meta-analyses of randomized controlled trials with conflicting conclusions, small numbers of patients or significant methodological flaws or nonrandomized studies and, although the weight of evidence favors efficacy of the treatment for a specific indication, the therapy may be useful and indicated in some, but not most, cases. keywords: medicine-based evidence, off-label, paediatrics background and objective: there is an increasing demand towards the involvement of the community pharmacists in health promotion. it has been reported that community pharmacists have a successful role in providing services, which help to improve and promote health with regard to smoking cessation, coronary heart disease, skin cancer prevention, drug misuse, sexual health, immunization, mental health, diabetes, nutrition and physical activity [ ] . the aims of this study were to describe the current practice of community pharmacists with regard to their provision of health promotion activities, identify their willingness to participate in health promotion and identify the barriers that may limit their participation. design: a descriptive cross sectional study, which included community pharmacies that selected via stratified and systematic random sampling. data were collected via face-to-face structured interview of the respondents using a pre-tested questionnaire. setting: community pharmacies in khartoum state. main outcome measures: the extent of the pharmacists' involvement in counselling patients about health promotion topics, their preparation to counsel patients in health promotion topics, and their success in changing the patients' health behaviour. results: the response rate was . %. seventy five ( . %) of the study participants were strongly involved in counselling patients on health promotion related to medications, but less involved in counseling them on the other personal health behaviours such as tobacco use ( . %), alcohol use ( . %) and exercise habits ( . %). seventy two ( . %) of the respondents perceived themselves as very prepared to counsel patients on taking drugs and less very prepared to counsel them on other personal health behaviours. fifty two ( . %) claimed a high level of success in helping patients to change their behaviour with regard to medications, but not in relation to other personal health behaviours. ninety eight percent of respondents indicated their willingness to participate in continuing education programs to gain more knowledge and skills about health education and promotion. the main barriers facing the community pharmacists' participation in health promotion as perceived by respondents were lack of information and/or training ( . %) and lack of pharmacists' time ( . %). conclusions: community pharmacists reported to achieve considerable success in helping patients to change their behaviours in relation to medications, but were less successful of their ability to change personal health behaviours. the majority of the respondents have the interest and willingness to be a prime source of advice and support on health promotion. results: during the first study period, inpatients were exposed to major or moderate pddis. ( %) of these pddis were judged clinically relevant by the pharmacist. recommendations including pddi information, and simply information leaflets were handed out to the physicians. % ( of ) of the recommendations were accepted. at hospital discharge, in % ( of reviewed instances, which were accepted) the drug changes due to the recommendations were implemented. during the second study period, patients at hospital discharge were exposed to major and moderate pddis. ( %) pddis were assessed as clinically relevant by the pharmacist. recommendations including pddi information, and simply information leaflets were sent to the physicians. % ( of ) of the recommendations were accepted. one year after hospital discharge, of drug changes due to recommendations were still existent. overall, in % and %, respectively, of all major and moderate pddis detected by pharmavista, clinical management was adapted accordingly. conclusions: the management of clinically relevant pddis can be improved by physicians' advice of clinical pharmacists. changes in medication due to pddis were found to persist up to one year after hospital discharge. background and objective: current treatment options for metastatic renal cell carcinoma (mrcc) are limited and there is a need to identify novel and effective therapies. sunitinib is an oral multitargeted tyrosine kinasa inhibitor, which has shown activity in cytokinerefractory metastatic rcc patients. this agent inhibits vascular endothelial grown factor receptor and platelet derived growth factor receptor. the purpose of this study is to analyse the efficacy and safety profile of this agent in patients with mrcc. design: retrospective assessment in seven patients treated with sunitinib as second-line treatment in mrcc. data were obtained from clinical histories and informatic records from the oncology pharmacy department. setting: oncology and pharmacy department. la paz university hospital. madrid. spain. main outcome measures: assessment of clinical response and adverse events. results: seven patients were evaluated ( men, women), median age was ( - ). six of them presented bone, lung, brain or liver metastases, all patients were treated with vinblastine and ifn-alpha as first-line therapy. patients received sunitinib at a starting dose of mg per day in repeated -week cycles for consecutive weeks followed by weeks off treatment. they started therapy with sunitinib because of progressive disease in patients and adverse events in patients on previous therapy. sunitinib was discontinued in four of them, causes were: adverse events ( patient), volunteered dropout ( patient) and progressive disease ( patients). the median progression-free survival was . months. the median number cycles received was six and of the patients are still in treatment at the time of data analysis. dosage was reduced mg daily because of unacceptable toxicity: hand-foot syndrome( patient) and hypothyroidism ( patient). the most common adverse events experienced were: asthenia ( patients), diarrhea ( patients), damaged nails( patients), insomnia ( patients), dermatitis ( patients)and dehydration ( patients). conclusions: in our experience, sunitinib has demonstrated an acceptable efficacy and safety profile as a single agent in second-line therapy for patients with mrcc. (ii) validated questionnaire to guide discussion; (iii) fostering group interaction to generate data; (iv) post-interview analysis of verbatim transcripts with specialized software (qsr nvivo . for windows Ò ), based on the grounded theory approach (classification of emerging themes). setting: groups: prescribing physicians ( ), nurses ( ) , and laboratory technicians ( ) , all involved in antibiotic tdm as performed in orthopaedic surgery, general surgery, neurosurgery, vascular surgery, haematology, and pulmonary wards in a beds teaching hospital. main outcome measures: (i) issues causing poor antibiotic overall tdm performance, (ii) approaches for optimizing tdm performance supported by group consensus results: key identified issues: (i) nursing work overload; (ii) insufficient education to pharmacokinetics and lack of specific training; (iii) insufficient information communication and lack of coordination and involvement of all stakeholders; (iv) conflicting guidelines; (v) lack of perception of positive benefit/risk ratio. approaches for optimization (consensus): (i) continuous education of all stakeholders; (ii) daily multidisciplinary collaboration with infectious disease physicians and clinical pharmacists; (iii) simplification and uniformization of guidelines and procedures; (iv) implementation of a simpler administration scheme (v) increased staffing. conclusions: correct performance of tdm and its implementation in routine clinical care needs to be critically assessed and appears to be mainly dependent on non laboratory-related parameters. background and objective: new data published at the end of and the beginings of the , suggest not to exceed a haemoglobin level of g/dl to avoid cardiovascular morbility-mortality in patients with anaemia and chronic kidney disease (ckd) treated with recombinant human erythropoietin (rhuepo). before these evidences the optimal target haemoglobin levels was greater than g/dl. our aim is to evalue if these new published evidences have changed the clinical practice in pre-dialysis ckd patients. design: retrospective observational study. all the pre-dialysis patients who received rhuepo were including. in order to evaluate the possible changes in clinical practice, we measured the levels of haemoglobin prior to the publication of evidences (march-may of : group ) and after the publication of these evidences (march-may of : group ). we made a descriptive analysis of independent data. setting: department of hospital pharmacy. main outcome measures: the main outcome measures were: age, sex, mean glomerular filtration rate (gfr), mean haemoglobin level, mean haematocrit and type of rhuepo used. results: we studied patients ( in group and in group ). patients age ranging between to years (median = years). the proportion of women was . %. mean gfr for both years located around ml/min and the most frequent stages of renal injury were and . the most rhuepo used was darbepoetin alfa ( . % of patients). mean haemoglobin level for group was . g/dl (sd = . ) and . g/dl (sd = . ) for group . mean haematocrit was . % (sd = . ) and . % (sd = . ) for group and , respectively. conclusions: our nephrologist are cautious about of prescribing rhuepo, not only after the publication of the new scientific evidences on this subject, but before this too. it s worth questioning if clinical practice in ours hospital is different from the published evidences. background and objective: tacrolimus (tac)-based immunosuppression is effective in adult renal transplant patients with acute or chronic rejection or cyclosporin (cya)-related toxicity. the conversion from cya to tac resulted in improved cardiovascular risk profile and increased prevalence of post-transplant diabetes mellitus (ptdm)compared with treatment with cya. the aim of this study was to review clinical documents for renal transplant patients and assess patients' outcomes. design: a retrospective review of clinical data. excluded from the study were patients converted to tac less than months posttransplantation. statistical analysis (one sample paired -tailed t test) was performed using microsoft office excel . the graft survival was analysed with kaplan-maier survival curve using xl stat software. the study was approved by the northern ethics committee, auckland, new zealand. setting: tertiary care setting. main outcome measures: mean serum creatinine, incidence of ptdm, mean total cholesterol, hdl cholesterol, ldl cholesterol, total/hdl cholesterol ratio, mean blood pressure and antihypertensive scores, graft survival censored for death. results: forty-four patients were converted to tac more than months post-transplantation from to june . mean serum creatinine (scr) increased in the months prior to conversion from lmol/l ( % ci - ) to lmol/l ( % ci - ) at months post conversion to tac (p-value = . ). thirty-four patients were taking cya for more than months. the mean scr increased from lmol/l ( %ci - ) at the months prior to conversion to lmol/l ( %ci - ) at months post conversion (p-value . ). if scr for seven patients who had an acute rejection episode were excluded, the mean scr did not show any change in slope after conversion and showed a tendency to gradually increase from lmol/l ( %ci - ) to lmol/l ( %ci - ) months post conversion (p-value . ) eleven out of patients were affected by diabetes mellitus. six patients were diabetic pre transplantation and remained diabetic post transplantation and post conversion to tac. two patients developed new onset ptdm post transplantation and two became glucose intolerant. after conversion to tac, glucose intolerance resolved in one patient and one patient ( %) developed new onset ptdm. in patients converted to tac more than months post transplantation, mean total cholesterol was reduced from . to . mmol/l (p-value . ) and mean ldl cholesterol from . to . mmol/l (p-value . ). in june , / patients ( . %) were taking tac with a mean scr of +- lmol/l. four patients ( %) lost their grafts. mean graft survival time was . months. -year graft survival was . %. conclusions: conversion from cya to tac was beneficial with respect to renal function and cardiovascular risk profile. the conversion had no added benefit on renal function in patients with stable renal function taking cya more than months post transplantation. the reported incidence of ptdm was found to be low ( %). background and objective: most of the cancer patients suffer from severe pain especially during the terminal phase of the disease. it is essential to monitor these patients to achieve adequate and successive pain management, not just because of the importance of the effects, side effects and overdose problems; but also to improve quality of life. the aim of the study was to evaluate oncology pharmacist interventions on pain management. design: numeric pain scales was conducted prospectively among the cancer patient who were over years old and were selected randomly. patients were separated into two groups: of the patients was control group, pharmacist had been effectively included to the rest patient's pain management strategies, which was pharmacist intervention group. all of the patients had been evaluated by numeric pain scales (time ). the patients who were on pharmacist intervention group were monitored by pharmacist on treatment effectiveness and side effect profile every three days during the study. after one month, numeric scales were repeated (time ). the interventions that pharmacist done were pain evaluation, suggestion on appropriate pain reliever, dose management, patient education and patient monitoring. our therapy recommendations were made on the basis of the world health organization's analgesic ladder following the results of assessments. setting: oncology outpatient unit of a university hospital main outcome measures: the demographic and diagnostic information of the patients were collected. the results of the evaluations via numeric pain scales were calculated by using arithmetic mean value. results: the mean of pain intensity was significantly decreased in pharmacist intervention group when compared with control group ( . ± . vs. . ± . , p = . ) and between time and time ( . ± . vs. . ± . , p = . ). the mean of pain's effect on daily activity was significantly decreased in pharmacist intervention group when compared with control group ( . ± . vs. . ± . , p = . ) and between time and time ( . ± . vs. . ± . , p = . ). the mean of drug effectiveness was significantly increased in pharmacist intervention group when compared with control group ( . ± . vs. . ± . , p = . ) and between time and time ( . ± . vs. . ± . , p = . ). conclusions: the harmonious working of the pharmacist with the other health care staff working in oncology unit, helped patients to achieve more effective pain management. in this study; pain intensity was decreased, pain interfered less with daily activities was, and the reported effectiveness of drugs was increased in the pharmacist intervention group compared to the control group. all these outcomes show that the clinical pharmacists have an important role in oncology services, especially pain management. background and objective: to investigate and compare the frequency and nature of prescrbing errors requiring contact with the prescriber at community pharmacies in norway, estonia and sweden. design: a protocol, based on a scheme originally presented by rupp ( ), revised and developed by kennedy ( ) and translated and transformed to the nordic context by haavik ( ), was used in all three settings. in norway the protocol was self-completed by the pharmacists; in sweden and estonia observers (trained students) recorded and classified the interventions. setting: norway - community pharmacies in southern and western norway; estonia - community pharmacies in three cities; sweden - community pharmacies in swedish cities and public pharmacies at hospitals in sweden. main outcome measures: prescriptions with errors or ambiguities where the pharmacist decided to contact the prescriber to correct, clarify or complete the information on the prescription. results: the total numbers of dispensed prescriptions were: norway , , estonia , , sweden , (community pharmacies) and , (public pharmacies at hospitals). the proportion of handwritten prescriptions and prescriptions where pharmacists contacted the prescriber was higher in estonia than the other countries. administrative problems -reimbursement issues; prescriber data and distribution and licensing issues -were the reason for more than one third ( - %) of all contacts with the prescribers in all settings. however, the patterns of prescription problems with potential clinical hazards varied -in estonia and norway, errors concerning strength, administration form and number of doses were the most common errors and constituted and % of the problems. in sweden, errors concerning the prescribed dosage were the most common reasons. conclusions: the proportion of problem prescriptions requiring a clarifying contact with the prescriber was higher in estonia compared to norway and sweden. the main reason may be that most prescriptions in estonia were handwritten. administrative problems (reimbursement and availability of prescribed products) constituted a similar large portion in the three countries. however, prescription problems with potential clinical consequences for the patients, varied. , presenting with salmonella bacteremia and neurological deterioration due to cerebral toxoplasmosis was admitted to the intensive care unit. he was immediately intubated. to treat toxoplasmosis, cotrimoxazole was started in a dose of mg smx/ mg tmp qd. days later the patient developed leucopenia (absolute wbc count: . /l, neutrophils: . /l). folinic acid mg od was associated to restore white blood cell count. neutrophils further dropped to attain its nadir ( . /l) on day of cotrimoxazole therapy. cotrimoxazole was stopped and clindamycin mg td was used instead. neutrophil count restored, normalizing on day after stopping cotrimoxazole. this event was attributed to the administration of cotrimoxazole. the time relation between the administration of cotrimoxazole and the onset of neutropenia as well as the normalisation of neutrophils was clear. other explanations, such as the contribution of concomitant medication (ranitidin, ceftriaxon, ethambutol, isoniazid, rifampicin, aciclovir, amphotericin b, enoxaparin)could be ruled out. the naranjo score, which estimates the probability of adverse drug reactions, is . the use of folinic acid as rescue therapy in association with cotrimoxazole is controversial, as it can theoretically antagonise the anti-infective action of cotrimoxazole. therapeutic failure in aids patients, receiving this combination for pneumocystis jiroveci pneumonia, has been reported. nevertheless, we decided to start folinic acid to further prevent nosocomial infections in this severe immunocompromised host. we don't know whether folinic acid contributed to quick recovery of neutrophil count in our patient. further studies are necessary to clarify its role as rescue agent during treatment with folic acid antagonists. conclusions: this case report illustrates that cotrimoxazole, frequently used in opportunistic infections, can be associated with agranulocytosis. this dangerous complication in immunocompromised patients with severe infections must be prevented, although the effectiveness of folinic acid as rescue therapy is still a matter of debate. background and objective: intravenous immunoglobulin (ivig) therapy is increasingly used in inflammatory and autoimmune disorders, because of its therapeutic benefit and its good safety profile. cutaneous adverse events are rare and include prurit, rash, alopecia and eczema. in the literature, about cases of eczematous skin reactions have been reported. most of the cases were treated for a neurological or neuromuscular disease. erythematous eruptions on hands and feet have been notably reported after high-dose infusion. in most of the cases, the eruption was progressively extending to involve the entire body. when ivig were readministered, eruptions were more rapid and more intensive. we report an eczematous skin reaction of the palms after ivig infusion without extensive eruption, in spite of three administrations. design: case report. setting: neurology ward, university hospital, grenoble, france. main outcome measures: a -year-old man was treated with ivig (tegeline Ò , lfb, france) for an inclusion body myositis. he developed a skin reaction, days after the end of a days ivig infusion (dose of . g/kg was given daily for consecutive days). the eruption was a non-pruriginous erythematous maculopapulovesicular rash located on the palms. this reaction occurred th day after completing the second therapy and did not extend. the lesions regressed progressively with topical application of fatty ointment. three days after the third infusion, the same lesions reappeared, and regressed the same way. results: clinical pharmacist with the help of pharmacovigilance experts and doctor worked collaboratively: because of the chronology of exposure to other treatments, intrinsic imputability and recurrence on reintroduction, we ruled out an adverse drug reaction to any other medication. we decided not to interrupt the infusion. we advised the patient to continue fatty ointment application and to tell the healthcare team if the reaction became more serious. conclusions: dermatologic adverse reactions such as eczematous skin reactions are rare and usually mild. there is no reason to limit the use of ivig in a case like this one, as long as the treatment is effective. however, a narrow clinical and biological follow-up is required. if necessary, this adverse effect can be prevented by antihistamines or even steroids. anticoagulants must be monitored closely by physicians, because this products have a narrow therapeutic index. numerous interactions with herbs are documented, either increasing or decreasing the anticoagulant effect. our main objective is to identify this interactions in our surgery and if they are clinically significant. design: six months observational study; interviewing patients with their inr alterated about herbs that they were taking at that moment. literature review. setting: the anticoagulant oral treatment surgery. main outcome measures: the two oral anticoagulant drugs available in spain are acenocoumarol and warfarin. the international normalized ratio (inr) is the laboratory test used to measure therapeutic efficacy and safety of vitamin-k antagonists. a control test is done every four weeks and if necessary it can be done earlier. results: among patients with inr [ , six of them were taking herbs at the same time, and we could relate the increase of the effect of oral anticoagulants to those products. one of this patients who was taking dandelion (tarxacum officinale) had a inr. an other one who was taking chamomille (matricaria capensis) and passion flower (passiflora incarnata) had a . inr. all of these products have coumarins compounds. two patients who were taking equinacea (equinacea purpurea, equinacea angustifolia) also had their inr test altered: one had a . inr and the other one . . an other one was taking bilberry (vaccinium myrtillus) and had a . inr. both, equinacea and bilberry inhibit different isoenzimes of cytochrome p . the last patient was taking garlic oil (allium sativum) and had a inr. garlic increases the anticoagulant effect. conclusions: it is commonly believed that herbal products are inofensive, that is the reason why mainly of the patients do not take medical advise before starting a treatment with them. however, there can appear interactions with the usual treatment. if we fix on the vitamin-k antagonists the risk resides on the hemorragic or strokes events. in conclusion, we believe that patients should be educated about the potential risk of using herbal products while being treated with vitamin-k antagonists. a year-old man, treated with clopidogrel after coronary stenting, is hospitalized for aa (neutrophils: g/l ( . - g/l); haemoglobin: . g/dl ( - g/dl); platelets: g/l ( - g/l)). his permanent medications were insulin, perindopril, omeprazole, atorvastatine, bisoprolol, and acetylsalicylic acid. clopidogrel ( mg/d) was prescribed weeks before aa occurence. clopidogrel is withdrawn and aa therapy is started, consisting in the sequential association of anti-thymocyte globulin therapy ( mg/kg) and ciclosporin ( mg/ kg/d) in a filtered-air room. but the severe co-morbidities lead to early stop ciclosporin, then relayed by androgen therapy (norethandrolone). finally, at weeks from the diagnosis, the evolution ends to a resolution of aa, but with platelet-transfusion dependance. after the elimination of the other aetiologies, iatrogenic cause is envisaged. to blame clopidogrel is difficult with regard to the other drugs, especially perindopril and omeprazole known to induce bone marrow failures. four arguments lead to target clopidogrel: (i) the length of treatment by perindopril and omeprazole without complications, (ii) the timing between the onset of aa and the addition of clopidogrel to treatment, (iii) the resolution of aa whereas neither perindopril nor omeprazole were withdrawn, and (iv) the support of the literature. conclusions: clopidogrel seems to be responsible of this side effect. we unfortunately lack in specific biological tests to prove it. keywords: clopidogrel, side-effects, pharmacovigilance background and objective: informing patients on their medicines is a patient right. what does current information provision on antidepressants to patients with a depression admitted to a psychiatric hospital look like? what is the current practice of health care professionals? what are the experiences of patients? this study aims to explore current practice on drug information provision in psychiatric hospitals. design: a qualitative study consisting of semi-structured interviews with separate interview guides for health care professionals and for patients. interviews were tape recorded, verbatim transcribed and analyzed using nvivo software. setting: eight flemish psychiatric hospitals. main outcome measures: identification and evaluation of current approaches to drug information provision on antidepressants from the point of view of health care professionals as well as patients. results: patients get information on antidepressants, firstly, through psychiatrists and, secondly, through nurses. hospital pharmacists have a supporting role. the approach in giving information depends on patient characteristics and his/her mental state. information is provided mainly orally. leaflets are not frequently distributed to patients. patients also get information on antidepressants during psycho-educational sessions. on request, patients can read a package insert under supervision of a health care professional. health care professionals consider non-verbal cues of patients to verify if information has been understood. information is repeated when the first instruction was not clear for patients. there are no systematic interdisciplinary contacts on information interventions. patients as well as health care professionals are satisfied with current practice on information provision. health care professionals reported lack of time and lack of interdisciplinary contacts as negative aspects. patients indicated that health care professionals take too little initiative to give information about medicines. positive aspects reported by health care professionals are the hospitals' openness and the opportunity for patients to ask their questions to psychiatrists as well as nurses. suggestions for improving practice are: providing more medication information to patients, in particular on side-effects; enhancing the availability of easy readable information; and organizing continuing education for nurses on medicines. patients are informed about their antidepressants through various pathways. however, there seems to be room for improvement as a number of suggestions were formulated to support these pathways of drug information. keywords: medication information, antidepressant, psychiatry claire chapuis , christine chevallier , céline villier , pierrick bedouch , benoît allenet , jean calop , gérard besson pharmacy, pharmacovigilance, neurology, university hospital, grenoble, france background and objective: the use of intravenous immunoglobulin (ivig) is expanding. the risk for adverse effects can be minimized by taking some precautions. there are yet no standardized practice guidelines for prevention and management of adverse effects occurring during the infusion, and there is a need for it. the purpose was to conduct a study of their knowledge among the nurse community and to make a review of the best practices. design: we search in medline and carried out a questionnaire for nurses. we evaluated knowledge and practices of nurses in neurology, pneumology and haematology units, experienced in intravenous immunoglobulins administration, in order to define their role and the prescribers role in ensuring patients safety during therapy. we used all information and synthesized it in a table. for every type of adverse reaction, we indicated mechanism, frequency, seriousness, risk factors, practical guidelines of management and prevention and actor. the guidelines were reviewed by experts (pharmacist in charge of human derivative products, pharmacovigilance experts and neurologists). setting: university hospital, grenoble, france. main outcome measures: formalisation of practical guidelines on prevention and management of intravenous immunoglobulin adverse effects, for prescribers and nurses in the local hospital network and possibly other hospitals. results: nurses always checked the doses before administration ( / ), always prepared the product aseptically ( / ), warmed up the product until it reached room temperature ( / ), but only few recorded the patients tolerability during the infusion ( / ), and very few knew that most adverse events could be minimized first by slowing down the rate of infusion ( / ). all nurses called a doctor as an adverse effect appeared. conclusions: nurses must be involved in the management of adverse effects, even if the prescriber remains the one who makes the prevention by evaluating risk factors, co-medications, dosing and frequency of treatment and the one who makes the decision to interrupt the treatment if an adverse effect occurs. the clinical pharmacist in care units works collaboratively with both prescriber and nurse. he plays a central role for preventing drugs' adverse effects while counselling every member of the healthcare team background and objective: fludrocortisone tablets - lg (f) is mainly used in the treatment of adrenocortical insufficiency. it may also be used in treatment of orthostatic hypotension. f is manufactured by ageps (public special-order manufacturer) and dispensed to outpatients by hospital pharmacies, as a ''hospital preparation''. in order to follow gmp guidelines, a patient information leaflet for f was elaborated in our pharmacy outpatient unit. the leaflet was approved by our regulation unit. to evaluate the usefulness of this leaflet and to improve its quality, we performed a patient satisfaction survey. design: during days, for every dispensation of f, a leaflet was presented to the patient and an anonymous satisfaction survey was performed. setting: pharmacy outpatient unit, agence générale des equipements et produits de santé (ageps) (ap-hp), paris, france. main outcome measures: the questionnaire consisted of three items: general information about patient and its treatment; patient's knowledge of f before reading the leaflet (uses, precautions, adverse events, storage); patient satisfaction of leaflet (general presentation, language simplicity, information volume, utility). results: patients answered the questionnaire. the mean age was years ( - years). mean f treatment duration was years ( months- years). % of patients were already informed about f: % by physicians and % by associations and internet. % knew the indication ( % adrenocortical insufficiency and % orthostatic hypotension). % knew about precautions, % knew about side effects, and % knew about storage conditions. % of patients did not read the leaflet and had no opinion about satisfaction items. % were satisfied of general presentation. language was understandable for %, and non understandable for %. information volume was sufficient for %, insufficient for %, and too large for %. leaflet was useful for % of pts. patients who found the information insufficient suggested the following items: results of clinical trials, management of acute situations due to disease or f, and contacts of qualified centres in case of serious events. conclusions: nearly half of the patients were informed about f by their physicians, but information is communicated orally without written support. the majority of patients treated by f knew about precautions, side effects, and storage conditions. however, patients were satisfied of our information leaflet and find it useful. leaflet appears to be a good tool to communicate information from the pharmacist to the patient when not available in the packaging. of these recommendations taken into account ( %), within a period of days for most (n = ), involved the intervention of a pharmacy student, were given only via the computer software, and via a telephone call. conclusions: computerisation of prescriptions is an indispensable tool in order to make the pharmaceutical distribution circuit safer. however, its use as a vehicle for pharmaceutical interventions is limited, as shown by this study. it is impossible to analyse a nonresponse of our recommendations: is our advice even red, is it considered as inadequate? a discussion with the clinician (via pharmacy students or on the telephone) allowing a constructive exchange of knowledge, leads to a better transmission of recommendations. background and objective: in hospital setting, employees may be exposed to hazardous drugs. risks and protective measures needed when handling parenteral cytotoxic drugs are well described, whereas information related to drugs like monoclonal antibodies or antivirals are lacking. we developed a standardized method to evaluate drugs potential toxicity and occupational risks taking into account the pharmaceutical forms of the drugs to balance the risks. design: development of an algorithm for toxicity evaluation using material safety data sheet (risk and safety phrases), international agency for cancer research (iarc) classification and official manufacturers' data. . evaluation of chronic toxicity (mutagenicity, carcinogenicity), acute toxicity (sensitisation or irritation in contact with skin, eyes or by inhalation) and toxicity to reproduction . balancing of toxicity according to the pharmaceutical forms . assessment of protective measures (centralization of drug preparation in the pharmacy, wearing of mask, gloves and/or glasses) centralization of drug preparation in the pharmacy is recommended only in case of documented mutagenicity and carcinogenicity and when there is a risk of respiratory or cutaneous exposure related to the pharmaceutical form. setting: university hospital ( beds). main outcome measures: • chronic (r , r , r or iarc group , a or b), acute toxicity (r - , - , - ; s - , - ) and toxicity to reproduction (r - ; cat.d,x) • pharmaceutical forms associated with a risk of respiratory (e.g. tablets crushing), cutaneous (e.g. drug in solution) or ocular contact (e.g. inhalation) results: occupational risks of parenteral monoclonal antibodies, oral and parenteral antivirals, oral cytotoxics and other drugs forms were analysed. according to our algorithm, crushing of % of the tablets forms should be done in the pharmacy (e.g. valganciclovir). only parenteral antiviral should be reconstituted at the pharmacy (ganciclovir). monoclonal antibodies were found not to be at risks of mutagenicity or carcinogenicity and only gloves will be recommended for their manipulation. no ''class-effect'' has been pointed out (e.g. only a few antivirals were found to be hazardous). products were at risks for pregnant women. protective measures to be taken by pregnant nurses or those wishing to have a baby will be discussed institutionally. conclusions: toxicity evaluation of hazardous drugs handling in hospital should take the pharmaceutical forms into account as some toxic drugs may not be associated with occupational risks (e.g. coated tablets). our method allows a standardized way to evaluate whether a drug should be treated as hazardous or not. results will be discussed institutionally in order to implement applicable policies and procedures. results: lidocaine % injectable solution is indicated for tracheobronchial anesthesia, via bolus of mg in adults, and to mg in children. the maximal dose is restricted to mg/kg in adults and - mg/kg in children. epinephrine is indicated in hemorrhagic complications occurring during interventions; the solution is diluted to mg/ ml with nacl . %; a lg bolus is injected and can be repeated up to mg. terlipressine can be used in heavy bleedings; the powder should be reconstituted with nacl . %, at mg/ ml; mg is injected, repeated if necessary. mesna is used to dissolve mucous plugs, especially in patients with cystic fibrosis. the solution is diluted to mg/ml with nacl . %; bolus of ml are injected to allow visibility in the lower airways. there are no data available on the maximal dose. all preparations have to be compounded aseptically and extemporaneously by the nurse when requested by the physician, because of the lack of stability studies in those ranges of concentrations. conclusions: these guidelines are intended to standardize flexible bronchoscopy procedures between the different units, in order to minimize the occurrence of medication errors. almost half of the enquiries ( . %) were about stability and incompatibility in intravenous (iv) admixtures. the frequency of these calls was significantly higher than the calls came from other health professionals (p \ . ). the following types of enquiries were about dosage ( . %) and availability of pharmaceutical products ( . %). while . % of enquiries were answered by hizbim in less than minutes, in % of all calls took more than day to gather and tailor which requires more literature search. the mostly ( . %) used references in retrieving information was general references followed by micromedex ccis inc. with . %. • hizbim has been consulted by nurses in a rising pattern. this means that this service is of importance for them because of its rapidity, accuracy and currency • the preparing iv admixtures that has been left to nurses' responsibilities in practice in our country can be reconsidered by pharmacists since this service has been fulfilled by ''drug experts'', namely pharmacists in many countries. • drug information centers can provide not only emergent information for nurses but also education such as seminars and conferences in some topics they need. the establishment of drug information centers in hospital settings will be of use to stimulate the frequency of consultations by nurses and to improve patient care provided by them. background and objective: the concept of pharmaceutical care (pc) is capturing the attention of a growing number of pharmacists. the strategy followed by us to spread out the implementation of pc in pharmacies involves the utilization of internet tool as an innovation of traditional education. design: to do so, we designed an on line pc course with interactive cases. the specific goals of the course are: • the enhancement of the pharmacy practice. • the promotion of practice research. • the personal and professional development of pharmacists. the objective was to analyse the evolution of the program, whose pedagogical design was based in a process of teaching-learning in the field of the clinical pharmacy and pharmaceutical care that permit the training of the future pharmacists in the use of medicines. design: all the classes were designed with practical-theoretical modality including workshops, reading and analysis of the bibliography, discussion of cases and utilization of virtual simulators. setting: clinical pharmacy. department of biological sciences main outcome measures: students evaluation was carried out by tests of the general contents, degree of active participation during the workshops, resolution exposition and discussion of the cases. results: the development of clinical pharmacy education began in . the students appreciated this experience and the % of them are satisfied with the process of teaching-learning employed. this teaching system improved them the adequate and rational use of the medicines. in these two years the % of the students has approved the examination. the students also realized two poster presentations during this period, namely: . ''comparative study of the information supplies in the leaflet of tablets of omeprazol mg'', in and . ''study of the information supplied by the pharmaceutical laboratories in the television media'' in . conclusions: we consider the importance of the incorporation of clinical pharmacy in the new pharmacy curricula, because the students have major task about the practical education involvement patients and related to their professional future. background and objective: clinical trials' managing and dispensation is one of the obligatory missions of a hospital pharmacy. the respect of good clinical practices is necessary to ensure proper trial performance and to be aware of errors in prescription and in drugs dispensation. the aim of our study was to analyse the nonconformities in the steps of prescription and dispensation and to evaluate their severity. design: the pharmacy department manages clinical trials for all clinical wards with a pharmacist and a technician who change every four months. there is no specific computerized system but an excel software for data filing. we realized a retrospective study of ongoing clinical trials. all the prescriptions were reviewed and we focussed on all the items required for the prescription (e.g., identification of the protocol, the patient, the investigator, the dosage) and for the dispensation (e.g., identification of the drug, the quantity dispensed, batch number, expiry date) setting: results: gps participated to the survey. they agreed (median = , iqr = - ) that the following concepts are crucial in a patientcentred approach: the need of a specific training in counselling in under and post graduate education; the necessity of working with patients to develop mutually agreed-upon goals; the role of information in the decision making process, the ability to understand patients readiness to make change, and to identify barriers to change, the importance to recognize that patients are the experts when it comes to their own behaviour related issues. for only one item (time dedicated to the consultation) iqr changed (iqr = - ) indicating some difficulty in implementing this aspect in practice. conclusions: for benevento community gps, a patient-centred approach is a useful way to help change and promote behaviour. knowing how to support it is an important skill for all care professionals, but education is needed to shift from theory to practice. type ii and gestationnal diabetes. the average age was years and for the half of these patients, the pathology developed since more than years. patients were painful and patients presented a positive score to dn questionnaire. symptoms frequently observed were: pins and needles, prickles, and numbness. among these patients, were treated by antidepressants (amytriptiline) or antiepileptics (clonazepam, gabapentine, tegretol, carbamazepine or pregabaline) or both. the average number of molecules received by patients was . . the average number of lines of treatment was: . . first intention treatment insisted of an anti-epileptic monotherapy in patients. second line treatment involved the introduction of another anti-epileptic or an anti-depressant drug. the drugs have been well tolerated except a respiratory depression under clonazepam. among the not-treated patients, only one benefitted from a treatment initiation. conclusions: patients are treated by ''old'' molecules with a large prescription of clonazepam but their efficacy is very variable. the physicians have been sensibilised to dn questionnaire and they concluded that it is easy to use. however there is a lack of physician's informations about the management of neuropathic pain; besides they are hesitant to initiate a treatment. the relationship between pharmacists and physicians and the development of clinical pharmacy seems important to optimize the management of this pain. background and objective: pharmacy education in the faculty of pharmacy and biochemistry of the university of buenos aires is taught as a product-oriented profession with a focus on the basic sciences. however in pharmaceutical care and clinical pharmacy was integrated as an optional course into the pharmacy curriculum by resolution cd / . the object of the emphasis was on the students' ability to provide clinical pharmacy and pharmaceutical care upon graduation. hence, therapeutic plays a significant role in building students' knowledge and skills in preparation for clinical practice. design: theoretical education and program for students and collaborative implication in the hospital activity or in the community pharmacy. the development of the program is carried out in two phases. in the first phase the clinical activities of the pharmacists, the unidose drug distribution, the role of the drug information centers, pharmacoepidemiology and surveillance studies are explained. in the second phase the concept of pharmaceutical care is introduced and its implementation in different pathologies is developed. an active approach of the patient and contact with the treating physician was considered as tool in a strong learning environment. setting: undergraduate pharmacy students at university of buenos aires. main outcome measures: the students find them abilities to identify drug related problems and to assess patient care and follow-up. results: more than students have attended pharmaceutical care and clinical pharmacy to: % passed and % failed. students option was that the strongest aspect are the case discussion and the weakest the very few number of hours not enough to discuss other important illnesses. they also say that many topics should be taught sooner in the career and it was not considered an emphasis an the clinical and patient oriented-aspects of the profession. conclusions: an approach to clinical pharmacy education in which the integration of teaching and learning are collaborative creates an atmosphere that is conducive to effective student learning. moreover the clinical pharmacy is a valued and important tool of the general practice team regarding quality improvement in drug therapy. all of the most popular cpd linked pharmacy activities were from the competency-'participation as a member of the multidisciplinary team'. telephone interview findings showed pharmacists cited 'priority for their service development' as the principle reason for cpd identification. no pharmacist identified a cpd need for: 'supporting patient/family motivation'; 'ecording problems in blood glucose control requiring balancing food intake and insulin dose'; 'sharing reflections of where your performance leaves room for improvement within a pharmacists group' and 'taking part in a local multi-disciplinary mentoring group.' conclusions: currently cpd workbooks appear not to be widely used within the pharmacy profession in the uk although there are examples of successful use of reflective portfolio. , almost half of the participants chose the workbook as a means of support leading to a substantial number of identified cpd issues. for community pharmacists to deliver high quality care for diabetes, more attention is required to forms of training and to both uniprofessional and multiprofessional peer support. setting: we retrospectively reviewed all prescriptions of ivig issued from three infectious disease departments ( beds) in a french bed university hospital. main outcome measures: for each ivig prescription, the following data were collected: patient identification, name of ivig product, quantity of ivig issued, date of ivig release, indication for treatment and level of relevance. these levels are determined as follows. level : indications approved by health authorities or for which comprehensive guidelines have been published (high level of proof). level : relevant indications based on scientific publications. level : off-label indications more difficult to prove on a scientific basis (few or no high quality randomized controlled clinical trials). results: during the studied period, grams of ivig were administered for a total of patients and prescriptions. . % ivig used saccharose as a stabilizing agent, other products contain either glucose ( . %), or maltose ( . %). the purpose of this study is to produce an evaluation focus on the risk profile and counselling activities concerning therapeutic and lifestyle change. design: descriptive study. individual measurements were recorded by pre graduation students on a standardized datasheet. blood pressure was measured using a digital wrist device. blood glucose monitoring systems of two different brands were used. setting: the screening was made in the street using passer-by volunteers. in the course of a single day in may , a total of subjects ( . % males and . % females, mean age . years, sd = . ) had glycaemia and blood pressure measured. main outcome measures: age, gender, medication taken, cigarette smoking, body mass index (bmi), blood pressure, capillary blood glucose results: . % of the sample presented bmi [ kg/m. . % had elevated systolic blood pressure values and . % elevated diastolic blood pressure values. . % had elevated occasional blood glucose. . % are cigarette smokers. systolic (t = - . ; p = . ) and diastolic (t = - . ; p = . ) blood pressure values were significantly higher in smokers than in non-smokers. concerning patients taking diabetes medication, fewer patients with blood glucose controled and more patients blood glucose uncontrolled were found than those expected, suggesting either low compliance or lack of efficiency of medication (v = . ; p \ . ). concerning the hypertension medication, similar results were found. more patients under therapy with blood pressure uncontrolled were found than expected. the concordance within the two measures of the blood glucose with different monitorizing system was found to be strong and significant (k = . ; p \ . ). positive and significant correlation between bmi and diastolic blood pressure was found. however, no significant correlation between bmi and systolic blood pressure was found. conclusions: events such as this screening improves the quality of education, as well as develops the interests and opinions of students. as well as it shows face to face were can be apply their knowledge of clinical pharmacy furthermore, events such as these are found by the students to be invaluable in acquiring training in similar-to-professional setting and expertise in field work. background and objective: nhs education for scotland (nes) has worked with the scottish executive health department (sehd) to develop training packages to support the use of validated needs assessment tools (nat) for several longterm conditions. consequently a specific training package was then developed to support and standardise needs assessment and pharmaceutical care delivery by palliative care pharmacists in the local networks set up in scotland. additional support materials (trainers package) was developed for representatives from the scottish palliative care pharmacists' association to deliver the training to their local network pharmacists in a consistent manner. design: development and evaluation of a training package and course for palliative care pharmacists. evaluation of the outcomes from using a nat for delivery of care. identification of issues %; relevance of questions %; time to complete nat - mins; barrier -time; benefits -care issues identified by nat; care issues -counselling and compliance issues, side-effects identified (nausea, dry mouth, constipation), pain relief not adequate. conclusions: nes are proactively supporting national policy and practice through a process of identifying and meeting the educational needs through direct and self-directed learning for continuing professional development (cpd). the needs of palliative care patients are seen as an appropriate target group for pharmaceutical care. the evaluation and feedback from the courses, training pack and outcomes from the use of the nat in practice have been very positive and amendments will be made for further implementation in scotland. background and objective: pharmacy students represent a broad spectrum of learning preferences and styles. this diversity presents a responsibility for the lecturers and instructors to meet the educational needs of all students. in order to develop appropriate learning approaches the instructors need to know the students learning preferences. therefore, the aim of this study was to identify the learning preferences of pharmacy students. design: the visual, auditory, reading/writing, kinesthetic (vark) questionnaire identifies student's preferences for particular modes of information presentation. the vark questionnaire is freeware that can be completed online. however, we administered the vark questionnaire as a hard copy at the end of the 'clinical pharmacy practices' final exam to the fourth-grade pharmacy students. setting: marmara university -faculty of pharmacy. main outcome measures: the frequency of students' preference for modes of information presentation. results: we administered the vark questionnaire to students and ( %) returned the completed questionnaire. almost half of the students ( . %) preferred a single mode of information presentation. among these students, % preferred visual (learning from graphs, charts, and flow diagrams), . % preferred auditory (learning from speech), and . % preferred printed words (learning from reading and writing), and % preferred using all their senses (kinesthetics: learning from touch, hearing, smell, taste, and sight). the other half ( . %) preferred multiple modes [ modes ( . %), modes ( . %), or modes ( . %)] of information presentation. a total of ( . %) students preferred 'kinesthetic' learning solely or in a multimodal combination. conclusions: the students represented a variety of learning styles. student motivation and performance improves when instruction is adapted to student learning preferences and styles; so, it is the responsibility of the instructor to address this diversity of learning styles and develop optimum learning approaches. escitalopram, fluoxetine and mirtazapine were rarely prescribed. the posology and taking plan were generally respected. however, some improvements in terms of treatment optimization could have been brought. they could have lead to actions of clinical pharmacy within the framework of prospective study: posology optimizations and taking plan optimizations. nineteen patients ( %) had an adjustment in their antidepressant treatment: nature and dosage. for all the antidepressants, a sufficient duration was respected before increasing the doses. an average number of interactions by prescription were . but none was clinically significant. conclusions: therapeutic strategies corresponded to guidelines recommendations. the dosage adjustments and duration before increasing the doses respected the indication of antidepressants. in the future, to optimize the medicinal treatment, decision-making tools carried out could facilitate psychiatrists' prescriptions. the pharmaceutical validation of prescriptions will be facilitated by complying with them within the framework of clinical pharmacy activity. background and objective: al-amal hospital is a bed oncology/ hematology hospital. al-amal hospital is now the first hospital in qatar to be accredited by the joint commission international (jci), the worldwide leader in improving the quality of healthcare. the objective is to implement clinical pharmacy services in al-amal hospital in the state of qatar by training the pharmacists about clinical pharmacy services. design: a pharmacist designed the training program and took the initiative and responsibility for training other pharmacists in aah about clinical pharmacy. the department of medical oncology/ hematology, the hospital administration and the pharmacy department agreed that the pharmacists should have central responsibility for antineoplastic agents and other drugs related problems. pharmacists for the program were selected from the existing staff. the healthcare team is consisting of two pharmacists rotating every months. each pharmacist join teams consisting of a pharmacists, a consultant, a specialist, a resident, a rotating resident, nurses, a dietitian, physiotherapist, social worker and a psychologist. we used to have oncology teams and hematology team. both pharmacists participate in the medical rounds and morning report days per week. the pharmacists provide clinical pharmacy services including chart review, pharmacy patient profile review, laboratory tests, therapeutic drug monitoring, antibiotics monitoring, interviews with patients and/or relatives. drug related problems were identified, resulting in interventions. setting: in patient wards, al-amal hospital, qatar. main outcome measures: to identify drug related problems, which well result in interventions and to help the medical team and the patients to reach their treatment goals. patient outcomes were evaluated by follow up with the medical team or by patient interview. we refer patients to the dietitian, physicians, the clinical psychologist as needed. results: more time is needed to evaluate the clinical pharmacy services provided by the pharmacists as the program was just started. patient and physicians were satisfied by starting the training program. conclusions: hematology/oncology setting provides an excellent opportunity to involve pharmacists. a. leads to encephalopathy and progressive neurodegeneration in the infant who is not treated. early diagnosis and dietary management can prevent complications and may allow for normal intellectual development. however, neurologic function may deteriorate rapidly at any age because of acute metabolic decompensation. these severe episodes are caused by catabolism of endogenous protein, which may be provoked by physiological stress (infections, post-surgery). during these crisis, the patient must have immediately intravenous glucose infusion and enteral nutrition free of b.c.a.a. design: case report. setting: department of pharmacy, hospital charles nicolle, rouen. main outcome measures: case report results: one patient with classical m.s.u.d. is followed in our establishment since many years. his disease has been diagnosed in neonatal period. a diet free of b.c.a.a. has been instaured. this diet is successful, now this patient is years old and had a normal development except myalgia and hypoesthesy of the left leg. however, when the diet is not well followed or when he's infected, acute episode occurs (on average or times per years). as the crises starts, the patient is sleepy and confused. in order to be able to treat him very quickly, the medical staff decided to set up an emergency protocol, which include an adapted enteral nutrition formulation. the pharmacy is implicated in this protocol to prepare the mixture. the formula includes: m.s.u.d mix, dextrin maltose, oligoelements, ions, lipids (sunflower oil), vitamins and water. the pharmacy must be able to carried out the preparation at any time and the components must be always available. conclusions: because m.s.u.d is an unherited disease, published report of treatment are rare and they are no consensus for the treatment of acute decompensation. since years, this protocol is successful: b.c.a.a. levels decrease between to days after the setting-up and the patient always recovered rapidly. this formula is administrated by nasogastric tube and avoid the use of hemodialysis which is the last solution to remove b.c.a.a. this is an example that a personnal follow-up program (with plan for clinical and metabolic evaluations) during common intercurrent illnesses can have optimal outcomes. keywords: leucinosis, metabolic decompensation, adapted enteral nutrition nutr- ensuring phosphorus adequacy of human-milk-fed preterm babies canadell laura , cañete carmen , pardo rocio , albujar mar , valldeperez cinta , carretero juan , gallart m jesus , closa ricardo pharmacy service, neonatology, hospital universitari joan xxiii, tarragona, spain background and objective: human milk is the feed of choice for preterm infants both for nutritional and non-nutritional reasons. phosphorus levels in human milk are insufficient for most premature infants. this deficit is the major cause of osteopenia in prematurity. fortification with a commercial multinutrient product should only be considered after weeks of mother's milk feeding, however, phosphorus supplement must be given initially. to describe a standardized scheme for early nutritional support with phosphorus of very preterm infants (\ - g)and describe the phosphorous oral solution we use as a supplement is the aim of this study. design: clinically relevant reports were reviewed to establish a standardized scheme for early nutritional support with phosphorus of the very preterm infants. a standardized formula of oral phosphorous was established to diminish the medical errors when the addition of this mineral is required. setting: pharmacy service and neonatology unit of a third level hospital. main outcome measures: to describe the scheme of adding phosphorous to human milk as well as the standardized formula we use, ''phosphorous oral solution'' ( mg p/ ml). results: phosphorous oral solution procedure: composition, stability and the scheme of addition to human milk to ensure the requirements for bone substrate needs in preterm infants to avoid osteopenia of prematurity. conclusions: various methods have been tested to decide when additional supplements must be given. individual adjustment is not possible due to the delay of laboratory results on milk analysis and the fast changes in infants' requirements. therefore, it is necessary to make a standard adjustment scheme on the dose of the fortifier that needs to be added. shortly to the pancreaticduodenectomy, total parenteral nutrition (tpn) was started ( kcal in progress until reaching his energy requirements). in addition to parenteral nutrition, supplementation enteral nutrition was delivered via jejunostomy along four postoperative days. on post day , transition to a complete enteral formula was achieved (standard formula, ml = kcal: kcal/d). on day , patient complained of colic pain in upper hemiabdomen. an emergency tc revealed presence of liquid in the abdominal cavity from anastomosis pancreatogastric. with the suspect of a leak from jejunostomy, the catheter was removed. tpn was reintroduced and kept as the only way of nutrition until later when oral tolerance was started. during hospital stay ( days) periodic blood controls were performed. main methabolic complication was high blood sugar, needing the administration of insuline. from day to , mean plasma levels of albumin ( . vs . g/dl), total proteins ( . vs . g/dl), total serum cholesterol ( vs mg/dl), total lymphocite count ( . vs . %) and prealbumin ( . vs . mg/dl) increased significantly conclusions: the leak of artificial nutrition to the abdominal space in patients with jejunal feeding is a frequent complication of ne. its incidence is probably related to the length of the tube inserted into the lumen. protocols are need to prevent complications like tube displacement and to encourage early enteral nutrition. increase in plasma concentrations of nutritional parameters suggests effective uptake admixtures might be either prescribed and made ''a la carte'' according to the newborn's needs or provided by pharmaceutical companies as standard formulations. the aim of the study is to review individual pn prescriptions in a neonatology care unit in order to assess the potential for using standardized pn instead. design: prospective study one day per week during weeks. setting: neonatal intensive care unit, strasbourg university hospital. main outcome measures: the major criteria for the comparison are carbohydrate concentration and then amino acid intake. results: prescriptions were analysed and compared with a standardized formulation, pediaven Ò (fresenius kabi). the first point of comparison based on carbohydrate concentration resulted in an exclusion of % ( / ) of the total prescriptions because their carbohydrate concentration was less than g/ ml or more than g/ ml (pediaven Ò glucose concentration, g/ ml). among the prescriptions retained, only prescriptions whose amino acid concentration was less than . g/ ml were included (pediaven Ò : . g/ ml background and objective: it is known that propofol protect myocardial tissue against global myocardial ischemic-reperfusion injury in the isolated rat heart model. the aim of this study was to investigate whether propofol, at a clinically relevant concentration infused during both preischemia and reperfusion (peri-ischemic) period, also provide protective effect against regional myocardial ischemic-reperfusion injury in vivo. design: mail sd rats weighing between and g were anesthetized with mg/kg of ketamine and mg/kg of xylazine. a haparinized g catheter was placed in the left femoral vein. the trachea was intubated and then mechanically ventilated with room air using a volume-controlled rodent ventilator. a left thoracotomy was performed, and the pericardium was opened. for the ischemia-reperfusion experiments, a snare was passed around a left anterior coronary artery territory to induce regional myocardial ischemia. coronary occlusion was produced by pulling the snare and clamping it with a mosquito hemostat. reperfusion was produced by releasing the clamp. setting: rats were subjected to minutes of coronary artery occlusion followed by hours of reperfusion. propofol or intralipid was administrated during minutes starting minutes before the onset of ischemia until minutes after the onset of reperfusion. main outcome measures: the micro-manometer catheter was advanced into the left ventricle via right internal carotid artery and hemodynamic function was checked after hours of reperfusion. infarct size was determined by triphenyltetrazolium staining after hours of reperfusion. results: propofol administration during both preischemia and reperfusion (peri-ischemic) period showed protective effects on myocardial function and infarct reduction. in the control group, the peak rate of ventricular pressure rise (+dp/dtmax) and the peak rate of intraventricular pressure decline (-dp/dtmin) significantly decreased than sham group. in the propofol group, the +dp/dtmax and -dp/dtmin significantly improved than conrol group. infarct size was . % of the area at risk in control group, and was reduced markedly by administration of propofol during peri-ischemic period to . % in the propofol group (p \ . ). infarct size of intralipid group was . % of the area at risk, intralipid had no effect on infarct size compared with the control group. conclusions: propofol, at a clinically relevant concentration infused during peri-ischemic period, provided protective effect after regional myocardial ischemic-reperfusion injury at in vivo rat heart model. the results showed hemoglobin level of less than g/dl in . % of the subjects, transferrin saturation (tsat) of less than % in . % of the hd patients, tsat \ % and ferritin \ ng/ml in . % of the patients, serum alb level of less than g/dl in % of the patients, serum p level of more than . mg/dl in . % of the subjects, ca p product of more than in % of the patients, parathyroid hormone (pth) \ pg/ml (adynamic bone disease) in . % of the subjects and serum pth concentration of more than pg/ml (uncontrolled secondary hyperparathyroidism) in . % of the subjects. the results showed that more than half of the hd patients need erythropoietin and ferrous dose adjustment or follow up for resistant anemia, more than half of the subjects need phosphate binders dose adjustment or replacement and about % of he patients need rocaltrol dose adjustment. we are planning to compare these results with the findings following the participation of a clinical pharmacist in this hd center rounds and monitoring of hd patients. since enough management of complications of crd patients and their drugs monitoring are necessary to improve quality of life of hd patients, clinical pharmacist may have a major role in hd centers. background and objective: computerization of our drug circuit has been deployed gradually to every hospitalisation units of our hospital since . pharmacists coordinated the extension, the installation and the support for starting. they were the first interlocutors to analyze dysfunctions and to help solving them. difficulties encountered by nurses were often notified to head nurses and transmitted to pharmacists. the objective was to study as a whole difficulties of users and to bring a workable solution to their problems. design: a working subgroup depending on the drug commission was created. it was composed with nurses from different departments (intensive care, infectious, pediatric and rehabilitation departments), head nurses and pharmacists. several meetings, organized between october and december , made it possible to the participants to announce their difficulties. reports were written and diffused for validation. to evaluate the pharmacist -patient communication and the level of counseling for otc and prescription drugs dispense; to improve the professional relationship between the patient and the community pharmacist; to assess the effect of clinical pharmacist intervention over those parameters. design: interventional study (visits done by clinical pharmacists, especially employed for), repeated after weeks and again after months. setting: chain pharmacies from bucharest, romania. main outcome measures: the investigation was conducted using a multiple sections protocol. the assessed parameters were: pharmacist's attitude toward the patients, his/her availability to communication and the level of counseling when otc or prescription medication is released. results: during the first visit, in sixteen pharmacies only ( %) the pharmacists greet the patients. two weeks later after the intervention, this number increased to ( %), although after six moths it decreased to pharmacies ( %). in more than % of the chain pharmacies, the professionals had a positive attitude toward the patients. as an example, an empathic approach has been encountered initially in pharmacies ( %), then in pharmacies ( %) and finally raised up to pharmacies ( %) after months. although the clinical pharmacist's intervention (therapeutic counseling) had positive impact, the extent of minimal counseling at otc or prescription drugs dispensing was found to be low at the first visit, since it increased from to pharmacies ( to %) only, during the study period. the processed data showed a very low level of minimal counseling ( % at the end of surveillance period). by considering the patients benefits (quality of life, better control and management of chronic diseases, reduction of medication costs), the pharmacist interventions are imperatively needed in bucharest chain community pharmacies. background and objective: to compare the level of minimal consultation services in chain community pharmacies located in city center or district of bucharest (capital city) vs. independent pharmacy in a country town (cluj-napoca). design: prospective, months, multicenter study. setting: pharmacies accepted to fill in the study protocols. both shifts were covered, monday to friday (week-end days not included). main outcome measures: the investigation was conducted using a multiple sections protocol. the assessed parameters were: the level of minimal consultation when otc and prescription medications are dispensed and the extent of chronic medication release without a medical prescription. at the end of trial period, the results were centralized on weekly and monthly protocols. the interpretation of the collected data was done using percentile calculations. results: to evaluate the minimal consultation, the percentage of counseled patients from the monthly total was calculated, separately for otc and for prescription drugs dispense. the period of the study (from june to january ) was divided in various slices of consecutive months, when certain pharmacies were compared. the level of otc medication counseling in the five studied pharmacies is different and varies from to % (maximum level reached in the country town pharmacy). the counseling level for medication on prescription varied from to %. by counting separately, the percentage of patients who requested chronic medication without presenting a prescription is as high as up to %. conclusions: the level of counseling, especially for otc drugs (recommended or auto-medication), was generally low in the studied pharmacies and may threat the health state of the patients, due to improper administration. as a third of patients come in pharmacy and request chronic medication without a physician's prescription, this commonly leads to complications which aren't discovered and treated in time. background and objective: the quality of medication use in nursing homes (nhs) is subject to growing concern. focus should not only be on appropriateness of prescribing, but also on correct pharm world sci ( ) : - administration of the medication. the aim of this study was to investigate ) the type and frequency of medication administration errors in nhs, ) their clinical relevance and ) whether a training session by a pharmacist on good medication administration practices can contribute to the prevention of the detected errors. design: the study had a pre-post design. during the first phase (pre), medication administration was observed during days per ward by pharmacists (barker method). phase (intervention) consisted of a general information session on good medication administration principles provided by the pharmacists to the nursing staff. moreover, the observed errors were discussed with the head nurse of each ward. phase (post) took part one month after the intervention and consisted again of a -day observation on each ward. finally, in the last phase (phase ), the clinical relevance of the detected errors was scored by an expert panel (geriatrician and clinical pharmacist). setting: volunteering nhs with different medication distribution systems. in total, medication administration was observed for residents. results: the number of detected errors was considerably lower in nh than in nh . however, the type of errors did not differ. besides the unnecessary or forgotten preparation of medication, most problems occurred during the administration stage. . % of crushed medications indeed were not suitable for crushing. the same applied to . % of the opened capsules. moreover, the crushing hygiene was problematic: all medications for one resident were crushed together and the crushing device was not cleaned between different residents. inhalation techniques were inadequate in almost all cases (insufficient inhalation by the resident, coordination problems or expiration in the device). furthermore, specific administration moments were not taken into account. for example, the administration of alendronate (fosamax Ò ) was observed in a horizontal position after breakfast, while it should be administered minutes prior to breakfast in a vertical position. the nursing staff experienced the training course by the pharmacists as very interesting. . % of the attendants found that the discussed topics were not sufficiently covered during their education. background and objective: the off-label use of intravitreal injection of bevacizumab (iib) for the treatment of macular edema (me) requires the approval of its use by health authorities. pharmacy department (pd) participates in that process, assessing each treatment request and preparing a sterile syringe for intravitreal administration. our aim is to evaluate the short term anatomic and visual acuity (va) response after iib in patients affected of me due to diabetic retinopathy or retinal vein thrombosis. the aim is to give an answer within hours. setting: all three pharmacists are working in the virga jesse hospital, a large peripheral hospital of beds in belgium. main outcome measures: implementation of the clinical helpline in the entire hospital. to make sure clinical pharmacy services are known by every physician and nurse and are easy to contact. results: we made an e-mail address and a schedule, so every day another clinical pharmacist is responsible for answering the questions. to let the physicians and nurses on the ward know we exist, we made flyers with the address and the explanation of the service. on a patient safety congress in the hospital, the clinical pharmacists presented a lecture concerning the advantages of clinical pharmacy services. the main aim is to explore other ways of delivering clinical pharmacy services. in belgium, the hospitals don't have a tradition of clinical pharmacy and there is no governmental support for this pharmaceutical function. with the clinical helpline we try to spread our services without having a clinical pharmacist on every ward. in the pharmacy we prepare the question thoroughly on paper. the clinical pharmacist has computerized access to all necessary medical information and pharmaceutical data. afterwards the pharmacist goes to the ward, to see the patient and to have a discussion with the physician. the physician can decide if he agrees with the given pharmaceutical advice or not. the clinical pharmacist has only an advisory function and doesn't do any therapeutic changes in the prescription. by collaboration of several caregivers, the patient receives a more complete and optimal therapy in our hospital. conclusions: by implementation of a clinical helpline, by an e-mail address, it is possible to spread our clinical pharmacy services over the entire hospital, without having a clinical pharmacist on every ward. the aim is to make an advice and go to the ward to discuss it with the doctor. not only physicians can use this e-mail address, also nurses can ask their questions. in this way we reach every caregiver. % of these pi was followed by modification of the prescription few days later. this study showed that % of the opinions were related to psychotropic drug overdose (often confirmed by psychiatrists after pi), especially neuroleptics, the most prescribed therapeutic class on the establishment. . % of the pi was related to inappropriateness to available guidelines. we note an important proportion of no respect of correct use recommendations of long-acting rispéridone injection: no respect of posological equivalence, patients not stabilized by oral way, insufficient period of co-administration oral/im during the initialization of treatment… . % of pi was guiding to drug management and to clinical and biological monitoring. drug related problems still under estimated without clinical and biological data accessible to pharmacists. however, pi may identify the risks related to therapeutic, to prevent potential problems, to reinforce the clinical and biological monitoring. comparison with a similar retrospectif study in shows that the number of prescriptions was increased ( in vs ), and number of pi doubled. however, nature and type of pi are virtually the same. conclusions: in order to reduce drp of overdose (the most frequent problem), an information strategy targeted to psychiatrists was developed and a updated list of maximal psychotrops posology was diffused and put on line. our study doesn't include problem of second -generation atypical antipsychotics association, this association still increasing despite fewer evidence and lucid guidelines; a second study will be soon conducted to identify pi having a significant clinical impact. conclusions: this study showed that clinical practices don't change even after reminding guidelines. information by fact sheet is not the best tool to spread guidelines. study's results will be submitted to an interactive presentation in medical staff, and clinical trials with iva are discussed and changed with acetaminophen oral route. the proportion of gp's that received, reviewed and returned the patient selection to the pharmacist, and the proportion of long-term users that received the informative letter. results: substantially more pharmacists in the intervention ( %) than in the control group ( %) handed over the patient selection to their gp's. % resp. % of the gp's received (n.s.), and % resp. % of the gp's reviewed and returned the list (n.s.). substantially more pharmacies in the intervention group got back any lists ( % vs %) and sent any letters ( % vs %). % and % of all longterm users received the informative letter in the intervention resp. control groep (n.s.). conclusions: the maximal implementation strategy was effective in getting the pharmacists started. the main outcome measures were not significantly different in both groups, though the realized effect on a large scale was relevant in practice. of the participants, total of . % has heard of the term 'pharmacovigilance' in the period- , which is entirely the academicians, while it is increased to . % in the period- (chi-square test with yates correction, p \ . ), which are mainly expressed by the hospital ( . %) and academician ( . %) pharmacists. during the period- , only % of the participants know where to report any adrs ( . % academicians and . % hospital pharmacists), whereas during the period- , this figure is increased to % ( . % academicians, % hospital and . % community pharmacists) (p [ . ). the participants preferred to report any adrs mainly by the internet ( . % vs %) and by the telephone ( % vs . %) at the period- and the period- , respectively (p [ . ). in terms of having reported any adrs among the participants, it is indicated that none of the pharmacists reported adrs at the period- , but only three hospital pharmacists reported an adr at the period- . conclusions: by the national regulations for pharmacovigilance, the pharmacists are entitled to report any adrs to the turkish pharmacovigilance centre. although this study is limited by the small number of pharmacists and location, it shows that there is an increased awareness and knowledge about pharmacovigilance. by the provision of pharmaceutical care, pharmacists' involvement in detecting and reporting adrs will improve, mainly in hospital and in community settings. background and objective: in france, global drug dispensing (gdd) is the common way to dispense drug inpatient. after an experience of implementation of individual drug dispensing (idd) the objective of the department of pharmacy was to prove the benefit offered by this system in comparing the clinical impact of the intercepted dispensing errors of both dispensing system. design: thirty days prospective study. setting: orthopaedic surgical care unit; department of pharmacy. main outcome measures: data related to drug preparation were collected by two pharm d students over a days period and analysed. identified preparation errors were classified in four groups: discordance between prescription and drug administration, exceeding or missing treatment and, unidentified delivered drugs. then errors were classified in potential or effective errors. at last, pharmacist and prescriber have quote this errors. preparation errors were classified according to their clinical impact from (no clinical impact) to (life threatening). results: drugs units were prepared with gdd vs with idd. eighty effectives errors ( . %) were observed with gdd and ( . %) with idd. clinical impact were ( %), ( %), ( %) for gdd and ( %), ( %) and ( %) for idd. a khi test highlight a difference between the dispensing system for clinical impact and (p \ . ). moreover, the mean value of weighting was about . with gdd vs . with idd (p \ . ). conclusions: this study shows the major benefit offered by idd versus gdd. errors weighting represent a relevant parameter for physicians. the results provided by this study highlight the role of the pharmacy staff, to reduce the incidence of medication errors and to promote a rational use of medicines. this work was the second step of our quality medication process; the next step will be the development of idd in several care unit by use and test automated process for preparing doses. for each prescription we collected information about the patient, the prescribed drug, the steps involved in its preparation and its administration. results: we collected prescriptions ( different drugs) concerning children (average age: years). sixty-two percent of medications were oral forms: % liquids, % tablets, % capsules. thirty-two percent of the tablets were cut; only % of those were authorized. due to the age, % of the tablets were crushed to facilitate administration whereas grinding was allowed in only % of the cases. most of the capsules were opened ( %) and % fractionated for an adapted dose. opening of capsules was possible in % of the cases. intravenous drugs represented %, the average injection was . % of the vial; in %, less than a quarter was given. conclusions: about % of pediatric preparations were inappropriate. the results of this study highlight the need to provide drugs adapted to pediatric care, which is one of the main tasks of the pharmacy. we are thus developing more appropriate pharmaceutical formulations for children, such as oral suspensions. a comparative statement of solubilization rates in liquid of crushed tablets or capsules after opening has to be established. moreover if a pharmacist is present in the care units, most medication error will be avoided. background and objective: the world's population is aging. the elderly have many chronic disorders and consequently use more drugs than any other age group. safe, effective pharmacotherapy is one of the results: fifty patients received antibiotics according to several schemes. nineteen patients received prophylactic treatments during . days on average. the employed molecules were mostly part of beta-lactams' family ( . %) including . % of co-amoxiclav. the prophylactic treatment seemed to be effective in . % of case because it wasn't followed by other treatment. thirty-one patients received probabilistic treatment: . % of them received quadruple therapies, . % received triple therapies, . % bitherapies, and . % monotherapies (only beta-lactams). the average duration of the probabilistic treatment was days. twenty-three patients got curative treatment. compared with the probabilistic treatment or with the treatment at the entry, the curative treatment corresponded to a reduction of the spectrum in % of cases with mainly an arrest of the vancomycin ( %). monotherapy was the most prescribed ( . %) and especially beta-lactams ( . %). then came bitherapies ( . %) and triple therapies ( . %). the most frequent isolated germs were escherichia coli ( cases), staphylococcus aureus ( cases), pseudomonas aeruginosa ( cases) and pneumococcus sp. ( cases) alone or associated, including . % of multiple-drugsresistant bacterias. the monitoring of aminosids and vancomycin was globally well carried out. only . % of vancomycin's dosages and . % of aminosides' dosages were not done. thirty-two patients increased their transaminases and/or their creatininemy. these increases were often physiopathological, related to multiviscérales failures or to septic shocks. the antibiotics could be clearly blamed in only one case. conclusions: in the surgical intensive care unit, antibioprophylaxy is longer than in recommendations. the probabilistic treatments used often associate active molecules on multiple-drugs-resistant bacterias. this can be explained by the gravity of infections, and the increased risk of bacteriologic resistances due to former treatments. moreover, bacteriological tests are systematically done, so antibiotics can quickly be adapt to the germs' resistances. background and objective: most of proton pump inhibitors (ppis) do not have legal mention for a paediatric use. however these drugs are largely prescribed to children. one disadvantage resides in the absence of liquid form which causes problems for their administration in nasogastric tubes. indeed, the absence of use recommendations involves many misuses responsible for inefficiency and/or tube obstruction. we tried to evaluate if ppis can be administered through paediatric nasogastric tubes. design: to quantify the transit of different ppis through paediatric nasogastric tubes and to optimise their modes of administration. setting: laboratory of clinical pharmacy and biotechnics. faculty of pharmacy. main outcome measures: we administered four ppis (mopral Ò , ogast Ò , inexium Ò , ogastoro Ò ) through nasogastric tubes by respecting their positioning in a child in a °elevation. for each ppi a study plan was drawn up to assess the influence of different variables: the volume of water to dissolve or put in suspension the ppis ( or ml), the rinse volume ( . or ml), the length ( or cm) and the diameter ( or french) of the polyurethane tubes. for every tests (n = ) we carried out an analysis of each active ingredient at the tube outlet by uv spectrometry. results: all f tubes were obstructed by ppis. through f tubes, we observed a mean recovery of active ingredient of % for ogastoro Ò , . % for inexium Ò but only . % for ogast Ò and . % for mopral Ò . the length of the tubes had no significant influence on the loss of ppi at the outlet of the tube. a water volume of ml instead of ml increased only the final concentration of inexium Ò (+ %). a rinse volume of ml improved significantly the transit of mopral Ò , ogast Ò and ogastoro Ò (+ . %, + . %, + . % respectively). this rinse volume allowed to obtain a . % recovery of lanzoprazole for ogastoro Ò whatever the water volume employed for its administration. conclusions: the most satisfactory results were obtained with ogastoro Ò : an administration volume of ml and a rinse volume of ml allowed a near-complete transit of lanzoprazole. under these conditions only % of inexium Ò was recovered. it is disadvised using mopral Ò and ogast Ò through f nasogastric tubes because no condition ensure the transit of an efficient concentration of active ingredient. keywords: nasogastric tubes, proton pump inhibitors, children background and objective: feeding tube occlusion is a frequent problem. practices to make the clogging off are very varied and are not the subject of any consensus. no study have assessed the impact of the different products on the inner surface of the tubes. in this context, it seams to be important to evaluate if these products are safe in order to rationalize the practices. design: to study the inner surface of nasogastric feeding tubes after contact with various products used to unblock them. setting: laboratory of clinical pharmacy and biotechnics. faculty of pharmacy. main outcome measures: we have put in contact f nasogastric tubes made of silicone or polyurethane with the following products: water, . % sodium bicarbonate, orange juice, pineapple juice, cola, papain syrup, pancreatic enzymes. an analysis of the inner surface of the tubes was carried out after , and days by scanning electron microscopy (sem). photos of unexposed tubes were used as negative controls. photos of tubes exposed to heat, ether or sodium hydroxide were used as positive controls. results: the analysis by sem shows that the silicone tubes are not altered by the different products tested. on the other hand, the surface of polyurethane tubes is modified in the presence of . % sodium bicarbonate and pancreatic enzymes. the papain syrup seems to settle on the surface of the tubes without altering it. water, fruit juices and cola do not modify the biomaterial whatever the exposure time. conclusions: . % sodium bicarbonate, pancreatic enzymes and even papain syrup should not be used in practice to unblock the feeding tubes. the orange and pineapple juices as well as cola can be recommended because of their harmlessness with biomaterials. keywords: nasogastric feeding tubes, occlusion, scanning electron microscopy pc- assessment of administration practices of extemporaneous formulation pediatric capsule preparations helene richard , anne jalabert , sylvie hansel-esteller pharmacy unit, lapeyronie and arnaud de villeuneuve hospitals, montpellier, france background and objective: to assess administration practices of pediatric capsules made as an extemporaneous formulation preparation by the laboratory of the pharmacy unit, in pediatric units. design: a questionnaire was designed and filled in by asking questions directly to nurses about their administration practices, from february to april . setting: altogether, six pediatric units were consulted, corresponding to the units for which the laboratory carries out the most pediatric extemporaneous formulation preparations. main outcome measures: the questionnaire concerned the ten most made up pediatric preparations, which are: amiodarone, warfarine, captopril, propranolol, ursodesoxycholic acid, omeprazole, fludrocortisone, spironolactone, hydrocortisone and calcium carbonate. items filled in were: hygiene rules, the existence of administration procedures in units, preparation conservation, and practical administration details. results: in months, questionnaires were filled in. concerning hygiene rules, nurses wash their hands before every manipulation, % wear gloves, % wear a mask or a mobcap. no administration procedures were available in units and more than % of nurses would like to have one. in every unit, preparations were conserved at room temperature, in a dry place, and % in a light-free place. for amiodarone, propranolol, fludrocortisone, spironolactone and hydrocortisone capsules, nurses use sweetened water (g %) to dilute capsule contents, sometimes milk (especially in newborns units). for the other drugs, the vehicules the most used were: sweetened water ( %), solid vehicules like yogurt, apple sauce, jam ( %), fruit juice or syrup ( %), milk ( %), and coca-cola ( %). the vehicule volume used fluctuates between ml and cl. nurses administer capsules by syringue into the mouth ( %), per os ( %), or by enteral nutrition ( %). conclusions: most of the administration practices of pediatric preparations are homogeneous in the different units (except the vehicule volume used). in the absence of administration procedures, the administration of preparations is more adapted to the child than to the drug. the aim of this study is to provide pediatric units with guidelines about good use of extemporaneous formulation pediatric preparations. services compared to a pharmaceutical care model. items pertaining to pharmacists' communication with the patient and the physician as well as the pharmacists potential to manage drug therapy were assessed. results: of the patients approached, ( %) response rate was achieved. cronbach's alpha = . (expectations) and . (satisfaction). females were ( %), married ( %) and % had post-secondary education. some % expect accurate dispensing of their medications, % expect pharmacists to simplify their medications and % expect the pharmacist to spend as much time as possible with them. expectations were resolved into components: humaneness, friendly attitude and professional competence. only % were satisfied with the professional appearance of the pharmacy, the rest of the items received dissatisfaction rating. two principal components of satisfaction were identified as humaneness and professional competence. marital status and level of education were associated with satisfaction scores. conclusions: patients' expectations of pharmaceutical care services were high but the satisfaction with current services compared to pharmaceutical care was below average. professional competence and humaneness were important dimensions of both patient expectations and satisfaction. there is a need to introduce pharmaceutical care. results: fourteen criteria were defined. a yes, no or not applicable answer has been given to each criterion according to the guidelines. drawing lots have been realised to set up a representative sample of twenty patients among those included in the study: six males, fourteen females, average age: . years old. two patients are below the average. the average mark of the patients is . %. hemoglobin level of % patients is inferior to the targeted hemoglobin level ( g/dl) at the end of the study. six criteria obtain a score superior or equal to %. five criteria obtain a score under %. the three criteria which obtain the best results concern the monitoring of the hemoglobin levels during correction phase and maintenance phase, and the maximum weekly dose of erythropoetin. the three criteria which obtain the lowest results concern the assessment of iron status before erythropoetin therapy starts ( %), the rate of increase in hemoglobin levels which should be - g/dl per month ( %) and the adjustment of total weekly erythropoetin dose. conclusions: the average grade obtained by the patients highlights the deviation from the guidelines. this indicates the needs of improving the anemia management in our haemodialysis unit. so it is necessary to make another time the team of doctors and nurses aware of the problem and to reinforce the pharmaceutic implication into the haemodialysis unit. a re-evaluation of practices (in the guise of clinical audit) must be planned in order to estimate the impact of the setting up of correctional measures. inclusion criteria were: oral and injectable drugs' prescriptions concerning patients who were present in the ward since more than hours. results: medical records were analyzed. patient age varied from to years old and the average duration of the hospitalisation from . to days. omitted variables were: patient's weight in all cases, prescriber's quality in % of cases, prescription's hour in % and prescriber's signature in . %. for each patient, all drugs prescribed since the beginning of the hospitalization in the unit was studied i.e. lines of drugs. we have noted the inn was absent in % of the cases, pharmaceutical form in % and administration route in %. only one prescription had all variables. thus, the global rate of prescription conformity was %. in the wards, nurses write the original prescriptions on a card-index (ci). then, drugs administrations are written on a temperature chart (tc) and on pharmacy's book (pb) for drugs order. we have compared documents one by one, for each drug. conformity rates are . % (prescription/ci), . % (ci/ tc) and % (ci/pb). the noted differences are multiple(modification of the administration or hour route, increase or dicrease of dosage…). the clinical relevance of non conformity was not studied. conclusions: from this study, it can be concluded that many prescriptions do not comply to the regulation and many retranscriptions are not identical to original prescriptions. it constitutes of course a potential iatrogenic impact. the development of computerized physician order entry (cpoe) in our hospital should be a corrective measure. the next stage will consist of realizing this study with cpoe and compared the studies. anne-claire buire , emilie prevost , françois lebargy , bertrand gourdier pharmacy, pneumology, reims teaching hospital, reims, france background and objective: assessment of antibacterial prescriptions regarding community-acquired lower respiratory tract infections and comparison with national guidelines. design: patients treated with antibiotics were included each day, during the analysis of the computerized prescriptions in the pharmacy. then, a report sheet was indicated in the unit with the prescribers for each patients with pneumonia or exacerbation of chronic obstructive lung disease. one month prospective study (in april ) included all patients hospitalised for pneumonia or exacerbation of chronic obstructive pulmonary disease (ecopd) in a unit of the pneumology department and treated with antibiotics. setting: pneumology department -reims university hospital. main outcome measures: for each patient the following data were assessed: age, hospitalization duration, diagnosis, severity factors, comorbidities and antibiotic prescriptions were analyzed. treatments were thought consistent when following the national guidelines [ ; ] . results: new patients were hospitalized during this month. ( %) were treated with antibiotics: with no pulmonary pathology and with pulmonary infection ( patients with pneumonia, with ecopd, with pleurisy, with exacerbation of asthma, with chest secondary infection, with acute respiratory infection, with thoracic pain and with cough). then, the study focused on patients: pneumonia and ecopd (m/f = / , mean age: years old). hospitalization duration was about days. patients ( %) had at least one co-morbidities factor (the majority: with pulmonary antecedents) and ( %) a severity factor (the majority: with an attack of the vital functions). antibiotic treatments were initiated in the unit and out ( in emergency department and by general practitioner). all treatments initiated in the unit were consistent with the recommendations and revaluated with the bacterial results (except one treatment) or changed because of bad tolerability. bacteriological documentation was always researched and the results were significant for patients ( %): streptococcus pneumoniae, pseudomonas aeruginosa, proteus mirabilis with morganella morganii and haemophilus influenzae. when it was possible, per os relay was realized in the at hours, except for patients (relay in the days). conclusions: in this survey, the management of pneumonia and ecopd was globally consistent with the national guidelines. nevertheless, the bacterial documentation is poor and the antibiotics prescriptions for bronchopulmonary infections are difficult and need using molecules with large spectrum. collaborate with all of the health care professionals and patients and to identify causes of errors. the unique position and possibilities of a pharmacist enable him to follow up the errors, from a fact that he is an expert on medication properties and is basically the last in a row who deals with drugs before their administration to the patients. the aim of this study was to describe and evaluate the role of pharmacist in identification and dealing with medication errors in czech pharmacy. design: pharmacists identified and recorded all medication errors over a period of six months of pharmaceutical care. basic characteristic of pharmacists: mean age . years; mean length of pharmaceutical practice . years; of them worked in the hospital pharmacy. of them got the first grade of attestation in pharmacy (by years of working experience in pharmacy and by passing exams). pharmacists collected the following data: types and causes or errors, their interventions, drugs and time concerning errors, subjects making errors and patient's characteristics as age, gender, other drugs used and co-morbidities. all the data were processed by descriptive statistics. background and objective: there is no standard of care to prevent oral mucositis for patients with cancer treated by chemotherapy. most common treatment is local (mouthwashes). no commercial mouthwash solution is available. special preparations are compounded by clinical units. a new . % sodium bicarbonate solution presentation was recently proposed for local treatment. our hospital drug committee decided to evaluate the clinical practices of oral mucositis prevention related to anti-neoplasic agents. design: an observational study conducted in pitié-salpétrière hospital. interview of nurses and physicians by pharmacy students about mouthwashes prescription and practice. data recorded on pre-established questionnaire and analyzed in pharmacy department using microsoft excel Ò . setting: study performed in oncology, hematology and radiotherapy clinical departments and in clinical units with oncologic activity (gastroenterology…). during one year, more than patients received anticancer chemotherapy. main outcome measures: questionnaire items were: use of a specific mouthwash procedure within the service, use of a single agent or in combination. data collected from the nurse point of view were: preparation and administration practices; from the physicians' perspective: circumstances of prescription and duration of the treatment. results: questionnaires were analyzed (nurses: , physicians: ) from clinical units. there was a standard written procedure in only one clinical unit. several formulations were used: each physician proposed his own, including antifungal prophylaxis (amphotericin b, nystatin), antimicrobial agents (povidone, chlorhexidine), mucosal surface protectant (sucralfate), alkalin solution (sodium bicarbonate), anti-inflammatory agent (aspirin), anaesthetic drugs (lidocaïn) and other agent (glycothymoline). preparations were not systematically labelled with patients name, formulation, date of preparation and stability duration. these were administered from to times daily regardless the stability compounding. for physicians, prescriptions of mouthwashes were done for patients with specific toxic anticancer drugs ( -fu, anthracyclin, capecitabin and sunitinib), were concomitant with chemotherapy and systematic after radiotherapy. conclusions: there are variations among clinical units in terms of mouth care regimen used. treatment efficacy was never evaluated. drug committee worked on guidelines in order to prescribe antifungal therapy only for curative aim or avoid anaesthetic drugs (swallowing difficulties). good practices included, before chemotherapy, dental hygiene. maintenance is realized by the patient himself (mouthrinses with alkalin solution or chlorhexidine). analgesics can be taken orally in case of mouth pain. design: the open, randomized, single-blind two-sequence, two-period crossover study design was performed. setting: under fasting conditions, each subject received a single oral dose of mg olanzapine tablet as a test or reference formulation on treatment days. the treatment periods were separated by a oneweek washout period. main outcome measures: the plasma concentrations of drug were analyzed by a rapid and sensitive hplc method with uv detection. results: the pharmacokinetic parameters included auc - h, auc -infinity, cmax, t / , and ke. the mean auc -infinity of olanzapine was . and . ng h/ml for the test and reference formulation, respectively. the maximum plasma concentration (cmax) of olanzapine was on average . ng/ml for the test and . ng/ml for the reference product. no statistical differences were observed for cmax and the area under the plasma concentration-time curve for test and reference tablets. % confidence limits calculated for cmax and auc -infinity of cefixime were included in the bioequivalence range ( . - . %). conclusions: therefore, the two tablet formulations were considered to be bioequivalent. conclusions: clinical pharmacists effectively validate % of these prescriptions but one third of prescriptions will inevitably remain validated by pharmacist residents during night and week-ends. performance criteria must be proposed to measure impact of pharmaceutical improvement initiatives (validation procedures writing, continuous education for example). we suggest to test clinical pharmacy activities related to economic indicators and to medication events reduction. background and objective: education of patients with type diabetes is a key point of non-medical management of that disease. thus objective was evaluation of patients' knowledge about their disease and its management for further development of pharmaceutical care protocols. design: prospective cohort control study. total patients casually were divided in two equivalent groups: study group (n = ), age . ± . , diabetes duration . ± . who were questioned by face-to-face technique and received pharmaceutical care during the interview; control group (n = ), age . ± . , diabetes duration . ± . and filled in questionnaires without clinical pharmacist. inclusive criteria were: presence of type diabetes mellitus, duration of the disease was not considered as criteria. patients were inquired once following standardized questionnaire. all included patients could read and write. two groups controlled their diabetes mostly by oral antidiabetics, only n = in study group and n = in control used insulin. setting: out-patient setting of lviv clinical hospital no , endocrinologist's office. main outcome measures: assessment of patients' knowledge about diabetes and self-monitoring in study and control groups. results: only . % and . % of inquired patients in both groups respectively stated that they possess good knowledge about diabetes. but as it was shown by evaluation of their level of knowledge through assessment of keeping to diet, regular physical activity, self monitoring it didn't conform completely. diet was implemented by almost % of patients in two groups, while regular physical activity was declared only by . % in study and % in control groups. smoking was reported by . % and . % respectively. next step was evaluation of self-monitoring. it has been revealed that only . % and . % of patients in two groups performed blood glucose monitoring at home; body weight was controlled by . % and . % respectively; blood pressure by . % and . % as well. target level of blood pressure was achieved by . % of subjects in study group and in . % -in control. in study group foot examination was performed everyday by . % of patients when in control only by . %. no one from both groups evaluated glycated haemoglobin regularly as it is recommended by american diabetes association, those they couldn't state their present or previous parameter. conclusions: it was estimated that knowledge about necessity of diet following, regular physical activity, and particularly -self-monitoring was very poor in diabetic patients, no regarding compliance which possibly also will be low. even if patients stated good knowledge about the disease they had problems with self-monitoring. it is obvious that patients of this out-patient setting require adequate education, which should be a component of pharmaceutical care program implemented by the clinical pharmacist. protocols of pharmaceutical care for these patients must be developed and include standard procedure of type diabetes patients' education. pharmacy department, hospital universitari vall d'hebron, pharmacy department, pharmacy department, hospital universitari vall hebron, barcelona, spain background and objective: patients who are admitted for a programmed orthopedic surgery in a tertiary hospital are usually elderly and present high co-morbidity which makes therapy complexity increase. the objective is to evaluate whether a pharmaceutical care is necessary before patients hospital admission. design: we analysed the domiciliary treatment in patients who attended to a pre-surgery visit. a form designed by the pharmacy department and validated by anaesthesiology unit was delivered to the patient to fill in with domiciliary therapy. the average of prescribed drugs was . per patient, being this reduced to . drugs in patients younger than and increased to . in patients older than . over one third of patients ( / ) were taken orally nonsteroidal anti-inflammatory drugs (nsaids). from ai, would need a pharmacological evaluation in the preoperative. those were included in drugs, meaning the . % of the different drugs prescriptions. this percentage belonged to patients. conclusions: the fact that a high percentage of patients over with an orthopedic pathology take a considerable amount of drugs at home makes it necessary to monitories the therapy in order to minimise the iatrogenic problems during the admission. we have seen that this situation is so frequently ( %) in our study, so the pharmacy department has established a collaborative job with anaesthesiologist unit to reduce as much as possible therapy problems. levation. through each tube, a ml nutritive solution was delivered on h each day during one week. after dissolution in ml water the ppis were administered once a day after stopping of the enteral nutrition and rinsing of the tube with ml of water. the tubes were then rinsed with ml of water and the nutrition was started again. during each administration of ppi the suspension was collected at the tube exit in order to quantify the ppi by uv-spectrometry. results: no tube was obstructed. the enteral nutrition mixture did not adversely affect the transit of lansoprazole through f nasogastric tubes. the transit of lansoprazole through the tube was complete and regular during the days of the study ( . ± . ). for esomeprazole the mean recovery of active ingredient was of . ± . (coefficient of variation: %) this variability can be explained by the incomplete and inconstant dissolution of esomeprazole because of the low volume of water usable in paediatry. conclusions: orally disintegrating tablet of lansoprazole can be administered through f nasogastric tubes in a concomitant way to an enteral nutrition mixture. for esomeprazole there is a variability of the administered active ingredient. however enteral nutrition doesn't seem to affect the esomeprazole transit. low volumes of water used in paediatry seem to be responsible for the variability. results: we analyzed pharmacological treatment in patients, with a mean age of years old ( - ). the average of drugs per patients was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . after checking the sources we detected possible pi ( severe, moderate and slight), observed times. pi were detected in of patients and mean per patient was . ( - ) . the following pi were described: increase of sedation ( patients), risk of bleeding ( patients), serum potassium levels alteration ( patients), hypotension ( patients), risk of hepatotoxicity ( patients), increase of creatin kinase levels and risk of myopathy ( patients). from all these, only two were observed: sedation which was observed in all patients and hypotension which permitted the reduction of patient antihypertensive treatment. conclusions: the most frequent pi was sedation which is considered beneficial in order to reduce anxiety in sci patients. arterial tension, electrolytic balance, hepatic and renal function, as well as risk of bleeding, are regularly controlled in the sci unit. this way, if one of these parameters was altered it would be easily detected. to conclude, it would be important to carry out regular checking to detect pi, especially for those drugs that are not usual and for those symptoms that are not controlled regularly in the sci unit. background and objective: pharmacists' individualized counselling of patients has positive impacts on the management of hyperlipidaemia, including improved compliance and better treatment endpoints. the objective was to evaluate patient knowledge on hypercholesterolemia and its treatment and to assess impact of pharmacist intervention at the lipid clinic. design: one hundred and fifty statin-treated patients were recruited by convenience sampling. following completion of a scored pre-intervention questionnaire, the pharmacist provided education on hypercholesterolaemia and the use of statins. a leaflet was prepared, evaluated and distributed to the patients. the patients completed again the same questionnaire after the intervention (post-intervention). results: patient demographics: % ( ) were males, % ( ) were females, mean age was years (range - years). a response rate of % was achieved with patients completing both questionnaires. following the educational intervention by the pharmacist, knowledge regarding the correct action to be taken if muscle pain or tenderness occur during statin therapy increased by % (p = ). the awareness regarding the normal total blood cholesterol level increased by % (p = . ) and the knowledge regarding the need for low-fat diet consumption during statin therapy increased by % (p = ). face and content validity of the patients' leaflet were strong. the average gunning fog index obtained for the leaflet was . indicating good readability for individuals. the leaflet was endorsed by the local health promotion department and copies were printed and distributed to patients. background and objective: in order to assess the performance of bayesian individualization of busulfan (bu) dosage regimens, venoocclusive disease (vod) rate was monitored for paediatric patients undergoing allogeneic bone marrow transplantation (bmt). design: consecutive patients undergoing allogeneic bmt with bu as conditioning regimen during five years period (january to febuary ) were retrospectively reviewed ( patients). setting: vod was major outcome variable. preconditioning risk of vod was estimated for each patient using a scoring system that included type of transplant, recipient cmv-positive status and total parenteral nutrition provided pretransplantation. a risk-adjusted cumulative sum method was used to compare observed versus predicted outcome by assigning a risk score, based on log-likelihood ratios, to each patient. main outcome measures: the cumulative scores were sequentially plotted with preset control limits for ''signalling'' where results were substantially different than expected (doubling or halving of odds ratio). results: sixty-six children received bmt after oral busulfan-based conditioning regimen with median age . years, . % of male. median preconditioning risk of vod was . range ( . - . ). observed vod rate was . % (n = ) which was . % ( patients) fewer than the expected number estimated by the risk score. the resulting risk-adjusted score for each patient was plotted sequentially. this plot adopted early a negative slope, crossing the lower control limit twice, after and patients, indicating improved results compared to those expected. background and objective: geriatric patients use numerous drugs; because they have several concurrent diseases. % of those years old and over have at least one chronic disease, % have or more chronic diseases ( ) . the purpose of this study is to evaluate data on the geriatrics' drug usage, assess the appropriateness of their drug treatment and identify their pharmaceutical care requirements. design: patients, who were years old and over and live in a nursing home in the anatolian part of istanbul, were included in our study. by interviewing the patients, individualized information was obtained regarding the drugs they used, dose and frequency of drugs, the purposes of medication use and side effects, and who suggested or prescribed the drug. the patients at risk of drug induced problems were defined and a risk map was developed. patients who have or more risk factors were accepted as being in a high risk category. setting: a nursing home. main outcome measures: the demographic, clinical and drug data of the patients were recorded. the pills count that patients used daily and totally; side effects of the drugs; knowledge of patient's diseases and drugs; risk category of patients were assessed. results: polypharmacy was identified in % of those included in the study (total of patients who take drug therapy). generally it was observed that the drugs were prescribed at an appropriate dosage and time; however % of the patients didn't know for what they were taking drugs. just ( . %) of the patients were aware of the conditions under which they should take drugs. of the patients ( . %) were not aware on how to and when they should receive their drugs. patients ( . %) were using their drugs by self-administration. the drugs of patients ( . %) were administered by their nurse. . % of the patients were receiving no medication. mean of number of drug used by patients was . ± . . . % of patients were in a high risk category. conclusions: as a result, drug effects alter due to polypharmacy, physiological and psychological changes. drug treatment should be individualized and monitored in geriatrics. according to our results, patients have lack of knowledge on drug use and they have never been educated in this matter. it is necessary to begin meeting their factor analytical technique can be either exploratory or confirmatory. exploratory factor analysis (efa) remains one of the standard and most widely used methods to demonstrate construct validity of new instruments. it is used to help development of the instrument by revealing items that may be made redundant from the questionnaire because they contribute little to the presumed construct. the seip consists of items in five domains and is scored on a four-to-fivepoint likert scale. the aim of the study was to assess further psychometric property of the seip using principal component factor analysis (pca). the strength of the inter-correlations among the items will be assessed by the presence of coefficients greater than . in the correlation matrix. if few correlations above this level are found, then factor analysis may not be appropriate. issues were identified including related to inr controls not performed and due to a poor/no adjustement of the oat dosage. % of the issues resolved following the pharmacist recommandations conclusions: computerized follow-up system allows to check inrs at the right date and to reduce the loss of results. pharmacists' recommendations were well accepted by physicians. the impact of the follow-up on the reduction of the overdose incidence will have to be evaluated. indications were hip (n = ) and knee (n = ) total replacement, other orthopaedic surgery of lower limbs (n = ) and pulmonary embolism treatment (n = ). indications were ''off label'' for patients with allergic reaction to heparine and were not documented. at least one of the haemorrhagic risks factors was identified in patients ( %). conclusions: fondaparinux is mainly used in approved indications. within the patients with haemorrhagic risks factors, no haemorrhagic accident was notified in the pharmacovigilance records of our hospital. nevertheless, fondaparinux has to be administred cautiously in this population of patients for whom the . mg dose will be necessary and hopefully available in a few month. diagnose group a streptococcal (gas) acute pharyngitis. this study aimed to evaluate the service; examine whether current clinical records were adequate; and test hypotheses investigating the association between clinical prediction rules (center criteria, cc), rapid antigen detection tests (radt) and antibiotic prescription. design: initially, a semi-structured interview was conducted to gain an insight into the service. data was retrospectively obtained from a standardised template (apef), completed by a pharmacist at the time of each patient visit. patient demographics and symptoms, radt results, cc scores and follow up rates were analysed. chi squared analyses were performed to investigate the aforementioned hypotheses. setting: jones pharmacy, spokane, washington dc. main outcome measures: establishing adequacy and effectiveness of clinical records and relationships between clinical prediction rules, radt and the antibiotic prescription. results: out of a total of patients (mean age = ; male = ) there were children (mean age = . ; male ) and adults (mean age = ; male = ). ten ( . %) of the negative radt results amongst children were referred to a primary healthcare provider. out of patients, ( . %) needed a radt to be performed. only ( . %) out of patients were followed up. significant association existed between radt outcomes and the prescription of antibiotics (p = . , p \ . ). conclusions: the findings from this study indicate that pharmacists need to be educated on the importance of a comprehensive clinical record. inconsistent practices occur amongst pharmacists due to the conflict between us guidelines, particularly relating to the referral of children with negative radt results to a primary care provider. the template was an efficient tool for data collection. jones did not tailor their data collection for the purpose of the study: with improved data collection, jones can yield information demonstrating the value of this service in future studies. only % of the rhophylac prescriptions. lg of anti d ig were administered when natead was available, whereas lg with rhophylac excepted times where , or lg were administered. times the pharmacist has induced a modification of the posology. however, none prescription was made according to the afssaps recommendations. prescriptions were made for children in hematology unit concerning boys and girls. among prescriptions of lg natead, % were correct and % for the rhophylac. the dose administered was not standard ( , or lg) and none prescription was conformed to the recommendations. conclusions: this study shows that since rhophylac was commercialized (more expensive than natead), the doses administered have doubled and the national recommendations (existent for adults only) are not followed. the reason is that hematologic patients may have a lot of transfusions so they want to protect them from any immunization, despite they are immunocompromised patients. new recommendations are needed, more applied to the practice and precising doses for children. the role of the pharmacist is then to remind physicians good practices of prescription. pharmacy, chu bicêtre, le kremlin bicêtre, france background and objective: computerized prescriptions are settled in clinical wards of our hospital. as pharmacist we have to validate those prescriptions and make recommendations to change part of the prescription such as dose, drug drug interactions. the objective of this study is to evaluate what kind of pharmaceutical interventions physicians really pay attention to. design: the prescriptions had been analysed for three months in three medical care units by two pharmacists. one of them take part in the physician round in order to integrate particular medical practices. pharmacist's interventions were recorded and categorized. the ratio of accepted interventions by the physicians was assessed. setting: three medical care units: internal medicine services (acute care unit: beds and long term hospitalisation: beds) and acute geriatric unit ( beds) in a -bed french university hospital. main outcome measures: description and analysis of pharmacist's interventions in clinical wards. results: we analysed prescriptions. interventions were performed and categorized. it should be noticed that % of pharmaceutical interventions were for misused of the new software: wrong selection of unit ( %) and redundant order ( %). the other % interventions were related to the prescription, our suggestions were as follow: time of administration ( %), adequate drug formulation ( %), dose adjustment ( %), therapeutic drug monitoring or biologic follow up ( %), to stop treatment ( %), route of administration ( %). among these recommendations, % were the consequence of drug-drug interaction. % of the interventions led to change in the prescription. % of the physicians maintained their prescription despite the recommendations, mainly for staggered administration to avoid drug interaction. background and objective: sliding scale insulin therapy (ssi) is a commonly used method of adjusting insulin in an attempt to control a patient's blood glucose levels. previous research investigating ssi use in the hospital setting has determined that ssi therapy leads to poor glycaemic control and poor patient outcomes. therefore, a corrective schedule for ssi therapy is recommended by the american diabetes association (ada). the aims of this study were therefore to determine, for the first time whether ssi recipients experience problems in the home care setting and whether ada guidelines on ssi use are being adhered to. design: eligible patients were identified through electronic records of patients admitted from st january to st december . the list was utilised to obtain medical charts of the patients. relevant information including patient demographics, blood glucose readings and documented problems were recorded using a standardised data collection form. chi-squared statistical analysis was determined using spss version . . setting: the visiting nurses association (vna) home care agency, spokane, washington state, usa. main outcome measures: use of 'traditional ssi therapy' versus 'corrective' version recommended by ada. results: of the total (male = , female = ; mean age = . , age range = - ) patient medical records examined in this study, . % (n = ) had at least one problem documented with their insulin regimen. the most common problem that affected over a quarter of the population, . % (n = ) was 'lack of control' which included any hyper-and hypoglycemic events. more than a third of sliding scale recipients, . % (n = ) had preprandial blood glucose levels above mg/dl. in total . % (n = ) of patients were prescribed the non-recommended traditional ssi therapy and only . % (n = ) were using the recommended corrective ssi therapy. conclusions: the findings of this study support previous concerns that ssi use is prone to problems and poor glycaemic control. furthermore, this study has established the lack of adherence to the ada recommended use of the corrective ssi schedule in the home care setting. it is hoped that this study will influence use of ssi in hospital and home care agencies as well as national and international guidelines. background and objective: prolonged (more than hours) mechanical ventilation (mv) is the most important factor associated with nosocomial pneumonia ( ) . nosocomial pneumonia (np) is differentiated in to ventilator-associated pneumonia (vap) if the process arose after the patient has been receiving at least h of mv ( ) . vap is defined as an inflamation of the lung parenchima caused by infectious agents not present or incubating at time mv was started ( ). design: longitudinal, prospective and observational study. setting: we made a prospective evaluation of the clinical files of a patient population of cases with vap diagnosed between april and december , who were assisted in hospital garcia de orta. a total of patients, % male and % female, aged ± years were diagnosed with vap. vap was defined as new positive respiratory culture after at least hours of mv. main outcome measures: these data sugest that the increase of pcr for documented vap caused by pseudomonas aeruginosa ocurred more frequently with ceftazidim than other antibiotics. results: in all vap episodes, an aetiologic microrganism, was isolated from hemocultures and bronchic secretions. the gramnegative bacteria were the most commonly isolated microorganisms ( %). we collected pcr and leucocytes data of seven documented schedules (n = ) for erradication of pseudomonas aeruginosa: ( ) ceftazidime ( g q h) + gentamicin ( mg/kg qd), ( ) ceftazidime ( g q h) + ciprofloxacin ( mg q h), ( ) piperacillin-tazobactam ( g/ mg q h) + aztreonam ( g q h), ( ) piperacillintazobactam ( g/ mg q h) + gentamicin ( mg/kg qd), ( ) piperacillin-tazobactam ( g/ mg q h) + amikacin ( mg/kg qd), ( ) imipenem-cilastatine ( mg q h) + gentamicin ( mg/kg qd), ( ) meropenem ( g q h) + gentamicin ( mg/kg qd). the mean duration of antibiotic therapy was days. there was an increase of the pcr values of the patients who were scheduled with ceftazidim but in the other groups there was a decrease of this parameter. the number of leucocytes didn't have any impact of the pcr variation (p [ . , t-test). considering the group of the patients, % ( ) of the positive cultures for pseudomonas aeruginosa which were sensitive to either ceftazidim or a carbapenem or piperacillin-tazobactam were treated with ceftazidim instead. conclusions: this approach provides useful information on the relation of host defenses and the clinical outcome. it is also useful to study the prevalence of acquired resistance to several antibiotics that may be used in documented antibiotherapy for pseudomonas aeruginosa. background and objective: rfviia is increasingly used as rescue therapy in uncontrolled bleeding, however little information is available regarding its safety and efficacy in this indication. -indication for use: massive bleeding when first-line treatment (surgical control of bleeding, use of blood products) has failed; -to achieve the correction of factors that may interfere with coagulation (hypothermia, severe acidosis, hypocalcemia); -before administration of rfviia the patient or his family should be informed about the treatment; -the prescription of fviia should be initialized by a referent physician -to conform the dose of mu/kg in cardiac surgery patient. conclusions: several solutions have been proposed to the physicians to improve their professional practices: to develop an algorithm for use of rfviia, to fill in a checklist before administration of rfviia to be sure to follow the guidelines, … this study will be extended in others departments using rfviia as gastroenterology and traumatology. pharmacy, administração regional de saúde de lisboa, pharmacy, administração regional de saúde de lisboa, lisboa, portugal background and objective: the pharmacist can contribute to the maintenance and recovery of population health conditions participating in patient house visit s health teams. pharmaceutical care at this level may also have a real impact on the health system costs. the aim of this project is to establish a pathway at this care level in which all aspects of pharmaceutical care are explained and defined. design: program description. participation of the pharmacist in health care teams. definition of field areas, between the pharmaceutical hospital care and the community pharmacy and health care centers. articulation between the hospital pharmacist, the health care center pharmacist and this new ''home pharmacist''. definition of the different types of pharmaceutical care to be implemented in this setting. background and objective: hip fracture is a major public health problem with a high incidence and prevalence in people aged years and older. changes in body composition and organ function, drug-drug interactions, and co-morbidities should be taken into account in the pharmaceutical care of this group of patients. the aim of this study is to analyse pharmacological treatment of elderly patients ongoing hip fracture in order to improve pharmaceutical care in this group of patients. design: a prospective pilot-study was performed during one month, (may-june ) in patients admitted in a tertiary hospital ongoing hip fracture. these variables were recorded for each patient: sex, age, body mass index (bmi), diseases antecedents, serum creatinine and creatinine clearance estimated by cockroft-gault formula, serum albumin levels, lymphocytes count, sodium and potassium levels. drug treatment was recorded from pharmacy database. setting: patients with hip fracture admitted in a tertiary hospital. main outcome measures: prescription profile in elderly patients with hip fracture. results: of patients, were female. mean age was . years old ( - ). mean bmi was . (n = , range - ). albumin levels were lower than . g/dl in patients. sodium levels were out of the normal range in patients. five patients had creatinine clearance lower than ml/min, of them less than ml/min. we analysed prescriptions which included drugs. they were classified in categories: not adjustment required ( drugs), adjustment required ( ) , inappropriate based in beer's criteria ( ), precaution in elderly people ( ) and not enough information available in geriatric population ( ) . mean number of drugs per patient was ( - ). of prescriptions revised, required adjustment and of them were correctly adjusted. of prescriptions in precaution group were correctly prescribed. conclusions: dosage adjustment or precaution was required in % of prescriptions. of these, % ( / ) needed dosage adjustment according to renal function. besides, % of patients had renal function alteration. thus, it is important to improve pharmaceutical care in this group of patients specially for those drugs that need dosage adjustment in renal failure. keywords: pharmaceutical care, hip fracture, elderly patients pc- hospital pharmacists and community pharmacists: an experiment of pharmaceutical information transmission carried out in an anticancer center anne lebreton , erwin raingeard , christelle audeval , sophie rochard anticancer center, centre rené gauducheau, nantes, france background and objective: to evaluate a programme of pharmaceutical information transmission from hospital pharmacists to the community pharmacists about drugs, particularly anticancer drugs, dispensed until then by hospital pharmacy and now distributed by them. design: while doing the last dispensation by the hospital pharmacy, an informative fax was sent to the community pharmacists indicating the name of the patient, prescribed drug and its posology, date and quantity dispensed, approximate date of the next dispensation and general information about the delivered drug. one month later a questionnaire was sent to the pharmacists to get their appreciation about this document. in the case of having no answer from them, the same questionnaire was re-sent. setting: pharmacy of french anticancer center, centre rené gauducheau, nantes. -appropriateness of the way of transmission -pertinence of information sent -efficiency of the programme results: out of patients treated ( vinorelbine oral, erlotinib, sorafenib, sunitinib), ( . %) were registered in this study, involving pharmacists. six pharmacists ( . %) answered after the first sending of the questionnaire and ( . %) answered after they received the remainder. fourteen pharmacists ( . %) did not answer. all the pharmacists were satisfied with the way of transmission. however, one of them suggested having the information sent by e-mail. seventeen professionals ( %) thought information was useful and ( %) thought that it was sufficient for their practice. only pharmacists ( %) encouraged us to continue the programme; the others did not express any opinion about its efficiency. moreover, none of them called us even though we suggested so. conclusions: this experiment seems to be interesting and to correspond to the needs of the pharmacists. it would also be an easy way to make dispensation safe. nevertheless, many problems appeared: much time spent and the difficulty making an exhaustive follow-up of all the patients thus limiting the application of this kind of programme to larger cohort. background and objective: to make a proposal of software that facilitates the analysis of clinical relevance of antiretroviral drug interactions, in the medical prescription, dispensation and dader methodology of pharmaceutical care study phase. design: pubmed and other databases evaluate revision. antiretroviral drug interactions were classified in four levels according to probability and severity of the interaction. the probability was grouped in categories: defined, probable and possible. so, severity was grouped in categories: serious, moderate, and slight. the levels are: level (serious and defined or probable); level (serious and possible, moderate and defined or probable); level (moderate and possible, slight and defined or probable) and level (slight and possible). we used the pubmed and database review for identified and organized the information to software elaboration. were by the enzymatic inhibition. antiarrhythmics, antihistaminics, ergot alkaloids, prokinetics, benzodiazepins, statines, calcium channels antagonists, phosphodiesterase inhibitors, azoles antifungics, selective serotonin reuptake inhibitors, opioid analgesic, immunosuppressants, macrolides, classic anticonvulsivants, and riphamicins were the most common drug therapeutic groups with anti-retroviral drug interactions. conclusions: interactions were classified, which % were drug-drug interactions; as well, . % were pharmacokinetics interactions and in their majority ( . %) were mediated by the enzymatic inhibition. about . % of interactions were level and , this levels of greater clinical relevance and whose the alert generated by software are contributions that help to analyze and take decisions with respect to the handling from the same ones. outcomes (e.g. mortality, morbidity, adverse drug reactions.); a profile of patients and clinical activities; an update of task description based on evidences and context. results: studies demonstrate that pharmacists have an impact on selected clinical outcomes following clinical pharmacy activities (e.g. drug therapy monitoring, pharmacokinetics and education for medical and paramedical professional). patients admitted in the intensive care unit have a higher level of complexity of care than average patients in the hospital, but a similar length of stay. for pharmacy services, their drug cost per admission is higher ( $cad vs $cad), as the number of pharmacist paid hours per admission ( . vs . ) and the number of pharmaceutical interventions per admission ( . vs . ). the approach helped us to identify solutions to problems like the nonparticipation to the cardiology patient's round, the absence of a medication reconciliation process or the inconstant documentation of interventions. a revised task description will be tested by both clinicians. conclusions: this study illustrates an approach for the evaluation of a pharmaceutical care model in a pediatric intensive care unit. background and objective: from , an increase in the consumption of biological and synthetic glues was noted in the cardiac service of surgery. these are drugs and expensive medical devices, which represent an expenditure of more than k€. the impact of their use was evaluated on the post-operative bleedings, the duration and the cost of stay by the way of a economic medical study. design: an observational exploratory study was carried out between january and march . all the operated patients were included. setting: the computerized consultation of the patient files made it possible to identify the following criteria of judgement: indication, surgeon, type of glue used, catch of platelet aggregation inhibitors or oral anticoagulants, volume of drainage, number blood transfused, duration of hospitalization. the statistical analysis related to two groups of patients, treated or not by glues, with a stratification on the hemorrhagic factors of risk. main outcome measures: the comparison of the averages of the various parameters was carried out by tests of student, for the large samples presenting comparable variables, and of fisher in the other cases. the cost of each hospitalization was calculated from the numbers of stays. results: during the three months of study, patients, whom average age was years [ - ], were operated. the two principal indications were the valvular replacement ( . %) and aorto-coronary bridging ( %). on all six surgeons, % of the interventions were dealt with by three. on the whole, patients receive a glue ( %), of biological type with tissucol Ò ( . %), and synthetic with bioglue Ò ( %), arista Ò ( %) and the grf Ò ( %). some patients received two types of glues ( . %). no significant difference between the two groups appeared in the total analysis. among the patients who received a pre-operative anticoagulant treatment ( %), only % were treated by a glue, for which the number of transfused globular bases and the duration of stay in reanimation were significantly lower (p \ . ; p \ . ), compared to untreated patients. conclusions: in general, the use of glues in cardiac surgery does not decrease the post-operative bleedings, but increases the cost of the stay. it however finds its utility with patients at the hemorrhagic risk. a standardization of the local practices of the surgeons is in progress because there is not any national consensus. these results should be confirmed by randomized studies on a large scale. although za is times more expensive than pa, it seems more effective with a shortened administration time ( minutes vs - hours). in respect of the contract of good use (cbu), our objective was to evaluate the real cost of a daily hospital (hdj) session per patient treated with bp, and to compare it with the one obtained from the national study of costs (enc) in order to determine if whether our hospital gained or loosed benefit from this new refunding status. design: retrospective study. setting: conception hospital, bd baille, marseille ce-dex , france. main outcome measures: for every hdj session, we accounted pharmacy direct expenditures (including implants, medical devices or drugs), medical technical acts, and structure and logistic supports costs. moreover, we evaluated matching of prescriptions with the cbu criteria. we analyzed data together with the public health and medical information ward and the department of management control. results: real costs of hdj session amounted to € without bp, and increased to € and € with pa and za administration, respectively. according to enc results, each session including intravenous bp was refunded for . €. in , on a total of hdj sessions ( patients), sessions had bp administration ( . %) and concerned patients ( . %). real costs of hdj were € ( € and €, for and hdj sessions with pa and za, respectively). if bp administrations were integrated in the ghs at this time, the sessions would have been refunded for € ( € and € with pa and za, respectively) resulting in a profit of € for the hospital. among bp prescriptions, % matched approved indications, . % were part of temporary protocol of use and . % were medical publication-based. internal medicine ward initiated % of the prescriptions. conclusions: using pamidronic acid compensates the deficit generated by zoledronic acid use. in respect with the cbu, zoledronic acid use will be restrained to approved indications in outpatients and pamidronic acid will be preferred in all others indications. keywords: biphosphanate, refund, economy pec- evaluation of the implementation of automated medication-dispensing system in an intensive care ward gregory gaudillot , marie antignac , fabien heck , nadine casimir , robert farinotti pharmacy, groupe hospitalier pitié-salpétrière, paris, france background and objective: the development of the implementation of automated medication-dispensing system in french hospitals is the main aim, defined in the ''good use'' contract voted in . the purpose is to improve the safety around the drug dispensing by the nurses. the objective of this work was to evaluate this implementation in thrusts: safety, economic and organization. design: comparison between two different organization ways: before the implementation (pharmacy order by nurses chief) and months afterwards (automated order and arrangement by a chemist assistant). setting: surgery intensive care unit ( beds) in the pitie-salpétrière hospital (ghps), a large teaching hospital. main outcome measures: study ''before and after'': follow up of prescribing and dispensing matches, analysis of time repartition between nurses and chemist assistants, follow up of line of emergency order, analysis of the results of a nurses satisfaction survey and costs study of drug consumption and drug storage. results: this study, performed over days, showed very small differences between prescribing and administered medications ( % before versus % afterwards = no significant difference). organization: implementation of automated device allowed a better division of activities, the management by nurses chief of the pharmacy order decreased (from % to % of their weekly working time), because this part was attributed to the chemist assistant ( % of their weekly working time). satisfaction: % of nurses preferred the automated system and especially because they find that this system was safe. in the same time, % of them appreciate with the new relationship with the pharmacy department. costs study: a huge decrease of the storage: - % of cost ( , € versus , €) and - % of references number ( versus ). in the same time, over months, the drug consumption of the unit has been reduced by % (- , €). conclusions: even if the study did not demonstrate a decrease of the number of medication errors (due to the tiny number of them as much before than afterwards the implementation), this automated system allowed a safety access to the drugs (biometric system) and contributed to reduce the risk of medication errors. the other great interest is the real involvement of the pharmacy in the clinical wards. the presence of the chemist assistant ensures a better management of drug storage (decrease of emergency order), a direct follow up and allowed a contact with nurses. results: in in france, intracranial stents with various technical characteristics are available (steel or nitinol, learning curve: to procedures, follow-up of patients is from months to years). stents with a hight radial force are used for intracranial artery angioplasty. more precisely, those devices are implanted in patients with recidive stroke, with an intracranial stenosis c % and who had failed medical therapy. two stents are identified in this therapeutic use: wingspan Ò (boston) and pharos Ò (micrus). about implantations are estimated for in france, whom implantations (cost = , €) in paris hospitals. the need is not actually clearly identified: the number of eligible patients is not already known and not systematically searched by neuroradiologists. so number of implantations will evolve. intracranial stents are used in combination with detachable coils embolization in patients with wide-necked cerebral aneurysms: léo Ò (balt), neuroform Ò (boston), entreprise Ò (cordis) and pharos Ò (micrus, double therapeutic use). for , about to implantations are estimated in france ( to % of endovascular treatment of intracranial aneurysm), whom implantations (cost = €) in paris hospitals. those data might increase. indeed, there is evidence of the effectiveness of stent implantation in intracranial aneurysm which generates lower rate of aneurysm recanalisation. conclusions: intracranial stents has been identified in precise therapeutic uses. however, an exact quantitative assessment can not be realised: those medical devices are innovating and are actually changing the management of patients concerned. those quantitative results might evolve. further similar studies will be necessary in order to follow up those innovating therapeutic uses in neuroradiology departments and to estimate their cost impact, actually negligible. keywords: stent, intracranial angioplasty, intracranial aneurysm, implantable medical device, cost evaluation pec- feasibility of economical impact of management of cytotoxic remainders in a centralized cytotoxic unit hélène corneau , déborah schlecht , sébastien bauer , sylvie froger , jacqueline grassin background and objective: the french law forecasts to reimburse the most expensive cytotoxic drugs to the real quantity administered to the patient. so to set up a secured procedure to use remainders of cytotoxic drugs in a centralized cytotoxic preparation unit in order to conform to the french law. design: prospective study. setting: clinic unit of oncologic pharmacy. main outcome measures: this procedure was tested during ten weeks and had concerned the three most expensive cytotoxic drugs used in digestive cancers. generated remaining quantities are conditioned inside isolator in radio-sterilized bags, and identified with the number of register of prescriptions, the drug's name, the remaining quantity, the conservation' conditions, the opening date, the duration of physico-chemical stability according to the data of the literature. bags are joined when they are gone out of the isolator. a theoretical differential is daily established between the doses which are prepared with or without management of remainders. results: the management of remainders involves that a rigorous manipulation during the conditioning and a daily management of the out-of-dates. the average of realized savings € a week, that represents , € extrapolated to one year and a decrease of . % of expenses for these three drugs. pharm world sci ( ) : - our software of the preparations of drugs is adapted for the use of the remainders. but the invoice-software allows only one invoice for one flask, which involves with the management of the remainders an unequal invoicing system for the patients conclusions: the management of remainders generates a real financial profit. but the really administered quantity cannot be imputed to the patient because the software of inventory control and invoicing does not manage the fraction of flasks. nevertheless, according to the french law we must express under fractional shape the quantities of cytotoxics, which are administered by stay to the patients for the most expensive drugs. background and objective: since july , financing of drugs in belgian hospitals is based on a lump-sump system. this decision favours efforts leading to more rational use of medication like for example the sequential treatment. efforts like posters, recommendation letters and information rounds were part of the strategy. since - - a clinical pharmacist puts also attention on this subject by contacting physicians and nurses regarding individual drug therapies. documenting the results of interventions suggested by a clinical pharmacist is often quite difficult. the number of ddd of intravenous administered drug versus the total amount of ddd [oral + iv] of the particular drug administered has been described. this parameter can be disturbed by the use of the oral form over a long period of time or by the early discharge of patients combined with a continuation of the therapy at home. to follow up the sequential treatment on the emergency department, this parameter seems to be accurate by the fact that the stay of the patient here is between and days. cost savings by sequential treatment of paracetamol and levofloxacin were euro and euro, calculated from the start of the activities the clinical pharmacist (for months). old habits are difficult to change among them the administration of drugs by intravenous route. almost every medical and surgical patient admitted to the emergency department receives an intravenous line, so the threshold for intravenous administration is low. furthermore a wide variety in patients' medical conditions added to a rapidly changing timetable for technical examinations and surgery necessitates an individual approach of the most suitable route of drug administration. official letters and posters may be useful. however this report confirms the importance of a clinical pharmacists' permanent presence on the ward for maintaining awareness of sequential treatment. results: applications for compassionate use treatment were processed ( . processings/ inhabitants). the higher number of applications has corresponded to gynecology unit, processings of misoprostol to use in delayed curettage. secondly, botulinum toxin was processed in cases, . % of them corresponding to anaesthesic and reanimation unit for miofascial pain. active substance that has caused a higher impact on the hospital s budget was inhalated tobramicin, processed for a total of patients with bronchiectasias colonized by pseudomonas aeruginosa. the expenses for this indication has added up to , € during . secondly, as regards to economic impact we found botulinum toxin which raised up to , €, expenses that were attributed in % to anaesthesic and reanimation unit. the highest cost/treatment by patient during corresponded to inhalated tobramicin that has increased up to , €, followed by infliximab approved for hydrosadenitis treatment which accounted for , €. total cost of treatments for compassionate use has involved approximately . % of total consumption for drugs during . conclusions: the higher number of processings in corresponds to misoprostol requested by gynecology unit although its economic impact on the consumption of medicinal products for compassionate use is very low. inhalated tobramicin utilization for colonized bronchiectasias involves the highest global cost and the highest cost/treatment on total medicinal products for compassionate use. the percentage accounted for medicinal products for compassionate use on total consumption of medicinal products is low. it would be interesting to perform a multicenter study in order to value economic impact in last years of medicinal products for compassionate use. the vacuum-assisted closure (vac) therapy: a -months medico-economic retrospective study stéphanie roche , nathalie herment , sandrine havet , amélie pruvost , willemin jean-claude , frances carole pharmacie, reims teaching hospital, reims, france, background and objective: in the management of wounds care, spectacular results have been achieved through the application of negative pressure wound therapy. this approach known as vacuum-assisted closure (vac) involves the use of a defined controlled negative pressure (delivered by an ambulatory motor) over a polyurethane or polyvinyl sponge (which are considered as consumables) placed in the wound. in our hospital, this therapy was first introduced for acute traumatic wounds. in june , the interdisciplinary wound and cicatrisation group decided to extend indications to chronic wounds. to improve management regarding this larger and complex use through all units, a specific prescription form associated with recommendations was set up. this document is available as well as paper or electronic form. the purpose of this study was to evaluate conditions of use and global costs of vac therapy. design: a -months retrospective study was based on the analysis of nominative prescriptions of vac consumables (canisters with gel, small, medium or large foam dressing kits and y connectors . the cost of consumables was estimated to . euros per day per patient. total cost over the study period amounted to euros, including the hiring of the vac system ( . euros per day). these data indicate that the use seems to be appropriate and optimized without overuse. conclusions: facing the high cost of this technical therapy, its use must be closely managed. this study suggests that the multidisciplinary collaboration in our hospital between medical staff and pharmacist unit contributes to guarantee the optimal use of this specific therapy. to analyze the effectiveness of an educational programme to increase the adrs reports during this period. design: clinically relevant events possibly caused by exposure to drugs have been analysed in a retrospective study for a period of five months. we analysed the prevalence of adrs reported, the medical conditions of the patients, the relationship between adr and the suspected drug using karch-lasagne algorithm and the severity of the reaction using who criteria. during this period, we implemented a pharmacovigilance programme in order to increase the reports and to estimate the prevalence of adr in this unit. setting: pharmacy service and critical care service of a general hospital main outcome measures: to evaluate prevalence, characteristics, nature and severity of adrs in uci. to measure the effectiveness of an educational programme to improve the awareness and detection of adrs. results: a total of patients were hospitalized during this period, adrs were detected ( . %). severe sepsis and cardiac arrest were the most frequent diagnosis in this group of patients. . % males and . % females, . years in average. dermatologic effects as urticaria rashes and haematological effects as pancytopenia were the most frequently noted, with more than % each. therapies most often associated with the reported events were antibiotics (piperacillin/tazobactam, ertapenem, azitromicin) in . % of cases and nitroglycerin in . % of them. the adr reported were classified as low severity in . % of cases, medium in . % and high severity in % of them. level of causality more frequent was ''probable'' in a . % of the reports followed by ''possible'' in . % of them. since the implementation of the educational programme the number of reports of adr have increased from . % to . %. the high level severity of adrs reported has increased in this period from % to %. conclusions: communication and educational programmes should be implemented to promote detection, identification, reporting and evaluation of adrs. the analysis to determine the probability, causality and severity of adr is necessary to establish the measures needed to improve the security and the quality of health attention. background and objective: ace inhibitors are used for controlling blood pressure, treating heart failure and preventing kidney damage in people with hypertension or diabetes. although ace inhibitors are generally well-tolerated by the most individuals, they are not free of side effects. dry cough is one of the most common side effects seen in patients during ace inhibor therapy. in this study, we have evaluated the incidence of dry cough that appears during the ace inhibitors therapy and relationships with the other coughing factors and the other side effects that may appear. design: the questionnaire was applied on ambulatory patients ( m/ f) who have used or been using ace inhibitors and hypertension patients as control group who use also anti-hypertensive drugs except ace inhibitors. ace inhibitors, and the reactions against the dry cough were determined by pharmacist's questionnaire on the patients who come to the community pharmacy. results: dry cough was observed on the patients out of , during their using of ace inhibitors ( %). % of male patients and % of female patients were having a cough. the patients out of ( %) from control group were having a cough. the incidence of dry cough that appears on the patients who use ace inhibitors were; silazopril %, ramipril %, lisinopril %, fosinopril %, qinapril %, perindopril %, enalapril % and trandolapril %. the treatments of patients out of who complain from coughing during the therapy of ace inhibitors were changed with angiotensin receptor antagonists and calcium antagonists by their physician. treatment changes were resulted in increasing in the cost by . ytl monthly if it was calculated on the base of generics. conclusions: as a conclusion, the incidence of dry cough from ace inhibitors was found to be % in the blacksea region of turkey. the pharmacist can play an important role in determining side effects such as dry cough and refer the these patients to physician. patient counselling and drug therapy monitoring in the community pharmacies will increase the compliance and provide better outcomes in many chronic diseases. setting: community in _ istanbul main outcome measures: visual analouge scale (vas) was used for assessment of pain. the universe of the study consisted of randomly selected women and men (n = ). a pilot study was run on individuals from different occupation groups to determine the validity and intelligibility of the questionnaire. results: the data were analyzed using a spss . program. the level of significance was accepted as p \ . . the results show that women experience more intense pain than men; their mean vas score is higher than men ( vs ). headache is the most common type of pain ( . %) and also its vas scores reached the highest level ( ) ( ) . this pain is especially caused by migraine and hypertension. in addition, % of questionees prefer to take an analgesic drug in order to manage their pain problem. it was recorded that especially non-steroidal antiinflammatory drugs (nsaids) and preparations containing paracetamol are the first choice in pain management. most respondees took analgesics when pain begun ( . %), when pain increased ( . %) or when was intolerable ( . %). conclusions: the majority of those who participated in the study took their analgesic medication without consulting a health professional. this indicates a high level of self medication in our population. this gives rise to a number of potential drug problems such as nsaids usage in gastrointestinal disorders, hypertension and renal failure. although many participants used their drugs in a rondom and improper way, unfortunately the pharmacist was rated second to last as a drug consultant. background and objective: many patients visit the pharmacy for their oral problems like toothache and ask for appropriate pain relievers. the purpose of this study is to examine the attitude and role of pharmacists, dentists and non-health workers towards solving of dental and oral health (like management of toothache). design: different questionnaires were applied randomly on pharmacists, dentists and non-health workers. setting: canakkale -turkey. main outcome measures: dentists' and pharmacists' approach to patients with toothache, drug usage evaluation in dental problems, the type of information given by pharmacists, patient behaviors. results: % of non-health workers (n = ) indicated that if they complain about toothache they choose their pharmacist as their consultant. % of non-health workers (n = ) indicated that they use various medications without consulting a dentist ( % naproxen sodium, % paracetamol, % methimazole, % flurbiprofen, % amoxicillin, % carnation essence). the most common suggested antibiotics was amoxicillin ( %) by pharmacists and amoxicillinclavulanate ( %) by dentists. the most common suggested pain relievers were naproxen sodium by both pharmacists ( %) and dentists ( %). only % of dentists declared that they consult with a pharmacist about drug usage. % of dentists indicated the importance of consultation of patients by pharmacists. conclusions: according to our results; pharmacists must take an important role in prevention and management of oral and dental health problems including informing the patients about convenient drug usage. also collaboration between dental staff and pharmacists need to be improved. background and objective: in hibbard and smithells suggested a link between inadequate maternal intake of folic acid and neural tube defects in their offspring ( ) . consequently, it has been recommended that all women planning to become pregnant should consume additional folic acid before conception and during the first weeks of pregnancy. despite these recommendations, periconceptional intake of additional folic acid is still low in many developed countries and a substantial percentage of women are not aware of its benefits ( ) . design: a questionnaire was used in a face-to-face encounter. setting: postnatal wards of a teaching and a private hospital in iran. main outcome measures: awareness of the effects of folic acid on the fetus was evaluated among women. the questionnaire included questions about demographic information, folic acid supplementation before and during pregnancy, its effects and the most susceptible periods in pregnancy and the source of information regarding the drug's effects during pregnancy. results: the mean age of women was . (± . ) years old. the majority of the subjects had more than high-school education ( % vs. %). out of subjects, ( . %) took folic acid supplement before and during pregnancy. only . % believed that its usage was unnecessary, . % believed in its positive effects. in the subjects' opinion, the most important time for taking this supplement was the first trimester ( . %), then prior to pregnancy ( . %). the second and third trimester were noted important by . %. . % believed in the importance of this supplement during all nine months. the advisor for taking this supplement was doctors ( . %), health visitor ( . %), self-medication ( . %), tv and radio ( . %), family members and friends ( . %) and pharmacist ( %). conclusions: awareness of the value of periconceptional folic acid was high among women of iranian nationality compare to similar studies ( ) . the majority of the participants believed in the positive effects of folic acid. the advices provided by doctors and pharmacists had the greatest and least effect on the use of this medication. regarding the best time of usage of this supplement, the most emphasis was on the first trimester and next on prior to pregnancy. background and objective: diabetes mellitus type-ii is a metabolic disorder that is primarily characterized by insulin resistance, relative insulin deficiency, and hyperglycemia. before type ii diabetes stage, people almost always have ''pre-diabetes''; in which blood glucose levels are higher than normal but not yet high enough to be diagnosed as diabetes. while some people with type-ii diabetes have symptoms, the majority may go - years without apparent symptoms. because some of the symptoms for diabetes mimic other diseases or conditions, makes it harder to predict an precise diagnosis without any additional information. the purpose of this study is early diagnosis of pre-diabetes, prevention or delay of the complications with a collaboration of community pharmacists and patients. design: pharmacists used a structured questionnaire containing questions concerning demographic data and informations which indicate prediabetes symptoms. setting: four community pharmacies in istanbul. main outcome measures: data: age, gender, body mass index (bmi), genetic predisposition, blood pressure, pysical activity and hypoglycemia symptoms. results: one hundred people were screened for undiagnosed diabetes. and the risk for pre-diabetes is evaluated according fasting plasma glucose (fpg) and total oral glucose tolerance (ogtt) test results. blood glucose level between and mg/dl with the fpg test and and mg/dl with ogtt test are considered as pre-diabetes. conclusions: diagnosis of pre-diabetes can prevent the development of type ii diabetes and making changes in nutrition and increasing the level physical activity may even be able to return the elevated blood glucose levels to the normal levels. pepi- awareness among pregnant women of the effects of drugs on the fetus and mother maryam dilmaghanizadeh , simin mashayekhi , masoud naghizadeh , zahra fardiazar , roghaiieh bamdad moghaddam pharmaceutics department, the faculty of medicine, tabriz university of medical sciences, tabriz, iran (islamic republic of) background and objective: since the talidomide catastrophy [ ] concern about the safety of drugs in pregnancy has been increasingly evident. studies have revealed that pregnant women continue to take considerable quantities of drugs. however, all pregnant women worry about whether to take any medications. because of an estimated % of birth defects resulted from maternal drug exposure [ ] , this fear is well justified. little is known about the knowledge of pregnant women regarding the safety of medications during pregnancy. to our knowledge the present study is the first performed in iran. design: a questionnaire was used in a face-to-face encounter. setting: postnatal wards of a teaching and a private hospital in iran. main outcome measures: awareness of the safety of drug use during pregnancy among women. the questionnaire included questions about demographic information, drugs use before and during pregnancy, information regarding the safety of drugs during pregnancy and the most susceptible periods in pregnancy, the source of information regarding drugs' safety during pregnancy. results: the mean age of women was . years old. only an . % and . % used conventional medications and herbal remedies during pregnancy, respectively. a great percentages ( . %) believed in harmfulness of drugs during pregnancy, but only a . % believed in harmfulness of herbal remedies. the first trimester and the second trimester were believed to be the most and the least susceptible period, respectively ( . % vs. . %). the sources of information for the subjects regarding the safety of medications was specialist doctors ( . %), general practitioner ( . %), pharmacist ( . %), midwives ( . %), health center ( . %), media and books ( . %) and friends and family member ( %). discussion: a common concern about the care of pregnant women involves the medications, which led us to establish a special initiative to review available knowledge among our general population. the present study highlights weakness of the role the pharmacists play in providing the information to this vulnerable and eligible group of people, who nourishing our next generation. conclusions: a common concern about the care of pregnant women involves the medications, which led us to establish a special initiative to review available knowledge among our general population. the present study highlights weakness of the role the pharmacists play in providing the information to this vulnerable and eligible group of people, who nourishing our next generation. ayce celiker , nergiz nemutlu , gulru ozkaya hacettepe drug and poison information center, hacettepe university, ankara, turkey background and objective: poisoning casualties require be approached with utmost attention due to their ''medico-social emergency'' nature. children are more vulnerable because of their inherent interests for knowing the environment besides ignorance and carelessness of adults. drugs are among the leading offending agents in children poisonings. the services of drug and/or poison information centers have been regarded as one of the main challenge areas of clinical pharmacy practice. being a pioneer in turkey, hacettepe drug and poison information center (hizbim), has been run for years in working hours basis. objective: the objective is to evaluate the demographic and epidemiological characteristics of drug poisonings in children, thus, to contribute to clarify the actual ''intoxication profile'' and identify necessary measures for the children in turkey. design: the data of childhood (aged \ years) poisoning enquiries received by hizbim between january , and december , were collected retrospectively and analyzed with spss . Ò setting: hizbim is affiliated to hacettepe university, faculty of pharmacy main outcome measures: categorization and comparison of data of children intoxicated with drugs during ten years results: children were involved in % of all poisoning cases and % of those cases were due to drugs. there was no gender difference among very young children, however, girls dominated as the age increases (p \ . ). % of the cases were accidental, and analgesics were involved in % of the accidental poisonings (p \ . ). while the most offending agent group was analgesics in children younger than years (p \ . ), multiple drug ingestions were the main causes of the cases involved older children (p \ . ). multiple drugs were mostly encountered ( %) in suicidal attempts where the dominant gender was girls ( %) (p \ . ). the most frequently reported symptoms indicated central nervous system involvement almost in all intoxication cases and in all age groups. conclusions: pediatric poisonings are rather high in turkey like many other countries and drugs are accounted for mostly in those injuries whether accidental or suicidal exposures. some regulations, the attitudes of physicians, pharmacists, and parents and other care givers make contributions to that outcome. in the prevention of childhood drug intoxications it is essential to make cooperation between drug manufacturers, regulatory authorities, health professionals, and families, besides increasing social awareness. drug and/or poison information centers stimulate rational drug use through providing accurate and rapid information to health care providers, educating people directly, documenting current epidemiological data. recently, we noticed a great interest of pharmaceutical companies in drugs such as monoclonal antibodies or in diseases such as inflammatory rheumatism. the aim of this study is to put in evidence the orientations of biomedical research. we particularly analysed the pathologies concerned, the type and the target of the experimental drugs, and the aim of the biomedical researches. design: analysis of the protocols and of the investigator's brochures of the ongoing clinical trials in january . setting: clinical trials sector of lapeyronie-arnaud de villeneuve hospital, montpellier. main outcome measures: methodological aspects were first analysed: aim of the study, phase, type of sponsor, type of binding, inclusion rate. then, we focused on the experimental drugs involved: type of drug, target, therapeutic area concerned. results: % of clinical trials are promoted by pharmaceutical companies. % are phase trials, % are open-label trials. objectives can be found: testing a new molecule on a new target ( %), testing a new molecule in an known pharmacological group ( %), testing a new formulation ( %), testing an known molecule in a new indication ( %), evaluating a therapeutic strategy ( %). % concern rheumatology, % pneumology, % infectiology, % haematology, and % nephrology. the most frequent pathologies concerned are inflamatory rheumatism ( %), malignancies ( %), asthma/cobp ( %), hiv infection ( %), and post renal transplantation immunosuppression ( %). the percentage of patients included (number of patients in the trials concerned/total number of included patients) and the inclusion rate (real number of inclusions/ number of expected inclusions)are respectively % and % in rheumatology, % and % in pneumology, % and % in haematology, % and % in infectiology and % and % in nephrology. % of experimental drugs are injectable. % are little molecules obtained by chemical synthesis, and % are issued from biotechnologies: monoclonal antibodies ( %), peptide ( %), and gene therapy ( %). the new targets ( % of clinical trials) are receptors ( %), enzymes ( %), gene transcription ( %), cytokines ( %). conclusions: this analysis gives an idea of the future commercialized drugs. it puts in evidence the development of drugs in therapeutic areas which concern a lot of patients and whose financial rentability is high. furthermore, only % of clinical trials concern new drugs and new targets. development of me-too and optimization of therapeutic strategies are the most frequent clinical trials. background and objective: the increasing use of performanceenhancing substances and methods in sport threatens not only the meaning and the ethical value of the sport itself, but also the health of the athletes. this study aims to assess the drug utilization profiles of the amateur football players, as well as their attitudes and knowledge on ''performance enhancing drugs''. design: this study was conducted on male players of the amateur football league. the players were asked to fill in a standard questionnaire, where information about their drug utilization profiles as well as their attitudes and knowledge on ''performance enhancing drugs'' were sought through various questions. setting: various amateur football clubs in turkey. main outcome measures: drug consumption rates of the players. answers to the pre-prepared questions. results: the age of the players ranged between and years. forty-four ( %) players thought that drugs have a positive impact on sports performance; while % did not share this idea. the resource of this idea was a team-member for . %, the trainer for . %, sports magazines for . % and a family-member for . %. the players were asked to name the drugs that could be used for performance enhancement and . % replied as vitamins, while . % replied as central nervous system (cns) stimulants and . % replied as anabolic steroids. thirty-six players ( . %) reported that they use various drugs with the aim of performance enhancement. the drug utilization profile was as follows: vitamins were consumed by . % of the players; where cns stimulants, anabolic steroids, diuretics and growth hormone were consumed by . %, . %, . % and . % of the players, respectively. the players reported the reasons referring them to drug-use as follows: . drugs always have a positive impact on sports performance ( . % of the drug-users); . drugs are necessary in case of inadequate training ( . % of the drug-users); . performance enhancement leads to individual success in the team and this brings prices and rewards in return ( . % of the drug-users). about % of the players thought that cns stimulants have the main effects of increasing the heart rate, endurance and strength. the main potential adverse effects of the cns stimulants were reported as gastrointestinal problems, dependency and tachycardia. about % of the players thought that anabolic steroids increase muscle volume, endurance and strength. the main potential adverse effects of the anabolic steroids were reported as hypertension, hepatotoxicity and dependency. conclusions: the results of the questionnaire suggests that drug-use with the aim of performance-enhancement was common among the amateur football players; and the players were not adequately and properly informed on the effects and adverse effects of the (so called performance-enhancing) drugs. this reality yields new responsibilities in this challenging area of practice, for the clinical pharmacist. background and objective: psychiatric disorders and opiate misuse are associated with chronic pain syndromes, but their incidence in fibromyalgia (fms) is unknown. the aim of this study was to identify if the incidence of affective disorders, and opioid misuse, was more common in patients with fms than those with other forms of nonmalignant chronic pain. design: a prospective, cohort study was carried out involving patients, who were internally referred to a chronic pain management program. subjects with a working diagnosis of fms were matched by age (mean = ) and sex ( % female) and compared to a control group of patients with alternative forms of non-malignant chronic pain. individuals were compared using urine toxicological screens, drugrelated criminal convictions, diagnoses of affective disorders, and responses to the following inventories: screener and opioid assessment for patients in pain, the pain disability index, the personal health questionnaire and the fibromyalgia impact questionnaire. patients also underwent a standardised physical examination using american college of rheumatology (acr) guidelines to diagnose fms. setting: this was a quantitative, hypothesis-testing cohort study, conducted in an academic general internal medicine practice. main outcome measures: diagnosis of fibromyalgia, clinician's awareness of acr guidelines, pain intensity and impact of fibromyalgia on physical and psychosocial activity. results: response rate was % (n = ; mean age = , median = , age range = - ; male = ); the most common background and objective: the increase in the frequency of the metabolic syndrome and its implication, in the development of ischemic cardiovascular disease and type ii diabetes mellitus, represent a real public health problem and of much interest in the medical field. otherwise, the cardiovascular pathologies are twice more frequent among chronics psychotics patients, for that reason we were interested in the prevention of these pathologys. this phenomena have been accentuated with the arrival of second generation antipsychotic drugs which were associated with weight gain, disorders of glycemia and lipidemia. in the aim to elaborate recommendations, at first we proceeded to the assessment of biological and clinical follow-up of the patients hospitalized in the saint-egreves hospital. design: literature review, months prospective study. setting: we asked doctors of each unit ( ) to answer questionaries corresponding to patient files. we worked out a general questionary to avoid revealing our objective. main outcome measures: blood pressure, body weight, height, abdominal perimeter, glycemia, total cholesterol, triglyceridemia, cholesterol's fractions(hdl and ldl). results: our results showed a good clinical follow-up but the frequency of biological control was not sufficient. the blood pressure and weight were evaluated respectively in and % of the patients, the total cholesterol, glycemia and triglyceridemia were in % of patients. on the other hand, cholesterol's fractions (hdl and ldl) were rarely evaluated. as for the abdominal perimeter, where the increase is predictive of cardiovascular disease, is never measured. conclusions: it seems difficult to evaluate the risk of either cardiovascular disease or metabolic syndrome of these patients or to determine if there is any possible relationship between the nombre of cardiovascular risk factors and the apparition of this syndrome. these findings imply to identify these high risk subjects and to define the optimal preventive, or curative, management strategy of metabolic syndrome and this, through simple measurements to realize in clinical practice. background and objective: availability of a medicine in western markets can be delayed either due to differential submission strategies of companies or differences in review process between countries. the aim of this study was to examine delays in patient access to medicines for compounds approved by two or more authorities (us fda, eu emea, australian tga, health canada and swissmedic), by characterising potential drivers for new active substances (nas) approved between and , from both a company and regulatory agency perspective. design: nass approved by fda since were compared to nass approved by the other agencies. this data was analysed comparing the difference between submission and approval dates and characterised by; type of approval route, company size, and therapy area. setting: data on nas's approved by the authorities was collected from agencies and from public domain sources. main outcome measures: the difference in patient access to new medicines in different countries and factors influencing such differences. results: nass have been approved by fda and one or more of the agencies studied. the median time ranged between submissions to fda and another authority from days at emea to days at tga. the difference between approval dates ranged from a median of days at emea to at health canada. however these differ depending on company size, therapy area and approval route. conclusions: availability of a new medicine is a mixture of company submission strategies and approval process, although therapeutic profile of submissions and company size are also influencing factors. in europe the main driver to patient access is review timelines rather than delay in submission by companies. main outcome measures: data on sex, age, origin of ppi prescription and indication were collected by a standardized questionnaire and were retrospectively analysed. results: men and women were reviewed. the median age was years (range, - ). % of patients received ppi therapy by pantoprazole (available in our hospital) when hospitalized. % of patients received daily mg of pantoprazole and % received mg a day. % of the prescriptions were validated. the main off-label indications were prevention of hemorrhagic risk of antiplatelet agent ( %), hemoglobin decrease( %), anticoagulant co-prescription( %), steroids co-prescription( %). conclusions: this prospective study confirms the large prescription of ppi therapy in a department of internal medicine. nevertheless, this study highlights the difficulties to interrupt this well tolerated therapy after the first prescription by family physicians. clinical pharmacist interventions in the department consist of explaining the difference of indications between pantoprazole mg and pantoprazole mg, he makes physicians aware of prescribing ppi therapy with a cautious reweighted cost/benefit consideration. background and objective: to develop and validate a system for regulatory authorities to provide feedback to companies on the quality of their submissions while companies report to authorities on the quality of the review. a standardised report format will allow performance comparisons within and across companies and agencies. design: draft scorecards were tested in a study on the same four compounds, each reviewed recently by the agencies in australia, canada and switzerland. the agencies provided feedback on the quality of submissions and sponsors, astrazeneca, gsk, novo nordisk and pfizer gave views on the conduct of reviews. background and objective: adherence with chronic medication such as inhaled corticosteroids (ics) has repeatedly been reported to be low. non-adherence could be related to inadequate knowledge of ics' actions and lack of ics' instructions on the use of inhalers. this has not been reported previously to our knowledge among new users of ics who discontinued ics treatment early. the aim of the study is therefore to describe, among new users of ics that discontinued, their knowledge of ics' actions and whether they were instructed on the use of their inhaler. design: a cross-sectional study among new users of ics that discontinued use. patients were interviewed by telephone and their gp received a mailed questionnaire. automated dispensing records of all patients were retrieved. setting: community pharmacies in the netherlands. main outcome measures: by use of conditional logistic regression the association between knowledge and study variables was assessed. results: from eligible patients, ( . %) were interviewed. the majority ( . %) of these new users of ics who discontinued ics early was not aware of the anti-inflammatory actions of ics. most patients ( . %) were instructed on the use of their inhaler, predominantly by the gp ( . %). after adjusting for symptom experience by acq, asthma diagnosis, having persistend asthma or use of medication only age (or . % ci . - . ) and male gender (or . % ci . - . ) were associated with unawareness of anti-inflammatory actions. conclusions: this study shows that a substantial number of new patients that did not refill their ics prescriptions, were unaware of ics' inflammatory actions. surprisingly only age and gender seemed associated with awareness of ics actions. most patients were instructed on the use on their inhaler by a health care provider. physicians and pharmacists could cooperate in identifying and motivating these patients to continue ics use. background and objective: to assess the quality of antibiotic therapeutic drug monitoring (tdm) in routine hospital practice and establish baseline status for rationally defining future actions aimed at improving it (by implementation of clinical pharmacy services). design: months prospective observational study with validated data collection form using predefined criteria for tdm quality assessment. descriptive statistics performed with spss . for windows Ò . setting: orthopaedic surgery, general surgery, neurosurgery, vascular surgery, haematology and pulmonary wards of a beds teaching hospital, using vancomycin twice daily and amikacin once daily administration schemes. main outcome measures: adherence to predefined criteria for sample timing, information transmission, and follow up of dose adjustment recommendations. criteria: (i) sampling time: less than ± min (amikacin) and ± min (vancomycin) deviation from preset time for peak levels; less than ± min for trough levels; (ii) information transmission: patient's full name, dose, schedule of administration, time of previous and current dose, actual time of peak and trough level sampling; (iii) quality of the analysis [internal and external controls]; (iv) acceptance of dose adjustment (more than %) recommendations. results: inclusion: patients ( vancomycin and amikacin courses). correct sampling times: (i) peak levels: % (n = ) for vancomycin and % (n = ) for amikacin, (ii) trough levels: % (n = ) for both antibiotics. correct information transmission: % (n = ). no issue noted for the quality of the laboratory analyses. implementation of recommendations: % (n = ) for vancomycin and % (n = ) for amikacin. conclusions: incorrect sampling times and deficiencies in communication between the ward and the laboratory are key factors affecting the quality of tdm, leading to dosage adjustment recommendations that are only infrequently implemented. the companion abstract examines the underlying reasons for such poor performance of the tdm process using a qualitative approach. corresponding values of d were: background and objective: to evaluate the relation between vancomycin and amikacin pharmacokinetic (pk) parameters in an intensive care unit population. design: data from intensive care unit patients were collected over a -month period, through a retrospective review of medical records and therapeutic drug monitoring (tdm) reports. patients were included only if at least two blood samples, at steady state conditions, had been drawn. data were first evaluated for completeness and consistency of recorded sampling and dosing times. individual pk parameters were estimated (bayesian analysis) using a one-compartmental pk model for amikacin and a two-compartmental pk model for vancomycin (pks Ò abbot). phase i of the study determined relationships between vancomycin and amikacin pharmacokinetic parameters, mainly clearance and volume of distribution. for that purpose, linear regression analysis of data from out of patients (analysis dataset) was performed. phase ii tested the predictability of the developed equations in an additional sample of patients (validation dataset) by comparing predicted pk parameters from equations (predeq) to those estimated by bayesian analysis (predbay) . t-test between predeq and predbay from each antimicrobial was performed. bias and precision were evaluated calculating the mean prediction error (mpe) and mean absolute error (mape), respectively (s-plus ). setting: intensive care units. tertiary university hospital. main outcome measures: patients demographics, clinical and tmd records, creatinine clearance by cockcroft-gault, vancomycin and amikacin blood levels and pk parameters. results: eighty-three critically ill patients ( females, males)were recruited for the study (mean values: age . yr, weight: . kg, cr: . mg/dl). a correlation between vancomycin and amikacin regarding their cl was found (clvancomycin = . clamikacin + . ; r = . ). however, no correlation was observed for vd (r = . ). concerning phase ii, differences in demographic data from both datasets were not statistically significant. no significant differences were observed when performing predeq versus predbay t-test. nevertheless, boxplot graphs for predeq and predbay residuals showed a wide variability of the values distribution and a lack of precision for both antimicrobials. conclusions: in our patient population this studied approach reveals an existing relation between amikacin and vancomycin pk parameters (or vice versa). however, the poor precision and large bias of residual values prevents us from recommending the use of these equations as pk parameters predictors (or regimen dose predictors) in intensive care patients. further studies with larger samples are definitely required in such an heterogeneous population. they were asked to identify which items of the ashp guidelines and gedefo they considered that must be filled in, in a prescription or in an identification label. consensus was defined as an agreement rate c %. prescriptions/labels evaluation: all breast or colon intravenous chemotherapy prescriptions, from a central hospital, have been evaluated from january to december (n = ), based on the parameters identified in the consensus document. a two month analysis of identification labels was performed. results: consensus document: a total of hospital pharmacists ( . %) completed the rounds of the delphi. consensus was obtained for . % of the prescription items and for . % of the labels items. prescriptions/labels evaluation: more than / of the analysed prescriptions were for breast cancer ( %) and the rest for colon. none of the analysed prescriptions had all the consensus items filledin. information that allowed the validation of the prescription by the pharmacist (ex: height, weight, body surface or number of cycle) was present in less then % of the prescriptions. no one had the prescriptor telephone, or the justification for dose reduction (when appropriate). only . % ( / ) of the labels mentioned the full identification of the solvent ( % miss the concentration) used and none of them stressed out the need for filter use when applicable. conclusions: consensus was obtained about a large number of items, which may constitute a difficulty in daily practice the evaluation of prescriptions highlights the lack of information that could allow confirmation by the pharmacist. labels do not seem to alert about special administration conditions. background and objective: background: the ministerial advisor on hepatitis c in catalonia has established a series of recommendations concerning hepatitis c treatment distinguishing between two groups: viral genotypes and , and viral genotypes and . in genotypes and it is necessary to evaluate treatment continuity after and weeks, depending on viral load and it is also necessary to prolong the treatment to weeks if there is viral response. in genotypes and it has not to be longer than weeks regardless of viral load. objective: to evaluate the adequacy of hepatitis c treatment and analytic monitoring, following the recommendations of the catalonian ministerial advisor. design: observational and retrospective study. setting: patients that started treatment with peg-interferon plus ribavirine in this hospital during . the information obtained was: viral genotype, the beginning and the end of treatment, quantitative basal rna (in all genotypes), quantitative rna ( weeks) and qualitative rna ( weeks) in genotypes and and at the end of the treatment in all genotypes. main outcome measures: the application of global advices ranges from % to % according to viral genotype and established recommendation. results: the compliance degree in genotypes and : % application of quantitative basal rna and % after weeks. % of treatments were discontinued with quantitative rna positive after weeks, % with qualitative rna positive after weeks and % the treatment was continued longer than weeks. in genotypes and : % application of quantitative basal rna, % application of qualitative rna after weeks and % the treatment was continued longer than weeks. conclusions: following the recommendations on viral response evaluation after and weeks allows the early suspension of therapy in non-responsive patients. this leads to and improvement in patients' quality of life, a reduction in adverse side-effects and savings in medical care costs. treatment monitoring by hospital pharmacist provides medical decision support. in consequence these patients constitute a target group to establish pharmacy care programs focused on hospital outpatients. topical application of mitomycin . % during two minutes and postoperative stenting for a period of four-ten weeks were used, no second application of mitomycin was used. the follow-up was years in bilateral case and six months for the unilateral case. setting: pharmacy and otorhinolaryngology service. hospital universitari joan xxiii de tarragona. spain. main outcome measures: the success of the repair was measured according to the following items: endoscopic evaluation of the patency of the choanae, respiratory distress and nasal drainage. results: bilateral membranous choanal atresia was surgical repaired five days after birth, using transnasal endoscopic approach and topical mitomycin . % during de proceeding. no operative complications occurred and stents were removed four weeks after repair. the choanae was inspected endoscopically to asses healing and no presence of re-estenosis was found. no clinical symptomatology. unilateral mixted atresia on the left side was diagnostic at six years old and surgical repaired because of association of respiratory distress and nasal mucus drainage symptomatology. no restenosis has appeared and syntomatology has improved. nome patient required surgical revision. conclusions: although, the exact role of the topical application of mitomycin . % must to be further investigated, the use of this drug as an adjunct to the surgical repair of choanal atresia may offer decreased need for revision surgery due to re-estenosis. keywords: mitomycin . %, choanal atresia pt- adherence to clinical guidelines for upper respiratory and ear infections in out-of-hours primary carea retrospective study sara claesson biofarmaci, uppsala university, täby, sweden background and objective: infections in the upper airways and ears are a frequently occurring reason for patients to visit primary care settings. prescribing adherence to local guidelines for handling infections of ears and upper airways and antibiotic prescribing is of both local and national concern. increasing antibiotic resistance is one reason, cost and patient quality of care are others. the objective of this study was to investigate physician adherence to clinical guidelines at the out-of-hours primary care clinic in täby. design: a retrospective study. clinical case notes were scrutinised for all patients seeking care for problems with ear, nose, throat, fever, cough or cold between january and march . data was analysed for patients who were diagnosed with specified ear or upper respiratory infections. laboratory tests taken and antibiotic prescriptions were anonymously documented. antibiotic prescription filling dates were investigated. setting: husläkarjouren, the out-of-hours primary care clinic in täby. main outcome measures: adherence to and fulfillment of local therapeutic guidelines and professional quality criteria was defined with respect to immediate, delayed or no prescription, drug choice, dose and duration and the use of diagnostic tests. adherence was defined as complete or not, and deviations from the guidelines were separately analysed. prescription filling was analysed with respect to time from clinic visit to pharmacy visit. results: data from patient visits were analysed. adherence to local guidelines was disappointingly low. general treatment of infections was only according to guidelines in % of the cases and only laboratory testing met the quality criteria. adherence to antibiotic prescribing guidelines was even lower, only % of antibiotic prescriptions were completely according to local guidelines. % of all antibiotic prescriptions were filled within one day from the visit to the clinic. conclusions: communicating guidelines to prescribers and continuous follow up of prescribing behaviour is essential for improving patient care and decreasing the risk of antibiotic resistance in the community. this study exposes gaps in the quality of care that may not be picked up by traditional follow up measurments. studies with a wider scope and in depth analysis of reasons for nonadherence to guidelines are warranted if antibiotic use is to be improved. . lines after other therapies. before bortezomib one patient received therapeutic with thalidomide/dexametasone, one vad, one cyclophosphamide (ctx), three followed by vad, one mp followed vad and followed ctx, and another with vad followed by ctx. the therapeutic selection followed the nccn guidelines in all patients. the average number of cycles with bortezomib has . . from the patients, stopped, one had a generalized face oedema bortezomib related, although the disease was in remission, and another died by sepsis not related with this drug. in relation to bortezomib's effectiveness, ( %) patients had a very good response, since the immunoglobulin decreased and three ( %) of these patients are actually at consolidation cycles ( th and th). conclusions: the use of bortezomib in our hospital was according the nccn guidelines and the experience was very positive. nevertheless, and considering also the high cost of this therapeutic, we consider very important to continue to follow up this group in order to evaluate the rate of response to bortezomib during time. pt- evaluation of the time interval between admission on the emergency department and administration of the first dose of antibiotics background and objective: when patients are admitted with a proven or suspected infection on the emergency department, adequate antibiotic treatment must be started as soon as possible. literature reveals that the time between admission and administration of the first dose of antibiotics can reach about hours and this can influence the prognosis of the patient. international guidelines for community acquired pneumonia (cap) and bacterial meningitis define this time interval of hours( ) and less than hours( ) respectively. to evaluate the practice on the emergency department of our hospital, with an average daily admission of patients, a study on this interval was carried out. . % of all administered antibiotics is in adherence to the local guidelines; however this was only evaluated by the clinical pharmacist. a possible explanation for the relatively short time intervals could be that the antibiotics which are frequently used are available at the emergency department and that the guidelines are at all time available on our hospital intranet. the time intervals of cap and bacterial meningitis are shorter than the defined international guidelines.( , ) conclusions: the time interval, found in our study, between admission on the emergency department and administration of the first dose of antibiotics is short, compared with similar conducted studies.( , ) pharmacy, otolaryngology, de octubre university hospital, madrid, spain background and objective: a woman diagnosed with laryngeal papillomatosis. treatment consisted of laser excision of the granulomatous lesions, followed by mitomycin c instillation over the surgical bed. description of the preparation and utilization of mitomycin c instillation over the surgical bed for the treatment of laryngeal papillomatosis. design: request by the ent service for compassionate use of mitomycin c. following authorization from the health authorities, a literature search was made. after determining the dose/day for the patient, elaboration was carried out according to the literature references. setting: vials of mg of mitomycin c were used as starting material, with -ml syringes to facilitate instillation in the operating room. dilution was made to double the standard in our centre ( ml). main outcome measures: two -ml syringes were prepared per cycle, with a mitomycin c solution of . mg/ml for instillation, though finally in all cases only one of them was used. stability was established as hours at room temperature, without special considerations regarding light exposure, as specified by the literature. the entire procedure was carried out in a laminar flow chamber, in compliance with the specifications for manipulating cytostatic agents. results: the patient received a total of three cycles of mitomycin c, the last two being maintenance cycles. the patient has experienced no papilloma relapse, and only right vocal cord hyperaemia is observed, probably secondary to surgery. conclusions: collaboration between the service of pharmacy and the ent service allowed adequate treatment and recovery of the patient, without apparent adverse effects. swollen and tender joints over joints evaluated, and the value of erythrocyte sedimentation rate, comparing the das from one patient on two different time points; eular response, that classifies patients in groups according to treatment response, and decrease in mhaq (modified health assessment questionnaire), that indicates patient's awareness of disability. data were recollected at beginning and at weeks of initiating treatment with rituximab. differences between b-lymphocyte count at beginning and at weeks was of initiating treatment was used as a secondary variable. results: we collected data of patients, all being females, was rf positive and were anti-ccp positive. at women) a . % of patients received adjusted prophylaxis to their degree of risk ( . % with heparin prescription and . % without it) from all . % of inadequate prescription ( % of the patients with lmwh prescription); patients lost follow up. patients submitted to cancer surgery ( surgeries, men, women), % received apropiate prophylaxis ( . % with lmwh and . % without it). same percentage of patients ( %) was not adapted to correct prophylaxis ( % patients with lmwh); patients lost follow up. conclusions: there is a greater percentage of choledoco surgery patients with lmhw prescription in compliance with published guidelines than oncology surgery patients, however it will be necessary carry out a better implementation among healthy professionals in order to increase this percentage of patientes. results: prescriptions of these broad-spectrum antibiotics were collected and analysed. % of the prescriptions were initiated by residents, % by senior physicians. vancomycin was the most prescribed antibiotic ( %), mainly in the orthopaedic surgery unit. the indications of antibiotics were osteomyelitis ( %), septic arthritis ( %), prosthetic joint infections ( %) and pneumonia ( %). only % of antibiotic doses were not correctly adapted to creatinine clearances or to plasmatic vancomycin rates. the initial choice of antibiotic was considered appropriate in % of cases. regarding bacteriological results (bacteria, antibiogram), the continuation of the treatement was acceptable in % of cases. however in % of prescriptions, an adjustment of therapy with a more narrow spectrum antibiotic could have been done. conclusions: these results have to be extended with further investigation (at least months). were systematically reviewed to retrieve prospective trials describing esa doses in dialysis pts who converted from rhuepo to da. search words included: ''epoetin, darbepoetin, esrd, ckd, and dialysis.'' the inclusion criteria required a study to have dose data available during the evaluation period for both rhuepo and da. study selection and data extraction were performed by independent reviewers and verified by a rd. relative doses and dose changes after conversion from rhuepo to da were estimated using an initial rhuepo:da : conversion ratio (aranesp Ò eu label). study quality assessment was performed using the downs-black checklist, a standard method used to assess the quality of a study using ebm principles. setting: meta-analysis. main outcome measures: dose efficiency. results: the search yielded studies meeting the inclusion criteria. upon further review, studies were excluded ( had unextractable data, were retrospective analyses, and had predialysis pts). the remaining studies were analyzed: rcts with parallel control groups, cross-over trials, and observational conversion studies (table) . the studies yielded data on , rhuepo and , da pts, with a mean treatment duration being weeks. we found the average study quality was %, with rcts (n = ) having a higher quality score ( %) than crossover ( %; n = ) or observational ( %; n = ) studies. there was a notable dose efficiency observed when pts were converted to da from rhuepo. this effect was greater in the rcts ( . %) than in crossover ( . %) or observational ( . %) studies. conclusions: we found a notable da dose efficiency (up to %) in pts who were converted from rhuepo to da using a : conversion ratio. additionally, studies with the highest quality scores (eg rcts) had the greatest observed dose efficiency while non controlled studies scored lowest in both quality and dose efficiency. background and objective: the purpose of this study is to evaluate the frequency of otitis media and the assessment of its relationship to patients' socio-demographic characteristics and determination of systemic and topical drug profiles in otitis media. design: this retrospective study included the assessment of patients diagnosed with otitis media, who admitted to the study hospital during a months period (march-may ). demographic, clinical and prescription data of these patients were collected and analyzed. setting: the ear-nose-throat out-patient clinic of a states hospital. main outcome measures: the socio-demographic data of patients; the frequency of otitis media; type and percentage of prescribed drugs; the most used treatment regimens. results: patients ( women and men), who were diagnosed with otitis media, were included in our study. patients were diagnosed as chronic otitis media or serous otitis media or acute otitis media or external otitis media at rates of . %, . %, . %, and . %; respectively. in children, the acute and serous otitis media were seen more often than in adults (p \ . ). however, chronic otitis media were seen more frequently in adults (p \ . ). all patients were administered drug therapy for their diseases. it was observed that antibiotics (oral and/or topical), analgesics, decongestants, and topical corticosteroids were prescribed at rates of . %, . %, . %, and . %; respectively. prescribed oral antibiotics were cephalosporins [cefixime ( . %), cefuroxime axetil ( . %) and cefaclor ( . %)], amoxicillin-clavulanate, and floroquinolones [levofloxacin ( . %) and ciprofloxacin ( . %)] at rates of . %, %, and . % respectively. rifampin and ciprofloxacin were prescribed as topical antibiotics at rates of . %, . % respectively. when the number of drug used by the patients was evaluated, were on quadri-therapy, on tri-therapy, on dualtherapy and on mono-therapy. patients were treated with the combination of antibiotic-analgesic-decongestants. conclusions: our study indicated that the most frequently prescribed drugs were antibiotics in otitis media. clinical pharmacists have a potential role in rational antibiotic use by providing clinical pharmacy services such as antibiotic selection, drug monitoring and patient education; so that they would reduce both antibiotic resistance and treatment costs. background and objective: the sampling method is crucial for the physical and chemical quality control of antineoplastic chemotherapies. this step acts upon the dosage correctness and may lead to risk of needle-stick or cytotoxic drug projection during its achievement. beyond, the sampling time must be as short as possible and the sample be directly placed on the analysis machine. this work evaluates a new and improved sampling method, specially worked out for this application. design: this study was designed to ensure the vial airtightness and the volume sampling. a cost and time study was also performed. setting: the vial is an hplc type, chromacol Ò ml, mm dp = hpa, (interchim Ò , montluçon, ). the vial is airtight thanks to a ptfe silicon septum set with an aluminium collar. the vials are vacuum-packed in a pvc bag (didop Ò , compiègne, ). a void test was led on unpacked vials up to months, to ensure a maximum conservation, and showed a filling volume of ± ll, very close of the ll target. main outcome measures: one week samples have been weighed to calculate the filling volume in real conditions of use. this volume is ± ll ranging from to ll. since this sampling method has been set up, the percentage of refusal for insufficient volume is lower than . %. this technique was compared to the previous method in terms of cost: vial, sampling adjuncts, handlingtime and waste. the vials are filled with a secured double-needle eclipse Ò , mm, / (becton-dickinson Ò , le-pont-de-claix, ). results: about , chemotherapies controls are made each year in the hospital. the vial and the sampling device costs are higher than the previous ( € versus . €, and . € versus . €). on the contrary, the handling-time for sampling was estimated minute lower (which corresponds to . € less per sample). furthermore, the waste weight is gram lighter with the new devices, which costs . € less in the waste disposal. the total cost difference is . € higher per sample. an estimation of a needle-stick accident has been carried out, with the human cost (pharmacist technician's compensation and medical consulting) and the equipment including gloves, sterilization devices and post-sterilization check; the lowest estimation cost of an accident is . €. conclusions: the secured needle makes the sampling operation easier for the workers and it lowers the risk of needle-stick. besides, this closed system avoids completely the antineoplastic contact for the manipulators during the confection and the control. moreover, this system allows to secure the sample library. background and objective: the prevalence of diabetes mellitus in kuwait ranks amongst the highest in world at about %. diabetes is a well recognized independent risk factor for cardiovascular disease (cvd). the increased prevalence of several other known risk factors for cvd in kuwaiti diabetics further increases the risk. since cvd is the leading cause of death in kuwait, the high incidence of diabetes has major social and economic impact. diabetics aged years or older have, in general, an increased -year risk of developing cvd compared to younger patients but there have been no audits involving this group of patients in kuwait. the objective of this study was therefore to audit achievement of cvd risk factor goals according to pt- pharmacotherapy of first-episode psychosis in the psychiatry clinics of the north estonia regional hospital (nerh) and the tartu university hospital (tuh) jana lass , agnes männik , simon j. bell pharmacy department, north estonia regional hospital, tallinn, institute of pharmacy, university of tartu, tartu, estonia, faculty of pharmacy, university of helsinki, helsinki, finland background and objective: treatment guidelines provide recommendations for the evidence-based treatment of schizophrenia. adherence to these guidelines is often sub-optimal. our aim was to compare and contrast the pharmacotherapy of first-episode psychosis at the nerh and tuhs, with respect to both treatment location and evidence-based guidelines. design: retrospective study. case notes for consecutive patients with schizophrenia, schizotypal or delusional disorders (icd- ) admitted to the nerh and tuh between september and september were retrospectively reviewed. setting: psychiatry clinics of two tertiary care hospitals -nerh and tuh. main outcome measures: outcome measures included the choice and daily dose of antipsychotics, incidence of antipsychotic polypharmacy and reasons for changes in therapy plan. results: patients form nerh and from tuh were included in the final analyses. median age (sd) of the patients was ( . ) in the nerh and ( . ) in the tuh patients were hospitalised for longer in the nerh than in the tuh, ( . ) vs. ( . ). the most frequently prescribed antipsychotic was risperidone at both study locations - % of prescriptions in the nerh and % in the tuh. conventional antipsychotics were administered twice often in the nerh than in the tuh. in the tuh olanzapine was administered in higher prescribed daily doses than in the nerh. the number of antipsychotics prescribed per patient was higher in the nerh than in the tuh - . vs . . the prevalence of antipsychotic polypharmacy was . % among the patients in the nerh, whereas only one patient was treated with antipsychotic polypharmacy in the tuh. conclusions: analyses revealed significant differences in the pharmacotherapy of first episode psychosis at the nerh and the tuh. mechanisms to facilitate improved adherence to the evidence-based treatment guidelines should be investigated. pharmacy, hospital universitario de getafe, getafe, spain background and objective: to analyze the use of tnf-alfa inhibitors in rheumatoid arthritis diagnosed patients in a bed hospital. design: retrospective study of patients with anti-tnf-alfa during year . the following data were compiled: age, sex and anti-tnfalfa prescription including dosage and duration of treatment. setting: hospital universitario de getafe. main outcome measures: dosage and duration of treatment. results: a total of patients were included. patients ( . %) received just one anti-tnf-alfa drug, ( . %) needed two lines of treatment and ( . %) of them needed three. patients who were treated with just one drug had a median age of . years and those who required two lines of treatment had a median of . years. the first line drug was etanercept in . %, infliximab in . % and adalimumab in . % of patients. second option was etanercept in . %, adalimumab in . % and infliximab in . % of patients. the average duration of treatment with etanercept as forward edge was days. the treatment was suspended in . % of patients. when infliximab was used as first line, average duration was days, and treatment was interrupted in . %. with adalimumab, average duration was days and treatment was interrupted in % of patients. conclusions: those of our patients who need an only one treatment line are younger than those who need or , due to the chronic and progressive course of the disease. etanercept is used as much in first option (followed by infliximab) as in second one (followed of adalimumab), although these differences are not statistically significant and it would be necessary to make a study including more patients. the duration of treatment with infliximab is the longest, as this was the first drug available. regarding treatment failure, etanercept shows the greatest percentage. this should be taken into account when establishing first line treatment. background and objective: plantar warts are hyperkeratotic lesions on the plantar surface caused by infection with human papillomavirus. lesions caused by warts are commonly refractory to therapy and may become large and painful in immunodeficient patients. cidofovir is a cytidine analogue with activity against a broad spectrum of dna viruses. it is indicated for the treatment of cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome and without renal dysfunction. we describe a case of plantar warts that was treated with topical cidofovir in a highly immunodeficient patient. design: case report, evaluation and discussion based in clinical chart and literature review. setting: pharmacy department, general teaching hospital. main outcome measures plantar warts regression, which was evaluated on the basis of change in overall surface area of the treated lesions compared with baseline. to evaluate the organoleptics properties of the galenic formulation. results: a years old woman, who received kidney transplant in , presenting plantar warts refractory to conventional therapy since last four years. she was treated with topical % cidofovir cream twice daily. the treatment was authorised as compassionate use by the national regulatory agency on drugs. the glomerular filtration rate (gfr) was monitored in order to detect nephrotoxicity due to cidofovir. the % cidofovir ointment was compounded as follows: -cidofovir mg/ml ml vial .…….. ml -anhydrous lanolin ……………………….. g -beeler base …..sufficient to produce g it was packaged and labelled in a light-resistant containers and we assumed an expiration date of months based on the duration of treatment and published studies. the quality controls of organoléptics properties were made according to the good manufacturing practice (gmp) after weeks of therapy the patient did not show any improvement and developed severe local erosion, so treatment with cidofovir was withdrawn. two weeks later this local erosion disappeared spontaneously. no systemic side effects were observed. the colour, texture and smell organoleptics characters were complied with gmps. conclusions: there are not formal studies of optimal formulations or treatment regimens and further studies are needed to elucidate the role of cidofovir in treatment of plantar warts. the immunodeficiency of the patient and the large wart area could be related with the failure to the treatment. background and objective: hypersensitivity reactions (hr) to platinum salts can be serious and should lead to interrupt chemotherapy regimen. skin tests may be used to confirm diagnosis of hr. usually, these tests are prick tests and intradermal tests performed with diluted solutions of platinum salts. there is no standard solutions for these drugs, which local toxicity depends on concentration. the main objective of this study was to assess the safety of platinum salts skin tests performed in our hospital. the secondary objective was to assess their efficacy to verify the allergic nature of the reactions observed. design: pilot study of skin tests preparations between january and june . these preparations were dilutions ( / , / , / ) of a primary platinum salt solution, which concentration was roughly the one used in the chemotherapy regimen of most patients. the compatibility of platinum salts with dilution solvent was checked, and all solutions were prepared extemporaneously in a centralised cytotoxic drug preparation unit, in order to protect handlers. setting: allergology department and pharmacy department in a university hospital. main outcome measures: skin tests results: positive if a papule appeared, negative if there was no reaction, local toxicity if an irritative reaction happened. results: patients with clinical symptoms of hr with a chemotherapy regimen containing platinum salts were explored by skin tests. drugs assessed were: oxaliplatin ( patients), cisplatin ( ), and carboplatin ( ) . no patient developed local toxicity. tests results were positive in cases ( oxaliplatin and cisplatin), and negative in cases. patients received both cisplatin and oxaliplatin skin tests: patients had a single positive reaction with no cross reaction between the two drugs, and the third had no reaction. in cases, tests results and clinical history of hypersensitivity mismatched. conclusions: this study shows that these skin test solutions were safe. their efficacy was judged correct: positive reactions confirmed the diagnosis of hypersensibility for patients. the main limit of the results is the absence of control subjects. these tests allowed to explore patients' hr, and to help oncologists to choose the more appropriate treatment for them. stability studies are still needed to assess the pharmaceutical quality of these diluted solutions. these preparations have now been standardized in our hospital. background and objective: guidelines regarding appropriate use of prophylactic antibiotics have been implemented at university hospitals leuven. however, the degree of compliance with these guidelines is unknown. the aim of this study is to develop a method to quantify compliance with antibiotic prophylaxis guidelines and to apply this method to the clinical areas of appendectomy and heart valve surgery. design: a retrospective case series was carried out of all prophylaxis episodes related to appendectomy and heart valve surgery at university hospitals leuven between august and february . four grades of compliance with antibiotic prophylaxis guidelines were identified: grade compliance, reflecting administration of the antibiotic proposed by the guidelines in a dosage within - % of the recommended dosage; grade compliance, defined as the administration of the antibiotic proposed by the guidelines in a dosage outside - % of the recommended dosage; grade compliance, referring to the administration of an antibiotic equivalent to the antibiotic proposed, but not mentioned by the guidelines; and grade compliance, representing any other antibiotic prophylaxis scheme. setting: divisions of abdominal and cardiac surgery, university hospitals leuven. main outcome measures: the percentage of prophylaxis episodes that satisfy each grade of compliance with antibiotic guidelines. results: prophylaxis guidelines relating to appendectomy ( , episodes) recommend administration of three times cefazolin g and a single dose of metronidazol . g. the proportion of episodes that satisfied grade , , and of compliance with guidelines amounted to %, %, %, and %, respectively. cefazolin g and metronidazol . g was used in episodes. prophylaxis guidelines applying to heart valve surgery ( , episodes) recommend administration of cefazolin g. the proportion of episodes that satisfied grade , and of compliance amounted to %, % and %, respectively. grade does not apply to heart valve surgery as no equivalent antibiotics were identified. the difference in compliance with prophylaxis guidelines between both surgical procedures could be explained by differences in infectious pathology, the peri-operative adaptation of the antibiotic regimen by the abdominal surgeon, and the use of a second regimen related to the severity of the appendicitis. a case can be made for combining grade - compliance with respect to appendectomy, resulting in a higher compliance rate. conclusions: our proposed method to measure compliance needs to be validated by future research. the method can be applied to different surgical procedures, thereby stimulating surgeons to explain differences in compliance between procedures and promoting the development of instruments to enhance compliance. closer interaction with surgeons is required to further develop the measurement of compliance with antibiotic prophylaxis. keywords: antibiotic prophylaxis, compliance, guidelines pt- non-specific immunoglobulins for immune neonatal thrombopenia nuria ibañ ez , maria del pilar m. p. bautista , ana maria a. m. iglesias , roberto r. ortiz , javier j. sanchez-rubio , maria del carmen m. c. giron , marta m. arteta pharmacy, pediatry, hospital universitario de getafe, madrid, spain background and objective: non-specific human immunoglobulins are being used at the moment in neonatal population for treatment of immune thrombopenia. the dosis commonly used varies between mg/kg and g/kg from one to five days. corticoids and platelet transfusions can be used jointly. to study the effectiveness and safety of non-specific human immunoglobulins in a neonatal unit for treatment of immune thrombopenia. design: retrospective study of neonatal patients diagnosed with immune thrombopenia during and treated with non-specific human immunoglobulins. a revision of clinical histories is made and following data are collected: sex, gestational age, born weight, age at the moment of infusion, administered dose and duration of treatment, use of corticoids and platelet transfusions, number of platelets/ll before infusion, at , at hours of initiate the treatment and at discharge. possible adverse reactions is also considered. setting: hospital universitario de getafe. main outcome measures: the effectiveness and safety of nonspecific human immunoglobulins for treatment of immune neonatal thrombopenia. results: three children were included in the study, two of them were males. thrombopenia was diagnosed from probable alloimmune origin, including positive confirmation study in one of the cases. gestational ages ranged from + to + weeks. born weight ranged between . kg and . kg. immunoglobulin treatment was initiated between first and sixth day of life. administered dose varies between mg/kg/day and g/kg/day from two to five days. all children needed platelet transfusions, while only one of them was treated with corticoids. the number of platelets/ll before infusion of immunoglobulins, at hours, at hours and at discharge was: children : , , , , , and , platelets/ll. children : , , , , , and , . children : , and , platelets/ll hours after initiation of treatment, there were no analytical data at hours, but number of platelets at discharge was , . no adverse effects were observed in any children. conclusions: although eventually the three children recovered the number of platelets, it can not be concluded that this was due to immunoglobulin treatment, because it is overlapped with administration of platelet transfusions and corticoids. a higher number of patients is required to evaluate efficacy and safety of non-specific human immunoglobulins in treatment of neonatal thrombopenia. background and objective: pulmonary hypertension (ph) is one of the most difficult childhood disease to treat. in spain, oral sildenafil has recently been approved in adults to treat ph, but it s an off-label drug for children (its utilization must be derived to ''compassionate use'', which requires a prior national health authorities approval for every children), and an oral suspension must be formulated at the pharmacy department for them. the objective of this study is to analyse the use of oral sildenafil for ph in paediatric patients. design: years retrospective study. % paediatrics patients with oral sildenafil for ph. clinical data review. setting: paediatric cardiology unit and pharmacy department ( pharmacist) in a paediatric hospital ( beds), in a large general teaching hospital ( beds, pharmacists). main outcome measures: patient data (diagnosis, age, weight). treatment description (dose, length of treatment). treatment effectiveness: peripheral arterial oxygen saturation and six-minute walk test. treatment security: side effects registered. results: children ( girls). age: months to years, median . years. diagnosis: / ph secondary to surgery due to congenital heart disease and / primary ph. sildenafil doses ranged from . mg/kg/ h to mg/ h; median length of treatment was . months ( month- . years). children have used the oral suspension formulated and monthly dispensed at the pharmacy department. other treatments: spironolactone ( ), furosemide ( ) , captopril ( ), acenocoumarol ( ), aspirin ( ), ranitidine ( ) and propranolol ( ). patients have experimented clinical improvement and are on treatment. sildenafil was withdrawn in patients because it was indicated to ameliorate the effects of inhaled nitric oxide withdrawn. patients died. no data available in patient. only patient experimented occasional headache. mensual treatment cost range from - €/patient. conclusions: oral sildenafilo seems to be a safe and effective therapy for paediatric patients with pulmonary hypertensión. due to the lack of an oral formulation for paediatrics patients, it should be elaborated at the pharmacy department. background and objective: we will describe the case of a bi-pulmonary transplant women who developed an invasive aspergillosis located in the lungs and the brain. she received intravenous voriconazole during days. she was then diagnosed with an aspergillus endophthalmitis. even though a dual therapy consisting of caspofungin and posaconazole was initiated, the patient underwent a partial vitrectomy. this therapeutic failure could be explained by a late diagnosis and insufficient vitreous and aqueous humor penetration of the systemic drugs. design: a retrospective analysis of an endophthalmitis management. setting: clinical unit in a french teaching hospital main outcome measures: to secure a high ocular concentration, the ophtalmologist recommended voriconazole intravitreal injections. his prescription was based on several case reports. results: we found articles dealing with animal testing: one concluded that voriconazole was a safe intravitreal agent which may be injected in human eye. another study described the successfull use of intra-ocular voriconazole to treat a fungal endophthalmitis: it allowed a significant improvement in visual acuity and the patient's recovery. however, further studies are needed to assess the optimal dosage and frequency of administration. we prepared voriconazole syringes under a horizontal laminar air flow hood, as follows: -preparation of a mg/ml solution with ml of water for injection and dilution in ml of water for injection, to obtain a mg/ml solution pharm world sci ( ) : - -we sampled . ml of this solution in a ml syringe, which was closed with an occluder, labelled and refrigerated. since we had no data regarding stability, it was administrated extemporaneously. conclusions: intravitreal injections failed to prevent deterioration. had they been introduced precociously, they might have been more efficient. an early diagnosis and prompt management might improve the extremely poor visual prognosis of this devastating condition. were are currently studying the preparation stability. pharmacy service, hospital universitario de getafe, getafe, spain background and objective: in professionals were alerted about an elevated frequency of early virological failure in patients treated with tenofovir (tdf) and didanosine (ddi) associated to lamivudine. in similar results related to the administration of tdf and ddi, in association with a non-nucleoside reverse transcriptase inhibitor (nnrti) were notified. therefore similar events can be observed when tdf and ddi are co-administered in combination with other antiretroviral classes, such as protease inhibitors (pi). subsequent pharmacokinetic studies have shown that tdf when co-administered with ddi increases ddi plasma concentrations leves by up to - %, with a higher risk of didanosine-related adverse events, like pancreatitis and lactic acidosis. the administration of a reduced dose of didanosine ( mg) to avoid over-exposure to didanosine may also contribute to a higher rate of virological failure and emergence of resistance at early stage. the objective of the study is to asses the rate of virological failure in patients treated with tdf and ddi associated to a pi. results: during the study period patients had prescription for drotrecogin alfa for sepsis syndrome; . % were male and the mean age was . years (range - years). all patients had proven infection: . % had pneumonia (n = ), . % pyelonephritis(n = ), . % soft tissue infection(n = ) and . % abdominal infection(n = ). the main isolated micro-organisms were klebsiella pneumonia(n = ), escherichia coli(n = ), pseudomonas aeruginosa(n = ), enterococcus faecium(n = ), staphylococcus aureus(n = ), legionella pneumophila(n = ), proteus vulgaris(n = ), enterococcus faecium(n = ), klebsiella oxytoca(n = ). all patients started treatment within h of the onset of severe sepsis. the treatment was not completed in one patient due to adverse events. contraindications were present in patients: platelet count \ . /l (n = ), age under years (n = ) and major surgery (n = ). the mean organ failures was . (range - organs). adverse reactions were present in patients: thrombocytopenia (n = ), pancytopenia (n = ), bleeding (n = ) and elevation of activated partial thromboplastin time (n = ). mortality at days was found to be % (n = ). conclusions: despite the presence of some contraindications, in most patients drotrecogin alfa was used according to current guidelines. nevertheless, since apache ii score was not determined, the real risk of death is unknown and there can be no extrapolation to literature results. upon these findings, a systematic evaluation of apache ii score must be implemented in order to optimize patient selection and the risk-benefit ratio, improving the use of drotrecogin alfa. pharmacy, oncology, hôpital tenon aphp, paris, france background and objective: it is necessary to focus on side effects for pharmaceutical analysis. dosage reductions are commonly used in cancer chemotherapy. however, little is known concerning the way these reductions are performed in clinical practice. the objectives were to evaluate the incidence, the reason and the percentage of dosage reduction. design: prospective four-week study during which we analysed prescriptions with dosage reductions. setting: pharmacy and clinical oncology department in a paris university hospital. main outcome measures: we focused on prescriptions with dosage reduction and we recorded : -patient information -cancer localisation -chemotherapy regimen -dosage reduction characteristics (date, reduction percentage, reason) the toxicities were classified according to the nci-ctc criteria (grade to ). individual interviews were performed in order to assess how physicians decided the reduction ratio. results: patients ( % women; mean age years) have been treated during that period. diagnosis majority were breast ( %), colorectal ( %) and lung ( %) cancer. patients required a dosage reduction (incidence %). hematological toxicities were the main cause of reductions ( %). the hematological toxicities observed were thrombopenia ( %), neutropenia ( %) and neutropenia-thrombopenia associations ( %). the toxicities observed were grade ( %) or ( %). the other major causes of reductions were neurological ( %) and gastrointestinal ( %). the average percentage of reductions was between % and %. the individual interviews have shown that physicians didn't base the dosage reductions on literature results (established criteria) but on their own clinical practice (experience). conclusions: % of the prescriptions showed a decrease of the regimen. even if there is few literature, clinical trials recommend a decrease of % of the usual dosage of the drugs. the percentage in practice is lower than the one defined by clinical trials. the choices of reduction percentage were not standardized. recommendations for dosage reductions are still needed. keywords: dosage reduction, anticancer chemotherapy, toxicity pt- interdisciplinary approach to dose adjustment in patients with renal impairment in secondary care liekweg a, hinnerkort a, ebeling g, braband s, dreischulte t, heilenkötter k, sander s, schiffmann s, schrimpff u, siems m, wagner k, weiland t, zeigermann g, melzer s hospital pharmacy of the asklepios kliniken hamburg gmbh background and objective: as part of a unit dose dispensing system, patient medication profiles are routinely entered in an electronic database. medication profile and laboratory data are accessible online by clinical pharmacists. the project was conducted in order to optimise pharmacotherapy in patients with renal impairment and to integrate the clinical pharmacist in the therapeutic team. setting: unit-dose supplied wards (n = ) in four asklepios hopitals in hamburg with approximately patients per day. the project was conducted in cooperation with clinical pharmacists, physicians and the laboratory department over a period of . months ( / - / ). programm description: clinical pharmacists receive a list of all patients with an estimated glomerular filtration rate (egfr) \ ml/ min/ , m (mdrd) from the laboratory department on a daily basis. they screen medication profiles daily with regard to apparently inappropriate dosing of renally excreted drugs (q o \ . ). critical cases are reported to physicians by phone or entry in medical case notes. following an interdisciplinary discussion with the physician the drug dose or dosing interval is either adjusted, the medication is stopped or paused or an alternative is started. during the pilot phase the number of altered medications as a result of pharmacists' recommendations was documented. results: a prevalence of % of patients with a egfr \ ml/min/ . m was found in the examined setting. during the pilot phase of prescribed drugs ( %) were renally excreted or considered nephrotoxic. antibiotics ( %), antidiabetics ( %), diuretics ( %) or nsais ( %) were predominantly involved. overall, of pharmaceutical recommendations ( %) were accepted and acted upon by physicians. conclusion: the number of recommendations demonstrates the importance of this service in optimising pharmacotherapy. clinical pharmacists' contributions in matters of dose adjustment in patients with renal impairment is well received by physicians especially in non-nephrologic departments. the new service was found to be feasible in daily practice and has become part of the clinical routine. background and objective: the sources and availability of drug information for patients are growing, e.g. through the internet and official patient information leaflets (pils). however, the quality of the information on the internet might be questioned. furthermore, pils are not standardized, the layout is not reader friendly and the information covers all approved indications for the drug, some of them not relevant for rheumatic patients. also, over the years various information leaflets for drugs have been developed in the departments of rheumatology in norway. these are not standardized and the accessibility is limited. the objective was to develop a system for producing and maintaining reader friendly patient information leaflets about antirheumatic drugs, which takes the quality assurance aspect into account, and is easily accessible for the users. design: development project, consensus method. a national multidisciplinary project group was set up in december , with members from the social leagues (two members), pharmacists' organization (four) and rheumatologists' organization (two). mandate and regulations were approved by the organizations, as well as a legal disclaimer. the pharmacists make a draft for each drug which is e-mailed to all the members of the group. based on the comments a revision is made followed by another hearing until consensus is reached. the rheumatologists approve the leaflet. setting: national multidisciplinary consensus including patients associations main outcome measures: establishment of a dedicated website. number of leaflets published. results: a web address for publication of the leaflets is set up on the home page of the norwegian society for rheumatology: www.legeforeningen.no/nrf. there is a link to this address on the home pages of the social leagues and the norwegian association of hospital pharmacists. during the first year different drug leaflets have been developed and published on the web site. it is possible to search by trade name, generic name and groups of drugs such as ''antiinflammatory drugs'', so the numbers of hits adding up to . conclusions: this national multidisciplinary approach has made it possible to develop a system for making patient information leaflets about anti-rheumatic drugs, which are standardized and easily accessible. keywords: patient information leaflets, drugs in rheumatic diseases, multidisciplinary the need for pharmaceutical care in the prevention of coronary heart disease; an exploratory study in acute myocardial infarction patients the right medicine: a strategy for pharmaceutical care in scotland pharmacy for health: the way forward for pharmaceutical public health in scotland. glasgow: phis . . the sector skills council for health. skills for health: public health practice competences qualitative research: consensus methods for medical and health services research prescribing problems and pharmacist intervention in community practice a dictation system for reporting prescribing errors in community pharmacies a competency framework for the care of a person with diabetes pharmaceutical care of the patient with type diabetes mellitus: a consensus model for delivery of structured pharmaceutical care by community pharmacists in scotland development of a leadership course tailored for pharmacists in scotland pharmacy students attitudes and views about portfolio-based learning: a questionnaire survey using portfolios to learn about prescribing: qualitative insights into students experiences implementing clinical pharmacy services in an outpatient oncology clinic an evaluation of pharmacist contribution in oncology ward in a swedish hospital evaluation of clinical pharmacy services in a hematology/oncology outpatient setting rheumatic illness (ri): ( . %), multiple sclerosis (ms): ( . %), hepatitis c (hc): ( . %). : cfk: ( . %), others: ( . %), ri: ( . %), hiv: ( . %), ms: ( . %), hc: ( . %). : cfk: ( . %) total economic impact (tei): , € valorisation of clinical pharmacy activities: validation of a standard tool for routine interventions quotation in french hospitals keywords: drug related problems hiv-infected patients' perceived satisfaction with an outpatient pharmaceutical care unit (opcu) quality perceived by outpatients at the pharmaceutical care clinic antibiothérapie par voie générale en pratique courante au cours des infectons respiratoires basses de l'adulte et de l'enfant éme conférence de consensus en thérapeutique anti-references simultaneous determination of olanzapine, clozapine and demethylated metabolites in serum by on-line column-switching comparative study and optimisation of the administration mode of three proton pump inhibitors by nasogastric tube is the administration of esomeprazole through a nasogastric tube modified by concomitant delivery of a nutrition mixture? gerontology and geriatric medicine the clinical implications of platelet transfusions associated with abo or rh(d) incompatibility platelet transfusion: products, indications anti-d ig pc- pharmacist's interventions in three medical care units: analysis and impact on the physicians' prescriptions ventilator-associated pneumonia epidemiology and outcomes of health-care-associated pneumonia keywords: pseudomonas aeruginosa, antibiotherapy, vap (ventilator-associated pneumonia) folic acid metabolism and human embryopathy folic acid in general medicine and dermatology folic acid awareness and intake survey in the united arab emirates keywords: pregnancy, folic acid, neural tube defects pepi- pre-diabetes screening program: a proactive study in istanbul community pharmacies www.diabetes.org keywords: type-ii diabetes years later…where do we stand? over-the-counter medications in pregnancy north american association for the study of obesity. consensus development conference on antipsychotic drugs and obesity and diabetes second-generation (atypical) antipsychotics and metabolic effects. a comprehensive literature review keywords: metabolic syndrome, second-generation antipsychotic, biological and clinical follow-up references analysis of taurine in blood plasma of epileptic patients using an improved isocratic hplc method for amino acids cardiovascular actions of taurine pharmacokinetics and pharmacodynamics of the effects of taurine on human blood pressure and heart rate references criteris d'indicació en el tractament de les hepatitis víriques. direcció general de recursos sanitaris peginterferon-alpha a and ribavirin combination therapy in chronic hepatitis c prevalence, incidence and predictors of severe anaemia with zidovudine-containing regimens in african adults with hiv infection within the dart trial the anemia prevalence study group. prevalence of anemia and correlation with biomarkers and specific antiretroviral regimens in human-immunodeficiency-virus-infected patients: findings of the anemia prevalence study clinical pharmacy and medication safety keywords: clinical pharmacist, chronic kidney disease, treatment safety reference nccn clinical practice guidelines in oncoloy for multiple myeloma a phase study of bortezomib in relapsed keywords: antibiotics, emergency department the use of mitomycin-c for respiratory papillomas: clinical, histologic and biochemical correlation mitomycin c: prevention and treatment of anterior glottic synechia preliminary results of intraoperative mitomycin-c in the treatment and prevention of glottic and subglottic stenosis airway complications from topical mitomycin c. otolaryngol head neck surg keywords: mitomycin c, laryngeal papillomatosis, papillomas pt- effectiveness of rituximab in rheumatoid arthritis background and objective: to assess the response to rituximab in patients with rheumatoid arthritis (ra) who were refractory to anti-tnf treatment. design: observational, cross-sectional study. performed on patients diagnosed of ra according to acr criteria the main variables used to assess clinical evolution were: decrease in das -esr, considering the number of references noss eh et al. rituximab as therapy for refractory polymyositis and dermatomyositis treatment of early and refractory dermatomyositis with infliximab: a report of two cases keywords: dermatomyositis, rituximab, infliximab were included in the study. main outcome measures: percentage of patients achieving optimum and minimum audit standards for serum total cholesterol, ldl-c, glycosylated haemoglobin (hba c), bp and take up of aspirin of these, optimum treatment standards for total cholesterol (\ mmol/l) and ldl-c (\ mmol/l) were achieved by . % (n = ) and . % (n = ), respectively. patients within the minimum audit goal for total cholesterol (\ mmol/l) and ldl-c (\ mmol/l) were joint british societies' guidelines on prevention of cardiovascular disease in clinical practice pt- pediatric use of infliximab: retrospective study vanida brunie reference french guidelines for assumption of responsibility of candida sp. and aspergillus sp. invasive infections. french society of anesthesia and reanimation keywords: assessment, antifungal agents comparisons of psychotropic drug prescribing patterns in acute psychiatric wards across europe to score personal risks factors ( to : standard risk, to : high risk) design of a therapeutic scheme following asco's guidelines, as follow. day : aprepitant mg per os h before chemotherapy ondansetron mg iv min before chemotherapy methylprednisolone (mp) mg iv min before chemotherapy days and : aprepitant per os mg methylprednisolone per os mg b.i.d. for the beam strategy, this treatment is given on day (carmustine) and on day (melphalan). the course of corticosteroid was reduced on purpose for clinical oncology guideline for antiemetics in oncology: update . kris and coll keywords: aprepitant, emesis, hematology pt- use of anti-tnf-alfa in rheumatoid arthritis intravitreal voriconazole for the treatment of endogenous aspergillus endophthalmitis intravitreal voriconazole for drug-resistant fungal endophthalmitis: case series fungal endophthalmitis caused by aspergillus ustus in a patient following cataract surgery intravitreal voriconazole: an electroretinographic and histopathologic study management of endogenous fungal endophthalmitis with voriconazole andcaspofungin histological examination of an eye with endogenous aspergillus endophthalmitis treated with oral voriconazole: a case report aspergillus endophthalmitis: an unusual complication of disseminated infection in renal transplant patients maria eugenia martínez nú ñ ez , javier sánchez-rubio ferrández , noelia garrido peño , carolina apezteguía fernández background and objective: zidovudine (zdv) is the first drug that approved for treatment of hiv infected patients and now has wide use in haart regimens. this drug can cause hypoproliferative anemia bone marrow toxicity. the object of this study is evaluation of incidence of anemia in iranian hiv positive patients that received zdv in haart regimens. design: in a prospective study, hiv positive patients were referred to iranian hiv research center that start zdv in haart combination were entered the study and have followed for at least one year. baseline and monthly hematological parameters were recorded. setting: iranian hiv research center. main outcome measures: patients demographic parameters, route of infection exposure, stage of disease, cd counts, cbc, and hematological parameters. results: twenty nine ( ) patients were excluded from the study because of impossible follow-up. from patients, of them have anemia (hemoglobin less than g/dl for female and less than g/dl for male). thirty there ( ) patients have anemia before starting haart. thirty four ( ) patients have showed anemia following received zdv. twenty ( ) patients have improved anemia after were changed zdv to stavudine. conclusions: about % of hiv positive patients that were received zdv have experienced anemia.background and objective: in june , the use of infliximab has been approved by emea for the treatment of severe active crohn's disease in pediatric patients aged to years old, who have not responded to conventional therapy (corticosteroid, immunomodulator and nutrition therapy). however, pediatricians were already using infliximab for patients with inflammatory bowel syndrome (ibd) such as crohn's disease (cd), ulcerative colitis (uc) and indeterminate colitis (ic). the goal of the study was to analyze infliximab prescriptions for children and to evaluate changes in prescriptions of corticosteroid due to the introduction of infliximab. design: retrospective study in ibd patients in a pediatric teaching hospital. setting: gastroenterology unit and pharmacy department. main outcome measures: indications, infliximab dosage, anterior treatments, reason of therapeutic change (non-tolerance or inefficiency of anterior treatment and/or cortico-dependance), evolution of corticosteroid dosage and months after the introduction of infliximab. results: thirty-three children were treated by infliximab: cd, uc and ic. age for diagnosis was an average of years old ( . - . ) and . years old ( - ) for the beginning of infliximab. previous treatment to infliximab was immunomodulators, single therapy for patients (azathioprine n = , mercaptopurine n = , methotrexate n = ) or dual therapy (n = azathioprine + methotrexate), with corticosteroids (n = ) and/or mesalazine (n = ). various etiologies justified infliximab administration: corticodependance (n = ), corticoresistance (n = ), non compliance to corticotherapy (n = ), insufficient efficacy of previous treatment (n = ), non tolerance to previous treatment (n = ). at the beginning, dosage of infliximab was mg/kg. dosages were increased ( mg/kg) for patients due to insufficient clinical results. one patient also had to be switched for adalimumab because he developed human antichimeric antibody (haca). among corticodependant patients ( ), corticosteroids have been stopped after or months, ( %) and patients ( %) respectively. for patients, corticosteroids were continued without reduction of dosages, six months after the introduction of infliximab. conclusions: infliximab is the only therapeutic alternative for children who are non tolerant or non respondent to conventional treatment. moreover, this treatment permits the use of decreased dosage of corticosteroids, limiting their side effects, especially on children growth. however, haca occurrence could limit its use in a long-term disease. keywords: infliximab, inflammatory bowel syndrome, pediatrics chemotherapy indication was autologous bone marrow transplant (bmt) ( %), leukaemia chemotherapy induction or consolidation ( %), leukaemia intensive chemotherapy ( %), myeloblastic allogeneic bmt ( %) and mini allogeneic bmt ( %).treatments were prophylactic ( %), empirical ( %) or curative ( % for aspergillus sp but no for candida sp infections); % of the prescriptions related to local candidosis and % remained unknown.although % of prescriptions were in accordance with internal guidelines concerned antifungal drug indication, % had wrong dosages e.g. no loading dose for voriconazole. moreover, only % of the prescriptions were in accordance with french recommendations: neither voriconazole is approved in prophylaxis of aspergillosis in patients with autologous bmt nor antifungal drugs associations (ten prescriptions). nevertheless, it may be a good way of medical management as hopeful patients outcomes have been obtained.conclusions: hematology department guidelines should be reviewed in accordance with french recommendations, department's ecology and the state-of-the-art about treatment of fungal infections in patients with haematological malignancies. the accordance to further recommendations should be regularly assessed as well as resistance emergence. background and objective: to evaluate the efficacy and safety of rituximab (rtx) for the treatment of refractory autoimmune cytopenia, including autoimmune hemolytic anemia (aha) and immunemediated thrombocytopenia (idiopathic thrombocytopenic purpura itp and thrombotic thrombocytopenic purpura ttp) design: descriptive, retrospective study based on rituximab prescriptions analysis. patients were identified through medical reports delivered by compassionate use program. data collection was made through the pharmaco-therapeutic profile and medical chart review setting: general teaching hospital ( beds) main outcome measures: patients who received any course of rtx for refractory immune cytopenia from january to may were evaluated. data recorded included patients details, diagnosis, previous treatment, rtx schedule, number of courses and baseline hemoglobin (hb) and platelet count (pq) values. effectiveness and tolerance were also considered. response was evaluated according to criteria found in the literature: clinical symptoms resolution and a normal pq count of . /mm for itp/ttp or an hb level [ g/ dl achieved and maintained for at least months for aha. additional response criteria for aha was an hb increase [ . g/dl month after the last dose of rtx. results: patients ( men), doses rtx; average age years (range - ). diagnosis: aha ( cases cold agglutinin disease), itp and ttp. in patients cytopenia (aha) was associated with chronic lymphocytic leukemia. all patients had been previously treated with steroids and had received or more other treatment modalities ( splenectomy, immunosupressive agents, intravenous immunoglobulin). patients received - rtx infusions at a standard dose of mg/m once per week, in combination with steroids therapy in cases. no serious infusion-related effects occurred, but patients reported hematologic toxicity (fever and infection). all patients with aha ( / ) and patients with itp ( / ) responded to the first course of rtx. one patient aha had relapse after months and responded to retreatment. itp responders achieved durable response ( and months) and were offered second course of rtx after relapse ( patients did not respond to retreatment). after months follow-up, patient with ttp remained with acceptable pq counts. hb levels increased by a median of . g/dl (range - , ) among the aha responders. itp + ttp responders achieved a median increase in pq count of . /mm (range - ). only responders who reached a months follow-up were considered for response duration assessment: aha, ttp, itp ( retreatment). median response duration was months (range - ) for aha and months (range - ) for itp + ttp conclusions: most of the literature findings for rtx in this setting were related to small series or isolated case descriptions. despite the common limitation of the number of patients, our results showed that rtx appears to be a promising agent for the treatment of refractory autoimmune cytopenia. key: cord- -sxd t tz authors: nan title: poster presentations date: - - journal: dev med child neurol doi: . /dmcn. sha: doc_id: cord_uid: sxd t tz nan what are the perspectives and understanding of healthcare professionals including occupational therapists on treatment and care of babies with infantile spasms and early-onset epilepsy? a qualitative design dm middleton university of roehampton-online, birmingham, uk objective: to explore the perspectives and understanding of allied healthcare professionals (occupational therapists, physiotherapists, speech & language therapists) that work with children and epilepsy in order to guide and advocate for this population group. methods: a qualitative study design using interpretive thematic analysis with the data from participants in semi-structured interviews. results: the professionals had worked across acute and community settings and had previous experiences of working with children with epilepsy with some awareness of these needs. there were themes that emerged: ( ) housing and social needs, ( ) epilepsy, psycho-social and mental health needs, ( ) therapy approaches, ( ) training for allied healthcare professionals, and ( ) adolescents, young girls, women and epilepsy. conclusions: there are gaps in service provision for certain areas and will be shared within the presentation. epilepsy requires additional considerations for safety that other conditions may not require. it is crucial in the interests of public health for children and families with epilepsy to be able to advocate for resources and their specific needs. poster no. time to onset of cannabidiol (cbd) treatment effect and resolution of adverse events in patients with dravet syndrome: pooled analysis of two randomised controlled trials solution) at mg/kg/day (cbd ; gwpcare ) or mg/ kg/day (cbd ; both trials) or placebo for weeks. cbd treatment started at . mg/kg/day and reached mg/kg/day on day and mg/kg/day on day . percent reduction in cumulative convulsive seizure frequency for each treatment day (including previous treatment days) and timing of adverse events (aes) were assessed. results: overall, patients were randomised to cbd and to placebo. cbd led to significantly greater percent reductions in convulsive seizure frequency than placebo in gwpcare (cbd % vs placebo %, p= . ) and gwpcare (cbd %, cbd % vs placebo %, p= . and p= . ). in the pooled data, treatment differences in seizure reduction emerged during titration and were maintained throughout the study, with nominal significance (p< . ) achieved by day for cbd and day for cbd . onset of the first reported ae occurred during titration in % of patients with aes. aes resolved within weeks of onset in % of patients and by the end of the study in %. increases in alt/ast (> upper limit of normal) occurred in ( %) patients for cbd , ( %) for cbd , and ( %) for placebo; all were on concomitant valproate. all elevations resolved, either spontaneously while continuing cbd, after discontinuing cbd, or after reducing cbd, valproate, and/or clobazam dose. conclusions: cbd treatment effect (seizure reductions and aes) may occur early, during titration. the majority of aes resolved during the study. poster no. low dose fenfluramine hydrochloride oral solution provides long-term, clinically meaningful (≥ %) reduction in seizure frequency in dravet syndrome: interim analysis of a long-term openlabel extension study objective: to characterize long-term safety and durability of effect for adjunctive fenfluramine (ffa) in treating dravet syndrome (ds). methods: patients ( - y) with ds entered a long-term openlabel extension (ole) ( ) after completing one of two phase studies: study ( wks; placebo or ffa . or . mg/kg/d [max, mg/d] or study ( wks; placebo or ffa . mg/kg/d [max, mg/d]) . stiripentol was excluded in study but mandatory in study . in , patients received ffa . mg/kg/d for month ; dosing was titrated to effect thereafter. effectiveness and tolerability were assessed at months , , and , then at -month intervals. results: at interim analysis ( -mar- ) , / patients continued into ole; % completed months of ffa (mean dose, . mg/d; median duration, d [range, - d] ). during the entire ole, median percentage change in monthly convulsive seizure frequency (mcsf) for ffa vs pretreatment phase study baseline was - . % (p< . ); clinically meaningful (≥ %) and profound (≥ %) mcsf reduction from baseline were % and %. at month , median and mean longest interval between convulsive seizures were and days (range, - d); % of caregivers and % of investigators rated patients 'much improved/very much improved'. the most common adverse events included appetite decrease, pyrexia, nasopharyngitis, and diarrhea. no valvular heart disease or pulmonary hypertension was observed in any patient. conclusions: treatment with ffa resulted in robust, sustained reductions in mcsf and was generally well tolerated. no valvular heart disease or pulmonary arterial hypertension was observed in any patient at any time. ffa may be an important, novel antiepileptic drug for long-term ds treatment. poster no. zx (low dose fenfluramine hydrochloride oral solution) provides long-term, clinically meaningful reduction of convulsive seizure frequency in young (< years old) dravet syndrome participants: analysis from a long-term open-label study results: a total of of ( . %) participants who enrolled in the ole were < years old upon entry into the phase studies. the median baseline monthly convulsive seizure frequency (mcsf) before double-blind treatment was . seizures/month (range, . - . ) in this patient subgroup (< y). at the time of the ole interim analysis, the median decrease in mcsf in the < years subgroup over the entire observation period compared to baseline was - % (p< . ) compared with - % in the overall study population ( - y). the most frequently reported adverse events included pyrexia, upper respiratory tract infections, decreased appetite, and diarrhea. no valvular heart disease or pulmonary arterial hypertension was observed. conclusions: treatment with zx provided sustained, clinically meaningful reduction in mcsf in ds participants < years old. importantly, effective control of seizures in this young age group might be expected to mitigate the negative neurodevelopmental outcomes reported to be associated with treatment-refractory seizures. the improving provision of epilepsy care for children in england and wales methods: all relevant health boards and trusts (hb/t) were invited to register to participate and identify a hb/t lead. a snapshot survey was completed via a bespoke online platform by the hb/t lead describing local provision as of april . data was analysed by the rcpch including regional and national aggregates and longitudinal comparison to previous , reports. results: hb/t with a paediatric epilepsy service across england and wales registered to participate and submitted data. . % ( / ) of hb/t employed a consultant paediatrician with expertise in epilepsy; . % ( / ) had some epilepsy specialist nurse (esn) provision; . % ( / ) had a defined epilepsy clinic seeing patients at secondary level. . % ( / ) of hb/t had agreed referral pathways to tertiary paediatric neurology services. satellite paediatric neurology clinics were hosted in . % ( / ) of hb/t. conclusions: there are improvements in the overall numbers of epilepsy nurse specialists, paediatricians with expertise and specific clinics for children and young people with epilepsies. the findings led to comprehensive recommendations to hb/ t and commissioners, informed updates to the epilepsy best practice tariff and themes within the nhs long term plan. poster no. diagnosing and managing seizures on picu: an explanatory sequential mixed methods approach tonic clonic seizures. awake and sleep eeg showed temporal focal slowing. she was labelled as non lesional focal epilepsy after a normal mri scan and was discharged on keppra. she had multiple admissions with cluster of brief seizures at the age of , , , , , and months associated sometimes with febrile illness with poor response to intravenous aed's. she was diagnosed with autism at months. nd child: months old younger sibling had seizure onset at months. seizures were tonic in nature, brief, multiple and in clusters over a period of to days. eeg's showed non-specific slowing during seizures. array cgh revealed chromosome p . microdeletion. keppra was commenced and increased but recurrent cluster of seizures at the age of , and months required admission with poor response to iv aed's. family history revealed that half-sister (biological father's daughter who had epilepsy and global developmental delay) was diagnosed with pcdh epilepsy. gene tests were requested on both siblings and both were heterozygous for pcdh mutation. she had delayed social and communication skills from years with a diagnosis of autism at months. rd child: year old half sibling (father's th child from rd relationship) has tested positive for pcdh . her development is normal and so far there have been no seizures. conclusions: pcdh epilepsy is increasingly recognised as one of the early onset infantile encephalopathies. gene testing is likely to yield a diagnosis with a family history or with a typical phenotype. poster no. seizure, developmental and cognitive outcomes in children post hemispherotomy tt tay , dr reed , vj josan , sr rust , jt tan university of manchester, manchester, uk; neuropsychology team, paediatric psychosocial service, royal manchester children's hospital, manchester, uk; neurosurgery, salford royal nhs foundation, manchester, uk; paediatric neuropsychology, royal manchester children's hospital, manchester, uk; paediatric neurology, royal manchester children's hospital, manchester, uk introduction: patients with focal refractory epilepsy secondary to structural hemispheric changes have been shown in retrospective studies to have significantly improved seizure outcomes following hemispheric disconnection. the aim of this study was to report the seizure and cognitive outcomes in our cohort and investigate prognostic factors for seizure outcomes. methods: this was a single-centre retrospective study on children and adolescents who had hemispherotomy for refractory epilepsy in the royal manchester children's hospital between and . results: twenty-two patients were included with median (range) age of seizure onset and of surgery of ( - ) and ( - ) months respectively. median (range) time from seizure onset to surgery was . ( - ) months. the most common aetiologies were antenatal/perinatal middle cerebral artery infarct (n= ) and malformations of cortical development (n= ). at year after surgery and at last follow-up (median [range] [ - ] months), % ( / ) and % ( / ) achieved complete seizure freedom. the number of anti-epileptic medications decreased for ( %) at last follow-up. lateralisation of ictal and interictal eeg (p= . , p= . ), aetiology (p= . ), age of first seizure (p= . ) were not associated with seizure recurrence. five who had formal neuropsychological testing using the wechsler intelligence scale for children (wisc) showed improvement in cognitive abilities across all subsets post-surgery. ten children showed reduction in median vineland adaptive behaviour score, from to . , indicating a failure to progress rather than regression of skills. nine ( %) had newly reported behavioural or psychiatric issues including sleeping problems, challenging behaviours, autistic spectrum disorder. sixteen ( %) were reported by parents/carers to show improved verbal abilities postoperatively while the rest had unchanged verbal abilities. conclusions: we present a cohort of children with early onset seizures who had hemispherotomy at a relatively early age. our cohort showed good seizure outcomes and cognitive improvements. there were no prognostic factors for seizure outcome identified in this small group. the mri phenotype of atp a -related disease contrast, all ahc patients with mri abnormalities ( %) had a hypoplastic corpus callosum. the only patient with normal mri was the patient carrying mutation p.g r, associated with a mild clinical phenotype. of the patients with clinical ataxia (n= ), ( %) had cerebellar atrophy on mri; patients with cerebellar atrophy were not ataxic. two ( %) of the patients with severe intellectual disability had cerebral atrophy. conclusions: atp a mutations have subtle radiological findings, clustering around callosal dysmorphisms, as well as pontine and cerebellar abnormalities that seem to form distinctive mri phenotypes for ahc and capos. study of larger cohorts is required to more accurately define mutation-specific phenotypes and allow for quantitative analysis. poster no. long-term safety and efficacy of adjunctive perampanel in paediatric patients (aged to < y) with partial-onset seizures (pos) or primary generalised tonic-clonic seizures (pgtcs) in study r flamini , a patten , ly ngo pediatric and adolescent neurodevelopmental associates, atlanta, ga, usa; eisai ltd., hatfield, hertfordshire, uk; eisai inc., woodcliff lake, nj, usa objective: study (nct ) was a multicentre, openlabel, single-arm study of perampanel oral suspension ( . mg/ ml) in paediatric patients (aged to < y) with pos (with/ without secondarily generalised seizures [sgs] ) or pgtcs. here, we report long-term ( y) safety and efficacy data of adjunctive perampanel in paediatric patients from study . methods: this analysis included cumulative data from all enrolled patients in the core study ( wks of treatment) and extension phase a ( wks of treatment). assessments included monitoring of treatment-emergent adverse events (teaes), median percent change in seizure frequency per days from baseline, and % responder and seizure-freedom rates. results: of patients enrolled in the core study (pos, n= ; sgs, n= ; pgtcs, n= ), patients entered extension a. of these, patients discontinued extension a; most common primary reasons for discontinuation were adverse events ( . %) and inadequate therapeutic effect ( . %). for all patients, mean (standard deviation [sd] ) time since diagnosis was . ( . ) years and mean (sd) duration of exposure was . ( . ) weeks. during baseline, . % of patients received two concomitant anti-seizure medications. teaes were reported in ( . %) patients; somnolence was the most commonly reported ( . %). median percent reductions in pos, sgs and pgtcs frequencies at weeks - were . %, . % and . %, respectively; these were maintained at weeks - and were . %, . % and . %, respectively. seizure-freedom rates for pos, sgs and pgtcs at weeks - were . %, . % and . %, respectively. conclusions: long-term ( y) adjunctive perampanel is generally safe, well tolerated and efficacious in paediatric patients aged to < with pos (with/without sgs) or pgtcs. poster no. long-term adjunctive perampanel and healthrelated quality of life (hrqol) in paediatric patients (aged to < y) with partial-onset seizures (pos) or primary generalised tonicclonic seizures (pgtcs): study ea portillo , a patten , g meier , m malhotra , ly ngo paediatric neurology unit, department of paediatrics, hospital universitario virgen del roc ıo, sevilla, spain; eisai ltd., hatfield, hertfordshire, uk; eisai inc., woodcliff lake, nj, usa objective: study (nct ) was a multicentre, openlabel study of adjunctive perampanel oral suspension in paediatric patients (aged to < y) with pos (with/without secondarily generalised seizures [sgs] ) or pgtcs. we report long-term ( y) hrqol data using the euroqol dimensions-youth (eq- d-y) scale from study . methods: this analysis included cumulative data from all enrolled patients in the core study and extension phase a ( and wks of treatment, respectively). eq- d-y was assessed at baseline, week and week , and included five domains (mobility, self-care, doing usual activities, pain/discomfort, feeling worried/sad/unhappy). the eq- d-y visual analogue scale (vas) was also assessed; increases in vas correspond with improvements. data are for observed cases. results: all enrolled patients were included in the eq- d-y analyses. the proportion of patients reporting 'a lot of problems' was similar during baseline vs week : mobility, / ( . %) vs / ( . ); self-care, / ( . %) vs / ( . %); doing usual activities, / ( . %) vs / ( . %); pain/discomfort, / ( . %) vs / ( . %); feeling worried/sad/unhappy, / ( . %) vs / ( . %). outcomes were also similar for 'no problems' during baseline vs week : mobility, / ( . %) vs / ( . %); self-care, / ( . %) vs / ( . %); doing usual activities, / ( . %) vs / ( . %); pain/discomfort, / ( . %) vs / ( . %); feeling worried/sad/unhappy, / ( . %) vs / ( . %). mean (standard deviation) change in eq- d-y vas from baseline at week was . ( . ). conclusions: long-term adjunctive perampanel treatment (up to y) does not negatively affect hrqol (based on all eq- d-y domains) in patients aged to < years with pos (with/without sgs) or pgtcs. poster no. efficacy and safety of adjunctive perampanel for partial-onset seizures (pos) in adult, adolescent and paediatric populations (studies , , , ) . in study , patients received perampanel ≤ mg/day (without enzyme-inducing anti-seizure medications [eiasms] ) or ≤ mg/day (with eiasms) ( -week treatment period). efficacy assessments included median percent change in seizure frequency/ days from baseline, % responder rate and seizure-free rate. safety assessments included the incidence of treatment-emergent adverse events (teaes). results: the median percent reduction in seizure frequency/ days was greater with perampanel at ( . %), ( . %) and mg/day ( . %) vs placebo ( . %; p< . ) in adolescent/adult patients and was . % in paediatric patients. the % responder rate during the maintenance period was greater with perampanel at ( . %), ( . %) and mg/ day ( . %) vs placebo ( . %; p< . ) in adolescent/adult patients and was . % in paediatric patients. seizure-freedom rates were greater with perampanel at ( . %), ( . %) and mg/day ( . %) vs placebo ( . %; p< . ) in adolescent/ adult patients and was . % in paediatric patients. teaes occurred in . %- . % of adolescent/adult patients with perampanel - mg/day (vs . % in placebo patients), and in . % of paediatric patients. teaes observed in pediatric patients were similar to those reported in adolescents and adults. conclusions: these studies suggest perampanel is efficacious and generally safe in paediatric, adolescent and adult patients with pos (with/without sgs). methods: patients who completed either of the rcts could enter this ole trial (gwpcare /nct ). patients received gw pharmaceuticals' plant-derived highly purified cbd medicine ( mg/ml oral solution). the primary endpoint was safety. the secondary efficacy endpoints were median percentage change from baseline in drop and total seizure frequency. results: overall, % ( / ) of eligible patients with lgs entered the ole. median follow-up was weeks ( d to wks); patients ( %) withdrew. mean age: years; % ≥ years; % male. baseline median seizure frequency/ days: drop seizures; total seizures. during the extended follow-up, the incidence of adverse events (ae) was %; serious aes %; aes leading to discontinuation %. most common aes (≥ %): diarrhoea, convulsion, pyrexia, somnolence, vomiting, upper respiratory tract infection, and decreased appetite. aes of alanine aminotransferase increased occurred in % of patients. there were deaths; none deemed treatment-related by the investigator(s). median percentage reductions in seizure frequency ( -wk windows over wks) was - % for drop seizures and - % for total seizures. conclusions: long-term treatment with add-on cbd in patients with lgs produced sustained seizure reductions, with no new safety concerns. poster no. management of status epilepticus in children with dravet syndrome jaa holland, u rajalingam paediatrics, hinchingbrooke hospital, huntingdon, uk objective: status epilepticus is reported to be the second greatest cause of mortality in children with dravet syndrome. we aimed to review the evidence on convulsive status management in children with dravet syndrome to guide local practice. methods: literature review. results: pubmed search using search terms 'dravet' or 'scn a' and 'status epilepticus' returned results, of which were relevant. only one of these articles presented specific data on reported effectiveness of medications used in acute seizure management; this was based upon retrospective questionnaire data and defined status epilepticus as seizures lasting minutes or longer. here, the most efficacious agents reported to terminate such seizures within minutes were intravenous barbiturates ( of patients) and benzodiazepines ( of patients). rectal benzodiazepines, chloral hydrate and intravenous phenytoin or lidocaine were reported as less effective. the remaining articles presented expert and consensus opinion, all advising early administration (some at seizure onset) of buccal or intravenous benzodiazepines. provision of rescue medication for home use, with individualised plans, is recommended. one author advocated giving three doses of benzodiazepines sequentially. an article summarising a consensus panel described sodium valproate as a preferred second line option where benzodiazepines are ineffective, but there was no overall agreement on other possible medications. several articles advised caution in using phenytoin in acute seizure management. one source discusses possible harm from high dose barbiturates. conclusions: status epilepticus management for children with dravet syndrome should feature early, rapidly acting benzodiazepine administration. for second line treatment, phenytoin and barbiturates are commonly used in 'standard' status epilepticus management protocols, but there are potentially concerns around their use in this patient group. these concerns, however, appear largely theoretical. in the absence of evidence favouring a specific management protocol, individualised care plans should be designed with involvement of patients and their carers. poster no. zx (low dose fenfluramine hydrochloride oral solution) significantly reduces frequency of generalized tonic-clonic seizures in dravet syndrome: pooled analysis from two phase clinical trials jh cross , a gil-nagel , b gunning , d battaglia , k riney , g farfel , , a mistry , , b galer , , g morrison , , a gammaitoni , , k pagano , great ormond street hospital, london, uk; servicio de neurologia, hospital ruber internacional, madrid, spain; stichting epilepsie instellingen, zwolle, the netherlands; gemelli hospital, rome, italy; mater children's hospital, brisbane, qld, australia; zogenix, inc and int, emeryville, ca, usa; zogenix, inc and int, maidenhead, uk objective: zx (low dose fenfluramine hcl oral solution) significantly reduced the frequency of convulsive seizures in patients with dravet syndrome (ds) in two phase clinical trials. we conducted a pooled analysis of these trials to analyze the effect of zx on the frequency of tonic-clonic seizures (tcs), recently identified as a major risk factor for sudden unexpected death in epilepsy. methods: the frequency of generalized tcs and focal-to-bilateral tcs in patients with ds enrolled in one of two phase clinical trials of zx added to current antiepileptic drug regimens were analyzed. results: patients ( % male, mean age y) were enrolled and randomized to placebo (n= ), or zx . (n= ), . (n= ), or . (n= ) mg/kg/day. the median baseline monthly frequency of generalized tcs ranged from . to . /month in the four dose groups, and decreased during treatment by %, %, and % in the zx . , . , and . mg/kg/day groups, respectively, and by % in the placebo group. focal-to-bilateral tcs were experienced by fewer patients and had a median baseline frequency of . to . / month. during treatment, median percentage reductions in focal-to-bilateral tc frequency were %, %, and % in the zx . , . , and . mg/kg/day groups, respectively, and % in the placebo group. most common adverse events included decreased appetite, diarrhea, and fatigue. no valvular heart disease or pulmonary arterial hypertension was seen in any participant at any time. conclusions: zx substantially reduced the frequency of tcs. zx may be an important, effective new treatment option for ds patients. objective: mutations affecting tbc d have been associated with an expanding spectrum of phenotypes including developmental delay, hearing impairment, doors syndrome and a range of epilepsies. a number of different movement disorders, including ataxia, spasticity and episodic paroxysmal dystonia have also been described. here we report two unrelated patients with biallelic tbc d variants, in whom exerciseinduced dystonia was a major disease feature. methods: both patients were diagnosed through whole-exome sequencing. clinical information was obtained by a review of the medical notes, clinical correspondence and available video footage. results: both patients were found to have compound heterozygous mutations in tbc d , associated with an episodic dystonic/dyskinetic movement disorder reliably triggered by exertion. in the case of patient , exertion of specific body parts induced specific localised symptoms: for example, singing would precipitate orolingual dyskinesia. both girls experienced truncal dystoniaspecifically, lateral flexion of the trunkbrought on by prolonged walking. both girls also had epilepsy; of note, the exercise-induced movements and postures were captured on eeg and had no ictal correlate. conclusions: although tbc d mutations are an established genetic cause of epilepsy, our study further confirms that not all paroxysmal events in people with tbc d mutations are epileptic in nature. tbc d should be included in the genetic differential diagnosis of patients with complex neurological syndromes associated with paroxysmal exercise-induced dyskinesia. objectives: heterozygous de novo rhobtb mutations have recently been reported in developmental and epileptic encephalopathy, but the associated movement phenotypes are not fully delineated. in order to better define the expanding phenotype and movement disorder in rhobtb -related disease, we report a series of unrelated patients presenting with complex movement disorders as well as epilepsy and developmental impairment. methods: cases were identified both in the uk (through the neurogenetic services at great ormond street hospital and the national hospital for neurology and neurosurgery, london), and from international collaborating centres. data were collected retrospectively by the patients' clinicians, using a standardised proforma. results: nine individuals were identified, aged from to years. / had epilepsy. of these, / had achieved seizure freedom at their last review. the commonest seizure types were focal onset with impaired awareness and/or focal to bilateral tonic-clonic seizures. / also had a paroxysmal movement disorder, which included hemiplegic or asymmetrical episodic weakness in / , generalised dyskinesia in / , episodic focal dystonia in / and episodic ataxia in / . all individuals affected by a movement disorder had at least two different types of episodes. movement disorders improved significantly after treatment with carbamazepine in three children. cognitive ability varied from average to severe intellectual disability and in all but one case, developmental delay predated the onset of epilepsy. conclusions: rhobtb mutations cause a complex neurological phenotype associated with both epileptic and non-epileptic paroxysms. paroxysmal events occurring in people with known rhobtb mutation should therefore not be assumed always to be epileptic in nature. our study confirms that a wide variety of movement disorders are reported, including some which fall within the spectrum of alternating hemiplegia of childhood (ahc). rhobtb should thus be considered as a potential gene for ahc, other complex movement disorder phenotypes and epilepsy-dyskinesia syndromes. poster no. evaluating seizure recognition and the use of electroencephalography in the paediatric intensive care unit objective: in the paediatric intensive care unit (picu), seizures are challenging to detect given patient complexity, comorbidity and sedation. this has led to both over-and under-treatment of seizures. there is growing literature on the use of continuous electroencephalography in picu, considered gold standard but not universally available, but little on standard electroencephalography (eeg). this study aims to investigate the indications for eeg requests, their efficacy and the use of antiepileptic drugs (aed) in picu, hypothesising a difficulty in clinically differentiating between epileptic and non-epileptic events and suboptimal use of aeds. methods: this retrospective study examined eeg reports over years at a tertiary picu. data was collected on participant characteristics, eeg indications and findings and aed use. results: eeg reports from participants were included. median age was months (iqr mo- y mo). indications for eeg (often multiple per eeg) included suspected clinical seizures ( %), suspected subclinical seizures ( %), prognostication ( %) and suspected encephalopathy ( %). % of participants with suspected seizures were sedated and % of all participants were encephalopathic. clinical episodes suspected to be seizures were captured in / eegs. only % of these were eeg-confirmed seizures. captured movements shown not to be seizures are qualitatively described. % of patients with suspected seizures had electrographic seizures with no clinical correlate. most confirmed seizures were in participants without pre-existing epilepsy. antiepileptic(s) were changed prior to / captured events. seizures were present in % of these cases, while % had neither clinical nor electrographic seizure activity. / participants with confirmed clinical seizures had aeds changed. conclusion: it is challenging for clinicians to differentiate between seizure and non-seizure movements in picu. moreover, there are issues of over-medication and low event-capture rate with eeg. we propose a multidisciplinary education strategy and investment in ceeg to address these issues. introduction: glucose transporter deficiency syndrome (glut -ds) is a rare neurometabolic disorder causing impaired glucose transport into the brain. in the majority of patients, it is caused by an autosomal dominant heterozygous mutation in the scl a gene. ketone bodies generated by a ketogenic diet (kd) provide the brain with an alternative energy source and is gold standard therapy. we report our experience for our cohort of patients at royal manchester children's hospital. methods: retrospective case note review of patients with glut -ds at royal manchester children's hospital from to . results: patients - male, female. age range to years. average age at diagnosis was years months (range mo- y). there was a history of seizures in of patients with average seizure onset of years months. seizures types were absences ( / ), generalised tonic-clonic ( / ), myoclonic ( / ), myoclonic astatic ( / ), tonic ( / ) and focal to bilateral tonic-clonic ( / ). ketogenic diet was used in all patients for a range of months to years months. no significant adverse effects occurred that required discontinuation. six patients complying with kd are seizure free and not taking antiepileptic drugs (aeds). one of these patients had occasional tonic-clonic seizures with illness and loss of ketosis but has been seizure free for > months. five patients are non-compliant with kdtwo have good seizure control with aeds, potentially limiting motivation, and two (siblings) have a parent with glut -ds and learning difficulties. learning difficulties were reported in patients. other symptoms included ataxia ( / ), dysarthria ( / ), tremor ( / ) and dystonia ( / ). one patient presented with episodic hemiplegia. conclusions: patients with glut -ds are a heterogeneous group leading to challenges in diagnosis, management and prognosis. ketogenic diet has been effective in managing this cohort but compliance was a limiting factor. objective: to conduct a survey regarding the management of relapse in children epilepsy in following weaning off aeds. methods: we conducted an online survey in the east of england (eoe) via the eastern paediatric epilepsy network (epen) regarding the management of relapse in children epilepsy after weaning aeds. epen is a network of paediatricians and nurse specialist with eoe who manage lead in management children with epilepsy within all the dgh's in the region. the questions in the survey asked about various aspects of management of patients after relapse, including the choice of anti-epileptic medication restarted, if started, any further investigations undertaken, and finally, the length of aed treatment before a second attempt at weaning might be considered. results: we received responses from paediatricians in dgh's across eoe. there was a large degree of variation in the responses to all of the questions in the survey. the frequency and semiology of seizures on relapse seemed to play a key role in decision making, as did the thoughts and views of the family and patient themselves. it was interesting to note there was a variation in response to whether any further investigations would be undertaken and if these were deemed necessary. most clinicians responded that they would continue aeds for another years before attempting weaning again. conclusions: there is variability in the management of epilepsy relapse in the eoe and we suspect that this may also be the case nationally. to investigate this further, we would envisage extending the survey nationally, via open ukwhich is an organisation that links the various regional paediatric epilepsy networks across uk. this would enable establishing a standardized guideline for management of epilepsy relapse in the future. objective: de novo dominant mutations in dhdds were recently identified as a cause of developmental and epileptic encephalopathy. dhdds encodes dehydrodolichyl diphosphate synthase, which is essential for dolichol monophosphate synthesis and protein glycosylation. we report two half-siblings with a new pathogenic, maternally inherited dhdds missense variant, c. g>a(p.arg gln), identified through whole-exome sequencing. method: case note and literature review. results: sibling , aged years, presented at months with global developmental delay, hypotonia and frequent absences with eyelid myoclonia. from age , she developed atonic drop attacks, myoclonic seizures, tremor, ataxia and facial dyskinesia. dyskinesia and mobility deteriorated from age and she is now largely non-ambulant. severe learning disability with possible cognitive deterioration and insatiable appetite are also features. sibling , aged years, developed blank spells associated with eyelid flickering at months and atonic drop attacks aged . development delay is present, but progress is greater than her sibling. dyskinesia, tremor, ataxia and deterioration in mobility are features. neither is dysmorphic. eegs on both showed bursts of irregular generalised spike wave associated with head nods and eyelid flutter. photosensitivity was not shown but both were treated with anti-epileptic medication. mri scans are normal. clobazam and zonisamide improved seizure control in both. mother has mild learning difficulties, tremor and dyspraxia. she had generalised tonic clonic seizures, from age to years, well controlled with lamotrigine. compared to the six known cases in the literature, our report confirms atonic seizures and dyskinesia as important features of this disorder, in addition to common characteristics of myoclonic component to seizures, hypotonia and tremor. learning disability is of variable severity. conclusions: this is the first report of familial inheritance of dhdds related developmental and epileptic encephalopathy and describes variable severity of the phenotype within family members. the features described are consistent with those previously observed. objectives: to evaluate whether the duration of treatment has an effect on the relapse rate in children with cae attending a paediatric neurology centre in cyprus, and whether the eeg can be used as a prognostic tool. methods: electronic patient database review of patients with cae, who have discontinued treatment attending the paediatric neurology clinic between years - . results: fourteen patients with cae, off treatment were identified ( male). age at presentation ranged from to years (median . y). all patients underwent an eeg to confirm diagnosis and those who presented with seizures other than absences were excluded. twelve patients were treated with valproic acid (depakine) and with ethosuximide (zarontin). in , absences resolved on first line monotherapy, whilst were refractory requiring combination therapy. positive family history was present in (non-identical twins), attention deficit in , and learning difficulties in patient. all initial eegs were consistent with cae, patients also underwent an eeg post seizure control to confirm resolution. mean time to seizure cessation was . months, mean duration of treatment . years; patients discontinued treatment after year of seizure freedom. prior to withdrawing treatment all patients had an eeg (normal , mildly abnormal with brief generalised discharges , photosensitivity , brief electrographic absence ). relapse occurred in patients who required re-instigation of treatment. mild abnormalities on eeg prior to coming off treatment did not correlate with a higher relapse rate. there was no difference in relapse rate in patients on treatment for , or more years. patients were followed up for a mean of . years. conclusions: treating patients with cae for less than years does not affect relapse rate provided patients are seizure free, also confirmed by eeg normalisation, which may be used as an additional predictor. background: mutations in unc , encoding part of the unc -unc -nalcn channel complex, causes autosomal-recessive severe infantile encephalopathy, this is a rare case of profound global developmental delay with psychomotor retardation. only individuals have been reported to date. unc deficiency is characterized by hypotonia, strabismus, oral motor dysfunction, postnatal growth deficiency, and developmental delay. the majority of individuals do not learn to walk. all individuals lack expressive language. additional features can include nystagmus, extremity hypertonia, a highpitched cry, repetitive and self-stimulatory behaviours, constipation, clubfeet, joint contractures, and scoliosis. there is no loss of skills suggestive of neurodegeneration. case presentation: -year-old, with a recent confirmed diagnosis of unc gene mutation and microcephaly. she had profound global developmental delay, learning disability, bilateral squint with cortical blindness, seizure disorder, sleep apnoea, head drops, movement disorders, feeding difficulty, scoliosis and constipation. term baby with normal anti-natal history. induction of labour for iugr. good apgar, at birth but developed respiratory distress with cardiac problems. birth weight g. neurologically: floppy with reduced muscle tone and microcephaly. had a short neonatal admission and discharged with cardiac, endocrine, neonatal and neurodevelopmental delay follow-up. she had no spoken words and communicated by crying. she was only able to sit transiently and never walked. she was wheelchair bound with gmfcs, macs, cfcs and edacs level each, needing full -hour support from patents and carers. ddd study confirmed unc gene mutation, her cousin was also noted to have same gene mutation via exome sequencing and with similar clinical picture. conclusion: early diagnosis is key for genetic counselling for further children and ensuring global support as reported individuals span ages from birth to year. the diagnosis is established in a pro-band with developmental delay and hypotonia by identification of bi-allelic pathogenic variants in unc on molecular genetic testing. poster no. cognition and disease burden in scn a positive dravet syndromea -year follow-up study development, disease burden and sleep profile of patients with dravet syndrome. methods: this is a follow-up to a study previously involving ds patients with detailed developmental and clinical information available. participants completed a structured postal questionnaire on epilepsy severity and disease burden, the adaptive behavioural assessment system (abas- ), the sleep disturbances scale for children, pediatric quality of life inventory (pedsql) and the strength and difficulties questionnaire. results: / from the original cohort were contactable and ( %) of carers completed the outcome measures. the developmental quotient at follow-up was significantly lower compared to the earlier study (p= . ), and % of affected individuals had a severe or profound learning disability. we observed the steepest decline in cognitive functioning in those that were youngest (age - y) at original study onset (p= . ). poorer developmental quotients correlated with early onset of initial developmental concerns (rs= . ; p= . ), later mobility problems (rs= . ; p= . ), higher levels of behaviour problems (rs= . ; p= . ) and worse pedsql scores (rs= . ; p= . ). carers health and wellbeing was negatively affected in % of cases and in %, at least one of the two carers quit their job due to their child's illness. sleep problems as measured by total sleep scale score were reported in % of patients, whilst % had at least one abnormal sleep scale category. only % of individuals with abnormal sleep scores received treatment. rs=spearman rho correlation coefficient. conclusions: this study highlights the ongoing cognitive decline in ds, particularly affecting younger patients, alongside often untreated sleep problems and a significant disease burden on primary carers. with new therapeutic opportunities on the horizon, early interventions appear crucial to avert the observed severe cognitive decline. poster no. forced normalisation as a factor in behaviour deterioration on the ketogenic diet e hassan , vj whiteley , , hj tan department of neurology, royal manchester children's hospital, manchester, uk; therapy and dietetics, royal manchester children's hospital, manchester, uk; school of health and society, university of salford, salford, uk introduction: there have been a number of reports that demonstrate a correlation between improved seizure management and deterioration of behaviour with psychosis in adults and children. forced normalisation is a concept where there is deterioration in behaviour when better seizure control is achieved with antiepileptic drugs (aeds) or epilepsy surgery. the ketogenic diet (kd) is a treatment option for children with refractory epilepsy with approximately to % showing at least % reduction of seizures and % of those patients reaching seizure freedom months after treatment. although forced normalisation has been discussed in literature following aeds and neurosurgical interventions, it has not been reported following the use of kd. cases: of the children that have commenced on kd over the last years at royal manchester children's hospital, . % responded to the diet (at least % improvement in seizures) and . % were non-compliant. we present patients under the care of the kd service, whose behaviour deteriorated on kd when seizure reduction was > %. the behaviour changes described by parents included poor sleep, unsettled, agitation, head-banging and shouting. five out of the six patients stopped kd treatment, with subsequent improvement in behaviour. conclusions: there are reports that patients on the ketogenic diet with seizure freedom show improvement in their behaviour, unlike our small cohort whose behaviour deteriorated. forced normalisation has been explored in paediatric patients as a cause for behaviour deterioration following surgical and medical management for intractable seizures. the associated factors of deteriorating behaviour have not yet been explored in depth with the ketogenic diet. objective: we wanted to determine how lacosamide was being used in children locally, and what their outcomes were at a year. methods: we undertook a registered, retrospective, clinical audit using hospital electronic records. we ascertained every patient aged < years who had been dispensed lacosamide january -january . the electronic health records were reviewed, and data collected using a standard proforma, including: patient demographics, age of seizure onset, seizure type, ecg and mri findings, baseline seizure frequency, seizure frequency , , and months on lacosamide, maximum dose prescribed (mg/kg/day), and adverse effects at , , and months. results: / ( %) patients were male, the median age was years (range mo to y), with a mean age of onset of years (range mo to y). / ( %) had epileptiform activity on eeg and / ( %) had an abnormal mri. / ( %) had focal seizures. / ( %) had a minimum of one seizure a week. / ( %) had previously tried or more antiepileptic drugs (aeds), and / ( %) had drug resistant epilepsy prior to starting lacosamide (already failed previous aeds). all patients had lacosamide alongside another aed. the mean daily dose of lacosamide was . mg/kg/day (range . - . ). at months, / ( %) of patients reported a > % reduction in seizure frequency. / ( %) remained on lacosamide year after starting, and / ( %) experienced an adverse side effect. conclusions: in this local audit, lacosamide was mostly prescribed for drug resistant epilepsies and was used in polytherapy. a third of patients saw a significant reduction in seizure frequency on lacosamide, although some were also started on other treatments during this period. most patients remained on lacosamide after months, and about in experienced one or more adverse side effect. cacna a is a large gene which encodes for the alpha subunit of a neuronal ion channel and it is expressed widely throughout the central nervous system (cns). pathogenic variants in this gene have been associated with many phenotypes. most commonly episodic ataxia type (ea ) and spinocerebellar ataxia type (sca ). rarer phenotypes include, familial hemiplegic migraine, paroxysmal tonic upgaze, epilepsy, and intellectual disability with autism. here we present the case of an month old girl who presented with new onset paroxysmal abnormal eye movements during an intercurrent illness. the referring clinicians felt these episodes may be epileptic. however, an electroencephalogram (eeg) captured these movements which were non-epileptic downbeat nystagmus. all other initial investigations including cerebrospinal fluid glucose and neurotransmitters were normal as was her neuroimaging. over the next year her nystagmus became constant. she had otherwise normal development. at months her gait was noted to be abnormally unsteady and broad based (even accounting for age). the nystagmus and ataxia changed in severity from day to day, she could have to more severe days followed by to better days, they never completely resolved. she had no family history of abnormal eye movements or ataxia. subsequent genetic testing revealed a cacna a c. g>a p(glu lys) missense variant described only twice previously in ea , both with very different phenotypes to our patient. neither of her parents carried the same genetic variant. this case is the first reported case of this cacna a variant presenting as downbeat nystagmus followed by ataxia. both her age of presentation and her initial presenting features are very different to the typical phenotypes associated with this gene. it broadens the phenotype of cacna a, and also broadens the differential diagnoses associated with abnormal eye movements in infancy. the importance of following up as yet undiagnosed patients who may go on to develop new and revealing symptoms is highlighted. objective: to undertake a questionnaire-based survey retrospectively exploring parents'/carers' recall of, and views on, the safety and risk advice given at the time of their child's epilepsy diagnosis. methods: questionnaires were distributed throughout scotland via scottish paediatric epilepsy network (spen). parents'/ carers' of to -year-old children were asked to complete the questionnaire prior to their seizure clinic appointment. results: questionnaires were suitable for inclusion. seizure burden was evenly distributed: % < seizure/month, % > seizure/month, % > seizure/week and % had absences only. respondents could recall post-diagnosis information being provided on: water safety ( %), taking medication regularly ( %), sports/activities ( %), seizures in sleep ( %), first aid ( %), prolonged seizures ( %) and/or sudep ( %). there was no statistically significant difference in the duration of epilepsy diagnosis between those who could recall information being given (m= . y, sd . ) and those who could not (m= . y, sd . ; t test p= . ). the majority of information was given via clinic discussions ( %). % received written information, % directed to websites and/or independent search ( %). most information was 'just right' ( % water safety, % on taking aed regularly, % on sports/activities, % on seizures in sleep, % on first-aid for seizures). approximately % of respondents want more information on seizures in sleep, water safety and sports/activities. % of respondents felt worried following information about seizures in sleep, % about prolonged seizures and % regarding sudep. conclusions: a substantial proportion of parents'/carers' do not recall receiving safety information on epilepsy despite this being standard practice through spen. this appears to be unrelated to the duration of their child's epilepsy. repeated timely reinforcement may be of benefit. a high proportion of parents'/carers' felt concerned following information provided on nocturnal seizures, prolonged seizures and sudep. this should be recognised with support in place for further discussions. poster no. seizure outcome in responsive vagus nerve stimulation therapy in children and young people v rasiah, n barnes, s carter, k das, r robinson, z tahir, s varadkar great ormond street hospital for children nhs foundation trust and ucl gosh institute of child health, london, uk aim: vagus nerve stimulation (vns) therapy is an established treatment for pharmacoresistant epilepsy. newer responsive-vns (rvns) systems use ictal-tachycardia detection as a biomarker of seizure onset and automatically deliver additional stimulation on detection to abort the seizure. we reviewed the seizure outcomes in children and young people (cyp) implanted with rvns at great ormond street between to . methods: data were collected prospectively on patients who had an aspiresr â rvns inserted during time period of to . reduction in seizure frequency and severity, wean of medications and treatment complications or side-effects were assessed at time-points of year, months, years and years post-implantation. results: cyp (mean age . y) had rvns inserted. at year, % ( / ) had a positive response graded as > % reduction in seizure frequency or severity (i.e., duration), % ( ) had benefit though < % benefit, and % ( ) of cyp were non-responders. this increased at months to % ( / ) of children showing response > %, a further % showed response % and only % ( / ) non-responders. response was over-all sustained, with response lessening in only children between months and years. reduction of medication burden was achieved in % ( / ) (not attempted in all cyp). no patients achieved seizure freedom. replacement of vns from an older model to rvns showed further benefit. complications were infrequent: % ( / ). device removal for infection was required in one child of small body size; successful replacement was possible within the year. conclusions: vns is a useful treatment option for cyp with pharmacoresistant epilepsy. seizure outcomes with rvns in cyp are better than with standard vns. response is sustained. benefit may not be seen by year; therapy should be continued until at least months. in our patients who responded later than -year, further optimisations of duty cycle and current were made. replacement of older vns. devices with rvns led to additional benefit. these findings are consistent with reported outcomes from adult series, though seizure freedom is not seen in cyp. in our centre, cyp who seemed to benefit most were those whose epilepsy was of structural aetiology and those with focal seizures, although our numbers were not large enough to assess the significance of this. poster no. atp a mutation in twins presenting with apnoeic episodes, suspected seizures and possible dystonic events objective: we report the case of monochorionic diamniotic twins presenting at the age of months with infantile seizures and apnoeic episodes. the eiee gene panel revealed a mutation in the gene atp a , supporting the clinical diagnosis of alternating hemiplegia of childhood (ahc). methods: case report. results: twin r presented with staring episodes, eye deviation and tonic posturing of limbs. episodes occurring mainly in clusters, affecting either side and requiring rescue medications for termination. profound apnoeic episodes needing resuscitation were also noted. twin s presented few weeks later with a very similar presentation. developmentally making satisfactory progress with twin r showing only very mild delay. the array cgh from twin r was normal. several investigations were performed including two normal standard eegs, a normal sleep eeg, a normal ecg, an echo showing a small pfo and an mri scan demonstrating a left sided mesial temporal lobe sclerosis. similar mri findings were reported in twin s. investigations such as urine organic acids and amino acids, plasma amino acids, carnitine, acylcarnitine, transferrin glycoforms, mucopolysaccharidosis screen, ammonia and lactate were all normal. pyridoxine was tried with no improvement, levetiracetam was added and afterwards changed to carbamazepine. sodium valproate was commenced eventually after an episode of prolonged clinical seizure. the eiee gene panel revealed a de novo atp a mutation in both twins. flunarizine was commenced following this result. a video telemetry managed to capture both epileptic and non-epileptic episodes in twin r. the epileptic episode was characterised solely as apnoeic episode due to a left temporal seizure activity spreading onto the opposite hemisphere which is concordant with the imaging finding of left mesial temporal sclerosis. conclusions: knowledge of the atp a mutation allowed clinical correlation of a diagnosis of ahc, matching the wide clinical spectrum of ahc including paroxysmal dystonia and epilepsy. poster no. epilepsy in a child development centre population pc kenyon, njv cordeiro, gl duffy rainbow house child development centre, irvine, ayrshire, uk objective: to assess all the cases in a child development centre (cdc) population with epilepsy, to enable characterisation of the caseload. methods: all case notes of children with an epilepsy diagnosis coded on the cdc database were retrospectively reviewed for demographic, investigation and treatment data. results: children were identified. % were diagnosed before a year of age, and over half before their third birthday. % of patients had an eeg, and of these, % had an abnormal eeg. % had genetic testing performed, and of these, % had a genetic cause of their epilepsy identified. % had an mri scan, and of these, % had a structural cause for their epilepsy identified. % had global developmental delay, and % had a diagnosis of learning disability. one third have a diagnosis of cerebral palsy, % have autism spectrum disorder, and % have a hemiplegia. % are seizure free, the majority of whom have their epilepsy controlled with one medication. % had adherence concerns identified. conclusions: compared to a general paediatric epilepsy clinic, this group of children were diagnosed earlier in life, had higher rates of genetic or structural causes identified, and were less likely to be seizure free. results: case . a -year-old with autism spectrum disorder (asd) developed hand waving in front of her face in bright light from years. multiple myoclonic seizures occurred with screen use and her family live in complete darkness. eeg demonstrated photosensitivity, generalised spike-slow wave after hand waving and - . hz spike-wave with myoclonia. clonazepam has been commenced. case . a -year-old with learning difficulties and a family history of generalised seizures presented aged years with forehead rubbing leading to loss of part of her eyebrow. eeg showed photosensitivity and the generalised spike-wave of absences and eyelid myoclonia (em). sodium valproate was used but replaced with lamotrigine due to weight gain. case . a -year-old with a family history of generalised seizures presented aged years with hand waving in front of her face, requiring her nursery to provide a dimly-lit setting. eeg demonstrated generalised polyspikewave, -hz spike-wave and myoclonia with photic stimulation. lamotrigine was ineffective and replaced with sodium valproate. case . an -year-old with likely asd developed hand waving in front of her face in bright light aged years, triggering generalised tonic convulsions (gtc). she had a non-induced gtc in dappled sunlight. there was on-going anxiety and thoughts of self-harm. eeg showed photosensitivity and bursts of spikes-polyspikes. lamotrigine was ineffective; seizures stopped with sodium valproate. conclusions: the self-induced seizures of sunflower syndrome are difficult to treat and are associated with physical, psychological and social impairments. sodium valproate is the most effective medication which may be problematic in this predominantly female patient group. what are the information needs of parents whose child is diagnosed with glutaric aciduria type to help preserve neuro-developmental outcome? objectives: to assess the information needs and support of parents at the time of diagnosis of ga in their child, and how to support them in preventing metabolic decompensation and preserving neuro-developmental function. methods: a focus group with five parents was conducted using a topic guide to direct the discussion, which was recorded and fully transcribed. data were analysed using thematic analysis. two researchers were involved in initial coding of data and key analytic decisions. results: two main themes were identified. 'understanding the condition' explored parent's needs to understand the scientific complexity of ga and to be aware of the 'worst case scenario' associated with loss of metabolic control, and brain injury. parents reported clinicians did not give then enough information on the ga , and were forced to use other information sources, sometimes seeking out scientific papers. information on managing crises was insufficient, with parents not understanding what the doctor meant about commencing the emergency regime when their child was 'sick'. parents reported living in terror of their child experiencing metabolic decompensation and permanent brain injury. 'managing the condition' explained how parents coordinated and controlled the involvement of other carers and outlined parents' need to be active partners in medical management to feel in control. parents wanted to know the results of regular biochemical tests for reassurance, but found they were not easily accessible. parents could not leave their child in the care of another adult because they did not have sufficient knowledgeable about ga or were known to 'cheat' by offering the child food they should not have. the transition into school was a particular challenge. conclusions: the study highlights the importance of addressing parents' initial and ongoing informational needs so they can fulfil their role and protect their child from metabolic decompensation and permanent brain injury. poster no. normal transferrin isoelectric focusing in a child with cog related congenital disorder of glycosylation objectives: congenital disorders of glycosylation (cdg) are a large group of rare multisystem diseases caused by defective linkage of oligosaccharides to newly synthesised proteins or lipids. several cdg subtypes are the result of mutations in subunits of the conserved oligomeric golgi (cog) complex. this includes cog -cdg, an autosomal recessive disorder caused by pathogenic variants in the cog gene. in the two cases previously reported transferrin isoforms were abnormal, consistent with defective n-glycosylation. methods: we describe a -year-old female born to non-consanguineous parents. she presented with severe global developmental delay, dysmorphic features, postnatal progressive microcephaly, complex epilepsy, rhizomelia, spastic quadriplegia, and feeding problems from early infancy. results: mri brain showed global cerebral atrophy, predominantly supratentorial, with relative cerebellar sparing. trio exome sequencing and analysis identified compound heterozygous cog variants in the proband, a maternally inherited pathogenic splice site variant c. + g>a and a paternally inherited likely pathogenic splice site variant c. + g>a. messenger rna analysis showed that the c. + g>a variant caused aberrant splicing, with skipping of exon and the introduction of a premature stop codon in exon , likely to result in nonsense mediated decay. analysis of transferrin isoforms was normal (by both isoelectric focussing and mass spectrometry). since cog -cdg also affects o-glycosylation apolipoprotein ciii (apociii) isoelectric focussing was undertaken, however this too was normal. conclusions: transferrin and apociii isoelectric focusing are screening tests for n-and o-glycosylation defects. however, both have their limitations and some cases of cdg have normal transferrin or apociii glycoforms escaping those screening tests. this is the first case of a patient with cog -cdg with normal biochemical markers to be described. this case also demonstrates the diagnostic power of next generation sequencing for rare metabolic disorders, where the biochemical screening may be inconclusive. poster no. developmental delay in a young infant with nonclassical combined malonic and methyl malonic aciduria (cmamma) caused by homozygous missense mutation in acsf gene kd dayasiri , eg goh , sk kodagali , jb baruteau , ga anand oxford university hospitals nhs foundation trust, oxford, uk; great ormond street hospital, london, uk introduction: acylcoa synthetase family member (acsf ) activates malonylcoa and methymalonylcoa into their respective thioesters. acsf deficiency causes non-classical cmamma, a rare inborn error of metabolism characterised by presence of methyl malonic acid in higher concentrations than malonic acid in urine. the reversal is seen with classic cmamma caused by malonylcoa decarboxylase deficiency (mcd). case report: -and-a-half-month old male infant second born to consanguineous south asian parents presented with severe failure to thrive and recurrent vomiting. his older sibling who had failure to thrive and neuro-developmental delay died at months without a genetic diagnosis. initial blood tests revealed metabolic acidosis, pancytopenia and coagulopathy. neuroimaging was unremarkable. subsequent evaluation revealed normal levels of methionine, homocysteine and red cell folate. significant methylmalonic aciduria with mild malonic aciduria without evidence of other abnormal metabolites (propionyl-coa metabolites: hydroxypropionate, and methylcitrate or tiglylglycine) in urine suggested the diagnosis of non-classic cmamma, confirmed by homozygous missense variants in acsf gene revealed by trio-exome sequencing. neurodevelopmental assessment at months revealed global developmental delay with general hypotonia; gross motor ( - mo); fine motor ( - mo); speech ( - mo) and social (under mo), and without any regression. carnitine was supplemented to avoid secondary depletion caused by the excretion of mma. parents were advised to avoid prolonged fasting and to provide emergency regimen (powdered carbohydrate drink mix) in the event of acute deterioration. conclusions: this report describes an unusual paediatric presentation of non-classic cmamma. urine organic acids allows identification of increased ma and mma excretion and highly suggestive of the diagnosis, thus avoiding additional investigations determination of urinary mma/ma ratio can help differentiating between classical and non-classical forms. methods: we conducted retrospective case note analysis of the five paediatric cases with confirmed diagnosis of the late onset pompe disease, referred to the highly specialised metabolic service. results: three of five patients (current age - y) presented with delayed motor milestones in early childhood (mean age: . y). one patient initially presented with episodes of thigh pain and high ck. in addition, when years he re-presented with recurrent abdominal pain with high ck. the remaining one presented with muscle pain upon exercise with high ck. all apart from one had muscle weakness affecting limb girdle muscles and axial muscles. the remaining one presented with proximal muscle weakness by the age of years. all patients remained ambulant, one developed scoliosis and two were on non-invasive ventilation. cardiac involvement as ventricular dysfunction requiring targeted treatment was observed in one. pathology showed vacuolated deposits in three patients and non-specific myopathic changes in one. four are on enzyme replacement therapy (ert) and tolerated well. conclusions: late onset pompe disease is a multisystem disease and should be considered in cases of isolated respiratory problems, lower back pain, rigid spine, and myopathy or exercise intolerance with elevated serum ck if these symptoms cannot be attributed to another disorder. poster no. delay in diagnosis and misdiagnosis of ataxiatelangiectasia: a systematic review pubmed, scopus). the cochrane library was also searched. the search protocol is available. the inclusion criteria were: all dates, all languages, all ages, human participants and clinical relevance. the exclusion criteria were: no reference to ataxia-telangiectasia within the article, not an original article, animal studies, article not clinically relevant. results: search returned articles; titles and abstracts were reviewed after removing duplicates. full text review includes articles of which case series and case reports were identified ( , exclusions; , articles not found or not accessible). mean age of first sign or symptom of a-t in cases reviewed to date was . months (range - d to mo). the mean age of diagnosis in cases in which it has been reported was . months (range - d to mo). there was a mean time of . months from presentation to clinician, to diagnosis of a-t (range - to mo, median mo) in the cases in which this was reported. / ( . %) cases had a documented alternative diagnosis prior to the diagnosis of a-t. / ( %) of these children were incorrectly diagnosed with cerebral palsy and / ( %) with hyper-igm syndrome. the mean delay from incorrect diagnosis to a diagnosis of a-t was months with the longest delay months. conclusions: this study is the first comprehensive systematic review of scientific literature on ataxia-telangiectasia. we aim to describe the natural history of the condition and, along with results from the natural history of a-t (n-hat) study, systematically define, where possible, the conditions presentation, course, and prognosis. ( %) people with a-t presented with gait ataxia or disturbance, and / ( . %) with truncal ataxia. the most common presenting feature in cases without ataxia were developmental delay, or regression, and choreoathetoid movements. the second most common neurological presenting sign was dysarthria in / ( . %) cases, and at least of these had no associated ataxia. dystonia was a presenting sign in / ( . %) cases, including / ( . %) with no associated ataxia. / ( . %) initially presented with no neurological signs or symptoms. conclusions: this study is the first comprehensive systematic review of scientific literature on ataxia-telangiectasia. these results show that . % of people with a diagnosis of a-t presented initially with at least one neurological sign or symptoms. this completed review will lead into the natural history of a-t (n-hat) study, a longitudinal, retrospective and cross-sectional study. the role of serum oxysterol in the diagnosis of niemann pick c m alcheikh, g connolly, n cluskey, s osullivan royal hospitals belfast health and social care trust, belfast, uk introduction: neimann pick c is a neurovisceral disease that is caused by cellular cholesterol trafficking disruption. historically, the diagnosis of niemann pick c was made using filipin staining and skin fibroblast cultures. recently genetic testing of npc an npc genes are available. mutations of either gene also affect cellular trafficking of cholesterol and detecting oxidative cholesterol metabolities can also be diagnostic of nieman pick c. serum oxysterol can be used as a first line test with subsequent genetic confirmation and has a positive predictive value of > %. methods: we present a case of an -year-old boy who was referred to genetics initially with absence of up gaze, severe restricted downward gaze, developmental delay, regression of skills and frequent falls. in the last year his parents and school observed progressive deterioration of his symptoms with gelastic cataplexy, markedly decreased tone, increasing difficulty with memory loss and slurred speech. these symptoms are strongly suggestive of niemann pick c disease and oxysterols were requested which showed elevated oxysterol level of . ng/ml (normal range . - ). he was started on miglustat. genetics confirmed the diagnosis. results: overall the child's parents report that since commencing the miglustat he is more confident and they have recently seen him hop and skip which they haven't seen in quite a while. conclusions: oxysterol is suitable biomarker for neimann pick c disease and can be used as first line with the genetic confirmation of gene npc and npc at later stage. as modifying treatment with miglustat is available it is important to attempt diagnosing the condition as early as possible and oxysterol level can be used as screening test for neimann pick c when clinically suspected. introduction: biotinidase deficiency is a rare autosomal recessive inborn error of biotin metabolism. biotinidase catalyses biocytin to biotin, a deficiency of which can present with neurological symptoms including hypotonia, seizures, feeding difficulties, lethargy, optic atrophy, and sensorineural deafness. case: a -week-old female presented with a -week history of seizures and developmental delay. examination revealed generalised and axial hypotonia and delayed smile. she continued to have seizures despite initial treatments including levetiracetam and carbamazepine. mri brain was normal and initial interictal eeg on day post admission revealed no significant abnormalities. ambulatory eeg on day showed a focal onset epileptic seizure with sharp and slow wave activity originating predominantly from the left occipito-parietal region. normal investigations included paired plasma and csf glucose, lactate and culture, csf neurotransmitters, microarray and epilepsy gene panel. on day post admission her biotinidase result was reported showing no activity. biotin was commenced at mg once daily and her seizures abruptly stopped. she was discharged home on day and weaned off levetiracetam and carbamazepine. her development was normal at -month follow-up. genetic testing was declined by the family. discussion: biotinidase deficiency can present from the neonatal period up to years of age with a mean age of . months. in recent years our understanding of pathogenic changes in the biotinidase gene has increased through sequencing for novel mutation. this has important implications for families and consideration should be given to offering affected families genetic counselling. treatment is available with oral biotin that rapidly improves symptoms, with seizures usually resolving within days and other symptoms showing improvement within weeks. objective: we present a previously well -year-old boy with a known m. t>c mutation experiencing weeks of vomiting, lethargy and exercise intolerance. method: he was mildly dehydrated, fully consciousness but tachycardic and hypotensive. his ph was . with be - . , hco . and lactate of . . electrolytes, fbc and inflammatory markers were normal. he was admitted to picu for fluid management and sodium bicarbonate. tachycardia persisted during the first hours though he remained stable. he had a good urine output, was on non-invasive monitoring and an echocardiogram was normal. his gas lactate ranged from . to . . the following day he deteriorated with kussmaul respirations, tachypnoea, increased tachycardia and hypotension. venous blood revealed a ph . , pco . hco . be - and lactate . . he became unresponsive with refractory hypotension and multiorgan failure. arterial blood showed a ph . , pco . and a lactate > with indeterminable be or hco . for over hours he had a blood lactate level of > . rhabdomyolysis and acute kidney injury occurred with a ck of > requiring haemofiltration. encephalopathy, with multiple white matter microhaemorrhages on mri brain, and acute liver failure, with thrombocytopenia and coagulopathy, ensued. multiple inotropes were required. the prognosis was very guarded. off sedation he was unresponsive, apnoeic and areflexic however an eeg showed an alpha rhythm which prompted on-going heroic efforts. he required prolonged haemofiltration, ventilation and inotropes with days intensive care. results: the patient made an astounding recovery. he required month of neurorehabilitation and returned to his cognitive baseline, achieving a grades at gcse months later. liver and renal dysfunction resolved. conclusions: this case demonstrates that mitochondrial metabolic crises in melas can be severe and result in profound acid-base derangements. our patient was expected to not survive but uniquely did so without significant neurodisability. neuronal ceroid lipofuscinosis in children from central africa gl fisher, n shah, p watts, ja te water naude noah's ark children's hospital, university hospital wales, cardiff, uk objective: the effective and rapid diagnosis of neuronal ceroid lipofuscinoses (ncls) has become more relevant with the advent of disease-modifying treatments. some ncls have a more stereotyped clinical presentation: we describe two cases in a non-consanguinous family, originally from the democratic republic of the congo, with variant ncl. methods: retrospective case series. results: the index case was initially diagnosed with a focal epilepsy: on review this child had myoclonic seizures in the context of a slow developmental decline, with mild spasticity. ophthalmology was not diagnostically helpful, and a putative diagnosis of ncl was suggested by lymphocyte inclusions. neither enzyme nor dna analysis was available at that stage, although dna was retained. a brother presented with nystagmus and visual inattention in : examination showed myoclonic jerks with a bull's eye maculopathy and an abnormal peripheral retinal vascular leak. mri imaging showed some element of cerebellar atrophy, which on review was also the case with his brother's scans. some lymphocytes ( %) contained fingerprint bodies, suggestive of variant ncl. this was confirmed by dna sequencing which was consistent with a diagnosis of mfsd /cln -related ncl. the identical dna alteration was also found in the index case. conclusions: ncl is not described in children from central africa: the presentation, investigations and laboratory findings and evolution are consistent with that for other children with variant ncl. obesity screening of patients affected by duchenne muscular dystrophy (dmd) in a tertiary paediatric neuromuscular centre and the effectiveness of metformin use in weight control in those with confirmed insulin resistance m neocleous , s spinty , r madhu , p dharmaraj , c degoede , k cooke , c greaves alder hey hospital, liverpool, uk; royal preston hospital, preston, uk objective: to assess whether patients affected by duchenne muscular dystrophy (dmd) who are currently followed up in alder hey hospital, uk are receiving obesity screening when clinically appropriate. to assess whether metformin use in those who are insulin-resistant, has been effective in controlling weight. methods: using the neurology department records, a list of patients with dmd currently under our services and those transitioned to adult services in the last years, was generated. the patient record system, meditech, was used to collect patients' demographics, latest weight/height value and bmi. for patients classified as overweight/obese, completion of obesity screening was assessed as well as initiation of appropriate treatment (metformin). for patients on metformin, the following parameters were collected: weight pre and post-steroids, age of start of excessive weight gain, confounding variables and medications, weight/height/bmi at initiation of metformin and at -monthly intervals, side-effects, cessation of medication and reasoning. results: sixteen out of patients were found to be above the th weight centile. in patients, weight was at or more centiles above height. using the non-dmd standardised bmi classification, patients were identified as being overweight/ obese. patients received obesity screening; were found to be insulin resistant. of those were started on metformin. patients overall were started on metformin. of those exhibited overall weight loss. patients were found to have gained weight and patient showed weight increase up to months post-metformin initiation with subsequent weight loss. conclusions: there is a need for a validated and agreed bmi classification in dmd. screening for insulin resistance in this patient group should be considered for implementation as standard practice, especially if patient is classified as overweight/obese. a larger-scale study would be required to assess the effectiveness of metformin in this patient population. objective: niemann-pick disease (npd) is an autosomal recessive metabolic disorder with a prevalence of . to . / worldwide, marked by varying degrees of lipid storage and foam cell infiltration in tissues, associated with hepatosplenomegaly, pulmonary insufficiency or central nervous system involvement. npd type a and b are allelic disorders caused by mutations in the sphingomyelin phosphodiesterase- gene, smpd ( p . - . ), characterized by a primary deficiency of acid sphingomyelinase activity, resulting in an accumulation of sphingomyelin. in contrast to npd-a, npd-b is the milder, lateronset form, with no neurological involvement. in this paper, we report on three paediatric cases with npd-b who present an atypical phenotype marked by neurological involvement. methods: the three patients were diagnosed at the age of with hepatosplenomegaly. the first is a girl who presented psychomotor regression at the age of and epileptic seizures at the age of . she died at the age of . the second is an years old girl who presented growth retardation, kyphosis and neurodevelopment regression since the age of . the third is a years old boy with a mild phenotype marked by developmental delay and an aggressive behaviour. splenectomy was performed at the age of . results: genetic testing was performed, and all patients presented mutations of the smpd gene, confirming the diagnosis of niemann-pick type b. the c. t>g(p.trp gly) mutation was common in all cases. in addition, heterozygous mutations c. delt(p.ser alafs* ) and del c. _ del were found in the first and second case, respectively. conclusions: all cases present a complex phenotype, marked by psychomotor regression which is atypical for npd type b. the severity of the disease seems to be correlated to the genetic mutation-the most severe phenotype was associated with c. delt. further work is necessary to more clearly delineate genotype-phenotype relationship in npd. objective: acute encephalitis syndrome (aes) is a group of symptoms and signs, which help diagnose encephalitis. since there is no definite treatment for most, role of fluids seems crucial. therefore, the objective of our study was to describe the association of low admission weight and weight loss in the hospital (as clinical marker of dehydration) with outcome of patients of acute encephalitis syndrome. to describe the association between changes in weight and blood lactate levels (at admission and discharge as indicators of hydration and acid base status) and outcome in children with acute encephalitis syndrome. methods: all children aged month to years with fever and altered sensorium and/or new onset seizures from september to september attending kanti children's hospital, kathmandu, nepal were recruited. weight-for-age (wfa) using z score and serum lactate were assessed at admission and discharge. total fluid input and output was monitored daily. results: of the patients, % had low admission wfa or lost weight-after-admission (lwaa) (group a) and % no low wfa or didn't lwaa (group b). there was times risk of death and times risk of bad outcome (death or sequelae) in group a compared to b. bad outcome was significantly associated with less admission wfa, more fluid deficit, and trend for higher admission serum lactate. death was significantly more in those with low wfa, more lwaa, longer illness, more % dextrose and . normal saline, higher sodium and higher urea at admission. methods: we conducted a prospective cross-sectional study recruiting children aged between month to years attending kanti children's hospital, kathmandu, nepal with altered sensorium and two of the following: fever, seizure, focal neurological deficit, csf pleocytosis, electroencephalogram and computer tomography suggestive of encephalitis, over year. in these patients, ve was if csf cell count was < cells/ mm (lymphocyte predominance) and absence of non-viral pathogens in the csf or blood. bm was csf cell count > cells/mm (polymorph predominance) and csf protein > . g/l and csf/plasma glucose < %, and/or positive gram stain and/or bacterial culture. je was ve with ≥ units of anti je-igm in the csf and/or serum. all cns infections were defined as, suspected cases by treating clinician with or without fever with lp showing csf cells > /mm . results: out of , bm was found in %, je % and other causes in %. although who definition of aes was not significantly associated with all cns infections (p= . ), it was significantly associated with ve (p< . , sensitivity %, specificity %, ppv %, npv %) and bm (p< . , sensitivity %, specificity %, ppv %, npv %). conclusion: we validate who aes definition of bm and ve as a significantly useful screening tool for children with these diseases specially in resource poor settings, endemic areas and where confirmatory tests were not easily available. objective: the aim of this case series is to raise awareness of this autosomal recessive encephalopathic syndrome that presents after birth in the multi-ethnic population in england. although aicardi goutieres syndrome (ags) is rare, its importance lies in the fact that that its presentation may be mistaken for other neurological conditions associated with congenital infections. results: all of the patients were seen in our paediatric outpatient neurology clinic. the age of presentation ranged from the neonatal period to the first weeks of life. all patients were of pakistani origin and were from consanguineous marriages. they all had an uneventful antenatal period with normal birth weight and head circumference. the initial presentation seems to be of poor feeding and irritability. further observations include truncal hypotonia, limb spasticity intermittent dystonic posturing coinciding with the onset of poor head growth and chilblains. of our patients had abnormal movements with diffuse slow wave electroencephalogram activity. nystagmus with visual inattention and poor visual acuity were a typical finding in all of them by the age of months. the ct scans showed cerebral calcification in all of them and mri suggested brain atrophy. the most striking abnormality was a raised level of csf interferon-alpha (infa) in an absence of other infection or metabolic disorder. csf inf a is a reliable diagnostic marker and can thus be used to differentiate patients with ags from other conditions. three of our patients had the same gene mutation, rnaseh c. conclusions: ags is a rare disorder, however in patients from consanguineous marriages that depicts microcephaly, poor tone and global developmental delay, diagnosis of ags should be considered. as ags is a progressive neurological condition, early support and prognosis can be provided for affected families. t thomas , ht yeo , sv barron , paediatric neurology, kk hospital, kampong java, singapore; university of newcastle, newcastle, uk objective: we report the association of mild encephalopathy with a reversible splenial lesion (mers) with a primary dengue virus infection. this case implies the existence of a wider spectrum of neurological involvement in dengue virus infections. case description: a -year-old girl presented with acute confusion, dysarthria and bilateral limb weakness following a -day history of fever. symptoms resolved after hours; neurological examination was completely normal. she later experienced a second episode of slurred speech, dysphasia and right arm weakness which lasted an hour. a contiguous lesion involving the genu, body and splenium of the corpus callosum and bilateral posterior periventricular white matter was evident on the mri brain scan, with restricted diffusion and t -hyperintensity. cerebrospinal fluid analysis showed no inflammation and polymerase chain reaction assay for respiratory viruses was negative. her clinical and radiological features were consistent with mild encephalopathy with a reversible splenial lesion (mers). on day of admission, she developed a generalised maculopapular rash with leukopenia (white blood cell count . /l) and thrombocytopenia (platelets /l). serology (igm/igg) for dengue virus was negative and a positive dengue ns antigen was thus indicative of a primary dengue virus infection. she was given fluid rehydration and advised bedrest. at discharge (day admission) she was well with no sequelae. conclusions: mers is a mild form of virus associated encephalopathy (vae), which are a spectrum of clinico-radiological syndromes associated with common childhood viral infections. the clinical and neurological symptoms in our patient occurred early in the course of illness (typical to vae) as opposed to after or late in the illness as is typical for postinfectious encephalopathy syndromes associated with dengue virus infections (e.g., acute disseminated encephalomyelitis). shouldering the burden of sepsis norfolk and norwich university hospital nhs trust, norwich, uk; sheffield children's hospital, sheffield, uk aim: we report a case of a -year-old boy who presented with right brachial plexus neuritis secondary to meningococcal group b sepsis. brachial plexus neuritis or neuralgic amyotrophy (also known as parsonage -turner syndrome) is a rare disorder affecting the brachial plexus. it can be caused by various infectious agents and is characterized by acute onset of intense pain in the shoulder and arm followed by weakness, sensory loss and atrophy. methods: a -year-old boy, previously fit and well presented to the emergency department with an acute onset of excruciating pain in his right shoulder, radiating down his arm and hand with associated paresthesia. few hours later, he developed an evolving non-blanching purpuric rash to the chest, back, shoulder and right arm. he gradually developed weakness in the right arm and sensory loss over the ulnar aspect of the right hand. he then began to complain of headache, photophobia with subsequent vomiting. he was treated for meningococcal sepsis with intravenous ceftriaxone and received three fluid boluses for hypotensive shock with vitamin k correction for his associated coagulopathy. he received analgesia for right shoulder pain. results: blood cultures and blood pcr confirmed neisseria meningitidis group b type, nt subtype. mri of the shoulder showed inflammation consistent with brachial plexus neuritis with motor impairment affecting the right side c to t myotomes and sensory impairment involving the right c dermatome. the patient was treated with oral prednisone and gabapentin whilst receiving neurorehabilitation from physiotherapy and occupational therapy. he made a very pleasing recovery after few months and currently has no motor or sensory deficit of his right shoulder and arm. conclusion: brachial plexus neuritis should be considered in the differential when a child presents with sudden onset pain and weakness of the shoulder and arm. in review of literature, brachial plexus neuritis associated with meningococcal infection has not been described previously. to the best of our knowledge, this is the first reported case of its kind. introduction: previous cohort studies on paediatric multiple sclerosis (ms) have reported very low frequencies for a primary progressive ms course (ppms) ranging from to %. an age-dependent increase in the rate of primary-progressive courses has been well described in the adult ms population. objectives and methods: we describe five patients presenting prior to the age of years and fulfilling the mcdonald criteria for ppms. patients were identified from the national hospital for neurology and neurosurgery (nhnn) and the uk childhood inflammatory demyelination (uk-cid) network. results: patients presented at a median age of years (range: - y), with at least -year history of progressive deterioration of their balance (n= ) or progressive worsening of lower limb function (n= ). over time, all patients developed lower limb spasticity, three patients developed cognitive difficulties, three had visual problems, three had bladder involvement. median edss at years was (range: to ). cerebrospinal fluid (csf) oligoclonal bands were detected in all patients tested. dissemination in space on first mri was seen in all patients with peri-ventricular (n= ), cortical juxtacoritcal (n= ), infratentorial and spinal cord (n= ) lesions. all patients showed new lesions on repeat mri imaging. contrast enhancement was present in out of ( %) during the disease course. three patients had genetic investigations to exclude other mimics. a trial of iv methylprednisolone was unsuccessful in patients. all patients were on symptomatic treatment for spasticity and pain, including oral/intra-thecal baclofen, gabapentin and sativex. conclusions: given the rarity of primary progressive course in paediatric ms, presentation with progressive neurological symptoms and signs in young people should prompt evaluation for genetic causes. nevertheless, our five patients presented with clinical, mri and immunological features consistent with a diagnosis of primary progressive multiple sclerosis. objective: clinical course in nmdar-antibody encephalitis is variable and difficult to predict. we aimed to identify clinical features in the presenting disease episode associated with worse functional outcome and/or relapsing disease course. methods: systematic review of the literature was conducted to identify published cases with individually reported data. clinical and treatment characteristics at first episode, outcome at ≥ months, and monophasic vs. relapsing disease course were recorded. results: cases were identified from articles ( % female; % ≤ years old at onset). % received immunotherapy at first episode: corticosteroids in %, ivig in % and therapeutic apheresis in %. second-line immunotherapies were used in % at first episode, most frequently rituximab ( %), cyclophosphamide ( . %), or both ( . %); emerging second-line treatments (intravenous/intrathecal methotrexate, subcutaneous/intravenous bortezomib, intravenous tocilizumab) were used in . %. life-threatening adverse events or death related to immunotherapy occurred in . %. in a univariate analysis of cases with ≥ months follow-up data, poor final outcome (defined as modified rankin scale [mrs] score - ) occurred in % and was associated with very young or elderly age at onset, movement disorder, decreased consciousness, autonomic dysfunction, mechanical ventilation, higher mrs score in the acute phase, longer hospital stay, extreme delta brush on eeg, abnormal mri, csf pleocytosis and elevated csf protein (all p< . ). a subset of cases followed up for ≥ months were analysed to identify associations with relapsing course, which occurred in %. in univariate analysis, factors protective against relapse were < days delay in first-line immune therapy, therapeutic apheresis, ivig, rituximab and other second-line treatments at first episode (all p< . ). conclusions: worse functional outcome of nmdar-antibody encephalitis is associated with very young or elderly age at onset and worse disease severity in the acute phase. relapsing disease course is associated with delayed or insufficient early immunotherapy. objective: we describe three children with familial hemophagocytic lymphohistiocytosis (fhlh), who presented with an atypical chronic demyelinating illness. an initial working diagnosis of 'clippers' (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) was made in two cases. methods: retrospective case series. results: case : an -year-old girl presented with diplopia and squint with evolving ataxia. mri showed multiple enhancing white matter lesions in the pons, medulla and cerebellum raising the possibility of 'clippers'. her symptoms and neuroimaging responded only partially to treatment with ivig and steroids. genetic testing revealed a compound heterozygote mutation in the rab a gene consistent with griscelli syndrome type with fhlh. case : a -year-old boy had nocturnal headaches with a squint evolving over time. mri showed demyelination and swelling predominantly in the cerebellum. significant radiological resolution with steroids was followed by recurrence of demyelination on weaning steroids. a brain biopsy lesion was consistent with 'clippers'. genetic testing revealed a heterozygote variant in the stxbp consistent with fhlh v. case : a -year-old girl had a -month of intermittent fevers, deranged lfts and recurrent bilateral optic neuritis responsive to steroids/ivig. mri brain showed multiple areas of demyelination largely in the subcortical white matter. oligoclonal bands were positive in the csf. she developed a pleural effusion, high ferritin, deranged coagulation, lymphadenopathy and a rash found to be a cutaneous t-cell lymphoma. genetic testing revealed a homozygous mutation in the unc gene consistent with fhlh . all three children are awaiting stem cell transplantation. conclusions: fhlh can present with an isolated atypical demyelinating illness or with neuroimaging suggestive of 'clippers'. there may be no signs of systemic inflammation. we propose that all children with atypical recurrent cns inflammation and presentations consistent with 'clip-pers' undergo genetic panel testing for fhlh and natural killer cell functional testing. objective: the most common paediatric presentation of mog-ab disease is with acute disseminated encephalomyelitis (adem), or optic neuritis (on). with increasing recognition of the association of mog-abs with seizures in children, we present a case series of affected children. methods: retrospective anonymised case note review of affected children presenting between - , from uk paediatric neurology centres. patients were followed up for median of years (range . - ). results: cases ( female) of mog-ab-positive epilepsy patients were identified; median age at first presentation was (range - y). the most common preceding mog-ab disease was multiphasic adem (mdem ; adem ; adem-on ; adem and transverse myelitis ; nmosd ; on ). median time to recurrent seizure onset was months (range - ). focal epilepsy/seizures were most common ( / ). eeg abnormalities were found in / patients, all demonstrated slowing/encephalopathy which was generalised or focal; epileptiform discharges were reported in patients. brain mri was abnormal in all patients ( with multifocal hazy/ poorly marginated lesions involving grey and white matter; leukodystrophy-like pattern, cortical encephalitis and reported with subtle changes in brainstem). patients received immunotherapy, all required at least anti-epileptic drug (aed) and children continue to have on-going breakthrough seizures. median mrs (modified rankin scale) at last follow-up was (range - ), indicating no significant disabilities despite symptoms in clinical examination, age appropriate behaviour and development. conclusions: focal epilepsy is more common and more likely to follow an mdem presentation in children with mog-abs. with the relapsing nature of mog-ab disease there is a high risk of long-term cognitive impairment. further preclinical studies are urgently required to determine whether this epilepsy is due to ongoing inflammation or as a result of the mri changes commonly seen. this will help inform future management decisions regarding immunotherapy. poster no. maternal mid-gestation cytokine dysregulation in mothers of children with autism spectrum disorder autism spectrum disorder (asd) is a developmental disorder characterised by a spectrum of deficits in social interactions/ communication combined with stereotypical, repetitive behaviours. recent evidence suggests maternal immune activation (mia) during pregnancy may predispose offspring to asd. the aim of this study was to examine the mid-gestation cytokine profile in mothers of children with a subsequent asd diagnosis. maternal-child dyads were recruited to a prospective population-based pregnancy study; the scope study, new zealand. children with confirmed diagnosis of asd at years were enrolled in the nested cohort, along with matched neurotypical controls. cytokine concentrations (pg/ ml; mean [sem]) were examined in maternal serum samples taken at and weeks gestation using mesoscale discovery proinflammatory, cytokine and chemokine assays. of mothers recruited to the scope-nz study, children completed follow-up and had reported asd at years. these were analysed alongside neurotypical matched controls. downregulation of il- a occurred at weeks gestation in cases when compared to controls (mean [sem]). -way anova revealed a relationship between il- a concentration and weeks' gestation f( , )= . ; p= . , and also il- a concentration and asd status f , )= . ; p= . . posthoc uncorrected fisher's lsd revealed a significant difference between cases (- . [ . ] ) and controls (- . [ . ]) at weeks gestation p= . . ifnc is also downregulated at weeks gestation in cases when compared to controls. -way anova revealed a relationship between ifny concentration and weeks gestation f( , ) = . ; p= . . posthoc uncorrected fisher's lsd revealed a significant difference between cases ( . [ . ] ) and controls ( . [ . ]) at weeks gestation p= . . we have shown altered cytokine expression at weeks gestation in mothers of children who progress to develop asd. this adds to the growing body of evidence that maternal immune regulation may play a role in foetal neurodevelopment. objective: acute disseminated encephalomyelitis (adem) is an immune mediated inflammatory cns disorder, predominantly affecting white matter, with a wide differential ( ). here we describe a rare mimic of adem that is essential to consider in order to avoid a catastrophic outcome. case history: a -year old girl presented with a day history of confusion, dysarthria, ataxia and left-sided squint, preceded by weeks of general malaise and headache. examination confirmed encephalopathy and a left third cranial nerve palsy. mri brain was suggestive of adem and mri spine was normal. a recommended work up for adem was performed. rapid resolution of her symptoms occurred following intravenous methylprednisolone for days. years later she presented with acute left lower limb ischaemia and underwent emergency embolectomy of a popliteal arterial obstruction, with myxomatous material identified. preoperative echocardiogram confirmed a large atrial mass which was surgically removed. pathology confirmed an atrial myxoma (am). retrospective review of her initial mri images concluded that embolic phenomena from the am was the most likely explanation of her first presentation. conclusions: am is a very rare primary cardiac tumour and left sided am can embolise to the cerebrovascular system. early identification of am is important as, untreated, it can cause multiple embolic events and sudden cardiac death. % of adults with am present with neurological symptoms and this can mimic multiple sclerosis. am presenting with acute neurological symptoms masquerading as adem in paediatrics has not been previously reported. careful follow up is essential as late neurological complications (including cerebral arterial aneurysms) are recognised. this case highlights that adem is a diagnosis of exclusion and that mimics for acute focal neurology with encephalopathy and t hyperintensities on mri require careful consideration, including embolic phenomena. clinical examination alone does not exclude am and consideration of echocardiography is recommended. we describe an year old boy with a rare demyelinating disorder: balo's concentric sclerosis. a routine optician review raised concerns about papilloedema in an asymptomatic child. a ct brain identified a well-demarcated high-density lesion in the left posterior frontal lobe with surrounding oedema. mri brain with contrast identified the lesion had central rim enhancement and slight diffusion restriction. alternating layers of high and low signal intensity gave it an 'onion bulb' appearance. the differential included balo's concentric sclerosis, a single demyelinating lesion, or a tumour. routine blood tests were unremarkable. csf oligoclonal bands were normal as were other csf indices. markers of immunology, including ana, anca, anti-mog, anticardiolipin, and aquaporin antibodies were all negative, with normal complement levels. esr was mildly elevated when taken during an episode of acute tonsillitis. imaging months later demonstrated an increase in the size of the lesion. a biopsy revealed inflammatory demyelinating pathology mediated by a perivascular and parenchymal t-and b-lymphocyte infiltrate and macrophage activity with associated demyelination lacking a perivenular distribution. there was no evidence of neoplasia, vasculitis, granulomas, or viral infection (including negative pcr testing). no treatment with corticosteroids was given, and the child remained asymptomatic. imaging, at months from presentation, revealed the lesion had substantially reduced in size. there was still a rim of enhancement. as with all single demyelinating lesions, it is difficult to predict the clinical course. we opted to adopt a 'wait and see policy' and offer surveillance imaging and clinical review. balo's concentric sclerosis is a rare demyelinating disease, characterized by concentric lamella of alternating demyelinated and partially myelinated tissues. mri shows one or more concentrically mulitlayered ring-like lesions, usually in the cerebral white matter. most case reports describe cases predominantly in young adults, with few reports of cases in children. objective: cognitive and acquired neurodevelopmental deficits have been reported in children with opsoclonus-myoclonus syndrome (oms) and are associated with more severe and relapsing disease course. however, there is a paucity of data regarding cognitive dysfunction in children with stable neurological disease. we report on serial cognitive assessments of children with oms demonstrating evolving cognitive dysfunction with milder disease course. methods: retrospective analysis of clinical features at presentation, investigations, treatments, clinical course including relapses and neuropsychological testing. results: four children (m:f : ) diagnosed with oms between and months were followed up for to years. neuroblastoma was identified in one child. oms severity scores ranged between to / at presentation. patients underwent immunotherapy in accordance with european oms protocol. all patients were in remission by months (range - mo), with treatment maintained for year. one child remained relapse free whilst other children had one clinical relapse which was immunotherapy responsive again. in all cases, progressive cognitive dysfunction was reported despite being in remission and stable off treatment for months (range of - mo; oms score / and one / ). sequential neuropsychological testing scores showed mean declines in fsiq of ( - ) , viq of ( - ) and piq of (- to ) between time of oms remission/stable disease and longer term follow-up time point ( - y). conclusions: our cases demonstrate progressive cognitive dysfunction occurring in children with oms who have a milder disease and long after completion of treatment. children continued to develop but with a widening gap in comparison with peers. damage to cerebellar-cortical circuits at onset of the disease that becomes more apparent with time or indeed persistent ongoing low grade inflammation may explain this deterioration. the past decade has seen increasing cases of acute flaccid paralysis (afp) associated with enterovirus d (evd ) infection. it presents in clusters approximately every years. we report three cases of afp due to evd that presented in november-december . cases: two patients developed afp following a viral upper respiratory tract infection and one developed lower limb hypotonia and weakness during an inpatient admission with refractory epilepsy. two required admission to the paediatric intensive care unit for respiratory compromise and required tracheostomy ventilation. mri showed acute flaccid myelitis (afm) consistent with evd in / cases, consisting of central cord t hyperintensity in the cervical region over multiple segments with subsequent enhancement of the thalamus and cauda equina on follow-up imaging in one patient; and ventral surface enhancement of the conus and cauda equina in another. mri in the third patient was normal. electromyography and nerve conduction studies were normal in two patients but revealed a severe generalised motor axonal poly-neuronopathy in the third. two patients received intravenous immunoglobulin, corticosteroids or plasma exchange therapy and showed slow motor improvement in a distal to proximal pattern. the one patient without mri changes had received long-term oral corticosteroids but received no additional treatment and returned to baseline neurological function within weeks. discussion: our cases demonstrate the range and clinical course of peripheral neurological presentations secondary to evd infection. we highlight the importance of sending repeat samples from multiple sites when the diagnosis is suspected, given that initial samples tested negative, and of sending samples to a national surveillance laboratory for confirmatory testing. ongoing national and multinational surveillance studies will hopefully continue to advance our understanding and treatment of this disease. poster no. nmda receptor encephalitis a potential complication of biologic therapy for juvenile idiopathic arthritis? n abbassi , t rossor , r close , a skippen , k armon , p bale , g ambegaonkar paediatric neurology, addenbrookes hospital, cambridge, uk; paediatric rheumatology, addenbrookes hospital, cambridge, uk a -year-old girl presented with headaches, confusion and agitation, followed by seizures. she had presented at months with polyarticular arthritis and was managed over subsequent years on methotrexate alone ( y) with added etanercept (anti-tnf alpha, y), tocilizumab (anti il- , y) and abatacept (cd / t-cell modifier, y prior to presentation). flares of disease following a period of control necessitated the changes in monoclonal antibody therapy. at this presentation she was managed on methotrexate, abatacept and mg prednisolone for polyarticular rheumatoid factor negative juvenile idiopathic arthritis (jia). at presentation the patient was agitated, non-verbal and had one generalised seizure. examination demonstrated acute confusion, with increased tone, brisk reflexes and bilateral clonus in her lower limbs. iv ceftriaxone, acyclovir and clarithromycin were commenced. full blood count, liver function tests and inflammatory markers were unremarkable. infective serology was non-contributory. csf was unreactive with normal protein and jc virus pcr negative. mri brain days after presentation showed increased t and flair signal intensity in the white matter of the right parietal lobe, in-keeping with an inflammatory process. eeg showed diffuse slowing with delta brush. she commenced iv methylprednisolone, followed by prednisolone. she continued to deteriorate and underwent plasmapheresis for treatment of presumed nmda receptor encephalitis, subsequently confirmed by anti-nmda receptor antibodies in serum and csf. she was commenced on rituximab (b-cell depletion, anti-cd ), and continued to undergo plasmapheresis over the course of weeks. she gradually improved and was discharged home after a -week inpatient stay. several adult and two paediatric cases of nmda receptor encephalitis are reported in patients on biologic therapy for autoimmune disease. autoimmune diseases are more common in those already affected by one autoimmune condition. it is unclear what contribution an autoimmune history or immunomodulation made on the development of this condition. introduction: the incidence of acute flaccid myelitis (afm) associated with enterovirus infection occurring in biennial clusters since has been reported in the us (bmj , ; :k ) and recently in europe. previously, cases with transverse myelitis (tm) with anterior-horn cell or peripheral nerve involvement have been collectively termed tm-plus (neurology ; ;s -s ). we aimed to identify cases of tm-plus from a retrospective cohort of children to identify potential cases of 'undiagnosed' afm, and to evaluate the clinical and radiological features alongside long-term outcome. methods: consecutive cases of children (< y of age) who presented to a large paediatric neurosciences centre from to fulfilling the transverse myelitis consortium working group criteria modified for the paediatric population (neurology ; : - ) were retrospectively evaluated for additional features of anterior horn-cell involvement (fulfilling criteria for afm (current treat options neurol ( ) : )) or peripheral nervous involvement; and were collectively evaluated with the contemporary tm-plus cohort ( ) ( ) ( ) . results: cases of tm were identified, of which were excluded from further analysis; ms (n= ), adem (n= ). cases of tm-plus were identified, before and after, all associated with a viral prodrome. flaccidity (n= ) and asymmetry (n= ) was noted at presentation, with corresponding nerve conduction studies revealing a motor axonopathy with sensory sparing (n= ) and anterior horn cell involvement confirmed in cases. all cases with anterior horn cell involvement had poor outcomes while both cases with good outcomes had peripheral involvement and normal mri brains. conclusions: tm-plus was detected in our cohort from to with biennial clusters noted in and . the clinical presentation, investigations and long-term outcomes appear consistent in both groups. acute necrotising encephalopathy is more severe when associated with influenza background and objective: acute necrotising encephalopathy (ane) is a rare but potentially life-threatening condition associated with viral infections. a familial and recurrent form (ane ) has been identified by mutations in the nuclear pore ran binding protein (ranbp ). we report the morbidity and mortality when associated with influenza infection. methods: we performed a review of paediatric ane cases from to evaluating the clinical, biochemical, microbiological and neuroimaging appearances as well as outcomes. results: the cohort comprised children ( boys), age ranging from months to years months (< y n= ), of which had a confirmed genetic diagnosis and were ranbp negative. there were episodes of encephalopathy, with recurrences in cases ( ane ). of these episodes had infectious aetiology identified: coronavirus n= , parainfluenza n= , adenovirus n= , h influenzae n= , influenza (h n n= , h n n= ). clinical features of fever and encephalopathy were consistent ( %), and seizures and sixth nerve palsies prominent ( % each). csf revealed absent pleocytosis, normal-elevated protein and negative virology. symmetric involvement of the thalami bilaterally was present in all cases, and all ane cases were associated with haemorrhage and external capsule/claustrum involvement ( % specific and sensitive). the outcome following influenza infection was striking, death n= , vegetative n= , limb motor and movement disorder n= . of these cases had previous episodes of encephalopathy with noninfluenza infection and did have recovery, albeit with moderate to severe disability. all cases were never immunised against influenza infection and suffered grave outcomes. conclusions: influenza infection in ane has the poorest outcome therefore vaccination should be a mandatory consideration for the known cases of ane. introduction: acute flaccid paralysis (afp) is characterized by a rapid onset of limb weakness. we describe six cases of afp in children aged months to years of age who presented to a tertiary paediatric neurology service in the east of england over a -year period from november -november . retrospective analysis of the six cases was performed, reviewing their clinical course and management, as well as their radiological, electrophysiology and laboratory results. results: case , a -month-old boy, presented in november with a viral urti requiring escalation of care to picu due to a significant respiratory compromise. only on subsequent recovery was the child found to have a unilateral upper limb flaccid paralysis. this child was positive for enterovirus serotype d . cases and in our series presented in with acute weakness of the lower limbs with an mri brain and spine showing enhancement of the lumbar spinal roots. both have made a good recovery. enterovirus was not detected in either case. the final three children in our series presented in autumn with weakness of a unilateral upper limb following a viral urti, with all three being positive for enterovirus. unfortunately, they have shown minimal recovery of motor function of the affected upper limb. one child, a year-old girl, showed a more severe clinical course involving a prolonged period of intensive care and a tracheostomy for long-term ventilation. she has undergone neurorehabilitation and an upper right arm nerve transfer. conclusions: in our case series, four patients presented with an acute viral urti associated with an upper extremity weakness, and subsequently all four were positive for enterovirus. clusters of acute limb weakness in paediatric patients have been linked to outbreaks of non-polio enteroviruses, termed acute flaccid myelitis (afm). objective: to present an interesting case of recurrent anti-mog demyelinating disease and provoke discussion regarding possible immunomodulatory therapy. methods: a year old girl presented, initially at years of age, with headache and vomiting. she was initially treated as atypical tuberculosis meningitis based on csf cell counts, but later developed a th nerve palsy and was diagnosed with optic neuritis. anti-mog antibodies were positive and they were commenced on iv methylprednisolone. she clinically improved and was discharged on weaning oral prednisolone, antibodies were negative following treatment. results: a few months later she had her first relapse, with an acute decline in visual acuity. an mri showed new lesions in her optic chiasm and both optic nerves with associated bilaterally reduced visual evoked potentials. she was again treated with iv methylprednisolone, with rapid improvement, followed by a switch to weaning oral prednisolone. anti-mog antibodies were negative following treatment. she was symptom free for years until her second relapse, when she presented with facial palsy, swallowing difficulties and slurred speech. mri showed brainstem and periventricular white matter demyelination, with positive anti-mog antibodies. she was again treated with iv methylprednisolone, followed by oral prednisolone, but was maintained on low dose prednisolone as her anti-mog antibodies remained weakly positive despite being symptom free. these were stopped at patient request due to low mood and abdominal pain in february , with no recurrence of symptoms as yet. repeat mog antibodies have been sent and are awaited. conclusions: this case shows an interesting relapsing/remitting pattern of anti-mog demyelinating disease, which appears to be very steroid responsive, however on her second relapse her anti-mog antibodies remained weakly positive despite steroid therapy. discussion is welcomed on whether prophylactic immune modulation therapy should be considered with this child, such as azathioprine, mycophenolate mofetil or rituximab. objective: to highlight the utility of early mr imaging in children presenting with acute severe encephalopathy and to consider whether there might be a subgroup of children with myelin oligodendrocyte glycoprotein antibody (mog-ab)associated demyelination who might be candidates for early intense immunomodulation. methods: we report two cases with mog-ab-associated acute demyelination who relapsed with new neurological symptoms after initial steroid therapy had been discontinued. results: two toddlers were initially admitted to intensive care with acute encephalopathy and acute symptomatic seizures. both had an initial ct head during picu admission; one was reported normal; the other was suggestive of diffuse cerebral oedema. both children improved with supportive care only and were discharged home within a week. both children presented again over the following to weeks with new neurological symptoms but without encephalopathy. mr imaging demonstrated demyelination and they were treated with steroids. both children relapsed as steroids were being weaned and/or stopped. repeat mr imaging at this stage demonstrated new enhancing lesions. it was subsequently found that both children were mog-ab positive. conclusions: reliance on cranial ct imaging in the context of a young child with acute encephalopathy and seizures can be misleading. prediction of the severity of mog-ab-associated demyelinating syndrome at onset is challenging. mr imaging in the acute phase with early follow up imaging may identify this subgroup. case: hb is a year old boy who presented with sudden onset diplopia and painful ophthalmoplegia, following a day history of frontal headache. on examination, he had a left vith nerve palsy, partial left iiird nerve palsy and normal right eye movements. the remainder of his neurological and general systems examination was normal. his initial ct head scan and pre-contrast mri of the brain were normal. he was discharged from the local hospital following normal blood tests and imaging. clinical course: nine days later, his symptoms worsened including severe vomiting, worsening frontal headache and photophobia. he was treated for a possible underlying infective cause with ceftriaxone and acyclovir. given the broad underlying differential diagnoses, hb had extensive infectious and immunological blood workup which was unremarkable. a repeat mri brain scan with contrast revealed a lesion in the left cavernous sinus, possibly of vascular origin. differentials included cerebrovascular venous sinus thrombosis, tumour and inflammatory causes such as tb, sarcoid and zoonoses. hb continued to be conservatively managed and completed his course of ceftriaxone and acyclovir. repeat mri imaging months later showed some resolution of the lesion and a diagnosis of tolosa-hunt syndrome was provisionally made. hb's symptoms continued to improve and further repeat mri scan months later showed ongoing resolution of the lesion. discussion: according to the ichd- beta classification of tolosa-hunt syndrome, hb fulfilled the diagnostic criteria given his presentation of unilateral headache, granulomatous inflammation of the cavernous sinus on mri, palsies of ipsilateral iiird, ivth and vith cranial nerves. steroid use has been reported to be beneficial although more evidence is required in the paediatric population, refractory cases may respond to azathioprine and methotrexate. objective: we present a case of internuclear ophthalmoplegia unresponsive to steroid treatment which clinically improved with folinic acid supplementation. method: a retrospective chart review. results: our patient presented with acute internuclear ophthalmoplegia, ataxia and bilateral ptosis. she had a background of hypoplasia of the corpus callosum and optic atrophy with visual impairment, learning difficulties and asd. mri brain demonstrated symmetrical high signal intensity in the region of the medial longitudinal fasciculus and periaqueductal grey matter. she was investigated to exclude an inflammatory cause and was treated with high dose steroids. follow up mri did not show any improvement post steroids and there was no clinical improvement. subsequent csf investigations showed a low level of -methyltetrahydrofolate of nmol/l (normal range - nmol/l). she was commenced on folinic acid mg once daily and her symptoms improved. on follow up her eye movements had significantly improved as had her ptosis. follow up mri brain showed partial resolution of the areas of abnormal signal in the periaqueductal grey matter. conclusion: internuclear ophthalmoplegia is a sign usually associated with an inflammatory or demyelinating cause. our case did not respond to steroid treatment but has associated low levels of -methyl tetrahydrofolate and has responded to treatment with folinic acid. this is sometimes associated with underlying mitochondrial disorders but muscle biopsy in this case did not show any evidence of mitochondrial disease. mri brain has shown partial resolution of the abnormal signal in the periaqueductal grey matter. introduction: paediatric intracranial aneurysms are rare. the pattern of disease is different to that in adults and there is far less literature available. i provide a case as an example of the presentation and progress of a child with a dissecting vertebrobasilar artery aneurysm. presentation: -year-old boy presented to his local hospital with sudden-onset headache, photophobia and vomiting. bloods and observations were normaldischarged. symptoms recurred more severely the following day. managed as meningitis. lumbar punctures were 'bloody' and considered failed. mri brain days post-admission demonstrated a vertebrobasilar aneurysm. transferred to the regional neurosurgical centre. transfer to neurosurgical/neurovascular centre: cerebral angiography revealed dissecting vertebrobasilar aneurysm ( mm). fusiform component extending beyond aici/ pica origins. wide-necked saccular component. procedure and progress: loaded with aspirin and clopidogrel. underwent endovascular procedure the following daycoil embolization, flow-diverting stent to the aneurysm. ongoing low dose dual anti-platelet therapy. made an excellent recovery with no neurological deficits. further imaging -x-ray cervical spine for possible arcuate foramen or atlantoaxial instability, normal. ultrasound liver/spleen, normal. discharged home days post-transfer. patient background: past medical historyunder the gp for months of headaches. traumasignificant fall from bicycle years before with forced lateral flexion of the neck. posited that this may have been a contributing factor in aneurysm development. no significant family history. lifestylean active boy, enjoys weightlifting and motocross. weightlifting also posited as a contributing factor. conclusions: i provide a case which i hope will raise awareness of paediatric intracranial aneurysms and stimulate discussion concerning their management and aetiology. poster no. cavernoma in children: cddft experience of two cases d jayachandran, s chandraiah darlington memorial hospital, cddft, darlington, uk aim: to report two cases of congenital cavernoma diagnosed in children presenting with neurological symptoms. cases: case : -year-old female presented with multiple left facial focal seizures in the form of twitches with full awareness. there was no family history of epilepsy. a typical event was captured lasting seconds during the awake eeg and was reported as focal seizure arising from right hemisphere. an mri brain scan showed popcorn balls lesions within the frontal/fronto parietal lobes, one on each side (right>left) with evidence of bleeding. she remains seizure free on carbamazepine. ccm gene results are awaited and neurosurgeon opinion was not for intervention and for local follow up. case : -year-old male had presented with confusion at years of age. he also had transient loss of vision, vomiting, headaches with a few minutes unresponsive episode during admission. with a diagnosis of migraine, he had an mri brain scan as op that showed multiple cavernous haemangiomas in the cerebrum and cerebellum with the largest demonstrating a fluid level in the left parieto-occipital region. family history revealed that father had seizures secondary to brain cavernomas. he was positive for krit (ccm ) mutation. neurosurgeons advised active monitoring and he presented again at years with focal onset seizures with impaired awareness. eeg was normal but mri showed a new cavernoma in the left temporal horn with bleeding. he remains well on carbamazepine with a plan for yearly mri scans. conclusions: congenital cavernomas of brain can be sporadic or familial, can be multiple and in any location including brain stem and can result in physical disability secondary to bleeding. in the majority of cases bleeding is spontaneous and diagnosed on mri scans after a neurological event. objective: foxp -related intellectual disability syndrome is characterised by developmental delay, variable physical features and autism. diagnosis has increased with better access to broad genetic testing. we present a case report of a child with foxp mutation whose presentation was notable for significant cerebral venous ectasia. case: child s presented aged year with gross motor delay (not sitting or weightbearing) along with relative macrocephaly ( st- th centile), strabismus and prominent superficial forehead veins. intracranial imaging was arranged in which ct angiogram raised a possibility of an arteriovenous fistula. subsequent catheter angiography excluded this but demonstrated extensive tortuous cerebral venous ectasia. the venous ectasia was not felt to explain her developmental difficulties. initial genetic testing including microarray and pik ca and pten analysis was normal. s made some developmental progress but remained globally delayed compared with her peers. reanalysis of her dna against a panel of genes associated with intellectual disability identified a de novo heterozygous pathogenic variant in the foxp gene, c. c>t, p.(arg ter) (east anglian medical genetics service). discussion: foxp acts as a transcription factor and is likely to be involved in the development of many different tissue types. a wide range of genetic aberrations affecting foxp , including point mutations and large structural anomalies, lead to overlapping clinical phenotypes. this patient demonstrates many relevant clinical features including developmental delay with autistic traits, relative macrocephaly with a prominent forehead, strabismus and early gross motor developmental delay. however, descriptions of associated neurovascular anomalies in foxp syndrome are scarce, with a single case report recording a venous angioma and none of cerebral venous ectasia to our knowledge. foxp follow up studies and whole exome or genome sequencing may help determine whether there is an additional genetic cause for this child's cerebral venous ectasia or whether it is foxp related. objective: a rcpch guideline was published to increase awareness of stroke in children and standardize best practice. the need for urgent (within h) ct angiography in children presenting with suspected stroke and criteria for thrombolysis were set out. we aimed to review the acute management and investigation of pais in children ( mo to y) since the introduction of the guideline with an emphasis on identifying candidates for thrombolysis. methods: retrospective notes review in a single regional neurology centre over a -month timeframe. results: eighteen cases were identified ( f: m) with two mortalities. age range months- years (mean . y). / presented in peripheral hospitals and / in the regional centre. no cases had pednihss score documented on presentation. / had dedicated vascular imaging (cta/ mra) on initial imaging. / presented with a hemiparesis, / with seizures, / dysphasia, / headache, / ataxia. / cases had a stroke post cardiac surgery, / idiopathic stroke, / post varicella angiitis, / arterial dissection, / cardiomyopathy and / embolic stroke as a complication of central line insertion. / presented with an acute hemiparesis with a clear time of onset. no cases received thrombolysis. / was imaged within hour of presentation. / had vascular imaging (mra or cta) on presentation. / cases was discussed acutely with paediatric neurology; this case was not suitable for thrombolysis due to cardiomyopathy. in retrospect the other / cases were suitable candidates for thrombolysis. conclusions: the results highlight the continued need for enhanced awareness of paediatric stroke as a medical emergency. most acute strokes will present to peripheral hospitals. therefore, there is a need for regional multidisciplinary integrated pathways amongst emergency department physicians, paediatricians and radiologists to ensure prompt vascular neuroimaging and discussion with a paediatric neurologist about the possibility of thrombolysis in suspected pais. poster no. 'a nudge, a fall and a weakness'a common but missed cause of paediatric stroke r shyam , r bahri , , a kumar , v jain department of paediatric neurology, santokba durlabhji hospital and medical research institute, jaipur, india; norwich medical school, university of east anglia, norwich, uk objective: this study retrospectively analysed paediatric strokes with further evaluations and outcomes of strokes related to minor injury, to isolate characteristic features and outcomes in these patients. methods: paediatric patients ( mo to y age), presenting with acute stroke between january to january were retrospectively recruited from a tertiary care hospital in north india. from this cohort, strokes following minor injury were analysed for clinical profile, investigations and outcomes (measured by international paediatric stroke study scoring system, ipss). results: of the total cases, ( . %) were post-minor injury (m: f . : ; mean age . ae . mo). of the remaining (n= ; mean age ae . y) most common aetiologies were moya-moya disease (n= , %) and transient unilateral arteriopathy (n= , %). the post-minor injury group revealed a median time of minutes from trauma to stroke onset. more than / rd ( %; n= ) had transient episodic hemi-dystonia on the hemi-paretic side after a median of days of symptoms onset. % ( / ) of children where results were available had anaemia. ct head in all (n= ) showed calcification of the lenticulo-striate vessels. subsequent brain mri (n= ) confirmed ct findings of basal ganglia ischaemia. mr angiogram and thrombophilia screen (n= ) done in the first few patients were normal and hence not pursued subsequently. follow ups of / ( - mo; median= mo) showed good recovery in the majority ( %; n= / ). the median ipss score for these children was . . conclusions: trivial injury leading to basal ganglia stroke was the most common cause of paediatric stroke, occurring exclusively in less than year-olds. ct head was diagnostic (calcification in lenticulo-striate blood vessels and ischemia) with no further information revealed from vascular imaging or thrombophilia work-up. children were commonly anaemic, a potential causative association. often transient episodic hemidystonia of the hemiparetic side after a few days was witnessed. neurological outcomes in most children with this entity is good. introduction: rcpch launched guidance on paediatric stroke in march . we present a series of paediatric patients who presented with stroke following this publication. we audited this group of patients against the key standards of the rcpch guidance. methods: we retrospectively analysed cases between april and april . we identified cases from a neurology database and audited acute management using rcpch guidance as standard. results: we identified children with stroke in the last years. ages ranged from months to years with a mean age of years at presentation. children had haemorrhagic stroke and had ischaemic stroke. the majority involved the anterior cerebral circulation ( / ). underlying aetiology was identified in patients, of whom had haemorrhagic stroke. of the patients died. only out of patients had brain imaging within an hour of presentation. only one patient was eligible for thrombolysis, however due to contraindication she underwent thrombectomy. discussion: stroke pathways are well developed in adult services. due to the rarity of stroke in childhood and challenges with recognising symptoms, treatment is often delayed. symptoms in children need a high index of suspicion. the findings of this audit support the development of an all wales paediatric stroke pathway. we aim to facilitate activation of the stroke pathway when children present with the fast symptoms. we also hope to increase awareness of stroke in childhood. withdrawn. objective: stroke is a common childhood neurological disorder, affecting at least children in the uk each year. the majority of children have residual sequelae across a wide domain of functions, with significant personal and societal consequences. recent rcpch guidelines have proposed criteria for hyperacute treatments; this would require rapid recognition of the potential diagnosis by clinicians. here we describe the acute care pathway of a group of children with confirmed arterial ischaemic stroke (ais). methods: parents of children aged > days and < years referred to gosh (ais) ( - ) were approached and sent a questionnaire exploring their experience of navigating through the healthcare system on initial presentation. responses were tabulated where possible and reported as frequencies; qualitive results were thematically coded and categorised for analysis. results: / eligible parents responded. and the gp were the first port of call for the majority (n= for each). ten parents stated they had 'no idea' what initial symptoms might represent. when directly asked if they had suspected a stroke, nearly / stated 'no'. f.a.s.t features (f: face a: arm s: speech t: time) were noted in a third of patients and only patients were given a diagnosis of stroke at first presentation. on initial discharge, a correct diagnosis of stroke was provided to patients. notably, the need for improved education of paediatric stroke, for healthcare providers was raised by nearly % of parents surveyed. conclusions: the study demonstrates the need for further education to be delivered in pre-hospital, primary and secondary healthcare settings for recognising acute stroke in children. this will be an essential step in the delivery of hyperacute treatments. background: hereditary spastic paraparesis refers to a heterogeneous group of inherited neurodegenerative disorders characterized by progressive lower limb spasticity and weakness. there is marked genetic heterogeneity in hsp with all modes of inheritance described for the different loci and causative genes implicated up to now. we present a case of a child with a complex diagnosis of hsp with a homozygous missense mutation in nt c underlying hereditary spastic paraplegia spg . case presentation: this child had initially been diagnosed as having bilateral cerebral palsy with diplegic pattern and gmfcs ii. he had gross motor and speech and language delay. there was a family history of consanguinity. mri scans had initially been described as showing evidence of periventricular leukomalacia and he had been referred for consideration of sdr. following tertiary assessment there were clinical concerns that the overall diagnosis may need to be reexplored. review of his mri scans demonstrated similarities to a case series of hsp with a rarer form of hsp (spg ). he subsequently tested positive for spg nt c . a second case with similar clinical findings has now been identified in our region. mri scan findings will be presented. summary: spg is a rare but important cause of a cerebral palsy phenotype and testing for nt c should be considered in the differential diagnosis and investigation of patients presenting with cp. recommendations on patient suitability for sdr has focused on children functioning at gmfcs level ii or iii. sdr has been considered for gmfcs levels iv and v however the decision to progress can be challenging. the goals in these children are significantly different with the focus being around comfort and pain relief rather than mobility. we describe the case of a boy with a mixed pattern movement disorder involving limbs which had initially been managed with oral medications baclofen, trihexiphenidyl and intramuscular botulinum toxin. due to the child having a vp shunt the family didn't wish to consider itb pump. despite optimisation of oral medications and intramuscular botulinum toxin spasticity was a significant issue adversely impacting on quality of life. escalation of baclofen was unsuccessful due to loss of head control and duration of action of botulinum toxin injections appeared to be limited to to weeks before tone increased again. this resulted in significant difficulties with moving and handling. in view of this the option of selective dorsal rhizotomy was explored. the goal was to improve ease of personal care and sleep. post-operative outcomes greatly exceeded the family expectations. along with a reduction in tone in the lower limbs they were delighted to report several unexpected improvements. these included: improved functional ability with the left upper limb which facilitated switch access; improved truncal control making moving and handling easier; a reduction in extension posturing which had been particularly problematic pre-operatively; significant improvement in sleep; improved mood. this resulted in the local team exploring eye gaze technology with him. these functional benefits have significantly improved the quality of life for not only the patient but his family. further research into the benefit of sdr in this group of patients should encompass care and comfort outcomes, sleep assessment and measurement of pain. introduction: clonidine has become increasingly repurposed for the management of childhood dystonia. one potential advantage of clonidine is the availability of patches for transdermal delivery. we aimed to review the use of transdermal clonidine patches in our institution. methods: a retrospective notes review of children and young people (cayp) with dystonia issued transdermal clonidine patches as identified from pharmacy records. results: a total of cayp were identified, median age at initiation of clonidine of years months (range mo to y and mo). prior to initiation of patches / cayp were already receiving clonidine, including acutely receiving iv clonidine infusions. one child with difficult iv access experiencing an acute deterioration of dystonia was lost to follow up following transfer to local services. the commonest indications for transdermal clonidine were concerns about 'on/off' effect of enteral doses (n= ) and concerns about enteral absorption (n= ). transdermal clonidine was discontinued by / cayp ( as patches wouldn't adhere, receiving patches as a temporary bridge from iv to enteral clonidine and due to severe local cutaneous reaction). one additional clonidine naive child experienced significant hypotension with a . µg/kg/hour transdermal dose but tolerated a reduced dose of . µg/kg/hour. follow up for the remaining / children ranged from months to . years (median y). the median transdermal dose was . µg/kg/hour (range . - . µg/kg/h). additional enteral clonidine was used by / cayp. efficacy of transdermal clonidine was difficult to determine, but / cayp retrospectively scored on the clinical global improvement-scale, suggesting significant improvement. conclusions: in cayp receiving enteral clonidine switching to transdermal clonidine patches appears to be well tolerated, with . % of cayp continuing with longer term use. further prospective work is required to determine the efficacy and safety profile of transdermal clonidine. objective: to review the indications for and outcomes following itb for children and young people (cayp) at our centre. methods: patients were identified undergoing itb pump insertion from to . had reports available. a retrospective note review was performed, with data extracted using a standardised data collection proforma. results: median age at itb pump insertion was (range to ). hypertonia was described as dystonia, spasticity and/or dyskinesia. median length of follow up was years (range: mo to y). choice of outcome measure was dependent upon the goals identified for surgery. care provider child health index living with disability (cpchild) data was available for cayp at baseline and cayp at year. cpchild improved from a median score of . to . at year (p= . , wilcoxon signed rank test). burke-fahn-marsden dystonia rating scale (bfmdrs) data was available for cayp at baseline (median: . for motor, for disability), cayp at year (median . for motor, median for disability), all with a clinical picture of dystonia. gross motor function measure (gmfm) was available for cayp at baseline (median= ), cayp at year (median ) and cayp beyond year (median= . ). gmfm and bfmdrs were not statistically significant. pain was measured with paediatric pain profile, available for cayp at baseline, cayp in year and cayp beyond year. median of most troublesome pain improved from at baseline to in year. conclusions: for a heterogeneous cohort of cayp with motor disorders, itb appeared to improve ease of care and comfort, indicated by change in cpchild. multiple measures are required to fully capture benefits seen in this cohort, which should be focused on their individual needs for intervention. objective: to evaluate neurosurgical interventions and outcomes in the management of hemidystonia. methods: the pubmed database was searched including terms 'hemidystonia', hemi-dystonia', 'unilateral dystonia', 'dystonia and (pallidotomy or thalamotomy)', 'dystonia and (dbs or 'deep brain stimulation')' and 'dystonia and (itb or 'intrathecal baclofen')', up to may . papers were included if written in english and presenting outcome data for human participants undergoing a neurosurgical intervention for management of hemidystonia. reference lists of included papers were also reviewed. individualised patient data was extracted. to facilitate comparison across patients with and without validated dystonia scale scores individual patient outcomes were categorised on a -point scale ranging from 'worsened compared to baseline' to 'very marked improvement'. results: we identified reports meeting inclusion criteria, describing unique patients ( < y of age). ablative methods ( / cases) most commonly targeted the thalamus, and dbs ( / cases) the gpi. in recent years dbs is reported far more commonly then ablative surgery. reported follow up ranged from months to years. one patient underwent itb but no further individual data was available. out of the cases had individual outcome data. objective measures were available in dbs and ablation cases, most commonly the bfmdrs. reported outcomes in dbs patients were / worsening compared to baseline, / no change, / slight improvement, / moderate improvement, / marked improvement and / very marked improvement. for the ablative cases / worsened, / no change, / slight improvement, / moderate improvement, / marked improvement and very marked improvement. complications were reported in dbs cases ( shielded battery syndrome, one infection) and ablative cases ( depression and transient hemiplegia). conclusions: available evidence for the neurosurgical treatment of hemidystonia is of low quality, but suggests generally positive results, with few complications reported. introduction: acute flaccid myelitis (afm) is a recently characterised condition causing multiple muscle paralysis and life-changing disability in children. no medical treatment is effective. however, recovery of denervated muscle function is possible via nerve transfer surgery. such treatment is complex, specific to the individual and should be carried out by specialist teams. objective: to describe the clinical features, management and outcomes of nerve transfer surgery following the afm outbreak. methods: retrospective analysis of patients with afm treated with nerve transfer surgery in . surgical criteria: persistent motor deficits (paralysis) months post onset with neurophysiologic signs of denervation and donor nerve availability. results: eight patients (m=f, aged - months; mean ) were referred between march and july . at initial onset/ infection: / had involvement of all four limbs and trunk and / had involvement of the phrenic nerve. mean date of initial assessment within specialist centre was . months post onset (range - ). at this time had upper limb paralysis ( right, left) and had bilateral lower limb paralysis. following consultation, declined surgical intervention and are awaiting surgery. / patients have proceeded to surgery: / cases presented with three-or-more nerve root involvement. nerve-transfers have been performed (median per patient). no surgical complications were encountered. early clinical functional outcomes from this cohort following surgery are currently being collated and evaluated and will be presented in full at conference. conclusion: this study supports international experience that nerve transfer surgery can improve functional outcomes in afm. the delivery of care in the nhs requires coordination and referral to specialist centres. experiences with this cohort will inform decision making and improve patient outcomes and family expectations during the next outbreak of afm. poster no. a catastrophic case of acute flaccid myelitis t chakrabarty , c lundy , g doherty , d bhattacharya , p moriarty , d peake royal belfast hospital for sick children, belfast, uk; royal victoria hospital, belfast, uk objective: acute flaccid myelitis (afm) is a rare but serious neurological condition characterised by acute onset of flaccid weakness in one or more limbs with distinct abnormalities of the spinal cord grey matter on magnetic resonance imaging (mri) and without any features suggesting an upper motor neuron disorder. in recent years, there has been a global increase in the incidence of afm associated in some cases with a non-polio enterovirus, ev-d . the long-term prognosis in most cases remain poor. we present a severe case of afm in a -year-old boy with catastrophic consequences. method: retrospective review of clinical course, neuroimaging, treatment and neurorehabilitation. results: a -year-old boy presented with clinical encephalitis. he deteriorated over hours and developed an encephalopathy, multiple cranial nerve deficits, and complete flaccid paresis requiring picu support. csf weeks apart showed a resolving lymphocytic pleocytosis with increased protein ( . to . g/dl). serial mri brain and spinal cord showed extensive signal abnormality involving thalamus, dorsal pons, medulla, cervical cord, conus along with cauda equina. nerve conduction studies were consistent with a severe acute motor axonal neuropathy. eeg showed a posterior dominant encephalopathy. infective (including edv- ), metabolic, immunological (aqp and mog abs) and genetic (ranbp ) tests were negative. immunomodulation therapies (methylprednisolone, ivig, and plasma exchange) resulted in no clinical improvement. resolution of signal changes in the thalami, brainstem and spinal cord along with mild generalised cerebral atrophy was noted in repeat mri after months. months following presentation he remains fully ventilated with no significant motor improvement despite intensive rehabilitation including use of passive range of movement devices and functional electrical stimulation. conclusion: this is one of the most severe cases of afm, representing the wider spectrum of afm involving encephalopathy, dominant bulbar signs and quadriparesis. mirror movement disorder (mmd) is a rare movement disorder with a prevalence of less than in a million in which involuntary symmetrical movement is observed in the limb contralateral to the voluntary limb movement. we report children with an mmd. case : a -year-old girl following an uneventful pregnancy and normal delivery, born to nonconsanguineous parents presented with difficulties with fine motor activities like writing. parents noticed from age of eight that her left hand would make similar movements to her right hand in activities like writing, combing etc. maternal grandfather has mmd. case : a -year-old girl following an eventful pregnancy and normal delivery to non-consanguineous parents presented with an mmd at age of years first noticed whilst writing and this continues affect her activities of daily living. there is no family history of mmd. both children are neurodevelopmentally normal and have normal mri brain and spine. mmd have been described congenitally due to prenatal insult before weeks gestation, kallman syndrome and klippel-feil syndrome or as an acquired due to hemiplegic stroke and parkinson's disease in adults. pathogenesis is thought to be due to lesions in supplementary motor area, corpus callosum or cervical lesions. mutations in dcc and rad gene are present in % of the cases. the multimodal mri and neurophysiological studies have revealed that the motor system is completely disorganised with abnormal crossing at brain stem level and abnormal communication between both brain hemispheres in these children. there is a positive family history in some cases. the upper limbs are commonly involved. diagnosis is usually clinical and treatment is symptomatic with support at school and limiting repeated complex and sustained movements involving both hands. poster no. acute spinal cord infarction in children: a review of the presentation, aetiological investigations and outcomes in children m shehata, ar hart, cd rittey, e davies department of paediatric neurology, sheffield children's hospital nhs foundation trust, sheffield, uk aims: acute spinal cord infarction is poorly understood in the paediatric population. we reviewed cases presenting to a single paediatric neurology centre in uk between and to explore common themes of presentation, aetiology and outcome. material and methods: cases of spinal cord infarction presenting to a single centre were identified from our spinal database and medical records were reviewed to determine clinical presentation, aetiological investigations, management and outcomes. results: six children/young people were identified, male, female, age range to years. participants presented with symptoms after seemingly trivial movements or trauma, including: being kicked in the back whilst playing football, bending forwards to tie hair up, getting up to walk in the garden, and performing a crab gymnastic movement. had no obvious precipitants. initial presentation was neck or back pain in all patients, progressing to bilateral lower limbs weakness, sensory deficit, lost reflexes, and urinary/bowel involvement. mri imaging failed to reveal the diagnosis when performed early in participant. the level of lesions for each participant were: t - ; t - ; t -t ; c -t ; c -t ; and isolated to the conus. aetiological investigations, including thrombophilia screens, failed to reveal a cause in any participant. initially received steroids because the differential diagnosis included an inflammatory disorder. patients received aspirin, / gained motor improvement but none returned to normal. all had residual bladder problems, had bowel sequelae. conclusions: spinal cord infarction may be related to minor trauma or movements. the association with a chiari malformation is previously described in adults. outcome is poor. although motor improvement can be seen, children do not return to normal functionally. aetiological investigations and treatments vary within a single centre. national recommendations are required to standardise practice. cost of care for long-term ventilation patients r belderbos, v kumar, l alkhalidi east lancashire nhs trust, lancashire, uk background: advances in neonatal and paediatric intensive care have increased the survival of children with life threatening or life limiting conditions. there has been a significant rise in children on long-term home invasive ventilation. high profile cases have been in the media recently with debate on whether such interventions should be implemented focussing on ethics but without evidence of cost benefit analysis. children on long-term invasive ventilation are a high cost group with complex and varying underlying medical conditions requiring input from multiple teams, including hour carers, medical and multidisciplinary team input as well as recurrent hospital and picu admissions. in addition, the cost of equipment and drugs makes this a costly intervention. in any limited healthcare system rationing decisions have to be made: drug and other therapies are subject to health economic analyses. this study aims to assess cost per annum for ltv and a cost benefit analysis. objective: identify patients on ltv including comorbidities. assess cost of ltv to quantify cost-benefit analysis. measure outcomes: death/admissions/recovery. methods: review of patients requiring home long-term invasive ventilation july -july . analysis of costs: clinic visits, hospital admissions, costs of equipment; cost of medication. outcomes and quality of life: mortality, admissions and length of stay; decannulation, ability to communicate and mobility analysis; ability of parents to work. results: patients: died (aged , and y), decannulated, ongoing ltv (aged mo, and y), night package £ pa, accessories £ pa, replaceables/service £ , average cost home ltv around £ pa. conclusions: ltv ventilation is an expensive treatment: its use should be analysed on a cost benefit analysis in a similar way to other available treatments. objective: to assess the feasibility of recruiting to a study, performing and interpreting aeeg in preterm infants, and to assess family and staff members' views. methods: a prospective feasibility study. preterm neonates between and weeks postmenstrual age were recruited for continuous aeeg monitoring using adhesive electrodes whilst receiving nicu care. we studied optimal methods of attaching leads, impedance data, number of electrode changes, and preliminary aeeg findings. staff and parents were asked for feedback on the process and their involvement. results: we recruited . % of eligible babies. nuprep and sorbaderm were the most effective combination for skin preparation. the aeeg recording was good quality if staff were engaged and knew when electrodes needed to be changed. four of the seven ( . %) babies showed seizure activity on aeeg, none of which were diagnosed clinically. babies with seizures were born earlier, had lower birthweights, and had more complications than babies without seizures. feedback showed parents and staff were positive, although staff reported caring for the baby was harder. . % of parents and . % of staff would 'definitely' recommend the study to parents with a premature baby. conclusions: the use of continuous aeeg in preterm neonates in feasible, with similar recruitment rates to other studies in the department, and a positive experience for parents and staff. a high rate of electrical seizures was detected. background: the 'magnetic resonance imaging (mri) to enhance the diagnosis of fetal developmental brain abnormalities in utero' (meridian) study showed improved diagnostic accuracy and confidence for detecting fetal neurological abnormalities compared to ultrasound. the additional information provided by in utero mri altered prognosis in % of women. the meridian study did not report whether the neuro-developmental prognoses given to women varied between clinicians or were accurate. objectives: to assess the variation in prognosis given to pregnant women by clinicians in feto-maternal units for different fetal brain abnormalities. methods: we contacted one clinician at each of the meridian feto-maternal units and asked what percentage chance of normal neuro-developmental outcome they would give pregnant women for fetal neurological abnormalities: isolated ventriculomegaly to mm; unilateral hypoplasia of the cerebellar hemisphere, isolated hypoplasia of the cerebellar vermis, isolated cisterna magna, and isolated blake's pouch cyst. respondents were asked to give a percentage chance of normal outcome, although some used free text to answer. results: responses were received from senior obstetricians in feto-maternal units. there was general agreement for isolated mild ventriculomegaly with respondents replying that to % would have normal developmental outcome. wider variation was seen for posterior fossa abnormalities, with the suggested chance of normal outcome for one condition ranging from to %. conclusion: estimating long-term neuro-developmental outcome based on antenatally detected neurological abnormalities is challenging due to limited high-quality data. our data highlights there is high variation in outcomes offered by different clinicians for the same abnormality. further work is needed to determine what advice is given by obstetricians on the potential developmental outcomes of a wide range of fetal brain abnormalities in current practice, how well these agree with published evidence, and whether the involvement of paediatricians with experience in neuro-developmental disorders improves prognostication. background: in-utero mri (iumri) detects fetal brain abnormalities more accurately than ultrasonography (uss) and provides additional clinical information in around half of pregnancies. there is little published data on whether postnatal neuroimaging beyond months of age changes the diagnostic accuracy of iumri nor its ability to predict developmental outcome. methods: families enrolled in the meridian study whose child survived to years of age were invited to have a case note review and assessment of developmental outcome with either the bayley scales of infant and toddler development, the ages and stages questionnaire or both. a paediatric neuroradiologist, blinded to the iumri results, reviewed the postnatal neuroimaging if the clinical report differed from iumri findings. diagnostic accuracy was recalculated. a paediatric neurologist and neonatologist categorised participants' development as normal, at risk, or abnormal, and the ability of iumri and uss to predict developmental outcome were assessed. results: participants had case note review, of whom ( . %) had mri after months of age. the diagnostic accuracy of iumri remained higher than uss (absolute differ-ence= %, % ci % to %, p< . ). developmental outcome data was analysed in participants: ( %) were normal, of whom ( %) had a normal or favourable prognosis on uss and ( %) on iumr (difference in speci-ficity= %, % ci % to %, p= . ). no statistically significant difference was seen in infants with abnormal outcome (difference in sensitivity= %, % ci - % to %, p= . ). conclusions: iumri remains the optimal tool to identify fetal brain abnormalities. it is less accurate at predicting developmental outcome, although iumri is better at identifying children with normal outcome than uss. further work is needed to determine how the prognostic abilities of iumri can be improved. poster no. introducing hypothermia or not decision algorithm (honda) guideline in the assessment of neonates following hypoxic insult at birth in a district general hospital a sproule, j courtney, m mcgowan ulster hospital, belfast, uk introduction: hypoxic-ischaemic encephalopathy (hie) accounts for up to % of cases of cerebral palsy. hie can be caused by multiple events and occurs in / births. hypoxic insult at the time of birth can result in an encephalopathic state characterised by: need for resuscitation at birth, neurological depression, seizures and electroencephalographic abnormalities. the toby study demonstrated that induction of moderate hypothermia within hours of birth for hours duration in infants who had perinatal asphyxia resulted in improved neurologic outcomes in survivors. therapeutic hypothermia is the only proven neuroprotective treatment for hie. an assessment tool was required as there was no standard proforma for neurological assessment for babies with a low cord ph (< . ) in our district general hospital (dgh). this was to ensure that all infants who met the toby criteria received the appropriate treatment within the recommended timeframe. methods: the honda assessment tool was developed for use in the tertiary neonatal intensive care unit. this assessment tool was adapted to use in a dgh as a guideline. the honda included the criteria from the toby study with a user-friendly flow chart. a comprehensive neurological examination is outlined with text and images to ensure reliable and repeatable findings by different clinicians over time. results: the honda tool ensured a standard algorithm was used to assess those infants who had a hypoxic insult at birth. it has standardised record keeping and repeated neurological examination of at-risk infants. conclusions: the honda is a comprehensive and userfriendly algorithm to ensure those infants who meet requirement for therapeutic hypothermia are being appropriately identified and treated. poster no. foetal exposure to misoprostol and mobius syndrome s tilib-shamoun, a siddiqui, v ramesh king's college hospital, london, uk background: mobius syndrome is a rare condition comprising a collection of specific congenital anomalies, usually congenital lower motor neuron th and th cranial nerve palsies. hydrocephalus, cerebellar hypoplasia, orofacial and limbs deformities have been reported in some. the literature links mobius syndrome to early foetal exposure to misoprostol, a synthetic prostaglandin e analogue widely used for medical termination of pregnancy. for abortions it is used by itself or with the anti-progestogen mifepristone; the combination is % effective during the first trimester of pregnancy. the mechanism by which misoprostol disrupts brainstem development resulting in hypoplasia or absence of central brain nuclei is not elucidated as yet. suggested mechanisms include selective vulnerability to hypo-perfusion and ischaemic injury of the foetal brain stem due to direct disruption of the foetal vasculature or to global foetal hypoxia because of uterine contractions and placental ischaemia. clinical case: we report a case of an infant with known exposure to misoprostol from failed medical termination of pregnancy (top) at weeks gestation, who presented with an abnormally increased head circumference, multiple lower motor neuron cranial nerve palsies ( , and th cranial nerves). his mri scan showed hydrocephalus due to cerebral aqueduct stenosis, inferior vermian hypoplasia and loss of bulk of the right facial collculus of the pons. conclusions: it is vitally important to counsel expectant mothers following exposure to misoprostol and failed top of possible congenital anomalies if the woman elects to continue with the pregnancy. poster no. neurological examination in unwell neonates: health care professionals' perspectives a fadilah, ar hart department of paediatric neurology, sheffield children's hospital, sheffield, uk objective: to explore health care professionals' opinions of neurological examination in unwell neonates. methods: a questionnaire designed to assess views on examining unwell neonates neurologically was distributed to all uk neonatal and paediatric neurology units. questions included likert scales, with scores ranging from to . scores of to were taken to be positive, to negative or equivocal. answers were compared between consultants and other staff members using chi-squared testing, with p< . assumed statistically significant. results: responses were received, although not every question was answered. / ( . %) responders were based in general paediatrics, / ( . %) in tertiary neonatal units, and / ( . %) in paediatric neurology. / ( . %) were consultants. / ( . %) performed a neurological examination in all unwell neonates, / ( . %) in most. . % of consultants felt confident performing a neurological examination, compared to . % of other health care professionals (p< . ). consultants were also more confident at interpreting the results and using them to formulate management and prognosis (all p< . ). / ( . %) did not find a high-quality neurological examination documented routinely in medical notes of half or more unwell neonates. / ( . %) reported using the classical neurology examination adapted for neonates, ( . %) used the hammersmith neonatal neurological examination or an adapted version. the most difficult aspects were fundus and cranial nerve examination. the most frequently cited challenges were: effect of medication; difficulties in interpretation; equipment and lines; experience; time limitations; and risks of handling unwell neonates. / ( . %) wanted a new standardised neurological examination for unwell neonates; ( . %) did not. conclusions: non-consultant grade health care professionals feel less confident performing a neurological examination in unwell neonates. all responders highlighted a number of challenges to performing and interpreting the results. around three-quarters of responders want a new, standardised neurological examination for unwell neonates, which could address these challenges. use of re-standardised griffiths scales of child development ( rd edition) in a healthy cohort at to months of age objective: the griffiths scales of child development (gscd) is an established tool for the developmental assessment of children from birth to years. in , the gscd underwent significant revisions, and was re-standardised using contemporary cohorts. to date, no studies have reported on its use in healthy children post-marketing. our aim is to examine the use of the gscd-iii in a healthy population of infants aged to months and to provide the first published data on the use of the revised griffiths-iii. methods: in a prospective observational study of healthy, fullterm infants, participants were recruited into a randomized controlled trial of infant massage. griffiths iii assessments were performed by aricd-trained practitioners across subscales and a general development quotient (gd) at to months. results: children were considered in the analysis, male: female ratio / . mean (sd) birth weight was . ( . ) kg and mean birth gestational age was . weeks (sd . ). mean (sd) age at assessment was . ( . ) months, with ( . %) children being assessed according to / rounded norms, and ( . %) to / norms. no difference was found in either arm of the study in any subscale. scores were considerably greater than average (dq - ) in all subscales but particularly subscales b, d and gd. mean (sd) developmental quotients (dq) in a= . ( . ); b= . ( . ); c= . ( . ); d= . ( . ); e= . ( . ) and in gd= . ( . ). using the published cutoffs, we found that . % (n= ) of our cohort scored 'above average' or greater in gd. conclusions: we have provided the first data on the use of griffiths-iii in a healthy cohort. scores were higher than expected across all sub-scales. this may be due to the characteristics of our cohort but raises concern that griffiths-iii may overestimate ability in young infants. objective: metabolic investigations are important in the investigation of children with disordered development. the aim of this audit was to determine if paediatric metabolic investigations were ordered as per current best practice evidence at tallaght university hospital, dublin, republic of ireland. methods: we used recommendations from seven publications to guide this audit and identified indications for performing metabolic investigations. we reviewed metabolic investigations sent on paediatric patients at tallaght university hospital from january to december . we identified the clinical indication for investigating patients by reviewing dictated clinic letters available on the hospital intranet and confirmed investigation results by reviewing scanned copies available on the hospital intranet. we compared the indications for metabolic investigations with published expert guidelines. results: metabolic investigations were performed on patients from january to december . six patients had inconclusive results and were referred to the metabolic team at temple street children's university hospital dublin for further assessment. there have been no metabolic diagnoses made to date as per tallaght university hospital dictated letters. of the patients, had a diagnosis of autism spectrum disorder (asd). of those with asd, had a confirmed or suspected intellectual disability. patients ( %) met best practice recommendations for metabolic investigations. of the patients who did not fulfil recommendations, ( %) were for children with asd. conclusions: we identified two areas that could improve patient care by optimising diagnostic yield and improving resource utilisation at the hospital. first, we recommend clinicians send targeted investigations and avoid blanket investigations for children with disordered development, including asd. second, we recommend clinicians include relevant clinical details on request forms to improve diagnostic yield. finally, we question the value of metabolic investigations for intellectual disability in the absence of other clinical risk factors or comorbidities and suggest this requires further study. the early developmental course of babies with sturge-weber syndrome n thapa , t fosi , , v siyani , j sloneem , h richardson , s aylett , university college london medical school, london, uk; ucl great ormond street institute of child health, london, uk; neurodisability, great ormond street hospital, london, uk background: sturge-weber syndrome (sws) is a rare neurocutaneous condition which arises from a mutation in g protein subunit alpha q. the hallmark is leptomeningeal angiomas often associated with a facial port-wine birthmark. seizures, stroke-like episodes and hemiplegia are common clinical presentations. objective: to describe clinical features of infants with sws under years and their developmental trajectory in relation to seizure onset. methods: a retrospective case note review was conducted on children aged below years with sws under clinical review at our centre. the medical history and standardised developmental test results (language, cognition, motor and visuospatial skills) contained in patients' assessment reports were analysed. results: common clinical features of children with sws aged under years were: seizures in patients ( %), hemiplegia in patients ( . %) and glaucoma in patients ( . %). their developmental trajectory was a decrease in the mean percentiles (for language, cognition and motor skills) and mean developmental quotients (for visuospatial skills) over the first months. infants with unilateral brain involvement had significantly higher cognitive percentiles than those with bilateral brain involvement (p< . ), but both groups showed the aforementioned pattern. children with epilepsy had worse language (p= . ) and cognitive outcomes (p= . ) than children without seizure onset. there was seizure onset in the first year in infants ( . %). in these patients, earlier seizure onset was associated with a higher language percentile (p= . ) at age months or at the time of seizure onset. conclusions: following treatment of early seizures in sws language recovery appears to occur over time relative to cognition. the functional plasticity of language might account for these observations. it is proposed that seizure prevention and optimal seizure control in the crucial first year of life will benefit cognitive and language development in patients with sws. objective: rett syndrome (rtt) is a rare neurodevelopmental disorder primarily affecting females, characterized by loss of speech, stereotypies, abnormal hand movements, motor and cognitive impairment. diagnosing rtt before regression occurs remains a challenge and there is an increasing interest in early diagnosis, due to the ongoing gene therapy clinical trial in rtt. methods: retrospective case notes review. the patient was born at term after induction of labour for reduced movements, with meconium-stained liquor, but was well. poor crying and suck noted at birth with gradual deterioration of feeding, with frequent chest infections, necessitating peg-feeding at months. peripheral/axial muscle weakness and hypotonia were noted at this time. mri brain showed mild underopercularisation of sylvian-fissures; thin corpus-callosum. mrs, mri spine, echocardiogram, and eeg were normal. vitamin b deficiency was found, treated with hydroxycobalamin. sleep study showed hypoventilation with frequent apnoeas and low respiratory rate, leading nocturne bipap. emg was myopathic. muscle biopsy showed marginal loss of complex-i activity in the respiratory-chain-enzymes analysis. results: videofluoroscopy showed delayed swallow and disorganised pharyngeal stage leading to peg feeding. over the following months, no regression noted but only minimal motor progression seen; she was interactive and smiled. at months, regression in her motor abilities was notedshe stopped fixing, following and smiling with progressive microcephaly and hand writhing movements. eeg showed epileptic encephalopathy with tonic/myoclonic jerks. whole-exomesequencing showed a de-novo pathogenic mutation in the mecp gene (nm_ . :c. _ del,p.[leu fs] ) and the diagnosis of rtt was confirmed. after months, she restarted smiling and fixing/following and making motor progress but continues to have seizures. conclusions: this case illustrates early-onset features in atypical rtt with central breathing abnormalities, bulbar insufficiency, generalized hypotonia before regression. evidence of mitochondrial dysfunction is in keeping with recent reports suggesting neuronal redox imbalance in rtt as one of the disease pathogenic contributors. objective: neurodegeneration with brain iron accumulation (nbia) comprises a group of rare genetic disorders characterized by progressive extrapyramidal and other neurological symptoms due to focal iron accumulation in the basal ganglia. b-propeller protein-associated neurodegeneration (bpan) is the most recently identified subtype of nbia caused by heterozygous variants in wdr at xp . . we report a new subtype of bpan caused by a de novo wdr variant in a -year-old girl. methods: case report on a new subtype of b-propeller proteinassociated neurodegeneration (bpan) caused by a de novo wdr deletion in a -year-old girl and review of the literature. results: we report a year old girl with bpan due to a large ( bp) de novo chrx:g. , , _ , , del (hg ) deletion in wdr , presenting with early-onset global developmental delay, hypotonia, seizures, and speech apraxia. the patient presented at the age of months with hypotonia and motor developmental delay, following a normal birth history, and at months developed complex partial seizures and later on steroid-responsive electrical status epilepticus of slow-wave sleep (eses). she has made minimal developmental progress and has remained profoundly globally developmentally delayed and cognitively impaired, and has still not achieved independent ambulation. conclusion: we have described the clinical, neurophysiological and neuro-imaging findings in a -year-old girl, the unique combination of which may assist in the diagnosis of further similar cases. bpan is an exceedingly rare, severe and debilitating disorder with a broad spectrum of clinical heterogeneity and variable age at presentation with early-onset symptoms. early detection and diagnosis are very important in order to offer proper genetic counselling to affected families and provide symptomatic treatment to patients. next-generation broad-spectrum genetic analyses will enable early detection of bpan in the paediatric age group in order for patients to be diagnosed prior to reaching adulthood. introduction: how to measure the effectiveness of an early intervention program in low resource setting. can assessments lead to interventions? and with improvements leads to new interventions, can new assessment lead to new interventions? can this system be measured for its effectiveness and improved based on feedbacks and results? an attempt to set up child development centres in low resource countries using software, apps and e-learning. method: years of data in early interventions was analysed in lucknow, india. in phase , children with non-progressive neurological problems were given best available local interventions. only % compliances and improvement were seen. based on the feedback algorithms were written to create individual profile of children based on their skills (uk curriculum of excellence), disability score, information processing preference, educational and behaviour problems. based on the score each child generates an individualised profile and an intervention plan delivered by app for parents (p-bac-drv) and app (t-bac-drv) at child development centres. the assessment is repeated every months and new individualised profile is generated with new set of intervention. in total more than interventions are developed, and the algorithm helps in deciding which main areas to target at one time. result: the current system in low resource settings have either no service or results are close to % prevent disability in non-progressive neurological problems. our system has shown to prevent disability in about % of children. supported by government start up initiative the program has won in top data innovations in india. conclusion: use of technology to provide training, exams and support professionals in the low resources areas is the solution to provide effective services. pattern recognition is the key delivered by software and auto audits has been placed to measure and improve the system. introduction: medical advances in the treatment of cns tumours has enhanced survival but also impacted on levels of residual morbidity and participation. service provision has not increased alongside the improvement in survival, with many patients not being able to return to their previous level of activity and participation following their oncology treatment. nice cancer services for children and young people state: 'children and young people who have had a central nervous system malignancy should receive a specialist neuro-rehabilitation care package'. robbie's rehab, a charity funded physiotherapy service embedded within the southampton children's hospital therapy service, launched june , provides supplementary physiotherapy for children diagnosed with brain and spinal tumours under the care of southampton children's hospital. objective: to accurately identify and quantify the need for this service. method: prospective data was collated and reviewed june -may . results: year : patients; year : patients. new episodes of physiotherapy (average . per month), direct clinical contacts. reasons for accessing the service: need for enhanced intensity of rehabilitation on discharge (n= ), enhanced inpatient rehabilitation (n= ), bridge the gap whilst awaiting community services (n= ), change in symptoms (n= ), pre-op assessment (n= ), support for palliative care planning (n= ), support for complex social and emotional needs (n= ), disease progression (n= ), higher level rehabilitation not fulfilling community criteria (n= ), facilitate access to local exercise facilities (n= ), within oncology clinic for assessment/one-off treatment (n= ), post-op assessment (n= ), individualised goal orientated participation (n= ). patients had an estimated weeks reduction in acute bed days. conclusions: robbie's rehab referrals are for a variety of multifactorial reasons with rereferral often needed within their pathway. it has enabled earlier discharge, improved transition to community services and opportunities for therapy access previously not available. results: our proband presented at weeks with marked stridor and bulbar weakness after a normal pregnancy. he subsequently developed respiratory failure requiring nocturnal bipap and was found to have a type i laryngeal cleft. initially he met developmental milestones but at months developed features of axial weakness with further regression at months with limb weakness and loss of deep tendon reflexes. emg confirmed denervation in genioglossus, as well as proximal and distal limb muscles without evidence of neuropathy. genetics for smn gene and smard were negative. inherited peripheral neuropathy gene panel testing identified a heterozygous missense variant c. t>c, p.(cys arg) in exon . the variant is predicted to alter a highly conserved amino acid, has not been reported before and has not been identified in control databases. in silico prediction tools supports the pathogenicity of the variant. mutagenesis of the equivalent amino acid in mice produces impaired motor control and denervation. conclusions: the gars gene encodes an ubiquitously expressed glycyl trna synthetase which has an integral role in protein synthesis in all eukaryotic cells. missense gars mutations can lead to distal hereditary motor neuropathy as well as a sensorimotor neuropathy phenotype (cmt d) typically with adolescent or early adulthood onset. objective: to discuss sma, which is one of the differentials in a hypotonic child and bring to light the diagnosis is not always cerebral palsy (cp). method: descriptive case report. results: case : -month-old girl admitted to icu with severe pneumonia. case : -month-old boy, both admitted to the intensive care unit with severe pneumonia. case : -month-old girl, presented to outpatient with progressive 'floppy' limb weakness and swallowing and breathing difficulties. case : attended opd with worsening respiratory distress, difficulty feeding, difficulty managing secretions. all had perinatal histories of uncomplicated deliveries but subsequent early respiratory distress and oxygen requirement for the first few days of life. all had been 'floppy' since birth, with severe gross motor delay, feeding difficulties, poor weight gain and recurrent chest infections. cases , and had been diagnosed with cp despite having normal neuroimaging. examination of all children was similar and consistent with clinical diagnosis of sma. findings included an alert, interactive child; frog-legged posture; -limb hypotonia and weakness with legs more affected than arms; absent deep tendon reflexes; bell-shaped chest; and tongue fasciculation. genetic testing for all confirmed homozygous deletion of exon of the smn gene. in all the cases creatinine kinase levels were normal, ruling out myopathy. conclusions: the incidence of sma is / livebirths. it can be diagnosed clinically from pathognomic features when genetic testing is unavailable and should be considered in any hypotonic child, irrespective of perinatal history. a wide clinical spectrum that ranges from early death to near-normal adult life exists. families must be counselled regarding implications of this genetic diagnosis. correct early diagnosis and multidisciplinary intervention can vastly improve outcomes. poster no. syros studylong-term reduction in rate of respiratory function decline in patients with duchenne muscular dystrophy (dmd) treated with idebenone l servais , c lawrence , oh mayer , cm mcdonald , u schara , t voit , e mercuri , gm buyse respiratory function decline in dmd is caused by the underlying weakness and degeneration of the respiratory muscles leading to impaired inspiratory and expiratory effort and associated complications. idebenone reduced the rate of respiratory function decline over weeks in the phase iii delos trial. syros is a long-term study in former delos patients who transitioned to idebenone under expanded access programs following a variable untreated period. here, we aimed to characterize the long-term effects of idebenone on respiratory function. patients were managed according to routine clinical practice. respiratory function was assessed by calculating the annualized decline in forced vital capacity (fvc) and peak expiratory flow (pef), expressed as percent predicted (%p). comparisons were made between treated and untreated periods and to matched external controls. data on bronchopulmonary adverse events (baes) and hospitalizations were collected. data from / former delos patients were available. at delos baseline, mean (sd) age and fvc%p were . ( . ) years and . % ( . %); all patients were glucocorticoid non-users and . % were non-ambulatory. patients were treated for an average (min-max) of . ( . - . ) years compared to an average untreated period of . ( . - . ) years. the annual rate of fvc%p decline was almost halved ( . % vs . %) when comparing these periods. for the external comparisons, declines remained lower across all treatment years (up to y) compared to the matched group of untreated patients. comparable results were seen for pef%p. the risk of baes was reduced by % during longterm idebenone treatment versus untreated periods, leading to fewer hospitalizations due to respiratory causes ( . vs . events per year). long-term treatment with idebenone results in a consistent and sustained reduction in the rate of respiratory function decline for up to years. two placebo-controlled trials of -week duration (phase ii delphi, phase iii delos) showed that idebenone consistently reduced respiratory function decline rate in patients with advanced dmd. long-term data from the delphi-extension (delphi-e) study and syros (delos patients who transitioned to idebenone under an expanded access program) are now presented. the aim was to assess the consistency of the long-term effect of idebenone on respiratory function across both placebo-controlled trials and their respective long-term data collections. delphi-e and syros patients with abnormal (< %) forced vital capacity (as percent predicted, fvc%p) were treated with idebenone for an average of . and . years respectively. annualized fvc%p decline rates were compared to untreated patients from syros or matched external controls (matched for baseline fvc%p) from the cinrg duchenne natural history study (cinrg-dnhs). mean (sd) baseline age was . ( . ) and . ( . ) years in delphi (n= ) and delos (n= ), respectively, and fvc%p was . % ( . %) and . % ( . %). for the first -year period, where data were available for both studies, the average annual decline rate was comparable in treated patients ( . % and . % in delphi-e and syros) and lower than in untreated syros patients and external controls ( . % untreated and . % in cinrg-dnhs). during years to , the annual decline rate was consistently lower than for matched controls. treatment with idebenone resulted in a sustained reduction in the rate of decline in respiratory function across both placebo-controlled week studies and across both long-term data collections, with follow-up time of up to years. the consistency observed across independent datasets adds to the robustness of the treatment effect of idebenone and its potential to modify the course of respiratory function decline in dmd. poster no. a rare mutation in dync h causing a mixed clinical phenotype of spinal muscular atrophy with lower extremity predominance and hereditary spastic paraplegia: a case series in a family el goh , , s jayawant , g anand objective: to describe the identification of a rare mutation in the dync h gene as a cause of a mixed clinical phenotype of spinal muscular atrophy with lower extremity predominance (sma-led) and hereditary spastic paraplegia (hsp). methods: case series of three family members (father and two sons) across two generations. results: there was a history of early childhood-onset, progressive lower limb muscle weakness and atrophy. no relevant family history of neuromuscular disorders was reported on both the paternal and maternal sides of the family. examination revealed markedly diminished tone and power in the lower limbs, with wasting and a positive crossed adductor reflex. there were no abnormalities detected in the upper limbs and sensation was preserved throughout. neurophysiological testing showed moderate to severe chronic denervation of the lower limb muscles with sparing of the peripheral sensory nerves. hsp panel was negative but charcot-marie-tooth (cmt) panel demonstrated a heterozygous sequence change in the dync h gene: c. a>t p.(glu val), which was present in all affected family members. discussion and conclusions: mutations in the dynein gene are typically associated with sma-led or cmt. a mixed sma-led and hsp phenotype has previously been shown to be caused by mutations in bicd . bicd encodes a golgin, which is a component of dynein-based transport, and plays a key role in mrna transport during oogenesis and embryogenesis. we present the first case series of a mixed clinical phenotype of sma-led and hsp occurring due to a mutation in dync h . this was the first observation of the c. a>t p.(glu val) variant at our laboratory and was not listed in the genome aggregation database, suggesting an extremely rare variant. opening the lid on unilateral ptosis in paediatric nf e hassan , e witter , z mughal , l robinson , d weisburg , sa roberts , e hupton , j eelloo , e burkitt wright , , s garg , l lewis , dg evans , , sm stivaros , , , g vassallo , , introduction: neurofibromatosis type (nf ) is a genetic disorder with a birth incidence of in - individuals and prevalence of around in worldwide. ptosis is a welldocumented feature in this condition and is known to be associated with plexiform neurofibromas or in the noonan phenotype, with bilateral ptosis. unilateral ptosis in the absence of a plexiform neurofibroma is not a common feature in nf . we describe a number of patients with nf who demonstrated unilateral ptosis. methods: a retrospective cohort study was carried out using the patient database within the nf service based in st mary's hospital, manchester, uk. children and young adults aged to years with nf were identified via the patient database and patients with a presentation of ptosis were identified. results: six children with unilateral ptosis were identified, four females and two males (ages - , mean= . y). five had unilateral ptosis affecting the right and one the left, with no differences observed between sporadic or familial disease. five patients had complex disease; however, none had any other associated complication to account for the unilateral ptosis apart from nf . they did not meet the diagnostic criteria for noonan syndrome, and none had plexiform neurofibromas in the orbital or peri orbital area. discussion: it is unclear why there is an increased incidence of unilateral ptosis in our cohort of nf patients, in the absence of plexiform neurofibromas and noonan's syndrome. ptosis in nf has been associated with a noonan syndrome phenotype in nf patients. the general hypotonia and myopathy observed in these patients could also factor into the causes for ptosis. further research is necessary to investigate the aetiology of increased unilateral ptosis in nf patients. objective: sma is a severe neuromuscular disorder characterised by progressive muscle atrophy and weakness. scoliosis is a highly prevalent complication and surgery is almost invariably required in 'sitters'. data on secondary outcomes are limited, and this study investigates post-surgical respiratory (fvc%) and motor function, weight gain, pain and satisfaction. methods: we retrospectively reviewed the notes of patients who never walked or lost ambulation (sma type ii/iii) who successfully underwent scoliosis surgery at great ormond street hospital: spinal fusion ( ), magnetic ( ) or traditional ( ) growth rods. we performed phone interviews and run a focus group for families on pre and post-surgical satisfaction. results: median follow-up before and after surgery was . ( . - . ) and . ( . - . ) years respectively. mean annual rate of fvc% decline improved post-surgery in sma ii: - . versus - . (p< . ), with similar trajectories in sma iii. mean annual rate of hammersmith functional motor scale's scores decline did not change significantly (- . vs - . , p< . ), while the revised upper limb module's scores showed a less progressive deterioration (- . vs - . , p= . ). a negative deviation from previous weight curve after surgery was observed in / requiring food supplements ( ); one/ with significant weight loss (> % of total weight) needed gastrostomy. pain was frequently documented, especially hip pain ( / ) requiring painkillers ( ), intra-articular steroids ( ) and surgery ( ). nine/ families participating in the phone interview reported major improvements in posture, physical appearance, self-image; all rated the procedure as very successful. however, / did not report significant improvements in quality of life due to reduced mobility and increased unmet care needs. five families attended the focus group reporting on both positive and negative aspects of their experiences. conclusions: this study provides relevant data and suggestions to improve the current multidisciplinary approach of scoliosis surgery in children with sma. poster no. sunfish part : -month safety and exploratory outcomes of risdiplam (rg ) treatment in patients with type or spinal muscular atrophy (sma) objective: spinal muscular atrophy (sma) is a severe, progressive neuromuscular disease caused by reduced levels of survival of motor neuron (smn) protein due to deletions and/or mutations of the smn gene. while smn produces fulllength smn protein, a second gene, smn , produces only low levels of functional smn protein. risdiplam (rg / ro ) is an investigational, orally administered, centrally and peripherally distributed small molecule that modulates smn pre-mrna splicing to increase smn protein levels. sunfish (nct ) is an ongoing, multicentre, double-blind, placebo-controlled study (randomised : , risdiplam:placebo) in patients aged - years, with type or sma. methods: sunfish part (n= ) is a dose-finding study assessing the safety, tolerability and pk/pd of risdiplam; pivotal part (n= ) assesses the safety and efficacy of the risdiplam dose level that was selected based on results from part . sunfish part included patients of broad age ranges and clinical characteristics (functional level, scoliosis and contractures). an interim analysis of part (data cut-off, july ) showed a sustained, > -fold increase in median smn protein versus baseline after year of treatment. adverse events were mostly mild, resolved despite ongoing treatment and reflective of the underlying disease. despite not being designed to detect efficacy, risdiplam improved motor function measures over months versus natural history. results: safety, tolerability and pk/pd will be reported from all patients in part who have received treatment with risdiplam for a minimum of months. updated part exploratory efficacy data, including motor outcome measures, will also be presented. the clinical benefit of risdiplam is being assessed in part , which is ongoing worldwide. objective: ryr encodes the skeletal muscle ryanodine receptor, an intracellular calcium-release channel that is crucial to excitation-contraction coupling in muscle. gene variants can cause heterogeneous myopathies, including dominantly inherited central core disease. both autosomal dominant (ad) and autosomal recessive (ar) pattern of inheritance have been reported. methods: retrospective case notes review. results: sibling : female, presented during the first year of life with motor developmental delay. at years of age she is able to sit unsupported and crawl but not stand or walk. she has facial weakness, but no feeding difficulties or ophthlamplegia. she has axial and proximal weakness with antigravity power in neck flexors and hip flexors (mrc / ) and sub-gravity power in hip abductors/extensors and knee flexors/extensors (mrc / ). there are severe hip, knee and ankle fixed contractures. power and joint range is normal in upper limbs. muscle biopsy showed type- fibre predominance and core-like structures. sibling : female, presented at birth with feeding difficulties. at months of age she is fully nasogastric fed. there is no facial weakness or ophthlamplegia. she has good head control with active head lift in prone, and antigravity power in hips, knees and ankles. she has mild hip and knee contractures and shoulder girdle weakness. both siblings have been confirmed to be heterozygous for a ryr pathogenic frameshift variant (c. _ dupca p.(met fs)) inherited from father and a likely pathogenic missense variant (c. g>c p.(lys asn)) inherited from mother. both parents are asymptomatic. conclusions: the clinical and pathological features of ad ryr -related myopathy are well recognized but much less is known about ryr -related disorders secondary to an ar pattern of inheritance. we report two siblings with ar ryr related myopathy with similar genotypes but different phenotypic features demonstrating intra-familial variability and expanding current knowledge on this disorder. results: our probands were the second and third children of consanguineous irish parents who were fourth cousins. antenatally, reduced fetal movements and amniotic fluid was noted with both probands. at birth, both had arthrogryposis and the second sibling required prolonged intubation at birth. both had significant developmental delay; a more severe phenotype in the younger. on examination, both had myopathic facies, inability to bury eyelashes, full eye movements, high arches palates, drooling, a weak cry, micrognathia but a preserved suck. they both had long thin fingers, with thumbs held adducted and dimpling of elbows and hands. peripheral reflexes were absent but there were good anti-gravity movements of the lower limbs. both were noted to have pectus excavatum and progressive scoliosis. muscle biopsies showed dystrophic features of fibrosis, hypertrophy and atrophy of fibres and variation in fibre size with increased fibrous connective tissue. occasional central cords and multiple mini cords were also seen in the second proband. whole exome sequencing identified the compound heterozygote mutation (ttn c. delc in combination with ttn c c>tp. (ser leu) and ttn c. g >a p. (asp asn)). conclusions: mutations in the titin gene (ttn) have been implicated in several skeletal and or cardiac phenotypes to date. each individual variant of the compound heterozygote has not been reported as pathogenic mutations and have been detected in the general population at . % frequency. however, the presence of the triple count may certainly account for the severe phenotype of our probands. poster no. gene-replacement therapy (grt) in spinal muscular atrophy type (sma ): long-term follow-up from the onasemnogene abeparvovec phase / a clinical trial objective: sma is a rapidly progressing neurologic disease caused by biallelic survival motor neuron gene (smn ) deletion/mutation. the smn grt onasemnogene abeparvovec (formerly avxs- ; approved in us) treats the genetic root cause of sma and is designed for immediate, sustained smn protein expression. in a phase / a trial (start [cl- ]; nct ), sma patients received a one-time onasemnogene abeparvovec infusion at low dose (cohort , n= ) or high dose (cohort , n= ), and demonstrated improved outcomes versus natural history. no patients in start received nusinersen during the -month follow-up after dosing. sma patients in start could rollover into a long-term follow-up study (study lt- ; nct ). primary objective: long-term safety. methods: sma patients have annual visits ( y), then phone contact (additional y). patient record transfers are requested. safety assessments include medical history and record review, physical examination, clinical laboratory evaluation, and pulmonary assessments. efficacy assessments include developmental milestone evaluation to determine maintenance of the highest achieved milestone in the parent study. results: as of march , patients (cohort , n= ; cohort , n= ) had enrolled in study lt- and had a baseline visit. for patients in cohort , the mean (range) age and time since dosing were . ( . - . ) years and . ( . - . ) years, respectively. all patients in cohort ( / ) were alive. no developmental milestones achieved in start were lost, and new milestones have been achieved, supporting the durability of onasemnogene abeparvovec. updated data will be presented. conclusions: one-time onasemnogene abeparvovec administration at the high dose continues to provide prolonged and durable efficacy with milestone development in lt- . poster no. micu -myopathy: a mitochondrial disorder that mimics a congenital muscular dystrophyreport of siblings with variable phenotypes m fernandez, m sa, v gowda evelina london children's hospital, london, uk objective: micu encodes a selective calcium-channel subunit within mitochondrial inner membrane whose function is essential for buffering cytosolic ca + transients and activating atp production. mutations in micu have been reported in different families with muscle weakness, fatigability and developmental delay, with normal lactate despite being a mitochondrial disorder and persistently elevated creatine kinase (ck) usually in the range of congenital muscular dystrophies (cmd). the phenotypic spectrum is highly variable and keeps expandingother features include progressive extrapyramidal signs, learning disabilities, nystagmus and cataracts. we report the clinical features of siblings from a consanguineous family with the homozygous c. - g>c splicing mutation in micu . methods: retrospective case notes review. results: sibling : boy, older sibling, presented aged years. he had short stature which was investigated when found to have ck of iu/l. he complained of occasional cramps. muscle biopsy showed mild dystrophic changes with reduced alpha-dystroglycan that indicated a possible congenital disorder of glycosylation. his mri brain was normal. he was diagnosed with autism. sibling : girl, diagnosed antenatally with cerebellar hypoplasia, confirmed postnatally as inferior-vermis hypoplasia. presented at years with occasional cramps, mild tightness of tendo-achilles, and ck of iu/ l. her height and weight were on nd centile. muscle mri showed a small area of high signal in the left adductor magnus related to a group of normal vascular structures. neurophysiology studies were normal. no other systemic involvement was seen in either of them. next generation sequencing revealed the micu mutation described. conclusions: our work expands the phenotypical spectrum of micu deficiency and highlights the variability in patients within the same family. targeted analysis of the micu gene in patients with high ck levels resembling a cmd picture may be warranted, even in the absence of prominent muscle features. the role of dystrophin brain isoforms on early motor development and motor outcomes in young children with duchenne muscular dystrophy half of patients have central nervous system (cns) manifestations. two dystrophin isoforms, dp and dp , play an important role in cns function. those lacking dp have a more severe cns phenotype, most marked in those lacking dp and dp . our objective is to determine whether lack of dp and dp also has an adverse impact on early motor development. methods: the northstar ambulatory assessment (nsaa) is a scale of motor function. clinical information for dmd participants was classified by dmd mutation location and effects on isoform expression as follows: dp +_dp + (dp absent, dp /dp present), dp -_dp + (dp /dp absent, dp present) and dp -_dp -(dp /dp /dp absentall isoforms affected). results: amongst to year olds, median total nsaa scores were lower in the dp -_dp + (p= . ) and dp -_dp -groups (p= . ) than the dp +_dp + group, most markedly in the dp -_dp -group. for example, for -year olds, median total nsaa scores were (dp +_dp +), (dp -_dp +) and (dp -_dp -). amongst to year olds, a lower percentage of participants achieved a full score of (normal, achieves goal without assistance) for the nsaa sub-items in the dp -_dp + (p< . ) and dp -_dp -(p< . ) groups than in the dp +_dp + group, most markedly in the dp -_dp -group. for example, amongst -year-olds, percentage of visits for which a full score was recorded for jump were as follows: % (dp +_dp +), % (dp -_dp +) and % (dp -_dp -). conclusions: in addition to the known cns phenotype, young dmd patients lacking dp also exhibit lower median total nsaa scores and greater early motor delay, most markedly seen in those lacking both dp and dp (lacking all dystrophin brain isoforms). this has important implications for patient prognostication and clinical trial design. background: most commonly known as a rare subtype of guillain-barr e, miller fisher syndrome (mfs) has evolved since it was first described in . the syndrome is characterised by a triad of ophthalmoplegia, ataxia and areflexia but clinical variations do occur. it occurs more often in men than woman (ratio : ) with the average age of onset . years. mfs is associated with positive anti gq b antibodies, which is concentrated in cranial nerves iii, iv and viexplaining the link with ophthalmoplegia. clinical case: we present an unusual case of a -year-old boy with background of macrocephaly and pre-existing developmental delay with a previous mri which showed mild signal change in periventricular white matter bilaterally. he was admitted with a subacute history of proximal muscle weakness and fatiguability. he had no obvious focal neurological signs apart from intermittent lid hopping and ptosis. differential diagnosis included myasthenia, demyelinating disorders or an underlying pre-existing luecodystrophy. anti gq b antibodies were checked along with extensive metabolic investigations, lumbar puncture, muscle biopsy, anti-cholinesterase and antimusk antibodies along with repeat mri. all investigations were negative including mri which showed no significant change from previous. the only findings were strongly positive anti gq b antibodies. in the interim, the patient was started on trial with pyridostigmine with significant clinical improvement. conclusion: atypical variants of mfs should be a differential in children with subtle eye signs without ophthalmoplegia. lid hopping and fatiguability should raise the suspicion of mfs and anti gq b antibodies should be tested. pyridostigmine has been reported to be effective in mfs. potential utility of muscle mri in congenital myasthenia syndrome secondary to agrn mutation found on whole exome sequencing (wes) congenital myasthenia syndromes (cms) are caused by genetic defects affecting neuromuscular transmission, resulting in muscle weakness and fatigability. agrin, an extracellular matrix molecule released by the nerve is essential at the neuromuscular junction. the large coding gene agrn, has a number of exons and with increasing variants found on wes, it is time consuming and complex to undertake functional studies to define pathogencitiy. previous reports of agrn mutations have a phenotype with prominent distal leg weakness and changes in the soleus on mri. we describe a differing presentation and striking changes on mri, especially in the posterior compartment of the thigh. a -year-old presented with deterioration in his gait and difficulty climbing the stairs. he was born at term, via a normal vaginal delivery. his parents were consanguineous, and he had three well siblings. he was reported to walk by years. on examination he had a waddling gait and was unable to run or hop. he had proximal weakness with a positive gowers sign, together with weak eye closure. muscle biopsy showed non-specific myopathic features, however an mri of the lower leg found widespread fatty muscle atrophy of the thigh and calf with relative preservation of the adductor longus, rectus femoris and semitendonosis. wes revealed an agrn mutation (c. _ del) and a homozygous mutation in the nebulin gene (not felt to be clinically relevant). single fibre emg confirmed electrodecrement on repetitive nerve stimulation. the patient has been commenced on treatment with salbutamol. our patient had very distinctive changes on mri and nonspecific muscle biopsy changes. muscle mri changes prompted further genetic testing when symptoms fitted a clinical diagnosis of a congenital myasthenic syndrome. with increasing variants found of unknown significance in these patients, collation of mri imaging to try and elucidate patterns of changes will be important. mcardle disease (glycogen storage disease type v) is an autosomal recessive condition caused by pathogenic mutations in both copies of the muscle glycogen phosphorylase (pygm) gene encoding the muscle-specific isoform of glycogen phosphorylase, 'myophosphorylase' exclusively affecting skeletal muscle. it is the commonest form of glycogenosis. mcardle disease shows significant clinical variability, with symptoms ranging from mild discomfort during exercise to marked muscle weakness and rhabdomyolysis with myoglobinuria. the second wind phenomenon is unique to mcardle disease and consists of improved exercise tolerance with a decrease in heart rate after a rest. despite the majority of patients recalling symptoms during the first years of life, mcardle is infrequently diagnosed in children, % of patients being diagnosed after years of age according to a recent review. here we report two patients diagnosed with mcardle disease at the age of and years respectively. case one presented with fatigue and inability to increase pace of walking from the age of . hills lead to earlier fatigue. she was able to participate in gymnastics and dancing. presentation was with fluctuating ck levels ( to ). she had no second wind phenomenon or myoglobinuria. case two presented at years with a history from months of reduced exercise tolerance and myalgia after low intensity physical activity with no evidence of myoglobinuria or second wind. on formal assessment there was no evidence of muscle weakness or functional impairment. ck was persistently raised ranging from to . in the light of symptoms and ck levels a rhabdomyolysis panel was requested in both cases leading to diagnosis. objectives: to explore characteristics of anxiety experienced by young males with duchenne muscular dystrophy (dmd) using: . qualitative analysis of focus group discussions with dmd boys and their parents. . parent-report scales of anxiety/emotional problems. methods: eight boys aged to years with dmd and dmd parents participated in separate child and parent focus groups. perspectives on anxiety were elicited using semi-structured discussions, and framework analysis was applied to identify themes. scores on five parent-report scales were determined and scales were compared for content and sensitivity. results: from group discussions, six characteristics of anxiety were recurrently reported: catastrophic conclusions; rigidly held anxieties; extreme distress; unexpected/unfamiliar; social anxieties; physical changes and needs. many features echo the anxiety phenotype in autism spectrum disorder (asd). four further themes described relevant contextual factors: individual, family, social and environmental responses. from parent-report scales, younger dmd boys ( - y; n= ) had significantly higher total, general and social anxiety scores compared to population means on at least two scales (p< . ; p< . ; p< . ). the older dmd group ( - y; n= ) trended towards higher scores in total, general and separation anxiety (p= . ; p= . ; p= . ) compared to population norms. different scales varied in their diagnostic sensitivity and item content, which may influence their utility in dmd. conclusions: anxiety can be a pervasive and impactful issue in dmd. it appears to have some shared traits with anxiety in asd and may be influenced by situational factors, such as living with a disabling, life-limiting condition. screening with standard anxiety scales may not accurately capture the full spectrum of the phenotype in dmd, therefore further evaluation to determine optimal screening instruments in dmd is warranted. however, multi-modal assessments tailored to dmd are key to identifying those in need of support to optimise the mental well-being of young people with dmd. objective: as part of the clinical psychology service in paediatric neurology we developed a tic management group to support young people and their parents to develop positive coping in relation to their tics. the group combined psychoeducational, emotional regulation and habit reversal therapy (hrt) components. this evaluation aimed to establish the effectiveness of these groups in reducing tics and associated distress. method: twenty-eight children, aged to years and their parents attended one of seven tic management groups facilitated between february and november . these children had been referred to the clinical psychology for support with tics. each group consisted of weekly, -hour sessions with a review session weeks later. a parent group was held in parallel. both the young persons and parent groups were facilitated by the clinical psychology team. homework tasks were provided to support hrt skill practice and consolidation of learning of the group content between sessions. the following pre and post group measures were completed by the young people and their parents: the paediatric index of emotional distress, the yale global tic severity scale, the parent tic questionnaire and session rating scales. measures were collated and descriptive data reviewed. results: % of children found the group was helpful in the management of tics. % of children were 'less bothered by their tics'. % of children felt more confident in controlling their tics. parents reported a greater understanding of tics and a reduction in the severity of their child's tics. conclusions: results indicate the tic management group is effective in building young peoples' understanding of tics, confidence in tic management whilst providing peer support. the findings also indicate that parents found the groups informative and valued the opportunity to share experiences with others. background: patients with epilepsy often have deficits in cognitive, physical, psychological and social functioning, and treatment should aim to alleviate these deficits. epilepsy surgery is considered for medication refractory epilepsy with aims to improve patient quality of life. a recent study highlighted the importance of a multidisciplinary workup prior to epileptic surgery, including a neuropsychiatric assessment. part of this assessment should identify patient expectations of epilepsy surgery, so that these can be addressed peri-operatively. at king's college hospital (kch), london, these assessments are routinely performed by the paediatric liaison service as part of the children's epilepsy surgery service (cess). aim: to analyse retrospective data of pre-operative patient and carer expectations between october -september at kch. methods: a record of patient and carer expectations is routinely recorded as part of kch cess neuropsychiatric assessments. the responses were compiled and analysed using qualitative content analysis. results: a preliminary survey of cases with an average age of (range - ) identified responses that were grouped into broader classifications (cognitive, seizure experience, social process, school experience, mental state and general improvements). simple analysis showed carers most often expected surgery to reduce the need for medications ( %), ablate seizures ( %), increase school performance ( %), independence ( %) and overall quality of life ( %). this compared to child responses, where the most common expectations were a reduction in lifestyle restrictions ( %), a cure for epilepsy ( %), decrease in medications ( %) and increased independence ( %). conclusion: consideration of both child and carer expectations during pre-epilepsy surgery neuropsychiatric assessments is important in order for services to manage each individual's expectations. unmanaged unrealistic expectations may lead to a negative psychological outcome for either child or carer. expectations should be weighed up against an individual's clinical profile. poster no. neural correlates of conversion hemianaesthesia in an adolescent: a novel fmri case study m ray, a zaman, t alam leeds teaching hospital nhs trust, leeds, uk aim: to highlight the novel functional magnetic resonance imaging (fmri) findings in an adolescent with rare conversion hemianaesthesia. methods: we hereby report a right-handed y old boy who presented with inability to perceive sensations on the right half of body without any motor weakness causing him to have frequent injuries on his right leg as well as burns on his right hand without realizing. when he wore a jacket, he felt warm on one side of the body more than the other. his birth and developmental history were non-contributory. neurological examination was unremarkable except for right hemisensory disturbance. the mri of brain and spine, peripheral nerve conduction studies and somatosensory evoked potentials did not show any evidence of dysfunction were normal. he underwent fmri on a t philips achieva. the paradigm consisted of stimulating both the right and left hands and feet with three dissimilar stimuli (cold, brushing, pin-prick-pain) . the order of the stimuli was pseudorandomised and after each stimuli delivery, feedback was obtained. results: both the hand and foot sensory motor cortices were successfully stimulated. irrespective of which hand was being stimulated, there was left hemisphere sensory motor cortex dominance (with the brushing and cold stimuli), however selfreport from the participant confirmed detection of stimuli on the left-side only. there was more sensory-motor activation when the stimuli were delivered to the right hand. pain stimuli successfully activated parts of the 'pain matrix', furthermore enhanced attention effects (frontal pole activations) were observed with right-sided stimulation (supports lack of stimuli detection ability). the pain stimuli were more effective on the hands than foot, reflected by increasing activation and also self-report from the participant. conclusions: the fmri findings are unique and support the evidence of neuroplasticity and the current study paves the way for future studies investigating conversion hemianaesthesia. poster no. chronic paroxysmal hemicrania presenting as facial pain in a child with autism and bipolar disorder: diagnostic challenges case presentation: a boy diagnosed with disintegrative psychosis aged , revised to autism with bipolar disorder, had been on carbamazepine with risperidone for poor mood control. withdrawal of risperidone produced tardive oromotor diskinesia responsive to clonidine. aged , when mood improved on aripiprazole, carbamazepine was withdrawn. he then presented with episodes of distress preceded by withdrawal, unilateral but not side-locked facial flushing, with additional flushing of neck, back and wrists. behaviours included hitting wrists off walls, chewing of hard objects and requesting pressure to his head. episodes occurred - times/ day, lasting - minutes. he showed rhinorrhea and tearing, attributed to crying, during events. the attacks self-terminated. results: mri and electroencephalogram were normal. failed pharmacological trials included paracetamol, amitriptyline, gabapentin and oxcarbazepine. diclofenac provided mild pain relief and morphine reduced the incidence of attacks. reintroduction of carbamazepine resulted in improvement at mg/kg/day but did not eliminate pain. sequencing of scn a was normal. a plan to wean morphine alongside a trial of indometacin, initially at mg twice-daily was successful at mg twice-daily. episodes ceased, including all autonomic features. exacerbation at weeks occurred in context of an intercurrent illness and was managed with an additional dose of indometacin. conclusions: cph is underreported in the paediatric age group. in our case, the patient's inability to describe events, and an additional psychiatric diagnosis added complexity. the possibility of pain as a cause for early psychotic breakdown in a developmentally vulnerable child cannot be excluded. criteria emphasising side-locked headache and autonomic features, and not recognising associated symptoms elsewhere may also delay recognition in children. objectives: piih can be a challenging condition to diagnose and manage with risks of misdiagnosis, permanent sight loss and frequent comorbidities. we aimed to review our practice to identify areas of uncertainty to help formulate important questions to address within a clinical guideline. methods: a single centre retrospective case notes review of all cases referred to neurology with suspected piih (papilloedema confirmed by a consultant ophthalmologist in all cases) during an -month period. results: ( f: m) cases were identified. age range to years. mean years. / had a bmi > th centile. one case was referred to an obesity service. / had a comorbid headache disorder and / had anxiety/depression. all cases had neuroimaging ( mri, ct) with / having dedicated venography. in / cases lumbar punctures (lp) were conducted under general anaesthesia (ga). in / cases lp was not done; due to presence of a chiari malformation and due to procedural failure related to body habitus. intracranial pressure (icp) monitoring was done in one of these four cases. all children were treated with acetazolamide as first line therapy. frusemide, zonisamide and topiramate were also used in single cases. / children had repeat lps due to failure of resolution of symptoms. / cases had sight threatening piih with permanent visual loss in one case. / cases were discussed with neurosurgery. one child with evolving visual failure had an emergency ventriculo-peritoneal shunt. conclusions: important questions raised were: should all obese children with piih have access to a specialised obesity service? should all children have dedicated venographic imaging? how reliable is measuring csf opening pressure under ga? where lp is not possible should icp monitoring always be done? should repeat lps be done for persistent symptoms? should csf diversion surgery be restricted to cases of sight threatening piih only? objective: to describe a case of revesz syndrome due to a de novo missense variant in tinf . case report: a male infant was born at weeks gestation by emergency lscs due to maternal hypertension and reduced amniotic fluid. from week's gestation, reduced fetal growth was identified. the proband was born by at weeks. birth weight was . kg ( . th- nd centile) and occipitofrontal circumference (ofc) was . cm ( nd- th centile). he spent days in the scbu. he developed thrombocytopenia (nadir: /l), which resolved pre-discharge. periventricular calcifications on cranial ultrasound prompted torch screen and ophthalmology review. a right pre-retinal haemorrhage with overlying organised vitreous haemorrhage was identified, which remained stable on subsequent reviews. aged weeks, he was smiling, fixing and following with good head control. aged months, he developed new wobbly eye movements and was no longer fixing or following. bilateral retinal detachments were identified. ct and subsequent mri showed diffuse calcification within the thalami, posterior limb of the internal capsule, deep white matter, cerebellar atrophy and thin corpus callosum. findings on examination included ofc of . th centile, rotatory nystagmus and central hypotonia. whole-exome sequencing identified a pathogenic de novo variant in tinf (c. g>a, p.arg his). he subsequently developed thrombocytopenia and anaemia and is transfusion dependent. discussion: trf interacting nuclear factor- (tinf ), protein regulates telomerase and prevents telomere shortening. revesz syndrome is a severe form of dyskeratosis congentia, with multi-system involvement and early onset in-utero. revesz syndrome is characterised by intrauterine growth retardation (iugr), microcephaly, cerebellar hypoplasia, bilateral exudative retinopathy, intracranial calcifications and progressive bone marrow failure. revesz syndrome is distinguished from hoyeraal-hreidarsson syndrome by the presence of retinopathy. telomere disorders should be considered in infants with a background of iugr, thrombocytopenia, retinopathy and intra-cranial calcifications with a negative torch screen, as early features mimic congenital infection. objective: currently the most commonly reported neurological complication of sca is overt stroke. reversible cerebral vasoconstriction syndrome may be more frequent in patients with sickle cell anaemia than reported at present. the scarcity of prevalence studies however makes it difficult to improve diagnostic accuracy in these patients. methods: a -year-old ghanaian female was rushed to the paediatric emergency room with first episode of sudden severe global headaches initially started hours prior to arrival. the headache was so excruciating that she described it as her heart was beating in her head. there was associated neck pain, back pain, dizziness, and vomiting. there was no fever or dark urine. she was first diagnosed with sickle cell anaemia (genotype ss) at years of age after she was treated for dactilitis. she had since then been in her usual state of health with no history of blood transfusions or surgeries or admissions. she was compliant with her medications (folic acid mg daily). a physical examination and all investigations were also normal. on day six of admission patient had a generalized tonic clonic seizure with some degree of left sided weakness after having her bath. this was aborted with intravenous diazepam and a magnetic resonance imaging (mri) of the brain was requested. the mri of the brain revealed diffuse narrowing of the cerebral arteries with no areas of bleeding or oedema. reversible cerebral vasoconstriction syndrome was therefore suspected. results: the headache rapidly improved after starting nimodipine and repeat angiography at months showed no vasoconstriction, confirming the diagnosis. on follow up she is doing well academically with no neurological deficits. conclusions: the true incidence of rcvs in patients with sickle cell is uncertain, thus sensitizing medical practitioners is important. introduction: status dystonicus (sd) is a life-threatening disorder of generalised, painful dystonic movements and muscular spasm in patients with severe neurodisability. while rare, it may be complicated by rhabdomyolysis, multi-organ dysfunction, and death. infection, pain, gord, and medication failure are common triggers, but in approximately one-third of cases, sd is idiopathic. mordekar et al. ( ) identified a series of patients in whom sd occurred secondary to gi dysfunction. assisted feeding (e.g., via gastrostomy), and aberrant bowel peristalsis may trigger the onset of sd. this was a retrospective analysis which aimed to estimate an incidence rate for feed-induced sd (fisd). methods: patients presenting to sheffield children's hospital over a -year period with sd were identified. episodes were studied to assess for the nature of the onset of sd and as to the likelihood that the trigger was feed related. incidence of fisd as a proportion of total sd was calculated and or calculation performed to explore relative risk of sd between individual trigger factors. results: twenty-four individual episodes of sd were identified. ( %) arose from non-feed-related sources (nfisd), and were felt to be fisd ( %). additional patients were entered into a feed-induced dystonia (fid) group, whom showed clinical evidence of dystonia in relation to gi sources, but not sd. with the exception of infection, the relative risk of sd secondary to gi dysfunction was significantly higher than pain/gord and medication failure combined (or . ( % ci . - . ) and . ( % ci . - . ) respectively). conclusion: gi dysfunction coupled with severe neurodisability could serve as a trigger in a number of previously idiopathic sd cases through disruption of the neuro-enteric axis. however, overlap between triggers for fisd and nfisd, and significant variation between groups is evident, in addition to a lack of statistical study power. large, prospective studies are needed in the future to corroborate with these findings. poster no. dystonia can twist the patient, physician and the scans: hypermanganesemia, a rare cause of dystonia in children r kumar, s ali liaqat national hospital, karachi, pakistan introduction: manganese (mn) is a chemical element with symbol mn and atomic number . mn in the environment can cause toxicity with dystonia and other movement disorders. waterborne mn has a greater bioavailability than dietary manganese. according to results from a study, higher levels of exposure to mn in drinking water are associated with increased intellectual impairment and reduced intelligence quotients in school-age children. we have recently reported a suspected autosomal recessively inherited syndrome of hepatic cirrhosis, dystonia, polycythemia, and hypermanganesemia in cases without environmental mn exposure. the rarity of the disease can become a challenge for the physicians to recognize this as a cause of dystonia in children. it also has a characteristic finding on mri with t hyperintensity in basal ganglia rather than on t . case report: we present a case of a -year-old girl with dystonia who was previously healthy. she has been suffering from this for the last months and currently one of her years old sister started showing similar symptoms. physical examination revealed marked dystonia (score of on baryalbright dystonia scale) and polycythemia (haematocrit ). magnetic resonance imaging (mri) brain showed basal ganglia hyperintensity on t weighted images. hypermanganesemia was suspected and samples send for serum level which came out to be high. water samples were tested, which came out to be normal. chelation was done and the dystonia improved. conclusions: dystonia in children should be thoroughly investigated and rare, treatable causes should not be ignored. objectives: sodium valproate is used primarily for the treatment of epilepsy in children. it is a well-established teratogen, with in babies at risk of developmental disorders and in babies at risk of birth defects. this risk has been known since the s and yet it is estimated that since then children in the uk have been left with disabilities as a result. in , the medicines and healthcare products regulatory agency released guidance for its use, which included a risk acknowledgement form. patient safety alerts were issued in asking all organisations to identify females taking this medication. we aimed to identify all girls taking sodium valproate in the south eastern trust under paediatrics requiring annual risk assessment; patients under the additional care of a neurologist; patients receiving an annual review. methods: patients were identified through paediatric epilepsy nurse records and data collected through the electronic care record and medical notes from august to december . results: % (n= ) of girls with epilepsy currently taking sodium valproate, % under the age of years, % profound learning difficulties/disability and considered to be at low risk of pregnancy, % (n= ) potentially currently at risk, % were under the additional care of a neurologist, % reviewed in the past year. conclusions: sodium valproate must not be considered first line treatment in girls with epilepsy and > % of girls in our trust are not receiving it. of those receiving it, the majority are felt to be low risk due to young age and/or profound disability. we identified two patients at risk and steps were taken to ameliorate this. we have demonstrated good awareness; however lifelong education of families is crucial to reducing the burden of fetal valproate syndrome. rett syndrome (rtt) is neurodevelopmental disorder affecting approximately in - live female births, most commonly associated with mutations in the mecp gene. hand stereotypies and gait disturbance, as well as spasticity and dystonia, have been noted in rtt since the first descriptions of the syndrome. objective: this review aimed to explore the prevalence of reported movement disorders in rtt. data sources and extraction: pubmed and embase databases for papers describing features of movement disorders in rett syndrome. papers were selected for inclusion to be reviewed if they included description of case report, cohort or case-series of patients with rtt which included a description of clinical features of their movement disorder. selected papers were divided into epochs: (i) pre- , (ii) to , and (iii) onwards. results: studies ( in the first epoch, in the second epoch and in the third epoch) reported on movement disorders including stereotypies in rtt patients. hand stereotypies were almost universal in reported cases, diminishing but not disappearing over time. gait disturbance and ataxia/tremor were also very common (> % cases). elements of hypertonia were also common, increasing with age. in earlier descriptions spasticity was commonly described, with more frequent reference to dystonia/rigidity in more recent reports. myoclonus and choreoathetosis are uncommonly reported in rtt. conclusions: movement disorders beyond hand stereotypies are common in rtt, most notably tremor. hypertonia is a common feature seen in rtt, increasing in prevalence with age, and with an apparent change in nomenclature over time, (i.e., early epoch spasticity, late epoch dystonia). dystonia was specifically reported in / cases. further work is required to explore the relative contribution of dystonia and rigidity to hypertonia in rtt, as well as the impact of these impairments when present. introduction: headache is the common complaint in children, and the source of it, a great deal of worry for general practitioners and parents. one of the commonest causes of headache in paediatrics is migraine. methods: a prospective study was conducted to evaluate the demographic data, clinical spectrum and grading the child with migraine by using the paediatrics migraine disability assessment (ped-midas) questionnaire and to start prophylactic treatment for those with the higher grades in the department of paediatrics in tertiary care hospital. all children with migraine from age to years were included while all other types of headache cases were excluded. results: total children with migraine were studied. approximately % children complained of bilateral frontotemporal headache in which . % presented with throbbing type. other associated features were photophobia, phonophobia, nausea and vomiting. % had skipped meal, followed by altered sleep and exam stress as aggravating factors. . % required medication for headache relief. headache duration and frequency was approx. days and days/month. . % cases were diagnosed migraine without aura and . % cases were diagnosed as migraine with aura. loss of full school days due to headache was approx. days for period of months. based on ped-midas score, % of children with migraine had grade i disability while . % and . % cases had grade ii and grade iii disability respectively. correlation of ped-midas score with frequency and severity were significant (p< . ) while with duration of headache was insignificant (p< . ). conclusions: all patients with higher ped-midas grade are warranted prophylactic treatment. both ped-midas scores and grading can be successfully used for assessing the migraine disability and its easier, less time consuming, bedside diagnostic tool, can be used widely in routine clinical evaluation and management. objective: to review the cases referred to this uk-wide study of children with possible variant creutzfeldt-jakob disease (vcjd) and report the differential diagnosis in children presenting age years or older. methods: children meeting the case definition for progressive intellectual and neurological deterioration (pind) were identified via the british paediatric surveillance unit. details were obtained by standard questionnaire. results: between april and august , children had been notified to the study. were found not to meet the pind case definition. had an underlying diagnosis to explain their deterioration, with over different disorders including vcjd cases (the last identified in ). there were children who presented to clinicians when aged years or over, including all the vcjd cases. of the other disorders in this age group the commonest were: mitochondrial cytopathy , adrenoleukodystrophy , lafora body disease , huntington's disease , neuronal-ceroid lipofuscinoses , niemann-pick type c , metachromatic leukodystrophy , sspe , wilson's disease . when reviewed in there was no underlying diagnosis in pind cases; of them had diedonly underwent autopsy. the recent identification of the first patient with vcjd who was mv heterozygous at prnp codon reinforces the need for continued vcjd surveillance, particularly as a study of archived appendix samples from uk hospitals published in indicated that approximately in of the uk population is carrying abnormal prion protein in the gastrointestinal tract. in the absence of a validated vcjd screening test the pind study remains the only means of performing systematic surveillance of the neurodegenerative diseases that make up the differential diagnosis of vcjd. objective: transient lesions in the splenium of corpus callosum (scc) are rare findings in mri brain in paediatrics. in literature, it has been described as reversible splenial lesions syndrome (resles) and mild encephalitis/encephalopathy with reversible splenial lesions (mers). the condition has diverse aetiology and widely variable neurological presentation but the prognosis is usually favourable. we present two cases of resles with predominantly expressive dysphasia but varying causal associations. method: retrospective review of resles case series exploring clinical course, investigations, neuroimaging, treatment and recovery. result: case : a year-old-girl presented with confusion, fever and low oxygen saturation. she had alagille syndrome and partially corrected tetralogy of fallot. her neurological manifestations were expressive dysphasia, dysarthria and difficulties with spatial awareness. interestingly she was able to use occasional words that were abusive in nature. mri showed prominent focus of abnormal signal and restricted diffusion in scc. her blood culture grew staphylococcus aureus and echo revealed infected shunt. treatment involved shunt replacement and prolonged iv antibiotics. repeat mri showed resolution of splenial lesions. she continued to improve neurologically. case : a year-old-girl presented with paroxysmal episodes of head turning, head drop and staring for a few seconds. she refused to feed. she showed emotional lability with expressive dysphasia but preservation of expletives. neurologically she was intact. mri brain showed high signal with restricted diffusion in scc. her blood and csf investigations including mog, aquaporin, nmdar, lyme antibodies were negative except asot was . her eeg was normal. she received a course of ivig and azithromycin. her repeat mri showed resolution of the lesion in splenium. she made complete recovery over next few months. conclusion: splenial lesions are rare but clinically significant but not 'non-specific'. expressive dysphasia is a prominent symptom. awareness of resles/mers will avoid unnecessary investigations and assist in the prognostication. background: the evidence-base on managing paediatric-headaches is sparse resulting in wide variation in practice with nice guidelines commencing over years of age. this study aims to evaluate outpatient management of paediatric headaches. objective: to investigate paediatric headache referrals to a tertiary hospital over a -year period, exploring patient demographics, headache type, role of neuroimaging, management and outcome. methods: this prospective study reviewed headache referrals for the year - . the data was collected following weekly emails to relevant clinicians. the patient demographics, headache classification, imaging, management and outcome were collated on a proforma from the electronic patient-records. results: there were patients. the median age of patients at first outpatient appointment was years (range - y); . % were female. incidence of headaches increased with age. female preponderance of headaches existed in all age groups and was most substantial post-puberty with a . : female-to-male ratio in patients aged to years. migraine was the most common diagnosis, affecting . % of patients. % of referred patients underwent a brain mri scan, all of whom had a normal neurological examination. no mri scans found pathology contributing to headache presentation. % of patients were discharged from neurology clinic after first or second neurology appointment. non-pharmacological management was the most common intervention and consisted of: headache diary, lifestyle advice, education, relaxation techniques. the most common medications prescribed bar simple analgesia were sumatriptan ( %), propranolol ( %) and pizotifen ( %). conclusions: a multidisciplinary and biopsychosocial approach to managing paediatric headaches, consisting of non-pharmacological and pharmacological methods resulted in a positive outcome, with majority discharged from tertiary care after first appointment. prescription of sumatriptan and propranolol first line for acute and prophylactic management respectively, was in accordance with current clinical recommendations. the role of mri scanning for paediatric headaches requires further exploration and perhaps more stringent guidelines. objective: the head-up tilt test (hutt) is the gold standard autonomic function test for identifying disorders of blood pressure (bp) and heart rate (hr) regulation, specifically with excessive falls in bp and or hr, as well as excessive postural tachycardia (pt). the minute active standing test (ast) is quicker and easier to apply, e.g., in an outpatient clinic, and may be more sensitive in demonstrating pt. we aimed to compare the yield of these abnormalities when using ast vs hutt. methods: this was a retrospective, clinical notes review, and registered clinical audit of unselected consecutive children and young people undergoing hutt immediately preceded by an ast. results: data was available on children and young people, ( %) female, aged to years (median ). / ( %) with complete data sets for the first minutes of hutt and the ast had abnormally large drops in bp and or hr on hutt. only / positive on hutt was also positive on ast. however, an additional / ( %) were positive on ast but not on hutt, giving / ( %) positive in total. / ( %) with hr data sets for minute hutt and ast had abnormally large rises in hr on hutt. only / positive on hutt were also positive on ast. however, an additional / ( %) were positive on ast but not on hutt, giving / ( %) positive in total. while hutt yielded more cases with significant falls in bp and or hr than ast ( % vs %), combining the tests gave the highest yield ( %). while ast yielded more cases with significant rises in hr than hutt ( % vs %), combining the tests gave the highest yield ( %). conclusions: we recommend routinely undertaking a minute ast prior to the minute °hutt, in children and young people. objective: the aim of our work is to describe the respiratory function trajectories and their correlation with motor function in a cohort of spinal muscular atrophy type and non-ambulant sma paediatric patients. methods: this is a retrospective -year study in patients recruited in the ismac natural history study (uk, italy, us). the following respiratory data were collected: lung function data (forced vital capacity absolute (fvc) and fvc% predicted, non-invasive ventilation (niv) requirement. recumbent or ulnar length were used as surrogate for height in fvc%pred. calculation. comorbidities affecting lung function such as aspiration were collected. anthropometrics and motor function scores as hammersmith functional motor scale (hfms), revised performance of upper limb (rulm) were noted. we excluded patients in interventional clinical trials and nusinersen therapy. results: data were available for patients: sma , sma . mean age at first visit was . (ae . ) and . (ae ) years for sma and . / ( %) sma and / of significant lesions. a review of practice of asking routine or non-urgent mri requests should be considered in view of an unlikely significant result. retrospective review of brain magnetic resonance imaging referrals in children less than years (r[ ] ) is an ultrarare disease characterised by drug-refractory epilepsy, cognitive impairment and behavioural problems. non-pharmacological treatments should be considered alongside antiepileptic drugs (aeds) early after diagnosis to benefit prompt seizure control and preserve cognitive function. we aimed to understand the use and experience of ketogenic diet therapy (kdt) in r( ) by patients families carers (pfcs) and healthcare professionals (hcps), assessing its efficacy and safety, and contrasting nhs kdt service provision with patient demand. methods: literature searches were conducted on use of kdt in r( ) and similar complex epilepsies. two surveys were developed to gather demographic, diagnostic and clinical care information. surveys were qualitative and descriptive with patient and expert collaborators assessing content accuracy and readability. responses were discussed at a patient and expert workshop. results: the number of responses ( pfcs, hcps) was considered significant given the ultra-rare status of r( ). % of pfcs had tried kdt. seizure activity, behaviour and cognitive outcomes were ranked equally important by hcps and pfcs. significant improvement in seizure activity, cognition and alertness were reported; side-effects were typically mild but with one report of increased seizure frequency. the high rate of comorbidities, older age at presentation, behavioural problems and cognitive impairment can make implementing kdt in r( ) challenging. pfcs report quality of life would be most improved with reduced aed side-effects; hcps report they would consider reducing or withdrawing aeds where kdt is successful. conclusions: kdt may not be suitable for every r( ) patient, but there is a strong consensus that it should be considered as an early intervention. in the uk, nhs kdt services are predominantly available for paediatric patients, with very limited adult access. a detailed health economic analysis illustrating reduced acute care costs and improved quality of life may encourage more widespread kdt implementation. objectives: whole exome sequencing (wes) with a -week result turnaround time has become available on the nhs for children in an intensive care setting. we aimed to determine the diagnostic utility and impact on clinical care of wes in a regional paediatric neurology centre. methods: retrospective case notes review. results: six cases ( m, f) were identified. three patients were dependent on long-term respiratory support. a pathogenic mutation was detected on wes in / cases ( %). one case required 'reverse phenotyping' with an abnormal transferrin glycoform electrophoresis confirming that two heterozygote variants of the rtf gene were consistent with a congenital disorder of glycosylation (cdg). no other variants of unknown significance were found. three children presented with neonatal onset epileptic encephalopathy (two cases had scn a, one case wwox), one child with intractable epilepsy from months of age (rft mutation associated with cdg) and one child with hypotonia and ventilator dependence after a respiratory infection at months of age (ighmbp mutation associated with spinal muscular atrophy with respiratory distress). wes found no pathogenic mutation in a -year-old with intracranial calcification, microcephaly, epileptic encephalopathy and severe developmental regression. in / cases other single genes/panels had been sent prior to initiation of wes with multiple single genes/panels sent in / cases. in / cases wes detected the gene thought most likely based on clinical phenotyping on the request form. conclusions: wes has a high diagnostic yield in this cohort of patients. reaching a prompt diagnosis facilitated withdrawal of care in one case (ighmbp ) and helped to exclude an epilepsy surgery hypothesis in four cases as well as guide prognosis in all cases. wes should be considered as a cost-effective alternative when multiple single genes and/or genetic panels are being sent off in parallel due to clinical urgency. objective: the care provided in the time surrounding the death of a child shapes long-term memories and has potential to impact on the grieving process. there are no specific guidelines for picu staff in relation to what good care looks like at this time. we sought insight into practice across the uk to build an evidence base, improve care provided and share good practice. conclusions: from the survey feedback, we found this was an area that all units believe can be improved. in relation to acps, we hope this will be more widely introduced. we know that % of patients admitted to picu are life limited. these difficult conversations with family help guide management, understand wishes, and formal documentation ensures all staff are aware. several units with higher uptake of hospice/home care found early conversations with families beneficial. units with a dedicated palliative nurse stated this allowed more time with families. we believe this should become a standard of care. staff training is limited in most units. for something so difficult and frequently encountered, it is vital we equip staff better. prioritising children with epilepsy in the first seizure clinic cp white, s brown, ka hapgood, s tuohy children's epilepsy service, morriston hospital, swansea, uk objective: rising demand for limited first seizure clinic appointments was leading to increasing waiting times and the feeling that children with epilepsy were waiting too long for their first assessment. concern was also expressed that families were not receiving our first seizure leaflet or given instructions about capturing any further episodes either on video or by making a written record when initially seen. methods: from april all families were sent a letter acknowledging the referral and asking them to contact the specialist epilepsy nurse if they had any concerns prior to the appointment. later modifications included a seizure information leaflet and a seizure record document. we have analysed the results of the first year of using this system. patients were identified from the clinic database and further information was obtained by reviewing clinic letters. results: our initial concern that the specialist nurse would be inundated with phone calls from worried parents were not realised as only % ( / ) of parents contacted the service before their appointment. these were invariably parents whose children had had a second episode ( / ). had had further generalised tonic clonic seizures. children had eegs performed before their first appointment. this included all the children given a diagnosis of epilepsy. % of these children ( / ) were given a diagnosis of epilepsy made compared to . % of other referrals (p< . ). although a higher percentage of families who were reminded about videoing any further episodes did so the difference between the two groups was not statistically significant. unfortunately, overall waiting times were not affected. conclusions: a simple change to the way in which the service is delivered has led to earlier identification of those children with epilepsy. we are looking at other ways of improving the accuracy and timeliness of the appointments. introduction: paediatric idiopathic intracranial hypertension (iih) is an uncommon disorder and presentation is varied with children presenting to paediatricians, paediatric neurologist, and ophthalmologists. there are many areas of diagnosis and management where evidence is limited. a national adult evidence and consensus-based guideline was published in . no national paediatric guideline exists to aid the further investigations and management of the cases. the iih meeting at the bpna conference in and january set the scene for collaborative work on this topic. aim: to develop a national paediatric iih guideline based on the available literature such as modified dandy criteria, friedman classification and icdh- classification and consensus amongst various members of bpna chan group, members of rcpch, ophthalmology, neurosurgery and radiology, and patients. methods: a core children's headache iih guideline development group was established and has met at four national special interest group meetings between november and september . topics discussed include incidence of papillioedmea, csf dynamics in iih, bpnsu iih data, ophthalmology good practice, regional iih pathways in uk and setting up of the delphi process. the paediatric iih study day in september with invited patient/parent representatives highlighted the impact on families with the disorder with need for better communication about the disorder, clear guidelines and sharing of good practice amongst clinicians. an email list of bpna chan group, rcpch members, ophthalmologists interested in the guideline was created. results: a set of statements were drafted for delphi consensus work. these are currently being reviewed by the core guideline development group prior to being circulated to the wider working group. conclusions: goal setting for the next process with the delphi process to work with the core committee and a wider working group will be presented at the bpna conference . objective: nhs england's marginal rate emergency threshold (mret) and readmission fund funded the chameleon project (twitter account: @chameleonproje ), to improve children's end of life care. this funded a lead disability paediatrician with expertise in paediatric palliative care ( h/wk), a children's palliative care nurse ( d/wk) a network administrator ( d/wk), and additional hours for paediatricians in the critical care, oncology, and neonatal units, and in each of the local district general hospitals (total h/wk). methods: tools were developed to aid identification of children in the last year of life and to support anticipatory care planning. the team attended ward rounds and provided teaching sessions, advice and support. children who died an expected death in the months of the project were ascertained from the child death review teams. non-elective admissions, bed days, and costs were tabulated. we also evaluated the documentation of care plans and post bereavement family feedback questionnaires. results: children died an expected death. the same number died during the previous months. the median number of non-elective admissions reduced from to per child, specialist ward bed days reduced from to ( % reduction). for children admitted to picu in the last months of life, the total picu bed days reduced from to ( % reduction), the median length of stay reduced from days to days, and the maximum length of stay reduced from days to days. the percentage of children who died an expected death who had documented anticipatory care plans rose from % to %. conclusions: the network of clinicians with expertise in paediatric palliative care working together across a region improved anticipatory care planning and reduced admissions and bed days for children in their last year of life: better care with reduced costs. child a, a boy with speech and language delay, presented at years of age with self-resolving episodes of floppiness, ataxia, and disorientation. there was associated muscle weakness and drooling. these unusual episodes occurred to times per week and were often triggered by excitement, especially physical and emotional overstimulation. they lasted from a few minutes to an hour, with no residual deficit. episodes could also be triggered by having late meals (fasting episodes). investigations including an mri/mra brain, eeg, sleepdeprived eeg and video telemetry did not reveal any significant abnormalities. metabolic and endocrine tests were normal. as his presenting symptoms were consistent with episodic ataxia, possibly a periodic paralysis spectrum, a trial of acetazolamide was given, which showed some improvement in the number and severity of the episodes. at years of age, genetic sequencing results revealed child a has a recessive kb deletion within the long arm of chromosome , band q . . this is a homozygous intragenic deletion within the tango gene. tango is a 'transport and golgi organization ' homolog. the function of tango is unknown; however, in previous studies, depletion in drosophila s tissue culture cells was observed to cause fusion of the golgi with the er. a recent study of individuals with tango , illustrated that child a has a clinical phenotype which is consistent with those previously reported in the literature. although seizures are present in % of individuals with tango , child a has not had any seizures to date. although no effective treatments for this rare condition are known, early diagnosis is important so that individuals and their families are aware of the potential encephalomyopathic crises and arrhythmias which occur. further research in elucidating the structure and function of the tango protein may lead to effective therapies in the future. objective: hie affects around . / live births. prognostication relies on clinical progress, neurophysiology, neurological examination, and magnetic resonance imaging (mri). there is limited information on the relationships between mrs brain results and visual appearances of the brain on mri and clinical features. this work studied the use of mrs in this cohort. methods: mrs is used routinely in all neonates with hie in our unit, so approval for this service evaluation was obtained from our clinical governance department. we identified neonates with hie between jan and march who had mri and mrs in the first days of life. medical notes were reviewed, and mri results categorised as normal or abnormal. mrs results and clinical features were compared between mri groups using parametric or non-parametric testing. correlation and regression analyses studied relationships between clinical features and mrs results. p-values of < . were assumed to be significant. results: participants were identified, were excluded because they did not meet our inclusion criteria. data from a total number of neonates were analysed using r studio. babies with abnormal mri scans had significantly lower birth weight (p= . ), gestational age (p= . ), and higher scores in the sarnat staging scale (p= . ). the analysis of the mrs data also revealed that these babies had lower levels of n-acetylaspartate (naa) in their parieto-occipital region (p= . ), as well as higher levels of lactate and lactate to choline both in the parietooccipital region (p= . and p= . respectively). finally, these significant mrs variables were significantly correlated with time to normalisation of lactate in single linear regression. background: more children and young people are surviving with an acquired central nervous system injury (traumatic or non-traumatic). the first nhs england (nhse) specialist specification for paediatric neurorehabilitation services was written in . evidence for benefits of early neurorehabilitaion after adult stroke are compellingevidence for early neurorehabilitation in cyp is emerging. methods: service information was collected from all england and wales pnr units in . results: / units contributed. activity is increasing ( ( / ); ( / ); ( / ). / ( %) are major trauma units ( %) have dedicated coordinators. several units cannot offer daily therapy. most units discharge cyp home. conclusions: considerable neurorehabilitation in-patient activity is taking place but there remains an absence of secure funding, adequate staff, dedicated beds, key members of the mdt, protected time for pro-active patient specific discharge planning. neurorehabilitation is an integral part of the neuroscience clinical pathway and our children deserve a fully resourced service as described in the service specification. tuberculosis/sarcoidosis ( ). out of the sub-categories, the group of refractory seizures/status epilepticus were most likely to have repeated imaging with either ct or mri within years ( %), followed by the group of ventriculo-peritoneal shunt blockage ( %), space occupying lesion ( %) then head injury ( %). out of patients with refractory seizures/ status epilepticus, were already known to have epilepsy. also, most repeated imaging included a subsequent head mri. conclusions: most common indications for ct head were head injury and shunt blockage (as this was a neurosurgical centre). the groups most likely to have repeated imaging were refractory seizures/status epilepticus and shunt blockage. with children presenting with known epileptic seizures in the emergency department, it is important to consider clinical data and seek to devolve decision to image. poster no. isolated radial nerve palsy, a rare presentation of congenital wrist drop c duggan, n mcsweeney cork university hospital, cork, ireland isolated congenital radial nerve palsies are a rare phenomenon and typically spontaneously recover within months. the true incidence is not known, but in a recent study . % of infants presenting to a brachial plexus injury clinic had an isolated congenital radial nerve palsy. patient a is a -week-old male who presented at birth with a left sided wrist drop following a non-traumatic elective caesarean section at + / . his birthweight was . kg ( st centile). movement of the wrist and digits were impaired to absent with preservation of function at the shoulder and elbow. there was a nodule noted in the left upper limb, anatomically superficial to the radial nerve. it was a normal pregnancy with no antenatal or postnatal issues. he attended physiotherapy and occupational therapy who provided a splint. on examination at weeks, there was weakness of the extensors of the left wrist. the rd, th and th digits remained fully flexed at rest and could be extended passively but not actively. extension of the thumb and index finger had recovered at -week review. function at the shoulder and elbow joints were preserved with normal flexion of the wrist and digits. a scar was noted superficial to the radial nerve at the same location as the lesion described at birth. the remaining systemic and neurological examinations were normal with typical development and appropriate growth. the working diagnosis at present is an isolated radial nerve palsy likely caused by in-utero compression. the nodule and scar noted above are consistent with lesions described in a previous case series. these were hypothesised to be areas of fat necrosis secondary to compression; resulting in the palsy. patient a's lack of further neurology such as a generalised brachial plexus palsy makes a birth injury less likely. further investigations and follow-up are awaited. background: valproate is an effective antiepileptic medication. if a woman becomes pregnant while taking valproate, her baby is at risk of congenital malformations ( in ) and developmental disorders ( in ). furthermore, it is associated with an increased risk of autism spectrum disorder and adhd. in , the nhs/hse recommended new restrictions on the use of valproate, including a national pregnancy prevention program (prevent) and avoidance in prescribing to female patients of childbearing potential unless other treatments are ineffective or not tolerated. objective: to review the use of valproate in a well-defined population of at risk females with moderate to profound intellectual disability (id). identify the patients at risk and imbed the guideline into our practice. methods: a retrospective chart review was carried out of all girls aged between and years, attending the daughters of charity disability service (doc) in dublin, ireland. data such as diagnosis, valproate use, degree of id/gross motor function classification system (gmfcs), documentation of menarche and discussion regarding risk of valproate use were recorded. results: in total females aged between and years where identified as currently using valproate out of charts reviewed ( %). of the patients identified, / had moderate id (gmfcs iii) and / had severe to profound id (gmfcs iv-v). / had menarche documented. / had the risk of valproate discussed. conclusions: in our cohort, a significant number of girls remain on valproate. % complied with new guidelines regarding discussions around the risks of valproate; highlighting the % of patients in need of counselling. an annual risk acknowledgement form was placed in their charts to prompt discussion next visit. in children with intellectual disability, conversations regarding contraception are difficult but essential. if valproate is used, then the risks must be fully understood by parents and carers. evaluation of the management of children up to age of years with cerebral palsy in southend university hospital large district university general hospital against nice guidelines (nice guidelines ng ). methods: clinic notes of all registered children with cerebral palsy (cp) up to years of age as of june were included in the study. this was because there was no early data on children above years age. results: patients were age to years and patients age to years. were male and females. had hemiplegic, quadriplegic, diplegic and dystonic cp. only ( %) had gmfcs levels recorded. ( %) were < weeks, ( %) were to weeks and ( %) were term. mri head findings: white matter changes including pvlin ( %), ( %) hie changes, ( %) basal ganglia changes, ( %) congenital brain malformation, ( %) infarction. migrated to area with no mri report. all the children received multidisciplinary team (mdt) input including physiotherapy. comorbidities werechildren on medications for gastro-esophageal reflux - (with peginsertions). for epilepsy - , for dystonia/spasticity - , for constipation - , for poor salivary control - . behavioral issues noted in and was on adhd medications. had botulinum toxin injections and had selective dorsal rhizotomy for spasticity. documented discussion of diagnosis with family was in ( %) patients and none in patients ( %). only % patients had vitamin d levels checked. conclusions: management was in line with nice guidelines. they all had mdt input. there is a need to improve documentation of -evidence of discussion with parents, gmfcs level by age ½ years plus, hip surveillance from age years for gmfcs level iii to v and annual vitamin d levels especially for gmfcs level iii to v, peg fed and children on multiple anti-epileptic medications. poster no. intracranial hypertension in children: an updated systematic review l di genova , n desai , s esposito , p prabhakar pediatric clinic, department of surgical and biomedical sciences, universit a degli studi di perugia, perugia, italy; department of paediatric neurology, great ormond street hospital nhs foundation trust, london, uk; neurosciences, great ormond street hospital nhs foundation trust, london, uk objective: our goal is to provide an overview on paediatric intracranial hypertension. methods: given that the last update of the diagnostic criteria of idiopathic intracranial hypertension was published in , a thorough medline search of all english articles was conducted between and . results: intracranial hypertension may be primary, with a paediatric annual incidence ranging between . and . per children or arise from a secondary cause. misdiagnosis or delayed intervention can lead to poor quality of life and morbidity. in , this condition was reconsidered, due to new accepted values for opening pressure and advances in neuroimaging; the importance to develop effective therapeutic strategies in order to prevent blindness was thus highlighted. to date, the main strategies described involved both medical and surgical approaches; nevertheless, there have been no paediatric intervention studies. disease monitoring plays a key role in the definition of the best timing and modality of treatment. recently, a risk stratification has been proposed with the aim to facilitate an adequate evaluation and proper care of children with intracranial hypertension: visual monitoring could represent an objective tool to manage these patients. in recent years, important evidence for the efficacy of acetazolamide emerged in the idiopathic intracranial hypertension treatment trial. surgical treatment is the modality of choice in children with worsening vision impairment, intractable headaches despite maximal medical management or in case of intolerance to medical therapy. conclusions: there are poor evidences about paediatric intracranial hypertension's outcomes. unfortunately, children's quality of life is heavily influenced by pain and permanent vision loss. standardized therapeutic strategies remains uncertain, highlighting the need for longitudinal studies to identify the best treatment in childhood. in order to alleviate symptoms and prevent permanent chronic sequelae, careful clinical evaluation and ophthalmological monitoring could be a useful guide to better manage this medical condition. objective: cerebral sinovenous thrombosis in childhood is a life-threatening neurological entity with uncertain epidemiology, potentially complicated by secondary intracranial hypertension. in the literature, there is a lack of evidence supporting the main strategies to approach both these medical conditions. our objective is to highlight the value of a prompt diagnosis aiming to define a tailored management approach based on children monitoring. methods: we review the main findings regarding cerebral sinovenous thrombosis and intracranial hypertension in children through illustration of a case with otogenic sinus thrombosis and secondary intracranial hypertension. results: a -year-old boy developed a local venous sinus thrombosis because of the spreading of a primary infective process from his middle ear into the sigmoid sinus complex, facilitated by anaemia and dehydration. the venous outflow disturbances led to secondary intracranial hypertension. the management aimed to treat cerebral thrombosis with anticoagulants and intracranial hypertension through medical and surgical strategies. the insertion of the lumbar-peritoneal shunt was necessary when medical approached failed and visual function deterioration was evident. careful clinical evaluation and ophthalmological monitoring helped us in the tailoring of the best treatment with the aim to alleviate symptoms and prevent sequelae of increased intracranial pressure. in the literature, no paediatric intervention studies regarding the main strategies to reduce intracranial pressure have been published. moreover, there is a lack of evidence supporting the safety of anticoagulation therapy, reducing the possibilities to safely manage cerebral thrombosis in childhood. conclusions: in children, a multidisciplinary approach is essential to manage both cerebral thrombosis and intracranial hypertension and ensure an optimal follow-up, aiming to prevent visual and therapy-related complications, possible relapses and their early diagnosis. from our perspective, monitoring our patient with clinical manifestations and visual status helped us to plan the best timing and modality of treatment and intervention. yearly rate of progression of fvc% predicted (available in n= ) was . % in sma and . % in sma . in sma , fvc% predicted declined steeply from to years of age, followed by a levelling. conversely, in sma patients fvc% predicted declined slower but steadily from years of age. / ( %) sma and / ( %) required non-invasive ventilation due to respiratory infections or hypoventilation conclusions: the results of this ongoing collaborative work suggests that in sma and lung function declines from age and respectively. lung and motor function correlate well in both sma and . this data will help the assessment of the long-term efficacy of new treatments for sma this review aims to study the appropriateness of mri brain referrals following implementation of local changes to improve compliance to the nice cg standard. methods: following an earlier survey (es; / / - / / ) of mri brain referrals for headaches in children over years, key recommendations included adding pop-ups in the neuroimaging request system (ice) of nice cg and headsmart clinical guideline v as well as verbal consent obtained from senior paediatrician before request was made. following these implementations, requests for mri brain were analysed during / / - / / in the same district general hospital. referral was deemed compliant if the nice guideline cg standard were met. results: children were referred for mri brain scan (mean / month vs /month in es). ( %) referrals were compliant (vs % compliance in es). ( %) referrals were 'urgent' (vs % urgent es) and ( %) 'routine' or non-urgent (vs % routine es). ( %) of urgent referrals (vs % es) and ( %) of routine referrals (vs % es) were compliant mri brain guidelines for neuroimaging in less than years exist (headsmart clinical guideline v and nice epilepsy qs ) but are limited. this study aimed to assess current practice of mri brain referrals in children under years. methods: retrospective review of mri brain referrals in children under years performed between mri brain scans were done (m:f . : ) ( %) referrals under headsmart and ( %) of these were urgent requests; significant brain abnormality was seen in ( %) in urgent and ( . %) in nonurgent cases. ( %) referrals under epilepsy qs and ( %) were urgent requests; significant brain abnormality in ( %) in urgent and ( %) in non-urgent cases. ( %) were miscellaneous requests and ( %) were urgent; significant brain abnormality in ( %) in urgent and ( %) in non-urgent cases. overall mri brain showed significant abnormality in urgent requests ( %) compared to non-urgent requests ( %) poster no. investigating factors that influence unplanned admissions and a&e attendances in those with pre-existing neurological conditions in childhood s dowsell , k kananaviciute , r parslow , am childs university of leeds, leeds, uk; paediatric neurology, leeds general infirmary, leeds, uk objective: previous papers have shown increasing demands and costs to the nhs in relation to the inpatient care of children with neurological conditions. unplanned admissions may reflect a lack of effective care and have been shown to correlate with high outpatient clinic did not attend (dna) rates . the aim of this study was to determine factors underlying unplanned admissions and accident & emergency (a&e) attendances in a cohort of patients under the care of the leeds regional paediatric neurology service over a -year period. methods: all children < years who had paediatric neurology outpatient appointments in were identified using hospital databases. clinical and demographic data was extracted from electronic case notes. those without a definitive neurological diagnosis or who had moved to adult services during the study period were excluded. the cohort was cross referenced to a&e databases and admission records from to . poisson regression was used to identify any correlation between specific predetermined factors to assess their influence on a&e attendance and admission rates. results: a cohort of patients was established and had a total of unplanned admissions during the study period. patients had a&e attendances with a total of attendances. higher dna rates, younger age and certain diagnostic categories correlated with increased rates of unplanned admissions. the role of emergency care plans in preventing admission was unclear as only / patients with epilepsy had care plans in place. conclusions: this study confirms the association between increased rates of a&e attendances and unplanned admissions in children with specific neurological disorders and high dna rates. this is relevant for service planning as it highlights the need to target scarce resources towards 'higher' risk patients with more complex diagnoses where more integrated care and support may prevent or reduce unplanned hospital attendances.poster no. audit comparing great ormond street hospital headache clinic diagnoses and management of patients aged to years to nice clinical guidelines a ward , , p prabhakar neurology, great ormond street hospital, london, uk; university of glasgow, glasgow, uk introduction: between / / and / / the gosh headache clinic saw new patients aged to years. the nice clinical guideline (cg ) on the diagnosis and management of headaches in over s covers tension-type headache, migraine, cluster headache and medication overuse headache. this audit aims to compare gosh diagnosis and management to those of the cg . methods: using the patient list from the headache clinic data was gathered by accessing outgoing clinic letters via epic. raw data was collected on; age, gender, description of headache (pain location, quality, intensity, duration and frequency) and associated symptoms, triggers, previous imaging, previous and current treatments. the management data collected include: diagnosis and treatments offered, as well as whether gosh offered lifestyle advice, psychology, occipital nerve block or riboflavin. this data was then compared to cg . results: ( . %) of diagnoses made by gosh matched the cg diagnosis. ( . %) diagnoses differed, with of these due to discrepancy between chronic/episodic and/or presence of aura and due to the vague diagnoses of migraine-type, new daily persistent, migrainous etc. fitting the cg definition of chronic migraine. all but one patient was managed in line with the guidelines. . % of patients had brain imaging prior to attending the clinic, with . % of these reporting positive findings. discussion: despite patients' diagnosis differing between gosh and cg , all but one patient was managed in line with the guidelines. this is likely due to nice recommended management being the same for any type of migraine. improvements could be made in documentation of frequency and duration of headache and aura, as well as more routinely offered lifestyle advice, psychology and riboflavin recorded in outgoing clinic letters. objective: to review the purpose of ct head requests from emergency department of a busy tertiary hospital as part of quality improvement. due to increasing evidence of ct scan radiation predisposing to leukaemia and brain tumours, it is best to keep ct scans to the minimum if clinically indicated. this project reviewed the indications for ct head and also looked at patients who had repeated ct or mri head scans within years. methods: data was collected retrospectively looking at a snapshot period of months between september-november . patients were < years of age and they had a ct head from emergency department at king's college hospital, london. trauma patients were excluded. data was collated with aid of the neuro ct department 'cris' system. results: out of patients, reasons for ct included: head injury ( ), ventriculo-peritoneal shunt blockage ( ), refractory seizures/status epilepticus ( ), space occupying lesion ( ), orbital cellulitis ( ), intracranial haemorrhage ( ) objectives: mutations in kif a are associated with a wide range of neurological disorders, ranging from hereditary spastic paraparesis (hsp) to sensory neuropathies to a severe infantile neurodegenerative disorder. collectively, they are extremely uncommon but likely to be under-recognised. we aim to report the spectrum of kif a-related disorders from a single tertiary neurology centre, with a view to improving understanding and awareness of these rare conditions. methods: affected individuals known to great ormond street hospital were identified through liaison with consultants involved in the care of children and young people with movement disorders. clinical information was collected through a retrospective review of case notes. results: twelve individuals in families were identified. all had heterozygous kif a mutations including three previously unreported variants. severity ranged from a fatal neonatalonset disorder with contractures, absence of visual development, and agenesis of the corpus callosum on mri to hsp with preservation of ambulation into the second or third decade of life and entirely normal mri. upper motor neuron signs were found in / children and a primarily sensory neuropathy was present in / children assessed. / children also had extrapyramidal signs (dystonia). some degree of learning difficulties and/or disorders of mood or behaviour were present in all children. optic atrophy, mr brain white matter changes and epilepsy were also common, especially in those children who were more severely affected overall. conclusions: kif a related disorders are so diverse that it is arguably misleading to consider them as a single disease entity. features common to the majority of affected patients include upper motor neuron involvement, and neuropathy (even in the absence of an obvious sensory deficit), with high risk of other neurological and neurobehavioural comorbidities. objective: ataxia with oculomotor apraxia type (aoa ) is a slowly progressive, autosomal recessive disease characterised by the triad of ataxia, oculomotor apraxia, and sensorimotor neuropathy that results from mutations in the gene encoding senataxin (setx), a dna/rna repair protein essential for genomic stability. we investigated a -year old male with a history of unsteady gate for genetic and molecular changes associated with aoa . in this report we describe a case of aoa with two clear pathogenic setx mutations, one of which is novel, as well as two further setx changes likely to be in cis polymorphisms that have previously been reported as pathogenic. methods: two independent lymphoblastoid cell lines obtained from the patient were used for western blotting of senataxin and protein markers of other autosomal recessive cerebellar ataxias. the setx gene was sequenced to identify possible disease-causing mutations. results: western blotting showed reduced levels of senataxin. serum afp level was elevated at lg/l (normal . - . lg/l). genetic sequencing revealed two clear pathogenic setx mutations. one of these was a novel mutation, c. delg; p.(cys phefster ), a deletion causing a reading frameshift resulting in truncation and loss of expression of senataxin protein from this allele. the other, c. c>t; p.(pro leu) was a missense mutation within the helicase domain which has previously only been reported in the homozygous state in a japanese aoa patient. two further sequence changes, c. a>g; p.(asn asp) and c. c>a; p.(gln lys), were also identified in our patient. conclusions: the reduced senataxin expression and elevated afp levels support a diagnosis of aoa in our patient. genetic analysis found a novel pathogenic mutation and documented the first case of another pathogenic mutation in the helicase domain outside of japan. the case contributes to the growing diversity of setx mutations known to be responsible for aoa . key: cord- - t t x y authors: smith, sean r; jenq, grace; claflin, ted; magnant, chris; haig, andrew j; hurvitz, edward title: proposed workflow for rehabilitation in a field hospital setting during the covid‐ pandemic date: - - journal: pm r doi: . /pmrj. sha: doc_id: cord_uid: t t x y the novel coronavirus disease (covid‐ ) pandemic has challenged healthcare facilities throughout the world. in many regions, the need for acute inpatient healthcare services has exceeded the capacity of hospital systems, and field hospitals are being utilized as one part of the response strategy. given the urgency and novelty of this pandemic, healthcare systems are attempting to rapidly execute plans for field hospitals, and rehabilitative care in this environment merits particular consideration given the potential impacts of mobilization and rehabilitative therapies on morbidity, mortality, duration of ventilation, and lengths of icu/hospital stay. in order to address this need, a model for rehabilitation in field hospitals is presented here. this article is protected by copyright. all rights reserved. the novel coronavirus disease (covid- ) pandemic has challenged healthcare facilities throughout the world. historic models project that % of hospitalized covid- patients will need rehabilitation following their illness, and % more will need in-home care. [ ] these numbers likely represent hundreds of thousands of patients worldwide, and may underestimate the actual need because of the increased risk of functional decline seen in high-risk groups such as older patients and patients with pre-existing co-morbidities. additionally, covid- has been associated with significant cardiopulmonary impairment including arrhythmia, myocardial injury, and acute respiratory distress syndrome [ ] and numerous potential neurologic deficits, including ataxia, encephalopathy, myopathy, and cerebral vascular accidents, with more severe cases carrying an increased risk of neurologic injury. [ ] providing sufficient rehabilitation care is a particular challenge for regions with high per-capita infections that have to rely on temporary field hospitals to supplement over-capacity hospitals. unfortunately, there exists no framework for distributing rehabilitation care in field hospitals during a pandemic, and traditional models for disaster care focus on triaging patients after traumatic events (natural disaster, warzone). [ ] field hospitals are designed to maximize bed capacity and likely do not allocate space solely for rehabilitation; providers must therefore think of innovative ways to deliver care in this atypical setting. in the case of the authors' field hospital, original plans were for one physical therapist per patients until members of the department of physical medicine and rehabilitation became involved in facility planning. complicating matters, typical options for post-illness rehabilitation may not be available -skilled nursing facilities (snfs) and inpatient rehabilitation facilities (irfs) may not accept covid- positive patients due to a lack of resources and concern for infectious spread amongst existing patients. [ ] furthermore, even if these facilities accept covid- positive patients, there are not enough beds nor personal protective equipment (ppe) to accommodate all patients who will require rehabilitation following acute hospitalization. [ , ] without rehabilitation, numerous patients may require extra days in the field hospital setting, taking up needed bed space and increasing use of ppe and healthcare personnel. the best way to prevent covid- hospitalizations is to prevent viral spread; the best way to improve throughput and reduce length of stay this article is protected by copyright. all rights reserved. once hospitals are full is to address modifiable factors. much of the disablement related to covid- is likely modifiable with rehabilitation interventions. we propose the following framework to triage rehabilitation care in a resourcelimited environment during a pandemic, such as a field hospital. [ figure ] traditional hospital-based acute care therapy: change the trajectory acute care represents the time when patients first develop impairments from the disease, and therefore rehabilitation is an essential intervention for patients with functional deficits and who can participate. [ ] rehabilitation at this level is likely more accessible than in a field hospital, but should still be dosed to accommodate staffing and ppe limitations. for more functionally impaired patients, twice-daily therapy -similar to what one would receive at a skilled nursing facility -should be offered if available, and patients with barriers to discharge involving physical limitations should be prioritized. the goal of hospital-based therapy is to "change the trajectory" that patients are on. that is, reducing debility through early intervention may obviate the need for patients to be discharged to a snf or irf, reduce the level of rehabilitation needed in the more resource-constrained field hospital, and/or reduce overall length of stay. in resource-constrained environments such as field hospitals, rehabilitation must be distributed strategically to patients. we propose a hierarchy of need based on patients who are clinically stable and who have barriers to discharge home that can be overcome with rehabilitation. [ table ] to distribute resources, we developed the rapid covid- rehabilitation assessment (rcovr) to identify patients with rehabilitation needs. [ figure ] this assessment tool was created based on clinical characteristics of covid- patients and from components of an assessment published by the international rehab forum [ ] and the barthel index. [ ] the assessment is designed to be brief given the high volume and rapid rate of patients admitted to the field hospital setting, so it does sacrifice granularity for the sake of being administered in this setting. we will determine the rcovr tool's content validity based on its accuracy of identifying patients who need (and do not need) rehabilitation care. this includes reviewing how many patient scores indicated high rehabilitation needs, and if those patients ended up receiving therapy. patients who continued to receive therapy during their stay at the field hospital would be considered to have actually needing rehabilitation because a physical therapist or physiatrist would have evaluated the patient and continued (or discontinued) therapies based on the patient's clinical presentation. additionally, the rcovr tool will be evaluated from a feasibility standpoint, as the providers who screen patients with this tool will be asked to evaluate its effectiveness and ease of use. the number of times the tool was used compared to the number of patients admitted to the field hospital will also be recorded, since if the tool is arduous to use or perceived to be inaccurate, triage personnel may stop using it. unfortunately, it would be difficult to compare the rcovr tool with other assessments, as triage must be efficient and field hospital care and extra assessments for the purposes of clinical research should be minimized. in addition to function, the assessment also evaluates patients based on their clinical status with regards to covid- , such as how much oxygen they require and if their status is worsening or stable. unstable patients may need to transfer to a traditional hospital setting, and patients with high supplemental oxygen demands may not be able to participate in therapy. it also takes into account cognition, as deficits may be a sign of neurologic damage from the disease (and therefore rehabilitation is indicated). of course, patients with impaired cognition may have delirium without a brain injury and still benefit from field hospital rehabilitation. in addition to adding exercise to their field hospital care, skilled therapy and/or physiatric evaluation allows for routine re-assessments of their cognitive status, which may improve during their stay at the field hospital. regardless of the degree of cognitive impairment, these patients will likely benefit from seeing a physiatrist and/or other rehabilitation team members as an outpatient once discharged. evaluating cognition on admission would presume to increase the likelihood that patients with deficits are seen by appropriate providers and eventually be transitioned to outpatient care. patients with more impaired function and who have clear barriers to discharge modifiable with rehabilitation intervention -including not being able to navigate steps to enter their house and requiring assistance for transfers -will be triaged to receive as much physical and occupational therapy as resources allow, with physiatry involvement as indicated to help with discharge planning and symptom management. this may reduce length of stay by addressing a patient's physical barriers to discharge during the time they would be under medical observation, and allow discharge as soon as they are clinical stable (e.g. afebrile for days with stable oxygen demand). this article is protected by copyright. all rights reserved. the second level of need is for patients with less clearly defined goals, which will receive rehabilitation care if available. patients in this category may have an uncertain caregiver situation, have delirium or other cognitive deficit limiting their ability to carry-over learned information, or have too many impairments to realistically be able to be discharged home directly from a field hospital with the rehabilitation resources available. these patients should still receive physical and/or occupational therapy if available, but may still require discharge to a snf or irf when that level of care is available. a third level is for patients who either do not require rehabilitation or are too ill to participate (e.g. too high or worsening oxygen requirements, or obtunded). all therapies should be tailored to individual needs as much as possible. to increase physical activity options for patients, rehabilitation personnel should be utilized in flexible positions. for example, many rehabilitation technicians and physical therapy assistants could carry out the work of a medical or nursing assistant (such as checking vitals) while also being able to mobilize patients with proper mobility techniques to enhance physical activity (e.g. walking programs). as an example, during down time or at the time of checking routine vital signs, a physical therapy assistant can walk with a patient. this not only increases the amount of physical activity in the day, but also allows for measuring of oxygen saturation and blood pressure during activity. all patients should receive education about exercises they can perform while in bed and information about ensuring a safe discharge. [ figure ]. the rehabilitation course of patients at field hospitals will be dependent on available therapy and equipment resources. patients with greater need should be prioritized, such as those with premorbid disabling conditions. given the high volume of patients in a field hospital setting, identifying patients who need rehabilitation may be inaccurate at times and lack granularity. using the previously described triage system, however, is one way for patients to be evaluated by a physiatrist or physical and/or occupational therapist. from there, a more specific triage of needs is possible. for example, the rcovr tool may indicate that % of patients admitted to the field hospital require rehabilitation, triggering an evaluation by a rehabilitation team member. that team member may then discover that the patient is severely impaired from critical illness neuropathy and require intensive rehabilitation in an irf setting when available. other times, it may be clear this article is protected by copyright. all rights reserved. that with - sessions a day of skilled therapy, a patient will be able to overcome barriers to discharge without additional rehabilitation beyond the field hospital. if patients are considered good candidates for an ongoing inpatient rehabilitation program, transition to an accepting inpatient rehabilitation facility or subacute rehabilitation facility can be considered. if these programs are not available to infected patients, the physical and occupational therapists should continue to follow these patients as frequently as they're able. field hospitals are designed to efficiently house as many patients as possible in a defined area, but if sufficient space is available at a field hospital, we recommend that therapy equipment such as exercise bikes, treadmills, and training mats be made available, particularly for patients requiring more intensive rehabilitation and/or aerobic conditioning. if space is limited, priority should be given to pieces of equipment that represent the best balance between optimal therapeutic utility and ease/effectiveness of decontamination. available space and what the health system can purchase or bring from the main hospital will ultimately dictate what equipment can be used. when a field hospital has no dedicated space for rehabilitation, patients should receive appropriate ongoing therapies and be provided with information regarding bed exercises, exercises with family, and home exercise programs that appropriately address the symptoms of the disease. digital resources represent an appealing medium as most rehabilitation providers in developed nations can access them, and they can be updated as more information becomes available. typical discharge planning services, such as social work and care management providers, may not be available to patients in a field hospital. additionally, discharge teaching and education may be abbreviated or eliminated altogether given the high volume of patients and chaotic nature of the setting. to prevent lapses in postdischarge care, and to give patients guidance on what to do after they leave the field hospital, all patients discharged from a field hospital setting should be provided with education explaining steps they can take to optimize their overall health and function once home. [ figure ] if available, virtual visits by home care physical and/or occupational therapists should be arranged for those who need it. this article is protected by copyright. all rights reserved. records of the patients who required increased rehabilitation care at the field hospital should be kept in a secure manner so that these patients can be contacted post-discharge to establish follow-up rehabilitation care. many covid- patients admitted to field hospitals will require rehabilitation care and there may not be a clear discharge pathway to snfs and irfs. given the resource-constrained nature of the field hospital, with limited staffing and equipment, identifying patients with severe disability and/or rehabilitationmodifiable barriers to discharge should be prioritized for interventions such as skilled physical therapy and physiatrist consultation. conflicts of interest: the authors have no relevant conflicts of interest to declare. this article is protected by copyright. all rights reserved. total score interpretation: +: daily extra pt/ot - : normal/some therapy - : ask again tomorrow postacute care preparedness for covid- : thinking ahead clinical characteristics of hospitalized patients with novel coronavirusinfected pneumonia in wuhan neurological manifestations of hospitalized patients with covid- in wuhan, china: a retrospective case series study the principles of triage in emergencies and disasters: a systematic review. prehospital and disaster medicine impact of covid- outbreak on rehabilitation services and physical and rehabilitation medicine (prm) physicians' activities in italy european journal of physical and rehabilitation medicine rehabilitation following critical illness in people with covid- infection covid- screen tool. international rehabilitation forum functional evaluation: the barthel index: a simple index of independence useful in scoring improvement in the rehabilitation of the chronically ill. maryland state medical journal what is the patient's current oxygen use (liters per minute)?what is the patient's current level of cognition? ☐ grossly normal ( ) ☐ needs cueing to respond to questions ( ) ☐ answers are not appropriate ( ) ☐ obtunded (stop) how many steps to enter the patient's home?did the patient previously use an assistive device for ambulation? ☐ no ( ) ☐ yes -cane, walker, or wheelchair ( ) does the patient have someone to stay with at discharge? ☐ yes, with physical help ( ) ☐ yes, minimal/no physical help ( ) ☐ no ( ) part one score: __________________ part two: what the patient can do right now (modified barthel index):instructions: assistive devices are ok. "needs help" implies % or more patient effort. supervision is the same as needing help. score can be patient-reported or observed by healthcare personnel.comb hair, shave, wash ☐ able ( ) ☐ needs help ( ) ☐ cannot ( ) put on and take off clothes ☐ able ( ) ☐ needs help ( ) ☐ cannot ( ) toileting (the entire process) ☐ able ( ) ☐ needs help ( ) ☐ cannot ( ) get into a chair and back ☐ able ( ) ☐ needs help ( ) ☐ cannot ( ) walk > feet this article is protected by copyright. all rights reserved. you can do it! clear thinking and mental toughness are your best tools. • you know how to do this--you've done it before: for sports, a performance, an exam or a tough job.set goals, time frames, and contingencies. • don't go it alone. build a team and be a good leader. enlist family and friends. motivate your healthcare team. set goals, plans, and time frames. • if you feel too overwhelmed, talk to your clinician. we know covid- can cause anxiety, depression, post-traumatic stress disorder and other medical diseases that affect thinking and motivation. exercise from day clears your lungs, strengthens your heart and gets your legs ready to walk out of here.• do something that makes you breathe hard and get tired for ½ hour every day.• with permission, walk or do light squats at your bedside.• if you're stuck in bed, lift your legs up and down for ½ hour every day. lying in bed can make muscles and joints tight and painful.• twice a day, stretch each joint in your arms and legs. hold each stretch for a few seconds, then relax.• have someone do the stretching for you if you need help. food is the body's fuel, so eat well. • talk to your clinician if you have stomach problems, difficulty swallowing, or trouble handling food.• pooping is important, too. if constipation or bowel problems are happening, talk to your clinician.• if you have arthritis, nerve problems, mental health or other disabling disease, fine-tune these with your clinician's help. discharge means lining up all your resources. think: where will you go after the hospital? how will you get there? who will be there to help you at first? what do they need to learn? can you get around bedroom, bathroom? can you exit in an emergency? will you be safe? will you have enough money/food?/heat?/water? how will you avoid infecting others? do you know your medicines and treatments? how will you get them at home? do you have the crutches, canes, toilet seats, or other equipment you'll need?the first steps home are all yours. you can do this! key: cord- -oswgjaxz authors: nan title: abstracts: (th) european congress of trauma and emergency surgery may – , brussels, belgium date: journal: eur j trauma emerg surg doi: . /s - - -z sha: doc_id: cord_uid: oswgjaxz nan introduction: frequently fractures of modern sport disciplines are fractures of the clavicle. most of them are uncomplicated and still treated without operation. therefore there is a lack of bigger studies about the treatment of clavicle fractures by elastic stable intramedullary nailing (esin). nevertheless this method becomes more and more popular, especially for young and active people. intention of this investigation was to analyze risks and results of this method to check the indication for operative treatment of simple fractures in this group of patients. material and methods: this study is a retrospective analysis of patients whose fractures of the clavicle were treated by intramedullary nailing. crucial for the decision for operation was the individual request of the patient after information of the relative indication. included were patients with fractures of the middle third, fractures of the lateral third and fractures with concomitant shoulder injuries from to . the duration of operation, intraoperative radioactive loading and complications were analyzed from the medical file. the functional outcome was measured by the constant-score. the anatomical reduction was proved by measuring the difference of the length of both clavicles ( - month after operation). results: the average duration for the middle third was min ( - ), for the lateral third ( - ) minutes and for fractures with concomitant injuries min . the mean radioactive surface dose was , cgy/cm . four complications ( %) cause revision operations: one secondary dislocation which leads to pseudarthrosis and two imminent penetrations of the medial end of the nail. one patient had developed a painful pseudobursa due to lateral penetration of the nail. additional there were two prematurely nail extractions because of medial irritation of the soft tissue. altogether we documented complications in % of the operations. overall an open reduction was necessary in %. after healing there has been no significant shortening of the fractured clavicle in comparison of both sides. the constant-score showed good postoperative results (average: , median: , lowest / ). conclusion: esin with titan nails is an alternative method of treatment with good results. nevertheless we documented complications in %. in the literature complication rates from - % has been described. the complication rate of esin seems to be comparable to the conservative treatment. in our opinion the relevant intraoperative radioactive dose is an often underestimated factor. the operation time is often longer than thought before starting and often an open reduction is necessary. because of these reasons the conservative therapy should still be the standard. esin can be an alternative especially for young athletic ambitious patients after a detailed information about the risks. disclosure: no significant relationships. introduction: the optimal management of clavicle fractures is still controversial, although the nonoperative treatment remains the standard in most fractures. recent studies have reported a higher nonunion rate and unsatisfactory functional results after nonoperative treatment. therefore, there is an increasing interest in the primary operative management of displaced midshaft fractures. however, no treatment-consensus exists at this moment. the goal of the present study was to compare plate fixation with nonoperative treatment of displaced midshaft clavicle fractures in adults with a minimum of weeks follow-up. material and methods: in a multi-center prospective clinical trial patients with a fully displaced midshaft clavicle fracture were included within one week after the injury. after a standard information procedure, patients were asked if they wanted to have a operative or a nonoperative treatment. outcome analysis included standard clinical follow-up, the constant shoulder score, the disability of the arm, shoulder and hand (dash) score and complication rate at and weeks after the injury. results: between january and october a total of patients were included: patients were treated operatively ( . % men, mean age . years) and patients were treated nonoperatively ( . % men, mean age . years). constant and dash scores were significantly higher in the operative group compared with the nonoperative group at weeks ( vs and . vs . ). there was no significant difference at weeks ( vs and . vs . ). in both groups two patients developed pseudartrosis, all four required surgery. in the nonoperative group symptomatic malunion was more frequent: twelve patients at weeks ( . %) versus none in the operative group. other complications in the operative group were mostly hardware related: pain and irritation requiring plate removal after consolidation in four patients ( . %), two broken plates due to the earlier mentioned pseudartrosis ( . %), one early outbreak of the plate ( . %) and one woundinfection ( . %). furthermore, patients with heavy professional work activities returned to their jobs at an average of three weeks after injury in the operative group compared with seven weeks in the conservative group. at weeks after the injury, the patients in the operative group were more satisfied compared to those in the nonoperative group ( % vs %). conclusion: operative fixation of a displaced midshaft clavicle fracture results in improved functional outcome at weeks after injury and in a higher satisfaction rate at weeks. this study shows that patients with heavy jobs restarted their professional activities sooner if they were treated operatively. furthermore, higher satisfaction with the appearance of the shoulder may be a reason for surgery. introduction: the unstable shoulder girdle with a fracture of the clavicle (floating shoulder, ipsilateral serial rib fractures) is a classical indication for a plate osteosynthesis of the clavicle. despite a relatively high complication rate ( - %), such as implant failure, non-union and refracture after implant removal, open reduction and internal plate fixation (orif) has been the gold standard for many years. this open procedure with direct reduction maneuvres might be blamed for at least some of the complications due to iatrogenic damage of the blood supply of the fracture fragments. our hypothesis is that a closed method with indirect reduction might reduce some of the complications. the goal of our study was to test the practicability of the mipotechnique in clavicle fractures in unstable shoulder girdles. material and methods: between and we included, out of internally fixed shaft fractures in total ( x plate, x elastic nail), patients with either a floating shoulder (n = ) or a clavicle fracture in combination with ipsilateral serial rib fractures (n = ), in this study. operative technique: a locking compression plate (lcp) . with - holes was anatomically shaped to the anterior (-caudal) contour of the contralateral clavicle and then inserted percutaneously from lateral to medial using a short incision at the anterior border of the lateral end of the clavicle. using mainly indirect maneuvres, the fracture was reduced and then fixed in a pure bridging technique never using interfragmentary lag screws. free unloaded rom was allowed immediately after the operation with full loading - weeks later. follow-up examination was performed to years later with clinical (dash-score, shoulder function, length measurement) and radiological (fracture healing, length measurement) examination. results: / fractures healed without complications. clinical and radiological length measurement showed no significant differences to the contralateral side (range: + mm to - mm). in all patients a very good functional result was achieved with an average dash score of . ( - ). one implant failure occured two years after the initial trauma in a road workman. at reoperation only a partial consolidation of the original fracture was observed. restabilization and bone grafting led to an uneventful healing. conclusion: the mipo technique is feasible even in clavicle fractures and can lead to good functional and cosmetic results. the advantage might be its low invasiveness which better preserves the vascular supply of the fracture fragments. however it is technically demanding mainly due to the small size of the fractured bone. therefore in our opinion it requires a surgeon experienced in the mipo technique of treating fractures of larger bones as tibia and femur. introduction: there are some reports on the difficulties of removing the locking compression plate in clavicle fractures, due to problems of removing the self tapping locking screws. we retrospectively investigated if this was also the case in our institution in removal of lcp plate of the clavicle and if this was incidential or becoming a trend. material and methods: from october till october , we have removed locking compression plates after claviclefracture stabilization. all of the locking screws were inserted by trauma surgeons with the use of the torque limiting srewdriver according to the manufacturer's recommendations. a total of screws where removed. they consisted of fifty-one . mm self tapping cortical screws and hundred and twenty . mm self tapping locking screws. results: from the locking compression plates that where removed after claviclefracture stabilization, in eleven patients ( %) a problem with removal of the plate arised. this was caused by a total of self tapping locking screws. in all cases jamming of the screwheads in the plate was found to be the reason. there was ''cold welding'' between the threaded head of the locking screw and the locking plate. for removal four different strategies were used. in two screws the head was drilled off and the plate removed and subsequent the rest off the screw removed with forceps. five times the plate was bend around the screw and by rotating the plate (helicopter) both were taken out. in eight screws the recess of the head of the screws were enlarged and a conical extraction screwbit . was used to remove the screws. two times a combination of cutting the plate and helicopter tecnique was used succesfull. in comparison the fifty-one . mm selftapping cortical screws were removed without any problem. conclusion: the locking compression plate is a usefull attribute in fracture treatment of the clavicle. however in one-third of the patients removal of locking compression plates and especially the . mm self tapping locking screws from the clavicle, becomes an increasingly challenging procedure. we find this an unacceptably high percentage. number of mri studies it was possible to describe the intraarticular disc. until now there was no in vivo verifying of one of these mri protocols. the introduction of a high resolution mri protocol using a superficial coil ( d wats and t ffe) that has been developped in an ex-vivo model allows the visualisation of the intra-articular structures. the aim of this study is to ascertain the significance of the mentioned mri protocol and the applicability in the clinical practice in a limited patients cohort with instability of the ac-joint. the mri findings are compared to the arthroscopic findings. material and methods: in a one year period patients with chronic acromioclavicular-joint dislocation rockwood type ii and iii were seen in the outpatient clinic the major symptom was pain followed by loss of power. inclusion criteria where a history of more than three month the exclusion of subacromial pathologies, age over and the indication for arthroscopic revision of the ac-joint. the radiological examiner was blinded to the clinical findings. the mri-scan was performed on both sides. at the time of the operation the surgeon was blinded to the mri reading. the surgical procedure was performed by arthroscopy in beach chair position. the surgical findings have been documented by video and also in a descriptive manner. the examination was performed on a . t mri-system . results: throughout the radiological examination, in / patients a rupture of the intra-articular disc was suspected. in / cases degenerative alterations were described. in one case the reading was negative (e.g. ,,no rupture of the intra-articular disc''). during the surgical examination / patients showed ruptures of the intraarticular disc. in one patient no signs of macroscopical disintegration of the disc could be detected. in the case with negative radiologiocal reading, the disc was verified as intact during surgery. in all other cases the disc was disintegrated, including those with the radiological reading ''alterations without clear signs of rupture''. the significance of the described mri protocol was %. introduction: cancer of the colon is a common disease. the choice of treatment after diagnosis is surgery, in an elective setting, to remove the tumor. however, a large number of patients present with colonic obstruction requiring acute surgery before the diagnosis is known, or before the set date for elective surgery. previous studies have shown a worse outcome for patients who undergo surgery in the acute setting compared to patients in scheduled care. the aim was to establish characteristics and prognosis in patients with acute obstructing colon cancer compared to patients who underwent elective colon cancer surgery. material and methods: all patients diagnosed with colon cancer during - in the linkoping area were identified through the swedish colorectal cancer register (n = ). a retrospective analysis of patients with colonic obstruction (n = ) was done using various criteria from the medical records. exclusion criteria were acute surgery due to reason other than obstruction (n = ), non-surgical treatment (n = ), other diagnosis (n = ), or missing medical records (n = conclusion: acute surgery due to colonic obstruction of colon cancer is common. tumor stage seems to be more advanced in patients with obstructing disease than in patients scheduled for elective surgery and consequently the rate of complications is higher and the outcome is worse. however, when stratified for different tnm-stages, the worse outcome in -year survival for patients with acute obstructing colonic cancer still remains. the explanation for this difference is to be elucidated in further studies. disclosure: no significant relationships. introduction: acute colonic obstruction due to malignancies is often a surgical emergency. hartmann's procedures or one stageresection with primarary anastomosis (with or without ileostomy) have been the treatment of choice. however these procedures are associated with a significant morbidity and mortality rate. self expanding metallic stents (sems) have shown their efficiency as palliative treatment in colonic cancer. colonic stenting has been advocated as a''bridge'' towards surgical procedures in potentially resectable diseases. the aim of this study is to evaluate the efficacy of colonic stenting in the emergency treatment of large bowel occlusion either for palliation or to enable to planned surgical procedure. s. tamulis, e. v. gaidamonis surgical, vilnius unuversity emergency care hospital, vilnius, lithuania introduction: to evaluate the results of the treatment of patients with the small bowel obstruction due to intestinal adhesions. material and methods: medical records for the patients treated with small bowel obstruction due to adhesions from to were reviewed. the patient's age, gender, previous abdominal operations, method of the treatment and outcomes were analyzed. results: there were patients admitted to the vilnius university emergency hospital during years period. appendectomy as a previous operation was recorded in % of cases. surgery was required in of the cases ( . %). strangulated small bowel was found in patients ( , %). in cases ( , %) the surgical procedure was limited to adhesiolysis, whereas in cases ( , %) an intestinal resection was performed. enterodecompresion tube was used in cases ( , %). the operative mortality was , % ( cases). mortality after the treatment due to strangulation was , % ( cases). conclusion: there were % of surgicaly treated patients. main reasons of adhesions formation was previous performed apendectomy and midline lower laparotomy. the criteria of uneffective conservative treatment were absent of the positive results of the physical, laboratory, rentgenological and ultrasound examination. mortality after the strangulated small bowel resection was higher. operative enterodekompresios reduces the risc of the postoperative complications and mortality. disclosure: no significant relationships. introduction: hartmann's procedure (hp) still remains the most frequent performed procedure in diffuse peritonitis due to perforated diverticulitis. [ ] [ ] [ ] nevertheless it is associated with high morbidityand mortality . the aim of this study was to assess feasibility, morbidity and mortality of resection with primary anastomosis (pa) with or without diverting loop ileostomy versus hp in case of diverticular peritonitis. , . material and methods: we retrospectively reviewed our prospectively collected database from / to / of patients who were operated in the emergency department of bellvitge university hospital. only patients operated on generalized diverticular peritonitis (hinchey iii-iv) were included. data on patients' demographics, asa classification, hinchey score, peritonitis severity score (pss), surgical procedure, post-operative morbidity, mortality and post-operative hospital stay were studied. results: a total of patients [median age ( - ) years], female . % were included. sixty ( %) had undergone hp and ( %) pa. only in patients ( . %) a diverting ileostomy was performed. overall post-operative morbidity was . %, most frequent complications were wound infection . %, respiratory complications . % and sepsis . %. overall mortality was . % ( pt). these patients had a mean pss of . while the survival group . . there was an overall reintervention rate of . %, after pa . % and after hp . %. significant differences were found in the hp versus pa group in asa score (asa i-ii: % v %, asa iii-iv: % v %) and the median pss ( versus ) . % ( / pt) with pss £ underwent pa, but none ( / ) with pss ‡ . the post-operative morbidity was significantly higher for hp ( . %) compared to pa ( . %). focusing on hospital stay there was a significant difference between pa (mean . days) versus hp (mean . days). in the stratified analysis considering patients with hinchey iii peritonitis we found a mortality of . % ( / pt) in the hp group versus . % ( / pt) of the pa group. the mortality rate stratified for asa and surgical procedure shows no difference in asa i-ii, but in asa iii-iv a lower postoperative mortality for hp ( . %) versus pa ( . %). including only patients with pss less than ( patients) there is a significantly lower morbidity in pa ( . %) versus hp ( . %). conclusion: our data show that pa can be performed safely with lower morbidity and mortality for diverticular peritonitis in patients with asa i-ii, hinchey iii peritonitis grade or pss less than respectively to hp. these findings are supported by a shorter hospital stay in favor to pa. y. arlettaz orthopaedics and trauma, chcvs hô pital du valais, sion, switzerland introduction: one of the most demanding steps of intramedullary nailing is the distal locking. most of young surgeon are ''affraid'' to treat a long bone fracture by a nail because of the distal locking. the aim of this study is to evaluate a new frendly radiation free targeting device on cadavers. material and methods: the study was conducted on fixed cadavers. femurs were available. the method consists of the following steps: determining the zero position of the device; opening the tip of the great trochanter; introducing the nail (sirus nailÒ x (zimmer inc.)); introducing an emitter inside the nail to be positioned in the distal holes; adaptation of the guide on the standard handle with a receptor; moving the receptor to be aligned to the emitter; changing the receptor for the sleeve and performing the drilling and the locking. for the second or even third screw, the targeting device needs a little adjustment. results: on the distal locking procedures ( screws), we observed only one failure due to the breakage of the prototype. this translates as a % success rate for two screws with a mean time of . min. two surgeons conduct this study. not only the inventor but also a inexperimented surgeon tested the new device with the same succes. conclusion: this new device has the advantage to be fully mechanical, to be solidly linked to the patient and to be totally radiation free. it can be used in any hospital, by any surgeon. the procedure is easy to learn and reproducible. it could be adapted to any nail system and does not need external power supply. introduction: anterior knee pain is one of the most frequent complication of tibial nailing. its aetiology remains unclear, potentially being a multifactorial event. the aim of this prospective study was to evaluate if anterior knee pain has any negative influence on: bone healing(the hypothesis is if the patient has anterior knee pain he or she will not put weight on the affected leg and this will not stimulate the bone healing), ability to return to work and quality of live. material and methods: european level trauma center was involved in this study. methods: between januari and december , patients with a tibia fracture was admitted to the trauma departments we used a standard t tibia nail(stryker) with the possibility of proximal and distal fixation with screws the approach was trans or parapatellar. results: at - weeks, months, months follow-up we had , , patients with anterior knee painthe vas decreased from , to , , bone healing was % and for % of patients it was possible to do their previous full time job after months. the quality of life (walking up and down stairs normally without any help, putting on shoes and socks, sitting/standing from a chair, total weight bearing,) was improving. conclusion: we conclude that anterior knee pain in this study is mild, that the two different method of patellar tendon approach(trans or paratendinous approach) have no relevance and it does not have a negative influence on bone healing, ability to return to work and the quality of live. introduction: the aim of this study was to see if there is any difference between manual traction and fracture was applied in one step. twenty-seven femurs and thirthy-three tibias were treated. the mean distraction rate was . mm (range . - . mm) for the femur and . mm (range . - . mm) for the tibia. the necessary pressure to advance the distraction in the tibia was average of bar (range - bar), to distract the femur, bar (range - bar). results: bone healing index for tibia . and femur . months/cm distraction. implant failure five cases; infections three cases. nonunion of the distraction site or docking site four cases. we did not encounter major stiffness of the adjacent joints. conclusion: although the presented technique is a semi-closed distraction procedure, we find this system appealing because of it simplicity in use, low cost and the ability to immediate weight bearing. introduction: bone transport for treatment of segmental bone defects as a salvage procedure is related to a high complication rate. posttraumatic soft tissue problems and callus insufficiency are to be dealed with especially in posttraumatic conditions. the ilizarov ringfixator allows a stable external bone fixation enabling full weight bearing. in bone defect reconstruction bone transport is commonly used. a major problem is the skin cutting wires for bone fixation. a new method of the cable transport with intramedullary cable passing avoids skin cutting thus reducing skin problems. material and methods: patients with a metaphyseal and diaphyseal bone defect of the tibia after open trauma and posttraumatic infection were treated with debridement, bone resection and soft tissue coverage by local and free flaps. after soft tissue healing the monolateral external fixation was replaced in each patient by a four ring ilizarov fixator with a proximal percutaneous tibia osteotomy. for bone transport a flexible cable was placed around the distal part of the segment and passed intramedullarly through the distal segment out of the tibia and onto the ilizarov fixator and the transport clickers. the bone segment was transported after a delay of days anterograd by the intramedullar placed cable one mm per day. results: in all patients the bone defect was closed by the bone transport. in one patient early consolidation of the regenerate occurred and a rupture of the cable. two patients had an insufficiency of the callus. the distal docking site was augmented in all patients after the segment transport with iliac bone graft for consolidation. the one patient with early consolidation was treated by a second osteotomy; the two patients with insufficiency were augmented during the docking operation with iliac bone graft. conclusion: the intramedullar cable transport is a new modification of the bone transport with the ilizarov ringfixator. the main advantage is the soft tissue spearing and protecting transport mechanism enabling bone transports after free flap soft tissue coverage with micro vascular anastomosis. therapeutical course before and after amputation (number of operations before and after amputation) in relationship to co-morbidities and bacteria which caused the infection. results: hospital data from ( female, male) patients were available for septic amputations in the lower extremities on account of non-manageable infections. the average age was . years ( to years). the first age peak lies with , the second with years. in cases infected endoprostheses were found ( total hip arthroplasties, total knee arthroplasties) in cases osteomyelitis was diagnosed. before amputation the patients underwent an average of . interventions (between and ) in oder to control the infection. the average treatment period before the amputation was . days (from to days). post amputationem an average . interventions were necessary (from to ). the average period of treatment was about . days (from to days). the analysis of the co-morbidities showed that hypertension was the most frequent, cases ( . %), followed by diabetes in cases ( . %), coronary desease in cases ( . %), obesity in cases ( . %) and copd in cases ( . %). conclusion: a statistical relevant risk-assesment based on these data (correlation of microbiological findings co-morbidities and risk of amputation) cannot be carried out due to the relatively small number of patients. however, a trend may be estemated: combination of mrsa, diabetes and cardial disease in combination with a great number of operations leads to an increased amputation-risk independent to the individuals age. introduction: maggot debridement therapy (mdt) as an ancient method is succesfully used for the treatment of acute and chronic wound infections in trauma surgery . the underlying mechanisms of action of mdt are unknown, but could provide information for a novel treatment modality against infection, which is important in these times of increasing antibiotic resistance. therefore, in this research the effect of living maggots on planktonic cells was investigated. furthermore, the influence of maggot excretions on planktonic cells and on bacterial biofilms was tested. material and methods: sterile tubes were filled with living maggots in a bacterial suspension and every two hours samples were cultured and compared with controls. a turbidimetric assay was performed to test the susceptibility of six bacterial species to maggot excretions. bacterial biofilms were formed in vitro on polyethylene, stainless steel and titanium and maggot excretions were added to test their influence. results: the results show that living maggots as well as their excretions stimulate the bacterial growth of s. aureus, e. faecalis, cns, s. pyogenes and k. oxytoca (all p-values £ . ). only p. aeruginosa had a decrease of bacterial growth (p = . ). the strongest biofilms in vitro were formed by s. aureus, s. epidermidis and p. aeruginosa in contrast to the weak and inconsistent formed biofilms by e. faecalis, e. cloacae and k. oxytoca. for p. aeruginosa, stainless steel was the best biomaterial with respect to biofilm formation and for s. aureus and s. epidermidis, the best biomaterial was titanium. maggot excretions were added to the strongest biofilms, named above, and reduced these on all biomaterials. the maximal biofilm inhibition by maggot excretions was seen on polyethylene: % for p. aeruginosa (p < . ), % for s. aureus (p < . ) and % for s. epidermidis (p < . ). conclusion: this study shows that nor living maggots, neither maggot excretions have direct antibacterial properties. however, maggot excretions do reduce biofilms formed by different bacterial species on commonly used biomaterials. future research will focuss on the exact mechanism and the substance(s) that cause biofilm reduction. furthermore, possible indirect antibacterial activity will be investigated and the potential role herein of the immune system. introduction: tetanus is an acute disease caused by a neurotoxin produced by the bacterium clostridium tetani, characterised by generalised rigidity, muscle spasm and fatality. open orthopaedic injuries are at particular risk of developing infection from tetanus spores found in the environment. the uk department of health has established guidelines for the prevention of tetanus infection. we assessed the adherence of these guidelines on the initial pre-operative management of tetanus prone open orthopaedic injuries in trauma patients admitted for surgery. material and methods: a retrospective case note review was conducted on patients admitted to the orthopaedic department for intervention with a tetanus prone wound between february and june . tetanus prone injuries included open fractures, soft tissue injury requiring surgical intervention that is delayed for > h, wounds with significant devitalised tissue, wounds in contact with soil and open injuries containing foreign bodies. we assessed to what extent these patients had their immunisation status ascertained, application of wound irrigation and appropriate dressing, correct tetanus prophylactic cover (tetanus toxoid booster versus human tetanus immunoglobulin) and appropriate administration of antibiotics. results: of the patients included in the study, ( %) of patients were considered to have a 'high risk' tetanus prone injury and ( %) patients were deemed as having a 'low risk' clean wound based on the nature and extent of injury. performance within the high risk category showed that % of patients had their tetanus immunisation status ascertained, % correctly received wound irrigation and betadine dressing, % of patients were appropriately given prophylactic antibiotics. only % of patients with a high risk tetanus prone wound received tetanus immunoglobulin and % of patients were given a tetanus toxoid booster as a method for prophylaxis. conclusion: our study showed that a large proportion of patients correctly received supportive wound care and antibiotics. we also demonstrated that patients with open tetanus prone orthopaedic injuries are not adequately receiving correct tetanus immunoglobulin as the indicated prophylaxis. a large number of patients were given tetanus toxoid instead, which does not protect immunity early enough to cover the acute injury period, thus posing a major risk of developing a devastating and largely preventable infection. the orthopaedic and trauma doctor attending these patients must adhere closely to the correct initiation of simple measures in the management of tetanus prone orthopaedic wounds. all patients were irrigated and debrided, before the application of vac system. required debridements were maintained during vac therapy. time elapse between the injury time and vac application time was days on the average (min , max ). when the granulation tissue became sufficient to cover the bone, these wounds have been closed secondarily with several methods. time elapse between the start of vac and wound closure or formation of sufficient granulation tissue for grafting was days on the average (min , max ). results: distribution mean postinjury time for the osteosynthesis was , hours. three of these wounds were closed spontaneously without any need for other wound closure procedures. split thickness grafting is applied in patients, free flap to patients, full thickness grafting to patients, secondary suturing was applied in wound to close it. there was no infection in any extremities that we had osteosynthesed by internal or external methods. conclusion: wound care is as much important as osteosynthesis in open fractures. even if osteosynthesis is successful, failures in wound care may result in loss of extremity. vac alone does not suffice for wound closure. expectation in this therapy is to obtain ideal granulation tissue and to prevent infection development via appropriate wound care. the greatest disadvantage of vac therapy at the time being is its high economic cost. introduction: surgical haemostasis in trauma patients can be difficult and hazardous. commercial products are promoted to accomplish this task at a reasonable cost. in this study we compared the effectiveness of two topical gelatin-based haemostatic agents, flosealÒ and surgifloÒ in a porcine liver trauma model. material and methods: we compared the activity of flosealÒ (with human or bovine thrombin), surgifloÒ and surgifloÒ with added bovine thrombin in two porcine models. one anesthetised piglet mimicked ''normal'' conditions, while the other was kept in a status of hypotension, hypothermia and haemodilution, necessitating inotropic support (''critically ill''). laparotomy was performed, after which we inflicted five identical stab wounds on each liver lobe. each wound was treated with one of the four agents, while one wound was kept as a control. haemostasis was evaluated clinically. after euthanizing the piglets, the pathologist performed a macroscopic, microscopic and electron microscopic evaluation, blinded for which agent was used in which wound. results: clinically, surgifloÒ was able to produce a clot in some of its applications in the healthy piglet (''normal'' conditions), which was not the case in the critically ill animal, not even with the added thrombin. flosealÒ induced clotting in every wound. both microscopic (hematoxylin and eosin and mallory stain) and electron microscopic examination of the stab wounds confirmed that flosealÒ created a stable and dense agglomerate of gelatin and fibrin, firmly attached to the adjacent liver tissue, whereas with surgifloÒ, the gelatin contained more air bubbles, there was a lot less fibrin included in the clot and the clot was not strongly adherent to liver tissue. conclusion: it would seem that flosealÒ is a superior haemostatic agent, creating a dense and stable blood clot, even in a critically ill animal, hence ensuring haemostasis. disclosure: no significant relationships. introduction: bleedings stemming from splenic traumas are still among important causes of morbidity and mortality. aim of this study is comparison of fibrin glue with hemostasis effectiveness of ankaferd blood stopper lower lob resections on spleen of rats. material and methods: the study was performed at the animal laboratory of istanbul university after obtaining an approval from the ethics committee. twenty-four rats were randomly divided into three groups, namely, fibrin glue group (n = ), abs group (n = ) and control group (n = ). a wedge resection was performed on the lower lobe of the spleen. in fibrin glue group, spleen was hemostasis with fibrin glue (tisseel), while abs was administrated on the lower lobe surface in abs group. chronometric measurements were made to determine bleeding times. blood samples from the tail and vena cava were used for whole blood count and blood chemistry. histopathological scores were measured postoperatively on day th. results: in abs group, chronometric bleeding period is , s. whereas in fibrin glue group it takes , secods (p > , ). it was noted that the hemogramme test results, hemoglobin and hematocrit levels on the th days of abs and fibrin glue groups did not show sensible differences from one another ( . vs . ) p = . ( , vs , ) p = , . conclusion: there are no differences between the hemostasis speed and effectiveness of ankaferd blood stopper and fibrin glue as an applied material in bleeding stemming from experimental partial lower lob resections on spleen of rats. of the hemoperitoneum in right iliac fossa was performed and days after trauma, resulting in drainage of and cc of blood. patients were discharged month later and follow up was successful. conclusion: in selected hemodynamically unstable patients and upon availability of appropriate facilities, nom can be safely challenged over the usual limits. the indicators of tissue perfusion such as ph and be seems to be more reliable and sensitive prognostic parameter than hemodynamic instability evaluated by blood pressure and heart rate, in selecting the patients needing surgical control of hemorrhage. a moderate iah in young patients able to tolerate an increased intra-abdominal pressure, can allow a mechanical compression of the injured parenchyma achieving the arrest of hemorrhage, and extend the indications for nom in selected hemodynamically unstable patients, without signs of severe tissue hypoperfusion. material and methods: our case describes a year old male who fell m and landed on the right side of his torso dislocating a rib through the diaphragm, causing a transecting grade liver injury to liver lobes iv and vii, the right hepatic artery and a lesion of the retrohepatic vena cava (vc). the patient presented alert, hemodynamically stable with normal breath sounds. ct scan showed right sided hemothorax and a grade liver injury. a right sided chest tube drained ml of blood. the patient became unstable and was transferred to the or. profuse haemorrhage from the liver was encountered and massive blood transfusion protocol was initiated. the right hepatic artery showed to be injured and was ligated. pringles manoeuvre and packing of the liver were not enough to control the bleeding. an injury to the retrohepatic vc was suspected and manual compression was not sufficient to gain control. endovascular assistance was called for and using a bilateral femoral vein approach two occlusive balloons were placed and inflated under x-ray and open view in the vc to gain proximal and distal control. the patient stabilized and the injury to the vc could be sutured and covered with a topical haemostatic agent. the balloons were deflated but were left in place as a security measure. the liver was then again packed. the pringle manoeuvre had intermittently been used for approximately h in total. two vessel loops were left tension free around the hepatodoudenal ligament and brought out through the midline incision as a security measure. units of rbcs, units of ffps and units of platelets were given. angioembolization of the right hepatic artery was performed after the first surgery. during the second operation, the haemostats, vessel loops and occlusion balloons could safely be removed. days after the injury the patient showed increasing signs of liver failure. the patient was accepted for liver transplantation days after the injury; this procedure was carried out successfully. the combined open and endovascular approach in this case was crucial. the nature of the injury, the pringle manoeuvre, packing of the liver and arterial embolization caused permanent damage to the liver which had to be managed with liver transplantation which was successful. the use of endovascular occlusive balloons might also have had a role in the permanent damage of the liver, but had great benefit in saving the patients life. introduction: the incidence of pulmonary failure in multiple trauma patients is postulated to be influenced by several factors such as thoracic trauma and liver injury. the incidence of pulmonary failure increases in patients with an abbreviated injury scale thorax ‡ (ais) and they are more likely to face poor outcome. thus, the aim of the present study was to test the hypothesis that patients sustaining significant thoracic trauma (ais thorax ‡ ) in combination with a relevant liver injury (ais liver ‡ ) are more likely to develop pulmonary failure when compared to patients which sustained thoracic trauma without additional liver injury. material and methods: records of multiple trauma patients documented in the trauma registry of the german society for trauma surgery were analyzed using uni-and multivariate analyses. patients were subdivided into four groups according to their liver and thoracic injury: group (ais thorax < ; ais liver < ); group (ais thorax ‡ ; ais liver < ), group (ais thorax < ; ais liver ‡ ) and group (ais thorax ‡ ; ais liver ‡ ). potential relevant variables were subjected to univariate analysis between groups using the chi square test to predict the probability for pulmonary failure rate. subsequently, multivariate logistic regression analysis was performed, employing pulmonary failure as the dependent variable. differences at the level of p < . were considered statistically significant. results: , patients with a mean age of . ± . years and a mean iss of . ± . points fulfilled the inclusion criteria and were enrolled in this study. the overall rate of pulmonary failure was ± %. % of the patients in group , % in group and % in group developed pulmonary failure. the largest proportion of patients ( %) who developed pulmonary failure was found in group . those factors which proved to show a significant correlation with the incidence of pulmonary failure were included in a subsequent multivariate analysis. however, the presence of relevant lung injury, male gender, pre-existing medical conditions (pmcs), transfusion of more than packed red blood cells (prbcs) as well as iss and age played a significant role. in contrast to our hypothesis, liver injury did not proof to be associated with the incidence of pulmonary failure. conclusion: pulmonary contusion and significant liver injury seem to have a synergistic effect on the incidence of pulmonary failure. however, multivariate analysis with adjustment of further relevant factors reveal, that liver injury is not a predictive factor for the incidence of pulmonary failure. rather male gender and reported pmcs together with relevant lung injuries are more likely to develop pulmonary failure following multiple trauma. nethertheless, patients with combined pulmonary and liver injury are at higher risk for pulmonary failure with critical outcome. disclosure: no significant relationships. introduction: thoracic trauma is the leading death cause in % of politraumatised patients and contributes to the death of another % of these fatalities. identifying the determining causes, assessing their severity, early and qualified intervention in a multidisciplinary team may improve outcome of these patients. the goal of this paperwork is to assess the effects of thoracic trauma on clinical management, morbidity, mortality and outcome. material and methods: retrospective study of politraumatised patients admitted in the emergency department of st. pantelimon hospital between jan and jun . the followed parameters were most common injuries, severity, mortality, survival rate correlated with iss and rts, using data from emergency charts, hospital charts and anatomopathologic exams. results: out of patients, associated thoracic trauma, with a survival rate of , %. patients had blunt trauma. injuries that claimed early surgical intervention and had the highest death rate were: massive haemothorax patients ( % mortality rate), aortic and great vessels injuries patients ( % mortality rate), open pneumothorax patient ( % mortality rate), tension pneumothorax patients ( % mortality rate), flail chest patients ( % mortality rate). conclusion: thoracic trauma is often associated to politrauma and may increase significantly the mortality rate of these patients. lifesaving surgical procedures must be immediately performed, on patient arrival. it is important to adopt intervention protocols for multiple trauma, with a leading role of the emergency department medical staff. disclosure: no significant relationships. introduction: to evaluate treatment modalities of penetrating and/or contusive hemothorax, we reviewed our experience with patients admitted for traumatic hemothorax to our center for thoracic surgery. material and methods: from january to we treated consecutive patients (mean age, + sd years; m/f, / ) presenting traumatic hemothorax: patients had contusive hemothorax (cont) following car accident ( %), fall ( %), motorbike accident ( %), crushing trauma ( %), bike accident ( %); patients had penetrating trauma (pen) following stab wound ( . %), gunshot ( %) and impalement ( . %). we recorded demographic data, injury severity score (iss) at admission, endo-and extrathoracic injuries, method of treatment and outcome. results: there were no statistically significative differences between cont group and pen group regarding mean age ( vs years), gender (m/f = / vs / ), mean iss ( vs ) and icu admission rate ( % vs %). the cont group however presented a higher rate of extrathoracic lesions (bone, visceral, cns) than the pen group ( . % vs %: p < . ). in all patients a chest tube was immediately inserted, as the definitive treatment in % of cont pts and in % of pen pts (p < . ). surgical introduction: evaluation of penetrating injuries to the chest presented at a level traumacenter. the main study question was to see whether there was an increase in incidence in time. material and methods: in this retrospective study fifty-nine consecutive patients were included with penetrating injuries of the chest during the period of june until june . the penetrating injury had to be caused by gunshot or stab incident. statistical analyses of the data was performed using spss . . results: the study group consisted of fifty-nine patients. ninety percent were male with a mean age of years (range - ). the mechanism of injury were stab ( , %) and gunshot wounds ( , %). sixteen patients required a thoracotomy. in four other cases a laparotomy was performed. twenty-two ( , %) patients were admitted to the icu. the number of patients treated in the first year of the study period ( of the patients with a shotwound % died of their injuries and mortality rate of the patients with a stabwound was . %. in the last year of the study period the mortality of gunschot wounds was . %. conclusion: there is an increase in incidence of penetrating injury of the thorax for both stabwounds and gunshot wounds. the increase of gunshot wounds was especially large in the period july -june . the risk of suffering a gunshot or stabwound to the chest in our traumaregion is gender related. with the increase in the number of gunshot wounds, and thus experience, the mortality seems to decrease. introduction: rib fractures and more specific the flail chest are currently treated conservative. in our level one trauma centre we have on average patients with rib fractures and flail chests/yr. until recently we mainly treated the patients conservative. according to the literature the morbidity and mortality increases twofold with or more ipsilateral rib fractures and an age > yrs old. , some studies have also shown that operative fixation of rib fractures may reduce the morbididity significantly with this data and the recent development of specific dedicated osteosynthesis material for rib fractures we devised a pilot study in order to analyse the efficacy of this new matrixÒ rib fixation system (synthesÒ) and the effect on the morbidity/mortality of the patient. material and methods: during a month period we included all patients with the before mentioned criteria( rib fractures, > yr) or with a flail chest. we analysed operation details, lenght of icu stay, hospital stay and recorded complications. the results were compaired with a matched control group from . results: patients were included with an average age of yrs and a m:f distribution of : . patients had a flail chest and patients had or more rib fractures. on average all patients were operated within days ( - ). on average ( - ) rib were stabilized with an operating time of min ( - ). no implant failures were seen. patients had an average icu stay of days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . total hospital stay for the whole group was days ( - ), specific for flail chest it was days and for the ipsilateral rib fractures it was days. one patient sustained an extra rib fracture due to the procedure and one patient sustained an iatrogenic pneumothorax. one patient died due to neurologic complications. one patient had a superficial wound infection. no deep infections, pneumonia or chest related mortality occurred. compared to a matched control group of , the overall length of stay was not significant different. vs days. the length of stay for the ipsilateral fractures was not significantly shorter, vs . however the length of stay for the flail chest was significantly shorter in the study group vs (p < . ) the control group had significant more pneumonia, vs (p < , ). conclusion: the new matrixÒ system is easy and safe to work with. the system has good stabilizing capabilities. operative treatment reduces pneumonia and length of stay with flail chest. these results warrant a randomised study, comparing operative treatment vs conservative treatment. introduction: severe thoracic wall injuries can result in long time icu stay with ventilatory support substantial morbidity and even death. if the patient recovers persistent thoracic wall pain, restricted respiratory capacity and/or non union of the rib fractures can be the consequence. in a systematic review of literature we demonstrated that there is some evidence that early internal fixation can shorten the on-ventilator time, the icu stay and lower the short time morbidity. long term pulmonary function is not altered by internam fixation, however the rate of rib nonunion and chest wall pain is decreased. however high quality evidence is lacking. in order to evaluate the feasability of rib osteosynthesis with a new plating system: the synthes matrix system a preliminary study is performed and its results presented. this study preceeds a randomised controled trial comparing plate ad screw osteosynthesis and conservative treatment. material and methods: consecutive patients with flail chest and or serial rib fractures involving at least five ribs necessitating measures other than analgetics to maintain pulmonary function are included and prospectively documented. exlusion criteria: *hemodynamic instability necessitating a damage controle approach *intrathoracic injuries necessitating surgery *normal pulmonary function *patient refusing surgical treatment *patient not available for follow-up all patients are operated upon with use of the matrixrib system. postoperative icu stay, on-respirator time, pain at defined moments of follow-up, healing of the rib fractures and complications are recorded prospectively. patients grade their rate of satisfaction (functional and esthetical) on a scae of to . the results in these patients concerning on-ventilator time, icu stay and morbidity are compared to a historical series of patients with comparable iss. prospective case series with historical control group.(level iii) results: preliminary data indicate: *a shorter time on ventilator than anticipated (based on comparisson to historical data) * a shorter time on icu * less pneumoniae * no intra-operative complications * good healing results of the rib fractures * no implant failures * acceptable pain scores * good overal satisfaction * acceptable cosmetic results conclusion: internal fixation of rib fractures (flair chest or multiple sequential fractures with pulmonary function compromise) results in a earlier recuperation of pulmonary function with shortened icu stay. the overal satisfaction of the patient after operative treatment is good, with acceptable cosmetic results. there were no implant related complications. these results form the basis for a randomised control trial comparing operative fixation with the matrix rib system to conservative treatment. disclosure: no significant relationships. a. e. elsherif , m. fawzy , n. badr , m. marashda surgery, tawam hospital/johns hopkins international, abu dhabi, uae, surgery, tawam hospital, abu dhabi, uae, surgery, tawam hospital/johns hopkins international, abu dhabi, uae introduction: acute airway emergencies result from a wide variety of malignant and benign diseases. for both the patient and the clinician, the presentation can be frightening, and advanced interventional pulmonary/endobronchial techniques are required to achieve prompt relief of symptoms. general anesthesia is sometimes prohibited in these situations with complete loss of airway. we report our initial experience with these patients in a tertiary referral center. material and methods: three patients (two males) with acute proximal airway emergencies were included. two patients presented with acute stridor. the third presented with massive bronchial air leak and purulent drainage after an acute traumatic event. all patients were treated emergently with bronchoscopy and placement of an ultraflex bronchial stent under local anesthesia. all patients were followed up after discharge. results: there was no perioperative mortality or morbidity. the median age was . one patient had anaplastic thyroid cancer obstructing the trachea and was denied treatment elsewhere. the second patient had a malignant tracheoesophageal fistula. the third patient had an acute bronchopleural fistula following pneumonectomy for a gunshot wound. complete symptom relief was obtained after stenting under local anesthesia in all patients. median length of stay was days for the patients with malignancy. on a median follow up of months; two patients were symptom free, one patient died from malignant disease progression. conclusion: stenting under local anesthesia is feasible with acute airway emergency. obstruction of the central airways by malignant tumor is associated with poor prognosis.the alleviation of central airway obstruction by tumor is most often palliative, with improvement of quality of life the primary goal rather than cure. introduction: on april th an earthquake measuring . on the richter scale stuck a large area of the abruzzo region in central italy. the first notice suggested a lot of injured people and destroyed structures, incuded the main hospital of the area, the san salvatore hospital. material and methods: the national civil protection immediately send the field hospital (fh) of the marche regional government, the neighbouring region, together with a large amount of medical staff and personnel by the non governmental organization ares (regional association sanitary emergencies). this association, already involved during other national and international disaster situations and relief efforts, sent professionals volunteers (md and nurses) whit disaster knowledge and specific medical specializations. the international literature demonstrated that a fh is a complex structure and often the time required to be completely functionally is very long, indeed longer than the affected people needs. results: from april th , june th when the mission ended, the fh provided medical treated to almost patients, and the ares personnel ( ) where backed by the sanitary personnel of the san salvatore hospital. conclusion: a well planned medical response is very important to provide health assistance during a disaster, yet it is very hard to substitute a damaged hospital in the hearth of the disaster area. a modular sanitary structure, very light at the beginning, with specific and restricted medical supplies, with a little number of specialists in disaster medicine and disaster logistics, could improve the already good results obtained in the l'aquila abruzzo mission. disclosure: no significant relationships. around , people died, twice as many were injured, and almost million people were made homeless. in any situation of disaster, both natural and complex, may be produced a large number of victims that defeat the ability of local health resources to provide adequate health care. on one hand, the system may be overwhelmed with a high number of casualties. on the other hand, hospitals and other health care facilities generally may be compromised heavily: buildings may be destroyed or damaged and the supply of water, electricity, medical gasses, etc. may be limited. the transportation infrastructures may be severely damaged, creating problems for both people and equipment arriving at the hospital. damage to the health care infrastructure will further compromise the delivery of health services. material and methods: italian government responded immediately to this emergency after the official request for international relief efforts from the president of pakistan. two days after the impact, the first italian evaluation emergency team was already arrived in pakistan and the initial field structure was already fully operative, offering medical care, especially advanced trauma care and life support intervention, provided by specialists. later, when the structure had been completed and became larger provided also hospitalization, and surgical abilities, appropriate treatments and essential drugs. all the medical activities of the responding italian mission team field hospital in manshera were recorded and evaluated. results: a total of , patient contacts occurred at the field hospital during the days it operated, patients were admitted in the field hospital with a total number of nursing days with a average length of stay per admission of , days and with the occupancy rate of , %. a total number of major operations were performed. introduction: mass casualty incident's (mci) management is a present problem which is now more frequent because of iraki, afghan wars and terrorists actions. numerous new plans are evolved in each emergency association or military organization. nato as built a ''masscal'' plan to help teams in role ii in afghanistan to take care mci. through two experiences of mci in french role ii in afghanistan (kaboul) and through the litterature, we discuss the different ways of taking in charge mci. material and methods: the french role ii is located in kaboul near helicopter area. there are surgical teams ( pax, nationalities), emergencies boxes, icu beds and operating theatres. we have a pool of blood units, an echograph, a first generation ct-scan and all materials for traumatologic surgery. for mci, we use nato triage classification. each trauma undergoes ressucitation room, has needing x-ray exams, fast echography and intensive care if necessary. patient who needs urgent surgery runs immediately to operating theatre. iss score is calculated. the first mci concerns patients involved in a suicid bomber's explosion near the role ii. all were taken in charge min later. the second concerns an attack against a french coy occured km in the east of kaboul. there were casualties and soldiers died. they were taken in charge belatedly between to h later. results: fisrt mci : surgical interventions, one %burned, and a blast injury. second mci : surgical interventions, injuries with no surgery, blast injuries. we organize for these second mci a stratevac in france for casualties in less than h. mean iss score is for alive injuries and for the died soldiers. through these mci, we analyse the litterature and discuss about presents concepts in mci management. conclusion: the contemporary history of war, especially in iraqi and afghanistan constrains military surgical teams to improve their way of management of mci. training is necessary. first of all we have to define clearly each place of each actor, the conditions of triage, wich priority for which surgery and the possibility of modern communications and fast and efficient transports. the lower extremity ( %). % suffered multiple severe injuries, % upper extremity injury, % upper extremity and head/neck injury, % back injury, % head/neck injury, % upper and lower extremity injury, % abdominal injury and % miscellaneous. patients ( %) underwent an primary amputation of one or more extremities. ( %) patients underwent secondary amputation. all primary amputated limbs were shortened later. patient ( %)died one day after arrival in the cmh because of multiple severe injuries. conclusion: this single-center, and therefore complete dataset of the repatriated military personnel demonstrates the impact of participating in a nato mission for a small european country. it puts a high and challenging burden on the shoulders of the medical personnel in our hospital. further it shows, in contrast to studies from owens and dougherty, a higher prevalence of lower extremity injuries than upper extremity injuries. data regarding admission time, infection rate, disposition and quality of life will be presented. a lot of medical-ethical decisions had to be made about continuation of medical threatment or to decide whith patient will be treated and with patient will not be treated. as war surgeon you have to do operation for which you were not educated. because there is no other surgeon you have to the operation or the patient will die. it gives the opportunity to learn and gives a lot of surgical experience. this can be useful in civilian circumstances also. conclusion: the period as war surgeon in afghanistan has been of a forse impact. i had to take a lot of medical-ethical decisions and to do operations in which i was not trained. but i have learned a lot about war surgery and on human aspects also. introduction: there are a lot of unique challenges for the medical personnel which are assigned to the combat environment in afghanistan. especially the medical groups are in contact with patients from different nationalities and with different characteristics under special and difficult war circumstances. this article evaluates the effectiveness of the co-operation between a german and a greek surgical team during a -month period in a role ii hospital in north afghanistan. material and methods: from st july through th september , patients were admitted. there were male ( %) and female ( %). we reviewed the type of diseases, mechanism and location of injuries, management, type of surgical procedures performed, blood supply and outcome. results: . % of the patients were international security assistance force (isaf) personnel. most of the patients were men in a percentage of %. four children were included among the local patients. . % of the patients had surgical diseases while the rest . % were of orthopaedic interest patients. ( . %) patients underwent a surgical operation; ( . %) of them were operated immediately. gunshots were the main mechanism of injury for local patients whereas isaf personnel were usually presented with burns after improvised explosive devices (ieds) and rocket attacks. conclusion: the co-operation between medical teams from different countries, when appropriately trained, staffed, and equipped, can be highly effective in order to manage war casualties. introduction: in the emergency caused by natural and social disasters there are evident deficits between the health needs of affected population and the local health system capacity. the causes of disasters are various and not predictable, usually the health structures can not face up to the population needs. knowing that disaster medicine has different protocols and materials from ordinary medicine structures and that improvisation during the disaster's acute phases is not a good practice, it has been created an emergency operating health group, the non-profit ares association. (regional association sanitary emergencies) material and methods: the ares, whose members are about , all over the nation, is configured as an extraordinary health resource, activated by the national civil defence operations centre, in according with the regional centre of marche, in disater situations results: the main objectives of ares are training and organization of medical staff and structures and its growth crosses several missions including: ae earthquake in molise, introduction: cephalomedullary nails rely on a large lag screw that provides fixation into the femoral head. there is an option to statically lock the lag screw (static mode) or to allow the lag screw to move within the nail to compress the intertrochanteric fracture (dynamic mode). the purpose of this study was to compare the biomechanical stiffness of static and dynamic modes for a cephalomedullary nail used to fix an unstable peritrochanteric fracture. material and methods: thirty intact synthetic femur specimens (model # , pacific research laboratories, vashon, wa) were potted into cement blocks distally for testing on an instron (instron, canton, ma). a long cephalomedullary nail (long gamma nail, stryker, mahwah, nj) was then inserted into each of the femurs. an unstable four-part fracture was created, anatomically reduced, and the cephalomedullary nail was reinserted. mechanical tests were conducted for axial, lateral, and torsional stiffness with the lag screws in: ) static and ) dynamic modes. a paired student's t-test was used to compare the two modes. results: the axial stiffness of the cephalomedullary nail was significantly greater (p < . ) in the static mode ( . ± . n/mm) than in the dynamic mode ( . ± . n/mm) (fig a) . similarly, the lateral bending stiffness of the nail was significantly greater (p < . ) in the static mode ( . ± . n/mm) than the dynamic mode ( . ± . n/mm). the torsional stiffness of the nail was significantly greater (p = . ) in the dynamic mode ( . ± . n/mm) than in the static mode ( . ± . n/mm). a post hoc power analysis with a = . and ß = . revealed that the paired t-test on samples was sufficiently powered to determine a difference in mean axial stiffness of . n/mm ( . % of static stiffness), a difference in mean lateral bending stiffness of . n/mm ( . % of static stiffness) and a difference in mean torsional stiffness of . n/mm ( . % of static stiffness). conclusion: our results show that there is a n/mm reduction in axial stiffness of the cephalomedullary nail when the lag screw is changed from static to dynamic mode. this represents a . % reduction in axial stiffness with a change from axial to dynamic modes which may be clinically significant. the differences in lateral ( . n/mm, . %) and torsional ( . n/mm, . %) are small enough that they are likely not clinically significant. we felt that a difference of greater than % in axial stiffness and a difference of greater than % in lateral or torsional stiffness would be clinically significant. our study was adequately powered to detect these differences. given the significant reduction in axial stiffness with dynamization of the cephalomedullary nail construct, we recommend use of the static mode when treating unstable peritrochanteric fractures with a cephalomedullary nail. disclosure: no significant relationships. introduction: minimizing tip-apex distance has been shown to reduce clinical failure of sliding hip screws used to fix peritrochanteric fractures. the purpose of this study was to determine if such a relationship exists for the position of the lag screw in the femoral head using a cephalomedullary device. material and methods: thirty intact synthetic femur specimens (model # , pacific research laboratories, vashon, wa) were potted into cement blocks distally for testing on an instron (instron, canton, ma). a long cephalomedullary nail (long gamma nail, stryker, mahwah, nj) was inserted into each of the femurs. an unstable four-part fracture was created, anatomically reduced, and repaired using one of lag screw placements in the femoral head: ) superior (n = ), ) inferior (n = ), ) anterior (n = ), ) posterior (n = ), ) central (n = ). mechanical tests were repeated for axial, lateral and torsional stiffness. all specimens were radiographed in the anterioposterior and lateral planes and tip-apex (tad) distance was calculated. a calcar referenced tip-apex distance (caltad) was also calculated. anova was used to compare means of the five treatment groups. linear regression analysis was used to compare axial, lateral and torsional stiffness (dependent variables) to both tad and caltad (independent variables). results: anova testing proved that the mean axial (p < . ) and torsional stiffness (p < . ) between the five groups was significantly different, but lateral stiffness was not statistically different (p = . ). post hoc analysis showed that the inferior lag screw position provided significantly higher mean axial stiffness ( . ± . n/mm) than superior ( . ± . n/mm; p < . ), anterior ( . ± . n/mm; p = . ) and posterior ( . ± . n/mm; p = . ) lag screw positions. there as no significant difference in mean axial stiffness between inferior ( . ± . n/mm) and central ( . ± . n/ mm) lag screw positions (p = . ). post hoc analysis revealed significantly less mean torsional stiffness for the superior lag screw position compared to other lag screw positions (p < . all pairings). there were no significant correlations between tad and axial (r = - . , p = . ), lateral (r = - . ,p = . ) or torsional (r = . , p = . ) stiffness. there were significant correlations between caltad and axial (r = - . , p < . ), lateral (r = - . , p = . ) and torsional (r = - . , p = . ) stiffness. conclusion: our results suggest that placement of the lag screw inferiorly in the femoral head when using a cephalomedullary nail to treat an unstable peritrochanteric fracture results in the stiffnest construct in axial and torsional biomechanical testing. a simple radiographic measurement, caltad, provides an intraoperative method of determining optimal cephalomedullary nail lag screw position to achieve greatest construct stiffness. introduction: a potential of polymethylmethacrylate (pmma) augmentation to increase the purchase of cephalic implants in the treatment of intertrochanteric hip fractures has been proven in sev-eral biomechanical studies [ ] [ ] [ ] [ ] . the aim of this study is to compare the cut-out ratio of pmma augmented helical blades to not augmented ones in human cadaveric femoral heads. material and methods: six pairs of osteoporotic cadaveric femoral heads were instrumented with a proximal femoral nail antirotational (pfna) blade in a standardized manner. within each pair, one blade was augmented using ml of pmma cement. cyclic loading was performed at hz. starting at n, the load was monotonically increasing by . n/cycle until failure of the construct. x-rays were taken at cycle increments to monitor the movement of the blade with respect to the head. paired nonparametric test statistics were used to identify differences between groups. results: a significant higher number of cycles to cut-out was found for the augmented group (p = . ). a significant correlation was observed between bone mineral density and cycles to cut-out for the non-augmented specimens (p < . , r = . ), whereas no correlation was found for the augmented group (p = . introduction: when treating distal tibial deformities or fractures with the ilizarov external fixator the ankle joint and foot is often transfixed within the ring construction. for some patients full weight bearing can only be achieved in assembling a walking device on the distal ring. the biomechanical effect of the indirect loading on the fixator stiffness, the osteotomy and the wire tension is still unkown. material and methods: on the basis of a standarized ilizarov external fixator ( rings, mm diameter) with two , mm wires per ring applied in anatomical position on composite tibiae ( rd generation sawbones) direct and indirect loading was analyzed using a universal testing machine (model , uts germany). a middiaphyseal osteotomy of , mm was performed. the following parameters were recorded: micromotion at the osteotomy, relative movement between bone and rings, compressive forces at the osteotomy and strain of the wires. each experimental setup was tested ten times with kg maximal axial loading. results: the osteotomy gap closure occurred at n at direct loading and at an average of n at indirect loading. the compressive forces at the osteotomy were almost double as high at direct loading. regarding the relative motions between rings and bone the amplitude of motion was higher at indirect loading. the stress on the wires was up to four times higher when the walking device was applied on the distal ring for indirect loading. conclusion: the indirect loading using a walking device has a substantial influence on the mechanical characteristics of the ilizarov fixator which determine the biomechanical environment of the osteotomy/fracture. the results showed a higher mechanical load while achieving less compressive forces at the osteotomy. in the need of the walking device we suggest to apply additional half-pins at least in the distal fragment. ) . three randomized groups of pairs were formed. after the osteosynthesis with the implants was done the fracture (a . ) was made with a jigsaw. for further destabilsation the troch. minor was removed. the femura were fixed in the testing machine and tested under dynamic condition with a physiologic load for normal walking ( . x bodyweight) under cycles. we measured the load on the implant, the migration and rotation of the bone around the implant. the data was dokumented with lab view, results: the intramedulare implants showed significant lower migration rates (mean . mm) of the head compared to the extramedular implants (mean . mm). the rotation of the head around the lag screw startet earlier within the dhs an showed higher rates (mean °) followed by the gamma (mean °) until the end of the cycle. the best stabilisation against rotation was documented for the pfn a (mean °). the post x-rays showed a significant migration and sintering process of the femoral head with lateralisation and fracture of the lateral wall. this was even higher in probes with a low bmd. introduction: excising part of an implant through the femoral head is a rare but severe complication of osteosynthesis of proximal femoral fractures. there is little evidence in the literature about incidence and management of this complication. according to opinion leaders in an recent international user meeting most cases end up in total hip arthroplasty (tha). the value of re-osteosynthesis remains unclear. most patients that suffer an excision are geriatric and multimorbid patients, rather suitable to less invasive revision surgery. to assess the incidence and management of cutting out of the pfna blade (proximal femoral nail antirotation by synthes gmbh international) was the aim of this multicenter study. material and methods: the incidence and management of excision of the pfna blade in trochanteric femoral fractures was assessed retrospectively in cases in participating hospitals all over europe in a time period between and . all implantations were screened for this complication. the preoperative, follow up x-rays and patients' medical records including the surgical reports were collected and analysed with a special focus on revision surgery until union or tha. results: the incidence of excision of the implant was . % ( / ). the mean age of patients was years. % of mostly female ( %) patients sustained an unstable a fracture according to the ao classification. final revision surgery was performed with tha in cases ( %). in cases re-osteosynthesis led to union ( %). reosteosynthesis was either exchange of blade with or without cement augmentation alone or re-nailing. in % of tha revisions additional revision was necessary. in % of revisions with exchange of blade additional revision was required (all tha). % ( / )of revision cases with cement augmented blades healed. in % of revision with re-nailing, additional surgery was inevitable. on average . operative procedures were performed after excision of the pfna blade. conclusion: cutting out of the blade of the pfna is a rare complication. nevertheless the management after removal is challenging as indicated by the high number of surgical revisions. revision with total hip arthroplasty showed a lower rate of reoperations compared to re-osteosynthesis. nevertheless % of all revision cases were managed successfully with a minimally invasive osteosynthesis. this gives a rationale for osteosynthesis in managing this complication in geriatric multimorbid patients with a high risk for operation. references: . simmermacher, r. k., j. ljungqvist, et al. ( ) . ''the new proximal femoral nail antirotation (pfna) in daily practice: results of a multicentre clinical study.'' injury ( ) in a prospective series of subtrochanteric fractures with or without involvement of the pertrochanteric region and in revision procedures of this area the pf lcp was applied. in out of patients a fixation failure was observed. this paper reports on these fixation failures. material and methods: all patients with a multifragmented subtrochanteric fracture with or without involving the trochanteric or the femoral neck region which where judged to present a compromised nail entry point from may until may were stabilized using the pf lcp. the plates were applied in a minimally invasive manner through soft tissue windows (mipo). intrinsic stability of the fixation was increased by excentric drilling or applying the tensioning device. all patients were followed up to fracture healing. intraoperative and postoperative complications were noticed. intraoperative and postoperative x-rays were analysed using the ccd angle and the gardens alignment index. results: we report out of patients who sustained a fixation failure with secondary varus collapse requiring revision surgeries until healing. revision consisted in a reosteosynthesis in one, a plate exchange to a o blade plate in the second and a dhs in the third patient. in all our reported cases of implant failure the posteromedial buttress was missing [two ao a and two seinsheimer type v], and all patients were not able to restrict wheight bearing due to different reasons like, noncompliance (alcohol abuse, limited force, advanced age) leading to increased axial bending forces and finally to breakage of the femoral neck screws with varus collapse of the fracture. conclusion: in conclusion the pf lcp proximal femoral plate . / . due to its guide wire technique allows for straightforward plate application and reduction also in very complex fractures of the trochanteric region, including fractures with extension into the greater trochanter or reverse oblique intertrochanteric fractures. however in fracture patterns with missing posteromedial support and limited ability to restricted weight bearing (e.g.: advanced age, additional handicap or mal-compliance) an alternative fixation device should be considered, e.g. the hook plate extension of the lcp proximal femoral plate to apply higher intrinsic stability of the fixation when using the tensioning device. further clinical and biomechanical studies are needed to evaluate the potentiality and limitation of this device for the treatment of these challenging fractures of the trochanteric region. the majority of the the former fixation was replaced by a blade plate. in % we performed a total hip prosthesis. in these cases we saw an overproportional tend to prosthesis-luxations. conclusion: we conclude that mechanical complications like cut out are a little more frequent after dhs-implantation and should be treated by change to a blade-plate-osteosynthesis. this allows a fracture consolidation in that the minor trochanter becomes that stable, that a regular total hip replacement becomes possible. this seems to be the best prevention of mechanical complications after posttraumatic hip replacement like luxations. disclosure: no significant relationships. introduction: hip fractures often concern elderly patients with a high degree of co-morbidity and therefore susceptible for the associated postoperative morbidity and mortality. according to the literature, several factors have an influence on the amount and severity of postoperative complications after hip fractures. low preoperative haemoglobin levels (hb) in elderly patients seem to be associated with increased short-term morbidity and even mortality after surgery. the aim of this study was therefore to establish the impact of anaemia and blood transfusion on postoperative recovery of hip fracture patients. results: there were women and men with medium age of , years ( - years) and with medium follow-up of years ( - years). the lesions occur in sports, % of the fractures occur while practicing soccer. the fractures were bimalleolar (n = ), medial malleolus (n = ), lateral malleolus (n = ), with sindesmotic lesion (n = ) and trimalleolar (n = ). months after surgery % of the patients returned to sports activity ant at months %. at months the younger patients (p = , ) and men (p = , ) returned earlier to sports activity. at one year % of the amateur and % of the professional athletes, had returned to sports practice. fractures of the lateral malleolus returned earlier in , weeks than medial malleolus fracture in , weeks. the smfa and aofas scores were high in all types of fracture. conclusion: correct treatment of instable ankle fractures in athletes, with anatomic reduction and preservation of the integrity of the articular surface, is crucial to the return to sports practice. the fractures that influence an earlier return were younger age, male sex and less severe fracture, and negative predictors were older age and female sex. athletes submitted to open reduction and internal fixation with adequate and precocious programme of physical rehabilitation, can return to the same level of sports practice, despite the seriousness of the fracture without pain and functional limitation( ). results: in all cases anatomic reduction could be achieved. no secondary dislocation was observed and all fractures healed uneventfully. conclusion: indirect reduction of the volkmann triangle from anterior makes an image intensifier mandatory and has potential of not achieving anatomic reduction due intercalated tissue. in larger fragments the fixation with a lag crew from anterior, the buttressing effect might not be sufficient to avoid secondary displacement. with the use a postero-lateral approach and dorsal plate for fixation of the volkmann triangle, it is possible to reliably obtain an anatomical reduction of the dorsal articular surface of the tibia, thus potentially minimizing the risk of posttraumatic osteoarthtitis. introduction: after ankle-and hindfoot fractures, edema often delays surgery and postoperative mobilisation. therefore effective treatment of edema is of great importance. the aim of this study was to evaluate the efficacy of the continuous lymphological multi-layer compression therapy and of the av-intermittent impulse compression (avi) in reducing ankle-and hindfoot edema. material and methods: randomized, controlled, single-blinded, clinical trial. patients ( ± years, m, f) with unilateral fractures of the ankle or hindfoot pre-or postoperatively were randomized into a) the control group (elevation and cold packs), b) the continuous multi-layer compression therapy group (cct) or c) the av-impulse compression group (avi). primary outcome was the pre-respectively postoperative reduction of edema as measured with the figure-of-eight methode . results: pre-and postoperatively the continuous lymphological multi-layer compression therapy (cct) showed a significant better edema reduction when compared to the control group. after three days of intervention the mean preoperative edema reduction in the control group was - . ± . mm ( . %) figure-of-eight methode vs. - . ± . mm ( . %) in the cct group (p < . ) and vs. - . ± . mm ( . %) in the avi group. three days postoperatively the mean edema reduction was - . ± . mm ( . %) in the control group vs. - . ± . mm ( . %) in the cct group (p < . ) and - . mm ± . ( . %) in the avi group. pre-and postoperatively the cct group shows moderate effect sizes after two days of intervention and large effect sizes after three days. avi is more effective when combined with elevation during off-session periods. conclusion: continuous lymphological multi-layer compression therapy leads to a clinical relevant and significant better reduction of ankle-and hindfoot edema as compared to the standard treatment with elevation and cold packs. av-intermittent impulse compression shows a tendency towards a better edema reduction compared to the standard treatment. continuous lymphological multi-layer compression therapy reasonably can be applied when edema delays operation or postoperative mobilisation. considering the avi application we strongly recommend to elevate the leg during off-session periods. introduction: the objective of the study is to define the global hospital costs of a group of patients that suffered from severe trauma. additionally we identify the distribution of the expenses between the different services and the different procedures fulfilled to the patient. ( ), season ( ), moon phases ( ), times on duty ( ) and weather condition ( ) . the observed mortality was adjusted with the risc based prognosis and the smr calculated. results: the selected collective had an average age of . years and % of the patients were males. the mean iss was . and the mean hospital mortality was of . %. for the time of day the highest rate of admission was between : and : p.m., with the highest numbers on saturdays. in the times of on-call duty (weekend, public holiday, weekday between : p.m. and : a.m.) twice as much trauma patients were delivered to trauma centers as within the regularly working hours. in summer, the admission rate was highest ( . %) and lowest in winter ( . %), with more victims of car accidents in autumn and winter as in the warm season and more victims of motor-and bicycle accidents in spring and summer as in the cold season. but none of the mentioned factors showed an effect on survival (smr between . and . ). the moon phases had no influence either on frequency of accidents nor on outcome. the effects of temperature was similar to this of the seasons: with warm temperatures/month less car accidents and more bike accidents occurred (and the opposite for cold temperatures). in the subgroup with temperatures under zero degree the mortality was % higher ( . %) than in the subgroups with temperatures above zero ( , to , , even though a similar iss ( , vs. , to , ) . in a second step a multivariat analysis was done in order to improve the predictive power, but none of the external factors could improve the prognosis. conclusion: there are large variations in the incidence of severe accidents due to time of day, day of week and time of year. but there is no effect of patient's outcome in regard to medical care in german trauma centers. the quality of medical trauma care is consistent around the day, the week and throughout the year. additionally, we observed an increasing difference between mortality rate and risc prediction rate from - , % to - , %, means less deceased polytraumatized patients than predicted. within the late secondary transferring patients with spinal cord injuries were leading ( %), followed by patients with pelvic injuries ( %), infections ( %) and complex extremity injuries ( %). conclusion: with this investigation, we tried to characterize the influence of the new mapping of germany on patient data using the example of the regional trauma network ''saar-(lor)-lux-west-rhineland-palatinate''. although, knowing a lot of interferences, we noticed an abrupt rise of primary admittances of trauma patients in our level- hospital since starting networking. among the load rejection for smaller hospitals this fact leads to a distinct concentration of the treatment of polytraumatized patients in specialized trauma centers. the improved routine by increased quantity could be responsible for the improvement of process and outcome quality in the treatment of severely injured patients. but, the enormous quantity of emergency patients also reflects a future challenge in dealing with emergency operations besides routine operations as well as seldom icu-beds in these trauma hospitals. the role of the nlfc is to work in parallel to doctor led clinics, assessing and treating uncomplicated musculoskeletal injuries with a favourable natural history. since its inception, throughput in this clinic has increased and with greater clinical exposure and training, the spectrum of referred injuries has also broadened. the aim of the present study was to determine patient satisfaction with the nlfc using a validated questionnaire with a specific emphasis on how patients viewed being seen by a nurse rather than a doctor material and methods: consecutive patients were prospectively recruited in the nlfc in january . patients were referred by their resepective consultants after reviewing the presenting history, examination findings and radiographs. after their consultation with the nurse, each patient was asked to fill in a item questionnaire consisting of different domains related to patient satisfaction based on a validated patient satisafction questionnaire adapted for use in the fracture clinic setting. results: there were respondents, men and women, with a mean age of years (range - years). questionnaires were completed by parents, by carers and the remainder by the patients themselves. the most common treated injuries were distal radial, metatarsal and metacarpal fractures. % of patients felt they received the best care from the staff working in the clinic with greater than eighty percent of patients registering satisfaction with the nurse's assessment of their injury, their bedside manner and the treatment and information given. only % of patients felt that they would rather be seen by a doctor for their injury. the highest rates of dissatisfaction related to the building and seating comfort. conclusion: generally, over % of patients were satisfied with their clinic visit with the vast majority of patients not having any objection to seeing a nurse rather than a doctor. patient satisfaction with treatment remains the ultimate outcome measure by which healthcare interventions should be assessed. the results of this study demonstrate the nlfc to be an effective method of managing selected patients in a clinic setting thus reducing the workload of patients which would traditionally be reviewed by the doctor. this has significant implications for improving opportunities for doctors training as well as reducing clinic waiting times. [ ] [ ] [ ] [ ] . the aim of this study is to evaluate the anatomical correlation between the lateral end of the clavicle and the attachment area of the supraspinatus tendon. material and methods: using a mathematical model based upon ct-scan data performed on healthy individuals, the dimensional correlation between the lateral and of the clavicle and the rotator cuff is analyzed. each individual is examined in supine position, using different positions of the arm (maximum external rotation, maximum internal rotation and maximum abduction and external rotation (''aber position''), respectively). for every position the contact area of the lateral end of the clavicle and the spupraspinatus tendon is calculated. results: six healthy individuals ( shoulders) could be included into the study. the average contact area between the lateral end of the clavicle and the supraspinatus tendon (%) is . % for maximum external rotation, . % for maximum internal rotation, respectively. in the aber position only / shoulders showed a contact area > % (av. . %). conclusion: according to these morphological findings the contact area between the lateral clavicle and the supraspinatus tendon is less than %. this contact zone is located in the dorsal aspect of the clavicle. therefore the additional resection of an osteophyte, especially at the anterior part of the lateral clavicle should not have a significant influence on the outcome after subacromial decompression. and good to moderate outcome in the cs (mean ), one patient had a moderate dash score of with a poor cs of . irrespective of treatment strategy the majority of the patients regained normal range of motion and grip strength in the affected shoulder. the most common complication was impingement of the shoulder, which occurred three times in the conservatively and four times in operatively treated patients. all but one conservatively treated patient with a non-union healed without complications. conclusion: minor ( £ mm) and moderate ( - mm) displaced greater tuberosity fractures can successfully be treated conservatively with good to excellent long-term rehabilitation of function with a low risk of complications. whereas there is no doubt that major displaced fractures (> mm) should be treated operatively, special attention must be paid to moderate ( - mm) displaced fractures, as the degree of displacement may be misinterpreted on plain standard radiographs. disclosure: no significant relationships. introduction: a recent study found that after median term follow-up disability correlated with pain rather than the limited residual impairments in motion and strength. we studied impairment and disability an average of twenty-one years after injury in a cohort of dutch patient, with the hypotheses that ) objective measurements of impairment correlate with disability, ) depression and misinterpretation of nociception correlate with disability; and ) patients injured when skeletally mature and immature have comparable impairment and disability. material and methods: seventy-one patients were evaluated an average of years after injury. the majority of the skeletally immature patients were treated conservatively with closed reduction and cast immobilization and the majority of the skeletally mature patients were treated with plate and screw fixation. objective evaluation included radiographs and measurements of range of motion and grip strength. questionnaires were used to measure arm-specific disability (disabilities of the arm, shoulder and hand: dash), misinterpretation or over interpretation of pain (pain catastrophizing scale-pcs-), and depression (ces-d). multivariable analysis of variance and multiple linear regression were used to analyse the ability of the independent variables to account for variation in the dash-score. (spss . , spss inc., chicago). results: there were men and women with a an average age of forty-one at time of follow-up (range, to ). fractures were classified as ao/ota-type a in patients (simple), b in (including wedge fragment) and c fractures in patients (comminuted). the average dash score was points ( to ) and % reported no pain. both rotation and wrist flexion/extension were % of the uninjured side; grip strength was %. there were small, but significant differences in rotation ( versus degrees, p = . ) and wrist flexion/extension ( versus degrees, p = . ), but not disability between skeletally mature and immature patients. the best predictors of dash score were pain catastrophizing, pain, ipsilateral injury and grip strength, explaining % of the variation in dash scores. pain alone accounted for % of variation in dash scores. conclusion: twenty-one years after initial fracture, both skeletally immature and mature patients have limited impairment (averaging over % motion and grip strength) and disability after non operative and operative treatment respectively. patients that were skeletally immature at the time of injury had better motion, but comparable disability. disability correlated with pain and pain catastrophizing rather than motion. results: the mesenteric injuries vizualized on initial ct-scan were mesenteric vascular beading or extravasation in cases, and mesenteric infiltration or hematoma in cases. associated abnormalities of the gastrointestinal tract (thickening, abnormal enhancement, perforation) were present in / cases ( %). nine patients underwent surgery ( %), patients in the early hours, and others after a delay of more than h. indication for surgery was hemodynamic instability in cases and suspicion of bowel perforation in cases. in total, intestinal perforations were found in patients. three patients ( . %) died of associated injuries. no false positive scan has led to unnecessary surgery. however, the negative predictive value of initial ct was % for intestinal associated lesions. conclusion: the mesenteric injuries in blunt polytrauma patients are uncommon but serious. the whole body scanner is a powerful tool for the diagnosis of these mesenteric lesions. conservative treatment is feasible but a clinical and paraclinical reassessment is essential for early detection of intestinal lesions initially undiagnosed, or aggravation of initial lesions. disclosure: no significant relationships. introduction: drug smuggling by gastrointestinal concealment, body-packers, is an increasing problem in developed countries. although conservative treatment is usually successful in most cases, some of these patients suffer complications such as obstruction, gastrointestinal perforation or massive drug intoxication due to a leaking package. despite an urgent surgery and a careful management in the icu, morbidity and mortality remain high. our aim was to assess the outcomes of conservative and surgical management of these patients in our hospital, the referral centre for this entity in madrid. ( ) ( ) pre-hospital fatalities were more frequent (although not statistically significant), which may reflect improvement of trauma organization in recent years ( ) ( ) ( ) ( ) . domestic (may related to delay due to victim's solitude) and urban environment (inexperienced personnel, delay due to referral to another hospital) incidents lead more frequently in pre-hospital death. age and iss as indicators of physiologic reserve and severity of injury were independent predictors of fatality before the victim reaches hospital. introduction: the triad of the elbow is a complex traumatic injury. these injuries have traditionally been considered a poor prognosis for the consequences that arise as a secondary instability, stiffness and loss of functional ability. the objective of this free paper is to review from a clinical and radiological perspective our experience with cases. material and methods: we retrospectively reviewed patients with this type of injury. in patients was not carried out a comprehensive treatment of all existing lesions. the coronoid process was not addressed specifically and fractured radial head was removed or and an osteosynthesis was performed. in the remaining were treated by a treatment protocol trying to repair all the damaged structures (coronoid synthesis, radial head arthroplasty/orif and ligament repair, at least in the external lateral ligament complex). the median followup was months ( - ).the results were evaluated by the scale of may elbow performance score (meps), range of mobility, radiographic parameters and complications during follow up. results: patients treated according to protocol in a systematic manner trying to repair all damaged structures had better outcomes in both the radiological point of view as functional, as well as a lower rate of complications. meps in these patients the average was points (vs. the other group), the arc of º flexoextensió n (vs. º) and the arc pronosupinació n º (vs º). conclusion: despite being an injury traditionally associated with poor results, which have been established treatment protocols that try to treat all manner of injured structures involved in the injury outcomes have improved significantly. we think it must be performed a radial head artroplasty/orif (not resection), anchorage/ osteosynthesis coronoid process and a ligament repair at least of the external lateral ligament complex. if residual instabilty results it may be repaired the medial colateral ligament complex and a temporal external fixator may be used. disclosure: no significant relationships. tion. patients received a secondary implantation including chronic luxations, nonunions, failed osteosynthesis and reimplantation after deep prosthetic infection. the mean follow up was ± months. the functional outcome was measured by using the mayo elbow performance score. results: we had female and male patients with a mean age of ± years. all patients achieved very good results based on the ,,mayo elbow performance score'' with a postoperative mean of points (range between and points) with a maximum performance of points. the mean range of motion concerning extension and flexion was degrees ( to degrees), concerning pronation and supination degrees ( to degrees). the mean flexion deformity was degrees ( to degrees), the mean maximum flexion was degrees ( to degrees). we had two partial ruptures of the triceps tendon, one treated by operative refixation and one conservative, one temporary lesion of the ulnar nerve with complete recovery and one postoperative hematoma which needed surgical treatment. one patient needed revision surgery and resection arthroplasty due to a deep infection, but received a new prosthesis after two months. we recorded no radiographic loosening or other mechanical problems so far. conclusion: according to the used ''mayo elbow performace score'' all patients achieved a very good functional outcome. eventhough they all had severe injuries of the elbow. with modern types of elbow prosthesis the rate of complications and revision surgery is quite low. Ô ur findings indicate that total elbow arthroplasty should be considered as an additional treatment alternative. patients with a lower functional demand and of higher age benefit most from a prosthesis. for younger patients preservation of the joint should be achieved as far as possible. introduction: it is not always possible to reconstruct complex radial head fractures. as non-anatomical reconstruction and healing disturbances result is loss of motion and severe post-traumatic arthritis of the elbow joint, radial head resection as been proposed for these cases. however secondary overload of the lateral facet of the humero-ulnar joint (with consequent arthritis), instability (especially in the presence of medial collateral ligament injury), painfull anteroposterior instability of the radial stump, and radial shortening (in essex-lopresti lesions) with wrist pain can be the result. radial head arthroplasty widely is proposed as prevention of these complication. however as we demonstrated in a systematic review of the litterature, radial head arthroplasty has equally high secondary arthritis rates as radial head resection. the complex anatomy of the radial head, articulating both with the capitellum and the proximal ulna is not reproduced by most contemporary radial head prostheses. material and methods: we describe the complex radial head anatomy based upon an analysis of mriâ e tm s of the elbow performed in healthy volunteers under standardised situations. we describe the next variables: â e¢radial head shape and diameter at the most proximal part of the pruj (proximal radio-ulnar joint) â e¢radial head shape and diameter at the midpoint of the pruj â e¢radial head height medial and lateral â e¢depth of the radial head through â e¢offset of the radial headâ e tm s through relative to the center of the radial head â e¢offset of the radial headâ e tm s through relative to the axis of the radius â e¢offset of the radial head relative to the axis of the radius â e¢angulation of the radial neck to the axis of the radius we compare these parameters to the available radial head prostheses. results: there is a high variability of the different parameters and no relation between all of the parameters could be determined. the existing radial head prostheses do only reproduce the anatomy to a limited extend. conclusion: the high rates of post arthroplasty arthritis can be related to the non-anatomical shape of the existing designs. as the proximal radius articulates both with the capitellum and the proximal ulna, a precise reconstruction of both joints is a necessity to avoid maltracking and/or edge contact in both joints. given the high variability this only can be realised using a theoretic modular prosthesis that allows for reconstruction of the synchronisation between both joints. we found no significant differences (p > . ) in the deficit of the range of motion. flexion: screws ± °, prosthesis ± °, plate ± °e xtension: screws ± °, prosthesis ± °, plates ± °p ronation: screws ± °, prosthesis ± °, plates ± °s uppination: screws ± °, prosthesis ± °, plates ± °a ccording to elbow functional evaluation criteria by broberg and morrey, we found excellent and good results in % of all patients treated with screws, in % of all patients treated with prosthesis and in % of all patients treated with plates (p > . ) the average dash score of patients treated with screws was ± points, of patients treated with prosthesis ± points and of patients treated with plates was ± points (no significant differences, p > . ). the physical and mental component of the sf- score was at the time of follow-up within the normal range at all patients (physical component: screws ± . , prosthesis ± . , plate ± . ; mental component: screws ± . , prosthesis ± . , plate ± . ). in the subcategory of physical functioning, screws performed better than prosthesis (p < . ). no other items of sf- were significantly different (p > . ). conclusion: according to our results osteosynthesis with only screws seem to be the best of the three studied methods. radial head prosthesis replacement yields better functional results than treatment with plates. it must be considered that prosthesis replacement of the radial head has the long-term risk of loosening, especially in young and active patients. plates showed worse clinical results especially in rotation of the forearm even after removing the plate in patients. disclosure: no significant relationships. s is angular stable osteosynthesis of the olecranon more economical than traditional treatment? n. spaepen , k. govaerts , s. nijs , p. broos trauma surgery, uz leuven, leuven, belgium, department of traumatology, university hospitals leuven, leuven, belgium, traumatology, university hospitals leuven, leuven, belgium introduction: although tension band wiring is considered as the gold standard in the treatment of simple olecranon fractures and olecranon osteotomies, the complication rate is high (delayed healing in up to % of cases, hardware migration %). in an historical series using anatomical preshaped lcp plates, we could lower the rate of healing disturbances, but the volume of the implant did make hardware removal necessary in the majority of patients. the lcp , mm hook plate is a low volume angular stable compression plate, designed for the treatment of simple fractures and osteotomies of the olecranon. in this study we want to evaluate the early results of using this new device for the treatment of acute fractures and osteotomies at a level trauma centre. material and methods: we prospectively include all patients treated by lcp , mm hook plate between and. months results considering range of motion (as measued by), meps (mayo elbow performance score), complications and radiographic results are presented. we perform a cost analysis of primary operation using the different implants available, length of stay and time off work. we also perform a cost analysis for reoperation because of delay in union results: we included patients. average age is , years (range - ). there were female and male patients. at months average extension deficit was °, the average flexion °. there was no substantial loss of pro-supination. all factures but one united anatomical (early loss of reduction, but patient refused reoperation). there were complications: early loss of reduction (treated conservatively), crps (complex regional pain syndrome) and arthrofibrosis necessitating implant removal). because of symptomatic hardware two additional hardware removals have been performed. according to the mayo elbow performance score all but patient scored good to based upon the cost analysis the predicted average cost per patient is significantly lower in the hook plate group as compared to the tension band and anatomical preshaped plate group. conclusion: although still a limited series, the early results of this implant are very promising. we document ranges of motion witch are comparable to those described previously in tension band wiring or anatomical plating, but at lower complication and reoperation rates. based upon an analysis of the cost of treatment and of reoperation we advocate the routine use of the olecranon hook plate in the treatment of simple olecranon fractures and osteotomies. disclosure: no significant relationships. material and methods: dutch surgeons (n = ) were asked to draw two incisions for an olac on embalmed human specimen (n = ). they also filled out a questionnaire of their experience. all incisions were photographed and digital measurements were taken. each incision was compared to the gold standard on criteria. incisions should not be closer than two-thirds of the distance between: ) distal tip of the lateral malleolus and the achilles tendon. there was no correlation between number of mistakes and number of procedures per year or years of experience (spearman correlation: . and - . respectively) the median of the mistakes for l-shaped incisions was (iqr = ) and (iqr = ) for j-shaped incisions (p = . , mann-whitney). the spearman correlation between the mistakes for the two incisions drawn by each surgeon was . . conclusion: conclusions: inter-surgeon variation of incision lines was high and since the number of mistakes per incision was not correlated to the surgeon's experience, casam can be useful in two ways: ) pre-operative planning using casam, might assist the surgeon in determining a 'tailor made' safe zone in each patient. ) for educational purposes casam is able to compare a student's incision with the gold standard or the computed location of the sural nerve, thus providing personal feedback. introduction: a precise sustentaculum tali screw placement is crucial for the fixation strength of operatively treated calcaneus fractures, as shown in biomechanical studies. due to the complex anatomic shape of the calcaneus and the limited visualization of the sustentaculum tali fragment via the common lateral approach, the exact screw positioning is demanding and a bright knowledge of the surgeon is mandatory. with the introduction of navigation procedures an increased precision of implant positioning could be achieved for different applications, as reported for pedicle-and iliosacral screw placement. the aim of this study was the evaluation of different navigation procedures compared to the conventional technique for the placement of the sustentaculum tali screw. material and methods: sustentaculum tali screws were placed via a standard lateral approach in artificial calcanei with a prefabricated soft tissue envelope. we used different navigation techniques: group i: d-based fluoroscopic navigation group ii: d-based fluoroscopic navigation group iii: fluoro-free navigation compared to the standard procedure without navigation (group iv). for each screw the time of procedure and time of fluoroscopy was measured. the precision was evaluated in postoperative ct scans. results: no x-ray exposure was necessary for the standard procedure and the fluoro free navigation, whereas ± . and . ± . s of fluoroscopy time were needed for the d-and d-based fluoroscopic navigation. significant differences were observed for the mean procedure time: . ± . (group iv), . ± . (group iii), . ± . (group i) and . ± . min (group ii). no significant differences were seen for the precision with one mal-placed screw in each group. whereas for the image based navigation procedures wide experience in computer assisted surgery was necessary, the fluoro free navigation procedure could easly used without that experience, due to a simplified and self-explanatory workflow. conclusion: all three navigation procedures increase the intraoperative orientation for the placement of the sustentaculum-tali screw, but significant differences of precision compared to the standard technique could not be observed in our experimental set up. potential reasons are a visual and tactile memory effect, despite a randomized order of drillings and a better visualization of the osseous structures in the used artificial model. in clinical situations a lack of surgical routine for this rare injuries and a limited display of anatomic landmarks exist, making all of the evaluated navigation procedures to a helpful tool. if the fracture reduction is controlled intraoperatively by an d fluoroscopic scan, we recommend the d navigation, otherwise we use the fluoro free navigation. disclosure: no significant relationships. overall satisfaction of functional status was measured using a visual analogue scale (vas; range zero to ten). results: four-hundred metatarsal fractures were identified in patients. the distribution of fractured metatarsals was: first metatarsal %, second %, third %, fourth %, and fifth %. multiple metatarsal fractures were seen in . %. most fractures were caused by an inversion injury or fall from height ( %). more than eighty percent of fractures were undisplaced or minimally displaced, and most fracture patterns were transverse or oblique/spiral. a total of patients ( . %) returned the questionnaire with a median follow-up of months. responders were female in % and had a median age of years (p -p - ). in . % of cases the left side was affected. the median aofas-score was points (p -p - ), the median vas was points (p -p - ). in the univariate analysis the aofas and vas score were inversely dependent of the body mass index (r s = - . and - . ; p < . ). patients with known diabetes reported lower vas (p = . ) and aofas scores (p = . ). female patients reported a lower aofas (p = . ). an increase in dislocation (> mm) resulted in a decrease in vas (p = . ). no correlations were identified with outcome and which metatarsal was affected, number of fractured metatarsals, fracture type and location, articular involvement, and smoking habits. in the multivariate analysis the bmi correlated with the aofas (p < . ) and vas (p = . ) and the dislocation with the vas (p = . ). conclusion: this is the first investigation using two validated outcome scoring systems to determine functional outcome in metatarsal fractures. overall outcome in metatarsal fractures is high, as almost all fractures healed without complaints at months. outcome is dependent of bmi, diabetes, gender, and dislocation at the fracturesite. disclosure: no significant relationships. introduction: incidence of fracture non-union is increased after severe trauma. the systemic inflammatory response syndrome (sirs) resulting from major trauma appears to play a role in this healing impairment. especially the cellular reaction associated with sirs influences the inflammatory response, which is of vital importance in fracture healing. we hypothesize that systemic inflammation may impair healing through an altered interaction between neutrophils and stem-or osteoprogenitor cells within the fracture hematoma. we therefore investigated the effect of neutrophils on differentiation of mesenchymal stem cells (mscs). material and methods: osteogenic differentiation of mscs was assessed using an alkaline phosphatase colorimetric assay on the adhered cell lysate after culturing mscs for days in the presence of different quantities of neutrophils. chondrogenic differentiation of mscs was assessed within the same samples using a glycosaminoglycan colorimetric assay in the cell medium. proliferation was measured within the same samples using a picogreen(r) dsdna fluorescent assay. to assess whether any effect was mediated through release of soluble factors or through direct cell-cell contact, supernatants of stimulated neutrophils were used. stimulation of neutrophils was achieved during h with tnf-alfa. tnf-alfa in the supernatant was subsequently blocked with humira prior to interaction with mscs. results: low neutrophil concentrations resulted in increased alkaline phosphatase concentrations compared to control levels. high concentrations of neutrophils resulted in increased glycosaminoglycan concentrations and decreased alkaline phosphatase concentrations. introduction: angiogenesis is a cue element in the early wound healing and is considered most important for tissue regeneration. in addition to aiding research in understanding the regulatory mechanisms of angiogenesis and vasculogenesis, the concept of co-cultures has helped to better understand the mechanisms of interactions between osteoblasts and endothelial cells focusing on new therapeutic approaches for critical size bone defects. here, we describe in detail the cellular and molecular interaction between human osteoblasts (hob) and human endothelial progenitor cells (epc) in a complex d-environment. material and methods: we investigated endothelial differentiation and morphological organization of human epc in cocultures with hob using methylcellulose sphaeroids as well as collagen biomatrices. cocultures of human umbilical vein endothelial cells (huvec)/ hob were used as controls. epc were tracked with cell tracker red, whereas hob were transduced using a lentiviral egfp-vector to allow direct cell visualization using confocal laser microscopy and analysis of cell-specific gene expression. we studied the survival of both cell types and formation of vessel-like sprouts as a criterion of endothelial activity of epc. expression of several relevant angiogenic and osteogenic markers, as well as different extracellular matrix proteins was investigated using quantitative rt-pcr. results: using the hybrid coculture technology we could clearly show that hob regulate the survival, proliferation, and spouting of epcs. concordantly, expression of endothelial cell markers cd and vwf was significantly up-regulated by cocultivation with hob. by contrast, epcs did neither proliferate nor did they form any apparent vessel-like structures when cultured in a monoculture. using the lentiviral egfp-reporter transduction method the expression of osteoblast marker genes was also estimated accurately. we could clearly show that epcs inhibit the terminal differentiation of hob by interfering with expression of specific transcription factors runx and sp . in contrast, cell proliferation and expression of the early osteoblastic differentiation marker alp were induced in cocultures. conclusion: in the present study we demonstrate that human endothelial progenitor cells interact with human osteoblasts on the cellular level. we have identified a complex regulatory mechanism which accounts for endothelial cell survival and cell differentiation of both cell types. this study provides new insight into regulatory mechanisms of bone regeneration and may unveil potential applications in bone tissue engineering and fracture healing. introduction: failure of fixation is more common in osteoporotic than in other fractures. early treatment of osteoporosis as well as early stimulation of the fracture healing may improve the later clinical outcome. bisphosphonates are effective in osteoporosis treatment, and bone morphogenetic proteins (bmps) stimulate fracture healing, although several studies show less effect in estrogen deficient models. in order to determine the effect on early fracture healing of bisphosphonates and bmps in osteoporotic fractures, these treatment modalities were applied in estrogen deficient rats. material and methods: fourty rats underwent an ovariectomy (ovx), followed by low calcium diet during six weeks. ten rats underwent a sham operation, followed by normal diet. after six weeks, a closed femoral fracture was induced in all animals. the ovx animals were then assigned to four different groups: ovx alone, injection of bisphophonate, injection of bmp- in the fracture gap, or the combination of these. all animals received a normal diet after the fracture. after sacrifice at two weeks, fracture healing was evaluated using radiographs and four-point bending stiffness andstrength. results: radiographs showed a higher score in the bmp- treated animals, with or without the bisphosphonates (p = . , kruskal-wallis test). no delay in healing was seen in estrogen deficiency as compared to the sham group. bending stiffness was higher in the bmp- treated groups compared to the others (p = . , kruskal-wallis), as was the strength (p = . , kruskal-wallis). no significant improvement was found by the injection of bisphosphonates conclusion: early fracture healing is significantly stimulated by injection of bmp- in the fracture gap in estrogen deficient rats. early treatment with bisphosphonates showed no effect on fracture healing. introduction: traumatic brain injury (tbi) is associated with an increased rate of heterotopic ossification within skeletal muscle, possibly due to humoral factors. however, the pathophysiological mechanism of heterotopic ossification after tbi is still not fully understood. this study investigated whether cells from skeletal muscle adopt an osteoblastic phenotype in response to serum from patients with tbi. material and methods: blood was collected from patients with severe tbi as well as ten control subjects. primary skeletal muscle cell cultures were isolated from orthopedic surgery patients and characterized using immunohistochemical techniques. proliferation and osteoblastic differentiation were assessed using commercial cell assays, western blotting (for osterix protein) and the villanueva bone stain. results: all serum-treated cell populations expressed osterix after one week. cells treated with serum from both study groups in mineralization medium had increased alp activity and mineralized nodules within the mesenchymal cell subpopulation after three weeks. serum from patients with tbi induced a significant increase in the rate of proliferation of these cells compared to the controls (p < . ). introduction: the current gold standard to establish the diagnosis of osteoporosis and to follow the pharmacological treatment is the measurement of the bone mineral density (bmd). with a growing number of predicted fractures due to osteoporosis the expenses for bmd-measurement will increase. it was therefore the objective of this study to determine parameters that possibly allow a laboratory follow-up of these patients. material and methods: since we operated patients (Ø . y, % female) with an osteoporotic fracture (group ). all of them were more than years old and underwent a laboratory screening including the serum levels of vit-d -oh, vit-d . -oh, calcium (s-ca), phosphate (s-pho), p np, b-cross-laps, intact pth, osteocalcin, tsh and sex hormones as far as the urine concentration of calcium (u-ca) and phosphate (u-pho). in vit d -oh insufficient patients without treatment a therapy with alandronat lg once a week and daily calcium and vitamin d substitution was started. patients (Ø . y, % female) of the orthopedic department underwent the same screening and served as a control (group ). these patients did not sustain a fracture or relevant surgery within at least months. in a second part we checked the evolution of group -patients laboratory screening at a , and -months postoperative interval. results: group and displayed significant differences with regard to s-ca, u-ca, u-pho (p < . ), osteocalcin (p < . ) and vit-d -oh level (p < . ). after separating male and female patients significant serum concentration differences of testosteron (p < . ) in the male patients and of fsh (p < . ) and oestradiol (p < . ) in the female patients could be observed. during the follow up at , and months we could demonstrate a significant elevation of s-ca (p < . ), s-pho (p < . ), osteocalcin (p < . ) and vit-d -oh (p < . ) concentration. further we found a significant elevation of fsh-(p < . ), lh-(p < . ) and testosteron (p < . ) concentration as well as a significant decrease of the oestradiol (p < . ) concentration. as former studies showed we confirmed by comparing group and a deficiency of vit-d -oh, s-ca and an elevation of u-ca in patients with osteoporotic fractures. we could also show a significant difference of the concentration of osteocalcin. by following these blood parameters during treatment we found an improvement or normalization of these differences as a result of the treatment. therefore we believe that vit-d -oh, s-ca, u-ca and osteocalcin could serve as follow-up parameters in the treatment of osteoporosis. further our preliminary results suggest that under the treatment there is a decrease of the testosterone level in male patients and a decrease of the fh-and increase of the oestradiol-concentration in female patients which has not been reported in the literature yet. in consecutive cycli an alternating traction of newton was exerted on the subscapularis and infraspinatus, while a continuous force was applied for the supraspinatus. the motion of the tuberosities and the shaft were recorded by high-speed cameras. the following parameters were investigated: failure of osteosynthesis, intertuberosity motion, motion lesser tuberosity-shaft, motion greater tuberosity-shaft, motion metaphysis-shaft. results: group : cable fixation was significantly more stable for intertuberosity motion and tuberosity-shaft motion. furthermore we found failures for the lesser tuberosity in the suture group. we found no significat difference for the metaphysis-shaft motion. group : the greater tuberosity-shaft motion was significantly lower using two cables. all other parameters showed no significant difference. we found no failures. group : since the tuberosity-shaft motion and the intertuberosity motion were significant higher using fibre-wire, this series was abandoned after / pairs. conclusion: cable fixation is significantly more stable than suture fixation for tuberosities in shoulder arthroplasty. double-cable fixation does not improve intertuberosity stability. we found tendencies for an enlarged tuberosity-shaft stability. introduction: the results following prosthetic treatment of primary humeral head fractures present great variability. dissolving of tuberosities leading to dysfunction of the rotator cuff with limited motion, pain and instability are often reported. the short term results on inverse prosthesis on the one hand are promising, whereas scapular notching turns out to be a major problem leading to a high failure rate in the long run. high complication rates are also reported. material and methods: in an ongoing prospective and consecutive multicentre study until today, cases with an inverse shoulder prosthesis system are documented. in this series we analyse the results of the cases treated for primary fracture as indication. in all cases the affinis Ò fracture inverse prosthesis has been used. this implant was specially designed as a reversed treatment option for selected fracture cases. mechanical and biological notching should be reduced due to the special design features of the prosthesis. patients were asked to describe pain and satisfaction for the injured shoulder one week before the trauma and also to fill in the ases score. the constant score for the healthy shoulder was measured whenever possible. postoperatively constant and the ases score were assessed. the x-rays were evaluated for notching and the healing of the tuberosities. results: from february until today a total of n = cases ( females and males) were treated for primary fracture with the fracture prosthesis. mean age at operation was . years (range . - . ). according to the neer classification we treated patients with a -part fracture, with a -part fracture and cases with a head split fracture. after a mean of months (range - ) the cs reached . points. active forward elevation was . °and passive . °. the active lateral elevation (abduction) was . °for the active movement and . °passive. the ases score was . points at the latest follow-up and the value for pain and satisfaction were . and . respectively. we found no notching in this series and the tuberosities were judged as anatomically healed in % of the cases. we found no difference in the clinical outcome between patients with healed tuberosities compared to the group with non visible tuberosities. postoperatively two complications occurred one fracture of the clavicula and one fracture of the acromion. so far we did not have any luxations or implant disconnections. introduction: the purpose of this study is to evaluate the survival and function of splenic autotransplants using spleen imaging with tc m labeled heat-damaged erythrocytes. material and methods: patients with splenic rupture underwent spleen imaging with tc m labeled heat-damaged erythrocytes at to months after splenic autotransplantation (early scans); also, of them underwent the same imaging technique at to months after operation (follow-up scans). results: on early scans, splenic autotransplants were faintly and the intensity of radioactivity in autotransplants was lower than in liver. the increase of intensity of tracer accumulation in autotransplants was significant higher on follow-up scans. one week after operation the levels of cd , cd and cd /cd ratio were significantly lower than those of controls and returned to normal months later. conclusion: the spleen imaging with tc m labeled heat-damaged erythrocytes is a valuable and effective method for evaluation of the survival and function of splenic autotransplants. , respectively / in the group ''skiers''( %) and / in the group ''snowboarders''( %). the aast grade of injury was: aast case; aast cases; aast cases; aast cases; aast case. of the ''skiers''( %) and of the ''snowboarders''( %) showed a high grade (aast > ) splenic injury. patients has an injury severity score > ( / skiers and / snowboarders): cases of severe brain injury, case of associated liver injuries, cases of associated left renal injuries. patient had associated colonic and pancreatic injury. four patients were not stables at admission and had immediate laparotomy with splenectomies. patients were elected for nonoperative management. results: splenectomies was performed with a splenic salvage rate of. %. there was no mortality and morbidity was %. for thr three patients who had immediate splenectomy the recovery was uneventfull. in te group nonoperative management three patients had angioembolization and four had delayed laparotomy ( for delayed splenic rupture at post injury , and resectively; for sirs). in the patients with availables data, mean hospital stay was days ( - ), . days ( - ) for the group skiers and - days ( - ) for the group snowboarders. patients( %) were recovered less than days. patients were admitted initially in icu ward(from h to days). conclusion: ski accidents are in cause for more the one-third of all splenic injuries admitted to grenoble university hospital. the mean age is lower and male incidence is higher than splenic injuries admitted for others causes (road traffic accident, falls, other mountain accidents). an high number of snowboarder's' accidents was observed and pattern of injury is poor in these patients. the incident of polytrauma cases was the same in two groups and this observation confirm that snowboard practice is at higher risk than skiing for severe splenic injuries. in france, if number of raod traffic accidents is decreasing, the number of sport accidents is imcreasing in the last years. a better comprehension of mechanism, epidemiology and hystological findings of splenic injuries resulting from skiing and snowboarding is necessary to improve trauma preventiin programs. introduction: management of splenic injuries has evolved over the past three decades. prior to that time, a diagnostic peritoneal lavage positive for blood was an indication for exploratory laparotomy because of the concern about ongoing hemorrhage and/or missed intraabdominal injuries. in children the nonoperative management (nom) of splenic injuries rapidly gained interest because of the significant incidence of post-splenectomy sepsis as well as the complications associated with non-therapeutic laparotomies. the last decade has witnessed a proliferation of reports of nom in adults with injuries to the spleen. inclusion criteria for nom in adults, which have been a source of controversy, continue to evolve. moreover we noted that most publications focused on isolated splenic injury and not on patients with multiple injuries. this study was conducted to summarize the indications for the nom of blunt splenic injury with special attention to the multiply injured patient. material and methods: we conducted a medline search. the search was designed to identify english language citations between and : using the keywords: blunt splenic injury, conservative management, multiply injured patients and blunt abdominal trauma. the bibliographies of the selected references were examined to identify relevant articles not identified by computerised search. one hundred articles were identified. a cohort of three trauma surgeons selected articles for review and analysis. we used the methodology developed by the agency for health care policy and research of the united states department of health and human services to group the references into three classes. reviewing all data showed that the nom of blunt splenic injury is a save treatment modality in isolated cases but also the multiply injured patient. conclusion: currently the non-operative management of blunt injury to the spleen is the treatment modality of choice. important is a haemodynamically stable patient, with no signs of peritonitis on physical examination. patients who only maintain their blood pressure by the constant infusion of crystalloid or blood products are not haemodynamically stable and need surgical intervention. ct scan findings and grade of injury are not, in themselves, criteria for laparotomy. these criteria are applied to isolated injuries to the spleen but can also be applied to the multiply injured patient. age itself is not a contraindication. the general condition of an individual patient needs to be decisive. and finally hospitals with a low trauma incidence can safely use these guidelines in their management protocol. introduction: the treatment of trauma patients with solid organ injury has changed over the last years towards a less invasive treatment. still our algorithms especially in dealing with trauma patients with ongoing internal abdominal haemorrhages is still based on fast control en stopping of the bleeding by any means. the use of ct-abdomen and subsequent performing angiography and embolization takes time. we analyzed the time path involved in angiographic control of the bleeding spleen. material and methods: a retrospective study. the study group consisted of ten patients presenting at our institution with a traumatic spleen injury in the period november till november . all patients were managed according to the principles of atls. data were analyzed using spssÒ . . results: the study group consisted of seven men and three women. average age was years (range till ). the iss was on average (range - ). all patients in the study group received an angiography after ct-abdomen which showed an active bleeding focus in the spleen. organ injury score were eight grade and two grade spleen injuries. average time from admission to angiography was min. time to control of bleeding by embolization took average min. time loss between ct and angiography was on average min. conclusion: the time paths involved in managing this group of trauma patients with spleen injuries by embolization are much longer than expected. the time involved after diagnoses to actual control of the bleeding spleen injury is much longer than anticipated. logistic changes to limit the time loss in interpretation of data from the ct-a, transfer of the patient, preparation of the angio-suite and less time consuming technique to actual embolization are needed. articles were eligible if they reported the failure rate of nom with or without angio-embolization (ae) in pediatric patients with splenic and/or liver injuries with a contrast blush on ct and included two or more trauma patients. two reviewers independently assessed the eligibility and the quality of the articles and performed the data extraction. interrater differences were resolved by discussion. results: nine studies were included describing pediatric patients. the median sample size was five (range - ). seven studies (including patients) reported a total of patients with failure after nom without ae. failure rates across these studies ranged from . to %; the pooled percentage was . % ( % ci: . %- . %). the failure percentages after nom with or without ae ranged from to %; the pooled percentage was % ( % ci: . %- . %. two studies (including patients) reported a total of patients with failure after nom with primary ae: a percentage of . %. conclusion: despite the current low level of evidence on failure rate of nom when a contrast blush is present on ct we emphasize that there is a significant amount of patients in whom nom fails. we therefore recommend that the management of splenic and hepatic injury in children should not only be based on the physiological response but also when a contrast blush is present on ct. results: primary blast injury: this form of injury results from the deleterious effects of the blast wave passing through the body. these waves have little or no effect on solid organs but have their major destructive potential in air containing organs, especially lungs. secondary blast injury refers to the impact on a patient's body of projectiles usually inert. the addiction of destructive metal fragment, nails and other such objects to bombs increase the severity of injury and lethality. tertiary blast injury refers to the deceleration and impact with the ground, wall or other inanimate object of the patient whose body is displaced by the blast. quaternary blast injury refers to the miscellaneous forms of injury by-products of explosions, burns, inhalation of dust, contamination in case of ''dirty bombs'' or penetration of allogenic body parts shrapnel. this last one asks the question of contamination by hepatitis or hiv and modalities of surveillance and treatment. conclusion: blast injuries are complex and require the expertise of surgeons for their evaluation, treatment and longterm recovery. the victims of this form of terrorism sustain unusually severe and complex multidimensional forms of trauma not typically encountered in routine surgical practice. surgeons must be leaders and active participants in disaster planning and management; they are uniquely qualified to manage the physical trauma that results from most forms of mass casualty events, including blasts. disclosure: no significant relationships. a. s. dogjani general surgery, military university central hospital, tirana, albania introduction: as the risk of terrorist attacks increases in the world, disaster response personnel must understand the unique pathophysiology of injuries associated with explosions and must be prepared to assess and treat the people injured by them. the explosions at the army depot in gerdec village, some km north of tirana, were heard more than km ( miles) away. introduction: during the last decades there is a debate concerning the fact if the facial fracture can cause further damage or somehow to protect the brain parenchyma from a more severe injury. the aim of our study is to analyze the effects of facial trauma exerted upon brain parenchyma. material and methods: a series of patients with craniofacial fractures was studied. the injuries were separated into five grades of severity based on neurological examination including cranial ct. the injuries was also grouped into three categories based of facial regional involvement ct -facial reconstruction results: the control group included patients with head trauma but without any facial fracture or brain injury. in group a included ( , %) patients with both facial fracture and brain damage.among them diagnosed with temporal-mandibular fractures accounting for , %, patients( , %) had lower mandibular fracture, patients ( , %) diagnosed with nasal fractures and patients ( , %) had orbital fractures. in group b were categorized patients with only brain damage accounting for %. conclusion: the data demonstrated that patients with upper facial fractures were at greatest risk for serious closed head injury (chi).injuries to both the mandibular and the midfacial regions with no upper facial involvement more frequently resulted in mild chi with a modest likelihood of no neurological deficits. trauma to only the mandibular region or to only the midfacial region was least likely to involve chi disclosure: no significant relationships. introduction: post-traumatic stress disorder (ptsd) is a psychiatric disorder that results from exposure to a traumatic event. the individual may develop symptoms of three distinctive types: intrusive and unwanted recollections, avoidance followed by emotional withdrawal, and heightened physiological arousal. people who are exposed to traumatic events may also have somatic symptoms and physical illnesses, particularly hypertension, asthma and chronic pain syndromes. hospitalized victims of suicide terror attacks are unique due to the circumstances and severity of their injuries which could have possibly affected the occurrence of ptsd and delayed the recognition of ptsd development. our objectives were to evaluate the prevalence and severity of ptsd among hospitalized victims of suicide bombing attacks and to assess variables of physical injury as risk factors for the development of ptsd. material and methods: forty-six hospitalized victims of suicide bombing attacks were evaluated for ptsd using the pss-sr questionnaire by phone. demographic and medical data considering the severity of injury, type of injury and medical treatment were collected from the medical files. injury severity scale (iss) was used to assess severity of physical injury. results: the prevalence of ptsd among hospitalized victims of suicide bombing attacks was . %. presence of blast lung injury was significantly higher in the ptsd group compared with the non-ptsd group ( . % vs. . % respectively, p < . ). there was no significant difference in iss values between ptsd and non-ptsd groups. blast lung injury and intracranial injury were found to be predictors of ptsd (odds ratio and , respectively). no correlation was found between length of hospital stay, length of icu stay or severity of physical injuries to the severity of ptsd. conclusion: hospitalized victims of suicide bombing attacks are considerably vulnerable to develop ptsd. they should be evaluated with a high level of suspicion in order to identify ptsd symptoms and treated as soon as possible in conjunction with physical treatment. blast lung injury and intra cranial injury are predictors of ptsd. victims suffering from these conditions should be monitored closely and treated in conjunction with their physical treatment. conclusion: from the use of the smart adopted for the evaluation of the code of entrance in emergency department, we have deduced and confirmed the facility and the speed of use of this new model of triage. the triage smart typically holds not only besides in consideration the traumatic pathologies but also internists that, it is an usable advanced triage both on the territory and in the hospital. we can classify the model smart triage as a valid system in case of a disaster as is reliability and sensibility of assessment of patients result to be more appropriates in comparison to the other models of triage taken in examination. conclusion: we showed that alcohol, massive bleeding needed blood transfusion and age were risk factor of trauma and japanese emergency medical technician attendance was effective for trauma care. we suggested the reason of detachment by the injury form was that japanese penetrating wound include many stub wound not gun shot wound. introduction: rapid aging of japanese population is causing numbers of emerging problems in trauma patients care which consists of trauma in elderly people and increased pre-existing co-morbidities such as cardiovascular diseases, neoplasms and organ failures. nevertheless, little is known about the relationship between co-morbidities and trauma. the aim of the study was to clarify the influences of co-morbidities on the trauma mortality, using data from the japan trauma data bank (jtdb), a multicenter, nationwide and prospectively recruited trauma registry in japan. material and methods: we selected the records from jtdb which fulfilled the requirements to estimate trauma injury severity score (triss) system. logistic regression analysis after adjustment for baseline trauma severity based on triss system assessed the risk of in-hospital trauma death for following co-morbidities: hypertension (ht), diabetes (dm), psychotic disorders (pd), dementia (de), stroke (st), chronic obstructive lung diseases (cold), bronchial asthma (ba), coronary diseases (chd), congestive heart failure (chf), liver cirrhosis (lc), chronic hepatitis (ch), chronic renal failure on dialysis (crf) and active cancer (acn). we conducted a couple of analysis which were adjusted or unadjusted by age in consideration for confounding between co-morbidities and elderly in age. introduction: monitoring the quality of trauma care is frequently done by analyzing the preventability of trauma deaths and errors during trauma care. in the academic medical center traumatic deaths are discussed during a monthly morbidity and mortality meeting. in this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a dutch level- trauma center for (potential) preventability. material and methods: all patients who died during or after presentation in the trauma resuscitation room in a two year period were eligible for review. all information on trauma evaluation and management was summarized by an independent physician. an external multidisciplinary panel individually evaluated the cases for preventability of death. disagreements in classification were resolved during two consensus meetings. potential errors or mismanagements during the admission were classified for type, phase and domain. overall agreement on (potential) preventability was compared between the panel and the amc consensus. results: of the evaluated trauma deaths one was judged preventable and were judged as potentially preventable by the review panel. overall agreement on preventability between the review panel and the amc consensus was moderate (kappa . ). the classification of the panel was more favourable than the amc consensus. the interobserver agreement between the review panel members was also moderate (kappa . ). the panel judged errors to have occurred in the (potential) preventable death group and errors in the non-preventable death group. most frequently mentioned errors were related to choice or order of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies. conclusion: the preventable death rate in the present study was comparable to the available literature. external review does not seem necessary to improve our current internal reviewing system. however, multidisciplinary reviewing of our trauma deaths provided us potential insights to optimize trauma care. disclosure: no significant relationships. arab emirates (uae). the aim of this paper is to report on the long term effects of our early analysis of this registry. material and methods: data in the early stages of this trauma registry were collected for patients during a period of months in . data was collected on a paper form and then entered into the trauma registry using a self-developed access database. descriptive analysis was performed. results: most were males ( %), the mean age (sd) was . ( . ). uae citizens formed . %. road traffic collisions caused an overwhelming . % of injuries with . % of those involving uae citizens while work-related injuries were . %. the early analysis of this registry had two major impacts. firstly, the alarmingly high rate of uae nationals in road traffic collisions standardized to the population led to major concerns and to the development of a specialized road traffic collision registry three years later. second, the equally alarming high rate of work-related injuries led to collaboration with a preventive medicine team who helped with refining data elements of the trauma registry to include data important for research in trauma prevention. conclusion: analysis of a trauma registry as early as six months can lead to useful information which has long term effects on the progress of trauma research and prevention. disclosure: no significant relationships. as a result of injuries related to skating on natural ice. we analysed epidemiological aspects, diagnostically examinations, prevalence of injuries per anatomical location as well as the necessary therapeutic interventions and costs for national health services. results: injuries related to skating on natural ice accounted for % of all attendances. the mean age for man and women did not significantly differ ( , and , years resp.; p < . ), but adults aged - years are more prone to injuries. women were affected in %. radiological examinations were requested in % ( % xrays; % ct-scans). the upper extremity was affected in %, with the wrist accounting for % of those injuries. fractures accounted for % of all ice-skating related attendances. an operative therapy was indicated in %. the mean costs for national health services were e per patient. conclusion: fractures, especially those of the upper extremity, were the predominate type of injury as a consequence of collectively performed skating on natural ice. this incidence is > times higher compared to fractures occured during skating on artificial ice-rinks [ ] . wearing wrist guards is an effective tool in protecting skaters against injuries. we recommend wearing wrist guards during skating on natural ice [ , ] . especially (employed) adults aged - years are very prone to injuries resulting in a high loss of work days [ ] . in contrast to children, adults might be more accessible for wearing protectors [ ] . in future it seems reasonable for national health services to provide steps to increase public awareness on the benefits of prophylactic safety measures. this might result in a substantial reduction of costs for health care and society. introduction: liver cirrhosis has been shown to be associated with impaired outcome in patients who underwent elective surgery. we therefore investigated the impact of alcohol abuse and subsequent liver cirrhosis on outcome in multiple trauma patients. material and methods: using the multi-center population-based trauma registry of the german society for trauma surgery, we retrospectively compared outcome in patients (iss > = , > = ) with pre-existing alcohol abuse and liver cirrhosis with healthy trauma victims in univariate and matched-pair analysis means were compared using student's t-test and analysis of variance (anova) and categorical variables using chi (p < . = significant). results: overall , patients met the inclusion criteria and were, thus, analyzed. ( . %) patients had a documented alcohol abuse and ( . %) suffered from liver cirrhosis. patients abusing alcohol and suffering from cirrhosis differed from controls regarding injury pattern, age and outcome. more specific, liver cirrhotic patients showed significantly higher in-hospital mortality than predicted ( % vs. predicted %) and increased single-and multi organ failure rates. while alcohol abuse increased organ failure rates as well this did not affect in-hospital mortality. of note, alcohol abuse significantly decreased -hour mortality. conclusion: patients suffering from liver cirrhosis are at maximised risk for impaired outcome after multiple injuries. pre-existing condition such as cirrhosis should be implemented in trauma scores to assess the individual mortality risk profile. introduction: early in-hospital treatment of severely injured patients has been internationally standardized by the implementation of algorithms such as the atls Ò -concept. however, due to lack of time, the instability of the patients and the complexity of injuries, there is a risk that some lesions will be missed at this stage. the purpose of our study was to evaluate the incidence and significance of these missed injuries. material and methods: retrospective chart analysis (in-hospital and follow-up as outpatient) of data prospectively collected via an accessÒ-based documentation system was performed. missed injuries were determined as injuries not found during primary and secondary survey. introduction: complication registration is important for monitoring the quality of health care. aim of this article was to describe the incidence, type and impact of complications occurring within months after the initial trauma in multitrauma patients. second, we assessed potential risk factors for the occurrence of complications. material and methods: during a -year period all trauma patients presented to the academic medical center and having an injury severity score of ‡ were included. patients who were directly transferred to other hospitals were excluded. we used the prospective dutch national surgical complication registry of the amc, a level- trauma center, to assess complications within months after the initial trauma. for verification we additionally performed a chart review and searched the decubitus specialists-and icu registration. complications were graded (no real health loss) to (lethal). identification of risk factors associated with an increased risk of complications was performed by univariate analysis. we also analyzed an autopsy findings of these patients and found that of ( . %) had a difference between clinical and autopsy iss. the most frequent missed injury were rib fractures. six of these patients were hospitalized in a period when we did not use msct routinely in multiple injured patients. conclusion: triss is not a clinical prognostic tool but is used retrospectively for clinical and epidemiological research, performance evaluation, and resource allocation. it is required as a basis for quality assessment and improvement. in combination with autopsy findings, triss methodology can be an valuable tool for recognition of unexpected trauma deaths and further analyze of possible treatment errors. patients had to be operated , times and were treated days in the icu and stayed days in hospital. mortality rate was % and rate of multi-organ failure %. % demonstrated severe senso-motoric dysfunction as well as residues of severe head injury. % recovered well or at least moderately. out of survivors answered the polochart. a personal interview was performed with patients. the state of health was at least moderate in % of patients. in % interpersonal problems and in % severe pain was observed. in % problems in working ability concerning duration, as well as quantitative and qualitative performance were observed. symptoms of post-traumatic stress disorder were found in %. the more distal the lesions were located (foot/ankle) the more functional disability affected daily life. in only %, working ability was not impaired. out of interviewed patients demonstrated complete work disability. conclusion: even severely injured patients after polytraumatization have a good prognosis. the iss is an established tool to assess severity and prognosis of trauma, whereas prediction of clinical outcome cannot be deducted from this score. introduction: one of the most common cause of preventable deaths in severe trauma is represented by delay in diagnosis and treatment of injuries, therefore a good teamwork aimed to reduce time consumption and errors is essential. there is in fact good evidence that the outcome of trauma care depends on effective trauma team performance (ttp). critical points during trauma management are represented by lack of leadership, information sharing, difficult communication and decision making. to improve ttp, advanced simulators with full scale realistic patients ( ) and trauma crew resource management (crm) educational programmes are increasingly being used. material and methods: we made a survey among health care professionals (hcp) from different level i and level ii trauma centers in the milan area that confirmed that difficulties in communication and conflictual behavior during trauma action is perceived as a barrier to ideal management. after a focus group interview to establish the need to improve performance we tested in our hospital a tailored trauma teamwork course using an advanced human patient simulator. the peculiarity of this course is the recreation of the same location of the trauma bay using same trauma team components and teamwork laboratory conducted by a professional coach as facilitator for the teamwork. this role is particular important since with this facilitation hcp can reach the awareness of wrong attitudes that lead to errors and bad performance. in particular, the tasks of the facilitator were the following: to help people understand their common goals to assists the trauma team to plan to achieve common goals to assist the group in achieving a consensus of any disagreements that preexist or emerge in the meeting so that it has a strong basis for future action a second survey few months after the course was made among hcp of our institute to evaluate the possible improvement of the ttp. results: the second survey confirmed a perceived benefit among hcp who started to work in a proactive manner. in particular % of hcp reported the feeling of a better ttp and % suggested regular practice with advanced simulation. conclusion: integration of a tailored advanced simulation and a facilitator assisted teamwork could be a powerful method to improve quality of treatment in trauma patients. a score index to evaluate the improvement of the ttp during the course and in reality is although needed and is under evaluation. introduction: our university hospital is one of the only two national university hospitals in tokyo and our emergency medial center is one of the busiest emergency center in japan that receives to ambulances per day. japan has a quite unique emergency medical system in the world. in japan, emergency patients are stratified into tiers, minor-primary, moderate-secondary, severe-tertiary. japanese emergency doctor, that is not same as the emergency physician in the usa, take care only for the most severe emergency cases, tertiary level emergency patients. and if they find out the patient who needed an emergency operation, then they do the surgery by themselves. if the patients need to admit to icu, they take care the patient in icu by themselves. this unique system was installed in mid- s. japanese emergency doctors do not only trauma cases, but also nontrauma severe emergency cases. for talking about trauma, they do not only the initial management of trauma patients but also do emergency surgery and trauma critical care. the mou came into effect with the signatures of the appropriate representatives, acknowledging that four courses had been run in portugal prior to its signature and that all future courses would be conducted in accordance with the essential requirements established by iatsic. in practical terms, the first two courses run after signing the mou must be of the form and nature as laid down by iatsic. thereafter, variations as determined by the nsc may be allowed. the slide material will be provided ''locked''. after the two initial courses, the ''unlock'' code will be provided. details of all modifications must be lodged with the iatsic. nsc will be responsible for ensuring the maintenance of high standards in the conduct of all courses and the selection of participants, ensuring that they meet the minimum standards as laid down by iatsic. nsc is entitled to appoint two representatives at international subcommittee meetings. introduction: clinical skills must be to the fore of medical occupation, especially in surgery, where the mastery of basic skills is of great importance for the young learner. the acquisition of basic clinical skills during surgery clerkships has been shown to be inadequate. this work presents an analysis of different teaching methods in a standardized training program for basic clinical skills in surgery. material and methods: the program is part of a four week surgical rotation for th year medical students, consisting of the one-week training program in basic surgical skills and a three-week clerkship on surgical ward. during the skills training, a maximum of students per group rotate through modules. in a randomized study, the effects of different teaching modalities as skills lab, simulation and role play, as well as different teaching methods as four-step-approach, short-lecture, video were tested on their effect on theoretical and practical skills acquisition. results: a total of students participated on a voluntary basis. the theoretical and practical examinations revealed significant differences in the acquired skills comparing the different teaching modalities and methods. the use of video as part of the -step approach was effective for training the basic skills such us suturing and wound care. least effective for all skills were short-lectures. conclusion: the choice of teaching modality and method has a significant impact on students' skills acquisition and its long term retention. disclosure: no significant relationships. training in trauma center: where to pay attention to? l. handolin traumatology, helsinki university hospital, helsinki, finland introduction: systematic trauma team simulation training was started in helsinki university hospital in . in terms of getting the optimal advantage of training and maintaining the justification of resource allocation, an advantageous balance in various team training principles has to be applied. the aim of the present study was to analyze the standardized written feedback given by trainees after training sessions. material and methods: the study period was three years ( ) ( ) ( ) . the collected data consisted of a subjective self-assessment on the level of knowledge, skills, and team work in traumaresuscitation. also a selfassessment on the effect of training on decision making, communication, skills, team work, and leadership, as well as a general rating of training session were collected. self-assessment was done using five step scoring system from one to five. results are presented as means. conclusion: the actual evaluated interspinous devices led to a significant reduction of rom during flexion-extension, but to a significant increase of rom for the whole specimen (l -l ) during lateral bending and rotation, which increases the risk of adjacent level degeneration. therefore the decision for the optimal individual treatment should be made on the knowledge of the biomechanical effect of each device and the underlying disease of the patient's symptoms. introduction: gait analysis is a powerful tool to monitor the degree of convalescence in fracture care after fracture fixation and during bone healing. because of the availability of a large array of monoclonal antibodies and gene-targeted animals, the mouse has become the preferred species for molecular studies on fracture healing. of interest, gait analysis after fracture fixation and during the bone healing process has not been performed in mice yet. we present a novel technique for dynamic gait analysis in mice and report the change of motion pattern after femur fracture and fixation. materials and methods: all animal procedures were performed according to the national institute of health guidelines for the use of experimental animals and were approved by the german legislation on the protection of animals. ten cd- mice were divided into two groups: fracture group (n = ) and control group (n = ). all mice were anesthetized by an i.p. injection of xylazine ( mg/bw) and ketamine ( mg/bw). a standardized closed midshaft fracture according to ao-classification a -a was stabilized by a common pin. the non-fractured tibia was additionally marked with a pin, allowing a measurement of the tibio-femoral angle by a digital videoradiography system recording images/s. for the control group, one pin was inserted into the femur and one into the tibia without producing a femoral fracture. dynamic gait analysis was performed at day fourteen after surgery in a x-ray compatible running wheel and the following gait parameters were determined: the minimum and maximum tibio-femoral angle, the stride frequency, the stride time, the stride length and the stride velocity. eighteen representative strides per mouse were analyzed. all measurements were done using osirix imaging software and the open source program imagej. all data are given as means ± standard error of the mean (sem introduction: single distal locking screw insertion had been accepted as an option in clinical practice of femoral nailing. however, effect of number and location of the screw on rotational stability of the construct was still doubtful. therefore, this experimental study was conducted to compare rotational stability of the femoral nail construct among three different conditions (two distal screws, single distal screw in different locations). materials and methods: eight right femoral sawbones were selected for this study. each of which was implanted with gk femoral interlocking nail ( · mm) and a static proximal locking screw follow by single distal screw insertion in the most distal screw hole. then, transverse osteotomy was performed at the mid-shaft to simulate simple fracture. after the femur was stabilized on the custom holding jig, rotational force was applied to the femoral condyle by using a torque wrench connecting to the distal part of the jig starting from to nm in nm increment. total rotational angle in each situation was measured by modification of navigation system. thereafter, testing protocol was repeated to the same specimen but two distal locking screws and single distal locking screw in the most proximal screw hole, sequentially. different angle in each testing condition was compared among the different constructs by using paired t-test. results: rotational stability was significantly better in the group of two distal locking screws in every testing condition (p < . ). single distal screw in the most proximal screw hole provided more rotational stability than that in the distal screw hole at nm (p = . ). conclusion: this study demonstrated that two distal locking screws provide more rotational stability than single screw in the case of simple mid-shaft femoral fracture stabilized with interlocking nail. if single distal screw was considered, insertion in the most proximal hole would be a better option in term of rotational stability than that in the most distal hole. introduction: the exothermal reaction of pmma leads to an extensive interaction between the bone cement and the plastics of the application system. this chemical reaction changes the structure of the bone cement and especially makes air pockets. it is necessary to develop application systems with a special composition of the plastics so that there is no interaction between the cement and the application system. in this study a new application system is presented for the first time which does not interact with the bone cement. materials and methods: two different application systems for bone cement were tested in this study. one popular and frequently used system made of polyethylene and a new system made of polypropylene. a special testing unit, in which the application systems were mounted, was used. the testing unit worked with a certain pressure so that a defined amount of bone cement was injected. the resistence data and the time were digitally collected and statistically evaluated. in all procedures were carried out. after the injection all application systems and the injected bone cement were microscopically analyzed. results: two groups, old versus new application systems, were divided. both groups showed significant differences. when using the old application systems made of polyethylene the time frame for injection of the cement was min while the time frame with new system made of polypropylene was min. microscopically there is a significant interaction between the plastics and the cement in the old systems with massive air pockets. in contrast there is no interaction, no air pockets and a homogeneous pattern of the cement when using the new systems. conclusion: the new application system made of polypropylene showed a significant longer time frame for application of the cement as well as no interaction with the plastics. it is possible to treat more than one localization with one application system which makes it financially rewarding. additionally there are no air pockets reducing the danger of infection und increasing the structural stability of the bone cement. introduction: femoral neck fractures are common fractures. despite the frequency of this fracture and the consequences associated with it, little is known about the functional changes that can be expected during and after rehabilitation. the aim of this study was to identify prognostic factors for functional outcome, using a modified harris hip score, after a femoral neck fracture treated with an arthroplasty. materials and methods: we included patients who sustained a displaced femoral neck fracture treated with an arthroplasty. functional outcome after surgery was assessed using a modified harris hip score, and was evaluated after (hhs ) and (hhs ) years. we analyzed the following prognostic factors for functional outcome of patients after treatment of femoral neck fractures with an arthroplasty: age, pre-operative co-morbidity, asa-score, type of arthroplasty (hemi-or total hip replacement), surgeon experience (resident or attending surgeon), interval between trauma and operation, blood loss, direct (associated with the arthroplasty) peri-and post operative in-hospital complications related to the arthroplasty and general post operative in-hospital complications. to challenge the outcome of the analyses we used the cronbach's alpha coefficients for testing the internal consistency. results: after one year the existence of co-morbidities ( ‡ ) was a significant predictor for a poor functional outcome. with and without co-morbidities the mean hhs was . and . , respectively. after years all potential prognostic factors did not have significant influence on the functional outcome. to further analyse this outcome, internal consistency of the hhs was assessed. when pain and function of the hhs were analysed together the internal consistency was poor (hhs : . and hhs : . ). the internal consistency of the harris hip score solely in function (without pain) improved to . (hhs ) and . (hhs ). when the potential prognostic factors were analysed with only the functional aspect, age and the existence of co-morbidities could be defined as a predictors for the functional outcome of femoral neck fractures after and years (r and % resp). conclusion: pain has such a dominant position in the harris hip score that even immobile patients without pain can obtain a reasonable hhs score. the hhs, with the omittance of pain, is therefore a more reliable score to estimate the functional outcome. after using the hhs in this modification, age and the existence of preoperative co-morbidities appeared to be predictors of the functional outcome after and years. many studies have shown that delay to theatre beyond h has an associated increased risk of morbidity and mortality in this cohort. our data revealed that there is certainly room for improvement regarding treated more patients within the h guideline however, there will always be a group of patients whom medical input is required prior to surgical management. lack of theatre time appears to be a significant administrative reason for delay. this is an area of potential improvement however it must be noted that any system of this nature will carry an intrinsic delay in processing. . x-rays and post-op data were analyzed on displacement, postoperative reduction, loss of reduction, and avascular necrosis (avn) and revision rates. high volume surgeons were defined as surgeons who performed > fixation procedures for proximal femoral fractures annually. results: mean age ( vs. years) and percentage of fracture displacement ( vs. %) were equal in both groups. re-operations following loss of reduction or infection was seen in ( %) patients. less frequent complications were avn ( %), coxarthrosis ( %) and pain due to screws bulging out ( %) led to a total conversion rate to arthroplasty in %. displaced fractures show a higher rate in loss of reduction ( %, p < . ) and revision ( %, p = . ) than non-displaced fractures ( . %; . %). patients > years showed % loss of reduction, % avn and taking the reoperations due to coxarthrosis and pain into account, a total revision rate of % was seen compaired to , , and % in younger patients. radiological analyses revealed that the lack of medial support lead to revisions in % of the cases, dorsal angulation in %. low volume surgeons did not perform worse than high volume surgeons. the latter group showed % loss of reduction, % avn and total revision rate %, compared to , and % in the low volume group. we found no differences in the outcome of treating displaced fractures. conclusion: the outcome of fixation of femoral neck fractures is poor. especially displaced fractures, inadequate fracture reduction and high age were associated with poor outcome. therefore, arthroplasty should be considered in patients older than years with displaced fractures that cannot be reduced anatomically. we could not demonstrate that high volume surgeons performed better in this group but we are convinced that further specialization of care is mandatory to improve results of this unsolved fracture. ( ) ( ) ( ) ( ) . internal fixation has shown to provide minor results. the majority of these patients are therefore treated by a hemiarthroplasty of the hip. since the primary goal is to regain the pretraumatic level of mobility as soon as possible( ; ), we sought to investigate, if a minimal invasive anterior approach would be beneficial in regard of perioperative blood loss ( ), postoperative pain( ; ) and thus postoperative mobility ( ) . material and methods: in a randomised controlled trial, patients were treated by a hemiarthroplasty of the hip via an anterior or lateral approach in supine position within hours after trauma( ). apart from parameters like age, asa-score or body-mass-index, the main focus was set on perioperative blood loss, pain and postoperative mobilisation. all data collected were compared between groups to detect statistical significant differences. additionally the same parameters were checked for significant differences comparing patients with or without complications within their group. results: a significant difference between groups was found for postoperative pain within the first hours and for operation time, both to the disadvantage of the minimal invasive approach group. within groups, time of operation and patient's age were significantly higher in patients with complications in the minimal invasive group such as pain at hours was rated higher in patients with complications in the lateral approach group. these results though did not seem to influence postoperative mobility since no significant differences were found between groups at follow-up. conclusion: despite some differences in the postoperative course, postoperative mobility does not seem to be greatly influenced by the choice of the approach for hemiarthroplasty of the hip in femoral neck fractures. still, the operation time was significantly linked to postoperative complications. in this respect, it can be concluded, that the approach an individual surgeon is most familiar with is likely to lead to best results. of the patients, ( . %) received a formal assessment for antiresorptive therapy. the outcomes of this assessment is as follows: . % did not require any antiresorptive therapy, . % awaiting bone clinic assessment on discharge, . % awaiting a dexa scan, . % of patients were started on antiresorptive therapy and % were continued on antiresorptive therapy from pre-admission. conclusion: our study highlighted that in our trust only . % received this assessment formally. we can conclude that when this assessment occurs the guidelines and hence subsequent fragility fracture secondary prevention is addressed. we have then presented this data locally and amended our integrated neck of femur documentation pathway to include a section on antiresorptive therapy assessement. to follow this up we plan to re-audit from st january to st january . in the upper thoracic spine / ( %) could be placed with navigation, / ( %) were controlled intraoperatively. occasionally, scan-setup was problematic, in addition, we experienced technical problems. correct placement was seen for each screw, thus correlating well with theintraoperative findings. conclusion: the application of the combination of intraoperative d-imaging and navigation for posterior instrumentation of the cervical and the upper thoracic spine is technically feasible and reliable in clinical use. user-and software-dependant sources of error could be solved during the first course of the series. image-quality at the cervical spine is depending on individual bone density, and possible metal artifacts. with undisturbed visibility of the vertebral body, the reliability of d-based navigation at the cervical spine is comparable to that of ct-based procedures. additionally, it has the advantage of skipping preoperative acquisition of data as well as thematching-process. furthermore, exposure to radiation is reduced due to the possibility of sparing pre-and postoperative ct. disclosure: no significant relationships. the average lka measurements in order were: . °, . °, . °( p < . ), and for aca: . °, . °, . °(p < . ). while a significant difference between the averages of lka, e/f of group and group (p < . ), no statistical difference was found comparing the average aca angle (p = , ). while there was no significant change in e for all groups (p > . ), the increase in f after surgery was considered significant (p < . ), and no difference was observed between the averages of group and group (p > . ). vas was . ( - ). conclusion: at the end of an average year follow up period of posterior tl fractures no difference was found between the early and late period measurements of aca and anterior height although lka showed a statistical loss in height the correction degree achieved in the late period was found to be significantly higher than preop. ( cases), crushing without skeletal injuries ( cases) in all these cases, pulse was present at the first evaluation, and the onset of acute post-traumatic ischaemia was at - hrs after trauma . tha diagnosis, based on clinical suspicion, became definite after doppler evaluation and arteriography. the anatomical base of ischaemia was late thrombosis ( cases) and compressive hematoma ( cases). thrombosis was due to obstruction of the big arteries ( cases) and microcirculation, due to overrun compartment syndrome- cases.vascular restoration and fasciotomy was performed whenever muscles were viable, but amputation was necessary in cases results: the patients were analysed from the point of view of the corelation between the moment of onset of the ischaemia, the type of injury, the status of the muscular structures, the algorithm of diagnosis, the type of the treatment, and the clinical outcome. the study revealed that the clinical outcome was better when the time between trauma and ischamia onset was less, since the muscular ischaemic had less time to develop. in the same time, there were cases in which clinical symptomes were not corresponding to the imagistic evaluation. conclusion: high energy trauma affect all the structures of the limbs. clinical suspicion has particular importance especially when trauma affects one of the regions which is known as establishing a dangerous environment between the arteries and the bones / joints. in all the cases that authors analyse, complete and early diagnosis and treatment of acute post-traumatic ischaemia, based on the close monitoring of the patient and '' clinical alarm signs '' seemd to be the conditions for the favourable outcome of the patients. introduction: the aim of presentation is to demonstrate the surgical treatment and postoperative period of a patient who was caught on a fence-pole and suffered severe injuries of perineal region and lower extremity. material and methods: after a long time of technical rescue the patient arrived to our department with a one meter long portion of fence in his perineal region. after the urgent extraction of metal fence we performed an intraoperative rectoscopy. during the debridement and exploration of deep perineal injuries we realised a heavy swelling around the punctated wound of the left leg. we made a femoral incision and exploration and recognised the several injury of the femoral vein and artery. we provided the cm long injuries with stitches. results: in the postoperative period we made a second-look and debridement because of lymhphatic retention and small skin necrosis around the incision. no real vascular or circular lesions were recognised during the control period of the patient. injuries were totally improved. conclusion: the edification of this case is that it's never sure that the major wound makes the biger trouble to the patient or to the surgeon. in our presentation we plan to demonstrate the intra -and postoperative pictures and the results of controll period. results: the incidence of various types of trauma were blunt in patients ( %), gunshot wounds in patients ( %), and stab wounds in patients ( %). only ( %) patients were hemodynamicaly stable. isolated abdominal vascular trauma was detected in patients ( %). vessels injured included aorta ( , %), inferior vena cava ( , %), named visceral arteries ( %), named visceral veins ( %), iliac arteries ( , %), and iliac veins ( , %), epigastric, hypogastric, intercostal arteries ( , %), epigastric, hypogastric, intercostal veins ( %), gonadal vessels ( %), renal veins ( %), non-named mesenteric vessels with segmental bowels necrosis ( , %). two or more vascular injuries were found in ( , %) patients. according to organ injury scaling, st grade injuries were found in ( %), nd -in ( %), rd -in ( %), th -in ( %), and th -in ( , %) patients. the most frequent associated injuries were small bowel - , liver - , colon - , stomach , duodenum - , diaphragm - , pancreas - , spleen - , with an incidence of %, %, %, , %, , %, %, % and , % respectively. all injuries were managed according to injury score. infrarenal v. cava ligation was performed in all cases of hemodynamic instability. minor named abdominal vessels were ligated in all cases. segmental intestinal resection was performed in all patents with th grade of intestinal injuries due to devascularisation. overall mortality rate was %. the vessels with the highest mortality rates were inferior vena cava ( % - / ). there were no mortalities in isolated abdominal vascular trauma patients and in cases of st grade of injury. mortality rate in accordance to ois was: nd - patients ( %), rd - patients ( , %), th - patients ( %), th - patient ( %). no differences in mortality rate were found according to type of trauma (blunt or penetrating). the associated injuries with the highest mortality rates were pancreas ( / - %), diaphragm ( / - , %), liver ( ( ), a rupture of the heart ( ) or a aneurysma dissecans with a rupture of the aorta ( ). in addidtion to the detailed forensic examination and autopsy, we took the anthropometrical measurement of all corpses in dimensions, so that we were able to create a biomechanical simulation of the accidents with ''finite element models''. there the shear forces affecting the aorta can be calculated. as three forces (frontal impact, side impact and deceleration) are the most important, we will present three comprehensible example accidents. the reason of death is always the ''aortic rupture'', but every time the biomechanical way of application of the force was completely different. in detail they are a car accident (frontal collision of a small car with a wall); a downfall from the height of meters in suicidal purpose and a compression of the thorax of a eight year old boy with a shovel of an excavator. results: although all three accidents have completely different course of crash, we were able to see the same reason for death: a rupture of the aorta at the onset of the ligamentum arteriosum botalli. by using the numerical simulation, it can be shown that three main directions of force are important in an accident: the frontal impact, the side impact and the deceleration. in all these examples, it was able to simulate the reaction of the aorta in relation to the development of the force. the simulation will be presented as well as all clinical treatement made by the medical stuff. conclusion: although the rupture of the thoracic aorta is a frequent cause of death, the injury mechanism has not been comletely known. a database with several victims of aortic ruture was created and special accident types will be presented and simulated. introduction: overlooked compartment syndrome represents a catastrophic complication for patients and orthopedic surgeons. invasive compartment pressure measurement continues to be the gold standard. however, repeated measurements in uncertain cases can be difficult to achieve. we, therefore, developed a model for a noninvasive technique to assess tissue pressure by ultrasound based elastography. material and methods: a perforated plastic tube filled with saline was surrounded by a silicone sealed plastic cover, mimicking the shape of the tibial compartment. a pressure transducer inside the compartment was installed. a second pressure transducer was installed on the ultrasound probe to allow simultaneous monitoring of the pressure inside the compartment and the tissue deformity. for calibration, ultrasound images were generated at and mmhg. the plastic cover to tube distance was measured before and after compression (delta d). subsequently, increments of mmhg pressure increases were used to generate a standard curve ( - mmhg), thus mimicking rising compartment pressures. the intra-observer reliability was tested by using subsequent measurements. a correlation was determined between the skin to bone distance (delta d) and the pressure measurement (p). the pearson correlation coefficient was calculated, and a regression analysis was performed. ( ), better antibiotics and computed tomography-guided percutaneous drainage ( ). however, when everything else has failed, the burder of decision making the choice of a 'last resort' operation will be shifted again to the surgeon. we here described our recent experience with such cases treated by abbreviated laparotomy using the bogota bag technique ( ). results: for the seven first patients, we performed colon resection with colostomy. after extensive debridement, lavage and drainage, the peritoneal cavity was closed with a sterile gastric bag sutured on the rectus aponeurosis according to the so-called bogota-bag procedure ( ). the mean operative time was minutes. a second look laparotomy was planned after hours: one patient required one reexploration, four patients required two and two required three. the decision of re-exploration was based on the visual aspect of the peritoneal content, the clinical evolution and the bacteriologic results. for the last three cases, we elected perform colon resection without colostomy followed by anastomosis in two patients in the second look laparotomy and colostomy in one because of two relaparotomies. none of the ten patients required further percutaneous drainage. two patients died in multiple organs failure (one with perforated diverticulitis and one with ischemic colon after aneurysm repair). conclusion: abbreviated laparotomy with temporary closure of the abdominal wall associated with planned re-exploration of the peritoneal cavity is a simple and effective way to treat patients with severe abdominal sepsis. introduction: pelvic fractures usually are the result of high energy trauma and such patients often have many associated injuries. long term outcome data of pelvic injury patients is sparse, we present our information with special emphasis on poly-trauma patients, with consideration for the combined involvement of associated injuries on functional outcome. material and methods: general functional outcome and clinical outcome were determined with an examination by a physician and patient assessment at a minimum of years after the injury. pelvic fracture patients that had suffered poly-trauma were categorized by fracture location: acetabular, pelvic ring, or a combination. results: the long term outcome in the patients with pelvic ring fractures (exclusive of acetabular fracture) was the worst clinically, as evidenced by evaluation of pain( . %), increased use of special medical aids( . %), a poor merle d'aubigne score( . %), and worse sf- and haspoc scores. patients with acetabular fracture had poorer general functional outcomes than those with combined pelvic acetabular fractures and were noted to have higher incidence of associated injuries such as type iv pipkin fractures. further subcategorization of pelvic ring fractures into anterior, posterior or combination showed specifically those patients with combined anterior posterior pelvic ring fractures had the worst long term outcome. conclusion: a combined anterior posterior pelvic ring injury accounts for the worst long term outcome of pelvic injury poly-trauma patients. we found that bilateral pelvic injury and particular associated injuries greatly influence long term functional outcome. disclosure: no significant relationships. material and methods: canulated screws were placed in human semi-cadaver models and plastic pelvis models in d navigated, d navigated and conventional matta technique. aim of this study was to evaluate intraoperative time, intraoperative radiation dose (fluoroscopy time, area dose product and images per screw) and accuracy (amount of exactly placed screws, mean deviation of tip placement and misplaced screws per group). results: the accuracy of d navigated procedures is significantly higher (p < , ) than in the conventional technique. there is a significant lower radiation dose in the navigated procedures (p < , ) for the operation team. the intraoperative radiation dose is increasing significantly from conventional method to d navigated to d navigated procedures for the patient (p < , ). there is a significant higher time per screw necessary for navigated procedures (p < , ). conclusion: the usage of flatpannel technology seems promising in d navigation. our data shows a benefit from using navigated procedures in transilliosacral screw placement. the higher precision and lower radiation exposure for the operation team show that d navigation is superior to d navigated procedures. the higher accuracy of the d navigated procedures renders a postoperative routine ct scan obsolete thus lessening the total radiation exposition of the patient. introduction: the purpose of this biomechanical study was to determine whether locking screws or smooth locking pegs optimize fixation of ao a distal radius fractures. material and methods: pairs of fresh-frozen human distal radii were used. ao a extra-articular distal radius fractures were created by removal of a -cm-wide dorsal wedge of corticocancellous bone centered cm from the articular margin of the distal radius and were fixed using palmar locking plates. the radii were divided into matched-paired groups for comparison. the side order, the fixation order and the testing order were randomized. the distal fragment in group i was stabilized with angular stable screws. the distal fragment in group ii was fixed with locking pegs. the proximal fragment in both groups was fixed with screws. the probes were tested with . nm for torsion and with n axial load for cycles each. stiffness was measured from the first cycles regarding torsion and axial load. then the differences of the stiffness were recorded during the remaining cycles. the wilcoxon test was performed, a value of p £ . was considered statistically significant. results: there were no statistically significant differences in the first load cycles within the eight matched pairs. after cycles the constructs with locking screws (group i) showed statistically higher stiffness values (p = . ) compared to the constructs with smooth locking pegs (group ii introduction: plate fixation of the odontoid process without c -c arthrodesis appears to a practicable option for the management of odontoid fractures that are not suitable for conventional screw fixation. although previous biomechanical works have evaluated the effectiveness of different odontoid screw fixation techniques, no study has quantified the mechanical stability of odontoid fixation by a plate device. the purpose of this study was to measure the mechanical stability of odontoid plate fixation using a specially designed plate construct, and to compare the results to those after odontoid single-and double screw fixation. material and methods: the second cervical vertebra was removed from fifteen fresh human spinal columns. the specimens were fixed to the experimental apparatus, with the load cell at the articular surface of the odontoid process. in a first test series, stiffness and failure load of the intact odontoid were measured. type ii odontoid fractures were created by °oblique extension loading at the articular surface of the odontoid process. afterwards, the specimens were randomly assigned to one of the following three groups: in group i (n = ) the fractures were stabilized using a specially designed plate construct, in group ii the fractures were fixed using two . mm cortical screws, and in group iii we used one regular . mm cortical screw. in a second test series, stiffness and failure load of the stabilized odontoid fractures were assessed for comparison and statistical analysis. results: group i (plate device) showed a significantly higher mean failure load than group ii and group iii. the mean failure load of group i after fixation of the odontoid fracture was % of the mean failure load that was necessary to create a type ii odontoid fracture, initially. comparing group ii (double screw technique) and group iii (single screw technique), there was no significant difference regarding the mean failure load. in both groups the mean failure load after odontoid fixation was approximately % of the mean failure load of the intact odontoid. statistical analysis also revealed a significantly higher stiffness of the stabilized odontoid after plate fixation, than after single or double screw fixation. conclusion: plate fixation of the odontoid process as an alternative procedure in certain fracture patterns provided a significantly higher biomechanical stability than the technique of odontoid screw fixation. using a specially designed plate construct fixed with two cancellous screws into the body of c and an additional cortical screw inserted in the odontoid process, % of the original stability of the intact odontoid was restored. single or double screw fixation of the odontoid only restored approximately % of the original strength. results: extension and flexion were not influenced of all implants significantly. all dynamic implants and also the rigid implant led to a significant increase of the mobility during side bending and rotation in the area of the adjacent segments. conurrently the cephaled adjacent segment (l /l ) showed a significantly higher mobility than the caudal adjacent segment (l /l ). conclusion: dynamic implants such as the interspinous spacer enlarge the mobility of the adjacent segments during side bending and rotation in a comparable size as the rigid implant. to this extent is to be assumed that reinforced adjacent degeneration cannot be prevented by the use of the interspinous spacer substantially. introduction: osteoporosis is a systemic skeletal disease characterized by reduced bone mineral density and disrupted microarchitecture of bone tissue. the most severe consequence of osteoporosis are osteoporotic fractures. these are mainly low-energy fractures, which anamnestically, clinically and radiologically differ from fractures in healthy bone. we tried to find the answer to a queston, whether it is possible, that osteoporotic compression fractures are single events, or if they represent a gradual, progressive vertebral collapse in patients with osteoporosis. we evaluated the forces, necessary for vertebral fractures, regarding the bone mineral density. material and methods: cadaver vertebrae were isolated with the approval of ethics committee. we mesured their bone mineral density and then subjected them to the stress-test. we used the computer-controlled hydraulic press and stress vertebrae to the fracture point and beyond, monitoring the deformation and the load. a sigma-epsilon diagram was constructed from the data. results: with the loading of vertebrae the pressure grew exponentially as a function of deformation to the breakage point. then we observe a plateau of saw-like shape, which corresponded to the progressive vertebral collapse. further deformation led to gradual compacting of vertebrae and we observed once again an exponential increase in pressure. this bone compaction is therefore the first mechanisms of fracture repair. the saw-like plateau form suggests progressive collapse of vertical trabeculae and their jaming into the horizontal, which then with the increasing deformation and load also fail. a similar phenomenon can be observed in the collapse of buildings during the demolition. (the - phenomenon). conclusion: unlike a high energy vertebral fractures, the osteoporotic fractures are presented as a gradual vertebral collapse. they take place parallel with the processes of bone reparation and remodelation. from this standpoint, osteoporotic fracture is unique. vertebral collapse increases the bone mineral density in the broken vertebrae, what is observed radiologically and densitometrically. repair of medium to large, but reparable, rotator cuff defects, augmented with a restore patch or not. patients have been randomly assigned to receive standard repair augmented with the restore implant or to receive non-augmented standard repair as the repair procedure is exactly the same in both patient groups, and the implantation of the restore implant does not necessitate any additional incision or measures, neither the patient nor the assessors are aware of the fact an implant has been used. the ethical committee of the university hospitals leuven has approved the study. all patients get full information and are enrolled in the screening program after written consent only. clinical evaluation, both pre-operatively and at months post-operative is performed by the same, independent physiotherapist trained in shoulder evaluation using the constant score structural evaluation is performed by ultrasonography, performed by a radiologist specialised in musculoskeletal radiology and sonography. unpaired two-tailed t tests, performed with prism software for mac osx, were used to compare the results of the scores in the control group with those in the xenograft group. fisher exact tests were used to evaluate the significance of differences in the proportions of retears in the patients for whom a sonography was obtained. results are expressed as the mean and standard error and significance was set at p < . . results: we included patients. there were female and male patients. in the non-augmented group there were females and males. in the restore group there were female and male patients. the average age of patients was years of age. in the non-augmented group the average age is , y (+/- , ) years of age, in the restore group , y (+/- , ). the mean pre-operative constant score of the non-augmented group was , +/- , points whereas it was +/- , points for the restore augmented group. post-operative the functional outcome months after surgery again was scored using the constant score. the mean score in the non-augmented group was +/- , points; in the restore group it was , +/- , points in the non-augmented group we documented a retear in / patients, in the restore group we had a retear in / patients ( small tears, massive tear). introduction: it has been estimated that up to % of adults suffer from rotator cuff tears [ ] , which can impair their ability to work or perform household tasks [ ] . management of rotator cuff tears is difficult as a large proportion of technically correct surgical repairs re-rupture, estimated between - % [ ] . it has been estimated that thousands of extracellular matrix repair grafts are used annually [ ] to augment surgical repair of rotator cuff tears and act as temporary scaffolds to support tendon healing. the only mechanical assessment of the suitability of these grafts for rotator cuff repair has been made using tensile testing only, and compared grafts to canine infraspinatus [ ] . as the shoulder is subject to shearing as well as uniaxial loading, we compared the response of repair grafts and human rotator cuff tendons to shearing mechanical stress. we used dynamic shear analysis (dsa), which is a form of rheology and allows the study of flow and material deformation. material and methods: the shear properties of four different commercially available rotator cuff repair grafts were measured (restore, graftjacket, zimmer collagen repair and sportsmesh). mm punch biopsies were taken from the grafts and subjected to oscillatory deformation under compression. the bulk storage modulus (g') was calculated [ ] and used as an indicator of mechanical integrity. to assess how well the repair grafts were matched to torn and normal rotator cuff tendons, the storage modulus was calculated for human rotator cuff specimens obtained from the edge of rotator cuff tears during surgery, from patients aged between and years. age and sex matched normal controls were also obtained during shoulder hemiarthoplasties and stabilisations. results: we report a significant difference in the shear moduli of all four rotator cuff repair grafts (p < . , way anova). of the repair grafts (restore and graftjacket) had a significantly lower storage modulus when compared to human rotator cuff tendons (p < . , dunn's multiple comparison test). only the zimmer collagen repair and sportmesh had a storage modulus which was comparable to that of normal rotator cuff tendons (p > . ), and thus were most closely matched. conclusion: with increasing numbers of repairs of rotator cuff tears, and augmentation of these repairs, there is a need to understand the mechanical and biological properties of the both repair grafts and the tendons they are designed to augment. there is no clear definition of the ideal mechanobiological properties. current rotator cuff repair grafts display a wide variation in their shear mechanical properties, and how closely they are matched to the mechanical properties of human rotator cuff tendons. it is hoped that this study, in conjunction with others, will help to guide surgeons in deciding on the most appropriate repair graft. three-dimensional computed tomography reconstructions also improved the average intraobserver reliability for all fracture characteristics, from j d = . (substantial agreement) to j d = . (substantial agreement). the addition of three-dimensional images had limited influence on the average interobserver reliability for the recognition of specific fracture characteristics (j d = . versus j d = . , both moderate agreement). three-dimensional computed tomography images improved interobserver reliability for the recognition of coronal plane fractures from fair (j d = . ) to moderate (j d = . ) but this difference was not statistically significant. conclusion: three-dimensional computed tomography is helpful for; ) individual orthopaedic surgeons for preoperative planning (improves intraobserver reliability for the recognition of fracture characteristics), and for ) comparison of clinical outcomes in the orthopaedic literature (improves interobserver reliability of classification systems). disclosure: no significant relationships. introduction: in recent years, d fluoroscope has used increasingly in orthopaedic surgery because it offers some advantages such as generation d data without anatomic registration requirement. previous studies have focused on the clinical use of d fluoroscope in surgical procedures such as calcaneus or acetabular fracture reduction, or placement of screws in spinal surgery. there are no reported data on radiation exposure of d flu to orthopaedic theater staff. we want to correlate radiation exposure and distance concerning the patients and members of surgical team during using three-dimensional fluoroscope and study how far is enough until radiation exposure can not be measured. material and methods: an isocentric c-arm fluoroscope (siremobile isoc d) was used for the study. human cadaveric extremity was used for target. digital dosimeters (mydose mini pdm- , aloka) were used to measure radiation exposure at specific distances. dosimeters were systematically exposed by the following protocol. represented positions were direct contact and every -cm. radius from the center of the beam. the distances were increasing until the dosimeters could not detect the radiation. each radius distances were designed to record different positions; top, bottom, left and right side. dosimeters were exposed and removed ( dosimeter positions at a time from each radius). first we used low resolution scan technique to obtain the images. after all radiation exposure records were collected, we changed to use high resolution scan technique and repeated the protocol. each technique was repeated in times to obtain the mode of data. results: radiation dose at ground zero is lsv in high resolution and lsv in low resolution. radiation in high resolution technique can not be measured beyond meter from the center of the beam at the top, bottom, and right direction and . meters at the left direction. in low resolution, radiation cannot be detected farther than cm. in the top, bottom and right direction and . meters at left direction. conclusion: radiation dose measurements in each direction are decreased during increasing distance and dose in left direction is higher and farther than others. beyond . meters is safe from radiation in knee application. high resolution gives higher radiation and farther than low resolution. introduction: tibial plateau fractures with impression are often associated with poor outcomes and a high rate of complications. the current guidelines advocate anatomic reduction, re-establishment of tibial alignment, stable fixation, and filling of the sub-articular defect. we hypothesized that fixed-angle liss-plates provide adequate stabilization with less need for void filling, minimal complications and good radiological outcome. material and methods: retrospective evaluation study. in the period - , we operated patients with an intra-articular tibial plateau fracture. forty were treated with a liss-plate. mean age was years, were male. all fractures were classified as ao type b or c; were schatzer type ii, type iv, type v, and type vi. five patients were initially treated with external fixation. mean time until definitive surgery was days (range, - days). in fractures, the subchondral void was filled with either hydroxy or bone graft, in the other cases no graft was used. demographic data and fracture classification were equal in both groups. articular impression was measured by independent evaluators pre-operatively, post-operatively and months after surgery on plain x-rays. results: mean pre-operative impression was . mm (with void filling . mm, without . mm, ns). thirty-four fractures were additionally stabilized with k-wires or screws. the post-operative impression was on average . mm. evaluation criteria included the lysholm and tegner activity score. all fractures were stabilized post primarily. the surgical main approach was strictly medial. exposure of the entire medial condyle fracture was first performed anteromedial following the fracture line to the articular border. the posterolateral impaction was addressed directly through the main fracture gap. small fragments were removed, larger reduced and preliminarily fixed with separate kwire(s). the posteromedial part of the condyle was then prepared for main reduction and application of a buttress t-plate in a posteromedial position, preserving the pes anserinus and medial collateral ligament. in addition a parapatellar medial mini-arthrotomy through the same main approach was performed for reduction and pds-suture-fixation of the anterior eminence (acl and anterior horn of lateral meniscus). results: we treated patients with fractures. median age was years ( - ). we could evaluate patients ( %), patients were lost to follow-up due to foreign residency. the fractures were treated post primarily at an average of days, of them in a twostaged procedure with initial knee-spanning external fixator. all fractures healed without secondary displacement or infection. patients showed none to moderate osteoarthritis after a median of years. one patient showed a severe osteoarthritis after years. all patients judge the result as good to excellent. the lysholm score reached ( - ) and the tegner activity score ( - ). all patients have achieved a minimum flexion of °. conclusion: in our view it is crucial to recognize this increasingly observed type of knee injury in winter sport areas. with our strategy we achieved good results in nearly all patients. the described larger medial approach allows addressing most of the injured parts of the tibial head (medial condyle with posteromedial buttressing, tibial spine, posterolateral impaction). material and methods: it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator (sif). there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanicaly. in clinical use it has been applied to metaphyseal fractures of distal femur and proximal and distal tibia. the age of patients was from to years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. for opened fracture it has been used high mobile external fixation system as temporarily ( fractures) or definitive ( fracture) method. results: received clinical results are promising, as it has been shown early callus formation and radiological union within the . - months. it has been allowed to patients early full weight bearing, if fractures not intraarticular. during the treatment it has been confirmed working of self-dynamisation concept, which probably all together with d configuration resulted in unexpectedly quick fracture healing. follow up was months ( - ). when used external fixation system, axial dynamisation has been regularly activated. conclusion: according to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site if no intraarticular dislocation. it can be used as primary method or soon after external fixation if damaging control concept used. introduction: disaster, is the disproportion between the need for medical care and the means available in the community. this discrepancy of needs /means is the major problem in every step of the rescue chain, when a disaster situation is present. this is more obvious at the end of the chain, which is the hospital and especially, the bottleneck of the entire disaster's management system, the emergency department. material and methods: in greece, the most common and frequent disaster situation is the earthquake. and so, the most expected pathology of the victims is trauma. because of the lack of . special organization of emergency medicine and . independent modern emergency departments in greek hospitals, their directors did not give the appropriate attention to organize a disaster plan (internal or external introduction: accurate response to major incidents requires accurate decisions on all levels, from command level to the care of the individual patient. development, evaluation and training of the process of decision-making requires standardized models providing complete and accurate information as a base for the decisions; a decision based on incomplete or incorrect data can not be properly evaluated. the aim of the present project was to design a simulation model that could be used both for evaluation of different methods in the response to major incidents and for training and evaluation of skills in making correct decisions. material and methods: a system was created providing the information required for this process in the whole chain of management and performance: scene, transport, hospital response, co-ordination and command. input data were based on real scenarios and real resources. for evaluation of methodology, all parameters except the one studied, in this study triage, were standardized. the results from (a) physiological and (b) anatomical triage, performed by staff on different levels of competence and experience, serving as their own controls, were compared. for training, the system was used in courses in medical response to major incidents with training of the whole chain of management and performance, from prehospital patient management to over all co-ordination and command. results: the methodological evaluation showed differences in priority and outcome between anatomical and physiological triage related to the level of experience and to the position in the chain of response, providing a base for choice of method related to those factors. the results from training with the use of the system, so far only evaluated by the participants own ranking, showed high percepted improvement of relevant skills. conclusion: a methodology for simulation of major incident response designed for scientific evaluation of methodology also provides a very good educational tool, since correct and complete data as a base for decision making also gives an effective and realistic training. disclosure: one of the authors, sl, has the copyright to the mac-sim system, a non-commercial system intended mainly for scientific use. equipment for training can be produced by users, but also purchased for production costs. introduction: interhospital referral of traumapatients for reasons of special (most neuro-)surgical competencies to a specific level traumacenter, is common practice in the netherlands. these traumapatients are sometimes admitted directly through specialized intensive care units and therefore do not enter the emergency department (ed). therewith the standard assessment according to the atls guidelines is bypassed in these cases. this withholds the risk of an incomplete assessment. we therefore consistently coordinate the assessment of all transferred traumapatients. in this study we analysed the number of newly found injuries in referred polytraumatized patients and the clinical consequences in terms of extra treatment, permanent damage or death to the patient. we also analysed possible risk factors for missing injuries. introduction: synchronous admission of large numbers of patients into the hospital requires a perfect coordination of activities of designated teams in the process of reclassification at the entry to the hospital and subsequent continuous provision of medical care for the patient in the course of examination and treatment, up to his hospitalisation at the target department, in accordance with the characteristics of the injury and seriousness of his medical condition. this process cannot be accomplished through improvisation but only with creating a uniform organisational scheme, defining the recommended structure of medical teams and their activities during a multiple admission of casualties into the hospital. in this article, we present a proposal of such consensual organisational scheme, partially verified in practice. the organisational scheme is defined in the following areas: -space arrangements -places of admission and organisation of work -creation of mini trauma teams (anaesthesiologist, traumatologist and surgeon or another traumatologist take over the most serious patients, the teams are accompanied by consulting specialists of relevant specialities (neurologist, neurosurgeon, radiologist), the whole teams or at least parts of them, accompany the patients for the whole period up to the definite treatment at operating theatre, or his placement at a destination department -the continuity of care is secured in this way, without the need to pass on any findings and information -placement of patients into individual hospital departments (follows certain rules, it is necessary to direct all the admitted patients into as few departments as possible (one or two), and thus keep the best possible view over the priorities during their treatment -entry corridors -,,green corridor'' -patients are immediately transported through this area by transport teams into the ''green'' designated area, the ''red'' and ''yellow'' entry area does not have to be extremely large, however it requires an adequate equipment from the material and technical point of view results: multiple admission of patients must be well-organised and managed, most often by a head-physician of the ua department, or another authorised specialist (in hospitals without the ua department). the idea of the traumanetwork d dgu is to built up regional networks of various trauma centers with the objective to standardise and optimise the treatment of severely injured patients -with the additional involvement of rescue services, physicians and competent facilities and centres for the treatment of specific injuries as severe burn or spinal cord injuries etc. to assure that all participating hospitals meet the criteria needed for the treatment of trauma patients, a certification firm (diocert) was assigned to accomplish the audits and to control the process of certification. thus, every hospital has to pay a sum of nearly eur for audit, certification, benchmarking, yearly quality reports and the use of special it-tools which were designed for the traumanetwork d dgu. material and methods: coordination of traumanetwork implementation coordination of audit and certification process results: since the beginning in the year actually hospitals are participating the traumanetwork d dgu. these hospitals are organized in regional traumanetworks. % of the hospitals are preliminary categorized as local trauma centers, % as regional trauma centers and % as over-regional traumacenters (the highest category). % still aren¢t categorized. hospitals have already signed the contract with the german trauma society and paid the participation fee. hospitals meet the criteria for audit and hospitals are already audited by the firm. in october the first regional trauma network (trauma network east bavaria / tno) was certificated with a total of participating hospitals. conclusion: in the past years the number of participating hospitals increased year by year. the nationwide acceptance and the high level of participation in the traumanetwork d dgu in germany show that the treatment of severely injured patients is one of the main topics and exercises for trauma surgeons in germany. if the expected improvement in treatment quality and the decline in trauma mortality is only wish and fiction or reality and fact has to be proven by studies in the next years. therefore a working group with focus on quality improvement, changes in mortality, improvement in rehablitation results etc. was founded. introduction: one of the challenges in trauma care is diagnosing all injuries. any delay in treatment can lead to increased morbidity, prolonged length of hospital stay, costs, and even mortality. despite the use of standardized guidelines for initial evaluation such as atls, the incidence of missed injuries in the literature is considerable. the aim of this study was to assess the rate of missed injuries in trauma patients evaluated in two dutch level- trauma centers and to determine potential factors that contribute to injuries being missed. we assessed all radiological reports during initial admission and operation records of the patients included in the prospective randomized react trial. this study was part of a randomized trial conducted in two dutch level- trauma centers investigating the role of ct scanning in the trauma room. missed injuries were defined as not diagnosed during initial radiological evaluation in the trauma room. we assessed all missed injuries and the phase in which these injuries were diagnosed. second, we assessed potential contributing factors by univariate analysis. results: there were a total of total calls performed with real patients and test calls. of the actual calls, ( %) were performed while moving and ( %) were done from a stationary position. initial video quality in was rated good in cases ( %) and initial audio quality was rated good in ( %) cases with actual patients. of the actual calls ( %) experienced some sort of temporary video drop during the entirety of the call and calls ( %) experience some sort of temporary audio drop. these drops were a result of the setup of mesh wifi and the need to jump from router to router. users in the hospital found the program to be a very useful trauma and emergency medicine tool, but adjustments need to be made to improve the network. conclusion: the use of telemedicine in a pre-hospital setting may play a significant role in the management and treatment of trauma and critically ill patients as hospital medical staff can intervene in real time during transport. patients can be evaluated in real time which allows the necessary staff and resources to be available on arrival. initial user feedback has been encouraging with users acknowledging its usefulness as a pre-hospital tool. ( ) in the elective setting it is logical that a lower egfr reflects poor renal function and low overall physiological reserve. the same is not obviously true for emergency patients who may have an ''artificially'' low egfr merely as a reflection of acutely altered fluid balance. change in egfr from admission to hospital to itu admission was also significantly different between survivors and nonsurvivors. this would suggest that egfr reflects a response to treatment as well as renal function. this study supports the use of egfr in the decision making process when trying to predict outcome in emergency general surgery patients. introduction: the surgical medium care (smc) in our hospital is a bed ward with monitoring facilities, and is used critical ill patients from the trauma and other surgical wards. over the last years there has been an increase in the number and severity of trauma patients admitted to out hospital, as well as there has been an increase in patients undergoing major elective surgery. the aim of this study was to verify if these trends are reflected in an increase in patient-and workload on our smc. in this study we describe the patient-and workload on the smc between and using the tiss- . the modified therapeutic intervention scoring system (tiss- ) is a validated score of therapeutic activities and an alternative approach to evaluate outcome of critically ill patients ( ) ( ) ( ) . material and methods: a prospective cohort study of all consecutive patients admitted to the smc between / / and / / was performed, using the tiss- database. of all admitted patients a daily tiss-score was performed. besides the tiss data, patients demographics, referring ward, discharge destination, length of stay, and hospital mortality were retrieved from the database. results: there were a total of admissions of patients in the study period. % of patients were male, % were female. the median length of stay was days ( - ). the overall hospital mortality rate was , %, with no significant differences over the years. % of the patients admitted to the smc came from the icu, % came from the emergency department, , % came from home, , % came from the recovery ward, and % came from the trauma and surgical ward. these percentages did not change over time. the average tiss score during the study period was and did not significantly differ during the study period. there was, as expected, no significant difference in tiss score between patients who survived and the non survivors. introduction: the demands placed on systems and organisations that protect the general population are constantly growing. the reasons for this include, among other things, circumstances altered by the threat of inter-national terrorism and the increasing frequency and magnitude of mass public events and natural catastrophes. crisis situations such as these present unique, often completely unprecedented chal-lenges to those affected and to all actors with responsibility for crisis management and the protec-tion and rescue of people.with regard to effective interdisciplinary crisis management, both germany's security and rescue forces and its general population suffer from widely acknowledged and scientifically proven deficits. impact on people and the society. in this context, all natural and man-made threats will be considered (''all hazards approach''). elearning and virtual reality modules based on these scenarios will be offered to target groups via the internet on an individualised basis. results: the aim of this project is to develop a platform to prepare security and rescue forces, doctors, caregiv-ers and the general population for terrorist attacks, crises and disasters. an online platform with a modular structure (employing teaching methods such as e learning, blended learning etc) will offer innovative and specialised instruction and advanced training to all users. conclusion: experts agree that the modern teaching methods and computer-based simulations mentioned here (such as virtual reality methods) are excellent tools to help train people efficiently to respond to events that cannot be planned, such as terrorist attacks and other catastrophes. the use of these innovative methods and com-pletely novel, userfriendly, web-based instruction and information modules is designed to address -to a heretofore unprecedented degree -all security and rescue forces concerned as well as the general population in particular. ultimately this will signifi-cantly improve security and rescue operations in the event of terrorist attacks, crises and disasters. conclusion: in a proper setting, laparoscopic emergency is feasible, effective, safe and beneficial for patients to be a part of a common surgical practice, as long as adequate training is obtained and proper preparation observed when more advanced procedures are attempted in critically patients. the diagnostic and therapeutic versatility afforded by the laparoscopic approach avoids extensive preoperative studies, averts delay in operative intervention and minimize morbidity and shorten the postoperative hospitalization. we do think that laparoscopy should be incorporated into general surgeon's armamentarium for the management of patients with acute abdomen as just as another tool to be used selectively when indicated. laparoscopy, however, must not be used as an alternative to good clinical judgment. about our algorithm in patients with acute abdomen: if there aren't any contraindications to laparoscopy, obtained an informed consensus, in presence of a well trained surgical team in minimally-invasive surgery, excluded any major gynaecological diseases (about which we and our gynaecological colleagues haven't a skilled experience with a laparoscopic approach), we always approach laparoscopically. introduction: stable patients with thoracoabdominal penetrating or blunt injuries resulting in diaphragmatic injuries represent a difficult and challenging management dilemma. although laparoscopy and thoracoscopy have now emerged as the most reliable and efficient diagnostic and treatment modality of these injuries, a conversion to laparotomy for mere evidence of peritoneal penetration and or diaphragmatic injuries is common for most trauma surgeons. we hypothesized that laparoscopically-assisted mini-thoracotomy for repair of diaphragmatic injuries will be as effective as open laparotomy or thoracotomy and will prevent the morbidity associated with open technique and should be used in hemodynamically stable trauma patients. we designed a minimally invasive technique that combines laparoscopic exploration of the intraperitoneal cavity and existing injury site as an entrance to the injured site or organ. open hassan technique, using vertical midline incision is used to create the pneumoperitoneum. additional two to three or mm ports are placed to enable thorough examination of the peritoneum, running the small bowel and examining other abdominal viscera. diaphragmatic lacerations are repaired by extending ( - cm) the existing thoracic stab or gunshot wound. the diaphragm is grasped with two graspers and brought to the operative field. continuous or interrupted suture are used for repair. we applied this technique to hemodynamically stable trauma patients (la group) treated over a year period at the university level i trauma center and compared to trauma patients requiring laparotomy (og) for isolated diaphragmatic injury repair . all laparoscopically assisted procedures were performed by the senior author (rl). length of stay, morbidities and complications were studied in both groups. both groups were matched for iss, age, and gender and mechanism of injuries. results: there were patients (five with stab, two with gunshot wound and one with blunt trauma and chronic diaphragmatic injury) in the la group. introduction: acute small bowel obstruction is mostly due to adhesions ( %), while internal hernia can cause acute small bowel obstruction in % of cases. this clinical condition has been considered for many years a relative contraindication for laparoscopic surgical treatment. with the introduction of ct-scan in the diagnosis of this clinical situation and the experience in laparoscopic techniques, more surgeons are now attempting laparoscopic management for this indication. the advantages of laparoscopy in abdominal surgery are now well defined, such as a shorter intestinal function recovery, a shorter hospital stay and less post-operative pain complained by the patients. in our presentation we want to analyse the importance of laparoscopy in the diagnosis and the treatment of acute small bowel obstruction, in order to underline advantages and limits of this technique. material and methods: in san raffaele hospital milan (italy) a total of patients underwent a surgical intervention for small bowel obstruction from january to december . % of the obstructions was due to adhesions, % to internial hernias. all the patiens underwent preoperative abdominal x-ray and ct-scan. results: of the total of patients, have been operated on with a laparoscopic approach, with a conversion rate of . %. postoperative morbidity was % in the laparoscopic group and . % in the traditional surgical approach, with a shorter hospital staying in the first group. conclusion: the analysis of our data suggests us that the selection of patients that can benefit from a laparoscopic approach to acute small bowel obstruction has to be made accurately, better with the use of ct-scan, in order to limit the percentage or useless laparoscopy and to diminish the conversion rate and to give the patient the better curative option. introduction: intestinal obstruction has remained one of the most common surgical emergencies. the aim of our study is to evaluate the feasibility, safety and palliative role of laparoscopic bowel surgery in the management of large bowel obstruction. material and methods: in a period of years, patients were subjected to loop sigmoidostomy. in patients the diagnosis was bowel obstruction due to rectal cancer. in patients the obstruction was attributed to ovarian cancer. from those patients with rectal cancer, patients had contominant liver and lung metastases and had an unresectable liver lession. in that period lapassisted ileo-transverse anastomosis were performed due to obstruction from cecum carcinoma together with mlitple liver and lung metastases. single surgeon-performed pocus in the evaluation of acute appendicitis led to a correct diagnosis in , % ( / ). surgeons trained in us ordered a ct scan in , % of cases and ratio of negative appendectomy was , %. surgeons not trained in us ordered a ct scan in , % and their ratio of negative appendectomy was , % (including pts that underwentent surgery on clinical investigation basis only). conclusion: surgeon-performed pocus has a high sensitivity in the assessment of acute appendicitis and it is a powerful tool that minimize the use of ct scan and ratio of negative appendectomy with reduction of hospital and social costs; furthermore an advantage for the patients in terms of radiation exposure can be achieved. moreover, to reduce additional costs, laparoscopic approach should be indicated only when the appendix cannot be perfectly visualized and localized. introduction: severe bleeding is, besides head injury, the most important predictive factor in severe trauma. therapy of hemorrhagic shock starts already at the scene of accident. however, the best strategy regarding preclinical volume therapy is controversially discussed. the traumaregister of the german society for trauma surgery (tr-dgu) observes the routine management of severely injured patients since many years. this registry will be used to describe the behaviour of preclinical volume administration as well as the consequences in early hospital care and its changes during the last ten years. material and methods: the tr-sdgu is a voluntary anonymous documentation of severely injured patients for the purpose of quality management. data collection started in . about parameters are collected per patient. for the present investigation only adult patients (age >= ) admitted directly from the scene to one of the participating hospitals during the past ten years ( - ) were considered. a minimum injury severity of iss > = and available data for volume administration and blood transfusion were required. means and prevalence rates were analyzed on a yearly basis. results: a total of , patients injured between and were analyzed. mean age was . years, and % of patients were males. in % of cases there was a blunt trauma mechanism, and % of cases were unconscious at the scene (gcs £ years that required presentation in one of the two level- trauma centers (amc or vumc) were eligible. in the amc the ct scanner was located in the trauma room (intervention group) and in the vumc the scanner was located in the radiology department (control group). randomization was performed prehospitally at the time of dispatch from the scene. primary outcome measure was the number of non-institutionalized days within the first year following trauma. secondary outcomes were mortality, length of initial admission and transfusion requirements. preplanned subgroup analyses consisted of multitrauma patients and severe traumatic brain injury (tbi) patients. results: in total, patients were included for analysis of which were multitrauma patients and had severe traumatic brain injury (tbi). demographic data were comparable between both groups except that there were more multitrauma patients evaluated in the amc. introduction: the effective initial treatment in the emergency room of polytraumatized children requires a sound knowledge of common injury patterns, incidence, mortality, and consequences. the needed inital radiological imaging remains controversial and should be adapted to the expected injury pattern. material and methods: in this retrospective study, the injury patterns of polytraumatized paediatric patients (age £ years) in the period from december to may were evaluated. all children were initially diagnosed with a whole body ct scan. the cause of accident, the localization including the detailed diagnose, the lethality and the severity of the injuries were analyzed. the ais (abbreviated injury scale) and iss (injury severity score) were used to classify the severity of injuries in different body regions. moreover the number and the kind of operation as a consequence of the initial made diagnoses were investigated. results: the mean score of the iss was ± in boys and girls with a mean age of ten years. the lethality was % and only % in the first hours. the most severe and most frequent injury was craniocerebral trauma in % with an ais ‡ in %. surgical intervention of the head was done in %. thorax injuries were found in % with % with an ais ‡ and in % a thoracic drainage was needed. abdomial trauma was found in % (surgery %) with an ais ‡ in %. fractures of the spine occured in % (surgery %) with an ais ‡ in % and pelvic injuries were diagnosed in % (surgery %) with an ais ‡ in %. injuries of the upper extremity were found in % (surgery %) with an ais ‡ in % and of the lower extremity in % (surgery %) with an ais ‡ in %. conclusion: especially because of the detected high percentage of head and thorax injuries in polytraumatized children and the needed head surgery the authors recommend a whole body ct scan in children who are potentially polytraumatized. not only in adults but especially in children the authors suggest the initial use the quickest imaging with a high sensitivity-the whole body ct scan. introduction: patients who suffer physical injuries following a traumatic event are at risk for developing posttraumatic distress. care workers in hospitals treating polytrauma patients are in an optimal position to screen and identify patients developing posttraumatic stress disorder (ptsd). to start early intervention procedures and possibly lower the prevalence, a screening instrument to identify patients at a higher risk is needed. aims of this study were to determine if the severity of injury is related to the prevalence of ptsd and to review the personality traits of patients with ptsd. with these results a screening instrument might be developed. to simulate an unstable extraarticular distal radius fracture, an osteotomy with a mm gap was made. axial loads of - to - n and torque loads of - , to , nm were applied by a testing machine to the intact radii and to the radii after each device was fixed as recommended by the manufacturer. after that, cycles of dynamic torque load alterations of , to , nm (or - , to - , nm convenient to side) at , hz with a preload of - n were performed. in the specimens that were still intact after cycles, loading in torque was continued until failure occurred. axial and torque stiffnesses of the osteosynthesis system were calculated. results: with a median of , n/mm axial stiffness of xscrewÒfixed specimens was higher than of dnpÒ-fixed specimens with a median of , n/mm but did not reach statistical significance. with a median of , nm/°torque stiffness of xscrewÒ-fixed specimens was significant higher than of dnpÒ-fixed specimens with a median of , nm/°. the xscrewÒ-group reached % of the axial stiffness and % of the torque stiffness and the dnpÒ-group reached % of the axial stiffness and % of the torque stiffness of the intact radii. conclusion: fixation of unstable extraarticular distal radius fractures with a xscrewÒ provide biomechanically more stability than a fixation with a dnpÒ. disclosure: no significant relationships. after distal radius fractures occur in % to % of fracture cases. the resulting deformity resembles madelungs deformity and is also called pseudo-madelungs deformity. this deformity leads to ulnocarpal impaction and dorsal dislocation of the distal radioulnar joint (druj). several treatment options such as lengthening of the radius and shortening of the ulna or epiphysiodesis of the distal ulna have been described. the taylor spatial frame (tsf) is a hexapod based external ring fixator, which is widely used to perform six-axis deformity corrections of the lower limb. tsf-planning is web based (www.spatialframe.com) but its use is only available for lower extremities. the purpose of this study was to apply the tsf to the upper extremities to correct pseudo-madelung deformities. material and methods: defining the nomenclature to correct bony deformities with the tsf, one must determine the deformity parameters, the frame parameters, and mounting parameters for the web based planning program. the six deformity parameters and the four mounting parameters use the anatomic nomenclature for the lower extremities. to use the tsf on the forearm, one must transfer the nomenclature of the deformity parameters and the mounting parameters to the nomenclature of the forearm with the transferred nomenclature, one can correct forearm deformities with the correction mode long bone of the planning program for the lower limb. patients two boys (patient , years, patient , years old) and two girls (patient , years, patient , years) were seen in our clinic with progressive pseudo-madelung deformities after an epiphysial fracture of the distal radius at age in the boys and in the girls. skeletal maturity (rus, tw method) was equivalent to the patientâ e tm s age. results: in the four patients, the multiplanar deformitiy of the distal radius could be corrected anatomically with the tsf. there were no frame changes or frame modifications necessary for deformity correction. patient was slightly overcorrected because of some growth in the distal ulnar growth plate. during the distraction, each patient had two low-dose ct scans for better visualization of the radiocarpal and radioulnar joint. the web-based planning program was adjusted twice until total deformity correction was achieved. no further immobilization after frame removal was required. the one-year follow-up showed an anatomic aligned forearm/hand relation with increased pronation and supination compared to the preoperative range of motion in all patients. the wrist and especially the druj were stable and reduced at the one-year follow-up examination. the patients did not complain about any pain or functional deficits in the hand. conclusion: in conclusion, the power of the tsf with the ability to move two fragments precisely can be transferred to the forearm. this allows for the correction of multiplanar radial deformities simultaneously without the need for frame modifications of rotational and translational deformities, as is necessary with the standard ilizarov system. material and methods: thirty-four consecutive patients with a suspected scaphoid fracture (post-injury tenderness of the scaphoid and normal radiographs) underwent ct and mri within ten days after trauma. ct-reconstructions were made in planes defined by the long axis of the scaphoid. the reference standard for a true fracture of the scaphoid was -week follow-up radiographs in four views, based on current available evidence in the literature. a panel including surgeons and radiologists came to a consensus diagnosis for each type of imaging considered in a randomized and blinded fashion, independent of the other types of imaging. we calculated sensitivity, specificity and accuracy as well as positive (ppv) and negative predictive values (npv) for both imaging modalities. results: according to the reference standard there were six true fractures of the scaphoid (prevalence % both mri and ct are better at ruling fractures out than in ruling them in and both were subject to false positive and false negative interpretations. the best reference standard for a true fracture is debatable, but for now it is not clear when bone edema on mri and small unicortical lines on ct represent a true fracture. we advice ct because costs are lower and overall availability is higher. introduction: the scaphoid bone is the carpal bone most commonly fractured in wrist trauma. traditionally, non-displaced scaphoid fractures are considered by most as stable with predictable rates of healing with conservative treatment. conversely, displaced fractures are recognised as unstable, with a significant risk of non-union if not treated surgically. there is a current trend in orthopaedic practice, however, to treat non-or minimal displaced fractures also with early open reduction and internal fixation. this trend is not evidence based. in this systematic review and meta-analysis, we pool data from trials comparing surgical and conservative treatment for acute scaphoid fractures, thus aiming to summarise the best available evidence. material and methods: fourty fresh frozen cadaver scaphoid bones have been sampled at our disposal for testing of screws. the bone density measurement of all specimens has been performed using a qct scan. a transverse osteotomy will be performed at the waist of each scaphoid simulating a b fracture according to the herbert classification. a load cell will be interposed, in an already established method, between the proximal and distal pole of the bone to measure compression force while introducing the screw. the screws will be applied as recommended by the manufacturer using original instruments. the intrascaphoid compression will be recorded at the peak during insertion of the screw, and after and seconds, , , and minutes. results: preliminary results determined that a greater compression can be sustained over a time by headless compression screws with significant differences between those screws. the tests will be finished at the end of january and we will present the final results. conclusion: in more than % of our cases a fracture was missed with the initial radiograph. bone scintigraphy is still a good choice to detect an occult fracture around the wrist. introduction: operations in trauma patients represent a second insult and the extent of the surgical procedures influences the extent of the inflammatory response. the aim of this study was to evaluate the operative burden related to femoral intramedullary nailing. our hypothesis was that a reamer-irrigator-aspirator (ria) system would cause lesser inflammatory response than traditional reaming (tr) due to a lesser intramedullary pressure increase and thereby reduced intravasation of bone marrow content. material and methods: coagulation, fibrinolysis and cytokine responses were studied in norwegian landrace pigs during and after intramedullary reaming and nailing with the two different reaming system; the tr (n = ) and the ria (n = ) reaming system, and compared to a control group (n = ). the animals were followed for hours. simultaneously arterial, mixed venous and femoral vein blood were withdrawn peroperatively and until two hours after the nail was inserted for demonstration of pulmonary, systemic and local activation. results: significantly procedure-related increased levels were found for tat, t-pa and il- in the tr group and tat in the ria group. the local and the pulmonary activation of coagulation, fibrinolysis and cytokine response was more pronounced in the tr than in the ria group, but the difference did only reach significance for il- (femoral vein) and pai- (arterial). the arterial levels of il- and tat exceeded the mixed venous levels indicating an additional pulmonary activation. these differences, however, did not reach significance. two animals in the tr group, who died prior to planned study end point, demonstrated higher inflammatory response compared to rest of the tr group. conclusion: the inflammatory response to the reaming and nailing procedure was modest, and the response was lesser in the ria group than in the tr group. introduction: approximately . million joint arthroplastic operations are performed annually worldwide. implant failure due to massive bone loss and aseptic prosthesis loosening, however, is a major complication of joint replacement. it is generally accepted that small particles (''wear debris'') and activated macrophages play a key role in aseptic loosening. but also the prosthesis loosening fibroblast (plf) plays an important role. material and methods: between and abg- -hip arthroplasties were implantated. after a year analysis % had to be removed because of massive wear of polyethylene (pe) and consecutive acetabular osteolysis. we analysed the influence of patient and surgeon, the implantdesign incl. pe-thickness, anchorage coupler, material roughness i.e. and the material i. medtronic) the application of the cements was done according to the specifications of the manufacturer. after extrapedicular kyphoplasty on cadaveric lower thoracic spine vertebrae (th - ), the intervertebral distribution pattern was investigated by microtomography ( lct). besides creating high resolution d and d reconstructions, the mathematic calculation of the porosity of the vertebra, the bone substitute material and the relative part within the different compartments was performed. of special interest were the characterization of the bone substitute material -spongiosa -interface and the penetration of the calcium phosphate cement into the adjacent spongiosa. the following parameters were investigated: . trabecular structure, porosity and hydroxylapatite concentration of the native vertebrae . structure (homogeneity, distribution of pores) of the bony substitute material . characterization of the bone-bone substitute-interface a. central located, filled kyphoplasty defect b. transition zone with spongiosa and bone substitute material c. solitary spongious bone results: the investigation of the native spongiosa yielded a comparable trabecular structure, porosity and hydroxylapatite concentration in the intra-individual comparison of the vertebrae of the lower thoracic spine. between the cements differences in the solitary structure as well as distribution pattern during kyphoplasty were observed. especially the analysis of the ability to penetrate into the spongiosa adjacent to the centrally located kyphoplasty defect yielded significant differences. the main influencing factor of the ability to penetrate into the spongiosa is the different viscosity of the -according to manufacturer specification -used calcium phosphate cements. the cements differ in their native structure as well as in their distribution pattern during kyphoplasty. the differences in micro-morphology of the calcium phophate cements have a high probability to influence the degradation of the sedimentation products and later osseointegration. disclosure: this research was funded by a grant of ao germany. introduction: it is difficult to predict the long-term clinical outcome in the early period following an acetabular fracture. introduction: the tremendous increase of acetabular fractures in the elderly provides new challenges for the surgical treatment of acetabular fractures. surgical reduction of the acetabular joint represents the most reliable possibility to prevent the development of premature arthrosis even in the elderly. biomechanical studies showed, that plates with periarticular long screws result in an increased stability of the osteosynthesis, it has to be considered that the insertion of these screws always bears the risk of penetrating the joint the aim of this study was to evaluate the biomechanical properties of these standard plates and newly developed minimal invasive osteosynthesis techniques for stabilization of an anterior column combined with posterior hemitransverse fracture type (acphtf), which represents a typical acetabular fracture in the elderly. material and methods: using a single-leg stance model we analyzed different implant systems for the stabilization of acphtfs in synthetic pelvises (standard reconstruction plate, new developed prototype and definitive repofix Ò (adi -ao foundation, switzerland). applying an increasing axial load in a biomechanical testing machine, fracture dislocation was analyzed with a multidirectional ultrasonic measuring system (zebris, germany). differences in change of center of gravity are statistical analysed by man-whitney-u -test. results: analog to a long bow, the repofix Ò supports the quadrilateral surface sufficiently and reconstructs the surface of the pelvic brim from the inner side of the pelvis. in synthetic pelvises, the new repofix Ò is associated with a significantly less pronounced dislocation (center of gravity) of the fractured quadrilateral surface when compared to prototype and the standard reconstruction plate. the biomechanical results could be seen at a measuring point at the quadrilateral surface and in the rotation around the x -axis (angle y results: we collected data on acetabular fractures. a conventional image intensifier was used in cases (group a), d-navigation was used in cases (group b). in group a the kocher-langenbeck-approach was used in most of the cases ( %), followed by the maryland-approach ( %). in group b, the kocher-langenbeck-approach and the ilio-inguional-approach were used in an almost equal number of patients ( % / %), but extended approaches were only used twice. in % of the cases in group b fractures were stabilised by navigated placement of percutaneous lag screws. when we excluded the percutaneous operations in group b (n = ), the difference in or-time between navigated (n = , ± min) and conventional treatment (n = , ± minutes) was significant (p < , ). in group a we detected relevant postoperative complications in % of patients. the complication rate was significantly lower in group b ( %, p < , ). the postoperative radiological analysis revealed a better qualitiy of reduction in group b (n = ) with an average post-op fracture gap of , mm vs , mm in group a (p < , ). conclusion: by using a navigation system and a d image intensifier we found a significant increase in the or-time in the navigated group. however, in the postoperative radiological analysis, we detected a better quality of fracture reduction in the navigated group. navigation in combination with the -dimentional pictures of the iso-c d led to a better visualisation of the acetabulum, therefore the need for extended approaches was reduced. to our opinion, this explains the significant reduction of postoperative complications in group b. we conclude that navigation and a d image intensifier should always be used for orif of acetabular fractures. disclosure: no significant relationships. introduction: the traumatism is the first cause of the mortality in patients under . it means a serious incapacity in of trauma patients. the initial management in trauma patients is essential to improve these results material and methods: this is a prospective and multicentric study with the participation of hospitals in catalunya (spain). the objectives are to improve the evaluation and the initial management of trauma patients, and to improve the knowledge of the frequency, the magnitude and the approach of these trauma patients. we defined points to improve which are: to intubate patients with glasgow < ( ); to not remove the cervical collar without clinical or radiologic cervical exploration ( ); to move trauma patients monitorized ( ); to not move haemodinamically instable trauma patients ( ); to use two thick intravenous cannulations ( ); to take thorax and pelvic simple radiographies in the trauma box ( ); to fix pelvis fracture with a grassland before moving the patient ( ) we took more thorax and pelvic radiographies in the trauma box (from . % and % in the first period to . % and . % in the second period, p < . ). and we also fixed more pelvis fracture with a grassland before moving the patient, from % in the first period to . % in the second period. conclusion: the registration of the information about trauma patients allows the identification of the points to improve. we improved the evaluation and the initial management of the trauma patients, especially in the monitorization of trauma patients and in the management of the thoracic and pelvic traumatism introduction: there is wide evidence about the importance of having good protocols for assisting trauma patients and a teaching system for the personnel involved in this assistance is needed. it is also well known that the formation for assisting trauma patients in spain is not very much spread in general. material and methods: we describe how we have arranged the care for this type of patients in a level ii center and a teaching system for our staff and we prospectively analyze the impact of this specific formation by means of a questionnaire and analyzing how correctly the trauma team is activated. results: from november through october ( months), editions of our course have taken place and people have participated ( , % of the staff for whom the course is aimed to). we found a clear improvement on the results of the test (prior and after the course: % of improvement for physicians and % for nurses, p < . ) and the qualification of the final exam was superior. the incidence of rightly activated trauma team improved as the staff was completing the course. conclusion: we conclude by enhancing the importance of having adequate protocols for treating these patients and the correct means for teaching the personnel because they can improve the care of these patients. (tonk) score. this system is specialty specific and tries to eradicate the weaknesses in a previously published scoring system, which was generic. material and methods: a total score of is assigned to each firm from the beginning and marks are deducted for missed documentation. sets of notes are randomly selected from discharged patients for each firm, one from trauma and one from elective surgery, each having at least entries. each case note is given marks and the total deduction for both case notes are then subtracted from the total score of to give the resultant score. the tonk score has four major parts comprising initial clerking, subsequent entries, discharge letter and legibility. an objective system of scoring the legibility of medical notes is part of the tonk score. this scoring system is easily reproducible and it's been validated using the kappa statistic. introduction: despite the increasing mechanization in medicine, clinical skills must be to the fore of medical occupation and consequently must have a main focus in medical training. especially in surgery, the mastery of basic clinical skills is of great importance for the young learner as it besides the knowledge of elementary principles substantially contributes to the understanding of the subject, the development on the wards, the operation theatre and the ambulance. in order to assure a standardized training using reliable, effective modern teaching methods, a ''train-the-teacher''-course was developed. material and methods: in an -hour training, the important teaching modalities and methods for surgical skills as skills lab, simulation, role play, -step approach are presented and trained in small groups with a maximum of participants per group. furthermore, the training focuses on ,,giving adequate feedback'' and examining practical skills. the training is evaluated using a standardised evaluation form. furthermore, the teachers are evaluated by their students after each of their teaching sessions before and after the training. results: a total of surgeons participated in the training program ( chief physicians, senior physicians). overall, the training was rated to be very good ( %) or good ( %). in students' evaluation, there was a significant increase in positive ratings for teachers' didactical compentencies as well as for their overall training after the participation in the training program. introduction: sports injury risk management and prevention is a very complex challenge that must be addressed . one of the basic tasks is to perform epidemiological studies to estimate the risk in different types of sport. up to now many studies were conducted on injury rates in specific organised sports . just a few taking into account any physical activity (pa) . therefore only for specific sports data about the influence of higher sport skills on injury risk can be found . the goal of our study was to investigate the relevance of motor skills and sport education on injury risk, including the total pa and the occurrence of any injury in any type of sport. material and methods: in two austrian secondary schools (gymnasien) fifty-five of classes were asked to fill out a two sided questionnaire regarding pa and sports injuries within the last year. demographic data and information about the types of sport, the intensity and the occurrence of injuries was collected. pupils, from a ''normal'' school (ng) and from a ''sports-school'' (sg) filled out the questionnaire. in the sg every child has to pass an entrance exam containing basic coordinative and motor tasks as well as complex motion sequences in different types of ballgames. in the educational program of this school a strong emphasis is placed on sports. in the ng just the basic sport lectures are held. results: the total physical activity (pa) containing organised, unorganised sports and leisure time activities was significant higher in the sports-school (sg), . hours per week vs. . h/w (p < . ). the most performed types of sport were similar: in the sg soccer (n = , %), riding bike (n = , %) and running (n = , %); in the normal school (ng) riding bike (n = , %), soccer (n = , %), snowboarding (n = , %) and running (n = , %). proportionally there were more boys than girls in both schools: % boys, % girls vs % boys, % girls. boys ( . h/w, . h/w) were more active than girls ( . h/w, . h/w) in both schools. the rate of injury was statistically significant higher in boys ( . ) than in girls ( . ) (p < . ). the mean age was higher in the normal school . vs . years. the proportion on injured children was at the same highest level ( %) in and , and , and in and year-olds. the ratio of injury per pupil is statistically significant higher in the sg ( . ) than in the ng ( . ) (p < . ). but including the extension of activity the injury risk is a little bit lower in the sg: . injuries in hours of pa vs . . conclusion: it seems that better motor skills and intense sport education have no effect on the population risk . the individual risk has to be investigated more extensively in future studies. references: fuller, spinks, spinks, schwebel disclosure: no significant relationships. introduction: pain is one of the main complaints of trauma patients in emergency medical care ( ). in the netherlands, a third of all prehospital emergency medical systems (ems) rides concern trauma patients and yearly . patients are treated in the accident & emergency department (ed) due to an injury. significant deficiencies in pain management in emergency medicine have been identified ( ) . as a consequence, patients unnecessarily suffer from pain, and also recovery and healing are delayed. furthermore, chronic pain is reported one year after trauma ( ). there is no appropriate systematic approach to acute pain management in the chain of care for trauma patients in prehospital ems and the ed. aim: the aim of the research project is the development of a national evidence-based guideline for the management of acute pain in adult trauma patients in prehospital ems and the ed. during the open reduction we applied a incision allowing to remove soft tissues and to set fragments of fractured bone correctly. in patients we performed close reduction of the fracture without the fixation because of a patient's age. results: xr month after surgical procedure was done and in all cases we achieved consolidation of the ulnar fracture and good of radial head reduction. complication after the treatment was the paresis of the median nerve, neurosurgical procedure needed. the nails were remove , month after procedure ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . after obtaining the union of the fracture and rehabilitation of the limb we removed the nails ( - month after procedure). conclusion: featured way of the operative treatment doesn't claim wide opening region of the fracture and reduces possibility of complications. dislocated radial head after close reduction and immobilization period shows full stability. years. data and x-rays were retrospectively gathered and analyzed. all fractures were scored according to the ao-pediatric classification. patients were treated with solely closed reduction and cast immobilisation and patients were additionally treated with k-wire fixation. spss version . was used for all statistical analysis. results: incidence of recurrent dislocation was significantly higher in patients treated solely with closed reduction ( %) compared to patients treated with additional k-wire fixation ( %) (p . ). the proportion of patients requiring a second surgical intervention was also higher in patients treated with closed reduction: % versus % of patients treated with additional k-wire fixation (p . ). additional k-wire fixation results in a relative risk reduction of % and % for recurrent dislocation and secondary surgical interventions respectively. complications of k-wire fixation comprised local infection (n = ) and k-wire migration (n = ). conclusion: additional k-wire fixation might reduce the incidence of recurrent dislocation and secondary surgical interventions after closed reduction of displaced distal forearm fractures in children. larger and randomized studies will have to be obtained to confirm the results from our data. radiographic controls were planned after one and six month and until the removal of the intramedullary nailing. we documented all peri-and postoperative morbidity, further operative procedures, the radiographic findings as classified by capanna and the time till removal of the nails. results: a cohort of children (four girls, six boys) was recruited. mean patient age was , years ( - y). the bone defects included eight juvenile and two aneurysmatic bone cysts. four patient suffered earlier unsuccessful treatment after pathologic fracture. the other six presented with acute pathologic fractures (five humeral, one femoral). no postoperative complications occurred after the treatment combination of elastic intramedullary nailing, curettage, artificial bone substitute and autologous platelet rich plasma (gps Ò-system). the radiographic findings showed at six month a total resolution of the cysts in eight cases (capanna typ i), in two cases a tiny residual cyst remained (capanna typ ii). the removal of the nails was possible after six to nine month. one fourteen year old boy (typ ii capanna) wished a further gps application to reach a total resolution. all patients showed very good functional results and no refracture occurred. conclusion: the gpsÒ-system enhances the treatment of bone cysts in children. it is a save method without additional perioperative complications. by this, total treatment time can be shortened and secondary procedures as difficult changes of the elastic nails will be lessened. technically the decisive factor is the debridement of the . albumin values were significantly lower in patients with two or three complications than those with zero complications (zero and two complications p = . , zero and three complications p = . ). no significant difference in levels was found between one and zero complication (p = . ). admission albumin was not significantly lower in patients with wound infection than those without ( . ± . g/l versus . ± . g/l, p = . ). patients with a dry and intact wound had a higher mean albumin value than those with wound healing complications (mean albumin ± . g/l versus ± . g/l, p = . ). conclusion: our study findings support the hypothesis that lower preoperative albumin levels are associated with a more adverse inpatient post-operative recovery. these patients can be identified and optimised early in preparation for adverse events likely to occur in the post-operative period. material and methods: the targon fn is a new kind of side plate with six locking screw ports. the two distal holes are used to fix the plate to the lateral cortex of the femur with angle stable . mm cortical screws. the proximal holes allow the implementation of up to four ''telescrews'' which cross the fracture site. these . mm screws are dynamic and allow therewith the collapse of the fracture at the femoral neck. we present a prospective study on patients with a comparative patients case control with a total hip cementless arthroplasty for the same indication at the same period. results: this new device show a lower incidence of complications on the first weeks than with the total hip group. wereas the month control show no difference between the two groups. there are an x rays neck collapse one year folow up in osté oporotic patients with singh an stade with no significant consequences on the functional score. conclusion: targon fn is a good alternative for older and multimorbid patients with less surgical burden and reduced early access morbidity in comparison to the prosthesis group. conclusion: the number of re-interventions and the mortality within one year after hip fracture surgery is sizable. nonetheless, our numbers are not unfavourable in comparison with international literature. the percentage of re-interventions in the cannulated hip screw group is significantly higher than in the other subgroups. on the contrary, the mortality in this group is low. this is undoubtedly an expression of our attempts to preserve the femoral head in vital, active patients. possibly, the combination of the two standardsnamely the re-intervention and mortality-is a new accurate performance indicator. informed. the operative treatment with lcp and tension bandages shows small morbidity regardless the comorbidities and the geriatric cohort. it remains standard procedure for periprosthetic fractures of the femur at our institution. we are expecting the number of periprosthetic fractures to be increasing rapidly. introduction: periprosthetic femoral fractures are rare but severe complications following total hip-or knee-arthroplasty. the incidence for of these fractures are increasing, caused by a raising frequency of total arthroplasty for both younger and elderly patients as well as by a higher life expectation. so far there are very little long-term results regarding this issue. material and methods: patients ( female, male) with a mean age of years ( - ) were clinically and radiologically examined on average months after surgery. we investigated the prosthesis (total hip arthroplasty vs. total knee arthroplasty) and compared the treatment (revision arthroplasty vs. osteosynthesis) in this study. for the clinical examination we used the harris-hip-score (hhs), oxford-hip-score (ohs), the oxford-knee-score (oks), the sf- and the funktionsfragebogen hannover (ffh) which measured the functionality of patients in his daily routine in his environment. results: tha + osteosynthesis (n = ) % of the patients had fair or better results with an average hhs of . % of this group had a good or excellent result with an average ohs of and % had a ffh score of ‡ %. % of the patients had a possible hip flexion of ‡ °and ( % ‡ °). the average sf- score for this group was . tha + revision arthroplasty (n = ) % of the patients had fair or better results an average hhs of . % of this group had a good or excellent result with an average ohs of and % a mean ffh score of ‡ %. % had a possible hip flexion of ‡ °( % ‡ ° the results of the scores are mainly caused by the high age, the common multimorbidity and the low overall functionality of the patients and confirm the severity and importance of these kinds of fractures. most authors suggest a treatment of these fractures according to the classification by using osteosynthesis to treat stable fractures and revision for unstable fractures. however we see a slightly better outcome of the revision arthroplasty compared to the patients that were treated with osteosynthesis. we suggest more studies with a higher number of patients regarding this issue. introduction: fracture dislocation of the proximal humerus is a rare but challenging situation for the orthopaedic surgeon. if a closed attempt to reduce the dislocation fails, a demanding surgical procedure is required and the emergency setting is not always the best situation to face difficult cases. as a matter of fact a proper approach to this fractures involve an experienced surgeon, more than one assistant and a variety of instrumentation that often lack in emergency. fracture dislocation of the humeral head is related with a significant increase of the risk of the humeral head necrosis and it is widely accepted that these lesions are best treated in emergency, but there are no reports on the influence of the dislocation time on the results of the surgical procedure. with this study we wanted to determine if a delayed procedure could affect the outcome of these lesions and if there is a rationale in postponing the procedure to allow a better organisation of the surgical time. material and methods: we retrospectively analysed the clinical and radiological records of patients admitted at out institute for fdhh between jan and jan . ten out of them were operated in emergency while with a minimum delay of hours. all the patients underwent open reduction and fracture fixation with locking plates. results: the results of the two groups were similar and influenced mainly by the bone quality and age of the patient. it seems that a delay in the procedure do not alter the result in terms of rate of necrosis of the humeral head or influence a worse clinical outcome conclusion: on the basis of these results we do not consider these fractures as emergencies anymore: our preference is still an immediate operation provided the presence of an experienced surgeon, assistant and nurse and the availability of the proper instrumentation, conversely we believe that the risks of an immediate procedure overwhelm its benefits. introduction: minimal invasive plate osteosynthesis (mipo) should belong nowadays to the armentarium of each trauma surgeon. applied correctly, mipo not only meets the criteria of a ''biological'' osteosynthesis by minimizing invasivity as well as iatrogenic soft tissue damage caused by the operation, but can also provide adequate reduction and stability for fracture healing and early functional aftertreatment. up to date, only few publications report on mipo of humeral shaft fractures mainly using the antero-lateral deltopectoral approach for plate insertion - . material and methods: in this present study, we evaluated patients (mean age years, range - ) with displaced metadiaphyseal fractures of the proximal humerus treated in mipo technique using an angular stable long philos Ò -plate. a lateral deltoid-split approach was used proximally and a brachialis/ brachioradialis intermuscular approach with exposure of the radial nerve was used distally. there were acute fractures including two periprosthetic as well as one pathological fracture. three patients were operated after failed conservative treatment, one for delayed-union and two cases were revision surgeries. results: there were no infections and no iatrogenic injuries to the axillary and radial nerve, respectively. all the patients were immediately allowed active shoulder and elbow movement. one patient had to be reoperated ten weeks postoperatively for redislocation of the distal fragment with screw breakage, which was most likely due to incorrect screw placement. this patient was successfully operated using the same method and implant. whereas one patient refused follow-up, patients showed entirely healed fractures and satisfactory shoulder and elbow function after a mean follow-up of months (range - months). conclusion: minimal invasive long philos Ò -plate osteosynthesis using a combined lateral deltoid-split and brachialis/brachioradialis intermuscular approach proved to be a safe and viable procedure for the treatment of metadiayphyseal fractures of the proximal humerus with low morbidity and good functional outcome. introduction: plating for reduction and stabilization of proximal humerus fractures is a common orthopaedic procedure. however, angular and rotational malalignment is not an infrequent result, and extensive use of fluoroscopy is commonly involved. we checked the accuracy of a computerized navigation system(vector vision trauma navigation system, brain lab) to enhance multiplanar fracture reduction and to decrease the requirement for fluoroscopy. material and methods: men and women aged to (mean, ) years underwent philos plate fixation for proximal humeral fractures. all fractures were closed with no associated injuries and classified as -a (n = ), -b (n = ), and -b (n = ), according to the ao classification. the cases were assessed operation time, radiation time. and accuracy measurements were taken. results: patients were followed up for to (mean, ) months. all the fractures united and occured no avascular necrosis. the mean operation time and radiation time were minutes (range, - ) and . minutes (range, - ). the mean distance between fluoroscopy and navigation of reduction accuracy at the fracture site were . mm (range, - ). conclusion: the fluoroscopic operation using pilos plate was troublesome, but navigated operation was easy to reduce the fracture because of the direction visualization at the same time. and computerized navigation has the potential for increasing precision in fracture reduction while minimizing fluoroscopic requirements at proximal humerus fractures. introduction: the proximal humerus fracture is a frequent fracture in the elderly people. the lower density of the bone with increasing age is one of the main reasons for implant failure after osteosynthesis with a range of - %. the options of therapy are including the screw-, platelet-or nail-osteosynthesis or the endoprosthesis.belonging to failure rates and the demand for early activity there is a tendency to be seen for early and strong stabilisation. material and methods: since august proximal humerus fractures were operated with the retron-humerus-shortnail. the average of age was , +- , ( - ) years. the demographic data, bone quality and fracture classification were documented including procedure of reposition, details of the implants, complications and postoperative course. results: there were , % a fractures, , % c , , % c and , % c fractures (ao-classification). the reposition was done in a closed mannor with a direct percutaneous assistance respectively. intraoperatively secondary dislocations and corticalis brake was to be seen. there have been insufficient nailing procedures. screws had to be exchanged. the gymnastic began immediately after operation or with a delay of - weeks depending on the fracture classification. the evaluation of the constant score is on the way. the results show a good stability of the nail especially in osteoporosis. comparing with platelets or antegrade nailing it is a minimal invasive procedure. the exraarticular access avoids any damage to the shoulder structures, especially to the rotator muscles. therefore early gymnystic of the shoulder is possible. shoulder impingement, screw dislocation and problems with the shoulder are avoided principally. the learning curve is short. shoulder score was used to evaluate functional outcomes. anova was used for statistical analysis, with significance set at p < . . results: files were available on patients. failure rate was . % at mean follow-up of . years and a mean ases-score of . . there was a reoperation rate of . %. mean age at operation was . years. mean operative delay was days (range - ). delay did not influence outcome. young age at operation was associated with better results. when evaluating fracture characteristics significant better outcomes were evaluated with ao type aand b-fractures, valgus or neutral fracture type, the presence of impaction and less displaced fractures. quality of reduction and fixation of the fracture was evaluated with significant better results with anatomic reduction of the medial cortical border, less residual displacement and a ccd-angle that was corrected or in residual valgus. osteosynthesis failed significantly more in c-type fractures, in fractures with an avascular head fragment, in varus displaced fractures and in fractures where an anatomical reposition was not obtained. introduction: fractures of the proximal humerus are responsible for - % of all fractures.the most extensive used operative treatments are the plate osteosynthesis and the intra-medullarry nail fixation with proximal locking nailsscrews. especially the latter technique can give iatrogenic injury of the axillary nerve. in this study, we define a safe-zone by using radiological parameters material and methods: the following procedure was performed in ten shoulders of embalmed specimen. first, the deltoid muscle was dissected from the clavicle. then the axillary nerve was identified together with its branches and was marked with clips and radioopaque wires. the muscle was then re-attached to its anatomical position.standard ap radiographs were made with the forearm in neutral (anatomical) position and exorotation. on these radiographs, the distance between the cranial side of the humeral head and the axillary nerve and its branches was measured. results: the median distance from the head of the humerus to the axillary nerve is mm (sd = . mm, range - mm) measured on the ap radiograph in degrees exorotation. the mean number of branches to the deltoid muscle is three. the distances vary from to mm. the median distance from the first proximal branch measured from to the humeral head is mm (n = , range - mm), to the second branch mm (n = , range - mm), to the third branch mm (n = , range - mm) and to the fourth branch mm (n = , range - mm). conclusion: there is a great variation in the course of the axillary nerve and its branches. with the insertion of an intra-medullar nail from the proximal side or by placing locking-screws nails the surgeon has to reckon with the course of this clinically important nerve. it is unsafe to place the locking-screws nail in the zone between mm and mm from the humeral head with the arm in exorotation. the greatest risk to damage the main branch of the axillary nerve is in the zone between and mm. this study provides distances to avoid damage to the axillary nerve. in contrast to the existing literature these distances are measured from the humeral head. there are several reasons to use the humeral head instead of the acromion are: first, the distance between the humerus and the acromion can vary due to the preceding trauma, relaxation of the deltoid muscle or by manipulation of the arm. second, from an anatomical perspective, the position of the axillary nerve is determined by the position of the humerus due to the connection to the deltoid muscle. results: emg/eng records were without pathologic variances of the axillary nerve. of them pre-operatively showed pathologic variances. of these continued to show variances months after the operation, which indicates a chronic lesion. just one patient showed a pathologic eng after surgery which was not seen before. the constant score was as expected. introduction: patella recurrent dislocation and patellofemoral pain syndrome is a common cause of instability in young patients and especially athletes. in the present study we present the results of the extension mechanism realigment throughout the fulkerson oblique osteotomy of the tibial tubercle and soft tissue balancing. material and methods: during the last two years patients ( men, women, mean age . / range - ) were treated operatively for recurrent dislocation of the patella using the fulkerson procedure. all our patients had as onset a traumatic dislocation of the patella that developed to recurrent. all patients were underwent knee arthroscopy for the treatment of potential chondral trauma or loose bodies removal and lateral retinaculum release. after that, we performed oblique osteotomy of the tibial tubercle, medialization and internal fixation with two cortical screws. this oblique osteotomy provides additionally to the medialization, anteriorization of the tibial tuberosity as we move it medially. moreover we perform medial plication. all patiens used functional brace locked in  º immediately after the operation and gradual rom increase untill the th p.o. week. results: the patients had no initial or long term complication. during their last follow up examination had a painless knee with full rom and marked improvement of the patella tracking. the mean lysholm score was improved from . to . . no patella dislocation was referred. conclusion: our findings show that fulkerson procedure of the tibial tubercle osteotomy and anteriomedialization, with additional intervention on the lateral and medial patella retinaculum is an excellent option for the treatment of recurrent patella instability and relief of patellofemoral pain. disclosure: no significant relationships. introduction: injuries to the knee involving the anterior cruciate ligament (acl) are very common related to sports especially in soccer and skiing. more than % of those with acl injury will develop radiographic osteoarthritis (roa) within years of injury although it is not known if return to sports is a risk factor for longitudinal roa development. in this retrospective study, we evaluated the long term radiographic and clinical results of acl reconstruction by comparing the injured knee with the contralateral knee in athletes returning to pre-injury sports. material and methods: twenty-eight patients ( men and women, mean age years at the time of acl surgery, bmi . ± . kg/ m ) were studied. patients returning to previous sports and without meniscal injury at baseline were selected. acl reconstruction was performed using patella tendon or hamstrings tendon graft. radiological assessments using x-ray and a -t mri of both legs were obtained at a mean follow up of years after acl reconstruction. roa was determined according to the classification of bohndorf. the ikdc score and tegner activity index were used for clinical evaluation and the knee injury and osteoarthritis outcome score (koos) for evaluating self-reported knee function. results: the -t mri revealed positive signs of roa on the operated knee in % and on the non-operated knee in %. these changes were however limited to small localized areas of the knees. the statistical difference of morphological and clinical outcome of acl reconstructed patients weeks after injury vs. replacement after this period showed no significance (p = , - . ). the total ikdc score was . ± . points and the total koos was . ± . . the median pre-injury tegner score was (range - ) corresponding to (range - ) at follow up. in % of the patients the tegner score was unchanged from pre-injury to follow up. according to the ikdc score % had type a symptoms, % type b, % type c, and none type d. conclusion: eight years after acl reconstruction in athletes returning to pre-injury sports, the risk of developing knee roa in the injured knee was not higher than the risk of developing roa in the contra lateral knee. disclosure: no significant relationships. radiographs and a mri of the knee were available for all patients. all patients were followed prospectively and lysholm, tegner and ikdc score were surveyed before treatment and after at least months. after diagnosis, a brace immobilization with tibial supporter with full extension of the knee was applied for weeks followed by another to weeks of pcl brace with tibial supporter and posterior elastic rubber band to prevent posterior sagging of the proximal tibia. all patients received concomitant physiotherapy. after at least weeks, stress radiographs were taken for evaluation of the pcl. the further treatment depended on the harner classification based on the stress radiographs. in cases of grade a or asymptomatic grade b injuries, conservative treatment was continued. in cases of symptomatic grade b, grade c or d injuries, operative treatment with arthroscopic transtibial pcl reconstruction using single bundle hamstring tendons was performed. results: patients were treated conservatively (group i), patients had an arthroscopic pcl reconstruction (group ii). mean patient age was . years (range - years). the mean tegner score in group i raised from . before treatment to at follow up, in the operative group from . to . . the mean lysholm score ascended in the conservative group from to , in group ii from . introduction: the virtual reality (vr) d arthroscopy surgical simulator provides arthroscopy training on knees in a controlled, stressfree, and virtual-reality environment. it is unknown whether better visomotoric three-dimensional ( d) condition will facilitate arthroscopic training. therefore, our objective was to evaluate the visomotoric condition to novice individuals and assess whether visomotoric abilities ameliorates arthroscopic performance within a d surgical environment. material and methods: medical students without any knee arthroscopic experience were investigated. both groups received a fixed protocol of simulator based arthroscopic skills training and a visomotoric skills test. this consisted of an arthroscopy of a longitudinal meniscus tear on a vr knee arthroscopy simulator. . their learning curve was assessed objectively using motion analysis. time taken, path length and roughness for probe and camera were recorded. results: motion analysis demonstrated objective improvement in performance during simulator training, if visomotoric skills performed better. conclusion: better condition of visomotoric skills lead to subsequent improvement at an arthroscopic vr skills training simulator. this may assume that visomotoric skills training before arthroscopic vr skills training is a useful tool. however further studies are necessary to find preliminary practice exercises to get a better performance at an arthroscopic vr skills training simulator. -ii and c-iii after tscherne § open fractures o-ii and o-iii after gustilo o urgent operative treatment § first stabilisation with miniosteosynthesis and external fixation § soft tissue debridement and their temporary closure o second look after - hours, next looks after the soft tissue condition o delate treatmentdefinitive stabilisation -osteosynthesis conversion in - days after injury. o type of osteosynthesis § orif with lcp distal tibia platesmedial or anterolateral § imterlocked intrtamedullary nail § external fixation -in cases of serious soft tissue defects we prefer fracture stabilisation ae serious soft tissue defects closing with rotation or microsurgery stem lobs. introduction: fractures of the distal tibial metaphysis account for . % of fractures over the distal end of the tibia. many of them are high-energy injuries causing extensive articular damage and compromise the soft tissues. managing these fractures continues to challenge most orthopaedic surgeons, as soft tissue injury could be further compromised by unjudicious surgical technique. aim of the treatment is to restore physiological alignment of the distal tibia and stabilize the fracture with minimal damage to soft tissues. material and methods: we designed an implant for the stabilization of distal tibial metaphyseal fractures, and gave the name ''angle stable''. the features of the implant are: precontoured plate with holes above the distal metaphysis providing positioning of screws with angular stable characteristics. the screws are self tapping and self cutting at the threaded part (far end) and have a cylindrical shape with a rim at the near end, that tightly fits into the holes at a special angle, guided by a targeting device. the distal screws penetrate the opposite cortex, and when they are tightened, compression is achieved. the plate is introduced through a small incision and guided onto the surface of distal tibia. screws can be inserted distally, proximal screws are inserted through stab wounds. biomechanical tests of this system were performed on cadaver bones. since the ''angle stable'' system has been used in patients in cases as a primary stabilization, and in cases as conversion of external fixation. follow-up time was months. outcome was assessed with regard to function, pain and alignment. introduction: the fracture of the distal lower limb with or without participation of the ankle joint remains a challenge to the surgeon. due to the high energy released at the time of fracture, these injuries are usually accompanied by a severe soft-tissue damage. the success of the surgical therapy of tibial pilon fractures depends largely on the extent of the soft tissue damage as well as the quality of reconstruction of the tibial joint surface. a problem of the minute anatomical reconstruction is an increase in soft tissue problems and bone infection. aim of this study was to investigate the results gained by a primary stabilization by external fixator followed by a multidirectional locked plate osteosynthesis after soft tissue consolidation. material and methods: setting is a level trauma centre, the design a consecutive series with a retrospective data evaluation. between and , patients with high-energy fractures of the tibial plafond were treated using a two-staged treatment plan: . the fracture was stabilized with an external fixator immobilizing the ankle joint. . after stabilization of the soft tissue situation (mean . days) internal fixation with a locked-screw plate was performed. the implant used was a multi-directional locking internal plate fixator (tifix, litos, hamburg/germany), made of pure titanium with locking holes for titanium screws which can be fixed in different angles and is available in seven different lengths ( - holes in the diaphyseal area). the mean follow-up time was . months. all follow-up examinations were supervised by a specialized orthopedic trauma surgeon. the examination consisted of a set of standardized questions, clinical evaluation, the aofas score and radiographs. results: superficial wound-necrosis was noted times, conservative treatment led to complete wound healing. dvt of the injured leg occurred in cases. in cases autologous bone graft was necessary after and months. deep wound infection or postoperative osteomyelitis was not observed. the definitive treatment was performed after an average of . days. in cases an autologous bone graft was used. in a further cases a later autologous bone graft was performed for delayed union at and weeks after orif. full weight bearing was reached after an average of . weeks. bony union was achieved in all cases after an average of . months as determined by conventional radiographs. in cases range of motion (rom) of the ankle did not show any restriction compared to the opposite side. in cases the range of motion was reduced by less than / compared to the opposite side, of up to / in patients and restriction of > / was not noted in cases. the mean aofas score was . . conclusion: a twostage treatment plan in fractures of the distal lower limb with external fixation followed by locked-plate osteosynthesis reduces local complications with a good functional result. disclosure: no significant relationships. introduction: the internal fixation for complex distal tibial fractures is sometimes challenging. nowadays, successful outcome were reported about osteosynthesis through medial and anterior approaches including minimally invasive plate osteosynthesis (mipo). however, there are cases in which such methods are not indicated because of their soft tissue problems or their fracture pattern. in this presentation, the new posterior plating procedure using the mipo technique is reported. material and methods: this procedure was indicated only when no other internal fixation methods were present, which includes intramedullary nailing or medial/anterior plating, were found. so the indication for this procedure was extremely rare. from to , cases of ao classification -a and c type fractures were treated operatively in our institution. cases met the criteria. both of them were female and aged and . the follow up period was and months. the procedure was as follows; before the operation, the spanning external fixator was applied and the alignment was reduced as properly as possible. the patient was in the supine position and the knee was flexed at about degrees. the distal window for mipo was positioned between the distal fibula and achilles tendon, which is called a ''posterolateral approach.'' blunt dissection was performed, and exposed the edge of the flexor hallucis longs muscle (fhl). the tunnel over the periosteum at the posterior surface of the distal tibia was made and the plate was inserted. then an incision was made at the posteromedial border of the tibial shaft and exposed the proximal part of the plate (proximal window). the plate was placed properly under the image intensifier and fixed with screws. the wounds were irrigated and sutured in layers. postoperative rehabilitation included a range of motion exercise and non-weight bearing gait and use of crutches immediately begun. full weight bear was permitted around twelve weeks post operatively. time to union, complication and final ambulatory ability were evaluated. results: bony union was uneventfully completed within three months in both cases. there were no complications such as infection, skin problems, or plate irritation/impingement. free gait was achieved within four months in both cases. conclusion: posterior plating using the mipo procedure for complex distal tibial fractures can be a good option, although our experience is very limited. however, this procedure should be indicated only when no other osteosynthetic methods are found because irritation/ impingement of the fhl or the achilles tendon or some other complications may arise, which has already been reported in open reduction and internal fixation through posterolateral approach. references: hayes ag, nadkarni jb. extensile posterior approach to the ankle. j bone joint surg ; b: - . disclosure: no significant relationships. introduction: even the most modern technology has failed to induce satisfactory functional regeneration of traumatically severed peripheral nerves. delayed neural regeneration and in consequence slower neural conduction seriously limit muscle function in the area supplied by the injured nerve. this inferiority study aimed to compare a new nerve coaptation system involving an innovative prosthesis with the classical clinical method of sutured nerve coaptation. besides the time and degree of nerve regeneration, the influence of electrostimulation was also tested. material and methods: the ischiatic nerve was severed in female gö ttinger minipigs with an average weight of approx. - kg. the animals were randomized electronically to four groups: group i: nerve prosthesis without stimulation; group ii: nerve prosthesis with stimulation; group iii: microsurgical coaptation without stimulation; group iv: microsurgical coaptation with stimulation. in groups iii and iv, the nerve was sutured microsurgically, while the animals in groups i and ii received the new nerve prosthesis. postoperative monitoring and the stimulation schedule covered a period of months, during which axonal budding was evaluated monthly. results: preliminary data indicate that results with the nerve prosthesis are comparable to those with conventional coaptation. the results of this pilot study indicate that implantation of the nerve prosthesis allows good and effective neural regeneration. this new and simple treatment option for peripheral nerve injuries can be performed in any hospital with surgical facilities as it does not involve the demanding microsurgical suture technique that can only be performed in specialized centers. disclosure: no significant relationships. in mean there were , previous operations. in cases a change of osteosynthesis was neccessary. in cases bmp was used alone. in cases bmp was expanded by autologeous bone grafting. in cases the bmp was extended by autografts or ceramic scaffolds. results: divided in a healing group and a not healing group we found in the healing group a excellent clinical result by . points (able for sports) for the atrophic non unions and a good result of . points (walking long distances) for the post infected non unions. the radiological score is as high . / . ( cortices healed and bridging callus). in the non healing group the clinical rate was . / . (walking with splint) and the radiological rate was . / . (two cortices healed) the overall healing rate was %. divided in several groups the healing rate increases from % (infected non unions not tibia) to % (atrophic aseptic non union tibia). overal the secondary intervention rate was %. the healing time is . months in the middle. we see only mild side effects in %, like swelling. the most serious complication was the bony reinfection in %. there were amputations. conclusion: compared to the literature the healing rate of non unions could be increased using a strong concept in the treatment. as a part of the treatment the bmp treatened group increases the healing rate from % (friedlä nder) to %. the results are similar to the papers from kanakaris or zimmermann. there were no significant side effects noticed. material and methods: methods: at our level i trauma institute, from july, to september, each patient who presented with a clavicle fracture that was deemed operative received plate fixation alone or supplemented with bioresorbable calcium phosphate cement or autogenous bone grafting. patient records and radiographs were retrospectively reviewed. follow-up included standard radiographs to evaluate union at a minimum of months. all complications were also reviewed. results: results: two different clavicle plating systems, smith and nephew (smith and nephew, memphis, usa) ( clavicles) and implant technology systems (i.t.s., lassnitzhohe, austria) ( clavicles), were used with orif alone ( ), autogenous bone graft ( patients), or bioabsorbable calcium phosphate ( clavicles). of patients treated with open reduction internal fixation, complications have occurred at a minimum of month follow-up. three prominent hardware occurrences necessitated plate removal. one nonunion, one distal screw cut-out and one hardware breakage have been treated successfully with revision plating. using fisherâ e tm s exact test, no statistical significance was seen between the orif alone, autogenous bone grafting ( ) and bioabsorbable calcium phosphate ( ) in regard to overall failure incidence (p = . ). complications necessitating revision orif with bioabsorbable calcium phosphate ( ) and bone graft ( ) were not statistically significant either (p = . ). conclusion: there appears to be no statistically significant difference between union and complication rates between orif alone, or orif augmented with bioresorbable calcium phosphate cement or autogenous bone graft in this retrospective study. introduction: the purpose of the present study was to determine the effect of two anti-osteoporotic treatments on fracture healing in osteoporotic ovx rats, days after fracture occurrence. pth which has been proven to influence fracture healing in ovx rats, was taken as a control treatment. strontium ranelate is acting on both resorption and formation. we combined the rat model of a closed, standardised diaphyseal fracture of the femur with the model of a post-ovariectomy osteopenic rat, mimicking post-menopausal bone loss. material and methods: forty-five animals were ovariectomised at the age of weeks and a further were sham operated. at the age of weeks, osteopenia in the ovx rats was diagnosed. then, in all animals, a standardised mid-diaphyseal fracture was induced. at the time of fracture, the animals were divided into four groups. group was the sham control group, groups , and were the ovx treatment groups. groups and were treated with nacl . % s.c. daily, group was treated with mg/kg/d strontium ranelate p.o. daily and group received lg pth - x/ week s.c. the animals were killed after days and the fractured femur removed. the samples were scanned using microct by scanco medical, zurich, switzerland. the evaluation of the data focused on outer callus contour, cortical contour and marrow contour as well as cortical thickness. torsion testing on the bones was carried out using the axial-torsional system by instron (darmstadt, germany). results: treatment with strontium ranelate significantly improved the mechanical properties of the callus when compared to the ovx control group, while the improvement induced by the treatment with pth - did not reach significance. pth - and strontium ranelate both showed a significant increase in bone volume of the callus when compared to ovx control rats with no significant difference between the two treatments. as for the callus tissue volume, the increase induced by strontium ranelate was significant compared to ovx whereas pth induced no change and the difference between both drugs was significant . in both the pth - -and strontium ranelate-administered animals bv/tv was significantly increased compared to the ovx control rats . the bv/tv of the pth-treated rats was even higher than in the sham rats. conclusion: this is the first report on the enhancement of fracture healing with strontium ranelate. the callus in strontium ranelatetreated animals is even more resistant to torsion in comparison to ovx and sham-untreated animals and even to those treated with pth - . pth did not significantly enhance the resistance of the callus versus ovx, despite a significant increase in bv/tv within the callus. the superior results obtained with strontium ranelate compared to pth could be the consequence of a better quality of the new bone formed within the callus. introduction: recent clinical and animal studies suggest an elevated homocysteine serum concentration to be a risk factor for osteoporosis and fragility fractures ( ) . in vitro studies showed that increasing homocysteine concentrations stimulate the activity of human osteoclasts ( ). however, there is no data demonstrating that circulating homocysteine is related to structural and biomechanical properties of human bones. this study aimed to investigate the relation between morphological as well as biomechanical bone properties and homocysteine serum concentrations in humans. material and methods: fasting blood samples and femoral heads were obtained from males and females who underwent hip arthroplasty. bones were assessed by dual energy x-ray absorptiometry (dxa), biomechanical testing (indentation method), and histomorphometry. blood was sampled to measure homocysteine, folate, vitamin b , and vitamin b . according to their homocysteine serum concentration, subjects were classified as hyperhomocysteinemic (> lmol/l, n = ) and normohomocysteinemic (< lmol/l, n = ). results: folate and vitamin b , but not vitamin b , were significantly lower in hyperhomocysteinemic subjects when compared to controls. however, dxa, biomechanical testing, and histomorphometry did not reveal significant differences in bone quality between hyperhomocysteinemic subjects and controls. the results of the present study do not indicate a significant relation between circulating homocysteine and morphological as wells as biomechanical bone properties. introduction: sometimes fractured bones heal poorly with standard treatment and sometimes a bone defect is a major problem. although the bone grafting technique is considered a standard, there is a need for enhancement of this procedure. healing of the cancellous bone is a complex process in which many inflammatory and signaling molecules take part. to improve the outcome of the healing process, one can influence it by applying platelet rich plasma gel locally, thereby releasing cytokines and growth factors ( ). cancellous bone is rich with mesenchymal stem cells that produce new bone when stimulated. material and methods: we enlisted patients with hard to heal fractures and fractures that demonstrated poor healing in the study. five of the patients had osteomyelitis in the fracture and all fractures resulted in a bony defect as a serious complication after treatment. we designed a protocol for the preparation of allogeneic platelet rich plasma gel with suspended autologous cancellous bone, based on laboratory experiments in vitro ( ) . cancellous bone was harvested from iliac bone crest. we used standard ab and rhd identical, leukocyte depleted and irradiated platelets from a blood bank. activation of the platelet gel was achieved by using a cacl and thrombin mixture. we accepted patients after fulfilling the inclusion criteria and they were operated on in a standardized manner by their elected surgeons under technical supervision. in their follow-up, the ingrowths of bone grafts were measured by using x-ray analysis ( ). results: in patients the transplant was sufficiently incorporated in the fracture to give a limb full function. there were no major complications related to the platelet rich plasma additives. in one patient a nerve paresis was observed, which resolved spontaneously. in patients bone graft was not sufficiently incorporated, once because of poor compliance and the other time because of complex nature of distal tibia fracture. the clinical outcome of the operated patients ( %) is satisfactory and encouraging. conclusion: the preliminary clinical results show that using platelet rich plasma and cancellous bone in the treatment of large bone defects has a promising therapeutic potential. ( ) marx re. platelet-rich plasma: evidence to support its use. time from injury to reduction and to surgical intervention was noted. apoptosis was verified by microscopy with tunel, hematoxilin and eosine stained specimens after decalcification of the samples, a time consuming process. the number of live, apoptotic and necrotic chondrocytes were counted. the patients are followed with harris hip score, merle de aubigne score and radiographs for two years. results: patients were admitted directly to our hospital, the rest transferred from other hospitals. patients had their hip reduced after a mean time of minutes. had femoral traction applied and patients were not reduced. mean time from trauma to operation was ± . days. three patients received total hip arthroplasty. the results of will be presented at the congress. conclusion: the conclusions will be given at the presentation. introduction: distal inter-locking using free-hand technique in intramedullary nailing is always a time consuming procedure. the use of xray amplifier is mandatory and the exposure to radiation is rarely modest. if we use navigation devices we rarely trust the device completely and that is why we check the position with x-ray amplifier more than we need to. that is why we did laboratory testing of the new system using the electromagnetic navigation with the use of micro sensors for free-hand interlocking technique in laboratory without the use of x-ray amplifier to ensure the use of system in the operating theatre. material and methods: three residents with little experience in distal interlocking and no experience with this device were testing the electromagnetic navigation system with the use of micro sensors for free-hand interlocking technique. interlocking holes were drilled by the use of guiding star platform in lidis module, ekliptik, slovenia. the system producer had minutes of introduction time, afterwards drilling was done. distal locking was done on utn synhes nail and instead of bone, cannulated hard wood rods were used. we measured time needed for calibration and time needed for reaming and weather we were successful or not. introduction: percutaneous catheter drainage (pcd) is a useful method to manage pericardial effusion. however, pcd is not always effective in a case of hemopericardium due to clot. to perform subxiphoid pericardiotomy within a minute for emergency cases, we have done this procedure in a blind method following finger dissection by subxiphoid approach, which was preliminary reported in . we present the final data to report the usefulness of blind subxiphoid pericardiotomy (bsp) for emergency cases with acute hemopericardium. material and methods: we designed a study to determine a favorable management for cardiac tamponade due to hemopericardium. emergency patients with acute hemopericardium secondary to trauma (n= ), acute aortic disease (n= ) and cardiac rupture following acute myocardial infarction (n= ), were the subjects. board certified surgeons performed bsp (n= ) and other emergency physicians performed pcd (n= ) for patients with cardiopulmonary arrest (cpa) or near cpa due to cardiac tamponade from to . since , bsp (n= ) or pcd (n= ) has been performed at the physicians' discretion. results: bsp was effective to relieve cardiac tamponade in all cases but pcd was ineffective in cases ( . %, p=. ) because of clot in pericardium (n= ) or right ventricular puncture (n= ). in addition to ineffective drainage, acute occlusion of percutaneous drainage tube (n= ) were observed and resulted in deaths in the pcd group. procedure-related complication rates of bsp and pcd and survival rates of bsp and pcd were % and . % (p=. ), . % and . %, respectively (p=. ). sixteen patients (bsp, ; pcd, ) could discharge following emergency surgery (n= ) or conservative treatment (n= ). conclusion: blind subxiphoid pericardiotomy was safe and could be performed quickly in an emergency situation. percutaneous catheter drainage for hemopericardium could not avoid critical complications because of clot in pericardium in some cases. disclosure: no significant relationships. introduction and objectives: heart trauma, mostly penetrating, is not common in our community, but carries a significant morbidity. its clinical presentation can be variable. our objective was to asses the incidence, clinical presentation, associated injuries and mortality of our patient population with trauma to the heart. material and methods: observational, descriptive, retrospective analysis of patient with heart trauma included in our trauma registry between and . we reviewed demographic characteristics, mechanism of injury, associated injuries, injury severity score (iss) and new injury severity score (niss), mortality, triss probability of survival (ps), and hospital length of stay. results: we found ( . %) patients with cardiac traumatism out of . patients included in our registry, ( %) with associated injuries and ( %) isolated; ( . %) were from penetrating trauma, and only ( . %) were from blunt trauma. mean iss and niss were of (+/- ) and (+/- ), respectively. three patients presented ''in extremis'' (agonal status), nine presented with hemodynamic ''stability'' (sbp> mmhg) ( % of them with a hr> bpm), and five patients presented with hemodynamic instability. only % of the patients presented with cardiac tamponade, without hemothorax. two pericardiocentesis ( %), pericardial windows ( %), and emergency room thoracotomies were done ( . %). the most frequent location was in the left ventricle, followed by right atrium and right ventricle. the most frequent associated injuries were in the lungs ( %), followed by the abdomen and vascular injuries ( . %). fifty-nine percent required icu admission, with a median length of stay of days. ten patients died ( %), and three of them ( . %) were dead on arrival. two patients ( . %) died with a ps > . . conclusion: heart trauma is not frequent in our community, and displays great variability in its clinical presentation, with a high mortality. over half of the patients presented with hemodynamic ''stability''. disclosure: no significant relationships. approach of two cases of secondary aortoesophageal fistula results: the st patient was a -y-old man in which fistula was secondary to a fish-bone ingestion, days before the admission. in the nd cause, a -y-old man, fistula was secondary to rupture in oesophagus of a known thoracic aortic aneurysm. diagnosis was made by a contrast-enhanced ct scan; a gastrografin x-ray in the st and an endoscopy in the nd case completed the examination. in both cases the lesion consisted of a few-mm-diameter defect of the oesophageal wall. in the i case an emergent endovascular repair of thoracic aorta by bolton relay · mm stent graft was per-formed; in the ii case, endovascular repair of thoracic aorta (by bolton relay x mm) was associated to an endoprosthesis placement for primary treatment of a preexisting infrarenal abdominal aortic aneurysm. postoperatively tpn was administered. definitive treatment of fistula was performed in both cases by an explorative right thoracotomy (in v and vii post-operative day respectively): oesopagus was primarily repaired and reinforced by a pedicled intercostal muscle flap and a nutritional jejunostomy was associated. subsequent post-operative course consisted in ne administration, prolonged nasogastric suction, resuscitation with fluids, antibiotics. hemorrhagic complications or infections were excluded by repeated ct scan. oral feeding was in th and th postoperative day, after exclusion of a persistent fistula at a gastrografin x-ray of oesophagus. hospital stay was of days in both cases. no late complications were registered at follow-up. conclusion: when an aortoesophageal fistula occurs (if consists of a small oesophageal lesion), emergent treatment of endovascular aortic repair can be successfully associated to a second-step primary repair using a pedicled intercostal muscle flap via a right thoracotomy. results: case : a -year-old male is taken to our hospital after a car crash. on ct scan there was a periaortic hematoma from isthmus to diaphragm, multiple rib (flail chest) fractures, and a pelvic fracture. the aorta was repaired with an endograft with good immediate results. case : a -year-old male, injured in a frontal car crash. on ct scan a mediastinal periaortic hematoma was seen, with a pseudoaneurysm at the origin of the descendent thoracic aorta, distal to the sublavian artery. the aorta was repaired with an endograft, which was replaced at day th because of a leak. on follow-up he is doing very well. case : a -year-old male, injured in a car crash. ct scan findings were as follows: a left diaphragamatic herniation, bilateral lung contusion, traumatic laceration of the descending aorta, pelvic fracture and spleen laceration. he underwent an emergency laparotomy with splenectomy and diaphragmatic repair. on the nd postop. day an endograft was placed at the descending thoracic aorta, without complications. case : a -year-old male, injured in a frontal car crash. on ct scan there was a thoracic aortic laceration, distal to the isthmus, and an aortic endovascular repair was undertaken at day th , after complete hemodynamic normalization. the patient died at day th from multiple organ failure. conclusion: traumatic thoracic aortic injuries are frequently associated to severe thoracic, abdominal and orthopaedic injuries. traditional early surgical aortic repair through thoracotomy, with single lung ventilation and, occasionally, extracorporeal circulation carries a high morbidity and mortality. that is the reason why aortic repair has classically been delayed, but this carries an additional mortality rate of between % and %. endovascular treatment allows for an early management in severely traumatized patients who otherwise wouldn't stand such a risky surgery. it has also revealed lower rates of paraplegia after years of follow-up. introduction: injuries in zone i of the neck are rare and difficult to manage particularly in environment of war. this area gathers aerodigestive, vascular, lymphatic and nervous elements. all the difficulties lie in diagnosis of the lesions, in the decision of a surgical exploration and in the way of repair if necessary. in that situation, fistula between carotid artery and jugular vein is very uncommon, accounting for % of all arterial injuries. through one case, which has occurred in afghanistan, we discuss the various possible solutions to repair such a lesion. material and methods: we report one case of a french soldier, yo, who was wounded by a rocket splinter on left side of the area i of the neck. he was transported immediately in french role ii in kaboul. respiratory tracks are not injured, there's no neurologic lesions. he had a huge haematoma of the area with a tracheal back pushing (xray exam). during an effort of cough, a haemorrhage through the wound occurred requiring an oro-tracheal intubation and a surgical exploration by a cervicotomy. no obvious vascular lesions were found but just a thrill at the base of the neck. the patient was hemodynamically stable. he was transferred by medevac to france in the night. an angioscanner showed a fistula between carotid and jugular vein ( photos). results: he was re-operated h after. the fistula was just behind the first rib requiring an enlarging by sternotomy to control the origine of left carotid. there was a section of left pneumogastric nerve. after exclusion of the fistula and the vein, we interposed an allograft on carotid artery ( photos). the patient discharged from the hospital one week later without lateral damage except a bitonal voice with no need of re-education. conclusion: arterio-veinous fistula is an uncommon consequence of carotid injury. the taking in charge of this patient and the decision of the kinds of repair are difficult. stenting has also been used to repair distal internal carotid injuries that are not easily approached surgically. the favorable outcome of this case illustrates that surgery is a reasonable alternative when an endovascular approach is not feasible in patients with trauma-acquired arteriovenous fistulae. allograft or vein graft, if possible, is also a good solution for this kind of injuries. introduction: we report cases of subclavian artery injury caused by traffic accidents. in all cases, surgical vascular reconstruction was undertaken. in of the cases, the subclavian artery was obstructed by intimal dissection caused by falling down from a motorcycle. in the remaining case, subclavian artery aneurysm caused by seat belt injury occurred. material and methods: case : -year-old male while driving a large motorcycle, the patient collided with a car and the left side of his body was trapped in the car. this resulted in traumatic pneumothorax and severe ischemia of his left upper limb, and he was transported to our level trauma center for surgical treatment. bypass surgery using a mm diameter ptfe was performed. postoperative arteriography showed good patency of the graft and the patient was discharged. recovery from the motor dysfunction caused by brachial plexus injury took months. case : -year-old male for this case, the patient ran into a wall while driving a cc motorcycle. bypass surgery and clavicular orif were undertaken simultaneously for right clavicular fracture and ischemia of the right upper limb. postoperative arteriography showed good patency of the graft and the ischemia improved. however, rehabilitation was needed for the motor dysfunction caused by brachial plexus injury. case : -yearold female the patient ran into a tree while driving a car resulting in hemorrhagic shock caused by bilateral femoral and humeral fractures. she was transported to our center by helicopter. a scar from seat belt injury was found in the right cervical area. she presented with an expanding mass around the subclavian artery with accompanying pulsating pain. arteriography detected a cm-diameter pseudoaneurysm and aneurysmectomy was undertaken. postoperative computed tomography confirmed the disappearance of aneurysm and she was discharged. results: these cases showed favorable outcomes with surgical vascular reconstruction. conclusion: traumatic subclavian artery stenosis is caused by crushinduced local dissection and is frequently complicated with brachial plexus injury. subclavian artery aneurysm caused by seat belt injury occurred. disclosure: no significant relationships. results: case description: years old male patient who was brought in after receiving a large stab wound below the mid-portion of the left clavicle. severe external bleeding was prevented by manual compression in transit to the hospital. three foley catheters introduced through the wound at the ed failed to temporarily control the bleeding due to its large size, and he was rushed to the or. an emergency left antero-lateral thoracotomy allowed for the blind manual compression of the bleeding vessel from within the thoracic cavity, and was very successful in stopping the external bleeding. a long supra-and infra-clavicular incision was done, and the clavicle was divided. this failed to expose the bleeding vessel, due to the large muscle mass of the patient. a decision was taken to split the sternum in a ''trap-door'' approach, which nicely exposed a large laceration of the subclavian vein. this was suture-ligated, and the incision closed, in a surgical field with profused oozing from coagulopathy. he was taken to the icu, and then back to the or two hours later because of persistent bleeding through the chest drains. the ''trap-door'' incision was reopened and careful haemostasis was performed. the patient had a protracted course in the icu but eventually recovered. as a striking and very uncommon sequel he developed severe blindness from bilateral ischemic optic neuropathy attributed to hypotension and use of vasopressors. he is free of pain at the incision and with good cosmetic results conclusion: ''trap-door'' incisions are very infrequently used nowadays, but should be kept in mind in the armamentarium of trauma surgeons. disclosure: no significant relationships. conclusion: mortality in patients with ivc injuries can be well predicted by hemodynamic parameters on arrival and intra-operative findings .hemodynamic instability and intraoperarive findings of expanding hematomas and active intra-peritoneal bleeding are associated with high mortality. introduction: vascular complications due to intravenous drug abuse pose significant challenges to vascular surgeons and no standardized surgical management of the resultant infected pseudoaneurysm was established. material and methods: we present our successful management of a case of an expanding retroperitoneal haemathoma due to external iliac artery pseudoaneurysm caused by self inflicted trauma (heroin administration). mri showed an external iliac artery pseudoaneurysm surrounding by an infected old haemathoma, venous thrombosis (external illiac and femoural) and multiple muscular abscesses of the left thigh. a self-expandable stent-graft was deployed across the pseudoaneurysm after crossing the lession with an exchange glide wire through the left brachial artery route. post-stenting angiography showed complete exclusion of the pseudoaneurysm with no residual stenosis. we decided local surgical debridement; after haemathoma evacuation we identified external illiac artery presenting a stent graft and reinforced it by double layer of tissue sealing surgical patch. results: postoperative course was favorable under complex general and local therapy. conclusion: endovascular treatment of arterial pseudoaneurysms has become feasible as natural extension of the endovascular techniques. ct, mri, sonography and angiography may all be valuable in the imaging working of pseudoaneurysms. prompt diagnosis and treatment are necessary to avoid the morbidity and mortality secondary to hemorrhage and rupture. although endovascular stent-grafting is not considered a standard therapy for infected aneurysms, our case suggest that stent-graft deployment, secondary surgical debridement and major antimicrobial therapy may be the most favorable treatment option for patients unfit for major surgery. introduction: the incidence of traumatic vascular injuries (tvi) has increased significantly in the last decades, with penetrating trauma as the most frequent mechanism. our aim was to estimate the incidence, management by interventional radiology, and the preventable death rate in our patient population. material and methods: a retrospective observational study based on our trauma registry covering a -year period (july to july ) . we have assessed the demographics, severity, diagnostic and therapeutic approaches, outcome, and triss probability of survival (ps). results: patients ( % males, with a mean age of years) suffered a tvi located at the head ( ), neck ( ), thorax ( ), abdomen ( ), upper extremities ( ) and lower extremities ( ), respectively. ( . %) were caused by a blunt mechanism, and ( . %) by an open one. the average time spent before being taken to hospital was minutes. upon arrival to hospital, were in shock, required orotracheal intubation, and a cardiac massage. the diagnostic methods used were a ct scans in , dpl in , fast in , angiography in , echocardiogram in and duplex-doppler in . ( . %) patients underwent emergency surgery and ( . %) were treated with interventional radiology ( of them associated with surgery). only ( . %) were treated conservatively. overall mortality was of patients ( . %) ( of them died upon their arrival to hospital or in the operating room, all of them with an aortic injury), out of which ( . %) had a triss ps > . . the incidence of tvi increased from cases in the - period to in - , remaining stable in - ( ) . however, the mortality rate has shown a steady decline over the years (from % in - , to % in - ) . conclusion: the incidence of traumatic vascular injuries has increased considerably during the last years in our hospital. these injuries are most commonly located in the lower extremities, followed by the thorax. % of patients could be managed by interventional radiology techniques. introduction: the tip apex distance (tad) is a simple measurement that predicts screw cut out in the femoral head in peritrochanteric fractures treated with a fixed angle sliding hip screw device. we wanted to assess whether the tad measurements in our centre were comparable to previously published results, how reproducible these measurements were between observers and how accurate we were at reducing the fractures. material and methods: a retrospective review was conducted of consecutively treated peritrochanteric fractures over a month period. patients were excluded because they did not sustain a peritrochanteric fracture, had treatment of a pathological fracture or because of incomplete radiographic data. three observers used a standardised method to measure the tad (from orthogonal projections with a correction for magnification). the stability of the fracture patterns and the accuracy of reduction were measured according to criteria from the original baumgaertner paper introduction: distal locking screw insertion of the short gamma nail is normally performed by using a targeting device attached firmly to the proximal part of the nail. generally, the accuracy of targeting device should be promising. however, missing the target in the process of drilling might be a potential risk. we report cases of such condition in term of early radiographic finding, method of solving and the result of treatment. material and methods: the patient records, operative notes and intraoperative c-arm images of the patients underwent short gamma nailing for unstable pertrochanteric fractures during october to october have been reviewed in order to identify an error of distal locking screw insertion via a targeting device. the intraoperative radiographic finding, solving procedure and the outcome has been analyzed. results: there were cases of short gamma nailing over the past one year in our institute. five of which had an error during distal screw insertion even using the targeting device. an error occurred in the drilling process in all cases. intraoperative images showed that the drillbit missed its target posteriorly after perforating the near cortex of the femur. all has been corrected by using a free-hand technique under c-arm guidance. no any serious complication afterword and all fractures healed in an appropriated time. conclusion: distal screw insertion during gamma nailing can be missed even though using the targeting device. therefore, radiographic confirmation on the lateral view after perforation the near cortex is recommend in all cases in order to obtain early detection prior to bicortical perforation. freehand technique can be carried out in order to correct the error. . systemic antibiotics were used in patients ( %). ten different types of antibiotics were used after wound exploration for a period between and weeks. in-hospital mortality was %. sixty-nine percent (n= ) was finally discharged from follow-up. conclusion: we conclude that our infection rate was higher than reported in literature and the infections classified initially as superficial required a prolonged treatment as well. moreover, the treatment of this disastrous complication showed no uniformity whatsoever and should be the topic of further research, resulting in a clear protocol to increase survival and decrease morbidity. introduction: allograft meniscal transplantation is known as a possible procedure to solve pain and loss of function in the knee of patients with a history of subtotal or total meniscectomy. medium-term and long-term results after meniscal allograft transplantation in the knee are scarce. in this study patients who received an arthroscopically assisted meniscal allograft transplantation with a follow-up between and years were evaluated using subjective questionnaires, a clinical and a radiographical evaluation. material and methods: demographic data of all patients were collected and pre-operative results, using the koos (knee injury and osteoarthritis outcome score), the lysholm score, the tegner score, the sf and the vas (visual analogue scale) for pain were compared with actual results of those questionnaires to evaluate the therapeutic effects of allograft meniscal transplantation in the knee during medium-term follow-up. patients were evaluated with a standardized clinical examination of the knee to objectivate knee related symptoms. standard weight bearing radiographs and a full leg standing radiograph were performed to evaluate the evolution of osteoarthritis and malalignment. results: for all questionnaires (vas, koos, lysholm, sf ) there is a significant (p< , ) and clinically relevant increase in postoperative score. this improvement stays consistent during the followup period. the more severe the osteoarthritis, the lower the improvement. despite the meniscal transplantation, there is still a significant (p= , ) increase in osteoarthritis. an increase in osteoarthritis grade was seen in % of the patients, as scored following the kellgren-lawrence classification. when strictly respecting the indications, there is no significant correlation between preoperative cartilage damage, pre-operative osteoarthritis, alignment deviation, gender and body mass index on the one hand and outcome scores or improvement on the other hand. conclusion: meniscal allograft transplantation results in important pain relief and functional improvement in patients with a history of (sub)total meniscectomy and pain localized in the affected compartment. strictly following the indications, meniscal transplantation can give good and predictable results. introduction: intramedullary nailing of the tibia has become the conventional therapy for tibial shaft fractures. one of the most common complaints associated with this procedure is chronic knee pain. incidence rates between % and % have been reported and a significant number of patients have problems in kneeling, affecting professional and recreational activities. surgical damage to the infrapatellar nerve is one possible causative factor for post-nailing knee pain. the infrapatellar nerve is exclusively sensory and runs subcutaneously almost perpendicular to the patellar tendon just below the patella. the purpose of this study was to determine the prevalence of chronic knee pain in our institute and its relation with sensory disturbances in the knee area. material and methods: a chart review was conducted. all patients between and years with healed traumatic tibial shaft fractures treated with an intramedullary nail between and were included. exclusion criteria were: fracture lines extending into the knee or ankle joint, any other fracture in the affected leg, lacerations in the knee area, pre-operatively existing knee pain and loss of follow-up. chronic knee pain was defined as persisting pain in the knee area months after tibial nailing. sensory disturbances were defined as hyperesthesia or anesthesia at the nail entry site. introduction: femoral nailing causes an influx of fat in the circulation. in the multiply injured patient, especially in the patient with concomitant lung or brain contusion, this can lead to ards, fat embolism syndrome and multiple organ failure. the timing and kind of fixation of femoral fractures in patients with multiple injuries is controversially. the advantage of damage control orthopaedics (external fixation) would be less fat embolisation but some authors report more problems of infection and delayed healing. the aim of our study was to investigate the effect of external fixation on healing and infection rates of femoral shaft fractures in the multiply injured patient. material and methods: between january and januari , we treated femoral shaft fractures. in this group there where polytrauma patients with a total of fractures. we compared the rate of infection and delayed union in the group treated by damage control external fixation to the group primarily treated by intramedullary nailing. results: no significant difference in infection or union rates could be demonstrated between the damage control external fixation and the primary nailing group. we also noted that there's a correlation between the complexity of the fracture and the percentage of prolonged healing. and although not statistical significant there seems a tendency of less healing problems with the reamed femoral nail in comparison with the unreamed femoral nail. introduction: the diagnostic information power of a level one emergency room has risen excessively within the last years. the need for quality control, judicial regulations, insurance claims and forensic reasons still lead to a high number of autopsies being performed in patients not surviving the first h after admission to the er. however, the number of autopsy clarification featured in a level one trauma centre after trauma related deaths considerably vary and also the rate of deathly diagnoses missed within er assessment of early stage deceased patients differ in the literature. the aim of this study was to assess the value and necessity of autopsy after modern er assessment with a multi-slice ct-scan as an integrated part of the diagnostic algorithm. material and methods: prospectively reviewing our emergency database, case histories, laboratory values and radiological findings compared to findings in autopsy between jan and sep , we charged for missed deathly diagnoses in early stage deceased trauma patients (< h). patients were classified into two groups: group : patients with limited diagnostic assessment (conventional xray, sonography). group : patients with full er assessment (msct). all patients in group could not be sufficiently stabilised in terms of circulation patterns and therefore did not receive full assessment. non-trauma patients and patients reaching the er under cpr were excluded. results: the autopsy rate of all included patients was %. the overall incidence of missed deathly diagnoses was . %. in terms of missed deathly diagnoses, groups varied significantly (group : . %;group : . %).the iss after autopsy increased significantly in group from to . . in group there was no difference of iss between status emergency room and after autopsy. the most concerned region of missed deathly injuries was thorax with . % of all patients with autopsies followed by pelvic ( %) and spine injuries ( . %). conclusion: in spite of complete and nearly ideal conditions within a modern emergency room assessment nowadays, detecting all diag-noses is still challenging. overall, our findings show that almost every tenth early stage deceased patient showed at least one missed potential deathly diagnose in a level one trauma centre. regarding the insufficient assessment performance in group , the relative high rate of missed diagnoses seem explicable. nevertheless, even having acquired full assessment power (group ), still . % deathly diagnoses were missed. for this reason, autopsy is still the most powerful and indispensable tool in finding the ''whole'' diagnosis. completeness of autopsies after trauma related death therefore is essential referring a continuous gain of quality. introduction: in a physiological environment metallic biomaterials undergo corrosion through a variety of mechanisms. this study investigated whether, beside the well recognized electrochemical aspect of corrosion, human osteoclasts are able to directly corrode titanium alloys, uptake and finally release corresponding metal ions into their environment. the released ions are believed to cause inflammatory reactions and activate osteoclastic differentiation and activity, which most likely play a role in the pathophysiological mechanisms of aseptic loosening [ ] . material and methods: human monocytes and in vitro generated osteoclasts were seeded onto titanium and aluminum (positive control) foils. after days scanning electron microscopy analysis was performed in order to assess whether monocytes were able to grow and differentiate on the metals. in order to visualize uptake and distribution of intracellular metal ions, a novel protocol using confocal microscopy analyses with newport greentm dcf diacetate ester staining was developed [ ] . additionally, the concentrations of metal ions released into the culture supernatant were measured using atomic emission spectrometry. ). nine bre-gfp mice were used. mice were allowed unrestricted activity. a mini-external fixator fixed to the proximal and distal tibia was applied under general anesthesia on day . the animals were permitted full weight baring and unrestricted activity after awakening from anaesthesia. the gfp signal of tibia and fibula in bilateral limbs was measured on days , , , and after application of the external fixator. results: baseline measurements of the gfp-signal ranged from . x e photons to . x e photons between individual mice. after application of the external fixator, the gfp signal of the unloaded tibia and fibula decreased in all mice to on average % of baseline on day (sd ± %, p = . ), % on day (sd ± %, p < . ), % on day (sd ± %, p < . ), % on day (sd ± %, p = . ) and % on day (sd ± %, p < . ). in the contra-lateral non-operated limb, the gpf signal increased to an average % on day (sd ± %, p = . ), % on day (sd ± % p < . ), % on day (sd ± %, p = . ), % on day (sd ± %, p < . ) and % on day (sd ± %, p < . ). introduction: the aim of the present study was to assess the effect of antibiotic loaded fresh-frozen allografts and compare it with antibiotic loaded acrylic bone cement in staphylococcal tibia osteomyelitis and to combine the effects of bone repair and eradication of infection in one stage surgery. material and methods: a unicortical . -mm-diameter defect was created in the proximal tibial metaphysis of thirty-six new zeland albino rabbits. after contamining the wounds with x colony forming units of staphylococcus aureus, we divided the animals into four groups. the negative control group received no treatment, the positive control group received teicoplanin-impregnated polymethylmethacrylate beads, the allograft group received fresh-frozen allografts and the experimental group received teicoplanin-impregnated fresh-frozen allografts. histopathological evaluation with light microscope were made and intraosseous tissue cultures were performed on postoperative day . clinical evaluation in a daily-routine were made. results: the cultures showed no evidence of intramedullary infection in the experimental or the positive control group in eight of the nine rabbits, but they were positive for staphylococcus aureus in one of the nine rabbits in the experimental group, one of the nine rabbits in the positive control group and all of the rabbits in the negative control and allograft groups. the experimental group and the positive control group has similar effects in eradication of the infection. conclusion: teicoplanin-impregnated allografts was effective in preventing intramedullary staphylococcus aureus infection in a staphylococcal tibia osteomyelitis model. this combination therapy could potentially eliminate the need for surgical removal of cement beads. using an antibiotic-graft compound, eradication of pathogens and grafting of bony defects may be carried out in a one stage procedure. introduction: we first report a case of an infection in humans by streptococcus pluranimalium, a new streptococcal species that has been isolated in the genital tract and tonsils of cattle, tonsils of a goat and a cat, and from the crop and the respiratory tract of canaries. according our knowledge there are a few reports in the literature reporting infections by this strain of streptococcus in animals, but never since now in humans. a year old farmer, fit and well, nonimmunocompromised has been treated in our department, for a close tibial plateau fracture (schatzker vi), with a circular external fixator. postoperatively, i.v antibiotics -cefuroxime mg every h was administrated for hours. radiological and clinical healing of the fracture achieved successfully within weeks of the fracture. the frame removed and the patient was followed up as an outpatient. six days after the removal of the frame, the patient turned up to the a&e department, systematically unwell, complaining for a swollen painful knee, and a discharging abscess in one of the proximal pin sites near by the joint line.fluid samples from the abscess and the knee aspiration, obtained and revealed streptococcus pluranimalium in all samples. debridement of the abscess and an arthroscopic wash out was performed twice, followed by i.v antibiotics according to the sensitivity test (levofloxacin ( mgx ) ceftriaxone ( grx )) for six weeks, and p.o antibiotics (clarithromycin mg every h and levofloxacin mg every ) for another two weeks. results: symptoms were settled and the patient is free of infection for the last months. conclusion: we hypothesized that the bacterium was settled on the wires of the circular fixator and was inoculated in the patient during the removal of the frame. according our knowledge, it is the first case of infection in a human individual by this specific strain of streptococcus. disclosure: no significant relationships. introduction: post traumatic knee joint contracture is the most difficult complication of the lower limbs traumas, considerably limits the functional abilities and make the patients invalids. besides, the frequent consequence of knee joint injure is gonarthrosis, and kinesitherapy is one of the element of the complex treatment. the basis of the procedure is the joint relief, leading to adjoining muscles tonus lessening, and paraarticular tissues general tense lessening and infrajoint hydrostatic pressure, joint tissues nourishing improvement. the introduction: ilizarov frames are still removed in the operating theatre in a lot of centers. this is due to a variety of reasons, the main one being that it is a painful procedure. we decided to evaluate patient satisfaction and pain experienced on removal of ilizarov frames in an outpatient setting, using oral analgesia and entonox. material and methods: seventy consecutive patients, who had their frames removed in the out patients department, had their level of pain scored using a visual analogue score (vas) and a simple questionnaire. results: the mean score for frame removal was . on the vas. there was no difference between male and female scores. the age of the patient does make a difference in the pain score, the pain score decreases with the age of the patient. pain increases when there are or more olive wires to be removed conclusion: removal of ilizarov frames in the outpatient department is a moderately painful but well tolerated procedure. introduction: the proximal metaphyseal tibial fractures are difficult to treat due to their frequent association with tibial plateau fracture and due to their aspect, which is often comminuted and has a significant impact on the function of the knee. surgery has to restore local anatomy and to allow early rehabilitation, meaning proper evaluation and stabilization of the fracture. material and methods: cases, operated between . . - . . (mean age - yrs) with proximal metaphyseal tibial fractures, were analysed. pre-operative planning using ct scan was used. the fractures were complicated with compartment syndrome ( cases) which needed additional fasciotomy.the fractures were stabilized with : plates and screws ( cases) or external fixation ( cases) depending on the soft tissue status. bone graft was used in cases. the patients were monitorised at , , , and months postoperative, concerning: bone healing, restoring of the axis of the knee, joint mobility, septic complications. results: the axis of the knee were completely restored in all the cases. bone healing appeared in all the patients (starting from months- cases, at months in the rest of the fracture) depending on the initial aspect of the fracture. flexion of the knee was limited in cases ( % of the pactients) and extension was affected in patients, depending, also, on the initial characteristics of the fracture. the frequency of the complications depended on the initial aspect of the fracture, initial stabilization, time from intial stabilization to final fixation. conclusion: results after surgery for tibial plateau fractures depend on the initial aspect of the fracture, but also on the results of surgery . the method proposed by the authors, which allows the suspension of the articular surphace, is valuable especially when the fracture is cominuted and has small fragments. the double plate fixation (medial and lateral) with single anterior incision is the best, effective and simple procedure in treatment of complex proximal tibial fractures (type v and vi of schautzker classification). introduction: compartment syndrome is one of the most frequent complications after proximal metaphyseal tibial fractures, due to the anatomical characteristics of this area. the importance of the problem is that the compartment syndrome radically changes the local and general and especially the type of fixation of the fracture. the purpose of this study is to evaluate the impact of the compartment syndrome on the outcome of the patients with this type of fracture, when recognized and treated early and complete. material and methods: the authors analyse cases of proximal metaphyseal tibial fractures treated in the emergency hospital, bucharest, between . . - . . . from these, in cases, compartment syndrome was diagnosed. in all these cases, the patients were operated and the fracture stabilized (with plates and screws in cases and external fixation in cases). decompressive fasciotomy was performed in all the cases with installed compartment syndrome and intra-compartimental pressure was monitored post-operative in all the other cases. frome these, in cases secondary compartment syndrome developed and fascitomy was necessary - hours after surgery the patients are analysed concerning: the moment of surgical treatment, and the characteristics of the patient in that moment, post-operative treatment, the postoperative local and general outcome, local and general complications. results: the incidence of the complications was influenced by the time between trauma and complete surgery. there were cases of superficial infection and case of deep infection, without needing implant removal. all the fractures healed, the interval proved to be longer when external fixation was first used. there were no systemic definitive complications after these trauma. conclusion: compartment syndrome is frequent after proximal metaphyseal tibial fractures and the incidence of this complication was significant in the group of patients we studied, and the outcome was good when the treatment was early and complete . the compartment syndrome influenced the local and general prognosis, due to the importance of microcirculation in healing after trauma. results: a ct pulmonary angiogram illustrated a metallic density, which appeared to lie in the lumen of the main pulmonary artery just proximal to the pulmonary valve. conclusion: in this case, the respiratory symptoms and signs were due to a metallic pulmonary embolus rather than fat or thrombus. formal anticoagulation was initiated and the patient's clinical condition consistently improved without the need for cardiothoracic surgery, although this is described in the literature with retained catheter fragments. eight months after the injury, the fracture has consolidated with the patient returning to work. toid is often necessary to obtain adequate exposure. as an alternative to this we promote the minimal invasive transdeltoid approach. material and methods: the operative technique of the minimal invasive transdeltoid approach is explained in a first section. this approach has the advantage of direct access to the fracture site with more opportunities for adequate reduction and good plate placement without extensive distraction of the muscles. an important step in the procedure is the palpation of the axillary nerve. in a second section the results of a prospective cohort of the first patients treated with this technique will be presented. the neer criteria were used as guidelines for operative treatment. fractures were classified according to the ao-classification. the ases shoulder score was used to evaluate functional outcomes. preoperative xrays were used to evaluate displacement, vascularity of the humeral head (according to the hertel criteria) and ao fracture type. postoperative x-rays were analyzed for quality of reduction of the ccd angle, reconstruction of the medial hinge and reposition of the tuberosities. follow-up x-rays were evaluated for healing, avascular necrosis, loss of reduction and implant related failures of osteosynthesis. the -year-old male patient was taken to hospital after a traffic accident. he was a pedestrian hit by a car. he suffered comminuted proximal humeral fracture on the dominant right side. the fracture was closed. the glenoid cavity was damaged and acromion was broken. the fractures of the v-vi th ribs were found without complication. otherwise the patient's condition was good. he had only a controlled hypertension. for preoperative planning ct scan was performed. as pieces of the humeral metaphysis wedged into the glenoid cavity insertion of glenoid component seemed uncertain. an early shoulder replacement was done on the th day. the denudated fragments were removed. the tubercles with the muscle attachments were preserved. as a long bone defect remained in the metaphyseal zone normal stem would have been insufficient. a cm long stem used in tumor cases was implanted. the length of the arm and size of the humeral head were compared to the intact side. the tubercles were attached to the prosthesis by non absorbable sutures. after the operation long bone defect remained which was filled up by heterotopic bone visible on x-ray. the postoperative period was complication free. fever, severe pain, hematoma did not occur. the arm was in rest for weeks, only controlled pendulum exercises were done from the second week. active physiotherapy was started on the th week. after months the patient finished the follow up treatment. he was pain free and self-sufficient. conclusion: for three-or four-part displaced fractures in which replacement is indicated, hemiarthroplasty with tuberosity reattachment remains the reference treatment/ , /. in trauma cases short prosthesis stem is usually sufficient but in comminuted fractures involving the metaphyseal zone long stem has to be used for certain bone-prosthesis contact. introduction: there is a trend to apply plate and screw fixation directly medial and lateral (so-called parallel plating), and many implants designed specifically for the distal humerus extend more laterally to improve fixation. this may risk injury to the origins of the common extensor and flexion musculature and the collateral ligaments either via operative dissection or by damage to the blood supply. internal plate and screw fixation is often accomplished with subperiosteal elevation of muscle attachments and tight apposition of the plate to the bone, but this should not be done over the epicondyles. plates applied to the medial and lateral aspects of the lateral and medial epicondyles should be placed directly over the soft tissues without elevating or disturbing them. damage to the collateral ligaments could cause elbow instability. material and methods: in order to emphasize these important technical aspects, we report three patients in whom detachment of the origins of the lateral collateral ligament and common extensor muscle origins from the lateral epicondyle led to post-operative instability after open reduction and internal fixation of a fracture of the distal humerus. results: while the cases are very complex and the exact cause of elbow instability by necessity somewhat speculative, our concern is that the operative dissection performed to apply implants to the lateral side of the elbow contributed to the ulnohumeral instability. injury to the lcl is the most common cause of recurrent elbow dislocation. attempts to place a direct lateral implant directly on the bone by elevating soft tissues will put the origin of the lcl at risk. it is preferable to place implants directly over the soft tissues, although there is a risk of interfering with blood supply leading to soft tissue insufficiency. it seems safe to assume that the operative treatment contributed in some way to the instability in each patient. patient one in particular had osteoporotic bone noted intraoperatively, so that one would expect failure to occur through bone with any subsequent trauma. the failure through the ligamentous structures seems to implicate the operative technique. conclusion: in any case, these three patients establish that instability of the ulnohumeral joint is an uncommon complication or sequel of the operative treatment of a bicolumnar fracture of the distal humerus. our intention in reporting these cases is to increase awareness of these potential complications and we encourage others to report any similar cases so that we can learn enough to limit the risk of this complication. introduction: orif of comminuted distal humerus fractures carries a high risk of complications such as secondray loss of reduction, pseudarthrosis and heterotopic ossifications. especially elderly patients with osteoporotic bone quality are struck by these complications. therefore total elbow arthroplasty (tea) is gaining more and more in importance as it has proven to achieve good results in elderly patients with poor bone quality. the latitude total elbow system (tornier inc., stafford, usa) is a modular, convertible implant that allows not only linked and unlinked tea with or without radial head replacement but also hemiarthroplasty. the aim of this system is to reproduce the patient's anatomy to reconstitue the elbow's physiologic kinematics. therefore the latitude prosthesis is offered in four different sizes, respecting the flexion-extension axis and three different humeral offsets based on anatomical findings. the purpose of our study was to evaluate the short-term results after elbow arthroplasty with the latitude system. introduction: it is not always possible to reconstruct complex radial head fractures. as non-anatomical reconstruction and healing disturbances result is loss of motion and severe post-traumatic arthritis of the elbow joint, radial head resection as been proposed for these cases. other authors propose radial head arthroplasty as an alternative to radial head resection to avoid the complications of radial head resection. different concepts of radial head prostheses are available: silicon prosthesis, monopolar prosthesis (loose fit and cemented/thight fit) and bipolar prostheses. evidence is lacking on the exact place for arthroplasty as opposed to radial head resection. to answer this question we performed a systematic review of litterature. material and methods: inclusion criteria are clinical studies reporting on radial head resection or radial head arthroplasty, published between and today in english, french, german or dutch language. a search has been performed using the pubmed and embase databank. a secondary search has been performed based upon the reference list of the included publications. exclusion criteria are: â e¢cadaver or animal studies â e¢biomechanic studies â e¢clinical studies with a follow up of less than years â e¢clinical studies with less than patients data extraction â e¢elbow function â e¢complication rate â e¢arthritis rate data are reported according to the moose guidelines. results: only low evidence studies are available. we did not find any randomised controlled trial comparing resection to radial head arthroplasty. there is evidence that radial head resection results in high complication rates (including arthritis) and poor function in case of elbow instability and/or essex-lopresti lesions. the rate of complications in these indications is higher than for radial head arthroplasty. in cases without instability or essex-lopresti lesion there is a trend to better function in radial head resection. complication rate is higher in the prosthesis patients. the rate of post-traumatic arthritis is not significantly differing between the resection and the arthroplasty group, and remains very high (+/_ %). conclusion: complex radial head fractures remain difficult to treat. based upon the findings of this systematic review we suggest: â e¢that adequate level of evidence studies are a necessity â e¢that in case of fracture without evident instability or essex lopresti lesion resection results in better function and less complications than arthroplasty â e¢that in case of fracture with evident instability or essex lopresti lesion resection results in worse function and higher complication rates than arthroplasty â e¢as secondary arthritis rate remains %, further therapeutic optimisation is a must. often, mortality. a new pelvic stabilizer (t-pod Ò ) provides secure and effective simultaneous circumferential compression of the pelvis. material and methods: in this study we have managed fifteen patients with a prehospital untreated unstable pelvic fracture with signs of hypovolaemic shock with the t-pod Ò . before and minutes after applying the t-pod Ò , heart rate and blood pressure were measured. an x-ray before and after applying the t-podÒ was made to measure the effect on reduction in symphyseal diastasis. results: application of the t-pod Ò reduced the symphyseal diastasis with % (n= ; p= . ). the mean arterial pressure (map) increased significant from . to . mmhg (n= ; p= . ) and the heart rate declined from beats per minute to (n= ; p= . ). in ten patients of whom circulatory response before and after the t-pod Ò was recorded, there were seven good responders, one transient and two poor responders. conclusion: in the acute setting, the t-pod Ò device has a clear compressive effect on the pelvic volume in unstable pelvic fractures. the t-pod Ò is therefore an easy to use and effective way of (temporarily) stabilizing the pelvic ring in an acute setting. introduction: thoracolumbar and lumbar fractures treated with surgical methods aim to decompress the spinal cord and correct the deformity. we aimed to compare the effects of anterior, posterior and anterior-posterior surgery on the local kyphosis angle in thoracolumbar and lumbar vertebral fractures. material and methods: thoracolumbar and lumbar, burst or compression fractured and surgically treated patients were evaluated retrospectively. preoperative, postoperative and follow-up local kyphosis angles were measured on the x-rays and changes in these angles were compared according to the applied surgical treatment methods. results: early application of surgical treatment following trauma decreases the correction loss suffered after surgery. the increase in correction loss continues after removal of the hardware. it is observed that laminectomy applied in the course of posterior surgical interventions has no effect on the correction loss. the length of the implantation, fusion and the addition of a hook to the lamina of the vertebra which is located one segment lower than the transpedicular screw applied vertebra do not affect the loss of correction. conclusion: in the surgical treatment of thoracolumbar and lumbar vertebral fractures, different degrees of correction loss are observed after each surgical treatment modality. considering the corrective effect of combined anterior-posterior surgery on the correction of kyphotic derformity due to trauma and the preoperative local kyphosis angle, follow-up correction achievement is higher when compared with anterior and posterior surgical approaches. domain questionnaire (eq- d), the point self-rated back pain (vas) and device and/or procedure related adverse events. the ethic committee of the hospital did not accept a randomized study because of the results in this proof of concept, they accepted the study with a minimum of patients (based on the results of a previous proof of concept). the incidence of missed injuries without the application of the tertiary survey was % and this incidence has been reduced to % with the application of the tertiary survey (it means a reduction of the . % in the incidence of missed injuries). the incidence of clinically significant missed injuries without the application of the tertiary survey was % and it has been reduced to % with the application of the tertiary survey (it means a reduction of the % in the incidence of missed injuries). the tertiary survey is an essential task in the management of the trauma patients to reduce the incidence of missed injuries and clinically significant missed injuries. introduction: knee-arthroscopy is a complex surgical ability. it is a combination of factors like anatomical knowledge, hand-eye coordination, three-dimensional mental activity and operating experience. surgeons as well as students were not able to train knee arthroscopy before. parts of these abilities were trained by playing video games. former studies indicated a correlation between a better performance in virtual reality (vr) laparoscopy simulation and video game experience. the aim of this study is to show that experienced video gamer perform better in a virtual arthroscopy simulation. material and methods: medical students did an arthroscopy of a longitudinal meniscus tear on a vr knee arthroscopy simulator (the insight arthro vr Ò gmv, madrid, spain). the students completed a questionnaire asking for their game experience: none (n = ), monthly (n = ) weekly (n = ) daily (n = ) before they did the arthroscopy. the simulator assessed different parameters: time, distance moved and roughness both for probe and camera and a global score (combination of all metrics). results: students with game experience (n = ) performed significantly (p <= , ) better than not experienced students (n = ). there is a tendency that the performances get better with more game experience. conclusion: gamer performed better in a vr knee arthroscopy than not gamer. these result correlates to the laparoscopic simulator training. there is a tendency of achieving a better performance in vr arthroscopy simulation due to a higher frequency of playing games. extensive training on the simulator improves the abilities of nongamers with respect to their arthroscopy skills. we will evaluate these dates in the future. ) and mostly injuries of tendons (n = ) and/or vessels / nerves (n = ). buzzsaws of different manufacturers and different price ranges were used. the work conditions were well in all cases, the saws were placed firmly on the ground and the lighting was sufficient. most injuries appeared on the week-end (friday n = , saturday n = ). a break or a meal, taken shortly before the accident, had no influence on the injury risk. all patients had a several years lasting experience in dealing with buzzsaws, half of the patients even for at least years. the safety device of the saw was folded back in most cases (n = ), only few patients (n = ) had correctly put on the saw safety device at the accident time, patients provided moreover no information. the accident had entered in cases shortly before working end, mostly with the last cut. in cases a wooden piece had become stuck in the saw and the patient had tried to solve it. conclusion: a many years' routine in dealing with buzzsaws can lead to the fact that necessary safeguarding measures are not followed any more and so cause an increased injury risk. in particular shortly before working end the attention decreases and the injury risk rises. an especially injury-laden situation is becoming stuck of wooden parts in the saw. the attempt to solve these parts without switching off the saw before bears a high injury risk. the patients showed predominantly heavy injuries. this might be the result of our clinic as a university clinic. patients with less severe injuries are concerned to be treated in smaller clinics next to their residence . ethibond was then used to anatomically oppose the ends of the sleeve fracture. the construct was reinforced with a circlage wire with the wire twisted so that it could be retrieved later through a small lateral incision post operatively the legs were immobilised in lightweight casting material for a period of weeks followed by an unlicked hinged knee brace for weeks. the circlage wires were removed at months. the child now has full, pain free range of motion. the knee is stable and he has no functional problems. conclusion: we report a rare case and emphasize the timing of diagnosis as being crucial in outcome. early operative intervention with accurate open reduction will yield good results. this publication serves to educate and refresh those who deal with general and paediatric lower limb trauma. introduction: the purpose of this study was to evaluate the effect of electromagnetic fields in healing progression of delayed union of long bones in the lower extremities. we defined delayed union, as failure of expected healing progression and nonunion when a minimum of nine months has elapsed since injury and failure or halting of healing progression was observed in three successive monthly radiographs (infection ruled out results: an average of . x-rays were performed on each patient from the time of diagnosis to discharge from clinic. none of these fractures displaced on follow up x-rays. conclusion: stable undisplaced ankle fractures treated conservatively with a below knee non weight bearing cast do not displace. hence these patients do not require to be followed up frequently with serial x-rays as they may be exposed to unnecessary harmful radiation and follow up appointments thereby saving time, money and resources. ( ). we aim to describe the rate of postoperative complications after calcaneal plate osteosynthesis in relation to the hospital fracture load as a means to increase insight into the clinical audit data. material and methods: a search was performed using the disease code for intra-articular calcaneal fractures and operative code for orif for the period - . the medical records of all included patients were obtained. as postoperative complications we included superficial and deep wound infection, mobilisation problems with need for orthopaedic shoes or walking aid and secondary arthrodesis. current complication rate of deep infection and arthrodesis rate from the clinical audit were compared with the mean logarithmic correlation coefficient relating complication rates with the institutional fracture load data, reported earlier in the literature ( ) . results: over a period of months a total of intra-articular calcaneal fractures were reconstructed with a calcaneal plate using orif (mean institutional fracture load = . fractures per month). eight patients had a wound infection, six of them were treated with antibiotics and two of them needed surgical debridement. thirteen patients have mobilisation problems, patients suffered from pain when walking, patients used orthopaedic shoes and one patient mobilised using a wheelchair. two patients had an secondary arthrodesis (n = , . %). in seven patients the osteosynthesis was removed due to pain. both deep infection rate and arthrodesis rates related to the institutional fracture load were below the % ci reported in the literature. the outcome of open reduction and internal fixation of intra-articular calcaneal fractures is known to be determined not only by factors related to patient and the fracture, but also to the institutional fracture load ( ) . the complication rate regarding deep wound infection and arthrodesis is below the data reported in the literature, related to the institutional fracture load. clinical audits studying the complication rate should take the institutional fracture load into account. introduction: toe fractures are the most common fracture of the foot. there is little data on demographics and no studies on functional outcome of toe fractures. material and methods: the initial radiographs of all consecutive patients with toe fractures treated between january and september at the reinier de graaf groep in delft, the netherlands were re-evaluated; patient and fracture characteristics were collected. all patients in aged to ( patients) were sent a questionnaire concerning pain, activity and functional limitations, footwear, walking distance, and gait (aofas midfoot score). overall satisfaction was measured using a visual analogue scale (range zero to ten). results: a total of patients with digital and phalangeal fractures of the foot were identified. the distribution of fractured toes was: first %, second %, third %, fourth %, and fifth %. multiple digital fractures were seen in . %. most fractures were caused by stubbing the toe or a crush injury ( . %). more than % of the fractures were undisplaced or minimally displaced and most fracture patterns were transverse or oblique/spiral. a total of patients ( %) returned the questionnaire with a median follow-up of months. responders were female in . % and had a median age of years (p -p - ). in . % of cases the left side was affected. the median aofas-score was points (p -p - ), the median vas was points (p -p - ). no correlations were identified with outcome and which toe or phalangeal bone was affected, number of fractured toes, fracture type and location, articular involvement, gender, age, body mass index, smoking habits, and diabetes. in the univariate analysis a trend was found for dislocation and aofas score (p = . ). in the multivariate analysis the vas was dependent of age (p = . ) and gender (p = . ). the aofas midfoot score was not influenced by any of the parameters. conclusion: this is the first investigation using two validated outcome scoring systems to determine functional outcome. almost all toe fractures were healed without complaints at months. patient satisfaction is slightly less in younger female patients. the appendix has been one of the most common site of carsinoid tumors( ). carsinoid tm is seen incidental in appendectomised cases( , - , ) and frequently in female( , ). mean diagnosis age is between - in literature, whereas in our serise it is ( ). postoperative living prognosis is good in incidental carsinoid tumors of appendix ( ) .in our cases, additional surgical procedure was not applied because tumor is less than cm, mesoappendix is healthy, and vascular invasion was not seen in hystopathologic examination. introduction: for clinical importance, two cases are presented who were operated with diagnosis of acute apppendicitis. intraoperatively,appendixes were normal, for this reason meckel's diverticulas were explored and diverticulitis were seen. material and methods: two cases are explored retrospectively results: case :the case is years old male patient.he admitted to emergency department with abdominal pain for days.there were defans and rebaund on the right inferior quadrant of the abdomen. leucocytosis( , x /mm ), aperistaltic intestinal ans in ultrasonografic examination were seen. in the operation appendix was normal,so meckel's diverticula researched and diverticulitis was seen at th cm from ileocecal valve.wedge resection for diverticulitis and appendectomy for appendix were performed.in microscopic pathologic examination appendix was normal, and meckel's diverticulitis was seen case :the case is years old male. he admitted to emergency departmant with abdominal pain for days because his pain increased last days. he has nausia, vomiting, fever( , °c), leucocytosis( , x /mm ), defans and rebaund on the right inferior abdomen. in the operation appendix was normal,so meckel's diverticula researched and diverticulitis was seen at th cm from ileocecal valve.wedge resection for diverticulitis and appendectomy for appendix were performed.in microscopic pathologic examination appendix was normal, and meckel's diverticulitis was seen. conclusion: meckel's diverticula is the most congenital anomalies of the gastrointestinal anomalies and it was found % in autopsy ser-ies. ( ) .it is asymptomatic generally. risk of complication is - %( ). preoperative diagnosis may not be done frequently, so to delay of operation may be serious complication.( )in our clinic, we explore meckel's diverticula, over(in female) and duodenum, if we do not see pü rü lant material on the appendix. results: patients with abdominal tb were diagnosed by laparoscopy and peritoneal biopsy in cases and by laparotomy in cases. from these patients we observed peritoneal tb in cases, intestinal tb in cases, mesenteric lymph nodes tb in case. at admission patients presented complications: cases with perforations and peritonitis, case with intestinal obstruction and cases presented as ileo-cecal ''tumors'' (solved by right colectomy); other surgical procedure performed was enterectomy with either entero-entero-anastomosis, either ileo-colic anastomosis. in abdominal tuberculosis ascites was present in cases. other common findings were weight loss ( cases), weakness ( cases), abdominal pain ( cases), anorexia ( cases) and night sweat ( cases). only patients had chest radiography suggestive of a new tb lesion. in those patients with peritoneal tuberculosis subjected to operation, the findings were multiple diffuse involvements of the visceral and parietal peritoneum, white ''miliary nodules'' or plaques, enlarged lymph nodes, ascites, ''violin string'' fibrinous strands, and omental thickening. biopsy specimens revealed granulomas, while ascitic fluid showed numerous lymphocytes. postoperative management was applied by the tb medical system. all patients were treated for months by specific drug therapy, with favorable evolution. pcr of ascitic fluid was positive for mycobacterium tuberculosis (m. tuberculosis) in all cases. introduction: abdominal trauma represents an important cause of morbidity and mortality in children. conservative management is preferred in blunt trauma with hemodynamic stability although there is a risk of intestinal damage when free fluid without solid organ injury is found in image studies. early laparotomy may be unnecessary in most cases but a delay in diagnosis of bowel perforation could lead to increased rate of complications. on the other hand the presence of a penetrating abdominal trauma is considered an absolute indication of laparotomy. we present five cases of abdominal trauma treated in our department in which laparoscopy proved to be an optimal diagnostic and therapeutic tool. material and methods: chart review of our cases and literature review results: three cases of blunt abdominal trauma underwent laparoscopy. we found a small bowel perforation in one case that was repaired by externalization of the jejuna loop by one of the ports. in the other two cases we found intestinal and mesenteric contusions that were treated by peritoneal drainage. two cases of penetrating trauma underwent laparoscopy. one of them presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. conclusion: in our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure in blunt abdominal trauma in stable children with abnormal abdominal examination and moderate free fluid and no solid organ injury in image studies, and it could be a first and sometimes definitive approach to minimal penetrating abdominal trauma. %) patients, biliary tract injury in ( . %) patients, multiple stones in the abdomen due to perforation in ( . %) patients, inadequate technical equipment in ( . %) patients, liver injury in ( . %) patient, intraoperatively detected umbilical hernia in ( . %) patient, uncontrollable bleeding in trocar entry site in ( . %) patient, insufficient insufflation in ( . %) patient, and unstoppable bleeding of arteria cystica in ( . %) patient, respectively. conclusion: although laparoscopic cholecystectomy is the golden standard of treatment in cholecystectomy, it involves the risk of conversion to open surgery. the rate of conversion to open surgery has been reported to be between - % in many series and is considered to be % on average. in our study, we found it as . %, a rate which is close to the rate reported in the literature. chief reasons for conversion from laparoscopic to open cholecystectomy include the difficult dissection of callot's triangle due to obscured anatomy and adhesions, gallbladder perforation, bleeding, the failure to produce pneumoperitoneum, gallbladder cancer, and injury in main biliary tracts and neighboring organs. the presence of pericholecystic adhesion and liquid in acute cholecytitis cases and the presence of edema in the tissue affect regional anatomy and complicate dissection, which increases the risk of gallbladder perforation. in our study, changes due to acute cholecytitis and difficulties in the preparation of callot's triangle ranked first among the indications for open cholecystectomy with a rate of . % ( / introduction: the most difficult decision in the management of the patients with severe necrotizing pancreatitis is whether surgery is required and which of the complementary approaches to necrosectomy and drainage is appropriate. recently a great deal of data has emerged suggesting that a pulsating irrigation stream delivered at high pressure and with a high flow effectively decreases bacteria, foreign bodies, and necrotic crushed tissue in wounds and decreases the incidence of resultant wound infection. this study evaluates the effect of inter pulse jet irrigation, used for the first time in open abdominal surgery. material and methods: twelve patients presenting proven infected/ non-infected pancreatic necrosis during course of acute pancreatitis and not responding to radiological or laparoscopic drainage were prospectively offered necrosectomy using itner pulse jet irrigation. open necrosectomy and subsequent jet irrigation were performed using a midline laparotomy. in all patients, to tube drainages were placed during necrosectomy for continuous closed lavage. temporary abdominal closure using modified mesh-foil laparostomy was applied for relief of abdominal compartment syndrome. results: no intraoperative complications were recorded with a median operative time of +/- minutes. in cases two sessions of necrosectomy were sufficient to completely clear the necrotic tissues. another patients with extended retroperitoneal necrosis required irrigation procedures. necrosectomy using inter pulse jet irrigation was successful in all patients, and none required complementary surgical or radiological treatment. introduction: intra-abdominal hypertension (iah) and abdominal compartment syndrome (acs), have been described often in patients with abdominal trauma or after emergency abdominal surgical operations. we present patients with vomiting, meteorism, acute abdomen and acute respiratory insufficiency provoked by phytobezoars. aetiopathogenesis, symptoms and differential diagnosis are analyzed and a brief report of the literature is discussed. material and methods: three patients, were admitted to the emergency department of our hospital during the last year. all patients were presented with acute respiratory failure, abdominal pain, discomfort, meteorism and vomiting. the first patient, a years old man, alcoholic was admitted with meteorism, acute abdominal pain and discomfort. a fr nasogastric tube was introduced and the symptoms were remitted after gastric evacuation. the second patient suffered from bowel obstruction after closure of colostomy as a result of traumatic injury of sigmoid colon. a laparotomy was performed and a phytobezoar was revealed at the level of anastomosis. the last patient was presented with meteorism, vomiting and dyspepsia, as a result of enlarged gastric mass, revealed after endoscopy. results: gastric evacuation in the first patient revealed lt of fluid mixed with a smelly gas under pressure (iap = cmh o after evacuation) followed by washouts. laparotomy was performed in the second patient revealing a large phytobezoar at the level of anastomosis. mini laparotomy and gastrotomy in the third patient (after two unsuccessful gastroscopies) revealed large phytobezoars. introduction: the objective was the substantiation of using dcs tactics in wounded with ctmi. material and methods: in case of cranial injuries dcs tactics implied treating superficial wounds of skin, arrest of exterior bleeding and subsequent evacuation of the wounded within the first hours after getting trauma. in case of extremity injuries, dcs tactics implied first of all the operations on the occasion of gunshot injuries, including the arrest of bleeding, application of the external fixation apparatuses, application of temporary shunts for injured vessels. the burn wounds treating were carried out after helping the patient out of shock. in case of the wounded with chest injury in the presence of hemo-and pneumothorax, drainage of pleural cavity of silicone tubes with active air aspiration was fulfilled. in case of abdomen injuries after laparotomy abdominal cavity was cleaned and inspected including examination of the most probable sources of bleeding: liver, spleen, magistral vessels. on the background of unstable hemodynamics the abdominal cavity tamponage along the right and left side canals, supraliver and underliver space and small pelvis. results: thus, in accordance with dcs principles in case of ctmi, operations regarding gunshot injuries were made in the first turn, and operations connected with burns -in the second turn. the first were urgent operations. then, intensive therapy in the conditions of resuscitation unit. conclusion: the repeated operation of the second stage -final removal of lesions -was carried out after the condition of the wounded had been stabilized. introduction: the aa highlight the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube. material and methods: man, age , rd pod after total gastrectomy with precolic reconstruction for gastric cancer (t n mxr ) in another institution. no significant past diseases. mechanically ventilated, in septic shock, with purulent drainage from right hemithorax and blue drainage from right abdominal upper quadrant, after ''methilene blue'' swallow. distended abdomen. relaparotomy with median frenotomy (pinotti) and damage control procedures for oesophagojejunal and cardiophrenic pleural sinus perforation by an esophagojejunal tube, with right pleural empyema, mediastinitis and peritonitis: primary closure of the perforation, washing and drainage of the pleura, mediastinum and peritoneum, delayed abdominal closure (dac, rotondo and schwab) and intensive care unit (icu). on th pod, revision of the mediastinum and peritoneum, no evidence of fistula: internal pleural drain retired, fibrin glue and collagen placed to protect the anastomosis, dac and icu. on th pod, anastomotic leak: a ttube (kehr) has been placed as a minimal drainage procedure; dac and icu. on th pod, descendent feeding jejunostomy and abdominal closure. on th pod, subfrenic abscess on ct scan: surgical drainage through the upper third of the previous closed laparotomy. on nd pod, intestinal suboclusion: drainage jejunostomy above the feeding one. on st pod, right pleural drainage: oesophagoscopy, t-tube removed and expansible silicon covered oesophageal prosthesis inserted, covering the anastomotic fistula. on nd pod, patient left the icu. results: on th pod, patient sent back to the institution where he has been operated first. on th pod, endoscopical removal of the prosthesis with baritated swallow control, with patient sent back home. conclusion: this case highlights the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube. disclosure: no significant relationships. y. el-ashaal , a. hefny , y. saadeldinn , f. m. abu-zidan al-ain hospital, department of surgery, al-ain, united arab emirates, al-ain hospital, department of radiology, al-ain, united arab emirates, surgery, department of surgery, uae university, al-ain, united arab emirates introduction: acute gastric dilatation due to superior mesenteric artery syndrome in healthy subjects is extremely rare. herein we report its sonographic findings and highlight the value of point of care bedside ultrasound in such a case. material and methods: a -year old female was admitted to al-ain hospital complaining of epigastric pain of two days duration following excessive eating. she was nauseated but could not vomit. succussion splash was positive. bedside ultrasound has shown a hyperactive duodenum, a distended stomach compressing on the ivc, and a narrowed angle between the superior mesenteric artery and the aorta. these findings were confirmed by abdominal ct scan. the angle between the aorta and superior mesenteric artery was only â -p p . gastrographin follow through has shown complete obstruction of the third part of the duodenum. nasogastric tube immediately drained ml of yellowish fluid. results: five days later gastrographin follow through has shown free passage of the dye to the small intestine with significant reduction in the stomach size. the patient was discharged home in a good condition. conclusion: bedside ultrasound has proven extremely useful for both the diagnosis and management of this rare case. introduction: a rare and potentially lethal complication during right hemicolectomy material and methods: a year-old male, underwent a right hemicolectomy due to malignancy in the cecal region. during the operation the relatively constant venous anastomosis between the middle colic vein and the inferior pancreaticoduodenal vein close to the lower border of the pancreas was injured, resulting in excessive haemorrhage. in the effort to manage the bleeding, the superior mesenteric vein (smv) was torn, and after multiple unsuccessful efforts to repair the vein, we finally had to ligate the smv. the operation was completed by typical right hemicolectomy and the abdomen was closed. five hours later the patient showed acute distention of the abdomen together with respiratory distress. due to increased abdominal pressure (> cm h o), the patient was taken back to the or. the small bowel was edematous, bluish but viable. the abdomen left open and was closed by using the vac. the patient was taken to the icu. six days later the small bowel returned to normal colour and thickness, but the generalized edema made the closure of the abdomen impossible. by day ten the patient was on full enteral feeding, and was taken to the or, where free partial thickness skin grafts were used to close the abdomen. results: the patient was extubated by day sixteen and was taken to the rehabilitation center. conclusion: accidental injury of the venous anastomosis between the middle colic vein and the inferior pancreaticoduodenal vein close to the lower border of the pancreas, may prove a potentially life threatening condition. we present this case in order to point out this rare complication of right hemicolectomy. aimed to explore the influence of different surgical diagnosis groups on long term health status and to make comparisons with general population norms. material and methods: qol was measured in all surviving surgical icu patients admitted to a dutch teaching hospital between and . patient-reported data on qol were collected with the euroqol- d + after a mean follow up of (range - ) years. patient characteristics, surgical diagnosis group, length of icu stay and survival were prospectively registered. eq-utility scores (eq-us), eq visual analoge scales (vas) and prevalences of domain-specific health problems were calculated. the effect of surgical diagnosis group on eq-us/eq-vas was assessed by multivariable generalized linear regression analysis. logistic regression was used to explore the influence of surgical diagnosis group on domain specific health problems. long term quality of life of surgical icu patients was compared to an age-and sex-matched general dutch population using the t-test analysis. results: patients survived the icu and were available for follow up. in ( %) patients the health-related qol was measured. for all surgical groups combined, after - years nearly half of all patients still suffered from problems in the dimensions mobility ( %), usual activity ( %), pain ( %) and cognition ( %). compared to the age-and sex matched general dutch population hrqol was worse with a difference of . on the eq utilities score (range - ). oncological surgery patient had the best (eq-us . ) and vascular patients had the worst (eq-us . ) hrqol. trauma (odds ratio between . - . ) and vascular surgery ( . - . ) showed significantly increased prevalences of problems in mobility, self-care, usual activities and cognition. conclusion: more than years after a surgical icu admission, quality of life of this patient population is largely reduced. many patients still suffer from a variety of health problems, including decreased cognitive functioning. treatment advances should be made to reduce the current health deficit of surgical icu survivors compared to the general population. disclosure: no significant relationships. u. sekmen , g. altaca , s. aktas kalayci , g. moray general surgery, baskent university, ankara, turkey, general surgery, baskent university, ankara, turkey, internal medicine and division of gastroenterology, baskent university, ankara, turkey introduction: predicting the prognosis in severe acute pancreatitis is cruciate in order to constitute effective treatment strategies. material and methods: thirteen consecutive patients admitted with the diagnosis of severe acute pancreatitis according to glasgow or ranson criteria were evaulated. we searched the prognostic values of age, gender, etiology of pancreatitis, comorbidity and labarotory values and their affects on complications and length of hospital stay. results: mean age was , years (range: - yrs). etiology was biliary in patients ( after ercp). acute cholecystitis was also present in patients. patients had diabetes mellitus. two patients had percutaneous cholecystestostomy. five patients had ercp at a mean of , days after admission. cholecystectomy was performed in patients, either at the first admission (n: ) or after - weeks. mean wbc, alt, ast, and ldh values on admission and mean highest hscrp levels and mean lowest serum calcium (ca) levels in the first hours were /mm , u/l, u/l, u/l, and mg/l and mg/dl, respectively. pancreatic necrosis ( , %) was diagnosed by computerised tomography in patients ( / in diabetics, / in nondiabetics); a total of patients ( %) had systemic complications. mean ldh ( u/l vs u/l) and lipase levels ( u/l vs u/l) were higher in patients who developed necrosis, though not statistically significant. other parameters were similar in patients with or without necrosis. two patients who had pancreatitis due to ercp underwent pancreatic necrosectomy. median hospital stay was days (range: - days). all patients survived. mean highest hscrp and lowest ca levels in the first hours correlated significantly with the hospital stay (r: . p: . for hscrp, and r: - . p: . for ca). conclusion: although we have a limited number of patients, we may conclude that high levels of ldh, lipase, hscrp and low levels of ca can be used as predictive factors for severe pancreatitis. pancreatitis seen after ercp and in diabetic patients tend to be more severe. abdomen. abdominal imaging reveals persistent bleeding and multiple bone lesions compatible with bone hemangioma with low blood platelets count -kasabach-meritt syndrome. patient is transferred to a central hospital for arterial embolization of the right hepatic artery that is not effective. the authors describe surgical control of the bleeding without liver resection. second look surgery was undertaken with removal of hepatic packing and pringle's manoeuvre with temporary control of the haemorrhage with haemostasis and ligation of the right hepatic artery. it was needed several surgery's more with additional packing, haemostatic mesh and haemostatic products in order to control the bleeding. the patient was proposed for liver transplant during the process but was not accepted. introduction: management of splenic injury has evolved over the past years. nonoperative management has gained currency, first in children and after in adults. material and methods: we present a case of a years-old man who falled for m, haemodinamically stable, presenting pain on the left part of thorax and upper abdomen. results: the patient fall for m hours before the arrive in our er; he was haemodinamically stable (bp= / mmhg, av= bpm) and presented pain on the left thorax and left hypocondrium. laboratory showed , g/dl haemoglobin. radiologic test: laterally th left rib fracture. ct scan revealed iv grade spleen injury and perisplenic hemoperitoneum. we choosed non-operative managementafter days ct scan showed reduced dimensions of dilacerated spleen injury and no hemoperitoneum. the patient status was stable during the days hospitalisation. imagistic control after month: homogenous spleen structure. conclusion: the haemodinamic status of the patient is the most reliable criteria for non-operative management, not ct aspect of the injury. years old) submitted to upper partial splenectomy for blunt trauma. residual spleen after surgery was / and / respectively. ceus was preceded by standard b-mode us with color flow mapping in all cases; videoclips of each exam were stored for forensic medicine issue too. mean time for ceus exam was - minutes. results: ceus allowed to recognize regular perfusion of the residual spleen in both patients. conspicuity of ceus imaging was high and impressive. homogeneous complete distribution of the contrast medium in the parenchyma was observed on day in both pts. ceus follow-up on day and did not add any supplementary information. pts were discharged on day and day respectively, without indications for vaccinations or antibiotic prophylaxis. conclusion: ceus is an effective method for assessing perfusion of the residual spleen after partial splenectomy. ceus can be performed bedside by the surgeon in the early po period or on an outpatient basis. imaging interpretation is immediate and distribution of the contrast medium assure about viability of the splenic tissue. ceus imaging allowed us to omit prophylactic vaccinations. it is the first description of the use of ceus in this particular setting. introduction: injuries to the abdominal visceral vessels are uncommon but devastating entities that incur extremely high rates of mortality.the rarity of these injuries prevents many trauma centers and trauma surgeons from developing a significant knowledgement learning curve. the authors describe a case with abdominal visceral vascular abdominal blunt trauma, presented with laceration in the confluence of inferior mesenteric vein and splenic vein, laceration of the hepatic artery associated with hepatic hematoma, periduodenal and peripancreatic hematoma. the routine principles of vascular surgery were applied to the management of these visceral blood vessels injuries :adequate exposure, proximal and distal control, dé bridement of the vessel wall,meticulous arteriorraphy and venorraphy with fine monofilament vascular sutures and early instituition of damage control resulting a successfull repair. material and methods: the authors made a review of several large series in the literature wich are also consistent with a low incidence of visceral vessel injuries. vascular trauma is complex and ideally is carried out by experts in a multidisciplinary environment a broad spectrum of surgical specialities are involved in the ressuscitative phase of trauma care including general, trauma, thoracic and vascular surgery . despite a relatively low incidence of vascular trauma in portugal, the results are satisfactory because of active and early management by surgeons on call, weather with vascular training or not, treating all kinds of vascular surgical emergencies. a trauma and emergency surgical speciality is a challenge. results: little information describing the first repair or ligation of any visceral vessel injuries can be found in the literature. visceral vascular injuries carry a significant mortality rate. vascular injury poses a small but significant challenge in portugal trauma care. opportunities such as better practise guidelines and minimum standars will allow surgeons to improve delivery of quality care to the next generation of vascular trauma victims. training in the management of vascular trauma surgery with integration of vascular and general surgeryin trauma care should optimize outcomes. conclusion: from reviews of large series dealing with the management of abdominal vascular injuries, the incidence can be estimated to be between . % to . %of all vascular injuries. few data are available describing the mortality rate for patients with portal veins injuries. te author's vision is that all vascular and general surgery trainees would eventually undertake the definitive surgical trauma care course and improve outcomes and reduce mortality. introduction: high rates of intra-abdominal pressure, has been proved to increased mortality, especially in multi-trauma patients followed laparotomy. multiple organ failure syndrome (mofs), derived by intra-abdominal hypertension, has been called abdominal compartment syndrome (acs), the epidemiology and the characteristics of which, have not been thoroughly determined. introduction: intercostal pulmonary hernias are rare and mostly resulting from complications related to the chest trauma.the authors report a case of traumatic intercostal pulmonary hernia in a -yearold man. he was admitted to the hospital as a traumatic patient after a motor-cycle accident . material and methods: beside multiple polytraumatic injuries the patient had a blunt injury to the left chest.physical examination revealed a bulge on palpation of the left chest wall.computed tomography (ct) scan of the chest revealed the protrusion of lung tissue outside the intercostal space.size of hernia, incarceration and respiratory insufficiency mandate immediate surgical intervention.postoperative course was uneventful, and there has been no sign of recurrence of hernia. results: post -traumatic lung herniation through a defect in chest wall is an uncommon injury .various methods of tratement and repair have been described, including both purely thoracoscopic to full open techniques.the authors repaired a case using a minithoracotomy. conclusion: lung hernia is an uncommon entity defined as the protrusion of pulmonary tissue and pleural membranes through defects of the thoracic wall.chest trauma is the most common cause.timely surgical intervention is critical to favorable patient outcomes.effective management, surgical approaches and repair of thoracic injuries are discussed and the available literature. of the hernia from the outside, dé bridement and closure layer-bylayer with maxon- was performed. the postoperative course was uneventful. conclusion: a tawh after blunt trauma is a rare entity. the reported incidence of acute hernia ranges from ,%- , % . in our case the tawh was already diagnosed in the trauma room. mahajna et al. reported the case of herniation of the right colon with vessel strangulation, which wasn't seen in the primary survey. a right hemicolectomy had to be performed on the nd posttraumatic day. in our case we decided intraoperatively to perform a primary reconstruction of the abdominal wall without mesh repair. the potential advantage of a mesh implantation lies in the augmentation of the abdominal wall, thereby potentially lowering the risk of incisional hernia. however, the benefits of such augmentation should be cautiously weighed against the risk of foreign body contamination when resecting bowel during the same operation. introduction: impalement is an uncommon and spectacular injury, which combines aspects of both blunt and penetrating trauma. impalement injuries from falls are rarely seen, because most of the patients die at the scene of injury. we present an unusual case in which a patient survived a perineal impalement after a fall.with reference to our latest case and discuss the initial management and the operative treatment of this rare injury according to a literature review. material and methods: a young man was working on a construction site when he suddenly lost his footing and fell m off a scaffold. he orientated such that he landed in a sitting position on a vertical aluminium u-tube, which penetrated his perineal region and stucked. upon arrival at the emergency room he was in stable condition, intubated. after the initial treatment and diagnosis according to atls a ct of the abdomen was performed; it showed a penetrating tube perianal left, from caudal into the cavity of the pelvis, the point of the tube stucked in the sacrum -in the hole of neuroforamina s . there was no intraabdominal or laceration. the patient was taken to the operating room in stable condition. the laparotomy was performed. there was no laceration detected, explorating the praesacral cavity brought out a profuse bleeding of the main pelvic vein. after the active bleeding was stopped the tube was removed from the outside. after lavage and positioning of drains, a protective loopileostoma was placed to avoid further contamination. the perineal wound was carefully debrided, drains were inserted and the wound was not completely closed by adapting stitches. a wash-out of the colon was performed, he received antibiotics and the perineal wound was rinsed daily. he was dismissed days post-trauma. results: impalement injuries result when a solid object pierces a body cavity or extremity. the object often remains fixed within the body. this case report showed a positive outcome. impalement injuries are impressive but also rare, so it is important to show an algorithm in management of such injuries. the object should be in situ during transport. in large or immoveable objects, the impaling device should be cut just above the skin. the management of the injuries depend on the particular body region of penetrating. perineal impalement often appear quite complex. these injuries may need the assistance of gynecology and urology surgery praesacral drainage and distal rectal washout is recommended. wound care is essential in the care of impalement injuries. the skin should generally left open. even uncomplicated wounds have to be treated with antibiotics. conclusion: impalement injuries are rare and treating is a challenge for the surgeon. the degree of the injury determines the functional result. strict adherence to the transportation and management principles outlined in this paper are necessary to decrease morbidity and mortility disclosure: no significant relationships. introduction: the insertion of foreign objects into the anus and rectum is a well-known phenomenon. rectal foreign bodies can present a difficult diagnostic and management dilemma. . a foreign body may be inserted by a doctor for diagnosis or treatment like rectal thermometer, enema tubes or anal packs, by the patient for self eroticism or by a third party as a result of assault or sexual activity, but the most common cause for insertion of a foreign body is sexual stimulation. , , . anorectal foreign bodies are more common in men than in women . they can be caused by a wide variety of objects, lead to variable degrees of local trauma to the surrounding tissues, rectal bleeding and can be associated with perforation or delayed injury. material and methods: in this study, in the ten years from to , we used the medical records of patients with foreign bodies in the rectum have been diagnosed and treated,at izmir teaching and research hospital,izmir. results: all patients were men.they ranged in age from to (mean age ).two of these patients had impulse body spray, two patients had bottle, one patient had eggplant,one patient had brush and one patient had wishbone (after oral ingestion) in the rectum. five objects were removal transanally extracted by anal dilatation under general anesthesia.two patients required laparotomy.one patient of these the object was high lying in the rectosigmoid and performed laparotomy.the object was removal transanally extracted by abdominal manuplation.one patient had a intraperitoneal rectosigmoidal perforation.the perforation was treated by primer suture, proximal colostomy and appropriate antibiotic therapy. routine rectosigmoidoscopic examination is performed after removal.one patient had perforation of the rectosigmoid and had lacerations of the mucosa. no patient had a mortality. conclusion: foreign bodies in rectum should be managed in a wellorganized manner. the diagnosis is confirmed by means of plain abdominal radiographs and rectal examination. manual extraction without anaesthesia is usually only possible for very low lying objects. patients with high lying foreign bodies generally require general anaesthesia to achieve complete relaxation of the anal sphincters to facilitate extraction.open surgery should be reserved only for those patients with perforation, peritonitis and impaction of the foreign body. results: definitive pathological examination confirmed the diagnosis of pancreatic pseudocyst. the patient postoperative outcome was unremarkable and was discharged from the hospital at the seventh postoperative day. conclusion: retroperitoneal and ''well protected'' location implies that a high energy traumatism is needed to injury the pancreas. the fact that in this case a non-classical injury mechanism has occurred, makes the diagnosis more difficult to reach. pancreatic pseudocyst is the most frequent complications in this type of traumatisms. effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch uncomplicated mason type-ii and iii fractures of the radial head and neck in adults. a long-term follow-up study surgical treatment of intra-articular fractures of the distal part of the humerus. functional outcome after twelve to thirty years disclosure: one or more of the authors received funding from the small bone innovations (dr) fractures of the neck of the talus. long-term evaluation of seventy-one cases tuberosity malposition and migration: reasons for poor outcome after hemiarthroplasty for displaced fractures of the proximal humerus tuberosity osteosynthesis and hemiarthroplasty for four part fractures of the proximal humerus abdominal -mdct for suspected appendicitis: the use of oral and iv contrast material versus iv contrast material only socioeconomic factors, medicolegal issues, and trauma patient transfer trends: is there a connection? are patients being transferred to level-i trauma centers for reasons other than medical necessity? the delaware trauma system: impact of level iii trauma centers improving outcomes in a regional trauma system: impact of a level iii trauma center jupiter -metaanalysis: nondisplaced scaphoid fractures. operative vs. nonoperative management(update to nov dodds -minimally invasive management of scaphoid nonunions chess -a biomechanical analysis of intrascaphoid compression using the herbert scaphoid screw system. an vitro cadaveric study is the mortality rate for septic shock really decreasing? systemic inflammation after trauma in vivo effects of a synthetic -kilodalton macrophage-activating lipopeptide of mycoplasma fermentans after pulmonary application alveolar macrophages from septic mice promote polymorphonuclear leukocyte transendothelial migration via an endothelial cell src kinase/nadph oxidase pathway macrophage inflammatory protein- alpha mediates lung leukocyte recruitment, lung capillary leak, and early mortality in murine endotoxemia fracture-dislocation of the hip joint. the nature of the traumatic lesion, treatment, late complications, and end results cervical spine trauma in the pediatric patient spinal injuries in children and adolescents long-term clinical and radiographic outcomes after open reduction for missed monteggia fracture-dislocations in children elastic stable intramedullary nailing as alternative therapy for pediatric monteggia fractures unstable diaphyseal fractures of both bones of the forearm in children: plate fixation versus intramedullary nailing delayed radial paralysis after monteggia fracture-a case report, unfallchirurg a simple modified arthroscopic procedure for fixation of displaced tibial eminence fractures a fracture of the intercondylar eminence of the tibia treated by arthroscopic fixation an analysis of different types of surgical fixation for avulsion fractures of the anterior tibial spine modified arthroscopic suture fixation of a displaced tibial eminence fracture tibial spine fractures in children fractures of the tibial spine in children seventeen-year follow-up of a reattachment of a nonunited anterior tibial spine avulsion fracture arthroscopic fixation of displaced tibial eminence fractures: a new growth plate-sparing method the mechanism of clavicular fracture: a clinical and biomechanical analysis functional outcome following clavicle fractures in polytrauma patients evidence-based orthopaedic trauma working group. treatment of midshaft clavicle farctures: systemic review of fracturese: on behalf of the evidence-based orthopaedic working group harnroongroj t, vanadurongwan v. biomechanical aspects of plating osteosynthesis of transverse clavicular fracture with and without inferior cortical defect autologous bone versus calcium-phosphate ceramics in treatment of experimental bone defects iliac crest autogenous bone grafting: donor site complications clinical results of harvesting autogenous cancellous graft from the ipsilateral proximal tibia for use in foot and ankle surgery healing and graft-site morbidity rates for midshaft clavicle nonunions treated with open reduction and internal fixation augmented with iliac crest aspiration literature review of current techniques for the insertion of distal screws into intramedullary locking nails a new fluoroscopy-free navigation device for distal interlocking screw placement disclosure: we all are surgeons at gregorio marañ ó n hospital, madrid. dr. turegano is the chief of the emergency surgery department. references: -nandapalan and al factors related to mortality in inferior vena cava injuries: a year experience disclosure: we certify that all our affiliations with or financial involvement (employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending) with any organization or entity with a financial interest. references: . blaisdell, f.w. the pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review. references: robinson cm evaluation of consecutive patients with the extended data set of the standardised audit for hip fractures in meniscus allograft transplantation: a current concepts review homologous meniscus transplantation: experimental and clinical results cell survival after transplantation of fresch meniscal allografts: dna probe analysis in a goat model freezing causes changes in the meniscus collagen net: a new ultrastructural meniscus disarray scale meniscus replacement with bone anchors: a surgical technique meniscal allograft transplantation: long-term clinical results with radiological and magnetic resonance imaging correlations clinical evaluation of arthroscopic-assisted allograft meniscal transplantation knee joint biomechanics following arthroscopic partial meniscectomy an evaluation of a shockroom located ct scanner: a randomized study of early assessment by ct scanning in trauma patients in the bi-located trauma center north-west netherlands (react trial) overlooked spine injuries associated with lumbar transverse process fractures frequency and importance of transverse process fractures in the lumbar vertebrae at helical abdominal ct in patients with trauma traumatic lumbosacral dislocation: report of two cases references: prevalence of suicide ideation and suicide attempts in nine countries uptake and intracellular distribution of various metal ions in human monocyte-derived dendritic cells detected by newport green dcf diacetate ester biomechanical analysis of bicondylar tibial plateau fixation:how does lateral locking plate fixation compare to dual plate fixation? operative treatment of tibial plateau fractures.:five to years follow-up results treatment of high energy tibial plateau fractures with half ring external fixation combined with minimal internal fixation. nan fang yi ke da xue xue bao disclosure: no significant relationships de smet l, debeer p, degreef i. fixation of a periprosthetic humeral fracture with ccg-cable system results of non-operative and operative treatment of humeral shaft fractures. a series of cases complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. surgical technique the anteromedial facet of the coronoid process of the ulna ring d, doornberg jn. fracture of the anteromedial facet of the coronoid process. surgical technique broberg ma, morrey bf. results of treatment of fracture-dislocations of the elbow disclosure: one or more of the authors received funding from the small bone innovations (dr perilunate and axial carpal dislocations and fracture dislocations evaluation of the spanish versió n of the dash and carpal tú nel síndrome health-related quality-of-life instruments: cross-cultural adaptation process and reliability philadelphia: w. b. saunders company; . p. - . . meyer pr. complications of treatment of fractures and dislocations of the dorsolumbar spine no significant relationships. references: . general medical council. consent: patients and doctors making decisions together is informed consent effective in trauma patients is informed consent in trauma a lost cause? a prospective evaluation of acutely injured patients' ability to give consent factors affecting the quality of informed consent the impact of objective assessment and constructive feedback on improvement of labrascopic performance in the operating room united arab emirates, medical education at the main trauma hospital. results: patients were studied ( . % males) having a mean age of . years. % of patients were from the indian subcontinent and % were uae nationals. % of patients presented immediately following injury. ambulances brought only % of the patients. % of trauma took place in the street or highway, % in work places and % at home. the mechanisms of injury were road traffic collision in % and falls in %. % of injuries were to extremities, % to head, face and neck, and % to chest. the mean iss was . . the mean (range) hospital stay was . ( - ) days; ( %) patients needed icu admission of whom ( . %) died. the mean icu stay was . days (range - ). overall mortality was ( . %). conclusion: road traffic collisions and falls are the main cause of trauma admissions in al ain city. extremities, head, neck, face and chest are the main body regions sustaining injuries. disclosure: no significant relationships hip fractures in the elderly: a world-wide projection disclosure: no significant relationships. references: d. ring et al.: predictors of acute carpal tunnel syndrome associated with fracture of the distal radius pm non-surgical treatment of the distal radial fracture. is there an advantage in immobilization in degrees dorsiflexion compared to immobilization in a neutral position? janzing , l. horta emergency department, viecuir medical centre the netherlands introduction: according to the literature immobilization of collespoints where radiological (dorsal dislocation, radial inclination), functional, the necessity for surgical intervention a comparison of methods of plastic cast fixation in treatment of loco classico radius fracture. a prospective, randomized study, unfallchirurg pm buzzsaw injuries: mechanisms of damages and predisposing factors r. ziegler , w. knopp woodworking injuries: an epidemiologic survey of injuries sustained using woodworking machinery and hand tools references: beasley ls, vidal af. traumatic patellar dislocation in children and adolescents: treatment update and literature review long-term functional outcome after lateral patellar retinacular release in adolescents: an observational cohort study with minimum -year follow-up mri of traumatic patellar dislocation in children reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children injuries to the inferior pole of the patella in children disclosure: no significant relationships pm results of electromagnetic fields in healing progression of delayed union in the lower extremities the effect of low-frequency electrical fields on osteogenesis references: complex trauma of the limbs with vascular injuries-olivera lupescu, mihail nagea carcinoid tumour of the appendix:an analysis of consecutive emergency appendectomies tuberculous peritonitis of the wet ascitic type: clinical features and diagnostic value of image-guided peritoneal biopsy. dig. liver dis at perforated ulcer treatment, suture of the place of prefotation was used at ( , %) people, billroth ii stomach resection at six ( , %), suture of the place of prefotation with psv at three ( , %), and billroth i stomach resection at one ( , %) patient. postoperative complications were noticed at ( , %) people. we had postoperative mortality at four ( , %) patients. recidive ulcer was registred at ( , %) patients who were surgically treated for perfored ulcer before. conclusion: ulcer perforation is an acute complication of the ulcer disease that appears most frequently after bleeding and which usually requires surgical treatment. references: . behçet disease complicated by a perforated ileal ulcer presenting as an acute abdominal emergency gastro-duodenal ulcers with perforation caused by short-term acetylsalicylic acid ingestion: case report culafiÄ à d, matejiÄ à o perforated gastroduodenal stress ulcer melinte c, dragomir c pubmed -indexed for medline] spontaneous rupture of the spleen as immediate complication in autologous transplantation for primary systemic amyloidosis delayed splenic rupture as a cause of haemoperitoneum in a capd patient with amyloidosis boluda garcà a f, calvo català ¡ j, campos fernà ¡ndez c, parra rà denas jv, gonzà ¡lez cruz mi laparoscopic cholecystectomy for acute cholecystitis disclosure: no significant relationships. references: . pokorný j. et al. urgentní medicína, . st edition: praha, galé n . stetina et al. medicína katastrof a hromadný ch neštÄ >stí pt perforation of oesophagojejunal anastomosis by venous anatomy of the right colon: precise structure of the major veins and gastrocolic trunk in cadavers pt validation of fournier's gangrene severity index score (fgsis) general surgery dobrzanska l, newell r. readmissions: a primary care examination of reasons for readmissions of older people and possible readmission risk factors pt spontaneous rupture of giant cavernous hemangioma of the liver in a patient with systemic hemangiomatosys and kasabach-meritt syndrome. an interactive and multidiscipline case b general surgery general surgery portugal introduction: hemangiomas are frequent benign tumors of the liver nonoperative management of blunt splenic and liver injury is ct grading of splenic injury useful in the nonsurgical management of blunt trauma? management of blunt splenic trauma: ct contrast blush predicts failure of nonoperative management references: . ochsner mg. factors of failure for nonoperative management of splenic injuries associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management introduction: aim. to establish the diagnostics and management trauma, ( , %) -head trauma, ( . %) -limbs injuries, and ( %) -severe shock. in cases the splenic injury was initially manifested - ( . %), and in ( , %) cases the clinical signs developed later (p < . ) practice management guidelines for the evaluation of blunt abdominal trauma: the east practice management guidelines work group diagnostic accuracy of surgeonperformed focused abdominal sonography (fast) in blunt paediatric trauma surgeon-performed bedside organ assessment with sonography after trauma (boast): a pilot study from the wta multicenter group disclosure: no significant relationships. pt incidence of abdominal compartment syndrome in patients with multiple injuries. a single institution experience koulas , o. mousafiri hatzikosta general hospital, ioannina, greece, intensive care unit, g. hatzikosta general hospital intensive care unit, g hatzikosta general hospital delayed presentation of traumatic parasternal lung hernia management of retained colorectal foreign bodies:predictors of operative intervention disclosure: no significant relationships. treatment. disclosure: no significant relationships. references: .demetriades d, velmahos g. technology-driven triage of abdominal trauma: the emerging era of nonoperative management management of high grade renal trauma: -year experience at a pediatric level i trauma center pt blunt abdominal trauma. year experience in our department greece ( , %), without spinal fractures. resection/anastomosis was permorbidity. in first group, there were deaths ( , %), cases due to intestinal injuries. the second group (without seatbelt sign) had deaths ( , %), none due to intestinal injuries but related with multiple thoracic and cranial lesions. conclusion: in this study we found a consistent evidence that ''seatbelt sign small-bowel and mesentery injuries in blunt trauma mortality reduction with air bag and seat belt use in head-on passenger car collisions disclosure: no significant relationships. references: management strategies in isolated pancreatic trauma disclosure: no significant relationships. references: enterocutaneous fistula complicating trauma laparotomy: a major resource burden the american surgeon staged management of giant abdominal wall defects injured patients -documentation of black spots j. heinzmann , u. culemann , t. pohlemann universitä tsklinik des saarlandes, klinik fü r unfall-, hand-und wiederherstellungschirurgie, homburg, saar, germany, trauma-, hand and reconstructive surgery, university of saarland, homburg, saar, germany, klinik fü r unfall-, hand-und wiederherstellungschirurgie, universitä tsklinikum des saarlandes, homburg, saar, germanyintroduction: nonunions of the tibia represent a complex problem, particularly if they occur at the distal third of the tibia. the aim of the study was to evaluate a standardized treatment concept to manage different types of nonunions of the tibia with regard to their location within the tibia. material and methods: prospective, non randomised study ( / - / ); nonunions of the diaphyseal and metaphyseal tibia (ao type / ); standardized treatment concept: diaphysis: reamed intramedullary nailing; dia-metaphyseal junction and pilon: lcp with a minimal invasive approach or an open approach plus bone grafting from the iliac crest; infected nonunions: external fixator. analysis parameters: demographic data, fracture type (ao classification), primary surgery, healing process, time to union (radiographic), complications. results: forty-eight patients ( m, f; mean age , y) with hypertrophic (primary surgery: x nail, x external fixator) and atrophic nonunions of the tibia (primary surgery: x nail, x plate, x screws and x external fixator) were included in the study. fifteen tibial nonunions had been primary treated in our department, patients had been admitted from other hospitals. seventy-three% of all nonunions were located at the distal third of the tibia ( % at the diaphyseal-metaphyseal junction, ao-classification type ; % at the pilon, ao-classification type ). seventy-five% of the dia-metaphyseal fractures and % of the pilon fractures were primary treated with an intramedullary nail. the mean time between injury and nonunion-surgery was , ( - ) months. follow up: / patients ( %) for an average time period of , months; union-rate: / (hypertrophic nonunions / ; atrophic nonunions / : re-nonunions each). complications: death by lung embolism, re-nonunion (united after second surgery), implant (plate) loosening with the need of reosteosynthesis, x varus malalignment, x valgus malalignment, x peroneal nerve lesion. conclusion: especially the distal third of the tibia still represents a high risk area for nonunions. impaired perfusion, thin soft tissue coverage, as well as the rising number of nailing even of distal tibial fractures are some of the causes. we think that the herein introduced treatment concept is effective to manage tibial nonunions. thus, the union-rate in this study population was % , . an adequate primary osteosynthesis as well as the prevention of extensive soft tissue damage during surgery are mandatory to improve the outcome of tibial fractures. besides, new therapy options as e.g. the application of growth factors and ultrasound have to be considered also for the treatment of tibial nonunions. g. heinrichs , a. p. schulz , e. wilde , r. oheim , c. jü rgens trauma&orthopedics, university lü beck, lü beck, germany, trauma&orthopaedics, university lü beck, lü beck, germany, trauma + orthopaedics, university lü beck, lü beck, germany, trauma&orthopedics, university lü beck, hamburg, germanyintroduction: high energy tibial head fractures with bicondylar involvement have a much poorer outcome compared to the other forms of tibial head fracture. soft tissues are almost allways compromised. bilateral plating carries the risk of soft tissue and bone infections. due to loss of reduction, steps or gaps might remain in the joint surfaces. aim of this study was to evaluate the clinical and radiological outcome of schatzker , and six type fractures treated with locked osteosynthesis plating. material and methods: between january und january we treated patients suffering from a tibial head fracture. in cases osteosynthesis was performed with the use of an angular stable implant, this group forms the study population. indication for locked screw plates were bicondylar fractures treated unilateral to avoid bilateral approach with double-plate osteosynthesis and tibial head fractures with a shaft involvement (schatzker ). follow-up was performed after an average of . months after surgery. we treated male and female patients with an average of . years of age ( to years). there were no patients with open fractures or primary nerve injury included in this study. operative treatment was performed after an average of . days after trauma. we used an angular stable plate fixator made from pure titanium (tifixÒ, litos, hamburg/ germany). the plate is consisting of the softer titanium grade ; the screws are made from harder titanium grade .results: there was one case of a postoperative peroneal nerve lesion with spontaneous regression after two weeks. no postoperative wound necrosis or infection occured. all patients showed bony consolidation after a mean of . weeks as judged by radiographs. additional autologous bone transplantation was not necessary. we did not observe any secondary loss of reduction or loosening of the internal plate fixator when comparing direct postoperative radiographs to those at follow up. rom of the knee did not show any restriction compared to the opposite side in patients. cases showed mild and cases a remarkable restriction of rom compared to the not injured side.applying the rasmussen score, cases achieved a good and very good result. patients had to be judged as moderate and as poor conclusion: unilateral plate fixation for the treatment of bicondylar tibial head fractures seems to offer advantages in particular concerning infection rate and implant failure in the treatment of tibial head fractures. results: the adjacent level th-l fracture was found in . % ( / patients) in kyphoplasty group and in % ( / patients) in vertebroplasty group. we did not found any serious complication but established postoperative bmd loss. we did not found any intradiscal cement leakage in cases with adjacent level fractures. intraoperative correction of kyphosis was better achieved in kyphoplasty group; pain relief was similar in both groups.conclusion: natural process of further bone loss seems to be the most influent factor for future compression fractures in elderly patients. trauma patients represent a challenge in terms of obtaining informed consent as they are often in significant pain and maybe under the influence of strong medication at the time of the consent process. we designed a prospective, randomised un-blinded control study to test the hypothesis that there would be no difference in the ability of trauma patients to recall details of the consent process whether the patients were given verbal compared with verbal and written information.material and methods: a consecutive cohort of trauma patients presenting to a major teaching hospital were recruited and randomised into two groups. group a received structured verbal information only. group b received structured verbal information and written information about the proposed procedure. all patients were interviewed within the first post operative week (mean . days) and scored on their ability to recall key facts given in the original consent interview. results were analysed using the mann-whitney u test.results: patients have been recruited. information recall was significantly improved in the group receiving written information (mean questionnaire score % vs % for verbal information alone, p= . ). patient satisfaction with the consent process was also significantly improved in the group receiving written and verbal information, with . % of patients reporting they understood the risks of surgery when they signed the consent form, compared to . % who received verbal information alone (p= . ).conclusion: written information improves patient recall of the consent process. it is a simple, cost-effective intervention with high patient acceptability. introduction: survivorship of second hip fracture patients is worse than initial hip fracture patients. however, previous studies included in-hospital mortality. the actual survivorship of initial hip fracture patients with subsequent second hip or major long bone of extremity or vertebral body fracture by exclusion of in-hospital mortality patients have not been studied. we aim to compare the actual survival of initial hip fracture patients with and without second hip or subsequent major fracture. in addition, risk factors, mortality causes, and hazards ratio of each fracture groups were studied. material and methods: in - , after exclusion of in-hospital mortality patients, initial hip fracture patients were reviewed and divided into four groups. group i, ii, iii, and iv were initial hip fracture patients with second hip, subsequent major long bone of extremity, vertebral body fracture, and without any subsequent fractures, respectively. we set group i, ii, and iii as study groups comparing the data with group iv (control group). age, gender, mobility-status, co-morbidity, causes of death, and survival years after hospitalization of last fracture treatment of each group were recorded. actual survival rate and risk factors difference between initial hip fracture with and without subsequent fracture were analyzed by chi-square test. hazards ratio differences among the groups were analyzed by cox regression models.results: there were ( . %), ( . %), ( . %), and ( . %) subjects in group i, ii, iii, and iv respectively. at one-year and one-to-five year mortality of group i were . % and . %, group ii were . % and . %, group iii were . % and . %, and group iv were . % and . % respectively. statistical analysis by using chi square test of one-year mortality and one-to-five year mortality rate showed no significant difference among four groups (p > . ). but from cox regression analysis, second hip fracture produced significant hazards ratio as . (p = . ). the actual survivorship of initial hip fracture patients with second hip or other subsequent fracture were not different from patients who have only one hip fracture. however, special care should be focused in patients with second hip fracture which produced significantly highest hazards ratio for mortality.reduction or redislocation after one week of treatment. due to the lack of sufficient patient data a statistical analysis was not carried out. it was obvious that the dorsal dislocation after reduction was worse in the dorsiflexion group. there was no obvious difference in radial inclination or functional outcome between the two groups. conclusion: mainly the dorsal inclination was worse in the degrees dorsiflexion group. a possible explanation for these results is the technique used when modeling the plaster cast. in our hands immobilization in dorsiflexion yielded poorer results then immobilization in a neutral position. due to the poor results the study was terminated prematurely. the traumatic patellar luxation in adult patients is operatively treated with medial reefing and lateral release. the value for the treatment of adolescents is still discussed controversially in literature. the aim of the present study was to evaluate the efficacy of the minimal-invasive treatment of traumatic patellar luxation in adolescents. , that was treated with acute angular shortening using a monolateral ao fixator followed by gradual correction using the taylor spatial frame (tsf). the conversion in the tsf was achieved in exchanging only two half-pins. results: the deformity was anatomically corrected without any soft tissue complications. the fixator was worn for weeks under full weight bearing while the actual correction took only days. we did not see any typical external fixator complications like pin trac infection. conclusion: acute angular shortening can lead to direct soft tissue closure without any additional plastic surgery. the accuracy the the fixator allows the gradual anatomical reduction of the fracture and simplifies the correction of the mostly multiplanar deformities. when the surgeon is familiar with the tsf even a primary treatment of such fractures could be recommended. the image control (plain x-rays, ct) revealed and definitively determined whether a two-part or three part triplane fracture in the distal tibial physis were present, the amount of the displacement, and the co-existed fracture of the fibula. the principal goal must be the anatomical reduction of the fracture initially closed and in failure opened. an open reduction and fixation with steinmann via anterior approach followed. a long-leg cast worn for initial weeks, followed by a short-leg cast for weeks. results: at a minimum of fourteen months of clinical follow -up all patients lacked complaints and had full range of motion in ankle.conclusion: these injuries occur in the adolescent age group generally slightly younger than the child with a tillaux fracture, needed good image control (ct) and must reduced anatomically and fixed. disclosure: no significant relationships. it is necessary in - % of patients. to provide dynamisation using conventional methods, it is necessary to perform one additional surgery. in this presentation it is shown one new method of selfdynamisation. material and methods: it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator. there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanicaly. in clinical use it has been applied to , patients in treatment of femoral fractures. the age of patients was from to years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. this reduction device provides possibility of reduction with minimal using of fluoroscopy or even, after more experience without using of any imaging technique as fluoroscopy, ultrasound or computer navigation. results: received clinical results are promising, as it has been shown early callus formation and radiological union within the - months. it has been allowed to patients early full weight bearing. during the treatment it has been confirmed working of self-dynamisation concept (in % of patients), which probably all together with d configuration resulted in unexpectedly quick fracture healing. follow up was months ( - the severity of injury was measured by the injury severity score (iss). the outcomes for categorical variables were tested using v test and a significance level at p < . was maintained. delayed complications were defined as any complication directly attributable to the splenic injury that occurred more than hours after injury. the following data was retained: age, sex, mechanism of injury, iss, number of icu days, overall length of stay, number of blood units transfused, day of operation and discharge status. results: our study found , % incidence of delayed complications after nom. these complications include delayed hemorrhage ( cases), splenic artery pseudoaneurysm ( ) and splenic abscess ( case). the need for operation due to ongoing bleeding was retained in following situations: more than u of blood to maintain a hb higher than g/dl, systolic pressure to less than mm hg despite resuscitation and evidence of peritoneal signs. of the patients failing nom, % failed between days and and % in the first week. in all cases a splenectomy is performed with no mortality rate. the results of this study indicate independent risk factors of failure of nom: a high ct grade of splenic injury (grade iii and above) and a transfusion with more than u of blood. results: results : out of the patients suffering of liver injuries patients had grade , and grade liver injuries and were treated conservatively. patients had grade and liver injuries and were operated. patient who was initially managed conservatively was operated due to inability to control the blood loss. out of the patients suffering injuries of the spleen, were grade and grade and were successfully operated and were grade and and were treated conservatively. all patients suffering of injuries of the retroperitoneal space, unilateral kidney injuries and injuries of the hypogastrium were managed conservatively. conclusion: blunt abdominal injuries can be managed successfully and safely by conservative treatment whenever it is allowed by the circumstances. the ct scan is a very sensitive diagnostic scanning, capable of diagnosing intrabdominal haemorrhages retroperitoneal lesions as well as the extent of the organ injury and is a necessary tool for the physician in order to diagnose accurately any abdominal injury. disclosure: no significant relationships. introduction: more and more hepatic injuries are treated non operatively if the hemodinamic's and lesion's stability is confirmed. the count and the scaling of lesions doesn't directly influence surgical indications. we report about cases of blunt trauma with serious hepatic and renal lesions treated successfully with a non operative management material and methods: we treated liver and renal injury associated in a period from to . patients were admitted to tor vergata -roma and hospital universitario clínico san carlos-madrid. data collected were: age, sex, comorbidities, sequence of events, type and number of associated lesions, management, morbidity and mortality. all liver and renal organ's injuries were evaluated by abdominal ct scan with contrast and classified according to ct-based scale results: middle age was ± sd years. patient were male in ( , %) of cases. ct scale of liver lesion was °for ( , %) patient and °for two ( . %) patients. renal lesions were i°category in cases ( , %) and ii°category in patient. no ureteral or major vessels rupture were founded. all patients have been treated non operatively. a ct based follow up of lesions was planned (at admittance, after hours, after a week and after a month). the mean length of hospitalization was ± sd days. during hospitalization, patients were monitored by clinic and labs daily. all patients were dismissed in good conditions and are in in health on a months follow up. at ct follow up, one patient presented an intra-hepatic biloma, that was successfully treated with ct-guided drainage conclusion: this work support the hypothesis that the association of liver and renal lesions in a blunt abdominal trauma, doesn't necessarily influences indications for an explorative laparotomy. if an ureteral rupture is suspected, a more aggressive treatment is necessary, in order to prevent peritonitisintroduction: the aim of this study is to analyze the most frequent mechanisms of injury, the evaluation in the emergency department and the period of increase of the blunt abdominal trauma incidence. material and methods: during the last years ( - ) patients were admitted to our department for blunt abdominal trauma.the most frequent mechanisms of injury were: traffic accidents (automobile crashes and motor vehicle collisions) ( , %) work accidents ( , %) . others (fall from high altitude, beating) ( , %) we analyzed the most frequent injuries observed, the final treatment for these patients and the period of increase of blunt abdominal trauma.results: the peak incidence occurs in persons aged - years. the male/female ratio was : . the most frequent abdominal injuries regarded: spleen ( , %), liver ( , %), large bowel ( , %), small bowel ( %), pancreas ( , %). patients underwent surgical treatment ( , %). the incidence of missed injuries is quite low, one case with pancreatic injury and one with small bowel injury. during summer period a significant increase in blunt abdominal trauma incidence occurs because of the increase of population due to tourism. the initial physical examination, after appropriate primary survey and initial resuscitation with the help of diagnostic studies such as ultrasonography, abdominal ct scan, is essential for the final treatment for these patients, operative or not operative. abdomino-throcal injuries were found in ( %) patients.abdominal organ injuries were found in decreasing frequencies in small bowel( %),liver ( %),large bowel ( %), spleen ( %), major vasculer, stomach and others. thoracal injuries were found in lung and heart in and cases.one organ injury was found in ( %) patients,mostly small bowel,and these group had a good haemodynamic status.thirty-two( %) patients had two organ injuries which of them associated with lung injury.three, and < organ injuries were found in , and patients. haemodynamic unstability at presentation,and shock was found in five patients( , and organ injury in , and cases). the overall mortality was found in ( %) patients.mortality from gun injury was % from major vascular injury ,lung,pancreas and large bowel ,lung and large bowel one.mortality from penetrating trauma was % from lung and multipl abdominal organ injury ,heart ,lung,spleen and stomach injury and major vasculer injury from blunt trauma in one ( %) patient. five patients who remain haemodynamically unstable after resuscitation died intraopreoperative period.these group was not received some resuscitation, and they referred to our hospital later than hours of injury. introduction: retroperitoneal location of the pancreas makes the diagnostic of any traumatism to be difficult, especially when this is not suspected. we report on a case of blunt pancreatic trauma with months delayed diagnosis, after injury due to maneuvers in a difficult birth. material and methods: we report on a case of a twenty-nine year-old female who consulted at the emergency department for constant right upper quadrant pain that didn't ease with any analgesic prescribed by the general practitioner. these symptoms started after a birth six months before and loss of kg of weight was associated. after reviewing the previous history of the patient, the birth had been difficult and forceps, suction pad and repeated abdominal pressure maneuvers were needed. abdominal examination showed a painful non-pulsatile mass located at epigastrium and both right and left upper quadrants. abdominal ultrasonography and enhanced ctscan were performed and demonstrated the presence of multicystic x x cm mass located between the stomach, spleen and left kidney. the high density content seemed to be blood. the mass was pushing the stomach anteriorly and no communication between both of them was shown. the splenic vein was pushed superiorly and thinned and plenty collateral circulation was evidenced. the tail and the body of the pancreas were not identified in any of the studies. the first choice diagnosis was posttraumatic complicated (with bleeding) pancreatic pseudocyst. the patient underwent emergency operation and a big cystic pancreatic mass was encountered, with plenty of collateral circulation. intraoperative biopsy confirmed that it was a pseudocyst and therefore, the majority of the cyst was removed and roux-en-y pancreatojejunostomy was performed. cholecistectomy was also done. introduction: unnoticed traumatic injuries produce avoidable morbidity, mortality and a higher medical cost. we present a special case of the reconstruction of a catastrophic abdomen with several intestinal fistulae and giant abdominal wall defect. material and methods: we present the case of a year old woman with blunt thoraco-abdominal trauma secondary to a road traffic accident. several lower left rib fractures, a fast echo with free fluid without solid organ injury and fractures of l and l were seen in the initial assessment. on the third day surgery was required due to septic shock with diffuse peritonitis due to a jejunal laceration and section of the body-tail of the pancreas. simple suture of the jejunal laceration, distal pancreatectomy, and abdominal packing without closure of the abdomen was performed. she developed several intestinal and colonic fistulae. over surgical procedures were performed on her and she was discharged months later with night parenteral nutrition, a closed abdomen by secondary intention and intestinal fistulae. she was readmitted a year later for reconstruction. we performed monoblock resection of the abdominal wall and the fistulized loops, subtotal colectomy and bowel transit reconstruction with three enteroenteric and an ileosigmoid anastomosis, leaving , m of small bowel. abdominal plastia with permacol mesh was also performed. results: surgical time was of minutes and oral tolerance was initiated on the th postoperative day. she was discharged on the th day postop. the only complication was a fever secondary to infection a central venous catheter on the rd day. key: cord- - h rcih authors: sharififar, simintaj; jahangiri, katayoun; zareiyan, armin; khoshvaghti, amir title: factors affecting hospital response in biological disasters: a qualitative study date: - - journal: med j islam repub iran doi: . /mjiri. . sha: doc_id: cord_uid: h rcih background: the fatal pandemics of infectious diseases and the possibility of using microorganisms as biological weapons are both rising worldwide. hospitals are vital organizations in response to biological disasters and have a crucial role in the treatment of patients. despite the advances in studies about hospital planning and performance during crises, there are no internationally accepted standards for hospital preparedness and disaster response. thus, this study was designed to explain the effective factors in hospital performance during biological disasters. methods: qualitative content analysis with conventional approach was used in the present study. the setting was ministry of health and related hospitals, and other relevant ministries responsible at the time of biologic events in islamic republic of iran (ir of iran) in . participants were experts, experienced individuals providing service in the field of biological disaster planning and response, policymakers in the ministry of health, and other related organizations and authorities responsible for the accreditation of hospitals in ir of iran. data were collected using semi-structured interviews in persian language. analysis was performed according to graneheim method. results: after analyzing interviews, extraction resulted in common codes, subcategories, and categories, which are as follow: detection; treatment and infection control; coordination, resources; training and exercises; communication and information system; construction; and planning and assessment. conclusion: hospital management in outbreaks of infectious diseases (intentional or unintentional) is complex and requires different actions than during natural disasters. in such disasters, readiness to respond and appropriate action is a multifaceted operation. in ir of iran, there have been few researches in the field of hospital preparation in biologic events, and the possibility of standardized assessment has be reduced due to lack of key skills in confronting biological events. it is hoped that the aggregated factors in the groups of this study can evaluate hospital performance more coherently. the deadly pandemics of infectious diseases are rising worldwide. in the twentieth century, have caused death of more than million people in many parts of the world ( ) . in the last relatively mild h n pandemic in , - of people were killed who were not necessarily in high-risk groups ( ) . according to the report of www.warontherocks.com, about cbrn events were reported between and ( ) . also, the possibility of using microorganisms as biological weapons is a real and increasing probability all around the world ( , ) . increasing the tendency to use biological weapons due to increased terrorist attacks, their relative convenience use, and low cost have led to many health concerns ( , ) . between and , - persons were killed in major terrorist incidents nearly every months ( ). hospitals are vital organizations during biological disasters and play a crucial role as a place of care and treatment for such patients ( , , ) . hospitals should have an essential role in biological disasters ( ) ( ) ( ) ( ) . having specialists and staff with knowledge and skills relevant to biological events can play a significant role in reducing mortality and morbidity in the community, especially in the first few hours, which is called the golden time. the result is hospital preparedness to deal with biological events, which improves the response rate and accelerates the process of rehabilitation ( ) . hospital services are differentiated from other institutions by their types of activities, resources, staff, multiple specializations, and equipment used ( ) . the response of hospitals has a multidimensional function (approach) ( , ) . despite the advances in studies about hospital planning and performance during crises, there are no internationally accepted standards for hospital preparedness and disaster response ( ) . to date, there has been no valid methodology for assessing the preparedness of hospitals for disasters ( ) . however, after the onset of disasters, it is necessary that hospitals be prepared to deal with the new circumstance and surge capacity ( , ) . disaster preparedness is recognized as one of the top priorities in the medical field ( ) . this process varies in cbrn events ( ) . according to the recommendation in the process of planning, preparing, and responding to disasters in the health system, it is necessary to use the "all-hazards" approach ( ) . however, in practice, this approach does not seem to be suitable for man-made and technologic disasters such as biological, chemical, or nuclear events. nevertheless, evaluating hospitals' performance during crises, especially the one caused by biological disasters (eg, the epidemic of diseases whether natural or intentional), is a topic that has been dealt with inadequately. since in the face of disasters and biological threats different conditions prevail in hospitals, thus, evaluating the performance of hospitals in such situations requires a different mechanism. in addition, no comprehensive plan has been developed to manage biological events in iran. therefore, the present study was conducted to identify factors affecting hospital response in biological disasters. qualitative content analysis with conventional approach was used in this study. the qualitative content analysis approach was used for subjective interpretations of text data by systematic classification process, coding, identifying categories, or patterns. using this approach, the researcher avoids classification with background thoughts and allows categories formation during the research process ( ) ( ) ( ) . hospitals under the supervision of ministry of health and other relevant ministries responding to biologic events in ir of iran at (including the defense ministry) were included in this study. participants in this project were experts, experienced individuals providing services in the field of biological disaster planning and response, policymakers in ministry of health, and other related organizations and authorities responsible for the accreditation of hospitals in ir of iran. data were collected through conducting semi-structured interviews in persian language with the aim of explaining factors affecting the performance of hospitals in response to biologic threats. initially, the researcher met each participant and presented the research goals and obtained their consent for participation. three participants did not respond to the request and introduced another person as an expert in the field of research. two participants stated that these questions were not in their field of expertise. a total of interviews were done. the age range of the participants was - years. the purpose of the interviews was to explain and explore the factors influencing hospital performance in response to biologic threats. interviews began with simple and general topics and went on to specific questions. some questions were changed during the research (after completing the third interview and analyzing the data). types of questions were as follow: open questions, based on the default, and case-by-case. some of the interview questions were as follow: . what are the effective factors in assessing hospital performance at the time of biological events? . what are the management problems that you have experienced or may experience during a biological threat? . what are the strengths and weaknesses in assessing a hospital's performance of biological threats? . what is the difference between assessing the performance of hospitals in natural disasters and in biological distasters? during the interview, the researcher observed and noted the participants' interactions with the environment and their reactions, which were considered in the data analysis. the number of participants was determined based on the saturation of the obtained codes, so that the new codes were not extracted by new interviews. sampling was done using purposeful and snowball method. the interview took about - minutes. at first, interviews were conducted with the participants, their voice was recorded, and transcription was done a short while after each interview. data analysis began after the first transcription. to analyze the data, the researcher studied the data deeply, reread, and considered the text of the interview, gained understanding of the data, and finally completed the analysis ( ) . after each interview, transcription was done and field observations notes were reviewed several times. the final text was approved by each participant (member check). after the third interview, the questions were redesigned. in this study, interviews and field notes were the analysis units. the texts were divided into content areas and meaning units. meaning units were summarized and codes were extracted. multiple codes were compared with each other in terms of differences and similarities; then, categories and subcategories were formed. the extracted categories were discussed by scholars; finally, the basic and essential meanings of the categories were edited. data collection continued until saturation was reached for each concept. in a qualitative research, rigor shows concepts of credibility, dependability, transferability, and different dimensions of trustworthiness ( ) . to achieve maximum credibility, the research team used a range of expert participants. participants were among authorities of health in ir of iran, officials and staff of biologic laboratories, and some experienced officials from civil and military organizations with a history of managing infectious disasters. after each interview, transcription of texts was performed in a short interval. interviews were listened repeatedly, and the researcher extracted the meaning units. then, based on the condensation and abstracting of meaning units, the codes were extracted. similar codes were placed in subcategories, and the categories were formed according to the similarities and differences between subcategories. in the case of extraction of codes, subcategories, and categories, expert opinions were taken from the research team, and agreement was reached among researchers, experts, and participants about the differences. this study has been conducted in the context of ir of iran. according to researchers' view, the results can be generalized to other countries, but the choice has been left to readers ( ) . this study was approved by the national committee of ethics of ir of iran (code number: ir.sbmu.retech. rec. . ). all participants were aware of the research objectives. informed consent was taken from all participants and their participation was kept confidential. all interviews were recorded with participants' permission and were fully transcribed within a short period after the interview. analysis was done simultaneously. the demographic characteristics of the participants are presented in table . participants answered all the questions during the interview. after analyzing interviews, codes were extracted. codes were categorized in subcategories after analysis. according to the similarities and differences in nature of subcategories, categories were extracted: detection; treatment and infection control; coordination; resources; training and exercises; communication and information system; construction; and planning and assessment. the graphic diagram of the extracted categories and subcategories is shown in figure . table contains extracted categories, subcategories, and common codes by content analysis. after analyzing the data, it was found that all participants considered the ability to detect biologic outbreaks or emergencies in hospitals as an effective factor in hospital performance. the first step in controlling a biologic emergency is to detect the event in a hospital. the subcategories of determining the type of event (intentional or unintentional) and early detection were extracted. - : according to the participants, the delay in diagnosis with subsequent possibility of developing outbreaks of communicable diseases could be a major factor in hospital performance. one of the participants (p ) mentioned, "rapid detection is an important factor in proper performance in biological disasters. in the crimean-congo fever epidemic, if diagnosis was not established on time, the disease would have spread further". - : determining the deliberate or unintentional cause of a biological event can affect hospital performance. in intentional events, the biologic agent may still exist in the environment which will cause the disaster to be continued. another participant (p ) said, "it is difficult to diagnose the cause of deliberate biological events because there is less experience about it. treatment has been discussed on the textbooks, but the bioterrorism detection has not reviewed extensively, and it is very difficult". from the participants' perspective, the ability to treat and control the infection in the hospital was considered as an important factor in the proper hospital performance in biological disasters. the obtained subcategories were as follow: the ability to manage the biologic event and treat patients; the ability to care for the patients; the ability to decontaminate the injured people and surfaces; the ability to perform biologic triage; and pre and post exposure prophylaxis in affected individuals. - : drug therapy of patients and pre and post exposure prophylaxis: the extracted common codes according to participants' interviews were possibility of appropriate response after a biological event in a hospital, prompt and suitable treatment of the patients, having an efficient team of rapid response, the ability to discharge if necessary, pharmaceuticals prescription, having adequate stockpiles, and the ability to perform pre and post exposure prophylaxis. one participant (p ) said, "if prevention is not imminent with different medications and appropriate vaccines, the disease would spread. for example, if respiratory anthrax or plague becomes prevalent, vaccination and appropriate therapeutic prophylaxis are the only way to prevent the disease progress in the community". - : nursing: the presence of skilled and capable nurses was one of the subcategories obtained in this study. nurses who are trained, skilled, and familiar with personal protective equipment may have positive effects on hospital performance. one of the participants (p ) mentioned: "having skilled nurses to care for infectious patients is valuable as patients' treatment in epidemics. one day i went to the hospital for a visit and saw the aids patient wearing a mask. the head-nurse had told him to do so". - : isolation: according to the participants, the ability to isolate patients with communicable diseases in the hospital and in the designated sites for group isolation was an important component of infection control. one participant (p ) said, "isolation spaces are needed based on the causative agent (such as droplet or airborne isolation). in emergency situations, metal partitioning is better, and if not possible, minimal isolation should be executed even with curtains". - decontamination: most participants considered the ability to decontaminate victims efficiently as one of the important factors in hospital performance dealing with biological disasters, which is an important step in decontaminating patients, surfaces, and equipment in proper response to such disasters. one of the participants (p ) stated, "environmental health authorities should be active in tackling the issue. notifications should be declared as soon as possible. environmental decontamination is needed for each disease". - : triage: according to participants, the use of specialized triage in biological events affecting many victims will enhance hospital performance. biological triage which has a different mechanism than other triage systems helps to reduce infection transmission and provide high-speed treatment for people with high-priority care. it also provides the most services in the least amount of time to the largest number of victims. one participant (p ) said, "all hospitals should have a triage system and special checklists." biological triage is necessary. there are no triage systems for infectious diseases in my hospital, so there is not any sorting during an outbreak". - : infection control: participants considered infection control as an essential criterion for hospital performance in biological disasters. the common codes derived from these subcategories are as follow: the ability to control infections during deliberate or natural biological outbreaks; the availability of preventive drugs at a predetermined time during an epidemic of communicable diseases; appropriate vaccination of people at risk; and the safety of hospitalized or outpatients patients in the outbreak of infectious diseases; and waste management. one participant (p ) stated, "to see how a hospital performs, we need to see how much patient's safety is considered. sometimes, with a simple maneuver such as washing hand, transmission of the infection would be prevented". participants considered inter-sectoral and intra-sectoral coordination as an important factor in the proper hospital performance during biological disasters. - : intra-sectorial coordination: a common subcategory was coordination and collaboration within the hospital during a biological disaster, including predetermined inter-organizational tasks. one participant (p ) said, "when epidemics occur, it is highly important that internal parts of the hospital (such as laboratory, radiology, emergency departments, and others) be coordinated. in the early days of influenza epidemic, we did not know where to send the patients' samples for definite diagnosis, which made the process more complicated". - : inter-sectorial coordination: the common codes in this subcategory were as follow: existence of memoranda between hospitals and partner centers (such as organizations for corpses burial, drug production companies, vaccines and personal protective equipment producers, reference laboratories, buildings' owners that can be used for mass storage or isolation). one of the participants (p ) stated, "if there is a suspicious anthrax case and the hospital is a regional one, they should know which laboratory would help, and there should be an accepted guideline for referral". according to participants' viewpoint, the availability of appropriate human resources, necessary equipment, appropriate physical structure, and enough funding has a beneficial effect on hospital performance in biological disasters. these subcategories created the category of resources. - : human resources: according to the participants' perspective, one of the most important factors affecting hospital performance was the availability of human resources in biological emergencies in terms of quality and quantity. defining an organized structure of the staff for the response, duty description for the team, the right staff, and an efficient manager in the hospital seemed necessary at the time of biological disasters. one participant (p ) said, "sometimes we have cases of flu, meningitis, and tuberculosis, but the hospital performance is not appropriate and practical. although training was provided and relative preparedness was expected, during the swine flu outbreak, all staff were afraid and wore masks in hospitals. even the staff in the infectious diseases ward wore masks, which was not necessary and only caused horror. only those who are within a meter of the patient should wear a mask". . : physical structure: based on participants' viewpoint, appropriate physical structure of hospitals to respond to biological disasters is an effective factor in dealing with biological disasters. the proper physical structure of a hospital, enough space for biologic triage, suitable isolation space considering the type of agent, a proper radiology and laboratory structure, and a standard lab were effective subcategories of this category. one participant (p ) said, "one of the performance evaluation factors is whether the hospital has been standardized; having a triage space and decontamination room before entering to the main ward and isolation from the emergency department are highly important. in the influenza epidemic, all hospitals were ordered to separate the patients upon arrival at hospitals, but this was not possible in some hospitals". - : equipment: the subcategories were equipping some ambulances ready for a biologic event, having special and practical equipment when dealing with biological disasters, adequate personal protective equipment, and the ability to maintain laboratory biosafety. one participant (p ) recommended, "having enough equipment to be able to provide good biosecurity is of significant importance. there is not a special stretcher for contagious patients in our hospital, and the lack of a special stretcher for carrying infected patients can impair performance". - : budget: according to the participants' opinion, allocation of appropriate budget for hospital was an effective factor in assessing the hospital performance during biological disasters. insurance of staff and the hospital, and proper allocation of funds were the common subcategories of this category. one of the participants (p ) said, "my hospital manager is concerned about the financial aspect, and he has limitations on training and recruiting human resources. we do not have financial resource even for equipment and training, and our managers do not believe in spending money for managing these disasters. they prefer to deal with tangible issues rather than intangible issues such as biological disasters that have not yet happened". training and exercise influence hospital performance. the subcategories were appropriate educational content in accordance with the up-to-date changes in the field and intermittent exercises. - : educational content: the following subcategories were extracted: having rich and up-to-date educational content with emphasis on biological group a & b agents; providing training on how to use personal protective and prevention equipment, triage, isolation, secure area, control, and treatment; and providing training for misbelief correction. one of the participants (p ) said, "there should be an educational content related to the subject; it can be a part of hospital accreditation. some employees even do not know the correct pronunciation of diseases". - : training: all participants considered staff training as one of the most important factors in hospital performance. the extracted subcategory was receive training in the field of biological agents, including continued and regular education, up-to-date training, and training about preventive and personal protective equipment (mask types and time), isolation types, triage, secure area, and group a & b agents. one participant (p ) recommended, "up-to-date training should be available for staff with an interval of maximum of up to year. our personnel have been graduated many years ago, and their training has not been updated at all". - : exercise: by analyzing the data, intermittent and proportional exercises were obtained as common codes in the exercise subcategory. according to participants, the factors of this subcategory included the need to conduct a biological exercise in the hospital, and presence of a range of exercises such as top table exercise for managers and coordinators and other types of exercises, and execution of intermittent drills within a specified time schedule. one of the participants (p ) declared, "our managers did not have any experience in biological disaster management, even in the form of a drill. we should exercise and learn what we lack". another participant (p ) said, "there should be an exercise index for evaluation (drills about personal protective equipment) ". according to the results of the data analysis, the risk communication system, information security, risk understanding, and surveillance system were subcategories of the communication and information system category. - : risk communication systems: having a risk communication system, information security, risk understanding, and a surveillance system were determined as subcategories of this category. - : information security: information security is important in an outbreak of infectious diseases in hospitals, as non-patients may go to the hospital for fear of panic or patients may not come to the hospital for fear of stigma. the common codes were as follow: the possibility of sending written reports or internal automation to senior officials, laboratories, and the ministry of health, and lack of public notification in some instances. one of the participants (p ) said, "a false outbreak would occur without proper communication with the economic authorities. each time after a rumor about an infectious disease, many will come to hospitals as false patients, and controlling such situations would be very difficult". - : risk understanding: this subcategory was also derived from the information and communication category. participants believed that developing a positive attitude towards the possibility of biological disasters in hospital managers is crucial, because if a manager or staff does not believe in the possibility of biological disasters, there would be no possibility of necessary and timely action. one participant (p ) declared, "hospital managers do not have a proper attitude about this kind of problems. even after being trained by senior officials, they still do not have a good perception of the biologic disasters". - : surveillance system: according to participants, the use of surveillance systems in hospitals and the active registration of infectious diseases were considered as effective factors in hospital performance. one participant (p ) said, "the center for diseases control of ministry of health has a tradition of its own. in the health sector, they have a disease expert who will inform you if something happens. they themselves do not actively seek out any disease". the existence of an appropriate hospital incident command system (hics) for biological events was one of the main obtained categories in this study. extracted categories were the need for existence of a code for the biological crisis, type of system activation, existence of a unique command, use of qualified advisors in a commanding system, and proper organization of the staff. one of the participants (p ) announced, "having an incident command plan during a biological disaster is highly important. commanding systems do not work well in our hospitals in important and dangerous disasters such as earthquake and floods". planning and assessment were among the other key elements that influenced hospital performance during emergencies. risk assessment in hospitals was identified as a basic point in evaluation of hospitals. in the absence of a risk assessment in a hospital, finding priorities for risk reduction measures can lead to resources loss and parallel work. participants considered the factors that impacted hospital performance: the existence of qualified self-assessment mechanisms along with appropriate indicators in assessment checklist and a well-defined cutoff point. extracted subcategories were existence of updated instructions and guidelines, a special response and recovery plan for biologic threats, using the all-hazards approach to preparedness, and a lab plan. another participant (p ) said, "readiness assessment checklist must be completed every - months for each center. our hospitals do not have any assessment checklist for infectious diseases". in this qualitative study, which was done using content analysis, the effective factors for hospital performance in biological emergencies in ir of iran were identified as follow: diagnosis; treatment and control of infection; resources; coordination; training and practice; communication and information systems; construction; and planning and assessment. detecting a biologic event is one of the primary influencing factors in hospital performance. early diagnosis is one of the important factors for initiating immediate action and response to prevent further development of a biological agent ( ) . controlling hospital outbreaks requires rapid diagnosis and search for clusters; then, appropriate controls are executed ( ) . early diagnosis of the disease prevents its spread and can be effective in the timely treatment of exposed individuals and doing biologic triage. while an epidemic is rapidly discovered, its spread can be prevented by isolating patients and prompt prophylaxis. also, recognizing the type of biological disaster (intentional or unintentional) aspect may have an impact on hospital function because management of such biological emergencies may en-counter many complications considering type of agent, genomic manipulation, event location, geological and climatic conditions, and disease spread in the community prior to definitive diagnosis ( ) . over the past decades, the intentional enhancement of using biological agents has increased the demand for risk assessment and monitoring of such events, which often involves modeling approaches based on certain assumptions such as the ability to generate, store, and distribute. the ability to release a biological agent as a weapon does not only result in the creation of airborne transmissible microorganisms but can be transmitted from human to human and spread. management of deliberate transmissible is different from that of non-transmissible epidemics ( ) . another effective factor in hospital performance in biological events is treatment and infection control. in a biologic emergency, treatment measures and timely response to the event are important factors. triage is an important factor in controlling hospital infection during a biological emergency ( ) . most triage systems deal with traumatic or kinetic injuries ( ) . such systems are not applicable to other types of disasters, including biologic emergencies, because some factors (eg, exposure and symptoms) do not affect the infection control and make rapid diagnosis and treatment more difficult. victims are unlikely to be harmed, and there may not be a particular scene of disaster ( ) . therefore, it is necessary to consider a special system of triage instead of conventional systems ( ) . in accordance with burkle's recommended method, biologic triage is used for patients in an incident with a large number of injured people and divides them into groups: ( ) susceptible but not exposed; ( ) exposed but not yet infectious; ( ) infectious; ( ) removed by death or recovery; and ( ) protected by vaccination or prophylactic medication ( ) . in settings where infectious diseases are easily transmitted, deaths from infectious diseases are more likely than traumatic events ( ) . therefore, applying biologic triage is vital for controlling transmission. during biologic emergencies, triage makes it easier to control and treat the patients, prevents loss of resources, and reduces the probability of transmission of communicable diseases, and decreases the burden of hospitalization by reducing the number of visits to hospitals ( , ) . in this regard, access to drug and vaccine supplies and appropriate measures can reduce the number of patients or decrease the disease severity. effective actions in performance are hand washing and self-protection methods for staff, and proper isolation based on the type of disease ( , ) . providing care for patients within the hospital is an important part of patients' treatment and infection control at treatment centers ( ) . therefore, having competent nurses and trained infection control specialists as well as self-protection methods are other measures related to performance improvement ( ) ( ) ( ) ( ) ( ) . in biologic emergencies, one means of differentiation with other common emergencies is the need for self-protection methods of staff, especially physicians and nurses who have close contact with the patients ( , priate measures stops the transmission of the infection between patients and staff, including nurses ( , , , ( ) ( ) ( ) ( ) ( ) ( ) . decontamination spaces of biological patients will make these disasters distinct from others. decontamination is less important in disasters with large number of traumatic patients, but in biological disasters (especially man-made), the entry of noncontaminated patients into hospitals and the implementation of individualized and collective quarantine are of great importance ( , , ) . risk management approaches for infectious disasters are necessary to reduce the risk of secondary contamination with regards to decontamination measures and surveillance ( ) . based on the results of this study, human and financial resources, physical structures of hospitals, and equipment (including personal protective equipment, laboratory, appropriate vaccine, and antibiotics) are effective factors in the proper functioning of hospitals. these findings were consistent with those of other studies ( , ( ) ( ) ( ) ( ) . an appropriate response requires access to laboratory facilities ( ) . decontamination facilities and access to personal protective equipment for triage and decontamination teams are among the limitations of performance in biological events ( , , ) . adequate budget is usually not allocated due to the high cost of preparedness and performance measures in infectious disasters. several studies have shown that the number of public health staff may decrease at the time of biological disasters (such as flu pandemics) ( ) ( ) ( ) . typically, volunteers will meet the required human resources (efficient and trained personnel) in disasters ( , ) ; however, this would not be the case in biological disasters. although the amount of motivation to work during biological disasters varies from country to country, the total amount of motivation is lower than in other events ( , ) . this drop in staff motivation is also evident in the number of volunteers ( ) . however, more research is needed to study the willingness of public health staff in disasters ( ) . therefore, one of the most important factors in biological disasters is the provision and management of manpower required in hospitals. previous studies have shown that male gender, being a physician, having a full-time job, self-protection, and communication equipment for staff, and basic needs such as water have a positive impact on the willingness to work in such events ( , , ) . motivation facilitators for working in infectious emergencies include access to vaccination and personal protective equipment, flexible work shift, taking care of staff children, and information sharing ( ) . regarding the release of a biologic agent, the strategic storage of the vaccines as well as pharmaceuticals for treatment of the agent can be important because easy access to antibiotics and vaccines is very effective. access to ventilators for the management of infectious respiratory disasters is a necessity ( , ) . there are currently antiviral drug storages for responding epidemics that cost a lot ( ) . the lack of funding and financial resources is a major obstacle to the preparedness and proper performance in infectious disasters ( , ) . appropriate supply strategies, adaptation to the severity of the event, and the type of microorganism have a preventive and controlling role in infection from person to person ( , ) . also, having a proper physical structure to respond to biological events is important for proper functioning. this factor has been mentioned in numerous articles ( ) ( ) ( ) ( ) . examples which may be presented here are the existence of a separate entrance door for the emergency department, proper design of the rooms and the hospital, and proper equipment (eg, separate ventilators in the emergency department) ( ) . based on the findings of this study, staff training was one of the main elements of the proper functioning of hospitals in biological events. reviewing articles also indicated that education and training are key elements in disaster preparedness ( , ) . many efforts have been made to explain the capabilities and design of training curricula for management and response to cbrne events, but there is still lack of capability-based plans ( ). emergency department physicians, nurses, and support staff are the main groups for training and education. hospitals will not be able to respond appropriately in disasters without the upgraded educational guides ( ) . training is an important challenge in managing disasters which was obvious in events such as ebola outbreak. control of communicable diseases such as ebola and other infections may be affected by lack of educational materials, curricula (educational curriculum, development of educational contents, training resources, and tools), and educational contents ( ) . most of training courses (during and after ebola epidemic) have been performed for infection control staff and has not been addressed for other stakeholders ( ) . best practices for ebola education are engaging all stakeholders (eg, crisis managers, infectious disease control staff, and health workers) in educational programs. the most important educational challenges are annual budget and misdeclaration of sufficient training in an organization ( , ) . sustained education for combating the spread of infectious diseases requires annual budget, full support of the organization management, and engaging all stakeholders ( ) . the reports show poor knowledge about disaster planning and biological events in emergency departments around the world ( , , ) . it is imperative to ensure full recognition of risk reduction plans in infectious disasters for all those responsible for reducing the risk. in an egyptian study, medical residents had less training on personal protective equipment than specialists and counselors ( ) . however, education in this regard is one of the key points in infection transmission and control. occupational and non-occupational stresses in physicians were more than nurses, indicating the need for further training on the nature of pandemics, the results, complications, and methods of infection prevention ( , ) . in the absence of comprehensive support and failure to address the motivation or needs of professionals, effective education and the use of educational opportunities would be a challenge ( ) . developing educational standards and guidelines for a medical response to disasters (especially cbrn) has a major impact on emergency response to disasters ( content, determining the type of training, and evaluation of tools. a review article of cbrne training courses between - indicated that course evaluation was not done by any study ( ) . essential elements of education are personal protective training, hospital incident commanding systems for emergencies, surge capacity, and assessment and risk determination in accordance with biological disasters ( ) . coordination is one of the disaster management requirements in communities and hospitals. disaster management occurs in a complex context. this complexity is the result of a variety of different functions of the external and internal sectors in a hospital. coordination of these sectors would result in proper disaster management. in this study, internal and external coordination were key factors in response to biologic disasters. the presence of the emergency coordinator promotes health sector preparation activities. coordinators also provide a road map for moving in and out of hospital-crisis-related factors. avery et al indicated that the presence of a coordinator increases the level of readiness in the health sector in a disaster ( ) . this is evident especially in infectious disasters which require more coordination between infectious disease control centers and security sectors. jones et al showed that the coordinator had a direct relationship with the readiness of hospitals in pandemics. the connection was not linked to readiness in other settings such as casualty incidents, general preparedness of the hospital, and inefficiency of the hospital infrastructure. this could be a sign of the difference in infectious disasters. management requirements of such events include provision of vaccines, drugs, and personal protective equipment, and sufficient equipment and personnel resources at local, national, and international levels. memoranda of agreements (moas), memoranda of understanding (mous), and planning partnerships with other hospitals, health centers, government, local authorities, and other providers of support services are examples of out of organization coordination ( ) . capability of hospital external evacuation also requires external organization coordination, which according to the review of articles in the field of interhospital memoranda, has the lowest rate for children and infants ( ) . risk communication is one of the central components of proper performance of hospitals during infectious disasters ( ) . communications and information systems were derived as one of the main categories in this study. when an outbreak occurs and general public health is compromised, direct interventions and treatment options may be limited due to lack of time and the need for resources. therefore, communication, notification, and guidance are often the most important tools of public health in risk management during such events ( ) . communication readiness reduces the response time of the crisis ( ) . other impacts of communication and information systems during disasters are confidence of people in managers and acceptance of protective behaviors, disease surveillance, and reduction of confusion ( ) . to effectively respond, information should be organized in a timely fashion and be disseminated through multiple channels along with appropriate training ( ) . health communication includes key elements: message, receiver, source of information, and the channel for information exchange. the above elements should exist and function properly in any health-related communication plan. communication would be implemented in the field of informing the public as well as in health systems, especially with respect to infectious disasters ( ) . public health stakeholders, although not directly involved in public health emergency management, will take timely decisions, plan, and control timely access to information ( ) . moreover, to effectively implement communication in these disasters, standardized educational content, clear national guidelines, and pre-prepared plans in the field of communication in hospitals are required ( ) . ineffective communication is one of the potential reasons for the failure of infection control in health workers ( ) . hospital communications should be completely clear, scientific, and understandable. health workers are an important criterion for community's trust in resources and their knowledge and dealing with the situation will affect the trust of the community ( ). bonneux et al suggest that the management of unpredictable panic of hospital staff is more difficult than controlling the spread of disease ( ) . the clear release of information can prevent the fear of staff and society ( ) , and a long negative impact will occur with no on time intervention on hospital performance ( ) . understanding the proper risk from leading risk is a decisive factor in disaster management. today, in a world where the information transfer (whether right or wrong) is done at a rapid pace, the perception of risk from truly risky cases is less than estimated, and the risk of rare cases is overestimated ( ) . understanding the risk is related to the mental sensation of control. the threat of an epidemic may in part be frightening because of feeling lack of control that leads to an unwanted activity ( ) . verbal communication and standard communications (eg, guidelines, education, electronic communications, and marketing) are definitive communication pathways in infectious disasters. experiences indicate that traditional methods are unsuccessful in changing and maintaining the best performance in infection control, although newer methods (such as electronic communications and marketing) have some problems. some approaches (eg, involving health staff in the communication processes or up-down communication) can improve communication methods ( ) . the timely identification of cases of infectious diseases with increased patients over a given period of time is a critical necessity for the ipcs. survival systems in hospitals are currently focusing on a small set of microorganisms such as methicillin-resistant staphylococcus aureus, carbapenem-resistant enterobacteriaceae, and clostridium difficile ( ) . there are several pathways for the transmission of pathogens (staff to patient, environment to patient, patient to patient, visitors to patient, etc.) due to dynamic health care in hospitals. better monitoring of the epidemics onset would be implemented by operating the modern and multifunctional surveillance systems, including observing symptom reports in specific time spots, syndromic surveillance systems, prediagnosis and nonspecific criteria monitoring, and health behaviors observation (eg, absenteeism from work or school, pharmacy referral or even search rate in search engines with specific words that indicate an increase in the incidence of infectious diseases) ( ) . although more modern systems such as electronic surveillance systems have high sensitivity, their positive predictive value is low ( ) . united states has conducted surveillance systems and epidemiological surveillance with a large budget in the framework of biowatch program to monitor the deliberate propagation of biological agents ( ) . in this study, an incident management commanding structure in accordance with biological emergencies was found to be the proper structure of the main element of performance. hospital incident command systems are used as a model for disaster response in some countries. this system is an attempt for standard performance of hospitals in disasters ( , ) . in recent years, incident command system has been implemented for iranian hospitals to manage disasters with an all-hazards approach ( ) . application of this system is part of the requirements for the accreditation of hospitals in ir of iran. however, this system has limitations such as not addressing the vulnerability of hospitals and not assessing the hospital performance in disasters ( ) . the participants considered the incident command system (consistent with biological events) as an effective element of hospital performance in biological events. use of the incident command system is part of an appropriate response to cbrn events ( , ) . the hospital incident commanding system is an integrated structure that despite the volume and effects of the events can provide coordination, control, operations, planning, support, and other necessary functions for event management, if properly implemented. it also explains responsibilities clearly leading to appropriate response ( ) . the effectiveness of this system has been indicated in outbreaks of infectious diseases ( , ) . if the response to biological emergencies will be designed as a systematic approach, it would lead to faster response by establishing coordination, speed of communication, recalling staff, etc. ( ) . this adaptation could include selection of specialized infectious and epidemiologic consultants, proper planning, operations based on infection control requirements, treatment and care, and other requirements for managing biological crises. in addition, matching these systems with biological emergencies can speed up the response by increasing external and intra-organizational coordination of multiagent organs ( ) . planning was one of our extracted main categories. the existence of disaster management plans in hospitals is essential to ensure preparedness and response, even before the emergence of events. a disaster management plan is a set of procedures, policies, interactional patterns, roles, and contingencies which are developed to prepare and implement appropriate response to a crisis ( ) . this plan includes staff training plans, responding to potential biologic agents, pollution prevention, rapid communication plans, potential quarantine exposure (individual and group), resource production and planning, and rapid diagnostic plans ( , ) . the existence of evidence-based guidelines is one of the deficiencies in infection control in iranian hospitals. self-assessment, external evaluation, and the use of intra-organizational and external experts for scientific review of guidelines and plans can have a positive effect on improving hospital performance. however, performance evaluation can be assessed in real terms after disasters and from lessons learned ( ) . security issues affecting the health and national systems and context of intentional biologic events were limitations of the present study, which did not allow all selected managers to participate in the study. however, the limitation was resolved by continuing the interviews with the main managers, determining the alternative ones, and continuing the interviews until saturation. hospital management in outbreaks of infectious diseases (intentional or unintentional) is complex and requires different planning than natural disasters such as earthquakes, floods, etc. in such disasters, readiness to respond and appropriate action is a multifaceted operation that has not been addressed in ir of iran and other countries so far. in this study, the factors affecting performance in such events were qualitatively explained and categorized. also, to properly perform in such disasters, each of the categories and their subcategories should be carefully implemented with detail. developing a model for assessing hospitals' performance in biological events should be considered in future studies. the researchers also recommend developing tools for evaluating hospitals performance and preparedness for biological disasters. practical suggestions include testing the efficacy of extracted elements of this study in hospital drills, full-scale practices, and actual hospital events. european pandemic influenza preparedness planning: a review of national plans innovative pandemic influenza preparedness framework 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iran from investigation of hospital protocols and guidelines to designing a generic protocol for responding to chemical, biological, radiological, and nuclear incidents organization of a hospital-based victim decontamination plan using the incident command structure incident command structure using a daily management system and the centers for disease control and prevention's patient notification toolkit drives effective response to an infection control breach lessons learned from implementing an incident command system during a local multiagency response to a legionnaires' disease cluster in sydney sars and the hospital emergency incident command system (heics): outbreak management as the mother of invention we would like to thank all of participants who spent their valuable time for interviews and other surveys. all authors disclose that there is not any actual or potential conflict of interest, including any financial, personal, or other relationships with relevant authorities or organizations within years of starting the study. key: cord- -j jbohi authors: cheng, chun-hung; kuo, yong-hong title: rfid analytics for hospital ward management date: - - journal: flex serv manuf j doi: . /s - - - sha: doc_id: cord_uid: j jbohi in this paper, we present an rfid-enabled platform for hospital ward management. active rfid tags are attached to individuals and assets in the wards. active rfid readers communicate with the tags continuously and automatically to keep track of the real-time information about the locations of the tagged objects. the data regarding the locations and other transmitted information are stored in the ward management system. this platform enables capabilities of real-time monitoring and tracking of individuals and assets, reporting of ward statistics, and providing intelligence and analytics for hospital ward management. all of these capabilities benefit hospital ward management by enhanced patient safety, increased operational efficiency and throughput, and mitigation of risk of infectious disease widespread. a prototype developed based on our proposed architecture of the platform was tested in a pilot study, which was conducted in two medical wards of the intensive care unit of one of the largest public general hospitals in hong kong. this pilot study demonstrates the feasibility of the implementation of this rfid-enabled platform for practical use in hospital wards. furthermore, the data collected from the pilot study are used to provide data analytics for hospital ward management. in the era of big data, companies and organizations are able to capture, process, manage, and analyze large volumes of data and turn them into valuable information and managerial insights that can help design better products, enhance service quality, improve operations, and make decisions. big data analytics not only supports businesses and commercial organizations to create further profits, but also helps governments and public sectors with providing high-quality services to citizens, and consequently benefits the populations by enhancing the quality of life. although many sectors like retail and banking have already embraced big data for many years, the healthcare industry has lagged behind them due to several reasons, such as medical service providers' resistance to change, underinvestment in information technology because of uncertain returns, security issues, and patient privacy concerns (groves et al. ; kayyali et al. ) . while there are various barriers to utilize big data in the healthcare industry, without a doubt big data can substantially benefit the healthcare stakeholders, for instance, by conducting comparative effectiveness research, developing clinical decision support systems, remotely monitoring patients, promoting personalized medicine, and analyzing disease patterns (manyika et al. ) . in this paper, we present a platform, which is based on radio-frequency identification (rfid) technology, for hospital ward management. with a prototype developed based on the architecture of this platform, a pilot study was then conducted in two medical wards of the intensive care unit of one of the largest public general hospitals in hong kong to demonstrate the feasibility of its practical use. prior to the introduction of rfid technology to the healthcare industry, healthcare facilities had to keep track of patients and valuable assets manually, or by the use of barcoding; the adoption of rfid in healthcare management has facilitated those practices. rfid has advantages over barcodes; barcodes have to be scanned manually one at a time within the line of sight of the reader, while multiple rfid tags, even if they are covered by some other objects, can be detected automatically and simultaneously by an rfid reader, whose read range is longer than the read ranges of barcode scanners. this automated process can save labor hours for performing some hospital routine tasks. the time saved from these non-value-added activities can help to reduce operational costs, or be transferred to provide additional professional services that can benefit patients. rfid not only reduces healthcare expense, but also facilitates automating and streamlining patient identification processes in healthcare operations (chowdhury and khosla ) . the identification processes can help to reduce medical errors and mitigate patient risk. overall, those healthcare facilities which had implemented rfid believed that the technology has more advantages than disadvantages (reyes et al. ). our work was motivated by the outbreak of severe acute respiratory syndrome (sars) in hong kong. in the incident, a significant number of individuals, including patients and hospital staff, were infected with sars within a hospital. a project team from the chinese university of hong kong (cuhk) considered the deployment of rfid technologies to trace the physical contacts of individuals within the wards in case of an infectious disease outbreak, in order to immediately and effectively isolate potentially infected individuals to mitigate the risk of disease widespread. although many healthcare professionals around the world have put enormous efforts into avoiding cross-infection among people in healthcare facilities since the sars outbreak in , risk mitigation of infectious disease in healthcare settings appears to be not very effective. it is not uncommon that individuals working in or visiting a healthcare unit are infected by some disease carriers. for example, the recent outbreak of middle east respiratory syndrome (mers) in south korea, where most of the infections took place in health facilities (bbc news ) , has again raised public worry about the spread of infectious disease in healthcare settings and has further affirmed the importance of tracing physical contacts between individuals in order to quickly and effectively isolate individuals suspected of carrying mers. the goal of the project presented in this paper is to develop a platform that enables traceability of individuals in healthcare settings. in addition to the traceability, our proposed platform also benefits the healthcare stakeholders by enhanced patient care, and increased operational efficiency and throughput. our paper is organized as follows. in the next section, we give a literature review on the use rfid for healthcare applications. in sect. , we describe the main components of our proposed platform, its architecture, and its benefits to hospital ward management. section provides the details of the pilot study and presents the capabilities and analytics that we can obtain from the rfid tracking data. section concludes our work. literature review rfid has been widely applied in numerous industries, including aviation (wyld et al. ) , construction (wang ) , food retailing moon and ngai ) , logistics (jones and chung ) , and supply chain (angeles ; prater et al. ; tajima ; sarac et al. ). rfid applications not only have practical contributions to optimizing operations in business and public sectors, but also have research values; in particular, academic journals in the field of operations and processes management such as production and operations management, international journal of production economics, and international journal of production research devoted special issues to papers of real-life rfid applications (dutta and whang ; ngai ) . for overall rfid applications, literature review, and future research, we refer the reader to chao et al. ( ) , , liao et al. ( ) and zhu et al. ( ) . although rfid technology has been widely applied in many industries, its adoption in the healthcare industry is still far behind from others due to various reasons, such as long payback periods, the need to modify the existing processes, the lack of applicable standards (reiner and sullivan ) , and privacy and security concerns (rosenbaum ) . for recent reviews of literature on the adoption and implementation of rfid technologies in the healthcare industry, we refer the reader to health industry business communications council ( ), wamba ( ) , yao et al. ( ) , coustasse et al. ( ) and wamba et al. ( ) . there have been various successful rfid-enabled applications in the healthcare industry. a major proportion of work deployed rfid to reduce medical mistakes or errors, which aims to improve patient safety. medical mistakes are the third leading cause of death in the united states (hospital safety score ) and are estimated to cause , preventable deaths of patients (james ) . among all kinds of medical errors, misidentification is a major source (yao et al. ) . positive patient identification (aguilar et al. ) , which requires each patient to wear a rfid wristband that contains the patient demographic information, has been proposed to provide a solution for reducing those errors due to patient misidentification. dalton and rossini ( ) used rfid technologies to avoid blood transfusion errors. the staff members of the blood donation centre used rfid readers to scan the rfid wristbands of patients and checked with their pdas if the information is identical with the blood bag tag. fuhrer and guinard ( ) developed a web-based application, which is called the rfidlocator, to track and locate patients. the system made sure that the correct operation is performed on the right patient at the right operating theater. yen et al. ( ) proposed two rfid-based solutions to reduce inpatient medical errors by nurses. an offline solution was proposed for the use in a hospital environment that does not support wireless communication. the nurses had to download the latest inpatient's prescription records from the system at the nurse station to their pdas before visiting their patients, and to upload the their drug administration records from their pdas to the system after their visits. an online solution was proposed for the use in an environment that wireless communication is enabled, so that the nurses could download and upload realtime drug administration information from and to the system at any moment. for both solutions, the nurses used their pdas, which were equipped with an rfid reader, to read the rfid tags in the wristbands of the patients and in the corresponding unit-dose packages to eliminate medication errors during drug administration tasks. in addition to positive patient identification, there are also other applications of rfid to reduce medical mistakes. kim et al. ( ) used rfid and sensor network to restrain blood deterioration during transportation. rfid tags were attached to blood bags to track their locations, and continuously monitor their temperatures to ensure that the blood samples are suitable for transfusion. reicher et al. ( ) demonstrated the use of rfid for preventing improper positioning of the endotracheal tube, where an rfid tag was secured, during intubation. francis et al. ( ) deployed rfid to limit the incidences of mislabeling tissue specimen bottles in gastrointestinal and colorectal surgery endoscopy units. pleteršek et al. ( ) developed an automatic disinfectant tracker that verifies the disinfection of the hands of medical staff, patients, and visitors in hospitals. a smart active label, which was capable of measuring and recording the time stamp of application, its duration, temperature, and ethanol concentration, was used to transmit the information to readers. they proposed two methods, differential dynamic method and static disinfection control, to monitor hand disinfection of people in hospitals. to fight against drug counterfeiting, pharmaceutical companies have also deployed rfid for drug packaging and labeling to prevent fake products from entering their supply chains (young ) . another way of deploying rfid to enhance patient safety is to detect patients' adverse events, which can potentially be fatal to patients. lin et al. ( ) applied rfid to monitor dementia patients in both indoor and outdoor environments. their developed system will warn caregivers whenever a patient is within a dangerous zone or strays too far. yao et al. ( ) proposed complex event processing to manage large volumes of rfid data, detect medically significant events for contextaware applications, and model surgical events and critical situations. al-masri and hamdi ( ) introduced an rfid-based system, called rfidtrack, to continuously monitor patients. the system would alert the medical staff, by sending a text message, in case of any early detection of adverse events (e.g., a steady rise in the body temperature, abnormal heartbeats, and improper movements of a patient). besides monitoring patients, asset tracking is another popular application of rfid in hospitals. the benefits include increase in resource utilization and prevention of losses of equipment. Østbye et al. ( ) conducted a prospective controlled evaluation in two similar hospital wards, where one ward used an assettracking system enabled by infrared signals and radio frequency while the other did not. they found that utilization of infusion pumps was higher in the ward that adopted the system. hakim et al. ( ) adopted a passive rfid system to track assets in a hospital in connecticut. the system aimed to monitor the telemetry transmitters in the hospital and prevent people from stealing them. mun et al. ( ) deployed rfid to track hospital assets such as infusion pumps, beds, and wheelchairs. they integrated their rfid asset management system with d barcode technology to improve processes in the hospital and patient safety, and reduce operational costs. shirehjini et al. ( ) proposed an rfid-enabled system that integrates tags into the floor and mounts readers on objects to determine the locations of mobile objects in a hospital. they used basic vector operations to achieve a better measurement of position and orientation of an object. the system can monitor the medical equipment and high-risk patients. rfid has also been demonstrated to be an effective technology to optimize healthcare operations. fry and lenert ( ) presented a real-time asset location system that used rfid to track patients, equipment, and staff for supporting operations and decisions during mass casualty events. the system provides tag position information, and data from medical information systems, registration applications, and the us navy's tacmedcs triage application, which facilitated emergency response. miller et al. ( ) used rfid to collect data on activity durations at a hospital emergency department. the data were then used to model processes in the simulation model of the emergency department. magliulo et al. ( ) presented an approach that combined rfid locating system and electronic medical management systems to optimize the patient flow of a radiotherapy department. parlak et al. ( ) demonstrated the feasibility of using rfid to track tools, recognize trauma team, and hence to support fast-paced and complex teamwork in a trauma center. marchand-maillet et al. ( ) developed an rfidbased system to record the time spent by patients between their admission and discharge from an academic ambulatory surgery center; the data were then used to construct operating room schedule. rfid can also save healthcare operational cost and reduce system inefficiencies. bendavid et al. ( ) presented a case study of applying an rfid-enabled traceability system for managing consignment and costly items in an operation room environment. they showed that their system together with the redesign of replenishment processes could facilitate item-level traceability and inventory management, upgrade service levels, and increase time for patient care activities by saving time from non-value-added activities. romero ( ) showed that an rfidbarcode identification system could reduce inefficiencies in pharmacy operations, such as poor inventory management, medicine shrinkage, intensive manual labor, long procurement cycles, and time-consuming product recalls. kumar and rahman ( ) conducted a case study of a singaporean hospital, which demonstrates that the usage of an rfid system could provide clear visibility in linen stock control. although there have already been various healthcare applications of rfid, most of them are implemented at an operational level, while the data generated by rfid systems are seldom analyzed. furthermore, staff at hospitals were rarely tracked in those applications. in this paper, we present an rfid-enabled system that can provide additional capabilities by tracking patients, ward staff, and medical assets. we also present a pilot study that we utilize the rfid data for establishing traceability of resources at hospital wards. an rfid-enabled platform for high-quality inpatient care and risk mitigation in hospital wards rifd is a technology that uses electromagnetic fields to transfer data. the purposes of rfid are mainly to automatically identify objects and keep track of their locations over time. an rfid-enabled application consists of two components of hardware-tags and readers-and a middleware. an rfid tag contains electronically stored information, such as its unique tag serial number and object-related information, and is attached to an object (products, assets, and even individuals), when in use. information stored on a tag can be updated, or locked. rfid tags can be active or passive. an active tag requires internal battery to power the tag and transmits signal periodically, while a passive tag has no internal battery and relies on the radio energy transmitted by an rfid reader to power the tag. therefore, passive rfid requires stronger signal strength, compared to the signal strength to operate active tags. in general, active rfid has a longer read range (i.e., the range that a tag and a reader can communicate) than passive rfid (more than meters for active rfid; around meters for passive rfid), but is more expensive (usd to for an active rfid tag; usd . to for a passive rfid tag) (jovix ) . passive rfid is mainly used for identification, while active rfid is mostly applied to track objects. the principle of rfid can be briefly described as follows. when a tagged object falls within the read range of a reader, the reader will transmit an encoded radio signal to interrogate the tag of the object. after the tag receives the signal, it will transmit an identifier and some other specific information, depending on the application, to the reader. the reader will then deliver the information to the middleware. in most applications the middleware is integrated with the legacy computer system of the application. the transmitted information is delivered from the middleware to the computer. the system will then create a unique id and a timestamp for this record and store the transmitted information. users can therefore retrieve the up-to-the-minute information, e.g., locations, regarding the tagged objects from the computer system. rfid data stored in the computer system can also be analyzed offline. for example, aggregating all the observations transmitted over time, the computer system can help to trace the location of any tagged object at any time. this helps to obtain the information about ''who or what is where, and when''. here, we present the concept and architecture of an rfid-enabled platform for hospital ward management, which aims to provide inpatient care of higher quality, reduce patient risk, and optimize operations. a prototype developed based on this architecture was also tested in a pilot study, which will be described in detail in sect. . the development of this platform aims to deploy a set of rfid technologies, which most hospitals are able to afford, for hospital wards management and achieve the following goals: . to strengthen the care coverage of inpatient treatment; . reduce risks incurred during inpatient period; . analyze ward activities and interactivities. with active rfid technologies, objective (i) can be actualized by real-time tracking of patients' locations and monitoring their health statuses, objective (ii) is achieved by patient identification and tracing paths of hospital-acquired infections, and objective (iii) is done by analyzing automated, continuous streams of tracking records. similar to other rfid-enabled applications, the architecture framework of our proposed system requires the three major components: rfid tags, rfid readers, and a middleware. the middleware can be integrated with the legacy ward management system of the hospital so that ward staff are able to retrieve real-time information related to all objects in wards to facilitate operations. we use active rfid technology for continuous tracking purposes. active rfid tags are attached to the objects in the hospital wards. in addition to patients, the tagged objects also include ward staff and medical equipment, which empowers additional capabilities and allows us to generate further insights into the interactions among the three categories of objects. each object is registered in the computer system and is given a unique id which makes each of them identifiable. patient personal information (name, gender, age, etc.) and case history are also available in the ward management system so that hospital staff can retrieve the information whenever necessary. this application of rfid technologies can also eliminate the traditional physical constraint that patients' health monitoring devices must be physically connected to the hospital legacy system to transmit patients' health-related data. due to the recent technological advancement, these health monitoring devices have become smaller and lighter so that they are portable and wearable. for example, microsoft band is a light wristband with multiple sensors installed and has the capabilities of continuously monitoring heart rate, body movement, skin temperature, and galvanic skin response. such wearable health monitoring sensors can be connected to an rfid tag to establish linkage for health-related data transfer. once data about health status have been transmitted from the sensors to the rfid tag, all real-time information regarding the corresponding patient (e.g., location and health status) can be sent from the tags to the readers via radio frequency data communication continuously. the real-time information is then delivered from the readers, via the middleware, to the ward management system for processing and storing the data. from the ward management system, ward staff would be able to locate each objects on the map at any moment, and monitor the health statuses of patients. for offline use, the stored data can also be used to report ward statistics and provide insights, intelligence, and analytics to hospital administrators for future planning. figure depicts the flow of our proposed rfid-enabled platform. our proposed platform can facilitate hospital ward management at both operational and analytical levels by the capabilities of real-time monitoring and tracking of individuals and assets, reporting of ward statistics, and providing intelligence and analytics. below we describe the benefits of our proposed rfid-enabled platform to the healthcare stakeholders. fig. the major components of the rfid-enabled platform and its flow the main advantage of deployment of this platform is the enhanced patient safety. first, the system can improve compliance by avoiding medication errors due to misidentification of patients, for instance, a wrong dose, drug, or medical treatment is given to a wrong patient. to avoid such errors, nurses can use portable electronic devices, e.g., pdas, smart phones and tablets, equipped with rfid readers to obtain the accurate personal information from the tag attached to the patient to verify his/ her identity, and confirm medication or medical treatments. a record will also be created in the system after the patient has finished his/her assigned dosage taking process or medical treatment to improve regulatory compliance. second, the system enables patient tracking; ward staff will be notified immediately whenever a patient is within a dangerous area or a suicidal patient leaves the ward. third, ward staff will also be alerted if the patients are in dangerous conditions, by real-time monitoring their health statuses and body motions (e.g., falling). another advantage of the adoption of this platform is increased operational efficiency and throughput. some paperworks and manual processes for inputing data into the system and can be automated by the data capturing and storage features of the platform. this automated procedure also reduces human errors and, thus, contributes to enhanced patient safety. moreover, by the asset tracking capability, ward staff can easily and quickly locate their required medical equipment. this can save a significant amount of time from searching for the equipment and can transfer the saved time from this kind of non-value-added activities to services that provide additional professional care to patients. furthermore, the data collected in the system related to staff and equipment activities in the wards can provide hospital administrators with insights into manpower and resource planning. the data can reflect the usage durations for different classes of staff and equipment. hospital administrators can therefore calculate the utilizations of different types of resources, identify scarce resources, and determine their optimal levels for future use. hospital administrators can also look at the activities of ward staff at different time periods on different days of the week to determine a better work-shift schedule. at an operational level, the capability of asset tracking prevents theft losses of valuable medical equipment. last but not least, the platform enables infectious disease traceability in hospital. the locations that patients visited at every moment were recorded in the ward management system. in case of an infectious disease outbreak within the hospital, the hospital management can quickly trace back the person-to-person physical contacts by retrieving, from the ward management system, the data about the locations and times that the (confirmed and suspected) disease carriers visited in the incubation period and a list of individuals who visited the same locations at the same times. this provides a way such that the hospital can promptly and effectively isolate those potentially infected individuals to mitigate the risk of disease widespread. furthermore, the traceability also enables the hospital to figure out the spreading paths and source of infection, which is exceedingly helpful for infectious disease control. in most of the rfid applications in the healthcare domain, tags are attached to patients or hospital assets; hospital staff are rarely tagged objects. in our proposed platform, hospital staff are also tagged because they can also be infected by disease carriers within the hospital when providing medical cares. in the next section, we will describe the prototype that was developed based on our described architecture and our pilot study. . before who announced the outbreak of this deadly disease and placed a high alert on the situation, the hospital management of pwh had already suspected that there was a communicable disease outbreak within the hospital when eleven medical staff members working in the same ward reported sick leave simultaneously. although pwh had eventually identified the index case-patient and then immediately isolated this patient and other infected carriers, a total of individuals, including medical staff, students, patients, and visitors, were cross-infected with sars in pwh due to the unawareness of this previously unknown disease when this patient was admitted (sars expert committee of hong kong sar government ). after the outbreak of sars, a project team from the cuhk considered the feasibility of using rfid technology to enable traceability for person-to-person physical contacts in order to provide immediate response to the widespread of infectious diseases and better risk management within hospital wards. in case of confirmed or suspected cases of infection, the hospital management can easily and quickly trace back the contacts between people in the wards, by retrieving the data about the locations the infected patients had visited and listing the individuals who visited those places at the same times, from the ward management system. healthcare-associated infection, i.e., infection acquired in healthcare facilities, is not a rare incidence that only took place during the outbreak of sars in hong kong, but the most frequent adverse event in healthcare delivery systems all over the world (who ) . infectious disease outbreak by cross-infection among individuals in health facilities is also a kind of healthcare-associated infection. such cross-infection can be difficult to prevent as carriers of some deadly infectious disease may only show mild symptoms (such as fever, cough, and muscle pain) at an early stage after being infected so that medical staff are not able to identify these carriers and isolate them in the first place. the outbreaks of sars in hong kong and mers in south korea are examples of cross-infection of deadly diseases among people in healthcare settings. since an effective and prompt isolation of potentially infected individuals can substantially mitigate disease widespread, the project team of cuhk aimed to apply advanced technology to facilitate the isolation procedure. the project team conducted a pilot experiment pwh to study the feasibility of the implementation of the rfid-enabled platform for hospital ward management. pwh is one of the largest public general hospitals in hong kong and also the teaching hospital for the faculty of medicine of the chinese university of hong kong. it has around , hospital beds and , staff, and serves the region of new territories east (more than . million people). in particular, the experience that the hospital management and medical staff had gained during the outbreak of sars and their advice were very valuable and exceedingly helpful when designing this platform. this motivated the project team to select wards at pwh to conduct this pilot study and demonstrate its practicality. two medical wards, named ward and ward in the rest of this paper, of the intensive care unit of pwh were selected to implement this pilot project. each ward was subdivided into different zones, where active rfid readers were installed at the corners of each zone. therefore, there were at least four rfid readers used to locate each object with a high accuracy of the location data. the active rfid readers and tags, that were used to track the locations of the objects, were manufactured by the department of electronic engineering of the chinese university of hong kong. fig. an rfid reader that was installed in a ward of our study rfid analytics for hospital ward management figure shows an rfid reader that was used in this project. the tags were attached to the patients, caregivers, and equipment (infusion pumps, cardiac meters, oxygen cylinders, stretchers, and wheelchairs) of the two wards to track their locations. the rfid tags were inexpensive (less than usd ), and small enough (around cm) so that they could be embedded in the badges of the caregivers and the patients could wear them as wristbands. figures , and showed the rfid tags that were used in the pilot study. in this project, in total, there were patients, caregivers, and equipments tracked in the rfid-enabled environment. all of them were given a unique object id and registered in the system. in summary, the data captured by this platform were location data about the tagged objects in the wards and have the following characteristics: • velocity: in every second, the readers and the tags communicated and the object-location data were stored in the system. • volume: the fast data collected from the readers were stored into the system continuously. there were in total more than million records (excluding those records that the location data remained constant in a period of time) captured by the system. • veracity: multiple readers were installed in different locations of the wards to obtain object-location information of high accuracy. in the outbreaks of sars in hong kong and mers in south korea, by the time these previously unknown deadly diseases had been identified and some patients were tested positive for infection, these patients had already been pathogen carriers for a certain time and had transmitted the viruses to the others (in communities or within health facilities) during the incubation period. in order to effectively and fig. the front and back of an active rfid tag that was used in the implementation promptly identify and isolate the high-risk groups of people that had contacted the carrier, a system that can trace the physical contacts associated with this patient will be exceedingly helpful. our platform is able to report person-to-person physical contacts. a user can define a person-to-person physical contact.the user has to specify how close two individuals were and how long they were together to constitute a physical contact. for example, the user can define a physical contact between two individuals if the two individuals were staying together continuously for s with their distance less than meter. with the user's definition of person-toperson physical contacts, the platform is able to list all pairs of individuals that had contacts. this person-to-person physical contact relationship can be reported using a network diagram, where a node represents an individual and an edge represents a physical contact between them . figure a shows a network diagram which represents the person-to-person physical contacts. the node size and edge size are proportional to the number of individuals that the represented person contacted in the ward and total contact time between them. we can also select a particular person fig. the active rfid tags that were embedded in a plastic plate and the plates were placed on the medical equipment fig. a patients was wearing a wristband which has an active rfid tag embedded and identify the individuals that this person has contacted in the incubation period, where an example is illustrated in fig. b . this data visualization technique can enable the hospital management very quickly to trace back whom the patient has contacted physically and identify high-risk contact groups, e.g., the individuals that have a significant duration of physical contacts with the carriers or have contacted a number of carriers. the times and durations that the physical contacts have taken place are also stored in the system for more detailed risk analysis. at an operational level, the platform enables the capability of tracking objects in real time. at any time, the ward staff can easily identify the current locations of patients and medical equipment, as demonstrated in fig. . this practice can save their time in searching for objects and hence can transfer the time to provide extra medical care to patients. the system will also alert the staff if patients are within dangerous areas or tagged objects move out of the monitoring area. this capability not only improves patient safety, but also prevents ward assets being stolen. this pilot project was conducted between december, and march, . the real-time location data of tagged objects came to our system almost continuously; during that period, the tags and readers communicated every second. for each tagged object, to reduce the storage required for the large amount of data, we only kept the tracking records that the object moved from one location to another; other records that the object was continuously staying at the same location were all discarded. after removing those records, the total number of tracking records in this period was , , . table lists the numbers of tracking records regarding different objects in the two wards. for each observation, the data attributes include a unique observation id, the timestamp of the observation, the x-and y-coordinates of the object on the floor plan at the time that it was identified by a reader, the reader id, the object id, and the object type (i.e., patient, caregiver, or equipment). due to privacy concerns, in the rest of this paper we present only the data related to the equipment, where those regarding patients' and caregivers' activities are not reported. excluding those patients' and caregivers' activities, the total number of tracking records regarding the equipment activities was , , . the stored offline data can be used by hospital administrators to better understand the actual equipment activities, derive insights, and support decision making. below we demonstrate some of the ways that the administrators can analyze by using data visualization. in fig. , we plot the locations of equipment for a selected day (at the top) and for a selected hour (at the bottom). the different colors represent different objects. the size of a circle is directly proportional to the total time that an equipment spent in the location; the larger the circle, the longer time the equipment spent in that location. this helps the hospital management better understand the proportion of time each equipment is spent in each zone on each day and which equipment is frequently used in different zones. hospital management may consider to add resources to those zones which frequently request some specific equipment. similar figures can be obtained if we include the data related to caregivers' and patients' activities. in fig. , we plot the paths that the equipment moved for a selected day (at the top) and for a selected hour (at the bottom). the platform is also able to calculate the walking distance of an object within a particular time period. when the walking distance is calculated for a ward staff, the ward manager is able to identify the staff fig. usage time (in seconds) of equipment in a selected day who have moved too frequently and may redesign the workflow. the time-location data about staff can also be associated with those about the equipment and the patients. if a caregiver was with a particular equipment and a patient for a significant time duration, it is very likely that a caregiver was providing the patient with some service using that equipment. since each equipment is designed for some specific purpose (e.g., an infusion pump is used for injecting medication or nutrients into a patient's body), the concurrence of a caregiver, an equipment, and a patient at the same location point can imply the type of service that the caregiver was providing in that period. this can also help hospital administrators understand the activities of the nurses for better workforce planning and avoiding unbalance workload. the platform also enables the hospital administrators to understand the equipment utilizations. using a similar previous argument, we define the usage of an equipment if it has been with a patient for a significant time duration. the platform allows the users to retrieve the durations of which the resources have been busy. figure shows the total time that the equipment was busy in a selected day at an item level. the data can also be aggregate to visualize the usage of all equipment. figure shows the total duration that the equipment were being used. the x-axis of fig. represents the dimension of hour of the day. as an example, we observe that the evening hours, between : to : , were the peak hours on that day, while the equipment were relatively free between : and : . in this pilot study, the project team also faced some barriers to implement this rfid-enabled platform. these barriers are not technological challenges, but the patients' resistance to wearing a rfid tagged wristband during the their length of stay. out of the patients who were referred by the ward staff to participate this pilot study, declined. there were physical obstacles that the patients were not able to participate. for example, it was not recommended because patients' both wrists were full of needle applications or due to their skin conditions. besides patient physical conditions, some of the patients were reluctant to participate due to various personal reasons, e.g., resistance to advanced technology and unwillingness to being tracked during the length of stay. this indicates that there are still human issues to be resolved prior to the adoption and implementation of rfid technology to track patients, which are beyond the technical challenges that researchers and engineers are able to handle. in the era of big data, healthcare units are able to capture, process, manage, and utilize big data to generate extra values to benefit the healthcare stakeholders. although there have been various applications of big data for healthcare use, the healthcare industry is still lagging behind other industries such as retail and banking. this indicates that there is a need to further promote big data in the healthcare domain. in this paper, we presented an active rfid-enabled platform to keep track of the locations of patients, ward staff, and medical equipment, for hospital ward management. the platform empowers real-time monitoring and tracking of objects, reporting of ward statistics, and providing intelligence and analytics. a distinctive feature of our proposed platform is that, all the individuals, including ward staff, are tagged and their locations are tracked continuously. this enables the traceability of person-to-person physical contacts in case of an infectious disease outbreak so as to provide immediate and effective response to mitigate risk of disease widespread within the hospital. a pilot study which deployed a prototype developed based on our proposed architecture of the platform was conducted in two medical wards of the intensive care unit of one of the largest public general hospitals in hong kong. although the pilot study demonstrated its feasibility for practical use, we also report some of the human issues that obstruct its adoption and implementation, which are beyond the technical challenges that researchers and engineers can handle. furthermore, installation of a rfid-network can be costly due to the infrastructure (e.g., active rfid readers, wiring, and some construction work) and the development of a middleware so that hospital management may hesitate to adopt the technology. nevertheless, these costs are mostly one-time initial set-up costs, because the tagged wristbands can be reused, while the maintenance cost is relatively lower. the hospital also further benefits from cost saving by preventing valuable medical equipment being stolen [e.g., the price of a cardiac monitor ranges from a hundred to several thousand us dollars according to alibaba.com ( ) ] and well-utilizing the scarce medical staff, who have been in huge shortage in the medical system particularly in hong kong (chinadaily asia ). we also believe that the implementation of this rfid-enabled platform would benefit the healthcare stakeholders by the advantages of enhanced patient safety, increased operational efficiency and throughput, and mitigation of infectious disease widespread. most importantly, the enhancement in effectiveness and efficiency of medical service delivery to patients and the capability of mitigating patient risk can improve patient health outcomes and even save more invaluable human lives that can hardly be measured in monetary value. in south brazil. he has recently led a project team to design and implement operational systems for an air-mail center and two museums in hong kong. he has also provided consulting services to local industries. positive patient identification using rfid and wireless networks rfid-based approach for monitoring patient's health inside hospitals cardiac monitor rfid technologies: supply-chain applications and implementation issues south korea declares 'de facto end' to mers virus rfid-enabled traceability system for consignment and high value products: a case study in the healthcare sector determining technology trends and forecasts of rfid by a historical review and bibliometric analysis from to rfid-based hospital real-time patient management system impact of radio-frequency identification (rfid) technologies on the hospital supply chain: a literature review using rfid technologies to reduce blood transfusionerrors. white paper by intel corporation, autentica, cisco systems and san raffaelehospital dutta a, whang s ( ) radiofrequency identification applications in private and public sector operations: introduction to the special issue a quality initiative to decrease pathology specimenlabeling errors using radiofrequency identification in a high-volume endoscopy center mascal: rfid tracking of patients, staff and equipment to enhance hospital response to mass casualty events building a smart hospital using rfid technologies the 'big data' revolution in healthcare. mckinsey quarterly hakim h, renouf r, enderle j ( ) passive rfid asset monitoring system in hospital environments understanding radio frequency identification (rfid) in healthcare: benefits, limitations, and recommendations hospital safety score ( ) hospital errors are the third leading cause of death in u.s., and new hospital safety scores show improvements are too slow a new, evidence-based estimate of patient harms associated with hospital care the benefits, challenges and impacts of radio frequency identification technology (rfid) for retailers in the uk active rfid vs. passive rfid the big-data revolution in us health care: accelerating value and innovation. mckinsey & company rfid-enabled process reengineering of closed-loop supply chains in the healthcare industry of singapore contributions to radio frequency identification (rfid) research: an assessment of sci-, ssci-indexed papers from a healthcare integration system for disease assessment and safety monitoring of dementia patients novel technique radio frequency identification (rfid) based to manage patient flow in a radiotherapy department accuracy of patients turnover time prediction using rfid technology in an academic ambulatory surgery center using rfid technologies to capture simulation data in a hospital emergency department the adoption of rfid in fashion retailing: a business value-added framework active rfid system augmented with d barcode for asset management in a hospital setting rfid technology and applications in production and supply chain management rfid: technology, applications, and impact on business operations rfid research: an academic literature review ( - ) and future research directions evaluation of an infrared/radiofrequency equipment-tracking system in a tertiary care hospital introducing rfid technology in dynamic and timecritical medical settings: requirements and challenges clinical progression and viral load in a community outbreak of coronavirus-associated sars pneumonia: a prospective study monitoring, control and diagnostics using rfid infrastructure future impacts of rfid on e-supply chains in grocery retailing use of radio frequency identification (rfid) tags in bedside monitoring of endotracheal tube position rfid in healthcare: a panacea for the regulations and issues affecting the industry improving the logistics operations of the hospital pharmacy using a barcode-rfid identification system radio frequency identification (rfid) in health care: privacy and security concerns limiting adoption a literature review on the impact of rfid technologies on supply chain management equipment location in hospitals using rfid-based positioning system strategic value of rfid in supply chain management rfid-enabled healthcare applications, issues and benefits: an archival analysis ( - ) a literature review of rfid-enabled healthcare applications and issues enhancing construction quality inspection and management using rfid technology summary of probable sars cases with onset of illness from health care-associated infections fact sheet where is my suitcase? rfid and airline customer service leveraging complex event processing for smart hospitals using rfid the adoption and implementation of rfid technologies in healthcare: a literature review two rfid-based solutions for secure inpatient medication administration fda embraces rfid to protect drug supply a review of rfid technology and its managerial applications in different industries he started his teaching career at kentucky state university. later, he returned to hong kong. professor cheng's research reflects his interest in information systems and operations management key: cord- -ekf mja authors: nan title: abstracts for the th ipna congress, iguaçu, brazil, september : oral presentations date: - - journal: pediatr nephrol doi: . /s - - - sha: doc_id: cord_uid: ekf mja nan years was % for pbs and similar to cou ( %) and rhd ( %). age-adjusted death-censored risk of graft loss was not significantly different for pbs as compared to cou (hr . ; % ci . - . ) or compared to rhd (hr: . ; % ci . - . ). conclusions: in contrast to previous reports, we found encouraging outcomes in the largest cohort of pbs children on rrt reported so far, which were similar to those with renal dysplasia. the protective arm of the renin angiotensin system may counteract the intense inflammatory process in fetuses with posterior urethral valves t.r.r. prestes ( ) , É.l.m. vieira ( ) , f.m. bastos ( ) , l.m. kangussu ( ) , n.p. rocha ( ) , a.c. simoes e silva ( ) ( ) ufmg, brazil, belo horizonte, brazil; ( ) universiy of texas, houston, united states objectives: previous studies showed that cytokines, chemokines and components of the renin angiotensin system (ras) might take part in renal damage observed in other obstructive nephropathies. the aim of this study was to evaluate if molecules related to inflammation and components of the ras can be detected in the urine from fetuses with posterior urethral valve (puv) and if these biomarkers are associated with the pathogenesis of this congenital anomaly. methods: urine samples from fetuses with puv at a mean gestational age of weeks ( - w) were collected and compared to urine samples from healthy male newborns (control group). cytokines, chemokines and ras components levels were measured by cytometric bead array (cba) and enzyme-linked immunosorbent assay (elisa). results: in comparison to healthy male newborns, fetuses with puv had significantly increased urinary levels of il- (p< , ), il- (p< , ), il- (p= , ), il- (p< , ), ifn-γ(p< , ), eotaxin (p< , ), mcp- (p= , ), soluble receptors of tnf type (p= , ) and type (p= , ). this intense elevation of inflammatory molecules was accompanied by significantly increased urinary levels of angiotensin i (p= , ), angiotensin-( - ) (p< , ), and ace (p< , ). on the other hand, ace concentrations were significantly reduced and angiotensin ii levels were similar when compared to control group. conclusions: the increased levels of cytokines and chemokines suggest that puv leads to a pro-inflammatory state that might be part of the pathophysiology of this anomaly. the observed activation of the protective arm of the ras, formed by ace -angiotensin-( - )-mas receptor, may play a role in modulating the intense inflammatory process triggered by puv. objectives: to compare outcomes of patients (pts) with luto stratified by severity using a prenatal classification system. methods: retrospective chart review of luto cases evaluated at the texas children's hospital fetal center from - . luto classification: stage i: normal amniotic fluid level (> wks gestation), favorable fetal urinary indices*, absence of renal cysts or dysplasia; stage ii: oligohydramnios (> wks), severe bilateral hydronephrosis, favorable urinary indices, absence of renal cysts or dysplasia; stage iii: oligohydramnios (> wks), severe bilateral hydronephrosis, unfavorable urinary indices, presence of renal cysts or dysplasia. *favorable fetal urinary indices: na < meq/l, chloride < meq/l, osm < mosm/l, β -microglobulin < mg/l results: total luto cases were seen in the study period. five underwent termination of pregnancy and had intrauterine fetal demise. therefore, pts were evaluated: stage i, stage ii and stage . no pts with stage i luto had fetal intervention, while % of stage ii and % of stage iii underwent vesicoamniotic shunting. gestational age at delivery and birth weight were similar between the groups. a greater percentage of neonatal deaths occurred in the stage iii group ( %) compared with stage ii ( %) or stage i ( %). % of surviving stage iii pts required dialysis as neonates, and % were dialysis dependent by yr of age. overall, % of pts were alive at yr. five pts underwent neonatal dialysis with % yr survival. for non-dialysis pts estimated gfr at yr was not significantly different between stage i and ii. conclusions: prenatal luto staging is clinically useful as it is strongly associated with both neonatal survival and the need for neonatal dialysis. in addition, luto pts who survive the neonatal period, regardless of the need for dialysis, are likely to be alive at yr of age. s -blood pressure: high to low fp-s - abpm in children and adolescents with renovascular hypertension b. leite ( ) , g. batista ( ) , l. suzuki ( ) , l. drager ( ) , e. furusawa ( ) , v. koch ( ) , a. watanabe ( ) ( ) instituto da criança -hc -fmusp, sao paulo, brazil; ( ) hospital das clínicas -fmusp, sao paulo, brazil objectives: to describe clinical presentation and ambulatory blood pressure monitoring (abpm) profile in a pediatric cohort with renovascular hypertension (rvh). methods: retrospective descriptive study of a cohort of pediatric patients (pts) with rvh including analysis of abpm profile. results: pts with rvh are described. the initial clinical presentation was hypertensive encephalopathy in / ; congestive heart failure / ; abdominal pain / ; irritability / ; epistaxis / and asymptomatic in / pts. median age was years. all pts had systemic arterial hypertension stage . fibromuscular dysplasia was diagnosed in / pts, takayasu arteritis in / , williams syndrome in / , neurofibromatosis in / , pt was diagnosed with renal artery compression by pheochromocytoma. the vascular lesion presented as mid aortic syndrome with bilateral renal artery stenosis (ras) in / pts, unilateral ras in / and bilateral ras in / pts. besides anti-hypertensive medication, angioplasty was performed in / pts, aortorenal surgery in / , auto-transplantation in / , excision of pheochromocytoma in pt; / pts were managed exclusively with anti-hypertensive medication. left ventricular hypertrophy was diagnosed in / children. abpm studies were performed in pts at different treatment phases; abpm recordings were analyzed ( were excluded by failure of the measures). after therapeutic management, only / pt achieved bp control by abpm standards: systolic and diastolic (s/d) bp means < th percentile and bp load < %, with s/dnocturnal bp dipping of . % and . % respectively. the remaining pts demonstrated severe ambulatory hypertension, with sbp/ dbp means values â'â'> th percentile and loads > %. s/d nocturnal bp dipping was present in / (range % - . %) and / (range . % - . %) recordings respectively. conclusions: rvh in children presents with severe hypertension and high morbidity. abpm is fundamental for bp control evaluation. fp-s - escort trial -effects of strict control of blood pressure in pediatric renal transplant recipients -final results from a randomized controlled trial t. seeman, j. dusek, n. simankova, k. vondrak, j. zieg university hospital motol, charles university prague, nd faculty of medicine, prague , czech republic objectives: the aim of this year randomized controlled trial was to investigate whether strict bp control can protect kidney graft. we present the final results. methods: all children who fulfilled the inclusion criteria were randomized to standard bp group (stand, target hr map - th percentile, n= ) or intensified bp group (intens, target hr map < th percentile, n= ). the primary endpoint is the yearly change in egfr (schwartz), the secondary bp, proteinuria and left ventricular mass. results: a total of children completed the study ( children withdrawn due to steroid-resistant or antibody mediated acute rejection). the results on bp and proteinuria are given in the table, the results on egfr will be presented at the meeting. & map = mean arterial pressure, map index = mean patient's map/ th perc. conclusions: this is the first randomized controlled trial on bp control and its effects on graft function. it demonstrates that strict bp control is possible in the majority of children and that proteinuria did not change significantly. the data on graft function will show, whether strict bp control can retard progression of chronic graft dysfunction. supported by grant azv of the ministry of health cze - a.. first evidence of progressive left ventricular mechanical dysfunction during four year follow-up in children with ckd: the c study. m. chinali ( ) , m.c. matteucci ( ) , a. franceschini ( ) , c. esposito ( ) , k. azukaitis ( ) , a. doyon ( ) , f. drago ( ) , f. schaefer ( ) ( ) bambino gesù pediatric research hospital, rome, italy; ( ) university of heidelberg, heidelberg, germany objectives: we have previosuly shown (cjasn ) that despite normal traditional markers of cardiac funtion, children with ckd exhibit mechanical systolic dysfuntion characterized by lower radial strain and transmural systolic gradient. objective of our study wars to analyze the evolution of cardiac mechcanics through repeated echocardiografic examination in a large sample of children with ckd. methods: one hundred patients from the c study with repeated echocardiographic examinations troughout four years of follow-up were included in the study. left ventricular (lv) hypertrophy was defined using the simplified approach recently described by our group (j peds ). advanced parameters of cardiac funtion included longitudinal epicardial and endocardial strain, circumferential epicardial and endocardial strain as well as radial strain. results: during four years of follow-up no significant changes in ejection fraction could be observed in the whole population. in contrast changes in cardiac mechcanics parameters could be observed during the study period in both endocardial circumferential strain (mean difference . +/- . %) and longitudinal strain (mean difference . +/- . %; p for both < . ). no change in parameters of cardiac mechanics could be observed in children with normal lv mass at baseline (p=ns for all), while a significant reduction of cardiac systolic parameters was found in children with baseline lv hypertrophy in both endocardial circumferential strain (mean difference . +/- . %) and longitudinal strain (mean difference . +/- . %p for both < . ). in time varying covariate analysis, main determinants of progressive reduction in cardiac mechaincs were the presence of lv hypertrophy and of lv concentric geometry. conclusions: despite parameters of traditional caridiac function remain normal during the years, in the presence of lv hypertrophy, progressive deterioration of cardiac mechanics can be observed in children with chronic ckd. objectives: to assess the prevalence of blood pressure abnormalities by ambulatory blood pressure monitoring (abpm) in a large european cohort of children with autosomal dominant polycystic kidney diseases (adpkd). methods: multicentric retrospective study. inclusion criteria: age < years, abpm recording, basic anthropometric and laboratory data, adpkd diagnosis based on family history and renal cysts or on genetic test. results: patients were enrolled in european centers (m:f ratio : ; mean age . ± . years). when present, paternal and maternal inheritance were equally distributed ( % - %). a minority of patients underwent genetic testing: pkd and pkd mutations were reported in % and % of patients, respectively. only patients ( . %) had a egfr < ml/min/ . mq. overall, % of patients had h mean abpm values > th percentile or were treated with blood pressure medications. pre-hypertension was present in % of patients and borderline hypertension in % of patients. daytime heart rate was significantly lower in adpkd children compared to healthy controls (p< . ). a significant proportion of patients had elevated nighttime blood pressure values: % were non-dippers and % had isolated nocturnal hypertension. as expected, the proportion of patients with enlarged kidneys increased with age; conversely, correlation between age and hypertension was weak. further rhythm analysis revealed a very high prevalence of circadian and ultradian rhytms in adpkd patients, including pre-pubertal children. these abnormalities exceeded those reported in children with chronic renal failure. conclusions: despite potential recruitment biases, this study shows very high prevalence of blood pressure abnormalities in children with adpkd, suggesting autonomic dysregulation and early onset of cardiovascular damage. fp-s - detection of novel non-labelling biomarkers of progressive glomerulonephritis using fourier transform infrared spectroscopy m-c. yu ( ) , r. peter ( ) objectives: more reliable biological markers using near patient technology are desirable to improve early diagnosis of patients at risk of progressive kidney disease. over the past two decades, fourier transform infrared spectroscopy/microscopy has been increasingly applied to biomedical research such as cancer. however, thus far ftir methods have not yet been applied to detection of progressive kidney diseases. therefore, in the study, this technology was employed to analyze urine and plasma samples collected from rodent models of progressive glomerulonephritis (gn), with the aim of discovering more sensitive biomarkers of renal injury. methods: experimental gn: nephrotoxic nephritis (ntn) was induced in male wistar kyoto rats. urine and plasma were collected from nephritic rats on day , day , day and day and compared with samples from normal rats . corticosteroid treatment in experimental gn: ( ) healthy control group ( ) treatment group: ntn rats treated with . mg/ kg of dexamethasone (dxm), ip every days, and ( ) vehicle group : ntn rats treated with pbs, ip every days. a series of urine was collected and plasma samples were taken at the time of cull. sample spectra were recored by ftir spectrometer and data was anayzed using origin . . results: three spectral markers at cm - , cm - and cm - were identified in urine and their intensity changes were in accordance to acute renal injury, progressive renal injury and chronic renal failure, respectively. in particular, the intensity of urinary cm - marker was reduced in response to dxm treatment. besides, there were three potential plasma spectral markers identified at , and cm - , respectively, showing that their intensity changes were parallel to the deterioration of renal injury. conclusions: the specific urinary/plasma ftir biomarkers can be the noninvasive and sensitive approach of early diagnosing and/or real-time monitoringprogressive kidney disease. objectives: although esi has been linked to peritonitis in pediatric pd, little data exists as to esi frequency and clinical factors influencing its manifestation. scope aims to reduce pd-associated infections through the systematic implementation of standardized care practices, including stipulated es care and an es-scoring tool. we sought to elucidate esi rates, predisposing clinical factors, and esi outcomes in children on pd. methods: scope data collected / / - / / were analyzed, including demographic and infection detail. esi was defined as purulent drainage or exit site score > or treatment for esi. fp-s - the role of peritoneal biopsy for the pediatric patients on peritoneal dialysis suspected of encapsulating peritoneal sclerosis. r. harada ( ) , r. hamada ( ) , h. satoh ( ) , y. hamasaki ( ) , k. ishikura ( ) , h. hataya ( ) , r. fukuzawa ( ) , m. honda ( ) ( ) tokyo metropolitan children's medical center, fuchu-shi, japan; ( ) toho university faculty of medicine, tokyo, japan; ( ) national center for child health and development, tokyo, japan objectives: to evaluate the usefulness of peritoneal biopsy in japanese pediatric patients on peritoneal dialysis (pd) suspected of encapsulating peritoneal sclerosis (eps). methods: we retrospectively studied the data from children who underwent peritoneal biopsy from january to december at tokyo metropolitan children's medical center. all patients had at least one of the following characteristics, clinical symptoms of eps, poor ultrafiltration and a long period of pd (more than years). the results were divided into an existing symptoms group and an asymptomatic group based on their clinical symptoms of eps such as vomiting and/or bloody ascites. we compared the pathological results and the treatment after biopsy of two groups. results: fifty-four cases were reviewed in this study. the median age at introduction of pd was . (range . - . years). ten cases were existing symptoms, while were asymptomatic before peritoneal biopsy. at the biopsy, the median duration of pd continuation was . years ( . - . ) and . years ( . - . ) respectively. in both groups, most of the biopsy results showed mesothelial denudation, interstitial fibrosis, capillary angiogenesis and vascular sclerosis. after biopsy, all the patients in the existing symptoms group needed treatment for preserving peritoneum. while in the asymptomatic group, / ( %) required treatment, but / ( %) were able to see the progress without treatment. the biopsy results of the patients without treatment in the asymptomatic group were significantly fewer instances of mesothelial denudation and vascular sclerosis than those of the patients required treatment (p< . ). there were two cases of peritonitis after biopsy as complications. conclusions: the peritoneal biopsy is useful for deciding treatment intervention for those who have no eps symptoms. the pd membrane microvasculature in uremia and pd -recent findings from the international pediatric pd biobank b. schaefer ( ) , m. bartosova ( ) , c. taylan ( ) , j. vande walle ( ) , u. querfeld ( ) , r. krmar ( ) , b.a. warady ( ) , c.p. schmitt ( results: the parietal peritoneum exhibits marked age dependent differences in vascular density, with highest blood capillary density and endothelial exchange area in infancy and lowest values in children aged - yrs. lymphatic vessel density is markedly lower, but again % higher in infants. omental blood capillary density correlates with parietal capillary density (r = . ; p = . ), small lymphatic vessels are few. uremia reduces omental but not parietal blood vessel density by %, angp- levels are % lower. the submesothelial vessel layer structure dissipates with low gdp pd, blood vessel density increases - fold, as do tgf-ß/psmad, vegf, activated fibroblast and cd /cd + macrophage abundance. mild lumen narrowing develops in % of blood vessels, lymphatic vessel density remains low. emt and profibrotic cd + fibroblast subpopulations appear more prevalent with high gdp pd-fluids. d/p creatinine ratios correlate with parietal peritoneal vessel density at baseline (r= . , p< . ), and while on pd (r= . , p= . ) but not with submesothelial thickness. conclusions: peritoneal vessel density defines peritoneal membrane transport function. despite low gdp fluid usage, progressive blood capillarisation develops with time on pd, while lymphatic vessel density remains low. fp-s - pkhd mutation in autosomal recessive polycystic kidney disease (arpkd) : genotype-phenotype correlations from a series of cases s. hamo ( ) , j. bacchetta ( ) , a. bertholet-thomas ( ) , p. cochat ( ) , l. calemard ( objectives: arpkd is a recessive orphan disease due to pkhd mutations. the main objective of our study was to characterize the phenotypic variability of patients with pkhd mutations, according to the different types of mutations. methods: this study was performed in a cohort of arpkd patients with a genetic diagnosis made in our genetic centre. we asked prescribing physicians to provide minimal clinical data, and sent them a questionnaire to retrospectively update the main outcomes. results: patients were divided into three genotypic groups: the first group (g ,n= ) consisted of patients with two truncating mutations, the second group ( g , n= ) of patients with one truncating and one non-truncating mutation, and the third group ( g , n= ) of patients with two non-truncating mutations. the proportion of severe arpkd (e.g. pregnancy termination or neonatal death) was significantly greater in g : % in g , % in g and % in g (p< . ). patients suffered from chronic kidney disease (ckd): g n= , g n= and g n= . notably, two patients from g developed ckd before the age of months. renal transplantation was performed in patients ( g n= ; g n= ; g n= ). portal hypertension occurred in patients at a mean age of . years; oesophageal varices were present in patients and complicated by bleeding in patients (g : n= , g : n= , g : n= ). three patients received a liver transplant (g n= , g n= , , and years), and one patients underwent combined kidney/liver transplantation (g , yrs). seven patients died after the neonatal period, from g , from g and from g (p< . ). the presence of two truncating mutations in pkhd is associated with a more severe perinatal and later-in-life phenotype. however, there is a phenotypic variability that requires great caution during prenatal councelling. fp-s - d-us with a correction factor is a good alternative in estimating total kidney volume in children with objectives: total kidney volume (tkv) has been shown in adult autosomal dominant polycystic kidney disease (adpkd) to be an independent and strong predictor for disease progression. in the current interventional clinical trials, tkv measurement by magnetic resonance (mr) imaging has been shown to be more accurate, reproducible and able to detect small changes over a short period of time compared to ultrasound (us). since future therapies in adpkd could be extended to include children, we aimed to examine whether the high-resolution d-us tkv measurements might be used as an alternative method to mr measurements in adpkd children methods: prospective evaluations of renal mr, d-and d-us were performed, whereby tkv was calculated by means of manual delineations (mr, d-us) or by the ellipsoid method ( d-us). correlations and differences between parameters were evaluated using pearson r and wilcoxon signed rank tests. after correction using the optimal linear regression, the variability of the measurements was examined using bland-altman plots results: we studied patients ( male, female) with a median age (sd) of . ( . ) years and egfr ( ) objectives: mutations of the pkhd gene cause autosomal recessive polycystic kidney disease (arpkd). pkhd encodes fibrocystin (fpc), a ciliary type i membrane protein of largely unknown function, suggested to affect adhesion signaling of cells. contributions of epithelial cell adhesion and contractility to the disease process of arpkd are elusive. here, we establish a link between loss of fpc function and epithelial morphogenesis in d cell culture, cell contact formation and cytoskelal networks. methods: we analyze fpc function in madin-darby canine renal collecting duct epithelial cells (mdck) based on pkhd silencing. cells are studied on micro-pattered chips in d cell culture conditions allowing analysis of polarity, lumen formation and ciliogenesis in epithelial spheroids. quantitative automated image processing is applied to analyze z-stacks of -color fluorescence images. to determine critical differences in cell adhesion parameters, mdck cells are studied also on chips in their one and ( )-cell stages. activation of adhesion signaling is addressed based on phosphorylation of the fak/src axis. results: using defined adhesion conditions, we quantified the impact of fpc deficiency on size / density of adhesion sites, cell shape characteristics and initiation of an apical surface. effects on apicobasal polarity and lumen formation correlate significantly with positioning of centrosomes in ( )-cell stages and activation of adhesion signaling. in addition, fpc deficient cells reveal defects in the formation of correctly polarized epithelial spheroids. transient reduction of actomyosin contractility restores % of correct epithelial morphogenesis (p< . ). conclusions: fpc silencing in mdck cells disturbs adhesion signaling and cell-cell interaction resulting in impaired epithelial morphogenesis. using a cell-based model system, we address molecular consequences of and analyze quantitatively rescue strategies for fpc deficiency in collecting duct epithelia. followed by those on hemodialysis ( . , p=< . ) but even those with high score did not reach % of the score. on multinomial logistic regression and using those with high scores (> ) as referent group, dialysis patients had a significantly lower hct readiness score. conclusions: despite the socioeconomic difference in the populations served at both institutions, the sample's overall low score. patients who have a renal transplant had the greatest hct readiness scores, and this may reflect the more intense preparation and patient education prior to transplantation. three-year-pediatric peritoneal dialysis experience in benin: challenges and successes f. lalya ( ) , y. tohodjede ( ) , m. d'almeida ( ) , a. hadonou ( ) , p.c. hounkpe ( ) , b. ayivi ( ) objectives: nigeria has the largest burden of sickle cell anaemia (sca) in the world. kidney abnormalities are established findings in children with sca and are known to start early in childhood. the study objective was to determine the risk factors associated with microalbuminuria in children with sickle cell anaemia and the relationship between it and glomerular filtration rate methods: the study was descriptive and cross sectional involving children with sickle cell anaemia in steady state and equal number with normal haemoglobin, age and sex matched as control. they were aged months to years and consecutively recruited from the paediatric outpatient department of the jos university teaching hospital between september and december . anthropometric, demographic characteristics and clinical parameters of each child and the social status of the parents were obtained. spot urine and venous blood samples were obtained for determination of microalbuminuria, packed cell volume and serum creatinine respectively. results: the prevalence of microalbuminuria in children with sca was % in children, compared to . % in controls. of this, % were aged ten years or less and there was no sex difference. anaemia and elevated glomerular filtration showed strong positive correlation with microalbuminuria, however, age, low socio economic status, number of siblings with sca, did not. glomerular filtration rate was higher in subjects with sca than controls and as well in those with microalbuminuria compared to those without microalbuminuria (p< . ). conclusions: the prevalence of microalbuminuria in children with sca in this study is high. the mean glomerular filtration rate is particularly higher in those with microalbuminuria compared with those without. this finding underscores the need for concerted effort at routine screening of sca children for microalbuminuria for the purpose of earlier detection of sickle cell nephropathy and appropriate therapeutic measure. s -global perspectives on registries fp-s - congenital nephrotic syndrome of the finnish type, espn/era-edta registry data t. holtta ( ) , m. bonthuis ( ) , k. jager ( ) , j. groothoff ( , and most of recipients were male ( . %). the most common underlying renal etiologies were congenital anomalies of the kidney and urinary tract ( . %) and glomerulopathy ( . %). according to donor source, ( . %) of transplants were performed with deceased donors (dd). graft survival rates according to donor source at , , and months were %, %, and % for living donor (ld) and %, %, and % for dd, respectively (log rank test, p < . ). graft losses ( %) were most frequently caused by vascular thrombosis, chronic allograft nephropathy, death with functioning kidney, acute rejection, and recurrent renal disease. recipients of dd had . ( % confidence interval: . - . ) times the hazard of graft loss compared with those of ld (p < . ). patient survival rates at , , and years were %, and % for ld and %, %, and % for dd, respectively. the mortality rate was . %, mainly as the result of infection and cardiovascular disease. conclusions: the results of this collaborative pediatric transplant study are comparable to international registries. our effort has been able to maintain an exchange of information, both among the participating centers and with other international registries. fp-s - turkish atypical hemolytic uremic syndrome registry: evaluation of long term prognosis a. soylu ( ) , k. gÜllero?lu ( ) , İ. gökçe ( ) , g. parmaks?z ( ) , h. evrengül ( ) , g. kaya aksoy ( ) , m. hayran ( esrd risk was increased in children > years of age at onset, while chronic renal disease was higher in the presence of extrarenal organ involvement, nephrotic range proteinuria at onset and cfh mutation. presence of hypocomplementemia was associated with lower risk of chronic renal disease. interestingly, proteinuria, hypertension and overall chronic renal disease rate was higher in those treated with eculizumab. conclusions: more than half of the children with ahus developed chronic renal disease. age over years at onset, extrarenal organ involvement, nephrotic range proteinuria and cfh mutation were associated with poor renal prognosis. fp-s - serum fractalkine (cx cl ) is associated with abnormal carotid and femoral intimal medial thickness in pediatric chronic kidney disease. q.z. chee ( ) , i.d. liu ( ) , m. than ( ) conclusions: cx cl , an inflammatory atherogenic chemokine, is associated with severe arteriopathy in children with ckd. fp-s - novel method for the definition of left ventricular hypertrophy improves identification of risk phenotype in children with ckd m. chinali ( ) , m.c. matteucci ( ) , c. esposito ( ) , a. doyon ( ) , a. franceschini ( ) , f. drago ( ) , f. schaefer ( ) , f. emma ( ) ( ) bambino gesù pediatric research hospital, rome, italy; ( ) university of heidelberg, heidelberg, germany objectives: we have recently reported that traditional indexation of lv mass to the allometric power of . , as curretly reccomended by current guidelines, may result in a significant overestimation of lv hypertrophy in younger children. accordingly we have suggested a simplified indexation approach to overcome this issue (j peds ). objective of the present study was to verify whether our proposed indexation improves risk stratification in ckd children. methods: overall children with available echocardiographic data, from two multicenter european studies on ckd were included ( from the escape trial and from the c study). presence of lv hypertrophy was defined using partiction values suggested by currect guidelines (lvm> g/m . ) and by our recetluy suggested approach [lvm>( g/m . )+ . ]. differences in the two methods in the identification of children with impaired systolic function were reported. results: using the traditional partition value lv hypertrophy (tlvh) could be identified in children representing . % of the total population. in contrast, our proposed method identified lv hypertrophy (nlvh) in children, reporesenting . % of the whole population. despite major accordance among methods (kappa score . ), tlvh was identified in patients without nlvh, while nlvh identified patients without tlvh. of note, children with tlvh, but not nlvh were significantly younger as compred to the rest of the population ( . +/- . years vs . +/- . years) and did not show any reduction in measures of chamber and or regional cardiac funtion (all p=ns). conclusions: traditional definition of lv hypertrophy significantly overestimates the prevalence of lvh in children with ckd. overestimation is more prominent in the very young children, in which no abnormalities in cardiac function are in fact found. our porposed simplified approach for the definition of lv hypertrophy reduces this overestimation and improves correct risk stratification in ckd children. fp-s - very high resolution ultrasound reveals intimal and medial vascular remodelling in dialysis and transplant patients f. dangardt ( ) , d. bhowruth ( ) , a. rapala ( ) , m. charakida ( ) , d. thurn ( ) , f. schaefer ( ) , j. deanfield ( ) , r. shroff results: at baseline, radial artery it and pedal mt were increased in patients compared to controls, most markedly in children on dialysis. children who had been on dialysis for more than one year had significantly greater carotid and dorsal pedal mt compared to those on dialysis for less than one year (p= . ). in the ckd and dialysis cohort (n= ), higher carotid mt at baseline was associated with increased serum phosphate (p< . , r= . ) and pth levels (p= . , r= . ). no correlation was seen with hydroxyvitamin d, fgf or bmi on any vascular measures. higher carotid and radial it were associated with higher lipid levels (p= . , r= . ) in all patients. at -year follow-up transplanted children had a % decrease in carotid mt (p= . ) but not it. increased dorsal pedal it in transplanted patients was associated with a higher systolic bp z-score (p = . , r = . ). the composite measure of cimt by cus did not reveal any significant changes in it at baseline and follow-up. conclusions: ckd patients have modifiable risk factors for intimal and medial vascular disease which were not detected by cus. our findings suggest vascular remodeling in response to a changing cardiovascular risk factor profile after transplantation and provides important information for effective cv risk stratification and treatment. fp-s - x linked hypophosphatemia (xlh) and growth: gh and mapki treatments r. fuente ( ) , h. gil-peña ( ) , l. alonso ( ) , o. hernández ( ) , Á. férnandez ( ) objectives: to analyze the potential effect on growth and bone of p-erk / inhibition (blocking of fgf -mapkinase pathway) in comparison with gh treatment using young hyp-mice, a model of xlh. methods: groups (n= ) of mice: wild-type (wt), control hyp (hyp), hyp treated with gh (hyp-gh, . mg/kg/day) and with p-erk / inhibitor (hyp-mapki, . mg/kg/day). studies after week: serum phosphate, kidney p-erk / expression and napi-transporter function, tibia's growth plate histomorphometry, igf- expression, proliferation and apoptosis, bone mineralization and structure (uct and von-kossa) and osteoclastic activity (trap). results: both treatments improved hypophosphatemia (wt= . ± . , hyp= . ± . , hyp-gh= . ± . , hyp-mapki= . ± . mg/dl; p< . ) but not as a result of higher renal napi activity. nose-tail and tibia lengths were significally increased by these treatments. in growth plate ( figure) , gh as well as mapki increased the terminal chondrocyte' height, local igf expression and chondrocyte proliferation rate (table) . caspase signaling was negative for all hyp groups, indicating marked alteration of apoptosis. growth cartilage disorganization was only improved by mapk inhibition which also increased bone mineral density (wt: . ± . ;hyp: . ± . ;hyp-gh: . ± . ;hyp-mapk: . ± . cm /g; p< . ) and trabecular number (wt: . ± . ;hyp: . ± . ;hyp-gh: . ± . ;hyp-mapk: . ± . ; p< . ). in contrast, gh enhanced cortical thickness to a greater extent (wt= . ± . , hyp= . ± . , hyp-gh= . ± . hyp-mapki= . ± . mm; p< . ). trap and von-kossa staining fitted with micro-ct analysis, and disclosed lower amount of osteoid in treated mice (table) . conclusions: gh administration and blocking of mapk pathway improve hypophosphatemia, bone mineralization and body length in hyp mice, but only mapki is able to normalize growth plate structure and orientation. gh administration did not correct these alterations, which may imply an increased risk of bone deformities. fp-s - progression of ckd and its determinants in children with ocrl mutations -retrospective analysis of a large international cohort d. böckenhauer ( ) , m. zaniew ( ) , a. bökenkamp ( ) , m. ludwig ( ) , m. konrad ( ) , f. anglani ( ) , m. addis ( ) , h. il cheong ( objectives: lowe syndrome (ls) and dent disease (dd ) are both ultrarare x-linked disorders associated with mutations in the ocrl gene and characterized by progressive chronic kidney disease (ckd). here, we aimed to investigate determinants of ckd and its progression in children with these tubulopathies. methods: retrospective, analyses of clinical and genetic data in a cohort of boys (ls: and dd : ). for genotype-phenotype analysis, we grouped mutations according to their type and localization. results: median egfr was lower in the ls group compared to dd ( . vs. . ml/min/ . m , p< . ). ckd stage ii-vwas found in % of all patients, of these % and % had moderate to severe ckd, in ls and dd respectively. esrd was found in three individuals with ls. trajectories of egfr showed a slow progression of ckd with a decline in egfr at the age of years in the ls group, whereas in subjects with dd , egfr remained stable throughout childhood. moreover, patients with mutations clustered in exons - had lower egfr and worse ckd progression. there was no significant association between type of mutation, presence of nephrocalcinosis, hypercalciuria, proteinuria and number of adverse clinical events and ckd. overall, % were treated with alkali therapy for acidosis. conclusions: this study shows worse ckd progression for children with ls compared to dd . localization, but not type of mutation is associated with ckd progression. fp-s - significant increase in urinary excretion of apolipoproteins and fatty acid-binding protein in children with nephrolithiasis and hypercalciuria l. kovacevic ( ) , t. govil-dalela ( ) , n. kovacevic ( ) , h. lu ( ) , j.a. caruso ( ) , r. thomas ( ) , y. lakshmanan ( ) ( ) children's hospital of michigan, detroit, united states; ( ) institute of environmental health sciences, wayne state university, detroit, united states objectives: using a proteomic model and pooled samples, we have recently identified several urinary proteins involved in lipid transport and metabolism in children with nephrolithiasis and hypercalciuria (cal). in the current study, we aimed ( ) to confirm these results in individual samples by performing enzyme-linked immunosorbent assay (elisa), and ( ) to examine the relationship between the urinary excretion of selected proteins with demographic, dietary, blood, and urinary parameters. methods: prospective, controlled, pilot study comparing the urinary excretion of apolipoprotein a (apoa ), apolipoprotein c (apoc ), and fatty acid-binding protein (fabp ) between cal (n= , females, mean age . +/- . years), and their age-and gender-matched healthy controls (hc)(n= )(ttest). exclusion criteria included obese children (bmi>/= the th percentile for children of the same age and sex). results: statistically significant increase in the urinary excretion of apoa , apoc and fabp in cal group vs hc was found (table) . apoa and apoc levels were higher in boys compared to girls. in the cal group, urinary apoa was positively correlated with urinary apoc (r= . , p< . ), and intake of meat (r= . , p< . ). -hour urinary calcium excretion significantly correlated with concentrations of apoc (r= . , p< . ), and fabp (r= . , p= . ). & apolipoprotein a (apoa ), apolipoprotein c (apoc ), and fatty acid-binding protein (fabp ) conclusions: we found marked increase in urinary excretion of lipid metabolism/transport-related proteins in non-obese children with nephrolithiasis and hypercalciuria. these findings suggest that abnormalities in lipid metabolism may play an important role in nephrolithiasis. targeting these proteins may have preventive and therapeutic benefits. objectives: single center studies report neonatal acute kidney injury (aki) incidence of - %; neonates with aki appear to have worse outcomes. these findings prompted the formation of the neonatal kidney collaborative (nkc) and the development and implementation of the awaken study. the objective of this study is to assess the incidence of neonatal aki and its association with outcomes in a large, multi-national cohort methods: nkc includes institutions from countries (usa, canada, australia and india). neonatal intensive care unit (nicu) admissions from jan to mar , were screened. inclusion criteria need for intravenous (iv) fluids ≥ hrs. exclusion criteria: ) admission at > weeks of age, ) congenital heart disease requiring surgical repair at < days of age, ) lethal chromosomal anomaly, ) death within hours of admission, ) severe congenital kidney disease. aki was defined as either urine output (uop) < ml/ kg/hr during any hour period from days - of life, a rise in serum creatinine (scr) of . mg/dl from previous lowest value and/or receipt of renal replacement therapy. (table) conclusions: our study demonstrated that at least . % of infants admitted to nicu who required iv fluids develop aki. subjects with aki have worse increased risk of death and longer los. our data contribute to the growing evidence that neonatal aki is common, with significant impact on clinical outcomes. further analysis of this robust database is underway. fp-s - the follow up and outcome of children requiring renal replacement therapy for acute kidney injury following cardiac surgery in new zealand c. chan, t. kara starship children's hospital, auckland district health board, auckland, new zealand objectives: to examine the characteristics, follow up and availability of long term outcome data in a cohort of new zealand children with acute kidney injury (aki) requiring renal replacement therapy (rrt) following cardiac surgery at starship hospital over a six-year period. methods: the cohort used was identified in the previously published "epidemiology and outcome of acute kidney injury in new zealand children". aretrospective review of medical records of all the children requiring rrt for aki following cardiac surgery from january to december was repeated to add further data regarding their cardiac history. patient characteristics were summarised. primary outcome was rates of renal surveillance. evidence of renal dysfunction and possible contributing factors were also studied. conclusions: this study suggests that a proportion of children who have had cardiac surgery have ongoing renal dysfunction at years. the care of this group of children, and identification of others at risk, could be improved by increasing awareness. a standardised monitoring guideline could provide surveillance over time and enable collection of further data. fp-s - hemodialysis in neonates and infants: a systematic review r. raina ( ) , m.s. ascha ( ) , j. darusz ( ) , s.k. sethi ( ) ( ) akron children's hospital, cleveland, united states; ( ) case western reserve university, cleveland, united states; ( ) medanta, the medicity, gurgaon, india objectives: background: hemodialysis (hd) in neonates and infants can be both difficult to implement and to maintain. objectives: to determine the effectiveness, safety and feasibility of hemodialysis in infant population by a systematic review. methods: design: systematic review, onwards studies. pubmed/ medline search using the search term, "hemodialysis". the medical subject heading (mesh) term "infant" was used to return results that pertain to pediatrics. population: neonatal patients - months of age treated with hd for indications related to acute kidney injury (aki). selection criteria: retrospective reviews not including studies solely concerned with peritoneal dialysis or continuous renal replacement therapies, studies of economic or ethical issues in dialysis care, pharmacological studies, and articles not reporting data on a majority of patient's ages. of the returned results, only studies were eligible for review. results: nine studies reported hd use in a total of neonatal patients. a pooled mean age of . months (range: days to months) was calculated. among all subjects, there was % mortality, and a % rate of transplantation. % of patients presented with metabolic issues, % with acute kidney injury, and % with renal dysplasias. hd prescription vascular access was primary achieved via the internal jugular vein followed by the subclavian. the most common complications were mechanical catheter dysfunction and hemodynamic issues such as hypotension and anemia patient outcomes of total patients died, resulting in a mortality rate of . %. conclusions: treating neonatal and infant patients with hd may pose many challenges, but it is a feasible treatment modality and when executed properly can quickly reverse pathology. such techniques such as blood priming, minimizing extracorporeal volume, and increased maintenance of vascular access can all potentially improve patient outcomes. s -therapies for difficult the nephrotic syndrome fp-s - hyporesponsive t-cell activation subsets predict favorable rituximab response in patients with focal segmental glomerulosclerosis (fsgs) c.y. chan ( ) , i.d. liu ( ) , l.p. resontoc ( ) , k-h. ng ( ) , y-h. chan ( ) , k-p. lam ( ) , w-s. yeo ( ) , h-k. yap ( ) ( ) national university of singapore, singapore, singapore; ( ) agency for science, technology and research (a*star), singapore, singapore objectives: the use of rituximab in refractory idiopathic nephrotic syndrome especially fsgs has met with variable success. as b-cell depletion can impact t-cell function, this study aimed to characterize t-cell subsets in fsgs patients in order to identify an immunological signature predictive of favorable response to rituximab therapy. methods: consecutive fsgs patients (median age . years, range . - . years) who received rituximab as third line therapy following steroids and calcineurin inhibitors (cni), were included in the study. clinical parameters including urinary protein excretion and serum albumin, as well as immunological subset monitoring were performed at baseline, -days, -month, and subsequently -monthly until relapse. baseline immunological subsets were compared between rituximab responders and non-responders, as well as patients with minimal change nephrotic syndrome (mcns) in relapse and healthy controls, using mann-whitney u test. paired comparison was done using wilcoxon signed rank test. results: of patients ( . %) responded to rituximab therapy, defined as resolution of proteinuria and ability to wean off steroids and cni at months following rituximab treatment. mitogen-stimulated t-cell activation subset expressions are shown in the table below. mitogen-stimulated cd + cd + cd + expressions before rituximab were significantly lower in fsgs responders compared to non-responders and controls. ifn-γ + cd + and il- + cd + were similarly decreased in fsgs responders compared to nonresponders, mcns and controls. significant recovery of all subsets in fsgs responders occurred months post-rituximab treatment. using roc analysis, activated cd + cd + cd + (auc . , % ci . - . ), ifn-γ + cd + (auc . , % ci . - . ) and il- + cd + (auc . , % ci . - . ) were good predictors of response to rituximab. & table : t-cell activation subsets pre-rituximab and months postrituximab in fsgs rituximab responders and non-responders compared to mcns patients in relapse and healthy controls. conclusions: t-cell subset hyporesponsiveness to mitogen stimulation predicted a favorable response to rituximab in fsgs patients. fp-s - risk factors for relapse after b-cell recovery : a course after rituximab treatment in children with steroid-dependent nephrotic syndrome h. nagata ( ) , k. kamei ( ) , t. yoshikawa ( ) , m. sato ( ) , m. ogura ( ) , s. ito ( ) , k. ishikura ( ) ( ) national center for child health and development, tokyo, japan; ( ) department of pediatrics, yokohama city university school of medicine, yokohama, japan objectives: rituximab is used for the treatment of refractory steroiddependent nephrotic syndrome (sdns) in children. we have previously reported that a history of steroid resistant nephrotic syndrome (srns) is a risk factor for early relapse after the treatment of single dose of rituximab followed by immunosuppressants (kamei k et al. pediatr nephrol ) . however, duration of b-cell depletion is different between each patient. here, we investigated the duration between b-cell recovery and first relapse and calculated risk factors for early relapse after b-cell recovery. methods: we retrospectively reviewed the medical records of children with refractory sdns who received a single dose of rituximab ( mg/m ) between june and november . all patients continued immunosuppressants after rituximab treatment. b-cell recovery was defined as cd > % lymphocyte after rituximab treatment. kaplan-meier analyses for relapse after b-cell recovery were conducted. the differences between groups (history of srns (sr) vs. no history of srns(nsr)) were compared using the log-rank test. hazard ratio and % confidence interval (ci) for relapse after b-cell recovery was evaluated by the cox regression analysis. results: fifty-five patients ( boys and girls) received rituximab. the median follow-up period were days ( - , days). fifty-percent relapse free survival was significantly shorter in sr than in nsr ( days vs. , days, p= . ) ( figure ). results of cox regression are shown in table . controlling for age of onset, age at rituximab administration, gender and renal histology, the risk ratio of a history of srns for relapse after b-cell recovery was . ( % ci, . - . ; p= . ). conclusions: a total of . % of the children experienced ns relapse in years after b-cell recovery. a history of srns was a significant risk factor for early relapse. intensified immunosuppressants with rituximab may be beneficial for these patients to prevent early relapse after b-cell recovery. fp-s - effect of atorvastatin on lipid profile and carotid intima media thickness (cimt) in children with refractory nephrotic syndrome: a randomized double blind, placebo controlled, trial p. hari, a. satpathy, r. thergaonkar, p. khandelwal, s. hari, r. lakshmy, a. sinha, a. bagga all india institue of medical sciences, delhi, india objectives: role of statins for treatment of hyperlipidemia in children with nephrotic syndrome is unclear. we examined the lipid-lowering efficacy of atorvastatin and its effect on the cimt and brachial artery flow mediated dilatation (fmd) and safety in children with refractory nephrotic syndrome and hyperlipidemia. methods: children with refractory nephrotic syndrome and ldl-cholesterol (ldl-c) > mg/dl were randomized to receive atorvastatin ( mg/day) or placebo for year. lipid, creatinine phosphokinase (cpk), serum albumin, transaminase, c-reactive protein (crp) levels and estimated gfr were measured at baseline, , and months; cimt and brachial artery fmd was measured at baseline, and months. primary outcome was mean difference in reduction of lipid levels, cimt and brachial artery fmd. results: children (mean age . yr) were included; each were randomized to receive either atorvastatin or placebo ( figure ). baseline characteristics were similar in both groups. at months, median reduction in lipids in atorvastatin versus placebo was similar in total cholesterol, ldl-c, triglyceride, apolipoprotein a and high density lipoprotein (p> . ; table & study flow and outcome after months of administration of atorvastatin conclusions: therapy with atorvastatin ( mg/day) for a year significantly reduced apolipoprotein b levels but was ineffective in reducing other lipoproteins in children with refractory nephrotic syndrome; there was no beneficial effect on cimt and brachial artery fmd. serum albumin was a strong independent predictor of the lipid levels in these children. fp-s - il- disruption improves anemia but not growth in developing mice with ckd v. dalal ( ) , o. akchurin ( ) , a. sureshbabu ( ) , g. kaur ( ) , s. cunninghamrundles ( ) , m. choi ( ) , s. rivella ( ) ( ) weill cornell medical college, new york, united states; ( ) children's hospital of philadelphia, philadelphia, united states objectives: interleukin- (il- ), a major activator of hepcidin, is elevated in children with advanced ckd and in the adenine-based rodent model of ckd. anti-il- therapies improve anemia in many inflammatory disorders but it is unknown if il- blockade improves anemia in juvenile ckd. methods: ckd was induced by a . % adenine diet given for weeks to wild type (wa) and il knockout (il a) male mice starting at weeks of age. respective littermates fed a regular diet served as controls (wc and il c). blood was obtained at sacrifice at weeks of age and nose to tip of tail length was measured to assess linear growth. results: wa and il a mice showed -fold elevated bun, serum creatinine and phosphorus, as compared with wc and il c, respectively (p< . ); il disruption did not improve these markers of ckd. all hematologic (cbc) parameters were similar between wc and il c groups. adenine-induced ckd led to anemia in wa mice, as evidenced by significantly decreased hemoglobin, hematocrit, and mean corpuscular volume, compared to wc mice (p< . ). these erythroid parameters, however, were similar between il a and il c groups. this was likely achieved in part via activation of erythropoiesis in il- a group, as indicated by greater reticulocytosis in the il a group as compared to wa group. body length, weight, and body mass index (bmi) were all significantly decreased in wa vs. wc mice and in il- a vs. il -c at the end of experimental period (p< . ). there were no significant differences in these measurements between the wc and il- c, nor between the wa and il- a groups. conclusions: il disruption rescued the anemia phenotype in developing male mice with adenine induced ckd, thus suggesting that the efficacy of anti-il- therapies in anemia control should be tested in juvenile / pediatric ckd. the mechanism likely involves suppression of hepcidin, which is being validated in our ongoing experiments. in contrary to other inflammatory conditions, il disruption did not improve linear growth in this model. fp-s - erythropoietin pathway dysregulation in anemia of chronic kidney disease d. landau ( ) , l. london ( ) , y. segev ( ) ( ) schneider children's medical center of israel, petach tikva, israel; ( ) ben gurion university, beer sheva, israel objectives: anemia is a known driver for hypoxia inducible factor (hif) which leads to increased renal erythropoetin (epo) synthesis, resulting in inhibited apoptosis of bone marrow (bm) erythroid precursosrs, increasing back red cell mass. anemia of ckd is due to numerous factors, including impaired renal epo synthesis and intestinal iron absorption. epo resistance in ckd is a known clinical problem, but its mechanisms are poorly understood. epo receptor (epor) signals are transduced through a jak -stat pathway. here we investigated the hif-epo-epor axis in kidney, bm and proximal tibia/epiphyseal growth plate (egp) in anemic juvenile ckd rats. methods: ckd was induced by / nephrectomy in young ( d old) sd rats while c group was sham operated. an additional control group was daily bled for days to induce iron deficiency anemia (c-a). rats were sacrificed after weeks of ckd. a single bolus of iv rhepo ( u/kg) was provided minutes prior to sacrifice. results: hemoglobin levels were similarly reduced in ckd and c-a ( . +/- . and . +/- . vs . +/- . g/dl, p< . ). serum iron and transferrin levels were unchanged in ckd. kidney hif a was elevated in c-a but unchanged in ckd. remnant kidney epo protein and mrna levels were unchanged in both c-a and ckd. bm epo protein (which reflects circulating epo) was increased in c-a but unchanged in ckd. bm and egp epor were unchanged in c-a but decreased in ckd. egp phospho-stat was significantly increased in c but unchanged in ckd. conclusions: anemia in young ckd rats is associated with a multilevel inappropriate response: kidney hif a and bm epo are not increased, contrary to what is normally seen after hemorrhage. in addition, bm and egp epor levels are reduced, as well as egp pstat response to epo, suggesting epo resistance as an additional mechanism. s -developmental nephrology: new concepts fp-s - promotion of usp to tgf-β -induced emt in renal tubular epithelial cells is regulated by akt through stabilizing tβri j. zhou, j. pu, y. zhang, z. huang, l. wang tongji hospital, tongji medical college, huazhong university of science and technology, wuhan, china objectives: we aimed to explore the role of ubiquitin-specific peptidase- (usp ) in tgf-β induced epithelial-mesenchymal transition (emt) during renal fibrosis, and investigated that if decreased activation of akt exerted a critical effect on emt via usp /tβri pathway. methods: usp , pakt and tβri proteins in the obstructed kidneys of unilateral ureteral obstruction (uuo) rats were detected by immunohistochemistry assay and western blot method. e-cadherin, α-sma, usp and pakt proteins in nrk- e cells with different concentration tgf-β were detected at different time points. nrk- e cells were transfected with usp -specific sirna, and then stimulated with ng/ml tgf-β for h to detect ecadherin and vimentin, e-cadherin and tβri by immunofluorescent double staining assay. we pre-treated nrk- e cells with pi k inhibitor ly followed by tgf-β to detect pakt, e-cadherin, α-sma, vimentin and tβri protein expression level. meanwhile, the location of usp was visualized by immunofluorescent assay in nrk- e cells. results: the usp expression was upregulated in the tubular epithelial cells of uuo rats. we also found that tgf-β upregulated usp expression in nrk- e cells during their emt. importantly, depressed expression of usp inhibited tβri expression and partially reversed emt stimulated by tgf-β . in the meantime, blunted phosphorylation of akt promoted the e-cadherin expression, and inhibited α-sma and vimentin expression in response to tgf-β . however, inactivation of akt failed to induce usp to shuttle between the nucleus and the cytoplasm in nrk- e cells and emt process stimulated by tgf-β . conclusions: these data imply that usp is a harmless molecule induced by tgf-β , regulated by akt activation and promotes tgf-β -induced emt via tβri during renal fibrosis. fp-s - exploring the mechanism of gen regulating the development of metanephros in mice and the association of gen x. wang ( ) , h. wang ( ) , q. shen ( ) , y. zhang ( ) , j. liu ( ) , c. wang ( ) , x. wu ( ) , h. xu ( ) ( ) children's hospital of fudan university, shanghai, china; ( ) institute of developmental biology and molecular medicine of fudan university, shanghai, china objectives: gen was recently identified as a holliday junction resolvase with a key role in repair of dna double-strand breaks. our previous research found that gen mutant mice showed varied cakut phenotypes. our goal is to explore the underlying mechanism that gen may regulate the outgrowth and branching of ureteric bud (ub). methods: by whole mount in situ hybridization and real-time pcr, we identified the pattern and level of expression of gen in the developing kidney of mice. we analyzed the characters of varied phenotype of cakut in homozygous mice. using novel hoxb /myr-venus transgenic mice, we observed the budding and branching of ub of wtand mutant mice, both in vivo and in vitro. by rna-seq techniques, we further investigate the different expression of related transcriptions after the disruption of gen . results: ) gen is ubiquitously expressed in the mesoderm of e . embryos, including mm and ub regions. over % gen pb/pb newborn pups were detected different abnormalities of kidney and urinary tract, in which duplex kidney were the most common anomalies, hydronephrosis, renal agenesis, renal hypoplasia, vur and uvjo also were not rare. ) over % gen pb/ pb mice grew supernumerary ectopic ub. the nd of e . d gen pb/pb mice cultured in vitro didn't show higher sensitivity to gdnf compared to wt mice. rna-seq analysis of e . mm revealed grem , a bmp antagonist that positively regulates ub formation, as the only gene that was significantly up regulated. in situ hybridization with an anti-sense rna probe confirmed grem up-regulation ingen pb/pb embryos. ) the number of tips of branching ub was significantly reduced in gen pb/pb mice, bothin vivo andin vitro cultured explants. the suppression on branching in gen pb/pb mice may due to the consistently down-regulation of six , which play an important role in the branching development. conclusions: this study reports good short-term renal allograft survival in kidneys that were initially declined for paediatric recipients and then subsequently transplanted. while most children who have a kidney declined on their behalf will eventually be transplanted, they wait more than months on average to get a kidney transplant. in view of the advantages of timely transplantation in children, criteria for accepting kidneys for paediatric recipients could be reviewed. fp-s - the effect of donor-recipient age-matching on graft survival in pediatric renal transplant recipients -an espn/era-edta registry study n. chesnaye ( ) , k.j. van stralen ( ) , m. bonthuis ( ) , j.w. groothoff ( ) , j. harambat ( ) , f. schaefer ( ) , k.j. jager ( conclusions: we demonstrated a differential risk of graft failure dependent on recipient and dd age combinations. in the youngest recipients, dd agematching results in a higher risk of graft failure compared to the allocation of slightly older-than-recipient dd grafts. objectives: to characterise impact of complement abnormalities on phenotypes and outcomes of patients (pts) with atypical haemolytic uraemic syndrome (ahus) enrolled in the global ahus registry prior to eculizumab treatment. methods: all pts with ahus are eligible. demographics, medical history, and treatment outcomes data are collected at enrolment and then every six months. results: as of november , pts were enrolled ( childhood, adult onset). family history of ahus was positive in %. median age at first ahus manifestation was . , . , . and . years in pts with mcp, c , cfh and cfi mutations, respectively, and . years for pts with cfh autoantibodies (fig ) . for pts diagnosed since , renal, gastrointestinal, cardiovascular, central nervous system and pulmonary tma manifestations occurred in the months prior to baseline in ( %), ( %), ( %), ( %) and ( %) paediatric pts, respectively and were least common in pts with mcp mutations. five years after disease onset, end-stage renal disease (esrd) had occurred in % of paediatric pts as compared with % of adults (fig ) . overall, incidence of esrd was not significantly different in pts with or without any identified mutation. five-year renal survival was %, %, %, % and % in pts diagnosed with cfh, cfh autoantibodies, c , cfi and mcp mutations, respectively, and % in pts with no identified complement abnormality. conclusions: we describe the phenotype and natural history of ahus in the largest cohort of pts to date, which includes pts of all ages. this is the first report to show extra-renal manifestations occur in > % of paediatric patients and that pts with cfi mutations have later onset of ahus compared with other complement abnormalities. esrd occurred significantly less frequently in pts with childhood compared with adult-onset. renal outcomes were most favourable in pts with mcp mutations and least favourable in pts with cfh mutations and cfh autoantibodies. fp-s - targeted exome sequencing in patients with atypical hemolytic uremic syndrome (ahus) and negative anti-complement factor h (fh) antibodies reveals multiple variations r. thergaonkar ( ) , a. narang ( ) & figure : distribution of variants conclusions: genetic susceptibility in anti-fh antibody negative ahus is complex. our scheme of prioritization was useful in identification of diagnostic as well as background genetic variation. fp-s - predictors of poor long-term renal prognosis in children with hemolytic uremic syndrome l. alconcher ( ) , l. lucarelli ( ) , m. rivero ( ) , e. rodriguez ( ) ( ) hospital interzonal dr. jose penna, bahia blanca, argentina; ( ) universidad nacional del centro de la provincia de buenos aires, tandil, argentina objectives: approximately % of hemolytic uremic syndrome (hus) patients evolved to different stages of chronic kidney disease (ckd). more days of anuria imply a worse long term renal prognosis. our aim was to look for predictors of poor renal outcome. methods: observational, longitudinal and retro-prospective study. postdiarrheal hus patients with at least years of follow-up were included. to evaluate long term renal outcome, patients were divided in groups: no sequelae, ckd stage and ckd stage - . predictors analyzed included: gender, age at onset (< , - , ≥ years), neurological involvement (seizures and/or coma), maximum white blood cells (wbc) counts (≤ or > ), days of dialysis ( , - and ≥ ), initial hematocrit (≤ or > %), and red blood cells (rbc) transfusion requirement. a bivariate and multivariate analysis were performed, a p< . was considered significant. results: patients ( males) with a median follow-up of . years were included. gender, age at onset and neurological involvement were not associated with long term renal outcome. wbc count > and hematocrit > % were significant ckd predictors only in the bivariate analysis (p= . and . ). the risk to evolve to ckd stages - in patients who did not require dialysis was similar to those with < days (p= . ). ckd risk increased . and . times in patients with ≥ days of dialysis and those not requiring rbc transfusions (ci % . - . , p< . and ci % . - . , p= . respectively). considering only patients with ≥ days of dialysis, % of those who received rbc transfusions were in ckd stage - vs. % of those who did not (p= . , or . ci % - ). the association between ≥ days of dialysis and no transfusion requirement was the most important predictor of long-term ckd. no transfusional requirement implies less hemolysis probably related to more severe vascular occlusion leading to more ischemia and poor long term renal outcome. fp-s - the impacts of interdialytic weight gain on chronic hemodialysis in low weight children c. henriques, m.f.c. camargo, m.f.s. jardim, s. komi, s. vieira, p.c.k. nogueira hospital samaritano, sao paulo, brazil objectives: to assess the impacts of interdialytic weight gain (idwg) in low weight children undergoing chronic hemodialysis (hd). methods: prospective cohort of patients ( f, m), with mean age of . years ( days - . years), mean weight of . kg ( . - . ) and median follow up of days (iqr= - ). the median number of hd sessions/week was (only child underwent conventional hd with sessions/week). we evaluated the median of monthly idwg, defined as the difference between the weight pre hd sessions and the estimated dry weight and then tested its association with: a) z-score of left ventricle mass index, b)hemodynamic stability of the patient, assessed as the dose of vasoactive drugs needed to treat hypotension during the sessions and c) growth, assessed as the delta of repeated measurements of height/age z-score (last minus first measurement). results: perfoming univariate linear regression, we observed significant associations between the median idwg and: a) left ventricle mass, meaning that each % rise in the idwg is associated with an elevation . sds in the left ventricle mass index (p= . ) and b) dopamine median dose during sessions, showing that each % increase in idwg is related to a dopamine dose increase of . mcg/kg/minute (p= . ). with regard to growth, patients with idwg below the median of the sample ( . %) showed an increase of . sds in height/age during follow-up, whereas patients with median idwg greater than . had a significantly smaller . sds increase (p= . ). conclusions: in our series, idwg was associated with negative impacts such as augmented left ventricle mass, increased need for vasoactive drugs during hd and inferior growth. these facts reinforce the need for a strict control of idwg in dialysis of small children. fp-s - predominance of central venous lines (cvl) in pediatric hemodialysis (hd) despite much higher complication rates -report from the international pediatric hemodialysis network (iphn) d. borzych-duzalka ( ) , r. shroff ( ) , y.n. lim ( ) , s. testa ( ) , h. xu ( ) , b. warady ( ) , f. schaefer ( ) , c.p. schmitt ( ( / mo.) , mainly including thrombosis ( %), puncture failure ( %) and insufficient flow ( %). in cases an access revision was performed, while in a new access was created. one, two and three year patency rates were significantly higher for avf/avg than cvl ( . , . , . and . , . , . , respectively). the use of cvl increased the risk of access revision . -fold (p< . ), as compared to avf/avg conclusions: this is the largest prospective pediatric report on vascular access in hd. cvl remain by far the first choice, despite much higher complication rates. infectious complications exclusively occurred in pts with cvl, and access dysfunction risk markedly increased with cvl use fp-s - acute pancreatitis in children on chronic dialysis: incidence and clinical characteristic in a nationwide registry. e. vidal ( ) , i. alberici ( ) , m. martino ( ) , s. picca ( ) , c. pecoraro ( ) , c. corrado ( ) , i.m. ratsch ( ) , e. verrina ( objectives: the risk of acute pancreatitis (ap) is increased in patients (pts) with end-stage renal disease (esrd) on dialysis. to our knowledge, this hypothesis has never been explored in children. in this study we evaluated incidence, clinical characteristics and outcome of ap in a large pediatric chronic dialysis population. methods: ap cases were identified by reviewing files of all pts starting dialysis at < yrs of age recorded from jan to dec in a nationwide registry. results: and eligible pts were identified in the peritoneal dialysis (pd) and hemodialysis (hd) groups, respectively. had ap, were treated with hd and with pd. the incidence rate of first-time ap was . per person-years for the overall cohort, . / pers./yrs for pd and . / pers./yrs for hd (p= . , fisher's test). the median age at ap diagnosis was yrs (range - ) and median time on dialysis was months ( . - ). in pts ( %) diagnosis leading to esrd was renal dysplasia and patients ( %) were affected by motor-cognitive abnormalities. all pts were hospitalized for a median time of days ( - ). median peak serum amylase and lipase was ui/l ( - ) and ui/l ( - ), respectively. instrumental diagnostic features at presentation included enlarged pancreas ( %) and peripancreatic fluid collections ( %). in case, ap was diagnosed shortly after an abdominal surgery with exposure to propofol. at ap diagnosis, pts were receiving valproic acid and pts enalapril. in cases, ap course was complicated by a pancreatic pseudocyst. one child required a shift from pd to hd because of abdominal pain. two pts experienced recurrent ap, while there were no deaths related to ap. conclusions: in our experience, children on dialysis show a significantly increased risk for ap compared with the general pediatric population (estimated incidence rate of . / pers./yrs). a higher incidence is observed in children on hd and in those with neurological co-morbidities. objectives: bartter syndrome (bs), a normotensive hypokalemic tubulopathy, has been clinically known for decades and genotypically characterized. as pediatric diagnosis and patient management improve, more patients survive to adulthood, potentially developing new complications. we summarized our experience with a group of young adults with bs of genotypic variants: type , due to mutations in romk (bs- ) and type , due to mutations in the barttin gene (bs- ). all bs- patients carry the same mutation and belong to an extended family of arab origin. methods: medical records were reviewed retrospectively. all patients have been treated since infancy with standard of care medications, including salts (nacl and kcl) supplementation. indomethacin was administered only when egfr was normal. results: patients (m:f= : ; bs- :bs- = : ) had an average age of . ± . (range - ) years, without difference between the groups. most of bs- vs none of bs- continue to need oral potassium supplementation, and their potassium concentration is lower ( . ± . vs . ± . meq/l in bs- , p< . ). mean egfr was not different between groups (mean total: . ± . ml/min), but bs- (vs. no bs- ) patients had an egfr < ml/min. mean uric acid level was higher in bs- ( . ± vs . ± . mg/dl, p= . ). two bs- patients had gouty attacks. no patient with bs- had hypercalciuria or nephrocalcinosis, compared to all bs- patients with these complications. three bs- also had symptomatic nephrolithiasis. serum pth levels were mildly increased in both groups ( ± . and ± . pg/ml in bs- and - respectively, p= . ). conclusions: young adults with bs- and bs- display a phenotypic variability: decreased egfr was seen only in bs- , in association with persistent hypokalemia, hyperuricemia and gout. bs- patients showed a preserved egfr and normal potassium levels (despite less need for drug therapy), but more significant hypercalciuria and nephrocalcinosis, with several cases of symptomatic nephrolithiasis. objectives: socio-economic disadvantage is increasingly recognised as an important risk factor for chronic disease, but the strength of the association with the development of chronic kidney disease (ckd) and the contribution of the various domains of disadvantage are uncertain. the aim of this study was to synthesise the evidence regarding the risk of ckd and end stage kidney disease (eskd) in the general population according to markers of socioeconomic disadvantage. methods: we performed a systematic review and meta-analysis with risk of bias was assessed using the newcastle ottawa scale and summary effects were estimated using random effects meta-analysis and meta-regression. we included published primary articles in medline, embase or cinahl (until december ) that were cohort studies conducted in the general population. we included studies investigating the risk of incident ckd (and stage) and any of the following social determinants: ethnicity, education, income, occupation and area level measures of socio-economic status. results: we identified studies (n= , , ) - investigated risk by ethnicity, education ( ), income ( ), area level socio-economic status ( ) and occupation ( ). only two of the included studies were of high risk of bias. black americans have more than double the risk of eskd compared to white americans (hazard ratio . , % confidence interval . to . , i %). low income was found to increase risk of eskd in four of the six studies identified, however low education and low ses were not consistently identified as risk factors for ckd. conclusions: although there is a substantial body of evidence regarding the association between socioeconomic disadvantage and ckd, there appears to be an inconsistent relationship. this may be artefactual, due to difficulties in quantifying disadvantage, or reflect true underlying differences in the association across different settings. quality of life and its determinants of children on renal replacement therapy: a multicentre study l. tjaden ( ) , a. splinter ( ) , k. cransberg ( ) , l. koster-kamphuis ( ) , a. raes ( ) , c. taylan ( ) , m. grootenhuis ( ) , j. groothoff ( objectives: to assess health-related quality of life (hrqol) across three renal replacement therapy modalities (preemptive transplant, non-preemptive transplant and dialysis) in comparison with the healthy norm and other chronic disease cohorts, and to explore which patient factors are related to hrqol. methods: all prevalent end stage renal disease (esrd) patients aged - years in the netherlands, belgium and part of germany were approached to complete the paediatric quality of life inventory . (pedsql™) questionnaire. we determined differences between groups on pedsql™ mean scores, and the proportion of children with an impaired hrqol (≥ sd lower than the healthy norm). linear regression models were used to explore determinants of hrqol. conclusions: this is the first international study examining hrqol in the paediatric esrd population. we found important decrements in hrqol in this specific population, even after successful transplantation. physicians should be aware of the impact on social development and academic performance of paediatric renal transplant recipients and adjust their practice where possible in order to improve autonomy development. furthermore, to develop tailored interventions for children with esrd, qualitative studies are needed to gain more insight in the predictors of hrqol. disease (the k-cad study) m. didsbury ( ) , j. craig ( ) , a. van zwieten ( ) objectives: poverty and social inequality are major barriers for achieving optimal health outcomes in children, but their impact on outcomes in children with chronic kidney disease (ckd) is unclear. the k-cad study is an australian and new zealand multicentre longitudinal cohort study that aims to describe the prevalence of economic hardship among caregivers and to determine the relationship between socioeconomic status of caregivers and self-rated health of children with ckd. methods: two hundred and ninety-three children aged - years with ckd [stage - (n= ), stage - (n= ), dialysis (n= ), transplant (n= )] were recruited from four children's hospitals across australia. comparisons by quintile of socioeconomic status for nominal self-rated health outcomes among children with ckd were analysed using adjusted multinomial logistic regression. results: the mean ages of the caregivers and children were . years (sd: . ) and . (sd: . ), respectively. more than % of all households earned less than $ aud per week. only % (n= ) of caregivers engaged in fulltime employment and % (n= ) had completed tertiary education. across the cohort, carers who reported higher levels of financial difficulty were twice as likely to report that their child's health was poor than those with lower levels of financial difficulty ( conclusions: socioeconomic status of caregivers appears to have a profound impact on the self-rated health in children with ckd. longitudinal follow-up will help delineate the cause of socioeconomic disadvantage in these children and the long-term effects on disease progression and wellbeing outcomes. fp-s - renal gene panels promote rapid diagnosis in paediatric renal disease of variable phenotype h. mccarthy ( ) , a. mallett ( ) , a. mallawaarachchi ( ) , k. holman ( ) , g. ho ( ) , b. bennetts ( ) , s. alexander ( & table . results per panel in nearly % of cases referred for diagnostic renal gene panels, a pathological result was found to explain the phenotype. certain panels are highly likely to reveal a useful result e.g. alport's panel and the tubular panel, whereas the panel for cakut remains low yield reflecting that previously described. prior to , testing for renal genes within australasia was extremely limited. the arrival of diagnostic panels for a variety of renal conditions provides the referring clinician with an additional and important tool in the diagnostic pathway to be used in conjunction with imaging, serology and histology. this model has demonstrated the potential of genetic analysis in paediatric nephrology and suggests it will become mainstream practicein the next few years. objectives: at least % of adults who receive renal-replacement therapy (rrt) have an inherited kidney disease.we sought to determine the frequency of gene mutations in a heterogeneous population of children with end-stage renal disease. methods: this study used next generation sequencing to screen genes, including the genes known to be associated with mitochondrial disease. the first pediatric patients collected from department of nephrology and rheumatology, children's hospital of fudan universitywere chosen with comprehensive phenotypic detail. significant variants detected by next generation sequencing were confirmed by conventional sanger sequencing and segregation analysis was performed using parental dna samples. results: a total of patients (females , males ) with rrt(pd , hd , tx ) were identified, with a mean age of . ± . years (range from . to . years). analysis revealed known and novel disease-associated variations in genes (nphs , nphs , plce , wt , slc a , ttc b, agxt, scnn g, coq and adck ) associated with inherited kidney diseasein . % ( / ) of patients. of these patients, had compound heterozygous mutations, had heterozygous mutations (de novo mutation), had homozygous mutations. conclusions: more than half children who receive renal-replacement therapy haveknown and novel disease-associated variations in genes associated withinherited kidney disease. this study shows that next generation sequencing analysis of pediatric end-stage renal disease patients is accurate and revealing. this analysis should be considered part of the routine genetic workup of end-stage renal disease, where the proportion of genetic mutation is high but requires sequencing of multiple genes. conclusions: urinary metabolomic profiling is a feasible technology to help identify metabolites that can distinguish srns from ssns. can urinary proteomes be used as non-invasive markers for renal involvement in childhood febrile urinary tract infection (uti)? s.m. chao ( ) , j. connolly ( ) , y.h. ng ( ) , i. ganesan ( ) , l. bernett ( ) ( ) kk women's and children's hospital, singapore, singapore; ( ) institute of molecular and cell biology, singapore agency of science and technology, singapore, singapore objectives: we hypothesized that proteomes expressed as downstream effectors of uti that are easily obtained from urine, can serve as early markers of acute pyelonephritis (apn) and predictors of renal scarring (rs). leveraging on advances in high throughput technologies and bioinformatics, we attempt to examine an extended range of urinary proteomes that may be implicated. methods: in this prospective cohort analytical study, patients aged month or more with a clinical diagnosis of st febrile uti were recruited. apn and rs were diagnosed by dmsa scans done within days of uti and at months respectively. urine for proteomic study were collected at recruitment. us and mcu were done. using multiplexing bioassay, cytokines, soluble receptors and kidney markers were measured and data analysed using bioinformatics software. conclusions: this prospective study of an extended repertoire of urinary proteomes during uti showed promising results esp.in the prediction of rs which can potentially be translated to clinical application of using urinary proteomes as early non-invasive markers and predictors of renal cortical involvement. larger cohort studies are needed to test the validity and reproducibility of these biomarkers. fp-s - immunogenicity of human papillomavirus recombinant vaccine in children with ckd d. nelson ( ) , a. neu ( ) , a. abraham ( ) , s. amaral ( ) , d. batisky ( ) , j. fadrowski ( ) ( ) johns hopkins university school of medicine, baltimore, united states; ( ) johns hopkins university bloomberg school of public health, baltimore, united states; ( ) university of pennsylvania school of medicine and the children's hospital of philadelphia, philadelphia, united states; ( ) emory university school of medicine, atlanta, united states objectives: there is a disproportionate burden of human papillomavirus (hpv)related genital tract disease in patients with ckd and kidney transplantation, therefore the potential impact of the quadrivalent hpv vaccine (gardasil®) is profound. immune abnormalities associated with ckd and immunosuppression may prevent optimal vaccine response. our objective was to determine antibody response to the hpv vaccine in female adolescents with ckd. methods: cohort study conducted from - of female patients age - years recruited from pediatric nephrology clinics with ckd (n= ), on dialysis (n= ), or status post kidney transplantation (n= ) who received the standard -dose vaccine series of the hpv vaccine. antibody levels to hpv genotypes , , , were measured prior to vaccine dose (baseline), less than months after vaccine dose (blood draw ), and months or greater after vaccine dose (blood draw ). seropositivity was defined as antibody level above an established threshold for each hpv genotype. not all participants completed blood draws. & bd, blood draw; v, vaccine results: antibody response to all hpv genotypes was % in the ckd and dialysis groups with samples drawn at < months and ≥ months after dose of the hpv vaccine. among the transplant patients, the percent of patients achieving seropositivity was significantly lower at blood draw for hpv genotypes ( . %, p= . ), ( . %, p= . ) and ( . %, p= . ) and blood draw for hpv genotypes ( . %, p= . ), ( %, p= . ), ( %, p= . ), and ( %, p= . ). & whiskers represent the th or th percentiles + ( . x interquartile range) antibody levels in transplant patients compared to ckd patients and to dialysis patients for hpv genotypes , , , . there was no statistically significant difference betw conclusions: antibody response to the quadrivalent recombinant hpv vaccine was robust and sustained in girls and young women with ckd and on dialysis. a less robust response to the vaccine was observed among those with a kidney transplant. further study is needed to determine if vaccination before kidney transplantation or an alternative vaccination regimen would benefit transplant recipients. chronic kidney disease can be identified reliably by urinary proteome analysis in children after orthotopic liver transplantation j. drube ( ) , p. zuerbig ( ) , h. mischak ( ) , l. pape ( ) ( ) hannover medical school, hannover, germany; ( ) mosaiques diagnostics gmbh, hannover, germany objectives: chronic kidney disease (ckd) is a common cause for morbidity and mortality not related to the primary disease inchildren after solid organ transplantation. a urinary proteome pattern publishedby good et al. was shown to identify adult patients with primary ckd with higher reliability than creatinine based methods. our study aimed to proof this pattern's reliability in pediatric patients following orthotopic liver transplantation (polt). in this population kidney function is usually over-estimated by creatinine based methods due to extreme low muscle mass of the patients. methods: the urinary proteome patterns of children with biliary atresia followed by pediatric orthotopic liver transplantation were analyzed by capillary electrophoresis coupled to mass spectrometry and compared to the known proteome pattern of ckd. cystatin c based estimated glomerular filtration rate (egfr) was chosen as comparator. in addition, estimation of creatinine based gfr was also performed in all patients. results: thirteen children (f: ; median age . yrs.; range . to . ) had a reduced cystatin c gfr below ml/min/ . m , patients (f: , median age . yrs., range . to . ) showed no renal impairment. sensitivity to detect renal impairment using the ckd-pattern was % ( % ci - %) and specificity was % ( % ci - %). the area under the curve was . ( % ci . - . ; p= . ). creatinine based estimation of gfr detected only / patients ( %) correctly resulting in a sensitivity of x %. using multiple testing corrections, peptides were identified that significantly differentiated patients with renal impairment from those without. tandem mass spectrometry sequencing revealed fragments of collagen alpha- (i), of collagen alpha- (iii) and one fragment of collagen alpha- (xvi). the urine proteomics ckd-pattern can reliably identify children with secondary renal impairment after polt with a significantly better sensitivity as compared to standard creatinine based egfr. fp-s - outcome and prognostic factors of nephropathic cystinosis: data from the eunefron cohort f. emma ( ) , e. levtchenko ( ) , g. ariceta ( ) , m. greco ( ) , w. van't hoff ( ) , p. niaudet ( . after modelling the hr, a nearly linear relationship was observed with the age at which cysteamine was started from . to . years and the risk of dialysis; correcting for leucocyte cysteine levels did not change significantly this relationship. over the same period of time, linear growth has improved. factors associated with improved outcome were the use of cysteamine, of indomethacin and of growth hormone. conclusions: this study represents one of the largest cohorts of nephropathic cystinosis patients assembled to date, and shows a gain of approximately years in the median age to reach dialysis over a period of years. early treatment with cysteamine and the use of indomethacin influenced positively renal outcome. fp-s - a french cohort of patients with cystinosis: variability in the compliance to two formulations of cysteamine, use of electronic monitoring devices s. gaillard ( ) , l. roche ( ) , b. kassai ( ) , g. deschenes ( ) , d. morin ( ) , c. acquaviva bourdain ( ) , a. bertholet-thomas ( ) , p. cochat ( ) ( ) hospices civils de lyon -chu lyon, lyon, france; ( ) aphp -hôpital robert debré, paris, france; ( ) chu montpellier, montpellier, france objectives: cystinosis is an inherited autosomal recessive disease. our objectives are (i) to describe the profiles of compliance to cysteamine treatment and white blood cell (wbc) cystine levels in cystinosis patients followed up for one year; and (ii) to explore the differences of compliance under delayedrelease or short-acting cysteamine. methods: crystobs is a french cohort of cystinosis patients. thirty patients are expected. all subjects receive oral cysteamine. four patients have received short acting cysteamine then delayed-release formulation. a descriptive analysis is performed on subjects followed-up for one year. compliance is described as a continuous variable, using an electronic monitoring system. levels of compliance ( : bad compliance; : correct compliance and : good compliance) are computed individually for the patients: i) monthly; ii) quarterly; and iii) overall during the first year. mean compliance scores are summarized quarterly as median, and percentiles, minimum and maximum observed. the "number of hours covered by cysteamine" is generated per day. patients' self-evaluations of compliance are available at each visit. results: seventeen patients (mean age: . years; % female) were analyzed. seven patients were transplanted and under dialysis. egfr remained stable over time. while wbc cystine levels remained under μmol/ ½ cystine/g protein, there was a great variability among patients and over time in the mean quarterly compliance score (median: . at inclusion - . at m , min = . -max= ). however, subjects were globally well covered by their study treatment: to hours daily coverage. the compliance scores seemed improved under delayed-release formulation. conclusions: crystobs is the first study measuring objectively compliance to cysteamine in cystinosis patients. we observed a great variability among compliance profiles, and a trend towards improvement in compliance under delayed-release cysteamine. objectives: cystinosis is a lysosomal storage disorder characterized by accumulation and crystallization of cystine in different cell types. if not treated, renal failure invariably develops within the first decade of life. we have shown excessive number of podocytes and proximal tubular cells in urine of cystinosis patients. now, we hypothesized that in compensation for cell loss, ongoing regeneration might happen, and it could be reflected by the presence of kidney progenitor cells in urine of the patients. methods: we quantified the number of kidney progenitor cells in urine using qpcr analysis of mrna extracted of urine samples of healthy donors (n= , age range - y.o) and cystinosis patients (n= , age range - y. o). patients had no kidney graft. the expression of vimentin was correlated to calibration curves derived from known numbers of adult kidney progenitor cells and normalized to volume of urine. we cultured and characterized urinary cystinosis progenitors by qpcr, facs and immunofluorescence analysis. later we differentiated progenitor cells into functional podocytes and proximal tubular cells. results: we demonstrate a significant increased excretion of kidney progenitor cells in cystinosis patients (progenituria), while in controls no progenitors were found in urine. progenitor cells isolated from cystinotic urine expressed mesenchymal stem cell proteins and the kidney progenitor markers cd and cd . the cells were positive for nephron progenitor markers, such as vimentin, pax and cited and were able to differentiate into functional podocytes and proximal tubular cells. conclusions: our data demonstrate the presence of kidney progenitor cells in urine of cystinotic patients, which might indicate a fast turnover of cells and the attempt of tissue regeneration to compensate cell loss. urinary cystinotic progenitor cells might have a therapeutic application in regenerative medicine once the correction of the genetic defect and consequent correction of the phenotype are successful. fp-s - study of hierarchical management model of asymptomatic urine abnormalities in children in shanghai y. gong ( ) , x. hong ( ) , q. shen ( ) , z. li ( ) objectives: school urine screening can detect a great quantity cases with asymptomatic urine abnormalities. long-term follow-up is necessary for potential cases with kidney diseases. this project intends to explore the effective mode of school urine screening network in shanghai. methods: during . to . , a hierarchical medical model in asymptomatic hematuria children was built in three districts in shanghai. the asymptomatic hematuria children were founded by school urine screening program. they were confirmed and diagnosed in the district central hospitals. tertiary referral needed in some patients. results: . model building ) the level transferring system consisted of school urine screening agencies, local district cental hospital and children's hospital of fudan university (chfu), a tertiary pediatric nephrology center. ) there were three models of school urine screening in accordance with three different screening agencies, community health service centers (chsc, model a), center for disease control and prevention (cdc, model b) and physical examination department (model c), respectively. . practical study ) students were screened in this project, the prevalence of urine abnormalities was . % in elementary school students and . % in junior middle school students. ) % of cases went to the district cental hospitals in model a, % in model b while only . % in model c. totally cases of asymptomatic hematuria, of mass hematuria and of proteinuria. of those, about % of cases met the criteria transferring to chfu and . % completed the referral. all the cases got followed up, cases of alport syndrome and of chronic interstitial nephritis. conclusions: hierarchical medical model for asymptomatic hematuria patients was feasible and helpful for the follow-up of potential patients with kidney disease. the complement system is highly activated in pd associated arteriolopathy b. schaefer ( ) , m. bartosova ( ) , j. lorenzo ( ) , s. tarantino ( ) , r. büscher ( ) , c. aufricht ( ) , k. kratochwill ( ) , c.p. schmitt ( ) ( ) university of heidelberg, heidelberg, germany; ( ) institute of medical biometry and informatics, university hospital heidelberg, heidelberg, germany; ( ) zytoprotec gmbh, vienna, austria; ( ) department of pediatrics ii, university hospital essen, essen, germany; ( ) department of pediatrics and adolescent medicine, medical university of vienna, vienna, austria objectives: cardiovascular disease is the leading cause of death in children on peritoneal dialysis (pd), underlying mechanisms are still incompletely understood. methods: omental arterioles covered with fat, i.e. located beyond pd fluid penetration level were microdissected from non-uremic children, age and gender matched children at time of first pd catheter insertion and children treated with low gdp pd fluids [pd vintage ; - months). children with diseases potentially affecting vessel integrity were excluded. - arterioles per patient with similar structural dimensions (as defined by aperio®automated image analysis after evg staining vessels) were selected, neighboured sections were used for whole transcriptome and proteome analysis. results: uremia induced up-regulation of and down-regulation of arteriolar genes (p< . ) compared to age and sex matched healthy controls. in patients on low gdp pd, genes were up-and genes down regulated compared to respective uremic controls, while in children on high gpd pd genes were up-and genes downregulated.intima media thickness was comparable in all groups. gene ontology analyses demonstrated activation of various inflammatory, immunological and stress response cascades with uremia and even more with pd. in children treated with low gdp fluid the complement system and respective regulatory pathways were upregulated most significantly. complement factors demonstrated comparable upregulation on rna and protein level, cd was suppressed. findings were validated immunohistochemically in an independent cohort of children per group; c q and c c were and . fold increased with low gdp pd compared to uremic controls. conclusions: omental arterioles are uniquely suited for global assessment of molecular pathomechanisms of uremia and pd associated arteriolopathy. we for the first time demonstrate specific activation of the complement cascade in arterioles from children on low gdp peritoneal dialysis, prior to overt arteriolopathy. objectives: chronic kidney disease (ckd) is a state of klotho deficiency and excess of the phosphaturic hormone fibroblast growth factor (fgf ). although, both findings were shown to be associated with endothelial dysfunction in humans, direct vascular effects of fgf remain largely elusive. here, we investigated the effects of fgf in relation to its coreceptor klotho on nitric oxide (no) synthesis and reactive oxygen species (ros) formation and detoxification in human coronary artery endothelial cells (hcaec) in vitro. methods: hcaec were stimulated with fgf ( ng/ml) in the presence or absence of a pan-fgf receptor (fgfr) or klotho inhibitor, and investigated by quantitative real-time pcr, immunoblotting, and flow cytometry. results: hcaec express fgfrs and membrane-bound klotho. fgf increases the expression of the klotho shedding protease adam and consequently the secretion of soluble klotho. fgf activates fgfr , and stimulates no release via akt-dependent activation of endothelial no synthase (enos). both, ros formation via nadph oxidase (nox ) as well as ros degradation via superoxide dismutase (sod ) and catalase (cat) are stimulated by fgf treatment. the effects of fgf on no synthesis as well as on ros formation and degradation are fgfr-dependent. pre-incubation with a klotho inhibitor blunts the fgf -stimulated akt-enos activation and no synthesis, decreases ros degradation by blocking sod and cat enzymes, whereas fgf -stimulated ros synthesis via nox is unaffected, resulting in low no bioavailability and increased oxidative stress. in the presence of klotho, fgf induces no release in hcaec and its stimulating effects on ros production are counterbalanced by increased ros degradation. in the absence ofklotho, fgf -mediated no synthesis is blunted and ros formation overrules ros degradation. our results suggest that in states of klotho deficiency, e.g. ckd, fgf excess may primarily promote oxidative stress and thus endothelial dysfunction. fp-s - dysregulation of hepatic cholesterol transporter abcg in il -induced hypercholesterolemia in a rat model of minimal change nephrotic syndrome (mcns) c.y. chan ( ) , l.d. low ( ) , j. chen ( ) , k-h. ng ( ) , h.h. yang ( ) , h. yu ( ) , m.r. wenk ( ) , h-k. yap ( ) ( ) national university of singapore, singapore, singapore; ( ) agency for science, technology and research (a*star), singapore, singapore objectives: our il gene overexpression rat model of mcns showed that hypercholesterolemia correlated significantly with serum il , and appeared to precede the development of proteinuria. this study aimed to investigate the mechanism of il -induced cholesterol dysregulation in our rat model of mcns. methods: hepatic transcriptome of il -transfected nephrotic rats (late event) was studied using microarray and qpcr. this was compared with the gene expression profile of hepatic cholesterol metabolism at the onset of hypercholesterolemia in the pre-proteinuric phase (early event, hc rats). il -mediated cholesterol effluxes via abcg and abca were measured using taurocholate and apoai as cholesterol acceptors respectively in rat primary hepatocytes. the role of lxra was validated using luciferase assay. results: 'abc transporters' was identified as the most relevant pathway in cholesterol metabolism, of which abcg expression showed the greatest downregulation in il -transfected nephrotic rats (late event), and was associated with hmgcr upregulation. plasma cholesterol was significantly elevated from week (hc rats) and preceded the onset of significant proteinuria at week . study of these hc rats (early event) also showed reduced abcg , and was accompanied by downregulation of abca and lxra. similarly, il -stimulated hepatocytes demonstrated downregulation of lxra, abcg and abca , with reduced abcg -and abca -mediated cholesterol effluxes. moreover lxre-luciferase transfected il -stimulated hepatocytes showed decrease in luciferase signal indicating reduced lxra activity. conclusions: hypercholesterolemia observed early in hc rats could be due to downregulation of lxra-abcg /abca pathway with reduced cholesterol efflux into bile, resulting in increased intracellular free cholesterol, further inhibiting hepatic uptake of cholesterol. hepatic upregulation of hmgcr occurred secondarily as a late event following development of gross proteinuria exacerbating the hypercholesterolemia. autophagy is activated to protect podocyte from immune-mediated injury in membranous nephropathy y. zhang, f. yang, q. lv, .z. huang, h. yuan, j. zhou department of pediatrics, tongji hospital,tongji medical college, huazhong university of science and technology, wuhan, china objectives: autophagy is induced in podocytes during various kidney diseases, however, whether this is protective or injurious remains controversial. here, we address this question by pharmacologic blockade/activation of autophagy using in vivo and in vitro model of membranous nephropathy. methods: we studied female sd rats at day after induction of passive heymann nephritis (phn) by injection of anti-fx a. expressions of autophagy markers and apoptosis-associated proteins were analyzed . confocal microscopy was used to explore the expression patterns of f-actin and nephrin. attachment assay was used to assess the adhesion of podocyte. apoptosis and expression of integrin-α were measured by flow cytometry. results: first, autophagy was induced in vivo in podocytes of phn rats (shown by increased autophagosome number, conversion of lc -i to lc -ii, and beclin- expression). -methyladenine ( -ma) blocked autophagic flux and worsened renal injury in phn rats. compared with control littermates, the -ma-treated rats were markedly more sensitive to nephritis as indicated by increased urinary protein excretion, glomerular lesions, and podocyte apoptosis. subsequently, we utilized immortalized mouse podocytes (mpc ) to study the autophagy mechanisms involved in mn with sc b- incubation in vitro. podocyte damage, apoptosis and deadhesion were demonstrated in the sc b- -incubated mpc cells. furthermore, sc b- induced beclin- and lc -ii expressions and autophagosome formation. inhibiting autophagy by -ma further promoted cellular lesions, apoptosis and actin reorganization-associated deadhesion in the sc b- -incubated mpc cells. in contrast, rapamycin, an autophagy inducer, promoted beclin- and lc -ii expressions, which mitigated sc b- -induced changes in the injury-related morphology, apoptosis, and deadhesion of mpc cells. conclusions: our results establish a renoprotective role of podocyte autophagy in complement-mediated podocytopathy where it may interfere with cell killing and adhesion mechanisms. results: data on children ( male) from centres were analysed. shortterm dialysis (< weeks) was required in ( %) children (pd in , cvvh in and hd in ) at a median age of ( - ) weeks for a median duration of ( - ) days secondary to sepsis (n= ), acute fluid overload (n= ) or aki following acei (n= ). thirteen ( %) patients required long-term dialysis by the age of months, ( %) by year, ( %) by years, ( %) by final follow up at a median of months. of those, ( %) patients did not have nephrectomies, ( %) had nephrectomies before and ( %) after commencingdialysis. in ( %) pd was the modality of choice. amongst those on pd, ccpd with a day exchange was the commonest prescription ( %). eleven ( %) patients needed to switch to hd due to pd catheter dysfunction (n= ), peritonitis (n= ), inadequate uf (n= ) or development of pleuro-peritoneal fistula (n= ). peritonitis rate was . / patient months. none developed thrombosis on pd. all patients on hd received sessions of hours per week. no hd line infections and no development of thrombosis were reported. there was no difference in growth between pd and hd patients. twenty-five patients ( %) received a transplant at a median of . ( - ) months after start of dialysis of which with living donor. one patient died whilst on pd (palliative treatment) and patients died whilst on hd (hyperkalemia and candida peritonitis). the need for long-term dialysis in children with cns is very likely by the age of year. pd is the modality of choice, however the peritonitis rate was higher than recommended, but may reflect the high percentage of infants in this study. a significant number switched between dialysis modalities. vascular access in children on hemodialysis: a report from the espn/era-edta registry m. boehm ( ) , m. bonthuis ( ) , m. noordzij ( ) , j. harambat ( ) , j. groothoff ( ) , c. aufricht ( ) , k. jager ( ) , f. schaefer ( , showed lower hemoglobin levels (cvc: . ( . - . ) g/dl; avf: . ( . - . ) g/dl) and lower height-sds (cvc: - . (- . ; - . ), avf: - . (- . ; - . ) at start of hd. likelihood of receiving an avf was lower for children with glomerulonephritis (aor: . , % ci: . - . ), vasculitis (aor: . , % ci: . - . ) and missing or unknown diagnosis (aor: . , % ci: . - . ). after two years . % of avf patients and only . % of cvc patients were still treated with their initial vascular access. the overall likelihood of receiving a renal transplant within two years was not different, children who received ld were more frequently started with cvc (ahr: . , % ci: . - . ) . conclusions: in conflict with the kdoqi recommendations, cvc is the most often applied type of vascular access in children who start with hd, despite the significantly higher need for a second vascular access. the higher number of ld in cvc children suggests a conscious policy, which should be reconsidered, as the overall waiting time for transplantation is equal in both groups of patients. genetic and clinical characteristics of female x-linked alport syndrome : cases study t. yamamura ( ) , k. nozu ( ) , k. nakanishi ( ) , s. minamikawa ( ) , t. ninchoji ( ) , k. nakanishi ( ) , n. yoshikawa ( ) , k. iijima ( ) ( ) kobe university graduate school of medicine, kobe, japan; ( ) department of pediatrics, wakayama medical university, wakayama, japan; ( ) national center for children health and development, tokyo, japan objectives: the aims of this study are to clarify the genetic and clinical characteristics of the large number of female x-linked alport syndrome (xlas) patients in japan and the contribution of skewed x inactivation to disease severity. methods: we conducted a retrospective analysis for female patients in families who were genetically diagnosed with x-linked alport syndrome in our department. we analyzed clinical and laboratory data from medical records. the data included proportion of patients with proteinuria and the age at which proteinuria was detected, proportion of patients with end-stage renal disease (esrd) and the age at which they reached esrd, hearing loss and specific ocular changes, genotype-phenotype correlation. we also performed a x-inactivation analysis for the severe patients who reached esrd before age . results: the median age of our cohort was years (age from to years). proteinuria was detected in patients ( . %) and the median age developing proteinuria was . years. patients reached esrd and the median renal survival period in this study was . years and % patients reached esrd at the age of . specific ocular changes were detected in only patients and hearing loss was patients. no obvious genotype-phenotype correlation was observed. x inactivation analysis was held to severe patients, but skewed x inactivation was detected in only one patient and its contribution to disease severity was unclear. conclusions: phenotype of female xlas patients is not always mild. therefore clinicians have to pay attention to their clinical course and treatment. there is no genotype-phenotype correlation and the contribution of xinactivation to disease severity is still unclear. it is assumed that the mechanism of determining severity of female xlas remain multifactorial. were excluded. following therapy of relapse, prednisone was tapered to . mg/kg ad. stratifying for dependence, patients were randomly assigned to prednisone at . - . mg/kg daily or . - . mg/kg ad for -months. relapses were treated with prednisone, followed by return to intervention. outcomes, based on intention-to-treat, included number of relapses, proportions with therapy failure (≥ in -months or significant steroid toxicity) & sustained remission, time to first relapse & frequent relapses, cumulative prednisone received & adverse events. assuming that daily therapy will reduce relapses by % over ad treatment, patients were required at power of % and two-tailed α of . , with % attrition. results: of patients, one did not return following randomization & was excluded from the analysis (fig. ) . baseline features were similar in the two groups. patients receiving daily prednisone showed significantly less relapses than those on ad therapy ( . ± . vs. . ± . relapses; mean difference . ; %ci . - . ; p= . ). daily therapy was associated with higher proportion in sustained remission ( % vs. %; p= . ), lower treatment failure ( % vs. %; p< . ), delayed time to first relapse (log rank p= . ) and to treatment failure (p< . ) (fig. ) and lower prednisone use ( . ± . vs. . ± . mg/kg; p= . ). adverse events were similar. conclusions: in patients with frns, daily administration of low-dose prednisone was more effective than standard-dose alternate day therapy in sustaining remission and enabling steroid sparing. levamisole increases the time to relapse in children with steroid-sensitive idiopathic nephrotic syndrome: results of a multi-center, double-blind, placebo-controlled, randomized clinical trial m. gruppen ( ) , j.c. davin ( ) , a. bouts ( ) ( ) pediatrician, amc, amsterdam, netherlands; ( ) pediatric nephrologist, acm, amsterdam, netherlands objectives: levamisole has been considered the least toxic and expensive drug for preventing relapses of steroid sensitive idiopathic nephrotic syndrome (ssins). however, evidence is limited, as previous randomized clinical trials (rcts) were found to have methodological limitations. this is why we conducted an appropriate rct to reassess its usefulness in prevention of ssins relapses in children. methods: the study was conducted in an international multi-center, placebo-controlled, double-blind rct for one year, in order to evaluate efficacy and safety of levamisole in children with ssins and frequent relapses. results: the intention to treat population (itt) consisted of patients from countries. time to relapse (primary endpoint) was significantly increased in the intervention group compared to placebo (p-value . [ % ci . - . ], p-value . after days post-randomization). after months of treatment, remission persistence was more frequent in levamisole than in the placebo group ( % vs %: p = . ). the most frequent serious adverse event (sae) ( / ) possibly related to levamisole was asymptomatic moderate neutropenia ( - cells/ μl), reversible spontaneously or after treatment interruption. rare, severe side effects of levamisole reported in treatment of ssins included hepatitis, convulsions or antineutrophil cytoplasmic antibody (anca) vasculitis were not observed in this study. however, anca-related arthritis was reversible with levamisole interruption, and reported in one patient. conclusions: in children with ssins and frequent relapses, levamisole prolongs time to relapse and also prevents recurrence for one-year of treatment in % of patients. regular blood controls are necessary for safety issues. defective complement inhibitor cd mrna expression in peripheral mononuclear cells of patients with progressive iga nephropathy. r. coppo ( ) , l. peruzzi ( ) , e. loiacono ( ) , m. bergallo ( ) , m.l. russo ( ) , a. krutova ( objectives: report a case of vesicoureteral reflux degree iv in child treated conservatively methods: review of medical record provided by western paraná university hospital results: y.b.s. two years-old, reporting fever of °c, associated with chills, weakness for days. it evolved with emesis, appetite loss, pain in hypogastric and discomfort when urinating, but the urine had normal color. gentamicin associated with ceftriaxone was started for pyelonephritis and used for seven days. after the end of therapy were requested two urine cultures and both came negative. urethrocystography was requested and showed a vesicoureteral reflux right degree iv. started using nitrofurantoin mg once a day. the patient was discharged nine days after. six months after the episode, scintigraphy showed a slight tubular function impairment and cortical shrinkage in the right kidney. the current scan showed both kidneys with preserved tubular function and no cortical lesions; and indirect radionuclide cystography presented absence of bilateral vesicoureteral reflux. in october , the patient was discharged from the pediatric nephrology not making more use of nitrofurantoin. conclusions: vesicoureteral reflux (vur) is a common urologic disease in childhood. the prevalence in patients presenting urinary tract infections (uti) ranges from % to %. uti and vur are risk factors for permanent kidney damage and renal scars, amongst them %- % occur at the first itu. urological studies are recommended at the time of the first acute pyelonephritis in children of any age. despite of high prevalence, the treatment is still a discussion. surgery is curative about % of cases, however it is associated with a considerable risk. antibiotic prophylaxis to prevent damage is controversy because of low compliance rates and side effects. in a retrospective recent study, , % of the patients with vur grade iv and v were conducted surgically. we present a case of uvr grade iv conservatively treated that evolved for complete cure. - . ] . seventy-six percent of all tests were x-rays, and nuclear medicine studies accounted for % of cumulative radiation exposure. less than children were exposed to a potentially toxic cumulative dose greater than msv. longer duration of chronic kidney disease (ckd) before transplant was correlated with greater cumulative effective dose (table) . conclusions: children that receive kidney transplants undergo many imaging studies with radiation exposure predominantly from nuclear medicine studies, especially those that have longer ckd duration. greater awareness of cumulative ionizing radiation is needed to minimize exposure as children age into adulthood. & objectives: a short stature as a result of poor growth is common in pediatric esrd and has been associated with adverse psychosocial and clinical outcomes. through improved management of growth failure, its prevalence after kidney transplantation (kt) is supposed to have decreased over time. we aim to analyze longitudinal growth after kt, trends over time, and to identify potential determinants of height sds in a large cohort of transplanted children using data from the espn/era-edta registry. methods: a total of , patients from european countries transplanted before years of age between and , with available longitudinal follow-up were included. height standard deviation scores (sds) were calculated using recent national growth charts or european growth charts for countries without recent reference data. we used generalized equation models to estimate the prevalence of growth retardation and linear mixed models to calculate adjusted mean height sds and its potential determinants. results: overall mean adjusted height sds post kt was - . ± . . % of children had a height sds within normal range, % showed moderate, and % severe growth retardation. girls were significantly shorter than boys. in multivariable analysis, living donor kt, steroid free immunosuppressive regimen, higher egfr, and not being hypertensive or anemic were associated with better post-kt height sds. patients with cakut and metabolic disorders were shorter compared to other primary renal diseases. catch-up growth by years post kt was observed in both boys (+ . ) and girls (+ . sds). children < years were shortest at kt and showed the greatest increase (+ . ) in height sds, whereas there was no catch-up growth in children transplanted > . post kt growth did not improve over time. conclusions: catch-up growth post kt remains limited, was mainly observed in the youngest recipients, and did not show substantial improvement over time, resulting in short stature in nearly half of transplanted children in europe. fp-s - the global pediatric nephrology workforce: a survey of the international pediatric nephrology association d. glenn ( ) , s. ocegueda ( ) , m. nazareth ( ) , y. zhong ( ) , a. weinstein ( ) , w. primack ( ) , p. cochat ( ) , m. ferris ( ) ( ) univeristy of north carolina at chapel hill, chapel hill, united states; ( ) dartmouth hitchcock medical center, lebanon, united states; ( ) hôpital femme mère enfant & université claude-bernard, lyon, france objectives: the global pediatric nephrology workforce is poorly characterized. the objectives of our study were to characterize the global pediatric nephrology workforce and training environments, assess pediatric nephrologists' perceptions of the adequacy of this workforce, and understand regional challenges to fellow recruitment and job acquisition. perceptions regarding optimal length of training and research requirements were also queried. conclusions: globally, there is a high level of perceived inadequacy in the pediatric nephrology workforce. regional variability exists in perceived workforce adequacy, ease of recruitment, and job acquisition. interventions to improve recruitment should be targeted to specific regional barriers. objectives: to evaluate an interinstitutional cooperation program between an experienced pediatric transplantation center and a developing center in other state, km apart, and the count of kidney transplantation surgeries performed during the -year duration of the cooperation. methods: the cooperation consisted of short periods of fellowship (max month) of pediatric nephrology residents, nurse and physicians (one pednephrologist and surgeon), along a -year period, as well as weekly teleconferences for case discussions once a week. the yearly count of pediatric kidney transplants (p-kt) in the developing center along the period was compared to the national mean as well to the state's mean. in total, samples were taken from patients before the eculizumab infusion in the induction (weekly), maintenance ( -weekly) and tapering (every , , and weeks) phases of therapy. results: our newly-developed eculizumab assay had variation coefficients of . % (intra-assay, μg/ml) and . % (inter-assay, μg/ml) and detection limit of μg/ml. the samples with > μg/ml demonstrated < % of complement activity in classical and alternative complement pathways. the eculizumab levels had ranges of - μg/ml and - μg/ml during induction and maintenance phases, respectively, with samples from patients < μg/ml, required for efficient complement inhibition. during tapering, ranges of - μg/ml, - μg/ml and - μg/ml were measured at , and week infusion intervals, respectively. conclusions: our data demonstrate large differences in attained eculizumab concentrations among patients at all treatment stages. in induction and maintenance, the detected concentrations were up to - fold higher than required for efficient complement inhibition ( μg/ml), although samples did not reach this target value. thus, eculizumab therapy should be adjusted to meet the needs of individual patients and monitoring of eculizumab concentration is useful to guide the treatment schemes. we have shown that target eculizumab values (> μg/ml) may be reached with extended intervals; extension of intervals for these patients may improve cost-effectiveness of therapy. outcomes from an observational clinical trial evaluating the long-term safety and effectiveness of eculizumab use in paediatric patients with atypical haemolytic uraemic syndrome (ahus) l. pape ( ) objectives: to describe the long-term outcomes of paediatric patients (pts) with atypical haemolytic uraemic syndrome (ahus) treated with eculizumab (ecu). methods: pts with ahus who participated in a previous ecu clinical study were invited to continue to be monitored in this observational, multicentre, multinational long-term follow-up study (nct ). this analysis included paediatric pts (< years old at first ecu dose) who enrolled, including pts treated outside of the recommended regimen. change in renal function and targeted serious adverse events (tsaes: serious infections, meningococcal infection, sepsis, leukopenia, infusion reactions, renal or hepatic impairment and malignancy) were assessed. results: median age at first ecu dose was . (range - ) years and median follow-up from first ecu dose was . (range . - . ) months (n= ). at least complement abnormality was identified in ( %) pts, including mutations in factor h ( pts), membrane cofactor protein ( pts), factor i ( pts) and c ( pts). prior to first ecu dose, ( %) pts were on dialysis and ( %) had prior kidney transplantation. eight ( %) pts had experienced ≥ thrombotic microangiopathy events prior to first ecu dose. median time from ahus diagnosis to first ecu dose was . (range - . ) months. improvement in renal function (increase in estimated glomerular filtration rate) following ecu initiation, was maintained (figure ), and dialysis was stopped in ( %) pts. two ( %) pts remained on dialysis throughout the study. no new dialysis or kidney transplants occurred. during this follow-up study, no pts died, ( %) pts experienced a total of tsaes, including meningococcal infections. both pts recovered and remained on ecu. & figure . mean estimated glomerular filtration rate (+/-sd) over time, in pts with ongoing treatment with ecu conclusions: this is the first report to include paediatric pts with ahus treated with ecu for over years. throughout this follow-up period, ecu was generally well tolerated and effective in paediatric pts. objectives: elevated intact parathyroid hormone (ipth) levels can contribute to morbidity and mortality in children with chronic kidney disease (ckd). the present studies evaluated the pharmacokinetics, efficacy, and safety of oral paricalcitol in the reduction of ipth levels in children with stages - ckd. methods: two phase studies enrolled children aged - years with stages - ckd. the first study evaluated oral paricalcitol pharmacokinetics, efficacy, and safety in children with stage / ckd with an initial -week doubleblind period followed by a -week (minimum) open-label period wherein all children received paricalcitol. the second study evaluated the efficacy and safety of oral paricalcitol (no comparator) for weeks in children with stage ckd undergoing hemodialysis or peritoneal dialysis. results: in the stage / ckd study, children received μg paricalcitol and were assessed for intensive pharmacokinetics (mean c max , . ng/ml; auc −∞ , . ngâ'h/ml). population pharmacokinetic analysis showed that ckd stage does not influence the pharmacokinetics of paricalcitol in children. thirty-six children were randomized (baseline ipth, mg/dl) and . % of the paricalcitol group achieved two consecutive ipth reductions of ≥ % from baseline vs no childrenin the placebo group (p= . ). adverse events were observed in a higher proportion of the placebo group compared with the paricalcitol group in the double-blind ( . % vs . %; p= . ) portion of the stage / ckd study. in the stage ckd study, of the ( . %) children enrolled had two consecutive ipth reductions of ≥ % from baseline (baseline ipth, pg/ml, n= ), and ( . %) had two consecutive ipth values between and pg/ml. clinically meaningful hypercalcemia occurred in ( . %) paricalcitol-treated children in the stage ckd study. conclusions: oral paricalcitol dosing in children aged - years with stages - ckd reduced ipth levels and was well tolerated. fp-s - calcimimetic (cinacalcet) and hemodiafiltration versus conventional treatment of secondary hyperparathyroidism in children with end-stage renal disease on regular hemodialysis r. galal ( ) , f. fadel ( ) , s. sabry ( ) , m. farouk ( ) , m. ghonim ( ) , a. ismail ( ) ( ) cairo university, cairo, egypt; ( ) ministry of health hospitals, cairo, egypt objectives: to compare the efficacy of treatment strategies, namely cinacalcet-based regimen and hemodiafiltration modality, with conventional care (vitamin d and phosphate binders) for control of hyperparathyroidism and the high calcium phosphorus product in order to achieve the recommended targets of the nkf/doqi guidelines. methods: a case -control study was performed over months on children with esrd on regular hemodialysis. they were randomly divided into groups: the first group ( cases) on regular hemodialysis and received cinacalcet mg/day in addition to conventional care (vitamin d and phosphorus binders) as needed, the second group ( cases) on hemodiafiltration for at least months and received conventional care only, and the third group ( cases) [control group] on regular hemodialysis received conventional care only. monthly follow up of serum calcium, phosphorus and alkaline phosphatase was done in addition to baseline and -monthly parathormone level (intact pth). results: the mean age of whole study population was . ± . years (range - years), and the mean weight was . ± . kg (range - . kg). both groups i & ii, but not group iii, showed a statistically significant increase in hct level and a statistically significant decrease in alp and pth after the study period. there was a significant percent reduction of pth level in group i patients compared to those in group iii. there was no statistically significnat difference between percentage of achievement of the nfk-k/doqi recommended goals in the three groups. conclusions: in spite of the costs of cinacalcet and hemodiafiltration, patients with resistant hyperparathyroidism should use one of these modalities to avoid complications of the metabolic bone disease. the cost of cinacalcet and hdf should be calculated in the context that they will save in other items as decreasing the dose of erythropoietin and vitamin d analogues and decreasing the complications, and consequently therapy, of bone disease. objectives: vesicoureteral reflux (vur) is a common urological anomaly among children. the genetic correlations between gene mutations and some of the syndrome, which has vur phenotype, have been determined in recent years. however, the disease-causing genes of isolated vur were not well understood yet. methods: to determine the disease specific genes involving in isolated vur, the whole exon sequencing (wes) was performed in vur patients. of these patients, were isolated vur.exon-enriched dna was sequenced by the illumina hiseq platform following the manufacturer's instructions (illumina) . results: wes data shows mutations ( novel) in genes in patients ( . %) from families (table ) . these genes include (number of mutations): tnxb ( ), trap ( ), kansl ( ), ret ( ), robo ( ), upk a ( ), gene ( ), xrn ( ), sall ( ), sall ( ), bicc ( ), eya ( ), and other genes shows one mutation. several mutations of ret and hnf b genes consistent with previously investigation. further analysis by perniciousness of mutation demonstrated that the mutation of tnxb is significantly correlated with vur risk stratification. the staging of vur of patient harboring or above mutations is much higher than the patient harboring or bellowed (or score is ) ( table ). our findings may provide a clinical molecular marker in vur for risk stratification. finally, it is reported that c orf mutation could cause meckel-gruber syndrome. in present study, we identified a run-on mutation were shared by vur patients out of the patients. although the maf in chinese thousand-genome project is around . %, much higher than western population, it may be a susceptibility gene candidate in chinese population, which needs to be validated in a larger sample size. conclusions: our data demonstrated that the whole exon sequencing is a reliable approach to identify disease-causing genes in isolated vur, and c orf may involve in the vur pathogenesis. fp-s - a cost-consequence analysis of treatment of vesicoureteral reflux (vur): which children benefit from antimicrobial prophylaxis? n. shaikh ( ) , v. rajakumar ( ) , j. gorski ( ) objectives: antimicrobial prophylaxis for children with vur reduces the risk of recurrences of uti, but requires daily administration of an antimicrobial for extended periods. repeated utis can rarely lead to long-term consequences such as hypertension, preeclampsia, and end stage renal disease. we used a cost-consequence model to evaluate whether the benefits of antimicrobial prophylaxis outweigh its risks, and if so for which subgroups of children prophylaxis may not be cost-effective. methods: we compared the costs and consequences of antimicrobial prophylaxis with trimethoprim-sulfamethoxazole to no antimicrobial prophylaxis in children aged < years diagnosed with vur grades i-iv after a first or second uti. we also examined the results in subgroups defined by grade of vur, presence of bladder bowel dysfunction (bbd), and presence of fever at the time of uti. costs and consequences were evaluated over the patient's lifetime. we included the following consequences in our model: hypertension, preeclampsia and end stage renal disease. results: average costs of treatment for patients who develop long-term sequelae is $ , . treatment of all children with vur with antimicrobial prophylaxis would cost $ , per sequelae avoided. in contrast, treatment of children with both vur and bbd with antimicrobial prophylaxis would cost $ , per sequelae avoided. conclusions: antimicrobial prophylaxis is most cost-effective in children with both vur and bbd. screening children for bbd can help select those who would benefit the most from long-term antimicrobial prophylaxis. fp-s - genetic discovery in vesicoureteral reflux (vur) using exome sequencing: a pilot study r. thergaonkar ( ) , v. manchanda ( ) , a. yadav ( ) , b. varma ( ) , d. dash ( ) , m. mukerji ( ) , a. bagga ( ) , p. hari ( in the family, autosomal dominant (ad), recessive (ar) and x-linked (xl) models were used. objectives: immunization with various vaccines is recommended for children with idiopathic nephrotic syndrome (ns) because of their high risk for severe infections. while vaccinations could precipitate ns relapses, there are no available data regarding influenza (flu) virus vaccines. methods: we retrospectively reviewed the medical records of pediatric patients with ns who had received flu vaccines between and . the period from pre-vaccination days to post-vaccination days was defined as -x to +y. flu vaccines were given during except for the period administered mg/kg/day of prednisolone or on relapses. comparison of ns relapse rates in pre-or post-flu vaccination periods was evaluated using poisson method. risk factors for ns relapses were evaluated using generalized linear mixed model about parameters such as pre-or post-flu vaccinations, sex, age at onset of ns, past history of steroid resistant, renal histology, being on various immunosuppressants or not. results: a total of pediatric patients ( boys and girls) received flu vaccines. mean age at onset of ns, mean age at first flu vaccinations, and mean observation period were . ± . years old, . ± . years old, and . ± . years, respectively. during - to + , the total number of ns relapses and relapse rate were episodes and . times/personï½¥year, respectively. compared with relapse rate in - to ( . times/ personï½¥year), those in to + , to + and to + were . (risk ratio (rr): . , % confidence interval (ci): . - . objectives: to evaluate the imaging results of childhood uti in a developing country setting, and examine if it would be appropriate to apply the recent guideline changes regarding imaging studies as routine practice in thailand. methods: medical records of children aged - years who had uti and were admitted at the department of pediatrics, prince of songkla university from january -december were reviewed. renal ultrasound (rus), cystogram and m tc dimercaptosuccinic acid (dmsa) renal scanresults to determine congenital anomalies of the kidney and urinary tract (cakut) and renal damage were evaluated. mild cakut was defined as primary vur grades i-iii or isolated hydronephrosis and all other abnormalities were defined as severe cakut. results: boys and girls had at least one imaging study after uti. their median (iqr) age was . ( . - . ) year; . and . years for boys and girls, respectively (p= . ). children had an rus performed, of which ( . %) were abnormal. cystograms were performed in children, of which ( . %) cakuts were detected; primary vurs, posterior urethral valves, neurogenic bladders with vur and duplex kidneys and urinary tract fistulas. children had a dmsa performed, of which ( . %) were abnormal, including scarred kidneys, dysplastic kidneys, with dysplasia and scarring in the contralateral kidney, enlarged kidneys, with generalized decreased uptake in one kidney and with a non-functional kidney. overall, cakuts were detected in ( . %) children of which were severe and were mild. rus together with cystogram provided higher sensitivity ( % vs . %) and specificity ( . % vs . %) to detect severe cakut than rus together with dmsa. conclusions: a cakut was detected in more than half of the children with first uti, with one third having severe cakut. there is no single optimal imaging study guideline after first uti, as patient settings and resources vary widely. an open labelled randomized control trial on the utility of antibiotic cover to prevent urinary tract infection in children undergoing voiding cystouretrogram b. maji ( ) , r. sinha ( ) , s. saha ( ) ( ) institute of child health, kolkata, india; ( ) amri, kolkata, india objectives: to conduct an open labelled randomised controlled trial to assess the utility of antibiotics for preventing urinary tract infection (uti) in children undergoing voiding cystourethrogram (vcug). methods: children ( month - year) referred for vcug were confirmed to have sterile urine and were thereafter randomized in : ratios to either undergo vcug under antibiotic cover (cotrimoxazole or cephalexin was started a day prior vcug and continued for a day post procedure) or without antibiotic cover. sample size was calculated at for a power of % with alpha . . urine routine and culture was done days prior vcug to rule out underlying uti and repeated days post vcug to diagnose post procedure uti. results: children ( % male, age: median month, range to months) were recruited. no significant difference was noted in the demographic criteria between those receiving antibiotic (n= ) and not receiving antibiotic (n= ). overall children ( %) developed post vcug uti. incidence of uti was significantly lower among those receiving antibiotic (n= , %) when compared to those not receiving antibiotic (n= , %), p= . . % (n= ) of children with abnormal ultrasound (n= ) developed uti post vcug when compared to % (n= ) of children with normal ultrasound (n= ) p = . . the rct demonstrated that vcug performed under antibiotic cover results in significantly less uti. it also revealed that risk of post vcug uti is significantly higher among those with abnormal ultrasound. future studies are needed to explore whether using antibiotic only among those with abnormal ultrasound will reduce the usage of antibiotic without increasing the risk for post vcug uti. conclusions: the incidence of paediatric urolithiasis is rising in the uk, with increasing older children and females. metabolic abnormalities commonly predispose urolithiasis and recurrence rates are high, justifying the comprehensive screening of all children. objectives: we report preliminary observations from a first-in-human clinical trial of aln-go , a subcutaneously administered investigational small interfering rna therapeutic for the treatment of primary hyperoxaluria type (ph ). ph is a rare, inherited, life threatening condition characterized by end stage renal disease and multiple end organ damage. the disease results from an inherited defect in the hepatic peroxisomal enzyme, alanine glyoxylate aminotransferase (agxt), causing an overproduction of the toxic metabolite, oxalate. currently, liver transplantation provides the only definitive correction of the hepatic metabolic defect. aln-go is targeted to hepatocytes, where it inhibits glycolate oxidase (go), an enzyme upstream of agt, thereby reducing the substrate for oxalate production. in pre-clinical models, treatment with aln-go has demonstrated a dose-dependent increase in the non-toxic metabolite, glycolate, with a corresponding reduction in oxalate excretion, suggesting a potential for therapeutic benefit. methods: a placebo-controlled single-ascending dose phase / study of aln-go is ongoing in healthy adult volunteers. the primary endpoint is safety and tolerability. changes in plasma glycolate to determine selection optimum dosing regimens for patients with ph will also be evaluated. results: safety, tolerability and emerging dose-dependent pharmacodynamic data will be presented. the results of this phase / trial of aln-go will guide future stages of development of aln-go in patients with ph . fp-s - do patients diagnosed with primary hyperoxaluria through family screening have different characteristics compared with those diagnosed conventionally? d.j. sas ( ) , f.t. enders ( ) , r.a. mehta ( ) , x. tang ( ) , f. zhao ( ) , b.m. seide ( ) , d.s. milliner ( ) , j.c. lieske ( ) ( ) mayo clinic, rochester, united states; ( ) shanghai changzheng hospital, second military medical university, shanghai, china objectives: primary hyperoxaluria (ph) is an inherited disease characterized by excessive production of oxalate leading to recurrent nephrolithiasis, nephrocalcinosis and progressive kidney damage. most ph patients are diagnosed through evaluation initiated for clinical suspicion (cs) based on signs or symptoms. however, some are detected by family screening (fs) once an affected family member has been identified. we sought to characterize differences between these two groups. l. greenbaum ( ) , g. ariceta united states; ( ) emory school of medicine and children's healthcare of atlanta calcitriol treatment ameliorates fgf /fgfr -induced cardiac myocyte hypertrophy in vitro and in vivo m. leifheit-nestler ( ) vitamin d deficiency and excess of fgf are contributors to cardiovascular mortality in ckd patients. fgf exclusively activates fgf receptor (fgfr) to stimulate lvh, and cardiac expression of fgf correlates with the presence of lvh in ckd. , -dihydroxyvitamin d ( , d) is known to have cardioprotective properties, but may further stimulate fgf synthesis and thus lvh in ckd. here, we investigated the dose-and timedependent effects of calcitriol treatment on i) fgf /fgfr system and lvh in / nephrectomized rats (nx), and ii) fgf -induced hypertrophy of cardiac myocytes in vitro. methods: / nx were treated with , d ( - ng/kg bw/d) for and weeks, respectively. hearts were investigated for fgf signaling, cardiac remodeling, and lvh. isolated neonatal rat ventricular myocytes (nrvm) were stimulated with , d and/or fgf and evaluated for myocardial hypertrophy. results: vehicle-treated / nx rats show enhanced expression of fgf in bone and myocardium both bone and cardiac fgf gene expression, and total cardiac fgf protein levels are further stimulated by , d, whereas full-length intact cardiac fgf protein, fgfr , and calcineurin-nfat signaling are suppressed. expression of rcan , trpc , and pro-hypertrophic genes are increased in / nx rats, and downregulated by , d. in nrvm, , d induces fgf and fgfr mrna levels, whereas the expression of rcan and bnp, and the size of cardiac myocytes remain unaffected. , d treatment blunted fgf -induced hypertrophy in nrvm. conclusions: , d ameliorates lvh in / nx rats and rescues fgf -induced cardiac myocyte hypertrophy in vitro s -vesicoureteric reflux: what's new? fp-s - whole exon sequencing (wes) reveals recurred germ line mutations in vesicoureteral reflux china & table : list of possible candidate genes results: median depth of coverage was x & target coverage % at x. mutations & cnvs in essential gene-sets are shown no mutation was shared. mutation was noted in tmem , a possible candidate gene that is also in a candidate cytoband & / patients with recurrent uti, worsening renal scarring, hypertension, proteinuria & voiding disorders, respectively. xl model identified variants in arsd,located within a bp intronic region; - of these were seen in all boys but not the girl. ad model identified mutations in aga and slit & table : variations in essential gene-sets and cnvs conclusions: exome sequencing using sharp phenotyping is a promising method for genetic discovery in vur. tmem , aga, slit & arsd are candidate genes. s -infections and the kidney fp-s - examination of clinical relationship between influenza virus vaccine and relapse of nephrotic syndrome in children kamei ( ) , s. ito ( ) , k. ishikura ( ) ( ) department of pediatrics mycophenolate mofetil (mmf) as induction and maintenance therapy in childhood lupus nephritis (ln) f. nuzzi ( ) , m.m. balletta ( ) , g. malgieri ( ) , m. d'armiento ( ) histologic classes (weening) were: ii in pts, iii in , iv in , v in . before mmf, methylprednisolone i.v. pulses were administered. hematuria was always present, proteinuria ranged from . to > g/day, decreased c and increase in anti-dsdna ab were present. treatment outcome was monitored through assessment of sledai score, renal function, proteinuria, serological markers and side effects. mmf was administered twice daily at mean dose /mg/kg/day. oral prednisone (p) was associated to mmf. results: after a mean followup . yrs ( . - . ) all pts had sustained remission: proteinuria was absent or < . g/day in , . - . g/day in , > g in .; all but one of children with renal failure at onset normalized; c mormalized in ( %). a steroid sparing effect (p maintenance dose . mg/kg/alternate day in pts). until now pts are off therapy from . yrs mean period ( . - . ) after at least yrs therapy, no flares from yrs, proteinuria < g/day, normal pcreat, inactive urinary sediment. in pts a second serial renal biopsy, after yrs, showed decrease of activity indexes, chronicity indexes did not change. no hematological side effects were seen; because of gastrointestinal signs in pts, mmf was shifted to gastroresistant formula; one pt had herpes zoster infection s -complications following renal transplantation fp-s - post-transplant acute kidney injury (aki) predicts development of chronic kidney disease (ckd) in paediatric non-kidney transplant recipients c. williams ( ) , k. borges ( ) , t. banh ( ) aki status (defined per international guidelines) was assessed at , and months post-transplant. patients were followed until ckd (creatinine-based estimated glomerular filtration rate (egfr) < ml/ min/m for months), end stage renal disease (esrd, initiation of dialysis or receipt of a kidney transplant) or last follow-up. those who received dialysis prior to transplant or were followed < days were excluded. risk of ckd as a function of aki and other covariates was evaluated in cox regression models. results: a total of children were transplanted at a median age of . years (iqr: . - . ); % were male. a total of children developed aki with a mean of . ± . aki episodes over the first year post-transplant and developed ckd. less than children developed esrd, all within days posttransplant and thus were not included in subsequent analysis. in a cox regression model, those with or more aki events versus no aki event by each of the pre-specified time points ( months, months, year post-transplant) had a significantly greater risk for developing ckd over subsequent follow-up after controlling for age, sex, baseline egfr. conclusions: aki occurs commonly in the first year after transplant and more than episode of aki is associated with - times greater risk of developing ckd fp-s - focus on physical activity can improve cardiorespiratory fitness (vo peak) in children after renal transplantation h. thorsteinsdottir ( ) , a. lie ( ) , t. tangeraas ( ) , a. Åsberg ) as well as all renal transplanted patients at the age of < yrs in the period - were invited to participate in this follow-up study. the participants were tested on the treadmill (vo ,max ) and went through a thorough physical examination, including ambulatory blood pressure monitoring and measurements of plasma lipids. the present interim analysis is performed half way into the study. results: so far out of patients ( girls) met the criteria for vo ,max the median age at transplant was . years (iqr= . - . ) and the median time on dialysis was months (iqr= . - . ). fifty-eight patients ( %) underwent kt with deceased donor, the median follow-up at the study time point was . years (iqr= . - . ) and the median gfr was ml/min/ , m (iqr= - ). only child presented coronary calcification ( . %) and with regard to echocardiography, multivariable linear regression revealed significant association between the lvm-sds and serum renalase (each ng/ml increase in serum renalase is associated with . greater lvm-sds, p= . ) and a trend of association with gfr (each ml/min higher gfr is associated with - . lower lvm-sds, p= . ). conclusions: to summarize, our data showed relatively good heart health in the study sample. these results may be due to the young age of the patients and the short time of renal replacement therapy s -nephrocalcinosis & nephrolithiasis fp-s - no stone unturned: the epidemiology and outcomes of paediatric urolithiasis in the united kingdom significant family history was strongly predictive of metabolic aetiologies (or . : vs. no family history). % of children had multiple aetiological factors, complicating their investigation and management. % of children with ≥ year follow-up experienced recurrence. critically, we report an association between paediatric urolithiasis and adverse long-term renal outcomes. of children that underwent dmsa scanning demonstrated abnormal results key: cord- -e b vg authors: wu, jie; shen, bingzheng; li, dan; song, wei; li, jing; zhang, mengke; liu, gang; zhou, benhong title: pharmacy services at a temporary covid- hospital in wuhan, china date: - - journal: am j health syst pharm doi: . /ajhp/zxaa sha: doc_id: cord_uid: e b vg in an effort to expedite the publication of articles related to the covid- pandemic, ajhp is posting these manuscripts online as soon as possible after acceptance. accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. these manuscripts are not the final version of record and will be replaced with the final article (formatted per ajhp style and proofed by the authors) at a later time. to covid- "ark hospitals" (ie, temporary makeshift hospitals housed in preexisting nonmedical buildings). a to ensure effective treatment of patients with covid- admitted to these covid- ark hospitals, a range of pharmacy services had to be provided, including formulation of a catalog of required drugs, medication supply chain management, storage of drugs, medication dispensing, and evaluation of the effectiveness and safety of drug therapy. pharmacy services provided in ark hospitals played an important role in controlling the covid- epidemic in wuhan. the outbreak of covid- , which is caused by severe acute respiratory syndrome coronavirus (sars-cov- ), emerged in wuhan, the capital of hubei province, in december . sars-cov- is highly infectious and is spread rapidly by human-to-human transmission via respiratory droplets or direct contact. the main clinical symptoms of sars-cov- infection include respiratory symptoms, fever, cough, shortness of breath, and breathing difficulties. genomic analysis showed that sars-cov- differs from sarsassociated coronavirus (sars-cov) or the coronavirus that causes middle eastern respiratory syndrome (ie, mers-cov). as the local epidemic was getting worse, health officials recognized a problem: the growing number of patients with mild covid- , whose initial symptoms did not require admission to one of the city's established acute care hospitals but who might spread the illness among family members if they continued to reside in the community. to address this problem, gymnasiums, exhibition centers, and other large buildings in wuhan were converted to covid- ark hospitals. diagnosed patients exhibiting milder symptoms were admitted to covid- ark hospitals so that patient care-usually only oral pharmacotherapy but also higher-level treatment if necessary-could be provided in a concentrated way. the covid- ark hospitals, typically housing a medical function unit, ward unit, and technical support unit, provided services ranging from clinical examination to emergency treatment and surgical intervention. each ark hospital was typically staffed by doctors, nurses, and pharmacist caring for about patients. within the covid- ark hospitals, medical facilities and medicines were allocated to a "treatment district" and a "rescue district." a pharmacy emergency leadership team consisting of a drug supply group, drug dispensing group, quality control group, and clinical pharmaceutical services group was designated to be responsible for providing pharmacy services to covid- ark hospitals. a drug catalog was formulated according to guidance documents issued by the chinese government, including the document "diagnosis and treatment for covid- (trial version )," as well as the national essential drugs list and national formulary. these sources mainly list drugs for symptomatic treatment, prevention of complications, treatment of underlying diseases, and salvage drugs, comprising antiviral drugs, liver-protective drugs, antibiotics, antipyretic analgesics, glucocorticoids, microecological regulators, and drugs for respiratory system diseases, digestive system diseases, diseases of the psychoneurotic system, cardiovascular system diseases, metabolic diseases, and endocrine system diseases, as well as antianaphylaxis drugs, vitamins and electrolyte drugs, traditional chinese medicines, and first-aid medicines. the permanent hospital responsible for supplying medications to covid- ark hospitals has a mature purchasing system, which helped to ensure that drugs were supplied in a timely manner and of reliable quality. the drug supplies reserved by the responsible hospital were helpful in establishing a drug supply system for covid- ark hospitals in a short time. the pharmacy of each covid- ark hospital was set up in a space that was suitable for the scope of diagnosis and treatment and the quantities of drugs needed, relatively independent, and convenient for management purposes. the pharmacy was either located in a separate office or compartment or housed in a large, secure container outside. medicine cabinets, refrigerated cabinets, backing plates, and other required equipment were installed. pharmacists at covid- ark hospitals dispensed prescription drugs according to prescription administrative policy using the following procedures and workflow: ( ) review prescription to determine whether the indication is suitable or not, the drugs selected are suitable or not, the routes of administration are suitable or not, the usage and dosage are suitable or not, the drug combination is suitable or not, and there is repeated administration or not; ( ) dispense drugs on a first-in/first-out basis by batch number; ( ) check the name, specification, and quantity of each drug; and ( ) deliver the drugs to the nurse. since specific drug therapies and vaccines for covid- are still not available, antiviral drugs commonly used in clinical practice, especially broad-spectrum antiviral drugs and traditional chinese medicines, were chosen to treat patients with covid- . pharmacists in covid- ark hospitals focused on the therapeutic and adverse effects of antiviral drugs through the following steps: ( ) evaluate disease progression after treatment to confirm the effectiveness of drugs administrated; ( ) monitor adverse drug reactions, especially in the aged, children, and patients with underlying diseases, and report adverse drug reactions; and ( ) timely adjust the treatment plan to ensure the safety of medication use. in summary, implementation of covid- ark hospitals helped to relieve the severe shortage of hospital beds, isolate sources of infection, and restrain the local epidemic in wuhan while also helping to ensure that diagnosed patients with milder symptoms were treated as early as possible. a editor's note: the term "ark hospital" appears to have been derived from a mandarin chinese term also used to describe a makeshift temporary hospital, "fangcang" (literally, "square cabin"), which when spoken is said to sound like the chinese term for "noah's ark." sars-cov- and covid- : the most important research questions world health organization declares global emergency: a review of the novel coronavirus (covid- ) severe acute respiratory syndrome coronavirus (sars-cov- ) and coronavirus disease- (covid- ): the epidemic and the challenges a review of coronavirus disease- (covid- ) emerging novel coronavirus ( -ncov)-current scenario, evolutionary perspective based on genome analysis and recent developments rapid information support system for ark hospitals during the novel coronavirus prevention and treatment establishing and managing a temporary coronavirus disease specialty hospital in wuhan, china mobile emergency (surgical) hospital: development and application in medical relief of " . " lushan earthquake in sichuan province, china national health commission of the peoples republic of china. diagnosis and treatment for covid- (trial version ) key: cord- -rx n authors: medeiros, eduardo alexandrino servolo title: challenges in the fight against the covid- pandemic in university hospitals date: - - journal: rev paul pediatr doi: . / - / / / sha: doc_id: cord_uid: rx n nan calendars, including schools of medicine, with revision of college admission exams and evaluations of medical residency, will have a significant impact. the main challenges for hospitals, especially university hospitals, are: reorganize the care provided, increase the number of intensive care unit beds, guarantee the availability of personal protective equipment, particularly protection masks and gowns, which are in short supply, and have enough tests for diagnosis. many health professionals are getting sick and having to stay out of work, which can lead to the collapse of hospital care, as seen in countries such as italy and spain. research support is essential in the search for effective medications -in the clinical protocol phase at the moment -and a vaccine, which will probably be available only in , after this pandemic is over. as health professionals, we must prepare for the worse in the coming weeks, protect ourselves, have hope, and be on the front line, contributing to this critical and historic fight against this novel coronavirus. the -new coronavirus epidemic: evidence for virus evolution a novel coronavirus from patients with pneumonia in china a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster epidemiological characteristics of pediatric patients with coronavirus disease in china the authors declare no conflict of interests. this study did not receive funding. key: cord- -t w cdr authors: nan title: royal academy of medicine in ireland date: - - journal: ir j med sci doi: . /s - - - sha: doc_id: cord_uid: t w cdr nan the tuberculin-skin-test is the most commonly used test to screen for tuberculosis worldwide. in most cases it is administered by the most junior member of the medical team. there is some anecdotal evidence to suggest that junior doctors have limited knowledge of how to administer and interpret this test correctly. the aim of this audit was to assess the proficiency of interns and senior-house-officers in st. vincent's university hospital at performing the tuberculin-skin-test and improve standards. a multiple choice questionaire was used to assess doctors' knowledge of tuberculin-skin-test administration, interpretation, alternatives and the availability and awareness of information regarding the tuberculin-skin-test within the hospital. interns and senior-house-officers were assessed. of those questioned . % correctly identified intradermal as the method of administration. . % knew to correctly assess the induration at - h, but only % knew that the induration should be measured across the forearm. only . % were aware of the information leaflet within the hospital. . % of senior-house-officers correctly identified intradermal injection as the method of administration. it is apparent that the tuberculin-skin-test is often administered and/or interpreeted incorrectly. we recommend formal teaching for junior doctors in this area, coupled with improved availability of the information leaflet. mucinous tubular and spindle cell carcinoma (mtscc) is an extremely rare type of kidney tumour that has only recently been described, with less than eighty cases in the literature. this was only recognized as a specific entity in the world health organization classification of renal cell carcinoma (rcc). mtsccs are polymorphic renal neoplasms characterized by small, elongated tubules lined by cuboidal cells with cords of spindled cells separated by pale mucinous stroma. we report the case of a -year old lady who had an incidental finding of a mass in her right kidney. the radiological features were consistent with a rcc and following a multidisciplinary team discussion she underwent a laparoscopic radical nephrectomy. macroscopic examination revealed a well circumscribed . . right lower pole mass. histologically it was composed of elongated tubules, small tubules and papillary structures with a necrotic centre. the cells demonstrated cuboidal and spindle cell morphology. histological grade was fuhrman grade . subsequent ct thorax abdomen and pelvis staged the tumour as pt b. the majority of mtsccs are indolent, and there is only one report of a distant metastasis which responded favourably to adjuvant sunitinib. to date there is no international consensus on long term surveillance of these patients. due of the favourable prognosis with this type of tumour, mtscc must be differentiated from papillary renal cell carcinoma to avoid administration of excessive adjuvant treatment to patients. this is the first recorded case of this recently classified, rare tumour in ireland. this incidental finding of solid pseudopapillary neoplasm (spn) was discovered when a -year-old female underwent a chest x-ray to investigate a wheeze. a subsequent ct abdomen revealed a cm well circumscribed mass adjacent to the tail of the pancreas. this neoplasm had reached a significant size of cm appreciable on radiological imaging and yet was asymptomatic and not palpable on physical examination. laparatomy revealed a highly haemorrhagic and calcified mass emanating from the pancreas. this was adherent to the omentum, distal pancreas and splenic vessels. distal pancreatectomy was performed with en bloc resection of the mass. repeated ct scans at , and months failed to demonstrate recurrence. solid pseudopapillary neoplasms are rare entities accounting for between . and . percent of pancreatic tumours. this neoplasm has a predilection for females under the age of . these tumours are indolent and usually reach a large size before detection. diagnosis is confirmed on histology and complete surgical excision of localised tumours is curative. we aimed to assess the prevalence of smoking among patients with vascular disease and the role of the health care profession in encouraging smoking cessation. patients who attended the vascular outpatient department were surveyed over a month period in . patients gave verbal consent to partake in the audit and the surveyor entered the responses into a standardised questionnaire response sheet. % of patients were current smokers, % ex-smokers and % had no history of smoking. % smoke over cigarettes per day and % had a smoking history spanning over years. just % of smokers who are under the care of the vascular service have been advised to give up smoking in the past by a healthcare professional. smoking has long been established as a major modifiable risk factor for the development of atherosclerosis however % of patients attending the vascular service continue to smoke. just half of patients who were offered smoking cessation advice found it was effective. therefore a system needs to be put in place where all vascular patients are advised of the benefits of smoking cessation and the manner in which information is dispensed needs to be revised. to investigate the optimum location for the teaching of procedural skills to medical students english n, o'flynn s introduction: procedural skill training is a vital component of medical education. traditionally it has been teaching hospital based however general practice rotations may provide greater opportunities than previously thought. aims: this study aimed to ascertain whether a general practice setting or a teaching hospital setting provided a better environment for acquiring procedural skills in terms of opportunity to practice and the variety of skills performed. the correlation between end of year osce results and the amount of procedural skill exposure was also looked at. methods: a cross-sectional quantitative study which included all rd year medical students at ucc was conducted. a log book listing procedural skills was made available to all students before beginning both general practice and teaching hospital rotations. students were instructed to indicate on the log when they performed any of these skills and in which location. logs were returned to medical school. data was obtained and analysis performed using spss . results: a response rate of % was achieved. . % of students performed more skills at the gp setting. . % (n = ) did not perform any skills while in a teaching hospital . skills were performed significantly more frequently in a gp setting while were performed more frequently in a teaching hospital. students who performed a high number of skills in one location were no more likely to perform a high number in the other. conclusions: students were able to take greater advantage of procedural skills opportunities in a gp setting. as this was the students first clinical year it is likely that the one-to-one teaching scenario provided them with a more suitable location to practice skills for the first time. this study also highlighted the diverse nature of procedural skills which a general practice setting can provide. accuracy of sentinel node biopsy in determining the requirement for second axillary surgeries in t -t breast cancer with retrospective application of z criteria background: lymph node status is the most important prognostic marker in breast cancer management. in tandem with breast conser-vative surgery, surgical approaches to the axilla have also become less invasive thus decreasing the morbidity associated with axillary clearance. the acosog z trial reported no difference in survival in patients undergoing sentinel lymph node biopsy (slnb) alone versus axillary lymph node dissection (alnd) in t -t tumours. our aims were to establish whether sentinel lymph node biopsy was a true representative of axillary burden. we also analysed whether retrospective application of criteria from z trial would have prevented patients undergoing second axillary surgery. methods: all patients with t -t tumours undergoing sentinel node biopsy were included in our study (n = ). analysis of our prospectively updated breast cancer database was performed. minitab version . was used to carry out statistical analysis of the data results: slnb procedures for t & t tumours were performed over a year period. patients were reported as histologically negative and were positive. of the lymph node positive group, patients progressed to axillary clearance. staging of patients remained unchanged with only patients having [ axillary lymph nodes reported as positive. patients from the slnb negative group also had an axillary clearance. of these patients had further axillary disease with patient being upstaged having [ axillary lymph nodes positive. with retrospective application of z criteria % of patients would have avoided second axillary surgery. conclusions: sentinel node biopsy is a strong indicator of axillary tumour burden. this study highlights the accuracy of sentinel lymph node biopsy in staging disease and representing overall tumour burden. flaherty ra, kelly bd, coyle d, quinlan mr, d'arcy ft, rogers e, jaffry sq we report the first case of a spontaneous right nephrocutaneous fistula (ncf) with an accompanying fistula limb communicating with the right ureter. a -year-old man presented with a groin mass, which was initially diagnosed as a hernia. he was scheduled for an inguinal hernia repair. upon incision there was extravasation of urine from the wound and the procedure was abandoned. a ct urogram identified a ncf running from the right lower pole calyx, anterior to the psoas muscle and emerging on the right groin skin with an accompanying fistula limb communicating with the right ureter. during the course of investigation it was discovered that the patient was suffering from chronic indolent calculus pyelonephritis which led to the formation of both aberrant pathways from the kidney and the ureter and that both had calculi located at their origins. the patient was first treated with a nephrostomy and ureteric stenting to relieve urinary obstruction and after this failed to resolve the fistula, was successfully treated with percutaneous nephrolithotomy for removal of the calculi and fibrin glue injection into the fistula. this case is one of only a few reported cases of spontaneous nephrocutaneous fistula and the anatomy of the fistulous tract in this case is very unusual and posed a particular challenge for surgical management. this case report further advocates the use of fibrin glue in the management of complicated ncf. this is a retrospective case study. there were six cases of ocular tuberculosis over the year period, one annually, four of whom are women, with ages ranging from to years old. two were foreign-born. all patients presented with reduced visual acuity. four developed posterior uveitis, one anterior uveitis and one panuveitis. this was also complicated by vitritis, retinal detachment and retinal vasculitis in four. the median duration of symptoms until commencement of treatment was months. all cases had a positive mantoux and one case had evidence of pulmonary tuberculosis on chest x-ray. tuberculosis was isolated in two cases. the intended duration of anti-tuberculous therapy for all patients was months. vision improved in all cases. ocular tuberculosis is rare in developed countries, with prevalence ranging from \ to %. however, it is important to be considered in all cases of uveitis. despite the use of pcr, most cases are presumptive. this leads to delayed commencement of therapy causing further complications. a high index of suspicion is required. we describe the case of a -year-old gentleman who presented to our emergency department (ed) with a very unusual complication of central venous catheterisation. this resulted in spontaneous extrusion of a retained intravenous guide wire from the base of the occiput. this has been described only once previously in the literature, but not at such a delayed time interval from insertion [ ] . this -year-old gentleman presented to the ed reporting that he felt the point of a sharp object irritate his finger in his midline occipital area. he had successfully retrieved approximately cm of a thin metal wire. he had a history of rheumatic fever and had undergone an elective aortic valve replacement years previously, necessitating central venous cannulation. he had remained asymptomatic up to this time. plain radiography of his neck revealed a short segment of wire in the posterior spinal musculature. this segment of wire (approximately cm) was removed manually with minimal force and minor manipulation. the procedure was uncomplicated and the patient was discharged shortly afterwards. retained foreign bodies may migrate slowly over many years eventually extruding from the body, without any serious complications. events such as retained or lost guide-wires are rare. this phenomenon may become more frequent with increasing complexity of medical care and with increasing use of cv catheters in the treatment of sepsis and other emergent critical conditions. physicians should be aware of the possibility of retained foreign bodies and should be somewhat re-assured by reports of simple uncomplicated removal. we present the case of a -year-old gentleman who was recently admitted with symptomatic right heart failure and new onset atrial fibrillation. our patient had been treated in the community for symptoms suggestive of ccf but had not previously been investigated. of note, he has no history of a chronic inflammatory condition and no symptoms suggestive of an underlying neoplastic process. on presentation he was also noted to have evidence of an arthropathy affecting his knees and ankles and bipedal oedema. renal function was abnormal with a urea of . and a creatinine of . urinalysis was positive for protein and h urine collection for protein is ongoing. liver enzymes were also elevated and revealed a cholestatic picture. echocardiogram showed a reduced ejection fraction of % and findings consistent with amyloidosis. biopsy of abdominal fat pad at time of writing is pending. amyloidosis refers to an uncommon group of disorders characterised by extracellular tissue deposition of a variety of proteins in an abnormal fibrillar pattern which are resistant to degradation. it can occur alone (primary) or can complicate many chronic inflammatory conditions (secondary). the major sites for clinically reported amyloid deposition are the kidneys, heart and liver. clinically patients present more often with right heart failure; pulmonary oedema is rare. amyloid infiltration results in increased echogenicity on echocardiogram and gives a ''sparkling'' appearance to the myocardium. biopsy is diagnostic. this was achieved using a retrospective review of all children receiving gh therapy (n = ) over a -year period (october -october ). of patients on gh therapy had ghd. of these, had ighd ( male) and had cphd ( male). all had appropriate work-up and follow-up. age at presentation to endocrinology was older in the ighd group (mean . years) than in those with cphd (mean . years). / children with ighd presented with short stature, compared to only with cphd; the remainder presenting with clinical features of other pituitary hormone deficiencies. the mean height centile at diagnosis was lower in the ighd group ( . th) versus the cphd group ( th). mri brain/pituitary was abnormal in the majority of patients ( / ) with cphd, compared with / with ighd. both groups responded well to treatment and height increased by one centile on average at months. all patients diagnosed with ghd at temple st had appropriate work-up and follow-up. children with ighd presented later than those with cphd, and had shorter height centiles at diagnosis. there was a strong male predominance in children presenting with ighd, which may reflect psychosocial factors. structural pituitary abnormalities were more common in those with cphd, and their clinical presentation was more varied. response to therapy was similar in both groups. background: out of hospital cardiac arrests have poor survival rates approx - %. improving outcomes in ireland have been seen in the past decade. better outcomes are seen if arrest is witnessed and when bystander basic life support was initiated. worse prognosis is seen in a rural setting due to delay in paramedic response times and in administration of advanced cardiac life support. case report: a -year-old donegal male experienced chest pain in his rural home and subsequently cardiac arrested. his spouse, whom months prior had trained in basic life support as part of a fas course contacted the 'out of hours' gp and ambulance service and commenced cpr. the gp failed to reach the house and the first ambulance broke down. on arrival of second ambulance, one person cpr had been administered for [ min. paramedics delivered dc shocks and intubated the patient. in the regional hospital pc was admitted to the intensive care unit for days being managed with acute respiratory distress syndrome (ards). transoesophageal echocardiogram on day of admission showed ef %. ct brain carried out showed no acute pathology. once stable, angiography was carried out showing multivessel disease. discussion at st james's hospital (sjh) cardio-thoracic conference resulted in plan for transfer and pci. in sjh pressure wire study of left anterior descending (lad) coronary artery was positive and stenting (drug-eluting) commenced. lad stents, left circumflex stents and right coronary artery (rca) stents. patient is currently well with no overt signs of hypoxic brain injury and is enrolled in cardiac rehabilitation programme. discussion: this is an incredible case of an out of hospital cardiac arrest. elapsed time in the chain of survival events would predict a negative outcome. however, adequate cpr was administered preventing long term brain injury and certain death. this highlights the need for a greater community-based cpr skill base. recently citalopram and escitalopram have been reported to cause dose dependent qtc prolongation. prescribing guidelines have since changed including contraindication of co-prescription with other qtc prolonging agents. domperidone is a dopamine antagonist widely used as an anti emetic. qtc prolongation and ventricular arrhythmias have also recently been highlighted with domperidone and, since november , caution advised when prescribing domperidone, particularly in patients [ years of age, or at doses [ mg/day. in this audit, we aimed to study whether information on qtc prolongation affects prescribing practice by looking at the prescription of a commonly used medical drug, with recently highlighted qtc effects, and its co-prescription with psychotropics. a list of drugs with substantial evidence for qtc prolonging effects was obtained. a kardex review was completed from acute medical and surgical; long stay and rehabilitation wards. kardexes with domperidone were reviewed for dose, age, gender and co-prescription of other qtc prolonging agents. of surveyed kardexes, % (n = ) were prescribed domperidone. % were[ years. % were on[ mg/day. coprescription with another qtc prolonging agent seen in % of cases; of these % were psychotropics, most commonly citalopram (n = ). four patients were co-prescribed [ qtc prolonging agent. qtc prolonging agents were commonly co-prescribed with domperidone, which continues to be used even in at-risk groups. psychotropics were the most likely class to be concurrently prescribed. further work in this area is necessary to inform clinical psychiatric practice and encourage responsiveness to new evidence regarding cardiac risk. the development of a mathematical model to predict the time to osteoporosis (tto) using dexa scanning background: dual-energy x-ray absorptiometry (dexa) is the gold standard used for measuring bone mineral density and such readings are currently used to predict osteoporosis and osteoporotic fractures. however, no similar prediction model has been developed to identify the time it will take to become osteoporotic based on dexa scanning. objective: the aim of this study was to develop a mathematical model to determine the tto based on two or more dexa scans with tto defined as the age at which the patient will enter the osteoporotic t-score range. methods: fifty patients who had previously undertaken five dexa scans were identified from the dexa database. t-scores were graphed against patient age using graphpad prism software. straight line curves for the most recent scans and cumulative scans were generated with the age at which the curve intersects t = - . being classed as tto. results: the mathematical model developed successfully predicted the time to osteoporosis for each patient, as well as creating a cumulative osteoporotic trend based on total dexa scans performed. additionally, if the patient was classified as osteoporotic following dexa scanning, the model also successfully predicted the time out of osteoporosis. implication: the tto provides a simple and informative parameter of dexa scanning that a patient can immediately comprehend and understand, while also providing a more simple measure to monitor response to therapy. based on the results presented tto can be incorporated into future dexa scans result summaries. further research will involve validation of this tool. an audit of clinical outcomes in transcervical resection of the endometrium compared to outpatient balloon thermablation anglim bc, von bunau g department of gynaecology, adelaide and meath children's hospital, tallaght, dublin thermablation was introduced to the coombe in november and thus far it has provided a quick and effective means of treating women with menorrhagia refractive to medical treatment. a retrospective audit was carried out over a year period in tallaght hospital from november to october . the aim of the study was to compare the efficacy of balloon thermablation compared to transcervical resection of the endometrium (tcre) with or without mirena coil insertion, in the treatment of menorrhagia. patients in total were studied, of which underwent a tcre, and of which underwent balloon thermablation. out of those who underwent a tcre had successful treatment of the menorrhagia and and weekly follow up, had continued menorrhagia which may require a future hysterectomy, however one of which was due to a large fibroid, and one patient described a reduction in menorrhagia however an increase in dysmenorrheoa. out of those who underwent thermablation were treated successfully, had continued menorrhagia to be considered for hysterectomy, had reduced bleeding but increased dysmenorrhoea and one patients symptoms had resolved however she then developed idiopathic thrombocytopenia purpura which led to a recommencement of symptoms. one can therefore conclude that there are both pros and cons to both procedures, tcre being less expensive, however it requires general anaesthesia and may require mirena insertion. thermablation is more expensive however it is a quick outpatient procedure ( min, s) and is done under local anaesthetic. akinmoluwa s, tormey s department of breast surgery, mid-western regional hospital, limerick breast pain is a common problem especially among women of reproductive age. it accounts for a great percentage of gp visits by young women. it represents a huge proportion of gp referrals to the breast clinic. the palpable effects of this include, among others, an increase in waiting time, increase in healthcare cost, stress on the limited resources and ultimately a decrease in quality of care. in this era of unfavorable economic climate, it is prudent to sanitise our healthcare systems by way of identifying and eliminating practices that have not been proven to alter the course of care. in this study, i reviewed the number of breast pain cases referred to ms tormey's breast clinic in the month of march. the objective of this study is to determine whether or not all breast pain complaints should be referred for specialist review. to achieve this objective, i reviewed all the cases of breast pain referred to the breast clinic in march. the table represents my findings. it is evident from the study that hormonal mastalgia accounts for majority of breast pain complaints in women of reproductive age while a few other cases are attributed to musculoskeletal and other benign disorders. these women, with no risk factors, only need reassurance and pain relief. they do not require specialist intervention. alrashed d introduction: anaemia is a common finding in the elderly population. it may be a sign of chronic disease, underlying malignancy, nutritional status, or blood loss. depending on the classification of anaemia, further investigations such as haematinics and endoscopy may be warranted, as replacing the haemoglobin deficit is never a definitive treatment. objective: to determine the prevalence of anaemia in a population of elderly in-patients and whether further screening was performed. methods: this was a cross-sectional review of all patients years and older under a gastroenterology, a rheumatology, and three geriatrics services at a large teaching hospital. patients' full blood counts were reviewed during their current admission. anaemic patients were then categorised based on anaemia subtype and whether haematinics were investigated. results: out of patients under the five teams, were years and older. out of of these elderly patients were anaemic. none of these subjects had microcytic anaemia during their current admission. out of of these patients had normocytic anaemia. out of of anaemic patients had macrocytic anaemia. haematinics were investigated in out of , including out of patients with normocytic anaemia and out of patients with macrocytic anaemia. one patient had abnormal haematinics after being investigated for macrocytic anaemia. conclusion: anaemia was very prevalent in the patients selected for this audit, with the normocytic subtype being the commonest. haematinics were investigated in half those patients. anglim b, murphy c aims: to determine the nature of surgical management of ovarian cysts in the adolescent and paediatric population over a year period. methods: a retrospective audit was carried out over a year period in tallaght hospital from january to december . this audit reviewed cases of ovarian cystectomy, oopherectomy and salpingooopherectomy using both a hospital online database and records of theatre procedures to identify these patients. results: a total of cases were identified. the commonest presentation was due to pelvic pain. there was a total of ovarian cystectomies, fimbrial cystectomies, oopherectomies, bilateral oopherectomy, and salpingo-oopherectomies. a total of appendicectomies were performed in conjunction with these. histology varied from functional and non functional cysts to dermoids and cystadenomas. there were a total of functional cysts, of which were hemorrhagic. there were follicular cysts, fimbrial cysts, paratubal cysts, dermoid cysts, endometrial cysts, cystadenomas, ovarian torsions and fimbrial torsions. of the total amount of procedures performed were done by a paediatric surgeon, and by a gynaecologist. notably there were fewer cases of benign histology in those procedure performed by gynaecologists. conclusions: adnexal surgery is commonly performed in adolescents and children. pathology is frequently benign. there may be a role for more conservative management. we suggest that imaging of the pelvis and tumour markers should be used more frequently in the pre-operative period. protocols may be developed for future implementation. anglim bc, crowley p day surgery is an efficient way of using hospital beds, provided patients are discharged as planned on the day of surgery. unplanned overnight stay following day surgery places an extra burden on a hospital with the busiest accident and emergency department in ireland. a retrospective audit was carried out of one years day case admissions to determine the incidence and causes of unintended or unplanned overnight stay. women were admitted as day cases over the period of st july to june th . a total of diagnostic laparoscopies, operative laparoscopies, diagnostic hysteroscopies, ninety-three operative hysteroscopies, tension free vaginal tapes (tvt) and miscellaneous minor procedure were carried out during this time period. women ( . %) were retained overnight. the main reason for overnight stay was excessive post-operative pain. additional reasons included voiding difficulties, reactions to spinal anaesthetic, asymptomatic tachycardia and the need for intravenous antibiotics. there was no evidence of inappropriate selection amongst the laparoscopies and hysteroscopies, however % of the patients undergoing tvt required admission. one can conclude from this study that most patients were appropriately selected for day case admission. patients undergoing tvt surgery should be scheduled for a h hospital stay. a vulval clinic is an ideal and efficient way of detecting patients with vulval cancer. once potential patients have been flagged by general practice clinicians or other specialities within the hospital, immediate steps can be taken to rule out malignancy. a retrospective audit was carried over a month period on a new vulval clinic which commenced in tallaght hospital on / / . the aim of the study was to determine the need for a specialised vulval clinic for detection of vulval cancer. a total of patients were referred to the four clinics which took place over this time frame. the majority of referrals were from general practice, other referrals were from dermatology, gynaecology and colposcopy clinics. the main reason for referral was vulval pruritis and pain. nine patients were referred with suspicious lesions on clinical examination. a total of biopsies were taken, two of which showed vulval intraepithelial neoplasia (vin). amongst the other biopsies were cases of lichen sclerosis and the remaining biopsies showed non specific dermatitis. one can conclude from this study that a combined dermatological-gynaecological clinic would be of benefit. in addition a . % detection rate of vin was achieved and therefore highlights the necessity of this clinic. the prevalence of renal disease in patients aged above with normal serum creatinine balasubramanian i, peters c, lyons d and o'connor m department of ageing and therapeutics, mid-western regional hospital, limerick background: the prevalence of chronic kidney disease (ckd) increases with age. older patients have lower lean muscle mass and therefore using serum creatinine alone as marker of renal function can lead to underdiagnosis of ckd. objective: the aim of this study was to review the prevalence of ckd amongst a cohort of elderly patients with normal serum creatinine. methods: doctot application on the smartphone was used to calculate egfr in a cohort of patients over years with a normal serum creatinine on admission. patients were included. this application is based on the mdrd formula (includes age, sex, ethnicity and serum creatinine). patients were then classed into the various stages of ckd. results: of the patients reviewed, had renal disease. interestingly, only had a diagnosis of renal impairment recorded in the medical notes. of the patients had stage ckd and the other had stage ckd. of the patients with renal impairment especially stage , were found to be frail females over years. this group also had a number of co-morbidities including diabetes and hypertension. conclusion: egfr is better than serum creatinine alone for assessment of renal function in the elderly. it is important not only for diagnosis but also for appropriate medical investigation and drug prescribing. as the mdrd formula excludes bmi, further research is warranted to compare measurement of egfr using mdrd formula with the cockcroft and gault equation in this older population. chronic obstructive pulmonary disease (copd) is increasingly prevalent worldwide and the main responsibility for it's prevention and management lies with general practitioners. the aim of this audit was to analyse current standards of care of copd patients in a suburbanrural general practice by examining icgp criteria and comparing results with best practice guidelines. the existing coded population of active patients with copd were telephoned and consent was obtained to ask a set of questions designed to examine certain criteria chosen from the icgp copd quick reference guide [ ] . . of the patients included in the audit (n = ), % of patients were male, the mean age was years (sd = . ) and % were general medical service (gms) patients. there was poor recording of smoking status, high uptake of influenza vaccines compared to international figures, a lower uptake of pneumococcal vaccinations and an increased need for osteoporosis prophylaxis. vaccination reminders, smoking cessation advice and information leaflets have been posted to these patients. development of protocols for coding and management have been implemented. in conclusion, general practitioners must focus on ensuring optimum managment of copd in the community. clinical audit is a useful tool to initiate change. we assessed the accuracy of continuous non-invasive haemoglobin measurement using the sphb pulse co-oximeter Ò when compared to traditional laboratory haemoglobin assessment in an outpatient antenatal population. a total of women were recruited. traditional laboratory haemoglobin samples were taken and quantified in the hospital laboratory. the sphb pulse co-oximeter Ò was calibrated and the mean of three non-invasive measurements of haemoglobin were recorded prior to venipuncture. bland-altman plots were used to determine acceptability of the new non-invasive test as a replacement for invasive testing in a clinical setting. the mean gestation at haemoglobin estimation was . ( . ) weeks. laboratory haemoglobin values ranged from . to . g/dl with a mean of . ( . ) g/dl. the range for the sphb pulse co-oximeter Ò assessment was . to . g/dl with a mean of . ( . ) g/dl. non-invasive haemoglobin measurement provides a clinically acceptable accuracy compared to traditional haemoglobin testing. pressure wound therapy (npwt). in this review we examine the role of npwt in wound healing, compare the products available to clinicians in irish hospitals and explore cost implications today. we achieved this through review of online data, peer reviewed articles regarding efficacy, collection and assessment of data from suppliers of npwt and examining the use and cost of npwt in the mater misericordiae university hospital. we summarise the mechanism of action of npwt, patient selection and indications for its use. the products available on the irish market are compared. through examination of these elements we clarify a role of npwt in management of complex wounds and identify flaws in the management of this service that are both wasteful of money and hospital services and create barriers to discharge. potential strategies to correct the issues identified are detailed, for example, funding of the product by the treating hospital rather than by local authorities in the community or selection of less costly devices in negotiation with suppliers by local health authorities. the solutions we outline will potentially have a financial benefit to the hospital, will lead to the more efficacious running of the hospital system and as such will benefit the patient. we conclude that this is a fundamental service and that there are alternative approaches to implementing use of the product in a more efficacious manner. poster q fever: questions to be answered? brandon l, bannon c, fleming c department of infectious diseases, university hospital galway q fever, an aptly named condition, describes infection with gramnegative bacteria coxiella burnetti. q denotes a question, and there are many to be answered in this rare, but not unknown, condition. take mr. m.c, a -year-old farm worker, who had an aortic valve replacement in , for congenital aortic valvular disease. he next presented to medical services in , with fevers, sweats, fatigue and weight loss. investigations at the time diagnosed autoimmune hepatitis, following liver biopsy. he commenced prednisolone and azathioprine. in , again symptomatic, he had another aortic valve replacement. post-operatively, he required weeks of antibiotics for a culture negative valvular infection. in , still on immunosuppression, he developed culture negative meningitis, requiring weeks of antibiotics. azathioprine was discontinued. a renal biopsy revealed proliferative glomerular nephritis in , carried out for macroscopic haematuria. he commenced high dose prednisolone and cyclophosphamide. throughout this time, he regularly presented to medical personnel with high fevers, up to c, present since . they responded to steroids but relapsed on doses below mg. in , the fevers were investigated with a toe, and vegetations seen on the aortic graft. he was diagnosed with culture negative bacterial endocarditis, and subsequently tested positive for q fever. this case highlights the q behind q fever, and raises important issues for medical personnel. when should we remember it? when should we test for it? and what can we do to ensure high risk populations dont slip through the cracks, as this gentleman did? previous point prevalence studies of antimicrobial use in sch have consistently produced the same conclusions and recommendations pertaining to prescribing habits, highlighting doctors' failure to meet ideal standards of antimicrobial prescription. the aim of this study was to assess antimicrobial prescribing habits from the doctors' point of view, to compare this to available prescription data and to raise awareness of the principles of prudent antimicrobial prescribing. a multiple choice questionnaire was used to examine antimicrobial prescribing habits with regard to documentation of indication, documentation of a stop/review date, awareness of local empiric guidelines and other principles of prudent antimicrobial prescribing. trainee and consultant doctors were surveyed. of those questioned, % claimed they always ensure that an indication for commencing antimicrobial treatment is documented in the patient's healthcare record. only % always document a stop/ review date when prescribing antimicrobials, while % indicated that they had failed to do this at least once in the preceding month. % of those surveyed sometimes or never consult local guidelines. when switching patients from intravenous to oral therapy, % believed oral bioavailability to be an important factor, with only % citing cost as being relevant. identifying doctors self-reporting of their deficits allows us to target appropriate interventions to these deficits. our survey identifies areas where awareness of diverted resources and safety issues could be used as a fulcrum for changing prescribing practices. we recommend formal teaching for doctors in this area, with particular emphasis on prudent prescribing and the correct use of empiric guidelines. venous thromboembolism (vte) is a cause of inpatient morbidity and mortality which may be reduced by appropriate thromboprophylaxis. it is well established that vte risk assessment and thromboprophylaxis prescribing may often be inadequate. recently it has been estimated that as many as , deaths per year due to hospital-acquired vte in england may have been prevented with appropriate prophylaxis [ ] . in the current study, a cross section of inpatients was examined to establish concordance with current evidence-based guidelines for vte prophylaxis. data was collected from inpatient charts and drug kardexes relating to patients on three medical wards. laboratory data was also obtained from the hospital it system. data relating to patient mobility was obtained from medical charts, nursing staff, observation, and the patient themselves. sixty-three medical patients and surgical patients (including one patient under obstetrics and gynaecology) were included in the study. ( . %) out of at-risk medical patients who were suitable candidates for thromboprophylaxis had sub-cutaneous heparin prescribed, whereas out of of the suitable at-risk surgical patients were prescribed thromboprophylaxis. medical patients ( . %) and surgical patients ( %) were prescribed anti-embolism compression stockings. prescribing of thromboprophylaxis is relatively thorough in this patient population although it remains less than optimal. there exists some evidence of disagreement amongst clinicians regarding the optimum vte prophylaxis strategy [ ] . implementation of hospitalspecific guidelines regarding thromboprophylaxis is recommended in keeping with recognised guidelines [ ] . ali sheikh a, chandra r, gardezi a, o'hare j mid-western regional hospital, limerick background: good documentation represents good medical practice. objectives: to assess our current standard of documentation of allergy in admission notes, synchronicity with risk alert bands, information given by the patient, documentation on the front allergy alert section of medical notes and drug kardex. methodology: we assessed five parameters i.e. drug kardex, alert band, medical and admission notes and gathered information from each patient staying in medical and surgical services. there were patients in hospital. results: % of the patients admitted under medical and surgical teams had allergy or allergies to different drugs. % had single allergy, whereas % had multiple allergies. penicillin allergy was the commonest . % followed by opioids . %. furthermore, it is found that recording of allergies was under par as % was on front page and % appeared in medical notes. more than half of allergy information was found on drug kardex %, patient knowledge % and allergy bands %. it is well documented that use of elastic compression stockings (ecs) prevents post thrombotic syndrome in patients with prior deep venous thrombosis (dvt). a % reduction in these complications has been noted, with year duration of therapy suggested [ ] . the advice given to patients, their understanding of the benefits of this therapy and adherence issues has not been documented at sligo general hospital (sgh), this research aimed to address this. a short patient questionnaire was undertaken. this consisted of demographic information, and questions regarding the advice and use of ecs. the population consisted of patients with prior dvt attending the warfarin clinic at sgh. this data collection took place from october -february . the questionnaires were collated and results identified using microsoft excel with simple statistical analysis. eleven patients were included in the study, % were not advised to wear ecs, and only % wore the ecs daily. reasons for nonadherence include; difficulty fitting, discomfort and no benefit noted. improvement in adherence could be achieved if advice was given promoting use, the benefits explained, optimal frequency/duration of use advised and correct measurement. as research strongly supports use of ecs, it is essential adherence is encouraged to reduce the risk of post-thrombotic syndrome and future dvt. opiate injecting drug use is a well-established phenomenon in inner city dublin. the complications arising from this practice affect a predominantly young cohort of patients, who under different circumstances would be expected to enjoy good health. acute infections, acute vascular issues such as pseudoaneurysm, and chronic medical conditions such as hepatitis c and hiv are well recognised and frequently encountered by medical physicians who care for these patients. we present the case of a lady in her thirties with a long history of opiate injecting drug use. approximately months prior to presentation, she underwent left sided pseudoaneurysm repair. she presented to the emergency department in a drowsy opiate induced state. on waking, she stated that she had lost some needles while injecting into her groins. plain radiology of pelvis revealed the two ''lost'' needles ( fig. ) . on closer questioning she admitted to significant manipulation of the needle injecting path and angle in the weeks prior to presentation. she had attributed this to her previous surgery and the duration of her injecting drug use. follow-up duplex sonography revealed bilateral intact femoral arteries. further surgical management was non-operative with the focus on addiction counselling and further attempts at facilitating cessation of heroin use. bilateral ''lost'' needles is an unusual complication of injecting drug use and certainly would not rank as one of the protean manifestations of such practices. the aim of the study was to investigate patients' recall of their surgery and influencing factors. a questionnaire was given to patients at outpatient follow up and surgical details were recorded. patients completed the questionnaire. the median age was years (range - ) and the median follow up was months (range - ). the extent of surgery did influence patients' recall with those having an alnd (n = , %) having significantly more accurate recall of their surgery as opposed to those who had slnb (n = , %), p = . . the presence of ongoing postoperative symptoms also significantly improved recall, p = . . almost half the patients who had slnb ( . %) could not accurately remember the extent of the surgery they had but . % were more careful of their arm or would not allow cannulation. the patient's consent process influenced patient accuracy. patients who filled the consent at both the outpatient consultation and in the hospital were significantly more accurate than those who had signed the consent at the clinic or hospital alone, p = . . patients who have minimally invasive surgery, such as slnb are not accurate at recalling their surgery. this misinformation results in confusion over the subsequent vigilance of their upper limb. the consent process may have a role in improving patient recall. introduction: waiting times can exceed days for general surgical clinics and can reach up to months in different surgical specialities. many outpatient slots are lost by patients who do not attend (dna) to their scheduled appointment. we sought to ascertain whether a reminder text message (rtm) could decrease the number of patients who dna to surgical outpatients. methods: a single text message was sent to patients days before their scheduled appointment, reminding them of the date and time of their upcoming surgical outpatient visit. this incentive was initiated in january . outpatient appointment scheduling and attendances for a single surgical team were analysed over a year period, encompassing two month periods before and after implementation of the rtm service. data was exported to spss v for statistical analysis with p \ . considered statistically significant. results: over the month period there were , scheduled outpatient appointments for the surgical service, with attending prior to the implementation of the reminder text message service and the remaining attending in the months following its implementation. the percentage of dna patients did not differ significantly ( . classically, focussed assessment with sonography in trauma (fast) addresses a yes/no binary question as to whether fluid is present in the context of trauma. fast generally concentrates on four areas: perihepatic, peri-splenic, pelvic and a sub-xiphoid view of the pericardium. we report on two patients who were the victims of trauma. both patients had normal haemodynamic parameters. in both patients, the initial fast ultrasound scan was technically negative but it exhibited other signs of intraperitoneal injury. in the first case, a young gentleman sustained a penetrating injury to his right upper quadrant area. morison's pouch (the interface between the liver and the right kidney) did not exhibit any fluid. there was, however, a thin anechoic strip around the gallbladder. ct confirmed the suspicion of peri-cholecystic fluid and this patient required urgent laparotomy and repair of his hepatobiliary injury. in the second case, a gentleman in his thirties sustained a blunt injury to his left upper quadrant. ultrasonography exhibited heterogeneous echogenicity of the spleen. this patient proceeded to have urgent laparotomy and splenectomy for this shatter-type injury. as experience with fast techniques grows, the binary question of whether intra-peritoneal fluid is present becomes more nuanced. the objective of this audit was to review the hospitals compliance with hospital guidelines, to get an overview of how fluids are being prescribed in the hospital and to produce quality improvement plans. thirty drug kardexs were chosen randomly from wards around the hospital, both medical and surgical. if a kardex was found to have no fluid prescription, an alternative kardex was chosen in its place. note was taken on whether the prescription had the patient name and hospital number, the date, name, dosage and strength of the prescription, the route of administration and the frequency and rate of administration. the main areas of non-compliance were found to be: name: only ( . %)orders out of had the name on the order medical record number: only ( . %)orders out of had the mrn on the order, and the route of administration was not present on any of the orders checked. in conclusion, this audit would suggest that there is a lack of compliance with detailing the patients name and mrn on fluid orders, that the route of administration was not written on any kardex, however the back page of each is exclusively dedicated to iv fluid prescription and also that non-approved abbreviations are being used when prescribing fluid orders. spontaneous hip fractures, or fractures without a fall have been described in up to % ( , ) of cases of hip fracture. an upsurge in such cases was recently observed in our emergency department. we present these in the form of a retrospective case series. patient is a -year-old ex intravenous drug user who presented with non-traumatic right-sided hip pain over a period of weeks. initial plain films did not reveal fracture. over week her symptoms deteriorated to the extent that she became unable to weight-bear. patient is a -year-old gentleman with increasing left sided hip pain following a seemingly innocuous fall months prior to index presentation. again initial radiographs did not reveal an abnormality. patient is an -year-old bed-bound nursing home resident with end-stage alzheimer's disease. she was noted by nursing staff to have bilateral hip symptoms post seizure. the patient was unable to mobilise independently and had not fallen out of bed at any stage. patient is a -year-old lady who presented with unilateral sacroiliac pain following a recent intensive exercise program including kickboxing week previously. in each of these cases, subsequent review and plain films demonstrated fracture and in one case bilateral fractures secondary to seizure were demonstrated. our cases highlight the need for diagnostic vigilance and a structured approach in dealing with possible radiologically occult hip fractures, even in patients with no proximate antecedent history of trauma. delerium, or acute confusional state, is a common presentation to our emergency departments, and occurs in up to % of hospitalised patients. we describe the case of acute deterioration in mental status, on a background of alzheimer's disease, with an interesting aetiology. mr k's family sought emergency medical review of days deterioration; withdrawal, somnolence and general disorientation. he is a -year old with moderate alzheimer's disease. history and initial investigations were unremarkable. he was mildly dehydrated and physical exam showed only mild truncal ataxia. further investigations to elucidate cause included lumbar puncture, mri brain and immunological and vasculitic parameters. serology revealed human immunodeficiency virus (hiv) infection with acute seroconversion pattern. a history obtained with help of his family identified several casual heterosexual partners within past year. this included a contact who may be an intravenous drug user, with involvement in commercial sex work. symptoms abated within a week of admission, following pattern of hiv viral load. he has subsequently commenced antiretroviral therapy. this case highlights several areas of interest. sexual history is often overlooked in the older patient, which can be deleterious to outcomes. trends of hiv infection in ireland include primary infection in the older person, in addition to greater longevity of people infected in earlier adult life. we would advocate opt-out testing within the emergency department, and this is currently under study in our tertiary emergency department. comparison of comorbidities in patients with pre-diabetes to those with diabetes mellitus type the management of type diabetes and its complications are well researched. the prevalence of these complications in pre-diabetes has not been researched to the same extent. there has been no research comparing the prevalence of complications in pre-diabetes and type diabetes in ireland. a cross sectional study performed on pre-diabetes and type diabetes patients, selected from the diabetes interest group database (a database of the diabetic patients in general practices in cork region) using stratified sampling for age and gender. a questionnaire was designed and completed in each practice assessing the presence of diabetes related complications in pre-diabetes and type diabetes patients. data was analyzed on spss. the prevalence of complications was determined and the chi square test performed to see is there a statistically significant difference in the prevalence of these complications between pre-diabetic and type diabetic patients. the prevalence of ischaemic heart disease and autonomic neuropathy is actually higher in pre-diabetes but the prevalence of renal disease and cerebrovascular disease is higher in type diabetes. none of these differences in prevalence are statistically significant. the prevalence of peripheral vascular disease, eye disease and peripheral neuropathy is higher in type diabetes, this difference being statistically significant. the prevalence of many of the complications in pre-diabetes is as high as in type diabetes which may have implications for the screening and management of these conditions and the related comorbidities. the both groups were evenly matched. the median age was and median homocysteine level was (range - . ). results: in group b, immediate clinical improvement was equivalent between the normal homocysteine group and treated hyhc group. median time to binary restenosis in hyhc was months and in normal homocysteine was months. p = . . secondary endpoints and all cause survival showed no significant difference. pre-treatment multivariate logistic regression for group a; depicts that hyhc is the main culprit of graft occlusion and limb loss p \ . . multivariate logistic regression for treatment group reports that corrected hyhc is no longer a significant factor of operative outcome. conclusion: patients with treated hyhc have similar outcomes compared to those with normal homocysteine. it is therefore crucial to measure homocysteine in all patients with cli and correct aggressively prior to intervention to improve outcomes. the efficacy of clinical guidelines in promoting co-prescription of bone protection with glucocorticoids among hospital doctors treating inpatients background: therapeutic glucocorticoids (gc) rapidly decrease bone mineral density, inducing a catabolic shift by promoting osteoclast differentiation and activation and by inhibiting osteocytes. current guidelines ( ) direct that bisphosphonates (bp's) and calcium carbonate , mg (ca ++ co -) with vitamin d (vit. d ) should be given at initiation of gc therapy as it is known that bone catabolism occurs early with steroid usage. we circulated these guidelines within our hospital after auditing the existing practice of the hospitals doctors and year later we sought to measure the efficacy of our intervention by completing an audit loop. methods: a cross sectional audit was performed of all adult medical and surgical inpatients in a tertiary referral centre teaching hospital. it was noted if inpatients had been prescribed gc and if concurrent anti osteoporotic medication had been prescribed. subsequent to the initial audit, guidelines promoting the use of bp's, ca ++ co and vit. d when prescribing gc's were advertised on hospital notice boards, in hospital bulletins, hospital prescribing guidelines and on the hospital website. one year after publishing the new guidelines the audit loop was completed by performing a similar cross sectional audit. results: all inpatient medical records (n = ) were reviewed in jan of whom % were female and % were older than . / ( %) inpatients were prescribed gc's. ca ++ co with vit. d was prescribed for % of patients on gc's with % also receiving bp therapy. % of patients were also receiving-post menopausal hormone replacement therapy. in nov year after guideline publication all inpatient medical records (n = ) were reviewed of whom % were female and % were older than . / ( %) inpatients were prescribed gc's. ca ++ co with vit. d was prescribed for % of patients on systemic steroids with % also receiving bp therapy. creation and circulation of hospital guidelines resulted in an improvement in the co-prescription of ca ++ co and vit. d and bp's with gc's by the order of . and respectively. however % of patients on systemic steroids received no bone protection and % received suboptimal bone protection from steroid induced osteoporosis. conclusion: publication and advertisement of current bone protection guidelines when prescribing systemic steroids resulted in a substantial but suboptimal improvement by hospital doctors in our hospital in the co-prescription of bone protecting drugs to prevent steroid induced osteoporosis. in this audit it appears that the majority of prescribers do recognise the necessity to protect bone health when a patient requires steroids. however a substantial number of patients did not receive any bone protection. it is our perception that most physicians are not aware that short courses of steroids reduce bone mineral density and therefore greater efforts must be made to enhance doctor awareness of the necessity for bone protection to be prescribed at initiation of systemic steroids. there is a trend towards longer total survival for jetflow tcvcs. these results suggest a potential advantage from using this line type, however, further study and formal cost analysis needs to be undertaken prior to changing our practice. with increasing resource restrictions, appropriate ordering of blood tests is vital for medical economic viability. this study evaluated the pattern and cost of thyroid function test (tft) requests and aimed to determine if tsh alone identifies thyroid abnormalities. a retrospective review of tfts performed on in-and-out-patients at a -bedded regional hospital was undertaken in january , evaluating the number, results and costs of tsh, t and t levels. tsh, t and t were ordered. / patients ( . %) were euthyroid. tsh abnormalities occurred in / ( . %) ( table ) only / ( . %) patients had a normal tsh despite an abnormal t or t level. / ( . %) of these patients had known thyroid disease, undergoing treatment with thyroxine or thyroidblocking medications. / ( . %) had t levels \ nmol/l outside the normal range and asymptomatic so were considered to be euthyroid. / ( . %) had a variety of diagnoses, for example, pituitary disease. tft reagents alone cost € , . ir j med sci ( ) (suppl ):s -s this study has identified that non-selective requests for t and t add little diagnostic value, except in certain circumstances like treatment of thyroid disease, in pregnancy or if pituitary disease is suspected. optimising tfts requests could save in the region of € , /per annum. tsh alone would appear to be adequate for the majority of patients. case study: neurodegenerative disorders we present a case with an unusual combination of neurodegenerative disorders. a fit and healthy -year-old man, with no history of medical or psychiatric illness deteriorated progressively over a year span, presenting initially with speech and language difficulties, followed by development of extra-pyramidal signs non responsive to levodopa. neurological permacol Ò mesh is an acellular porcine-derived dermal collagen surgical implant used in a wide variety of surgical reconstructions and repairs. we describe two cases where permacol Ò mesh was used to anchor the contents of the femoral triangle in patients undergoing radical block nodal dissection as part of the surgical management for metastatic penile squamous cell carcinoma, one of whom had an atrophied sartorius muscle due to previous infection with poliomyelitis. both patients underwent successful inguinal node dissections and femoral triangle repairs, with permacol Ò proving to be an effective means of protecting the femoral vessels in both patients despite complications related to wound healing secondary to a fixed flexion deformity in one patient. a -year-old gentleman, with a past history of vestibular schwannoma requiring a ventriculoperitoneal shunt (vps) was admitted with acute diverticulitis. his condition worsened and required a laparotomy for bowel perforation and faecal peritonitis. this case reports the successful perioperative management of the patient with a vps in situ in the setting of an emergency abdominal surgery. vps placement is an effective treatment of hydrocephalus, diverting cerebrospinal fluid (csf) into the peritoneal cavity. unfortunately, the shunt devices have a high incidence of malfunction mainly due to catheter obstruction or infection and are associated with various complications, % of which are abdominal [ ] . incidental pathology unrelated to the vp shunt can also occur such as appendicitis [ ] , endometriosis [ ] and diverticulitis as in this case. no standard current set of guidelines for perioperative management of vps exists for patients undergoing general gastrointestinal or urologic procedures with varying degrees of contamination [ ] . this case reports successful and conservative management of a patient with a vp shunt that underwent contaminated abdominal surgery. there is no consensus on the management of vps in patients undergoing elective or emergent abdominal surgery and further studies are required in this area. the use of antithrombotic therapy on management of atrial fibrillation in an irish general practice malomo k , breen n , dunne l , farrell g , bryne p ucd (university college dublin), ireland, now intern, mid-western regional hospital, limerick; general practice, dublin, ireland; pottersway medical centre, bunclody, ireland background and objective: atrial fibrillation (af) is a common cardiac arrhythmia associated with increased risk of stroke events [ ] . to assess the use of antithrombotic therapy in patients with known af attending an irish general practice (igp) and use of stratification schemes to assess their suitability for oral anticoagulant therapy. methods and subject: permission to carry out the study was sort from university-college-dublin ethics committee. there were patients with af attending the igp identified using the computerized disease coding system who international classification of disease (icd- ). thirty patients were diagnosed between / / and / / and their data from the computerized medical notes was used to calculate chads , cha ds -vasc, has-bled scores and identify antithrombotic therapy they were using. results: there were af patients. sixty-three percent (n = ) were males and % (n = ) were females (ratio . : ). twentythree percent (n = ) of patients were aged \ years, % (n = ) - years inclusive and % (n = ) =/[ years. two patients with chads score zero were on warfarin although one of them had cha ds vasc score of one. sixty-percent (n = ) were on warfarin alone, % (n = ) aspirin alone, % (n = ) warfarin plus aspirin, % (n = ) aspirin plus clopidogrel and % (n = ) on warfarin plus clopidogrel. seven patients were not on warfarin for various reasons. the has-bled score revealed patients at low risk, moderate risk and at high risk of bleeding. implications: ninety-three percent of patients were correctly managed and two patients were on warfarin with chads scores of zero. the use of evidence based management guidelines is necessary to manage patients. keywords: atrial fibrillation, chads score, cha ds vasc score, has-bled score meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. only % of meckel's diverticulum are symptomatic [ ] . it can cause complications such as ulceration, obstruction, intussusception, haemorrhage and perforation and these complications are more common in the paediatric age group. a -year-old has a lifetime risk of . of developing a complication, this falls to zero over time [ ] . adults most commonly present with bleeding [ ] . we have a case of a -year-old male who presented with a day history of abdominal pain, constipation and anorexia. on examination he had rif tenderness, but no signs of peritonism. a provisional diagnosis of appendicitis was made. the patient was taken to theatre the next morning for laparoscopy and appendicectomy. the appendix was normal and surgery proceeded to laparotomy. an inflamed and perforated meckel's diverticulum was found. a terminal ileum resection with side to side anastomosis was performed. the patient made an uneventful recovery and was discharged to opd follow up. this case illustrates the importance of further evaluation following normal laparoscopy in the case of the ill patient. references: neonatal graves disease is a rare condition, caused by transplacental transfer of thyroid stimulating antibodies from mother to fetus. . % of pregnant women have graves disease and . % of their offspring will have overt hyperthyroidism. a further % will have biochemical thyrotoxicosis without symptoms. this is the case of a baby girl with neonatal graves disease. her antenatal course was uncomplicated until weeks gestation. at this point, her mother became clinically thyrotoxic. maternal blood tests showed an elevated free thyroxine level ( pmol/l) and positive thyroid receptor antibodies. a diagnosis of graves disease was made. she was commenced on treatment but remained thyrotoxic at the time of delivery. the baby was healthy at birth. however, thyroid function tests on day of life showed an elevated free thyroxine ( pmol/l) and thyroid receptor antibodies were positive. clinically, she remained asymptomatic and examination was normal. treatment with carbimazole was commenced and the dose titrated to maintain her euthyroid. most neonates affected by neonatal graves disease will have biochemical thyrotoxicosis but are clinically asymptomatic. the minority will be severely affected with goitre, eye signs, weight loss, tachycardia, arrhythmias and heart failure. it is a transient disorder, limited by clearance of maternal thyroid receptor antibodies and is usually self-limiting over - weeks. mortality rates of up to % are reported in untreated cases, usually from arrhythmias and heart failure. this case emphasises the importance of close monitoring of pregnant women with a history of thyroid disorders, before and during their pregnancy, as well as monitoring their babies in the neonatal period. fibreoptic bronchoscopy is considered a safe diagnostic tool [ ] . it is suggested however that post-bronchoscopy complication rate increases with age [ ] . we decided to study the complication rate and the outcomes of bronchoscopy in patients over the age of years in our institution. a retrospective review of the case notes of patients aged greater than years who underwent bronchoscopy between september and november was carried out. data on complications experienced during and after bronchoscopy and the influence of the results on subsequent management of patients were collated and analysed. ninety-six patients were included. the mean age was . years (sd . ). thirty subjects ( . %) had a documented lung disease. fifty-nine patients ( . %) were current or ex-smokers. indications for bronchoscopy were; to evaluate for malignancy ( . %) and to evaluate for tb ( . %). post bronchoscopy complications were noted in eight ( . %) cases including hypoxia ( . %), infection ( . %), tachycardia ( %) haemoptysis ( %) and pneumothorax ( %). six patients required treatment including nebulised bronchodilators ( . %), antibiotics ( . %), and oxygen therapy ( . %). malignancy was diagnosed in twenty cases ( . %). clinically significant pathogens were detected in six cases ( . %). as a result of bronchoscopy fourteen patients ( . %) had alterations to their drug therapy, three ( . %) received lung cancer treatment with curative intent, eighteen ( . %) had palliative care input, seventeen ( . %) were referred for further investigation and thirty-seven ( . %) had no change to their management. in conclusion, bronchoscopy is relatively safe and has good diagnostic utility in patients aged more than years. patient records were identified from a database of patients who underwent a spinal mri to investigate spinal metastatic disease between november and april . an analysis of the management of those diagnosed with mscc, specifically radiotherapy and/or surgical intervention was performed. three hundred and sixtyone patient records were identified with one hundred and seventy-one patients having metastatic spinal column disease. of these, thirty-four had mri evidence of metastatic spinal cord compression. radiotherapy alone was the most common therapy employed for patients with mscc. a multidisciplinary team approach was not taken in the majority of cases. a surgical opinion was sought in the minority of cases. this is not congruous with nice guidelines as a management protocol. the complexity of management decisions for metastatic spinal cord compression demands a multi-disciplinary approach. current practise in this major supra-regional cancer centre does not routinely employ this approach. a surgical opinion is sought in the minority of cases. this reflects the national trend with some centres having no spinal surgeons as staff. we recommend the establishment of a care pathway in order to comply with best evidence based practise as outlined by the nice guidelines. pet ct as a staging modality in primary cervical cancer; to establish the correlation between histological subtype and fdg- avidity of the primary lesion purpose: pet ct has become one of the mainstays of diagnostic imaging both in staging and prognosis of cervical cancer. we wanted to establish the link between fdg- uptake in the primary lesion and correlation with specific histological subtypes of cervical cancer including squamous cell carcinoma, adenocarcinoma and other rarer subtypes such as clear cell and adeno-squamous carcinoma. methods and materials: the main audit involved working out the fdg uptake in the primary lesions from the cervical cancer database of patients. the patient list was derived from a database of patients collated by the gynaecological services at sjh of all patients who received workup and treatment for cervical cancer from - . the computer system at sjh was employed for analysing pet-ct reports and histology reports. microsoft excel was used to store this information parameters and complete statistics on the data. results: the results of this study are to follow. conclusion: there is a correlation between fdg avidity and histological subtype of cervical cancer and this provides valuable information on the reliability of pet-ct findings in a specific cohort of patients with cervical cancer. we present the case of a -year-old male with a primary piriform fossa squamous cell carcinoma (scc) who attended for staging positron emission tomography/computerised tomography (pet/ ct) scan. distant to the primary lesion, focused f fluorodeoxyglucose (fdg) uptake was noted in the left iliac bone, without underlying abnormality on the accompanying ct scan. low grade uptake was also noted in subcentimetre upper mediastinal nodes, without any underlying lung parenchymal abnormality. these nodes were felt to be inflammatory or reactive in origin. though an unusual pattern for metastatic head and neck scc, the left iliac bone lesion was concerning for malignancy. thus, a percutaneous biopsy of this region was performed under image guidance. histology revealed non caseating epithelioid granulomata consistent with sarcoidosis. the patient was subsequently able to have potentially curative treatment of his head and neck primary. discussion: sarcoidosis is a chronic inflammatory multisystem condition characterised by the presence of non-caseating granulomas in affected organ tissues. it commonly affects young and middle aged adults with a slightly higher prevalence in women. the disease shows a predilection for adults under , peaking between and , with a second peak in women over [ ] . despite its unknown aetiology, it is felt that t lymphocytes play a central role in the development of sarcoidosis, as they likely propagate an excessive cellular immune reaction. it has been shown that abnormalities with the cd /cd ratio and production of t helper and (th /th ) cytokines such as interferon and tumour necrosis factor (tnf) are found in sites of disease activity [ ] . the importance of tnf in sarcoidosis is demonstrated by the efficacy of anti-tnf medications such as pentoxifylline and infliximab [ ] . it is estimated that bone lesions occur in - % of sarcoidosis patients [ ] . these figures are however based on radiographic data and are likely an underestimate as the majority of bone lesions would be asymptomatic [ ] . varying osseous manifestations of sarcoid have been described; punched out lytic lesions, lace-like destruction and subperiosteal resorption mimicking hyperparathyroidism. commonly, the small bones of the hands and feet (predominantly the middle and distal phalanges) are involved often bilaterally and symmetrically. while pulmonary involvement occurs in % of patients with sarcoidosis [ ] , bony involvement is rare without other clinical manifestations of the disorder [ ] . indeed our patient had low grade subcentimetre mediastinal nodes. the fdg avidity of sarcoid is a well documented phenomenon. indistinguishable from metastatic disease on f fdg pet scan alone it can lead to false-positive appearance of metastatic disease on pet/ ct. furthermore one-third of pet/ct positive sarcoidosis have osseous abnormalities on pet/ct the majority of which will not be evident on low dose ct [ ] . this case serves to remind us of the diagnostic limitations of f fdg pet in the differentiation of inflammatory and metastatic processes. in a patient with an unusual pattern of 'metastatic' disease tissue diagnosis is a necessity. distinct islet auto antibodies against antigens insulin, gad , ia and znt have been identified. the presence of autoantibodies has been shown to be predictive of reduced beta cell mass. international data suggests that - % of patients with newly diagnosed t dm are positive for at least one of the above antibodies. our aim is to study the prevalence of autoantibody positivity in our population of children with newly diagnosed t dm over a year period ( ) ( ) ( ) ( ) ( ) . details of all children newly diagnosed with t dm were collected using the endocrinology department database and chart review was undertaken. children diagnosed elsewhere whose care was transferred to our centre and children who had non type diabetes were excluded. one hundred and thirty-six children were diagnosed with t dm in our centre, of which ( %) presented in diabetic ketoacidosis. age at diagnosis ranged between months and . years. the male to female ratio was : . other autoimmune conditions (coeliac disease, hypothyroidism, addison's) were present in %. ninety-six percent (n = ) were tested for one of the three antibodies. % were positive for at least one antibody, % positive for two, % positive for all three antibodies. the most common antibody found was anti gad ( %). positive autoantibodies are helpful in confirming the presence of t dm and their absence in raising the possibility of monogenic diabetes. the absence of pancreatic islet autoantibodies at diagnosis can be predictive for maintained beta cell function during the years after diagnosis. maternal obesity, based on a body mass index (bmi)[ . kg/m , is associated with increased pregnancy complications. moderate exercise during pregnancy is associated with decreased complications such as pre-eclampsia [ ] and gestational diabetes mellitus [ ] and has a beneficial effect on mood with those who exercise experiencing fewer symptoms of depression and anxiety both during and after pregnancy [ ] . the purpose of this study was to determine if obese women exercise less during pregnancy. we recruited women at their convenience after a routine scan confirmed an early ongoing pregnancy. maternal height and weight were measured accurately and bmi calculated. women completed the international physical activity questionnaire. of the studied in early pregnancy, . % took no exercise, . % walked only, . % undertook moderate exercise and . % undertook vigorous exercise. of the obese women (n = ), only % reported moderate-vigorous exercise in early pregnancy compared with . % in women from the normal bmi category (n = ). also % of the obese group reported doing no exercise compared with % of those with a normal bmi. women with a bmi of or more were found to sit for an average of min per day whereas those with a normal bmi sit for min per day on average. although bmi increases with age and parity, these variables were not found to influence exercise levels in early pregnancy. exercise may be physically challenging in obese women, particularly if morbidly obese, but due to its beneficial effects it should be encouraged antenatally in all pregnant women irrespective of their bmi category. references: angiogram showed an absence of coronary artery disease and echocardiogram ruled out structural abnormality. exercise stress test showed short runs of vt in recovery. further tests included ajmaline and adrenaline challenges. cardiac mri showed right ventricular outflow tract scarring consistent with either a primary diagnosis of arvc or secondary with that of myocarditis. sarcoidosis was outruled by further laboratory and radiological means. non-sustained runs of vt on telemetry were noted and a dual chamber implantable cardiac defibrillator was placed. on discharge, medication included atenolol mg daily and patient will undergo genetic screening. follow up for the siblings included phenotyping and mri. discussion: history, presentation and pathology uncovered are consistent with a diagnosis of arvc. suspected paternal inheritance of an autosomal dominant genetic defect predisposed to the ventricular arrhythmias which at first, manifested as self-limiting palpitations however, later caused a near fatal event. long term management may include cardiac transplantation. prevalence of diagnosed atrial fibrillation in adults: national implications of rhythm management and stroke prevention: the anticoagulation and risk factors in atrial fibrillation (atria) study complications of fiberoptic bronchoscopy at a university hospital the relationship between age and process of care and patient tolerance of bronchoscopy central skeletal sarcoidosis mimicking metastatic disease sarcoidosis is a th /th multisystem disorder osseous sarcoidosis treated with tumour necrosis factor-inhibitors: case report and review of literature. spine (phila pa ) musculoskeletal manifestations of sarcoidosis multiple atypical bone involvement in sarcoidosis imaging in sarcoidosis. semin respir crit carre med f- fdg pet/ct for detecting bane and bone marrow involvement in sarcoidosis patients poster diaphragmatic rupture: delayed diagnosis and its consequences-a case report diaphragmatic rupture: a frequently missed injury in blunt thoracoabdominal trauma patients diaphragmatic rupture due to blunt trauma: sensitivity of plain chest radiographs the introduction: lymphoscintigraphy has been shown to be accurate in identifying sites of potential nodal metastases in melanoma patients. recent guidelines published by the eortc-eanm have defined specific criteria with relation to performing lymphoscintigraphy in melanoma patients. methods: the aim of this study was to audit all patients with malignant melanoma who underwent sentinel lymph node biopsy (slnbx) and lymphoscintigraphy in university college hospital galway between - . results were compared with eortc-eanm recommendations. results: melanoma patients underwent slnbx during the study period. patients had preoperative lymphoscintigraphy using intradermal injections of technetium m. sentinel nodes were identified in of patients ( . %) on lymphoscintigraphy. . % of lymphoscintigrams were reported on the same day as the procedure, . % after day and . % greater than day postop. obligatory imaging, as defined in the eortc-eanm guidelines, was obtained in % of all patients undergoing lymphoscintigraphy. no nodal uptake was reported in patients, of whom received imaging in accordance with the guidelines. the location of those melanomas with no nodal uptake was . % on the head and neck, and . % on the trunk. the overall rate of false-negative lymphatic mapping and sentinel node biopsy was . %. in patients receiving lymphoscintigraphy the false negative rate was . versus . % in patients who did not have lymphoscintigraphy. conclusion: preoperative lymphoscintigraphy is an essential adjunct in identifying the sentinel lymph node in clinically node negative melanoma patients and should adhere to eortc-eanm guidelines. conflict of interest: none. on examination, she was alert, hr , bp / . she was tachypnoeic, but reported this to be her baseline. there was a palpable, non-reducible mass in the left upper quadrant. a chest x-ray showed loops of bowel above the diaphragm. ultrasound showed an abscess in the rectus sheath, which drained mucopurulent fluid.mb opted not to have the diaphragm repaired, despite medical advice. she was readmitted weeks later with a recurrence of the abscess. her clinical condition deteriorated, with severe abdominal pain, and oxygen saturations of %. an emergency laparotomy was performed, which showed an obstructing lesion in the descending colon, with large and small bowel above the diaphragm. she had an extended right hemicolectomy, with restoration of bowel to the abdominal cavity and mesh repair of the diaphragm. histology showed an descending colon adenocarcinoma, t n m .traumatic diaphragmatic rupture is a rare problem, occurring in - % of blunt and penetrating traumas. ( ) plain films and ct scans are not always diagnostic in the acute phase, due to concomitant injuries. ( ) repair is essential once diagnosis has been reached to avoid herniation of abdominal viscera. patients with ongoing dyspnoea after blunt trauma may benefit from a repeat chest x-ray. a -year-old retired veterinary surgeon was referred to tertiary referral with a months history of a painless enlarging neck mass. clinical examination showed a right side neck mass approximately cm cm in size which extended through both anterior and posterior triangles. cervical lymphadenopathy was not appreciated and the patient was clinically euthyroid. patient was admitted under the care of the maxillofacial service, where he underwent a needle core biopsy of the neck mass. this was returned showing poorly differentiated spindle cell tumour with large pleomorphic nuclei and abundant abnormal mitoses. the immunoprofile was consistent with metastatic poorly differentiated sarcomatoid carcinoma and the differential diagnosis included origin fro the kidney, lung or thyroid.the case was discussed at the head and neck mdm and a consensus was reached that the patient as developed a sarcoma of the neck, with a level neck dissection the most appropriated intervention.intraoperatively, following the removal of the neck mass it was noted that the right lobe of the thyroid was enlarged. an intra-op fna was performed on the mass in the right lobe of the thyroid. the fna was returned showing bizarre giant cells, suggestive of malignancy. ultimately the patient underwent a total thyroidectomy but, despite surgery the patient died weeks post-operatively. using feedback from the pilot study and analysis of the preexamination consultant and registrar-led teaching schedule for students a further 'intern-led' tutorial timetable was structured. it allowed for a weekly maximum of h of teaching dependent on demand and intern availability. programme duration was weeks, january to march . group sizes were a maximum of students. tutorials were all at the patient bedside. feedback forms were distributed at the end of the programme.sixty-four tutorials were given in total. seventy feedback forms were returned. mean number of tutorials attended per student was . . students rated statements - ( -strongly disagree, -disagree, -neutral, -agree, -strongly agree). median scores were used. scoring showed improvements were made from last year in terms of level of intern preparation for tutorials and importantly, the students own subjective view of their level of preparation for forthcoming examinations. most importantly, students agreed that tutorials improved their history taking skills and strongly agreed that their examination skills improved. matching feedback from the pilot study, students strongly agreed that intern-led teaching is an appropriate adjunct to the final year programme.of the intern working in st james's hospital, participated. seventeen of these had received tutorials on the pilot programme. of the that did not participate, many had never received formal intern teaching.the feedback obtained from the pilot study was invaluable in organising and delivering this teaching programme. ongoing improvements will be made for next year based on this audit. this also highlights that the intern-teaching tool is extremely beneficial, yet largely underused. key: cord- -hvd jv authors: jimenez, e. j. title: emergency mass critical care date: - - journal: intensive and critical care medicine doi: . / - - - - _ sha: doc_id: cord_uid: hvd jv at any moment regular television programming could be interrupted with news of the emergence of a new strain of infective agent, a major industrial accident, or a terrorist event. many devastating events are widespread and naturally occurring, like hurricanes, in which we have ample warning time to enact preparation plans; while others, like earthquakes, volcanoes, or tsunamis may kill or injure thousands before the news reports hit the airwaves. industrial accidents and terrorist events are usually sudden and occur without any warning. any of these events may have a local or regional effect; some may even have a global impact [ ]. regardless of the cause, after such an event, large amounts of the populace will be seeking medical care, whether from their primary care providers, public health departments, or local hospitals. at any moment regular television programming could be interrupted with news of the emergence of a new strain of infective agent, a major industrial accident, or a terrorist event. many devastating events are widespread and naturally occurring, like hurricanes, in which we have ample warning time to enact preparation plans; while others, like earthquakes, volcanoes, or tsunamis may kill or injure thousands before the news reports hit the airwaves. industrial accidents and terrorist events are usually sudden and occur without any warning. any of these events may have a local or regional effect; some may even have a global impact [ ] . regardless of the cause, after such an event, large amounts of the populace will be seeking medical care, whether from their primary care providers, public health departments, or local hospitals. as healthcare professionals it is our duty to be prepared for any of the above, to be able to provide the best possible care to our communities. this requires an awareness of the vulnerabilities of one's region, as well as on-going global surveillance. development of a response plan is requisite for any hospital to have a significant expectation to be able to respond in a meaningful way to a sudden disaster that leaves large amounts of the population seeking emergency medical care. preparedness plans include performing hazard-vulnerability analysis (hva), coordinating of response plans with all potentially involved entities, reviewing results of routine drilling, and revising the plan based on results of practice. in order to prepare and plan accordingly for different possible scenarios that may overwhelm routine operations, it is essential to identify available resources, specifically people, materials, and physical locations -often referred to as; staff, stuff, and space [ ] . within this chapter we will focus our attention on the most important considerations for managing patient care within the hospital with an emphasis on critical care in response to a mass casualty incident (mci), as we plan to expect the unexpected. disaster preparedness medicine focuses on preparation, response, surge, administration of resources, and recovery from events that generate demands that overwhelm the local medical community's capacity to deliver care. emergency mass critical care (emcc) [ ] is defined as the organization of critical care delivery when presented with situations manifested by increased -and for the most part -unexpected demand or surge. this results in a shortage of specialized staff, medical equipment, supplies, and available patient care areas. this lack of resources could actually limit the number of patients that can be treated while maintaining accepted standard of care interventions. when faced with an overwhelming demand for care that far outstrips the resources, in order to increase the chances of survival for the largest number of patients, only essential processes may be maintained during an mci. historically, disaster preparedness has concentrated on the management of multiple trauma casualties, generated by accidents, weather events, civil disturbances, or armed conflicts [ , ] . in these situations, the most severely injured frequently die onscene, often before the arrival of first responders. those that initially survive and are able to be transferred to hospitals usually have nonlife-threatening injuries during the initial period. however, many of the survivors may have prolonged hospitalizations and require critical care services due to the development of severe sepsis, acute lung injury (ali), acute respiratory distress syndrome (ards) [ ] , or multiple organ dysfunction syndrome (mods) [ ] [ ] [ ] [ ] . this pattern forces us to realize that our disaster preparedness must include a focus on caring for the critically ill for a period of time well beyond the initial insult. critical care, in particular the provision of mechanical ventilation and hemodynamic support, becomes the mainstay of treatment when highly contagious or lethal biological agents are encountered, as in a pandemic influenza or a biological terrorist attack. it is also crucial when dealing with severe, life-threatening exposures to chemicals [ ] or radiological agents that result in acute respiratory compromise and other severe organ dysfunctions. in most instances, the ability to expand critical care capacity at any given time is limited. hospital critical care units are often fully occupied, or do not have enough staff to be at capacity, whether due to shortage or economic strategy. for this reason, when presented with an unexpected, large-volume surge in demand, the hospital census, and in particular lack of available critical care beds, can become a limiting factor for survival [ , ] . it is important to keep in mind that in these situations, the duration of surge demands on emergency departments may be several hours, while the critical care support required may last from days to weeks after the initial incident [ ] . throughout the world, public health departments and civil defense, antiterrorist, and military agencies have developed scenarios that focus on predicting the potential numbers of casualties. the usa's center for disease control (cdc) has made software available for public access [ ] (e.g., flu surge) that can help estimate the potential surge of different patients geographically. the majority of plausible events result in overwhelming numbers of critically ill patients who without critical care available to them will not survive [ ] . hospitals should have a pre-established organizational structure to be activated in emergency situations. in the usa and many other areas of the world, the hospital incident command system (hics) [ ] , initially developed in california, has been used for this purpose (see fig. . ). planning and drills must contemplate a wide range of situations, with different degrees of social and institutional disruption. basic plans should include response to an isolated or local event with an intact support infrastructure. complex planning should anticipate response to a widespread disaster with loss of institutional and commercial facilities in an entire community or region. it is important to specifically determine anticipated needs and plans when large-scale events often disrupt access to external supply lines for both the hospital and the entire community. geographical, social, economic, and political factors are essential considerations when defining the risks for a given location. completing an hva tool, like the one suggested by kaiser permanente [ ] or by the joint commission of the united states [ ] , can be useful in defining priorities. the hva tool considers three major areas: probability, risk (or impact), and preparedness, and is presented in appendix . the hva should be based on an "all hazards approach," establishing an initial list of all possible disasters, regardless of their likelihood, geographic impact, or potential outcome. this list can be divided into typical categories that include natural, technological, and human events. the list will later be prioritized, taking into consideration the probability of occurrence, overall impact, current level of preparedness, and time requirements. the probability of occurrence can be derived from historical records, statistics, and expert opinions. the impact of various events should also be evaluated as many can be ameliorated by sufficient back-up systems, i.e., generators for the loss of electrical power. some communities have specific seasonal disasters like hurricanes, tornadoes, floods, or wildfires. the dependence on technology and continued integrity of supply lines must be considered as well. the tool uses the qualitative terms of high, medium, low, or no probability of occurrence. the potential risk or impact must be analyzed to include a variety of factors, listed as follows in order of importance: • threat to human life • threat to health and safety • property damage • systems failure • economic loss • loss of community trust/goodwill • legal ramifications the hva tool gives the highest score individually to the threat to human life, followed by the threat to health and safety. the remaining elements from the table: property damage, systems failure, economic loss, loss of community trust, and legal ramifications are all considered together when determining the level of risk. an organization's preparedness plan(s) developed to manage any given disaster should also involve the input of community agencies, as healthcare facilities will not be responding to an emergency by themselves. the coordination with the local emergency medical system and other hospitals is necessary, as planning for patient disposition should be determined before any event occurs. police and fire departments are also very important, as security may need to be augmented. all plans need to be tested and studied in order to detect potential flaws. in the usa, the joint commission [ ] requires for accreditation a minimum of drills per year, two of them as tabletop exercises and the others with full simulation of casualties and hospital flows. once the hva tool is completed, the factors are multiplied to give an overall total score for each hazard. i.e., a hazard with no probability of occurrence for a given organization is scored as zero, and will automatically result in a zero for the total score. this tool may help in a more objective prioritization of preparedness planning. when preparing plans derived from the hva keep in mind that there is no perfect plan to address every potential threat and all plans will need to be developed with a degree of flexibility to adjust, while still preserving a core structure. also, there may be significant social issues affecting staffing as healthcare workers (hcws) and support staff may not be able to come to work due to: community compromise, lack of transportation, illness of dependents or self, fear, closed schools, lack of basic utilities or food; they have essentially gone into a "family survival" mode. planning should also address how to support the hcws to facilitate them coming to work and also having their basic needs met. it is of utmost importance to develop an emcc committee at your hospital, with representatives from all departments that will be involved in the response. the initial task of this committee is to complete an evaluation, with a "staff, stuff, and space" approach. detailed inventories of equipment and their functional state, supply levels and their distribution should be completed and reviewed carefully. hospitals should plan to maintain enough supplies and foodstuffs to be able to function for at least days without any deliveries, to be prepared for an adequate response to a large-scale event that disrupts usual supply routes or community infrastructure. coordination with external agencies may provide assistance in an organized regional response with better resource utilization, back-up systems, and "shared" costs when building inventories of equipment and supplies. with the input of building engineers, floor plans should be analyzed to identify areas that could be potentially converted to intensive care unit (icu) wards, or isolation wards with improvised seals to generate negative pressure areas, via portable units or by reversal of ventilation systems. personnel contact information and rosters should be maintained and updated regularly to ensure current contact information is available. creative planning may include provision for child care or temporary schooling if there is discontinuation of community services (i.e., closed schools), to enable hcws to work and have their basic needs met. the following is a summary of recommendations for preparing a disaster preparedness plan and delivery of emcc, based on the most recent publications from the american college of chest physicians task force [ ] and the fundamentals of disaster management (fdm) [ ] course of the society of critical care medicine, with emphasis in the staff, stuff, and space orientation: staff . in any circumstance, and specially when facing a disaster, it is of utmost importance to maintain or, when necessary, enhance the protective measures of all hcw. failure to do so may leave the institution in a situation with an excessive demand for resources and limited hcws. the lack of available hcws may be due to disease, injury, or fear of acquiring disease and exposing families and close contacts. therefore, it is paramount that the hcw is reassured that their level of personal protective equipment (ppe) is more than adequate and that continuous surveillance, screening, and quality compliance programs have been implemented across the facility for their protection. . staffing plans require careful consideration, as due to direct and indirect situations, their actual number may be lower than during routine operations, as the hospital faces an increased demand. some key points include: • decision making and patient management should be performed by the most experienced physicians, nurses, and ancillary personnel available, and within their scope of work. • physicians and nurses without significant critical care experience may be reassigned to icu areas following a tiered staffing organization (fig. . ). adequate ratios of supervision must be maintained with experienced personnel, utilizing clear guidelines and protocols. previous basic training with courses like fundamental critical care support course (fccs) [ ] and fdm would facilitate this model. . rationing of critical care should only be considered after all efforts at augmentation have been exceeded. the province of ontario, canada, after their experience during the severe acute respiratory syndrome (sars) epidemic, developed a critical care/ventilator triage protocol based on the sequential organ failure assessment score (sofa) [ ] to be used in case of a pandemic, in view of the potential limitation in the number of ventilators. all decisions should follow well-defined, objective protocols using this score or similar approaches. all patients should receive basic care, including comfort and palliative support in extreme situations, even when the standard of care cannot be maintained. . biological threats [ , ] : • hospitals are high-risk areas for secondary spread of contagious diseases. • hospitals should implement high-level ppe whenever an infectious agent is suspected, and adjust the level of protection, once the contagion is identified. • agents transmitted by droplet may require higher precautions (i.e., airborne), when patients are subjected to high risk for aerosolization procedures or devices; these may include: -noninvasive ventilators -endotracheal intubation -airway suctioning with an open circuit -bronchoscopy -high flow oxygen masks -administration of nebulizers (i.e., bronchodilators) -chest tube insertion . some of the cdc recommendations to don and doff ppe have been linked to an increased risk of contamination [ ] [ ] [ ] . a summary of basic recommendations follows with modifications: • strict hand hygiene and sanitation measures remain the primary interventions in decreasing the potential for transmission. • the ppe for routine care (no aerosolization procedures are expected) [ , ] : -two layers of light, disposable, impervious gowns -two layers of patient care gloves, taped longitudinally to facilitate removal as one piece with gown -appropriate eye protection (regular eye glasses don't offer adequate protection) -n- mask (minimum grade) -disposable surgical cap -shoe covers (optional) or preferably, a nonporous, synthetic material shoe, that can be easily disinfected. • the highest level of airborne protection requires the use of a powered air purifier respirator (papr) (fig. . ) . • papr for icu use only protects against biological particles and cannot be used for decontamination procedures at the hospital's entrance, as they do not offer protection for volatile chemicals. the infection control plan should clearly delineate criteria for isolation, quarantine, prophylaxis, and treatment. . hospitals should prerecord instructions for personnel on a specific hotline, so they can better prepare themselves and their families for their interactions with the situation. -elevation of the head of bed to °-turning the patient routinely -oral care • renal replacement therapy • enteral nutrition . mechanical ventilators utilized for surge response, should have the following characteristics [ , , ] : • capable of supporting pediatric and adult patients with conventional modes and deliver a peep of up to cm h o • have an internal compressor device that allows them to function without an external compressed air source and low-flow oxygen • have alarms for: low minute volume, apnea, circuit disconnect, low gas source, low battery, and high peak airway pressures • battery power for at least - h • have high-efficiency filtering devices for exhaled gases, to prevent aerosolization of secretions into the environment, when dealing with a potential contagion . pharmacy regulations should include clear tables and algorithms including dosing for all ages, adjustment for patients with renal and/or liver insufficiencies, substitutions, authorized prescribers, restrictions and, if authorized by health authorities, guidelines for medication shelf life extension. . facility protection is another crucial aspect of the response, including possible contaminations of physical spaces or systems (i.e., air handlers, water, food). secured access may be the most important safety program during an incident, including perimeter definition and its maintenance with attention to strategic areas such as switchboards, medical gas depots, generators, and pharmacy. enhanced security will help the facility maintain independence, as the facility may become the target of desperate community members if all other institutions in the locale have failed. . the plan should consider ideally a surge of up to times the normal icu census and -day self-sustainability [ ] . . the plan should have a graded response based on the potential size of the demand, from multiple casualty events to catastrophic situations, with clear delineation of interinstitutional coordination and participations. . transfer agreements should be obtained with regional and extraregional facilities (joint commission requirement in the usa) [ ] in situations where the hospital integrity and/or functionality are compromised. . the designation of resources should follow a prioritization scheme based on severity, available expertise at the site, and institutional surge capacity. the person performing triage should be experienced and follow objective guidelines with classification criteria and facilitate patient flow to predesignated surge areas depending on level of support required and number of casualties. . physical space used for delivery of emcc should have the infrastructure to support expected critical interventions, such as mechanical ventilation (which requires a supply of medical gases), monitoring, and emergency generator-supported electricity. areas of expansion may include elective procedure recovery wards in outpatient surgical centers, pre-and postangiography or cardiac catheterization units, and endoscopy suites. other suitable areas include mobile (i.e., tents or trailers) icu facilities, and even veterinary hospitals. many plans purposefully avoid delivering prolonged care in postanesthesia care units (crucial for the utilization of the operating rooms) and the ed, in order to maintain the functionality of these to departments as much as possible. should more critical care space be required, consideration should be given to expand, sequentially, to intermediate or step-down care units, telemetry units, and eventually hospital wards. other nonmedical facilities should be avoided, as they require significant repurposing for emcc. they should be considered only in extreme circumstances on a temporary basis, when there has been a significant impairment of the hospital infrastructure. emcc. this plan should be coordinated with local, regional, and national initiatives and entities. . the internal organization diagram for the implementation of the emergency plan should follow the hics recommendations, including an incident commander and four sections: operations, planning, logistics, and finance ( fig. . ). . hospitals should prerecord instructions on well-publicized hotline numbers, so the public at large, incoming patients and other inquirers can obtain guidance in accessing the facility or other information. . a web page can assist in posting information about unidentified patients or the deceased, as well as to provide instructions for hcw. . coordination with local media (tv, radio, newspapers) to provide the public with instructions on how to access care in the community, as some health-care facilities may be designated to a specific type of ailment or severity. for example, hospital a may be designated the receiver for the event patients, while hospital b is accepting routine emergency care (i.e., a broken leg, dog bites, etc.) response to any mci or disaster should be proportional to the event and objective and follow pre-established guidelines. following an organizational structure similar to that of hics, the plan should be implemented and carried out by the most experi-enced personnel available (i.e., physicians, nurses administrators, facility engineers). if the amount of patients overwhelms the system to the point that critical care support needs to be rationed, clear, objective triage guidelines should be used and applied consistently [ ] . these guidelines should be developed with ample consideration of the associated ethical, moral, and legal aspects addressing the potential inability to provide complex, aggressive care to all during an extreme emcc implementation. hospitals, physician, nurses, and legislators must work together to develop the necessary regulations and laws for their implementation. "previous preparation prevents poor performance." any plan should be tested routinely with drills utilizing local and regional or national resources; it should be assessed, modified accordingly, and then retested in a continuous cycle. only a complete and wide-spread understanding of the required response by all key participants will increase the probability of decreasing the potentially deleterious effects of an event. all preparations should have started yesterday. the international disaster database. available at definitive care for the critically ill during a disaster: summary of suggestions from the task force for mass critical care summit definitive care for the critically ill during a disaster: a framework for optimizing critical care surge capacity the provision of sophisticatedcritical care beyond the hospital: lessons from physiology andmilitary experiences that apply to civil disaster medical response engendering enthusiasmfor sustainable disaster critical care response: why this is ofconsequence to critical care professionals? mass casualty respiratory failure reduction incritical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the london bombings on two new york cityhospitals' surgical response to the : the terrorist bomb explosions in madrid, spain an analysis of the logistics, injuries sustained and clinicalmanagement of casualties treated at the closest hospital the - commission'sinvitation to imagine: a pathophysiology-based approach tocritical care of nuclear explosion victims critical care requirements after mass toxic agentrelease medical surge capacity andcapability: a management system for integrating medical and health resources during large-scale emergencies the influenza pandemic: insights for the st century critical care delivery: the experience of a civilian terrorist attack emsa): hospital incident command system guidebook joint commission on accreditation of hospital organizations: hazard vulnerability analysis comprehensive accreditation manual for hospitals: the official handbook society of critical care medicine fundamental critical care support course book development of a triage protocol for critical care during an influenza pandemic clinical review: allocating ventilators during large-scale disasters-problems, planning, and process personal protective equipment contamination: a comparison of personal protective systems the use of personal protective equipment for control of influenza among critical care clinicians: a survey study virus transfer from personal protective equipment to healthcare employees' skin and clothing stand on guard for thee: ethical considerations in preparedness planning for pandemic influenza: a report of the university of toronto joint centre for bioethics pandemic influenza working group key: cord- - atk pt authors: puro, neeraj a.; feyereisen, scott title: telehealth availability in us hospitals in the face of the covid‐ pandemic date: - - journal: j rural health doi: . /jrh. sha: doc_id: cord_uid: atk pt background: telehealth is likely to play a crucial role in treating covid‐ patients. however, not all us hospitals possess telehealth capabilities. this brief report was designed to explore us hospitals’ readiness with respect to telehealth availability. we hope to gain deeper insight into the factors affecting possession of these valuable capabilities, and how this varies between rural and urban areas. methods: based on data from the american hospital association survey, area health resource files and medicare cost reports, we used logistic regression models to identify predictors of telehealth and eicu capabilities in us hospitals. results: we found that larger hospitals (or(telehealth) = . ; p < . ) and system members (or(telehealth) = . ; p < . ) (or(eicu) = . ; p < . ) had higher odds of possessing telehealth and eicu capabilities. we also found evidence suggesting that telehealth and eicu capabilities are concentrated in particular regions; the west north central region was the most likely to possess capabilities, given that these hospitals had higher odds of possessing telehealth (or = . ; p < . ) and eicu capabilities (or = . ; p < . ). rural hospitals had higher odds of possessing telehealth capabilities as compared to their urban counterparts, although this relationship was marginally significant (or = . , p < . ). conclusions: us hospitals vary in their preparation to use telehealth to aid in the covid‐ battle, among other issues. hospitals’ odds of possessing the capability to provide such services vary largely by region; overall, rural hospitals have more widespread telehealth capabilities than urban hospitals. there is still great potential to expand these capabilities further, especially in areas that have been hard hit by covid‐ . telehealth has played a growing role in improving patient access and care in the united states. the ability for patients to have access to quality care remotely has important implications particularly for those in rural areas, or in cases where it is necessary to quarantine patients, such as in the case of the covid- outbreak. the rapid spread of the disease has been dominating world headlines and agendas, and its characteristics have highlighted the need for quick solutions. one potential solution, which calls for rapid adaptation within the health care space, is to replace conventional diagnostics with newer technological methods of consultation to ensure all patients receive the attention and diagnosis from a health care professional. this is especially important in rural areas, which lack the usual preparedness and resources to which urban areas have access. this fact has not gone unnoticed by policy makers, as the march , , legislation passed in response to the pandemic includes provisions for increased telehealth capabilities. research has examined to some extent the effectiveness of telehealth on particular outcomes. for example, it is known that hospitals adopting telehealth possess the potential to improve outcomes for high-risk obstetric patients in rural communities. additionally, telehealth facilitated the use of anti-microbial stewardship programs in rural areas where infectious disease physicians were not available. it is of particular importance in the case of pandemics, such as covid- , where severe respiratory complications are common and widespread contagion threatens to overwhelm hospitals' limited resources. telehealth capabilities have shown remarkable abilities to facilitate emergency airway management in rural emergency departments (eds). yet, there are barriers to adoption that still remain, hindering the ability to maximize the potential of telehealth. for one, although there is demand for telehealth services in rural areas, rural ed providers perceive its usefulness in particular specialties and its anticipated frequency of use less favorably than their academic center counterparts; clinician acceptance barriers in general can pose a threat to successful telehealth implementation. furthermore, it is apparent that demand and availability vary systematically by region, and that other barriers, such as internet connectivity, state reimbursement, technological, regulatory, insurance and geographic restrictions, play a role in limiting adoptions. - recent popular press articles even call into question hospital telehealth readiness. thus, a timely and important question exists as to the state of us hospital readiness with respect to telehealth capabilities. the objective of this brief report is to explore the readiness of us hospitals with respect to the availability of telehealth resources. with this examination, we hope to gain deeper insight into the factors affecting the ability to provide these valuable resources, and how they vary between rural and urban areas. ultimately, we aim to help policy makers and hospital stakeholders ascertain the extent to which hospitals are ready for events such as a pandemic, and how they can understand more about characteristics that facilitate increased telehealth availability. this study utilized a cross-sectional analysis of acute care hospitals in the united states to examine the association between various organizational and environmental factors, and rural hospitals' possession of telehealth and eicu capabilities. broadly speaking, telehealth and telemedicine encompass the abilities to consult specialists when patients are unable to be physically present with the provider, and for providers to consult remotely with other specialists in the event that assistance is necessary. provision of eicu services allows remote monitoring of icu patients when sufficient icu staffing is unavailable, whether due to excess demand, remote location, or off hours. we relied on national data from the american hospital association (aha), which included , unique acute care hospitals from . data from the aha annual survey were combined with county-level data from area health resource files and medicare cost reports to obtain the independent variables, which were lagged by year. first, we tabulated the distribution of rural hospitals that possess telehealth and eicu capabilities as a percentage of all rural hospitals by state. subsequently, we ran separate logistic regression models with our dependent variables: ( ) possession of telehealth capabilities by hospitals and ( ) possession of eicu capabilities by hospitals. we used survey questions from the aha data to measure dependent variables. the first dependent variable for this study was a binary variable that captured whether or not a hospital reported possession of telehealth capability. the second dependent variable for this study was also a binary variable that captured whether or not a hospital reported possession of eicu capabilities. the variables were coded as " " if the hospitals possessed these capabilities and " " if otherwise (the organization did not possess telehealth or eicu capabilities, respectively). specifically, we used hospitals' responses to the aha survey questions referring to the possession of "telehealth consultation and office visits," and "telehealth eicu" capabilities. hospital size was a continuous variable measured as the number of staffed hospital beds. system affiliation was assessed with a binary indicator variable ( = independent, = system). teaching status was assessed with a binary indicator variable ( = independent, = part of council of teaching hospitals). environmental complexity was measured using variables: market competition (herfindahl-hirschman index [hhi]) and medicare market penetration. hhi, which measures market competition, was a continuous variable ranging from to , or low concentration/high competition to high concentration/low competition and calculated as a ratio of number of hospital's admissions in a given year by county's hospital admissions in a given year. geospatial factors are important in addressing access to telehealth and eicu services to a total population size within a defined population and defined area range. we used the rural-urban continuum codes (rucc) to group counties into metropolitan counties (rucc - ), nonmetropolitan/urban adjacent counties (rucc - ), and rural counties (rucc - ). we divided states into census regions ( : new england to account for other differences in the organizational and environmental characteristics, hospital ownership (notfor-profit, for-profit, and government), coded using a categorical variable ( , , and , respectively), medicaid payor mix, medicare payor mix, and whether hospital was financially distressed ( : no, : yes) were controlled for. we used altman z score to measure financial performance of the hospital. an altman z score below . was considered a measure of financial distress for a hospital. , descriptive statistics for the entire sample of hospitals (n = , ) are shown in table . more than one quarter ( . %) of the hospitals possessed telehealth capabilities, while % of the hospitals possessed eicu capabilities. most hospitals included in the sample were not-for-profit ( . %) and affiliated with a multihospital system ( . %). on average, hospitals in the sample had approximately beds staffed for use. the sample hospitals were also located in relatively highly concentrated markets with an average hhi score of . , and a medicare managed care penetration rate of . %. second, we displayed graphically the percentages of rural hospitals with telehealth capabilities (measured as a ratio of rural hospitals with telehealth capabilities to the number of rural hospitals in each state) (see figure ). noticeably, coastal states, which have been hit the hardest by the initial wave of covid- cases, had the lowest prevalence of rural telehealth capability. the concentrations range from % in multiple states to % in connecticut. table presents the results of a logistic regression model predicting hospitals' possession of telehealth capabilities. hospitals that were members of a system (or = . , p < . ) and had teaching status (or = . , p < . ) had higher odds of possessing telehealth capabilities. regarding hospital size, an increase of staffed beds per hospital increased the odds of telehealth capability possession by . % (p < . ). hospitals in rural areas were more likely to possess telehealth capabilities compared to hospitals in urban areas, although the odds ratio was only marginally significant (or = . , p < . ). however, hospitals that possessed telehealth capabilities were clustered in the west north central census region (or = . , p < . ), while hospitals in the east south central region (or = . , p < . ) and west south central census region (or = . , p < . ) were less likely to possess telehealth capabilities. model in table presents the results of a logistic regression model predicting hospitals' possession of eicu capabilities. hospitals that were members of a system (or = . , p < . ) were more likely to possess eicu capabilities. hospitals that possessed eicu capabilities were clustered in the south atlantic (or = . , p < . ), east north central (or = . , p < . ), west north central (or = . , p < . ), and mountain regions (or = . , p < . ), as they had systematically higher odds of possessing eicu capabilities. in this brief report, we undertook an examination of the extent to which us hospitals are prepared to use telehealth and telemedicine to aid in the battle with covid- , among other patient issues. we found that hospitals' odds of possessing such capabilities vary to a large extent by region; overall, the rural health system appears to have more widespread telehealth capabilities than urban hospitals. us hospitals have the potential to greatly expand these capabilities, especially in hard-hit areas. this research has the potential to inform policy makers and health administrators with regard to successful pursuit of this important capability. the concentrations of rural hospitals possessing these capabilities varied widely by state. coastal areas, such as new york, florida, california, and washington, lacked to a great extent the capability to provide e-services in rural areas. telehealth in particular is in short supply in these states. across all hospitals, telehealth capabilities are predictably available in larger hospitals and teaching hospitals; thus, a focus on providing support to smaller hospitals appears to be a wise policy move. another key predictor of telehealth capabilities is system membership. those hospitals that belong to systems presumably tap into the support network available, and benefit from the economies of scale and stores of knowledge present in these networks. there were some limitations in this study. first, the most recent data that we had available for all of our variables was . from what we can ascertain, however, telehealth did not spread appreciably in ; we cannot be certain, however, as to the spread of telehealth in through march . second, there are potential barriers to adoption for which data were not available to us for the time frame under study. these included such issues as the adequacy, reliability, and quality of internet services in the rural community, the proportion of residents who are subscribers to high-quality internet services and have devices that can connect to currently used telehealth systems, and the attitudes of providers and patients in the rural health system toward having patient visits using telehealth services. state medicaid and other payer telehealth reimbursement policies could also affect adoption, and they might also be examined in future research. future research could explore the extent to which the education and technology literacy level of the rural community influences telehealth availability and utilization. in particular, it could be that among less educated seniors, the use of their cell phone may be limited to simply the telephone function, they may have outdated technology, or they may have issues related to updating the technology that they are using to connect for telehealth. from a strategic planning/financial return point of view, a rural health system has to be sure that both the community and providers are likely to use telehealth, in addition to the extent to which structural barriers prevent it. in conclusion, it is important to realize where the readiness of our health system is in terms of capabilities to provide remote services. not only are rural populations some of the most vulnerable to diseases such as covid- , they might be called upon to provide back-up service to overflowing urban hospitals in the event such systems are overwhelmed. going forward, telehealth is likely to play a large role in diagnosing patients, particularly in coming months as long as social distancing is a preferred strategy for preventing the spread of covid- . this virus might also become seasonal, and until a vaccine is introduced, telehealth will likely be increasingly integral to diagnosis and treatment. furthermore, including telehealth generally as an option for reaching and maintaining rural patient contact and providing care can be an integral mechanism to improving rural health. telehealth: a balanced look at incorporating this technology into practice remote obstetric anesthesia: leveraging telemedicine to improve fetal and maternal outcomes available at: https: //www.healthleadersmedia.com/innovation/presidenttrump-signs- -trillion-stimulus-package-telehealthgets-another-boost meeting the challenge for effective antimicrobial stewardship programs in regional, rural and remote hospitals-what can we learn from the published literature? rural remote health telemedicine-assisted intubation in rural emergency departments: a national emergency airway registry study perceptions and perceived utility of rural emergency department telemedicine services: a needs assessment facilitators and barriers for implementing an internet clinic for the treatment of pressure injuries evaluation of barriers to telehealth programs and dermatological care for american indian individuals in rural communities feasibility and acceptability of internetdelivered parent-child interaction therapy for rural australian families: a qualitative investigation telehealth among us hospitals: several factors, including state reimbursement and licensure policies, influence adoption telemedicine still not widely available despite need for 'distancing' amid coronavirus. nbc does telemonitoring of patients-the eicu-improve intensive care? a lack of hard data to answer the question argues for doing comparative effectiveness research on care delivery the impact of hmos on hospital-based uncompensated care financial distress and bankruptcy prediction: a comparison of three financial distress prediction models in acute care hospitals. j health care fin applying altman's z-score model of bankruptcy for the prediction of financial distress of rural hospitals in western pennsylvania. indiana university of pennsylvania key: cord- - gfs sl authors: sezgin, duygu; o’caoimh, rónán; liew, aaron; o’donovan, mark r.; illario, maddelena; salem, mohamed a.; kennelly, siobhán; carriazo, ana maría; lopez-samaniego, luz; carda, cristina arnal; rodriguez-acuña, rafael; inzitari, marco; hammar, teija; hendry, anne title: the effectiveness of intermediate care including transitional care interventions on function, healthcare utilisation and costs: a scoping review date: - - journal: eur geriatr med doi: . /s - - - sha: doc_id: cord_uid: gfs sl background and aim: intermediate care describes services, including transitional care, that support the needs of middle-aged and older adults during care transitions and between different settings. this scoping review aimed to examine the effectiveness of intermediate care including transitional care interventions for middle-aged and older adults on function, healthcare utilisation, and costs. design: a scoping review of the literature was conducted including studies published between and with a transitional care and/or intermediate care intervention for adults aged ≥ . searches were performed in cinahl, cochrane library, embase, open grey and pubmed databases. qualitative and quantitative approaches were employed for data synthesis. results: in all, studies were included. interventions were grouped under four models of care: (a) hospital-based transitional care (n = ), (b) transitional care delivered at discharge and up to days after discharge (n = ), (c) intermediate care at home (n = ), and (d) intermediate care delivered in a community hospital, care home or post-acute facility (n = ). while these models were associated with a reduced hospital stay, this was not universal. intermediate including transitional care services combined with telephone follow-up and coaching support were reported to reduce short and long-term hospital re-admissions. evidence for improved adl function was strongest for intermediate care delivered by an interdisciplinary team with rehabilitation at home. study design and types of interventions were markedly heterogenous, limiting comparability. conclusions: although many studies report that intermediate care including transitional care models reduce hospital utilisation, results were mixed. there is limited evidence for the effectiveness of these services on function, institutionalisation, emergency department attendances, or on cost-effectiveness. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. intermediate care including transitional care services are models of care that support the integration and continuity of care as well as prevention of avoidable admissions to hospital [ ] [ ] [ ] . they have a particular importance in preventing the onset and progression of frailty and functional decline in adults, particularly older adults [ , ] since they provide comprehensive geriatric assessment, enablement and rehabilitation aimed at optimising independence and recovery [ ] [ ] [ ] . these services are time limited [ ] as they are mainly employed at times of a deterioration in health or at times of transition such as when moving from one's home to hospital, assisted living or long-term care [ , ] . these models operate as part of the continuum of care. they help manage preventable complications associated with hospitalisation and enable older adults to maintain or recover their functional ability following an illness, injury or hospital admission [ , ] . a recent delphi study examining these models emphasised that intermediate care is a broad range of time-limited services, ranging from crisis response to support over weeks to months that aims to ensure continuity, improve quality of care and promote recovery, particular at transitions between different levels of care and settings [ ] ,transitional care interventions may be delivered as a subset of intermediate care [ , ] . although transitional and intermediate care services may be limited to several weeks [ , ] , they are more comprehensive than discharge planning activities or chronic care management [ ] . in addition, both services provide care closer to home, support early discharge and reduce readmission to acute care [ , ] . despite the recent growth in their use as a bridge to care transitions, there is limited data on the impact of these relatively new models of care on activities of daily living (adl) function-related outcomes, healthcare utilisation and cost-effectiveness for adults, particularly older, frail and multi-morbid adults [ ] . therefore, this scoping review seeks to identify and analyse a broad range of literature published in relation to the effectiveness of intermediate care including transitional care for middle-aged and older adults and to understand the benefits of these interventions, with a specific focus on health-related outcomes including function (activities of daily living), healthcare use and associated costs. scoping reviews are conducted as a preliminary investigation to assess the potential size and scope of available research literature on a topic [ ] . they are useful in summarising evidence to show the breadth and depth of a given field [ ] . this scoping review was conducted to incorporate evidence from the existing literature across a broad range of study designs regarding the effectiveness of intermediate and transitional care interventions for middle-aged and older adults. the methodological framework recommended by arksey and o'malley [ ] for conducting a scoping review was used and the following steps were taken: -identification of the research question, -identifying relevant studies, -study selection, -charting the data, -collating, summarising and reporting the results. the preferred reporting items for systematic review and meta-analyses (prisma) extension for scoping reviews (prisma-scr) guidelines were used for reporting purposes [ ] . the review protocol was registered on prospero (crd ). the primary objective of this scoping review was to identify the effectiveness of intermediate care including transitional care interventions for middle-aged and older adults (aged ≥ ) in the existing literature. the the search was conducted in four databases, cinahl, cochrane library, embase, and pubmed, using the search string: (("intermediate care" or "transitional care") and (frailty or frail or "older person*" or "older adult*" or "hospital at home" or "reablement" or "independ*" or "readmission" or "prolonged stay" or "community hospital")). opengrey was also searched with the terms "intermediate care" or "transitional care" for reports published within the same period. titles and/or abstracts (where available) of the located records were independently screened by three pairs of reviewers (ds-ah, amc-lls, rra-cac) considering the inclusion and exclusion criteria. disagreements were discussed by the pairs of reviewers and any persisting conflict was resolved by a third independent reviewer. data extraction was performed by five reviewers (ds, ah, mod, ms, lls) for the full-text records. data extraction was carried out using a single standard template. this template had fifteen sections including: ( ) author names, year, title, and country; ( ) evidence type; ( ) aim of study; ( ) definitions provided for transitional or intermediate care; ( ) intervention details; ( ) technology usage; ( ) population characteristics (such as mean age and sample size); ( ) health condition/problem; ( ) context/setting that the recruitment took place; ( ) structure/ governance of intervention; ( ) outcomes reported (function, ed visits, hospital stay, institutionalisation, other); ( ) resource implications (such as cost and staffing); ( ) transferable lessons for policy and practice; ( ) barriers/ limitations reported; and ( ) additional recommendations/ comments. qualitative and quantitative analyses of the included studies were performed. the included studies were read in detail and were grouped and classified according to their type and setting. the measures captured by the data extraction template guided the data synthesis process (supplementary file). classification and synthesis of studies were discussed within the team and decisions were made with consensus. a core team of reviewers (ds, ah, mod, ms) had regular email correspondence and virtual meetings to classify and synthesise data from included studies. the initial search yielded records. cross-referencing of a systematic review and narrative review articles resulted in additional articles. the search for grey literature added a further reports, resulting in a total of articles for screening. further details of the screening process are outlined in fig. (prisma-scr flow diagram). in total, studies measuring the effectiveness of transitional and/or intermediate care interventions in middle-aged and older adults (aged ≥ ) were identified. details on the characteristics and outcomes of these studies are summarised in the supplementary file. in summary, the total number of participants in the included studies were , , with the sample sizes ranging between and , (available for studies). most studies were from the usa (n = ). eighty studies reported the mean age of their participants, which ranged between - . years. overall, the mean age was . ± . years. twenty-nine interventions were delivered to high-risk patient populations, e.g. those with advanced age, high risk of readmission, multimorbidity, though there was no standard description for high-risk. only three interventions were designed primarily for frail older adults. interventions were heterogeneous, and most were complex, consisting of a mixture of multiple elements delivered in hospital and/or in the community settings. in total, sixty-five studies were delivered by interdisciplinary teams. as illustrated in tables , and fig. , the interventions were grouped under four main categories based on the type of evidence, location, timing of care and healthcare outcomes: only eight studies examined transitional care interventions delivered exclusively in the hospital. these focused on coordination and hospital-based education for patients and/or caregivers and implemented discharge planning, of which the majority were a nurse or social worker-led interventions. reduced readmission was observed for coaching delivered by social workers [ ] , as well as some transitional care interventions delivered by hospitalists or nurses [ , ] . while no reductions in readmissions were reported for a combination of patient education and discharge planning by nurses or social workers, reduced rates of admission to long-term care was observed [ ] . many studies ( %) reported on transitional care delivered in hospital and for up to days after discharge, with fifty-five conducted in the usa or canada, six in hong kong, six in europe, and three in australia. most comprised a complex bundle of interventions in hospital and in the community delivered by a nurse, pharmacist or social worker; and ( %) were interdisciplinary. since these complex multi-component interventions were very heterogenous, the studies were further classified according to their provider, approach and specific focus, to better describe the potential benefits and value. some studies were included under more than one category. outreach by hospital professional(s) (n = ) the majority of studies implemented and evaluated combined interventions including education, assessment, follow-up, medication management and other interventions but were markedly heterogenous. outreach by a hospital-based professional, often a nurse, was described in most of the transitional care models. key positive outcomes of these interventions were on hospital readmissions (n = ), ed visits (n = ), and costs (n = ). only one study reported positive outcomes related to function [ ] , none were reported for institutional care. for example, a telephone-based nurse-led outreach model, aiming at empowering older adults and caregivers in medication management and encouraging them to contact healthcare providers when needed, reduced -day re-hospitalisation rates from to % [ ] and led to estimated net healthcare cost savings of $ per person [ ] . one-third of the outreach interventions associated with reduced hospital stay were delivered via interdisciplinary teams. an example of an outreach transitional care programme is the bridge care coordinator model, which involves discussion of the cases within a multidisciplinary hospital team, review of inpatient medical records by a social worker, and home follow-up visits. the bridge care model also reported reductions in -day re-hospitalisation by % [ ] , with average hospital costs reduced by $ , per person per episode of care [ ] . community based or in-reach models (n = ) communitybased providers were involved in less than half of the postdischarge transitional care interventions. these models were mostly associated with reduced hospital stay [ ] , fewer rehospitalisations (reductions ranged between . - %) (n = ), and lower costs (ranged between $ - per patient, where applicable) (n = ). few illustrated positive outcomes on ed visits (n = ) and adl function (n = ). none reported outcomes on institutional care. almost all the models (n = ) that were associated with reduced hospital stay consisted of combined interventions, six of which were delivered via interdisciplinary teams. all interventions that reported reduced costs implemented patient or carer education and used telephone support. a large retrospective study of the preventable admissions care team, an in-reach model involving a social worker-led in-hospital holistic assessment and personalised care planning, followed by home-based post-discharge care coordination, illustrated significantly lower readmissions at , and days, and reduced mortality at over days [ ] . similarly, a transitional case management programme in the usa involved immediate identification and telephone services for recently discharged patients (mean age ) [ ] , reduced readmissions at and days. pre-and postdischarge assessments for care needs, medication reconciliation, support for self-care delivered by a primary care-based nurse care coordinator reduced post-discharge costs among medicare fee-for-service beneficiaries discharged from hospital and the primary care provider in the usa [ ] . transitional care clinics (n = ) transitional care clinics were assessed in seven studies and were often combined with telephone and/or nurse follow up. a retrospective study [ ] reported reduced rehospitalisation for patients who completed a scheduled transition clinic appointment compared with those who neither attended the transition clinic nor their primary care physician. similarly, a reduction in rehospitalisation, as well as potential medicare savings were observed by baldwin et al. [ ] for patients attending a multidisciplinary discharge clinic in the usa. telephone follow-up (n = ) forty-eight studies illustrated a variety of telephone support interventions ranging from one or two 'light touch' prompts in the first few days after discharge to more frequent calls for up to days after discharge. the effectiveness of telephone support was mixed. for example, a rct including participants ( intervention, control) aged ≥ (mean age ) [ ] reported insignificant results for a single scripted telephone call from a trained nurse following discharge from the ed for -day rehospitalisation or death. however, a pre-discharge holistic assessment and telephone support by a social worker at days for medical and surgical inpatients aged ≥ improved adherence with follow-up appointments in primary care settings [ ] . twenty-one studies ( %) conducted home visits alongside telephone follow-up as part of their intervention. there was mixed evidence for a reduction in re-hospitalisation for interventions delivered by different healthcare professionals. for example, a pilot study [ ] investigating home visits by social workers in high-risk patients in the usa reported lower ed visits and rehospitalisation at days post-discharge. similarly, home visits on day five post-discharge by a pharmacist [ ] reduced -day unplanned rehospitalisation and improved compliance in those aged ≥ (median age ) in australia. however, in another study, home visits by pharmacists at two and eight weeks post-discharge were linked to increased hospitalisation in patients with emergency admission aged ≥ (mean age ) in the united kingdom [ ] . patient and caregiver education or coaching (n = ) almost all transitional care interventions included patient and/or carer education or coaching. there was a specific focus on medication management in half of the studies while the others investigated the effects of coaching and support to prevent additional treatment or review. results in relation to costs and readmissions were generally positive [ ] [ ] [ ] . other outcomes included improvements in patient satisfaction [ ] [ ] [ ] , quality of life [ , ] , improved information sharing and communication with members of the healthcare team and self-management [ , ] , as well as improved self-rated health and self-efficacy [ , ] . electronic health records and patient information tools were used in most studies; however, few (n = ) described specific decision support tools as the main element of their intervention. although they provided mixed evidence on readmissions [ ] [ ] [ ] , there were positive outcomes in relation to healthcare adherence and quality of care [ , ] . for example, a rct implementing electronic transfer of patient discharge forms reported improved post-discharge outpatient follow-up rates in a diverse group of patients (mean age ) admitted to a small community teaching hospital in the usa [ ] . another study in the usa, deploying a transitional care bundle using patient-centred electronic data collection tools, supported the spread of transitional care across multiple sites and reduced medication errors in patients with a mean age of , half of whom had a high risk of readmission [ ] . forty-one studies of intermediate care delivered at home were identified with thirteen studies conducted in north america, in australia or new zealand, in europe, four in singapore and one in thailand. while studies had a focus on medication reconciliation and review, all combined several interventions including telephone advice and support, coaching for self-management and recovery, and follow up care. several intermediate care interventions delivered at home reported no evidence on length of hospital stay [ , ] or reduced hospital readmission rates [ , [ ] [ ] [ ] . however, many combined interventions had positive effects on reducing short-term and long-term (re)hospitalisation rates [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] reducing ed visits [ ] , improving quality of life [ ] , and reducing costs [ ] . due to heterogeneity between studies, the interventions were grouped by the professionals supporting the interventions and their approach to care (table ) . interdisciplinary support with rehabilitation (n = ) interdisciplinary rehabilitation was included in % of the intermediate care interventions at home. many were geriatrician or physician-led programmes with collaboration of a team of nurses, allied health professionals, and social care workers, and employed a comprehensive geriatric assessment approach. their focus was on improving function in middleaged and older adults and re-able them to be independent in their adl. for example, an early supported discharge with an intensive multidisciplinary community rehabilitation programme in england [ ] reduced mean length of hospital stay by nine days and led to improved adl and psychological well-being in older adults aged ≥ (median age ) . similarly, an australian study [ ] reported improvements in instrumental adl scores from a combined nurse and physiotherapy intervention at home delivered to participants aged ≥ (mean age ). interdisciplinary support without rehabilitation (n = ) half of the interdisciplinary programmes did not deliver a rehabilitation intervention but used combined approaches including time-limited case management usually by a trained nurse. those were mostly from the usa (n = ) and singapore (n = ), followed by a few european countries. for example, hernández et al. [ ] reported reduced in-hospital days following a hospital outreach telemedicine monitoring service for a large group of patients with chronic illnesses (n = ). furthermore, all patients, carers and health professionals involved in the programme expressed high levels of satisfaction ( %) with the service. on the other hand, intermediate care at home for recovery and self-management illustrated mixed outcomes for adl and iadl scores. a transitional care bridge programme delivered by a transitional care nurse and geriatrician, without rehabilitation, showed no effect on adl functioning but decreased -month post-hospitalisation risk of death [ ] . single profession led interventions (n = ) ten studies included uni-disciplinary support, mostly nurse-delivered interventions. they were mostly associated with positive outcomes related to hospital utilisation and readmissions. for example, an extended transitional case management programme delivered by an advance nurse practitioner decreased -month rehospitalisation and total hospital days, resulting in decreased health care costs [ ] . similarly, support for self-management and coaching by a nurse coordinator reduced rehospitalisation and ed attendance at - weeks post-discharge and increased quality of life and self-rated health [ ] . crisis response or hospital admission avoidance (n = ) seven studies reported outcomes of hospital avoidance or crisis response models, while some of them were built on an established early supported discharge service. they had limited evidence on cost effectiveness [ ] but reported positive outcomes for patients and caregivers [ , [ ] [ ] [ ] . for example, a nurse-led multidisciplinary hospital at home intervention via a hospital outreach programme increased patient satisfaction and decreased caregiver strain index scores [ ] . despite the fact that this hospital at home service was not cost effective, this was explained as being due to not operating the service at its full capacity. avoided costs were not reported [ ] . the setting for follow-up except one, all intermediate care at home interventions implemented home visits. follow-up services delivered via home visits during the post-discharge period were associated with improved communication [ ] and patient satisfaction with care [ ] . in addition, compared to outpatient provider visits, home visits within a week following discharge from a skilled nursing facility (snf) reduced the risk of -day rehospitalisation [ ] . fourteen studies reported the effectiveness of bed-based intermediate care. these were mostly from europe (n = ), followed by north america (n = ) and australia (n = ). many investigated the effect of having beds dedicated to rehabilitation in community hospitals or residential care units. for example, a discharge to intermediate care hospital intervention resulted in fewer days spent in intermediate care beds during a -year period [ ] . the most frequently reported outcome was hospitalisation, with studies reporting reduced length of stay or readmissions. three out of five studies considering long term care as their endpoint observed reduced institutionalisation [ ] [ ] [ ] . all the facilities aimed to ensure recovery and provide rehabilitation via teams consisting of nurses, allied health professionals, or social care workers. since there were differences in relation to the content of the services, the timing of transfer, and support provided for staff members, the interventions were grouped according to several features. eleven studies implemented interdisciplinary rehabilitation via in-reach support or in patient facilities (community hospitals). most of the rehabilitation activities were delivered on site or by telephone advice by interdisciplinary teams led by physicians. the main outcomes included reduced hospitalisation and improved function. for example, telephone-based medical consultations delivered by telephone to support on-site care teams decreased hospital costs and shortened the length of hospital stay [ ] . another intervention by a community hospital providing intermediate care closer to home and to social and care networks increased independence and reduced mortality at months [ , ] . three studies conducted in different community settings addressed early transfer from acute care settings to bedbased intermediate care. in general, they had positive effects on function and independence [ , ] . for example, young and colleagues [ ] reported that early transfer to a community hospital for older patients with complex care needs improved their adl. three studies considered the effectiveness of education for staff members in bed-based intermediate care units. their outcomes included reduced readmissions and ed visits [ , ] . for example, education and training for snf staff members who coordinate discharges reduced -day rehospitalisation and enhanced patients' preparedness for discharge [ ] . this scoping review provides an analysis of the effectiveness of a wide range of intermediate care including transitional care models for middle-aged and older adults. since they were conducted in many different care settings, applied different inclusion criteria and evaluated a range of different outcomes (i.e. re-hospitalisation, ed admissions, and healthcare costs as well as function), the studies were inherently heterogeneous. given this, it was challenging to identify and summarise a common pattern for effectiveness and value, questioning the generalisability of the overall findings for service planning and clinical practice. nevertheless, following further analyses, we were able to synthesise the results and classify and group services under four different models of care: hospital-based transitional care, transitional care interventions, intermediate care at home and bed-based intermediate care, the findings of which are discussed in turn below. hospital-based transitional care was described in a small number of studies that reported mixed results in relation to reductions in hospital readmission of middle-aged and older adults, for all disciplines that conducted a planning and coaching based transitional care intervention. in the literature, a cochrane review by griffiths et al. [ ] reported limited evidence for the effectiveness of nursing-led units for care transitions. although there were improved processes and positive outcomes for preparing patients for discharge within those units, more research was recommended to prove their effectiveness. in our scoping review, the strongest evidence for effectiveness and costs was from interventions for older adults utilising a multidisciplinary comprehensive geriatric assessment (cga) [ ] , where € was saved per person and ed or hospital (re)admissions were reduced by . % over three months post-discharge. transitional care interventions in both hospital outreach and community settings illustrated positive outcomes including positive patient experience, self-management, self-efficacy, and self-rated health. benefits were also observed at the healthcare system level with reductions in early hospital readmissions as well as ed admissions. transitional care interventions can bridge the gap between acute care and community settings and so ensure the continuity of care [ ] . they can also help address the changing needs of middle-aged and older adults at post-discharge periods [ ] . we identified that post-discharge telephone follow-up was a low-cost intervention that reached a high volume of patients in transitional services yet the evidence for their effectiveness is limited. intermediate care at home showed benefits for short-term and long-term re-hospitalisation rates, ed admissions, function, and healthcare costs. evidence was strongest for discharge supported by an interdisciplinary team and rehabilitation at home. this outcome was also encouraging for hospital avoidance of middle-aged and older adults but there was a limited number of empirical studies to support this evidence. in practice settings, both early supported discharge and intermediate care at home are provided by services considering the individualised needs of the patients and families. a systematic (cochrane) review of rcts for admission avoidance using hospital at home models [ ] concluded that if this type of service provides the option of hospital transfers when needed, it could be an effective alternative to hospital care. services providing early supported discharge can offer crisis response as well as hospital at home alternatives, which aid building confidence and capacity in patients and their families and/or informal caregivers for managing clinical risks. however, more evidence in this area is needed. shepperd et al. [ ] reported in their cochrane review that early discharge to a hospital at home model is a costeffective alternative to usual care and it also aids improvements in health. however, a more recent version of this systematic review [ ] concluded that although early discharge hospital at home services are cheaper options compared to inpatient care, there is no strong evidence for their economic efficiency or support for improvements in health. although we found some evidence for cost benefits and positive outcomes for intermediate care at home, more research is needed to identify cost-effectiveness at scale. bed-based intermediate care interventions reported reduced readmission rates and length of hospital stay, although few reported reduced admissions to long-term institutional care. enhanced specialist team support was most likely to be effective, however, there was no evidence to specifically identify the ideal provider or optimal care setting. in addition, no studies made comparisons between intermediate care provided in different settings such as a community hospital, nursing facility, residential care home, or transitional care unit. this paper has a number of strengths and weaknesses. this scoping review was conducted by academics and clinicians from a variety of disciplines across multiple european countries providing an international and interdisciplinary standpoint. a broad perspective on the transitional and intermediate care interventions was ensured since no restrictions were placed on the setting or level of evidence. despite these factors, this review has some limitations. firstly, the heterogeneous nature of the interventions resulted in barriers to data synthesis, which did not make it possible to perform a systematic review and meta-analysis. to overcome this issue, the data were classified according to the timing and setting of interventions and synthesised according to their principal elements. secondly, given our broad focus on middle-aged and older adults, we did not include condition-specific interventions, such as stroke rehabilitation (e.g. esd for stroke). we did, however, identify and include three studies [ , , ] deploying interventions designed for frail older adults. once again, these interventions were markedly different in their approach. although this review includes papers published before the ongoing global covid- pandemic, it is important to acknowledge the important role intermediate care is playing in managing those with and without covid- . covid- is known to disproportionally affect older adults, particularly those who are frail [ , ] . worldwide, alternatives to hospital treatment have been scaled-up during the pandemic through virtual consultations and access to intermediate care at home and in step-up and step-down facilities. although the challenges and effectiveness of delivering intermediate care during this pandemic are yet to be investigated, it features in pathways for those recovering from covid- who require support and rehabilitation as they transition to home or long-term care [ ] . intermediate care generally consists of a series of multidimensional services combining transitional care with complex rehabilitation and recovery alternatives within interdisciplinary and integrated team work [ - , , - ] . overall, intermediate including transitional care models can provide positive outcomes for middle-aged and older adults and make an important contribution to healthcare systems, despite the challenges of delivering such complex services in different settings due to a high volume of interventions and costs. when models of care combine telephone follow-up and coaching support, they can reduce short and long term hospital re-admissions. moreover, 'rehabilitation at home' services delivered via an interdisciplinary team, demonstrated improvements in adl function. although several intermediate and transitional care interventions resulted in reductions in hospital utilisation and improvements in quality of life, their effectiveness on function, ed admissions, institutionalisation for long-term care and costs remains unclear. additional studies are now required to investigate the impact of these models on middle-aged and older adults within the broader health and social care context to compare whether outcomes vary for different settings and providers of care. considering the heterogeneity of the interventions reported in the literature, there is a need for systematic reviews and meta-analyses with a specific focus on highquality experimental studies and in particular healthcare settings, which may allow more robust comparisons between previously reported interventions. funding this work was completed as part of the joint action on frailty prevention 'grant number /advantage', which has received funding from the european union's rd health programme ( - ). the relevant data can be provided to interested individuals on request. conflict of interest on behalf of all authors, the corresponding author states that there is no conflict of interest. disclaimer the content of this article represents the views of the authors only and is their sole responsibility; it cannot be considered to reflect the views of the european commission and/or the consumers, health, agriculture and food executive agency or any other body of the european union. the european commission and the agency do not accept any responsibility for use that may be made of the information it contains. ethics approval not applicable. code availability not applicable. expanding the inspired copd outreach program to the emergency department: a feasibility assessment why are people increasingly attending the emergency department? a study of the french healthcare system hospital-at-home integrated care programme for the management of disabling health crises in older patients: comparison with bedbased intermediate care impact of post-acute transition care for frail older people: a 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screening tools to select older adults susceptible for direct transfer from the emergency department to subacute intermediate-care hospitalization key: cord- -cyhcbk j authors: nan title: ps - date: - - journal: intensive care med doi: . /s - - -y sha: doc_id: cord_uid: cyhcbk j nan in our -bed icu-cum-hdu of a -bed tertiary referral cancer centre, medical oncology admissions increased from < % of total admissions to over % in the last years. we audited outcomes in these patients to determine prognostic factors that may aid patient selection and management. methods. consecutive admissions ( males, females, age > years) from february , to february , were prospectively studied. the total sofa score on day (sofa ), the highest sofa score of the first three days (max ) and the change in sofa score between day and day (delta ) and between day and day (delta ) were calculated. predictors of outcome were identified using univariate and multivariate binary logistic regression. results. patients had solid tumours , had leukemia, lymphoma, myeloma, and had other diagnoses. mean age was . ± years and apache ii score was . ± . . icu mortality was % and hospital mortality . %. / patients ( . %) with icu stay < day died. overall length of icu stay was . ± . days. in survivors vs. nonsurvivors, sofa , delta and delta (median, interquartile range) were . ( . to . ) vs. . ( . to . ; p< . ), - . (- . to ) vs. . (- . to . ; p< . ) and (- . to . ) vs. . (- . to . ; p< . ), respectively. several factors were associated with mortality on univariate analysis (table ) . on multivariate analysis, only need for vasopressors (or . , p= . ) and max (or . , ci . - . , p= . ) were independently associated with hospital mortality, while type of cancer and leucopenia were not. for patients staying > days, no factor predicted hospital mortality, but sofa (or . , ci . - . , p= . ), delta (or . , ci . - . , p= . ) and delta (or . , ci . - . , p= . ) predicted icu mortality. usually, the cgr transfused in our icu are old (about % of rbc are stocked more than days). icu outcome is independently associated with the number of rbc transfused, but not with their age. this result in contradiction with previous report could possibly be explained by the systematic leucodepletion performed before storage in france, contrary to precedent studies where rbc were not leukodepleted. we compared them with ≥ years old and an icu stay < days patients, the differences in icu mortality, apache ii, age, gender and the necessity for renal replacement therapy (rrt) were not significant (see table) . the survivors patients (≥ years old and an icu stay ≥ days) were more older and ( ' %) were still alive one year later. when we analyzed the overall patients, according their stay < or ≥ days, did not find statistically significant differences between both groups in the mortality (p= ' conclusion. icu mortality rates in elderly patients with a stay < or ≥ days at icu were comparable. the year-survival of elderly patients with a long-term intensive care unit stay was high. results. seventy patients were admitted to our icu with the diagnosis of acute pancreatitis during study period and of them were later confirmed as having sap. the average icu length of stay in patients with sap was days compared to days in patients with mild form of the disease. pancreatic infection was present in patients. the mortality rate in the group with sap was % compared to , % in the group with mild acute pancreatitis, p< , . the most common etiology of patients with sap was biliary and this was similar both in survivors and non-survivors. the most common cause of death in the group with sap was multiple organ dysfunction/failure syndrom(mods/mof) in % followed by bleeding complications in %. twelve patients with sap ( %) underwent the surgical intervention. mortality in the group of patients who underwent a surgical intervention was % ( patients). , +/- , , +- , apache ii score( mean+/-sd) , +/- , , +- , * necrotising form (%) infected necrosis (%) ct guided fnab (%) * p > . conclusion. the patients with mild form of acute pancreatitis had low mortality rate (similar to general ward population) despite positive icu admission criteria in our case series with fifty per cent development of severe form with organ dysfunction/failure later on. apache ii score was better predictor of mortality in patients with sap than presence, extent or infection of pancreatic necrosis. patients with higher risk for development of severe form of acute pancreatitis should be admitted to multidisciplinary icu prior to definitive diagnostic evaluation of pancreas. further studies are warranted. conclusion. absi is an aprropiate score for estimating the probability of death in critical brun injury patients. preexisting cardiac and liver diseases have a little influence on mortality and its addition to the absi variables don't predict mortality more accurately. poisoned patients constituted up to , % of all icu admissions in our hospital. demographic data and specific poisons have been presented at the table. the total poisoned mortality rate was , %. methyl alcohol poisoning has a higher mortality than others poisoning. conclusion. childhood poisoning is usually accidental and is usually associated with a low morbidity and mortality. in adults, self-poisoning is usually deliberate suicide or parasuicide) and has a higher morbidity and mortality rate. ( ) the most important part of the poisoned patient's care are the general supportive management and specific antidotes therapy. it has abundantly been demonstrated that duration of mechanical ventilation can be reduced by the use of protocols for weaning and sedation [ , ] . utilization of the required sedation scales and adherence to protocols, however, is poor in daily practice, as has been shown in recent studies [ , ] . it has been proposed to use daily checklists to improve the quality of care [ ] . to improve adherence to the established guidelines for weaning and sedation in our icu, we included two questions in a checklist printed on patients' charts which had to be answered daily by the physician on duty: conclusion. the checklist as a daily reminder to observe established weaning and sedation protocols may have significantly accelerated weaning from mechanical ventilation. we carried out a prospective and descriptive study in patients admitted to our icu from to . we defined tolerance as the need to use more than mg/h, at least for four hours, or the need either to use or to change to other sedatives to obtain a to level on the ramsay scale ( ). the appearance of tolerance in the first hours was considered as tachyphylaxis or early therapeutic failure to this sedative. in our sedation protocol we use propofol preferably in patients who need frequent neurological consciousness evaluations, or in patients whose sedation is expected to have short to medium duration, and who have haemodynamic stability. also, we use propofol as a sequential strategy when early weaning from ventilation is expected. all patients received analgesic drugs. during this time, we admitted patients, of them needed mechanical ventilation and in patients we administered continuous analgesic and sedative infusions. continuous propofol infusions were administered in patients at some point of their sedative strategy, and ( % of the sedated patients) received propofol for more than hours. tolerance development was observed in patients, % of the patients sedated with propofol. in thirty-seven of them, this situation was present in the first hours (early therapeutic failure). conclusion. in our sedative protocol for propofol use, the incidence of tolerance in patients sedated with this drug was %, which is substantially less than the usual described midazolam tolerance. most of these cases ( %) happened in the first hours. diabetes mellitus (dm) with its chronic and acute complications puts patients suffering from the disease at increased risk. none of the scoring systems used for risk prediction in intensive care units accounts for diabetes as a risk factor, although, in everyday practice, patients with dm admitted to icus may be recognized as those with higher risk. not much data is available on how much risk can be attributed to diabetes. we have compared course and outcome of patients with dm with non-diabetics to try to answer this question. we have analyzed data from the "croicu.net", national pilot-project which collects data on patients from icus in croatia. data collected during the first months (nov -dec have been analyzed. adult patients from icus in university hospitals were included; three most frequent admission diagnoses were selected for comparison of diabetic and non-diabetic patients. the diagnosis of dm had to be established prior to admission according to the usual criteria. icu mortality and icu length of stay (los) were primary outcome measures. incidence of organ failure was a measure of disease course. in the analysed period there were admissions to the analysed icus, ( . %) with documented dm prior to admission. patients with md did not differ significantly from non-diabetics in age or sex distribution. overall mortality was higher for dm patients ( . % vs. . %), as was los ( . vs. . days). three most frequent diagnoses were: sepsis (n= ; . %), pulmonary oedema ( ; . %) and myocardial infarction (n= ; . %). patients with diabetes had significantly higher mortality and higher los in all three subgroups. in the sepsis subgroup, patients with diabetes had higher incidence of organ failure and higher number of failing organs. in the other two subgroups, the differences were not significant. in multivariate analyses which was performed separately for all three diagnoses and included dm, age, apache ii score and sofa score, diabetes mellitus was shown to be an independent predictor of mortality and los in all three cases. although some chronic effects of diabetes mellitus can be included in multiparameter scoring systems such as apache ii score, the disease itself is not scored. we have shown on three most common diagnoses in icus of university hospitals that diabetes mellitus is an independent predictor of mortality and los and that it has significantly higher incidence of organ failure in sepsis. patients with dm should be given appropriate attention as high risk patients in the icu. introduction. neuromuscular abnormalities are common in critically ill patients with systemic inflammation and organ failures. we assessed the incidence of a clinically diagnosed critical illness polyneuro-myopathy (cipm), and its potential impact on mortality and long-term neurological outcome. methods. consecutive critically ill patients on mechanical ventilation for hours and with the presence of or more sirs criteria were prospectively studied. based on daily clinical neurological examinations, cipm was defined as symmetric limb muscle weakness [ or more muscle groups, m or less (mrc)] without other explanation than cipm in patients with normal neurology at icu admission. a barthel index (score for activities in daily living) was performed at day and months after icu discharge. after months a neurological examination was also performed. . cipm was diagnosed in patients ( %). patients with suspected cipm had a prolonged icu stay and a high mortality. the barthel index was significantly lower in this group at day but improved over the next six months. of patient who survived could be reached months after discharge and of them were clinically examined. at this time the most compromised activity in daily living is climbing stairs. patients with a clinical diagnosis of cipm have a high mortality. if they survive, they are severely limited in simple daily activities one month after icu discharge, but improve later. host infection by pathogens triggers innate immune response leading to a systemic inflammatory response, often followed by a paradoxical compensatory antiinflammatory response. this immune dysfunction can impair the eradication of primary infections and favor the emergence of nosocomial sepsis. dendritic cells (dcs) have a central role in initiation and control of innate and adaptative immune responses to infectious challenges. dcs might contribute to sepsis-induced immunodepression. indeed, depletion of dcs has been reported in secondary lymphoid organs of patients who died from sepsis and in animal models of lethal sepsis. in order to investigate the mechanisms of sepsis-induced immunodepression, we studied quantitative and functional features of dcs in a murine model of sublethal sepsis. we developed a sublethal murine model of polymicrobial sepsis through cecal ligature and puncture followed by short course of antibiotics and volume resuscitation. we isolated splenic dcs by immunomagnetic procedure and generated bone marrow-derived dcs (bmdcs) by -day culture of medullar progenitors in the presence of gm-csf before stimulation with lps to induce maturation. we counted spleen dcs and studied the following functional features of spleen dcs and bmdcs in the early (day ) and late (day ) phases of sepsis : maturation (expression of mhcii, cd and cd through facs analysis), production of cytokines (tnf-alpha, il- , il- ) and priming of cd -positive t-cell lymphocytes ( h-thymidine proliferation assay in allogeneic mixed lymphocyte reaction). upon anesthesia induction with isoflurane sepsis was initiated by cecal ligation and double puncture in groups of c bl/ j-mice per group [ g, g, g] (clp). control mice underwent laparatomy and manipulation of the cecum only (sham). , and hrs post-surgery in and g mice and hrs post surgery in g mice single cell suspensions of thymus and spleen were analyzed by means of cell surface staining and flow cytometry. fluorescence-labeled antibodies included cd , cd , cd , b , igm, igd, cd , cd . data are presented as mean+sem. results. similar to previous results, thymi primarily demonstrated a time-dependent reduction of cd +cd + double-positive cells which was more pronounced during severe sepsis ( + g). at hrs post-clp cd + cells and cd + t-cells recovered to values of sham mice in g animals, which previously recovered fastest with highest survival rates of about %. in contrast cd + cells and cd + cells, respectively, raised to maximum levels at hrs in g animals. concerning spleocytes cd + and cd + cells were similarly reduced to about % and % after hrs and to % and % in g and g mice compared to sham mice. splenocytes of g-treated mice, which could only be investigated at hrs postclp showed no difference to sham mice. as far as b cells are concerned no significant differences between the groups or different time points could be detected. relative numbers of peripheral t cells expressing the early activation marker cd or cd were clearly more pronounced at hrs compared to hrs in and g mice. in g treated mice cd and cd positive t cells were significantly higher at hrs compared to sham mice. a mild clp model is more appropriate to study during murine sepsis. the rapid occurrence of peripheral activated t cells suggest a very early function of the adaptive immune system during sepsis. considering a milder disease course of g mice they seem to more efficiently use their t cells to fight the infection. thymocyte data suggest a block in lymphopoiesis from cd -cd -to cd +cd +. b cells are not likely to play a major role in polymicrobial murine sepsis. further studies have to be performed to elucidate the turnover and the homing of lymphocytes during sepsis. endotoxaemia is associated with intestinal perfusion deficits and gut barrier failure. regional sympathetic blockade by means of thoracic epidural anaesthesia (tea) has been shown to positively affect intestinal microcirculation during endotoxaemia. this study tests the hypothesis that the microvascular changes observed with tea go along with an increase in overall gastrointestinal blood flow. in addition we investigated whether the use of tea influences gut barrier function. after approval of the animal care committee rats were anaesthetised (urethane/ketamine), hemodynamically monitored and mechanically ventilated with room air. lidocaine % or normal saline were administered as a bolus ( µl) and subsequent continuous infusion ( µl x h − ) via an epidural catheter (tip at t / , spread t -t ). organ blood flow (n = rats) was measured by the fluorescent microspheres technique at baseline, min after epidural infusion, and min and min after the infusion of endotoxin (e. coli lipopolysaccharide, . mg x kg- x h − ) or normal saline. for assessment of gut barrier failure rats (n = ) received a bolus infusion of endotoxin ( mg x kg- ) or normal saline and epithelial permeability to low molecular fluorescein isothiocyanate-dextran ( kd) was quantified using a ligated loop of terminal ileum after hours of normotensive endotoxaemia. in hypodynamic shock models pure o breathing was shown to redistribute blood flow in favour of hepato-splanchnic organs and to improve survival. in contrast, this therapeutic approach has not yet been evaluated in hyperdynamic septic shock, since an increased production of o radicals, which is directly related to the increased o partial pressure, is considered as harmful. therefore, we investigated the effects of pure o breathing on hepato-splanchnic macro-and microcirculation, energy balance and tissue cell death during porcine fecal peritonitis. after induction of fecal peritonitis, pigs were randomly ventilated for h with % o (n= ) or an fio adjusted to yield a sao > % (n= ). before as well as at and h of peritonitis we measured cardiac output as well as hepatic artery and portal vein (pv) flows (ultrasound flow probes), microcirculation in the intestinal wall (laser doppler flow), intestinal wall oxygenation, portal and hepatic-venous acid-base status, and lactate/pyruvate (l/p) ratios. apoptosis was analysed post-mortem in liver biopsies with the tunel assay. within group effects were analyzed using a friedman anova on ranks, intergroup differences with an unpaired rank sum test. at the end of experiment the contribution of both pv and total liver blood flow to cardiac output was significantly higher in the hyperoxic animals than in the control group (qliver/co ( ; )% vs. ( ; )%, p= . ; qpv/co ( ; )% vs. ( ; )%, p= . , respectively), which was concomitant with attenuated regional venous metabolic acidosis and lower hepatic-venous l/p-ratios. intestinal wall microcirculation and oxygenation did not significantly differ between the two groups. the hyperoxic animals presented with a markedly reduced number of apoptotic cells in the liver. our results show that early % o ventilation redistribute blood flow in favour of the hepato-splanchnic system even in peritonitis-induced hyperdynamic septic shock. furthermore, the hepatic energy balance is improved and the morphologic integrity of the liver better maintained under these conditions. grant acknowledgement. supported by the eli lilly-esicm sepsis elite award, the alexander-von-humboldt-stiftung, and the deutscher akademischer austauschdienst glucocorticoids are known as strong modulators of immune response that play an important role in patophysiology of sepsis and inflammation. they have strong influence on the development of immune system, its effector functions, and trafficking of immune cells.the biological activity of glucocorticoids depends not only on their plasma concentration, the number of receptors and the responsiveness of the target cells but also on the local metabolism of glucocorticoids that is predominated by b-hydroxysteroid dehydrogenase ( hsd). two isoforms of hsd are known. the isoform hsd operates in vivo predominantly as a nadph-dependent reductase that locally increases glucocorticoid concentration (cortisol, corticosterone) by reduction their -oxo derivatives (cortisone, dehydrocorticosterone) . the isoform hsd is a sole nad+-dependent dehydrogenase that inactivates biologically active glucocorticoids to their inactive -oxo derivatives. the aim of this study was to investigate peripheral metabolism of glucocorticoids in immune cells and tissues in experimental model of sepsis and inflammation. sepsis was induced in balb/c mice and wistar rats by intraperitoneal administration of lipopolysaccharide or pooled fecal inoculum. in these animals and in healthy controls we measured expression and activity of hsd in lymphatic nodes, peripheral blood leukocytes and alveolar macrophages. activity was measured by incubation with corticosterone and -dehydrocorticosterone, following hplc determination. the abundance of hsd mrna was measured by semi-quantitative real-time rt-pcr. for years etomidate has been known to cause adrenal insufficiency in the critically ill and is a confounder when studying corticosteroids in septic shock. subgroup analysis of a prospective, randomized, placebo-controlled study of corticosteroids in septic shock. patients underwent a short high dose acth test before study drug administration. patients received d treatment with hydrocortisone (hc) or placebo (p). the affects of etomidate administration on acth responsiveness and d mortality were studied. results. patients were enrolled. overall . % patients died in the hc group and % in the p group (p= . ). in total % of patients received etomidate. received etomidate before baseline [ % hc group + % p group] and in after baseline [ % hc group + % p group]. overall, more of the patients receiving etomidate were acth nonresponders [ % vs %] . no mortality differences was seen between patients receiving etomidate at any time during study and those who did not receive etomidate [ . % vs. . %](p= . ). there was a possible trend towards a difference in mortality between patients who received etomidate in the hrs before randomisation [ % hc vs. % p] or not receiving etomidate during this time period [ % hc vs. % p](p= . ). etomidate was commonly used in patients in the corticus study. etomidate was associated with an increased likelihood of adrenal hyporesponsiveness in all patients. there was no increase in mortality associated with etomidate administration at any time, there was a trend towards increased mortality in those who received it in the hours before trial baseline. this result comes from an underpowered subgroup and should be considered exploratory. d. pestaña* , e. martinez-casanova , a. buño , r. madero , a. criado anestesia-reanimación, análisis clínicos, bioestadística, hospital universitario la paz, madrid, spain introduction. steroids are indicated in septic shock patients when relative adrenal insufficiency is suspected. our aim was to study if the measurement of total proteins ( ) and eosinophil count ( ) improves the accuracy of cortisolemia to predict the hemodynamic response to steroid treatment in this setting ( ). we analysed data from consecutive surgical patients with criteria of septic shock receiving steroid treatment. four criteria were chosen to define hemodynamic improvement based on the combination of noradrenaline (na) withdrawal (at and h) and an increase of the hemodynamic index (hi = mean arterial pressure/na dose) of % at h and of % at h. the accuracy of the baseline cortisolemia to predict the hemodynamic response to steroid treatment following the four criteria was determined by roc curve analysis. the largest area under curve (auc) was found for the noradrenaline withdrawal or an increase of the hi > % at h after starting the steroid treatment (table ) . this criteria was met by patients ( %) and was associated with a lower mortality ( . % vs . %, p= . , % sensibility and . % specificity). however, no clear cortisolemia cut-off value for the diagnosis of adrenal insufficiency based on the hemodynamic response could be found. neither the basal proteins nor the eosinophils improved the accuracy of cortisolemia to predict a hemodynamic improvement. mortality was also related to age (p= . ), apache ii (p= . ) and sofa score (p= . ). neither basal cortisolemia nor lactate were related with icu mortality. twelve septic shock patients admitted to the icu < hours after family consent were enrolled. we excluded all patients in use of steroids in the preceeding months, etomidate, espironolactone, oestrogens, oral contraceptives, ketoconazole or any other drug known to suppress adrenal function; aids, pregnancy, history of disease of the hypothalamic-pituitaryadrenal axis, shock of other etiologies. after a baseline serum cortisol was obtained, a ld ( ug) corticotropin stimulation testing was performed. subsequently, serum cortisol at and min was measured. four hours later, another bc was obtained. then, a hd ( ug) corticotropin stimulation testing test was performed and serum cortisol was again measured after and min. results. both baseline serum cortisols were similar. delta hd cortisol was higher than delta ld cortisol ( . ± . vs. . ± . ug/dl, p= . ). five patiens had a bc < ug/dl, but only one showed rai in both tests. concordance between ld and hd tests was % ( / ). it was strong for responders ( %, / ) but weak for non-responders to ld test ( %, / ). the preliminary results of our study suggest that a ld test is a more sensitive test than a hd test. a further study comparing treatment of rai defined by a ld or a hd test is still needed. the potassium channels (kc), atp-sensitive k+ (katp) channels and calcium-activated potassium (bk) channels, may be implicated in shock induced vasoplegia. the aim of our study was to demonstrate that the potassium channels are overexpressed in experimental shock independently of the etiology. three rats models of shock were used : peritonitis by caecal ligation and perforation (clp, n= ) observed at h, ischemia-reperfusion model (hemorrhagic shock + resuscitation + laparotomy, n= ) observed at h, and pressure fixed hemorrhagic shock (n= ) observed at h. these three models were compared to a control group. we performed quantitative real-time pcr (lightcycler technology -roche -and sybr green -sigma) and western blot on aorta and mesenteric arteries. we studied the expression of the vascular smooth muscle katp channels -kir . and sur b subunits -and bk channels -bk alpha subunit. we assessed the inflammatory syndrome in studying inos expression. we were able to detect kir . , sur b, bk alpha and inos arnm in both vessels. quantitative real-time pcr results (reference gene : beta-actine) clp clp ir ir hs hs aorta mesenteric aorta mesenteric aorta mesenteric inos . ± . * . ± . * . ± . * . ± . * . ± . * . ± . * expression kir . . ± . . ± . * . ± . * . ± . * . ± . * . ± . * expression sur b . ± . . ± . * . ± . * . ± . * . ± . * . ± . expression bk alpha . ± . * . ± . * . ± . * . ± . * . ± . . ± . expression * : p< . vs control group conclusion. various potassium channels are activated and up-regulated during shock independently of the etiology. thus, potassium channels likely play a major role in sepsis but also in prolonged and severe hemorrhagic shock and in ischemia reperfusion. (cars) . a predominantly anti-inflammatory reaction induces immunosuppression with impaired host defense. application of gm-csf to patients with major surgery or sepsis has been proposed to improve host-defense. in this study we investigated the differential effects of gm-csf production in an ex-vivo model. and lps on the tnf-a. whole blood of healthy donors (age - years, mean years) was used to determine optimal concentrations and incubation time for lps. the immunomodulating properties of gm-csf (leukine ® (sargramostim), berlex)) were investigated in whole blood of healthy donors ( - years, mean years) and icu patients suffering from sepsis. six of the patients had immunoparalysis as defined according to local standards by a monocytic hla-dr expression of < mfi and an ex-vivo stimulation test of < pg/ml after lps incubation (dpc biermann, bad nauheim , germany), whereas the other displayed a hla-dr expression of > mfi and a ex-vivo stimulation test of > pg/ml. samples were primed either with gm-csf, gm-csf simultaneously or lps prior to incubation. tnf-a and il- concentrations were determined with the immulite chemoluminescence immunoassay system (dpc-biermann, bad nauheim, germany). leukocyte phenotyping was performed by dual-colour flow cytometry using whole blood lysis technique and monoclonal antibodies. in healthy donors, ex-vivo stimulation with lps leads to a massive increase of tnf-a production. however, if whole blood is incubated with gm-csf hours prior to the lps challenge, the tnf-a production is significantly increased. the simultaneous incubation with lps and gm-csf leads to a significant decrease in tnf-a levels in the same patient population. gm-csf stimulation of whole blood hours after the production. in patients lps challenge causes no significant change in tnf-a levels of with sepsis and endogenous tnf-a < pg/ml, gm-csf pre-incubation production, whereas patients leads to a significant increase in ex-vivo tnf-a had a blunted ex-vivo reaction to lps with higher endogenous levels of tnf-a stimulation. both the sequence of stimulation with either gm-csf or lps and the presence or absence of systemic tnf-a determine the ex-vivo cytokine response of whole blood. hence, it may be speculated that . the administration of gm-csf prior to the inflammatory stimulus would be most efficient, and that . the lack of stimulation effect in patients with high endogenous tnf-a may mirror endotoxin tolerance. the most common acquired causes of weakness and muscle wasting in the critically ill patient in the intensive care units (icu) are critical illness polyneuropathy and critical illness myopathy. there is significant clinical and neurophysiologic overlap between the two conditions, such that the term critical illness polyneuropathy and myopathy (cipnm) is often used. over a -mo period, critically ill patients who needed prolonged intensive care were studied. clinical manifestations include delayed weaning from the respirator not explained by pulmonary complications, muscle weakness and prolonging of the mobilization phase. included patients were classified as having mof, sirs and sepsis according to established consensus definitions. the occurrence of a positive emg for cipnm, as defined by an electrophysiologist who was blinded for treatment allocation, was analyzed during icu stay. variables recorded at baseline and during follow-up included patient demographics, principal diagnosis, routine blood tests and microbiological culture results. levels of tnf-alpha, il- , il- , il- , procalcitonin (pct) and c-reactive protein concentrations were repeatedly measured by elisa. all patients were divided in: patients without cipnm at any time (group a, n= ), with a positive emg during icu stay (group b, n= ), and with a diagnosis of cipnm since the admission (group c, n= ). emg testing demonstrated severe acute denervation with striking involvement of proximal muscles in patients. patients died of complications of sepsis. critically ill patients without cipnm showed serum il- levels lower (p < , ) than those with a diagnosis of cipnm while no differences were found as concerned serum il- levels. il- and tnf-alpha did not show any difference between the two groups. il- levels resulted higher in groups a and b (p < , ) while il- levels were higher in group a (p < , ). in the group b, we observed a characteristic pattern of il- and il- serum concentrations that may be important for clinical outcome. il- levels were higher than il-l in patients with worse clinical outcome. the opposite pattern was observed in those with a good prognosis. no differences in clinical and laboratory variables were observed between patients with and without cipnm. pct appeared to be most helpful in differentiating patients with sepsis from those with sirs (p < , ), exhibiting a greatest sensitivity ( %) and specificity ( %). conclusion. the analysis of the serum cytokines il- , il- , tnf-alpha and il- to standard indicator did not improved the predictive power of detecting cipnm but may contribuite to explain its pathogenesis. high dose glucocorticoids are known to induce muscle weakness. we investigated in a pilot study the occurrence of cip/cim in septic shock patients treated with low dose hydrocortisone (hc). patients were enrolled in the randomized controlled study of hc in septic shock (corticus) and received hc ( mg q h for days, tapered until day ) or placebo (pl). electrophysiological testing (ep) consisted of the assessment of compound muscle (cmap) and sensory nerve action potentials (snap), spontaneous activity (spa), and muscle membrane excitability investigated by direct muscle stimulation (dms). clinical muscle weakness was defined by a medical research council scale (mrc) below . cmap and snap were categorized based upon normal age related values. ep results were categorized as unspecific (cim or cip or both) when cmaps and spas were pathological in >/= muscles. presence of cip was defined by pathological snaps in >/= nerve, and cim by dms values < mv. data are shown as mean and %ci, chi square test and mann-whitney-u-test were performed for statistical analysis. from jun -feb , patients were enrolled in sites: hc and pl. median time for ep assessment was days ( - ) after study enrolment. pl and hc patients had unspecific electrophysiological signs; pl patients, but only hc patient had reduced snaps indicating cip. in patients dms could be performed, / pl and / hc patients showed reduced muscle membrane excitability indicating cim. in patients (pl , hc ) evaluation of mrc score was possible. muscle strength did not differ between placebo [ . ( / . )] and hc group [ ( . / . )]. none of the parameters reached statistical significance. conclusion. the frequency of cip/cim diagnosed by electrophysiological examination was higher in patients who received placebo. the clinical diagnosis of muscle weakness assessed by mrc scale was not different in both groups. with limitations of the small sample size, this first prospective evaluation showed no impact of hc on the development of cip/cim in this cohort of patients with septic shock. surviving sepsis campaign guidelines recommend treatment with hydrocortisone in septic shock patients requiring vasopressor support. however, the association of fludrocortisone remains controversial. the objective of the study was to determine if the association of fludrocortisone in patients with septic shock and adrenal insufficiency treated with hydrocortisone is related to an improved outcome. from a database including patients with septic shock requiring vasopressor support, we retrospectively studied patients who fulfilled criteria for adrenal insufficiency (baseline cortisol less than µg/dl and/or an increase after injecting µg synacthen less than µg/dl). all patients included received treatment with hydrocortisone (h) or hydrocortisone plus fludrocortisone (h+f) for at least h. data are presented as mean ± standard deviation. groups were compared by using student's t test for continuous variables and chi-square test for categorical variables. long rank test and kaplan-meier curves were used to analyze time to shock reversal and mortality. forty-eight patients received hydrocortisone (h group) and hydrocortisone plus fludrocortisone (h+f group). overall mortality was % ( patients). both groups were comparable in baseline clinical and demographic characteristics. no differences were found in age (mean age ± ), gender, weight ( ± vs ± , p , ) (kg), infection site and severity scores: saps ii ( ± vs ± , p , ), apache ii ( ± vs ± , p , ) and sofa max ( ± vs ± , p , ). both groups presented no differences regarding baseline ( ± vs ± ,p , ), stimulated ( ± vs ± , p , ) and delta cortisol values ( , ± , vs , ± , , p , )(µg/dl). we did not find differences between both groups in norepinephrine(ne)maximal dose received(µg/kg/min), time to shock reversal (days of ne use), time of mechanical ventilation, icu and in-hospital length of stay (days) and mortality ( prospective, randomized, double-blind, placebo-controlled study of -day mortality in patients with septic shock for less than hr who underwent a short high dose acth test in centres in european countries. patients received -day treatment with hc ( mg q h for days, q h for days, q hr for days) or placebo (p). serum electrolytes levels were obtained at baseline, day (d ), day (d ), day (d ) and day (d ) from randomisation. from mar -nov , patients were enrolled. baseline serum sodium were ( ) mmol/l and ( ) mmol/l in the hc and p group respectively. serum sodium peaked at d ( mmol/l) and remained elevated up to d ( mmol/l) in the hc group. in the placebo group, serum sodiumpeaked at d ( mmol/l). the mean change in serum sodium were, in hc treated and p treated patients respectively, at d : . ( . sd) vs . ( . ) mmol/l; d : . ( . ) vs . ( . ) mmol/l; d : . ( . ) vs . ( . ) mmol/l; and at d : . ( . ) vs . ( . ) mmol/l. the difference between groups reached statistical significance at day (p= . ). there were no significant changes in mean potassium levels over time between the two treatment arms. according to the guidelines for the management of severe sepsis and septic shock, low doses of steroids are recommended in septic shock patients requiring vasopressors, despite adequate fluid replacement. the aim of this retrospective case control study was to assess the effectiveness of low doses of hydrocortisone in patients with late septic shock and mods. the study was held in a bed multidisciplinary icu of a tertiary hospital. twenty four norepinephrine dependent (> . γ /kg/min) patients, fulfilling the criteria of septic shock, were enrolled in the study. patients were divided in groups according to the continuous administration of mg hydrocortisone for days (group a: pts) or conventional treatment (group b: pts). end points of the study were, the within days vasopressors weaning, evolution of mods and -day as well as -day survival. mods was described by sofa score. statistics : statistical analysis was computed by using paired t-test and linear regression analysis. groups were similar regarding demographics ( ± vs ± y), initial sofa score ( ± vs , ± ), initial norepinephrine dose ( . ± . vs . ± . γ /kg/min) and mean elapsed time from the onset of shock ( . ± . vs . ± . days). an early and significant decrease in norepinephrine dose (p< . ), was observed in all group a pts, while no difference was detected in group b pts. this decrease was associated with hemodynamic stability. on days and mean abp was significantly higher in group a pts (p< . , p< . ). weaning from vasopressors within days was achieved in pts in group a ( . %) and pts in group b ( . %). seven day mortality was . % in group a vs % in group b while -day mortality was % and % respectively. in the treatment group a positive correlation between the within days shock reversal and survival (cor coeff = . , r = . , p= . ) was found. there was no relation between the time elapsed from the onset of shock to the steroid administration and survival (p= . ). oxygenation parameters (fio /po ), sofa score and creatinine did not differ between groups. wbc in group a pts were significantly higher (p< . ) only on day . no significant adverse effects were detected. in late septic shock patients with mods the administration of low doses of hydrocortisone is associated with decreased vasopressors requirements, hemodynamic improvement and beneficial effect on survival. the within days shock reversal was a good predictor of survival. introduction. early microcirculatory impairment followed by mitochondrial dysfunction may combine to produce multi-organ failure in sepsis. we recently reported that tissue oxygen tension (tpo ), the balance of local o supply/demand, is variably affected in four different organs (kidney cortex, liver, muscle, bladder) at h' post-endotoxin challenge ( ). we seek to measure temporal changes in tpo in these organs in a resuscitated rat model for up to h following the onset of faecal peritonitis. here we present our -hr timepoint results with assessment of the impact of fluid loading. methods. male wistar rats (approx g weight) with tunnelled right jugular venous cannulae in situ received i.p. injection of faecal slurry. fluid ( : mixture of % glucose/ % hetastarch; ml/kg/h) was started h later. at h, rats were anaesthetised with isoflurane, and then instrumented with a left common carotid arterial line and tissue po probes (oxford optronix, uk) sited in thigh muscle, between right and left liver lobes, in the left renal cortex and within the bladder lumen. after -min stabilisation, recordings were made of bp, tpo , and end-diastolic volume (edv) and cardiac output (co) by echocardiography (vivid , ge healthcare, bedford, uk). this was performed before (bi, baseline instrumented) and after fluid challenge (f) of ml/kg bolus of % hetastarch given to optimise lv filling. comparisons were made against sham-operated animals that underwent instrumentation but received no i.p. injection. notwithstanding considerable volume resuscitation beforehand, left ventricular filling and output were significantly reduced at h in this faecal peritonitis model. despite the % reduction in output, baseline tpo values were similar in bladder and renal cortex compared to sham animals but showed a decreased trend in muscle and a significant reduction in liver. fluid loading restored cardiac output to control values, however only muscle and liver tpo increased, albeit not significantly. these data suggest a combination of microcirculatory and mitochondrial dysfunction with each predominating in different organ beds at this timepoint. confirmation is required using complementary techniques. microcirculatory dysfunction leads to inadequate tissue oxygenation and multi organ failure during sepsis or septic shock. aim of this study was to compare non-invasive assessment of tissue oxygen saturation (sto ) with systemic oxygenation using mixed venous oxygen saturation (svo ) as an indicator in an established model of porcine septic shock. in a prospective animal study anaesthetised, ventilated pigs ( . ± . kg) were investigated. animals received g/kg/body weight faeces into abdominal cavity to induce sepsis and were observed over hours. volume therapy was administered to maintain a central venous pressure of mmhg. svo measured by co-oxymetry (radiometer, copenhagen) was obtained hourly after induction of sepsis. at the same time quadriceps muscle sto was measured by near-infrared spectroscopy (nirs) (inspectra tm , hutchinson, usa). correlation was analyzed by linear regression analysis. a total of measurements were performed in animals. sto was significantly correlated with the svo . r = . (r = . ) (p< . ) and y = , x + , . comparing the change in sto and svo of two successive measurements reveals a correlation of r = . (r = . ) (p< . ). changes in sto and svo were parallel in % of two successive measurements (both measurements changed at the same time in the same direction). although there is a significant correlation between sto and svo in our experimental septic shock model, paired sto and svo changed in the same direction only in %. thus, svo may not be estimated on the basis of sto in treatment of experimental septic shock and tissue oxygenation may not be estimated on the basis of svo either. whether a combination of sto and systemic oxygenation measurements is a useful monitoring approach in sepsis needs to be revealed. grant acknowledgement. inspectra device was provided by hutchinson. systemic immune response syndrome (sirs) frequently develops in critically ill patients and may lead to multiple organ dysfunction or failure even in the presence of normal or normalized global hemodynamic parameters, mainly due to tissue dysoxia and microvascular dysfunction. near infrared spectroscopy (nirs) is a validated method for the assessment of tissue oxygenation but its accordance with routine parameters has not yet been sufficiently studied. aim: to compare nirs parameters to routine monitoring parameters of the critically ill. thirty two consecutive critically ill patients (age= ± years, male/female= / , length of icu stay= ± days) were enrolled. all patients were evaluated with nirs and the occlusion technique within hours of icu admission. all patients were mechanically ventilated and were sedated. routine hemodynamic parameters (mean arterial pressure= ± mmhg, central venous pressure= ± mmhg, heart rate= ± ), full blood analysis (hemoglobin= . ± . g/dl, white blood cells= , ± , /dl) and arterial blood gases analysis were recorded. sofa, apache ii and saps iii ( ± ) scores were assigned on icu entry day. tissue oxygen saturation (sto %) was continuously monitored before, during and after -min occlusion of the brachial artery via pneumatic cuff inflated up to mmhg above measured systolic arterial blood pressure. (elwi) has been demonstrated to predict mortality and to correlate to pao /fio -ratio and to the compliance of the lungs in patients with sepsis and ards. however, with an increasing number of obese patients, there is the question which body weight should be used for indexation of elwi. therefore it was the aim of our study, to investigate the correlation of elwi to pao /fio -ratio and oxygenation index (mean airway pressure* / pao ) using different weight parameters for indexation. in patients of a medical icu with a body mass index > kg/m , measurements of extravascular lung water were performed using the picco system (pulsion, munich; . . software). extravascular lung water was indexed using the actual body weight (abw), predicted (pbw), ideal (ibw) and adjusted body weight(adbw) , respectively. these data were correlated to pao /fio -ratio and oxygenation index. spearman correlation, spss-software. the highest correlation to pao /fio -ratio was found using adbw, the highest correlation to oxygenation index for elwi adjusted to pbw. .) although the extent of correlation varied within smaller limits (- , to - . and . to . , respectively), the distribution of the patients within "normal", "modestly elevated" and "significantly elevated" elwi would have changed markedly using different indices. .) with regard to impaired respiratory function in the patients of our study, pbw, ibw and adbw seem to more accurately reflect "functional" extravascular lung water than abw with % of the patients in the normal range. our objective is to analyse the hemodynamic profile and the extravascular lung water in the first stages of severe acute pancreatitis (sap) that are admitted at the intensive care unit (icu), through the collected data by transpulmonary thermodilution. observational and prospective study, in which -sap-diagnosed patients consecutively admitted at the icu were analyzed. all of them were monitorised at their admission with continuous cardiac output system picco ® (pulsion medical systems). demographic variables, general (apache ii and sofa) and specific (balthazar) severity scores as well as the development or not of respiratory failure, were collected. the ordinary hemodynamic parameters [heart rate (hr), mean arterial pressure (map), cardiac index (ci), vascular resistances (svri)] were determined on days , , and as well as preload parameters [intrathoracic blood volume index (itbi), global end-diastolic volume index (gedi)], extravascular lung water index (elwi) and pulmonary vascular permeability index (pvpi) according to picco ® methodology. the results are expressed as means±sd and percentages. the non-parametric mann-whitney test for quantitative variables was performed and statistical significant level was established at p< . . age was ± years with a majority of males ( %). the biliar was the most frequent cause ( %). apache ii= ± and sofa= ± . all patients showed an alteration determined by ct scan (balthazar grading system) degree c or higher. seven patients ( %) needed mechanical ventilation in the first hours. hospitalary mortality was of %. on day , the ci ( . ± . l/min/m ) and the rvsi ( ± din.seg.cm - .m ) were at normal parameters and only patients needed vasopressor support. however, on days and , the preload parameters were low (itbi= ± ml/m and gedi = ± ml/m ) and improved on the th day (itbi= ± ml/m and gedi = ± ml/m ). patients with respiratory failure and mechanical ventilation showed neither higher elwi nor higher pvpi than the rest (day , elwi: . ± . vs . ± . ml/kg; pvpi: . ± . vs . ± . ; p=ns). in our population, certain hypovolemia degree in the first stages of the disease was found, corresponding to the development of the third space. the respiratory failure associated is not mainly due to an extravascular lung water increase or to a permeability increase. . ( . - . ) . ( . - . ) . cpo after dobutamine (w) . ( . - - ) . ( . - . ) . poap: pulmonary occlusion arterial pressure, swi: stroke work index. conclusion. cpodelta after dobutamine challenge is a good predictor for mortality in ss. septic shock is a common disorder with a high mortality. recent guidelines for the haemodynamic management of severe sepsis have emphasized the importance of aggressive volume resuscitation in the initial phase. central venous pressure (cvp) and pulmonary capillary pressure (pcp) are common end-points for volume resuscitation, however these cardiac filling pressures are poor predictors of fluid responsiveness in septic patients. right ventricular end diastolic volume index (rvedvi) is a better predictor of preload, and it allows the identification of patients with right ventricular (rv) dysfunction and dilation (> - ml/m ), as well as predicting mortality. we correlated rvedvi with pcp, cvp and hypoperfusion variables during septic shock initial management. longitudinal, prospective and observational study. demographic, haemodynamic (rvedvi, pcp, cvp) and hypoperfusion (lactate, base deficit) variables were obtained. descriptive statistics with mean ± sd (numerical variables) and frequencies and percentages (categorical ones). comparisons between groups with u mann-whitney test and x and fisher exact test as needed (statistically significant value if p< . ). results. patients (mean age ± )were divided in: survivors n= (rvedvi ± ml/mt ) and non-survivors n= (rvedvi ± ml/mt ). early dilation of rv predicts survival with a sensibility of % sensibility and specificity of %. methods. ten patients with severe sepsis ± yr, patients with septic shock ± yr and polytrauma patients with hemorrhagic shock ± yr, who remained in icu more than hours were included in the study. serial bnp measurements were performed for at least days. consecutive hemodynamic measurements were done using a right ventricular ejection fraction (rvef) thermodilution catheter (edwards). transthoracic echocardiography was performed in the first two days. . bnp values ( st day) was dramatically elevated in septic shock ( ± pgml- ), significantly elevated in severe sepsis ( ± pgml- ), but within normal limits in hemorrhagic shock ( ± pgml- ) (p< . ). inotropes (noradrenaline) were similar in patients with septic or hemorrhagic shock on day . bnp levels did not correlate with pulmonary arterial wedge pressure, right atrial pressure, rvef or left ventricular ef (lvef) measured by echocardiography. eleven patients with septic shock, with sepsis and with hemorrhagic shock died during days. bnp decreased gradually in survivors from septic shock after day . septic shock survivors had lower apache ii, and increased rvef and lvef compared to non-survivors ( ± , ± and ± vs ± , ± and ± respectively, all p< . ), but not bnp ( ± vs ± pgml- ). in conclusion, bnp is significantly elevated in sepsis, mainly in patients with septic schock, probably indicating the level of inflammation severity. inotropes, shock and myocardial stretch, as it is expressed from hemodynamic parameters, do not seem to be implicated to bnp release. sepsis and septic shock are major causes of mortality and morbidity in the icu. if inflammatory mediators responsible of sepsis remain elevated or if there is a poor cardiac function, septic myocardial dysfunction may occur, increasing morbidity and mortality. brain natriuretic peptide (bnp) is an adequate biomarker for cardiac failure so our objective was to determine its utility in predicting myocardial dysfunction in septic patients. the role of hemofiltration, its dose and biological effects in sepsis remain a contentious issue. although some beneficial effects on systemic hemodynamics and reduced vasopressor requirement were reported, the potential of hemofiltration to prevent sepsis-related disturbances of microcirculation and energy balance has not been evaluated. therefore, we investigated the effects of standard hemofiltration (hf, ultrafiltration rate ml/kg/h) and high volume hemofiltration (hvhf, ml/kg/h) during h hyperdynamic porcine septic shock. in mechanically ventilated and instrumented pigs fecal peritonitis was induced by inoculating autologue feces. h after induction of sepsis pigs were randomly assigned to three groups: ) controls (n= ), ) hf (n= ), ) hvhf (n= ). before, , and h after the induction of peritonitis we measured, in addition to systemic and regional hemodynamics, ileal mucosal and renal cortex microvascular perfusion (ops and laser doppler flowmetry). energy balance was determined by measuring arterial lactate pyruvate (l/p) and hepatic venous ketone body (kbr) ratios. in the control group hyperdynamic septic shock resulted in a progressive deterioration of intestinal mucosal and renal cortex microvascular perfusion despite well-maintained regional blood flows. altered microcirculation was paralleled by gradually increased l/p and kbr indicating disturbed energy balance. compared to six animals in the control group, only three and two pigs required noradenaline support in hf and hvhf group, respectively. however, neither hf nor hvhf blunted the sepsis-induced alterations in microvascular perfusion and cellular energetics. in this clinically relevant model of septic shock, the protective systemic hemodynamic effects of early hemofiltration did not translate into the improved microvascular perfusion and energy metabolism. hvhf did not confer any additional benefit. the value of hemodynamic improvement as a surrogate marker for efficacy of hf is therefore ambiguous. patients in prolonged septic shock show enhanced pressor sensitivity to vasopressin(vp) yet decreased response to norepinephrine(ne). as both act via g protein-coupled receptors and activate the inositol phosphate cascade to increase vascular smooth muscle(vsm) ca + levels, the reason for this disparity is uncertain. we postulate that these drugs may have diverse effects on different ca + mobilisation pathways during sepsis. we investigated this using specific modulators of ca + release and influx on contractile responses to vp and ne in mesenteric arteries from septic and sham-operated rats. sepsis was induced in awake, fluid-resuscitated wistar rats by ip injection of fecal slurry. paired sham controls received no injection. rats were sacrificed after h, and mesenteric arteries mounted on a wire myograph to measure isometric tension responses to vp and ne. the contributions of sarcoplasmic reticulum(sr) ca + release and ca + entry through the store-operated channel(socc) were assessed by removing and returning extracellular ca + respectively. the contribution of the voltage-gated ca + channel(vgcc) was assessed by applying vp/ne in the presence of nifedipine. contractions were significantly enhanced to vp but depressed to ne in septic vessels . in all arteries, constriction to both agonists relied predominantly on extracellular ca + influx rather than sr ca + release. ne responses were more sensitive to extracellular ca + removal in septic vessels. the ca + influx in response to ne was almost entirely vgcc-mediated, with a negligible contribution from soccs in both sham and septic arteries. soccs contributed significantly to vp contraction however, and socc-rather than vgcc-mediated influx of ca + predominated in septic arteries. patients in prolonged septic shock show enhanced pressor sensitivity to vasopressin (vp) yet decreased responsiveness to norepinephrine (ne). we have reproduced this pattern in ex-vivo contractile responses of resistance arteries taken from rats subjected to a clinically realistic septic insult ( ). we hypothesise that an underlying mechanism is vp-mediated sensitisation of the vascular smooth muscle contractile apparatus to calcium. to investigate this, we performed simultaneous wire myography and fluorescence microscopy to examine the relationship between contractile response and intracellular calcium concentration ([ca + ]i). sepsis was induced in conscious, tethered, male wistar rats by intra-peritoneal injection of faecal slurry. paired sham controls received no such injection. both groups received ml/kg/hr of intravenous fluid. after hours, animals were sacrificed, and rd order mesenteric arteries dissected and mounted on a wire myograph (danish myo technology). arteries were loaded with a fluorescent calcium indicator (fura- , mum) for hour and imaged by fluorescence microscopy. [ca + ]i and isometric tension kinetics were measured simultaneously in response to vp ( nm) and ne ( mum). ]i was higher in arteries taken from septic rats. tension responses to vp were significantly enhanced in septic arteries, however the associated increases in [ca + ]i were comparable in septic and sham groups. tension responses to ne were significantly decreased in septic arteries, with a similar degree of depression in delta [ca + ]i. data were analysed for statistical significance using un-paired t tests. conclusion. the higher baseline [ca + ]i in the vascular smooth muscle of septic arteries suggests an abnormality of intracellular calcium storage. the ability of vp to produce a greater contractile response in septic compared to sham arteries, despite an equivalent degree of [ca + ]i elevation, implies sensitisation of the contractile apparatus to the effect of vp. there was contractile hyporesponsiveness to ne in the septic vessels and no evidence of calcium sensitisation to this agonist. these findings provide one potential explanation for the hypersensitivity to vp observed in patients with septic shock. mitochondrial dysfunction and compromised cellular energetic status are associated with poor outcome in septic patients [ ] . maintenance of mitochondrial function is mediated in part by activity of transcription factors nrf- and nrf- , the transcriptional co-activator pgc -alpha and mitochondrial transcription factor alpha (tfam). these markers of mitochondrial biogenesis were elevated in a rodent model of endotoxaemia [ ] . in an ongoing study in critically ill patients, we have investigated the relationship between cellular energetics and mitochondrial biogenesis. with ethics approval and appropriate consents, critically ill patients were recruited within h of icu admission. age-matched control patients were undergoing elective hip surgery. muscle biopsies were taken from vastus lateralis. atp and creatine compounds were determined by hplc of perchloric acid extracts and standardised to total creatine [total cr = phosphocreatine (pcr) + creatine (cr)]. mrna levels for pgc -alpha, nrf- and tfam were determined by rt-pcr and standardised to s mrna. data were analysed for significance using one-way anova. the ratio of pcr/cr was significantly decreased in both survivors and non-survivors. mrna levels of the mitochondrial biogenesis markers pgc- alpha and nrf increased in survivors but not in non-survivors. a similar pattern was observed with the mitochondrial transcription factor tfam, although statistical significance was not reached. ( ) the decreased pcr in both survivors and non-survivors indicates increased demand for atp in the acute phase of critical illness. ( ) increased levels of markers of mitochondrial biogenesis in survivors indicate that maintenance of mitochondrial function, specifically atp synthesis, may be crucial to recovery. failure to maintain adequate mitochondrial function through biogenesis may contribute to atp depletion and mortality. local metabolic changes are not well investigated in sepsis and sirs. our aim was to describe subcutaneous metabolic changes using microdialysis (md) concurrently with systemic hemodynamics over days in patients with sepsis/sirs and circulatory failure. methods. patients with severe sepsis/sirs were recruited. at inclusion, all patients had circulatory failure despite resuscitation according to the rivers concept. cardiac index (ci), intrathoracic blood volume index (itbvi), extravascular lung water index (evlwi), blood lactate (p-lac), md lactate (md-lac) and md lactate-pyruvate ratios (md-lac/pyr) were analysed - hourly. data were tested for differences over time using anova. patients were subdivided into sepsis and sirs groups, and intergroup differences were tested using the rank sum test. mean apache scores were & for sepsis & sirs respectively. sofa decreased from . to . with no difference between sepsis & sirs. ci increased over time and itbvi, evlwi, p-lac & md-lac decreased. md-lac & p-lac were maximal at day . lactate concentrations were generally higher in md than in blood, and in the sepsis group. severe sepsis and septic shock have been recognized as a serious clinical problem that shows an increasing incidence and that is responsible for substantial morbidity and mortality in intensive care units. sepsis has been defined as the systemic host response to infection with an overwhelming systemic production of both pro-and anti-inflammatory mediators. continuous hemofiltration has been suggested as possible therapeutic option that may remove the inflammatory mediators. on the other hand, hemodialysis and hemofiltration were reported to influence cardiac electrophysiological parameters and to increase the arrhythmogenic risk. therefore, in this study we have investigated the effects of hemofiltration on electrophysiological properties of the septic pig heart. methods. pigs of both sexes were divided into groups: ) control group without hemofiltration; ) control group with conventional hemofiltration ( ml/kg/hour); ) septic group without hemofiltration; ) septic group with conventional hemofiltration ( ml/kg/hour); ) septic group with high-volume hemofiltration ( ml/kg/hour). in septic groups, the sepsis was induced by fecal peritonitis and maintained for hours. hemofiltration was applied for the second hours of this period. ecg was measured just before and after -hours period of sepsis in septic groups and at the same time points in non-septic groups. action potentials were recorded in isolated ventricular preparations obtained from the hearts at the end of experiments. . rr and qt intervals were significantly shortened by sepsis in all septic groups, in non-septic groups they were not influenced by the experiment. action potential duration (apd) was also significantly shortened by sepsis (septic group without hemofiltration vs. control group without hemofiltration) at all cycle lengths tested ( , , ms). both conventional and high-volume hemofiltration in septic groups shortened apd further at slow pacing rates. hemofiltrate obtained in septic groups by both conventional and high-volume hemofiltration prolonged significantly and reversibly apd at all pacing rates. substitution solution alone had no effect on apd. neither hemofiltration nor hemofiltrate in control, non-septic groups influenced apd. we conclude that the hemofiltration in septic groups and the septic hemofiltrate influence significantly the electrophysiological properties of the heart, probably due to removal/content of various inflammatory mediators in the septic hemofiltrate. introduction. the precise mechanism by which multiorgan failure develops in severe sepsis and septic shock remains unclear. potential mechanisms include alterations of microvascular flow distribution, mitochondrial dysfunction and treatment effects. we investigated the effects of lps and different catecholamines on oxidative respiration of rat skeletal muscle fibers and hepatocytes. muscle fibers (m. gastrocnemius) were isolated from anesthetized male wistar rats ( - g). human hepatocytes (hepg cells) and human monocytes (monomac -mm ) were also used. to avoid systemic effects of endotoxin and catecholamines, experiments were performed in vitro using the skinned-fiber technique. the mechanically dissected muscle fibers were incubated with lps ( µg/ml) for h. after h of lps incubation, norepinephrine, dopamine, and dobutamine ( µm each) were added. monocytes and hepatocytes were treated with different concentrations of lps only. mitochondrial respiration was determined after permeabilization with saponin, using a clark type electrode (oxygraph k, orobros instruments, innsbruck, austria). septic shock is associated with severe cardiac dysfunction, whose mechanisms remain only partly defined. recent data suggested that it might be triggered by the direct action of microorganisms and their products on the heart itself. we previously shown that flagellin (flag), the protein monomer from bacterial flagella, is a potent activator of nf-κb-dependent pro-inflammatory signaling in cultured cardiomyocytes. therefore, the aim of the present study was to evaluate whether flag might induce such an inflammation in the heart in vivo and contribute to cardiac dysfunction. h c cardiomyocytes were stimulated with recombinant salmonella muenchen flag ( - ng/ml, min to h). in vivo, balb/c mice were injected (tail vein) with - µg flag ( min to h). the effects of flag were evaluated by its ability to activate nf-κb, and to induce transcription of tnfα and mip- cytokines. in vivo, cardiac neutrophils recruitment was evaluated by myeloperoxidase (mpo) activity. the expression of the flag receptor tlr was also determined. in vivo physiological measurements: left ventricular pression-volume curves. a microtip pressure-volume (pv) catheter (spr- ; millar instruments) was inserted into the left ventricle (lv) via the right carotid artery. the pressure and volume signals were continuously recorded and heart rate, cardiac output, end-systolic and end-diastolic volumes, stroke volume, ejection fraction and end-systolic and end-diastolic pressures were measured. load-independent indices of lv systolic and diastolic functions were determined by the slope of the end-systolic, respectively end-diastolic pv relationships in conditions of rapidly reduced preload (transient compression of the vena cava). . flag activated nf-κb in cardiomyocytes in vitro and in vivo, and also upregulated the transcription of tnfα and mip- . flag also increased cardiac neutrophils recruitment. flag induced significant increases in end-systolic and end-diastolic lv volumes, indicating cardiac dilation, and a significant reduction of the load-independent indices of lv systolic function (end-systolic pv relationship, espvr, and maximal elastance, emax), indicating significant lv systolic dysfunction. in contrast, no change in the slope of the end-diastolic pv relationship (edpvr) was noted. bacterial flagellin induces a prototypical inflammatory response in cardiomyocytes in vitro and in the myocardium in vivo. these effects are associated with a profound alteration of the lv systolic function in vivo, suggesting that flagellin may represent a critical mediator of cardiac dysfunction in septic shock. current guidelines recommend either dopamine (da) or norepinephrine (ne) as the initial vasopressor in septic shock (ss), but the management of moderate to severe ss is still controversial. to explore this issue is important, because pharmacodynamic differences between vasopressors might be irrelevant in mild cases, but could potentially affect outcome in more severe patients. beside clinical implications, there are also economical considerations since these drugs are not cost-equivalent. this subject may be specially important for developing countries. the aim of our study was to compare ne vs da as the exclusive vasopressor for established moderate to severe septic shock (requirements of > . mcg/k/min of ne or > mcg /k/min of da to maintain map to mmhg) multicentric rct involving nine polivalent icus from argentina, brazil and chile, randomizing moderate to severe ss patients to ne or da titrated to target map or maximal dose of mcg/k/min ne or mcg/k/min da. after inclusion patients were switched blindly to the assigned drug. the study could be stopped if severe hypotension or arrhythmias developed. epinephrine was used as a rescue drug. main outcome criteria were day mortality, organ dysfunctions and adverse effects (ae). the study was stopped early after randomizing patients because of low enrollment rate. only patients were evaluable. main results are shown on the table. adverse effects with da were cases of atrial fibrillation (af) and supraventricular paroxysmal tachycardia (spt), which were considered serious in cases. aes with ne were two af and one spt, which resolved with no drug suspension. aes occurred more frequently with higher doses of da. conclusion. the use of dopamine as exclusive vasopressor for established moderate to severe septic shock appears to be associated with a worst outcome and more adverse effects. this should be explored in a future better powered rct. although arterial blood pressure (abp) is a widely used guide for hemodynamic therapy in sepsis, few data exist on its association with mortality and on critical abp limits that should be maintained. in this retrospective cohort study, clinical, hemodynamic, and laboratory parameters were extracted from a prospectively collected database in sepsis patients. the severity and duration of hypotension was calculated by the area under the curve (auc) of systolic arterial blood pressure (sap), mean arterial blood pressure (map), and mean perfusion pressure (mpp = map -central venous pressure). laboratory parameters included the most aberrant variables during the icu stay. urine output per hour during the first hours and need for renal replacement therapy were recorded. the sepsis-related organ failure assessment (sofa) score was calculated from given clinical and laboratory parameters. binary and linear regression models were corrected for the severity of disease by inclusion of the saps ii (excluding sap count) as a covariate and were used to examine the association between abp and day-mortality or organ function. similarly, a binary logistic regression model including saps ii as a covariate was used to determine the best discriminating cut-off limit of abp in regards of day-mortality. the goodness of fit of each limit was assessed by the r -value according to the nagelkerke method. . sap and map were recorded for . ± . hours, mpp for . ± . hours. there was a significant association between day-mortality and the auc of sap (p< . , r = . ), map (p< . , r = . ), mpp (p< . , r = . ). the area under map mmhg and mpp mmhg was associated best with day-mortality. one or more episodes of map < or mpp < mmhg increased day-mortality by . (ci % . - . , p= . ) and . (ci % . - . , p= . ), respectively. there was a linear association between time under the critical map and mpp limit and day-mortality. while abp was significantly associated with the sofa score, arterial lactate levels, and renal function, no association with liver function or troponin i was observed. the critical map and mpp limits for the need for renal replacement therapy were mmhg (r = . , p< . ) and mmhg (r = . , p< . ), respectively. during early sepsis, abp is associated with day-mortality and organ function. mpp shows the best association with mortality and may be a new resuscitation target. animal models of traumatic brain injury (tbi) are used to elucidate sequelae underlying human head injury in an effort to identify potential neuroprotective therapies. although human tbi is a highly complex multifactorial disorder, animal trauma models tend to replicate only single factors involved in the pathobiology of clinical head injury and may thus partly underlie the discrepancy between preclinical and clinical trials of neuroprotective therapeutics. we here present our experience with a large animal model of tbi which was designed to closely resemble the forces impacting the brain in e.g. traffic accidents. anesthetized, mechanically ventilated instrumented sheep (n= ) were placed in prone position with the head resting on a support to allow free lateral movements of the head. a left-temporal head impact was then delivered by mechanical stunning device (mk , schermer, germany), which is approved for euthanasia of domestic lifestock. a captive bolt with a mushroom-shaped head is propelled from the muzzle of the stunner against the skull by the discharge of blank cartridge inserted in a chamber behind the proximal end of the bolt. depending on the charge and the positioning of the stunner, this device delivers an intracranial atmospheric pressure of approximately bar in sheep at a bolt velocity of approximately ms- . to prevent skull fractures, a steel plate was attached to the left temporal fossa. a fiberoptic intracranial pressure (icp) catheter and a brain tissue oxygen (pbro ) probe were introduced in the parietal white matter. unilateral ultrasound flowprobes were attached to the internal carotid artery to measure cerebral blood flow. after measurements, sheep were killed and the brains removed for neuropathological examination. brain injury was characterized by a marked increase in icp from ± to ± mmhg (mean values ± standard deviations) hours after head impact. intracranial hypertension was accompanied by a significant decrease of cerebral blood flow. pbro significantly decreased from ± to ± mmhg. the decrease in sinus venous oxygen saturation did not reach statistical significance. in instrumented control animals (n= ), parameters remained unchanged. neuropathological examinations revealed the presence of multifocal traumatic subarachnoid hemorrhage in , and diffuse axonal injury in out of animals. while interstitial brain edema was found in all sheep brains, contusion zones were present only in a minority of the animals. the pathobiological characteristics of the head impact model presented here closely resemble the alterations frequently found in human tbi. the relatively high variability of neuropathological changes after head impact may be seen as a disadvantage of this model. non-neurologic organ dysfunction triggered by infection represents a frequent and independent predictor of poor outcome in traumatic brain injury (tbi) patients admitted to intensive care units ( ). because tbi itself significantly increases susceptibility to infection ( ) and infection is a potentially modifiable risk factor, we developed a combined experimental model of tbi and sepsis in the rat. controlled cortical impact (cci) was produced in left parietal cortex by using a mm diameter tip (velocity m/sec; depth mm). sepsis was induced contemporarily by cecal ligation and puncture (clp). the outcome was evaluated in terms of mortality, neurological function (via the morris water maze (mwm) and beam balance (bb) tests)and histologically. rats were subdivided into groups: sham, cci, clp, and cci + clp. -day mortality was % in sham, % in cci and % in clp group respectively. adding clp to cci increased mortality up to % (p< . vs cci and p< . clp alone). at h and week post-injury mwm and bb test performance was significantly worse in cci and cci + clp than in sham and clp groups (p< . ). lesion volume was similar in injured groups. ca cell loss in left hippocampus was unaffected in the sham and clp groups, while it was % in cci and % in cci + clp groups (p< . cci vs cci + clp). our results show that the occurrence of systemic sepsis exacerbates mortality and cerebral damage in rats subjected to traumatic brain injury. t. j. p. lieutaud* , j. rhodes , p. j. d. andrews anesthesiology and intensive care medicine, hospices civils de lyon, lyon, france, anesthesiology and intensive care medicine, university of edinburgh, edinburgh, united kingdom introduction. human recombinant erythropoietin (epo) appears promising in different brain injury models but its cellular mechanisms remain poorly understood. following brain trauma injury (tbi), inflammation (il- b) and chemokine expression (mip- , neuropath appl neurobiol ) are important. the aim of this study was to measure the effects of acutely administered rhepo on il- b and mip- after tbi. methods. with home office approval, under isoflurane anesthesia rats sd were subject to lateral fluid percussion tbi ( . - . atm) (dixon j neurosurg ) of the left parietal cortex. epo ( , or iu/kg) or placebo were injected in a random and double blinded manner by the intra-peritoneal (ip)route. the ipsi-and contra-lateral cerebral cortices were removed h later and homogenized. il- b and mip- were measured in the surnageant using elisa kits. results are expressed as pg/mg of protein (mean ± sem). there was a significant increase in il- b and mip- in the ipsilateral cortex in comparison with the contralateral side for both proteins analyzed. neither nor and iu/kg rhepo did not exhibited any significant effect (figure ). conclusion. this study confirms that inflammation is important and occurs early after lfp-tbi. epo did not display significant effects on two of the main inflammation mediators. the purpose of this study was to evaluate the effects of agmatine on histopathological damage following traumatic injury using a clinically relevant model of diffuse axonal injury (dai) on the rat. a total of male sprague-dawley rats weighing - g were anaesthetized and subjected to head trauma using marmarou's impact-acceleration model. the rats were then separated into two groups; one group was treated with agmatine and the other group was treated with saline for up to four days immediately after the head trauma. rats from both groups were killed one, three or eight days post-injury. the brains were examined histopathologically and scored according to the neuronal, vascular and axonal damage. there were no significant histopathological differences between the control and agmatine-treated group after one or three days (p> . ), but evaluation after eight days revealed a significant improvement in the group treated with agmatine (p< . ). our data indicate that agmatine has a beneficial effect in diffuse axonal injury and should be tried for therapeutic use in the management of this condition. d. morii*, y. miyagatani critical care department, national hospital organization kure medical center, kure, japan the disadvantageous effect of haemorrhagic shock on head trauma related mortality are well known. thus, efficacious shock treatment is a surely significant measure against the development of secondary brain damage. the small volume resuscitation by hypertonic saline has been shown to promote systemic and cerebral haemodynamic benefits. similarly, many clinical studies have demonstrated the effects of long-term mild hypothermia on outcome of traumatic brain injury. in this study, we evaluated the new strategy consisting of therapeutic mild hypothermia and hypertonic saline therapy to the multiple trauma patient with severe traumatic brain injury. severe multiple trauma patients (iss>= , head ais>= ) were studied to evaluated the efficacy of therapeutic hypothermia ( . ˚c for h) and hypertonic saline therapy (na+: meq/l for the first h , meq/l for to h, meq/l for to h) which were applied to them in parallel with massive blood transfusion . we evaluated glasgow coma scale (gcs), injury severity score (iss), the probability of survival (ps), the volume of blood transfusion, infusion and urine volume during the first days, and glasgow outcome scale (gos). we monitored the extent of brain swelling by head ct. four male patients (age: ± y.o., mean±sd) were examined. the characteristics of injury mechanism were explosion , mva , fall . on admission, gcs, head ais, iss and ps were . ± . , . ± , ± and . ± . , respectively. the sum of blood transfusion, infusion, and urine volume during the first h were ± ml, ± ml, ± ml. no patient was died and their gos on posttrauma day was . ± . . the combined therapy of therapeutic hypothermia and hypertonic saline to multiple trauma patients with brain injury may lead to good outcome in spite of the necessity of a large quantity of blood transfusion and infusion. recent data suggest that commonly used anaesthetic agents, e.g. propofol, cause neurodegeneration in the developing brain. the intention of our study was to investigate the effects of propofol on primary neuronal cultures referring to the cell survival rate. primary cortical neuronal cultures were prepared from wistar rat embryos at days gestation. to test the effect of propofol on neuronal survival, cultures were exposed to µl gibco neurobasal-a medium per well with propofol at a concentration of mg/ml for , , , , , and hrs. cell viability was assessed using the methyltetrazolium method (mtt) and was related to untreated cells as controls. all cells were kept in normoxia. after three and six hours of exposition to propofol cell viability values of the propofol treated cells were significantly higher ( . ± . %, p= . and . ± . %, p= . , respectively) compared to untreated control cells ( %). after hours, values were decreasing to levels of the control cells ( . ± . %). after , and hours of exposition to propofol, in contrast, cell viability was significantly reduced ( . ± . %, p= . , . ± . %, p< . and . ± . %, p< . ) compared to controls. at high concentrations, propofol has a time-dependent effect on the viability of primary cortical neurons. during the first hrs propofol has a potential neuroprotective effect, whereas it seems to cause neurodegeneration in the period of to hrs of exposition. e. paramythiotou* , j. papanikolaou , p. ntagiopoulos , a. armaganidis , a. karabinis icu, attikon university hospital, icu, george gennimatas hospital, athens, greece multiple trauma patients constitute a significant majority of admissions in a general icu. brain injury is often present in those patients. the aim of our study was to investigate demographic, clinical and management characteristics in trauma patients suffering a brain injury in a five year period. in a retrospective study all trauma patients hospitalized in the -bed multivalent icu of a bed -tertiary hospital between st jan and th dec suffering a traumatic brain injury were enrolled. recorded data included age, gender, cause of the injury, icu length of stay, initial glasgow coma score (cgs), submission or not to an emergent neurosurgical intervention, all cause mortality and neurological outcome. a total of trauma patients were hospitalized during the study period. tbi was present in patients ( . %). among them, were women ( %) and ( %) were men. their mean age was . years (range - ). icu length of stay (los) ranged between two and days (mean . days). traffic road accidents were the cause in cases ( . %) while tbis ( %) were due to fall from a height on the ground which happened either accidentally or as a result of a suicide attempt. the rest cases ( . %) were due to accidents during work. mean glasgow coma score was seven (range - ). an extradural hematoma was present in p and a subdural one in p. intracerebral hemorrhage was noticed in p, hemorrhagic contusions in p (with or without diffuse axonal injury) and a traumatic subarachnoid hemorrhage in p. twenty nine patients were submitted to craniotomy and p were submitted to unilateral or bilateral decompressive craniectomy. mean los was . d for p submitted to a surgical intervention versus d for the other group. barbiturates were used in p ( %). a total of patients survived ( . %). death was due to neurological cause (herniation of brain stem and subsequent cerebral death) in p. other causes of death included sepsis, multi organ failure, severe injury in other organs, and hemorrhage from upper gastrointestinal tract. a poor neurologic outcome (mean glasgow outcome score < ) was noticed in % of patients. almost two thirds of trauma victims suffer from a cerebral injury. most of them are young males, victims of traffic road accidents. the injury is often severe and one third of patients are submitted to a neurosurgical operation. though overall mortality is rather low, long duration of treatment is often required and severe disability is present in a not negligible number of patients. in the majority of the intensive care units (icu), several of the admissions involves patients with primary nervous system illnesses. a great progress of the technologies used in the icu in the last few decades had reduced neurological illnesses mortality and morbidity. since september of we had beginning an longitudinal e prospective coort study verifying the characteristics of the patients years older that had been admitted in the icu for primary neurological cause (clinical or surgical). the study occurred in a private hospital icu with beds. we recorded patients until the moment. the number of neurological patients corresponds % of the admissions in the unit. the average age of this group of patients is significantly lesser of the remain icu patients ( vs. years), however does not have difference estatistically significant between apache ii ( vs. ) and the mortality ( vs. %) of the neurological patients and others. the stay of length in the unit is bigger ( , vs. , ) . we also recorded mechanical ventilation time length ( % ventilated patients with for average time days). in ventilated patients, % was tracheostomyzed (on average in days). % developed sepsis ( % with septic shock). the patients were divided and analised in several goups (for example: trauma, surgery, central nervous sistem infection, vascular disease,...). neurology was one of the most benefited specialties with the intensive care units progress and evolution. however, high mortality and morbidity caused by the neurological illness, and the social and economic impact that its sequels cause, still deserve the attention of the involved professionals cares of these patients in the acute illness. n. baffoun* , w. gdoura , h. ouragini , k. baccar , m. lamourou , t. chaoua , r. souissi , c. kaddour , n. ben romdhane , s. mahjoub anesthesia and intensive care, national institute of neurology, departement of haematology, chu la rabta, tunis, tunisia trauma victims develop frequently various degrees of haemostatic disorders. the severity of such post traumatic coagulopathie is considered to be major detrimental factor of outcome. the aims of our study were: to identify the origin of such disorders, time course and their correlation with mortality. our aim was identification of coagulopathy disorders and relation to outcome in severely head injured. prospective study,june -march . included:critically ill isolated closed severe head trauma. collected data:demographics,management prior and during icu hospitalization (sedation, catecolamin drug use, blood product transfusion, intra-cranial pressure monitoring, neurosurgical emergency surgery etc.),ct-scan results, daily worst glasgow coma scale, admission simplified acute physiology score ii. we inserted an arterial catheter for invasive pressure monitoring, a central venous catheter and a unilateral jugular bulb in front of the most damaged brain hemisphere(cf. ct-scan). jugular bulb thrombosis was prevented by continuous infusion of ml per hour isotonic serum without heparin. blood samples were obtained simultaneously from the central venous line(k) and jugular bulb(b) at admission, th, th hour, and then in case of neurological aggravationt or daily till th day. we measured platelet count,prothrombin time (pt),activated partial thromboplastin time (act),fibrinogen concentration (fib), prothrombin fraction + (f) and thrombin anti-thrombin complex (tat). during the study only central venous blood samples (pt, act, fib and platelet count) could be available if necessary. otherwise blood samples were centrifuged and preserved refrigerated for post hoc analysis. statistical analysis by student's t test, paired t test for paired results and analysis of variance. significance set as p< , . results. n= ; survivors(s) and deaths (ns). no differences between s and ns in demographics,management modalities, admission gcs( ± ), ct-scan,saps ii ( ± vs ± , p= , ). b vs simultaneous k platelet count was significantly lower in all drawn blood samples,with a trend to decrease overtime. s vs ns at day and day : ± vs ± (p= , ). admission b thrombin fractions was higher in ns( ± vs ± , p= , ). b day tat was higher in ns: ± vs , ± p= , . no difference for other tests between b vs k and s vs ns for different paired tests. pro-coagulant factors (f and tat) are valuable prognostic factors at day in closed isolated severe head trauma. severe traumatic injury is a multisystemic disease where normal homeostatic mechanisms are lost. this situation involves an increase in physiological needs. usually these patients present anormalities in the hypothalamic-hypophyseal axis, which become neuroendocrine dysfunctions with deteriorated physical or neuropsychological secuelae. the aim of this study is to improve our knowledge about this part of the axis in acute phase of politraumatism. methods. an observational prospective study was carried out, with patients who were admitted to our icu with a critical traumatic injury, for six months. demographic and epidemiological data were registered. apache-ii (acute physiology and chronic health evaluation system) and apache-iii scores during the first three days were measured. tiss (therapeutic intervention scoring system) score during the hospital stay was recorded. also gh (grown hormone), igf- (insulinlike-grown-factor- ) levels and nitrogen urinary losses in the first three days after traumatic event were measured. statistical data were analysed with the spss . program. in our study , % ( cases) were men and , % ( cases) were women. the average age was , years old. the hypothalamic-hypophyseal-somatotrophic axis role in the first three days was characterized by a progressive increase in gh levels and a progressive decrease in igf- levels. connections between average hormonal levels in the first three days and apache-ii, apache-iii and tiss scores during this time were studied. a good inverse connection between igf- and prognosis was shown si (spearman index) - , , - , p value , and , respectively with apache-ii and apache-iii. this appropriate connection could not be shown with tiss score sp - , p value , ; but the connection between gh and tiss was better, sp , p value , . conclusion. gh levels increase and igf- levels decrease in the first three days after acute trauma. lower igf- levels can mean a worse prognosis. there are no connections between igf- and sanitary resources used (tiss score) but these connections seem to get better when gh levels are higher. trimodal distribution of deaths and the golden hour concepts are in part responsible for the genesis of all modern trauma systems but these concepts have been challenged recently. our aim was to describe distribution of death in trauma using data from a trauma system and discuss what can be done from the organizational point of view to improve outcome. all traumatic deaths occurring between and in a trauma system were. data on age, gender, time and place of injury, time of first and second hospital arrival, cause of trauma and type of accident, hospital characteristics, dominant injury and time of death were collected for this study. for mortality distribution the variable time was transformed applying a natural logarithm. results. deaths occurred over a period of months. % at the scene, % in the level i trauma centre, % in level iii trauma centre and the remaining in level iv/v trauma centre. death distribution using a logarithmic scale in minutes showed four peaks: deaths at the scene, deaths in the first hours, deaths in the first two days and finally deaths in the second week that we referred as minutes, hours, days and weeks peak (image ). we found statistically significant differences in age and dominant injury concerning timing of death. a tetramodal pattern of death distribution could be described. our data support the need to focus on the treatment of severe head injuries namely in the intensive care environment. anaemia is usually detected in critically ill patients. red bloos cell transfusion is not free of risk. we want to start an alternatives to transfusion protocol but fist we tryed to dercrive our critically ill patients anaemia. our objectives were to: study the red blood cell and iron metabolism in the icu patients at admission. observe changes in these parameters across the first seven days after admission. observe rbc transfusion and his relation whit morbidity and mortality. find transfusion predictors at the admission moment. during tree mounths of , we include all the admissions in a trauma and neurocritical icu of our hospital that stay in unit more than hours. at the moment of admission we determinated haematocrit, (hto), haemoglobin (hb), and reticulocytes (%retic) levels, iron metabolism, folic acid, b , epo and creatinin (kr) we repeated determinations seven days after admission if patient was still in icu. adverse events occurred during icu stay were also registered (mainly infections) together the number of rbc transfusions (with hb levels before and after administration). we included in the study patients. severe traumas ( %), neurocritical patients ( %), tumoral neurosurgery ( , %) and other patients ( %) . average age was . years and apacheii . ± . points. % were males . results of admission blood determinations and seven days after are exposed in table i . there is a tendency to decrease in hto and hb parameters, but not significant. the only parameter we observe difference statistically significative was the reticulocites rate (%retic), significative lower days after admission. (p< . ) in graphic we describe anaemia groups in admission and the evolution of anaemia groups seven days after admission. we appreciated that no anaemia group suffers a severe decrease. % of patients were transfused during their fist week stay. average levels of pre-transfusional hb were . g/dl . we analysed transfusion predictors. hto and hb levels at admission predict transfusion. there is no other analytical parameter at admission that predicts transfusion. we also detected tracheal intubated patients at admission and patients with inotropic drugs perfusions at admission were significative more transfused (p< . and p< . ). conclusion. the high mortality rate in our patients is related to the initial gcs and cranial cat at the moment of admission. it is necessary to continue the study to determine the influence of the rest of the variables in the mortality rate of these patients. introduction. traumatic brain injury, subarachnoid hemorrhage (sah) and spontaneous intracerebral hemorrhage (ich) are associated with systemic inflammatory response syndrome (sirs). early diagnosis of sepsis versus sirs is frequently difficult in neurointensive critical care units. procalcitonin (pct) has been used as a predictor marker of bacterial infection in different groups of patients. there is variable and scarce information about pct in neurocritical patients. the aim of this study was to evaluate the utility of serum pct in the early diagnosis of fever from bacterial infectious origin in patients with acute brain hemorrhage. we made a prospective diagnostic study between july and january . we analyzed serum level of pct and c-reactive protein (crp) on consecutive patients with diagnosis of sah, ich or tbi who have fever during the intensive care unit admission. we excluded patients with antibiotic therapy previous to admission. pct and crp were blindely measured from samples of serum extracted within hs of fever onset and within hs of antibiotic administration. blinded to pct and crp results and according to previously defined criteria patients were classified in two groups: proved bacterial infection (pbi) and non proved bacterial infection (npbi). serum pct was measured by immunochromatographic semiquantitative method brahams pct-q (brahams diagnostica, berlin, germany). its sensitivity is . ng/ml. we analyzed sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of serum pct and crp for diagnosis pbi. we defined negative serum pct as < . ng/ml and negative crp as < mg/l. we studied patient, with sah ( %) and with ich ( %). ten patients had pbi ( %, %ci - %). pbi were pneumonia ( ), urinary tract infection ( ), meningitis ( ) and central line associated blood infection ( ). two patients had simultaneous infection sources. there were bacteremic infections. pct was positive in patients in pbi group ( pneumonia and bacteremic central line associated blood infection) and in of npbi. sensitivity was % ( %ci - %), specificity % ( %ci - %), ppv % ( %ci - %) and npv % ( %ci - %). crp was positive in pts, pbi and in npbi. sensitivity was % ( %ci - %), specificity % ( %ci - %), ppv % ( %ci - %) and npv ( %ci - %). in this study serum pct had an adequate ppv to diagnose pbi, without false positives results. however, it has a low negative predictive value to diagnose pbi. due to the results obtained, we consider that the quantitative pct assay with a sensitivity limit of . ng/ml should be used for the future study to evaluate the role of pct as a predictor marker of acute bacterial infection in patients with acute brain hemorrhage. in different published series cerebral infarction occurs in - % of patients with symptomatic vasospasm after subarachnoid hemorrhage (sah) despite maximal therapy. standard triple-h treatment is associated with life-threatening side-effects (such as myocardial ischemia and pulmonary edema) and has not been properly validated. milrinone, a phosphodiesterase iv inhibitor, has few side effects and exhibits inotropic, vasodilatory and immunomdulatory properties besides inhibiting platelet aggregation and thromboxane a synthesis. we present our experience using our m&h protocol (milrinone and homeostasis) in patients with vasospasm. it consists of cvp-guided normovolemia (maintain cvp=or> ), aggressive temperature control, maintenance of normal serum sodium and step-wise interventions based on symptoms (milrinone . - . mg/kg bolus plus infusion, levophed and angiogram plus intra-arterial milrinone). we retrospectively reviewed the charts and imaging studies of patients diagnosed with symptomatic vasospasm based on the development of focal symptoms and the results of angiographic and doppler studies. cerebral infarction was defined as a new hypodensity on ct scan appearing at least days after aneurysm clipping or coiling. conclusion. among the different physiological scores, the sah-pds was most strongly associated with the major outcomes and the h&h score was better than the other aneurysmal bleed scores. the strong association of physiological scores with outcomes suggest that interventions targeting physiological derangements may improve outcomes in sah patients. contrast induced nephropathy (cin) is the acute deterioration of renal function due to parenteral administration of radio-contrast media. cin is defined as an increase in serum creatinine concentration of > µmol/l ( . mg/dl) or % above baseline within hours after contrast administration. [ ]epidemiologic data in neurosurgical patients undergoing endovascular coiling are sparse and only one study in stroke patients reported figures of % prevalence. [ ] cin is associated with increased morbidity, length of hospital stay and costs. pre-existing renal failure and the dose of contrast media are known risk factors for the development of cin in cardiac patients where the condition is well-described. [ ]although the pathogenesis of cin is not entirely clear, several mechanisms for contrast-induced renal injury have been proposed, including alterations in renal medullary perfusion, direct cytotoxicity and oxygen-free radical generation. [ ] we conducted a twelve month retrospective electronic patient record based review of data from patients presenting to the hospital for endovascular coiling. renal dysfunction was based on increase in serum creatinine of µmol/l ( . mg/dl) or % above baseline within hours after contrast administration; the incidence of contrast induced nephropathy was investigated. peri-operative care and post-operative management were analysed. a multi-variate analysis of risk factors was conducted and statistical tests done using microsoft excel. . patients visited our hospital neurosciences unit and underwent endovascular coiling over a one year period (sept -sept ). the incidence of contrast induced nephropathy was %. . % had pre-existing renal disease and . % needed haemofiltration on intensive care for renal failure post-operatively. the odds ratio for developing cin in patients with diabetes mellitus was . ( . - . ) p= . . the odds ratio for developing cin with pre-existing kidney disease was . ( . - . ) p= . . the development of cin did not show any correlation with patient age, emergency or electively performed procedure or the number of coils used. no anti-oxidants were given for prophylaxis and no protocol for peri-operative hydration was used though fluids were administered intra-operatively. conclusion. cin is a common cause of acute renal functional impairment and accounts for significant morbidity in patients undergoing endovascular coiling. patients with pre-existing renal failure are at high risk; other predisposing factors should be identified. there is some evidence regarding use of peri-procedural hydration and anti-oxidants and, therefore, management protocols should be developed. open prospective observational study. were studied patients treated by embolization after spontaneous intracranial aneurysm rupture. included: embolization complicated by rupture of aneurysm during the obliteration procedure. rupture was ascertained by extravasation of contrast. current results of period ranging from july till october . thirty two patients embolized for aneurysms. one patient pesented a rupture during the embolization: she was a y.o female; she came to our institution's emergency suffering from acute headache, nausea vomiting and a mild meningism. she got no neurological defect (wfns grade i). ctscan showed a mild sah (fisher class ). an angiography followed, confirming presence of a mm ruptured pericallosum aneurysm. during embolization procedure, a sudden hemodynamic instability (bradycardia, unstable blood pressure) was noticed and rerupture of aneurysm confirmed by extravasation of contrast medium. this complication occurred during placement of the first coil. the procedure continued successfully and aneurysm was completely obliterated by three coils. ctscan performed immediately after end of the procedure showed no massive cerebral haemorrhage (class fisher). the patient was thereafter transferred to our icu where she was extubated. she developed a transient neurological defect (right hemiparesis). she was discharged alive without any disability. aneurysmal perforation during embolization seems to be a rare event. in our case it doesn't cause much damage, but clinical severity is variable and far from being predictable. re-bleeding can result in severe intracranial hypertension and ultimately brain death. aneurysm thrombosis complicated procedures, and was fatal for both (respectively and days after embolization) due to massive ischemia (aneurysm of the internal carotid artery) and refractory intracranial hypertension (aneurysm of anterior communicating artery). those two patients got respectively wfns grade / fisher classification: iii/ and ii/ . the patient with wfns grade iv got a successful uncomplicated procedure days after the initial insult and partial clinical recovery. he continued to improve and was discharged alive from hospital without major neurological disability (gos: good, modified rankin scale = ). conclusion. endovascular coiling could be an efficient therapeutic tool. incidence and outcome of procedures complications is still to be determined. strategy in patients with high wfns grade is certainly try embolization because of too risky surgery. right management timing is still to be determined. the quantitative estimation of blood loss helps in the choice of the best treatment tactics. the purpose of the study is to evaluate the ability of central blood volume index (cbvi, volume in heart and lungs and large vessels divided on body weight) and total end diastolic volume index (tedvi, sum of the end-diastolic volumes of the atria and ventricles divided on body weight) to reflect the magnitude of a hemorrhage. normo-volumic values of cbvi and tedvi were measured in cardiac icu cardiac patients, pigs and rats with weight range of . kg to kg. blood loss in the order of - ml/kg ( - steps) was applied in rats and pigs. ultrasound dilution technology utilizes the decrease in blood ultrasound velocity caused by injecting isotonic saline, and can be used in species of any size. cardiac index (ci), cbvi and tedvi were measured by hcp (transonic systems inc., usa) before and after blood loss. a disposable extracorporeal av loop filled with heparinized saline was connected between an existing artery catheter and central venous catheter. reusable ultrasound sensors were clamped on to the arterial and venous limbs of the loop. a peristaltic pump (nipro, japan) was used to circulate the blood from the artery to the vein at - ml/min for - min. measurements were obtained by injecting . - ml/kg (max ml) of isotonic saline. at the conclusion, the av loop was flushed with heparinized saline. in normo-volemic situations indexes are in the range of cbvi = - ml/kg and tedvi = - ml/kg, despite times differences in weight. a dramatic blood loss of - ml/kg in experimental animals produces the same magnitude - % decrease in cbvi and tedvi. severe dysphagia associated with silent aspiration and the danger of asphyxia requires translaryngeal intubation or tracheostomy. the aim of the study was to apply the clinical screening test (cst) and fibrooptic evaluation of swallowing test (fest) to determine the best method of upper airway protection. it was a prospective cohort study during the period of - . it included patients operated for fpt. all patients were delivered to icu intubated and mechanically ventilated after operation. after full recovery from anesthesia, returning to consciousness and passing spontaneous breathing test (sbt) (if not -mechanical ventilation continued) they underwent cst of points. the patients who passed cst without deficit were considered to have none or low level of dysphagia. the patients who passed cst with some deficit were considered to have dysphagia. all the patients were extubated and underwent fest. in patients with poor cst, icu crew was ready to perform translaringeal intubation immediately if necessary. patients with severe cases of dysphagia underwent tracheostomy and received cuffed tracheostomy tubes to prevent aspiration and ensure free air passage. on the next day after performing tracheostomy, swallowing rehabilitation therapy began. tracheostomiesd patients underwent fest every week. after passing fest with blue dye, decanulation was possible. results. patients of total group who did not recover consciousness or did not pass sbt in hours after operation were determined for prolonged artificial ventilation and were excluded from further study. the patients who passed cst without any deficit were successfully extubated and showed absent or mild dysphagia in fest. patients passed cst with deficit and after fest were divided into three groups by the level of dysphagia -mild, -intermediate and -severe. the regress of swallowing disorders was evaluated by fest every week. in the first group the earliest recovery was in three days, in the two other groups none recovered earlier than after three weeks. the latest recovery was determined after a year of swallowing rehabilitation therapy. two patients were not decanulated at all. postoperative recovery made possible to reduce rs. but insufficient rs exhaust the patient and may result in secondary impairment of the brain. the aim of the study was the analysis of different respiratory strategies in these patients to choose the best. it was a prospective cohort study of patients after removal of pft with complicated postoperative period during and no significant difference in± - . the age of the patients was severity of complications and neurological status. all patients included into study demanded rs after operation because of low rd. all patients had bulbar palsy syndrome (bps). patients with bps were tracheostomiesed. after full recovery from anesthesia and returning to consciousness ventilation modes were simv+ps or cpap+ps (ventilator pb ). rr (respirator and patient), tv, ps, fio , peep, pao and paco and neurological status were evaluated and registered daily. the criteria of readiness to wean were determined as: pao /fio > , peep< , ps< - , spo > %, rr< , fio < %, gcs> . weaning was successful if patient could breathe spontaneously for more than hours without neurological deficit arise. patients were divided into groups: . simv+ps ventilation (respirator rr - % of total rr) - cases; . cpap+ps ventilation - cases; . failed extubation in first hours - cases. all patients of the group were ventilated in simv+ps after reintubation. the patients of the group were extremely unstable and the modes of ventilation were corrected - times per day. duration of ventilation was minimal in the group with maximum replacement of spontaneous breathing with artificial ventilation -simv+ps (table ). in this group was minimal number of breathing disorders (minimal number of ventilator mode corrections) and patients were most stable. in first group was tendency to regress of bps ( %) and there wasn't cases of arising neurologic deficit. but in the group there was increase of bulbar palsy syndrome in % cases and no regression. c. a. eynon* , p. collins neurosciences icu, wessex neurological centre, southampton, wessex regional transplant, queen alexandra hospital, portsmouth, united kingdom the management of severe brain injury in the uk is undergoing significant change. national recommendations are that all severely brain-injured patients are referred to specialist centres. protocolised guidelines for the management of brain injury have resulted in improvements in mortality and morbidity. with this has come a reduction in the numbers of brainstem dead patients suitable for solid organ donation. however, there still exists a group of patients for which continued treatment is felt to be futile and who may be suitable as solid organ donors following death by cardiorespiratory criteria. all deaths during a -month period were audited prospectively. when patients did not fulfill the requirements for brainstem testing, futility in continuing medical treatment was determined by the supervising consultant neurosurgeon, neurointensivist and senior nurse. in such patients, treatment other than comfort care was withdrawn. patients (< yrs) where medical treatment was to be withdrawn were considered for nhb organ donation. . patients died during a -year period. patients had death confirmed by brainstem tests of which became solid organ donors. patients were potential nhb donors. nhb donation was considered in cases and offered to the family in . in one case the next of kin were untraceable, in one case the coroner refused permission. consent for donation was obtained from the family in / cases. nhb organ donation occurred in cases. in the remaining cases, patients died outside the time window for organ retrieval, in one the next of kin withdrew permission and in one the coroner did not grant permission. of the patients who died outside the time window for nhb organ donation, subsequently donated tissue. a total of kidney transplants, liver transplants and one double lung transplant were performed from nhb donors. conclusion. the number of brainstem dead patients is declining in the uk. patients in whom continuation of medical care is felt to be futile can provide a source of solid organs suitable for tranplantation. successful transplantation of solid organs from potential nhb donors occurs in a significant proportion of cases. feedback from family members has been supportive regarding the decision to donate. the studies on treatment of patients with head injury and brain damage, with sudden cardiac arrest due to various reasons revealed, that it is very useful to introduce neuroprotective therapy in those patients. it allows to decrease the consequences of local and global brain ischemia. the aim of the study was to present the efficacy and tolerance of treatment with amantadine sulphate (amantix, merz, germany), as a neuroprotective therapy. in the intensive care unit, between and we monitored a group of patients with consciousness disorders, in the age of . +/- . , with average bmi of . +/- . . the level of coma's deepness and its reasons were different. the examination plan, methods used, choice and classification of patients were carried out based on previously prepared protocols. the minimal period of treatment with intravenous infusion of amantadine sulphate was days, however, if possible, the therapy was continued for days. after this period the patients received amantix in tablets. many additional therapeutic measures from different groups were used in those patients. an endotracheal intubation and ventilation were necessary in all of the patients. amantix was used as treatment's supplementation in the dose of x mg/day. at the admission the patients were classified with the use of gcs (glasgow coma scale). in order to evaluate the effects of use of the preparation, some specific function of the patients were examined before the use of amantix and after finishing of the therapy. the examination was carried out by the intensive care unit doctors, neurologist and nurses taking direct care of the patients. the results were compared with the control group of patients, age , +/- , . those patients were treated with the use of standard methods. all of the collected data were worked up statistically. the authors revealed statistically important difference in gcs grading between the groups. the average gcs score in amantix group at the admission was: . +/- . , and at the discharge: . +/- . . analogically, in the control group the admission score was: . +/- . , and at the discharge: . +/- . . in patients using amantix we have noted the presence of side effects, usually it was hiperactivity. patients were transferred to different wards. patients died. the average hospitalization period in the amantix group was: . +/- . , and in the control group: . +/- . days. . this has been fuelled by increasing evidence demonstrating either sub-optimal care or poor end of life decision making as antecedants to cardiac arrest calls on acute wards. outreach and medical emergency teams have developed as a result, but their effectiveness remains unproven [ ] . at southend, development of a critical care outreach service began in . the aim of this study was to establish the trends in cardiac arrest call rates from the acute wards in the years prior to, during and after the introduction of the outreach team, to assess any potential impact this may have had. hospital switchboard records were analysed retrospectively to provide data relating to the date, time and location of ward cardiac arrest calls occurring between january and december . arrest calls to all acute wards except the critical care unit were included. the data collected was then related to hospital inpatient activity (in terms of completed in-patient consultant episodes, supplied by the hospital's information department) to enable meaningful interpretation of the observed trends. table summarises the results from the medical and surgical wards separately and then together to present data for the hospital's acute wards as a whole. the data shows an upwards trend for the years prior to and during the establishment of the outreach service, and a falling trend subsequently. conclusion. the establishment of a comprehensive outreach service that promotes all aspects of outreach critical care (expediting appropriate and preventing inappropriate critical care admissions, following up patients post critical care discharge and promoting critical care skills throughout the hospital) is likely to lead to a reduced frequency of cardiac arrest calls. however, this effect may take years and not months following introduction to be manifest. we suggest all outreach services should collect and present this simple data locally to demonstrate the potential impact of their activities. intracerebral haemorrhage (ich) represents - % of all strokes. the acute and subsequent blood pressure management presents a therapeutic dilemma. it is necessary decrease high systolic blood pressure, but there is the risk of decrease cereb. objective: can the regional cerebral oximetry helps us to determine individual adequate blood pressure? ral perfusion pressure and risk of ischemia developing. methods. regional oxymetry is the method of measurement the cerebral oxygen content based on near-infrared spectroscopy, which is carried out by means of the invos device (in vivo optical spectroscopy). this method is non-invasive, delivers continuous information and it allows the possibility of emergency therapeutic response. rso is transcutaneous monitoring of regional cerebral saturation with hemoglobin oxygen (rso ) in mixed blood in the frontoparietal regions, which represents interface beetween the basin of the anterior and middle cerebral arteries. the normal value of rso is beetwen - % in a majority of the population, and every change from the baseline in both directions by more than - % signifies the risk of ischemia for the observed tissue. during a twelve-month period all pacients admitting with ich in our neurointensive care unit (nicu) were managed by regional cerebral oximetry (n = ). arterial blood pressure was monitored and was corrected farmacologically. the functional outcome of patients when discharged from the nicu and after six month were evaluated by the glasgow outcome scale, barthel index and modified rankin scale. data was collected retrospectively for comparison with pacient which didn't monitor by rso . we found correlation between discovery of patological rso values and age, initial gsc and volume of ich. there are less septic and hemodynamic complications in the group with monitoring rso . using this method, the probability of successful improving outcome all patients with intracerebral haemorrhage will be estimated. there is the need for guidelines regarding the blood pressure managemet of these patients. elaborated data are available on iccollege.be. of ( , %) icu directors, representing icu beds completed the extended query. main findings were: visits limited < h/day ( h + h ) ; hcp dedicated to family ( %) children admitted from y of age ( %) ; family accompanied by hcp during resuscitation ( %) ; no witnessed resuscitation procedures ( %) ; scare possibilities for family to stay during night ( %) ; insufficient bad news delivery ( , %) ; poor team psychological support ( - %). icu physicians completed the follow-up simplified query. main findings were: psychological support for family ( , %) and team ( , %) ; post-resuscitation debriefing ( , %) ; identification of dedicated hcp ( , %) ; use of ( , %) and written ( , %) dnr-orders ; comprehension of ( , %) and family witness ( , %) of patients' will ; structured bad news delivery ( , %) ; witnessed resuscitation ( , %) and invasive procedures ( , %) ; children accepted < y ( , %). in belgium, although there's obvious concern from the majority of icu's to communicate with relatives, recommendations for psychological team support, teaching bad news delivery, schedule of visits and witnessed procedures are made. sudden death constitutes an important sanitary problem. early diagnosis and advanced cardiorrespiratory live support are considered the most important factors related with short term prognosis. the objective of this study was to analyze the prognosis, clinical characteristics and evolution of patients who initially recovered after an episode of out-of/hospital or in-hospital cardiac arrest and who were admitted to a medical-surgical intensive care unit (icu). sixty three consecutive patients were included and retrostectively studied when they were admitted to a medical-surgical icu. for two years, from april of until april of , sixty three consecutive patients were included. eighteen of the patients were women ( . %) and were men ( %). cpr was given out of hospital to patients, and patients suffered sudden death on a conventional hospital ward and patients in special units (surgery, coronary, emergency room, etc.). the etiology of the arrest was considered to be of probable primary cardiac origin in % of the episodes and the rest of the origin of arrest was considered secondary to other pathologies (respiratory, sepsis. . . ). mortality in icu was . % and , % were discharge alive but of that percentage of patients only % were released without important neurological damage. patients recovering following cardio-pulmonary arrest out of hospital and hospital ward had greater mortality than those who suffered an event in a monitored area ( %).(p< , ) the lengthy resuscitation times (greater than minutes), elevated apache ii scores and advanced age is associated with greater mortality. recovered cardiac arrest is a pathology with high mortality and morbidity in intensive care. in our series only % were released alive without severe neurological damage. the existing condition of the patient and the excessively long resuscitation times were decisive factors in these results. we conducted a retrospective case-note study in a six-month period at an innercity district hospital (distant from any international airport), and report three patients who deteriorated about the time of overseas travel by air. results. case . a retired gentleman of -years with progressive idiopathic pulmonary fibrosis requiring home oxygen therapy travelled by air without a medical escort. he deteriorated shortly after his arrival at the family home in the uk. he presented to the emergency department in respiratory failure requiring non-invasive ventilatory support. he died during prolonged hospitalization. case . a -year old woman with obstructive sleep apnoea reduced her diuretic prescription without her physician's knowledge prior to a long-haul flight. she deteriorated with acute shortness of breath shortly after her arrival at the family home in the uk. she was brought by her family to the emergency department where she was found to be in cardiogenic pulmonary oedema, requiring non-invasive ventilation. she survived hospitalization and was discharged with home oxygen therapy. case . a -year old man collapsed in the street explaining to passers-by that he had swallowed some packages. he had a travel ticket from the airport in his possession but was able to give no other history. he was taken to the emergency department and required intubation due to extreme agitation. he was found radiographically to have ingested multiple wrapped packets. he required laparotomy to remove differently coloured packs some of which had ruptured releasing their contents. urinalysis revealed cocaine metabolites. he subsequently made an uneventful recovery after extubation and transfer to a surgical ward. patients may present to hospitals distant from international airports with clinical deterioration consequent upon risks associated with long-distance air travel. ( ) prospective observational study of a cohort including every septic patient admitted in a medical icu of an university hospital from may to december . demographic, clinical, laboratory and therapeutic variables were registered. a clinical examination assessing motor deficit and tendon reflexes was daily performed in order to check cipnm criteria. univariate and multivariate logistic regression tests were used. . septic patients were included with age ± , apache ii score ± , maximum sofa score . ± , icu mortality %, in-hospital mortality %. patients survived at least days. patients did not require mv and none of them developed cipnm. finally the analysis was performed with the patients who survived at least days and required mv, with a cipnm incidence of %. variables were included in the univariate analysis. after multivariate analysis, it was found that several variables were significantly related with risk for the development of cipnm (odds ratio, or; % confidence interval, ic; signification level of change in log likelihood, p): . mv length (days): or . patients in the icu often develop an acute neuromuscular disorder characterised by difficulty of weaning from mechanical ventilation and associated with variable degrees of muscular weakness including quadriplegia [ ] . often associated with steroid treatment, neuromuscular blocking agents (nmba) and septic patients, the pathogenesis of cim is poorly understood [ ] . originally thought to be neuropathic in nature, however, today myopathy is more often diagnosed [ ] . to further clarify this point we present a series of patients. between and a retrospective study was carried out on patients diagnosed with cim and whose muscle samples were analysed in the dept. of neuropathology of chuvi, spain. in the clinical studies special attention was paid to the neuromuscular status apache ii, and treatments with steroids, nmba,total parenteral nutrition (tpn)and insulin. all patients underwent electromyographic studies and biopsy and in those with sensitive neurography an abnormal nerve biopsy. of the patients, were women and were men, all aged between and , (mean ± ). in three of the patients admission to the icu was not necessary. all save two received prolonged high doses of steroids and two were on chronic treatment of steroids. only one was treated with nmba for more than days. two patients were diabetic with no electromyographic signs of neuropathy. seven needed insulin to control glucemia during the critical period. received tpn, and had sings of sepsis. muscle biopsy showed signs suggestive of cim (atrophy of both types, alteration of the intermiofibrilar pattern) and in some cases miofagia and thick filament loss. in two cases there was discrepancy between neurophysiologic and biopsy findings (muscle and nerve). the seven patients that survived the acute illness showed neuromuscular symptoms on release from hospital. follow up was possible on three patients for , and years respectively. all recovered muscle strength, the electromyography normalized and currently have normal independent daily life activities. the aim of this clinical trial is to study cip in icu patients (pts) after surgical procedures. we enrolled retrospectively icu pts ( men ( . %), women ( . %) who underwent at least one surgical procedure under general anaesthesia and developed cip. all of them were mechanically ventilated and stayed > days. underlying diseases: multiple trauma , complicated surgery , pancreatitis . mean age: . ± . years. operation sites: abdomen , cns , orthopaedics , thorax , other . mean anaesthesia time: ± min. in all pts an electromyogram was performed twice, as well as daily neurological examination. we analyzed several parameters predisposing to cip. conclusion. ) sepsis predisposes to cip, but cip can be appeared without sepsis ( . %). ) age and serum albumin values do not predispose to cip (p< . ); however the early implementation of a nutritional protocol is useful. ) although not well correlated, we try, if possible, to avoid neuromuscular agents. ) high pgl predispose to cip (p< . ); it is important to maintain pgl < mg%. ) cip prolongs lmv (p< . ), los in icu (p< . ) and los in hospital (p< . ), but does not increase mr significantly (p< . ). s. kjaergaard* , s. e. rees intensive care, anaesthesia and intensive care, region north jutland, aalborg, center for model-based medical decision support, aalborg university, denmark ( ) is accepted as the gold standard method of describing pulmonary gas exchange. in the clinical setting, if any, only very simple one-parameter models are used. the parameters of these varying upon changing the fio . in a previous paper we have compared the miget with a simpler model, and shown that this simpler model is a good fit to the inert gas data obtained from the miget experiment ( ) . this study explores whether the simpler model can reproduce oxygenation data in an oleic acid lung damage model upon changing the fio and compared these results with those obtained using the miget. seven pigs were used for the study. lung damage was induced by an intravenous infusion of oleic acid. six inert gases were infused to estimate the distribution of v/q-ratios of the miget model and dead space, shunt and a parameter describing v/q mismatch, i.e. fa , of the simpler model ( , ). measurements were taken at five different ventilator settings. the two models were then used to simulate arterial oxygenation data when the model-parameters along with measurements of mixed venous blood gases at different values of fio were given as input to the models. both models can be used to simulate sao at varying fio . this is shown in the figure where the models have been used to simulate sao at varying values of fio (miget "+", simple "squares") ranging from . - . . it shows that the models simulate identical values of sao with a mean difference = - . +/- . . since the miget and the simpler models provide both equally good fit to the inert gas data ( ) and precise predictions of arterial oxygenation, they might be interchangeable in a clinical setting where only a limited amount of data are accessible. in addition, the parameters of the simpler model can be obtained quickly and non-invasively ( ). the model could therefore have applications a clinical situation. ethanol may be used in the management of toxic alcohol poisonings , or as sedation in alcohol withdrawal. ethanol may be a component within drug formulations, for example nimodipine infusion or chemotherapeutic agents . ethanol flush has also been used to restore the patency of occluded catheter lumens . in clinical practice, ethanol should only be infused via a pcvc and not a peripheral venous cannula, as the high osmolality of ethanol can cause thrombophlebitis. given anecdotal reports of pcvc deterioration during ethanol infusion , , this study applied a bench testing method and statistical modelling to develop clinical practice guidelines at our institution. the test solutions used were: dextrose (d) %; ethanol (e) %, %, %, %, % and %. each test solution was perfused through pcvcs. a total of pcvcs were perfused. (b) hour perfusion. the test solutions used were: d %, e %, e % or e %. each test solution was perfused through pcvcs. after perfusion, the strength of all pcvcs was assessed. the pcvc was attached to a force gauge. a known force was applied to the pcvc and the pcvc length was measured. this was repeated for increasing forces until the pcvc broke. length-force relationships were plotted and were described statistically using linear mixed effects models. . this bench test model produced reproducible data. the pcvcs were not directly traumatised by the testing apparatus. (a) minute perfusion. pcvcs perfused with e % , e % or e % perished with obvious structural deterioration. two distinct length-force relationships were described on linear mixed effects models: e %, e % or e % weakened the pcvcs , whilst d %, e %, e % and e % had no effect upon pcvc structure (p< . ) (b) hour perfusion. the pcvcs did not perish. on linear mixed effects models, e % and e % weakened the pcvcs, whilst d % and e % had no effect (p< . ). conclusion. this model quantifies the effect of ethanol infusion upon pcvcs. this has not been demonstrated previously. the infusion of e % e % or e % via pcvcs should be avoided. infusion of e % and e % for hours weakens pcvcs. nimodipine and other drugs using ethanol as a carrier vehicle should be infused via pcvcs with caution. these potential hazards should be outlined in individual pcvc package inserts and drug product information leaflets. ( ) in septic shock patients tissue microcirculation is altered despite an increased tissue oxygen tension ( ). microcirculatory distress could be one of the earliest stages in the progress of sepsis to multiple organ failure, and microcirculatory shunting could be an important contributing factor to this development ( ) . sofa score has been suggested to clinically assess the level of organ dysfunction( ). we've done a prospective observational study to determine if changes in the rate of thenar muscles tissue deoxygenation during stagnant ischemia in patients with severe sepsis and septic shock are related to changes in organ dysfunction using the sofa score. fourteen septic shock patients were included in a preliminary study during the first days of sepsis evolution. , hutchinson?thenar muscle sto was measured noninvasively by nirs (inspectra technology, usa) before and during upper limb ischemia. sto decrease (downslope) after limb ischemia were analyzed during first and fifth day after icu admission. changes in sto downslope, sofa score, cardiac output, lactate and the use of vasoactive drugs between first and fifth days were recorded. we found good correlation between ∆sto downslope and ∆sofa between the first and the fifth day. (spearman's rho = - , ; p< , ). our results are in accordance with those reported by pareznik( ) wich correlated isolated values of sto with sofa in septic shock patients but moreover we show that changes in both variables during evolution are also correlated. in septic shock patients, thenar muscle ∆sto downslope is well correlated with changes in ∆sofa, a clinically accepted tool to measure organ dysfunction evolution during sepsis. ∆sto downslope monitoring could be not only a good marker of microcirculatory state but also a good indicator of organ dysfunction evolution during sepsis and consequently a potentially therapeutic objective. one of the important tasks that the anesthesiologist should perform is to monitor the functions of body organs; lung airway pressure is among the most important ones. a real-time continuous monitoring device which would be designed in a small volume and is portable could be used by anesthesiologists for this purpose. so, this device could improve the quality of anesthesia care while being efficient and cost containing. the device consists of four consisting parts as follows: sensors (pressure transmitter and gas velocity transmitter), processors (two avr microprocessors), monitor and software. software simulation: the performance of the monitor was controlled through a simulation process with matlab-simulink software (the mathworks inc. ma, usa),( ). the monitoring device demonstrated acceptable results, both clinically and at the lab assessments. the study demonstrated this device as an effective, reliable and cost containing device. a. rodríguez salgado* , a. socias , b. comas , a. llompart , i. losada , p. ibáñez , m. borges intensive care unit, emergency department, internal medicine, h. son llàtzer, palma de mallorca, spain since we have a global computerized system on our hospital we used it to develope an integral and multidisciplinary working protocol for the early recognition of sepsis and its appropiatte therapy. prospective study conducted in a four-hundred bed teaching hospital with medical and surgical areas and the support of a global computerized system and on line internet conexion among areas. a computerized protocol to improve management of sepsis was developed. it automatically produces an annotation on the medical chart and a serie of analytics forms when activated. additionally clinical guidelines on sepsis management can be consulted. it was started on january , and here we present all patients included until january . during the study period patient were included in the protocol, with a mean age of , ( , ) y, , % were male. we have observed an ascending tendence in the number of patients included in the protocol, having arised from patients on january to on january . the protocol was activated at the icu in ( , %) cases, at the emergency department in ( , %) and at hospitalization units in ( , %). two-hundred and two ( , %) patients were admited at the icu. though initially the protocol was exclusivelly directed to patient with severe sepsis or septic shock, lately some patients with sepsis have been included. so, ( %) had sepsis, ( , %) severe sepsis and ( , %) septic shock. only ( . %) had fever and ( . %) had arterial hypotension at the protocol entry. sepsis was community-adquired in ( , %) cases, nosocomial-non icu adquired ( , %) cases and icu adquired in ( , %). the the most frequent site of infection was the lung in ( , %) patients, followed by the abdomen in ( , %) patients. isolation of the causal microorganism was achieved in ( %) patients. blood cultures were positive in ( . %) cases. forty seven ( %) had organ disfuntion (od), ( . %) od, ( . %) od and ( . %) or more od. mean lactate levels were , ( , ) mmol/l, , ( , ) mmol/l and , ( , ) mmol/l at the activation moment, at and a hour respectively. mean c-reactive protein levels were , ( , ) mg/l. eighty-five ( , %) patients deceased, of whom ( %) had sepsis, ( , %) severe sepsis and ( , %) septic shock at the moment of activation. conclusion. it is possible to implement a global multidisciplinary computerized protocol for identification and management of the sepsis, although this is a laborious and continual process. t. kyprianou* , g. panayi , d. zeinalipur-yazti , m. dikaiakos intensive care unit, nicosia general hospital, ngo, intensive care forum, dept of computer science, universiy of cyprus, nicosia, cyprus introduction. the physiological condition of icu patients is marked by rapidly evolving and frequently life-threatening derangements as well as 'silent' yet important alterations in homeostasis. reliable monitoring i.e. the capability to collect, store, process, and share inpatient monitoring data along with physicians' remarks can bring tremendous benefits to all aspects of intensive care medicine (practice, research, education). currently, grid infrastructures assemble an extensive collection of resources and expertise (egee grid: + sites around the world with more than , cpu's - pb of storage, adequate for storing and managing icu-related data. we present the design and implementation of the intensive care window (ic-window), a software tool that enables the retrieval and integration of data from patient-attached medical sensors. ic-window follows a modular design to retrieve data from different patient monitoring devices. the tool includes a full-edged interaction protocol and graphical user-interface to interact with the phillips intellivue mp monitor. ic-window is implemented in the context of icgrid (intensive care grid), a novel data-grid framework that utilizes the egee infrastructure to enable the seamless integration, correlation and retrieval of 'clinically interesting episodes' across intensive care units clusters. we present preliminary data from software's use in icu patients. conclusion. ic window belongs to a new generation of tools that could improve dramatically intensivist's capabilities as offers virtually unlimited storage capacity for every possible type of patient's data. in the future we plan to extend the ic-window application to communicate with other medical devices found within the icu. this will provide an open platform for the aforementioned applications. introduction. strict glycemic control by lowering blood glucose levels to - mg/dl reduces the intensive care unit (icu) mortality, morbidity, duration of the hospital stay, and overall medical care costs. to provide an intelligent system for tight glycemic control, the eu-project "closed loop insulin infusion for critically ill patients (clinicip)" was started in january . three different sensor technologies -two based on an enzymatic reaction with immobilised glucose oxidase using either amperometry or fluorimetry as transducer and another based on reagent-free infrared spectroscopy -have been developed to continuously monitor the glucose levels in the subcutaneous interstitial body fluid. monitoring of the subcutaneous interstitial fluid is realized using a microdialysis catheter cma from cma microdialysis ab as a body interface to all glucose sensors. experiments were carried out at the center for medical research (graz, austria), lasting up to h with the probands starting under fasting condition, but receiving later their normal diet. after microdialysis probe implantation, the perfusate (either % mannitol solution or elo-mel) flow rates were around µl/min. for reference measurements, dialysate samples were collected. in parallel, blood glucose concentrations in venous blood samples, collected under arterialised conditions with the arm resting in a hot box, were determined using a glucose analyzer from beckman instruments. a clarke error grid analysis of the results from all three sensors has shown all values in clinically acceptable zones. the blood reference and sensor measurements were further compared using bland-altman plots. owing to the tubing connecting the catheter outflow and sensor, the lag times for the sensor readouts were between and min. for the electrochemical and infrared sensors a simultaneous micro-dialysis recovery rate determination has already been implemented for improving the correlation of the sensor readout to the whole blood levels. some observational studies suggest that the use of pulmonary-artery catheters to guide therapy is associated with increased mortality. we performed a randomized trial to study outcome benefit of using pulmonary artery catheter (pac) in ards patients when compared to standard care using central venous catheter (cvc). the subjects were ards patients on mechanical ventilator who were assigned either to pac (pac group), or cvc (cvc group). the base-line characteristics of the two treatment groups were similar. the primary outcome was icu and in-hospital mortality from any cause. the pac group had a significantly lower icu mortality than the cvc group ( vs , p value= . ) but there was no difference between the groups in in-hospital mortality (one case mortality in cvc group). there were no significant differences between pac and cvc groups in urine output ( . ± . vs. . ± . ), use of vasopressors ( . ± . vs. . ± . ), and length of hospital stay ( . ± . vs. . ± . ) respectively. our findings suggest that pac can be used in ards patients for better hemodynamic assessment that may result in reduced icu stay and mortality rate. ethanol may be used in the management of toxic alcohol poisonings , or as sedation in alcohol withdrawal. ethanol may be a component within drug formulations, for example nimodipine infusion or chemotherapeutic agents . ethanol flush has also been used to restore the patency of occluded catheter lumens . in clinical practice, ethanol must be infused via a pcvc, as its high osmolality can cause peripheral thrombophlebitis. given anecdotal reports of pcvc deterioration during ethanol infusion , , this study applied a bench test and a statistical model to develop clinical practice guidelines at our institution. each cm triple lumen pcvc was perfused with a single test solution only. (a) minute perfusion. the test solutions used were: dextrose (d) %; ethanol (e) %, %, %, %, % and %. each test solution was perfused through pcvcs. a total of pcvcs were perfused. (b) hour perfusion. additional pcvcs were perfused with d %, e %, e % or e %. after perfusion, the strength of all pcvcs was assessed. the pcvc was attached to a force gauge. a known force was applied to the pcvc and the pcvc length was measured. this was repeated for increasing forces until the pcvc broke. length-force relationships were plotted and were described statistically using linear mixed effects models. . this bench test model produced reproducible data. the pcvcs were not directly traumatised by the testing apparatus. (a) minute perfusion. pcvcs perfused with e % , e % or e % perished with obvious structural deterioration. two distinct length-force relationships were described on linear mixed effects models: e %, e % or e % weakened the pcvcs , whilst d %, e %, e % and e % had no effect upon pcvc structure (p< . ). (b) hour perfusion. the pcvcs did not perish. e % and e % weakened the pcvcs (p< . ). not been demonstrated previously. the infusion of e % e % or e % via pcvcs should be avoided. infusion of e % and e % for hours weakens pcvcs. nimodipine and other drugs using ethanol as a carrier vehicle should be infused via pcvcs with caution. these potential hazards should be outlined in individual pcvc package inserts and drug product information leaflets. ( ) introduction. inadvertent esophageal intubation may lead to serious complications such as hypoxia, cardiac arrythmias and death. auscultation of breath sounds may be an inaccurate method to determine correct endotracheal tube placement of endotracheal tube placement. vibration response imaging (vri) is a novel non-invasive technology that measures vibration energy of lung sounds during respiration. as air moves in and out of the lungs, vibrations propagate through lung tissues and are recorded by sensors spacially distributed on the patient's back over the lungs and a dynamic image is created. a year old female patient presented with lung cancer. plain chest radiograph and ct scan revealed a large left lung mass comparable for a neoplasm. she was admitted for left lung lobectomy. after informed consent was obtained, she underwent vri before and after intubation. the esophagus was inadventently intubated and recognized immediately after the vri recording was obtained. the patient went on to have a successful operation. analysis of the vri data obtained during esophageal and tracheal ventilation are compared along with a normal vri image. during esophageal ventilation most of the vibrations ( %) were detected by the upper sensors and the least by the lower sensors ( %) (fig. ) . following the endotracheal intubation as well as in a normal image, the vibrations were more evenly distributed with the sensors from the middle region receiving more vibrations. quick detection of inadvertent esophageal intubation is crucial to prevent serious complications but commonly used methods of confirmation such as auscultation and plain chest radiograph are inaccurate or do not provide timely results. vri is a novel technology that offers the potential to quickly identify inadvertent esophageal intubation in the or and perhaps other settings. the acapella ® is a small hand-held vibratory device that combines the resistive features of the positive expiratory pressure (pep) and the vibratory features of a flutter valve to mobilize secretions in the airway. vri is a novel dynamic imaging technique that measures vibration energy of lung sounds generated during respiration. in this study, our aim is to determine, using the vri, what regions of the lungs receive the most vibrations when the acapella is being used. a second vri recording was performed on a healthy volunteer during normal breathing (first three breaths) and while using the acapella device (last four breaths). the vri recordings were obtained in second periods of respiration. dynamic digital images and numerical raw values for vibration energy are analyzed and compared any regions of interest. . vri images at maximal expiration while using acapella show increased total vibration intensity. when the distribution of expiratory vibration is examined, it appears that vibration from the acapella goes more to the lower lung regions (figure and ) . asymptomatic catheter-related central vein thrombosis (cvt) which is diagnosed by venographic studies is mentioned to be as high as %. moreover, when thrombosis occurred, the risk of catheter related sepsis was declared to be . % higher. in this prospective study we aimed to diagnose cvt early as possible, its incidence and risk factors. icu patients (pts) that needed a central venous access for at least hours without chemotherapeutic agents administration were included in this prospective study. the catheters were inserted via internal jugular or subclavian vein at bedside under aseptic conditions using the seldinger technique. diagnosis of vein thrombosis was detected by color doppler ultrasound examination performed in less than h after catheter removal (picture). the protocol was approved by the ethic committee. three hundred and thirty eight pts ( f, m), mean . years old ( - years), were included in the study. catheters mean duration time was . days and duration of insertion mean time was . min ( - min). in pts catheter insertion was performed with a single puncture, in pts with double and in pts with three and more punctures. catheter localization was : in pts right subclavian vein, in pts left subclavian vein, in pts right internal jugular vein and in pts left internal jugular vein. catheter related thrombosis was diagnosed in pts ( . %) while catheter infection was seen in patient ( . %) (table). generally the chemotherapeutic agents administered via the central vein catheter have thrombogenic effect. when we study our cvt diagnosed pts we found out that all of them were over years old, the mean catheter duration time was . days (table) . but these results were not statistically significant when compared with the other pts under years old and more than . days of mean catheter duration time. out of pts who were not under anticoagulant therapy had cvt while out of pts under anticoagulant therapy had cvt diagnose which was found statistically insignificant (p> . ). our results show that patients under anticoagulant therapy have a three fold more cvt risk ratio than the others who are not using this anticoagulant therapy. patients under anticoagulant therapy have to be followed more closely regarding to cvt. the provision of good glycaemic control is thought to have some beneficial aspects in critical care patients. we have previously described the introduction of a web-based insulin dose calculator program to support the control of blood glucose in critical care. the aim of this study is to describe a modified version of a calculator program based on van de berghe's studies. this allows nursing staff to enter blood glucose values together with the insulin infusion rate into a calculator. the calculator then provides a recommended insulin infusion rate to control blood glucose with the added ability to recommend small bolus doses of insulin when appropriate, store blood glucose concentrations, insulin rates, bed number and the date and time of calculation. we also modified our feeding protocol to restrict the target enteral feed from kcal to kcal per day and removed the night time rest period. we studied the data stored by the program which was used for all patients admitted to a -bedded intensive care unit (approximately % of whom have neurological injuries) between june and may . overall there were patients admitted (mean apache ii score [sd +/- ], with a mean age of years [sd +/- ]. patients died prior to icu discharge. there was a total of patient days with recorded calculation data points. the mean blood glucose concentration was . mmol ( ci . - . ). there were episodes of treated hypoglycaemia of which were on an insulin infusion. there were two troughs in the time of data entry that corresponded with staff handover. there was no diurnal variation in blood glucose concentration or in insulin infusion rates, although this did peak slightly in the early morning. the mean value of the insulin infusion rate was . units / hr (sd +/- . ). in normal subjects there is a decreased level of endogenous insulin in the early morning, that is only partly lost with constant nutrition. from this study we concluded that the web based insulin calculator facilitates the dosing of insulin in critical care in an economic manner. the lack of diurnal blood glucose concentration variation, suggests that once daily estimation of blood glucose may be an acceptable method of monitoring blood glucose concentrations in critical care. systemic inflammatory response syndrome (sirs) is a common entity in the intensive care units. early institution of an appropriate antimicrobial regimen in infected patients is associated with a better outcome. both c-reactive protein (crp) and procalcitonin (pct) are accepted sepsis markers. however, there is still controversy concerning the correlation between serum concentrations, infection and sepsis severity. objective:to determine the clinical aplication of procalcitonin (pct) and c-reactive protein (crp) plasma concentrations in the detection of sirs related to infection and sepsis and the assesment of severity of sepsis. desing: prospective observational study. setting: medicosurgical intensive care unit. patients: over a period of months (january-february ), forty seven consecutive adult patients admitted in a intensive care unit for an expected stay > hrs.and sris symtoms and signs. informed consent was obtained from all patients. measurements: pct and crp plasma concentrations and white blood cell counts , apache ii y sofa within the first h . each patient was examined at the time of enrollment and was classified in one of the following four categories according to the accp criteria: siris and sepsis group (sepsis, severe sepsis and septic shock). statistical analysis: were performed with spss . . differences in continuous variables between infected and non infected patients were compared with the nonparametric mann-whitney test. and lineal.regressión. pct levels were significantly higher in the severe sepsis(p= , ) and shock septic group (p< , ). pct and cpr levels no weren found differences between sepsis of less gravity group and noninfectious sirs. pct and crp levels are significantly correlated to the severity of organ dysfunction (sofa y apache ii). pct and crp levels were significantly higher withing short space of time in patient with infection than in patients with non-infectious sirs, but for sepsis of less gravity, pct and crp plasma values not differentiate between sepsis and non-infectious sirs. investigators have reported microcirculatory alterations in critically ill patients using various techniques. persistent microvascular alterations might be associated with the development of organ failure and death. in this study, microcirculatory blood transit time was measured in intensive care patients using micro-channel flow analyzers and related to the severity score and mortality. thirty-one patients were included in this study. mean apache-ii score was . . patients were divided into two groups, group l (apache-ii< , n= ) and group h (apache-ii>= , n= ). in both groups, blood transit time was measured using microchannel flow analyzers (mc fans). the micro-machined silicon chip is utilized in these instruments to simulate human capillary blood flow. microcirculatory alteration was presented as a blood transit time (second) of heparinized blood through micro-channel array under the pressure difference of cmh o. hematocrit, white blood cell (wbc) count, platelet count, and labolatory data were obtained at the same time. blood transit time was significantly longer in group h comparing that in group l ( . +/- . sec, . +/- . sec, p< . ). wbc count was larger in group h comparing that in group l ( +/- /ul, +/- /ul, p< . ). triglyceride (tg) and immunogloblin (igg/m/a) levels were significantly higher in group h comparing these in group l. none of the group l patients died, however, hospital mortality rate was . ? in group h. blood transit time through micro-channel array was prolonged in patients with high apache score )wbc, tg, and immunogloblin levels might be associated with patients blood fluidity. ) micro-channel flow analysis may become a valuable tool to monitor microcirculation in critically ill patients. a. roman* , t. el mahi , c. hanicq , d. gnat , f. vertongen , e. stevens intensive care, clinical chemistry, chu saint-pierre, brussels, belgium bedside glucose monitoring is mandatory for icu patients under tight glycemic control. point-of-care (poc) glucometers are based on glucose-dehydrogenase coupled with pyrroloquinoline-quinone/ferricyanide (gd/pqq)or phenanthroline-quinone/nad (gd/pqnad), or glucose-oxydase/ferricyanide (go) enzymatic methods for whole blood measurements. the laboratory reference method is hexokinase for measuring the plasma glucose levels. some drugs and metabolites can interfere with poc methods. the aim of this study was to evaluate the effect of the uric acid levels on the accuracy of these bedside methods. in this prospective observational study, arterial blood glucose was measured simultaneously on the accu-chek inform roche (gd/pqq), on the precision pcx abbott (gd/pqnad), on the rapidlab bayer (go) and each value was compared with the reference laboratory result. measures were done in adult icu patients. uric acid was obtained only once a day. a bland-altman analysis was done. biases were expressed as the poc minus the laboratory result. data were also analysed using linear regression. spearmann's rho squares were calculated to evaluate the uric acid level effect on the difference between poc and laboratory methods. the uric acid level range was . to . mg/dl. the biases, the % limits of agreement between each poc method and the reference method, the r of spearmann for the correlation between uric acid level and the difference of result glucose level for each poc method are shown in table . the accu-chek inform overestimates moderately the glucose level while the precision pcx and the rapidlab underestimate it slightly. the wilcoxon ranked test with bonferroni correction gave a p < . for comparing the bias from the accu-chek to the bias from the precision pcx, p < . when compared to the bias obtained for the rapidlab. no statistical difference between the precision pcx bias and rapilab was found. the r of spearmann correlating the effect of the uric acid level and the difference between the accu-chek and the reference method was . . the weak effect of the uric acid level of the patient on the overestimation of the glucose measured by the accu-chek can be summarized as : glucose difference(accu-chek-laboratory) = . x uric acid (mg/dl) - . . for the other poc glucometers, such correlations were absent. a patient presented with severe acidosis, point-of-care (poc) lactate of mmol/l, suspicion of mesenteric ischemia and potential need for laparotomy. however, plasmalactates was < mmol/l, and ethylene glycol (eg) ingestion was subsequently diagnosed. we, therefore, wished to determine why discrepant lactates occur and if this "lactate-gap" could be clinically useful. we phlebotomized blood, added various concentrations of eg metabolites, and tested with the five most common lactate analyzers. the pressure-volume(p-v)curve of the respiratory system defines the mechanical properties of the lung and the chest wall by relating airway pressure(paw)in no-flow conditions with lung volume at the same pressure level. objective:to evaluate a new technique for p-v curve tracing. two p-v curves were obtained in ali/ards patients using the continuous positive airway pressure (cpap) method and an automated system built into a commercial ventilator (p-v tool , galileo, hamilton). for the cpap method, ventilators were switched to cpap and pressure was raised from to cmh o in cmh o steps and then decreased while respiratory inductive plethysmography measured lung volume. for the automated method, we selected the automatic pv mode(galileo, hamilton)with flow l/m and maximum pressure of cmh o. lung-volume and airway-pressure data were recorded. p-v pairs were fitted to a mathematical model. lower (lip) and upper (uip) inflection points on the inspiratory limb and maximum curvature point on the deflation limb were obtained. correlation between methods was calculated using bias and % agreement limits for lips and uips and the intraclass correlation coefficient (icc) for absolute agreement for each pressure level. no adverse events were observed. p-v curves were equivalent for each method, with icc > . for each pressure level. bias and precision for lip and uip were:lip . ± . cmh o and uip . ± . cmh o. the automated method for tracing p-v curves is equivalent to the cpap method. easily applicable at the bedside, it avoids ventilator disconnection and can obtain both inspiratory and deflation limbs of p-v curves. introduction. hypoxic hepatitis (hh) is a common cause of acute hepatic impairment. however, few is known about the degree and duration of the reversal of the liver impairment. therefore we assessed the liver function by indocyanine green (icg) clearance via limon (pulsion medical systems, munich, germany) in patients with hh. icg clearance was assessed in critically ill patients fulfilling the criteria of hypoxic hepatitis. mean apache iii score was ± . nine patients were male. icu survival was %. icg -plasma disappearance rate (pdr) (normal range: - %/min) and the retention rate of icg extrapolated to minutes (r ) were obtained on the day of development of hh and till day five. nine patients with decompensated liver cirrhosis child c requiring intensive care therapy served as control group. results. icg-pdr and r expressed as mean ± standard deviation were . ± . %/min and . ± . %, respectively ( patients), on the day of development of hh. icg-pdr and r were . ± . %/min and . ± . %, respectively, in the control group and was comparable to the hh group (p=ns). icg-pdr and r improved continuously from time of development of hh to day five ( patients alive and at icu) and were comparable to the course of laboratory data during observation period (table ) . exhaled breath condensate (ebc) is a non-invasive means of collecting samples of airway lining fluid from the lower respiratory tract and monitoring respiratory diseases. we have used ebc acidification to study the effects of mechanical ventilation. ebc was collected ( - minutes at - o c: ecoscreen, jaeger). immediately after collection and as soon as the sample returned to room temperature, we measured conductivity and ph before and after deareation with helium ( minutes). results are expressed as median (interquartil range). we have applied spsswin with spearman correlation and mann-whitney test. our earlier evaluations of a decision support system for tight glucose control (tgc) in the critically ill utilising model predictive control (mpc) documented clinically acceptable performance with hourly bg sampling. the mpc advises on insulin infusion based on blood glucose (bg) measurements and carbohydrate content of parenteral and enteral nutrition. in the present study, we evaluated an improved version of the mpc (v . . to . . ), which extends the advice by suggesting the time of the next bg measurement in the range from half-to four-hourly to reduce nurse workload. patients were admitted at one medical (mug; n= ) and two surgical (kul: n= ; cup: n= ) icus. patients were followed for a minimum of hours and up to hours. we evaluated safety of tgc (hypoglycaemia frequency), efficacy (mean bg; hyperglycaemic index, hgi; and time spent in the target range . - . mm), and efficiency (time between bg measurements). nonparametric statistical tests evaluated differences among icus. one hypoglycaemia (bg < . mm) occurred in one subject at mug and in another at cup. there was no hypoglycaemia at kul. bg was within the target range but differed among icus with values of . ( . - . ), . ( . - . ), and . ( . - . ) mm [median ( strict glycemic control of plasma glucose has become general practice in most icus. frequent glucose control is required to titrate the amount of insulin infused and detect episodes of hypoglycemia. for practical reasons bedside glucometry is often used. aim of our study was to determine the accuracy of several glucose point-of-care (poct) devices in critically ill icu patients. arterial blood samples from unselected icu patients were collected and glucose measurements were performed on a bloodgas analyzer (glucose-oxidase; rapidlab bloodgas analyzer, bayer diagnostics) and three different poct devices (gdh-pqq, accu-chek sensor, roche diagnostics), gdh-nad+ (precision, abbott diagnostics) and modified gdh (hemocue). results of paired measurements were compared in three ways. paired values were plotted on a bland-altman plot. the pearson correlation coefficient (r) between the different methods was determined by linear regression. each pair was also analysed using the international organization for standardization (iso) criteria: -glucose > , mmol/l value within % of reference -glucose ≤ , mmol/l value within . mmol/l of reference. comparison between accu-chek and rapidlab of samples from unselected icu patients (n= ) showed a good correlation (r = . ). bland-altman analysis and analysis by iso criteria revealed clinical significant differences in . % of pairs. in all cases the poct values were higher than the values from the bloodgas analyzer. comparable results were found using the precision and hemocue: although correlation was high, analysis by iso criteria showed differences in / ( . %) and / ( . %) of pairs. a clinically important inaccuracy was found between poct devices and bloodgas glucose measurements in critically ill icu patients. in the most cases values from poct devices were false high, increasing the risk of hypoglycemia. in the context of an insulin infusion protocol for aggressive glucose control in sedated icu patients poct devices are potentially dangerous and should be avoided. acute hyperglycaemia associated with insulin resistance is common in critically ill patients. acute tight control of blood glucose is considered important, although difficult to perform in routine care. we developed a software to implement tight glycaemic control (cgao): after each glucose level measure, the cgao advises a new insulin pump rate and the schedule for the next glucose control, gives indication for correcting any hypoglycaemia episode, and presents numerous parameters describing the quality of glycaemic control. in a retrospective case control study, we compared the software cgao (lk , igny, france) used routinely in our unit since may with our previous method for glycaemic control based on daily medical prescriptions. patients without cgao (group pres) were randomly selected from our prospective intensive care database (admission after january , ) and matched : for sex, age, simplified acute physiologic score (saps ii), medical or surgical category, history of type diabetes, and length of stay (los) with patients for whom we used cgao. type diabetic patients or patients with los < days were excluded. endpoints were average glucose level, hyperglycaemic index calculated above . mmoles/l, fractions of time (ft) resp. with normoglycaemia [ . - . mmoles/l] and hyperglycaemia [> . mmoles/l], cumulative duration of hypoglycaemia [< , mmoles/l], average insuline requirements per day, and mean sampling interval for glucose control. we included patients (mean age: ± years, saps ii: ± , surgical: %, type diabetic: %), permitting to compare cgao patients with pres patients. a. sigalas*, d. w. patch, a. k. burroughs, j. p. o'beirne liver transplantation and hepatobiliary medicine, royal free hospital, london, united kingdom recently a number of studies have reported that relative adrenal insufficiency (rai) is common in critically ill cirrhotics. depending on the definition used the prevalence of rai in critically ill cirrhotics has been reported to be - %, whilst in patients immediately post liver transplantation the incidence of rai has been reported to be %. given the high prevalence of rai in critically ill cirrhotics and patients undergoing liver transplantation, we hypothesised that adrenal function impairment may be a feature of chronic liver disease per se. the aim of this study was to define the prevalence of impaired adrenal function in patients with stable cirrhosis. we also examined whether the use of the µg or µg acth tests was associated with different responses. methods. patients with biopsy proven cirrhosis (or compatible imaging and biochemistry) underwent adrenal function testing with the µg (n= ) or µg(n= ) short synacthen tests (sst). patients were those with stable cirrhosis undergoing evaluation for transplantation or assessment for tips insertion for refractory ascites. patients with a recent history of infection or bleeding were excluded. . patients underwent adrenal function testing. the median age of the group was (iqr - ). the commonest cause of cirrhosis was alcohol in %. disease severity was measured by meld and childs-pugh scores. the median meld was (iqr . - . ) and the median childs-pugh score was (iqr - ). patients ( %) showed a baseline cortisol < nmol/l and an increment < nmol/l following sst. patients ( %) had an increment in cortisol < nmol/l following sst. patients ( %) had a baseline cortisol < nmol/l. overall abnormalities in the sst (low baseline, peak or increment) were seen in patients ( %). there were no significant differences in the frequency of abnormalities in the sst between the µg or µg sst groups. in multivariate analysis only meld score significantly predicted abnormalities in the sst. the above data suggest that adrenal dysfunction is a frequent finding in patients with stable cirrhosis and is correlated with liver disease severity. the underlying mechanism of this finding is unknown but may account for the very high frequency of rai in critically ill cirrhotics. the direct relation between glucose and lactate levels in critically ill patients has hardly been studied. we studied the relation between glucose and lactate in general and during hypoglycemia. intensive insulin therapy was performed with the nurse-centered grip computer system that aimed at a glucose level of . mmol/l or less. glucose and lactate were routinely measured together. all hypoglycemias detected over a -month period at the surgical icu were analyzed. hypoglycemia was divided in mild ( . thru . ), moderate ( . thru . ) and severe (<= . mmol/l) hypoglycemia. . , glucose/lactate measurements were analyzed in patients. glucose and lactate both were not normally distributed. after taking these distributions into account no evident relationship between simultaneous measurements of glucose and lactate was seen. hypoglycemias were identified ( mild; moderate; severe). lactate showed a with a nadir value two hours after the hypoglycemia. the magnitude of hypoglycemia was not related with lactate response. evidence accumulates that improved glucose control in intensive care patients results in better outcome. improved glucose control requires rapid point of care glucose measurement. however, the reliability of point of care glucose measurements has been questioned. this study was done to evaluate the accuracy of accucheck point of care glucose measurement in intensive patients as compared to glucose measurement by the central hospital laboratory. the unit is a bed mixed closed format icu. glucose regulation is performed by nurses for all patients using a computerised protocol( ). for this study, paired glucose measurements were randomly done in patients in the icu, only when glucose measurement was clinically indicated and only if workload permitted the extra task. the accucheck inform device (roche diagnostics) measures whole blood glucose in a single drop of blood. the central laboratory uses glycoseoxidase vitros to measure glucose in serum. from patients paired measurements were obtained (table ) . central laboratory glucose measurement was generally higher than accucheck glucose measurement. the mean difference was , mmol/l. correlation coefficient r was , . the difference was more than , mmol in % of cases. blood samples were mostly ( %) derived from arterial lines. the correlation and bland altman plots are presented in figure . related literature was examined for benchmarking purposes. data collection was carried out over a one month period, two days a week, in the icu. each blood sugar level (bsl) was recorded and ensuing action chosen on adjusting the insulin infusion rate, and resultant information analysed. a survey was carried out on nursing staff regarding their views on the protocol. statistical analysis was carried out using microsoft excel ® . the bsls were in the target range of . - . mmol/l . % of the time (n= ). the proportion of bsls that complied with the surviving sepsis guidelines target of less than . mmol/l was good at . %. the incidence of severe hypoglycaemia, defined as less than . mmol/l, was low at . %. compliance with the action chosen on adjusting the insulin infusion rate was high at . %. total compliance (action and timing) with the protocol was %, and a relationship between compliance and achieving target bsls was shown. in general, a positive view of the protocol was obtained from the nursing staff regarding the protocol. the amnch icu insulin infusion protocol is effective at achieving tight glycaemic control in a safe manner. the low incidence of severe hypoglycaemia and high proportion of bsls complying with the surviving sepsis guidelines illustrates this. compliance with the protocol is achievable, demonstrated by the high level of compliance on action taken on the insulin infusion rate and the survey responses. however the timing of bsl checking needs to be addressed in future drafts of the protocol, as this is an area that needs improvement in terms of feasibility and compliance. further changes and auditing of the protocol are necessary to ensure consistency and improvement of the tight glycaemic control. introduction. intensive insulin therapy might be able to reduce mortality and/or morbidity in critical patients. besides adherence to strict protocols this strategy implies multiple, accurate measurements of glycemia. gold-standard laboratory assessment isn't able to provide immediate readings and capillary or arterial blood samples may differ too much when bedside reflectance meters are used, particularly in shock patients. our aim was to assess the accuracy of two methods of blood glucose analysis (bedside "glucometer" using capillary and arterial blood) in two groups of critical ill patients (shock and non-shock). prospective non-randomized, cohort study, in a university hospital general icu. a group of consecutive icu patients with shock syndrome and vasoactive amines and another contemporary patients without shock, were included (shock-sg and non-shock-nsg groups). for each patient to "triplets" of blood samples were collected in a h period, and included concomitant samples of blood drawn from fingerstick (cap) and non-heparinized arterial line(art). drops of capillary and arterial blood were analyzed with a bedside glucometer (glucotouch ® , lifescan), and a sample of arterial plasma was sent to laboratory for glycemia determination (lab). . total group had a median age of years, mean saps ii of , . sg was older (median age - vs ys) and more ill (mean saps ii , vs , ) than the nsg. total mortality was , % (sg- , %; nsg- , %). in the sg , % had septic and , % cardiogenic shock. in the nsg , % had politrauma and , % pneumonia. a total of "triplets" were studied. non parametric wilcoxon test was applied to test agreement between cap-lab and art-lab paired samples. although we've found a highly significant correlation (spearman r> , ) between cap-lab and art-lab values, agreement were rejected by -tailed wilcoxon signed ranks test, both in total, sg and nsg (p= . ). an error grid-analysis using iso for blood glucose determination showed that , % of cap and , % of art determinations had a deviation more than % the reference lab value in the sg. in the nsg % of cap and % of art samples had more than % deviation. this study show that the glucometer we used had an unacceptable accuracy, both in shock and non-shock patients, far from the iso criteria that imposes only % of values can be more than % apart the reference value. glucose control is a major issue in the icu and standard procedures for its determination are still lacking. introduction. arginine (arg) is a precursor of the vasodilator nitric oxide (no), while asymmetric dimethylarginine (adma), derived from proteolysis of methylated arg residues, is a no synthase inhibitor. accumulation of adma is related to oxidative stress, impairing its degradation, and to renal-and liver failure. accumulation is associated with increased mortality ( ). aim of this study was to evaluate the relation between plasma arg, adma, arg/adma ratio, organ failure and survival in patients with shock. we measured plasma concentrations of arg, adma and lactate, sofa scores and hospital mortality in septic (ss) or cardiogenic shock (cs) patients on d , d and d of icu admission. patients were enterally fed with impact (arg-enriched). values are presented in mean ± sd or median (iqr). for regression analysis, arg, adma and arg/adma were log transformed. of the patients, had ss, cs. mean age was ± yrs, sofa ± , apache ii ± . . hospital mortality was %, predicted mortality was ± %. at d , median (iqr) of arg was ( - ) mumol/l (normal range - mumol/l), adma . ( . - . ) mumol/l, arg/adma ( - ) and lactate . ± . mmol/l. arg and arg/adma at d were inversely related to lactate (r = . , p < . , for arg; r = . , p < . for arg /adma), and to sofa scores. the table presents the relation between arg and arg/adma to sofa score during sampling, and of arg and arg/adma on day to maximum sofa score. apneic oxygenation (ao) is apllied during several operations in thoracic surgery and some procedures in th icu. retention of co often leads to hypoxemia, limiting the tolerable time in ao. this experimental study was designed to evaluate the effects of recruitment maneuver on oxygenation, co retention and survival times ao. following the ethic committee approval, male sprague-dawley rats were anesthetized, tracheostomized, cannulated via the a. carotis and ventilated with pressure controlled ventilation (peak pressure: cmh o, frequency: /min, cm h o peep) for minutes. following the basal (t ) arterial blood gas sample, they were randomized into groups and disconnected from the ventilator: in group (n= ), rats underwent ao with a cannula inserted to carina (o -flow: . l/min), in group (n= ), recruitment maneuver ( cm h o (peep) ventilation pressure during seconds) was performed before ao. in control group (group , n= ), data were recorded after apnea (this group was stopped after the first subjects have died during the study period). further arterial blood gas samples were drawn in st, rd and th minutes, and ph, po , pco , hco and be values were recorded. survival times after the initiation of ao were also investigated. kruskal-wallis test was used to compare the values in different times, and mann-whitney-u the values in different groups. there were no significant difference in t values. compared to t values, there was a significant decrease in po and a significant increase in pco during rd and th minutes in all subjects, with a less change in g . there was a significant difference between g and g in po after and minutes p< . ; table ), the difference in pco was not significant. survival time in g was significantly longer (g : , ± , min; g : , ± , min; p< . ). to investigate potential prognostic factors and to predict extent of risks for postoperative pulmonary complications by logistic regressive analysis, and to evaluate the role of non-invasive ventilation in reducing the incidence of complications in elderly patients. stair-climbing test was carried out with asa score, fev , changes of spo and hr et al were noted at the same time. logistical regressive analysis based on the parameters above were used to assess the relation between potential prognostic factors and postoperative complications. patients with limited pulmonary reserves were selected using the equation, and protective effect of non-invasive ventilation on these patients was assessed. incidence of postoperative pulmonary complications for high-risk patients with non-invasive ventilation was . %, and incidence of pulmonary complications for high-risk patients without non-invasive ventilation was . %. there was not a significant difference between these two groups with low-risk (p> . ). conclusion. the mathematical model of logistic regressive analysis using stair-climbing testing combined with other parameters is a simple, reliable method to predict the cardiopulmonary reserved function in elderly patients. non-invasive ventilation can effectively reduce the incidence of postoperative pulmonary complications for high-risk patients, but it has no effect on patients with low-risk. continuous epidural analgesia (ea) and intravenous analgesia (ia) are widely used for postoperative thoracic pain control. the aim of this study is to compare the advantages and the disadvantages of both analgesic techniques. ropivacaine . % to mg/h using thoracic epidural catheters (ea) vs intravenous analgesia with remifentanyl . µgr/kg/min (ia). one hundred patients, undergoing pulmonary surgery, were recruited and divided, after randomization into groups. patients included in ea group had an epidural thoracic catheter placed at th -th space, received ropivacaine . % by continuous infusion (rate ml/h). patients included in ia group received an ev continuous infusion of remifentanyl (rate . µgr/kg/min for hours). rescue medication consisted of morphine mg ev at patients demand. analgesia at rest and while coughing as evaluated by visual analogue scale (vas). haemodynamics, motor blockade (bromage scale) and side effects such as nausea, vomiting and pruritus were observed. the follow-up took place after weaning and every hour to hours at rest and coughing. data are reported to media ± standard deviation (sd). analgesic effects were compared by using chi square statistics (p< . ). both groups showed good analgesic effects. remifentanyl seems to decrease the incidence of side effects and the need of rescue analgesia. conclusion. )our data show that both analgesic techniques are able to guarantee a good pain relief after thoracotomy. )epidural analgesia was more difficult to perform and it showed less acceptance by patients. non-invasive ventilation (niv) has become an effective treatment to reduce morbidity and mortality in patients with acute respiratory failure. its application has been restricted to critical care o intermediate care areas, and little data is available on its usefulness in the post-anaesthesia care units (pacu). the aim of this study is to document our experience after eight patients treated in the pacu. we undertook a retrospective audit of patients treated with niv between october and december . data of past medical history, age, asa physical status, surgical procedure, anaesthesia modality, type of respiratory failure, ventilatory mode, and time of niv were recorded. we also recorded side effects related to niv application. descriptive statistical analysis was used. eight patients were included. the mean age was . ± . (sd) years. five patients were classified as asa ( . %), two as asa ( . %), and one as asa ( . %). three patients had morbid obesity, two chronic heart failure, and two chronic obstructive pulmonary disease. general and regional anaesthesia were employed in and cases respectively. type of surgery was thoracic ( %), urologic ( %), and plastic ( %). there was one case of abdominal surgery and another one of oral surgery. hypoxemic failure was detected in three patients ( . %), and cpap was applied in these cases. bipap was applied in cases of hypercapnic ( . %) or global ( %) respiratory failure. the mean time of niv was . ± . (sd) minutes. no complications related to niv occurred. no patient required either intubation or transfer to the icu. all of them were transferred to the surgical wards the same day. conclusion. niv can be safely applied to selected patients in the pacu, to treat respiratory failure after either general or regional anaesthesia. it is an effective method to avoid intubation and icu stays, with minimal side effects. further studies should be conducted to analyze the clinical and economic impact of niv in the pacu. the routine use of volatile anesthetics in intensive care medicine has been limited so far due to technical difficulties and the need for an anaesthetic machine. the new anesthetic conserving device (anaconda)can provide a safe application of isoflurane or sevoflurane under intensive care conditions. this system is a modified heat and moisture exchanger which includes activated carbon fibres and works as a miniaturized vapor with recirculation. we studied the effectiveness of sevoflurane sedation in operative intensive care patients undergoing mechanical ventilation. we included ventilated patients (neurosurgery, septic patients) in our retrospective analysis. the anaesthetic conserving device (anaconda-system) replaces the common heat and moisture exchanger in the ventilator circuit. the volatile anaesthetic is continuously applied in liquid status via a syringe pump to the minivapor where the anesthetic is vaporized. the expired anaesthetic gas is stored in the carbon filter and about % are resupplied into the breathing circle. first experiences with sevoflurane at our institution with a mean application time of . ± . hours per patient, showed a mean dose of . ± . ml sevofluran to achieve the individually targeted sedation level. . ± . minutes after the end of sevoflurane application, the patients could be neurologically evaluated or transferred to spontaneous breathing or extubated. no relevant side effects like nausea, vomiting or elevated enzymes were observed. we could demonstrate a safe application route, no development of tolerance as well as short wake-up times after long-term sedation with sevoflurane. the current literature suggest that volatile anaesthetics present an alternative for long-term sedation on intensive care units, providing optimized pathways from a medical as well as from an economical viewpoint. safety and effectiveness of sedation and analgesia in permanent pacemaker implant (ppm) is of special concern, due to age and comorbidity of the implanted patients. remifentanil pharmacological properties appear to be of interest in this setting. to date, there are no reports describing the use of remifentanil in this procedure, without the use of mechanical ventilation. consecutive patients in whom a ppm or other procedures, such as pacemaker battery change, was scheduled were included. a sedation and analgesia protocol for ppm implantation was performed: metoclopramide premedication, remifentanil infusion ( mg/ml), local anaesthesia with mepivacain %, magnesic metimazol administration at the end of procedure, and remifentanil infusion withdrawal minutes later. remifentanil infusion was initiated at a rate of mcg/min, increasing the rate to attain a sedation ramsay scale grade or , to a maximum of mcg/min. remifentanil failure was defined as the need to administer a different sedation after the maximum dosage was attained. adverse effects, lenght of infusion and dosage were recorded. .two hundred and thirty-six consecutive patients were included. the men age was , ± , . procedures: bicameral pacemaker , %, unicameral , %, battery change , %, other , %. infusion description and adverse effects are showed in tables and . serious adverse effects were resolved with remifentanil infusion withdrawal. all the procedures were completed. remifentanil is safe and effective as sedation and analgesia for ppm implantation, even for old patients, with the dosages used in our protocol. nausea is the most frequent adverse effect. serious adverse effects are uncommon and can be resolved with infusion withdrawal. glass psa, gan tj, howell s. a review of the pharmacokinetics and pharmacodynamics of remifentanilo. anesth analg ; : s -s . peripheral arterial occlusive disease (paod) can cause intense neuropathic/ischemic limb pain in patients (pts) with end stage renal disease (esrd). although fentanyl may be an excellent choice in esrd due to the absence of active metabolites, the use of fentanyl as pca in esrd has never been reported. we used iv fentanyl pca for ischemic lower extremity pain in esrd patients ( m, f), of whom were scheduled for amputation. pts received iv fentanyl pca via a gemstar (abbott) pump. initial settings were mcg bolus, min lockout, no basal, and dose was adjusted as needed to achieve visual analogue scale (vas) score < . pca started hours preamputation and continued postoperatively for h in pts ( pts had epidural postoperative analgesia and one terminal cancer pt did not have surgery). pain was assessed twice daily with vas. the mcgill pain questionnaire (mpq) -total ranked rating index (pri(r)), was administered immediately before and h after pca started. sedation was assessed twice daily on a four-point scale: ) agitated, ) awake, ) roused by voice and ) unarousable. pain scores were compared with paired t-test. group data are presented as mean ± sd. mean sedation score was in men and in women. we did not observe respiratory depression in any patient. the aim of this study was to determine risk factors for relapse, and for icu-mortality in patients with ventilator-associated pneumonia (vap) related to nonfermenting gram negative bacilli (nf-gnb). retrospective case-control study based on prospectively collected data. vap diagnosis was based on clinical, radiographic and microbiologic (endotracheal aspirate ≥ cfu/ml) criteria. patients with monobacterial vap related to nf-gnb were eligible. patients with subsequent superinfection or persistent pulmonary infection were excluded. patients with relapse of nf-gnb vap were matched ( : ) with patients without relapse according to duration of mechanical ventilation before vap occurrence. univariate and multivariate analyses were used to determine risk factors for relapse, and for icu-mortality in cases and controls. . patients were eligible. patients were excluded for superinfection. no persistant infection was diagnosed. ( %) patients developed a relapse of nf-gnb vap, and were all successfully matched with controls. pseudomonas aeruginosa was the most frequently isolated bacteria ( %), followed by acinteobacter baumannii ( %) and stenotrophomonas maltophilia ( %). no significant difference was found between cases and controls with regard to age ( ± vs ± ), male gender ( % vs %, p = . ), and surgery ( % vs %). however, saps ii at icu admission ( ± vs ± , p = . ) was significantly lower in cases than in controls. duration of adequate antibiotic treatment for first vap episode was significantly shorter in cases than in controls ( ± vs ± d, p = . ). inadequate initial antibiotic treatment was the only variable independently associated with relapse of vap related to nf-gnb (or [ % ci] = . inadequate initial antibiotic treatment is independently associated with relapse of vap related to nf-gnb and with icu-mortality. ∆ radiologic score and saps ii at day after vap diagnosis are independent risk factors for icu-mortality in these patients. s. blot* , j. solé-violán , j. blanquer , j. almirall , a. rodriguez , j. rello icu, ghent univ hosp, ghent, belgium, icu, dr negrin hosp, gran canaria, respiratory care, clinic hosp, valencia, icu, mataró hosp, barcelona, icu, joan xxiii univ hosp, tarragona, spain practice guidelines suggest processes of care such as timely pulse oximetry monitoring and antibiotic therapy, as quality indicators for the management of communityacquired pneumonia (cap). the objective of this study was to determine whether postponed initial processes of care such as pulse oximetry monitoring delays initiation of antibiotic therapy and adversely affects intensive care unit (icu) survival in patients with severe cap. a prospective observational multicenter study was conducted including patients with cap admitted to the icu in hospitals. a secondary analysis was conducted to evaluate processes of care and icu survival. postponed blood culture sampling, arterial blood gas sampling and pulse oximetry monitoring was predictive for delayed antibiotic administration (p< . ). linear regression analysis demonstrated that a delay of > h in blood culture sampling was associated with a delay of . h ( % confidence interval [ci], . - . ) in antibiotic therapy, a delay of > h in blood gas sampling with a delay of . h ( % ci, . - . ), and a delay in pulse oximetry monitoring of > h with a delay of . h ( % ci, . - . ). a delay in antibiotic administration of > h was associated with increased mortality in univariate analysis (relative risk [rr], . ; % ci, . - . ), but not after adjustment for disease severity. a delay in pulse oximetry monitoring of > h was associated with increased mortality in univariate analysis (rr, . ; % ci, . - . ) and after adjustment for disease severity (hazard ratio, . ; % ci, . - . ). in patients with severe cap timely executed processes of care are associated with a short time to antibiotic administration and reduced risk of death. appropriateness of antibiotic therapy is associated with reduction of bacterial load. c-reactive protein (crp) is a valid biochemical surrogate. our objective was to determine the correlation of bacterial load, measured by quantitative tracheal aspirate (qta), with crp as an indicator of inflammatory response in episodes of lower respiratory tract infection. to evaluate whether appropriateness of antibiotic treatment influences microbiologic (qta), biochemical (crp) and clinical resolution criteria (temperature, wbc, sofa and po /fio fraction). prospective cohort study. sixty-five intubated patients with monomicrobial lower respiratory tract infection were included. crp and bacterial load variation were evaluated through the ratio between d and d measures. a qta was performed on lower respiratory tract onset (d ) and h afterwards (d ). its logarithm value (logqta) was recorded. logqta correlated positively with crp, temperature and wbc. logqta has decreased significantly more from d to d in patients receiving appropriate empirical antibiotic therapy compared to those with inappropriate treatment (logqta ratio . vs . , p< . ). mean crp levels showed a similar pattern, decreasing from d to d in patients receiving appropriate empirical antibiotic treatment, but not in episodes with inappropriate treatment (crp ratio d /d . vs . , p< . ). ancova showed that crp level on d was significant lower in patients with appropriate antibiotic treatment compared to inappropriate empiric treatment ( ± mg/l vs ± mg/l, p< . ). the best cut-off to predict appropriateness of antibiotic therapy is a crp levels reduction of % on d (auc= . ). conclusion. c-reactive protein correlates with bacterial load and is a valid biochemical surrogate of bacterial burden in lower respiratory tract infection. follow-up measurements of crp anticipate the appropriateness of antibiotic therapy. a. günther* , p. schenk , m. maggiorini , a. betbesé , p. f. laterre , n. fedorovskiy , f. j. h. taut , r. g. spragg university of giessen, lung center, giessen, germany, , medical university vienna, vienna, austria, , universitätsspital zürich, zurich, switzerland, , hospital sta cruz y san pablo, barcelona, spain, , hôpital saint luc, brussels, belgium, , city clinical hospital n , moscow, russian federation, altana pharma ag, a member of the nycomed group, konstanz, germany, , uc san diego, san diego, united states the formal diagnosis of ards requires the acute onset of a severe impairment in oxygenatio(pao /fio <= mm hg), exclusion of a hydrostatic cause, and the presence of diffuse bilateral opacities. pneumonia is one of the most common underlying reasons for development of ards, but when only unilateral opacities are present, these patients fail to fulfil ards criteria. it is currently not known whether fulfilment of the formal ards criteria has any impact on -day mortality in patients with pneumonia suffering from severe gas exchange abnormalities. the valid study, a randomised, double-blind study in intubated and mechanically ventilated patients with severe respiratory failure (pao /fio <= mm hg) due to pneumonia or aspiration of gastric contents investigates the effect of rsp-c surfactant (venticute ® ) on mortality. the study does not require a formal diagnosis of ards for patient enrolment. however, the presence or absence of ards is documented. we conducted univariate and multivariate logistic regression analyses using preliminary blinded data from the first patients randomised with a diagnosis of pneumonia. the prognostic value of the formal diagnosis of ards was determined. univariate logistic regression analysis failed to identify a significant correlation (p= . ) between the formal diagnosis of ards and mortality at day . pao /fio was more likely to be associated with mortality (p= . ) as was the number of quadrants on chest radiograph that showed opacities (p= . ). age and apache ii score were highly associated with mortality (p< . ). multivariate logistic regression identified age (p< . ), the number of involved quadrants (p= . ), and apache ii (p= . ) as independent factors affecting -day mortality. conclusion. the prognosis of ventilated patients with pneumonia is not dependent on the formal diagnosis of ards. instead, age, apache ii score, and the number of lung quadrants with radiographic opacities are more predictive of outcome. bernard gr et al. intensive care med. ; : - . to determinate the clinical-epidemiological characteristics and risk factors for postsurgical pneumonia (psp) after lung cancer resection in a university hospital. a retrospective case-control paired study ( : ) was performed in cases of lung cancer collected from to . definition of psp case was a new or changing radiographic infiltrates with two or more of the following criteria: fever > o c, wbc> mm or/and purulent secretions. control group was formed by patients matched by age and lung cancer stage. . patients were evaluated ( psp and controls). overall, data of both groups were: age ± yr, males ( %), smoking habit (active or past smokers) patients ( %), copd patients ( %) and weight loss over kg in patients ( %). incidence of psp was %, crude mortality rate and attributable mortality estimated for psp was % and %, respectively. in the psp group, we found the following isolates ( %): p. aeruginosa ( %), s. viridans ( %), h. influenzae ( %) s. pneumoniae ( %) and undeterminated ( %). psp was associated with low bmi (p= . ), low fev (p= . ), stage iiia (p= . ), anaesthetic time (p= . ), pneumonectomy (p= . ), thoracic pain (p= . ), reintubation (p= . ) and haemorrhage (p= . ). conclusion. the incidence of psp in our series is low but with a high mortality. identification of risk factors (some of them suitable for medical intervention) may improve the management of lung cancer patients treated with surgery. j. karhu* , h. syrjälä , p. ylipalosaari , j. laurila , p. ohtonen , t. i. ala-kokko anesthesiology, division of intensive care, infection control, surgery, oulu university hospital, oulu, finland introduction. scap (severe community acquired pneumonia) and hap (hospital acquired pneumonia) requiring icu treatment have been shown to be associated with significantly higher mortality compared to those not requiring icu treatment ( , ). we compared pneumonias acquired outside the icu to that acquired in the icu, during mechanical ventilation (ventilator-associated pneumonia, vap). patients admitted into a mixed university level icu during a month period whose icu stay was longer than hours were included. the occurrence of scap, hap and vap were prospectively assessed. the following information was collected: age, severity of underlying disease on admission, underlying malignancy and recent use of immunosuppressive therapy. the length of icu and hospital stay as well icu, hospital and day mortalities were recorded. a total of patients fulfilled the inclusion criteria during the study period. there were a total of pneumonias. majority of the pneumonias were scap ( / ), while there were hap and vap cases. patients with hap tended to be older ( . , p= . ) and a larger proportion of them had malignancy ( %, p< . ), compared to vap ( years, %) or scap ( years, %). there were no significant differences between the mean admission apache ii scores (scap . vs. hap . vs. vap . ) . the icu length of stay was longest in vap; while the hospital stay was longest in patients with hap (table ). the survival rates were highest in hap, although this did not reach statistical significance. in apache ii and age adjusted multivariate logistic regression analysis vap (or . , % ci . - . , p= . ) and scap (or . , % ci . - . , p< . ) remained significant risk factors for hospital mortality together with immunosuppression (or . , % ci . - . , p= . ). heart surgery in infants is often associated with pulmonary inflammatory process. at the same time, the blood level of pro-inflammatory factors: interleukin- (il- ) and interleukin- (il- ) is increased. the number of polymorphonuclear leukocytes (pmn-elastase) and neutrophils is raised as well. a qualitative evaluation of the factors, cellular composition analysis of nonbronchoscopic trachebronchial lavage (ntl) combined with clinical findings can help early diagnose pneumonia. the objective of the study was to reveal the peripheral blood level of pro-inflammatory cytokines (il- , il- ), the activity of pmn-elastase and α antiprotease inhibitor (α -pi), as well as examine the ntl cellular composition and cytokine level in infants before and after heart surgery. we studied infants aged from days to months, weighting between . and kg. patients underwent cardiopulmonary bypass surgery, patients were operated on without cardiopulmonary bypass. in cases a clinical diagnosis of pneumonia was made between and days postoperatively. early postoperative survival was %. the peripheral blood cytokine concentration in operated infants pre-and postoperatively is presented in the study (table ) . a significant increase in pro-inflammatory factors after surgery can be observed. we examined the ntl of infants who underwent heart surgery and who did not develop pneumonia. we noticed that the number of neutrophils increased significantly in all patients after cardiopulmonary bypass surgery, sometimes reaching %. we consider it as a sign of pulmonary inflammatory process. the number of nonviable alveolar macrophages before and after surgery exceeded %. it indicates a decrease in cellular pulmonary protection. the pmn-elastase peripheral blood activity was . ± . iu/ml preoperatively and ± . iu/ml postoperatively; the α -pi level was . ± . iu/ml and . ± . iu/ml, respectively. conclusion. thus, an increase in the peripheral blood level of pro-inflammatory cytokines was observed in infants who underwent heart surgery. at the same time, the ntl relative number of neutrophils was increased. an early detection of the mentioned factors appears to be a diagnostic marker of the pulmonary inflammation reaction onset. all colistin resistant gram-negative isolates from patients hospitalized in a -bed icu during one-year period were retrospectively recorded. demographic data, the underlying disease, prior antimicrobial therapy, microbiological data and the clinical and bacteriological response to treatment were recorded. the antimicrobial susceptibility of the isolates was determined using the disk-diffusion (kirby-bauer) method, the vitek ii system and the etest method (ab biodisk, solna-sweden). interpretation of the susceptibility results was in accordance to the clinical and laboratory standards institute (clsi). nine patients with infections caused by colistin resistant gram-negative isolates were recorded. all patients had prolonged icu stay, were under mechanical ventilation and had a significant exposure to antibiotics including colistin for mdr gram-negative bacteria. three k.pneumonia isolates producing metallo-beta-lactamases (mbl), two k. pneumonia isolates producing extended spectrum b-lactamases (esbl) and mbl, two acinetobacter baumannii isolates susceptible to tetracyclines, one pandrug resistant (pdr) acinetobacter baumannii and one pdr pseudomonas aeruginosa were recorded. the bacteria were isolated from bronchial secretions in four cases and from the blood stream in five patients. in five patients antibiotic treatment was based on susceptibility tests, with clinical and bacteriological success. antibiotic combinations including colistin plus meropenem or colistin plus cefepime were provided in patients harbouring pdr isolates. these patients failed to respond to treatment and had a fatal outcome. the overall clinical success and survival rate was . % at days. conclusion. the development of colistin resistant strains with increasing mortality rates urges for the continuous surveillance on these highly resistant organisms and the strict implementation of infection control practices. ventilator-associated pneumonia (vap) is one of the most severe infections in the icu, continuing to complicate a high percentage of the patients receiving mechanical ventilation and leading to increased morbidity and mortality, especially when it is due to highrisk pathogens. our aim was to study the incidence and outcome of vap due to mdr bacteria in our icu. prospective, epidemiological study, in a mixed icu of a tertiary care hospital. all patients admitted from august to march were included. lower respiratory tract samples of all patients with suspicion of vap were cultured. standard diagnostic criteria were followed. statistical analysis was performed with spss v. . during the months period of the study patients were admitted. their mean age was years and % of them were male. their mean apache score was and the average duration of stay in the icu was days. forty-two episodes of vap due to mdr bacteria were recorded in patients. the bacteria isolated from lower respiratory tract samples were acinetobacter baumanii, pseudomonas aeruginosa, klebsiella pneumoniae and enterobacter cloacae, while in cases concomitant bacteremia was recorded. the mean time from admission to the icu to diagnosis of vap was days. positive outcome was noted in % of cases and was found to be reversely related to the apache ii score (p= . ), to days of stay in the icu (p= . ) and to multi-organ failure (p= . ). of the patients with vap, had normal renal function before the lung infection. of these, developed renal failure due to the lung infection and had to be started on renal replacement therapy. the mortality of these patients was significantly higher than for the patients who did not develop renal failure (p= . ). regarding the crude mortality of patients with and without vap, this was found to be . % and . % respectively (p= . ). (pa) is not a frequent pathogen in this setting but could be associated with poor prognosis. in our population of patients undergoing cs, we compared risk factors and prognosis of pa-eop with eop due to others micro-organisms. this retrospective study performed on years ( - ) involved patients (pts) who underwent cs with cardiopulmonary by-pass. diagnostic of pneumonia was based on clinical and laboratory criteria: t˚> . , purulent tracheal secretions, wbc> , /mm , chest x-ray changes and microbiological criteria (broncho-alveolar lavage> cfu/ml). pre, per and postoperative risk factors, empiric antibiotic, and prognosis of pa-eop were compared with those obtained for eop due to others germs. the groups were compared using chi-square. p< . was considered significant. over the studied period, eop occurred in pts (incidence %), including pts ( conclusion. in our experience, pa-eop following cs seems to be more frequent than what was previously reported. criteria for prediction of pa-eop remain to be assessed. in case of pa eop, empiric antibiotic is often inappropriate with a possible increased risk of mortality. these results lead us to modify our empiric broad-spectrum antibiotic treatment and to take into account pa, especially in severe forms of eop and in copd pts. antibiotic exposure and timing of pneumonia onset influence ventilatorassociated pneumonia (vap) isolates. the first goal of this investigation was to evaluate whether trauma also influences prevalence of microorganisms. a retrospective, single-center, observational cohort study. . vap isolates in a multidisciplinary icu documented by quantitative respiratory cultures and recorded in a -month database were compared, based on the presence (t) or absence of trauma (at). causative microorganisms were classified in four groups, based on mechanical ventilation duration (> days), and previous antibiotic exposure. one hundred eighty-three patients developed episodes of vap ( trauma). methicillin-sensitive staphylococcus aureus (mssa) was more frequent ( . % vs . %, p< . ) in trauma, whereas mrsa was more frequent ( % vs . %, p< . ) in nontrauma. no significant differences were found between trauma and nontrauma patients regarding prevalence of other microorganisms. in trauma patients, mssa episodes were equally distributed between early and late-onset vap( % vs %) but no mrsa episode ocurred in the early-onset group. conclusion. trauma influences the microbiology of pneumonia and it should be considered in the initial antibiotic regimen choice. our data demonstrate that patients with trauma had a higher prevalence of mssa, but the overall prevalence was sufficiently high to warrant an s. aureus coverage for both groups. on the other hand, since no mrsa was isolated during the first days of mechanical ventilation on trauma patients, mrsa coverage in these patients is only necessary after ten days of admission. a retrospective study of a hiv patient's cohort that stays in icu with acquired community pneumonia in the period between january and december . data analyzed included age, clinic stage, years of disease evolution, antiretroviral therapy, cd levels and viral charge at the hospitalization, positive hcv and/or hbv, severity scores and microorganism isolated. chi-square analysis was used to compare categorical data. continuous data was compared using student's t-test. prognostic factors of mortality were studied by multivariate logistic regression analysis. . fifty-three patients were studied. % were males. the average age was ± years. the most frequently risk practice was intravenous drug addiction ( % we prospectively collected data regarding demographics and microbiology of bacteremias. blood cultures were obtained on clinical suspicion of bacteremia and followed up on days , , and th. severity of illness scores, apache and sofa were recorded at baseline and days , , and th. improving hand hygiene is a cost-effective way of decreasing hospital-acquired infection rates. in this study we recorded opportunities for and compliance to hand hygiene in our icu. four trained nurses and a doctor monitored opportunities for hand hygiene performance (hand antisepsis and glove use) as well as compliance to the cdc guidelines in our icu for days. the procedure was anonymous, involved all icu personnel and was performed in -min sessions, throughout all shifts. we collected opportunities for hand hygiene, mostly related to nurses ( %). compliance to hand antisepsis was %, higher in nursing and assistant staff ( % and %, respectively) compared to doctors ( %). compliance was lowest before contact of healthcare staff with a patient or his inanimate environment ( % and %, respectively). the activity index (=the need for hand antisepsis performance) for the nursing staff was high ( opportunities per hour per nurse in the morning shift, ie opportunities per shift). however, no significant correlation was found between compliance rate and activity index of the staff (r=- . , p= . ). alcohol-based hand-rub was used in % of the cases. technique of antisepsis performance was uniformly poor and mean duration of the procedure was low ( . seconds). compliance with glove use guidelines was % and was high in all staff categories and all types of opportunities. is an aerobic non-fermenting gram negative bacillus. it is generally considered an opportunistic pathogen. s. maltophilia is increasingly recognised as a cause of nosocomial infection among ventilated and immunocompromised patients, and in those receiving broad spectrum antibiotics. s. maltophilia infections are commonly resistant to multiple antibiotics including beta lactams, quinolones, aminoglycosides and carbapenems. reported mortality rates for patients with bacteraemia due to s. maltophilia vary from - %. the mid western regional hospital, limerick, ireland, is a bed hospital located on three sites. the intensive care unit(icu) is a seven bed medical and surgical unit with approximately admissions per year. the s. maltophilia clusters prompted epidemiological investigation, restriction fragment-length polymorphism typing (rflp) of genomic dna of outbreak strains, and finally, instituting revised infection control measures to limit spread. we conducted a retrospective chart review of affected patients noting admission apache ii scores, medical co-morbidity, immunocompetence, antibiotic history, and patient outcome. we collected cultures of icu cubicle/ room surfaces, sinks, ventilatory equipment, and water sources. patients and environmental isolates were examined by rflp typing. this preliminary analysis suggests that pct can be use to accurately early identify sepsis only at levels above ng/ml and then use them to decide to rapidly beginning the use of antibiotic. in patients with pct below ng/ml we cannot use them to exclude the diagnosis of sepsis. with the cutoff , ng/ml we found the same analysis. other studies with more samples are necessary to confirm this conclusion. during these three years patients were hospitalized in total. one hundred and thirty one ( . %) were hospitalized less than h and were excluded. a total of bacteremias were observed. forty -four bacteremias were catheter related bloodstream infections. fifty five were due to gram negative microorganisms (pseudomonas aeruginosa %, acinetobacter baumanni %, klebsiella pneumonia %). in the following table, resistance to broad spectrum antimicrobials is presented during these three years. infection in patients with severe stroke is an important problem and the sensitivity and specificity of its diagnosis with clinical criteria are deficient. fever is a common event and, as leucocytes or c-reactive protein, its specificity is very low in this kind of patient. our objective was to evaluate the utility of a biological marker such as procalcitonin (pct) in the diagnosis of infection in patients with severe stroke. we followed patients with severe stroke receiving mechanical ventilation because of coma. during the first days of evolution nih and apache ii scales were registered, we measured pct and c-reactive protein on days and and if infection was suspected microbiological samples were collected. infection was diagnosed if the patient fulfilled the cdc criteria. mann-whithney u and x-square tests were used. twenty-six cases corresponded to haemorrhagic stroke. baseline characteristics were: mean age years, % males, glasgow scale ( - ), nih scale ( - ), apache ii ( - ), temperature . o c ( - . ), leucocytes /mm ( - ), pct . ng/ml ( . - . ) and c-reactive protein . mg/dl ( . - ). on the third day of evolution cases of ventilator-associated pneumonia were diagnosed. when compared with the noninfection group there were no differences in baseline characteristics and on the infection day we only found differences in pct, . ng/ml in front of . ng/ml; p < . . seventeen ( %) of the patients without infection presented a temperature o c sometime during the follow-up and in all cases pct did not show any change. these results indicate that pct is a useful tool in the diagnosis of infection in patients with severe stroke. the ongoing challenge of accurately diagnosing infection in the icu motivates a search for novel molecular diagnostics. we reported recently that microarray analysis of circulating leukocytes can be used to derive a "riboleukogram", which captures the dynamics of the host response to and recovery from ventilator-associated pneumonia (vap). in the current study, we tested the hypothesis that the informational content of circulating leukocytes differs, thereby allowing one to rank leukocyte populations on their potential to contribute to rna diagnostics for pneumonia. sixteen patients ( male, female) at risk for vap were entered into our irbapproved study that collects blood and clinical data every hours for up to days. four of the sixteen patients developed vap as diagnosed and treated by the attending icu physician. previously reported blood protocols were used to isolate buffy coat, enriched neutrophil, and enriched monocyte populations by using negative selection. cellular purity was assessed by facs for one of the vap patients. genome-wide expression analysis was performed on rmanormalized signal from affymetrix u . plus genechips. edge software (fdr= . ) was used to determine changes in mrna abundance over time for each cell population. during the -day window in which each of the four patients (all males) developed vap, significant changes in gene expression were observed (table) , but the information content (number of genes altered) varied across leukocyte populations. these differences were not due to signal variance (coefficient of variation, cv) or differences in the number of samples available for analysis. moreover, only . % of the monocyte gene list overlaps with the neutrophil list, arguing that neutrophil contamination of monocyte populations is insufficient to explain the -fold difference in gene number. the aim of the present study was to evaluate the relationship between the cytokine expression in bronchoalveolar lavage fluid and bacterial burden in mechanically ventilated patients with suspected pneumonia. mechanically ventilated patients with suspected pneumonia admitted in icu from november to january were prospectively enrolled. fiberoptic bronchoalveolar lavage (bal) was performed with ml of sterile isotonic saline in aliquots of ml, local anesthetic were not used. bal samples for microbiologic quantitative cultures and bal cytokines: interleukin (il) , il , tumor necrosis factor-alpha (tnf-alpha), granulocyte colony stimulating factor (g-csf) and granulocyte-monocyte colony stimulating factor (gm-csf) were measured. . patients were included, most of the patients ( . %) were with prior antibiotic therapy. patients ( . %) had a positive bacterial culture defined than a diagnostic threshold of > colony-forming unit/ ml. the concentration of tnf-alpha was significantly higher in the group of patients with positive bal (table ) . it has been demonstrated in a swine model that therapeutic hypothermia ( ˚c) facilitated transthoracic defibrillation. however, the mechanisms leading to reduced defibrillation threshold (dft) remain unclear. we hypothesized that therapeutic hypothermia promotes the wavefront organization of ventricular fibrillation (vf), therefore facilitating defibrillation. methods. by using a two-camera optical mapping system, epicardial activation patterns of vf were studied in isolated rabbit hearts at baseline ( ˚c), -min therapeutic hypothermia ( ˚c), and -min rewarming ( ˚c). in additional hearts, dft (voltage required to achieve % probability of successful defibrillation, n= hearts) and apd (action potential duration)/conduction velocity (cv) restitutions (n= hearts) were determined at these stages. results. comparing with at baseline ( ± %) and rewarming ( ± %), there was a higher percentage of vf duration containing organized repetitive activities during hypothermia ( ± %, p< . ). however, there was no significant difference of dft among these stages ( ± , ± , and ± v, p= . ). the electrophysiologic characteristics of ventricles at these stages were summarized in table . in brief, hypothermia prolonged apd, decreased cv, and subsequently shortened wavelength. hypothermia also failed to flatten the slope of apd restitution. furthermore, apd dispersion at the epicardial surfaces of both ventricles and cv heterogeneity among epicardial lines were all enhanced by hypothermia. (pt) with acute coroanry syndrome (acs) at admission is a associated with a high mortality. the mechansims are poorly understood. we sought to determine an interrelation between no coronary reflow after percutaneous coronary intervention (pci), the likelihood of developing cardiogenic shock, death in hospital and plasma glucose level at admission. we performed a prospective analysis of consecutive pt presenting with an acs in our emergency room. we recorded basis data (gender, age, bmi), cardiovascular risk factors, burden of coronary artery disease (cad), coronary blood flow after pci, killip-classification, left vetricular ejection fraction, probabilty of developing cardiogenic shock and the likelihood of dying in-hospital. our findings suggest that elevated bs at admission is a useful risk marker to identify pt with a high risk to develop coronary no reflow-phenomenon after pci. this may be due to increased inflammatory activity and hypercoagulability. if one dies in cardiogenic shock, these pt present always with elevated bs at admission. prull mw, trappe hj. activation of blood coagulation in nstemi: does diabetes mellitus matter? intensivmed . we measured serum cortisol levels before and minutes after a , mg corticotropin stimulation test in pts with cs following acute myocardial infarction (mi) and in a control group of pts with uncomplicated mi at day , , , , , and after onset of shock/mi. rai was defined by an increase in serum cortisol levels in response to corticotropin of less than µg/dl. data were correlated to vasopressor-need and interleukin (il) levels (il ,il ,il ,il ). baseline cortisol levels in pts with cs were significantly higher than in control pts especially on day ( ± vs ± , p= . ). in cs-pts the test-series were stopped at day to because the physician in charge started a therapy-trial with hydrocortisone due to increasing vasopressor need. three other pts died within the seven day period. rai was observed only at day in of the cs-pts but in none of the control pts (p= . ). these cs pts with rai had higher il- and il- levels at baseline ( during tidal mechanical ventilation, an end-expiratory pause abolishes the cyclic increase in intra-thoracic pressure. this may produce a transient increase in cardiac preload and then in cardiac output in volume responsive patients. our objective was to test whether the effects of an end-expiratory pause on cardiac index and pulse pressure may help in detecting fluid responsiveness in patients with acute circulatory failure. in mechanically ventilated patients with an acute circulatory failure and no spontaneous ventilator triggering who were deemed at volume expansion, we performed a -sec end-expiratory pause. we continuously measured the systemic arterial pressure and the pulse contour-derived cardiac index (picco device) at baseline, during the last seconds of the end-expiratory pause and after a ml saline administration. volume expansion induced an increase in cardiac index ≥ % in patients (classified as responders). in these patients, volume expansion increased the cardiac index by ± % from . ± . l/min/m . before volume expansion, the end-expiratory pause had induced an increase in cardiac index by ± % and in pulse pressure by ± % as compared to the baseline values. by contrast in the non-responders, before volume expansion the cardiac index and the pulse pressure did not change during the pause as compared to baseline ( ± % and ± % increases, respectively). importantly, an increase in cardiac index ≥ % during the end-expiratory pause predicted fluid responsiveness with a sensitivity of % and a specificity of %. a pause-induced increase in pulse pressure ≥ % detected fluid responsiveness with similar sensitivity and specificity ( % and %). in responders, a second end-expiratory pause was performed again immediately after volume expansion. in patients, the increases in cardiac index induced by this second pause induced had dropped below %. in the remaining responders, the second pause induced an increase in cardiac index still higher than % ( ± %). in these patients, the pause-induced increase in cardiac index was abolished by a second ml saline administration. conclusion. an increase in cardiac index and in pulse pressure during an end-expiratory pause enables to detect fluid responsiveness in critically ill patients with mechanical ventilation and acute circulatory failure. , and tissue doppler imaging measurements of the mitral annulus velocities like early (ea) peak diastolic velocity. the aim of the study was to examine which echocardiographic index is the best marker of preload by making the hypothesis that a good measure of preload should increase with fluid-induced increase in stroke volume (sv) but not with dobutamine-induced increase in sv. comparison of the capacity of the intra thoracic blood volume index (itbvi) and the central venous pressure (cvp) to predict fluid responsiveness in critically ill patients with acute circulatory failure (systolic blood pressure < mmhg or vasopressor requirement). methods. this prospective interventional study performed in a surgical intensive care unit of a tertiary university hospital included ( males) mechanically ventilated and sedated patients with acute cardiovascular failure requiring cardiac output measurement (transpulmonary thermodilution technique)and a fluid challenge. intervention: fluid responsiveness was defined as an increase in stroke index (si = cardiac output/heart rate/body surface area) ≥ %. receiver operating characteristic (roc) curves were generated for itbvi and cvp. in eligible patients, could not be included because of cardiac arrhythmia (n = ) or moribund status (n = ) or protocol violation (n = ). the cause of acute circulatory failure was septic shock in ( %) patients, haemorrhagic shock in ( %) patients, and systemic inflammatory response syndrome in ( %) patients. fluid challenge induced an si increase ≥ % in ( %) patients (responders(r). no statistical difference was shown between responders and non responders for cvp and itbvi. the areas under the roc curves of itbvi and cvp were . [ % ci: . - . ], and . [ % ci: . - . ], respectively, without any statistical difference (p = . ). the best cut of value for cvp and itbvi were mmhg (sensitivity = %; specificity = %) and ml.m- (sensitivity = %; specificity = %), respectively. the relative changes in si and ci were correlated with relative changes in itbvi (r = . , p = . ; r = . , p = . respectively) but no correlation was found between relative changes in si and ci and relative changes in cvp (r = - . , p = . ; r = . ; p = . ). conclusion. itbvi is similar to cvp to predict fluid responsiveness in critically ill patients with acute circulatory failure. the pulse pressure variation (ppv) is used to predict fluid responsiveness in mechanically ventilated patients. nevertheless false positive of this parameter have been reported especially in patient with right ventricular dysfunction. the peak systolic velocity of tricuspid annular motion (sta) assessed by doppler echocardiography (dec) is a parameter of right ventricular systolic function. the aim of the study was to find out whether sta can discriminate between false and true positive of vpp. methods. mechanically ventilated patients were prospectively included. all patients had a measurement of ppv> %. a dec was realised before and after infusion of ml of colloid solution. patients were separated into groups as they were responders (r) (at least % increase in stroke volume (sv)) or non-responders (nr) to fluid infusion. all data are expressed as mean [standard deviation]. the comparison of demographic, hemodynamic and echocardiographic parameters in r and nr patients was performed using a t-test. a p value < . was considered statistically significant. roc curves were plotted. a threshold value of sta was calculated with roc curve. in the resting patient, pulse pressure (pp = systolic -diastolic pressure) is mainly related to arterial stiffness and stroke volume index (svi). the dynamic effects of fluid loading on pp are poorly documented and were studied in the critically ill using arterial tonometry. we tested the hypotheses that i) arterial stiffness was unchanged after fluid loading, ii) pp changes paralleled svi changes such that pp increased in fluid-responders only, and iii) aortic pp was more indicative of svi changes than radial pp. twenty-two critically ill patients ( f), mean age(sd), ( ) years, were prospectively included. radial pressures were calibrated from brachial cuff pressures. radial applanation tonometry (sphygmocor ® ) allowed us to estimate aortic pp, left ventricular ejection time, and the augmentation index which quantifies wave reflection. the svi was calculated by transpulmonary thermodilution. the arterial stiffness was estimated from the aortic pressure curve using standard formula. fluid challenge ( ml saline . %) was required by the patient's hemodynamic status. data were obtained before and immediately after fluid loading. responders had increases in svi > %. baseline mean values were as follows: svi = ( ) ml.m- , heart rate= ( ) bpm, mean arterial pressure (map) = ( ) mmhg, radial pp = ( ) mmhg, aortic pp = ( ) mmhg. after fluid loading, svi increased from ( ) to ( ) ml.m- and map increased from to ( ) mmhg (each p < . ). arterial stiffness was unchanged ( . ( . ) vs . ( . ) mmhg.ml- . m ) as well as heart rate, left ventricular ejection time, radial and aortic pps and augmentation index. there was a positive linear relationship between the svi changes and the changes in radial pp (r = . ) and aortic pp (r = . ) (each p < . ), not map (r = . ). when responders (n= ) and non responders (n= ) were compared, the increases in map were similar while the changes in pp were higher in responders (radial: mmhg, %; aortic: mmhg; % ) than in non responders. (radial: - mmhg, - . %, aortic: - mmhg; - . %) (each p< . ). given the unchanged arterial stiffness throughout the fluid infusion, the changes in aortic pp (and slightly to a lesser extent radial pp) paralleled the changes in svi. both radial and aortic pps increased in responders but not in non responders, while map similarly increased in the two groups. the capability of arterial pp changes to track svi changes during fluid loading appears promising but deserves a further large scale study. new device may be used in intensive care unit to measure cardiac output (co) by arterial pulse pressure waveform analysis , but comparative studies with co thermodilution in cardiac surgery have shown large bias between the methods . aim of this study is to evaluate in critical ill patients not submitted to cardiac operation -cardiac output (co wave) obtained using flo track tm vigileo . -the correlation with co obtained by thermodilution (co therm). methods. critical care patients admitted to a general intensive care were enrolled in the study . all patients were mechanically ventilated ( tv - ml /kg pl press < cmh ) and connected to an integrated monitoring system ( flow trac tm / vigileo tm , ewdards lifescience ,irvine ,ca, usa ) that attaches to an arterial cannula . a central venous catheter and a pac ( thermodilution catheter ; arrow international , inc ., reading ,pa,usa ) was inserted via the jugular internal vein . after haemodynamic stabilization co wave was calculated from an arterial pressure based algorithm that utilises the relationship between pulse pressure and stroke volume , primarily based on the standard deviation of the pulse pressure waveform. at the same time a co therm. determination was performed by triple injection of ml of iced isotone na cl into the central line of the pac. every patients had two co determination at two time point. for each measurement of co therm corresponding simulataneous co wave was documenteted . a regression analysis and bland altman analysis was used to compare the two methods of co determination. a total of co determination was performed in patients . co vigileo correlated co thermodilution with r = . , p< , . at table are reported the bland altman's results. the left ventricular ejection fraction (lvef) as measured by echocardiography is considered as the reference estimate of the lv global contractility at the icu bedside. the transpulmonary thermodilution technique (picco system) continuously provides a measure of the cardiac function index (cfi), which is the ratio of cardiac output over global end-diastolic volume. thus it could be considered as a marker of cardiac global contractility and could enable a continuous monitoring of this key parameter. we tested whether cfi could actually behave as an indicator of lv systolic function by testing if it fulfilled the following criteria: (i) increase with inotropic stimulation, (ii) no alteration by fluid loading, (iii) correlation with the echographic lvef and (iv) ability to track the changes in lvef during inotropic stimulation. in patients ( cases) with an acute circulatory failure, we simultaneously measured the echographic lvef (transthoracic -chambers apical view) and the cfi at baseline, after a ml saline administration in a group of cases and after -min of dobutamine administration in a group of cases. volume expansion did not alter lvef significantly ( ± % vs. ± % at baseline) nor cfi ( . ± . vs. . ± . min- at baseline). by contrast, dobutamine infusion induced a significant increase in lvef from ± % at baseline to ± %(+ ± %) and in cfi from . ± . at baseline to . ± . min - (+ ± %). considering the whole set of cfi:lvef pairs of measurements (n= ), a significant correlation was observed between cfi and lvef (r= . , p< . ). importantly, a cfi value < . min - predicted a lvef value higher than % with a sensitivity of % and a specificity of %. in patients receiving dobutamine, there was a significant correlation between the changes in cfi and the changes in lvef induced by dobutamine infusion (r= . , p< . ). our study demonstrates that cfi fulfilled the criteria that are required from a bedside indicator of lv contractile function: it was increased by inotropic stimulation while it was not altered by volume expansion, it was fairly correlated with the echographic lvef and it was able to track the changes in echographic lvef with reliability. this suggests that the continuous monitoring of cfi provided by transpulmonary thermodilution could help in assessing the effects of inotropic therapy and could alert the physician in case of abrupt lv contractile deterioration. passive leg raising (plr) is a predictive test of preload responsiveness in patients with acute circulatory failure. it could predict fluid response to fluid loading in mechanically ventilated patients. critically ill patients have an increased risk of lower extremity deep venous thrombosis. elastic compression stocking (ecs) is frequently used in association with unfraction or low molecular weight heparin. the aim of this study was to evaluate the effect of the elastic compression stocking on the plr test variations. methods. patients undergoing cardiac surgery were included. all of them were anaesthetised and mechanically ventilated (tidal volume ≥ ml/kg). pre-operative left ventricular ejection fraction was > % for all patients. they were monitored with central venous pressure (cvp), invasive blood pressure and esophageal doppler. hemodynamics parameters were obtained before and after plr, without and with elastic compression stocking respectively (ssv = systolic stroke volume, co = cardiac output, ppv = pulse pressure variation and sbp = systolic blood pressure). results are presented as median [inter quartile range](iqr) and compared with mann whitney test. . table represents hemodynamics variations after plr without and then with elastic compression stocking. second table represents hemodynamics effects of the elastic compression stocking in supine position (sp). conclusion. this study shows a clear improvement in gut permeability after surgery. the effects of early feeding shall be assessed in a future study. methods. descriptive-prospective study. pre and post-class question -survey (administered one week before and after). the transplant co-ordination team gave informative classes in secondary schools, - / - . . surveys collected; pre/ post-class: % of eso ( years old), % bachiller ( years old) and % ciclo formativo ( years old) / post-class: % eso, % bachiller and cf % . % had some prior awareness and % broad knowledge. massmedia is usually sole information channel ( %), ticked in all cases. other sources were: family, school and peers. regarding attitude to donation: we found no differences in refusals between own donation or relatives'( %); or in doubts % - %. related to transparency and parity of the health system: % believed equality did not exist and % had doubts. % felt this inequality was worse abroad. % are convinced that organ trafficking exists and % assume it is possible. pre-course standpoint by course is showed in figure . % had prior knowledge about spanish transplant law. following classes the students claim higher awareness ( %). in general they maintain their standpoint on donation, % have reconsidered their previous attitude. regarding transparency and equality, % maintain doubts and % are convinced of its absence. on trafficking: % assume it is possible, % occurs exclusively abroad, uniform group distribution. post-course attitudes by course are in figure . despite an in-depth discussion about the law and its consequences (presumed consent), they generally disagree and some consider this too extreme , refusing to accept that donation is an obligation (only % agree) and believing that it should be an optional act of solidarity ( %). conclusion. knowledge about donation and transplant in urban areas is slanted, due to information sources ( usually mass media ) and a warped (tv-dominated) perception of the health system's transparency and equality. a considerable number of students still refuse donation or maintain their scepticism, despite a decrease following classes. however, our desire is not to convince them to become donors, we simply wish to provide decision-making tools. generally college students ,without gender differences, are the most resistant to the process, having the greatest incidence of refusals and doubts about transparency, equality and organ trafficking. ( - ) . c (pao /fio ) / peep day . ( . - . ) . ( . - . ) . c (pao /fio ) / peep day . ( . - . ) . ( . - . ) . c (pao /fio ) / peep day . ( . - . ) . ( . - . ) . c conclusion. the pao /fio ratio on day one is useful to predict mortality, but not in the subsequent days. the (pao /fio )/peep index is a better predictor in later days, specially on the third and seventh day of mv. a. roch* , l. fouché , j. forel , d. blayac , c. aglioni , d. lambert , j. carpentier , l. papazian réanimation médicale, dar, hôpitaux sud, réanimation, hôpital laveran, marseille, france introduction. general anesthesia promotes atelectasis of the dependent parts of the lung. we evaluated the differential effects of neuromuscular blocking agents (nmba) on consolidation formation in healthy or injured lungs. methods. pigs ( ± kg) were anaesthetized with pentobarbital, fentanyl and ketamine in order to prevent spontaneous ventilation and ventilated using volume controlled ventilation (vt ml/kg, fio . ) for hours after randomization into groups: healthy lungs ventilated without (hzeepno) or with nmba (cisatracurium, hzeepnmba), healthy lungs ventilated with nmba and peep (hpeepnmba) and injured lungs ventilated without (tweenpeepno) or with nmba (tweenpeepnmba). lung injury was induced using instillation of . ml/kg of . % tween . injured lungs were ventilated with peep , fio . and vt ml/kg. after lung removal, six sections of equal thickness were obtained from the right lower lobe and from the upper. sections were photographed and analyzed using a software (sigmascan pro , spss inc). the areas of consolidated, edematous and normal parenchyma were measured on each section and then added to obtain the percentage of consolidated lung. . nmba use induced a two-fold increase of the consolidation (from ± to ± %)that was totally prevented by peep . the deleterious effect of nmba on derecruitment did not occur in injured lungs. consolidation was located to the dependent parts in healthy lungs and nmba extended consolidation towards more cephalad parts. in injured lungs, consolidated parenchyma was diffuse and its cephalo-caudal distribution was not affected by nmba. pao to fio ratio was affected neither by nmba nor by peep. * p< . vs hzeepno and hpeepnmba; **p< . vs hzeepno and hzeepnmba. conclusion. nmba increase dependent lung consolidation during volume-controlled ventilation of healthy lungs. this effect is prevented by a moderate peep level. in contrast, nmba do not increase the extent of pathologic lung areas in injured lungs ventilated during a -h period. th esicm annual congress -berlin, germany - - october s m. amigoni* , m. scanziani , g. bellani , g. balconi , e. zanotto , s. masson , n. patroniti , r. latini , a. pesenti dept of experimental medicine, milano-bicocca university, monza, cardiovascular research, istituto di ricerche farmacologiche mario negri, milano, italy introduction. surfactant dysfunction seems to play a pivotal role in the deterioration of gas exchange and lung mechanics that occurs in ali/ards following aspiration pneumonitis. we investigated the effects of exogenous surfactant administration in a murine model of unilateral acid-induced lung injury. we instilled . ml/kg bw of . m hydrochloric acid in the right bronchus of anesthetized and mechanically ventilated mice (vt - ml kg- bw, rr min- , fio and peep of . cmh o). mechanical ventilation was stopped minutes after injury; animals were then placed in an oxygenated chamber (fio . ). after ', hr or hrs from acid instillation, the mice were reintubated and received a single bolus of surfactant in the injured lung at a low or high dose. each animal was again mechanically ventilated for minutes, placed in oxygenated chamber until full awakening. acid-injured mice instilled at the same time and with the same volume ( ml/kg bw) of sterile saline ( . % nacl) were used as controls. lung mechanics, blood gas analysis, and lung myeloperoxidase activity (mpo) were assessed hrs after acid aspiration. no effect of surfactant administration was present upon oxygenation hrs after the injury. at the opposite the high dose group showed a significantly better compliance at hrs, when compared to both the low dose and control groups. this effect was present only in the late ( hrs) administration group. mpo activity did not change after surfactant treatment in the right (injured) lung while in the controlateral, it tended to be lower in both low and high dose when treatment administration occurred at hrs (n= /group: n right lung ± left lung . ± . ; s(low dose) right lung . ± . left lung . ± . ; s(high dose) right lung . ± . left lung . ± . ). pulmonary aspiration is associated with significant morbidity and mortality . several risk factors for aspiration have been highlighted in the literature . the aims of this study were to: (i) identify specifically which patient factors predispose to aspiration and (ii) determine the outcome of patients admitted to our inner city hospital intensive care unit (icu) with a diagnosis of aspiration. we identified patients with a diagnosis of pulmonary aspiration on our icu over a year period (august - ), by using our institution's icnarc (intensive care national audit and research centre) database. of these patients' case notes were able to be retrieved and reviewed in detail. patient demographics, risk factors for aspiration, number of ventilated days, icu & hospital length of stay and mortality were analysed. we also looked at any documented signs that supported the diagnosis of aspiration. median age of the patients was years (range - ). / patients ( %) were male. the main risk factor was a reduced glasgow coma score ( / patients, %): the median score was (range - ). the following risk factors were also identified: obesity ( / patients, %), excessive alcohol intake ( / , %), acute cerebrovascular event ( / , %) and cardiorespiratory arrest ( / , %). the following signs were most frequently observed: perioral vomitus ( / patients, %), acute hypoxaemia ( / , %) and a new radiographic infiltrate ( / , %). one patient exhibited all three markers. all patients required mechanical ventilation. the median duration of ventilation was days (range - ). the median length of icu stay was days ( - ) and the median length of hospital stay was days ( - ). icu mortality was % ( / patients) while hospital mortality was % ( / ). patients who presented to our inner city icu with aspiration had risk factors that included impaired conscious level, obesity, a recent cerebrovascular event or cardiorespiratory arrest. signs that supported the diagnosis of aspiration were the presence of perioral vomitus, acute hypoxaemia and a new radiographic infiltrate. icu and hospital length of stay were both prolonged, but icu and hospital mortality were no higher than our institution's overall rate. a high index of suspicion should be applied to these patients at risk of aspiration, to facilitate the early initiation of appropriate care. reference(s). . hickling k. a retrospective survey of treatment and mortality in aspiration pneumonia. int care med ; : - . . kozlow j. epidemiology and impact of aspiration pneumonia in patients undergoing surgery in maryland, - . crit care med : - . t. tagami* , s. kushimoto , t. atsumi , r. oyama , k. matsuda , m. kawai , h. yokota , y. yamamoto surgery, tokyo metropolitan saiseikai central hospital, critical care medicine, nippon medical school, tokyo, critical care medicine, yamanashi prefectural central hospital, yamanashi, japan introduction. restoration of intravascular volume by massive fluid administration without pulmonary edema formation is one of the biggest challenges in the early treatment of burn shock. although it is not easy to predict the development of the respiratory failure before the treatment, the hallmark of the edema is increased capillary permeability which may be possible to measure by the pulmonary vascular permeability index (pvpi). the aim of the present study was to clarify whether the pvpi is predictable indicator of pulmonary edema formation in patients with burn. we studied mechanically ventilated patients with burn involving more than % of the body surface area that were treated at intensive care burn unit between july and january . all patients had a central venous catheter and a thermistor-tipped arterial thermodilution catheter (picco system) for hemodynamic management. we measured the extravascular lung water index (evlwi) and the pulmonary vascular permeability index(pvpi) as soon as the picco catheter was inserted. infusion volume was calculated according to the parkland formula. only crystalloid fluid (lactated ringer's) was infused during the first hours after the thermal injury. we investigated the medical records and defined the respiratory failure during the period of burn shock as a clinical syndrome of acute respiratory distress associate with pulmonary rales and radiographic evidence. inclusion criteria were: )acute onset and rapid progress, )oxygenation index (pao /fio ratio< and ) bilateral infiltrates on chest x-ray. those are the part of the standard criteria of acute respiratory distressed syndrome. the pvpi was significantly higher in the patient with respiratory failure (n= pvpi: . ± . ) than in patient without respiratory failure(n= pvpi: . ± . ) before the fluid treatment. there was no significant difference between the groups in terms of evlwi at the beginning ( ml/kg vs . ml/kg). although the evlwi increased after hours in the patient with respiratory failure, it did not change in patient without respiratory failure( . ml/kg vs . ml/kg). the pvpi increased before the evlwi increased in patient with respiratory failure. the pvpi is considered to be the predictable value to identify the risk of respiratory failure during the period of burn shock. ultrasonography allows observation of diaphragm. in healthy subjects, a correlation was found between its excursion and the tidal volume. in addition, diaphragm thickness variation measured in the zone of apposition has been used to evaluate paralyzed diaphragm. we assessed the accuracy of these indexes to assess diaphragmatic function and respiratory workload. five patients were studied in spontaneous ventilation (sv) and during noninvasive ventilation at different levels of pressure support (ps). diaphragmatic excursion (e) was carried out subcostally. diaphragm thickness was measured in the zone of apposition and the thickening fraction (tf) was calculated as tf = (thickness at inspiration -thickness at expiration)/thickness at expiration. diaphragmatic pressure time product per breath (ptpdi) was measured by assessment of esophageal and gastric pressure. ptpdi and tf both decreased as the level of pressure support increased (fig and ) . a positive correlation was found between ptpdi and tf(r= . ; p= . ; fig ) . in addition, there was also a significant correlation between tidal volume and e (r= . ; p< . ; fig ) . ultrasonography of the diaphragm could be applied in intensive care to assess diaphragmatic function. tf and ptpdi decrease as the level of pressure support increases. these results suggest that tf could help to assess diaphragmatic contribution to respiratory workload. reference(s). ( ) fantus g. metformin's contraindications: needed for now frequency of inappropriate metformin prescriptions systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing arteficial ventilation catheter infection is a common concern in the intensive care unit (icu). recent works have pointed that the site of catheters is related to this problem. we analysed data obtained from our data base to confirm the results of previous works. methods. catheters were inserted in a surgical-medical icu, along five years. semiquantitative cultures were obtained if the catheter was kept in place more than hours and it was no longer necessary, the catheter was withdrawn because of fever of unknown origin or an infection was suspected at the point of insertion. every catheter site, culture and germ was registered in our patient data base. we studied the following variables: type of catheter, site and results of cultures. statistical analysis: variables were compared by chi-square. a p< , was considered statiscally significant. results. a total of . catheters were registered (venous catheters , arterial ). rate of germs was as follow: gram-positive , %, gram-negative , %, fungi %, contaminated flora , %. site and germs were not statistically associated. table shows type, site and rate of infection of cultured catheters. femoral arteries were more frequently cultured than radial arteries (p< , ); no differences were found for cultured venous catheters. femoral arteries were infected more frequently than radial (p< o, ); yugular and femoral venous catheters were more frequently associated to infection. (sc) in non neutropenic patients is increasing with a high cost and mortality. we define the clinical and epidemiological profile of patients admitted to our icu and the microbiological aspects of the pathogen. mortality analysis was done, including sevilla score system (sss). we include patients admitted in icu from to with candidas ssp (cd) positive blood cultures (bacter system). we analysed demographic factors, reason for admission to the unit, associated risk factors, need of multi-instrumentation or parenteral nutrition, value of apache ii, and length of stay in the icu. the kind of cd diagnosed, its sensitivity profile, and the existence or not of previous wide spectrum antibiotic or antifungic therapy were determined. the sevilla score system was applied and correlated with mortality. chi square, t-test and multivariant analysis were made. there were . % male patients, with years old median age and with a length of stay longer than days. the reason for admission was sepsis ( %), surgery ( . %), acute respiratory failure ( . %) and trauma patiens ( %). apache ii median was . points.risk factors related with fungal infections were diabetes ( . %), neoplasia ( %), steroid therapy ( , %), a length of stay longer than days ( %) and antibioticoterapy. none had neutropenia. % of patiens received antibioticoterapy previous to diagnosis, . % parenteral nutrition and % of them underwent multi-instrumentation. patient isolation was achieved in % of them ( % in period - ). candida albicans was isolated in . % of cases against . % of candida nonalbicans, specially c. parapsilosis , %. first antifungal therapy was fluconazole ( %), caspofungin ( . %) and lipid amphotericins ( . %). we found a significant increase of sc cases along the years, ( % in - vs . % in - , p< . ), being unresponsive to azoles . %. mortality was specially high ( . %), unrelated with cd type; those with high/moderate sss risk had a significative higher mortality (p< . ). candida albicans was more frequently found in septic patients while candida nonalbicans was gaining place in patients under parenteral nutrition (c.parapsilosis).conclusion. ) systemic candidiasis affects men admitted with sepsis or surgery, with a high apache ii index, multiple organ failure, multi-instrumentation and more than two weeks intensive care unit stay. ) we observe a progressive incidence of non albicans candidiasis (c. parapsilosis). ) type of candida ssp did not affect mortality. ) c. albicans was more frequently isolated in septic patients, while candida nonalbicans was predominant in cases with parenteral nutrition. ) mortality was greater in moderate/higher sss risk group. f. alvarez-lerma* , m. palomar , p. objetive: to present changes of multiresistance markers in icu-acquired infections. a prospective, cohort, multicenter study. all patients admittted to the participating spanish icus between the years and were included. patients were followed until discharge from the icu or up to a maximum of days. the following infections were studied: mechanical ventilation-related pneumonia (mv-p), catheter-related urinary tract infection (cr-uti), and primary bacteremia (pb). markers of multiresistance were those defined by the cdc ( ) of a total of , pacientes included in the study, , ( . %) developed , infections ( . %) during their stay inthe icu, in which a total of , pathogens were identified.multiresistance markers are shown in table . pulse pressure variation greater than % predicts fluid responsiveness in patients ventilated with large tidal volumes. the aim of this study is to evaluate the influence of a low tidal volume on the capacity of pulse pressure variation (deltapp) to predict fluid responsiveness.methods. this is a prospective interventional study that took place in a -bed university hospital medico-surgical icu. the study included eighteen mechanically ventilated critically ill patients with a low tidal volume ( - ml/kg) requiring fluid challenge. fluid challenge was performed with , ml crystalloids or ml colloids. complete hemodynamic measurements including deltapp were obtained before and after fluid challenge. overall, the cardiac index increased from . ± . to . ± . l/min/m (p < . ). it increased by more than % in patients (responders). pulmonary artery occluded pressure was similar ( . ± . vs. . ± . mmhg, p= . ) but deltapp higher in responders than in non-responders ( ± % vs. ± %, p= . ). fluid responsiveness was equally predicted by deltapp (roc curve area . ± . ), pulmonary artery occluded pressure ( . ± . ) and right atrial pressure ( . ± . ) (p=ns). the best cutoff value for deltapp was % with a sensitivity of % and a specificity of %. the preliminary results suggest that deltapp is not a better predictor of fluid responsiveness then paop or rap in mechanically ventilated patients when tidal volume is - ml/kg. if used, a lower critical value may help to predict fluid responsiveness. svv and ppv are proven influenced by the different airway pressures due to depth of tidal volume and peep. the effect of respiratory rate or respiration frequency on svv and ppv is however unclear. aim of this study was to evaluate the effect of respiration frequency on svv and ppv in mechanically ventilated patients. after obtaining informed consent, (coronary bypass grafting) patients were studied immediately after surgery. cardiac output (co), svv and ppv were assessed by arterial pulse contour analysis (lidco, lidco ltd). all patients were ventilated in pressure controlled mode (settings: fio . , tidal volume ml/kg, peep cmh o, frequency min- ) and sedated with propofol. in this study svv and ppv were evaluated with fixed ventilator frequencies of , and min- . this protocol was repeated to times (before and after volume loading of ml) in each patient. during the study the mean airway pressure was maintained constant by adjusting inspiration time. collected data points are described in means (sd) and evaluated using anova. in six patients (female/male ratio / ) after coronary bypass grafting, mean age (± . ) years [range - years], data points by fixed respiratory frequencies could be analysed ( / , / and / ). all measurements were performed in hemodynamically stable conditions, hr mean (± . ) min- , map . (± . )mmhg, cvp . (± . )mmhg and co . (± . ) l/min (p for all ns). mean airway pressure . (± . )mbar (levene statistics, p = . ), for resp-f . (± , )mbar, resp-f , (± , )mbar and resp-f . (± . )mbar. on fixed respiratory rates svv and ppv were unchanged: for svv (resp-f ) . (± . )%, (resp-f ) . (± . )%, (resp-f ) . (± . )%, p = . , for ppv (resp-f ) . ( . )%, (resp-f ) . (± . )%, (resp-f ) . (± . )%, p = . . in ventilated cardiothoracic surgical patients, svv and ppv were not influenced by forced changes in respiratory frequencies between and min- . (svv) has been studied as a dynamic preload marker to predict fluid responsiveness in critically ill patients. patients undergoing major abdominal surgical procedures with the aid of pneumoperitoneum may have a difficult preload management, due to either a preoperative hypovolemic status or an excessive intraoperative fluid loading to maintain an adequate volume and tissue perfusion. the aim of this study was to use the svv to optimize the fluid management in patients undergoing major abdominal robot-assisted laparoscopic surgery. methods. patients (asa score - ; mean age . +/- . ) were prospectively enrolled. cardiac index (ci), stroke volume variation (svv), and central venous saturation (scvo ) were calculated with the vigileo system. gastric carbon dioxide pressure (pgco ) was measured with a gastric tonometer. before the induction of anesthesia, ml/kg normal saline solution was administered. later, colloids were infused whenever a svv > % resulted. hemodynamic variables and pgco were measured before, during, and after the end of surgery. the total amount of intraoperatively administered fluids (iaf) was calculated. subsequently, the iaf was compared with theoretical iaf using the formula proposed by miller. analysis of variance and student's t-test were applied. mean surgery time was . +/- . hours. ci ranged from . to . liters/min/m . scvo ranged from % to %. the pgco ranged from . to . mmhg. anova did not show significant variations of ci, scvo and pgco . mean baseline and postoperative svv% were +/- . and . +/- . , respectively. with respect to preoperative values, anova showed a significant reduction for svv%. moreover, at the end of surgery the svv% resulted less than % for each patient. the total amount of fluid was . +/- vs . +/- . ml/kg per hour (calculated vs theoretical, respectively. p< . ). no patient showed signs of hypoperfusion. no complication or death occurred.onclusion. the vigileo system seems to be a reliable tool to provide indications for fluid administration and volume responsiveness. it could be useful especially in major surgical procedures at risk of fluid overfilling. svv continuously monitored may help physicians to avoid fluid overloading in patients undergoing major abdominal robot-assisted laparoscopic surgery. recently, the preload parameters global enddiastolic volume gedv and intrathoracic blood volume itbv measured with transpulmonary thermodilution were convincingly shown to be superior to the historically used central venous pressure . the extravascular lung water evlw was shown to be a prognostic marker in critically ill patients . however, in our clinical experience, we failed to achieve the proposed normal ranges for gedv/itbv indexed to body surface area in a substantial number of patients. as hypothesis, we investigated the dependence of transpulmonary thermodilution parameters on the patient's age. we retrospectively analyzed the transpulmonary thermodilution data in a series of patients treated on our neurosurgical intensive care unit. diagnosis was predominantly severe subarachnoid hemorrhage, but included traumatic brain injury and polytrauma, too. itbvi and gedvi were measured with the picco ® system (pulsion medical systems ag, munich, germany). measurements were performed with cc iced saline injected repeatedly in a central venous line. all data was stored online and pooled for analysis. mean patient age was . (sd . ) years. pooled thermodilution measurement sequences consisting of single injections were analyzed. mean gedvi was (sd ) ml/m , mean itbvi was (sd ) ml/m and mean evlwi was . (sd . ) ml/kg. younger patients had lower mean values calculated by linear regression, with an increase of . ml/m for gedvi and . ml/m for itbvi per patient year. evlwi was independent of age.conclusion. the thermodilution data from our patient collective contrasts the use of fixed age-independent normal values for gedvi and itbvi but not for evlwi. this data set, however, comprises a neurosurgical patient collective and may not be validly extrapolated to other clinical surroundings. . michard f., et al.: chest ; : - . sakka, s., et al.: chest : - thirty mechanically ventilated patients with severe sepsis or septic shock (age ± ; apache-ii score ± ; male) requiring invasive hemodynamic monitoring due to cardiovascular instability were included in a prospective observational trial. the study was performed in a university hospital setting with a -bed medical intensive care unit (icu) and a -bed anaesthesiological icu. volume-based hemodynamic parameters were assessed using the single-pass thermal-dye transpulmonary dilution technique. simultaneously, ivc diameter was measured throughout the respiratory cycle by transabdominal ultrasonography. we found a statistically significant correlation of both inspiratory and expiratory ivc diameter with central venous pressure (p= . and p= . ), extravascular lung water index (p= . , p< . ), intrathoracic blood volume index (p= . , p= . ), the intrathoracic thermal volume (both p< . ), and the pao /fio oxygenation index (p= . and p= . , respectively).conclusion. sonographic determination of ivc diameter is useful in the assessment of volume status in mechanically ventilated septic patients. this approach is rapidly available, non-invasive, inexpensive, easy to learn and applicable in almost any clinical situation without doing harm. ivc sonography may contribute to a faster, more goal directed optimisation of fluid status and may help to identify patients in whom deleterious volume expansion should be avoided. it remains to be elucidated whether this approach influences the outcome of septic patients. a severe burn injury is associated with hypermetabolism and catabolism that has been shown to persist for over months post injury. propranolol has been shown to reduce hypermetabolism during the acute hospital course. the effect of propranolol, a nonselective beta blocker, on respiratory variables in children with severe burns has not been established. beta-blockade is associated with a known risk of bronchoconstriction in children with hyper-reactive airway disease, but it is not known whether the effects are also seen in severely burned children. the purpose of this study was to determine the effect of propranolol, given during acute hospitalization, on respiratory variables. forty-six patients with burns > % total body surface area (tbsa) were enrolled into the study and randomized to receive propranolol at . mg/kg/day (n= ) or placebo (n= ). administration of propranolol was started the day following the first operation and continued for three weeks. respiratory variables were measured by a flow transducer attached to a bicore cp respiratory monitor. all patients were breathing spontaneously and non-intubated. study variables included respiratory rate (rr), minute ventilation (mv), tidal volumes (vt), and peak inspiratory/expiratory flow rates (pifr/pefr). baseline measurements were taken at rest before the drug or placebo was initiated. follow-up measurements were performed at the end of the study period. data were analyzed using paired t-test within groups and un-paired t-test between groups. data are reported as mean ± sd. significance was accepted at p< . . the mean age in both groups was ± years. as expected, heart rate was reduced by approximately % in the propranolol group compared to placebo (p< . ). there was a significant increase in pefr from . ± . to . ± . l/s in the propranolol treated group (p= . ). in contrast, neither placebo nor propranolol significantly affected rr, vt, ve or pifr. results indicate that short term administration of propranolol showed significant effects on pefr suggesting increased pulmonary conductance. further studies on the effects of propranolol on gas exchange and lung compliance are needed. grant acknowledgement. funded by nih grants p -gm and ko -hl a. storesund* , e. wallestad , l. rygh postoperative section, surgical department, surgical department, haukeland university hospital, bergen, norway international studies point out that to work with agitated children, described as restless and disorientated are particularly stressful for the child, parents and caregiver. this project is based on the assumption by nurses in the post anaesthetic unit (pau) that there was a noticeable post anaesthetic agitation difference between the children who received long-term opioids initially and in the end of the operation (refill, a) compared to those who only got long-term opioids in the beginning of the operation (no refill, b). the main purpose of this project was to examine whether there were any difference in postsurgical agitation between the refill and no refill group. further, this project seeks to uncover if there are any factors that can be improved per-and postoperative for these patients. we observed post anaesthetic children, lip-(n= ), cleft-(n= ), and palateclosure (n= ), adeno-(n= ), & adeno-tonsillectomy (n= ). these children were recruited using a convenience sampling strategy at the pau at haukeland university hospital, norway, over a week period in - . a pilot-tested fixed cross sectional designed questionnaire was utilised by the nurse responsible for each patient. several statistical tests by the use of spss made it possible to analyse and answer the research question: are children who only get long-term opioids in the initial anaesthetic phase (b) of the operation more agitated than those who where also given a refill of long-term opioids (a)? we found that / got refills of long-term opioids (a), / did not get refills (b), % were recorded as missing values. t-test result = , is greater than , , hence there is no statistically significant difference between the two groups. levene's test tells us that the two variances are not significantly different (levene's test sig= , ). there were no significant relationships between the parameters recorded. however, there was a tendency that more preoperative anxious children got refills ( / ) compared to non-anxious children ( / ) (fisher's exact test p= , ). the latter results may conceal the agitation-scores in the two groups; refill and non-refill-group. this possible bias may have been eliminated if the patients had been randomized to either refill or non-refill. the present study confirms previous observations by others indicating no singular factors can explain why some children experience agitations and others do not. analysis of the parameters studied did not discover any statistical significant relationships. thus, how to minimise the cohort of children who experience post anaesthetic agitation still remains a recurrent challenge. pulmonary hypoplasia with severe cardiorespiratory dysfunction is often the leading cause of death in neonates with congenital renal disease and oligo-anhydramnios. aim of the study was to determine whether ino is effective to improve respiratory function in these critically ill neonates. we retrospectively reviewed the charts of all newborns who were admitted between february and september with the diagnosis of oligo-anhydramnios of renal origin. during this period all patients were treated according to a standardised algorithm. they were intubated either if post cpr or if fio had to be increased above . . mg/kg of bovine surfactant were applied for improvement of ventilation. pre-and postductal oxygen saturation were measured simultaneously with target values of - %. if fio remained above . a transthoracic echocardiography was performed. the presence of a ductal or atrial right to left shunt or a difference in oxygen saturation between the pre-and postductal measurements of > % led to the diagnosis of pulmonary hypertension and to the initiation of ino therapy. further, ino was applied as a rescue therapy if oxygen saturation remained below % despite a fio of . and optimization of ventilator settings and therapy with catecholamines. all patients had informed parental consent. the patient population (n= ) included children receiving ino of whom suffered from obstructive uropathy and two had polycystic kidneys, whereas patients did not receive ino treatment. in this group there were children with obstructive uropathy and born with polycystic kidneys. all data are presented as median (range). we concentrated on the group receiving ino. in this group mortality was . %. therapy was started at an age of . ( - ) hrs. initial dose of ino was . ( - ) ppm with peak dose of . ( - ) ppm. ino led to a decrease of oxygenation index (oi) from . ( . - . ) to . ( . - . ). five children suffered from obstructive uropathy. three of them had a favourable long-term outcome, one child died immediately, whereas one child was initially stabilized but finally succumbed to its underlying disease. two children demonstrated genetically determined pulmonary hypoplasia due to the presence of polycystic kidneys. both children died within the first three days despite ino treatment. children with obstructive uropathy and severely impaired oxygenation seem to benefit from ino therapy. patients suffering from a hereditary renal and pulmonary hypoplasia did not respond favourably to ino therapy and had a fatal outcome. a. khaldi*, k. menif, a. bouziri, a. hamdi, s. belhadj, n. ben jaballah pediatric intensive crae unit, children's hospital, tunis, tunisia the use of high-frequency oscillatory ventilation (hfov) and ino resulted in a decline in the need for extracorporeal membrane oxygenation (ecmo) in near-term and term neonates with persistent pulmonary hypertension (pphn). association of hfov and ino is actually an accepted treatment modality even in non-ecmo centers. however, because not all neonates respond to hfov + ino, identification of factors related to a poor response is very important for prognosis and for early transfer to ecmo canters if possible. the objective of this study was to identify the risk factors predicting poor shortly outcome in near-term and term neonates with pphn treated with hfov and ino in a tertiary care pediatric intensive care unit in a university hospital. we conducted a prospective clinical study including all neonates with gestational age ≥ weeks with echocardiographic signs of pphn. patients with pulmonary hypoplasia or congenital diaphragmatic hernia were excluded . patients were ventilated with conventional mechanical ventilation (cmv) with ino ( - ppm). hfov were instituted if patient required, on conventional ventilation (cmv)+ino, a fraction of inspired oxygen (fio ) . , and a mean airway pressure > cm h o to maintain adequate oxygenation or a peak inspiratory pressure > cm h o to maintain tidal volume between and ml/kg of body weight. hfov were used in association with ino in seventy infants (gestational age, ± , weeks), after a mean duration of cmv of ± hours. arterial blood gases, oxygenation index (oi), and alveolararterial difference in partial pressure of oxygen (p[a -a]o ) were recorded prospectively before and during hfov. there were a rapid and sustained decreases in mean airway pressure (map), oi, and p[a -a]o during hfov (p ≤ . ). this improvement, along with decreased need for oxygen, was sustained through the subsequent course of hfov. sixty-six infants ( %) were weaned successfully from hfov. five infants ( %) were classified as meeting treatment failure and died from their underlying disease. treatment failure was associated with lack of improvement in p[a -a]o and oi at hour of hfov (p < . ) and the presence of intractable shock requiring epinephrine or norepinephrine (p= , ). in near-term and term neonates with pphn, the association of hfov and ino lead to a rapid and sustained improvement in gas exchange in the most cases. the magnitude of improvement of oi and p[a -a]o at hrs can predict outcome early. early burn sepsis is notable for the complexity of diagnostics, malignant course and high lethality. the problem remains actual for the children who got a severe burn trauma (more than % body surface area). purpose to define procalcitonin test (pct) effectiveness for early sepsis diagnostics for children with thermal trauma. during the period of time from january up to april there were children in our clinic with extensive burns from %up to % body surface area (bsa) at the age from months to years old. patients at the age from months to years old with the burns from % to % bsa were included in our research. all the children got surgery in shortest time after trauma (tangential excision with authodermoplastics), antibacterial, and infusion therapy. from the moment of registration in icu all the patients, who were suspected to have sepsis, simultaneously with traditional examinations (blood analysis, bacteriological investigation) were taken pct analysis with the help of "pct-express test" (brahms, germany). . patients ( , %) were diagnosed sepsis, children died. these patients pct level was from to ng/ml; together with this all the patients had increasing quantity of leucocytes, acceleration the level of c-reactive protein, fever. ( %) patients had no sepsis, so pct figures fluctuated in the bounds of , ng/ml. among these patients traditional markers of inflammation were increased. no trustworthy difference is found as for the level of leucocytes and c-reactive protein figures between the patients without infectious complications and with sepsis. only with the help of pct the beginning of sepsis and sirs manifestation can be differentiated.conclusion. . burn trauma itself is not the reason for pct increase. pct level increases in cases of burn injuries as the sign of infectious complications joining. . with the help of traditional sepsis markers it is difficult to differentiate sirs manifestation and first stages of infectional complications in case of thermal trauma. . in cases of severe burns pct test is a highly sensitive method of sepsis early stages diagnostics. . surgery treatment at early stages after trauma allows to avoid development of severe sepsis. h. knoester* , m. b. bronner , a. p. bos , m. a. grootenhuis pediatric intensive care unit, psychosocial department, emma children's hospital, amc, amsterdam, netherlands introduction. improved survival in children with critical illnesses has led to new disease patterns due to long-term complications and effects of the original illness and its treatment. as a consequence, health related quality of life (hrqol) has become an important outcome measure in pediatric intensive care unit (picu) survivors. little is known about hrqol in picu survivors,. hrqol evaluation could contribute to improvement of support after discharge. the purpose of this study was to assess hrqol in picu survivors. october all parents of children, acutely admitted to our picu were invited to complete hrqol questionnaires, and months after discharge. hrqol in children from - years of age was evaluated with a dutch validated questionnaire, the tno-azl preschool children quality of life questionnaire (tapqol). the tapqol covers domains of hrqol; norm data from the general dutch population are available. data analyses was done by non-parametric testing (patients versus norm group) and by calculating effect sizes (difference in mean scores between the patients and the norm group divided by the standard deviation of the scores in the norm group). effect sizes give an indication of changes in hrqol in comparison with the norm group. . of ( . %) eligible patients were evaluated. statistically significant differences with the norm group were found on domains, and months after discharge (more lung problems and worse liveliness) and on domain months after discharge (better appetite). moderate ( . ) and large ( . ) effect sizes were found on five respectively four domains and months after discharge: indicating worse hrqol on lung problems, sleeping problems, motor functioning, anxiety, positve mood and liveliness; and indicating better hrqol on problem behaviour. no statistically significant changes over time were found for all domains and months after discharge. our results indicate that hrqol in young picu survivors is decreased in some domains of physical and emotional functioning. these problems do not diminish over time. positive evaluation by parents regarding appetite and problem behavior could be influenced by response shift (changing of internal standards and values due to confrontation with a life-threatening disease). more research is necessary because of the small study group and to determine the influence of risk factors such as length of stay, age of the child at admission, severity of illness and physical sequelae of the disease and its treatment on hrqol. hrqol evaluation can be a useful tool as part of screening after picu survival to determine the necessity for follow-up care. coarctation of the aorta is not an uncommon congenital heart defect. one of the possible postoperative complications is the so-called postcoarctectomy syndrome (mesenteric arteritis). the purpose of the present study is to assess the changes in gut flow through the dual sugar permeability test. five patients have been included in the study until now. median age month ( . - ) and median weight . kg ( - ). premedication and anaesthesia was the same for all the patients. the test solution contains -o-methyl-d-glucose, d-xylose, l-rhamnose and lactulose. patients received ml/kg of the test solution after induction of anaesthesia, at and hours after the initial dose. urine production is measured during a three-hour period after each instillation. the sugar content is analysed by capillary gas chromatography (normal values l/r = . , omdg and xylose - %). a. monsel , p. durand , v. haas , c. beaujard , p. rouleau , s. el aouadi , d. benhamou , k. asehnoune* anesthesie reanimation, reanimation pediatrique, anesthesie réanimation, hopital de bicetre, bicetre, anesthesie réanimation, chu hotel-dieu, nantes, france pediatric epidural anesthesia (ea) is considered to be without hemodynamic impairment in children. however, when compared with information relating to adults, little is known about the hemodynamic effects of epidural anesthesia on the cardiac output (co) in infants. using transesophageal doppler (ted) monitoring of co, we prospectively studied infants < kg who were scheduled for abdominal surgery. during sevoflurane general anesthesia, ted monitoring of co was performed before and after lumbar ea with . ml/kg of . % bupivacaine and : , adrenaline. co, arterial blood pressure, and heart rate were measured before and , , and minutes after performance of ea. in patients anesthetized with sevoflurane and sufentanil, ea resulted in an increase in stroke volume by % (p< . ) and a decrease in heart rate by % (p< . ). ea also induced a significant decrease in systolic, diastolic, mean arterial blood pressure and systemic vascular resistances by %, %, %, and % respectively. conversely, co remained unchanged. the increase in sv observed is probably explained by optimization of afterload due to the sympathetic blockade induced by ea. these results confirm that ea provides hemodynamic stability in infants weighing < kg and support the use of ea in this pediatric population. bleeding is the most frequent complication during extracorporeal life support (ecls) after pediatric cardiac surgery. we would like to present our experience with ecls and recirculation blood saving, volume auto-regulation system using the law of connected vessels based on converted cpb set in infants after cardiac surgery with significant bleeding. since to ecls in the postoperative period was performed ( , % of all cardiac operations in this period). the significant bleeding (> ml/kg/h) was noted in pts. in most recent pts the volume recirculation system was implemented, whereas in previous patients blood was sucked out the circuit. the retrospective analysis of data was carried out. there were infants with single ventricle anatomy and with two-ventricle anatomy. there were no significant differences with respect to age, weight and prevalence of single ventricle anatomy between groups. the indication for ecls was cardiac arrest in , low cardiac output in , hypoxemia in and sepsis in patients. the overall mortality rate was %. the mortality did not differ significantly between groups ( , % versus % in non-recirculation group; p= , ). there was significantly lower number of blood products transfusions(p< , ), lower number of surgical explorations(p< , ) lower mean lactate level hours after ecls institution p(< , ) and shorter ecls duration (p< , ) in the recirculation group. the system of blood recirculation in children with bleeding on ecls is simple, highly effective in stabilization of the haemodynamics and no-cost consuming. it can reduce necessity of chest exploration, blood product transfusions and duration of support. t. tunc* , t. topal , m. kul ,Ö.Öngürü , a. korkmaz , s.Öter neonataloji bilim dali, fizyoloji anabilim dali, patoloji anabilim dali, gülhane askeri tip akademisi, ankara, turkey necrotizing enterocolitis (nec) is the most common gastrointestinal emergency in the premature infant. the major risk factors in nec include prematurity, hypoxia, enteral feeding, and bacterial colonization. these factors predispose at-risk infants to an exaggerated intestinal inflammatory response leading to ischemic bowel necrosis. experimentally induced ischemia and reperfusion (i/r) of the intestine is a model which can be appropriately used to imitate nec. n-acetylcysteine (nac), erdosteine (erd) and alpha-lipoic acid (ala) are well-known antioxidants with similar structural properties. in the present study, the effectiveness of these three sulfur-based antioxidants against intestinal i/r-injury was evaluated.methods. one month old male spraque-dawley rats were randomly divided into five groups (n = for each): i/r (control), i/r+nac, i/r+erd, i/r+ala and sham-operated group without i/r. animals were operated at a temperature of o c under ketamine anesthesia. ischemia was provided by occluding the superior mesenteric artery via a microvascular clamp. collateral vessels of the small intestine were ligated to prevent collateral circulation. min of ischemia was followed by min of reperfusion. nac ( mg/kg/day, i.p.) was administered first min before operation and followed once daily for days. erd ( mg/kg/day, oral gavage) administration was begun days before operation and continued daily doses. ala ( mg/kg/day, i.p.) was injected only one time h before operation. at day after operation the ileum was resected and the rats were sacrificed. protein oxidation (carbonyl content, pco), lipid peroxidation (malondialdehyde, mda), superoxide dismutase (sod) and glutathione peroxidase (gsh-px) were measured in the ileal tissue. oxidative and antioxidant parameters of resected ileal segment (mean ± sd) groups as a clinically relevant model to nec, our experimental i/r protocol resulted with marked rise in oxidative stress levels and fall of antioxidant enzymes activities. these changes were ameliorated with the antioxidants used. among all, ala presented the strongest and nac the weakest effect. this outcome promises beneficial usage of these sulfurbased antioxidants against oxidative stress which plays an important role in nec pathogenesis. a. khaldi* , k. menif , a. bouziri , a. hamdi , s. belhadj , n. ben jaballah pediatric intensive crae unit, children's hospital, pediatric intensive crae unit, children's hospital, tunis, tunisia high-frequency oscillatory ventilation (hfov) may significantly improve oxygenation and outcome in newborns with respiratory dysfunction and beyond the neonatal period in patients with a variety of diffuse alveolar diseases. in small airway disease like respiratory syncytial virus (vrs) bronchiolitis, hfov is considered potentially hazardous because of the risk of air trapping. however, a few studies had reported utility of hfov in children with acute hypoxemic or hypercapnic respiratory failure caused by vrs and failing optimal conventional mechanical ventilation (cmv). the objective of the study is to evaluate the effectiveness and safety of hfov in pediatric patients with acute respiratory failure due to rsv and failing cmv. we conducted, over -year period (october to october ), a prospective clinical study in a tertiary care pediatric intensive care unit. fourteen ( ) patients (ages to days) with acute respiratory failure due to rsv bronchiolitis and failing optimal cmv were included. passage to hfov was indicated for severe hypoxemia in patients (median alveolar-arterial oxygen difference [p(a-a)o ]: [ - ] mmhg, median oxygenation index [io]: [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) and for severe hypercarbia in patients (median ph: , [ , - , ] , median paco : [ - ] mmhg). hfov was instituted after a median length of cmv of ( - ) hours. ventilator settings, arterial blood gases, oi and p(a-a)o was recorded before hfov (h ) and at a predetermined intervals during hfov and compared using the one-friedman rank-sum procedure and a two-tailed wilcoxon matched-pairs test. after starting hfov, a distinct decrease in fio at hrs that continued to hrs (p< , ). in all patients, there were significant decreases in oi and p(a-a)o at hrs, that were sustained up to hrs (p< , ). target ventilation was achieved in all cases and paco significantly decreases after hr of hfov (p= , ) and remained within the target range thereafter ( - mmhg). the median maximum pressure amplitude used on hfov was ( - ) cm h o and the median maximal paw was ( - ) cm h o. no significant complications associated with hfov were observed. twelve patients ( %) survived to hospital discharge without supplementary oxygen. tow patients ( %) died from septic shock. in pediatric patients with either hypoxemic or hypercapnic acute respiratory failure due to rsv bronchiolitis, hfov can be used successfully and safely if conventional ventilation fails to improve gas exchange. however, randomized controlled trials are needed to identify its benefits over conventional modes of mechanical ventilation. and are influenced by numerous factors like patient's disease severity, policies of the treating unit, religious and cultural traits, education and awareness of the patient's family, financial status of the family and legal provisions. majority of published studies on eol reflect either european or american ethos; that is either physician's paternalistic approach about the patient or patient's autonomy and self determination,( , ) about this sensitive process. studies on eol which reflect the influence and pivotal role of closely knit indian family on eol decision making are scant. we retrospectively analysed the eol decisions taken by the family in our icu as majority of the patients which merit eol care were not in a condition of decision making. setting- bedded multidisciplinary icu of a bedded tertiary care teaching hospital in pune in india. case papers of all icu admissions during one year i.e. st january to st december where eol decision was documented, were reviewed. data collected included demographics, underlying disease process, duration of aggressive treatment till eol consent, duration between eol decision and death, consenting person's relation with the patient, organ failure & level of life sustaining supports at decision and mode of payment of the treatment. during the study period patients died in our icu of which eol decision and consent was explicitly documented in cases which constitute study population. average age of the patient was years (range to ), average duration of active treatment till eol consent was . hours(range to ),average duration between consent and death was . hours(range to ). . % consents were signed by close relatives( son/daughter, brother/sister, spouse, father/mother) and . % were by other relatives( cousins, son in law/daughter in law). at the time of eol decision . % patients were having glassgow coma scale and below, . % patients were on mechanical ventilation, . % were on vasopressors and . % were needing renal replacement. metastatic disease ( . %) and traumatic or vascular brain injury( . %) were the commonest causes of death. only . % patients had medical insurance or employer assistance as a mode of payment for the treatment and in . % cases family members were the payers. withholding of non beneficial life sustaining therapies as eol process was practised in . % of the total icu deaths. all ( %) eol decisions as well as directive requests and consents were signed by patients' relatives, reflecting the importance of close family ties in indian eol practices. our objective was to study frequencies of withholding and withdrawing treatment and time until death in a dutch university hospital icu. between october and february we collected data of all patients that died. data were collected from patient files and during interviews with the doctors and nurses who were responsible for the patient at the time of death. we analyzed which treatments were withheld or withdrawn and calculated the time until death following withholding or withdrawal. preliminary results show that of admissions, patients died ( %). nonsurvivor's (median age years [range - ]) median length of stay was days (range minutes - months). in patients ( %) treatment was withdrawn and in patients ( %) treatment was withheld but not withdrawn. of all patients ( %) were mechanically ventilated of which ( %) were weaned and extubated before death. in of these patients it was decided not to intubate again and other patients not to intubate at all (median time until death: hours). in ( %) ventilator-dependent patients mechanical ventilation was withdrawn; ( %) were extubated. the median time until death after ventilator withdrawal was minutes. when patients were also extubated, it was minutes (p= , [mann-whitney test]). in patients mechanical ventilation was not withdrawn, but fio was decreased to . (median time until death minutes). in patients ( %) inotropic medication was withdrawn (median time until death minutes). in cases, the withdrawal of inotropic medication was combined with the withdrawal of mechanical ventilation. in patients ( %) it was decided not to increase inotropic support (median time until death : hours). in patients ( %) the decision was made not to resuscitate in case of cardiac arrest. median time of this decision before death was hours. in the patients that died treatment was withdrawn in the vast majority of patients. withdrawal of mechanical ventilation and/or withdrawal of inotropic support were most often used. a considerable number of patients died within minutes following withdrawal of therapy. r. veiga* , g. silva , g. campello , c. dias , c. granja intensive care department, hospital pedro hispano, matosinhos, biostatistics and medical informatics, faculty of medicine, porto, portugal the high mortality of critically ill patients underscores the need for icu teams to recognize end-of-life care as an integral component of critical care. besides survival, the success of intensive care should also include the quality of lives preserved and the quality of dying. the aim of this study was to evaluate the incidence and type of end-of-life decisions in critical patients that died in an icu. retrospective analysis of all patients that died in the icu in the period of january to december and evaluated the following variables: demographic characteristics (age, gender); co-morbidities: (heart failure, chronic obstructive pulmonary disease (copd), diabetes mellitus, neoplasia, chronic renal disease, hiv/aids, alcoholism); reason for admission; saps ii; length of icu stay (icu los) and type of end-of-life decisions. three concepts were defined in order to classify the end-of-life decisions: comfort care: a change from curative therapy to comfort care therapy; limited therapy: maintenance of curative therapy but without escalating it (e.g. not raising rate of vasopressor agents, no renal substitution); without previous end-of-life decisions: when no attitudes toward end-of-life care were considered. given the diminished number of patients in the without previous end-of-life decisions group we decided to evaluate them apart from the other two groups.results. two-hundred and twenty seven patients were admitted in the icu and of them died ( %). reason for admission in those who died was septic shock/ severe sepsis ( %), post-cardiac arrest ( %); cardiogenic shock ( %); acute respiratory distress syndrome ( %). the most common co-morbidity was alcoholism ( %), followed by diabetes mellitus ( %), neoplasia ( %), heart failure ( %) and copd ( %). forty seven patients ( %) died after comfort care decision, eleven patients ( %) after limited therapy decision and four ( %) patients died without previous end-of-life decisions. comparing the groups comfort care and limited therapy we found significant differences in the following variables: hemorrhagic shock at admission ( % vs. %) (p= . ); saps ii ( vs. ) (p= . ); icu los ( . days vs. . days) (p< . ). patients in the limited therapy group had more admissions with hemorrhagic shock, a higher severity score and stayed less time in the icu. this analysis suggests that end-of-life decisions in this group express their higher severity. patients of the comfort care group presented less severity and stayed longer in the icu. their shift of curative therapy to one designated to provide comfort care reflects an absence of a clinically favorable response. the low percentage of patients without previous end-of-life decisions is consistent with previous reports and should be seen as a positive issue. non invasive positive pressure ventilation (nippv) is widely accepted as an initial approach to providing ventilatory support to many patients with acute respiratory failure (arf). palliative approaches focused on the quality of life and comfort; represent a challenge for family's physicians and the patients. nippv is an attractive option to treat acute respiratory failure in end stage patients when the failure is irreversible and it is a final outcome of the primary disease. the approach to providing ventilatory support to patients with arf, to relieve them from the sensation of dying suffocate without intubating them because they don't wish it either, is very challenging. after institutional approval and patients consent, we conducted a prospective observational study of patients that fulfilled the criteria. cases received nippv ( with end stage cancer and with pulmonary fibrosis). when nippv was ordered we recorded: respiratory rate, heart rate, arterial blood pressure, neurological status and arterial blood gases, before nippv initiation (baseline data) and then st, th and th hour. at the time of initiation of nippv, all patients were alert and cooperative with nippv. analgesia and/or sedation were used when it was necessary. pao , pco and ph measures were analyzed using statistical methods. percentage changes from baseline (pre-nippv) of these measures were used as dependent variables. (mean value of measurements at different time points was used). dependent variables (percentage of pao , pco and ph) were regressed on time, for each patient. in all cases the results were statistically significant, with p-values ranging from a low of . to a high of . . for all patients, the regression coefficient for the percentage change was positive; indicating that the percentage change was increasing with time. we can remark that pao increases over time, pco and ph p values > . . we believe that nippv via helmet cpap is a means of potentially ensuring the highest quality of end-of-life care. nippv can be applied for palliative care, and it might be used to keep patients whom developed acute respiratory failure comfortable before the inevitable. decisions regarding the resuscitation status of patients are among the most difficult facing healthcare professionals, patients and families. these groups often need to discuss decisions regarding resuscitation yet their understanding and expectations can differ greatly. this study sought to determine the knowledge and beliefs of doctors, nurses and the general public regarding resuscitation decisions.methods. an observational study was designed. three study groups (doctors, nurses and general public) were interviewed using a face-to-face interview by a single interviewer and questionnaires completed. questions examined opinion, factual knowledge and knowledge of the ethics surrounding hospital resuscitation attempts. . doctors, nurses and general public were randomly selected. % doctors, % nurses and % of public correctly estimated survival to discharge following in-hospital resuscitation attempt. the remainder overestimated survival. . % of doctors and % of nurses consider resuscitation decisions to be made too infrequently. deficiencies were identified in doctor and nurse knowledge of the ethics governing resuscitation decisions and public opinion was found to conflict with ethical guidelines. public understanding of the nature of cardiopulmonary arrests and resuscitation attempts, and of the implications of a dnar order is poor. . % of public report television medical dramas as their primary source of information on such matters. knowledge regarding resuscitation principles, outcomes and ethics is poor among both healthcare staff and the general public. these knowledge differences may not be appreciated or addressed in discussions regarding resuscitation and this reduces the likelihood of meaningful discussion and acceptable decisions. there is a need for educational initiatives to address these deficiencies. public apprehension surrounding this subject needs to be identified and corrected during discussions and this could be facilitated with a patient information leaflet. [ ] poor communication during this process may lead to unnecessary anger and a delay in the grieving process that could linger for many years to come. giving the family the option to be present during resuscitation offers a more compassionate and family-centred approach to this crisis. this option of family presence however is frequently met with resistance and uncertainty by health care workers who may view the family's presence as increasing their risk of making a mistake or worse, being sued. a study in the uk estimated that out of one-hundred-and-sixtytwo uk emergency departments family witnessed resuscitation was allowed by % for an adult patient and % for a child. [ ] another us study also found that amongst patients in emergency departments, % preferred to have their family present during resuscitation. [ ] a survey was conducted amongst the doctors, nurses and paramedics who work in two uk eds to assess their attitudes and beliefs. experience, life support training, years in practice, consent issues, ethical factors and concerns regarding medico legal implications were sought for. a -point likert scale was used and mean scores analysed using microsoft excel. . staff were surveyed. % of doctors, % of nurses and % of paramedics believed in the concept in trauma fwr. in cardiac arrest patients, % were in favour of it, % opposed to it and % undecided. % of staff believed that litigation was possible with family witnessed resuscitation. % of respondents thought that critical incident de-briefing would be of benefit to assist staff dealing with stress. fewer doctors believed in cardiac fwr compared to nurses (p= . ) and paramedics (p= . ). in trauma, difference was non-significant. as health care professionals caring for families in the emergency departments, we need to recognize the need for compassionate family-centered care. with a well trained and motivated team equipped with effective, well thought out guidelines, there is considerable benefit for family members and staff in this difficult situation. thorough information about the events that are going to take place in the icu after an elective procedure might facilitate the awakening process and weaning from the ventilator, mitigating patient's anxiety and increasing their comfort. the aim of this study was to analyze the impact of preoperative information on the patient's perceptions and reactions to the usual inconveniences, such as orotracheal tube (ott), associated with the first postoperative hours in the icu. prospective, cohort study with a group of cases (a) and a control group (b). duration: two months. inclusion criteria: all patients undergoing elective cardiac surgery. there were no exclusion criteria. setting: cardiac surgical icu of a tertiary hospital. the survey was made in the first hours. the study was blinded for the doctors in charge of the patients. the characteristics of both groups are presented as a/b with the p value into brackets. the quantitative variables are shown with the mean value and the qualitative variables as a percentage. the number of patients included was : cases (a) and controls (b). age: , / , years ( , ); men: / %( , ); time receiving sedative drugs: , / , hours ( , ); total hours with ott: , / , ( , ); hours with ott after stopping sedation: , / , ( , ). the first patient's perceptions were: discomfort related to ott in , / , % ( , ); surgical pain in , / , % ( , ); thirst in , / , % ( , ); welfare or calm in , / , % ( , ), and nothing in , / , % ( , ). additional sedatives were required in , / , % ( , ). information was considered very useful in , %. patients valued very positively the provided information. in addition, this information had a significant impact on the tolerance to the ott, requirement of additional sedatives, and in the sense of welfare. there were not differences in the time under sedative drugs or in the perception of thirst or pain. a multiparameter questionnaire was sent to icu. each questionnaire comprised informational topics groupe into categories (table). one relative per patient was asked to quote (yes/no) within days after admission, each item, i.e. if he would like to find information on that item in an ib. if "no" was quoted, he was asked to say why (closed answers). demographic data on patient and relatives were correlated to the scores (nbre of "yes"), in each item category (factor analysis with varimax rotation followed by stepwise multiple linear regression). . questionnaires were analyzed (patients: age ± year, saps : ± , sofa: ± ). table: % of positive response for each item ("would you like information on this topic in an icu booklet?") grouped into categories. "no" answers were mostly explained by "i trust the team to manage information about this" (median: %, range: - ). mulitvariate analysis showed that demographics data describing patient condition (age, saps , chronic disease) correlated (p< . ) with "yes" score of the items comprized in "icu rules" (table) but not with other items grouped in other information categories. conclusion. interestingly, as a whole, most items were highly wished in a booklet, suggesting that - % of relatives express a plea for transparency in face of "difficult icu issues", without taboo. only the "yes score" to "icu rules" items correlated with patient status whereas items from other topics did not. this sounds, as relatives visiting the most severe patients may consider visiting rules as crucial. other items did not correlate to profiles, and may thereby be considered as societal standard requirements in terms of information. in / , our -bed medical icu signed a convention with the asp iroise association defining hv's role and presence. the association, a member of a national network of hv associations, works with our university hospital. four hvs took alternate turns in the icu one afternoon per week. hv were free to meet any conscious patient or any family member who wished so; icu staff also asked them to meet patients or families who seemed particularly distressed. hv wrote a brief commentary in a special transmission logbook which could be consulted by the staff and gave feedback about their visits whenever needed. patients (pts)and families (fam)who met an hv were sent a questionnaire either in / or in / . pts were admitted during the period of study: the hv met pts ( , %) and families ( , %). people answered the questionnaire ( , %): pts and fam: spouse, parents, sister, children( no answer). ethics consultation has been introduced into the practice of medicine during the last decades as a way to help physicians and nurses come to a decision about a medical treatment where value-laden conflicts are involved. the primary goal is helping to identify, analyze, and resolve ethical problems. the aim of this study was to evaluate ethics consultation in a dutch university hospital intensive care. intensivists, residents, fellows and nurses can consult a clinical ethicist specialized in intensive care for advice in value-laden situations. we evaluate ethics consultation on our icu between january and april . the clinical ethicist was consulted times. in / cases ( %) advice was asked before withdrawal of life-sustaining therapy. in this category / ( %) cases concerned palliative care. in / cases ( %) the independent advice was in confirmation with the physician's view. in / cases ( %) advice was sought in cases were there was doubts to proceed with intensive care therapy. in four cases relatives wanted to withdraw therapy, where the intensivist did not consider this as futile. in / cases ( %) the advice was in accordance with the treatment plan. in cases ( %) questions about information asked by non-relatives. all advises were followed. cases concerned triage, cases withholding therapy, brain death declaration, a deadly iatrogenic complication and in patients a question concerning emergency research. in ( %) cases a lawyer specialized in health care was consulted. in the cases about 'withdrawal of therapy', the advise could be given within minutes in % of the cases. ethical advise by a clinical ethicist specialized in intensive care can be additional, affirmative and reassuring, and improves quality of care. in most cases advice could be given immediately. . deferred consent has been proposed as a surrogate for a priori subject or proxy consent. the aim of this report is to evaluate the practicality and efficacy of a deferred consent procedure in an ongoing dutch multi-centre clinical trial. screening logs were collected from two participating centres of a clinical trial that is currently conducted to evaluate the efficacy of early lactate-directed therapy and that uses deferred consent. screened patients were analyzed for eligibility and reasons for exclusion. ( %) were not reported to the study investigators, patients ( %) were not included for medical-ethical reasons (e.g. treating clinician deemed risk/benefit ratio of the study intervention unacceptable), in patients ( %) study participation was practically impossible (e.g. unavailable study materials) and the reason was unknown in patients ( %). only patients (or their relatives)( %) refused informed consent. in an ongoing dutch multi-centre emergency clinical trial using deferred consent, only % of patients or their relatives refused informed consent. deferred consent in emergency research is practical and facilitates a high inclusion rate. adult respiratory distress syndrome (ards) and peep have been linked to right ventricular dysfunction (rvd). this has been attributed to elevated pulmonary artery pressure (pap) and pulmonary vascular resistance (pvr) due to ards as well as increased intrathoracic pressure due to peep therapy. we wondered if rvd was a late phenomenon in ards or could also be detected during early peep treatment of hypoxia in patients with multiple ards risk factors. pulmonary embolism is a highly prevalent disease associated with severe morbidity and mortality. although the hemodynamic changes induced by pulmonary embolism are known, the alterations in respiratory mechanics after an embolic event are not completely understood. the aim of this study was to evaluate acute changes in hemodynamics, static and dynamic respiratory mechanics and lung histology induced by an experimental model of pulmonary microembolism. ten large white pigs (weight - kg) were instrumented with arterial and pulmonary catheters and pulmonary embolism was induced in pigs by injection of polystyrene microspheres (diameter ∼ µm), in order to obtain a pulmonary mean arterial pressure (pmap) of twice the baseline value. five other animals were injected with saline and served as controls. hemodynamic and respiratory data were collected and pressure x volume (pxv) loops of the respiratory system were performed by a quasi-static low flow method. animals were followed for hours and after death lung fragments were dissected and sent to pathology. the average amount of microspheres necessary to generate microembolism was . ± . mg/kg. pulmonary embolism induced a significant reduction in stroke volume ( ± ml/min/bpm pre vs ± post, p< . ), an increase in pmap ( ± mmhg pre vs ± post, p< . ) and pulmonary vascular resistance ( ± mmhg/l/min pre vs ± post, p< . ). respiratory dysfunction was evidenced by significant reductions in pao /fio ratio ( ± pre vs ± post, p< . ), dynamic lung compliance ( ± ml/cmh o pre vs ± post, p< . ) and increase in dead space ventilation ( ± pre vs ± post, p< . ). pxv curves of the respiratory system were affected by embolism, with shift of the loops to the right and consequent reduction in static compliance and pulmonary hysteresis. pathology depicted inflammatory neutrophil infiltrates, alveolar edema, collapse and hemorrhagic infarctions. pulmonary microembolism induced by polystyrene microspheres is associated with cardiovascular dysfunction, as well as respiratory injury characterized by decrease in oxygenation, dynamic and static lung compliances and pulmonary hysteresis. pathology findings were similar to those verified in inflammatory-induced acute lung injury. the similarities between respiratory and histologic features of this model and those from conditions associated with lung inflammation suggest that pharmacologic and ventilatory interventions already used to treat acute lung injury may also be tested in pulmonary embolism. the presence of patent foramen ovale (pfo) is frequently underdiagnosed in icu patients suffering from refractory hypoxemia. however, it is relatively common in the general population. we examined the prevalence of pfo in mechanically ventilated icu patients with refractory hypoxemia and abnormal chest x-ray findings. over a period of five years, mechanically ventilated patients with refractory hypoxemia and abnormal chest x-ray findings were examined with transesophageal echocardiography (tee) for the presence of pfo as a contributing factor to their hypoxemia (right to left intracardiac shunt). all patients were ventilated with tidal volume - ml.kg - and peep between - cmh o. their mean pao /fio ratio was ± mmhg. the coexisting pathology consisted of: ards ( cases), massive pulmonary embolism ( cases), copd ( cases), cabg surgery with rv infarction ( cases), cerebrovascular accident ( case) and pulmonary oedema due to fluid overload ( case during a two-month period we investigated the possibility of opening of the foramen ovale during a recruitment maneuver in either patients with ards or in patients with atelectasis and a pao /fio ratio< . we enrolled consecutive patients (ards: cases, patients with atelectasis and hypoxemia: cases), likely to benefit from a recruitment maneuver. mean pao /fio ratio was and mean compliance was ml.cmh o - prior to the maneuver. all data regarding the mechanical properties of the lung were recorded from the ventilators monitor screen. after deficits of intravascular volume had been addressed and hemodynamics had been optimized, a baseline transesophageal echocardiographic study using contrast material was performed to rule out the possibility of a foramen ovale already patent prior to the maneuver. the recruitment inflation pressure was chosen as the lesser of cm h o or the peak pressure at ml.kg - tidal volume. the ventilator was then adjusted to deliver this high inflation pressure for secs. five seconds after the onset of inflation, ml of a contrast material were injected through a central venous line with the transesophageal probe already in place to detect the passage of the material to the left atrium. passage of the contrast material to the left side of the circulation was detected using two dimensional echocardiography. we found that the sustained high inflation pressure resulted in foramen ovale opening in patients, whereas it did not produce such a result in patients. in of the studied patients, the baseline transesophageal study revealed a patent foramen ovale before recruitment was attempted. no adverse effects following the recruitment maneuver were noted. mean pao /fio ratio was and mean compliance was ml.cmh o - twenty minutes after the recruitment maneuver, with only one of the recruited patients showing a significant improvement in oxygenation.conclusion. patent foramen ovale may be a contributing factor of refractory hypoxemia in icu patients. opening of the foramen ovale is not an unlikely event during a recruitment maneuver. acute respiratory distress syndrome (ards) remains a major problem in critically ill patients, with mortality rates of - %. to date, no specific treatment has been shown to decrease mortality, but this may largely be due to the heterogeneity of the populations meeting the ards criteria.objectives: to evaluate patients who died with a clinical diagnosis of ards and who had a postmortem examination in order to: -define the pathological alterations associated with the syndrome, with particular reference to the typical pattern of diffuse alveolar damage (dad); -evaluate whether etiologies or precipitating factors were missed; and -speculate whether a lung biopsy could have guided the clinical management. three year ( ) ( ) ( ) review of all patients with ards (using the aecc criteria) who had a postmortem examination. comparisons between ante-and post-mortem diagnoses were classified as major and minor discrepancies using the goldman classification. results: of a total of admissions, patients had a clinical diagnosis of ards. of these, died; had a postmortem examination and of these had complete data for analysis. the main causes of death were multiple organ failure in ( %) and refractory hypoxemia in ( %). postmortem lung examination revealed dad in ( %) patients ( associated with a lung infection), (broncho)pneumonia without dad in ( %), invasive pulmonary aspergillosis without dad in ( %), and other diagnoses in ( %). major unexpected findings were found in ( %) patients, classified as goldman class i errors and class ii errors. the class i errors included cases of invasive pulmonary aspergillosis.conclusion. ards as a syndrome, can be due to various pathological patterns; at autopsy, only half of patients with ards have typical dad. special attention should be paid to the possibility of aspergillosis; in this setting, lung biopsy may have a role. g. s. georgieva*, s. kurata, c. zhu, a. bilali, t. imai critical care medicine, tokyo medical and dental university, tokyo, japan development of efficient lung preservation method has been anticipated and we elucidated that positive pulmonary venous pressure (pvp) ( mmhg) prevented ischemia-reperfusion (i/r) injury in isolated mechanically ventilated rat lungs. the aim of this study is to determine whether cpap accompanied with mmhg of pvp would be effective for prevention of i/r injury. after tracheostomy rats were ventilated at strokes /min with air ( % c ) and with peep of . cmh , cannulated to the left atrium and pulmonary arteries (pas), and perfused with krebs -henseleit solution supplemented with albumin ( %) ( . ml/g/min). the lungs and heart "en block" were isolated and placed in a chamber; right and left bronchus as well as pas were dissected which permit each lung to be ventilated and/or perfused selectively by selective occlusion of each bronchus and/or pa. after min control condition, the left lung (ll) was maintained under cpap (selective occlusion of left broncus); the control right lung (rl) was ventilated with peak airway pressure of cmh above peep;perfusion to the both lungs was stopped (ischemia). pulmonary venous outflow was elevated so as to be applied mmhg to the left atrium during ischemia. after -min ischemia, reperfusion with mmhg pvp and both lung normal ventilation were resumed for min. perfusion pressures of rl and ll was measured at the beginning and at the end of the experiment by occlusion either the left or right pulmonary artery, as appropriate. albumin content in bronchoalveolar lavage fluid (balf) separately for each ll and rl, and lung weight were measured. protein content in balf was calculated as (mg of protein)/(ml of balf)/(g of lung dry weight). all the data were compared by wilcoxon's rank-sum or mann-whitney u-test and expressed as mean +/-sd. in i/r lung maintained at cpap, wet/dry and balf as well as perfusion pressure increased compared to the control rl. conclusion. cpap( . cmh ) and mmhg pvp cannot prevent ischemic lung injury despite constant distention of pulmonary vasculature and alveolar space. this suggests that gas exchange during ischemia would be necessary for escaping from i/r injury. potential peripheral airway obstruction is of importance for the choice of ventilatory strategy in acute lung injury (ali). use of a limited expiratory time counteracts early regional expiratory collapse but might cause hyperinflation in case of significant peripheral obstruction. the aim of this study was to assess regional expiratory time constants and gas trapping in early ali. ten anesthetized pigs were ventilated in volume-controlled mode with i:e ratios of either : or : at a rate of breaths per minute. starting from the end-inspiratory level, sequential computed tomography (ct) exposures were performed during passive, uninterrupted expiration to the atmosphere. the procedure was performed before and after oleic acid-induced lung injury (oai) had been induced in the lower lobe on one side. the gas volume of bilateral dependent and non-dependent regions of interest (rois) was calculated from radiographical attenuation values. the expiratory time constant was calculated from a mono-exponential decay of roi gas volumes during expiration. gas trapping in injured and non-injured regions were compared. during ventilation with i:e ratio : , oai caused overall compliance to decrease from +/- . to +/- . ml/cmh o (p< . ). dependent, injured regions showed a shorter time constant and a lower volume of gas than dependent non-injured regions regardless of whether the preceding end-inspiratory volume had been increased or not by application of a limited expiratory time. in non-dependent, non-injured regions, the gas volume was similar on both sides after both patterns of ventilation. one of the additional approaches in the therapy of the acute respiratory distress syndrome (ards) is the use of a pumpless arteriovenous extracorporeal membrane oxygenator (interventional lung assist (ila)). the aim of our study was to test the effects of an ila system on hemodynamics and gas exchange during resuscitation and to establish whether ila should be kept open or clamped under these circumstances. the study was designed as a prospective experimental study. the experiments were performed on pigs ( to kg body weight). the pigs were anesthetized and mechanically ventilated. one femoral artery and one femoral vein were cannulated and connected with ila. acute lung injury was induced by repeated bronchoalveolar lavage until arterial partial pressure of oxygen (pao ) was lower than torr for at least min during ventilation with % o . ventricular fibrillation was then induced by an indwelling pacemaker. manual compressions of the thorax were started at once and continued for minutes. in animals, ila was kept open, in the other it was clamped immediately. statistical analysis was performed using graphpad prism. two-way analysis of variance was applied and significance was accepted at p values < . . the data is given as mean ± sd. with a mean systolic arterial pressure in the group with ila open of ± mm hg and ± mm hg with ila clamped and mean blood pressures of ± mm hg with ila open and ± mm hg with ila clamped the blood pressure did not differ between the two groups. endtidal carbon dioxide decreased from ± torr with ila open and ± torr before intervention to ± torr and ± torr, respectively. the arterial partial pressure of carbon dioxide (paco ) was significantly lower in the group with the ila system open ( ± mm hg versus ± mm hg at minutes) and the pao was higher (although significant only at minutes, mm hg ± mm hg versus mm hg ± mm hg). the blood pressure generated with thorax compressions did not differ significantly between the two groups and endtidal co was also in the same range. therefore we assume that circulation was not significantly affected by ila and that the shunt caused by the ila system did not deteriorate circulation. paco was significantly lower in the group with the ila system open and pao was higher. our results indicate that the ila system was not harmful during resuscitation, it even might have a beneficial effect.grant acknowledgement. the study was partially supported by novalung, hechingen, germany. respiratory failure -miscellaneous - increased thorax rigidity and high intraabdominal pressure reduce the stretch ability of the thoracic cage and modify the regional lung function. this phenomenon is often seen in intensive care patients, e.g. with abdominal compartment syndrome. objective of this study was to determine the effect of decreased thoracic cage compliance on regional distribution of spontaneous ventilation in different postures by the non-invasive method of electrical impedance tomography (eit). for this survey we examined ten healthy male spontaneously breathing volunteers (mean age ± sd: ± years; body weight: ± kg, height: ± cm). the compliance of the thoracic cage was restricted by external abdominal and thoracic corsets respectively. the eit examinations were performed with the goe-mf ii eit device (viasys healthcare, höchberg, germany). sixteen self-adhesive electrodes ( m red dot , m health care, borken, germany) were applied on the chest circumference in one transverse plane and used for rotating electrical current injection and voltage measurement. the eit data were acquired at a rate of scans/s. impedance data and spirometry were obtained during spontaneous ventilation in three body positions (sitting, left and right side). statistical analysis was performed using repeated anova with bonferroni's multiple comparison test and student's t test. p values < . were considered significant.results. the regional distribution of ventilation in subjects without restrictions revealed a close match with physiologically expected values. thoracic and abdominal restrictions led to reduction of ventilation in the dependent lung areas. the non-dependent lung areas were not affected. the fractional ventilation in the dependent lung areas was reduced in the right side position from . ± . % to . ± . % (thoracic restrictions) and . ± . % (abdominal restrictions), in the left side position from . ± . % to . ± . %, and . ± . %. thoracic and abdominal restrictions of the thoracic cage reduce ventilation only in the dependent lung regions in spontaneously breathing healthy volunteers. eit is a suitable method for non-invasive determination of regional lung ventilation. k. raymondos* , k. vieweger , j. ahrens , m. przemeck , m. homann , s. piepenbrock anaesthesiology, medical school hannover, anaesthesiology, annastift, johanniter-unfall-hilfe e.v., ortsverband wasserturm, hannover, germany germany are still performed with ambulances in that only limited monitoring and usually only volume-cycled emergency ventilators can be used. we established an intensive care ambulance system and evaluated the transfers of critically ill patients performed with this system. we prospectively recorded interhospital-transfers. the ventilatory modes before and during the patients' transfer and further characteristics of the interhospital-transfers were evaluated. transport ventilation was performed with the raphael ® silver ventilator (hamilton medical ag, rhäzüns, switzerland) with that also pressure-support ventilation (psv), airway pressure release ventilation (duopap ® /aprv) and the combination of both could be used. indications for the interhospital-transfers included ischemic ( . %) and other ( . %) cardiac diseases, cerebral diseases ( . %) of which % required neurosurgy, pulmonary disease ( . %) and others ( . %). ( . %)% of the transferred patients received ventilatory support, patients ( . %) breathed spontaneously with and patients ( . %) without oxygen insufflation. the majority of the mechanically ventilated patients received ventilatory modes supporting spontaneous breathing before ( . %) and during the transfer ( . %). the patients were transferred in minutes ( minutes - hours) over a distance of km ( - km) (median (range)). at least motor syringe pumps were needed during the transfer of patients ( . %). monitoring during the transfer was similar or more extended compared to the monitoring in the hospital prior to transfer (ecg % vs. %, pulse oximetry % vs. %, non-invasive blood pressure % vs %, intraarterial pressure % vs % and capnography % vs. %). most ventilated patients received weaning techniques and most of these ventilatory modes were continued during the transfer. these ventilatory modes and a more extended monitoring including intraarterial pressure monitoring and capnography cannot be applied in emergency ambulances. the less invasive ventilatory modes and the extended monitoring enable a less invasive and safer interhospital-transfer as the intensive care treatment and monitoring prior to transfer is maintained or even extended during the transport. a. sánchez*, m. palomar, r. alcaraz, a. socias, d. moreira intensive care unit, hg vall d'hebron, barcelona, spain introduction. some series have shown the bad prognosis of patients with pulmonary fibrosis (pf) who require admittance at icu for respiratory failure. there are doubts of the benefit of the ventilatory support if the precipitating cause is not well defined. lung transplant (lt) could be a therapeutical option. the aim of this study was to analyze the prognosis of the patients with pf who are admitted to an icu of a hospital with lt program.methods. case-series, observational study of patients with pf and acute respiratory failure admitted to the icu of a third level hospital with lt programm between january until june . information about the cause of pf, clinical course, current status, ventilatory support, length of stay, pulmonary functional tests, possibility of trasplantation, complications and mortality was collected. . patients ( men, women) with pf ( idiopathic pf, connectivopaty and due to radiotherapy) were admitted for acute respiratory failure (arf) to our icu. mean age was , ( - ) years. the median duration of illness from diagnosis until admittance was , ( - ) years. apache-ii score was ( - ). the precipitating cause of arf was identified in patients: bacterial pneumonia was documented in patients; had a pulmonary embolism; fungic infection and cases were due to the progression of the disease. in cases the precipitating cause could not be identified. mechanical ventilation (mv) was required by patients ( , %) during an average of , ( - ) days with a mortality rate of , %. pa o /fi o at admittance ( - ) mm hg; and paco at admittance ( - ) mm hg. respiratory functional studies were available in eleven patients with a fev of . ( . ) l and fvc of . ( . ) l. patients ( %) died during their stay at icu. the cause of death was multi-organic failure in ( . %); refractary hypoxemia in ( . %) patients and of them died while the transplantation was being performed. mean length of stay was ( - ) days. patients were included in the urgent lt list and were transplanted. no donor was found in cases and died on the waiting list. there were performed single-lung and double-lt. mean age was ( - ) years. the time from the admittance until transplantation was ( - ) days. of them ( %) required mv with a mortality rate of , %. from this group ( , %) patients died during their stay at the icu. of the patients died while the transplantation was being performed.conclusion. literature shows a bad prognosis of patients with pf who need admittance to an icu for arf. in our experience the survival was % so the existance of a lt programm could offer a chance to these patients. m. e. lugarinho*, p. p. souza intensive care unit, hospital de clinicas mario lioni, rio de janeiro, brazil introduction. acute kidney insufficiency (aki) worsens the outcome in critical ill patients. we investigate whether the presence of aki had any effect on lenght of mechanical ventilation and mortality rate. observational, prospective study in a -bed general intensive care unit (icu) from january to december . the inclusion criterion was invasive mechanical ventilation for more than hours. aki was defined as the presence of dialysis during the icu stay. patients were then separated into aki and non-aki patients (control group). the primary end point was duration of total length of mechanical ventilation and the secondary end point was the icu mortality. a total of patients were studied: with aki and non-aki. the groups were similar in regard to age, sex, and apache ii score. the median (interquartile range) duration of mechanical ventilation [ - ] versus [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] days, (p< , ). the icu mortality rate were significantly greater in the aki patients: % versus , % (p< , ).conclusion. this study shows that renal insufficiency has serious impact on the duration of mechanical ventilation and morbi-mortality in critically ill patient. these data elicits the poor outcomes of mechanical ventilated patients who demands for dialytic methods. it will be useful in end of life discussions and decisions in our icu. introduction. -ht a-r-agonist -oh-dpat has been shown to counteract morphine induced ventilatory depression, while opiate antinociception remained unaffected. repinotan-hcl, another -ht a-r-agonist, is unlike -oh-dpat suitable for the use in humans. it was hypothesized that repinotan-hcl is capable to antagonize ventilatory depression without impairing anti-nociception in rat. with approval from local animal care committee, rats were anesthetized with sevoflurane and tracheotomized to record respiratory rate (rr), tidal volume (vt) minute ventilation (mv). inguinal vessels were catheterized to monitor arterial blood pressure and apply drugs iv. nociception was assessed by tail-flick reflex. morphine was administered at increments of mg/kg until a target % reduction of rr was achieved. subsequently, repinotan-hcl was added cumulatively at increasing doses ( . , . , , , µg/kg, n= ). another group received nacl . % to serve as control (n= ). morphine ( . ± . mg/kg) depressed rr to - ± %, and tfr was abolished with first dose of morphine in any experiment. repinotan-hcl antagonized ventilatory depression dose-dependently, mcg/kg repinotan-hcl re-established ventilation almost at pretreatment level (rr + . ± %, p< . , -anova, compared to control). tfr remained absent throughout repinotan administration. repinotan functionally antagonized morphine-induced ventilatory depression, while suppression of nociceptive reflex sustained. -ht a-r-agonists such as repinotan-hcl appear to be promising candidates to stabilize spontaneous breathing. a. makowski* , b. misztal , c. plowright , k. safranow anaesthetics, medway maritime hospital, gillingham, united kingdom, biochemistry, pomeranian medical university, szczecin, poland vapotherm's (vap) patent pending membrane technology makes higher flows from to lpm possible by saturating breathing gases with water vapor at body temperature. fio is ranging from . - . . heat and humidity allow nasal flow to be well tolerated by the patients. high flow in animal study caused small amount of peep. can we achieve desired therapeutic goal in treatment of respiratory failure (rf) with this very simple, non-invasive method? we investigated effectiveness and hospital outcome of patients with rf treated on vap at surgical hdu between december and march . data were taken during retrospective investigations. we analysed type and reason of rf as well as respiratory rate (rr), fio , flow, arterial blood gases (abg). data were collected before (bef) vap was commenced, hour after, and every day of treatment. we also recorded length and outcome of vap therapy and patient satisfaction. data were analysed with wilcoxone and also spearman's rank correlation tests. the patients ( % female, % male) at age - ( . ± . ) were treated - ( . ± . ) days. we applied vap therapy for . % patients with type i rf and . % with type ii rf. the reasons of rf were pneumonia in . %, sepsis in . % pulmonary oedema in . %, copd in . %, others in . %. for . % patients there was a sufficient and definite treatment whereas . % required mechanical ventilation and icu admission. the . % of patients were satisfied with therapy. the . % survived and were discharged from the hospital. high flow and small amount of peep reduce work of breathing and significantly decrease rr. after effective vapotherm therapy we observed in abg significant increase of oxygen saturation and pao . vast majority of patients were satisfied during the treatment. in critically ill patients who need long-term mechanical ventilation, early tracheostomy may facilitate weaning and shorten the length of stay in intensive care ( ). however, there are no clinical tests that identify patients as being at an increased risk for prolonged ventilatory support; clinicians must predict the duration of arteficial ventilation by their clinical experience. in our surgical intensive care unit we conducted a prospective clinical study to determine if there was an association between different clinical parameters (age, body mass index, gcs, saps score, vasopressor use, pao /fio ratio) and long-term mechanical ventilation. furthermore, we examined the positive predictive value of clinicians' prediction; to do that, clinicians had to indicate whether they considered prolonged mechanical ventilation as the most likely (but not always certain) outcome or not. we enrolled patients and collected date on days - th and th of treatment. prolonged meshanical ventilation was defined as at least more days on respirator. none of the examined parameters could be used alone to predict long-term mechanical ventilation. overall sensitivity of clinicians' prediction was . %, and positive predictive value was . %. . % of patients died, . % was weaned from respirator ( . % extubated) within days despite predicted by clinicians as having prolonged ventilatory need. suprisingly, the best positive predictive value ( . %) was found on the day of admission, the worst ( . %) on day ; the difference was not significant (p= . with chi-square test). this result could be explained by the fact that most patients in the study group were ventilated on day , but only a few on day .conclusion. prediction of prolonged mechanical ventilation was found to be very inaccurate, and did not improve in the course of first week of treatment. however, in our department where many neurosurgical patients are treated, only a minority could be extubated within days when long-term ventilatory support was predicted. as selection of patients who need tracheostomy seems not to be better after one week of treatment than at an early stage, there can be a reason for early tracheostomy if we anticipate prolonged arteficial ventilation. n. abidi , h. thabet* , o. béji , h. elghord , n. brahmi , m. ben othmen , n. kouraichi , m. amamou intensive care medicine, emergency medicine, centre d'assistance médicale urgente, tunis, tunisia introduction. acute exacerbation of copd is a frequent cause of admission in icu and usually have a poor outcome. such a patient consume a large amount of resources particulary if they need endotracheal intubation. the aim of this study is to report epidemiological, clinical features,treatment and outcome of patients admitted in icu for acute exacerbation of copd. a retrospective study was carried out of consecutive admisions in icu over a years (from january to december ). american thoracic society criteria are usued to define copd. exacerbation is defined as a worsening of copd symptoms. a total of patients were included in this study with episodes of acute exacerbation. mean age was ± , years. the sex ratio was , (m/f: / ). eighty percent were current tobacco users. seventy two percent had one or more associated comorbities mainly cardiovascular disease. according to copd severity , % of patients were in stage iii. , % were receiving home oxygen and ( %) were previously mechanical ventilated. on icu admission severity score are apache ii ± ; igsii ± . patients ( %) have a shock and ( , %) have a coma (gcs< ). treatment consist of starting non invasive ventilation (niv) for patients ( %); patients ( %) need immediate intubation and mechanical ventilation. failure of niv was noted for patients. in the course of hospitalisation in icu main complications were: nosocomial infection for patients ( , %), barotrauma patients ( , %) and thromboembolic complications for patients ( , %). the median icu stay was , ± , days and mortality was , % ( patients). the main cause of mortality were septic shock ( cases, , %) and ards ( cases, %). in this retrospective study patients admitted for exacerbation of copd need a mechanical ventilation in , %. failure of niv were %. main complications were nosocomial infection ( , % of cases). mortality is high , % but not different for patients admitted in icu for other disease. it is described, that gelatin leads to red blood cell (rbc)-coating, which is protective against shear stress in extracorporeal circuits. ( ) an increase of mean corpuscular volume (mcv) without an increase in mean corpuscular hemoglobin content as well as a reduction of red blood cell (rbc) counts can be assumed to reduce pulmonary oxygen transfer. increased rbc aggregability (accelerated blood sedimentation rate, bsr), as could occur due to coating, impairs microcirculation. since adequate oxygen delivery is important in ventilated patients to counteract metabolic acidosis, we compared rbc features in acidotic pigs undergoing hemofiltration. healthy pigs (male, dlxde, - kg) were anesthetized, received acid infusion ( . m) and low tidal ventilation with fio > . resulting in normoxic acidosis (ph . - . ; paco - mmhg). tris-hydroxymethylaminomethane (tham) was infused to titrate a ph of . - . . either hes or gel (n= - /colloid-group) was infused additionally to crystalloids (colloid to crystalloid ratio was : ). samples were collected before acid and colloid infusion (bs), after induction of acidosis (baseline acidosis, bsa), and after h of continuous acidosis ( ha). thereafter, acid infusion was stopped and tham was infused with . mol/kg/h for h in order to normalize ph-values. final values (fv) were taken. parameters investigated were: paco , rbc counts, mcv, and bsr. the fio /pao ratio was also determined. compared to hes application, gel infusion was associated with a reduction in rbc count, an increase in mcv and an accelerated bsr from bsa until fv. values did not recover from initial deterioration (bsa) even not after normalization of ph (fv). based on the healthy lungs in this porcine model, these changes did not impair pao /fio ratio. whether increases in mcv were due to gel coating or due to unhampered swelling of rbcs during acidosis could not determined. however, in acidotic pigs gel induced unfavorable effects concerning rbc features with respect to rheology while hes did not. in individuals with impaired pulmonary function and hypodynamic state the described difference between the two types of colloids could become crucial with respect to total oxygen delivery. perctaneous dilational tracheostomy (pdt) has become more common procedure used in intensive care. however, several complications, such as hemorrhage, posterior tracheal wall injury, tracheal stenosis have been recently reported. the aim of this study was to confirm whether the ultrasound can easily and clearly delineate the pretracheal anatomy and identify the potential problems for pdt. we also examined the accuracy in identifying the correct puncture level between and tracheal cartilages blindly (by hand). we studied patients and volunteers. before ultrasound scanning, the circumference of the neck was measured and the puncture level between and tracheal cartilages was marked blindly in each subject. in ultrasound scanning, we examined the relationship of the thyroid to the trachea, aberrant vascular anatomy in the pretracheal region, counted the number of extrathoracic tracheal rings. the distances from the skin to cricothyroid ligament and anterior tracheal wall at the level between and tracheal cartilages were estimated and the relationship between depth of trachea and circumference of the neck was analyzed by simple regression. we also checked the level of trachea pointed by operator blindly was correct or not by comparing the level identified by ultrasound images. the mean age and circumference of the neck were ± years (range: - ) and ± cm. ultrasound examination of the trachea and thyroid was easily carried out in each subject except subjects. approximately extrathoracic tracheal rings could be imaged with ultrasound. anterior jugular veins were seen in subjects ( %) and six were near the midline. the depth of trachea between and tracheal cartilages were varied in each subject ( . - . cm) and there were stastistically relatioship between circumference of the neck and depth of trachea (r = . , p= . ). the accurate decision of trachea level was made in % of the subjects.conclusion. this study showed that: ) ultrasound can delineate the neck structure and detect variations related to the complication of pdt; ) blind identification of the puncture level for tracheostomy without ultrasound was not necessarily correct. our results demonstrated that the routine use of ultrasound could be recommended before pdt. introduction. fluid therapy system of critically ill patients is very variable, and it is based in the interpreting of differents physiologic parameters with a double aim, by one hand keep an adequate perfusion of vital organs, and the other hand avoid overload volumen. our objective was analyze changes in critically ill patients fluid therapy when we including evlw in treatment protocol and evaluate response in short time. observational and prospective study in a neurotraumatological icu. we included consecutives patients that were admited with acute lung injury/adult respiratory distress syndrome and/or septic patients who needed monitoring with central venous and arterial catheterization with picco system. we made a therapeutic reassessment of the fluid therapy and/or vasoactives after we knew evlw when one of the following events in the patient evolution hapenned: hypoxemia, hypotension, olyguria/anuria, or its addition. response in short time was also evaluated. our sample included patients and determinations( patients with determinations, patient with determination and patient with determination). after we knew evlw we changed initial therapeutic plan in . %; this change affected fluids in . % and vasoactives in . %. evlw in patients who therapeutic plan was modified was . ± . and if therapeutic plan was not modified, evlw was . ± . (p< . ). association is observed between evlw value and decision about fluids, so when we decided increase fluids was . ± . ; if the decision was decrease fluid, evlw was . ± . and in the cases that diuretics were added . ± . , in all cases statistics significant was found. no differences was observed in evlw values about vasoactives decision. we found improvement of initial event in short time after intervention in . %.conclusion. evlw determination affects in important way to fluids therapy plan in critically ill patients. we think that inclusion of evlw contributes to a more racional management of these patients. patients who had received ino were identified from icnarc records. hospital notes and icu charts were reviewed. data collected included diagnosis, apache ii and unit and hospital outcome. the pao /fio ratio (in mmhg) was recorded prior to starting ino (day ) and subsequently on days - using the data from the time at which oxygenation was best in each hour period. . patients received ino. patients received it for treatment of hypoxaemic respiratory failure, and for treatment of pulmonary hypertension. mean apache score was . on admission (survivors . ; non-survivors ) . the mean pao /fio ratio was . on day and improved to . on day . in unit survivors, the mean pao /fio increased from . to . on day , compared with unit non-survivors in whom it increased from . to . . ( %) of patients were responders to ino (defined as a > % increase in pao /fio ratio). unit and hospital survival figures for responders and non-responders are presented below. hospital surviviors (n= ) hospital non-survivors (n= ) responder (n= ) ( %) ( %) non-responder (n= ) ( %) ( %) fisher's exact test ( tailed) p= . conclusion. ino was used in patients with more severe hypoxia than those included in randomised trials. ( ) in this review, responders were found to have a significantly reduced unit mortality and a reduced hospital mortality compared with non-responders. we believe ino may be a valuable therapy in ards patients with severe refractory hypoxaemia, and that studies in this subgroup of patients are warranted. outcome predictors of hfov in severe ards are not well studied. we prospectively evaluated the outcome predictors of hfov in adult ards. methods. ards patients receiving mechanical ventilation as per the ardsnet protocol with po /fio ≤ inspite of peep≥ cm and fio ≥ . ,were considered for hfov. continuous distending pressure(cdp),frequency ,amplitude, inspiratory time and bias flow of hfov were optimised with the help of frequent blood gas analysis. weaning from hfov to pressure support ventilation was attempted once po /fio ratio remained ≥ with cdp≤ cm &fio ≤ . . responders(r) were defined as patients who were successfully weaned to a state which required no ventilatory support for > hrs. non responders(nr)were defined as patients who could not be weaned off ventilatory assistance. results. out of total patients were r & were nr. both the groups were similar prior to hfov as shown in table. improvement in po /fio ratio and oxygenation index (oi) at hrs & hrs in r group was statistically significant as compared to that in nr group. we could show that chaotic variation of pressure support improves pressure support ventilation (psv), and named this new mode noisy psv. in this work, we compared noisy psv to conventional biphasic positive airway pressure ventilation (bipap), which has been claimed to be a "gold standard", in experimental acute lung injury. after approval by the local animal care committee, juvenile pigs ( . - . kg) were anesthetized and mechanically ventilated (dräger evita xl lab; volume controlled ventilation, vt = ml/kg; fio = . ; peep = cmh o). after induction of acute lung injury by saline lung lavage ( ml/kg), lungs were recruited and a decremental peep trial was performed to determine the optimal peep according to the elastance of the respiratory system (ers). thereafter, spontaneous breathing was resumed and animals were randomly assigned to noisy psv or bipap groups (n= each group). the ventilator settings were as follows -bipap: fio = . ; plow = according to peep of minimal ers; phigh = titrated to generate vt of ml/kg; thigh = s; tlow = s -noisy psv: fio = . ; peep = according to peep of minimal ers; mean pasb = titrated to generate vt of ml/kg. noisy psv was accomplished by means of remote control of the evita xl lab by a laptop, which generated a sequence of respiratory cycles with different pressure support levels (mean = pasb; sd = % of mean). gas exchange, respiratory parameters and hemodynamics were measured at baseline, injury, after resuming of spontaneous breathing (baseline ) and during an observational period of h. statistical analysis was performed with general linear model statistics adjusted for repeated measures using baseline as covariate. significance was accepted at p< . . bodyweight, peep and number of lavages as well as hemodynamics did not differ significantly between groups. oxygenation and co elimination were significantly improved with noisy psv (p< . both). analysis of respiratory parameters revealed significant lower mean airway pressures with noisy psv as compared to bipap (p< . ), as well as increased mean peak airway pressure, spontaneous respiratory rate, and mean tidal volume (p< . all).conclusion. this study represents the first evaluation of the recently developed noisy psv combined with peep levels titrated according to lowest ers. noisy psv was found superior to conventional bipap with regard to gas exchange and respiratory parameters. further experimental studies are necessary to determine the potential role of noisy psv in intensive care therapy. we investigated if chaotic variation of pressure support (noise) can improve the performance of pressure support ventilation (psv) in experimental acute lung injury (ali). with approval of the local animal care committee, pigs weighing to kg were anesthetized, intubated and mechanically ventilated (volume-controlled mode, fio = . , peep= cmh o, tidal volume= ml/kg). following that, ali was induced by surfactant depletion, and biphasic intermittent positive airway pressure (bipap) was initiated with: lower cpap (cpaplow) = cmh o, higher cpap (cpaphigh) titrated to obtain tidal volumes of - ml/kg, respiratory rate set to obtain paco between - mmhg. then, depth of anesthesia was decreased to allow spontaneous breathing, and animals were ventilated with two different modes ( hour each, random sequence): ) traditional psv, with pressure support level set at cpaphigh -cpaplow; ) noisy psv, with random variation of pressure support and mean value set at cpaphigh -cpaplow, and standard deviation set at % of the mean value (normal distribution). gas exchange, inspiratory drive (p . ) and inspiratory pressure time product of esophageal pressure (ptp) were assessed. helical computed tomography (ct) of chest was performed at end-expiration and the hyperaerated, normally aerated, hypoaerated and non-aerated lung compartments were calculated in animals. patients with respiratory failure treated with vm with fio . were included. after minutes of oxygen therapy, arterial blood gases were collected and patients were asked to quantify (from to ) three items: dyspnea, dry mouth and general confort. then, vm was changed for hfnc (optiflowtm, fisher & paykel, new zeland) . the same variables were collected after minutes using hfnc. results are expressed as median (interquartil range). we have applied spsswin v . with wilcoxon test. patients n= ( m), age ( - ). in the moment of inclusion, one patient ( %) presented mods and sofa score was ( . - . ). during their evolution, five patients ( %) finally need endotracheal intubation. main results are presented in the following tables: a computer-driven system (cds) has been recently used to optimise psv to patient's needs during weaning. in some pts, the cds fail to find a "comfort window" despite stepwise increase in pressure support (ps) levels. for these pts, cds could further increase respiratory muscle workload. we speculate that failure to adapt respiratory rates (rr) and vt following changes in ps levels might identify a subset of pts unlikely to benefit from the cds.to test this hypothesis, we used a bedside test before switching ventilated pts to a closed-loop algorithm of psv. we studied pts at initiation of weaning with psv using the smallest ps level resulting in rr≤ , vt> ml/kg. we collected baseline values and assessed changes in vt (dvt), rr (drr) during min after cmh o-increase and decrease in ps levels. then, a cds session was started at the baseline ps level. we searched for correlations between dvt, drr, and outcome (failure/success) of the cds sessions. a cds session was deemed successful when the system detected criteria for separation of the ventilator or when psv was efficiently adjusted by the cds within h after starting the session. in pressure support ventilation auto-peep is considered a major contributor to the inspiratory work of breathing. measurement of auto-peep requires esophageal pressure tracings, which are not routinely available. the presence of auto-peep is likely, when flow is interrupted at end-expiration, a pattern well-established in controlled ventilation. we studied expiratory flow-volume relationships as substitute for detection of auto-peep in patients on pressure support ventilation. in patients successively admitted to our icu respiratory mechanics were obtained from consecutive breaths on pressure support ventilation. auto-peep was considered present when in flow-versus-time recordings flow was interrupted at end-expiration. from flow-volume relationships expiratory time-constants were calculated and related to actual expiration times. all measurements were obtained with a nico-computer; for analysis a computer program analysis plus was used (both respironics/novametrix, inc.). in of the patients flow at end-expiration was interrupted suggesting the presence of auto-peep (interrupted flow group). in the remaining patients flow was zero at end-expiration (zero flow group). in the flow-volume curves of patients in the interrupted flow group versus the zero flow group end-expiratory flows varied between . - . l/s and . - . l/s respectively. the expiratory time-constants ranged from . - . s in the interrupted flow group and . - . s in the zero flow group. the ratios between expiration times and expiratory time-constants varied between . - . and . - . for the interrupted and zero flow groups respectively . the means and standard deviations for both groups were:means +/-sd in patients on pressure support ventilation with interrupted flows at endexpiration higher expiratory time-constants and lower ratios between expiration times and time-constants were found, suggesting the presence of auto-peep. these variables can be used as substitute for detection of auto-peep. non invasive ventilation (niv) is the delivery of assisted mechanical ventilation to the lungs, without the use of an invasive endotracheal airway. niv has decreased the need for invasive mechanical ventilation and its attendant complications. acute cardiogenic pulmonary edema (acpe) is defined as an episode of acute heart failure accompanied by severe respiratory distress and oxygen saturation < % on room air before all treatment. our study aimed to asses the respiratory effects of a device that delivers a continous positive airway pressure via face mask in patients with severe acpe, the feasibility of using this technique in an emergency department (ed) and estimed the need of endotracheal intubation (ei). we evaluated a series of patients consecutively treated in our ed for acpe, from june to december . a peep level of cm h o delivered by cpap-boussignac device (vygon, ecouen, france) was used in all patients. fio was estimed to range from to %. clinical and blood gas parameters were recorded at entry and also after minute and hour of treatment. all patients were treated with standard medical therapy. the average of age was years ( - ), were male and were female. the inclusion criteria for niv were: ph < , but > , , paco > mmhg or an acute augment of - mmhg, respiratory rate > /min, pao /fio < mmhg on room air and score kelly max . resolution of respiratory distress occurred from to minute ( media minute). all patients showed an improve of clinical and emogasanalytic impairment. only patients needed ei and were transferred in icu. patients were treated in ed and after normalization and stabilization of their vital signs they were discharged in other medical departments ( cardiology department and pneumology department). the rate of ei was %.conclusion. cpap delivered using boussignac device is feasible in an emergency care setting. it can quickly improve respiratory distress in acpe patients and reduce the need of ei. in clinical practice niv is being used as a sole respiratory support modality or in the weaning period in at least % of arf patients admitted to emergency department. the remaining patiens need imv as primary and secondary forms of respiratory support. failure of niv seems to predict higher mortality rates. as a conclusion we need both support modalities and the physician has to use them carefully according to patients condition and their expertise. methods. medline, pubmed, cochrane, & cinahl databases ( to were searched using the terms: aprv, bipap, bilevel & lung protective strategy, individually and in combination. reference lists of identified papers were also examined. two independent reviewers determined eligibility of papers based on predefined criteria. database searching yielded citations, of which were selected on review of title and abstract. data were abstracted onto pre-designed forms from experimental studies and discussion articles on further review. of the experimental studies, used a randomised design, were cohort studies and case series. aprv was the named mode in ( %) studies, bipap in ( %), and inverse mandatory pressure release ventilation in one study. extreme inverse inspiratory:expiratory (i:e) ratio was used in ( %) aprv compared to bipap studies (p = . ); ( %) aprv and ( %) bipap studies used mild inverse ratio (up to : ). a : ratio was used more often with bipap ( , % vs , %, p = . ) as was a normal i:e ratio ( , % vs , %, p = . ). in adult studies, mean inspiratory pressure was cmh o (aprv) and cmh o (bipap) (p= . ). mean expiratory pressure was . cmh o for both modes (p= . ). seven aprv studies described synchronisation, ( %) stated the mode did not synchronise to patient effort. all bipap studies that described synchronisation stated it was available.conclusion. aprv assumes inverse ratio ventilation (irv). some studies advocate extreme irv with short release times to improve gas exchange, haemodynamic stability, renal and splanchnic blood flow( ). extreme irv was used in only % of aprv studies, % described an i:e ratio of : . further, ventilator settings used for studies of aprv may be indistinguishable from bipap studies ( , ) . given the variation in ventilatory settings described, uncertainty of optimal settings may exist. commercial ventilator branding may further add to confusion. generic naming of ventilatory modes, as with drug prescribing, combined with consistent definitions of the parameters that define the modes, may avoid confusion, improve consistency of patient response and assist the implementation of these modes into clinical practice. pav is intended to normalize neuro-ventilatry coupling by assisting each breath in proportion to patient effort, but requires reliable measurements of elastance (e) and resistance (r). pav+ allows to (a) automatically and non invasively measure e and r, and (b) continuously adjust ventilatory support accordingly. aim of our study was to test the physiological effects of pav+ versus cmv (ardsnet lung protective strategy) in a model of ards. in pigs ards was induced through chloridric acid inhalation ( ml/kg). at t (after damage) each pig was randomly assigned to pav+ or cmv. gas exchange and lung ct scan at (t ) hours were compared with those obtained at t (delta = t -t ). data are mean +/-standard deviation; *) p < . pav+ versus cmv cmv pav+ ∆ hyperinflated areas (cm ) +/- +/- ∆ normally aerated areas (cm ) - +/- +/- * ∆ poorly aerated areas (cm ) +/- +/- * ∆ nonaerated areas (cm ) +/- - +/- * ∆ pao /fio - +/- +/- * ∆ paco (mmhg) +/- - +/- * our data suggest the ability of pav+ to improve gas exchange, principally through an increase in normally aerated areas. the impact of pav+ on ventilator induced lung injury deserves further investigation.grant acknowledgement. university of bari. introduction. the major advantage of high-frequency oscillatory ventilation (hfov) to conventional mechanical ventilation (cmv) is delivery of smaller tidal volumes to an optimally recruited lung. assuming there is a save window in the pressure volume curve of the lung between a lower zone with atelectasis and a upper zone with overdistension, surpassing this zone would result in either cyclic recruitment and decrecruitment, overdistension, or both. in diseased lungs this safe window may be too small to harbor the relatively large tidal volumes of cmv. co removal (v'co ) and therefore paco is a function of frequency (f) and alveolar delivered tidal volume (vt): v'co = f x vt . it is an inherent technical feature of all oscillators that vt at maximal power decreases as frequency increases. in addition, pressure swings fall down the endotracheal tube and the airways. this fall in pressure swings is a function of frequency and mechanical properties of the respiratory system. as a result of both phenomena vt delivered to the alveoli decreases substantially at higher frequencies. up till now oscillation is set at a fixed frequency, in adults at hz, in children and neonates at hz. paco is regulated by adjusting the power, and thus the pressure swings (delta p) and the delivered volume. if the maximum power has been reached, decreasing the frequency can lower the paco further. we calculated vt required to keep v'co constant at different oscillation frequencies and measured the delivered vt at maximal power as function of frequency with the sensormedics a. . vt needed to keep v'co constant and maximal delivered vt can be plotted against oscillatory frequency. by increasing frequency, vt needed to keep v'co constant and maximal delivered vt both decrease. however, a point is reached at which the required vt to maintain v'co equals the maximal delivered vt. at this point vt has its lowest possible value to maintain paco . at higher frequencies the delivered volume of the oscillator is lower than required and paco would rise above the pre-arranged level. we advocate a ventilatory strategy with the oscillator set at its maximal power and the frequency to be adjusted according to the paco . with this strategy the lowest vt is delivered to the alveoli with the largest safety margins between atelectasis and overdistension. automatic tube compensation (atc) compensates the resistance caused by the endotracheal tube. tube resistance is defined by the equation hagen-poiseuille: r = ( x x l) / π x r . (r= resistance, = viscosity, l= length of the tube, r= radius of the tube). atc is designed to lower the work of breathing in intubated spontaneous breathing patients by creating a higher initial flow and therefore a higher peak pressure. the aim of this study was evaluate the consequences of atc during controlled mechanical ventilation without spontaneous breathing activity on peak pressure distal of the tracheal tube, in comparison to the set pressure. moreover, the time needed to reach the set inspiratory pressure distal of the tube with and without atc was assessed. in an experimental laboratory setting using an artificial lung the maximum pressure in the ventilator (draeger evita ), proximal and distal of the tube with and without % inspiratory atc in a tube id , and a tube id , were measured. the time needed to reach the set inspiratory pressure distal of the tube with and without % inspiratory atc were compared. baseline ventilator settings were bipap, asb , peep mbar, i:e-ratio : , fio %, rise time seconds. a set of measurements where performed for each of the following settings: pressure constant group (pcg): frequency of respectively: , and a minute at a fixed pinsp of mbar. frequency constant group (fcg): pinsp of respectively: , and mbar at a fixed frequency of a minute. no peak pressure were measured at any time distal of the tube regardless of frequency or set pressure. the pressure distal of the tube never exceeded the set pressure level in the ventilator. the time needed to reach the set inspiratory pressure distal of the tube was significant shorter during atc. (see table) conclusion. there is no danger of creating a higher pressure distal of the tube than the set inspiratory pressure at any time during the use of atc % with the draeger evita . with the use of atc the set inspiratory pressure at the distal end of the tube is reached more quickly. atc creates a faster rise time on the tracheal level, resulting in a higher mean airway pressure. key: cord- - am l ms authors: nan title: spr date: - - journal: pediatr radiol doi: . /s - - - sha: doc_id: cord_uid: am l ms nan dear colleagues, i confess i haven't read many "welcome letters" at the beginning of the spr program book over the years. perhaps the only defensible benefit of this is that there is no preconception about the content of this message…or the length. i will be brief. this meeting is about building bridges…bridges from our past to the future and bridges between all of us who believe fundamentally in maintaining or improving the health of our children. the content, which is detailed on subsequent pages, speaks for itself. this material will be presented during the sessions with an appreciative look back at past accomplishments-the legacy of our subspecialty-with a vision to the future of pediatric imaging. we can only measure how broad and deep our successes have been by connecting with these beginnings. looking beyond the titles (and the speakers), i think you will see that the material is not only about techniques and tactics but about ideas, insights, energy, all conspiring in the creative process … an aggregate for excellence in pediatric imaging. the content is also punctuated by a strong presence of our clinical colleagues. again, this builds bridges. how can we maintain and expand these relationships? moreover, the connections between science and clinical practice are evident in the structured blending of scientific papers and topical presentations by both imaging and clinical experts. this blending is also "fraternal" in that there will sometimes be disagreement and critical commentary, but this is essential in the advancement of medicine. support and criticism make a stronger mortar. in the end, this gathering is about fostering a connected community, including technologists, nurses, physicists and other allied health experts including industry experts. finally, the emblem of pediatric radiology has always been embossed by cooperation, passion, commitment, and humanistic care. i believe the program content, the presenters and you, the participants, all embrace this. i hope that you will feel the spirit and the passion of the meeting and all of us will in many ways be better able to care for children because of this-even if you never read this message! donald p. frush the gold medal of the society for pediatric radiology is our most distinguished honor. the spr medal is awarded to pediatric radiologists who have contributed greatly to the spr and our subspecialty of pediatric radiology as a scientist, teacher, personal mentor and leader. marilyn goske has always wanted to make a differenceand what a difference she has made! her role as an educator, and her lifelong commitment to improving training for residents, fellows, faculty, medical staff and radiologic technologists has resulted in many wonderful initiatives that have benefited all in pediatric radiology. the work she is most proud of-the cleveland clinic web based curriculum, working with the leadership of spr's philanthropic campaign for children, launching the image gently campaign and the pediatric research component within the american college of radiology's dose index registry share a common theme: educating others in providing the best care possible for children. born in berea, ohio, marilyn's father, george, was a chemical engineer. her mother, cornelia aka "corky", loved writing as one of the first women journalists for the associated press and later teaching, passions she passed on to her daughter. while marilyn was blessed with a strong female role model in her mother, it was her brother, james, who was her cheerleader, always pushing her to dream big. he encouraged her to follow in his footsteps first at ohio university, then on to the ohio state college of medicine to pursue an md degree during an era when nursing would have been a more conventional goal. marilyn met her husband rick on a double date in college-unfortunately, they were with different dates! luckily, they were able to get together for an actual date with each other months later. they quickly became engaged and married within a year of that first true date. when rick started his residency in internal medicine, marilyn transferred to the university of connecticut school of medicine in farmington. it was here that she met her first pediatric radiologist-and what a giant-mike ozonoff! when rick moved on to a neurology residency in rochester, new york, marilyn followed and met another pediatric radiology giant: beverly wood, at strong memorial hospital. beverly proved to be a wonderful teacher, mentor, co-researcher and lifelong friend. marilyn describes beverly as inspirational and "fearless" in trying new technologies. it was during her time in rochester that marilyn went to her first spr meeting and, not surprisingly, won the caffey award for her work on "experimental neonatal intraventricular hemorrhage: clinical, radiographic and pathologic features." by then marilyn had two young children and moved on to the private sector, practicing part-time for several years first in rochester, then in cleveland, ohio. her years in private practice were particularly helpful in learning the importance of patient oriented service-and paved the way for her intuitive public relations strategies when designing the image gently campaign in later years. dr. goske was asked to join the cleveland clinic in , as the first full-time section head of pediatric radiology. it was here that she built a new section and spearheaded the web based education program for pediatric radiology residents with co-founder janet reid. this important free web site with modules is used widely by over radiology residencies nationally and internationally. her passion for education continued, inspiring her to complete a medical education fellowship focused on professionalism within the cleveland clinic lerner college of medicine. her work towards this fellowship has led to many creative educational initiatives including yearly educational summits at the spr. she was named chair of the professionalism committee of the rsna where she along with her committee have sponsored interactive workshops on this topic dear to her heart. dr. goske's energy and effective leadership skills brought her to become involved in the society for pediatric radiology, first as the coordinator for spr's first video-taped course in . mentors diane babcock and carol rumack proposed her for the nominating committee. this was followed by chair of the membership committee, where she organized the first formal survey of the society, then as a board member, then as secretary, and finally as president and chair of the board of directors, completing years on the spr board. working together with stuart royal, she successfully energized the campaign for children raising funds for the research and education foundation of the spr and expanded the work of prior presidents in further organizing the corporate support committee. marilyn's years as president and chairman of the board of the spr were highly successful with many unique strategic goals. she was instrumental in the founding of the junior spr. she led the wonderful spr national meeting in miami which included the first educational summit to enhance knowledge in adult learning and resident competencies. most people would rest after completing their arduous year as president but as chairman of the board, marilyn was just beginning! she moved to cincinnati children's hospital, joining the radiology department and was named the dr. corning benton endowed chair for radiology education where she got to work with dr. janet strife, another influential mentor and friend. acknowledging spr's long focus on reducing radiation doses in the imaging of children but concerned about the lack of change in practice by a majority of radiologists despite increasing reports of possible side effects, marilyn developed a public relations and awareness campaign. her goal was to inspire all to work towards decreasing radiation exposure to children when possible. with the help of many, she founded the alliance for radiation safety in pediatric imaging and the image gently campaign, initially focusing on ct. her ability to encourage numerous experts and societies to work together and get involved in "child sizing the amount of radiation used" has resulted in a groundswell of research and activity in this area. currently organizations with over , members have joined the alliance including international societies. the web site, www.imagegently.org, has been immensely successful filled with free information pamphlets in over languages, pqi projects, and modules for parents, physicians, and technologists. the image gently campaign has received several awards including the associations advance america honor roll, rt image magazine group with the "most influence in radiology" and the most effective philanthropy program from aunt minnie. image gently has spawned the creation of the adult-focused image wisely campaign. the alliance has been named by the joint commission, u.s. food and drug administration, and the american medical association in their influential statements on radiation dose as providing much needed guidance and information. marilyn's exceptional talent is inspiring and coordinating experts in multiple fields to work together towards common goals. she continues to work hard on the image gently campaign with more safety and quality messages planned for the coming years. she is also proud of her work with the acr dose index registry and quality improvement registry in ct scans in children in working toward developing diagnostic reference levels with a talented consortium of pediatric radiologists, medical physicists and technologists. she has acted as a national and international expert in her work with the international atomic energy agency, the world health organization and the national council on radiation protection in medicine and the fda. dr. goske's multiple committee appointments are taken seriously, and her work is always meticulous, well thought out, and brought to successful completion. she has been an active member of numerous national and international societies including the john caffey honorary society, acr, rsna, espr, aawr, and scorch. it is important to remember that dr. goske is also a successful researcher with numerous grants obtained through the spr ref including the thorne griscom education award and the rsna scholar grant. she has published over peer-reviewed articles, electronic publications, chapters, and presented scientific exhibits as well as given numerous scientific presentations. an articulate and engaging speaker, she has been invited to give over lectures locally, nationally and internationally. while marilyn has been very focused on her work with the spr, she believes that it is her amazing family and their love that really fuels her life. her husband rick is an internationally known neurologist and researcher in multiple sclerosis. her adult children jamie and brian, both in manhattan, remain close, and spending quality time together as a family remains the joy of her life. whether it is relaxing together in florida cooking or fishing, or taking an exotic vacation to india, being with rick, jamie and brian makes her the happiest. marilyn's genius is partly refusing to take "no" as an answer. along the way, at every turn there were those who believed that what she wanted to do couldn't be done. her approach was to draft the nay-sayers to the team and charge ahead with their willing and enthusiastic help. daniel burnham might have been talking about marilyn and not about his plan for the city of chicago when he said: make no little plans; they have no magic to stir men's blood and probably themselves will not be realized. make big plans; aim high in hope and work, remembering that a noble, logical diagram once recorded will not die, but long after we are gone be a living thing, asserting itself with evergrowing insistence. as an amazing change agent, inspirational leader, and wonderful role model, the spr is proud to honor marilyn goske with the gold medal. she made big plans! dorothy i. bulas, md pioneer honorees were first acknowledged in as a means to honor certain physicians who made special contributions to the early development of our specialty. it is time to reevaluate the meaning of the pioneer honoree. the subspecialty of pediatric radiology has been in existence now for more than years. we are beyond "the early development"; we must recognize other pioneering paths and should consider contributions to the subspecialty beyond the bounds of a modality, a technique, an observation or a change in practice. whatever this advancement is, it must be forged with vision, innovative ideas, and the ability to enable and sustain science and application. george s. bisset, iii, m.d. why george bisset? has he been part of the pediatric radiology landscape these last ten years? been part of the dialogue that has been increasingly influential across all of radiology, a conversation steeped in a deep tradition of excellence in diagnosis and treatment, and the safety and welfare of our children? been a leader in science and application? part of the landscape? no. but he has been beyond that and has worked tirelessly within the horizon, surveying…a step before, but guiding us on towards our destiny. a conversant? part of the dialogue? maybe. but he has been defining thought and concept upon which such conversation is born and nurtured. part of the science and application? yes, as much as anyone who promotes, who facilitates and sustains discovery, then here we are. horizons, innovation, and the gift of en-abling…what else is needed to define a true pioneer? how was this done? simply stated, george bisset has devoted at least the last decade to the advancement of our specialty in truly novel ways through his leadership, especially in rsna and the abr. in the rsna, as the scientific program committee chair several years ago he was instrumental in the conception, development and implementation of the integration of scientific papers and refresher course topics. this has been a resounding success, is currently used in other categories during rsna and is a model for other meetings, including the annual meeting for the society for pediatric radiology over the past few years. pediatric radiology was first in this effort. george continued to endorse topics that were marquees for pediatric radiology over the year in his education role on the rsna board of directors. he endorsed and implemented the pediatric campus concept at the rsna. early returns are that this was an extremely successful model to consolidate experts in pediatric radiology (and those interested in this subspecialty), pertinent science, education and administration. george is now the president of rsna, perhaps the most widely respected scientific and educational organization for our profession across the globe…and i would argue, with more promise for our future success in pediatric radiology than has ever existed. and george bisset, who through two terms as the pediatric trustee for the board of trustees for the abr, again, was on the horizon of a critical, sometimes perilous, and complete transformation of our certification examination process, always mindful of his constituency and colleagues, his duty as a physician, and the public and patients. this required delicate diplomacy, forward thinking, professionalism, and enlistment of a cadre of experts from within our subspecialty to assure excellence in pediatric radiology through abr certification. he was also a leader in the development, validation and implementation of the imagerich computer based examination model (the pediatric caq) now the standard for the new abr examinations. with these successes in mind, who better to embody the concept of bridging horizons that is the theme for this entire meeting? if you were looking for more numbers and accolades, i apologize. here are some: more than contributions to medical and scientific literature, advancing care through pediatric body ct and mr imaging research, a litany of presentations and invited lectures, vice chairs, chairs, chiefs, boards of directors, committee member and committee leader, clinical excellence including as a pediatric cardiologist and interventional radiologist, a superb speaker and author.… all are on his cv but i believe serve really as signposts for his gifts, some of those mentioned above, that a cv simply cannot convey. he could have played it safe with all of these successes on his cv. but pioneers don't play it safe. they are on the horizon, too busy defining thought and enabling (our) advancement-building bridges. i believe it is time to reevaluate the meaning of the pioneer honoree and i have the greatest honor and pleasure of introducing george s. bisset, iii for the pioneer award for . linked with past awardees, he continues an exceptional legacy and i don't believe his explorations and discoveries are finished… donald p. frush, md the society bestows presidential recognition awards on members or other individuals whose energy and creativity have made a significant impact on the work of the society and its service to its members. in , david kushner was recognized by the spr with its first presidential recognition award for his vision and foresight in working with both the american college of radiology (acr) and the society for pediatric radiology (spr) in developing an important new relationship and for his service to the spr. in summarizing his considerable efforts for that award, i noted that he "contributed substantively to the increased visibility of the spr within the acr. his tenure as our treasurer placed our organization on a firm financial foundation." with the current award, the society recognizes his indefatigable continuing efforts on our behalf including: his work with the acr: . establishing a pediatric radiology caucus at the annual acr meeting, . convincing the acr of the value of managing specialty societies by making the spr its first successful new model for imaging society management, . advocating tirelessly for pediatrics and children's health within the acr by serving on the council steering committee and then as acr council vice speaker and speaker, . helping establish the first pediatric commission, assuring that pediatric issues will receive support of the college and its resources while serving on the board of chancellors of the acr for the past five years. the spr's "image gently" campaign was a beneficiary of this pediatric commission of the board of chancellors, . continuing to shepherd and contribute to the pediatric component of the acr practice guideline process. his work with the spr: since his earlier award, david has served as: foundation from to , including the launch of the formal fundraising effort, "the campaign for children," . spr president - , organizing and running a very successful meeting in savannah, . chair of the board of directors of the spr from to , including leading a strategic planning process that resulted in a new, more focused division of labor amongst board members and defined board responsibilities. david was born in fargo, north dakota, received a ba from the university of minnesota, and received his medical education at the university of pennsylvania. this was followed by two years of training in pediatrics at children's hospital, boston. he then did a two-year fellowship at the national institute of health in bethesda, performing research in embryology and teratology. he returned to massachusetts general hospital for training in diagnostic radiology. this was followed by a year of residency in pediatric radiology at children's hospital boston, followed by a one-year fellowship. he then became director of the pediatric radiology section at massachusetts general hospital, a position he held from to . from to , david was chief of the division of diagnostic imaging and radiology at children's national medical center in washington, dc attracting a strong faculty, training many fellows and promoting research. during that time, he served as a volunteer radiologist and pediatrician to inner city healthcare systems aiding the indigent and homeless, and developing telemedicine capabilities linking free clinics with radiology experts. in , our man inside the beltway moved a bit outside by accepting the medical directorship of radiology at the children's hospital of the king's daughters in norfolk, virginia, and professor of radiology and pediatrics at the eastern virginia medical school. he assures me that life there is good, being a bit more "laid back" with fishing and sailing just outside the door. he also finds time for italian cooking and practicing jazz on his several guitars. fortunately for all of us in the spr, david is close enough to our central office and the acr that he will be able to continue work on our behalf for many years to come. the society bestows presidential recognition awards on members or other individuals whose energy and creativity have made a significant impact on the work of the society and its service to its members. the spr presidential award is given in recognition of stuart's numerous significant and outstanding contributions to the spr over many years of service. the awardee is selected by the honors committee, a committee comprised of the three most recent past presidents of the society. dr. royal is a proud native of birmingham, alabama. he is a second generation physician who came naturally to his desire to care for children as the son of a pediatrician, arnold royal, who took care of children in the birmingham community until he was years old. dr. royal attended rice university in houston, texas followed by md and ms degrees from the university of alabama at birmingham. he subsequently moved to san francisco, where he completed a pediatric internship followed by a diagnostic radiology residency at the university of california, san francisco. dr. royal credits dr. charles gooding at ucsf for influencing his decision to pursue a career in pediatric radiology. during his internship stuart observed dr. gooding make a plain film diagnosis of tapvr, type on a severely ill and perplexing newborn, and he was immediately hooked into radiology. while at ucsf dr. royal was also appointed as a national institute of health research fellow in the department of radiology. following residency, stuart completed a fellowship in pediatric radiology at the children's hospital medical center in boston. from boston, stuart returned to his roots in birmingham, alabama in , where he was appointed as a pediatric radiologist at the university of alabama and subsequently the children's hospital in birmingham. in recognition of his outstanding leadership skills and accomplishments at the children's hospital, dr. royal was appointed as the radiologist-in-chief in , and subsequently the harry m. burns endowed chair of pediatric radiology. he also holds appointments as clinical professor of radiology and pediatrics at the university of alabama at birmingham and serves on the children's hospital board of trustees. at alabama dr. royal has earned the high esteem of his colleagues, referring physicians, and staff for his outstanding clinical acumen as a diagnostic radiologist and for his undaunting commitment to excellent care of children. colleagues describe stuart as one who fosters a strong work ethic, high commitment to teaching, and sincere compassion for children. in , stuart was the recipient of the children's advocate award by childcare resources for improving the quality of care and access to radiological services for underserved children in birmingham. stuart has been married to the love of his life, barbara royal, for the past years. stuart and barbara are the proud parents of two very accomplished children, jeremy a budding radiologist in training at the university of alabama, and rachael, who has an mba and works as a vice president for moody's in new york. stuart and barbara are also the proud grandparents of three grandchildren. in conversation, stuart is quick to pull out his iphone and share the latest pictures of family members while recounting their latest activities and milestones. throughout his professional career, dr. royal has worked tirelessly to advance the mission of the society for pediatric radiology. he is past president and chairman of the board of the spr and has served on numerous spr committees. he ran a highly successful spr meeting in new orleans in . those in attendance will recall the jubilant parade stuart led through the streets of new orleans to culminate the meeting. as president and then chair of the spr board, stuart played a critical and instrumental role in bringing the spr management contract under the umbrella of the acr. the synergy achieved by the spr-acr relationship has yielded results well beyond a simple management contract. pediatric radiology and spr now have a voice at the "radiology table." stuart has also been a strong advocate for supporting translational research to advance the care of children via imaging. to help achieve this goal, he has worked aggressively to secure increased funding for the society of pediatric radiology research and education foundation. following the launch of the ref's campaign for children in , stuart made it his personal mission to work with the leadership of the society, both past and present, to discuss major gifts to the foundation. through stuart's personal effort, the foundation received pledges for many significant leadership gifts, including from spr pioneers drs. hooshang taybi and ed singleton and from himself and barbara. the spr is highly fortunate to have benefited from stuart's numerous contributions and dedication to the care of children. the society is very proud to bestow the president's award on dr. stuart a. royal. the society extends honorary membership to individuals outside of pediatric radiology who have made outstanding contributions to the care of children. this evening, dr. harvey l. neiman, whose leadership of the american college of radiology is resoundingly praised, is the recipient of the honorary member award. for , as in when his contributions were similarly recognized, dr. neiman's selection by the society for pediatric radiology honors committee was made in appreciation for the strength of his efforts to further the spr's philosophy, goals, and programs for responsible diagnosis and treatment of the young patient as embodied in the acr and spr's "image gently" campaign. image gently has succeeded not only in raising awareness of the great diagnostic benefits we can offer to pediatric patients but also directs us to acknowledge the downside of overzealous diagnostic efforts where excessive radiation becomes a risk. importantly, the "image gently" campaign, an upbeat, positive program rather than a punitive one, a smile rather than a frown, makes pediatric and all radiologists aware that their best practice reflects balanced, educated, up-to-date utilization of state-of-the art technology with exercise of responsible leadership in protecting the pediatric patient. for adults, awareness of the need for patient protection is communicated in image wisely. dr. neiman's vision and successful achievements are evident on every page of his curriculum vitae. a consummate strategist in assembling teams to make forward-looking goals a reality, harvey now stands at the top of our specialty as the first physician executive director of the american college of radiology. at this time in big-business medicine, as we see the physician, leader of the patient care team, being diminished to one of many "providers," it is so important for our patients' well-being for us to recognize the obligations commanded by our training, clinical experience and commitment. dr. neiman's recognition of the need for physicians' leadership in improving the quality of patient services and his development of programs in all areas of the college's activities have been just short of miraculous-image wisely for adults, quality and safety including the performance guidelines and accreditations, education, government relations, economics, imaging metrix, acrin, and the new radiology leadership institute-to name only a few. all have contributed significantly to the care of our patients and the stature of our specialty. dr. neiman was born in detroit and attended mumford high school. from wayne state university, he received his b.s. in and his md in . harvey's postgraduate training was at the university of michigan, where he was a resident in radiology ( - ), chief resident ( , and a - fellow in angiography (cardiovascular radiology), receiving abr certification in and a caq in vascular and interventional radiology in february . dr. neiman often expresses his gratitude to and profound respect for his mentor and beloved chief at the university of michigan, dr. william martel. dr. neiman was chief of cardiovascular radiology at walter reed army hospital and a lecturer in cardiovascular radiology at the afip from - . in , he joined the northwestern radiology faculty, rising to professor in , and for ten years he headed up the section of angiography and sectional imaging, advancing its technology and honing the skills of northwestern's radiology residents. harvey also offered a highly sought-after fellowship in interventional radiology, us, and ct. in , dr. neiman left northwestern to assume the chair in medical imaging at the western pennsylvania in pittsburgh. i was the first woman to have completed his fellowship in us, ct, and interventional radiology at northwestern and accompanied him to pittsburgh. his tenure at west penn attests to his talent in making his visions a reality: the department became a highly respected, successful academic private practice notable in many areas including ultrasound, breast and women's imaging, and interventional radiology. harvey instituted an excellent radiology residency program in as well as fellowship programs in in the areas of excellence noted above. during the years since harvey received his md, he has been awarded honors from many national, international, and specialty societies, has been an invited lecturer over times on ultrasound, interventional radiologic, radiologic educational, management, turf issues, disruptive and new technology topics to name just a few. dr. neiman, who was a founder of the sru (society of radiologists in ultrasound), has to his credit peer-reviewed articles, scientific presentations and exhibits, a text co-authored with dr. james yao, angiography of vascular disease ( ) , and book chapters. he has received many honors including fellowship in the american college of radiology, american institute of ultrasound in medicine, society of radiologists in ultrasound and the society of cardiovascular and interventional radiology (now sir). as part of his strong commitment to the future leaders of radiology, for diagnostic radiology he has served as a member of the residency review committee of the accreditation council for graduate medical education. he has been a member of the american college of radiology and its committees and commissions for many years including the commissions on education, ultrasound, and economics. he also served as chair of the commissions on ultrasound and economics. from to , he was a member on the acr board of chancellors, serving as its chairman - . he was president of the radiology advocacy alliance from to . in , nine years ago, dr. neiman became the acr's executive director. he currently serves in this position, where his excellent business skills, knowledge of health policy and economic issues, and strong administrative background have furthered our specialty. his goal, to ensure that the acr's resources benefit all radiologists and patients across all economic strata, is evident in his actions at the college. harvey has a devoted, wonderful family that often included me and my youngest daughter on many pittsburgh occasions. his beautiful, elegant wife of many years, ellie neiman, is here tonight to celebrate with him the spr's recognition of his many achievements. dr. neiman has two accomplished, lovely daughters, jennifer, extremely successful in her marketing career, and hilary, an attorney. jennie's husband, dr. seth kligerman, one of many young radiologists whom harvey has mentored, is on the radiology staff at the university of maryland. how harvey has had time between, through, and among all of these achievements to have become mentor, colleague, and friend to me and to so many others who have been inspired by his ability to see into the future and to shape it in a positive way is remarkable. now that dr. neiman has taken all of radiology under his wing, not just its component parts, the future of our specialty, one of the best, can be assured but also recognized for its centrality to all of medicine. it is my honor and privilege to introduce to you harvey l. neiman md, facr as this year's society for pediatric radiology honorary member. the singleton-taybi award is given in honor of edward singleton and hooshang taybi, in recognition of their personal commitment to the educational goals of the spr. initiated in , the award is presented annually to a senior member of the spr whose professional lifetime dedication to the education of medical students, residents, fellows, and colleagues has brought honor to him/her and to the discipline of pediatric radiology. it comes as no surprise to those who know him that dr. daneman, "dr. d" as some of us call him, has been named the recipient of the singleton-taybi award in recognition of his many years of dedication to the education of residents, fellows, and colleagues. born in south africa in , he received his medical degree at the university of the witwatersrand, johannesburg, receiving the harwood-nash award for the most successful student in surgery. initially, dr. d thought he would become a pediatric surgeon; but after passing the part i examination offered by the royal australasian college of surgeons, he changed his mind and began his training in diagnostic radiology. he chose a radiology residency at the royal prince alfred hospital, in sydney, australia. this included a year in pediatric radiology at the royal alexandra hospital for children in sydney where his interest and love of pediatric radiology began. dr. d then had the foresight to pursue pediatric radiology fellowship training at the hospital for sick children in toronto, canada. after completing the fellowship, he was immediately offered a position as staff radiologist at "sick kids." he became director of body imaging in and radiologist-in-chief in serving in that capacity for years. his management style was simple but effective. he chose staff that were young, but smart and innovative. he nurtured them and provided them with all the tools they needed to become successful professionals, like him. but contributing to his own department was not enough for him. he also found the time and strength to contribute, teach, train, and help pediatric radiologists in the most remote portions of the globe in every continent, which resulted in recognition from prestigious organizations in places such as south america, israel, europe, taiwan and australia: he is an honorary member of the european society for pediatric radiology and the sociedad latinoamericana de radiologia pediatrica as well as other national societies. dr. d is an "institution" inside the great institution that is sick kids. his teaching is unique and praiseworthy in being enthusiastic, provocative, and fun at the same time. his lectures have been regarded as both instructive and practical by his students and trainees due to his special gift of making the most complicated things look as simple as possible. in sharing his diagnostic knowledge and know-how, he passes his own, innate teaching spirit on to his apprentices. he has earned several awards for this, including the outstanding teacher award granted by the university of toronto fellows at sick kids for the past consecutive years. dr. d receives numerous invitations to present at national and international meetings and symposia and has been invited as a visiting professor to more than a hundred institutions across the globe. he does not only teach us the ins and outs of pediatric radiology, but he makes sure that we learn to love it and understand the importance not only of good practice but also the imperative to pass knowledge on by teaching and publishing. dr. d is someone who inspires us to reach beyond our limits, someone we want to emulate. he shares his knowledge, his wisdom, and his advice freely. he shares with us the most incredible secrets of his own career, so we understand from his personal experience. dr. d never tells you what to do, he suggests to you, in an incredible articulate fashion, what you want to do yourself. dr. d has been and is for many of us, more than an educator, more than a mentor, he is our "coach." well before this concept was introduced into medicine by a. gawande , dr. d intuitively had the vision to "coach" his trainees, trying to get the best out of them, without pressure, but with love and passion, and especially emphasizing the importance of achieving a worklife balance in order to prevent the now so common "stress and burnout" affecting the radiology community . he warned us that many high achievers reach their goals only at the expense of their personal lives, but dr. d has been as successful personally as he is professionally. his wonderful wife of years, louise, his two daughters and his recently newborn granddaughter serve as sources of strength and pride. he is a truthful and generous friend to many, both in and out of radiology. it is not uncommon for many of us, who came through sick kids, to come back and visit and be invited to his house to share a wonderful dinner with other invitees, who may be radiologists from north america or from other parts of the globe visiting sick kids to learn from him. dr. daneman's research has widely influenced the field of pediatric radiology. examples include the work of dr. daneman and his colleagues on intussusception, which has promulgated the use of ultrasound for diagnosis, and the use of air enema for reduction. this approach has been adopted as standard practice at many institutions in north america and across the globe. to share his research with others in the field, dr. daneman has authored or co-authored more than publications, including peer reviewed articles and book chapters on a wide range of topics related to the imaging of children. dr. d is one of those rare people who are irreplaceable. he is a superb teacher, a gifted academician, a capable administrator, and a person called "friend" by so many of us. we are thrilled and proud to present our society's singleton-taybi award to dr alan daneman in recognition of his lifelong accomplishments and personal commitment to the educational goals of the spr. we cannot imagine anyone more deserving of this award than dr. d. thank you "coach"! monica epelman, md and oscar navarro, md john caffey, md - dr. caffey was regarded throughout the world as the father of pediatric radiology. his classic textbook, pediatric x-ray diagnosis, which was first published in , has become the recognized bible and authority in its field. the seventh edition of this book was completed several months before his death in . it has been among the most successful books of its kind in the medical field. dr. caffey was born in castle gate, utah on march , . it is interesting that he was born in the same year that roentgen discovered the x-ray. dr. caffey was graduated from university of michigan medical school in , following which he served an internship in internal medicine at barnes hospital in st. louis. he spent three years in eastern europe with the american red cross and the american relief administration, and returned to the united states for additional training in medicine and in pediatrics at the universities of michigan and columbia, respectively. while in the private practice of pediatrics in new york city at the old babies hospital of columbia university college of physicians and surgeons, he become interested in radiology and was charged with developing a department of pediatric radiology in . he frequently expressed appreciation and admiration for the late ross golden, chairman of radiology at columbia presbyterian hospital, who allowed him to develop a separate department of diagnostic radiology without undue interference, and who was always available to help and advise him. dr. caffey's keen intelligence and inquiring mind quickly established him as the leader in the fields of pediatric x-ray diagnosis, which recognition became worldwide almost instantaneously with the publication of his book in . dr. caffey received many awards in recognition of his achievements. outstanding among these were the mackenzie davidson medical of the british institute of radiology in , the distinguished service award of the columbia presbyterian medical center in , the outstanding achievement award of the university of michigan in , the howland award of the american pediatric society in , the jacobi award of the american medical association in , and the gold medal award of the american college of radiology in . he had been a member of the american journal of roentgenology. he was a counselor of the society for pediatric radiology and was an honorary member of the european society of pediatric radiology. dr. caffey's contributions to the pediatric radiologic literature were many. he was instrumental in directing attention to the fact that a prominent thymic shadow was a sign of good health and not of disease, an observation that literally spelled the end to the practice of thymic irradiation in infancy. infantile cortical hyperostosis was described by him and is called "caffey's disease." dr. caffey in first recognized the telltale radiographic changes that characterize the battered child, and his students helped disseminate his teachings about these findings. it was dr. caffey who first recognized and descried the characteristic bony changes in vitamin a poisoning. he recognized and described the findings associated with prenatal bowing of the skeleton. in , three years after his retirement from babies hospital, he joined the staff of the children's hospital of pittsburgh as associate radiologist and as visiting professor of radiology and pediatrics at the university of pittsburgh school of medicine. although dr. caffey came to children's hospital and the university of pittsburgh in an emeritus position, he worked daily and on weekends throughout the years he was there. in pittsburgh, he made four major new contributions to the medical literature. he described the entity, "idiopathic familial hyperphosphatasemia." he recognized and described the earliest radiological changes in perthes' disease. he called attention to the potentially serious effects of shaking children, and used this as a subject of his jacobi award lecture. he described, with the late dr. kenny, a hitherto unrecognized form of dwarfism that is now known as the caffey-kenny dwarf. the john caffey society, which includes as its members pediatric radiologists who have been intimately associated with dr. caffey, or who have been trained by his students, was established in . this society is now among the most prestigious in the field of radiology. his book and the society named in his honor will live on as important memorials to this great man. his greatness was obvious to all who worked with him. he was warm, kind, stimulating, argumentative, and above all, honest in his approach to medicine and to x-ray diagnoses. his dedication to the truth was expressed in his abiding interest in the limitations of x-ray signs in pediatric diagnosis and in his interest in normal variation in the growing skeleton. he was concerned with the written and spoken word and was a skilled semanticist. his book and his articles are masterpieces of language and construction. he stimulated and was stimulated and loved by all who had the privilege of working with him. radiology and pediatrics have lost a great man, but they shall ever have been enriched by his presence. interstitial lung disease, which is more common in infants than older children, is defined as a rare heterogeneous group of parenchymal lung conditions primarily due to underlying developmental or genetic disorders. affected infants typically present with clinical syndromes characterized by dyspnea, tachypnea, crackles, and hypoxemia. mainly due to a lack of evidence based information regarding underlying pathogenesis, natural history, imaging findings, and histopathologic features of interstitial lung disease, the understanding of interstitial lung disease in infants has been limited in the past. however, in recent years, the understanding of interstitial lung disease in infants has been substantially improved primarily due to: ) advances in imaging technology for better detection; ) improvement of thoracoscopic techniques for lung biopsy; ) established pathologic criteria for consistent diagnosis; and ) development of new classification system based on underlying etiology of the interstitial lung disease. in fact, several forms of interstitial lung disease in infants that exhibit distinct clinical, radiological, and pathological patterns are currently emerging. the overarching goal of this article is to review a new classification system, imaging findings, and pathological correlation of interstitial lung disease in infants. improved understanding of this often challenging disorder can aid in early and accurate diagnosis, which in turn, will result in improved patient care. large airway disease in pediatric patients: impact of advanced post-processing techniques catherine m. owens, bsc mbbs mrcp frcr the introduction of multidetector row computed tomography (mdct) scanners has altered the approach to imaging the pediatric thorax. in an environment where the rapid acquisition of ct data allows general hospitals to image children instead of referring them to specialist pediatric centers, it is vital that general radiologists have access to protocols appropriate for pediatric applications. this lecture will focus on the main principles of volumetric ct imaging that apply generically to all mdct scanners and in particular we describe the reconstruction techniques for imaging the pediatric thorax and the low-dose protocols used in our institution on a -slice dual source ct scanner. examples of important clinical applications with the impact and added value of post processing are also given. neoplasms, by definition, comprise an abnormal uncoordinated proliferation of cells that persists even after the inciting stimulus as ceased. the resulting mass may be benign or malignant and arise from any tissue that is normally found in the location where the mass develops. thus, tumors of the chest may arise from bone, lung, pleura, lymphatics, muscle, etc. whether benign or malignant, chest masses may be incidental findings on imaging obtained for other reasons. this presentation will focus on malignant tumors of the chest, address the imaging characteristics and staging of the most common chest malignancies and discuss characteristics that may aid in distinguishing these lesions from their corresponding benign or infectious counterparts. included in this presentation will be the most common chest wall malignancies (ewing family of tumors and rhabdomyosarcoma), mediastinal malignancies (lymphoma, germ cell tumors, and neurogenic malignancies) and pulmonary primary malignancies (pleuropulmonary blastoma and carcinoid). the changing appearance of selected tumors in patients treated with new targeted therapies will be introduced. lung disease is the most common chronic disease of childhood, but young children cannot perform the breathing maneuvers required for the most commonly used method for assessing lung function, spirometry. ct provides exquisite structure information about the lung but concerns regarding the long-term consequences of the relatively high radiation dose limit its use particularly in the pediatric population. magnetic resonance imaging (mri) has the potential to provide regional information about the lung without the use of ionizing radiation. while conventional proton mri has found widespread clinical application in most organs of the body, mri of the lung lags behind because the lung is intrinsically difficult to image with mri. the strength of the mr signal depends on the physical density of protons in the tissue being imaged and the local environment of the protons. the lung has a low physical density and thus a low proton density so little mr signal is generated by the lung. furthermore, the magnetic susceptibility effects from its many air-tissue interfaces cause what little signal is generated to rapidly decay so that the lung typically appears dark on conventional proton mr images. a variety of strategies have been developed to overcome the inherent difficulties of mri of the lung, resulting in recent substantial improvements in image quality. additionally by administering an inhaled gaseous contrast agent, such as the hyperpolarized noble gases helium- or xenon- , direct visualization of lung airspaces in an mr image is possible. a number of unique strategies for evaluating the structure and function of the human lung using hyperpolarized gas mri have been developed. although the level of structure detail possible with lung mri may never equal that of ct, mri may nonetheless has the potential to provide clinically useful information and be a sensitive, effort independent test of pediatric lung disease. for a matter of time, we will focus in this presentation only on the following: intestinal malrotation a normal visceral situs can be inferred sonographically in relation to the right-sidedness of the superior mesenteric vein, to the retromesenteric location of d and to the right iliac position of the ileocecal valve. conversely, intestinal malrotation is likely when the aforementioned features are reversed. in addition, cdu can display the whirlpool pattern in case of midgut volvulus or internal hernia, alleviating the need for preoperative opacification. the reliability of us in diagnosing intussusception is well documented since the early s. the value of us in predicting the success or failure of pneumatic reduction and/or bowel necrosis is more debatable, based upon a coexisting bowel occlusion, the presence of interloop fluid, bowel wall changes (intramural air, dilated mural vascular channels), absent blood flow at cdu. the continuous down-grading of us in comparison to ct, and the opposite conclusions of various series regarding imaging of pediatric appendicitis are based upon different prerequisites and definitions. historically and in most usa institutions, sonography reports are either negative (entire normal appendix), positive (abnormal inflamed appendix), or equivocal (non-visualization or partial visualization of appendix). the equivocal group is then logically investigated by a subsequent abdominal ct. in europe, some usa centers, and in our practice, us reporting include groups and take into account ancillary findings: . normal appendix (blind-ended, lamellated, compressible, < mm in diameter, without peristalsis; . appendix not depicted, no secondary signs; . appendix not depicted, with one of the following: hyperchoic mesenteric fat, fluid collection, local dilated small bowel loop; . appendix inflamed. group represents most cases of perforated appendicitis, groups and the negative sonogram. ct is then indicated only in obese patients and to assess the feasibility of percutaneous interventions. inflammatory bowel disease in the recent literature, mr enterography is often preferred to ct enterography. small bowel series look prehistoric and us is rarely mentioned. sonography however is very valuable both for screening children presenting with abdominal pain, diarrhea, weight loss, or gi bleeding and for following the course of the disease and searching for complication. hypervascularization has been proved to parallel the disease activity. initially mentioned by dr. rita teele, the interest of us for differentiating high-intermediate/low varieties of imperforated anus has been re-emphasized more recently. a perineal rectal cul de sac distance of mm is quoted as the significant cut-off value. us can also display rectourinary fistulae outlined by air. update on mdct and mri of hepatobiliary disease in children: what's new lisa h. lowe, md a variety of disorders may affect the pediatric liver. recent advances in histopathological knowledge and imaging techniques have led to important changes that radiologists must be aware of in order to allow for an accurate limited differential, and in some cases, specific, diagnosis. this presentation will focus on recent developments that have lead to a better understanding of the embryopathogenesis for fibropolycystic liver diseases (including choledochal cysts and caroli disease), histopathological findings that have led to new classification systems for of pediatric vascular anomalies, technological advances and contrast agents in magnetic resonance imaging that are useful to characterize and limit the differential diagnosis of hepatic masses. diagnostic errors in pediatric abdominal imaging: diagnostic pearls and pitfalls george a. taylor, md this presentation reviews the types of diagnostic errors in abdominal imaging occurring over a -year period in an academic pediatric radiology practice. radiologists engage in two interrelated processes when interpreting imaging studies: perception and analysis. failures in perception (failure to identify an important finding) are a common source of diagnostic error in pediatric imaging, while failures in the analytic portion of the process (over-or faulty interpretation of a finding) are not as common. under-interpretation of findings can be related to a number of perceptual and visual phenomena including visual isolation where attention is selectively focused on a main area of the image while less or no attention is given to secondary areas, and satisfaction of search which occurs when additional lesions remain undetected after detection of an initial lesion. many analytic errors are the result of commonly used heuristics or shortcuts in reasoning. these include the availability heuristic in which likelihoods are based on memory of a similar case, the framing effect in which a different diagnosis is reached based on how the information is presented, and the anchoring heuristic in which the initial impression is difficult to change, despite conflicting new information. another recognized pitfall is blind obedience, in which a diagnostician stops thinking when confronted by authority. this authority can be human or technical (reliance on a laboratory value). finally, diagnostic errors can result from an attitude of overconfidence. examples of these heuristics and strategies to minimize cognitive errors will be discussed. marta hernanz-schulman, md, faap, facr this session will consider abdominal masses that present in the neonatal period, spanning developmental, inflammatory and neoplastic conditions. time constraints do not allow an exhaustive list or description, but the more important or frequent lesions are discussed. the presentation is subdivided by systems. the renal section discusses various conditions presenting with hydronephrosis, such as ureteropelvic junction obstruction and duplication anomalies, followed by autosomal recessive polycystic kidney disease and multicystic dysplastic kidney, cystic entities commonly presenting in the perinatal period. neoplastic renal entities include lesions with benign behavior, such as ossifying renal tumor of infancy, with the discussion extending to entities with very poor prognosis such as clear cell sarcoma and rhabdoid tumor, while discussing the congenital mesoblastic nephroma, its histologic subtypes and the differences in their presentation, imaging findings and clinical behavior. suprarenal lesions include the adrenal hemorrhage, congenital neuroblastoma and subdiaphragmatic sequestration. hepatic lesions include developmental anomalies that present as mass lesions, such as choledochal cysts, vascular lesions such as congenital and infantile hemangiomas, and neoplastic lesions such as the mesenchymal hamartoma and hepatoblastoma. differences in clinical presentation, imaging characteristics and behavior of the lesions are discussed. the section on pancreatic lesions discusses pancreatic cysts and pancreaticoblastoma. gi tract and mesenteric lesions include duplication cysts, lymphangioma, and meconium pseudocyst, and their relationship to bowel obstruction and persistent perforation. ovarian cysts can present as large masses in neonatal girls, and should be high in the differential diagnosis of large masses encountered in female infants; the imaging characteristics of simple and complicated cysts are described, as well as their course and potential complications. pediatric procedures: from imaging to intervention the spectrum of vascular anomalies in pediatric patients: multimodality imaging evaluation and current treatment patricia e. burrows, md vascular anomalies are categorized into two main groups, vascular tumors and vascular malformations. genetic and molecular regulation of vascular genesis of angiogenesis, and mutations responsible for some of the vascular malformations, have been delineated. in order to implement future targeted treatment of vascular lesions, accurate diagnosis is important. imaging modalities that are effective in distinguishing the various types of vascular anomalies and demonstrating the extent include ultrasonography with doppler interrogation, mri and various forms of mr vascular flow imaging, conventional angiography and venography. techniques used to image lymphatic channel anomalies, conventional lymphangiography, lymphoscintigraphy and infrared fluorescent lymphangiography. in this presentation, common forms of vascular anomalies will be described and rare or recently recognized anomalies will be mentioned. current treatment of the different forms of vascular anomalies will also be discussed, including pharmacotherapy using beta blockers, angiogenesis inhibitors and mtor inhibitors. endovascular techniques used in treating vascular malformations, including embolization and sclerotherapy will be presented. pediatric vascular disease is extremely varied, with a wide range of conditions requiring diagnostic or therapeutic intervention. technological improvements in non-invasive imaging modalities such as mri and ct have reduced the need for diagnostic angiography; however, with advances in interventional techniques, arteriography in the pediatric patient is now often performed for therapeutic reasons. pediatric arteriography presents unique issues and challenges. tremendous variability in patient size and physical maturity limits the ability to standardize technical aspects of performing arteriography. in addition, radiation protection, sedation/anesthetic support, monitoring of fluid balance, and maintaining patient warmth must be considered. a regimented protocol for assessment of the pediatric patient must be followed, with review of the indications for the study requested, and review of patient-specific issues such as coagulation profile, concurrent medical disease, patient weight, and anesthetic concerns. appropriate patient monitoring is imperative to ensure patient safety. vascular access can be quite challenging. ultrasound and micropuncture access techniques have tremendously improved successful access while reducing associated complications. the smallest catheter that can accomplish procedure objectives should be used. for most diagnostic cases, french systems can be used for children> kilograms, while french catheters are preferred in those < kg. intraprocedural heparinization ( - iu/kg) is also more often used, especially in children weighing less than - kg. rates and volumes of contrast injected for pediatric arteriography are not standardized, as in adult patients. in general, contrast dose should be limited to - ml/kg, and - ml/kg in premature infants and neonates. all these new technique are less invasive, improve patients' outcomes and reduce morbidity. they are also cost-effective as patients are discharged home earlier and recover faster from the intervention. the future holds promising new technologies such as high-intensity focused ultrasound (non-invasive method of thermal ablation) and nanoparticles for drug delivery. pediatric interventional radiology will continue to be an essential part of these minimally invasive therapies. musculoskeletal imaging: from planning to performance kirsten ecklund, md the purpose of this talk is to review advanced mr imaging techniques currently being used in the evaluation of pediatric musculoskeletal tumors. the goals of these techniques include improved image resolution and quality, lesion tissue characterization, and increased acquisition speed. diffusionweighted (dw) and perfusion imaging will be emphasized; however, whole body, metallic artifact mitigation, and volumetric sequences will also be discussed. dw mri is based upon the brownian motion of water within extra and intra-cellular spaces which depends upon tissue cellularity. dwi can aid in the differentiation of benign from malignant lesions, which generally have restricted diffusion. there is even greater potential for dwi in the assessment of tumor response to therapy. the apparent diffusion coefficient (adc) maps are critical to accurate interpretation of diffusion sequences. adc maps distinguish between restricted diffusion and t effect, both of which appear bright on dwi. both qualitative and quantitative tissue assessments can be made with dwi. challenges for dwi in the pediatric musculoskeleton include susceptibility artifacts from bone, motion vulnerability, and geometric distortion at larger fields of view. our current protocols and parameters for dwi will be presented. contrast-enhanced (dce) mr using one of a variety of vendor specific sequences. qualitative and quantitative assessments of inflow and distribution of contrast have been shown to help differentiate between benign and malignant lesions and to evaluate drug efficacy during therapy. this technique is especially promising in those patients undergoing antivascular and antiangiogenic therapy. tal laor, md congenital abnormalities of the musculoskeletal system can result in alterations of limb size, configuration, and/or segmentation. these disorders often affect both the osteocartilaginous skeleton as well as the surrounding soft tissues and can be localized or diffuse. in this session, we will focus on the imaging features of several congenital abnormalities that result in a small or short limb, in altered configuration of a limb, or in abnormal segmentation. deformities of both upper and lower limbs will be examined. like congenital abnormalities, developmental disorders of the pediatric musculoskeletal system can be limited to a single area or can affect numerous sites within the body. for example, neonatal brachial plexopathy is a localized disorder that produces characteristic musculoskeletal alterations about the shoulder girdle and elbow of affected children. the alterations of morphology and function of the shoulder develop over time with growth of the child and change in response to a variety of therapies. we will review the features of developmental anomalies of the pediatric musculoskeletal system and evaluate the role that imaging plays in the initial evaluation and in the subsequent assessment of these children during treatment. multimodality imaging of skeletal trauma in children: using all of the tools peter j. strouse, md skeletal trauma is a common indication for imaging throughout the pediatric age range. newborns may suffer birth trauma. infants and toddlers may be subject to abusive injury. children of all ages may suffer accidental injury. older children and adolescents are increasing hurt in sporting activity and vehicular accidents. fracture patterns vary with maturation of the child. interference with normal growth is a potential complication. imaging of skeletal trauma begins with radiography. proper anatomic and age specific radiographic technique assures optimal diagnostic yield. radiography suffices in most cases to diagnose fracture or confirm normalcy. "clinical correlation" aids in diagnosis. ultrasound, ct, mri and nuclear medicine may play a role in specific instances where plain radiographs are non-diagnostic or to better delineate certain fractures. arthrography and conventional tomography have occasionally been used in the past and tomosynthesis may prove useful. follow-up radiographs may be useful for diagnosis or confirmation of some fractures. this presentation will focus on the imaging of acute skeletal injury. technique and approach for plain radiography will be emphasized. specific indications and roles for ancillary imaging techniques will be defined and illustrated with representative cases. although classically thought of as a disease of adulthood, stroke is much more common in the pediatric population than was once appreciated. this may be due to many factors, not the least of which is increased awareness due to the presence of subspecialty stroke teams now fairly commonplace in many children's hospitals, and the fairly recent advent of more advanced imaging technique such as diffusion-weighted imaging (dwi) and its routine use in imaging the central nervous system (cns) in the child and adolescent. causes of stroke in children can be protean, and range from idiopathic on one end of the spectrum, to traumatic on the other, with many causes in between, many of which may not be intuitive to the clinician without further research. moyamoya disease and its many causes, such as sickle cell disease (scd), trisomy and neurofibromatosis type i (nf i) can all lead to stroke in children, as can congenital clotting deficiencies such as factor v leiden deficiency and congenital cardiac lesions with their resultant shunting of blood between the left and right cardiac circulations. although usually arterial in nature, strokes may arise from the venous system in clinical scenario of venous thrombosis with resultant venous infarctions. factors contributing to venous thrombosis in children and adolescents can be due to dehydration (especially in the very young), severe iron deficiency anemia, inflammatory bowel disease and exogenous hormone ingestion such as is seen with oral contraceptives (ocp) in young women. advanced imaging techniques for neuroimaging in pediatric patients: where are we now? blaise v. jones, md the past decade has seen a large number of advanced imaging techniques introduced to the clinical armamentarium of the pediatric radiologist. from the development of multidetector ct scanners that can obtain whole head diagnostic studies in less than s to the routine use of t mr imaging, technical advances have dramatically changed our ability to diagnose and manage neurological disorders in children. however, all of these advances are not of equal clinical utility, and it is imperative that the pediatric radiologist be well versed in their judicious and appropriate application. this presentation will discuss the effective use of volume ct scanning, cta, swi, asl, fmr, pmr, and other advanced imaging techniques in the diagnosis of neurological disorders presenting in childhood. at the conclusion of the presentation the attendee will have a better understanding of how to ideally apply these technologies in practice. a spectrum of abnormality in pediatric neck: practical imaging choices and interpretation caroline d. robson, mbchb learning objectives: . become familiar with an optimized imaging approach for head and neck infections . recognize the complications of head and neck infections . recognize the utility and interpretation of imaging for neck masses this talk will cover the imaging approach and interpretation of findings in head and neck infection and neck masses. infection includes acute complicated sinusitis, coalescent mastoiditis, neck infection and local and intracranial complications. optimized imaging protocols and image interpretation for neck masses will also be discussed and illustrated. acute complicated sinusitis is diagnosed when acute sinusitis is accompanied by orbital symptoms (e.g. proptosis) and/or mental status changes, seizures or other neurological findings. coalescent mastoiditis is diagnosed when otomastoiditis is accompanied by tenderness and/or swelling over the mastoid process. ct and mr provide complementary information. ct is obtained with contrast. mr sequences include fatsuppressed t , t , diffusion, and fat-suppressed contrastenhanced t weighted images with mr venography. intracranial complications include epidural abscess, subdural empyema, meningitis, cerebritis, brain abscess, venous thrombosis and venous infarction. the limitations and usefulness of ct in the diagnosis of neck abscess will be illustrated. the imaging approach to masses depends on patient age, and the size and location of the mass. us, ct, mr, and nuclear medicine studies provide complementary information. as for infection, optimized imaging approaches and key imaging features for various masses will be discussed. embryology and diagnostic approach in spinal dysraphism l. santiago medina, md, mph and esperanza pacheco-jacome, md congenital anomalies of the spine are malformations that can be confusing due to the complexity of their embryology, and to the sometimes unclear classifications and terminology. the purpose of this review is to give a clear and basic understanding of the different stages of the embryological development of the spinal cord, starting with the bilaminar disc in the first week of gestation. during the second week, the formation of a trilaminar disc (gastrulation), the notochord, and the formation of the neural tube or neurulation. also, a review of the development of the distal cord: conus medullaris, filum terminale, ventriculus terminalis, by a different mechanism, canalization and retrogressive differentiation. beside the embryological review, a case correlation will be presented using mr imaging to demonstrate these malformations. open spina bifida entities include meningocele and myelomeningicele. closed or occult spinal dysraphism (osd) is characterized by a spinal anomaly covered with skin and hence with no exposed neural tissue. osd spectrum includes dorsal dermal sinus, thickened filum terminale, diastematomyelia, caudal regression syndrome, intradural lipoma, lipomyelocele, lipomyelomeningocele, anterior spinal meningocele and other forms of myelodysplasia. several studies have shown that mri and ultrasound have better overall diagnostic performances (i.e., sensitivity and specificity) than plain radiographs for detection of occult spinal dysraphism. for h n , most patients had mild illness but a small percentage required mechanical ventilation and icu admission. the high risk groups include children < years old and those with chronic medical conditions in particular neurodevelopmental impairment. pediatric mortality was . % of all deaths associated with the pandemic reported in the u.s. in both conditions, the most prominent radiographic and ct features were airspace disease including ground glass opacities (ggo) and consolidation, commonly with multi-focal and bilateral involvement. pleural effusion, adenopathy and cavities were absent. in some patients with viral infection, respiratory symptoms may be mild but are complicated by neurological manifestations. a brief review of mri features in h n related encephalopathy including acute necrotizing encephalopathy (ane) will be given. bernard f. laya, do tuberculosis (tb) is a worldwide major public health problem with one-third of the world's population being infected. it is a leading cause of death and disability from infection worldwide. children are amongst the most vulnerable group because of their immature immune status. a child usually gets tb infection after being exposed to a sputum-positive adult. depending on many factors, the infection can lead to latency or tb disease. it can affect virtually any organ in the body and can be devastating if left untreated. tb in children remains a diagnostic challenge. in addition to history of tb exposure, signs and symptoms, laboratory and microbiologic tests, medical imaging remains a valuable tool in its diagnosis. although findings are nonspecific, the radiograph is the most commonly ordered initial imaging tool for screening and diagnosis of pulmonary and musculoskeletal involvement. computed tomography and magnetic resonance imaging offer more detailed assessment especially in cranial and abdominal involvement. medical imaging is also utilized to follow up patients during or after anti-tb treatment. knowledge of the common imaging patterns, pitfalls and dilemma are very important in establishing the diagnosis of tb in children. the pathophysiology of pediatric tb will be discussed as it correlates with imaging findings. the wide spectrum of imaging manifestations in various modalities will be presented. imaging updates along with pitfalls and dilemma in the interpretation will also be discussed. tb can affect almost every organ system but the author will present cases that are more commonly encountered. and concurrent ct/ pet-ct (k . ) panels. there were more indeterminate nodule predictions by pet-ct (n of ; %) and concurrent ct/pet-ct (n ; %) than by ct alone (n ; %). the overall accuracy of ct alone was %, pet-ct alone % and concurrent review %. worst case sensitivity and specificity were % and % for ct alone, % and % for pet-ct alone, and % and % for concurrent ct/pet-ct. conclusions: pet-ct assessment of pulmonary nodules in children is feasible but limited by non-diagnostic quality ct images and atelectasis caused by sedation. subjective assessment of nodules by pet-ct does not appear to improve the ability to distinguish benign from malignant histology in children with solid malignancies. semi-quantitative nodule assessment using the standardized uptake value may improve the performance of pet-ct in this setting and will be investigated in the future. purpose or case report: nec is the most common lifethreatening medical/surgical emergency of the gastrointestinal (gi) system in neonates, with an incidence up to % in infants weighing < g. with advances in treatment of nec, increased survival rates result in rise in post-nec gi complications such as feeding intolerance. development of post-nec bowel strictures results from healing of involved bowel and can result in bowel obstruction. it has been routine to study the bowel of infants after medical treatment for nec by contrast enema and small bowel follow-through prior to initiating feeding. however, in order to "image gently" we are attempting to decrease the radiation exposure to these patients. we postulate that in patients with no abnormal bowel dilation prior to initiation of feeds, the incidence of colonic stricture would be so low that routine enemas would be unnecessary and could be eliminated from the workup. recorded as present or absent in anatomic abdominal regions defined as: and -from the dome of the diaphragm to top of l to the right and left of midline, respectively; and -from top of l to the iliac crest to the right and left of midline, respectively; -from the iliac crest to the top of the sacrosciatic notch; -below the top of the sacrosciatic notch. we assessed the frequency of findings in each region and how often findings in regions and were associated with findings in regions - . % confidence intervals were calculated. results: the fewest pertinent findings were present in region in . % ( / ) ( % ci: . - . %) of radiographs. findings included: abnormal bowel % (n ), bowel gas paucity . % (n ), pneumatosis . % (n ), inguinal hernia . % (n ) and osseous abnormalities . % (n ). pertinent findings were present in region in . % ( / ) ( % ci: . - . %). findings included: abnormal bowel . % (n ), bowel gas paucity gas . % (n ), pneumatosis . % (n ), free air . % (n ), and abnormal bowel with pneumatosis . % (n ). among patients with an abnormality in region , ( . %) also had an abnormality within at least one of regions through . among the patients with an abnormality in region or , ( . %) also had an abnormality within at least one of regions through . catheter/tube tips were located in region in . % (n ) and region in . % (n ) of radiographs, respectively. pneumatosis was present most frequently in regions ( . %), ( . %), and ( . %). free air was present most frequently in regions ( . %), regions and ( . % each). conclusions: our preliminary data suggest that pertinent findings on neonatal portable abdominal radiographs are rarely isolated to the pelvis, implying that gonadal shielding of regions and should not compromise diagnostic accuracy. purpose or case report: the purpose of this study was to determine the sensitivity, specificity, and positive and negative predictive value of ultrasound in diagnosing appendicitis when the appendix is visualized, using three diagnostic categories: positive, negative, and equivocal. the -category diagnostic accuracies for appendiceal diameter and radiologist impression were compared. methods & materials: a retrospective study was performed evaluating all right lower quadrant ultrasound reports dictated over a -month period. included studies were interpreted as positive, negative, or equivocal for appendicitis. report impressions that did not specify one of these categories and studies where the appendix was not seen were excluded. the pathologic diagnosis of appendicitis was considered the gold standard for a positive diagnosis. because virtually all pediatric surgical cases in the region are referred to our hospital, it was assumed that the patient did not have appendicitis if surgery was not performed. logistic modeling using appendiceal diameter as the independent variable established cutoff diameters of ≤ mm negative, > mm positive, and <x≤ mm equivocal. sensitivity, specificity, and positive and negative predictive values were calculated for both methods. results: of the patients imaged during the study period, ( %) met the inclusion criteria; ( %) reports did not categorize the impression and in ( %) studies the appendix was not seen. surgery was performed on ( %) subjects, of which ( %) had a pathologic diagnosis of acute appendicitis. using the radiologist impression, there were true positives (tp), false positives (fp), false negatives (fn), and true negatives (tn), for a sensitivity of % ( % ci - %), specificity of % (ci - %), ppv of % (ci - %), and npv of % (ci - %). there were ( %) cases reported as equivocal; of these, ( %) had a pathologic diagnosis of appendicitis. using appendiceal diameter, there were tp, fp, fn, and tn, for a sensitivity of % (ci - %), specificity of % (ci - %), ppv of % (ci - %), and npv of % (ci - %). there were ( %) cases categorized as equivocal; of these, ( %) had a pathologic diagnosis of appendicitis. conclusions: the use of diagnostic categories enables high ppv and npv with a relatively low number of equivocal cases. using appendiceal diameter alone results in higher ppv than that of the radiologist impression, but also yields a higher number of equivocal cases. purpose or case report: intussusception is an obstructive condition that a segment of the bowel invaginates into adjacent bowel and is an urgency that needs to be reduced as soon as possible to prevent bowel ischemia or necrosis. when it occurs in the infants and young child, it usually develops idiopathically and reduced by the technique such as air enema under the fluoroscopic guidance or saline enema under the ultrasound guidance. the success rate of the non-surgical reduction has reported over %. the pneumatic reduction is to introduce air into the patients' rectum via a ballooned foley catheter by hand pump. a mercury manometer connecting with the foley catheter calibrates the pressure of insufflation, and the recommended maximum pressure is mmhg. the hydrostatic reduction is to drip saline from a bag at the height of ft that may be different according to the institute's guidelines. until recently, in both techniques, the precise measurement of the intraluminal pressure was not possible. with the purpose of intraluminal pressure monitoring, we introduced a specific digital pressure gauge that can measure both pneumatic and hydrostatic pressure in various units and can give the collected data to our workstation. with the data, we purpose to make the curve of intraluminal pressure during the procedure and to compare the pattern and difference in both techniques of reduction, which permits suggesting the better technique for reducing the intussusception. from february , we performed the intraluminal pressure monitoring in children; cases of pneumatic reduction and cases hydrostatic reduction. the results indicated that the curves were similar in both techniques. however, the hydrostatic reduction tended to need longer time and higher pressure difference than the pneumatic reduction. we assumed that a higher flow rate and more fluctuating introduction of pressure in the pneumatic reduction made the difference between both methods. purpose or case report: anecdotal evidence suggests that some pediatric brain tumors, particularly pilocytic astrocytomas, demonstrate greater enhancement on delayed post-contrast t weighted mr imaging compared to early post-contrast imaging. our goal was to compare immediate post-contrast imaging with delayed post-contrast imaging in pediatric brain tumors. methods & materials: the research protocol was granted exempt status by the institutional review board (comirb# - ). between november and march , all patients for whom an mri of the brain was ordered to follow-up known brain tumor or to evaluate new brain tumor underwent a modified protocol that included both immediate and min delay post-gadolinium images. the modified protocol sequence order was dwi, t mprage, contrast injection, immediate post-contrast t mprage, t , flair, min delayed post-contrast t mprage. this sequence allowed both immediate and delayed post-contrast imaging to be performed without scanner downtime. a total of unique patients met inclusion criteria of an enhancing primary brain tumor with the delayed imaging performed within a window of - min. these studies were evaluated independently by pediatric neuroradiologists (ns and lf) and a radiology resident (jm) to compare the degree of lesion conspicuity and edge discrimination, and to determine an overall preference. in cases of discrepancy between reviewers, final grading was determined by group consensus. results: delayed post-contrast images were preferred in / tumors ( %), immediate post-contrast images were not preferred in any case, and / cases were graded as equivalent ( %). notably, delayed imaging was preferred for / pilocytic astrocytomas ( %). in / cases ( %), the improvement in conspicuity and edge discrimination on delayed imaging was felt to have a potential impact on clinical management, e.g. by extending resectable or treatable tumor margin. conclusions: delayed post-contrast imaging can be performed easily by reordering existing mri protocols, and no scanner downtime is required for this protocol change. our results indicate that pediatric brain tumors (particularly pilocytic astrocytomas) often enhance more conspicuously on delayed imaging, that no diagnostic confidence is lost on delayed imaging, and that clinical management may be more accurately guided. -directions) were retrospectively reviewed, after irb approval. both sporadic (n ) and nf- associated optic gliomas (n ) were included. tumors confined to intraconal optic nerve were excluded due to technical limitation of epi dwi within the bony orbit. apparent diffusion coefficient (adc) of the solid portions of the tumor was measured using the region of interest method both at baseline and on follow-up mri. results: for the patients, required treatment (surgery and/or chemotherapy) for symptomatic tumor progression ( sporadic opg and cases of nf- ). median follow-up interval was . years (range: months to . years, sd . years). there was no difference in adc values between sporadic and nf- associated opg. opg that required therapy had significantly higher baseline mean adc ( x - mm /s, sd . ), whereas opg with low mean adc ( x - mm /s, sd . ) remained clinically asymptomatic or stable (stratified mann-whitney test, p . ). an increase in mean adc of x - mm /s doubled the odds the patient will require treatment (or . , % ci: . - . , p< . ). enhancement patterns did not predict tumor behavior or nf- status (fisher's exact test, p . ). conclusions: significantly higher mean adc was seen in opg that required therapy for tumor progression. mri may be a useful prognostic tool in further defining a subset clinically significant sporadic or nf- associated opg. purpose or case report: fast brain mri imaging has recently been introduced for assessing brain ventricles in patients with ventriculo-peritoneal shunts (vps). however, there is minimal literature on how this method could be beneficial for other indications. compared to ct, this method reduces lifetime cumulative radiation dose and has multiplanar capabilities. it is much faster than full brain mri, reducing exam costs and potentially reducing the need for sedation. however, fast brain mri has lower resolution than a standard brain mri and cannot detect hemorrhage. the goal of our study is to retrospectively assess additional clinical applications for fast brain mri. methods & materials: patients who had undergone fast brain mri were found in xenobase, a database which references deidentified electronic medical records at our institution. xenobase was then used to identify subgroups by diagnosis. one of the most common diagnoses was arachnoid cyst. after irb approval, patients with fast brain mri and arachnoid cyst were identified so that their fast brain mri could be compared to any full brain mri and to clinical outcomes. fast brain mri findings were excluded if there was not a full brain mri within year. agreement with full brain mri, and documented effect on clinical management were coded for statistical review. results: between and , there were arachnoid cyst patients with fast brain mri exams. in members of this group, fast brain mri was used alone or in comparison with a full brain mri in the decision to follow or discharge the patient. exams failed to report a pituitary cyst and mass effect which were reported on prior exams. patients had no complications in the year following their fast brain mri. the most common complication was headache ( cases). conclusions: fast brain mri reduces radiation exposure, time, cost, and the need for sedation in vps patients. these benefits may cautiously be extended to other patient groups also requiring routine imaging, such as those with arachnoid cysts. disclosure: the authors disclose that they will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: susceptibility-weighted imaging (swi) is a new technique that exploits susceptibility differences in different tissues, to provide a different type of tissue contrast. swi is a gradient echo sequence utilizing both phase and magnitude data to achieve exquisite sensitivity to tissue magnetic susceptibility effects. it is extremely sensitive to even minute amounts of paramagnetic substances and therefore for detection of blood products (hemosiderin, ferritin), deoxygenated blood, calcium, iron, and small vein depiction. it is particularly suited for vascular imaging, especially in cerebral ischemia. swi has been shown to be more sensitive in detecting cerebral microbleeds than is conventional t *-weighted gradient-recalled echo imaging (gre) partly because of its inherent sensitivity, increased spatial resolution and the thinner slices acquired. recent studies have shown that swi detected more microbleeds in more patients, irrespective of their location and that swi may be more sensitive in detecting traumatic lesions than ct or mri. methods & materials: between january and october we have performed swi on pediatric patients (from day to yrs old) affected with different pathologies. mri was performed using either a -or . -t magnet (achieva ; philips healthcare, best, the netherlands). among these patients also received a classic gre sequence. results: our experience confirms a greater sensibility of swi than gre in detecting microbleedings and larger bleedings. swi is much more helpful in patients younger than year since it can distinguish hemorrhagic and non hemorrhagic punctuate white matter lesions detected as hyperintensities on t -w images. it is more accurate in distinguishing petechial hemorrhages and ischemic foci in patients with germinal matrix hemorrhages. swi can provide important diagnostic information not only in vascular pathologies but also in tumors showing the altered tumor microvascularity, the degree of intratumoral necrosis and the presence of subtle defects of the bbb within the surrounding parenchymal tissue. the technique also allows the detection of possible bleedings in infectious lesions. conclusions: swi is a valuable technique in the evaluation of a wide variety of intracranial pathologies in the pediatric population and its use is advisable on a routine basis. purpose or case report: a common problem with pediatric mr imaging is motion. diffusion-weighted imaging (dwi) is highly sensitive to the effects of both rigid-body motion and brain pulsation. the resulting motion artifacts can manifest in several ways, and include blurring (motion between volumes), slice 'drop-outs' (motion during the diffusion encoding), and aliasing (motion during the parallel imaging/ghost calibration scan). in order to improve image quality in pediatric dwi and avoid the potential for repeat scans, we have implemented our grappa-accelerated diffusion tensor (dt)-epi sequence on over , pediatric patients at our institution, and have developed tailored reconstruction software to correct for large motion and reduce the need for general anesthesia (ga). methods & materials: grappa-accelerated epi dti data was collected on patients at . t and , patients at t between the ages of month and years old. with these data, we investigate the use of a method to select the best grappa and ghost calibration weights; d rigid-body realignment with importance weighting; a new volume rejection criterion for large motion; together with other procedures to lower image noise and reduce phase artifacts. all image reconstruction was performed using compiled threaded matlab code on the vendor's (ge) multiprocessor reconstruction hardware. results: using the maximum motion detected from the d realignment procedure on the , dti exams, % of patients did not move (either through co-operation or ga, denoted here by < mm of motion); % of patients moved between - mm; % between - mm; % between - mm; and % between - mm. except for patients in total, the motion correction steps employed here were extremely robust in correcting for motion. in addition, the motion correction steps employed here do not blur or negatively affect the data on non-moving patients. conclusions: our proposed integrated reconstruction scheme suggests that correcting for different types of motion at different stages of the dti acquisition is critical to provide scans of diagnostic quality. apart from the very rare instance ( . %) where the patient moved continuously an extensively throughout the scan, our motion correction procedures employed here are extremely robust. using this scheme, we show that highly diagnostic motion-corrected dti data can routinely be read on our patient database within min. . participating sites followed mutually agreed upon vendor-specific dti protocols used for neonates in clinical practice: ss-epi; b ;~ mm voxel; - directions; te~ msec; acquisition; parallel imaging; multi-channel ( - ) head coil. tensor data was analyzed at one site using internally developed software in idl. b and eddy current distortion were assessed by analyzing grid line distortion on acr slice ; deviations from linearity were measured in the phase encoding direction. acr slice was used to assess snr of the center and periphery of the b image, and fractional anisotropy (fa) of the phantom, which should approach . deviations from specified sequence parameters were recorded. results: both siemens scanners had some image degradation due to vibration susequently corrected by the vendor. nonlinear gridline distortion was highest on the ge followed by philips but was corrected with the use of nd order shimming. eddy current distortion was consistently smaller than acquisition voxel size after image registration. te varied from - msec; acquisition bandwidth range was - hz/pixel. the mm slice thickness was problematic on clinical ge scanners resulting in non-isotropic voxels. across vendors, snr was consistently higher in the image periphery than center by a factor of . - . ). the greatest difference was showed in patients with fhc. no association was found between the value of ldl-c and imt. the . % received drug treatment at the time of evaluation. in dbt- a no association was found between the imt and the levels of hba c and lipids. and in the ob group found no association between imt and bmi z score. fhc %, % of dbt- and % of ob showed atherosclerotic plaques and intima irregularities. conclusions: the imt ultrasonography was able to demonstrate that patients with chronic diseases, with increased cardiovascular risk in adulthood, showed early alterations of carotid intima media in children. this allows clinical applications of preventive and therapeutic guidance. a benchmark for precision of flow assessment was determined from differences between aortic and pulmonary arterial flows, which should agree. the precision of flow when utilizing a slow flow structure (vein) and a fast flow structure (artery) was then determined, serving as an indicator of the precision of slow flow measurements. this was done in pairs for the upper body (svc flow vs difference between ascending and descending aortic flow), lower body (ivc flow vs descending aortic flow) & total body (svc flow+ivc flow vs ascending aortic flow). paired t-tests were used to identify significant differences in the respective arterial and venous flow rates. with an f-test, the relative precision of the arterial flow (determined from aortic and pulmonary arterial flow) was compared against the precision of agreement between upper, lower, and total body flows, each of which has a slow flow venous component, thus assessing precision of venous flow measurement. results: arterial & venous flow measurements were strongly correlated for the upper body (r . ), lower body (r . ) and total body flow (r . ); net aortic and net pulmonary trunk flow rates were also tightly correlated (r . ). moreover, there was no significant difference in the precision of arterial & venous flow measurements (t-test, p . ). lower venc ( cm/s or lower) improves the accuracy and precision associated with low velocity venous flow, a finding that tended to but it did not reach statistical significance. conclusions: with -d pc mri, the accuracy and precision of venous flow quantification are comparable to arterial flow quantification, though venc settings may improve venous flow assessment. disclosure: dr. tariq has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the spatial resolution requirements for imaging tiny target vessels in neonates have so far precluded its use of cemra in this patient population. the purpose of our study, therefore, was to explore the potential of high resolution cemra at . t in neonates with suspected congenital vascular anomalies methods & materials: neonates (mean age . days, range - days; mean weight . kg, range . kg- . kg) underwent cemra at . t. cemra was performed under controlled apnea on a -channel . t system using either a -channel head-neck coil ( pts) or a -channel adult knee coil ( pts). gd contrast delivery was calculated based on a total dose of . mmol /kg. parallel imaging factors of - were used, generating . x . x . mm voxels in an acquisition time of - s. images were scored for quality and the presence of artifacts independently by two observers. the cemra series were evaluated to identify pulmonary arterial and venous anatomy. extra-pulmonary vascular anatomy was divided into sections for image quality assessment on mpr. results: the mra data sets had high mean image quality and low mean artifact grading scores. no significant difference was evident between the two observers for scoring image quality and artifact (p . ), and there was good interobserver agreement (k . , % ci: . - . ). the pulmonary arteries were confidently visualized to at least the nd order branches in all patients, at least the rd order branches in ( %). out of evaluated segments, ( %) were graded as the vessel "very well visualized with excellent definition of vessel" pa abnormalities were diagnosed in patients and pv anomalies in patients. correlation was made with open surgical findings in cases, confirming the cemra diagnoses with no discrepancy between the operative and imaging conclusions. the results of our study suggest that high resolution cemra at . t is extremely promising in neonatal cchd and, in combination with echocardiography, may often provide comprehensive information for treatment planning. with appropriate use of physiological motion compensation, parallel imaging and coil configuration, voxel volumes less than . mm are routinely achievable. purpose or case report: it is not well understood whether transfusion-dependent children (mainly those who have hereditary anemias subject to excessive iron levels from regular blood transfusions) with no or mild cardiac iron overload and without signs of heart failure exhibit early changes in cardiac dysfunction. this study aims to evaluate intramyocardial deformation and subsequent cardiac dysfunction in such patients using the cardiovascular magnetic resonance technique of myocardial tagging as well as assess iron overload by another cardiovascular magnetic resonance technique of t star (t *). we hypothesize that transfusion dependent children undergoing chelation therapy will be at high-risk for cardiomyopathy despite normal or slightly elevated iron levels and no signs of heart failure due to progressive myocardial deformation as assessed by myocardial tagging; that is, we expect abnormal mechanical parameters to exist despite t * values which correspond to normal or slightly elevated myocardial iron levels. methods & materials: patients (mean age yrs) requiring regular blood transfusions for various reasons (e.g. thalassemia, sickle cell disease, other anemias) were investigated using harmonic phase magnetic resonance tagging and t * imaging. various myocardial mechanical parameters were quantified and correlated to cardiac iron levels as measured by t *. results: children with no overt signs of heart failure (as measured by ejection fraction and volume indices) exhibited normal t * iron levels in combination with global circumferential abnormal myocardial strain and children exhibited regional strain. conclusions: this preliminary data suggests that transfusiondependent children without overt signs of heart failure exhibit early signs of cardiac dysfunction (an effect of strain as assessed by myocardial tagging) in direct relation to normal or slightly elevated myocardial iron levels (as measured by t *). a larger sample size of children could support the idea of abnormal myocardial mechanics being a diagnostic imaging marker for the development of myocardial iron overload and eventual iron-mediated cardiomyopathy. the choice of coil and field of view varied according to the age and size of the patient. imaging was performed on a . t magnet (philips mri system). after the cine gradient echo time of flight sequences were acquired, the dynamic keyhole mr angiographic sequence was applied in the coronal orientation. this sequence commenced - s after initiation of the first bolus administration of - ml of undiluted gadopentetate dimeglumine ( . mmol/ml, magnevist) at a rate of - ml/sec followed by - ml of saline at a rate of ml/sec. image acquisition was repeated multiple times without delay for s during shallow breathing. contrast material was administered through a peripheral or central venous line, and sometimes via simultaneous bilateral extremity injections. rarely manual hand injection was performed. the parameters were as follows: centra k-space filling, acquired voxel size - . x - . x - , reconstructed voxel size . - x . - x - . , number of dynamics - , keyhole percentage - %, sense (parallel imaging) factor x - x , dynamic times - . s, and injection rate - cc/second. image analysis was based on original contrast-enhanced data sets, mip and volume rendering. the quality of the mrv was graded by a subjective scale from - ( excellent, no limitations; nondiagnostic). comparison with unenhanced mr venographic sequences and doppler ultrasound were available in all cases. results: d mrv provided diagnostic information on patency of venous segments in all cases, including the presence of venous occlusion or stenosis, the segments involved, and collateral venous pathways. conclusions: d mr venography using the method outlined is a reliable means of estimating central venous thrombosis in children, using short dynamic scan times with high spatial and temporal resolution, creating an effect similar to conventional venography. paper #: pa- analysis of optimal phase interval for prospective ekg-triggered cardiac ct in children prakash masand, md, texas children's hospital, savivek bogale, lorna browne, rajesh krishnamurthy purpose or case report: evaluate high temporal resolution cine mri of the heart in children to determine relationship of heart rate to the optimal motion free interval during the cardiac cycle, and to derive a chart depicting optimal reconstruction intervals across a range of heart rates which could be applied for prospective ekg triggered ct imaging of the heart. methods & materials: pediatric patients who had high temporal resolution cine steady state free precession sequence ( frames acquired across a single cardiac cycle) performed as part of a mri/mra of the heart from - were included. a single reader analyzed the high temporal resolution cine data to determine the location and duration of the motion-free phase interval in systole and diastole for heart rates ranging from - bpm. the following information was collected: age, heart rate, duration of systole and diastole, ekg phase and phase percentage of motion-free interval, and duration of motion-free interval. heart rates were grouped in ranges of ( - , - , - etc.), with at least patients in each group. wilcoxon sum rank test was performed to compare the static durations of systolic and diastolic phases for each heart rate group. two-tailed p-values< . were considered to indicate statistical significance. a chart matching heart rate range to the optimal phase of image acquisition and reconstruction was created. results: optimal reconstruction intervals for motion-free imaging of the heart in systole and diastole, and single best phase for a given heart rate are as follows: (please see table ) mean duration of the motionless phase in systole and diastole for a given heart rate is as follows: (please see table ) conclusions: this is the first time that variability in location of the motion-free interval within the cardiac cycle with respect to heart rate in children has been studied in rigorous fashion. this chart will have immediate application in the so-called 'target scan', which uses prospective ekg triggered acquisition of data in combination with half-scan reconstruction to minimize radiation dose with respect to retrospective ekg gated imaging. results: a total of patients were found to have aberrant pda by ccta. nine patients had a pda emanating from the brachiocephalic artery to the pulmonary arteries and one patient had pda emanating from the carotid or the subclavian artery according to the operative report. all ten patients had echocardiography in addition to ccta. nine of the ten patients underwent surgery. one patient was lost to follow up. comparison between ccta and echocardiography to operative report showed the following: out of the echocardiograms agreed completely with ccta and operative report. out of the echocardiograms did not report aberrant pdas which were seen on ccta and confirmed during surgery. in one patient, the echocardiogram reported a double aortic arch which was found to be an aberrant pda from the left brachiocephalic artery; a finding that changed the surgical management and pre-surgical planning. the results were statistically significant with a p value of < . . conclusions: diagnostic accuracy of ductus arteriosus anatomy is important in pre-surgical planning and management of patients with ductal dependent pulmonary circulation. cardiac ct angiography is more accurate as compared to echocardiography in diagnosis of aberrant patent ductus arteriosus. ) in patients younger than year of age. the prospective ecg-gated protocol scanned % of the cardiac cycle with msec padding in patients with heart rates greater than bpm. two experienced radiologists evaluated the image quality and course of the coronary arteries. image quality was assessed based on the degree of homogeneity of vascular enhancement, presence of stair-step artifacts, image signal and noise as well as the overall subjective image quality based on a point scale. the course of the left and right coronary arteries was also evaluated based on a point scale, focusing on how well the evaluator was able to visually follow the coronary artery from its origin to its termination. radiation dose was recorded and compared. results: the mean score of the homogeneity of vascular enhancement, stair step artifacts, image noise and signal, overall image quality, and score given to visualization of the course of the coronary arteries showed no significant difference (p> . ) in the retrospective and prospective ecg gated groups. the mean estimated effective dose was significantly lower for the prospective ecg gated group compared to the retrospective group, ( . msv vs . msv) respectively (p< . ). conclusions: prospective ecg-gated cardiac mdct provides comparable assessment of coronary anatomy, image quality with significantly less radiation dose when compared to the retrospective ecg-gated mdct. prospective ecg gated cardiac mdct is a powerful adjunct to the treatment and surgical planning of pediatric patients with congenital heart disease less than yr of age with lower radiation dose. methods & materials: pediatric neuroradiology lectures were recorded and made available to radiology residents at a university program through on-line streaming video viewed through an internet link. topics included brain tumors, phakomatosis, and congenital brain malformations. one lecture per week was recommended prior to case conferences that reviewed the same topic. pre-and post-tests and a feedback survey were administered. nonparametric paired sign test and analysis of covariance were used to evaluate changes in test scores overall and according to feedback responses. spearman's partial rank correlation coefficient was used to evaluate the relationship between the number of viewed videos and test scores. results: twenty-nine residents completed the pre-test and the post-test. the means (sd) scores were . % ( . %) and . % ( . %) respectively. there was a significant improvement in test scores (p . ). residents that agreed/strongly agreed that the streaming technology lectures were convenient had greater improvement than those who did not ( . vs. - . %, p . ). similarly, those who agreed/strongly agreed that being able to replay a lecture was helpful had greater improvement than those who did not ( . vs. - . %, p . ). finally, those who agreed/ strongly agreed that the streaming technology lecture format was a better teaching tool had greater improvement than those who did not ( . vs. - . %, p . ). significant positive correlation between number of videos watched postconference and improvement was present (spearman's rho . , p . ). conclusions: on-line streaming video with live case conferences enhances radiology resident learning of pediatric neuroradiology. step (mpps) software provided an accurate measurement of scan time. visual charting made gaps in utilization apparent. technologists and nursing notes correlated to gaps identified barriers and opportunities for improvement. nursing and anesthesiology reduced redundancies. standardized protocols lead to more consistent scan times. appointment access for sedated mri was measured by the third available appointment. results: manually entered data points were time consuming, inconsistent and unreliable. the process improvement was most effective when fewer more reliable data points were used to evaluate the effect of change. the program resulted in a reduction of appointment access for sedated mri from days to days with no change in the hours of operation. magnet utilization was increased from % to %. induction outside the scan room provided the most efficient process tested. we ranked first in utilization in a children's healthcare cooperation of america (chca) survey as measured by exams per scanner. patient preference for a.m. scheduling was shown by survey and corroborated by scheduling data. consistent scan times were achieved by protocol standardization augmented by indication driven decision support. conclusions: a consise definition of mr utilization established a metric that was used in the process cycle of analyze-optimize-measure. anesthesia induction outside the magnet was the most efficient practice but required collaboration between nursing, mr technologists and anesthesiology. protocol standardization were valuable aspects of process improvement essential to optimizing parallel sedation. these adjustments reduced appointment access from days to days, increased utilization from % to % and produced a number one rank in utilization by chca survey. we exploited the synonym option in epic order entry to translate indications into procedures mapped to specific protocols for mri neuroimaging. the order screen allows the provider to enter an indication. that indication is linked through a synonym option to a specific exam and protocol. the recommendation is based upon institutionally created clinical care guidelines, and can be accepted with a single click to complete the order. the requesting provider retains the option to override the recommendation. an step in process development utilized an order queue established within the epic inbasket. a pediatric radiologist monitored the queue and communicated with referring providers to obtain additional history and educate toward best imaging practice. these interactions facilitated development of a robust index of clinical indications used to create the synonym pool. results: mri neuroimaging indications were expanded into a robust data set linked to specific mri exams aligned with specific protocols. the synonym option within epic created the opportunity for the requesting provider to simply enter an indication which drives the procedure and recommended protocol. provider satisfaction has been high and concurrence with recommendations nearly universal. conclusions: indication driven order entry was achieved through the synonym option in order entry within the epic emr. imaging recommendations are based upon institutional clinical care guidelines developed through consensus. a robust compilation of pediatric mri neuroimaging indications has been created and linked to specific exams and protocols. compliance with the indication driven recommendation has been high. modifications of the current system are currently under development for all cross sectional modalities and organ systems. paper #: pa- cost-effectiveness of routine neonatal renal ultrasound in non-syndromic complex congenital heart disease elfrides traipe, tch, extraipe@texaschildrens.org; jill v. hunter, marthe munden purpose or case report: to assess the prevalence of abnormal renal ultrasound in non-syndromic complex congenital heart disease (cchd) and assess the cost-effectiveness of routine renal ultrasound in this population. we restrospectively reviewed the initial neonatal renal ultrasound and any subsequent renal imaging in patients with non-syndromic cchd. etiologies included hypoplastic left heart syndrome (hlhs), transposition of the great vessels (tga), coarctation of the aorta (coa), truncus arteriosos (ta), double outlet right ventricle (dorv) with or without patent ductus arteriosus. patients were recruited consecutively as part of a prospective trial for pre-and post-operative magnetic resonance imaging of the brain. results: the neonatal pre-operative renal ultrasounds were analyzed in female and male patients. only of the patients showed any congenital renal anomaly. this patient was born with hypospadias, that would have routinely stimulated neonatal follow up. conclusions: knowledge of embryology would not lead us to anticipate a high co-incidence of congenital renal and cardiac pathology. based on this statement and our findings, our recommendation to improve cost-effectiveness is not to perform routine neonatal renal ultrasound in non-syndromic cchd, but only if otherwise clinically indicated. purpose or case report: to conduct a meta-analysis of the diagnostic performance of contrast enhanced voiding urosonography (cevus) in comparison to voiding cystourethrography (vcug) or direct radionuclide cystography (drnc). a literature search was conducted for studies published on cevus in the pediatric age group. studies were included if the ultrasound contrast agents (usca) levovist® (bayer-schering pharma, germany) or sonovue® (bracco, italy) were used and enough data was available to extract x tables. if the cevus was compared to both vcug and drnc in the same patients the results for each were analyzed separately. a bivariate hierarchical model that takes into account the heterogeneity in cevus sensitivity and specificity in different studies was used for the assessment of the summary diagnostic metrics. the summary roc curve was derived and presented graphically from the parameters of the model. additionally, the % confidence intervals (ci) and the positive (lr+) and negative (lr-) likelihood ratios were calculated. results: out of publications only comparative studies fulfilled the inclusion criteria. these encompassed cevus studies in comparison with vcug and with drnc with regards to detection of vesicoureteric reflux. in studies the usca levovist® and in sonovue® were used. a total of children with pelvi-ureteral-units (puus) were included in the meta-analysis. cevus compared to vcug and drnc had a sensitivity of % (ci: - ) and a specificity of % (ci: - ) with lr+and lr-of . and . , respectively. the performance of cevus was better when compared to drnc than to vcug (sensitivity %, specificity % versus % and %, respectively. the meta-analysis of the diagnostic performance of cevus regarding the urethra included patients ( boys). excellent imaging of urethral anatomy was reported in over % of the patients. however, currently there is only one comparative study with patients available. in this study % sensitivity and % specificity were reported. conclusions: sufficient evidence is available clearly demonstrating the high diagnostic performance of cevus compared to vcug or drnc regarding the detection or exclusion of vur in children. these findings combined with the absence of radiation should be convincing reasons for promoting the widespread use of cevus in children. disclosure: dr. darge has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: prenatal ultrasound (us) has increased identification of infants with asymptomatic renal pelvic dilatation. society for fetal urology (sfu) grading is used in the sonographic evaluation of pediatric hydronephrosis. based on us findings, a nuclear medicine diuretic renogram may assess renal function, which could result in operative intervention. standardized protocols for diuresis renography, the "welltempered renogram," already exist; however, no current study has assessed effect of intravenous hydration (iv) status with us in the evaluation of childhood hydronephrosis. our study assesses the effect of hydration on sfu grading. in this prospective irb approved study, pediatric patients diagnosed with pelvicaliectasis requiring a diuretic renogram were recruited to undergo pre and post hydration renal us. a urinary catheter was placed followed by renal us pre and post iv hydration ( ml/kg normal saline bolus). imaging was performed by the same sonographer on the same us machine. a well-tempered renogram was then performed. all images were reviewed by two blinded radiologists, one pediatric radiologist who assigned sfu grades to each kidney. results: data were collected from studies, with ages ranging from weeks- years, with an average age of months. there were unique patients. of these, underwent a single renogram, underwent two renograms, and underwent renograms. one patient had a solitary kidney due to mcdk. thus, there were usable paired sonograms ( kidneys) for analysis. sfu grades were compared in the pre-and post-hydration us for each kidney. two-sided statistical tests were done to assess whether sfu grades changed significantly after hydration (sign test). of ( %) kidneys remained the same grade post hydration. when there was a difference, most demonstrated an increase ( of kidneys and p< . ). no change in sfu grade pre-and post-hydration differed by more than . only kidney went from grade to grade . sfu above grade is considered clinically significant. no kidney that was grade - pre-hydration became grade - post-hydration. when sfu is dichotomized grade - vs. - , there was no significant change in grade from pre to post hydration (p ). conclusions: hydration does not appear to have a clinically significant effect on sfu grade. therefore, performance of a "well-tempered" us is unnecessary. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. study type was significantly associated with both total and weighted score (both p < . ). rus was better and mag was worse than vcug, rnc, and dmsa, which did not differ from each other. other factors associated with worse total scores included patient age - years (p< . ) and non-white race (p . ). gender, prior testing history, wait time, and parent education were not associated with total scores. in the multivariate model, rus remained the best, mag the worst, and dmsa, vcug, and rnc in the middle (p< . ). compared directly, dmsa and vcug total score did not differ (p . ). conclusions: this study documents significant differences among gui studies with respect to the patient and family experience, but there was no overall difference between dmsa and vcug. these findings may be useful to aid decision-making when considering gui for pediatric patients. we retrospectively reviewed the imaging findings of consecutive patients with histologic diagnosis of cd ( males, females; mean age . years; age range - years) who underwent mre between / / and / / . the mre was performed in a siemens avanto . tesla scanner. standard departmental volume of polyethylene glycol and fluid were administered for bowel distention. the imaging protocol included dwi with eight b values ranging between sec/mm and sec/ mm and gadolinium enhanced dynamic d vibe (volume interpolated breath hold exam) in the coronal plane. the studies were qualitatively evaluated in a blinded fashion by two board certified radiologists. disease activity was defined as bowel wall thickening and enhancement in the gadolinium enhanced images. dwi abnormality was defined as bowel thickening, increase signal on dwi images and decrease signal on adc maps of the ileum. intra voxel incoherent motion (ivim) dwi parameters were used as quantitative biomarkers for the analysis of slow diffusion (d) and fast diffusion fraction (f). results: gadolinium enhanced vibe images identified abnormal thickening and enhancement of the ileum in / ( %) patients. dwi identified abnormal signal in / ( %) patients. the sensitivity and specificity of the qualitative dwi for identifying ileitis, as shown by gadolinium enhanced imaging, were % and %, respectively. quantitative analysis showed statistically significant difference in ivim maximal values for f (fast diffusion fraction) between abnormal (mean . , std . ) and normal (mean . , std . ) ileum segments (p . ). there was statistically significant difference in ivim maximal values for d (slow diffusion) between abnormal (mean . μm /ms, std . μm /ms) and normal (mean . μm /ms, std . μm /ms) ileum segments (p . ). abnormal loops of bowel had decreased slow and fast diffusion parameters. conclusions: diffusion weighted imaging has excellent sensitivity and specificity for the detection of active ileitis in pediatric cd. furthermore, quantitative ivim model parameters provide effective biomarkers for this condition. ivim dwi has the potential to assess bowel inflammation without intravenous contrast enhancement and further increase our understanding of cd. methods & materials: forty pediatric patients (median age . years, range . - . ) with suspected (n ) or confirmed ibd (n ) were included and underwent gastroileocolonoscopy with biopsies followed by mre (median interval days, range - ). the mre results were compared with macroscopic and microscopic assessment of the ileum. the clinical importance of the mre results was registered. results: crohn disease (cd) was diagnosed in cases, ulcerative colitis (uc) in , and ibd unclassified (ibdu) in three. macroscopic ileitis was detected in / ( %) of cd cases and in / ( %) of uc (backwash ileitis). microscopic inflammation was found in another four cd cases and one ibdu patient. in total, discrepancy between macroscopic and microscopic inflammation was found in cd, uc and one ibdu patients. the sensitivity of mri was % (against macroscopy and/or microscopy) to % (against macroscopy alone), while the specificity was % and %, respectivley. mre findings was decisive for diagnosis in / ( %) and led to treatment adjustments in / ( %) in the following six months. conclusions: mre is a reliable method for imaging of intestinal inflammation in pediatric ibd, and can be supportive or essential for clinical treatment decisions. results: of children with ec, had ct imaging of the abdomen and pelvis. these children ranged in age from months to years (mean . years +/− . ) with a male predominance (n , %). the most common presenting symptoms were abdominal pain (n ), bloody diarrhea (n ), and rectal bleeding (n ). ec was characterized as a dense and predominant eosinophilic inflammatory infiltrate in the lamina propria and/or epithelium without granulomas. ct scans were abnormal in ( %). no colonic luminal contrast was present in patients, and in one of these, the colon appeared normal. abnormal ct findings included cecal wall thickening (n , %), mucosal enhancement without colonic wall thickening, (n , %), mesenteric lymph node enlargement (n , %), terminal ileal thickening (n , %), jejunal and ileal thickening (n , %), and pneumatosis (n , %). of the patients with cecal involvement, primarily involved the cecum with less severe or no ileal or downstream colonic involvement. pneumatosis extended along the length of the colon with rectal predominance. conclusions: the predominant ct finding in our ec series was wall thickening, most severe in the cecum with variable extent downstream with mild or no involvement of the terminal ileum. although there is overlap, these findings are different from the most common patterns encountered with ulcerative colitis or crohn disease and should raise the possibility of ec in children presenting with abdominal pain and bloody diarrhea. purpose or case report: timely identification of childhood arterial ischemic stroke (ais) is critical to development of acute treatment strategies. we present our experience prior to and following development of a pediatric stroke alert system (sas). through multi-disciplinary collaboration in a tertiary care setting, a pediatric sas was established in . we describe the system, imaging protocol evolution, and impact upon the time between admission and mri initiation (time-to-mri) in patients with childhood ais. of patients in our stroke database (comirb # - ), % met inclusion criteria for stroke alert initiation (acute focal neurological deficit within h). eleven pre- and nine post- patients met criteria. we compared the time-to-mri between these two groups, utilizing a two-tailed t-test. results: the pediatric sas has two phases: i-neurological evaluation and ii-imaging and treatment consideration. phase i stroke alert is initiated when a child presents with an acute focal neurologic deficit. if neurology confirms stroke symptoms and ct head is negative for an alternative etiology, a stroke alert is called prompting an emergent brain mri. if mri confirms an acute stroke, hyperacute therapies are considered. initial mri protocol included dwi, t , flair, d tof cow mra, d tof neck mra and fat saturated t neck imaging. after internal quality review, t mprage brain and contrast enhanced d neck mra were added. the sequence order was also altered so diagnostic sequences were scanned first (dwi and cow mra). there was a trend towards decreased time-to-mri in the post- group (mean min, sd +/− ) as compared to the pre- group (mean min, sd +/− ; p . ). conclusions: institution of a pediatric sas improved urgent neurologic evaluation and demonstrated a trend towards shorter time-to-mri. ongoing quality review has enhanced imaging quality and decreased time-to-mri. continued refinement of pediatric sas's will be critical to the success of recently funded phase i clinical trials in the evaluation of hyperacute therapies. results: there were female and male infants. the mean post-gestational age at presentation was days (range - days), while the corrected age was less than days for all patients. patients presented with seizures and signs of infection; presented with lethargy and later proved to have protein c deficiency. mri was performed - days from presentation in these patients. another patient with known protein c deficiency underwent mri at d for followup of screening us abnormalities. there were a total of deep cerebral white matter lesions: frontal, parietal, temporal lobe. lesions were fluid signal cavities with restricted diffusion. larger lesions had dependent debris. all lesions had associated hemorrhage and most lesions had evidence of adjacent small vessel venous thrombosis. lesions imaged after gad showed peripheral enhancement. three lesions were seen to increase in size on follow-up imaging. three patients, with meningitis confirmed via microbiology and with presumed meningitis by csf counts, underwent surgical aspiration of a total of lesions. all specimens were sent for pathology and culture and were negative for microorganisms. conclusions: recognizing the mr appearance of necrosis and liquefaction after deep white matter cerebral venous infarction in neonates can distinguish this entity from cerebral abscess and potentially avoid an unnecessary neurosurgical aspiration procedure. all four children were initially treated with aspirin but experienced recurrent events on therapy. all four were subsequently anticoagulated. two children have remained on warfarin for - years without recurrent events, while the other two had recurrent events despite adequate anticoagulation. these two children underwent uncomplicated coil embolization of the affected vertebral artery segment, and they have remained symptom-free for five and months since then. conclusions: dava was diagnosed by ca in / patients. all four children with dava in our series suffered recurrent strokes despite aspirin therapy. two of the four experienced further strokes on anticoagulation, necessitating endovascular therapy. these findings suggest that dava in children may require ca to diagnose, and that it may be refractory to standard adult therapies. ongoing multicenter efforts in childhood ais should further evaluate the diagnostic approach and recurrence risk of childhood dava. ) and cerebral gray matter abnormalities were present in ( %). posterior fossa lesions were seen on us in . % , but mastoid views were included in only % of the centrally read us. conclusions: in the largest extreme preterm cohort to date with near-term mri and serial us, % had mod-severe wma on brain mri, similar to previous reports. cerebellar abnormalities were detected more frequently by mri than by us. neurodevelopmental outcomes at - months and school age will assess the relative and combined values of mri and us as outcome predictors. , an analysis technique based on task-free resting state fmri recording, can be useful in assessing disruption of connectivity in certain disease states, including epilepsy. in healthy control subjects, functional connectivity reveals strong bilateral interhemispheric connectivity in such system as sensory-motor, visual, auditory as well as dorsal attention and default mode networks. in patients with epilepsy associated with unilateral diffuse hemispheric disease such data is limited. differences in the pattern of activation would suggest alteration in connectivity in these entities. this finding would impact the typical interpretation of this data that is becoming routinely collected for epilepsy pre-surgical evaluation. methods & materials: siemens (erlangen, germany) system, -tesla (trio) scanner was used for imaging (epibold sequence, te ms, flip angle °). resting state fmri scan were performed in both awake and anesthetized patient. awake patients were instructed to relax and rest while keeping their eyes open. analysis was performed using functional connectomes project scripts based on afni and fsl software packages. resting state data were analyzed for connectivity with the following seeds: somatomotor, visual, auditory, and default mode (posterior cingulated cortex (pcc)). results: we applied this technique to evaluate patients with hemispheric seizure disorders, including rasmussen's, neonatal infarct and migration disorders. all the subjects demonstrated some deviation from typical interhemispheric connectivity with a spectrum of findings. the figure below shows connectivity patterns in a patient with cortical dysplasia. while some interhemispheric connectivity remained in somatomotor (sm) and auditory (a ) systems, it was disrupted in visual (v ) and default mode (pcc) networks. variable patterns were found across the cases that corresponded to lesion side, supportive of disruption in interhemispheric connectivity as measured by fmri. conclusions: resting state functional connectivity patterns are well documented in healthy subjects. these results suggest that interhemispheric connectivity disruption is a typical feature of unilateral diffuse hemispheric disease though variable in presentation, either being limited to select systems or demonstrating broad disconnect between the two hemispheres. these results should be carefully considered when evaluating data for pre-surgical epilepsy evaluation. purpose or case report: premature birth is associated with white matter injury leading to a wide ventricular system. however,normative standards for ventricular size are lacking for this particular group.aims: we aimed to, in a controlled, population based norwegian cohort of ex-prematures without major handicaps, and for men and women separately,to ) create standards for radiological indices of ventricular dilatation, )investigate associations of these measurements with subjectively assessed ventricular size, ) examine differences in ventricular size between ex-prematures and healthy controls methods & materials: the initial birth cohort included neonates, birth weight below g (low birth weight)born within hordaland county, norway, between april st and august th . of eligible survivors (without major handicaps)underwent mr examination during the period january to may . of these were expremature (born before gestational age weeks) and were included in this sub-study. based on t weighted images, the ventricular size was subjectively judged as being normal, mildly, moderately or severely dilated by an experienced paediatric neuroradiologist, while objective measurements were performed in a blinded fashion, by a second observer (sma) using an imaging software program (nordic ice®). results: the normative standards for the ventricular system in ex-premature young adults showed wide variations, in particular for the occipital horns. the agreement between subjective and objective assessment of ventricular size was good. ex-prematures had smaller heads than those born term (control group). there was no difference in ventricular size between the two groups, even after adjusting for head size. ex-premature males had larger ventricles than females; however, the difference disappeared after adjusting for head size. conclusions: young adults born prematurely with a birth weight below g do not have larger lateral ventricles than healthy controls born term, even after correcting for a smaller head size. paper #: pa- best practice for reproducibility when measuring t *: implications for liver and cardiac iron assessment mark ferguson, md, radiology, seattle children's hospital, markferg@uw.edu; randolph otto, seth d. friedman purpose or case report: patients with red blood cell transfusion-dependent conditions receive high amounts of iron that can lead to abnormal iron accumulation in tissues resulting in organ damage. while the liver is the dominant excess iron storage organ, iron related cardiotoxicity is a leading cause of morbidity and mortality in patients with transfusion-dependent thalassemia. therefore, accurate determination and tracking of tissue iron levels in both the liver and the myocardium is important for patient prognostication as well as monitoring treatment changes. while multi-echo gradient echo mri (t *) is widely used and validated method employed for iron assessment, less attention has been given to derived metrics. specifically, the literature almost exclusively reports and uses the mean value for t * from a pixel-wise (pw) map. infrequently used is the median. the median is a potentially superior metric than the mean because it is insensitive to outliers. outliers will always occur in data because of either noise or imperfect vessel exclusion. to compare mean versus median on reproducibility of t * measurement, subjects who had paired heart/liver measurements were examined. the entire liver (excluding vessels) and the interventricular septum myocardium were traced on representative images from each series. mean and median t * values were generated from the pixel maps. r * ( / t *) and coefficient of variation (cv) were computed on a patient-by-patient basis. these measures were then summarized for the group. results: markedly higher r * values were observed in both heart and liver using median summary measures (liver: t − . , p . , heart: t − . , p . ). these findings were accompanied by lower cv's (better reproducibility) for the median approach (liver: t . , p . ; heart: t . , p . ). conclusions: the consistent difference in derived t * values between the methods (median>mean) should be considered when comparing derived r * values to established normal ranges. cv data support that using the median as the final summary metric will always outperform mean metrics for measuring change in r *. this finding has immediate implications for the scientific literature and for guiding therapeutic management over time. results: twelve children (age mo- yo; m:f : ) with gsds ( abca mutations, sp-c mutations, undefined mutation) and children (age wk- yo; m:f : ) with other dlds (including pulmonary interstitial glycogenosis, neuroendocrine cell hyperplasia of infancy, lymphocytic interstitial pneumonia, lipoid pneumonia, diffuse alveolar damage, granulomatous infection, capillaritis and other pulmonary hemorrhage syndromes) were identified. ct findings with highest sensitivity for gsds were ground glass attenuation ( %), parenchymal cysts ( %), and interstitial thickening ( %). parenchymal cysts, honeycombing, and pectus excavatum were more specific for gsds compared to other dlds (p< . ). the combination of either parenchymal cysts and honeycombing or ground glass attenuation and pectus excavatum provided the highest specificity ( %) but low sensitivity ( %). the combination of parenchymal cysts and ground glass attenuation provided good specificity ( %) and modest sensitivity ( %). no combination of findings provided both high sensitivity and specificity. conclusions: ground glass attenuation is the most sensitive finding for gsds, while parenchymal cysts, honeycombing, and pectus excavatum are more specific findings for gsds than other chronic dlds of childhood. however, no single finding or combination of findings on chest ct is both highly sensitive and specific for gsds, and chest ct cannot substitute for genetic testing or lung biopsy for the differentiation of gsds from other dlds. pes were observed in scans of patients without a history of congenital heart disease (chd), and pes in scans of patients with a history of chd. z-axis scan lengths for the chest ct exams ranged from . - . cm. a z-axis scan length of cm centered . cm below the carina captured all pes in all patients, and a length of cm centered . - cm below the carina in patients with chd. a z-axis scan length of cm centered cm below the carina was sufficient to capture at least one pe in all patients, and a length of cm centered - cm below the carina in patients with chd. the radiation effective dose of the chest ctpa exams ranged from - msv. limiting the z-axis scan length on ctpa exams to cm or cm would have resulted in a % or % decrease in z-axis coverage, respectively, and estimated radiation effective dose reduction of - % due to less radiation exposure to the intrathoracic structures, thyroid gland and upper abdominal viscera. conclusions: limiting the z-axis scan length coverage for ctpa exams based on a model of the typical anatomic distribution of pes relative to the reference level of the carina permits a substantial reduction of radiation dose in children without reducing the sensitivity for detection of pulmonary emboli. purpose or case report: to determine whether the addition of multiplanar reformation mdct images affects reader performance parameters and provides added diagnostic value compared to the use of axial ct mdct images alone for diagnosing pe in children. this was an institutional review board-approved retrospective study of consecutive pediatric patients who underwent ctpa for clinically suspected pe. two faculty pediatric radiologists and two radiology residents independently reviewed each study initially using only axial mdct images and later using mpr mdct images in any x-, y-, or z-axis for detecting pe. diagnostic accuracy, confidence level, and interpretation time of mpr mdct images were compared to axial mdct images using mcnemar's test and paired t-tests. the kappa coefficient was calculated to assess interobserver agreement. diagnostic accuracy was compared between faculty pediatric radiologists and radiology residents by logistic regression whereas confidence level, interpretation time, and added diagnostic value were evaluated with analysis of variance (anova). results: the final study cohort consisted of ctpa studies from children ( m/ f; mean age . years). nine ( %) of ctpa studies were found to have pe. diagnostic accuracy in correctly detecting pe ranged from . to % (mean . %), with no significant differences between the use of axial and mpr mdct images. logistic regression indicated no significant difference in diagnostic accuracy of detecting pe between faculty pediatric radiologists and radiology residents for axial mdct images (p . ) or mpr mdct images (p . ). confidence level and interobserver agreement were significantly higher and average interpretation time was longer in evaluating pe with mpr mdct images compared to axial mdct images for all reviewers (p<. ). compared to faculty pediatric radiologists, significantly greater increases in confidence level, interobserver agreement, interpretation time, and added diagnostic value using mpr mdct images compared to axial mdct images to diagnose pe were found for radiology residents (p< . ). conclusions: use of mpr mdct images in diagnosing pe on ctpa in children significantly increases confidence, interobserver agreement, and interpretation time among faculty pediatric radiologists and radiology residents. because mpr mdct images provide significantly greater improvements in reading parameters for residents than for faculty members, their routine use should be encouraged for trainees. paper #: pa- chest ct in children, anesthesia and atelectasis beverley newman, md, radiology, stanford university, bev.newman@stanford.edu; elliot krane, terry e. robinson purpose or case report: in spite of advances in ct equipment and speed, sedation/ anesthesia is required in many young children for optimal quality ct for detailed parenchymal evaluation; resultant atelectasis is a common and important quality issue. our purpose was to evaluate the safety and effectiveness of a standardized lung recruitment technique. methods & materials: with irb approval and parental informed consent, controlled ventilation, low dose, chest ct's (cooperative effort between anesthesia, pulmonology and radiology) were performed in children ( had - cts) ( f, m; ages . - . yrs, mean . yrs). indications included cystic fibrosis ; ciliary dyskinesia ; chronic or interstitial lung disease ; evaluate pulmonary metastases . ct parameters were - kvp, - mas, iv contrast . various prior methods employed by the pediatric anesthesiologists to maintain lung inflation had unpredictable results (a brief survey showed / nonintubated anesthetized cases had problematic atelectasis). a standardized intubation technique was therefore adopted: .use of a tight fitting face mask during induction and iv placement, inspiratory pressures of - and peep of . . introduction as early as possible using an appropriately sized cuffed endotracheal tube. . alveolar recruitment maneuvers- - s breaths to cm h o/ ( - in st cases). . three breaths at / , inspiratory breathold followed by - cm on th breath for scout and inspiratory scan, and complete ventilator disconnection for expiratory scan. recruitment breaths repeated before each scan. two experienced readers reviewed and scored the images on a point scale for overall quality and atelectasis. results: all studies were completed safely with no procedural complications. one child had propofol-related postoperative emergence delirium. all ct scans were diagnostically good to excellent with small subsegmental atelectasis in ( / were the initial cases with lower recruitment pressures) and segmental atelectasis in . cases had prior cts, without this technique, that were suboptimal due to moderate procedural atelectasis, in spite of tracheal intubation in the majority of cases. conclusions: an intubation lung recruitment technique can be performed safely and consistently by different individuals using a standardized protocol. procedural atelectasis that affects quality is reliably absent and repeat sequences are not needed. obtaining a high-quality dynamic airway imaging study is critical for accurate interpretation and subsequent medical decision-making. the ideal mri sleep study is one that allows successful completion while maintaining spontaneous breathing without artificial airway, which can be an anesthesia challenge. dexmedetomidine has been shown to have sedative properties paralleling natural sleep with minimal respiratory depression. we hypothesized that dexmedetomidine compared to propofol would have less effect on upper airway tone and airway collapsibility and provide favorable conditions with less airway interventions required during dynamic mri airway imaging in children with osa. in this prospective study, we examined the requirement for airway intervention for propofol ( - mcg/kg/m) and dexmedetomidine( - mcg/kg/h) in children and adolescents with osa. severity of osa was analyzed by overnight polysomnography. for children with history of mild osa there was no intervention unless oxygen saturation decreases below %; while for children with history of moderate/severe osa, an artificial airway was placed when oxygen saturation decreased below %. results: demographics and osa severity by polysomnography were comparable. requirement for artificial airway by severity of osa as documented by polysomnography will be shown. mri sleep studies required airway intervention in / ( %) children in the dexmedetomidine group versus / ( %) children in the propofol group. mri sleep studies were successfully completed without the use of artificial airways in children ( %) in the dexmedetomidine group versus children ( %) in the propofol group. conclusions: safe and effective anesthetic management is a key factor in obtaining good quality mr images of the airway. although there was no statistical significant difference in the need for airway intervention between drugs, dexmedetomidine provided acceptable sedation for mri sleep studies with less airway intervention in children with osa. dexmedetomidine may be the preferred agent for sedation during mri sleep studies in children, and may offer benefits to children with sleep disordered breathing requiring anesthesia or sedation for other diagnostic imaging studies. an open mouth and administration of cpap resulted in smaller ap diameter of the retroglossal airway compared to images without cpap due to cpap pressure pushing the tongue posteriorly. in patient volume of oral cavity anterior to the tongue increased from . ml to . ml. meanwhile, the ap diameter of the retroglossal airway decreased from . to . mm ( % decrease). in patient the mouth was initially closed but parted when the pressure of cpap was added with the oral volume increasing from . ml to . ml. the ap measure of the retroglossal airway decreased from . mm to . mm ( % decrease). in patient the mouth was then closed and cpap reapplied resulting in an ap measurement of . mm ( % increase). the ap diameter difference between cpap and no cpap were tested with paired t-test, but were not statistically significant (p . ). conclusions: positive airway pressure on a patient by full facemask and an open mouth can have an adverse effect on the retroglossal airway. this adverse effect is an important consideration in the use of positive airway pressure to support airways for osa, or during emergency resuscitation when a full facemask is used. paper #: pa- the purpose or case report: a nanoparticle blood pool iodinated contrast agent (nctx) has been designed and tested in preclinical animal models. we report data in animal models exemplifying its advantages over conventional contrast in the setting of ct pulmonary angiography methods & materials: nctx blood pool nanoparticles of nm diameter with an encapsulated total iodine concentration of~ mgi/ml were administered by intravenous injection to mice, rabbits, dogs, pigs and sheep. (these studies were actually conducted for other purposes and a review of the data revealed the similarities that motivated this paper.) total injected volumes were~ ml/kg in large animals, and as high as ml/kg in small animals to provide satisfactory vessel enhancement. iohexol or iopamidol was administered for comparative studies with conventional contrast. in a subset of pigs, iatrogenic pulmonary arterial emboli were introduced prior to contrast administration. toxicity studies were conducted in mice and monkeys. results: the visualization of pulmonary vessels using nctx blood pool nanoparticles was generally at least equivalent to using conventional contrast, and superior in several cases, particularly in small veins and when bolus timing of the conventional contrast was suboptimal. in all cases, satisfactory vessel enhancement was achieved for a duration of several hours following a single infusion of nctx blood pool nanoparticles. there was no evidence of renal toxicity, and only transient elevation of hepatic enzymes at relevant dose levels. conclusions: nctx nanoparticle blood pool agents demonstrate several advantages over conventional glomerularfiltered iodinated contrast agents for ct pulmonary angiography in animal models, including no nephrotoxicity, no dependence on bolus injection technique, superior depiction of small veins, and capability of re-imaging for follow-up studies without needing contrast re-injection. potential applications in human pediatric subjects include the diagnostic and post-therapeutic evaluation of cardiopulmonary anomalies and pulmonary embolism, especially in patients with renal insufficiency or tenuous vascular access. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa- cardiovascular image quality using a nanoparticle ct contrast agent: preliminary studies in a pig model rajesh krishnamurthy, radiology, texas children's hospital, rxkrishn@texaschildrens.org; ketan ghaghada, prakash masand, abhay divekar, eric hoffman, ananth annapragada purpose or case report: image quality in a separate study using a long circulating, liposomal-based nanoscale blood pool iodinated contrast agent (nctx) suggests clinical utility in pediatrics, potentially reducing difficulties in contrast-ct of children with congenital heart disease (chd) including the size of intravenous cannula, need for accurate timing, inability to simultaneously opacify multiple targets of interest (requiring repeated contrast administration and/or repeated imaging). methods & materials: six pigs (average weight kg) were imaged after slow intravenous infusion of nctx ( mg i/ml) at an iodine dose of approximately mg i/ kg ( . ml/kg). retrospective ekg gated ct imaging was performed h later using a -slice dual-source ct scanner at and kvp. two radiologists analyzed and graded (on a -point scale with : unreadable, : excellent) images aimed at anatomic structures relevant to chd. quality of images obtained at and kvp were compared. uniformity of contrast opacification was measured using a roi-based ctnumber method at various intracardiac and extracardiac sites and mean non-uniformity was calculated. results: there was excellent agreement between the two readers on all counts at kvp. kvp images received lower scores for coronary morphology ( / ), and aortic valve visualization ( . / ), but were comparable in other aspects. pulmonary artery and pulmonary vein branch visualization extended up to the th generation in all cases. visualization of coronary artery branches was possible up to the second generation, with good arteriovenous separation. subtle morphologic features including crista terminalis, thebesian valve, foramen ovale, membranous septum, and chordae of the mitral valve were demonstrated in all cases. automated functional analysis and myocardial mass quantitation was feasible in all cases. there was no significant difference in blood pool attenuation between the atria, ventricles, and extracardiac vasculature on quantitative assessment. no image artifacts were visible on the reconstructed images. conclusions: these findings suggest that nctx promises to be superior to conventional contrast agents for ct imaging of complex congenital heart disease, due to the absence of nephrotoxicity, avoidance of repeated contrast administration, and reduced number of scans performed. avoiding the need for accurately timed scans precludes the need for large bore intravenous access. these attributes make it a promising agent that warrants further studies. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa- theoretical cost and x-ray dose reduction in pediatric congenital heart disease imaging by the use of a nanoparticle contrast agent robert bell, the university of texas-houston; rajesh krishnamurthy, gabriela espinosa, christopher petit, ananth annapragada purpose or case report: the purpose of this study is to determine the effective, population averaged reduction in costs and radiation dose that can be achieved in the diagnosis of congenital heart disease by use of a nanoparticle long circulating blood pool contrast agent. methods & materials: a markov model of the decision tree followed at the texas children's hospital in the image based diagnosis of congenital heart disease was constructed in treeage software. the model included ct angiography, mr angiography, cardiac catheterization, and echocardiography diagnostic modalities. patient records, accumulated between and were examined to inform the model. the radiation dose and cost for each step were encoded as penalty functions. markov simulations were run for two decision trees: ( ) utilizing ct angiography and ( ) replacing conventional ct angiography with blood-pool agent based ct angiography. the overall population x-ray dose and accrued cost was calculated for each pass through the model. results: x-ray dose distributions for the example populations showed substantial reductions per ct study, as much as %. averaged over the population, since a sizeable fraction of patients are diagnosed without ever being exposed to any x-ray based modality, reductions were more modest, but still substantial. costs per ct study were slightly higher when the blood pool contrast agent was used. when the diagnostic probability using the blood pool agent increased, it led to an automatic overall cost reduction. conversely when the diagnostic probability remained unchanged, costs rose, commensurate with the increased cost of the contrast agent. conclusions: the use of a blood pool contrast agent for ct angiography leads to substantial reduction in radiation dose in the setting of congenital heart disease. cost reductions are more modest, and are driven almost completely by the reduction in the number of mr and invasive angiography procedures resulting from increased diagnostic success using blood pool based ct angiography. the model as constructed does not account for potential workflow changes that might result from the use of a new contrast agent. actual reductions realized may therefore be higher. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa- frequencies and patterns of situs discordance in chest and abdomen justin boe, stanford, justinj.boe@gmail.com; beverley newman, shreyas vasanawala, frandics chan purpose or case report: incidence of situs anomalies, including heterotaxy and situs inversus, is estimated at . % of population. as the first step in the segmental analysis of structural heart disease, the determination situs position is of fundamental importance. abdominal situs, as defined by splenic position and morphology, and cardiac situs, as defined by atrial morphology, are usually but not always in agreement. echocardiographers also employ the relative position of the great arteries and vein at the hiatus to determine cardiac situs. we evaluate the frequencies of discordances among abdominal, hiatal and cardiac situses. methods & materials: with retrospective irb approval, imaging records from to were reviewed for the diagnosis of cardiac situs inversus and heterotaxy. patients who had cardiac ct or mri were included. images were evaluated on a d-processing station by a cardiac radiologist. cardiac situs was determined by the morphology of the atrial appendages. when an atrial appendage was not adequately visualized, cardiac situs was assessed by the relative position of the main pulmonary artery and bronchi. hiatal situs was determined by the relative position of the aorta and the systemic venous return, and abdominal situs by the position and morphology of the spleen. results: thirty-five cases were identified, with cardiac ct and mri. patients' age ranged from day to years old. in the abdomen, the numbers of situs inversus, asplenia, and polysplenia were ( %), ( %), and ( %). for the heart, the numbers of situs solitus, inversus, rightisomerism, and left-isomerism were ( %), ( %), ( %) and ( %). the abdominal and cardiac situses were discordant in ( %) cases. polysplenia had the highest number of discordance with the heart. hiatal situs was discordant with the abdomen in cases ( %) and with the heart in ( %) cases. conclusions: situs disagreement between the abdomen and the heart is not uncommon and they should be documented separately in radiology reports. hiatal situs, as used by echocardiographer, disagrees with the cardiac situs in a quarter of the cases. it should be used with caution in the segmental analysis. paper #: pa- diminished asl intracranial perfusion in children with neurofibromatosis type kristen yeom, md, stanford university, kyeom@stanford. edu; cynthia campen, patrick barnes purpose or case report: neurofibromatosis type (nf ), a neuro-cutaneous syndrome affecting / children is associated with moyamoya syndrome (mms). however, no comparisons of cerebral perfusion in patients with nf and nf -associated mms to healthy controls exist. we hypothesize cerebral blood flow (cbf), as measured by magnetic resonance imaging (mri) arterial-spin-labeled (asl), is diminished in children with nf compared to healthy controls, with the lowest levels seen in patients with nf -associated mms. methods & materials: twenty children aged - years with nf , four with mms, and age-matched controls underwent asl cbf on a t magnet. pseudocontinuousspin-echo-asl technique was used. measurements were taken bilaterally in cerebral cortical-subcortical regions, and the deep gray nuclei. trends in measurements as a function of disease severity were tested with the jonckheere-terpstra test for ordered alternatives. a bonferroni-adjusted p-value less than . was considered significant. results: we identified / areas with significantly diminished asl cbf (ml/ g/min) in patients with nf (midrange), and nf -associated mms (lowest) compared to healthy controls (highest). these included the: thalami (left: p . , right: p . ); superior/middle temporal lobes (left: p . , right: p . ); temporooccipital lobes (left: p . , right: p . ); occipital poles (left: p . , right: p . ); centrum semiovale (left: p . , right: p . ); and left parietal lobe (p . ). conclusions: cerebral perfusion diminishes in a graded fashion in children with nf and nf -associated mms, particularly in the posterior circulation and the mca-pca posterior watershed zones. future studies may demonstrate an important role for asl in the presymptomatic diagnosis of cerebral vasculopathy, and the definition of nf -related vasculopathy patterns. paper #: pa- cingulate gyrus mri sign in pediatric nf patients: a novel imaging marker nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; nabila hai, rhea udyavar , amir noor, gilbert l. vezina, maria t. acosta purpose or case report: we observed a magnetic resonance imaging (mri) signal abnormality in the anterior cingulate gyrus of pediatric patients with neurofibromatosis type (nf ). the cingulate gyrus could play a role in cognitive deficits of nf patients. the first objective here is to document inter-rater reliability scores for visual detection of this sign. the second objective is comparing adc values of the cingulate gyrus in areas of visually abnormal mri signal in nf patients to matched normal mris to confirm a pathophysiological basis of the visual mri sign. methods & materials: retrospective analysis, irb approved, nf patients and matched controls. in the visual assessment part, two blinded neuroradiologists rated presence or absence of mri signal abnormality in the cingulate gyrus in three different age groups of nf patients mixed with normal controls. cohen's kappa inter-rater reliability coefficients were calculated. the same blinded neuroradiologists evaluated the cohort one year later, this time by agreement at the workstation. in the adc measurements part, two researchers, one blinded, manually placed roi's in the anterior and posterior cingulate regions of nf patients and their matched controls, and student t-test was used to assess for significance of differences in measured values. results: cohen's kappa for the three age groups showed very good agreement (kappa coefficients were either . or . ). rater agreement at the workstation was %. all subjects with a positive finding also had nf and the sign was not seen in any of the normal controls. the prevalence of the sign was %. adc measurements showed significantly higher adc values in the anterior cingulate gyrus of nf patients when compared to normal controls and also when compared to the posterior cingulate gyrus in nf patients. conclusions: our results show that visual t /flair mri abnormalities in the anterior cingulate gyrus are present in % of patients with nf from ages to years. adc measurements confirm a pathophysiological basis for this finding. future correlation with clinical manifestations, such as learning and behavioral manifestations in patients with nf , are under way to further evaluate the clinical importance of this finding. tract-based spatial statistical analysis of diffusion tensor imaging in pediatric patients with mitochondrial disease seth friedman, phd, seattle children's, seth.friedman@ seattlechildrens.org; andrew v. poliakov, sandra l. poliachik, dennis w. shaw purpose or case report: often diagnosed at birth or in early childhood, mitochondrial disease presents with a variety of clinical symptoms, particularly in organs and tissues that require high energetic demand such as brain, heart, liver, and skeletal muscles. in a group of pediatric patients identified to have complex i or i/iii deficits, but with white matter tissue appearing qualitatively normal for age, we hypothesized that quantitative dti analyses might unmask deficits in microstructural integrity. methods & materials: dti and structural mr brain imaging data were collected in pediatric patients with confirmed mitochondrial disease and clinical control subjects matched for age, gender, scanning parameters, and date of exam. paired tract-based spatial statistics (tbss) were performed to evaluate differences in fractional anisotropy (fa) and mean diffusivity (md). results: in patients with mitochondrial disease, significant widespread reductions in fa values were shown in white matter tracts. md values were significantly increased in patients, having a sparser distribution of affected regions compared to fa. results of tbss statistical analysis will be shown. to be shown in green is the mean fa skeleton which represents the centers of main white matter tracts. all results p<. . red and yellow represent a significant increase, blue and light blue represent a significant decrease. conclusions: despite qualitatively normal appearing white matter tissues, patients with confirmed mitochondrial disease have widespread microstructural changes measurable with quantitative dti. this supports the evaluation of such metrics in other populations where gross imaging features may be normal. to extend our studies to patients with other plp mutations, we analyzed the brains of male pmd patients (ranging in age from to ) and female carriers for whom the plp genotype had been determined and analyzed by mri. for each patient we measured, white matter volume (wmv) and the intercaudate distance (icd). the mri data were correlated with functional disability scores (fds) using a system we developed for clinical evaluation of pmd patients and which was validated by assessments of pmd patients. brain volume and segmentation were measured using nih image . . the average number of coronal slices analyzed from each patients mri was slices. when graywhite contrast was not adequate, then the intercaudate distance (icd) and intercaudate ratio were measured as described in caon et. al., ( ) . results: comparison of the mr measurements and the fds demonstrated that white matter volume inversely correlates with functional disability, suggesting that the initial disability does correlate with the extent of myelination. the intercaudate distance also correlated with the fds, and may usefully substitute when gray-white matter segmentation is not possible. conclusions: pmd is a clinically and genetically heterogeneous disease caused by mutations in the gene encoding the major cns myelin protein, proteolipid protein (plp). myelin is a major target of disease pathogenesis in most cases of pmd, but how the various mutations cause clinical disability is not fully understood. our data demonstrate that the extent of brain white matter atrophy, measured directly by volumetric fractionation, or indirectly by analyzing the intercaudate ratio, is significantly correlated with the patient's functional disability. white matter atrophy is thus the main cause of clinical disability in patients with pmd of all ages and mutation type. paper #: pa- maturational effects on language localization in children demonstrated by fmri susan palasis, md, children's healthcare of atlanta at scottish rite, spalasis@yahoo.com; binjian sun, laura l. hayes, richard a. jones purpose or case report: language localization is of paramount importance when contemplating surgery in children with intractable epilepsy or brain tumors. the potential risk of injury to language centers in the developing pediatric brain needs to be weighed against the potential benefits of surgery. in the past, language localization was crudely and invasively determined using the wada test. most institutions are now transitioning to non invasive localization using functional mri (fmri). the purpose of our study was to analyze language localization relative to age in children using age appropriate language paradigms and fmri. methods & materials: forty three healthy, english speaking, right handed children underwent fmri evaluation for language localization. the studies were performed on a t system. three novel age appropriate language block paradigms were utilized, targeted both to expressive and receptive language processing. these paradigms were the auditory category decision task (audcat), the auditory description decision task (addt), and the listening task. the spatial statistical maps generated by the fmri data were fused to the d anatomical mri dataset. language areas were localized and statistical analysis was performed with age as the variable in a general linear model. results: our results demonstrate a distinct trend in language localization and lateralization with brain maturation. in the young age groups (less than years) the localization tended to be less focused and bilateral in the frontal and temporal regions of the brain. in the older age groups (greater than years), language became more localized and lateralized to the expected left sided pattern. the findings were more robustly demonstrated with the addt task and were statistically significant (p< . ). conclusions: our study clearly demonstrates the plasticity of language centers in the maturing pediatric brain. this observation is significant for neurosurgical planning and rehabilitation in the pediatric population. ( ) no slc a mutations were found in , and subjects, respectively. significantly higher association with slc a mutations was found in bilateral eva+v/c dysplasia ( / ). double mutations of slc a is more often associated with combined eva+ v/c dysplasia, while a single mutation with eva only. cochlear aplasia without eva ( / ) and snhl with normal imaging ( / ) are less likely associated with slc a mutation. conclusions: slc a mutation is highly associated with eva and v/c dysplasia. once eva with or without v/c dysplasia are found at imaging, genetic investigation is recommended for slc a mutation because of possible thyroid involvement. moderate-severe hie who were randomized to cooling ( . °c for h). there were in the hypothermia group and in the control group. all mris were reviewed by a cental reader masked to the clinical findings, groupings, and outcomes. the mri findings were scored according to pattern and extent of injury, including involvement of the cerebral hemispheres, basal ganglia, thalami, internal capsules, and other structures. brain injury scores were correlated with death or disability at months postnatal age. results: no mri abnormalities were observed in of infants ( %) in the hypothermia group and in of infants ( %) in the control group (p . ). infants in the hypothermia group had fewer areas of injury ( %) as compared with the control group ( %, p . ). there were of the infants with death or disability at months. the brain injury score correlated with outcome of death or disability (p . ) and disability among survivors (p . ). conclusions: fewer areas of brain injury on mri were observed following whole-body hypothermia. the mri brain injury score is a marker of death or disability at months following hypothermia for term hie. . presence or absence of the "red dot" on fa color maps was correlated to clinical (ataxia, oculomotor abnormalities etc.) and morphological data, and to fa and md measurements. results: the "red dot" was absent in js and hgpps (genetic cross wiring impairment diseases) and present in coma and wvs (no reported gene abnormalities so far) as in normal controls. js and coma presented on mri molar tooth appearance. hgpps presented "split pons" appearance. js and coma patients presented oculomotor apraxia, wvs and hgpps palsy of the horizontal gaze. mirror movements were found in js and in wvs. ipsilateral responses are present in hgpps. wvs presented multiple cranial nerves impairment. in js, fa and md values of scp, pt and pc were significantly lower than in normal controls (p > . ). in hgpps high fa and low md were found in pc and pt (p > . ) and normal in scp. conclusions: the "red dot" absence is unrelated to morphological or clinical abnormalities. absence of the "red dot" is associated to abnormal measurements of fa and md in pc and pt( low in js and high in hgpps). these findings indicate a pivotal role for the pc in the physiopathology of these diseases. the "red dot" absence seems to be a marker of genetic cross wiring diseases. in this view, coma and wvs should not be considered as part of these diseases. sonographic predictors of intermittant testicular torsion in the pediatric patient jennifer williams, md, pediatric radiology, texas children's hospital, jlwilli @texaschildrens.org; marthe munden purpose or case report: intermittent testicular torsion (itt), defined as sudden onset unilateral scrotal pain with spontaneous resolution, is difficult to confirm both clinically and sonographically. the purpose of this study was to determine if sonographic predictors exist for diagnosing itt in the pediatric patient. methods & materials: a search of the pacs data system for patients presenting with suspected intermittent testicular torsion was performed. fifteen patients with a total of episodes presenting over a year period were found. a retrospective review of the medical records for clinical presentation, surgical outcome, and comorbidities was performed. scrotal ultrasound images and reports were reviewed for testicular size and echotexture, testicular flow, epididymal appearance, vascular bundle appearance, and presence of hydrocele. results: an abnormal appearance of the vascular bundle was found in % of episodes ( / ). initial absence of testicular flow followed by reperfusion during the scan was seen in % of episodes ( / ); % had increased flow ( / ), % had decreased flow ( / ), and % had normal flow ( / ) . nine of the patients had surgery; of these were found to have evidence of itt and was found to have acute testicular torsion. of patients with itt, % ( / ) had an abnormal vascular bundle. testicular flow was not initially visualized but returned during the exam in % of patients ( / ), was increased in % of patients ( / ) and was decreased in % patients ( / ). conclusions: itt is a difficult diagnosis. the most reliable sonographic indicator is an abnormal spermatic cord, found in % of episodes and % of surgically proven itt. dedicated views of the spermatic cord must be obtained in order to differentiate an abnormal epididymis from an engorged vascular bundle (the so-called pseudomass). attention to testicular flow is of particular importance. while visualization of a transition from no or decreased testicular flow to normal flow during the sonogram is certainly diagnostic of itt, increased testicular flow should not lead to false reassurance. purpose or case report: testicular torsion is a common acute condition in boys requiring prompt and accurate diagnosis. the objective was to evaluate ultrasound accuracy and findings, and clinical predictors in testicular torsion in boys presenting to the stollery pediatric emergency department (ed) with acute scrotal pain. methods & materials: retrospective review of us, surgical and ed records for boys aged month to years, presenting with acute scrotum from to , was performed. age, demographics, clinical symptoms, physical findings, us and surgical techniques, findings and diagnoses were recorded. surgical results and follow-up were used as the gold standard as all pediatric urology in our region is performed at our centre. results: patients presented to ed with acute scrotum with the following diagnoses: testicular torsion, possible torsion-detorsion, torsion of appendix testes, epididymo-orchitis, and other. of us performed, boys had torsion confirmed by surgery. there were inconclusive us reports, none of which had torsion at surgery or follow-up. the false positive rate of us was . % ( patients), and there were no false negatives. six torsion patients had no us. median time from ed to us and surgery for torsion patients was and min. six patients had non-salvageable testes. diagnostic accuracy of us compared to surgery was % for torsion and % for other. sonographic heterogeneity was seen in % of patients with testes that the surgeon felt were non-viable at surgery and % of patients with viable testes (p . ). sudden-onset scrotal pain ( %), abnormal position ( %) and absent cremasteric reflex ( %,) were most prevalent in torsion patients. conclusions: color doppler us is accurate and sensitive for diagnosis of torsion in the setting of acute scrotum. despite heterogeneity on pre-operative us, many testes were felt to be salvageable at surgery. rate of salvage of torsion was high. common symptoms and findings of torsion were sudden onset of pain, abnormal testicular position and absent cremasteric reflex. paper #: pa- diagnostic twists of tubal torsion srikala narayanan, md, children's national medical center, snarayan@childrensnational.org; anjum n. bandarkar, dorothy bulas purpose or case report: fallopian tube torsion is a rare cause of acute pelvic pain in a young female and requires prompt diagnosis for immediate surgical intervention. our purpose is to review varied imaging findings of surgically proven cases of tubal torsion. methods & materials: retrospective review of our data base from to revealed cases of surgically proven fallopian tube torsion. ages ranged from to years of age. all had pelvic ultrasound performed, cases had additional ct performed for acute pelvic pain. results: us findings included thickened dilated tubular hypoechoic structure ( ), cystic mass ( ); adnexal ( ), midline ( ). five cases had normal ovaries bilaterally ( with paratubal cysts). ct imaging findings include dilated, fluid filled, thickwalled tube with internal hyperdensity ( hu) likely debris/ hemorrhage in case. additional findings included cystic adnexal mass ( cases), beak sign ( case) and increased vascularity ( case). secondary signs included free fluid ( ), peritubular fat stranding ( ), vascular congestion and thickening of the broad ligament ( ) and enlarged draining vein ( ). laparoscopic salphingectomy was performed in cases (including cases with isolated tubal torsion). laparoscopic detorsion was performed in a total of cases. in addition, laparoscopic cyst drainage was performed in out of these cases. detorsion with paratubal cystectomy and hemorrhagic ovarian cystectomy was performed in of the cases. conclusions: imaging diagnosis of tubal torsion can be difficult. it can occur in isolation with a dilated thickened tubular structure adjacent to a normal ovary or potentially mimic appendicitis, pyosalpinx, complex adnexal cyst or cystic adnexal neoplasm. presence of normal ovaries, beaked tapered tubular structure with intratubal fluid level and hemorrhage may help in making the diagnosis. it is important to recognize this entity in a patient with acute pelvic pain to facilitate prompt tubal sparing surgery. paper #: pa- adjusted renal length in pediatric bone marrow transplant recipients nicholas bodmer, md, university of washington, nbodmer@gmail.com; teresa chapman, sangeeta hingorani, marguerite parisi purpose or case report: bilateral nephromegaly has been observed in the bone marrow transplant (bmt) patients at our institution. this study aims to quantify this observation, thereby providing radiologists with an adjusted baseline agedetermined renal growth curve for bmt patients. methods & materials: a retrospective clinical chart and imaging review was performed on patients who underwent bmt between and and who had abdominal imaging including the kidneys. ultrasound, ct, and mri exams were used for renal length measurement. renal lengths were assessed for each age group, first as an average length of all the patients within that age group overall, and subsequently as an average renal length by age group divided into the following time frames after transplantation: - days, - days, - days, and + days. clinic chart information collected included bun, creatinine, weight, and medication use. results: renal length was measured using imaging cases, distributed across each age group as follows: - months, n ; months- . years, n ; . - . years, n ; . - . years, n ; . - . years, n ; . years and higher, n . renal lengths were greater, on average, within every age group, compared with previously established normative age-related renal lengths (rosenbaum et al.) . the augmented renal lengths universally were observed in the - day post-transplantation timeframe. return to normal renal lengths typically occurred by months post transplant. clinic chart review revealed that the majority ( %) of patients received nephrotoxic medication within two weeks of imaging. conclusions: pediatric bmt patients have larger kidneys in the absence of known renal disease than age-matched peers. a revised, age-based renal length chart for post-bmt patients has been generated which should help prevent the misdiagnosis of nephromegaly in this population, eliminating unnecessary diagnostic evaluations. multiple etiologies to explain renal enlargement in these patients are possible, including fluid overload, nephrotoxic medication, or direct effect of the transplant. purpose or case report: mr urography can be a comprehensive exam for anatomical and functional pediatric renal evaluation. quantification of renal function may benefit when dynamic contrast enhanced images can be obtained at high spatiotemporal resolution and with minimal respiratory motion artifacts. though respiratory triggering may decrease motion artifacts, it results in loss of temporal resolution by a factor of about three. a two-echo gradient echo sequence with segmented outer k-space sampling and view-sharing/dixon image reconstruction (disco, differential subsampling with cartesian ordering) was chosen as a starting point due to its high temporal resolution. it was then modified to enable respiratory triggering while maintaining temporal resolution of one temporal frame every one to two respirations, with segments of k-space only acquired in the expiratory phase of respiration. imaging parameters were: °flip angle, ± khz bandwidth, tr~ . , matrix x , fov - cm, slice thickness mm, and x spatial acceleration. with irb approval and informed patient consent consecutive patients referred for mri renal function evaluation were recruited (age range; . to . years, mean±sd: . ± . years; males % females %), and scanned on a ge t mr using a -channel torso array with the respiratory-triggered high spatiotemporal resolution technique to extract regional gfr maps. two readers by consensus assessed image qualitative snr, motion artifacts and volumetric fat-water suppression performance. results: data acquisition was obtained to completion in all subjects without triggering failure. temporal resolution was approximately s for two respiratory cycles. no case had major fat suppression failure, whereas minor fat suppression failure was seen in % ( % c.i. to %). all cases had diagnostically acceptable snr. no motion artifacts were noted in / cases, while some artifacts with ghosting in / cases. regional gfr maps could be successfully extracted for each patient without the need for image registration. attached figure shows image quality. conclusions: view-sharing offsets loss of temporal resolution from respiratory triggering. thus, high spatiotemporal resolution renal dynamic contrast enhanced respiratory triggered images can be obtained with minimal motion artifacts in a pediatric clinical setting to evaluate renal function. disclosure: dr. chowdhury has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. methods & materials: the study cohort was selected from the irb approved children's oncology group aren b study. cases are evaluated for pre-operative wt rupture based on central review of surgical/pathology findings. wt cases with rupture were matched to wt controls by age and tumor weight (within months and g). ct scans were independently reviewed by blinded radiologists, for presence/absence of rupture and the following ct signs: poorly circumscribed mass, perinephric fat stranding, peritumoral fat planes obscured, retroperitoneal fluid, ascites beyond cul-de-sac, peritoneal implants, ipsilateral pleural effusion, intratumor hemorrhage. sensitivity, specificity of ct for assessing pre-operative wt rupture was determined. the relationship between ct signs and rupture was assessed by mcnemar's test, and the most predictive ct signs determined by backward selection multivariate logistic regression. results: sensitivity, specificity for detecting wt rupture were: reviewer - . %, . %, reviewer - . %, . %. kappa coefficient for interobserver agreement was substantial: . (p< . ). all ct signs tested, except peritoneal implants and intratumoral hemorrhage, had significant association with tumor rupture (p< . ). for reviewer , ascites and fat stranding around tumor were most predictive (odds ratio . and . , p< . ). for reviewer , ascites and retroperitoneal fluid were most predictive (or . and . , p< . ). conclusions: ct has high specificity but relatively low sensitivity for detecting preoperative wt rupture. the presence of ascites beyond cul-de-sac is the best indicator of preoperative rupture, followed by fat stranding and retroperitoneal fluid. paper #: pa- the failed pyeloplasty: evaluation with mr urography damien grattan-smith, children's healthcare of atlanta, damien.grattansmith@mac.com; ricahrd jones, stephen little, wolfgang cerwinka, hal scherz, andrew kirsch purpose or case report: to identify imaging characteristics associated with failed pyeloplasty seen with mr urography. we have performed mr urography in children following pyeloplasty. from this group, children had follow-up surgical intervention with repeat pyeloplasty or balloon dilatation of the upj. imaging features reviewed included degree of hydronephrosis, calyceal transit times, renal transit times, signal intensity versus time curves, as well as functional analysis based on volumetric and patlak differential function and change in the asymmetry index. results: all children who underwent a second surgical procedure had delayed calyceal transit times. the degree of hydronephrosis and renal transit times were either stable or worse when compared to pre-operative evaluation. functional derangement could show stability, slight improvement or deterioration. the asymmetry index estimated the severity of the obstruction. conclusions: mr urography is valuable in the evaluation of children who have undergone pyeloplasty. the calyceal transit time appears to be the most reliable discriminator when comparing successful and failed pyeloplasty. calyceal transit times may be prolonged before the hydronephrosis becomes progressive. disclosure: dr. grattan-smith has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: initial attempts at interpreting functional mr urography (fmru) can be challenging. a time intensive navigation through a multitude of both subjective and objective functional results is necessary to render a useful interpretation. this is a guided review of fmru, noting the important functional findings in high-grade unilateral pelvicalyceal dilatation (pcd), in the absence of ureterectasis, with a contralateral normal kidney allowing for an optimal functional comparison. methods & materials: a retrospective functional evaluation of cases with unilateral pelvicalyceal dilatation (pcd), without prior pyeloplasty, was conducted. the fmru studies were carried out according to a standard protocol and post-processing using the chop-fmru software. this included iv hydration, bladder catheterization and iv furosemide administration. fifteen minutes after diuretic administration, a dynamic coronal d fat saturated t sequence was performed in a supine position over min. a sagittal d t and delayed single coronal t , both fat saturated, followed in a supine and/or prone position. the following functional features were evaluated: visualization of the ureter, the presence of a contrast-urine level and swirling of contrast in the dilated renal pelvis. the functional results included in the analysis were calyceal transit time (ctt), renal transit time (rtt), time-to-peak (ttp), parenchymal volume (pv), differential renal functions (volumetric-vdrf, patlak-pdrf and volumetric patlak-vpdrf) and the difference between vdrf and pdrf. results: patients were comprised of males and females with an age range of . - . years (median . yrs). of the kidneys with pcd, the ureter was visualized in , during the dynamic sequence, / during supine delay and / only in prone position. a contrast-urine level was present in of the dilated systems, and swirling in . the ureter was visualized during dynamic sequence in all contralateral normal kidneys and at no time was swirling or a contrast-urine level identified. the average functional parameters are seen in table . a statistically significant (p< . ) difference between the normal and dilated pelvicalyceal systems was achieved in ttp, pdrf and vpdrf for this small sample size. conclusions: awareness of multiple functional features and the range of calculated results may aid in subsequent combined interpretation of the fmru with the morphologic analysis. disclosure: dr. lecompte has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. and . demographics, clinical presentation , diagnostic studies and treatment outcomes were evaluated. post-procedure imaging was evaluated for clot burden reduction (patency) and residual venous stenosis by two-reader consensus. results: ten patients ( male; female, mean age years, range - ) presenting with acute upper extremity swelling and pre-procedure imaging revealing % occlusion of the axillary and subclavian veins received successful endovascular therapy. all patients underwent infusion catheter placement for thrombolysis with tissue plasminogen activator or urokinase. patients received additional pharmacomechanical treatment. angioplasty was also performed in all patients. the mean treatment duration was h (range - ). post-procedural imaging revealed that of patients achieved - % patency (clot burden reduction) and patient achieved - % patency. the residual venous stenosis was graded: patients had - % stenosis, patients had - % stenosis and patients had - % stenosis. all patients were discharged on full anticoagulation therapy with low molecular weight heparin. patients had surgical rib resection postthrombolysis with an average length of time from thrombolytic therapy to surgery being days (range - ). patients had re-thrombosis events during the follow-up period (mean months; range - ), with one re-thrombosis event occurring within one week of thrombolytic therapy, prior to surgery and the other two occurring - weeks post-rib resection. there were no procedure related complications. one patient was lost to follow-up after initial successful catheter directed therapy. conclusions: percutaneous endovascular techniques such as pharmacomechanical thrombolysis and angioplasty appear to be feasible and safe options for paget schroetter syndrome in otherwise healthy adolescent patients. in attempt to prevent rethrombosis and chronic symptoms, we refer all patients for adjunctive surgical decompression. future larger studies are needed to address optimal strategies for these patients. combined d fluoroscopy image guided percutaneous intervention with real-time optical sensing at the tip of a needle for tissue characterization rami nachabe, philips, rami.nachabe@philips.com; john m. racadio, drazenko babic, ross schierling, jasmine hales, benno hendriks purpose or case report: to investigate the feasibility and potential of real-time tissue characterization at the tip of a needle with diffuse optical spectroscopy (dos) sensing capabilities during d fluoroscopy guidance using cone beam ct and dedicated needle path planning software. methods & materials: a c-arm x-ray system that combines fluoroscopy and d imaging from a cone beam ct was used to image a woodchuck with hepatocellular carcinoma (hcc). the imaging system enabled needle path planning, which was used to perform insertion and navigation of a needle toward the liver tumor. the needle was integrated with optical fibers for real-time tissue spectral sensing at its tip. optical spectra measurements were obtained continuously as the needle passed through healthy liver tissue and then into the tumor. from the diffuse optical spectra measurements, the following clinical parameters were extracted for tissue characterization: blood volume fraction, blood oxygenation, lipid volume fraction and tissue light scattering (related to tissue density). the tissue parameters were compared for healthy liver and tumor using the kruskal-wallis test. results: the tissue density of the healthy liver was lower than that of the tumor. higher blood and lipid volume fractions as well as oxygenation levels were observed in the healthy liver as compared to the tumor. all differences were statistically significant (p< . ). additionally, a much wider heterogeneity in tissue density was observed in the tumor as opposed to the healthy liver. conclusions: differences in tissue properties between tumor and healthy liver enable discrimination between these two types of tissues. adding real-time optical sensing at the tip of a needle to d fluoroscopy image guidance is a feasible technique that complements the imaging information with relevant physiological parameters; it facilitates more precise definition of tumor boundaries despite any target motion during needle insertion. disclosure: dr. racadio has disclosed that he is a consultant for philips healthcare and receives travel reimbursement. rami nachabe, drazenko babic and benno hendriks are employees of philips healthcare. methods & materials: two children aged months and months were treated at this institution for liver failure resulting from urea cycle disorders, with a hepatocyte transplant procedure. the recipient liver was irradiated prior to transplant to facilitate engraftment. the procedure involves the injection of prepared hepatocytes from a suitably screened, compatible donor, via a main portal vein branch into the recipient liver. in both procedures access to the umbilical vein was achieved by the surgery service and a french arterial sheath was placed. a french angled catheter was used for diagnostic runs and to access the right and left main portal vein. a french fogarty catheter (edwards lifesciences, irvine, ca) was placed to isolate each portal vein branch in turn and hepatocytes injected using hand injections. pressures in the main, right and left portal veins were measured and hand injections of contrast made at regular intervals. careful attention must be paid for evidence of pruning of portal branches, indicating occlusion of small portal branches, or portal to hepatic vein shunting. if shunting is seen, infusion must be stopped as embolism of hepatocytes into pulmonary arteries may result with serious clinical sequelae results: in both patients, the desired number of hepatocytes were successfully delivered into the recipient liver. in both cases, mild pruning of the portal vein branches was evident at the end of the procedure. portal vein presssures remained steady. there was no venographic or clinical evidence of pulmonary arterial embolization. conclusions: the interventional radiologist plays a central role in the hepatocyte transplant procedure. familiarity with catheterizing portal branches from an umbilical vein approach, measuring venous pressures, using small occlusion catheters and recognizing venographic end points such as portal vein pruning and portal to hepatic vein shunting are necessary to the safe and successful completion of this new technique. purpose or case report: the aim of the study was to evaluate the trends in term of type of tube placed, number of procedures per year, number and age of the patients as well as the number of procedures per patient and the interval of time between two placements, and finally the irradiation burden borne by the patients. methods & materials: after reb approval the radiologic files of the patients who underwent naso-duodenal-jejunal (ndj) or gastro-jejunal (gj) or jejunal (j) tube placement under fluoroscopy over the past five years ( to ) were extracted from the ris and reviewed. the results were tabulated as a single batch and stratified by year. results: eighty-nine patients representing procedures ( ndj, , gj, j) were included. only patients underwent a single procedure. the average number of procedures per patient was . with a maximum of during the study period. the average patient's age was . months (sd . , median . ). the average fluoro time per procedure was . min (sd . , median . ). the average interval between two procedures was days (sd , , median ). the average fluoroscopy time per patient combining those having a single procedure and those having multiple ones, was . min (range . to . , sd . , median . ). conclusions: fluoroscopic placement of enteric tubes delivers a significant amount of irradiation. our data led to two interventions with respect to insertion and management of the tubes. on one hand, when the attempt pursued by a radiologist is not successful after min of fluoroscopy other strategies should be considered including another operator or an alternative technique for tube positioning. on the other hand, information will be distributed toward the clinicians and nurses in order to improve the management of these tubes and avoid fortuitous displacement which was responsible of a significant amount of repeated procedures leading to undue irradiation. purpose or case report: to evaluate drug elution pharmacodynamics of doxycycline in an albumin-based solution, as used in percutaneous imaging-directed therapy of aneurysmal bone cyst (abc) and microcystic lymphatic malformation (lm) methods & materials: doxycycline mixed with % human serum albumin (hsa), and doxycycline mixed with saline solution (both mg/ml) were evaluated using a fluid diffusion chamber system over h, recording ph and doxycycline concentration. static ph and doxycycline concentrations were recorded every min for the first min, then every min for a total of h, averaged over trials in each of the hsa and saline systems. statistical analysis evaluated standard deviation and rate of change for the trials in each system. drug elution dynamics data were correlated with clinical experience in the doxycycline/albumin treatment of patients ( treatments) with aneurysmal bone cyst (abc) and patients with lymphatic malformation microcysts. results: drug elution was linear in both the hsa and saline systems, with statistically significant (p<. ) slower elution drug release from the albumin system as compared with the doxycycline and saline solution, both over and h. purpose or case report: to describe a successful interventional radiologic approach to the management of paget schroetter syndrome presenting as acute arm swelling in adolecent athletes. methods & materials: institutional review board approval was obtained for this retrospective study. five patients aged to years (mean . years) were treated at this institution over a year period all presenting with acute arm swelling (july -july ). ultrasound confirmed subclavian vein thrombosis in all cases. all were treated with placement of an infusion catheter (ev , plymouth, mn), infusion of tissue plasminogen activator (tpa) at a rate of mg/hour overnight and aspiration of remaining clot with a "trellis" (bacchus vascular, santa clara, ca, usa) thrombectomy device. results: clot was successfully removed in all five patients. complete clearance of clot was confirmed by contrarst venography in all cases. in four patients balloon angioplasty of a narrrowing at the junction of the subclavian and brachiocephalic veins was carried out. in one, the thrombus recurred within h. the patient was retreated the next day with aspiration of clot using the "trellis" device and an infusion catheter placed with low dose ( . mgs/hour) tpa commenced until surgical review; this patient was operated on within h of final thrombolysis. all patients were seen by a vascular surgeon with an interest in this condition. all underwent surgical decompression; at end of the study period all patients were asymptomatic. conclusions: interventional radiologic management of acute axillo-subclavian thrombosis due to paget schroetter syndrome is safe and highly successful in the adolescent population. early recurrence of thrombus is not uncommon and prompt surgical consultation with a view to early surgical decompression is recommended. purpose or case report: diagnostic reference levels (drl) or target radiation dose ranges for pediatric ct scans are needed in the u.s. the first u.s. pediatric ct dose index registry (quircc) within the american college of radiology recorded estimates of patient radiation dose using a new method (ssde) based on body width(bw) for the purpose of developing diagnostic reference levels (drl). in addition to developing drl at the th percentile, the purpose of this study was to determine the ssdes associated with the lower range of acceptable image quality through subjective image quality evaluation. methods & materials: six children's hospitals participated in a retrospective review of abdominal ct with iv contrast on patients < yrs of age. from exams, each site submitted de-identified images for selected cases based on ssde and patient width. a total of cases were selected from the lowest, first quartile and median ssde. six investigators reviewed images from each case under identical viewing conditions and rated them for subjective quality according to a score sheet and reference scale of images with known quantum mottle. cases were considered non-diagnostic if at least of reviewers ranked them as such. results: first, second, and third quartile ssde and ctdi-vol values from sites for each bw will be shown. / cases were ranked non-diagnostic by the reviewers. / non-diagnostic cases were below the th percentile based on ssde. / of "non-diagnostic" cases had ssde less than the th percentile. the unacceptable case with ssde above the th percentile ( cm, ssde . mgy) was due to subcutaneous metal implant with artifact. the quircc th percentile using ctdivol for a yr old is . mgy which is % lower than the acr ct accreditation data's published th percentile. conclusions: this consortium developed target dose ranges (drls) for ct of the abdomen with iv contrast for routine exam indications based on evaluation of image quality that establish lower and upper ranges ( - percentile) of patient dose(using ssde) associated with clinically acceptable images. this study demonstrates that pediatric radiologists in this consortium are comfortable interpreting images at or above the percentile ssde and judged all but one image within this target range as diagnostically acceptable. table ). with the exception of neonate chest, most used age-based techniques; only two centers reported using thickness. no survey used grids for wrist images, while / of the surveys used grids for chest and abdomen exams in -year-olds. at the most common sid there was up to a kvp variation ( year-old chest ap) and up to -fold variation in mas ( year old scoli lat). only two surveys used equipment that displayed the new iec exposure index. conclusions: participants report variability in the techniques and methods used to acquire common radiographic studies, reflecting differences between detector types and users. radiologists, technologists, medical physicists, manufacturers, and the fda have an opportunity to work together to standardize the techniques based on detector type to optimize radiation exposure for pediatric radiographic exams. disclosure: dr. don has indicated that he performs contract research for carestream and that he is on the speaker's bureau for siemens and receives an honoraria. purpose or case report: this study assesses community adoption of ct radiation dose guidelines after a -year international initiative to reduce medical radiation exposure in children. size-specific dose estimates (ssde) from community pediatric body ct scans are compared to ssde from matched scans obtained at a children's hospital that adheres to image gently campaign principles. we reviewed pediatric ct scans ( chest (c), abdomen/pelvis (ap), chest/abdomen/ pelvis (cap)) transferred from community imaging centers to our university children's hospital between july and february . community scans were acquired with variable parameters and reconstructed with traditional filtered back projection (fbp). comparison was made to children's hospital ct scans, performed in accordance with principles of the image gently campaign. because iterative reconstruction (ir) software was added to our scanner during the study, enabling us to reduce ctdivol by %, children's hospital scans were divided into two groups: a) scans obtained with standard weightbased pediatric protocols and fbp (october -october ; c, ap, cap) and b) scans obtained with reduced-dose weight-based pediatric protocols and blended ir/ fbp (october -april ; c, ap, cap). ctdivol and greatest lateral dimension were recorded from each scan and were used to calculate ssde. mean ssde from community scans was compared to mean ssde from children's hospital groups a and b. statistical analysis was performed with student's t-test. results: patient age range was - years in both community and children's hospital groups. mean ssde for community c, ap, and cap scans was . , . , and . times higher than mean ssde for matched scans in control group a (p< . ) and . , . , and . times higher than mean ssde for matched scans in control group b (p< . ). conclusions: ssde was significantly higher for community pediatric body ct scans than for matched scans performed at a children's hospital that adheres to image gently campaign principles. results suggest that more community outreach and education are required in implementation of low-dose ct protocols outside of children's hospitals. concurrent use of ir provides a means of achieving even greater ssde reduction than is possible with fbp alone and should be encouraged. paper #: pa- optimization of tube voltage and current in size-based pediatric ct imaging: a phantom study boaz karmazyn, md, radiology, riley hospital for children, bkarmazy@iupui.edu; yun liang, keith kaser, peter johnson, mervyn cohen purpose or case report: determine the change in ct dose index (ctdivol) required to maintain the same quantum mottle noise when using lower tube voltages ( and kvp) relative to kvp in different sized cylinder water phantoms (cwp) representing a wide range of pediatric body sizes. we performed mdct scans of , , , and cm cwp. thirty scans were performed for each phantom. the tube currents ranged from to mas with increments of mas, and the tube voltage levels were , , and kvp. the noise (standard deviation in hu) was measured using center region of interest (roi) that was % of phantom's area. two other rois (each % of the area) were placed at the center and periphery of the phantom images to measure noise gradient. results: in the smallest ( cm) cwp, approximately the same noise level was maintained with all three tube voltages without a significant change in ctdivol. for the , , and cm phantoms, the average ctdivol needed to be increased by %, %, and %, respectively, to maintain same noise level when the voltage was decreased from to kvp. the average ctdivol needed to be increased by %, % and % to maintain the same noise level in the , , and cm cwp when the tube voltage was decreased from to kvp. the difference between central and peripheral noise increased on average by . %, . %, . %, and . % in the cwp of , , , and cm, respectively. in each cwp, the central to peripheral noise difference was more pronounced (up to . % more) with decrease in kvp from to or . conclusions: noise measurements in the water phantom model indicate that tube voltage could be decreased from to in cwp of cm without significant change in ctdivol. it is also possible to decrease the voltage from to kvp with a minimal (< average %) increase in dose in cwps of , , and cm. the noise gradient increases with larger cwp and smaller kvp. paper #: pa- comparison of radiation dose estimates, image noise, and scan duration in pediatric body imaging using -row and -row ct jennifer johnston, md, radiology, cincinnati children's hospital medical center, jhtai@yahoo.com; daniel j. podberesky, erin angels, terry t. yoshizumi, greta toncheva, donald p. frush purpose or case report: to compare effective dose (ed) estimates, image noise, and scan duration for pediatric chest, abdomen and pelvis protocols using -row and -row ct scanners in various acquisition modes. methods & materials: organ doses were measured using mosfet dosimeters. dose, scan duration, and noise measurements were made in a -year-old anthropomorphic phantom for conventional helical, -detector helical and volume acquisition modes for chest, abdomen and pelvis protocols on a -row ct, and for helical mode on a row ct (aquilion one and aquilion , toshiba medical systems, otawara, japan) using similar scan parameters representing currently used clinical protocols. mean organ doses from three runs for each protocol, in combination with icrp tissue weighting factors, were used to obtain ed for each protocol. noise was measured as the standard deviation of hounsfield units in equivalent locations at levels for each protocol with an roi tool. ed and noise were compared with a paired t-test or sign test. results: compared to helical acquisitions on the -row ct, ed of all tested acquisition modes on the -row volume ct were significantly lower for chest, abdomen/pelvis (ap) and chest/abdomen/pelvis (cap) protocols (table) . scan durations were lower across the board on the -row volume ct. compared to acquisitions on the -row ct, noise was in general similar to those on -row ct protocols, but some acquisition protocols on the -row ct produced greater noise (table) , specifically volume acquisition for chest ct and -detector helical and volume modes for ap and cap protocols. conclusions: dose savings can be achieved for chest, ap and cap ct examinations on a -row ct scanner compared to helical acquisition on a -row ct, with shorter scan durations. image noise was in general comparable between protocols. although noise differences between some modes did reach statistical significance, the impact on overall image quality will need to be studied further. paper #: pa- the observed to expected total fetal lung volume as a predictor of short-and long-term morbidity in surviving infants with congenital diaphragmatic hernia emily stenhouse, the royal hospital for sick children, emilysten@doctors.org.uk; neil patel, judith simpson, watt andrew, gregor walker, carl davis purpose or case report: observed-to-expected total fetal lung volume (o:e tflv) is a validated mr measure which we have previously demonstrated to be significantly reduced in non-surviving infants with congenital diaphragmatic hernia (cdh). our aim was to investigate the relationship between o:e tflv and short-and long-term morbidity outcomes in surviving infants with cdh. methods & materials: a retrospective analysis of cases of isolated left-side cdh referred to our institution for fetal mr evaluation between - weeks. mr imaging studies were performed on a . t philips system using a phased array body coil. the observed tflv was calculated by multiplying the summed area of the region of interest by the section thickness. the expected tflv was calculated with a formula previously described in the literature using the gestational age of the fetus. the observed tflv was expressed as a percentage of the expected tflv at a given gestation. morbidity outcome data was obtained from the case records of all surviving infants. specific measures of illness severity relating to short-term intensive care management and long-term outpatient management were recorded. differences in o:e tflv between outcome groups were assessed by t-test. results: liveborn infants with isolated left-side cdh and antenatal mr scans were identified. scans were performed at - weeks gestation. infants survived to discharge; gestation . ( . - ) weeks, birth weight . ( . - . ) kg. median length of admission was ( - ) days, median duration of follow-up was . ( . - . ) years. o:e tflv was significantly lower in non-surviving infants; vs. %, p . . o:e tflv was significantly lower in infants who received high frequency oscillation ventilation (hfov) versus those who were conventionally ventilated ( % vs %, p . ). o:e tflv was also significantly lower in those infants who had a length of admission greater than the median of days ( % vs. %, p . ). o:e tflv trended lower with other measures of increased morbidity; inhaled nitric oxide use, patch repair of diaphragm, rehospitalisation within year, supplemental feeding at discharge, gastro-oesophageal reflux, and developmental delay. conclusions: as well as predicting survival, lung volume measurement by o:e tflv is a promising predictor of outcome and morbidity in surviving infants with cdh. further studies in larger populations are required to provide quantitative predictive risk data. characterization of the inherent acoustic noise of a dedicated nicu mri system jean tkach, phd, cincinnati children's hospital medical center, jean.tkach@cchmc.org; yu li, ron g. pratt, christopher villa, beth m. kline-fath, charles dumoulin purpose or case report: we have developed a small foot print . t mri scanner specifically for neonatal imaging that can be easily installed in a neonatal intensive care unit (nicu). the scanner has a maximum patient bore diameter of . cm (without rf coil), and roughly twice the gradient performance of the best conventional adult whole-body . t mr systems. it is known that sensory stimulation such as acoustic noise can elicit autonomic instability in both term and preterm neonates. the inherent noise properties of the nicu mri system were measured as part of the initial safety evaluation of the system and compared against that of a conventional . t mri system. to evaluate the inherent acoustic noise characteristics of the nicu mri scanner, sound pressure level (spl) measurements were performed on it and on a conventional adult sized whole body . t hdx ge mri system (ge healthcare, waukesha, wi). a brüel & kjaer model sound level meter (brüel & kjaer sound & vibration measurement a/s, denmark) was used to perform the spl measurements for several different mr acquisitions (spin echo, gradient echo, fast rf spoiled gradient echo, fully balanced steady state free precession, gradient echo echo planar, and diffusion weighted) using acquisition parameters consistent with clinical protocols. the mr sequences, acquisition parameters, noise measurement equipment and methodology were identical for the two mr systems. the maximum spl in units of a weighted decibels (dba) was recorded for each of the mr acquisition/mr system combinations evaluated. results: the maximum spl values measured during each of the mr acquisitions were lower for all sequences (average . dba (range - dba)) for the nicu mri unit as compared to the conventional mri scanner ( table ). the average measured maximum spl value, reported in dba, across all acquisitions was . ± . for the nicu scanner, and . ± . for the conventional mri scanner. the highest spl values were measured for the diffusion-weighted sequence: and dba, for the nicu and conventional mri scanner respectively. conclusions: because of the smaller dimensions of the gradient coils in the nicu mri system, acoustic noise is less than that of conventional mri scanners despite the superior gradient performance of the smaller coils. the lower inherent acoustic noise level of the nicu system provides improved safety for the neonate, and facilitates siting of the unit in the nicu. disclosure: dr. tkach has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. paper #: pa- late neurologic events in extremely premature infants carlos guevara, md, radiology, duke university, cjg @duke.edu; brett bartz, caroline l. hollingsworth, caroline w. carrico, michael c. cotten, charles m. maxfield purpose or case report: germinal matrix hemorrhage (gmh) is a major complication of prematurity. persistence of germinal matrix and immature neurovascular autonomic regulation in the premature neonate is thought to predispose to gmh. most gmh in premature population occurs during the first days of life, and yet the persistence of the germinal matrix to weeks gestation may allow for post-natal gmh outside of the immediate perinatal period. to our knowledge, this is the first systematic review of late gmh (after the first week of life) in a large population of extremely preterm neonates (less than weeks of gestation). this irb approved retrospective review included patients weighing less than g or born at less than weeks of gestation from through . the study population included infants who had a head ultrasound (hus) within the first week of life and at least one follow hus after the first week of life. all hus were reviewed by three experienced pediatric radiologists for the presence and grade of ich or late developing hemorrhagelike lesions (hll). infants with and without hll were evaluated for several clinical variables, including neurodevelopmental outcomes (bayley scales). results: average gestational age of study population was . weeks. the incidence of gmh in the first week of life was % grade , . % grade , . % grade / , and . % posterior fossa. new echogenic foci (hll) at the caudothalamic groove were seen in . % after the first week of life. % of these lesions were bilateral. a four-fold increase in incidence of hll was seen in infants < g compared to those> g. higher grade hemorrhages were not seen in this patient population, although % of infants had late posterior fossa hemorrhages. the clinical course of infants with hll trended towards a higher incidence of stressors, but this was not statistically significant. the psychomotor development index scores were lower than those infants without hemorrhage. conclusions: small hll at the caudothalamic groove are common in extremely preterm infants after the first week of life. higher grade ( - ) hemorrhages were not seen. there were no cases of intraventricular extension and no direct complications. if isolated, this finding necessitates no follow-up imaging, but may be associated with poor neurodevelopmental outcome. disclosure: dr. guevara has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: tof/apv is a rare congenital heart lesion in which pulmonary arteries may become aneurysmally dilated and compress adjacent airways. pulmonary arterioplasty is often required to relieve tracheobronchial compression in addition to intracardiac repair. the purpose of this study was to review pre and postnatal imaging findings and their impact on patient management and clinical course. methods & materials: a retrospective database search identified infants with tof/apv between - ( fetal diagnosed cases and diagnosed postnatally). for fdc, prenatal ultrasound (us) and fetal mri were correlated with postnatal ct for the size of the central pulmonary arteries, airway compression, and presence / distribution of air trapping/atelectasis. for all cases postnatal ct findings (between - days of age) were correlated with clinical management and outcome. results: prenatal diagnosis of tof/apv was suggested sonographically, based on dilated central pas, between - weeks gestational age (ga). fetal mri, performed between - weeks ga confirmed the diagnosis and aneurysmal central pas and demonstrated air trapping &/or atelectasis in / with normal appearing lungs in fetus. size of the pas ( / ) and presence and distribution of lung abnormality ( / ) correlated closely between fetal mri and postnatal ct, although detailed visualization of the central airway/ vascular relationships were better defined on ct. fetal mri identified an unexpected diaphragmatic hernia (dh) not seen on us. for the pnd cases, ct showed aneurysmal pas and airway compression with air trapping &/or atelectasis in / infants. seven infants with airway obstruction on ct required pulmonary arterioplasty; infant with no air trapping did not have arterioplasty. / operative patients survived, one with concomitant dh died at age days due to hemorrhagic shock. one fdc was inoperable due to poor cardiac function and died at age days. conclusions: prenatal mri correlates well with postnatal ct for assessing pulmonary artery size and location and severity of lung abnormality in patients with tof/apv, this allows for appropriate management planning and may negate the need for an immediate postnatal ct. ct accurately depicts the location and extent of airway compression and resultant air trapping or atelectasis, serving to guide the need for and extent of the arterioplasty procedure. paper #: pa- craniosynostosis syndromes: prenatal findings by us and mri eva rubio, md, cnmc, rubioeva@yahoo.com; anna blask, alexia egloff, dorothy bulas purpose or case report: craniosynostosis with associated malformations is a feature of several related syndromes resulting from a fgfr or twist genetic mutation. syndromes include apert, crouzon, pfeiffer, and carpenter syndromes. our purpose was to review imaging findings which aid in suggesting the diagnosis prenatally. we retrospectively reviewed prenatal us and mri findings in cases with prenatal ( with postnatal/molecular) diagnosis of a craniosynostosis syndrome: cases of apert, case of carpenter, and cases of pfeiffer syndrome. results: / cases were correctly diagnosed prenatally. in the second trimester findings may be subtle, with mild calvarial changes; digit abnormalities, in particular, may elude the imager in unsuspected cases. although the diagnosis could be made with either modality, the full spectrum of abnormalities was best appreciated using a combined imaging approach of mri and us. by us many salient features were depicted: turribrachycephaly/trigonocephaly/cloverleaf ( / ); syndactyly ( / ); polydactyly ( / ). agenesis of the corpus callosum was identified by us in ( / ) cases. conversely, mri, performed in all cases, contributed additional observations not well seen by us: the fetal airway was well delineated in all cases ( / ); a low lying spinal cord was noted ( / ), midface hypoplasia ( / ) and migrational/sulcation abnormality ( / ). additional findings of absent ductus venosus with biliary atresia ( / ), abdominal wall defect ( / ) and renal anomalies ( / ) were seen with both modalities. reimaging in later pregnancy depicted important changes ( / ), including worsening hydrocephalus and resolution of suspected airway occlusion. conclusions: us and mri are complementary modalities in evaluating fetuses with craniosynostosis. airway patency, midface hypoplasia, spinal cord abnormalities and intracranial abnormalities are often better seen with mri. fetal activity, digits, bone detail, and cardiac anomalies are better appreciated by us. findings may be subtle in the second trimester. repeat imaging in later pregnancy may reveal specific information affecting delivery planning. paper #: pa- pcpra best paper hyperpolarized carbon- mrsi for pediatric disease john mackenzie, md, department of radiology and biomedical imaging, ucsf, john.mackenzie@ucsf.edu; yi-fen yen, linda nguyen, jeffrey gu, john kurhanewicz purpose or case report: to study the potential of carbon- mr spectroscopic imaging ( c-mrsi)-a radiation free molecular imaging strategy-for the detection and treatment monitoring of pediatric disease. methods & materials: the potential of c-mrsi to detect pediatric disease was tested in rodent models of pediatric arthritis. animals were induced with arthritis and subsequently given intravenous hyperpolarized c-pyruvate, and imaged. the amount of c-lactate produced from pyruvate in normal and arthritic joints was measured both at single points in time and dynamically at either or tesla. the c-mrsi data were compared with clinical measures of arthritis, cell stimulation studies, and joint changes on conventional anatomic mri and histology. results: alterations in lactate production as measured by c-mrsi appear to depict sites of arthritis and correlate with other more established but potentially less reliable or more invasive measures of disease status. imaging robust mouse models of pediatric disease may be feasible at telsa. this method may also be translated from high-field to clinical equipment with reasonable hardware and software modifications that allow detection of hyperpolarized c compounds. c-mrsi depicts increased lactate production at specific regions of inflammation within arthritic joints and is confirmed by histological inspection and anatomic mri. on average, lactate production is increased by % in areas affected by inflammation. conclusions: the intravenous injection of hyperpolarized carbon- compounds and subsequent imaging with c-mrsi provides a unique molecular imaging strategy to noninvasively monitor pediatric disease. this non-invasive imaging strategy may eventually provide clinical utility for several pediatric diseases involving inflammation, infection and tumor. disclosure: dr. mackenzie has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. methods & materials: using the hemangioma-vascular malformation clinic registry at cincinnati children's hospital, we searched for patients diagnosed with khe whose evaluation included mri. twenty such patients were found, although three of the patients had no pre-therapy mris. the imaging studies were reviewed by the authors with assessment of the following characteristics: location, margin definition, soft tissue involvement, and pre and post contrast signal intensity. results: location: lesion location was as follows: trunk ( ), extremity ( ), extremity plus trunk ( ), and head/neck ( ). signal: all lesions were dark on t weighted sequences with diffuse enhancement after contrast administration. the majority of the lesions were bright on t weighted sequences, but there were cases that had heterogenous to low t signal (with all involving the retroperitoneum). of the cases, only one had both high arterial and venous flow by mri. margin definition: four of the lesions had well defined borders (greater than % well circumscribed) with minimal to no adjacent infiltration/edema. two of those four cases were exophytic masses. the remaining cases were poorly defined lesions with adjacent infiltrative fluid signal intensity and enhancement. tissue/organ involvement: tissue/organ involvement was counted if abnormal fluid-signal intensity or enhancement was identified at that site. review of these cases showed fifteen patients with muscular involvement. dermal and subcutaneous involvement was observed in all but cases, with the uninvolved lesions being isolated and deep. additional sites of suspected involvement included bone ( ), pleura ( ), penis ( ), and pancreas ( ). conclusions: khe is a rare neoplasm of infancy with a spectrum of features by mri. poorly defined lesions are much more frequent than well-circumscribed masses. however, pathologic correlation of such infiltrative margins is usually not available as treatments after biopsy are primarily medical rather than surgical. common additional mri features include predominant involvement of muscle, subcutaneous fat, and skin over viscera and bone with lesions generally showing increased t signal and enhancement. is dedicated chest ct needed in addition to pet ct for evaluation of pediatric oncology patients? ibrahim tuna, montefiore medical center, dristuna@yahoo. com; jeffrey levsky, jeremy rosenblum, rosanna ricafort, benjamin taragin purpose or case report: to evaluate the diagnostic accuracy of low dose ct performed during pet-ct as compared to dedicated chest ct in the assessment of pulmonary findings in children with malignancy. the institutional review board approved this hipaa compliant research. pediatric oncology patients, ages between - , with known solid malignant tumors who were referred to pet-ct and standard chest ct within days for staging or assessment of treatment response between - and - were eligible for this retrospective study. radiology reports were reviewed for potential discrepancies. two radiologists re-evaluated the standard chest ct and low dose chest ct portion of the pet ct of the discordant cases, while comparing with the most recent prior studies. studies were scored for pulmonary nodules, bony metastasis, adenopathy, and pleural effusions. true discrepancies were assessed by a panel of pediatric oncologists to judge whether the differences in reports might lead to a significant change in management. results: ( female, male) patients were identified. radiologic reports of different patients ( female, male) had potential discrepancies based on review of the reports. the primary tumors were rhabdomyosarcoma (n ), hodgkin's lymphoma (n ) and others (n ). reevaluation of the original images showed true discrepancies in . % ( / total ). in studies, the discrepancy had no clinical significance. in studies, a pulmonary nodule was identified on standard chest ct which was not described on the pet-ct. both of these patients had rhabdomyosarcoma. one of these patients had findings that pediatric oncologists considered significant enough to alter patient management. conclusions: we found a low false negative rate for clinically significant findings on the low dose portion of pet-ct as compared to standard chest ct. in the future, improvements in acquisition technique and post processing of the ct portion of the pet-ct may further improve its diagnostic utility, obviating the need for a routine separate diagnostic ct, thereby minimizing radiation exposure in these young patients. methods & materials: low-dose cta examinations were performed in pediatric patients over a three year period to evaluate suspected vascular traumatic injury with some patients receiving scans of more than one area of the body. areas scanned in this include the head and/or neck (n ), chest (n ), abdomen and/or pelvis (n ), upper extremity (n ) and lower extremity (n ). in of these patients, suspected vascular injury was due to a history of either blunt (n ) or penetrating (n ) trauma. patients were referred directly from the emergency department, while were inpatients and the remaining were referred from an outpatient setting. patients ( f: m) ranged in age from to years old (mean age ). studies were performed on a -channel mdct scanner with or kv, to mas, . to . mm section thickness, reconstructed with % overlap, and . to . pitch. contrast medium was power-injected using weight-based protocols to optimize iodine delivery. exams were interpreted on a workstation using advanced imaging techniques. patient radiation dose was calculated in all cases. clinical outcome was assessed through a month follow-up when possible. results: all studies were technically adequate. . % (n ) of studies revealed no vascular injury, while . % (n ) revealed acute vascular pathology. vascular injuries included vascular occlusion (n ), vasospasm (n ), narrowing/dissection (n ), pseudoaneurysm (n ), and transection (n ). extravascular traumatic findings were demonstrated in . % (n ), including fractures, lung injury, soft tissue hematomas, and a ruptured baker's cyst. of the patients with acute vascular findings, . % (n ) underwent surgical management (including for vascular injury), while . % (n ) were managed conservatively. one patient with active extravasation was managed with angiographically-guided embolization. in no case was catheter angiography required to confirm cta findings. conclusions: low dose cta is a reliable means to screen pediatric patients emergently for acute vascular injury. vascular and non-vascular pathology can be diagnosed noninvasively for efficient patient management. paper #: pa- elasticity measurement by acoustic radiation force impulse (arfi) technique of normal liver, kidney and spleen in healthy children mi-jung lee, radiology, severance children's hospital, mjl @yumc.yonsei.ac.kr; myung-joon kim purpose or case report: there are many previous studies about using acoustic radiation foce impulse (arfi) value to measure the elasticity of tissue, mainly the liver in adult patients. however, there was limited study about arfi measurement in the children. the purpose of this study is to evaluate the arfi value in the normal liver, kidney and spleen in healthy children and to evaluate the effect of sex, age, and body mass index (bmi). the study prospectively enrolled healthy pediatric volunteers who are under years old, and underwent abdominal ultrasonography and arfi between july and august . arfi velocity measuring was performed by - mhz linear probe for children under years old and - mhz convex probe for older children. arfi velocity was measured three times at each organ. however this measurement was stopped if the child cannot tolerate. results: two hundred two children (m:f : ; mean age, ± . years) were enrolled. and arfi measurement was performed only two time for some organs in three children. the mean arfi value was . ± . m/s in liver, . ± . m/s in right kidney, . ± . m/s in left kidney, and . ± . m/s in spleen. arfi velocity was not different between boys and girls. however, arfi velocity was different between right and left kidneys (p . ). the arfi value of right kidney, left kidney and spleen was correlated with age, height, weight and bmi (p< . ). however, the arfi value of liver was not correlated with these parameters. conclusions: arfi measurement is feasible in children with only three times acquisition for each abdominal organ. the mean arfi velocity was increased according to the age, height, weight and bmi in kidney and spleen, but it was constant in liver. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: diagnostic image quality can be achieved over a wide range of radiation exposure in digital radiography. "exposure factor creep" or "dose creep'" in which technologists tend to increase dose to avoid the appearance of noise has been well described. using the alara principle, acceptable images can be achieved while minimizing dose. at our institution "dose creep" has been observed in bedside pediatric chest radiography. to address this we coupled a data mining tool with a continuous quality improvement (cqi) initiative which educates individual technologists on appropriate technique. methods & materials: radiation dose in digital radiography is estimated from an exposure index, a proprietary format that varies among manufacturers. our institution uses a fuji computed radiography system which calculates an s, or sensitivity value, that provides an approximation of the radiation dose to the imaging plate, using an inverse scale. overexposed bedside chest radiographs were defined by a s value less than . a data-mining program was developed to extract from the dicom header the s value and other relevant information, on a monthly basis. these data were used to provide training and feedback on a one-on-one-basis. results: with ad hoc feedback and group training initiatives prior to implementation of this new system, approximately . % ( / ) of bedside chest radiographs were overexposed over a four month period. after one-on-one intervention with the technologists, preliminary findings reveal a trend towards fewer overexposed radiographs with approximately . % ( / ) with s< . conclusions: our tool provides a simple method for systematically identifying overexposed radiographs and the corresponding responsible technologists. we anticipate that this personalized educational program will continue to reduce the proportion of overexposed radiographs and thus the radiation dose to our pediatric patients. purpose or case report: ensuring radiation protection for children undergoing ct scans is challenging due to rapidly changing technology, differences in ct equipment and potential lack of understanding of unique aspects of scanning children. the joint commission has named technologists' training as an "action" item. we developed online training modules to fill potential gaps in ct technologists' education. methods & materials: four modules were created by pediatric radiologists, radiologic technologists and medical physicists; were developed by education/training experts from major ct vendors (ge, philips, toshiba, siemens) through the medical imaging technology alliance. modules were created as microsoft word documents containing de-identified images and edited by education specialists at the american society of radiologic technologists and the alliance for radiation safety in pediatric imaging. they were converted to audio/video format using question/answer narration. vendor modules were created in microsoft powerpoint format and edited. all modules were converted into adobe captivate learning program to achieve uniformity of appearance. modules are hosted on the asrt server and linked to the image gently website. a certificate may be printed as documentation of completion. results: all modules are available at www.imagegently.org. two introductory modules discuss basics of ct equipment and medical physics related to radiation dose in children. the third and fourth modules discuss dose-saving strategies for neu-roct and body ct. four vendor-produced modules address unique aspects of equipment design such as automatic exposure control and dose saving strategies for children. conclusions: through collaborative efforts with medical imaging professionals and vendors, we have developed free online modules addressing radiation protection for children. ct technologist training in specific dose saving strategies for children is variable and limited. these modules have the potential to improve ct technologists' understanding of equipment. end confusion which focused attention on improving communication with patients and families. there is little research regarding health literacy (hl) in radiology. the purpose of our study was to determine if an educational intervention (brochure) improves hl for parents whose child will undergo a fluoroscopic study. methods & materials: an education exemption was obtained from the irb. a multidisciplinary team developed brochures for fluoroscopic procedures. participants were randomly selected and asked to complete a survey to assess their knowledge of the procedure and use of radiation both before and after reading a brochure. a final survey to rate and gain feedback about the brochure was completed. results: median age of children whose parents participated (n ) was years. vcug was most commonly performed ( %). prior to the brochure, % of participants knew the name of the test their child was having. after the brochure, % knew the name (p < . ). prior to the brochure, % felt informed about the test, whereas % felt informed after (p<. ). test scores showed an improvement in parent knowledge about the procedure with a median increase of points after the brochure (scale of - ; p<. ). even after reading the brochure, % of parents wanted more information. prior to the brochure, % of parents knew the test involved radiation compared to % afterwards (p<. ). parents improved their understanding of the relative amount of radiation compared to background from % before to % after the brochure (p<. ). overall, % rated the brochure > on a -point scale with % rating the brochure (p<. ). written feedback was uniformly excellent. conclusions: improving hl for parents is part of the mission of radiology medical professionals. our study demonstrates that there is room for improvement in communicating with parents about fluoroscopy. straightforward information for parents provided as a brochure improves their understanding of radiologic fluoroscopic procedures. paper #: pa- compendium of resources for radiation safety in medical imaging anum minhas, duke university, anum.minhas@duke.edu; donald frush purpose or case report: diagnostic imaging, including ionizing radiation modalities, maintains a foremost role in evaluation of medical disorders. there is increasing awareness and need for information across varied sectors about low level radiation and potential risks. many medical/scientific organizations have resources discussing radiation risk and management. however, there is no one resource compiling the same available information. methods & materials: websites, including those of national and international medical organizations (e.g., acr, "image gently" alliance, iaea) were reviewed for information on radiation dose, risk, justification, optimization, guidelines (which included general information about improvement in quality and dose reduction without specific mention of optimization techniques), appropriateness criteria, and general principles of radiation safety for radiography, fluoroscopy/angiography, and ct. this information was divided by modalities and separated into adult and pediatric populations. information from organizations that were not arbitrarily considered to be national (e.g., subspecialty society, regional organization, individual institution/practice) was not reviewed. the resources were then organized into tables, organized by modality. websites with training modules were noted as well. results: websites were explored. overall, less information is available about medical radiation safety in children compared to adults. across both, most information is available on ct, then fluoroscopy, and finally radiography. across all groups and modalities, there is no information available for patients/parents on optimization, appropriateness, or guidelines, with the exception of adult radiography where there were some guidelines. conclusions: this compendium on medical imaging radiation serves as a collective resource for communities including the public and regulatory organizations. additionally, the compendium can be used to determine redundant or deficient areas, providing opportunities for more comprehensive and efficient efforts in medical radiation protection for patients. inappropriate and cloned histories in children: how big a problem is it? leann linam, md, radiology, uams/ach, llinam@uams. edu; chetan c. shah, s bruce greenberg purpose or case report: acr standards require appropriate clinical history for obtaining imaging examinations. cloning clinical histories is a federal violation. our purpose is to determine the frequency of inappropriate histories (ih) and/or cloning histories (ch) at a tertiary children's hospital. methods & materials: three pediatric moc radiologists reviewed clinical histories for radiographs obtained at a tertiary children's hospital on randomly selected dates ( weekdays and weekend day) for appropriateness and cloning. appropriate histories have associated icd- codes. cloning is defined by identical clinical histories occurring on consecutive days and could be clinically appropriate or inappropriate. only the first patient radiograph on a day was included. χ testing was performed to determine significant differences. results: % ( / ) of exams had ih. ih were significantly more common in inpatients than outpatients (p< . ). nicu examinations accounted for % of all ih and were significantly more frequent than other inpatient locations (p . ). the cvicu examinations accounted for % of all ih and was the second most common patient location for ih, but not significantly different from other inpatient locations (p . ). the increased frequency in ih on the weekend reflects a change in patient mix with fewer outpatient examinations performed than on weekdays and was not significant (p . ). the most common ih included: evaluate ett or evaluate lungs ( each). cloning only occurs in inpatients and was combined with ih in % of patients with ch. the nicu accounted % of ch which was significantly greater than other inpatient locations (p . ). conclusions: in radiographs had ih which can lead to misdiagnoses or nonpayment by insurance companies. inpatients, especially the nicu were the most common patient locations. cloning was also a common problem and was frequently combined with ih. identifying the extent of ih allows for corrective educational measures to be instituted which should improve compliance with existing medical and legal standards for ordering radiographs. paper #: in vivo validation of size-specific dose estimates (ssde) through breast entrance skin dosimetry (esd) during pediatric chest ct angiography sjirk westra, md, radiology, massachusetts general hospital, swestra@partners.org; xinhua li, mannudeep kalra, bob liu, suhny abbara purpose or case report: ssde is a new ct dose measure that corrects scanner console ct dose index (ctdi) for cross-sectional body diameter, being a better estimate of absorbed dose in individual patients of varying body size. ssde has been developed through phantom studies and computer simulations of ct dose, but has not yet been validated in vivo. the purpose of our study was to determine correlation between ssde and measured breast entrance skin dose (esd) for pediatric chest cta across a variety of scanning techniques, scanner models and patient sizes. methods & materials: our study was irb-approved, with waiver of written informed consent. during consecutive chest cta exams done on different scanners over a period of years, we measured mid-sternal esd as an approximation of breast dose with skin dosimeters, which was also expressed as mammogram equivalents. for each scan, we recorded patient age, weight, effective ma, kvp, console ctdivol- cm and dlp- cm (from which we calculated age-adjusted effective dose (ed)). we measured effective chest diameter Ø to convert ctdi to ssde, and we correlated ssde with measured breast esd, using linear regression. we evaluated image quality with regard to answering the clinical question. (table) , due to systematic introduction of automatic exposure control, low kv and high pitch scanning techniques. all studies were of diagnostic image quality to address the clinical question. conclusions: ssde is a valid measure of ct dose in pediatric patients undergoing chest cta over a wide range of scanner platforms, techniques, and patient sizes, and may be used to model breast and other organ dose, and to document results of dose reduction strategies over time. purpose or case report: the purpose of this project was to create an automated system capable of quantifying slice-byslice ct image quality and radiation dose data based on patient size. the information generated from this system should enable size-specific optimization of ct scan parameters in order to obtain images of diagnostic quality at the lowest possible radiation doses. methods & materials: a mathematical model was developed to predict ct image noise based on kvp, effective mas, and water-equivalent diameter of the patient. a conical water phantom was used to calibrate the model on multiple scanners and accounting for different operational modes and scan parameters, including tube voltage (kvp), tube current (effective mas), bowtie filter, and focal spot size. a software application was created to process image data from the scout topogram and incorporate dicom metadata from the axial images. a database and data viewing application were developed to display individual and aggregate study data. all of these systems were integrated and automated to enable real-time monitoring of image quality and radiation dose as a function of patient size. results: since the completion of the automated system, ct exams have been processed. a search application allows the user to find an individual study or a collection of studies based on parameters such as body part imaged or study protocol. the viewing application displays slice-by-slice patient diameter, radiation dose, and image quality for each study. radiation dose estimates are adjusted for patient size, yielding size-specific dose estimates. the application also graphs individual study data compared to those of comparative studies that are included in the search. conclusions: we have successfully developed an automated system that monitors ct image quality and radiation dose data based on patient size. the system enables simultaneous real-time monitoring of all studies performed on all ct scanners at our institution. specifically, the system enables size-specific radiation dose estimates at every scan level. this system will be used to guide protocol adjustments in order to optimize ct image quality and thus optimize radiation dose. disclosure: dr. larson has disclosed that he has a patent application in process through cchmc for ct radiation dose reduction. purpose or case report: at many institutions, ct scan parameters for children are determined by patient age or weight. aapm task group recommends cross sectional body dimension, such as patient width to determine size specific dose estimates. the purpose of our study was to develop prediction models of body width based on patient age and weight and compare these models with actual measured body widths for children undergoing body ct. methods & materials: children's hospitals participated in a -month retrospective review of abdominal ct scans on patients < years of age after local irb approval. recorded values included patient width(cm) from an axial image at the level of the splenic vein, patient age (yrs) and patient weight (lbs). a regression model for predicting patient width as a function of age and weight was determined. results: exams, had all measurements. both age and weight were significant predictors of patient width (p<. ). there was also a significant interaction between weight and age (p<. ), indicating that the relationship between patient width and weight depended on the age of the patient. the r for the regression model for predicting patient width from age and weight individually were . and . respectively. the r for the model including both age and weight and their interaction was . leaving % of the variation unexplained. the regression equation for this model is: patient width . + . x age(yrs)+ . x weight(lbs)- . x age x weight. despite the r of . for the model using both age and weight, the average error (rmse) for predicting patient width compared to a direct measurement of width was . cm. the plot of observed minus predicted values (residuals) versus predicted values indicates that the best model (combination of weight and age) results in measurable errors of predicted patient width relative to direct measurement. conclusions: a combination of both patient age and weight results in a more accurate patient width prediction than using age or weight alone. while age and weight can be used to predict body width, this is not sufficiently accurate for generating ct protocols. therefore, direct measurement of body width form either physical measurement on the patient or from the scout view or an axial image is preferred to select appropriate scan parameters for pediatric abdominal ct. paper #: pa- automated size-adjusted dose monitoring for pediatric ct dosimetry olav christianson, clinical imaging physics group, olav. christianson@duke.edu; ehsan samei, donald frush purpose or case report: the potential health risks associated with low levels of ionizing radiation have created a movement in the radiology community to minimize radiation dose during ct imaging; this is especially important for pediatric patients due to their increased sensitivity to radiation. it is thus essential to accurately assess the risks to pediatric patients undergoing ct imaging. current efforts to monitor radiation dose, however, are limited because they do not account for differences in risk from ionizing radiation due to variability in patient size, age, and gender. in this context, we developed an automated size-adjusted dose monitoring program capable of performing patient-specific risk estimation to facilitate protocol optimization. methods & materials: dicom routing software was used to send dose reports and scout images to an image repository on a dosimetry server. optical character recognition was used to extract dose-relevant data from dose reports; patient size was determined from corresponding scout images. based on anatomical location, risk estimation conversion coefficients (qfactors) were determined for each series in the dose reports. the q-factors were adjusted according to patient size, age, and gender and then multiplied by the dlp to estimate the risk to each patient. this process was applied to the cohort of pediatric patients undergoing ct examination at our institution. to evaluate the impact of including patient size, age, and gender, risk estimates were obtained excluding and including the dependencies on size, age, and gender. the results were computed in units of cancer incidence per cases exposed (cpt). results: the average patient-generic risk estimate for a pilot group of patients undergoing body ct was . ± . cpt. by including patient size, the risk estimate was increased to . cpt± . cpt. by including patient age and gender, the average risk estimate was further increased to . cpt± . cpt. conclusions: we developed a new size-adjusted dose monitoring program for pediatric ct dosimetry. comparisons between patient-generic and our new patient-specific risk estimates show that failure to consider patient size, age, and gender resulted in risk estimates that were too low by a factor of seven. additionally, the increase in standard deviation we observed demonstrates that our method of including patient size, age, and gender is sensitive to the inherent variability in the patient population. disclosure: dr. christianson has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: treatment of prenatally diagnosed lung masses is controversial, with many specialists recommending elective surgical removal in the first year of life because of a reported or perceived increased risk of infection and malignancy, while other centers recommend a conservative approach to management. the natural history of unresected lung masses is not clear. in our center, our standard recommendation is prophylactic resection of asymptomatic lesions, although not all families choose this option. we asked whether respiratory morbidity increased during the time prior to elective resection of prenatally diagnosed lung masses. methods & materials: ninety-eight pregnant women carrying fetuses with chest masses were imaged by ultrasound (us) and magnetic resonance imaging (mri). medical records of the liveborn infants were retrospectively reviewed. results: fetal diagnosis of a lung mass was made at a mean of weeks gestation (range - wks). intrauterine fetal demise was documented in pregnancies. there was one elective termination of pregnancy. three infants were lost to follow up. thus, outcomes were available for children ( % m, % f) with prenatally diagnosed lung masses. significant respiratory morbidity (rm) was defined as the occurrence of pneumonia, asthma, chronic coughing or wheezing, or respiratory symptoms severe enough to require an emergency room visit or hospitalization. of the children who had surgical removal of their lung mass, ( %) had rm prior to surgery. fifteen out of children did not have surgery but have been followed expectantly, and of ( %) developed some form of rm. fifteen of ( %) infants had immediate and significant rm (tachypnea, grunting, increased work of breathing, increased oxygen requirements or need for intubation) in the newborn period leading to urgent surgery (range of age at surgery: - d; mean . d). of the initially asymptomatic infants, ( %) developed rm prior to elective removal of the mass (range - weeks, mean weeks). of the lesions removed, histology revealed: cystic adenomatoid malformation (ccam) %, ccam + sequestration %, sequestration %, congenital lobar emphysema (cle) %, ccam+cle %, other %. conclusions: the risk of respiratory morbidity appears to be increased during the time prior to elective resection of prenatally diagnosed lung masses, which may be important for parents and pediatric specialists to consider when deciding whether to remove an initially asymptomatic lung mass. purpose or case report: it is now accepted that fetal mri with its superior tissue resolution can be very helpful in clarifying anomalies detected during obstetrical ultrasound. this is particularly the case with intracranial abnormalities, although indications are expanding. the current english medical literature, though, appears to be focused on evolving mri techniques and how mri compares to ultrasound with regards to image quality and detection of additional findings which may alter the diagnosis. however, we found no study specifically evaluating the clinical relevance and impact of the information obtained by fetal mri to the specialists who counsel and treat these patients. a "satisfaction and clinical impact" survey was created and sent to all the members of our fetal diagnosis and treatment group, asking specifically how the clinicians rated their satisfaction with this type of imaging, its influence on their counseling and on various clinical decisions, both prenatal and postnatal. results: we received responses from specialists in different clinical disciplines. the greatest number of respondents came from our obstetricians ( %), many of whom perform their own ultrasounds, and from members of our medical geneticists/genetic counselors ( %), although % of respondents were from various other clinical disciplines, both medical and surgical. there was a surprisingly high degree of satisfaction overall with the quality of the images and with the type and amount of information provided. most respondents indicated they felt fetal mri was "moderately" or "extremely" useful for their particular clinical decisions, and most respondents agreed that fetal mri impacted "moderately" or "significantly" on counseling and management of these pregnancies. impact appeared greatest on the counseling of the parents and their decision to terminate/pursue the pregnancy, and the least impact was on issues around delivery. conclusions: fetal mri, in addition to providing images of better quality, particularly in certain conditions, has clinical value in that it directly impacts on the counseling of parents and on clinical decisions. - . ultrasound reports were reviewed to determine sonographic diagnoses. selected patients from this cohort underwent mri using ge . tesla magnet without contrast (sequences included ssfse, fiesta, fgre or dual echo in planes). the images were reviewed and multiple characteristics were assessed for specifiying the area of obstruction. the features included: presence of normal fluid-filled bowel, small rectum for gestational age, signal of meconium in the rectum, and meconium filled dilated bowel. results: cases of sonographically suspected bowel obstruction were identified during the study period; of these underwent fetal mri. of these cases, had normal mri and postnatal outcomes, cases did not have postnatal findings available, and had postnatal meconium peritonitis but no obstruction. one case of congenital chloride diarrhea was diagnosed by fetal mri. a variety of bowel abnormalities were observed amongst the remaining cases. proximal obstruction was diagnosed in cases: jejunal atresia (n ) and multiple atresia (n ). distal obstruction was diagnosed in cases: ileal atresia (n ), meconium plugging (n ), closed gastroschisis (n ), enteral duplication cyst (n ), and imperforate anus (n ). characteristic patterns of features were identified amongst these cases that specified the location of obstruction. these patterns of findings allowed accurate localization of the level of obstruction in all cases when compared to postnatal findings. distal obstruction was characterized by normal fluid-filled small bowel and high t signal in distended loops. jejunal atresia was characterized by multiple loops of dilated bowel with high t signal primarily in the left upper quadrant. small rectum for gestational age was not consistently associated with proximal or distal atresia. conclusions: evaluation of fetal mri with attention to specific features allows localization of bowel obstruction. this may aid in counseling and postnatal management, including the need and type of postnatal imaging study. early diagnosis and treatment of ph may prevent clinical deterioration. pvt may produce a spectrum of imaging appearances, which has not been fully recorded in the literature. the goal of this paper is to review the spectrum of imaging appearances of neonates and survivors of neonatal pvt with special emphasis on the role of us and to correlate these findings with the clinical findings including outcome. methods & materials: a retrospective review of consecutive neonates admitted between - and diagnosed with pvt was conducted. diagnosis was established by us at a mean age of days (range: - ). health records, initial and follow-up (f/u) imaging were reviewed. findings were classified as non occlusive, single branch, pvt (grade ); occlusive pvt (grade ) and pvt with extensive parenchymal ischemia (grade ). results: pvt was diagnosed in patients, of whom were followed up to for years or longer. twelve patients were excluded due to liver disease, expired and were lost to f/u. of the in whom f/u was available, at the time of initial diagnosis, grade pvt was present in , all were on the left. grade pvt was diagnosed in and grade pvt in . on f/u physical exam, findings were unremarkable in / patients. liver function tests (lft) and thrombophilia assessment were available in children, mild lft abnormalities were noted in and children had evidence of thrombophilia. us exams were available in / children. among the survivors of neonatal pvt, us was regarded as normal in only children; showed left lobar atrophy (lla), had slowly progressive splenomegaly without other signs of ph, and developed clinically significant ph requiring shunting. conclusions: pvt has a wide spectrum of imaging appearances, it is possibly underdiagnosed and clinically unsuspected. varying degrees of lla are likely a sequela of clinically silent left pvt. us is a sensitive method for the detection of disease and assessment of progression. paper #: pa- fetal mri in arthrogryposis hedieh eslamy, md, radiology, lucile packard children's hospital, hkeslamy@gmail.com; erika rubesova, louanne hudgins, britton rink, richard a. barth purpose or case report: to present the fetal mri findings in fetuses with a prenatal diagnosis of arthrogryposis and correlate with postnatal outcome or autopsy results. arthrogryposis refers to contractures involving more than one joint which often represent deformational changes secondary to decreased or absent fetal movement. prognosis varies widely dependent on diagnosis, ranging from isolated contractures in amyoplasia to lethality in some cases. we hypothesized that fetal mri may demonstrate central nervous system (cns) pathology and muscle abnormalities which are important for predicting postnatal outcome. methods & materials: we identified fetuses with a diagnosis of arthrogryposis between january and october . all had fetal mri which was performed on a ge . tesla magnet, with ssfse, fiesta and fgre sequences in planes. the fetal mri's were evaluated for cns and muscle abnormalities. the extremities were evaluated for: muscle mass, increase in subcutaneous fat (indicative of muscle atrophy), and extremity joint positioning. these findings were subsequently correlated with the clinical exam of the neonates, pathology in the abortus and karyotype when available. results: results of fetal us, amniocentesis, fetal mri and post-natal or post-termination outcomes will be summarized. five fetuses had ≥ limb joint contractures. a sixth case had neck hyperextension and lateral flexion associated with akinesia and hydrops. on mri, no structural brain or spine abnormalities were identified. the abnormalities detected in the extremities were: severe decrease in muscle mass associated with increased subcutaneous fat ( cases); normal muscle mass ( cases); moderate decreased muscle mass associated with increased subcutaneous fat ( case). in the cases that delivered, the diagnoses were amyoplasia ( ) and distal arthrogryposis ( ). in a fourth case that underwent elective termination, autopsy was consistent with amyoplasia. two cases are pending delivery. conclusions: while fetal mri can be useful to rule out cns anomalies, it may also provide important information on decreased muscle mass as an important prognostic sign in a fetus with arthrogryposis. in our series, severely decreased muscle mass was predictive of amyoplasia, and joint contractures limited to hands and feet with preserved proximal muscle mass was predictive of distal arthrogryposis. both diagnoses are associated with relatively good prognosis and usually normal intelligence. purpose or case report: the purpose of this study is to assess the effects of iterative reconstruction technique (irt) on image quality metrics measured in child-sized anthropomorphic phantoms as kvp is changed. methods & materials: ct scans were performed on anthropomorphic phantoms with sizes of , & years (atom phantoms, cirs, norfolk virginia) using low dose pediatric chest protocols ( . , & msv) to determine baseline noise and dose levels. subsequently three voltage levels ( , & kvp) were used while adjusting mas to maintain baseline ctdivol and without mas adjustment which allowed varied ctdivol. images were reconstructed using % filtered back projection (fbp) and blends fbp: ir ( : , : , & : ) . parameters including ctdivol, dose length product, scan length, kvp, and mas, were recorded for each scan. image noise, contrast:noise (cnr), and signal:noise (snr) data were recorded from rois in phantoms and dilute iodine contrast filled syringes ( , , . %). results: as kv is lowered from to , image noise is doubled if mas is not increased to maintain ctdivol, and cnr is increased but snr is decreased due to the increased image noise. as kvp is lowered from to , image noise is increased nominally ( - %) if mas is increased to maintain ctdivol; therefore the increase in cnr and decrease in snr is negligible. ctdivol is reduced > % in all phantom scans as kv is reduced from to . irt reduces image noise by up to % [range - %] in all phantom sizes and in clinical images. as ctdivol is maintained in patient scans, image noise, cnr, and snr are reduced in patients (p< . ), resulting in improved image quality. conclusions: when lowering kvp, compensation with increases in mas is necessary to maintain ctdivol. however, lower target ctdivol can be achieved when adding irt as image noise can be decreased. for these phantoms, cnr and snr improved using all [selected] levels of ir, even when kv was reduced, resulting in lower ctdivol in phantoms. at all kvp settings when irt is applied, image noise is reduced, resulting in improved cnr and snr for all phantoms. disclosure: dr. bardo has indicated she is in the speaker's bureau and receives an honorarium from koninklijke philips. paper #: pa- adaptive iterative dose reduction in evaluation of the pediatric abdomen with ultra-helical -channel mdct jeffrey hellinger, md, stony brook university, jeffrey. hellinger@yahoo.com; bernice hoppel, richard mather, monica epelman purpose or case report: radiation reduction is paramount for pediatric patients. ultra-helical -channel mdct allows for rapid acquisitions at low dose. we evaluated the ability of a new adaptive iterative dose reduction algorithm (aidr) to reduce noise in low-dose ultra-helical pediatric abdominal ct scans. aidr is an iterative algorithm that adaptively reduces noise in the raw and image domains while preserving image structure. the raw data from consecutive low-dose pediatric abdomen exams was gathered. a dose simulation tool which adds noise to raw projection data was employed to simulate tube current at / of baseline ma. data were reconstructed with both standard filtered back projection and with aidr. regions of interest were drawn in the liver and lumbar musculature to determine the signalto-noise (snr), contrast-to-noise (cnr) and overall diagnostic quality of each data set. statistical significance was determined using a student's t-test. subjective image quality was evaluated by two reader blind review using a five point scale ( excellent, unacceptable). results: the snr and cnr were significantly lower for the % dose reduction datasets compared to the original filtered back projection reconstructions (snr: . vs . , p< . ; cnr: . vs . , p . ). when aidr was applied to the % dose reduction data, the snr and cnr improved to be superior to the native case (snr: . vs . , p< . ; cnr: . vs . , p . ). the average image quality score for the low dose datasets with aidr was . compared to . with standard filtered back projection at the baseline ma conclusions: aidr significantly improves the image quality of pediatric abdominal ct images. with a simulated % reduction in dose, aidr produces images with significantly greater snr and cnr. the subjective image quality scores for aidr showed dramatic improvement over standard filtered back projection. aidr processing algorithms with ultra-helical mdct will allow % reduction in radiation exposure while achieving the same diagnostic quality as compared to routine pediatric abdomen mdct radiation protocols with filtered back projection processing algorithms. purpose or case report: to explore incorporating asir into pediatric head ct protocols, to reduce patient radiation dose while maintaining image quality. methods & materials: an alderson rando head phantom was estimated to approximate the size of a -year-old child's head, and was scanned at decreasing % ma intervals ( to %, to ma) relative to this institution's age-based head ct protocols. each of these studies was then was reconstructed at % asir intervals ( % to %), and a mm roi was obtained in a consistent location behind the frontal bone to estimate noise (sd). using this phantom data, our ventriculoperitoneal (vp) shunt follow-up ct protocol was modified, and patients were scanned at % asir with approximately % ma reductions relative to our normal age-based mas. these asir studies were then anonymously compared to older non-asir head ct studies from the same patients (with identical kvp/slice thickness) by two blinded attending pediatric neuroradiologists. all studies were evaluated subjectively for diagnostic utility ( - ), sharpness ( - ), noise ( - ), and artifacts ( - ). - mm rois were drawn in consistent locations to estimate noise in air, bone, csf, and white matter (wm). results: the phantom study suggested similar same noise levels at % ma/ % asir ( . ) and % ma/ % asir ( . ). patients (average , range to years) were then scanned at approximately % ma reductions, with an average of days (range to days) between the asir study and prior non-asir study. the average ctdivol and dlp values of the % asir studies were . mgy and . mgy-cm, and for the non-asir studies were . mgy and . mgy-cm, representing statistically significant decreases in the ctdivol ( . %, p . ) and dlp ( . %, p . ) values. there were no significant differences between the asir studies and non-asir studies in respect to diagnostic acceptability (p . ), sharpness (p . ), or noise (p . ). there was a non-significant trend that the asir studies had a lower artifact score ( . vs . , p . ). there was good to perfect (kappa . to . ) agreement. the asir studies had statistically significant decreased csf noise ( . vs . , p . ), but no noise differences were seen in air (p . ), bone (p . ), or wm (p . ). conclusions: our findings suggest that asir can provide dose reductions in pediatric head ct without affecting image quality. purpose or case report: to validate the t map as a noninvasive quantitative biomarker of fatty infiltration of muscles and to determine whether the t map can differentiate between boys with dmd and healthy boys. methods & materials: two groups of boys with similar ages (range - years) were evaluated: boys with dmd (mean age . years) and healthy boys (mean age . years). mr images were performed at t. fatty infiltration of the pelvic and thigh muscles on t -weighted images (wi) was graded from to . on t maps with and without fat suppression, the muscle with the greatest fatty infiltration on t -wi was selected, and a region of interest was placed to obtain t values. t values from t maps with fat suppression were subtracted from values of t maps without fat suppression and designated as the "t fat value." t fat values were obtained from the same muscles in all boys. comparison was made between the t fat values of the two groups. the upper reference limit of the reference interval (ri) of t fat values was obtained from the control group to establish the normal range and applied to both groups to determine the accuracy of the t map. results: the gluteus maximus muscle had the greatest fatty infiltration on t -wi. median t fat value was . msec for dmd ( % ri . , range . - . ) and . msec for the control group ( % ri . , range . - . ). when applied to the two groups, the upper reference limit of the ri for control patients yielded % sensitivity, % specificity, % positive predictive value, and % negative predictive value. conclusions: utilization of t maps for the quantitative measurement of fatty infiltration of muscles can clearly differentiate between dmd and normal control boys with a high degree of accuracy and precision. this advanced noninvasive technique may potentially replace invasive muscle biopsies currently used for diagnosis. purpose or case report: prior work has shown that the gluteus maximus muscle has the greatest t relaxation time on mr imaging using t mapping in boys with duchenne muscular dystrophy (dmd). however, an increased t value on t relaxation time mapping may reflect both fatty infiltration and inflammation of the muscle. fatty infiltration characteristically follows inflammation in this disease process. therefore, the purpose of this study was to determine the contribution of each component (fat and inflammation) within gluteus maximus muscles and to correlate each component to clinical assessments. methods & materials: forty-six boys with dmd (ages: - years) were recruited. mr imaging of the pelvis using t maps with and without fat suppression were performed. the t map "fat values" (t value calculated from the t map without fat suppression [fs] minus t map with fs) and the t map "inflammation value" (t value from the t map with fs) were obtained. clinical assessments typically used to evaluate dmd patients (including clinical functional score, ft run, gower score, and step-up time) were also performed. spearman correlation coefficients between fat and inflammation values and the clinical assessments were calculated. results: there was a statistically significant correlation between the fat value of the gluteus maximus muscle and each clinical assessment test (p< . ). however, the inflammation value of the gluteus maximus muscle did not correlate with any clinical assessment. conclusions: in dmd, the amount of fatty infiltration of the gluteus maximus muscle has excellent correlation with clinical assessment. the amount of inflammation of the gluteus maximus muscle, however, does not correlate with clinical function. therefore, further study is needed to determine whether components (fatty infiltration or muscle inflammation) of the single most involved muscle reflect the components of all the muscles of the pelvis and thighs and whether the cumulative muscle involvement of each component represents clinical disease severity. utility of contrast-enhanced mr imaging in children with osteonecrosis: does gadolinium help? lamya atweh, md, radiology, texas children's hospital, laatweh@texaschildrens.org; robert c. orth, wei zhang, r. paul guillerman, herman kan purpose or case report: at our institution, gadolinium contrast-enhanced mr sequences are often obtained to assess epiphyseal and non-epiphyseal osteonecrosis in children. several studies have shown that dynamic contrast-enhanced sequences may provide prognostic information about long-term complications and healing of osteonecrosis. to our knowledge, no studies have determined the added value of routine post-contrast mr imaging in assessing acute complications related to chronic osteonecrosis. the purpose of this study was to evaluate the utility of intravenous gadolinium contrast in the mri identification of complications in children with an established diagnosis of osteonecrosis. methods & materials: patients were restrospectively identified (age range: . years to . year; m:f : ) with an imaging diagnosis of chronic osteonecrosis who underwent contrast-enhanced mr studies between / and / . the pre-and post-contrast mr images were consensus reviewed by two caq pediatric radiologists. pre-and post-contrast images were reviewed at separate times. the pre-contrast images were available during the review of post contrast images. studies were assessed for: osteonecrosis location (epiphyseal, non-epiphyseal osteonecrosis, or both), joint effusion, marrow edema, and epiphyseal collapse. % confidence interval (ci) and cohen's kappa coefficient(κ) was calculated to assess observed agreement. results: the diagnosis of osteonecrosis without complicating features was made in . % (ci: . - . %) ( / ) of pre-contrast studies and . % (ci: . %- . %) ( / ) of post-contrast studies. when chronic osteonecrosis with complicating features was identified,pre-and postcontrast images idenfied joint effusion in . % ( / ) and . % ( / ) (κ . , p< . ); marrow edema in . % ( / ) and . % ( / ) (κ . , p< . ); and epiphyseal collapse in . % ( / ) and . % ( / ) (κ . , p< . ), respectively. myositis or muscle strain was incidentally diagnosed in . % ( / ) pre-contrast and . % ( / ) post-contrast (κ . , p < . ) studies. conclusions: the high observed agreement between the pre-and post-contrast mr images shows that the addition of intravenous gadolinium may not be necessary in the majority of children with chronic osteonecrosis. paper #: pa- systematic protocol for assessment of the validity of bold mri in a rabbit model of inflammatory arthritis at . tesla michael chan, bhsc, university of toronto, mw.chan@ utoronto.ca; afsaneh amirabadi, anguo zhong, antonella kis, rahim moineddin, andrea s. doria purpose or case report: blood oxygen level-dependent (bold) mri has the potential to identify regions of early hypoxic and vascular joint changes in inflammatory arthritis. at this point, there is no standard protocol for data analysis of bold mri measurements in musculoskeletal disorders. standardization of the technique is paramount to compare results between studies and assess the validity of this technique in tissues outside the blood-brain barrier. our objective is to optimize bold mri reading parameters in a rabbit model of inflammatory arthritis by determining the diagnostic accuracy of ( ) statistical threshold values (r> . vs r> . ), ( ) summary measures of bold mri contrast [ the mean of the % bold signal differences within the region of interest (roi) (diff_on_off) and the percentage of suprathreshold voxels within the roi (pt%)], and ( ) voxel activation algorithm (positive, negative, and positive_negative). methods & materials: using bold mri protocols with a carbogen stimulus on a . t magnet, we imaged injected and contralateral knee joints of juvenile rabbits at baseline, and days , and after a unilateral intra-articular injection of carrageenin. nine non-injected rabbits served as controls. receiver operating characteristic (roc) curves were plotted to determine the diagnostic accuracy of the reading parameters. the bold measures from [(injected knee-control knees)/control knees] were counted as positive cases, while the bold measures from [(contralateral knees-control knees)/control knees] were regarded as negative cases. areas under the curve (aucs) were calculated to determine the most accurate parameters. results: using diff_on_off and positive_negative activations as constants, r> . was found to be more accurate than r> . (p . at day ). comparison of diff_on_off and pt% yielded no statistically significant difference (p> . ). finally, positive_negative activations for diff_on_off and negative activations for pt% using r> . were the most diagnostically accurate (auc . , p< . at day , and auc . , p< . ). conclusions: from the results of this study, the most diagnostically accurate and clinically relevant reading parameters included the use of a more lenient threshold of r> . , a diff_on_off measure of bold contrast, and a positive_negative voxel activation algorithm. pt% may used as an ancillary measure of bold contrast. quantitative versus semi-quantitative mr imaging of cartilage in blood-induced arthritic ankles andrea doria, md, phd, diagnostic imaging, the hospital for sick children, andrea.doria@sickkids.ca; ningning zhang, carina man, pamela hilliard, ann marie stain, victor blanchette purpose or case report: to cross-sectionally compare the ability of a scoring system (semi-quantitative method) with a manual segmentation technique (quantitative method) to evaluate the status of the articular cartilage of growing ankles of children with blood-induced arthritis. methods & materials: boys, with hemophilia (a, n ; b, n ) and with von willebrand disease, median age (range, - ) underwent a high resolution mri protocol at . tesla, x-rays, and physical examination using the hemophilia joint health score (hjhs) system. two blinded radiologists scored the mri examinations for cartilage items (horizontal component: surface erosions, scores - and vertical component: cartilage degradation, scores - ) according to the semiquantitative method (international prophylaxis study group mri scale). an experienced operator applied a validated quantitative d-mri method (horizontal components: ac, vc, vctab, thctab; vertical component: thccab) to corresponding high resolution mr images of ankles. results: internal correlation of the semi-quantitative method components was substantial (r . , p< . , tibia) to high (r . , p< . , talus) in any site of investigation, but it was site-specific with the quantitative method, being significant only in the talar trochlea (r . , p< . ). external correlation of corresponding components of the semiquantitative and quantitative methods was moderate (r . , p . ) to poor (r . , p . ) for horizontal components, and non-existent for vertical components. components of the semi-quantitative method highly correlated with lifetime number of previous ankle bleeds (r . - . , p< . ), pettersson x-ray (r . - . , p< . ), and hjhs scores (r . , p< . ). this correlation was poor (r . , p . ) to moderate (r − . , p . ) for horizontal components of the quantitative method. conclusions: the biologic concepts of the semi-quantitative and quantitative mri methods are distinct for assessment of ankles. the semi-quantitative method is valid for assessing cartilage changes in cross-sectional studies of blood-induced arthropathy, however the quantitative method is suboptimal or less powerful for this purpose. paper #: pa- shoulder mr arthrography in skeletally immature patients nancy chauvin, md, department of radiology, the children's hospital of philadelphia, chauvinn@email. chop.edu; camilo jaimes, victor ho-fung, diego jaramillo purpose or case report: there has been a well documented increase in sports participation in children which has lead to an increase in sports-related injuries. to date, there are no studies describing the value of shoulder mr arthrography compared with the gold standard, arthroscopy. we retrospectively reviewed mr shoulder arthrograms obtained in pediatric patients between and who underwent subsequent shoulder arthroscopy. interpretation of the images was performed by three pediatric radiologists who were blinded to the arthroscopy findings. images were evaluated in consensus and independently. assessment included evaluation of the osseous structures, labral-ligamentous complex, joint space and the rotator cuff interval. the mr results were compared with reported surgical findings. sensitivity and specificity were calculated. results: nine patients were excluded due to technical reasons. of the remaining patients, were boys ( . - . years, mean . years) and were girls ( . - . years, mean . years). at arthroscopy, patients ( %) had injury to the anterior inferior glenoid labrum. mr sensitivity was % for depiction of bankart-type injuries with a specificity of %. patients ( %) had hill sach lesions and mr had sensitivity of % with specificity of %. superior labrum anterior posterior (slap) tears ( %) were identified at arthroscopy with mr sensitivity of % and specificity of %. overall, mr arthrography had a positive predictive value of % for identification of a surgical lesion. agreement between the observers was high. interobserver reliability was calculated with an intraclass correlation coefficient (icc)of . with a cronbach's alpha of . . conclusions: mr shoulder arthrography can accurately depict labral and osseous injury and provides pertinent preoperative information. a novel multi-channel mr coil for improved pediatric elbow coil imaging suraj serai, phd, cchmc, suraj.serai@cchmc.org; randy giaquinto, kathleen emery, charles dumoulin purpose or case report: single flex coils or adult size coils are currently used for imaging the pediatric elbow. this frequently results in uncomfortable patient positioning, motion, poor fat suppression, low snr and there is currently lack of a dedicated pediatric elbow coil in the commercial market. our goal was to explore the usefulness of a new coil array dedicated for pediatric elbow imaging and to compare quantitative & qualitative imaging findings to commercially available coils. methods & materials: an eight channel elbow coil was designed. the coil frame was designed to be rigid and lightweight. seven identical loop coils were built into a polycarbonate frame and an eighth coil built into a paddle that fits into the top frame. the coil elements were constructed with heavy copper to provide a high q-factor and increased snr. the complete coil including electronics & covering, weighs only . kg. mr imaging under irb approval was performed on a ge . t scanner using a routine clinical elbow protocol including t w, pdw, t w, fat-sat, non-fat-sat, d & d sequences. subjects were positioned feet-first with the elbow on the side & were subjectively assessed for comfort level. images obtained from the new coil & from the current commercial coils were compared for snr. results: scan positioning was reported to be comfortable. snr was between - % higher as compared to the routine coils. fat saturation was uniform, indicating that the magnetic susceptibility of the coil is well-matched to human anatomy. anatomical detail depiction was subjectively better for anatomic features such as trochlea. detection & diagnostic confidence of elbow disorders were improved with the new coil & greatly decreased motion artifacts were observed. conclusions: the new pediatric elbow coil provided excellent image quality, patient acceptance and clinical performance improvements over existing coils. the open coil design also allows for imaging of the elbow in a partially flexed position or in a cast. the advantages provided by the new coil are expected to include shortened image acquisition times (via parallel imaging) & increased snr. disclosure: dr. serai has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. incremental value of knee radiography in the interpretation of pediatric knee mri yen-ying wu, texas children's hospital, yxwu@ texaschildrens.org; robert c. orth, wei zhang, r. p. guillerman, herman kan purpose or case report: the acr appropriateness criteria recommendation for the imaging work-up of knee pain is radiography followed by mri. in many cases, mri is performed prior to review of radiographs or the referring subspecialist does not feel radiographs add value, particularly when ligamentous injury is suspected. the purpose of this study is to determine if radiography adds incremental value in the interpretation of knee mr studies electively referred by pediatric sports medicine and orthopedic subspecialists. knee mri studies referred from pediatric sports medicine physicians or pediatric orthopedic surgeons between / and / (n , ages - years, m:f : ) with accompanying radiographs were identified. patients were separated into groups based on mri findings: normal, ligamentous injury, or osteochondral injury (osteochondral lesions, bone contusions/fracture, and avulsion injury). knee radiographs were consensus reviewed by two caq pediatric radiologists blinded to mri findings and categorized into the same groups. radiograph and mri findings were compared and categorized into groups: neutral if radiograph and mri findings were the same, misleading if findings were discordant, or helpful if radiographs improved mr interpretation. the latter group was analyzed for impact on mr diagnosis. results: for knee radiographs, were normal, showed ligamentous injuries, and showed osteochondral injuries. when radiographs were interpreted as normal (n ), by mr % were normal, % had ligamentous injury, % had osteochondral injury, and % had both ligamentous and osteochondral injury. when radiographs were interpreted as ligamentous injury (n ), by mr % were normal and % had ligamentous injury. when radiographs were interpreted as osteochondral injuries, by mr % had ligamentous injury, % had osteochondral injury, and % had both ligamentous and osteochondral injury. subset analysis of true positive radiographs (n ) found % to be helpful and % to be neutral in mr diagnosis. for radiographs considered helpful, % resulted in a change in mr diagnosis. in regards to the influence of radiographs on mr interpretation, % ( / ) were misleading, % ( / ) were neutral, and % ( / ) were helpful. conclusions: a minority of pediatric knee radiographs aided mr diagnosis, and none resulted in a change in diagnosis. pediatric knee mri and interpretation should not be predicated on radiologist review of knee radiographs in this subset of patients. paper #: pa- sonographic evaluation of pediatric skeletal lesions: is it worthwhile? henrietta rosenberg, md, radiology, the mt. sinai medical school, henrietta.rosenberg@mountsinai.org; amish patel, neil lester purpose or case report: the purpose of this paper is to demonstrate how ultrasound(us) may serve as a readily available, cost-effective, non-invasive, non-ionizing, practical tool for the evaluation of a variety of skeletal abnormalities in the pediatric age range. we reviewed the clinical and imaging findings in patients seen during the past years in whom us demonstrated abnormalities related to the skeletal system, excluding patients with hip joint effusions or ddh. results: us proved useful in the following situations: evaluation hard superficial immobile mass (osteoma shin) ( ), absent medial end clavicle on x-ray in region of neck mass (us showed abc medial end clavicle)( ), to determine if soft tissue mass involves adjacent bone nodular fasciitis surrounding clavicular head ( ), for diagnosis and followup fracture (displaced/non-displaced) in infants ( ), diagnosis osteomyelitis in patients with cellulitis ( ), question of fracture underlying cephalohematoma or subgaleal hematoma ( ), rib mass (osteochondroma) ( ) or mass costochondral junctions (contour deformities costochondral cartilage) ( ), firm posterior knee mass (baker's cyst) ( ), firm anterior knee mass (septated cystic mass suprapatella region due to rheumatoid disease) ( ), immobile hard scalp mass due to epidermoid cranial vault ( ), painful mass occipital bone with soft tissue components extending through the skull externally and internally due to langerhan's histiocytosis ( ), indeterminate mass clavicle clinically thought to be post-traumatic sequellae, resolved on follow-up ( ), assessment craniosynostosis ( ), for differentiation of pathological entity from normal anatomic structure (lump on back of slender baby proved to be normal posterior spinous process) ( ). conclusions: us is worthwhile for evaluation of wide range of pediatric skeletal abnormalities and helps to determine if the a lesion is one that is "touch" or "don't touch". to maximize diagnostic accuracy, the imager should have thorough knowledge of the clinical history, physical findings, laboratory and other imaging findings. in equivocal cases or in those patients in whom the field of view (fov) is insufficient for complete visualization of an obvious lesion or if malignancy is suspected, us serves to triage those patients in whom further imaging is necessary. high incidence of vertebral fractures in children with acute lymphoblastic leukemia months after the initiation of therapy mary ann matzinger, md frcp(c), university of ottawa, matzinger@cheo.on.ca; nazih shenouda , brian lentle, josée dubois, helen r. nadel purpose or case report: vertebral fractures due to osteoporosis are a potential complication of childhood acute lymphoblastic leukemia (all). to date, the incidence of vertebral fractures during all treatment has not been reported methods & materials: we prospectively evaluated children with all during the first months of leukemia therapy. lateral thoracolumbar spine radiographs were obtained at diagnosis and months. vertebral bodies were assessed for incident vertebral fractures using the genant semi-quantitative method, and relevant clinical indices such as spine bone mineral density (bmd), back pain and the presence of vertebral fractures at diagnosis were analyzed for association with incident vertebral fractures. results: of the children, ( %, % confidence interval [ci] % to %) had a total of incident vertebral fractures, of which ( %) were moderate or severe. thirteen of the children with incident vertebral fractures ( %) also had fractures at the time of diagnosis. vertebral fractures at diagnosis increased the odds of an incident fracture at months by an odds ratio of . ( % ci . to . , p . ). in addition, for every . standard deviation reduction in spine bmd z-score at diagnosis, there was . -fold increased odds for incident vertebral fracture at months ( % ci . to . %, p . ). conclusions: children with all have a high incidence of vertebral fractures months after diagnosis, and the presence of vertebral fractures and reductions in spine bmd zscores at diagnosis are highly associated clinical features. purpose or case report: to provide objective measures of acetabular morphology utilizing volume-rendered ct and to better characterize normal acetabular development in adolescents. implications for the diagnosis of femoroacetabular impingement (fai) will be discussed. methods & materials: hips in consecutive patients ( female, male; ages - years) who underwent abdominal and pelvic ct for non-hip related complaints were retrospectively examined. examinations were performed for a variety of complaints, including abdominal pain, nephrolithiasis, vomiting etc. patients with obvious hip pathology were excluded. pelvic rotation was eliminated, and pelvic inclination was measured and corrected to °u tilizing a volume rendered ct model. measurements of femoral head diameter (fhd), anterior femoral head coverage (fhca), and posterior femoral head coverage (fhcp) were obtained. femoral head area (fha) was defined as π(fhd/ ) . percent anterior femoral head coverage (%fhca) was defined as (fhca/fha)* . percent posterior femoral head coverage (%fhcp) was defined as (fhcp/fha)* . acetabular version by volume-rendered ct (avvr) was defined as (fhcp/fhca). results: average pelvic inclination angle (sd) was . ( . ) for females and . ( . ) for males. average (sd) %fhca was . ( . ) for males and . ( . ) for females. average (sd) avvr was . ( . ) for males and . ( . ) for females. among males, average avvr decreased with subject age. on the other hand, there was little change in average avvr with age among females. conclusions: average avvr is greater for females than males, and this difference becomes more striking with increasing subject age. this represents an unexpected finding given the reported increased incidence of "pincer" type fai among females. characterization of acetabular morphology among adolescents with clinical fai should consider subject age and gender. in this regard, volumerendered ct is capable of providing an objective measure of acetabular morphology. mistakes in musculoskeletal plain film interpretation james crowe, pediatric radiology, texas children's hospital, jecrowe@texaschildrens.org; george s. bisset purpose or case report: to evaluate the mistakes made by trained pediatric radiologists when interpreting radiographs of the extremities obtained for the evaluation of outpatient acute pain (mostly post-traumatic). we retrospectively evaluated all radiographs and associated interpretations obtained during a month period from april , , to october , , of the elbows, wrists, knees and ankles in pediatric outpatients who presented with acute pain in the affected area. all radiographs were previously interpreted by a caq-certified pediatric radiologist varying in experience from year to years. abnormals were identified, including elbows, wrists, knees and ankles. all radiographs were determined to be "as dictated", missed significant finding, or overcall. attention was focused on the missed findings and overcalls. results: findings were as follows: elbow radiographs- missed findings and overcalls, wrist radiographs- missed findings and overcalls, knee radiographs- missed findings and overcalls, ankle radiographs- missed findings and overcalls. this resulted in a total of missed findings ( . % of abnormals) and overcalls ( . % of abnormals). of the misses, % were fractures. the highest mistake percentage occured in the ankles where the combined misses and overcalls approached %. this was also the location where we found the highest percentage of missed fractures ( . %) conclusions: when just abnormal cases were considered, fully trained pediatric radiologists have a mistake rate of approximately . %, if misses and overcalls are included. from a quality improvement perspective, we will review all of the types of misses and overcalls to expose common themes. longitudinal assessment of osteoporosis in a blood-induced hemophilia rabbit model using quantitative ultrasound kuan-chieh wang, university of toronto, kc.wang@ utoronto.ca; afsaneh amirabadi, anguo zhong, christopher tomlinson, andrea s. doria purpose or case report: the reduction of physical activities in hemophilic patients may lead to bone demineralization and consequent osteoporosis. quantitative ultrasound (qus) is free of ionizing-radiation, relatively inexpensive, and easy to use that making this technique suitable for follow-up of hemophilic children with clinical suspicion of osteoporosis. to our knowledge, no previous study has investigated the value of qus for longitudinal assessment of growing bones in an animal model which is paramount for clinical translation of the technique once change in measurements could relate to either the baseline pathology or physiologic bone growth variability. the objective of this study is to investigate the intra-and inter-operator reliability of qus over time, and its ability to discriminate bone loss in pathologic vs control knees of a rabbit model of blood induced arthritis. methods & materials: sixteen juvenile white new zealand rabbits distributed into two groups: received intraarticular blood injections over weeks (n pathologic and contralateral knees), and noninjected rabbits were used as controls (n knees). midshaft tibia speed-of-sound (sos) was measured at baseline, and weeks and of the experiment. two operators scanned each site twice at each time point. qus measurements were compared to microct (reference standard) on week to validate the study results. results: the sos measured in the control group increased significantly (p< . ) over the week period. there was not such an increase in the arthritis sos value (p> . ). in both groups the overall intra-operator coefficient of variation of sos measurements was % at baseline and decreased to % at week likely due to increased tibia size. the inter-operator reliability was % at baseline and % at week . with regard to the effect of bone growth on qus measurements for the control group (n ), sos values increased by . m/s, whereas for the pathologic group (n ), they only increased by m/s. statistically significant differences in ratios of sos between final/baseline results were noted (p . ) between the pathologic and control groups. conclusions: the longitudinal use of qus has an acceptable intra-and inter-operator reliability. even accounting for the significant impact that bone growth has on qus measurements over time, qus can differentiate pathologic from control knees in the proposed animal model and holds potential for clinical use in the assessment of osteoporosis in hemophilic children. methods & materials: the study was approved by the institutional review board. pediatric patients with abdominal tumors ( malignant and benign lesions) underwent diffusion-weighted mr imaging (dwi) on clinical . t (n ) and t (n ) mri scanners. adc maps were generated from b dwi and adc values were retrospectively and independently measured by two radiologists. adc values of benign and malignant tumors were compared with the welch two sample t-test. a p value of . was considered to indicate statistical significant differences. in addition, a receiver operating curve analysis (roc) was performed to determine the optimal cut-off adc value for differentiating benign and malignant tumors. results: the mean adc value (mm /sec) of benign tumors was . x - for the first reader and . x - for the second reader. the mean adc value (mm /sec) of malignant abdominal tumors was . x - for the first reader and . x - for the second reader. the differences between benign and malignant tumors were statistically significant (p< . for both readers). roc analysis revealed an optimal cut-off adc value for differentiating malignant and solid tumors as . x - mm /sec. conclusions: diffusion-weighted imaging with adc maps can be used to differentiate between benign and malignant pediatric abdominal tumors. creation of a database to evaluate imaging findings in long-term survivors of pediatric malignancy alexander towbin, md, radiology, cincinnati children's hospital medical center, alexander.towbin@cchmc.org; seth hall purpose or case report: over the past years, there have been significant improvements in the treatment of pediatric malignancies. improved therapy has led to an increase in the number of long-term survivors. many of these survivors are now experiencing late effects as a result of the original disease process or its treatment. these late effects are frequently identified on imaging. the purpose of this study is to create a database of the imaging findings of long-term survivors of pediatric malignancy in an attempt to begin to classify the findings and identify associations. methods & materials: after irb approval, the institutional cancer registry was searched to identify all patients younger than years of age who were diagnosed with a solid tumor between and . patients were included in the database if they survived for more than years from the date of their initial diagnosis. the electronic medical record system was then used to obtain demographic and treatment information for each included patient. the dictated reports from all cross-sectional imaging studies evaluating the chest, abdomen, or pelvis performed more than two years from the date of diagnosis were then reviewed. each positive imaging finding was classified by the involved organ. results: after querying the institutional cancer registry, patients were identified who met the inclusion criteria for this database. the most common neoplasms were neuroblastoma, wilms tumor, and astrocytoma. of the included subjects, had imaging of the chest, abdomen, or pelvis. overall, reports were evaluated and classified. findings were most commonly identified in the lungs, musculoskeletal system, kidneys, liver, and lymph nodes. conclusions: a database examining the late effects in longterm survivors of pediatric malignancies was created. this database has the potential to help identify the radiologic manifestations of the complications of cancer therapy and thus help guide rationally determined long-term risk-benefit ratios in the treatment of pediatric malignancies. imaging followup of lymphoma in pediatric patients: is pelvic ct necessary? javier lopez bueno, md, children's hospital of eastern ontario, jlopezbueno@cheo.on.ca; nishard abdeen purpose or case report: pelvic ct is often included in the imaging followup of patient with lymphoma before, during and after treatment to assess response to treatment and monitoring for relapses. while such followup is expected to improve detection of relapse, there is little objective evidence of its effectiveness in lymphoma. anecdotally, there are few pelvic relapses in pediatric patients with lymphoma regardless of primary site. we hypothesize that pelvic ct could be avoided as part of the followup without adverse impact on survival or in the detection rate of relapses, and with subsequent significant reduction in the radiation dose, particularly to the gonads. methods & materials: research ethics board approval was obtained. patients diagnosed with lymphoma and with at least one year of followup at our tertiary care pediatric hospital were included. sex, age, type of lymphoma, stage, primary site, site of relapse if any as well as the number of ct scans of the head, neck, chest, abdomen and pelvis were recorded. results: a total of patients met study criteria. there were males and females, with an average age of . years (range - years). eighteen patients had hodgkin disease ( %) and eleven had non-hodgkin lymphoma ( %). mean length of followup was . years (range - years). an average of . pelvic scans per patient were performed for surveillance (range - ). three relapses were detected. of these only one was in the pelvis, in a patient whose initial t cell non-hodgkin lymphoma was extensive and involved the neck, chest, abdomen and pelvis. conclusions: this study suggests a low incidence of pelvic relapse in pediatric patients with lymphoma. the routine use of pelvic ct in surveillance protocols may therefore be of little benefit while imposing a significant radiation burden. our study is limited by small sample size and short length of followup. further large scale studies are required. (esft) is performed by measuring the size of the tumors before and after chemotherapy. the proposed method of measuring tumor size, however, differs amongst recist . (response evaluation criteria in solid tumors), who (world health organization) and cog (children's oncology group) response criteria. in our project, we assessed whether response classification differs between the three different methods. methods & materials: after irb approval, we retrospectively analyzed mri studies of patients with ewing sarcoma who were treated at stanford and ucsf medical centers. tumor size was assessed before and after therapy. tumor measurements were obtained using recist . (longest single diameter), who (longest diameter and perpendicular diameter), and cog criteria (three measurements to calculate tumor volume). tumor response was assessed by the differences in sizes of the tumors before and after treatment using four response categories: progressive disease (pd), stable disease (sd), partial response (pr), and complete response (cr). concordance between the three response classification systems was assessed using cohen's kappa (k) coefficient and percentage of disagreement per response category. results: the k statistic for concordance in cog/who, cog/ recist and recist/who were . , . and . respectively. disagreement rates for recist/who, cog/ who, and cog/recist were . , . , and . % respectively. using tumor volume, twenty-six patients were reclassified: twenty-four cases of stable disease coded by recist were reclassified as progressive disease by cog and two cases of partial response coded by recist were reclassified as complete response by cog. conclusions: this study demonstrates poor agreement between the recist . and cog response criteria in esft. given the degree of discordance between response criteria in esft, evaluation of the prognostic impact of each of these classification systems may guide selection of the optimal system for future use in this disease. imaging recognition of chylous ascites following surgery for abdominal neuroblastoma zeyad metwalli, md, baylor college of medicine, metwalli@bcm.edu; r. p. guillerman, heidi v. russell, eugene s. kim purpose or case report: surgical resection is a standard part of multimodality treatment of neuroblastoma, the most common abdominal malignancy of infancy and early childhood. chylous ascites is a rarely reported complication of surgery for abdominal neuroblastoma, and is likely underrecognized, posing the risk of nutritional deterioration and sepsis. to facilitate early diagnosis and institution of appropriate therapy, we present the salient imaging findings of the largest known series of chylous ascites following surgery for abdominal neuroblastoma. methods & materials: all patients with abdominal neuroblastoma complicated by post-operative chylous ascites over a five-year period at a large children's hospital were identified by a database search. a retrospective review of the imaging studies and clinical charts was conducted. results: chylous ascites developed following surgical resection of abdominal neuroblastoma in of patients, with the diagnosis made between postoperative days and . four cases were high-risk neuroblastoma and one was intermediaterisk neuroblastoma. all cases involved resection of an adrenal mass and dissection around the abdominal great vessels. all cases manifested with abdominal distention on physical exam, and ascites was suspected clinically in cases. computed tomography (ct) in all cases revealed a large volume of ascites of near-water attenuation (range of − to . hounsfield units). the cases imaged with ultrasound (us) showed hypoechoic or anechoic ascites without septations. the chylous ascites resolved after - months of treatment with dietary fat restriction, medium chain triglycerides, intravenous octreotide, or peritoneal catheter drainage. conclusions: chylous ascites is an under-recognized complication of surgical resection for abdominal neuroblastoma, occurring in % of patients in this series. the diagnosis is supported by the demonstration on ct or us of a large volume of ascites causing abdominal distention - weeks post-operatively. the ascites is typically near-water in attenuation rather than fatty in attenuation and should not be misattributed to peritonitis, hemorrhage, bowel leak, or early tumor recurrence. cervical spine injuries in patients with suspected physical abuse nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; zarir p. khademian, tanya hinds, katherine deye, allison m. jackson, eglal shalaby-rana purpose or case report: to evaluate the incidence and nature of cervical spine injuries and relationship to posterior fossa abnormalities in children who underwent brain and cervical spine mri as part of the clinical workup for suspected physical abuse. methods & materials: authors retrospectively analyzed records of eighty-five children less than three years of age who were documented by the child protective services at a level one pediatric trauma center over a period of four years ( ) ( ) ( ) ( ) ( ) . only patients who underwent both mri imaging of the cervical spines (c-spine) in addition to brain imaging as part of the clinical workup were included. cspine and posterior fossa of brain mris were independently reviewed by two pediatric neuroradiologists, both blinded to clinical details. c-spine abnormalities (bone marrow edema, cord edema, intrathecal blood, disc pathology, soft tissue/ ligamentous injury, vascular injury) were documented and correlated with abnormalities seen in the posterior fossa (blood, brainstem edema, cerebellar edema). results: at this time, / patients have been reviewed. twenty patients ( %) had both cervical spine injuries and posterior fossa abnormalities. there were no patients with isolated cervical spine injuries without posterior fossa abnormalities, but there were five patients ( . %) that had posterior fossa abnormalities in the absence of c-spine injuries. fifteen patients ( . %) did not have any spinal or posterior fossa imaging abnormality. none of the patients had bone marrow edema, disc pathology, or intrathecal blood. one patient had vascular neck injury and cord edema. conclusions: our results show that the incidence of cervical spine injury in children under investigation for abusive head trauma is as high as %. our data show further that cervical spine injury predicted posterior fossa injury in all patients, while presence of posterior fossa injury predicted concomitant c-spine injury in only %. the incidence of c-spine trauma we found in these patients is higher than reported elsewhere in the literature and may impact whether or not routine c-spine mri will be included in national imaging guidelines for children under investigation of abusive head trauma. pediatric skull fracture andre loyd, phd, biomedical engineering, duke university, aml @duke.edu purpose or case report: skull fractures are often seen in the setting of non accidental trauma (abuse) abuse, and are usually attributed to falls from heights above m. part of the difficulty in assessing height is due to uncertainties in actual distance. objective: to determine what types of skull fractures can occur in pediatric and adult post-mortem human specimens during controlled impacts on hard surfaces from various heights. methods & materials: skull fracture patterns in postmortem human specimens from a unique bank of pediatric specimens ( -week gestation to -years-old, n ) were subjected to controlled drops from both arbitrarily low heights ( and cm) and high heights ( m) onto an aluminum platen. the specimens were dissected from the neck at the occipital condyles and intracranial were sealed inside the head using pmma. the heads were dropped on to five different impact locations. fractures were identified using palpation and high resolution mdct. results: no specimens between -weeks-gestation and days-old sustained fractures from the - cm drops. three out of four ( %) specimens ages between -and -months old fractured due to the or cm drops. the -and -year-old specimens and all adult specimens survived the - cm drops. all specimens subjected to the m drop fractured. the specimen between -months and -months sustained either a linear fractures or diastatic fractures from the cm and cm drops. the results indicate that some aged infants and young children can sustain skull fractures by being dropped or falling from relatively low heights. drops, as low as cm, can cause linear and diastatic fractures in pediatric skulls. the presences of compliant sutures and fontanelles in neonatal heads allow the head to deform during impact. these data add very important information to mechanisms of skull fractures across ages, including ages in which child abuse is a consideration. evaluation of a new classification system for temporal bone fractures in children aimed at increasing prognostic value badriya al-qassabi, md, mcgill university, albahlania @ yahoo.com; lucia carpineta, rania ywakim, bahar torabi, andrew m. zakhari, lily h p. nguyen purpose or case report: to compare a new classification of temporal bone fractures which specifically evaluates involvement of the otic capsule against the traditional classification system (transverse versus oblique versus longitudinal), to evaluate whether this new classification is able to better identify patients at risk of adverse otologic outcome and neurologic complications in the pediatric population. methods & materials: a retrospective hospital chart review was performed by ent colleagues searching for all patients with temporal bone fractures seen at our center over the past years. this was followed by a blinded review of the ct heads by a resident and a trained pediatric radiologist with neuro expertise. these cts were evaluated for petrous involvement, otic capsule involvement and any associated intracranial lesions. this information was then correlated with clinical outcome measures including post-traumatic hearing deficit, facial nerve palsy, persisting csf leak and global neurologic sequelae. the new classification was compared to the traditional one, and specifically analysed for the ability to better predict the clinical outcomes. results: expectedly, pediatric temporal bone fractures were infrequent and otic involvement even more rare. fractures with involvement of the otic capsule (versus otic sparing) were found more frequently in boys. they were also more likely to be associated with immediate otologic signs and neurologic findings on presentation. these fractures also had the highest association with conductive hearing deficit (> %) and were twice as likely as otic sparing fractures to be associated with immediate facial nerve palsy and with more important concomitant intracranial injuries such as midline shift. conclusions: while our numbers are small, our results suggest a trend that when temporal bone fractures show involvement of the otic capsule, there is higher risk of adverse otologic outcome and neurologic complications even in the pediatric population. absence of a causal relationship between mr detected subdural hematomas (sdh) in neonates with hypoxic-ischemic encephalopathy (hie) deniz altinok, children's hospital of michigan; jay shah, harut haroyan, gulcin altinok, nitin chouthai purpose or case report: the existing controversy regarding subdural hemorrhages noted in patients with hie is an important discussion in the medical, legal and child-welfare realms. it is our goal to provide additional information to this critical debate through mr findings on patients with clinically diagnosed hie. methods & materials: all patients born with clinically diagnosed hie, and treated at children's hospital of michigan in the past years were examined; those with head mri taken within days of life were selected. in total, patients fit the criteria, this included: males and females, and an age range of - days at scan (average age of days at scan). all traumatic births, coagulopathies, and other pertinent clinical findings were noted. mr imaging was reviewed and reported by a blinded pediatric neuroradiologist, these reports were then compared to the "original read". results: all patients were confirmed radiologically to have hie. the causes of hie in all cases examined were either intrauterine/delivery asphyxia, aspiration, or congenital disease. of these cases, the findings were: sdh, parenchymal hemorrhages, intraventricular hemorrhages, cephalohematomas, subarachnoids, large subcutaneous hemorrhage and instance of mca stroke. all patients with mr detectable sdh had or more confounding factors ( meningitis, coagulopathies, chest compressions, cardiac malformation, pph, severe pulmonary hemorrhage requiring transfusion of plasma and prbc). conclusions: it has been hypothesized that sdh is often found incidentally in children diagnosed with hie, this is however a dubious conclusion considering our results. in fact, the presence of sdh and hie concomitantly is low even when including a population with traumatic births such as ours. sports-related concussion in children: an mri and mrs study kim cecil, phd, cincinnati children's hospital medical center, kim.cecil@cchmc.org; todd a. maugans, james l. leach, mekibib altaye purpose or case report: the pathophysiology of sportsrelated concussion (src) is poorly understood, especially for children. following src and mild traumatic brain injury in adults, a few mri and proton mrs studies have identified axonal injury with declines in the neurometabolite n-acetyl aspartate (naa). we wanted to examine a src adolescent population with proton mrs, diffusion tensor imaging (dti) and other mri methods within h of concussion and with short term followup to determine if there were differences in imaging metrics with age and sex matched healthy control participants. methods & materials: twelve children, ages - years, who experienced src were evaluated with impact neurocognitive testing, t -weighted mri, susceptibility weighted imaging (swi), dti, proton mrs, and phase contrast angiography (pca) at less than h, days and days or greater post-concussion. healthy, age and sex matched controls for each src participant were recruited and evaluated at a single time point. quantitative imaging metrics included fractional anisotropy, metabolite concentrations, and global cerebral blood flow (cbf). group comparisons were examined by paired t-test or wilcoxon signed rank test. correlational data employed spearman rank correlation. results: impact results revealed significant differences in initial total symptom score (tss), and reaction time (rt) for the src group compared with the control group, with tss resolving by a mean of days and rt at days. no evidence of structural injury was observed qualitatively for either group. analyses between groups or over time within the src group found no decreases in naa or elevation of lactic acid upon mrs, and no changes in fractional anisotropy upon dti. within the src group, significant changes in the global cbf were observed. improvement towards control values occurred by days for % and by days for % of src group participants. conclusions: pediatric src affects global cbf without evidence of structural or metabolic injury. predictive value of high resolution mr imaging of brain and sella in children with clinical optic nerve hypoplasia for hypopituitarism charles glasier, radiology, arkansas childrens hospital, glasiercharlesm@uams.edu; raghu h. ramakrishnaiah, julie shelton, chetan c. shah, paul h. philips purpose or case report: to review the spectrum of cns abnormalities and their incidence in children with optic nerve hypoplasia and to calculate the sensitivity and specificity of magnetic resonance imaging in predicting endocrine abnormalities. methods & materials: this is an irb approved retrospective study of children with clinical optic nerve hypoplasia who underwent mri of the brain and orbits as part of the clinical workup in a tertiary care pediatric hospital. high resolution mri studies were performed on . tesla scanners. mri studies were reviewed for optic nerve hypoplasia, absent or ectopic posterior pituitary, absent pituitary infundibulum, absent septum pellucidum, migration anomalies and hemispheric injury.radiologists were blinded to patients endocrinologic status.all patients had clinical evaluation by a pediatric neuro-ophtalmologist and endocrinologist. a standardized panel of serologic testing that included serum cortisol, acth, tsh, and free t levels were performed on all patients. statistical analysis was performed to determine the sensitivity and specificity of mr findings in predicting endocrinologic deficiency. results: study included children( males and females) who had clinical optic nerve hypoplasia. the mean age of the study population was yr (sd: . yr). children had unilateral and children had bilateral optic nerve hypoplasia by mri. children had absent posterior pituitary bright spot and had ectopic posterior pituitary, had absent infundibulum, had complete callosal agenesis, partial callosal agenesis and had callosal thinning. had absent septum pellucidum. had hypopituitarism. of the patients with hypopituitarism had abnormal abnormal pituitary on mri, had absent septum pellucidum, and child had migration abnormality. none had corpus callosal abnormality. the sensitivity and specificity of mri in predicting hypopituitarism by demonstration of abnormal pituitary is % and % respectively. the positive predictive value and the negative predictive value is % and % respectively. among the patients with normal endocrinologic function, none had pituitary abnormalities on mri. conclusions: pituitary abnormalities are the most common intracranial abnormality in patients with optic nerve hypoplasia followed by absent septum pellucidum. detection of pituitary abnormalities by the mri has high specificity and high negative predictive value for endocrine abnormality. paper #: pa- ct imaging pearls for shunted pediatric brains srikala narayanan, md, children's national medical center, snarayan@childrensnational.org; nadja kadom purpose or case report: shunted pediatric patients frequently present emergently with symptoms that could indicate shunt malfunction, such as headache and vomiting. here, we present imaging pearls on non-contrast head ct in shunted children. methods & materials: illustration of each of the following: . shunt tip and volume averaging-consider location of side holes and use of multiplanar reformatted images. . shunt at burr hole-consider radiolucent shunt parts. . shunt rupture in the neck-remember to investigate the lower extracranial shunt parts. . shunt in cyst/subdural shunt (vs dislocation)-consider primary shunt location in a cyst rather than shunt dislocation. . enlarged temporal horns-look for it. in infants occipital horns may dilate first. . enlarged rd ventricle-look for bulging of lateral walls. . sulcal effacement-use the "three shades of gray" rule. . small cisterns-detecting shape distortion can help. . periventricular edema-easily overlooked because of similar low density compared to ventricular fluid. . slit-ventricle -requires cautious reporting. conclusions: careful evaluation of ct images in shunted pediatric patients can reveal important clues for making an accurate diagnosis, even when prior images are not available. successful treatment of mice with creatine transporter deficiency kim cecil, phd, cincinnati children's hospital medical center, kim.cecil@cchmc.org; diana m. lindquist, matthew r. skelton, gail j. pyne-geithman, joseph f. clark purpose or case report: creatine transporter deficiency (ctd) is an untreatable x-linked mental retardation syndrome with severe cognitive and speech impairment. patients are identified by an absence of creatine in the brain on mr spectroscopy (mrs) and distinguished from two creatine synthesis deficiency syndromes with genetic testing. for ctd, the absence of the transporter (slc a ) prevents creatine from crossing the blood brain barrier and entering brain cells. a brain specific ctd knockout mouse was developed replicating key features of the human disease and establishing an animal model for treatment of ctd. we report the successful treatment of the ctd knockout mouse and present confirmation by mrs. methods & materials: brain specific knockout and littermate control mice were randomly assigned and treated with on one of three supplements: agentx (confidential), creatine or maltodextrine as placebo. h and p mrs data were collected on a t mr system (bruker). mice (n ) were studied with mrs after weeks of supplementation. single voxel h data were acquired on a ul voxel covering the cerebrum using a double spin echo sequence. p data were acquired with an isis sequence from the same voxel. metabolite quantification was performed with jmrui and compared between groups and over time with statistical tests for significance (t-tests, anova). results: creatine and phosphocreatine levels in the brain were all significantly higher after weeks supplementation of agentx in knockout mice, compared to creatine and placebo fed knockout mice (phosphorus mrs [ ul brain voxel] with phosphocreatine (pcr) ( ppm) observed only in agentx treated knockout mice. adenosine triphospate (atp) gamma (− . ppm), alpha (− . ppm) and beta (− ppm) peaks are noted in all three knockouts. conclusions: successful treatment was achieved in a slc a brain specific knockout mouse for the second largest known cause of x-linked mental retardation in humans, ctd. disclosure: dr. cecil has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. prevalence of abusive injuries in siblings and contacts of abused children kenneth feldman, md, general pediatrics/children's protection program, university of washington/seattle children's, kfeldman@u.washington.edu purpose or case report: siblings and children who share a home with a physically abused child are thought to be at high risk for abuse. however, rates of injury in these children are unknown. disagreements between medical and cps professionals are common and screening is highly variable. our objective was to measure the rates of occult abusive injuries detected in contacts of abused children using a common screening protocol. this was a multi-center, observational cohort study of child abuse teams who shared a common screening protocol. data were collected for all children < years undergoing evaluation for physical abuse and their contacts. for contacts of abused children, the protocol recommended physical examination for all children < years, skeletal survey and physical exam for children < months, and physical exam, skeletal survey and neuroimaging for children < months old. results: among , children evaluated for abuse, met criteria as "physically abused" and these had contacts. for each screening modality, screening was completed as recommended by the protocol in approximately % of cases. of contacts who met criteria for skeletal survey, new injuries were identified in ( . %). none of these fractures had associated findings on physical examination. physical examination identified new injuries in . % of eligible, examined contacts. neuroimaging failed to identify new injuries among imaged, eligible contacts less than months old. twins were at significantly increased risk of fracture relative to other non-twin contacts ( . % vs . %, or . ). conclusions: these results support physical examinations and skeletal survey, regardless of physical examination results, for contacts of abused children < months of age. too few children had cranial imaging to change recommendations to image contact children less than months old. even for children where no injuries are identified, these results demonstrate that abuse is common among children who share a home with an abused child. they support including contacts in evaluations and interventions (foster care, safety planning, social support) designed to protect physically abused children. the project was supported by the health resources and services administration/maternal shown that pediatric rib fractures may be a marker for significant intrathoracic injury. this information has been used to suggest that children with rib fractures and no underlying intrathoracic injury may have sustained them due to insufficient bony mineralization and minor trauma rather than inflicted injury. methods & materials: irb approval was obtained for a retrospective review of all children under years of age with imaging diagnosis of rib fracture over a -year period at two university hospitals. children with prior thoracotomy, previously recognized metabolic bone disease, and prematurity < weeks were excluded. medical records were reviewed and children with documented abuse or accidental trauma were evaluated. children with indeterminate injury mechanisms were excluded. sixty-six patients with rib fractures were included in analysis, due to abusive injury and due to accidental trauma. children were analyzed for associated intrathoracic, abdominal or intracranial injury, additional fractures and retinal hemorrhage. results: abused children were younger ( . +/− . months) than accidentally injured children ( . +/− . months, p< . ). children with rib fractures due to accidental trauma had a higher incidence of intrathoracic injury compared to those due to abusive injury ( % vs %,p< . ). there was no difference in the incidence of abdominal or intracranial injury between groups. mortality and icu admission rates were similar. abused children had a higher total number of rib fractures (mean . vs . , p< . ) and were more likely to sustain additional fractures outside of the thoracic cavity ( % vs %, p< . ). conclusions: abuse is a more common cause of rib fractures in young children than accidents. children with rib fractures due to abusive trauma are less likely to have intrathoracic injury compared to those sustaining rib fractures due to accidental trauma. this suggests differences in mechanism of injury between groups. pediatric elbow fractures: a different angle on an old topic shannon zingula, md, pediatric radiology, cincinnati children's hospital medical center; kathleen emery, christopher g. anton purpose or case report: the most common elbow fractures classically reported in pediatric orthopedic texts are supracondylar (sc) ( - %), lateral condylar (lc) ( %), and medial epicondylar (me) fractures ( %) with fractures of the proximal radius (including but not limited to fractures of the radial neck) being relatively uncommon ( - %). our experience at a large children's hospital suggests a different distribution. purpose: ) to describe the frequency of different elbow fracture types in a large pediatric population, and ) to determine the fracture types that were occult on initial radiographs but detected on follow-up. methods & materials: review of medical records identified children, median age years and interquartile range for age of - years (range, . - years) diagnosed with elbow fractures at our institution from october through july . initial and follow-up radiographs were reviewed in blinded fashion independently by two experienced pediatric musculoskeletal radiologists to identify fracture type(s) on initial and follow up radiographs. note was made of fractures identified on follow up only. results: the most common fractures included sc (n , %), radial neck (rn) (n , %), and lc fractures (n , %). as compared to classically referenced incidences, rn fractures were seen significantly more (p< . ) and me fractures (n , %) significantly less (p . ) than would be predicted. in patients without fracture seen on initial films, occult fractures were seen on follow up; sc (n , %) and rn fractures (n , %) were most common. the frequency of rn fractures compared to the overall group ( % vs. %) approached but did not reach statistical significance (p . ). patients with one fracture had additional fractures seen on follow-up not seen initially with olecranon fractures most frequent (n , %.) this was significantly more common than the number identified on initial radiographs (n , %) (p< . ). conclusions: sc fractures are the most frequent elbow fracture seen initially and in follow up followed by rn and lc fractures in a distribution different than classically described. the relatively high frequency of rn and olecranon fractures detected on follow up speaks to their potentially occult nature. careful attention to these areas is warranted in patients with initially normal radiographs. purpose or case report: previous studies have found that fractures involving the spine, hands and feet are rare on skeletal surveys for suspected child abuse, leading some authors to suggest eliminating views of these regions from the initial skeletal survey protocol. the purpose of this study was to assess this recommendation by performing a historical review of these injuries in a population undergoing screen-film based skeletal surveys for suspected abuse. this cross-sectional, retrospective irb approved study reviewed the reports of the initial skeletal surveys of all children < years of age with suspected abuse imaged between april, and december, . infants underwent skeletal surveys according to acr standards acquired on a mammographic type screen-film imaging system with at least line pairs per millimeter resolution. studies in toddlers were performed using a par speed screenfilm system. results: % ( / ) of all skeletal surveys demonstrated positive findings, and % ( / ) had > fracture. . % ( / ) of all studies had fractures involving the spine, hands or feet. of all positive skeletal surveys, . % ( / ) had fractures involving the spine, hands or feet, and . % ( / ) of all patients with > fracture on skeletal survey had fractures involving these regions. conclusions: these data, acquired in the screen-film era, suggest that fractures of the spine, hands and feet may not be rare in infants and toddlers in cases of suspected child abuse. the benefits of eliminating views of these regions from the initial skeletal survey should be carefully weighed against the cost of missing these potentially important injuries in at-risk pediatric populations. purpose or case report: dating fractures is critical in cases of suspected infant abuse, but there are little scientific data to guide radiologists, and dating is generally based on personal experience and conventional wisdom. we previously reported a scientific scheme for dating fractures in infants based on an analysis of subperiosteal new bone and callus formation in birth-related clavicular fractures. we hypothesize that when used as a guide this system can significantly improve the ability of radiologists to accurately date fractures in young infants. methods & materials: radiographs of presumed birthrelated clavicular fractures in infants - months were reviewed by pediatric radiologists with (reader a) and (reader b) years experience in two reading sessions separated by one year. for the first read, no guidelines were provided. training was carried out prior to the second session, and readers were given the dating scheme as a guide during fracture analysis. readers were asked to provide an estimate of the minimum and maximum fracture age in both sessions. the primary outcome was whether or not the reader's estimated range for fracture age included the actual fracture age. a secondary outcome was the width of the estimate of fracture age. these outcomes were compared across the two reading sessions. results: the rate of correct response significantly increased after training for each reader (reader a: % to %, p<. ; reader b: % to %, p . ). the width of estimated fracture age after training was significantly smaller for each reader (reader a: mean width days to days, p<. ; reader b: days to days, p . ). conclusions: our results suggest that the ability of a radiologist to accurately date fractures can improve significantly when provided with a scientifically based system outlining patterns of fracture healing. this scheme can be applied in radiologic practice and may prove particularly useful in cases of suspected abuse, where fracture dating often has forensic implications. purpose or case report: to demonstrate the acute and subacute features of proximal femoral physeal fractures in the abused child. also to demonstrate how to recognize this injury in patients with unossified femoral heads. the database of patients with suspected non-accidental trauma, accumulated over years, was reviewed. out of a total of patients ( %) were proven to be cases of non-accidental trauma, as determined by the child abuse pediatrician. from these patients, the cases of proximal femur growth plate fractures were identified. results: patients with proximal femur growth plate fractures were identified for a prevalence of . %. one patient had bilateral proximal femoral fractures, for a total of fractures in patients. were boys, were girls with ages ranging from . mos to yrs mos. in patients, the fracture was revealed on imaging performed because of refusal to bear weight; in the other patients, the fracture was found during imaging for the skeletal survey. the fracture was on the left side in cases and on the right side in (the patient with bilateral fractures). in all of the fractures, there was lateral displacement of the femoral shaft. in fractures, the femoral head was not yet ossified simulating the appearance of a dislocation. location of the femoral head in the hip joint was verified by ultrasound or ct (ct abdomen had already been done in patient) thus delineating the presence of a physeal fracture. / fractures were salter-harris i and the other were salter-harris ii fractures. the fracture was acute in cases and subacute in cases. in these subacute cases, periosteal reaction and/or calcifying subperiosteal hemorrhage was present in , and irregularity and scalloping of the metaphysis was present in the other . conclusions: proximal femoral growth plate fractures are quite uncommon in non-accidental trauma. the injuries are typically salter-harris i or ii fractures, seen more often in the healing phase. in the presence of an unossified femoral head, the laterally displaced femoral shaft can simulate hip dislocation; this can be clarified with hip sonogram. purpose or case report: in recent years, metal stents have been used to overcome airway obstruction in children for whom no better surgical option is available. these devices are not designed for use in the airway, however, and may cause significant complications. bioabsorbable airway stents may avoid some of the problems associated with metal stents. methods & materials: this is a retrospective review of all endoluminal insertions of bioabsorbable airway stents at a single institution from april to september . custom-made polydioxanone stents of various sizes (ella dv, ella, czech republic) were used. results: twelve stents were inserted in the airways of seven children. indications were: recurrent obstruction after slide tracheoplasty ( ), persistent airway compression after correction of a congenital cardiac lesion ( ), collapse of stem cell supported tracheal homograft, tracheomegaly following fetal balloon insertion, and syndromic tracheobronchomalacia (tbm). eleven stents (diameters to mm) were placed in the trachea and one in the left main bronchus. two stents had to be removed and replaced for technical reasons (one was too long and the other too narrow). the child with syndromic tbm died when treatment was withdrawn because she could not be weaned from the ventilator. the remaining children are alive at a median follow-up of nine months (range to months). the granulation tissue response was similar to that seen after placement of metal stents. the stents were observed to absorb gradually over a period of approximately three months, requiring serial stenting in two children. conclusions: bioabsorbable airway stents are more difficult to insert than metal stents. they cause similar early complications, especially granulation tissue formation, but appear to avoid potential long-term complications of metal stents, including vascular erosion and growth limitation. disclosure: dr. mcclaren has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: renal angiomyolipomas (amls) in tuberous sclerosis complex (tsc) grow at a faster rate, exhibit a wider and more problematic range of symptoms, and hemorrhage more frequently than sporadic amls. we examined the efficacy of prophylactic embolization of renal amls in tsc in decreasing tumor size, alleviating symptoms, and preventing hemorrhage while preserving renal function. we retrospectively reviewed the charts and imaging studies of consecutive patients who underwent transarterial, transcatheter embolization of amls. tumor volume was measured from available ct or mri imaging before and after embolization. pre-and postembolization symptoms and creatinine levels were documented. results: patients had available follow-up imaging at a mean of months post-embolization. the mean preembolization tumor volume was ml and postembolization was ml; median decrease in volume was %. using the schwartz method, the mean glomerular filtration rate before embolization was calculated to be . ml/min/ . m . after embolization the mean value was statistically unchanged at . ml/min/ . m . none of the patients experienced renal hemorrhage or symptom recurrence during the follow-up period. conclusions: selective embolization of renal amls in patients with tsc decreases tumor volume, relieves symptoms and reduces the risk of future hemorrhage while preserving renal function. etoh was injected percutaneously with g needle; transductal ablation performed through a f micropuncture sheath. drug volumes, technical difficulties, percentage reduction in saliva production, family reported clinical significance, and complications were recorded. results: salivary gland ablation (sga) included bilateral smg and slg ablation without parotid gland ablation in cases, and with unilateral parotid gland ablation in cases. one case of bilateral parotid gland ablation following surgical resection of bilateral smgs. mean etoh dose for smg . ml, and . ml for slg. one case of focal skin necrosis was noted; no other complications. patient families reported response to sga in / cases ( %) with mean saliva production of %. greatest health and family impact was reported with elimination of hospitalizations for recurring aspiration pneumonia ( cases), elimination of choking in bed ( cases) , and improved patient sense of self-hygiene in cases. one complication occurred with temporary marginal mandibular nerve paralysis (resolution in months). conclusions: percutaneous and transductal sga is feasible, safe, and effective in this small patient series, offering an alternative to surgical salivary gland resection, or treatment option following failed surgical intervention. paper #: pa- mr-guided procedures in children: initial experience joao amaral, md, diagnostic imaging, the hospital for sick children, joao.amaral@sickkids.ca; michael temple, dimitri parra, philip john, bairbre connolly purpose or case report: the primary purpose of this study was to review our initial experience with mr-guided procedures in children. our secondary objective was to share some aspects on how to start an mr-guided program in a tertiary pediatric center. patients with lesions identified only on magnetic resonance (mr) imaging were selected to undergo an mr-guided procedure. patients' demographic data, primary diagnosis, referring team's clinical suspicion, lesion's anatomical location, tissue adequacy for pathology, final diagnosis and clinical follow up were reviewed. aspects of starting a program of mr-guided procedures, safety concerns, imaging and technical challenges, and mr compatible materials were also addressed. results: to date, procedures ( bone biopsies, soft tissue biopsy and pre-surgical needle localization) were performed in patients during months. there were girls and boys with a mean age of . years ( y mo- yrs). one patient had a nasopharyngeal carcinoma, cardiofacial syndrome, wilm's tumor and had no previous medical issues. the clinical suspicion for procedures in patients was metastatic disease and for procedures in patients was primary malignancy or infection. lesions were located in the tibia ( -metaphysis and diaphysis), femur ( -metaphysis and epiphysis), thigh ( -soft tissues), sacrum ( ) and retroperitoneum ( ). all biopsies provided adequate tissue for diagnosis. needle localization and hook deployment was also accurate. malignancy was excluded in all patients. final diagnosis included chronic recurrent multifocal osteomyelitis (crmo), osteomyelytis, fibrous tissue, osteoid osteoma, and scar tissue. mean follow up was . months. no patient required a second procedure to confirm the diagnosis. conclusions: mr with its unique soft tissue resolution and lack of ionizing radiation is an excellent method to guide interventions in children. one of the greatest advantages of this method is the precise target localization especially in lesions located in the bone marrow or lesions better identified on mr. special safety measures, specific mr compatible material (needles, surgical instruments), dedicated imaging techniques to reduce or increase material/needle artifact and careful technique are paramount. - . m, f; . - months, mean . months, median months, mode months. sonographic approach expanded as our experience grew over months. studies performed by a single pediatric radiologist. bilateral sonography included: interscalene and supraclavicular neck, nerve roots at neural foramina, cervical spinal canal, diaphragm during spontaneous respiration, rhomboid muscle, serratus anterior muscle, posterior shoulder, all performed and interpreted blind to other imaging. results: interscalene and supraclavicular neck evaluated in all patients. all exhibited echogenic interscalene portion of brachial plexus.size and extent of traction neuroma varied. nerve roots at foramina noted in axial and coronal planes. in cases enlarged root(s)noted. cervical spinal canal studied in patients: cord oscillated normally, no syrinx, cord concentric in canal. intracanalicular traction pseudomeningoceles on concurrent ct myelography or mri were not apparent on us. in cases a "clumped" retracted nerve root on the cervical cord was later found to correspond to a pseudo-meningocele on ct myelogram. otherwise, cervical spinal canal us was unremarkable in cases. diaphragm motion was evaluated in patients during spontaneous respiration; no phrenic nerve palsy. rhomboid muscle was evaluated for atrophy in patients; had atrophy. the rhomboids are innervated by the dorsal scapular nerve which arises solely from c , prior to c joining the brachial plexus. intact rhomboid indicates that the central c root is intact. serratus anterior muscle, innervated by the long thoracic nerve (c ,c ,c ), was evaluated for atrophy in patients; had atrophy. dynamic evaluation of the posterior shoulder looking for posterior laxity was evaluated in patients; had laxity. posterior shoulder dislocation or subluxation is a known sequela of brachioplexopathy which sometimes requires muscle transfer when the child is older. conclusions: comprehensive us evaluation of perinatal brachioplexopathy detects: extent of traction neuromafibroma from the interscalene region peripherally toward clavicles (important for neurosurgeon), thick nerve roots, phrenic nerve diaphragm palsy, muscle atrophy from denervation, and posterior shoulder subluxation. us misses: intracanalicular traction pseudomeningoceles. paper #: alt- impact of the image gently campaigns in adult-focused hospitals: a survey of practice leaders brett bartz, duke university medical center; donald frush, kimberly applegate, michael callahan, laura coombs, marilyn goske purpose or case report: the alliance for radiation safety in pediatric imaging is an organization that uses social marketing to promote radiation protection for children and effect change across radiology practices. the impact of the alliance's image gently campaigns on practice patterns in radiology practices has yet to be assessed, especially outside of freestanding children's hospitals. the purpose of this investigation was to assess the impact of the image gently campaigns on academic and private practices/institutions that treat children but primarily serve adults. a web-based survey was emailed to leaders in radiology practices (n ) who do not practice at freestanding children's hospitals utilizing the acr's pred database. the survey consisted of questions designed to measure the recognition and impact of the image gently campaigns, including the impact on practice patterns. results: a total of practice leaders in u.s. states and territories responded for a response rate of . %. the majority ( %) of sites image pediatric patients in their practices. respondents consisted of department chairs ( %), group presidents/ceos ( %), and division chiefs ( %). the majority ( %) of respondents described their practice as a hospital-based private practice without a dedicated pediatric radiology division. the vast majority ( %) of respondents was familiar with the image gently campaigns; % of respondents reported that image gently had effected a change on how they imaged children. specifically, respondents (%) reported that the campaign caused a modification to lower dose protocols for head ct ( %), chest ct ( %), and abdominal/pelvic ct ( %). slightly more than half of respondents ( %), however, estimated that the image gently campaign resulted in no modification of pediatric fluoroscopy exposure. conclusions: to our knowledge, this is the first survey evaluating the impact of the image gently campaigns. there is near universal recognition of the campaigns, which have impacted practice patterns beyond the freestanding children's hospital in ct, but not in fluoroscopy. reliability of shear-wave velocity using different frequencies in acoustic radiation force impulse (arfi) elastography mi-jung lee, radiology, severance children's hospital, mjl @yumc.yonsei.ac.kr; suyon chang, myung-joon kim purpose or case report: although there are many studies about acoustic radiation force impulse (arfi) measurement, standard protocol has not been established. and a new probe with high frequency has been developed which can be applied for pediatric patients. the purpose of this study was to assess the reliability of shear-wave velocity (swv) at various depths using different frequencies to suggest standard measurement in arfi elastography. methods & materials: arfi elastography of both the elasticity phantom and normal liver was performed at different depths ( - cm) with convex ( - mhz) and linear ( - mhz) probes. ten valid swv measurements at each depth were performed. it was repeated ten times with the phantom and it was done in healthy volunteers (m:f : , age - years; mean . ). the mean value and standard deviation of swv were calculated. results: in both the elasticity phantom and the liver, variability of swv was different between the depths in both probes. the depth with lower variability in the phantom was and cm with the convex probe and cm with the linear probe. in the liver, the depth with lower variability was cm with the convex probe and and cm with the linear probe. in comparison of two probes, the linear probe showed lower variability at and cm depth in the phantom and at cm depth in the liver whereas the convex probe showed it at cm depth in both the phantom and the liver. conclusions: in arfi elastography, measurement of depth shows different variability in both low and high frequency probes. to obtain the most reliable measurement of swv, using high frequency probe is recommended for - cm depth and using low frequency probe is recommended for - cm depth. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. imaging -year-old fetuses sabah servaes, children's hospital of philadelphia; teresa victoria, ann johnson, sandra kramer, richard markowitz, diego jaramillo purpose or case report: to demonstrate normal anatomy and pathology of medical museum specimens without disturbing the specimens. methods & materials: nine fetal specimens from a medical museum were imaged with ct and mri ( . t and . t) when possible with the specimens in their preserving fluid and containers. results: the fetal specimens are estimated to be approximately years old. one specimen is from the first trimester, seven are from the second trimester, and one is from the third trimester. normal anatomical structures at various stages of development including the brain (and varied sulcation pattern), lungs (lobar anatomy), and skeletal structures (several developmental features such as the ossification centers, perichondrial structures, and marrow cavitation) can be evaluated using imaging without causing harm to the specimens. pathologic entities including anencephaly and sirenomelia are also evaluated demonstrating features of these entities. conclusions: imaging historical fetal specimens provide an opportunity to evaluate normal developmental changes and pathological entities and also to gain a better understanding of the museum pieces without damaging the museum specimens. pediatric ct interpretations: does a tertiary care radiologist make a difference? wendy d. ellis, monroe carell jr. children's hospital at vanderbilt university; sumit pruthi, david johnson, christopher eakins, chang yu, marta hernanz-schulman purpose or case report: to determine whether a substantive difference exists between the pediatric imaging reports of community radiologists and reinterpretations by tertiary care radiologists at a free-standing children's hospital; and how those interpretations were related to the final diagnosis. methods & materials: this retrospective review examined the computed tomography (ct) reports of all pediatric patients referred to our tertiary care children's hospital over a month period ( / / - / / ). the outside reports and the requested second interpretation reports were compared and their content categorized as "agreement" vs. "disagreement: major or minor". a representative sample of major disagreements in which there was reliable followup information was correlated with the final diagnosis to determine if there was added value provided by the reinterpretation. results: ct scans from patients were submitted for reinterpretation. disagreements were found in / cases ( . %); with . % ( / ) classified as major disagreements. among the neurologic cases, major disagreements occurred in patients ( . %) and minor disagreements in patients ( . %). among the body scans, major disagreements occurred in cases ( . %) and minor disagreements in cases ( . %). in the cohort of cases reviewed for final diagnosis, the second read interpretation was more accurate in . % of cases with a p-value of < . (neurologic . %, p < . ; body . %, p < . ). conclusions: in our review, discrepancy rates between community and tertiary care radiologists in interpretation of pediatric ct scans were substantial, with discrepancies occurring in more than % of cases. further review of the cases for final diagnosis, showed that a significant number of the tertiary care interpretations were more accurate. possibilities that may account for this discrepancy include subspecialty training and elapsed time since performance of the study, which might provide additional clinical data in some cases. diagnostic ct scans performed at outside institutions should not be repeated considering added radiation burden to the child and additional expense. our data indicates there is added value to the reinterpretation which impacts the accuracy of the report (as assessed by the final diagnosis), and should be recognized by payors as integral to optimal patient care. ionizing radiation exposure from radiography in the neonatal intensive care unit-per-patient cumulative effective doses amaya basta, radiology and biomedical imaging, ucsf; jesse courtier, john mackenzie purpose or case report: to better understand the levels of exposure to ionizing radiation for infants in the neonatal intensive care unit (nicu). we retrospectively collected the number and types of radiographs performed per infant in our nicu by searching our radiology information system database over a five-year period. we focused on the most common examinations ( % of all radiographs) and assigned each an estimated equivalent dose based on published literature: chest and abdomen . micro sieverts (μsv), one-view chest . μsv, abdomen . μsv, twoview chest . μsv, two-view abdomen μsv. we then calculated a cumulative equivalent dose (ced) for each infant based on the number of each type of examination they received. descriptive statistics were generated to depict the distribution of number of examinations and ced. results: over five years, , infants cared for in our nicu received at least one radiograph of the chest and/or abdomen. the number of examinations obtained on these infants was . , , , (mean, median, minimum, maximum). the st quartile was and the rd quartile was examinations. the cumulative equivalent dose these infants received was . , . , . , , . μsv (mean, median, minimum, maximum) . the st quartile was . and the rd quartile was . μsv. two hundred infants ( . % of the study population) received a ced of over μsv. conclusions: descriptive statistics provide a valuable assessment for the broad range of radiation that infants receive in the nicu. although the distribution is skewed towards a low level of exposure, a subset of patients ( . %) received a ced of over μsv. identification of factors that cause infants to enter this group will be important for future dose reduction strategies. poster #: cr- congenital cardiac fibroma: a case report earic bonner, meharry medical college, ebonner @email. mmc.edu; seth crapp, david parra purpose or case report: a -week-old male presented to his pediatrician with a ii/vi systolic ejection murmur along the left sternal border. he had mild tachypnea without cyanosis. his oral intake was adequate with no evidence of failure to thrive. he was referred to a pediatric cardiologist who performed an ecg and a transthoracic echocardiogram. the ecg showed normal sinus rhythm at beats per minute with no abnormalities. the transthoracic echocardiogram showed a x x mm homogeneous mass originating from the anterior free wall of the right ventricle, and mild dilation of the right ventricle. mild dynamic subpulmonary stenosis and a secundum atrial septal defect were also noted. although the murmur was significantly louder at one month follow-up, a repeat echocardiogram did not reveal any increase in the size of the mass. at months of age, a cardiovascular magnetic resonance imaging (cmri) study under general anesthesia was performed. cmri revealed a x x mm cardiac tumor that was causing narrowing of the right ventricular outflow tract. the tumor was hypointense on t -weighted imaging and hyperintense on t weighted imaging, with positive delayed enhancement. these findings, along with the size and location of the mass, are consistent with a diagnosis of a cardiac fibroma. chest mra, that was also performed, showed normal extracardiac vascular anatomy with no evidence of peripheral branch pulmonary stenosis. cardiac fibromas do not usually increase in size; however, the concern is the child's risk of arrhythmias. frequent holter monitoring was recommended for this patient. considerations were also made for an electrophysiology study in the next - years to determine the risk of ventricular ectopy. at that point, the patient can be assessed for the possibility of resection of the fibroma. purpose or case report: treatment of pulmonary atresia is complex and demands intricate solutions. one solution is the creation of a conduit between the right ventricle and the main pulmonary artery. the lifespan of these conduits is limited by progressive occlusion over time, which can be treated with endovascular stent placement in lieu of surgical re-intervention. however, these stents are at high ( %) risk for fracture, typically at the stent waist. the radiologist should be aware of this complication, as they may be the first to identify it on chest radiograph. the purpose of this electronic poster is to familiarize radiologists with this entity by presenting cases of stent fracture and migration. methods & materials: over a month period, we identified three children with rv-pa stent fractures and associated stent migrations on chest radiography. imaging analysis was focused on the appearances of these fractured stents. patient management and outcomes were reviewed. results: three children, males, female (ages , , and years) were found to have asymptomatic rv-pa conduit stent fractures with fragment migration. one chest xray was performed in the er for fever and cough; one was pre-op for gi surgery; one was done to confirm abnormal findings seen on a routine cardiac echo. the time between stent placement and fracture detection ranged from to months. two patients had stent fractures and embolizations to the right ventricle that required open surgery to remove stent fragments. the third patient had embolization to both pulmonary arteries, but did not require treatment. all patients did well. conclusions: stent fractures and migrations are a relatively common complication of rv-pa conduit stent placement. pediatric radiologists need to be aware of this complication in order to provide value-added interpretations. purpose or case report: we describe the case of a week stillborn fetus with a . cm diameter craniopharyngioma detected by ultrasonography. a g p woman in her third decade had ultrasonographic examination showing hydrocephalus, polyhydramnios and an intracerebral mass. the nature of the mass was uncertain and intracerebral hemorrhage was considered. the pregnancy was terminated at weeks gestation. at postmortem examination the decedent was a g male fetus with a head circumference of . cm and a crown-rump length of . cm. anterior and posterior fontanelles appeared large. no other external abnormality was found. the placenta was unremarkable and cytogenetics on placental tissue showed a normal male karyotype. examination of fetal viscera was remarkable for mildly underweight adrenal glands ( . g, expected . g) and hepatomegaly ( . g, expected . g). intracranial csf was increased in volume. there was a suprasellar . cm diameter somewhat gritty, but smooth-surfaced tumor. the brain and tumor together weighed g. the floor of the cranium and sella turcica were grossly normal. histologic examination of the tumor showed an adamantinomatous type craniopharyngioma with characteristic epithelium, stellate reticulum, focal keratinizing squamous epithelium and calcification. pre-and postnatal mri of caudal regression syndrome claire b. beaumont, md, university of arkansas for medical sciences, cbbeaumont@uams.edu; nafisa k. dajani, leann e. linam purpose or case report: caudal regression syndrome is a rare form of caudal dysplasia characterized by a spectrum of findings including agenesis of the lumbosacral vertebra, multiple orthopedic deformities in the lower limbs, as well as anomalies of the gastrointestinal and genitourinary tracts. the mechansim of caudal regression syndrome is not completely understood but is believed to be secondary to a defect in the induction of caudal elements. mri is a valuable tool for identifying the specific anomalies involved with caudal regression syndrome on a case-by-case basis. the following is a case from our institution which includes both pre-and postnatal mri. unsuspecting tuberous sclerosis diagnosed on neonatal cranial ultrasound vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; puneet gupta, richard thomas, vaseem iqbal, jan najdzionek. purpose or case report: tuberous sclerosis (ts) is a rare autosomal dominant genetic disorder causing hamartomatous proliferation in number of organ systems. because the classical triad of epilepsy, mental retardation and adenoma sebaceum is not commonly seen on clinical examination, imaging plays a central role in the diagnosis and treatment of tuberous sclerosis. central nervous system features of ts include subependymal nodules, cortical tubers, subependymal giant cell astrocytoma, white matter bands and cysts. in patients with ts, cerebral involvement in the form of subependymal nodules is seen in % to % and white matter abnormalities are noted in % to % of cases. knowledge of expected radiological features is thus important in making the correct diagnosis. recent studies have indicated that earlier appearance of brain lesions indicate a greater risk of mental retardation and a more severe clinical course. we present a case of a -day-old neonate who was referred to us with concerns for hydrocephalus. the cranial ultrasound demonstrated multiple echogenic subependymal nodules of varying sizes and mild asymmetry of the ventricles. the differential diagnosis included ts, torch infections, and x-linked subependymal heterotropia. areas of increased echogenicity were noted within the white matter of the left frontal lobe, which favored ts. subsequently, an mri was performed to validate these findings and assess for additional white matter lesions. the mri showed classic manifestations of ts that included periventricular lesions and streaky, linear, wedge-shaped hyperintensities on flair imaging. a noncontrast ct scan was also performed which revealed classic calcified subependymal nodules. cardiac rhabdomyoma and renal angiomyolipoma are the other recognized manifestations of ts and were respectively excluded by subsequent echocardiogram and renal ultrasound. pyloric atresia with epidermolysis bullosa: fetal mri diagnosis with postnatal correlation arnold c. merrow, md, radiology, cincinnati children's hospital medical center, carl.merrow@cchmc.org; jason s. frischer, anne w. lucky purpose or case report: pyloric atresia (pa) is an uncommon disorder, accounting for % of congenital gastrointestinal atresias. up to % of cases have associated anomalies, the most common of which is epidermolysis bullosa (eb). prenatal findings have been reported sonographically for each of these anomalies, both in isolation and in the rare case of association. a case of isolated pa has been reported by fetal mri. we present the first reported case of pa with eb diagnosed by fetal mri with corroborative postnatal imaging and surgical findings. the mother of this child was initially referred to the fetal care center of cincinnati at weeks gestation for a possible myelomeningocele diagnosed by prenatal ultrasound at an outside facility. these ultrasound images were not available for review at the time of our workup. a fetal mri was the first study to be obtained at our institution. the mri showed no myelomeningocele or brain anomalies. the stomach was moderately enlarged throughout the exam and did not empty. subjective polyhydramnios was also noted. no duodenal dilation was seen, and there was minimal fluid in the distal bowel loops. this constellation of findings raised concern for pyloric atresia, resulting in a careful search for any sign of epidermolysis bullosa due to a known association of these disorders. prominent debris was seen layering dependently in the amniotic fluid and in the dilated fetal stomach, and the external ears were abnormally small and misshapen. the pa-eb association was proposed as the underlying diagnosis based on our mri findings. it was also postulated that skin blistering over the lumbosacral spine at the time of the prior outside ultrasound could have mimicked a myelomeningocele, thus prompting the referral to our center. at delivery, the baby had numerous skin defects, and the ears were malformed. an abdominal radiograph obtained after nasogastric tube placement and air injection showed no gas beyond the stomach. a pyloric ultrasound showed a distended stomach without a patent pyloric channel to the duodenal bulb, consistent with pyloric atresia. a skin biopsy confirmed epidermolysis bullosa, and the patient underwent a resection of the pa with gastroduodenostomy. the baby subsequently expired less than two weeks later, most likely due to sepsis based on wound cultures and autopsy results. our case demonstrates the ability of fetal mri to diagnose this rare condition and highlights the key imaging manifestations of the pa-eb association. disclosure: dr. merrow has indicated that he is an author for amirsys and receives a royalty accordingly. purpose or case report: we demonstrate a case where the changing position of the contrast filled appendix lead to the diagnosis of malrotation, with review of the embriology of intestinal rotation. a newborn preterm female presented with a golf ball sized umbilical mass, that reduced by itself, thought to represent an umbilical hernia vs omphalocele. she was unstable to undergo an upper gi exam under fluoroscopy, therefore a limited contrast study was performed at bedside and was inconclusive for malrotation. subsequent nicu radiographs showed changing position of the appendix filled with residual contrast, visiting all quadrants of the abdomen in a random pattern over a few days period. this confirmed our suspicion for malrotation. it is well know that in malrotation the position of the cecum can be variable, most commonly located in the right upper quadrant or left lower quadrant. to our knowledge it has not been described yet that the changing position of the appendix can lead to the diagnosis of malrotation. through this case we display the embriology of the intestinal rotation and the radiologic signs of malrotation. poster #: cr- mr imaging patters of liver transplant complications in the pediatric population edward richer, md, emory university, richerej@gmail. com; adina alazraki, jonathan loewen purpose or case report: pediatric liver transplantation is a relatively common surgery, with more than transplants in the united status annually. the spectrum of post transplant complications has been previously described, primarily utilizing ultrasound. as mri has become a more widely used technique in pediatric imaging, and ultrasound findings may be non-specific, knowledge of mr imaging patterns is an important adjunct in the post-transplant evaluation. we present a spectrum of complications, including vascular, biliary, hepatic parenchymal, and systemic complications. methods & materials: using an electronic record system, we identified pediatric patients with prior liver transplantation who subsequently underwent abdominal mri at our institution and were found to have a post transplant complication. patient management and outcomes were reviewed. results: our review of a subset of the available patients shows vascular complications to be the most commonly encountered abnormality at our institution, including hepatic artery stenosis/thrombosis, and portal vein stenosis/ thrombosis, cavernous transformation of the portal vein. biliary complications were relatively common, including bilary stenoses and bilomas. hepatic parenchymal and systemic complications, such as ptld, were less common. we demonstrate the mr imaging patterns of these complications. conclusions: pediatric liver transplantation is a relatively common surgery, and the mri appeance of post transplant complications warrants illustration as abdominal mri becomes more widely used in pediatric imaging. we present a pictorial review of common patterns of complication. imaging of progressive familial intrahepatic cholestasis (pfic) matthew d. dobbs, md , radiology, vanderbilt university medical center, matthew.dobbs@vanderbilt.edu; sumit pruthi, stephanie e. spottswood purpose or case report: progressive familial intrahepatic cholestasis (pfic) is a relatively rare pediatric liver disease due to a genetic mutation (abcb gene on chromosome q - ) in a bile salt export protein causing cholestasis leading to chronic inflammation within the biliary system. the diagnosis is made clinically with detection of a low ggt in the face of an elevated bilirubin and alkaline phosphatase. genetic testing confirms the diagnosis. one of the subtypes, type , was shown in to be highly related to the development of hepatocellular carcinoma. the vast majority in children in this study developed hcc at less than years of age. radiological contribution to the management of these chronic liver disease patients is to perform surveillance imaging to detect hcc. due to the rarity of this condition, almost no reports exist in the radiological literature describing the imaging features or management of this condition. our presentation will review the imaging findings in our small population of pfic type patients on us, ct, and mri. we will also review suggested surveillance imaging techniques and imaging algorithms. renal rhabdoid mimics wilms tumor vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; paul montgomery, jan najdzionek, vaseem iqbal purpose or case report: in the past most pediatric renal tumors have been classified together under the umbrella of wilms tumor. however, over the last decade with advancement in imaging, several distinctive imaging features specific to renal tumors have been recognized which aid in their classification as being distinct pathologically. we present a case of rhabdoid tumor where in the primary tumor arose from the kidney. it had classical imaging features of wilms tumor. we want to highlight that even with the most sophisticated imaging techniques, specific renal tumors cannot always be diagnosed with preoperative imaging and how this alters the management and prognosis for child with a renal mass. in our case, the postoperative findings, pathology and immunohistochemical techniques confirmed a rhabdoid tumor. differentiation of these two tumors is essential since in patients with rhabdoid tumor survival is poor with -year overall survival rates of % for stages i and ii and % for stages iii, iv, and v. on imaging, there are several features that suggest the diagnosis of rhaboid tumor. these include subcapsular fluid collections, linear calcifications outlining tumor lobules, and vascular invasion. also, a pertinent feature of rhabdoid tumor due to its aggressive nature is the presence of lung metastasis ( %) and synchronous malignant brain lesions ( %). these findings were not present on our case, which led us in formulating a diagnosis of wilms. our patient is unusual in the fact that the local renal findings and absence of metastasis, synchronous malignant lesions, and vascular invasion led us to an incorrect diagnosis of wilms tumor. in conclusion, we would like to stress that diagnosis of rhabdoid tumor of the kidney on imaging presents a challenge because of its imaging similarity to wilms tumor. ectopic ureters in young infants: mru findings shin-lin shih, md, department of radiology, mackay memorial hospital; yi-fang chen, chun-chao huang, fei-shih yang purpose or case report: to localize the terminations of ectopic ureters by mri methods & materials: mr urography (mru) was conducted in four female patients with hydroureter and a suspected ectopic orifice. mr imaging was performed with a t mr scanner (achieva; philips). the imaging protocol mainly consisted of a single-shot t -weighted turbo spin echo sequence with a slice thickness of mm and multiplanar reformations. the ages of the four patients were day, days and months (for two). the latter two patients presented with urinary tract infection. the newborn patients presented with abnormal prenatal examination. the pertinent findings and descriptions of a variety of renal anomalies were described. results: the locations of the ectopic ureters were two in the vagina, one in the uterus and one in the bladder neck. the associated renal anomalies were a right duplex kidney in four, a left duplex kidney in one, a left ectopic dysplastic kidney in one and vesicoureteral reflux in one (confirmed by vcug). conclusions: mru may demonstrate the exact point of termination of an ectopic ureter and also the associated renal anomalies. poster #: cr- acquired polycystic kidneys in neuroblastoma survivors richard bellah, , radiology, the children's hospital of philadelphia, bellah@email.chop.edu; bernard kaplan, camilo jaimes, yael p. mosse, jill p. ginsberg, kevin e. meyers purpose or case report: neuroblastoma (nbl) is the most common extracranial solid malignancy of childhood. with current therapy, the prognosis and long term survival of patients affected by this condition has dramatically improved. nevertheless, the treatment for nbl may account for some complications further in life. in patients with neuroblastoma, acute renal failure can occur usually as a result of a thrombotic microangiopathy associated with bone marrow transplantation. in addition, end-stage renal disease has been reported in long-term survivors of nbl. this exhibit describes and illustrates the first case series of five patients with treated nbl in whom the imaging features of polycystic kidney disease (pkd) developed over time, and in some cases, as progressive renal failure ensued. methods & materials: medical and imaging records were reviewed (irb approved) of patients with treated nbl in whom pkd became apparent during the course of followup imaging. results: five patients displayed findings of pkd on us and/or ct. three of the five patients (where images were available) had normal renal imaging at time of nbl diagnosis. the mean age at nbl diagnosis was . years (range . - . yr). the mean age at time pkd was detected was . years (range - yrs). none of the patients had a family history of pkd, or had previously undergone dialysis. all patients received chemotherapy and total body irradiation prior to bone marrow transplantation. four patients survived nbl therapy but eventually developed end-stage renal disease. conclusions: an association between acquired pkd and nbl has not been previously reported. the etiology of this observation is still unclear, but a toxic insult is likely to account for the renal changes. further research is needed to establish the epidemiology, prognosis, and etiology of this association. abnormal migration of the retention anchor suture in a case following gastrostomy tube insertion surendra narayanam, mbbs, dmrd, dnb, division of image guided therapy, department of diagnostic imaging, the hospital for sick children, nrssbabu@gmail.com; joao amaral, luke toh, bairbre connolly, vicente deoliveira, dimitri parra purpose or case report: during percutaneous gastrostomy tube placement, retention anchor suture(s) are deployed into the stomach to tack the anterior gastric wall to the abdominal wall. in our practice the thread of the retention anchor suture is cut at days and the metallic portion passes pre rectum. we report an interesting and very rare migration of the metallic portion of the retention anchor suture in post-primary gastrostomy tube insertion. an -month-old girl, with a mitochondrial disease and severe hypotonia underwent percutaneous gastrostomy placement. during the procedure the retention anchor suture thread snapped and the metallic portion of the suture remained within the stomach. day post procedure, the child became uncomfortable, so a gastrostomy tube check was performed. the suture was not visible in the abdomen on abdominal x-ray or fluoroscopically. on close review of the images, the suture was found projected over the distal esophagus. initial impression was the anchor suture had refluxed into the esopahgeal lumen. careful attempts were made to remove it along with the nasogastric tube, from above under fluoroscopic control. however on withdrawal of the nastogastric tube, the retention anchor suture moved enbloc with the nasogastric tube. once removed the retention anchor suture was confirmed to be within the nasogastric tube. this case illustrates the importance of examining the chest x-ray carefully before assuming a retention anchor suture has passed. to understand the appropriate post procedural radiographic workup and its technique for timely diagnosis. . to learn the potential complications of delayed diagnosis. pediatric retroperitoneal synovial sarcoma ahmad aouthmany, university of toledo medical center, ahmad.aouthmany@utoledo.edu; asif abdullah purpose or case report: pediatric synovial sarcoma most commonly affects the extremities, especially the lower thigh and knee region; other primary sites such as the retroperitoneum have been only infrequently reported. we report an extremely rare case of a retroperitoneal synovial sarcoma masquerading as retroperitoneal hematoma in a -year-old white female with non-traumatic back pain and non-contrast enhanced ct findings of right quadratus lumborum and psoas region presumed hematoma. coagulation studies revealed factor xi deficiency also known as hemophilia c. however, on follow-up imaging, the presumed retroperitoneal bleed persisted and a subsequent mr examination revealed a solid enhancing mass. ct, mr, and fdg-pet findings as well as a brief histopathology are discussed. our case is rare in the regards that the tumor occurred in an uncommon retroperitoneal location in a pediatric patient and was mimicking a retroperitoneal hematoma which posed a significant diagnostic challenge. despite a rare entity, synovial sarcoma among other sarcomatous lesions maybe considered in the differential consideration of a spontaneous retroperitoneal hematoma even in hemophiliac patients. longitudinal bracket epiphysis michael jubang, geisinger, mjjubang@geisinger.edu; farzad sedaghat, william j. malone, george wu, william mirenda purpose or case report: longitudinal bracket epiphysis is a rare anomaly with multiple synonyms such as delta bone, triangular bone, and congenital angular deformity. the purpose of this case report poster is to discuss an -month-old male born with an adducted right great toe with a broad nail and a notch in the center of the distal phalanx. the review will discuss radiographic findings, the natural progression of the disease, the treatment options, the mri findings used for pre-surgical planning, and associated pathology. whole body mri in pediatric non oncologic diseases: pictorial review ramy el jalbout, md, radiology, chu sainte justine, ramy.jalbout@yahoo.com; vijay moorjani purpose or case report: with the advances in scanning techniques and the scanning sequences, the role of wbmri is expanding. mri has a great role in the pediatric population owing to its inherent advantages namely lack of radiation, high tissue specificity, and high diagnostic yield at the level of the entire body under a single sedation. unlike the application of wbmri in the assessment of metastasis and bone marrow involvement in leukemia, its role in systemic diseases is yet to be further investigated. certain diseases such as crmo are very often multifocal. the extent of osteonecrosis in patients on steroids, dermatomyositis and the lesions related to child abuse are very often wide spread in the skeleton. we intend to present some of the findings of these pediatric systemic and multifocal diseases on wbmri. chronic relapsing multifocal osteomyelitis (crmo): crmo can be acute or chronic and is multifocal. the abnormality manifests as high signal intensity. wbmri can guide for the best site for biopsy and provides monitoring for response to treatment. osteonecrosis: only few small studies evaluated the usefulness of wbmri in the diagnosis of both the symptomatic and asymptomatic sites of osteonecrosis in all patients on steroid therapy. wbmri is more sensitive than conventional radiographs. the abnormalities are typically geographical areas of high stir signal intensity. myopathies: wbmri has also the role of detecting the extent of idiopathic inflammatory myopathies such as dermatomyositis in the entire skeleton. child abuse: wbmri has a low sensitivity for the highly specific fractures that are pathognomonic for child abuse. conclusions: wbmri is a useful examination in the pediatric patient that is radiation free, quick and allows imaging of the entire body. it is an adjunct to dedicated mris to look for multifocality and extent of systemic diseases such as crmo, osteonecrosis in patients on steroids and dermatomyositis. it has a great potential as a screening examination but at the same time can detect both the symptomatic and the asymptomatic lesions in the bone marrow and muscles that are otherwise not seen on conventional radiography. it also allows guidance for biopsy and monitors response to treatment. mobile "cerebroliths" in hemihydranencephaly: a case report usha d. nagaraj, md, the ohio state university medial center, usha.nagaraj@osumc.edu; brent adler purpose or case report: hydranencephaly is a congenital central nervous system disorder manifested by the replacement of the cerebral hemispheres with a thin membranous sac filled with cerebrospinal fluid and necrotic debris. hemihydranencephaly is an extremely rare brain condition in which the vascular anomaly is unilateral, with fewer than cases previously reported in the literature. this is a case of a -month-old male who presented to the ophthalmologist for evaluation of possible leukocoria of the right eye. the patient had a history of a difficult vaginal delivery that required forceps delivery with possible associated trauma to the right eye. dilated fundoscopic exam revealed retinal calcifications. this caused a clinical concern for retinoblastoma and ct and mri of the orbits were obtained. ct demonstrated profound dilatation of the left lateral ventricle with only a thin rim of cortex surrounding it. there was some midline shift to the right with mild dilatation of the right lateral ventricle. the thalami and brainstem were spared. there were multiple soft tissue bodies that layered in the dependent portion of the left lateral ventricle, which were isodense to grey matter. mri revealed similar findings consistent with hemihydranencephaly involving the left cerebral hemisphere. there were multiple round soft tissue masses that measured up to cm in size that layered posteriorly in the left lateral ventricle. these masses were isointense to grey matter on t and hyperintense on t . when the patient was placed with his head turned to the left, these masses moved to the dependent portion of the left lateral ventricle. the orbits were normal on both ct and mr. these soft tissue collections are presumed to be mobile collections of infarcted brain tissue. this unusual appearance has not been described in the radiology literature. we review the ct and mr findings and review the relevant literature. purpose or case report: citrullinemia type i is a rare inborn error of urea cycle metabolism resulting in hyperammonemia. in the classic form, the newborn presents with poor feeding, vomiting, progressive lethargy and signs of increasing intracranial pressure - days after birth, rapidly progressing to apnea, coma and death if left untreated. we present a case of a term infant who presented to the hospital on the th day of life with a typical history of poor feeding and profound hypotonia. upon admission he had multiple episodes of apnea and hemodynamic instability prompting intubation and intensive support. laboratory evaluation revealed multiple abnormalities, most notably, hyperammonemia ( umol/l) and elevated citrulline (> umol/l). mri of the brain performed on the th day of life showed findings consistent with term hypoxic ischemic encephalopathy with restricted diffusion in bilateral rolandic cortex and subcortical white matter, bilateral caudate heads and lenticular nuclei, bilateral insular cortex, and bilateral cerebral peduncles. the genu of the corpus callosum, bilateral deep frontal white matter, and the left parietal white matter also demonstrated restricted diffusion suggesting infarction secondary to thrombosis of deep intramedullary veins. an area of restricted diffusion in the right parietal cortex was suspicious for superficial venous infarct. review of the literature reveals that this case of neonatal citrillunemia has unique mri findings. while our patient had diffusion changes with some shared similarities to the previous two cases in the literature, there are also findings consistent with deep intramedullary venous thrombosis and infarction. poster #: cr- duplicated internal auditory canal: a rare anomaly of the temporal bone ahmad aouthmany, university of toledo medical center, ahmad.aouthmany@utoledo.edu; asif abdullah purpose or case report: duplicated internal auditory canal (iac) is a rare anomaly of the temporal bone, which is usually associated with sensorineural hearing loss. only a few cases have been previously described in literature. we describe an extremely rare case of duplicated right internal auditory canal in a six month-old patient with a history of down syndrome. a six month-old male with trisomy presented with profound bilateral sensorineural hearing loss. the patient failed the newborn hearing screening tests. past medical history was unremarkable for recurrent ear infections. on focused physical examination, the auricles were normal appearing. external auditory canals were patent bilaterally revealing clear and translucent tympanic membranes. patient did not reveal a facial palsy. subsequently, a high resolution computed tomography (hrct) of the temporal bone was performed. duplicated appearance of the right internal auditory canal with separation of facial and vestibulocochlear segments was noted. the facial nerve canal demonstrated normal caliber while there was significant narrowing of the cochlear canal near the fundus. significant stenosis of the vestibulocochlear segment of the duplicated iac was identified at the porus acousticus. dehiscent right posterior semicircular canal was also seen. an enlarged right vestibule was also noted. a single iac was identified on the contralateral side with significant stenosis at the porus acousticus. high-resolution magnetic resonance imaging of iac was recommended which revealed normal appearance of the bilateral cochlear and vestibular nerves. duplication of the iac is an extremely rare anomaly involving a redundant osseous canal extending from the cerebellopontine angle through the otic capsule bone toward the labyrinth or cochlea. a duplicated iac may or may not be associated with congenital sensorineural hearing loss secondary to aplasia or hypoplasia of the vestibulocochlear nerve. to evaluate for structural abnormalities that may preclude cochlear implantation, it is important to evaluate pediatric patients with sensorineural hearing loss radiologically. although hrct is the best imaging modality for evaluation of osseous iac, the iac contents are best viewed on mri in oblique sagittal planes of the iac using a -d volumetric steady state sequence. neuroimaging in hemiplegic migraine: cases and review of the literature nicholas v. stence, md, children's hospital colorado-radiology, nicholas.stence@childrenscolorado.org; sita kedia, john a. maloney, jennifer armstrong-wells, timothy bernard purpose or case report: hemiplegic migraine (hm) is a rare variant of migraine with aura. it is characterized by a motor deficit lasting up to h that is fully reversible. little neuroimaging data for hm exists in the literature. we report our experience with two pediatric cases of hemiplegic migraine. we also review published cases of pediatric hm with abnormal findings on neuroimaging. methods & materials: cases and presented to our institution with severe headache (ha), acute right-side weakness, aphasia, and altered mental status (ams), which did not resolve after h. magnetic resonance imaging (mri) and genetic testing are reviewed for these cases. the literature was reviewed for pediatric cases with neuroimaging changes during hm attacks. results: initial mri, including diffusion-weighted imaging (dwi), was negative in both patients within h of onset. repeat mris at h (case ) and h (case ) were both positive for mild hyperintensity on trace diffusion images, and corresponding reduced diffusion on adc maps, involving regions of the cortex and juxtacortical white matter in left middle cerebral artery distributions. these findings completely resolved at months in both cases. mr angiograms (mra) were negative in both cases. case had a family history of migraines and was found to have an unreported mutation in atp a gene at a highly conserved location in vertebrates. case had a family history of hm and was found to have an indeterminant mutation in the cacna a gene. infectious, metabolic and hypercoagubility work up was negative. case required inpatient rehabilitation and at year follow up was requiring speech therapy. case resolved completely. in the literature, cases of hemiplegic migraine with neuroimaging changes were reported. all cases had prolonged hemiplegic migraines (symptoms> h) and showed cerebral edema with or without restricted diffusion. conclusions: all eight hm cases in the literature with abnormal findings on neuroimaging had prolonged attacks. mris for our two cases and two cases reported in the literature were initially normal at admission. mild swelling and restricted diffusion developed in our two cases after h, and resolved on follow up mris. subtle findings on diffusion and t imaging may lag behind the clinical picture in hm, therefore serial neuroimaging may be useful in individuals with prolonged symptoms. most cases eventually show resolution clinically and on mri. correlation of neurosonographic anatomy with matching mr scan planes denise castro, hospital for sick children, denisecastro @ gmail.com; pam rasalingham, omar islam, don soboleski purpose or case report: new high-resolution mr sequences have allowed for exquisive anatomic detail and enables reconstruction of images in any scan plane desired. this ability allows for precise matching of mr image planes with the standard oblique coronal, sagittal and axial images obtained during routine neurosonography. the purpose of this poster is to correlate the morphology demonstrated on neurosonography with the mr image, utilizing this ability in order to enhance our understanding of the neuroanatomy distinguishable on sonographic imaging. we believe this will allow a better appreciation of the subtle differences in echotexture of neuroanatomic structures which are often ignored or overlooked on neurosonography and help improve our detection of subtle sonographic abnormalies. ectopic cerebellum in the posterior cranial fossa: report of a case and review of the literature usha d. nagaraj, md, the ohio state university medical center, usha.nagaraj@osumc.edu; daniel boue, lisa martin purpose or case report: cerebellar heterotopia is a common congenital anomaly frequently encountered in the form of cell rests around the fourth ventricle. however, isolated well-differentiated cerebellar ectopia is extremely rare. of the previously reported cases in the literature, only have presented as a discrete, extraaxial mass and none have been described in the posterior cranial fossa. we present a case of a -year-old male who initially presented with persistent daily headaches. physical exam including a detailed neurologic exam was within normal limits. non-contrast computed tomography (ct) of the brain was initially performed, demonstrating no abnormalities. further work-up with magnetic resonance imaging (mri) was performed, which revealed a well-defined, extra-axial mass superior to the cerebellum and inferior to the tentorium, immediately beneath the vein of galen. the mass was isointense to grey matter on t and t sequences and there was no significant enhancement on post-contrast images. there was mass effect on the vermis and the cerebellar tonsils were displaced mm below the foramen magnum. neurosurgery was consulted and the mass was removed for diagnosis and treatment of the patient's symptoms. the mass was easily identified intra-operatively and gross total resection was accomplished successfully. pathologic analysis of the mass revealed well-formed cerebellar tissue without evidence of neoplasia. to the best of our knowledge this is the only case of ectopic cerebellum presenting as a discrete extra-axial mass in the posterior cranial fossa. our case shows that an extra-axial mass that parallels grey matter on all sequences can be a presentation of ectopic cerebellum. we describe the ct and mri findings, surgical and histopatholgical results and review the relevant literature. pediatric isodense acute subdural hemorrhage jeffrey s. kao, md, msee, university of kansas-wichita, run boston@gmail.com; debbie desilet-dobbs purpose or case report: the density (attenuation coefficient) of subdural hemorrhage (sdh) in computed tomography (ct) is important in assessing the acuity of sdhs. an acute sdh is traditionally described as hyperdense and then becoming isodense in approximately weeks when entering the subacute phase. in this report, we document the case of a pediatric patient with the new appearance of an acute sdh within h of the prior ct that was isodense. greater than % of the collection was isodense, with a small focus of hyperdensity. acute sdhs are known to be isodense to gray matter in patients with anemia (wp smith, am j neurorad ). however, the hemoglobin and hematocrit was within normal limits. in addition, acute sdhs that are only a few hours old can have a mixed hyperdense and hypodense appearance because of uncoagulated blood before clotting takes place (j provenzale, ajr ) . thus, an acute sdh can have an isodense appearance in a non-anemic patient. radiologists should consider the possibility of an acute sdh with an isodense appearance, especially in case of possible non-accidental trauma where timing of an injury is important. undifferentiated sarcoma of the esophagus in an year-old male: case report and radiologic/pathologic correlation michael e. daniel, md, ut southwestern / children's medical center dallas, michael.daniel@utsouthwestern. edu; lisa sutton, sandy cope-yokoyama, neil j. fernandes purpose or case report: mesenchymal neoplasms of the gastrointestinal (gi) tract occur infrequently in the adult and are extremely rare in the pediatric population. the occurrence of these lesions in the esophagus is limited to a collection of case reports in the available literature. most esophageal mesenchymal tumors in the pediatric gi tract are benign leiomyomas. the vast majority of malignant mesenchymal tumors in children are categorized as either sarcomas or gastrointestinal stromal tumors (gist). we report a case of a high grade undifferentiated sarcoma of the distal esophagus in an year-old male. while this tumor most closely resembles a gist, the immunohistochemical profile of the lesion is not typical of any distinct mesenchymal neoplasm. a review of the literature demonstrates a single case report of a likely benign undifferentiated mesenchymal neoplasm of the distal esophagus in an adolescent. to our knowledge, this is the first reported case of an undifferentiated esophageal sarcoma in a pediatric patient. we provide radiologic and pathologic features of the above lesion, and review the typical imaging and pathologic characteristics of mesenchymal gi neoplasms. potential airway management issues in sedated children kimberly fagen, md, ms, children's national medical center, kfagen@childrensnational.org; nadja kadom, ira cohen purpose or case report: many pediatric imaging studies require sedation. it has been shown that a variety of health care professionals other than anethesiologists may provide sedation, including advanced practice registered nurses, nurse practitioners, physician assistants, fellow level trainees, emergency medicine physicians, intensivists, pediatricians and, last but not least, radiologists. moderate sedation, also called "conscious sedation", does generally not require an anesthesiologist as there is usually adequate spontaneous ventilation and no airway intervention required. however, in case of a complication during the imaging study intubation may become necessary. for patients with certain congenital or acquired conditions emergent intubation may be very difficult and should be brought to the attention of an anesthesiologist prior to inducing moderate sedation. the four "d's" is a quick way to assess potentially difficult airways that necessitate consultation with anesthesia prior to moderate sedation: dentition (incisor/tooth size, dental alignment, and macroglossia), distortion (swelling from infection, tumor, or trauma), disproportion (hyoid-chin ratio, such as with micrognathia), and dysmobility (jaw or cervical spine movement issues, i.e. trauma or atlanto-occipital instability). presence of some of these features may be an indication to consider general anesthesia for sedation; at the very least, anesthesiologist's awareness of a potentially difficult intubation adds to patient safety during moderate sedation. purpose or case report: lymphangiomatosis describes the presence of multiple lymphangiomas often with multiorgan involvement; typically bones, spleen, mediastinum and lungs. although lymphangiomatosis has been described in patients ranging from birth up to years, it most frequently presents in childhood. the lesions can occur in any tissue in which lymphatics are normally found, with a predilection for neck and chest involvement. the clinical presentation is variable including pleural or pericardial effusion, hemoptysis, protein wasting enteropathy, peripheral edema, hemihypertrophy and disseminated intravascular coagulopathy. the coexistence of lytic bone lesions and chylothorax serves as an important diagnostic clue. we describe typical radiographic, ct and mri findings in the appropritate clinical setting that narrow the differential diagnosis and raise concern for this rare entity as the etiology for the patient's symptoms. we report a -year-old girl and year-old boy with pulmonary lymphangiomatosis with typical presentation and imaging findings. results: bilateral interstitial infiltrates, pericardial and pleural effusions are evident on chest radiograph. sampling of the pleural fluid demonstrates chylous effusion. ct scans of the thorax reveal diffuse smooth thickening of interlobular septa and bronchovascular bundles with extensive infiltrative involvement of mediastinal fat. osseous and splenic lesions are demonstrated both on ct and mr. differential diagnosis includes interstitial edema, lymphoma and sarcoidosis. conclusions: the natural history of pulmonary lymphangiomatosis is characterized by progressive growth and compression of adjacent structures. therapy should aim to decrease the compressive effects, to control chylous effusions, and to maintain cosmesis. the success of surgical resection is limited by inability to separate lymph collections from normal structures. characteristic clinical and radiographic presentation, chylothorax, and extrathoracic lymphatic dysfunction should prompt a consideration of lymphangiomatosis and prevent delay in diagnosis. aortic arch congenital anomalies: what the radiologist needs to know luana stanescu, radiology, seattle children's hospital, stanescu@u.washington.edu; stephen done purpose or case report: . review classic imaging findings in congenital aortic arch anomalies which can improve detection on radiographs and barium esophagogram . describe pertinent embryologic basis of the radiologic findings . describe correlative imaging findings on ct and/or mri in dedicated cases . describe common diagnostic pitfalls methods & materials: after obtaining institutional irb approval we reviewed various patients presentations with this condition and analyzed images to characterize this particular entity and it's manifestations for better definition of diagnostic criteria. results: radiographs and barium esophagogram: algorithmic approach in reviewing chest radiographs in order to improve detection of aortic arch anomalies; classic findings and common pitfalls. cross-sectional imaging (ct and mri): what the surgeons need to know before surgical repair; detection of associated cardiac anomalies. sample cases: double aortic arch, double aortic arch with complete or partial atresia of one of the arches. conclusions: major teaching points of this exhibit are: . review of classic features of congenital aortic anomalies on radiographs, esophagogram, ct and mri with pertinent embryologic basis . describe the utility of various imaging modalities in congenital aortic anomalies, emphasizing common pitfalls. cardiovascular and mediastinal imaging in children with unexpected clinical presentation shunsuke nosaka, md, radiology, national center for child health and development, nosaka-s@ncchd.go.jp purpose or case report: children with cardiovascular and mediastinal diseases can be congenital or acquired in etiology. they usually present with straightforward clinical course. in certain situation, however, some of the children show unexpected clinical presentation predominantly with those of neighboring organs such as respiratory tract, hepatobiliary system, and gastrointestinal tract. these unexpected presentations can be the cause of delay in proper diagnosis and treatment. the purpose of this exhibit is demonstrate a variety of imaging findings of cardiovascular and mediastinal diseases in children with unexpected clinical presentation. this exhibit is case based presentation of cardiovascular and mediastinal imaging in children including tips, pitfalls and lessons learned among patients presented with unexpected clinical presentation. diagnostic imaging modalities for cardiovascular disease usually consist of various combinations of plain radiography, ultrasound, ct, mr imaging, fluoroscopy, nuclear medicine, and angiography. the general concept of alara-as low as reasonably achievable-should always be utilized when radiation-producing modalities are indicated in children. the diseases included will be double aortic arch found during workup for the cause of aspiration pneumonia, unilateral pulmonary vein atresia presented with recurrent episodes of pneumonia, severe mitral regurgitation secondary to chordal rupture mimicking fluminant hepatic failure, myocarditis initially present as acute abdomen, cardiomyopathy as unusual initial presentation of neuroblastoma, and thymolipoma mimicking gradual development of cardiomegaly. conclusions: it is important for radiologist to be familiar with imaging findings of cardiovascular and mediastinal diseases in children with unexpected clinical presentation. cardiac embryology made easy: a novel teaching approach using claymation andrew phelps, children's hospital boston, aphelpsmd@ gmail.com; purpose or case report: congenital heart disease can be an intimidating subject for radiology residents, and cardiac embryology is key to its understanding. however, this can be an equally intimidating topic to teach! various diagrams and animations are available in textbooks and online, but much like advanced origami, many of these resources suffer from being visually too complex for the first-time learner. to overcome this teaching obstacle, i created my own cardiac embryology animations using modeling clay and incorporated them into a comprehensive didactic lecture on congenital heart disease. methods & materials: cardiac embryology animations were created using modeling clay, a digital camera, and microsoft powerpoint. surface and cross-sectional views were generated, depicting the key events in cardiac embryology: heart tube formation, cardiac looping, chamber division, truncus arteriosus division, and pulmonary venous connection. example models are shown in figure . results: in this lecture, the animations are presented alongside actual embryonic heart photographs. the lecture then uses the embryology knowledge as a basis to explain the common congenital heart diseases and their mri appearances. examples of septal defects, ventricular hypoplasia, and transposition of the great arteries are presented, among others. conclusions: understanding cardiac embryology is required in order to approach congenital heart disease in a logical fashion. modeling clay animations are a cheap and easy way to simplify this complex topic. arterial tortuosity syndrome: an introduction to the clinical and radiologic manifestations in the pediatric population neal desai, umkc som, neal @gmail.com; suchit patel, ayushi gupta, marius hubbel, doug rivard purpose or case report: . to describe the clinical findings of arterial tortuosity syndrome and give a brief discussion of the disease process. . to describe the radiologic manifestations of arterial tortuosity syndrome. . to give a brief discussion of loeys-dietz syndrome-a disease with similar arterial findings, but with unique molecular characteristics from arterial tortuosity syndrome. . to use this knowledge to help establish the diagnosis and reduce mortality. methods & materials: arterial tortuosity syndrome overview • epidemiology • molecular basis • pathophysiology • review of signs, symptoms and presentation • brief discussion of treatment differential diagnosis of arterial tortuosity syndrome • loeys-dietz syndrome-similarities and differences radiologic findings and discussion • chest radiograph • computed tomographic angiography • magnetic resonance angiography-neck • magnetic resonance angiography-head • conventional angiography making a diagnosis • sample case report • review questions conclusions: arterial tortuosity syndrome is a rare disease whose chief manifestation is severe cardiovascular connective tissue defects. due to the nature of these defects and the significance of rapid intervention, it is important to be aware of and recognize the radiologic manifestations associated with arterial tortuosity syndrome in the presence of appropriate clinical history to help offer a better prognosis to the patient. dynamic pulmonary computed tomography for evaluation of cardiopulmonary disease shilpa v. hegde, md, arkansas childrens hospital, university of arkansas, shilpavhegde@gmail.com; s. bruce greenberg purpose or case report: dynamic pulmonary computed tomography (dpct) is a wide-detector ct technique that allows for continuous chest imaging during respiration. when combined with intravenous contrast, the technique is a unique tool for evaluation of cardiopulmonary abnormalities in children with cardiopulmonary abnormalities. the purpose of this poster is to illustrate the technique of dpct for evaluation of cardiopulmonary disease in children with congenital heart disease and persistent respiratory distress. methods & materials: methods and materials: dpct exams with intravenous contrast were performed on infants with a history of congenital heart disease and palliative surgery. four continuous msec gantry rotations were obtained with respiratory rates set at /minute. the imaging was accomplished during the time of a single respiratory cycle. kvp and low ma resulted in effective dose of≈ . msv. eight respiratory phases were reconstructed to create d and mpr cine loops for evaluation of cardiopulmonary abnormalities. results: cardiopulmonary abnormalities were detected in all patients. patency of sano shunt, blalock tausig shunt or patent ductus arteriosus stent was established. intimal thickening was identified in one sano shunt. hypoplastic branch pulmonary arteries were present in infants and pulmonary vein thrombosis in infant. left bronchomalacia was identified in four of five infants and best or only identified on the expiratory phase of respiration. left lung air trapping was present in two patients. conclusions: dpct with intravenous contrast is the ideal study for evaluation of the post-operative infant with congenital heart disease and persistent respiratory distress. the role of low-dose ct angiography in the evaluation of renovascular hypertension in children jessica kurian, md, chop, kurianj@email.chop.edu; monica epelman, kassa darge, els nijs, jeffrey hellinger purpose or case report: historically, the evaluation of renovascular hypertension has been accomplished via us and conventional angiography. based on the reported adult experience we introduced renal ct angiography (cta) for the evaluation of renovascular hypertension in mid- . our institution has a robust, well-established protocol, which results in reproducible, high quality images. we aim to present our imaging strategies for the evaluation of these patients and to discuss and illustrate the role of low-dose cta with -d imaging as a noninvasive alternative in the evaluation of pediatric renovascular hypertension. methods & materials: we used our department information system to identify pediatric patients (< years of age) who had documented renovascular hypertension confirmed either by conventional angiography and/or surgery during a -year period. we present our protocol and discuss the indications, limitations and benefits of renal cta. ct thin slice data, obtained employing dose reduction strategies, was reviewed and reconstructed in d and d renderings. pertinent us and mr studies as well as demographic and clinical data were reviewed and recorded. several causes for renovascular hypertension were documented and relevant ct angiographic findings were selected for presentation. results: radiation dose ranged . - msv. fibromuscular dysplasia was the most common diagnosis followed by neurofibromatosis type . vascular pathology included stenoses, beading, occlusions, and aneurysms. disease was noted in the extraparenchymal renal arteries in approximately % of the cases. the choice of the imaging modality for the investigation of renovascular hypertension in pediatric patients remains controversial. in the authors' experience, cta with -d imaging is a valuable, non-invasive diagnostic tool for the evaluation of pediatric renovascular hypertension. low dose protocols can reduce the radiation exposure associated with ct. this method can spare patients the complications associated with conventional angiography. fetal mri: brain, head and neck malformations-a pictorial essay sumit singh, md, children's hospital of wisconsin, sumitsingh @yahoo.com; mohit maheshwari, teresa c. gross kelly, tushar chandra, ibrahim s. tuna, craig johnson purpose or case report: the purpose of the exhibit is to illustrate various brain, head and neck massses/vascular anomalies on fetal mri. we will also briefly discuss the normal fetal brain anatomy as seen on fetal mri. methods & materials: major indications for fetal mri include evaluation of inconclusive sonographic findings in cases of cns malformations. in our institute patients are scanned on . t mr scanner. a body surface six channel phased array coil is used to maximize signal to noise. all the scans are checked by a neuroradiologist to make sure adequate plane imaging of the brain or other lesion in question were performed. plane scanning of the fetal body is also performed for the laterality determination of the lesion and also screen for other congenital anomalies. results: prenatal usg is frequently inconclusive for evaluation of complex fetal brain and head and neck anomalies. most studies suggest that mri after first trimester is safe. in addition, advent of rapid mri sequences like single shot fast spin echo (ssfse) have helped in reducing scan time and motion artifacts leading to availability of diagnostic quality images. these have led to increasing use of mri as supplemental tool to further investigate inconclusive fetal sonographic findings. mri provides better anatomical delineation of these complex abnormalities. it helps in making appropriate diagnosis with high confidence and aids in appropriate obstetric and prenatal/neonatal surgical planning or intervention. this educational exhibit will illustrate few common fetal anomalies. these will include agenesis of corpus callosum, malformation of cortical development, posterior fossa malformations, ventriculomegaly, in-utero stroke, orbital abnormalities and some fetal neck masses/ vascular malformation. correlation and confirmation with the postnatal mri will also be provided for some cases. conclusions: technical and therapeutic advances have driven the development of fetal mri. it is an important adjunctive tool for prenatal imaging in those instances in which a complex anomaly is suspected by sonography, when fetal surgery is contemplated, or when a definitive diagnosis cannot be determined. it has prognostic implications and may help in optimal and timely obstetric and neonatal management. purpose or case report: this educational report will provide a review of the imaging appearance of intradiaphragmatic and subdiaphragmatic pulmonary sequestrations on fetal mri. the proposed pathophysiology, review of sequestration subtypes, and surgical management options will also be described. case examples will be provided to illustrate the fetal mr imaging findings of these variants of pulmonary sequestration that help support the diagnosis. specifically a "triangle sign" of t hyperintense tissue directed toward the diaphragm will be demonstrated. illustrative case examples will be placed in the context of a differential diagnosis for subdiaphragmatic masses seen on prenatal imaging. imaging signs that help make a diagnosis of these pulmonary sequestration variants and separate this entity from other lesions will be emphasized. poster #: edu- mri of the fetal head and neck masses alok jaju, md, mallinckrodt institute of radiology, alokjaju@gmail.com; joshua shimony, per amundson purpose or case report: fetal magnetic resonance imaging (mri) is a useful problem solving tool for abnormalities detected by prenatal ultrasound (us). masses of the head and neck region can vary from benign incidental lesions to devastating neurological lesions and life threatening tumors. we share our experience in characterizing these lesions by prenatal mri, that can have a bearing on follow up imaging, perinatal management and overall prognosis. we did a retrospective review of all fetal mri studies performed at our tertiary care children's hospital between / and / , to identify fetuses with head and neck masses. we reviewed the maternal demographic and clinical data, prenatal ultrasound, fetal outcomes and post natal imaging (when available). results: out of the fetal mri studies, had dominant head and neck masses. majority were encephaloceles ( occipital, parietal). the remaining included variety of masses such as nasal glioma, teratoma ( ), epidermoid cyst, hemangioma and lymphatic malformation ( ) . mri played a useful role in distinguishing encephaloceles from other masses based on underlying bone defect and intracranial extension. it also helped in characterizing other masses based on location and signal characteristics. the presence and degree of airway compromise was determined. intracranial anomalies associated with encephaloceles including callosal dysgenesis, cerebral and cerebellar hypoplasias, migrational disorders and spinal anomalies were also correctly identified. conclusions: we present the prenatal mr imaging findings of a spectrum of head and neck lesions, correlating with prenatal ultrasound, postnatal imaging and clinical or pathological outcomes. purpose or case report: the immaturity of the cns in neonatal infants makes neurologic assessment difficult. neuroimaging plays an essential role in the assessment of brain injury by helping to indentify the injury and expected neurologic outcome. cranial ultrasound (us) is usually the first neuroimaging modality used since the technique is portable, does not involve radiation and can be used sequentially. magnetic resonance imaging (mri), however, is the most sensitive imaging modality for the detection of hypoxic brain injury. the goal of this presentation is to compare the us and mri performed within a -hour interval, and evaluate these findings to improve the interpretation of the us which is usually the first methodology used to evaluated these patients. we performed a retrospective review of the neonatal imaging studies with us and mri performed within -hour interval on preterm and term newborns with clinical history of hypoxia-ischemia. the imaging findings of the two modalities, mri and us, were correlated with the pattern and severity of the injury and brain maturity. results: diffuse white matter abnormalities were observed in % of the patients by us or mri. the ultrasound identified diffuse increased echogenicity which did not show correlation with mri in % of patients. focal white matter abnormalities were better identified by mri on non-cavitary leukomalacia which is the most common pvl observed in premature neonates with low birth weight and the most difficult to identified using us. cavitary leukomalacia showed strong agreement in both methodologies. the mri identified % more cases of intraventricular hemorrhage, however, the corresponding increase in hemorrhage was of minimal clinical significance. in most cases extra axial hemorrhage was better identified by mri. conclusions: after viewing this exhibit, the viewer will gain a better appreciation and understanding of the neuroimaging characteristics of hypoxia-ischemia in us and mri, and thus improving the interpretation of the us which is usually the first imaging modality used to evaluate this patient population. purpose or case report: the most common thoracic lesions found on prenatal imaging, congenital pulmonary airway malformation (cpam), bronchopulmonary sequestration (bps), and congenital diaphragmatic hernia (cdh), usually have characteristic imaging findings previously described in detail. however, common entities presenting with atypical findings and rarer thoracic entities do occur and can be characterized by fetal magnetic resonance (mr) imaging. the purpose of this educational exhibit is to show examples of atypical presentations of common thoracic lesions and more unusual thoracic entities on fetal mr. when applicable, prenatal mr is compared with prenatal ultrasound, postnatal imaging, operative findings, or pathology. methods & materials: using a radiology information system database, the reports of all fetal mr exams at our institution from january through january were reviewed. when unusual thoracic findings were described in the report, all prenatal and postnatal images (when available) were evaluated. in the cases selected, medical charts were reviewed for operative findings and pathologic reports. results: the cases to be described, both pulmonary and extrapulmonary in location, include: hybrid lesion in a horseshoe lung, cpam extending across the midline, bilateral bps, bps located within the mediastinum, bps located within the leaves of the diaphragm, ectopia cordis and cdh as components in pentalogy of cantrell, cdh with herniation of liver into the pericardium, elongated esophageal duplication cyst, chest wall lymphatic malformation, and tight double aortic arch causing congenital high airway obstruction syndrome (chaos). conclusions: after studying this educational exhibit, the reader will be acquainted with a variety of unusual fetal pulmonary and extrapulmonary lesions, with emphasis on fetal mr. prenatal and postnatal imaging findings in megacystis-microcolon-intestinal hypoperistalsis syndrome (mmihs) mary kitazono, chop, mkitazono@gmail.com; richard bellah purpose or case report: to review the classic constellation of findings seen in prenatal and postnatal imaging of megacystis-microcolon-intestinal-hypoperistalsis syndrome (mmihs), as well as to illustrate additional imaging features that are variably seen in this syndrome. the imaging database at our children's hospital was searched for all cases of mmihs diagnosed since . all available prenatal and postnatal imaging studies were reviewed in patients with a diagnosis of mmihs, and representative images are provided with a description of the findings. results: since , patients ( girls, boy) have been diagnosed with mmihs at our institution, including on prenatal mri and us. the characteristic prenatal imaging findings include marked urinary bladder distension, bilateral pelvicaliectasis, and dilated, tortuous ureters, as well as a diminutive colon containing no or minimal t w-hyperintense meconium on mri. postnatal imaging studies also characteristically demonstrate a massively distended urinary bladder (with no apparent mechanical cause of obstruction) as well as a small, unused colon with dilated, hypoperistaltic small bowel seen proximal to the microcolon. additional findings which are variably seen include intestinal malrotation, stomach and esophageal hypoperistalsis or aperistalsis, gastroesophageal reflux, and biliary stasis. conclusions: although a rare syndrome, the constellation of imaging findings in mmihs is pathognomonic, and recognition of the classic pattern of findings can allow the radiologist to make a diagnosis of mmihs in both the in-utero and postnatal setting. early diagnosis is essential for allowing prenatal counseling regarding this generally fatal disorder, as well as to optimize early management options. purpose or case report: gastric mass lesion are uncommon. this presentation is an educational review of pediatric gastric mass lesions including gastro-intestinal stromal tumor (gist), inflammatory myofibroblastic tumor (pseudotumor). burkitt's lymphoma, squamous cell carcinoma, gastric teratoma, gastric varices, gastric hamartoma, gastric polyp and hypertrophic pyloric stenosis (hps). clinical presentation is varied with upper gi bleeding, feeding intolerance, pain, weight loss and fatigue manifesting. the imaging work-up might initially have been endoscopy or ultrasound. cross section imaging (ct mr) can be invaluable. the role and impact of fdg pet on the management, staging and follow up of the oncologic pathology will be emphasized. imaging findings in megacystic microcolon intestinal hypoperistalsis syndrome, a rare disease kiery braithwaite, pediatric radiology, emory-egleston, kieryb@yahoo.com; kiery braithwaite, paula dickson, marianne m. ballisty purpose or case report: megacystis microcolon intestinal hypoperistalsis (mmih) syndrome is a rare congenital form of severe functional intestinal obstruction which is more commonly found in females. the presenting clinical and imaging features of this disease can often mimic other causes of proximal bowel obstruction in the neonate. in combination with its common association with intestinal malrotation, the clinical picture of mmih syndrome may be confusing at times. awareness of additional imaging features characteristic of mmih syndrome may help the radiologist suggest this diagnosis. the purpose of this study is to enhance the ability of the pediatric radiologist to suggest this rare diagnosis by recognizing this unusual constellation of imaging features. we retrospectively reviewed the clinical data and imaging studies of four patients with mmih syndrome at our institution. imaging studies included plain radiography, ultrasonography, fluoroscopy, and cross sectional imaging. the initial presentation and clinical outcome was also reviewed. results: the clinical presentations of our patients, who were all female, were somewhat varied but typically included symptoms of intestinal obstruction. the diagnosis of mmih syndrome was made in our patients from the first few weeks of life through early childhood. the four patients demonstrated imaging features characteristic of this disease including a very large dilated bladder, severe bilateral hydroureteronephrosis, gaseous distention of the stomach and proximal small bowel, intestinal hypoperistalsis, and a very small colon. the clinical course of these patients that we observed was also quite variable, with some patients dying in neonatal period while another patient continues to do reasonably well at years old after a multi-organ transplant. conclusions: mmih syndrome is a rare and frequently lethal disease. the ability of the pediatric radiologist to recognize this constellation of imaging findings can help the clinical team arrive at a diagnosis of mmih syndrome. more prompt diagnosis can aid in the development of a long term management plan for the patient and in counseling the family regarding the prognostic implications of this disorder. pathologies of omphalomesenteric duct remnant: radiologic-surgical correlation swapnil bagade, md, pediatric radiology, mallinckrodt institute of radiology, bagades@mir.wustl.edu; geetika khanna, rebecca hulett purpose or case report: . to facilitate understanding of embryology of the omphalomesenteric(vitelline) duct and normal anatomy of the umbilicus. . review the spectrum of omphalomesenteric duct malformations and diversity of clinical presentations of these remnants. . illustrate the imaging findings of omphalomesenteric remnants, from the common such as meckel's diverticulum to the uncommon such as the omphalomesenteric duct cyst, with surgical correlation. methods & materials: cases with complications of persistent omphalomesenteric duct were collected from the joint surgery/radiology conferences at a tertiary level children's hospital. imaging features were correlated with intraoperative findings. conclusions: preoperative diagnosis of complications related to the omphalomesenteric duct remnants can be challenging because clinical and imaging features overlap with other etiologies of acute abdomen. knowledge of the embryologic, clinical, radiologic, and surgical characteristics of omphalomesenteric duct remnants will aid in early and accurate diagnosis. neonatal bowel obstruction-a pictorial essay tanmay patel, university of kentucky; harigovinda challa purpose or case report: bowel obstruction is the most common abdominal emergency in the newborn period and in most cases is secondary to a congenital anomaly requiring early surgical intervention. however not every case of abdominal distension or dilated bowel is secondary to mechanical bowel obstruction or underlying surgical condition. radiologic imaging forms a central role in the work up of newborns with suspected intestinal obstruction. the role of the radiologist is to identify whether or not mechanical obstruction is present; if obstruction is identified on initial radiographs, to determine the level of obstruction, and finally to identify the etiology of obstruction. initial plain radiographic evaluation also helps to determine the subsequent diagnostic or therapeutic approach. methods & materials: a retrospective review of multiple radiographic and fluroscopic examinations in patients with diagnosis of neonatal bowel obstruction was performed at kentucky children's hospital. multiple examples of classical imaging findings were compiled and placed into a pictorial review. results: neonatal intestinal obstruction generally presents with nonspecific symptoms such as abdominal distention, vomiting, or failure to pass meconium depending on the level of obstruction and time of occurrence of underlying congenital lesion/atresia in the intrauterine life. initial plain radiographs of the abdomen reveal dilated bowel loops when obstruction is present. high intestinal obstruction is suspected when only few dilated loops are identified, while multiple dilated bowel loops are seen in low obstruction. most cases of high obstruction may not need another diagnostic imaging test. all cases of distal intestinal obstruction require water soluble enema to identify the etiology of obstruction. in conditions like functional immaturity of the colon, and meconium ileus water soluble enema is therapeutic and thus surgery can be avoided in most cases. the objective of this presentation is to present an educational exhibit of classical imaging findings of various types of neonatal bowel obstructions, and how to differentiate between them. conclusions: bowel obstruction is the most common abdominal emergency in the new born period. most cases are secondary to a congenital surgical condition and early diagnosis and treatment significantly reduces mortality and morbidity. radiographic evaluation plays a central role in the diagnosis and treatment of these conditions. poster #: edu- d t -weighted mrcp in the pediatric population-a pictorial review nathan egbert, mbbs mph, university of michigan, nathaneg@med.umich.edu; jonathan r. dillman, peter j. strouse purpose or case report: to demonstrate the utility of d t -weighted magnetic resonance cholangiopancreatography (mrcp) in the pediatric population, and to illustrate the mrcp findings of various conditions affecting in the pediatric pancreaticobiliary system. we identified all mrcp exams performed on pediatric patients (< years of age) from january , through august , by searching institutional electronic medical records. we then identified representative d t -weighted mrcp images of various conditions affecting the pediatric pancreaticobiliary system. results: representative d t -weighted mrcp images (including source, maximum intensity projection, and volume rendered images) from the following conditions will be presented: abnormal biliary narrowing/stricture (including sclerosing cholangitis, anastomotic strictures following kasai procedure & liver transplantation, and "pseudostricture"), biliary atresia, choledochal cyst (including various subtypes, based on todani classification), choledocholithiasis & cholelithiasis, congenital anomalies of the pancreaticobiliary system (including pancreas divisum and anomalous pancreaticobiliary junction), pancreatobiliary system trauma (including main pancreatic duct transection), and other rare conditions affecting the pancreaticobiliary system (including rhabdomyosarcoma of the biliary tree). conclusions: d t -weighted mrcp has become an extremely useful tool in the evaluation of children with suspected disorders of the pancreaticobiliary system. since mrcp has distinct advantages over alternative diagnostic techniques, such as endoscopic retrograde cholangiopancreatography (ercp) or percutaneous cholangiography, including lack of ionizing radiation and noninvasiveness, mrcp is a much preferred initial study for pediatric pancreaticobiliary imaging. this pictorial review is intended to highlight the d t weighted mrcp appearances of various pancreaticobiliary conditions occurring in the pediatric population. purpose or case report: magnetic resonance enterography (mre) is rapidly emerging as an important imaging tool for the diagnosis and follow-up of inflammatory bowel disease (ibd). its lack of ionizing radiation makes this imaging modality especially vital to the pediatric population. using a casebased approach, we will demonstrate the usefulness of diffusion-weighted imaging (dwi) as part of a comprehensive mre protocol for the assessment of ibd in children. the basics of dwi will be discussed with particular attention to abdominopelvic techniques. the role of mre dwi for the evaluation of pediatric crohn disease (cd) and ulcerative colitis (uc) will be reviewed using a case-based approach. key images from pertinent imaging studies will be identified by searching institutional electronic medical records and presented with relevant clinical data. results: a review of pediatric mre examinations suggests dwi can be used to detect the following: ) small and large bowel segments affected by ibd (both cd and uc) ) abdominopelvic abscesses (including within the mesentery, body wall, iliopsoas muscle, and liver) ) abnormal lymph nodes ) sacroiliitis ) perianal disease (including abscesses and other penetrating complications). conclusions: dwi has the potential to play a very important role in the diagnosis and follow-up of pediatric ibd. this mre technique is particularly useful for detecting a variety of disease-related complications. as the exact meaning of bowel wall restricted diffusion is poorly understood to date, continued investigation will be necessary to determine the clinical and histologic significance of this finding. cases of cf involving the gi tract were collected from clinical workflow encounters of the authors and from the main hospital medical records database. relevant imaging studies were reviewed for known gi manifestations of cf. these imaging studies were correlated with clinical histories and available intraoperative and pathologic findings. results: cf involvement of the gi tract presents over a wide range of ages, organs involved, and associated symptoms. these manifestations can generally be divided anatomically into those involving the alimentary tract, hepatobiliary system, and pancreas. alimentary tract manifestations consist of meconium ileus in uncomplicated and complicated forms (with the latter including secondary intestinal atresia, volvulus, and perforation with meconium peritonitisdistal intestinal obstruction syndrome, constipation, rectal prolapse, duodenal fold thickening, and appendiceal dilation. hepatobiliary disorders secondary to cf include microgallbladder, cholelithiasis, biliary ductal abnormalities, neonatal hepatitis, and cirrhosis (including complications such as portal vein thrombosis and ascites). pancreatic expressions of cf include fatty infiltration, calcifications, and cysts/ cystosis, frequently in the setting of malnutrition and/or stooling abnormalities. this exhibit will demonstrate the spectrum of clinical and radiologic gi findings in this disease from the fetal and neonatal period through adolescence across a range of imaging modalities. conclusions: gastrointestinal manifestations of cystic fibrosis occur frequently in the pediatric population and may be the earliest clinical expression of the disease. familiarity with the variety of gastrointestinal imaging findings of cystic fibrosis can expedite appropriate diagnosis and therapy, particularly in those children in whom the primary disease is not clinically suspected. beyond acute appendicitis: imaging of additional pathologies of the pediatric appendix kelly dietz, md, cincinnati children's hospital; arnold c. merrow, daniel j. podberesky, alexander j. towbin purpose or case report: primary acute appendicitis (or appendiceal inflammation caused by a superimposed bacterial infection in the setting of appendiceal obstruction) is by far the most common pathology of the appendix, and imaging evaluations to exclude this diagnosis occur daily in the pediatric radiology setting. the clinical and imaging differential diagnosis in a patient with right lower quadrant pain and suspected appendicitis is a broad but well-recognized list that predominantly involves structures adjacent to the appendix including the ovaries, small and large bowel, and ureters. there are, however, less common pathologies primarily involving the appendix which can create an imaging diagnostic dilemma in the setting of right lower quadrant symptoms. our goal is to review the imaging and clinical manifestations of these less commonly encountered appendiceal abnormalities. methods & materials: cases of appendices that were abnormal by imaging but ultimately determined not to be due to primary acute appendicitis were collected from clinical encounters by the authors as well as through a search of the radiology and pathology report databases. clinical course, surgical findings, and pathology reports (if available) were subsequently reviewed through the main hospital medical records system. results: the collected cases demonstrate a wide range of additional pathologies of the appendix outside of primary acute appendicitis. a variety of imaging modalities were employed in the workup of these cases. examples reviewed in this exhibit include crohn's disease, ulcerative colitis, cystic fibrosis, carcinoid tumor, inguinal hernia with incarceration, retained foreign body, pinworm infestation, and ileocolic intussusception. conclusions: despite the frequency of primary acute appendicitis, there is a differential diagnosis when an abnormal appendix is found by imaging. familiarity with these alternative diagnoses may be particularly helpful in guiding management of the patient whose clinical presentation is not typical for primary acute appendicitis. methods & materials: a hospital pacs database search from the past years for patients with bws. selected cases, with multimodality imaging, were cross-referenced with pathology reports from patient records database. results: intricate abdominal pathologies are depicted utilizing multimodality imaging, such as plain films, us, ct, mri and pet/ct, and with pathologic correlation. cases with highlight the following: liver: hepatoblastoma, nonspecific hepatobiliary cysts, multiple hemangiomas mimicking metastatic disease; adrenal: dysplastic organomegaly mimicking neoplasm; pancreas: diffuse and focal hyperplasia in the setting of hyperinsulinism, organomegaly; renal: neprocalcinosis, including medullary sponge kidney, nephroblastomatosis, organomegaly; adnexal: ectopic paraovarian adrenal tissue mimicking metastatic lymph node; urinary bladder: benign fibro-uroepithelial polyp. conclusions: diagnosis of bws can be difficult when the classic clinical and radiological findings are not present. these few cases highlight the unusual abdominal pathologies, so when detected, a radiologist can aid in the appropriate diagnosis and help guide therapy for these young patients. this poster will discuss pharmaceuticals the fda considers investigational for their intended use. disclosure: dr. lecompte has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. radiologic-pathologic review of pancreatic masses encountered at a tertiary pediatric hospital over a -year period no kwak, md, radiology, long island jewish medical center, kwak_nb@yahoo.com; karen naar, jeanne choi-rosen, lee collins, sukhjinder singh, anna thomas purpose or case report: review of pathologically proven pancreatic masses in pediatric patients encountered at a tertiary pediatric hospital over a -year period. describe the key morphologic features and other pertinent findings using various imaging modalities. correlate pathologic and radiologic findings. methods & materials: illustrate the various imaging characteristics of pathologically proven pancreatic masses including pseudocyst, pancreatoblastoma, solid pseudopapillary tumor, acinar cell carcinoma, ductal adenocarcinoma, lymphoma, pancreatic neuroblastoma, and inflammatory myofibroblastic tumor. correlate pathologic and radiologic findings. identify the key imaging features that allow narrower differential diagnosis. results: pancreatoblastoma and solid pseudopapillary tumor are the more commonly encountered pediatric primary pancreatic tumors. both are bulky and heterogeneously enhancing tumors with solid and cystic elements. pancreatoblastoma occurs more commonly in young children. internal hemorrhage and fibrous capsule favor solid pseudopapillary tumor which more commonly occurs in adolescent girls. ductal adenocarcinoma, acinar cell carcinoma and an inflammatory myofibroblastic tumor, which were pathologically proven in our pediatric patients, are exceedingly rare entities. the imaging findings of these cases and their pathology when available will be presented, as well as a quick literature review of these rare tumors. illustration and correlation of the pathologic and radiologic findings. conclusions: pancreatic masses in children are rare but in general have a better prognosis than in adults. salient imaging findings for the various tumors encountered at a tertiary care center with pathologic and radiologic correlation. evaluation of hepatoblastoma with gadoxetate disodium-typical, atypical, pre and post treatment evaluation arthur b. meyers, radiology, cincinnati children's hospital, arthurbmeyers@yahoo.com; alexander j. towbin, daniel j. podberesky purpose or case report: gadoxetate disodium (gd-eob-dtpa) is a hepatobilliary mri contrast agent that is widely used in adults for characterization of liver tumors and is being increasingly used in pediatric patients. hepatoblastoma is the most common primary hepatic malignancy of childhood. the purpose of this presentation is to describe our experience with the use of this agent in the mri evaluation both before and after initiating therapy in patients with hepatoblastoma. methods & materials: the radiology report system at our institution was queried for all patients with pathology proven hepatoblastomas who underwent a liver mr with administration of gadoxetate disodium between / / and / / . the mr imaging characteristics of the patient's primary hepatoblastoma pre-and post-therapy (when available) and post treatment findings (when available) were reviewed. results: mri studies in different patients were reviewed. the patients ranged in age from months to years. patients had pre and post treatment evaluation with gd-eob-dtpa enhanced mri, patient had only pretreatment evaluation and patients had only post treatment evaluation. of the hepatoblastomas did not take up gd-eob-dtpa during the hepatocyte phase and were therefore low signal intensity during the hepatocyte phase of imaging. this was useful in the pretreatment evaluation of hepatoblastoma, particularly in defining the relationship of the tumor to hepatic and portal veins. post treatment gd-eob-dtpa imaging allowed characterization of the biliary anatomy and demonstrated the communication of a postoperative fluid collection with the biliary tree, consistent with biloma. atypical hepatoblastoma showed uptake of gd-eob-dtpa on hepatocyte phase imaging, similar to what has been described in adults with atypical hepatocellular carcinoma. conclusions: gadoxetate disodium enhanced mri is useful in the imaging evaluation of hepatoblastoma, particularly in defining the relationship of tumor to vascular and biliary anatomy and in characterizing post-treatment complications. disclosure: dr. meyers has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. imaging of the gallbladder and biliary tree in pediatric age group ihsan mamoun, md, cleveland clinic, ihsanmamoun@ yahoo.com; s. pinar karakas, unni udayasankar, neil vachhani, ellen park purpose or case report: interactive educational exhibit to illustrate the embryology, anatomical variants as well as congenital and acquired diseases of the bile ducts and gallbladder in pediatric patients. methods & materials: a)the embryology of the gallbladder and biliary tree will be demonstrated with diagrams. b) imaging techniques for gallbladder and biliary tree including us, ct, mri, ercp and intraoperative cholangiogram will be discussed. c)imaging findings of various lesions with special emphasis on key findings that can lead to accurate diagnosis will be discussed. d)an appropriate list of differential diagnosis will be provided. e)an algorithm for the assessment of suspected biliary pathology will be presented. f)the exhibit will be interactive and the reader will answer questions about the discussed entity, related imaging algorithm and management. results: a)discuss congenital anomalies including duplicated and septated gallbladder, choledochal cyst, caroli disease, situs abnormalities and biliary atresia. b)discuss infectious and inflammatory conditions including cholecystitis, kawasaki's disease, sclerosing cholangitis and hepatitis. c)discuss iatrogenic complications including post transplant biliary stricture and leak. d)discuss benign and malignant neoplasms invoving the gallbladder including polyps, ptld and rhabdomyosarcoma. conclusions: this exhibit will demonstrate a logical approach to imaging of the congenital and acquired diseases of the gallbladder and biliary tree based on the embryology and underlying pathology. postnatal work up of congenital uronephropathies-a pictorial essay harigovinda r. challa, radiology, university of kentucky, hch @uky.edu purpose or case report: the use of obstetric ultrasound routinely in the prenatal care has lead to the discovery of many fetal anomalies. uronephropathies in the newborn represent one of the largest groups of anomalies amenable to neonatal management. since these uropathies are detected mostly in asymptomatic patients the treatment is mainly preventive. the pediatric radiologist has a key role in the post natal work up and management of these patients with prenatally diagnosed neprhouropathies and familiarity with the congenital urinary tract abnormalities is necessary. methods & materials: a retrospective review of multiple radiographic, sonographic and fluroscopic examinations performed in the newborn babies and infants with prenatal diagnosis of urinary tract abnormalities was performed at kentucky children's hospital. multiple examples of classical imaging findings were compiled and placed into a pictorial review. results: numerous anomalies can be detected in utero, including anomalies of renal number, position, morphology, collecting system dilation and bladder, urethral abnormalities. of these postnatal work of congenital hydronephrosis is the most common routinely encountered clinical entity. renal ultrasound is the initial examination in the evaluation in all cases of prenatal hydronephrosis, which is best performed around postnatal day . if collecting system dilatation persists on postnatal ultrasound, further imaging work up with vcug, radionuclide imaging may be required depending on degree of dilatation. conclusions: uroneprhopathies are increasingly detected in the prenatal life with increasing use of obstetric ultrasound. the objective of this presentation is to demonstrate in a pictorial essay of different neprhouropathies and their workup in newborns. isolated fallopian tubal torsion: causes, imaging findings, and how to suggest the diagnosis jesse courtier, md, ucsf dept of radiology, jesse. courtier@ucsf.edu; amaya m. basta, rebecca maine, pierre-alain cohen, shinjiro hirose, john d. mackenzie purpose or case report: the purpose of this educational report is to describe the rare entity of isolated fallopian tubal torsion in the pediatric population and depict the cross sectional imaging findings that help make a diagnosis and guide management. the proposed pathophysiology, predisposing factors, and surgical management will be described. an illustrative case example of -year-old female patient will be provided with surgical correlation. the exhibit will review imaging findings on us, ct and mri that help support the diagnosis including, dilated tubular structure in the pelvis, normal ovaries, and corkscrewing and beaking of the proximal fallopian tube. isolated fallopian tubal torsion will be placed in the context of a differential diagnosis for girls presenting with pelvic pain and the imaging signs that help make a diagnosis of isolated tubal torsion and separate this entity from other causes of pediatric pelvic pain will be emphasized. multimodality imaging characteristics of genitourinary rhabdomyosarcoma rhea udyavar, md, george washington university medical center, rudyavar@gwmail.gwu.edu; amir noor, pranav k. vyas purpose or case report: in this pictorial essay, we will demonstrate salient imaging features of mr, us, and ct modalities for the diagnosis of genitourinary rhabdomyosarcoma in male (n ) and female (n ) children ages - years, evaluated at our institution over the past years. background information, including tumor biology, staging, and treatment will also be discussed. the swollen scrotum: ultrasound technique and differential diagnosis kelli r. schmitz, md, oregon health & science university, schmitzk@ohsu.edu; roya sohaey purpose or case report: to review the ultrasound protocol for the performance of scrotal ultrasound and illustrate the ultrasound appearance of conditions resulting in scrotal swelling in pediatric patients. a retrospective review of the imaging database at a tertiary pediatric referral center was performed to identify pediatric patients who presented with scrotal swelling and underwent diagnostic ultrasound. when available, surgical/pathologic correlation was obtained. results: a variety of pathologic processes result in scrotal swelling. causes illustrated include: testicular torsion, epididymitis/orchitis, hydrocele, varicocele, inguinal hernia, trauma, adrenal rest, and testicular or paratesticular neoplasm. conclusions: the causes of scrotal swelling are myriad, including infectious/inflammatory, developmental, traumatic, and neoplastic etiologies. in children, the clinical presentation of a swollen scrotum is nonspecific, and ultrasound plays a key role in making the correct diagnosis. experiences of starting a functional mr urography program at a university hospital: trials and tribulations steven l. blumer, bsc, montefiore medical center/albert einstein college of medicine, sblumer@montefiore.org; ibrahim tuna, amanda north, benjamin taragin, netta blitman, terry l. levin purpose or case report: starting a functional mru program can be challenging as there are numerous potential hurdles to overcome. this presentation describes the process of starting a functional mr urography (fmru) program at a university hospital and discusses the difficulties encountered starting such a program. selecting a sufficient patient referral base, resolving common and uncommon technological issues, and education of clinicians, patients and technical staff are some of the challenges that will be discussed. conclusions: awareness of the common pitfalls in fmru imaging and close partnering with referring physicians can make establishing a functional mru program easier. despite many potential obstacles, the benefit of exquisite anatomical and functional information provided by fmru in children, without exposure to ionizing radiation, greatly outweighs any challenges. disclosure: dr. blumer has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. pictorial review of ultrasound findings in boys presenting to emergency department/urology with acute scrotum teresa liang, faculty of medicine, university of british columbia, teresaliang @gmail.com; peter metcalfe, william sevcik, michelle noga purpose or case report: testicular torsion is a common acute condition in adolescent boys. rapid and accurate diagnosis is critical. diagnosis is currently based on history, physical findings, and ultrasound (u/s) with doppler. the objective of this poster is to demonstrate ultrasound findings from a retrospective review of acute scrotum over years, and to demonstrate some pitfalls of the technique with regard to testicular torsion diagnosis. we reviewed the u/s, surgical and ed records at the stollery children's hospital for boys aged month to years, presenting with acute scrotum from july , to . age, demographics, clinical symptoms, and physical findings, u/s and surgical techniques, findings, diagnoses and follow-up were also recorded. results: patients presented to uah stollery ed with acute scrotum: were diagnosed with testicular torsion ( inguinal torsion), were suspected of a torsion-detorsion, torsion of appendix testes, epididymitis/orchitis, and other diagnoses including hydroceles, varicoceles, epididymal cysts, abscesses, cellulitis and hematomas. for the patients who had ultrasound, % sensitivity and % specificity for testicular torsion. the ultrasound findings including size, vascularity and echogenicity associated with both salvageable and necrotic testicles including use of color and pulse doppler will be reviewed. the sonographic findings and pictorial examples associated with the more common acute scrotum etiologies will be presented. sonographic findings from problematic cases (those with inconclusive ultrasound reports or false positive reports) will also be addressed. conclusions: ultrasound imaging problem case examples and characteristic findings of common acute scrotum presentations at stollery hospital at the university of alberta are reviewed in this poster. primary and secondary amenorrhea in pediatric patients: from the beginning to the end cesar cortes, md, miami children's hospital, n c @ hotmail.com; yanerys ramos, ricardo restrepo, alejandro diaz, lorena sequeira, edward lee purpose or case report: to describe the role of imaging in evaluating patients with primary and secondary amenorrhea and to illustrate the normal imaging findings of the reproductive organs in the pediatric population as well as the imaging findings of the different etiologies causing amenorrhea. a search of the literature is done to determine the different etiologies of amenorrhea and the role of imaging in their evaluation. first, we will focus on the normal physiologic hormonal influence and changes of the girl's reproductive organs since birth until adolescence on ultrasound and mri. images of the normal appearance of the female reproductive organs as well as imaging findings of the different common and uncommon etiologies of amenorrhea will be shown. then, specific reference will be made to crucial related concepts such as minipuberty of infancy, latest criteria for polycystic ovarian disease and ovarian failure syndrome among others. finally, the treatment, either medical or surgical will be briefly discussed. results: causes of amenorrhea in children range from disorders affecting the hypothalamus, pituitary gland, adrenal glands, and ovaries, as well as uterine and vaginal structural abnormalities. even though history and clinical exam are essential in evaluating a patient with amenorrhea, the pediatric radiologist plays a pivotal role helping guide the area to be imaged and thus the modality that should be used. mri and ultrasound are the main modalities in the evaluation of amenorrhea. conclusions: ultrasound and mri are the main imaging modalities used in the evaluation of amenorrhea in children and are usually part of the work up. amenorrhea in children can have implications in girl's fertility allowing pediatric radiologists to play an important role in helping not only the patient but also their offspring. imaging of mullerian duct anomalies in children kelly k. horst, md, radiology, university of michigan, khorst@med.umich.edu; maryam ghadimi mahani, deepa pai, jonathan r. dillman, peter j. strouse purpose or case report: the purpose of this educational exhibit is to provide an up-to-date appraisal of mullerian duct anomalies presenting in the pediatric population. the appearances of anatomic variants on ultrasound and mri will be used to illustrate the strengths and potential pitfalls of these imaging modalities. methods & materials: patients who have previously undergone ultrasound and/or mri in the course of their clinical workup within the university of michigan health system (umhs) were identified using electronic medical records. imaging reports were reviewed by a single author in order to identify relevant imaging findings (interesting anatomic variations, associated anomalies, etc.). pertinent images from these imaging examinations were de-identified and saved to a secure hard drive. the medical record was accessed by a single researcher to obtain relevant information regarding the patients' clinical presentations. in cases of corrective surgery, pathology reports were reviewed, if available, for correlation with the imaging findings. results: cases of mullerian duct anomalies were reviewed within the pediatric population. clinical manifestations were correlated with imaging appearances. conclusions: mullerian duct anomalies represent a range of developmental variants. although functioning ovaries and age-appropriate external genitalia are characteristic, there may be anomalies ranging from uterine and vaginal agenesis, to duplication of the uterus and vagina, to minor uterine cavity abnormalities. müllerian malformations are frequently associated with abnormalities of the renal and axial skeletal systems, and pediatric patients in particular may present with these associated anomalies. menstrual abnormalities may represent a more typical presentation in the adolescent age group. this is in contrast to the adult population, which may be more likely to present with infertility. the variation in clinical presentations make mullerian duct anomalies difficult to diagnose and, because surgical techniques for correction and treatment depend on the underlying anatomy, understanding these variants in the context of imaging studies is important to their diagnosis and management. patient had radiographs which showed an irregular left humeral metaphysis with an associated fracture. patient had a phase bone scan that showed slightly increased uptake on the angiographic and blood pool phases and increased activity on the delayed phase in the right femur. radiographs showed a moth eaten appearance of the right femur with soft tissue swelling. patient had radiographs that showed periosteal reaction in the right tibia with an associated fracture. patient , in addition to radiographs, had an mri that showed osteomyelitis of the left humerus and scapula with an associated subperiosteal abscess. patient had multi focal osteomyelitis that was demonstrated on radiographs by irregular cortices and periosteal reaction involving the upper and lower extremities. conclusions: neonatal osteomyelitis is an uncommon entity that can have severe complications if not diagnosis and treated promptly. it is important to review cases and to review the appearance of neonatal osteomyelitis on multiple modalities. radiographs will usually demonstrate periosteal reaction and possibly soft tissue swelling. additional studies may be obtained to evaluate for complications, such as abscesses or involvement of the joint space. purpose or case report: review the epidemiology of ddh. describe the critical diagnostic imaging findings of ddh. understand the role of imaging accompanying treatment. methods & materials: images including radiographs, ultrasound, ct and mri will be used to demonstrate the current and historical role of imaging in caring for patients with ddh. discussion of the importance of reducing radiation exposure when choosing imaging studies will be included. results: radiographs and ultrasound are used primarily in making the diagnosis of ddh. ultrasound and mri are most often used during the course of treatment to assess its effectiveness. mri is increasingly utilized without sedation for patients in spica cast. conclusions: imaging is critical in the care of patients with ddh. pediatric musculoskeletal ultrasound of the proximal lower extremity (pelvis to thigh) julia rissmiller, md, dept of radiology, children's hospital boston, julia.rissmiller@childrens.harvard.edu; howard christianson, michael j. callahan purpose or case report: to review indications for ultrasound of the proximal lower extremity (pelvis, hip and thigh), and to illustrate the practical use of ultrasound in evaluation of the proximal lower extremity, emphasizing the sonographic appearance of various musculoskeletal disorders. ultrasound is a well-established modality for the evaluation of painful hip, developmental hip dysplasia, soft tissue infection, palpable masses, and foreign bodies in children. in general, ultrasound has a more limited role for the primary evaluation of other pediatric musculoskeletal disorders including trauma, articular and periarticular diseases and tumors or tumor-like processes. advantages of ultrasound, a relatively non-invasive technique, include excellent spatial resolution, low cost, lack of ionizing radiation, lack of need for sedation, and the ability to image the patient in real-time. the major disadvantage of ultrasound is operator dependency, which is particularly evident in musculoskeletal applications. we present ultrasound examples of pathology involving the proximal lower extremity (pelvis, hip and thigh). cases include developmental hip dysplasia, hip effusion, osseous metastasis to the iliac bone, osteomyelitis of the hip, femoral acetabular impingement, rectus femoris hernia, vascular malformation, ewing's sarcoma and myositis ossificans. results: a range of images from pediatric diagnostic ultrasounds performed of the proximal lower extremity (pelvis to thigh) will be presented emphasizing the sonographic appearance of various musculoskeletal disorders. conclusions: ultrasound is an excellent modality for evaluating the proximal lower extremity in children, beyond the current indications of painful hip, developmental hip dysplasia, soft tissue infection, palpable masses, and foreign bodies in children. a multi-modality pictorial review of lesions of the epiphysis in infants and children ernesto i. blanco, md, st. christopher's hospital for children, eiblanco @gmail.com; jacqueline urbine, evan geller, peter pizzutillo purpose or case report: to review the imaging spectrum of epiphyseal lesions in infants and children. a retrospective review of our imaging database was performed to identify studies with either primary lesions of the epiphysis or processes that affect the epiphysis. results: multiple epiphyseal lesions were elucidated primarily by radiography, with cross-sectional imaging included where clinically necessary. congenital lesions include the epiphyseal dysplasias represented here by chondrodysplasia punctata. epiphyseal infarction may due to multiple etiologies including slipped capitol femoral epiphysis, developmental dysplasia of the hip, sickle cell disease, or idiopathic reasons. neoplasms may occur in the epiphysis, including chondroblastoma and histiocytosis. traumatic lesions include fracture and avulsion. osteomyelitis can occur in the epiphysis as well. pseudolesions that mimic pathology will also be reviewed. other pathologies that can affect the epiphysis include juvenile idiopathic arthritis and hemophilia. conclusions: a wide spectrum of congenital and acquired pathologies may affect the epiphysis in the infant and child. plain radiography, computed tomography, and magnetic resonance imaging all contribute to the diagnosis of these varied lesions. purpose or case report: we aim to present the spectrum of common and uncommon hip disorders in pediatric population. we will formulate a systematic approach and present a flowchart to workup and characterize hip diseases. methods & materials: relevant imaging appearances of normal as well as pathological hip will be presented. normal hip anatomy will be discussed through anatomic drawings and radiological images (plain radiographs, ct, usg, and mri). we will illustrate the various anatomic landmarks, measurements and lines on plain radiographs and ultrasound of hip. results: evaluation of limp and hip pain in the pediatric population has undergone rapid evolution. surgical treatment for these disorders continues to be refined, and our ability to identify patients along the spectrum of disease continues to improve. yet, despite our advances, obtaining an accurate diagnosis can remain challenging, especially in the setting of mild structural abnormalities. many imaging studies can be used to evaluate the bones and soft tissues, but conventional radiography is the primary imaging modality for most clinical conditions. plain radiographs usually are obtained first because they are sensitive and specific for a wide range of bone pathology. more sophisticated imaging modalities including radionuclide scintigraphy (bone scan), ultrasonography (usg), computed tomography (ct) and magnetic resonance imaging (mri) are reserved for specific clinical situations. each of these imaging modalities has specific advantages and disadvantages. it is the aim of this review to guide in selecting and interpreting the appropriate imaging modality for a variety of common disorders. this exhibit will illustrate imaging features of developmental dysplasia of hip, perthes disease, slipped capital femoral epiphyses, hip malformations in syndromes, femoral acetabural impingement, labral disorders, septic arthrits and other disorders. the role of various imaging modalities in evaluation of these disorders will be discussed, along with common imaging pearls and pitfalls. conclusions: a systematic approach is necessary for evaluation of pediatric hip disorders. familiarity with normal appearances, pitfalls and specific imaging of these entities is essential for proper diagnosis and management. osteoid osteomas: a pain in the "night" diagnosis nancy k. laurence, md, the children's hospital of philadelphia, nkang @gmail.com; monica epelman, richard markowitz, camilo jaimes, diego jaramillo, nancy chauvin purpose or case report: a common benign bone-forming lesion, osteoid osteoma comprises approximately % of all benign bone tumors. the tumor is composed of a nidus of vascular osteoid tissue and woven bone lined by osteoblasts, frequently with considerable surrounding inflammation. the radiolucent nidus surrounded by variable degrees of reactive sclerosis usually leads to a straightforward diagnosis; however, sometimes the diagnosis of osteoid osteoma can be challenging, as it may have a non-specific and misleading appearance on different imaging modalities, particularly on mri. the purpose of this exhibit is to review the typical and atypical features of osteoid osteomas on different imaging modalities. we present diagnostic dilemmas of osteoid osteomas from our institution and how imaging characteristics can aid in diagnosis. we performed a retrospective review of our imaging database to identify cases of typical and atypical osteoid osteomas, with special emphasis on cases which posed a diagnostic dilemma on imaging. results: when osteoid osteomas occur in atypical locations the diagnosis can be elusive. when located in the intraarticular space there is often minimal or absent cortical thickening and there may be a joint effusion with synovial hypertrophy. phalangeal lesions may cause extensive bone marrow edema and surrounding soft tissue swelling. both of these types of osteoid osteomas can be mistaken for infection. the recently described "ct vessel" or "vascular groove" sign, a low density vascular groove adjacent to the nidus, is highly specific for osteoid osteoma. in the authors' experience, a rim of sclerosis surrounding the nidus may aid in diagnosis on mri and can be identified as an outer hypointense halo on all sequences. we illustrate the findings in cases of atypical osteoid osteomas which may be difficult to diagnose including intraarticular, phalangeal, and vertebral osteoid osteomas. we also show examples of the newly described sign which has high specificity for osteoid osteoma. conclusions: imaging findings in osteoid osteomas can be misleading and cause misdiagnosis, especially in atypical cases. knowledge of their appearance in atypical locations and specific findings can aid in the correct diagnosis. ultrasound of normal entheses in the growing skeleton nancy chauvin, md, department of radiology, the children's hospital of philadelphia, chauvinn@email.chop. edu; pamela f. weiss, monica epelman, diego jaramillo purpose or case report: ultrasound is an underutilized modality in the evaluation of the pediatric musculoskeletal system. evaluation of tendon insertions about the elbow, knee and foot can be easily performed with ultrasonography. a good knowledge of the age dependent normal ultrasound appearance of the entheses is crucial in order to evaluate for pathology, such as trauma or ethesitis-related arthritis. this exhibit will serve to provide the reader with a practical approach to imaging when assessing tendon insertions. optimal patient positioning and transducer selection will be discussed. in addition, important anatomic landmarks will be described to allow for reproducibility and avoiding pitfalls. methods & materials: transverse and longitudinal ultrasound images of entheseal insertion sites were performed on healthy girls and boys between the ages of and years. ultrasound of the elbow was performed while in full extension and the insertions of the common flexor and common extensor tendons were evaluated. the quadriceps and patellar insertions were imaged with patients in the supine position, with the knees flexed at degrees. the achilles tendon and plantar fascia insertion were evaluated with the patient prone, with the feet hanging off the edge of the table. results: tendons demonstrated the expected fibrillar pattern with parallel echogenic lines. the appearance of the entheses changed as the insertion matured from sonolucent cartilage to echogenic bone. conclusions: using a systematic approach and knowledge of the normal anatomy, sonography of the tendons of the elbow, knee and foot can easily be performed in children. pediatric musculoskeletal ultrasound of the distal lower extremity (knee to ankle) howard christianson, md, radiology, children's hospital boston, howard.christianson@childrens.harvard.edu; julia rissmiller, michael j. callahan purpose or case report: ultrasound is a well-established technique in children for evaluation of the painful hip, developmental dysplasia of the hip, soft tissue infection, palpable masses and foreign bodies. in general, ultrasound has a somewhat more limited role for the primary evaluation of several other pediatric musculoskeletal disorders in the setting of trauma, articular and periarticular diseases and tumors and tumor-like conditions. inherent advantages of ultrasound include excellent spatial resolution, a lack of ionizing radiation, a relatively non-invasive technique and lack of a need for sedation. real-time imaging allows problem solving not available with other modalities which is well suited for musculoskeletal applications, particularly in the setting of trauma. the major disadvantage of ultrasound is operator dependency, which is particularly evident in musculoskeletal applications. the purpose of this study is to illustrate the practical use of ultrasound in the evaluation of the distal lower extremity (knee to ankle) emphasizing the sonographic appearance of various musculoskeletal disorders. examples include: ) cystic lesions around the joints: baker's cyst, synovial cyst, ganglion cyst and suprapatellar bursitis; ) infectious processes: pretibial, subperiosteal and intramuscular abscess; ) tumor and tumor like lesions: nerve sheath tumor, tumoral calcinosis; ) trauma related injuries: sinding larsen johansson, tibialis anterior muscle herniation, hematoma. methods & materials: cases selected for presentation from a series of diagnostic musculoskeletal ultrasounds performed at our institution. results: a range of images from diagnostic ultrasounds performed of the distal lower extremity (knee to ankle) will be presented emphasizing the sonographic appearance of various musculoskeletal disorders. conclusions: selected musculoskeletal ultrasounds of the distal lower extremity are presented to familiarize the audience with the sonographic appearance of various musculoskeletal disorders and to highlight the tremendous potential of ultrasound in evaluating musculoskeletal disease in children and adolescents. role of conventional and dynamic contrast enhanced magnetic resonance imaging in diagnosis of hemihypertrophy syndromes in children shrey k. thawait, md, phd , radiology, yale university-bridgeport hospital, sthawai @jhmi.edu; gaurav k. thawait, sally e. mitchell, laura m. fayad, john a. carrino, kate puttgen purpose or case report: hemihypertrophy syndromes in children are complex and there is some overlap among these conditions. hence, establishing a diagnosis can be challenging. identification of the correct vascular anomaly associated with these overgrowth disorders helps to correctly classify the disease into one of the several syndromes, which in turn guides management. in this educational poster, we will review the definition, clinical presentation, conventional magnetic resonance imaging (mri) and contrast enhanced magnetic resonance angiography and venography (mra / mrv) features of hemihypertrophy syndromes in children. methods & materials: . learn the diagnostic criteria for overgrowth syndromes in children such as klippel-trenaunay syndrome (kts) and parkes weber syndrome (pws) with special emphasis on associated vascular anomalies. . gain knowledge of high resolution mri technique for evaluation of vascular anomalies associated with the hemihypertrophy syndromes. . understand the additional value of dynamic contrast enhanced mra / mrv in the differentiation of the hemihypertrophy syndromes in the pediatric age group. results: . mri technique for a dedicated "vascular anomaly protocol" consisting of fat saturated t weighted, pre contrast axial t weighted, and post contrast triplanar t weighted fat saturated imaging will be described. . special emphasis will be provided on dynamic contrast enhanced mra/mrv. . conventional and dynamic mri features of clinically proven cases of hemihypertrophy syndromes will be demonstrated. conclusions: systematic mri interpretation utilizing a dedicated vascular anomaly protocol enables the radiologist to correctly identify the hemihypertrophy syndrome, and provide detailed extent of disease. correlative ultrasound, mri imaging and physical examination of elbows in hemophilic children andrea s. doria, md, the hospital for sick children-diagnostic imaging, andrea.doria@sickkids.ca; frederico xavier, arun mohanta, carina man, ningning zhang, pamela hilliard purpose or case report: .to report a systematic ultrasound (us) protocol for assessment of hemophilic elbows. . to discuss advantages and disadvantages of us and mri for evaluating hemophilic elbows in comparison with physical examination. .to illustrate us and mri findings and associated pitfalls in hemophilic joints. background: the value of physical examination for assessment of early arthropathic changes in hemophilic joints is unknown. us does not require sedation in young children, but involves operator training and standardized technique. mri is the reference standard imaging modality for assessment of pathology in hemophilic joints. standardization of a systematic protocol for data acquisition and interpretation of us findings and understanding of the correlation of findings between physical examination, us and mri in hemophilic elbows is essential for the use us as an outcome measure both in clinical practice and research. so far such information is not available for growing elbow joints. methods & materials: eight hemophilic boys (age range/ median, - / years) with a history of prior elbow bleeds underwent us and mr imaging, and physical examination on the same day. corresponding images on us and mri were highlighted to illustrate abnormalities and pitfalls. soft tissues (effusion/hemarthrosis,synovial hypertrophy,hemosiderin deposition) changes were characterized as small, moderate, or large. erosions, cartilage and subchondral abnormalities were graded based on depth or extent of articular changes. results: . us is helpful for discriminating synovial hypertrophy, joint effusion/hemarthrosis, and large hemosiderin deposition which otherwise generates susceptibility artifacts on gradient-echo mri obscuring adjacent tissues. . us can visualize erosions, cartilage and subchondral abnormalities at the joint periphery. however,differentiation between subchondral cysts and erosions is usually unfeasible by us. . prior knowledge of the degree of joint maturation is essential for an accurate evaluation of cartilage loss by us. . physical examination has limitations for assessment of early joint changes in contrast to us. conclusions: us can be useful for assessing hemophilic elbows, with advantages over mri in the evaluation of soft tissues. further development of an us-mri atlas on normal cartilage in growing joints is needed for definition of the value of us in the assessment of minimal osteochondral abnormalities. digital atlas of skeletal surveys of common skeletal dysplasias shawn parnell, mbbs, md, dnb, radiology, seattle children's hospital, shawn.parnell@seattlechildrens.org; corey wall, edward weinberger purpose or case report: skeletal dysplasias are conditions of abnormal bone and cartilage growth which result in short stature. developing expertise in the radiographic evaluation of skeletal dysplasias can be difficult, as more than dysplasias exist. exhaustive description of individual dysplasias can be found in hard copy textbooks, without the ability to compare individual dysplasias side by side. by providing radiographic images and descriptive text of thirteen common skeletal dysplasias and two comparative normal skeletal surveys, we aim to facilitate understanding of the terminology and highlight the differences in imaging appearances one may commonly encounter in interpreting skeletal dysplasias. methods & materials: initial skeletal surveys and/or follow up radiographs obtained for evaluation of skeletal dysplasias at our institution from to were compiled and reviewed for best quality images. selected images for each case were labeled according to body part and view, to include ap and lateral views of the spine and skull and ap views of the extremities and pelvis. for neonates, ap and lateral babygram images were used. the software program used for viewing the atlas, written in c#, may be freely downloaded. it permits linked scrolling and resizing of the images, and simultaneous comparison of different cases is available. cases may be viewed as unknowns or in a selfteaching mode. results: radiographic images for thirteen common skeletal dysplasias and two comparative normal skeletons (neonate and child) are provided within an interactive digital atlas. cases include achondroplasia, pseudoachondroplasia, cleidocranial dysplasia, thanatophoric dysplasia, diaphyseal dysplasia, multiple epiphyseal dysplasia, osteopetrosis, osteogenesis imperfecta, multiple hereditary exostoses, dysostosis multiplex, fibrous dysplasia, asphyxiating thoracic dysplasia (jeune syndrome), and spondyloepiphyseal dysplasia. conclusions: by displaying radiographic images of several common skeletal dysplasias in an interactive and comparative format with descriptive text, understanding of basic radiographic terminology and appearances will be facilitated. purpose or case report: . to classify various pediatric msk soft tissue masses . to describe pathogenesis, imaging appearances and differential diagnosis of these lesions methods & materials: radiology and clinical medical records were reviewed and pediatric patients with musculoskeletal soft tissue masses were identified. representative images were collected as examples of each lesion. the lesions were then classified into different groups based on the similar pathology and etiology. brief discussion is done for each of these masses with their multimodality imaging appearances. results: the search yielded pediatric soft tissue masses of multiple different etiologies, including post-traumatic (hematoma, fat necrosis, fibromatosis coli, myositis ossificans), inflammatory or infectious (cellulitis, abscess, granuloma annulare, retained foreign bodies), pseudotumors (synovial cysts, ganglion cysts, vascular malformations) and neoplastic lesions (fatty, vascular, neural, fibrous, muscular). multiple different imaging modalities were used to evaluate these masses, including ultrasound, ct and mri. representative examples of different lesions and their appearances on different imaging modalities will be presented and an organized approach to the diagnosis of these lesions will be discussed. conclusions: musculoskeletal soft tissue masses are relatively common in children. majority of these are benign; however, up to % of these lesions can be malignant "sarcomas". multiple different imaging modalities often provide complimentary information in the work-up of these lesions. despite multimodality imaging approach, tissue diagnosis or short interval follow-up is still often required when the mass does not show typical features of a benign etiology. pediatric radiologists should be familiar with various pediatric msk soft tissue masses and their imaging appearances, and should be able to guide appropriate management. results: elbow mri examinations were reviewed on children aged months to years with ( %) of these investigating clinical instability in children. mechanism of injuries included congenital dislocation ( %), traumatic dislocation ( %), fracture or avulsion ( %) and other injuries ( %). the patient's with congenital elbow dislocations most commonly presented with radial head dislocation and associated dysplasia or flattening, effusion and less frequently dysplasia of the olecranon or capitellum. patient's with traumatic dislocations were frequently associated with ligamentous or capsular disruption, bone oedema and epicondylar avulsion with effusion, loose osseous bodies and fractures less often. the epicondylar avulsions and ligamentous or tendon injuries occurred equally often in those few patients with unspecified injury mechanism. conclusions: a number of the bony, ligamentous, articular and developmental anomalies evident on elbow mri have been illustrated highlighting the importance of careful and systematic review of all elbow structures when presented with a child with elbow instability. accurate identification of these abnormalities is vital to facilitate their appropriate management. methods & materials: from our computerized radiology information system, we retrieved all patients that have foot ultrasound for evaluation of vertical or oblique talus deformities in the last years ( / - / ). the us was performed by a pediatric radiologist using a high resolution linear and tight convex curve probes with foot in neutral, plantar flexion and dorsiflexion. all medical charts, ultrasound scans and foot radiographs were reviewed by a pediatric radiologist. results: we identified nine patients' with foot deformities who were suspected of vertical or oblique talus and were evaluated by ultrasound. seven patients are male; two of them had initial foot radiographs that were not diagnostic. two female patients had unilateral oblique talus deformity. there were patients with vertical talus deformity; three of them had bilateral deformities. conclusions: us can directly visualize the unossified navicular, the talar cartilage and their alignment. dynamic us can. ultrasound evaluation of costal chrondral pathologies in children presented as anterior chest wall mass or pain nucharin supakul, md, radiology, riley hospital for children, tanyasupakul@yahoo.com; boaz karmazyn purpose or case report: to summarize our experience with the use of ultrasonography (us) for evaluation of costal cartilage pathology presented as anterior chest wall mass. methods & materials: from our computerized radiology information system, we retrieved all patients that have chest wall ultrasound for evaluation of a mass in the last . years ( / - / ) . the us was performed by a pediatric radiologist using a localized scan with high resolution linear probe. all medical charts, pathology results, ultrasound scans and other imaging studies were reviewed by a pediatric radiologist. results: ten patients were found with costal chrondral pathologies. nine patients presented with anterior chest wall mass and one with chest wall pain. eight patients had angular deformity of a single costal cartilage and one patient had biopsy proven osteochrondroma, presented with anterior chest wall mass. one patient had a non-union fracture after motor vehicle accident, presented with anterior chest wall pain. in patients with rib deformity, the mass was non-tender. nine patients had prior imaging study including chest x-rays (n ), ct scan (n ), breast mr (n ). all these studies were negative. conclusions: us optimally demonstrated costal cartilage abnormities. chest radiographs and cross sectional studies were negative. we therefore recommend using high resolution chest wall us in children with negative chest radiograph and anterior hard chest wall mass. challenges in pediatric marrow imaging-boning up on current mr techniques srikala narayanan, md, division of radiology, children's national medical center, snarayan@childrensnational.org; neha kwatra, nabile safdar purpose or case report: a wide range of pathologies demonstrate similar findings when imaged using conventional mr sequences. however, pediatric musculoskeletal imagers are increasingly leveraging newer techniques to add specificity to their diagnoses when abnormal marrow signal is detected. the purpose of this educational exhibit is to review the application of current mr techniques to pediatric marrow imaging across the spectrum of normal, variant, and pathologic processes. methods & materials: cases with potentially overlapping imaging appearances on conventional mr sequences, including hematopoetic marrow, sickle cell disease, osteomyelitis, chronic recurrent multifocal osteomyelitis, and infiltrative neoplasms, will be presented. the basis of various mr techniques including chemical shift imaging, "whole body" marrow imaging, diffusion weighted imaging, and fat-water separation techniques such as dixon or ideal (ge) will be reviewed. the strengths and weaknesses of such techniques in differentiating between infection, neoplasm, and normal variation will be emphasized through the case examples. challenges and pitfalls in the imaging of these pathologies using such techniques will be discussed. results: current mr imaging techniques add specificity to diagnoses of marrow pathology which are otherwise difficult to differentiate using traditional sequences alone. the use of opposed phase imaging can be helpful in differentiate hematopoietic marrow or infection from infiltrative and neoplastic conditions. "whole body" marrow imaging may serve as an alternative to other modalities which involve significant radiation exposure. the use of diffusion weighted imaging is a promising, but developing, technique being applied to marrow pathology. conclusions: pediatric bone marrow mr imaging is a challenging area for a vast majority of the radiologists. understanding normal developmental bone marrow changes and being aware of the pitfalls is crucial to render accurate diagnosis. current techniques such as ideal, chemical shift imaging, and "whole body" mri have a potentially important role in further characterization of marrow abnormalities. radiologists beware: unusual imaging manifestations in child abuse eglal shalaby-rana, mbbs (hons), children's national medical center, erana@childrensnational.org; allison m. jackson, tanya hinds, katherine deye purpose or case report: to present less common imaging manifestations of injuries in child abuse that may not be readily recognized as possibly abusive injury. methods & materials: through bi-monthly review of cases with the child protection team over a period of years, the imaging studies of patients with suspected non-accidental trauma were recorded. of the pts with suspected nonaccidental trauma, outcomes were available in patients. the child protection team concluded ( %) were cases of non-accidental trauma with reasonable medical certainty. this data base was reviewed for less common injuries that were found in these medically confirmed cases of child abuse. results: less common manifestations of abuse identified by radiographs included salter-harris injuries in the proximal humerus, and proximal femur. pelvic fractures were rare and when present were associated with sexual abuse. severe chest wall injury, with associated rib fractures, causing complete or near-complete white-out of the chest was occasionally encountered. soft tissue injures, such as hematomas were found in various locations in the body including the buttocks and anterior abdominal wall, were imaged on ultrasound and ct. paraor prevertebral injuries, with or without associated bone injury were identified; one infant presented with retropharyngeal soft tissue swelling. mri identified cervical spine injuries which included ligamentous injury and intrathecal hematomas. conclusions: while classic metaphyseal lesions and rib fractures are the most common, specific injuries documented by radiologic work up of suspected non-accidental trauma, less common injuries to the soft tissue and skeletal system may occur as a result of child abuse. the ability of the radiologist to recognize these uncommon manifestations of demonstrated in axial, coronal, and sagittal planes. the ligament of interest will be denoted by arrows. at the conclusion of the anatomy section, there will be a self assessment exam. the participants then will be asked to identify the ligament. if answered correctly, a summary slide will be displayed and, if common, images of the relevant pathology will be demonstrated. if an incorrect answer is indicated, a slide will appear denoting the incorrect answer with explanation. conclusions: hopefully, with review of this educational exhibit, the participant will have a better understanding of the relevant ligamentous anatomy of the ankle and hindfoot. purpose or case report: the purpose of this educational exhibit is to demonstrate the pathologic sonographic findings, one might encounter in the pediatric ankle. a systematic methodological approach including patient positioning, transducer orientation and sonographic technique are vital for ideal sonographic assessment of the pediatric ankle. using a data search program from a large academic institution, pediatric ankle ultrasounds performed in the last years were reviewed. pathologies include trauma, inflammation/infection, masses and congenital abnormalities. examples of normal anatomy will be included particularly when demonstrating ligament and tendon pathology. the normal side was often assessed for comparison purposes. results: ankle sonography is a useful modality to evaluate commonly encountered pathologies in the pediatric ankle. radiographically occult fractures may be discovered. ligament and tendon pathology, such as tears of the anterior talofibular ligament, high ankle sprain and peroneus longus tendon tears, can be easily detected. signs of infection that can be radiographically occult such as subtle periosteal reaction or fluid collections can be identified. finally, "lumps and bumps" can be characterized. for example, one of the most commonly encountered masses in the pediatric ankle is a ganglion cyst which can be well characterized sonographically. awareness of imaging pitfalls is also critical to avoid misdiagnosis and to guide appropriate management. conclusions: with basic ultrasound skills and knowledge of normal anatomy, sonography of the pediatric ankle is a useful modality to evaluate soft tissue structures and other pathologies. it is comparable to mri and allows for dynamic evaluation without need for anesthesia. resonance angiography (mra) using time resolved imaging is a relatively new technique that has become increasingly utilized in the diagnosis of vascular anomalies. we will describe the technique used at our institution, time resolved imaging of contrast kinetics (tricks, ge healthcare, milwaukee, wi), and the parameters that can be adjusted to optimize the exam. we will review key imaging features of hemangiomas and vascular malformations in various modalities, with a special emphasis on the tricks appearance. we performed a retrospective review of all the tricks studies performed at our institution for suspected vascular anomalies. in addition to the mr imaging features, we specifically analyzed the t weighted with fat saturation post tricks enhancement and the temporal tricks enhancement pattern. we reviewed all additional imaging including plain film, ultrasound, and ct and correlated the radiographic imaging with the available clinical and histopathologic features. results: we present illustrative cases of hemangiomas, kaposiform hemangioendothelioma, venous malformations, arteriovenous malformations, lymphatic malformations, and other pitfall lesions. we propose a diagnostic algorithm that relies heavily on the post contrast t weighted with fat saturation post tricks enhancement pattern and the temporal tricks enhancement pattern. conclusions: time resolved contrast-enhanced mra has become an increasingly important adjunct in the diagnosis of vascular anomalies. optimization of the exam technique and familiarity of the tricks imaging appearance is essential and can often assist in accurate lesion characterization. purpose or case report: vertical expandable prosthetic titanium rib (veptr) is increasingly used in the treatment of thoracic insufficiency, scoliosis, and chest wall defects in children. in contrast to spinal fusion surgery, veptr allows for growth while stabilizing the deformity. we review the indications, pre-operative imaging, normal radiographic appearance, and complications of this device. methods & materials: on review of the literature, the indications for veptr have expanded in the past several years to include thoracic insufficiency, idiopathic and neuromuscular scoliosis, and chest wall defects. we illustrate the normal radiographic appearance of the three common configurations of veptr (cradle-to-cradle assembly, cradle with lumbar extension assembly; cradle-to-ala hook assembly). we discuss the potential complications of veptr, including infection, rib fracture, dislodged hardware, and neurological injury, with an emphasis on imaging diagnosis. results: there is a relatively high rate of reported complications with veptr in the literature. therefore, awareness of the growing number of indications, as well as the expected and unexpected appearance of this device, aids in radiographic diagnosis of complications. conclusions: vertical expandable prosthetic titanium rib (veptr) is gaining acceptance in the treatment of thoracic insufficiency, scoliosis, and chest wall defects in children. recognition of the indications, normal radiographic appearance, and complications of this device will facilitate timely and accurate diagnosis. disclosure: dr. philips has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. spectrum of pediatric spinal neoplasms: an interactive tutorial benjamin t. haverkamp, md, radiology, university of missouri-kansas city, haverkampbt@umkc.edu; salvador f. iloreta, maha jarmakani, lisa lowe, seth gibson purpose or case report: the objective of this educational electronic exhibit is to provide the radiologist with an approach to pediatric spinal neoplasms. emphasis will be placed on narrowing the differential diagnosis using a combination of lesion location, characteristic imaging findings, relevant history, and associations. the exhibit format will include a casebased review of various pediatric spinal neoplasms, radiologicpathologic correlation, and a brief discussion of imaging findings useful in guiding surgical management. an interactive selfassessment exam will be presented at the end of the exhibit. results: a review of the specific etiologies will be presented with classification as intra-and extra-medullary and extradural lesions. radiologic images will be related to gross and microscopic pathology. conclusions: after viewing this exhibit, the learner will be able to: . recognize the clinical, imaging, and pathologic characteristics of pediatric spinal neoplasms. . understand relevant imaging findings useful in surgical management. . test their understanding of the presented material through an interactive exam. poster #: edu- craniosynostosis jason tsai, mbchb, children's hospital boston, jason. tsai@childrens.harvard.edu; diana p. rodriguez purpose or case report: to review the normal developmental appearance of the cranial sutures with computed tomography (ct) and to describe ct findings of the various forms of craniosynostoses. in this irb-approved retrospective study we reviewed ct images of subjects diagnosed with craniosynostosis between and september . we included patients with single-suture synostosis, isolated bilateral coronal synostosis, pansynostosis, and combined craniosynotoses. additionally, we identified individuals with normal appearing sutures from to years of age imaged with head ct to describe the pattern of normal development of the cranial sutures. results: a description of the normal developmental ct appearance of the cranial sutures using computed tomography has been provided. of the group of patients with craniosynostosis the following variables were recorded: age at presentation, the pattern of sutural fusion, skull shape, presence of hydrocephalus, genetic testing, and types of surgical correction. conclusions: we have demonstrated the normal developmental ct appearance of the cranial sutures and the ct patterns of the various forms of craniosynostoses, with clinical, genetic and surgical correlation. posterior fossa tumours: a pictorial review sam byott, md, manchester children's hospital, sambyott@ hotmail.com; neville wright, vivian tang, abdu shabani, stavros stivaros purpose or case report: posterior fossa tumours account for - % of childhood brain tumours. the most common differentials include pilocytic astrocytoma, medulloblastoma and ependymoma. mr imaging is crucial to diagnosis, staging and identification of complications such as hydrocephalus and haemorrhage. soft tissue characteristics alongside tumour location, invasion and clinical history facilitate radiological discrimination prior to surgery. however, there is significant clinical equipoise with regards to the imaging appearances in a significant proportion of cases making definite diagnosis difficult. the aim of this study is to evaluate the radiological findings and correlate with histological data. this will allow identification of the key morphological features that discriminate different tumours. these can then be presented to educate fellow radiologists. methods & materials: radiology pacs and patient notes were used to collate radiological, histological and clinical data. results: there were patients presenting at our institution with posterior fossa tumours. had pilocytic astrocytomas, had medulloblastomas and had ependymomas. one patient had an atypical teratoid rhabdoid tumour (atrt). traditional features alongside more advanced mr characteristics were correlated with histology, and the features allowing for discrimination of tumour types are presented in this pictorial review. conclusions: posterior fossa tumours have a highly variable radiological appearance. we present a range of appearances and describe the important morphological features that allow radiological discrimination of tumour type. poster #: edu- dt imaging of the pediatric spine teresa c. gross kelly, children's hospital of wisconsin, tkelly@chw.org; ibrahim s. tuna, mia s. kelly, tushar chandra, sumit singh, mohit maheshwari, hervey d. segall purpose or case report: some abnormalities of the pediatric spine can be challenging. we have discovered that in many such cases, diagnosis of spinal lesions can be faciliated by using the dt weighted sequence. the purpose of this educational poster is to demonstrate the remarkable usefulness of dt weighted images for delineating pathology of the pediatric spine. methods & materials: lesions of the spine that will be reivewed in this educational exhibit will be categorized as: ( ) vascular ( ) due to infection/inflammation ( ) neoplastic/ neurogenic ( ) congenital ( ) traumatic/iatrogenic ( ) endocrine/metabolic. the imaging characteristics of lesions found in the pediatric spine will be described and the utility of d t -weighted mr sequences for the evaluation of these lesions will be discussed. finally the role of imaging in the treatment planning of abnormalities of the pediatric spine will be addressed. results: this educational exhibit will provide numerous examples of how d t -weighted imaging can elucidate diagnosis of lesions involving the spine. examples include enhancement of the cauda equina in guillain barre syndrome, lipomatous malformations, spondylolysis in children with low back pain, thecal cysts, filar cysts, metastasis, hydromyelia and ventriculus terminalis. conclusions: d t -weighted images of the spine performed in the sagittal plane with coronal and axial reformations, as well sagittal oblique reformations (scotty dog reformations) for evaluation of spondylolysis, can facilitate the evaluation of lesions involving the pediatric spine. the normal pediatric spine: a pictorial review of mr anatomy and development in the infant, child and adolescent ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; teresa c. gross kelly, tushar chandra, mohit maheshwari, sumit singh, hervey d. segall purpose or case report: radiological evaluation of the pediatric spine can be more challenging in child than in the adult patient due to the wide range of normal anatomic variants and synchondroses, combined with the unique effects of trauma in children. mri is an excellent imaging modality for the evaluation of the pediatric spine. however, in order to provide an accurate interpretation of acute posttraumatic changes in the pediatric spine, particularly in the setting of abusive head trauma, a fundamental knowledge of normal anatomy, variants and pathology of the pediatric spine is required. the aim of this educational exhibit is to illustrate normal mri anatomy of the spine in the infant, child and adolescent. methods & materials: this exhibit will first describe basic spinal embryology and development of the vertebra and spinal cord, followed by mri depiction of the developmental anatomy of the spine from infancy through adolescence. the changing appearance of the spinal canal, spinal cord and vertebral bodies with age will be illustrated using normal cases from the radiology database. sagittal and transverse diameter of vertebral bodies, thickness of the dural thecal sac, dimensions of the spinal canal, normal bone marrow signal changes, vertebral body heights, level of conus medullaris, prevertebral and paraspinous soft tissues and epidural fat thickness will be described and changes according to age will be pointed out. results: in early life, the spinal cord extends to the inferior aspect of the bony spinal column. because the vertebral bodies grow longitudinally faster than the spinal cord does, the conus medullaris may change. ossification of the vertebral bodies and posterior elements is nearly complete by age , with a resultant decrease in the spinal canal diameter. the nucleus pulposus becomes smaller after years and spans approximately half the disk space in the sagittal plane. the spinal cord is elliptical in cross section in the cervical spine and demonstrates a difference in signal between the normal gray and white matter of the spinal cord which should not be mistaken for intramedullary pathology. conclusions: a solid understanding of normal spine anatomy and embryological development is essential in evaluation of pediatric spine, mainly in the setting of trauma. familiarity with normal anatomic variants is essential to provide an accurate interpretation of pathology in the pediatric spine. spectrum of intracranial cystic lesions in infants and children ernesto i. blanco, md, st. christopher's hospital for children, eiblanco @gmail.com; eric faerber purpose or case report: to review the imaging spectrum of intracranial cystic lesions in the pediatric population. methods & materials: a retrospective review of our imaging database was performed to identify studies obtained in which the findings included intracranial cystic lesions. results: multiple cystic lesions were elucidated primarily by computed tomography or magnetic resonance imaging. these lesions can be divided into nonneoplastic and nonneoplastic tumor-associated cysts. the nonneoplastic cysts, which is the largest group, include: cavum septi pellucidi and cavum veli interpositi, choroid plexus cyst, enlarged peri-vascular spaces, pineal cyst, the large spectrum of arachnoid cysts, colloid cyst, epidermoid cyst, rathke cleft cyst, and porencephalic cyst. nonneoplastic tumor-associated cysts include: craniopharyngioma, optic glioma, pilocytic astrocytoma, hemangioblastoma, and ganglioglioma. conclusions: intracranial cystic lesions are relatively common entities in the pediatric population. a wide spectrum of nonneoplastic and nonneoplastic tumor associated pathologies are presented using both computed tomography and magnetic resonance imaging. kelly, sumit singh, ibrahim s. tuna, hervey d. segall purpose or case report: the aim of this educational exhibit is to provide a comprehensive review of imaging features, classification and management of pediatric spinal cord tumors. we also aim to elicit the differences between pediatric spinal cord tumors and their adult counterparts. we will summarize the differences between the individual tumors based on histological cell types and the pertinent implications on management and outcome methods & materials: this exhibit will provide an overview of the common as well as uncommon tumors of the pediatric spinal cord. various classification systems for these tumors-anatomical as well as histological will be discussed. we will illustrate the relevant imaging findings that can help in differentiating these tumors. results: pediatric spinal cord tumors account for % to % of all pediatric central nervous system tumors. mri is the mainstay for the initial diagnosis as well as the post surgical evaluation and surveillance of these tumors. pediatric and adult spinal cord tumours differ both in terms of anatomical location as well as histology. the disease and treatment related morbidities are also different in children as compared to adults. astrocytomas, ependymomas, glioneural tumors and csf metastasis represent the vast majority of cord neoplasms in the pediatric age group. some of cord tumors may also be associated with inherited syndromes (like neurofibromatosis type ) or may have genetic predisposition. these would also be discussed. we will also illustrate and discuss common non neoplastic spinal masses that may mimic tumors. conclusions: pediatric spinal cord tumors have varied clinical presentations, imaging appearance and outcome. this review would improve the understanding of these tumors thereby helping in diagnosis, management and follow up of these uncommon neoplasms. multi-modality imaging of pediatric head and neck lesions jason au, md, oklahoma university health sciences center, jasonmau@gmail.com; anthony alleman, mahmoud elkaissi, roy jacob purpose or case report: the purpose of this study is to present a side by side comparison of the multi-modality imaging features of pediatric masses. using cases that have been imaged with multiple modalities, the exhibit will delineate the sonographic, mr, and ct appearance of congenital, infectious, and neoplastic head and neck lesions in the pediatric population. methods & materials: a restrospective search of pacs was performed on studies completed at the oklahoma university medical center on the oklahoma university health science center campus from january to the present. ultrasound, ct, and mr examinations were selected that depicted relevant pediatric head and neck pathology. all studies were de-identified prior to image export. results: over twenty representative cases of pediatric infections, fibrous tumors, cystic neoplasms, vascular malformation, bony tumors, developmental anomalies, and other neoplasms were selected for inclusion. results: pictorial review of cases including the following representative cases: myelonmeningocele associated with arnold chiari malformation, lipomyelomeningocele, tethered cord with spinal lipoma/fibrofatty filum, tethered cord and dermal sinus tract, and chiari i with syringohydromyelia. several unique cases including the following will be presented as well: thoracic meningocele with arnold chiari malformation, terminal myelocystocele, diastematomyelia, and myelomeningocele without arnold chiari malformation. while mri demonstrates the cranio-cervical junction and the cervicothoracic spinal cord better than ultrasound, ultrasound often allows for improved resolution of the distal spinal cord, lumbosacral spinal canal, and spinal dysraphism structures near the skin surface in the neonate. conclusions: congenital spinal malformations are complex and variable in imaging appearance. it is important to understand the classification in order to determine the appropriate management and prognosis. in the neonatal period imaging should be performed with ultrasound and mri studies, as they may provide different and complementary information. conclusions: hypoxic ischemic injury is a common condition resulting in a wide spectrum of severe neurological defects. while in the past treatment only consisted of supportive care for hii, recent advances have yielded promising treatment options if initiated within a limited time window. thus due to the severity of the disease and the need for rapid intervention, it is important to recognize radiological manifestations of hii along with its clinical signs and symptoms to offer a better prognosis to the patient. craniosynostosis: looking beyond the sutures tushar chandra, md, children's hospital of wisconsin, drtusharchandra@gmail.com; teresa c. gross kelly, mohit maheshwari, sumit singh, ibrahim s. tuna, hervey d. segall purpose or case report: the aim of this educational exhibit is to provide a framework upon which the diagnosis of the various types of craniosynostosis can be facilitated. our goal is to provide an efficient way to evaluate craniosynostosis for the radiologist in clinical practice. we plan to accomplish this goal by providing a succinct review of the sutures, an overview of the various classification schemes for craniosynostosis and potential complications associated with premature sutural closure. the role of imaging in the evaluation of craniosynostosis will be described and the features of craniosynostosis that are most important to the craniofacial surgeon will be elucidated. finally, surgical strategies for the repair of craniosynostosis and postoperative findings will be described. results: some of the forms of craniosynostosis may have a genetic basis, but many are spontaneous in nature. untreated progressive craniosynostosis can lead to inhibition of brain growth, and an increase in intracranial pressure. mdct with mip and d surface reformations is the preferred modality for diagnostic evaluation of craniosynostosis. it is also a robust modality for post operative assessment and long-term follow up. mri is a useful adjunct for assessment of associated intracranial anomalies and complications. timely and appropriate imaging is essential to assess for potential complications of craniosynostosis which may include intracranial hypertension, anomalies of external and middle ear, hydrocephalus, chronic tonsillar herniation, cranial base deformity, impaired venous drainage, enlarged emissary foramina and veins and optic atrophy. on the other hand, positional plagiocephaly should not be misinterpreted as craniosynostosis. surgical management is typical for nonsyndromic craniosynostosis, which involves correction of craniosynostosis between three to six months of age. conservative management is the mainstay for syndromic craniosynostosis. postoperative follow up imaging for surveillance for ventricular size and signs of raised intracranial pressure are necessary. conclusions: craniosynostosis is a challenging area of pediatric neuroimaging. knowledge of the sutural anatomy, an understanding of the potential intracranial complications caused by premature sutural closure, as well as the role that imaging plays in presurgical planning, can provide a practical way for the radiologist to evaluate craniosynostosis in a fast-paced clinical setting. poster #: edu- the perinatal brain and spinal cord-imaging across a life border: a case-based approach anand dorai raju, md, radiology university of tennessee, araju@uthsc.edu; harris l. cohen, matthew whitehead, asim choudhri purpose or case report: to review normal and abnormal perinatal ultrasound (us) and magnetic resonance (mr) imaging findings and note their significance for the analysis of the fetal and neonatal brain as well as spinal cord and vertebral column using a case based approach. to highlight us and mr capabilities in allowing correct perinatal diagnosis of congenital and acquired central nervous system abnormalities. methods & materials: cases will be shown of normal and abnormal anatomic findings in fetal and neonatal brain and spinal cord imaging. key teaching points necessary for the diagnosis of such brain abnormalities as ventriculomegaly, chiari malformations, holoprosencephaly, and agenesis of the corpus callosum as well as dandy walker malformations and avms will be discussed. intraventricular hemorrhage, periventricular leukomalacia, anoxic injuries and infectious abnormalities will be reviewed. abnormal anatomic findings in fetal and neonatal spine evaluations for congenital and acquired abnormalities and key teaching points necessary for the accurate diagnosis of tethered cord, myelomeninocele, caudal regression syndrome, hydromyelia, diastomatomyelia and sacrococcygeal teratoma will be reviewed. some diagnostic difficulties and controversies will be addressed. conclusions: ultrasound aided by mri can provide ready diagnosis to many central nervous system abnormalities involving fetuses and neonates. ever improving perinatal imaging experience and technique allow for better prenatal as well as postnatal diagnosis. cases showing such imaging and key points helping such imaging diagnoses will be reviewed. overview of imaging of pediatric extraocular orbital tumors srikala narayanan, md, division of radiology, children's national medical center, snarayan@childrensnational.org; nadja kadom, gilbert l. vezina purpose or case report: to show the spectrum of benign and malignant extraocular orbital tumors in children. methods & materials: we reviewed the cross-sectional imaging of orbit (ct and mr) done in the last years. specific imaging signs of extraocular tumors including benign and malignant tumors such as hemangiomas, lymphangiomas, optic nerve glioma, optic nerve sheath meningioma, pseudotumors, rhabdomyosarcoma, orbital myofibroma, eosinophilic granuloma and neuroblastoma metastases will be shown. important imaging features that should be considered when formulating a differential diagnosis will be described. conclusions: the spectrum of diseases affecting pediatric orbit is substantially different from what we see in the adults. it is not easy always to differentiate between different tumors. important imaging characteristics will help us towards better differential diagnosis. in this exhibit, we will illustrate ultrasound anatomy of the neonatal spinal cord. discussion of the normal anatomic variants and pathological conditions of the spinal cord will be provided. representative images of a variety of common and uncommon pathological conditions of the spine will be presented to illustrate teaching points. in abnormal cases, follow up mri images will also be illustrated for comparison. results: ultrasound is a robust screening modality for evaluation of the lumbosacral spine in neonates. it is cheaper, readily available, safer first line imaging modality in neonates suspected to have spinal malformations. under able and well trained operator, diagnostic accuracy of spinal ultrasound approaches mri. however, mri remains the gold standard for imaging evaluation of spine. normal variants that simulate disease processes like ventriculus terminalis, prominent filum terminale and central echo complex will be presented. congenital malformations of the cord such as tethered cord, hydromyelia, lipoma, diastematomyelia, myelomeningocele, lateral meningocele and presacral masses will also be discussed. conclusions: ultrasound is a very useful screening technique for evaluation of pathological conditions of lumbosacral spine in neonates. this review would improve the understanding of utility and limitations of ultrasound in evaluation of neonatal spinal malformations. purpose or case report: although mri is the standard for detecting epilepsy and brain tumor abnormalities, pet-ct is performed to ascertain metabolism related to epileptogenic regions or characterize tumor metabolic activity. asymmetric metabolism often correlates to structural abnormalities like cortical dysplasia. metabolic activity often correlates with tumor aggressiveness or grade. fdg pet is commonly used to assess seizure and tumor metabolism. the lesser utilized amino acid pet tracers (c methionine, fdopa) show increasing value with lower grade tumors due to high tumor to normal tissue contrast. literature is accumulating regarding c methionine (cmet) in the detection of lesions like cortical dysplasia and its ability to delineate low grade seizure related tumor lesions. despite the established fdg and accumulating cmet literature, little information exists about the imaging seen with both in pediatrics. as these studies are increasingly viewed as part of fusion mri images, there is more scrutiny of focal metabolism correlating with mri findings and less interpretative reliance on abnormality based solely on asymmetry. methods & materials: review of patients who underwent cmet and fdg brain pet-ct was performed. each was imaged on a philips scanner and had prior mri. studies demonstrating a variety of tumors, postoperative findings of residual or recurrent tumor, and pseudoprogression were selected. epilepsy cases with structural cortical abnormalities or seizure-associated tumors were also selected. cmet and fdg studies were analyzed by pediatric neuroradiologists and the imaging findings correlated with prior mri and any pathology or follow-up imaging. pictorial galleries of the cmet and fdg imaging patterns were created. results: pathologically proven low-grade glial tumors showed increased cmet uptake and no hypermetabolism on fdg. high-grade tumors showed increased uptake on cmet and hypermetabolism on fdg. patients with residual or recurrent tumors showed uptake similar to their original tumor. granulation tissue and pseudoprogression changes showed increased uptake on cmet and no hypermetabolism on fdg. epilepsy surgery patients with cortical dysplasia or low grade glial tumors showed increased uptake on cmet and fdg hypometabolism. conclusions: this study illustrates the variety of findings on cmet and fdg pet-ct in pediatric patients clinically evaluated for brain tumor and epilepsy. this atlas provides readers with a guide to the appearance of these findings on an emerging imaging technique. pediatric head and neck neoplasms: a multimodality pictorial review alok jaju, md, mallinckrodt institute of radiology, alokjaju@gmail.com; marilyn j. siegel purpose or case report: neck masses are common in children and most occur in the suprahyoid region. knowledge of the fascial spaces involved in conjunction with imaging features can help in diagnosis. in this pictorial review, we present a multimodality imaging approach based on anatomy of the suprahyoid fascial spaces for evaluation of pediatric neck tumors. methods & materials: radiology information system (ris) at our tertiary care children's hospital was queried to identify patients with suprahyoid neck masses who had imaging performed between july and present. a variety of conditions having congenital, inflammatory, neoplastic, or vascular origin were identified and the anatomic location in the neck as well as imaging and clinical findings were retrospectively reviewed. results: the imaging evaluation included ultrasound, ct and mri. lesions arose within the following fascial spaces of the suprahyoid neck: superficial, carotid, masticator, submandibular, sublingual, parotid, parapharyngeal, visceral, retropharyngeal and prevertebral. key imaging features important in diagnosis included lesion vascularity, calcification, necrosis and bone invasion. we discuss and illustrate these imaging findings and relate them to specific suprahyoid fascial spaces. specific lesions include vascular and lymphatic malformations, teratoma, nerve sheath tumors, thyroglossal duct and branchial cleft cysts, pleomorphic adenoma, dermoid cyst, ranula, lymphadenopathy, abscess, lymphoma, rhabdomyosarcoma, neuroblastoma and nasopharyngeal carcinoma. conclusions: knowledge of fascial spaces of the suprahyoid compartment and key imaging features on multiple modalities can aid in the diagnosis of pediatric neck masses. pediatric sinusitis: spectrum of imaging findings with clinicopathologic correlation roy jacob, md, university of oklahoma, drjacobr@gmail. com; paul digoy, robert s. glade, anthony alleman purpose or case report: the clinical spectrum of sinusitis in children can range from uncomplicated bacterial sinusitis to invasive fungal sinusitis. most cases respond favorably to medical management. however, complications occasionally occur due to the spread to adjacent structures. imaging plays an important role in characterizing the disease and guiding the clinical and surgical planning and treatment. this electronic presentation outlines the following- . review radiologic anatomy and unique characteristics of pediatric sinuses. . review the clinical features, pathophysiology, and microbiology of sinusitis. . review of ct and mri imaging characteristics of sinusitis with representative cases such as complicated sinusitis and invasive fungal sinusitis. . review the treatment approaches of sinusitis. methods & materials: a retrospective search of pacs was performed on studies completed at the ou children's hospital in oklahoma city for the last three years. ct and mr examinations were selected that depicted relevant disease processes. corresponding nasal endoscopic pictures were obtained from cases which required surgical management. all studies were de-identified prior to image export. results: over fifteen representative cases of the clinical spectrum of sinusitis and its complications were selected for inclusion. conclusions: this educational exhibit provides a concise review of imaging, clinical features, and treatment of pediatric sinusitis. findings will be richly illustrated with radiological and clinical images. microcephaly or hydrocephalus. knowing the embryology of the cerebellum and th ventricle is important to perceive the development of posterior fossa malformations and to further understand the imaging findings. several classifications schemes have been proposed from a pure embryologic to an imaging-based approach using some essential findings such as the size of the posterior fossa, the presence of csf collection or expansion of csf space, and the size and morphology of the cerebellum. mr is the gold-standard for adequately access and characterize the posterior fossa structures. this pictorial essay will review the mr findings of some of the most common posterior fossa malformations including dandy-walker malformation, persistent blakes pouch, mega cisterna magna, arachnoid cyst, paleocerebellar hypoplasia, cerebellar agenesis, cerebellar and pontocerebellar hypoplasia, cerebelar cortical malformations, isolated brainstem hypoplasia/dysplasia and chiari malformations. we will provide a practical approach to the mr findings of posterior fossa malformations in children. conclusions: mr plays a crucial role in identifying and characterizing malformations of the posterior fossa structures. it should give a logical approach to these complex malformations thus guiding the refereeing physician into the clinical approach and in determining further investigations. results: neuroimaging features of abnormal thalami as encountered in the pediatric population were detailed, and wherever applicable, the relevance of additional mr imaging sequences and techniques to determine etiology was described. while there was considerable overlap in imaging appearances, making a precise diagnosis was found to be challenging in difficult cases, and by and large, a stepwise approach was successfully formulated and used to: . diagnose the more emergent conditions and to . devise a management algorithm for the less acute abnormalities. conclusions: bilateral thalamic lesions are occasionally encountered in pediatric neuroimaging and have a limited differential; a good knowledge base and adequate technique are imperative to tease out the precise diagnosis and institute appropriate management. cortical developmental abnormalities in pediatric seizure patients ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; mohit maheshwari, teresa c. gross kelly, sumit singh, tushar chandra, hervey d. segall purpose or case report: to describe various cortical malformations with illustrative examples. we will also briefly discuss the embryology, genetic basis, classification schemes and characteristic imaging findings . methods & materials: this exhibit will illustrate three main categories of cortical malformations: neuronal proliferation, migration and organization. understanding of this complex topic would be facilitated by brief discussion on the embryological basis and proposed genetic causes of some of these cortical malformations. classification schemes on embryology and imaging will be discussed. characteristic imaging findings of these malformations will be discussed and examples from the authors database will be shown. results: neuroimaging in pediatric seizures is challenging. mri is considered the imaging modality of choice because of superior soft tissue contrast and better ability to characterize the pathologic process. we will also discuss the dedicated seizure protocol which is used in our institute. pet-ct imaging can also provides additional information in cases where mri is negative, inconclusive or does not correlate with eeg/clinical findings. brief discussion on advanced imaging techniques will also be presented. malformations are frequently detected in infancy. however, if the initial mri scan performed in infancy is negative, a repeat scan after years of age may be helpful. conclusions: evaluation of cortical malformation in seizure patients still remains a challenging area of pediatric neuroimaging. reviewing of the embryological basis, classification schemes and characteristic imaging findings would improve the understanding the cortical malformations and interpreting the images. poster #: edu- sprs best poster cystic neonatal lesions associated with the spinal cord: discussion and differential diagnosis for these uncommon lesions jacob pirkle, md, jpirkle@mc.utmck.edu, james boyd, brian dupree purpose or case report: to review intradural cystic neonatal spine lesions and discuss the various causes and appearance of these lesions. this poster presentation provides a brief review of neonatal cystic spine lesions, including their etiologies, and presents the targeted audience (radiology resdients, fellows, and practicing radiologists) a helpful differential diagnosis of these lesions based upon their imaging appearance. methods & materials: a brief overview of neonatal cystic spine lesions, their etiology, and imaging appearance is presented in poster format utilizing both literature search and printed reference material. images from several cases of cystic neonatal spine lesions are presented. results: a brief overview of neonatal cystic spine lesions, their etiology, and imaging appearance is presented in poster format utilizing both literature search and printed reference material. images from several cases of cystic neonatal spine lesions are presented. conclusions: neonatal spine ultrasound is often performed to evaluate for abnormalities related to the presence of sacral dimples, cutaneous stigmata, skin tags, hairy tufts, during the evaluation of other congenital anomalies, or when prenatal ultrasound/mri demonstrates an abnormality warranting postnatal follow-up. the identification of cystic spinal cord lesions is relatively rare in the neonate. however, the etiology of these lesions can often be deduced or surmised based upon the location and the imaging appearance of the lesion. the most common cause of a cystic intramedullary spinal lesion is ventriculus terminalis, with a reported incidence of . %. additional lesions include transient dilatation of the central canal, filar cyst, syringohydromyelia, intramedullary arachnoid cyst, and myelomalacia related to in utero/birth trauma. extremely rare etiologies in the neonate include epidermoid/dermoid, cavernous malformation, intranatal cystic infections etiologies, neuroepithelial cysts, and cystic neoplasms. mimics include diastematamyelia, spinal lipomas, and intramedullary hematomas. numerous imaging examples of these lesions are provided in the accompanying poster. brain mri in peroxisomal disorders: a pictorial essay bruno p. soares, md, radiology and biomedical imaging, university of california at san francisco, bruno.soares@ucsf. edu; leonardo vedolin, guido gonzalez purpose or case report: our presentation aims to illustrate the brain mri patterns in peroxisomal disorders. peroxisomes are intracellular organelles involved in important cellular processes including beta-oxidation of very-longchain fatty acids and plasmalogen production. peroxisomal disorders can be categorized into disorders of peroxisomal biogenesis, in which the peroxisomes are abnormally formed and several peroxisomal functions are deficient, and in defects involving a single peroxisomal function, in which the structure of the peroxisome is intact. disorders of peroxisomal biogenesis include zellweger syndrome, neonatal adrenoleukodystrophy, infantile refsum disease and rhizomelic chondrodysplasia punctata. numerous disorders are caused by loss of a single peroxisomal function including x-linked adrenoleukodystrophy and acyl-coa oxidase deficiency. clinical findings in peroxisomal disorders include dysmorphic features, hepatic dysfunction, neurodevelopmental delay, retinopathy and hearing impairment. methods & materials: pictorial essay illustrating brain mri patterns in peroxisomal disorders, including disorders of peroxisomal biogenesis and disorders with loss of a single peroxisomal function. results: brain abnormalities in peroxisomal disorders have a wide spectrum of patterns. neuronal migration disorders with abnormal myelination are typically seen in zellweger disease and neonatal adrenoleukodystrophy. specifically, the association of abnormal myelination with germinolytic cysts is suggestive of zellweger syndrome. classic x-linked adrenoleukodystrophy typically shows posterior central white matter involvement and symmetric demyelination also involving the corticospinal tracts and corpus callosum. a similar pattern of white matter involvement is seen in acyl-coa oxidase deficiency and infantile refsum disease. conclusions: brain mri helps narrow the differential diagnosis and guides subsequent evaluation in infants presenting with clinical features concerning for peroxisomal disorders. therefore, knowledge of the brain mri patterns in peroxisomal disorders is important for the radiologist interpreting neuroimaging studies. clots in tots: role of imaging in diagnosis of acute stroke and its causes in children asif abdullah, c.s. mott children's hospital of the university of michigan, asifa@med.umich.edu; ellen hoeffner, augusto elias purpose or case report: stroke is a major cause of morbidity and mortality in children. long-term neurologic deficits occur in % to % of infants and children after arterial ischemic stroke. limited awareness regarding pediatric stroke among physicians and in general community is a major concern. imaging plays crucial role in the diagnosis of pediatric stroke. the goal of this presentation is to provide awareness to the reader about the role of imaging in childhood stroke and its myriad causes in children. we will provide a case based approach to imaging diagnosis of acute pediatric stroke based on three categories: ( ) arterial ischemic stroke, ( ) cerebral venous thrombosis, and ( ) hemorrhagic. arterial ischemic stroke (ais) is classified according to the pediatric stroke classification (psc). psc includes eight subtypes of ais: ( ) sickle cell disease, ( ) cardioembolic disease, ( ) moyamoya syndrome, ( ) cervical arterial dissection, ( ) stenoocclusive cerebral arteriopathy, ( ) other determined etiology, ( ) multiple probable etiologies, and ( ) undetermined etiology. we will describe the role of computed tomography (ct) and magnetic resonance imaging including angiography (mri/mra) in identifying these causes in relation to available clinical data. the etiologies of cerebral venous thrombosis related infarction would be discussed from an imaging perspective with a case-based approach with emphasis on mrv and swi techniques. finally, we will focus on hemorrhagic causes of childhood stroke such as vascular malformation, aneurysm, neurocutaneous disorders, coagulopathy, and a variety of other causes from an imaging standpoint. perfusion imaging in pediatric stroke demonstrates flow within the brain and can detect areas that are at risk of ischemia; however, further studies in the pediatric population need to be validated for the role of this technique in pediatric stroke. results: the most important factors in the diagnosis of childhood stroke are causal investigation, appropriate laboratory tests, and imaging studies. imaging is frequently the first step in the evaluation of an acutely ill child. conclusions: pediatric stroke is a debilitating disease that requires urgent multidisciplinary approach for diagnosis and treatment. in cases of both ischemic and hemorrhagic origin, the radiological approach to be obtained in emergency setting leads to the initial screening and the first therapeutic possibility. methods & materials: this exhibit will illustrate the characteristic imaging findings of vascular anomalies in the head and neck region. vascular anomalies are divided into vascular tumors and vascular malformations which include slow flow malformations (capillary malformations, venous malformations, lymphatic malformations and their combinations) and high flow malformations (arteriovenous fistula and arteriovenous malformations). complex malformations are also seen in several syndromes including klippel-trenaunay syndrome, phace syndrome, etc. cases from author's database will be used for illustration. results: a review of clinical manifestations, characteristic imaging findings and interventional treatment strategies in cases of head and neck vascular anomalies will be presented with pre and post treatment imaging features. ultrasonography and mri are the mainstay in diagnosis of these malformations. ct scan and catheter angiography may occasionally be needed for diagnosis and treatment planning. various imaging findings and main treatment options will be listed. conclusions: head and neck vascular malformations are common in pediatric population. understanding the characteristic imaging findings and clinical presentation is essential in evaluating the vascular malformations. interventional procedures are generally the preferred treatment modality, either alone or in association with surgery in majority of these cases. isolated cortical diffusion restriction in pediatric brain mri ihsan mamoun, md, cleveland clinic, ihsanmamoun@ yahoo.com; sarah stock, s. pinar karakas, unni udayasankar, janet r. reid purpose or case report: diffusion-weighted imaging continues to emerge as a powerful neuroimaging tool. isolated cortical restricted diffusion is a particularly striking pattern with specific differential in the pediatric population. we aim to review this specific imaging pattern supplemented by case examples and key physiologic and imaging concepts. methods & materials: review the concept of diffusion restriction a) pathophysiology b) specific imaging appearances pictorial review of pediatric conditions that lead to cortical restricted diffusion: a) post ictal change b) infection-i. meningoencephaliitis ii. herpes c) hypoxic ischemic injury d) infarct: venous and arterial e) posterior reversible leukoencephalopathy f) mitrochondrial cytopathy g) metabolic: hypoglycemia. discuss certain artifacts. summary table and differential clues conclusions: the pattern of isolated cortical restricted diffusion has specific differential diagnosis in the pediatric population. the radiologist should be aware of this as use of dwi continues to grow. this exhibit with familiarize the reader with common conditions that specifically affect the cortex and produces true restricted diffusion. methods & materials: high resolution ct scan and mri are mainstay of diagnosis and assessment in patients with sensorineural hearing loss. in this exhibit we will present a pictorial review of ct scan and mri images of various causes of sensorineural hearing loss (snhl) that are seen on imaging. reviewing the embryologic basis of these anomalies would enable better understanding of this complex subject. results: the new system classifies these malformations according to descending order of severity into complete labyrinthine aplasia, cochlear aplasia, common cavity, cystic cochleovestibular malformation or incomplete partition-i (ip-i), cochleovestibular hypoplasia, and incomplete partition-ii (ip-ii). there is a lot of confusion in literature pertaining to mondini deformity. the new classification divides incomplete partition into ip-i representing cystic cochleovestibular malformation and ip-ii representing the classic mondini deformity with three components (cystic cochlear apex, dilated vestibule, and large vestibular aqeduct). recently a subclassification of ip-i and ip-ii has been proposed (subdividing into typical and atypical subtypes)[ ]. this will be discussed briefly. isolated large vestibular aqueduct without associated cochlear abnormalities will also be discussed. we will discuss the relevant embryology with correlations of malformations to the timing of embryologic insult. conclusions: the new classification system provides precision in description of inner ear malformation. this also helps in providing a uniform scale for comparison of effectiveness of cochlear implant for different malformations. purpose or case report: congenital cranial nerve anomalies often present as sensory and/or motor deficits of unknown etiology in the pediatric age group. the early recognition of a definitive cranial nerve abnormality using high-resolution imaging can focus further clinical investigation and shorten the time to diagnosis. methods & materials: to promote appropriate recognition of cranial nerve anomalies, we present the imaging findings of the most commonly affected cranial nerves and provide correlation with clinical presentation. all studies were performed on a . t magnet with dedicated high resolution imaging of cranial nerve exit zones. results: ours is a tertiary care pediatric hospital with an extensive neuroimaging database. we intend to review all known cases of cranial nerve anomalies from the prior years and present interesting and representative images including optic nerve hypoplasia as part of septo-optic dysplasia, kallman syndrome, duane retraction syndrome, and mobius syndrome. conclusions: congenital cranial nerve anomalies present with varied symptomatology including anosmia, impaired vision, occulomotor deficits, and hearing loss. additionally, clinical manifestations of cranial nerve anomalies can be difficult to recognize in the pediatric age group. effective imaging and prompt diagnosis is crucial to initiate appropriate clinical management. purpose or case report: mr is the standard for evaluation of tumors or epilepsy. pet-ct imaging is often performed to ascertain metabolic asymmetries related to epileptogenic regions or to better characterize the metabolic activity of tumors. a baseline for normals with pet-ct fdg- and c methionine does not exist. methods & materials: retrospective review was performed of the pediatric patients who underwent pet-ct with c methionine and fdg. representative studies were selected for patients imaged during infancy (< yr), early childhood ( - ), childhood ( - ), late childhood ( - ), teenage ( - ). c methionine and fdg studies were analyzed for normal patterns of uptake and any trends identified across the stratified age groups. representative pictorial image galleries of the c methionine and fdg imaging patterns through development were created. results: the pattern of radiotracer uptake on c methionine differed from that of fdg. the c uptake remained low level throughout development compared to fdg uptake, which was robust in much of the cortex. the cortical fdg uptake within the frontal lobes progressively increased with age. the c uptake within the brainstem and thalamus was equal to cortex throughout development. the fdg uptake within the basal ganglia was equal to cortex while the brainstem and thalamic uptake was generally less than cortex. several anatomic structures showed robust c uptake not seen on fdg. these included the lacrimal, submandibular and parotid glands. incidentally, the pituitary gland and hippocampus consistently showed c uptake equal to cortex contrary to their appearance on fdg. our institutional protocol regarding the performance of combination c methionine and fdg brain pet-ct studies is presented. conclusions: this study illustrated the normal appearance of brain pet-ct imaging performed with c methionine and fdg in a representative cohort of the pediatric patients through development. normal variance imaging patterns and developmental trends seen with each radiotracer was demonstrated. the pediatric cerebellum: a pictorial review of normal anatomy using mri and diffusion tensor imaging ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; sumit singh, teresa c. gross kelly, mohit maheshwari, tushar chandra, hervey d. segall purpose or case report: the aim of this educational exhibit is to illustrate normal anatomical and functional anatomy of the cerebellum in the pediatric patient. the cerebellum receives sensory input from the brain and spinal cord and integrates this information to coordinate motor control. in addition, the cerebellum also plays a role in some cognitive functions such as attention and language. the first step toward understanding how cerebellar abnormalities can lead to neurological dysfunction, is to provide a solid understanding of the neuroanatomy and functional pathways of the cerebellum. we will describe basic cerebellar embryology, the various cell types and gross anatomy using mr images as well as dti fiber tractography. methods & materials: this exhibit will describe the microstructure, gross anatomy and functional pathways of the cerebellum through illustrations, mr images, diffusion tensor imaging (dti) and pathological correlation. first embryology of the cerebellum will be described, followed by mri depiction of the developmental anatomy of the cerebellum from infancy through adolescence. finally dti tractography images will be used to delineate functional pathways to and from, as well as within, the cerebellum. pathological specimens will be photographed to further illustrate gross anatomy. results: afferent white matter pathways travel mainly via the inferior and middle cerebellar peduncles. the main efferent cerebellar white matter pathway is through the superior cerebellar peduncle. transverse fiber tracts are present in the vermis. there are mainly two main systems of cerebellar white matter fibers which are easily visualized with dti color mapping; however more anterior components of dti tracts are intermixed with afferent white matter projections following the middle cerebellar peduncle. conclusions: knowledge of the precise neuroanatomy and white matter tracts of cerebellum may elucidate our ability to comprehend the clinical manifestations of cerebellar diseases in children. a solid understanding of normal cerebellar anatomy, development and functional fiber tracts in the pediatric patient can provide a baseline that may help predict the clinical outcome of various diseases or interventional procedures. gastroesophageal reflux scintigraphy: a low radiation alternative to gerd evaluation in children vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; feraas jabi, jan najdzionek, vaseem iqbal purpose or case report: gastroesophageal reflux disease (gerd) is among the common causes for failure to thrive, recurrent cough and aspiration in children. early diagnosis of gerd is essential in avoiding long-term sequelae such as growth delay, chronic lung disease, esophageal stricture, and esophagitis. gastroesophageal reflux scintigraphy, a noninvasive imaging modality, has been applied for detection of gerd and gastric emptying in children over the past few decades. the radiation burden is considerably small given that a very low dose of radioactivity via a short half-life radioisotope like technetium- m tagged to oral sulfur colloid is administered to a patient. this feature makes reflux scintigraphy especially attractive as the patient can be scanned for prolonged and delayed periods without increasing radiation dose permitting not only identification but also assessment of severity of gerd. characterizing gerd severity is essential in determining how aggressive the pediatrician should be with therapy. gastroesophageal reflux scintigraphy also allows a child to be fed their regular meal tagged to radiopharmaceutical without altering food taste. qualitative and quantitative parameters like gastrointestinal transit and gastric emptying time can be measured, respectively. scintigraphy is highly sensitive to low grade reflux making it very desirable for monitoring response to therapy. while scintigraphy like all other imaging modalities,has limitations, it continues to be an excellent technique for gerd identification and characterization as well as in monitoring response to gerd therapy. the pediatric kidney-a review of common and uncommon renal anomalies ruby lukse, staten island university hospital, drjosemorey@gmail.com; josé morey, jeremy neuman, arnold brenner, oren herman, adam bernheim purpose or case report: renal parenchymal imaging in nuclear medicine has long been performed with mtcdimercaptosuccinic acid (dmsa) due to its sufficient binding to the renal tubules to permit renal cortical imaging. dmsa is of particular value when high-resolution images of the renal cortex are needed. this poster will be a pictorial review of common and uncommon congenital anomalies evaluated on dmsa imaging, such as horseshoe kidney, pelvic kidney, sshaped kidney and crossed-fused ectopia. the poster will also correlate planar imaging findingss with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), fluoroscopic imaging and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). purpose or case report: in this poster we will review the differential diagnoses of congenital anomalies that give the appearance of hydronephrosis on renal imaging of the pediatric patient. we will show a pictorial review of both common and uncommon congenital anomalies such as congenital megaureter, ureterocele, uretero-pelvic junction (upj) obstruction, uretero-vesicular junction (uvj) obstruction and posterior urethral valves (puv). we will also review common mimickers of hydronephrosis such as multicystic dysplastic kidney (mcdk) and pseudo-obstruction secondary to bladder overdistention. the poster will also correlate planar imaging finds with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), fluoroscopic imaging and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). the pediatric bone scan-a review of neoplastic pathology shrita smith, staten island university hospital, drjosemorey @gmail.com; josé morey, jeremy neuman, arnold brenner, daniel klein, purpose or case report: bone imaging continues to be the second greatest-volume of nuclear imaging procedure performed today, offering the advantage of total body examination, low cost, and high sensitivity. the diagnostic utility, sensitivity, specificity and predictive value of m-tc bone imaging of malignant conditions have long been established. in fact, more than , , bone scans were performed in the united states in . in this poster we will review the current indications for planar bone imaging for the evaluation of malignant and benign neoplasms in the pediatric population, such as osteoid osteoma, langerhan cell histiocytosis (lch), osteoblastoma, ewing's sarcoma, lymphoma, osteosarcoma and osseous/hepatic metastatic disease from neuroblastoma. the poster will also correlate planar and single-photon emission computed tomography (spect) imaging findings with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography (pet), and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). the many faces of duplex kidneys on dmsa scans-a pictorial essay neha kwatra, children's national medical center, nskwatra@childrensnational.org; massoud majd purpose or case report: renal duplication is the most common malformation of the urinary tract and is often seen in children with urinary tract infections (uti). the purpose of this study is to learn to recognize duplex kidneys on dimercaptosuccinic acid (dmsa) scintigraphy, review their entire spectrum of findings and correlate with other imaging modalities. methods & materials: dmsa scintigraphy is routinely performed in the nuclear medicine department with a single-head gamma camera (siemens e.cam, schaumberg, illinois). about . h after injection of dmsa, posterior and posterior oblique images are obtained using parallel and pin hole collimators. differential renal function is also calculated. dmsa scan reports containing the words "duplex" or "duplicated" from - were populated using a radiology search engine (montage health care solutions inc.). the images were then reviewed in pacs and representative examples were selected for the poster. the scans were evaluated for renal position, size, contour, any evidence of duplication and parenchymal damage. results: patterns of duplication included non complicated duplex kidney recognized by asymmetric renal size and a prominent cortical bar separating the two moieties, complicated duplex systems with hydronephrosis, scarring or pyelonephritis of one or both moieties. a small nonfunctioning upper moiety was sometimes evidenced by just an indentation along the superomedial aspect of the larger lower moiety. cases with bilateral duplex kidneys were also seen. illustrative examples of each will be provided. correlating findings on other imaging modalities will also be included. conclusions: establishing the diagnosis of duplex kidney on a dmsa scan requires a careful systematic review of the images. the findings can be subtle and it is important for the radiologist to recognize them. correlation with other modalities such as ultrasound or voiding cystogram can be complementary. the assessment of parenchymal function of the upper and lower moieties separately on dmsa scintigraphy can be of immense value in patient management and in choosing surgical options. poster #: edu- f-fdg pet/ct imaging of pediatric brain tumors, neurofibromatosis (nf ) and non-lymphomatous head and neck tumors. lisa states, md, radiology, chop, states@email.chop.edu; purpose or case report: this educational poster will review the current literature and summarize the value of f-fdg pet/ct in standard clinical practice in the evaluation of pediatric brain tumors, nf plexiform neurofibromas and malignant peripheral nerve sheath tumors, and nonlymphomatous head and neck tumors. normal variants and pitfalls will be reviewed. comparison with other pet tracers will be briefly discussed. case examples will be used to illustrate the value of f-fdg pet/ct in grading, staging, assessment of therapeutic response and detection of residual or recurrent disease in various pathologic entities. results: examples of cases will include: benign brain tumor, residual brain tumor in the post-operative bed, brain metastasis, malignant peripheral nerve sheath tumor in nf , head and neck rhabdomyosarcoma, mandibular osteosarcoma, and infection. conclusions: an understanding of the value of pet molecular imaging is essential to the success of the next phase of hybrid imaging with pet/mri which has the potential to play an important role in the development of new diagnostic and therapeutic approaches for the treatment of pediatric brain tumors, nf , and pediatric head and neck tumors. disclosure: dr. states has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the pediatric bone scan-a review of non-malignant pathology josé morey, staten island university hospital, drjosemorey@ gmail.com; jeremy neuman, arnold brenner, vinh phan, cheryl lin purpose or case report: bone imaging continues to be the second most performed nuclear imaging procedure, offering the advantage of total body examination, low cost, and high sensitivity. the diagnostic utility, sensitivity, specificity and predictive value of m-tc bone imaging of benign conditions have long been established. in fact, more than , , bone scans were performed in the united states in . in this poster we will review the current indications for planar bone imaging for the evaluation of non-malignant diseases in the pediatric population, such as acute osteomyelitis secondary to salmonella enterobacteriaceae and tubercle bacillus (tb), chronic osteomyelitis, reflex sympathetic dystrophy, spondylolysis, bone infarcts in the setting of sickle cell disease, fractures (occult/stress), ankylosing spondylitis, dermatomyositis and non-accidental trauma. the poster will also correlate planar and single-photon emission computed tomography (spect) imaging findings with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography (pet), and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). purpose or case report: we review the radiologic features of pathologic conditions linked to diesel exposure. the hydraulic fracturing ("fracking") technique is increasingly used in many areas of the country to extract natural gas from rock formations. diesel fuel, or fluids containing diesel, are one component of fracking fluid and create a potential for ground water contamination and risk to air quality. the toxic effects of diesel exhaust are described in the literature, and include asthma, hydrocarbon pneumonitis, and leukemia. there are no scientific data currently available on the effects of chronic diesel ingestion. methods & materials: multi-modality examples of pathology were obtained from a radiology database at a tertiary care pediatric hospital. the specific cases displayed are not known to have diesel exposure, but are intended to serve as representative examples of the type of pathology that may be encountered in the setting of chronic diesel exposure. results: imaging findings of asthma include hyperexpansion, atelectasis, peribronchial thickening, and air-trapping. hydrocarbon pneumonitis may demonstrate low attenuation consolidation and subsequent pneumoatocoeles with ct. leukemia may present on plain radiographs with lucent metaphyseal bands and with marrow infiltration on mri. conclusions: in conjunction with other symptoms not necessarily evaluated in the radiology department, including rhinitis, laryngitis, acute coronary syndrome, and dementia, the radiologist may suggest the diagnosis of diesel toxicity, particularly in populations that may be at high risk of exposure. pediatric radiology in the philadelphia region: a historical review* richard markowitz, md, children's hospital of philadelphia, markowitz@email.chop.edu purpose or case report: the specialty of pediatric radiology in the philadelphia region has grown and evolved over the past eight decades originating from early "visiting" radiologists to drs. hope and kirkpatrick, the "giants" of the s and ' s, to over fifty practicing pediatric radiologists today. clinical excellence, commitment to teaching, and advancement of knowledge through research remain the goals and ideals, much as they were many years ago. philadelphia has been a fertile home and environment for this evolution, mostly because of outstanding leaders and role models who have trained and influenced generations of pediatric radiologists. developments and leadership at the children's hospital of philadelphia, st. christopher's hospital for children, and a.i. dupont institute are highlighted. the purpose of this poster is to tell the story of the growth and development of pediatric radiology in this area and to explore the intellectual origins, professional "genealogy," and legacies left by those who created and those who have carried on this tradition. *note: this material is based on a previously published article: pediatric radiology ( ) : - and "addendum" (pediatric radiology : - ), but never presented at spr. superficial lumps and bumps henrietta k. rosenberg, md, radiology, the mt. sinai medical school, henrietta.rosenberg@mountsinai.org; diane belvin, neil lester purpose or case report: superficial soft tissue masses in the pediatric age range can be quite challenging to the pediatrician and the imager. the purpose of this presentation is to demonstrate the efficacy of duplex/color doppler ultrasound for the diagnosis and follow up of a large gamut of superficial lumps and bumps. methods & materials: we reviewed our experience during the past years using ultrasound to evaluate superficial soft tissue masses that had been encountered in many parts of the body, from the skull to the soles of the feet, in a large group of patients ranging in age from newborn to years. all sonograms were performed after obtaining pertinent clinical information as well information regarding the clinical characteristics of each of the masses, e.g. location, consistency (firm [solid], compressible [cystic]), fixed or easily movable, smooth or irregular surface, tenderness. the masses were palpated by the imaging team and duplex/color doppler ultrasound was performed. comparison sonographic views of the opposite side were obtained as needed. clinical followup and surgical/pathological correlation was obtained in most of the patients. results: most of the masses were benign and included a wide variety of etiologies. most often, us was sufficient for assessment of soft tissue masses if the entire mass was included in the field of view. if the lesion was too large for the field of view or malignancy was suspected, ct/mri were required preoperatively. nuclear medicine studies are reserved for midline masses likely due to ectopic thyroid and pet was used for more complete evaluation of a lesion that was likely malignant. conclusions: duplex/color doppler ultrasound (us) is the modality of choice for evaluation of superficial lumps and bumps! this modality allows for rapid acquisition of information without the use of ionizing radiation, intravenous contrast material, or sedation/anesthesia. reliable information can be rapidly acquired regarding the size, shape, borders, location, internal consistency, vascularity, vascular encasement/displacement. correlation of the ultrasound and clinical findings helps narrow differential diagnosis. sonography helps to determine what is the next best step: watchful waiting (clinical observation, follow-up us), surgical resection, or us guided interventional procedure. present day imaging of down syndrome rupa radhakrishnan, md, radiology, university of cincinnati college of medicine, radhakrp@ucmail.uc.edu; alexander j. towbin purpose or case report: down syndrome is a common genetic condition characterized by unique physical traits and multisystem anomalies. the purpose of this exhibit is to portray the imaging findings of down syndrome and discuss with illustrative examples, the use of imaging in multidisciplinary management. methods & materials: published literature was reviewed to identify the multisystem imaging findings in down syndrome. the electronic medical record system was then searched to find illustrative case examples from our institution. results: in patients with down syndrome, abnormalities can be found in the musculoskeletal, cardiovascular, respiratory, gastrointestinal, and central nervous systems. abnormalities can range from emergent, life threatening conditions such as malrotation with midgut volvulus to chronic conditions such as scoliosis. examples of abnormalities from each organ system and the modalities used for diagnosis and management are described. cardiovascular system: echocardiogram and cardiac mri and ct are useful in evaluating congenital heart disease associated with down syndrome. respiratory system: micrognathia with macroglossia and hypotonia predisposes patients to sleep apnea which can be evaluated with dynamic mri. chest ct demonstrates subpleural cysts which are characteristic of this syndrome. gastrointestinal system: fluoroscopy and/or radiographs are the mainstay in diagnosing many gastrointestinal disorders including duodenal atresia, malrotation, annular pancreas, imperforate anus, and hirschsprung disease. central nervous system: choroid plexus cysts may be identified on prenatal ultrasound in a fetus with down syndrome. imaging is used in the evaluation of epilepsy, hearing loss and alzheimer disease that is more common in these individuals. musculoskeletal system: multiple skeletal anomalies can be present in patients with down syndrome. radiographs are often used as the method of identifying and, if needed, following the anomalies. prenatal imaging: increased nuchal translucency is the earliest imaging finding. other features of down syndrome can be identified on prenatal ultrasound or mri. prenatal imaging is helpful in determining the prognosis of the fetus and in guiding management. conclusions: modern day multidisciplinary management has improved quality of life and survival in individuals with down syndrome. imaging plays a critical role in guiding management in these individuals. imaging the spectrum of lymphatic malformations in the pediatric patient andrew schapiro, md, radiology, university of wisconsin, aschapiro@uwhealth.org; kara gill, bradley maxfield purpose or case report: lymphatic malformations (lm) occur as a result of abnormal development of the lymphatic system during embryogenesis. as % of lm present by years of age, these lesions represent an important pediatric entity. lm can often be suspected clinically in an infant with the classic presentation of an asymptomatic, soft mass in the head, neck, or axilla. however, myriad presentations are possible as lm occur in numerous other anatomic locations, can be multiple, and can be a component of mixed vascular malformations. in addition, the true extent of lm is often not apparent clinically. given these considerations and the implications for proper management, imaging plays an important role in the assessment of lm. the purpose of this exhibit is to review the spectrum of radiographic, ct, sonographic, and mr imaging findings of a variety of lm presentations. methods & materials: cases of lymphatic malformation in pediatric patients identified at a single institution over the past ten years with available imaging were reviewed utilizing pacs. results: images of lm involving the head and neck, chest, abdomen, retroperitoneum, extremities, and skeletal system were identified. in addition, cases of lymphangiomatosis and mixed venolymphatic malformation were identified. various imaging modalities including radiography, ct, sonography, and mr were represented. conclusions: adequate knowledge of the imaging characteristics of lm across multiple modalities enables proper diagnosis, assessment of disease extent, and guidance of appropriate therapy in pediatric patients. results: ct and mr imaging findings in nine cases will be presented. they include ) congenital absence of the inferior vena cava with thrombosis of the external iliac vein secondary to venous stasis ) pyelophlebitis complicating ruptured appendicitis ) left iliac vein thrombosis in a patient with may-thurner syndrome ) splenic vein thrombosis complicating pancreatitis ) splenic vein thrombosis following splenectomy ) renal vein thrombosis in an infant of a diabetic mother ) adrenal vein thrombosis as the presenting sign of antiphospholipid syndrome ) budd-chiari syndrome associated with underlying myeloproliferative disease ) iliac vein thrombosis as a manifestation of behcet's syndrome (hughes-stovin syndrome, a variant of behcet's syndrome, which presents with systemic venous thrombosis and pulmonary artery aneurysms will also be discussed). conclusions: thrombosis of large abdominal and pelvic veins in children and adolescents is uncommon. certain conditions, both congenital and acquired, predispose to the development of venous thrombosis. ct/mr imaging defines the extent of thrombosis, and demonstrates additional findings that may elucidate the nature of the underlying condition leading to clot formation. purpose or case report: because abnormal gait in a young child has a wide range of causes, imaging plays a critical role in establishing the definitive diagnosis. the purpose of this exhibit is to review the clinical clues (age, duration, laboratory markers) and imaging findings of the causes of abnormal gait in a toddler and to assess the strengths and limitations of radiographs, ultrasound, magnetic resonance imaging (mri), and computed tomography (ct). methods & materials: cases, from a single institution experience with various causes for abnormal gait in a toddler, are reviewed and categorized into congenital, traumatic, inflammatory, neoplastic, or neuromuscular etiologies. results: there are various causes of abnormal gait in a toddler. the congenital causes include spinal dysraphism, proximal and distal skeletal deformities and dysplasias. the traumatic causes include non-accidental trauma, toddler's fracture, foreign body, and soft tissue injuries. the inflammatory causes include juvenile idiopathic arthritis, transient synovitis, and infection, including osteomyelitis, septic arthritis, discitis, cellulitis, and abscess. the neoplastic causes include various neurogenic, bone, and soft tissue tumors. the neuromuscular causes include cerebral palsy and spinal bifida. the combination of clinical presentation, supporting laboratory findings, and classic imaging findings help to distinguish the possibilities and often allows confident diagnosis. conclusions: knowledge of imaging findings and clinical factors can demystify the diagnosis of abnormal gait in a toddler. familiarity with the clinical presentation can ensure the performance of the appropriate diagnostic studies, timely diagnosis, and effective treatment. nonaccidental causes should never be overlooked. ultrasonography has become an important tool in the radiologist's armamentarium, augmenting radiography, mri, and ct. approximately different contrast agents for mri and ct are now commercially available for use. although most of them are fda approved in adults, information on usage and safety in children is not readily available. the most important reason is lack of controlled studies in children, especially for the age of - years. however, the lack of fda approval has not limited the use of these promising agents in children. in fact, there is widespread off-label use of these agents in most major pediatric hospitals in the country. based on a review of relevant literature in children, and based on a survey of radiology faculty at major pediatric hospitals, this poster will address the gap between approved use and reality in the setting of pediatrics. results: using a tabular format, this poster will provide a list of mr and ct contrast agents that are available for clinical use, their relevant clinical properties (ionic or nonionic, viscosity, linear or macrocyclic, degree of relaxivity for mri, iodine concentration for ct, cost, dosage, halftime, incidence of allergic reactions, nephrogenic systemic fibrosis and other adverse reactions), fda approval status (for ages - days, days- years, and - years), common pediatric applications, and contrast injection protocols for common applications. conclusions: to enlighten imaging personnel about usage and safety of contrast agents in children. disclosure: dr. krishnamurthy has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. a pictorial essay and literature review of the spleen in sickle cell disease david hindson, md, boston medical center, david. hindson@bmc.org; heather imsande, philippa sprinz, ilse castro-aragon purpose or case report: the morbidity and mortality of sickle cell disease (scd) results from acute and chronic infarction events that affect almost every organ. repeated infarction has some of its greatest visual and physiologic impact within the spleen. continuous hemolysis, sequestration and vaso-occlusion within the spleen result in loss of splenic function early in life and frequently autosplenectomy thereafter. by years of age, approximately % of children with hemoglobin ss disease will have diminished splenic function, putting them at increased risk for infections. treatments for scd have evolved over the last years, and among others include penicillin prophylaxis and immunizations, hydroxyurea and transfusion therapy (or hypertransfusion program). imaging findings are a reflection of the different treatments and their efficacy. methods & materials: our institution cares for a large group of patients with sickle cell disease, from birth to adulthood. this offers an unprecedented opportunity to document the imaging findings of the spleen with different treatment regimens, and over many years. the splenic size and morphology can be followed, by ultrasound, in a very straightforward way. we have compiled a pictorial essay of the various imaging characteristics of spleens from infants to adults. we also performed a literature review to compare and supplement the findings of our images. results: there is a spectrum of imaging findings in the spleen of patients with scd that changes from birth to childhood. the findings range from the normal appearance of a spleen to a calcified spleen, and include regenerative nodules, fibrosis, altered parenchymal echotexture, increased echogenicity, and changes in size, including enlargement secondary to sequestration. the ultrasound characteristics not only change with advancing age, but also appear to depend on whether or not the patient has received specific treatments, and at what age treatment was initiated. conclusions: the ultrasound appearance of the spleen in patients with scd is variable. treatments such as blood transfusions and hydroxyurea, patient compliance with therapy and type and severity of the disease are some of the factors that affect imaging characteristics. cystic fibrosis: not just for children cindy miller, md, radiology, yale-new haven hospital, cindy.miller@yale.edu purpose or case report: cystic fibrosis has been recognized for hundreds of years with the first descriptions of it including such anecdotes as mothers licking the foreheads of their children and knowing that if it tasted salty, an early death could be predicted. it was not until that the disease was first named by dr. dorothy andersen, and for the following years, treatment was largely supportive, and imaging was essentially done with plain films alone. in with the elucidation of the cftr gene, there was an explosion of knowledge which included the range of increased awareness and understanding of the suspected etiology, imaging findings and significance of the ductus bump. the contribution of d imaging for evaluation of the pediatric central airways jessica kurian, md, the children's hospital of philadelphia, kurianj@email.chop.edu; monica epelman, david a. mong purpose or case report: evaluation of the central airways in children has historically been accomplished by flexible bronchoscopy, an invasive technique associated with inherent risks and complications. multidetector ct (mdct) with volume rendering offers a noninvasive alternative for airway evaluation. in this educational exhibit, we will review imaging techniques and clinical applications of mdct for the assessment of large airway maladies in children. methods & materials: mdct imaging in children with a variety of tracheobronchial disorders is reviewed. for each entity, the characteristic clinical features are described, and key imaging features are illustrated. emphasis is placed on the contribution of d techniques for characterizing complex airway anomalies. dose reduction strategies are also highlighted. results: the entities reviewed in this exhibit include, but are not limited to, congenital anomalies of tracheobronchial branching, airway malformations associated with situs, and congenital or acquired airway compression and/or obstruction. conclusions: mdct with volume visualization is a useful adjunct for evaluation of the pediatric central airways in a variety of pathologies. as a noninvasive technique, it avoids sedation risks and spare patients from complications associated with conventional flexible bronchoscopy. low dose protocols should be used to minimize radiation exposure. bronchopulmonary foregut malformation that result from abnormal budding of the primitive foregut. currently, many such anomalies are initially detected by prenatal ultrasound and are further delineated by fetal magnetic resonance imaging (mri), while others may be incidentally detected on postnatal radiologic examinations or later in life in the setting recurrent pulmonary infection. imaging plays a very important role in the diagnosis and characterization of these lesions and assists surgical planning. the purpose of our educational exhibit is to illustrate the common and uncommon radiologic appearances of cpams using various imaging modalities, including radiography, computed tomography, prenatal and postnatal ultrasound, and prenatal and postnatal mri. methods & materials: all pediatric and adult cpam (including both sequestration and ccam) patients were identified using electronic medical records. pertinent imaging reports (including radiography, prenatal and postnatal ultrasound, ct, and prenatal and postnatal mri) were reviewed by a single author in order to identify relevant imaging findings. relevant images from these imaging examinations were de-identified and saved to a secure hard drive. medical records were accessed by a single researcher to obtain relevant demographic information as well as data regarding the patients' clinical presentations. in cases of corrective surgery, operative and pathology reports were reviewed, if available, for correlation with the imaging findings. results: cases of pediatric and adult cpam were identified and presented in a variety of clinical contexts. their appearances were reviewed through multiple imaging modalities. conclusions: congenital pulmonary airway malformations are varied in their clinical presentation and imaging appearance. the purpose of this pictorial essay is to enhance understanding of their diagnosis and to use a multidisciplinary approach in order to highlight imaging aspects that may alter clinical management. disclosure: dr. horst has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the imaging evaluation of cystic lung disease in children: an evidence-based approach jordan caplan, md, pediatric radiology, lucile packard children's hospital, stanford university, caplan@stanford. edu; beverley newman purpose or case report: the goal of the poster is to provide a framework for use when confronted with cystic lung disease in a child. methods & materials: the differential diagnosis for the types and causes of cystic lung disease in children will be presented using an evidence-based, age appropriate approach. categories of disease discussed and illustrated with case examples will include: a. congenital cystic bronchopulmonary malformations b. infectious cysts c. autoimmune/inflammatory/vasculitic disease with cavitating lesions d. neoplastic conditions e. collagen/soft tissue abnormalities f. mimics of cystic lung disease results: the pathophysiology, imaging appearance, and demographics of the above entities will be reviewed with attention to relevant recent literature. important educational points include the differentiation of bronchopulmonary malformations from neoplasm, notably pleuropulmonary blastoma (ppb), the relationship between lung cysts and ppb, and the management and surveillance of lung cysts in children. conclusions: an evidence-based approach to the broad spectrum of causes of cystic lung disease in children is a useful starting point in forming a concise and pertinent differential diagnosis. an understanding of the pathophysiology, imaging appearance, and demographics of these entities is essential in guiding patient management. pediatric interstitial lung disease (ild): a pictorial review with radiologic and pathologic correlation hollie west, md, diagnostic radiology, vanderbilt university, hollie.c.west@vanderbilt.edu; melissa a. hilmes, sudha p. singh, jennifer soares, lisa young purpose or case report: while adult interstitial lung disease is a well-described and fairly well understood group of disease processes, pediatric interstitial lung disease (ild) remains a subject of uncertainty and misunderstanding for many clinicians and radiologists. confusion surrounding the phenomenon of pediatric ild stems not only from the rarity of the disease, but also from the extensive list of disease entities that can produce ild, the existence of certain patterns that are restricted to infants and children and the fact that patterns of ild manifest differently in a child's developing lung than in an already developed adult lung. imaging plays an important role in diagnostic work-up of this disease and can guide lung biopsy in specific patient populations. methods & materials: the irb approved retrospective study will show patients at our institution over a year period diagnosed with various types of ild, including pulmonary insterstitial glycogenolysis (pig), diffuse neuroendocrine cell hyperplasia (nehi), surfactant deficiency diseases, and lung diseases associated with other systemic processes such as downs syndrome and inflammatory bowel disease. we will include patients with biopsy proven ild and will provide examples of the major ilds, including clinical, radiologic and pathologic correlation. our pictorial review will describe the radiologic patterns associated with the different forms of ild, emphasizing what the radiologist needs to know and how to be helpful to a multidisciplinary team in the diagnosis and treatment of these diseases. results: the study will report the frequency of ild at our institution, including a breakdown of the various subtypes of ild. we will show examples of the subtypes with correlative chest radiography, computed tomography, and pathology. we plan to highlight specific differentiating factors between the different diseases and demonstrate how a radiologist can be helpful in collborating with clinicians in diagnosing and treating these diseases. conclusions: pediatric ild can be a confusing topic for radiologists. increasing knowledge and awareness of these diseases, their clinincal presentation, work up, and treatment is important for pediatric radiologists who work as part of of a multidiciplinary team. poster #: sci- ct radiation dose delivered by community hospitals and imaging centers stephen little, children's healthcare of atlanta, stephen. little@choa.org; damien grattan-smith, bonnie johnson purpose or case report: to evaluate and compare ct radiation dose for pediatric abdominal and cranial ct examinations performed by community hospitals and imaging centers. methods & materials: consecutive ct examinations ( cranial, abdominal) from community hospitals and imaging centers were reviewed following transfer of care. the examinations were performed between january and july . consecutive ct examinations ( cranial, abdominal) performed at our own institution were also reviewed. ctdivol and dlp were obtained from the dose report for each examination ( cm-phantom for abdominal exams, cm-phantom for cranial exams). patient age and weight were obtained from the medical record. results: average ctdivol for abdominal ct performed by local community hospitals and imaging centers was . mgy, while average ctdivol was . mgy for abdominal ct performed at choa. there was a wide variation in ct radiation dose delivered. while some sites delivered a ct radiation dose comparable to our own, others delivered a substantially greater dose. in fact, % of pediatric abdominal ct exams performed by local community hospitals and imaging centers exceeded the notification value recommended by the aapm ( mgy using the cm phantom). low kvp technique for imaging small children was infrequent. multi-phase examinations were more often performed, resulting in additional elevation in ct radiation dose when dlp is considered. average ctdivol delivered by local community hospitals and imaging centers for cranial ct was mgy compared to a ctdivol of mgy for cranial ct performed at choa. % of pediatric cranial ct exams performed by local community hospitals and imaging centers exceeded the notification value recommended by the aapm ( mgy for - years, mgy for > years). conclusions: despite ongoing efforts at education, there is wide variation in ct radiation dose delivered for pediatric abdominal and cranial ct examinations performed by local community hospitals and imaging centers. appropriate use of dose check software on newer scanners may help reduce the number of children subjected to excessive ct radiation dose. ultimately, each site performing pediatric ct must take responsibility for minimizing radiation dose while producing diagnostic quality exams. the impact of adaptive statistical iterative reconstruction on ct image quality parameters -a phantom study karen thomas, md, radiology, hospital for sick children, karen.thomas@sickkids.ca; nancy ford, angjelina protik, paul babyn purpose or case report: to quantify the effect of adaptive statistical iterative reconstruction (asir) on ct image quality parameters. methods & materials: phantom (catphan ) studies were performed on a ge hd -slice scanner to investigate the impact of a) % asir compared to routine filtered back projection using variable kvp ( - ) and mas ( - ), and b) incremental asir % ( , , , , %), scanning at mas and variable kvp ( - ). pitch, acquisition fov and detector width were kept constant. image noise, spatial and contrast resolution, contrast noise ratio (cnr) and wiener spectrum analysis were performed on . mm ax, mm ax mpr and mm cor mpr series. results: % asir resulted in a mean decrease in noise of % ( . mm ax), % (ax mpr) and % (cor mpr) and improvement in cnr of - %. incremental advantage was seen with stepwise increase in asir %. however, application of asir was associated with a small reduction in spatial resolution ( - % at % asir). low contrast detectability (lcd) improved except at the smallest target lesion size. image quality effects at very low mas and at high asir % will be presented. conclusions: image noise reduction and improvements in cnr and lcd with asir hold considerable potential for dose reduction in pediatric ct. this study provides quantitative data that may be used to design asir-enhanced protocols with consideration of diagnostic task, balancing image quality benefits and potential pitfalls. pictorial essay on cardiac mr for congenital heart disease on t mr scanner with rf multi-transmit technology (tx) taylor chung, md, diagnostic imaging, children's hospital & research center oakland, taylorchung @gmail.com purpose or case report: this is a pictorial essay (e-poster) to show artifacts on cine ssfp images pre-tx and post-tx upgrade on congenital heart disease cardiac mr; to illustrate methods prior to tx-upgrade to minimize artifacts. disclosure: dr. chung has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. revisiting the relationship between anthropometric parameters and left ventricular mass abdullahi adamu, md, phd, ahmadu bello university, scorpion kd@yahoo.com purpose or case report: the purpose of this study was to find the correlation between anthropometric parameters and left ventricular mass in normal adolescents and young adults. methods & materials: healthy individuals in the age range to years ( males and females) were included in this study. anthropometry was performed with standard anthropometry kit and measurements of height, weight, body surface area (bsa), upper arm circumference and upper hip circumference were taken. echocardiography was performed and the american society of echocardiography (ase)-recommended method was employed for calculation of left ventricular mass (lvm). statistical analysis was performed using statistica . (stat soft, usa). results: the mean value of lvm for all our subjects was found to be . ± . g. there was significant correlation between lvm and height (r . , p< . ), weight (r . , p< . ) and bsa (r . , p< . ). correlation with upper arm circumference was moderate (r . , p< . ), while it was found to be weak with upper hip circumference (r . , p< . ). diagnostic. both field strengths can be used successfully for cardiac and vascular imaging. the decision as to which to use is weighted by local availability and the relative requirement for detailed vascular vs intra-cardiac imaging. disclosure: dr. nguyen has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. poster #: sci- color coded d cardiac cta of congenital heart disease: a five year experience nhi huynh, md, radiology, st. joseph hospital and medical center, e.nhihuynh@gmail.com; randy richardson purpose or case report: post-processing of cardiac computed tomography angiograms can be performed on a commercially available workstation to create color coded d volume rendered images of the segmented heart and great vessel anatomy in patients with congenital heart disease. these studies optimally demonstrate complex anatomy, streamlining communication between members of the healthcare team and providing a tool for communicating complex anatomy and treatment options with families. these studies have been ordered with more frequency over the past five years. we retrospectively reviewed the types of congenital heart disease demonstrated by cardiac d cta over the past five years at a congenital heart center. methods & materials: color coded cardiac cta postprocessing was performed from ecg gated prospective and retrospective cta data on a commercially available workstation for / patients over the past three years. the anatomy was initially segmented and colored into individual parts of the anatomy of the heart and great vessels as follows rv purple, lv light red, aorta red, pulmonary arteries blue, systemic veins and right atrium aqua, pulmonary veins and left atrium pink, pda or collaterals green, airway yellow, coronary arteries neutral. the anatomy was then reassembled and images obtained every °in a °rotation for display. results: d color coded cta images were used in the treatment and care of congenital heart patients for the following types of congenital heart diseases: cases of complex anatomy (tga, truncus arteriosus, hlhs, tricuspid atresia, tof…), coronary artery anomalies, cases of pulmonary atresia or stenosis, cases of systemic and venous anomalies, cases of coarctation or interruption of the aortic arch, and tracheobronchial tree anomalies. conclusions: color coded cardiac cta post-processing is an effective and viable method for demonstrating anatomy in complex congenital heart patients. it is an excellent tool for demonstrating anatomy which is difficult to see by echocardiography such as: coronary artery anomalies, pulmonic atresia, aortic arch coarctation or interruption, and tracheobronchial anomalies and/or stenosis. neuroimaging in the evaluation of hie in term neonates post hypothermia therapy julio m. araque, md, radiology, medical college of georgia, jaraque@georgiahealth.edu; jatinder bhatia, leann vanlandingham purpose or case report: to illustrate and review the potential utility of brain mri, ct and ultrasound in hypoxic ischemic encephalopathy in newborns treated with hypothermia. neuroimaging studies including brain ultrasound, ct and mri of fifteen term newborns treated in our institution with therapeutic hypothermia, since april were evaluated retrospectively. more relevant lesions are depicted and the diagnostic and prognostic value of the findings is discussed and compared with a review of the literature. results: recent studies showed that patients treated with cooling had a more favorable prognosis than was suggested by the clinical grade of encephalopathy compared with infants treated with standard care. our institutional protocol includes the performance of mri, and ultrasound. ct is performed when is a clinical impossibility of perform mri. brain ultrasound was performed in all the patients. mri scans were obtained in neonates. ct was obtained in patients. all mri studies included dwi. the utility of dwi and adc maps as an aid in diagnosis of non-ischemic lesions is becoming increasingly established. mri evidence of brain injury was visible on basal ganglia in cases with negative ultrasound. abnormal signal intensity in the posterior limb of the internal capsule coexists with lesions in the basal ganglia and thalami have been associated with abnormal motor outcome. the remaining newborns did not develop significant mri evidence of brain injury. it has been suggested that the ability of mri to predict subsequent neurological impairment is unaltered by therapeutic hypothermia. further research is needed for defining the relation between mri findings and cooling. it is possible that imaging findings might be delayed in cooled infants. conclusions: mri offers the highest sensitivity in detecting anoxic injury of the neonatal brain. mr biomarkers in combination with clinical markers may identify patients with adverse outcome with therapeutic implications. disclosure: dr. araque has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: to correlate bowel wall diffusionweighted imaging (dwi) apparent diffusion coefficient (adc) values with multiple mr enterography (mre) and clinical findings in pediatric small bowel crohn disease. methods & materials: pediatric crohn disease patients with mre exams containing diffusion-weighted imaging and demonstrating terminal ileitis were identified. minimum bowel wall adc values were tested for correlation/association with other mri findings and clinical parameters (including laboratory values). results: there is negative correlation between adc value and degree of bowel wall thickening (r (−) . ; p . ). lower adc values were significantly associated with striated pattern of arterial phase postcontrast enhancement (p . ), greater degree of arterial phase postcontrast enhancement (p . ), and presence of stricture (p . ). adc values were not associated with diseased bowel length, degree/pattern of delayed postcontrast enhancement, degree of mesenteric inflammation or fibrofatty proliferation, or clinical markers of inflammation. conclusions: restricted diffusion in pediatric small bowel crohn disease is associated with other mri findings of that are suggestive of active disease, including degree of bowel wall thickening and degree and pattern of arterial phase postcontrast enhancement. our data also suggests that dwi may be useful when attempting to characterize small bowel strictures as either predominantly inflammatory or fibrotic, although further investigation is needed. quantification of blood flow into and out of the liver with d phase contrast mri in the pediatric patient binh huynh, md, radiology, stanford, bhuynh@stanford. edu; shreyas vasanawala, albert hsiao purpose or case report: the ability to probe blood flow dynamics in the liver may aid management of children with liver disease, including shunt fractions in portal hypertension and arterial flow fraction in diffuse liver disease. the purpose of this study is to evaluate the ability to measure blood flow into and out of the liver with time resolved volumetric ( d) phase contrast mri in the pediatric patient. methods & materials: nineteen consecutive patients were retrospectively identified who underwent d flow imaging through the level of the hepatic vessels on . t and t magnets. a software enabling d flow program was utilized to first assess for the feasibility of measurement of flow in the hepatic artery (ha), portal vein (pv), splenic vein (spv), superior mesenteric vein (smv), supra (sivc) and infrahepatic (iivc) inferior vena cava. if measurable, calculations were performed to evaluate for internal consistency by comparing the sum of smv and spv flow to pv flow. calculations were then performed to compare hepatic inflow (pv+ha) to hepatic outflow (sivc-iivc) and for the percentage of pv and ha contribution to hepatic inflow. results: of the nineteen patients, all of the above mentioned six vessels were visualized and measurable in two patients, both of which were imaged on the . t magnet. in the remaining patients, flow measurements were limited by respiratory motion artifacts obscuring the smaller vessels, and severe eddy currents, particularly in patients imaged with the t magnet. the evaluation for internal consistency demonstrated an average of . % ( . % & - . %) difference between smv+spv and pv flow. hepatic inflow was found to closely match the measured hepatic outflow with an average difference of . % ( . % & . %). the portal vein was found to contribute . % and . % to hepatic inflow, while the hepatic artery contributed . % and . %. conclusions: measurement of hepatic flow with phase contrast mri is more challenging than assessment of thoracic flow. when respiratory artifacts are minimal, vessels can be identified and measurements have internal consistency and good agreement between hepatic inflow and outflow at . t. conversely, flow measurements were limited at t by eddy currents. thus, ongoing efforts are aimed at mitigating respiratory motion artifacts at . t. poster #: sci- mri findings in post-fontan hepatopathy adina alazraki, md, radiology, emory university/children's healthcare of atlanta, adina.alazraki@choa.org; pinar bulut, kiery braithwaite, miriam vos, rene romero, nitika a. gupta purpose or case report: as advances in congenital heart disease continue to improve both mortality and quality of life, associated complications are becoming more prevalent. amongst patients who have had fontan repair for hypoplastic left heart syndrome, tricuspic atresia, or other right heart dysfunction, it is well known that liver disease is a complication. we describe the mri findings in post-fontan patients and propose mri as a useful tool to the hepatologist's evaluation of these patients. methods & materials: irb approval was obtained for a retrospective review of patients who underwent fontan repair and were subsequently referred for hepatology evaluation between - . all but one patient was scanned on a siemenstriotrim t magnet; one patient was scanned on a ge twinspeed . t magnet with an equivalent protocol due to orthodontics. a standardized departmental protocol was utilized. mri findings were correlated with age at surgery and years since surgery. mr images were reviewed independently by pediatric radiologists and compared with the dictated report in the patients record. results: patients underwent mri of the abdomen. patients had mri incompatible hardware and patients were not scanned secondary to insurance denial. patients were divided into groups based on elapsed time since surgery: less than years, - years, - years, and greater than years.(table ) mr images were evaluated for the presence of fibrosis, congestion and any other hepatic abnormalities. fibrosis was determined based on a specific pattern of delayed reticular enhancement in combination with liver morphology. congestion was deemed present if there was increased t signal in the liver parenchyma or periportal regions in combination with cloud-like enhancement on dynamic post-contrast images. all patients demonstrated morphologic changes in the liver with varying degrees of hepatic fibrosis and hepatic congestion. fibrotic changes were often non-uniform, and thus could be underdiagnosed by biopsy. interestingly, patients, %, had focal arterially enhancing lesions speculated to represent vascular proliferative lesions, however, none warranted biopsy. conclusions: it is established that patients who undergo fontan develop hepatic abnormalities. mri is a reliable, non invasive technique that accurately demonstrates these findings. mri may be a more sensitive method to evaluate the etiology and full extent of hepatic disease. poster #: sci- complications within the interventional radiology division of a tertiary care children's hospital: initiatives for ongoing quality and practice improvement brian dillon, children's hospital boston, brian. dillon@childrens.harvard.edu; pamela sanborn, yolanda milliman-richard, darren orbach, stephan voss purpose or case report: between and , procedure-related complications occurring within the division of interventional radiology at our institution were recorded and classified according to level of severity. the goals of this study were to determine rates of procedurebased complications based on severity, to establish thresholds for complications, and to determine whether measurable trends in complications over time were evident. methods & materials: between and , , interventional procedures were performed within the division of interventional radiology at our institution. adverse events were characterized both according to level of severity (using an institutional point severity scale), and with brief descriptions of individual events. adverse events were reviewed monthly at the division's morbidity and mortality conference, with respect to procedure type and operator. based on review of our interventional radiology data and benchmarks rates used for diagnostic errors, threshold complication rates were established by consensus between the department quality improvement committee and the division of interventional radiology. for severe events (level and ) there is no allowable threshold; all such events were subjected to both internal and institutional review. results: the overall complication rate was less than % for all procedures performed. the complication rates for the respective severity levels were: level ( . ), level ( . ), level ( . ), level ( . ), and level ( . ). the severity of a given complication was not associated with procedural complexity. no operator-specific trends were identified. conclusions: since , the society of interventional radiology has offered guidelines and strategies for improving safety and quality in interventional radiology. however, no specific benchmark data or procedural recommendations are available for pediatric interventional procedures. our results demonstrate rates of complications well below published overall complication rates for interventional radiologic procedures. this database of procedure-based complications serves as a foundation for a quality improvement program that allows review of complications with respect to specific procedure types, individual operators, and procedural complexity, in an effort to institute an ongoing and continuous process of quality improvement within interventional radiology. purpose or case report: dysosteosclerosis (dss), an extremely rare dense bone disease, features short stature and fractures and sometimes optic atrophy, cranial nerve palsy, developmental delay, and failure of tooth eruption in infancy or early childhood consistent with osteopetrosis (opt). bone histology during childhood shows unresorbed primary spongiosa from deficient osteoclast action. additionally, there is remarkable progressive flattening of all vertebrae mimic ppi blocking mineralization. during ehdp treatment for gaci, in our patient prolonged high dose ehdp resulted in severe skeletal deformity resembling hypophosphatasia which was reversable with drug stoppage. methods & materials: a -year-old boy with gaci referred for profound, acquired, progressive skeletal deformity. he was receiving mg/day of ehdp and was wheelchair bound. we studied him and his response to stopping ehdp. results: skeletal radiographic findings resembled pediatric hypophosphatasia with pancranial synostosis, widened physes with metaphyseal osteosclerosis, "tongues" of radiolucency, along with cupping and fraying, and long-bone bowing. in addition there were large intra and extraarticular calcifications. radiographic features of bp-induced opt included femoral erlenmeyer flask deformity and osteosclerosis (lumbar sine dxa z-score + . ). biochemical parameters of mineral homeostasis were essentially normal although serum osteocalcin was low and he had markedly elevated serum levels of creatine kinase and trap- b consistent with osteopetrosis (opt). after stopping ehdp, he improved quickly with remarkable healing of his rachitic appearing skeleton and decreased joint calcifications. conclusions: our patient with gaci had profound skeletal deformities from high-dose ehdp therapy that significatly improved with drug stoppage. magnetic resonance imaging in the evaluation of infants with hypoxic ischemic encephalopathy julio m. araque, md, radiology, medical college of georgia, jaraque@georgiahealth.edu purpose or case report: to illustrate and review a spectrum of brain abnormalities of infants with hie. defining the most useful approaches and mri sequences, to facilitate identification and early diagnosis of lesions with the potential to predict outcome and abnormal neurodevelopment. methods & materials: reviewed available evidence on mri strategies for evaluating infants with hypoxic ischemic encephalopathy. different cases illustrating lesions are presented and discussed for proper diagnosis correlating physiopathology and imaging appearance. more relevant findings are depicted with didactic illustrations. identifying studies where new techniques such as dwi, adc, dti, swi, or mrs adds significant diagnostic value to the overall interpretation. results: mri is routinely performed as a very sensitive method for detection of hie lesions. advanced mr techniques, such as dti, dwi, adc, mrs, swi offer the possibility of detecting injuries at a time when intervention is theoretically possible. the understanding of the physiopathology allows for prediction of the location and extent of lesions, facilitating identification and appropriate classification. the identification of infants with potentially abnormal neurodevelopment, offers the opportunity to provide therapeutic neurodevelopmental interventions in early childhood. mrs is the best mr biomarker to predict neurodevelopmental outcome in asphyxiated full-term neonates. brain metabolite ratios and regional adc values may vary between mr systems and coils. development of normal values for each institution is required, and support of physicists is mandatory. conclusions: mri continues to evolve as a valuable adjunctive tool routinely obtained in nearly all cases of hie. advanced mri techniques increase sensitivity of conventional t and t -w images and outperform computer tomography and ultrasound for confirming the diagnosis of hypoxic-ischemic brain injury or providing prognostic information for the care of patient with hie. disclosure: dr. araque has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. posterior fossa abnormalities in children amit gupta, mbbs, radiodiagnosis, r.n.t. medical college, udaipur, rajasthan, india, amitsensation@yahoo.co.in purpose or case report: the aim of this exhibit is to demonstrate various conditions involving the posterior fossa in children with emphasis on importance of embryologic development of cerebellum in reaching a correct diagnosis. methods & materials: this pictographic presentation displays the imaging features of cases encountered in our clinical practice on . tesla magnetic resonance (mr) imaging. results: with the advent of mr imaging, there has been a revolution in identification and characterization of malformations of the brain this is especially true in posterior fossa, where the sensitivity and specificity of mr imaging with its multidimensional imaging capability are far superior to those of computed tomography (ct) in the detection of subtle morphologic abnormalities. however, there is still a great deal of confusion regarding their classification, terminology, and spectrum of expression and this is where neuroembryology is of great help. this exhibit demonstrates : ) review of embryology and normal anatomy of cerebellum. ) mr appearance of spectrum of conditions involving posterior fossa in children which includes developmental abnormalities (dandy-walker complex, arnold chiari malformations, cerebellar dysplasia/ hypoplasia, joubert's syndrome, etc.), cysts (arachnoid cyst, giant cisterna magna etc.), tumours (medulloblastoma, ependymoma, hemangioblastoma etc.) and miscellaneous conditions. significantly reduces dose ( / of other gadolinium based contrast agents), and doesn't require trigger imaging. conventional mri provides important information regarding the anatomical extent, size, and relation to critical anatomical structures thus when combined with twist, mri provides the best information without use of radiation in children. functional connectivity mri in pediatric brain tumor patients with and without epilepsy andrew v. poliakov, phd, radiology, seattle children's hospital; david bauer, edward novotny, seth d. friedman, dennis shaw, jeff ojemann purpose or case report: functional connectivity mri (fcmri) is a way to evaluate cortical networks across different modalities such as motor, sensory, vision, and the default mode network using functional magnetic resonance imaging. fcmri relies on correlation in fmri image intensity that occurs between functionally connected regions. this effect can be seen in awake as well as anesthetized patients. we evaluated these pathways in pediatric patients with brain tumors. methods & materials: patients were randomly selected from our tumor database. inclusion criteria included age less than , history of brain tumor resection, and complete fcmri data. imaging was performed on a t siemens trio system. functional mri data were acquired as part of a clinical imaging protocol over . - min using a gradient echo, echo-planar sequence. preprocessing of fmri data followed by independent component analysis (ica) was performed using fsl software. functional connectivity analysis was performed using software provided by functional connectomes project, based on afni and fsl software packages. correlation maps were produced by extracting the bold time course from a seed region, computing the correlation coefficient between that time course and the time course from all other brain voxels, correcting for multiple sampling and degrees of freedom and thresholded at a z value of . . results: fourteen patients were included in the study, eight female and six male. tumor types include ganglioglioma ( ), pleomorphic xanthoastrocytoma ( ), juvenile pilocytic astrocytoma ( ), ependymoma ( ), anaplastic astrocytoma ( ), glioblastoma multiforme ( ), and primitive neuroectodermal tumor ( ). seven patients had tumor-associated epilepsy, and seven patients did not. the figure shows connectivity patterns in the motor network in patients without (a) and with (b) epilepsy. in the patients without epilepsy, functional connectivity was often displaced but not decreased or absent. in the patients with epilepsy, we observed decreased or absent functional connectivity. similar results were found for default mode network: connectivity was diminished or absent in the patients affected by epilepsy. conclusions: fcmri is a novel technique that may prove useful for evaluation and presurgical planning by giving us insight into how tumors disrupt function. functional connectivity was often displaced but relatively preserved in the patients without epilepsy. it was disrupted or absent in the patients with epilepsy. poster #: sci- corpus callosum dti measurements in neurofibromatosis type and normal controls nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; amir noor, rhea udyavar, marine bouyssi-kobar, iordanis evangelou, maria t. acosta purpose or case report: many patients with neurofibromatosis type (nf ) have corpus callosum enlargement; pathogenesis and underlying pathophysiology are unclear. the goal of our study is to investigate the pathophysiological basis of corpus callosum enlargement in nf patients through mri diffusion tensor (dti) measurements. methods & materials: retrospective study, irb approved. patients consecutively selected from institutional data base; inclusion criteria: established diagnosis of nf , brain imaging with dti sequence, abnormally high corpus callosum to skull ratio; excluded were patients with complications of nf that could affect size of the corpus callosum. age and gender matched normal controls were randomly selected from the radiology data base. roi were placed manually over the corpus callosum for dti measurements using dti-studio by two independent researchers, one blinded to diagnosis. results: fifteen nf patients and matched controls were analyzed. the corpus callosum to skull ratio was found to be significantly different between the experimental and control group (p . ). for nf patients we found: a trend to lower apparent diffusion coefficient (adc, p . ), significantly higher radial diffusivity (p . ), significantly lower axial diffusivity (p . ), and significantly lower fractional anisotropy (fa, p . ). conclusions: the significantly lower axial diffusivity in nf can indicate that there are more crossing fibers in the corpus callosum of nf patients than in normal controls. further studies using comparative dti tractography may be helpful in further investigating this stipulation. the significant increase in radial diffusivity can be explained by a variety of factors, including thinner myelin sheaths, increased interstitial fluid, smaller axons, or a combination thereof. the trend of lower adc may indicate low axonal diameter, as adc has been shown to more strongly correlate with axonal diameter without the myelin sheath. in future studies we will correlate abnormal corpus callosum dti markers with cognitive functions in nf patients to see if relationships exist that can be used as predictors of cognitive deficits in nf patients. screening for vitamin d deficiency in children with suspected non-accidental fracture conor kain, md, tripler army medical center; veronica rooks, laura keller, jordan pinsker, allyson cordoni, sarah frioux purpose or case report: determine if routine screening of vitamin d levels after suspected non-accidental fracture detects vitamin d deficiency and changes clinical outcomes. methods & materials: after irb approval we reviewed all skeletal surveys performed at tripler army medical center (tamc) in the last years and selected the children who were evaluated for suspected non-accidental fracture. we determined if -hydroxyvitamin d [ (oh)d] level was requested for these patients and characterized the provider's clinical suspicion of vitamin d deficiency as high or low. per the institute of medicine report and endocrine society guidelines we defined vitamin d deficiency as a (oh)d level of less than ng/ml. we calculated the prevalence of children with low (oh)d levels whose providers had low clinical suspicion for vitamin d deficiency. results: skeletal surveys were done at tamc from november to july . were performed after identifying a suspected non-accidental fracture. of these patients children from ages to months had (oh)d levels requested. for children whose providers had a low pre-test suspicion for vitamin d deficiency, the prevalence of vitamin d deficiency was . % ( % binomial ci . - . , of cases. these results indicate that at least one out of every three hundred children evaluated for nonaccidental fracture could have vitamin d deficiency despite a low clinical suspicion by their provider, although the actual rate is likely much higher given that we found one in eight cases. the child we identified with a low vitamin d level whose provider had no suspicion for rickets was treated with ergocalciferol and continued to be evaluated for abuse. conclusions: routine vitamin d level screening after nonaccidental fracture may detect vitamin d deficiency in children for whom there is low clinical suspicion. as our population resides at a low latitude and receives greater than average sun exposure, the rate of deficiency in children with suspected non-accidental fracture may be much greater in other areas. comet tails and dirty shadows: the secrets behind artifacts in pediatric ultrasound adam edelstein, pediatric radiology, massachusetts general hospital; anuradha shenoy-bhangle, katherine nimkin purpose or case report: to review common ultrasonographic artifacts, explain what causes them, and show how they can be used to aid in diagnosis in a variety of pediatric conditions, including less common entities. methods & materials: ultrasonographic images in patients less than years of age were reviewed. cases were selected that showed classic artifacts which helped with the diagnosis of a variety of entities. results: ultrasound artifacts include comet tail, reverberation, ring down and "dirty" shadowing. these can be used to help characterize a variety of pediatric conditions including gossypiboma, bezoar, subcutaneous foreign body, complications of nec, and staghorn calculus. artifacts can also be used to confirm the presence of stool or bowel gas. conclusions: familiarity with ultrasonographic artifacts is critical for tissue characterization and can help narrow the differential diagnosis in difficult pediatric cases. cardiac cta: non-vascular ring tracheobronchial compression secondary to enlarged patent ductus arteriosus in infants with congenital heart disease. nhi huynh, md, radiology, st. joseph hospital and medical center, e.nhihuynh@gmail.com; todd chapman, randy richardson purpose or case report: tracheobronchial compression or narrowing secondary to a vascular ring has been well documented. the purpose of this study is to describe the frequency of airway compression secondary to an enlarged patent ductus arteriosus detected by ccta without the presence of a vascular ring. methods & materials: a retrospective study of ccta exams in infants was performed over the period between / / and / / . ccta was performed with a -slice mdct, with ekg gating, followed by three-dimensional reformations. results: of the congenital heart disease infant patients, there are patients with tracheobronchial compression or narrowing. of these patients, patients reported to have patent ductus arteriosus as the primary cause of tracheobronchial compression or narrowing. approximately % of patients with airway compression in patients with congenital heart disease are secondary to an enlarged and/or tortuous patent ductus arteriosus. none of these cases were due to a vascular ring. of these patients, , , and patients demonstrated to have mild, moderate, and severe airway compression respectively. conclusions: tracheobronchial compression or narrowing secondary to vascular ring with a patent ductus arteriosus has been well documented. in this study, we demonstrate that a significant percentage of airway compression in patients with congenital heart disease without a vascular ring is due to a tortuous enlarged patent ductus arteriosus. cardiac cta is uniquely equipped to evaluate airway compression due to an enlarged patent ductus arteriosus and can help improve patient care in congenital heart disease patients with respiratory symptomatology. pediatric liver mr elastography: a primer suraj serai, phd, cchmc, suraj.serai@cchmc.org; daniel j. podberesky, alexander j. towbin purpose or case report: a wide variety of pediatric liver disorders may be complicated by the development of liver fibrosis and ultimately cirrhosis. with early interventions, the progression to hepatic fibrosis can be slowed, halted, and in some cases reversed. liver biopsy has long been considered the gold standard for assessing the presence and degree of liver fibrosis. however, liver biopsy has disadvantages, due to its potential sampling error, risk of complications, relatively high cost, intra-and inter-observer variability, and, in general, poor acceptance by pediatric patients and their parents. mr elastography (mre) is a relatively new, non-invasive technique that provides a safe, rapid and cost-effective method for objectively evaluating of a wide variety of hepatic diseases by quantitative stiffness evaluation of the liver-parenchyma. the purpose of this exhibit is to review our clinical experience with this technique and illustrate the application of liver mre in the pediatric population at our medical center. methods & materials: a review of pathogenesis and staging of liver fibrosis in children and current methods available for assessing liver fibrosis will be provided. a review of mre physics and technique, including the specific liver mre protocol used at our institution will be illustrated. we will review widely-used and emerging clinical indications for liver mre, as well as benefits and limitations to the technique, supported by brief literature review. results: in addition to sharing our liver mre technique, we will illustrate clinical case examples from our institution of a variety of liver disorders including non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, storage disorders, cardiac disease, and idiopathic elevated liver enzymes. conclusions: this educational exhibit will review our experience with liver mre, a safe, newly available technique which will play an increasingly important role in the noninvasive evaluation of pediatric liver disease. poster #: sci- spectrum of tuberculosis in children amit gupta, mbbs, radiodiagnosis, r.n.t. medical college, udaipur, rajasthan, india, amitsensation@yahoo.co.in purpose or case report: the aim of this exhibit is to present a spectrum of tuberculosis (tb) in the human body which commonly involves pulmonary, nervous, musculoskeletal, gastrointestinal and genitourinary systems. this pictographic presentation displays the imaging features of tb cases encountered in our clinical practice with reference to plain x-rays, ct and mri as appropriate. results: with the advent of the newer modalities, the utility of the plain skaigram has been largely limited a initial screening tool only. whereas ct scores over mri in pulmonary tb (parenchymal disease, lymphadenopathy, pleural effusion, empyema, miliary disease) and abdominal tb (spectrum from mesenteric lymphadenitis to visceral involvement), the magnetic resonance (mr) imaging is much better in diagnosing cns tb (tuberculoma, abscess, meningitis, subdural empyema and myelitis). in musculoskeletal and genitourinary tb, ct and mr imaging may be preferred based on the stage of disease and the character of the lesion. cardiac involvement (pericarditis) is among the less common affections of tb. conclusions: tuberculosis is a multisystem disease that can affect virtually any part of the body from head to toe. tb demonstrates a variety of clinical and radiologic findings and has a known propensity for dissemination from its primary site and therefore can mimic numerous other disease entities. hence it is imperative for radiologists to understand the typical disease distribution, patterns and imaging manifestations of tb. janet l. strife, md carol m. rumack md ole a. eklof, md clement c. faure, md andres giedion, md denis lallemand, md arnold lassrich md donald r. kirks, md beverly p. wood, md hooshang taybi md marta hernanz-schulman, md, facr m. ines boechat, md, facr neil d. johnson, mbbs dorothy i. bulas, md *deceased singleton-taybi award investigator award this award is given to the author of the best paper presented by a resident or fellow at the spr meeting md ricardo faingold, md andrea doria, md nina m. menezes, phd anthropometric parameters are a strong determinant of lvm in healthy individuals kiyarash mohajer, pierangelo renella, paul j. finn purpose or case report: despite theoretical advantages of higher field strength ssfp cine imaging, time-resolved magnetic resonance angiography (tr-mra), and high resolution contrast-enhanced mra (ce-mra) were performed. two readers independently evaluated the data for image quality, vessel and cardiac chamber definition, and presence of artifacts. snr and cnr were calculated. results: % of ssfp cine images at t were rated as good or excellent quality with % having mild and % having moderate artifacts (k . ) % of arterial and venous phase ce-mra images were considered good or excellent cardiac chamber definition was considered good or excellent in % of arterial and venous phase ce-mra images (k . ). % ce-mra images showed good or excellent definition of the thoraco-abdominal vessels on average, both readers scored cine ssfp images higher at . t and cemra images higher at . t. overall diagnostic performance was high at both field strengths. conclusions: mri of pediatric patients with chd and vascular abnormalities at . t is feasible. relative to . t, snr and cnr are both improved at higher field strength and higher resolution cemra is achievable t are more prevalent, they rarely render cine imaging non-poster # exclusion criteria were lack of correlating us or follow up information. two pediatric radiologists blinded to us findings reviewed the mr images and analyzed the contents of abdominal wall defect, organ location and attachment; spine anomalies; umbilical cord and limb anomalies. results: our search yielded patients. all fetuses had ventral wall defects, small thorax and eviscerated liver and bowel. in two cases kidneys were in extracorporeal location. in / there was no membrane covering extruded organs. in five mr showed organs attached to the placenta or uterine wall (mainly bowel and liver) mahmoud al-hawary and, by adolescence, paradoxical metaphyseal osteopenia with thin cortical bone. reports of consanguinity indicate autosomal recessive inheritance our studies, spanning ages - mo, showed weight %, but length diminishing from~ % to − . sd. head circumference was + sd. she had frontal bossing, blue sclera, normal teeth, genu valgum, and unremarkable joints. radiographs showed orbital and facial sclerosis, basilar thickening, "bone-in-bone" appearance in the pelvis, sclerotic long bone ends, and fractures of ribs and extremities. progressive metaphyseal widening occurred as vertebrae changed from ovoid to flattened and became beaked anteriorly. consistent with opt, serum pth concentrations reflected dietary calcium levels. serum bone alkaline phosphatase, osteocalcin, and trap b were sub-normal. iliac crest contained excessive primary spongiosa and no osteoclasts. splice sites and exons were intact for the genes encoding cholride channel , t-cell immune regulator , opt-associated transmembrane protein the hallmarks include stippled epiphyses, nasal hypoplasia, and hypoplastic distal phalanges and developmental delay. punctate calcifications are seen not only in the epiphyses but also in the paravertebral regions. paravertebral puncta are commonly associated with defective ossifications in the cervical spine. the malformation of the cervical spine causes spinal canal stenosis and instability, which occasionally necessitate surgical intervention none of the cases had brain infarction. conclusions: tortuousity and luminal narrowing of the cervical arteries is a common finding in cdp-bt. this previously unknown malformation is an important factor to discriminate patients at increased risk of cerebral ischemia, particularly in patients undergoing surgical intervention. disclosure: dr. okabe has indicated that she will discuss or describe severe skeletal toxicity from protracted etidronate therapy for generalized arterial calcification of infancy william h. mcalister, md, mallinckrodt institute of radiology campbell sheen purpose or case report: generalized arterial calcification of infancy (gaci) is an autosomal recessive disorder caused by deactivating mutations within the gene for ectonucleotide pyrophosphatase phosphodiesterase- (enpp ). enpp on osteoblasts, chondrocytes, and vascular smooth muscle cells hydrolyzes nucleotide triphosphates to nucleotide monophosphates and inorganic pyrophosphate (ppi) can time-resolved contrast-enhanced mra (twist) classify soft tissue vascular anomalies in the head and neck in children accurately? aylin tekes, md children from - years of age were enrolled. twist and conventional mri was performed (triplanar t -weighted [t -w] imaging with fat saturation, pre-contrast axial t -weighted [t -w] imaging, and post contrast triplanar fat-suppressed t -w imaging). twist was performed in coronal plane using blood-pool mr contrast agent (ablavar-lantheus) to enhance image quality and spatial resolution of mra. two pediatric neuroradiologists evaluated all patients in two different sessions, days apart: one session conventional mri with contrast was evaluated, in the second session twist was evaluated. clinical evaluation and/or percutaneous venogram/lymphogram data were the gold standard. results: our patients had diagnosis of infantile hemangioma (n ), venous malformation (n ), and lymphatic malformation (n ). twist alone could accurately classify / , conventional mri with contrast could accurately classify / . conventional mri with contrast combined with twist could accurately classify all cases. conclusions: twist offers high temporal resolution in the order of seconds, and provides functional data about the dynamics of contrast enhancement comprising the arterial, venous and delayed venous phases kiery cr- , sci- edu- , edu- edu- , edu- , pa- edu- , pa- a- , pa- , pa- , pa- , pa- edu- , edu- , edu- , edu- , edu- , edu- , edu- edu- , edu- , edu- , edu- , edu- , edu- suraj sci- , pa- , pa- edu- pa- , edu- , pa- the society for pediatric radiology gratefully acknowledges the support of the following companies in presenting the th annual meeting and postgraduate course: cme committee reviewers for this activity have disclosed any relevant financial relationships. no conflicts of interest exist.abuse and offer potential mechanisms of injury may help make the diagnosis of child abuse. the pediatric elbow-mri findings with multimodality correlation michael guandalini, md, royal children's hospital; murray bartlett purpose or case report: to describe and illustrate elbow abnormalities identified by mri performed in a cohort of pediatric patients with multimodality correlation. methods & materials: retrospective review of mri elbow studies performed at the royal children's hospital, melbourne between and . the studies were reviewed by a pediatric musculoskeletal radiologist and pediatric radiology fellow with patient demographics, clinical indication, findings and selected images recorded. results: elbow mri examinations were reviewed on children aged months to years ( boys, girls) with equal numbers of left and right sides examined. clinical indications included previous trauma in cases ( %) and nontraumatic conditions in ( %). the most common traumatic indication was suspected or confirmed fractures or avulsions ( %) followed by osteochondral or cartilage injuries ( %), growth arrest ( %), loose bodies ( %) and ligament injuries ( %). hemophilia ( %) was the most frequent nontraumatic indication followed by neoplasm ( %). mild to severe arthropathy, fractures, physeal growth arrest, subluxations, osteochondral lesions and loose bodies were the most frequently demonstrated abnormalities. ligament strains and tears, bone oedema, neuromuscular abnormalities, infections and several neoplasms including lipomas, vascular/lymphatic malformations and bone tumors also featured. conclusions: this pictorial review illustrates the broad range of abnormalities one might expect to encounter on pediatric elbow mri studies, highlighting the major features and corresponding appearances on ct and plain x-ray. spectrum of patellar tendon avulsive injury on mri in children: differentiation between acute and chronic avulsive injuries of the inferior patellar pole and tibial tuberosity zeyad metwalli, md, baylor college of medicine, metwalli@ bcm.edu; herman kan, scott rosenfeld, r. p. guillerman purpose or case report: the extensor mechanism of the knee is an intricate component of the joint and is frequently injured in pediatric athletes. due to the strength of the patella tendon, trauma to the anterior knee is often manifested by avulsive injuries, which may occur on an acute or chronic repetitive basis. purpose: this pictorial review will illustrate differentiating radiographic and mri features of acute and chronic avulsive injuries of the pediatric knee. outline: . anatomy and physiology a. discuss the anatomic differences of the pediatric and adult knee extensor mechanism b. pathophysiology and biomechanical basis for chondro-osseous avulsion injuries versus tendon tears in the skeletally immature. purpose or case report: the purpose of this educational exhibit is to demonstrate the magnetic resonance imaging (mri) appearance of the ankle and hindfoot ligaments using an interactive approach. methods & materials: a tesla siemens mri scanner with a multichannel ankle coil was utilized in the acquisition of images of ankle and hindfoot. three dimensional volume acquisition proton density images will be used to demonstrate the ligamentous anatomy of the ankle and hindfoot in axial, axial oblique, coronal, and sagittal planes. results: the exhibit will begin with an interactive review of the ankle and hindfoot ligamentous anatomy with each ligament poster #: edu- cns imaging findings in hemophagocytic lymphohistiocytic syndrome rupa radhakrishnan, mbbs, md, dnb, radiology, university of cincinnati college of medicine, radhakrp@ucmail. uc.edu; marcia k. kukreja, alexandra filipovich, alexander j. towbin purpose or case report: hemophagocytic lymphohistiocytosis (hlh) is a rare, life threatening condition caused by an uncontrolled proliferation of activated lymphocytes and histiocytes with high levels of inflammatory cytokines. the organs most commonly involved in this disorder include the liver, spleen, lymph nodes, bone marrow and central nervous system (cns). the purpose of this exhibit is to review the cns imaging findings associated with hlh, its complications, and its management. the published literature was reviewed to identify the potential imaging findings hlh. the electronic medical record system was then searched to find illustrative case examples from our institution. cases demonstrating the primary imaging findings as well cases highlighting complications of the disease or its therapy were selected. results: cns involvement is common in hlh with approximately % of patients demonstrating neurological symptoms. ct findings of cns involvement include diffuse parenchymal atrophy, low attenuation lesions in the white matter and calcifications. mr findings include diffuse leptomeningeal and perivascular enhancement, t hyperintense lesions with nodular or rim enhancement as well as confluent white matter lesions, and diffuse parenchymal volume loss of the cerebrum and cerebellum. restricted diffusion has been demonstrated in some lesions. ring enhancing parenchymal lesions have been described representing active demyelination. intracranial hemorrhage may occur as a result of thrombocytopenia and coagulation abnormalities. sepsis with opportunistic organisms can involve the cns and produce intracranial findings such as parenchymal abscesses. cns changes, such as posterior reversible encephalopathy syndrome, are also seen with the commonly used immunomodulatory regimen used in the treatment of hlh. conclusions: this exhibit will aid the viewer in identifying the cns imaging findings of hlh as well as the complications of the disease and its therapy. while the cns imaging findings are not specific, they may help the radiologist formulate a diagnosis in association with the other clinical and imaging findings; furthermore, imaging can help the clinical team in managing the disease and its complications. methods & materials: medical records of our pediatric patients with palpable head masses over the last years, were reviewed and images were collected. correlation of us of these lesions with other imaging modalities and/or pathologic diagnosis was done. results: us appearances of various head masses including congenital/developmental (encephalocele, meningocele, dermoid, occipital protuberance), traumatic (cephalhematoma, subgaleal hematoma, calvarial fracture), inflammatory/infectious (sebaceous cyst, histiocytosis, dermatitis), vascular (malformations, pseudoaneurysm) and neoplastic (benign and malignant lesions including metastases) etiologies, will be illustrated with case based approach. mri and/or ct or tissue diagnosis can be problem solving. role of ultrasound guidance for percutaneous procedures (biopsy, sclerotherapy) will also be described. conclusions: ultrasound can play an important role in the delineation, diagnosis and guiding further management of pediatric palpable head masses. us can differentiate various scalp lesions and suggest the underlying calvarial defect or involvement to some extent, helping to narrow the differential diagnosis for such lesions. color doppler us can be useful to detect vascularity within the lesion or vascular lesions. given that us is often requested for the evaluation of palpable head masses, pediatric radiologists should be familiar with their sonographic features. posterior fossa malformations-a pictorial review rui santos, md, bc children's hospital, ruiradiologia@gmail. com; khalid khashoggi, angela t. byrne purpose or case report: posterior fossa malformations are a group of central nervous system anomalies that may be detected during pregnancy or present early infancy with features that include hypotonia, developmental delay, mutations responsible for the disease and proposals as to mechanism of action of the mutation with respect to disease manifestations. this preceded the development of hypotheses regarding the relationship between genotype and phenotype and the attempt to utilize imaging modalities that could better assess disease activity as it related to functional status. the purpose of this exhibit is to briefly review the history pre- and to focus on the numerous ways in which the understanding has improved since that time. conclusions: . there are over different mutations of the cftr gene responsible for cystic fibrosis with varying prevalence throughout the world. . the class of mutation often dictates its particular mechanism of action. . there is some relationship between genotype and phenotype-particularly with respect to pancreatic involvement. . newer imaging modalities including ct and mri with or without hyperpolarized helium are better predictors of disease severity than is plain film. imaging pulmonary tuberculosis in infants: what are the most useful diagnostic radiological findings? handan cakmakci, pediatric radiology, dokuz eylul university hospital, handancakmakci@gmail.com; nevin uzuner, filiz tetik purpose or case report: early diagnosis and treatment are very important for infants with tuberculosis. infantile pulmonary tuberculosis is more symptomatic, and the risk of severe and life-threatening complications such as tuberculous meningitis or miliary tuberculosis is higher. bacteriologic confirmation of the disease in children is difficult and in younger infants (< months), the tuberculin skin test is frequently negative. therefore, radiological findings play important role in diagnosing tuberculosis in infants. the purposes of this study are to identify chest x-ray and lung ct findings in pulmonary tuberculosis of infants and consider the most useful diagnostic findings of these age group patients.methods & materials: chest radiographs and chest ct images of infants who were diagnosed in our hospital from to were retrospectively reviewed. the study group included boys and girls ranging in age from to months (mean age, months). chest x-ray and computed tomography images were analyzed considering air space consolidation, nodular lesions, cavitating lesions, mediastinal enlargement, hyperinflation, bronchial narrowing, atelectasis pleural effusion on plain radiography and additional mediastinal calcific or caseating lymph nodes on ct images.results: air space consolidation was seen on out of chest x-ray and computed tomography images. nodular lesions were seen out of chest x-ray and computed tomography images. cavitating lesion was seen on out of chest x-ray and computed tomography images. mediastinal enlargement suggesting lymph node was seen out of chest x-ray and computed tomography images. hyperinflation, bronchial narrowing was seen out of chest x-ray and computed tomography images. atelectasis, pleural effusion was seen out of chest x-ray and out of computed tomography images. mediastinal caseating lymph nodes, mediastinal calcific lymph nodes were seen out of computed tomography images. conclusions: frequent and the most useful diagnostic radiological findings of pulmonary tuberculosis in infants are mediastinal or hilar lymphadenopathy with central necrosis and air space consolidations. disseminated nodules including miliary lesions and airway complications are also detected in this age group. ct can show detailed parenchymal lesions and tuberculous lymphnodes especially calcified ones. the ductus bump: radiographic findings of this normal variant and differential diagnoses anusuya mokashi, staten island university hospital, anusuya.mokashi@gmail.com; jeremy neuman, cheryl lin purpose or case report: the ductus bump: review of radiographic findings, differential diagnoses and current controversies. the ductus bump was first described in by berdon et al as a transient physiologic mass in the chest in newborn infants. some controversy remains as to the exact etiology and clinical significance. although initially thought to represent a dilated ductus arteriosus, recently it has been suggested that it actually represents a ductus arteriosus aneurysm that spontaneously resolves. others contend it represents dilation of the infundibulum of the closing ductus. regardless of etiology, the time of discovery, location, and rapid resolution are characteristic of this entity. in this presentation we will review the radiographic and echocardiogram findings of the ductus bump, as well as discuss the differential diagnosis. the frontal radiographic findings are a round mass to the left of the vertebral spine projecting from the mediastinum near the aortic arch. this mass does not indent the esophagus and it cannot be seen on the lateral view. it is classically said to resolve within the first few days of life. the controversy regarding the etiology has also led to some disagreement involving the clinical significance and appropriate follow up, which will also be discussed. after reviewing this educational poster, the reader will have conclusions: abnormalities of the posterior fossa are often difficult to differentiate solely on the basis of their radiologic appearances alone. however, an accurate diagnosis is essential for proper treatment planning and genetic counselling. therefore it is imperative for radiologists to be well versed with the normal anatomy and development of cerebellum so as to correctly diagnose the various posterior fossa abnormalities.poster #: sci- imaging of oculoauriculofrontonasal syndrome with low-dose -dimensional computed tomography paritosh c. khanna, md, radiology, seattle children's hospital, pkhanna@uw.edu; kelly evans, gisele ishak, joseph gruss, michael cunningham, anne hing purpose or case report: oculoauriculofrontonasal syndrome (oafns) combines elements of abnormal morphology of the frontonasal and maxillary processes of the face. the aim of our exhibit is to demonstrate the low-dose computed tomography (ct) features of this syndrome, in seven patients who have been followed at seattle children's hospital (sch) over years. we underscore the imaging features of this condition, and describe additional features including bony nasal abnormalities not previously described in the literature, to improve imaging recognition of this spectrum. we present d ct imaging features of a series of eight patients with oafns. in keeping with the alara (as low as reasonably achievable) concept and the image gently recommendations (www.imagegently. org), ct head and face studies were obtained on six of eight patients at sch, while two had prior exams at outside institutions. using a -slice multidetector ct scanner (ge lightspeed vct, waukesha wi), low-dose ct ( kv, mas or lower depending on age) of the head and face was obtained. planar bone window and d surface rendered images were analyzed. results: our series of patients demonstrated bifid nasal bones, uni-or bilateral mandibular hypoplasia, temporomandibular and zygomatic dysplasia and bony external auditory canal abnormalities. one patient had an interfrontal bone with a frontal bony defect that was contiguous with the metopic suture. we describe additional previously unidentified ct anomalies of the nasal bones, anterior nasal spine and nasal septum. these structures are involved in all patients who had ct imaging available, although unique features are present in each case. conclusions: ct is the mainstay of imaging of craniofacial anomalies in the post-natal period, both pre-and postoperatively. in addition to our low-dose ct imaging findings of oafns, novel nasal bone anomalies identified by our group serve to identify a new subset of patients with this syndrome and may help refine the phenotype of the oafns spectrum. key: cord- - l scdqk authors: kiechle, frederick l.; arcenas, rodney c. title: utilization management in a large community hospital date: - - journal: utilization management in the clinical laboratory and other ancillary services doi: . / - - - - _ sha: doc_id: cord_uid: l scdqk the utilization management of laboratory tests in a large community hospital is similar to academic and smaller community hospitals. there are numerous factors that influence laboratory utilization. outside influences like hospitals buying physician practices, increasing numbers of hospitalists, and hospital consolidation will influence the number and complexity of the test menu that will need to be monitored for over and/or under utilization in the central laboratory and reference laboratory. clia’ outlines the four test categories including point-of-care testing (waived) and provider-performed microscopy that need laboratory test utilization management. incremental cost analysis is the most efficient method for evaluating utilization reduction cost savings. economies of scale define reduced unit cost per test as test volume increases. outreach programs in large community hospitals provide additional laboratory tests from non-patients in physician offices, nursing homes, and other hospitals. disruptive innovations are changing the present paradigms in clinical diagnostics, like wearable sensors, maldi-tof, multiplex infectious disease panels, cell-free dna, and others. obsolete tests need to be universally defined and accepted by manufacturers, physicians, laboratories, and hospitals, to eliminate access to their reagents and testing platforms. this chapter will review the numerous factors that infl uence laboratory test utilization in a large community hospital (table . ). assessment of laboratory test utilization usually relies on data compiled after a utilization review or analysis of the necessity, appropriateness, and effi ciency of laboratory tests on a concurrent and/or retrospective basis. most laboratory utilization studies have been reported from academic medical centers [ - ] , however, there are often common fi ndings in large community hospital settings [ - ] . the major difference between an academic center and community healthcare system is usually the number of hospital-employed physicians versus independent physicians with their own offi ce practices. some large community hospitals have only employed physicians on their medical staff like kaiser permanente, henry ford hospital, and others. generally, it will be easier to assemble a group of specialists to convene a laboratory utilization committee meeting, if the physicians are accustomed to leaving their practice responsibilities and going to a hospital-oriented committee meeting in the middle of the day. since the focus of this committee is to review the evidence-based evaluation of a new or old laboratory test to rule in or out a specifi c disease, attendance and the quality of participation will vary depending on the physician's commitment to the project. in a large community hospital, it may "save time" during these meetings if homework is assigned beforehand. "this includes what do people need to read, think about, bring with them, or come prepared to discuss so the meeting will be more productive" [ ] . one of the authors (flk) has worked for years directing the clinical laboratory and outreach laboratory at a large community hospital (william beaumont hospital) in royal oak, mi and for the past years at a six hospital county healthcare system (memorial healthcare system) in hollywood, fl with the co-author (rca). we will review several of the issues listed in table . . in preparation for the shift from fee-for-service to a valuebased payment system [ ] large community hospitals have been actively engaged in three enterprises which will impact laboratory test utilization: buying physician practices, increasing the use of hospitalists and consolidation of hospitals. in the early s during the initiation of health maintenance organizations (hmos) , hospitals purchased physician practices. in general, at that time, hospitals had a diffi cult time managing the physicians and their practices. during this second more recent phase of buying, contracts are designed to enhance physician productivity [ - ] . the "key motivation for hospital acquisition of physician practices is the ability to gain market share for inpatient admissions and outpatient services by capturing referrals from physicians employed by the owned practices" [ ] . carlin et al. [ ] documented a shift in inpatient admissions, outpatient ct scans and mri procedures from three large multispecialty clinic systems to a two hospital-owned integrated delivery system (ids) after the ids purchased them. this same shift of referral patterns to the new hospital owner will also be true for laboratory tests ordered by newly acquired physician practices. in the usa % of physicians were independent in compared to % in [ ] and % of male and % of female physicians in [ ] . in , % of physicians were employed by hospitals compared to % in [ ] . a downside of this trend is the fi nding that hospitals charge more when the doctors work for them attributing the cause to higher overall costs [ ] . this current trend should drive more laboratory testing from new hospitalbased physicians to the hospital central laboratory with the consequence of potential utilization issues. the hospitalist model of inpatient care is one of the most rapidly growing forms of medical practice in the usa since its introduction in the mid- s [ , ] . in , there were more than , hospitalists in the usa [ ] which has increased to , in [ ] . most hospitalists practice in hospitals with greater than beds [ , ] . their average starting salary was greater than that for internal medicine or family practice physicians in [ ] . hospitalists work strictly in the hospital and oversee the care of complex patients with the goal of reducing the need of transferring patients from one physician to another [ ] . most large community hospitals use a voluntary hospitalist system in which primary care physicians can choose to admit to a hospitalist service or attend to their own patients [ ] . large community hospitals are more likely to adopt a hospitalist model if their case mix complexity was greater than the national average for medicare's diagnosis rated group index, while high health maintenance organization market share resulted in lower interest in this model [ ] . the hypothesis that the hospitalist model will lead to a reduction in the patient's length of stay and total hospital costs has been demonstrated [ , - ] . hospitalists may order excessive diagnostic tests secondary to their lack of previous knowledge of the patient [ ] . the choosing wisely campaign sponsored by the american board of internal medicine foundation, consumer reports, and more than specialty societies have recommended reduction or elimination of inappropriate use of radiologic, laboratory, and therapeutic procedures [ , - ] . the fi rst societies provided fi ve selections each, of which % were related to laboratory tests or pathology [ ] . one of these lists from the society of hospital medicine recommended reducing the use of repetitive common laboratory testing when the patient is clinically stable [ ] . in a quality improvement project focused on hospitalists, an effort was made through education to reduce the repetitive use of complete blood counts and basic metabolic panels [ ] . these panels are often embedded in order sets established for specifi c diseases or for specifi c physicians to simplify computerized physician order entry [ ] . there was a -month baseline period before the intervention followed by a -month intervention period [ ] . the intervention resulted in a % reduction of these two panels ordered per patient day associated with decreased direct costs of $ . per patient and annualized savings of $ , [ ] . this study illustrates how a small segment of laboratory test ordering physicians can impact expenses through overutilization and by analogy underutilization of laboratory tests. like the fi rst round of hospitals buying physician practices started in the early s, so did the consolidation or mergers of hospitals [ ] . there has been a recent increase in both horizontal and vertical consolidation [ , ] . horizontal consolidation involves hospitals merging with other hospitals that supply similar services in geographic proximity [ , ] . these mergers are most likely to be investigated for antitrust violations [ ] . vertical consolidations involve hospitals consolidating with other health care provider entities [ , ] . from to , hospital mergers and acquisitions were announced involving hospitals [ ] . sixty percent of hospitals are now part of health systems. the downside to these mergers has been a - % increase in prices secondary to increased market share [ ] . strategies have been suggested for avoiding this market disequilibrium [ , ] . no us hospital markets were rated highly competitive [ ] while the german market is competitive and the number of hospital systems decreased by % from to [ ] . there are myths associated with the latest hospital merger activity. the fi rst myth is that consolidation is equivalent to integration [ ] . the second is that higher quality is associated with size rather than leadership and competition [ , ] . evidence supports the suggestion that hospitals in competitive markets tend to have better administrative management [ ] . the combination of hospital mergers and increased hospital-employed physicians [ ] will lead to increase in laboratory test volumes and the need for robust utilization management practices. the clinical laboratory improvement amendment of (clia' ) went into effect september , . the regulations categorize laboratory procedures based on test complexity using well-defi ned criteria: waived, moderately complex, and highly complex or provider-performed microscopy . these regulations defi ne the universe of tests that a large community hospital laboratory is directly or indirectly responsible for their utilization management. there are a variety of clia-tests that have been classifi ed as waived by the fda and a list of them from to present can be found at www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfclia/ testswaived.cfm . the implementation of point-of-care testing (poct) usually involves a desire to decrease the total turn-around time for an analytical test and improve patient outcome [ ] . however, decreased turn-around time does not always equal improved patient outcome [ , ] . two prospective studies analyzed the effect of the poct i-stat device (abbott, abbott park, il) on length of stay in the emergency department after a control period when the central laboratory was used. the i-stat cartridge that analyzed sodium, potassium, chloride, urea, glucose and calculated hemoglobin was used. neither study revealed any change in the length of stay or clinical outcome for emergency department patients, although both showed a decrease in time required to obtain laboratory results for the six tests on the cartridge when the istat was used. the blood test was not the rate-limiting step in the patient's length of stay [ ] . in a similar study using fi ve different testing cartridges for the istat (inr, lactate, brain natriuretic peptide, troponin t and chemistry with hemoglobin and hematocrit), singer et al. [ ] reported a reduced turn-around time for poct compared to the central laboratory which translated into a reduction in time to completion of iv contrast ct and the length of stay of those specifi c patients. it is not clear whether relocating poct tests to the patient's bedside increases [ , ] or decreases [ ] the test volume of that test in the central laboratory. it has been reported in both adult and newborn intensive-care units that patients with indwelling arterial lines have more blood drawn for laboratory studies than patients without arterial lines [ , ] . the blood loss may be great enough to require a transfusion [ ] . certainly, utilization management of poct programs will require investigations to determine the relationship between total laboratory turn-around time for results, patient outcome and hospital costs using cost effectiveness analyses [ ] . there are at least different sources of body fl uids in a human [ ] . some of these are laboratory specimens that are examined under the bright-fi eld or phase contrast microscope and are classifi ed as provider-performed microscopy (ppm) by clia' [ , ] . a separate cms license is available for sites performing these assays which include koh preparation, pinworm detection, fern test, microscope urinalysis, semen analysis for presence of sperm and motility, and eosinophils in nasal smears [ , ] . it is wise for the laboratory poct administrative committee to assist in the initiation of a ppm testing program in collaboration with the ppm license holder for that clinically defi ned program, like fern testing in the labor and delivery area under the direction of a staff ob/gyn physician. in this model, training and utilization management is not under the direction of the hospital poct administrative committee [ , ] . in order to audit laboratory test utilization year to year it is "essential to understand how test volumes are actually counted" [ ] . are test panels bundled and counted as one test or are the test panels unbundled and each test in the panel counted separately. in an evaluation of the total inpatient test volumes from to for the department of clinical pathology at william beaumont hospital, royal oak, mi, it was determined that the method for counting inpatient tests changed in and [ , there are two categories for cost reductions : "hard" cost savings and "soft" cost avoidance. tangible "hard" cost savings are often achieved by bringing reference laboratory tests inhouse to the clinical laboratory (or eliminating the reference laboratory test altogether) [ , ] . the more intangible "soft" cost avoidance includes such things as decreases costs associated with the introduction of a new laboratory test with the intent to decrease costs in the future. it also can occur when a cost is lower than the original expense that would have otherwise been required if the cost avoidance exercise had not been undertaken. since processes consume overhead and overheard costs money, any signifi cant process improvement could represent signifi cant cost avoidance for an organization. total cost includes direct and indirect costs [ ] . direct cost includes personnel time to prepare and perform the test, reagents, quality control, profi ciency testing, and equipment depreciation. indirect costs including reporting costs (computer) and hospital overhead. incremental or marginal costs include only variable direct costs and not the indirect costs [ - ] . therefore, incremental costs demonstrate what it would cost to perform one more laboratory test, assuming the equipment and facility are already available. neither total cost analysis nor incremental cost analysis includes an analysis of the defect rate or failure to achieve established goals, like turn-around time [ ] . they are defi ned as internal or external failure rates. internal failure costs are incurred by the testing center as a consequence of a defect in the testing system. the receiver of the test results incurs the external failure costs. over utilization of laboratory tests incurs both internal and external failure costs in the excess time spent in the laboratory to generate the result and then excess insurance charges to the patient and nursing/physician time to evaluate the results. to illustrate cost avoidance , consider the presentation of potential enterovirus meningitis in the emergency department. children and adults with detectable enterovirus in the cerebrospinal fl uid (csf) may exhibit symptoms of meningitis including photophobia, stiff neck, acousticophobia , severe headache with vomiting, confusion, diffi culty concentrating, seizure and sleepiness. a molecular test for enterovirus detection will alter the patient's length of stay in the emergency department. if the patient is positive for enterovirus in the csf specimen, the patient will be discharged for home care until the viral meningitis resolves (table . ). if the patient does not have enterovirus in the csf, they will need further hospitalization to rule out a bac-terial source for the meningitis with culture and sensitivity studies (table . ). romero [ ] has demonstrated the cost range for hospitalization related to enterovirus testing/care of infection to be $ - with an average length of stay of - days. we used $ for the calculation in table . , which illustrates a cost avoidance of $ , for patients with or without enteroviral detection by molecular methods. "cost per unit went down if you could make longer and longer runs of identical products. this gave rise to the theory of economies of scale " [ ] . the laboratory achieves economies of scale and lower unit costs per test by expanding the volume of laboratory tests it analyzes. in the early s, the number of inpatient laboratory tests at william beaumont hospital began to decrease. to fi ll the gap, after a -year preparation period, we initiated an outreach program (beaumont reference laboratory) expanding our laboratory testing services to non-patients from physician offi ces, nursing homes, and other hospitals [ , ] . several years later ( ) beaumont reference laboratory joined a regional laboratory network of other hospital-based laboratory outreach programs in michigan, joint venture hospital laboratories , to accommodate the wide geographic coverage required by third party payers [ , ] . the participating laboratories are independently owned and operated. a central network administrator coordinates negotiations for managed care contracts. the volume of brl specimens grew to half of the total volume of clinical pathology procedures of six million tests in . this increased volume permitted an expansion of the test menu in each laboratory section. in , we reviewed , , procedures ordered by physicians in nine subspecialty areas (family practice, pediatrics , internal medicine, cardiology, endocrinology, gastroenterology, nursing home, ob/gyn, and urology). the requisitions for physician, procedures per requisition and procedures/physician were calculated for each of the nine groups of physicians [ ] . family practice ( physicians) and internal medicine ( ) ordered the greatest number of total procedures as well as procedures/physician while urology ( ) ordered the least of these two categories [ ] . the tests ordered by each of the nine groups were counted in seven laboratory sections. all nine groups ordered more chemistry tests than any other category but the percent varied from . % for ob/gyn to . % for internal medicine. the most popular individual tests in fi ve laboratory sections (chemistry, hematology, immunology, microbiology, and molecular diagnostics) were calculated as an average number of a specifi c test ordered per physician per month. using this data, a laboratory section could prepare themselves for the increased utilization from a six-member internal medicine group that the beaumont reference laboratory sales force just signed up as a new client. this type of deep dive into specifi c physician specialty ordering patterns is an invaluable resource for managing a growing outreach business [ ] . the million requests for chemistry, hematology, and microbiology tests were included for all physicians in calgary, canada who ordered a test in fi scal year - [ ] . the physicians were divided into subspecialties and the average yearly cost per group and average yearly cost per physician in each of the groups was calculated. family practice and internal medicine had the greatest average yearly cost per group while hematology and nephrology had the highest average yearly cost per physician per group secondary to utilization of more expensive laboratory tests [ ] . this cost-based approach to utilization review requires the calculation of an average median cost for each test which in the usa would be much less than the price listed on the hospital's charge master. there was a synergistic relationship between the growth of beaumont reference laboratory and test mix complexity in each laboratory section. in the molecular diagnostics laboratory started in , chlamydia trachomatis (ct) nisseria gonorrhoeae (ng) were performed in urine using the ligase chain reaction in and pcr in [ , ] . more than % of the requests for these two assays are from brl clients (table . ). the increased volume of these two assays helped turn the molecular diagnostic section into a profi t center in years. annual utilization review revealed that the outreach program contributed , / , = % of the volume, hospital a ( / , = %) and hospital b ( / , = %). the multiplex assay using primarily urine specimens made a margin of $ . per assay billed (at that time) based on an average medicare reimbursement ($ . ) and cost/test of $ . . why was there an exceptionally low ng volume from hospital b? after an investigation it was learned that hospital b chose to do the less sensitive ng culture assay [ ] to retain laboratory test volume which was encouraged by their hospital administration. also, a myth existed at hospital b that ng would not survive the transport time ( - min) to hospital a. the ordering physicians at hospital b prevailed and the request for molecular detection of ng at hospital b was followed. this case illustrates just how complex problem solving in utilization management issues can be in a large community hospital. some new technologies are defi ned as disruptive innovations , when they offer new paradigms in diagnostics (table . ) [ , , ] . all seven of the technologies listed in table . share similar issues including clarifi cation of the best applications for routine clinical use, paucity of evidence-based outcome literature to review, education of practitioners and physician users of the clinical information generated and software to convert big databases the method generates into useful information. the references in table . will direct attention to these issues for the seven disruptive innovations [ - ] . as the paradigm shifts and these strategies become incorporated into daily clinical practice, the debate about appropriate utilization will diminish. this next section will devote time to describing the impact of current changes in microbiology ( mass spectrometry for bacterial identifi cation [ , , ] and multiplex molecular panels for infectious agent detection for respiratory viral panels and gastric pathogen panels) and future changes ( microscopy for antibacterial drug sensitivity). traditionally, the laboratory diagnosis of most infectious disease pathogens has relied on culturing and in vitro growth of the causative agent. once culture growth has been achieved, then automated and/or manual biochemical tests can be performed to identify the microbial organism(s). these methodologies are dependent on skilled medical technologists to perform the manual tasks required to determine the bacterial identifi cation (id). the approach to id and antimicrobial susceptibility testing (ast) has been dependent on testing a single pathogen at a time, regardless if the culture [ , ] growth yielded multiple, signifi cant pathogens. although automated id and ast systems can run multiple isolates to help streamline the workfl ow and maximize throughput, the basic testing is still individually performed for each isolate being analyzed. another limiting factor for culture based detection methods is that some bacteria do not grow well or at all in vitro adding to the potential of missing a signifi cant organism(s). viral cultures are time-consuming because cytopathic effects (cpe) must be observed before other methods can be used to determine the viral identifi cation [ - ] . the development of viral antigen based testing [direct fl uorescence antigen (dfa) and other rapid antigen testing devices] directly from the sample shortened the culture time to obtain a faster diagnosis. however, the reliable performance of the viral antigen based testing is highly dependent on the quality of the sample collected and is less sensitive than viral cultures [ ] . a suboptimal specimen could lead to a false negative antigen/dfa result. are viral cultures and antigen based testing truly needed in a clinical microbiology/virology laboratory since molecular methods are becoming the new gold standard? [ - ] . many routine clinical microbiology/ virology laboratories do not have the capabilities to perform viral cultures lacking the physical space and expertise to interpret the cpe [ ] . as technology advances, the traditionally " agrarian society " of the laboratory is becoming more industrialized with the implementation of automation, molecular based testing, and use of mass spectrometry ( maldi-tof -matrix-assisted laser desorption ionization-time of flight). many of these advances are revolutionizing how microbiology testing is performed and disrupting how traditional clinical microbiology workfl ows and processes are set up. however, all of these technological advances are shortening the time for a laboratory diagnosis and ultimately maximizing the impact to patient care and how physicians at a large community hospital will utilize the more rapid microbiology laboratory services. there is a trend in clinical microbiology to develop syndromic panels using molecular techniques. for example, positive blood culture panels have been developed to reduce time to start the most appropriate antibiotics in the patient. once a blood culture bottle is fl agged as positive, a gram stained smear is prepared to determine the presence of bacteria (and potentially yeast) in the patient's blood sample. if any organism(s) are seen, a call is made to the patient's healthcare provider so that broad-spectrum antimicrobial therapy can be initiated until the confi rmed microbiological id is resulted. a caveat for the clinician is that s/he must make their best educated guess for determining which antibiotic treatment to use. clinical microbiology laboratories typically publish an antibiogram so that clinicians and hospital pharmacists know the prevalence of susceptible and resistant phenotypes for their most common bacteria isolated. although this provides a good start and useful reference, there is a heavy emphasis on antimicrobial stewardship and tailoring therapy as soon as possible so that there is less pressure for the development of antimicrobial resistance . many institutions have developed or are in the process of developing formal antibiotic stewardship programs/committees in an effort to improve the utilization of antimicrobial treatments. molecular methods have been developed that will, within one test, identify a number of pathogens from a positive blood culture sample. these methods have decreased the amount of time to provide a more defi nitive id and an abbreviated antimicrobial resistance genetic profi le. advandx/ biomerieux, inc. utilizes pna-fish (peptide nucleic acidfl uorescent in situ hybridization) and detection of a positive fl uorescent signal directly from a positive blood culture . gram stained smear fi ndings typically are resulted as "gram positive cocci in clusters" or "gram negative rods" (table . ). this information is useful in deciding broadspectrum therapy, but a more focused therapy is the ultimate goal to ensure that the pathogen is adequately treated. the pna-fish assays offer four basic assays [ staphylococcus (gram positive), enterococcus (gram positive), gram negative, and candida ] that complements the gram stain result so that clinicians at least have a presumptive genus identifi cation. additional pna-fish probes do have the ability to separate s. aureus /coagulase-negative staphylococcus and a meca probe for the identifi cation of mrsa. use of these pna-fish assays requires a fl uorescent microscope to visualize the results. a number of studies have shown the clinical benefi ts of pna-fish implementation as part of the blood culture workup before the confi rmatory culture growth and potentially identifying methicillin resistance genotype, in the example of s. aureus , before the full antibiotic susceptibilities can be performed [ - ] . antibiotic therapy can, therefore, be tailored or deescalated as appropriate. similar to the pna-fish scenario, when utilizing cepheid's xpert mrsa/sa blood culture test the gram stained smear prepared from the positive blood culture smear will determine whether cepheid's assay should be run. cepheid's methodology is real-time pcr based and does not require any subjective interpretation of the results by the laboratory staff. the cartridge for the xpert mrsa/sa test houses all the reagents and is compartmentalized to accommodate the nucleic acid extraction, pcr amplifi cation, and detection in one device. the testing is automated once the sample is loaded into the test cartridge and the software analyzes the pcr amplifi cation curves to determine if a patient's blood sample is positive or negative for mrsa or mssa [ - ] . the cepheid and advandx tests must be added to the already existing workfl ow, and serves as another laboratory tool to more quickly determine the pathogen identifi cation and a preliminary ast profi le. nanosphere, inc. and biofire diagnostics, inc. approach testing from positive blood culture bottles by targeting the most common pathogens (bacteria or yeast) that can cause sepsis. this is a unique approach due to the overlap in patient symptoms for a specifi c syndrome or condition. when the symptoms overlap, clinicians have diffi culty defi ning the causative pathogen(s) infecting their patient solely from the clinical picture, and delaying specifi c pathogen-based therapy. use of these syndromic multiplex molecular panels streamlines the testing process to more of a "one-and-done" approach. nanosphere offers different panels: ( ) gram positive ( bc-gp panel ); ( ) gram negative ( bc-gn panel ); and ( ) yeast ( bc-y panel ) and the organism(s) observed from the gram stained smear will determine which panel(s) to run. additional testing with the gram positive and gram negative panels also includes testing for certain antibiotic resistance genes encoding for methicillin ( meca ) and vancomycin ( vana and vanb ) resistance (table . ). there are many studies showing overall good performance for the bc-gp panel [ - ] , gram negative species and candida spp. panels [ , ] . there are limitations with molecular testing as observed by buchan et al. [ ] . a positive meca target was not able to be assigned due to the presence of a mixed infection. in this case the full antibiotic sensitivity testing is still recommended because the traditional methods test each bacterial pathogen individually. beal et al. [ ] noted that when blood culture infections were caused by one pathogen, there was good performance of the multiplex molecular assays. when polymicrobial blood culture infections were noted, there was only % agreement with the routine cultures. mestas et al. [ ] also noticed a lower percentage agreement for polymicrobial infections when compared to monomicrobial infections. polymicrobial bacteremia is relatively rare, but can potentially be severe [ ] . again, cultures are still required to identify the full antibiotic susceptibility profi le, and to identify pathogens that are not included in the multiplex molecular panels. the filmarray blood culture identifi cation panel (bcid) is another comprehensive panel that covers gram positive, gram negative, and yeast pathogens (table . ) and a gram stain is not required. however, it is still good routine practice to perform the gram stain to correlate results with the molecular panel results and the eventual culture testing and antibiotic susceptibility testing. altum et al. [ ] observed that certain pathogens were detected in routine cultures that were not detected in the filmarray panel because those pathogens were not in the molecular panel. so although the comprehensive panel covers the most common pathogens, clinical intuition is still ultimately needed especially when clinical symptoms and other laboratory data point to a bacteremic process in the setting of a negative filmarray panel. overall, these assays show the potential for a decreased tat and a preliminary susceptibility profi le based on the antibiotic resistance genes tested [ , , , ] . the ability to have a more rapid answer that is technically more sensitive and specifi c will have positive downstream effects on patient care and antibiotic stewardship. the impact of these rapid pcr blood culture assays on the clinical end users (infection control, pharmacy, length of stay, and overall hospital costs) is not well defi ned. one study by bauer et al. [ ] demonstrated clinical benefi t after implementing the cepheid xpert mrsa/sa assay for positive blood cultures. a -month pre-pcr period was evaluated followed by a -month post-pcr period. there was an overall shorter length of stay ( . days shorter) and mean hospital costs were $ , less than what was observed in the pre-pcr period. infectious disease pharmacists were more effective in deescalating or changing to more specifi c antibiotic therapies compared to the pre-pcr period. benefi ts were gained by having a more rapid and sensitive test. when adopting newer molecular methods, the laboratory must work with their clinical counterparts to determine the clinical utility of a more rapid test. the cost and potential benefi ts of the newer tests may not be warranted if the clinical staff is not able to effectively utilize this information in their workfl ow. even though the downstream benefi ts have been documented and are almost inarguable from a clinical perspective, there are fi nancial and workfl ow impacts to the microbiology/molecular laboratories that implement these assays. as mentioned prior, the gram stain results from the positive blood cultures will help drive the culture workup. thus, there is the time required for a blood culture bottle to alarm as positive, and then the culture time waiting for growth on the culture plates. the use of these molecular methods must be introduced into the workfl ow and will add additional work because culture id and ast methods still must be performed. in the setting of having a continual decrease of incoming medical technologist graduates and an increasing number of laboratorians retiring, this puts the burden of additional testing on the existing staff. another example of a clinically benefi cial, but disruptive test within the laboratory is the development of respiratory pathogen panels. molecular multiplex panels have been developed to target the general syndrome of a respiratory illness. table . shows that there are a variety of fda-approved assays available with a varying number of pathogens offered within their respective multiplex assay. each assay also requires varying levels of hands-on-involvement and molecular expertise required by the medical technologist. prior to the implementation of a respiratory virus panel (rvp) in our institution, the only viral testing offered were the rapid antigen immunochromatographic devices for infl uenza a/b and respiratory syncytial virus (rsv). with the addition of offering rvp testing, we are now able to provide our clinicians with a more comprehensive answer of which virus(es) are occurring in their patient. this benefi ts transplant, immunocompromised, and oncology patients who have more frequent respiratory viral infections [ - ] . we had serendipitously brought in the rvp before the h n -infl uenza a outbreak which demonstrated the poor performance of the rapid antigen testing [ ] . because of this observation, many laboratories have discontinued their rapid antigen test offerings and now only offer molecular tests. in our laboratory, we have observed a decline in rapid infl uenza and rsa antigen testing (fig. . ) . the spike in volumes in - was related to the h n infl uenza a outbreak. we will eliminate these rapid antigen tests in favor of a rapid molecular test for infl uenza and rsv. an algorithm will refl ex a negative rapid molecular infl uenza a/b and rsv test to a more comprehensive viral and/or bacterial panel. when compared to the dfa and/or shell vial culture, a molecular multiplex respiratory virus panel saved time and lowered costs to the patient [ , ] . despite the clinical benefi ts observed, a limitation of molecular based methodologies is that they are batched and can take hours to perform in the laboratory. for example, in our laboratory the testing time is - h as compared to the -min it takes to run the rapid antigen testing. that trade off in time to result is offset by the increase in sensitivity, specifi city, and breadth of viral pathogens discovered. this can be a challenge for clinicians because many times they will want a fast answer for the purposes of triaging or taking action on a patient. however, the question that should be asked of them is whether they want a bad quality, rapid answer or a good quality, not-so-fast answer. biofire diagnostics, inc. has attempted to solve the testing time problem by offering a comprehensive respiratory pathogen panel that tests directly from the respiratory specimen. only one patient can be run on one instrument and the assay time is approximately h. there will be certain institutional settings where this technology will have benefi ts such as an urgent care clinic, smaller community hospital, or within a laboratory that has minimal molecular testing experience. however, for those institutions with a higher volume where batch testing is more optimal, the biofire may not be the best solution. there are other commercial panels that differ in the number of pathogens offered as well as various levels of medical technologist involvement (table . ). the decision to implement one of these panels is driven by a myriad of factors such as cost, workfl ow, physician demand, and the technical capabilities of the laboratory staff. whatever respiratory pathogen panel is introduced, remember that the sample testing volume is highly dependent on seasonal variations. figure . shows a graph of our volumes over two respiratory virus seasons (august through april ) with our peak volumes occurring over the winter months. this variability can have a signifi cant impact to how microbiology/molecular laboratories are staffed. physician demand, coupled with an increase in testing volumes, may be high enough to warrant increasing the number of runs per day as the staffi ng levels allow, potentially leading to an increase in employee overtime hours. interestingly during fig. . the decline in the rapid antigen infl uenza and rsv testing volumes in response to the introduction of rvp testing in conjunction with the h n /infl uenza a outbreak the respiratory virus season, amidst reports of the infl uenza vaccine having suboptimal effi cacy [ ] , we observed a large increase in rvp testing volumes compared to the prior season. thus, one factor that is virtually impossible to control is the antigenic drift/shift of the infl uenza a virus affecting the effectiveness of the current vaccine in use. assay performance may also be affected due to genetic mutations being introduced into the pcr targeted gene regions. with the limitations of culture and antigen based testing , co-infections were greatly under-appreciated for respiratory viral infections. one can expect an increased incidence of co-infections with multiplex molecular panels. figures . and . show our experiences with co-infections among pediatric and adult patients. the clinical signifi cance of these co-infections is not completely understood in relationship to modulation of disease severity [ - ] . research is needed to fully understand virus-virus and bacteria-virus co-infections and their interactions with the other pathogens present as well as the pathogen-host interactions . every respiratory virus season, our laboratory publishes a " virogram " that shows the prevalence of viruses currently circulating among the patient population (fig. . a, b ) . infectious gastrointestinal illness is another syndrome targeted by commercial vendors. as of this writing, there are a number of fda-approved assays from luminex, inc. , biofire diagnostics, inc. , becton dickinson diagnostics, inc. , nanosphere, inc. , and genprobe-prodesse (table . ) . clinicians are often unaware of what pathogens are actually included when they order a stool culture and ova & parasite (o&p) testing [ ] . similar to respiratory illness symptoms, the symptoms of an infectious gastrointestinal (gi) illness overlap also making it diffi cult to ascertain the true pathogen(s) causing the disease. the development of an infectious gi panel that targets bacterial , viral , and parasitic pathogens , provides a more effi cient approach to diagnosis compared to standard practices. the appeal to the clinical microbiology laboratory is the consolidation of culture, antigen, biochemical, and single-molecular analyte testing into one comprehensive panel. the implications to the state and public health laboratories that rely on culture isolates for epidemiological typing and characterization may not be immediately recognized when considering these molecular stool panel tests. because of the improved ability to detect a pathogen(s) with molecular methods as compared to culture, there will be scenarios when the molecular test is positive and the culture growth is negative. it is imperative that clinical laboratories communicate with their state/public health laboratory counterparts to come up with an amenable solution given that there will be discordant molecular and culture results if an isolate is required to be sent to the state/public health laboratory. similar to respiratory co-infections , gi co-infections are also an under-appreciated aspect of disease and pathogenicity. what potentially makes gi co-infections more confusing and would require some additional clinical scrutiny is that some bacteria can be colonizers (i.e., c. diffi cile ) and so the burden of determining clinical signifi cance is left to the clinician. maldi-tof is another technology that shortens the time to result for determining the microbial identifi cation of clinically signifi cant pathogens. the reader is referred to a number of reference review articles on the technology itself [ - ] . recently, maldi-tof systems have been made commercially available for use in the clinical microbiology laboratory. how this technology compares with the currently available testing (culture/biochemical and dna sequencing) is outside the scope of this chapter [ - ] . maldi-tof does outperform the conventional methods in overall accuracy and time to result. our laboratory has implemented maldi-tof as an identifi cation tool. results are available in approximately day earlier when compared to our traditional culture based testing. branda et al. [ ] found that maldi-tof reduced turn-around time by . days compared with their traditional testing. a side effect that we have observed is an increased number of calls from clinicians asking for the antimicrobial susceptibility results. these results are available the next day from our automated ast system. in addition laboratories will need to adapt their workfl ow processes when maldi-tof testing is implemented. the upfront cost of instrumentation is high (approximately $ , ), resulting in delayed implementation in some clinical microbiology laboratories. the fi nancial savings are realized in the cost per isolate of running the maldi-tof compared to the cost per isolate for a traditional work-up [ , , ] . there can be reductions in the reagent and laboratory costs when compared to culture/ biochemical methodologies [ , ] . despite the initial capital expenditure to obtain the instrumentation, there are cost-savings after maldi-tof is implemented. if the organism is not in the maldi-tof database, it will need to be confi rmed by traditional methods and/or dna sequencing . another potential limitation is that the defi nitive speciation by maldi-tof can confuse clinician end users when they see a new bacterial genus/species name that they do not readily recognize and may pose challenges in deciding what antibiotics to prescribe. this new defi nitive identifi cation is a result of technological advancements that have a greater ability to further speciate bacteria when only a genus answer may have been given with traditional techniques (i.e., coagulase-negative staphylococcus or enterobacter cloacae complexes). from the laboratory perspective, changes in nomenclature must be updated in the laboratory information system as appropriate when microorganisms undergo taxonomic reclassifi cations. future advancements with maldi-tof technology also will affect the clinical microbiology laboratory workfl ow. studies have preliminarily shown the ability to detect the pathogen directly from a patient sample (i.e., positive blood cultures [ , , ] and urines [ - ] ), bypassing the current requirement for testing on a culture isolate. however, it should be stressed that direct sample testing is in the very early stages of development. antibiotic susceptibility testing has also been examined and hrabak et al. [ ] provide an in-depth review of using maldi-tof for these purposes. interestingly, this technology has also been described in identifying the species of ticks potentially minimizing the ectoparasite experience normally required [ ] . technological advancements are focused on shortening the time of pathogen detection so that clinical action can be taken much more quickly. two relatively new companies have been working on methodologies that will further disrupt clinical microbiology practices. t biosystems, inc. has recently received fda approval for the detection of fi ve candida species ( c. albicans , c. tropicalis , c. parapsilosis , c. krusei , and c. glaboratoryrata ) direct from the patient's blood sample without prior incubation within a blood culture bottle. the t biosystems assay claims to detect these candida species within h. this technology shortens start time for appropriate candidemia treatment. patient mortality is decreased, the earlier treatment is started [ ] . having the ability to identify the particular candida species is critical since c. glaboratoryrata and c. krusei have signifi cant rates of azole resistance [ , ] . similar to the other blood culture tests mentioned above, this technology will not eliminate the need for culture/pcr and antimicrobial susceptibility testing after a blood culture bottle becomes positive. the technology allows for processing of the whole blood sample, since a thermostable mutated dna polymerase that is not affected by inhibitors in whole blood detection is used to amplify dna. detection of any pcr product is done via t magnetic resonance technology. ( www.t biosystems.com ). clinical trials data show an overall sensitivity of . % with a mean time of . h for detection and species identifi cation [ ] . the limit of other studies have demonstrated earlier detection and its effect on antimicrobial stewardship [ , ] . because this is a relatively new technology, hospitals and other healthcare institutions are currently determining the most optimal and cost effective way to utilize this technology. this test is not intended as a screening tool, but should be used in a more targeted patient population where candidemia is more signifi cant and more likely to occur. accelerate diagnostics, inc. has developed a methodology for both rapid pathogen identifi cation and antimicrobial susceptibility testing that can purportedly be performed within h ( www.accerlatediagnostics.com ). the company is conducting clinical trials on blood culture pathogen panel at the time of this writing. the technology utilizes fish dna probes to identify the panel pathogens that may be present. the antimicrobial susceptibility testing results are determined by single-cell microbiological analysis via time-lapse computerized images of the pathogen's growth characteristics in the presence of a particular antibiotic. the blood culture pathogen panel assay is intended to be the company's fi rst fda-approved assay with other sample type panels in their assay pipeline. automation in the microbiology laboratory has been a slow to make an impact unlike the other laboratory sections (i.e., chemistry, urinalysis, etc.) attributable to the inherent manual process of specimen preparation required. vendors are developing automated plate streakers for more consistent yields with culture plating. also, companies are developing automated specimen processors that can be programmed to inoculate a battery of plates. one can imagine the advantages to be gained with high volume sections of the laboratory such as urine cultures [ - ] . the implementation of microbiology automation is in its infancy and there is debate on the utility of automation and its widespread adoption. the potential is there for a large impact on the manual workfl ow and disruption of how clinical microbiology laboratories function. obviously, there is a fi nancial aspect to the implementation of automation and the estimated total cost of a total automated microbiology solution can be in the millions of dollars [ ] . it is not out of the realm of possibilities for further advancements for a total microbiology laboratory automated technological solution where clinical microbiologists may be able to function from a "virtual" bench able to work up cultures and set-ups for other downstream tests from a computer touchscreen/tablet eliminating the potential hazard of being exposed to pathogenic and/or bioterrorism organisms. the arrival of new equipment in a large community hospital laboratory, chemistry automation [ ] for example, creates a lot of stress on the staff to complete the performance verifi cation of the new quantitative analytical systems [ , ] . the practicing physician and healthcare system depend on this equipment to perform well. the assays will require verifi cation of calibration , linearity , analytic measurement ranges, accuracy, precision, appropriateness of the reference range and quality control requirements [ - ] . a variety of poct and main chemistry laboratory methods for hba c have been evaluated to see if that meets the total allowable error goal set by the cap proficiency testing program and the national glycohemoglobin standardization program (ngsp) [ - ] . "clearly, many methods, including a few poc methods, do perform well in laboratories, as seen by data from the cap proficiency surveys" [ ] , our new system was not one of those good performers. we replaced immunoassays for hba c (roche diagnostics method, siemens medical solutions diagnostics-potential new method) with a capillary electrophoresis method (sebia) [ - ] . during the evaluation of these three hba c methods, the roche immunoassay reported hba c values ( . - . %) for four patients with no hba but had hbsc. during the screening of random patients, % had homozygous or heterozygous variants [ ] . hb n-baltimore comigrates with hba c on capillary electrophoresis while hb silver spring and other hb variants did not [ ] . in this case, a method for hba c had to be quickly evaluated to replace the immunoassay originally planned for implementation to prevent repeated profi ciency testing failures and potential discontinuation of the hba c assay. an obsolete test is a test that is no longer in use or no longer useful (table . ) [ , - ] . an effective way to evaluate whether a test has become obsolete is to review it at the laboratory utilization committee that is responsible for the laboratory formulary [ ] . the formulary concept comes from the play book of the pharmacy and therapeutics committee that approve medication for use by medical providers and under what circumstances. when a newer more effective drug is fda approved it may replace an older less effective drug in the formulary. in the laboratory, the perfect obsolete test cannot be ordered by a medical provider because the reagents are no longer provided by the in vitro diagnostics industry. for example, protein bound iodine (pbi) [ ] is no longer available at any reference laboratory because the test reagents are no longer manufactured. however, t uptake is just as obsolete and useless; however, its reagents are still manufactured by many vendors and still offered by reference laboratories [ ] . in a utilization review of our hospital's send out test volume, it was asked by the reference laboratory why physicians ordered so many t uptake assays from them. i said it is not on our formulary just like ck mb [ - ] , but both of these obsolete tests and others are still ordered and performed by your reference laboratory. the response was "we offer the test because physicians order the test," however, if the reagents were not available from the manufacturer, it is unlikely the reference laboratory would develop a laboratory developed test to support obsolescence. the workaround for removal of the obsolete tests from the hospital laboratory formulary usually involves the use of an emr that has reference laboratory test ordering built for the convenience of the medical providers. if this feature is not inactivated for inpatients the hospital laboratory formulary develops a leak from which a fl ood of abuse can originate. until locally defi ned obsolete tests are universally accepted and eliminated from the test lists of hospitals, manufacturers, and reference laboratories, the discovery of ingenious work-arounds will occupy the time of the medical providers who by habit are accustomed to having the obsolete test results by their side. the utilization management of laboratory tests in a large community hospital is similar to academic and smaller community hospitals. there are numerous factors that infl uence laboratory utilization (table . ). outside infl uences like hospitals buying physician practices, increase in the placement of hospitalists and hospital consolidation will infl uence the number and complexity of test menu that will need to be monitored for over and under utilization in the central laboratory and reference laboratory. the laboratory utilization committee and laboratory formulary stewardship are key to a successful beginning. there are numerous excellent suggestions and reports of the successful implementation of remedies that have been reviewed and arranged in generic toolkits or tool boxes [ , , ] or with solutions for specifi c laboratory sections like microbiology [ , ] , toxicology [ ] , chemistry [ ] , transfusion medicine [ ] , and molecular diagnostics [ - ] . this useful approach provides a resource for the exploration of laboratory test utilization management issues and their potential resolution using a method that is successful in your local geographical environment. 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other respiratory viruses coronavirus causes lower respiratory infections less frequently than rsv in hospitalized norwegian children identifi cation of viral and atypical bacterial pathogens in children hospitalized with acute respiratory infections in hong kong by multiplex pcr assays survey of physician diagnostic practices for patients with acute diarrhea: clinical and public health implications what is new in clinical microbiology: microbial identifi cation by maldi-tof mass spectrometry application of maldi-tof mass spectrometry in clinical diagnostic microbiology applications of maldi-tof mass spectrometry in clinical diagnostic microbiology maldi-tof mass spectrometry applications in clinical microbiology matrix-assisted laser desorption ionization-time of fl ight mass spectrometry: a fundamental shift in the routine practice of clinical microbiology maldi-tof mass spectrometry for microorganism identifi cation comparison of two matrix-assisted laser desorption ionization-time 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desorption ionization-time of fl ight mass spectrometry for identifi cation of clinically signifi cant bacteria that are diffi cult to identify in clinical laboratories performance and cost analysis of matrix-assisted laser desorption ionization-time of fl ight mass spectrometry for routine identifi cation of yeasts for the diagnosis of infectious diseases direct identifi cation of bacteria in positive blood cultures: comparison of two rapid methods, filmarray and mass spectrometry evaluation of three rapid diagnostic methods for direct identifi cation of microorganisms in positive blood cultures direct identifi cation of bacteria causing urinary tract infections by combining matrix-assisted laser desorption ionization-time of fl ight mass spectrometry with uf- i urine fl ow cytometry procedure for microbial identifi cation based on matrix-assisted laser desorption ionization-time of fl ight mass spectrometry from screening-positive urine samples direct identifi cation of urinary tract pathogens from urine samples by matrix-assisted laser desorption ionization-time of fl ight matrix-assisted laser desorption ionization-time of fl ight (maldi-tof) mass spectrometry for detection of antibiotic resistance mechanisms: from research to routine diagnosis matrix-assisted laser desorption ionization-time of fl ight mass spectrometry for rapid identifi cation of tick vectors mechanism of fl uconazole resistance in candida krusei clinical practice guidelines for the management of candidiasis: update by the infectious diseases society of america t magnetic resonance assay for the rapid diagnosis of candidemia in whole blood: a clinical trial t magnetic resonance: a diagnostic platform for studying integrated hemostasis in whole blood-proof of concept comparison of the t dx instrument with t candida assay and automated blood culture in the detection of candida species using seeded blood samples automation in clinical microbiology point-counterpoint: the automated clinical 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rare hb variants on hb a c measurements in eight methods hemoglobin a c: evaluation of methods antiquated tests within the clinical pathology laboratory requiem for a heavyweight: the demise of creatine kinase-mb creatine kinase-mg. the journey to obsolescence should the qualitative serum pregnancy test be considered obsolete? aetna clinical policy bulletin: obsolete and unreliable tests and procedures the interpretation of the serum protein-bound iodine: a review cerebrospinal fl uid myelin basic protein is frequently ordered but has little value. a test utilization study acg clinical guidelines: diagnosis and management of celiac disease laboratory formularies the laboratory test utilization management toolbox reducing unnecessary laboratory testing using health informatics applications. a case study in a tertiary care hospital effect of population-based interventions on laboratory utilization. a time series analysis utilization management in the blood transfusion service clinical requests for molecular tests. the -step evidence check improving molecular genetic test utilization through order restriction, test review, and guidance genetic counselor review of genetic test orders in a reference laboratory reduces unnecessary testing differences in brca counseling and testing practices based on ordering provider type key: cord- -cnd l d authors: rajakulasingam, r.; dasilva, e. j.; azzopardi, c.; fernandez, t.; botchu, r.; hargunani, r. title: standard operating procedure of image-guided intervention during the covid- pandemic: a combined tertiary musculoskeletal oncology centre experience date: - - journal: clin radiol doi: . /j.crad. . . sha: doc_id: cord_uid: cnd l d abstract aim to evaluate the response measures in continuing an image-guided intervention service in two tertiary-level musculoskeletal oncology centres during the covid- pandemic. materials and methods the present study was a retrospective review of all patients undergoing image-guided intervention in the computed tomography (ct) and normal ultrasound (us) rooms from march to may (during the covid- pandemic peak) at royal national orthopaedic hospital, london, and royal orthopaedic hospital, bristol, uk. measures were put in place to address air pressures, airflow direction, aerosol generation, and the safe utilisation of existing scanning rooms and work lists for interventional procedures. results three hundred and thirty-one patients ( at royal national orthopaedic hospital and at royal orthopaedic hospital) underwent image-guided procedures at both sites in the ct and us rooms. at the royal national orthopaedic hospital, % of all procedures were performed under general anaesthesia. these consisted of ct biopsies, seven ct radiofrequency ablations (rfas), and us biopsies. at the royal orthopaedic hospital, % of all procedures were performed under local anaesthetic, with no general anaesthetic procedures. these consisted of ct biopsies and us biopsies. all patients having procedures in the ct room had no post-procedural complications or covid- -related symptoms and morbidity on follow-up. conclusion by adopting a pragmatic approach with meticulous planning, a limited, but fully functional image-guided interventional list can be run without any adverse patient outcomes. the covid- pandemic is unlike anything seen before in modern day medicine, placing enormous strains on healthcare systems worldwide. although not seemingly frontline, radiology services have been greatly affected with a significant decline in imaging capacity. within this context, there has been a drastic change to workload and working patterns in radiology departments across all national health service (nhs) hospitals, including curtailing all elective work, home reporting, and reduction of referrals and virtual attendance at multidisciplinary team (mdt) meetings. despite this, essential imaging and procedures in the setting of a tertiary level musculoskeletal oncology service have still continued. the royal college of radiologists (rcr) has recently published guidance stating that urgent interventional procedures remain one of the patient categories for which services should continue. musculoskeletal-related soft-tissue and bone sarcoma patients referred to specialist centres remain a protected pathway throughout the pandemic, with a view to avoid treatment delay, which could have a detrimental effect on outcomes and survival for cancer patients. aerosol-generating procedures (agp) have been defined by public health england (phe) as procedures that may generate higher concentrations of infectious respiratory aerosols than coughing. endotracheal intubation, a component of general anaesthesia (ga) for many biopsy patients is considered an agp. clearly, if no precautions were taken, there would certainly be a higher probability of patients contracting covid- with unforeseen consequences. bearing this in mind, it was decided to assess the safety of the current set-up for image-guided intervention at the royal national orthopaedic hospital and royal orthopaedic hospital. the decisions made were reviewed retrospectively in order to continue a fully functional but somewhat limited sarcoma biopsy and intervention service across both sites. the present study outlines considerations related to airflow exchanges and the need for extraction ventilation during ga induction. it will also briefly discuss changes to the biopsy worklist, workflow pattern, and personal protective equipment (ppe). the intricacies of ga induction will not be discussed. finally, the number of cases performed at each site and any complications at follow-up are present. the aim of the present study was to evaluate and explain the rationale behind the approaches taken at both institutions to continue with urgent diagnostic interventional procedures, whilst ensuring low viral transmission risk to patients and staff. although most elective work has been halted across the country, the authors' combined experience demonstrates that it is possible to offer a safe image-guided intervention service as long as all the necessary precautions are taken. for ga cases, full ppe was worn in the form of a filtering face piece respirator and eye protection in accordance with rcr guidelines. anaesthetists followed their relevant royal college-based guidelines, depending on the case type. , sedation according to phe is, however, not considered an agp, thus full ppe as mentioned above was not a requirement, and a surgical gown with facemask and gloves sufficed; , however, the radiologist and anaesthetist carrying out the procedure often felt safer wearing full ppe, and so personal preference for sedation procedures was usually the deciding factor. this is understandable, as in theory, sedation cases could be upgraded to full ga and wearing full ppe avoided any potential problems removing and putting on new ppe. the potential for viral transmission brought about many logistical challenges that needed to be addressed. at both sites, patient consent would be done in the ward and never in the imaging department itself. at the royal national orthopaedic hospital, all ct-guided procedures were undertaken by one consultant radiologist. at the royal orthopaedic hospital, a consultant or radiology fellow were present with preferably only one person in the room. a minute to h turnaround time slot was allocated between each patient. this ensured enough time for removal of any contaminated items and allowed a deep clean of the whole ct room. the patient was taken back into the recovery room at the end of the procedure for extubation. in accordance with the centers for disease control and prevention (cdc) guidelines, the room was also left empty for at least minutes after the patient had left the department to ensure enough air exchanges had taken place. this was felt sufficient to remove . % of any potential airborne contamination. given the time needed for deep cleaning and minimising potential viral transmission, the biopsy list was curtailed to have only a maximum of four ga cases at the royal national orthopaedic hospital. at the royal orthopaedic hospital, usually one sedation case per list was performed with roughly two to three local anaesthetic (la) cases. the overall numbers were greatly reduced during the pandemic period; normally, eight to cases would be biopsied on a fully functional list at either site. all cases to be biopsied were discussed the week before within a sarcoma mdt setting ensuring they were urgent and could not wait until after the covid- pandemic peak. all non-urgent cases were deferred. the coronavirus is mainly transmitted by respiratory droplets with some evidence for airborne transmission. , the act of intubation itself does not produce aerosols, rather it is coughing through inadequate paralysis where viral transmission can occur. , aerosols could also be produced by other means during the peri-intubation period, such as delivering high-flow oxygen or suction. in general, intubation represents a very high-risk moment for contact or droplet transmission, and so, is regarded as a high-risk procedure. the virus particles are too small (< µm) to be contained by even the best air filters. thus unlike larger droplets, which may just evaporate within milliseconds, the coronavirus can remain suspended in air for up to h within normal indoor conditions and on surfaces for a few days. if potential agps are required, ventilation systems should exist that permit extraction, increasing air-exchange rates, and allowing as much outside air circulation into the area of concern. the health technical memorandums released by the doh stated that operating rooms should have a minimum of , with the ability to increase to air exchanges per hour (ach) for high-risk patients. interestingly, no specific guidance for radiology interventional suites is stated, but both departments agree that a minimum of ach should be used, as stated for minimal access interventions elsewhere. the ach is designed to supply a high rate of clean (filtered) air for interventional procedures reducing infectious risk. in addition, satisfactory m distancing between all involved health professionals needed to be adhered to within the interventional room. as well as appropriate air-exchange rates, a negative-pressure environment was ideally needed. although in principle a positive-pressure room with adequate air changes could quickly eliminate the virus, an adjacent negative pressure meant that all contaminated air was kept within the environment reducing dispersion. this in theory meant that health personnel were at increased risk of direct virus contact; hence, strict ppe adherence was required. a physical air-quality monitoring report was commissioned by the royal national orthopaedic hospital and provided by the east and north hertfordshire nhs trust quality and control department after visiting the royal national orthopaedic hospital scanning centre. the layout of the ct suite and neighbouring rooms with measured air pressures and ach is illustrated in fig. . unfortunately, the existing ct room did not have an extraction ventilation system and was deemed unsuitable for ga induction. fortunately, the adjacent mri preparation room across the corridor measured ach and could be used. being the only adjacent room with the requisite ach and pre-installed ventilation extraction system, a decision was made to carry out all ga inductions in that room. outside air was introduced into the room, and room air was extracted through flap vents located throughout the ceiling. there was also a requirement for the corridor immediately outside this preparation room to have a pressure of minimum - pa, this fortunately measured - . pa. following consultation with the infection control team, it was deemed safe to transfer patients from the mri preparation room, across the small corridor, and into the adjacent ct room. fortunately, the natural pressure gradient already in the corridor meant that no further adaptation or installation was needed. at the royal orthopaedic hospital, the estate and facilities department commissioned a company to undertake airflow tests in the ct room. again, no extraction ventilation system was present with less than required minimum number of ach; however, unlike the royal national orthopaedic hospital, there was no neighbouring room with adequate ach and no method of maintaining a negative pressure environment. ultimately, a decision was made to stop performing all ga biopsy cases; however, the ct room was still deemed safe for la, sedation, and regional anaesthesia. cases suitable for sedation or regional anaesthesia would be fully discussed between the consultant radiologists and anaesthetists, usually after meeting the patient on the day of the procedure. guided rfas were carried out both under regional block anaesthesia and sedation. in one rfa case, sedation and regional block was not sufficient and full ga was required with endotracheal intubation. table the scope of interventional radiology has evolved dramatically in the past years especially within a tertiary-level musculoskeletal oncology service. image-guided biopsies in such centres are usually the main investigation performed to obtain a histological diagnosis for bone and soft-tissue sarcoma. given its importance, it is surprising that ventilation systems in most ct rooms still lag behind those in operating theatres. this likely reflects the fact that the biopsies are done within the ct room itself rather than a true dedicated interventional suite. moreover, bone sarcoma biopsies were traditionally performed under x-ray guidance and only more recently under ct. the main source of potential coronavirus airborne contamination is the skin of personnel moving within the procedure room. in operating theatres, airborne virus particles can be diluted by supplied air, with air then flowing to less sensitive areas. in addition, studies have shown that the airborne microbe counts increase with the degree of movement and personnel numbers, supporting the decision to have only one radiologist and anaesthetist physically present in the scanning room. the principle of modern theatre ventilation is to remove airborne contamination generated in the room and to prevent the ingress of contaminated air from surrounding areas. a dedicated extraction system actively supplies relatively clean air into the room faster than excess air can be removed passively. for minimal access interventions, guidelines state that the procedure room should be ventilated mechanically to achieve - ach with a pressure differential of at least pa to maintain this condition. , although the ct room at the royal national orthopaedic hospital provided insufficient air changes, the adjacent mri preparation room had a pre-installed extraction system with a measured . ach and pressure differential of - . pa relative to the corridor. thus, ga induction could be performed here prior to ct room transfer. once a breathing circuit filter had been placed to provide protection during disconnection of the airway circuit, the patient was transferred across into the scanning room where the biopsy itself was performed. similarly, at the royal orthopaedic hospital, there was no dedicated ventilation system within the ct room and insufficient ach. furthermore, the adjacent rooms also had no appropriate extraction systems. thus, a decision was made to stop performing all ga cases at royal orthopaedic hospital, with only sedation and la being utilised. it should be noted that sedation unlike endotracheal intubation is not an agp and so deemed safe to proceed in the scanning room itself. studies have shown how operating rooms can be adapted to obtain a negative pressure gradient but the time constraints and general set-up within the nhs meant this was not feasible. the differences in the available ventilation set-ups account for the main results across both sites. at the royal orthopaedic hospital, only one sedation case per session would be performed with the majority of the list taken up with us la cases. at the royal national orthopaedic hospital, the list mainly contained ga cases, a small minority of which would be converted to sedation or la on the day itself. with a clear decision not to perform any ga cases at the royal orthopaedic hospital, all outstanding cases were reviewed by the radiology team in the weekly sarcoma mdt and decided whether sedation or la would be appropriate. the large number of ct la cases at the royal orthopaedic hospital reflects this approach, which was not necessary at the royal national orthopaedic hospital given that a functional ga list (albeit with less capacity) could still be run. a similar number of sedation cases were done at both sites. there was a concerted effort across both sites to convert some ga cases to sedation if at all possible to avoid intubation. in fact, certain radiologists and anaesthetists preferred this approach. ct rfa for osteoid osteoma was not undertaken initially, and was only slowly phased in during the last few weeks of may at both sites. this is understandable given that although it is potentially very symptomatic it, is not life threatening; however, the necessary ppe precautions and protocol changes had been fully established during the month of may. moreover, both sites had a relatively low number of known covid- -positive cases meaning that with the necessary precautions, such cases could be performed. rfa should be performed under ga ideally, with one case at the royal orthopaedic hospital converted from a regional block with sedation to ga. as routine practice, all rfa patients are contacted by telephone a few weeks after the procedure to highlight any change in symptoms. no covid- -related morbidity was detected. one hundred and forty-eight diagnostic us studies were performed at the royal national orthopaedic hospital and at the royal orthopaedic hospital. these all constituted imaging related to sarcoma patients, e.g., exclusion of deep vein thrombosis (dvt), skin marking of small tumours, assessing incidental findings, and primary tumours. the number of procedures at both sites reflect a functional, but somewhat limited, service designed to only biopsy the most necessary and urgent cases. it should be noted that at the royal national orthopaedic hospital, two extra sessions not usually timetabled were arranged to undertake a biopsy list. despite travel restrictions during lock-down, performing urgent procedures at a specialist centre is considered best practice to increase the likelihood of a diagnostic biopsy. thus, no urgent cases were referred back to the local hospital during this study period. interestingly, when comparing data using the same study dates in , there was a % and % reduction in the number of ct biopsies performed during this period at the royal national orthopaedic hospital and the royal orthopaedic hospital, respectively compared with . although this reflects the current reduced intervention service, the current workload demonstrates that a sizeable proportion of this vital patient pathway can be maintained. in addition to a curtailed list, differences in work output may be partially explained by patients not presenting via normal referral pathways due to the potential fear of contracting covid- . the exact impact of this is unknown. the reduction in numbers was also due to a concerted effort by the sarcoma mdt to perform as many primary excisions as possible when clinically appropriate, particularly for smaller lesions, which has been shown to be safe practice. this no doubt assisted with the delivery of a reduced capacity but safe and functional intervention list. it also ensured that a large backlog of patients awaiting image-guided biopsy was avoided and all outstanding non-urgent cases could be dealt with swiftly post the peak of the pandemic. the importance of the mdt in facilitating this service cannot be overstated here. a dialogue between the sarcoma surgeons and radiologists is crucial in deciding which cases should be biopsied, with priority given to children, radiologically high-grade tumours or clinically urgent cases. all patients undergoing a procedure in the ct room were contacted as part of followup. typically, a -week interval was normally given from the procedure date to follow-up. as physical outpatient appointments were essentially halted, a telephone consultation was felt sufficient. no local procedure-related complications or covid- -related symptoms or morbidity were highlighted. given the lack of trust-wide patient testing, it is unclear if performing procedures on definitive covid- positive cases would have altered the outcomes. there is currently a wide sensitivity range ( - %) for the covid- swab test with no true reference standard. for the purpose of performing a biopsy and subsequent surgery, it is unclear how much value should be placed on an apparent positive or negative result, especially in asymptomatic individuals. various measures have been proposed to tackle this dilemma including patient shielding for days, repeated swab testing and even low-dose ct chest studies for selected surgical patients; however, in the setting of urgent sarcoma, waiting up to week for additional swab tests and scan results was not felt to be appropriate. the authors' approach of treating all patients as "covid- positive", ensuring appropriate ppe at all times minimises the risk of potential virus transfer whilst ensuring no delay in patient management. although hospital-wide swab testing for patients is useful, in reality this does not alter current practice for the near future. hospital-wide antibody testing is only currently available for staff at both sites. this article is designed to illustrate that even though intervention lists at both sites were curtailed, they can still be carried out and performed safely. although this mainly depends on the existing ventilation set up, the contrasting arrangements at royal national orthopaedic hospital and royal orthopaedic hospital shows that concerted effort can be made to adapt rather than outright halt all interventional lists. a mdt approach and discussion of all cases is advised. all relevant personnel should be flexible in modifying their normal practice, e.g., converting to la or sedations, surgeons carrying out more biopsies in theatre, etc. in addition, attention to detail is crucial with staff willing to discuss the logistics required. this includes designating areas for ppe "donning and doffing", physically marking boundaries and safe zones, ensuring the correct number of personnel is present in the room, etc. a summary of the standard operating procedures for ga biopsy lists is highlighted in table . it will be interesting to note how clinical practice at both sites after the covid- pandemic alters, e.g., will as many biopsies under sedation or la be performed or will there be a push to still do mainly ga biopsies? although the topic of steroid injection is certainly interesting, they were completely halted during the study period, and therefore, discussion was deemed beyond the scope of the current paper; however, certain steps have already been implemented to reintroduce steroid injections at both sites. at the royal national orthopaedic hospital, an enhanced consent process specifically detailing potential lowered immunity to virus exposure is to be highlighted by clinicians at the time of requesting the procedure and then again by all radiologists. all referrals are on a consultant-toconsultant basis, with particular consideration for high-risk patients following individual risk analysis. at the royal orthopaedic hospital, normal steroid injection lists have resumed since june , but are only performed on a low-risk patient group, with a view to appropriately scale up to a wider patient population following audit review. there is clearly a large amount of planning needed hospital-wide to ensure the safety of running image-guided intervention lists, and the relevant radiology clinical leads and service directors need to be at the heart of this. as of june , there are and outstanding urgent biopsies at the royal national orthopaedic hospital and royal orthopaedic hospital, respectively, waiting to be done. this highlights a great effort by all relevant teams to run almost daily interventional lists safely across both sites. it is hoped that the authors' approach to ventilation systems, workflow, and ppe can be emulated by other centres in the uk. this is clearly a dynamic process changing on an almost weekly basis. more modifications to current practice will be needed given that the next phase of re-introducing a fully functional interventional list slowly and safely is fast approaching. clinical guide for the management of radiology patients during the coronavirus pandemic covid- : infection prevention and control guidance covid- personal protective equipment. ppe guidance by healthcare context, . : aerosol generating procedures department of health. guidance. coronavirus (covid- ): getting tested guidance on coronavirus testing anaesthetic-management-of-patients-during-a-covid- -outbreak (accessed ?? guidelines for environmental infection control in health-care facilities aerosol and surface stability of sars-cov- as compared with sars-cov- heating and ventilation of health sector buildings (htm - ) guidelines on the facilities required for minor surgical procedures and minimal access interventions isolation facilities for infectious patients in acute settings ???) . covid symptom study mobile application. powered by zoe factors influencing microbial colonies in the air of operating rooms conversion of operating theatre from positive to negative pressure environment small, superficial, indeterminate soft-tissue lesions as suspected sarcomas: is primary excision biopsy suitable interpreting a covid- test result schematic highlighting the layout and adaptations made to the royal national orthopaedic hospital imaging department during the covid- pandemic. full anaesthetic ppe was donned at location (old reporting room). the radiologist rajakulasingam r experimental studies / data analysis rajakulasingam r, azzopardi c, botchu r . statistical analysis the authors thank all radiologists, anaesthetists, allied anaesthetic practitioners, ct radiographers, sarcoma mdt members, infection control team, radiology nursing staff, departmental managers, and associated administrative staff for their efforts with planning and safely performing all image-guided interventions at both the royal national orthopaedic hospital and royal orthopaedic hospital during the covid- pandemic. would don their ppe at location in the scanning room where the sink is located on the side wall. endotracheal intubation/extubation was performed in location (preparation room) where ceiling extraction flap vents were pre-installed. this provided adequate air exchanges ( ach) and a - . pa pressure gradient relative to the adjacent corridor. if images needed to be viewed, a designated zone was set up in the control room for the scrubbed radiologist, location . the radiologist would remove their gown at location . upon leaving the room, the facemask and visor would be disposed of at location in accordance with phe guidance. in one rfa case, sedation and regional anaesthesia was inadequate and general anaesthesia undertaken b all rfa cases had regional anaesthesia and sedation c in addition, diagnostic us studies were undertaken ct, computed tomography; rfa, radiofrequency ablation; us, ultrasound, ga, general anaesthesia; la, local anaesthesia. • covid- has had a significant impact on ct interventional procedures.• air pressures and appropriate ventilation systems need to be considered.• a pragmatic and meticulous approach is crucial in operating a functional service. ☐ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: key: cord- -b kubfl authors: milcent, carine title: hospital institutional context and funding date: - - journal: healthcare reform in china doi: . / - - - - _ sha: doc_id: cord_uid: b kubfl this chapter focuses on hospital ownership and supervision. public hospitals are mostly, but not always, under the supervision of the health ministry. there are a certain number of other governing bodies that are directly involved in the management of hospitals. a cross-ministry group was set up in to facilitate the implementation of hospital reforms. apart from the organizational structure, the funding of hospitals and its evolution is studied. between and , the government introduced a co-payment system in healthcare establishments. in , the ministry of health officially granted greater autonomy to public hospitals. they were authorized to deliver paid services and to make profits, but were made responsible for their losses and debts. by , central government funding had fallen to % of the hospital budget. as a result, public hospitals in china behave very similarly to for-profit firms, while being governed as any traditional public structure. the next step is the current experiment of a diagnostics related group-based payment in china. along with the financial autonomy of public hospitals, different reforms have been directed at developing private hospitals, even though many obstacles still remain. in this chapter, we separate the hospital by ownership (public/private) for discussion. because of the historical healthcare system context, the public sector is more mature than the private one. as a consequence, some pilot reforms are introduced only in the public sector. as example is the implementation of a diagnostics related group-(drg)-based payment presented at the end of the first section of this chapter. actually, this does not mean that the private sector will be immune to these new forms of funding. in the united states, for instance, when the drg-based payment was introduced, it was designed for medicare patient (patients aged over ) without focusing on a specific hospital ownership by also targeting private hospitals. ownership after the implementation of the "three-tier public provision system", most hospitals were under the direct supervision of the health ministry, with support from local health offices. nevertheless, some remained dependent on state-owned companies or the army. other governing bodies were involved in maternity and family planning centres, at county and township level. whatever the governing body, the healthcare supply was provided by the public sector. today, health centres in both rural and urban areas are split between public and private structures. in rural zones, community clinics are mostly private whereas urban county hospitals remain mostly public. comparing figs. . and . illustrates that the healthcare supply shift from the public sector to the private sector is an ongoing process. public hospitals are mainly but not solely under the supervision of the health ministry. there is still a certain number of governing bodies, ministries or state-owned companies that are directly involved in the management of hospitals. for instance, the people's liberation army (pla) and some large state-owned industries, such as the railways, have their own hospitals and medical schools. most hospitals and medical schools affiliated with the pla are considered to be of a high quality and provide services to political leaders. that have not yet been classified. the "non-profit" category mainly consists of organizations owned by government and companies (available data do not permit a disaggregation of the non-profit category by ownership) this fragmented structure is a hurdle to the implementation of any hospital reform, with four main ministries involved: the national development and reform commission (ndrc), the ministry of human resources and social security (mohrss), the ministry of finance (mof) and obviously the ministry of health (moh). these ministries do not have the same objectives. as a consequence, healthcare suppliers do not respond to the same incentives, which leads to a lack of co-ordination between healthcare providers. the effect of the reforms implemented may be affected by this multiplicity of governing bodies. the sars epidemics in has crystallized the importance of public health and care. many experts and officials have pointed out the flaws in the health system that led to the quick spread of the sars virus. as a consequence, a think tank was created to give strategic direction to future reforms: the development research centre (drc) reports to the chinese state council. one of its reports heavily influenced the reform package. to solve the complexity of implementing chinese health system reforms, a cross-ministry group was set up in to facilitate the implementation of hospital reform. this leading group for coordination healthcare system reform is dependent on the ndrc and health ministry and its first chairman was the future prime minister li keqiang. in , this group in the state council was restructured with the mission to co-ordinate all stakeholders of healthcare reform, from provincial governments to ministries involved and administrations in charge of implementing reforms. it made various and important policy initiatives at the central level. this leading group consists of representatives from ministries including the moh, mohrss, mof and ndrc. as a support, one agency from each of the four main ministries is in charge of a specific part of the reform. resources from other governing bodies are also tapped for more specialized aspects (see table . ). besides which, every province set up a local team for health reform. they are in charge of a specific checklist of tasks from the state council that can be completed by the provincial authority. as a consequence, all reforms implemented since are not coordinated by the ministry of health but by a special unit reporting directing to the state council (or more precisely to the health reform office of the state council). yet, this unit does not have the ability to actually implement the decisions taken. it needs to go the ministries to execute decisions. in reality, these reforms involve a large numbers of governing bodies. the national development and reform commission (ndrc) and the ministry of finance (mof) in particular have a key role. the different ministries involved can sometimes have conflicting priorities. for instance, if we take the example of health insurance, mohrss is in charge of insurance in urban areas, whereas the ministry of civil affairs (moca) manages a programme for the underprivileged that includes insurance covering basic care. in parallel, the china insurance regulatory commission (circ) has a mission to encourage the development of a private health insurance market. another example is any reform touching hospital human resources. the office of central institutional organization, the ministry of education as well as mohrss, because it manages the career of civil servants, are necessarily involved. daily governance is also complex. for instance, for investment decisions for public hospitals, two ministries share responsibility: the moh and the national development and reform commission (ndrc). as a result, public hospitals may receive conflicting policies and regulations. in addition, for the execution of policies, many other bodies are involved: authorities at provincial level, district level and city level, bureaus of labour and social security, health and finance. this huge number of stakeholders shows the complexity of hospital reform in china. if the central government defines the general direction and objectives, this actual implementation takes place under steering at a more granular level-provincial and below. this, combined with a large financial autonomy, makes it possible to factor in local specificities in the actual execution of reforms but can also generate important territorial inequalities. a costly reform implemented in an area hit by economic downturn will not produce the same effect as when implemented in a soaring region. to mitigate this risk, each authority in charge of implementation at the local level is given measurable targets, for instance, the number of people covered by public health insurance at a certain date. these targets are cascaded into the individual objectives of local political leaders, having a direct impact on their career advancement and promotion into the party's apparatus. nonetheless, many health reform objectives are not easily quantifiable, for instance better governance, leaving widespread nuances in interpretation. at the beginning of the s, the central government was paying for % of hospital expenditure. over the - period, the government introduced a co-payment system in healthcare establishments. the aim was to provide greater flexibility in terms of profit, and thus to incite establishments to improve the quality of the services they offered and professionalize their medical staff ). in , the ministry of health officially granted greater autonomy to public hospitals, through an official document published in september by the state council, "instructions on health reform". by this, public hospitals were authorized to deliver paid services and to make profits, but were made responsible for their losses and debts. they have to self-finance their investment in equipment and infrastructure as well as a salary bonus policy. they are also entitled to enter into joint ventures with private companies, including setting up for-profit departments within the public hospital itself. as a result of this reform, bigger hospital structures developed, as well as improved quality, thanks to the acquisition of high-tech equipment. since then, public hospitals in china have the particularity that they behave as companies, aiming to maximize profit through investment and price setting, while being governed as any traditional public structure. they are the sole recipient of public funding, be it from the central or local governments. staff management is under the supervision of central governing bodies, mainly the morhss, from both a resource allocation perspective as well as individual career management. while they keep this strong bond with central authorities, they have financial autonomy. they are able to determine their price policy, which can turn out to be a problem in cases where they are in a monopoly situation in certain geographical areas, and hence without the market regulation of pricing. by central government funding had fallen to % of hospital expenditure. the fall in state financing was offset by charging for medicines and diagnosis procedures. in china, as in many other asian countries, patients do not consult doctors in their doctor's office-outside any healthcare facilities-but in the hospital outpatient department. prescriptions are given at the end of the consultation by default (patients are not asked if they want to purchase them). the total cost is the sum of the price of the consultation and that of the prescribed medicine. patients do not have an explicit choice in not accepting the doctor's prescription. in this context, prescription prices can be varied in order to compensate for the fall in the hospital's central funding. this practice has been severely questioned during the recent healthcare reforms in china. prescriptions currently account for about half of healthcare expenditure. the overprescription of medicine and the over-use of high-tech equipment for diagnostic purposes have often been identified as the cause of the rapid increase in healthcare expenditure (eggleston et al., a ; . the current healthcare system has been judged to be both too costly and more sophisticated than is medically necessary (world bank, ; blumenthal and hsiao, ). it is very likely that these factors affect the demand for and use of healthcare. following the -reform, some public facilities set up healthcare centres with a fee-for-service payment. as expected, these for-profit firms reoriented their activity to the most profitable healthcare areas. these forprofit health centres did not have to provide any public-service mission. the healthcare prevention programme was then neglected: epidemic control, health education, maternal and child health all suffered. the sars epidemic put the public health role of public hospitals to the forefront again. the negative side-effects of financial autonomy appeared sharply in that context. this led to a clear split between medical operations and hospital management functions. additionally, it was demanded that for-profit activities be clearly split from the rest in hospital books of account. nonetheless, in , health expenditure for pharmaceutical products still accounted for % of total health expenditure. this compares with a % average share in organisation for economic co-operation and development (oecd) countries. per capita medicine expenditure reach rmb . nearly million surgeries were performed in china in . this figure is nearly one-sixth of the world's total surgical operations. the biggest share of procedures is in the obstetrical and gynecological areas, followed by digestive and gastrointestinal system procedures. according to yip and hsiao ( ) , "from to , personal health spending per capita increased by a multiple of from rmb to rmb (or from roughly to usd) while the consumer price index increased by . times during this period. a huge portion of this expenditure was for high-tech tests and unnecessary drugs." , in the s, the main objective of the regulator was to make it possible for hospitals to acquire technology and to improve their level of quality. in parallel, the aim was also to reduce the burden of hospital expenditure funding. the series of reforms implied three main changes: • financial autonomy of public hospitals • managerial autonomy for a part of public hospital staff • financial incentives for physicians to profit. financial autonomy of public hospitals: this has been achieved at the expense of accessibility for many. the share of health expenditure in total income has rocketed during the past years. in , per capital health expenditure in urban areas was still contained at a very low level of rmb , whereas it reached more than rmb , in . another effect of the financial autonomy of public hospital has been a certain loss of authorities over medical practices. managerial autonomy: in parallel, hospitals have autonomy in personnel management for their for-profit activity. for that part of the activity, personnel are not under the same governance and control by authorities. this co-existence is bound to create tensions, as salary differences appear between the official public salary scale and unregulated salaries of the forprofit activities. additional benefits can be granted to physicians and other medical personnel, based on a very non-transparent basis, leading to many frustrations. pursuit of profit can become the top priority while it was totally disregarded in previous situations. the objective function of medical personnel includes an increasing component of profit maximization. financial incentives for physicians: in public hospitals, physicians are civil servants (bianzhi) . this status implies certain benefits that will be described later and ensures a fixed income, independent from their volume of activity. yet, this fixed income is often described as being fairly low in view of both their responsibilities and other revenue sources. an additional income source has been authorized dependent on the for-profit activity of the hospital. one can then easily see that physicians have an incentive to develop the for-profit activities, for instance increasing the number of consultations, delivering over-diagnoses or over-prescribing. in such cases, it is a win-win situation for both medical personnel and hospital management. in addition, this healthcare system nurtures the pre-existing practices of bribes and other types of corruption. they tend to become widespread, creating an increasingly tense atmosphere between patients and hospital personnel. the chinese healthcare system has long been accused of failing to efficiently deliver healthcare services at an affordable cost. in , a set of reforms were implemented, giving the state a bigger role in the production and distribution of health services. nonetheless, public hospitals receive only limited funding from the regulator. figure . shows the different sources of funding. it is quite striking that direct public funding from the government only represents a minimal share of the total ( %). in reality, the involvement is more pronounced with indirect funding through public health insurance set up in both rural and urban areas. companies also participate in the financing of healthcare, accounting for almost one-third of the total. patients' share accounts for % of hospital revenue, but patients usually do not bear the total costs, as part is covered by public or private health insurance. the covered part has been increasing steadily over the past few years. in the end, patients' out-of-pocket payments rose from % in to % in , but then decreased to a current rate of around %). , a landscape analysis of the health insurance market in china is presented in chap. . some experiments, presented here, aimed at switching from a fee-forservice payment to any form of prospective payment. the goal is to modify incentives for healthcare providers: from driving up service prices to introducing and encouraging competition with a price ceiling system. in urban areas, the insurance schemes existing before the economic reform were based on a principle of regulated pricing. when the basic medical "other" includes private health insurance (both supplementary and stand-alone); employer contribution to group private health insurance, which is around $ million. total funding is around $ million. source: hospital interviews; government statistics , "healthcare in china," a kieger report on the chinese healthcare market . www.mckinsey.com/...service/healthcare% systems% and% services/health% international/hi _china_healthcare_reform.ashx insurance (bmi) scheme was introduced, a mechanism to contain expenditure from the demand side was implemented (the medical savings accounts-msa). on the supply side, there was no change in the provider payment introduced by central government. however, at local government level, examples of the implementation of some form of prospective payment can found from the early bmi pilot. in , the social insurance bureau of hainan province implemented a prospective payment, concerning six key hospitals. this payment was quite similar to a global budget system. studies led by eggleston ( and , show that average expenditure by admission fell below that of other hospitals on a fee-for-service basis. besides, spending growth on expensive drugs and high-tech services was reduced dramatically. the defined limits of these studies concerns the fact that the data were not available to control for the potential reduction of quality of care, risk selection and cost shifting to the uninsured. implementation of similar forms of prospective payment systems were nonetheless implemented in many areas throughout china, as in qingdao, shandong province, for instance. some other cities introduced payment per capita as an alternative prospective payment form. in , jiujiang city switched to capitation: a fixed amount per capita (contrary to per inpatient or per inpatient day as presented so far) on a defined geographic area. medical expenditure per insured inpatient fell dramatically and the share of drug expenditure in total spending fell drastically. however, lack of information about the impact on the healthcare level of quality prevents any conclusion being drawn. the diagnosis related group (drg) payment is a reimbursement scheme that was first implemented in the united states at the beginning of the s. this type of payment is a form of prospective payment system and consists of a lump sum based on the pathology and procedures to be carried out on the patient. a categorization of pathologies, diagnoses and actions is made ex-ante. all patients are affected in one these categories, collectively called the diagnosis related group (drg). each drg defines a pathology, associated diagnoses and all procedures already implemented or yet to be implemented. this way, each patient falls into a drg and each drg corresponds to a predefined lump sum, based on the expenses the hospital has to incur to carry out treatment for this type of patient. the advantage of this lump sum is that it is not correlated with the treatment actually performed while covering the theoretical expenses necessary to cure the patient. this gives an incentive to limit cost, explaining why this type of payment is widespread, not only in china but in a vast majority of oecd countries. the efficiency of such a system relies heavily on the quality of the information system that goes with it. it is quite complex, as, for each patient, information regarding diagnoses, procedures and comorbidities is to be collected and compiled. china aims at putting in place a comprehensive information system with medical history and patient admission details. this project is still in the early stages though. zhenjiang, a bmi pilot city, started to experiment with a drg payment system for diseases. the reimbursement rate for each disease was set according to average expenditure incurred over the previous three years in treating each disease, minus any "unreasonable" expenditure. in , the average spending for diseases using the drg payment was % lower than the province average in hospitals of the same level. once again, because of the poor quality of data at the micro-level, studies on the impact of the drg payment system on the quality of care and risk of selection impact have unfortunately not been published yet. after that, drg-based payment systems spread across china, for instance, in cities such as guangzhou, dalian, liushou and mudanjiang. in guangdong province, as early as , a total of out of municipalities were already using such systems. however, this drg-based payment is still restricted to specific diseases. besides, these cities also use different prospective payment systems alongside a fixed charge per inpatient. studies on this aspect provided less strong evidence for drg-based payments or other forms of prospective payment on a reduction of healthcare spending. , , following the bmi offices' example, some local offices of ncms (public health insurance for inhabitants in rural areas) adopted a prospective payment system to reimburse the health providers. for instance, two counties in shaanxi province adopted a fixed-price reimbursement system for some selected thcs and selected county hospitals according to specific criteria. some providers moved from a ffs service to a prospective payment system but not in conjunction with a public insurance scheme. in heilongjiang province, by the end of , hospitals started to use a drg-based payment system. one goal was to attract private investment and more business by developing a reputation for transparency in pricing. , so far, there is no scientific study paper on the effect on quality of care or strong evidence on healthcare expenditure. to date, there are two main viable drg systems, the beijing-drg ( ) and the c-drg system set up by the nhfpc ( ). because of inconclusive results, in , these different forms of prospective payment are still being studied and this is an on-going field of research. we use here "private" in a wider sense, to cover all hospital structures apart from the public ones (minying), be it through joint ventures, cooperatives or private structures with capital from mainly hong-kong, macao, taiwan but also all over the world. until , it was legally impossible to set up a private hospital. different reforms since then have been directed at developing them, along with the financial autonomy of public hospitals. as of , . % of hospitals were registered as private structures, most of them being specialized establishments. nonetheless, the average size of private hospitals is much smaller than public hospitals. in , the average number of inpatient beds for a private hospital was , which is in sharp contrast to the average number of beds for a public hospital. recently, when classifying hospitals by their ownership, % of the hospitals in china are public, including state-owned and indirectly stateowned ones; the remaining % are private. in terms of level, according to the official hospital classification, the percentage of publicly owned hospitals by admissions is % for level and % for level hospitals. as a result, % of chinese patients choose to visit public hospitals. private hospitals in china only account for around % of the service volume and for % of beds while being operated at a lower level (fig. . ) . the picture is quite the opposite in the united states, where public hospitals make up % of total hospitals and only % of patient visits. nonetheless, the private hospital sector has been steadily increasing over the past few years. in , the share of beds in private hospitals reached . %, . % up from the previous year. the number of public hospitals grew from roughly in to , in . from to , the number of patients treated in a private hospital grew by . %. we can then observe a constant increasing trend but no sharp change (fig. . ) . in rural zones though, the situation is totally different. a large part of primary care is carried out in dispensaries that are now almost exclusively private and paid for on a fee-for-service mode. yet, it is quite difficult to precisely measure the actual progression of the activity of private healthcare establishments. until very recently, the information on the public or private status of a hospital was not made available in official statistics. in conclusion, the number of private healthcare facilities is increasing but, in terms of number of visits, there is no private hospital boom. the ministry of health has stated on various occasion that it wants to develop the private health sector. the objective set by the state council is for it to command % of the market by . why such support? as previously explained, public hospitals are largely in a monopoly situation in their geographical area. the decrease in public funding has led to a deregulation of healthcare pricing. the partially stated goal here is to increase competition between public and private hospitals to help regulate pricing. this is very similar to the mechanism in place in the united states for a large part of the population. using competition between public and private sectors to better regulate hospital care is also increasingly popular in a number of european countries (e.g. germany, the united kingdom, the netherlands and france). in china, the th five year plan ( - ) and the th five year plan ( - ) emphasize the development of private hospitals. until then, setting up a private healthcare structure had been legally possible for two decades, but almost impossible in practice, in particular due to the difficulties of hiring medically qualified personnel. private hospitals have been addressing, as a priority, three markets segments: high-end healthcare for expats and the affluent local population, healthcare targeted to very specific pathologies and finally healthcare in direct competition with that offered by public hospitals. the first segment enjoys sold growth. initially directed at expat consumers, it turns out to be increasingly used by high-end consumers. "half of our outpatients are expats working or living in china, such as diplomats and executives of foreign-invested companies. and the other half is high-income chinese residents. we sell by word of mouth," said zhu ying, president of the beijing bayley & jackson medical centre in downtown beijing, a private hospital with headquarters in hong kong. this is an example of what can be observed in very big cities in china. however, so far, this phenomenon is too new to draw an conclusion apart from this initial assessment. in the third segment, that of private hospitals in competition with public structures, the former sometimes have to face distorted competition, through public subventions. however, they also have to overcome the difficulties of attracting the best practitioners and resistance from the public towards a new structure with neither a track record nor endorsement from the community. this difficulty in attracting patients seems hard to understand in the context of dissatisfaction over the service provided by public hospitals, but it actually sheds light on the priority criteria of patients/customers. the quality and reliability offered by public hospital, through their high level of equipment and skilled and trained personnel, prevails over the annoyance of congestion and the price of care. as mentioned previously, recruitment of highly skilled professionals is one of the main obstacles to the development of private hospitals. the status of physicians in public hospitals, the benefits it brings and the additional wages received in various forms are often roadblocks to a migration to a private structure. a mckinsey report entitled "china healthcare reform" gives the example of beijing municipality. it addresses community healthcare centres (chcs) but the configuration is identical for private hospitals: "a few cities have tried to force more patients to go to chcs, but these efforts have generally been unsuccessful. in january , for example, one local government implemented a policy of requiring patients with certain chronic diseases to be treated at a chc before they could receive care at a class iii hospital. however, the local department of health withdrew this policy one month later, saying that the quality of the chcs needed to be improved before the policy could be implemented." the status and financial obstacles to hiring well-known professionals in private hospitals creates a vicious circle. as they do not manage to hire renowned physicians, private hospitals are obliged to hire young doctors with little experience. for both patients and professionals, this type of structure tends to become a second choice, when public hospitals are not an option. the story of an hua and li peng provides a good example. they are reputed physicians in a level hospital in beijing. they confided that working in a private structure could resolve their current, difficult, working conditions. where they work, they have to deal with an extended number of working hours, an excessive number of patients and a patienthospital staff antagonistic climate. however, according to them, the size of private facilities is too small to attract a sufficient number of patients; the healthcare equipment is too limited; and the professional environment does not provide a sufficiently stimulating setting in which to work and grow. this difficulty in recruitment is a recurring theme mentioned by professionals as well as academics. dr. wang zhen, from the chinese academy of social sciences (cass) gives the example of the creation of a private hospital in shenzhen in . it was a showcase collaboration between hong kong university (hku) and the shenzhen municipality. in , this state of the art facility has not managed to fill all the physician positions. out of full-time positions, are yet to be filled, to a point where it is seriously considering shift the establishment to a public status to solve the recruitment issue. in parallel, another obstacle to the development of private hospitals is the restrictive conditions on the reimbursement of healthcare expenses by public insurance. this does not include the reimbursement of healthcare in private facilities. however, a main part of the population can only afford to get healthcare access using public insurance. as a consequence, the restrictive rule of public insurance excludes a large part of the population from access to private facilities. recently, in some cases and in some areas, expenses in private facilities have been partially reimbursed by public health insurance. it would be interesting to assess the effect of such a change on the individual's preference in the choice of healthcare providers. so far, if some reforms have tended to develop the private health sector, there are still some keys determinants that limit this central state support. yu ying, a former physician in a famous beijing hospital, the peking union medical college hospital, is a key figure and spokesperson for public hospital doctors. her weibo blog (chinese equivalent of twitter) has more than million followers. on it, she has been describing her hesitation about leaving the public sector, her difficulties after crossing the bridge, but also the fulfillment it created for her. yu ying, who had chosen "emergency room superwoman" for her pseudoname, is one of the few professionals to have left a level hospital to create a private medical centre. when she decided to leave her public hospital, her objective was to open her clinic in beijing city, within the fifth ring road. however, as she explained, this was not as easy as expected. a series of administrative constraints and barriers prevented her from opening a centre there. all her efforts failed. having resigned from her previous hospital and given up her civil servant status, returning to the public sector was no longer an option. she decided to take her chance in chengdu, sichuan province, where she tried again to open a private clinic providing the most basic medical services. she failed again. during this time, she used her weibo blog to explain part of her difficulties and the obstacles encountered along the way. when i interviewed her, the term "bribery" was never mentioned. as she said, she was able to explain her disappointment without going too far into detail about the local administrative process. in march , she used her weibo account to explicitly address the authorities about her situation asking, "which deputy of the national people's congress can tell me why it is so difficult for a doctor, who has worked in the country's top-grade hospital for years and has held a doctorate degree after eight years of professional medical education, to open a regular clinic through formal channels?" the timing was perfect. it was between the plenary session of the national people's congress and the chinese people's political consultative conference, allowing a strong echo to her protest. the outcome was finally positive, even though she had to drop the idea of setting up her own facility. she is now the ceo of a private general clinic in beijing city run by the amcare group, a public-private partnership joint venture, two and a half years after having resigned from a top public hospital. despite her million fans, she has to struggle to both promote the quality of a market-oriented institution and recruit staff members from big public hospitals. her experience illustrates the difficulty faced by medical professionals in opening their own private health centres compared to the situation in most oecd countries. new series of policies since , a new series of policies have been released. the goal of these policies is to lower the barrier to entry for private health establishments. this should create a more adequate business environment and improve the share of private health structures in the healthcare market. in , a notification on "further encouraging and leading social capital to participate in healthcare institutions" was published. this document promotes and encourages social capital to run private hospitals. it covers more practical, detailed information on beneficial policies for running a private health structure. in order to facilitate the development of the private hospital sector, it also allows a lowering of the entry barriers for private medical institutes with foreign capital. as a pilot experiment, some local governments have lifter some constraints on public hospitals: for instance, experimenting with the privatization of public hospitals. currently, the private healthcare market has developed a model based on chains of private specialized hospitals. more specifically, the medical services provided by the private sector are mostly for dental treatment, ophthalmology and plastic surgery, as well as diagnosis labs and centres. these sectors are medical sectors where customized services may generate higher margins. maternity is also considered as a potentially profitable sector. for instance, by may , amcare had assisted in more than , births and its total revenue soared % to million yuan ($ million). in , us-based warburg pincus llc invested $ million in beijingbased amcare women's and children's hospital to support its expansion. today amcare accounts for about half of the high-end healthcare market for women and children in beijing, which is now dominated by private hospitals. according to the roland berger report illustrated in fig . , "investors with various backgrounds are entering china's private hospital market. foreign hospital chain investors, such as chindex have built up high-end chain hospitals in smaller size in china. local financial investors, real estate companies and pharmaceutical companies are mostly targeting at mid-end market and specialty hospitals. pharmaceutical companies such as shanghai fosun pharmaceutical group aim at broadening their value chain and boost selling of their own drugs by establishing hospitals or participating in public hospital privatization". a cluster of private medical companies and hospitals owned by people from the city of putian, commonly known as the "putian clan" (putian ji), also constitutes great power in the healthcare industry as over % of private medical companies in china are affiliated with the putian clan. the members of the putian clan have organized themselves into a chamber of commerce named "putian (chinese) health industry association" (putian (zhongguo) jiankang chanye zong shanghui) since . another part of the reform aimed at developing private hospitals is their inclusion into public health insurance schemes. until recently, a patient admitted into a private hospital was not eligible for reimbursement from public insurance. this constraint is progressively eased, in one province after the other. rules tend to vary depending on the area, but there is an increasing number of cases for which care provided in private healthcare centres can be covered by public insurance schemes. in addition, in some provinces or municipalities, private hospitals can be directly subsidized. again, it is important to note the decentralized structure of the chinese healthcare system. general direction and target is given by the central government but provinces have wide autonomy in actual implementation. in august , the national health and family planning commission jointly announced with the ministry of commerce that fully foreign-owned private hospitals were allowed in seven provinces (beijing, tianjin, shanghai, jiangsu, guangdong, hainan and fujian). , in future, key factors private health structures need to develop are: ( ) patient recognition that private health establishments can be as trustworthy this point ( ) is a prerequisite condition. the development of the private sector is based on a high level of healthcare quality. the over-arching goal of profit maximization must not contaminate the level of quality provided. in , press articles drew attention to private healthcare companies that severely undermined doctors' medical professionalism. as witnesses, doctors previously employed by putian clan hospitals, stated that to achieve profit targets set by their superiors they performed unnecessary medical treatments. they added that these practices are not uncommon in these hospitals as doctors are directly employed by the hospitals they serve. a necessary challenge will be to make a profit without undermining the level of quality provided. even at a slower pace than anticipated, things are starting to change and the private sector is now showing significant growth. according to the nhfpc, from september to september , the number of private hospitals has increased by , while the cohort of public hospitals was reduced by . from through , patient visits to private hospitals have increased by . % from third trimester to third trimester , overstepping the growth of visits to public hospitals, which have grown at . % on a quarter-to-quarter basis. in fact, since the economic reforms of the s, there have been two schools of thought regarding the direction the health system in china should take. one is a pro-market group that advocates market liberalism to improve the quality of healthcare and efficiency. the other is a progovernment group that advocates the need for a large government role in the production and distribution of health services. the latter prioritize issues of equity or fairness and aim at reducing social inequities. depending on the period, each school of thought has had the upper hand in the direction given to reform. the last round of reform since is very much market-oriented, the market being expected to play a decisive role in the allocation of resources. the third plenum of the th central committee of the communist party, in november , emphasized a higher priority for economic growth. therefore, the conditions required for the development of the private sector in the healthcare market are fully in place with favourable policies. in a near future, with this preferential environment and the ongoing governmental commitment, a rapid growth of the private sector is to be expected. this evolution should have, at least, two consequences. one could be to put pressure on public hospitals and push them to keep going at improving their level of quality, not only in terms of medical services but also in the overall service quality (including accommodation, catering, etc.) and operational efficiency. the other consequence could be to limit the demand for public hospital access (for in-and outpatients) and reduce congestion in the level and aaa public hospitals. these forecasts on the effect of a more prominent presence of private healthcare providers in the healthcare market are based on a major assumption: that the income or wealth of a society is equitably distributed. the hypothesis is very strong and very restrictive. with increasing income inequality, the part of the population who cannot afford to access to healthcare will increase. an adequate and efficient alternative may be universal healthcare access for all. while this may be too costly for society it may avoid the failure of the market in providing equal access to healthcare. the healthy china project includes universal healthcare access by the year for basic healthcare supplies. besides the success of this programme, the central question will be "what is included in the 'basic healthcare supplies' basket?" notes health care systems in transition: people's republic of china. part i: an overview of china's health care system china's health system: from crisis to opportunity chinese health care reform: problems, reasons and solutions health service delivery in china: a literature review economic reforms and health insurance in china state council of prc, opinions on further reforming of health care systems health service delivery in china: a literature review impacts of medicine price on new cooperative medical scheme taking stock of china's rural health challenge privatization and its discontents: the evolving chinese health care system what drove the cycles of chinese health system reforms? report of china national health accounts, beijing: china health economics institute early appraisal of china's huge and complex health-care reforms million-surgeries-performed-china-last-year inappropriate tuberculosis treatment regimens in chinese tuberculosis hospitals we will see later that bianzhi status is very specific reform of how health care is paid for in china: challenges and opportunities success factors for women's and children's health study groups provider payment reform in china: the case of hospital reimbursement in hainan province addressing government and market failures with payment incentives: hospital reimbursement reform in hainan, china the authors used a difference-in-difference econometric method using data from payment arrangements for contract hospitals jiujiang health insurance office, the ' ' urban health insurance arrangement the impact of provider payment reforms on cost containment drg-based payment reform for urban health insurance scheme the impact of urban health insurance reform on hospital charges: a case study from two cities in china reform of medical insurance system in chinese cities: discussion on equity of cost allocation drg-based payment reform for urban health insurance scheme world bank mission team about drg payment reforms review of provider organization reforms in china the growth of private hospitals and their health workforce in china: a comparison with public hospitals china healthcare: where to position for growth investment injection see paragraph on bianzhi status chc is a healthcare facility providing care for outpatients when expenses incurred in private facilities are reimbursed by public health insurance, the reimbursement rates are lower than those for public facilities yu ying: china's 'face of er' who runs new beijing hospital amcare corporation operated seven medical facilities for women and children in china the prc government's no. document ( . . ): notification on further encouraging and leading social capital to participate in healthcare institutions entering china's private hospital segment putian ji: youyi zhong cheng wangguo-zhongguo de minying yiyuan bacheng du shi tamen de" (putian clan: wandering doctors become a kingdom-eighty percent of private hospitals in china belongs to them restrictions loosened on overseas ownership of hospitals, china daily they are forcing us to be immoral: putian-clan doctors revealed how hospitals make money), southern weekly the argument about the new health reform lines: government and market about drg payment reforms privatization and its discontents: the evolving chinese health care system economic reforms and health insurance in china health service delivery in china: a literature review health service delivery in china: a literature review chinese health care reform: problems, reasons and solutions inappropriate tuberculosis treatment regimens in chinese tuberculosis hospitals health care systems in transition: people's republic of china. part i: an overview of china's health care system reform of how health care is paid for in china: challenges and opportunities they are forcing us to be immoral: putian-clan doctors revealed how hospitals make money), southern weekly china healthcare: where to position for growth jiujiang health insurance office, the ' ' urban health insurance arrangement success factors for women's and children's health study groups reform of medical insurance system in chinese cities: discussion on equity of cost allocation the impact of provider payment reforms on cost containment review of provider organization reforms in china the impact of urban health insurance reform on hospital charges: a case study from two cities in china investment injection payment arrangements for contract hospitals the growth of private hospitals and their health workforce in china: a comparison with public hospitals china's health system: from crisis to opportunity impacts of medicine price on new cooperative medical scheme taking stock of china's rural health challenge yu ying: china's 'face of er' who runs new beijing hospital drg-based payment reform for urban health insurance scheme addressing government and market failures with payment incentives: hospital reimbursement reform in hainan, china provider payment reform in china: the case of hospital reimbursement in hainan province what drove the cycles of chinese health system reforms? early appraisal of china's huge and complex health-care reforms the argument about the new health reform lines: government and market key: cord- - d fnjt authors: wang, jiao; shen, jin; ye, dan; yan, xu; zhang, yujing; yang, wenjing; li, xinwu; wang, junqi; zhang, liubo; pan, lijun title: disinfection technology of hospital wastes and wastewater: suggestions for disinfection strategy during coronavirus disease (covid- ) pandemic in china date: - - journal: environ pollut doi: . /j.envpol. . sha: doc_id: cord_uid: d fnjt hospitals are important sources of pollutants resulted from diagnostic, laboratory and research activities as well as medicine excretion by patients, which include active component of drugs and metabolite, chemicals, residues of pharmaceuticals, radioactive markers, iodinated contrast media, etc. the discharge of hospital wastes and wastewater, especially those without appropriate treatment would expose the public in danger of infection. in particular, under the coronavirus disease (covid- ) pandemic context in china, it is of great significance to reduce the health risks to the public and environment. in this study, technologies of different types of hospital wastes and wastewater disinfection have been summarized. liquid chlorine, sodium hypochlorite, chlorine dioxide, ozone, and ultraviolet irradiation disinfection are commonly used for hospital wastewater disinfection. while incineration, chemical disinfection, and physical disinfection are commonly used for hospital wastes disinfection. in addition, considering the characteristics of various hospital wastes, the classification and selection of corresponding disinfection technologies are discussed. on this basis, this study provides scientific suggestions for management, technology selection, and operation of hospital wastes and wastewater disinfection in china, which is of great significance for development of national disinfection strategy for hospital wastes and wastewater during covid- pandemic. hospitals are important sources of pollutants resulted from diagnostic, laboratory and research activities as well as medicine excretion by patients, which include active component of drugs and metabolite, chemicals, residues of pharmaceuticals, radioactive markers, iodinated contrast media, etc. (verlicchi et al., ) . in addition, it is estimated that % of the wastes produced by hospitals are general health care wastes, while the remaining % are regarded as hazardous infectious wastes (prüss et al., ; taghipour et al., ) . improper disposal of infectious hospital wastes and wastewater could cause serious risks to public health and environment. an unexplained case of pneumonia was first reported in hubei, china (chan et al., ) . by january th, , chinese scientists had isolated a severe acute respiratory syndrome coronavirus (sars-cov- ) from patients in wuhan . following the severe acute respiratory syndrome coronavirus (sars-cov- ) outbreak in and the middle east respiratory syndrome coronavirus (mers-cov) outbreak in , sars-cov- becomes the third coronavirus to emerge in the past two decades, which has put global public health institutions on high alert (munster et al., ) . chan et al. ( ) carried out a study on a family of six patients, they noticed that one family member, who did not travel to wuhan, became infected after contact with other family members. according to world health organization ( ), the transmission routes of sars-cov- include droplet transmission and contact transmission; airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed. so far, over eighty thousands of people have been diagnosed as coronavirus disease (covid- ) all over china (fig. ) . in the globe, the number of confirmed cases have exceeded . million, and the amount of confirmed cases is still climbing with the accumulated death over , . in the united states, spain, italy, germany, the united kingdom, france, and turkey, the number of confirmed cases have all exceeded thousands as of april , . the discharge of hospital wastes and wastewater, especially those without appropriate treatment would expose the public in danger of infection. in particular, under the covid- pandemic context in china, it is of great significance to reduce the health risks to the public and environment. thus, it is necessary to appropriately disinfect and dispose of the hospital wastes and wastewater before being transported or discharged. although domestic and foreign scholars have carried out a variety of studies focusing on the wastewater treatment, general waste disposal, hospital management, etc., the systematic studies concerning disinfection of hospital wastes and wastewaters, especially specific disinfection suggestions during covid- pandemic, are rare to date. therefore, the current review will concentrate on disinfection technologies for treatment of hospital wastes and wastewater, and provide suggestions for hospital wastes and wastewater disinfection during covid- pandemic in china. ozone, ultraviolet irradiation, liquid chlorine, chlorine dioxide, and sodium hypochlorite disinfections are commonly used technologies for hospital wastewater disinfection (chen et al., ; lizasoain et al., ; yu et al., ) . fig. shows the general wastewater disinfection system in the hospital. every disinfection technology has unique advantages and disadvantages as summarized in table . the utilization of a certain type of disinfection technology should be determined by the comprehensive consideration of both economic and feasible factors, such as the amount of wastewater, safety conditions, the supply of disinfectants, the distance between the wastewater treatment system and the ward as well as the residential area, investment and operation costs, operation management level, etc. (fig. ). bleaching powder is commonly used for the chlorination pretreatment (nhc, ) . for each ward and restroom of an infectious disease hospital or the infectious disease area of a general table comparison of disinfection technologies for hospital wastewater (fan et al., ; kühn et al., ; kleinb€ ohl et al., ; messerle et al., ; yu et al., the ability of decoloring and deodorizing and quick decomposition of microorganisms high operation costs and hazardous by-products hospital, kg of bleaching powder containing % of available chlorine per beds should be added to times before further disinfection. the optimal addition time is at the end of the peak period of the restroom use. the added bleaching powder should be flushed into the septic tank with flowing water and the residual chlorine would be measured at the outlet of septic tank in case of violation of the water quality standard. chlorine is a kind of strong oxidizer, which is one of the most early used disinfection methods in disinfecting hospital wastewater (yu-mei et al., ) . when using chlorine as the disinfectant, a vacuum siphon fixed-ratio chlorine dosing system is generally adopted in hospital wastewater treatment system. the pipes of the chlorination system are installed in open areas, and buried pipes are located in pipe trenches with good support and sufficient slope. when the water collection pipe in the hospital wastewater treatment system is higher than the public wastewater pipe outside the hospital or the water level (usually a height difference of mm is required), a siphon-type fixed-ratio chlorine disinfection system could be used (mee, ) . when wastewater needs to be lifted in order to be discharged, a wastewater pump is required to be set up in front of the disinfection mixture contact tank. the disinfectant addition equipment and the lift pump could operate synchronously. the water level of the water collection tank controls the automatic activation of the wastewater pump, and the simultaneous operation of the dosing system. usually, mg/l- mg/l and mg/l- mg/l chlorine is added to wastewater after primary treatment and secondary treatment, respectively (nhc, ) . while the actual amount of chlorine added to the wastewater could be adjusted according to the residual chlorine remaining in the outlet of the wastewater treatment system and the content of reducing substances in the wastewater. in chlorine disinfection, the effective constituent is hclo. the mechanism of chlorine disinfection is: ( ) . . . liquid chlorine when using liquid chlorine for wastewater disinfection, a vacuum chlorinator must be used, and the outlet of the chlorine injection pipe should be submerged in the wastewater (braden, ) . it is strictly prohibited to directly add chlorine to the wastewater without a chlorinator, or using pipes that are not resistant to chlorine gas corrosion, such as polyvinyl chloride, and metal pipes such as copper, iron, and other pipes which are not resistant to chlorine solutions. copper pipes and hard pvc pipes should be used to transport chlorine gas and chlorine containing disinfectant solutions, respectively (zhu et al., ) . due to relatively high storage risk, the liquid chlorine disinfection technology is not a proper disinfection technology in regions with high population. so far, chlorine dioxide is known as one of the efficient disinfectants with high oxidization capability even under acidic conditions (wang, ) . the solubility of chlorine dioxide is five times that of chlorine and the oxidization capacity of chlorine dioxide is . times that of chlorine gas. it is generally recommended that the amount of chlorine dioxide used to treat hospital wastewater is / . that of the available chlorine (nhc, ). the dosing system of chlorine dioxide for wastewater disinfection is consistent with the sodium hypochlorite disinfection technology, i.e. a double siphon automatic fixed-ratio dosing chlorine system is adopted for chlorine dioxide disinfection. when using a chlorine dioxide generator, the content of chlorine dioxide must be higher than %, and it should ensure safe operation and automatic addition of disinfectants with certain proportion (wang et al., ) . chlorine dioxide could trigger the denaturation of enzyme and protein (ogata, ) . it destroys the anabolic pathways of protein and thus kills the microorganism, including bacteria, viruses, fungi, spores, and clostridium botulinum. the chlorine dioxide has the ability of decoloring, deodorization, oxidation, and increasing the oxygen content in wastewater. due to its chemical structure, the chlorine is inconvenient to be stored or transported, though it still has advantages of lower costs of operation as well as preparation (fan et al., ) . sodium hypochlorite disinfectant could be prepared using standard naclo generator, which could significantly reduce the costs (casson and bess, ) . a double siphon automatic fixedratio dosing chlorine system is usually adopted for sodium hypochlorite disinfection. the content of available chlorine in sodium hypochlorite is approximately %e %. and the mechanism of sodium hypochlorite disinfection is: compared with other chlorine-containing disinfectants, the use of sodium hypochlorite is featured with relatively lower toxicity, simpler equipment, more stable operation, easier control, and lower operation and preparation costs, which makes this disinfection method more feasible in smaller scale hospitals (yu et al., ) . though it should be pointed out that sodium hypochlorite disinfection has higher energy consumption, stronger corrosiveness, and higher pollution (emmanuel et al., ) . therefore, when using on-site prepared sodium hypochlorite for disinfection, a safe and reliable sodium hypochlorite generator with high electrical efficiency, low water consumption, low salt and electricity consumption, long operating life, and convenient operation should be employed. when raw salt is used as the raw material, the salt solution should be precipitated and filtered before being added to the sodium hypochlorite generator. containers, pipes, equipment and accessories that contact the sodium hypochlorite solution should be made of corrosion resistant materials. ozone is a disinfectant featured with high bactericidal effect, which has been widely used in water supply engineering and wastewater treatment (chiang et al., ; kist et al., ) . the wastewater flows into the first-stage sedimentation tank, and then flows to the second-stage purification tank after purification. after proper treatment, it flows to the regulating storage tank. it is then pumped into the contact tower by the sewage pump, and fully exposed to approximately mg/l- mg/l ozone in the tower for e min before being discharged. generally, a hospital with beds is suggested to build an ozone treatment system with a wastewater treatment capacity of t/h to t/h (nhc, ) . since the ozone disinfection has the capacity of decoloring and deodorizing, the wastewater after treatment becomes bright and transparent without odor. also, the molecule structure of ozone is unstable, which implies that strong oxidative atomic oxygen produced by the decomposition of ozone molecule would quickly decompose microorganisms, such as bacteria and viruses, in wastewater. although ozone disinfection could improve the water quality in shorter time with higher efficiency, the operation costs of ozone preparation are high (arslan et al., ) . moreover, the byproducts, which are produced through the chemical reaction with bromide and iodide, are hazardous to human health (kleinb€ ohl et al., ) . and over-dose of ozone is easy to cause bad smell and secondary pollution. therefore, ozone disinfection is mainly suitable for smaller scale wastewater treatment system, especially wastewater treatment system with relatively high effluent quality. ultraviolet light (uv) refers to the electromagnetic wave with length between nm and nm. the uv was first used in disinfection of drinking water in (white et al., ) . the uv could be divided into wavebands based on different wavelength, including ultraviolet a ( nme nm), ultraviolet b ( nme nm), ultraviolet c ( nme nm), and vacuum ultraviolet ( nme nm). thereinto, vacuum ultraviolet could not be used in disinfection because it is absorbed by the wastewater. the bands with wavelength between nm and nm could damage the structure of both dna and rna of the bacteria, viruses, and single-celled microorganisms and thus inhibit the protein synthesis. therefore, the ultraviolet b and ultraviolet c have the best bactericidal effect. it is generally believed that the band with wavelength of . nm is optimal for ultraviolet disinfection (meulemans, ) . compared with chlorine disinfection, the investment and operation costs of uv disinfection are significantly lower. however, disinfection with uvc is sometimes unsatisfactory since the depth of penetration is inadequate and there are occupational health risks (kühn et al., ) . different with the disinfection of hospital wastewater, the hospital wastes are usually classified before disinfection as shown in fig. (blenkharn, ) . the typical composition of healthcare waste is approximately % general non-infectious, % infectious/ hazardous, and % chemical/radioactive (who, ) . this section first summarizes main types of hospital waste disinfection technologies, including incineration, chemical disinfection and physical disinfection, and then illustrates the proper disinfection technologies used in different situations. similar with disinfection technologies for hospital wastewater, the hospital wastes disinfection technologies have their own characteristics. therefore, factors such as the amount of waste, costs, maintenance and types of waste, etc. should be taken into consideration when selecting appropriate disinfection technologies in a certain hospital as shown in fig. . for example, the incineration technology could be adopted when the amount of wastes is large and the investment is sufficient when disinfecting pathological or pharmaceutical wastes. if the scale of the hospital is smaller and the investment is limited, chemical disinfection and high temperature steam disinfection which are easily maintained are preferred. incineration is safe, simple and effective, which has been one of the most widely used disposal technology especially in developing countries (ghodrat et al., ) . the temperature of the incinerator (outlet temperature) is over c. this high temperature could not only completely kill microorganisms, but also incinerate and burn most organic matters and transform them into inorganic dusts. after incineration, the volume of solid wastes could be reduced by approximately e % (lee and huffman, ) . except for explosive and radioactive wastes, other hospital wastes could be incinerated. the waste preparation, waste incineration and flue gas purification in different hospital waste incineration treatment facilities are different. so far, the common incineration technologies include pyrolysis vaporization incinerators, rotary kiln incinerators, plasma incineration technology, etc. (jiang et al., ; sapuric et al., ) . thereinto, pyrolysis vaporization incinerators and rotary kiln incinerators are widely used in china (chen and yang, ) . when the pyrolysis vaporization incinerator operates, the air measured below the theoretical chemical reaction is first sent to the fixed furnace level of the primary combustion chamber for combustion. thus, the organic components of the waste are decomposed into flammable gases in order to avoid dusts due to the turbulence caused by the excess air. as a result, the emission of particulate matters is reduced, the residue is continuously discharged from the end of the hearth, and the flammable gas is sent to the secondary combustion chamber. and sufficient air is supplied to make it completely burn. a high temperature environment above c is conducive to the complete destruction of toxic and hazardous components, thereby reducing the production of toxic pollutants such as dioxins due to low temperature combustion (zhu et al., ) . this kind of rotation during the operation of the incinerator not only helps the wastes to be automatically transported in the kiln, but also allows the wastes to be well mixed, thereby improving the incineration efficiency. the rotary kiln incinerator technology has advantages on a wide range of applications, good adaptability, handling a variety of different types of wastes, good gas and solid contact, and uniform reaction (pei and wu, ) . the temperature could be as high as , c or more, which effectively destroys most hazardous substances. however, for small and medium scales equipment below the disposal capacity scale of t/d to t/d, the investment costs are relatively high and the investment recovery rate is relatively low; in addition, the excess air demand is higher than that of pyrolysis incinerator, and the dust content in the exhaust is slightly higher (chen and yang, ) . the mechanical parts of the incineration system are complicated and the maintenance costs are also high. plasma incineration technology is a novel wastes disposal technology (chang-ming et al., ) . the essential of this technology is to transfer energy through the plasma, so that the wastes could be quickly decomposed into small molecules and even atoms. thus, there are no intermediate products of large molecules. most of the gases produced are flammable and sent to the secondary combustion chamber for complete combustion. it is then discharged into the atmosphere after simple purification. compared with conventional incineration technologies, the plasma incineration shows a higher energy efficiency, which demonstrates a promising application prospect (messerle et al., ) . chemical disinfection technology has a long history and a wide range of applications. chemical treatment of hospital wastes is usually used in combination with mechanical crushing treatment (zhang, ) . generally, the crushed hospital wastes are mixed with chemical disinfectants (such as sodium hypochlorite, calcium hypochlorite, chlorine dioxide, etc.) and stayed for a sufficient time. during the disinfection process, organic substances are decomposed, and infectious microorganisms are killed or inactivated. chemical disinfectants are featured with low effective concentration, rapid action, stable performance, and broad sterilization spectrum, they not only kill microorganisms, but also bacteria spores (wu et al., ) . therefore, sodium hypochlorite, calcium hypochlorite, chlorine dioxide, etc. are generally used because they are non-corrosive to items, odorless, tasteless, colorless, inflammable, safe, and easily soluble in water but not easily affected by physical or chemical factors with low toxicity and no residual hazard after disinfection (chen and yang, ) . when the amount of hospital wastes is small, chemical disinfection technology could be considered. microwaves are electromagnetic waves with a wavelength of to , mm and a frequency between hundreds of megahertz and , mhz. microwave frequencies used for disinfection are generally ( , ± ) mhz and ( ± ) mhz (neto et al., ) . the microwave passes through the medium and is absorbed by the medium to generate heat. the heat is generated by the substance molecules vibrating and rubbing for billions of times per second, thereby achieving the effect of high temperature disinfection. the microwave disinfection technology is characterized with energy saving, low action temperature, slow heat loss, rapid action, light damage, and low environmental pollution with no residues or toxic wastes after disinfection (ohtsu et al., ) . it has a wide disinfection spectrum of bacteria, which can kill various microorganisms. regarding the ability to destroy pathogens, there is now convincing evidence that specially constructed microwave systems are able to sufficiently inactivate microorganisms; however, the process has to be strictly controlled by special microwave devices. conventional microwave units have no means to control the inactivation process and the moisture content. though a few sophisticated microwave technologies with appropriate measurements are currently only used for the treatment of biohazardous wastes, it needs to be evaluated whether they would also have advantages for processes involving the control of water content such as the drying of biotherapeutic products (walters et al., ) . microwave disinfection technology, as an effective supplementary technology for incineration, is gradually being promoted in china, which will effectively promote the diversification of hospital wastes disinfection technologies in china. according to technical specifications for microwave disinfection centralized treatment engineering on medical waste (on trial) published by ministry of ecology and environment (mee) of china, the disinfection effects of microwave disinfection technology could achieve: ( ) the logarithmic value of killing bacteria, fungi, lipophilic or hydrophilic viruses, parasites, and mycobacteria of propagules ! and ( ) logarithmic value of killing bacillus subtilis black spores ! . high temperature steam disinfection refers to the wet heat treatment process that uses high temperature steam (saturated water vapor with temperature higher than c) to kill microorganisms on the transmission medium (zhang et al., ) . the hospital wastes are exposed in an environment with a certain temperature of water vapor for a certain period of time. due to the latent heat released by the water vapor, pathogenic microorganisms undergo protein denaturation and coagulation, which leads to the death of microorganisms (bao et al., ) . in china, it is required that the logarithmic value of the killing of thermophilic lipobacillus spores should be ! (mee, ) . limited by various factors, the sterilization temperature in the sterilization room is generally set to c, and the fluctuation range is less than c. at this temperature, the time required to achieve the disinfection effect usually does not exceed min. when the equipment has a high disinfection capacity, the sterilization chamber has a large loading capacity, and the time for steam to penetrate into the hospital wastes packaging is longer. however, the high temperature steam disinfection method has low volume reduction rate, and easily generates toxic volatile organic compounds during the disinfection (teng et al., ) ; therefore, it is unable to disinfect all kinds of hospital wastes. table demonstrates advantages and disadvantages of main disinfection technologies of hospital wastes. it should be pointed out that high temperature incineration is a very effective disinfection technology that can simultaneously achieve the harmlessness, reduction and resource utilization of hospital wastes. although the high temperature incineration method has a large disposal amount, the investment is high, the heat value of wastes must meet certain requirements, and there is a risk of generating hazardous substances such as dioxins during low temperature combustion (vermeulen et al., ) . however, pyrolysis vaporization incinerators and rotary kiln incinerators have already met the requirements of relevant environmental standards with appropriate intervention measures (zhao et al., ) . from the perspective of investment and operation costs as well as economic and social benefits, high temperature incineration is still one of the most valuable hospital waste disinfection technology in china. therefore, when the amount of hospital wastes generated is large, high temperature incineration technology could be considered. table summaries main types of hospital wastes, including domestic wastes, infectious wastes, pathological wastes, sharp wastes, pharmaceutical wastes, chemical wastes, and radioactive wastes. most of the hospital wastes are not hazardous, which does not need special treatment or disinfection. however, once these non-hazardous wastes are mixed with other hazardous or infectious pollutants, special disposal and disinfection are required. therefore, the classification of hospital wastes is a prerequisite for effective disinfection of hospital wastes. in addition, different disinfection and disposal methods should be adopted based on unique characteristics of different hospital wastes. wastes in hospitals should be appropriately disposed of because these wastes are proved to be associated with in-hospital transmission of infection or injury (rutala and sarubbi, ) . liu et al. ( ) investigated hospitals in china, and found that main wastes are infectious wastes and sharp wastes, which account for . % and . % of the total hospital wastes, respectively, with the hospital waste generation rate of approximately . kg/bed/ day. according to technical standard for disinfection (nhc, ) , for wastes of infectious disease patients, the feces, vomit, urine should be disinfected using bleaching powder, restrooms, clothes, towels, etc. should be disinfected using solution containing sufficient available chlorine. in addition, leftovers that could be used as animal feed must be boiled for min before being transported. inflammable solid wastes with no use value, sharp wastes, and infectious wastes could be incinerated as much as possible under permitted conditions. used disposable syringes, infusion sets, transfusion apparatus and other items must be disinfected and destroyed on-site, and collected by the designated unit of the local agency for centralized collection and disposal (huang et al., ) . it is strictly prohibited to sell to other non-designated units or discard at will. disposable medical supplies should be disinfection via direct incineration. if the incineration method is not available, they could be alternatively soaked in a disinfectant containing sufficient effective chlorine before being destroyed. for a small amount of pharmaceutical wastes, landfill and storage could be adopted, and they could also be incinerated with infectious wastes; while for a large number of pharmaceutical wastes, incineration is preferred (nhc, ) . the pharmaceutical wastes could also be disposed of at sanitary landfills after sealing. glass ampoules cannot be incinerated, but they could be crushed first and then processed with sharp wastes. general chemical wastes, such as sugar, amino acids, and specific salts, could be disposed of with municipal wastes or discharged into the drainage system (zhao, ) . if the amount of hazardous chemical wastes is small, such as residual chemical in the package, they could be treated via pyrolysis incinerator, storage or landfill. while if the amount of hazardous chemical wastes is large, flammable wastes could be treated by incineration, others could also be treated using chemical disinfectants. the excrement of patients treated with radiopharmaceuticals should be collected and disposed of. the excrement in the special septic tank should be stored for half-lives and discharged into the drainage system. when collecting feces from patients with À i, naoh or % ki solution must be added at the same time and table comparison of disinfection technologies for hospital wastes (chang-ming et al., ; ghasemi and yusuff, ; ohtsu et al., ; pei and wu, ; zhao and xie, table classification of hospital wastes (nhc, ) . domestic wastes domestic wastes are generated from the hospital management and the maintenance of buildings, and it is usually disposed of according to the principle of urban waste disposal. infectious wastes refer to wastes that may contain pathogenic bacteria, viruses, parasites, or fungus in concentrations and quantities sufficient to cause disease in humans, which mainly include: ( ) medium of bacterial colonies and pathogenic strain as well as culture preservation solution used in the laboratory; ( ) wastes of infectious patients, such as tissues, contaminated materials, and instruments after surgery or autopsy; ( ) wastes from infectious wards, such as feces, dressings for surgical or infected wounds, heavily contaminated clothes, etc.; ( ) wastes of infectious patients produced in hemodialysis, such as dialysis equipment, test tubes, filters, apron, gloves, etc.; ( ) infected animals in the laboratory; ( ) any equipment or materials which are contacted by infectious disease patients or animals; ( ) used disposable syringes, infusion sets, blood transfusion apparatus, etc. pathological wastes including tissues, organs, parts of the body, fetal death and animal carcasses, blood, body fluids. sharp objects refer to objects that could puncture or cut people, including needles, hypodermic needles, scalpels, infusion sets, surgical saws, broken glasses and nails. pharmaceutical wastes the pharmaceutical wastes include expired, eliminated, crushed or contaminated medicines, vaccines, and serum. chemical wastes chemical wastes include solids, liquids, and gases that are toxic, corrosive, flammable, reactive, or genotoxic in the process of diagnosis, testing, cleaning, management, and disinfection. such as formaldehyde, photography agents, organic compounds, etc. radioactive wastes radioactive wastes contain solids, liquids, and gases contaminated with radionuclides. such as solid waste (absorbent paper, mop, glassware, syringes, small medicine dishes) with low activity, residues and diagnostic agents in containers of radioactive materials. sealed and stored for disposal. however, if patient excrement also contains pathogenic microorganisms, it must be collected separately with special containers, which is not allowed to be discharged into the drainage system until storage, decay and disinfection have been completed . recently, rna of sars-cov- has been found in feces of patients, which triggered concern to the disinfection of wastes and wastewater of designated hospitals during covid- pandemic in china. ong et al. ( ) believed that transmission may also occur through fomites in the immediate environment around the infected person. based on previous studies concerning the pathogen transmission in wastewater system, gormley et al. ( ) claimed that under some circumstances, the wastewater system has the potential to enable airborne transmission of sars-cov- . these are consistent with the fact in a study that sars-cov- from a single stool specimen has been cultured (zhang et al., ) . it is also reported that wastewater discharged from a covid- designated hospital was sars-cov- rna positive, indicating that the virus might contaminate the drainage system (china citywater, ). in addition, the disinfection of hospital wastes is also in high necessity since the waste generation increases exponentially during this period, which may accelerate disease spread and pose a significant risk on both medical staffs and patients without proper collection and disinfection (yu et al., ) . there is only few studies on inactivation of sars-cov- so far. while, chan et al. ( ) reported that the genome of the sars-cov- strains are phylogenetically closest to the bat sars-related coronaviruses, and the spike protein has a % nucleotide identity with the human sars-cov- . due to the similarities between sars-cov- and sars-cov- , the sars-cov- might also be sensitive to either environment factors or disinfectants. therefore, disinfection technologies adopted during sars epidemic could be used as good reference to inactivation of sars-cov- in hospital wastes and wastewater. sars-cov- could exist for days, days, and days in the hospital wastewater, stool, and urine at c, respectively . all sars viruses could be inactivated in min at c with more than . mg/l residual free chlorine or . mg/l residual chlorine dioxide left (chen et al., ) . chen et al. ( ) compared disinfection performance of different technologies and reported that chlorine and uv irradiation were the most efficient followed by chlorine dioxide, though efficiency of ozone disinfection was not ideal. this result was in line with findings reported by wang et al. ( ) . up to january , , there has been covid- designated hospitals all over china. in wuhan, local mee has established an emergency scheme for disposal of wastewater from temporary treatment centers, which are newly built covid- designated hospital for cases with mild symptoms in wuhan, china. chlorine disinfection (liquid chlorine, chlorine dioxide, and sodium hypochlorite), which has long been used in hospital wastewater disinfection in china, is adopted in this scheme. the available chlorine is recommended to be approximately mg/l. for disinfection septic tank, the contact duration should be longer than . h with residual chlorine over . mg/l and fecal coliform colonies less than per liter. in addition, uv irradiation and heating are also suggested for wastewater disinfection in other covid- designated hospitals because of fewer by-products and ideal disinfection performance. the water quality of wastewater discharged from the hospital should meet requirements below (table ) . moreover, the infectious wastes should also be collected in time under protective conditions. they are suggested to be disinfected using solid or liquid chlorine containing disinfectants with available chlorine concentration of g/l and disinfection duration of h. pharmaceutical wastes and chemical wastes are suggested to be incinerated. radioactive wastes contaminated with sars-cov- are suggested to be disinfected as infectious wastes after storing for at least half-lives and. disposable protection products should also be treated as infectious wastes. for example, respirators should be soaked in % alcohol for min. moreover, chlorine disinfectants with mg/l and , mg/l are suggested for disinfection of other protection products without or with obvious contamination, respectively. the disinfection performance of hospital wastes should meet requirements below. hospital wastes and wastewater (as well as the sludge) must be treated and disinfected properly before discharge. without disinfection, they should not be allowed to be arbitrarily discharged or used as agricultural fertilizer. the use of any infiltration wells/pits to discharge wastewater and sludge, or the discharge into sanitary protection zone of drinking water sources should also be strictly forbidden. in addition, government should take measures to improve the management of hospital wastes and wastewater, especially during the covid- pandemic. the hospital should set up a recycling system and assign special personnel to take charge, and strengthen the management of each department to prevent waste loss. personnel involved in the disposal of disposable medical supplies must be qualified and strengthened in personal protection. in recent years, many new advances have also been made in hospital wastes and wastewater treatment technologies, such as radiation disinfection technology, reverse polymerization disinfection technology, plasma disinfection technology, and thermal gasification disinfection technology. they have certain promotion value, but due to the high investment costs, these technologies have not been used at a large scale. with the improvement of hospital wastes and wastewater disinfection technologies, the costs of disinfection will continue to decrease, and secondary pollution to the environment will be gradually controlled. during the disinfection, the environmental pollution or effects on human health could be significantly reduced if the operation strictly obeys the requirements. in order to develop more secure, efficient, economical disinfection methods, local environment and actual conditions should be brought into consideration in future studies. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. application of o /uv/h o oxidation and process optimization for treatment of potato chips manufacturing wastewater the general process of medical 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recommendations. world health organization (who) application progress of hospital wastewater treatment methods research on simple disinfection system for medical wastewater of township hospital design and running for a hospital wastewater treatment project reverse logistics network design for effective management of medical waste in epidemic outbreaks: insights from the coronavirus disease (covid- ) outbreak in wuhan (china) study and application on chemical disinfection technology of medical wastes notes from the field: isolation of -ncov from a stool specimen of a laboratory-confirmed case of the coronavirus disease (covid- ) development and application prospect of high temperature steam technology of medical wastes application research on disposal technology for urban medical wastes. china environmental protection industry current status and application trend of disposal technology of medical wastes in china levels and characteristic analysis of dioxins in fly ash from waste incinerators of shenzhen study on pyrolysis of typical medical waste materials by using tg-ftir analysis effects of pipe materials on chlorine-resistant biofilm formation under long-term high chlorine level this work was supported by the national natural science foundation of china [grant number ]. the authors would like to acknowledge all health-care workers involved in the diagnosis and treatment of patients in china; we thank prof. xiaoming shi for guidance in study design; and we thank ms. yan liao and many other staff members at the china cdc for their contributions. key: cord- -srkny v authors: yu, hai-ping; ma, li-li; hung, yun-ying; wang, xue-bin; peng, you-qing; chen, chi; zhuang, hui-ren title: application of ‘mobile hospital’ against -ncov in china date: - - journal: epidemiol infect doi: . /s sha: doc_id: cord_uid: srkny v nan the world health organization (who) has declared the outbreak of the novel coronavirus ( -ncov) a public health emergency of international concern [ ] , which poses a great challenge to china's health system. as of february , the total number of confirmed covid- patients had reached , with deaths [ ] . to effectively control the spread of the epidemic and provide medical services, the government directed general hospitals to rapidly open fever clinics. more than fever clinics are required to provide services to the public in shanghai. however, due to the sudden outbreak of the epidemic and the arrival of the spring festival, most hospitals have been unable to cope with the consequences of the -ncov outbreak. a mobile hospital is a kind of temporary medical institution that can be rapidly deployed [ ] , and is often used as a medical resource to rapidly implement treatment in case of an emergency. our hospital has an international emergency medical team, which is certified by the who and equipped with perfect mobile hospital facilities. in this anti-epidemic battle, our hospital adopted the mobile hospital to deal with patients in the early stage of the outbreak in shanghai and as a supplement medical facility to assist the wuhan keting medical shelter. here, we describe the lessons learned during these deployments. as a temporary facility in the early stage of the outbreak on january, we completed the layout of the mobile hospital fever clinic in just h, which not only effectively deals with fever patients, but also saves precious time for our hospital to complete the formal reconstruction of its fever clinic. from to january, fever patients were registered in the mobile hospital, including one confirmed patient, without any medical staff being infected. our experiences are described below. we established a management team, including experts in infection control management, medical and nursing administration, it management, pharmacy, laboratory testing, material procurement and logistics management. the anti-epidemic management team was led by a hospital leader, and everyone performed their duties and cooperated sincerely ( table ) . the layout of the mobile hospital was completed according to the requirements of infectious diseases, and consisted of folding tents. each tent covers an area of m with separate negative pressure air purification systems. the following areas were set up: triage and waiting room, consultation room, laboratory, pharmacy, treatment room (equipped with six infusion chairs), two isolation wards (equipped with beds and mobile toilets) and rest and dressing rooms for medical staff (figs and ). all staff members were required to wear personal protective equipment. each shift was staffed by two doctors, two nurses, one pharmacist, two laboratory technicians, one cleaner and one security guard. all staff in the mobile hospital were provided with level ii protective equipment (protective clothing, goggles, n masks and gloves), and the laboratory technician was provided with level iii protective equipment (as for level ii, except that the goggles are replaced with a face mask). strictly enforced temperature measurements were implemented. to prevent cross-infection and ensure the accuracy of temperature measurements, the nurses used ear temperature guns to measure the temperature of patients, and used disposable earmuffs. if necessary, mercury thermometers were used for accurate thermometry. the patients were required to provide complete personal information and were questioned about their epidemiological history, such as: have you been to an epidemic area within the last days? have you contacted people from the epidemic area? patients also signed a letter of commitment for the information they provided. twenty waiting chairs were set up, m apart. all patients and caregivers were required to wear masks, and the hospital provided masks free of charge to those without masks. the patients were screened by using nasopharyngeal swab, blood sampling and lung computerised tomography (ct) scans. anti- -ncov experts in the hospital consulted about the suspected patients, and these patients were reported to the district health supervision institute. the mobile hospital was equipped to carry out samplings that were then sent for nucleic acid detection in the center for disease control and prevention. while awaiting the report, the patient received relevant treatment in the isolation room, and the hospital provided all daily necessities. then, the confirmed patients were transferred to infectious disease hospitals using a special ambulance. this outbreak occurred suddenly and during the chinese spring festival, and few epidemic prevention materials were available. in the cleaning area of the mobile hospital, five cabinets were used for storing protective materials. the nurse manager was responsible and accountable for the management of these protective materials. given the flexibility of the mobile hospital, we were able to quickly and effectively set up three areas and two 'channels'. polluted areas, semi-polluted areas and a clean area were well divided, and two separate channels were built for patients and medical staff (fig. ) . a quick hand disinfectant facility was set up. coronaviruses are sensitive to alcohol disinfectants, and alcohol hand disinfectants were placed on all tables and next to registration machines. two ultraviolet disinfection lamps were fixed for air disinfection. indoor articles were wiped with mg/l chlorine, and the ground was mopped with mg/l chlorine, every h. the vomitus excreta of the patients was treated as class i infectious disease excreta. the excreta were disposed of in the mobile toilet. two layers of infectious storage bags were placed in the pedestal pan in advance. the excreta were pretreated with mg/l effective chlorine. after pouring the effective chlorine, the mouth of the bags was sealed, and the bags disposed of using the delivery box after h. the bed articles used by the patients were placed directly into the double-layer infectious storage bags, and chlorine ( mg/l) poured into the bags. double bags and double seals, which were marked, were handed over to the washing unit for treatment. the final disinfection of the confirmed patient's room was done using spray disinfection and a hydrogen peroxide machine. given the inadequate airtightness of the tent, the room was sealed with sealing strips before disinfection. the total amount and time needed to disinfect a room was calculated based on the room volume. for a tent with an area of m , min of disinfection was required, followed by min of ventilation. on february, our international emergency medical team was ordered to assist the wuhan keting medical shelter hospital. the medical shelter was originally reconstructed from the wuhan culture and art center, with a total of beds. as of : on february, it had received patients with mild disease. the clinical manifestations of the patients with mild disease were slight, or they had a fever, respiratory tract problems and other symptoms. the imaging findings showed ground glass, no dyspnoea and chest distress. arbidol hydrochloride tablets combined with chinese oral medicine was the main treatment method. if the patient's condition worsened beyond the capacity of the shelter hospital, staff of the headquarter were responsible for contacting the designated hospital and arranging special vehicles for medical staff to transport patients to the designated hospital. (the designated hospital is the comprehensive hospital closest to the fangcang, for example, the designated hospital for keting fangcang is jin yin tan hospital, km away.) there was medical staff staying in this shelter, including doctors, nurses, imagers, five pharmacists, two infection control experts and laboratory technicians. given that the shelter was reconstructed from an art centre, the layout of the medical facilities was imperfect. as soon as we arrived, our rescue team built a mobile hospital using tents, including outpatient services, a pre-inspection space, observation rooms, monitoring rooms, a pharmacy, offices, meeting rooms, dressing rooms, restrooms, a canteen and bathrooms and toilets. seven tents were used as the medical channels of the shelter hospital, which greatly contributed to the smooth operation of the hospital (figs - ) . however, we also encountered many problems during implementation of the mobile hospital, including: how to supply water and power, how to transfer patients to receive ct examination (because it was impossible to perform ct scans in the mobile hospital) and how to transport patients' specimens and excretory wastes. to solve these problems, the following measures were taken: we chose to build the mobile hospital at a certain distance away from the main building, but close enough to connect a water source and power supply; we set up a special ct unit in the emergency department reserved only for those patients with fever, and also set up a special channel for patient transport to and from this ct unit with transfer wheelchairs (fig. ) and made use of special specimen-transferring boxes and sealeddischarge-transferring boxes (figs and ). mobile hospitals have some shortcomings that need to be further improved. first, due to the thin material of the tent, the thermal insulation is poor, and given that air conditioning cannot be used (because this would assist in spreading the virus), the medical staff reported that they felt cold working in the tent. also, there are certain security risks associated with the weather. the mobile hospital in shanghai encountered days of rain, and water needed to be cleared and anti-skid matting used. in wuhan, there was heavy snow (fig. ) , which needed to be cleared. how mobile hospitals can better cope with bad weather should be addressed in future work. in conclusion, mobile hospitals, which are characterised by flexibility, have played a critical role in this anti-epidemic campaign. these mobile hospitals have been rapidly put into use, thereby alleviating the shortage of medical resources in the early stage of the anti-epidemic campaign. available at https:// www.who.int/news-room/detail/ - - -statement-on-the-second-meetingof-the-international-health-regulations-( )-emergency-committeeregarding-the-outbreak who. novel coronavirus ( -ncov)situation report - use of an innovative design mobile hospital in the medical response to hurricane katrina cleaning up snow in wuhan acknowledgements. the authors wish to thank the anonymous reviewers, associate editors and editors for their thoughtful reviews and suggestions in this paper. conflicts of interest. the authors declare no conflicts of interest. key: cord- -l jniccw authors: wilder-smith, annelies title: as travel medicine practitioner during the sars outbreak in singapore date: - - journal: travel medicine doi: . /b - - - - . - sha: doc_id: cord_uid: l jniccw nan common problem in singapore. he consulted a physician in new york. indeed, leukopenia and thrombocytopenia was noted, thus confirming his suspicion of dengue. however, his chest x-ray also showed pneumonia. there was no way he could have connected his symptoms with that of his patient he had seen in the previous week. this all occurred in the couple of days before the term 'sars' was coined and before the who sent out the alert on march. dr. l felt so unwell that he decided to cut short his stay in new york and he embarked on the next singapore airlines flight to return to singapore. just before he departed, he called a doctor friend in singapore to announce that he was diagnosed with pneumonia and was returning home. meanwhile, back in singapore, 'all hell' had broken loose. on friday after our morning grand rounds, several nurses, friends and visitors came down with the same symptoms -and all had been in contact with elly in the preceding week. they were admitted and immediately isolated. by the end of the weekend, we had numerous admissions and we knew that something really unusual was happening. we had staff working around the clock, we had huge media attention and atop this we received a visit by the minister of health. by early monday morning, the first list of the most common symptoms and laboratory findings was put together. i will never forget the staff meeting on that monday morning. the director of the communicable diseases center announced, "we have an outbreak at hand, and it appears to be bigger than we thought". we had no clue how big it was going to be, or what sinister effects it would have... the next two weeks, we lived with great uncertainty. these were the worst two weeks of the epidemic, for we neither knew what the causative agent was nor its mode of transmission nor its treatment. we were horrified to see one medical or nursing colleague after the other coming down with the disease. by now, the first patients that we had seen were starting to die. in the first week after our first cases, the who named the disease "sars", and they sent out global alerts. meanwhile dr. l was on his flight back to singapore, unaware of what was going on in singapore. his friend, whom he had contacted just prior to his departure, was astute enough to conclude, however, that the symptoms dr. l displayed, and his recent contact with the index case, were highly suggestive of this new disease and he alerted the ministry of health. the ministry in turn alerted singapore airlines and this led to the halt of the flight in frankfurt. to his amazement, dr. l was escorted from the airport in full protective gear, admitted to a frankfurt hospital. within hours, his name was in all the news media around the world. his pregnant wife also fell ill, but his mother-in-law for some mysterious reasons did not, although all three of them had been in close contact over a prolonged time. the passengers and crew were debriefed about sars, the recognition of its symptoms and signs, and they were given advice to seek care if they developed any such indications. four days later, a -year-old stewardess of that flight sought help at our clinic when she developed a fever and cough. during the flight, dr. l was kept isolated in the back of the plane. the stewardess had only brief contact with him while serving food, picking up trays, and the like. she kept as much distance as possible and this included minimal communication. sars was confirmed in the stewardess making her the first reported case of in-flight transmission. let me go back to the first few days when the outbreak started to unfold. as you can imagine, my travel clinic was swamped by the public demanding the flu vaccine and any other information about sars. our communicable diseases centre turned into a major screening hub. we screened hundreds of contacts in made up tents using portable x-rays. it soon became clear that as a sole department, we would not be able to cope with all the screening. the screening was therefore moved to the main building of tan tock seng hospital under the auspices of the accident & emergency department. my travel clinic was closed and my staff had a change of job: from advising travelers and administering vaccines to taking their temperatures and asking about any respiratory symptoms. march, the hard decision. close down our hospital completely. it became the designated sars hospital, admitting only probable and suspect sars cases. large numbers were seen and although we were a , bed hospital, we were soon short of isolation rooms.... sars came suddenly and caught us unaware. it's novelty, ease of transmission, and the speed of its spread, put us all in a state of fear. the epidemic progressed rapidly, and it was tragically associated with high death rates. one after another of elly's relatives and friends died: first her father, then her pastor, her mother and finally her uncle. her grandmother was also in the icu, but mysteriously she survived. elly herself survived. we kept her in hospital for a very long time, partly because we were unsure how long she would be able to transmit the disease to others, partly also to protect her from all the media attention. i often wondered how she was coping. characterized by a high rate of transmission to healthcare workers, sars struck deep and hard and affected every one of us with varying degree. the constant fear of getting infected was felt throughout. this fear intensified, as colleagues became patients and young patients died. more distressing was the fear of inadvertently transmitting the infection to loved ones, especially children. many moved out of their usual abode and did not touch their children or spouses for weeks. we became also suspicious of each other. i remember vividly how one colleague wanted to whisper something into my ear, and i jumped away out of fear of getting infected. fear of death became a daily reality. n masks soon became a shortage, and we had to learn how to use the same mask for one whole day. n masks muffled speech, hid expressions of your face, and worse, if one quickened the pace of walking, then we ended up gasping breathlessly for air. in the smouldering humid heat of singapore, the sweat would drop underneath our hair covers, soak the masks and slowly droop down our faces, leaving us in doubt whether the masks were still working. we also had to rationalize our gowns and gloves. frustrations abounded as policies were changed almost daily. we wrote so many guidelines; and every day seemed to bring up a new revision of those from the previous day. although singapore was exemplary in its transparency and abundance of information, as healthcare workers we felt we were scrambling for information. i was literally glued to the websites to gain more up-to-date information of the global outbreak. in the view of the public, the outbreak was mainly associated with our hospital. healthcare workers were shunned by the public. there were stories of nurses not being allowed to return to their rented apartments. buses would not stop at our hospital so that transportation home was not possible. taxis refused to come by. we felt stigmatized. instead of the moral support that we craved for, we felt left alone. my children were not invited to birthday parties anymore. our neighbors did not let their children play with ours. i became infuriated about the way the press dealt with elly. the media also obtained information on patient's names that were eventually published. the atmosphere in the hospital was eerie. instead of the usual buzz with visitors, restaurants and coffee shops, the hospital was empty. i only met masked healthcare workers. movements within the hospital were restricted. visitors were not allowed. every minute of the day, we were geared up. in one of my e-mails, i wrote to my friends back home: "i am masked, gloved, gowned -but not yet cloned". the end time atmosphere in the hospital was accentuated by the tv sets that aired the start of the war in iraq. in april, the previously hidden large number of sars cases in china was suddenly revealed to the world. this news made me loose all hope. i imagined that the epidemic would now turn into global proportions sweeping the world, thereby killing % of its population. i imagined my life as a doctor from now to be a life geared up physically in masks and gowns, psychologically geared for death. in singapore, the outbreak was initially only hospital based, but in april the news was out that sars had affected a large vegetable market. overnight, thousands of people had to be quarantined. the market was closed. that evening i went shopping and realized that there were no more vegetables in supply! many patients had died, but death struck really home when a young medical officer died on april. his mother, a doctor, who had cared for him initially during his illness, was also struck by the disease. she eventually died. one of my infectious disease colleagues was admitted to hospital because of fever. fortunately, her fever turned out to be due to the flu that she had caught from her kids, and she was discharged. not long after, i started feeling unwell myself. i wondered "am i going to be the next?" i was afebrile, but i decided to separate myself from my family, said farewell to my children and my dear husband from the distance, and spent the night isolated in a room. i measured my temperature every hour, ready to get myself admitted if it reached the threshold. alone like this, i reflected over my life and wondered whether i was ready to die. that night was a life-changing experience. the news of the death of carlo urbani, the italian who doctor who was instrumental in the control of sars in vietnam, sent our hospital staff into depression. there was both grief and shock in the air. the final blow came when the husband of a friend of mine contracted sars. he was a surgeon in his mid-thirties, a very bright and popular consultant. he deteriorated rapidly and because of the strict isolation regulations in practice, there was no time for adequate farewell. from his isolation room, he communicated with his wife via text messages. i was grief stricken when i later heard that he had succumbed to sars. even worse, there was no funeral, only a rushed cremation the very next day, as these were the rules for sars-related deaths. with this tragedy, my facade crumbled and i broke down, the first time during all these weeks. i sobbed. i grieved for his widow, a friend and colleague with whom i still teach in community medicine, often finding myself wakening up at night and praying for her. the worst about dying during sars was the fact that this was a lonely death. in total, we lost a total of five healthcare workers to sars in singapore: doctors, nursing officer, nursing aide and hospital attendant. there was a strong group spirit of commitment and determination amongst us, and this enabled us to continue working. voices to quit were few; almost everyone stayed on. dr. carlo urbani's words were a reality for us: "health and dignity are in-dissociable in human beings. it is a duty to stay close to victims and guarantee their rights". after the initial stigmatization, and ostracization, against healthcare workers, there was a turning point in public opinion. all of a sudden, we became the heroes of the nation. we were in a battle against sars together. we were showered with thank you cards, gifts, vitamins and herbal medicine. the walls of our hospital were plastered with well wishers comments and 'thank you' posters sent by companies, institutions, schools, churches, non-government organizations, individuals, etc. almost every day, the media highlighted a healthcare worker with a full story and pictures in the newspapers. emotional support and positive affirmations were morale boosters. the hospital management under the leadership of dr. lim suet wuen arranged frequent staff updates; and the transparency increased our trust in the authorities. our status as healthcare workers was elevated, and with it our morale. progressively stricter infection control measures were put in place. our temperatures were measured three times per day. audits were made to ensure compliance with all the measures. infection control was now part of our daily lives. two to three weeks into the epidemic it became clear, that infection control measures were effective; no more new cases occurred amongst the staff of our hospital. we started feeling safe at work. in fact, we became the safest hospital to work in as new cases continued to arise in the other hospitals in singapore. it may sound strange but because of the implemented strict infection control measures i even felt safer in the hospital than outside. never did i think that i should leave singapore. there was only one moment when i seriously considered it: the newspaper suddenly announced that doctors whose spouses were also doctors but working in different hospitals should be separated. my husband is indeed a doctor in another hospital. i thought "if they separate us, then i will separate myself from singapore". luckily, the plan was never put in action, as it turned out that a vast majority of singapore's doctors are married to other doctors who often happen to work in different hospitals or practices. by may, it became evident that sars was under control in singapore. on st may we were declared sars free. worldwide, also, cases were diminishing. my despair had turned into hope -a hope that sars will not continue to have a deathly grip on our daily lives. once we had hope, life at the sars hospital now also meant facing up to the scientific challenges of this newly emerging coronavirus. the operation center at our hospital became a large center where dozens of people sat long hours every day, even weekends, to do data entry, to analyze data and interpret new findings. i was tasked to do a seroepidemiological cohort study among healthcare workers exposed to sars in the first month of our nosocomial outbreak. the goal of the study was to investigate the incidence of and factors associated with asymptomatic sars-cov infection. while i took blood samples from the more of study subjects, i listened to heartbreaking stories. the findings were interesting. of all exposed (before infection control measures were instituted) healthcare workers, . % had asymptomatic sars (sars serology positive). multivariate analysis showed that asymptomatic sars was associated with lower sars antibody titers and higher use of masks compared to sars that presented with pneumonia. this was an interesting study, however, my main interest circled around sars and its relationship to travel. sars, travel and travel medicine were intricately interlinked. travelers belonged to those primarily affected in the early stages of the outbreak, travelers became vectors of the disease, and finally, travel and tourism themselves became the victims. in fact, travelers not only turned a newly emergent local virus into a global outbreak, but travelers were also the first to unmask the mysterious disease in southern china. i followed up all imported cases of sars, and all incoming flights to singapore with sars cases on board. of the six imported cases, which all occurred before screening measures were implemented at the airport, only the first resulted in extensive secondary transmission. none of these cases resulted in in-flight transmission. of , air passengers screened after measures were implemented, were sent to our designated hospital for further sars screening; none was diagnosed as having sars. the sars outbreak in singapore can be traced to the first imported case. the absence of transmission from the other imported cases was most likely a result of relatively prompt identification and isolation of cases. new imported sars cases therefore need not lead to major outbreaks if systems are in place to identify and isolate them early. screening at entry points is costly, has a low yield and is not sufficient in itself. however, the costs and efforts may be justified in light of the major economic, social and international impact, which even a single imported sars case can have. use of simple laboratory features to distinguish the early stage of severe acute respiratory syndrome from dengue fever experience of severe acute respiratory syndrome in singapore: importation of cases and defense strategies at the airport low risk of in-flight transmission of severe acute respiratory syndrome: the singapore experience asymptomatic sars coronavirus infection among health care workers this article is dedicated to my friend and colleague, dr. woon puay koh, who lost her surgeon husband to sars. key: cord- -xhx pzhj authors: nan title: nd world congress on pediatric intensive care rotterdam, the netherlands, – june abstracts of oral presentations, posters and nursing programme date: journal: intensive care med doi: . /bf sha: doc_id: cord_uid: xhx pzhj nan we present the results of a prospective population-based audit of paediatric intensive care activity in two comparable communities with markedly different delivery systems. in the trent region of the uk ( . million people), children receive intensive care largely without the supervision of a paediatric intensivist in a variety of hospitals, few of which have designated paediatric intensive care units (picus). critically ill children otherwise receive intensive care in children's wards, special care baby units (scbus) or adult intensive care units. in the australian state of victoria ( . million people), children receive intensive care almost exclusively in one centre -a picu staffed by full time paediatric intensivists. the two regions are otherwise demographically comparable. in both groups, data were collected on all children admitted to an intensive care unit between / / and / / and children who received intensive care (defined by levels of intervention and nurse dependency) in other sites during the same period. values of each variable at first contact with the icu, and the highest and lowest values over the first hours were recorded. the principal outcome was survival to discharge from the intensive care unit. severity of illness was assessed using pim (paediatric index of mortality) and prism. risk-adjusted mortality was compared using flora's z test and logistic regression. the rate of utilisation of intensive care (> admissions in each region) were similar. there was some variation in case mix between the two groups, but crude mortality rates were similar ( . % in trent and . % in victoria). however severity corrected data and other measures of picu performance were dramatically better in' the centralised delivery system. the substantial excess mortality in the trent region provides strong evidence for the benefits of centralisation of paediatric intensive care services. there are considerable difficulties in evaluating the efficiency and effectiveness oflcare in children presenting with respiratory failure during acute medical illness. optimal outcomes for such episodes include survival and the shortest length of stay (los) in intensive care with negligible risk of readmission. we have tried to determine whether or not the time course of acute severe medical illness with respiratory failure is predictable. study i (n= ): a retrospective study of intubated and mechanically ventilated children (> days, < years) with acute severe medical illness. measures: diagnosis, intensive care los in calender days, and survival. results: the underlying diagnosis fell within one of three broad categories: respiratory disease (n= , mortality . %), central nervous system (cns) disease (n= , mortality . %), and systemic inflammation or multisystem (sims) disease (n= , mortality . %. the los in survivors was: respiratory -median (interquartile range) ( - ) days, cns ( - ) days, £p, £ ( -g) days. :i'~'-+cen diag~,~is-rc!ated-grnnp~ (drgs) were identified ( respiratory, cns, sims disease) and each have been characterised by mortality and los. study ii (n= ): a prospective study of patients supported by the hypothesis that los for the above drgs was predictable (compared with study i data). in certain instances attributable causes for variances in los were identified: e.g. disease severity, timing ofdrug therapy, and associated disease. with daily paediatric risk of morality scoring within each drg, four profiles of instability were identified. discussion: the time course of acute severe medical illness with respiratory failure is predictable and variance may be attributable to specific care or diagnostic factors. we are now developing a means of linking drg-specific clinical care pathways with an integrated computerised decision support and education facility at the bedside. the objective of this open, prospective study was to assess the relation between basic patient characteristics as well as effectiveness of treatment on the one hand and resource utilization in pediatric intensive care on the other. as universal, non-monetary indicators of resource utilization we used the therapeutic intervention score system (tiss) and length-ofstay (los), from which indicators for total resource utilization per admission (tisstot) and average daily resource utilization (tiss-mean = tisstot/los) were obtained. overall admissions, totalling days, were included. mortality was . %; non-survivors accounted for . % of overall resource utilization. in non-survivors, both total resource utilization per admission and average daily resource utilization were higher, whereas los was not different from survivors'. severity of illness, surgical status, the presence of substantial chronic comorbidity, emergency admission and transfer from another hospital constituted the major predictive determinants of tisstot (r:= . ) and tissmean (ra= . ) in multiple regression analysis (p< . ). hence these indicators are appropriate non-monetary measures of resource utilization, a considerable proportion of which are determined by a concise set of basic clinical characteristics. subsequently we analysed the relation between effectiveness of care and resource utilization by assessing severity of illness corrected mortality in low, medium and high resource users, respectively. these categories were delineated by percer/tiles of resource utilization (< p , p -ps , > ps ). despite on average long los and high resource utilization in the high risk group, a relatively low standardized mortality was found, probably warranting prolonged intensive treatment in this patient category. summary: objective:the primary purposes of intensive care are to provide treatments to patients with life-threatening physiological dysfunction or to monitor and observe patients perceived to be at significant risk of dying. this collaborative study was performed to describe our patients and their outcome. in order to improve our results we tried to identit~ high risk groups, patients and methods: picus entered the study, the data included all the admissions with > hs. during a days period between the l°june and the th september . the records included: age, sex, weight, mechanical ventilation (mv), post-operative condition (p.op), malnutrition, diagnosis, length of stay, prism score and outcome. student test, mann-whitney or wileoxon were performed for univariate analysis. fisher exact test or chi square for dicotomic variables. risk group analysis was performed by logistic regression, odds ratio and % confidence interval. results: patients entered the study. mean age was . months (ds hh¢# ) and median months. we found significant statistical differences in calculated ,is observed mortality rate comparing malnourished with euthrofic patients; mechanical ventilated (mv) with non mv patients. no differences in ter ~,h of stay or di~ noses were found. effect of the un sanctions on the morbidity rate araong the iraqi small children ( below years old of age ) in bagdad. abdulsamad a.abood / institute of medical technology, bagdad. meningitis is essentially a childhood disease (i). the risk of infection are increased by powerty and overcrowding ( ). the impah'ed immunity may be an important pathogenic factor underlying the susceptibility to infections in undernourished subjects ( ). in general, malnutrition is a man made disease and it begins quite in the womb and ends in the grave (i). small children, below years of age were admitted to the pediatric hospital in washash with meningitis over cold months in i , in contrast to only child admitted with meningitis over the same period in . all of the children who admitted in were frankly undernourished, % of them were infected with enterobacteriae, because they were exposed to faulty hygiene and lack of asepsis. these facts showed precisely that our small children had suffered at most from the un_ sanctions against iraq, because of food, milk and drug shortage, since years which had resulted a severe undernutrition among them, which impaired their immune status. m wells, of riera-fanego, j lipman. baragwanath intensive care unit, university of the witwatersrand, south africa. background the use of prism or other scoring systems in the icu is of great importance for evaluating the efficacy and efficiency of a particular icu, the prism score was developed and validated in the usa and europe but has recently been shown to be inaccurate in a south american population, a south african population as well as several european studies. part of the poor performance of the prism score is as a result of differences in the case mix between the reference population and other paediatric icus. since scoring systems should generally be used only in populations similar to the reference population from which the prediction model was developed, a modification of the prism score is necessary to improve its discriminatory ability in a wide range of patient groups, aim to improve the predictive power of the prism score in a south african paediatdc icu population. patients & methods we analysed prism, demographic and clinical data collected prospectively from consecutive paediatrie icu admissions. the prediction of actual mortality by prism was evaluated by standard statistical methodology (goodness-of-fit test and receiver operating characteristic (roc) analysis), the components of the prism logistic regression equation (prism score, operative status and age) and the physiological variables making up the prism score in addition new variables analysed (nutritional index, the need for inotropes and institution of mechanical ventilation) were subjected to discriminant analysis to determine their association with outcome. results the goodness-of-fit test showed a significant failure of prism to accurately predict mortality over a wide range of expected mortality (chi [ ] = , p = ). prism underpredicted mortality at lower prism scores, but overpredicted mortality in patients with high prisms. similarly roc annysis indicated apoor predic~jve power (az = . ± . ), with an area under the curve significantly less than that for the prism reference population (p = ), prism showed equally poor discriminatory function at all age groups and diagnosfic categories. '~mth the addition of an index of nutrifional status (proportional weight-far-age), and indicators of early respiratory and cardiovascular failure to the logistic regression formula, and a recalibration of the acute physiological score component, the roc can be improved to . ± . , with a good fit described by the goodness-of-fit test (cn ] = , p = . ). discussion the prism score is not accurate in our patient population has been recalibrated in view of the poor discriminatory function that we have shown. part of the inaccuracy derives from the different demographic characteristics of our icu population and a different pattern of diseases. in addition to assessments of acute physiological aberrations, an assessment of nutritional status and early respiratory and cardiovascular failure significantly improve the discriminatory ability of the prism score, these parameters have been devised with a view to improving the accuracy of prism in our population, while not decreasing its accuracy in icus similar to the reference population. in interviewing parents regarding how physicians have communicated bad news, the response i have received is that it has not infrequently been done without appropriate care, understanding and compassion. personal experience and the lessons learned from parents, chaplains and others who deal extensively with these situations have provided me with an approach that has been supportive, compassionate, and caring. an especially difficult communication situation for the intensivist occurs when the parents have to be informed of the death of their child. for the parent, death is the hardest loss of all -the ultimate unalterable loss. circumstances surrounding the death are an important consideration (e.g., a fatal crash caused by a drunken driver, a prolonged illness, a suicide, aids). each produces a different grief reaction. the physician needs to inform parents of their child's death sympathetically coming right out with the news and leaving details until later. allow pauses and time for the paren~ to express sorrow and grief, the best communication may be thoughtful silence and a tender touch. there is disbelief that this happened. it is necessary to repeat oneself. acknowledgment of the parent's "feeling terrible" and the physician's acknowledgment of how terrible he/she feels that the life of the child could not be saved is an important first step in the parent's dealing with this tragic loss. with prolonged resuscitation, it is helpful to have a member of the icu team talk to the parents while the resuscitative efforts are ongoing so that the parents are not left unsupported at this time. a progress report should be delivered in a caring, lucid, and sensitive.manner, indicating that every effort is being made to save the life of their desperately injured child. after a child has died, it is helpful to the family if the physician maintains some contact with them. this should take the form of follow-up telephone calls at approximately , , and months. this can help to screen for depression in the parents. in giving bad news to the family and making every effort to support them through this tragic time, it is necessary to remind oneself that the intensivist has personal needs for dealing with grief and will also require support to pass through this stage. direct evidence that child mortality is lower in specialist pediatric icus comes from studies. a study in oregon (ccm ; : - ) found that mortality adjusted for severity of illness was % of expected in pediatric units and % of expected in general units (p< . ). a study in holland (ccm ; : - ) found that mortality in high risk patients was % of expected in tertiary pediatric units, and % of expected in nontertiary units (p< . ). a third unpublished study, has found that children in victoria (who almost all receive intensive care in a pediatric icu) have a much lower standardised mortality rate than children in the trent region of the uk (where many children receive intensive care in adult icus). there is indirect evidence that icus looking after many children are likely, on average, to perform better than icus looking after few children: numerous studies in many specialities have found that units looking after many cases of a particular disease have better results than units with few cases. see luft hs, "hospital volume, physician volume, and patient outcomes", happ, ; and farley d, medical care ; : - . compared to general icus, medical and nursing staff in pediatric icus are likely to be better at looking ~fter children, and plcu rmos have greater skills in pediatric intubation, ventilation, iv drip insertion and drug doses. picus are more likely to have appropriate equipment to manage children -especially for uncommon but life-threatening situations. icus in pediatric hospitals are more likely to have physicians and surgeons with pediatric expertise available for consultation at all times. the american academy of pediatrics, the society of critical care medicine, the british paediatric association and the australian nh&mrc have all said that children should receive intensive care in'specialist pediatric units. the weight of authoritative opinion, and direct and indirect evidence is strongly in favour of looking after children in dedicated pediatric icus. neurological deficit showed higher cbf values ( . / . ml/ g/ rain.) than the patients with good outcome (mean cbf . sd + . ; cbf . sd _+ . ml/ g/rain}. discussion: in asphyxia decrease of ph is due to reduced tissue oxygenation and indicates the severity of metabolic derangements. co reactivity in newborns with perinatal asphyxia correlates with the lowest ph and therefore may reflect severity of asphyxia. continuous monitoring of cerebral activity is carried out in our unit on all admissions at risk of cerebral dysfunction, a number of monitors are commercially available and we report our experience with the cfam which provides in addition to amplitude integrated eeg analysis, continuous raw eeg display and frequency distribution. bilateral recordings are commenced as soon as possible and continued while clinically indicated. forty one children ranging in ages from weeks to years were monitored for periods from hours to i days, diagnoses included traumatic brain injury ( ), sepsis/meningitis/encephalitis ( t), status epilepticus ( ) and miscellanous others ( ). results are tabulated below. patients status epilepticus * beta activity * background voltage * < i o/zv or more of above * (*z p < , ) asymmetry developed in children, all of whom died. positive predictors of good outcome included a mean background activity of > zzv, the presence of faster frequencies (usually ) in response to sedative drugs and the absence of seizures. all monitoring is performed by the picu staff and increasing expertise in interpretation has resulted in earlier therapeutic and diagnostic interventions. regional it was previously found that histamine, a vasoactive mediator, accumulated in brain compartments (kov~ics et al neurosci lett : ) , and antihistamines prevented brain edema formation (dux et al. neuroscience : ) in asphyxiated newborn pigs. in the present study we investigated the effect of intracarotid histamine injection on the blood-brain barrier (bbb) permeability, left internal carotid artery of newborn pigs ( - h; , - , g; ketamine anesthesia, mg x kg ) was catheterized through the external branch and different doses of histamine ( , - , xi - , - , x , m, respectively, in groups of animals; n= in each) diluted in . ml isotonic saline was injected into the vessel through rain. bbb permeability was determined for a small (sodium fluorescein, sf, da) and a large (evans blue/albumin, eba, kda) tracer ( %, mlxkg , rain circulation time for both dyes) concomitantly in frontal, parietal and occipital cortex, hippocampus, and periventrieular white matter both on left and right sides h after the challenge. then, intravascular dyes were removed by perfusion and bbb permeability for both tracers was quantified by fluorescence spectrophotometry (wavelengths for excitation and emission were nm and nm for sf; and nm and nm for eba, respectively). histamine injection, in doses higher than . m, significantly (p< . ; kruskal-wallis one way anova on ranks followed by dunn's test) increased bbb permeability for both tracers in each brain region. changes in left hemisphere were more intense (p< . ) than those in right one after the doses of xi - and - m in each region, i m histamine administration induced similar edema in both sides. increased intracarotid histamine levels resulted in a dose-dependent vasogenic brain edema formation. histamine might have a pathogenetic role in neonatal hypoxicischemic cerebral injuries. supported by otka f- and h-u.s,-jfno. , $ in coma caused by traumatic brain jnjury, an indication of the likely outcome is provided by the best motor response to pain in the first .$ hours after the insult. in a study in our picu, the proportion of children who died or had a severe disability was % in who had no response to pain, % in with an extensor response, % in with a flexor response, and % in who localized in response to pain. the long term outcome of traumatic brain injury appears to be worse in children < years old. other risk factors in traumatic brain injury are absent basal cisterns, midline shift or subdural haemorrhage on ct scan (or loss of grey-white differentiation in nontraumatic injury); or an intracranial pressure > mmhg despite hyperventilation, mannitol and barbiturate infusion. apart from brain death, there are two findings implying such a poor prognosis that consideration should be given to stopping treatment: first, after traumatic injury, the absence of any motor response to painful stimulus in the cranial nerve distribution (providing drug effects and a post-ictal state have been excluded); and second, in acute brain injury from trauma, infection, hypoxia, or ischaemia, the b{lateral absence of short-latency somatosensory evoked potentials (providing brain stem haemorrhage, subdural and extradural effusions, and decompressive craniectomy have been excluded). in children over months of age, recovery from prolonged coma or a vegetative state is exceedingly rare when more than months have elapsed after traumatic brain injury, and when more than months have elapsed after nontraumatic injury. overproduction of nitric oxide (no) via an inducible isoform of" no synthasc (inos) produces profound vasodilatation in adult septic shock. high nitrate levels have been reported in hypotensive children with sepsis syndrome ]. cardiovascular collapse is a prominent feature of severe meningocoecai disease (mcd). however, systemic vascular resistance (svr) was slightly higher in a group of non-survivors ~ and the rote of no in ivicd remains unclear. children with a presumptive diagnosis of mcd were enrolled. parental consent was obtained. blood was drawn on admission and hrly thereafter. plasma was separated immediately and stored at - °c. the final concentrations reported represent the product of nitrite and nitrate (nox). nox was measured spectrophotometrically using the greiss reaction. children were studied (median age (range); m ( - )). the diagnosis of mcd was confirmed in children, of whom had a glasgow meningococcal score (gms) of" ~ . in this group with severe mcd there were deaths. peak nox was significantly higher (,. ( - ) vs ( - )nmol/ml, median) and systolic btood pressure was significantly lower in children with severe mcd than mild mcd (p< . . wilcoxon rank test). there was a significant correlation between peak nox and gms (spearman's rank correlation r= . (p= . )) and prism (r= . (p: . )). nox production from adm.ission onwards was also higher in the severe mcd group (p: . , kmskal ~wallis). we have demonstrated that plasma nox levels are elevated in children with mcd, correlate directly with the severit ' of disease and are inversly related to systolic blood presssure. similar to hypotensive septic syndrome, mcd appears to be associated with an up-regulation of the l-arginine-no pathway.. non-survivors with mcd have higher svrs and may be relatively hypovolaemic. in our group of severe mcd there was a significantly lower systolic pressure and increased no formation. excess inos expression at different stages in mcd may contribute to the pathology of the disease. the identification of agents which can boost and/or inhibit no reiease may therefore represent different treatment strategies for mcd. u. merz, th. peschgens, g. kusenbach, m. b hle, h. h rnchen in this controlled, prospective study ventilated premature infants with a birth weight < g were randomized to receive treatment with dexamethasone (dex) either on day of life or on day of life. dex was given over days tapering from . mg/kg/day to . mg/kg/day. the infants treated with dex on day of life could be weaned earlier from the ventilator -in median after days (range - ) versus days (range - ) in the [ate treatment group (p = . ). the need for supplemental oxygen was shorter in the early treatment group -in median days (range - ) versus days (range - ) (p = . , ns). the incidence of chronic lung disease was lower in the early treatment group - of infants ( . %) versus of patients ( . %) (ns). to evaluate the long-term efficacy of early dex treatment we performed a respiratory function test in the age of - months using an infant whole body-plethysmograph. the intrathoracic gas volume (itgv), the airway resistance (r.w) and the airway conductance (gaw) were measured and no significant differences could be detected between the groups. the frequency of adverse effects due to dex therapy was found to be without significant differences between the early and the late treatment group. we conclude that early dex treatment had short-term improvements in pulmonary outcome in our study population, long-term efficacy however, remained unproven. several factors contribute to the development of chronic lung disease (cld) in premature infants including structural immaturity of the lung, mechanical ventilation, and oxidative stress. reactive oxygen species are formed during normal cellular metabolism but they are generated in higher concentrations during inflammation or inhalation of high oxygen concentrations. to study the relationship between increased oxidative stress, antioxidants and the development of cld we examined ventilated premature infants with birth weights below t g. infants developed severe chronic lung disease of prematurity (cld), defined by radiological signs of cld and an increased oxygen requirement at a postconceptional age of weeks, and infants had moderate cld with an increased oxygen requirement on day but not at an age of weeks. ventilator settings (fio , peak inspiratory and mean airway pressure) and the incidence of early-onset-sepsis were significantly higher in the severe cld group than in infants with moderate cld or without cld (n= ) during the first week of life. plasma concentrations of the two antioxidative substances bilirubin and uric acid (ua) were comparable in all groups during the first days of life. however, on day seven bilirubin and ua were significantly decreased in the plasma of infants with severe and moderate cld compared to the non cld group (p<o. ). there was no difference between both cld groups. in serially obtained tracheal aspirate fluids (taf) malondialdehyde (mda) was measured by hplc as an indicator of lipid peroxidation reflecting oxygen injury of the lung. ua was found in higher concentrations in taf than bilirubin. ua has been proven to be a potent antioxidant, capable to react especially with hydroxyl radicals and hydrochlerous acid, which play an important role in the induction of lipid peroxidation. infants with severe cld had significantly higher mdnua ratios in taf from day to compared to the non-cld group (p<o. ). mdnua ratios in taf of infants with moderate cld were significantly higher from day on but still lower than in the severe cld group. in addition, the ratio oxidized / reduced glutathione was significantly increased in taf of infants with cld compared to infants without cld between day and . the data support the hypothesis that an imbalance of oxidative stress and antioxidant defense contributs to the onset of cld at the end of the first week of life. introduction. rocuronium bromide (roe), a neuromuscular blocking agent with an onset time dose to that of succinyleholine l'z, has been studied in american society of anesthesiologists' physical status (asa) i or ii pedlatrie patients under non-critical elective conditions. there is a paucity of studies looking at the pharmacodynamics of roc under emergent conditions, involving pediatric patients who are asa iii or iv, without the use of adjuvant inhaled anesthetics ~. methods. with approval of our committee on clinical investigations (irb), roe . mg/kg was administered to asa iii/iv pediatric intensive care patients (age days to months; m:f= : ) on intravenous sedation. the time to reach % a~d % of b~elinc tetanie stimulus response was recorded using a r.elaxogra'ph/qmt- nerve stimulator/recorder (datex, helsiaki). depth of clinical relaxation at the % level was recorded. results. the time from rapid bolus to % was . + . see with a range of - see; and to % was . + . see, with a range of - see. at the % level, excellent clinical relaxation was seen. conduslon. in critically ill children, use of roe at . mg/kg produces rapid onset of neuromuscular blockade and excellent clinical relaxation, such that roe should be considered for rapid sequence intubation. int anesth clin. ; ( ): - . anesthesiology. ; ( ) computed tomography of the chest (ct) in mechanically ventilated adults can detect intrathoracic pathology not appreciated on chest radiographs (cxr) and influence intensive care management. no such data exists for ventilated children. aims: ) to assess if ct provides additional information over cxr regarding extent and nature of intrathoracic disease in ventilated children. ) to determine whether such information alters clinical management, inclusion criteria : ventilated children with cxr changes inconsistent with their respiratory status underwent ct if either a) pao :fio ratio < and/or mean paw> cm h or b) there was an unexplained increase in ventilatory requirement. methods : high resolution ct was performed in patients and spiral ct in patierits, to ensure minimal transport related morbidity, patients were transferred to the ct scanner by a specialised mobile intensive care team. results: in / patients ct demonstrated greater extent of disease than appreciated on cxr but did not significantly alter clinical management. in / patients ct provided additional information regarding the nature of disease present, in / children this involved a further diagnosis and in / children the exclusion of a suspected pathology. new information led to a positive therapeutic intervention in children, prevented inappropriate manoeuvres in , and had no significant effect on acute management in children. conclusions: initial data suggests that in a selected group of mechanically ventilated children chest ct can add to the sensitivity and specificity of intrathoracic diagnosis provided by the chest radiograph and directly influence acute management. case selection criteria and choice of the most appropriate protocol requires further study. pressure control ventilation (pcv) utilizes a decelerating flow pattern which may improve gas distribution and lead to alveolar recruitment. in contrast, volume control ventilation (vcv) employs a constant flow. in children, the effects of pcv as compared to vcv are unclear. the purpose of this study was to determine how these two modes compare in terms of dynamic compliance (cdyn). peak iaspiratory pressure (pip), and mean airway pressure (paw) at equivalent minute ventilation. methods: sixteen infants and pediatric patients ranging in age from day to years were studied. diagnoses included ards ( ), postoperative cardiac surgery ( ), head trauma ( ), and resfrictive lung disease ( ). patients were randomized to pcv ( ) or vcv ( ). initial measurements of gas exchange (abg's) and respiratory mechanics (ventrak, novametrix medical systems) were obtained after a minute stabilizadon period. respiratory mechanics included pip, peep, paw, delivered tidal volume, and cdyn (avolume/apressure). the patients were then crossed over to the alternate mode of ventilation holding delivered tidal volume, peep, inspiratory time, minute ventilation, and fio constant. data were collected after minutes, in each mode the absence of intrinsic peep was confirmed. to assure that the measurements were not affected by changes in clinical status, the patients were returned to the initial mode of ventilation and measurements repeated (final) . patients were ventilated with a siemens c or sv . reselts: data were analyzed using -way analysis of variance with repeated measures. ~ < . vs. vcv) vcv pcv ~ initial ] final ! cdljn . _+ . . _+ . * . _+ . . _+ . i , pip + . l-_t. * _+ , +- , paw . _+ . . i-_ . * . + . . -!-_ . pao _+ +- _+ _+ discussion: at the same minute ventilation, the decelerating flow pattern of pcv resulted in a % increase in cdyn and an % increase in paw while decreasing pip by %. the lack of a significant change in oxygenation may be a result of the limited time in each ventilator mode as well as the inclusion of patients with both normal and abnormal lungs. there was no significant difference in initial and final measurements indicating patient stability. the beneficial effects of iecre~l~iug cdyn and paw while decreasing pip indicate that pcv may be a preferable mode of ventilation in patients with lung injury. further randomized studies examining the effect of pcv on respiratory outcome measures in pediatrics are indicated. prolonged positive pressure ventilation following repair of cdh is associated with a high prevalence of iatrogenic lung injury, in our unit dudng - late deaths after repair of cdh were due to chronic lung disease. since babies requiring assisted ventilation for more than days following surgery were transferred to a cnep chamber to limit lung injury. cnep of - cm of h was combined with positive pressure ventilation via an endotracheal tube dudng the transition phase. immediate reduction of peak inspiratory and positive end pressures were possible and following extubation respiratory support was maintained by cnep v~th appropriate inspired oxygen. overall outcome: [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] n= deaths before surgery (%) ( ecmo during - / who were ventilated for more than days received cnep and there were no deaths and no chronic lung disease in that group. cnep assisted ventilation may be an important management option for babies who require prolonged respiratory support to avoid the adverse effects of chronic positive pressure ventilation, introduction so far modes of liquid ventilation (lv) have been used in experimental animals and, exceptionally, in humans: . total liquid ventilation (tlv)-functional residual capacity (frc) is filled by perfluorocarbons (pfc), and slow tidal volume (tv) breathing is performed by pfc. . partial liquid ve, ti,la~ion (page) -only frc is filled by pfc. gas tv is delivered by conventional mechanical ventilation (cmv), high frequency jet ventilation (hfjv) or high frequency oscillation (hfo). the aim of our study is to present our limited experience with page in newborns and infants. page was used in two groups of infants: , in infants with brain death before disconnection from cmv, because recipients for organ transplantation were not available. these infants have relatively normal lungs (fio~ less than . ). infants stayed on page for hour, during that period no ventdator manipulations were made. after page, infant were switched to cmv for next hours. . very critically diseased infants with ards (rds) - on ecmo more than days, before cannulation for ecmo, on hfo because of intractable respiratory failure, preoxygenated rm (miteni, italy) was used in the doses up to ml/kg intratrachealy. blood gases and parameters of pulmonary mechanics were followed (dynamic compliance -c dyn, airway resistance -raw, bicore monitor). page was combined with no inhalation ( - p.p.m, in infants). in both groups ad hoc an approvement from e local ethical commission and informed parental consent were obtained. in the first qroud with relatively normal lung parameters of oxygenation drops after pfc instilation intratracheally and stayed depressed for - hours. slight pco retention occured in both cases during page. c dyn increased almost double during page period, raw drops transitorily after pfc instilation but in minutes they were identical like in prepage period, parameters of oxygenation (peo /fio ) after - hours after page improved and were better than in prepage period. after that time infants were disconnected and died. in the second group no improvement of oxygenation was seen in one ecmo baby, in spite ()f transient improvement of c dyn. in the second ecmo baby, oxygenation improved and flow of pump could be decreased by more than %. none of these babies, however, survived, improvement was only transient in spite of repeated dosis of pfc. in these babies serious problems were to maintain the adequate frc by liquid, because of severe air leak, in babies on hfo/hfjv with severe ards/rds the improvement of oxygenation were seen in all the cases immediately after pfc instiletion for the period of - hours. after that period, pfc dose had to be repeated. two babies of this group survived. conclusion. page is going steadily from tabs to clinical practice. it is simple, could be performed anywhere, cheaper than tlv. however, because liquivent -perflubren (aliance pharmaceutical) is not available in europe, rm of (mitenti, italy) is the only solution, which could be currently used here. before the widespread use of page in clinics, liquid network among most nicus and picus must be built up, the criteria for page must be defined and ethinal-legal problems resolved as well. after resolution of these particular problems page can be life saving procedure for very special part of critically ill newborns end infants. catherine caronia, peter silver, laura nimkoff, cad quinn, jack gorvoy, and mayer san. division of pediartic critical care, medici,, schneider children's hospital, new hyde park, ny , imroduetiun: cystic fibrosis (cf) patients awaiting lung transplantation present a therapeutic dilenuna when severe respir, aory decompemalion occurs, endotracheal intubation and mechanical ventilation is known to have no long term benefits and is associated with high morbidity and mortality. noninvasive respiratory support appears to be a beneficial alternative. methods: we instituted bipap (respironics, inc,, murrayville, pa) in end-stage cf patients who were admitted to the pediatric icu with severe respiratory decompeusation. all patients were awaiting tung transplantation. after a control period, bipap was applied via a tight fitting nasal or facial mask, using the spo~aneous breathing mode, expiratory pressures were set at - cm hhzo. inspiratory pressures were started at cm ~i o and increased in cm i-i increments until the patient's respiratory comfort was achieved and substantiated by non-invasive monitoring. patients were instructed to use bipap during night sleep and whenever subjectively required, data are reported as mean _+ s.d. results: all patiems utilized nocturnal bipap for - hours/day during a follow-up period of - months. compared to their pre-bipap status, the patiems' oxygen requirement and respiratory rate both oz~ cundusion: bipap tl~rapy improves the respiratory status of decompeusatir!g end-stage cf paacnts. it is well tolerated for long term use at home, and provides an extended period of respiratory comfort and stability for cf patients awaiting lung transplantation. l. bindl*, g. kiihl**, p. lasch***, appel**, j.m er**** and the "arbeitsgemeinschaft ards im kindesalter" background acute respiratory distress syndrome (ards) is a therapeutic challenge in pediatric intensive care in view of the high mortality, in about german paediatlic hospitals founded a working group aiming on collaborative clinical research in this field. aims and methods the aim of both a prospective and retrospective survey conducted in german pediatric intensive care units in was to accumulate data on the epidemiology, risk factors, natural history and treatment strategies in a large group of pediatric ards patients who were treated in the tt~ee year period from to .all patients had acute bilateral alveolar infiltration of noncardiogenic origin and a po ~io ratio < mmhg. the influence of sex, underlying disease and single organ failure was analyzed using the fischer's exact test, the influence of additional organ failure on mortality was tested with the cochran-mantel-haenszet statistics. results patients were reported giving an incidence of cases per admissions to pediatric icus. median age was month. in % of the cases, ards was associated with a pulmonary, in % with a systemic underlying disease. in % immunocompetence was impaired. mortality was % and not dependent on age, sex and triggering event. the number of associated organ failures, however, strongly influenced mortalib,. mortafity in immuno-compromised patients was t %. the analysis of treatment modalifies employed in the patients revealed a lack of uniform therapeutic strategies. on the other hand, the patients were exposed to interventions not yet supported by controlled trials. conclusions the observation of the lack of uniform treatment strategies led to the elaboration of recommendations on ventilator therapy and patient monitoring within the working group. the data gathered in this survey provide the basis for the design of prospective multicenter studies urgently needed to evaluate innovative treatment modafities in pediatric ards. recurrent apnea and respiratory failnre due to severe lower respiratory tract disorders such as bronchiolitis or pneumonia are the most common reasons for mechanical ventilation during respiratory syncytial virus (rsv) infection. acute respiratory distress syndrome (ards) has been described as a complication of severe rsv infectionj in contrast to the low mortality rates associated with rsv infection (< %), mortality rates in the range of - % have been reported in pediatric patients with ards. however, studies on ards are usually lumped in respect to causation and the disease course of rsv induced ards has not been previously studied. we examined the lung function abnormalities of infants with rsv induced respiratory failure requiring assisted ventilation, measurements included respiratory mechanics, maximal expiratory flow-volume curves and lung volumes, ards was defined clinically using the criteria which were recently proposed by the american-european consensus conference on ards~: acute disease onset, pao /fio~ ratio _< mrn hg, bilateral infiltrates on chest radiograph and absence of clinical evidence of left atrial hypertension. we calculated the murray lung injury scores modified for use in pediatric patients from total respiratory system compliance, radiographic findings, ventilator settings and blood gas results. we identified infants with severe restrictive lung disease that fialfilled the clinical criteria fbr classification as ards. all had lung injury scores above . which is the recommended cut-off for a diagnosis of ards, twenty-seven infants had obstructive disease consistent with a clinical diagnosis of bronchiolitis. the ards patients were significantly younger, had a longer time of assisted ventilation (p < . ) and a greater proportion of infants with preexisting illnesses (p= . , odds ratio = . ) when compared to the patients with obstructive disease. with the exception of one immunodeficient patient, none of these infants died. given the low mortality despite a clinical picture of severe lung injury, there is evidence that rsv induced respiratory failure may represent a relatively benign cause of ards in pediatric patients, bachmann an audit of patients with severe acute bypoxic respiratory failure (ahrf) receiving highfrequency oscillatory ventilation (hfov) in our unit ( n= , mortality %) revealed that sub-groups with severe underlying disease (n= , mortality %)and those with mu~pie organ failure ( > systems failing, n= mortality %) accounted for all the deaths beyond the neonatal period. v~ therefore hypothesized that in a modem paedistric intensive care unit (picu): a) children greater than one month of age with ahrf do not die in the absence of severe, pre-existing disease or multi-organ dysfunction syndrome, b) respiratory parameters alone will predict outcome poorly in ahrf. method prospect~/e sty/of all adm~ns to our tertiary picu. data it, citing the respiratory parameters (oxygena~n index [ol] , aiveolar-artedal oxygen tension gradient , pao /fio ratio) were collected hourly from the bedside charts throughout admission. patients were included in the study if ahrf was present at admission either none or in combination with other organ dysfun~on. ahrf was defined as the acute (< hour) onset of respiratory dysfunctk:~l with a pao /fio ratio.< for six consecutive hours dunng the first hours of admission (with no evidence of left anal hypertension), x-ray review defined a sub-group of patients with acute respiratory distress syndrome (ards) by the presence of bilateral interstitial infiltrates. results to date children (ages - months, weight . - kg) have been admitted in ahrf. of these also had ards. the overall mortality was . % ( / ), and greater in the ards group than the non-ards group ( t , . % vs, , . %, p< o. ) . it was not possible to predict survivors from non-survivors on the basis of the seventy of the respiratory failure alone, the a-ado on the day of admission (best in hours) was not significantly different between survivors and non-survivors: (mean, + sd)( mmhg +_ , vs mmhg _+_ ). kdl non-survivors were immunodeficient (n= ), previously extmrnsly premature infants (< ),(n= ) or suffedng fcom chronic metabolic or gastrointestinal disease (n= ). no previously normal child died. conclusion the severity of respiratory failure does not allow predioljon of outcome in our patients. we believe that this reflects that modem picu is so effective at providing respiratory support that pre-existing pathology alone de~ prognosis. this suggests that an abnormally regulated host response or abnormal persistence of a pathogen may be required to induce lung injury of sufficient severity that the resulting respiratory failure cannot be supported in a modem picu. introduction: postural changes (supine to prone) is a therapeutic intervention that could be useful in children with adult respiratory distress syndrome. objective: to determine the effects of postural changes in the oxygenation of young children with ards. method,s: a prospective stud ," was performed in eleven subjects aged to months (mean= ) with the diagnosis of ardsreceiving vendlatory support. (mean peep and fio of and . respectively). postural changes was performed every - hours, during a period of time ranging from to days. arterial blood gases were determined before and - n~n after the postural change, no modification in the mechattical ventilation other that changes in the fio were performed. the oxygenation was determined by the index pao /fi (p/f). to study the differences between the oxygenation mean, before and after the postural changes the wilcoxon test for paired samples was used, results: changes were performed ( from supine to prone and from prone to supine). a % increased p/f ratio was obtained after the change from supine to prune. although, not all the patients receiving postural changes improved their p/f. six of them (group i) showed an improve in the p/f when changed from supine to prone, returning to their base line when positioned from prone to supine. no improvement on the p/f was observed in the remaining subjects (group ii)after postural changes (table ) . during the maneuver no complications were observed. two patients had a pneumothorax, not related with the postural change. conclusions: postural changes (supine to prone) is an easy way to improve oxygenation in some children with ards. change to prone change to supine introduction: the common noninvasive diagnostic efforts to identify possible obstruction of the intrathorucic airway, are of limited value. invasive procedures such as bronchoscopy and bronchography may also be noncontributory and entail risks. we evaluated the usefulness of d-ct in the diagnosis and management of pediatric patients with suspected intrathoracic airway obstruction (itao). methods: we used a diagnostic algorithm (see diagram) in patients with suspected itao resulting in respiratory distress. three-dimensioual imaging of the tracheobronchial tree was reconstructed, following high speed spiral ct scan, by specific computer software (advantage window computer work station, general electric, milwaukee, wisconsin). non-ionic contrast medium was injected, in some patients, to delineate the intrathoracie large vessels.. results: eight patients were studied. in patients the d-ct revealed intrathoracic airway abnormalities. these patients underwent further invesive studies which confirmed the following diagnoses: patients had bronchomalacia, had bronchial stennsis due to a dilated pulmonary artery mad patients had subglottie stenosis extending to the thoracic cavity. three patients had no significant disruption in the configuration of the tracheobronchial tree and thus did not require invasive diagnostic procedures. conclusion: computer reconstruction of three dimensional images of the tracheobronehial tree is a safe and reliable diagnostic tool for itao. ards and ecmo; preliminary data from a randomized clinical trial. j fackler, c steinhart, d nichols, d bohn, m heulitt, t green, l martin, k newth, m klein, j ware. many suggest ecmo be considered experimental for ards and undertaken only with careful data collection and reporting. a mtflticenter pediatric rct is in progress to determine whether ) ecmo and/or ) permissive hypercapnia, offer significant advantage for the treatment of ards. methods: all patients aged wk to yr (without congenital heart disease) are eligible for study. data collection begins when a patient receives at least % oxygen and a peep of cm h for hours (stage t). if the predicted mortality reaches % within days (stage ), eligible patients are asked for written consent for randomization. patients are excluded from randomization with significant chronic lung disease, immune compromise, cardiac disease; or profound acute central nervous system damage. the prime outcome variable is survival. at the studies onset, pts were estimated to be required so that pts were randomized per arm. results: patients are enrolled from centers. data are complete on . patients never reached stage (i.e. % mortality). patients improved and died. of the latter, had randomization exclusion criteria even if stage was reached. patients reached stage . had exclusions from randomization and all died. eight patients ( survivors were eligible for randomization; consent was obtained in no case. two patients received ecmo. overall survival is % ( / ). in patients without randomization exclusions, survival is % ( / ). morbidity m survivors (discharge -admission popc or pcpc score >_ ) was seen in none of the stage surviviors and % ( / ) of those who reached only stage !. conclusion: the rct requires completion. the records of hospital in-patients at king faisal specialist hospital and research center who received external cardiac massage as part of their cardiopulmonary resuscitation were reviewed. success of resuscitation was analyzed as ( ) short term (restoration of spontaneous circulation), and ( ) long term (discharge from hospital). of such patients, ( . %) survived the initial resuscitation, and ( . %) were discharged. success of outcome was not related to age, location of patient, time of day, or rhythm at arrest, including asystole. longer resuscitation time was associated with less chance of restoration of spontaneous circulation (p< . ), but not associated with hospital discharge rate. results for patients with congenital heart disease were similar to those with other medical or surgical conditions. in this series, . % of ward in-patients survived to discharge, compared to two "*;'~r ~r;~' ,.,.'her,, the r-e~ult~ were c/ "'~d ~, ~,°(. overall, % of patients who survived the initial resuscitation were discharged from hospital. where resuscitation continued for more than minutes, . % of patients had tong term survival. outcome from asystole was no worse than for other cardiac rhythms, we believe that previous reports of poor outcome from asystole in pediatric cardiac arrest should noi influence decisions to stop resuscitation for pediatric in-patients prematurely. successful restoration of spontaneous circulation with long term survival can be achieved after prolonged resuscitation. abdelmoniem~ lindsey jahusou~,mariano fiallos, university of florida, prudential drive, suite jacksonville, florida usa central acidosis is well recognized as a marker of inadequate tissue perfusiou, and ventilation. however, obtaining central venous blcod is difficult and fraught with complications in the child undergoing cardiopuimonary resuscitation. intraosseous blood may be used instead of central venous blood to judge ph and pcoz during short durations of cardiopulmonary resuscitation and during hemorrhagic shock. the purpose of this study is to compare the ph and pcoz status of intraosseous and central venous during prolonged cardiopulmonary resuscitation after fluid and drug infusion. we hypotbesized that there would be no difference in ph and pco values of simultanecusly obtained intraosseous and central venous blood samples. eighteen ( ) introduction: cardiopulmonary arrest (cpa) in children is usually preceded by a deterioration of cardiac or respiratory function due to sepsis, dehydration and hypovolemia. early recognition of clinical and laboratory signs followed by immediate intervention are essential for prevention of cpa. the purpose of the present study was to identify factors which contributed to high rates of mortality from cpa in patients admitted to a paediatric intensive care unit (p cu). methods: a prospective study was done of all non-surgical patients with cpa who were admitted to the picu, hospital baca ortiz, quito ecuador from january to october . clinical and laboratory variables before and after admission to the picu, time from hospital admission to picu admission and the pediatric risk of mortality score (prism) were recorded on a questionnaire designed specifically for this study. results: of the non-surgical patients admitted to the picu, ( %) were admitted after developing cpa on the general pediatric wards. mean age was + . months, with of patients under months of age. initial diagnoses upon picu admission included meningitis (n= ), respiratory failure (n= ), congenital heart disease (n= ), severe neurological impairment (n= ), end stage neoplastic disease (n= ), hypovolaemic shock (n=l), peritonitis (n=l) and sepsis (n=l). mean time from hospital admission to p cu admission was _+ . hours. the mean prism score upon hospital admission was + . (score > = > % mortality). % ( / ) of the patients died. one of the three survivors had severe neurologie injury. prior to picu admission, patients experienced tac~,cardia (n= ), hypotension (n= ), neurological deterioration (n= ), respiratory, distress (n= ), oliguria (n= ), bradycardia (n= ), metabolic acidosis (n= ), hyponatremia (n= ), hypokalemia (n= ), hypocalcemia (n= ) and severe hypoglycemia (n= ). there were serious delays from the time of development of clinical and laboratory abnormalities to the time of admission to picu. conclusion: in the critically ill pediatric patient, rapid recognition of clinical and laboratory signs of deterioration, followed by immediate intervention, are required to prevent end stage shock and cpa. we found serious delays in intervention following development of important premonitory clinical and laboratory abnormalities in patients less than months of age on the general pediatric wards, which iikely contributed to the dismal % mortality rate. hospitals throughout ecuador should institute immediate improvements in ctinical supervision, and provide training in paediatric advanced life support (pals) to decrease excessively high rates of and mortality from cpa. intraosscous access is recommended by the american heart association and american academy of pediatries as a means of rapid access to the vascular system for childhood emergencies. bone marrow and fat embolism is a concern and has been reported post intraosseous infusion in stable animals but has never been studied in animals subjected to cardiopuimonary resuscitation. we undertook this study to investigate the incidence and magnitude of lat and bone marrow embolism with the use of intraosseous infusion during prolonged cardiopuhaonary resuscitation and after fluid and drug infusion. we hypothesized that there will be no difference in the magnitude of fat embolism between cardiopulmonary resuscitation only and other cxperirnental conditions. thirty-one ( ) piglets were anesthetized, mechanically ventilated, and instrumented (carotid artery, pulmonary artery and intraosseous earmulas ). the animals then underwent bypoxic cardiac arrest followed by chest compressions with the mechanical thumper (michigan insmunents) and mechanical ventilation for a minimum of minutes. the animals were divided in groups: a (n= ) which had no intraosseous, ~'oup b (n= ) had intraosscous with no infi~ion, and groups c (n= ), d (n= ), e (n= ) had intraosseous with infusion of adrenaline, normal saline and sodium bicarbonate, at cessation ofcardiopulmonary resuscitation, representative lung samples were collected fi'om upper and lower lobes of each lung, embedded in ocp and firozen immediately. ltmg specimens were stained using oil red-o dye and observed for fat globules and bone marrow elements. the amount of emboli present was rated as a percentage in relationship to iung tissue, by a pathologist blinded to the experimental groups. buffy coat specimens were collected before and at cessation of cardiopuimonary resuscitation, stained with oil red-o dye and observed for fat globules. percentage of fat present were compared using analysis of variance. fat globules were seen in the prebronchial blood vessels and in intravascular areas throughout all lung fields. there was no difference in appearance or distribution of fat globules between groups. quantity varied in the different groups[(a) %, (b) %, (c) % (d) %, (e) %], but were not statistically significant (p = . ). fat globules in the buffy coat were few and inconsistent with lung findings. fat and bone marrow emboli were present in all experimental conditions, the use of the intraosseous cannula does not increase the magnitude of embolization during cardiopuimonary resuscitation. the decision to use the intraosscous route should not be influenced by the risk of embolization. tzareva iv/,, md*, nedialkova r, md**, *dept. of pathophysiol, *~dept. of child surg. and icu, emergency medical institute pirogov, sofia, among children with blunt abdominal trauma, treated in emi pirogov during the last five years, children had serious disturbances of the basic vital functions, connected with the trauma, and most often with massive haemorrhage, for this reason being an object of reanimation and intensive care. in the group of children who survived - , predominated the trauma of only one abdominal organ (mainly the spleen, rarely the kidneys, the intestine) and only children had injuries of more than one abdominal organ. in the same group, in children the abdominal trauma was combined with chest or head trauma or bone fractures. in the group of children who died - , a profound combined trauma was present. the haemodynamic parameters in all children showed a characteristically significant tachycardia along with normal or even high blood pressure, while hypotonia was present in only % of the children on the first trauma day. despite the fact that only . % of the children had direct chest injury as well, the gas exchange was considerably disturbed - ' of the children were hypoxemic during the first, and % during the third trauma day -in % significant -below . kpa ( mmhg). together with the markable decrease in haemoglobin levels, this determines the pronounced disturbance in oxygen transport. during the first trauma day all the children were acldo~c, and a metabolic alkalosis was present during the following days. twelve of the children with severe combined trauma died within several hours, with the symptoms of irreversible haemorrhagic shock, or in the next - days, developing multiple organ failure. in conclusion, the intensive therapy of children with severe abdominal and combined trauma, should take in consideration the special haemodynamical trauma answer in children, and requires dynamic monitoring of the most influenced homeostatic parameters -blood gases, acid-base metabolism, haemostasis. introduction: endocrine emergencies, other than diabetic ketoacidosis, are uncommon causes of pediatric intensive care unit (picu) admissions. we report our experience of children diagnosed of adrenal insuficiency (ai) admitted in the picu, during the last four years. subjects: five eases of ai requiring intensive care unit admissions are presented. four females anna male, with ages ranging from days to years, none of them had a previous systemic or endocrine diseases that could suggest al the initial clinical manifestations were: dehydration ( ), vomits ( ), abdominal pain ( ), seizures ( ), lethargy ( ) and hyperpigmentation in the muco-genitat area in a newborn male and ambigna genitalia in a newborn female. the reason for their admission in the p cu were: shock in two subjects; three because of hyperkalemia and hyponatremia (k/na: . / ; / ; , / meq/l); and two with severe hyponatremia (na: ; meq/l). laboratory findings: severe hyponatremia ( ), increased concentration of urinary sodium and chloride ( ); metabolic acidosis ( ); hyperkalemia ( ); increased levels of urea ( ) and hypoglycemia ( ). in all of them, the electrolytes abnormalities did not normalize with replacement and only normalized after the administration of hydrocortisone. tile ai was due to: autoimmtme disease in two subjects, congenital adrenal hypoplasia, congenital adrenal hyperplasia secondary to alia hydroxylase deficiency and in one no etiology was found, at the present time, comments: aiis an uncommon disease in the pediatric age. anearly diagnosis is crucial, as if the treatment is delayed could lead to patients death. in subjects with arterial hypotension and electrolytes abnormalities refractory to the usual treatment, they should be treated with corticosteroids, if no etiology is found. although, previously samples must be obtained to make the diagnosis, : denotes the number of cases. gerbaka b; hakme c; akatcherian c. toxics are frequently involved in domestic accidents during childhood; among non medical products ingestion, carbohydrate poisoning is a serious injury often made possible by inadequate stocking. over years, children aged years and less were examined in the emergency department of hotel-dieu de france hospital for carbohydrate ingestion. , % are boys; age goes from months to years (moan = , years). kerosene is found in , % of cases; all were admitted (mean = , days). , % were symptomatic on first examination but % of all children presented signs of gastric ( %) or respiratory ( , %) irritation sometime during their history; , % had neurological signs and , % presented some fever. leucocytosis is found in % of cases; , % of the children received antibiotics. chest x ray was abnormal in , % of cases: mainly parahilar infiltrates were found, all children survived; , % with a normal course ( , days of hospital stay) whereas those who presented complications (severe pneumonia, coma) stayed in the hospital for days (mean) with short course of assisted ventilation for two of them; long term follow up was not possible. we fonnd nick's criteria for hospital admission to be of value: -symptomatic children with normal x ray } to hours monitoring -asymptomatie children with x ray abnormality } -symptomatic children with x ray abnormality: hospital admission -asymptomatic children with normal x ray : no admission. these criteria would have helped to avoid admission in children and would have allowed a short t hours stay for more. we found chest x ray to be mandatory in carbohydrate ingestion; other tests were not helpful, aside arterial blood gases measurement in case of respiratory involvement; we now also advocate more restriction in antibiotic use. prevention remains efficient and should be stressed on. severe liver failure [slf] is a rare but severe condition in infants. we report our experience. patients: slf was defined as liver insufficiency with hepatic encephalopathy and a decrease in the level of factor v to below %. between and , infants (mean : mo) were admitted for slf (neonates excluded). main causes were metabolic disorders ( . %) (tyrosinemian= , hemochromatosis n= , reye's syndrome n= , other n= ), virus-induced flf ( . %) and hematologic diseases ( . %). in cases, the causes remained undetermined. results: olt was contraindicated in cases because of multiple organ failure (n= ), or underlying disease. all of them died within days after admission. patients had no indications for olt, all but one are alive. ( of them was transplanted later for tyrosinemia and died lately (virus induced-slf). among the t infants who underwent emergency olt, are alive and died because of primary non function of the graft. conclusion: slf in infants admitted before their first birthday is a severe condition with an overall mortality rate reaching %. inherited metabolic disorders are the first cause of slf at this age. contraindications for olt are frequent because of underlying disease or multiple organ failure. a number of children undergo primary graft failure after liver transplantation. it is unknown if there is any increased morbidity or mortality following retransplantation. this study seeks to explore these issues. methods: a pediatric intensive care/iiver transplant database is in formation. records of all liver transplant patients are reviewed and abstracted. this data is then computerized to allow analysis. this data provides the source for this study. statistical analysis was performed via student's t-test where appropriate. results: of the patients who have thus far received at our center orthotopic liver ransplants, the records of who underwent transplants form the basis for this review. twenty-three patients underwent multiple transplants, required one additional, three required organs, and one patient survived after a fourth organ transplant, there was no significant difference in age at first transplant between those who received multiple organs and those who did not ( vs, months, p=ns). the anesthesia time for the procedure did not significantly increase tbr subsequent transplants ( . vs, , hours), nor did time in the intensive care unit (t . vs. . days), nor did time on the ventilator ( . vs. . days) subsequent transplants did not predispose to having more bleeding in the intensive care unit for usage of packed red blood cells or platalets was not significantly altered ( vs ml and vs ml respectively). patients who required retransplantatior~ did receive mere fresh frozen plasma (ffp)daring their first transplant than in the subsequent ones ( vs ec, p < . ). however ffp use was not significantly different than patients who did not require retransplant. patients who underwent retransplant had a markedly increased mortality ( %) than the overall mortality for liver transplants at our center ( %), conclusion: children who require another liver transplant have a markedly increased mortality. bleeding and prolonged icu stay is not significantly different between the first and subsequent transplants, fulminant hepatic failure and ortothopic liver transplantation.dr.sasb n,j;centeno,m;entin,e;acarenza,m;ciocca, m:gofii,j;bianco,g;weller, g;imventarza,o. unidad de cuidados intensivos.hospital de pediatria "dr.j.p. garrahan" .buenos aires.argentina. introduction:fulminant hepatic failure (fhf) is a clinical syndrome, defined by the development of hepatic encefalopathy within weeks from onset of illness in a previously healthy person.by far,the most comun cause of pediatric fhf in all series, is acute viral hepatitis.we report our experiences with the pediatric fhf and ortothopic liver transplantation (olt) as attemative of treatment. patients: childrens with fhf diagnosis were admitted at the picu from / / to / / .symptomatic treatment was given to all children and all were put on list for olt,) following the king's college criterion (protrombina time,age,atiologies,bilirrubin,and encefalopathy state). results:etiologic causes corresponded to the childrens were: , hav ( %); , noa nob ( %); ,autoinmune ( %).the age was mean: years (range: month- years).seventeen patients were transplanted, chidmn were discarded because:no donors: ;withdrow of the list: ,because sepsis in and bleeding of cns ;and no admission at list: because genetic syndrome ,massive intestinal necrosis, ,mitral valvulopathy and sepsis, . patients ( %) had at least one complication dudng the post operative period.the most frequent was the acute renal insufficiency(ari) and patients requiered continuos hemofiltration.the gtobal mortality rate was %.the mortality of patients without olt was % and the mortality of patients with olt was %, patients dayed because sepsis, ( candidiasis) and the others because mof.the actuarial survival at year is % and the follow up of months. conclusions:the fhf is a very severe and frequent disease at picu. supportive treatment only is associated with a very poor prognosis and high mortality rate.the most frequent etiology in our country is the hav. the olt is applicable in this cases and is a valid alternative of treatment (mortality in our series %).the ari is the most frequent complication during the post opeative period.in argentina,due the high prevalence of hav,prevention must be considered the main and only way to avoid this catastrophic illness.- to assess the efficacy of gastric intramucosal ph (phi) for evaluation of tissular perfusion and prediction of hemodynamic complications m critically ill children. patients and methods: thirty critically ill children ( boys and girls) whose age ranged from month and years old were studied. a tonometry catheter was placed in the stomach of all patients at their °admission in pediatric icu. intramucosal ph measures were made at the admission and each - hours during the study: a total of determinations were made. the catheter was removed after extubation and/or checking of hemodyrmmic stability of the patient. the intramucosal ph was derived from application of the henderson-hasselbaeh formula using the pco value from the tonometer and the arterial bicarbonate. values of phi between . and . were considered normal. the relationship between phi and severity of patient measured through prism, presence of major (cardiorespiratory arrest, shock) and minor (hypotension, hypovolemia or arrhytlmtias) hemodynamic complications, mortality and stay in the picu, was analysed. results: the admission value of phi was . -t- . (range . - . ). five patients ( %) had an admission phi < . . no relationship was found between an admission phi < . and a higher incidence of hemodynamic complications. sixteen patients ( %) showed some values of phi < during their evolution. patients with phi < . had a higher number of hemodynanuc complications than the rest (p< . ). every cardiorespiratory arrest (cra) and shock cases were related to a phi < . . patients with major complications (cra and shock) had a phi lower (p= . ), as well as a higher number of measurements of low phi (p= . ) than patients with minor hemodynamie complications. the value of phi lower than presented a % of sensibility and % of specificity with regard to hemodymanic complications. there was no relationship between phi < . and prims score and stay in picu. patients with phi < . presented a prims higher than the rest of patients (p< . ). conclusions: the phi value may be an early sign of presence of hem dyaaimc complications in the critically ill child. we tested the hypothesis that gastric intramural ph (phi) can be used as an early sign of failure m weaning pediatric patients because the blood flow from nonvital areas is diverted to meet the increased demands of respiratory muscles. methods: children (mean age ( . _+ . ) years + sd) who were thought by their physicians to be weanable from mechanical ventilation (mv.). these patients were ventilated on serve c ventilators, receiving ranitidine, and had intestinal tonometer (tonometrics, inc.) minutes before obtaining a sample.. all children were placed on pressure support (ps) at levels judged to overcome the resistance of the endotracheal tube and ventilatory circuit ( em h.,o). a sample of arterial blood and a sample oftonometer were obtained during vm and weaning (ps). phi, hemodynamic and respiratory data were recorded during vm and weaning we did not interfere with the primary caretaker's decisions regarding extubation. patients were considered to be successfully weaned if they were able to sustain spontaneous ventilation for more than hours after extubation. paired t-test were used to compare the values obtained during mechanical ventilation with those obtained during weaning trials. unpaired ttest were used to compare values from the group that was successfully weaned (a=i ) with those from the group that were not (b= ). results: we did not find statistical differences in any of those variables mesured during mv for patients who were successfully weaned(group a) and those who were not (group b). gastric phi was in group a: . + . (vm) and + . (weaning); in group b: . _+ . (vm) and . t _+ . (weaning). discussion: although we did not find differences in gastric phi during vm, the group a had a lower value than group b because of the number of cardiac patients ( %) and transfusion therapy, in fins group. in group b % of patients showed a problem in upper airway (subglottic edema, and enlarged tonsils). we found it after extubation. conclusion: ) gastric phi is a good predictor of risk in critically ill patients but maybe because of the small size of the sample, in our study is not of practical value as a predictor of failure in weaning pediatric patients from vm. ) this test is not a predictor of problems in upper airway~ important etiology of failure weaning in children. objectives: i-to determine the prognostic value of the gastric intramueesal phi in mortality and multiple organ dysfunction (sdmo) in critically ill children. -to compare this value, with the pediatrics risk index mortality score (prims). methods: aprospective study was performed with critically illcbildren, aged from mouth to years. the athnittiug diagnosis was: post-surgery ( neurosurgery, spinal fusion and thoracic or abdominal surgery), sepsis, polytraumatism, adult respiratory distress syndrome and with miscellaneous. all the subjects were monitorized on picu admission and treated for their underlying condition. gastric intramucnsal pt{ was measured following the tonometric method, ou admission and every - hours depending on the patients state. the severity of the clinical condition was evaluated using the the prims, on admission (prims-i) and during the first hours, when the clinical condition deteriorate, the worse score was utilized for the statistical analysis (prims- ). to perform the statistical analysis the subjects were divided in two groups, one with the phi< . and the other with phi> . .aunivariate analysis (student's tand wilcoxon two tailed test, chi-square) and multivariate analysis were used. results: out of the subjects dyed. of children developing multiorgan failure (mof) expired. % of the patients admitted to the picu with sepsis, ards and miscellaneous had a phi < . . in contrast, with % of post-surgical and none of the postqraan~atism. the mortaliry rate, in children with a phi< . was % (ci %: . ; , ) and . % (ci %: , ; . ) in children with phi> . (p= . ). mofwas observed in , % of children withphi< . v.s, . % with phi > . .no relatiouship was observed between the phi and the score of prims-i and . perforating an unconditional logistic regression analysis, two independent variables have mortality predictive value: the phi and the prism- . (table i) following induction of anaesthesia, a laser doppler probe (moorsoft instruments ltd) was inserted cm into the patient's rectum, the probe's special design ensuring that the optical prism lay against the mucosa. continuous monitoring of rectal mucosal perfusion ("flux") was continued throughout the operation. after rain cpb at °c, "steady state" readings of nasopharyngeal temperature, mean femoral arterial pressure (map) and flux were recorded over a further min before cpbinduced core cooling to - °c. steady state was defined as a rain period with no change in core temperatures or map. other rain steady state recordings were taken immediately prior to low flow, immediately prior to rewarming and after rewarming to °c, before initiation of any vasoactive drugs. the cpb flow rate was kept at m l k g - min q, the pcv at _+ %, the p~co at . + . kpa and the pro at + kpa. results: initial warm and rewarm map (both mmhg) were significantly lower ( = . ) than during the cold cpb periods ( & mmhg). the mean cold flux before ( ) and after ( ) low flow were both significantly lower (p= . ) than the mean initial warm cpb flux ( ). the mean rewarm cpb flux ( ) was significantly lower than all other flux values (p= . ). there were no siglaificant correlations between map and flux except at the first warm cpb period (r= , , p= . ). conclusions: although hypothermia significantly reduces rectal mucosal perfusion, rewarming produces an even greater reduction in gut perfusion which, considering that mucosal oxygen constmaption is highest during this time, may prove crucial in the postoperative development of mof. therapy aimed at improving gut perfusion during cpb should be directed at the rewanning period in particular. abstract this work is aimed at establishing a clinical procedure for the diagnosis of enteritis necroticans (en), even at the communal level, and to define criteria for diagnosis able to distinguish between acute forms. subjects and method : cases admitted at the institute for protection of children's health dpch), having characteristic symptoms, were examined clinically, by roentgenography of the abdominal cavity, with the analysis of the blood (total protein, electrolytes, hematocrite) and cultures of intestinal fluid and faeces. through surgical operations, the pathological lesions were observed and recorded. results: common epidemiological features: the average age is - years old ( - ) ; male/female : . ; in % of the cases, the disease occurred after a meal rich in protides. the acute toxic form accounted for % : severe shock appearing early, with very severe dehydration associated with profoundly decreased blood protein concentration and lowered natriemia as well. the lesions of the small intestine were expanded, all of them were necrotic. in the surgical form ( %), the predominant feature was an obstruction -peritonitis syndrome, the peritoneal fluid showed a characteristic inflammatory reaction. for the rest of cases % were the internal form, the shock syndrome was less severe, the abdominal distention was light and disappears gradually, the inflammatory reaction of the peritoneal fluid was not so characteristic. conclusion (ino) is a selective pulmonary vesodilator that is rapidly inactivated compared to intravenous vasodilators. these qualities make ino an attractive agent for the treatment of pulmonary hypertension (pittn). the efficacy of ino has been studied in persistent fetal circulation, acute respiratory distress syndrome (ards), and congenital heart disease (chd). potential adverse effects oflno include: nitrogen dioxide (no toxicity, methemoglobinemia, and platelet dysfimction. our objective was to evaluate the safety of ino in pediatric patients (pts). methods: pediatric pts. with phtn from ards or chd were studied under an established, approved protocol conforming to fda guidelines tbr an investigational new drug. informed consent was obtained for each child prior to treatment. no was sequentially titratad from parts per million (ppm) to , , , and ppm at ten minute intervals. parameters monitored before and during therapy included nitric oxide (no) and no~ concentrations (cone.), mean arterial blood pressure (map), and percent methemoglobin (mhg). no and noz levels were continuously monitored using an inline dr~ger electrochemical detection device. ~,litp was continuously measured with an indwelling arterial catheter. mhg was measured by co-oximetry. a mhg level e % or no cone. ~ ppm were considered adverse effects by study criteria. pretreatment map was compared to map at and ppm ino using paired t-tests. ap value < . was considered statistically significant. results: thirty-two mechanically ventilated children with phtn ( with ards, with chd) were studied. five pts. were treated following cardiopulmonary bypass. methemoglobin (met-hb) levels were routinely measured in two prospective clinical studies on no inhalation in pediatric patients with pulmonary hypertension following heart surgery with extracorporeal circulation and in pediatric and neonatal ards patients, the observed differences between the groups prompted in an in vitro study, red blood cells (rbc) of patients sampled before and after surgery with and without extracorporeal circulation (ecc), respectively, were incubated with ppm no for rain, met-hb, atp, and nadht nadph concentrations were compared, during therapeutic exposure no increased met-hb from . - -_ . to . _+ . % in cardiac surgery patients and from . ± , to . ± . % in ards patients (p < . ). rbc's having undergone ecc were more susceptible to met-hb formation (p< , ) whereas intracellular coenzymes did not differ neither between the groups (table) nor before and after no exposure. ecc predisposes to increased methemoglobinemia upon exposure to no both in vivo and in vitro. our data suggest a reduced activity of met-hb reducing enzymes rather than diminished availability of energetic substrates, variation of the inhaled nitric oxide concentration with the use of a continuous flow ventilator. anne pmc de jaegere ~, frans im jacobs , nico gc laheij , john n van den anker t . dept. of paediatrics ~, central instrumentation , sophia children's hospital, erasmus university rotterdam, rotterdam, the netherlands. objective: to investigate the homogeneity of nitric oxide (no) concentration in a delivery system with a continuous flow ventilator. design: bench study, setting: biomedical laboratory. interventions: a nitrogen/nitric oxide (njno) gas mixture was injected at three different sites in the patient circuit: just before and just behind the humidifier, and centimetres before the y-connector. ventilator flow ( , , l/rain), ventilator rate ( to , increments of ) and compliance of the testlung ( . ; . ; . ml/cm h ) were changed. carbon dioxide (co ) instead of n /no was injected at the same points in the circuit. measurements and main results: a) though the flow ratio of the njno and the ventilator gas were kept constant, the no concentration ([no]) raised with increasing ventilator rates. the increase in [no] was up to % when the n /no injection site was close to the y-connector of the ventilator circuit. minimal changes in [no] were noticed when the n~/no was mixed to the ventilator gas before the humidifier. b) analysis of the ventilator flow pattern showed variations at different places in the ventilator circuit. the magnitude cf the p, ow change depended on the meas~:rement site. the closer to the expiratory valve the highest the flow change was. the duration of the flow change was inversely proportional to the adjusted ventilator flow. c) real time measurements of the co concentration ([coz]) showed variations during tile respiratory cycle. these [co ] variations were higher when the co gas was blended closer to the yconnector. conclusions: the ventilator flow variations in relation to the fixed side flow of the n /no gasmixture result in changes of the inhaled [no] during the respiratory cycle. the no concentration during inspiration is always higher then during expiration. this could not be detected with the available monitoring system. to ensure a constant [no] by blending a njno gas balance in a continuous flow ventilator, the site of injection should be as close as possible to the inspiratory outlet. nitric oxide, a potent and selective pulmonary vasodilator, has recently been successfully used to treat pulmonary hypertension of variable etiology in infants and children. side-effects and complications in infants are so far not well known. we describe here two cases in which prolonged ( and- days respectively) high-dose ( - ppm) nitric oxide was used to treat refractor~¢ pulmonary hypertension. one patient was a newborn infant with pulmonary hypertension secondary to a large leftsided diaphragmatic hernia. nitric oxide was begun under conventional ventilation (babylog ) at hours of life with a slight initial improvement in oxygenation. he was then placed on oscillation with the same nitric oxide concentration due to worsening respiratory failure. he died on th day of life. monitored nitric dioxide concentration never exceeded ppm. the other patient was a months old infant with severe pulmonary hypertension due to a complete atrioventricular septal defect. he required high-dose nitric oxide to come off cardiopulmonary bypass after surgical repair of his heart defect. he slowly improved over the week following surgery but developped suddenly respiratory failure due to massive pulmonary hemorrhage and died. surprisingly, a particular autopsy finding in both infants was a massive acute necrotizing tracheobronchitis. we conclude that nitric oxide is an excellent and sometimes lifesaving treatment of pulmonary hypertension in infants. tracheobronchitis has not yet been reported as a possible complication of nitric oxide administration. we suggest that caution needs to be taken with prolonged high-dose administration and this possible complication to be looked for at autopsy. introduction: permissive hypereapnia (ph) is a beneficial strategy for patients with acute respiratory distress syndrome (ards) to minimize barotrauma by decreasing the peak inspiratory pressure (pip). hypercapnia and hypoxia cause pulmonary vasoconstriction, pulmonary artery (pa) hypertension, and, thus, an increased afterload to the right ventricle. this increased afterload may result in increased right ventricular (rv) work load and subsequent rv dysfunction. one therapeutic approach is the use of inhaled nitric oxide (inn), a selective pa vasodilator. the objectives of this study were to test the hypothesis that in a swine model of ards with ph, inn would improve rv work load and not change intrinsic rv contractility. methods: in swine ( - kg), ards was induced by surfactant depletion. hypercapnia was achieved by decreasing the pip while increasing the peep to maintain a constant mean airway pressure, inn was administered in concentrations of , , and ppm in a random order. pulmonary blood flow (qpa) was determined by an ultrasonic flow probe. rv total power (tp) and stroke work (sw) were calculated by fourier transformation of the pa pressure (ppa) and qpa data. preload recruitable stroke work (prsw), a preload and afterload independent measure of ventriculur contractility, was determined by a shen-subtraction method and vena caval occlusion. respiratory failure with pulmonary hypertension in piglets gerfried zobel*, bernd urlesberger*, drago dacar**, siegfried rtdl*, fritz reiterer* and ingeborg friehs** depamnents of pediatrics* and cardiac surgery**, university of graz,austria objective: to evaluate gas exchange, pulmonary mechanics and bemodynamic data during partial liquid ventilation (plv) combined with inhaled nitric oxide (no) in acute respiratory failure with pulmonary hypertension. design: prospecfive~ randomized, controlled study. setting: university research laboratory. subjects: twelve piglets weighing to kg. interventions: acute respiratory failure with pulmonary hypertension was induced by repented lung lavages and a continuous infusion of the stable endoperoxane analogue of thromboxane. thereafter the animals were randomly assigned either for plv or conventional mechanical ventilation. initially perfhiorocarbon liquid ( ml/kg) was instilled into the endotracheal tube over min followed by - ml/kg~. all animals were treated with different concentrations of no ( - - ppm) inhaled in random order. measurements and results: continuous monitoring included ecg, cvp, mpap, map, san and svo measurements. during plv pao /fio increased significantly from _+ . mmhg to ± mmhg (p< . ) within rain, while pao ]fio remained constant at -+ . mmhg. qs/qt decreased significantly from -+ % to -+ % (p< . ) during plv and did not change during conventional mechanical ventilation. static pulmonary compliance (cstat) increased significantly ff~m . r± . to . _+ . ml/cmh /kg (p< . ) during plv and decreased slightly from . _+ . to . e . ml/cmh /kg during conventional mechanical ventilation. the infusion of the endoperoxane analogue resulted in a sudden decrease of pao /fio from _+ to _+ . mmhg in the plv group and from ± to +_ . mmhg in the control group. inhaled no significandy improved oxygenation in both groups (pao /fio : _+ mmhg during plv and +_. mmhg during conventional mechanical ventilation). during inhalation of no mpap decreased significantly from -+ m ± mmhg (p< . ) in both groups. there was no significant change in oxygenation and mpap during inhalation of and ppm no. conclusions : plv significantly improves oxygenation and pulmonary compliance in acute respiratory failure. the additional application of inhaled no further improves oxygenation and pulmonary hemodynamics when acute respiratory failure is associated with severe pulmonary hypertension. inhaled no is very effective in improving oxygenation and pulmonary blood flow even at low doses. the work was supported in part by grants of the austrian nationalbank nr . as in neonates, severe respiratory failure in infants and children can be aggravated by pulmonary hypertension, resulting in further deterioration of oxygenation due to increasing intrapulmonary shunting. we analysed the influence of inhalational nitric oxide (ino) in treatment, course and outcome of severe ards in a pediatric population. since infants and children (age: - months) with ards and oi > (mean value: . ± ) underwent a trial with ino (concentration: , , , and ppm) to prevent further respiratory failure. patients had a significant improvement of their oxygenation (rise of pa > mm hg) for at least hours (responders); mean best ~fficient no dose: . ppm. the non-responders had only a short-term improvement or ino had no effect. in responders and nonresponders there was no significant difference with regard to age, underlying disease, ards severity, time on mechanical ventilation, blood gases and ventilator settings before notrial, nor was there a different grade of pulmonary hypertension (estimated by echocardiography). the only difference was an higher ol in the group of the non-responders: . ± .i vs. . ~ . , p < . . in the group of the respenders there was a secondary deterioration of lung function after i - days on ino in children (transient responders): in these patients, as well as in the group of the non-responders, alternative modalities of treatment (hfov and/or ecmo) became necessary. children ( %) died: transient respenders and non-responders. in infants and children with ards due to different underlying diseases ino can acutely lead to a significant improvement of oxygenation in about % of the cases. the right selection of patients for no therapy and the influence of ino on the survival rate of ards in childhood has to be evaluated in further studies. and pediatric cardiology, university of graz, a- graz purpose: after fontan procedure cardiac output is critically dependent on the pulmonary vascular resistance. even minor elevations of the pulmonary vascular resistance may significantly decrease cardiac output. inhaled no is an effective, selective pulmonary vasodilator in experimental and clinical situations of pulmonary hypertension. the aim of this study is to evaluate the effects of inhaled no on oxygenation and pulmonm , circulation in children after a bidirectional glenn-anastomosis (n-~) or a fontan-like operation (n= ). material and methods: from june t to january children with a mean age of . +~ . (sem) yrs and a mean body weight of . -+ . (sem) kg were treated with inhaled no after glenn-or fontan-like operations. all but one had complex cardiac malformations with single ventricle. all children were mechanically ventilated with an fin > . . inhaled (no) was applied using a rrdcrdproeessor based system which additionally allowed measurement of no/nox using the chemihimniscence method. methemogtobin concentrations were determined times a day. the major indication for postoperative inhalation of no was a high (> mmhg) transpulmonary pressure gradient (tpg--cvp-lap). severe myocardial dysfunction of the single ventricle was excluded by echocardiography. results: the mean duration of mechanical ventilation was . _+ . (sem) days the. mean dose of inhaled no was . -+ . (sem) ppm, the mean duration of no-inhalation was _+ (sem) hours. the mean methemoglobin concentration was . -+ . (sem)%. hemodynamic data and arterial oxygen saturation before inhaling no and minutes later are given in table acute hypoxaemic respiratory failure (ahrf) in children occurs in a heterogenous group of diseases with pulmonary pathophysiological processes ranging from reversible physiological intrapulmonary shunting to fixed structural lung damage. we hypothesized that inhaled nitric oxide (ino), a selective pulmonary vasodilator, might identify those patients with potentially reversible disease, i,e, large response may indicate a greater likelihood ef reversibility and thus survival. a retrospective review of the early response to ino in infants and children (aged month to years, median months) with severe ahrf( with ards). the mean p(a-a)o , pao / fio , oxygenation index (oi) and acute lung injury (all) score prior to the commencement of ino were +_ . , +_ . , _+ , and . +_ . respectively, the magnitude of response to ino was quantified as the % change in oi occurring within minutes of ppm ino therapy. this response was compared to patient outcome data. results. there was a significant correlation between response to ino and patient outcome, kendall tau b r= , , p< . (table) conclusion. in ahrf response to ino appears te define a subgroup of patients with improved outcome compared to nonresponders. we speculate that response to ino may be useful in selecting patients with potentially reversible lung disease for special support therapies such as ecmo. randomised controlled trials are needed to define the role of ino in paediatric ahrf. between may and december , patients (pts) were treated for mas. treatment groups were: group i only : pts; group i conventional mechanioal ventilation (cmv): pts; group ii hfo: pt; group iv hfo+no: pts. therapy was stepwise intensified until oxygenation improved ( i -) ii -) iii --) iv). "high volume strategy" was used with hfo (mawp - cm h ). the initial no-concentration was - ppm, with rapid reduction down to - ppm once oxygenation improved. results: one pt (group it) died of hypoxic-ischemic encephaiopathy (termination of therapy); all other newborn babies survived. in group iv pt and showed barotrauma prior to hfo. pt , and were treated with additional mgci (max. mg serum concentration . - . mmol/i). following the identification of inhaled nitric oxide "no) as a selective pulmonary vasodilator (frostell et al ) [ .+ , + . data are compared to baseline values within each group. *=p< . , **=p< . , ***=p< . l among patients who fulfilled ecmo criteria, improved with no and did not required extracorporeal life support. tltree out of ecmo patients eventually survived. conclusions: m our study low-dose of irthaled no showed a variable effect on oxygenation in newborns with acute respiratory failure. an acute response to no appeared to be correlated with a better short-term outcome and the avoidance of extracorporeal support in ecmo candidates. differently, lack of acute and/or sustained response was associated with death or need for ecmo. although the nature and severity of the underlying disease or the degree of prematurity may play an important role in these patients, we believe lack of acute response to no may be an early predictor of bad outcome, prompting toward alternative treatments such as ecmo or liquid ventilation. *picea s., °bartuli a.,°dionisi-vici c., *dello strologo l., §villani a., §bianchi r., ^salvatori g.,*rizzoni g, °sabetta g. *div. of nephrology, °div. of metabolism, §intensive care unit, ^div. of neonatology. "bambino gesfl" children research hospital. rome, italy. successful prevention of handicaps or death in newborns with ~ depends on rapidity and efficiency of treatment. poor response to nutritional and/or pharmacological treatment requires extracorporeal removal of nh . efficiency and cardiovascular tolerance are often difficult to obtain with peritoneal or hemodialysis in neonates. we report the results of cavhd in newborns with hc. methods: vascular access: femoral vessels. blood flow: - ml/min, dialysate flow: - ml/h. filter: amicon minifilter plusrm(polysulfone membrane; . sq.m.). no ultrafiltrate(uf) production, patients: case with carbamoytphosphate synthetase deficiency (body weight -bw-: . kg) showed hc at day , a relapse of hc occurred at day due to an infectious event. case and (bw: . and . kg), both affected by propionic aeidemia, showed hc at day and day , respectively. plasma nh (~tg/dl) decrease is shown in the complications: transitory ischemia of arterial cannulation limb and transitory thrombocytopenia occurred in case ; surgical repairing of artery after cavt-id was necessary in case ; no cardiovascular instability was observed during cavhd . outcome,'all patients recovered from hc in less than day: case : alive, mild b)iootonia at mos; case : dead after days from cavhd withdrawal for pulmonary hemorrhage; case : alive, normal development at mos. conclusions: ) in newborns with hc, ca~q-id provides good cardiovascular tolerance,high efficiency and quick removal of nh , even without uf production (i.e. only by diffusion). this allows easier management (no need of fluid and electrolyte balance). ) arterial complications seem frequent in neonates treated by cavhd. venovenous circulation could overcome this problem. vb nguyen, m jokie, c leeaeheux paediatric intensive case service, hospital university centre, avenue c te de nacre, caen cedex, france background, the implication of polymorphonuclear neutrophils (pmns) in the physiopathology of children's haemolytic.uraemie syndrome (hus) becomes more and more evident. the purpose of the present study is to role out their impact among other pronostie elements during the course of the disease. patients and methods. diarrheal prodrome and its duration, patient's age, maximal blood nitrogen level, anuria and dialysis time, extra.renal involvements, white enll and pmn counts and thrombopenia duration have been retrospectively analysed in infants with good outcome and in another children with unfavorable outcome. results. neither diarrhoea or its duration, nor children's age, nor blood nitrogen level, nor anuria or dialysis time had any predictive value for the disease evolution in the acute phase of our patients. adversely, extra-nenal involvements was accompanied by severe and complicated courses of the disease (p< , ). the elevation of white cells and pmns (heyon x /i) and pmns (more than x / ) as well as its persistence beyon a week were most frequently observed in complicated forms (p< , , p< , and p< , , respectively). a transient thrombopenia (less than day@ in patients with elevated counts of white cells may be a filrther obvious sign of an unfavorable course of the disease ( < , ). conclusion. the elevated count of white cells and pmns, either alone or associated to one rapid regeneration of platelets, seems enabled to predict an unfavorable evolution of the hus in children. msud results from an inherited impairement of catabolic pathway of branch chain amino-acids. high leucine blood levels may induce acute brain dysfunction. this dramatic complication led us to propose leucine removal procedures as continuous hemofiltration. patients and methods three newborns in acute msud onset were treated by hf, hdf and hd. extracorporeal circulation was performed through a . fr catheter, a circuit with a blood pump (priming volume = ml). patients and procedures characteristics are summarized below in the sucralfate (an aluminium salt of sucrose octa sulfate) is used to prevent and treat upper gastrointestinal bleeding in critically ill patients. with minimal absorption, the potential for side effects is thought to be limited, though aluminium toxicity has been reported in patients with chronic renal failure. these patients may already have had high body stores of aluminium. we report critically ill children with high serum concentrations of aluminium following sucralfate therapy. all had renal impairment. the normal aluminium level is < . gmol/l and in patients with chronic renal failure < . ].tmol/l. none of these patients had known preexisting chronic renal disease. cpb was conducted under deep hypothermia (t,° °c) and cardiocirculatory arrest (cca) or under hypothermia (t,° °c) and low-flow perfusion. continuous holter-electrocardiograms (h-ecg) were recorded from the ilranediate postoperative (po) period on for hours. h-ecg were also recorded prior to the operation and before discharge. following dr were observed: snpraventricutar (sv) and ventricular (v) extrasystoles (es) (> / h), sv and v tachycardia (svt and vt), accelerated junctional rhythm (ajr) and junctional ectopic tachycardja (jet), and nd and rd degree atrioventricular block (avb and avb ). the incidence of po dr was % in the pre-op h-ecg, % on the st, % on the rid, % on the rd po day and % befbre discharge. compared to the pre-op findings, an increased incidence of sves, ves, svt and avb on the st po day was observed, whereas vt and a jr or jet were exclusively observed po. all types of dr were observed up to the rd po day. ty e of dr before discharge was similar to pre-op findings and there was no definitive avb . considering patient groups according to the most frequent isolated op-procedure, the incidence of dr on the first po day was % after asd ii-closure (n= ), % after stthaortal vsd-closure (n=lg), % after correction of a complete avsd (n= ), % after correction of a tetralogy of fallot (n= ) and % after fontan-operation (n= ). incidence and type of dr were not significantly different between groups. longer cpb-dttration and use of cca were risk factors for po ves and vt (p< , and p< , , respectively) whereas use of cca and degree of hypothermia were risk factors for the development of a jr and jet (p< , and p< , , respectively). -our results indicate that po dr after cpb in children m'e frequent but mainly transient. in our series, specific cpb-related parameters are of greater influence than surgical procedure itseif for the development of dr and are discriminant risk factors for particular types of dr. the course of anp, cgmp/anp (as indicator for atrial natriurefic peptide biological activity), and no and no (as indicator for endogenous nitric oxide (no) synthesis) was investigated in i infants (median age months) undergoing cardiopulmonary bypass (cpb). patients were divided into groups according to whether they had (group , n= ) or not (group , n= ) preoperative heart failure (hf) and pulmonary hypertension (pht). group patients had preoperatively significantly higher levels of anp (p< . ), cgmp (p< . ) and no and no (,p< . ) but had significantly lower cgmp/anp (i < . ) than group patients. during cpb, anp was significantly higher in group patients ~< . ). as compared with prebypass values, cgmp/anp was reduced in both groups during cpb (p< . ). cgmp/anp inversely correlated with duration of cpb and aortic clamping time (p< . , respectively). no and no were significantly higher in group than in group patients (p< . ) without any intraindividual change during cpb. from the early postoperative period on anp, cgmp/anp and no and no were similar in both groups. after cpb, anp correlated in both groups with blood pressure (p< , ) and diuresis (p< . ). no and no inversely correlated with pulmonary arterial pressure immediately after cpb ( < . patients after a fontan-type of procedure have elevated central venous pressures (cvp) leading to congestion in the gastrointestinal system and often ascites. purpose of this study was to evaluate whether this causes a different postoperative gastric mucosal ph (phi). methods: we evaluated a series of patients, who underwent cardiac surgery with cardiopulmonary bypass (age: days to years (mean , yrs), weight: . to kg (mean . kg). a commercially available tonometer (tonometics®) for sigmoidal use in adults was inserted into the stomach after induction of anesthesia. the phi measurements were done according to manufacturer recommendations we compared three groups of patients: ) aeyanotic (n= ), among them p with vsd and p with avsd; ) cyanotic (n= ): tof: p, tga: p; ) cyanotic after a fontan-type procedure (n= ). phi were measured at picu arrival and after h. fudhermore we compared lactat levels at these time points. differences between the groups were evaluated with one way anova on ranks with pairwaise multiple comparisons (dunn's method). the relationship between cvp and phi was investigated by regression analysis. results: the median phi for groups i, and were . , . and . at ardval and . , . and . after h respectively. at picu arrival group was significantly (p< . ) different from groups and . there was no significant difference between the latter two groups, after h group was different from group , there were no other significant differences. the median lactate levels for groups t, and were . , , and . at ardval and . , . and . after h respectively. at ptcu arrival group was significantly (p< . ) different from group , after h there were no significant differences. there was a weak negative correlation between cvp and phi: r= - . ; p< . . conclusion: patients after a fontan-type of procedure have lower phi than patients after other cardiac surgical procedures, however, this is only in part due to the elevated cvp and venous congestion. eleven children were investigated months (median) after postoperative mof. iviof was defined as the failure of at least two vital organ systems (kidney, liver, lung, central nervous system) in addition to cardiac insufficiency and high fever. underlying surgical procedure was repair of tetralogy of fallot (n= ), fontan-(n= ) or seuning procedure (n=l). all patients fulfilled criteria for mof in the first postoperative (po) days. six patients needed peritoneal or hemodialysis for days (median) during the po period. one patient showed cerebral infarction due to thromboembolism in the territory of the right internal carotid artery immediately after the operation. the follow-up protocol consisted of extensive investigations of heart-, renalliver-, and lung functions as well as complete neurological and psychological examinations. all patients had adequate cardiac examination. lung function was normal in all but patients who had an obstructive syndrome. only patient showed an isolated decreased creatinine clearance. abnormalities of the liver ftmction tests were only noticed in patients after fontan procedure. severe neurological sequels such as paraplegia (n = ) and diplegia (n-i) were observed in of the patients. the remaining children presented with a delayed graphomotorical and speech development associated with normal intelligence. -in our series the most frequent and severe sequels after postoperative mof were neurological. -abnormal liver fimction tests are more likely to be a consequence of the fontan hemodynamics than a sequel of mof. the optimal dosing schedule of surfactant therapy for the treatment of neonatal respiratory distress syndrome (rds) remains unclear. goal: surfaetant function and the concentration of phospholipids (pl) in tracheal aspirates are compared in a prospective randomized trial involving neonates with rds who received either two or more ( or ) doses of survanta. methods; ventilated neonates < w with rds were treated with survanta oo mg/kg if fio >_ % or mean airway pressure _> , cm hzo, after h a nd dose was given (same criteria), if the support still exceeded the criteria h after the nd dose, the patient was randomized to no extra dose (two}, or to an extra dose of survanta (morel (and a th dose h later; same criteria), pl was measured in tracheal aspirates and corrected for dilution with the urea method. "active" large aggregates and "non-active" small aggregates of surfactant were separated by centrifugation and quantified. surface tension of the large aggregate fraction was measured by pulsating bubble surfactometer, results: neonates were randomized, x two and x more ( x and x doses), gestational age was , ± , w and birth weight ± g. most patients had severe rds with initial ventilation: rate . _+ , , peak inspiratory pressure (pip) , -+ . cm hzo, fio . ± . %. at randomization: rate . ± . , pip . -+ . cm hzo, fio . ± . %, and h after randomization: rate . ± . , pip . _+ . cm hzo, fio . ± . %, without signif, differences between the groups. there was relapse (again fio _> % within h) in group two and t bpd in group more. in total, tracheal aspirates were analyzed. pl was not signif, different before randomization (two . ± . vs more . ± . /jmol/ml), but neither after randomization (two . -+ . vs more . ± ,o /~mol/ml). there was no difference in the % small aggregates (two . ± . vs more . ± . %), the surface tensions (ran/m) were not signif, different (each time two vs more): before randomization . ± , vs . -+ . , in the h after randomization . ± . vs . -+ , , or - h after randomization . -+ . vs . ± . , or - h after randomization . _+ . vs . -+ . . conclusion: neonates who received more than two doses of survanta did not have higher pl, nor a better surfactant function than neonates who received only two doses of survanta. continuation of the trial is necessary to evaluate clinical outcome. may not indicate need for treatment p.c. clemens s.j. neumann university of hamburg, department of pediatrics, klinikum schwerin, wismarsche str.. , d- schwerin. aim of the study: the finding of elevated tsh and decreased t in the newborn usually is classified as "transient hypothyroidism", thus the elevation of tsh is classified as consequence of the lowered t . but on the other hand several data sets show that tsh elevation as well as low t , one independently of the other one, are associated with different kinds of perinatal stress. each of these laboratory deviations, if not associated with the other value being abnormal too, is generally accepted not to be an indication for treatment. from this we conclude, that more pefinatal stress, as in intensive care neonates, may produce tsh elevation as well as low t , but only coincidentially, not the tsh elevation being the consequence of low t , thus not to be classified as "hypothyroidism", thus not indicating treatment. if this hypothesis is right, we should find an association of increasing pefinatal stress with an increasing number of neonates from tsh and t normal via tsh or t abnormal to high tsh and low t . method: in the newborn screening program in germa w we determine primarily tsh, and only in the neonates with elevated tsh, in addition we determine t . thus in our study we asked whether we find an association of increasing perinatal stress with an increasing number of neonates from tsh normal via tsh abnormal while t normal to high tsh and low t . definitions for this study were: tsh elevation = > mu/ (as usual in the german screening programs), t lowered = < p_g/dl perinatal stress score was or or or in dependency of the neonate having stress in none to all of the following three categories: (a) forceps or vacuum extraction or sectio co) birth weight below g (c) at the th day existence of a relevant neonatal disorder (rds, ictems gravis, infection/sepsis, vitium cordis with hemodynamic relevance, severe malformation). results: our data of neonates show a high significant association (chi = , p < . ) of, on one hand, perinatal stress score with normal tsh, versus, on the other hand, perinatal stress score or with high tsh and low t . discussion: facing the background given above, in the intensive care newborn, the constellation of high tsh and low t may be only a coincidential addition of two independent abnormalities. in tbese cases -the high tsh not being the consequence of low t -the classification as "hypothyroidism" is not justified, thus a therapy not indicated. on the other hand of course there exist rare cases with high tsh as consequence of low t thus with hypothyroidism tlms with indication for therapy. unfortunately we have no criteria, that enable a certain discrimination of these two categories thus in respect to the question of therapy or not. conclusion: further research has to be done to learn how to discriminate the coincidential high tsh and low t from the causal constellation of high tsh and low t . until we have certain discrimination criteria we have to treat both groups of neonates. few studies have focused on fa composition of surfactant pc in preterm infants before and after surfactant therapy. methods: tracheal aspirates were collected in venttlated mfants from birth until extubatlon ( / _ /twk ga, .+ g bw). after lipid extraction, t.l.c,, and methylation, fas of pc were quantified by gaschromatography. intralipid a ( . % linoleic acid, : • ) was started h after birth. results: six infants developed respiratory distress syndrome (rds) and received survanta r i mg/kg (sr), all doses within h after birth (ix s r n=l, x s r~ n= , x s r n= ). one child did not develop rds. in alt patients, the patmitate % in pc was ~ % (before sr<=natural composition), increased to ~ % after s r, and remained > % for i h after lx s a, . .+i . h after x, and . .+ . h after doses. in patients, intubated long enough, the palmitate % decreased with a half-life of . _+ . h to a new plateau which was still higher than baseline after week. linoleic acid % was . _+ . (with rds), decreased after s r~ and returned to baseline due to the decrease in patmitate %. thereafter the linoleic acid % increased linearly with . % per h, in patient even up to . %. other fas did not increase after return to baseline. in neonatal medicine the current parameters, arterial oxygen saturation and arterial oxygen pressure, are poor indicators for oxygen delivery and oxygen demand. the purpose of this study was to obtain venous blood samples from the inferior vena cava in stable neonates with respiratory failure and to determine a parameter that reflects more adequately the balance between oxygen delivery and oxygen demand. "l~e study included neonates requiring mechanical ventilation tbr severe respiratory insufficiency. an umbilical venous and arterial catheter were inserted in the inferior vena cava and in the aorta respectively. paired blood samples were obtained at the time that the patients were hemodynamically stable. fifty paired arterial and mixed venous blood samples were analyzed. jnear regression analysis showed the following correlations: in a neonatal intensive care unit adjacent to a delivery room caring for mothers per year, (with a referral of mostly for preterm delivery), virtually every neonate <ls g was seen by the same ophtalmologist, j.o. the incidence of retinopathy of prematurity (rop) was in - of ii cases ( preterms <ls g with % surviving to discharge, and % rop in survivors; % if less than weeks). in - , cases of rop were diagnosed by the same ophtalmologist. were born at less than weeks, of which ( %) survived to discharge, and among those survivors, rop was present in ( %), with rates varying from % at weeks to % at . objective: to compare a method of teicoplanine (teico) infusion using an electrical syringe-pump with a manual injection. methods: infusion of teico was simulated through a standart neonatal i.v. system. the infusion system consisted of an life care infusion pump (abbo'it lab.) with its i.v. set for maintenance intravenous fluid (flow < mi/h) connected to a -way stopcock. an meter extension tubing (vygon lab.) was placed between the stopcock and a neonatal catheter, an another meter tubing (injection tubing) was connected to the stopcock. the volume of the injection circuit was . ml. simulations were realised for weights ( or kg), with a doses of mg/kg and a injected volume of , ml to ml. our goal was to perform a complete infusion in minutes. we compare one method of infusion with an electrical syringe-pump with manual methods: a: teico was infused with a syringe-pump pilot c (becton & dickinson lab.) according to a protocol using ) a priming before connecting the syringe to the tubing (for immediate starting of infusion), ) a programmed volume injected in minutes (the drug volume was greater than the dose prescribed to avoid loss of teico into the syringe), ) a ml wash out was performed over minutes with the syringe pump. b: teico was manually injected in a few seconds in the tubing followed by a ml wash out over minutes. c: idem as b but a nu site valve (medex) was connected to the proximal end of injection tubing to avoid leakage between removal of the teico syringe and connection of the wash out syringe. during each run, serial samples were collected every ten minutes over a one hour period. the samples were assessed using hplc method. results: the amount of drug delivred at minutes was calculated and expressed as a perventage of the total amount of teico prescribed. results are a mean of to rons. a b c kg . + , % , + . % , -+ . % kg -+ , % -+ , % . -+ % conclusion: with a drug volume injected < circuit volume and a valve, a direct i.v. administration of the drug in the circuit followed by a wash out seems an accurate alternative to drug infusion conbroled by a syringe pump and is easier to perform. doxapram hydrochloride is a central and respiratory stimulant which is used in neonatal intensive care units to treat caffeine-resistant apnoes of the newborn. routinely, doxapram is administered intravenously. oral administration would be much easier but data on bioavailability after oral administration are limited (two studies) and show a large variation. we therefore studied the oral bioavailability of doxapram in preterm infants. doxapram treatment was started with an intravenous loading dose of , mg/kg during minutes, followed by a continuous infusion of mg/kg/h. after h the intravenous administration was changed to continuous oral administration with the same dosage, blood samples were collected h after both the intravenous and oral administration and analyzed by hplc-assay. apnoea rates per hours were listed before and after starting doxapram treatment. the median apnoea rate per hours declined from to after both the intravenous and oral administration. the oral bioavailability of doxapram is between and %, indicating that the oral route can be used effectively in these infants . there were no differences in the decline of the apnoea rate after intravenous versus oral administration of doxapram, infasurf r has been comnared with exosurf r in two studies: one as drodhvlaxis and the other a rescue trial. similar. althouah non-sianificant benefits were found for the natural surfactant. in trials there was a sianificant reduction in dulmonarv air leaks for . : % ci . - . for babies treated with natural comnared to svnthetic surfactants. for trials ( babies~ comdarina natural and synthetic surfactants for rds { comdarina survanta r and exosurf r. and one infasurf r and exesurfr% neonatal mortalitv was sianificantlv reduced (or . : % ci . - . with natural compared to synthetic surfactant treatment. in two further trials different natural surfactant drenarations were compared. reduced oxvaen needs for hours after treatment were found for r r infasurf and curosurf respectively when each was compared to survanta r. andarent lonaer-term benefits from these surfactants were not statisticallv sianificant. further trials will be needed to ascertain differences between various surfactant preparations. introduction bacterial meningitis is a common cause of admission in the paediatric age group, and one which still carries a high morbidity and mortality. these complications are strongly associated with a delay in antibacterial therapy. a significant proportion of these patients require mechanical ventilation; it is in this particular group of patients that survival is greatly diminished. the identification of risk factors for mechanical ventilation associated with bacterial meninges may help improving survival by shortening the delay to icu referral. the paediatdc risk of mortality score (prism) is the most widely used scoring system in the paediatric icu literature; the accuracy of prism on predicting outcome in meningitis has been shown to be poor. aim we aimed to describe our population of patients with bacterial meningitis requiring ventilation, and then to identify predictors of survival. methods this study was conducted at the baragwanath hospital in south africa which is an universityaffiliated institution with end average annual paediathc admission of patients. baragwanath icu admits non-neonatal paediatdc patients per year. a retrospective chart review from january to december of consecutive paedistdc icu admissions with bacterial meningitis was performed. results approximately cases of bacterial meningitis are admitted to the general paediatric wards every year; this constitutes ± % of all admissions. the mortality of these patients is + %. during this time ( m, f) patients ( %) were accepted for icu admission, with a mortality of . %. the median age was months (range days to years). the median delay to hospital admission was hours, and the median delay to icu admission was a further hours. the median duration of tcu stay was hours ( for non-survivors, for survivors). the main presenting features were convulsions ( %), altered mental state ( %), fever ( %), respiratory symptoms ( %), headache ( %), and diarrhoea and vomiting ( %). the most common indications for icu admission were seizures ( %), coma ( %), shock ( %), respiratory failure ( %) and acidosis ( %). in % of patients there was a cardiorespirstory arrest prior to admission. the most common organisms in the csf was pneumococcus ( %), haemophilus influenza ( %) and e coli ( %). the presence of leucopenia (wcc < ), a low platelat count (< ), acidaemia (ph< . ), and the need for inotropic support were strongly associated with nonsurvival. tachycardia and hypotension were not significantly essorjsted with poor outcome, as has been previously reported. discussion early diagnosis of meningitis and prompt institution of antibiotic therapy requires a high level of clinical suspicion. paediatric patients with bacterial meningitis that require mechanical ventilation have a poor prognosis. there is little evidence to suggest that nomsurviva[ can be predicted prior to icu admission, but a rapid deterioration requiring ventilation and inotrepic support with evidence of severe sepsis (low platelet count, leucopenia) is nmost invariably associated with a fatal outcome. the long term functional outcome of these patients make this disease even more devastating; the rote of icu in the management of these patients has yet to be fully estanished. objective and study design: a retrospective study was pertbrmed for all patients diagnosed with hemorrhagic shock and encephalopathy syndrome (hse) during to . soroka medical center is the only medical facility in the southern negev region of israel serving a population of - , residents, consisting primarily of jews and bedouins. results: patients ( bedouins and jews) were diagnosed with hse. main features on arrival included profound shock and coma with con~alsions. active bleeding and/or disturbing coagulation tests with falling heuroglobin levels and thrombocytopenia was noted in every case. all infants developed diarrhea shortly after arrival. elevated urea, creatinine and liver enzymes was noted in all cases. annual incidence tbr inlhnts < year of age was : , for bedouins and . : , for jews. patients ranged in age from - wks and arrived at the hospital late night/early morning ( : am-ll: am), during winter/early spring (november-april). all were healthy prior to admission, with short prodromal symptoms of upper respiratory tract or gastrointestinal infection noted in cases. most infants had markedly elevated body temperature on arrival. a history of overwrapping and/or excessive hearing was obtained in of infants. bacteriological and virological cultures were negative in all infants. one infant died and neurological sequelae were observed in all survivors. the high prevalence of hyperpyrexia during sleep in the presence of negative microbiological results with no evidence of excessive hearing, and the high incidence of rise among a closed, culturally isolated society known to have a high incidence of congenital malformations, may support previous assumptions that hse results from hyqperpyrexia, originating in most cases from a "physiologic" heat induced trigger which starts and peaks during the night in previously healthy infants with susceptible, predisposing genetic underlie. approximately % of hospitalised infants with respiratory syaacytial virus (rsv) infection require mechanical ventilation. our general practice is not to use specific antiviral therapy. we have undertaken studies of rsv-infected mechanically ventilated patients without underlying congenital heart disease or immunodeficiency. study i (n= ): a retrospective review of infants (mean post-conceptual age weeks; median duration of intubation was days (interquartile range - ). blinded review of chest x-rays during the first three days of mechanical ventilation revealed a spectrmn of lower respiratory tract findings from marked diffiase consolidation in all zones without hyper-inflation (n= ) to gross hyperinfiation without consolidation (n= ), with the remaining patients have an intermediate picture (n= ). death occurred only in patients who were at the poles of this continuum ( / consolidation and / hyperinflation). patients at these poles could be differentiated by gender predominance, birth gestation, alveolar-artarial (a-a) oxygen gradient (p< . l), oxygenation index (p< . l), peak inspiratory pressure (p< . ), and intubation days (p< . ). study ii (n= ): prospective audit of infants with the aim of verifying the above differentiation. separating patients based on their early x-rays and a-a gradient we confirmed the above predictable difference in duration of supportive therapy (consolidation v intermediate: ( - ) v ( - ) p< . ). severe lower respiratory tract rsv-infecrion in young infants results in different distinctive partems of disease with characteristic radiological and clinical features, and each has a predictable timecot~se. conflicting reports on special therapy should be interpreted with respect to these observations before making conclusions about the efficacy of any specific treatment. the clinical data of children wich suffered from a severe mycosis between jan. -dac. and wich were treated with amphotericin b in spanish hospitals were collected. mean age was + . years; were mate ( %) and female ( %). the most common underlying diseases were leukemimymphoma ( %) and congenital heart defects ( %). the major pathogens isolated were candida albieans ( %), other candida ( %) and aspergillus ( %). and liposomal amphotericin (la) in ( %). in the ca group, the starting dose was , ~ , mg/kg, reaching a maximal dose of . + , mg/kg after . + days. maintenance time was + days and the cumulative dose: ~ rag. in the la group, the starting dose was . ± mg/kg, reaching a maximal dose of . _+ . mg/kg (p< . ) after + days. maintenance time was ~ days (p< . ) and the cumulative dose _+ mg (p< . ). the reasons for la use were: elective in % of cases, previous renal failure in %, and ca inefficacy in %. hepatic or renal function impairment was two times more frequent in la group than in ca group, the antifungal efficacy was % for ca and % for la. therapeutic failure or toxicity induced withdraw of ca in % of cases, vs, , % for la (p< , ). mortality was not different in both groups ( vs. %), adverse effects were related to ca in events vs, only one in la group (p< , ). the commonest side effects in ca patients were fever ( %), chilis ( %) and nausea ( %). in ca group, cases ( %) developped analitical anormalities related with amphotericin, vs. cases ( %) in la patients (p< . ). in the first group, the commonest serum alterations were hypokaliemia ( %), raised creatinine ( %) and bilirrubin ( %). in the second one, hypokaliemia presented in % of cases (p< . ), raised bilirrubin in % and creatinine in % (p< , ), the antifungal efficacy of la is at least the same of ca. from the clinical and analitical points of view, la is much less toxic than ca. la can be used at a greater dose than ca and is safe in children with renal failure. laurence desplanques -serge gottot -christian dageville d~artement de sant~ publique -facult~ xavier bichat - rue henri huchard paris -france -the french << reaped ~> network was created to implement a nosecomial infections (ni) quality care program in nicu and picu, the first objective was to describe the annual ni incidence rate in each icu population : all patients stayed more than hours in icu. methods : n] criteria were defined by the reaped group according to cdc criteria. all data were collected by a medical and nursing team. all infection data were validated by an external investigator. results : patients were admitted over a months period. % were newborns. ni were identified among patients. the overall ni incidence rate (ir) was . % and . °/ person day (from . to . °/ according to age, lowest rate for newborns). septicemia ( % of ni) and pneumonia ( % of ni) were the two main ni. according to age, the septicemia ir varied from . to . °/oo catheter day (lowest rate for newborns) and the pneumonia ir from . to . °/ ventilator day (lowest rate for newborns). there were very few other infections (uti : %, ir : . °/ catheter day). gram positive cocci were isolated in % of septicemia ( % of them were coagulase negative staphylococcal). gram negative bacilli were isolated in % of pneumonia ( % of them were pseudomonas). % of ni were caused by candida, mostly septicemia. the septicemia and pneumonia ir varied according to unit even after adjustment for age. discussion the aminoglycoside antibiotics are frequently used in newborns for the treatment of severe infection and sepsis due to gram-negative microorganisms. the currently recommended dosage schedule for tobra ( . mg/kg q h) does not take into account differences in gestational or postnatal age during the first weeks of life. we questioned the validity of these recommendations and studied the population kinetics of tobramycin to establish predictive equations that enables the clinician to select the appropriate initial dosing schedule. methods tobra trough (t= ) and peak values (t= ) were taken on day - after birth in newborns. tobra was administered as a -minute intravenous infusion already in an adapted dosage schedule: . mg/kg q h in infants with gas < weeks; . mg/kg q h in infants with gas between - weeks and . mg/kg q h in infants with gas > wks, tobra concentrations were analyzed by tdx-assay, a one-compartment model was assumed and non-linear mixed effect modelling (using nonmem) was applied to the data, a trough level < mg/l and a peak level between and mg/l was required, with the present dosage scheme % of the trough levels were too high and almost % of the peak levels too low. calculations showed that the following dosage schedule should result in optimal levels of tobra. preterm infants gas < wks: mg q h preterm infants gas - wks: . mg q h preterm infants gas > wks: the currently recommended dosage schedules for toeira result in high trough and low peak levels. prolongation of the dosing interval and increasing the amount of drug per dose according to the above scheme will improve tobra level control. since january british clinicians have been conducting a randomized controlled trial of neonatal ecmo. mature infants (>- weeks gestation and birthweight kg) with severe cardiopulmonary failure have been randomized to receive continued care in their referring institution or referral to a designated ecmo centre for further management. we now present the preliminary results which have prompted closure of recruitment to this trial. the final outcome will be assessed as intact survival against death or severe disability at one year of age for all the recruited patients. patients were categorised by diagnosis such as isolated persistent fetal circulation, secondary persistent pulmonary hypertension of the newborn or congenital diaphragmatic hernia and by severity of illness at the point of first contact with the clinical coordinators of the trial -judged primarily by the oxygenation index ( before randomization). patients were randomized ( in each arm). hospital outcome data are reported for all patients and year outcomes on t ( survivors). at this stage of the babies allocated to ecmo are known to have died compared to of those allocated to conventional management (rr . ; % ci . - . ; p= . ). fewer deaths have been obsea-ved amongst ecmo allocated babies in all the diagnostic categories used. a % incidence of disability and impah~nent has been observed amongst survivors. this rate is similar in both groups and the survival advantage is not offset by an increased rate of disability or impairment following allocation to ecmo. we consider that these data combined with those available from other studies provide conclusive evidence that the survival to discharge from hospital is substantially higher in patients allocated to ecmo than in comparable infants not so allocated. therefore recruitment to this trial has been closed whist awaiting complete one year outcome data. sigston pe, goldman ap. #keating j. crook r. ~e dj~. great ormond street hospital for children nhs trust, and ~biochemistry department, kings college hospital, london, united kingdom. isoflurane is a safe and effective means of long term sedation in both children and adults in the intensive care setting. the use of isoflurane, by adding it to the sweep gas allows the use of this volatile anaesthetic agent in patients on ecmo, enabling rapid control and weaning of sedation. a potential problem with the long term use of isoflurane is fluoride ion accumulation with the possibility of renal toxicity, the purpose of this study was to assess plasma fluoride levels in patients receiving prolonged isoflurane on ecmo. method: fifteen infants and children (aged day - years, median weeks) receiving ecmo support for either cardiac or respiratory failure were recruited to this study. the patients were sedated with isoflurane as well as intravenous agents (morphine and midazolam). isoflurane was administered ( % - %) via a calibrated vaporiser to the sweep gas, adjusting the level to maintain adequate sedation. blood samples were obtained on a daily basis for plasma inorganic fluoride assay. the relationship between plasma fluoride and amount of isoflurane administered, as %-hours (vaporiser setting in % x hours) was calculated by linear regression. results: the duration of ecmo ranged from to (mean ) hours, during which the amount of isoflurane administered varied from to (mean ) %-hours. blood samples were anaiysed, demonstrating individual peak plasma fluoride levels of . to . #mol/ , mean , p.molli (toxic threshold = gruel/f). the plasma fluoride positively co;related with the %-hours of isoflurane (r = . , p = < . ). conclusion: this study shows that although there is a dose related accumulation of inorganic fluoride ions in patients sedated with isoflurane on ecmq, the peak fluoride levels are well below the suggested toxic threshold. merzel y, lev a, bar yosef g, halbertal m, lorber a ecmo center, picu, emek medical center, israel. the mortality rate of pediatric patients with acute myocarditis is - % according to the severity of myocardial damage. a month old gzrl presented with high fever, respiratory and cardiac failure. diagnosis of acute myocarditis was made and the patient was ventilated with high pressures and fio of . . she required high doses of inotropes. echocardiography revealed a dilated la and lv with severe mr. lvedd was mm and lvsf %. calculated oxygenation index was . she was resuscitated after a cardiac arrest. she was commenced on ecmo (using biomedicus centrifugal pump and avecor oxygenator) at a flow of ml/kg/mm with immediate improvement of hemodynamlcs, oxygenation and pc . resptratory assistance and vasoactive drugs were reduced. the patient was transported by air, on ecmo, to the ecmo cevter. she developed arf and cvvh-d was performed. cardiac fimction started to improve after days. ecmo was discontinued on day . echo revealed lvedd mm and lvsf %. ippv was discontinued on day . on discharge, a month later, her lvedd was mm and lvsf %. she behaves normally for age without neurologic or other medical sequellae. literature search revealed no case of acute myocarditis, as severe, that was treated successfully. survavors of disease this severe usually suffer dilated cardiomyopathy and permanent disability. the use of ecmo allows myocardial rest which prevents long term myocardial damage. introduction ecmo is increasingly used in the care of critically ill newborns. despite the frequent use of betalactam antibiotics in the treatment of these infants there are no data available on the dispbsition of cefotaxime (ctx) and amoxicilfin (am) d ring ecmo. the purposes of this study were to determine the pharmacokinetics of these two drugs in infants on ecmo and consequently formulate appropriate dosing regimens. we therefore studied the pharmacokinetics of ctx ( mg/kg ql h) and am ( mg/kg q h) in term infants on day after birth, blood samples were taken before (t-o) and . , , , , (am) and t h (ctx) after the intravenous bolus injection and analyzed by hplc-assays. . ctx mg/kg q h results in adequate serum levels of ctx in fullterm infants on ecmo, am mg/kg q h results in very high serum trough levels. recalculation based on the known volume of distribution and elimination serum half-life of these infants resulted in the following dosage recommendation: mg/kg q h. persistent pulmonary hypertension of the new-born (pphn) is characterised by rapid fluctuations in pulmonary artery pressure (pap) and a clinical impression of stifflungs. lung mechanics were measured in term infants, mean age . +_ . days who were paralysed and ventilated within the first three days of life. fourteen infants had pphn with systemic or suprasystemic pap measured by echocardiography. in these patients, the respiratory system resistance was . % higher (p < . ) and compliance . % lower (p = . ) during systemic or suprasystemic pap compared to when the pulmonary hypertension had resolved. in contrast, there were no changes in resistance in the infants with respiratory distress syndrome (rds) and no pulmonary hypertension or in the seven infants with normal lungs, where two readings were taken hours apart. the changes in lung mechanics interfered with mechanical ventilation, resulting in a . mmhg rise in paco (p= . ) during pulmonary hypertension. inhalation of nitric oxide ppm resulted in a % decrease in respiratory system resistance and an improvement in oxygenation. the bronchial and vascular smooth muscle was increased by % in postmortem lung samples from eight infants with pphn compared to six age matched post-mortem controls with normal lungs (p< . ). these findings suggest a co-constriction and co-hypertrophy of bronchial and vascular smooth muscle during pphn. anatomically the pulmonary vasculature and bronchi lie in close proximity to each other. thus mediators such as endothelin- released locally may act on both vascular and bronchial smooth muscle to produce the observed vasoconstriction, bronchoconstriction and smooth muscle hypertrophy. prince of wales children's hospital university of new south wales, randwick, n.s.w. australia. introduction an increasing mortality in asthmatic children has been reported. the increased severity of asthmatic illness leads to an increased demand for icu admission, and a corresponding increased need for mechanical ventilation. geographic end environmental factors are thought to be partly responsible for differences in disease sevedty throughout the wodd. for this reason, epidemiological studies from diverse areas are important, risk factors for icu admission, and for the institution of mechanical ventilation should be identified, to optimise icu admission criteria and to avoid unnecessary delays in admitting at-risk patients. aim to document the clinical characteristics of ventilated and non-ventilated asthmatic patients admitted to icu. methods this is a retrospective study of all paediatric asthma icu admissions from january to december . results there were patients admitted to the icu for acute severe asthma in the study period. the male:female ratio was : , the mean age . • . months, the mean prism . - . %, and the mean duration of admission . hours. there was no seasonal variation in admissions. only % ( / ) patients required mechanical ventilation. in % of all patients this was the first presentation with asthma. there were some significant differences between ventilated and non-ventilated patients (see table) . there was a significantly higher incidence of concomitant and nosocomial pneumonias in the ventilated patients ( . % vs . %) as well as segmental lung collapse ( . % vs . %). there were no deaths. discussion the need of mechanical ventilation significantly increases the morbidity of and duration of icu stay of asthmatic patients. younger asthmatic paediatdc patients have a significantly higher risk of ventilation. the need for ventilation is predicted principally from a worsening pco and respiratory acidaemia, which is often independently interpreted by the clinician as respira ory exhaustion. this study has shown that icu admission is important in the management of young paediatdc patients with acute severe asthma and respiratgry fa!!ure. intravenous salbutamoi in the emergency, department management of severe asthma in children. g.j.browne,a. perma,x. phung,m.soo westmead hospital, sydney, australia. it is postulate that if an initial intravenous loading dose of salbutamol is given in severe asthma, a more rapid clinical response will occur, reducing requirements for continued high doses of nebulised salbutamoi with fewer side effects. this double blinded study was conducted in the emergency department of westmead hospital a university hospital in sydney, australia. all children with severe asthma had initial nebuliser therapy ( rag of salbutamol with ml of saline). if asthma remained severe minutes later, they were given a dose of intravenous hydrocortisone ( mg/kg) and either normal saline or salbutamol microgm/kg intravenously. frequent nebulised salbutamoi therapy continued during the initial first hour if clinically indicated. continuous respiratory and haemodynamic monitoring occurred in the first hours. serum potassium and glucose determinations were made at study commencement and hour after intravenous therapy. salbutamol determination was made at study commencement. children remained clinically monitored for the next hours, with their ongoing treatment determined by clinical response. children with severe asthma months to years of age were studied, with given intravenous salbutamol and given intravenous saline. the intravenous satbutamol group (ivsg) showed rapid reduction in asthma severity scale in the first hours, with reduced need for high frequency nebuliser therapy ( _< hourly), occurring . hours.earlier. no clinically significant side-effects were found in either group, although, tremor more frequent in the [vsg. biochemistry and salbutamol concentrations were similar in both groups. the use of intravenous salbutamol (i microgm/kg) in the management of severe childhood asthma is a safe and effective therapy with no significant side-effects and the potential to abort severe asthma attacks in the emergency department. intravenous terbutaline in picu piva j., amantra s, rosso a., zambonato s, giugno k, maia t. introduction: the admission to a picu of children with respiratory failure secondary to an acute obstructive lower airway disease is a common event, especially during winter seasons. these diseases have several causes, but most of them (especially asthma and chronic airway disease) have a good response to the administration of b -adrenergic drugs. objective: to find the dosis of intravenous terbutaline that is safe, efficient and with minimal adverse effects when used in children admitted to a picu with acute obstructive lower airway disease and respiratory failure. material and methods: we study the records of all children that were admitted to our picu during the winter of . only the patients that had respiratory failure and acute lower airway disease and who needed the use of iv terbutaline were selected. the records were divided in two groups: less than months and more than a year old these two groups were compared in the following aspects: the minimal and maximal dosis, and the length of time of use of iv terbutaline, frequency of tachycardia, hypokalemia, and mechanical ventilation. to establish any difference in the two groups we use the t exact test of fisher and x , with p< . , results: during the period of study were admitted patients to the picu, and ( , %) of them used of iv terbutaline. the mean age was . + . month, used iv terbutaline during . + . days ( . to days), the initial rate was . + . p~g/kg/min, and the means of therapeutic dosis was . +l. ~g/kg/min (ranged from . to . ). twelve ( . %) patients had tachycardia art obstacle to the increases in the rate of use of iv terbutaline during any time. mechanical ventilation was necessary in patients ( . %) and ( . %) patients died. the children under year of age used initial dosis of iv terbutaline lower than the children up of year old ( . p.g/ kghnin x . ~tg &g/rain, p< . ), but without difference in the length of use, the maximal dosis, the rate of mechanical ventilation and tachycardia. the frequency of hypokalemia was most common in the group of children under year of age. acute respiratory failure during status asthmaticus may require mechanical ventilation. current therapy includes paralysis, pressure control ventilation (pcv) and permissive hypercapnia to limit pulmonary barotranma and its hemodynamic consequences. asthmatic children exert a significant amount of respiratory effort during exhalation. with paralysis, this expiratory effort is lost. unloading the inspiratory work of breathing while maintaining the patient's expiratory eftbrt using pressure support ventilation (psv), may be beneficial. methods: children receiving pcv (peak inspiratory pressure (pip) = kpa. rate breaths/min) and pco > kpa were switched to psv. children were initially ventilated with psv . kpa and peep = . kpa (servo c). all children received beta agonist therapy, ipratropium and anesthesia with ketamine or inhalational anesthesia, and were breathing spontaneously. respiratory parameters and blood gases are shown be~bre psv, within minutes (start) and when the ph had normalized (during). data are presented as median and range, * p < . compared to before psv. results: children with hypercarbia during pcv responded to psv, normalizing pcos and ph within hours. the mean respiratory rate decreased from a median of ( - ) to ( - ) while the pip was decreased to . ( . - . ) kpa within hours. the i:e ratio also significantly decreased. conclusion: psv permitted patients to active/y exhale while unloading the inspiratory work of breathing. perhaps this strategy shifts the patient's respiratory effort from inspiration to exhalation, thus permitting the child to meet the excess work of breathing caused by bronchoconstriction. maged z. youssef, peter silver, laura nimkoff, and mayer sagv. division of pediatric critical care medicine, schneider children's hospital, new hyde park, ny . introduction: mechanical vemiladon of patients with severe bronchospasm can be difficult, due to poor chest compliance and increased airway resistance. ketarmne is a cormnonly used anesthetic agent that has been shown to have bronchodilator properties. the purpose of this study was to determine ifa continuous infusion of ketamine had an effect on the oxygenation and chest compliance of children with severe lironchospasm who were mechanically ventilated. methods: a retrospective chart review was conducted of pediatric patients in severe bronchospasm who were mechanically ventilated in our picu and treated with a continuous ketamine infusion. all patients were receiving aggressive bronchodilator therapy and adequate sedation prior to keramine. patients were excluded if any new bronchodilator or sedative agents were started within hours of initiation of ketamine treatment. all patients were simultaneously treated with benzodiazepines. for each patient, the pao /fio ~ ratio and dynamic compliance [tidal volume/(peak imp. pressure -peep)] was determined immediately prior to ketamine, and at , , and hours post-ketsmine initiation. data are presented as mean ± s.d., and were a~yzed using one way anova and the multiple comparison method of bonferroni. patients (age . ± . yrs.) received * p< . ketamine for severe bronchospastu during mechanical ventilation in our picu. both . .xto-* * the pao /fio ratio and dynamic . . -.... . compliance increased significantly following initiation of the ketamine infusion (see figure) . the mean ketamine dose was ± mcg/kg/min, and the -, mean infusion duration was ± too-[/ hours. one patient required glycopyrrotate ~' to control excessive airway secretions, and " one patient required an additional dose of o--j i ~-~ ~/me diazepam to control hallucinations after i cessation of ketamine. all patients were t~n~,mr~ *~am~ successfully weaned off mechanical ~l~s ~,~s~on ventilation and discharged from the picu. conclusion: continuous ketamine infusion to mechanically ventilated pediatric patients with refractory broncliospasm results in a significant improvement in oxygenation and dynamic compliance of the chest. reports of adults with status nsthraaticus document significant morbidity and mortality, whereas studies in children have had more varied results. different centers report mechanical ventilation (mv) in to % of admissions, occurrence of pneumothoraces or paeutuomediastinums in to %, and mortality in up to % of patients ~'t . we retrospectively reviewed status asthmaticus admissions to the pediatric intensive care unit (picu) between january and december . seventy-five of these patients were admitted fr~an the emergency department of chla (er admit). the mean length of stay in the picu was . days and the mean length of stay in the hospital was . days. based on patients who had arterial blood analyses, patients had hyperoapnia (pco > ). all patients received oxygen, inhaled albuterol (alb), and cortieosteroid therapy. ninety-five percent of patients also received methylxanthine (mx) therapy. of the admissions, patients ( %) required mv. only of these patients were admitted through our emergency department, whereas the remaining patients were intuhated at outside facilities. twenty-three cases required intr:wenous beta-agonist therapy, either isoproterenol osop) or terbutaline (terb). h~ff of the ea.~es re~%wed were complicated with hypokalemia (k+< . ). c,', ,~lications ofpoeumothoraces or pneumomediastinums were seen in % of ,'r:u~ported patients, but in only % of er admit patients. only % of these were in mechanic.all, )atients. there were no deaths in the review. respiratory mechanics measurements 'are useful in mechanically ventilated children to optimize ventilator settings. nevertheless, the transducers used to measure flow (f) and pressure (p) remain expensive. objective. to evaluate the performances of piezoelectric p transducers ( us dollar) in measuring f and p. methods. we used a previously described monitoring system measuring respiratory parameters [ ] . in this study f was obtained by a differential piezoelectric p transducer (_+ . cmi-i , honeywell) whose sensitivity has been reduced to +_ cmh by an electronic amplification equipment and p by a piezoelectric p transducer (_+ (). cmhzo, honeywell) connected to a grid pneumotachymeter &nt) ffleisch or ). volume (v) ( to ml) obtained by numeric integration off ( . to l/rnin ) and p ( to cmh ) were respectively delivered through a calibrated seringe and an electronical manometer (pic premier) and calculated by the computer. bland and altman analysis was used for assessment of results bias. coefficient of repeatability (cr) was estimated by the standard deviation of repeated measurements of the parameters as calculated in a oneway analysis of variance. results. mean difference (mdi between injected v ( to ml) and measured v using pnt was . ml, sd = . ml. difference and mean v were not correlated. sd of repeated v measurements were not correlated to v. cr was . ml. mdif between injected v ( to ml) and measured v using pnt was lrd, sd = ml sd of repeated v measurements were not correlated to mean v. cr was ml. mdif between injected p and measured p was . cmi-i , sd . cm h sd of repeated p measurements were not correlated to mean p. cr was . cmh . conclusion. inexpensive piezoelectrical transducers can be used to measure f and p and evaluate respiratory mechanics in ventilated children. previous studies have already shown the problem of the reproducibility of pft in preterm ventilated babies. were studied preterm ventilated babies {mean weight gr) in the first week of life in clinically stable condition, measuring flow, airway pressure and esophageal pressure simultaneously. each baby was studied twice with an interval of one hour and each study was done increasing the rate till to inhibit spontaneous breaths. none sedative has been used. only mechanical breaths were analyzed. compliance and resistence were calculated with a computer system using the linear regression method. we expressed quantitatively the intrapatient variability as the percentage of variation of tidal volume, compliance and resistence between the two studies in each baby. then intraclass correlation coefficient test (icc) was applied to confirm qualitatively our results (total agreement = , good reproducibjtity > . ). we h~£ed, an a eept~ble ~efiabirl¢, ~-~r;= '~ . during mechanical ventilation, an air leak (al) and plateau phase duration (pl) may influence dynamic and static compliance (cdy and cst, respectively). this study evaluated the effect of al and pl on two methods of measuring c.dy and est. methods. intubated, ventilated patients in a pediatric intensive care unit were evaluated after obtaining informed consent. patients were intuhated with a cuffed endotracheal tube and ventilated with a serve ( ventilator. cdy and cst were determined using the serve ands~rmedics . objective: evaluate the repercussion in respiratory mechanics and arterial blood gases and the impact of the ventilator adjustments on the auto-peep magnitude. material and methods: the measurement of the auto-peep was performed using an eletronic-pneumatic controlled device with a oclasion valve installed between endotracheal canutla and the ventilator circuit. the d~'ice was connected to a solenoid to detecte the end of inspiratuo phase and thus, the activation of the oclusion valve. the signs of pressure and flow were monitorized using a diferential transducer and it was processed using a pc computer and tmeumoview® software. the stud were divided in phases: phase a. where the ventilator adjustments was performed using the routine of the unit and phase b, where the targets of mechanical ventilation were to minimize the auto-peep. static compliance (crs) was ineasured by the single-breath occlusion technique, using a mean of ten occlusions for analysis. passive respiratory resistance measurements and the tidal breathing flow-volume loops were also obtained., while the ventilatory settings were siguificantly reduced soon atier ecmo was started. before ecmo crs measured in all patienls was . _+t). ml/cmh /kg (mean_+sem). for each patient the ecmo course was divided into four periods, proportional to the duration of the treatment, and the best ~alue of crs in each period was chosen for analysis. as shown on the figure. crs significantly improved (*p< , ) from the second half of the ecmo course in the group of patient that finally were successfidly weaned from ecmo. no change ill compliance was measured in the group of patients who failed to respond to the extracorporeal hmg support our data suggest that compliance measurements during ecmo can be useful togelher with overall clinical evaluation to predict both outcome and duration of cxtracorporeai support in the neonatal and pediatric population. objectives: brain temperature determines the amount of neuronal damage caused by hypoxic insults. thus measuring brain temperature at standardised conditions is in request. we investigated whether brain temperature of neonates varies with head insulation environmental temperature, body activity and time course. patients and methods: we investigated non-invasive brain temperature analogues in healthy prematures tess than two weeks of age in an incubator (gestational age . + . wks; x + sd, weight + g). we measured nasopharyngeal temperature (tnasoph) by a thermistor placed in the nasopharynx via a feeding tube, zero-heatflux temperature (zht) at the temple by a thermistor and healflux transducer, insulated by two pads, as well as rectal and incubator temperatures. patient activity was documented by video taping. measurements were performed during periods of increased insulation ) by turning the head with its measuring site on to the mattress ( ( ) ( ) - ( ) ( ) ( ) ( ) . ( ) ( ) { ) ( ) ( ) - ( ) ( ) ( )i ( ) ( ) ( ) ( ) . ( ) ( ) t ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) web (lmg/kg) at rain ( ) - ( ) ( ) ( ) ( ) - ( ) the vehicle had no effect. paf caused dose dependent rise in ao and pa pressure and reduction in flow to lpa (up to % like the vascular endothelium, the endocardial endothelium (ee) has a significant impact on adjacent myocytes, and may critically alter myocardial function.~ we have previously shown that ee cells are capable of sensing and responding to hypoxia by the release of prostacyclin (pgl). potassium channels in other cell types have been reported to be oxygen sensitive. to determine whether potassium channels modulate the ee hypoxic response, we investigated the effects of three potassium channel inhibitors on hypoxia-induced pg] release from ee cells. methods: ovine endothelial cells were harvested and passaged onto ,~ microcarriers. cells were constantly perfused with normoxic and hypoxic kreb's solution, and with three potassium channel blockers: glibenclamide (gb, #g/ml), tetraethyl-antmonium (tea, ram) and aminopyridine ( ap, i mm), perfusate was assayed for prostacyclin (ria). data were compared by analysis of variance. * p<. compared to normoxic control; # p< . compared to hypoxic control. adrenaline is extensively used for resuscitation in neonates with rds. however, effects of adrenaline on systemic, pulmonary and cerebral hemodynamics have not been defined in newborns with rds. thirteen anesthetized, and ventilated newborn piglets were subjected to repeated saline lung-lavage series while mean systemic arterial pressure (abp), mean pulmonary arteriat pressure (pap), mean left atrial pressure (lap) and mean central venous pressure (cvp), cardiac output and blood flow in the internal carotid artery (ica) were measured. systemic vascular resistance (s~), pulmonary vascular resistance (pvr) and cardiac index (ci) were calculated. sixty minutes after luug-lavage, the adrenaline group (a) (n= ) received adrenaline as a continuous infusion of . lag/kg/mi, while the control group (c) (n= ) received saline. none of the varlables were changed by saline. however, significant increases in abp (p< . ), pap (p< . ), ci (p< . ) and svr (p< . ) were observed after administration of adrenaline, whiie pvr and ica were not modified. mean±sd for abp/pap (p/a), fvr/svr (p/s) and ci (ml/mirdkg) were: ratios of pap/abp and pvpjsvr significantly increased following infusion of adrenaline. these data suggest: ) the cerebral perfusion is preserved during the infusion of adrenaline; ) effect of the adrenaline infusion on the systemic circulation is more pronounced than its effect on the pulmonary circulation in newborn piglets with surfactant deficiency. s demirak~a, ch knothe, kj hagel, j bauer department of pediatrics, justus-liebig-university giessen, frg inhaled no is a short acting selective pulmonary vasodilator. we studied the effects of ppm no and % oxygen during heart catheterization in children (age - years, median years) with heart defects and elevated pulmonary vascular resistance index (pvri) in order to asses the value of no as a tool of decision making for corrective cardiac surgery. patients were eligible for testing when they were more than one year old and had a pathologically elevated pvri in a previous heart catheterization. intubation, 'anesthesia and muscle paralysis were performed in all patients during testing of pulmonary reagibility. calculations of pulmonary vascular resistance and flow were based on the fick method. response to no was assumed when pvri declined more than %, of the patients were responders to no. effects of no and oxygen on pvri, mean pulmonary arterial pressure (mpap) and pulmonary vascular flow (qp) in all responders are described in the table below. cardiac surgery was offered to all responders, and of them were successfully operated. surgery is planned in another patients and parental consent for surgery was not given in one patient. in ebstein disease, during the first days of life, the ability of right ventricle to propel blood to the pulmonary artery is impaired due to high pulmonary vascular resistances. the flow is mainly directed to left atrium through tricuspid insufficiency, right atrium and foramen ovale. to decrease pulmonary resistances and increase pulmonary blood flow, high frequency oscillations, mechanical ventilation, nitric oxide and prostaglandin are required. after few days, a forward circulation is normally established. we cared two newborns with ebstein disease where this approach was hindered by a large pulmonary valve insufficiency. both of them were diagnosed in utero, showing a large tricuspid insufficiency with a non opened pulmonary valve and a ductal left to right shunt. one fetus was hydropic. at birth, blood stream from the ductus arteriosus was directed to the right ventricle through the pulmonary valve insufficiency then to right atrium, left atrium and ventricle, aorta and ductus arteriosus. a low pulmonary blood flow was demonstrated by low mean velocities ( cm/sec). a high reverse flow was seen in descending aorta with a negative flow in the renal artery. both of these newborns were oliguric because of ductus arteriosus steal. pulmonary blood flow doppler evaluation allowed different strategies of ventilation, switching between hfo and conventional ventilation, modulation of pge doses, inhaled pulmonary vasodilators (nitric oxide) and surfactant. the hydropic baby died, the other survived after weeks of intensive care complicated by supraventricular arythmia (wpw). in conclusion, during neonatal period, in ebstein disease, a large pulmonary insufficiency leads to a vicious circle where lungs are excluded, inducing severe asphyxia and high pulmonary resistances. the blood is backward propeled from the aorta through the ductus arteriosus to the right ventricle and atria, then left cavities to aorta. arec must be considered when pulmonary blood flow does not increase despite optimal therapy. guti~rrez-larraya f*, mandoza a*, velasco jm*, zavaneua ( **, gatindo a ~, s&nchez-andrede r, s&nchez jl***, mellon a***, mar f***. pediatric cardiology*, pediatric cardiac surgery**, pediatric intensive care unit***. hospital de octubre. madrid. background: transesophageal pacing (tp) is effective and sate both for diagnosis and treatment of pediatric arrhythmias. material and methods. eleven consecutive patients are included. a tri or quaddpolar or f temporal transvenous catheter with an interpolar distance of to mm was advanced through the nares and positioned to the point with the largest amplitude of atrial deflection, surface ecg and a bi or monopolar electregram were recorded simultaneously, selecting filters when needed ( to mhz). pacing was performed with a programmable stimulator (medtronic ) beginning with ms and increasing ma to and then increasing up to . ms. narula method was selected to diagnose sinusal node disfunction (snd) and overdrive pacing to treat tachyarrhythmias. results. tp was useful in all the patients and no complications were observed: in patients a snd was diagnosed (one needing a definitive pacemaker), in two patients with atrial ratter (ripe ) sinus rhythm was recovered, in one patient with a postoperative junctional ectopic tachycadia we were able to get atrial synchrony with marked bemodinamic improvement, and patients with paroxysmal supraventricular tachycardia sinus rhythm was easily and quickly restored ( of them recquirad repited episodes of tp until pharmacelogycal levels of antiarrhythmic drugs were raised). mean age and weight were months and . kg (one patient had . kg). there was a close relation between height and depht insertion (r= . ). mean stimulation parameters were , ms and . ma. discussion. in experiencied hands tp is an effective and safe way to treat and diagnose cardiac arrhythmias even in newborns. it should be tried before endovenous pacing is stablished and it is faster than pharmacologycal treatment. bailing g., eicken a., sebening w., vogt m., schumacher g., bl~hlmeyer k.; kinderkardiologie, deutsches herzzentrum m nchen, germany to assess the outcome of balloon valvuloplasty in infants with cardiac failure caused by critical aortic stenosis a retrospective study was performed. between and neonates, aged - days (median d), weight .t - , kg (median , kg) with critical valvar aortic stenosis were dilated by balloon (aovp) as the first line treatment. patients received prostaglandin el, needed inotropic drugs and mechanical ventilation. associated cardiac lesions : persistent ductus arteriosus (pda) in patients (restrictive pda in cases), a mitral regurgitation (mivr) in cases ( severe and moderate or mild mivr), angiographic findings of endocardial fibroelastosis (efe) in patients, mitral stenosis (mivs) in , coarctation of the aorta (coa) in , and finally a small musculary ventricular septum defect (vsd) in i patient. vascular approach for ballooning : a. axitfaris in cases ( %) a. femoralis in t ( %) and v. femoralis in cases ( %). the median ratio between inflated balloon and aortic valve diameter was , . dilatation was achieved in all cases. the peak systolic gradient across the aortic valve (pre aovp) ranged from to mmhg (median mmhg) and was reduced to to mmhg (median ; gradient reduction is significant (p < , )). aortic regurgitation (aovr) was absent or mild in , moderate in and severe in patient after aovp. children survived (actual suwival rate: %; early mortalffy: n = ; late mortality: n = ). mid term follow up ( - , years; mean , years) showed an increase of the systolic peak doppler gradient across the aortic valve (median mmhg) but no increase of aovr. re-interventions (re-aovp: n = , commissurotomy: n = , mitral valve replacement n = , resection of subaortic stenosis: n = , resection of coarctation: n = ,vsd-closura: n = ) were performed in patients. rv contractility and pulmonary vascular mechanics(pvm) in immature animal models are poorly underslood. we developed an acute rv injury model to measure rv contractility and pvm in response to commonly used cateehalamines. ten anesthetized piglets ( - kg) were instrumented with micromanometers in the lv, rv, pa, and la. a pulmonary artery flow probe was placed to measure cardiac output(qpa). ultrasonic dimension crystals were sutured to the myocardium and dynamic chamber volumes estimated using shell subtraction methodology. rv injury was induced with - cryoprobe injuries at - to - °c for - minmes each. da at mg/kg/min, db at mg/kg/min, and ep at . mg/kg/min were infused in random order. rv contractility was evaluated by calculating a load independent measure of contractility, the preload recmitable stroke work(prsw), during vena caval occlusions. to describe pvm, input resistances), characteristic impedance(z ), total pewer(tp), and efficieacy f=qimo"p) were measured. measurements were made pre-and post-injury, during infusions, and between infusions. clyoablation decreased prsw ( . _+ . to . + . , p< . ). at the end of the experiment, prsw remained depressed to this level indicating stability of the model. one factor contributing to organ dysfunction for infants undergoing repair of congenital heart defects (chd) is their "inflammatory response" to cardiopulmonary bypass (cpb). this response is characterized by an increase in cytokine release, complement activation and endothelial injury. modified ultrafiltration (muf) is a method for removing tissue water and inflammatory mediators by rapid ultrafiltration followin~ cpb, muf may acutely improve post-operative end organ function. in this study, we evaluated the effects of muf on the pulmonary and cerebral function of infants undergoing cpb for repair of chd. we prosnecrivety randomized infants (.~ mos) to either muf (n= ) or no muf (n= )(control) following correction for chd. the study intervals were ) before cpb, ) immediately after cpb, and ) minutes after cpb. pulmonary function was evaluated by measuring dynamic compliance (cdyn) and airway resistance (raw). for pts (mue= pts; control= pts) exposed to a period of deep hypothermie circulatory arrest (dhca), cerebral metabolism (cmro ) was calculated at each interval using the xe clearance technique for cerebral blood flow measurements and arterial and jugular bulb saturation measurements to calculate cmro . a reduction in cmro has been consistently demonstrated after dhca. the effects of muf on cdyn and on cmro are shown below: p< . vs pre-cpb; # p< . vs post-cpb • p--o. vs. post-cpb this study demonstrates that immediately following exposure to cpb, muf will improve pulmonary compliance. raw was not different between groups. there was no significant difference in hours of post-op ventilation for either group. in those pts exposed to dhca a trend towards better cerebral metabolic recovery compared to control was demonstrated. this is the first technique applied to infants undergoing dhca where cmro after cpb was greater than precpb measm~s. although this may be beneficial to postoperative hemodynamics, ventilatory management and long-term neurologic recovery, more patients and longer follow up will be necessary to verify such an effect. the effects of conventional mechanical ventilation (cmv) on left ventricular (lv). diastolic filling in neonates are not well established. one approach to improve lv filling is the use of cmv to provide a phasic increase in airway pressure {thoracic augmentation). this phasic increase in airway pressure may result in an increase in lv filling similar to that which occurs with cpr. thoracic augmentation has not been evaluated in neonates with ventricular dysfunction who frequently demonstrate increased heart rates. attempts to maintain low peak airway pressures during cmv may result in a prolonged inspiratory time that occurs over multiple cardiac cycles. this may alter lv filling in the later cardiac cycles. to determine the effects of inspiratory time on lv diastolic filling, infants were examined with doppler echocardiography less than hrs after surgery for the arterial switch procedtme. pulsed doppler recordings of the millal valve (mv) were obtained with the inspiratory time adjusted to occur over cardiac cycles ( sec.). a pressure transducer was placed in line with the ventilator, and the respiratory cycle was recorded superimposed on the doppler tracing to provide accurate determination of inspiration and expiration. doppler recordings were obtained from the apical -chamber view and the following measurements were made: peak e and peak a velocities, eia ratio, and deceleration time. compared to the expiratory phase of cmv, the initial beat during the iuspiratory phase of cmv resulted in an increase in mv peak e (. +-. vs . -+ . m/s, p< . ) and peak a (. + . vs . -+ . m/s, p< . ) velocities with no change in mv deceleration times (p<. ). compared to the initial beat during tile inspiratory phase, the third beat during the inspiratory phase resulted in decreased peak e (. + . vs . + . m/s, p< . ) and peak a (. + . vs . + . m/s, p< . ) velocities with no difference in deceleration times. thus, cmv augments lv filling during the initial phase of inspiration. however, as the increase in airway pressure is distributed over multiple cardiac cycles, lv filling falls below baseline levels. these observations indicate that while thoracic augmentation may be beneficial, to optimize lv filling the inspiratory time of cmv must be < cardiac cycles. energy expenditure in pediatric orthotopic liver tranaplantat~on, to determine the actual calorie requirements of critically ill children and evniuate the correlations between measured, stress-p~lictod and repleted energy exponditttm and the severity of illness. des/gn: a prospective, dinlcal study. se~ng: tertiary care pediatric icu in a university hospital. patients: ten patients aged to months with disorders prompting picu admission, including sepsis, respiratory failure, solid organ transplantation, and cardiovascular surgery. inta~entions: all patients were studied within hrs of major surgery or transplantation, or following acute illness. all patienls were severely stressed clinically and all but two were intubated by cuffed tubes, in three of them, still in a stress state, the study repeated on the third day of the disease, energy expenditure mensurements (mee), as well as illness seventy scoring systems, mtfltisystern organ failure scores and various anthropemetric and clinical indices of nutritional status, the stress-predicted energy expenditure (s-pee), the basal metabufie rote (pbmr), the repleted energy (re) and the recommended dietary allowances (rda) were measured or calculated in each patient. multiple regression analysis was used to analyze the data. measurements and main results: although the mean mee was significantly lower than the mean s-pee ( . + kcal/kg/day vs. . : kcal/kg/day, p<. ), it did not differ significantly from the pbmr (mean difference - . kcal/kg/day, range - . to + . kcal/kg/day). the s-pee/mee ratio ranged from . to . , while the re/rda ratio ( . : kcal/kg/day)/( . : kcal/kg/dny) ranged from only . to . . the prism/tiss ratio was not correlated better with mee than the diagnostic category (r~=. vs.. , respectively). the re was positively correlated withthe mee (rz=. , i)=. ) while negative oarrelatian has been found between mee and age, mid-arm circumference, triceps skinfotd and the use of vaseactive agents (r~. , - , -. , p<. and -. resp~lively). concl.m~: if s-pee is used for caloric repletion in the stressed oritic~ly fll el~d, these patients will be substantially overfed by as much as %. although pbmr appears to approximate the mee by ± %, other clinical and nutritional indices should also be ennsidered. objective: to deter .mine..t.he metabpli.c and.nutritional state of mechanically ventilated intants and children m relatmn wlm severity or msease. patients and methods: mechanically ventilated infants and children, median age months (range days to years), were studied. severity of illness was assessed using prism, prism-ii~ and fiss-scores. oxygen consumption (vo ), energy expenditure (mee) and respiratory quotient (rq) were determmed by mdirect calorimetry. total urinary nitroger(tun) and creatinine excretion, levels of albumin and crp were aetermmed in patients. in these patients daily caloric intake and substrate utilization were assessed. they were categorized in subgroups: a partial feeding (recent admission to p cu); b complete feeding. results: mee of the total group (n= ) a) i=intake g/kg/day (% total intake); u=utilization g/kg/day (% total production). nitrogenba]ance was negative in all patients in group a (mean - . -- : mffkg/day) and positive in all but one patient in group b (.mean . ± .d n~g/..kg/day;p= . ). no significant correlations were round between creatinine height index, crp, albumine, jun vs v u /kg conclusions: the mean measured energy expenditure does not exceed predicted resting energy expenditure, but ~ere is a wide range. in a majority ot patients with complete feeding h.igh carbohydrate intake resulted, in high kq and lipogenesis. in patients witla partial teeding the highly negatwe nitrogen'balance suggests that in the early phase of diseasean higher protein intake should be provided. severity of illness scores ann oiocnemicm markers of physiologic stress correlatedpoorly with oxygen consumption. leite,hp; iglesias, s; faria, c; ikeda, a; albuquerque, mp; carvalho, wb pediatric icu -s~o paulo federal university -s~o paulo, brazil objectives: ) to evaluate patterns of use and monitoring of nutritional support in critically ill children; ) to evaluate an education program in nutrition support given throughout the resident physician training in the pediatric icu. patients and methods: records of patients receiving nutritional support during were reviewed. aider this first phase, knowledge and understanding of the role of nutrition support was conveyed to the residents through didactic lectures. in a second phase thedata were reevaluated in children who were given nutrition support in . results: from a total of days ofthempy, the single parenteral route was utilized in , %, the digestive route (tube feeding or oral route) in , %. of this time. a previous nutr~ional assessment was performed in children; no patient had the nutr~on goals set. the nitrogen to nonprotein calories ratio ranged among : and : . only , % of the patients had their estimated caloric needs supplied and this goal was achieved only in those patients who were on enteral tube feeding. patients did not achieved their goals for vitamins. the supply ofoligonleme~s was adequate except the zinc. nutritional monitoring parameters including weight, serum albumin and serum triglycerides were performed in almost all the patients but without uniformity. the reevaluation ofthase parameters showed adequacy of protein and micronutrients supply; however deficiency in nutritional monitoring and infrequent enteral feeding were still detected. conclusion: there were lacks in the implementation of nutritional support, which were partially corrected in the rid phase of the study, although the training of residents may have contributed to give them cognitive skills, it didn't changed policies and procedures as desired. we recommend reinforcement of the education program concerning basic nutritional aspects, and the organization ofa multidisciplinary team in charge of coordinating the providing of nutritional support. plasme free fatty acids (ffa) are the meier energy source for mast tissues. during fasting ffa are released from the breakdown af triglycefides in edipose lissue (at). lipalysis, le. the rote of release o/ ffa, has been megsured in humans by means of stable isotope techniques using labeled pa or glyeerd as traces. no information is avoilob!e io dale on the ro of la. we infused albumin hound u c-pa and u c-la in critically ill infants, receiving kcel/kg/doy of iv glucose end na oral feeding (weight . ,i., kg;, range . - . ; ego : days, range ) and measured simultaneously the ra of pa and la from (he isotopic enrichment of plasma fea by gas chromatography-mass speclrome|ry ai : , : and : hours from tile shod of the infusion. a subcutaneous gluted at biopsy was obtained far fatty acid (fa) composition. we intended to ( ) in fie infants sbjdied atipa ~'os hi her than attla (~p<o.o )' and ihe ra of pa was higher then thai of la (~p= . §). however the ratio el the re's to the respeclive fa in at was higher for la than far pa (*p= . ). in conclusion the ra af la was higher then expected from ~he fa composition of at. we speculate [hat la is preferentially released during tipolysis and its contributuion to the energy metnbolism of the sick infonl could io !orger than what: is normai!y assumed from ihe fa composilion of at and of plasma fea. preoperative starvation can be prevented in infants undergoing non gi surgery by continuing feeds till as long as it is safe to do so. some gi disorders require withholding of feeds for a long period. for these and for infants already suffering from pem~ parenteral feeds are given preoperatively. peroperatively nutrition is maintained by ensuring adequate glucose supply in the infusion fluid and its smooth metabolism. proper placement of feeding tubes are also carried out peroperatively. postoperative early resumption of oral feeds is ensured by new techniques of anaesthesia and pain relief and methods to ensure early return of peristalsis. enteral feeds of pre digested substances and feeds through transanastomotic tubes and through gastrostomies and jejunostomies can prevent starvation in many situations. parenteral feeding is carried out only when enteral feeding is not possible, for example in necrotising enterocolitis~ gastroschisis, short gut syndrome, high enteric fistula and acute pancreatltls. the artedal ketone body ratio (akbr) is established as a valuable tool in the management of adult patients undergoing surgery for severe liver disease.the redox theory emphasises the central role of the liver in preserving homeostasis and the importance of the hepatic mitochonddal redox potential (nad+/nadh) in monitoring liver function and integrity.the akbr (plasma acetoacetate/ hydroxybutyrate) is a measure of hepatic mitochonddal redox status, reduced ratios associated with poorer outcome. the venous ketone body ratio (vkbr) is influenced by peripheral ketone utilisation and therefore thought unreliable in assessing hepatic redox its use has been dismissed as no correlation with the ratio in hepatic venous blood was found. inspite of this. vkbr is used in the diagnosis of lactic acidoses and respiratory chain defects. the objective of this study was to determine the relationship between the akbr and vkbr in a paediatnc intensive care population. children admitted to the paediatdc intensive care unit, with indwelling arterial and central venous lines as part of their routine care, were recruited for the study. the median (range) age was . years ( - . years) with prism score ( - ), simultaneous akbr and vkbr were measured. suppression of ketogenesis was confirmed using a rapid -hydroxybutyrate strip test (ketofilm, genzyme diagnostics) pdor to sampling. the median vkbr . (range . - . ) was lower than median akbr . (range . - , ), there was good agreement between artedal and venous ratios, bland-altman analysis giving a % confidence interval for relative bias of - . to - . . there was a significant correlation between vkbr and akbr r , , p, . (intercept . , slope , ) conclusions; values for akbr tend to be higher than vkbr, however there is a consistent relationship in critically ill children. in paediatdc patients in whom ketogenesis is suppressed, vkbr may be considered equivalent to akbr. this simple test may prove to be a useful adjunct in predicting mortality in cdt{cally ill children. to understand the present status of pediatric intensive care in china, we conducted a survey between october and december, , involving hospitals in provinces and municipalities. the results showed that there were totally icus for pediatric patients, including pediatric icus (picu), neonatal icus (nicu) and pediatric surgical icus (sicu), with total of beds. the physicians to bed and nurses to bed ratios were : . and : . respectively. the average number of equipment per bed was . ventilator, . multi-fnnction monitor and . infusion pump. very few of the icus had portable x-ray machine, biochemical and blood gas analyzers, and hemodialysis machines. the most frequently treated diseases/conditions were pneumonia, intracraniat infections, post-operation and sepsis in picus, and neonatal pneumonia, hypoxic ischemic encephalopathy and sclerema in nicus. pneumonia and respiratory failure accounted for . % and . % of all the diseases/conditions treated in the icus and the mean case fatality rate of respiratory failure was . %. the results of the survey suggest that there is shortage of tcu beds and modern equipment, and treatment is often delayed due to excessively strict criteria for mechanical ventilation. a set of simple, and nationally acceptable criteria for evaluation of severity and cure of the diseases/conditions is urgently required. the medical reports of children were reviewed and each admission was analysed in terms of age, sex, diagnosis, management within the hosp~al, length of hospital stay and type of poisoning. the youngest age was days and the oldest was years. hundred and twelve ( . %) of the children were girls and ( . %) were boys. the most common ( . %) reason of admission was intoxication among all of the cases and the greatest group ( . %) of the poisoned children had ingested medication which was followed by another group of patients ( . %) who had eaten mushrooms. the peak incidence of drug ingestion was salicylate intoxication ( %). forty drug poisoninigs were accidental while was intentional. the majority ( . %) of the cases that committed suicide was between and t years old, and the main cause of suicide was being unsuccessful at school. we conclude that poisoning -especially salicylate intoxication -is still a major problem in turkey and we believe that emphasis on the need to stere all kinds of drugs in a secure place and re-examination of a chin resistant packaging should help to reduce childhood poisoning significantly which is a preventable condition. included were all patients who died in the hospital, except those treated in the neonatal icu (predominantly premature and sga newborns) and those who died in the emergency room. among a total of hospital admissions (excluding the neonatal icu and emergency room), patients died ( . %). of these patients ( %) died in the pediatric icu, ( %) in the ward and ( %) in the operating room. a chronic underlying disease was present in ( %). withholding or withdrawal of therapy was implemented in ( %) children, ( %) died due to failed cpr, ( %) were brain dead and ( %) died following a dnr order. justification for therapeutic restrictions in the patients of the dnr and w/w groups was imminent death in ( %), lack of future relational potential in ( %) and excessive health burden in ( %). withdrawal or withholding of therapy was carried out by extubation in %, vasoactive drugs were stopped in %, and mechanical ventilation was withdrawn in %, analgetics and sedatives were frequently used (in % and %, respectively). hence decisions concerning restrictions of treatment are common in pediatric practice, mostly due to imminent death. patients in which treatment was restricted were characterised by a longer hospital stay, a worse prognosis, a higher frequency of chronic underlying diseases and a lower acute mortality risk. despite restrictions of intensive therapy, most patients were allowed to die in the pediatric icu. background microalbuminuria (mca), a subclinical increase in urinary albumin, reflects glomerular and overall vascular permeability " . an increase in urinary excretion of albumin occurs after burns and trauma. transcanillary albumin escape rate is also increased in response to elective surgery and in critically ill adult patients . we investigated a possible relationship between urinary albumin levels and clinical instability, as measured by pediatric risk of mortality (prism) scores. method we studied consecutive patients (median age of months, range - ). patients whith nephropathies or any abnormality of urine analysis were excluded from the analysis. prism scores, mca (mg. - ) (immunonepbelometric) and urinary creatinine (cu) (mmol.l -!) (jaffb) ( hour collection sample) were determined within hours from admission to the picu. the mca/cu ratio (mg.mmol. "l) was used to correct for urine output variability. diagnoses included respiratory failure ( ), postoperative ( ), neurologic ( ), sepsis ( ), trauma ( ) and miscellaneous cases ( ). pearson's correlation was performed to correlate data. results and conclusions. mean prism score and mca/cu were . ± . sd and - sd, respectively. a significant correlation was found between mca/cu and prism scores (r= . , p< . ). our observations show that, independently of the initial insult, the paediatric unstable patient may have increased capillary permeability, which is correlated with the degree of physiological derangement, as measured by prism scores. microalbuminuria can be rapidly determined since it is routinely used in the management of diabetic patients, it is inexpensive, simple to measure and blood-spearing. therefore, it might have a role in the clinical assessment of capillary permeability and transcapillary albumin escape worldwide the demand for paediatric intensive care services exceeds the supply. in developing countries sporadic access to such services alters expectation of care and can lead to children being either mechanically or handventilated in general paediatric wards. the outcome of children requiring ventilation in a major teaching hospital in india was reviewed.children were ventilated on an adult intensive care unit (aicu) if a bed was available, otherwise in the general paediatric wards. over a year period children were ventilated on aicu with deaths. yearly mortality rates varied between - %. over a month period patients were ventilated on the paediatric wards. of the p~tients over weeks of age died (chi squared .t >p> . ) reasons for the higher mortality rate on the paediatric ward likely include the higher patient:nurse ratio, and more limited resources. a predictor of mortality based on simple physiological observations without the need for expensive blood tests and including chronic health status would be a useful tool. the establishment of a paediatric intensive care unit is proposed to redress the balance of care. to assess the performance of the pediatric intensive care unit of hospital dona estef~nia by an international standard score, the authors did a prospective study of consecutive admissions to the unit during a period of months. mean age was . _+ . months; mean lengh of stay was . + . days. the effectiveness and efficiency were determined by the admission prism. admission efficiency was defined by two criteria: a) mortality risk > % or b) the administration of at least one intensive care unit-dependent therapy. the cumulative observed mortality was . % and the expected mortality was . %, with a standardized mortality ratio (smr) = . . the overall performance of the prism score-based predictive model was found to be good (goodness-of-fit test x [ ] = . ;p= . ). of patients admitted, combining the two criteria (icudependent therapy and mortality risk) an admission efficiency of ( . %) was found, equating to ( . %) of cu days. conclusion: in our study the assessment of the admission efficiency and of the effectiveness of the unit was possible by using the prism score of admission. there was no significant difference between mean values for otiss and ntiss)in level l patients (p= . paired t-test).for level and patients mean value of ntiss was greater than otiss (p< . ). there was a significant correlation between levels using either ntiss or otiss (mean difference level and , level and , ( p < o.oool). conclusions: a new tiss has been developed and used in a picu. nurses were able to accurately score the interventions on their shift. the assignment of patients to intensive care levels correlates with tiss values allowing a quantitative measure of severity. objective : to compare the rate of cerebral palsy (cp) between monochorionic-twins, dichorionic-twins and singletons born at to weeks' gestation. design : two-year prospective cohort study. setting : geographically defined study (region of franche-comt~., france). main outcome measures : type of plasentation was obtained by anatomopathological, or macroscopic examination of placenta and comparison of twins' blood-groups. neurological assessment was performed at two years of age (uncorrected for gestational age) by family doctor (pediatrician or physician), or neonatologist of the icu at tertiary center. sample : of i survivors aged of two years ( % follow-up rate), born between / / and / . triplets and chromosomic malformation were non included. results : thirteen ( %) of the singletons had cp.vs / ( %) of dichorionic twins and / ( %) of monochorionic twins (p= . ). four of the monochorionic twins ( %), / dichorionic twins ( %) and / ( %) nngletons suffer from quadriplegia (p< . ).in a multivariate approach, monochorionic twin placentation was the strongest risk-factor of cerebral palsy (or= . , ic % = a- , p< . ). others risk-factors of cp were : lack of father's profession (or , p< . ), maternal antecedent of abortion (or . , - , p< . ), vaginal delivery (or . , - , p< . ), hyaline membrane disease (or . , . -t , ~ . ). discussion : this is the first population-based study to uplight the role of monochorial twin-placentation as a strong risk factor of cp for premature infants. cp is more severe in monochodonic twins than in other infants. mecanism of cerebrat deficiency is not clear since none of our infants with cp was survivor of an in utero cotwin's death, and none of these infants was exposed to twin to twin transfusion syndrome. were these monochorionic-twins affected by an undiagnosed neurological structural defect that could lead both to prematurity and handicap remains an open question, a vital role of the intensivist is to ensure that knowledge and practice are imparted to trainees in the icu so that patients receive optimal care. teaching effectiveness varies widely leaving gaps in knowledge and practice in the trainee. being an effective teacher should not be a "gift" of a privileged few. the icu provides a fertile ground for using a variety of methods for teaching, e.g. didactic, at the bedside, emergencies, and in the performance ofproeeaures. in this environment, much can be learned. we have embarked upon a program to facilitate this learning process. i) teaching needs to be recognized as the foundation of good clinical care, i.e., patient related, and in its ability to generate discussion and research investigation. ) teaching structurally has many components including the speaker, audience, varying situations, and the message delivered. ) establishment of a program using these components to enhance teaching abilities at all levels, a) evaluate base-line teaching skills initially, b) individualize interventions to improve teaching skills, e) demonstration of learned skills with re-evaluation. this process is analogous to the analysis of a clinical disorder in a patient which, once recognized, interventions are then instituted and then re-evaluated. ) instill the desire to use these attained skills to teach and interest others to teach. teaching excellence should be recognized through awards, honors, and academic advancement. a major emphasis of this program is to provide participants with skills necessary to teach thought processes, decision-making skills (what to do, what to avoid) and implementing appropriate management during stressful emergency situations common to the picu. introduction: many" e-mail based discussion groups exist on the internet to provide medical professionals with a rapidly responsive medium for the international exchange of ideas relating to patient care. several such lists each serve more than a thousand professionals in more than countries, each distributing a dozen or more messages each day to every subscriber. there is very little known about the time being spent by professionals interacting with these lists, and very little known about the impact of the discussions on patient care. we wished to test the hypothesis that these discussion groups provide infortuation which is being used to change the care of individual patients and the general approach to patient problems. methods: in early january a pilot electronic survey was sent to a small fraction (n= ) of the memberships of e-mail discussion groups, picu@its.mew.edu, and nicu-net@u.washington.edu (the full memberships of both. groups (n=t for nicu-net, n= for picu) will be surveyed in early february of ). participants were asked for demographic information, experience and skill level relating to e-mail, time spent with the discussion groups, perceived usefulness of different types of discussions, and the ways in which the discussions were used clinically. the pilot study was analyzed for construct validity by correlating an overall assessment question with a summary of the specific questions. scale reliability was measured by cronbach's alpha statistic. results: the pilot survey response rate was ( %). the majority of respondents were male physicians, with an average age of +_ years, who had completed subspecialty training in intensive care, and were working at a university-affiliated hospital. most had been using e-malt for more than months, and considered themselves moderately adept in that use. % felt that the list helped weekly to keep them informed about current issues and practices in their field(s), and % felt that, at least monthly, they used information from the list(s) that was not readily available in medical journals. overall, % agreed that the list improved their professional competency. when asked to compare the value of months of membership on an e-mail discussion group with more traditional educational media, % compared it with attending a national conference, and % compared it to a journal subscription. cronbach's alpha was . , construct validity testing yielded coeff=. , p <. . conclusior~: internet-based e-mail discussion groups for health care professionals can be an important part of a strategy for maintaining professional competency. despite the very low cost of this medium for most, the value is felt to be comparable to that of t~r more expensive forums for education. further study will include distribution of the full survey in early february of . fronk shann, tony slater, gale pearson and the pim study group we have developed a new score for predicting the risk of mortality in children admitted to intensive care. the score is calculated from only seven variables collected at the time of admission to icu: mechanical ventilation (yes/no), booked admission after elective surgery (yes/no), the presence of any one of specified underlying conditions, both pupils fixed to light (yes/no), the base excess, the pao divided by the fio , and the systolic blood pressure. most scores used to predict outcome in intensive care require the collection of a large number of variables (so many icus do not calculate them routinely), and they use the worst value of each variable in the first hours in intensive care. this means they appear to be more accurate than they really are (about % of child deaths in icu occur in the first hours -so they are diagnosing these deaths rather than predicting them), and they blurr the differences between traits (a child admitted to a good unit who recovers will have a low score; but the same child who is mismanaged in a bad unit will have a high score -the bad unit's high mortality rate will be incorrectly attributed to its having sicker patients). pim was developed in the picu at the royal children's hospital in melbourne, and has been tested in six other picus in australia and one in the uk. objectives: to study the characteristics of the muhiorgan dysfunction syndrome (mds) in children. methods: a retrospective study with all the children with mds diagnosed from january to june is presented. children fulfilled the wilkinson criteria (i). in all of them the number of organs affected and the prims score were determined during the first hours. several groups were performed according to the clinical diagnosis, the hospital of origin and the order of organs affected. results: the subjects studied were an % of the pediatric intensive care unit admissions. of them expired ( %). no differences in age, sex and weight were observed between the children dying and the survivals. the most common causes of mds were sepsis, both nosocomial ( %) and medingococcal (i %) and acute respiratory failure. sixty-fivepercent of the patients were from the hospital wards and the remaining were directly admitted to the pigu from the emergency room. the systems affected were: respiratory ( %), cardiovascular ( %), hematologic ( %), central nervous system ( %), renal ( %) and (hepatic) liver ( %). the organs initially failing were: heart ( %), tung ( %) and central nervous system ( %). the children dying had a larger number of organs with failure than the survivors ( . v,s. . , p< . ).the prmis score was higher in the children expiring than in the survivors ( . v.s. , p < . ). s.mmary: the mds is a common pathology in picu, with a high mortality, the mortality is higher in children with a larger number of organs affected and a higher prism score. sepsis is the most common etiulogy. methods : from june ist to july th , all patients admitted to the pediatric icu were included. the score was measured at day (d ) and day (d ) and we used variables. for each organ system, we defined categories : dysfunction or failure, which we respectively confered or points. results : patients were admitted : newborns, children. were medical and were surgical patients. ( %) patients had two or more organ failure at the admission, ( , %) patients died, which ( %) in the first hours. the mortality rate was the same for children with two or more organ faiiure at d and d : / ( , %) at d , / ( , %) at d . the mean score is different for children who survived or who died : , versus , at d ; , versus , at . when the score is > , the mortality rate is significant. conclusion : in this study, there is a good correlation between the score of severity and the mortality rate but we have few included patients. we need a prospective multicentric study to assess these results and we must compare this score to other scores of severity used in picu. back.qround: injury to the central nervous system is the cause of death in the majority of pediatric trauma victims, studies have identified a wide range of factors associated with poor outcome from brain injury. however, when single features are analyzed, they are not sufficiently accurate predictors. few studies have used a multivariate analysis of these factors and pediatric outcome, methods: clinical and radiographic features of comatose children after traumatic brain injury were analyzed, clinical parameters, the initial cranial ct scan, and demographic characteristics were analyzed for an association with death or vegetative survival at months. a tree diagram in which risk factors may differ within the study subpopulations was constructed using recursive partitioning. results: chitdren with a motor score _< had an -fold increased risk of poor outcome compared to those with motor scores > . among patients with scores of _< , those with abnormal pupillary reflexes experienced a -fold increased risk of death compared to those with normal pupillary reflexes. among patients with a motor score > , an intracranial diagnosis code (no pathology, mild shift _< mm, swelling, shift > mm, surgical mass lesions, or non-operative mass lesions) was highly predicative of poor outcome at months. children with ct findings other than normal or mild swelling had a -fold increased risk of poor outcome. of children with swelling, shift or mass lesions, the pupillary light reflex was associated with outcome. children with abnormal pupils had a -fold increased risk of poor outcome. discussion: a few clinical and radiographic features stratified comatose children into fairly distinct risk groups. information available early after traumatic brain injury in comatose children provides useful prognostic information on the likelihood of death or devastating injury. a retrospective study of children with the diagnosis of epidural hematoma was made during - period. ages ranged between days and years ( % less than year, % between and years, and % older than years), % of them were admitted at the picu. % of the cases were due to falls, % to road traffic accident and % to other causes. on admission gcs was less than in % of the cases and more than in %. diagnosis was made during first hours in % of patients and delayed more than hours in % of them. neurologic impairment was present at admission in % of patients, and delayed in %. even so, % remained without impairment. radiological findings at first ct were skull fracture ( %); epidural hematoma localization was: in the right side ( %), frontal area ( %), temporoparietal ( %) and occipital (t %). associated lesions were: several ( %) or unilateral ( %) cerebral contusions, diffuse brain oedema ( %), unilateral hemispheric oedema ( %) and % showed shifted middle line. four patients died, half of them during the first hours. fully recovered ( . %) and have sequelae of different nature : were left with severe motor disability ( %); at the follow-up t have some degree of neurodisability. next datas keep correlation with death or neurosurgical impairment: only were significative multiple cerebral contusion (p= . ) and brain oedema (p= . ), gcs less than at the admission (p-- . ), shock (p= . ) and remaining cerebral contusion in control ct correlated with death or diasability at discharge. on the other hand, neither surgical drainage volume nor first or highest levels of icp ( cases),nor pupillary abnormalities ( cases) correlated with worse prognosis. conclusion: gcs equal or less than an shock are main factors related to worse prognosis, also multiple cerebral contusions in ct and diffuse brain oedema. the results of a modified gcs were compared to outcome and intensive therapy in children (mean age , t , years) with head and associated injuries ( , % of all cases) of different causes (traffic accidents, falls). the gcs was regularly used inn the course of intensive therapy. according to our own and other experiences the gcs was divided in stages: stage ( - points), stage ( - points) und stage ( - points) palhuiugy wile sp, tdhlg c~'lcb al blood ~ w. sabgcqucntl}. rhc slat,: rerltncd to t tl, iiltlils. the p st,~pem~v~ b}i~g wij!!,:q ! ,:_a!~p!ica!j n~:. ri~;¢ ill the level of sensibflizatjou lo tile cerebn~ anhgrns up to t. -o was flofcd iu i,alicnts. there wa.~ al~ iuclt~a~e ill cerebral vdociij,. ~m d~;'ati a il~ p¢fiphc~ai re~ista/isc of the large ce~'bral ve~ds. neur h;~c ~:yn'.pt,m~at !a~, (s::mno!en~', _r_uscu!~r l~:pot ni& !ryper*'flema) was nbserwed tu lt~ese pal~enls o. cbruc~l ~ nnds. rile ple~c.ut abse~vafion~ suggesl ihal die ~tttdy at" ihe stale ~f hematocr~chcplm/itic bm~ic~ in ckil&en with on emergensy is of abviou.~ !?ece~sib; in co~.te ctin g severe pa~ lo ~-i~mnediately f u wing ne ,:~per,'~fion. background: reconstruction of the heart by three-dimensional ( d) echocardiography provided new information on anatomy of complex congenital heart defects, we assessed the utility of d ultrasound in detecting morphological changes in cerebral anatomy in newborns before and after cardiac surgery. methods: transfontanel cross-sectional ultrasound, scans were obtained in standardized coronal and median sagittal planes. subsequently, rotational scanning was used to acquire the multiple sequential crosssections of the brain. for rotational scanning, a conventional mhz transducer was rotated degrees.scanning took less than one minute and required no sedation, data was stored in the image processing computer which allowed for off-line three dimensional reconstruction of different brain regions.twelve infants aged - (median ) days were assessed before and after cardiac surgery, results: cavity of lateral ventricle, choroid plexus and the periventricular brain parenchyma could be reconstructed in all. accurate estimation of size and volume of lateral ventricle, aqueduct, and other ultrasonographic visible pathological brain lesions could be performed. reconstruction of various brain areas was accomplished in - minutes. the localisation and extension of severe periventricular hemorrhage which was detected preoperatively in one infants was better visualized than in conventional ultrasonography. epicortical and subarachnoidal space could be reconstructed in all and allowed detection of hemorrhage in one case which was not detected by conventional ultrasound. conclusion: d reconstruction of different areas of the brain may provide additional quantitative information on size and volume of the internal ventricle and choroid plexus, and better understanding of the topographical aspects and the extension of intra-and periventricular hemorrhage than conventional cross-sectional ultrasound. introduction: intracranial cerebral blood has been estimated to be % venous, the invasive measurment of venous blood saturation in the jugular bulb provides quantitative information on cerebral oxygen supply and consumption. however, routine oxymetric measurement of blood saturation in the jugular bulb by insertion of a catheter line into the internal jugtdar vein is an invasive procedure which has limited use especially in infants and young children. thus the aim of this study was to investigate the correlation between the non-invasive spectroscopic measurement of rso and the oxymetric determination of the blood saturation in the jugular bulb in infants and children undergoing routine cardiac catheterization.. methods: during routine cardiac catheterization infants and children (age day- year, median , year) the rso was measured continuously using a two chanel cerebral oxymeter (invos a). the sensor was placed in standardized location at the left temporal head side. after the routine oxymetric blood sampling in the superior vena cava the oxymetric catheter was manupilated into the left jugular bulb. after control of the catheter position simultenuous values of the rso were documented. results: over a range of ( - %) sjo , a significant linear correlation was found between the spectroscopic measurement of rso and the oxymetric determination of venous blood saturation in the jugular bulb (r= , , p< , ) and the superior vena cava (r= , , p< , ). no significant correlation was found between rso and the arterial blood saturation in the descending aorta and as well as to the standared hemodynamic parameters. conclusion: meusurement of rso by mrs may provide continuous non-invasive information on cerebral venous blood saturation and thereby possibly on cerebral oxygen supply and consumption in infants and children. these may be of clinical value particulary during and immediately after heart surgery by means of non-pulsatile cardiopulmonary bypass. information on refractory status epilepticus (rse) from developing countries is scarce. we analysed cases of rse admitted over last yrs. the objective was to study etiology end evaluate efficacy of diezepam infusion. median age of the patients was . years irange . months to t . yrs); % were boys. onset of seizures was -t hours (median hours) prior to hespitalisation. the glasgow coma scale score ranged from . (mean+sd + ). the commonest underlying causes were acute cns infections ( / , %; bacterial meningitis, , encephalitis, ) and epilepsy ( / , %). oiazepam infusion in incremental dose (range . - . mg/kg/min) was used in patients over . _+ . days. seizures were controlled n ( %), mechanical ventilation was required in ( %)only, while none had hypotension; % patients survived. thiopental infusion (holus mg/kg followed by . mglkg/min, and increments of . mg/kg/min till seizure control) was used in patients over . _+ . days; seizure were controlled in all, but five patients needed mechanical ventilation, six developed hypotension needing infusion of vasopressoi drugs, out of ( %) died, overall mortality was %, mainly due to acute cns infections (n- ) and prolonged se. the patient was a -year-old gift di~aosed of dov,~'s s~drom¢, tetralogy of fallot. (t.f.) before admission a vasovagal crisis after coughing and vomiting was seen, and she was taken to the emergency room. mother said she had eyanosis in the mucous membranes of the mouth with exercise.on physical examination, she ~as afebrile, normal fundi and neurologic examination was normal. a harsh systolic murmur was hear~ with decrased intensity during bradycardia. chest rx disclosed a decreased pulmonary vascular markings. ecg: synus rhythm, with bradycardia and nodal escape rhyflmas. she was transferred to our picu because of severe h ,pertomc seizure, lost conciousness, and deeembrate poslamng~ ~t cyancx~is. the episode lasted for ~weral seconds, and ceased v~th diazepam. on admission she was lethargy, and neurologlc exammation showed weakness of left leg without babinski, and normal funduscopic. the patient had two episodes of bradycardia and isoproterenol was begun. during those episodes the patient was cyanotic, and the murmur was heard with the same intensity. act scan disclosed a tight parieto-temporai abscess with midline shift, lnmediately after the diagnostic ct, we administered antibiotics, antiedema treatment and it was drained. the abscess culture was negative. a ct control disclosed air and midlme shift. ~ the next two days she had three episodes of h oxia and c'yauosis ceased with o@gen, morphine and propanolol the patient died during a fourth episode. discussion: arrhytmias are uncommon in patients with tetralogy of fallot before surgery. in our case the first diagnosis was sick sinus syndrome vs bradycardia secondary to cyanotic episodes. the incidence of cerebral abscess in children with congenital heart disease (chd) is approximately %. tetralogy of fallot is the most common associated lesion, and is unusual in children under years of age. conclusion: ) brain abscess is a rare complication of patients with cyanotic chd, but should be suggested in patients with °'apparent" sick sinus syndrome. in patients with down's syndrome, t.f.,with cyanotic episodes, and difficult neurologic exploration, a brain ct scan is recommended. guillain-ba~re syndrome (gbs) is an acute autoimmune reaction, directed primarily toward the myelin encasing the peripheral motor nerves= this reaction causes a delay or block in nerve conduction. the presentation often can be very subtle but is followed by rapid loss of neuromuscular power, leading to acute respiratory distress, resulting from weakness of muscles and aspiration pneumonia. there were boys - , , and i i years old with gbs, treated in our icu. two of them due to the respiratory distress were intubated nasotracheally and ventilated mechanically with servo- ooc (siemens-elema, sweden) ventilator. duration of ventilation was i i and days, respectively. plasma exchange was performed in all cases. the numbers of plasma exchange sessions were - in each case. mean amount of plasma exchanged per session was , ml/kg. plasma was substituted with albumin, plasma or saline. the most important aspect of the management of patients with gbs in the icu involves the airway care, prevention and treatment of aspiration pneumonia and the mechanical ventilation if respiratory distress presents. endotracheal intubation should be performed whenever there is evidence of retention of pulmonary secretions, refractory to chest physical therapy, weakness of protective reflexes of the airway, leading to aspiration pneumonia and (or) atelecr~sis. cardiac arrhithmias too, is a main threat to the circulatory stability in gbs. therapeutic plasmapharesis has been shown to be beneficial, reducing the time for weaning from the ventilator and for achieving independent ambulation. however, plasma exchange is expensive and not without significant risks for the patient. some authors find that plasmapheresis is not effective for patients with fulminant course of gbs and blocking of nerve conduction. recent studies have demonstrated that intravenous high-dose immunoglobulin can be equally effective. there were no significant complications associated with plasma exchange. all presented patients survived without residual disability. tetraparesis associated with long-term paneuronium use in an infant. paneuronium is a muscle relaxant used in ventilatory management of patients with respiratory distress in intensive care unit. after the end of sedation some patients were found to have severe tetraparesis. paresis was accompanied by complete areflexia and diffuse atrophy of alt extremity muscles. this neuromuscular complication is caused by prolonged high-dosage pancuronium treatment. in the last years, numerous reports have linked the use of pancuronium bromide with prolonged paralysis, disuse atrophy and areflexia. this side-effect is well known in adults patients but rare in a pediatric intensive care unit. we describe one pediatric observation of tetraparesis after prolonged pancuronium treatment in a -month-old girl, this female infant developed respiratory distress syndrome and was intubated and mechanically ventilated. to decrease chest wall rigidity pancuronium bromide was administered during days. (she received approximately mg of pancuronium bromide). on day the drug was discontinued and the patient had severe tetraplegia and areflexia with normal head movements. electromyograpliy showed absence of any disorder of neuromuscular transmission. this infant showed a recovely of muscles after months. the other causes of peripheral neuropathies were eliminated. electroencephalograms and head scans were normal. the recovery pattern observed in our patient correspond to the process of regeneration after axonal degeneration. it is suggested that these neuromuscular complications were caused by prolonged high-dosage pancuronium treatment (associated with cortieoid and aminoglucosides). polyneuropathy syndrome in adult lc.u. appeared in literature in and is extremely common in long stay cases. the etiology of these disorders remains elusive. it is tempting to ascribe them to administration of drugs (muscle relaxants, steroids, aminoglycosidea), plolonged immobility, malutrition, sepsis and ischemia associated with reperfusion injury. to our knowledge there is only one case report of similar condition in a children i.c.u. (pascucci ) we present a serie of previously healthy children, aged months to years, who admitted in i.c.u with respiratory failure and who following weaning from m.v, remained in profound diffuse hypotonia with proximal and distal muscle weakness for various length of time, recovery of muscle strength occured in a week or months {the longest i months), all children, except one, - days before admission developed symptoms of either respiratory or upper airway infection with fever. on admission viral and bacterial cultures were positive in cases (haemophilus influenze, herpes virus). during treatment patients became septic. muscle histological and neurophusiological investigations have not been done. considering the multifactorial nature of the aquired nmd in adult critically ill pts, is impossible to attribute the muscle weakness of our pts to any specific cause, in conclusion, our findings suggest the need for further investigation of nmd in critically ill children treated in i.c.u. a van esch, ha van steen~l-m , ir ramtal, g derksen-lubsen, idf habbema. febrile status epilepticus (fse) is a prolonged and serious febrile seizure. little is known about the outcome of fse in neurologically normal children. this survey involved patients between months and years of age who had visited due to their first fse, the sophia children's hospital during the period of january till december . patients with a history of neurologic disorders were excluded. patients were identified, % were male. the cause of the fever remained unknown in % of the cases. in all case the fse was generalized and it most frequently occurred at night ( %). the mean age at fse was t. years ( . - . ), the mean temperature . °c ( . - °c). the mean follow up time was . year. twelve children ( %) had neurologic sequelea. the neurologic sequelae varied from speech deficit ( case mild, v - year delayed; case moderate > year delayed) to severe retardation and epilepsy ( cases). speech deficit was detected after a mean period of months (range - ), age, gender, temperature, family history and time of onset were no significant risk factors for neurologic sequelae. duration of seizure [rr . ( . - . )] and more than two drugs to treat fse (rr . (t. - . ) were related to neurologic sequelae. we recommend that fse children should be followed for at least a year to detect possible speech disorders properly and start early intervention. unusual presentation of myasthenlg gra%qs ibtza e. modesto ,v~ abe~gochea a, sanch]s l all, go l varas k folgado s, garcia e. p. .c.u. la fe, valencia. spain case report: the patient was a -year-o!d gift transferred to our pic because of severe respiratory failure. the patient, convaleseem of ehiekenpox, came into contact with horse manure previous afternoon. in the morning, she was lethargy, and irritability, with poor finding, and ~ an episode of coughing, cyanosis and acute respiratory failure after mucous vomiting when she was drinking milk. on admission she had severe respiratory distress, respiratory acidosis, and the sat was %. she was mtubated without difficulty, and was transferred to our p.i.c.u. physical examination reveals stable hemodynamies, pupils equal, round, reactive to light, normal fandi, and muscle relaxation. crusted vesicles diseminats~d. rhonehi over both lungs. hepatomegaly (+) and splenomegaly (+). ~lhe urine, hematologic, and c.s.f. laboratory findings were normal. c.t. scan of the brain, e.e.g., and ekg. revealed no'abnormalities. rx chest disclosed a retrocardiac atelectasis. speci~ts of stool and blood were obtained for cultures and study of c. botul#num toxins. pending receipt of these results, a broad-speotmm antibiotic and acyctovir was begun. the initial differennal diagnosis consisted of laryngospasm associated with aspiraqlon, botulism, and postmfecfious varicella encephalitis. after hours, weatm~ was begun. the neurologic examination showed a low modified glasgow coma ~ale (mgcs), generalized hypotouia and muscle weakness. these data suggested three diagnoses, posfnfecfious encephalitis, residual neuroumsoaar blockade, and excessive doses of sedative and analgesic drugs. after hours she regained skeletal muscle poxver and ufltlcient respiratory effort, the mcgs was acceptable, and blood gases were normal. she was given n~-tigmine and atropine, and her tr~ma was extubated. an acute respiratory failure ocurrs ram. after. chest radioga'aph disclosed a left inferior lobe atelectasis. after hours weaning begun~and the same episode w~as seen. at this point her mother stated that the girl showed weakness of the eyelids or extraneular muscles. it suggested myasthenic syndrome vs ~-barr syndrome. c. botul#num toxins were negative, chotinesterase level ~as normal. edrofoinum test ~as positive. anti-acetyleholine receptor antibodies were negatives. e.m.g. confirmed myasthenia gravis (congenital vs juvenile serenegative). pyridostigmine was begun and the trachea was extubated without complications. conclusion: din the differential diagnosis of weamng failure we must consider ~c gravis~ )myasthenia gravis could resemble encephalitis, because of low ocs, overall if is triggered by viral infection. )in some diseases (this case) gcs could not he an aemuate index of mental state. a burguet*, a menget*, e monnet**, a gasca-avanzi*, c fromentin*, h allemand**, jy pauchard*, ml dalphin*. * r animation infantile potyvaiente chu st jacques besancon cedex. ** d~padement de sant publique besancon cedex, france, objective : to point out that strabism is) of one-year-old premature is a good predictor of a poor neurological outcome at two years of age. design and setting : two-year prospective cohort study and geographically defined study (region of franche-comte, france). main outcome measures : neurological assessment was performed at one and two years of age (uncorrected for gestationnal age). a mailing questionnaire was sent to the famity and fuu-filled by thefamily doctor (pediatrician or physician), or neonatologist of the icu at tertiary center, s was diagnosed at one year of age by the examinator but s was not used to diagnose cerebral palsy (cp). sample : of survivors ( %) evaluated at one and two years of age. results : correlation of one and two years neurological evaluation is weak (kappa= . ). correlation of s at one year and cp at two year is fair (kappa= , ). the goal of this paper is to review evidence related to hypothesis that the "waiting" axons and cells of the transient subplate zone may participate in the structural plasticity of the human cerebral cortex after perinatai brain damage (kostovic et al, metabot brain res : , t ) and to correlate this phenomenon with different forms and mechanisms of structural plasticity. it is our basic assumption that all lesions occuring during cortical histogenesis will lead to more or less pronounced structural reorganization. here we show that various components of the subplate zone participate in several forms of the structural "plastic" responses in the human cortex: modification of convolutional pattern, changes in size of cytoarchitecturat areas~ columnar reorganization, dendritic and synaptic plasticity. the etiological factors which induce lesions and subsequent plastic changes act via the following pathogenetic mechanisms: * disturbances of radial unit formation (rakic); * changes in ingrowth of afferent fibres; * changes in the rate of normally occuring reorganisational events, depending on the critical period for a given histogenetic event. in the present study developmental lesions (localized perlventricular leukomalacia and haemorrhages) were demonstrated by ultrasound in live-born infants ranging between to weeks of gestation. in younger infants ( - w) who died shortly after birth, examination revealed lesions of the white matter with the preservation of the subplate zone. in infants who died one week of more after the lesion, we have observed localized micropolygyria, cavities, condensed layer vi -subplate zone, and columnations of the cortical plate. these changes are less prominent if the lesion occurs after diminishment of the subplate zone (after w). since in the fetal cortex the subplate zone serves as predominant source of growing fibers, transient neurons, trophic factors and contains cellular substrata for migration, this zone is the most likely candidate for major types of structural plasticity. in conclusion, cerebral cortex of the low -birthweight infants is more susceptible to the various lesions but shows vigorous structural plasticity and conspicuous functional recovery due to the growing, transiently located neuron at elements. the mortality due to meningoccocal sepsis is high in spite of important progress in emergency and intensive care medicine. during the last decade multiple scoring-systems have been developed in order to establish a therapeutic approach and to evaluate the final outcome of a meningococcal infection. different clinical and biological data (shock, ecchymosis, peripheral wbc and platelet count, coagulopathy, acidosis, meningism, etc) are taken into consideration and the importance given to these data depends on the scoring-system used. a review of the different scoring-systems is given and a clinical case is presented. we report the case of a year old male, who was transfered to our icu hours after onset of temperature and skin rash. the parents described a fast deterioration of his condition. the boy presented wide spread ecchymosis, high temperature, no signs of meningism, circulatory insufficiency and shock, coagulopathy and low peripheral wbc and platetet count. disseminated intravascular coagulopathy developed promptly. the glasgow meningococcal septicemia prognostic score (gmss) was used and the obtained score reached the highest level ( / ). this corresponds to a % mortality. the patient required mechanical ventilation for days. at admission he received human albumine, fresh frozen plasma, dexamethason, dopamine, dobutamine and a continuous infusion of adrenaline. antibiotical treatment consisted of ceftdaxone. the evolution was favorable and the infant fully recovered. retrospectively the gmss was compared to other meningococcal scoring scales which gave the same mortality ( %). we conclude that the scoring-systems are important to evaluate the seriousness and to assess the therapeutic approach, but they should be used cautiously even when % mortality is predicted by several risk evaluations scoring-systems. the aim of this study was to assess the haemodynamic status on admission and the critical care management of children presenting with meningococcat infection. this was a retrospective study of the charts of consecutive admissions. mean age was . years (+/- . ). the average duration of symptoms prior to admission was . hours (+/- . ). on admission . % were hypotensive, . % had clinical signs of haemodynamic instability and . % of cases that had a blood gas analysis on admission had a metabolic acidosis (bases excess < - .q): the mortality rate was . %. % of patients that died were hypotensive on admission and all had a metabolic acidosis. of the survivors . % were hypotensive on admission, % had clinical signs of haemodynamic instability, % required invasive pressure monitoring and . % were ventilated and received inotropic support. this study demonstrates that at the time of presentation with meningococcal infection children had a high incidence of established haemodynamic instability. successful management of this infection is dependent on early presentation and initiation of therapy and on aggressive support of the cardiovascular and vital organ systems. dept. of intensive care medicine and dept of infectious diseases, our lady's hospital for sick children, crumlin, dublinl , ireland. jude. pediatric intensive care unit, ch&u, lille-france. more than % of children surviving sip (defined as purpura with shock) have snli. objective. to search for a specific hemostatic profile in children with snli. patients and methods. between may and march , children with sip were admitted to our picu : ( . %) died and ( . %) ranged in age from to months (mean : ) survived, of them ( . %) with snli (defined as the need of a surgical procedure). in survivors, two hemostasis studies (between h and h , and h later) included the determination of coagulation factors (routine tests), protein c (pc : amidolytic activity, biogenic), total protein s (ps : elisa, stago), c b binding protein (c bbp : laurell's technique, stago), antithrombin (at : chomogenic test, stago), and plasminogen activator inhibitorl (pail : chromogenic test, biopool). three severity scores were determined at admission : french group of pediatric intensive care, gedde-dahl, and crp. statistical analysis used the wilcoxon's test. results. at admission (lst sample) severity scores and at , pc, ps, c bbp levels were not different between the group with snli and the group without snli ; quick time ( - % vs ± % ; p = . ), vti+x ( . % vs - % ; p = . i) and pall ( - ui/m! vs . ui/ml ; p = . ) were lower in the group with snli. on the nd sample there was no difference between the two groups. kinetics of hemostatic abnormalities was not different between the two groups. conclusion. in the literature, intravascular coagulation (dic), low fibronectin and at were identified as predictors of snli, and a negative correlation was found between the mean size of the skin lesions and pc activity, at , and total ps. in this series, apart from dic, there were no specific hemostatic abnormalities that support the use of treatments such as pc, at , and pail antibodies administration to prevent snli. further studies including more children are needed. the aim of study was to investigate the efficacy of intravenous immunglobulin with enriched igm content pentaglob/n /biotest/. in our pediatric intensive care unit ten septic children /group i/-their average age , years /sd:o, /, of them with gramm negative and one with gramm positive blood cultures, and two with unindentified bacteria-were treated with basis sepsis therapy and pentaglobin. the application of pentaglobin was as follows: , ml/kg loading dose for one hour, followed by a continuous intravenous infusion , - , ml/kg/hour depending on body temperatura /lanser scheme/ for - hours. another ten septic patients /control-group ii/the mean age , years/sd:o, /, their blood cultures were gramm negative bacteria , positive , and the bacteria was not indentified in two cases -were treated with only the basis therapy. results: the duration of intensive treatment decreased from an average , days /sd: , min -max days/ to , days /sd: , min -max days/ in the group treated wit pentaglobin. the difference was significant /x p< , /. in the group i nobody died, but three in the group ii. conclusion: the pentaglobin therapy can improve the efficacy of the basis therapy of sepsis. sinus bradycardia after an episode of sepsis is a rare symptom complex decribed in children with hematologic malignancies. we present a case of postsepsis bradycardia following severe typhlitis and septic shock in a year old boy with relapse common all. blood and ascitic fluid specimen grew clostridium species and pseudomonas aeruginosa. at surgery there was a necrotic gangrenous terminal ileum and cecum, requiring ileocecal bowel resection with ileostoma. while clinically recovering from sepsis he developed bradycardia for hours. extensive diagnositic procedures was given and the heart rate slowly increased to normal range of age. postsepsis bradycardia in children with hematologic malignancies after an episode of sepsis is self-limiting and after careful differential diagnostics warrants an expectative attitude. nitrate level is known to be enhanced during sepsis. serum nitrate is the stable metabolic end-product of endogenous nitric oxide generation. nitric oxide has demonstrated to be a powerful anti microbial final mediator and also a key molecule driving to the lethality of one of the most common complication of sepsis; the endotoxic shock. such facts prompted us to investigate the possible diagnostic and/or prognostic value of monitoring serum level in high risk, presumptive and confirmed sepsis patients. additionally we have explored the usefulness of this mediator as index of therapeutic response. in our study it is demonstrated that there is an important relationship between nitrate level and the occurrence of neonatal sepsis. septic newborn group showed fold higher nitrate level than that of healthy control group. in addition, the group of patients with high risk of sepsis which finally became septics, exhibited fold higher nitrate level at - hours before the first symptoms appeared, when compare with those who did not develop sepsis. however in the presumptive sepsis group, there was no difference between the patients which finaliy ,&'ere considered septics and those which not. in all septic cases, after days of a successful therapy with antibiotics, the level of nitrate diminish fold. our results suggest the utility of monitoring nitrate as index for the diagnosis of neonatal sepsis. the potential benefits of exchange transfusion, plasma exchange, and haemofiltration have all been described in children with overwhelming sepsis. however, little hard evidence exists to prove the benefits of any of these techniques. i have treated five patients with plasma exchange (pe), having been asked to see all these patients at a point when it was felt death was inevitable. two of the patients had staphylococcal, two meningococcal and one enterococcal septicaemia. all patients showed a dramatic haemodynamic improvement following pe with improvement in blood pressure, reduction in inotrope requirement and improvement in tissue perfusion. three patients survived. one of the patients with staphylococcal sepsis and both of the patients with meningococeal sepsis had developing gangrene of the limbs which showed remarkable reperfusion with pe. in two of the patients measurements of cardiac output (co) and systemic vascular resistance (svr) showed ~a reduction in co and a rise in svr over the course of a pe despite the reduction or cessation of vasoconstricting inotropes. many believe haemofiltration is of value in septic shock. a trial with a no treatment limb is difficult to achieve. i believe we now have enough evidence to justify a controlled trial of haemofiltration versus plasma exchange in patients with septic shock and unstable haemodynamic status whilst on inotropic support. during the next several days, cough and chest pain suggested pulmonary embolism confirmed by radiologic evaluation. echocardiographic examination showed multiple thrombosis of the superior vena cava, right atrium and ventricle and pulmonary artery. estimated protein c level was . % (normal range - %); identical deficiency was found in patient's mother and elder sister. cvc was removed, and alter -month heparin therapy and supstitution of protein c with fresh frozen plasma, there was almost complete thrombolysis of the great vessels and cardiac chambers. we conclude that invasive diagnostic and therapeutic procedures in such patients may result in higher risk for severe thrombosis at unusual sites, and numeuos further complications bronchopulmonary dysptasia (bdp) is a chronic pulmonary disease of preterm and term babies treated with mechanical ventilation for respiratory problems of different origin and requiring oxygen therapy days after birth. bpd is a disease affecting the growth and development of pulmonary tissue. such pulmonary }esions heal by squamous metaplasia leading to scar formation and fibrous tkssue r~growth, the pediatric intensive care unit makes the survival of babies w~h very low birth weight ( - g) possible. with the increase in their aulyival, the number of complications in low birth weight babies increases as well. bdp is a very serious complication. therefore the importance of early diagnosis and treatment of bdp must be stressed in order to reduce the consequences. babies with bdp must be under medical suveillance for at least years as the disease needs at least that long for complete resolution. tn the icu of pediatric department at madbor teaching hospital: during the past two years ( - ) newborns were treated with mechanical ventilation. the neonatal and postnatal death rate of all newborns admitted to our icu was , %o.ln the two years from to , newborns were admitted to our icu ( %~ of all newborn babies at maribor teaching hospital), with birth weight - g. in the icu, the survival of these babies and parallel to it the number of complications is increasing. during the mentioned -year period, babies with very low birth weight ( - g) survived: in and in t . in - %, first or second stage bdp was treated,there was no case of third of fourth stage bdp. the treatment consisted of eary removal from mechanical ventilation, oxygen therapy~ intensive treatment of infection, volume and caloric intake contro}, corticosteroid treatment throught weeks with decreasing doses, diuretic end antioxydant therapy. the children are to be reevaluated at the age of and months and again at i and years. oeure j van der, markhorst do, haasnoot k department of pediatrics, pediatric intensive care unit, free university hospital, amsterdam, the netherlands. case summary a %-month . kg girl of african origin was admitted to the pedfatric irtensive care unit with pneumonia and progressive respiratory irlsuffjderey. she was intubated and ventilated by pressure regulated volume controijed ventilation (servo c, siemens, soma, sweden). maximum conditions were inspiratory minute volume . l, peep cm h~o ahd % ~. chest x-ray showed bilateral interstitial consolidation. material obtained by broncho-alveolar lavage showed preumocystis car}nil htv-serology (elisa and westerll blott) and p -antigerl were positive, confirming the diagnosis of pediatric aids. she was then treated with high dose co-tllmoxazoie, penthamldine, z{(~ovudire and steroids iv. because of thee x-ray features, high need for o ( %, pad mm hg), not responding to elevatiofi of peep (max cm h=o) and pao /fio = < (s ). m acute respiratory distress syhdrome (ards) was diagnosed. because conventional ventilation (cv) failure, hfo-v ( ooa, serisor medics,yorba linda, ca) was initiated. starting mean airway pressure (map) of cm h~o was based or map of the cv, oscillatory pressure amplitude (dp) of was, at ii~itial frequency of . hz, adjusted ur~til chest wall vibrations were visible, it was required to raise map to cm h and dp to before optimal lung volume and ventilation were achieved and need for o reduced within hours, this was monitored by frequent blood-gas analysis and chest x-rays. map and dp could slowly be reduced, after a good response the first day, gradually demand reduced and the patient could be weaned from the ventilation. map, dp, fi and oxygenation index (map x pa ~jfio ) are shown in table i. chest x-ray follow-up showed gradually improving lung features, with marked improvement of aereation. after days hf -v she could be succesfully detubated when a map of cm h was acmeved. results : sianificant increase in ventilato~ rate and mean airway pressure was noticed after the change to savi. no differences in oxygenation, co partial pressure and systolic, diastolic or mean blood pressure between imv and savi periods were noted. in infants however an improvement in pao /p .ol/ and decrease in paco was observed after the switch to savi. these babies had a lower initial a/a oxygen tension ratio and required higher initial ventilator rate /p<o. / in comparison to the rest of the studied patients. conclusion:infants with low a/a po ratio who need high initial ventilator rate are likely to obtain benefit from savi.. fumimare hatori, haruo uchida, masao katayama, and rika muto department of anesthesia and critical care medicine chiba children's hospital, chiba city, japan. purpose: this study was made to find out whether the heat and moisture exchangers (hme) was effective enough to humidify in the respiratory management for children. patients: the study population consisted of patients who were provided with artificial airway. they were divided into the two groups: ii with heated humidifier (a) and i with hme (b). methods: hme could be used for those without pulmonary complication and with less leakage around the endotracheal tube. in both a and b groups, (i) we have measured relative humidity, temperature, and absolute humidity at the endotracheal tube connector. for these measurements, humidity sensor system was utilized. ( ) any troubles and complications caused by the artificial airway were investigated. results: (i) in group a, we confirmed the mean values as the relative humidity of . %, the temperature of . ~c, and the absolute humidity of . mg/l. in group b, they were . %, . °c, and . mg/l respectively. no difference was noted between the two groups as to the relative humidity, but the temperature and absolute humidity were lower in group b with a significant difference (p< . ). ( ) in neither of the groups, any respiratory complications such as obstruction or stenosis of the artificial airway were noted. in pediatric icu, hme can be used without any problems under given conditions. titei: objective: evaluate the precision, reproductibility and aplicability of a new device to measure auto-peep in pediatric patients during mechanical ventilation. material and methods: it's an electromc-pneumatic eontolled device with an oclusion valve and a pressure monitor installed between endotracheal canulla and the ventilator circuit. the measurements were performed with a sollenoid conected with to the ventilator to detect the end of inspiration phase and the actwation of the oclusion valve. the signs of pressure and flow were moniturized using a difere~rtial transducer and it was processed using a pc computer and a pneumoviaw® software. the auto-peep also displayed in the ventilator pressure monitor. results: we submitted children with neuromuscular disease or respiratory distress in this study. the incidence of auto-peep was %, with variability between , to cmh . all the measurements were performed times to verify the precision and the reproduetibility and evaluation of the pressure and flow curves. conclusion: the device is low cost, easy to use and can be used without the pneumotacograph. the auto-peep measurement can be done during mechanical ventilation with time cycled, pressure limited and continuous flow, the most commom ventilator used in pediatric patient. resistance was modeled by endotracheal tube (ett) sizes ( . , , , ), and compliance by test lungs ( and ml/crnh ), for each resistance -compliance arrangement, we measured tidal volume (vt) at various frequencies, peak to peak (p-p) and mean airway pressures. results vt increased when ett size increased with all ventilators in accordance with fredberg results (jap, ; : - ) . the maximum vt delivered was smaller with the hfv-babyiog than with the ohf or the sm a at a given frequency (figure on the left). increasing p-p resulted in a linear increase in vt delivery in the - % range of maximum p-p (figure on the right). hfv-babylog didn't provide significant vt increase when p-p was set above % and vt deliven/decreased when mean airway pressure decreased. --i ~ sm a a number of ventilatory parameters had been analyzed with russia-produced monitor humitemp htm (servisinstrument j,-s. co) in newborn infants with rdsn of t-iv stages on cmv, cppv, imv, and cpap steps using respirators of various kinds (stephan-staxel, bear- , newport rezee, sechrist). parameters investigated were: temperature of inspired mixture (t), relative and absolute humidity (rh and ah, respectively), static compliance (c), expired tidital volume (vte), expired minute volume of ventilation (mve). the monitor read these parameters in following ranges; rh-from to %; ah-up to mg/i; mve-up to . i/mini vte-from to ml; t-accurate to %; c-from . to t ml/cm h . continuous monitoring time ranged from to hours, it was noted, that during this time the monitor and transducers had no malfunctions, and it's using didn't require additional calibration, it was found, that humidifiers mr and mr (fisher, paykel) couldn't maintain parameters t and ah continuously (these values varied from , to . c and from , to . mg/i, respectively, when heating regulator position was unchanged). changes of parameters c depended clearly on cppv conditions and rdsn severity (with rdsn of stages i-ii c value ranged from . to . ml/cm h ; and with stages iit-tv-from . to . ). tn newborn suffering from rdsn of stages ii-ltl and ill-lv with pip> mbar, fi > , , peep= - mber, c-from . to . ml/cm h , effectivity of exosurf therapy was studied. in newborns in - hours of therapy pip decreased to . - . , and c increased to , - . ml/cm h . in newborn infants with aad > mmhg and c from , to . mltcm h positive effects of exosurf on lung compliance were not observed. in newborns the monitor had revealed decreased of c (from . - . to , - . ml/cm h ), manifested clinically by pneumothorax. in general, monitor htm made possible; ), to estimate the adequacy of cmv-parameters and regimes in newborn infants; ). to select optimal t and ah values in the respiratory outline in dependence on lung damage severity and infused volume; ). to reveal rdsn severity; ), to optimize indications and adequacy of surfactaot therapy; ). to diagnostieate the air leakage syndrome; ). to effects to some agents (broncholytics, spasmolytics); ). to obtain objective indications for imv/simv and cpap regimes. albano communication is an important aspect of human development and existence, and an inability to vocalise can be a problem in ventilatordependent patients. we present our experience with speaking aids as a means of enhancing verbal communication in four ventilatordependent children in our paediatric intensive care unit. the age of the children ranged from months to years, and the period of ventilation ranged from months to months via a tracheostnmy. they require continuous flow generated pressure limited or control ventilation at rates of - bpm. the reasons for ventilation include tetraptegia following a shrapnel injury; tetraplegia following congenital cervical spine damage; tetraplegia following atlanto-axial subluxation; and critical illness polyneuropathy following adult respiratory distress syndrome from prolonged ventilation for a severe head injury. the first three patients have passy-mnir one-way speaking valves and the final patient has a bivona foam cuffed tmcheostomy tube with a talk attachment in view of recurrent aspiration. an improvement in quaiity of speech has been shown by independent assessment. we will review the present literature on this subject and discuss the advantages and disadvantages of these two types of speaking aids in the light of our experience. the prognosis of antenatally diagnosed cdh is closely related to the degree of ph. there have been attempts to correlate antenatal or postnatal criteria to mortality: none have been demonstrated to be predictive of lethal ph. the aim of this retrospective study was to determine whether antenatal or early postnatal data could correlate with the findings of post-mortem examinations. patients and methods: between july and july , cdh patients have been antenatally and postnatally managed at our institution. twentythree infants underwent a post-mortem examination. ph was assessed by using the lung weight to body weight ratio (lw/bw) and the radial alveolar count (rac). antenatal results: cdh diagnosis was made at weeks of gestation (wg) ( - ). twenty-eight patients had a left sided cdh, had a right sided cdh, and one had a bilateral cdh. herniated organs were stomach none (n= ), or liver alone (n= ), or both stomach and liver (n= the patient was a -yenr-old girl with chronic renal insufficiency see~ to renal dysptasm, two months before admission a kidney trar~ptant was performed. one morah later she showed acute graft rejection with serum ereafinine (cr) level of . mg%. the rejection was unreslxmsive to an increased steroid dosage, and okt was begun with resolution of the rejection. one week arer, new rejection episode was seen marestxmsive to an increased steroid dosage, and transp~ ~s performed five days before admission to our ptc. hemedialysis and peritoneal dialysis (p.d.) each other day, was indicated (g.r.f.< ml/rnin). four days before admission t ~ rose to °c. "lhe diagnosis of opporttmistic pneumoma was made on the basis of tach ,pr',e~ hypoxi~ and diffuse interstitial infiltrates. senma ~ was positive for cytomegaloviras (cmv), and stool culture for c albicans. pentamidine, ganciclovir (dhpg), arai-cmv gamma globulin, eritromicine and amphotericin b was administered. on admission in our picu, trachea was mmbated, (a-a) o gradient was , paofffio~: , lung injury score > with peep level of cm hzo. she had normal fiver function. during te next days she had fever and developed ards. bal was negative. p.d. was of little efficiency. we adjusted pentanfdine, and dhpg doses for severe renal failure, with supplements after hero, sis, and at~rp.d.. during ~ next days she was afebrile, and the chest became radiologlcally normal. after ten days on menhani~al ventilation (mv.), the patient was extubated. cr. level was . rag%, (a-a) oz gradient was , and paoyfioz was , the patiem was discharged with chronic ambulatory p.d. discussion: opportunistic pneumonia is a major complicalaou in imm~romised children, specially after kidney tvansplaraafion. c m.v. infection can result at~r okt administration. in the treatment dhik} dose must be adapted to the degree of renal insu~cieney, with supplements after hemedialysis, and after pd. pneu~y~tis cann# tmeumov~ is ehemeterized by ventilafion-perfusion mistmaeh, decreased pulmonary compliance, hypoxia arld elevated (a-a) oz gradient, with diffuse interstitial infiltrates. in our ease bal was negative. although we did not find the etiology the prevoclons eombh~ation of arairmcrobiat therapy, along with m.v., and supportive measures were the most effective trealme~. conclusion: ) in patients with severe renal failure and life-threatening infections, we must co~ider drug adjuslments. ) in our patient we gave dhpg supplements at~r pd. with excett~at results, although p.d. was of little effiele~. introduction: endotracheal intubation and mechanical ventilation have become an important treatmem for many diseases accompanied by respiratory failure. with the frequent use of this treatment modality, an increasing number of complications associated with endotracheal intubation have gained clinical significance. material and methods: a transversal study was realized to find the prevalence of pulmonary aspiration with endotracheat tubes in infants and children. aspiration was assessed by applying two dyes (evans blue, er)¢rosine sodic) on the tongue and searching for the dye during suctioning in the endotracheal aspirate. the factors, that potentially have influenced the aspiration, including weight, age, sex, cause of respiratory failure, main pressure airway (map), level of consciousness, presence of swallowing and body position were evaluated. all the variables studied had their association with aspiration tested by chi-square method with relative risk considering a confidence interval of %. the results were adjusted by multivariate analysis. results: the overall prevalence of aspiration was . %. among all children who aspirated, compared to those who did not, there was a statistically significant difference in the presence of swallowing (p= . ). the odds ratio to aspiration in the presence of swallowing was . (t. - c.i. %) and the relative risk . . aspiration was not significantly affected by sex, weight, age, cause of respiratory failure, map, level of consciousness and position of the body during the ventilation. conclusion: the endotracheal intubated children frequently aspirate as intubated adults and that preventive measures are ineffective. the presence of swallowing movements is the main risk factor to aspiration of oropharingeal content in intubated patients. clinical features and shortterm outcome skling, rp gie pneumonia is the second most important cause of death in young south african children. the clinical features, intensive care course and outcome of children being ventilated for pneumonia in the developing world is unreported. aim: to describe the clinical findings, aetiology and shortterm outcome of children younger than months with pneumonia requiring ventilation. the data of all babies under the age of six months with a lower respiratory tract infection admitted to the paediatric icu for ventilation were prospectively collected over a period of months. tracheal aspirates and blood specimens were submitted for viral and bacterial cultures. results: forty-seven babies aged to days were ventilated for pneumonia. twenty-six infants had been born prematurely; t had been ventilated during the neonatal period and had bpd. the median duration of symptoms was day, the most common being cough, tachypnoea, apnoea and cyanosis. five babies ( %) died. the mean duration of ventilation was days (range - days) and of ward stay after icu discharge days (range - days), blood euttures were positive in children ( %). viruses were cultured in children ( %). conclusion: ) fifty-five percent of children below months requiring ventilation for pneumonia were premature infants, of whom % had been ventilated during the neonatal period. ) the median duration of symptoms prior to admission was day. ) ninety percent of the children survived and were discharged from hospital. ) viral pneumonia was responsible for % of the admissions. mechanical ventilation and atrial natriuretic factor release ulloa santamarfa, e, p rez navero jl, ibarra de la rosa i, espino hernladez m, velasco jabalquinto mj, frfas p rez m. picu. reina sofia children's llospital. c rdoba. spain. mechanical ventilation effects on renal function decreased diuresis and natriuresis due several factors including anf. several studies have demostrated anf released due increaasing pressure in right atrium. on the other hand, mechanical ventilation, overall peep modality, inhibits peptide release althougt cvp increased is found. this study was designed to demostrate anf stimulation is due rigth atrium stretch which be higher during mechanical ventilation instead of atrium pressure. we desing a prospective study including patients, age range months- years with congenital heart disease. all of them were admitted at pediatric intensive care unit after extracorporeal surgery and were assisted by mechanical ventilation. hemodinamic state was stabilized in all patients and nor renal neither neurological diseases were found. after hours with mechanical ventilation, plasmatic levels of anf were measurement, pvc, pericardical pressure were assessment; all patient were sedated with midazolan and paralized with neuromuscular blocking agent; mechanical ventilation technique was as follow: imv between and , tidal volume and fi o enough to mantain respiratory parameters in normal range. afterwards, at least twentyfour hours in spontaneous breathing, the study was made again in each patient. atrial stretch was assesssment according to following equation: transmural pressure= cvp -pericardial pressure. cvp were significantly higher with mechanical ventilation than when the patient was breathing by himself. ( . +__ . vs . + . mm hg; p< . ). however, transmural pressure during mechanical ventilation were lower than during spontaneous breathing ( . +__ . vs . +__ . mm hg; p < . ) equal, plasmatic anf levels were lower during mechanical ventilation ( . + . vs . + . pg/rnl; p< . ). in conclusion, anf secretion decreases during mechanical ventilation, even with cvp higher. anf release would depend on atrial stretch meassured by transmural pressure, lower in patients with mechanical ventilation and it would not depend on atrial pressure. the paediatric intensive care unit shaikh zayed hospital, lahore is an acute care area devoted to the care of critically sick children upto the age of years. in a bedded unit with limited equipment, constant care is ensured by the presence of at least one nurse aed one doctor round the clock. in this setup we have the facility to ventilate - children at one time, between sep. and dec. , out of patients admitted to icu, ( . %) were below yr of age, while ( %) were below month of age. life support was discontinued in ( . %). total mortality was ( . %), major mortality was in - month age group ( . %), and month to month ( . %). majority of the patients were of sepsis ( . %), cns disorder ( , %) followed by respiratory problems ( . %). it seems therefore that the major indicatiou for ventilation was overwhelming septicemia leading to multiple organ failure, rather than purely respiratory problems. high frequency oscillation (hfo) in the therapy for ards in pediatric patients requiring aggressive conventional mechanical ventilation (cmv) -routine or experimental mode ef pre ecmo therapy. fedora m., nekvasi~ r, vobruba v., srnsky p,, zapadlo m. dpt. critical care medicine, nicu and ecmo center, university children's hospita! brne, nicu of university hospital prague, czech republic. introduction: pediatric patients ( males, female, average age . months, average body weight , kg) with severe ards ventilated with aggressive regimen of pcv or prvc were connected to hfo (sensormedics ) as the last "rescue" therapy due to uncontrollable respiratory failure before intended ecmo. in the course of hfo of them were given no in the concentrations of - p.p.m., were subjected repeatedly to surfactant replacement therapy (alveofact). results: ecmo was needed in no patient, patients survived, patient was disconnected from the ventilator because of brain death in spite of conspicuous improvement of oxygenation and other parameters, some relevant parameters hours before and hours after starting hfo are given in table ~ in all the cases, the disconnection from hfo was carried out through the simv regimen, never directly to cpap. table : the levels of blood gases, oxygenation index (oi), aado ,map,fio and pao /fio ratio hours before and hours after starting hfo. conclusion: although none of the patient had to be subjected to pediatric ecmo, hfo should be carried out only in workplaces having the immediate possibility of using this method in the case of hfo failure. speculation: should not hfo be used ir pediatric patients with ards earlier than aggressive cmv? can hfo ce considered standard, not experimental method of therapy? refractory hypoxemia in premature patients is characterized in a persistent elevation of pulmonary vascular resistance, with right to left shunt through the ductus arteriosus and or foramen oval. we report the case of a vlbw patient (ga w, bw g) who present a severe hypoxemia related to hyaline membrane disease and a pulmonary and systemic infection to group b streptococcus, refractory to conventional ventilatory support and surfactant therapy, associated to hemodynamic failure falling in ecmo criteria used for term infants. a rescue therapy with hfov (sensor medics a) is decided at h of live, the table resume the patient's evolution before and after hfov. at w of postgestational age the patient present a fio of . with a chest x ray compatible with a cld type l at discharge no oxygen requirements was needed and actually he's doing well. conclusion: hfov, using an adequate alveolar recruitment strategy, was effective in the rescue of a severe hypoxemic respiratory failure with a rapid off of ecmo criteria entry in our vlbw premature patient, during the united nmioffs embargo ~nst yugoslavia the prevalence of the ast}nnafic ~acks in c~dldren aratsed. the mo~t common causes have beem dramm~e worsening of life standard, ecom~c disaster in global community, gr~ number of refugees from the other parts of former yugodavia. it wm obviom that mcio-ecoumnical conditions took a part in the exacerbations of previously known cldldhood asthra~, ~av~ of micro-and m~mclimaflc changes, psychosocis] and emotional cryses, lack of medics-m~nts for p~ve~on and tl~rspy of acute asflanatic attacks. about % of d-dldv~ tmslod in our picu for these year~ exp~dvncod ~vcr~ attack for the flint time iu ~jzeir lifts. it has been cu~ ~%~ children in mspir~ry picu of our hos~mt. the scut~ revere attack (more ~asn ~/o of hight clinical score) was detected in % of all children admitted with respirak~ problems. from tl~ mmlysss we exclu&d: bmncldolifis, ~i anomalies, ~eve~ i~ccqions. concerning our drug supplies (which wc~e reduced), we started our therapy by administration of oxygen, ~ta -ago~dst inhalations (but sometimes we had the solution for jet nebulizcm only for o~e inhalation per p~cnt), mwinophyllin and mefl~ylpr~ini~done in/ravenously. % of ih~ asthmatics needed repea~ doses of muinophyl~n pinch.ally, tnch.,ding the fluids. the bronchodilak)r msponm was poor ~r~cl slow, hospital stay in picu was for days and for days in other units sl~rwsvds. tim ~ of their stable condifio~ was hard at borne (or refugees camps), without p~ventkm, so they came bsvk to hospital for morn than times in % of cases, dtrdng ~e je last motlfl~s file dtustion improved, concerning tim drugs supply for prevention, and we hope that these lifc~restening conditions wouldd~ introduction: the incidence of ards is increasing as survival of critically ill patients is higher. the application of new therapeutic modalities have increased the survival rates in (ards) adult patients. objective: to study the therapeutic efficacy of new tleamlents in children with ards material and methods: a retros~ctive study was conducted from to . children with severe ards, (lung severity score > , ) (r), aged days to years, were included. the diagnosis were as follows: interstitial pneumonitis, non interstitial lung infection, with lung aspiration and with clinical sepsis. patients had different tipes of cancer and to suffer inmunodeficiency disease, the first subjects (group t) were treated with conventional measures. from october of new therapeutic modalities were introduced, including: less agressive ventilatory support, postural changes (prone to supine) in subjects, administration of corticosteroids in patients, rfitric oxide in , pe~ssive hypercapnia and administration of exogeans sarfactant in one, pao /fio , d(a-a)o , oxigenation index (oi) and the score of respirator), severity disease were similar in both groups. the two groups evolntiou was compared. results: -ten patients died, from group i and from group ii ( % v.s. : %,ns). -the evolution time, either to exitus or weaning from ventilatory support was higher in group ii ( . v.s. . days in group i, ns), -the incidence of barotrauma was observed in subjects ( . %), from group i and from ii. of these patients % expired. -during the course of the disease, ( %) patients had more than one damaged organ. only in one subjet mof was considered to be the main cause of death. the majority of the patients expired because of their respiratory disease, although, % of them met criteria of mof. -fifty percent of the subjects were infected at the time of death. stmmry: a trend toward a higher survival rate is observed in the subjects receiving the new modalifies therapeutic intervention (corticosteroides, postural changes and permissive hypercapnia). our results are not significative,probably because of the small number of subjects studied. a new doubleaurae~t two-stage et-tube (dl-ett) was desig~aed and tested in the rabbits with acute king injury under conventional mechanical ~entilation_ ventilation efficiency of dl-ett was emrrpared with that of canveniionally t~sed single lumen et-tube (sl-ett). meth~s: dl-ett was specially made out of two sl-ett. vertical crosssections at the distal end of two et-tube (td _ rmn portax) were adhered with each other to form a tracheal stage lumen wifu id . mm the two remained uncut parts of the tubes corlntithted the oval s~ge with two separate imnens. dl-ett and sl-ett were randomly applied to five adult paralyzed rabbits with acute lung injury (by . nffkg oleic acid. iv). a bird inter vetffttator (bird products corporation) was used for time-cycled pressure-limited ventilation at /min of respiratory rate, ern h of peak i_~piratory pressure, l: of ire ratio, ljmin. of flow rate and . of fich. peak inspirntory pressure, mean mrway pressure, posi ve end-expiratory pressure at tip of et-mbe and bemodynamics were measured and recorded continuously. arterial blood and expired gas were measured ~by avl blood gas analyzer) after each stabilization t.~iod of minntes. _analysis w~as by prated t test. result: dl-ett acaltety improve cos removal at all amman. pa(?oz was decreased by t . +_t. (p< . l) and physiologic dead space fraction (v~zvt) reduced by % +- . % (p< . t), compared with dl-ett. there were no significant change in arterial oxygenation. conelus|on: the double-lumen two-stage et-tabe significantly increases ventilation effmiency with simple operation in rabbits v, ith acute hmg injury, lts availability may influence future clinical management of ~ennated patient~. this ~muly was fimded by the science and technology. commiuee of beijing municipality. analis of hemostasis alterations on different coagulation cascades in children with septic shock has shown that coagulation disorder character is dependent on lung affection rate. the initial manifestation of the respiratory distress-syndrome (rds) are characterized by the obvious activation of blood thrombin potential, moderate coagulopathy and not sharply marked endoteliosis, the witlebrand's factor (wf) increase tot - %. progress in the clinical picture of "shock lung" leads to chronometric and structural hypocoagulation with potential hypercoagulation in "mix-test", high level of firbin derivative, thrombocytopenia with thrombocytopaty and the wf increase to ~ %, terminal stages of the rds, as a rule, are characterized by potential hypercoaguletion absense, depletion of at-lit and plasminogen, prevalence of antithrombin and antiaggregating activity, obvious endoteliosis (the wf to increase - %). the arteriowenous difference according to index of the thromboelastography (teg) in the rds ill-iv rates was , % less than in the - rates, disorder of lung filtering ability in severe rds is confimed also by minimal arterio-venous difference of activated euglobulin lyses (ael) in children with the rds ill-iv rates is only , %, while the patients whit rds i-i rates have the ael-activity in arterial blood , times as much than in venous blood. the use of then allows to determine the potential hypercoagulation rate, the at-ill level and fibrinogen quantity during the anticoagulant therapy and also the character of the x-factor activation and thrombocytic hemostasis. the effective therapy component of septic genesis rds in children is the controled coagulation method with the use of the individual selected heparin doses in according to desagregants, kryoplasma, proteolisis inhibitors and trombolytics. it is necessary to avoid the heparintherapy for children with the rds complicated with producting coagulopaties and termal phases of blood disseminated intravascular coagulation (dic). bronchoseopy has been used for evaluation of the potential problems of the airways and for investigation the bronchial specimens for diagnostic purposes. regent technical advances result in performing this procedure at the bedside manner and in critically ill patients. we have performed hronehoaeopy during last three years on pediatric patients with respiratory problems, in % of cases the opentube hroneh seopy was performed (for diagnostic as well as for therapeutic reasons) and collected secretions or bioptic material were examined. the indieatiuns were: acute upper respiratory problems, chronic wheezing, inspiratory strider, tracheal or bronchial bleeding, chronic eongh, retractable atelectssis, severe pulmonary infections, lymph node perforation in lung tuberculosis and soquells like bronehiectssis and fibrosis. our results were: anatomical malformations in %, mueosal oedema with chronic inflammation and thick secretions in %, easuos masses in %, granulation tissue and purulent secretions in foreign bodies and bronehieetasis in %, and only % of eases were normal finding. our exlxdenees pointed that this invasive procedure in carefully selected patients has important role in establishing the diagnosis and in the- introduction: tbg has been a useful investigation in the management of ventilator-dependent infants in our experience. one ml of contrast was hand ventilated into the respiratory tree via their nasotracheal tubes and their anatomy and dynamics demonstrated on radiological screening. case descriptions: three infants who were difficult to ventilate requiring high airway pressures, high peep and a significant oxygen requirement had tbgs. the ages ranged from to months. two cases were complicated by complex cardiac lesions. in all cases there were frequent episodes of desaturation, where hand ventilation proved difficult and various intermittent lobar collapses occurred. microlaryngobronchoscopies (mlb) performed on the infants by experienced paediatric ent surgeons failed to identify the airway problems. more than one mlb was frequently done. concern about introducing contrast into the airways of infants with limited cardiorespiratory reserve combined with an uncertainty about how much extra intbrmafion would be gained often led to a delay in investigation. when performed these fears proved groundless, the anatomy and pathology of the airways were demonstrated in full and the correct therapeutic plan started. in two cases tracheostomy and peep producing patency of bronchomalacic segments allowed weaning to low levels of ventitatory support. in one case tracheal reconstruction was undertaken and in the cardiac cases the respiratory component of the ventilatory dependence was fully assessed. at the age of months, a baby boy with a history of minor respiratory problems, was admitted to hospital with an upper airway infection and severe dyspnoea. shortly after arrival at the icu he had a total airway obstruction. after intubation there were still difficulties to establish a normal gas exchange, and he was tranferred to the regional picu. ct scan and bronchoscopy verified a congenital tracheal stenosis affecting the whole trachea except the upper mm below the vocal cords. the diameter was estimated to less than ram. an unsuccessful attempt was made to dilate the extremely rigid stenosis with a balloon. after the procedure he had a respiratory and circulatory arrest, and he was put on ecmo as a bridge to surgical correction. after stable days on ecmo, surgery was performed during ecmo with a tracheal homograft transplantation. immediately after surgery, ecmo was discontinued. a silastic dumont type stcnt was inserted inside the homogra~, and a nasotracheal tube was placed inside the stent for assisted intermittent mechanical ventilation. repeated bronchoscopies were performed to remove granulation tissue and secretions. at months of age, the stem was removed with an endoscopic procedure. however, the trachea was still soft and collapsable, and another silicon stent was placed inside the trachea for another months period, after removal he had some respiratory problems and he was treated with nebulized salbutamol, mcemic epinephrine and steroids. he was discharged from the hospital at months of age and his condition is now stable. this is the first procedure of its kind in sweden. it was accomplished by international and multidisciplinary collaboration. ecmo may be a bridge to corrective surgery and long time stenting may be necessary in the postoperative period. post mtubation laryngitis ( pil ) is still a frequent complication, occurmg in l - % of intubated patients. inhaled racemic epinephrine has for long been used as an accepted therapy, but this drug is not always available. the authors undertook a randomized, double-blind, placebo-controlled trial to determine the efficacy of inhaled l-epinephrine(le) in the treatment of plu in the period between july/ and may/ , patients were submitted to endotracheal intubation for ventilatory support. atter the extubation procedure patients were considered for enrollement if they met the following criteria: clinical signs of laryngeal estridor and a downes and rafaelly score for upper respiratory obstruction equal to or higher than patients with primary upper respiratory disease were excluded all patients enrolled reeieved either inhaled l-epinephrine % or normal saline. dexametasene ( , mg/kg/day) was given to all patients in both groups. after inhalations, au patients were monitored for a period of - minutes and monitoring included cardiac and respiratory rate, mean arterial blood pressure, arterial blood gases and the dowries and rafaelly score. statistical analysis included, qui-square with the fisher correction test and the z-test for paired variables. thirty eight patients ( , % ) met the criteria for enrollment, to the le group and to the placebo group.there were no significant differences in both groups in regard to age, sex, initial score ( , x , ) and endotracheal tube diameter. the period of ventilatory support and tracheal intubation was significantly higher in the le group ( , x , , p = , ). the follow-up score showed a significant drop only at minutes after the inhalations (p = , ). re-intubation due to laryngitis, occured in patient of the le group and in of the placebo group with no statistical sxgnificance (p = , ). no difference was observed on the monitored hemodynamic variables during the minutes, except for the mean arterial pressure at minutes, being heighar on the placebo group (p = , ). we concluded that, although the l-epinephrine group showed a trend in better scores post-inhalation and fewer re-intubations due to laryngitis, the results were not statistically significant. we especulate that the period of intubation may have affected our results. similarlly there were no differences in the incidence of adverse effects between both groups. objectives:to evaluate the complications of endotracheal intubation in children with upper airway obstruction due to epiglottitis or croup. methodes: during a year period ( - ) all patients with epiglottifis or croup were reviewed to determine the complications of endotracheal intubation, especially upper airway obstruction due to granulomas. results: patients were reviewed. in children (mean age . years) with epiglottitis the mean duration of intubation was . days ( - ). no complications were seen. in patients (mean age . years) with croup the mean duration of intubation until the first extubation was . days ( - days). elective extubation was performed if an airleak was present or after days without airleak but in the absence of fever and obvious secretion. reintubation was not necessary in children ( . %). in this group the mean duration of intubation was . days ( - ). in patients ( . %) reintubation was necessary because of severe upper airway obstruction due to granulomas. mean duration of intubation until the first extubation was . days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . there seems to be a difference in duration of intubation between these two groups with croup, however it is not significant (p > . ). all the patients with granulomas could be successfully extubated after microlaryngeal surgery, with a mean intubation period of . days ( - ). revealed no complications, where as endotracheal intubation in children suffering from croup showed a high incidence ( . %) of granulomas. however laryngeal steepsis and other serious complications were not sesn~ patients ( days averagely] was obviously seen in ~he peak =one of fl, f resonance and in the zone of high freq,-~ncy :r, ~;~e composition while cases( day~ average;y] :~bowed no abnormality both clinically and isryngoscopica!~y. / patients with catheter placement for more than week~ end p~tie,~ts for less than weeks had t;~ryngeal abnormal change in their larynges,abnormal changes of sound spectrogram were all seen in patients with placement for mope than weeks. our data suggest= ca] the complication of endotracheal intubation was increases with increasing length of time of catheter placsm. entjbut aeriuoa complication is rare i (b] the time limit of pernasal endotraoheal catheter placement is weeks within which the procedure is • comparatively safe and effective means for maintaining e tong term artificial airway. in a -year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) we diagnosed tbm as an apparent dilatation of the trachea and main bronchi ih four premature infants on continued mv for respiratory distress syndrome (rds). the infants were three boys and one girl with gestational age (ga) - weeks and body weight (bw) - g. mv was provided by bourns cub time-cycled and pressure-limited ventilator to attain normal gas tensions. no jet ventilation was used. chest radiographs were reviewed for a complete evaluation, and for the evaluation of the airway. after the intial subjective diagnosis of tbm, the width of the tracheal and main bronchial air column was measured at the lower level of the first and the third thoracic vertebal body it , t ) and near the carina; the width of the main bronchi below the carina was also measured. in all infants, tbm became apparent close to the lh day, that is, after - weeks of mv. therefore, for the time period from birth to the th day the following ventilatory parameters were reviewed and analyzed: ( ) the percentage of total ventilation time when more than % o concentration was required, ( ) the peak inspiratory pressure, ( ) the positive end-expiratory pressure, and ( ) the duration of high frequency ventilation ( - breaths per minute). also noted were the apgar scores ( and min after birth), the duration of hypotension (systolic bp below mmhg) and circulatory instability, the presence of systemic or tracheal conatal or later infection, the duration of mv, and the final clinical outcome. the records were also reviewed for other possible pertinent data. rigid respiratory endoscopy in children fraga j, amant a s, piva j, nogueira a, palombini b. introduction: the respiratory endoscopy is an important procedure to diagnose and treat many airway's diseases in children. although have had advances in radiologic investigation exams and pulmonary function tests, the direct anatomic visualization of airway is important to the management of many respiratory problems. objective: evaluation the respiratory endoscopies performed with a rigid bronchoscope in a pediatric reference hospital. material and methods: we study the records of all children that were submitted to respiratory endoscopy under general anesthesia from march to march . age, sex, clinical to indicate the procedure, diagnosis and complications of endoscopy were registered. results: three hundred and fifty six respiratory endoscopies were performed. the most common indications for endoscopy were strider ( %), suspected foreign body ( %), atelectasis ( %) and difficult tracheal extubation ( %). the most frequent diagnosis were laryngomalacia ( %) and subglottic stenosis ( %) in the glottic and subglottic areas, and foreign body ( %) and tracheomalacia ( %) in the tracheobronchial area. normal endoscopy was performed in ( %) of the children. only three slight complications of the endoscopy were observed. two patients presented bradycardia during the exam, and the third need tracheal intubation due to post-endoscopic subglottic edema. conclusion: the rigid endoscopy in children is efficient and has no serious complications. near drowning; indicators of acute and long term prognosis bernardien t.mj. thunnissen t, reinoud j.b.j. gemke , loes veenhuizer?, krijn haasnoot , a.johannes van vugh department of pediatrics, ~wilhelmina children's hospital, utrecht, sophia hospital, zwolle, and ~free university hospital, amsterdam, the netherlands. in this retrospective study factors that affect short and long term prognosis after submersion were analysed. all patients that were admitted to a tertiary pediatric icu between january i, and january i, were included. of patients, aged - years, died in the icu, one after hospital discharge. survivors and non-survivors showed significant differences with respect to central temperature, pupillary reactions, arterial ph, pediatric risk of mortality (prism) score and therapeutic intervention scoring system (tiss) upon admission (p < . ). non-survivors more frequently required mechanical ventilation, bicarbonate administration and active reheating. ards was seen in patients ( %), invariably within hours after admission. no patients with cardiac arrest on" admission snrvived without sequelae. hypothermia appeared to have no protective effect on hypoxic damage. survivors with persistent sequelae _> months after discharge had significantly higher prism and t ss scores (mean and , respectively) than those with complete recovery (mean and , respectively). long term cognitive problems were present in / survivors ( %) and emotional disturbances in / ( %). in conclusion, a concise number of clinical and laboratory parameters, representing acute severity of illness, are important prognostic indicators for survival and health status of children after submersion. there were ( %) bronchoscopies, and ( %) were oesophagoscopies.the average age was , years for bronchoscopies, and years for oesophagoscopies. the outcome of the patients was good. no complications were observed. extraction is recomended in every symptomatic patient. orphenadrine is an anticholinergic drug mainly used to decrease symptoms of parkinson disease. orphenadrine has a peripheral and central effect and overdose can result in athetoid movements, convulsions, cyanosis, coma, arrhythmias, shock and cardiac arrest. physostigmine is a specific antagonist of the peripheral and central effects and can be a useful antidote. we report the case of a two and a half year old female who was transfered to our icu for general convulsions. the little girl had, three hours before admission, accidently ingested rag of orphenadrinehydrochlodde (disipal®), which was her grandmothers anti-parkinson medication. three hours after ingestion she presented neurological signs: confusion, unstable walking, and periods of aggression. generalized tonic-clonic seizures appeared who were rebel to administration of multiple anti epileptica but ceased after iv administration of diazepam and endotracheal intubation and ventilation. an episode of ventdcular tachycardia responded well to the iv administration of tidocaine. the levels of orphenaddne in the serum were high at admission ( pg/l) and were present in the blood up to hours after ingestion. high serum levels are, in the literature, associated to a high mortality rate. physostigmine was administered three times at a . mg/kg dose in the first hours. we decribe the noted effects of physostigmine on the different symptoms. the patient survived and could leave the icu after one week. in conclusion: orphenadrine poisoning is a very complicated medical problem associated with high mortality. in severe intoxication, the benefit of physostigmine more than counterbalances its side effects. objective: to define the optimal volume of dilution for endotracheal (et) administration of epinephrine (epi) design: prospective, randomized, laboratory comparison of four different volumes of dilution of endotracheal epinephrine ( . , , and ml of saline) setting large animal research facility ofa universi~ medical center subjects and interventions: epinephrine ( . mg/kg) diluted with four different volumes ( , . . and i rot) of normal saline was injected into the et tube of five anesthehzed dogs. each dog served as its own control and received all four volumes in different sequences at ieast one week apart. arterial blood samples for plasma epinephrine concentration and blood gases.were collected before and . , . . . _ . . , . . , . , . , and minutes after drug administration. heart rate and arterial blood pressure were continuously monitored. measurements and main results: higher volumes of diluent ( and i ml) caused a significant decrease of pao , from :!: tort to ±i torr, compared to the tower volumes of diluent ( and ml), from ± torr tu +_ torr (p< . ). these effects persisted for over minutes. mean plasma epinephrine concentrations significantly increased within seconds following administration for all the volumes of diluent. mean plasma epinephrine concentrations, maximal epinephrine concentration (cmax), and the coefficient of absorption (ka) were higher in the ml and ml groups. the time interval to reach maximal concentration (tmax) was shorter in the ml and ml groups. yet these results were not significantly different. heart rate. systolic and diastolic blood pressures did not differ significantly between the groups throughout the study. conclusions: dilution of endotracheal epinephrine into a ml volume with saline optimizes drug uptake and delivery, without adversely affecting oxygenation and ventilation. the aetiology and outcome of paediatric out-of-hospital cardiac arrest was studied during a -year period in southern finland served by physician staffed emergency care units. the files of prehospital patients less than years old without palpable pulse and spontaneous respiration were analysed retrospectively. fifty patients were declared dead on the scene (dos) and resuscitation (cpr) was initiated in patients. the sudden infant death syndrome was the most common cause of arrest ( %) in the dos patients as well as in patients receiving cpr ( %). asystole was the initial cardiac rhythm in % of the patients in whom cpr was attempted. eight of the hospitalised patients were discharged, of them with mild or no disability, with moderate disability and one in vegetative state. in multivariate analysis the short duration of cpr (< minutes) was the only factor significantly associated with better survival. due to various aetiologies the survival rate from prehospital paediatric cardiac arrest is quite low. on the other hand, hypothermic near-drowning victims seem to have a relatively good prognosis. duration of cpr less than minutes was the best predictor of intact survival, our study supports the previous findings of the importance of early and effective resuscitation efforts for establishing ventilation and perfusion on the scene. in our system well trained physician staffed emergency care units are able to provide immediate and effective als on the scene. on the other hand, these units also appear to be able to refrain from resuscitation when the prognosis is pessimistic. objective: to assess the normal ,gastric intramucosal ph ~hi) by tonometry in healthy children patients and methods: twelve healthy children ( males and females) with age rmaged from months to years scheduled for minor plastic or urologic surgery. children were previously medicated with midazolam ( . mg/kg) and atropine ( . mg~) both i.m.. anaesthetic induction was standardized with -n ( %) administered via facial mask and increased halotane concentrations (up to %). all patients got an endotraeheal tube after iv. administration of femanile ( mcg:jkg) and vecuronium ( . mg/kg) or suxametonio ( mg/kg), pmaesthesia was maintained with o -n ( - %) and isofluorane ( . - %). during surgery, children needed mechanical ventilation and the others maintained spontaneous breathing. ekg, heart rate, blood pressure, and pulse oximetry were moniterized. after anaesthesia, a sigmoid tenometry catheter (tonometrics, inc.) was inserted in the stomach of the patients by direct visualization with laryngoscope and magyll clamps. children were all maintained normoventilated and with normal cardiorespiratery variables. cadet's balloon was £~led with . ml of saline. thirty minutes after the insertion rrd was extracted and rejected, just afterwards the remanent . ml was extracted and immediately analyzed. simultaneously an arterial gasometry by puncture was performed. gastric phi was calculated by the henderson-hasselbalch's equation using the pco obtained from the tenometry catheter and the bicarbonate value obtained from the arterial gasometry. results: average gastric phi was . -i- . , range ( . - . ). objective: demons~ating intramucesai ph (phi) alterations during transport of patients from operative room to pediatric intensive care unit (picu), material and methods: phi measurements were performed with gastric tonometer catheter in t patients undergoing cardiac surgery with cardiopulmona d" bypass (cpb), there was mate and female, the average age = yl ra, average weight = , kg, average time of cpb = rain. the measurements were made at the end of the surged' and when the patients had arrived in the picu statistical aualysis: average and ~andart deviation and test "t" student. objetive: to asses the efficacy of gastric iatramucosad ptt (phi) and arterial lactate levels to evaluate splacalc tissular perfusion in an experimental model of intestinal ischemia. suneets ~nd methods: twelve piglets weights t - kgs. undergoing orthot~ie liver trasplantation. the intestinal ischemia was induced by aortic damping. tonometry catheter (tonometrics inc.) w~s placed in the stomach after artaesthesia and ot intubation. phi ~s determined times and lactate levels was determined fi times in stages: i) pre-ae~hepatic stage (twice: before surgery and before aortic clamping ); ii) end anhepatic stage (only phi): iii) reperfusion stage (a , , and minutes). the phi was derived from application of the henderson-hassdbach formula using the pco value from the tonometer and the arterial bic~rbonate. all pipets received raaitidiila before sttrgery. values of phi above , and lactate levels between and mg/dl were considered nortrm. the results were statistically anaj.izated with anova and bonferroni tests. results: the phi was normal on pre anhepatic stage (> , ) and lactate levels were slightly increased ( , +_ , and , ± , mg/dl ns) . in relalion to we-anhepatics values, phi decreased signncatly at the mid of anhevatic stage ( , _+ , vs , _+ , p< , ), phi remain low in stage iii, at rain ( , + , p< , ) and min(g -+o, p< , ). arterial lactate levels increased significatly in relation to levels in stage i, at rain ( , _+ , p< ,o ) arid rain ( , ± , p< , ) of reperfusion stage. there is a slight improvement on phi and lactate ievels at and t rain althought the differences did not reach significance. cnmments: phi and arterial lactate levels propperly reflect hypoperfusion on the experimental model of acute intestinal isdlemia. b~kground : the paediatrie gallbladder diseases generally described are calculous ¢hol~tstitis, cystic duct obstruction, congenital anomaly of the biliary tract, and inflammation. in the neonatal period, noulithogenie gallbladder disease could be also due to erythroblastosis or hyperalimentation. obieetive : we describe an other type of disease affecting the gallbladder in neonates thought to be related to their vascular vulnerability. methods : four patients with abnormal gallbladder ultrasound not related to classical observations were included. we have studied and reviewed the biological and clinical data, the ultrasound findings and their evolutions. results : four patients, to ~.k-old neonates ~ffth a birthweight be~,een , and , kg, were intubated and under total parenteral nutrition for to days. none of them were symptomatic on repeated clinical evaluations. one newborn developped hypotensien on umbilical bleeding at hours of life. in two cases, signs of cholestasis were discovered : the total bilirubin level has risen to mg/dl; the direct bilirubin level was , mg/dl while the urina were dark and the ~o~,ls :mcolour~. the c~mplct~ ~crology as a!! the culvare~ remained negative. the ultrasound explorations were atypical : in the four eases, an initial increasing broad and thickness of the wall of the gallbladder with an hyperecbogenie inside content, which was not sludge, was discovered. in three eases the images resolved in ten to fifteen days. in one ease, an asymptomatie thrombosis of the vena portu which remained patent was discovered. in this case, at one month, the ultrasound showed images encountered in chronic ebolecystitis and, at one year, the gallbladder appeared atrophic. none of them underwent surgery. conelusiou : the gallbladder diseases are multifactorial. besides the prematurity, the infections, the total parenteral nutrition, the premature neonate is exposed to vascular vulnerability affecting also the gallbladder and this may explain our findings. progress in prognosis of pts with b-nhl had followed the use of multimodality chemotherapy (ct). with the prolonged survival, there are comlications due to myetosupression & desease process. the syndrome of neutropenic enterocolitis (ne) is one of the ominous problems because ofpts increased susceptibility to infection & overwhelming sepsis. this material included neutropenic pts ( - years) with the stages iil& iv of b-nhl who were treated with the modifired bfm- (mtx g/m in -h inf.); males, females. seventeen episodes of ne were observed & only after the first courses of ct ( of after tst, %; of after nd, %). the symptoms existed to days. wbc ranged from to in l~tl (median, ). the first signs of ne were directly correlated to the beginning of the neutropenia & the recovery of neutrophils led to the disappearance of abdominal recovery of neutrophils led to the disappearance of abdominal pain. the conservative treatment included gastrointestinal tract decompression, broad spectrum antibiotics initially, volume & electrolyte substitution, nutritional support, correction of acid-base balance, symptomatic treatment. sixteen pts were treated nonoperatively, died. on autopsy the transmural bowel necrosis due to thrombosis of branches of a.mes.sup, was found. the bowel perforation occurred in one patient, he was undergone laparotomy & hemicolonectomy & survived. we conclude that ne is a frequent complication in neutropenic pts with the st. lii& iv of b-nhl. it occurs after the induction courses of ct. close observation by surgeons, oncologists & pediatric intensivists is mandatory. conservative treatment is effective & more preferable until leucopenia resolves. operation is necessary only for those.with perforation. near infrared spectroscopy as a tool for evaluation of intestinal perfusionpresentation of an animal model. c. scheibenpflug, p. buxbaum and a.m. rokitansky the recent development of and investigations in the so called near infrared spectroscopy ( nirs --transcutanous emission and simultaneous registration of intensity of spectralcolours depending upon modulations of tissue perfusion ) enable physicians to measure and qualify organ perfusion and nowadays is mainly used to control cerebral as well as skeleton muscular blood flow in trauma patients at intensive care units ( icu ). today intestinal perfusion, hypoperfusion , cell damage caused by reperfusion injury, bacterial and toxin translocation are serious problems in critically ill patients at an icu. paediatric intensive care physicians put major concern on intestinal perfusion, which for. instance gains more and more importance, especially in the neonatal period for example as an etiologic factor for necrotizing enterocolitis. we established an animal model, in which we measured intestinal perfusion by nirs under various invasive and noninvasive conditions. methods and results will be referred. for preliminary conclusion we propose near infrared spectroscopy ( nirs ) also as a potent diagnostic tool to determine early intestinal malperfusion in order to prevent lethal outcome. fm'ther investigations in animals as well in paediatric iritensive care patients should be done to estimate our efforts. introduction: following the acute phase of necrotising enterocolitis (nec) starvation of the gut for a period up to weeks is a generally accepted treatment modality in many centres. objective criteria to refeed these patients are hardly available. recently the double sugar test has become available as a parameter for (ab)normal gut permeability ~' . aim of the study: to evaluate the changes in permeability of the small bowel in patients with nec and controls before introduction of enteral feeding. methods: a lactulose! rbarrmose (i/r) test was performed in two groups. group was studied - times within a -week period of starvation (n= , mean gest. age , range - weeks). in group seven different control patients were studied (mean gest.age , range - weeks). the test was performed by giving a patient after at least a hour fast ml/kg bodyweight l/r solution and determination of the /r ratio in a -hour urine sample by chromatography. results: objective: to evaluate the prognostic factors in the response to nitric oxide (no) in children with acute respirator/ distress syndrome (ards) and/or pulmonary hypertension (pht). patients and methods: critically ill children received no inhaled for ands and/or pht treatment. patient before and after cardiac surgery ( cardiac transplants), with bronchopneu~onia, multiple trauma, sepsis and cardiorespiratory arrest. patients showed /j~ds and pht, in with associated ards. we analyzed age, sex, diagnosis, pao , pa /fi , oxygenation index, pht, shock, and sepsis as prognostic factors and response factors to n . results : after no administration oxygenation did not improve in patients ( . %) and pht did not diminishe in one children ( %). patients survived ( %), / ( . % with /d%ds) and / ( %) with pht. the four patients with isolated pht survived , and the patients with pht and ards dead. patients after cardiac surgery presented less mortality ( . %) than the rest of patients ( . %). patients with shock presented higher mortality ( . %) than the rest of patients ( . %). there are no differences in response to no in respect of sex, age, diagnosis, shock, and sepsis. survivors showed higher increase of pao /fi . ± . to no than non-survivors . ± . (n.s). patients with pht showed higher increase in pa /fi to no administration ( ± . ) than patients with ards ( . ± . ), (n.s), but patients with ards showed a higher increase in !, ± . , than patients with pht . ± (p < . ). patients with pa /fi < i showed less increase in pa /fi , . ± . , than the rest of patients . ± . (n.s) conclusions: i. mortality of isolated pht treated with no is less than patients with ap~s. patients with shock and those with pht and ards showed higher mortality. . we have not found any clinical or analytical factor to predict clinical response to no administration. patients showed ards, and severe pht after cardiovascular surgery, in with associated ards. we registered respiratory assistance, blood gases, pao /fi , the oxygenation index (oil, and mean pulmonary pressure/ mean systemic pressure (pap/sap) before and after no inhalation. we measured continuous concentration of no and no by electrochemical method (noxbox, bedfont, airliquide). results: no administration improved oxygenation mean pao from ± tm~g to i ± ~g (p < . ), mean pa /fi fr<xa ~ to £± (p < . )and i from ± to ± (p < . ). patients did not improved with no administration. the oxygenation improved in the first five minutes and the best oxygenation was achieved with - ppm. there is no significant change in pac . pap/sap diminished from ± % to ± % ( p< . ), in one patient there is no response. the no administration was maintained between ~ minutes to days. the effect of no on pulmonary pressure and oxygenation was maintained without change during all the time it was administrated. n concentration were always less than ppm y metahemoglobinaemia less than . %. there are no side effects secondary to no administration. patients survived ( %). concluaions:l.administration of no improves oxygenation in children with ~/eds and diminishes pht after cardiac surgery. .no effect is fast and maintained during the evolution. high frequency oscillatory ventilation in combination with inhaled nitric oxide g~thberg sylvia, md, edberg k e md, phi), dept of paediatric intensive care, children's hospital, s- g teborg, sweden background: for man), years severely sick infants with congenital heart malformations or acute lung disorders have died due to pulmonary hypertension, hypoxia and multiple organ failure. today there are several therapeutic facilities coming up for these infants. ecmo progranunes have been introduced in severul centres as well as improved venlllatory techniques, as high frequency oscillatory ventilatior~ (hfov), which provides adequate ventilation with less risk for hmg injury.. in , the endothelium derived relaxing factor was identified as nitric oxide (no), and extensive studies have sho~-a that inhaled no reduces pnimonm o vascular resistance and improves oxygenation in hypoxic infants with pulmona~ hypertension. material.. from july to january , we have treated severely hypoxic children with combined ttfov-no. seven were newborn, with cdh, one with mas, one with irds, one with paediatric ards due to rsv infection and one with poor oxygenation atler open heart surgery. were between month and years and all had ards of differentorigin but one who was hypoxic after open heart surgery. method: hfov was given by means of sensormedics a oscillatory ventilator to patients, and dr~ger babylog was used in one case. mean airway pwssures varied from - cm h . oscillatory pressures varied from - cm h and ventilatory rates from - hz. fi o varied from , - , . no was administered by nomius classic. no and no was measured in the inspiratory limb with an electrcchemieal device. noconcentration varied from to ppm and the no -concentration between - , ppm. methemoglobin was never more than , % (average , ). duration of treatment varied from to days. combined trealment with hfov and inhaled no improved oxygenation and carbon dioxide elimination in out of treated childretl patients died, due to their underlying congenital heart disease, one of asphyxia due to rsv-infection and one of cdh with progressive hypoxia and multiple organ failure. combined treatment with hfov and inhaled no improves oxygenation in severely hypoxic children. treatment should be slarted early to reduce the risk for chronic lung injury following barotranma and high oxygen concentrations. we speculate that the combined hfov-no may reduce the use of ecmo, and that it may improve outcome in ceotres where ecmo programmes are not introduced. apart from its vasodilative properties nitric oxide appears to act also in physiologic immune defense. intracetlular concentrations of no synthesized by macrophages are in the range of above those produced by vascular endothelium. we investigated the bacteriostatic effect of nitric oxide at concentrations used during inhaled therapy for pulmonary vasodilation in neonates. ten different strains of five species were used (staph. anrens, staph. epidermidis, strop. group b [gbs], e. coil and pseudomenas aeruginosa), which are ~e most often tracheally isolated bacteria in mechanically ventilated premature infants and neonates. we compared bacterial growth of cultures applying three different concentrations of nitric oxide ( ppm. ppm, ppm) m the growth of the same strains in room air for a duration of hours. no bacteriostatic effect was demonstrable at no concentratioes of ppm. e. coil showed decreased bacterial growth at ppm and ppm, however without reaching statistical significance (p= . ). at nitric oxide concentrations of i ppm staph. epidermidis and gbs grew significantly less as compared to colonies of the same strains in room air. no effects were found regarding the growth of staph. aureus and pseudomonas aneruginosa. we conclude that nitric oxide has a selective bacteriostatic effect on some of the most often trachealb, isolated bacteria in premature infants and neonates. this effect appears to be dose-dependant and occurs in the upper range of dosages used with inhaled no therapy. further research is required in order to examine the mechanisms of action as well as specific interactions between different strains of bacteria and nitric oxide. the no,box monitor (bedfont, kent, uk) is used to monitor nitric oxide (no) and nitdc dioxide (no ) during no administration in ventilated neonates. according to the manufacturers specifications the monitor can be applied in cases where airway pressures range from to mbar. we investigated in-vitro the accuracy of the no monitor in a range of ventilatory conditions. using a dr~ger babylog we ventilated an artificial lung. no was administered { ppm no in % nitrogen) with a mass flow controller to the inspiratory tube, at a distance of cm from the y-piece. the no target value was set to ppm. the ventilator was operated in both cpap and ippv modes at different settings. the no sampling tube was placed on two different locations; in the inspiratory tube dose to the y-piece; in the expiratory tube haft way between the y-piece and the ventilator. the no-monitor was ca)ibrated with ppm no at mbar. fig. and show the sensitivity of the no-monitor for respectively static pressure (cpap) and pulsatile pressure (ippv) with the sampling tube located in the inspiratory tube. fig. shows the resur for pulsatile pressure with sampling in the expiratory tube. we conclude that the accuracy of the bedfont no-monitor is dependent upon airway pressure and sampling site, the latter possibly caused by incomplete mixing, pressure and no are linearly related when sampling occured further away from the administration site. based on this study we suggest to place the sampling tube in the expiratory tube. during neonatal care the clinician should be aware of varying inaccuracies depending on the respiratory pressures. hypothesis: availability of therapy with inhaled nitric oxide (ino) decreases ecmo use in patients referred .to a tertiary care hospital for treatment of respiratory, failure unresponsive to conventional therapies. background: at children's hospital of wisconsin (chw) treatment for patients who have failed conventional treatment for respiratory failure, sometimes called "rescue" therapy, has included ecmo since and high frequency oscillatory ventilation since . ino has been in experimental use at chw since may of i and has resulted in the perception of a decreased need for ecmo therapy in those patients referred for rescue therapy. this study was designed to tbst the validity of that perception. study type: retrospective cohort. methods: the medical records of all patients referred to chw from /lj to / / for rescue therapy for severe respiratory failure were included in the chart review. data were collected regarding diagnoses, illness severity, hospital course including interventions and complications, and outcomes. exclusion criteria w~ere the finding of structural heart disease or congenital diaphragmatic hernia as the basis for hypoxemia. qualification for ino treatment included an a-ado - or oi ~- for two hours or -> for twelve hours and echocardiographic demonstration of persistent pulmonary hypertension of the newborn. patients were classified into two groups based on the availability of ino at the time of their hospitalization. results: in the time period of the study, patients were referred for possible ecmo therapy. twelve patients greater than weeks old, with congenital diaphragmatic hernia and with congenital heart disease were excluded from this analysis, leaving patients for study, ino availability reduced ecmo use from of ( %) patients in the ~ino unavailable" group to out of ( . %) patients in the "ino available" group, p=& by fisher's exact test. the fact that the two groups were composed of patients of similar severity of illness is reflected by comparable rates of ecmo and ino rescue therapy ( % vs. %). conclusion: by providing an alternative rescue therapy, ino has reduced the need for ecmo in this group of neonates referred for respiratory failure. introduction: true hepatnrenal syndrome (his) is defined an acute renal failure {arf) in the presence of severe liver disease without other known causes of renal failure. hrs is frequently seen in the course of hepatic cirrhosis• in children, cirrhosis is rare; however, arf can be seen in combination with aseites and liver dysfunction• we describe patients with hepatic dysfunction and aseites in combination with ar~ and abnormal sodium-water handling, leading to the diagnosis of hrs. pathophysiology: three factors are considered in the pathogenesis of hr~: i) hepatic dysfunction, ) deranged hemodynamics, including abnormal blood pressure, reduced effective arterial blood volume and abnormal blood flew distribution, and ) neuro-humoral dysrsgulatiom, including elevated levels of aldosteron, renin, angiotensin-ll, ade, vasodilatim nitric oxide and vasoconstrictor peptide endothelin-l. the main pathogenetic feature is decreased cortical renal blood flow, decrease of glomerulur filtration rate (gfr), vastly increased sodium retention, uliguria, and azotemia. treatment: therapy is based on counteracting sodium and fluid retention by highdose aldosteron antagonists and loop diuretics, improving renal perfusion by lowdose dopamin, and strict restriction of fluid and sodium. interventions as paracenteals of aacites or n peritoneo-systemic shunt are associated with high morbidity and poor outcome in children. reversal of hem by conservative measures can only be attained at early stages of hrl liver transplantation is the only definitive treatment that can reverse ere at advanced stages. patients: the described patients developed severe ascites with insidious renal dysfunction and abnormal sodium-water handling during admission at picu and fullfilled clinical criteria fur hrs. treated according to the cited principles, all patients showed improvement of gfr, with increased natriuresis and gradual decrease of ascites. eventually, renal function normalised completly. conclusion: ere deserves greater recogmitimn in the picu population; diagnosis can be suspected on clinical criteria. with this increased awareness, therapy tun be instituted at an early phase, with better prospects for recovery. positive outcome of hem depends on early recognition of the clinical picture, understanding of the pathophysiology, and early institution of consistent treatment. mtx is an antimetatxflite widely used as chemotherapeutic agents. high dose ivitx (i to ~m ) administered as a prolonged intravenous infusion (over - hours), is often used to treat malignant paediatric diseases. major complications of this treatment are myelosuppression, orointestinal mucositis, dermatitis and impairment of anal function. we report two cases of mtx overd~age occurred in two children ( -year-old. month-old) t~ted for acute lymphoblastic leukaemia. they were treated by cavh and the mtx bhk~d levels rapidly decreasedavoiding multisystemic involvement. establishment of alkaline diuresis and monitoring of plasma mtx levels during treatment is essential to prevent nephrotoxicity. however. leuco',cnn rescue may not prevent the development of potentially lethal toxicities in patients with mtx concentrations persistantl} exceeding t mm. in theses cases, em'ly treatment of mtx intoxication may pm~cnt myelosuppression and reducerenal damage. the goal is to lower the concentration to below mmoll, at which time rescue agents aleme would be expected to be cllcctive. respective indications of these remo',at mctny.:is are still discussed : hacmt~ialysis t~ eharc(~l haemoperfusion should be prolx',sed for massive and acute intoxication. however, rebound has been reported after combined hcmodialysis and hemoperfusion. exchange transfusion may be proposed as a treatment for prolonged and moderate intoxication. peritoneal dialysis is an incflbedve method for remo~ al of mtx. cavh was used in our icu. cavh is a simple method for blood purification and n':dy iluid control. use of cavh was never be reported in this indication to our knowledge. simplicity, rap~d application and gco.l clinical tolerance are the main advantages of this technique. the technique presents ~peclal advantages in terms of low priming volume of extracorporeal circuit, low blood flow, low rate heparinisation. our results show a decreaseof plasma mtx concentration and a rapid reduction of halfqite of elimination (t hours over the period of cavh). moreover, we didn't delec~d rebound after stopping prc,xedure. small size of the i:ratients may present sometime special problems, but these technical problems can be overcome, no severe complication (needing, inlection) were observed during filtration, in summary, aggressive intravenous fluid hydration and alkaliniaation of the urine coupled with careful monitoring of renal function and plasma mtx concentrations during and al'tcr infusion along with lem~overin rescue has reduced the inndcace of life-threatening toxicity after highdose mtx. however, some mtx inu>xication still occurred, leading to se~em toxicity, particularly nephrotoxicity. in these cases, we think that cavh (or cavhd) is a reliable, rapid method without rcix~und increase in plasma mtx concentration or important adverses effects compared to other procedure removal. gouyon jb, germain jf, semama d, pr vot a, desgres j preliminary limited data suggested that hemofiltration and hemodiafiltration may be valuable in some neonates with decompensation of maple syrup urine disease (msud). venovenous hemofiltration (vvhf) and hemodiafiltration (vvhdf) were performed with a new neonatal hemo(dia)filter (miniflow , hospal) on anesthetized rabbits infused with branched-chain amino acids (leucine, isoleucine and valine) and c~-keto-isocaproate. the bcaa and aketo-isocaproate blood levels were close to those previously observed in neonates with msud when extracorporeal blood purification was required. vvhf and vvhdf performances were assessed with two different blood flows (qb = . and . ml/min). vvhdf was performed with dialysate flow rates (qd = , , . , . and . l/h). thus, each animal was submitted to successive procedures. within each studied period, clearances of the bcaa were strictly similar. bcaa clearances obtained by vvhf were similar to ultrafiltrate rates (respectively, . - . and . - . ml/min at high and low qb ; p < . ). the ~x-keto-isocaproate clearances obtained by vvhf were . - . and . - . ml/min at low and high qb (not significantly different). whatever qd value, the vvhdf procedures always allowed higher bcaa and c~-keto-isocaproate clearances as compared with the corresponding v'~hf period with similar qb. bcaa clearances obtained by vvhdf with a . l/h dialysate flow, were . - . mljmin and . - . ml/min at iow and high qb, respectively. the concurrent a-keto-isocaproate clearances were . -,. , ml/min and . _+ , ml/min. at both qb regimens, bcaa clearances provided by vvhdf were markedly higher than values previously obtained with peritoneal dialysis in human neonates with msud. the management of renal failure in the newborn is difficult. when dialysis is instituted peritoneal dialysis (pd) is usually the technique of choice. this is can be problematic and impossible in some patients with pre-existing intra-abdominal pathology. continuous arterio-venous haemofiltration (cavh) has been described in infants but sick preterm infants are not able to support the circuit. i have devised a means of having pumped haemofiltration in small/preterm infants (phis/pi) and describe its use in nine patients ranging in size from to gms for periods of to days. vascular access was achieved through or guage cannulae in either a peripheral artery and a central vein or through two central veins. blood was pumped out using an ivac infusion pump and through a gambro fh haemofilter. a second ivac pump was used to remove haemofiltrate from the filter and a third to infuse replacement solution. removal rate was set to give a clearance of mls/min/ . sq.m and blood flow rate set to between and times the removal rate. heparin was infused into the circuit to prevent clotting of the filter. biochemical and fluid balance control was achieved in all infants. guaranteed fluid removal allowed the administration of full nutritional support. four patients died when treatment was withdrawn because of an untreatable underlying problem. one recovered renal function but died some weeks later from unrelated problems, three survived and recovered renal function and one patient is still on treatment. this system allows a secure means of achieving fluid and electrolyte control in the preterm infant. the use of this technique may allow haemofiltration to become as applicable to preterm infants as it is to older children and adults. unibrtunately, children often receive no treatment, or inadequate treatment for pain and painful procedures. this prospective, multicentric study focuses on the efficacy, safety and side effects of novalgin (metamizol sodium) for this indication. patients and method: novalgin was administered to children, aged between - years, with acute, postoperative or procedural pain. novalgin ( - mg/kg) was given - hourly iv or im respectively, in some cases ( ) in combination with opioids (tramadol , piritramid , butorphanol ). the pain relief was assessed by six-step verbal rating scale (vrs) from to , vital signs were monitored, the side effects, that occured were recorded. results: pain relief was good (vrs less ) in children - . % of study patients. novalgin was very well tolerated, only one patient had adverse reaction -hyperpyrexia following intravenous application of the drug. discussion: novalgin (metamizol sodium) is safe and effective drug in the management of acute pain in children with low incidence of side effects. obie~qve: a prostx~tive study comparing simultaneous, indepeadent ratings conducted by intensi~ sts using an american (comfort) and an european chartwig) sedation scale for mechanically ventilated pediatric patients. measurements and results: the study comprised observations in mechanically ventilated pediatric patients (aged days to years) in a pediatric intensive care unit (from march to january . each patient was sedated by his/her managing physician with opiates, benzodiazepines, barbiturates, used isolated or in combination. each observation consisted of a -mid period of oly~ervatien of the patient in his or her pediatric icu bed, after each observation, the comfort (analyses dimensional physiologic and behavioral subscores -range to paints) and hartwig (analyses dimensional behavioral subsenres -range to points) were performed by the intensivist. we established the comfort scores ~ correspanding to adequate (range to ), excessive (range to ), and inadequate (range to ) sedation; and, hartwlg scores z correslxmding to adequate (range to t ), excessive (range to , and inadequate (range to ). statistical mmlysisj: agreement rate (kappa) and p <. was considere d s!l~nificant. comfort ( . %) ( , %/ ( . %) hap, twig , ( . %) ( . %) ( . %) to the comfort score, the average for adequately sedated, inadequately sedated, and too sedated was . +- . , z _+ . , and a.+_l , respectively. and to the ha~twig scorn, the average for adequately sedated, inadequately sedated, and too sedated was . :k-' . , . -&l , and . l- . , respectively. conclnsion: in our study there were no significantly statistical difference when you apply a more complex scale (conff'ort) or a less complex scale (hartwig) to assess the sedation of mechanically vemilated pediatric patients. the application of local and intravenous morphine infusion after surgery of urinary tract eva nemeth , m.d. semmelweis medical university , first oepartment of paediatrics , budapest , hungary in±roduction:continuous analgesia with morphine may be ~egaroed as a safe and effective method of pain relief during postoperative period. subjects and methods: children /mean age . years/ underwent elective ureteroneoimplanta±ion were randomly selected to receive either morphin intravenously of lo ug/kg/h /group one/ or bladder morphineinfusion ug/kg/h /group two/ after surgery. all patients were prospectively evaluated during their s±ay in the postanaesthetic care unit. cardiac and respirafory rates,blood pressure,sa ~,degree of alertness,pain perception and complaints of the paticnto ~cr~ recorded hourly. pruritus,nausea and vomiting,voiding difficul-±ies,sedation,dysphoria were systematically sough and quoted. statistical analysis was performed by chi square test. results:postoperative analgesia was the same in the two groups,but side effects were less in the bladder morphine group,because of the lower se morphine concentration.the differentes weren't significant in two groups. conclusions:the administration of bladder morphine infusion is a safe and effective method in children. objetive: compare the evaluations of sedation level made by physicians and nurses with the visual analog scale (vas) and the comfort scale (cs) in pediatrics patients receiving difforents modes of intravenous sedation. material ~ method." file evaluations were made by an attending physician and nurse with the vas and by another physician (always the same) using the cs. the observations were divided following the sedation mode: one drug (fentanyl or midazolan), two continuous drugs, one continuous and one intermi~ent drug and two intermittent drug (fentanyl and midazolan). the groups were compared using the t-student test. the groups also were compared between the percentual of agreement of the evaluations of sedation level made by physicians and nurses with the cs and vas using the x . results: we didnk find any statistical difference between the observations made by physicians and nurses with the vas in the differmts modes of intravenous sedation, the average of the observations using the cs betwom one drug and two drugs modes didnk exhibit also statistical difference. the observations made by physicians mad nurses using the the vas when compared with the cs didn't show statistical difference between the sedation level. we found statistical difference only in percentual of concordance of sedation level between physicians and nurses when compared the one and two drugs modes of sedation. conclusion: we didn't find differences in the observations made by physicians and nurses in the sedation level, only in concordance pereentua/ of observations when compared two modes of sedation. the observations using the cs (more complex) didnk show differences when compared with the vas. effects of age, concurrent administration of other pharmacologic agents, and disease [cardiac(n= ) & pulmonary(n= )] on the pk & pd of b were evaluated in volume overloaded infants aged days- mo (n= ). single doses of . , . , . , . , . , , , . , . & . mg/kg iv were given over - min after baseline evaluation. age was used as a continuous vadable to determine its effects on the variability in the pk & pd of b. values for pk parameters were compared between patients in cardiac and pulmonary disease groups. hierarchical multiple regression analyses were used to determine the effects of age, disease and other pharmacologic agents on the variability of bumetanide excretion rate (ber) and pd responses, e.g. urine flow rate (ufr) & electrolyte excretion. cit, cir & cinr increased with age (p< . ) while t, decreased markedly in the first monthe of life (p< . ). ber normalized for dose increased with increasing age. patients with pulmonary disease exhibited significantly greater clearance and shorter t~= (p< . ) than those with cardiac disease whereas vd~ was similar in both groups. the administered dose of b was the primary determinant of ber but increasing age also contributed. penicillin antibiotics decreased ber. dose response curves for ufr and electrolyte excretion were similar between disease groups. more of the variability in ber and pd responses could be accounted for in the pulmonary group than the cardiac group but this was not statistically significant. conclusion: the pk of bumetanide were influenced significantly by age and disease. differences in pk between patients with pulmonary and cardiac disease were primarily due to differences in total clearance. age and the administered dose of b were positive determinants of ber and pd responses while penicillin antibiotics had a negative impact on both, once b reached its site of action, no differences in pd responses were detected between disease groups. the pharmacodynamic effects of bumetanide were evaluated in volume overloaded infants (n= ) aged days- months. single doses of . , . , . , . , , , . , . , . & . mg/kg iv were given over - rain. bumetanide concentration in blood (n=l ) & urine (n= ) samples were quantified by hplc. baseline urine samples were collected over - hours prior to drug administration. determinations of urine volume, electrolytes (na ", k +, ci, ca ++ and mg++), creatinine and osmolality were performed before and at - , - , - , - , - and - hours after bumetanide dosing. changes in urine flow rate and electrolyte excretion were plotted as a function of bumetanide excretion rate which was considered the effective dose of the drug. peak bumetanide excretion rate increased linearly with increasing doses of drug and showed no evidence of approaching a maximum. time course patterns for urine flow rate and electrolyte excretion were similar for all dosage groups. urine flow rate and electrolyte excretion increased lineady up to a bumetanide excretion rate of approximately #g/kg/hr and either plateaued (urine flow rate) or declined at bumetanide excretion rates > #g/kg/hr. bumetanide had no detectable effect on serum electrolyte concentrations, conclusion: maximal diuretic responses occurred at a bumetanide excretion rate of about ;~g/kg/hr. higher bumetanide excretion rates produced no increased diuretic effect. peak bumetanide excretion rate of about #g/kg/hr corresponded to bumetanide doses of . - . mg/kg. neonates using an electrical syringe-pump. authors: tr~luyer j.m., sertin a., bastard v., settegrana, c., bourget p., hubert p. background and objective: many problems can be observed with drug administration by i.v. route, especially in neonates. so we evaluate different protocols of teico delivery using an electrical syringe-pump. methods: we simulate infusion of teico with a syrlnge-pump (pilot c, becton & dickinson lab.) trough d standart neonatal i.v. system. for weights ( or kg) we used doses of teico ( mg and mg/kg) and a dose volume _< . ml. our goal was to perform a complete infusion in minutes. the infusion system consisted of an life care infusion pump (abbott lab.) with its lv. set for maintenance intravenous fluid (flow _< ml/h) connected to a -way stopcock. an meter extension tubing was placed between the stopcock and a neonatal catheter. an another meter tubing (injection tubing) connected the teicoplanine syringe to the stopc, ock. the volume of the injection circuit (from the syringe to the distal part of the catheter was . ml methods of injections were assessed: a: injection of the predetermined volume of teico in minutes with no wash out. b: idem as a but the teico was injected in minutes, followed by a wash out ( ml / minutes). c: twice the required volume was introduced in the syringe and the volume to infuse was programed in minutes, followed by a wash out ( ml/ minutes). d: ]dem as c but a priming was performed before connecting theteico syringe to the tubing. during each run, serial samples were collected every ten minutes over a one hour period. the samples were assessed using hplc method. results: the amount of drug delivred at minutes were calculated. the results are a mean of to runs and expressed as the percentage of the total amount of teico prescribed. a , % , % b % , % c a % , % d , % % conclusiom for accurate and reliable intermittent drug infusion with a syringe pump it is mandatory to use a precise protocol of administration and to take in account ) a priming (for immediate starting of infusion), ) a drug volume greater than the dose prescribed and a programmed volume injected, ) a wash out of the tubing (with a volume ~ , x volume of tubing injection) caz is an antibiotic with activity against the major pathogens responsible for neonatal bacterial infections. we previously reported the pharmacokinetics of caz in preterm infants on day of life which showed that the clearance of caz increased with increasing gestationat age (ga). mean serum half-life of infants with gas < wks was . h. we wanted to investigate the effect of postnatal age on caz pharmacokinetics, we therefore studied caz pharmacokinetics on day - of life in preterm infants with gas < wks. caz ( mg/kg) was administered as an intravenous bolus injection. blood samples were coilected before (t = ), and . , , , , and h after the caz dose and analyzed by hplcassay, the pharmacokinetics of caz followed a one-compartment open model. during newborns with complex congenital heart defects requiering either htx or palliative staged single ventricle repair were admitted to our hospital: hlh n= , unbalanced cavsd, tga with hypopl. rv and hypoplastic aoa. tga with hypopl. rv, sas and dextrocardia. /i children had been admitted with cardiogenic shuck and mukiorgan failure due to intermittend closure ofductus arteriosus; in / stabilization failed. parents were informed about the known and unknown risks of the always palliative surgery; in cases parents denied further therapy. one pafiem with hlh underwent orthotopic htx at the age of month after the ducms art. had been stunted in the newborn period. month later he is still in favourable condition and without any sign of acute organ rejection. / underwent first stage of palliative single ventricle repair: norwood -op. ( ) ( n= ), damus-kaye-stansel -procedure ( ). the clue to adequate postoperative management was to archieve a balanced distribution of flow to systemic and pulm circulation, that is to protect the single ventricle from volume overload and to guarantee sufficient oxygenation and pulmonary development as well. with the centralvenous sato at about % provided maintaining the arterial sato at about _+ % is corresponding with a qp/qs of : . using modified bt-shunts of . mm resp. a central anrtopulm, shunt of mm in one case l severe puim. hypertension, surgery at weeks of age ) there was no excessive pulm. blood flow and no need to increase pvr with inspired co . one child ( norwood at weeks, preexisting pnim_ edema ) developed severe pulur hypertension and parenchymal pulm. dysfunction after prolonged bypass and multiple transfusions due to intraoperative bleeding: hypoxemia could be managed successfully by implanting a second shunt of mm hh later and temporarily using prostacyclin and no; at sternum closure dd later the second shtmt was banded to ram. follow-up ranges - month: all children are at home being assigned for second stage operation at about month of age. establishing clinical practice guidelines has become increasingly important in the current health care environment. significant effort has been focused upon development of post-operetive critical care pathways. however, benchmark data upon which such pathways should be based has not been well reported. length of mechanical ventilation (lmv) and length of stay (los) for children following cardiac surgery, for example, is poorly described. we prospectively recorded the lmv and los in patients who underwent cardiothoracic surgery between / / to / / . only patients who belonged in any one of five categories of congenital heart disease (ventricular septal defect _+ other septal defects (vsd), atrioventricular (av) canal, tetralogy of fallot (tof), transposition of great arteries (tga), and single ventricle physiology (fontan)) were included. eight non-survivors were excluded from the analysis. all patients were admitted to an intensive care unit cu) post-operatively where mechanical ventilation was managed by pediatric intensivists. lmv was defined as the period from post-operative admission to planned extubation. length of stay (los) was defined to be from le from the icu. cytokine patterns during and after cardiac surgery in young children. especially in children, cardiac surgery with cardiopulmonary bypass (cpb) can cause a systemic inflammatory response. this process is thought to be mainly a result of inflammation induced by surgery and exposure of blood to an artificial surface, and of reperfusion injury during weaning of bypass. complement activation, degranulation of granulocytes, induction of free oxygen radicals, endotoxemia and release of cytokines, are important contributing factors. we studied cytokine patterns before, during and after cpb in young children admitted for complex surgery or for septal defect correction. in the first group, significant amounts of il- and il-lra could be detected preoperatively. these findings could reflect the already existing hemodynamic dysregutation. in both groups, cpb procedure upregulated the circulating pro-inflammatory cytokines il- / , but not il- b. at the same time, il-lra became detectable. therefore, we suggest that in these patients the production of the anti-inflammatory cytokine il-ira was not induced by the preceding acnvity ot pro-inflammatory cytoidnes. during cpb, we noticed a sharp decline in the capacity of the leucocytes to secrete il- / . the ex-vivo production of il-lra however, was only slightly attenuated. we conclude that there is a differential regulatory pathway for the induction of il- / and il-lra. in addition, we studied the influence of dexamethasone administration on the cytokine pattern. administration delayed the appearance of il- / and il-ira in the plasma, interestingly, it did only interfere with the ex-vivo production of pro-inflammatory cytokines. the latter supports our hypothesis that production of il- / and of il-lra is regulated by two independent pathways, ( %) of pts. % ofpts < months of age developed metabolic alkalosis as compared with % ofpts > months of age.the infants with metabolic alkalosis received more citrated blood products and furosemide. following cardiac pulmonary bypass the highest ph-values and be-values were observed - hours and - hours, respectively. ii. prospective study: metabolic alkalosis was registerd in t children ( %), of those < month ( %) developed metabolic alkalosis and % of those elder than monms.durmg the postoperative course patients younger than months developed the highest ph-and base excess values after and t hours, in the subset of the older patients maximum ph and base excess was found after and hours, respectively. in one case the top level ofph-value exceeded . , the base excess + mvalb. conclusion: children undergoing cardiac surgery with cardiopulmonary bypass often develop metabolic alkalosis.in contrast to previous reports, we did not observe an association between metabolic alkalosis and mortality, nor greater frequency of cardiac arrythmias or prolonged mechanical ventilation. in context with decreasing serum lactate levels, our data show positive correlation of metabolic alkalosis with postoperative improvement of liver function. respirator, mechanics and weaning outcome in children undergoing cardipvascular surgery. vassallo j., cernadas c., saporiti a., landry l., rivello g., buamsha d., rufach d., magliola r. mechanical ventilation (mv) and acute respiratory failure are common events in children unergolg cardiovascular surgery (cvs), the development of new techniques helped to measure some of the main respiratory mechanics (rm) in a non invasive fashion. our goal was to evaluate the predictive value of these measurements in weaning (w) outcome in these patients, patients and methods: we prospectively evaluated children considered clinically to be ready for w with < kg and > hs mv. patients with diaphragm paralysis and those who failed w because of upper airway obstruction were excluded. before patient extubation the following measurements were recorded during spontaneous ventilation (cpap/t piece) using the cp neonatal pulmonary monitor bicore (lrvine, ca): total respiratory system static compliance (cssr) and resistance (rts), rapid shallow breathing index (rsbi). maximal inspiratory negative pressure (pi max) was measured using an unidirectional expiratory valve. threshold values predicting w success (ws) were: cssr > . ml/cm h , rts < cm h /l/sec, rsbi and pi max > - cm t . w failures (wf) -patient reintubation within the following hs, these values were compared between w success and failures using fisher exact test. an apriori level of statistical significance was chosen at p < . . considered, an increase in tnf-a levels is observed after cardiac surgery (p< . ) with a return to previous values after hours (p< . ). hours after cpb, similar values are observed in groups ii and ill, but there is a further increase in serum tnf-a levels in group i when compared with both other groups (p< . ). we found no statistically differences in any other moment. there was a significant correlation between serum tnf-o levels determined hours after surgery and cpb duration (p< , ). conclusions: cpb in childhood provokes a significant increase in serum tnfa levels, in newborns the inflammatory response is maintained hours after surgery. this enhancement of serum tnf-e levels indicates the existence of a relevant inflammatory response in these patients. introduction: cardiac surgery appears to induce a systemic inflammatory response. we have investigated the behaviour of il- i~ and il- before and after cardiac surgery. patients and methods: we studied serum il- and il- levels from children with congenital heart disease ( boys and girls), aged from days to years, undergoing open heart surgery, before cpb (d we found no statistically differences in the il-i levels in the different groups and moments. there is a significant increase in il- immediately after surgery (p< , ) with similar levels hours after cpb and a significant decrease (p< . ) hours after cpb. preoperatory il- levels were higher in the groups i and tl than in group i (p< . ). hours after cpb serum il- levels in group were significantly higher when compared with group (p< . ). conclusions: cpb in childhood induces a significant transient increase in serum il- levels, strongly relevant in newborns. cpb was not associated to a significant modification in serum il- levels. thus, cpb in childhood induces a dissociated behaviour in the proinflammatory il- and il- & pathways. obiective, to evaluate the effects of amg receipt on the clinical condition during the first hours after birth (t ), the morbidity and mortality in immature outborn neonates. methods. we studied outborn neonates with ga to wks, admitted during the years to . eighteen neonates exposed to amg (ga: , +lwks, bw: _+ g) and neonates did not (ga: , _+ wks, bw: _+ g). results. amg-exposed neonates compared to those not exposed had lower incidence of apgar score at min _< ( % vs %, p<. ), lower incidence of ph t < . ( % vs %, p<. ), decrease need of bicarbonate ( % vs %, p<. ), lower fio (fio min> : % vs %, p<. and fio max > : % vs %, p<. ), lower incidence of intubation ( % vs %, p<. ), lower requirements of surfactant ( % vs %, p<. ) and lower mortality ( % vs % p<. ). there were no differences between the two groups for the following parameters: type of delivery, hypothermia hypoglycemia and anemia during admission, hypernatremia, hypotension (map< mmhg), need of dopamine and or plasma , incidences of ptx pda sepsis nec severe rop major ivh (plus pvl) and bpd and duration of intubation. conclusions. the main beneficial effects of amg receipt on the immature outborn neonates were the decrease of mortality and the decrease of surfactant need. there was no effect of amg receipt upon other severe morbidity in this high risk group of neonates. premature babies are very sensitive on homeostatic disturbances, and often develope intracranial haemorrhage (ich). ultrasound scan of the bram shows four grades of ich: -grade i -only periventricular hyperechogenic areas -grade ii -haemorrhage ham the lateral ventricles -grade ili-dilated lateral ventricles -gtrade iv -intracerebral haemorrhage. the purposes of this study were: to show the incidence of ich in premature babies and its correlation with the gestational age, . to determine the severity of ich . to present the outcome &those babies. in the study were included premature babies successively-born at the department of gynecology and obstetrics before gestational week (g.w.) and grouped in three groups: less than g.w., - g.w., - g.w. to all of them was performed ultrasound scan of the brain. results : . the incidence of ich hi premature babies is % and there is ingh level of correlation with the gestational age: -babies born before t~ g.w. have % incidence of ich and graduated : i grade - %, ii grade - %, iii grade - %, iv grade - % -babies old between - g.w. have incidence of % : i grade - %, i[ grade - %, iii grade - %. -babies older than g.w. have incidence of %: i grade - %, ii grade %, iii grade - % . sixty of premature babies have died and it is . % lethality. in all died ilffant was confirmed the grade of ich diagnosed by ultrasotmd scan of the brain. d. maksimo~ c. z.braiko~ic, n.vunjak. p. ivanovski ( ~iversi~, children's hospital. belgrade, yugosla~, ia infantile intracranial hemorrhage is the most frequent and serious manifestation of late hemorrhagic disease of the newborn caused by ,,~tamm k deficiency in earl?,, ti~fancy. in the last two years, we recorded five cases of infantile intracranial hemorrhage due to "dtamin k deficiency, despite routine prophylax~s (intramuscular vitamin k, mg) , with bpieal clinical presentation: age was - days (average days): vomiting, poor feeding, lethar~'irritabiljty, palor, bulging t ntanelle and convatsiones were present in most cases.two patients developed signs of hemorrhagic shock, with hemoglobin level less than g. . in ~ f \qi level was less than % of predicted value. there was no evidence of head trauma or liver disease in none of patients. four inlants were breast fed, while one, who had diarrheal disea.se, was on adapted milk formula. routine therapy wa.s given (including vitamin k and fresh frozen plasma). two patients were discharged with no sequellae, one developed posthemon'hagic hydrocephalus as a complication and two patients died. late hemorrhagic diseo.se of the newborn is sill/ a significant cause of morbidib' and mortality in earl ' infancy, despite different approaches to prophylaxis developed in recent years. background: neonatal hearing screening in at risk newborns can detect % of the children with a congenital hearing loss. automated abr hearing screening (algo- ) has been introduced for healthy newborns. the aim of this study is to test the validity of this algo- screener in at risk newborns in a neonatal intensive care unit. subjects: at risk newborns (median gest.age: . wks, median birthweight g) selected according to the criteria of the american joint committee on infant hearing. interventions: algo-i automated abr-hearing screening at a level of db was performed in the neonatal intensive care unit. when bilaterally referred, further audiologic screening and/or therapeutic intervention took place. when passed uni-or bilaterally, children enrolled in a) a nation wide screening programme (ewlng) at the age of months and b) in a half yearly follow-up programme in which hearing and speech-and language development were observed according to egan an illingworth. results: screening without disturbance from ambient noise or from routine technical equipment was possible in the incubator, even during nasal cpap therapy. ( %) newborns passed algo- screening. ( %) did not pass bilaterally. of with a congenital rubella died shortly after screening.in of bilateral congenital hearing loss of -> db was confirmed. of the newborns passed were still alive at the age of year. ewing screening was performed in of ( , %). / passed, of had passagere conductive hearing loss, in / no further investigation was performed. all children enrolled in the i/ yearly follow-up programme had normal speech-and language development. in this study all at risk newborns with bilateral congeni "tai hearing loss were detected with algo- screening. screening results showed no false negatives at follow-up. the algo- infant hearing screener can be used as an valid automated abr-screener to detect hearing loss in at risk newborns in a neonatal intensive care unit. gancia gp, bruschi l pnlito e, ferrari g, rondini g -divisione di patologia nc~matate e turapia intensiva -irccs policlinico s. mattco -pavia, italy latrogenic esophageal perforations (iep) in preterm and term infants are seldom reported in litteraturc, in association with difficult endotracheal (et) intubation (with or without stylets), insertion of gastric tube, and pharyngeal suctioning with stiff catheters. crieopharyngeal muscle spasm caused by instrumentation may also lead m a narrowing of lumen, with increased risk of local injury. we report iep observed in intubatcd, mechanically ventilated newborn infants ( male, female, all outborn). a common feature of iep was inability to pass a nasogastric (ng) tube into the stomach, mimicking e~)phageal atresia.~se : birth weight (bw) (i g, gestational age (ga) wk, sepsis. before admission to n cu, the baby underwent multiple et inmbations, because of inappropriate securing of et robe. bloody secretions in pharynx were observed. the endoscopy showed a large lesion at the end of proximal third of the esophagus, case : bw g, ga wk, rds. chest x-ray (cxr) showed a retrostcrnal air leak: the ng tube was stopped }~etwcen d and d and soluble contrast was seen in upper mediastinum.case : bw (/g, ga wk, rds. the endo~opy showed an esophageal lesion. cxr showed a paravertebral route of ng tube and a right pneumothorax.case : bw (i g, cz ,.v!:. rd c. ~!,'.::;;: ::':'_'rvt!~' s l" ~k':.rvrx. cwr, d,,,,vs ~,,mr~e, ~n rhe upper mediastinum and abnormal route of ng tube through a false passage. surgical intervention is needed in case of mediastinitis or mediastinal abscess: conservative management included broad spectrum antibiotics, total parenteral nutrition, antireflux therapy and, if necessary, drainage of air leaks. enteral feeding has been stopped lor days and cautiously resumed after radiographic study. [x~cal sequelae and death are uncommon, but iep occur in newborns with high risk of death due to prematurity and other diseases. in our patients, et intubation has been performed by experienced personnel: therefore the lack of skills in resu~itative procedures is not always the main factor of iep. prevention of iep requires appropriate materials (et tubes, laryngoscope blades, suction catheters), and procedures (positioning of the infant with correct neck estension, firm et placement). sedation and pain control may help to prevent the muscle spasm. aggressive treatment has improved the tong-term outcome of extremely low birth weight neonates (elbw) but it has also increased the chances of iatrogenic lesions. reviewing the charts of our neonates we observed a high number of vascular injuries. from to , neonates were admitted to the neonatal intensive care unit (nicu); of them were elbw ( . %). studying the charts of these elbw we observed cases ( m - f) with vascular lesions ( . %). mean gestational age of these patients was . weeks (rain -max ). mean weight at birth was g . mean weight at diagnosis was g ( - ). in the same period patients with vascular injuries were reported in the neonates over g ( . %). the injuries observed in elbw group were: arteriovenous fistula ( bilateral) at femoral,level, carotid lesion and limb ischemic lesions. aetiology was in cases by venipuncture, in one case umbilical catheter and in the case of carotid lesion a wrong surgical maneuver. no general simptoms were observed. the vessels were repaired with microsurgical technique in six cases: the carotid lesion and five arteriovenous fistula; one case was solved with thrombolitic drugs; an amputation at knee level was required in one case after a long period of medical treatment. the last neonate with an arteriovenous fistula was only observed for parent's will. at follow-up (clinical and by ecodoppler) out of neonates presented normal vascular function without sequelae. from our experience elbw neonates have more chances than older neonates to develop iatrogenic vascular lesions. we advocate an aggressive microsurgery and/or medical treatment to obtain good results and prevent late sequelae. a retrospective comparison between natural surfactants l.j.i.zimmermang m.c.m,van oosten. dept. pediatrics, div. neonatofogy, sophia children's hospital/erasmus university, rotterdam, the netherlands. aim: retrospective comparison of alvofact (in ) versus survanta (in ) as rescue treatment for neonatal respiratory distress syndrome (rds). methods: both surfactants were given at an initial dose of mg/kg (except for alvofact mg/kg for mild rds grade mi). repeat doses were attowed (survanta mg/kg, alvofact mg/kg) up to a maximum of mg/kg, all parameters and outcome criteria were strictly defined beforehand. the initial response (good,mild,no response,relapse) to surfactam therapy was defined on the basis of the decrease in fio . results: there were no signif. differences in patient population and initial parameters: ga ( . +_ . vs a _+ , wks), birth weight (t _+ vs -+ g), severity of rds (grade ill-iv: . % vs . %), apgar scores, cord blood gases, initial ventilatory settings. in ' however, the initial surfactant dose was administered earlier than in ' ( . -+ . vs . _+ . hrs postpartum, p= . ). although the average total cumulative dose was equal in ' and ' ( . -+ , vs . _+ . mg/kg), more doses of alvofact were given compared to survanta { . _+ . vs . _+ . , p=o.o ) and more patients in ' received more than two doses than in ' ( % vs % of patients). there was no difference in the incidence of non-putmonarycomplications. aivofact ( there was a better initial response to survanta and a better respiratory outcome in : in the group < g the duration of ventilation was half in , and in the group >~ og the duration of extra o need was half in as compared to . we speculate that the main reason for this difference is the earlier and initially higher dosing used with survanta compared to that used with alvofact which was given in the same total cumulative dose but over a larger time span. background: e×ogerlous sur&ct~t raplacem~t treatmem has become rou~ne k~ the t~eatme~t of respira~"¢ dim'~ syndrome (i~ds) of pr~e~tur~, wh~eas its effica w th odi~ respiratory diseoses is sdi being wader mvesugatio~. objective: "eac~ mt ereat isto report ottr results of prospect/re, non-randomized "re~-o.e" study oe suffact~t replacement in outhom premamae infa~t~ with rds reruirmg me~aical ventilatioa (nfv). p~tien~ and metho .s: from j-aly to june , / ; ( %) out~ ~¢ infaats, at a mesa age of z , horn's ( boys, ~rls; ~ gestafioan age -+ . weeks, mera~ birth weight _+ g, ~ . i" at minutes) with rds, requiring mv, received bov~e-suff~amt (survanta, ros~/aboti, laboratotie~ columbus, ohio) eadotracheally, as was recomm~aded by maaufacturer. as the c,~:ttrol group o~bom premature infants (ot~ of ; %, admitted with rds from euiy to eune ) were saelected ~d who did not receive surfaaam, compared with ~hctant ~'oup they were admitted for treatmeat e~'li~" aft~" daliv~:y (at the age . :: . hours vs. . +- hours), but they did not diff~ in othe~ baseline dam'a~eri~cs at ~ti~ion. entry crkeda for ~¢fa~aut ~hcadou were fractional i~firat o~ oxtgem r~emeats -fio > . - . , ratio au-lerlal to alveolar oxygea pre~are~ao ~ao < , ~ad oxyge~at,~ i~.dex -ol > . primary o~comes were deter~caned by ~hanges m exs'ge~ab, c~ ~r~d vmtilatic~ ~ the following variable~; ( ) fi'aaic~ of i~spired oxtge~ (fio ); ( ) mesa nnvay presmzre (map) ( ) pag ~ao ratio, ( ) oxyge~ion index (oi). commo~ comphcadces of prem,musty ~d con~ol mechamcal v~ati]al~on (pater dumas merios.s, intracr~nlal haemcrn:hage, air leak, br onchop ulmrmm'y dy~pl~a ~d death) were reg~ded as sec~d,~y outcomes. r~suas: in warfactaat group we observed slg~ .c~t improve~aeat (p< . ) in oxygea~thia md veaatilation at hours all~ e~try k~to the m~dy in compari~ion to nons~fa~m" group. compa~on of secondao' outcomes in ~ts with p,.ds showes table l we did not observe ~y major acute hfe fl:u-eattming complicatlola,s m sxlrlhct~mt grou~ tr/lmediately after stu'~actsmt rcplacemev_t therapy. the duramm of mechmucal ven~ation ~ad oxygen lreau~ent m survivals of both groups did not dafter gmficautl y a-ore ead~ other. condusion: l!a premature mthats with rds treated with surfaaaat replacemeaat therapy we observed decrease m mc~de~ce of tme'~m~o~oraces add de~th (p< . and p< . ), whe~e~s m othe~ observed variables thee was uo ,igmfi~t d~=ecce infectious complications during the therapy of respiratory insufficiency in neonates with birth weight less than g in the course of yearsretrospective study. zitek infants on cmv, cppv, and imv were administered exosurf in dose of - mg/kg twice endotracheally (see table) . in newborns ( . %) hours after surfactant admin fi value decreased by . %, and after hours -by . % compared with initial value; pip and peep values decreased by - cm h and - cm h after hours, and by - cm h and - cm h after day, respectively accompanied by mean decrease of aado from , to . mmhg, qs/qt decrease from . to . % (see table) . mean time of cmv, cppv was . days, imv- - hours, cpap - - hours. respiratory therapy in newborns ( . %) was complicated by pneumothorax (bilateral -in infants chorioangioma is a rela~ively rare placentai malformation associated with considerable mortality and morbidity. a chorioangioma can be regarded as an arterio-venous shunt in the circulatory system of the fetus. this causes volume loading eventually resulting in cardiomegaly and high output cardiac failure. a female neonate (gest age wk, birth weight g, - . sd) was born with an apgar score of and after and rain respectively. the placenta showed multiple chorioangioma. ultrasound of the heart showed a hypertrophic cardiomyopathy. she developed severe hypertension ( / mm hg), treated with nitroglycerine and nitropruside. finally blood pressure decreased when enalaprillic acid was given ( . mg.kg ). we measuered the activity of the renin-angiotensinsystem. an elevation in renin-angiotensin system is shown probably to compensate for the low resistance circulation before birth, hypothesis: the instantaneous cut off of a large arteriovenous shunt did not result in a fast downregulation of the renin-angiotensin system resulting in hypertension. hypertension should be added to the list of complications of chorioangioma of the placenta. the authors studied cases of children's septicemia with blood culture yielding staphylocucetts aurens. the age of patients varied from months to years ( , % from years downward), % of the children caught their disease in the hot season (may to october). the deaths also occured in this season: , % ( / ). following were the anatomo-dinical lesions. -skin %, muscle , %, bone , %, joint . %. -viscera : lung %, heart . %, cerebrum . %, kidney . %, fiver , %. -simple lesion skin-muscle-bone joint: %, no death in this group. the concomitant lesions of the soft tissue,bone-joint and viscera : % with one viscera, % with two viscera, % with three viscera and % with four viscera. -bone lesion : mainly on the long bones ( % on the tibia, % on the femur, the remainder being the mandible ( ) and the humerus), inflammation of' the hip joint was the main one. -i,ung lesion had forms pneumatocele ( cases), bronchopneumonia ( cases), pleural effusion ( cases), multimicroabcess bursting into the pleura ( cases), most multimicroabcesses were lethal : / ( , %), -heart: all thethreelay~rs got le@~r~, % had or layers alrected and death ensued. -cerebrum : the meninges had three forms of lesions purulent meningitis ( cases), obturafing embolns of brain vessels ( cases) and cerebral abcess (one case). the characteristic clinical sign was paralysis and meningismus, phlebothrombosis of eavcrnous finus ( cases)was mually ther~sultofalxil vdfi:h burst there were cases of death with lesion of the meninges and cases of obturating embolns of brain vessels. -the main sign of lesion of the kidney was a change in the components of urine: % got proteinuria, % had leucocytes in their urine, % had erythrocytes in their urine, the urea in their blood increased (over rag%) in . % of cases.the lesion of the kidney seemingly had little relation to death. seven cases of ictertts due to an increase of direct bilirubinemia and a decrease of blood-albumin. -the biological characteristics of the pathogen staphylococci showed that all the isolated specimens had positive coagulaza ; the specimens from the dead patients were less semiti~e to, mad ~t to mali~ overag death rate was . % ( / ). the fungal infection to fusariun species in immunocompromissed child have been reported in the literature with a rare, severe and high, mortality rate in spite.of the use of antifungal drugs. we report a case of successful treatment of a severe disseminated fusariun infection in a ll-year-old boy with acute lymphocytic leukemia (lla-l ), after use a chemotherapy followed by absolute granuloeytopenia. the patient developed fever, skin lesions, pneumonia and fungaemia. fusariun species was cultured from the blood, necrotic skin lesions and lung secretion. the child developed multiple organ system disfunctiou in spite of use broad spectrum antibiotcs and antimycotic therapy needing. uci during days. the patient receive suport treatment (mechanical ventilation, inotropie d~.ugs, diuretics, imunestimulants, blood components, a broad spectrum antibiotes and antifungal agents). we absorved a gradual recovery in the white blood cell count and regression on the sites of infection. the association of preeoce diagnostic and the terapentic with increase in the white blood cell count was the most important in a successful treatment. a year old african-american child suffered a severe pulmonary injury in a house fire. initial survey revealed % total body surface burns, soot on the face, and bloody endotracheal secretions. initial chest radiograph revealed diffuse, bilateral infiltrates. severe respiratory failure with an oxygenation ratio of rapidly developed. he developed a pneumomediastinum and subcutaneous emphysema. although transient improvement occurred with inverse i:e ventilation and surfactant, he became more hypoxic (sac as low as %) and acidotic. on day post injury, he was placed on venc~venous extracorporeal life support (ecls). on ecls day he was decannulated. chest radiograph on ecls day showed an opacity in the left chest. ultrasound of the left chest was consistent with atelectasis rather than pleural fluid. flexible bronchoseopy failed to reveal any obstruction in the left lung. a computed tomography (ct) seen of the chest, which was performed after decannulation, revealed a large loculated collection of fluid in the left, anterior chest. under ct guidance, a f cope loop catheter was inserted and cc of thick blood was removed, follow-up ct performed immediately after this procedure revealed minimal change in the size of the fluid cavity. over the next hr, we instilled urokinase , units over minutes every two hours. a minute dwell time was allowed before draining the fluid. repeat ct scan done at the end of the urokinase infusion showed a marked decrease in the size of the fluid cavity. act scan was not performed prior to decarmulation because the ecls circuit tubing was too short to allow appropriate positioning of the child in the ct scanner. after a ct scan revealed loculated pleural fluid, a simple drainage procedure was diagnostic but inadequate treatment. we were able to successfully dissolve the thrombus after hr of urokinase therapy even though the thrombus was > days old. we suggest that large loculated plenral thrombi which develop as a complication of ecls therapy may be successfully managed with urokinase infusion. introduction: haemorrhages, particularly intracranial, are major complications experienced in - % of neonates treated with extracorporeal circulation. an induced thrombocytopenia and impaired platelet function play a key role in the increased bleeding tendency observed in these patients. the aim of the present study was to establish a dose-respons curve for the effect of a synthetic protease inhibiting agent, nafamostat mesilate (fut- ), on platelet membrane glycoprotein density and platelet activation during experimental perfusion. methods: two identical extracorporeal life support (ecls) circuits were primed with fresh, heparinized human blood and circulated for h. four different concentrations of fut- ( . mg/l blood/h; . mg/l/h; . mg/l/h+ % bolus at the start of the perfusion and & mg/l/h+ % bolus) were used in different perfusion experiments. a total of eight paired experiments were performed. platelet count, plasma betathromboglobulin levels and platelet membrane density of glycoprotein ib and lib/ilia were followed as well as plasma concentration of haemoglobin. results: a protective effect of the agent on platelet count, plasma concentration of btg and platelet membrane gpib could be observed during the first hours of the perfusion when a bolus dose was added. no positive effect could be recorded with the two lower doses used. plasma concentration of haemoglobin was higher in all the fut-circuits compared to the control circuits. conclusion: the addition of a bolus dose of fut- at the start of the perfusion seem to induce a protective effect on platelets during the first hours of perfusion. extracorporeal membrane oxygenation (emco) is a form of invasive cardiopulmonary support that can provide imporary physiologic stabilisation in reversible circulatory failure and or respiratory failure. we reviewed our expierence with extra corporeal membrane oxygenetion in children aged day to year between and . two neonates was succesfully decanulated, but died - well after decanulation due to septic complictions. one child years old, one neonates died on day and day" respectively while still on emco. complication which were and encountered were heavy bleeding in case (child), (neonate) and raceway rupture in case (neonate). problems which are specific developing countries like indonisia are: high cost ( . us for days) difficulty in transportation (transporting intubated baby) from the orgin hospital, lack of knowledge and understanding of the primary physician and nm-ses and difficulty organizing in hours emco team. resnratory mon tor/ng in picu z,zjvkovic, s. mihailovic, o, tosev respiratory monitoring in pediatric intensive care unit picu) provide the importartt informations for understanding of the pathophysiology of the clinical signs, aid with the diagnosis, and assist in therapeutic management and predicting prognosis. pien in children's hospital for ~flmonary diseases and tuberentosis remained for the t~s't two end a half years relatively limited for diagnomic tools and therapeutic regimens, mostly because of the poor fmnaeial suptx~rt. the number of children admitted for aurae asthmatic at.lzek~ severe pneumonias, bronehiolitis, complicated pulmonary tuberculosis, foreign bodies and exacerbations of ehronit'. pulatonary diseases was t . for all patients the respirator' monitoring system means: physie~d examination, ehe~ x rays, capillary bltxxl gas mmlyses (vevv few ehiktren experienced itwasive arterial blt~.~'i gases), noninvasive oxyntctry, measuring of the vital capacity in coopo-able patients, as~d capnography. later on, after the imtial critical illness, a complete hmg fimction tests was performed, as well ,~s bronehoscopy in selected eases, (~lr experience revealed that abotrt % of ehil&en heos suecessthl outcome, without s~lllens , instead they had been tremted in limited conditions. ']'he rest of our patients were previously diagnosed ~s ettronie pulmonary patients, with high risk score system ibr having seqnells 'llae mortality rate were , %. the continuous blood gas monitor, pasatrend (biomedical sensors, ltd., high wycombe, bucks, england) has the capability of measuring ph, pco , and po via an indwelling optical absorption optodelclark electrode sensor that is placed through an intra-arterial catheter. we evaluated the accuracy of the sensor in radial and femoral locations in critically ill pediatric patients. methods: the simultaneous values of ph, pcoz, and po recorded from the paratrend monitor were compared to values measured by standard arterial blood gas analyzer (coming , ciba-corning diagnostics, medfield, ma). criteria for the elimination of data points included a core vs. sensor temp. gradient, and sensor pulled back beyond accepted insertion distance. mean time of monitoring per sensor was hours (range . - . hrs). mean time of radial monitoring was hrs (range . - . hrs) and of femoral monitoring was . hrs (range . - . hrs.). linear regression and bland-altman analysis for bias and precision for each parameter were calculated. results: a total of patients (age range weeks to years) had paired samples of ph, pens, and poz made by the sensor and blood g&s analyzer. the range of measurements were ph . - . , pco, . -i . t(n r, and po - torr. the paratrend monitor demonstrated accuracy that is comparable to the accepted standard of blood gas analysis in a group of critically ill pediatric patients manifesting wide variation in ph, pen , and poz..this technique appears m be very useful especially in the extreme values of the parameters measured. funding provided by biomedical sensors. understanding of pulse oximetry d.semple, l.e.wilson. royal hospital for sick children, edinburgh, eh lf, scotland, uk. pulse oximetry is a useful, non-invasive monitor, routinely used on the itu and increasingly often on the general wards. we used a questionnaire incorporating questions on the theory and clinical uses of the pulse oximeter to assess understanding of pulse oximetry in medical and paramedical staff doctors indicated grade, speciality, pulse oximetry tuition and neonatology experience. doctors, itu nurses, t medical students and physiotherapists completed the questionnaire. some confusion existed between the principles of pulse oximetry and transcutaneous oxygen measurement. wide variations in the lowest acceptable saturation in fit children were seen ( - %), with around % of respondents in all groups accepting values of % or less. some potentially serious mistakes were made in the evaluation of oxygen saturations in the clinical scenarios. there were widespread variations in correct responses at all grades of medical staffing. nurses scored well on more clinically-orientated questions but relatively poorly on theory. only % of doctors (mostly senior grades) had received tuition in putse oximetry. neonatology rotations appeared to confer little additional knowledge on pulse oximetry. few doctors and nurses receive tuition in the use of pulse oximetry a significant proportion of nurses and doctors, of all grades, exhibited a lack o{" understanding of the principles of pulse oximetry. this may result in unsafe use of the equipment and put patients at risk. one can see from the table that blood composition in uv and ua differens in some characteristics, and similar in sgp magnitude. venous-asterlal gradients "gas functiomals" between uv and ua represent the measure of difference in this characteristics. the gradient cari be positive, zero -order or negative and change both in value and in sign but not reach apo (positive) and apco (negative) in absolute significance.minimization of "gas functionals" deviations atom the zero is achieved due to"mutual replacement acts" between po and pco in uv and ua blood. we suggest that presented tests can be useful in full evaluation of gas exchange in newborns. (pap) in the context of pulmonary hypertension is oft desired but rarely achieved. inhaled nitric oxide (no) has been shown to produce this desirable effect, but is relatively difficult to administer or monitor. we wondered whether np, chemicaily related to no but more stable in solution, would produce similar physiologic effects when administered in the convenient modality of nebulization. methods: piglets were anesthetized, mechanically ventilated, and surgically instrumented. systemic blood pressure (bp), pap, and cardiac output (co) were monitored continuously. after postoperative stabilization, . % nac} nebulization was begun, and pulmonary hypertensiorr was induced by reducing fio from . to . . the piglets were monitored for minutes during this hypoxic phase, next, without altering fio or ventilator settings, np ( mg/ml, dissolved in . % nacl, flow ipm) was substitued for . % nacl in the nebulizer circuit. np was nebulized for mins. results: during hypoxia, pao fell from to mm hg. pap rose during hypoxia from to torr (p< . ). ,^fhile bp and co did not change significantly. pap fell during nebulized np in each piglet, (mean apap = to torr; p< . ; mean reduction of hypoxia-induced rise in pap = %; range: to %; p < . ). pvr/svr fell by % during np nebulization (p< . ), while bp and co did not fall significantly ( to tort; to mllkg-min), the reduction in pap began within minutes of the onset of nebulized np, and appeared to reach a plateau by minutes. no tachyphylaxis to nebulized np was noted. nebulized np did not significantly affect pap, bp, or co under normoxic conditions. conclusions: ) like no, np selectively reduced hypoxia-induced pulmonary hypertension without altering systemic bp, ) unlike no, np can be administered by nebulizer, a technique familiar to virtually all health-care providers, and potentially adaptable to both intubated and non-intubated patients. } nebulized np may be beneficial in clinical contexts where inhaled no is impractical. dang phuong kiet and nguyen xuan thu examining cases of purulent pericarditis with various clinical forms treated by surgery, the authors drew the following experiences for their diagnosis. t. clinical factors. purulent pericarditis appeared like a cardiac tamponade in a septicemia due to staphylococci with dassieal symptoms: severe dyspnea, tachycardia, faint heartsound, big liver, prominent cervical vein ; rentgenography of the chest showing enlargement of the cardiac silhouette, a diminution of ventricular pulsations, ~i clear lung field. by an emergency operation, ml of diluted blood were drained. purulent pericarditis and pleural effusion appeared at the same time but at first tile symptoms of purulent pericarditis were masked by the predominant symptoms of plearal efihsion. after the pleura was drained, its pus was no more, the general state was relatively stabilized but there still were big liver, dyspnea, enlargement of the cardiac silhouette while central venous pressure increased. purulent pericarditis appeared late. in the first stage (about weeks) there was no suspected sign. later on gradually appeared such symptoms as dyspnea (during serum transfusion for instance). central veinous pressure also raised. the heart chest diametre increased at first (up to - %) then decreased (down to below % ) but the liver kept on swelling together with the particular changes of electroeaediegramme. now the pericardium had no more pus but get fibrous (up to ram) thus constricting the heart and its main arteries ike pick syndrome). . diagnostic values of electrocardiograms : common signs of ecg related of these purulent pericarditis were: a diminution of voltage, a widespread elevation of the st segment, the tf wave flattened and inverted. however, what should be stressed was : the diagnostic values of an electrocardiogram for purulent pericarditis was mainly in the dynamics of their signs: in the first week, the voltage diminished corresponding to a pericardium containing pus, while the st segment went up then seemed parallel to the fibrosis of the epicardium, the liver swelled, the central velnous pressure increased, the heart/chest dimension ratio decreased, the st segment went down, the t wave became more flat and inverted. between and neonates, aged - days (median ), weight , - kg (median , ) with critical valvar pulmonary stenosis were scheduled for balloon dilation (psvp), children ( %) were on pge and ( %) needed mechanical ventilation. after stepwise dilation a final balloon : pulmonary valve (pav) ratio of % ( - ) was achieved, there was a significant correlation (p< , ) between an adequately sized balloon and freedom of reintervention. two valves could not be passed, four neonates underwent surgical procedures (brock n = , commissurotomy n = ), two children ( %) died of sepsis. / patients ( %) were successfully palliated by psvp in the first month of life. the rv : systemic pressure value fell from % ( - ) to % ( - ), complications included transient dysrhythmias, transient hypoxia, vessel occlusions;- right ventricular outflow tract perforation. in / patients follow up data is available. the residual systolic peak doppler gradient over the pav on the last out patient visit ( - months after psvp) was - mmhg (median ). four children needed repea.ted psvp to months after the initial intervention. conclusion: psvp of critically ill newborns is possible. the risk of mortality is relatively low. psvp in neonates with an adequately sized balloon is a challenging alternative to surgical treatment. post hypoxic-ischemic (hi) reperfusion induces the formation of non protein bound iron (npbi), leading to production of the reactive hydroxyl radical. it was investigated if the ironchelator deferoxamine (dfo) could reduce free radical production and improve neonatal myocardial performance after hi. severe hi was produced in newborn lambs and changes from pre-hl values were measured at , and min post-hi for (mean) aortic pressure (mean pao), cardiac output (co) and stroke work (sw). left ventricular (lv) contractility and co were assessed by measuring lv pressure (tip-manometer) and volume (conductance catheter), using inferior caval vein occlusion to obtain slope (ees) and intercept of the end systolic pv relationship (v ). npbi, reduced and oxidized vitamine c ratio (vcred/ox) and lipid peroxidation (mda) were measured from sinus coronarius blood. lambs received dfo ( mg/kg i.v.) immediately post-hi, control lambs (cont) received a placebo. results: mean pao was stable, co and sw decreased up to and % respectively in cont as compared to pre-hi. in both dfo-groups co and sw remained within the normal range. ees and v decreased in all groups post hi, but did not differ between groups. npbi and mda were higher at min post hi (p<o. ), vcred/ox was lower at min post-hi (p<o.o ) in cont as compared to dfo-group, indicating more oxidative stress in cont. conclusions: dfo reduced the oxidative stress of the heart and prevented co and sw to drop, suggesting a positive effect of iron chelation on the myocardium after h{. from we published reports with analysis of performance of the heart as a whole organ.while analysing the heart performance as a whole, we recognize three block in it located intrapericardially: l."atrial"block -left (la) and rigth (ra) atriums; ."aorta-pulmonary" block-aorta 'bulb (a) and pulmonary artery(pa); .ventricular "three-chambered" block (vb) consisting of: -left (lv) and right (rv) myocardial chambers, both frith blood outflow into "aorta-pulmonary" block vessels, and -spongy (venous) myocardial chamber with the blood outflow through coronary sinus (cs) and thebesiau vein (tv) into "atrial" block. the following conceps are introduced for vb functions assessment "common" systole and "common" diastole of "three-chambered" vb. the process of normal "common" vb systole: -begins with blood ejection from vb spongy chamber into the "atrial" block; -continues with blood outflow from rv and lv into "aorta-pulmonary" block wi~ venous minimums -x-coiiapses -~btmation iu "a~riai" block; -completes with "three-chambered" vb general emptying. at this period the following blood volumes are transferring: -two-from rv and lv(their stroke volumes)into"aor~o-pulmonary"block; -two-from "spongy" chamber .into "atrial" block; -two-from systemic and pulmonary veins into "atrial" block during the process of so called "systolic" membrane suction (at pulling atrio-ventricular valves into rv and lv chambers as blood ejects out of them). it appears to be the regulation of blood inflow to "atrial" block by blond outflow from "three-chambered" vb into "aorto-pulmonary" block. objective: to evaluate the efficacy and complications of transpyloric enteral nutrition(ten) in critically ill children patients and methods~ from june to january children (i boys and girls), aged from days to years (mean l. ± . years) were treated with ten. patients were included after cardiac surgery, with acute respiratory failure, and after cerebral surgery. the indication of ten was mechanical ventilation in patients and failure of nasogastric nutrition in patient. children ( %) had previously received parenteral nutrition. and i fg enteral tubes was inserted into duodenus through nasogastric intubation en patients and by endoscopy in patients. rx and ph determination were used as methods to control tube situation. children received adapted formula, caseine hidrolisate, and enteral formulas. (in patients the nutrition formula was changed during ten). patients were supported with mechanical ventilation during ten, received midazolamperfussion(range to mcg/kg/min), fentanyl (i - . mcg/kg/h), and vecuronium ( . - . mg/kg/h). resulte: ten was used during to days (mean . ± . days). mean maximmnvolume ad~iniateredwas ± ml/kg/day (range ) .patients with midazolam, fentanyl and vecuronitml tolerated ten similar than children without sedatives. complications were diarrhoea patient, abdominal distension and/or important gastric fed residuals patients. pulmonary aspiration or respiratory complications were no registered. ten was ended in one patient due to diarrhoea, in due to change to oral or nasogastric nutrition, children continue yet with ten and was discharged of picuwith ten. conolusion: ten is an useful method of nutritional support in critically ill children with mechanical ventilation and/or nasogastric intolerance. introduction: the enteral nutritional support of the critically ill child may reduce the morbidity and mortality by attenuating, the hypermetabolic and catabolic response, decreasing the gut translocation and the septic complications, improving the bowel mucosa integrity and the wound healing. the aim of this study was to show the safety and tolerance of en. methods: we enrolled consecutive patients admitted to our unit from may to december , mean age . years (range imonth to i years). the prism, mechanical ventilation, inotropic use, opiates and other drugs were recorded. the en was delivered by continuous infusion across a polyuretane tube.we kept the patients head elevated °, and we used cisapride routinely. the gap betweeen admission and the en beginning, average time to meet the nutritional objective, en duration, selected formula, patients outcome and complications were recorded. results: prism groups were - = patients; - = ; - = ; - = ; - = . two patients with mof (multiorgan failure) died. % needed mechanical ventilation.the average time elapsed from picu admission to initiation of en was . days (range to ) and the average duration of the en was . days (range to t ). the average time to meet the nutritional objective was days (range to ). the selected formula were: lactose free infant formula in patients, elemental diet in , pediasure in and jevity in . we recorded vomiting in patients, diarrhea in and constipation in . none of them forced the en suspension. we didn't recorded any case of ~spiration or pneumonia. we found no relation between drugs, selected formula and complications. we think that en may be a safe and well tolerated procedure at the picu setting. generation of free radicals in iipid emulsions used in parenterai nutrition (pn) has been described recently. this seems to be due to high polyunsaturated fatty acid content. we studied lipoperoxidation status and antioxidant parameters presurgically and through the postoperative period ( days) in a group of twelve children (ranging from months to years of age), who underwent heart surgery and received nutritional support with pn. malondiaidehyde (mda), an end product of lipid peroxidation was used as a marker of oxidative stress. it was determined by the yagi spectrofluorometric method. antioxidant activity was measured with an assay based on the inhibition of spontaneous autooxidation of a brain homogenate, and vitamin e in serum by the technique of hansen and warick. erythrocyte mda release fonowing incubation in hzo in vitro was used as a functional measure of tissue vitamin e levels. data were compared using one-way variance analysis. there was not significant differences in the plasma mda production among the values obtained before surgery ( :t: . nmol/ml), postoperative pre-pn ( . +_ . nmol/ml) and through the course of pn ( . : . nmol/ml). levels of vitamin e previous to surgery were , : . #g/ml and decreased to . _+ . #g/ml at hours post-surgery before starting pn. while receiving pn, concentrations of vitamin e increased progressively up to + . l #g/ml (p = . ). pre-surgicai plasma antioxidaut activity values ( :i: %) dimiuished in the first postoperative day ( _+ . %) and then showed a clear increasing tendency, directly correlated with that observed in vitamin e levels. the measurements of the maximal percentage of mda release of erythrocytes in vitro, showed an inverse relationship with plasma vitamin e levels and with the plasma antioxidant capacity: preoperative . + . % and postoperative descending from . + % to _+ . %. our results indicate that during surgery and within hours postsurgery, a decline in antioxidant defenses occurs, in the postoperative period, while patients are on pn and taldng into account our obtained data: the unaltered mda values, the rise of plasma vitamin e levels, the recovery of both functional erythrocyte membrane antioxidant protection and the plasma antioxidant activity, they do reflect that during the intravenous administration of lipid infusions, oxidative damage does not occur, probably due to the addition of vitamin e to pn solutions in order to avoid autooxidation of lipid emulsions. garnitine is one of the essential nutrient in the diet of newborn infants. mother's milk represents the natural eamitine source for the newborn infants. we studied enteral earnitine intake in premature infants eutrophic (eu) and hypotrophic (hy), fed with mothers milk trough consecutive days-from fifth to tenth day of life. mean gestational age was (range - ) weeks for eu and (range - ) weeks for hy. birth weight was ranged - g for eu and - g for hy (p < , ). breast milk carnitine concentration was , i.tmol/i in mothers milk delivered eutrophic babies, and singnificant higher mean coenetration , l.tmol/i, of hypotrophic premature infants (p< , ). breast milk earnitine concentration was ranged between , - , ~moi,'l, and daily carnitine excretion was between , - , p.mol/i, mean , +- , i p.molll. the daily mean carnitine intake was from - , mgkg/d, in eutrophic and , - , mg/kg/d, in hypotrophic premature infants, in milk volumene intake from - mllkgld., the results of this study suggest that premature infants should be fed with own mothers mitk in eady neonatal pedod in attempt to prevent camitine deficiency. keto-acids and parenteral lipid admlnistration. castorina m., antuzzi d., ricci r., rendeli c., polidori g. pediatric intensive care unit -catholic university -roma (italy). some metabolic studies have suggested that the administration of mediumchain tltgticerides (mct) might induce a marked increase in ketone body concentrations; the aim of this study is to evaluate the effective ketogenetic risk of infusing mct emulsions in total parenteral nutrition (tpn). two groups of seriously infected children were examined: a- septic infants were given to tpn with a % of long-chain tryglicerides ( lct). b- septic infants, in wich the lipid source in tpn consisted in a - mixture of lct and mct. the children in the different groups showed similar severity and therapeutic scores (prism, tiss, ~, f~ , f~ ); the lipid intake was the same, corresponding to - . g, ckg bodyweight/day. in all patients a sample of urine was taken six times a day for the whole time of tpn the urine samples were screened by the diphenylhydrazone test, and the ketoacids excretion was confirmed by a chromatography. the urinary excretion of -keto-acids equivalent to p-ohphenyl-pymvate (mcg/ml urine) is summarized in the no significant increases in frequence and/or in severity of acid-base disturbances were found in all studied patients in consequence of the lipid infusion. the patients of b-group showed a lower excretion of -ketoacids. the c~-keto-acids excretion was ever unsignificant and seemed to be correlated with the illness severity more than with the lenght of the tryglicerides chain. this observations let us suppose that the mct, at employed doses, can be safely administred also in childen with metabolic acidosis and/or serious illness. reye syndrome cayetano heredia hospital, lima, peru five patients with reye syndrome were studied; included were those diagnosed from january to march and treated at cayetano heredia hospital. the age of presentation varied from z. to months. the syndrome occurred more frequently in males ( / ); the time of illness at the presentation varied from to lo days, and the following features were found: fever ( / ), akeration in mental status ( / ), seizures ( / ), gastrointestinal illnesses (diarrhea) ( / ), and respiratory insufficiency ( / ) --in this case ventilator)-support was needed, in all cases hepatomegaly, intracranial hypertension, hypokalemia hyponatremia, metabolic acidosis, hyperammonemia and elevation of hepatic enzymes were found. coagulation blood tests were abnormal in three patients. cerebrospinal fluid (csf) showed hypocellularity in all cases (less than cells/ram ). the cultives were negative, and the final diagnosis was confirmed by hepatic biopsy. no deaths were due to reye syndrome. a contribuhon to the study of reye's syndrome the aulhors analysed records of patients meeting all the clinical, biochemical and anatomic criteria put forward by hutrealoch~ and samaha ( ) who were ireated at the emergency and resusdlation depammlt tithe ipch in years. the average age of the children was years (the ~umgest monks and the driest year~ most of lhon ( / ) came from lhe countryside to lhe lmfia~ willfin hours of file oulbreak. a few days previously the patients w¢~ld have fever (some of ahem wilh diarrhea or cough) ,,rod vomit then rapidly fidl into coma and c~nvuksien. they ~me to the imtia~ with the signs of typical increased inlracranial pressure ( stages - according to lovejiy for most cases) but the liver was unllkely big. the main biocheafical dmnge of the blood was acute hepatic thilure -the bllod glucose decreased : (ha the aver~ , n~% ( ) ~ not measured in five cases (glucose a"aces). -the blood ammonia ino~ased riven to microg/dl fin lhe average , n = ) -the percentage of p~in was low, in the average , % (n-- ), % at the lowest (a case ofmekaa lasling five days was ctwed with vitamin k). -got and gpt enzymes increased - times (n= ) besides, tht~re was decompcmated addt~is with lhe average valnes ph = . ; pcoz = ~ mmhg and eli = - ~ ~, (n~). the charadaislic dumge in the ¢~'ebrospinal fluid was a low glucose tx~acenwalien h the average of k mg/dl ( cases of glucose it'aces) ; meanwhile protein decreased in the average of mg/dl ( cases below mg/dl). besides ~here was no inflammatory lesion ~tion) : very serious brain oedona and fatty degeneration of live~ scatteredly or parllally.microso~ically (biopsy and necropsy) in file brain appeared bright space around blood arteries and glioma extended v'lrdmw -robin space, with no inflammatory reaction. liver.-the sa~dure was intact there was no " "mtlammal~s ' cell, the kupffer cells did not show hyperplasia but show a heterogenous deg~nerafion~eart: also showed a fatty degencralion in some areas of the myocard eellkidney: the ihtty degenerati~l scattetedly in the tubular cell. pano~as:fatty degeneration scattetedly in file pancreatic cell. two cases of liver biopsy for lhe rid lime (check before leaving file inslitute) found that fatty degeneration was r~tta~ nearty ff~pletely. the exact muse remained unknown. objectives: to analyse whether there exists serum and urine electrolyte disorder in children with respiratory failure, methods: we have made prospective study of children in our icu during a month period, electrolyte concentrations were measured in serum and urine collected during hours (sodium-na, potassium k, chloride-ci, calcium-ca, magnesium-mg and phosphorus-p). results: average values in serum were: na . +/- , (rv: - ) mmol/i, k . +/- . ( . - . )mmol/i), cl . +/- . ( - ) mmol/l, ca .t +/- . ( . . )mm /i), mg . +/- . ( . - . )mmol/i. average electrolyte levels in hours urine were: na . ~/~ . ( - )mmol/day. k . +/- . ( - )mmol/day, ci . +/- . ( - )mmol/day, ca . +/- . ( . - . )mmol/day and p . +/- . ( . - )mmol/day. conclusions: average serum ci and ca levels were decreased in children with respiratory failure. in urine, average k, ci, ca and mg levels were decreased and urine p concentration was increased. we concluded that serum and urine electrolite disbalance may be expected in children with respiratory failure. the nurse is going to kill me! (icu syndrome) anita duvndam ~, sonia v.d,sluis ~dpt. of pediatrics, div. pediatric intensive care, sophia children's hospital, rotterdam dpt. of pediatrics, div. pediatric tntensive care, juliana children's hospital, the hague. content description: this presentation will provide the critical nurse with background information concerning the identification, the prevention and management of the critical ill child who has developed the icu syndrome. the results of a questionnaire concerning the occurrence of icu syndrome on a picu will be presented. behavioral objectives: at the end of this session the participant will be able to: . describe four clinical symptoms of the tcu syndrome, . identify major sources of picu environmental stress, . discuss nursing's unique role in helping the child to cope with the icu syndrome, . discuss nursing's unique role in preventing icu syndrome. content outline: the icu syndrome is a situation in which the individual is not able to deal with changes in observation and interpretation of both quantity and of patterns of sensory perceptions. in other words the borders between the inner and outer world becomes unclear for the person. the exact incidence of the icu syndrome in the critical care setting is unknown, we have limited knowledge of the occurrence of the icu syndrome in critical ill children. yet critical ill children in our hospitals sometimes show the symptoms of icu syndromes. to be able to identify the occurrence of icu syndrome we developed a questionnaire. the thesis of the questionnaire was: does the icu syndrome occur in critical ill children in the age between three and ten, who have been intubated and/or ventilated in a picu? eighteen questionnaires have been send out to parents of critical ill children in two hospitals. the response was percent. conclusions: . most of the children were anxious (n= ), showed regression (n= ) or had sleeping problems (n-lo) during the stay on the picu. . children showed the same problems after discharge. . there is no relationship between environmental factors and symptoms of the tcu syndrome during the stay. . there is no relationship between preexistential behavior and symptoms of the icu syndrome during the stay. because the lack of a scientific definition for the icu syndrome in children and good criteria for diagnosis, we were not able to get an answer to our thesis. more research is needed. continuous veno venous haemofiltration (cvvh) was adopted as a first line renal replacement therapy in our paediatric intensive care unit (picu) some three years ago. ~/he process of introduction and development of cvvh proved to be an exciting challenge for nurses as indeed it was for the whole multidisciplinary team involved. we have successfully used cvvh in the treatment of over infants and children, weighing between - kg. the range of conditions treated is ever increasing. to date we have not only used cvvh for patients in renal failure and fluid overload, but also to gain biochemical control in tumour lysis syndrome-and metabolic disorders. other distinct patient benefits in comparison with more conventional means of renal replacement therapies are that, it is a continuous controlled treatment being extremely effective in creating 'space' for nutrition, which is especially important in the fluid restricted, catabolic patient. of paramount importance in providing this level of service is the education and training necessary to impart the skills and knowledge for nurses to become expert practitioners in this field. we now have a teem of highly advanced practitioners who have developed their nursing skills to provide even more holistic care for their patients. this group are embracing new challenges and responding positively to the developing service whilst expanding their knowledge base. this paper will discuss the advantages and disadvantages of cvvh as we have experienced, relating i t to the wide variety of patients we have treated. we wish to share how cvvh has become an accepted role of the picu nurse and how the service has been successfully implemented. integrated care pathways (icp's) define the optimum course of events in the care of a patient with a specific condition, within a set timescale. aims and methods: icp's and case management (cm) were introduced to evaluate and improve clinical practice. icp's were developed for patients undergoing surgery for atrial septal defect (asd) ventricular septal defect (vsd) and fallots tetralogy. they were based on the median experiences of the last patients. patients have been managed using icp's. results: analysis of variation from the icp's shows a reduction in the following potentially avoidable causes of variation: delay in extubation has been reduced from % to %, and patients ( %) were extubated earlier than the median. prolonged stay on the intensive care unit (icu) has decreased from % to %, and patients ( %) were discharged to the ward a day earlier than the median. the number of patients receiving inadequate post operative analgesia has decreased from % to %. delayed feeding after operation has been reduced from % to %. unavoidable delays in extubation and discharge from icu occurred in patients ( %) because of haemodynamic instability" or lung problems. cm utilising individualised pathways for these patients has reduced variation in care which can improve patient outcomes. pathways have been developed for other conditions and it is anticipated that approximately, % of patients will be treated using an icp revision of icp's results in continuous evaluation and improvement of the care provided, conclusions: the use of icp's and cm has improved patient care and decreased avoidable delays and variations. the future development of other icp's, combined with a case managed model for selected patients, is seen as a viable method of continuously improving patient care. this paper is a retrospective audit of children who received continuous veno venous haemofiltration (cwh) whilst on the paediatrie intensive care unit (picu), data was collected over a month period from may to january . the girls and boys were aged from day to ½ years (median ½ years) and weighed between , and kg (median . kg). length of admission to picu was to days (median days). sepsis syndrome was diagnosed in cases: of these had bowel necrosis and meningoceccal disease. eight patients had an underlying haematological, oncolngical or immune disorder. the remaining children had inborn errors of metabolism ( ), nephrotic syndrome ( ), or cardiac failure ( ). cvvh was instituted for a variety of reasons. muttiorgan dysfunction was present in % of patients, % had acute renal failure, . % tumour lysis syndrome, . % uncontrollable metabolic acidosis with hyperammoneemia and % required fluid management. treatment was continued for between hours and days (median ½ days). haemofiltration was successful in achieving its desired effect in all except one patient. . % of children with haematological, ontological or immune disorders died despite successful haemofiltration. survival was higher in cases of septicaemia ( . %), nephrotic syndrome ( %) and errors of metabolism ( %). overall mortality was . %. this was attributed to the severity of the underlying disease process rather than the effectiveness of cvvh as a renal replacement therapy. asynchronous defibrillation and synchronized cardioversion deliver direct currents of high amplitude through the chest, to stop ventricular fibrillation or to convert life-threatening arrhythmias. since the human body is partially conductant, it should be possible that after a brief delay of time, a derivation of this monophasic defibrillation pulse is measurable in regions of the defibrillated body, other than the traject between anodal ("sternum") and cathodai ("ape~;") paddles. one could also estimate that health care personnel in the immediate environment of defibrillatoty shocks, are always at risk to possible electric injury. accidents might occur when health care personnel do not stand clear from the patient during firing and create an additional electric path from this patient through their own body. most likely, the nonisolated parts creating a transversal eiectric path, will be the hands of the caretaker. since defibrillation generates touch voltages up to v and - a in ved, short delay's ( to millisec), the total body resistance during skin to skin or skin to paddle contact, is calculated to be as [ow as ohm (percentile tank for the entire population). an experimental protocol was developed to evaluate the conducted currents during defibrillation. mature pigs with a weight of up to kg. were used as animal models. the:,, had barbiturate anaesthesia, inotropic support with dobutamine at l micmgrams/kg bodyweight and all had a sinasat rhythm at the begining of the test-rounds. synchronized defibrillation at j (approx. . j/kg) and asynchronized -at j (whenever ventricular fibrillation or ventricular tachycardia occurred), were attempted, through latero-lateral placed and firmly pressed defibrillation paddles and/or adhesive multi-function electrodes. gel pads were choosen as contactmedium to cross the skinpaddle barrier. subdermal electro-myography needle electrodes were put at different parts and regions of the pig's body, but not between the paddles. these electrodes were coupled to a resistance device of ohm and a measuring computer. we measured monophasic and low current pulses up to , a during the defibrillation burst. thus conducted currents are high enough to produce accidental electric shocks when additional electric paths are created by the caretaker. "llaese are usually harmless, but in some "worst case" (wet or transpiring hands, rings,...) or in association with defectuous equipment, peak currents might be harmfull, and can produce pain, bums, apnae or cardiac (transient or persistant) arrhythmias. maria skogbv. karin mellgren, lars-g ran friberg, g sta mellgren, hans wadenvik. g teborg, sweden. bleeding complications in extracorporeal circulation is partly due to perfusion-induced platelet dysfunction. the aim of this study was to evaluate an in vitro model for investigation of platelet function parameters in an extracorporeat system. study: two complete extracorporeal life support systems were perfused with fresh heparinized human blood for hours. piatetet membrane glycoprotein changes, platelet granule release and platelet count were followed. eight paired experiments were performed. one of the circuits was perfused by a roller pump (polystan) and the other by a centrifugal pump (biomecicus), other components were identical. results: a continuous increase in glycoprotein (gp) ib-negative platelets was seen in both circuits. a marked increase of plasma beta-thromboglobulin concentration and a decrease of the intracellular pool of serotonin was observed, indicating a marked release of alpha as well as of dense granules. the plasma concentration of glycocalioin increased in parallel with a reduced platelet surface expression of gpib, suggesting that the loss of gpib is caused by proteolysis rather than by a downregulation of this receptor protein. conclusion: hours of ecls perfusion induces pronounced platelet degranutation and causes changes of important membrane receptors. this is in accordance with clinical studies, suggesting that our in vitro model does mirror the platelet exhaustion observed in a clinical reality. no significant difference was observed between the two pumps. the purpose of this study was to examine signs of distress exhibited by several patients following the discontinuation of opioids and benzodiazepines (o & b) in a -bed pediatric intensive care unit. the authors compiled a list of all cases of possible withdrawal reactions reported by nurses in the study setting over a one-year period. five cases were selected for study in terms of their wide diversity of relevant circumstances. the cases were examined through a retrospective chart review. data pertaining to analgesic and sedative administration, along with nurses' reports of behavioral distress, were transcribed and coded. a remarkable pattern of behavioral distress was clearly associated with discontinuation of o & b. cessation of benzodiazepines was associated with severe distress. these reactions were characterized by various combinations of crying, irritability, tremors, grimacing, gagging, vomiting, or feeding problems. some of these persisted in spite of large amounts of bolus drug administration. these signs were manifested for to days following cessation of o & b. these findings demonstrate that the rapid weaning of o & b infusions, sometimes following short-term therapy, can cause severe withdrawal reactions. the particular course that a specific patient will follow will likely be modulated by underlying manifestations of "icu psychosis" and unresolved pain and emotional distress. hermana tezano mt, pilaf orive j, latorre garcia j, lizarraga azparren ma, lopez bayon j ucip hospital de cruces. bilbao. spain a female child, one year old, was referred to our unit from another hospital because she had ischemic syntomsjn her right forearm wich started three days before. she had ~i downs syndrome and fallot's tetralogy with a systemic-pulmonary by-pass. nine days before the admission in our hospital she was undergone to a cardiac catheterization by arterial and venous femoral punctures with no incidences. on the admission to the picu her forearm was cold and pale with absence of cubital and radial pulses and slow capilary filling. treatment with heparine was started unsucessfully in the firsts hours, so uroquinase was added that later was changed to rtpa plus brachial plexus blockade. by the time me arterial tlux became more and more evident (doppi~) il bccuute aiat) evident a regional aedema witch made necessary a fasciectomy &the wrist. she also developped necrotic delimitted areas that included her first and fifth fingers. she was discharged from the picu after days and a week later she went to the operating room where an amputation of the distal phalange of the fifth finger was made. the etiolgy of this ischemic picture can't be attributed to the catheterization itself, but probably it should be due to some attempts in arterial puncture in its course, attempts that could be guess by the little marks noticed at the elbow flexure when she was admitted. long maintenance of cardiovascular funtion by assisted ventricular device with membrane oxigenator hermana tezanos mt, pilar orive j. latorre garcia j, lizarraga azparren ma lopez bay n j. ucip. hospital de cruces. bilbao. spain a little girl of three and a half years came to the intensive care unit from the operating room. affected of great vessels transposition with a pulmona~' banding corrected vith rastelli technique, it became impossible to discharge her from the by-pass circulation. it was assumed that this factt was due to a transient myocardial disfunction dfter the surgeon x~ent through the technique and found no wrong step in it. at the picu admission she had an ejection fraction belox~ % (echncardiografy), and was manteined on veutricular assistance with a circuit consisting ofa plate's membrane oxigenator, a bio-medicus pump and pvc rubber tubes, with monitoring of pulmonary', right and left atrial pressures. initially she needed a ventncular support of . l/min with dopamine. dobutamine and adrenaline; gradually the ejection fraction rose to % aliowing a decrease in the mechanical and inotropic support. the organic function ,.'.-as preserved but x-ray of the thorax showed images of pulmonary aedema with an increase in the needs until a fi of . . even though she was placed in a transplant program, she was remouved when the ejection fraction rose to % on the lth da of the evolution. there were no signs of infection (profilactic coverage). on the fifhteen postsurgery day. with a good cardiac sound and an ejection fraction of at least %. it was considered the withdrawal of the ventficular support, but unsucessfully despite the increase ofinotropic drugs, so she died. we think that our patient is a good example of the posibiti~ to mantain x~ith ecmo during a prolonged period of time a potential transplant receiver without major complicatios. joan wierema; ma )an mourik. sophia children's hospital, department of pediatric surger,j, rotterdam, the netherlands. the success of an ecmo program is heavily determined by the organizational structure and the daily availability of both well trained nurses and physicians. until now there is no general guideline to determine the optimal training schedule to set up an ecmo program. objective: to evaluate the set-up of an ecmo program in an area without direct availability of perfusionists of cardiothoracic surgeons. description of the progress: during the preparation of the ecmo program which started november , different phases are identified. first phase, acquisition of experience by training abroad of one physician, staff member of the icu, physician acting as a fellow and one icu nurse with theprimary task to serve as an ecmo coordinator and train the nursing start. in the second phase animal experiments were performed by paediatric surgeons, staff physicians, fellows and nurses. third phase, start of the actual ecmo program, priming by one trained nurse and ecmo fellow, daily care of the patient by nurses, icu nurse taking care of the patient related activities, ecmo trained nurse taking care of the circuit. fourth phase, transition of the tasks for priming the system from the ecmo fellow to the ecmo nurse and changing daily care for the ecmo patient now including the circuit by trained icu nurse with special legislation for ecmo. ongoing training of to nurses working for at least half a year in the icu. during an ecmo run direct contact between the ecmo nurse and one of the staff members; patient data: in a year period neonatal ecmo cases were performed with an overall mortality of %, ranging from over % in meconium aspiration to % in congenital diaphragmatic hernia. in other patients pediatric ecmo (age range month - months) mortality was %. conclusions: ecmo can be established without perfusionists or cardio surgical back up once a predetermined training schedule is available, resulting in comparable results with the international ecmo registry both for neonatal as well as for pediatric cases. mechanical ventilation at home makes normal development of the child with chronic respiratory failure possible. the parents must be encouraged to accept the treatment at home; therefore, they should be enabled to take care of their children all by themselves and the continuous professional support has to be offered to them. it must be stressed that the nurse is the link between the diseased child and his family introducing them into the process of the medical care at home. all the equipment needed for the mechanical ventilation of the child at home (ventilator, suction device, pulse oxymeter, oxygen tanks) has to be provided before the child is discharged. it is paid by the national insurance company. the maintainance service workers will make the necessary installations available and they will renew oxygen and compressed air weekly. the ventilation assembly must not interfere with the childs activities. the related dispensary and nursing service should be notified of the child's condition and the list of the required material (suction tubes, cannulas, desinfectants etc.) has to be made. our experience is so far -from the nursing and medical point of view -satisfactory, however the social status of the parents needs further regulations, omphalocele. mourik m, sophia children's hospital, department of pediatric surgery, rotterdam, the netherlands. in patients with (giant) omphalocde operative closure is impossible due to the lack of intra-abdominal space and a variable degree of pulmonary hypoplasia. consequently conservative treatment allowing epithelialization is the treatment of choice with a high risk of infection and/or sepsis due to a sometimes very long stay in the icu. this conservative treatment consists of daily application of an antibiotic containing powder on the cele which is covered by sterile gauzes. furthermore the enteral intake is started as soon possible. objective: to evaluate whether this treatment renders a high risk for serious infections. patient characteristics: in a year period patients with a giant omphalocele were admitted; mean birth weight g ( - g) mean gestational age . ( - weeks). overall mortality ( %). patients had to be ventilated for a median duration of t days ( , - ). results: patients were discharged at the mean of days following birth ( - ) following complete epithelialization of the omphalocele. following the initial stabilisation period parents were involved in daily care of all patients even during artificial ventialation. enteral intake was started at a median of days ( - ). colonization of the omphalocele was observed within - days in all patients. although infectious periods were observed at regular intervals, sepsis was the primarily cause of death in only of the patients who died, in conclusion: nursing care to prevent sepsis in patients with (giant) omphalocele is feasible for a long period of time and can be performed with simple measures, since june , we have been using nasal cpap in the treatment of respiratory disorders in newborn infants (severe apnea syndrom, tachypnea, hyaline membrane disease). in newborns presenting hyaline membrane disease, we have used cpap and administered surfactant therapy to premature babies out of . clinical data were : mean ga : . + weeks. mean bw : + g. mean administration time was hours. before administration, mean fio was . + . , mean pao . + . kpa and mean a/ao ratio . . all babies were intubated for administration of surfactant (curosurf) and were extubated after half an hour to hours after administration. this treatment failed for seven babies and they were ventilated by oscillation ventilation ; all babies survived. complications : we have observed pneumothorax in cases and cerebral hemorrage. mean duration time of nasal cpap was hours for the babies without assisted ventilation. nurses in charge of babies with nasal cpap should be aware of neonatal care, of the possibility of surfactant administration and of complications during this type of treatment. therefore nurses should know very well the use of nasal cpap, the monitoring during this treatment, the fixation of the system on the baby, nursing of the babies during this treatment and finally should take care of the baby physical and psychological well being. as a conclusion, nurses in intensive care neonatal units should know the possibility of treatment of rds by nasal cpap and should be aware of baby-nursing. emco in the postcardiotomy infan_t : a simplified circuit and reduced management grillet lsabelle, bosson christa, goelz andrea, helmer pascale, icu nurses, tschaut rudy perfusianist aldo castaneda institute, clinique de genolier, suisse to improve postoperative survival of infants with repaired cardiac tessions but severe residual cardiopnlmonary dysfunction, emco was used in infants, ranging in age from l days to months and in weight from , kg to , kg. diagnosis included tga / intact ventricular septum ( ) (both subiected to rapid arterial switch operation because of unsuitable lv function) and tga +vsd ( ). "['he emco circuit included a sarns roller ump, a medtronic minimax plus hollow fiber oxygenator and tubing ( / - / inch) with bioactive surfaces, an arterial canula fr., venous canulas : right atrial fr, left atrial fr., an air oxygen mixer and a sarns heater. the act was kept between - sec. after the infant was connected to emco by the surgical team and the perfusion technologist, the patients were being cared for and controlled exclusively by the cu nurse assigned to the patient and the physician on call for the icu, pump flows of - ml / kg / mln were targeted to insure an adequate urine output, a brisk capillary fill and physiologic left and right atrial pressures. sodium nitroprusside was used to control systemic hypertension while all other inotropic drugs were discontinued. inspired oxygen fraction on the ventilator was reduced to , at a respiratory rate of - breaths per minute. body temperature was maintened close to normal. when the heart started to eject again, inspired oxygen was increased to about , . the preparation for weaning from emco was done by the icu nurse: including oxygen fraction and ventilator rate. weaning from emcowas coordinated by the medical / surgical team and the perfusion technologist. the duration of emco in the patients ranged from to days. three patients ( %) were saccessflly weaned from emco. one of the three died within hours from neurologic complications, unrelated to the emco. the other patients ( both with tga + vsd ) are long term survivors and are doing well. neither the survivors nor the patients who died bad hemorrhagic complications, despite the fact that of the were placed on emco because of failure to wean from cardiopulmonary bypass. the simplified emco circuit worked reliably throughout this experience and no complications occurred nor could any shortcoming be ascribed to the use of this reduced, cost effective management team. years of praciical experience wiih exiracorporeal membrane oxygenation (echo) -the viewpoint of the nursing siaef monika schindler in a training program was started for the introduction of echo in the kinderklinik of mannheim/germsny. years later ( ) the first european echo patient, a days old newborn baby, ~as treated successfully in our institution. with echo, more treatment modalities ~ere available after failure of conventional therapy in eases of severe lung diseases like meeonium aspiration syndrome, congenital diaphragmatic hernia, sepsis/pneumonia, primary persistent pulmonary hypertension of the newborn and -in infants and children -ards (acquired respiratory distress syndrome) due to multiple underlying illnesses. in the first ards patient, a years old girl, was treated successfully ~ith ecmo in mannheim. until now patients (age: i day - years) were treated with echo in our institution; additional patients were transferred to us from other institutions for therapy with echo, but could be treated ~ieh alternative moda]ities of therapy like improved conventional ventilatory support, high frequency oscillatory ventilation (hfov) and inhaled nieric oxide (no), unexpectedly the more ~ide-spread use of hfov and no -also in other ~ntensive care units -did not lead to a reduction of the echo frequency in our hospital. due to this long ecmo practice, which is helpful in many critical situations, a certain routine came up in the nursing staff of our intensive care units; but ecmo continues to be a maximum strain for all co-workers and implies an high personnel and material/financial-expense. but in our opinion the improved survival rates in severe respiratory failure-( % in neonates and % in infants and children, estimated survival rates under continued conventional management: < %) by the use of echo justifies this expense, even in times of less financial support for public health. • analyse the differences between each urdt. method : ni criteria were defined by the rt~a ped group according to cdc criteria. all data were collected by a nursing and medical team. data vere dealed with epi info software. all u-dections data were validated by an external mvestigatol : patients who stay more than hours in an icu were included over a months period. % were newborns, % infants and , % children. ni were idenlified among sll patients, the overall ni incidence rates was , % and , person day, septicemia was the first cause of ni ( %). staphylococcus epidermidis were isolated in % of septicemia cases. pneumonia was the other main ni ( %) with gram negatwe bacille isolated m % ( % of them beei,ng fseudomonas) accordmg to age, the septicemia mcidence rate varied from , ~., to . %,, catheter/day and pneumonia incidence rate from , %, to , % ventilation/daywith the lowest rate for newborns. : this survey was possible thanks to the collaboration between laboratories, bacteriologist, physicians and nurses, and allowed each concerned unit to work together in~tead of every one in his own field. 'lhe results of this survey bring changes in attlhades and empower the different team work the next step is to analyse the ditferent nurses procedures of indwelling central venous catheter in each unit ar)d implement a ni quatity care. program in all nicu anti picu. v~,~jl~j~'v~y : new born in~ra-v~ nous drugs ~md lheir pr~taration mcounter a lot of risk ~)f utters, due to inadapted conditionn~ng to podia)eric and minimal amount injec~.~d, th~ study t~ed to evaluate degrees of do.~age er~o~ dye tt) dru~ preparaek, n i~ nc,:,~atol~gy and to come out w~th ~ method of dihttion able to reduce risk to minima (errors _< %) at the ~eme t~me, ¢o~,~x-tueaces on cost were studioj methnd~ : amikacine was choosen because this antibiotic is regularly ~,~l in neonatology unit and its dosage is easily used by standardiaud method, amikacine doses ( , mg doses and , mg doses) were prepared" by nurse~ form mg for m) vial. each dose w'a~ diluted to obtain mi volume, tallowing usual ward method, for each dilution, amikacine con<entrati('m and it,s volume was measured and used equipment for preparation wa~ regi~tred. "first s utj(m" were prepared diluting ~t'~ mg amikacine pouder inn ) ml glucnse solution bag (viaflex baxter bag with transfer cap), from tho~e "first solution" doses at mg and doses of ~ rng were prepared, amik~cine coc, cenir,)tmn for each preparabon and their volume were measured, ai,~n ntttl~,ber of seringe were tounted. first soiuhon staeiiity was conrroieo aher one week conservation at + '>c. amjkacine concentration were measured by fluorescence process (tdx abbott) after sample dilurion. on a mg/l sample, tovhnical reliahility show~ > ~ % of result mpmductlon and < % of variation due to dilutions. results : when amikacine injection werv pro.pared from araikacme /) mg for mt vial > % do~ge, ermr~ were found in / cases ; ~ % in ,t ,to cases. if preparation is done from amikacine "~it'st soltltion", les.--concenvr~tcd, it i~ more preci,,,e and only one dosage error ~ % ( , %} is found in eli studied doses. in add)inn to )hal if doses were wep,m-'d from one "first soiatiol~' bag, the cost economy sl~ouid b~" of fr~, and ii dos~$ were prepared tram the same bag the saving mtmey should be o{ i its .cencluslon : .ur survey shows th~t h' ntu)nato|ogy the u~ of a "first sohation which can be kept fi~r one week is enable to reduce dosage erroes and i~ co,~tsavmg, regarding [,v. admimst'rahon method the survey is still on, introduction: so-called vein of galen m~iformations ale rare in~racranial embryologycal anomalies, repl~senti~g tess than of symptomatic intracranied artefiovenoas l~alform~tions. the spontlneous prognosis is ~s~u~lly fatal, because of cardiac frilure due to left-to-right shunt thrq~ugh the fistula. recent developments of new techniques of treatment of the malformation and its cardiac consequence have led to a revolution in the practical approach of children w~th galen malformation. our fukfose is to contribute, with our persoaal series of s newborns and infal~ts admitted in our unit after endov~,scular embolization, to a better management of these children. such a management requ!res a rnultidisciplinary approach. intensive care are required prior to embollzation for patients with cardiac failure or cardiogenic shock and after cmbolization in order to insure cardiac and cerebral hemodyna.mic stabilities. this overlooking suppose for the nursing team to understand: prior to embolization : heart failure and cardiogenic shock. after cmbolization : evaluation of neurological and hemodynamic consequences of this proccdure, without forgetting the nursing and psychologic aspects, in concl'iision, this last ten yerrs, these new approaches give to the patients and their famitiy a good reason to hope a total recovew, in our exl)erience, the global mortality is % aad % of children #j-e neurologically normal after embolizafion, ii ii~ i ~ii i ii i i l i iiii~ i ~i iii i background: venous oxygen saturation (svo z) reflects the residuai oxygen after tissue oxygen extraction and represents the relation between tissue oxygen supply and demand. we studied svo and arterial lactate during progressive isovolemic anemia to assess the relation between svo and tissue hypoxia. subjects: ten - day old anesthetized ventilated piglets sao and svq were measured continuously by a fiberoptic catheter (oximetrix, abbott lab.) in the carotid and pulmonary a~epy tissue hypoxia was confirmed by a reduced vo, and an increase in lactate. conclusion: svo reflects better a reduced dp obtained by progressive anemia surfactant replacement improves gas exchange in early-stage adult respiratory syndrome (ards) [ , ], but not in late-stage ards [ ] . we report the first case of successfull treatment of ards after repeated instillation of surfactant.a ten year old boy, weighing kg, presented with hemorragic shock. biphasic-positive-airways-pressure ventilation was performed (evita ii, dr~ger, germany). he had recieved nine units of packed red blood cells and underwent surgical exeresis of two bleeding gastric ulcus. post-operatively, a cardiac arrest required cardiopulmonary resuscitation for three minutes. hemodynamic status was subsequently stabilised. the chest-radiograph showed infiltrates of both lungs without signs of cardiac failure. on the third day, the patient became severely hypoxic with a pao /fio ratio of . gas exchange was not improved by high ventilator settings. peak inspiratory pressure (pip) and ventilatory rates were cmh~o and breaths/min respectively. inspiratory:expiratory time was : and the positive end expiratory pressure (peep) cmh . after increasing the peep level to cmh , we instilled over minutes, mg/kg of porcine surfactant (curosurf, serene france), in two equal volumes in both main bronchus,the spo~ rose to % within rain, the fie could be reduced to . . twenty four hours later, gas exchange worsened again (pao /fio ratio ). we increased the peep from to cmh , and instilled a second dose of surfactant ( mg/kg). again, fie could be reduced within minutes (spo ; fie . .). the patient was weaned from the ventilator and extubated on the tenth day. follow-up at four month showed normal lung function.we demonstrate improvement in oxygenation after repeated exogenous surfactant administrations. we assume that in early-stage ards, surfactant may potentiate shunt-reducing effect of peep as it has been demonstrated in experimental model of ards [ ] , and allow decrease in fie . in case of secondary deterioration, we think that a second dose of surfactant should be administered. . weg jg, balk ra, tharratt rs, et al. ,lama : : - . . spragg rg, gillard n, pdchman p, et al. chest t : : - . . haslam pl, hughes da, mcnaughton pd. et al. lancet : - . . huang yc, caimulti sp, fawcett ta, et al. jappl physiol : - % (ref) . the aim of this study was to verify these data: patients/~lethods: all pts admitted to our multidisciplinary nicu/picu in were included if they were in respiratory failure recruiting conventional mechanical ventilation (cmv) with peep >_ and 'fig -: % or high-frequency oscillation ventilation (hfo) with mean airway pressure _> t cm h for or more houm. diagnosis, maximal ventilatory parameters, barotrauma, organ/ system failures, mechanism of death and glasgow oulcome scale (gos) and months after study entry were prospectively collected. results: patients were admitted to the unit, o whom required mechanical ventilation for a mean duration of . days. overall mortality was %, patients fulfilled study criteria. survivors had gos , pts with preexisting neurological impairment survived with gos . neonatal diseases included hyaline membrane disease ( ), meconium aspiration syndrome ( ) and cardiovascular surgery ( ), pediatric diseases included bacterial ( ) and viral ( ) pneumonia, aspiration ( ) and cardiovascular surgery beyond the neonatal period ( ). - ) . patients and methods: cefotaxim was used as a prophylactic agent in patients in life threatening situations (e.g. multitrauma, neurosurgery atc.). more than % children required cefotaxim for the treatment of severe infections (epiglotitis, meningitis, sepsis, pneumonia mainly in immunodeficient and neutropenic patients) in monotherapy or in the combination with the other antimicrobial agents. results: cefotaxim as a prophylactic drug was successful in all cases ( %). the effectivity of treatment of infections was . % ( patients). the change of antibiotic therapy required patients ( . %). patients ( . %) died, but only in of them ( . %) the obduction confirmed infection. conclusion: we conclude that cefotaxim is very effective and safe antibiotic and represents "golden standard" in the treatment of severe infections in childhood. in order to improve nursing quality, we recently adapted nursing care to the "five nursing functions" (activities of daily living, accompagnment in crisis, treatment, prevention and research) as described by the swiss red cross in accordance to the new educational guidelines of the european community, the aim of this study was to document complications of "treatment nursing function".methods: all treatment complications were prospectively collected by the nursing and medical staff. the nursing staff included patient (pt) name, time of occurence and exact description of complication, proposal for prevention and information of parents. the medical staff reported type of complication together with pt information, diagnosis, medication, treatment and interventions, outcome and referral, all complications were discussed in monthly meetings including nursing and medical staff.results: from january until december , pts were admitted to the picu/nicu for nursing days ( % of total bed occupancy). pts needed endotracheal intubation for an average of . days and pts required nasal cpap. complications in pts were noted ( per pi): inadequate check-up of equipment ; accidental extubation ( in intubated pts); bedsores ; false drug dosing ; wrong drug ; umbilical bleeding ; wrong transfusion setup ; nasal septal necrosis ). there was no mortality due to these complications. exact documention of treatment complications and their meticulous discussion within the medical and nursing staff may improve "treatment nursing function". however, documentation and evaluation of nursing within all "five nursing functions" will be nessecary in order to achieve optimal nursing care. cardiac output determination by thermodilution, using iced injectate has been shown to be valid and reliable in pediatric patients. it has been demonstrated in adult patients that there is no difference in cardiac output values when using room temperature injectate as compared to iced temperature injectate. the purpose of this study is to examine the effect of injectate temperature on cardiac output values in pediatric patients. our study consisted of sixteen pediatric patients who had oximetric thermodilution catheters in place after cardiac surgery and who had cardiac output determined using both iced and room temperature injectate. with each patient, cardiac output was measured once on the day of surgery and again the following day. in each case cardiac output was measured using both iced and room temperature injectate. statistical analysis included a two-way, repeated measures analysis of variance for each individual injectate administered and no significant differences were found in cardiac output. no statistically significant differences were found between groups with regard to the order of injectate administration or volume of injectate used (i,e., or cc's). the correlation coefficients between groups for cardiac output measurements at each injectate administration time, and for the average measurements across times, ranged between . to . (p < . ). preliminary data analysis suggests that cardiac output measurements for children are not effected by the temperature of injectate. a lenghty stay at a paediatric intensive care unit will always have sideeffects on a child's well-being and will put a high strain on the parents. in order to minimize the side-effects longterm intensive care unit opened in at the childrens' hospital. admitted children are all ~ongterm-ill and technically-dependent and the ventilatory support can alter from a tracheostoma to cpap or portable volume ventilator. nutritional support is applied by gastrostomies. a homelike atmosphere surrounds the children, they share a dormitory, a living-room and a dining-room the main purpose is to send the child home with or without technical equipment. this can only be implemented by giving structured education (theory and practice) to all categories involved. the multi-disciplinary team consists of one anaesthesiologist, head nurse, clinical specialist, rn nurses, nurses, one habilitation doctor, one social worker and therapists. twenty-four patients have been admitted to licu during these six years. length of stay was from one day to four years. four are presently staying at the trait. the assessment of pain in children ( - yrs) is still difficult, because children of this age have limited language and cognitive skills. to standardize the assessment of postoperative pain and distress in the intensive care unit an observational mstrument was needed that met several criteria. it should be easy to use in daily routine care. be suitable for the i.c. situation, and in children of - hrs of age. the comfort scale, an observational instrument designed to assess distress in infants in i.c. units, met these criteria. to accommodate the use of the comfort scale in the i.c. units and in research, nurses should be trained to use the scale. an additional requirement was that the inter-rater reliability should be sufficiently high, (cohen's kappa > . ). objectives: ) to introduce the comfort scale in the i.c.u.; ) to examine whether this instrument can easily, be incorporated into routine care; ) to investigate the inter-rater retiabtlity. methods: the comfort scale is an -item instrument specifically designed for use in pediatric i,c, units and contains both physiological items (heart rate, blood pressure) and behavioral items (e.g., alertness behavior, calmness/agitation, body movement, facial expression respiratory response, muscle tension). the observation period is minutes. the scale is supplemented with an item on crying tbr children who are not mechanically ventilated. groups of t.c. nurses were trained by means of video's and observations at the wards. after the training, each nurse completed scores with other nurses, after which the cohen's kappa was computed. when the kappa's for the items met or exceeded our . criterium, a new group of nurses was trained. results: to date, nurses have been trained. nurses find the comfort scale easy" to administer and a valuable addition to routine care in the i.c. unit. the cohen's kappa's were higher than . for all items that the inter-rater reliability was high. the comfort scale is feasible in postoperative care in the i.v. and is considered a valuable instrument to improve and maintain high postoperative quality of care in the i.c. unit. introduction:children with neuro-muscular disease are believed to have a higher resting energy expenditure (ree), because of their increasedwork of breathing.the influence of nocturnal nasal mask ventilation on energy metabolism and nutritional state of these children has not been studied so far.objective:l,ls the ree inereased? . s there an influence of nasal mask ventilation on the ree? .what is the nutritional state? .what is the estimated total energy expenditure(ete) in relation to the caloric intake? methods:a pilot study of patients( - years) .the following measurements were performed:l.anthropometry. .bioelectric impedance- .ree was measured by indirect calorimetry during the day (in bed) with and without nasal mask ventuation,ree was compared with predicted ree according to schofield(pee), .caloric-intake and activities were recorded during hour before measurement. .total energy expenditure was calculated as follows:measured ree x estimated activity factor. results:tin all children weight for height was too low, <p . .aii children had a low % of fat. .according to the healthy group, ree is not increased. ,nasal mask ventilation lowered ree in patients, in patient we measured a clear decrease.conclueion:l.anthropometry and indirect calorimetry were helpful in evaluating the nutritional state. .there is no increased ree,in t patient there is clearly effect of nasal mask ventilation. .when caloric intake was related to ree and level of activity patients had too low caloric intake. .the influence of nocturnal nasal mask ventilation and nutritional assessment should be evaluated longitudinally. increasing awareness that the neonate can percept pain and suffer following surgical procedures, has major impact on pain management. in our unit continuous morphine infusion (t /~g/kg/hr) was introduced from january as a standard medicatton following surgical procedures. before morphine was given as a bolus (i.m., i.v., rectal) of /~g/kg up till four times a day. repeated gifts of morphine were only gwen following observation by the nurse that the child experienced pain. aim of the study: to evaluate pain management before and tbllowing introduction of a continuous morphine infusion for postoperative pain in our icu. patients and methods: term born babies with isolated oesophageal atresia and tracheo-oesophageal fistula were included in the study. the total amount of morphine (/~£/kg/ hours); number of days morphine was given; duration of artificial ventilation was evaluated in a case control study. res ults: - - central venous catheters (cvc) have been increasingly used also at our picu, university medical centre ljubljana. besides advantages, the cvc has brought numerous risks of complications; the catheter sepsis occurs most often and can be fatal for the patient. for example, in we dealt with children aged - years or in other words . cvp per a child treated at our picu. a specialized unit for preparing parenteral natrition started to function in the university medical centre pharmacy in . after that we equipped a special room for preparing other necessary infusion mixtures and organized a team of nurses -"catheter nurses".their tasks comprise: managing cvcs, replacing and installing infusion systems and mixtures made at pharmacy, preparing drugs and some necessary infusion mixtures in special room, permanent training and co-operation with related disciplines, pharmacy, epidemiology, microbiology, etc. all registered nurses at picu have been trained for this work. the routine is as follows: in the morningafter the doctor's visit, we first check the cvc and change the dressings; according to the nurse's observations, the doctor decides whether there is a need to remove or replace the cvc. if the catheter site is inflamed, swollen, or purulent, a swab is taken for microbiological culture and the area cleaned. in case of systemic infection signs, cvc has to be replaced, blood culture taken and the infection treated with antibiotics. the dressings are always changed by two tmcatheter nurses together. afterwards the infusion mixtures for the next hours are prepared for each child. the infusion mixtures which will not be used immediately are kept on + °c; before application they are, of course, warmed to at least room temperature. finally the "catheter nurse" supplies the cvc with new infusion mixtures made at our pharmacy. our observations show that such work requires responsibility and is demanding; but our pemanent care lessens the number of complications. thus the described scheme fulfilled our expectations. perl- perative management of neonates with hypoplastic left heart syndrome muir warren, blondel maryse, foltz rhonda, farine martine, icu nurses, the aldo castaneda institute, clinique de genolier, switzerland both the pre-operative and post-operative physiology of patient with hypoplastic left heart syndrome is critically determined by the puhnonary-tosystemic resistance ratio. a high ratio results in minimum volume work for the right ventricle but is at the expense of important hypoxemia. a low ratio is reflected in minimum hypoxemia but an unfavorable increase in excess ventricular volume work. a resistance ratio of approximately results in an arterial oxygen saturation of % - %, a qp/qs of , and ventricular volume work only twice normal. this latter physiology appears best for oxygen delivery and systemic perfusion with tolerable volume work. carbon dioxide (co ) in the inspired gas is known to increase pulmonary vascular resistance without significantly influencing systemic resistance in the range of to tort partial pressure. hyperventilation with no co in inspired gas decreases pulmonary vascular resistance. thus, managing co may be useful to modulate the pulmonary-to-systemic resistance ratio, in the tast months, patients with hypoplastic left heart syndrome were managed by a norwood procedur e. patients with endotracheal entubation pre-operatively had co added to inspired gas to modulate the pulmonary-to-systemic flow ratio. patients had co added to inspired gas post-operatively. all but patient had characteristically large pulmonaary-to-systemic flow ratio with oxygen saturation mean % preoperatively, even in those patients receiving co , co was accompanied by elimination of metabolic acidosis pre-operatively. the most comlnon partial pressure of co added post-operatively was torr. po ranged from mmhg to mmhg. all surviving patients developed a metabolic alkalosis ( mean) when treated with co . there were deaths, one from drug toxicity, one from excessive post-operative hemorrhage, two from sepsis or mocardial insufficiency. only one patient benefited from catecholamine support which can increase systemic resistance unfaborably. in this experience co was felt to be an important adjunct in some patients pre-operatively and most patients postoperatively to faborably modulate the critically important systemic-topulmonary flow ratio, to maximize oxygen delivery and systemic perfusion, while minimizing excessive right vantricular volume work. key: cord- -p q f c authors: nan title: posters_monday_ october date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: p q f c nan a huge variability in excess risk of death, ranging from to %, from ventilator associated pneumonia (vap) have been reported in the literature [ ] . this large between-study variation can be attributed to difference in definitions but also to incorrect estimation by standard statistical methods, i.e. inappropriate adjustment for informative censoring and time dependent confounders. the aim of this study was to take into account above statistical shortcomings and to assess the excess risk of vap by using an extension of a recently developed techniques from the field of causal inference [ ] . materials and methods. data was retrieved from a large longitudinal, high quality multi-centric icu database from france (outcomerea). a random sample of consecutive patients ventilated [ h from icus over a year period were included. vap was defined as clinical suspicion plus at least one positive proximal or distal sampling with quantitative count using classical thresholds. only the first vap episode was taken into account. we considered discharge from the icu as a competing risk and estimated the attributable -day icu mortality of vap by comparing the counterfactual cumulative incidence of death for the entire population under different hypothetical infection paths. baseline characteristics indicating underlying co-morbidity and longitudinal (daily measured) severity of illness indicators together with all other known confounders until vap developed were taken into account through the use of a marginal structural model [ ] . results. a total of , icu patients were included. mean (sd) age and saps ii score were ( ) and ( ), respectively. seventeen and % were admitted after scheduled and emergency surgery respectively, % were medical patients. forty-two percent had an underlying chronic illness (knaus). nine percent received dialysis in the icu. a total of ( %) patients developed vap within days of admission ( and % within and days, respectively). crude icu-mortality rates in patients with and without vap were and %, respectively. when taking into account all the confounders, we found a . % increase ( % ci . - . , p = . ) in the hazard of -day icu-death per additional day since the development of vap. provided vap could have been prevented in the whole population -day mortality would have decreased by . %. conclusion. the excess risk of death from vap estimated by marginal structural models is lower than commonly reported in the literature. this indicates that underlying comorbidities and the evolution of severity of illness until vap are insufficiently taken into account by current standard statistical methods. reference (s) . . rello et al ( ) introduction. the intensive care society (uk) has recently published national guidelines regarding many aspects of percutaneous tracheostomy management [ ] , however, these guidelines do not make any recommendations regarding antibiotic prophylaxis during the procedure. we recently audited uk practice and have established that only % of the units give prophylactic antibiotics for patients known to be colonised with methicillin-resistant staphylococcus aureus. the low rate of antibiotic use is surprising given that pneumonia and/ or bacteraemia following pt is frequently caused by organisms (non-mrsa) that colonise the patients' skin and/or airway [ , ] . objective. to establish the incidence of mrsa positive sputum and/or blood cultures following pt in patients colonised with mrsa in their nose or throat. methods. we audited all the patients who had pt performed between and who were known to be colonised with mrsa in their nose or throat, (but who had negative sputum cultures) before pt was undertaken. we wanted to find how many of these patients developed mrsa positive sputum and/or blood cultures in the first week following their pt. results. from a total of patients admitted to critical care between and only seven mrsa colonised patients required pt. all of these patients had mrsa colonised throat or nose with negative sputum and blood cultures prior to the pt. no patients were given prophylactic antibiotics during the pt as this was our standard practice. four ( %) developed mrsa positive sputum cultures in the first week following the procedure. one ( %) developed mrsa bacteraemia on day following pt. over the same period there were no case of mrsa bacteraemia in the mrsa colonised patients who did not undergo pt. microbiology bacterial biofilm has been observed in the surface of the endotracheal tube (ett) in mechanically ventilated patients and recent studies relate the presence of biofilm with the incidence of ventilator-associated pneumonia (vap). acinetobacter baumanii is a gramnegative opportunistic nosocomial pathogen involved in the production of vap, and capable of biofilm formation on abiotic surfaces. objective. to analyse the presence of biofilm in the ett by using scanning electron microscopy (sem) and to identify the microorganisms contributing to its formation in patients admitted in an icu endemic for a. baumanii. methods. from march to september , consecutive patients admitted to our unit and mechanically ventilated were included in the study. etts after extubation were (a) sent to microbiological culture, and (b) fixed with % paraformaldehyde- % glutaraldehyde for one hour, dehydrated with increasing ethanol concentrations, and processed for sem. etts were observed under sem to assess the presence and extension of the biofilm, and to recognize bacterial or fungal forms. results. there were males ( %) and females ( %) with a median age of years (range - ).the median apache ii score in the first h was (range - ). the median duration of intubation was days (range . causes of intubation were coma in patients ( %), respiratory failure in ( %), and heart failure in ( %). the microbiological isolations showed: a. baumanii ( %), staphylococcus non aureus ( %), pseudomonas spp. ( %), streptococcus viridans ( %), staphylococcus aureus ( %), enterococcus faecalis ( %), candida albicans ( %), and others ( %). under the sem, biofilm was identified in the % of all cases and was abundant in ( %), regular in ( %), and scarce in ( %). morphological identification of microorganisms observed under sem showed: cocci in ( %), bacilli in ( %), and yeast in ( % introduction. hospital-acquired infection is often linked to the standard of ward cleaning however the impact of increased quality of cleaning and deep cleans are unknown. objectives. this study aimed to determine the effect of enhanced cleaning on local contamination rates of hospital pathogens and whether this results in a reduction in patient colonisation. a cross-over one-year study was performed in the intensive care units (icu) of two teaching hospitals, which screened patients weekly for mrsa. in randomized two-month periods and in addition to conventional cleaning using detergent and mops, high contact areas were cleaned twice daily by a team of trained hygiene technicians using microfibre cloths. using contact plates, samples were taken at nine sites around the bed area and ward over bed-days per week. hand hygiene was encouraged and compliance audited. results. only . % of the planned , local samples were missed and this was equal between study phases. average hand hygiene compliance was similar between enhanced and standard phases [hospital a . % ( / ) vs. % ( / ) and hospital b . % ( / ) vs. . % ( / )]. patient characteristics were similar during standard and enhanced cleaning periods. of the sites tested, samples taken from bed rails were most likely to be contaminated with mrsa (or = . ; % ci: . - . ) followed by nurses' hands (or = . ; % ci: . - . ). analysis of these site-samples also confirmed that enhanced cleaning significantly reduced environmental contamination (or = . ; % ci: . - . ; p \ . ). the effectiveness of enhanced cleaning in removing mrsa contamination did not vary with the sample site. a sub-group analysis of samples only taken from nurses' hands showed a non-significant reduction in mrsa hand contamination associated with enhanced cleaning although associated uncertainty was large (or = . ; % ci: . - . ; p = . conclusions. this is the first prospective controlled study examining the effectiveness of enhanced cleaning in preventing spread of multiresistant pathogens within icu. although both environmental and hand contamination were reduced, enhanced cleaning of high contact surfaces was not associated with a reduction in cross infection. conclusions. isd of secretions reduces the incidence of vap in patients receiving. css alone, or in combination with isd has no significant effect on incidence of vap. hence, isd may be recommended for vap prevention, considerations other than prevention of vap should determine the choice of the suction system in a mechanically ventilated patient. to show a mortality benefit, larger, multi-center trials may be required. decreasing incidence of ventilator-acquired pneumonia (vap) is increasingly regarded as a priority in icu quality programs. subglottic secretion suctioning (sss) has been associated with a decreased risk of vap. a previous metaanalysis concluded that sss reduces the risk of vap, but it included only five randomized controlled trials (rct), and sss is still underused, perhaps considering the available evidence is insufficient. we planned a systematic review and metaanalysis of sss for vap prevention. pubmed, embase and cdsr were searched for rct studying the influence of sss on vap incidence. additional outcomes were mortality (within icu or hospital), icu and hospital stay, mechanical ventilation duration and time from intubation to vap diagnosis. additional references and sources of information were searched, and authors were contacted as necessary. rct were found, but one of them was excluded for not having enough data for analysis. rct were analysed, including , patients. quality of the rct was only moderate. qualitative outcomes were homogeneous between studies, so were analysed by a fixed effects model; quantitative outcomes were very heterogeneous, and were analysed by a random effects model. compared to control, sss decreased vap incidence (rr . ; % ci . - . ), but not mortality (rr . ; % ic . - . ). sss delayed vap onset for . days ( % ci . - . ), shortened mechanical ventilation for . days ( % ci . - . ) and decreased icu length of stay for . days (ic % . - . ). in two rct, no differences were found in the hospital length of stay. conclusion. sss reduces vap incidence and delays vap onset, shortening mechanical ventilation and icu length of stay, but not decreases icu or hospital mortality. data from rct support the use of sss as an adjunctive tool to prevent vap. introduction. in comparison to ventilator-associated pneumonia (vap), less data are available on ventilator-associated tracheobronchitis (vat). however, vat may be associated with considerable morbidity [ ] . aim. to investigate prospectively the incidence and outcomes of vat. we studied prospectively all patients who received mechanical ventilation in the general intensive care unit of a tertiary hospital in greece between september-november . vat diagnosis required temperature ([ °c) or leukocyte count [ . per ml or leukopenia \ . per ml) (at least one of these) plus new onset/change of purulent endotracheal secretions. vap diagnosis required the aforementioned criteria plus appearance of new and persistent pulmonary infiltrates on chest radiography. microbiological documentation was based on the growth of microrganisms in bronchial aspirations ([ . cfu) or bal ([ . cfu) . results. forty-six patients were included, median (iqr) age was ( . years. eleven ( %) patients presented vat, presented vap and patients presented none of these two disorders (np). there were no significant differences between vat and vap cases in terms of baseline characteristics (diagnosis, respiratory compliance, apachee, murray score), occurrence of sepsis or ards and microbiology; pseudomonas aeruginosa, acinetobacter baumannii, staphylococcus aureus and klebsiella pneum. were the most common bacteria in both vat and vap. patients who presented vat or vap had significant longer hospitalization and mechanical ventilation duration (days) compared to , ( - ) vs. ( - ), (p = . )] and [ ( - ) , ( - ), ( - ) , (p = . ), respectively]. icu mortality was , , %, for patients with vap, vat and np, respectively (p = . ). conclusions. incidence and microbiological pattern was similar in vap and vap in these case series. both vat and vap were associated with longer hospitalizations and mechanical ventilation duration. further analysis with a larger cohort of patients is required to give conclusive remarks. reference (s) . . nseir s et al ( ) nosocomial tracheobronchitis in mechanically ventilated patients: incidence, aetiology and outcome. eur respir j : - . g. c. choutas , v. g. nolas , a. kalantzi , a. moutzouri , g. k. anthopoulos intensive care unit, \ \ [ [ general air force hospital, athens, greece introduction. endotracheal suctioning is an essential part of care for patients receiving mechanical ventilation, to keep the airways free from bronchial secretions, assuring ventilation and oxygenation. there are two types of suction systems. in the open system, endotracheal suctioning requires disconnecting the patient from the ventilator and introducing a single-use sterile suctioning catheter into the endotracheal tube. closed systems are changed every and h. to determine whether ventilated patients treated with css in an intensive care unit (icu) differ as to airway bacterial colonization and colonization of the suction system based on cultivation of both bronchial secretion and suction catheter tip and if cultivation of suction catheter tip is adequate in place of bronchial aspirate cultivation. methods. patient, incubated and ventilated in the icu ward were studied in a period of one year ( to ) , on admission to the icu a css (trach care mac) was connected. closed multi-use catheters were changed daily. two-pass endotracheal suctioning was performed as needed. ba cultures were obtained on admission and the next day. radiographs taken before, during, and after ba and css cultures were graded for pneumonia and a modified score for vap. of the patients css samples ( . %) and ba samples ( . %) were sterile. airway colonization with gram-negative bacteria and fungi occurred in the majority of the patient . % and gram-positive bacteria in %. cultivation of css revealed gramnegative bacteria and fungi occurrence . % and gram-positive bacteria in . %. with the current sample no significant difference was found between the positive results of trach care tip cultivation and ba cultivation p = . . objectives. to reduce the use of sedatives and to decrease the amount of time spend on a ventilator by specific ramsay-instructions and checks for sedation-protocol-adherence. methods. in april , after introductional lessons to doctors and nurses, we started and collected data for months. a yellow reminder was attached to the medical-instructions-form and doctors were requested to fill in the ramsay-score on a daily basis. once in a week patients and records were screened to assess protocol-adherence. each nurse and each intensive care-unit received feedback on their compliance to the bundle-elements. the total amount of sedatives per month was divided by the number of ventilator days, resulting in an average dose midazolam/propofol per ventilator day. the median and interquartile range of ventilator days/patient was also calculated and all data were compared with the same period in . we accomplished a reduction in the use of sedatives and costs. introduction. ventilator associated pneumonia (vap) often occurs in patients who are mechanically ventilated. the incidence rate varies between and % for patients in the intensive care unit. it has been the second most common hospital-associated infection after that of the urinary tract. the diagnosis of vap is difficult because of different existing definitions. hypothesis. our hypothesis was, that lowering vap incidence rate, could be done by a bundle of five interventions. the purpose of introducing multiple ventilatory interventions as a bundle, was to lower vap incidence rate by %. methods. during the last months of all patients who were ventilated [ h, were investigated for vap. the diagnosis of vap was done according to the criteria supposed by the dutch working group on infection prevention. a new infiltrate on chest x-ray after h ventilatory support in combination with fever, leucocytosis, increased need for oxygen and culture of blind bronchial secretion c cfu/ml. a ventilator bundle was introduced on all icu wards as inspired by the institute of healthcare improvement. five interventions were introduced: head of bed [ °, reduction of sedatives as low as possible according to prescribed ramsay score, assessment of readiness to extubate, cuff-pressure measurement times a day with application of cuff pressures between and cm h o, and oral care with chlorhexidine . % times a day. icu nurses were trained in the first months of . the last months of were used to evaluate the bundle intervention in comparison with the last months of . results. patients were included in and in . after introduction of the ventilator bundle, the incidence per , ventilator days decreased from . % to . % per , ventilator days. introduction. continuous positive airway pressure (cpap) may improve oxygenation in patients with mild to moderate acute hypoxemic respiratory failure (ahrf) and avert further deterioration and need for intubation. objectives. aim of our study was to assess the physiologic effects produced by the addition of periodic hyperinflations (sigh) to cpap in patients with ahrf. we studied patients with non-cardiogenic ahrf. four trials of one hour each were performed at a constant fio % during ( ) spontaneous breathing (sb) via a venturi mask, ( ) cpap , ( ) cpap ? sigh/min of cm h o for s (cpap sigh ), ( ) cpap . cpap, via helmet, was maintained at cm h o troughout the whole study period. pao /fio ratio (p/f), paco , ph, respiratory rate (rr), arterial blood pressure (abp), heart rate (hr), dyspnea and patient comfort (by means of separate visual analog scales) were measured at the end of each trial. results. overall, p/f was significantly (p \ . ) improved by cpap (cpap ± mmhg, cpap sigh ± mmhg, cpap ± mmhg), as opposed to sb ( ± mmhg). overall, the sigh did not significantly improved p/f. in the six patients with bilateral infiltrates, however, the rate of improvement in p/f significantly (p \ . ) augmented with the introduction of a sigh as compared with those with monolateral infiltration ( vs. % respectively, being % the increase from venturi to cpap ). paco , ph, rr, hr, abp, dyspnea and comfort were not significantly different between trials. conclusions. in patients with ahrf, cpap improves oxygenation without affecting hemodynamics. the addition of a sigh to cpap further improved oxygenation only in patients with bilateral pulmonary infiltrates. background. adaptive support ventilation (asv) is a novel electronic ventilator protocol that incorporates the recent and sophisticated measurement tools and algorithms. the target tidal volume and respiratory rate are continually adapted to patient's respiratory physics and varying medical conditions. in injured lung, the asv should actively adjust ventilatory parameters achieving minimal work of breathing to meet the lung protective strategies. but there were little literatures describing its efficacy when applied to korean population. methods. from may to january , we observed initial mechanical ventilation parameters in patients receiving asv due to various causes ( lung injuries including community acquired pneumonia, hospital acquired pneumonia, interstitial lung diseases, pulmonary tuberculosis and idiopathic cases; without lung injury which comprise trauma cases, strokes, suicidal attempts and other cases). the mean age of studied population was . years (male:female = : ). the data were collected within the first h of mechanical ventilation. conclusion. as expected, adaptive support ventilation delivered smaller tidal volume and higher respiratory rates for injured lungs. asv efficiently operated in korean ali patients without any serious drawbacks and favorably adjusted the tidal volume and respiratory rates combination in relation with rcexp to meet lung protective strategies. introduction. neurally adjusted ventilatory assist (nava) is a mode of mechanical ventilation that uses the electrical activity of the diaphragm to control the ventilator obtaining an improved patient-ventilator synchrony and an efficient unloading of the respiratory muscles. nava is characterised by a variability of the breathing pattern and the absence of a constant flow, which makes impossible the determination of reliable data of respiratory mechanics by using the rapid occlusion method. we have previously demonstrated that the least squares fitting method (lsf) could be used during pressure support ventilation (psv), provided that the level of ps is sufficiently high to unload the inspiratory muscle. hence we made the hypothesis that ( ) reliable data of respiratory mechanics can be obtained by applying the lsf method during nava and ( ) the lsf method should work better during nava because of the characteristics of the flow and pressure traces. methods. ten patients undergoing mechanical ventilation for acute respiratory failure were enrolled. they were ventilated using randomly either psv or nava with the the same peepe and tidal volume (v t ). data of resistance (r rs ), elastance (e rs ) and total positive end expiratory pressure (peep tot ) were obtained by fitting the equation paw = r rs v ? v t / c rs ? peep tot during inspiration, because of the possible presence of expiratory flow limitation. the coefficient of determination (cd) of the applied equation was used to compare data obtained during nava and psv, the higher being the cd, the better the quality of the data. moreover patients were sedated and ventilated in volume controlled ventilation (acv) with the aim of calculating data based on rapid occlusion method and compare them with those obtained with lsf method by using the bland-altman analysis. ( ) data obtained with lsf were statistically more reliable during nava (mean cd: . ± . ) than during psv (mean cd: . ± . ; p \ . ). ( ) the cd obtained at every level of nava was always higher then . . on the contrary, the cd obtained at low level of psv was less than . due to the presence of inspiratory muscle activity. ( ) the bland-altman analysis demonstrated lower bias and higher precision between traditional data and those calculated during nava (bias: . ; limit of agreements: - . / . ) compared to psv (bias: . ; limit of agreements: - / . ). conclusion. the application of the lsf method during nava allows calculation of reliable data of rrs, ers and peeptot, which are independent of the level of nava applied. this is of clinical relevance since psv allows calculation of reliable data only at high level of pressure support. it appears that the influence of inspiratory muscle activity on respiratory mechanics is less relevant during nava ventilation, suggesting a more physiological ventilation during nava both in terms of timing and of delivering adequate level of assist throughout each breath. introduction. nava is a new spontaneous-assisted ventilatory mode based on the detection of diaphragmatic electrical activity (eadi) and its feedback to adjust ventilator settings. nava uses the eadi, an expression of the respiratory center's activity, to initiate pressurization, set the level of pressure support and cycle the ventilator into exhalation. therefore, nava should theoretically allow near-perfect synchronization between the patient and the ventilator. however there are few data documenting these effects in intensive care patients. to determine whether nava can improve patient-ventilator synchrony compared to standard pressure support (ps) in intubated intensive care patients. comparative study of patient-ventilator interaction during ps with clinician determined ventilator settings and nava with nava gain (proportionality factor between eadi and the amount of delivered inspiratory pressure) set as to obtain the same peak airway pressure as the total pressure obtained in ps. a min continuous recording with each ventilatory mode was performed allowing determination of trigger delay (t d ), patient neural inspiratory time (t in ), duration of pressurization by the ventilator (t iv ), excess duration of pressurization (t i excess = t iv -t in /t in ) and number of asynchrony events by minute: non-triggering breaths, auto-triggering, double triggering, premature and delayed cycling. results are given in mean ± sd. p is considered significant if . . . ± . . ± . . ± . n asynchrony/minute . ± . . ± . * . ± . respiratory rate (min - ) . ± . . ± . na * p \ . conclusion. compared to standard ps, nava improves patient ventilator interaction by reducing td and the overall incidence of asynchrony events. there is also a strong trend in reducing delayed cycling. this ongoing trial should provide evidence that nava can indeed improve patient-ventilator synchrony in intubated patients undergoing ps. introduction. high fio and hyperoxia may induce pulmonary injury and may increase oxidative stress. guidelines suggest a target arterial oxygen tension of kpa [ ] . a canadian questionnaire study found considerable variation in the attitudes, beliefs and practices of intensivists in the management of oxygen therapy [ ] . however, the actual response of intensivists to hyperoxia in patients has never been studied. in this retrospective database study we investigated adherence to guidelines concerning oxygen therapy in a dutch academic intensive care. all arterial blood gas (abg) data from mechanically ventilated patients from to were drawn from an electronic storage database (metavision) of a mixed -bed icu in a university hospital in amsterdam. mechanical ventilation settings at the time of the abg as well as the successive abg were retrieved. the statistical analysis was carried out with spss . . results. . abg's from mechanically ventilated patients were retrieved including corresponding ventilator settings. in . ( %) of the abg's po was[ kpa. initial ventilator settings and adjustments based on abg's of this group are shown in table [data represent median ( th/ th percentile)]. in % of the lowest fio group, fio was exactly %. in only % of cases with po [ kpa the fio was decreased. hyperoxia was accepted with no adjustments in ventilator settings if fio was % or lower. introduction. major patient ventilator asynchronies are frequent during non-invasive ventilation (niv) especially due to leaks.niv can be delivered using icu ventilators or specifically designed niv ventilators. although icu ventilators are traditionally used for invasive mechanical ventilation, specific niv modes have been recently implemented. the impact of these niv modes as well as niv ventilators on patient ventilator asynchrony is unknown. our objective was to compare the incidence of patient ventilator asynchrony between invasive or niv mode of icu ventilators and niv ventilators. patients and methods. icu patients with acute respiratory failure requiring niv were studied during three randomized consecutive min-periods of niv: icu ventilator with and without niv mode and niv ventilator. we used two icu ventilators: evita xl (dräger) and engström (general electrics) and niv ventilator: bipap vision (respironics). flow and airway pressure were continuously recorded to determine breathing pattern. to detect major patient ventilator asynchrony we used surface diaphragmatic and/or sternocleidomastoid electromyogram allowing to assess neural patient's inspiratory time and to define asynchronies: ineffective triggering, auto-triggering, double-triggering, prolonged and short cycles. asynchrony was quantified using an asynchrony index as previously described. results. these preliminary results concern ten patients ( males and female) with a mean age of ± and a saps of ± . reason for niv was acute exacerbation of copd (n = ), acute pulmonary edema (n = ) and post-extubation (n = ). at time of study, ph was . ± . , paco ± mmhg and pao ± mmhg. ventilatory settings were set by the clinician and kept constant during the three periods with a ps level of ± cm h o and a pressurization ramp of ± ms, a peep level of ± cm h o and a fio of ± %. using icu ventilators, inspiratory trigger was l/min and cycling off was % when adjustable. median asynchrony index was . % ( . - . ) using icu ventilators versus . % ( . - . ) using niv mode and . % ( . - . ) using bipap vision (p = . between invasive and niv mode, p \ . between niv mode and bipap vision). asynchrony index was greater than % in three patients using invasive mode, two patients using niv mode and no patient using bipap vision. auto-triggering was the main asynchrony. conclusion. niv ventilator (bipap vision) allowed a marked reduction in patient ventilator asynchrony during niv as compared to niv mode currently available on new generation of icu ventilators. grant acknowledgement. this study was supported by a research grant from respironics. a. armaganidis , k. stavrakaki-kallergi , c. sotiropoulou , a. koutsoukou , j. milic-emili , c. roussos athens university, athens, greece prevalence of expiratory flow limitation (efl) was estimated using the negative expiratory pressure method (nep) in anesthetized, paralyzed mechanically ventilated patients in icu. patients were studied in supine position at zero positive end-expiratory pressure (peep). a nep device especially designed and in build in an evita -draeger respirator, allowed the application of a pressure equal to- cm h o, starting at ms after the onset of expiratory flow and sustained throughout the end of the expiratory time set on the ventilator. patients were categorized in two groups: . non efl ( patients without flow limitation), in whom nep elicited an increase of expiratory flow over the entire expiratory flow-volume (v -v) curve. . efl ( patients with efl), in whom part or the expiratory v -v curve during nep was superimposed on the baseline v -v curve. half of our patients ( %) were flow-limited. no patient without pulmonary disease was found flow-limited, except of a percentage of morbidly obese patients ( %). efl was recorded in % of icu patients with pulmonary diseases: % of ards patients, % of patients with respiratory infection, % of asthmatics and % of patients with copd. time constant (s) and inspiratory flow (v insp) were found to predict the severity of flowlimitation expressed as efl % v t . objective. tidal volume (v t ) administered to ards patients can be adjusted depending on body weight. body weight may be estimated, measured or calculated for an ideal or a predicted value based on different formulas [ , ] . besides, those formulas require the measurement of height and may differ depending on gender. we hypothesized that v t value (ml/kg of body weight) may be different and show intrameasure variability depending on the method used. methods. ards patients were included prospectively in the first h after icu admission. the ventilatory parameters were selected by the attending physicians that were foreign to the study. all patients were ventilated by volume controlled-assisted mode. five independent observers estimated the weight (estw) of each patient. they also measured height with a metric tape for calculate the predicted body weight (pbw) [ ] and the ideal body weight (ibw) [ ] . after previous measurements, patients were weighed once with a calibrated scale (scaw). results were compared using analysis of variance. results. patients were studied, % women (age . ± . , saps ii . ± . ; apache ii . ± . ). ventilation parameters at inclusion: v t /scaw (ml/kg) mean ± sd . ± . . ± . . ± . . ± . . ** mean ± sd mean ± standard deviation, min minimum, max, maximum, pbw (men) or . (female) ? . (height in centimetres - . ), ibw (height in meters) , mean diff average of the intraindividual differences of calculated/estimated weight, range intraindividual difference in weight (estimated/calculated) expressed as minimum and maximum * estw versus pbw p \ . , pbw versus ibw p \ . , pbw versus scaw p = . ** v t /estw versus v t /pbw p \ . , v t /pbw versus v t /ibw p \ . , v t /pbw versus v t /scaw p \ . conclusions. our data show that there is no gold standard method for estimate or calculate body weight to adjust tidal volume in ards patients. recommendations based on pwb and ibw not guarantee that tidal volume administered is really those that we want to administrate. reference (s) . . ardsnet. nejm ; : - . . stewart te et al ( hôpital raymond poincaré ap-hp, service de réanimation médicale, garches, france, hôpital saint-louis, paris diderot university, paris, france, centre hospitalier d'etampes, etampes, france, université versailles saint quentin en yvelines, versailles, france rationale-objectives. dyspnea is a major respiratory symptom, which can reveal a severe disease. additionally, it can also result from an inappropriate ventilator setting in mechanically ventilated patients. if these patients are nowadays more and more conscious, prevalence of dyspnea and its clinical, biological and radiological correlates has never been assessed in this population. prospective cohort study conducted in two medical intensive care units (icu) during months. all patients intubated more than h and conscious have been included. the first day when the patient regained consciousness, dyspnea, anxiety and pain were assessed using a visual analogic scale (vas). if dyspnea was found, patient was asked if he experienced ''air hunger'', and/or ''excessive respiratory effort'' and if dyspnea vas was improved after ventilator setting has been changed. demographic, clinical, biological and chest x-ray data and ventilator settings have been collected. results. patients were included (age: ± years; simplified acute physiology score ii (saps ii): (iqr - ). reasons for mechanical ventilation included acute respiratory failure (n = , %), neuromuscular diseases (n = , %), coma (n = , %), and exacerbation of chronic obstructive pulmonary disease (n = , %). dyspnea was present in ( %) patients and was qualified as ''air hunger'' in patients ( %), ''excessive effort'' in ( %) and both in ( %). age, saps ii, reason for mechanical ventilation, respiratory rate, clinical examination, x-ray chest, pao /fio ratio, paco were not statistically different between patients with and without dyspnea. anxiety . ); p \ . ), assist controlled ventilation [ . ( . - . ) ] and diastolic blood pressure ; p = . ) were independently associated with dyspnea in multivariate analysis. ''air hunger'' tended to be associated with controlled ventilation (p = . ) whereas ''inspiratory excessive effort'' was significantly associated with low inspiratory flow, severe hypoxemia (median pao /fio ratio: , p = . ) and marked hypercapnia (median paco : mmhg, p = . ). in % of breathless patients, of ventilator resetting decreased dyspnea. length of icu stay was greater in patients with dyspnea (p = . ) whereas extubation within three days and icu mortality did not differ between the two groups. conclusions. dyspnea is frequent in mechanically ventilated patients and is strongly associated with anxiety, more frequently when controlled ventilation is used and is often reduced after ventilator resetting. assessment of dyspnea in conscious mechanically ventilated patients should be routinely performed in order to improve patients' comfort. methods. an experimental study design was used with a group of first year health care provider students. the students were divided into two groups related to familiarity of the location of exam. a part of students (n = ) were examined in demonstration room (dr) and the other part of students (n = ) in public place (pp) . every student received the same number of training hours ( h) and the same training method in demonstration room. during this exam the students performed a min long, single person cpr related to erc guideline. their performance was measured with calibrated ambu cpr software and the adapted point system of brendan b. spooner's scale. v and t test were used for comparison. p values less than . were considered statistically significant. we did not find difference between dr and pp groups in the correct sequence of bls steps, hand position, adequate frequency and depth of chest compression. between groups of characteristics of ventilation were not significant differences observed. it is first critical point in bls process to assess the quality of patients' spontaneous breathing; therefore it is crucial that the duration of check breathing may be sufficient long. the duration of checking for breathing was significantly (p = . ) shorter in dr groups than pr groups. in the pp groups time interval between chest-compression cycles were significantly (p = . ) longer-more than s-than in dr group. conclusions. the altered location of bls final exam shortens duration of checking for breathing which determines bls providers' decision making on starting chest compressions. the students may be full of confident in the well-known place represented by the shorter time of checking for breathing. the changed place of exam extended time interval between chestcompression cycles, therefore weaken the continuity of chest compressions, and decrease the chance of return of spontaneous circulation. aims. this paper reports an evaluation of the student experience of using a clinical competence assessment tool (ccat) in postgraduate critical care nursing education. the focus is on the perceptions of students in relation to the validity, reliability and usability of the assessment tool. the domains of competence assessed are based on five domains outlined by an bord altranais ( ) . they are: professional/ethical practice, interpersonal relationships, practical and technical skills, utilising a holistic approach to care, clinical decision making and critical thinking skills and organisation and management of care. the assessment process encompasses three clinical assessments and clinical competence is measured using the developmental process of novice, advanced beginner, and competent as described by benner ( ) . students are asked to reflect on their own learning needs prior to each assessment. the assessment includes a discussion on the knowledge that underpins practice thereby showing the integration of theoretical and practical knowledge. questionnaire was administered to all students who recently completed a graduate diploma in nursing studies (critical care) at a specific third level institution. results. the evaluation of the ccat as a mode of competence assessment in postgraduate critical care nursing education was generally positive from the students' perspective. some students considered the holistic nature of the ccat document to be a limitation, suggesting that their level of competency could have been better addressed with a tool that was more oriented toward critical care rather than being so 'broad' in nature. overall respondents considered that the ccat helped them to identify learning needs and found the use of the tool to be a positive experience and easy to use although some respondents considered that the wording of some of the sub-domains and indicators was difficult to interpret. competence assessment is about ensuring the delivery of safe and competent patient care. in order to determine competence a valid and reliable tool is needed. this small scale study presents the views of post registration critical care nursing students on using a competence assessment tool. the findings of this study cannot be generalised, however they do provide insight for educators and students using competence assessment tools in programmes preparing registered nurses for specialist nursing practice. the use of a holistic assessment process needs further explanation. students need to be encouraged to move away from the reductionist approach, which is focussed on tasks and move towards a broader understanding of competent practice. reference (s) . . an bord altranais ( ) requirements and standards for nurses registration education programmes, nd edn. . benner p ( ) from novice to expert excellence and power in clinical nursing practice. addison-wesley, california. to assess the usefulness of a web-based interactive learning package designed to supplement an undergraduate acute care course (very basic) taught to final year medical students. a web-based interactive learning package was developed to supplement a highly rated traditionally taught -day acute/critical care course consisting of pre-course reading, lectures, skill stations and interactive tutorials [ ] . the additional web-based package consisted of narrated lectures, interactive lessons, videos and animations to demonstrate practical procedures and clinical signs, self assessment quizzes and a question and answer forum. topics covered included arterial blood gas sampling and interpretation, acute metabolic disturbances, non-traumatic coma, acute respiratory failure and sepsis. both the package and the course are available to other medical schools free of charge. usefulness of the package was assessed by examining activity logs, a student questionnaire, formal focus group (conducted by an investigator not involved in course preparation or teaching), comparing the results of a post-course mcq based summative assessment with historical controls and comparing results of formative assessment included in the package with the summative assessment. results. over , student-activities were logged by students during the two week course. students completed the questionnaire. with regard to usability, [ % agreed or strongly agreed that interactive lessons and self assessment ran smoothly without faults, with a corresponding score of [ % for narrated lectures and ease of browsing. with regard to usefulness, c % agreed or strongly agreed that the question and answer forum was useful in clarifying areas of doubt and narrated lectures improved understanding of the course material; [ % agreed or strongly agreed that the content as a whole was useful in preparing the respondent to work as a doctor, interactive lessons improved their understanding of how to apply their knowledge, and their understanding of arterial blood gas interpretation and self assessment exercises improved their understanding of the course material. participants in the focus group indicated that the resources provided in the website were useful for learning, specifically the animations, narrated lectures and the question and answer forum. suggestions for improvement included improving the quality of the video and animations, increasing the range of topics covered and ensuring consistency with the printed course manual. there was no correlation between formative and summative assessments but, compared to historical controls, performance in the summative assessment improved ( vs. %, p \ . ). conclusions. the package provided a useful supplement to a traditionally delivered acute care course. introduction. faculty development refers to that broad range of activities that institutions use to renew or assist faculty in their roles. it includes activities that improve an individual's knowledge, skills and attitudes in important areas in teaching, education, research, leadership, administration and career development. in this abstract we will introduce one of the most important methods of faculty development programs. a meeting by the authors ''organizing group'' was conducted to decide on a topic for our workshop and discussed the planning and designing process. we decided on conducting a workshop on clinical teaching methods. a scientific and organizing committee was established, and accordingly work loads and assignments were distributed among them. we gave this workshop a title of ''i am the best clinical educator…are you!? our target audience was acute care management providers, with a capacity of up to participants. we gave a specific time and location of this event. venue was arranged. computers for group work, audiovisual and other logistics were provided. after summarizing the main points for the workshop the organizing committee distributed an invitation letters throughout the higher management and educational leaderships. an address remark was done through invitation from the organizing committee. hot and cold beverages and break lunch meals were provided. posters on the workshop were distributed through out the institution. folders with educational materials were provided for each candidate. pre-course registration was done. once the program for the workshop was finalized a reminder was sent out to the participants on the date and venue for the workshop. participants attended on time, folders, badges with usbs were handed out. a questionnaire was distributed to the audience to estimate their learning experiences and approaches towards teaching styles and methods which were used in their practice. certificates of attendance with cme credit hours were distributed. results. candidates attended this faculty development workshop. % were nurses and % were physicians, during this workshop, three topics were distributed over three groups, one group on how to break bad news. second group about how to conduct microteaching and the third group about how to give feedback. each group was evaluated by three members of the organizing committee, each group was ranked accordingly. all were performed by role play. at the end of the workshop an evaluation form was filled % responders. a five performance scale was used. the strength of the workshop was innovativity and ranked as strongly agree. the only weakness was the place constraint. conclusion. we concluded that a well organized workshop using role play, interactive sessions are effective modality for faculty professional development programs among acute care providers with high satisfaction rate. only of the respondents ( %) indicated they did understand the statistics they encountered in journal articles and % felt it was important to understand these concepts and that they would like to access more easily to biostatistics training. a patient is referred to a higher centre when services are needed to maintain continuity of care.there are guidelines for the safe inter and intrahospital transport of critically ill patients but no guidelines are available for the minimal mandatory content of interhospital referral notes of critically ill patients.this problem is manifold in developing countries. objective. to educate the critical care physicians regarding the deficits in the physicians referral notes with which critically ill patients are referred from one centre to another. it is a prospective observational study on out of hospital referred patients transferred to our intensive care unit (icu) over a period of year. after permission from the institutes ethical committee we reviewed the referral summaries of these patients at the time of icu admission regarding the information available of clinical details, course in the previous hospital and therapeutic interventions. patients with more than h of hospitalization before transfer were included in the study. introduction. in japan, closed icus have been gradually increasing at university hospitals. a closed icu is necessary for a university hospital not only for the hospital activity but also the education of medical students and the training of fellows. they can learn how to manage the circulation and respiration status of severely ill patients in icu. it is indispensable for effective education to ensure sufficient proper icu staffs. but the present condition of our country is that there are not so many intensivists enough to perform both of clinical duties and education of students and fellows. each icu of university hospitals is endeavoring to increase the number of intensivists. one of the popular methods is the announcement on web site to promote interest of young fellows. regrettably, the homepage of the japanese society of intensive care medicine has no such specific pages. each icu of university hospitals has to create attractive its own pages in the homepages of the hospitals. [ ] . most subjects are taught using lectures and group tutorials and the theory is applied in clinical areas to facilitate greater understanding of the newly acquired knowledge. there is no reported best practice mechanism for teaching medical ethics in a practical setting to medical students. objectives. the routine use of an ethical checklist has been proposed as a tool for the medical team to consider ethical issues on critical care [ ] . its use as a tool for teaching medical ethics within critical care has not previously been reported. the aim was to use this checklist to facilitate learning providing clinical case material for discussion in daily tutorials. one medical student (sm) undertook a one week period of study to learn about ethics in critical care practice. the checklist was used to review patient notes, guide further discussion with patients, when observing the professional behaviours and communication of the multidisciplinary team, and as a guide for case based discussions. results. the complexity and severity of patient conditions in critical care makes it the ideal setting for learning about ethics. sm considered more ethical dilemmas in this practical attachment than in the previous years of clinical placements. the checklist allowed identification of possible ethical issues relating to each patient and a deeper understanding of the patient's health care needs. it was used for daily tutorials to discuss the ethical principles and observed professional behaviours in a similar way to a discussion of clinical diagnosis and management of a patient case with a supervising doctor on a normal clinical attachment. complex issues such as capacity to consent, end of life treatments or resource allocation were seen in relation to ongoing care. on ward rounds it was observed that their conduct in an open environment could at times potentially compromise patient confidentiality. there was also a benefit from the consideration of ethics issues in a real time basis which allowed exploration and reflection on personal moral or spiritual beliefs and how they may differ from those of the patients and other medical professionals. conclusions. using an ethical checklist allowed application of theoretical lecture and workshop material to real life situations. by discussing the cases and observed behaviours with a senior critical care doctor it is possible for trainee staff to appreciate how difficult medical management decisions are made, and to improve the acquisition of the skills necessary to start to assess and discuss ethical issues surrounding a patient's care confidently. introduction. accurate data on patient's weight and height are important for management in intensive care units (icus). unfortunately, weight beds or bed scales are not available in a significant number of icus and these variables are often estimated by health care personnel. the accuracy of such estimations is poorly described. objective. to investigate the accuracy of visual estimation of weight and height in critically ill patients. methods. prospective study conducted in a -bed mixed medical and surgical icu. patients were consecutively weighed by an unblinded physician with a stretcher scale (t metric), and measured by a physical therapist using a measuring tape. the ideal weight was calculated using the ardsnet's formulas for predicted body weight. medical staff (ms), internal medicine resident (imr), nursing staff (ns), physiotherapist (pt) and nutritionist (nu) were asked to estimate patient actual weight, ideal weight and height. they were blind to the estimations during all the protocol. estimations in each healthcare group were computed as means, medians and percentage of error from actual and ideal weight and height, respectively. anova test was used to compare mean estimations between the groups. there were no significant differences between the groups in estimation of either weight (p = . ) or height (p = . ). conclusion. weight estimations from healthcare personnel are often inaccurate. there are no significant differences in accuracy between the estimations of weight and height in different healthcare groups. an effort should be made to weigh all critically ill patients. intraabdominal hypertension (iah) is often diagnosed in icu and it can lead to abdominal compartment syndrome, multiple organ failure and death [ ] . in clinical setting biochemical signals based on which iah is considered severe or detrimental on visceral tissues are scarce. currently, the only clinically relevant signal is decreasing hourly diuresis. in an attempt to find an early sign of metabolically relevant signal on clinically marked iah we investigated abdominal wall metabolite concentrations. previously high lactate/pyruvate has been detected in dialysate from rectus abdominis muscle (ram) in animal models of iah [ ] . in the present experiment we hypothesized that laparoscopic surgery which induces iah could lead to clinically significant increase of l/p ratio as a signal of anaerobic metabolism caused by iah and insufficient tissue perfusion. introduction. among the techniques proposed to assess microperfusion and oxygenation, nirs sounds to be convenient [ ] . if baseline measurements do not provide useful information for outcome of micro-vascular impairment, functional evaluation using vascular occlusion test (vot) seems to be promising [ ] . technological development of the nirs device (inspectra models and , hutchinson technology, hutchinson, minn) proposes to use a new probe measuring hemoglobin saturation at less depth than previously ( vs. mm between fiberoptic) with more data output ( value/ s vs. value/ . s) associated with an automated software to compute occlusion and reperfusion slopes. objective. to compare nirs results obtained, using the two different probes, at day of septic shock (ss) in two groups of patients having similar clinical characteristics. methods. patients (g ) and patients (g ) were included within the first h of ss. macrohemodynamic: heart rate (hr), mean arterial pressure (map), central venous pressure (cvp), cardiac output (co) and svo (mixed venous o saturation), ph, base excess, and lactate were collected as saps ii and sofa scores. baseline sto at thenar eminence was continuously monitored and a min upper arm(brachial artery) vot was performed. sto occlusion and reperfusion slopes were calculated manually in g (probe mm) using linear adjustment (r c . to be valid) or calculated by the software in g (probe mm) using the same method, p \ . was considered significant. results. median ± iqr. the two groups did not differ for macrohemodynamic nor for metabolic data (table ) . nirs data surprisingly were largely significantly different between the two groups for both baseline and slopes ( background. hypovolemia and hypovolemic shock are life-threatening conditions that occur in numerous clinical scenarios. near-infrared spectroscopy (nirs) has been widely explored, successfully and unsuccessfully, in attempt to function as an early detector of hypovolemia by measuring tissue oxygen saturation (sto ). in order to investigate the measurement site-and probe-dependence of nirs in response to hemodynamic changes, such as hypovolemia, we applied a simple cardiovascular challenge; a posture change from supine to upright, causing a decrease in stroke volume (as in hypovolemia) and a heart rate increase in combination with peripheral vasoconstriction to maintain adequate blood pressure. methods. multi-depth nirs was used in nine healthy volunteers to assess changes in peripheral vascular tone in the thenar and forearm in response to the hemodynamic changes associated with a posture change from supine to upright. a posture change from supine to upright resulted in a significant increase (***) in heart rate. thenar sto did not respond to the hemodynamic changes following the posture change, whereas forearm sto did. in the forearm, sto was significantly lower (***) in the upright position with respect to the supine position. conclusion. the primary findings in this study were that ( ) forearm sto is a more sensitive parameter to hemodynamic changes than thenar sto and ( ) cerebral hyperperfusion syndrome, caused by inflow at normal blood pressure into maximally dilated fine vessels, is a recognized complication of carotid endarterectomy (cea) strict blood pressure control in the early postoperative period can minimize the risk of cerebral hyperperfusion. until yet, diagnosis of cerebral hyperperfusion mainly relies on intermittent postoperative examinations (spect; ct angiography). non-invasive absolute cerebral oxygen saturation (scto by fore-sight technology) was validated to jugular bulb saturation (sjo ) monitoring with a constant difference of % higher for scto values. previously, sjo monitoring after severe head injury indicated cerebral hyperemia. in this study, we evaluated scto monitoring after carotid surgery as possible continuous on-line monitoring of cerebral hyperperfusion. fourteen pts scheduled for cea were monitored for h postoperatively after cea. bilateral scto monitoring was started before induction of anesthesia and maintained until h postoperatively. intra-operative eeg monitoring guided the decision to intraluminal shunt insertion. strict blood pressure control was applied at maintaining normotensive levels throughout the clamping procedure. early postoperative care focussed on strict maintenance of normotensive blood pressure. in no pt, any change in eeg was observed after carotid clamping. in all pts, ipsilateral scto significantly decreased after carotid clamping, without any scto value below %. we observed no changes in contralateral scto . mean clamping time was min ( - min). in all pts, clamp release restored ipsilateral scto to baseline values. in all pts, emergence from anesthesia was uneventful, without any new neurological deficit. in of pts, significant increases (scto [ %) in ipsilateral scto were observed in the postoperative period (m scto . %), without any changes in contralateral scto . this increase occurred at a mean of . h after carotid declamping with a mean duration . h. in these pts, we could not make any significant correlation to arterial blood pressure, as none of these pts needed more aggressive antihypertensive control. we noted that of these pts suffered from diabetes mellitus, while of pts revealed high ([ %) contralateral stenosis. further data will have to reveal the importance of these comorbide factors. non-invasive cerebral oximetry, enabling absolute cerebral oxygen saturation monitoring, could provide on-line estimation of cerebral perfusion state after cea. this could allow bedside detection (and eventual therapeutic interventions) of cerebral hyperperfusion after cea. introduction. analysis of microcirculatory alterations obtained by side-stream dark field (sdf) is time consuming. automated analysis with modern softwares could accelerate this process and help to quantify blood flow velocity. however, perfusion detection is based on the contrast between pixels and this may be influenced by image settings. objective. we aimed to compare data obtained with a new software to the traditional semi-quantitative analysis of sdf images. methods. we selected from our database six images of poor sublingual microcirculatory perfusion and six images of good microcirculatory perfusion registered by the sdf technique (microscan; microvision medical, amsterdam, the netherlands). the proportion of perfused vessels [ppv = (number of vessels with continuous flow/number of all vessels) ] \ % was used to define microcirculatory perfusion. total vessel density (tvd) was determined automatically by the software ava . (microvision medical) and also by the semi-quantitative technique, considered as the gold-standard (number of capillary crossing three equidistant vertical and horizontal lines divided by the total length of these lines). ava software was also used as default definitions or set to optimize analyses according to manufacturer instructions. vessels falsely detected (false positive = fp) or missed (false negative = fn) by the software, in comparison to the semi-quantitative evaluation, were also counted. results. tvd was significantly higher by the ava software either on default or on optimized mode than by the semi-quantitative method, and these differences were present with good or poor perfusion images (table ) . overall fp rate was %, and it was greater in poor perfusion images ( %). optimization of the ava set parameters attenuated fp rates both in poor and good perfusion images, at the expense of increasing fn rates (table) . due to intrinsic characteristics of the software, the mean total grid length was significantly lower in the ava than in the semi-quantitative analysis ( . vs. . introduction. perfusion index (pi) is the proportion of constant absorbed light compared to pulsatile absorbed light emitted from a pulse oxymeter. it ranges from a value below up to depedant of peripheral perfusion. it is measured primarily to evaluate the signal quality for the pulse oxymeter and is displayed by some pulse oxymeters to be acknowledged by the clinician. the pi changes with vasodilation and vasoconstriction. however, intubation is a stimulus able to increase endogenous catecholamines and thus leading to vasoconstriction possibly declining the perfusion index. therefore we found intubation with a double lume tube in a thoracic surgery setting as a suitable setting to evaluate changes in perfusion index as a reaction to intubation. after informed consent, we enrolled seven patients undergoing lung surgery requiring an double lume tube. they were monitored as it is standard of care in our institution with invasive blood pressure, ecg, and a pulse oxymeter displaying the pi. (radical , masimo, irvine, ca) the patients received the medication to induce anesthesia calculated adequately to their body weight. midazolam, propofol and fentanyl where used to anesthetize the patient, cisatracurium was used for muscle relaxation to facilitate intubation. pi, pulse and arterial saturation were recorded every minute from prior to induction until after successful intubation. a baseline value was recorded prior to induction and compared to the value minutes after induction. then the pi measured next to intubation was compared to the pi after induction and analysed using students t test. introduction. anticoagulation strategies for albumin dialysis suppose a difficult compromise between risk for bleeding and a high tendency to clot in the circuit. even thought the sessions are short, a premature clotting is a serious event because the lost of blood (high priming volume) and a high cost of the systems. we intended to demonstrate that the classical approach based in heparin is not adequate in these patients and should be substituted for a different strategy (mixed low dose of heparin plus epoprostenol). methods. data of a prospective registry of all cases treated in our centre (a third level, teaching hospital) with albumin dialysis (mars system). initially we used non-fractionated heparin at - u/(kg h) in patients without coagulation problems, epoprostenol [ - ng/ (kg min)] in cases with risk or thrombocytopenia and no anticoagulation when high risk for bleeding or contraindication for anticoagulation. after an intermediate analysis of our registry we detected a high number of filters clotted when heparin was used and changed our approach to use as first indication a mixed protocol with non-fractionated heparin [ u/(kg h) ] plus epoprostenol [ ng/(kg min) ]. data are presented as percentages. analysis was performed with chi-square test. to detect variables related to coagulation a stepwise backward logistic regression analysis was performed. we registered patients with a total of sessions. selecting only the first session for each patient to validate the first choice for anticoagulation, we used heparin in cases and detected the loss of filters ( . %) because clotting. after the change to mixed anticoagulation we used this as first indication in patients and in only ( . %) the sessions were prematurely ended because clotting (p ns). the rest of patients received isolated epoprostenol in cases (with - %-cases of premature clotting) and no anticoagulant in five cases (with - %-premature clotting). between the cases with heparin as first choice, three episodes of mild and one episode of severe bleeding were detected while no patients in the mixed group presented bleeding complications (p ns). in a logistic regression analysis over all registered sessions using coagulation of filters as dependent variable and type of patient, anticoagulant, arterial pressure, inr, tpta, platelets, haematocrit or bilirubin as independent variables, none of these was included in the regression model. even though more studies are necessary to validate this conclusion, a mixed protocol based in low dose heparin plus epoprostenol could be adequate as first indication for non-complicated patients submitted to a mars treatment with lower risk for bleeding than the classical approach of isolated non-fractionated heparin. optimizing oxygen delivery in critically ill patients is vital for the promotion of aerobic cellular metabolism. current practice includes the measurement of variables such as partial pressure of arterial oxygenation (pao ), cardiac index (ci) and percentage of oxygenated haemoglobin in arterial blood (sao ). these parameters reflect global oxygen delivery. the real point of interest is the end point of the oxygen cascade; oxygen utilisation in tissue mitochondria. near infrared spectroscopy (nirs) has been developed in an attempt to measure tissue oxygen saturation (sto ) in peripheral muscle microcirculation. manufacturers state normal values as ± %. it uses four wavelengths near the infrared spectrum ( - nm) to measure sto , a ratio of oxygenated haemoglobin to total haemoglobin. it is continuous and non-invasive. sto has proven efficacious in predicting oxygen delivery in trauma patients and claims to have been successfully used to guide early resuscitation [ ] . objectives. we were interested in assessing whether sto had a role in measurement of oxygen delivery in the intensive care population, and how it compared to the parameters currently used to predict oxygen delivery. we had particular interest in the usefulness of nirs in septic patients, where the pathophysiology of tissue oxygen utilization is disrupted. patients from a general, adult intensive care unit were enrolled over an month period. all patients had lidco monitoring. exclusion criteria were gtn, atrial fibrillation and patient refusal. mm sto probes were sited on the thenar eminence. serial recordings of sto , cardiac index, hr, sao , map, and pao were recorded. sto results were compared to more traditional parameters of oxygen delivery. sixteen patients were recruited, all met criteria for sirs and shock. four were excluded with incomplete data. results were analysed for individual patients and as a collective series. we found: • no statistical correlation between nirs and sao or pao . • a weak and clinically insignificant correlation between cardiac index and nirs (p \ . ). • supra normal nirs readings (normal [ %) were not infrequently gained in patients where all other parameters were indicating severe shock and poor oxygen delivery. conclusion. theoretically nirs has potential to be beneficial in measuring oxygen delivery. our results demonstrate that nirs is not accurate for our septic population. we found poor correlation with current methods used to predict oxygen delivery and it may well be more misleading than beneficial. more traditional methods of intensive care monitoring, although sometimes invasive, appear to provide a more accurate representation of a patient's oxygen delivery. background. urine output is a crucial parameter of renal function and fluid balance. conservative urine output monitoring harbors problems such as subjective reading, sampling time errors and nursing workload. an electronic urine collection device was introduced into the icu and connected to a computerized information system. this created a more reliable and accurate means for urine output monitoring and the ability to develop new calculated parameters. . to evaluate the effects of introducing an electronical urine collection device into a fully computerized icu. . to evaluate new parameters that were created by the combination of the device and a computerized data management system. patients included were all admitted to the icu at rambam medical center, haifa, israel, during the years - . urine production and flow were monitored continuously by the urinfo Ò device (med-dynamix, israel), a novel electronic urinometer, connected to a patient data management system (imdsoft, israel). graphical analysis of urine production was done and derived parameters continuously calculated. comparison was done to the conventional mechanical urine collection system. variables studied were: measurement accuracy, sampling time accuracy, nursing workload before and after the implementation process. correlation between derived parameters and conventional renal function measurements such as plasma creatinine and creatinine clearance time. results. the conservative urine output measuring system demonstrated percentage error span in range of - %, compared to a range of - % percentage error in measurement after implementation of the computerized system. before implementation, sampling time error span was found to be - min, while no sampling time error was present after implementation due to the automated recording system. time consumed by the workload of the conservative urine output monitoring system was measured at - min per nursing shift ( h). the computerized system eliminated this workload completely. derived parameters evaluated were continuous urine flow (in cc/min or cc/h), urine production acceleration rate (calculated via the slope of the ''up-rise'' in cc/min ) and the peak urine production rate (cc/min). these parameters were able to demonstrate immediate changes in renal function, hours before conventional measurements and calculations would show them. conclusion. implementation of a computerized urine monitoring system can lead to improved accuracy in renal function monitoring and eliminate a significant amount nursing workload. use of derived calculated parameters may lead to earlier detection of renal malfunction and thus lead to earlier intervention. ( g/ , ml), cica dialysate k tm (na mmol/l, k . mmol/l, mg . mmol/l, cl . mmol/l, hco mmol/l, glucose anhydrous . g/l, ph * , ) and calcium chloride mayrhofer tm cacl , mol/l. the filter was an ultraflux av s tm , the material of the bloodline tubing system was medical grade soft pvc. in three circuits used in two different patients we found an opaque white precipitation starting at the cacl side port growing along the line with the direction of the bloodflow up to a maximal mm wide and mm long stripe. to identify the composition of the white stripes we included histological examination of hematoxylin-eosin stained sections and lyophilisation with wet chemical analysis. blood samples were simultaneously taken from the venous port of the cvvhd circuit and the arterial line of one patient. results. histology showed **an organic material in form of calcific deposit, covered with coagulated blood. chemical analysis identified this deposit as calcium phosphate. the results of the blood samples are shown in table . calcium phosphate precipitates may have reached patient circulation and been deposited in the capillary bed of the lungs or other organs. no histological examinations of tissue were taken and adverse events could not be attributed to the described phenomenon. citrate anticoagulation was stopped and switched to combined heparin-epoprostenol sodium anticoagulation. conclusions. the combination of the fluids and materials used in this specific cvvhd circuit with citrate anticoagulation resulted in some patients in a detectable calcium phosphate formation in the circuit. physicians using the described setting should be aware of the phenomenon and stop citrate anticoagulation as soon as a deposit occurs. in vitro studies, using different compositions and concentrations of dialysate and substitution fluids and simulating different patient conditions (ph, ph, hb, alb,…) should clarify, which solutions could safely be used. in addition the material of the circuit should be investigated, since surface characteristics have been identified to influence the formation of a calcium phosphate layer [ ] . reference (s) objective. the aim of this study was to assess, in a medical population of critically ill patients, whether intraabdominal pressure at admission was an independent predictor for mortality and to evaluate the effects of intraabdominal hypertension on organ functions. all patients admitted to the medical icu of the hgu gregorio marañón over a period of days were studied prospectively. patients who fulfilled two or more risk factors for wsacs (diminished abdominal wall compliance, increased intra-luminal contents, increased abdominal contents and/or capillary leak /fluid resuscitation.) were included. iap was measured via a foley bladder catheter, according to the modified kron technique. data recorded on admission were the patient demographics with, acute physiology and chronic health evaluation ii score (apache ii), and type of admission; during intensive care stay, sepsis-related organ failure assessment score (sofa) and clinical concomitant factors and conditions. intraabdominal pressure were measured at least daily together with fluid balance. patients were followed throughout their hospital stay. forty-four patients were included in the study (age - , apache ii . . half were admitted for cardiopulmonary disease. twelve ( %) had pancreatic or gastrointestinal disease. twenty-two ( %) had severe sepsis or septic shock. the incidence of iah was %. mortality was %. the cause of the iah was capillary leak syndrome/fluid resuscitation in % of cases. there was no relationship between the presence of iah and the number of organ failure during admission. the only variables associated with mortality of the patients were sofa and apache ii. the presence of iah was not a factor associated with increased mortality, although these results may be confounded by sample size. conclusions. there is an unusually high incidence of iah in the population of critically ill medical patients with two or more medical risk factors for wsacs. however, unlike in other populations, our study does not demonstrate that the iap monitoring allow detecting a group at higher risk of developing multi-organ failure or death. background. drainage of ascitic fluid is a common practice in order to relief the respiratory discomfort of patients. the aim of the present study was to determine abdominal compliance after ascitic fluid removal by transcutaneous drainage. methods. twelve patients presenting with ascitic fluid were included. all patients had transcutaneous blind drainage with a wide catheter. the ascitic fluid removed was recorded, while the intraabdominal pressure (iap) was measured as proposed by wsacs. iap was measured before and min after the puncture. abdominal compliance (cabd) was calculated. results. the pre-drainage iap was . mmhg (ranging from . to . mmhg, sd . mmhg), while the post-drainage was . mmhg (ranging from . to . mmhg, sd . mmhg). the mean volume of ascitic fluid removed was ml (ranging from to , ml, sd ml). cabd after drainage was ml/mmhg (ranging from to ml/ mmhg, sd ml/mmhg). a linear correlation was found between ascitic fluid removal and iap variations. conclusion. the drainage of ascitic fluid reduces iap, facilitating in this way respiration. moreover, iap variation seems be in linear relation with the volume of ascitic fluid removed. this linear relation between iap and volume may probably predict the cabd quite accurately and vice versa. however, larger studies are necessaries in order to safely draw predicting diap-dv (cabd) diagrams, and determine the optimal ascitic fluid removal in order to achieve best comforting of the patient and slower fluid reformation. introduction. use of stroke volume variation (svv) to guide fluid therapy in preload responsive state has been studied well in patients undergoing cardiac or neurosurgery during anaesthesia. use of this dynamic monitoring variable has not been studied much in septic shock. we undertook this prospective study to evaluate utility of svv to optimize preload in patients with septic shock and ards. setting. bedded medical surgical icu of a bedded tertiary care centre in pune, india. inclusion criteria: ( ) patients with ards (po /fio b ), svv readings were taken every h with flotrac-vigileo system after confirming abolishment of spontaneous breaths by sedation or paralysis and increasing tidal volume transiently to ml/kg. fluid boluses were given to keep svv \ % for h after enrollment. attempts were made to reduce vasopressor doses keeping map c mmhg. results. patients with average age . ± . years and apache ii score . ± . were studied. each patient received an average . ± . l fluid in h after enrollment to keep svv below %. svv at h after enrollment was . ± . % improvement in microcirculation was evident as plasma lactate reduced from . ± . (at h) to . ± . mmol/l (at h) there was no worsening in pulmonary edema as po / fio increased from . ± . (at h) to ± . (at h) only out of patients needed renal replacement therapy. in patients, vasopressors could be stopped completely in . ± . h. of them survived till discharge from the icu and died of ards. in patients, vasopressors could not be weaned off completely and all of them succumbed. overall survival rate was %. conclusion. svv guided fluid therapy is a promising modality for pre load optimization in mechanically ventilated patients with septic shock and ards. introduction. cardiovascular function is an important determinant of outcome in sepsis, and heart rate (hr) has been associated with cardiovascular risk and mortality in large patient cohorts [ ] . to investigate the association between hr and or day mortality in septic shock. methods. this study is a post hoc analysis of septic shock patients who were included in the control group of a multicenter trial [ ] . demographic and clinical data, average hr and catecholamine requirements during septic shock, occurrence of acute circulatory failure, and day mortality were documented. a binary logistic regression model adjusted for the simplified acute physiology score ii (excluding hr) was used to investigate the association between mean hr and acute circulatory failure or / day mortality. a multiple logistic regression model was applied to identify independent risk factors for developing hr critical for outcome. conclusions. hr is associated with and days mortality in septic shock. hr persistently exceeding bpm during septic shock seems associated with a significant risk of death. introduction. different colloids can be used for treatment of hypovolaemia in septic pts. recently, small-volume resuscitation was introduced for initial therapy of severe hypovolaemia and shock. the concept of small-volume resuscitation encompasses the rapid infusion of a small dose of . % nacl/colloid solution [ ] . however, in septic pts hypovolaemia often associates with acute lung injury (ali). therefore in these pts great importance has influence of colloids on oxygen transport. objectives. the aim of the study was to evaluate and compare the effects of hhes and hes on oxygen transport in pts with sepsis and ss. methods. hypovolaemic pts with sepsis and ss were enrolled in the study. pts received - ml/kg ( ml) hhes ( . % nacl ? % hes) (fresenius kabi) within min and pts received hes / (voluven, fresenius kabi) ml/kg. in all pts before and after infusion the parameters of oxygen transport was measured by pulmonary arterial catheter and transpulmonary thermodilution (pulsion medical system). after infusion of hhes oxygen delivery index (ido ) increased because of increase of cardiac index (ci) despite of decrease of hemoglobin (hb) levels and absence of changes of arterial oxygen content. extravascular lung water (evlw) and shunt increased significantly immediately after hhes infusion, but this increase was not accompanied by deterioration of pao /fio . introduction. severe sepsis is characterised by a wide array of haemodynamic changes including increased capillary leak, vasodilatation, vascular hyporeactivity and myocardial depression. the resultant tissue hypoperfusion is an important catalyst of multi-organ failure [ ] . to further develop our understanding of the underlying mechanisms, we have developed and characterised a fluid-resuscitated mouse model of intraperitoneal polymicrobial sepsis. objectives. to assess alterations in cardiac performance in mice at , , and h following faecal peritonitis. methods. sepsis was induced in week old male mice (n = ) by intraperitoneal (i/p) injection of dilute faecal slurry. sham animals (n = ) received n-saline i/p. animals were fluid resuscitated at time ( ml/kg . % saline), and at and h ( ml/kg . % saline- % dextrose each time). under a minimum concentration of isoflurane to achieve light anaesthesia, peak velocity, stroke distance, heart rate and fractional shortening were measured in the short axis plane by echocardiography at the , and h timepoints. in separate sham and severe septic mice (n = per group) the cardiac response to intravenous colloid boluses was assessed at and h. results. we clinically characterised septic animals into 'mild' and 'severe'. mice with severe sepsis showed a % drop in peak velocity and cardiac output at h (vs. and % falls in the mild septic and sham-operated animals, respectively, p \ . ). while mild septic animals showed recovery by hr, cardiac output in severely ill mice remained significantly depressed (due to both low heart rate and stroke volume) compared to mild septic and sham animals [*p \ . ( fig. ) ]. stepwise . ml boluses of intravenous fluid at h in severe septic animals led to restoration of cardiac output to baseline ( h) values. however, in the h septic animals, fluid challenge produced an initial improvement in cardiac output followed by deterioration [ fig. purpose. myocardial dysfunction has been well-documented in sepsis even in hyperdynamic state, and may develop and contribute to morbidity and mortality. nicaraven, a radical scavenger, has been shown to protect the coronary endothelial and myocardial function from ischemia and reperfusion injury due to hydroxyl radical scavenging activity. the purposes of present study were to determine the effects of nicaraven on cardiac function and cytokine production in lipopolysaccharide (lps) induced sepsis. methods. this protocol was approved by our institutional committee. following arterial and venous cannulation and tracheostomy, rats ( - g) were anesthetized with pentobarbital, and mechanically ventilated with a control mode (v t = ml/kg, rr = rpm). after baseline measurements, rats (n = ) were administrated with lps ( mg/kg, intravenously) and randomly assigned to following two groups: the nicaraven group treated with nicaraven [ mg/(kg min), intravenously] and the control group treated with saline. the left ventricular pressure and volume were measured with the pressure and conductance catheter every one hour. cardiac function, including cardiac output (co), ejection fraction (ef), and maximal elastance of left ventricle (e max ) were analyzed with a computer soft. blood was collected, centrifuged ( , g, min, ) , and stored (- °c) from rats every h after operation to measure plasma concentration of tnf-a, il -b and macrophage migration inhibitory factor (mif) using enzyme-linked immunosorbent assays kits. blood lactate concentration was also measured. data were analyzed by repeated measure anova. results. the co in the nicaraven group was kept significantly higher than the control group (p \ . ). the ef and e max in the nicaraven group were also kept significantly higher than the control group (p \ . ). arterial lactate, tnf-a, il -b and mif were significantly lower in the nicaraven group versus the control group (p \ . ). conclusion. the current study indicates that the treatment with nicaraven improved cardiac dysfunction and reduced plasma concentration of cytokines, and improved lactic acidosis in septic model. methods. this protocol was approved by our institutional committee. following arterial and venous cannulation and tracheostomy, rats ( - g) were anesthetized with pentobarbital, and mechanically ventilated with a control mode (v t = ml/kg, rr = rpm). after baseline measurements, rats (n = ) were administrated with lps ( mg/kg, intravenously) and randomly assigned to following two groups: the oxytocin group treated with oxytocin ( iu/kg iv and followed by the continuous infusion of mg/(kg min), intravenously) and the control group treated with saline. the left ventricular pressure and volume were measured with the pressure and conductance catheter every h. cardiac function, including cardiac output (co), left ventricular peak pressure (lvpp), and cardiac work (cw) were analyzed with a computer soft. blood was collected from rats every h after operation to measure plasma concentration of blood lactate. data were analyzed by repeated measure anova. results. the co in the oxytocin group was kept higher than the control group but there is no significance (p \ . ). the lvpp and cw in the oxytocin group were kept significantly higher than the control group (p \ . ). arterial lactate was significantly lower in the oxytocin group versus the control group (p \ . ). conclusion. the present study indicates that the treatment with oxytocin improved cardiac dysfunction and reduced plasma concentration of lactate in septic model. introduction. conventional hemodynamic monitoring parameters like heart rate, mean arterial pressure (map), and central venous pressure may be misleading in assessment of circulating blood volume in severely septic patients. inadequate blood volume may compromise renal blood flow leading to acute kidney injury (aki). stroke volume variation (svv) is a sensitive indicator of relative preload responsiveness and has high sensitivity and specificity when compared to conventional indicators of volume status and their ability to determine fluid responsiveness. to assess the efficacy of svv guided fluid therapy in preventing aki in patients with severe sepsis on ventilatory support. mechanically ventilated patients with septic shock who had undergone resuscitation based on surviving sepsis campaign guidelines and still requiring vasopressor support were enrolled. patients with pre-existing renal failure were excluded. a total of patients were randomized to receive fluid therapy according to conventional indices or svv, in the first h after mechanical ventilation. svv was measured with flotrac vigelio after abolishing spontaneous ventilation by sedation and paralysis if required. fluid boluses were given to keep svv less than %. vasopressor therapy was optimised to maintain map [ mm hg. patients were followed during their icu course with respect to development of aki, need for renal replacement therapy (rrt), length of icu stay and icu mortality. aki was diagnosed as per the rifle criteria. primary outcome measure was development of aki. results. patients in both groups were similar with respect to age (p = . ), sex (p = . ), and admission apache ii score (p = . ). incidence of aki was / ( . %) and / ( . %) in conventional and svv groups, respectively (p = . ). there was no statistically significant difference in terms of need for rrt, icu length of stay and icu mortality ( [ ] . moreover, pnu- a (pnu), an inhibitor acting through the poreforming subunit of the channel, did not affect bp in our awake peritonitis rat model [ ] . given that vasoconstrictors, including ne, inhibit k atp channel activity [ ] , we speculate that the high sympathetic tone seen in sepsis [ ] objectives. the goal of this study was to determine if hfav improves microcirculatory alterations in ss patients. methods. by using side dark field videomicroscopy (microscan Ò , microvision medical) we evaluated sublingual microcirculation in ss patients who according to our local protocol care [ ] underwent a h-hfav as rescue therapy for refractory septic shock. hemodynamic parameters and microcirculation were assessed at baseline, after h of hfav, and h after stopping hfav. microcirculation assessments were performed at to different sublingual areas ( - s/image). images were analyzed according to recent consensus [ ] by semiquantitative scores of flow (mfi, mean flow index and ppv, proportion of perfused vessels), density (tvd, total vascular density; pvd, perfused vascular density), and heterogeneity (het mfi) of small vessels (\ lm introduction. disturbances within the microcirculation represent an important factor in the pathogenesis of multiple organ dysfunction in sepsis and septic shock [ ] . gender-specific effects may modulate the septic pathophysiology [ ] . therefore, we studied sepsis-induced changes within the intestinal microcirculation in randomly cycling and ovariectomized female rats. objectives. we hypothesized that estradiol (e ) and dehydroepiandrosterone (dhea) may have a beneficial effect on the microcirculation during experimental sepsis and resubstituted these hormones in the ovariectomized animals. methods. fifty female rats were divided in to five groups of ten animals. group received sham laparotomy without further treatment. in group - we induced experimental sepsis (colon ascendens stent peritonitis-casp model). animals of groups - were additionally ovariectomized weeks before sepsis induction. in group we administered mg/kg estradiol immediately after and h following casp surgery. the animals of group received mg/kg dhea immediately after sepsis induction. twenty-four hours after casp surgery intravital microscopy was performed to study leukocyte-endothelial interactions and functional capillary density. blood samples were taken for the measurement of estradiol, dhea and inflammatory cytokines. results. in ovariectomized rats subjected to casp the number of activated leukocytes was significantly increased in comparison to sham and not ovariectomized casp animals (p \ . ). in ovariectomized rats treated with e leukocyte adhesion was significantly reduced in comparison to untreated ovariectomized rats subjected to casp (p \ . ). the same observation was made in ovariectomized rats treated with dhea. in addition, in ovariectomized rats subjected to casp the functional capillary density was significantly decreased in comparison to sham and casp groups (p \ . ). in ovariectomized rats treated with e or dhea functional capillary density was completely restored. the results demonstrate the role of e and dhea in the sepsis-induced changes within the microcirculation. a rapid, non-genomic effect of both e and dhea is suggested [ ] . dhea may play a role through conversion to e or through direct acting on the e receptor. further investigations should be done to elucidate the underlying mechanisms. both e and dhea appear to be a promising adjunct for the prevention and treatment of sepsis-induced multiorgan failure. liver is involved in the production of no. the aim of this experimental study was to evaluate the time course of hepatic no production at the onset of hypotension occurring during septic shock. methods. male wistar rats were anesthetized with isoflurane Ò , and mechanically ventilated. a first group (sepsis group) underwent a cecal ligature and puncture (clp) peritonitis, the second one (control group) a laparotomy only. animals were euthanized at different times: h after surgery, at shock onset, and h after shock. shock was defined by systolic blood pressure lower than mmhg. each rat of sepsis group was matched with rat of control group. liver perfusion was measured using a direct laser doppler flowmetry probe. no generated in the liver was measured using a pulse voltametric method. results. rats were studied ( in each group). in sepsis group, shock occurred at ± min after clp. in sepsis group, a significant decrease of hepatic perfusion was identified h after clp ( fig. ) whereas hepatic no production was increased only at the time of shock onset (fig. ). intra hepatic no production conclusion. this study shows a time shift between hepatic perfusion disturbance, hepatic no production and shock onset in a septic animal model. introduction. microvascular blood flow alteration is a key element of severe sepsis and septic shock [ ] . one study show that microvascular alterations in septic patients could be improved with a nitric oxide donor nitroglycerin [ ] . studies in human have shown that infusion of magnesium sulphate has endothelium dependent and independent vasodilation properties, increase of red blood cells deformability in specific conditions. we hypothesized that combination of nitroglycerin with magnesium sulphate and order of priority influence microvascular improvement in patients with severe sepsis and septic shock. methods. ten septic patients who had already been fluid resuscitated randomly assigned to one of two groups. one group received magnesium sulphate infusion g/h with nitroglycerin . mg/h infusion added after min. another group received nitroglycerin . mg/h infusion with additional magnesium sulphate g/h infusion after min. if required we added crystalloids and use norepinephrine. sublingual microcirculation was evaluated using side dark field videomicroscopy (microscanÒ, microvisionmedical) . each patient's microcirculation was evaluated by examining different sublingual areas ( - s/image). in all patients measurements were obtained at baseline, at and min. images were analyzed by semiquantitative scores of flow (mfi, mean flow index; ppv, proportion of perfused vessels) and density (tvd, total vascular density; pvd, perfused vascular density). capillaries were defined as microvessels with a diameter \ lm. data are presented as median values (percentiles ; ). . the median age of the patients was ( ; ) years. in both groups we see tendency progressively increase of pvd, ppv and mfi after drug alone and combination after min, but pvd has tendency to be higher [ . ( ; . ) n/mm vs. . ( . ; . ) n/mm , p = . ] after min. in group, where magnesium sulphate infusion was given first. combination of magnesium sulphate with nitroglycerin, when magnesium sulphate is given first, has tendency to higher potential for improving of microcirculation in severe sepsis and septic shock patients, but further studies are needed to obtain more detailed results. severe sepsis remains one of the leading causes of death in critical care, with around % of patients dying within one month of diagnosis. rapid diagnosis and therapy of sepsis improves survival [ ] . in november the whittington hospital introduced a hospital severe sepsis guideline, based on the first surviving sepsis campaign guideline [ ] . the sepsis guideline was published on the hospital intranet and specified actions to be completed within the first h of the diagnosis of severe sepsis or septic shock [ ] . objectives. to assess whether publication of a sepsis guideline on the hospital intranet, coupled with departmental educational campaigns, improved the management of severe sepsis. the whittington hospital is a university associated general hospital in london. we audited the early management of severe sepsis and septic shock before and after the introduction of the new hospital sepsis guideline. the 'before' phase comprised patients with severe sepsis or septic shock admitted to critical care between november and november . the 'after' phase comprised patients with severe sepsis or septic shock admitted to critical care between january and november , after introduction of the guideline. data was retrospectively collected from case notes and observation charts. the audit tool compared immediate, , and h actions following diagnosis against the hospital guideline. the main outcome measures were compliance and day mortality. compliance was defined as the average of the percentage compliance with each of the items specified in the guideline. results were compared by chi squared. compliance with the severe sepsis guidelines was only % after publication of the hospital sepsis guideline, compared with % before publication (p. )! there was similarly no significant difference in day mortality (before %, after %, p. ). publication of a sepsis guideline on the hospital intranet, coupled with departmental teaching sessions, failed to improve compliance with surviving sepsis recommendations, perhaps because the guideline competes for attention with over other guidelines on the intranet. next we will implement an interdepartmental educational programme to try and improve guideline compliance. as guidelines proliferate it is difficult to ensure they are followed, but failure to implement a published hospital guideline may represent a significant clinical and medicolegal risk. methods. the icu is an intensivist-led bed intensive care in a bed non-academic teaching hospital. hospital mortality from sepsis in icu-patients was . % in . patients are treated under modern icu conditioning, including continuous venovenous hemofiltration and a lung-protective ventilation strategy including prone position. an intensive insulin therapy protocol for glycemic control is used. in the period between march until june , we prospectively screened all patients admitted to the icu for (severe) sepsis, without the knowledge of the nurses and most of the doctors. all severe septic patients were included in our surviving sepsis database. after h, we examined how many targets of the resuscitation and management bundles were applicable and reached. in the period between march until june , patients were admitted to the icu. twenty-two of them were suffering from severe sepsis ( . %), of which had a septic shock. focus of the sepsis was abdominal in patients ( %), pulmonary in five patients ( %), urogenital tract in five patients ( %), meningitis in one patient ( %) and catheterrelated in one patient ( %). table shows us the applicability and achievement of the bundle elements. only in one of the patients all targets were reached. however, mean individual bundle element performance was . % (sd . ). all patients received fluid resuscitation when indicated, and all patients on mechanical ventilation were ventilated in a lung-protective manner with plateau pressures \ cm h o. only percent of patients had glucose levels within the target range. scvo was never measured, though it was indicated in patients. one patient had an apache iiscore c and had no contraindications for administration of activated protein c. treatment was not considered for this patient by the attending physician. of these patients suffering from severe sepsis, three died within days after the diagnosis ( . %). introduction. the surviving sepsis campaign (ssc) guidelines give a group of interventions (''sepsis bundles'') expected to improve the outcome of patients with severe sepsis [ ] . objetives: the aim of this study was to evaluate the impact of the implementation of the ssc guidelines on the mortality in our intensive care unit (icu). methods. prospective, observational study. during one year period (january -january ) the sepsis bundles were applied to each patient with severe sepsis-septic shock and they were followed up until discharge. we considered as ''time o'' (the time of delay of the implementation of the sepsis bundles) the time of admission of the patients in the icu. for each severe septic patient the following data was registered: time delay, apache ii and sofa scores at icu admission, diagnosis, the rate of compliance with the resucitation and management bundles, microbiological data, evolution of levels of serum lactate, empiric antibiotic therapy, length of stay and mortality in icu. the application of guidelines impact on mortality was compared with historical data years before implementation in our icu ( . %) and spanish icu ( . %) [ ] . a total of severe septic patients were included in the study. ( . %) patients had severe sepsis and ( . %) septic shock. the median age was years. the mean apache ii was . (± ) and sofa was . (± . ). the main sources of infection were abdomen ( %), lungs ( %), urinary tract ( . %) and soft tissues ( . %). the most common clinical diagnosis related to an episode of severe sepsis was peritonitis ( %). a microbiological diagnosis of the infection was reached in . % and the infections were mostly caused by gram-bacilli. once the antibiogram was obtained, the initial treatment was considered appropriate in . % patients. the rate of compliance with sepsis bundles was %. the length of icu stay was . days. mortality was . %. the implementation of the sepsis bundles decreased icu mortality significantly ( . % before implementation vs. . % after implementation). non survivors were older (median age ± . ), had higher apache ii (mean . ± ) and sofa (mean ± . ), % had septic shock, . % had negative cultures and an increased on the levels of serum lactate in h. age, apache ii and sofa scores and the increased on the levels of the serum lactate were useful tools to predict mortality. conclusion. implementation of the surviving sepsis campaign guidelines was associated with a reduction in icu mortality. introduction. the objective of this before-after study is to assess the impact of a protocol of care for severe sepsis in a french emergency setting. methods. two months periods were surveyed before and after the initiation of a protocol of care for severe sepsis and septic shock. after the control period (p : november -february ), a procedure for early recognition, aggressive treatment and standardized antibiotherapy of severe sepsis was initiated. a campaign to raise medical physicians and nurses awareness concerning this new strategy of care was performed. the intervention period (p : november -february ) assessed the impact of these actions. . patients with severe sepsis or septic shock were included during p ( % of patients with a suspected infection and . % of all non trauma admissions) and during p ( . % of patients with a suspected infection and . % of admissions). the age and the proportion of patients with co-morbidities were similar during the p and the p periods ( years in median versus years, and vs. %, respectively). and % of the patients lived in long term care facilities. severe sepsis and septic shock were correctly identified by the emergency team in / ( . %) during p and in / ( . %) in p (p = . ). the delay between the admission in the emergency department and the administration of antibiotics was in median equal to h min in p and h min in p (p = . ). adequate iv fluid resuscitation was administered to % of patients in p and % of patients in p (p = . ). during p , % of patients did not qualify for admission to the intensive care unit compared to . % in p . hospital mortality did not change from . % ( / ) in p to . % ( / ) in p (p = . ). conclusion. the introduction of a standardized treatment protocol in an emergency department allowed a better recognition of severe sepsis with earlier adapted treatment . the study was not powered to demonstrate a reduction of the mortality in this elderly population. multiple studies have shown that early detection and therapy is crucial for the prognosis of a severe septic patient. many hospitals have joined the surviving sepsis campaign and its fight for the decrease of mortality in severe sepsis and have implemented the severe sepsis bundles into their daily practice. other institutions such as ours had so far not taken this step, perhaps because the process is hard and time consuming. we have tried to find an easy way to audit the implementation of severe sepsis bundles and its change in time in an institution without a set system and database for the implementation of severe sepsis bundles to help us prove, that a systemic change in clinical practice is essential. we have decided to use the first step of the resuscitation bundle-the measurement of lactate and audit the lactate requests in blood samples with elevated inflammatory markers in our hospital laboratory information system. we retrospectively audited the number of lactate requests in blood samples with c-reactive protein (crp) c mg/l and its evolvement in time between and before and after the introduction of surviving sepsis guidelines and severe sepsis bundles in our regional hospital with beds. we compared the total number of blood samples with elevated crp c over mg/l with or without procalcitonin request in our institution with the number of blood samples with crp c mg/l and lactate request (both arterial and venous) in the hospital laboratory information system. . the total number of lactate requests in samples with crp c mg/l had increased in time, the incidence widely differed between departments. the main increase was in patiens from intensive care units, the number of lactate requests in samples from general wards, emergency department and intermediate (step down) units had also increased ( lactate requests in samples with crp c mg/l- , % in and lactate requests in samples- . % in ) but still remains insufficient. surprising was that procalcitonin was in non icu patiens with crp c mg/l requested more often than lactate. although many lectures and seminars on severe sepsis bundles and the guidelines for the management of severe sepsis were organised in our intitution between the year and , it was not sufficiently effective. conclusion. retrospective audit in the hospital laboratory information system of the number of lactate requests in samples with elevated inflammatory markers appears to be a fast and a very easy first step for auditing how the surviving sepsis guidelines and severe sepsis bundles are implemented in your institution. the results help to quantify the present state, its change in time and may serve as an impulse to make systemic changes in the system of early detection and therapy of septic patients. introduction. early goal-directed therapy (egdt) is the accepted gold standard for resuscitation in septic shock [ , ] . international guidelines for the treatment of septic shock [ ] set an initial h limit to accomplish this goal. to test the hypothesis that egdt with fluids and vasopressors has better patient outcomes if each intervention is completed within h. thirty septic shock patients from the spring of and from spring were reviewed prospectively (n = ). septic shock was defined as a lactic acid c mmol/l and/or hypotension unresponsive to fluids. apache ii and sofa scores were calculated. patients were subjected to the hospital septic shock protocol according to guidelines [ ] . firstly, egdt compliance was met if the following interventions were achieved within h: lactate levels drawn, map c mmhg and cvp c mmhg; and secondly, if antibiotics were given\ h, blood cultures were taken before antibiotics and if ml/kg fluid bolus was administered prior to vasopressors. in patients / interventions were performed in time (''egdt-compliant''). the other were deemed ''egdt-noncompliant''. outcomes were mortality rate and discharge destination. fisher test was used in statistical analysis. . mr was % amongst the compliant and % amongst the noncompliant and admission to long-term care facilities (ltcf) was and %, respectively. neither one of these differences was statistically significant. a power analysis revealed that patients are required to attain statistical significance for mortality. discharge home was the same in both groups. there was no difference between groups in the number of new tracheostomies or new hemodialysis. conclusions. in a us community teaching hospital, compliance with guidelines in the treatment of septic shock had a trend towards lower mortality and higher discharge rates to ltcf but the difference was not statistically significant. larger numbers are needed for the benefits/effects of egdt-compliant therapy to reach statistical significance in the treatment of septic shock in this hospital setting. improve the survival rate of septic patients by means of education and implementation of a sepsis operative protocol including the activation of a specific consultation by an intensivist and an infectious disease specialist (i.e. sepsis team, st). aim of this study was to describe the first months activity of st, with a focus on the patients not admitted in intensive care unit (noicu). methods. the sepsis operative protocol, introduced in clinical practice in june , provides for specific instructions for the early identification and management of septic patients and for the early activation of the st for patients with severe sepsis or septic shock admitted in non-intensive departments. the st consultation ought to support the departmental health personnel in the management of septic patient and allows an early intensive care admission in case of shock or if mechanical ventilation is needed. to assess st activity, we evaluated in noicu patients the correct st activation rate, the number of st activations for each patient, the rate of central venous catheter insertion (cvc) and the days mortality. results. from june to december , the st was activated for patients ( . patients per month) whose ( %) were admitted to icu and ( %) were considered too sick to benefit. in ( %) of the remaining patients, st was properly activated: patients with severe sepsis and with septic shock. thirteen patients ( %) had no sepsis and ( %) had sepsis without organ dysfunction. % of st activations originated from medical departments (including emergency department) and % from surgical departments. the number of st activations for each single patient was ± . the days mortality was . % in patients with sepsis, % in patients with severe sepsis and % in patients with septic shock. conclusion. the rate of correct activation of st and the number of activations for each patient were acceptable considering that more than % of the activations refers to septic patients and that a mean of activations was sufficient for patient management. mortality rates observed are slightly lower than those reported by others, but further data are needed to evaluate the impact of st on patient outcome. a. estella , l. pérez fontaiña , j. i. sanchez angulo , e. moreno hospital of jerez, emergency and critical care unit, jerez, spain clinical evidence suggests that an early diagnosis and treatment of severe sepsis has been shown to improve outcome. frequently the initial management of septic patients occurs outside of the icu. objective. to describe clinical characteristics and outcome of septic shock patients admitted in icu and to compare mortality according origin prior admission in the icu (emergency department versus medical or surgical wards). consecutive patients with septic shock admitted in icu from july to november were registered. age, icu length of stay, source of infection, isolated bacteria, blood lactate concentration, apache ii score and mortality were collected. patients were classified according the origin prior admission in icu. . consecutive septic patients were admitted in icu during the time of study, global mortality was %. patients were admitted from medical or surgical wards and patients from the emergency department. mean age was years, male and female, icu length of stay was . ± . days, the mean apache ii score at admission in icu was . ± . abdominal infection, . %, was the commonest source of infection followed by pulmonary and urinary infection, . and . % respectively. patients ( %) had a positive bacterial culture, the mean baseline lactate level was . ± . mmol/l p \ . ( . ± mmol/l in the medical and surgical wards group versus . ± mmol/l in the emergency department group).there were not differences in clinical characteristics according origin prior admission in the icu except for lactate level, and mortality, . % in the medical and surgical wards group and . % in the emergency department group (p \ . ). conclusion. there were not differences in clinical characteristics, icu length of stay, source of infection, isolated bacteria and apache ii score between groups. mortality was lower in the group of patients admitted in icu from the emergency department than the group admitted from medical and surgical wards. although very high circulating concentrations are detectable in plasma, it is not known which organs actually produce the cytokines. we hypothesized that key abdominal organs affected by sepsis such as the kidney and liver produce cytokines and tested this hypothesis by measuring cytokine flux. materials and methods. pigs ( - kg) were randomised to control (n = ) and endotoxin (n = ) groups. hemodynamic measurements using picco and pulmonary arterial catheters and arterial blood gases were collected hourly. portal, hepatic and renal arterial blood flows were measured with transit time probes. arterial and venous cytokine concentrations (tnfa, il- b, il- and il- ) were measured from samples taken from each respective organ. cytokine flux was calculated as: organ blood flow (venous-arterial cytokine concentration difference). endotoxemic pigs had significant increases in heart rate (p \ . ) and mean pulmonary arterial pressure (p = . ) and decreases in cardiac output (p = . ). in contrast, these hemodynamic variables remained stable in the control animals. renal, hepatic and portal vein flows decreased significantly in all endotoxemic animals but remained stable in the control group. renal [ml/(kg min)]:control . ± . , . ± . , . ± . , . ± . versus endotoxin . ± . , . ± . , . ± . , . ± . for baseline, t = , , , respectively. portal [ml/(kg min)]: control . ± . , . ± . . . ± . , ± . versus endotoxin . ± . , . ± . , . ± . , . ± . for baseline, t = , , , respectively. hepatic [ml/(kg min)]: control . ± . , . ± . , . ± . , . ± . versus endotoxin . ± . , . ± . , . ± . , . ± . for baseline, t = , , , respectively plasma cytokines tnfa was detectable in very low concentrations (\ pg/ml) in of the endotoxemic animals, and none of the control animals. il- b, il- and il- increased significantly with time peaking at t = , and respectively in the endotoxin group. in the control group only few animals showed a cytokine response, in numbers insufficient for statistical analysis. in the endotoxin group there was a negative cytokine flux in the renal circulation, maximal at t = [- . ± . for il- b and - . ± . for il- (pg/ml), respectively]. there was a positive cytokine flux for il- reaching its peak at t = ( . ± . pg/ml). a similar pattern was seen in the hepatic ? portal circulation with maximal flux for il- b and at t = (- . ± and - . ± . pg/ml, respectively). for il- there was a positive flux peaking at -= ( . ± . pg/ml). although there was a negative il- b and il- cytokine flux in the renal, portal and hepatic circulations indicating net uptake, and vice versa for il- , none of these values reached statistical significance. conclusions. these data do not support that cytokines are produced nor consumed in the kidney and liver during endotoxemia. discussion. non-survivors show more severity at the beginning and during their icu stay, more altered biological markers and a higher mean glycemia, but do not show significant difference either at initial glycemia, history of diabetes, hypoglycemia event or insulin treatment. elevated mean glycemia appears to be a factor independently associated with higher mortality. hyperglycemia prevalence in critically ill patients is very high and the controversy whether it is a mortality marker or a mediator still remains. our results would justify starting an intensive insulin protocol and its subsequent analysis. the interest of continuous scvo was proven in the management of severe septic patients [ ] , but the place of discontinuous scvo remains unclear. objectives. to compare continuous scvo to discontinuous scvo concerning the number of therapeutic interventions in the management of severe sepsis (ss) and septic shock (ssc). methods. prospective randomized comparative study. inclusion criteria: age [ years, ss or ssc [ ] . two groups were defined: continuous scvo (c group) monitored by a central venous oximetry catheter (edwards lifescience x hs, irvine, usa), and discontinuous scvo (d group) measured on blood samples drawn every h and at the request of the treating physician. the hemodynamic management of these patients was based on the algorithm established by rivers [ ] . the primary endpoint was the number of therapeutic interventions (fluids, transfusions, inotropic drugs) triggered by a scvo \ %. non parametric tests (chi-square and mann whitney) and repeated-measures anova were used in statistical analysis (p \ . was considered significant). results. patients were included in a polyvalent intensive care unit (icu). the two groups were comparable concerning age, sex, weight, height, apache ii score, mods on admission and mechanical ventilation (mv). there were no statistical differences between the two groups concerning: mortality, duration of icu stay, duration of mv and the evolution of mods and plasma levels of lactate from day to day . the therapeutic interventions data are shown in table . introduction. the calcium activated potassium channel (bkca) exists in smooth muscle cells in most vascular beds and is believed to be important in sepsis induced hypotension and vascular hyporeactivity [ ] and also in neutrophil killing and macrophage production of proinflamatory cytokines. however the latter two roles have been disputed [ ] and we have found that bkca expression is not upregulated in aorta from septic mice using real time polymerase chain reaction. as its role in sepsis remains uncertain we sought to determine whether null mice for the bkca channel were (a) resistant to hypotension and (b) showed improved survival in a clinically relevant model of fecal peritonitis. methods. bkca null mice (based on balc) were obtained from jax Ò mice. agematched litter mates homozygous for bkca were wild types (wt). mice (age - weeks) had tethered arterial and venous lines inserted under isoflurane anesthesia. the tether enabled mice to roam cages freely whilst continuous blood pressure (bp) traces were obtained. h post surgery, echocardiogram and intraperitoneal injection of rat slurry was administered under anesthesia. fluid resuscitation of . ml/h voluven/ % dextrose ( : ) was given. at and h echo was recorded and mice culled with mesenteric arteries dissected for myography. data expressed as mean(sem) and statistical analysis anova. results. genotypic study and whole cell patch clamp recording in aortic smooth muscle cells confirmed bkca current was absent in null mice. fecal peritonitis induced equivalent hypotension in both wt (n = ) and bkca null mice (n = ) at - h (fig. a ). echocardiography at h post slurry showed no difference in cardiac output between wt- . ( . ) and bkca null mice- . ( . ) ml/min and no difference or improvement cf time (fig. b) . thus this fall in bp is due to reduction in total peripheral resistance not myocardial depression. in addition / of the bkca null mice died prior to h as opposed to / wt. hence myography was only performed on wt mesenteric arteries which were hyporeactive to norepinephrine (p = . , fig. c ). conclusion. there is no evidence from this transgenic mice study of fecal peritonitis that inhibition of the bkca channel would be beneficial for the treatment of hypotension in septic shock or would improve survival. reference(s). introduction. pro-and anti-inflammatory responses play a key role in the pathophysiology of sepsis [ ] . phosphodiesterase (pde) inhibition could play an anti-inflammatory role in this setting [ ] . previously, it was shown that among the three inhibitors of pde five currently available (sildenafil, vardenafil, tadalafil), only tadalafil could exhibit anti-inflammatory properties on endothelial cells (ec) stimulated by modified oxidized ldl or tnf alpha [ ] . to assess the potential anti-inflammatory role of tadalafil in ec stimulated by lps. methods. thp- cells ( . /ml in rpmi) were incubated alone (control group) or in the presence of either tadalafil ( lm; eli lilly, in, usa), lps from e.coli :b ( ng/ml; sigma-aldrich, inc.) or both. tnfa production, as a marker of inflammation, was measured in the supernatant (elisa assay; roche, mannheim, germany) after h of incubation ( independent experiments in quadruplet). comparisons were made by one-way anova, with bonferroni's post hoc test (mean ± sem). results. production of tnfa increased significantly after stimulation by lps alone compared to control ( . ± . -fold over the control, p \ . ) or tadalafil ( . ± . vs. . ± . -fold over control, p \ . ). levels of tnfa were significantly reduced in the lps ? tadalafil group, compared with the lps group ( . ± . vs. . ± . -fold over the control, respectively; p \ . ) (graph ). we hypothesized that daa provides varying protective effects in different organs as indicated by higher amounts of epcr in early murine sepsis. methods. sepsis was induced by cecal ligation and puncture (clp) in male nmri-mice (n = , body weight ± g). animals were randomly assigned to vehicle infusion (control), or clp sepsis with daa infusion [daa; lg/(kg hr)]. a third group received only sham operation and vehicle infusion (sham). h prior to clp all mice were given a permanent central i.v.-line and an arterial transmitter (pa-c , st. paul, mn, usa) to measure heart rate (hr) and mean arterial pressure (map). clp was adjusted to survive h. after h hearts, livers and kidneys were fixed in formalin and embedded in paraffin. immunohistochemical analysis of the paraffin sections was performed using the avidinbiotin-peroxidase complex (abc) method. for analysis an anti-mouse epcr antibody (clone , natutec, frankfurt, germany) was used (dilution : ) after heat pretreatment. anti-epcr positive cells were counted in fields in light microscopy (original magnification: . ) of each tissue and the average was recorded. data are presented as mean ± sd. *p \ . was considered significant. results. there were no significant differences in hr between the groups (sham ± per min; daa ± per min; control ± /min). map was significantly higher in sham group ( ± mmhg; p = . ) and non-significantly higher in daa group ( ± mmhg) when compared to control ( ± mmhg). anti-epcr positive cell count in heart tissue was significantly higher in sham-treated mice ( . ± . cells; p \ . ) and daa mice ( . ± . cells, p = . ) compared to controls ( . ± . cells). in kidney tissue epcr positive cells were significantly more in sham group ( . ± . ; p = . ) compared to control, but not in daa group ( . ± . ). liver samples showed no significant differences (sham . ± . ; daa . ± . ; control . ± . ). conclusion. our data showed higher amounts of epcr in murine sepsis undergoing daa therapy in heart and kidney tissues, but not in the liver when compared with control animals. this suggests that daa provides different effects in early experimental sepsis. background. caspofungin treatment is often initiated in hypovolemic shock patients, what could affect its pharmacokinetics and efficacy. the present study investigated the influence of hypovolemic shock and fluid loading on the plasma pharmacokinetic parameters and the pulmonary penetration of caspofungin in a pig model. after anesthesia and mechanical ventilation, pigs ( ± kg) were bled to induce a -h deep shock and resuscitated for h using normal saline based on hemodynamic goals. a -h perfusion of mg caspofungin was started at the beginning of the resuscitation period. lungs were removed h after the initiation of hemorrhage. sixteen animals were used as controls without hemorrhage. caspofungin concentrations were measured using high performance liquid chromatography method. in the shock group, the volume of removed blood was ± ml/kg and a volume of ± ml/kg of saline was infused through the resuscitation period. conclusion. hypovolemic shock followed by fluid loading in pig results in a significant decrease in plasma caspofungin exposition. it resulted in a decrease in the pulmonary concentration of caspofungin without affecting its diffusion to the lung. future investigations should focus on the interest for monitoring of plasma caspofungin concentrations in icu patients and on optimal dosing in these patients. objectives. the present study was designed to assess the effects of mps from septic origin on systemic hemodynamics as well as on the inflammatory, oxidative and nitrosative stresses. methods. forty healthy rats were randomly allocated to three groups: animals inoculated with mps isolated from control rats (cmps), animals inoculated with mps isolated from sham rats (shmps) and animals inoculated with mps isolated from rats with peritonitis (smps). rats were anesthetized, mechanically ventilated and were infused with the same amount of cmps or shmps or smps. we measured heart rate (hr), mean arterial pressure (map), carotid artery blood flow (cbf) and portal vein blood flow (pbf). hemodynamic parameters were recorded during h, and then animals were sacrificed. aorta and heart were harvested for further in vitro tissue analyzes. . the cellular origin (phenotype) but not the circulating concentration of mps was different in septic rats, characterized particularly by a significant increase in leukocyte derived mps. . smps but not cmps or shmps decreased mean arterial pressure without any effect on carotid artery and portal vein blood flows. all rats survived in the cmps and shmps groups whereas three rats died before the end of the experiment in the smps group. . rats inoculated with smps exhibited an increase in superoxide ion production and nf-kb activity, over-expression of inos with subsequent no overproduction and decrease in enos activation. pulse blood pressure recordings conclusions. rats with sepsis induced by peritonitis exhibited a specific phenotype of mps which could play a detrimental hemodynamic effect as a systemic vasodilatation. inoculation of smps in healthy rats decreased map likely by up-regulating nf-kb activity with subsequent inos, no and superoxide anion overproduction. these data confirm a proinflammatory detrimental role of mps in the vascular pathophysiology of septic shock. introduction. heat shock proteins (hsps) play an active part in modulating intracellular responses to stress. in the classical model for their activation de-repression of heat shock transcription factor (hsf ) occurs as a result of the titration of hsps away from hsf by misfolded proteins [ ] . however, hsps may change in many diseases without any changes in the levels of denatured proteins [ ] . objective. we propose that hsps are activated, in part, by a membrane dependent calcium channel receptor, possibly transient receptor potential vanilloid type- (trpv ). capsaicin, a known inducer of trpv , and capsazepine, a selective antagonist, were used on different mammalian epithelial cell lines. cells were pre-treated with micromolar concentrations of capsaicin or heat shock (hs) followed by treatment with capsazepine. results. capsaicin or hs induced hsf activation and the consequent accumulation of hsp , and chaperones. pre-treatment with capsazepine prior to hs or capsaicin abolished the heat shock response (hsr). capsazepine treatment prevented capsaicininduced stabilization of ikb and cell to cell adhesion and induced apoptosis. capsazepinemediated blockage of the heat shock response was reproduced with egta. moreover, treatment with trpv sirna resulted in a similar response to capsazepine. conclusion. hsr-sensing and signaling in mammalian cells depends, in part, on the transient entry of calcium by way of membrane dependent calcium channel receptor. these hsr modulators may hold promise in treating inflammation in the future. introduction. hydrogen sulphide gas, or its intravenous donor-sodium hydrogen sulphide (nahs), are promising therapeutic agents in ischaemia-reperfusion and haemorrhagic shock [ ] . we studied nahs in a short-term endotoxaemia model as relatively little is known about its effects during sepsis. methods. under isoflurane anaesthesia, male wistar rats (approx g weight) underwent left common carotid and right jugular venous cannulation for blood sampling/continuous bp monitoring and fluid administration, respectively. animals were kept normothermic on a heating mat. tissue oxygen tension (tpo ) was monitored using oxylite probes (oxford optronix, oxford uk) placed in thigh muscle. after a -min stabilization period, fluidresuscitated rats [ ml/(kg h)] were subjected to iv lps ( mg/kg over min). comparisons were made against animals receiving nahs ( . mg/kg bolus given immediately after lps, followed by a mg/(kg h) infusion). echocardiography (vivid , ge healthcare, bedford) and blood gas analysis were sequentially performed. sham-operated, non-septic animals also received nahs (n = ) or placebo (n = ). at the doses given, nahs had no effect on either sham-operated animals (data not shown), nor on the endotoxic rats (table ) . data shown as mean (±se). timepoints chosen reflect the biphasic response to endotoxin: = baseline, = initial hypotensive phase, = maximal recovery, = end of experiment. conclusion. nahs does not improve haemodynamics, tissue oxygenation nor shockrelated biochemical parameters in a severe model of fluid-resuscitated endotoxaemia. we will further investigate the effects of dose and time of therapeutic intervention in this model, in addition to testing it in a long-term septic model. intestinal endothelial and epithelial barrier dysfunction remain severe clinical problems as they may contribute to the development of sepsis and multiorgan failure. we have recently established an isolated rat small intestine model with access to vasculature, lumen and lymphatics for study of inflammatory changes in fluid balance [ ] stable for min, rendering it less suitable for examination of changes in gene and protein expression profile. the aim of this study was to assess the long term functional and metabolic stability of this model. adult female wistar rats were anaesthetized, small intestines cannulated and perfused vascularly ( . ml/min) and luminally ( . ml/min) and placed in a warm humidified chamber for up to h. arterial, venous and luminal pressures as well as venous, luminal and lymphatic effluent flows and intestinal weight were recorded continuously. as measures of metabolic integrity, oxygen consumption, lactate/pyruvate ratio and galactose uptake from luminally administered lactose were analysed every min. structural and barrier integrity were assessed as histostability score (mesenteric and antimesenteric fraction of fully epitheliated villi), wet/dry weight ratio and translocation of vascularly applied fitc albumin to lumen and lymphatics. data were compared using paired t tests. ± . / . ± . ml/(min g) dry weight (**)) as well as galactose uptake ( . ± . / . ± . mg/(min g) dry weight (n.s.)) were very stable with time pointing towards high metabolic stability. during the whole experiment, luminal effluent flow was slightly lower than applied ( . ± . ml/min, min) resulting in net liquid absorption over the whole time period ( . ± . / . ± . ml/min (n.s.)), and lymph production stayed in the physiologic range ( . ± . / . ± . ml/min (n.s.)). the organ weight did not change with time which, together with the balanced luminal fluid flow and end experimental wet/dry weight ratio of . ± . (compared to . ± . at the beginning of the experiment (**)), indicate absence of edema. minimal leakage of vascular fitc albumin to the lumen ( . ± . %) and a histostability score of . ± . show integrity of the vascular-luminal barrier until the end of the experiment. the isolated small intestine model presented earlier [ ] displays excellent long term physiologic, metabolic and histologic stability and opens up a wide field of applications including inflammatory gene transcription and protein expression. introduction. mitochondria play a major role during ischemia-reperfusion as well on cytotoxic pathways as protective such as ischemic preconditioning. the aim of this study is a better understanding of the mitochondrial pathophysiologic response to several oxygen regimens in an isolated mitochondria model. mitochondria were isolated from rat heart. enriched mitochondrial pellets were conditioned in presence of glutamate ( mm) and malate ( mm) inside the oxygraph chamber during min. oxygen partial pressures were: mmhg for control group; to mmhg for hypoxia group and mmhg for anoxia group. then, after a min oxygenation period, several measurements were realized: oxygen consumption (vo ) were measured with or without adp ( mm) (state and of mitochondrial respiration); calcium retention capacity (crc); mitochondrial membrane potentiel (dwm). to explore the involvement of reactive oxygen species (ros), mitochondrial vo were measured in presence of a specific mitochondrial antioxidant drugs (xbj). all results were expressed in percent of variation in comparison to control group [median (minimum-maximum)]. the different groups were analyzed using a kruskal-wallis, a mann-whitney with a bonferroni correction or a sign test when necessary. after hypoxia and reoxygenation the mitochondrial function was altered. this impairment of mitochondrial function was not found after anoxia and reoxygenation. this difference in mitochondrial function between hypoxia and anoxia suggests the involvement of ros. this hypothesis was confirmed by the effect of the antioxidant xbj that reestablished after hypoxia the same level of vo than after anoxia. [ ] . superoxide dismutase (sod) catalyses the dismutation of superoxide oxygen free radicals to oxygen and hydrogen peroxide (h o ). the therapeutic potential of exogenous sod administration in ards is evidenced by demonstrations of efficacy in acute lung injury models [ ] . anti-oxidant defenses, particularly the extracellular sod isoform, extracellular sod (ec-sod), are downregulated by endotoxin [ ] . we proposed that ec-sod delivered via a novel viral vector would ameliorate lung injury caused by lipo-polysaccharide (lps) pulmonary instillation. methods. three groups with nine rats per group were randomised to receive either adenoassociated virus expressing ec-sod (aav-ec-sod), adeno-associated virus coding for no product (aav-null), or vehicle control, days prior to planned lps instillation. a model of lipo-polysaccharide (lps) induced acute lung injury by pulmonary instillation was established in male sprague dawley rats. twenty-four hours following lps delivery, animals were anaesthetized and mechanically ventilated and their baseline compliance and oxygenation recorded. there was a statistically significant improvement in the oxygenation of animals recieving aav-ec sod as compared to aav-null or vehicle control (mean pao = . vs. . and . , respectively). there was a significant increase in amount of ec-sod as determined by real time pcr in the group who were administered aav-ec sod. no significant differences in static compliance or bronchoalveolar lavage cells counted were noted. conclusion. aav delivered ecsod is protective in a animal model of lps induced acute lung injury. the down regulation of the ec sod system seen in the systemic inflammatory response [ ] and its subsequent replacement exogenously may explain our findings. further work will focus on other components of cellular anti-oxidant pathways and confirmation of down regulation of ec sod in our injury model. aims. the endothelial specific angiopoietin (ang)-tie ligand-receptor system has been identified as a non-redundant mediator of endothelial activation in experimental sepsis. binding of circulating ang- to the tie receptor physiologically protects the vasculature from leakage, whereas binding of ang- antagonizes tie signaling and disrupts endothelial barrier function. we tested whether administration of exogenous recombinant ang- improves survival and attenuates multi organ failure in a lethal murine sepsis model. to induce septic acute kidney injury and to evaluate survival time cecal ligation and puncture (clp) was performed in twenty sv mice. half of the mice received an intravenous application of recombinant human ang- ( lg) immediately before clp and every h thereafter. in the other half, saline was administered in the same fashion. for tissue assessment (western blot, immunohistological) clp was induced in versus (ang- vs. saline) additional mice; animals were sacrificed after h. laparotomy served as sham control (n = ). further, a panel of cytokines has been assessed with a cytometric bead array (cba) system after h. . ± . mmol/l, p \ . ) were lower in ang- treated septic mice compared to controls. similar results were obtained at h after clp. renal tissue revealed that saline treated mice exhibit a marked loss of expression of vascular endothelial (ve)-cadherin, a major component of endothelial adherens junctions. in contrast, loss of ve-cadherin expression was prevented by ang- (pre-) treatment (wb densitometry: ang- : . ± . ; saline: . ± . ; p = . ). however, contrary to previous reports, intravenous injection of exogenous ang- enhanced not only the expression of adhesion molecules (icam- , vcam- ) in renal vasculature, but also circulating cytokine levels (tnfa, mcp- , il- , il- ). conclusions. our study demonstrates that administration of exogenous recombinant ang- improves survival time in a lethal experimental sepsis model. enhanced survival was accompanied by an improvement in microcirculatory function, probably via stabilization of adherens junctions. however, ang- injection deteriorated expression of vascular adhesion molecules and raised plasma cytokine levels. although ang- may have utility as an adjunctive agent for the treatment of septic multi-organ failure, additional dose-finding and efficacy studies are required. adaptive immune responses to infection. in contrast to neutrophils, macrophages or lymphocytes, there are virtually no data on the time course of circulating dcs in septic shock (ss). using a novel specific and sensitive assay, we analyzed the evolution of circulating myeloid (mdcs) and plasmacytoid (pdcs) dcs in ss. we enrolled immunocompetent adult patients with ss (n = ), shock from other etiologies (nss, n = ) and with sepsis without organ dysfunction (s, n = ). age-matched healthy controls (hc) served as reference for mdcs and pdcs. blood samples ( ll) were drawn on the day of shock, then after and days. dcs were counted using the dc-labelling kit trucount Ò assay (bd biosciences). cd c? cd -(mdc) and cd c-cd ? (pdc) cells were selected by flow cytometry (facscanto tm , bd biosciences). hla-dr mean fluorescence index (mfi) was measured. age, sex ratio, saps ii, sofa score, nosocomial infection (ni) and mortality rates did not statistically differ between ss and nss pts. at day , mdcs and pdcs counts were significantly lower in ss and nss pts as compared to hc and s ( fig. ). pts with ss had significantly lower mdcs and pdc counts than nss at days and . hla-dr mfi of mdcs and pdcs was lower in ss pts compared to hc (p = . and . , respectively). interestingly, of the ss pts developed ni after a median time of ( . - ) days in the icu. whereas mdcs increased in pts without ni, mdcs counts remained low at day in pts who developed ni: mdcs counts and their relative variation between day and were significantly lower in pts who developed ni than in those who did not (p \ . ). logistic regression analysis indicate that a negative mdcs relative variation is associated with an increased risk of nosocomial infection with an or ( . - ) (p = . ). figure conclusion . ss is associated with quantitative and qualitative abnormalities of circulating mdcs and pdcs as early as day , independently of the haemodynamic injury. the persistence of low counts of mdcs after ss is associated with the advent of nosocomial infection during the icu stay, suggesting that dcs play a role in the development of sepsisinduced immunosupression. introduction. liver dysfunction is common in sepsis but its mechanisms are unclear. the aim of the study was to evaluate the effects of lps on cultured primary human hepatocyte respiration over time. methods. human hepatocytes were isolated and cultivated from human liver resection specimens. cultivated cells were exposed to lps ( lg/ml) for , and h. after incubation, cells were trypsinized and respiration rates were measured using a high-resolution oxygraph (oxygraph- k, oroboros instruments, innsbruck, austria). glutamate ? malate (g ? m), succinate (s) or ascorbate/tmpd (a/t) were used as substrates to test the function of complex i, ii and iv, respectively. human hepatocyte mitochondrial function in the cells treated with lps for h exhibited a significant reduction in the maximal complex ii-dependent mitochondrial respiration [control: ± vs. lps: ± pmol/(s million cells) ( table ) ]. after and h of lps incubation no significant reduction in cellular respiration was observed ( and h: n = and h: n = ). statistics: paired t test, *p = . control vs. lps ( h incubation). introduction. acute kidney injury (aki) in critically ill patients is a frequent clinical problem and a rising incidence has been reported over the past several years. recently two consensus definition for aki have been developed: rifle [ ] in by the acute dialysis quality initiative workgroup (second conference) and akin [ ] in . insofar akin and rifle criteria have been applied in large retrospective studies, limited to the initial days of icu. nefroint is an italian initiative for an observational prospective multicenter study to evaluate epidemiology of aki in italian icus employing rifle and akin classifications. a pilot study has been performed in one of the centers enrolled. objectives. primary endpoints of nefroint are: application and comparison of rifle and akin criteria for aki definition in a prospective observational study; estimate, along such criteria, of aki incidence in critically ill patients; correlation of aki stages with prognosis. method. an observational prospective multicenter study has been designed, in italian adult icus (medical and surgical). all incident icu patients have been enrolled over a month period. exclusion criteria was age \ years, or icu stay \ h. data collection about patients was performed on a web-based electronic case report form. data included icu admission diagnosis, daily urine output ( h interval), daily laboratory data. sepsis events diagnosed on clinical and/or microbiological basis where as well marked for each patient. severity scores have been calculated at admission and daily. aki patients had higher severity of illness scores and higher serum creatinine values on admission. they also were older and more likely to have a respiratory diagnosis as reason for icu admission. conclusions. nefroint is an initiative aimed at comparing rifle and akin scores to promote a uniform use of a single definition of aki that will render subsequent studies comparable. early aki recognition could potentially allow implementation of timely corrective interventions, and hopefully prevent progression to more severe stages. aim. sepsis and septic shock remain the most important causes of acute kidney injury (aki) in critically ill patients and account for more than % of cases of acute renal failure (arf) in intensive care units (icu). its mortality varies with the severity of sepsis from % to %. the aim of this preliminary study was to investigate the differences in the course and prognosis of aki that was induced by community and hospital acquired sepsis. method. patients with sepsis induced aki were included in the study. rifle criteria were used to define aki. clinical and laboratory characteristics of the patients were compared with student t test and chi square tests. results. forty-one patients were included in the study and of them had community acquired septic aki (akic). ninety percent of the patients received mechanical ventilation (mv). etiologies of sepsis were mostly community acquired pneumonia and ventilator associated pneumonia. age, gender, admission apache ii scores and sofa scores at the time of aki diagnosis were similar across the groups (p [ . ). hospital acquired septic aki (akih) developed later when compared to community acquired septic aki ( th and rd days of sepsis respectively, p . ). akih was significantly and more frequently associated with oliguria ( vs. %, p . ), bacteremia ( vs. %, p . ), nephrotoxic antibiotic usage ( vs. %, p . ) and tend to progress more frequently to acute renal failure( vs. %, p . ) compared to akic. akic episodes were more frequently ( vs. %, p . ) and rapidly ( vs. days, p . ) reversible. mean blood pressure and scvo % were significantly lower and more vasopressor and steroid therapies were required during akih episodes compared to akic (p \ . ). while length of mv and mortality rates were similar, duration of hospitalization was significantly longer in the akih group ( vs. days, p . ). conclusion. these results suggest that, akih has worse clinic and prognosis than the akic so further and larger studies are necessary to investigate the preventive and therapeutic approaches. introduction. severity-of-illness or organ dysfunction scores are inaccurate to predict outcomes in patients with acute kidney injury (aki), even when specific aki scores are used. in recent years, the third versions of simplified acute and physiology score (saps ) [ ] and of mortality probability model (mpm -iii) [ ] scores were developed, and information on their use in patients with aki is scarce. objectives. to validate the use of saps and mpm -iii at the start of renal replacement therapy (rrt) in patients with aki. prospective cohort study conducted in the icus of three tertiary-care hospitals. data used to calculate the scores were collected at start of rrt. discrimination was assessed by area under receiver operating characteristic (aroc) curves and calibration by hosmer-lemeshow goodness-of-fit test. a total of consecutive patients were included between january and july . the mean age was . ± . years. the main contributing factors for aki were ischemia/shock ( %), sepsis ( %), contrast/nephrotoxins ( %), rhabdomyolysis ( %) and urinary tract obstruction ( %) (a patient could have more than one contributing factor). eightnine ( %) patients received rrt on the first day of rrt and ( %) thereafter; continuous rrt was used as first indication in ( %) patients. the icu and hospital mortality rates were and %, respectively. the mean saps score at the start of rrt was . ± . points. both the standard equation of saps and mpm -iii scores tended to underestimate mortality. discrimination was better for saps [aroc = . ( % ci, . - . )] than for mpm -iii [aroc = . ( % ci, . - . )], as was the calibration. however, mortality prediction and calibration improved when the customized equation of saps for countries from central and south america was used. in multivariate analyses, both higher prognostic scores and length of icu stay prior to rrt were the main predictive factors for hospital mortality. conclusions. the saps score at the start of rrt was accurate in our cohort of patients and seems a promising instrument for predicting hospital mortality critically ill patients with aki. objectives. the aim of this study was to investigate the effect of hes administration on kidney function compared with other colloids or crystalloids. methods. systematic review and meta-analysis of the effects of hes administration on kidney function. inclusion criteria for the study were prospective randomized trials comparing hes to control with reporting on variables of kidney function. aims. during the initiation phase of experimental acute kidney injury (aki), subtle but devastating changes, such as loss of brush borders, disruption of tubular cell polarity and cytoskeletal changes are detectable only to a certain extent by routine histologic methods. for this reason, subjective and moderate reproducible semi-quantitative scoring of tubular changes (e.g. vacuolization, detachment, cast formation, and necrosis) still remains the method of choice to quantify the extent of experimental aki. lectins are glycoproteins which are able to bind carbohydrate structures specifically. it has previously been shown that immunolabeling of the lectin phaseolus vulgaris erythroagglutinin (pha-e) is highly specific to the brush border of proximal tubular epithelial cells of rats, mice, and humans. the aim of this study was to ( ) develop a simple and fast lectin (pha-e) based staining protocol ( ) to objectively quantify, and ( ) to analyze brush border loss in a murine model of septic aki. methods. septic aki in mice (n = ) was induced by cecal ligation and puncture (clp). animals were sacrificed h after clp.sham operated (n = ) and healthy animals (n = ) served as controls. in order to specifically stain the tubular brush border, binding of biotinylated lectin pha-e was visualized by the biotin-avidin-complex (abc) glucose-oxidase (go) method coupled to tetranitroblue tetrazolium (tnbt) in -lm paraffin sections of renal tissue. the mean brush border area of five randomly chosen, non-overlapping cortical highpower fields was analyzed by planimetric software. lectin pha-e staining was highly selective for brush border of proximal tubules (black colour). virtually no staining was present in glomeroli and medulla. the xx software reliably identified lectin-positive areas, as confirmed by image overlay controls. we found a significant difference between sepsis induced aki, sham operated animals, and healthy mice (clp: . ± . ; sham: . ± . ; healthy controls: . ± . pixel ratio; p \ . ). our findings with the pha-e staining protocol correlated significantly with the conventional semi-quantitative scoring system (r = . , p \ . ). conclusion. the here presented lectin pha-e staining method followed by computerassisted planimetric quantification of brush border area is a highly reproducible and objective tool to analyze early histological changes during septic aki in mice. when an imbalance between oxygen supply and demand exist, anaerobic respiration commences and a metabolic acidosis develops. base excess and lactate have been used to identify a higher risk group of patients who should be admitted in icu prior to development of multiple organ failure. and at a time when appropiated therapy may previne the decline to death. acute kidney injury failure is a common complication in critically ill patients and it always difficult separate the acid base effects of critical illness per se from those of aki. the aim of this study was to examine wheter values of base excess or lactate taken on admission of patients with aki to a intensive care unit indicate prognosis and if wheter this can be used as screening tool for future intensive care admissions. we restropectively examinated data from patients with aki. to define the unique acid base characteristics of aki patients, we used a control group. the matched group consisted of icu patients wihtout aki matched for apache ii score. the base excess and lactate were collected at admission and then at h. a total of patients were enrolled at study over a month-period. there were no difference with respect age, sex and apache score between groups. the icu survival rates were % to the aki group and % to control group. the value of base excess with the best predictive prognosis ability was - mmol/l to the aki group and- . (p \ . ) to the matched group and the corresponding value for lactate was higher than . to both groups. the combination of these two markers on admission to the intensive care unit led to a sensitivity of % and specifity of % for mortality. conclusion. both base excess and lactate, or the combination of the two, can be used to predict day mortality in patients admitted to the intensive care unit. in patients with aki a different cut off of base excess should be used.these variables could be utilized to identify patients who have a higher risk for mortality to whom resources could be better directed. nonthyroidal disease (ntd) is a common finding in patients who are critically ill or on dialysis or with cardiovascular disease. its presence has been associated with inflamatory conditions. the aim of this study was to analyse the posible association of ntd with the development of acute kidney injury (aki). secondary targets where to estimate the incidence of ntd in a polyvalent icu and observe the realationship between the levels of t and some inflamatory markers: c reactive protein (crp), albumin and cortisol. during months in , after approval of the local ethical committee, we prospectively determined the following parameters in every patient admited to the icu: t , t , tsh, serum creatinine (scr), crp, albumin and cortisol. after excluding patients who died or were discharged before h, patients were studied. the degree of aki was calculated using the rifle scale. at admission the values of the analysed parameters were (mean ± sd): t . ± . pg/ml; t . ± . ng/dl; tsh . ± . liu/dl; scr [ ] . its incidence ( - %) is rising due to increasing numbers of ct scans and contrast studies conducted, and the higher prevalence of risk factors such as chronic renal impairment, diabetes mellitus and old age. although usually selflimiting, cin can be associated with a need for ongoing dialysis or increased mortality [ ] . to highlight the problem of contrast induced nephropathy and the difficulties in interpreting the current evidence for possible prevention strategies. we present the case of a year old man admitted to intensive care with acute pancreatitis. he underwent eight contrast-enhanced abdominal ct scans and received nacetylcysteine (nac) for all but one of these, after which he developed acute renal failure which did not recover. we also present a review of evidence for various proposed strategies. results. several studies have examined possible renal protective strategies around contrast administration. saline and bicarbonate have been shown to be beneficial when given pre-contrast [ , ] . theophylline has been shown in meta-analysis to have a significant beneficial effect, but heterogeneity of methodology between studies makes it difficult to clarify the degree of benefit achieved [ ] . nac has shown benefit in of trials. twelve meta-analyses showed inconsistent results, with showing nac to be beneficial. none showed harm. we analysed the heterogeneity of methods, endpoints and patient groups that makes these studies difficult to compare. critically ill patients may be considered at even greater risk of cin. only one study has specifically looked at this group. strategies such as volume loading may be inappropriate in some patients and there may not be time for nac for h pre-contrast. we were unable to find specific guidelines for the prevention of cin in critically ill patients. conclusion. the evidence for strategies to prevent cin specifically in critically ill patients is unclear. we review the current literature and propose renal protective strategies including hydration, nac and theophylline for this patient group based on the evidence available. objectives. the present study addresses the issue of how the different modes of rrt are currently used and performed. we conducted a prospective observational study in three portuguese intensive care units (icu). patient demographics, type of rrt used and outcomes were collected. we studied patients who were treated with rrt for rf, with a median age of years and a saps-ii score of . ± . , a sofa score of . ± . at admission; patients ( . %) were treated with continuous replacement therapy (crrt), patients ( . %) with sustained low-efficiency dialysis (sled)and patients ( . %) were initially treated with crrt and latter with sled. using the rifle criteria for the stratification of acute renal dysfunction at the beginning of the rrt we observed: risk- ( . %), injury- ( . %), failure ( . %), loss- ( . %), esrd- ( . %). we used anticoagulation in almost all patients ( . %). among patients who received anticoagulation, heparin was the most common choice ( . %), followed by low molecular weight heparin ( . %), and by sodium citrate ( introduction. in the intensive care unit (icu), severe sepsis and multiple organ failure are frequently associated with renal failure. continuous veno venous hemofiltration (cvvh), which is used as renal replacement therapy, also removes circulating inflammatory mediators. standard cvvh is currently prescribed with a substitution flow of ml/(kg min). theoretically, when hemofiltration is performed with higher volumes, buffer balance will be restored more rapidly, while also more inflammatory mediators will be removed. this may result in faster stabilisation from septic shock. indeed, animal-and some human studies show promising results, but have several (methodical) limitations. to evaluate hemodynamic and metabolic changes during hv-cvvh in patients with septic shock in comparison to (standard) cvvh. we performed a retrospective, observational, single-center study. all patients admitted with septic shock who were treated with cvvh in the period until were included. cvvh was defined as a substitution-flow b , ml/h, hv-cvvh as[ , ml/h. the decision to start with lv-cvvh or hv-cvvh was made by the attending icu-physician on an intention-to-treat basis. statistical analyses were performed with spss . introduction. haemostatic changes in critically ill patients are complex due to simultaneous pro-and anticoagulant processes. routine ptt and aptt assays monitoring clot formation poorly reflect hypo-or hypercoagulant state, especially during anticoagulation. endogenous thrombin potential (etp) comprises an in-vitro system for measuring thrombin generation beyond clot formation and may be more informative. objective. to assess whether etp has a role in monitoring systemic anticoagulation and predicting circuit clotting in critically ill patients receiving cvvh. methods. in a prospective study in an -bed general icu, we included patients with acute renal failure (arf) requiring cvvh (postdilution, - l/u). patients received a bolus of , iu of nadroparin followed by iu/h. samples of arterial and postfilter blood were taken at baseline and , , and h after start of cvvh to measure aptt, ptt, anti-xa and etp. we compared patients with early circuit clotting (circuit life £ lower quartile) and those with normal circuit life. median baseline arterial etp-area under the curve (auc) was ma (iqr - ma) (normal values - ma). baseline etp-auc was positively related to antithrombin and inversely to ptt, aptt, anti-xa (p \ . ) and sofa score (p = . ). median circuit life was . h (iqr - h). at baseline, the four patients with early filter clotting (£ h) had prolonged ptt and aptt, higher sofa score and a tendency to lower etp (table ) . during cvvh and nadroparin infusion, arterial and postfilter ptt and aptt were prolonged (p \ . ), antixa lower (p = . ) and etp-maximal concentration (cmax) lower (p \ . ) when circuits clotted early. while arterial etp-auc tended to be lower (p = . ), postfilter etp-auc was not different between groups. in critically ill patients with arf requiring cvvh with nadroparin anticoagulation, baseline etp is lower than normal and inversely related to organ failure and (a)ptt, probably reflecting consumption of coagulation factors. within the cvvh circuit, etp-auc and anti-xa show opposing patterns. the concurrence of early filter clotting with prolonged (a)ptt, lower antixa, lower etp and higher sofa score emphasizes the role of severity of disease and associated coagulation activation and heparin resistance in circuit clotting. introduction. nadroparin is a low-molecular-weight heparin (lmwh) used to prevent clotting in the extracorporeal circuit during cvvh. in renal failure lmwh accumulates and is associated with more bleeding (ref) . whether nadroparin is removed by hemofiltration and whether the anticoagulant activity accumulates during continuous infusion is controversial. objective. to study the kinetics and removal of anti-xa activity during continuous infusion of nadroparin in patients requiring cvvh using a cellulose tri-acetate filter. methods. in a randomized crossover trial in an -bed general icu, patients with acute renal failure (arf) were randomized. in group , postdilution cvvh was initiated at filtrate flow of l/h (blood flow (bf) ml/min), which was converted to l/h (bf ml/min) after min; in group , l/h was converted to l/h. patients (\ kg) received a bolus of , iu nadoparin followed by iu/h. samples of arterial blood, postfilter blood and ultrafiltrate were taken at baseline, h after the start and min, , and h after the conversion to measure anti-xa activity. results. fourteen patients with arf were equally randomized. patients in group had higher median sofa scores ( vs. , p = . ), baseline coagulation markers were not significantly different. arterial and postfilter anti-xa values are presented in fig. . during cvvh arterial anti-xa tended to decrease in time (p = . ). the median ratio of postfilter to arterial anti-xa was . (iqr . to . ). there were large differences between patients; differences between groups were not significant, except for postfilter anti-xa at h, which was significantly higher in group ( l/h) (p = . ) . anti-xa activity was not detectable in the ultrafiltrate. conclusions. critically ill patients receiving nadroparin during cvvh showed no signs of accumulation of anticoagulant activity, although extracorporeal removal of anticoagulant activity could not be demonstrated. apparantly, nadroparin is cleared by these patients despite renal failure. the differences in anti-xa between patients may be related to severity of disease. introduction. unfractionated heparin (ufh) is used as the first-line agent for anticoagulation of the extracorporeal circuit during continuous renal replacement therapy (crrt) in % of icus in the uk (uk) [ ] . its use is monitored with serial measurements of activated partial thromboplastin time (aptt) or its ratio (apttr) in % of icus [ ] . there is, however, considerable variation in practice [ ] . anticoagulation is useful for prolonging haemofilter life and facilitates the provision of continuous therapy, but must be balanced against the risk of haemorrhage, which has been correlated with increasing apttr [ ] . most icus in the uk use an apttr target of . - . [ ] , despite recent guidance that a target range of . - . provides adequate filter life with less risk of bleeding [ ] . objectives. to investigate the adherence to our local target range for ufh therapy (apttr . - . ) and the occurrence of over-anticoagulation in our patients. ]. there were apttrs ( %) which were above our target range, and incidences ( %) where the apttr was greater than or equal to . . the apttr was greater than . on occasions ( %). conclusions. this study was conducted in an icu which delivers crrt at a higher than average frequency [ ] , and which consistently has a standardized mortality rate below the national average. despite this, there was wide deviation from our target apttr range and a considerable incidence of significant over-anticoagulation, which may place our patients at risk of haemorrhage. the vast majority of apttrs were in excess of recent guidance [ ] . regional citrate anticoagulation (rca) may provide longer filter life with a lower incidence of bleeding [ ] . its use is increasing worldwide [ ] , though it is not commonly used in the uk [ ] . we are investigating the possibility of introducing rca in our icu. in the meantime, we will set a lower apttr target for our patients. we prospectively studied patients who received cvvh from july to december . age, gender, admission diagnosis, and apache-ii were obtained and the patients were divided into three groups: low dose heparin group, low molecular weight heparin group (lmwh), and no anticoagulation group (normal saline washing) based on assessment of coagulation status. for each circuit, circuit life, bleeding, platelet count, pt, inr, aptt, creatinine and urea were collected before and after crrt. results. seventy-seven critically ill patients with acute renal failure were treated with crrt and circuits were observed. among these circuits, received unfractionated heparin (ufh) anticoagulation, received lmwh anticoagulation and received no anticoagulation. the mean circuit life ( . ± . h) in low dose ufh group, was significantly longer than in lmwh ( . ± . h) and in no anticoagulation group ( . ± . h). there was no significant difference in baseline patient pre-crrt hb, creatinine and urea among three groups. the inr and pt and aptt in baseline were significantly higher in no anticoagulation group compared to the other two groups (p \ . ). the platelet count was significantly lower in the no anticoagulation group compared to ufh group and lmwh group in baseline and during crrt. there was no significant difference in the filter pt, aptt, among the three groups during crrt. the clearance of creatinine and urea during crrt were no significant difference among the three groups. bleeding complication secondary to crrt were no significant difference among the three groups. objectives. the purpose of the study was to assess the duration of time spent off therapy during the first five days of crrt in post-traumatic arf, and to identify the reasons for this. ullevaal between january and december , were retrospectively reviewed. the hospital is the regional trauma referral centre for approximately . million adult ([ years) persons. according to the local treatment protocol, dialysis filters were routinely changed after h due to time-out. individuals were identified and data collected using several institutional registries. patients were grouped according to presence of rhabdomyolysis based on peak serum creatine kinase levels exceeding , u/l or not. categorical data were compared employing two-sided pearson chi-square test, whereas continuous data were analyzed utilizing two-tailed mann-whitney u test. results. patients were included during the study period. during the first five days of therapy there was a total of dialysis days, and the total number of pauses was . the median duration of crrt was . h per day, giving a downtime of . h per day. the number of pauses per day was significantly larger in patients with rhabdomyolysis compared to patients without rhabdomyolysis ( pauses in dialysis days vs. pauses in dialysis days, p \ . ). this resulted in a shorter duration of crrt in rhabdomyolytic compared to non-rhabdomyolytic persons ( . vs. . h per day, p \ . ). overall the reasons for pauses during crrt were filter clotting ( %), therapeutic procedures ( %), catheter problems ( %), filter time-out ( %) and diagnostic examinations ( %). patients with rhabdomyolysis had more pauses due to therapeutic procedures ( vs. %, p = . ), whereas non-rhabdomyolytic persons had more pauses due to catheter problems ( vs. %, p = . ) and filter time-out ( vs. %, p \ . ). the number of pauses per day stayed relatively stable during the first five days of crrt, but the reasons for pauses changed during the study period. conclusions. this study indicates that trauma patients with rhabdomyolysis had more frequent dialysis pauses during the first days of crrt than those without rhabdomyolysis, resulting in shorter duration of dialysis therapy. the reason for this was more frequent use of therapeutic procedures, i.e. surgery and radiological interventions, in rhabdomyolytic compared to non-rhabdomyolytic persons. grant acknowledgement. the author is supported by institutional grants. introduction. treatment of acute pancreatitis is aimed at correcting any underlying predisposing factor and at the pancreatic inflammation itself. hypertriglyceridemia is an uncommon cause of pancreatitis. a serum triglyceride level of more then , to , mg/ dl is an identifiable risk factor. interestingly, serum pancreatic enzyme levels may be normal or only minimally elevated in such cases. severe necrotizing pancreatitis is associated with a high rate of complications and significant mortality. the reduction of triglyceride level to below , mg/dl effectively prevents further episodes of pancreatitis. this study aimed to determine the effectiveness of plasma exchange (pe) in reducing triglyceride levels during an acute attack of hyperlipidemic pancreatitis (hlp). methods. prospective, observational study including six patients hospitalized with hyperlipemic pancreatitis treated with plasmapheresis between and in the medical icu of a teaching hospital in malaga. demographic data, apache ii score, organ support needed and prognosis were prospectively collected. a total of hypertriglyceridemic patients with the complication of acute pancreatitis received one or two consecutive sessions. mean age was ± years and mean apache ii was ± . icu mortality was %. we performed sessions. the development of multiorgan failure in patients with hyperlipemic necrotizing pancreatitis was associated with grave prognosis ( %), needed mechanical ventilation, vasoactive agent and renal replacement therapy. however, we had a good outcome in the majority ( %) with a effective reduction of triglycerides after the session of plasmapheresis (pe). four of six patients ( %) recovered completely in a single session. two patients developed intraabdominal abscess, requiring more than one consecutive session and surgical debridement of infected necrosis and died due to both septic shock and multi-organ failure. the respective mean removal rates during a single pe for triglyceride were %. conclusions. the best treatment of hypertriglyceridemic pa is a drastic reduction of tg-s to normal. experiences with plasmapheresis are limited. we report six patients of hypertriglyceridemic necrotizing pancreatitis with mildly elevated amylase and lipase, treated successfully with plasmapheresis. in summary, pe treatment is an effective method to clear lipids and enzymes from plasma in a single session for most hlp patients. the presence of multisystem organ failure appears to be a more important indicator of outcome than does the presence of infection. results. sixteen ( %) patients were female and ten ( %) were male. the median age was years old. the median apache ii score was . . mechanical ventilation ( %), vasoactive agents ( %) and renal replacement therapy ( %) were the most common forms of organ support needed. sessions of plasmapheresis were performed. ( %) patients had been diagnosed with thrombotic thrombocytopenic purpura (ttp), six ( %) patients had hyperlipemic pancreatitis, five ( %) patients had pulmonary-renal syndrome (prs), three ( %) patients had guillain-barré syndrome (gbs) and two ( %) had myasthenia gravis. we obtained a decreased in the values of apache ii score following the plasmapheresis performed. there were six death ( % mortality) due of the severity of the disease. the number of complications were minimal and commonly described in the literature and there was a low mortality as a result. conclusion. results indicate that the performance of plasmapheresis was on a heterogeneous sample of patients with neuroimmunological diseases, rheumatology diseases and hyperlipemic pancreatitis. we conclude that plasmapheresis is a safe treatment which can be made by the staff trained in intensive care in any moment with a wide spectrum of clinical indications and with a minimum adverse effect. the aim of the study is to evaluate that early treatment of septic shock with cpfa may improve patient outcome. methods. twenty septic patients who were admitted to the icu have been enrolled in this study. cpfa treatment was performed immediately after septic shock was diagnosed (early group h after diagnosis). every patient had - cpfa treatments for h with q blood = ml/h, q ultrafiltration = ml/(kg h) and q plasma = % of q blood. we measured the plasma concentration of procalcytonin (pct), blood lactic acid levels, crp, serum creatynine, wbc and pao /fio ratio. the apache ii score, hemodynamic parameters, norepinephrine dosage were evaluated before cpfa (t ), t (after first cycle), t (after second), t (after third cycle) and t (after h). introduction. the development of electrolyte disturbances in intensive care patients could be prevented by the use of better adapted dialysis fluids. a common problem is hypophosphatemia which has been shown to occur in up to % of the patients. correction by intravenous phosphate supplementation is known to improve respiratory muscles, cardiac index, oxygen delivery to tissues and insulin resistance. lately it has been reported that phosphate can be added directly to the dialysis fluid. this facilitates phosphate handling, but there is a risk of precipitation with calcium. an additional problem is that the amount of phosphate required to correct total body deficit varies and repeated serum measurements are needed to establish phosphate insufficiency. the process is time consuming and leads to treatment delay and excessive cost. objectives. this study evaluated the possibility to achieve and maintain normal phosphate balance over time by using a new phosphate-containing dialysis fluid. objective. the purpose of this study was to evaluate the impact of different dialysate and replacement flows in the acid-base balance of the blood. furthermore we tried to assess the way partial pressure of oxygen (po ) in the blood is affected by high flow crrt. methods. this was a prospective observational study. thirty consecutive critically ill patients that were admitted in our icu and required crrt during their course were enrolled in the study. for each patient, blood flow, dialysate and replacement flow as well as ultrafiltration adjustments were performed by the responsible intensivist. any time that the clinical condition required a modification in any of these parameters, and after a period of time of no less than h, a simultaneous blood sample was drawn from both the arterial and the venous part of the circuit and the samples were analysed by a blood gas analyzer. arterial and venus samples were then compared for differences in ph, po and pco concentration. results. in total we performed measurements in patients. mean patient age was . years, mean apache ii score was , mean icu stay was days and mean crrt days was days. overall, ph in the venous line of the circuit was higher, pco was lower and po was lower as well compared to the respective values in the arterial line of the circuit, with no difference reaching a statistical significance. concerning the blood flow, we observed that when using high hemodiafiltration flows the difference in oxygen partial pressure between the arterial and the venous line of the circuit was greater, but again it did not reach statistical significance. conclusion. the use of crrt may influence the po in the returning blood. although we did not reach statistical significance in our study, there was a definite trend towards lower po in the venous line of the circuit when high flow crrt was applied. introduction. renal failure (rf) is a common complication in critically ill patient and is associated with high mortality and has a separate independent effect on risk of death. the continuous renal replacement therapy (crrt) is physiologically superior; however, there is lack of strong evidence to prove a clinical benefit. hybrid therapies (sled) that combine the benefits of intermittent haemodialysis and continuous therapies have emerged in the past few years. objectives. the aim of this study was to assess what type of renal replacement therapy (rrt) used and relate them to severity of the illness and outcome we conducted a prospective observational study in three portuguese intensive care units (icu). patient demographics, type of rrt used, saps ii and sofa score at admission and when we started the rrt and outcomes were collected. we studied patients who were treated with rrt for rf, with a median age of years and a median saps-ii score of ; patients ( . %) were treated with continuous replacement therapy (crrt), patients ( . %) with sustained low-efficiency dialysis (sled) and patients ( . %) were initially treated with crrt and latter with sled. aim. tetanus is traditionally treated with very high doses of diazepam and morphine. it often required prolonged periods of paralysis and was associated with very high mortality and prolonged periods of ventilation. magnesium sulphate (mgso ), due to its effects on neuromuscular and autonomic system should be effective in controlling muscle rigidity, spasm and autonomic instability in patients affected with tetanus. we introduced an icu protocol using mgso as first line treatment. we wanted to evaluate our patient outcome following the introduction of our protocol. we retrospectively analysed the effects of introduction of mgso in our intensive care for management of tetanus. aim. electrolyte disturbances were often seen in patients in intensive care unit (icu). hypomagnesemia is not enough described but can be contributed in icu mortality. the aim of this study was to define the prevalence of hypomagnesemia in critically ill patients and to evaluate its relationship with duration of mechanical ventilation day, length of icu stay and mortality. a prospective study was done on patients with respiratory failure admitted to the icu between . . and . . . total serum magnesium level, electrolyte levels, albumin, total protein, and lactate levels were evaluated at the admission. patients demographic features, accompanying neurological and cardiac diseases, apache ii score, duration of mechanical ventilation, and the length of icu stay and mortality were recorded. at admission % of patients had hypomagnesemia. a positive correlation was found between serum magnesium and calcium level (p = . ), but there was no relationship between other laboratory tests. also there was no relationship determined between hypomagnesemia and duration of mechanical ventilation, and the length of icu stay and mortality (p [ . ). conclusion. electrolyte levels are important in critically ill patients. however routine monitoring of serum magnesium level is not necessary. so we should increase the case number and also evaluate the serum magnesium level with urine magnesium level to see the effects of hypomagnesemia. method. medical records of copd patients who underwent invasive mechanical ventilation (imv) were reviewed. the patients' age, sex, body mass index (bmi), apache ii scores at admission, previous diagnosis of hypothyroidism or hyperthyroidism, history of thyroid replacement therapy or antithyroid medications, and the serum thyroid stimulating hormone (tsh), free triiodothyronine (ft ), and free thyroxine (ft ) at admission were recorded. the primary outcome measure was prolonged mv (pmv), which was defined as dependence on mv for [ days. the outcome and the relation between the serum thyroid levels were evaluated. results. ninety-five copd patients were included, % were male, with a mean age of . ± . years. bmi's of the patients were . ± . and the mean value of apache ii score was . ± . . only two patients ( %) had a history of hypothyroidism. two more patient were diagnosed hypothyroidism at admission and treated with thyroid medications. the patients treated with thyroid replacement therapy were liberated from mv successfully. patients ( . %) could not be weaned. serum ft level ( . ± . ) of the patients, who could not be weaned, was statistically lower than other group who could be liberated (p = . ).however there was no statistical difference between serum ft and tsh levels and two groups. hypothyroidism is an uncommon cause of ventilator dependent respiratory failure with an incidence of %, but it is treatable, so it should be considered in patients who can not be liberated.more prospective studies are also needed to evaluate the significance of hypothyroidism in patients with respiratory failure and failure to wean. smoke inhalation injury represents an important prognostic factor in patients admitted in the hospital after smoke exposition. objectives. we determined whether initial antithrombin (at) levels help in diagnosis and prognosis of sepsis after smoke inhalation. smoke inhalation was diagnosed according to classical clinical and laboratory findings in patients admitted in the hospital with suspected inhalation after smoke exposition. at levels, coagulation parameters (fibrinogen levels, prothrombin time (pt), activated partial thromboplastin time (aptt) and liver function tests were determined on admission and correlated each other and with outcome of the patients. . initial at and fibrinogen levels were significantly lower in patients with severe smoke inhalation compared to control (p \ . ). initial at levels were lower in the ones who developed septic complications with disseminated intravascular coagulation (dic) compared to those without dic (p \ . ). initial at levels were significantly lower in patients who died as compared to survivors (p \ . introduction. x-ray finding of pleural effusion is fairly common in icus. this may vary from mild to massive effusions and of different etiologies. epidemiological and outcome data for this icu problem are scarce in literature. the objective of this study was to find how common this finding is in our icu, their respective etiologies and any bearing on icu mortality. a single centre, prospective, observational study conducted in two mixed medical and surgical icus in kolkata, india. over six month period (october to march ) all consecutive patient admissions to these two icus were screened for a x-ray evidence of pleural effusion, either on admission or during their icu stay. as per icu protocol apache ii scoring were done in all patients. those with effusions were grouped according to etiology. finally in icu mortality were observed for those with or without an effusion. a total of icu admissions were studied. among these patients were found to have x-ray evidence of pleural effusion. median apache ii score was (iqr - ) among the study population with predominant ( . %) medical admissions. incidence of bilateral effusions were a total of ( %). the common causes of pleural effusion include chronic kidney disease (n - %), heart failure (n - %), pneumonia (n - %), post operative (n - %), chronic liver disease (n - %) and rest others (e.g. trauma, pancreatitis, pte, malignancy). the overall icu mortality was ( . %) and ( . %) in groups with and without effusion respectively with a p value of . , showing number of deaths in pleural effusion group were significantly higher. our study showed x-ray finding of pleural effusion quite common in icu patient population even many a times being bilateral. in this small study the overall icu mortality were also higher in pleural effusion group, but a wider multicentric study is needed. introduction. acute lung injury (ali) is a clinical manifestation of respiratory failure caused by lung inflammation and the disruption of the alveolar-capillary barrier. to prevent alveolar edema, it is of critical importance to preserve the physical integrity of the alveolar epithelial monolayer which is regulated by the balance between centripetal forces arising from cytoskeletal tension and cell-cell and cell-matrix tethering forces [ ] . intercellular junctions, such as tight junctions are closely related to actin cytoskeleton-related barrier regulation. proteins of the coagulation cascade such as thrombin (thr)-that stiffens [ ] and contracts [ ] alveolar epithelial cells (aec)-or activated protein c (apc)-an endothelial barrierprotective agent [ ] -could modulate this balance of forces in the epithelial monolayer. to study the combined effects of thr and apc on the barrier integrity through the tight junction zo- of aec by western blotting and immunofluorescence. methods. aec (a ) were incubated for h with apc ( lg/ml) or vehicle (control). subsequently, thr ( nm) or medium was added to the cell culture. for zo- western blotting, cell lysates were first ultracentrifuged ( , g, min, °c) to obtain membrane and cytosol fractions. then the samples were subjected to western blotting and the amount of zo- fractions was calculated by densitometry. for zo- immunofluorescence, aec were grown on glass coverslips and fixed in . % formaldehyde solution. zo- antibody was used to localize the tight junction and the zo- integrated optical intensity was then measured. . treatment with apc did not induce significant changes in any zo- amount of fraction protein analyzed by western blot. thr induced a *fivefold increase ( ± % of control values) in zo- membrane fraction while no changes were detected in zo- cytoplasm protein content ( ± % of control values). by contrast, apc concentration of lg/ml showed a clear tendency to reduce the effects induced by thr on zo- membrane fraction ( ± % of control values). for zo- inmunofluorescence, apc and thr treatments resulted in different patterns of zo- in the cell-cell contacts. after thr challenge cells showed discontinuous staining of zo- compared to untreated cells indicating a disruption of alveolar monolayer. conclusions. the increase in zo- amount of membrane fraction after thr challenge lends support to a protective mechanism avoiding cell-cell contacts disruption. treatment with apc reduced the increased zo- amount of membrane protein induced by thr suggesting an improvement of the barrier integrity in this model. ( ) interleukin- (il- ) is said to be involved in organ injury. we investigated the il- values of septic acute lung injury (ali) and acute respiratory distress syndrome (ards) patients. the subjects were patients during the -year period from to from whom it was possible to collect a blood specimen within approximately h of the onset of septic ali or ards. their mean age was years, and their mean apache ii score was . their sofa score was , and their mean pao /fio (p/f) ratio was . the p/f ratio was in the ali group and in the ards group. there were cases ( . %) in the -day mortality group, and cases ( . %) in the -day mortality group. the value of il- in died group was significantly higher than in survived group ( , ± , vs. , ± , pg/ml; p \ . ), and in the ards group also significantly higher than in ali group ( , ± , vs. , ± pg/ml; p \ . ). these results suggested that il- may play an major role in progression of ards in respiratory disorder as multiple organ failure (mof). [ ] . it is well-known that the pathophysiological mechanisms and factors involved in the liberation of no and the activation of inflammatory responses differ between aud and non-aud patients. objectives. the main hypothesis of this study is that ards patients with aud and non-aud differ in their response to the application of evidence based algorithms with respect to no response (aud patients are more frequent non-responders). patients with ards (meeting aecc criteria) were included in this ethically approved study. patients with severe chronic lung fibrosis and/or bridging for lung transplant were not included. patients were allocated to aud and non-aud patients. the auddetection was performed by the published algorithm [ ] . statistical analysis: wilcoxon-mann-whitney and chi-quadrat test was used. results. so far, patients with ards were included. prevalence of aud was % in our ards patients. baseline characteristics are given in table . frequencies of no nonresponse, extracorporeal lung support and mortality are given in table . frequency of no non-response was in tendency different: % in aud patients versus % in non-aud. overall mortality was % in aud patients versus % in non-aud patients. introduction. acute lung injury (ali) is a critical illness characterized by increased vascular permeability and impaired gas exchange leading to death in some cases. inflammation plays a pivotal role in the induction and maintenance of ali and is therefore therapeutic target to treat ali. rho, a small gtpase, is involved in the regulation of inflammation through the activation of recruitment of neutrophils to the site of inflammation and through activation of transcription factors such as nf-kb. we hypothesized that a rho kinase (rock) inhibitor, y- may be beneficial to dampen the inflammatory response in ali. male sd rats were intravenously pre-treated with either saline or rock inhibitor (y- , mg/kg). ali was induced by intratracheal instillation of mg/kg e. coli lipopolysaccharide (lps). control rats received saline intratracheally. h after the induction of ali, lungs were harvested and analyzed for myeloperoxidase (mpo) activity and expression of the proteins ijb, inos and enos. bronchoalveolar lavage fluid (balf) was used to assess total protein concentration as a measure of vascular permeability. pre-treatment with the rock-inhibitor resulted in significantly decreased levels of lps-induced mpo expression and prevented the upregulation of both lps-induced inos and enos expression. furthermore, lps-induced degradation of ikb was attenuated by pretreatment with y- . finally, y- improved vascular permeability by decreasing the lps-induced protein concentration in the balf. conclusion. inhibition of rho-kinase decreases lung inflammation and vascular permeability in acute lung injury and may therefore be a good approach to treat patients suffering from ali. we hypothesized that due to the cyclic changes of pulmonary air content there are po oscillations also in the mixed venous blood (pvo ), potentially influencing pao oscillations. in each of three healthy pigs of kg, anesthetized and ventilated with constant minute volume we studied three different tidal volume settings ( , and ml/kg) resulting in different respiratory rates. a calibrated oxygen probe (fiber optic, fluorescence-quenching probe, foxy-al ; ocean optics, dunedin, fl, usa) was inserted into the pulmonary artery through a fr catheter. the catheter position was previously controlled by pressure tracing. pvo was sampled with temperature compensation at hz with a multi frequency phase fluorometer (mfpf , tau theta, fort collins, co, usa) after a generated timestamp to synchronize with the electric impedance tomography (eit) signal (goettingen goemf ii, viasys healthcare, the netherlands) sampled at hz. eit and pvo were simultaneously recorded for min during each tidal volume setting and analysed with and without low pass filtering at the heart rate. we obtained pvo oscillations with amplitudes between to mmhg with the main frequencies matching the respiratory rate. ventilation with tidal volumes of ml/kg provided higher pvo amplitudes than ventilation with ml/kg. these results are preliminary and the source of the measured pvo oscillations is not clear. alternate backflow from the superior and inferior vena cava due to changes in intrathoracic pressures during mechanical ventilation may be responsible for these oxygen partial pressure oscillations in the mixed venous blood. conclusion. mixed venous oxygen partial pressure oscillates in accordance to the respiratory rate. whether arterial po oscillations are due to cyclic recruitment and derecruitment of the lung or to corresponding mixed venous oscillations remains to be evaluated. [ ] and in neonates [ ] . to our knowledge this is the first validation of the model using a large cohort of samples from intensive care patients. aim. to assess the ability of the severinghaus equations [ ] to estimate values for po and so in critically ill adult patients. methods. , sequential blood gas samples were analysed to validate the severinghaus oxygen dissociation curve, of these , measurements had a so b . % and were included in subsequent analyses. bland-altman plots were used to examine the agreement between measured po and that calculated from the severinghaus equations, and between measured and calculated so , both with and without correction for ph. the differences between measured and estimated values were analysed using paired t tests with a p value \ . considered significant. results. the severinghaus oxygen dissociation model accurately reflects the relationship between po and so observed in clinical samples. there is reasonable agreement between the measured and calculated values for po and so , with the majority of values falling between the lines of % agreement. there was a statistically significant difference between observed and calculated values of po even when adjustment for ph was made (p \ . ), however the mean difference between the groups was not clinical significant ( . mmhg when ph adjusted). there was also a statistical difference between measured and calculated values of so (p \ . ), again, however, this difference may not be considered clinically significant ( . %). patient data and severinghaus oxygen dissociation conclusions. the severinghaus equations accurately reflect the oxygen dissociation curve in critically ill adult patients and whilst they provide values for po introduction. zinc (zn) is an essential trace element, which plays a role in many biological functions including immune function. development of respiratory infections and changes in respiratory tract cells may be affected by low zn levels. in critically ill children mortality of septic shock and degree of organ dysfunction were associated to low blood zn levels , . our aim was to study serum zn in the beginning of acute respiratory failure (arf) and its association to development of organ failures and day mortality. during an -week study period (from april to june ) adult patients with arf were treated in intensive care units (= finnali-cohort). after consent blood sample for zn analysis was drawn at baseline). samples were taken in zn-free tubes, freezen and stored in - °c for analysis. all samples were analyzed with an atomic absorption spectrophotometry in the oulu university hospital laboratory. the range of normal values is - lmol/l. organ failures were assessed by daily maximal sequential organ failure assessment (sofamax) score. results. serum zn samples were obtained during h after the baseline with median time of h. only zn values were within and two over the normal range. median (iqr) serum zn levels were . ( . - . ) and . ( . - . ) lmol/l for survivors (n = ) and nonsurvivors (n = ), respectively, with no significant difference (p = . ). in patients with or without infection (pneumonia, respiratory infection or sepsis) during h prior to arf, zn levels were . ( . - . ) and . ( . - . ) lmol/l, respectively (p = . ). zn levels were significantly lower (p \ . ) in patients with cardiovascular sofa - than - , . ( . - . ) and . ( . - . ) lmol/l, respectively. a significant correlation of zn level and daily sofamax (spearman's q - . , p \ . ) was found (fig. ) . conclusions. low serum zn levels were detected in almost all patients with arf. no association to day mortality was detected to support the earlier findings with pediatric critically ill patients. however, we found a significant correlation to organ failure development in adult patients with arf. mountaineering is closely related to a range of adverse influences. the overriding factor that affects a climber may be the hypobaric hypoxia, which is compensated by hyperventilation and other adaptive changes in the pulmonary and systemic circulation. west ( ) theoretically predicted hypoxemia combined with respiratory alkalosis [ ] , and low oxygen saturation ( … %) has been observed on peak broad, karakorum [ ] . lack of adaptation is known as mountain sickness (occurrence … % [ , ] ), which may be alleviated by acetazolamide. the importance of understanding pathophysiology of mountaineering is dictated by the gradual expansion of western consumer-oriented society to higher altitudes. the goal of our study was to obtain precise information on changes in arterial blood gas composition, acid-base status, and degree of hemoglobin desaturation relative to altitude. materials and methods. experienced athletes-four males between and years and female years attempted to ascend mt. makalu ( , m) in april-may . acetazolamide , bid was used from april till may . femoral arterial blood rather than radial arterial blood was analyzed before reaching base camp ( background. ventilator associated lung injury is a complication of mechanically ventilated patients. knowledge about pathological pathways comes from animal studies, which are necessary to generate hypotheses to be tested in humans. various experimental methods of inducing acute lung injury (ali) have been used in animal models. the results of animal studies and human research appear to be conflicting; however, this may be a consequence from the different animal models used as such for comparison. we hypothesized that effects on gas exchange, respiratory mechanics, histo-pathologic lung damage and systemic inflammation are depending on the model of ali used. in five groups of pentothal anesthetized rats acute lung injury was induced by either lung lavage or hydrocloric acid aspiration. rats were then ventilated with lung protective settings in pressure controlled mode with positive endexpiratory pressure (peep) of cm h o or breathing spontaneously with continuous positive airway pressure (cpap) = cm h o for h. blood pressures, cardiac output, pulmonary mechanics and gas exchange were measured. results. the tidal volume was . ± . ml/kg in ventilated and . ± . ml/kg in cpap groups. respiratory rate and minute ventilation were constant in ali animals and controls, but showed variability in spontaneous breathing animals. only half of the cpap animals with ali survived [ h. no significant differences were found for pco , cardiac output or blood pressure between models, but mean arterial pressure decreased in ali. in the lavage and aspiration model, pao was lower after induction of ali ( ± and ± mmhg, respectively) than controls, and increased in lavage ( ± mmhg) but not the aspiration model ( ± mmhg) after h (p \ . ). dynamic compliance of the respiratory system decreased permanently after induction of ali to . ± . ml/cm h o (lavage) and . ± . ml/cm h o (aspiration) as compared to controls, which maintained at . ± . ml/cm h o after h. the lungs from five additional anesthetized, unassisted breathing animals, taken directly after induction, showed significant atelectasis, neutrophil infiltration and interstitial and alveolar edema (diffuse alveolar damage (dad) score . ± . ), as compared to control animals without ali (dad . ± . in ventilated, . ± . in cpap, respectively). the dad was higher in aspiration ( . ± . ) than in lavage ( . ± . ) induced ali, with no significant differences between ventilated and cpap animals. no hyaline membranes were observed. conclusions. anesthesia induces significant alveolar inflammation, which is partially reversible by use of peep. the ali model of acid aspiration induces persistent changes in gas exchange, respiratory mechanics and alveolar damage, which are more severe and consistent than those induced by the lavage model. background. acute lung injury (ali) is characterized by exaggerated inflammation and a high metabolic demand. mechanical ventilation can contribute to ali, resulting in ventilator induced lung injury (vili). a suspended animation-like state induced by hydrogen sulfide (h s) may reduce metabolism and co production, allowing for a lower minute ventilation to maintain gas exchange, thereby decreasing vili. h s may also limit lung injury via reduction of inflammation. the effect of h s-induced suspended animation on myocardial function is unknown. methods. in rats, vili was induced using a peak inspiratory pressure (pip) of mmhg and zero peep. controls were ventilated with a pip of and peep of mmhg. respiratory rate was adjusted to maintain normocapnia. suspended animation was induced by infusion of a h s donor, controls received saline. blood gases were drawn, bronchoalveolar lavage fluid (balf) was collected, lungs were removed. aortic flow was measured. statistics include kruskal-wallis and mann-whitney u. introduction. alveolar oedema is a hallmark of ards and ali. fluid clearance and the influence of anaesthetics on oedema resolution are poorly understood on a molecular level in the injured lung. oedema resolution is mediated by osmotic water reabsorption, following active sodium reabsorption via the apically located epithelial sodium channel (enac), driven by sodium-potassium-adenosin-triphosphatase (na ? /k ? -atpase). objectives. our aim was to investigate the influence of mac (= . vol%) sevoflurane on mrna and protein levels of enac and na ? /k ? -atpase in injured alveolar epithelial cells (aec). methods. primary culture of aec was stimulated with lipopolysaccharide (lps, lg/ ml) and exposed to normal air containing % co with or without sevoflurane. mrna levels were measured at h using the taq-man real-time pcr method. additionally, proteins for western blotting were analyzed at , and h (n = ). in the presence of sevoflurane mrna level of the a -subunit mrna of na ? /k ? -atpase in control cells was downregulated by % (p \ . ). a-subunit na ? /k ? -atpase protein expression, however, was not influenced by lps or sevoflurane at all time points. mrna of c-enac was decreased by % in the presence of sevoflurane and by % upon stimulation with lps. in the lps-sevoflurane group downregulation was even more pronounced with % (p \ . ) after h, but not statistically different from the lps group. on the protein level of c-enac protein expression a first change was observed at h with a downregulation of % upon lps exposure (p \ . ). sevoflurane did not have an effect of this transporter protein. previous studies have shown that halothane decreases na ? /k ? -atpaseand sodium channel activities in alveolar epithelial type ii cells [ ] . despite this finding for halothane, we could not see similar effects for the volatile anaesthetic sevoflurane. our results suggest that neither the driving force of alveolar oedema resolution, the sodium potassium atpase, nor c-enac, which is considered the rate limiting step in sodium coupled water reabsorption are influenced by sevoflurane and lps in an in vitro model of ards. to further characterize the impact of sevoflurane on water transport, functional analysis of these two transporters have to be performed. grant acknowledgement. objectives. we evaluated the effects of two nebulised sfa perfluorohexyloctane (f h ) and perfluorobutylpentane (f h ) at different dosages ( ml/kg vs. . ml/kg) on pulmonary mechanics and gas exchange in healthy lungs. design. after approval by the local animal care committee, prospective, randomized animal study. subjects. thirty-five new zealand white rabbits. interventions: tracheotomised and ventilated juvenile rabbits were nebulised intratracheally with either a high or a low dose of two different sfa (f h low/high and f h low/high ) or saline (nacl). ventilated healthy animals served as controls (sham). arterial blood gases, lung mechanics, heart rate and blood pressure were recorded prior to nebulisation and in min intervals during the -h-study period. results. immediately after starting aerosol therapy p a o /f i o -ratio and dynamic lung compliance decreased in all groups, with the exception of the f h low group which behaved like the sham group. although p a o /f i o -ratio showed a continuous improvement in the other groups over time respiratory mechanics still remained impaired. high dose groups with nebulisation of liquid perfluorohexyloctane (f h high ), perfluorobutylpentane (f h high ) or saline (nacl) showed no significant differences neither in oxygenation, blood pressure nor in pulmonary compliance and resistance. in contrast to f h high , there were no residues of f h high detectable in bronchoalveolar lavage. regarding f h low we were not able to detect any adverse effects on gas exchange or pulmonary mechanics. additionally, wet-dry-ratio of apical lung tissue samples revealed no significant edema. conclusions. high dose aerosolized sfa ( ml/kg), either f h or f h , equals effects of high dose inhalation of saline. when comparing the low-dose sfa-groups, there is a convincing discrepancy in favour of f h . f h low impairs pulmonary function, whereas a low dose application of f h (low) shows no interference. this may be due to the faster evaporation of f h . a new sfa-based pulmonary drug delivery system for lipophilic or water-insoluble substances could be developed on the basis of a low-dose application of f h . objects. hypertonic exposure reduces cell volume and thereby creates a relative excess of plasma membrane (pm). as a result the lipid bilayer of the pm can simply unfold with a minimal increase in lateral tension when an externally imposed shape change demands it. to test this hypothesis, we determined the effects of osmotic pressure on the susceptibility of deformation injury and pm wound repair. we measured deformation injury and repair responses of a . cell culture media were consisted of x hmem and mannitol (v/v / ) with osmolarity of (iso), (hyper) and mosm (hypo). cells conditioned with media were either stretched or deliberately injured with a scalpel. the fraction of wounded and healed cells was measured using a dual label method. . ( ) exposure to a hypertonic environment tends to lower the susceptibility of a to deformation injury ( . ± . % for iso, . ± . % for hyper), while exposure to a hypotonic environment uniformly increases it ( . ± . % for hypo) in stretch injury. introduction. the migration of polymorphonuclear leukocytes (pmns) into the lung plays a critical role in the development of acute lung injury (ali). adenosine receptor a (a ar) is one of four g protein-coupled adenosine receptors that has been demonstrated to modulate pmn trafficking in various models of inflammatory disorders including sepsis and asthma. however, the role of a ar in ali has not been investigated systematically yet. the objective of this study was to determine the role of the a ar in a murine model of lpsinduced lung injury and in an in vitro transmigration system with human cells. methods. the migration of pmns into the different compartments of the lung was determined by flow cytometry in adult male c bl/ mice (wildtype [wt] ) and homozygous a receptor knockout (a ko) mice. we used chimeric mice that were generated by transferring bone marrow between wild-type and a ko mice to differentiate the role of a on hemopoietic and nonhemopoietic cells. furthermore, microvascular permeability was assessed by the extravasation of evans blue and the release of chemotactic cytokines into the alveolar airspace was determined by elisa. paraffin-embedded sections of the lung were stained for pmns after lps inhalation to illustrate their accumulation in the lung. in a human in vitro assay, we quantified neutrophil transmigration across an epithelial monolayer (a cell line). in all murine in vivo experiments and in the in vitro transmigration assay, we assessed the effectivity of the specific a -agonist cl-ib-meca. all statistical analyses were performed by using anova. p \ . was considered statistically significant. results. inhalation of lps significantly increased the number of pmns in wt and a ko mice in all lung compartments. no differences in pmn counts were observed between wt, a ko, and chimeric mice. pretreatment with cl-ib-meca led to a significant decrease of pmns in all lung compartments of wt mice but not in a ko mice. pharmacological activation of a ar diminished the lps-induced microvascular permeability in wt mice but not in a ko mice. upon lps-inhalation, a ko mice exhibited significantly higher levels of the cytokines cxcl und cxcl / in the alveolar airspace than wt mice. in wt mice, pretreatment with cl-ib-meca reduced levels of tnfa and il- significantly. transmigratory activity of human pmns across an epithelial monolayer was reduced when a was activated in pmns. in contrast, pretreatment of the epithelial cells did not inhibit migration of pmns. introduction. lung overdistention during mechanical ventilation causes an increase in pulmonary vascular permeability, which is characterized by interstitial and alveolar edema secondary to a diffuse endothelial and epithelial injury. thrombopoietin (tpo), a humoral growth factor that stimulates the proliferation of megakaryocytes, has also been identified as a pro-inflammatory mediator in various clinical conditions. the receptor of tpo, c-mpl, is constitutively expressed on endothelial cells and may modulate the permeability of the endothelium. we investigated the contribution of tpo in the development of acute alveolar edema formation by mechanical stretch. in an ex-vivo model of mechanical ventilation (mv), lungs of c bl mice were ventilated for h with high stress pressure cycled ventilation (end inspiratory pressure = cm h o, peep = cm h o, i:e ratio = : ) and perfused with % bovine serum albumin rpmi medium at a rate of ml/min, in the presence or absence of tpo ( mg/ml). following ventilation, lung elastance was measured and protein concentration was analyzed in the bronchoalveolar lavage. data are mean ± se. mechanical ventilation (mv) to treat patients with ards or acute lung injury (ali) has the end objective to increase the dynamic functional residual capacity (dfrc), thus increasing overall functional residual capacity (frc). simple methods to estimate dfrc at the end of expiration for a given positive end expiratory pressure (peep) would provide a valuable metric to track and modulate therapy. however, such methods do not exist and current methods are time-consuming and relatively invasive. methods. this study utilizes a constant stress strain ratio for an individual patient's volume responsiveness to peep to estimate dfrc at any peep. the estimation model identifies two population parameters from clinical data to estimate a patient-specific dfrc, b and mb, where b captures physiological parameters of frc, lung and respiratory elastance and varies depending on the peep level used, and mb is the gradient of b versus peep. dfrc was estimated at different peep values ( , , , , ) cm h o, and compared to the measured dfrc for ali/ards patients to validate the model. patients and methods. in a years period patients ( males, females) with haematological malignancies were admitted in icu. malignancy type, reason for admission, haematological profile, requirement for invasive ventilation, bronchial and blood cultures and survival rate were recorded. results. patients suffered from: hodgkin's lymphoma ( ), non-hodgkin's lymphoma ( ), chronical lymphocytic leukaemia ( ), acute myelogenous leukaemia ( ) and multiple myeloma ( ) . admission to icu was precipitated by: emergency surgical procedure ( ), respiratory failure ( ), sepsis ( ), pulmonary oedema ( ) and coma ( ) . pulmonary infiltrates was the main finding in chest x-ray. bronchial secretions cultures were positives in patients while blood cultures were positives in patients. apache ii score ranged from to (average . ) and the icu days ranged from to (average . ). all the patients required invasive ventilation. all the patients with sepsis and serious neutropenia were died, while the total mortality was / ( . %). conclusion. the admission of patients suffering from haematological malignancies in icu is associated with high mortality. immunosupression that renders them susceptible to infections, thrombocytopenia, and invasive ventilation are factors that contribute to this. early recovery of bone marrow and non invasive ventilation could improve the outcome in these patients. in liver transplanted patients, immunosuppressive therapy can increase the risk of infections and post-operative arf. nimv has been proposed as an alternative technique to reduce complications related to endotracheal intubation. the aim of our study was to evaluate nimv in liver transplanted patients, developing arf in the post-operative period. materials and methods. in this study we evaluated liver transplanted patients, developing postoperative arf. measurements of respiratory and haemodynamic parameters were performed at baseline, after h and at the end of the treatment. we evaluated intubation rate, nimv tolerance, length of stay in the icu (los), icu and hospital mortality. results. ( %) out of patients were successfully treated with nimv, while ( %) failed and were intubated. we observed no significant differences among groups in gas exchange, but rr was significantly reduced in the success group during treatment (p \ . ). in both groups we found no significant differences in pao /fio initial improvement, but the success group showed a significantly higher rate of pao /fio sustained improvement (p \ . ). no significant differences between the two groups were found in terms of hours and days of nimv. success and failure groups were significantly different in saps ii (p \ . ) los (p \ . ), icu and hospital mortality ( vs. %, p \ . , vs. %, p \ . ). reasons for nimv failure were not related to respiratory causes, but acute systemic causes such as septic shock and mods. conclusions. nimv can represent a valid alternative to invasive mechanical ventilation for the treatment of postoperative arf in liver transplanted patients; in nimv success patients reduced los and mortality can be expected. the influence of body posture on expiratory flow-limitation (efl) was estimated in flowlimited, mechanically ventilated patients using the negative expiratory pressure (nep) method. a device especially designed and in build in an evita -draeger respirator allowed the application of a pressure equal to- cm h o, starting at ms after the onset of expiratory flow and sustained throughout the end of expiration. patients were considered flowlimited, if despite the application of nep part or the expiratory flow-volume curve was superimposed on the baseline curve. patients were studied in supine and in semi-seated position ( ) at baseline and then min after administration of bronchodilators ( mg of inhaled salbutamol) with a nebulizer connected to the inspiratory port of the ventilator. supine position was significantly related to the occurrence of efl (p = . ). efl was abolished in % of our patients when changing from supine to semi-seated position, while in general a significant improvement of efl was noticed (from to % of v t , p = . ). significant improvement of efl was achieved as well (p = . ) after bronchodilative therapy. peepi was the only variable significantly related to efl improvement when changing body posture from supine to semi-seated, while for bronchodilative therapy, none of the variables studied was significantly related to efl improvement. l. c. woodson , university of texas medical branch, anesthesiology, galveston, usa, shriners hospital for children, anesthesiology, galveston, usa aims. laryngeal injuries are common among burn patients and can result in long term functional deficits. we have included careful laryngeal examination with our initial fiberoptic bronchoscopic evaluation of burn patients. the goal has been to allow early identification of laryngeal injuries and to facilitate laryngology consultations. methods. digital video recordings were made of upper airway endoscopies performed during airway management on admission or at the time of anesthesia for initial wound excision. these recordings were used to identify laryngeal injuries and to facilitate laryngology consultations. a wide variety of laryngeal injuries were identified and the digital recordings (which can be communicated by email) greatly facilitated laryngology consultations. in many cases these recordings guided therapeutic interventions and were often sufficient to avoid a separate exam under anesthesia. diagnosis of thermal necrosis provided an indication for early tracheostomy. identification of the mechanism of mechanical airway obstruction (e.g. supraglottic edema, fibrinous exudates, granulomas, vocal fold dysmotility) resulting in failure of a trial of extubation frequently guided therapy. early identification of posterior glottic damage provided more timely corrective laryngological interventions. educational use of these videos helps increase awareness of risks of laryngeal injury in thermally injured patients. aims. the most used weaning predictor f/v t ratio, is not a consensual predictor. when it was reported on the first time, this ratio was considered highly sensitive and specific. but others papers seems to disagree with it, suggesting other cutoff values to determine weaning failure in specific populations, as the elders. advanced age is thought to be an import associated factor in the intensive care unit (icu), but its effect on the weaning process is unclear. no studies have found strong evidence that conventional weaning parameters are reliable for this population. the widest used weaning criteria, f/v t ratio, does not seems to keep the same performance in this kind of population. the main purposes of this study were to identify the possible differences of the f/v t ratio measured in a spontaneous breathing trial, between an adult and an elderly group. we designed a protocol to study the variation, sensibility and specificity of the frequency-to-tidal volume ratio between an adult group (ag; up to years) and an elderly group (eg; older than years) in a daily weaning screening trial. methods. the study cohort comprised patients ready to undergo weaning trial. the parameters studied were: weaning success ( h of spontaneous ventilation after extubation), respiratory rate (f), tidal volume (v t ), frequency/tidal volume ratio (f/v t ), gasometric and ventilatory parameters. the weaning method was spontaneous breathing trial (sbt). measurements were made in the beginning of sbt (t ) and min after (t ). we analyze possible differences in the sensibility and specificity of the f/v t ratio between elderly and adults and compare with previous values already published. the chi-square test, anova and the t test were used in the statistical analysis. weaning success was . % in eg and . % in ag (p = . ). the baseline characteristics were similar. comparisons of ag and eg at t and t showed statistical differences in weaning criteria: f, v t and f/v t ratio. conclusion. weaning success in our study was low, but similar to the described in other trials. elderly patients showed higher f and lower v t . consequently, f/v t ratio was lower too. the area under the roc curve for f/v t ratio was smaller than already published. results. / ( %) were successfully extubated and patients required re-intubation. the demographic data showed no differences in age, bmi, apache ii, icu admission diagnosis or sex distribution between groups (table ) . patients who failed extubation had small but statistically significant differences in vital capacity (vc), peak negative inspiratory pressures (pnip), pao /fio ratios (pf) and were ventilated longer prior to extubation. paradoxically, patients failing extubation had positive end expiratory pressures that were statistically but not clinically significant higher. the ratio of respiratory rate to tidal volume (f/vt) was not significantly different. patients failing extubation were also more likely to have weaker cough, gag, level of consciousness as measured by glasgow coma scale and more secretions ( table ). having no cuff leak did not predict failure of extubation. the most common reasons for reintubation were secretion retention and/or absence of cough ( %). pressure support ventilation (psv), a widely used assisted mode, has the purpose to avoid diaphragm disuse allowing the patient to generate spontaneous inspiratory efforts optimizing comfort and work of breathing. however, still little is known about the individual response of respiratory muscles under these conditions. we hypothesized that respiratory muscles of patients ventilated with clinic psv might result, at least sometimes, excessively unloaded. we performed an observational study in the intensive care unit on patients ventilated with psv set by the clinician in charge. twenty intubated, mechanically ventilated patients ( ± years old) during the weaning phase entered the study. the patients had no sedation at least for the last h. respiratory timing, tidal volume (v t ), peak airway pressure (paw peak ), electrical activity of diaphragm expressed as percentage of its maximum (edi/ edi max ), inspiratory (ptpes) and diaphragm (ptpdi) muscle effort were measured during min of clinic psv. results. we found that seven out of twenty patients generated a negative pes swing only during the psv inspiratory triggering phase (psv t ) in comparison with the remaining patients in whom pes was negative throughout most of the mechanical breath (psv n ). in the psv t group, pes swing was either flat or positive after inspiratory triggering. therefore, in the psv t group both ptpes /min and ptpdi /min were fivefold lower than normal values. v t / predicted body weight (pbw) was significantly higher in the psv t versus psv n group (see table ). during weaning with psv: ( ) a significant number of patients ( %) showed a pes shape similar to that observed during pressure assist/control modes, and inspiratory muscle effort abundantly lower than normal, both indicating excessive inspiratory muscle unloading; ( ) among the variables used to set psv, only a high v t /pbw (higher than ml/kg) hallmarked excessive unloading; ( ) due to the ample prevalence of the phenomenon, the question whether high levels of inspiratory muscle unloading can cause detraining and prolonged mechanical ventilation merits an answer from further research. introduction. the liberation from mechanical ventilation (mv) should be done as soon as possible in order to avoid complications and the risks associated with prolonged unnecessary mv, such as ventilator-associated pneumonia, ventilator induced lung injury, and increased icu and hospital stay. this procedure should be carried out properly and safely. objective. evaluate the extubation success rate, mv time and weaning time using a daily weaning screen followed by a spontaneous breathing trial (sbt). patients who were ventilated for more than h were subject to this procedure, which was carried out by respiratory therapists. methods. in our icu, between february and august of , all intubated patients who were ventilated for more than h underwent a daily weaning screen, which contained variables such as hemodynamic, gas exchange, consciousness and resolving the need for mv. if these variables were stable, these patients were submitted to a sbt and were extubated if they did not show any signs of respiratory discomfort or hemodynamic changes for at least min. conclusion. the use of a daily weaning screen followed by a sbt was associated with a high extubation success rate and a very short weaning duration with % of unsuccessfully extubations. c. chatt , d. pandit , g. raghuraman birmingham heartlands hospital, critical care, birmingham, uk, birmingham heartlands hospital, birmingham, uk aim. the aim of the study was to assess the impact of pmv on the course of weaning in mechanically ventilated patients. we wanted to assess the optimal pressure support at which pmv can be initiated which would enable prolonged use of pmv without affecting the duration of respiratory support. method. data on all patients who were mechanically ventilated for greater than eight days were obtained from icnarc database, who underwent tracheostomy as part of their weaning process. satisfactory level of pressure support was achieved (between and cm h o) pmv was introduced into the patient's breathing circuit and spontaneous ventilation was attempted. we applied mann whitney u tests for parametric data, fisher exact tests for non-parametric data and anova was used to compare the three groups with different pressure supports at initiation of pmv. a p value \ . be statistically significant. results. patients who were ventilated for greater than eight days identified. of these, patients were excluded because they did not have a tracheostomy during their period of ventilation. of the remaining patients, pmv was used in patients ( %). there were no significant differences between the demographic data (sex, age) or the data on admission to intensive care (apache ii score, ratio of medical to surgical patients) and duration of mechanical ventilation between the two groups. however, there were significant differences in the mortality, total respiratory support days after tracheostomy and length of stay in intensive care and length of hospital stay between the two groups. in the group on pmv, no record of aspirations was found documented on the intensive care charts. in patients in whom pmv was used (n = ), pmv was initiated at cpap (continuous positive airway pressure) in patients ( %). patients ( %) had pmv initiated at a pressure support of b cm h o and in patients ( %) pmv was initiated at a pressure support of [ cm h o. there was a significant difference in the duration of mechanical ventilation post tracheostomy (p = . ) and the length of hospital stay (p = . ) between the two groups, with the cpap group being ventilated for a shorter duration but with a longer stay in hospital the same difference was shown when comparing three groups of pressure support when pmv was commenced (cpap, pressure support b cm h o and pressure support [ cm h o). however, in the pressure support [ cm h o group we observed that the duration of use of pmv was lower than in the other two groups despite longer duration of mechanical ventilation and total respiratory support days. although this was not statistically significant, it could be clinically significant. our study suggests that use of pmv at pressure support b cm h o could increase the duration of its use without affecting the length of mechanical ventilation. we would therefore recommend weaning to a pressure support b cm h o before pmv is commenced in the acute setting. no data are available concerning the oxygenation target to aim during the weaning phase from mechanical ventilation. also, in opposition to ards patients there is no clear recommendation for the upper limit of spo to maintain during weaning. this study is part of a research project on peep and fio settings automation during mechanical ventilation. methods. this observational study was designed to assess the spo target aimed during the weaning phase of invasive mechanical ventilation (fio b . and peep b cm h o). patients were recruited in icus from several countries (canada, france, italy, tunisia, argentina). the following data were prospectively collected by the respiratory therapists at each round during a months period: spo , fio , peep level, ventilatory mode, anatomic site of the pulse oxymetry sensor, quality of the spo signal. results. data from centers ( icus) from quebec city, canada, and center from créteil, france are available. patients were prospectively included. , observations were performed. the mean level of fio was . ± . with fio c . and . in . % and . % of observation times respectively. the mean level of peep was . ± . cm h o and was below, equal or above cm h o in . , . and . % of the cases respectively. the most frequent ventilatory modes were pressure support ( %), simv ( %) and acv ( %). the pulse oxymetry sensor was applied on a finger of the hand in . % of the cases and was deemed of good quality in % of the time. the mean spo was . ± . % for the whole population and was . ± . % for patients with fio c . . spo was higher than % in % the observations. desaturation with spo below % were recorded in . %. the spo signal was deemed available by the bedside nurse in . ± . % of the time. conclusion. this study demonstrates that spo levels may be maintained at high levels unduly. this may have an impact on the weaning phase of mechanical ventilation. this study also shows that the spo signal availability was high enough to be used in a closed-loop oxygenation system. introduction. automated weaning systems are viewed as a challenge to weaning decision-making autonomy by some clinicians. clinician perceptions of the utility of such systems may influence uptake in to practice. to assess the perceived utility of the automated weaning system, smartcare/ ps. a survey was generated based on comprehensive literature review and -year's experience using smartcare/ps. survey pilot testing was conducted with senior clinicians experienced in smartcare/ps weaning in an independent icu. questions addressed perceived system usability and appropriateness of automated weaning, system benefits and disadvantages, as well as patient indications deemed suitable and unsuitable for smartcare/ps weaning. participants were also asked to indicate if they would continue using smartcare/ps on trial completion. the survey was administered to clinicians on completion of a randomized controlled trial conducted to compare smartcare/ps to non-protocolized weaning . of staff surveyed, surveys were returned by nurses and doctors (response rate %). eight respondents had no experience with smartcare/ps despite the year trial duration, leaving surveys with evaluable responses. the majority of respondents perceived smartcare/ps was easy to activate ( / , %) and to use once activated ( / , %). the system was observed to wean appropriately by / ( %) respondents; experienced smartcare/ps to wean inappropriately. comments on inappropriate weaning identified clinically unacceptably increases of pressure support (ps) for patients with profound tachypnea and complicated lung pathology. smartcare/ps' ability to reduce the overall duration of weaning was questioned by all but / ( %) respondents. ps adjustment according to patient requirements was the most frequently perceived benefit ( / , %). most respondents did not perceive any advantage of smartcare/ps for patient comfort / ( %), assessment frequency ( / , %) and automated control of weaning ( / , %). less control over weaning was the most regularly cited disadvantage of smartcare/ps ( / , %). system issues such as program abortion without identifiable reason and mandatory peep reduction prior to a spontaneous breathing trial to assess readiness for separation were less frequently cited disadvantages [ / ( %) and / ( %) respondents respectively]. most respondents ( / , %) felt smartcare/ps was best suited for weaning postoperative patients and should be avoided for patients with neurological dysfunction ( / , %). only / ( %) respondents stated they would not continue to use smartcare/ps. clinicians demonstrated moderate acceptance of smartcare/ps. more work is needed to identify those patients more likely to benefit and confirm the overall utility of smartcare/ps as a weaning tool. introduction. physician approaches to ventilation withdrawn varies among physicians whereas the prompt recognition of respiratory failure reversal and usefulness of weaning protocols in reducing duration of mechanical ventilation (mv) have been largely demostrated as nursing staff attend patients h a day its leadership in this process can be effective and safe. objective. to demonstrate that a nurse-directed protocol to withdraw mv could reduce a % its duration. prospective sequential study performed in two periods. during de first period ( months) data concerning weaning definite criteria appearance, duration of mv, reintubation or need for nonninvasive ventilation (nimv) and demographic data were collected to all mechanically ventilated patients blinded by attending nurses and physician. after a three months phase of staff training there was a second months period where weaning criteria were checked al each nurse working shift during the first days of mv. when criteria were fullfilled a min of spontaneous breathing trial was perfomed and tracheal tube removed if there were no intolerance criteria. same data as the first phase were collected. we used mann-whitney s u test to compare mv duration, time to reach weaning criteria (trwc) and extubation delay (mv duration minus trwc). weaning failure was compared using x square. data are presented as median ( - percentile). results. patients were screened ( in the first period and in the second) but only patient reached weaning criteria in the first days ( in the first period in the second), . % men, aged ( - ) years. aim of this study is present our experience about elective bedside pdt with the blue-rhino kit over an year period, in order evaluate its efficacy in terms of intraoperative and postoperative complications. patients and methods. the study included a total of consecutive icu patients requiring tracheostomy. all pdt were performed by icu staff physicians at patients' bedsides, using a blue rhino kit. the following data were recorded: age, sex, simplified acute physiology score (saps) ii, fraction of inspired oxygen (fio ) before the tracheostomy, days on mechanical ventilation before the tracheostomy, bleeding, tracheal tear, subcutaneous emphysema, pneumothorax, wound infection, hypotension, lowering sao during the procedure, inability to complete the procedure, and procedural mortality. distance follow-up included fiberoptic bronchoscopy to evaluate tracheal stenosis. results. there were a total of ( . %) complications (tracheo oesophagel fistula and bleeding). forty -one patients died in the icu ( %), although none of these deaths were related to technique complications. mean duration of the procedure was . ± . minutes. the pdt performed at bedside in the icu, using the blue rhino kit is a simple and safe procedure that offers many advantages in terms of safety and efficacy. objectives. questioning the need for several specialized physicians or extra assistance to perform a single percutaneous tracheostomy using fibrescopic tracheoscopy, we performed a prospective study into the complication rate of percutaneous tracheostomy without tracheoscopy on our mixed medical and surgical icu. , consecutive patients were included after having received a percutaneous tracheostomy. indication for tracheostomy was always a long anticipated duration of mechanical ventilation. if no contra indications were present, percutaneous tracheostomy was performed. if contra indications against the use of percutaneous tracheostomy without tracheoscopic control were present, tracheoscopy was performed to ensure maximum patient safety. the mean age at the time of receiving a tracheostomy was . ( - ) years. the cohort consists of male patients en female patients. only ttwo percutaneous tracheostomy were performed under fibrescopic control due to contra-indications for an uncontrolled procedure. in procedure, sixteen minor, and no major complications were encountered. this resulted in a . % minor complication rate. conclusions. the number of complications in our group is approximately the same as those which are suggested in international literature where tracheoscopy was performed during percutaneous tracheostomy. none of the complications encountered could have been prevented by the use of tracheoscopy. therefore we postulate that in the hands of an experienced team and in adherence to strict guidelines, percutaneous tracheostomy can safely and successfully be performed without tracheoscopy. objective. to assess the risks and complications associated with the bedside pdt in our years experience of over pdts in icu. pdt is a relatively newer technique and has been introduced as an alternative to open tracheostomy as a safer and convenient procedure. however, the risks and complications of the pdt have not been highlighted in the icu of a developing country. a retrospective analysis of the data gathered from patients undergoing pdt was done in a -bedded tertiary level multidisciplinary icu of a teaching hospital. the data was collected between april and march . all intubated patients with indications for elective tracheostomy, as well as patients who required emergency tracheostomy were included in the study. demographic and other clinical details of the patients who underwent pdt were collected. griggs [ ] technique was most commonly adopted while other adopted techniques were ciaglia [ ] , white tusk/blue rhino tapered dilator and percutwist technique. a total of , pdts were done in , patients, over a period of years. of the , patients ( %) were males and ( %) were females. the mean age of patients was . years. the average duration of intubation before pdt was . days. ( %) pdt were done bedside in icu while ( %) were done in wards, coronary care unit, high-dependancy unit and liver transplant unit. griggs technique was adopted in ( . %), ciaglia in ( . %), white tusk/blue rhino tapered dilator technique in ( . %) and percutwist technique in ( . %) patients. long-term ventilation was the most common indication in ( . %) followed by airway protection in ( . %), facilitation of weaning in ( . %) while airway obstruction/difficult intubation was observed in ( . %) patients. pre-procedure coagulopathy was observed in ( . %) patients, ( . %) were morbidly obese while ( . %) required emergency tracheostomy. no complications were observed in ( . %) patients. procedural complications were seen in ( . %) patients. bleeding from the site was the leading complication affecting ( . %) patients. difficult tube placement was seen in ( . %) patients, premature extubation in ( . %), false passage in ( . %), guidewire dislodgement in ( . %), subcutaneous emphysema in ( . %), arrhythmia in ( . %) and bleeding requiring transfusion was seen in ( . %) patients. no procedure related mortality was observed. conclusion. on the basis of this large single centric study we found that pdt is a safe, reliable and convenient procedure which can be easily performed bedside by experienced intensivists. results. of the recipients who underwent pdt, were liver, kidney and heart transplant recipients. the respective mean values for age, weight and apache ii score were . ± . years, . ± . kg, and ± . all pdts were performed at bedside by experienced staff anesthesiologists with direct bronchoscopic guidance. in all cases, the indication for pdt was prolonged mechanical ventilation due to acute respiratory failure. the mean time from transplant to pdt was ± months and the mean duration of endotracheal intubation before pdt was ± days. twelve patients had coagulopathies. the calculated lung compliance and pao :fio ratio improved after pdt ( . ± . vs. . ± . ml/cm h o, p = . and ± vs. ± , p = . respectively). transient hypoxemia (n = ) and mild extratracheal bleeding (n = ) were the only early complications. there were no procedural failures and no pdt-related late complications and deaths. conclusion. the results suggest that percutaneous dilational tracheotomy is an efficacious and safe technique for prolonged airway management with improved ventilatory mechanics in solid organ transplant recipients. a. vianna , g. cabral , r. azambuja , g. carleti , t. balbi , g. pereira clinica são vicente, rio de janeiro, brazil aims. we studied diferent aspects of tracheostomy procedures performed in intensive care units (icus) located in the municipality of rio de janeiro and compared them with the medical literature. a questionnaire was elaborated and sent through email to the coordinators of every icu in the city of rio de janeiro in the period of july to august . the questionnaire was sent to the coordinators of the icus located in rio, and was answered by ( . %) of them. among the studied icus, ( . %) are public, ( . %) are private, and ( . %) are part of university hospitals. ( . %) are medical/ surgical, ( . %) are medical, and ( . %) is a surgical unit. the average number of beds is ± . . the decision to perform the procedure is taken by the icu team in ( . %), by the patient's primary team in ( . %), and by both in ( . %). tracheostomy is performed by a surgeon in ( . %) units, by an intensivist in ( . %), and by both in ( . %). the procedure is performed at the bedside in ( . %) of the icus. the most frequent indications for tracheostomy are: prospect of prolonged mechanical ventilation, coma, and airway protection. . % of are performed between the first and second week of mechanical ventilation, and % between the second and third week. control chest x-ray is performed in . % of the units. surgical tracheostomy is available in all the studied units. only ( . %) units perform percutaneous tracheostomy. the reasons given for the preference for surgical tracheostomy were the lack of a qualified team for performing the percutaneous tracheostomy or material needed for this procedure. all icus that perform the percutaneous procedure use the ciaglia technique with bronchoscopic guidance. late followup is performed in ( . %) of the studied units. the study showed great differences between the tracheostomy protocols used in the hospitals of rio de janeiro and those found in the medical literature. in particular, the use of percutaneous tracheostomy is still infrequent in the icus of rio. on all the patients, aged at least years or more, admitted to our postoperative icu since january through december , we collected demographic profiles, operative data and short and long-term outcomes. spss . was used for statistical analysis and p \ . was considered the level of significance. a total of patients ( . %), . % males and with a median (iqr) age of ( - ) were admitted to our post-operative icu over the study period. iddm was recorded in the . % of the population, copd in the . %, hypertension in the . %, chronic renal failure in the . % and arteriopathy in the . %. out the total population, . % of patients, with a median (iqr) pre-operative crs of ( - ) underwent a coronary-artery bypass grafting (cabg) surgery, whereas . % of them, with a preoperative median (iqr) nyha of ( . - ) needed a valve replacement (vr) and . % of them combined (cabg ? vr) operations; moreover, . % of patients underwent other type of cardiac and aortic surgery. overall median (iqr) post-operative mechanical ventilation length was ( . - ) hrs. while no statistically significant difference was recorded in terms of mv duration among the four surgical groups. overall recorded mortality rate was %, with the lower . % for cabg and the higher . % for vr (p = . ). kaplan meier curves showed no differences in survival likelihood at th (log rank = . , p = . ) th (log rank = . , p = . ) and th (log rank = . , p = . ) days after surgery among the different surgical groups. conclusions. the outcome after heart surgery in octogenarians is excellent; the operative risk is acceptable and the late survival rate is good. therefore, cardiac surgery should not be withheld on the basis of age alone. introduction. re-do cardiac operations have been reported to be increasing in incidence and are associated with a higher operative risk [ ] . this study aimed to determine the impact on intensive care provision. methods. data from , procedures spanning twelve years (april -march ) was examined. the re-do operations were further analysed by gender, age, pathology (new, progressive, combined) , duration between procedure, theatre time, length of stay, complications and mortality. as the number of cardiac operations performed has increased over the twelve year period, the relative incidence of re-do procedures have remained stable at . %. operative length at re-do was significantly longer (mean min vs. ) however anaesthetic time pre surgical incision was not significantly increased. subsequent length of stay on the intensive care or high dependency unit increased by % (mean . vs. . days), with higher complication rates affecting all systems (except post operative myocardial infarction). renal and pulmonary complications showed the most significant increases. renal related complications occurred in % and pulmonary in . % of cases which represents an and % increase on first operation rates. infection rates were also significantly increased at double that of the initial procedure. the total hospital stay was found to be % longer (by . vs. . days, respectively) while in hospital mortality increased from . % at initial procedure to . % at re-do. mortality rates were further elevated in the presence of renal failure post operatively, as re-do valve mortality increased from . to % and re-do cabg from . to % in this subgroup. conclusion. these results, combined with the stability of percentage re-do surgery over the twelve year period, enable specific planning and management of intensive care provisions. the knowledge of extended theatre times and subsequent stay in intensive care/high dependency units has a further impact on the throughput of routine cases. the data also highlights the increased costs associated with these patients, as they not only require longer hospital stays but also suffer increased complications requiring more investigations and interventions. specific costing therefore applies to this subgroup of intensive care patients. objectives. we aimed to assess hrqol at days after surgery in relation to preoperative hrqol. we compared patients with decreased hrqol to patients with unchanged or increased hrqol to identify disparities between these two groups. a prospective cohort study including patient scheduled for cardiac, vascular, abdominal and orthopedic surgeries in a tertiary hospital was performed. patients filled-out a hrqol questionnaire (sf- ) the day before surgery and days after. preoperative, intraoperative, postoperative data were collected. changes of pre-and postoperative physical component summary ( simultaneus kidney-pancreas transplantation is the best treatment option for type diabetic patients with chronic kidney disease. currently, the medical and surgical complications have decreased significantly, although these represent a high risk of morbidity and mortality in the short term. objectives. this study sought to investigate the incidence of medical and surgical complications, the clinical characteristics and prognostic factors influencing graft and patient's survival in a recent cohort of pancreas-kidney recipients. patients and methods. the present study included patients who received simultaneous pancreas-kidney transplantation in our center from january to february . we studied demographic, clinical and immunological characteristics of patients, and surgical and medical complications during his admission to intensive care unit. results. the average age of recipients was . years and mean age of donors was . years. the median cold ischemia time was . h ( % confidence interval - ). the average stays on the waiting list was . days. % of patients were extubated within the first h. % of patients required transfusion during their icu admission, amine infusion was started at % patients in the early hours. during follow-up, surgical reintervention in the immediate postoperative occurred in % of the patients. major surgery complications reported in the literature are graft thrombosis, although in our serie there have been only kidney graft thrombosis and pancreas graft thrombosis. only % of patients died within the first months posttransplantation surgery. conclusion. surgical complications after pancreatic transplantation remain a significant concern. hence we our results add further evidence to support the notion that the double and simultaneous pancreas-kidney transplant is in fact the treatment of choice in selected patients with end-stage renal failure due to type diabetes mellitus. a. shono , t. mihara , y. murakami , j. ota , f. kono , y. saito shimane universiy hospital, anesthesiology, izumo, japan pulmonary catheter is widely used for cardiac surgery. the complications of indwelling pulmonary catheter, such as perforation of pulmonary artery, pulmonary embolism, are well known. however, the thrombosis associated with introducer sheaths has received much less attention. we evaluated the incidence and risk factors for internal jugular vein thrombosis (ijvt) associated with introducer sheaths for pulmonary catheter after cardiac surgery. methods. the patients who underwent cardiac surgery and insertion of introducer sheaths ( . f) at right internal jugular vein (ijv) were included. ultrasonographic evaluations of ijvt were performed prior to insertion and daily until introducer sheaths removal. we investigated demographic data, underlying disease, length of surgery, use of cpb and iabp, complications during cannulation and duration of catheterization. coagulation status (pt, aptt, platelet count, d-dimer) and cardiac index at before and after surgery were also recorded. the student's t test, v test, and fisher's exact test were used for statistics and p value of . was considered significant. results. patients were included in this study. mean age of patients was ± years (range - ), mean duration of catheterization was ± days. ( . %) patients developed ijvt which occurred only one day after insertion. the incidence of ijvt was related to presence of underlying disease (relative risk, . ; % confidence interval, . to . ) and was unrelated to emergency operation, the use of iabp and cpb, number of insertion attempts. there were significant differences between patients with or without ijvt in duration of catheterization ( . ± . vs. . ± . days, p = . ), cardiac index at day after surgery ( . ± . l/(min m ) vs. . ± . l/(min m ), p = . ), the value of d-dimer at day after surgery ( . ± . vs. . ± . lg/ml, p = . ). no clinical symptoms related to ijvt were found in observation period. our results demonstrated that ijvt associated with introducer sheaths was a frequent complication and cardiac index was significantly lower in patients with ijvt. though the incidence of ijvt was higher in patients with prolonged catheterization, it developed even on day after surgery and was usually asymptomatic. this risk should be carefully considered when the insertion of pulmonary catheter is chosen for cardiac surgery. methodology. it is a prospective study of patients admitted to our icu after undergoing robotic radical prostatectomy (da vinci) in the time interval going from january up to april . we analyzed clinical and demographic data, the length of stay in the icu and hospital, the need for blood transfusion, surgical times and the complications suffered during hospital stay. data are expressed as mean, median or percentage, using the student's t test and chi-square to compare averages and detect possible associations between variables. results. seventy three patients underwent surgery with a median of years. mean surgical time was min. in recent months this time is reduced to min. the mean haemoglobin at admission ( . g/dl) was significantly higher than when dismissed ( . g/ dl), p \ . . an average of two units of concentrated red blood cells was transfused in the surgery room in . % of patients. only one patient required transfusion at the icu. cardiac or renal mild complications appeared in . % of patients. this could not be associated with age. the median of mechanical ventilation length was h. one patient required conversion to open surgery due to profuse bleeding. there was no hospital mortality and no need for reoperation. mean stay at icu was day, significantly less than those patients who suffered complications (p \ . ). the median stay in ward was days. conclusion. robotic radical prostatectomy (da vinci) has a very low associated morbidity, minimal blood transfusion requirement and short is the stay at the icu and hospital, in contrast to published data with open surgery. there was no hospital mortality. objectives. to evaluate short-and long-term outcome in patients undergoing coronary artery bypass grafting (cabg), who received an intra-aortic balloon pump (iabp) prior to surgery. methods. between january and june , all patients (n = ) who received an iabp prior to on-pump cabg in our center were included. patients received the intra-aortic balloonpump for vital indications (i.e. either unstable angina refractory to medical therapy or cardiogenic shock; group ; n = ) or for prophylactic reasons (group ; n = ). a cox proportional hazards model was used to identify predictors of long-term all-cause mortality. compared with the euroscore predictive model, observed -day mortality in group ( . %) was not significantly higher than predicted ( . %). a dramatic decrease in -day mortality occurred in group (median predicted mortality was . % and observed was %, p \ . ; fig. introduction. physiological abnormality is associated with adverse outcome and a high percentage of patients admitted to icu have abnormal physiology in the hours prior to admission [ ] . track and trigger systems are used to enable timely intervention to a deteriorating patient. the mews system is used in our level care general wards with more intensive monitoring in our level care facilities. objectives. we hypothesised that the mews for patients admitted from the general wards were being inadequately documented and that this be may influencing outcome. we therefore also hypothesised that patients admitted from the level care general surgical and medical wards in our hospital had a poorer outcome following icu admission than those admitted from sites of level care, such as the high dependency unit (hdu), emergency department and theatre recovery. we undertook a prospective week audit of all patients admitted to our district general icu. all patients' case notes and monitoring charts were reviewed by an icu consultant with additional data (e.g. apache ii scores) obtained from the ward watcher icu database. day mortality data was obtained from the hospital's sci patient database. we then compared the data with that available for patients admitted over the previous year ( ) background and aim of study. aorto-femoral bypass (afb) is widely used for the patients with peripheral vascular disease (pvd). nevertheless, there is no consensus about the type of anesthesia for this difficult group of patients. we hypothesized that continuous spinal anesthesia (csa) will be more secure and suitable for the patients with pvd combined with pulmonary and cardio-vascular co-morbidities. the aim of our study was to compare alterations of the mean arterial pressure (map) and delivery of oxygen (do ) during afb and in the early postoperative period under the influence of ga and csa. after approval of our hospital helsinki committee prospective randomized study was performed between and : male patients with pvd were included in our work. risk of anesthesia was equal to the third degree according to asa scale. in the first group of patients (n = ) ga with mechanical ventilation was employed. in the second group of patients (n = ) csa was used. both groups of patients were similar with respect to age and co-morbidities (copd % in both groups, ischemic heart disease and arterial hypertension). for ga we used propofol, midazolam, fentanyl, and isoflurane. bupivacaine was used for csa. in combination with mental sedation by intravenous midazolam. map was measured directly through radial artery catheter and do with the help of tetrapolar rheovasography. both parameters were measured during fixed points: before the operation, at the end of induction of anesthesia, after cross clamping of the aorta, after release of aortic clamp, first hour after operation, h after operation and h after operation. mann-whitney test was used for statistical analysis of our results. in the patients with csa during the operation and in the early postoperative period, map was lower but statistically non significant. map was lower statistically significant only during the cross clamping of the aorta and in the first postoperative hour, most probably due to the influence of the sympathetic block. at the same time do had almost no difference in both groups. only in induction stage it was lower in the ga group that most probably was connected with negative influence of propofol on cardiac output. conclusions. both methods of anesthesia ga and csa gave us opportunity to preserve stable map and do during afb that we performed in this difficult pvd patients with copd and cardiovascular co morbidities. over the last few decades, several scoring system have been developed for use in critically ill patients, not only to assist therapeutic decision making but also to guide resource allocation and quality of care. to evaluate the tiss- in surgical intensive care unit (icu) patients and the possible relationship between tiss- and the type of surgery, severity of illness, and outcome in these patients. prospectively collected data from all patients admitted to a postoperative icu between st march and th june were analyzed retrospectively. a-priori subgroups were defined according to gender, age, saps ii score, sofa score, surgical procedures, and the occurrence of major morbidity or death in the icu or in-hospital. a total of , patients were admitted during the study period ( . % male, mean age . years) constituting , observation days. the highest tiss- scores were observed on the day of admission. the highest tiss- was observed in patients who underwent cardiothoracic surgery, the lowest in neurosurgical patients. during the first week in the icu, tiss- was correlated to the severity of sepsis syndrome; however tiss- scores remained elevated only in patients with severe sepsis/septic shock. tiss- score was correlated to saps ii (r = . , p \ . ) and sofa score (r = . , p \ . ) throughout the icu stay and was consistently higher in non-survivors than survivors during the first weeks in the icu. conclusions. the highest tiss- scores are observed on the day of admission to the icu with marked variations according to the type of surgery. tiss- correlates well with the severity of sepsis syndrome and outcome in these patients. our data could be helpful in icu planning, risk stratification, and resource allocation in the surgical icu setting. introduction. pain and opioids for treatment of pain can affect immune function in cancer patients, which may in turn influence metastatic capability of a primary tumour during and after surgical excision. it is also been shown morphine has a direct effect on cancer cells, but results of these studies have been conflicting. we therefore aimed to determine effect of morphine, commonly used in anaestehsia and intensive care, on in vitro breast cancer cell migration using two breast cancer cell lines. we used two cell lines: mcf is er positive breast cancer cell line while mda-mb- is er negative, less differentiated and more invasive. cells were incubated with or without morphine (concentrations - ng/ml) for , and h, corresponding to clinically relevant concentrations and exposure times. cell proliferation was determined using an mts (promega inc.). h cell migration was determined using a -well flourescent kit (chemicon). results were compared using independent sample t test for differences between the groups. morphine had positive effect on cell proliferation, which was greater in mda-mb- cells. proliferation of mda-mb- was increased the most at h incubation and higher concentrations ( and ng/ml caused and % increase in proliferation at h incubation and up to % increase at h incubation). proliferation of mcf cells was increased by % in and h incubation periods. morphine caused an increase in migration of both cell lines, which was again more evident with mda-mb- cells at higher concentrations of morphine ( , % and % increase with , and ng/ml respectively). our experiments have shown morphine has potential to directly stimulate breast cancer cell proliferation and migration in vitro, especially in less differentiated breast cancer cell line. further studies are needed to determine its effect on other metastatic mechanisms such as invasion and gene expression as well as the implication of these results for clinical practice. objectives. aim of this study was to evaluate the predictive value of nt-probnp levels and inflammatory markers (crp, il- , tnf) on late mortality in patients who underwent thoracic surgery for lung cancer. methods. patients median age ( ± years) without history of heart disease or renal failure. the blood tests for nt-probnp, crp, il- and tnf analyses were drawn one day preoperatively, h, h and days postoperatively. patients' demographic data, laboratory results and mortality were collected and assessed. results. nt-probnp at h was significant higher in non-survivors ( , ± , pg/ ml) compared to survivors ( ± pg/ml, p = , ). furthermore, nt-probnp at h was associated with survival in the cox-regression analysis (p = . , hr = , , % ci: , - , , units: pg/ml). crp preoperatively was significant higher in non-survivors ( ± mg/dl) versus survivors ( ± mg/dl, p = , ). il- preoperatively was significant higher in non-survivors ( ± pg/dl) compared to survivors ( ± pg/dl, p = . ). conclusions. high nt-probnp levels at h postoperatively, associated with increased mortality in patients undergoing thoracic surgery but there was no relation ship between crp, il- and mortality. introduction. the occurrence of post-operative delirium in elderly orthopaedic patients is associated with neurological complications and cognitive decline [ ] . although the etiology of the decline is less understood, cerebral ischemic events may be involved [ ] . high plasma concentration of n-methyl-d-aspartate (nmda) receptor antibodies (nr ab) has been proven highly predictable for occurrence of the postoperative neurological events in cardiac surgery [ ] . objectives. the aim of the present study was to investigate the predictive value of blood levels of nr ab for postoperative delirium, cognitive dysfunction or any other neurological complications after hip and knee replacement surgery. methods. the study enrolled consecutive patients, aged over , requiring acute or elective knee or hip replacement surgery. cognitive impairment was evaluated by minimental state evaluation (mmse) test administered before and after surgery. daily postoperative delirium was evaluated by confusion assessment method for intensive care unit (cam-icu). plasma levels of nr ab were recorded before surgery, at the moment of hospital discharge ( - days postoperative) and weeks after discharge. all other possible risk factors for postoperative delirium were also recorded. cognitive decline was present in patients ( %) before surgery and in patients ( %) at the moment of hospital discharge (p \ . ). plasma levels of nr ab were . ± . ng/ml preoperatively, . ± . ng/ml at the moment of hospital discharge and . ± . ng/ml weeks postoperatively, with no significant differences. conclusions. the incidence of cognitive decline in elderly patients after othopaedic surgery was significantly higher when compared with the preoperative status but there was no correlation between the cognitive decline and the plasma levels of nr ab. methods. patients older than years, whose performed endoscopic, colonoscopic or both procedures, under sedation performed by the intensive care deparment of the hospital del tajo. data were collected for months. demographic characteristics, medical history, asa (american society of anesthesiologists classification), drugs bolus and total dosages, respiratory and hemodynamic data, the length of procedure and recovery, and complications were collected. tolerance was assessed by endoscopist, with a (very bad) to (very good) scale. quantitative data are expressed with mean and standar desviation, and qualitative data with percentage. results. procedures were included. table shows main characteristics. tolerance and complications are referred in table . the . % of the procedures were appropriate ( or ) . the main complications were vomiting ( . %) and hallucinations ( . %). there were only incidences of respiratory depression and of hypotension. background. the authors hypothesized that the efficacy and quality of a remifentanil (r)-based regimen versus a piritramide (p)-based analgosedation in major post-surgical patients with renal and hepatic impairments still more potent even if prevention of narcotic induced hyperalgesia (nih) [ ] was done. the nih was made by sulphate magnesium (m), ketamine(k) or clonidine(c). methods. patients were randomly allocated to receive a blinded infusion of either r at a rate of . l/(kg min) (± . ) (g : n = ) or p at . mg/(kg h) (± . ) (g : n = ) coupled to an hypnotic sedation of propofol. r and p were titrated in icu after surgery, to achieve an optimal sedation as defined by a sedation conclusions. the remifentanil-based regimen allowed a more rapid emergence from sedation and facilitated earlier extubation diminishing total icu hospitalisation time and cost. even if we prevent the narcotic induced hyperalgesia by used of magnesium, ketamine or clonidine, needs of tramadol in rescue still lower in the remifentanil group due to its high power coupled with its high fexibility compared to piritramide. its reducing, by the way, risks of tramadol's metabolites accumulation in case of renal or leaver impairment. a ''fast track'' approach to cardiac surgery has significantly shortened the length of icu stay. however, quick awakening from anesthesia and subsequent extubation after discontinuation of sedative drug sometimes cause instability of hemodynamics, such as increase of bp or hr. dexmedetomidine (dex), a agonist, is a sedative drug that can be continuously infused during weaning and extubation. the aim of this double-blind study was to evaluate the effect of dex on time to extubation and hemodynamics during weaning from mechanical ventilation after cardiac surgery. with irb approval and informed consent, the patients undergoing cardiac surgery were randomly divided into two groups, dex group [infusion of . lg/(kg h) of dex] and saline group. drug administration was started at sternal closure and continued h. ramsay sedation score, times to extubation, systolic blood pressure, heart rate, respiratory rate, pulmonary artery pressure, central venous pressure, cardiac index were examined. we analyzed these parameters on icu admission, when the patients opened their eyes on order, at immediately before extubation, min, h, and h after extubation. unpaired t test was used for statistics and p value less than . was considered significant. results. patients were included in this study (n = in the dex group, n = in the saline group). there were no significant differences between two groups in age, length of surgery, length of anesthesia, and total dose of propofol and fentanyl. time to extubation was ± min in the dex group and ± min in the saline group (mean ± sd), which were also no significant differences. ramsay sedation score were maintained and no patients needed additional sedative drug during assisted ventilation in the dex group. althought mean systolic bp and mean pa, mean cvp, rr were similar in both groups during infusion. hr at eye opening, immediately before and after extubation were significantly lower in the dex group than in the saline group. conclusion. our results demonstrated that the infusion of . lg/(kg h) of dex decreased hr during weaning from mechanical ventilation. dex could not only provide adequate sedation but also suppress the stress response after cardiac surgery. dex is a useful sedative drug for preventing instability of hemodynamics on fast track approach. however, most anxiolytics impair intellectual function. dexmedetomidine (dex) is an alpha agonist that may offer sedation without overt cognitive decline. we performed a comparison between dex and propofol (pro), a drug often used for icu sedation. methods. prospective, randomized, double-blinded, cross-over study of awake and intubated brain-injured (bi, n = ) and non-bi ( ) icu patients, each receiving pro and dex using a cross-over design with periods of baseline (analgesic use fentanyl only), drug a, interval washout (fentanyl only), drug b. sedation was titrated to a score of or - (calm, cooperative) on the rass and hopkins nics scale. cognitive testing was performed at each study period using the validated -pt hopkins ace cognitive battery. objectives. we evaluated the effect on final outcome of a treatment regimen with lowdose haloperidol initiated when a positive cam-icu occurred as a quality improvement project. methods. the cam-icu was previously implemented in daily care in all patients who stayed[ h in our bed medical-surgical icu. in the first months of the study (period ), the cam-icu was used as an adjunct to daily care and the treatment of delirium was left to the physician on an intention to treat basis. subsequently, a month study pause was defined. thereafter, in the second months of the study (period ), the cam-icu was judged to indicate the presence of delirium and haloperidol was directly started with a loading dose of mg iv with subsequent daily dosing of . - . - mg iv (age \ ) or - oversedation is still common in many intensive care units (icu) despite the demonstrated benefits associated with sedation sparing strategies, including shorter duration of mechanical ventilation, and shorter length of stay in the icu and hospital. our aim was to observe whether a minimal sedation policy could be feasible in a multidisciplinary department of intensive care. prospective observational study over a two month period (december , to january , ) in a -bed medico-surgical department of intensive care of a university tertiary hospital. all adult patients who stayed in the icu for more than h were included. data were collected on duration, type, dose, and indication for sedative and opiate analgesic agents. self extubation was used as a safety surrogate. disease severity was assessed by the apache ii score within the first h of admission. statistical analysis was performed with spss software (spss incorporation, chicago, il, usa). a total of patients (male %) with a median age of years were included; ( . %) received some sedation, the majority [ ( . %)] during mechanical ventilation. midazolam ( %) and propofol ( %) were the most frequently used sedative agents. the most common indications for sedation were: early postoperative ( %), severe respiratory failure ( . %), short term procedures ( . %), and withdrawal syndrome ( . %). the median percentage of time during which patients received mechanical ventilation without sedation was . %, and was not related to severity as assessed by the apache ii score (rho . -p = . ). in the group of patients who required sedation for longer than just short procedures or uncomplicated postoperative care ([ h), the median percentage of time during which patients received mechanical ventilation without sedation was . %. analgesic opiates were often required ( %), predominantly by continuous infusion ( %). morphine was the most frequently used agent ( %). self-extubation occurred in patients, but only needed re-intubation. conclusion. in a mixed medical-surgical population of critically ill patients, a strategy of minimal or no sedation (''sedationless'') is feasible and without major adverse effects. we propose that comfort, hemodynamic instability, and mechanical ventilation should be abandoned as usual indications for sedation. grant acknowledgement. drs received grants from the doctoral fellowship program of capes/ brazilian ministry of education and from the federal university of rio de janeiro. r. russai the royal free hospital, anesthetics, northwood, uk postoperative cognitive dysfunction (pocd) is reported to occur frequently after cardiac surgery, even in low-risk patients. predictors of neurocognitive deficits can suggest the potential etiology and outcome of patient that has developed pocd. there is a wide range of neurological manifestations from subtle cognitive impairment to deadly stroke. over a period of weeks a population of patients underwent cardiac surgery in our hospital. we have looked for any signs of pocd in correlation with the possible etiology. data have been collected prospectively focusing on past medical history (pmh), possible contributors, manifestation, complications and treatment. pocd has occurred in patients ( male, female) with age range of to years (median age years), of whom % has had pmh of neurological impairment (predementia; cerebrovascular disease). multifactorial etiology was found: respiratory failure %, morphine %, tramadol %, renal failure %, remifentanyl %. in patients no related causes were recognised. all patients showed confusion as leading manifestation, although in patients confusion presented in combination with aggressive behaviour ( ), cognitive dysfunction ( ), paranoia ( ). in occasions pocd resulted in major complications such as difficulties in airway management ( ), removal of cvp line ( ), removal of arterial line ( ). the majority of patients ( ) required pharmacological treatment with single or multiple drugs therapy, the most common used was haloperidol ( % pts). the average length of stay in itu was . days, and the average length of hospital stay was . ( - ) days. conclusion. pocd is a common and potentially devastating complication with a complex and broad etiology, which may affect the rehabilitation process and the final outcome. early diagnose is essential for personalise treatments and therefore preserve in both life quality and life expectancy. introduction. sedation and analgesia is given to the icu patient for adaptation to the intensive care environment. however, side-effects of drugs used are increasingly acknowledged as negative factors increasing the risk of delirium, vasopressor therapy, prolonged ventilation and length of stay. objectives. the purpose of the proposed study was to study the practice of sedation in norwegian icu's and the challenges experienced by nurses and physicians. a national postal survey for clinicians in all norwegian icu's was conducted in september and october . all intensive care units treating mechanically ventilated patients for more than h (n = ) were included. two respondents from each unit ( intensive care nurse and icu physician) were invited to answer the questionnaire. the survey was based on two previous danish surveys. questions on practice and perceived problems were scored on a numeric rating scale and a lickert scale, as well as a few questions with response categories based on theme. results. the response rate was % (n = ). all icus were represented with nurses with formal education in intensive care and physicians specialized in anesthesiology as respondents. written protocols are not routine in norwegian icus, but half of the departments titrated sedation according to a scoring system, most commonly maas. the most commonly used sedatives were propofol and midzolam, while fentanyl and morphine were the most used analgesics. the main indication for sedation was to achieve tolerance to ventilation and to treat other bothersome symptoms. side-effects were reported to be frequent with both sedatives and analgesics. the most frequent side effects (% reported as often present or always present) with sedative agents were circulatory instability ( %), delayed awakening ( %) and sleep disturbances ( %), while the most frequent side effects experienced with analgesics were gastrointestinal problems ( %), circulatory instability ( %) and delayed awakening ( %). the main indication for tracheostomy was reported as longterm ventilation and the wish to reduce sedation. discussion/conclusion. written protocols were not routinely used. side-effects of sedation are perceived as a problem by the majority of clinicians, leading to circulatory instability and delayed awakening. tracheostomy is used first of all to be able to reduce longterm ventilation and sedation. these results indicate a potential for new sedative agents and analgesics with fewer side-effects and more focus on the use of sedation protocols. [ ] and has been associated with gaba agonist use [ ] . delirious patients may not be overtly agitated, so signs of delirium must be actively sought. the confusion assessment method for the intensive care unit (cam-icu) is a validated and easy to use screening tool [ ] . in a recent study on this bed medical and surgical intensive care unit (icu), more patients who had received gaba agonists were delirious compared with those who were sedative free [ ] . however, the percentage of patients having at least one episode of delirium was lower than expected ( %), perhaps because they were screened only once daily and in the daytime. we repeated this study with twice daily assessments (morning and after dark) and a larger number of patients in order to obtain a more accurate prevalence of delirium and confirm an association with gaba agonist use. methods. two doctors attached to the icu received a min tutorial on using the richmond agitation and sedation score (rass) and the cam-icu assessment tools. the cam-icu was performed on all rousable patients (rass score [ - ) twice daily (morning and after dark). the following information was also noted: ( conclusion. this study shows that the prevalence of delirium on this unit is comparable with published research [ , ] and higher ( . vs. %) [ ] when patients were screened after dark as well as in the daytime. the study shows that any sedating drug was associated with significantly increased prevalence of delirium. the unexpected higher prevalence of delirium in the patients receiving non-gaba agonists versus gaba agonists cannot be explained by haloperidol use to treat delirium. results. there were patients in the icus. the mean age was . years old with a predominance of chinese ( . %) and a slight male predominance of . %. forty-six per cent of the patients were mechanically ventilated and . % had tracheostomy done. there were an average number of devices per patient. sedation was administered in . % of the patients with no sedation scales used in a quarter of these patients. only . % of the sedated patients were on sedation protocol. the majority of patients ( . %) were monitored hourly and on propofol ( %) and midazolam ( . %). up to . % of sedated patients did not have daily interruption of sedation. there were no significant difference noted in the use of sedation between medical and surgical icus. slightly more than a third of patients were given analgesia (n = ) with no analgesia scales used in a third of these patients. one third of them were administered with paracetamol and about a third with morphine. patients in surgical icus were more likely to receive analgesia compared to medical icus patients. most of these patients ( . %) were monitored hourly. only patients were on neuromuscular blockade. there was no usage of any formal delirium assessment tools at all with . % of the patients being assessed for delirium based on clinical judgement of the caring team. only % of the patients had some form of sleep promotion in the icu. conclusions. this national multi-center study reveals several deficits in the adult icu with regards to sedation, analgesia and delirium assessment and management. several initiatives should be implemented to improve patients' safety and quality of care in the icu. methods. this study was conducted in patients who visited emergency care center following caustic ingestion during a period ranging from january of and august of , in whom a retrospective analysis of medical records was performed. findings for the esophageal lesion were classified according to the change of the esophageal wall and the infiltration of periesophageal soft tissue. also, clinical, laboratory, and endoscopic data from this patients were reviewed. the correlation between the degree of esophageal damage seen on ct scans and esophageal constriction seen on esophagography were then evaluated. a total of cases of caustic ingestion were identified (age range, - years). the most common caustic agent ingested was acid ( %). the most frequent cause for ingestion was attempt of suicide ( %) as opposed to accidental ( %). the findings of thoracic ct in patients were follows: first-degree esophageal injury in ( . %), seconddegree in ( . %), third-degree in ( . %), fourth-degree in ( . %). fourteen patients ( . %) developed caustic esophageal stricture. the degree of esophageal damage got closer to grade iv, the more prevalent esophageal constriction became. this correlation was statistically significant (p \ . ). of the total patients, underwent endoscopy in the early stage after they visited emergency care center. an analysis of the correlation between the degree of esophageal damage seen on endoscopy and that seen on ct scans was performed. this revealed a significant correlation (p = . , r = . ). conclusions. thoracic ct grading suggesting periesophageal soft tissue infiltration and fluid collection (grade iii to iv) rather than only edema (grade i) may be associated with stricture formation. early ct grading was very safe and useful for predicting the development of stricture induced by caustic ingestion. conclusion. in our area critical care transport teams provided safe transfers for critically ill patients.adequate preparation, strict adherence to checklists and adequate personal are the key of optimal solving of problems. introduction. although endovascular repair of traumatic aortic injury (ertai) has revolutionized the practice of vascular surgery, many questions still remain unanswered. endoleaks, coverage of the left subclavian artery, stent fold/collapse, access complications and durability are the most important complications associated with the procedure. we describe our experience with stent fold/collapse after endovascular repair of blunt aortic injury in otherwise healthy and young patients. from january to december , patients (mean age years, mean apache score , mean length of stay days) who underwent endovascular repair of a blunt aortic injury were admitted in our icu. every day clinical examination and invasive blood pressure monitoring were employed for all our patients. when persistent hypertension was detected, transthoracic (tte) and transoesophageal echocardiography (tee) were initially used, followed by spiral computed tomography (ct) and angiography as confirmatory methods. of the patients, ( %) developed a pressure gradient of [ mmhg at the level of the stent that was initially investigated with continuous wave doppler at the descending thoracic aorta (suprasternal view). the complication presented with refractory hypertension (requiring more than two classes of antihypertensives in high doses) and difficult weaning. the cause of hypertension in of those patients was a stent collapse, while in the other patients the stent appeared folded but not collapsed. endograft revision by open surgery was necessary in of the patients. conclusion. the absence of especially designed grafts for the treatment of blunt aortic injury and the subsequent use of oversized grafts are associated with severe complications. refractory hypertension after ertai can be a manifestation of poor stent alignment and/or stent collapse. echocardiographic monitoring proved to be a useful tool in the early diagnosis of this kind of stent-graft complication. as far as we know, it is the first time that echocardiography is described in the relative literature as an early diagnostic technique for this serious complicationction. facing an aging population, the number of interventions of the french emergency medical service (ems) among very elderly is increasing. a previous retrospective study showed that except from out-of-hospital cardiac arrest survival to discharge was remarkably high after ems intervention for life-threatening pathology [ ] . the aim of the present study was to evaluate prospectively outcomes of very elderly patients managed by ems. methods. after irb approval, we conducted a prospective study over year, including all patients aged years or more managed by our physician staffed ems department. characteristics of patients including previous medical status (mccabe and knaus scoring systems), functional independence (katz adl scale), clinical conditions, the index de gravité simplifié ambulatoire (igsa) severity score were recorded. patients were followed until their hospital discharge. the -month mortality was recorded as well as the adl score. data are expressed as mean ± sd, median [iqr] or percentage of patients and compared using univariate and multivariate analysis. a p \ . was considered the threshold for significance (*). results. of the patients included, died on-scene, were transferred to the hospital and patients were left on scene because of significant improvement in medical status making hospitalization unnecessary, or on the contrary in near-death situations. mean age was ± years ( men). their adl was ( - ) and % of patients were living at home. main conditions were pneumonia (n = ), acute coronary syndrome or chest pain (n = ) and acute pulmonary oedema (n = ). at months, survival rate was % (n = ). the proportion of patients living at home was % and adl among survivors was ( - ) (vs. ( - ) initially for this subpopulation, p = . ]. when compared with deceased patients, survivors were significantly younger ( ± vs. ± years*), had lower adl penetrating anterior chest wounds causing cardiac injury are typically fatal, with only % of patients surviving to reach hospital. while the majority of patients with thoracic trauma can be managed conservatively or with simple intercostals catheter, a small but significant number of blunt ( %) and penetrating ( - %) injuries, require emergency resuscitative mediam sternotomy as a component of initial resuscitation. case report. a years old men, fall from meters high, while working in a truss. he was immobilized with semirigid cervical collar and backboard in the scene and transport to our trauma center, witch was a h car-distance. anesthesiologist team was present since the initial management in emergengy room (er) and act according to advanced trauma life support principles. in primary survey, patient was paraplegic, had a gcs of / , a normal respiratory rate, a slight hypotension and a slight tachycardia. when surgeon places a chest drainage, it drains immediately more than , ml blood, and the patient vital signs started to fade, to extreme bradicardia. the patient was then intubated with a rapid sequence intubation, with a single lumen endobronquial tube, and ventilated with protective lung ventilation. hypotension postinduction was promptly treated with vasoactive drugs (nor-adrenaline and dobutamine) and ongoing volume resuscitation. an emergency resuscitative mediam sternotomy incision was perfomed in the er and reveled a clavicule and sternum fracture and laceration in the braquiocephalic artery which has repaired. maintenance was performed with total intravenous anesthesia with fentanyl and nondepolarizing muscle relaxant. monitoring include standard monitoring plus direct arterial and central venous pressures. during the surgical procedure we treat massive blood loss, with multiple transfusions of units of red blood cells (unmatched type-specific), seven units fresh plasma, and pools of plaquets, fibrinogen and cryoprecipitate. at the end of the surgery, still ongoing blood loses, made us suspect of coagulopathy, and to use octaplex Ò . it was also performed a nasal tamponade, to stop severe epistaxis and suture a major scalp wound with evidence of basal skull fracture. patient was transferred to an intensive care unit (icu) ventilated.we was extubated at the th day post-operative. after days, he still remains in icu, because he is recovering from lumbar spine fixation for a total fracture-dislocation of d -d . discussion. although he remains paraplegic, we think emergency sternotomy have had a significantly impact in this life-threating situation. the use of cell-saver Ò would have been beneficial, but it was unavailable in er. we included only patients attended in this unit by icu personnel. these patients belonged to the area assigned to cruces which has been reference centre of the northern area of spain until december . we collected all the information needed from the clinical history and the treatment sheet, and used the spss . programme to perform the statistic analysis. results. we found patients that meet the severely burned patients criteria and that were attended by the icu personnel in colaboration with the plastic surgey unit. their medium age was . ± . years, % of those patients were men, and the medium burned body surface was ± . %. these patients remained hospitalized in this unit during a medium time of . ± . days. during their stay, the % of them needed mechanical ventilation, % presented acute renal failure, % had a pao /fio less than , and . % suffered some kind of infection. methods. prospective and observational study developed in a burn unit, in which were included all patients with total surface body area burn (tsba) [ % and/or inhalation syndrome who were admitted in our unit from march to december . we used transpulmonar thermodilution by means of monitor picco Ò in a total of measurements per patient (admission and every h). we collected measurements of cardiac index (ci), intrathoracic blood volume (itbv), extravascular lung water (evlw), inhalation syndrome or not (it was diagnosed by broncoschopy), percentage of tsba and abbreviated burn severity injury score (absi) in a total of patients.the average change of measurements of ci, itbv and evlw was studied in the following determinations and their association with few factors with a general and lineal model of mixed effects longitudinal data unbalanced. results. the evolution of thermodilution measurements was the following (graphic ) cardiac index: ci = . , ci = . , ci = . , ci = . , ci = . , ci = . , ci = . , ci = . , ci = . , ci = . . intrathoracic blood volume: itbv = , itbv = , itbv = , itbv = , itbv = , itbv = , itbv = , itbv = , itbv = , itbv = . extravascular lung water: evlw = . , evlw = . , evlw = . , evlw = . , evlw = . , evlw = . , evlw = . , evlw = . , evlw = . , evlw = . . in our serie, % of patients were male and the average age was . ( - ). nine out of all the patients ( . %) suffered inhalation syndrome, the average absi was . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and the average of tsba was % ( - %). mortality in our serie was % ( patients).ci and itbv measurements increased significantly while the reanimation advanced (ci p . ) (vsit p . ). in evlw we only find significantly differences in post hoc study between first measurements and fourth one (p . ), th (p . ), th (p . ), th (p . ), th (p . ) and th (p . ).in the evlw/itbv ratio (permeability index = pi) we did not observe significantly changes in the evolution.the inhalation factor did not change ci outcomes neither magnitude nor in the measurements evolution (p . and p . respectively), the same form, itbv (p . and p . respectively), but inhalation modified evlw (p . ) and the permeability index was in the signification stadistic limit (p . ).mortality was higher in patients who ci was lower and evlw was in higher values. conclusions. thermodilution in the reanimation period in critically ill burn patient shows significantly haemodynamic changes in the evolution that can help to adapt the treatment.the inhalation syndrome only modified the measurements of evlw significantly in this period but it influenced neither ci, itbv nor pi. introduction. one major issue in trauma management is to get every patient directly from the scene to the appropriate hospital for the injury he sustained. patterns of interfacility transfers have been thouroughly investigated in trauma system settings, but scarce data are available about transfers in non trauma system settings. objectives. this study aims to assess interfacility transfers that eventuate in the abscence of a formal trauma system and to estimate the potential benefits from the implementation of a more organized process. the 'report of the epidemiology and management of trauma in greece' is a one year project of trauma patient reporting throughout the country. it provided data concerning the patterns of interfacility transfers. in greece there is no formal trauma system employed and to our knowledge, all available data concerning the epidemiology of trauma in the country are either extrapolations of relevant data from other countries or based on police reports and individual hospital reports. in this study, we attempted to evaluate the paterns of interfacility transfers, information reviewed included patient and injury characteristics, need for an operation, intensive care unit (icu) admittance and mortality. trauma patients were devided in two groups, the transfer group was compared to the non-transfer group. analysis employed descriptive statistics and chi-square test. interfacility transfers were furthermore assessed according to each health care facility's availability of five requirements; computed tomography scanner, icu, neurosurgeon, orthopedic and vascular surgeon. results. data on , patients were analyzed; . % were treated at the same facility, whereas . % were transferred. in transferred group there were more male, the mean age was lower than that of the non transferred group and the injury severity score was higher. transferred patients were admitted to icu more often, had a higher mortality rate but were less operated on compared to non-transferred. the transfer rate from facilities with none of the five requirements was . %, whereas the rate of those with at least one requirement was . %. facilities with at least three requirements transferred . % of their transfer volume to units of equal resources. conclusions. the assessment of interfacility transfers can reflect current trends in a nontrauma system setting and could indicate points for substantial improvement. results. , patients included, , injuries analyzed. average age was . , . % men. . % were car accidents, % falls, . % motorcycle, . % run over and . % bicycle. . % had one injury, . % two and . % three. most frequent injury was tbi ( . %), thoracic traumatism ( . %) and ortophaedic ( . %); severe tbi was . %. ctrate according to marshall classification was . % ii, . % v and . % iii. iss averaged , higher in dying patients than in the survivors ( ± . vs. . ± . ; p \ . ). of the non mechanical-ventilated patients, . % were so in the first h following admittance. during this, . % patients were given blood transfusions, platelets . %, plasma . % and prothrombinic complexes . %. in the first h . % underwent surgery, most frequent was neurosurgery ( . %). complications: nosocomial pneumonia ( . %), catheter related bloodstream infection ( . %), acute kidney injury ( . %), ards ( . %), cns infection ( . %). . % renal replacement therapy. invasive ventilation was used in . % with . ± . days, non invasive ventilation in . %. average stay in the icu was days. . % of the patients were transferred to a ward. . % were transferred to another hospital. gos on discharge was higher than on . %. % died in icu, % brain death. tbi as a main injury showed a . % mortality rate. depending on trauma type, mortality was higher in fall ( %) and run over ( . %). if due to car accident ( . %), motorcycle ( . %) or bicycle ( . %), mortality in icu was lower (p \ . ). prehospitalary variables related to mortality were age, gcs \ and a motor component \ , pupil alteration, shock, respiratory failure, prehospitalisation intubation and iss (p \ . ). on arrival to hospital, the variables were: haemodynamic instability in the first h, transfusions need and number, marshall iv-vi, mechanical ventilation (p \ . ) and initial fibrinogen (p \ . ). evolutive variables related to a higher mortality rate were days of stay, invasive ventilation, tracheostomy and the show up of complications (catheter related sepsis -p \ . -, nosocomial pneumonia, acute kidney injury, ards, renal replacement therapy (p \ . ). in a logistic regression model, prehospitalisation variables having an influence on icu mortality rate were age (or . ; p \ . ), mydriasis (or . ; p \ . ), gcs-motor component (or . ; p \ . ), shock (or ; p \ . ) and iss (or . ; p \ . ). conclusions. multiple trauma patients show a high need of resources, with many peaks of treatment involving a high monitorization and handling. many of the variables are related with a higher mortality rate in icu: iss, mydriasis, gcs motor component and shock. introduction. trauma systems are multifactorial modules that incorporate any aspect of traumatic injury from the very moment of the injury to the final outcome. a significant prerequisite for the development of a trauma system is the trauma registry. trauma registries are the actual core of any trauma system since they provide valuable information about the standard of care offered to the patients and are amenable to quality control and statistical evaluations, which in turn allow improvements and amendments in the definite care. contrary to what is common practice in the usa, trauma registries in european countries are in embryonic stage. in our country with no actual trauma system, the epidemiology of trauma and the reports on care outcomes are based on police reports and national emergency service reports. objectives. the purpose of this study was to assess the possibility of a national trauma registry in greece and to provide accurate data on the epidemiology of trauma in the country. methods. the project, entitled ''report of the epidemiology and management of trauma in greece'', was initiated in october and lasted for twelve months. all the national representatives of the hellenic society of trauma were invited to participate. the representatives are certified surgeons employed in hospitals receiving trauma. data presented here are those reported from two tertiary care facilities in athens and twenty eight other primary and secondary hospitals around the country. inclusion criteria were defined as trauma patients with documented need for admission in the hospital, patients that arrived dead or died in the emergency department of the receiving hospital and patients that required transfer to a higher level center. in total . trauma patients were included in the study in twelve months time. of them . % (n = , ) were male, aged . ± . (mean ± sd) and . % were female (n = ), aged . ± . (mean ± sd). as expected and reported in most trauma registries, males are leading in all subcategories of iss. the age group - years incorporates . % of the total injuries, in accordance to the axiom that trauma is the disease of the young. conclusions. trauma registries are the cornerstone of any trauma system. even in a non-trauma system setting, registries are a valuable tool for quality control of the provided health care and for further development of the health care system. objectives. determine the impact of rurality in epidemiology, injury severity, health care facilities, length of stay (los), mortality, functional outcome and quality of life in trauma patients. retrospective study in trauma patients that were admitted in our emergency room(er) between and . data was collected from the prospective trauma registry and follow-up registry months after the accident. we classified patients according to statistical national institute classification: urban areas-areas with more than inhab/km or have a place with more than , inhabitants; semi-urban areas-areas with more than inhab/km and less than inhab/km or have a place with more than , inhabitants and less than , inhabitants; rural areas-areas that were not classified as semi-urban or urban areas.patients were divided in three groups according to residence area: r (rural), su (semi-urban), u (urban). we studied several variables in order to find a relation with rurality: sex, age, type of injury, los in hospital and intensive care (icu), anatomic severity (ais), politrauma severity (iss), physiologic severity (rts), surveillance probability (triss index), pre-hospital care, previous admission in other hospital, icu admission and mortality. we report two outcome measures: euroqol to evaluate quality of life and extended glasgow outcome scale for functional outcome. we used qui-square test, t test, mann-whitney test, kruskal-wallis test for statistic analysis. results. , patients were admitted in the er. patients ( . %) were excluded with missing data related to residence area. we studied patients, where patients were from rural areas ( . %), from semi-urban areas ( %) and from urban areas ( . %). we find a statistical significant relation between rurality and pre-hospital care, previous admission in other hospital and icu admission. urban area patients had a higher incidence of pre-hospital care(r: . %; su: . %; u: . %, p \ . ). semi-urban and rural patients were admitted more frequently in other hospitals before admission in er (r: . %; su: . %; u: . %, p \ . ) and also had higher admissions in icu (r: . %; su: . %; u: . %, p \ . ). there were no statistical differences in the other variables studied. conclusions. rural trauma patients are similar from those that live in urban areas concerning epidemiology, injury severity and outcome. despite lack of pre-hospital care and higher previous admission in other hospital in rural patients, mortality between groups did not differed in our trauma centre. introduction. metformin-associated lactic acidosis (malta) is a rare but severe complication ( . / , patients/year) of metformin treatment in type-ii diabetes. metformin impairs neoglucogenesis and liver lactate clearance in the presence of a disease that enhances its production. although frequently used, there is no recommendations regarding hemodialysis in this poisoning. to study the prognostic factors of malta and the interests of blood metformin measurement. . on admission, patients presented profound lactic acidosis with arterial ph . ( . - . ), serum bicarbonate . mmol/l ( . - . ) and plasma lactate . mmol/l ( . - . ). early symptoms associated coma ( %), asthenia ( %), vomiting ( %), abdominal pain ( %), and diarrhoea ( %). renal function was significantly altered [creatinine clearance: ml/ min ( - ); p \ . ). all patients received massive alkalinization, / ( %) were hemodialyzed while / ( %) were mechanically ventilated and received catecholamines. six patients ( %) died in the icu. duration of icu stay was days [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . there was no significant differences regarding malta severity and treatments between suicidal and accidental poisonings. neither lactic acidosis severity nor acute renal failure were predictive of death. there was no correlation between prognosis and the time-course of plasma metformin concentrations, with or without dialysis. toxicokinetics showed significant tissue distribution when the patient was early admitted or plateaued concentrations if he was later admitted and survived, even though his situation improved and his lactates decreased. metformin dialysance suggested an interest for extra-renal elimination enhancement although its impact on survival could not be analysed based on this limited study. our study showed that malta is severe with elevated mortality in icu whatever the poisoning is accidental or intentional. metformin toxicokinetics are useful case by case to better understand the patient's outcome. the most important guidelines [ ] for trauma care recommend (us)-fast as the first step investigation to rule out major bleedings. however, us is less sensitive and accurate than multislice computed tomography (ct). the spreading concept that ''moderrn cts require little time'' often brings surgeons to ask for total body ct also in haemodynamically unstable patients. to understand how long it really takes to perform a total-body ct in patients suffering from major trauma (mt) we analysed the data of the ritg project, a pilot multicenter study to define the national standards for trauma care and establish a national trauma registry. methods. italian level trauma centers were involved into the first stage of the ritg project. data of all major trauma patients (iss [ ) who were admitted to either one of the three hospitals during a months period of time ( july - june ) were prospectively entered into the ritg database. time between hospital admission and the first scan were recorded for all patients. patients who, for any reason, were submitted to a ct with a delay of °or more were excluded. the time elapsed between the first scan and the patient's exit from the ct room was measured in a subset of pts from a single center equipped with a new generation ct next to the emergency room. during the study period mt patients were admitted to the three trauma center. patients were submitted to an emergency total body ct scan within . patients died before arrival in the ed. more died soon after admission and before the secondary survey. the interval times are shown in table . seven patients died in the ct room. the average interval between hospital admission and the first available scan was °. however, even where a new generation ct next to the er was used, the average time needed to stabilize the patients, get a correct position on the ct and start the scanning process was °as an average. in the most severely injured patients, who are frequently artificially ventilated, the time required to stabilize the patient and perform a total body ct scan is longer than expected and to a certain extent, independent from the ct scanner itself unless the very last technology as the sliding ct scanners are employed [ ] , thus ct should be considered with extreme caution in the unstable patients. in univariate analyses, survival to discharge was significantly lower with two of acute conditions (acute coronary syndrome and acute inflammation), and with five of chronic conditions (chronic heart failure, diabetes mellitus, kidney failure, hepatic cirrhosis and malignancy). recent surgery was strongly associated with higher odds of survival. the most consistent multivariate predictors of survival to discharge were liver cirrhosis (or . ; % confidence interval . - . ) and malignancy (or . ; . - . ). malignancy was not predictive for outcome after cpr attempts, whereas liver cirrhosis was predictive both in all dispatches and in dispatches involving cpr. recent surgery was strongly associated with higher multivariate odds of survival (or . ; . - . ) after cardiac arrest. in dispatches without cpr, absence of chronic conditions was associated with higher likelihood of survival (hr . ; % ci . - . ). increasing numbers of chronic conditions were significantly and continuously associated with lower survival (p for trend \ . ). advanced age only weakly predicted survival, but age c years was, along with malignancy, the strongest predictor of not attempting cpr in patients with cardiac arrest. conclusions. comorbidities are important determinants of survival after in-hospital met dispatches, with and without cardiac arrest. survival odds are lowest with malignancy and liver cirrhosis. recent surgery increases odds of survival by exclusion of those most severely ill. advanced age at best weakly predicts worse survival, but strongly predicts not attempting cpr. design. retrospective, cohort study. setting. emergency department (ed) and intensive care unit in a university hospital. measurements and main results. the study subjects included of consecutive severe trauma patients. a systematic review of the computer-based medical records of the patients was conducted to provide the base line characteristics and dic-related variables. the worst data of these variables were obtained at time points within h after arrival to the ed; time point , immediately after arrival at the ed to h after the arrival; time point , to h after the arrival; time point , to h after the arrival; time point , to h after the arrival. one hundred and forty one patients ( / , . %) diagnosed as jaam dic showed significant differences in the prevalence of multiple organ dysfunction syndrome (mods) and the outcome in comparison to the non-dic patients. a stepwise logistic regression analysis showed that the maximum jaam dic scores during the study period independently predicted the patient death (odds ratio . , % confidence interval . - . ). all of the patients who developed isth overt dic during the study period could be identified by the jaam dic criteria at early time points. the mortality rate and the incidence of mods of the patients with the isth overt dic were higher than those only met the jaam dic criteria. stepwise increases in the isth overt dic scores and the incidence of the isth overt dic were observed in accordance with the increases in the jaam dic scores. while the mortality rates were identical, there were marked differences in the incidence of mods and sequential organ failure assessment scores between the dic patients associated with trauma and sepsis. conclusions. the jaam scoring system has acceptable validity for the diagnosis of dic at an early phase of trauma. the jaam dic further exists in a dependent continuum to the isth overt dic. in addition to mods, other factors may affect the prognosis of the trauma patients associated with dic. introduction. in the uk, more than , units of fresh frozen plasma (ffp) are transfused every year. since there has been a reduction of % in its use, but it has been suggested that as many as % of transfusions in critical care may be inappropriate. there is significant morbidity associated with the transfusion of ffp. guidelines for the use of ffp do exist, but the indications for its use are limited. coagulation studies, such as prothrombin time (pt), abnormalities are often assumed to be a risk factor for bleeding prior to invasive procedures, but evidence suggests that ffp may not have a prophylactic role. in addition to this the pt or international normalised ratio (inr) were not intended to assess haemostasis in patients without a history of bleeding. review of the blood bank database between st january and st december revealed all prescriptions of ffp for patients on intensive care (itu). the case notes were analysed to find the indication and timings of administration and weight of the patient. the pathology database was examined to find the clotting studies immediately before transfusion. in patients received ffp; this was only . % of the total admissions to the itu. there were prescriptions and a total of units transfused. the mean prescription of ffp was . units and overall each patient received a mean of . units. the mean dosage of ffp was . ml/kg. the pt pre-transfusion mean was . ± . s with a median of . s. the aptt pre-transfusion mean was . ± . s with a median of . s. only . % of transfusions had not had a clotting screen done prior to administration of ffp. % of administrations were given prior to procedures being undertaken on the itu and a further % were given in preparation of the patient for the operating theatre. a significant number of patients are receiving ffp outside international guidelines. a third of transfusions were given for prophylactic correction of coagulopathy prior to an invasive procedure where there is least evidence for using ffp. most patients received a sub-therapeutic dose of ffp; there is ongoing debate on the correct dosage required to normalise coagulopathy, but it is likely to be greater than ml/kg. [ ] . little data exists on the demographics of mt and subsequent demand on a hospital's blood bank. we examined the mt requirements of a bedded tertiary referral hospital over a month period. objectives. to establish the mt demographic, speciality distribution, prbc demand and associated mortality; within a tertiary referral hospital over a month period. to assist with future mt logistics, planning, implementation and audit. methods. the hospital blood bank database was reviewed for cases of mt from jan to aug . inclusion criteria were the administration of c units of (prbc) within a h period. cross referencing with the laboratory records and medical notes was undertaken to establish patient demographics, hospital specialty, diagnosis, outcome and number of prbc transfused. results. patients received mt over a -month period; male ( . %) female ( . %). median age years (range - ). median mt of prbc was (range - ) units. units of prbc were transfused in the treatment of mt during the study period, accounting for a hospital expenditure of over € , . the main specialties associated with mt were the: emergency department ( patients, . %), cardiothoracic surgery ( patients, . %), and general surgery ( patients, . %). of the patients receiving massive transfusions ( . %), did not survive to hospital discharge. % of those patients who died, did so in the first h with a further % dying in the next h. % of the further deaths occurred within and % after thirty days. conclusions. mt in our establishment is associated with a high mortality and predominantly early deaths. recipients were generally elderly with significant co-morbidity. provision of prbcs and blood components for massive transfusion recipients, is challenging for blood bank services [ ] . the demand of mt, within our establishment, was predominantly within the acute specialties; emphasizing the need for close communication between them and the laboratory services. in light of this data we propose the implementation of a mt protocol together with continuous audit, to assess its effect on outcome. in the department of health updated the 'better blood transfusion' circular, a drive to decrease the use of blood products which have become increasingly scarce and expensive [ ] . there is evidence that blood product transfusions in icu patients are associated with an increase in morbidity, length of stay and mortality. there has been concern over the increasing use blood products and despite guidelines [ ] for their use, both national and local audits have demonstrated a high degree of inappropriate transfusion [ ] . derriford hospital is a -bedded tertiary referral centre. the blood bank database was examined for the use of blood products on icu from st january to st december . there was a steady rise in icu admissions from , patients in to , patients in . during this time there was a marked decline in both the transfusion of fresh frozen plasma (ffp) and cryoprecipitate. the decreased use of these blood products has occurred with only a very modest introduction of new pro-coagulant therapies, prothrombin complex concentrate (pcc) and recombinant factor viia (rfviia). usage of rfviia and pcc conclusions. our usage of blood products does not reflect the national trends of increasing use of cryoprecipitate and pcc with a small reduction in ffp transfusion, and is more in line with the hsc requirements for better use of blood products. this has been achieved with little use of the newer rfviia and pcc. the evidence for the use of all these blood products is not strong, particularly in critically ill patients. national guidelines exist for their use, but these are poorly adhered to. to test the hypothesis that transfusion of prbcs has a deleterious effect on clinically relevant outcomes in patients with septic shock receiving early goal directed therapy (egdt). retrospective cohort study of patients who presented in an academic center in septic shock and received egdt. data was collected on patients identified via the surviving sepsis campaign chart review database and linked to the project impact database. pearson chi square and fisher's exact test were used to test for clinical significance. primary outcome was mortality and secondary outcomes included mechanical ventilation days, intensive care unit (icu) length of stay, and hospital length of stay. . / patients presented via the emergency department. / patients received at least one prbc transfusion during their hospital stay. the two groups were balanced with respect to age, gender, apache ii, and baseline lactate levels. the prbc group had a mortality of . vs. . % in the no prbc transfusion group (p = ns). the prbc group also had more mechanical ventilation days ( . vs. . days, p = \ . ), longer hospital length of stay ( . vs. . days, p = \ . ), and longer icu length of stay ( . vs. . days, p = \ . ). conclusions. in this study, transfusion of prbc was associated with worsened clinical outcomes in patients with septic shock treated with egdt. this trial is limited by its small sample size and retrospective nature. however, the results are consistent with data from previous trials pointing to a deleterious effect associated with prbc transfusion. further studies are needed to determine the impact of transfusion of prbc within the context of early resuscitation of patients with septic shock, as the beneficial effects gained by an early and goal oriented approach to resuscitation may be lost by the negative effects associated with prbc transfusion. introduction. blood transfusion therapy (btt) is thought as one of transplantation of living cell, that means btt includes several risk such as infection and btt should be thought to derived from precious material by courtesy of donors. patients with traumatic cardiopulmonary arrest on arrival on the hospital (t-cpa) usually suffered from lethal hemorrhage and required rapid supplement of red blood cells for resuscitation of circulation and oxygen transport, that is to say btt. however, the prognosis of t-cpa patients is well known hopeless. the aim of this study is to evaluate the propriety of our strategy concerning btt for t-cpa patients. we retrospectively examined the medical records of t-cpa patients for the past years. we do btt until (the first period) for t-cpa patients regardless of rosc without any restriction. after then (the second period), we do btt case by case but only after rosc in principle. the rate of rosc, admission to icu, survive to discharge were compared between these two period, and were compared within the first period between the patients group who underwent btt (btt group) and the group who did not underwent btt (non-btt group). in blunt t-cpa and penetrating t-cpa patients, and % achieved rosc, and % admitted to icu, and and % were survive to discharge. in penetrating t-cpa in the first period, units of packed red cells (prc) were used before rosc for non-survivors. in the second period, no prc was used for non-survivor before rosc. in blunt t-cpa in the first period, prcs were used for non-survivors before rosc. in the second period no prc was used for non-survivors before rosc. concerning the effect of btt on the prognosis of t-cpa in all cases, the rate of rosc and admission to icu were statistically higher in the first period than in the second period (p = . and . ). however, there was no statistical difference in the rate of survive-to-discharge between these periods. there was a same tendency in witnessed cases. in cases with electrical rhythm on the scene, only the rate of rosc were higher in the first period (p = . ). restricted in the first period, only the rate of rosc was statistically higher in non-btt group than btt group in all cases, in witnessed cases, and in cases with electrical rhythm on the scene (p = . , . , and . ). however, there was no statistical difference in the rate of admission to icu and survive-to-discharge between these groups.. our retrospective serial study showed a possibility that btt before rosc for t-cpa improves the success rate of rosc but add no effect on the improvement of survival rate. btt is thought to be futile for t-cpa before rosc. management of refractory coagulopathy due to adult onset acquired autoimmune haemophilia. d. hendron , g. allen , m. brady , g. benson belfast city hospital, intensive care, belfast, uk, belfast city hospital, department of haematology, belfast, uk we report a case of life-threatening haemorrhage occurring as a result of a rare acquired condition caused by the production of an antibody to clotting factor viii. this necessitated administration of recombinant activated factor viia (novoseven) to bypass this step of the clotting cascade. a -year-old man presented to intensive care following ogd for acute upper gastro-intestinal haemorrhage, with recent haemoptysis and haematuria. ogd had demonstrated a large clot obstructing the oesophagus and extending through stomach into duodenum. this could not be removed and no bleeding points were identified. a coagulopathy was detected which failed to correct with administration of appropriate amounts of fresh frozen plasma, cryoprecipitate and activated prothrombin complex concentrate (apcc), necessitating clotting factor studies. this demonstrated a factor viii level of % with a detectable antibody inhibitor. acquired haemophilia was diagnosed and activated factor viia was administered resulting in rapid correction of coagulation studies and arrest of haemorrhage. it was necessary to continue daily activated factor viia at a dose of mg a day in addition to anti-inhibitor coagulant complex (feiba-vh)-an activated prothrombin complex with factor viii inhibitor bypassing activity. definitive treatment of the coagulopathy was chemotherapy with cyclophosphamide, vincristine and rituximab. this destroyed the factor viii inhibitor and returned his factor viii levels to almost %. laparotomy and gastrotomy were required to relieve the oesophageal obstruction from the accumulated clot. he was eventually discharged from hospital and remains well. acquired haemophilia is a rare haematological condition that presents with refractory haemorrhage and coagulopathy and these patients are likely to be referred to critical care services for ongoing support and management. it has an incidence of approximately . cases per million per year [ ] . underlying medical conditions can be identified in up to % of patients and include autoimmune disease, solid tumours, lymphoproliferative malignancies and pregnancy [ ] . international recommendations on the diagnosis and treatment of patients with this condition have recently been published and advise recombinant activated factor viia to control bleeding followed by a combination of corticosteroid and chemotherapy [ ] . the paucity of cases presents an obstacle for randomised controlled trials and therefore these recommendations are based on anecdotal evidence and expert opinion. reference (s) objective. to analyze the application of blood transfusion in critically ill trauma patients after wenchuan earthquake. a retrospective study was made in icu of huaxi hospital on patients who had received transfusion at least once during month after the earthquake. their primary diagnosis and clinical features and apacheii score were obtained at admission. non-active bleeding patients were classified into s group if operation was done during his icu stay, otherwise n group. the function of liver and kidney, and the state of circulation and oxgenation were compared between groups, as well as the hemoglobin level before each transfusion were investigated. a total of patients ( . %) had received transfusion at least once, among which were non-active bleeding. the average frequency was . ± . and . ± . , amount was . ± . ml and . ± . ml, the incidence of transfusion-related complication was . %( / ) and . %( / ) in active and non-active bleeding patients respectively. the apacheii score, mean arterial pressure, ast, serum creatinine, oxgenation index and hemoglobin level on day , , after admission to icu showed no statistically significant difference between s and n group. the frequency and amount of transfusion were similar also, while the hb level before each transfusion was significantly lower in n group ( . ± . g/l)than in s group ( . ± . g/l) (p \ . ). the incidence of transfusion-related and infectious complications, time with ventilator and the -day mortality were similar. conclusion. transfusion strategy is more strict in icu doctors than surgeons, while the similar result on organ function, incidence of complications and outcome raises the need for a more wide-accepted transfusion trigger. keywords. earthquake trauma transfusion trigger. extracorporeal life support (ecls) represents an ultimate rescue technique in poisonings. the optimal anticoagulation protocol remains unclear. objectives. we aimed to investigate the coagulation status at ecls decision in order to validate the best heparin protocol to administer. [ packs ( - ) ] and fresh plasma [ packs ( - ) ] transfusions were required within the first h. hemorrhages ( / ), thrombosis ( / ) or lower limb ischemia ( / ) seemed equivalent to previous series using more complicated anticoagulation protocols. conclusions. poisoned patients present at ecls time with important alteration in their clotting tests, associated with various degrees of hepatocellular failure, dic, defibrination, as well as dilution. a simple heparin protocol appears optimal to reduce complications in these critical situations. henna is the dried and powdered leaves of the henna plant. the plant is lawsonia alba and the powdered leaves are used to apply decorative designs over the skin. henna application is widely practiced in the arab and asian communities. they create fascinating designs over the skin, especially over the hands and feet. it is widely practiced during wedding ceremonies and at childbirth. g pd deficiency is common in the community of the arab world. lawsone, the chemical compound in the henna leaves, is capable of inducing severe acute hemolysis in g pd deficient cases. the compound is chemically related to naphtha. we report a case of acute sever hemolysis in a young girl who presented with dizziness and jaundice and diagnosed to have acute severe hemolysis. her symptoms had started while preparing for her wedding by henna application. the girl was g pd deficient, and found to have severe hemolysis resulting from henna application on her skin. very few cases have been reported of similar nature. the matter is also of tremendous practical implication in areas of g pd deficiency. the relevant literature is reviewed as well. background. lactate has prognostic use in critically ill medical and trauma patients, and is a core component in identification of early sepsis. elevated lactate levels in these patients prior to icu admission, e.g. in an a&e setting or pre hospital setting identify patients at risk of death and can trigger an earlier optimization of triage decisions and earlier targeted treatment. a range of poc methodologies for lactate measurement are available but there is little standardization between methodologies. stat sensor lactate is a new poc lactate meter based on a patented multiwell and multilayer electrochemical technology that incorporates control wells that measure and correct for common interfering substances. the electrochemistry technology is layered onto a gold platform providing a stable and robust surface for the electrochemical reaction kinetics. the aim of this study was to assess the performance and functionality of stat sensor lactate. whole blood venous samples were collected from adult patients admitted to a&e. samples were tested for lactate using statsensor lactate (nova biomedical) and the omni b bga (roche) routinely used for lactate measurement. precision was assessed using donated whole blood and spiked with a concentrated lactate solution. results. within run precision was acceptable at all levels tested. for the lowest level sample (mean . mmol/l) %cv for the two meters tested was ( . and . %) at the three other levels tested (mean . , . , . mmol/l) % cv precision was \ %. lactate values during the method validation ranged from . to . mmol/l by the reference method (nova . to . mmol/l background and objectives. this research work's intention is to describe the epidemiology in patients suffering from anemia who were interned into emergency room (er). a preliminary work will be conducted in which three days in june will be randomly chosen. during these days, all patients satisfying certain criteria will be registered. the criteria fitted to this work are the following: be using the emergency channel of the hospital, score any diagnostic and be over years old. paediatric, gynaecologic and traumatic cases fall out of this research. anemia was diagnosed according to who criteria. outcome. patients were interned through the aforementioned er channel. . % were subject of blood analysis using classification proceedings. from the latter, . % were diagnosed with anemia. age, intake of clopidogrel and/or aspirin, admission and place of admission resulted statistically significant among anemia patients versus non-anemia. anemia was to be found in . % of patients younger than years old, % of the times in patients between and and . % among patients above years old. according to vcm, . % were microcitic-anemia, % were normocític-anemia and . % resulted macrocític ones. conclusion. anemia is among a large share of patients coming into the hospital through emergency proceedings. its likelihood increases accordingly to the risk group analysed and dominating among the elderly population and among patients suffering from renal disfunction and non aggregated. most common are normocitic and macrocitic anemia-types. early identification and valuation could bear prognostic consequences. a. s. omar tawam hospital, critical care medicine, al ain, united arab emirates introduction. an elevated serum creatinin phosphokinae (cpk) and the presence of myoglobin in the urine characterize rhabdomyolysis. rhabdomyolysis had been described in various traumatic and non-traumatic conditions [ ] , there are few reports of its association with anaphylaxis. in this paper, we report cases of anaphylaxis both complicated with rhabdomyolysis. aim of the work. to discus the association between rhabdomyolysis and anaphylaxis and the value of early screening of cpk in such cases. setting. two patients were included in this review in multidisciplinary intensive care unit of tawam hospital/uae. the two patients survived, both developed rhabdomyolysis shortly after admission, evidenced by fivefold or greater increase in serum cpk [ ] . both patients had transient hypotension through the presentation, but none of them had persistent shock requiring vasopressors or complicated with acute renal failure. conclusion. we observed rapid increase in serum cpk in our two cases suggesting the potential benefits of early assessment of cpk in such patients which may amplify early goal guided management and avoiding logistic organ dysfunction. keywords. rhabdomyolysis, anaphylaxis. the blood oxygen and carbon dioxide levels are a direct measure of the effectiveness of ventilatory support in patients on mechanical ventilation. head injury patients require strict control of the cerebral homeostatic state. these patients also need careful management of sedation, maintaining a fine balance between patient comfort, hemodynamic instability and ability to assess conscious levels. biphasic intermittent positive airway pressure (bipap) ventilation is thought to be better tolerated by the patient allowing for spontaneous breathing at any point, thus reducing the amount of sedatives and muscle relaxants used. but the effectiveness of this ventilatory mode in achieving stable blood oxygen and carbon dioxide levels in this group of patients is not known. we hypothesised that bipap is more labour intensive to adapt to the target blood gas parameters as the volume delivery is not constant and that the blood gases may be more unstable in the initial resuscitation phase of head injury patients without conferring much advantages in terms of usage of sedatives and muscle relaxants. retrospective data collected from case record review of head injury patients with no primary respiratory insult, requiring mechanical ventilation with volume controlled synchronised intermittent mandatory ventilation (simv) was compared to the data from similar patients treated with bipap ventilation. both the data groups specifically looked at two time periods, the first h and - h after intensive care admission. blood gas parameters classified as hypocarbic, hypercarbic and/or hypoxic, use of muscle relaxants, number of episodes of raised intracranial pressure (icp) above mmhg as recorded in the intensive care chart every hour, number of episodes of cerebral perfusion pressure (cpp) below mmhg as recorded in the chart every hour was noted. need for muscle relaxant in the first h of admission was noted. the outcome was recorded as either ''alive'' or ''dead'' at the end of itu stay. the data was checked for normality of distribution and compared using non parametric tests (spss for windows). results. baseline characters were comparable between the groups. increased episodes of hypoxia ( . ± . vs. . ± % p = . ) and hypocarbia ( . ± . % vs. . ± . % p = . ) in bipap mode, compared to simv volume control mode. all measurements being percentages of total blood gases for that patient in the first h. there was no difference in the usage of muscle relaxant ( . vs. . % p = . ), raised icp, reduced cpp or mortality between the groups. conclusion. bipap mode of ventilation requires more intensive monitoring and changes in ventilatory settings before adapting to the target blood gas parameters in the first h of admission. at the same time the quoted advantage of using less sedatives and muscle relaxants is not significant. acute post-traumatic brain swelling is one variety of the pathological forms, which needs emergent treatment following traumatic brain injuries. we investigated the effects of clinical effects of decompressive craniectomy (dc) in patients with acute post-traumatic brain swelling (bs). seventy-four patients of acute post-traumatic bs with midline shifting more than mm were divided randomly into two groups: dc group (n = ) and routine temporoparietal craniectomy group (control group, n = ). the vital sign, the intracranial pressure (icp), the glasgow outcome scale (gos), the mortality rate and the complications were prospectively analysed. the mean icp values of patients in dc group at , , and h after injury were much lower than those of routine temporoparietal craniectomy group ( . ± . , . ± . , . ± . and . ± . mmhg vs. . ± . , . ± . , . ± . and . ± . mmhg, respectively). the mortality rates at month after treatment were % in the dc group and % in the control group (p \ . ). good neurological outcome (gos score of to ) rates year after injury for the groups were . and . %, respectively (p = . ). the incidences of delayed intracranial hematoma and subdural effusion were and %, respectively (p \ . ). in conclusion, dc has superiority in lowering icp, reducing the mortality rate and improving neurological outcomes over routine temporoparietal craniectomy. however, it increases the incidence of delayed intracranial hematomas and subdural effusion, some of which need secondary surgical intervention. therefore, the effects of dc in patients with acute post-traumatic bs should be further evaluated. we analyze among others variables: age, injury severity score (iss), abbreviated injury score (ais); admission and discharge glasgow coma score (gcs), extended glasgow outcome score (gose), complications, icu and hospital mortality. differences between groups were tested with students t test and v testing for statistical analysis. results. fourteen patients with intracranial hypertension were treated with decompressive craniectomy . compared with control group, patients with dc had a better gcs ( ± g ; ± g p = , ) and gose index not only at icu discharge ( ± g ; ± g p = , ) but also at hospital discharge ( ± g ; ± g p = . ). the mortality rate was lower in the craniectomy group (g : %, g ; % p = . ). conclusions. in our center, the use of dc for treat patients with severe tbi and refractory cranial hypertension (gcs b and pic c ) improved outcome and mortality significantly compared with medical conventional approach. method. in this retrospective study we present patients who underwent decompressive craniectomy following traumatic brain injury at king's college hospital between and . results. % of these patients presented at a&e with a glasgow coma scale of or below whereas the remaining % presented with gcs above and deteriorated following admission. the patients underwent decompressive craniectomy to reduce raised icp resistant to medical treatment (barbiturate coma excluded). the procedure resulted in significant decrease in icp. out of patients had the operation within h following their injury. we also found that dc in younger patients (\ years) was correlated with lower icp following the operation compared to older patients ([ ) . our study also showed that early dc (\ h) is correlated with a shorter stay in itu. conclusions. the findings of the present study are limited by its retrospective nature and small sample size which does not permit any definitive conclusions from these results. however, they form the basis for further investigation. we present the study with a review of the recent literature. introduction. the objective is to study the correlation of secondary icp indices with ct findings and outcome in tbi. a cerebrovascular pressure reactivity index (prx) can be determined as the moving correlation coefficient between mean icp and mean arterial blood pressure . it is a surrogate marker of cerebrovascular reactivity. the rap coefficient was calculated as the running correlation coefficient (r) between slow changes in pulse amplitude (a) and mean icp (p). it is a surrogate marker of pressure-volume compensatory reserve. all components of the icp waveform that have a spectral representation within the frequency limits of . to . hz can be classified as slow waves. methods. prospective observational study of patients with tbi at the royal london hospital. all patients were managed according to the local guidelines for the management of tbi . secondary indices derived from the icp waveform were analyzed by icm ? software. an initial ct was performed in all patients before admission to icu. marshall classification has been shown to predict mortality in tbi. we found a strong association between all these secondary indices and the initial ct findings. all these markers of cerebral haemodynamics correlate significantly with outcome in headinjured patients. conclusions. surrogate markers of cerebrovascular reactivity and pressure-volume compensatory reserve correlates with ct findings and outcome in tbi. these secondary icp indices may be used in the management of tbi. introduction. following the introduction of national guidance [ ] on the management of patients with head injury, the use computed tomography (ct) imaging of the head has increased markedly. the impact on anaesthetic and critical care services is unknown. . determine the impact of national guidelines on ct scanning in the head injured patient upon anaesthetic and critical care services in a university teaching hospital. . determine the incidence of acutely abnormal ct appearances in patients referred for ct scanning under the guidelines. . estimate in-hospital mortality in this population and its sub-groups. a case-note analysis was performed in october of consecutive emergency department (ed) patients who were recorded as having a ct head. of the cases, did not actually have ct head. details of the analysed subjects, indications for the scan and day mortality rates are reported in table . in patients with severe traumatic brain injury pro-and anti-inflammatory mediators are released into the systemic circulation. however, the relationship between the inflammatory response and the kind and duration of secondary insults remains unclear. objectives. the aim of this study was to investigate in severe traumatic brain injured patients the relationship between the systemic concentrations of pro-and anti-inflammatory mediators and the total duration of secondary insults occurring during the icu stay. methods. ten consecutive traumatic brain injury patients admitted to the icu were included. physiological variables were continuously recorded and analyzed minute-by-minute to identify the occurrence of secondary insults (intracranial hypertension, systemic hypotension, hypoxemia and hyperthermia) according to the edinburgh university secondary insult grading scale. serum samples were obtained at admission, , and h, in which pro-and anti-inflammatory mediators were analyzed by a bioplex assay. results. ten male patients were enrolled, mean age ± , gcs ± , apache ii ± , iss ± . patients were monitored for . days (median value, range - ; , total minutes recorded); intracranial hypertension occurred for , min ( . % of total period recorded, range . - %), hypotension occurred for , min ( . % of total period recorded, range . - %), hypoxemia occurred for min ( . % of total period recorded), not enough data were validated for fever. interleukin (il)- , il- beta, il- , il- and il- ra were in the detectable range. a significant correlation was found between the total duration of intracranial hypertension and the median value of il- (p \ . , r = . ), il- beta (p \ . , r = . ), il- (p \ . , r = . ), il- (p \ . , r = . ), and il- ra (p \ . , r = . ) measured during the period of observation. no correlation was found between these inflammatory mediators and the occurrence of hypotension or hypoxemia. no significant correlation was present between the baseline values of these inflammatory mediators and the severity indexes (gcs, iss and apache ii). conclusions. these results suggest that the duration of secondary insults such as intracranial hypertension was associated with a systemic inflammatory reaction, while the severity of injury on admission was not related to the initial concentrations of these inflammatory mediators. grant acknowledgement. aim. assessing behavioral responses to pain is difficult in severely brain-injured patients recovering from coma. we here propose a new scale developed for assessing pain in vegetative (vs) and minimally conscious (mcs) coma survivors: the coma pain scale (cps) and explore its concurrent validity, inter-rater agreement and sensitivity. methods. concurrent validity was assessed by analyzing behavioral responses of postcoma patients to a noxious stimulation (pressure applied to the fingernail) ( vs. and mcs; age range to years; non-traumatic and of traumatic origin). patients' were assessed using the cps and four other 'pain scales' employed in non-communicative patients: the 'neonatal infant pain scale' (nips) and the 'faces, legs, activity, cry, consolability' (flacc) used in newborns; and the 'pain assessment in advanced dementia scale' (pa-inad) and the 'checklist of nonverbal pain indicators' (cnpi) used in dementia. for the establishment of inter-rater agreement, fifteen patients were concurrently assessed by two examiners. results. concurrent validity assessed by spearman rank order correlations between the cps and the four other validated pain scales was good. cohen's kappa analyses revealed a good to excellent inter-rater reliability for the cps total and subscore measures, indicating that the scale yields reproducible findings across examiners. finally, a significant difference between cps total scores was observed as a function of diagnosis (i.e., vs or mcs). conclusion. the cps constitutes a sensitive clinical tool for assessing pain in severely brain injured patients with disorders of consciousness. this scale constitutes the first step to a better management and understanding of pain in patients recovering from coma. methods. study group: consecutive patients with cervical spinal cord injury admitted to icu. mean age: , years. patients asia a, asia b, asia c. the more frequent neurological level was c ( %). the requirement of mechanical ventilation was considered the key sign for establishing the diagnosis of severe respiratory failure. the blood gas values (po , pco , and pao /fio ) before and after connection to mechanical ventilation [mv(if needed)], were used to estimate the more probably mechanism of respiratory insufficiency. the increase of pco levels was considerate as a sign of neuromuscular weakness; the low po level before ventilation, and the persistence of pao /fio below normal values was considered a sign of v/q mismatch. for this purpose statistic analysis (mean values comparison using student t test) comparing blood gases before and after mechanical ventilation treatment was performed. results. ( %) patients developed severe respiratory failure. mean delay between admission and mechanical ventilation was h. previously to mechanical ventilation patients developed pulmonary atelectasis, and four pneumonia. the incidence en respiratory failure was significantly higher in patients with neurological level above c (p \ . ). conclusions. the incidence of respiratory failure is related with the severity of neurological deficit (relationship between incidence of respiratory failure and neurological deficit level). in addition, our data support that, besides the neuromuscular weakness (moderate increase of co levels), a significant v/q mismatch with shunting phenomena associated (significant hypoxemia no completely solved after mv) is involved in the respiratory failure of cervical spinal cord injured patients. . moderate and severe traumatic brain injury is more likely in middle aged men; more than one third present other major trauma and intensive first level medical treatment is required in most of them. . the most frequent complications found were infectious diseases like ventriculitis and vap. . independent mortality risk factors in moderate and severe trauma brain injury were age, high apache ii score, neuromuscular blocking drugs and icu los. . outcome was significantly improved after six months, and most of the patients only present mild disability and good recovery. nosocomial infections are leading causes of increased morbidity and mortality of severe brain injured patients [ ] . the mechanism underlying the susceptibility to the infections is a subject of great scientific interest and still to be clarified [ ] . it has been recently recognized that injury of brain induces a disturbance of balance between the central nervous and immune system [ ] . objective. the aim of this study was to investigate changes in frequency of lymphocytes subpopulation in peripheral blood of patients with severe brain injury during the course of intensive care treatment. human peripheral blood samples were taken from the severe brain-injured patients at day , and and peripheral blood mononuclear cells (pbmc) were immediately isolated by gradient density centrifugation. the percentage of lymphocytes subpopulation were analyzed by simultaneous detection of surface antigens using fluorochrome conjugated monoclonal antibodies directed toward cd , cd , cd , cd , cd , cd , cd . t lymphocytes were distinguished from the other lymphocyte subpopulation as cells labeled with anti-cd monoclonal antibody but negative for cd staining (cd ? cd - patients. eighty-seven patients with head injury, glasgow coma scale \ . measurements and main results. clinical and demographic data, and head ct scan were taken at admission. patients underwent advanced neuromonitoring and were treated according to brain trauma foundation guidelines. s b concentration was quantified at admission and , and h post-tbi (days , , and ). outcome was assessed months after discharge using glasgow outcome score. significant negative correlations were found between -year gos and s b concentrations on days - , but not on day (day , p = . ; day , p = . ; day , p \ . ; day , p \ . ). patients who deceased showed higher s b concentration than survivals for all the samples. good versus poor outcome (gos = - ) differed significantly on days and . logistic regression analysis showed that samples , and h post-tbi sample predicted death outcome. roc curve analysis showed -h sample was the strongest predictor for decease. poor outcome was only predicted by the -h sample. conclusions. s b levels h post-tbi was the strongest predictor for poor and fatal -year outcome, whereas levels at admission do not. a temporal profile of s b release from admission to h post-tbi is strongly recommended for use in identifying the subset of patients liable of developing a worse outcome. according to our results, s b protein might be an early, sensitive, accurate and useful biomarker for predicting long-term outcome in patients with acute severe tbi. grant acknowledgement. this research was made possible in part by the generous donation of protein s b electrochemiluminescence assay kits by roche diagnostics, mannheim, germany. introduction. brain intercellular fluid glycerol concentration as measured by microdialysis catheters has been recognized as an index of glial and neuronal cellular destruction. we present a data analysis correlating glycerol levels with intracranial pressure (icp), cerebral perfusion pressure (cpp), brain tissue oxygen partial pressure (pbtio ), lactate to pyruvate concentration ratio (l/p) and outcome. methods. data of head injured patients is presented. all had simultaneous monitoring of icp, pbtio and metabolic biochemistry by three brain intraparenchymal bolt catheters inserted via the same one burrhole (icp codman or camino, pbtio licox and microdialysis-cma). there was not a clear straight correlation of raised glycerol levels with bad outcome. however, glycerol elevation seemed to be a predictor of intracranial hypertension together with l/p raise. in subarachnoid hemorrhage patients glycerol elevation was an early sign of secondary ischemic insult. conclusion. multimodal monitoring with intracranial catheters is a useful clinical tool for management of critical neurosurgical patients. metabolic biochemistry as measured by microdialysis, and specially l/p and glycerol levels, can early predict incoming intracranial hypertension as well as secondary ischemia. the pulsatility index (pi), a parameter derived from the blood velocities along the cardiac cycle, has been used as an indirect way to evaluate intracranial pressure. the aim of this research has been to evaluate the accuracy of transcranial doppler sonography (through pulsatility index) in the inference of intracranial pressure. methods. population of the study group (high-pi-group): severe head injured patients (gcs at admission \ ; mean age . years; patients with diffuse injury (traumatic coma data bank) type ii ( %) and iii ( %)) who presented episodes of increase of pulsatility index (pi [ . ) in the acute phase of head injury. control group (normal-pi-group): severe head injured patients, with tcd recordings of normal pi (pi b . ). in all the patients the intracranial pressure (icp) was continuously monitored using a intraparenchymal device. all the tcd recordings are referred to the middle cerebral artery of the cerebral hemisphere were icp catheter was inserted. in the transcranial doppler recording, the pulsatility index was automatically calculated derived from the formulae: pulsatility index = (systolic velocity -diastolic velocity)/mean velocity. transcranial doppler sonography recordings of with pulsatility index c . (high normal value of pulsatility index) were correlated with the simultaneous icp value. the incidence of intracranial hypertension (icp [ mmhg) was analyzed in the high-pi-group, and compared with the incidence of intracranial hypertension in the normal-pi-group. methods. in a double-blind, randomized, placebo-controlled clinical trial, patients scheduled for elective cabg was randomly assigned into two groups. after matching inclusion and exclusion criteria and induction of general anesthesia, one group received intrathecal sufentanil (s) and the other group received the same dose of sufentanil plus supplemental bupivacaine (sb). except for this, all the cases were similar regarding anesthesia and surgery. mean arterial blood pressures were measured before and after induction of anesthesia, during the bypass time and after weaning from bypass were checked. also, the need of the patients for administration of inotropic agents after weaning was compared. results. there was more stable mean arterial blood pressure and less inotropic need after weaning from cardiopulmonary bypass in the sb group. also, the sb patients had a more stable hemodynamic profile during the bypass period; especially after the initiation of the bypass. less inotropic agents were needed after weaning in the sb patients. there was no difference between the two groups regarding the extubation time. discussion. the administration of intrathecal sufentanil plus bupivacaine seems to keep the hemodynamic status of the patients more stable than intrathecal sufentanil alone. methods. this study was approved by the hospital s ethics committee. prospective observational study including consecutive patients. preoperatory and postoperatory data were collected. interventions included blood samples for nt-pro bnp taken prior to operation, and and h in postoperative. troponin-i was taken and h postoperatively. blood obtained was processed for nt-probnp with cobas h system Ò point of care (poc) by roche diagnostics, with range from to , pg/ml. the serum nt-probnp level was also correlated with the logistic euroscore and ejection fraction (ef). serum ntpro-bnp and troponin i values were compared between patients with and without postoperative length of stay in the intensive cardiac unit (icu) [ h. and hospital [ days. all results are in median ± sd * p \ . , **p \ . tables ??? and ??? conclusions. preoperative euroscore and nt-probnp levels were higher in patients with ef \ %. the troponin i after surgery increased more in patients whose length stay in icu was longer. after surgery nt-probnp levels increased significantly,and they differ significantly between patients with length stay in icu for more than h and days at hospital. our data collection confirmed that measurement of nt-probnp is useful and helpful during postoperative period and it also predicted a higher possibility for a long stay in icu and a later hospital discharge. however, owing to the small size sample, these results must be regarded as preliminary. conclusions. in spite of the limitations of our trial, percutaneous aortic valve implantation appears to be safety. a high rate of maccv events were observed, essentially due to a disruption of the a-v conduction, in most cases transitional. despite the definition of ''inoperability'' is difficult, less-invasive aortic valve procedures will undoubtedly find a place within current cardiac surgical practice. objective. to describe the evolution of cardiac transplant patients, presenting clinical low cardiac output in the immediate postoperative period, and after handling routine, they are treated with levosimendán (lv). descriptive, prospective and observational in a postoperative care unit for cardiac surgery from a terciary hospital. study period: january -december . lv was used when the patient had inotropic dependence over h, to try to remove the amines or added to them in those cases that do not get these drugs with an adequate hemodynamics. bolus was used in occasions and then infusion of . - . mcg/ (kg min). we analyzed demographic variables, hemodynamic response to the input of the drug if you can reduce or discontinue other medications, clinical tolerance and side effects, overall development, the icu and hospital stay. we studied patients ( women and men). presented a mean age of . . before surgery, all of whom were in nyha functional class iii-iv. three patients were transplanted in emergency. in this series, there is a case without pulmonary hypertension (pah) pre-transplant, patients with mild htp and htp moderate to severe, with a transpulmonary gradient(gtp) between and mmhg. the patients with gtp [ mmhg had a positive reversibility test with sildenafil. ischemia time of surgery was . . in the immediate post, all the patients studied had low cardiac output syndrome by graft postoperative ventricular dysfunction, cardiac index measured by pulmonary artery catheter. in all patients echocardiography was performed to rule out a pericardial effusion with hemodynamic deterioration in cardiac cavities and showed ventricular dysfunction, right dominance in patients. in all patients we observed a good tolerance to the drug. in lv cases facilitated the withdrawal of the remaining. patients were used lv only after the withdrawal of treatment with inotropic dependence on it. in the remaining cases to be associated with other drugs. only two cases could not withdraw inotropic treatment after the lv infusion. in five patients with pulmonary arterial hypertension and prevalence of right ventricular failure, to reduce poscarga also added pulmonary arterial vasodilators. patients have a stay in icu between and days. one patient mortality. . the primary graft failure is a severe potential complication of post-cardiac, which is associated with a worse prognosis. . lv shows good tolerance, without serious adverse effects attributable to the drug, and facilitated the removal of amines and clinical recovery. . it is necessary to expand the case to confirm the results, and to establish the most appropriate indications and patterns of use of this drug. post-infarction ventricular septal defect (infarctvsd) is a rare but serious complication of myocardial infarction, usually quickly followed by low cardiac output. repair of infarctvsd is still a challenging procedure with a high risk of mortality. improvement of surgical outcome depends on results of large studies in this setting. the aim of this retrospective study was the evaluation of preoperative and surgical parameters influencing the -day mortality following surgical repair. conclusions. in this large study, pre-operative left ventricular function and troponin level were found to be the best predictors identifying patients at high risk for -day mortality following surgical closure of infarctvsd. both parameters may be helpful in deciding on the time of the operation and preoperative preparation. in contrast to other findings, in our cohort the location of the vsd (anterior vs. posterior) did not affect mortality. this may be due to improvement of surgical technique and perioperative management over time. adequate fluid therapy is the first step of hemodynamic optimization after cardiac surgery [ ] . cardiac surgery exposes patients to ischemia and reperfusion, which are well known risk factors for a systemic inflammatory response and increased capillary permeability in the lungs [ ] . it is still unclear what type of fluid should be given in the presence of increased pulmonary vascular permeability at hypovolemic status. objectives. aim of this study was estimate the optimal type of fluid for intravascular volume deficit treating without evoking pulmonary oedema. a prospective clinical study at the intensive care unit was performed on mechanically ventilated patients within h after elective cardiac surgery involving cardiopulmonary bypass. patients, divided into four groups, were subjected to fluid challenge according to the global end-diastolic volume index (gedvi) measurements with normal saline , ml or the colloids % gelatin, % hes / . or % albumin ml in min. hemodynamic and extravascular lung water index (evlwi), gedvi measurements were performed exactly before fluid challenge, afterwards and min after challenge. results. the change in evlwi did not differ between saline and colloid fluid challenge. gedvi increased by % in saline group, by % in % gelatine, in % hes / . and in % albumin. conclusions. all colloid fluid infusion leads to the greater increase in cardiac preload compare to normal saline (saline in four times larger volume). the change in evlwi did not differ between saline and colloid fluid groups and did not increase pulmonary oedema despite in the presence of increased pulmonary vascular permeability, when fluid overloading is prevented. introduction. the annual incidence of prosthetic valve thrombosis is up to - % (patients-year) despite the anticoagulant therapy. conventionally, the treatment of choice for this event was the surgical valve replacement. however, fibrinolytic therapy has become a valid alternative for the treatment of this serious complication, especially in high-risk surgery patients. to analyze the clinical factors, diagnosis and treatment management of patients with prosthetic valve thrombosis admitted to the acute cardiac care unit. we designed an observational-descriptive study, including patients admitted between and . clinical factors were analyzed: sex, age, prosthetic valve position, time from valve replacement, inr at admission, clinical features, diagnostic technique and treatment used. results. patients were included. . % were women, . % men. mean age was . ± . years. the highest incidence was at the tricuspid prosthetic valve position ( . %), followed by the mitral ( . %) and the aortic position ( . %). when a triple valve replacement was performed, the tricuspid position was the most often affected. mean time from the first valve replacement surgery was . ± . years. clinical features which led to the diagnostic were: acute heart failure ( . %), peripheral embolization ( . %), chest pain ( . %) and syncope ( . %). the diagnostic techniques used were transesophageal echocardiography (tee) and cinefluoroscopy in all the patients. inr at admission time was lower than adecuate anticoagulation recommendations in . % of patients. the most widely used treatment was the systemic fibrinolytic therapy ( . %), followed by surgery ( . %) and conservative treatment with heparin alone ( . %). the most widely used thrombolytic was rtpa in . % of patients, with a mean dosage of . ± . mg. one patient was treated with . mil. ui of streptokinase. unfractionated heparin was added to all patients whom received fibrinolytic therapy, with a mean dose of ± ui/h. a . % incidence of minor bleeding was found in the fibrinolytic group. there were no major complications due to fibrinolytic. total mortality rate was . %. our experience, suggests that systemic fibrinolytic therapy is safe and effective in patients with prosthetic valve thrombosis. objective. to describe the outcomes of patients with acute, refractory, non-ischaemic and not postcardiotomy, cardiogenic shock treated with extracorporeal membrane oxygenation (ecmo) and to evaluate whether survivors and non-survivors differed with respect to clinical characteristics, pre-ecmo treatment and laboratory values. design. in this retrospective cohort study, information is collected from a database with additional review of medical records. patients. consecutive adult patients, males, mean age . ± . year, presenting to hospital with non-ischaemic acute severe, refractory cardiogenic shock, supported by central or peripheral venoarterial (va) ecmo. measurements and main results. characteristics of survivors and non-survivors were compared using chi square test. twelve patients ( %) were transported to our institution on ecmo. eleven patients ( %) were weaned from ecmo, seven ( %) bridged to ventricular assist devices. in two patients ( %) ecmo support was withdrawn. mean duration of ecmo support was . ± . h. overall survival was %, and did not differ between patients with myocarditis (n = ), cardiomyopathy (n = ) and acute on chronic non-ischaemic cardiogenic shock (n = ). a larger proportion of the three patients with or more complications died as compared to the seventeen patients with less than complications ( % versus %, p = . ). pre-ecmo intra-aortic balloon counterpulsation (iabp) was used in patients, % survived, as compared to % of those who did not receive iabp (p = . ). we have not identified any other significant differences between survivors and non-survivors. conclusion. the survival of patients on ecmo in this unique heterogeneous patient cohort is similar to the survival of ecmo support for fulminant myocarditis in the literature. we recommend to institute ecmo early in all medical patients with acute non-ischaemic cardiogenic shock, refractory to conventional therapy, or to refer these patients in time to an ecmo centre. introduction. human parvo b virus is associated with a broad spectrum of clinical manifestations, mostly in children or immune-compromised patients. in adults, severe myocarditis due to this viral agent is a rare disorder, presenting as acute congestive heart failure. we describe a patient with rapidly progressive heart failure, needing circulatory support by extracorporeal membrane oxygenation (ecmo). methods. case report. a -year-old previous healthy female was admitted to our icu with nausea, vomiting, bradycardia and hypotension with a blood pressure of / mmhg. two weeks before admission, patient had signs of erythema infectiosum. on physical examination the patient was pale, with venous congestion, third heart sound and hepatomegaly. the initial electrocardiogram showed a slow, regular, ventricular rhythm. admission chest x-ray showed normal heart size with bilateral pleural effusion. echocardiography revealed dilated ventricles (rv and lv) with depressed systolic function and a thrombus in the rv apex. patient was initially treated with intravenous medical therapy, but unfortunately developed progressive cardiogenic shock. troponin levels, serum transaminases and bun were extremely elevated. it was therefore decided to implant a percutaneous ecmo by femoro-femoral cannulation which permitted to stabilize hemodynamic conditions while peripheral organ functions returned to normal range. progressive cardiac recovery was observed after days with a circulatory assistance with a mean flow rate of . l/min. as myocardial function improved, ecmo was gradually weaned and removed after days of support. however, atrioventricular conduction did not recover, necessitating implantation of temporary vvi-pacemaker, which was later replaced by a permanent ddd pacemaker system. pathology of the endomyocardial biopsy showed extensive lymphocytary infiltration with destruction of myocytes. parvo b dna-pcr was positive in both the biopsy and serum. these findings suggest that this patient developed severe myocarditis induced by parvo b viral infection. to our knowledge, parvo b viral infection is an uncommon cause of severe myocarditis in adult patients. sparse literature is available describing the use of ecmo in these adult patients. conclusion. this case report shows that parvo b virus should be recognised as a potential infective agent in adult patients presenting with severe myocarditis. furthermore, ecmo can be safely used to stabilize hemodynamics and peripheral organ perfusion in expectation of myocardial recovery in these patients. copeptin is easier to measure than vasopressin, and could be used as a marker of vasopressin release [ ] . the aim of the study was to compare plasma concentration of avp and cop during cardiac surgery, and specifically during post cardiac surgery vasodilatory syndrome (pcsvs). methods. two-month consecutive patients scheduled for cardiac surgery with cardiopulmonary bypass (cpb) were included in the study except patients suffering from chronic renal failure and under dialysis. blood samples were obtained from blood withdrawals routinely operated before cpb, during cpb and after surgery, at the postoperative hour (h ). these samples were used for avp and cop measurements. pcsvs, assessed as hypotension unresponsive to volume replacement therapy and without cardiogenic shock features, was treated with norepinephrine (ne). patients treated with ne have been compared to the others. statistical test consisted of variance analysis, non parametric test (mann whitney or wilcoxon) and linear regression. a p value of less than . (p \ . ) was considered statistically significant. results. patients have been included, out of which have been treated with ne. correlation between avp and cop plasma concentrations is significant (r = . , p \ . ). avp and copt concentrations increased significantly at h but the increase is less pronounced in ne-treated patients (fig. ) . ne-treated patients had lower preoperative left ventricle ef ( . ± . vs. . ± . %, p = . ), longer cpb ( . ± . vs. . ± . min, p \ . ) and clamping times ( . ± . vs. . ± . min, p \ . ), higher incidence of low output syndrome ( / vs. / , p \ . ) longer extubation time ( . ± . vs. . ± . h, p \ . ) and higher plasma cop before (t ) and during cpb (fig. ) . avp (ng/ml) et copeptin (cop, pmol/l), in patients. *p \ . ne versus others discussion. correlation between avp and cop is similar to that observed in other studies [ ] . the correlation coefficient is rather weak that is possibly related to avp dosage limitations (binding of avp to blood platelets, lack of antibody-specificity). increased cop plasma concentrations before and during cpb is observed in sicker patients undergoing more complex surgery, which seems to expose them to relative postoperative vasopressin deficiency and pcsvs. background. waiting list for heart transplantation has been growing up. high doses of cathecolamines has been an exclusion criterion for heart donation and norepinephrine use is still controversial. to assess if norepinephrine used on heart donors modify receptors outcome. methods. historical cohorts study from april to march . patients were divided in two groups: group : patients with local donors treated with norepinephrine (n = ). group : patients with local donors managed with other cathecolamines (n = ).cathecolamines were used at least for h and doses were between . and mcg/(kg min) if norepinephrine and between and mcg/(kg min) if dopamine or dobutamine. mortality risk factors published on the last international society for lung and heart transplantation guidelines were recorded. graft dysfunction risk factors were also collected. heart transplant outcome was measured by -day mortality, mortality rate at first, second, fifth and tenth years; and graft dysfunction incidence. chi-squared and t student test was used. multivariate logistic regression was used to evaluate norepinephrine impact on the outcome. mortality in group was . and % in group . no differences in mortality or graft dysfunction incidence were found in multivariate analysis. conclusions. norepinephrine used for donors management compared with dopamine and dobutamine does not increase mortality or graft rejection incidence in heart transplantation. groups were not uniform so further studies may be made to determine this association. introduction. coronary artery bypass surgery on cardiopulmonary bypass is associated with significant morbidity and mortality. with present technology, all arteries on the heart can be bypassed off-pump. the benefit of this technique is higher for patients whom are at increased risk of complications from cardiopulmonary bypass, such as those who have heavy aortic calcification, carotid artery stenosis, prior stroke, and compromised pulmonary or renal function. to evaluate the short-term follow up results of off-pump coronary artery bypass (opcab) and postoperative management of these patients admitted to our coronary care unit. we designed an observational study that included patients who underwent opcab from july to december . data were collected on preoperative age, sex, major cardiovascular risk factors, history of prior ami, number of affected vessels and ventricular function. after the surgery we evaluated: the extubation time, postoperative bleeding, troponin maximum level, need for blood transfusion, use of vasoactive drugs and intra-aortic balloon pump, development of renal failure, atrial fibrillation, neurological complications and reintervention. results. patients were included. . % were men and . % women. mean age was . ± . years. % of patients had one or more cardiovascular risk factor: hypertension was present in . %, smoking . %; diabetes mellitus . % and dyslipidemia in . %. there was prior myocardial infarction in . % of patients. prior coronary angiography showed . % of patients with vessels disease and . % of vessels disease. mean lvef was %. mean number of grafts was . . mean extubation time was . h. mean postoperative bleeding was estimated in cc. . % of patients needed blood transfusion; . % vasoactive drugs; and . % needed an intra-aortic balloon pump. . % of patients developed troponin t elevation with a mean level of . ng/ml. . % of patients developed atrial fibrilation, and . % renal dysfunction (two patients needed hemodialysis). there was no neurological complications. patient needed a reintervention. mean of intensive care unit stay was . ± . days. total mortality rate was . %. our experience shows that the off-pump coronary artery bypass graft surgery is a safe and effective technique for coronary revascularization, with low mortality and morbidity rates and reduced postoperative complications. objectives. to assess if deterioration of left atrial function in patients with severe sepsis and septic shock could predict mortality. we studied patients with severe sepsis or septic shock with mean age of . ± . . underlying echocardiographic parameters were measured on admission, th and th day, which comprised left ventricular ejection fraction (ef), and atrial function which is expressed as atrial ejection force (aef), with aef defined as the force that the atrium exerts to propel blood into the left ventricle (lv). all patients were subjected to bnp assay well. multivariate analyses adjusted for acute physiology and chronic health evaluation score ii (apache ii score) was used for mortality prediction. results. underlying source of sepsis was lung in patient ( %), blood in seven patient ( . %), abdomen in seven patients ( . %), while three patient ( %) had urinary tract infection (uti) as a cause of sepsis. only one patient had cns infection. severe sepsis was admission diagnosis for patients, patients were labeled as septic shock. look for days mortality. in-hospital mortality was . % ( patients) . admission ef showed significant difference between survivors and non-survivors . ± . versus . ± . % (p \ . ), on the other hand admission aef showed insignificant changes between the same groups . ± . versus . ± . k/dynes p = . , while bnp was significantly higher in the non-survivors , ± . versus . ± . pg/ml (p \ . ). multivariate logistic regression, the predictable variables for mortality was apache ii score, bnp then ef. conclusion. in septic patients, left atrial function unlike the ventricular function and bnp levels cannot be used as independent predictor of mortality. objectives. to analyse the relationship between plasma levels of nt-probnp and lcd diagnosed by echocardiograph during ss. methods. prospective observational cohort study. inclusion criteria: consecutive patients with ss [ ] . non inclusion criteria: creatinine clearance \ ml/min, years \ age \ years, cardiac surgery patients, pre existing coronary or cardiac insufficiency, neoplasia and systemic diseases. the evaluation of the left ventricular function was realised by a trans-thoracic or a trans-oesophageal echocardiograph on day . the lcd was defined by a left ventricular fraction of ejection \ % evaluated by teicholtz. the blood tests for nt-probnp analyses were drawn on days , , and . serum nt-probnp measurements were made automatically by elecsys analyser with the truss nt-probnp (roche diagnostics, myelan, france) by the electrochemiluminescence immunoassay method (eclia). data are expressed as mean ± sd and percentages. statistical analysis was performed by repeatedmeasures anova and roc curves (p \ . indicated statistical significance). . patients were included in a period of months (medical patients n = , surgical patients n = and trauma patients n = ), age = ± years, bmi = ± kg/m , apache ii = ± , igs ii = ± , duration of intensive care unit stay = ± days, mortality = %. lcd was observed in patients. the statistical analysis showed a significant elevation of nt-probnp in patients with lcd (table ) . on day , the area under roc curve was . , and the cut off value of nt-probnp predictive of lcd was , pg/ml (sensibility = %, specificity = %). introduction. fluid responsiveness can be predicted by the respiratory variation of arterial pulse pressure (ppv) or of pulse contour-derived stroke volume (svv) as well as by the changes in pulse contour-derived cardiac index during a passive leg raising manoeuvre (plr) or a tele-expiratory occlusion (teo). we evaluated the ability of an infrared photoplethysmography arterial waveform (cnap device) to estimate ppv. we also tested the ability of this non invasive estimate of ppv to predict fluid responsiveness compared to the invasive measure of ppv, to svv and to the plr and teo tests. in patients with septic shock ( ± years of age, receiving norepinephrine, saps = ± , lactate = . ± . mmol/l), we measured the response of cardiac index (pulse contour analysis, picco device) to fluid administration ( ml saline over min). before fluid administration, we recorded the ppv directly calculated from the non invasive arterial pressure signal (ppv ni ), the ppv directly calculated from the invasive arterial pressure signal (ppv i ), the ppv automatically provided by the picco device (ppv picco ), the svv automatically provided by the picco device, the changes in cardiac index induced by a plr test and the changes in cardiac index induced by a -s teo. results. five patients were excluded because the arterial curve could not be obtained by the cnap device due to excessive vasoconstriction. in the remaining patients, fluid administration increased cardiac index by more than % ( ± %) in ''responders''. the fluid-induced changes in invasive (? ± %) and non invasive (? ± %) mean arterial pressure were correlated (r = . , p \ . ). at bland-altman analysis, ppvni accurately reflected ppvi (bias %, limits of agreement ± %). for predicting fluid responsiveness in the patients, the receiver operating characteristics (roc) curves for ppv ni , ppv i , ppv picco , svv, plr and teo were . ± . , . ± . , . ± . , . ± . , . ± . , . ± . (all non significantly different). when considering only the patients ventilated with a tidal volume b ml/kg predicted body weight, were falsely classified as non responders by ppv ni , ppv i and two others by ppv picco and svv, but all four were well classified by plr or teo. in septic shock patients, provided that vasoconstriction is not excessive, the non invasive assessment of arterial pulse pressure seems valuable for predicting fluid responsiveness. introduction. mechanical ventilated patients often require inotropic support. however, the role of mechanical ventilation (mv) in myocardial depression is not well understood. septic patients often have impaired cardiac function and are in need of mechanical ventilation. we hypothesized that mv enhances sepsis-induced myocardial depression. objectives. in this study we investigated the influence of mechanical ventilation on cardiac function in an acute sepsis model. sepsis was induced in male wistar rats using ip injection of lps. healthy and septic rats were randomized to one of three ventilation groups; ( ) non-injurious ventilation with a tidal volume of ml/kg and cm h o peep (low tidal volume, ltv), ( ) injurious ventilation with a tidal volume of ml/kg and cm h o peep (high tidal volume, htv) and ( ) spontaneous breathing. arterial pressure was kept at least at mm hg. cardiac output (co, thermodilution method), central venous pressure (cvp) and mean airway pressure were measured in vivo. after h of ventilation, animals were sacrificed and cardiac function was measured ex vivo in a langendorff setup and expressed as developed pressure and ?dp/dt. cardiac wet to dry weight ratio was calculated. results. cardiac output in vivo was lower during htv ventilation than during ltv ventilation (p \ . ). cvp did not differ between ventilation strategies while mean airway pressure was higher in htv ventilation than in ltv ventilation (p \ . ). ex vivo, cardiac function of septic animals was depressed compared to healthy controls (p \ . ) in septic animals, cardiac function was better in htv ventilated animals than in non ventilated animals (p \ . ). ventilation lowered cardiac wet/dry ratio (p \ . ). developed pressure (p \ . ) and ?dp/dt (p \ . ) correlated inversely with cardiac wet/dry ratio. [ ] . perfusion may be also evaluated by other parameters such as lactate or venous-arterial pco gradient (delta pco ). objectives. to evaluate if early normalization of scvo after emergency intubation in septic patients persists over time and if it is associated with similar trends in lactate and delta pco . methods. ten septic patients subjected to emergency intubation for respiratory or circulatory failure and in whom scvo increased to [ % after the procedure. these patients were included in a large prospective study published elsewhere [ ] . patients used a common intubation protocol and we evaluated several perfusion related parameters before, min and h after emergency intubation. statistical analysis included friedman and wilcoxon tests. results. evolution of perfusion parameters after intubation is presented in table . five patients died during icu stay. as a whole, scvo remained stable in pts and decreased dramatically at h by[ % in non-survivor patients (lowest %). only pts had a high lactate before intubation that did not normalize at h (both non-survivors). delta pco exhibited erratic changes over time with no correlation with scvo changes and with mortality ( fig. ). introduction. venous to arterial carbon dioxide difference (pv-aco ) could reflect the sufficiency of blood flow in shock states. time evolution of pv-aco during early phases of resuscitation in septic shock has not been widely characterized. we proposed to describe the association between time course of pv-aco during the initial resuscitation and outcomes in septic shock. methods. patients with a new septic shock episode admitted to icu were included. general management was guided according surviving sepsis campaign recommendations. time (t ) was set when a central venous catheter was inserted to guide reanimation. simultaneous measurements of lactate and arterial-venous gases were obtained at t and h after (t ). pv-aco was calculated as the difference between venous co (blood samples drawn from a central catheter) and arterial co . a value of pv-aco [ was considered as high. survival at day was described for four groups: persisting high pv-aco (high at t and t ), increasing pv-aco (normal at t , high at t ), decreasing pv-aco (high at t , normal at t ) and persistently low (normal at t and t ). survival probabilities were estimated using kaplan-meier method. log-rank test was use to estimate a two-tailed p value for the differences in survival among groups. results. sixty septic shock patients were analyzed. mortality rate was . %. no demographic differences at baseline between survivor (s) and non-survivors (ns) were found. there were no differences in the amount of fluids administered at t and t . no significant differences in scvo at t for s introduction. septic shock (ss) has been defined as sepsis related hypotension despite adequate fluid resuscitation ? perfusion abnormalities such as lactic acidosis [ ] . despite this, an operationally simplified definition overlooking perfusion parameters, has been utilized in several landmark studies during the last decades [ ] [ ] [ ] [ ] . more recently, a new consensus reemphasized the pivotal role of hypoperfusion in ss definition and added low svo as a surrogate [ ] . several problems emerge from these apparently interchangeable definitions, including pathophysiologic and epidemiologic (incidence, outcome) issues. objectives. our aim was to evaluate if applicating different commonly used ss definitions to vasopressor-requiring septic patients leads to distinct outcomes. methods. we applied the two most utilized ss definitions to hypotensive septic patients managed with a ne-based algorithm [ ] for years, generating two major subgroups for analysis (fig. ) . statistical analysis included chi-square test. (fig. ) . pts of subgroup , exhibited persistent normal lactate levels with a mortality of . % which was similar regardless of svo [ or \ : p = . . (fig. ) . conclusions. commonly used ss definitions are not interchangeable and when applied to the same vasopressor requiring septic patients lead to statistically different mortalities. our data suggest that lactate and svo cannot be used indistinctly to define shock condition. a reappraisal of clinical septic shock definition appears to be necessary. objectives. to assess intra-and inter-observer agreement of ecg interpretation in adults with septic shock (vasst, nejm ; : ) . methods. patients were randomised to receive a blinded infusion of low-dose vasopressin or norepinephrine in addition to open-label vasopressors. eight icus participated in this ecg sub-study; and -lead ecgs were recorded at baseline (prior to study drug infusion), and h, and days after initiation of study drug. an intensivist (reader ) and a cardiologist (reader ), blinded to patient data and randomization group, interpreted all of the ecgs in duplicate, using a checklist. prior to ecg interpretation, a calibration exercise was performed to refine definitions and maximize inter-observer agreement; both readers reviewed ecgs (from the current study) representing the spectrum of normal to abnormal. cohen s kappa statistic was used to assess intra-and inter-rater reliability. methods. the model consists of eight elastic chambers including the heart and circulations. identification of the parameters is made only from measured pressures in the aorta and pulmonary artery, and the volume in the right ventricle. septic shock was induced in (n = ) healthy pigs with endotoxin infusion over min. right ventricular pressure-volume loops were recorded by conductance catheter and end-systolic ventricular elastance was assessed by varying right ventricular preload. consent was obtained from the university of liege medical ethics committee. errors for the identified model are within % when the model is identified from data, re-simulated and then compared to the clinically measured data. even with a limited amount of available experimental data to identify the parameters of the model, all simulated parameters trends match physiologically expected changes during endotoxic shock. in particular, a close match of the trends of the right ventricular end-systolic elastances are obtained, when compared to previously reported experimental results [ ] , including capturing of the peak after min and a decaying oscillation after min. conclusions. pig-specific parameters for the cvs model were accurately identified using a significantly reduced data set. this research shows the ability of the model to adequately and realistically capture the impact of pressure-volume changes during endotoxic shock. in particular, the model is able to aggregate diverse measured data into a clear, clinically and physiologically relevant diagnostic picture as the condition develops. this research thus increases confidence in the clinical applicability and validity of this overall diagnostic monitoring approach. background. conflicting data exist concerning the effects on the microcirculation of increasing mean arterial pressure (map) with norepinephrine (ne) in septic shock. nearinfrared spectroscopy (nirs) has been proposed as a tool to quantify microvascular dysfunction in patients with sepsis. by inducing a vaso-occlusive test (vot), a variety of nirsderived variables can be measured to assess local metabolic demand and microvascular dysfunction. this trial was conducted to test the effects of increasing map by ne on microvascular reactivity in patients with septic shock. after local ethical committee approval and informed consent, we enrolled patients in septic shock with an arterial pressure stabilized by ne. in addition to hemodynamic measurements, svo and blood lactate level, we measured thenar muscle oxygen saturation (sto ) and muscle tissue hemoglobin index (thi) by a tissue spectrometer (inspectra tm model , hutchinson technology inc, mn). serial vot (upper limb ischemia induced by a rapid pneumatic cuff inflation around the upper arm) were performed. we also recorded during the vot: basal sto , thi, the slope of the decrease in sto during the occlusion (desc slope; %/min) and the slope of the increase in sto following the ischemic period (asc slope; %/s). muscle oxygen consumption (nirvo i) was calculated as the product of the inverse of the slope value by the mean of thi over the first minute of arterial occlusion and is expressed in arbitrary units (u) (skarda shock ). all these data were obtained at different times: baseline and with map of mmhg, then at mmhg and mmhg of map by increasing the ne doses and finally to baseline . we report here data corresponding to the mean and sd of baseline and versus map mmhg analyzed by repeated measures analysis of variance (at % level) with bonferroni adjustment to account for multiple comparisons. increasing ne dose induced an increase in cardiac output (from . ± . to . ± . l/min, p \ . ) without any changes in heart rate and an increase of svo (from . ± . to . ± . %, p \ . objectives. to investigate: . the effects of ''successful'' protocolised resuscitation (egdt) on microvessel perfusion (particularly density). . whether there is different effects of egdt on the microcirculation of septic compared to critically ill non-septic patients and . whether there is a difference in the behaviour of ''true'' capillaries (i.e - lm) compared to larger microvessels ( - lm) at baseline or after resuscitation. prospective observational study in the emergency and intensive care departments of an urban teaching hospital. subjects: septic and critically ill control patients requiring shock resuscitation (map less than mmhg, ±cvp less than mmhg, ±central venous saturations less than %). all patients had invasive monitoring and identical cardiovascular targets. patients with known cardiogenic shock or pre-stabilised trauma were excluded. we performed sidestream dark field (sdf) videomicroscopy of sublingual microcirculation at the point of egdt initiation and again on attainment of at least out of cardiovascular goals. three sites were imaged for s and the clips were analysed randomly off-line to provide an average value for capillary density (total length and count per mm) and a semi-quantitative description of microvessel flow (continuous, intermittent or stopped) as previously described. vessels were grouped according to diameter as small ( - lm) and medium ( - lm). non parametric analysis was used for all within or between group comparisons, data is displayed as median values with [range]. *p \ . was considered significant. ( ) ( ) ( ) ( ) duration of occlusion (min), mean ± sd . ± . . ± . . ± . . ± . minimal sto (%), mean ± sd ± ± ± ± as expected, all septic shock patients, except one (for the vot fa % ) and two (for the vot a % ) had a recovery slope lower than normal when sto decreased to % during arterial occlusion. by contrast, when occlusion lasted min, many patients including patients who eventually died, were misclassified since their recovery slopes were in the normal range. these results could be due to the smaller decrease of sto and in turn a less strong hyperemic response when ischemia lasted only min. additionally, a significantly (p \ . ) shorter time to reach % was required when arm (compared to forearm) occlusion was performed. conclusion. when a vot is required for assessing microcirculatory disturbances in septic shock, we recommend performing it using an arm occlusion until sto reach %. aims. to analyze the correlation between sto (and its changes derived from a transient ischemic challenge) and global oxygen delivery (do ) parameters measured invasively using a pulmonary artery catheter (pac). observational study, performed in a -bed medical-surgical icu, at a university hospital. we recruited adult patients with cardiovascular insufficiency that required a pac placement for hemodynamic monitoring and resuscitation. we collected demographic data, and hemodynamic and oxymetric data derived from the pac. simultaneously, we measured sto and its changes derived from a vascular occlusion test (vot). results. twenty-two patients were studied. all the patients had a mean arterial pressure (map) above mmhg. the do index (ido ) range in the studied population was - mlo /(min m ). the mean svo value was ± %, mean cardiac index (ci) . ± l/ (min m ), and blood lactate . ± . mmol/l. the correlations found between sto and invasive oxygen delivery-related variables are shown in table . the sto -deoxygenation slope (deox) during the vot showed a significant correlation with svo (r . , p . ). we did not find any correlation between sto and global flow measurements, such as cardiac index (ci), but we found a correlation between sto and ido . this correlation seems related to the arterial oxygen content, and not to global flow. normal sto values could not rule out low ido and low ic states. therefore, sto seems to be poorly sensitive to exclude hypoperfusion states. in clinical practice there remains issues over the appropriate prescribing of antibiotics in patients with unproven sepsis. the prescribing of antibiotics is not without risk and creates a selective pressure on existing bacterial flora resulting in the emergence of virulent and resistant organisms [ ] . there is also a cost issue from the inappropriate prescription of antimicrobials [ ] . the diagnosis of sirs can be made with confidence [ ] , sepsis cannot and requires confirmation from microbial tests. empirical usage of antibiotic therapy is commonplace but not ideal. rapidly detectable, reliable markers of sepsis would help in directing antimicrobial therapy. objectives. the aims of this study are to determine the significance of % band forms in sirs patients suspected to have sepsis. can they be used as a diagnostic tool in conjunction with procalcitonin in order to direct antimicrobial therapy? methods. this is an observational study aiming to assess the ability of serum procalcitonin and percentage band forms in identifying nosocomial sepsis in patients with sirs. patients were recruited over an month period in a mixed medical-surgical university teaching icu. all patients had suspected sepsis arising 'de novo' and had not received prior antimicrobial therapy. patients had a septic screen performed along with baseline, and hpct and % band form count. introduction. pneumonia is the most frequent infectious complication after successfully resuscitated cardiac arrest (ca). however, diagnosis is difficult because of many clinical, biological and radiological confounding factors as well as the widespread use of therapeutic hypothermia. this could lead to a broad antibiotic prescription. to assess the utility of plasma procalcitonin (pct) measurements for diagnosis of early-onset pneumonia in successfully resuscitated ca. monocentric study (july -march with retrospective review of a prospectively acquired icu database focusing on all consecutive patients admitted for ca and surviving more than h. patients with an infection prior to ca or with an extra-pulmonary infection developing within days following admission were not studied. all files were reviewed to assess the diagnosis of early-onset pneumonia p(?), or not p(-) during the first days of icu stay. p(?) was defined by the presence of a new pulmonary infiltrate on chest radiography, persistent for at least h, associated with either positive quantitative culture of the endotracheal aspirates, either, in case of lack of bacteriological sample, conjunction of purulent sputum and hypoxemia (p/f \ ). pct was measured at admission, days (d) , and (brahms kryptor Ò ). among patients admitted for ca, were studied ( death before h, evolutive infections and incomplete samples). pneumonia was diagnosed in patients ( %), and antibiotics were prescribed in during the first days of icu stay. characteristics of p(?) and p(-) patients were (median, iqr): age ( - ) versus ( - ) (p = . ), ''no flow'' ( - ) versus ( - ) min (p = . ), ''low flow '' ( - ) versus ( - ) min (p = . ), shockable rhythm versus % (p = . ), cardiac etiology versus % (p = . ), therapeutic hypothermia versus % (p = . ), post-resuscitation shock versus % (p = . ) and icu mortality versus % (p = . ). using a threshold value of . ng/ml, negative predictive values were % at admission, % at d , % at d , whereas positive predictive values were , and %, respectively. patients with post-resuscitation shock had higher pct levels than those that did not require vasopressors: . versus . ng/ml at d (p \ . ), . versus . at d (p \ . ) and . versus . at d (p = . ). conclusion. diagnosic value of pct is poor in survivors of ca and pct should not be recommended to assess early-onset pneumonia. post-resuscitation disease could play a major role in the lack of specificity and predictive values. in acute community respiratory infection, low levels of procalcitonin (pct) have been shown to allow a marked reduction of antibiotic use. the aim of the study was to look for the same efficacy in case of suspicion of infection during icu stay. method. from april to december , patients hospitalized in the five intensive care units (icu) of the university hospital of liège in belgium, were prospectively randomized to either a procalcitonin guided approach to antibiotic therapy (pct group, n = ) or to a standard approach (ctrl group, n = ) when they were suspected of developing an infection. for pct group guided therapy only, the use of antibiotics was more or less strongly discouraged (pct level . or. lg/ml, respectively) and more or less recommended (pct level [ or[ . lg/ml, respectively) . number and duration of antibiotic treatments were recorded. diagnosis and treatment decisions were reviewed by infectious disease (id) specialists at the end of icu stay. results. there were no differences between groups in terms of age ( vs. ), saps ii score ( . ± . vs. . ± . ), type of patients (medical: vs. %, scheduled surgery: vs. %, emergency surgery: vs. %, trauma: vs. %), icu length of stay [ (iqr - ) vs. days (iqr - )] for pct and ctrl group respectively. suspicion of infection was either evoked on admission (in and %) or during icu stay (in and %) in pct group and ctrl group respectively. at the time of suspicion, pct levels was. lg/ l in . % of the infectious episodes in pct group and . % in ctrl group. episodes of suspected infection with pct level . lg/ml were recorded. clinicians decided not to treat % of these episodes (n = ). the remaining episodes were treated, of which % were eventually considered as probable or confirmed infections by id specialist (n = ). at the end of icu stay, id specialists classified infectious episodes of both groups as confirmed (n = ; . %), probable (n = ; %), possible (n = ; %) or absent (n = ; . %). for confirmed episodes of infection, pct levels were . lg/ml in as much as . % and above lg/ml in . %; for absence of infection, pct levels were . lg/ml in only . % and above lg/ml in . %. the ability of pct to discriminate between confirmed and probable infections on the one hand and possible or absent infection on the other hand, was tested by the measurement of the surface under the roc curve, which was . , which is too low to recognize pct as a valuable marker of infection. there were no difference in the number of treated patients ( vs. %) nor in the number of antibiotic days ( vs. %) between pct and ctrl group respectively. conclusions. procalcitonin level as an aid for the decision to treat infection in icu patients appeared not to be helpful. antibiotic consumption was not reduced using this tool in our study. introduction. respiratory infections, pneumonias in particular are a common cause of mortality in the intensive care unit (icu) patients worldwide. early identification and prompt management of these patients especially with associated sepsis is crucial in reducing the mortality. many clinical and laboratory markers have been studied extensively to predict the outcomes in them. there have been numerous studies on the clinical utility of serum procalcitonin (pct) in the past decade, in systemic inflammation, infection and sepsis. objective. to evaluate the role of serum procalcitonin, in predicting the outcomes of patients admitted in the icu with respiratory infections associated with sepsis. setting: bedded icu of a tertiary referral hospital. study design: prospective observational study. subjects: adult ([ years) patients admitted in the icu with lower respiratory tract infections with associated sepsis during the period july to january were prospectively followed up. primary outcome measure: day mortality. we measured pct levels using the brahms immunochromatographic technique(semiquantitative estimation) on the first day of admission into the icu . normal pct was taken as . ng/ml. patients were grouped into four groups-group a (pct \ . ng/ml), group b (pct [ . - ng/ml), group c (pct [ - ng/ml),group d (pct [ ng/ml). sepsis, severe sepsis, septic shock are defined according to the accp/sccm criteria. results. the overall mortality was . % with mortality of . , . , , and % in groups a, b, c and d, respectively. there is a statistically significant difference (p \ . ) in the mortality rates of groups c and d as compared with group a and b, but no difference was observed in the mortality rates between groups a and b and groups c and d .also significant statistically are the apache ii scores, septic shock and multiorgan failure incidence in the groups c and d as compared to groups a and b. conclusions. serum procalcitonin level [ ng/ml on the first day of admission in icu appears to be a good predictor of mortality in patients admitted with lower respiratory tract infections and associated sepsis. methods. in a retrospective study we assessed acutely ill patients investigated for pct and treated by a physician blinded for pct value. for each patient we also calculated new simplified acute physiology score (saps ii). we evaluated many clinical and instrumental parameters and diagnosis was done upon our usually clinical practice results. the mean age of patients (pt) was . yeats, shock was found in patients ( . %),median value of saps ii score was (iqr - ), and median estimated mortality from saps ii was % (iqr - ). bacterial infection was found in . % (septic shock . %, pneumonia . %, cholecystitis . %, pleural empyema . %, other infections . %) non infective disease in . % (pulmonary embolism . %, acute coronary syndrome . % heart failure . % other disease . %. a pct value [ . ng/ml was considered positive: so pct was elevated in . % of bacterial infection patients and in . % of non infective disease patients. we also compared pct values with antibiotic therapy and considered appropriate the administration if pct [ . ng/ml: there was discrepancy in . %. the review of these cases found medical decision wrong in cases versus ( . %); pt with pct \ . ng/ml had antibiotic therapy without bi and cases with pct [ . ng/ml did not have antibiotic therapy but had a bacterial infection. subsequent to this review discrepancy felt to . % (ci % . - . ) and was found especially in pt with pct \ . ng/ml. at cut off point of . the sensitivity was . (ci %: . - . ) specificity . (ci %: . - . ) or . and at point . the sensitivity was . (ci %: . - . ) specificity . (ci %: . - . ) or . , with high predictive positive value. all-causes mortality was . %. mortality if pct \ . ng/ml was . %, if pct . - . ng/ml was . %; if pct . - . lg/ml was . % and if pct [ ng/ml was . % without significant difference between bacterial infection and non infective disease group. comparing pct with saps ii score, area under roc-curve was not significantly different (pct . -ci %: . - . ) (saps ii . -ci %: . - . ). conclusions. pct in acutely ill patients is a useful marker to discriminate bacterial infections with high sensibility but low specificity and it may be useful to guide the therapy also with values higher than . ng/ml. our data suggest a real prognostic utility of pct in these patients, regardless of bacterial infections, but our efforts to elaborate a mathematical predictive model aren't still satisfying and further data are required in this setting. h. taniuchi , t. ikeda , k. ikeda , s. suda tokyo medical university, hachioji medical center, division of critical care medicine, tokyo, japan introduction. its apparent that detection of the causative bacteria is useful for the therapeutic strategy. however, conventional tests for the detection of the causative bacteria are not high sensibility. in order to diagnose sepsis or septic shock and start appropriate therapy rapidly, it's also important to know whether the infection is cause of gram negative bacteria, that is to say, whether the infection is cause of endotoxin. in this study, we investigate the severity level of sepsis and initiation criteria of direct hemoperfusion with polymixin b immobilized fiber column (pmx-dhp) treatment from the result of severity level by using endotoxin activity assay (eaa) and using measurement of procalcitonin (pct). subjects and methods. patients who developed severe sepsis or septic shock and admitted to icu were included. on the day of icu admission, a general blood biochemistry, eaa and pct levels, and apache ii and sofa score were measured. patients were evaluated retrospectively the relationship between the severity of sepsis and each measurements and investigated the relationship between the measurements and pmx-dhp. serum eaa level was measured using smart line eaa luminometers. serum pct level was measured using immune luminometric assay. results. the average age of the patients is ± , apacheii score was . ± . , sofa score was . ± . , the median pct was . ng/ml (range - ), eaa was . ± . . the underlying diseases of the enrolled patients were the abdominal infection ( patients), the urinary tract infection ( ), pneumonia ( ), the meningitis ( ), the soft tissue infection ( ) and other infection ( ) . the causative bacteria were gram positive bacteria ( ), gram negative bacteria ( ), virus ( ), and unknown ( ). there was no statistical correlations between eaa or pct level and apacheiiscore. there was no statistical correlations between eaa level and sofa score. although there was no statistical correlation between pct level and sofa score, the pct level tended to rise as pct level rises. we investigated the relationship between eaa and pct levels. there was also no statistical correlations between eaa and pct. we investigated the relationship between the causative bacteria (gram positive bacteria, gram negative bacteria and the others) and eaa or pct level. there was no statistical correlations between the causative bacteria and eaa level nor pct, that was contrary to our expectation that eaa level should be high for gram negative bacterial infection. we further investigated the relationship between whether or not the pmx-dhp was implemented and eaa or pct level. there was no statistical relationships. conclusion. high levels of the eaa and pct would not indicate the severe infection with gram negative bacteria, and the initiation of pmx-dhp. further study is needed, in which more patients will be enrolled and evaluated. introduction. sepsis still the major cause of death in the late post traumatic period in patients with major burns. early diagnosis of sepsis is crucial for management and outcome of critically burn patients. attempted in this study to assess whether plasma procalcitonin (pct) level was related to diagnostic and prognostic of sepsis in burned patients. patients and methods. pct was measured over the entire course of stay in patients with predictive signs of sepsis according to american college of chest physician. the patients were assigned to two groups depending on the clinical course and outcome: a = no septic patients, b = septic patients. optimum sensitivity, predictive values, and area under the receiver operating characteristic (roc) curve were evaluated. results. over a month period starting from july to december , patients were admitted. were investigated. in group a et in group b. procalcitonin was significantly higher in septic group . ± ng/ml compared to no septic group . ± . ng/ml. area under the curve was . on the day of sepsis diagnostic. pct cut-off value of . ng/ ml was associated with the optimal combination of sensitivity ( %), specificity ( %), positive predictive value ( %), and negative predictive value ( %). in survived septic patient the pct value was significantly lower than in deceased septic patients . ± . versus . ± . ng/ml. pct cut-off value for optimum prediction of outcome in septic patients was . ng/ml with sensitivity ( %), specificity ( %), positive predictive value ( %), and negative predictive value ( %). conclusion. procalcitonin appears to be a powerful marker of sepsis in burn patients. it is sensitive, specific, reliable and easy to measure. a high pct concentration ([ . ng/ml) would indicate poor outcome in septic patients. n. v. beloborodova , a. s. khodakova , a. y. olenin , s. t. ovseenko bakulev scientific center for cardiovascular surgery, moscow, russian federation objectives. accurate and timely diagnosis of sepsis remains challenging for clinicians. the diagnosis of sepsis is defined as typical symptoms of systemic inflammation (temperature, tachycardia, respiratory rate, leukocytosis) with clinical evidence of an infection site, but the criteria are met by a large number of intensive care unit (icu) patients. among studied biomarkers, serum procalcitonin (pct) has been described as one of the most promising predictors of bacterial sepsis, but in some clinical situations it is not enough. the search of reliable markers of sepsis is still in progress. in present study the significance of raised levels microbial phenylcarboxylic acids in serum of patients with sepsis are assessed. methods. the present study evaluated serum samples of patients (pts) with documentary sepsis, according to well known consensus criteria. the comparison groups were: no. - clinically healthy volunteers, no. - pts. with acquired heart diseases, no. - pts with ventilator-associated pneumonia. blood concentrations of phenylcarboxylic acids were determined by gas chromatography-mass spectrometry (gc-ms). results are presented as median and range of th and th percentiles. the statistically significant differences between the various groups were calculated using mann-whitney test. results. increased levels of phenyllactic (pla), p-hydroxyphenylacetic (hpaa), p-hydroxyphenyllactic (hpla) acids were observed in group of pts with sepsis. the level of hpaa was increased up to two orders in comparison with groups no. and [ . ( . - . ) vs. . ( . - . ) and . ( . - . ) lm, p \ . ). the levels of hpla and pla were increased up to one order [( . [ . - . ] table for illustration of importance of phenylcarboxylic acids blood level monitoring. introduction. acute kidney injury (aki) is a frequent complication of sepsis, and is associated with high mortality and morbidity rates. routinely used measures of renal function, such as levels of blood urea nitrogen (bun) and serum creatinine, increase only after substantial kidney injury occurs, resulting in delayed diagnosis of aki. therefore biomarkers, which enable early diagnosis, are needed. objectives. this clinical study was designed to investigate whether human interleukin- (il- ) and neutrophil gelatinase-associated lipocalin (ngal) are early predictive markers for sepsis-induced aki. urine and blood samples have been collected prospectively from icu patients, who met defined clinical criteria of severe sepsis. aki was defined by rifle criteria. urinary and serum levels of n-gal and il- have been quantified by elisa in patients with sepsis without aki (n = ) and in patients with sepsis induced aki (n = ). results. both, urinary il- and serum il- considerably increased (respectively, . and . -fold over the baseline) two days before the patients reached rifle risk. urinary ngal raised significantly ( . -fold over the baseline) one day before occurrence of aki, whereas serum ngal did not show any prior elevation. no increase in the levels of any of these markers could be found in patients who did not develop aki. conclusions. both urinary and serum il- seem to be sensitive early biomarkers for sepsis associated aki, while urinary ngal has less accuracy for aki prediction. objectives. to define a biomarker panel able to predict infection in case of severe acute dyspnea in emergency situations. we designed a prospective observational study of patients admitted in the emergency department (ed) and in medical polyvalent intensive care unit (icu) in a university hospital. inclusion criteria were acute dyspnea with spo b % and/or respiratory rate (rr) c b/min. patients with an immediate need of coronarography or with obvious spontaneous pneumothorax were excluded. five biomarkers were measured from blood sample at admission on ed or icu: nt b type natriuretic peptide (nt probnp), cardiac troponin i (ctni), ddimeres (dd), c-reactive protein (crp) and procalcitonin (pct). all clinical and biological data were recorded. an independent blinded data monitoring committee classified the patients according to all the available data including response to treatment and outcomes but blindly to biomarkers. the roles of biomarkers were assessed quantitatively and then using terciles of the distribution. the contribution of the biomarkers in the diagnosis was assessed using multiple logistic regression taking into account other clinical and biological explanatory variables. . patients were enrolled consecutively. the final diagnosis was: severe sepsis (n = ), acute heart failure (n = ), pulmonary embolism (n = ), copd (n = ), other causes (n = ). the days mortality was %. there was no significant association between infection diagnosis and dd, ctni, nt probnp. interestingly, a crp value of less than mg/l was not discriminant in predicting infection. adjusted on clinico-biological covariates selected, both pct with cutpoints of . and . ng/ ml (discrimination auc . ; p = . ) and crp with cutpoints of and mg/l (discrimination auc . ; p . ) were significantly associated with the diagnosis of sepsis. both biomarkers used simultaneously lead to a discrimination of the model (auc . ). conclusion. both crp and pct are able to predict the diagnosis of infection in case of severe acute dyspnea independently of clinico-biological variables. in this particular subpopulation, the best threshold for crp is higher than the standard one. an external validation is needed to prospectively validate the clinical utility of these findings. t. trefzer , i. nachtigall , a. weimann , c. de grahl , c. spies charite universitaetsmedizin berlin, campus virchow, department of anesthesiology and operative intensive care medicine, berlin, germany, charite universitaetsmedizin berlin, campus virchow, zentralinstitut für laboratoriumsmedizin und pathobiochemie, berlin, germany aims. infections are the most relevant icu-admission complication. crp and pct are labvalues used for diagnosis of infections. however, their use is often not evidence based. this study aimed to access whether the adherence rate increased after introducing an evidencebased standard operating procedure (sop). in an evidence-based sop was approved by experts of our department. in july it was made available to icu-physicians via intranet, which is accessible from every work station. altogether, we assessed sop-adherence rates of patients: in june (pre-sop), patients in august (one month post-sop) and in january ( months post sop). every crp and pct measurement was assessed for adherence to the standard operating procedure (sop). at first, the three periods were assessed for significant differences concerning the adherence. according to the percentage of sop-conform measurements the patients were then divided into two groups: the sop-group (c % of measurements sop conform) and the non-sop (nsop) group (\ % conform) in a second step, patients in the sop-and nsop-group were compared concerning icu scores (sofa, tiss, apacheii, saps) and outcome parameters (length of icu-stay, length of hospital stay, duration of mechanical ventilation, hospital mortality). statistics: p b . was considered as statistically significant; hospital mortality was assessed by a v test, icu scores and outcome parameters were compared using the mann-whitney u test. all parameters with p \ . were included into a logistic regression analysis. no change was observed concerning the implementation of the sop pre and postintroduction: . % in june , . % in august and . % in january . the non-conform pct-and crp-measurements resulted in additional costs of approximately . euros/year. the univariate analysis revealed significant differences in the sop-and nsop-group: the nsop-group had higher saps-, sofa-and tiss-scores, as well as increased length of icu-stay, length of hospital stay and duration of mechanical ventilation. logistic regression analysis revealed tiss score and length of hospital stay as an independent predictor for low sop adherence. conclusion. distribution of an evidence based sop without further education did not lead to a significant increase in adherence rates, but tiss score and length of hospital stay have shown to be independent predictors for low adherence to the sop. the significant higher tiss-scores in the nsop group might be a indicator for actionism of clinicians in the face of more severely ill patients. objetives. to asses the evolution of the risk-adjusted mortality rates of sepsis and septic shock in our icu in a ten years period. patients and method. analisys of prospectively recorded data of all pacients admitted with severe sepsis and septic shock in a bed icu during a period of years. patients were followed up until death or discharge from the hospital, excluding those with unknown outcome. mortality prediction was made using apache ii model with % confidence intervals. statistical analisys was made with spss . using anova test or t test to compare means and chi square test to compare categorical variables. results. from january to december a total of patients with sepsis were admitted, with an anual increase to reach % of all icu admissions. age and severity of illness increased anually as did sofa in the first h (sofa ) thus rising up calculated risk of death. from to mortality rate was between % ics of calculated risk of death, falling below inferior ic from and after . (fig. ). hospital mortality versus risk of death per year mortality was . % in the pre- period and . % from and on (p = . ) with non significant differences in apache ii, risk of death nor sofa , but with significantly greater age in the post- period ( . vs. . years p = . ). this non significant difference between the two periods of the study became significant when we analized the outcome in both sex. being significant in women (mortality . % in pre- period vs. . % in post- p = . ) but not in men ( . vs. . % p = . ). overall sepsis moratlity is lower in female without significant differences in age, apache ii score nor risk of death (table ) , being the only signifficant difference found in sofa ( . in male vs. . in female p = . ). introduction. low-grade systemic inflammation has been shown to play a key role in the pathophysiology of several chronic noncommunicable diseases [ , ] and may be attenuated by anti-inflammatory treatments such as administration of statins [ ] . so far, the association between acute systemic inflammation experienced during critical illness and long-term mortality after hospital discharge has not been investigated in intensive care unit (icu) patients. objectives. to assess the association between acute systemic inflammation, assessed by crp levels, and post-hospital mortality in non-surgical icu patients. methods. the study was performed as a prospective, observational follow-up study and included non-surgical critically ill patients with an icu length of stay [ h. patients who died during the icu or hospital stay, were \ years or pregnant, as well as patients discharged from the hospital with the plan to limit life support were excluded. demographics, chronic diseases, admission diagnosis, the simplified acute physiology score ii, length of icu stay, maximum crp levels during the icu stay (crpmax) and crp levels at icu discharge (crpdis) were documented. after a mean ± sd follow-up time of . ± . years, mortality and causes of death were determined. adjusted cox models were calculated to investigate the association of crpmax and crpdis with post-hospital mortality. a receiver operating characteristic analysis was used to identify optimal cut-off levels to predict post-hospital mortality. background. the prevalence of hiv infection is increasing worldwide as a public health problem. survival of hiv/aids patients has improved since highly active antiretroviral therapy, but sepsis has grown as an important cause of icu admission in this population. an international conference has set a system composed of specific risk factors, site and microbiology of severe infections and host response and organ dysfunctions (piro) to help identify patients at risk for sepsis. piro factors have not been classified for hiv/aids population yet. objectives. to identify predisposing factors, microbiology of infections, host clinical response and incidence of early organ dysfunctions of severe sepsis on hiv/aids patients, admitted to a specialized infectious diseases icu; to analyze long-term survival of hiv/aids critically ill patients. a prospective case-control study of septic and non-septic hiv/aids patients admitted between june and may was performed. demographic data, causes of admission, time since aids defining condition, cd cell count, and opportunistic infections were evaluated as predisposing factors to sepsis. microbiology and site of infections were registered. clinical response to severe infections was evaluated by ali/ards and shock incidence on day of icu admission. organ dysfunctions (sofa score) were reported soon after icu admission. icu length of stay, hospital and -month mortality were compared between septic and non-septic groups. a multivariate regression analysis was done to identify risk factors for icu mortality. kaplan-meyer survival curve was built. . icu admissions of hiv-infected patients were studied. half ( ) fulfilled criteria for severe sepsis diagnosis. septic group was younger ( . ± . vs. . ± . years, p \ . ) and had more female patients ( vs. %, p \ . ). time since aids diagnosis, cd cell count and opportunistic infections prevalence were not different. sites of infection were predominantly pulmonary ( %) and catheter-related ( %). ninety percent of infections were nosocomial. forty-three percent of septic patients presented bacteremia. pseudomonas sp, s aureus and enterobacteriacae were commonly identified, but five patients had mycobacterium tuberculosis isolated ( on blood cultures). multiple organ dysfunction syndrome was frequent, and incidence of cardiovascular, respiratory and hematological dysfunctions was significantly higher in septic group. longer length of icu stay ( . ± . vs. . ± . days, p \ . ) and icu mortality ( vs. %, p \ . ) was observed for septic patients. severe sepsis also influenced long-term survival, as mortality continues significantly higher after months (log rank . , p \ . ). conclusions. piro system is applied to septic hiv/aids patients. shock, ali/ards and hematological dysfunctions are prominent for septic hiv/aids population. septic hiv/ aids patients are at severe risk of short and long-term mortality. international guidelines for management of severe sepsis and septic shock suggest the use of recombinant human activated protein c (rhapc) in adult patients with high risk of death (apache ii c or multiple organ failure). the objective of this study is to analyse the characteristics and outcome of patients treated with rhapc in our medical intensive care unit. retrospective study of patients with severe sepsis/septic shock treated with rhapc between january to december . all of them were c years, with apache ii c and two or more organ dysfunction, and were treated on basis of a bundle for severe sepsis management: complete early goal-directed therapy, early administration of broadspectrum antibiotics; corticosteroids in vasopressors unresponsive patients and monitor for lactate clearance. chi-square analysis were used to compare categorical data. continuous data were compared using student's t test. prognostic factors of mortality were studied by means of multivariable logistic regression analysis. results. forty-one patients were studied. % were male. their mean age was ± years. % had comorbidities ( % immune pathology). severity scores. apache ii ± , sofa ± , % of patients had three o more organ dysfunction. % had septic shock. serum lactate level was . ± . mmol/l. the primary location of infections was: respiratory %, abdominal %, urinary %. . % were positive blood culture. % of patients needed mechanical ventilation ( ± days). % of rhapc infusions were not completed, mainly for bleeding risk ( %) and death ( %). . % of patients had bleeding event. at the end of the infusion % of patients remained with two or more organ dysfunction and % were vasopressors dependent. mean hospital stay was days and days in icu . days mortality was %, icu mortality . % and hospital mortality . %. analyzed data included age, comorbidities, primary location of infections, severity scores and serum lactate level. univariable analysis showed that statistically significant factors related to mortality were: apache ii ( ± vs. ± , p = . ), organ dysfunction number: vs. [ ( vs. %, p = . ) and primary location of infections: pneumonia versus others ( vs. %, p \ . ). a multivariable logistic regression analysis showed that age (or . , % ci . - . , p = . ), organ dysfunction number (or . , % ci . - . , p = . ) and serum lactate levels (or . , % ci . - . , p = . ) had statistically significant relationship to mortality. conclusion. in our study the patients with severe sepsis and septic shock remained with high vasopressors dependency and organ dysfunction at the end of the rhapc infusion. despite of rhapc therapy the mortality of patients was very high. the age and the severity at icu admission were independent prognostic factors of mortality. a higher incidence of severe sepsis in blacks compared to whites is well documented, however prior analyses do not discriminate whether this is due to a higher incidence of infections, a higher risk of developing organ dysfunction once infected, or both. objectives. we sought to understand whether higher severe sepsis incidence in blacks is due to higher infection susceptibility, higher risk of organ dysfunction once infected, or a combination of both. we analyzed , , hospitalizations from hospital discharge records of us states ( % of us population). we linked these records to us census data to generate age and sex-standardized incidence rates. we identified infections of bacterial and fungal etiology based on icd- cm criteria, including characterization by site and type of infection (gram negative vs. gram positive). we defined severe sepsis as documented infection plus acute organ dysfunction based on previous work by angus et al we estimated the risk of organ dysfunction among those hospitalized with infections using logistic regression, adjusting for age, sex and comorbidities (charlson score). fig. b ]. the combination of both events led to a % higher severe sepsis hospitalization rate for blacks ( . vs. . per , population, irr: . - . ). these differences persisted when stratified by sex, comorbidities, site and type of infection. infection incidence and severe sepsis risk conclusion. the higher incidence of severe sepsis among blacks is due to a higher hospitalization rate for infections, as well as a greater likelihood of organ dysfunction once infected. future interventions to reduce racial disparities in severe sepsis incidence should target both distinct events. grant acknowledgement. dr. mayr was supported by t hl - . objective. to describe recent epidemiological data and mortality risk factors of patients admitted to icu for severe pneumococcal pneumonia (pp). multicentric retrospective study (january -june ). prospective acquired data from patients admitted in french medical icu for severe pp were considered. patients with concurrent meningitis, severe copd with known sp colonization, hiv or aspiration pneumonia were not included. pp was defined by the combination of a suggestive clinical context, the presence of a new pulmonary infiltrate on chest radiography and a s.pneumoniae positive bacteriological sample (pulmonary quantitative culture, pleural fluid, blood culture or urinary antigen assay). all files were reviewed and approved by two independent investigators (nm, am). . patients were included. median age was ± . hospital survivors were significantly younger ( ± vs. ± , p = . ). sex ratio m/f was / , but male sex was associated with higher risk of death (male: vs. %, p = . ). active tabagism ( %) or alcohol abuse ( %) were more common than asplenia ( %). organ dysfunctions were mainly respiratory ( %), haemodynamic ( %) and renal failures ( %). low doses steroids were prescribed in % of patients with septic shock. icu mortality rate reached % ( % in the first days); hospital mortality rate was %. univariate analysis demonstrated that age, male sex, cirrhosis and organ failure support were strong predictors for icu mortality. multivariate analysis only highlighted age [or . ( . - . )], cirrhosis [ . ( . - . ) ] and renal replacement therapy [ . ( . - . )] as independent mortality predictors. activated protein c treatment was associated with decreased mortality [or . ( . - . )]. bacteremia had no impact on outcome. conclusion. this is the most important cohort of pp requiring icu admission. despite adequate antibiotherapy, mortality is still preoccupant. determination of factors related to the bacteria (virulence) or to the host (genetic susceptibility) could allow a better understanding of this important health problem. introduction. to identify the risk factors of mortality for patients with severe community-acquired bacteremic pneumococcal pneumonia. retrospective study realised in the intensive care units of two hospital medical centers. the studied population was patients with serious community-acquired bacteremic pneumococcal pneumonia. all the patients entered the intensive care units between january of and december of . study variables were: age, sex, concomitant pathology, toxic habits, pre-vaccinal ( - ) and postvaccinal periods ( ) ( ) ( ) ( ) ( ) ( ) ( ) , serotype and sensitivity of streptococcus pneumoniae to penicillin, the initial use of the non-invasive mechanical ventilation, the development of empyema pleural, apache ii and sofa scores during the first h after admission. results. the age average was of years. forty one percent of our patients required mechanical ventilation, and % had acute renal failure that required hemofiltration. average values of apache ii and sofa were . and . respectively. in hospital mortality of the series was of %. in patients with severe community-acquired bacteremic pneumococcal pneumonia: ( ) the presence of empyema pleural is an independent risk factor for mortality. introduction. procalcitonin (pct) is an interesting marker of pulmonary infection [ ] . it is useful as an help for infection diagnosis but also for treatment follow-up [ ] . besides, initiation of effective antimicrobial therapy is the strongest predictor of outcome in patients with septic shock [ ] . the aim of the study was to analyse whether kinetics of pct decline may reflect sensitivity of identified infectious agents to initial antimicrobial therapy (at). patients with diagnosis of severe pneumonia following major cardio-thoracic or vascular surgery were retrospectively included in the study. severe pneumonia was suspected as a combination of several manifestations including fever or hypothermia, hyperleucocytosis or leucopenia, new radiological infiltrate, and/or a clinical pulmonary infection score [ , pct [ ng/ml and pao /fio \ . initial antimicrobial treatment was chosen according to the guidelines in use in our institution for community-acquired or nosocomial infections. microorganism identification from endotracheal aspiration or bronchoalveolar lavage, and antibiotic susceptibility testing, allowed to classify patients according to appropriate (aat) versus inappropriate initial at(iat). pct was measured daily over days and its kinetics compared between both groups. data are expressed as median (extremes) or mean ± sd (decrease rate). results. patients aged ± ( - ), operated on vascular (n = ), thoracic (n = ), or cardiac surgery (n = ) have been studied from october to july . pneumonia occurred within the st to the st postoperative day (median . days), with a septic shock in cases and deaths at day . initial at was appropriate in % ( / ) patients. pct peak was not statistically different between aat versus iat patients ( . ± . ng/ml vs. . ± . , respectively) but pct decrease was significantly steeper and constant in iat patients (fig. ). pct decrease (%) from peak value over days discussion: the results suggest that absence of early decrease in pct within days may reflect failure of the at. conversely, an average decrease in pct plasma concentration of % in days seems to be a good marker of sensitivity of the causative infectious agent to the initial at. in case of unchanged pct within days at change should be considered. icu mortality was % for pts with rb early vap while it was % ( of cases) in those with sb or negative cultures (p = . ). mortality was higher than the predicted according to apache ii score in pts with rb vap ( vs. ± %, p \ . ). however, it was lower than predicted in those with negative or sensible isolates ( vs. ± %, p = . ). conclusions. rb were the most common cause of early vap among our patients. the burden of illness, los in icu before intubation and previous use of antibiotics were associated with early vap due to rb. inappropriate empiric therapy and mortality were higher among patients with early vap due to rb. to evaluate the performance of the saps piro model in patients with severe community acquired pneumonia (cap), over a period of years ( - ) , in a general icu in a central hospital. material and methods. we analysed data prospectively registered in an informatic data base, which contains information referring to all patients admitted in this unit. analysed were patients. discrimination was accessed by the area under the roc curve (aroc). calibration was evaluated by the by the hosmer-lemeshow Ĉ test. conclusion. implementation of a sedation protocol requires constant follow up and regular adaptation to prove efficient over time. constant feed back information to both the medical and nursing staff is mandatory. treatment of hyperactive delirium. hal haloperidol, bzd benzodiazepine, pro propofol, aa atypical antipsychotic, nd no drugs, na not answered discussion. there tends to be a general pessimism regarding obese patients within the intensive care community. our data indicates that this opinion could be misplaced. reduced ventilator days may reflect a reluctance to invasively ventilate obese patients. the apache ii scoring does not take into account the bmi which would eliminate any severity scoring bias. high bmi alone should not be a consideration in the decision regarding suitability for admission to critical care. during the last decades, a growing medical knowledges have changed the clinical approach to elderly patient diseases. they receive major surgery or intensive treatment for acute medical illness but often the recover is condictioned by the previous chonical diseases. this determines a long period to stay in intensive care unit (icu) because the slow improvement and cause an occupation of bed places. in our hospital, after a period of training performed by an intensivist (bc) and an internist (ag), icu patients who need a non invasive ventilation (niv) or tracheostomized elderly patients who have difficult weaning were admitted in a dedicated area in a medical department (md). this study desribes the results of one year of observation. in the last year, forty nine patients (age . ± . ; m f ) were transferred from icu to md. twenty three patients were treated with niv (age . ± . ; m f ), fourteen tracheostomized patients (age . ± . ; m f ) receive positive pressure ventilation because the difficult weaning in icu while twelve don't need any respiratory support. at the admission was performed a multidisciplinary plan and many specialists were involved (dietist,physiotherapist, pneumologist) and in invasively ventilated patients (ivp) was done a program of weaning. we follow all the patients until the discharge at home where someone need oxigenotheraphy, niv or mechanical ventilation. for the invasive ventilated patients we try to identificate significative differences beetween patients discharged at home and patients who died in hospital. data are given as mean ± sd and statistical analisis t test was performed results. patients underwent niv stay in hospital for . ± . days ( . ± . days in icu- . ± . in md) and ventilation was performed for the entire period in icu while for . ± . days in md. all the patients were discharged at home: twelve with niv, fourteen with oxygen. the lengh to stay in hospital for the ivp in wich weaning was failed in icu was . ± . days ( . ± . days in icu- . ± . in md). in md they continue the invasive ventilation for . ± . days. seven were weaned from ventilation after . ± . days, one was discharged at home with the ventilator while six died in hospital. patients who died were older ( . ± . vs. . ± . years-p . ), have more chronical diseases ( . ± . vs. . ± . -p . ), longer hospitalization ( . ± . vs. . ± . days-p . ), glascow coma scale ( . ± . vs. ). elderly patients often require a long period of recovery from acute ilness. in selected patients md could be a useful place where continue the treatment started in icu. in our study ivp who died had more chronical diseases and a more significative cognitive compromission. aim. documenting the qualitative and quantitative properties of administered and lost fluids is a common critical care monitoring practice. these nurse-registered fluid balances (fb) are used to optimize patient care and in clinical decision-making. this ''good clinical practice'' has also found application in research: recent studies reporting superior outcomes expressly refer to (negative) fb. we prospectively assessed the accuracy (review of all fluid balance charts and correction of arithmetic errors) and consistency (gold standard: body weight changes [bwc] registered with standardized measurements of body weight on admission and discharge [precision ± g]) of nurse-registered cumulative fb. total (tfb) and daily fb (dfb = total fb/los) were calculated. we analysed the unadjusted cumulative fb (unafb: without considering additional losses, i.e. perspiration/fever/liquid faeces) and the adjusted cumulative fb (adjfb: considering the above as proposed in the literature) in all patients (all) and in three subgroups (cardiaccerebral:card; septic:septic; others). exclusion criteria: lack of admission/discharge weight, incomplete fb data. we calculated l = kg. among patients admitted during the study period were eligible and analyzed. fb were inaccurate in cases ( %) (error range: - . to ? . l, mean arithmetic error ± sd: ? . ± . l, mean absolute error: . ± . l). the body weights at admission and discharge were . ± . kg and . ± . kg, with a bwc of . ± . kg ( . ± . kg per day). unatfb were . ± . l, unadfb . ± . l. adjtfb was . ± . l, adjdfb . ± . l. correlation (r ) and bland and altman was poor between bwc and unatfb ( . and - . ± . kg) and slightly better between bwc and adjtfb ( . and ? . ± . kg). the sd of the difference between bwc and fb per day of the icu stay was always [ kg. a multiple regression model including unatfb, duration of intubation, maximum temperature, estimation of liquid faeces, age and the calculated caloric deficit during the icu stay, only modestly improved correlation (r . ). compared to the two other groups, septic were significantly more severely ill, had a higher and longer fever, a longer los, larger bwc and cumulative fb, and presented larger differences between bwc and cumulative fb (poor correlation and bland and altman). though, consistency betwenn bwc and cumulative fb in card and other was still scarce. conversely, another multiple regression model (including only unatfb and the maximal temperature) in septic yielded an r of . . conclusion. fb are often inaccurate and they are not consistent with the gold standard of bwc. the correlation and the agreement with bwc of both adjtfb and unatfb are poor, with sd per icu day-stay[ kg or l. multiple regression models including several variables slightly improve correlation, yet remaining disappointing. consequently, clinical decisions should rather be based on other methods than fb. a prolonged hdu los was associated with a high sofa score for respiratory, hepatic and coagulation variables, preoperative ecg alterations, an increased urea and bmi and important bleeding. sofa score should be use in the first h to assess organ failure and a possible icu transfer for patients with an elevated score. evaluation of procalcitonin, neopterin, c-reactive protein, il- and il- as a diagnostic marker of infection in patients with febrile neutropenia financed by the following fellowships: rd / / from retics, fiss pi and fijc p-ef- reference(s). . bohoun c ( ) a brief history of procalcitonin biomarkers of sepsis: is procalcitonin ready for prime time? definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis procalcitonin assay in systemic inflammation, infection, and sepsis. clinical utility and limitations usefulness of procalcitonin for diagnosing complicating sepsis in patients with cardiogenic shock patients at our er, icu and wards of internal medicine and surgery meeting the ssc criteria were included. blood cultures were taken before administration of antibiotics, other cultures when appropriate. laboratory tests included wbc, crp, lactate, and pct. we categorized patients using bacteriological criteria group bacteriological proven infection (negative blood cultures but any other culture(s) positive) using chi square test there was no difference in survival, pct and findings on chest x-ray between the groups. with the mann whitney u test we found no differences in wbc, crp and lactate between survivors en nonsurvivors in a cohort of patients meeting the ssc criteria only % met bacteriological criteria for sepsis. wbc, crp, lactate and pct did not differ between patients with and without bacteriological proof of infection nor between survivors and non-survivors il rn and tnfr in the severity and outcome of community-acquired pneumonia to investigate whether polymorphisms within genes encoding for inflammatory or anti-inflammatory molecules are associated with susceptibility design. prospective observational, cohort study a cohort of , spanish caucasians with cap and subjects were genotyped for the following polymorphisms: tnfa - and - , lta ? sequential kaplan-meier survival analysis of tnfrsf b ? g/t polymorphism showed a protective role of the gt genotype. cox regression analysis adjusted for age, gender, hospital of origin and comorbidities showed that patients with gt genotypes had lower mortality rates compared with those patients with gg or tt genotypes (p = . our study does not support a role for the studied polymorphisms of the tnfa, lta, il and il rn genes in the susceptibility or outcome of cap. a protective role of heterozygousity for the functionally relevant tnfrsf b ? variability in genes involved in the inflammatory response in patients with community-acquired pneumonia to investigate whether polymorphisms within genes encoding for inflammatory or anti-inflammatory molecules are associated with susceptibility design. prospective observational, cohort study a cohort of , spanish caucasians with cap and , controlsinterventions: subjects were genotyped for the following polymorphisms: tnfa - and - , lta ? sequential kaplan-meier survival analysis of tnfrsf b ? tt versus gg/gt genotypes suggested a detrimental role of the tt genotype. longrank c tests at and days yielded p = . and . , respectively; cox regression for -and -day survival, adjusted for age, gender ghent university hospital, intensive care we aimed to describe the incidence and characteristics of healthcare-associated pneumonia (hcap) diagnosed at the emergency department of our university hospital compared to cap, hcap occurs in more debilitated or at-risk patients, is more frequently caused by nosocomial pathogens, and has worse outcome. nursing-home pneumonia is included within the definition of hcap but could have characteristics different from the other categories of hcap ) with a diagnosis of 'pneumonia'. episodes were categorized in cap and hcap according to the definition of the american thoracic society/infectious diseases society of america. within hcap, distinction was made between nursing-home pneumonia (nhp) and non-nhp hcap. severity of the pneumonia was assessed using curb- during the study period, episodes of pneumonia were diagnosed in patients; episodes ( %) were categorized as cap, and ( %) as hcap. within hcap, ( %), respectively ( %) episodes were further classified as respectively nhp and non-nhp hcap. median age of the patients was years ( - ) and % of patients were male median curb- pneumonia severity score in patients with cap and hcap was ( - ) and ( - ) respectively (p = . ); in nhp and non-nhp hcap, median curb in bivariate logistic regression analysis, both increasing curb- (or . , ci . - . ) and categorization as nhp (or . , ci . - half of the episodes of pneumonia diagnosed at our emergency department could be classified as hcap. severity of the pneumonia was higher in patients with hcap as compared to cap. categorization as nhp, but not as non-nhp hcap was independently associated with hospital mortality after adjustment for severity of the pneumonia medical intensive care unit community-acquired pneumonia (cap) is the leading cause of infectious death, severe sepsis and the seventh leading cause of overall death. severe cap (scap) is defined as need of aggresive intensive care unit (icu) management due to shock to describe the episodes of severe community-acquired pneumonia (scap) in a multicentric european study and to assess management practices and outcome of scap patients admitted to icu observational, prospective, multi-centre study conducted in icus of consecutive patients requiring invasive mechanical ventilation for an admission diagnosis of pneumonia or mv for [ h were recruited in each icu. statistic analysis was performed using spss years p \ . ) and presented a higher saps ii score at admission ( . sd . vs. . sd . p \ . ). patients were treated with monotherapy in . % and combination therapy . %. empirical antibiotic treatment was in accordance with idsa guidelines in ( . %) patients. combination was prescribed with macrolides in . % and quinolones in . %. in patients receiving combination therapy in accordance with idsa guidelines, a cox regression analysis adjusted by saps ii and age identified that macrolides use was associated with lower icu mortality when compared to the use of quinolones in patients with severe community acquired pneumonia who had therapy in accordance with the idsa guidelines, only combination therapy with macrolides was associated with better outcomes the eu-vap/cap project was endorsed by eccrn hospital de mataró, critical care, mataró, spain, hospital universitario germans trias i pujol, microbiology, badalona, spain, hospital de mataró, microbiology, mataró, spain, hospital universitario germans trias i pujol this leads to improved survival in a sterile acute lung injury model in wild-type mice, compared to mmp- knockout mice. we recently showed that mmp- deficient mice had better survival in a cecal ligation and puncture (clp) sepsis model than wild-type mice. in humans, functional genetic variations of the mmp- gene exist, but their relation to outcomes of severe infections, such as cap, is unknown. objectives. we hypothesized that functional human single nucleotide polymorphisms (snps) leading to increased mmp- levels are associated with worse survival and higher incidence of severe sepsis in patients with cap. methods. we examined data from genims, a multicenter prospective cohort study of patients with cap and analyzed potentially functional snps (rs , rs , rs ) in the mmp- gene in caucasians by polymerase chain reaction (pcr) the overall incidence of severe sepsis was . % (n = ), and . % of patients (n = ) died within days. the rs genotype distribution was significantly associated with -day mortality by armitage's trend test failure plot for rs conclusions. the non-synonymous rs snp is associated with -day survival in patients with cap. our findings suggests a trend towards a transcriptome analysis of ventilator associated pneumonia in trauma patients the sepsichip project the diagnosis of acute infection in the critically ill remains a challenge. transcriptional profiles (tp) of circulating leukocyte can be used to monitor the host response to infection. ventilator-associated pneumonia (vap) is a frequent complication of major trauma, raising morbidity and mortality data files were analyzed with r and bioconductor. unsupervised analysis was conducted using the dbf-mcl algorithm. supervised analysis was conducted using the significance analysis of microarray algorithm, using siggenes library. all statistical analysis used corrections for multiple comparisons. results. vap occurred in of the trauma patients ( . %). one hundred and fifteen samples were hybridized on husg k microarray ( sirs and sepsis samples for the patients who developed a vap, and sirs samples for those who did not). whereas clinical parameters (iss, chest trauma) discriminated trauma patients with or without vap, admission samples transcriptome analysis did not lead to the identification of prognostic markers. analysis of paired samples of the patients who developed a vap identified a transcriptional signature. these genes were involved in transcriptional regulation, cell survival, hemostasis and endocrine regulation. conclusions. by comparing whole blood admission samples, we were not able to identify transcriptional prognosis markers in trauma patients who did or did not develop vap. however, using vap as a model of sepsis in trauma patients, we identified a set of genes which may serve to diagnose vap in trauma patients to investigate the correlation between transfusion practice and the development of ventilator associated pneumonia (vap) in patients with traumatic brain injury (tbi) we analyzed which tbi individuals developed vap in regard to the transfusion practice and if the number of transfused prbcs increases the risk of pneumonia development. we counted the total amount of prbcs units received by each patient during icu stay, as well as those given before vap development. patient's data included: demographics, apache ii, iss, gcs, vap characteristics, duration of mechanical ventilation (mv), length of stay (los) and outcome. cpis and mods were calculated on the day of vap detection.statistical evaluation was performed using univariate and multivariate logistic regression, students t-test and pearson's chi square test %) tbi patients who developed vap received on average units of prbcs during icu stay, compared with non vap individuals who were transfused on average with two units of prbcs (p \ . ). vap patients received on average four units prbcs before vap development. after correcting for age, apache ii, gcs and iss, transfusion was independently associated with vap. the odds ratio for vap aspiration pneumonia (ap) in comatose patients (pts): clinical and microbiological findings ap is a common complication in comatose pts. we aimed to update data on their incidence standard guidelines were used for diagnosis and treatment of ap. daily chest x-ray were retrospectively reviewed. ap was diagnosed if pts met following criteria: persistent radiographic infiltrate within days following ti, and at least two of the following: purulent sputum, fever/hypothermia duration of mv was days ( - ) and length of stay in icu days ( - ) on the day of ap diagnosis, main pts characteristics were: saps ii %) received empirical antimicrobial therapy. main empirical antibiotics were coamoxiclav ( %) and third generation cephalosporin ( %) ) and mv duration ( vs. days, p \ . ), even considering only non-cardiac arrest pts. gcs h after ti and ap were associated with a [ days duration of mv in multivariate analysis ap was associated with higher overall -day mortality in univariate analysis ( vs. %, p = . ) but no longer in multivariate analysis mortality in the icu was . % with a corresponding hospital mortality of . %. a microbiological documentation was obtained in . % of the patients, with streptococus pneumonia being the most frequent ( % of the isolates). the cap was classified as localized in . %, unilateral mean (±sd) saps piro score was . ± . points, with a corresponding predicted mortality of . ± . % (standardized mortality ratio . ). the aroc was . ( . - . ). the value of the hosmer-lemeshow Ĉ test was saps piro presented a discrimination similar to the originally described. however, it significantly overestimated mortality sepsis mortality prediction based on predisposition, infection and response the piro-cap score was proposed earlier this year to stratify patients with severe community acquired pneumonia (cap) to evaluate piro-cap score in patients with severe cap, over a period of years we analysed data prospectively registered in an informatic data base, which contains information referring to all patients admitted in this unit survival curves were built as proposed by the original authors. outcome was evaluated at icu discharge overall, it was a severe population: . % of the patients presented at least one chronic disease, saps : . ± . points (predicted mortality . % ± . ), length of stay in the icu . ± . , icu mortality was . %. a microbiological documentation was obtained in . % of the patients, with s. pneumoniae being the most frequent ( % of the isolates). the cap was classified as localized in . %, unilateral icu mortality was piro-cap presented an excellent discrimination. however, mortality rates were greater than the ones described by the original authors in all groups (except group ), with the system significantly under-predicting mortality. consequently, we recommend caution in their widespread use. cumulative survival reference(s). clinical and biological assessments in icu patients delirium is a life-threatening, acute organ dysfunction with an incidence of % in uk mechanically haloperidol is recommended as treatment [ ] despite limited evidence base. objective. a national postal survey of consultant members of the uk intensive care society (ics) was performed to determine the current management of delirium in the ) drug treatment of hypoactive and hyperactive delirium as described by two clinical vignettes and ( ) level of agreement with five statements regarding delirium. results. six hundred and eighty one replies were received from , questionnaires senta response rate of %. twenty five percent of respondents routinely screen for delirium. only % use a validated screening tool, most ( %) of whom use the confusion assessment method, icu. hyperactive delirium is treated pharmacologically by %, the majority using haloperidol. hypoactive delirium is treated pharmacologically by %, with haloperidol again the most common treatment ( %) grant acknowledgement. intensive care foundation, intensive care society a practical algorithm to diagnose delirium in critical care-validity and reliability delirium occurs in up to % of critical care patients [ ], but often remains undiagnosed because standardized delirium monitoring is often dismissed as being too time-consuming or too complicated [ ]. the 'harvard flowsheet', derived from the 'confusion assessment method for intensive care unit' (cam-icu) [ ], provides a practical, algorithm-type handling advice to assess the four dsm-iv delirium criteria in a standardized fashion in intubated patients. it mostly allows for truncation of assessments to save time after approval from our institution's ethics committee, patients of a -bed surgical icu-department were screened in five sessions for delirium ( ) by a psychiatrist as the reference rater using the dsm-iv delirium criteria, and ( ) by two 'harvard flowsheet'-investigators, each unaware of other's ratings. motoric delirium subtypes were classified according to the richmond agitation sedation scale (rass) [ ], which was rated for the feature ('altered level of consciousness') of the 'harvard flowsheet'. patients were deemed as having hypoactive delirium if they were dsm positive by the reference rater and had rass - to , or having hyperactive delirium if their rass was between ? and ? . for interrater reliability the median time to complete the 'harvard flowsheet' in delirious patients was s (iqr, - s) vs. s ( - s)] in non-delirious patients. conclusions. the 'harvard flowsheet' has high sensitivity, high specificity and very high interrater reliability. false-negative ratings can occur infrequently and likely reflect the fluctuating course of delirium with intermittent lucid states a decrease of the overall cost of sedation and of sedation/day of mv followed protocol implementation and has been pursued each year: sedation cost which was greater than €/day in / has decreased to less than €/day in acute renal failure in critically ill patients: a multinational, multicenter study to evaluate current transfusion practice and the association between the age of red blood cells (rbcs) and outcome in critically ill patients design. prospective, multicenter observational study patients: critically ill adult patients receiving at least one unit of rbcs %)] revealed an unadjusted absolute reduction rate (arr) in mortality of % ( % ci - %). after adjustment for disease severity, patient age, other product transfusions, number of transfusions, pre-transfusion haemoglobin concentration, pre-icu transfusions, and cardiac surgery the odds ratio (or) for hospital mortality in critically ill patients in australia and new zealand transfusion of rbcs is delivered within current international recommendations. however, within such a practice patients enrolled included men and women, with mean age of ± years. there were ( %) liver transplantation, ( . %) renal transplantation and ( . %) pulmonary transplantation and ( . %) renal-pancreas transplantation. the days mortality for liver, renal, pulmonary and renal-pancreas was: ( . %), ( . %), ( . %) and ( . %). the mean saps score for liver, renal ic apache ii auc . % . - . , ic % . - . . conclusions. in these study, no differences were observed comparing saps and apache ii in the mortality prediction from liver, renal and pulmonary transplantation current opinion in critical care introduction of a rapid response team: why we are glad we met dew ma and members of the medical emergency response improvement team (merit) committee ( ) mature rapid response system and potentially avoidable cardiopulmonary arrest in hospital the effect of a rapid response team implementation in a private hospital adult patients often exhibit physiological deterioration hours before cardiopulmonary arrest to determine the effect of a rapid response team on the rate of in-hospital cardiac arrests, total and unplanned intensive care unit admissions, and icu and hospital mortality before and after implementation of a rapid response team standard criteria were used to activate the rrt and included acute changes in the patient's mental status, respiratory rate, heart rate, oxygenation, or blood pressure and hypoxia, chest pain, or worry from clinical staff. we measured: admitting diagnosis after rrt were a total the activations. the most common reasons for rrt activation were ventilator dysfunction ( %), cardiac changes ( %) and acute neurological changes ( %). % were transferred to icu and the main reasons were cardiac changes ( %), ventilatory dysfunction ( %) and acute neurological changes ( %) the rrt implementation was associated with decreases in rates of inhospital cardiac arrest, but was not associated with reductions in hospital or icu mortality the . lives campaign: setting a goal and a deadline for improving health care quality gender difference in critical care response team activations impact on outcome saudi arabia, king saud bin abdulaziz university for health sciences, riyadh, saudi arabia introduction. gender-related differences in outcome of ccrt intervention has been documented in the literature indicating that more men were admitted to the intensive care unit our center is the only center in the kingdome of saudi arabia which implements an intensivest-lead ccrt services h/ . the team is leaded by in house board certified in critical care medicine. ccrt services started in chest pain unit-viable option when risk of cardiac etiology is modest. multitudinous patient population brought together for structured survey and care at appropriate level what alters physicians' decisions to admit to the coronary care unit? m. camara , g. silva , s. silva , c. dias , j. nóbrega , e. maul hospital central do funchal, funchal, portugal introduction. procalcitonin (pct) and c reactive protein (crp) are markers of sepsis and the levels correlate with the severity of illness.aims. to evaluate the relationship of procalcitonin (pct) and c-reactive protein (crp) kinetics within the first days of sepsis with the appropriateness of antibiotic therapy and the outcome. a prospective cohort study, over months including patients with documented sepsis in our -bed intensive care unit. crp and pct were simultaneously measured four times (m -m ) during the first days of antimicrobial treatment. the pct and crp time course were analysed according to the appropriateness of the empirical antibiotic therapy as well as according to the patient outcome.results. between january and march of , patients were admitted to the icu. patients presented with sepsis on admission or during their stay. the most common infection site was the lung ( . %) followed by primary bacteraemia ( . %). gram-negative and gram-positive bacteria were isolated in the following proportion: . and . %, respectively. enterobacter, acinetobacter and escherichia were the most frequently isolated ( . % each). gram-positive sepsis was mainly caused by haemophylus influenzae ( . %). sepsis was polimicrobial in . % of cases. . % of the patients were given inappropriate antibiotics. the proportion of gram-negative bacteria isolated was significantly higher in patients who did not receive appropriate antibiotics. the magnitude of the pct and crp elevation was not associated with the appropriateness of antibiotic therapy. logistical regression analysis showed that infection without agent was an independent predictor of inappropriateness of antibiotic therapy.age, saps ii, apache ii and sofa were not associated with an unsuccessful treatment. regarding the absolute value of crp and pct there was no significant difference between successful or unsuccessful. multivariate analysis showed that dpct was not associated with antibiotic appropriateness and mortality.conclusions. although the sample is small, our study suggests that crp and pct kinetics are not associated with the appropriateness of antibiotic therapy and outcome. introduction. patients with hematological malignancy who need advanced life support in the icu because of a life-threatening complication may have a poor prognosis. that's why it is necessary to identify clinical, analytical and biological factors that can help doctors with the decision to admit these patients into the icu.objective. the aim of this study was to assess the utility of procalcitonin serum levels (pct) in predicting the outcome of patients with hematological malignancies admitted to the icu. a total of patients with hematological malignancy were admitted to the icu from january until march . epidemiological data were collected before admission, and patients were followed up clinically and analytically during icu stay. serum samples were collected from icu admission until a maximum period of days. pct values were measured by an immunofluorescent assay based on trace (time-resolved amplified cryptate emission) technology (kryptor pct, brahms ag, hennigsdorf, germany). mean age: (sd ); men/ women. among the patients included, hematological diseases were: non-hodgkin lymphoma ( patients), acute myeloblastic leukemia ( ), acute lymphoblastic leukemia ( ) , multiple myeloma ( ), chronic lymphoproliferative disorder ( ) , others ( ). twenty patients ( %) had previously received hematopoietic stem cell transplantation. thirty patients ( %) presented neutropenia at the moment of icu admission. the main causes for icu admission were respiratory failure in patients ( %) and septic shock in ( %). pct levels were not significantly higher in those patients that required mechanical ventilation. pct levels were significantly higher (p = , ) in those patients admitted because of septic shock. pct levels were lower in days , and in the patients who survived with respect to those who died: day : . ng/ml (sd . ) versus . (sd ); day : . (sd . ) versus . (sd . ) ; day : . (sd . ) versus . (sd . ). the differences were significant in days (p = . ) and (p = , ). there was a trend to have higher pct levels in those patients who had microbiologically documented infection respect to the rest; day : . ng/ml (sd . ) versus . (sd: . ); day : . (sd . ) versus . (sd . ) and day : . (sd . ) versus . (sd . ) .conclusions. serum pct levels are higher in patients with septic shock. serum pct measurement might be useful for predicting mortality in patients with hematological malignancy who require advanced life support. introduction. sepsis is a major cause of mortality in the intensive care unit (icu). efforts have been made to reduce the time needed to diagnose sepsis in order to reduce mortality from sepsis-related multiple organ dysfunction. procalcitonin (pct) has been reported elevated levels at the onset of bacterial infections and seemingly correlated to severity of infection. several clinical trials have detected a high pct level in patients with evidence of systemic bacterial infections, whereas relatively low pct levels occur in patients with only localized bacterial infections.objective. the aim of the present study was to assessed the ability of pct through sensitivity, specificity, positive and negative predictive value (ppv, npv) in patients with suspected sepsis, septic shock, inflammatory systemic response syndrome (sirs) and compared it with variables like crp, mortality, band%, renal failure, active cancer and an isolated bacterial cultures. finally we wanted to evaluate if exists a no infectious correlation in patients who received blood transfusions. we conducted an observational study including all patients admitted to the multidisciplinary icu of the abc medical center (tertiary reference hospital) to whom requested pct at admission in the suspect of sepsis and we followed their outcomes. total populations was patients (p). % were females and % were males. median age was years. of the total of pct sample % were positive and % were negative. the sensitivity and specificity in septic patients were and %. ppv and npv were and %, respectively. we did not found any statistical difference between positive value of pct and sepsis, septic shock, sirs, mortality, crp, band%, acute renal failure, acute lung injury, ards (acute respiratory distress syndrome), blood transfusions and active cancer. the mortality in the populations was %.conclusions. the pct has a wide range of diagnostic in the septic patients. in our study the rate of false positive was % and limited the use for sepsis diagnosis. we suggest that the better utility is for outcome biomarkers more than diagnosis biomarkers of sepsis. y. jin , c. guolong , iit study group of zhejiang province in china zhejiang hospital, hangzhou, china introduction. the use of intensive insulin therapy (iit) in severe sepsis and septic shock has been shown to decrease morbidity and mortality rates significantly when given to high risk surgical patients.objectives. the aim of this study was to assess the efficacy of iit in severe sepsis and septic shock patients in intensive care unit.methods. this is a muticentre, prospective, randomized and controlled study. we randomly assigned patients who admission to icu with severe sepsis or septic shock into three groups: a group (target range for blood glucose is - mg/dl); b group (target range for blood glucose is - mg/dl); c group (target range for blood glucose is - mg/dl as a control). primary end point ( -day mortality for any cause) and secondary end points (icu stay days, mv duration, apacheii scores and mods scores) were obtained serially for days and compared between the three groups. of the enrolled patients, were randomly assigned to group a and to group b and to group c; there were no significant differences between the groups with respect to base-line characteristics. -day mortality was percent in the group a and . percent in the group b assigned to iit, as compared with . percent in the group c assigned to conventional therapy (p = . ).during the interval from first hour to -day stay in icu, the patients assigned to group a and group b had a significantly lower apache ii scores( . ± . and . ± . vs. . ± . , p = . ) and mods scores( . ± . and . ± . vs. . ± . , p = . ) than those assigned to conventional therapy, there were no differences in icu stay days( . ± . , . ± . , . ± . , p = . )and mv duration( . ± . , . ± . , . ± . , p = . ) between the three groups. compared with the conventional therapy group, the group a had a higher rate of severe hypoglycemia [blood glucose level b mg/dl ( . mmol/l); . . vs. . %; p \ . ]. intensive insulin therapy provides significant benefits with respect to outcome and scores in patients with severe sepsis and septic shock in icu, on the other hand, intensive insulin therapy brings a higher rate of severe hypoglycemia. to determine the prognosis factors in elderly patients (c years) with severe sepsis admitted to an intensive care unit (icu).method. an observational, prospective and multicenter study was realized. it includes all the patients of the database edusepsis study (adults with severe sepsis admitted to spanish medical-surgical icus). the clinical and demographic characteristics of all patients including age, sex, origin of the infection, location of the patient at the moment of diagnosis of sepsis, apache ii modified score (apache ii score age excluded), number of organic failures, initial therapeutic strategy (measures of resucitación and measures of treatment), icu length of stay and hospital mortality were registered. the patient were classified in young cohort (\ years) and elderly cohort (c years). elderly cohort patients were also classified in young-old patients ( - years) and very-old patients (c years). descriptive comparative study of both cohorts was realized and multivariate logistic regression for the two subgroups of elderly patients was performed to study the risk factors of hospital mortality. a total of , patients wer enrolled ( . ± . years, apache ii modified score of . ± . , . ± . organic failures, hospital mortality . %). the elderly cohort (n = ; . %) presented a lower apache ii modified score ( . ± . vs. . ± . , p . ), higher abdominal infection as origin of the sepsis ( . vs. . %, p \ . ), higher nosocomial infection ( . vs. . %, p . ) and a lower application of measures at initial treatment ( . vs. . %, p . ) than the young cohort. there were not significant differences in the number of organic failures and days of stay in uci between both cohorts. the apache ii modified score (or . ; % ic . - . ; p \ . ), the nosocomial infection (or . ; % ic . - . ; p \ . ), the thrombocytopenia (or . ; % ic . - . ; p . ) and the acute renal failure (or . ; % ic . - . ; p . ) were associated independently to mortality in the subgroup of young-old patients. in the very-old patients only the apache ii modified score (or . ; % ic . - . ; p \ . ) was independently associated with higher mortality and in this population subgroup the application of measures of initial resuscitation was a protective factor (or . ; % ic . - . ; p . ).conclusions. the elderly patients (c years) admitted in the icu whith severe sepsis have higher mortality, more abdominal infections as origin of the sepsis and fewer application of measures of initial treatment than the young patients (\ years). nevertheless, in the subgroup of very-old patients (c years) the aggressive initial treatment decreases the mortality. objectives. the aims of this study were to determine the crude and related to bacteremia mortality rates in icu patients with bacteremia who receive appropriate empirical antibiotic therapy and to describe the factors associated to mortality in this appropriated treated patients material and methods. during a twelve years and a half period, from to , icu-patients with clinically significant bacteremia were prospectively evaluated. for purposes of this investigation, appropriate empirical antimicrobial treatment of a bloodstream infection (aeat) was defined as the microbiological documentation of infection that was effectively treated based on its antibiotic susceptibility at the time the causative microorganism were suspected. clinical and microbiological variables were recorded. logistic regression analysis was performed to determine the risk factors associated to global and associated to infection mortality. results. among icu-bacteremic patients, aeat was applied in patients ( . %). apache ii and sofa score were . ± . and . ± . , respectively and the incidence of septic shock was . % in this aeat patients. global and associated to infection mortality rates were . and . %, respectively in aeat patients. logistic regression analysis confirmed copd (or . ; % ci: . - . ) and age (or . ; % ci: . - ) as factors independently associated to global mortality and diabetes mellitus (or . ; % ci: . - . ) presentation as septic shock (or . ; % ci: . - . ) and serum levels of albumin (or . ; % ci: . - . ) as a protective factors for global mortality whereas factors as nosocomial origin (or . ; % ci: . - . ) and again serum levels of albumin (or . ; % ci: . - . ) were considered protective for related mortality to bacteremia conclusions. mortality rates remains excessively high in aeat bacteremic-icu patients. different factors were identified as predictive factors for global and associated to mortality in aeat patients. only serum levels of albumin seems to be an independent protective factor for both global and associated to infection mortalities. introduction. severe sepsis is hallmarked by organ hypoperfusion or dysfunction. the transition from severe sepsis to septic shock carries with it an increase not only in morbidity but also in mortality [ , ] . objectives. the aim of the study was to demonstrate the effect of shock at admission in sepsis comparing severe sepsis and septic shock admission diagnoses.methods. single center retrospective study in a bed mixed icu of a tertiary university hospital. during a -years period of study patients were unplanned admitted in the unit: the median was age of ( - ), the males were . % and the mean of sapsii was ± . we randomly select two groups: severe sepsis ( patients) or septic shock ( patients) at admission. statistical analysis of variables: v , mann-whitney test, unpaired t student test, cox regression. no statistical significant differences were found about age and sex between groups. about the origin of infection no statistical significant differences were found between groups, meanwhile the diagnosis respiratory infection appears to be more frequent in the severe sepsis group ( . vs. . %, p . ). the proportion of post-operative admissions (in surgical related conditions) was not different between groups. the sapss ii and sofa at h were higher in the septic shock group [ ( - ) vs. ( - ) , p \ . ]; ( - ) vs. ( ) ( ) ( ) ( ) ( ) , p \ , , respectively]. sofa at discharge appears to be higher in the shock septic group (excluding deaths) [ ( - ) vs. ( - ) (p . )]. the mortality and length of stay (excluding deaths) was higher in the shock septic [ . vs. . % (p \ . ); ( - ) vs. ( - ) (. ), respectively]. the ventilator associated pneumonia was not significantly different between groups. the probability of discharge, across an initial period of days, was lower in the septic shock group [hazard ratio . ( % ci: . - . )], mainly between the th and th days, as shown in the kaplan-meier plot (see graph ) .admission diagnosis: probability of discharge conclusions. septic shock at admission patients had a poorer outcome. the difference in the probability of discharge between groups was higher when mechanical ventilation related events are likely to occur [ , ] . we emphasize the importance of the institution of early goal-directed therapy in the wards and emergency departments prior to admission in an intensive care unit [ , ] .introduction. it is not clear whether patients with community acquired severe sepsis (cass) or hospital acquired severe sepsis (hass) have a same presentation. objectives. to evaluate the characteristics of a severe sepsis (ss) population admitted through the er (cass) and those coming from the ward (hass). all patients were treated by the same team of intensivists and er doctors in a shock room, so we could minimise the differences due to management. methods. all adult patients admitted to the medical icu were eligible if they met the criteria for ss. we collected demographic characteristics, apache ii and sofa score, comorbidities and immuno-compromised conditions. scvo or svo (if possible), lactate concentrations. the milestones of the surviving sepsis campaign (ssc) were measured regularly during the first h of treatment. the data collection went on in the icu stay too. treatment for septic shock was conformed to the recommendations of ssc. results. we enrolled pts with ss, including with cass and with hass. there was no difference in demographic features and comorbidities, including immuno-compromised conditions, haematological malignancy and chronic respiratory diseases .there were no significant differences in hemodynamic variables or indices of tissue perfusion like scvo (or svo ) and blood lactate levels, or in amounts of fluids infused or needs of vasopressor agents. the need for mechanical ventilation (mv) after the first has greater for hass than for cass patients, but during the icu stay the need for mv was the same for both groups; similarly, during the icu stay there was no difference in the need for extracorporeal renal support or need for adrenergic agents. at the beginning the scvo was around % for the entire population. after the first h both groups reached the target of %. at the admission % of patients had a scvo less than % ( . % for hass patients and . % for cass, without any difference between groups) and % of patients had a scvo higher than %. the mean svo for both groups was higher than % already at the beginning of the observational period. conclusion. only a half of pts with ss or sho had fever. the presence of fever is often associated with a positive microbiological diagnosis, but better prognosis. while hypothermia was often viewed in severe ill pts and was associated with a worse prognosis. to investigate the possible differences in characteristics and outcome between early and late-onset severe sepsis in surgical intensive care unit (icu) patients. we conducted a retrospective analysis of prospectively collected data from all adult patients ([ years) admitted to our -bed surgical icu between st march and th july .results. of , patients admitted to our icu during the study period, patients ( . %) had severe sepsis; ( . %) had early-onset and ( . %) late-onset severe sepsis. respiratory infections ( . vs. . %, p = . ) and infections of unknown origin ( . vs. . %, p = . ) were more frequently recorded in patients with late-onset than those with early-onset severe sepsis, whereas abdominal infections were more frequent in early-onset than in late-onset severe sepsis ( . vs. . %, p = . ). gram-positive infections were more frequent in late-onset than in early-onset severe sepsis ( . vs. . %, p = . ). the time of onset of severe sepsis was not independently associated with an increased risk of in-hospital death (early vs. late: or . % ci . - . , p = . ).conclusions. respiratory infections and infections of unknown origin were more frequently recorded in patients with late-onset than in those with early-onset severe sepsis, whereas abdominal infections were more frequent in early-onset than in late-onset severe sepsis. the time of onset of severe sepsis has no impact on mortality. objectives. to describe the causes, microbia spectrum, and prognosis of pregnancyassociated sepsis treated in icu in france along the last years. we conducted a retrospective study in a medico-surgical icu of beds in a non-teaching hospital in france where a high risk maternity unit was opened in . patients admitted between and for sepsis occurring during pregnancy or the post-partum period were included. the patients were excluded if the sepsis was due to a nosocomial icuacquired infection. charts were reviewed to collect data on sources of infection, microbia, maternal and fetal prognosis. data are shown as median (extremes) or percentage. data before and after were compared using non parametric tests.results. patients were admitted for pregnancy-associated sepsis ( % of total pregnancy-related icu admissions). included patients had the following characteristics on admission: age: ( - ) years, gravidity: ( - ) pregnancies, parity: ( - ) children, , . vasopressors, mechanical ventilation, and hemodialysis were required in respectively , , and % of cases.characteristics of infections are shown in table . microbiological data about bacterial infections, and specially infections of pelvic origin (chorioamniotitis, endometritis, septic thrombophlebitis), are shown in table .all urinary infections were due to e. coli. lung infections were most often documented clinically but not microbiologically.maternal mortality rate was % ( deaths before and deaths after ). for those infections that occurred in the pre-partum period, fetal mortality was %. after exclusion of fetal deaths that had occurred before icu admission, pregnancy was interrupted during icu stay in % of cases, resulting in fetal mortality of %.conclusions. despite of disappearance of post-abortum sepsis in france, sepsis remains a significant cause of icu admission during or after pregnancy, and a significant cause of maternal and fetal mortality.grant acknowledgement. none. introduction. the glasgow coma scale (gcs), universally used for assessing comatose states, has the advantage of ease of use making it accessible to all levels of clinical competence. there are, however, significant drawbacks. its relative subjectivity in the interpretation of verbal and eye responses and its mesencephalic limit in the rostro-caudal assessment of brain vitality. these two drawbacks limit its use particularly in icu intubated patients. we propose a new score, the sousse coma score (scs) that overcome the eye and verbal responses and explore the brain vitality up to brain death. the score ranges from (normal consciousness) to (brain death). the performance of this score was compared to a modified gcs (gcsm; gcs reduced to its only eye and motor components) and four score. our study interested prospective and consecutive comatose patients who were admitted to a medical icu, intubated and under ventilatory support. the level of consciousness was assessed at admission by physicians of different levels of competence. the inter-observer reliability was assessed by measuring the spearman correlation between the responses of different observers to the scs, gcsm, four score and their respective components. the prognostic predictive value of the three studied scores was assessed by the analysis of possible correlation with mortality and the roc curves. inter-observer reliability was excellent (spearman rho [ . ) for the three studied scores, but with better performance for the scs ( . , p \ . ) compared to the gcs ( . , p \ . ) and four ( . , p \ . ). the level of overall inter-observer reliability for gcs and four was paradoxically higher than that of their respective motor components. this is probably the result of a summation effect of their respective components.regarding the relationship between mortality and the studied coma scores, there was for all three scores a threshold below which mortality was %; / for scs, / for the gcs and / for the four. beyond this threshold, only the scs provides a highly significant correlation with the risk of death (spearman = - . , p = . ). a similar correlation was observed with the motor components of the gcs and four. a better correlation was found between mortality and the scs. the area under the roc curve, however, was poor for all three scores. in evaluating the minimally consciousness states and from eight value of scs, the gcs and four scores provided a wider and more subtle level of consciousness assessment. the scs provides a better inter-observer reliability and a better prediction of death while being easier to achieve. the apparently good inter-observer reliability of gcsm and four was simply the result of summation effect. however, scs was not very sensitive in detecting variations of the minimal consciousness states. the results of our study should be confirmed in larger multicenter studies for the external validation. introduction. the use of a sedation assessment scale and a sedation goal is recommended in critically ill adults [ ] . several studies have found a reduction of icu length of stay (los), of mechanical ventilation (mv) duration, and of cost [ , ] . but, durability and efficiency of such procedures over time have not been evaluated. a -bed medical icu in a university hospital. a sedation and analgesia protocol has been implemented since - . the sedation goal is prescribed each day by the intensivist; the ramsay sedation score is evaluated by the nurses every h and doses of drugs are adapted accordingly. we conducted an annual survey from to to evaluate the quantity of sedative drugs utilized, the impact on icu los and on mv duration, and cost of sedation; both the medical and nurse staff were regularly informed and the protocol was modified if necessary. u. guenther , j. weykam , u. andorfer , t. muders , h. wrigge , c. putensen university of bonn, anaesthesiology and intensive care, bonn, germany background. acute brain dysfunction (delirium and coma) is reported to occur in up to % [ ] , and to be associated with longer mechanical ventilation and stay in the icu, and increased -months mortality rates up to % [ ] . such outcome data, to the best of our knowledge, are predominantly given on medical patients with delirium incidences and mortalities much higher than we expected in surgical patients. this study assessed incidence and impact of acute brain dysfunction on length of stay on the ventilator and in the icu, and mortality in cardiac surgery patients. after approval from our local ethics committee, every patient admitted to our cardiac surgery -beds icu from october through november was daily monitored for delirium with the ''confusion assessment method for the intensive care unit (cam-icu)'' [ ] , level of consciousness was assessed with the richmond-agitation-sedation scale (rass) [ ] . acute brain dysfunction was diagnosed if patients were comatose without sedative medication or delirious. patients were contacted months later to obtain information about their further clinical course.results. patients were eligible for analysis [male , female , age, mean (iqr), ( - ) years]. % had acute brain dysfunction while in icu, these had significantly higher apache-scores on admission, higher tiss-and saps-scores, were longer mechanically ventilated [ ( - ) vs. ( - ) days, p \ . , mann-whitney test) and had longer stay in icu [ ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) vs. ( - ) days, p = . , mann-whitney test). patients were lost to follow-up; -months mortality in patients with acute brain dysfunction in icu was vs. % (p = . , log-rank test).discussion. incidence of acute brain dysfunction and mortality found here in cardiac surgery patients are lower compared to reports on medical patients. even though, duration of mechanical ventilation, length of stay in icu, and -months mortality were increased in patients with acute brain dysfunction in our icu.conclusion. these data emphasize the need for routinely monitoring of consciousness and delirium and to develop strategies to reduce incidence of acute brain dysfunction. introduction. the incidence of obesity is increasing globally, with billion overweight people (body mass index (bmi) [ kg/m ), and million of them obese [ ] (bmi [ kg/m ). the number of obese individuals presenting to critical care is likely to increase, but data on effect of obesity on outcome is conflicting [ ] . there is a general perception that obese patients are likely to have a higher incidence of adverse outcome in critical care. to investigate the effect of bmi on length of stay and mortality in patients admitted to critical care in city hospital, birmingham, uk.methods. an observational study was performed over a month period from february-april . pre-morbid data on bmi was collected from medical records and direct questioning of patients. apache ii score at h, critical care length of stay (los) and survival data to hospital discharge were collected. the figures were compared against their predicted mortality. readmissions, patients with a los \ h, patients \ years old and those without complete apache ii data were excluded. a total of patients were admitted. met the exclusion criteria, bmi data was unavailable for patients and apache data was unavailable for patients. patients were included in the final analysis. . % were female and . % were male. % of patients were above their ideal body weight, and % were obese. the obese cohort had a mean apache ii score of . with a mean los of . days and a mean hospital mortality rate of . %. the corresponding figures for the non-obese group (bmi \ ) was . , . days and . % (table ) . obese patients had reduced hospital mortality in comparison to predicted rates from apache ii scores. statistically, there was no increase in mortality of obese patients. the los and ventilated days were also comparable to the nonobese patients. introduction. managing glucose levels in critically ill hospitalised patients has been shown to play a role in improving clinical outcomes. as a result glycaemic control protocols are widely used in critical care settings and require rapid and frequent testing of patient glucose levels. poc glucose meters have migrated from ambulatory testing into hospital.there is increasing recognition that the clinical accuracy of nearly all commonly used glucose meters are affected by components or substances often present in the blood matrix of critical care patients giving rise to an increase risk of adverse incident. the aim of this study was to challenge the accuracy of a glucose meter designed to correct for these interferences.methods. paired random arterial whole blood samples were collected from icu patients admitted for [ h, samples were tested for glucose using stat strip glucose (nova biomedical) and the omni b bga (roche) routinely used for blood gas analysis.statistical methods: spearman rank correlation/regression, bland-altman analysis. results were compared to iso standard for glucose measurements. omni bga: correlation coefficient r = . , slope = . with intercept - . .bland altman plot for absolute glucose concentration showed that mean bias compared to reference was - . ± . mmol/l with limits of agreement - . - . mmol/l. study aim. to assess predictors of t and its impact on icu-, hospital-length of stay and costs in a cardiac surgical patient cohort admitted to our eight bedded icu, since through june .methods. all the pre-, intra-and post-operative variables were prospectively put into an electronic database. patients were divided into: ( ) ntg group, not needing a tracheostomy;( ) tg group, undergoing a tracheostomy. p values \ . were considered significant. out of a total of , patients with a median (iqr) age of years ( - ) ( ) from post-operative icu to the cardiac surgical ward and ( ) from the cardiac surgical ward to the rehabilitative one, increased significantly higher in the ntg group than in tg group (respectively: log-rank = . , p = . and log-rank = . , p = . ,). tg group showed a lower mortality ( . vs. . %, p = . ) than ntg one.conclusion. this study allowed us ( ) to define a predictive model for identifying patients that are likely to undergo a tracheostomy ( ) introduction. patients admitted to itu increasingly have significant medical comorbidities that require chronic therapy for adequate control . on admission to itu, acute medical problems take precedence and many long term medications, such as thyroxine, may be withheld or ceased. in chronic hypothroidism the patient is physiologically dependent upon ongoing administration of thyroxine. the optimal management of chronic medical conditions such as hypothyroidism within the itu may be essential to patient recovery and should be a quality assurance issue. to assess the prescription of thyroxine and the thyroid function in patients admitted to itu with previously diagnosed chronic hypothyroidism. a six year retrospective review of the electronic records of patients with hypothyroidism who were admitted to a bed tertiary referral hospital itu from to was performed. patients were included if they were admitted to the itu for a period of more than days and were on thyroid replacement therapy prior to itu admission. patient demographics, daily thyroid replacement dose/route, thyroid function tests (tsh and free t ) and rate and type of nutrition were obtained. patients were grouped by their worst recorded tsh according to predefined ranges . conclusions. patients did not receive their thyroid replacement for a significant proportion of their admission. this was predominantly due to either lack of prescription or lack of tolerance of enteral feed. the tsh was appropriate for the free t level. a significant proportion of patients ( %) did not have their tsh measured at all. of those that did, abnormal tests were inconsistently repeated or acted upon. having processes in place to ensure the appropriate prescription and adjustment of relevant chronic medications is essential in the provision of high quality care in itu.background. cell-free dna has been investigated as a diagnostic marker in many diseases, including acute conditions such as stroke, myocardial infarction, burns, sepsis etc. its serum and plasma levels have been shown to correlate with disease severity in all those. free circulating dna is released from dead cells (necrotic or apoptotic) and activated inflammatory cells. our hypothesis was that in acute pancreatitis free serum dna correlates with the extent of pancreatic necrosis and that it may be an early marker of severity. free dna was measured in sera from patients with acute pancreatitis at admission, on the first, fourth and seventh day following admission. severetiy of illness was assessed with atlanta criteria. on the first day following admission patients who would develop severe pancreatitis had significantly higher serum dna levels than those with mild disease (median . vs. . ng/ml respectively; p \ . ). this parameter showed very good characteristics as a potential predictor (area under roc curve . ). free serum dna was in correlation with the extent of pancreatic necrosis.conclusions. free serum dna correlates with the extent of pancreatic necrosis and is a potential early marker of severe acute pancreatitis.keywords. acute pancreatitis, cell-free dna, prognostic marker, pancreatic necrosis. introduction. the performance of general prognostic models in patients with transplantation in need for intensive care unit (icu) admission is poor, showing a tendency towards significant underestimation of the risk of dying. the objective of our study is to evaluate the acute physiology and chronic health score ii (apache ii) and simplified acute physiology score (saps ) and their days mortality prediction after liver, renal and pulmonary transplantation [ ] [ ] [ ] .methods. this is a prospective cohort study in a transplantation icu in porto alegre, brazil, during the period of may -december . clinical data of pos transplantation patients admitted at icu were collected at admission and saps and apache ii calculated with respective estimated mortality rates. the area under receiver operating characteristic curve (auroc) was obtained for both scores. objectives. to validate the saps model, over a period of one year, in a general icu. material and methods. we analysed data prospectively registered in an informatic data base (icdoc), which contain information referring to all patients admitted in this unit.we studied all the patients admitted in the year ( patients). excluded from the analysis were readmissions and one patient still in the hospital. analysed patients.results. discrimination was accessed by the area under the roc curve (aroc) and calibration by the hosmer-lemeshow ĉ test for the general equation and for regional equations (southern europe and mediterranean countries).the mean age of the patients was . ± . years. from the total of the patients, were medical ( . %), were scheduled surgical ( . %) and were emergency surgical ( . %). the mean icu and hospital mortality was . and . %. the mean saps score was . points ( - ). discrimination was good with an aroc of . ( . - . ).there was a statistical significant difference between the mortality predicted by the general equation and the observed mortality (ĉ = . ; p = . ); this discrepancy was not significant by using the regional equation (ĉ = . and p = . ). the saps overestimated hospital mortality with the predicted mortality by the regional equation getting closer to the observed mortality [standardized mortality ratio (smr) = . ] than the predicted by the general equation (smr = . ).conclusion. the saps model, particularly using the regional equation introduction. saps has been previously validated in our icu and it has been routinely used in hospital mortality prediction. as we have shown before, saps had a good accuracy regarding discrimination and calibration, with better predictions done by north american and western europe customized equations than the south american one [ ] . in a larger sample we have been observed deterioration in calibration model, especially among groups of lower probability of death, regardless of the equation in use. therefore we tested saps accuracy considering days mortality in comparison to hospital mortality. we considered consecutive admissions in a medical-surgical icu in a private tertiary hospital in sao paulo -brazil, in the period from january to november of . probability of death was derived from given equations of the original study [ ] . hospital and days mortality were considered as end point. discrimination was performed by the area under the roc curve (auroc) and calibration by the hosmer-lemeshow (hl) statistic. observed to expected (o/e) mortality ratio was also calculated. to assess factors concerning prognosis of patients older than years admitted to the icu: group a, to years old and group b, older than years. both groups were compared for the apache ii, admission group, lenght of stay, mortality and usual intensive care procedures (arterial and venous catheters, mechanical ventilation). statistical anlysis: quantitaive variables were expressed as mean and standard deviation (sd). student t test was employed for these variables. categorical variables were compared by the chi-square. p \ . was considered statistically significant. a total of patients were included in group a (mean age . , sd . ) and in group b (mean age . , sd . ). apache ii score was . for group a and . for group b (p = , ); predicted mortality was . and . % respectively (p = . ). ther were no differences for admission group or procedures among groups. mortality was significantly higher in group b ( . vs. . %, p = . ). when mortality was analyzed for admission groups, it was higher just in cardiological group, wich included ischemic cardiopathy, cardiac failure and arrhythmia ( . vs. . %, p \ . ). the investigation of the association between a differential access to intensive care services and patient or hospital outcomes is increasing markedly [ ] [ ] [ ] [ ] . objectives. the aim of this study was to compare demographic, clinical characteristics, and outcomes of patients admitted to tertiary-level intensive care units from a tertiary hospital ward (intrahospital transfer) to patients transferred from a secondary hospital ward (interhospital transfer). single centre retrospective study in a bed mixed icu of a tertiary university hospital. during the study period ( ) ( ) conclusions. the interhospital transferred patients are younger, but at admission severity of the disease is comparable.these findings, within this case mix of patients, suggest there are not significant differences in mortality, length of stay, icu-nosocomial respiratory infection or physiological disability at discharge between intrahospital and interhospital transferred patients to our unit. in this study we did not find a different impact in outcome considering these differential sources of admission. we prospectively analysed data of all patients (pts) undergoing cardiac surgery between january and june , and discharged from our icu by h from surgery. on all patients the following was collected:(i) demographics, risk factors and gravity scores anamnestic illnesses (ii) intra-operative variables [i.e. type of operation, cardiopulmonary by-pass (cpb) and aortic cross clamp (acc) times] (iii) icu-related variables. one-way anova test was used for continuous variables whereas, differences in proportions were compared using chi-squared test.a binary logistic regression model was used to estimate the effect of each considered risk factor on discharging from cardiac surgical to rehabilitative ward, considered as a dycotomous outcome (yes = early b days/no = late [ days). statistic analyses were performed using spss software. p values less than . were considered significant. on all the patients, aged c years, admitted to our post-operative icu since january through december , we collected demographic profiles, operative data and outcomes. a logistic regression model was set up to assess predictors of hospital outcome. a total of patients ( . %), . % males and with a median (iqr) age of ( - ) were admitted. the below table shows the outcome predictors (see table ). objectives. the purpose of this study was to evaluate prospectively in our medium the capacity of apache iii score to stratify prognostically critically-ill-patients upon their admission to the icu, not only with regard to hospital mortality, but also to hospital length of stay. study aim. to assess if cardiopulmonary by-pass (cpb), aortic cross clamp (acc) time and duration of mechanical ventilation (mv) may impact on icu and hospital length of stay in a cardiac surgical patient cohort admitted to our bedded icu, since through june . all the patient pre-, intra-and post-operative variable were prospectively put into an electronic database. on all patients the following was collected:(i) demographics, risk factors and gravity scores anamnestic illnesses (ii) intra-operative variables [i.e. type of operation, (cpb) and (acc) times] (iii) icu-related variables (i.e. duration of mechanical ventilation, use and type of inotropes. statistic analyses were performed using spss software. p values \ . were considered statistically significant. a total of , patients with a median (iqr) age of years ( - ) were admitted through the study period. . % underwent a cabg operation, whereas . % valve surgery and . % aortic and lung surgery. a bivariate analysis was performed considering as independents variables respectively the natural logarytm (nl) of ( ) cpb time, ( ) acc time, ( ) mv duration, whereas dependent variable was considered the nl of the total hospital stay. we showed that a linear correlation exists between total hospital stay (ln) and ( ) conclusion. this audit allowed us to assess that the longer is the cpb and acc time and mv duration the longer is likely to be the total hospital length of stay of the patients undergoing heart surgery. introduction. high-dependency units (hdu) were designed as a bridge between the operating theatre and the surgical ward for postoperative patients demanding a higher than standard level of care. the aim of our study was to determine the risk factors as well as the predictive value of four severity scores for a prolonged hdu length of stay (los). three hundred fifty-eight consecutive adult patients were included in the study for a period of months. asa, saps ii, possum and sofa scores were calculated for the first h following admission. the demographic and the scores variables were subjected to a univariate and, consecutively, a multivariate logistic regression analysis. a receiver operating curve (roc) model was used to determine the predictive value of the scores for a prolonged los. the presence of a patient for three or more days in the hdu was defined as prolonged stay.results. the median los was ( - ) days, patients were transferred to the intensive care unit and the in-hospital mortality was . % ( patients). the univariate logistic regression revealed the following variables as significant for a prolonged los (p \ . ): asa, possum preoperative, possum postoperative, possum total, possum cardiac, possum ecg, possum type of surgery, possum blood loss, sofa, sofa respiratory, sofa cardiovascular, sofa liver, sofa coagulation, igs ii, igs respiratory, igs urinary output, igs urea, igs potassium, igs bicarbonate, and bmi. seven variables were identified as having a statistically significant association with the los (table ) . according to the roc model, sofa score was the best predictor for a prolonged los, with an area under the roc (auroc) of . .warning systems and rapid response team: - s. saxena , s. jafrey , j. zwaal kingston hospital, anaesthetics, kingston, uk, kingston hospital, kingston, uk background. published data suggests that the patient group with the highest mortality in icus comprises those patients admitted from the hospital wards [ ] . studies have shown that in-hospital cardiac arrests are commonly preceded by physiological abnormalities [ ] . if admission to icu, is preceded by specific physiological derangement, then early identification of these high risk hospital in-patients may be possible. this may improve survival of patients. objectives. to determine . the effectiveness of new track and trigger pathway in identifying patients requiring icu admissions. . the impact of new system on outcome of icu admissions method. . retrospective case notes survey of all icu admissions from the ward over a month period. . the pathway is triggered when abnormalities are present in two or more of the following parameters: response to painful stimuli, respiratory rate, oxygen saturation, systolic blood pressure, and heart rate. . .triggering steps progress through involvement of junior medical staff and outreach teams at step , to more senior staff at step , to consultant involvement at step , depending on the level of deterioration of the patient. . forms were collected over a period of months. icu mortality: patients with abnormality at any time prior to icu admission: / ( %) icu mortality: patients with c abnormalities any time prior to icu admission: / ( . %) mortality of patients who were pathway followers: / ( %) mortality of patients who were pathway non-followers: / ( . %) average length of stay in icu who were survivors from pathway followers: days average length of stay in icu who were survivors from pathway non-followers: . days discussion. . there was low sensitivity of pathway for identifying icu admissions. . poor documentation of triggering events . pathway followed inadequately in majority of patients due to combinations of delay in, or absence, of triggering when indicated . lack of consultant involvement at step . no patients with chronic kidney disease admitted to intensive care have poor outcomes [ , ] . in % of cardiac arrest calls in our hospital were from the renal unit (personal communication.) at this time critical care outreach teams were recommended as means of improving intensive care outcomes through earlier ward assessment of critically ill patients [ ] [ ] [ ] . in modified early warning system (mews) charts to wards and a dedicated seven-day ward-based consultant led service ( - ) were introduced on our renal unit [ , ] . aims and methods. the impact of these change interventions was analysed. primary outcomes were the incidence of cardiac arrests calls to the renal unit, admission apache ii scores and icu mortality. secondary outcomes were age, sex, intensive care and hospital length of stay, in-hospital mortality, cpr prior to icu admission and emergency admissions to the renal unit. cardiac arrests, mortality rates and emergency admissions were compared with the v test; other outcomes via mann-whitney u test. a p value \ . was regarded as significant.results. the results are outlined in the table [ ] ; this group has a high mortality [ ] . deterioration in vital signs often precedes referral to critical care and this is evidenced by a rise in the patient at risk score (pars). higher pars may be associated with worse patient outcomes [ ] . most pars systems have a trigger value at which critical care input should be sought. we hypothesised that the duration of physiological deterioration prior to critical care admission would be associated with mortality and used the delay between pars trigger and admission as an estimate of this.methods. we collected data on over consecutive patients that had deteriorated on the ward and required admission to general critical care (hdu and icu) at both acute hospitals in sheffield. patients admitted to specialist facilities such as cardiac and neurosurgical units were excluded. those already triggering at time of hospital admission were also excluded. to assess if any of the ccrt activation criteria was associated with higher incidence of icu or hospital mortality. our hospital is bed tertiary care center. cohort analysis of prospectively collected data of each ccrt activation including demographic data of the patients and their outcome in terms of icu and hospital mortality and ccrt activation criteria. ccrt activation from st january to th september .the activation criteria for ccrt includes: threatened airway,tachypnea defined as respiratory rate more than or less than breath/min, hypoxemia defined as oxygen saturation less than % on oxygen flow l/min, arrhythmias defined as heart rate less than or more than beat per minute, hemodynamic instability if systolic blood pressure less than mmhg or more than mmhg, decrease level of consciousness defined as drop of gcs = or more points from baseline, seizure and serious concern about the patient.we analyzed each factor separately as independent predictor of icu and hospital mortality. [ ] . with this in mind efforts have been made to develop physiological early warning scoring systems which have been shown to predict subsequent outcome [ ] . we have recently introduced an early warning system (ews) chart for all patients in our hospital and we wanted to assess its impact on our icu admissions. to assess the calculation of the ews, the scores of patients admitted to icu and the compliance with guidelines regarding further intervention for patients who were ultimately admitted to icu.methods. chart review of twenty five consecutive emergency icu admissions, examining the ews in the h prior to admsission.results. ews charts were completed for % of emergency icu admissions; of these % of scores were calculated correctly. only % of ews had all parameters completed for all set of observations. the mean peak ews prior to icu admission was . with a range from to . higher peak ews was strongly associated with increased icu mortality: a ews of - was associated with mortality of . %, whereas a ews of - was associated with a mortality of % (see below). for each ews recorded specific action was required to be triggered according to the protocol. in % of cases appropriate action was taken, however, in % the required action was not taken and a number of patients were thought to have delayed referral to critical care as a result of this.conclusions. following this audit we have introduced a critical care outreach team and have embarked on an educational programme for staff with emphasis both on the complete and accurate recording of early warning scores and the necessity for appropriate action to be taken on the basis of these scores. aim. the quality of care prior to icu admission has been a focus of attention [ ] . mews had been chosen by the trust as a trigger device to identify deteriorating (sick) patients in the general wards. this retrospective study looked at the clinical characteristics of unplanned admissions to our icu and assessed the mews as a predictive tool to trigger early intervention in such cases.methodology. all patients who were non-electively admitted to our icu from the medical wards were included in the study (january-march [ ] score and standardised mortality ratio(smr) had occurred since the introduction of our nurse lead outreach serrvice and high dependency unit. this seemed counterintuitive so we decided to look at in futher detail and whether the phenomena of lead time bias occurred.objectives. primary end point was to assess if the apache ii scores and smr were different if assessed from the point of contact with outreach or hdu for patients admiitted to general intensive care. secondary endpoints looked at which physiological scores were most altered by these systems. a cohort prospective study was setup with ethics committee approval. all patients seen by outreach (group ) or on hdu (group ) prior to admission to general icu were included over a six month period. two sets of apache ii scores and mortality prediction were generated for each group, a 'pre' and 'post' score. the pre score was a h scoring period started from up to h prior to admission to icu on point of contact on hdu or by outreach. the post score was a period for scoring taken h from the point of admission to icu, ie the conventional apache ii score .therefore each patient had two sets of scores for apache ii and predicted mortality. the apache ii and predicted mortality scores were then compared using a two tail paired t test, the individual physiology scores were compared via a wilcoxon rank sum score. in total patients from hdu were included and patients from outreach were included.the primary question was answered as a significant difference in apache ii and smr was found in both groups. introduction. unplanned admissions to intensive care units (icu) are associated with an increased mortality. in order to identify in-hospital patients at risk of deterioration, several scores based on physiological parameters have been published. however, routine application of these parameters is not common in all european hospitals yet. the goal of this prospective study was to evaluate the efficiency of the current practice of handing over ward patients at risk for decompensation by physicians and nurses. furthermore, factors associated with admission to the icu or alarming of the physician on duty should be identified. the study was conducted at the university hospital of regensburg, germany on wards with predominantly gastroenterological and general medical patients ( beds). over a time period of months, the daily routine report of patients at risk to the physician on call after hours was recorded. in addition, the nurse assessment of patients at risk and the documentation of the decompensation defined by calling the physician on duty during the night were registered.results. patients were treated during the surveillance period. in total, patients ( women, men) with a mean age of ± years were either judged by the attending physicians or the nurses at risk for deterioration. patients suffered from decompensation during the night shift. of those, patients were correctly identified by physicians and patients by nurses, respectively. in patients ( %), an icu admission was necessary.discussion. only a small portion of patients reported at risk experienced a severe decompensation at night, defined as icu admission. interestingly, those were only in part correctly identified by the physician and nurse reports. a further evaluation of the correlation of those reports with the previously published ''early warning score'', and physiological parameters associated with decompensation are currently being performed in order to estimate the value of standardized patient assessment, and will be presented at the meeting. introduction. the need to implement a patient follow-up program after icu discharge arises from several facts: ( ) at icu discharge patients are now more fragile (aged, chronic comorbidities, complex). ( ) the demand for intensive care exceeds its availability. as much as % of patients die after discharge from the icu, many of them in spite of a low predicted mortality, perhaps due to premature icu discharge. ( ) compared to nursing care in the icu, the level of that received upon transfer to the floor, as measured by tiss- , may be reduced up to more than %. we believe that, in order to change icu behavior towards focus on long term outcomes, we need to increase global awareness of disability post-icu discharges, and expand the involvement of the icu team in key decision management outside the icu. we propose an alternative model of care for the critically ill patient. this involves an expanded role for clinicians with expertise in critical illness at several points along the continuum of care.objectives. due to lack of adequate clinical resources to care for some recoverable patients when are discharged to hospital wards after a long time in icu, we have planned a follow-up program focused in detecting risk factors associated to bad prognosis and, decreasing adverse events in general hospital wards. qualitative, prospective and interventional study realised during seven months (from march to september ), in the medical uci of a teaching hospital in malaga. we determined demographic data, icu admission reason, comorbidity index (charlson scale), follow-up reason (polineuropathy, tracheostomy, analgesia), family support in ward, difference in nursing activities score between icu and ward (tiss- ), intervention done out of icu with patient; satisfaction of patient, icu readmissions, reason to end follow-up and mortality at day after icu discharge. we enrolled patients in this analysis. comorbidity was charlson scale (very high) in . % of patients, apache-ii mean score points and mean expected mortality rate %. more than % of patients had five or more risk factors (age [ years, icu stay [ days, transfusions, inotropic drugs, mechanical ventilation, tracheostomy, kidney failure, parenteral nutrition, polineuropathy). nursing activities score in icu was . before discharge versus . in ward ( . % decreasement). mean follow-up were . (range - ).in hospital mortality rate was . %, rest of the patients were discharged at home. our study found the implementation of continue follow-up program from icu staff is associated with an important decreased of the mortality. encouraging clinical results and a non excesive workload for icu staff justify to continue this follow-up program in cases in which is going to be an important decrease in nursing care after icu discharge, and have bad prognosis risk factors. objectives. we examined the prevalence of adverse events (ae), suboptimal assessments of vital signs and whether there were advance directives prior to icu admission from the general wards among patients who died within days of icu admission. the patients were those admitted to the general icu from the general wards at the university hospital, lund in and who died within days after icu admission. there were patients with a mean age of years and a mean apache ii score of . we used the global trigger tool model for measuring ae (http://www.ihi.org). the frequency of vital functions assessments, and which parameters were controlled were studied in relation to patient status and the local routine for frequency of modified early warning scoring (mews).the patient records were also controlled for descisions to forgo treatment before admission to the icu. . patients ( %) suffered from at least one ae prior to icu admission. patients had an ae contributing to death, among those patients suffered from an ae that with a probability greater than % was deemed avoidable. seven of those patients suffered from a most likely avoidable ae contributing to death.vital signs were recorded inadequately in % of the patients in the h before admission to the icu. the vital signs most often recorded were blood pressure, heart rate and oxygen saturation, whereas consciousness and breathing frequency were the least recorded parameters.descisions to forgo resuscitation, or some other limitations due to ethical considerations were found only in % of the patients before admission to the icu.conclusions. patients admitted to the icu who died within days suffer from a considerable proportion of avoidable ae contributing to death. vital signs are not recorded in a satisfactory way during the h before admission to the icu in this most severely ill population. there are very rarely documented descisions to forgo treatment in this group of patients before icu admission. thus, poor control of vital signs in the general wards leads to severe and avoidable ae contributing to death. the lack of descisions to forgo treatment before icu admission in this group of patients most probably contributes to prolonged dying and suffering, and unnecessary intensive care. results. a significant correlation (p \ . ) was detected between the type of prehospital care and the early outcome among the patients. the majority of the patients was transported by ambulance services ( . %) from which half of the patients ( . % of the total) were seen by a paramedic and the rest by a physician beforehand. a relevant proportion of the patients visited the cpu without having been seen by medical personnel ( . %) before. a smaller group of patients was referred by an attending hospital physician to the cpu ( . %). . % of all patients were admitted to a cardiologic ward, . % to icu and . % underwent immediate cardiac catheterization. the rest was referred to other departments within the hospital, other hospitals or was discharged and no one died within h after admission to the cpu. almost half of the patients ( . %) who underwent immediate cardiac catheterization was transported by emergency physician car whereas half of the rest ( . %) visited the cpu as out-patient (p = . ). this very similar ratio can be seen within the patient admitted to icu ( . %). conclusion. the detection of the early symptoms of chest pain is an important prevention strategy for lay people because they can immediately turn to a chest pain unit ( . %) where almost half of them might have life threatening situation ( . %) requiring acute intervention (cardiac catherization or icu-treatment). the adequate in-time treatment can reduce the length of hospitalization and secure quicker recovery. key: cord- -oz eziy authors: munyikwa, michelle title: my covid‐ diary date: - - journal: anthropol today doi: . / - . sha: doc_id: cord_uid: oz eziy written in weekly instalments, michelle munyikwa's covid‐ diary reflects upon the experience of an unfolding pandemic from her dual role as a medical trainee and anthropologist living in the united states. her observations centre on everyday encounters with scenes or objects that reflect the growing crisis, from the absence of masks outside patient rooms to emergent forms of care through telemedicine. the diary follows the author as she experiences grief, ambivalence and disorientation in the first weeks of the pandemic. in this narrative, michelle munyikwa, an anthropologist and medical doctor-in-training, reflects on developments in the covid- pandemic in the form of a diary from philadelphia. how do you know when you are living through a crisis? crisis requires recognition -the point when a dawning awareness settles into an uneasy certainty. it may be the moment when you enter a store and find that the toilet paper or water you had intended to buy has gone -the empty shelf a signifier not only of what is to come, but of what has already happened. for me, that moment came when i could no longer easily don a mask to see patients. simultaneously reacting to and anticipating public panic, the hospital where i am a medical student had sequestered them in order to prevent theft and regulate use. in order to obtain one, you had to declare your intention to the unit secretary, who would look up the patient you were seeing and hand a mask to you only when she or he had verified you had a use for it. in an instant, the absent mask conveyed the impending change. over the last two weeks, the united states has undergone a transformation in its appreciation of the threat of covid- , the disease caused by the novel coronavirus sars-cov- . we have collectively struggled to make sense of the epidemic. scrolling social media feeds, one is inundated by reports from other countries, graphs and tables attempting to predict the future, and calls to understand the past of previous epidemics such that we might not repeat our errors. one is also bombarded by assertions that this is merely the flu, a media hoax or an example of the mass hysteria that the -hour news cycle can fuel. we live, and make choices, in an affectively saturated, information-rich (and often, truth-poor) environment. this uniquely st-century crisis is an object lesson in what it feels like to live through an emerging epidemic during what has often been described as an age of anxiety. how do we navigate unfolding uncertainty in a context where truth is wobbly and misinformation pervasive? i am a doctor-in-training and an anthropologist, currently completing clinical rotations, which means that i work in a different specialty every month. over my last few days in the hospital, i have watched the crisis unfold. hospitals are stripping down their staff to essential personnel, planning for the worst. teams that would normally see patients in large groups are paring down in the hopes of saving personal protective equipment (ppe), like masks and gowns, which are already in short supply. already, we have suspected cases in philadelphia, which was all but an eventuality, given the cases in new york. the question on everyone's mind is just how worried we should be. should we stock up for a doomsday scenario? or is this merely the flu, coupled with a politically inflected overreaction? i had been tracking the outbreak since its emergence in december. in january, i happened to be on a rotation in infectious diseases. my colleagues regarded the unfolding panic with an air of bemusement, more concerned about quotidian but deadly matters like the flu. still, i found myself sitting in on meetings where we discussed strategy with a growing sense of dread: how would we ensure that doctors out in the community felt adequately prepared? how many cases could we reasonably handle in our hospitals? could faster, more local tests be developed? this was before the virus reached other nations, let alone the united states, in significant numbers. throughout january and february, concern about an american covid- epidemic seemed tepid. most of my social networks were not talking about it, and i was only able to find communities talking about the virus in the hospital and online. this shifted around tuesday of last week, as more nations started to report cases and the case number went up substantially. soon, friends were contacting me about the virus, expressing their concern. the world health organization (who) recently announced that the worldwide death rate is . per cent, but all epidemiological evidence suggests that deaths are not evenly distributed. we also know that there is a high rate of nosocomial infection, with large quantities of healthcare workers getting infected. here in philadelphia, i am concerned by how our public health infrastructure and significant economic inequality will shape who is affected by the disease and who will die. philadelphia is often described as the poorest big city in the united states; . per cent of our resi-dents live below the federal poverty line, the highest rate among the nation's largest cities. while in a period of celebrated growth, the city is still recovering from the decline of manufacturing and its attendant public divestment and suburban flight, and the current landscape of the city is shaped by racialized class inequality and the assaults to public health that these dynamics produce. we also have a serious problem with hospitals; while there are many elite hospitals in philadelphia, that also means that we have a high concentration of complex, chronically ill patients, precisely those who will be at significant risk were covid- to become a significant public health problem here. like many american cities, we also lack a public hospital, and few ways to access care without concern for the massive, crushing bills that our specialized care foists upon patients. we will need to worry about the chronically ill and the fact that many american hospitals cannot handle a surge in patients at this time of year. in the best of times, patients can languish in the emergency department for hours while they wait for beds in increasingly crowded hospitals. in this first week, it feels as though there is nothing to do but wait, track the epidemic in other countries and hope the government pulls together a response. scepticism, anticipation, anxiety and disgust. other anthropologists have written extensively about the problems this epidemic lays bare, most notably the illumination of cleavages in our social fabric and the truly deadly implications of such divisions across the lines of race, class and national origin. this work has drawn attention to this pandemic's disregard for borders and the xenophobic and racist responses public domaina that contagion engenders. it highlights the ongoing negotiations around scientific expertise and practice and the dizzying array of projections and models that shape the daily response to the pandemic, particularly the infamous study from imperial college london. the situated labour of anthropologists has also drawn attention to the differential unfolding of this pandemic across different spaces and in local communities. as the sense of crisis transforms from a speculative possibility into a reality, i have also been struck by how overwhelming this is, in part because of a deluge of media that urges us to perform an affective reorientation to the present. affect theory offers us a language for examining the structures of feeling (williams [ ] ) that shape our response to the world. it helps us to understand the sense that we are living through history, situating our experience of the unfolding present (ahmed ; berlant ) . the lens of affect also helps us to understand how efforts to change the course of things necessarily entail attempts to manipulate such structures of feeling. as public opinion about covid- has oscillated between disgust, scepticism and anticipation, so too have the discursive strategies to combat each of these entrenched positions. as we navigate affectively shaped worlds, experts and laypeople alike engage in affective mitigation that tugs on the contours of the affective in order to transform individual sentiments and understanding. in other words, we attempt to transform one another's orientation to the epidemic in order to inform action that mitigates the crisis. scoffing on fox news, for example, politicians tug on concerns about immigrant invasions and the peril inherent in progressive politics to simultaneously maximize fear of the other and stoke confusion about the pandemic. affective mitigation also shapes our use of history, alternately stoking or taming a response through historical analogy: the flu, for example, or the sars (severe acute respiratory syndrome) and mers (middle east respiratory syndrome) events that never came to pass (arnett ). our response is characterized by a wild oscillation between scepticism and anticipation. scepticism has been attributed to members of the political right, whose news sources have projected the message that this epidemic is a fabrication of a panicked, over-anxious media. anticipation: the left, those plugged into the latest epidemiological models and projections. in the contemporary american moment, we can see that modes of preparation and prevention have failed to produce the desired effects. we find ourselves amidst a crisis that has been not only weeks, but decades in the making, with the sense that normative modes of prediction and anticipation have failed. we are daily negotiating emerging relations to expertise, authority and truth, which have always been at stake in the declaration and management of public health crises. this week, the picture is bleak. friends working in hospitals across america tell me of critical shortages of masks, sickened col-leagues and stolen equipment. due to concern about the possibility that medical students, perceived as young and healthy, could serve as asymptomatic vectors, schools around the country cancelled clinical rotations. i amalong with my classmates -at home, watching the pandemic from afar, as friends working in hospitals around the country supply me with a stream of updates. being away from the hospital, experiencing the pandemic through mediated resources, has shifted my sense of the crisis, making it at once more deeply felt and more distantly understood. doctors and advocates are organizing to halt detention, protect prisoners, feed and house the homeless and struggle to put together a social safety net hardy enough to withstand social distancing. we have seen beautiful acts of social solidarity, mutual aid and altruism. these acts balance the misery with hope, though they force us to question why they are necessary in the first place. so what does one do in the meantime? what are the stories one tells in dark times? how can a narrative of defeat enable a place for the living or envision an alternative future? (hartman ) we tell ourselves stories in order to live. (didion ) if i'm being honest, i suspect that there are no words that are adequate to the task of describing the slow-moving disaster we are living through. we often characterize this sensation as the ambiguous pleasure-paincuriosity of watching an accident unfold. i am reminded of a time when i was driving down the highway; as i approached, i saw an enormous plume of black smoke. whizzing by, it took a moment after i passed to realize that the smoke was emerging from an enormous fire in the engine of a car, which had been parked, strangely, in the opposite lane. only much later did i think to ask: what is a burning car doing on the highway? how did it come to be there? is everyone okay? there are harbingers of disaster around us: empty streets devoid of their usual traffic; a space on the shelf where your favourite bread normally dwells; cars piled full, mysteriously, with toilet paper; realizing just how often you have come to rely on small conveniences; a bizarre longing for hugs from strangers or quotidian, banal interactions. things are different. over the last week, nations around the world have locked down. the borders of the united states have closed; expatriates around the world have been encouraged to return home. here in philadelphia, we have continued to prepare for the worst. medical students, disconnected from clinical rotations, have organized to coordinate food deliveries and babysitting services for frontline providers. others have started collecting ppe, which is scarce, while still more gather to support local businesses that are suffering in the absence of foot traffic. there are efforts to aid the many people who are without housing and food, and campaigns to transform empty hotels into housing gain traction. letters circulate, some with thousands of signatures, imploring the ice (us immigration and customs enforcement) to decrease enforcement and the state to release prisoners. in moments like this, we turn to history (jones ). many of the articles circulated across my social media feeds encourage us to understand the past to orient our present response. we go clawing into the archive for lessons we wish we had already learned, and attempt to learn them too quickly, all at once. i may have read more about the - influenza pandemic in the last week than ever before in my life, and i am a student of medicine, history and anthropology. and yet, every day, another journalist uncovers these lessons with their moral: take this seriously. never forget. we, too, are vulnerable. perhaps one reason we tell ourselves these stories is because they convince us that we will, in fact, survive this. we hope that this means we might surmount the growing threat, for if others have lived to tell the tale of our devastating past, then perhaps there is hope for our future. but there is nothing to say that we are permanent presences on this earth, no reason to believe that we, unlike all other species, are not susceptible to extinction. that is not to say that the end of humanity is likely (however closely environmental collapse hovers, threatening to complete the job). it is, however, to suggest that the world that we have known up to this moment, no longer exists. returning to that normal ceased to be one of the possibilities many steps ago in this unfolding chain. its possibility was stifled most proximally by failures of government, but perhaps even more by the choices we made, entrenching rapacious capitalism, greed and immoral incompetence. we might have seen the proverbial smoke from a distance when we elected generations of leaders more invested in enriching the elite than strengthening the poor. when i am thinking about history, politics and its use, i often return to the poetic prose of saidiya hartman, whose historical imagination seeks to uncover but not redeem the past. she knows, as we all do, that we change nothing simply by noticing what has happened. after all, 'we all know better. it is much too late for the accounts of death to prevent other deaths; and it is much too early for such scenes of death to halt other crimes' (hartman ) . saidiya hartman was speaking, of course, of the not-quite-past of slavery and her repeated visits to the archive of that atrocity, saturated as it is with the tales of the dead whose loss we will never recuperate. as this pandemic visits devastation unevenly upon poor communities, people of colour and immigrants, the body count of racial capitalism mounts and we are left to account for it. if it is the case that we are always hanging in the balance between presence and absence when recounting the injustices of history, then what do we hope for with respect to telling these tales in the present? i want to believe that revisiting the lives that were unnecessarily lost years ago during the flu pandemic will spur us to do differently. i want to believe that being haunted by the archive of bodies piled in the streets might shift our perspective, such that we will successfully avoid what is to come. i want to think that knowing that this is all wrong may keep us from continuing to do it. i also wonder if by the time it occurs to us to marshal the evidence of the past, it is already too late. i fear that we are like i was: blinking into realization the image of a burning car on the road, long after i could have done anything about it. an image of destruction seared into my consciousness, for nought. when is it time to dream of another country or to embrace other strangers as allies or to make an opening, an overture, where there is none? when is it clear that the old life is over, a new one has begun, and there is no looking back? (hartman ) we're over , cases here in the united states, as many states have placed shelter in place orders and the economy has come to a grinding halt. hundreds of thousands have lost their jobs and the threat of economic disaster looms. politicians and citizens alike worry that our response is an overreaction. donald trump, concerned about stock prices, has been at the centre of a push to reopen the economy and loosen restrictions on those communities where disease prevalence is lower or allow lower-risk citizens to work. rallying around the cry that 'the cure cannot be worse than the disease', people desperate for economic relief suggest that we go back to the way things were, allowing the epidemic to run its course. perhaps, they suggest, we can merely isolate the 'at risk', allowing the rest of the country to go to work. this, despite the increasingly dire situation in new york and other cities around the country. this week has also seen the spread of covid- throughout africa, with a reported , + cases across the continent, likely an underestimate. i am now worried about the spread in these countries, which include my home nation of zimbabwe, where rumours surrounding our first death suggest that we are woefully underprepared for the task of fighting this pandemic. i worry about my extended family, who remain there, and what they will do if one of them becomes sick. while the conditions in countries with fewer resources will be dire, an abundance of wealth does not seem likely to prevent horrible outcomes in the united states, where we are quickly developing the worst epidemic in the industrialized world. in new york, massachusetts and michigan, medical students are being graduated early to help with the crisis. philadelphia-area doctors warn of an impending ventilator shortage, and the institution prepares guidance for the worst: rationing and the reality of preventable death. we are not there yet in philadelphia, but the anticipation permeates the entire health system. every day, hospital leadership sends new projections, attempting to calculate the impact of this pandemic -do we have enough beds? enough clinicians? enough gloves? -each time assuring us that we are ready. however, some projections are more terrifying than others, suggesting a flow of hundreds of patients a day into a hospital with just barely enough space for those patients we anticipate. my best friend, an emergency doctor, texts me news every day. 'intubated a -year-old woman today'; ' intubations in one shift, there's normally only one'; 'we're down to the donated ppe'. the hospital is a ghost town, with elective surgeries cancelled and other patients avoiding care for fear of contracting the virus. we are nowhere near the peak yet, so the hospital is the emptiest it has been in years. this feels like the calm before the storm. stories of young healthcare workers dying of respiratory failure circulate in my medical social circles. my mother, also a doctor, worries about the impending shortage at her hospital. it becomes clear that healthcare providers will be among those who bear the brunt of this, to say nothing of the poorly paid essential workers across many industries. hospitals around the country begin trialling hydroxychloroquine as prophylaxis, and as donald trump and scientists alike promote the possibility of the drug, we hope they are right. the debate around the drug reveals deep uncertainty about the proper course of treatment, bringing up important concerns about ethics, patient harm and medical responsibility. march- april: time compression, pandemic fatigue and the new normal as i am editing this, the united states has nearly , cases and over , deaths. the disease is now the largest cause of death in the country. my experience of the pandemic has transformed from a frenzy into a slow unfolding, each day simultaneously more terrible and mundane than the last. as we round out one month of sheltering in place, my experience of each day becomes more and more rapid, as i blink and days have passed. at the same time, it feels as if this pandemic has lasted a thousand lifetimes. this is in part because the nature of my work has changed so much, from intense labour in the hospital to digitally mediated interactions on video chatting platforms. i spend most of my day in front of a screen, like many of my peers, completing both school and volunteer work digitally. across the healthcare system, students and providers alike have been repurposed. psychiatrists and gynaecologists act as frontline providers in areas of the hospital where they usually do not work, while others pivot to telemedicine. as medical students, we have been forbidden from interacting with patients, but we continue to volunteer. some students participate in grocery delivery programmes, picking up an extra bag of food on their weekly trips and dropping them off for patients in need. others staff our tele-icu (intensive care unit), watching over intubated patients with a camera from a safe distance a mile away from the hospital and adjusting vent settings from afar -more a scene from science fiction than real life. i have signed up to a project attempting to address the social needs of patients in our massive healthcare system. a team of medical students and social workers has assembled to intervene in the social fallout from this disease, from unstable housing to domestic violence, health insurance woes to food insecurity. based on a referral from a doctor, the team calls to perform a screening: do you feel safe at home? do you have enough to eat? are you worried about paying your rent? my first call was to a woman who had lost her job and her insurance due to covid- related layoffs, just in time to contract the disease. or it should have been; i called her all morning, but her phone had already been disconnected. other patients, covid-positive and acting as caregivers for family members who were now at risk, needed help with food, making money, surviving. who will get my groceries if i can't leave my house and everyone who lives with me might also be contagious? can someone come to take care of my elderly grandmother who has dementia? can i go back to work? these conversations force athens airport, february : the covid- virus hell in italy is just beginning. i arrived in greece in early february before the chaos started; today, i am heading to kavála, the field base for my comparative project on the protest movements against the trans adriatic pipeline in greece and southern italy. out of habit, twice, perhaps three times, i say 'grazie' as i navigate airport procedures. it's enough to elicit worried looks and whispered comments among the bystanders. a sudden and uncomfortable feeling grips me. the next day, greece records its first covid- case, 'imported' from italy. ever since that announcement, an invisible wall has arisen between me and my greek neighbours. soon, it also affects my fieldwork. 'i don't speak to italians' i overhear while sitting in the car of one of my informants, as he calls a fellow activist and introduces me. next day, immediately after he posts a picture of us on facebook, the warnings fly: 'be careful! you're not even wearing masks!' though followed by smiley emojis, such 'joking' remarks are anything but. then there's the street vendor's inquisitive and concerned look when he places my accent, my neighbour's 'teasing' gesture of shielding himself from me by forming an x with his arms, and the pharmacist who suddenly steps back and denies me the much-requested disinfectant hand gel as it is destined 'only for local customers' -while grunting. in response, i speak as little as possible to avoid making mistakes in greek and to 'hide' my nationality. this hits me particularly hard as i'm usually warmly received in greece. i'm a southern italian who grew up in salento (puglia), where a variety of greek -'griko' -is still spoken. on this shore of the shared sea, griko tends to elicit admiration and self-celebratory comments about the durability of hellenism. suddenly i'm no longer called i ellinìda tis kato italias ('the greek from southern italy'). the distinction between purity and danger fills into symbolic -and physical -boundary maintenance, as mary douglas observed in her book purity and danger. abruptly, i'm simply italian and italian means 'polluted and polluting' -the enemy. meanwhile, gallows humour circulates via memes: 'not finding a seat on the bus? no problem. cough, say buongiorno a tutti -"good morning everyone [in italian]" -and sit wherever you want!' (facebook, february) . then again, irony can be a weapon as much as self-irony can be a defence: 'i'd say that if we keep coughing, we'll end up re-conquering the roman empire' (facebook, march) . however, as things in italy take a catastrophic turn, and as infections climb in greece, public expressions of concern and closeness towards italians follow. when the covid- nightmare started in matryx / pixabay.com questions of reciprocity, solidarity and obligation. every patient chart, every documented encounter, is an unflattering look into our devastatingly leaky social safety net. the virus continues to unmask the consequences of our late capitalist social order, which differentially exposes communities to death (taylor ) . in philadelphia, these are apparent in statistics collected by our public health officials, which reveal that it is easiest to get tested in our affluent neighbourhoods, despite a larger number of cases in poorer communities. to get a test outside of a hospital, you must wait in a drive-through line, leaving those without cars to scramble for other means of testing. meanwhile, my peers are still collecting ppe. my partner and i, not generally prone to crafting, pull out a long-neglected set of sewing machines to produce masks for ourselves and friends as the recommendations shift and community use of masks is encouraged. we draw on his expertise as an engineer to design and fabricate alternatives to n surgical masks, anticipating a day when our doctor and nurse friends will go to work to find protection absent. i'm reminded of a message my mother sent me early in the pandemic, as critical shortages of ppe became apparent and her daily work in the hospital revealed an overwhelming lack of preparedness. the message said simply: 'no gloves. no eyewear. no ppe. who's [this] s**thole country now?' it has become increasingly difficult to gain the distance from this pandemic that would allow me to make sense of it. at the same time, there has been a veritable boom in social theory since the pandemic began. every day, advertisements for webinars and digital lectures fill my inbox. calls for papers have already pivoted around this latest crisis, and i expect to see dozens of covid- -related panels at the next big conference. a prominent social theorist has already penned a book about the pandemic. i feel self-conscious about my dulled capacity to distance, to theorize, to make sense of something which is overwhelming and surreal. it is true that as anthropologists, we are precisely in the business of making sense of what is going on around us. perhaps it is a need for control, the will to know, that impels us to attempt to tame what ultimately can't be tamed. or it is worth noting that the federal poverty line is only one of the many ways of characterizing widespread precarity in the city of philadelphia, though it is most often cited. . here, i am thinking especially of some of the compelling contributions to somatosphere's covid- forum, particularly adia benton's elaboration of the racialized geography of blame also see: macgregor it is worth noting that it is not always the case that medical students are healthy and that this elides those who are living with chronic illness or are otherwise at risk. . i heard rumours before i started to see formal reporting, like nyoka ( ). also, a later account describes the family's perspective it is worth noting that the use of invasive ventilation for covid- is contested terrain, with considerable disagreement about when to intubate, the ethics of early intubation and the potential harm to patients of overly aggressive care affective economies years ago, another epidemic terrorized the city. the boston globe border promiscuity, illicit intimacies, and origin stories: or what contagion's bookends tell us about new infectious diseases and a racialized geography of blame. somatosphere (blog) cruel optimism the white album: essays venus in two acts history in a crisis -lessons for covid- novelty and uncertainty: social science contributions to a response to covid- covid- -struck family speaks of ordeal. the standard (blog) coronavirus: zimbabwean broadcaster zororo makamba died 'alone and scared'. bbc news counting coronavirus: delivering diagnostic certainty in a global emergency reality has endorsed bernie sanders. the new yorker the pew charitable trusts . philadelphia : state of the city keywords: a vocabulary of culture and society mona lisa protecting her environment from infection by covid- key: cord- -w trclz authors: oh, eunja; choi, jeong sil title: factors influencing the adherence of nurses to standard precautions in south korea hospital settings date: - - journal: american journal of infection control doi: . /j.ajic. . . sha: doc_id: cord_uid: w trclz background standard precautions (sps) serve as the first line of defense against exposure to blood and body fluids. the objective of this study was to explore the adherence of nurses to sps and to identify factors influencing adherence to sps. methods this study was an exploratory cross-sectional survey. a total of nurses from general hospitals and tertiary hospitals located in south korean cities were selected. hierarchical regression was used to examine the effects of sociodemographic, individual, and institutional factors. results a higher, or positive, attitude was the strongest influencing factor in adherence to sps in the final model, followed by administrative support, hospital types, and safety climate, in descending order. these variables accounted for . % of the variance in adherence to sps. conclusions the attitudes of nurses toward sps is important for increasing the adherence to sp best practices. the adherence of nurses to sps will improve if safe environments are created in different hospital types and if managerial support and administrative efforts are supportive and sustained. health care workers are at risk of exposure to blood and body fluids containing bloodborne pathogens. nurses are especially prone to exposure, owing to their involvement in direct, invasive, and continuous nursing activities. , standard precautions (sps) serve as the first line of defense against exposure to bodily fluids such as blood and secretions, mucous membranes, and nonintact skin, which were deemed infectious, regardless of a patient's diagnosis. in , the centers for disease control and prevention added respiratory hygiene and/or cough etiquette and safe injection practices to the list of sps. adherence to sps is essential in preventing health care−associated infection (hai). , , the middle east respiratory syndrome (mers) outbreak in south korea was the second largest health care−associated outbreak in the world. failure to adhere to basic sps and protocols, pursuant to different routes of disease transmission, contributed to the outbreak. this has assisted with an increased awareness of hais and efforts with improving the levels of adherence to sp. however, the level of adherence among nurses remains insufficient, requiring a behavioral change to improve adherence and prevent hais. , , , studies on the influencing factors of sp adherence have been investigated, including individual, work-related, and organizational factors or sociodemographic, individual, and institutional factors. occasionally, factors such as knowledge, attitude, safety climate, protective device, and workload have been examined without distinction of categories. haile et al reported that the sociodemographic factors reported to affect adherence to sp include being female, length of work experience, age, higher level of education, , and department the nurse is stationed in. health belief, awareness, and risk perception have been identified as influencers of adherence to sp among individuals, , , , with results varying by country, hospital type, and subject. recently, institutional factors such as safety equipment availability and accessibility, management support for safe work practice, safety performance feedback, and workplace safety climate have received attention for their importance in sp adherence. a study of registered nurses from public hospitals in china were affected by protective equipment, safety climate, and workload, whereas other studies show that workplace safety climate influences sp adherence among nurses in dialysis care and adherence to sp by nurses in psychiatric wards is correlated with organizational factors, including availability of personal protective equipment (ppe) and the security climate. haile et al also show that medical staff in university hospitals were found to be affected by training on sp, accessibility of ppe, and management support. this suggests it is necessary to investigate institutional factors affecting workplace safety climates, including physical, and other circumstances, together with administrative support. , this study aimed to understand how sociodemographic and individual factors, such as knowledge and attitude, along with institutional factors such as safety climate and administrative support, influence the adherence of nurses to sps in south korean hospitals following the mers outbreak. , evaluating the effects of sociodemographic, individual, and institutional factors, whereas considering the hospital size and type, will contribute to the improvement of sp adherence and to the creation of a safe environment and administrative system. this study is a descriptive survey exploring the adherence of nurses to sps and identifying factors that influence adherence to sps. this study was conducted with nurses from general hospitals ( - beds each) and tertiary hospitals ( - , beds) with infection control offices, all located within the metropolitan area of incheon, south korea. ten general hospitals and tertiary hospital declined participation. the inclusion criteria for this study's participants were nurses working in direct contact departments, excluding administrative departments and insurance review departments. participants were selected through convenience sampling, and the number of participants was calculated using g*power . . . . the minimum sample size required for regression analysis, with medium effect size of . , significance level of . , power of . , and predictive factors, was calculated to be . data were collected via a survey from february , , to april , . a total of questionnaires were collected by allocating persons from nurses per general hospital (n = ) and persons from nurses per tertiary hospital (n = ). questionnaires were collected from a total of nurses (response rate . %). after excluding incomplete questionnaires, a total of nurse responses were included in the analysis. the total number of questions was , and the survey took about minutes. all research tools were approved for use by the authors. all procedures followed were in accordance with the ethical standards of the institutional review board of gachon university ( - -hr- - ). informed consent was received from all patients prior to data collection. the participants were kept anonymous throughout the survey, and their personal data were kept confidential. the participants were given the option to stop the survey process at their discretion. the researcher visited the hospitals to collect the completed questionnaires in person. adherence to sps and attitude toward sps were measured using a -item questionnaire developed by askarin et al, then edited and translated to korean by jeung. the tool consisted of questions on hand hygiene, items on ppe, items on environmental management (cleaning, disinfecting, and laundry), items on needlestick and sharps injury prevention, and items on respiratory hygiene and cough etiquette. adherence to sp was measured on a -point likert scale ( = "never adhered," = "adhered sometimes," = "adhered most of the time," and = "always adhered"); a higher score indicated a higher level of adherence. the cronbach alpha with all questions was . in the study by jeung and in this study with all questions was . . attitude toward sp is defined as the degree to which the participant perceives sp to be important in the prevention of exposure to blood and body fluids. attitude toward sp was measured on a -point likert scale ( = "disagree," = "somewhat disagree," = "somewhat agree," and = "agree"); a higher score indicated a higher level, or more positive, attitude. the cronbach alpha was . in the study by jeung and in this study with all questions was . . knowledge on sps was measured using the -item survey developed by baek, who added items addressing respiratory hygiene and cough etiquette to the -item survey developed by suh and oh, based on the healthcare infection control practices advisory committee guidelines. these guidelines consisted of items on the definition of sp, items on hand hygiene, items on ppe, items on environmental management (cleaning, disinfecting, and laundry), and items on needlestick and sharps injury prevention. each item was measured based on the following scale: point if "yes" and point if "no" or "not sure." a higher score indicated greater knowledge on sps. in a previous study conducted by baek, the content validity index value of the whole questionnaire was found to be . when testing for the tool's validity; the knowledge section was scored on a range of to points, which was then converted into a percentage. safety climate refers to the physical, and other circumstances necessary to perform actions delineated by sp to prevent the risk of exposure to blood and body fluids. safety climate was measured using a -item questionnaire developed by cho and choi, and then revised and supplemented by suh and oh. each item was answerable by either "yes" ( point) or "no" ( point). reserved items were reversely coded. a higher score indicated a safer climate for prevention of infection. the safety climate score ranged from to points and was converted into percentage. the cronbach alpha was . in the study by suh and oh, and . in this study. administrative support refers to an organizational form of assistance and support that may encourage preventive action against infection. it was measured using a -item survey, which borrowed questions addressing "manager expectations and actions promoting patient safety" from the hospital survey on safety culture by the agency for healthcare research and quality and items about "administrative reinforcing" from the survey developed by baek. it was measured using a -point likert scale ( = "disagree," = "somewhat disagree," = "neutral," = "somewhat agree," and = "agree"); a higher score indicated better administrative support. the cronbach alpha was . in the study by baek and . in this study. the collected data were analyzed using spss/win . (ibm, armonk, ny). major variables were normally distributed (kolmogorov-smirnov test), and -tailed p values of <. were considered significant. the participants' general characteristics and related variables were calculated using frequency, percentage, mean, and. reliability of the variables was calculated using the cronbach alpha. differences in the level of adherence to sp in relation to general characteristics were analyzed using the independent student t test, analysis of variance, and scheffe test. correlations were computed using the independent pearson correlation coefficient. to identify the respective effects of knowledge, attitude, safety climate, and administrative support of nurses on adherence to sp, this study conducted a hierarchical linear regression, controlling for confounding variables that were found to have significant difference and correlation. based on the study of haile et al, analysis of sociodemographic factors as level (age, hospital types, and length of clinical experience), individual factor as level (attitude), and institutional factors as level (safety climate and administrative support) was performed in descending order. most of the participants were women ( . %), and the mean age was . § . years. approximately . % of the participants held a bachelor's degree or higher. a total of . % of the participants were employed in tertiary hospitals, and most of the participants were staff nurses ( . %). approximately . % of the participants worked in wards, and . % worked under a -shift system. adherence to sp differed significantly according to hospital type (p < . ), with tertiary hospitals having higher adherence scores ( table ) . level of knowledge, attitude, and adherence to sp, safety climate, and administrative support the mean score for knowledge on sp was . § . (out of points), . § . (out of points) for attitude, and . § . (out of points) for adherence to sp. the safety climate score was . § . (out of points). the question with the highest score ( . § . ) was "hand hygiene can be maintained with ease because washbasins and waterless alcohol hand sanitizers are readily available." by contrast, the question with the lowest score ( . § . ) was "there is not enough time to perform tasks while adhering to sps (reversed item)." the administrative support score was . § . (out of points). the question with the highest score ( . § . ) was "manager does not take infections of patients in the ward seriously (reversed item)." by contrast, the question with the lowest score ( . § . ) was "manager gives praises when i perform tasks according to sps" ( table ) . the adherence of the participants to sp was significantly correlated with their attitude, the safety climate, administrative support, age, and length of clinical experience (p < . ) ( table ) . hierarchical regression was used to examine the effects of major factors on the adherence of nurses to sp: the respondents' sociodemographic, individual, and institutional factors. in the first model, age, hospital types, and length of clinical experience increased the explanatory power of variance by . % (f = . ; p < . ). the standardized coefficients of hospital types (b = . ; p = . ) was significant. when the attitude of nurses was entered into the second model, the explanatory power of variance increased by . % (f = . ; p < . ). the second model accounted for . % of the variance in the adherence of the nurses to sps. when administrative support and safety climate were entered into the third model, the explanatory power increased by . % (f = . ; p < . ). in the final model, the standardized coefficients of attitude was the most influential factor (b = . ; p < . ), followed by administrative support (b = . , p < . ), hospital types (b = . ; p < . ), and safety climate (b = . ; p < . ). these variables accounted for % of the variance in adherence to sp (table ) . adherence to sp is affected by various factors, and changes in institutional factors, in addition to changes in sociodemographic and individual factors, must be explored to bring about a behavioral shift. among individual changes required to increase adherence to sp best practices, knowledge, attitude, awareness, risk perception, and health beliefs have been studied. , , , , in some studies, knowledge and attitude were found to be major influencers and have positive effects on adherence to sp best practices. , , however, in other studies, they did not exert a significant effect, or only exerted meaningful influence. in this study, the biggest influencer on adherence to sp was attitude. whereas sp adherence was not correlated with knowledge, knowledge had a correlation with attitude. a positive attitude was highly correlated to knowledge about infection control prevention around body fluids, including blood, which led to an overall improved adherence to sp. this shift in attitude indicates that it is possible to shift behavior. the higher degree of perception should take place across sub-items under attitude, including hand hygiene, ppe, environmental management (cleaning, disinfecting, and laundry), needlestick and sharps injury prevention, respiratory hygiene, and cough etiquette. given that sp should be applied to all patients before identifying the source of infection, an effective training system should be established to promote adherence to sp at all times as well as promotional and managerial programs addressing each sub-item under sp. this study sets itself apart from others in that it considers hospital type as a significant factor influencing adherence level. south korean tertiary hospitals serve as both educational institutions and advanced general hospitals. tertiary hospitals with - , beds are likely to have more infection control personnel and an infection control fee commensurate with their bed count. the infection control fee is paid to a hospital as compensation if the hospital meets staffing requirements: infection control doctor and or more infection control nurses for every - beds. additionally, tertiary hospitals are also required to have a strict infection control system based on hospital accreditation evaluation. , a similar study on nurses in hemodialysis care showed that adherence to sp was significantly lower among nurses in private hospitals than those in general or tertiary hospitals, which is a reflection of poor infection control system in private hospitals owing to blind spots created by medical laws. in spite of the heightened national and social awareness of hai and the amendment of the medical services act following the mers outbreak in , further efforts should be made to improve adherence to sp and to strengthen infection control in small to medium-sized general hospitals. the safety climate score was . (out of points), which was higher than . in a study of nurses working in south korean general hospitals. this increase is likely owing to the legal and administrative efforts following the outbreak of a new infectious disease. however, the fact that "there is not enough time to perform tasks, whereas adhering to sps (reversed item)" scored the lowest, with . § . points, shows that hospitals must not only supply sanitizers and ppe, but also work toward adequate arrangement of personnel and nursing so nurses can both finish tasks and adhere to sp. the high standard deviation in this item was considered to be owing to variance in the various subjective perceptions of time as well as in different hospitals and departments with various scale of bed counts. a previous study reported that chinese hospitals are also faced with frequent occupational exposure owing to a shortage of nurses and an increased workload, which detrimentally affect the adherence to sp, highlighting the importance of sufficient nursing personnel. in this study, administrative support consisted of several subitems, including management support, staff education, infection control protocols, staff health checkups, and vaccination. whereas items for administrative support vary across different studies, brazilian studies found that nurses with management support were more likely to comply with sp than those who had less frequent support and that training on sp guidelines enhances adherence level, encourages learning of recently updated protocols, and serves as a major contributor to continued adherence. an additional ethiopian study showed that managerial support for safety and staff training increased adherence to sp . -and . -fold, respectively. organizational infrastructure for infection control cannot be created without commitment and support from the management, hindering efficient adherence to sp. given that "manager gives praises when i perform tasks according to sps" was the item with the lowest score, not only surveillance but a reward system should be considered as well. managers should set up a training system to correct nurses' nonadherence, act as role models in adherence to sp, and stand at the forefront of sp amendment and policy making. administrative support would improve adherence of nurses to sp and enable efficient management. the results of this study suggest that administrative support and safety climate are additional factors to be considered for promoting adherence to sp. however, even if all of these environmental factors were provided, the most influential factor in adherence to sp was the attitude of the nurse. therefore, nurses should be encouraged to promote adherence to sp, and to cultivate a positive attitude toward sp. this study had some limitations. we used self-report questionnaires as opposed to actual observation to assess adherence. therefore, we suggest a follow-up study using observation to ensure objectivity in regard to adherence to sp. in addition, since general and tertiary hospitals were selected using convenience sampling, a selection of hospitals via systematic allocation considering the area and facility size would be necessary. furthermore, male nurses only accounted for . % of the sample, which is insufficient given that the average ratio of male nurses in south korea is %. last, this study focused on south korea, whose circumstances are rather particular with respect to the national outbreak of mers in ; and therefore, its results should be interpreted with caution. adherence by nurses to sp is critical in the prevention of hai, and behavioral change is needed to improve adherence levels. in a hierarchical analysis, the sociodemographic (model ), individual (model ), and institutional (model ) factors, with significant influence on adherence to sp, were found to be hospital type, attitude, and safety climate and administrative support, respectively. attitude was the biggest influencer of adherence to sp, followed by administrative support, hospital types, and safety climate. adherence to sp by nurses will improve if safe environments are created in different hospital types, and if managerial support and administrative efforts are sustained. to change the attitude of nurses toward sp, consistent promotion and a reward system should be put into place, along with practical training applicable to clinical practice. special care should be put into small and medium-sized hospitals, which are more likely to be overlooked when it comes to infection control, and institutional efforts should be made to secure adequate staff, physical safety environment, and nursing time required for creating safety climate. hospital administrators should take responsibility as role models and demonstrate consistent adherence to sp with determination and commitment. risk factors for bloodborne viral hepatitis in healthcare workers of pakistan: a population based case-control study malek mohamadi r. percutaneous exposure incidents in nurses: knowledge, practice and exposure to hepatitis b infection: percutaneous exposure incidents in nurses guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings reasons and consequences of low adherence to standard precautions by the nursing team knowledge of and compliance with standard precautions by nurses in intensive care unit factors influencing compliance with standard precautions in intensive care unit and emergency room nurses factors influencing emergency nurses' burnout during an outbreak of middle east respiratory syndrome coronavirus in korea crisis prevention and management by infection control nurses during the middle east respiratory coronavirus outbreak in korea factors influencing adherence to standard precautions among nursing professionals in psychiatric hospitals. rev da escola de enfermagem da compliance with standard precautions and associated factors among healthcare workers in gondar university comprehensive specialized hospital, northwest ethiopia influencing factors on use of standard precautions against occupational exposures to blood and body fluids among nurses in china factors influencing hemodialysis unit nurses' compliance with standard precautions using hierarchical linear modeling effects of nurses' knowledge, administrative support and environment for infection control on compliance of, standard precautions in geriatric hospital. master's thesis. the graduate school yonsei university power : a flexible s statistical power analysis program for the social, behavioral, and biomedical sciences knowledge, practice and attitude towards standard isolation precautions in iranian medical students awareness and performance for standard precautions among outpatient clinics nursing staffs in a university-affiliated hospital knowledge oh hy. perception, safety climate, and compliance with hospital infection standard precautions among hospital nurses hospital survey on patient safety culture korea ministry of government legislation psychosocial and organizational factors relating to adherence to standard precautions individual, work-related and institutional factors associated with adherence to standard precautions the authors would like to thank all of the nurses who so willingly participated in this study. key: cord- - d i ix authors: querido, micaela machado; aguiar, lívia; neves, paula; pereira, cristiana costa; teixeira, joão paulo title: self-disinfecting surfaces and infection control date: - - journal: colloids surf b biointerfaces doi: . /j.colsurfb. . . sha: doc_id: cord_uid: d i ix according to world health organization, every year in the european union, million patients acquire a healthcare associated infection. even though some microorganisms represent no threat to healthy people, hospitals harbor different levels of immunocompetent individuals, namely patients receiving immunosuppressors, with previous infections, or those with extremes of age (young children and elderly), requiring the implementation of effective control measures. public spaces have also been found an important source of infectious disease outbreaks due to poor or none infection control measures applied. in both places, surfaces play a major role on microorganisms’ propagation, yet they are very often neglected, with very few guidelines about efficient cleaning measures and microbiological assessment available. to overcome surface contamination problems, new strategies are being designed to limit the microorganisms’ ability to survive over surfaces and materials. surface modification and/or functionalization to prevent contamination is a hot-topic of research and several different approaches have been developed lately. surfaces with anti-adhesive properties, with incorporated antimicrobial substances or modified with biological active metals are some of the strategies recently proposed. this review intends to summarize the problems associated with contaminated surfaces and their importance on infection spreading, and to present some of the strategies developed to prevent this public health problem, namely some already being commercialized. microorganisms' spreading, and consequent infection propagation is a serious concern worldwide, yet there are still very few guidelines or legislation for infection propagation control in public spaces. the exception is made for healthcare facilities with the existence of few guidelines and orientations for infection prevention and control, nevertheless hospital acquired infection (hai) remains a tremendous problem. one of the main causes for the high number of hai reported by the world health organization (who) is related to the ability of the microorganisms to survive for long periods in hostile environments such as dry surfaces [ , ] . rooms occupied with infected patients often have their surfaces contaminated with pathogens leading to the contamination of hands and gloves of medical staff, and consequent transfer of these microorganisms to patients or onto other surfaces. this cross-contamination mechanism has already been recognized and lead to the implementation of hygiene procedures for hands when contacting with patients. still, it is more likely for a patient to get an infection when staying in a room previously occupied by an infected patient. thus, infected patients are the primary source of surface and material contamination. visitors and/or asymptomatic carriers also contribute to the spread of microorganisms, especially in situations where there is an apparent sense of safety [ ] . as said before, there are guidelines for surface cleaning and disinfection in hospitals, however, those recommendations are not sufficient to solve such a problem and the incorrect following of the disinfection instructions can even cause greater contamination problems [ ] . this review considered english-language articles retrieved from pubmed database literature searches, bibliographies from published articles, and infection-control books and chapters, in a total of references published between and , considering the following criteria: the most recent studies performed on microbiological analysis on different surfaces reporting samplings performed on food contact surfaces, public spaces and hospital surfaces, where microorganisms occur naturally. surfaces studies, the most recent and relevant works developed on surface modification or functionalization were selected and two main types of surfaces were considered for this review -anti-adhesive surfaces and antimicrobial surfaces, along with their subtypes. finally, products already commercially available with enough reliable manufacturers' information about the product and its adequacy to the topics discussed in this review were also included. contamination spreading by contact can occur either by direct contact with an infected patient, or indirectly through a contaminated object or surface [ ] . surfaces represent an important way of transmission of diseases since they can act as a reservoir of microorganisms that may spread to whoever contacts with the surface. especially in crowded spots as public transports or public spaces and places susceptible of the presence of microorganisms like healthcare facilities, surfaces may represent a serious source of infection spreading [ ] . table describes the microorganisms detected in hospital, food handling, and other environmental surfaces. it is estimated that each year, in the united states alone, . million episodes of foodborne illness occur resulting nearly , hospitalizations and over deaths. the microorganisms most commonly associated with this phenomenon are norovirus, salmonella spp., clostridium perfringens and campylobacter [ ] . food contamination can result from several factors and occur at different points of the preparation process. from farming to the moment of consuming, food goes through several steps where contamination by microorganisms can occur. temperature and storage conditions are important factors to prevent food spoilage however, there are other factors that can cause microbiological contamination [ ] . food-contact surfaces' contamination can cause food contamination with pathogens during processing or packaging. bacteria are naturally present in plants and animals and it is easy for them to attach to a food contact surface during handling. due to adhesion mechanisms bacteria can remain on the surfaces and contaminate other foods [ ] . chopping boards, knifes and preparation tables are just some of the food preparation instruments found contaminated with bacteria [ ] . saad et al. [ ] evaluated hygiene conditions on food preparation facilities by analysing food-contact surfaces and the results were quite table examples of microorganisms isolated from different surfaces and some of their associated pathologies. adverse, suggesting fecal contamination. coliform bacteria were found in dining tables ( %), food trays ( %), cooking pots ( %) and kitchen faucets ( %). in addition, e. coli was identified in some cooking pots. in this study, surfaces with a count of total mesophilic aerobes of > cfu/cm or > cfu/cm for e. coli and coliforms were considered to fail hygiene criteria, according to the commission of the european communities guidelines [ ] for hygiene conditions in fresh meat processing facilities. although most countries have guidelines about hygiene measures and good practice on food processing facilities not always the cleaning procedures are sufficient to prevent microorganisms propagation [ ] . most of the times the cleaning cloths used in cleaning can become contaminated if soaked with disinfectants in the wrong dilution (common fault in food handling facilities), contributing to microorganisms' spread to previously uncontaminated surfaces [ ] . in the food industry, the occurrence of biofilm formation is also a common event due to inefficient cleaning and disinfection. the remaining microorganisms can survive on the surfaces, especially if food residues remain. this will promote the development and multiplication of bacteria with consequent biofilm formation that is extremely hard to eliminate, becoming even more difficult to disinfect the surface [ ] . schools and day-care centers are hot spots of infection spreading. lack of hygiene habits, common among very young children, is one of the main causes of contamination between kids, leading to the contamination of other children, staff, parents or people in the community, either by direct contact or by contaminating surfaces. [ ] . ibfelt et al. [ ] evaluated the presence of bacteria and viruses in day-care centers in denmark and different surfaces from toilets, kitchens and playrooms were analyzed. the results proved contamination by several bacteria and virus. despite the main bacteria present were non-pathogenic, several surfaces revealed the presence of coliform and nasopharyngeal bacteria. respiratory viruses were mainly present on toys but also on pillows and playroom tables. gastrointestinal viruses although less prevalent were found in some surfaces, mainly on playroom pillows and toilet surfaces. a study by jerković-mujkić et al. [ ] analyzed potential contamination in public telephones and the results showed high presence of microorganisms on the surfaces. staphylococcus epidermidis ( . %) and bacillus subtilis ( %) were the most common bacteria identified, however more species were isolated. mukherjee et al. [ ] evaluated the presence of microorganisms on different surfaces of a fitness center. the samples were collected from skin-contact surfaces as floor mats and exercise instruments, regularly shared by many people. in total, species were identified with the presence of some pathogenic or potential pathogenic bacteria like salmonella, staphylococcus or klebsiella. staphylococci were present in the majority of the surfaces being one the most prevalent species, namely s. aureus, s. epidermidis and staphyloccocus saprophyticus. kandel et al. [ ] developed a study with stupefying results. they compared microbiological contamination of toilet surfaces with buttons on hospital elevators, and the buttons showed higher colonization ( %) than the toilets ( %). the most common bacteria on both surfaces were staphylococcus and streptococcus, however other bacterial species were founded, as wells as fungi. otter and french [ ] studied the presence of microorganisms in hand-touch surface in public transport system. the samples were collected from several surfaces in trains, stations and buses of london. the presence of bacteria was confirmed, and most sites presented a median bacterial concentration of cfu cm − . even though there are no guidelines for acceptable values for bacteria's presence on surfaces of public spaces this value is higher than the recommended for foodprocessing surfaces [ ] and hospital hand-contact surfaces [ , ] . it has been recognized that hospitals' contaminated surfaces and medical equipment contribute to the contamination of patients and medical staff [ , ] . several factors contribute to this occurrence but the mains reason is associated with the high prevalence of microorganisms in healthcare facilities. pathogens with the ability to cause high rates of infection come from different sources such as patients' endogenous flora ( - %), hands of medical staff and assistants ( - %), antibiotic-driven changes in patients' flora ( - %) and other, including contamination of the environment ( %) [ ] . carling et al. [ , ] have shown that in some cases less than % of hospital surfaces can be considered clean after terminal disinfection procedures. however, for specific surfaces the rate can be even more alarming with less than % of bedpan cleaners, bathroom hand-holds, light switches, and doorknobs being cleaned [ ] . contact between hands and gloves of medical staff with contaminated surfaces leads to pathogens' spreading to other surfaces and people [ ] . particularly if they are immunocompromised patients, the risk of developing an infection is very high [ ] . stiefel et al. [ ] found out that the level of contamination of gloves on medical staff after contact with patients' skin sites was actually quite similar ( % vs %) to the level of contamination after contacting with surfaces on methicillin-resistant staphylocococcus aureus (mrsa) carriers' rooms, suggesting that environmental surfaces may pose serious risks. an identical study from guerrero et al. [ ] found similar results for c. difficile contamination, proving that the risk of hand contamination after contact with patients' skin was the same than when contacting with rooms' highly-touched surfaces ( % vs %). this issue is also related to the compliance of hospital workers on performing disinfection protocols. a recent study from stahmeyer et al. [ ] showed that only % of healthcare workers washed their hands before contact with a patient, and % washed their hands after contact with the patient. also, this study found out that . % of healthcare workers' hand hygiene procedure lasted less than s (average . s), when the recommendations is that it should last around s. another study evaluating disinfection compliance by healthcare workers showed that only % of the enquired radiologists affirmed to disinfect their workstation daily, % admitted never to have disinfected their workstation, and % said to have never received any recommendation on how to perform the disinfection [ ] . several studies have proved that surfaces in rooms of patients infected with important pathogens are frequently contaminated, and that a person admitted to a room previously occupied by an infected patient has an increased likelihood of developing colonization or infection with that pathogen [ , ] . a study performed in portugal by geadas farias et al. [ ] revealed hospital surfaces' contamination with different microorganisms, mostly pseudomonas and staphylococcus. several surfaces were contaminated but some of those with higher microbiological presence were surfaces associated with water distribution system as sinks, taps, showers and drains. viana et al. [ ] performed an analysis on hospital mattresses, and resistant bacteria were found on about % of the evaluated mattresses. a. baumannii was the main species found, being present in . % of the mattresses, but also other pathogens were collected as k. pneumoniae and p. aeruginosa. this study also identified the microorganisms found on mattresses and showed that in % of the cases the microorganisms were not related to the current patient admitted in the room but to the previous one, concluding that even after cleaning microorganisms still remain on the mattresses being a possible source of contamination to other patients. despite most studies evaluating the effectiveness of room disinfection have focused on some specific surfaces considered dirty (sink, toilets, etc.), all spots must be considered since contamination can be present on unsuspected surfaces [ ] . actually, white et al. [ ] found out in an hospital that microbiologically the sinks and floors were cleaner than hand touch sites as chairs, beds and cardiac monitors buttons. shek et al. [ ] developed a study where hospital curtains of burn and plastic surgery units were microbiologically tested. the results proved a considerable presence of bacteria on the curtains, even multi resistant bacteria as mrsa. levin et al. [ ] found that in situations of poor infection control practices it is possible for patients to become a source for unresolved contamination of portable radiographic equipment with pathogenic bacteria, namely resistant bacteria. lestari et al. [ ] performed a similar study but evaluating ecg lead wires, and among the lead wires analyzed only were non-contaminated with some type of microorganism. coagulase negative staphylococci and aerobic spore forming bacteria, two important types of pathogens, were present in % and % of the wires respectively. the ineffective cleaning associated with the ability of microorganisms to survive on surfaces under hostile conditions, for long periods of time, is a serious cause of pathogens spreading to people and to other surfaces [ ] . the presence of biofilms, the substances used in the cleaning process, and the method and frequency of cleaning, all interfere in the grade to which microorganisms resist to the cleaning and disinfection procedures. badly executed cleaning procedures may bring bigger problems than not cleaning at all. the transmission of microorganisms from a contaminated surface to a clean one can occur if the cleaning method is not correct. also, most detergents do not have antimicrobial activity they only act in the microorganisms' removal, leading to the contamination of the cleaning cloths with viable microorganisms, and its consequent spread to non-contaminated surfaces [ ] . the frequency of cleaning is also an important factor, since surfaces such as toilets, sinks, and other known as dirty surfaces tend be cleaned frequently [ ] . however, other surfaces thought safe but still highly touched are often neglected, being poorly cleaned. for example, according to the practical guidelines for infection control in health care facilities [ ] , mattresses without plastic covers must be steam cleaned if contaminated with body fluids. however, if body fluid contamination does not occur the mattresses are not so often cleaned, allowing microorganisms to accumulate with time and use, as proved by viana et al. [ ] . also geadas farias et al. [ ] have found that surfaces usually not considered dirty but highly touched as light switches or nursing trays were contaminated with several microorganisms. a very recent study by johani et al. [ ] revealed the presence of biofilms in many surfaces of intensive care units despite regular disinfection procedures. several highly touched surfaces were analyzed and in %, the presence of biofilm was proved by scanning electron microscopy. in many situations the lack of adequate training of the environmental cleaning services or of the medical staff ultimately promotes the use of inappropriate detergents or germicides promoting the survival of microorganisms on the surfaces, even after cleaning [ ] . among the most used disinfectants are substances based on hypochlorite, alcohols, aldehydes, phenols and quaternary ammonium compounds [ ] . however, not all of these substances are efficient against some specific types of microorganisms, namely spore forming pathogens like c. difficile [ ] . some disinfectants may cause resistance on the microorganisms if not used within specific parameters [ ] . there are several guidelines [ , , ] for infection control that suggest cleaning and disinfection methodologies to be applied in healthcare facilities. these guidelines not only suggest how to disinfect medical equipment but also how to clean environmental surfaces as floors, furniture or toilet seats. however, different guidelines present different opinions on the frequency of cleaning or advisable disinfectants/detergents for each situation since there is no standardization for the methods and cleaning agents to be used. in addition, there is a lack of guidelines suggesting effective standardized methods to assess environmental cleaning. visual evaluation is still the most used method to determine a surface cleanness, however even if a surface is apparently clean it can contain a high microbial load [ ] . according to the commission of the european communities [ ] guidelines for hygiene conditions in fresh meat processing facilities, food-contact surfaces with > cfu/cm for total viable count and > cfu/cm for enterobacteriaceae are considered unacceptable. there are no established limit values for microorganisms on surfaces for public spaces, and there is poor control on cleaning performance. as depicted in section . surfaces in these places are often contaminated showing values higher than those allowed on healthcare facilities ( . - cfus/cm ). more regulation should be made to assess the cleaning and disinfection efficacy and compliance on such places, namely on spaces with more susceptible people as schools, day-care centers or elderly homes. more guidelines about how to clean and how often would be a good option, as well as a higher microbiological assessment on surfaces, that is rarely or never done in public spaces. for healthcare facilities, there is some controversy about the acceptable number of microorganisms on surfaces since there are no established thresholds, only tentative suggestions from researchers. for some authors, clean hand-contact surfaces in hospitals must have less than cfus/cm , with an increased risk of infection for values above that [ ] . other researchers have proposed the maximum value of . cfus/cm as the limit level of contamination in clean hospital surfaces [ , ] . for some specific microorganisms, considered indicator organisms, the limit value must be even lower. the presence of such microorganisms (for example s. aureus, c. difficile, vancomycin-resistant enterococci or acinetobacter spp.) is considered indicative of the need for cleaning even at levels of cfus/cm [ ] . some reference limit-values either from governmental entities or from research studies are listed in table . the limit of < cfus/cm for indicator microorganisms makes sense since it has been shown that an infectious dose of cfus/cm was sufficient to cause c. difficile infection on mice [ ] . also, it was observed that very low doses of norovirus have the capacity to cause infection [ ] . these results show that microbiological contamination on surfaces poses a real risk of infection, since the environmental infectious dose can be very low for some microorganisms. there is still the need for reaching a consensus and creating general guidelines for healthcare facilities. establishing clear limit values and implementing frequent microbiological assessment protocols are some of the steps that should be in the horizon. to avoid contamination and consequent infection propagation on surfaces, several alternative strategies have been developed recently. application of aerosols or uv light on contaminated surfaces are good examples of no-touch strategies, and they seem to be a good option to be applied in hospital environment [ ] . however, these approaches still present some limitations. uv light, in hospital facilities, can only be applied in empty rooms, therefore it cannot be used for a daily cleaning routine. also, it only disinfects areas directly reached by the uv light, so many objects and surfaces remain contaminated after this disinfection approach. aerosols are efficient but take a long time to decontaminate the surfaces compared to conventional cleaning or uv light. besides that, these strategies are also exclusively used in empty rooms. this factor increases the necessary time to do the final disinfection of the room and perform the beds turnover in hospitals [ ] . cold plasma technology is another disinfection strategy that has recently been applied on surfaces. plasma is the fourth state of mater and it can be generated from gases that became ionized with lots of ions, electrons and free radicals that will provide good electric conductivity. plasma is known to have high levels of energy and it can change molecules composition making them highly ionized and with many free radicals moving randomly in all directions. for example, when a molecule of hydrogen peroxide is exposed to this technology the double bond on the molecule is broken, creating reactive oxygen species like hydroxyl radicals that in need to seek equilibrium will bind to surrounding microorganisms destroying them by oxidation [ , ] this technology has already been tested in food industry to decontaminate vegetables [ ] and meat [ ] with good results obtained and also to decontaminate surfaces as packaging materials. puligundla et al. [ ] have tested the elimination of different bacteria such as e. coli, salmonella typhimurium and s. aureus, from several materials often used on food packages such as glass, polypropylene, polyethylene, nylon and paper foil. the results were quite promising with several log reductions after to minutes of treatment. even though the results of this emerging technology are quite encouraging as a possible strategy to disinfect surfaces, more studies are needed to assure its safety and profitability to disinfect larger surfaces. surface modification/functionalization is another common procedure to obtain anti-adhesive or antimicrobial properties on different materials. this approach has several advantages over conventional disinfection techniques. for example, antimicrobial surfaces are in constant process of activity oppositely to no-touch technologies or conventional cleaning. this way the antimicrobial charge on the surfaces is reduced immediately after contact preventing its propagation and consequent contamination of surrounding surfaces or people [ , ] . other advantage is the possibility of these surfaces to be present in populated environments since they cause no harm to people with no need to remove people from the rooms to perform the disinfection. in addition, modified surfaces are not restricted to external surfaces. medical devices such as urinary catheters, central venous catheters, prosthesis or contact lenses are some of the surfaces that have been functionalized to obtain better compatibility properties and lower infection risk when inserted on the human body [ ] [ ] [ ] [ ] . self-disinfecting surfaces are an emerging topic with more and more products coming up. some of the most recent strategies developed to obtain surfaces with anti-adhesive and antimicrobial properties are discussed below. several natural surfaces have suffered diverse evolutionary processes that turned them resistant to microorganisms' colonization. natural and bio-mimicked surfaces of insects' wings, sharks' skin, and lotus' leaves exhibit antibiofouling properties by preventing different cells, particles or microorganisms from attaching to their surface [ ] . considering this, some of these natural anti-adhesive or self-cleaning surfaces have been investigated for their potential application on micro/nanostructured surfaces development. however it is also possible to give anti-adhesive properties to a surface by modifying the material's chemistry, namely using self-assembled monolayers or polymer brushes immobilized on the surface (fig. ) ( [ ] ; [ , ] ). there are several ways to produce materials with anti-fouling properties acting at the level of surface modification with chemical structures. functional groups exhibited by the material's surface interact with those in the microorganism' cells determining the kinetics of microbial adhesion. for instance, surfaces highly negatively charged, i.e. polyanionic surfaces have the ability to repulse the bacteria with polyanionic glycocalice (most of gram-positive bacteria) through electrostatic interactions. however, gram-negative bacteria have policationic glycocalices, so this surface modification mechanism is only effective against some bacterial species and sometimes only against specific strain types [ ] . zwitterionic materials, such as carboxybetaine, sulfobetaine, and phosphobetaine also have anti-fouling properties. zwitterionic polymers have an equal number of anionic and cationic groups present in their repeating unit. this fact gives these polymers ultra-hydrophilicity and consequently great hydration ability [ , ] . studies concerning surface modification with zwitterionic polymers have proved to be a promising strategy to reduce microorganisms' adhesion [ , ] . very recently, a study using a tyramine-conjugated sulfobetaine polymer, grafted on polyurethane showed a great reduction in s. aureus adhesion to the surface [ ] . coating with polymeric brushes can also prevent microorganisms' adhesion. apart from avoiding direct contact between microorganisms and the surfaces, the polymers used for brushes are usually hydrophilic, so water will be attracted into the brush forming a repellent layer in aqueous environment. proteins and microorganisms encountering the brush surface will be repelled by steric hindrance due to the water bound in the brush and the elasticity of the polymer chains [ ] . polyethylene oxide (peo) and polyethylene glycol (peg) are two examples of polymers used to produce hydrophilic brush coatings on biomaterials. in a recent study by. hadjesfandiari et al. [ ] it was proved that peo brushes covalently immobilized reduced % the adhesion of staphylococci and e. coli to a surface. apart from the chemistry, also topography of a surface can be structured to increase anti-adhesive properties. as an attempt to find efficient alternatives over more classic antimicrobials, micro/nanostructured materials present themselves as possible solutions. recently, have been done an attempt to elucidate if alterations on micro or nanotopography of a surface could influence colonization and consequent contamination. an example of structure modification is the application of superficial nanostructures (nanoparticles, nanofibers or nanotubes) reducing the area available for microorganisms to attach [ ] [ ] [ ] . as said previously, mimicking the topography of anti-adhesive surfaces innately present in nature is an innovative way to obtain new self-disinfecting surfaces. many plants have special surface properties namely wettability. for instance, lotus leaves have micropapillae structures covered by nanostructures with fine branch-like shape. these structures along with epicuticular needle-shaped wax tubes that cover them give the lotus leaf a superhydrophobic surface and consequently antifouling properties. water droplets roll down the lotus leaf due to its great hydrophobicity dragging out any possible particles present, and maintaining its surface clean [ ] . other example of nature that inspired anti-adhesive surfaces' coating is sharkskin. sharks have a special scale micropattern, which consist of a rectangular base embedded in the skin with tiny spines on the surface. the ribbed texture of these scales is responsible for the selfcleaning, anti-biofouling, hydrophobic and drag reducing properties of shark skin [ , ] . such properties have made of sharkskin one of the most mimicked surfaces, not only in research environment but in industrial area too. sharklet af (sharklet technologies, alachua, fl, usa) is a company that uses shark skin topography in different surfaces in order to avoid bacterial adhesion and biofilm formation [ , ] . a study comparing sharklet micropattern surfaces with regular surfaces in a clinical simulated scenario proved that shark skin microtopography reduced the number of attached bacteria by about fold [ ] . there are several materials with intrinsic antimicrobial properties, as silver, zinc, cooper, or chitosan. nevertheless, materials can also be modified to acquire bactericidal activity [ ] . chemical or physical changes in the surface can produce antimicrobial effect. chemical substances such as antibiotics or biocides can be incorporated in the materials to give it antimicrobial properties. however, a balance between these properties and biocompatibility must be observed since the materials will be in direct contact with users' organism raising toxicity concerns. photo-activated surfaces are also an example of self-disinfecting materials recently developed. fig. presents some examples of different types of antimicrobial surfaces. some materials have intrinsic antimicrobial properties. they do not need antimicrobial loading to exert its activity since the material by itself has the natural ability to eliminate microorganisms. among the most known natural materials with antimicrobial properties are metals as silver, copper, or zinc and polymers like chitosan [ ] . for many metals with antimicrobial properties, it is the ionic form that presents higher bactericidal activity and not the elemental metal. silver and copper are good examples of that. silver has been used in medical field for many centuries due to its antimicrobial properties. its bactericidal mechanism is based on the binding of silver atoms with thiol (sh) and disulfide (s-s) groups present in the proteins of bacterial cell membranes, leading to its disruption and eventual cell death [ ] . silver has been used for many applications on medical field especially when added in the form of silver sulfadiazine to creams or wound dressings [ ] . several wound dressing containing silver are available on market, however, not always they comply the expectations. cavanagh et al. [ ] analyzed different silver dressings on market and only two of them showed bactericidal activity against s. aureus. apart from that, silver dressing may be related with increased serum silver levels with an associated decrease on white blood cells [ ] . this leads us to conclude that the delivery system of the antimicrobial is very important. a delivery mechanism that acts by contact without leaching silver ions to the surrounding areas or tissues would be good strategy to achieve antimicrobial action without compromise the safety of the product. more recently, silver nanoparticles have been greatly studied and used to produce potential antimicrobial materials such as catheters and surgery sutures [ , ] . however, for biomaterials implanted inside the organism there are some possible risks associated with releasing of silver ions causing local toxicity and possible accumulation in organs [ ] . silver may also have different ranges of efficacy according to the class of bacteria. gram-positive bacteria's cell walls do not have an outer membrane as gram-negative bacteria do, but they have several layers of peptidoglycans, making their cell wall thicker [ ] ; this, along with their negative charge results in the trapping of silver ions (positively charged) preventing their entrance into the bacteria [ ] . agc glass (ags glass uk ltd., rugby, great britain) developed an antibacterial glass by incorporating silver ions inside the glass. the company claims that this glass eliminates % of bacteria and prevents fungi proliferation which they demonstrated in the three bacterial and two fungi strains evaluated [ ] . surfacine development company (tyngsborough, ma, usa) is another company that developed a silver coating (surfacine ® ) that can be applied in several materials, from medical devices to food preparations and packaging industry or water distribution systems. this coating showed good antimicrobial activity against several bacteria, fungi and yeast [ ] . other company, purethread technologies inc. (cary, nc, usa) has developed purethread ® , a system that embeds silver salts into textile fibers, obtaining antimicrobial textiles. according to the company this system does not weaken or disappears during washing and kills . % of microorganisms after four hours of contact with the fabric [ ]. a scientific paper about a study involving hospital curtains incorporating the antimicrobial textile developed by this company proved that those curtains take more time to be contaminated for the first time when compared to regular curtains [ ] . similarly, to silver, copper has been used for many centuries as an antimicrobial agent especially for water treatment and transportation. copper was also very used in the nautical field, to prevent adhesion and growth of organisms in hulls of ships [ ] . the bactericide mechanism of copper is related to the release of copper ions that cause damage in the bacterial envelop and consequent leakage of the cell content and influx of copper ions into the bacteria. this will generate toxic radicals causing oxidative damage to cellular components and dna degradation [ ] . more recently copper came up as an alternative for preventing hospital acquired infections through its application in hospital surfaces and medical equipment [ ] . a study by souli et al. [ ] performed on a hospital intensive care unit, compared two rooms, one with copper coated equipment (beds, side table, intravenous pole stands, etc.) and the other with regular equipment. the copper coated equipment room presented a reduced percentage of colonized surfaces ( . %) compared to the regular compartment ( . %). this study showed both reductions in colonization by gram-negative and gram-positive bacteria and in total bioburden ( . vs . cfu/ cm ). sifri et al. [ ] also developed a study where a section of an acute care unit was equipped with copper impregnated materials, hard surfaces and textiles-patients' gowns, sinks, bed rails, tray tables, sheets and blankets. the results were quite promising with copper equipped section presenting patients' infection reductions of % when caused by c. difficile and % when caused by multi drug resistant organisms, comparing to a non-modified section in the same hospital unit. two companies that collaborate with each other, cupron medical textiles (cupron inc., richmond, va, usa) and cupron enhanced eos surfaces (eos surfaces, norfolk, va, usa) provided the copper impregnated materials used for this study. the product developed is a hard-antimicrobial surface impregnated with copper that continuously kills . % of harmful bacteria in two hours, according to its specifications. according to the company this surface is effective against s. aureus, enterobacter aerogenes, mrsa, e. coli and p. aeruginosa [ ] . there are several substances with antimicrobial activity that can be added to a surface to obtain an antimicrobial surface. antibiotics were one of the first substances to be applied to surfaces such as prosthesis or textiles for wound dressing production, to obtain antimicrobial action. despite the promising results, it is well known that the major disadvantage of antibiotics use is the microorganisms' ability to develop resistance. this drawback has led to an increasing search for alternatives to be used as antimicrobials. quaternary ammonium compounds, chlorhexidine, benzalkonium chloride or nitric oxide are some examples of substances that were already tested as an alternative [ ] [ ] [ ] . quaternary ammonium compounds are disinfectants used in hospitals and healthcare facilities for several clinical purposes as disinfection of surfaces and medical material. however, more recently the quaternary ammonium compounds have been tested as antimicrobial loading agents to different surfaces and materials, namely polymers [ , ] . antimicrobial peptides (amps) are a class of peptides, components of innate immune system, with a broad activity against bacteria, virus, fungus and more, providing a non-specific defense against a broad spectrum of invaders [ ] . recently, numerous studies [ , ] refer its use as antimicrobial loading agents for their excellent characteristics, presenting several advantages over classic antibiotics, namely fast and broad spectrum of action with low susceptibility to induce bacterial resistance [ ] . in contrast with the mechanisms of action of antibiotics, which are based in slow processes of enzymatic inhibition and target specific cellular activities as dna or protein, the amps are effective against different species of microorganisms and also reduce the risk of resistance development [ ] [ ] [ ] . for all these reasons, amps are being applied in the production of antimicrobial surfaces, either by simple adsorption on the surface or covalent immobilization [ ] . nevertheless, studies suggest that covalent immobilization offers many advantages toward physical adsorption, including higher local and long-term stability, and lowering toxicity [ , ] . all those antimicrobial substances are loaded to the surface either by immobilization or by incorporation on the bulk material; recent studies on the application of each type of loading strategy are summarized next. in materials' incorporation process, the antimicrobial substances are added to the ingredients during the phase of production, to obtain a homogeneous mixture of the bulk material with the antimicrobial. this system allows antimicrobial activity throughout the bulk material, even in deeper layers and not only on the surface. this allows the material to retain its antimicrobial activity even when worn out [ , ] . in a very recent study, ferreira et al. [ ] used levofloxacin to load a bone cement, achieving good results against s. aureus not only on its planktonic form but also on biofilm. that was quite positive since this bacterial strain is greatly associated with biofilm formation on bone implants. ciprofloxacin incorporation on textile fibers by electrospinning was tested by li et al. [ ] this strategy aimed to produce a bandage to prevent wound infection and the results in vivo (rats animal model) were quite positive for e. coli and s. aureus. in han et al. [ ] study they incorporated quaternary ammonium methacrylates in dental adhesives to prevent caries by avoiding the accumulation of bacteria and biofilm formation on teeth, testing the presence of three staphyloccocal species (staphylococcus mutans, staphylococcus gordonii, and staphylococcus sanguinis) and the results showed a decreased biofilm formation for the adhesives containing the quaternary ammonium methacrylates. nanoparticles containing quaternary ammonium polyethylenimine were tested in a study about endodontic sealers by barros et al. [ ] . the results were quite positive for enterococcus faecalis, with the endodontic sealers showing good antimicrobial activity. the amp, ll- , was incorporated by cassin et al. [ ] in a membrane of collagen and hyaluronic acid for the production of antiinfective films to cover injured tissues. antimicrobial coatings can be obtained either by adsorption of the antimicrobial substance, by covalently binding it to the material or by immobilizing it using self-assembled monolayers. this strategy can be an advantage for some substances that are too toxic to be used as bulk material but that immobilized in small amounts as surface coatings can exert their antimicrobial activity without the toxicity drawback [ , ] . the coatings can also be divided according to their mechanism of action. they can deliver the antimicrobial substance by leaching, releasing it to the surrounding area or direct contact with the surface where the coating is immobilized. some coatings release substances with antibacterial properties that will interact with microorganisms acting away from the bulk. this leaching mechanism has the advantage of a larger perimeter of action around the surface where it is immobilized. it is important, though, that this release into the surrounding area is controlled to avoid toxic effects by excess of substance [ ] . coatings can also attach certain antimicrobial molecules to the materials' surface. several coatings can be classified as "contact biocides" since they use non-leachable substances that kill by contact with the bacteria and with no need to be released from the surface. this strategy is very interesting for both the self-sterilizing effect and the long-lasting activity, acting just through a direct contact with bacteria without consuming itself releasing from the surface without need [ , ] . alt et al. [ ] realized a study where coating of rifampicin and fosfomycin was applied to prosthesis showing good efficacy against s. aureus, even the methicillin resistant strain, on a rabbit animal model. neut et al. [ ] performed a similar study using a gentamicin-releasing coating that was able to prevent staphylococci growth on a prosthetic hip surface for at least hours, showing promising results. in a work by iyamba et al. [ ] , quaternary ammonium compounds (hexadecyltrimethyl ammonium bromide and hexadecylbetainate chloride) were immobilized on medical catheters reducing s. aureus adhesion to its surface. zanini et al. [ ] also developed a work in which quaternary ammonium silanes were used to coat polyurethane catheters. the results were promising with this coating proving its antimicrobial activity against e. coli bacteria. in a recent study, casciaro et al. [ ] successfully covalently immobilized frog skin derived amp on contact lenses. this strategy not only reduced the adhesion of p. aeruginosa, a species highly associated with contact lenses associated keratitis, but it also proved to be nontoxic to mammalian cells and it did not compromise the lenses physical properties. amps have also been immobilized on nanoparticles as loading strategy. ma et al. [ ] immobilized the amp hhc- on titanium oxide (tio ) nanotubes by physical adsorption with the nanotubes acting as nanocarriers for peptides delivery. they obtained an antimicrobial and anti-fouling surface showing a reduction in s. aureus adhesion and great antimicrobial activity (> % activity). braun et al. [ ] immobilized the human peptide ll- on porous silica nanoparticles, achieving an antimicrobial delivery system. all the studies presented above prove the good potential of modified surfaces to be applied on infection control in different scenarios; still some aspects must be taken into account and more studies are still needed. most studies evaluating the antimicrobial/anti-adhesive activity potential of engineered surfaces do not take into account realistic physiological environments. this can affect the results, since the host's conditioning film may affect the surface in many different ways, for example, covering the surface creating a deterrent layer preventing the antimicrobial substance to leach or to contact directly with the microorganisms, reducing its antimicrobial efficacy [ ] . in addition, the composition of the surface may determine which components of the conditioning film will adhere and that on its turn will influence other cells adhesion, as bacteria. felgueiras et al. [ ] showed that different concentrations of octadecyl acrylate (c ) immobilized on polyurethane surfaces will affect the deposition of albumin and fibrinogen when the surface is in contact with human plasma, that on its turn will affect microorganisms' adhesion to the surface since albumin avoids bacteria adhesion and fibrinogen promotes it. besides, coatings with antimicrobial peptides can be degraded by some components of conditioning films such as proteases [ ] . despite the pointed weaknesses there are already on the market some successful cases of such as biocote limited (coventry, united kingdom) that developed an antimicrobial additive technology, biocote ® , that can be incorporated on textiles, polymers, ceramics and more. these additives are based on different antimicrobial substances such as silver, zinc or phenolic compounds, chosen according to their application and support material [ ] . sanitized ag (burgdorf, switzerland) is another company that developed an antimicrobial additive that can be incorporated in polymers and textiles for different areas of application such as healthcare, public transportation and food industry. this additive technology, sanitized ® , uses different active ingredients as silver, zinc pirithione, silane quat or isothiazolinone that can be added on liquid form, powder or paste according to specific production requirements of the final product [ ] . photo-activated materials have been used in different technological fields namely in antimicrobial surfaces development. the most studied material used in photo-activated surfaces production is tio . tio has high photocatalytic properties and is highly used in cosmetics and skin care products since it is not absorbed by human skin [ ] becoming a very interesting material for development of antimicrobial surfaces. in fact, its antimicrobial efficacy has already been proved against bacteria, fungi, protozoa and virus. the main advantage of this strategy is that tio is not degraded so its activity can be maintained for long periods. tio surfaces are only activated when irradiated by specific photon energy. when this irradiation occurs, reactions of photo-oxidation involving o and h o take place on the surface with consequent formation of oxygen free radicals. these free radicals will attack the cell wall and cytoplasmic membrane of the microorganism by peroxidizing its lipids, leading to leakage of cellular components and lately cell lysis [ , ] . recently, adán et al. [ ] published a study where a water microfiltration system using photocatalytic membranes produced with tio and porous steel showed good inactivation for the retained bacteria. in another study by joost et al. [ ] thin films with tio nanoparticles were illuminated with uv light and after min of exposure no bacteria (e. coli) had survived. the analysis of bacterial cell membrane showed modifications in the chemical structure of unsaturated fatty acids and decomposition of saturated fatty acids faster than normal, confirming the peroxidation of membrane lipids. in the market, there are already some products for microorganism elimination based on tio photocatalytic action. purehealth™ (orion, florence, italy) is a system developed by orion that coats walls and floors and is activated by special lamps of solar spectrum. this system promises to eliminate virus and bacteria [ ] . this review points out the great contribution of surfaces for infection spreading, not only in healthcare facilities but also in other public spaces and food processing facilities. there is an urgent need to pay more attention to surface contamination in different spaces since there is still a lack of guidelines for microbiologic assessment and established safe thresholds for health care facilities. in addition, it is important to establish infection control procedures for public spaces, namely schools since they often present high microbiological charges on surfaces, posing a real risk for children whose immunological system is still developing. both on public spaces and on healthcare facilities, it should be determined how to assess microbiologic presence on surfaces as well as how frequently this assessment should be made, and which methods should be used to obtain a realistic analysis rather than performing visual assessments. the implementation of standard acceptable limits of microorganisms on surfaces is also a key point for a better control of infection spreading. standardized definition of which microorganisms can be considered indicator microorganisms should also be achieved. the existing guidelines for cleaning and disinfection methodologies in healthcare facilities should come to a consensus about the disinfectants to be used in each setting, the frequency of cleaning and the methods to apply. the implementation of self-disinfecting surfaces is a good strategy for infection control, and this review presents some successful research already developed in this area. these surfaces show clear advantages over the regular surfaces with traditional cleaning: the state of continuous disinfection and the antimicrobial activity that permanently eliminates the microorganisms. there are still some issues to improve, like the long-term efficacy of the antimicrobial/anti-adhesive action, or the high cost of implementation of these surfaces in large areas. biomaterials, modified surfaces, or new scientific products in general, have to face some big challenges before they reach the market. problems such as costs of manufacturability, scalability on production, intellectual property issues or regulatory aspects are just some of the main obstacles those products will have to overcome in order to be commercialized [ ] . some products even with great results on laboratory will fail when brought to larger scale due to their high cost of production, making them commercially unattractive. but, looking at the numbers nosocomial bacteremia alone can cost a hospital over million euros per year [ ] , and antibiotic resistance-associated infections may cost more than million euros per year in european union. in fact the societal cost of infections due to the selected antibioticresistant bacteria were estimated at about eur . billion each year, between hospital related costs and losses in productivity due to patients' absence from work [ ] . therefore, maybe it is worthy to invest on new technologies, betting on infection prevention and control not only to avoid higher costs but also to avoid the harm and loss of human lives. self-disinfecting surfaces are a step forward to the future of infection control policies. more studies involving self-disinfecting surfaces 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challenge catheter-related infections in patients with haematological malignancies: novel preventive and therapeutic strategies the authors acknowledge the funding provided by fundação para a ciência e a tecnologia (fct -portugal) through the scholarship sfrh/ bd/ / (micaela machado querido) and the project "b-safecoat -desenvolvimento de novas tintas com propriedades autodesinfetantes" (poci- - -feder- ). key: cord- -m jyydf authors: grau-pujol, berta; camprubí, daniel; marti-soler, helena; fernández-pardos, marc; guinovart, caterina; muñoz, jose title: pre-exposure prophylaxis with hydroxychloroquine for high-risk healthcare workers during the covid- pandemic: a structured summary of a study protocol for a multicentre, double-blind randomized controlled trial date: - - journal: trials doi: . /s - - - sha: doc_id: cord_uid: m jyydf objectives: the aim of this study is to assess the efficacy of the use of pre-exposure prophylaxis (prep) with hydroxychloroquine against placebo in healthcare workers with high risk of severe acute respiratory syndrome coronavirus (sars-cov- ) infection in reducing their risk of coronavirus disease (covid- ) disease during an epidemic period. as secondary objectives, we would like to: i) assess the efficacy of the use of prep with hydroxychloroquine against placebo in healthcare workers with high risk of sars-cov- infection in reducing their risk of exposure to sars-cov- (defined by seroconversion) during an epidemic period, ii) evaluate the safety of prep with hydroxychloroquine in adults, iii) describe the incidence of sars-cov- infection among healthcare workers at high risk of sars-cov- infection, iv) identify clinical, analytical and microbiological predictors of covid- among healthcare workers at high risk of sars-cov- infection, v) set up a repository of serum samples obtained from healthcare workers at high risk of sars-cov- infection for future research on blood markers to predict sars-cov- infection. trial design: multicentre double-blind parallel design (ratio : ) randomized controlled clinical trial. participants: approximately healthcare workers of four spanish hospitals (hospital clínic of barcelona, hospital de la santa creu i sant pau of barcelona, hospital plató of barcelona, hospital general de granollers, barcelona) will be recruited. participants are considered to be at high-risk of sars-cov- infection due to their frequent contact with suspected and confirmed cases of covid- . for eligibility, healthcare workers with years old or older working at least days a week in a hospital with both negative sars-cov- polymerase chain reaction (pcr) assays and serological covid- rapid diagnostic tests (rdt) are invited to participate. participants with any of the following conditions are excluded: pregnancy, breastfeeding, ongoing antiviral, antiretroviral or corticosteroids treatment, chloroquine or hydroxychloroquine uptake the last month or any contraindication to hydroxychloroquine treatment. intervention and comparator: intervention group (prep): participants will receive the standard of care and will take mg of hydroxychloroquine ( tablets of mg per dolquine® tablet) daily the first four consecutive days, followed by mg weekly for a period of months. control group: participants will receive placebo tablets with identical physical appearance to hydroxychloroquine mg (dolquine®) tablets following the same treatment schedule of the intervention group. both groups will be encouraged to use the personal protection equipment (ppe) for covid- prevention according to current hospital guidelines. main outcomes: the primary endpoint will be the number of confirmed cases of a covid- (defined by a positive pcr for sars-cov- or symptoms compatible with covid- with seroconversion) in the prep group compared to the placebo group at any time during the months of the follow-up in healthcare workers with negative sars-cov- pcr and serology at day . as secondary endpoints, we will obtain: i) the sars-cov- seroconversion in the prep group compared to placebo during the months of follow-up in healthcare workers with negative serology at day ; ii) the occurrence of any adverse event related with hydroxychloroquine treatment; iii) the incidence of sars-cov- infection and covid- among healthcare workers in the non-prep group, among the total of healthcare workers included in the non-prep group during the study period; iv) the risk ratio for the different clinical, analytical and microbiological conditions to develop covid- ; v) a repository of serum samples obtained from healthcare workers confirmed covid- cases for future research on blood markers to predict sars-cov- infection. randomisation: participants meeting all eligibility requirements will be allocated to one of the two study arms (prep with hydroxychloroquine or non-prep control group) in a : ratio using simple randomisation with computer generated random numbers. blinding (masking): participants, doctors and nurses caring for participants, and investigators assessing the outcomes will be blinded to group assignment. numbers to be randomised (sample size): each intervention group will have participants, giving a total of participants. trial status: the current protocol version is . , (nd) of june . two hundred and seventy-fiveparticipants were recruited and completed first month follow-up until date. the estimated sample size could not be reached yet due to the declining national epidemic curve. thus, is the total number of participants included until date. the study has been suspended ( (th) of june) until new epidemic curve occurs. trial registration: this trial was registered on april (nd) at clinicaltrials.gov with the number nct . full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file ). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. primary objective: ) to compare the efficacy of the use of prep with hydroxychloroquine against placebo in healthcare workers with high risk of sars-cov- infection in reducing their risk of covid- disease during an epidemic period. secondary objectives: ) to assess the efficacy of the use of prep with hydroxychloroquine against placebo in healthcare workers with high risk of sars-cov- infection in reducing their risk of exposure to sars-cov- (defined by seroconversion) during an epidemic period. ) to evaluate the safety of prep with hydroxychloroquine in adults. primary endpoint: ) confirmed cases of a covid- (defined by a positive pcr for sars-cov- or symptoms compatible with covid- with seroconversion) in the prep group compared to the placebo group at any time during the months of the follow-up in healthcare workers with negative pcr for sars-cov- at day . secondary endpoints: ) sars-cov- seroconversion in the prep group compared to placebo in during months of follow-up in healthcare workers with negative serology at day . ) the occurrence of any adverse event related with hydroxychloroquine treatment. we will compare the incidence of clinical and/or laboratory adverse events in the hydroxychloroquine prep group and the non-prep group. ) incidence of sars-cov- infection and covid- among healthcare workers will be estimated by the number of healthcare workers diagnosed with covid- in the non-prep group, among the total of healthcare workers included in the non-prep group during the study period. ) risk ratio for the different clinical, analytical and microbiological conditions to develop covid- . ) a repository (biobank) of serum samples obtained from healthcare workers confirmed covid- cases for future research on blood markers to predict sars-cov- infection. this study will be hospital-based and will be conducted at hospital clinic of barcelona, hospital de sant pau, hospital plató and hospital de granollers spain. all healthcare workers from hospital clinic, hospital de sant pau, hospital plató and hospital de granollers will be invited to participate. specifically, all healthcare workers with a negative pcr at the last hospital clinic routine sars-cov- screening will be also invited to participate. study personnel will inform them about the option to enrol in this study. on the day of the screening visit, the following procedures will be performed: -nasopharyngeal swab to conduct pcr to detect sars-cov- . -detailed evaluation of previous medical history, allergies, current treatment, symptoms and physical examination (appendix ). - ml of venous blood will be taken for the following determinations: -blood test (wbc, lymphocyte populations, haemoglobin, platelets, liver and kidney function, bilirubin, ldh, pcr) -rapid diagnostic serology test (rdt) for sars-cov- (igm and igg) -hiv serology -pregnancy test (women of reproductive age - years old) - ml of venous blood to store two serum samples: - ml to perform a serology test to detect sars-cov- immunoglobulins m and g (igm and igg) - ml for biobank storage (for further research on diagnostics/biomarkers). - ml of whole blood will be collected for hydroxychloroquine pk analysis. -one strip ecg (v ) to evaluate cardiac rhythm -informed consent (appendix ) will be obtained from all healthcare workers willing to participate who fulfil the inclusion and exclusion criteria in case rdt serological test is negative at screening visit but the serum sampled stored to detect sars-cov- immunoglobulins m and g (igm and igg) is positive, the participant will be excluded from the analysis. participants fulfilling inclusion criteria and none of the exclusion criteria will be scheduled for recruitment visit. participants who fail to meet the inclusion and exclusion criteria will not, under any circumstances, be enrolled or receive study treatment. if any participant is enrolled by error, they will be withdrawn from the study, the pi notified and records kept. any participant incorrectly enrolled who started the intervention, will be followed up for ae. participants meeting all eligibility requirements will be allocated to one of the two study arms (prep with hydroxychloroquine or non-prep control group) in a : ratio. a real-time computer-generated randomization procedure will be used. at recruitment visit, a numbered case record form (crf, appendix ) will be filled out for all potential participants. the first tablets will be taken directly observed at the baseline visit. the rest of the tablets of the first month will be provided to the participant during that visit. the study will be double blinded. study participant flowchart regardless of their group of allocation, all participants will undergo the same procedures and will be followed-up monthly during months. we will conduct active and passive surveillance to all of them. active surveillance to each participant will be conducted monthly, when a standardized crf will be filled out by the study team medical doctor conducting the visit. follow-up visits will include: any of the trial sites . detailed evaluation of symptoms and physical examination (to either detect past and current symptoms and signs related with covid- or past and current adverse events of hydroxychloroquine treatment since the previous visit) . known close contacts with suspected and/or confirmed covid- cases . assessment of compliance with prep and other preventive measures, including the number of weeks during which they have been managing covid- patients. . ml of venous blood will be taken at month , and visits for the following determinations: wbc, lymphocyte populations, haemoglobin, platelets, liver and kidney function, bilirubin, ldh, pcr . ml of venous blood to store two serum samples: ○ ml to perform a serology test to detect sars-cov- immunoglobulins m and g (igm and igg) ○ ml for biobank storage (for further research on diagnostics/biomarkers). . one strip ecg (v ) to evaluate cardiac rhythm in addition, on day , , , (scheduled visit (m )) and (scheduled visit (m )), ml of whole blood will be collected to evaluate hydroxychloroquine concentrations. at every visit, the study medical doctor will also check for symptoms or possible adverse events. passive surveillance for each participant will be also conducted. a medical doctor will be available by phone hours a day during the study period. all participants will be allowed to call this number in case of presenting any adverse event or symptom. in that case, a standardized crf will be filled out to collect the information. a chest x-ray and a nasopharyngeal swab will be performed to all those participants presenting with fever or respiratory symptoms. recruitment visit (day ) publication and dissemination . . biobank de-identified samples will be indefinitely stored at the hospital clinic de barcelona biobank for future use in other scientific projects related to sars-cov- infection. samples will be stored at the "colección de patología importada", registered at the hospital clínic-idibaps biobank and in the national biobank registry with code number c. . those coded data and samples could be sent abroad to other research institutions for usage in research projects if necessary. in this case it will be assured that identical standards to the ones applicable for this research project are fulfilled. patients will sign a separated informed consent if they agree to the storage of their samples in the biobank (appendix ) and the shipment of the samples to other institutions. with an expected incidence of % of covid- in healthcare workers in the control group and % in the hydroxychloroquine group, a hazard ratio of . , for a significance level of %, statistical power of % and assuming a rate to lost-to-follow-up of %, a total of subjects is required, per group. ( ) an intention-to-treat analysis will be conducted, with all patients fulfilling inclusion criteria and without exclusion criteria that have had at least one follow-up visit will be included in the analysis. participants will be censored when they are lost to follow-up (i.e. follow-up visits are not conducted), when they stop the intervention treatment or when they fulfill the primary endpoint. all clinical, epidemiological, microbiological and radiological data will be entered in the case report form (crf) (appendix ) and introduced in a centralized database protected with username and password (using openclinica online database). for the statistical analysis software stata or r will be used. descriptive analysis will be done for all healthcare workers with at least one follow-up visit. categorical variables will be expressed as absolute frequency and percentage. continuous variables will be expressed as mean and standard deviation (sd) or median and interquartile range (iqr). one sample kolmogorov-smirnov tests will be performed to assess whether variables were distributed normally. the following information will be recorded directly on the crf and will be considered source data: demography, household co-habitants, risk factors and concomitant medication. • bivariate analysis: normally distributed numeric parameters will be compared between groups using the t-test or anova. mann-whitney u-test or kruskal-wallis tests will be used for non-normal variables. categorical variables will be compared between groups using the pearson's chi-squared test or fisher's exact test if the expected frequency is < . • multivariate analysis: o cox regression models for investigating the association between time to sars-cov- infection (defined as symptoms compatible with covid- and/or a positive pcr for sars-cov- ) ) in the prep group compared to placebo group at any time during the months of the follow-up, adjusted for age, sex, concomitant medication, concomitant diseases, laboratory parameters, number of weeks during which the participant was taking care of covid patients. o cox regression models for investigating the association between time to sars-cov- seroconversion (defined as igm or igg positive) in the prep group, compared to placebo in during months of follow-up, adjusted for age, sex, concomitant medication, concomitant diseases, laboratory parameters, number of weeks during which the participant was taking care of covid patients. o linear regression models for investigating the association between quantitative pcr and treatment group, adjusted for age, sex, concomitant medication, concomitant diseases, laboratory parameters, number of weeks during which the participant was taking care of covid patients. hierarchical testing will be considered for secondary analysis. once the primary objective will be established, secondary analyses will be performed. interim analyses will be performed monthly and overall type i error will be controlled (see section ). the study will be performed according to the declaration of helsinki (version of fortaleza, brazil, october ), current ich-gcp guidelines and all applicable national and local regulatory requirements (spanish royal decree / ). this study will be conducted under the auspices of a properly constituted ethics committee as defined by ich-gcp e (r ) guidelines and applicable regulations. this committee will review and approve the final study protocol and subsequent amendments, the final version of the informed consent form and any amendment and any other written information/material to be provided to the participants. prior to initiation of clinical activity, investigators will provide isglobal with a copy of the relevant ethics committee approval. if applicable, the investigators will be responsible for obtaining annual re-approval from the ethics committee. informed consent will be signed by all participants before their inclusion in the study. the study consent form will reflect the risks and benefits of participating in the study, and the specific sampling procedures to be done to each participant. sufficient time will be given to the participant's guardians to decide whether or not to participate in the study. candidates will be given the opportunity to enquire about the details of the study and any question regarding the study will be answered. participation in this study will be voluntary, and under no circumstances the clinical management of the participants will be affected by the decision to participate or not in the study. the participant will be free to withdraw at any time of the study. according to the ley orgánica / , del de diciembre de protección de datos personales y garantía de los derechos digitales; and the reglamento ue / del parlamento europeo y del consejo del de abril de , all information resulting from participating in the study will be confidentially treated. all data and samples collected will be allocated a study code so that they are unidentifiable. no use of any link to the participant's identity will be done. key identifying information will be kept in locked cabinets away from the coded samples and data and may only be accessed by the study investigators. management of patients diagnosed with covid- will be done following current national and hospital protocols. declaration of new confirmed covid- cases to agència de salut pública de barcelona, will be done as per normal practice. hospital clinic director will be also informed of any new case of covid- , following current hospital protocols. samples obtained under the umbrella of the specific consent form will only be utilized for the purposes of this protocol, and under no circumstances will be used for other purposes as those specified both in the protocol and the consent form. the pis will ensure that the written information and the consent form are revised when an amendment to the study protocol is made and approved. a medical doctor will be available by phone hours during the study period. all participants will be allowed to call this number in case of presenting any adverse event or worsening of symptoms. • from monday to friday, : - : h: • from monday to friday ( : - : h) and weekends: the principles of ich gcp require that specific procedures are set to notify and report adverse events in clinical trials. this is a responsibility of the sponsor and the study physician at each site. . . adverse events and serious adverse events: adverse event means any untoward medical occurrence associated with the use of an intervention in humans, whether or not considered intervention-related. thus, any undesirable medical occurrence in a participant including those events which do not necessarily have a causal relationship to the study drug regimen. prior to the administration of study drug, only adverse events that meet the definition of serious (see below) and adverse events that the study physician considers to be related to study design and/or procedures should be recorded. any untoward medical occurrence that at any dose: • results in death • is a life-threatening adverse event • requires inpatient hospitalization or prolongation of existing hospitalization • results in a persistent or significant disability/incapacity or substantial disruption of the ability to conduct normal life functions • or a congenital anomaly/birth defect. important medical events that may not result in death, be life-threatening, or require hospitalization may be considered serious when, based upon appropriate medical judgment, they may jeopardize the participant and may require medical or surgical intervention to prevent one of the outcomes listed in this definition. adverse events will be assessed by direct observations of the study physician or reported by the participant. from the moment a study participant receives the study medication, the study physician will monitor each subject for the development of any clinical evidence of an ae. the nature of the adverse event, its date and time of onset, duration and severity, therapy employed (if any) and the investigator's opinion of causality to study drug with an alternate aetiology, if appropriate, will be documented. for adverse events to be considered as intermittent or continuous, the events should be of similar nature and severity. the investigator will follow all adverse events to satisfactory clinical resolution or the establishment of a stable chronic stage upon study completion. the investigator will rate the severity of the adverse event according to the following definition: mild: the adverse event is transient and easily tolerated by the subject. moderate: the adverse event causes the subject discomfort and interrupts the subject's normal activities. severe: the adverse event causes considerable interference with the subject's normal activities, and may be incapacitating or life-threatening. the study physician at each site will use the above definitions to assess the relationship of the adverse event to the study drug. the study physician at each site is obligated to assess the relationship between investigational product and the occurrence of each ae/sae. the study physician will use clinical judgment to determine the relationship. alternative causes, such as natural history of the underlying diseases, concomitant therapy, other risk factors, and the temporal relationship of the event to the investigational product will be considered. the degree of certainty about causality will be graded using the categories below. probably: an adverse event has a strong temporal relationship to study drug or recurs on re-challenge, and aetiology is unlikely or significantly less likely. possibly: an adverse event has a strong temporal relationship to the study drug, and an alternative aetiology is equally or less likely compared to the potential relationship to study drug. the alternate aetiology should be provided by the investigator. unlikely: an adverse event has little or no temporal relationship to the study drug and/or a more likely alternative aetiology exists. the alternate aetiology should be provided by the investigator. an adverse event is due to underlying or concurrent illness or effect of another drug and is not related to the study drug. the alternate aetiology should be provided by the investigator. the study physician will be responsible for determining whether an ae is expected or unexpected. an ae will be considered unexpected if the nature, severity, or frequency of the event is not consistent with the risk information previously described for the study intervention. the occurrence of an ae or sae may come to the attention of study personnel during study visits and interviews of a study participant presenting for medical care, or upon review by the study monitor. all aes including local and systemic reactions not meeting the criteria for saes will be captured in the crf. information to be collected includes event description, time of onset, the study physician's assessment of severity, relationship to study drug, and time of resolution/stabilization of the event. all aes that occur during the study duration must be documented appropriately regardless of the relationship. all aes will be monitored to adequate resolution. any medical condition that is present at the time that the participant is screened will be considered as baseline and not reported as an ae. however, if the study participant's condition deteriorates at any time during the study, it will be recorded as an ae. changes in the severity of an ae will be documented to allow an assessment of the duration of the event at each level of severity to be performed. aes characterized as intermittent require documentation of onset and duration of each episode. the study physician at each site will record all events with start dates occurring any time after informed consent is obtained until the last day of study. at each study visit, the study physician will inquire about the occurrence of ae/saes since the last visit. events will be followed for outcome information until resolution or stabilization. all saes will be reported to the sponsor by the study site physician or an assigned representative within hours of the staff becoming aware of it, using a sae form, which should be completed, scanned and sent via email to the sponsor. the sae form should include nature of event, date of onset, severity, corrective therapies given, outcome and causality (i.e. probably, possibly, unlikely, unrelated). the study physician should assign the causality of the event. sae reporting will comply with local regulations for sae reporting to the sites research ethics committee and/or regulatory authorities. all unexpected saes must be reported to the ethics committee and the spanish regulatory agency (aemps) according to spanish legislation. in addition to the expedite sae reporting in h, monthly aggregate reports will be written by the study physician at each site. interim analyses of the efficacy and safety of hydroxychloroquine will be performed monthly and overall type i error will be controlled. after treatment initiation, hydroxychloroquine will be discontinued in participants presenting severe adverse events related to hydroxychloroquine intake or a confirmed sars-cov- infection by pcr assay in a nasopharyngeal swab or sputum sample. all serious adverse events will be notified to the sponsor. the study physician and investigator will evaluate the relationship with the study treatment. serious and unexpected adverse events that the cause is suspected to be related to hydroxychloroquine will be reported to the sponsor, to the ethical committee, to the pharmacy department of the hospital clinic of barcelona and to the agencia española del medicamento y producto sanitario (aemps). circumstances that may warrant termination or suspension of the study include: · determination of unexpected, significant, or unacceptable risk to participants · insufficient compliance to protocol requirements · data that are not sufficiently complete and/or evaluable · determination that the primary endpoint has been met · determination of futility during the study, regular monitoring will be conducted to: -confirm adherence to the protocol and applicable guidelines and regulations -ensure adequate recording of data -ensure adequate handling of biological samples and investigational product -verification of informed consent process and withdrawals the study will be supported by funds from each clinical trial site and may receive further support from the public or non-for-profit-private sector. laboratorios rubió has partially contributed to the funding of this project and with the required doses of hydroxychloroquine (dolquine ®). the results of the study will be published as an original article in an international journal. all co-i will be included as co-authors or in the acknowledgements of the article. a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster a novel coronavirus from patients with pneumonia in china world health organization. coronavirus disease (covid- ) preexposure prophylaxis for the prevention of hiv infection: evidence report and systematic review for the us preventive services task force remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus ( -ncov) in vitro in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus (sars-cov- ) covid- : a recommendation to examine the effect of hydroxychloroquine in preventing infection and progression a comparison of sample size methods for the logrank statistic key: cord- -xuwoqy authors: ortiz-barrios, miguel; gul, muhammet; lópez-meza, pedro; yucesan, melih; navarro-jiménez, eduardo title: evaluation of hospital disaster preparedness by a multi-criteria decision making approach: the case of turkish hospitals date: - - journal: int j disaster risk reduct doi: . /j.ijdrr. . sha: doc_id: cord_uid: xuwoqy considering the unexpected emergence of natural and man-made disasters over the world and turkey, the importance of preparedness of hospitals, which are the first reference points for people to get healthcare services, becomes clear. determining the level of disaster preparedness of hospitals is an important and necessary issue. this is because identifying hospitals with low level of preparedness is crucial for disaster preparedness planning. in this study, a hybrid fuzzy decision making model was proposed to evaluate the disaster preparedness of hospitals. this model was developed using fuzzy analytic hierarchy process (fahp)-fuzzy decision making trial and evaluation laboratory (fdematel)-technique for order preference by similarity to ideal solutions (topsis) techniques and aimed to determine a ranking for hospital disaster preparedness. fahp is used to determine weights of six main criteria (including hospital buildings, equipment, communication, transportation, personnel, flexibility) and a total of thirty-six sub-criteria regarding disaster preparedness. at the same time, fdematel is applied to uncover the interdependence between criteria and sub-criteria. finally, topsis is used to obtain ranking of hospitals. to provide inputs for topsis implementation, some key performance indicators are established and related data is gathered by the aid of experts from the assessed hospitals. a case study considering hospitals from the turkish healthcare sector was used to demonstrate the proposed approach. the results evidenced that personnel is the most important factor (global weight = . ) when evaluating the hospital preparedness while flexibility has the greatest prominence (c + r = . ). disaster incidents are one of the most endangering events in human life and emergency solutions are needed because of their sudden occurrence (hosseini et al. ) . as such events have devastating effects; they may cause some disruptions in the society to meet their health needs. man-made and natural disasters can interfere with the activities of some organizations such as healthcare facilities. sometimes the capacity of these facilities may not be sufficient to combat the physical and financial damage they may cause. although the ability to be ready for disasters varies by country, it can be said that in the last century, when the frequency and devastating effects of disasters have gradually increased, no country is fully prepared and safe. turkey, which has experienced many devastating man-made and natural disasters, faces with disasters per year (natural and technological) on average. these resulted in death and injured annually on average according to the figures in the emergency events database (em-dat). the disaster trends of turkey are demonstrated in figure . according to these statistics, these disasters have caused a serious total damage in terms of financial loss. turkey has passed a devastating earthquake in on th august, as can be easily inferred from the figure . also, in the following years after , earthquakes, mine accidents, floods, transport accidents, storms, epidemics, landslides, and miscellaneous industrial accidents have occurred in turkey. all of these disasters, especially earthquakes due to their destructive effects on human loss and financial damage, cause various problems in the operation of hospital operations and health services. nowadays, an overwhelming majority of the world is still fighting against a pandemic. covid- , a new type of coronavirus, is an infectious disease that first appeared on december , in wuhan, china. the world health organization (who) declared covid- later as an epidemic. in nearly months, the infection, which first expanded with iran and italy, is spread all over the world. as of april, , it has caused nearly . million cases and , deaths in the world (who, ) . the world has faced an unusual number of infected people in hospitals. this surge made it mandatory for countries to make their hospitals, field hospitals, or specific pandemic hospitals prepared in a considerable and short time. therefore, it is required to prepare the hospitals and all healthcare stakeholders for the disasters. in hosseini et al. ( ) , preparedness is defined as the inclusion of activities set up to build a mechanism for rapid responses to limit the risks and effects. one of the crucial components of improving disaster preparedness is to evaluate the readiness of hospitals and then propose a ranking of them. hospitals should be prepared for physical infrastructure and resource planning, as they are the only places to provide first care during a disaster. the postdisaster problems encountered by hospitals are stated in the literature as follows (gul and guneri, ; dursun et al. ): a surge in patient arrivals, communication issues, lack of adequate treatment and care area, problems in patient transfer. keskin and kalemoğlu ( ) pointed out that the most important post-disaster problem faced by hospitals is the excessive patient admission. similarly, the lack of coordination between disaster area and hospitals (kurt et al. ) , lack of telecommunication (ishii and nakayama, ) , chaos, and triage difficulty due to patient surge (yamauchi et al. ) are some of the other problems raised in the current literature. from these studies, it is inferred that disasters directly affect hospital activities. since the occurrence of disaster events causes mass casualties, public panic and chaos. most hospitals are unprepared to tackle thousands of patients arrived in case of a major disaster (foxell and mccreight ) . therefore, planning of hospital resources (treatment area, equipment and personnel) and determination of disaster preparedness levels of hospitals can be effective in reducing the damage caused by disasters. on the other hand, another issue related to disaster management is the importance of conducting risk analysis and loss assessment studies for urban areas (pitilakis et al. ; zuccaro and cacace, ; fawcett and oliveira, ) . these studies provide insight into the accessibility of hospitals as well as the assessment of losses and thus how they can affect the needs of healthcare services after a disaster. in this study, a hybrid fuzzy decision making model was proposed to evaluate the disaster preparedness of turkish hospitals. this model was developed using three well-known multicriteria decision-making (mcdm) methods named as fahp, fdematel and topsis. the ultimate target of the study is to determine a ranking among hospitals in terms of disaster preparedness. fahp is used to determine weights of six main criteria including hospital buildings, equipment, communication, transportation, personnel, flexibility and thirty-six sub-criteria under these six main criteria. ahp contains some important characteristics such as pair wise comparison, hierarchy, independency and consistency in decision making. since, fahp is frequently used as a weighting tool in the literature; we use it in this study with fdematel which has ability to evaluate interdependence between all the sub-criteria of the model. finally, topsis is used to obtain the ranking of hospitals. to apply the hybrid decision making model, two different questionnaires are created and assessed by five experts related to the field of disaster management of healthcare facilities. to provide inputs for topsis implementation, some key performance indicators are established and related data is gathered by the aid of experts from the assessed hospitals. the remaining of the study is organized as follows: section provides a review of the literature covering conceptual and research articles regarding the topic of hospital disaster preparedness evaluation. the third section gives the methodology used for the study. initially, applied mcdm methods are described then, the proposed hybrid approach is identified. fourth section concerns with a demonstration of the proposed approach. the evaluation criteria, the decision-making team, implementation of the questionnaires and results of each mcdm method are presented in this section. final section concludes the study with some future research recommendations and limitations of the current work. various conceptual-based and mcdm-based frameworks are proposed in the literature to assess the preparedness level of hospitals (hosseini et al. ; gul and guneri, ; top et al. ). in conceptual-based frameworks, researchers construct their disaster readiness frameworks without using any numerical tools. they directly focus on some dimensions such as structural, non-structural, functional, and human resources. on the other hand, in mcdm-based frameworks, researchers initially determine the main objective, disaster preparedness criteria and sub-criteria, alternative hospitals that will be assessed with respect to concerning these criteria/sub-criteria (the decisional hierarchy). then, a decision matrix is built that includes a weight matrix of criteria/sub-criteria. using this decision matrix, a final decision is made using an mcdm framework such as topsis. in the literature, the number of conceptual-based frameworks and cross-sectional surveybased studies are more than mcdm-based frameworks. as an example, hosseini et al. ( ) proposed a topsis-based ranking model for eight selected iranian hospitals. they ranked these hospitals in terms of disaster preparedness ability. four crucial criteria of structural preparedness, non-structural preparedness, functional preparedness, and human resources are taken into consideration in their study. the weights of these main criteria are assumed as %, %, %, and %, respectively. no mcdm method has been followed to determine weights to these criteria. results the results of the study suggest that any of the observed hospitals are not in on a well-prepared level. in another study, proposed an analytic decision-making preference model for the disaster preparedness of hospital emergency rooms in colombia. the mcdm model includes three well-known methods of ahp, topsis and dematel. gul and guneri ( ) made a conceptual study regarding the preparedness capability of hospital emergency rooms in istanbul, turkey. they combined the data of reports, literature, and one-to-one interviews with experts who experienced the recent istanbul earthquake. the interviews are analysed in terms of some earthquake key statements. the important issues faced during the earthquake from the viewpoint of hospital care are extracted. top et al. ( ) applied a questionnaire about hospital disaster planning in a total of turkish hospitals. a number of questions are included in the study. focus the focus of the questions are is about having any written hospital disaster plan and whether performing an exercise on an annual basis or not. the characteristics of hospital disaster plans are queried with respect to concerning the hospital category (public, private, university and all). unlike the above-mentioned studies, there exist many papers using a cross-sectional methodology, delphi, and similar tools (rezaei and mohebbi-dehnavi, ; saeid et al. ) . for a broad literature review in disaster preparedness of hospitals, scholars refer to the paper of alruwaili et al. ( ) . tabatabaei and abbasi ( ) performed a semi-quantitative cross-sectional study in some iranian hospitals to assess risks during disasters based on the hospital safety index. two different questionnaires were designed for collecting metrics (structural, functional, and nonstructural factors) supporting the evaluation of hospital disaster readiness are the general information of hospitals and disaster ability bythis is not fully numerical or mcdm-based study. otherwise, it benefits from a semi-quantitative disaster preparedness assessment method. similarly, naser et al. ( ) made a cross-sectional study to assess hospital disaster preparedness of public and private hospitals in south yemen. are included to the study. results the results of the study demonstrated that hospitals are in an unacceptable level of readiness. samsuddin et al. ( ) investigated disaster preparedness attributes and hospital's resilience in malaysia. a cross-sectional questionnaire has been performed among malaysian hospitals' staff considering a total preparedness attributes and resilience indicators are used in the study. the results showed that human resources & training and the ability to adapt in a timely manner promptly are were ranked as the most critical attributes. the results can help hospital's stakeholders in malaysia to improve the its preparedness capability. marzaleh et al. ( ) developed a model for hospital emergency room preparedness against radiation and nuclear incidents as well as nuclear terrorism in iran. by utilizing the delphi method, criteria are considered under three main classes, namely staff, stuff, and structure (system). in conclusion of the results, staff preparedness and stuff preparedness had the highest and lowest priority levels, respectively. shabanikiya et al. ( ) designed a tool for hospital preparedness for surge capacity during disasters. they used the delphi method in their developed toolkit as in marzaleh et al. ( ) and assessed components in five categories and sub-categories. the developed tool was used in evaluating hospital preparedness for surge capacity in disasters and planning the future of hospitals against disasters. the current study is differentiated from both studies mentioned under the class of mcdmbased frameworks in some aspects. the first difference concerns the comprehensiveness of the hospital disaster preparedness criteria set. while hosseini et al. ( ) considered four preparedness dimensions as mentioned above, constructed the hierarchy under seven criteria. in ortiz- , the decision-making team identified criteria and sub-criteria to evaluate the readiness of emergency departments for a disaster situation. the criteria set of our study include hospital buildings, equipment, communication, transportation, personnel, and flexibility. these criteria are more inclusive than the two studies and can easily be adapted to potential models that can be developed later. moreover, ortiz-barrios et al. ( )'s study is developed for specific emergency departments. a main dimension similar to the one we use in this study and which we called "flexibility" is not mentioned in hosseini et al. ( ) 's study. the second difference stems from methodological sides. in hosseini et al. ( ) , an assumption and full subjectivity are preferred in weighting the main criteria. the assignment of criteria weights is not clear. any weight assignment is not performed for sub-criteria. unlike this, we follow a group-decision making procedure via an experienced decision team in weighting both criteria and sub-criteria using fahp. besides, none of the studies proposes a fuzzy-based mcdm approach. however, by integrating linguistic expressions and corresponding fuzzy numbers into our approach, we aim to eliminate the insufficiency and preciseness of the crisp pairwise comparison in classical ahp in capturing the right judgments of decision-makers. as discussed above, many studies are existed have been undertaken for assessing hospital disaster preparedness. most of the papers contribute to the literature by proposing conceptualbased frameworks that we discussed. on the other hand, cross-sectional questionnaire-based models that suggest new attributes regarding hospital disaster readiness and review papers that provide a comprehensive overview to of the topic are also widespread. also, our brief review in this section shows the importance of hospital disaster preparedness assessment from the mcdm viewpoint of mcdm throughout the literature. it can be observed that there exist is a wide ranges of mcdm methods used in the literature with applied application to various areas. so far, however, there have been limited papers regarding the use applications of fahp, fdematel, and topsis in hospital disaster preparedness. by doing the current study, we aim to provide some contributions to the literature. these are as follows: . we developed a model specifically dealing with hospital disaster readiness assessment and ranking. this topic has been also addressed in other studies considering a number of service-quality criteria ; our model, however, incorporates on conclusion of the analysis of upon analyzing the published papers, it is observed that our study covers a number six disaster readiness criteria (hospital buildings, equipment, communication, transportation, personnel, and flexibility) and thirty-six sub-criteria representing the entire context of hospital disaster management. under six main headings of, thirty-six sub-criteria under these six main criteria are determined. most of the criteria are proposed and defined for the first time in the literature. . we developed a three-mcdm-integrated approach that includes fahp, fdematel, and topsis. fahp is was firstly used in for determining the initial weights evaluation criteria of hospital disaster preparedness criteria. furthermore, the fdematel method can derive the weights considering was then applied for assessing the interrelations among criteria. therefore, we also applied it to the determination of criteria weights. we have combined these two fuzzy mcdm methods with topsis in this study to rank hospitals in terms of readiness. in view of the characteristics of all these methods either individually and in integrated style, the proposed approach can handle the problem in a systematic and analytical manner. indeed, the hybrid approaches can tackle the limitations that single methods hold (zavadskas et al., ; ortíz-barrios, ) . for instance, topsis uses criteria weights that are usually defined randomly. fahp, specialized in prioritizing decision elements (saaty, ) , has been therefore proposed to address this drawback. on the other hand, fdematel has been incorporated into this approach since fahp is unable to evaluate interdependence among criteria. although anp can be also used to this aim, its application has been proved to be time-consuming and highly complex, especially in models with a significant number of criteria and sub-criteria (kumar and haleem, ) . on a different tack, topsis was deemed as a suitable method for ranking the hospitals according to their disaster preparedness level. this technique was preferred over ahp since the latter method entails many pairwise comparisons given a large number of hospitals. although a pilot application including hospitals is presented in this study, it is noteworthy that the proposed approach has been projected to be used at a national level in turkey where a significant number of alternatives needs to be considered. dea can be also employed for this particular aim; it, however, assumes that inputs and outputs are known which cannot be fully ensured in all disaster readiness criteria (velasquez and hester, ) . in table , we present a comparison with the four aforementioned studies based on some specific aspects. it can be seen from table that the proposed approach meets all three important aspects (pairwise comparison criteria, fuzziness in determination of criteria weights, and interdependence evaluation between criteria), and is more satisfactory in terms of quantity of criteria and coverage of the criteria. the rest of the approaches only cover two aspects at the most. based on the previous considerations, the novelty of this study is as follows: a) the inclusion of fuzziness in the calculation of criteria and sub-criteria weights using the fahp method. this is motivated by the need for dealing with the imprecision and uncertainty of linguistic evaluations which makes the model more realistic and coherent with the real scenario. besides, this aspect has not been addressed by the previous related studies as evidenced in table . b) the evaluation of fuzzy interdependence between disaster readiness criteria through fdematel for facilitating the design of long-term improvement plans by the government and other stakeholders. similar to the point a), this aspect has not been dealt in the reported related literature. c) the incorporation of several criteria that have not been considered in other related studies (i.e. flexibility and contingency staff). a six-step procedure (fig. ) is proposed to evaluate the hospital disaster preparedness and detect the weaknesses that should be tackled by each institution for upgrading their response to disaster incidents: step : a decision-making team is chosen considering their expertise (related to disaster management, healthcare management, and mcdm) and experience (at least years in the turkish healthcare sector) on disaster management and emergency care services. the selected participants (n) will be asked to provide insights on the definition, importance, and influence of assessment decision elements (criteria/sub-criteria) through fahp and fdematel techniques respectively. in this regard, it is critical to define the number of experts participating in the decision-making process so that criteria weights, interdependence results, and topsis scores can be calculated at a high confidence level (cl = % at a minimum) and low error level (e = % at a maximum). step : the assessment criteria and sub-criteria are determined given the related scientific literature, government regulations and experts' considerations. step : fuzzy ahp is implemented to estimate the relative weights of criteria and sub-criteria under vagueness (see sub-section . . ). step : fuzzy dematel is applied to pinpoint the dispatchers and receivers per each cluster while estimating the strength of influence among criteria/sub-criteria (see sub-section . . ). step : fahp and fdematel are later integrated to calculate the final criteria and subcriteria weights with basis on interdependence (see sub-section . . ). step : topsis is finally used for ranking the hospitals on the basis of disaster preparedness. in parallel, weaknesses are identified for propelling the design of focused improvement interventions in each institution (see sub-section . . ). in this subsection, we identify the applied mcdm methods either used in fuzzy sets or in crisp environment. therefore, prior to giving the details of fahp and fdematel method, an overview on the notations of fuzzy sets may be useful. zadeh ( ) introduced fuzzy sets for better reflecting of the human judgments and assessment in decision making. also, the usage of fuzzy sets is better for transforming linguistic decision of human judgment and reflecting uncertainty and ambiguity of the real world decision making processes. hence, many problems have used the fuzzy sets. the inclusion of fuzziness, however, entails more complex calculations compared to the existing related approaches. to tackle this disadvantage, an excel-based decision support system has been properly designed and adopted to accelerate the disaster preparedness evaluation in relation to: i) weighting and prioritizing disaster readiness criteria and sub-criteria, ii) identifying the dispatchers and receivers within the disaster management scenario, iii) ranking the hospitals according to their preparedness level, and iv) defining focused operational strategies for increasing the response of hospitals against outbreaks. one representation of fuzzy sets is the use of triangular fuzzy numbers. a triangular fuzzy number consists of comprises lower, medium, and upper numbers of the fuzzy as = ( , , ) where l, m and u which is crisp and real numbers ( ≤ ≤ ). the membership function of a triangular fuzzy number ( ) can be defined as follows. a triangular fuzzy number is presented in figure . table . defuzzification style: graded mean integration representation (gmir) "# $ % = ( $ + $ + $ ) ( fahp is one of the commonly applied mcdm methods. crisp ahp cannot mirror the subjectivity broadly. although saaty and tran ( ) stated that ahp integration with fuzzy sets cannot be effective, there are many studies in the literature that integrate ahp with these fuzzy sets. some arguments in these studies are as follows. kahraman et al. ( ) stated that ahp cannot reflect the thinking style of human, therefore, the fuzzy extension of ahp has been developed. chan et al. ( ) stated that with fuzzy cluster and ahp integration, mathematical uncertainty would be better expressed and could be therefore used in solving real-world problems. also, wang et al. ( ) expressed that ahp is integrated with fuzzy sets to better reflect uncertainty. therefore, ahp is improved by fuzzy sets to demonstrate uncertainty and vagueness. different improved versions of ahp by fuzzy sets are available in the literature (buckley, ; chang, ) . in this existing study, buckley's ( ) method is applied to determine hospital disaster preparedness criteria. in some fahp extensions, for example in chang's extent analysis, a limitation is released. an irrational zero weight generation problem in criteria weighting (chan and wang, ) is detected in chang's fahp. step -pairwise comparison of each criterion: linguistic terms are used in determining relative importance of each two criteria based on eqs. and . although the saaty natural scale ( : equal importance; : weak importance; : strong importance; : very strong importance; : absolute importance; reciprocals) was initially proposed to denote the preferences between two elements either criteria or sub-criteria (saaty, ) , a shorter and fuzzy version of this scale ( : equally important; : more important; : much more important; , : less important; , : much less important) (eq. ) has been adopted to deal with the imprecision of linguistic evaluations whilst reducing some bias and confusion during the comparison process (pecchia et al. ; ijzerman, van til, and bridges, ; ortíz-barrios et al. ). $ = , , , :;<=>;<?@ < <a b c?;>d e<=ℎ :;<=>;<?@ g < = g , , , , , :;<=>;<?@ g <a b c?;>d e<=ℎ :;<=>;<?@ < ( ) step -fuzzy geometric mean matrix: it is constructed using eq. . step -fuzzy weights: for each criterion, the fuzzy weights are obtained by the eq. . here, e k $ is the fuzzy weight of criterion i and e k $ = ( e $ , e $ , e $ ). here, e $ , e $ , e $ represent the lower, middle, and upper value of the fuzzy weight of criterion i. step -non-fuzzy weights: the best non-fuzzy weights are computed using gmir. finally, the consistency ratio (cr) is calculated via applying eq. - . here, ci denotes the consistency index while ri represents the random index. if cr < %, the matrix is concluded to be consistent and the derived weights are therefore valid for supporting the decision-making process. l" = rs ts ( ) the fdematel method is an improved version of classical dematel method initially proposed by gabus and fontela ( ) . classical dematel considers the relationship between the evaluation criteria in an mcdm problem and classified them into cause-andeffect criteria (akyuz and celik, ; gul et al. ) . the common plus of fdematel is to consider the fuzziness and to provide flexibility in a fuzzy mcdm environment (akyuz and celik, ; wu and lee, ) . step -set up of the expert team. step -determination of evaluation criteria: a five-point linguistic scale is used (no influence, very low influence, low influence, high influence, and very high influence) considering linguistic terms and corresponding triangular fuzzy numbers as given in table . step -initial direct-relation fuzzy matrix: the pairwise comparisons of experts are performed considering linguistics variables, as stated in step . as a result, initial direct-relation fuzzy matrix (u ) of experts is constructed (eq. - ). step -normalized direct-relation fuzzy matrix: in this step, benefiting from the initial directrelation matrix, the normalized direct-relation fuzzy matrix is constructed (eq. - ). step -total relation fuzzy matrix: hereafter the matrix [ , a total-relation fuzzy matrix is calculated as follows . where =̃$ z = ( $ hh , $ hh , ; $ hh ) step : after the computation of matrix e , ;$ + : and ;$ − : are computed. here, ;$ and :̃ show the sum of the rows and columns of matrix e . whilst ;? k $ + :? k shows the importance of criterion <, ;̃$ − :̃ shows the net effect of criterion <. step : defuzzification is the conversion of a fuzzy quantity to a precise quantity (ross, ) . thereafter in this case, ;̃$ + :̃ and ;̃$ − :̃ are defuzzified by using centre of area defuzzification style with eq. ( ). step : in the last step, the cause and effect relation diagram are drawn by the aid of ;̃$ + :̃ and ;̃$ − :̃ . in fdematel, we have used fuzzy arithmetic till step- . in step- , finally, we have applied defuzzification. although some authors from literature have used initially defuzzification then followed crisp dematel, we have done vice versa (si et al. ) . since the nature of our problem is under a situation where the output of the fuzzy process needs to be a single scalar quantity as opposed to a fuzzy set. as we will use crisp topsis in determining hospital rankings in terms of disaster preparedness, we need defuzzified values of weights from fahp and fdematel. therefore, we have applied defuzzification. as stated by oussalah ( ) , in many engineering applications, the need for a numerical value has been usually provided by a defuzzification process. in this study, we use fahp to obtain the relative weights of criteria i (i = , ,…, k) and subcriteria j (j = , , …, n). nevertheless, fahp does not analyse the dynamic interrelations inherent to the healthcare scenario (si et al. ; zhang et al. ) . we therefore propose the integration of fahp and fdematel methods to address this limitation. while fahp provides enough support for conducting short-term interventions, fdematel underpins the definition of improvement actions at a long-term horizon which is consistent with the timetables of the disaster management plans established by governments. the result of this combined approach is a set of weights on the basis of interdependence that are later incorporated in topsis method ( figure ). step-by-step procedure of the integrated fahp-fdematel approach the resulting global criterion importance gcw i (i = , , …, k), local sub-criterion importance pqr $ (j = , , …, n), and global sub-criterion weight gsw j (j = , ,…, n) derived from the hybrid approach can be estimated by implementing eq. , eq. , and eq. respectively. in these formulas, k denotes the total number of criteria whilst n represents the total number of sub-criteria deemed in the mcdm model. on the other hand, (l $ + " $ ) \st and (l $ − " $ ) \st are the prominence and relation parameters of criterion i (i = , , …, k) whereas #l + " % \st and #l − " % \st represent the prominence and relation of sub-criterion j (j = , , …, n) respectively. eq. - combine the weights derived from fahp and f-dematel to calculate the criteria and sub-criteria importance on the basis of interdependence. specifically, f-dematel weights are estimated through the vector length method as follows: u((l $ + " $ ) \st ) + ((l $ − " $ ) \st ) . these weights are further combined with fahp weights by incorporating the vector e (eq. ). lately, the terms topsis initially suggested by hwang and yoon ( ) step-by-step procedure of topsis step : the first step concerns with determination of criteria and alternative set. here, shows the set of alternatives, demonstrates the criteria weights. step : the second step is related to the normalization. it is formulated by eq. ( ). step : the third step presents a weighted normalized matrix which is determined by eq. ( ). step : the positive ideal point (pis) and the negative ideal point (nis) are obtained by eqs. ( - ). where j and j are the benefit and the cost criteria, respectively. step : the fifth step is on calculation of the separation from the pis and the nis. the separation from pis and nis values can also be computed using the euclidean distance formulae as in eqs. ( - ): step : then, the final topsis score is calculated by eq. ( ). by calculating the score in eq. ( ), the ranking orders are determined via a * k c value in descending order. the proper selection of a decision-making team is critical for determining the importance of criteria considered in the assessment of hospital disaster preparedness. likewise, it will provide significant support for identifying the presence of interdependence and feedback within the mcdm model. in this case, seven experts were finally chosen to participate in the decision-making process: academicians ( ), it technician ( ), and disaster manager ( ). it is noteworthy that the academicians are also consultants and researchers who have conducted several projects in the hospital sector. the number of experts (n = ) participating in this application was defined considering cl = %, p = %, e = %, n = (experts fulfilling the inclusion criteria described in step -" .methodology"); and is hence sufficient for obtaining reliable weights. a description of the experts' profile can be found in table : in particular, these experts were selected considering their job title, expertise area (≥ years), and experience (related to mcdm and healthcare). apart from these participants, three researchers with vast experience (≥ years) in disaster management and healthcare logistics acted as facilitators of the decision-making process. specifically, they built the multi-criteria model for evaluating the hospital preparedness when facing disaster situations. in this activity, the decision-making team provided meaningful insights on the criteria to be considered within the model. on a different note, the facilitators also designed the data-collection instruments and indicated experts how to conduct the paired judgments inherent to fdematel and fahp techniques. moreover, they established the indicators underpinning the topsis implementation. it is worth highlighting that this project was initially discussed with the participating experts to facilitate the comprehension on the study goals and obtain feedback before implementation. turkish healthcare regulations, the pertinent scientific literature and experts' opinion served as a basis for defining the criteria and sub-criteria to be included within the disaster preparedness assessment model. a short brief explanation of each decision element was incorporated in the fahp and fdematel surveys for ensuring proper understanding on the model. the final version of the multi-criteria structure is depicted in figure . in particular, criteria and sub-criteria were deemed to rank four hospitals (h , h , h , and h ) and detect their weaknesses as a support for focused improvement. an explanation of each decision element can be consulted in table . in "hospital buildings" (c ) domain, seven sub-criteria were considered: "physical infrastructure" (sc . ), "location" (sc . ), "number of floors" (sc . ), "capacity" (sc . ), "disaster gathering area" (sc . ), "insulation" (sc . ), and "ventilation" (sc . ). "physical infrastructure" (sc . ) evaluates whether the buildings are resistant to disaster such as earthquakes, fire, radiation, nuclear, and terror incidents. "location" (sc . ) is defined as finding the right place for construction of hospitals in terms of the degree and severity of earthquake occurrence. on a different tack, "number of floors" (sc . ) refers to the number of floors that the hospital has. "capacity" (sc . ) measures the total capacity capability that the hospital has in terms of human, medical equipment and treatment areas. on the other hand, "disaster gathering area" (sc . ) assesses the availability of any disaster gathering area of the hospital. "insulation" (sc . ) identifies the capability and/or availability of the insulation capability of the hospital. finally, "ventilation" (sc . ) evaluates the ventilation capability of the hospital. hospital whilst "drinking water" (sc . ) evaluates the availability and management of the drinking water for the hospital. on the other hand, "tent" (sc . ) assesses the availability and quantity of required tents for the hospital whereas "food" (sc . ) represents the availability and sufficiency of food for the hospital under disaster conditions. on a different note, "bed" (sc . ) denotes the availability and adequacy of beds for the hospital under disaster incidents while "triage tag" (sc . ) shows the availability and quantity of required triage tags for the hospital. lately, financing and supplying sources of the equipment are evaluated through sc . and sc . . concerning "communication" (c ) area, three sub-criteria were deemed: "emergency network" (sc . ), "communication tools/device" (sc . ), and "information quality" (sc . ). the first sub-criterion (sc . ) checks the communication ability of hospitals with the institutions having a say in disaster response. the second aspect (sc . ) verifies the type and quantity of communication tools/devices a hospital has. finally, "information quality" (sc . ) evaluates how reliable and effective the communication flows are within a hospital and with their partners during a disaster event. in "transportation" (c ) domain, four pillar aspects were included: "number of vehicles" (sc . ), "helipad space" (sc . ), "safety" (sc . ), and "accessibility (roads)" (sc . ). in this respect, "number of vehicles" (sc . ) considers the quantity of the vehicles that the hospital has for their usage during disaster situations. "helipad space" (sc . ) verifies whether the hospital has an available helipad space for admitting patients transported by helicopter. another element of consideration is "safety" (sc . ) which encompasses the general safety standards of the hospital under disaster situations. finally, "accessibility" (roads)" (sc . ) evaluates the presence and deterioration of roads providing access to hospital in case of disaster. on a different tack, "personnel" (c ) criterion was characterized through six decision elements: "education" (sc . ), "disaster drill" (sc . ), "emergency response team" (sc . ), "coordination" (sc . ), "number of personnel" (sc . ), and "working hours" (sc . ). "education" (sc . ) evidences the education level of hospital staff in terms of disaster preparedness and behaviour in case of disaster. "disaster drill" (sc . ) verifies the implementation of disaster drills for hospital staff and patients. another aspect of consideration in this domain is "emergency response team" (sc . ). in particular, this subcriterion determines the availability/implementation of education/training for emergency medical services. also, "coordination" (sc . ) was considered to examine the coordination level of staff in terms of disaster preparedness and behaviour in case of disaster. other subcriteria to be studied within this factor are: "number of personnel" (sc . ), and "working hours" (sc . ). the first one involves evaluating the quantity of trained staff that the hospital has for facing devastating situations; whereas the second sub-factor represents the number of working hours that the hospital trained staff have in relation to disaster events. the last criterion included in the mcdm model is "flexibility" (c ). for its assessment, four sub-factors were specified: "flexibility in the use of facilities" (sc . ), "contingency staff" (sc . ), "blood bank" (sc . ), and "supply chain of medicines and medical supplies" (sc . ). the first sub-factor (sc . ) considers the administrative areas that can be allocated for taking care of affected people. such areas can be primarily used for providing emergency care to people with minor affectations. on the other hand, "contingency staff" (sc . ) denotes the staff who do not work directly with the hospital but can be further linked for facing the disaster (i.e. professionals who are not located in the disaster occurrence city). another decision element considered in this assessment domain is "blood bank" (sc . ) which verifies the availability of a blood bank for effectively underpinning healthcare during a disaster. ultimately, "supply chain of medicines and medical supplies" (sc . ) has been included into the model considering that hospitals should count on supply chains providing medicines and supplies in the shortest possible time. in this intervention, a survey format was designed for collecting the paired judgments resulting from the fahp application. the format layout proposed in this study (figure ) was found to be comprehensible and easy to complete by the participant experts. in various studies, the appropriate design of the data-gathering tools has been concluded to be effective for decreasing the risk of inconsistency in related decision-making applications (pecchia et al. ; ortiz-barrios et al. ) . as depicted in figure , the following question was asked: table , where the collected judgments were aggregated and organized in accordance with eq. - . after this, the fuzzy weights were computed using eq. . the derived global and local priorities are presented in table . we later proceeded with the estimation of consistency ratios (cr) to check the reliability of resulting weights (table ). considering that cr values are not over the threshold ( . ), the calculated priorities are concluded to be appropriate for their use in the assessment model. it is noteworthy that the biggest matrix (equipment) was found to present very low inconsistency (cr = . ). such findings evidence the effectiveness of the assessment process based on: i) the careful design of the questionnaire, ii) the reduced comparison scale and iii) the high expertise of decision-makers. a questionnaire was also created to collect the paired judgments outlining the interdependence and feedback relationships among criteria/sub-criteria considered in the model ( figure ). in this case, it was asked: "according to your expertise, how much influence each criterion on the left exerts over each criterion on the right?" in difference to fahp, the experts performed the comparisons by employing the five-point linguistic scale (with triangular fuzzy numbers) illustrated in table . the judgment procedure was then iterated until finishing all the combinations "criterion i vs. criterion i" and "sub-criterion j vs. sub-criterion j". following this, the fuzzy paired comparisons were arranged in an initial direct-relation fuzzy matrix (u ) using eq. - . an illustration of matrix ƒ is presented in table . then, the normalized direct-relation fuzzy matrix " was achieved by applying eq. - (table ) . ultimately, the total relation fuzzy matrix … was estimated by implementing eq. - (table ). the prominence #:$ + ;̃ % and relation #:$ − ;̃ % values are calculated considering the results presented in table . such measures were defuzzified using the centre of area defuzzification style (eq. ) and further consolidated in table . receivers and dispatchers were also identified in this table. the results revealed that flexibility (c ) has the greatest prominence ( . ) and is therefore deemed as the main influencer when evaluating the hospital disaster preparedness. hence, flexibility (c ) should be targeted for continuous intervention within the disaster management plans. this was also pointed out by zhong et al. ( ) who concluded that disaster resilience arrangement of hospitals highly depends of flexibility in terms of resources, an aspect increasing the pre-disaster strength of each institution and propelling fast response and recovery. on a different note, significant correlations are observed among criteria (c + r > ) which are consistent with the interactive nature often found in healthcare scenarios (leksono, suparno, and vanany, ) . the interrelations within each sub-criteria cluster were assessed through impact digraph maps (figures to ). the influence diagram for criteria is presented in figure a . in this cluster, the adopted threshold (p) was established as ‹ = oe .o • } = . after defuzzifying the respective total relation fuzzy matrix … . from the graph, it can be discriminated that all the criteria are dispatchers. moreover, several interrelations are observed among these decision elements; some of them are of feedback nature (c -c ; c -c , c -c ; c -c ). in light of the above-mentioned considerations, multidimensional emergency operation plans should be designed, socialized, disseminated, simulated, and deployed by disaster managers to upgrade the performance of hospitals upon facing disaster events. simulation of such plans will provide further analysis on each criterion so that hospital weaknesses can be properly detected and tackled before the occurrence of a disastrous situation. sc . ) . the influence of sc . , sc . , and sc . on the rest of elements is based on the fact that these sub-criteria greatly restrict building, design, and location conditions of hospital infrastructure; aspects often considered by administrators when expanding, relocating, and adapting their facilities to the potential requirements derived from devastations. the influence diagram for "communication" (c ) sub-factors is depicted in figure a . in this configuration, the reference value was stated as ‹ = oe. o o } = . . in this domain, a feedback interrelation was detected between sc . and sc . . the need for constant communication support is critical for effectively underpinning the operation flows within ecns. in the opposite direction, the ecn configuration affects the quantity and deployment of communication devices in each hospital. as also found in the previous clusters, interactions are present in each paired relation which entails high degree of complexity for managers when including these aspects in the emergency operation programmes. finally, an influence map (figure b ) was drawn to analize the interdependence among "transportation" (c ) sub-criteria. the limit value considered in this cluster was set as ‹ = •.oeo • } = . . based on the diagram, the decision elements strongly interact with each other even in a double-direction form as presented in sc . -sc . , sc . -sc . , and sc . -sc . . also, "number of vehicles" (sc . ), "helipad space" (sc . ), and "accessibility (roads)" (sc . ) were concluded to be deliverers whilst "safety" (sc . ) was classified as receiver. it is noteworthy that all transportation modes used in the healthcare system are insights required for the correct deployment of safety measures seeking for protecting victims in the wake of a disaster. understanding the relationship between transportation conditions and patient safety will help disaster managers reduce potential adverse events during catastrophic events and establish guidelines for appropriate risk management. the global priorities of criteria (xlr $ ) and sub-criteria (xqr ) on the basis of interdependence were estimated by implementing eq. and eq. correspondingly. likewise, local interdependence weights of sub-criteria (pqr $ ) were calculated using eq. . the results derived from these equations have been compiled in table . based on fahp-fdematel outcomes, personnel (c ) was found to be the most important factor (xlr ' = . ) when assessing the hospital preparedness when facing devastating situations. little difference ( . ) was also detected between this criterion and equipment (c ). such results invite disaster management planners to fully consider these categories to effectively respond to the shock of disasters and return to stability. indeed, effective management of personnel (c ) and equipment (c ) is critical for upgrading the performance of emergency care networks when facing catastrophic events. for instance, the availability of medical teams, administrative staff, and resources play a key role for ensuring successful onsite-rescue and within-hospital medical care. moreover, sharing medical staff and other resources is one the main activities specified in the memorandums of understanding (mous) signed by hospitals. in particular, the presence of suitable and sufficient personnel and equipment supports hospital response, especially in the aftermath of a disaster. considerable efforts should be then made on c and c to establish appropriate supplier agreements and train medical staff in disaster management so that flexibility (c ) can be effectively pursued as highlighted in the previous section. following this, we have stratified our analysis to look into the importance of each subcriterion in each cluster. for instance, in hospital buildings (c ) category, the most important decision element was physical infrastructure (sc . ) (pqr = . ) whereas the second sub-criterion in the ranking was location (sc . ) (pqr = . ). such aspects represent more than a half of importance ( . ) in c criterion and they should be therefore urgently focused for continuous monitoring and improvement in hospitals. in particular, disaster managers should analyse the current state of the division of internal hospital spaces, the external envelope, structure, services, and contents to grant the safety of medical staff and victims after the catastrophic event. unfortunately, most hospitals fail to include built environment issues in their disaster management plans (cimellaro, reinhorn, and bruneau, ; loosemore and chand, ) . in this regard, it is recommended to: i) check and modify (if needed) the hospital layout to facilitate flow throughout the hospital during a disaster, ii) perform maintenance activities to minimize infrastructure vulnerabilities, and iii) review past disaster experiences and their effects on physical hospital infrastructure. in relation to location (sc . ), it is necessary to lessen the average travel distance for strikes' victims over a range of potential disaster scenarios. hospital location models (arlym et al. ; acar and kaya, ) should be then used for supporting this decision so that timely medical care can be provided to patients. in equipment (c ) criterion, medical equipment for es (sc . ) and medicine (sc . ) were concluded to be the most relevant sub-factors with local weights of . and . respectively. such results call for clearly determining the supplies and medical equipment needed for handling disasters effectively. in this regard, it is vital to partner with supply chains capable of providing the sufficient and appropriate resources during disasters without stockpiling within the hospitals' facilities. prior to this, disaster managers should identify, plan, and coordinate the timely supply of medical equipment and supplies so that hospitals can deliver the appropriate medical care before and after the strike. some other significant recommendations to properly manage these aspects can be found at de jong and benton ( ). looking into the results within the communication (c ) domain, it was concluded that the most critical aspect is emergency network (sc . ) (pqr o = . ). it is noteworthy that failure of hospitals during catastrophic events can highly affect public morale and increase needless deaths. in this sense, emergency care networks (ecns) may alleviate the burden faced by hospitals individually by co-ordinately sharing medical staff, emergency drugs, and other critical resources. thereby, the service level for disaster resources can be meaningfully improved which consequently ensures timely disaster response. notwithstanding the tremendous efforts made by governments in this particular aim, ecns are still at the earlier stages. in this sense, inefficiency factors such as the lack of coordination among hospitals and the presence of non-value added activities should be properly tackled by disaster managers to grant their adequate performance when facing devastating community events. with regards to transportation (c ) category, accessibility (roads) (sc . ) was identified as the most important sub-criterion with a local priority of . . road accessibility to hospital facilities is critical for granting rapid medical care to disaster victims. in this respect, ground failure, imploding buildings to road edges, and bridges collapse may occur and limit the patient flows during catastrophic situations. as accessibility changes after disastrous events (ertugay, argyroudis, and düzgün, ) , it is suggested to: i) evaluate road closure probabilities during the different types of disaster, ii) elaborate a disaster management plan in which hospitals can be pre-allocated to improve accessibility, and iii) implement accessibility models for helping emergency managers to better define emergency routes for evacuation and medical care. in relation to personnel (c ) area, the most critical aspect to be considered during disastrous situations is education (sc . ) whose local weight was calculated to be . . in the presence of unanticipated strikes, disaster management preparedness is recognized as crucial for medical staff and nurses so that effective care can be provided to the multiple victims arriving to the hospitals. indeed, continuing disaster management courses have become an important strategy for avoiding errors that may hinder the response of hospitals before and after devastating events (al khalaileh, bond, and alasad, ) ; hence sc . has been also considered as the sub-criterion with the major interdependence weight in the hospital preparedness evaluation (xqr = . ). some recommendations for effectively managing the disaster preparedness of staff include: i) continuously evaluate the core competencies, skills, and knowledge of physicians, nurses, and other support staff regarding the management of disastrous situations, ii) the inclusion of disaster preparedness in national curricula of medical staff so that worsening of events in mass causalty disasters can be effectively prevented, and iii) the implementation of disaster facility drills given the strong interrelationship found between this element and education. ultimately, blood bank (sc . ) was found to be the most crucial aspect in the flexibility (c ) domain with a local interdependence weight of . . undoubtedly, the use of blood products is vital for effectively addressing the diverse kinds of injuries emanating from disasters (either man-made or natural). in the wake in the past disaster experiences, it is then imperative to optimize the blood supply chain so that the healthcare system can navigate through events deviating from the normal day-to-day demands. in light of these considerations, it is recommended to i) determine the need for blood products depending on the potential disaster coverage, ii) ensure a seven-day supply of blood (simonetti et al. ) , and iii) model and simulate transfusion services throughout the long and short run of a disaster. this chapter details the application of topsis method whose main objective was to rank the hospitals based on their disaster preparedness whereas pinpointing the weaknesses that should be tackled by each institution so that better response can be expected when facing devastating events. moreover, the sub-criteria most contributing to the pis and nis of each hospital can be discriminated so that focused enhancement strategies can be effectively deployed in the practical disaster scenario. initially, a performance indicator (table ) was established per each sub-criterion. following this, initial topsis decision matrix x (table ) was arranged considering the hospital alternatives (" , " , " o , " • ), performance indicators, and sub-criteria. in particular, the performance indicators values were computed considering the mathematical formula depicted in pis and nis were also specified in table by employing eq. and eq. correspondingly. the normalized ratings are later calculated using eq. (table ) whereas the weighted normalized ratings were estimated by applying eq. (table ) . the interdependence weights of sub-criteria were calculated through the integrated fahp-fdematel approach illustrated in the previous section. on the other hand, the euclidean distance of each hospital (" , " , " o , " • ) from the pis (q v n ) was calculated using eq. (table ). in a similar vein, the separation of each hospital from the nis (q v , ) was estimated by applying eq. (table ). the ranking of hospitals and closeness coefficients l v * are shown in figure . such coefficients were computed using eq. . the results revealed that the hospitals performed between . (h ) and . (h ); there is therefore much room for improvement and interventions from the stakeholders. it is then necessary to estimate the distances from pis and nis to identify the weaknesses of each hospital (sub-criteria whose euclidean separation from pis is over zero || euclidean separation from nis is equal to ). in particular, it was found that h evidences low availability of medical equipment -sc . ( . %; separation from pis = . ) which may cause delays in medical care provided during disaster and consequently increase the risk of mortality. moreover, h is the hospital with the farthest distance from the target community -sc . ( km; separation from nis = ), an aspect that may limit the timely medical care also considering the potential collapse of roads and adjacent buildings. another weakness is the non-availability of a helipad space -sc . -which highly restricts the patient transferring process from the disaster zone to hospital facilities (separation from nis = ). additionally, there are no contingency staff -sc . -for facing the disaster situation (separation from nis = ). such disadvantage may compromise the hospital response mainly in large-scale catastrophic situations. on a different tack, similar to h , h concerns about the low availability of medical equipment -sc . ( . %; separation from pis = . ) and non-availability of helipad space -sc . (separation from nis = ) and contingency staff -sc . (separation from nis = ). also, it has the lowest number of floors -sc . ( floors, separation from nis = ) and ambulances -sc . ( vehicles, separation from nis = ), an aspect limiting the capacity for addressing the peaks of demand that may arise from the disaster. moreover, h does not evidence the use of tents -sc . (separation from nis = ) which also restricts its disaster preparedness. the major disadvantage is the number of disaster management programs organized by the hospital -sc . ( training programs; separation from nis = ), a fact that may trigger errors during on-site rescue, patient transportation, and medical care. regarding h , more investment and maintenance intervention is needed for increasing the availability of medical devices -sc . ( . %; separation from pis = . ). in addition, h also has the farthest separation from the target community -sc . ( km; separation from nis = ) and the lowest number of floors -sc . ( floors, separation from nis = ). apart from these findings, it is observed that h presents the shortest % of correctly insulated ed rooms -sc . ( . %; separation from nis = ) and % of rooms with appropriate ventilation -sc . ( . %; separation from nis = ). both conditions may hinder the correct deployment of disaster management plans in the wild; especially during medical intervention similar to h , h does not either denote tent usage -sc . (separation from nis = ). also, the number of beds -sc . -is limited compared to the rest of hospitals ( beds; separation from nis = ). shortage of beds has become a significant barrier for addressing large-scale outbreaks as those expected in the future. moreover, h only has one ambulance -sc . (separation from nis = ) which may not be enough for facing the potential upcoming events (i.e. coronavirus (huang et al. ) ). on the other hand, as all the hospitals participating in this study, no helipad space is available -sc . (separation from nis = ). moreover, h has the lowest number of security guards -sc . ( guards; separation from nis = ) which may not facilitate the patient flow and medical staff protection during a disaster. the number of training programms in disaster management is also low -sc . ( programs; separation from nis = ) and new courses should be therefore implemented for increasing the competences, knowledge, and skills of h workers. lately, this hospital was not found to be flexible as revealed through poor outcomes in the associated sub-criteria. finally, in relation to the leading hospital, the topsis results evidenced the need for intervention in the next sub-criteria: sc . ( ; separation from nis = ), sc . ( . %; separation from pis = . ), sc . (separation from nis = ), sc . (separation from nis = ), sc . ( training programs; separation from nis = ), sc . ( trained employees; separation from nis = ), and sc . (separation from nis = ). communication, transportation, personnel, flexibility and a total of thirty-six sub-criteria. fdematel is hereafter applied to uncover the interdependence between criteria and subcriteria. as a ranking tool, topsis is used to determine a ranking of hospitals. in application phase of the existed decision making model, two different questionnaires are created and assessed by seven experts related to the field of disaster management of healthcare facilities and academicians who are experienced for the disaster management topics. the numerical results demonstrated that "personnel" is the most important factor (with a global weight value of . ) when evaluating the hospital preparedness while "flexibility" has the greatest prominence (with a c+r value of . ). in the light of the numerical results obtained from this study, it is crucial that the observed and analysed hospitals design a better disaster preparedness plan in order to be more prepared against disasters. in relation to the scenario under study, the results revealed that the hospitals performed between . (h ) and . (h ); there is hence much room (gap to target: . - . ) for interventions increasing the current disaster readiness level. these interventions must address the main weaknesses detected in the cited set of hospitals: i) low availability of medical equipment, ii) lack of helipad spaces, iii) low availability of contingency staff, iv) lack of tents, and v) low number of disaster management training programs. thereby, these hospitals will be better prepared for facing future outbreaks in terms of timeliness, quality, and efficiency. this approach is useful for the related research field considering that methods measuring the hospital disaster preparedness levels are lacking (xin and xu, ; zhong et al. ). however, it has some limitations from both methodological and application viewpoints. we consider triangular fuzzy sets in both ahp and dematel stages. considering there exist various new versions of fuzzy set theory that reflect uncertainty and ambiguity of decision making process better, 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authors would like to thank prof. heriberto felizzola-jiménez for their valuable contribution to this research. also, many thanks to giselle paola polifroni-avendaño for her support during this project. ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: key: cord- - ip er h authors: grippaudo, francesca romana; migliano, emilia; redi, ugo; turriziani, gianmarco; marino, davide; d’ermo, giuseppe; ribuffo, diego title: the impact of covid- in plastic surgery departments: a comparative retrospective study in a covid- and in a non-covid- hospital date: - - journal: eur j plast surg doi: . /s - - -w sha: doc_id: cord_uid: ip er h background: covid- is a new human-infecting coronavirus for which the world health organization declared a global pandemic. the first italian cases occurred in february : since then, there has been an exponential increase in new cases, hospitalizations and intensive care assistance demand. this new and sudden scenario led to a forced national health system reorganization and review of welfare priorities. the aim of this study is to evaluate the effects of this pandemic on ordinary activities in two plastic surgery divisions in rome, hosted in a covid- and a non-covid- hospital. methods: the data of this comparative retrospective study was collected between march and april and the same period of from two plastic surgery units, one in a covid- hospital and second in a non-covid- hospital in rome, italy. the – data of the two hospitals was compared regarding the number of surgeries, post-operative dressings and first consultations performed. results: both units sustained a decrease in workload due to lockdown effects. statistically significant differences for day surgery procedures (p value = . ) and first consultations (p value < . ) were found between the covid- and non-covid- institutes, with a drastic trend limiting non-urgent access to covid- hospitals. conclusions: the long-term effects of healthcare reshuffling in the “covid- era” imply a delay in the diagnosis and treatment of skin cancer and cancellation of many reconstructive procedures. these findings pose a question on the future consequences of a long-term limitation in plastic surgery healthcare. level of evidence: level iii, risk/prognostic study. covid- is a new human-infecting betacoronavirus, first reported in wuhan (china) in december and rapidly spreading to all continents, causing a pandemic and a public health emergency. this virus is highly contagious with a human-to-human transmission and may present a benign course showing flu-like symptomatology (malaise, fever, cough) or a serious health hazard with severe acute respiratory syndrome (sars), acute cardiac injury and acute kidney injury [ , ] , among other systemic effects described. contact frequency among individuals is known as one of the major elements affecting the spread of the disease. liu et al. estimate the basic reproduction number (r ) of covid- , a mathematical term that indicates how contagious a disease is, indicating the average number of people who will catch covid- from one single infected patient as . [ ] . transmission from asymptomatic carriers has been demonstrated. italy has been highly affected by this pandemic since february [ ] , with , confirmed cases and , deaths according to the data of 'istituto superiore di sanità' on april [ ] . in rome, the number of patients infected to date is . the italian national health system is currently facing a challenge due to the high demand for intensive care assistance needed by - % of covid- patients [ ] and the lack of beds in intensive care units. therefore, remarkable efforts are spent to provide an efficacious reaction to the emergency, reorganizing the beds within the public health system hospitals to create new beds for covid- patients. italian hospitals have started to reduce elective activities to receive the high number of infected patients [ ] , and in an endeavour to preserve normal activities, 'covid- ' and 'non-covid- ' hospitals were identified in the nhs hospital network. it only makes sense that today's focus is exclusively on the sars-cov- , and the hospitals are primarily acting to defeat it. the coronavirus has deleted everything that can be felt superfluous and/or unnecessary. after the prime ministerial decree march [ ], the two leading italian plastic surgery organizations, sicpre (italian society of plastic, reconstructive and aesthetic surgery) [ ] and aicpe [ ] (association of aesthetic plastic surgery) provided recommendations to postpone any routine elective plastic surgery, with the exception of cancer or emergencies. most of the italian plastic surgery wards faced a reduction in beds and theatres to enable hospitals to free up healthcare staff to provide medical care for patients in other areas, given the need for a change in work organization to comply with limited outpatient clinic activities and reduced theatre availability for all hospitalization typologies and to cope with new pre-hospitalization modalities to screen up covid- positive patients among the ones scheduled for surgery. the aim of this comparative retrospective study is to ascertain the effects of the covid- pandemic on ordinary activities in two plastic surgery division in rome, italy, one in a covid- hospital and the other in a non-covid- hospital. this is a comparative retrospective study. data was collected from two plastic surgery divisions in rome, italy, of which policlinico umberto i (pu ) was set as a covid- hospital and san gallicano (isg) as a non-covid- hospital. pu plastic surgery department serves the faculty of medicine and dentistry at rome's sapienza university, italy, with a staff consisting of six consultants and eleven trainees. in , the in-hospital ward had ten beds and five weekly theatres treating patients; the day surgery ward had three beds and five weekly theatres treating patients; outpatient clinic surgery operations were performed and . outpatient consultations were carried out, of which . were referrals and . were dressing changes. isg plastic surgery department is located in a roman ircss, a biomedical institution of relevant national interest, which drives clinical assistance in strong relation to research activities. the staff is made up of nine consultants and one trainee. in , the in-hospital ward had seven beds and five weekly theatres treating patients; the day surgery ward had four beds and five weekly theatres treating patients; . ambulatory surgery operations were performed and . outpatients received a consultation, of which . were referrals and . were dressing changes. the study analysed the data collected between march (starting lockdown date in italy) and april and the same period of . outpatient, day surgery (ds) and inpatient (ip) medical charts were retrieved from both plastic surgery departments and the following data compared: both units sustained a decrease in workload due to the lockdown effects (fig. ) . routine follow-up visits were suspended and replaced by phone calls where feasible, except for dressing change in recently discharged patients. only patients referred as urgent by the general practitioner were scheduled for consultation. pu in-patient ward capacity was reduced to beds, to accomplish the -m social distance between beds; isg inpatient ward capacity was reduced to , thus accommodating one patient only in an originally double-bed room. theatre availability was reduced as well, in accordance with the work volume. outpatient clinic surgery was considerably reduced in both departments: % in pu and % in isg compared with the same period in . in both hospitals, only melanoma was treated, excluding basal cell carcinoma and squamous cell carcinoma. in both units, visitors for day surgery patients were not allowed; for in-patients, only one visitor per room was allowed, after a thermoscan check negative for fever. all patients and visitors were required to wear a surgical mask during their permanence on the hospital grounds. consultant staff shift remained unchanged in pu to help in covid- patients care, and daily resident number was reduced to two; while in isg a restricted staff policy was adopted to limit exposures, limiting the staff on duty to two surgeons each day and resident on duty only when surgery was scheduled. from march onwards, all patients requiring admission to both plastic surgery departments were screened h prior to admission, by means of a telephone interview by a doctor from each unit, to triage a possible covid- infection that would contraindicate hospital admission and require treatment in the appropriate setting (table ) . all patients in both hospitals also had to complete a preoperative health screening prior to admission, including one negative covid- test using the reverse transcription polymerase chain reaction on specimens from both upper respiratory tracts (nose and oropharyngeal samples), taken at least h before scheduled surgery. all non-oncologic surgery was curtailed in both hospitals. when compared with the same period of , witnessed a percentage decrease with regard to in-patient and outpatient procedures in both hospitals. in detail, pu faced a total in-patient surgery decrease of . %, while at isg it amounted to . %. figure shows the specific variation by type of in-patient surgery and highlights the reduction in non-urgent procedures such as lipofilling, post-bariatric surgery or periorbital surgery and the increase in surgical oncology and trauma surgery. ambulatory surgery decreased by % at pu and by % at isg when compared with the same period in . day surgery procedures decreased by . % at pu and by . % at isg. the average number of in-patient hospitalization days between and remained almost unchanged for pu (from . to . days) and for isg (from . to . days). overall, there is a clear decrease in welfare procedures in both hospitals, with statistically significant differences at chisquare test between the two institutes for day surgery procedures and first consultations ( table ). the primary objective of this study was to ascertain if there was a qualitative and quantitative modification in the activities of plastic surgery departments caused by the covid- pandemic. the secondary end-point was to ascertain whether the nature of covid- hospital or non-covid- hospital the pandemic-based guidelines of state authorities in many countries stipulate that all elective procedures that could be safely delayed must be cancelled [ , ] until the end of the pandemic, limiting the number of exposures for healthcare workers and reducing nosocomial transmission [ ] . despite the national government decree, plastic surgery activities show different managements depending on the covid- or non-covid- nature of the host hospital. after this work, it is possible to ascertain that both plastic surgery departments enrolled in this study are facing an overall decrease in activities, with a substantial cut in plastic surgery cares, which normally include a wide spectrum of diseases. fig. percentage change in in-patient procedures in isg and pu , during the period march- april and the period march- april . melanoma + sentinel lymph node biopsy (slnb) is the only increased surgery for isg, whereas skin cancer and post-traumatic surgeries are the increased procedures for pu : post-traumatic surgery is doubled (+ %). in pu , melanoma + slnb has not changed ( %). all other surgeries decreased in both hospitals (− % means that the procedure has not been performed) have you had shortness of breath or breathlessness over the past days? have you had a loss of smell or taste , even for a short Ɵme, over the past days? have you had pinkeye or conjuncƟviƟs over the past days? have you experienced over the last days vomiƟng or diarrhea? in the past days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? in the past days, have you been travelling outside italy? have you been tested for covid ? are you in quaranƟne for covid- ? have you been diagnosed with covid- ? if yes, when? are you in contact with anyone who has been confirmed to be covid- posiƟve, or that are in quaranƟne for exposure to study data shows the effects of the consequence of cancellation of plastic surgery elective surgeries in both hospitals during the lockdown, when the operating theatre was available only for such urgent procedures as melanoma or melanoma and slnb removal or for post-traumatic reconstruction in pu . these non-delayable procedures were unaffected in both hospitals, and this fact caused a relative increase in trauma surgeries and oncological figures compared with . that is not due to a surge of patient population affected by these pathologies but reflects the drop in elective procedures. due to the reduced availability of operating theatres and the restricted hospital policy admission criteria, the limited numbers of staff on duty were sufficient in both hospital to cover all the activities. the data qualitative analysis showed a similar decrease in both units about in-patient and day surgery cases and a statistically significant difference in workload between the units concerning the outpatient surgery and the referrals. this reduction in health services had a higher impact in pu , where some of the anaesthetist staff and intensive care beds were recruited for covid- patients. another reason for this difference is that patients requiring referrals or outpatient surgery are more apt to avoid covid- hospital for fear of nosocomial transmission and, accordingly, isg endured a lesser drop in these activities. procedures that are delayed until elective surgery because deemed safe include basal cell carcinoma removal, secondary breast reconstruction, post-bariatric surgery, regenerative medicine, hand surgery and electrochemotherapy for the treatment of cutaneous and non-cutaneous cancer. fuertes described the impact of covid- pandemic in spanish plastic surgery units on twelve plastic surgery unit across spain, investigating on different effects of the pandemic: team members schedule reduction, variation in type and number of surgical procedure, etc. [ ] fuertes results are comparable to ours in respect to the drastic reduction in overall surgical procedures (in-patient and outpatient) and consults, with a prevalence of oncologic case and a postponement of elective surgical activity. in this report, one hospital only, geographically located in a mildly affected pandemic area, declared to have maintained its usual activities. staff policy reductions were applied also in spain, with effects on increase of shifts numbers per consultants. at present, weeks after the lockdown began, there is no scheduled date yet to plan the return to full activities in both covid- and non-covid- hospitals, with the next national government guidelines expected on may. as a result, some patients could be damaged because of an undetected worsening of a long-standing lesion while in waiting list for planned elective surgery. other surgical specialties are facing the same problem, due to the restriction in elective surgery procedures [ , ] . emergency surgery addresses a broad spectrum of diseases of traumatic genesis or acute illness that need surgical treatment [ ] . conversely, elective surgery does not mean optional surgery but identifies a procedure assigned to a pathology that is not life-threatening in the immediate term and yet can seriously harm the patient if postponed for a long time [ ] . most of the procedures delayed by the plastic surgery units in this study are included in this definition. brücher et al. in a comprehensive article on pandemic surgery guidance described three surgical response phases depending on the epidemiological situation of covid- : phase with only few covid- patients, infection rate not in rapid increase and good availability of intensive care unit (icu) beds and ventilators; phase with many covid- patients and limited capacity of hospital and icu resources; and phase when all hospital resources are diverted to covid- healthcare and only life-saving operations are performed [ ] . when this manuscript was drawn up, rome was in phase , although all of italy was declared a red zone with similar restrictions in access to healthcare. therefore, a possible bias of this study is that it can be better compared only in regions in the same phase of the pandemic, since regions in which the pandemic has had the highest numbers will be much worst and, conversely, in regions with less covid- patients the figures will be better. further studies are needed to evaluate the consequences of covid- induced healthcare limitations in this class of patients with non-urgent pathologies. this is a preliminary study that evaluates the current situation in italian plastic surgery units amid the covid- outbreak. the decrease in procedures has relevant economic implications not to be underestimated. we are now working on guidelines in the event of similar future scenarios since, to date, we are not able to predict the foreseeable events. covid- -new insights on a rapidly changing epidemic clinical, laboratory and imaging features of covid- : a systematic review and meta-analysis the reproductive number of covid- is higher compared to sars coronavirus covid- : italy confirms deaths as cases spread from north covid- and italy: what next? critical care utilization for the covid- outbreak in lombardy, italy: early experience and forecast during an emergency response global guidance for surgical care during the covid- pandemic elective surgery in the time of covid- minimising intrahospital transmission of covid- : the role of social distancing agullo a current impact of covid- pandemic on spanish plastic surgery departments: a multi-center report safety recommendation for evaluation and surgery of the head and neck during the covid- pandemic maxillofacial trauma management during covid- . multidisciplinary recommendations aast committee on severity assessment and patient outcomes. emergency general surgery: definition and estimated burden of disease how to risk-stratify elective surgery during the covid- pandemic? covid- : pandemic surgery guidance publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements open access funding provided by università degli studi di roma la sapienza within the crui-care agreement.availability of data and material not applicable. authors' contributions francesca romana grippaudo conceived the presented idea, contributed to the interpretation of result and wrote the manuscript.ugo redi, gianmarco turriziani, davide marino and giuseppe d'ermo retrieved the data, contributed to the interpretation of result and designed the tables.emilia migliano and diego ribuffo contributed to the design and implementation of the study and supervised the work.all authors commented on the manuscript. code availability not applicable. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/ . /. key: cord- -z u d ec authors: shears, p. title: poverty and infection in the developing world: healthcare-related infections and infection control in the tropics date: - - journal: j hosp infect doi: . /j.jhin. . . sha: doc_id: cord_uid: z u d ec in many hospitals serving the poorest communities of africa and other parts of the developing world, infection control activities are limited by poor infrastructure, overcrowding, inadequate hygiene and water supply, poorly functioning laboratory services and a shortage of trained staff. hospital transmission of communicable diseases, a high prevalence of human immunodeficiency virus and multidrug-resistant tuberculosis, lack of resources for isolation and disinfection, and widespread antimicrobial resistance create major risks for healthcare-related infections. few data exist on the prevalence or impact of these infections in such environments. there is a need for interventions to reduce the burden of healthcare-related infections in the tropics and to set up effective surveillance programmes to determine their impact. both the global (g ) international development summit of and the united nations millennium development goals (mdgs) have committed major resources to alleviating poverty and poor health in the developing world over the next decade. targeting resources specifically to infection control in low-resource settings must be a part of this effort, if the wider aims of the mdgs to improve healthcare are to be achieved. summary in many hospitals serving the poorest communities of africa and other parts of the developing world, infection control activities are limited by poor infrastructure, overcrowding, inadequate hygiene and water supply, poorly functioning laboratory services and a shortage of trained staff. hospital transmission of communicable diseases, a high prevalence of human immunodeficiency virus and multidrug-resistant tuberculosis, lack of resources for isolation and disinfection, and widespread antimicrobial resistance create major risks for healthcare-related infections. few data exist on the prevalence or impact of these infections in such environments. there is a need for interventions to reduce the burden of healthcare-related infections in the tropics and to set up effective surveillance programmes to determine their impact. both the global (g ) international development summit of and the united nations millennium development goals (mdgs) have committed major resources to alleviating poverty and poor health in the developing world over the next decade. targeting resources specifically to infection control in lowresource settings must be a part of this effort, if the wider aims of the mdgs to improve healthcare are to be achieved. ª the hospital infection society. published by elsevier ltd. all rights reserved. 'the widening gap between the developed countries and the poorest communities of the developing world has become a central issue of our time.' this is not a quote from the global (g ) international development summit of , or from international awareness events such as the live aid and live concerts e it is the opening sentence of the pearson report of , a commission set up by the world bank to investigate why, after a decade of 'development', little impact had been achieved for the poorest communities of the tropics. , in , the alma ata conference of the world health organization (who) stated as its aim 'health for all by '. a visit to a village affected by human immunodeficiency virus (hiv) and malaria in tropical africa, to a shanty town in south asia with inadequate water and sanitation ( figure ), or to a displaced community in southern somalia suffering from cholera, dysentery and rift valley fever, suggest that these aims are yet to be fulfilled. many medical journals are currently devoting part of their current issues to the themes of poverty and infection in the developing world, in recognition of the commitments made by the g summit and the united nations (un) millenium development goals (mdgs) to improve maternal healthcare, reduce childhood mortality and the impact of human immunodeficiency virus (hiv)/ acquired immunodeficiency syndrome (aids), malaria and other communicable diseases. if g and the un mdgs are to be catalysts for change, it will be necessary to look beyond international conferences and mission statements and to concentrate on specific objectives that can be implemented in resource-poor settings. from the viewpoint of hospital infection control, the concern is how hospital and healthcarerelated infections affect poorer communities of the developing world, and what can be done to begin to make a contribution to reducing the associated morbidity and mortality. a visit to a sub-saharan african country, where i had been looking at laboratory services and hospital infection control, left two particular memories. the first is the overwhelming disadvantages faced by health workers surrounded by hiv/aids, multidrug-resistant tuberculosis, overcrowding and lack of resources for the most basic of hygiene activities. the second is the impossibility of knowing the magnitude of hospital-related infections and optimum treatment strategies without effective laboratory services. these comments would certainly have been equally appropriate or years ago. might be a turning point? with the current emphasis of governments and un agencies to focus again on poverty and health, there is an opportunity to move healthcare-related infections, and the support required in terms of laboratory development, education, hospital infrastructure, and appropriate professional training, into a focused agenda, rather than the 'cinderella' position that has until now been the case. the ebola virus outbreak in southern sudan in was a vivid reminder of the potential magnitude of hospital-acquired infection in tropical africa. on august , a student from nzara presented to the local district hospital at maridi in equatoria province, southern sudan, suffering from a severe febrile disease. he died a week later. over the next week, a nurse, a cleaner, and a hospital messenger became unwell, and then further medical and auxiliary staff. by the time a ministry of health/who team arrived in maridi approximately six weeks after the first case, one of the two doctors in the hospital had been infected and died, all six of the medical assistants had been infected and five had died, and twenty student nurses had died. further spread and deaths occurred until the impact of basic infection control strategies, involving gloves, gowns and masks for healthcare workers, and hygienic measures in dealing with body fluids and the deceased, brought the outbreak to an end. while the maridi ebola outbreak was an extreme case, it emphasised that the priorities for healthcare-associated infection control in the tropics, particularly away from tertiary or university hospitals in capital cities, cannot be a simple translation of expertise from the west. while limited systematic data exist on the overall patterns and prevalence of infection, experience from the field, and a review of available literature, indicate that the following are the major groups of infection control areas: since the outbreaks in sudan and zaire (now democratic republic of the congo, drc), nosocomial transmission of ebola virus has been reported in drc (kikwit), uganda, and probable cases in gabon and sudan. nosocomial transmission of other viral haemorrhagic fevers has included lassa fever in nigeria, and marburg haemorrhagic fever in angola. e prevention of transmission is difficult in resource-limited settings, with no total protective clothing or isolation facilities available. specific guidelines for control in district hospitals have been drawn up by who, and these cover issues including patient isolation, locally produced protective clothing, waste disposal, disinfectants, and community education. early diagnosis of the first cases, often in the community or peripheral health centres, is the mainstay of ensuring that preventive measures are initiated in a timely fashion and that transmission is kept to a minimum. if severe acute respiratory syndrome, pandemic influenza or h n avian flu were to become pathogens in these underresourced tropical areas, the pattern of the ebola outbreaks could be repeated. in any hospital infection control programme in much of africa, and large parts of asia and latin america, prevention of the spread of hiv, between patients, from patients to health workers, and from health workers to patients, is a priority. largely due to the un and who global aids programme, there is considerable literature and guidance available. at the level of the individual, poorly resourced hospital with limited reuseable equipment and disinfectants, hiv is a major concern for all health workers and local health education and support programmes have been shown to be effective. with the rise in hiv, there has been an increasing prevalence of tuberculosis, both in hiv-affected patients but also in the wider community, and in many areas an increasing prevalence of multidrug-resistant tuberculosis (mdrtb). this poses a risk for nosocomial transmission between patients, but particularly for health workers who will have direct contact, often with undiagnosed cases, and with less than adequate protective clothing. there are likely to be few rural hospitals in africa with a supply of pfr masks. the strict barrier precautions described by uk and centers for disease control and prevention (cdc) guidelines are unlikely to be practicable and workers dealing with these issues daily have developed more appropriate strategies. nosocomial spread of other communicable disease where hospital hygiene is limited, and wards are crowded, the risk of transmission of communicable disease is high. the source may be an inadequately isolated index case, relatives who are staying in the hospital to provide food and general care for patients, or contaminated food or water in the hospital. although from observation such transmission must occur, few such episodes have been recorded. nosocomial outbreaks of cholera have been published from tanzania and mozambique and these reports suggest that outbreaks of other faecal-oral infections, particularly shigellosis, typhoid and hepatitis a and e, must also occur. , other reported hospital communicable disease outbreaks have included measles and non-typhoidal salmonellae. , for communicable diseases in the tropics, the boundary between hospital and community infection is blurred. among relatives camping within the hospital compound, there may be a case of undiagnosed tuberculosis? is the infected person part of the community or part of the hospital? this distinction between public health and healthcare-related infection is particularly complex in the setting of refugee camps. , direct hospital acquired infections studies of surgical and other hospital-related infections have been published from several countries in africa, including kenya, nigeria, tanzania, ethiopia and burkina faso. e these studies show a similar pattern of pathogens that are seen globally; staphylococci, enterobacteriaceae and pseudomonas spp., with high levels of antimicrobial resistance and a high and somewhat arbitrary use of antimicrobials. the studies are necessarily selective e only those hospitals in which there is a functioning microbiology laboratory, and which have sufficient staff, can undertake such work. in addition, with limited laboratory facilities, only the more easily culturable bacteria may be isolated and the results may give only a partial picture of the true prevalence and antimicrobial resistance patterns of pathogens. in situations where more sophisticated microbiological studies have been undertaken in two particular non-western environments e the tsunami area of south east asia and repatriated combatants from afghanistan e unusual and multiply resistant isolates have been found. , occurrence of multi-resistant bacterial pathogens a common theme in all published studies of hospital infections in the tropics is the high prevalence of antimicrobial-resistant bacterial pathogens. this raises one of the major areas of concern. in terms of hygiene facilities, crowding and laboratory support, many hospitals in the tropics are like those of the 'pre-penicillin era', yet within them are the multi-resistant bacteria of the twenty-first century. data in many areas are limited or non-existent, but, where surveys have been done, meticillin-resistant staphylococcus aureus and extended-spectrum b-lactamase-producing and other multi-resistant gram-negative bacteria have been shown to be widely disseminated. e the problem is compounded as antimicrobials, including quinolones and third-generation cephalosporins, are available without prescription, many areas have no laboratory facilities to provide accurate susceptibility data, and, despite several past attempts, there are no functioning international resistance surveillance programmes. , hospital infrastructure and facilities the 'catalogue of disadvantage' for a rural district hospital in africa demonstrates the commitment of local staff in providing even the most basic services (figure ). the catalogue includes: poor building infrastructure, inadequate water supply, electricity for perhaps only a few hours a day, overcrowded wards with patients lying on the floor as well as on beds, lack of resources for cleaning the environment, beds or equipment, often an absence of soap, and remoteness from regional centres or the capital city. maridi, the hospital of the ebola outbreak in southern sudan, is km from khartoum, with a road link not possible for three months in the rainy season. this situation is compounded by civil strife in the democratic republic of congo, southern somalia or darfur, for example, where hospitals may have influxes of patients with both infected injuries and communicable diseases. , as patients with communicable diseases are admitted from crowded refugee camps, they may become the index cases for further spread within the hospital if infection control facilities are overstretched (figure ). there is no director of infection prevention and control in an african rural district hospital. nor is there usually a dedicated infection control nurse, almost certainly not a clinical microbiologist, and rarely clinicians with sufficient time to work with the laboratory staff. there have been developments in training personnel specifically to work in infection control in larger hospitals, those supported in some way by outside agencies, and in teaching hospitals in larger cities. most published work on training for infection control has been from south africa, with an understandable emphasis on hiv transmission, but many hospitals will have developed local, basic policies. the requirements to improve hospital infection control in the tropics have been considered in a number of valuable papers. e the key areas that have been identified include the following: e setting up national and regional infection control networks. many of these will only occur when there are the resources for major economic change and that is why it is necessary to consider poverty reduction, institutional as well as individual, rather than to focus on improving infection control as simply a 'health' or 'medical' problem. whether g or the mdgs for can achieve this poverty reduction remains to be seen. past experience of the pearson commission and health for all by suggests that targets alone, without addressing the fundamental causes of poverty or ill health, need to be handled with care. in the mean time, what can be done to assist the improvement of infection control in resource-poor settings? local health workers themselves are the most likely to achieve progress. the resources for hiv infection control that are part of the global aids programme represent one means for local improvement. the main who strategy to improve infection control internationally is the global patient safety challenge. this has involved many meetings and recommendations, but whether these will have a significant impact in resource-poor, tropical settings has yet to be seen. however, the initiative may give support to policy-makers in giving a priority to infection control. certainly, links that have been established between hospitals in the uk and individual hospitals in africa can provide muchneeded resources, can share expertise and provide training opportunities. the existence of the internet has in many ways revolutionised the ability of even remote hospitals to acquire information, to download who or cdc guidelines, to communicate with distant colleagues, and in some situations to be part of a telemedicine network. such initiatives include the raft network in francophone africa (réseau en afrique francophone pour la télémédicine) and the who health initiative for access to research information (hinari) programme. , if the aim of an internetlinked computer in every village in africa or asia or latin america, or at least in hospitals in those areas is to be achieved, there are practical issues of connectivity and band width that have to be faced. providing laptop computers without adequate connectivity and support will not be productive. efficient internet links will enable very real possibilities of support between hospitals in the uk and rural tropical hospitals. the absence of effective laboratory services at district hospital level is a major impediment to the long-term control of hospital-associated infections. unless the causative pathogens can be identified, and where appropriate the antimicrobial susceptibilities determined, there is a considerable risk that multiply resistant bacteria will become the dominant pathogens, with few antimicrobials available for treatment. within the mdgs, no specific mention is made of infection control or laboratories; without these, we cannot achieve the three specific health goals of: (i) improving maternal health, (ii) reducing child mortality and (iii) tackling aids, malaria and other communicable diseases. healthcare-associated infections have been near the top of the political agenda in the uk, resulting in increased funding and commitment for change. for the developing world the same priority is required if the aims of g and the mdgs are to be approached. the g and global health: what now? what next? partners in development: report of the commission on international development achieving the millennium development goals report of a who/international study team ebola outbreak in kikwit, democratic republic of the congo: discovery and 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northern tanzania epidemiological assessment of health and nutrition of ethiopian refugees in emergency camps in sudan communicable diseases in complex emergencies: impact and challenges nosocomial infections at kenyatta national hospital intensive care unit in aerobic bacterial nosocomial infections in paediatric surgical patients at a tertiary health institution in lagos risk factors for surgical site infections in a tanzanian hospital: a challenge for the traditional national nosocomial infections surveillance system index wound infection in tikur anbessa hospital surgical department survey of nosocomial infection prevalence on the surgery department of the central national hospital of ouagadougou rare bacteria species found in wounds of tsunami patients. gram negative bacteria from patients seeking medical advice in stockholm after the tsunami catastrophe multidrug resistant acinetobacter extremity infections in soldiers first report of mrsa from hospitalised patients in sudan staphylococcus aureus bacteraemia in the dakar fann university hospital nasal carriage of meticillin resistant staphylococcus aureus among health care personnel in abidjan (cote d'ivoire) extended spectrum beta lactamases among gram negative bacteria of nosocomial origin from an intensive care unit of a tertiary health facility in tanzania occurrence of extended spectrum beta lactamase enzymes in clinical isolates of klebsiella species from harar region, eastern ethiopia surveillance of antimicrobial resistance at a tertiary hospital in tanzania surveillance of antimicrobial resistance: the whonet programme burden of injury during the complex emergency in northern uganda the disease profile of poverty: morbidity and mortality in northern uganda in the context of war, population displacement and hiv-aids south african health service must strengthen infection control measures infection control in africa south of the sahara nosocomial infections in developing countries: cost effective control and prevention risk of nosocomial infection in tropical africa countdown to : will the millenium development goal for child survival be met? clean care is safer care'; the global patient safety challenge the raft network: years of distance continuing medical education and teleconsultations over the internet in french speaking africa who's health internetwork access to research initiative (hinari) access to electronic health knowledge in five african countries: a descriptive study none declared. none. key: cord- -w ysjf authors: nan title: th international symposium on intensive care & emergency medicine: brussels, belgium. - march date: - - journal: crit care doi: . /s - - - sha: doc_id: cord_uid: w ysjf nan ventriculostomy-related infection (vri) is a serious complication in patients with hemorrhagic stroke. in such patients, diagnosis of vris is complicated by blood contamination of csf following ventricular hemorrhage. we aimed to evaluate the diagnostic potential of white blood cells count (wbc), c-reactive protein (crp), and procalcitonin (pct) to identify vris in patients with hemorrhagic stroke during the time of external ventricular drain (edv) in situ. this retrospective study was conducted at the neurosurgical-icu, university hospital of zurich. a total of patients with hemorrhagic stroke and an external ventricular drain (evd) were admitted over a years period at the icu. of those, patients with vris ("vri"), defined by positive csf bacterial culture and increased wbc in csf (> /ul), and patients without vris and with serial csf sampling ("no-vri") were analyzed. patients with csfcontamination or suspected vri (negative csf cultures but antibiotic treatments) were excluded. wbc, crp, and pct were measured daily. csf was sampled routinely twice a week or by t> °c. for the analysis, mean peak values of wbc, crp, pct during the time of evd in situ were compared between groups (t test). data are expressed as mean with ci %. results: between groups, wbc and crp were similar (wbc: . g/l and . g/ l, p= . and crp: . mg/l and . mg/l, p= . in the group vri and no-vri, respectively) ( figure , panel a and b ). in the group vri, pct was low and significantly lower than in the group no-vri ( . ug/l and . ug/l, p= . in the group vri and no-vri, respectively) (panel c). wbc in csf were similar between groups ( . /ul and . /ul p= . in the group vri and no-vri, respectively). in this study, serum-inflammatory markers were not able to screen patients with vris. their routine measurement should be carefully evaluated. introduction: central nervous system (cns) infections constitute a potentially lifethreatening neurological emergency. patients admitted to the intensive care unit (icu) usually present with a severe disease and organ failure, leading to high mortality and morbidity. we have performed a retrospective analysis during a -year period of patients admitted to a polyvalent icu. clinical, demographic and outcome data were collected to evaluate its clinical impact on the outcome of patients with cns infections. we identified patients with the diagnosis of meningitis, meningoencephalitis and ventriculitis, where the median age was , years (range - ). upon clinical presentation, their most frequent signs were fever ( %), meningeal signs ( %), seizures ( %), and a glasgow coma scale score < ( %). all needed ventilation support and % needed cardiovascular support. a definitive microbiological diagnosis was achieved on patients and antibiotic therapy was adjusted on of them. most common microorganisms were streptococcus pneumoniae (n= ), listeria (n= ) and pseudomonas aeruginosa (n= ) (figure ). other gram negative microorganisms were detected and lead to more adverse outcomes. meningitis was the cause of admission on patients and on a minority (n= ) meningitis was considered to be a secondary diagnosis on patients admitted for other causes (traumatic brain injury, subarachnoid or intraparenchymal hemorrhage, postoperatively of neurosurgical tumor). patients that eventually died had at least one risk factor (age> , immunocompromised due to diabetes, corticotherapy, hiv or heart transplantation). patients admitted to the icu were not so aged, but had some comorbidities and risk factors leading to more uncommon microorganisms, increasing the risk of adverse outcomes. this lead to an increase of mortality: % in the icu and an overall of %. study of selenium levels in unresponsive wakefullness (uws) patients with systemic inflammatory response syndrome (sirs) e kondratyeva , s kondratyev , n dryagina the objective of this study was to evaluate the pharmacokinetics (pk) of levetiracetam (lev) in critically ill patients with normal and augmented renal clearance (arc), and determine if the recommended dosage regimen provides concentrations in the therapeutic range ( - mg/l) [ ] . a prospective observational study was conducted in a tertiary hospital. six blood samples were taken during a dose interval at steady state and lev was quantified by hplc. a population pk study was carried out. statistical analysis was conducted to evaluate the differences in pk between patients with and without arc. the suitability of drug concentrations was also assessed. results: seventeen patients were included, with normal creatinine clearance (crcl) ( - ml/min) and with crcl≥ ml/min (arc). ten patients received mg q h, one mg q h and two mg q h. the data were best fitted to a two-compartment model. figure shows lev concentrations during the dosing interval. mean clearance (cl) was l/h and mean volume of distribution of central compartment (v) was l. interindividual variability was and % for cl and v, respectively. no differences were identified between both groups (p> . ) in pk parameters. no correlation was found between lev cl and crcl. trough levels were below the minimum concentration (c min ) mg/l of the therapeutic range in all patients except . furthermore, between - h % of samples were below the c min . conclusions: administered doses were not able to maintain lev concentrations in the recommended therapeutic range. other dosage strategies, such the extension of infusion time with higher doses, could be evaluated in order to obtain a more favourable profile. no correlation between lev cl and crcl was found. the mechanical properties of muscles such as tone, elasticity, and stiffness are often affected in chronic critical ill (cci) patients. a hand-held device known as the myotonpro demonstrated acceptable relative and absolute reliability in a ward setting for patients with acute stroke [ ] . the technology works on the principle of applying multiple short impulses over the muscle bulk via the testing probe. the aim of our study is to assess the feasibility of objective measurement of muscle tone in cci patients with neurological dynamics and serum biomarkers. the study included cci patients with neurological disorders (stroke, traumatic brain injury, neurosurgical intervention for brain tumors) with more than a -weeks stay in icu. dynamic measurements of the muscle properties were taken on the deltoideus, brachioradialis, quadriceps femoris, gastrocnemius using the myo-tonpro. to identify the leading factor in impaired muscle tone also were measured neurological (s , nse), inflammatory (il- ), bacterial load (pct) biomarkers using elecsys immunoassay and the serum level of microbial metabolites using gc-ms (thermo scientific). results: all patients were divided into groups depending on positive and negative clinical dynamics. significant differences were obtained in parameters characterizing changes in muscle tone of lower limbs -f gastrocnemius (tone) - . vs . hz, r quadriceps femoris (the mechanical stress relaxation time) - . vs . ms (p < . , respectively). some significant correlations between five parameters of muscle tone biomarkers and microbial metabolites were revealed. the results of a quantitative measurement of muscle tone objectively reflect the dynamics of neurological status, which in the future may be promising technique for the personalized approach cci in patients. introduction: changes in hormonal status in patients with unresponsive wakefulness syndrome (uws) remains poorly understood. methods: patients in uws were examined at the period from to . patients ( men) with tbi and patients ( men) after hypoxia. acth, cortisol, tsh, free t and t , sth, prolactin and natriuretic peptide were studied in the period from to months uws. in men, the level of total testosterone, lh and fsh was additionally studied. the obtained data was compared with the uws outcome in - months (crs-r scale assessment). none of the studied hormones of the hypothalamic-pituitary-adrenal axis were a reliable criterion for predicting the outcome of uws. most often and consistently was revealed a tendency of disrupt the rhythm of cortisol secretion, with higher rates in the evening hours. the average value of sth was higher in men with the consequences of head injury who had recovered consciousness than in those who remained in uws. significant decrease in testosterone levels, regardless of age, was found in patients with a consequence of tbi. mean levels of lh were higher in patients with tbi and hypoxia who remained unconscious than in patients who later restored consciousness. the average level of fsh was higher in patients who had recovered consciousness . the increase of natriuretic peptide level was observed both in patients who remained in chronic uws and in those who restored consciousness. no certain endocrine background, characterising this category of patients was found. violations of some hormones secretion rhythms, in particular, cortisol can be considered usual for uws patients, especially in patients with tbi. therapeutic hypothermia has not been used before our research in chronically critically ill (cci) patients. temperature decrease in neuronal cells is a strong signal that triggers endogenic cytoprotection programs using early response genes expression. our goal is to determine influences of craniocerebral hypothermia (cch) on level of consciousness in cci patients. we examined patients with different types of brain injuries. males and females, mean age . ± . . patients were divided into groups: main group - patients (vegetative state (vs) - , minimally conscious state (mcs) - ), comparison group - patient (vs - , mcs - ), groups were equal on main parameters (severity, functional state, comorbidity). patients from main group received courses of cch, duration - minutes, scalp temperature - °С, cerebral cortex cooling up to - o c, session end was without slow reheating period, and session's amount was set -until signs of consciousness recovery. cortex temperature check done noninvasively by using detection of brain tissue emi in shf-range. consciousness recovery in vs and mcs patients controlled using crs-r scale. results: cch sessions significantly increased level of consciousness in vs and mcs patient groups. in vs patients vegetative state increased until minimally conscious state and mcs +, and in mcs group until lucid consciousness (p < . ) (figure ). craniocerebral hypothermia is used in chronically critically ill patients for the first time. our research results demonstrated effectiveness of cch as an additive treatment tool in such patients. this let us optimistically determine the perspective of inclusion of cch method in chronically critically ill patient's rehabilitation to increase level of consciousness. despite the clinical benefit of endovascular treatment (evt) for large vessel occlusion (lvo) in ischemic stroke, space-occupying brain edema (be) represents a common complication during the course of disease. routinely, ct imaging is used for monitoring of these patients, notably in the critical care setting, yet novel and easy bed-side techniques with the potential to reliably predict be without repetitive imaging would be valuable for a time and cost effective patient care. we assessed the significance of automated pupillometry for the identification of be patients after lvo-evt. we enrolled patients admitted to our neurocritical-care unit who received evt after anterior circulation large vessel occlusion. we monitored parameters of pupillary reactivity [light-reflex latency (lat; s), constriction and re-dilation velocities (cv, dv; mm/s), and percentage change of apertures (per-change; %)] using a portable pupilometer (neuroptics®) up to every minutes during the first hours of icu stay. be was defined as midline-shift ≥ mm on followup imaging within - days after evt. we assessed differences in pupillary reactivity between patients with and without be (u-test) and evaluated prognostic performance of pupillometry for development of be (roc analysis). in patients ( women, . ± . years) without be, , assessments were compared to assessments in patients ( women, . ± . years) with be. on day , day , and day after evt, patients with be had significantly lower cvs and dvs, and smaller perchanges than patients without be, whereas lat did not differ between both groups. roc-analyses revealed a significant negative association of cv, dv, and per-change with development of be. conclusions: automated pupillometry seems to identify patients at risk for be after evt. a prospective study should validate whether automated pupillometry harbors the potential to reduce unnecessary follow-up ct imaging. the aim of this preliminary analysis is to detect differences between the qualitative and quantitative evaluation of the pupillary function carried out by doctors and nurses of an intensive care unit (icu) of a tertiary level hospital. secondary purpose is to investigate new indications for the use of pupillometry in a population admitted in icu methods: the study has been conducted (currently in progress) at the intensive care unit and ecmo referral center at careggi teaching hospital (florence; italy). the enrolled patients are adult subjects (> years) with alteration of consciousness defined by a glasgow coma scale (gcs) < , following a primary brain injury and/or the use of sedative drugs. the studied parameters, obtained with neurolight pupillometer ® (id-med, marseille, france) are analyzed, integrated and visual/qualitative evaluation of the pupil function shows a lower reliability if compared to automated pupillometry. the estimated error in the proper determination of photomotor reflex is . % (p< . ). no significant difference is reported between quantitative and qualitative pupillometry in the detection of anisocoria. our preliminary results are compatible with previously reported data [ ] [ ] [ ] , even if there was no difference in anisocoria determination. interestingly, a longer latency period among patients treated with opioids has been observed. other results are still in progress. introduction: due to the dynamic of critical care disease, a rapid bedside, noninvasive and highly sensitive and specific method is required for diagnosis. in this study we set out our experience with trancranial color-coded duplex ultrasound (dxt) [ ] . the dxt study identifies cerebral arteries as well as hemorrhagic phenomenon, hydrocephalus, mass-occupying lesions and midline shift. this is the main difference between dxt and conventional transcranial doppler (dtc) which is a blind study and do not provide any image. descriptive, cross-sectional and observational study from december to june . patients were included. inclusion criteria: neurocritical patients. exclusion criteria: no acoustic window, presence of ultrasound artifacts. data collection was performed. it was used a lowfrequency transducer from . - . mhz with trancranial duplex preset ( figure) . the patterns were defined as normal, vasospasm, high resistance, hypermedia and cerebral circulatory arrest, depending on the cerebral flow velocity, lindegaard ratio (lr) and pulsatility index (ip). results: men ( . %) and women ( . %). average age . ( - ). patients diseases: subarachnoid hemorrhage , traumatic brain injury , av malformation , stroke , hemorrhagic cerebrovascular accident and mass occupying lesions . normal pattern: patients (rel. freq . ). vasospasm: patients (rel. freq . ). high resistance: patients (rel. freq . ). hyperemia: patient (real. freq . ). cerebral circulatory arrest: patient (rel. freq . ) conclusions: dxt should be part of the routine of neuromonitoring, it allows real time images especially useful in unstable conditions. although it will be needed a large amount of patients to be statistical significant, dxt is useful considering a non invasive study, bedside and it allows early identification of different clinic conditions. introduction: embolization of the draining vein during endovascular treatment of arteriovenous malformation (avm) may result in venous outflow obstruction and hemorrhage. anaesthesiologist can use deliberate hypotension to reduce blood flow through avm which may be somehow helpful to prevent this scenario. adenosine-induced cardiac arrest may facilitate the embolization too. the goal of our study was to improve the results of endovascular treatment of avm using adenosine-induced cardiac arrest. methods: after obtaining informed consent patients ( male, female) were selected for adenosine-induced cardiac arrest during endovascular avm embolization. main age was , ± years old. of them were evaluated as iii class asa, as iv. endovascular treatment in all cases was performed under general anaesthesia. propofol, fentanyl, rocuronium were used to induce anaesthesia, then all the patients were intubated and ventilated with parameters to keep etco - mm hg. sevoflurane , - , vol% ( cases) or desflurane vol% ( case) were used to maintain anaesthesia. hemodynamic monitoring consisted of ecg, pulsoximetry, non-invasive blood pressure measurement. onyx or/and squid were used as embolic agents. ct was performed to every patient just after procedure as well as neurological examination. results: adenosine dosage was . - . mg/kg. time of consequent cardiac arrest was - sec. there were cases we administered adenosine for time, in one case we had to administer it twice, in one fig. (abstract p ) . circle of willis and pulsed-wave doppler mode of middle cerebral artery - times and times in one more case as well. hemodynamic parameters recovered without any particular treatment in all the patients. embolization has been performed in all the cases uneventfully. postoperative ct showed no hemorrhage. nobody from investigated group had neurological deterioration in postoperative period. our study shows that adenosine-indused cardiac arrest is not very difficult to perform method and it can be useful during avm embolization. a major risk factor for stroke is atrial fibrillation (af). to treat af anticoagulation is needed. there are now several anticoagulants available. however, a lack of head to head data as well as the absence of accurate techniques makes it difficult to compare them and measure determine there efficacy. stroke is known to produce an abnormal clot microstructure which is a common factor in many thrombotic diseases. this pilot study aims to use a functional biomarker of clot microstructure (d f ) and clotting time (tgp) to investigate the therapeutic effects of different anticoagulants in stroke and af. we recruited patients ( af and stroke & af). two samples of blood were taken: before anticoagulation (baseline) and post anticoagulation ( - weeks) . patients were either given warfarin ( %) or axipaban ( %). d f and tgp were measured and compared before and after anticoagulation. results: warfarin increased t gp ( ± secs to ± secs (p< . )), and decreased d f ( . ± . to . ± . (p< . )). apixaban increased tgp ( ± sec to ± sec (p< . )) but did not change df ( . ± . & . ± . ). interestingly we found that in the apixaban group tgp significantly correlated (p= . ) with blood drug concentration levels. in this study we show that d f and tgp can quantify and differentiate between the therapeutic effects of two different oral anticoagulants. showing that warfarin prolongs clotting and weakens the ability of the blood to form stable clots. conversely apixaban prolongs clotting time but does not affect the bloods ability to form stable clots. this shows the utility of the d f and tgp biomarkers in comparing two different treatment options, something no other current marker has proven able to do. where d f and tgp may prove useful tools in a personalized approach to anticoagulation treatment and monitoring in an acute setting. hospital mortality compared to the model with the original hairscore. patients with poor-grade aneurysm subarachnoid hemorrhage (asah) world federation of neurological surgeons (wfns) grades iv and v, have commonly been considered to have a poor prognosis ( - % mortality). though early intervention and aggressive treatment in neuroicu has improved outcome in the past years, it is controversial because most of the patients left hospital severely disabled. the objective of this study was to investigate the clinical and social outcomes in intracranial aneurysm patients with poor-grade asah underwent different intervention therapies. a single center observational registry of poor-grade asah consecutive patients, defined as wfns grades iv and v, treated at tertiary chilean referral center from december to march were enrolled in this study. the clinical data including patient characteristics on admission and during treatment course, treatment modality, aneurysm size and location, radiologic features, signs of cerebral herniation (dilated pupils), and functional neurologic outcome were collected. clinical outcomes were assessed via gose and and sociooccupational outcome, both at discharge and at months. figure ). % mortality is less than previously reported, and survivors had a favorable recovery, confirmed with neuro psychological test. poor-grade asah patients in our study shows a more positive outcome than previously considered. prognosis of subarachnoid hemorrhage (sah) is scarce, indeed almost half patients die or become severely disable after sah. outcome is related to the severity of the initial bleeding and delayed cerebral infarction (dci). infection and more precisely pneumonia have been associated with poor outcome in sah. however, the interaction between the two pathologic events remains unclear. therefore, we hypothesized that dci may be associated to pneumonia in sah patients. thus the aim of our study was to analyze the association between delayed cerebral infarction and pneumonia in patients with sah. in this retrospective, observational, monocentric cohort study, patients included in the analysis were admitted in neurosurgical intensive care unit or surgical intensive care unit in the university hospital of brest (france) for non-traumatic sah. primary outcome was diagnosis of dci on ct scan or mri months after sah. multivariate analysis was used to identify factors independently associated with dci. a total of patients were included in the analysis (female male ratio / , median age [ - ] years). multivariate analysis was adjusted on sedation, intracranial surgery, fisher classification of sah severity, pneumonia occurrence and non-pneumonia infectious event occurrence ( figure ). pneumonia occurred in patients ( . %) and other causes of infections in patients ( . %). dci was found in patients ( . %). factors independently associated with dci were pneumonia (or . [ . - . ]; p= . ) and non-pneumonia infectious events (or . [ . - . ]; p= . ). interestingly severity table (abstract p ). correlation of safety and efficacy markers of thrombolysis and thrombolysis time with distance from stroke centre results expressed as odds ratio with % confidence interval of initial bleeding evaluated by fisher scale was not independently associated with dci. dci is independently associated with the occurrence of pneumonia or other cause of sepsis. those results may highlight the need for rigorous approach for prevention protocol, early diagnosis and treatment of hospital acquired infectious diseases in sah patients. introduction: traumatic brain injury (tbi) can have devastating neurological, psychological and social sequelae. increased psychiatric morbidity after tbi has been shown in both adult and the pediatric population. also, critical illness as such is a risk factor for psychiatric problems in youth. our aim was to assess risk factors for later being prescribed psychiatric medication in survivors of intensive care unit (icu)-treated pediatric tbi. we used the finnish intensive care consortium (ficc) database to identify patients - years of age, treated for tbi in four icu in finland during the years - . we examined electronic health records and ct scans and collected data on drug prescription after discharge. we used multivariable logistic regression models to find statistically significant risk factors for psychiatric drug reimbursement. we identified patients of which patients received psychiatric drug prescription ( %) during follow up. the median time to prescription was months after tbi (interquartile range [iqr] - months). patients received antidepressants, received stimulants and received antipsychotics. increasing age showed a positive association with all drug prescriptions except for stimulants, where an inverse relationship was observed (table ) . using multivariable analyses, we could not find any admission or treatment related factors that significantly associated with being prescribed psychiatric medications. teenage survivors with moderate disability (glasgow outcome scale [gos] ) showed high numbers of psychotropic drug utilization ( % received any medication, % received antidepressants, % received antipsychotics). our data suggests, that the risk of psychotropic drug prescription after tbi depends on factors other than those related to injury severity or treatment measures. the incidence of drug prescription is especially high in patients with moderate disability. the effects of -adamantylethyloxy- -morpholino- -propanol hydrochloride on the formation of steroid neurotoxicity in rats with brain injury a. semenenko , s. semenenko , a. solomonchuk , n. semenenko depending on the nature of the brain injury and the severity of the victims, mortality in traumatic brain injury (tbi) ranges from to % [ ] . one of the targets for pathogenetic influence on the course of tbi is the use of pharmacological agents that are able to counteract the negative effects of excess concentrations of glucocorticoids on brain. the therapeutic effect of new pharmacological derivative adamantylethyloxy- -morpholino- -propanol hydrochloride (ademol) in rats with tbi was evaluated for days. the pseudoperated animals and control group received . % nacl solution and the comparison group received amantadine sulfate. cortisol levels were used to determine the efficacy of the test drugs in tbi. in rats treated with ademol, the level of cortisol in the blood ranged from to ng/ml (p -p ) and was . -fold lower (p< . ) compared to control pathology group on the day of therapy. instead, the effect of amantadine sulfate on the level of cortisol in the blood was significantly less than that of ademol. the concentration of cortisol in rats with amantadine sulfate in the blood ranged from - ng/ml (p -p ), was . times lower (p< . ), compared with the control pathology group, and by . % (p< . ) exceeded the corresponding value in animals treated with ademol. therapeutic treatment of rats with severe tbi with a solution of ademol, preferably better than rats in the group with . % nacl and amantadine sulfate protect the brain from the formation of steroid neurotoxicity by cortisol (p< . ). although cerebrovascular pressure reactivity (prx) well correlate to patient's outcome [ ] , it requires continuous monitoring and mobile average calculation for its determination. we therefore hypothesized that a simplified model of variation between mean arterial pressure (map) and intracranial pressure icp over the first three days of admission would have been able to predict patient outcome: we call this new parameter cerebrovascular pressure correlation index (cpc). we performed a retrospective observational study of all adult patients with severe tbi admitted to icu from january to april inclusive. all consecutive patients with a clinical need for icp monitoring were included for analysis. both for icp and map data were mean value over -hours registration, for a total of observations/day, cpc was therefore calculated as the pearson correlation coefficient between icp values (x axis) and map values (y axis), obtaining one single value every hours. variables included in the model (i.e. cpc, cpp, icp, systemic glucose, arterial lactate, paco , icp, and internal body temperature) were collected for the first days since trauma. for the main outcome only the minimum value of cpc fit the regression analysis (p = . ). the correspondent roc curve showed an auc of . . the associated youden criterion was ≤ . (sensitivity = . ; specificity = . ). of all the variables considered for the secondary outcome only cpcmin fit the regression model (p = . ). table reports the median and iqr range for sg and nsg of all the variables considered in the model. this observational study suggests that cpc could be a simplified model of variation between map and intracranial pressure icp over the first three days of admission predicting patient outcome. introduction: impaired cerebrovascular reactivity (car) after traumatic brain injury (tbi) is a marker for disease severity and poor outcome. it is unclear how dynamic changes in body temperature and fever impact car and outcome. we calculated the pressure reactivity index (prx) using the center-tbi high-resolution intensive care unit cohort, as a moving correlation coefficient between intracranial pressure (icp) and mean arterial pressure (map). minute and hourly values of prx and temperature were averaged in patients with simultaneous recording of icp and abp. demographic data was based the core registry (v . ). linear mixed models were calculated based on minute-by-minute data using r with lme v . - and ggeffects v . . . generalized estimating equation models were used to analyze changes during effervescence (increase of temperature of > °c within hours). we assessed high frequency physiological data during days of patients admitted to the icu with predominantly a closed injury type (n= / ). median age was years (iqr - ), baseline gcs was (iqr - ), and % had at least one unreactive pupil. the main measurement site for temperature was the urinary bladder / ( %). half of the patients ( / ) developed fever(> h with mean t ≥ . °c) with a total of h fever and a median of h fever(iqr - ) per patient. of effervescence episodes ( %) reached the febrile threshold of . °c which was associated with an increase in prx from . (±sd . ) at baseline ( h before) to . (±sd . ) during the febrile peak (p= . ) (figure -a) . linear mixed models showed a quadratic relationship between prx and temperature (p< . ) with an increase in predicted prx with febrile and hypothermic temperatures ( figure b ). the association of increasing body temperature with worsening of car supports prevention of fever in severe tbi. prospective studies are needed to further differentiate between mechanisms involved (i.e. inflammation) and central autonomic dysregulation. fig. (abstract p ) . the patients with a good -month outcome (gose> ) after severe traumatic brain injury showed an increase in root mean square of successive differences between normal heartbeats (rmssd) (compared to baseline -minutes before tracheal succtioning) acute kidney injury (aki) is relatively common in patients with severe traumatic brain injury (stbi) and it can contribute to morbidity and mortality [ ] . nephrocheck is a point-of-care urine test that flags two biomarkers that indicate if a critically ill patient is at risk for aki. we investigated the incidence of subclinical aki in patients with stbi. we performed a prospective observational study of all adult patients with severe tbi admitted to icu from january to april inclusive. all consecutive patients with a clinical need for icp monitoring were included for analysis. urine samples of severe tbi patients was collected at icu admission from patients to measure nephrocheck (nc) test [igfbp ] x was performed using the nephrocheck® astute ™ meter. serum creatinine was collected at admission, during the first three days, at icu dismission and -days follow up to assess renal recovery. the diagnosis of aki was based on kdigo criteria. hemodynamics, electrolytes, peep, p/f, kind of fluid administered, fluid balance, % fluid overload, length of stay, the sequential organ failure assessment score, injury severity scores and mortality were collected. a total of patients ( %) presented a median nc higher values at icu admission. one patient with positive nc value experienced aki at hrs. the positive nc group had more plasma transfusion (p-value . ) and a lower median hematocrit at hrs (p-value . ), but similar hospital length of stay (p= . ) and mortality rate (p= . ) conclusions: nc at icu admission identifies subclinical aki in tbi patients and it maight be used to predictclinical aki. hemodilution (but not fluid overload) seems to be associated with development of subclinical aki. higher nc at icu admission is not associated with worst longterm outcome in tbi patients. severe traumatic brain injury (tbi) is considered a serious public health problem in europe. partly because of the heterogeneity of tbi, considerable uncertainty may exist in the expected outcome of patients. the international mission for prognosis and analysis of clinical trials in tbi (impact) and the corticosteroid randomization after significant head injury (crash) prediction models are considered the most widely validated prognostic models [ , ] . however, studies using these prediction models for benchmarking of outcomes have been scarce. we aimed to compare actual outcomes in a tbi cohort of critically ill tbi patients with predicted outcomes in a quality of care initiative in an academic hospital. in this retrospective cohort study, we included consecutively admitted tbi patients to the icu adults of erasmus mc, university medical center, rotterdam, the netherlands between january and february . we included patients with tbi. -day mortality was %, sixmonth mortality was % and six-month unfavourable outcome was %. the impact core+ct+lab model predicted % -month mortality (vs % actual, p= . ) and % unfavourable outcome (vs % actual, p= . ). the -day mortality prediction by crash prognosis calculator was % versus actual -day mortality of only % (p= . ), whereas -month unfavourable outcome prediction by crash was % (vs. % actual, p= . ) ( figure ). the impact model, although developed more than a decade ago, seemed appropriate for benchmarking purposes in this single center cohort in the netherlands, while crash predictions were less applicable to our setting. introduction: out of hospital cardiac arrest (ohca) continues to be associated with significant mortality and morbidity. centralisation of care has considerably improved patient survival but has resulted in increased morbidity in the form of neurological deficit. accurate neurological prognostication remains challenging incorporating repeated clinical examination and ancillary investigations [ , ] . data was collected retrospectively and analysed for patients admitted post ohca from october to october . patient arrest demographics were collected in conjunction with extensive inpatient investigation findings including ct, traditional pupil assessment, pupillometry and eeg. results: % of patients survived to hospital discharge. patients presenting in a shockable rhythm continue to have higher survival rates ( table ) . % of patients who received immediate cpr survived to hospital discharge in comparison to % of patients who did not receive immediate cpr. % of patients underwent non-contrast ct head. % of patients had traditional pupillary examination performed on arrival. pupillometry was introduced in december ; out of a possible patients had pupillometry during their inpatient stay. eeg was undertaken in % of cases. our data shows receiving immediate cpr and presenting with a shockable rhythm remain positive prognostic factors. ct head as a stand-alone prognostic modality is unreliable with % of patients who survived to discharge, with intact neurology, had an admission ct head reported as hypoxic brain injury. a new neuroprognostic strategy is required in our unit that adds further certainty to likely clinical outcome. this includes increased use of tests such as eeg and pupillometry and the introduction of biomarkers such as neuron specific enolase, somatosensory evoked potential testing and magnetic resonance imaging. introduction: post-resuscitation care of patients following an out-of-hospital cardiac arrest (oohca) is set out by the uk resuscitation council [ ] . this is in line with the european resuscitation council guideline [ ] . the aim of this audit was to review compliancy to this guideline at the intensive care unit at the bristol royal infirmary . a retrospective audit was performed over a six-month period in adults who were admitted to the intensive care unit at the bri following an oohca whom later died during that admission ( patients). the focus was on whether the neuroprognostication and end-of-life (eol) care received was as per the standards set by the uk resuscitation council. the main neuroloical examinations documented were pupillary reflex ( %), corneal reflex ( %) and motor response to pain ( %). . % of patients received an ssep analysis > hours post-rosc, . % underwent an eeg and . % had > serum neuron-specific enolase measurements recorded. all patients ( %) underwent a ct head during their admission. . % of patients were referred to palliative care during their admission. % of patients were prescribed all eol medications. most common prescriptions included alfentanil ( . %) and midazolam ( . %). finally, % of appropriate patients were referred to be potential organ donors. the audit reflected our local practice and that some parameters were not being maintained as set by uk resuscitation guideline. multiple introduction: the prognostication of neurological outcome in comatose out-ofhospital cardiac arrest (ohca) patients is an integral part of post cardiac arrest care. biochemical biomarkers released from cerebral cells after hypoxic-ischemic injury represent potential tools to increase accuracy in predicting outcome after ohca. currently, only neuronspecific enolase (nse) is recommended in european prognostication guidelines. in this study, we present the release dynamics of gfap and uch-l after ohca and evaluate their prognostic performance for long-term neurological outcome in ohca patients. serum gfap and uch-l were collected at , and h after ohca. the primary outcome was neurological function at -month follow-up assessed by cerebral performance category scale (cpc), dichotomized into good (cpc - ) and poor (cpc [ ] [ ] [ ] . outcome prognostic performance was investigated with receiver operating characteristics (roc) by calculating the area under the receiver operating curve (auroc) and compared to nse. results: of included patients had at least one serum gfap or uch-l value at , or h after ohca. gfap and uch-l levels were significantly elevated in patients with poor outcome. gfap and uch-l discriminated excellently between good and poor neurological outcome at all time-points (auroc gfap . - . ; uch-l . - . ) and overall predictive performance measured by auroc of gfap and uch-l was superior to nse (auroc . - . ) ( figure ). however, the roc at the highest specificities of uch-l and gfap overlap those of nse and comparing the sensitivities for uch-l and gfap with those of nse for the highest specificities (> %) revealed higher sensitivities for nse than for uch-l and gfap at and h. gfap and uch-l predict poor neurological outcome in patients after ohca excellently and with a higher overall accuracy than nse, but both biomarkers perform inferior to nse at specificities over % at and h limiting their clinical use to guide decisions on prognosis. blood pressure after cardiac arrest and severity of hypoxicischemic encephalopathy c endisch , s preuß , c storm introduction: blood pressure management in post cardiac arrest (ca) patients ensures sufficient cerebral perfusion to avoid secondary brain injury. in local chain-of-survival improvements affect p-ohca survival [ ] [ ] [ ] [ ] [ ] . also initial rhythm in p-ohca is an important predictor of survival [ , ] . little is known about the relationship between initial rhythm in p-ohca and long-term outcome [ ] [ ] [ ] . our aim was to establish the relation between shockable rhythm and favorable long-term outcome in pohca. all children aged day- years who experienced non-traumatic ohca between - and were admitted to the sophia children's hospital in rotterdam were included. long-term outcome was determined using a pediatric cerebral performance category score at the longest available follow-up interval. the primary outcome measure was survival with favorable neurologic outcome, defined as pcpc - or no difference between pre-and postarrest pcpc. the association between shockable rhythm and the primary outcome measure was calculated in a multivariable regression model, adjusted for the pre-defined variables. from the patients included in the year study period ( %) patients survived to hospital discharge of which patients ( %) had favorable neurologic outcome (median follow-up duration of months). the rate of favorable neurologic outcome rose from % in to % in (p < . for trend) (fig. ) the odds of favorable neurologic outcome at the longest follow-up duration were significantly higher after a shockable initial and unknown rhythm. secondly, trend analysis showed an increase in aed defibrillation and shorter cpr duration. this was followed, finally, by a rise in rosc, survival to hospital discharge and favorable neurologic outcome rate. low socioeconomic status is associated with worse outcome after cardiac arrest. this study aims to investigate if patients´socioeconomic status impacts the chance to receive early coronary angiography after cardiac arrest. in this nationwide retrospective cohort study, patients admitted alive after out-of-hospital cardiac arrest (ohca) and registered in the swedish registry for cardiopulmonary resuscitation were included. individual data on income and educational level, prehospital parameters, coronary angiography results and comorbidity were linked from other national registers. in the unadjusted model there was a strong correlation between income level and rate of early coronary angiography where % of patients in the highest income quartile received early angiography compared to % in the lowest income quartile. when adjusting for confounders (educational level, sex, age, comorbidity and hospital type) there were still higher chance of receiving early coronary angiography with increasing income, or . (ci . - . ) and . (ci . - . ) for the two highest income quartiles respectively compared to the lowest income quartile. when adding potential mediators to the model (initial rhythm, location, response time, bystander cardiopulmonary resuscitation and if the arrest was witnessed) no difference in early angiography related to income level where found. the main mediator was initial rhythm (figure ). higher income is strongly related to the rate of early coronary angiography after ohca. this finding is consistent when adjusting for known confounders. however, the association between income and early angiography seems to be mediated by initial rhythm. patients with low income more often presents with non-shockable rhythms which lowers the likelihood to undergo early coronary angiography. a. the total amount of mortality as a stacked bar: in light-red the number of patients who deceased at scene, in green the number of patients deceased during admission, in red patients who died after discharge. the grey line is the total number of inclusions. b. the rate of bystander aed use, rate of initial shockable rhythm, rate of less than minutes of cpr and rate of favorable neurologic outcome over time. p for trend significant for bystander aed use, less than minutes of cpr and favorable neurologic outcome. trend analysis performed using binary logistic regression for dichotomous data (and a kruskal-wallis test for non-normally distributed continuous data) effect of simulation teaching of cardiopulmonary resuscitation for nursing v spatenkova introduction: simulation teaching is a modern type of critical care (cc) education. the aim of this study was to assess the effect of simulation teaching of cc on a comparison of final examination in different model levels of cardiopulmonary resuscitation (cpr) after the first (cc ) and third, final cc . the success rate of cpr was tested in prospective study ( ) ( ) on two groups with a total of students in cc and cc at the faculty of health studies. three semester of undergraduate nursing simulation education (lectures and training) used the laerdal simman g. quality of cpr was evaluated according to parameters: compression depth, compression rate, chest release and time of correct frequency. we tested if cpr quality differed between the two groups. for the compression depth and compression rate parameters, first the conformity of variance was verified and then two-sample t-test. as the chest release and time of correct frequency are recorded as percentages, the wilcoxon rank-sum test was conducted for these parameters. to ensure good resuscitation, all recorded parameters must be properly performed during resuscitation. thus, pivot tables were used to generate statistics and test if the number of correctly performed resuscitation parameters for cc and cc differ. the compression depth parameter was statistically significantly higher for the cc than for the cc (p= . ). there were no differences in compression rate (p= . ), chest release (p= . ) and time of correct frequency (p= . ). it was also tested how many of the parameters were performed correctly by students at cpr. the chi-square test shows the relative frequency of cpr success is higher for the cc group than for the cc group. at least out of parameters were correctly performed by % of cc students compared to % of cc students. the study showed a significant improvement of cpr in the final cc and supported the three semester simulation education. changes in blood gases during intraoperative cardiac arrest jj wang, r borgstedt, s rehberg, g jansen protestant hospital of the bethel foundation, anaesthesiology, intensive care and emergency medicine, transfusion medicine and pain therapy, bielefeld, germany critical care , (suppl ):p introduction: blood gas analysis (bga) is a common approach for monitoring the homeostasis during surgery. while it is well known that cardiac arrest (ca) leads to circulatory collapse and disturbances in homeostasis, little is known about changes of blood gas during peri-operative ca. we retrospectively analysed patients ≥ years who suffered from peri-operative ca during non-cardiac surgery from / to / . peri-operative ca was defined as need for cardiac compression during anaesthesia care. collected data included ph, paco , pao , return of spontaneous circulation (rosc) and -day mortality after ca. within the study period, we observed peri-operative ca (m= , f= ; age ± ) during anaesthesia procedures (rosc occurred in patients ( %). days after ca, the mortality was % (n= ), % (n= ) were discharged, and % (n= ) still in hospital. % (n= ) of ca patients had an invasive blood pressure monitoring, % (n= ) had bga before and % (n= ) during peri-operative ca. prior to ca, the average values were: ph . ± . , paco ± and pao ± . during ca, the average values were ph . ± . , paco ± and pao ± . table shows the distributions of blood gas before and during ca. there were no statistical differences between the groups (ph: p= . ; paco : p= . ; pao : p= . ). hypercapnia and respiratory acidosis is common in peri-operative ca. these data suggests inadequate ventilation during peri-operative resuscitation. further studies should focus on its impact on the outcome. ]. comparing cases with and without rosc, there were significant more diagnostics done in the group without rosc but more therapeutic consequences seen in the rosc-group (table ) . icu-ca is frequent. diagnostics to detect reversible causes of ca were used rarely in icu-ca ( %), even in patients without rosc. notably, diagnostics often had therapeutic consequences particularly in rosc. further studies are required to define standardized diagnostic algorithms during icu-ca. continuous monitoring of cardiac patients on general ward were improved short term survival of in-hospital cardiac arrest uj go introduction: the importance of early detection in the in-hospital cardiac arrest (ihca) is emphasized. previous studies have reported that clinical outcomes are improved if ihca is witnessed, or if a patient admitted to a monitored location [ , ] . this study aimed to evaluate the association between continuous monitoring and survival of ihca on general ward. a retrospective cohort study of ihca in patients admitted to ward at an academic tertiary care hospital between january and december was performed. the primary outcome was return of spontaneous circulation (rosc). the secondary outcomes were hour survival and survival to hospital discharge. (table ) . cardiac patients with continuous monitoring on general ward showed improving rosc and -hour survival but not survival to hospital discharge in ihca. in-hospital cardiac arrest is associated with poor outcomes. although steroids are frequently used in patients with septic shock, it is unclear whether they are beneficial during cardiac arrest and after return of spontaneous circulation (rosc). of cardiac arrest patients evaluated, were enrolled. advanced life support was conducted according to the resuscitation guidelines. forty-six patients were randomly assigned to receive methylprednisolone mg during resuscitation, and to receive saline (placebo). after resuscitation, steroid-treated patients received hydrocortisone mg daily for up to days, followed by tapering . there was no significant difference between the two groups in scvo andall the secondary outcomes (p> . for all comparisons). the present study found no significant physiologic benefit of corticosteroid administration during and after resuscitation in hospitalized patients with cardiac arrest. the experiences of ems providers taking part in a large randomized trial of airway management during out of hospital cardiac arrest, and the impact on their views and practice. results of a survey and telephone interviews m thomas introduction: the aim is to explore ems experiences of participating in a large trial of airway management during out-of-hospital cardiac arrest (air-ways- ), specifically to explore: . any changes in views and practice as a result of trial participation. . experiences of trial training. . experiences of enrolling critically unwell patients without consent. . barriers and facilitators for out-of-hospital trial participation. an online questionnaire was distributed to ems providers who participated in the trial. in-depth telephone interviews explored the responses to the online questionnaire. quantitative data were collated and presented using simple descriptive statistics. qualitative data collected during the online survey were analysed using content analysis. an interpretive phenomenological analysis approach was used for analysis of qualitative interview data results: responses to the online questionnaire were received from % of airways- study paramedics and study paramedics were interviewed. paramedics described barriers and facilitators to trial participation and changes in their views and practice. the results are presented in five distinct themes: research process; changes in views and practice regardingairway management; engagement with research; professional identity; professional competence. conclusions: participation in the airways- trial was enjoyable and ems providers valued the training and study support. there was enhanced confidence in airway management as a result of taking part in the trial. study paramedics expressed preference for the method of airway management to which they had been randomized. there was support for the stepwise approach to airway management, but also concern regarding the potential to lose tracheal intubation from 'standard' paramedic practice. causes of medical care-associated cardiac arrest on the intensive care unit s entz introduction: cardiac arrest on intensive care unit (icuca) following therapeutic interventions is of imminent importance, because the interventions are comparatively predictable and precautions can potentially be taken. this study investigates medical care associated complications that led to icuca. intensive care database was screened for patients ≥ years who experienced icuca in a tertiary hospital with five icu (two medical, two surgical, one interdisciplinary, with a sum of icu beds) in germany from - . icuca was defined as receiving chest compression and/or defibrillation after admission on icu and classified as "medical care associated" if it was preceded by a therapeutic intervention (i.e. induced by medication, bedding procedures, iatrogenic injuries, procedure associated). subgroups included patients with recurrence of spontaneous circulation (rosc) vs. no-rosc and patients with vs. without vasopressor therapy before intervention. there were icuca in patients of totally , icu patients. medical care associated complications leading to icuca were detected in cases ( %) [incidence . / , (ci . - . )]. icuca following therapeutic interventions occurred because of circulatory insufficiency [n= ( %)], respiratory failure [n= ( %)] and airway associated problems [n= ( %)]. nine of the patients ( %) with care-associated icuca died. table demonstrates therapeutic interventions followed by icuca. care-associated complications were common reasons for icuca. most of events were induced by circulatory insufficiency due to induction of anaesthesia and bedding procedures. further investigations should focus on preventive strategies, such as vasopressor infusion before therapeutic interventions. in-hospital cardiac arrest (ihca) is a lethal event. however, ihca has received less attention than out-of-hospital cardiac arrest (ohca). there have been some studies on ihca; however, there is a lack of information on the evidence and clinical features of ihca compared with information for ohca. we therefore conducted this study to clarify important aspects of the epidemiology and prognosis of ihca in patients with code blue activation. we carried out a retrospective observational study of patients with code blue events in our hospital during the period from january to october . we obtained information on the characteristics of patients including age and gender, ihca characteristics including the time of cardiac arrest, event being witnessed, presence of bystander cardiopulmonary resuscitation (cpr), initial shockable rhythm, vital signs h or h before cardiac arrest, survival to hospital discharge (shd), and the cardiac arrest survival postresuscitation in-hospital (caspri) score. the primary endpoint was shd. we performed univariate and multivariate logistic regression analyses. a total of code blue events were activated during the study period. finally, patients were included in this study. overall, the shd rate was . %. the median time of cpr was min (interquartile range, - min). the rate of initial shockable rhythm was . %. there were significant differences in cpr duration, shockable rhythm, and caspri score between the shd group and non-shd group by univariate-logistic regression analysis. caspri score was found to be the most effective predictive factor for shd (or= . , p= . ) by multivariate-logistic regression analysis. our results demonstrated that caspri score is associated with shd in cpa patients with in-hospital code blue events. caspri score in ihca patients would be a simple and useful adjunctive tool for management of post-cardiac arrest syndrome (pcas). peri-operative cardiac arrest in prematurityincidence and causes at a tertiary care hospital between - g jansen, j popp, e lang, r borgstedt, b schmidt, s rehberg protestand hospital of the bethel foundation, anaesthesiology, intensive care and emergency medicine, bielefeld, germany critical care , (suppl ):p the peri-operative care of premature pediatric patients requires special expertise and is therefore reserved for specialized centers. although premature birth is described as a risk factor for peri-operative complications and cardiac arrest (poca) there are no data on its incidence and causality in this particular population [ ] . the present study investigates the incidence and causality of pediatric poca at a tertiary care hospital and level i perinatal center in germany. in the anesthesia database of the study center, all anaesthesiological procedures in patients < years of age were examined for poca in preterm infants (gestational age < th week of gestational age) between and . the peri-operative period was defined between the beginning of anesthesiological care up to minutes after anesthesia and/or sedation. we defined cardiac arrest as the necessity of chest compressions. the perioperative phase and the cause of the poca, gestational age and birth weight were recorded. between and , ( . %) of the , pediatric anesthesiological procedures were performed on premature infants. in total, poca occurred in of these patients (f= , m= ; average gestional age ± days; average birth weight ± g (incidence . %, ci . - . %). the time of occurrence and the causes of poca are shown in table . poca in premature babies is rare and has an incidence of . %, which is significantly higher than the non-premature babies. the main causes are problems or complications associated with the respiratory tract and its management, as well as massive hemorrhage. introduction: peri-operative cardiac arrest (poca) in children's anesthesia care is a dreaded event. depending on the country and population, studies describe incidences between . - . per , children's anesthetics. there are no data on the current incidence of pediatric poca in germany. the present study investigates the incidence of poca at a tertiary hospital and level i perinatal center in germany. in the anesthesia database of the study center, all anaesthesiological procedures in patients < years were examined for poca. the peri-operative period was defined between the beginning of anesthesia care up to minutes after anesthesia or sedation. cardiac arrest was defined as the necessity of chest compressions. age, weight, asa status, cause of death and survival after days were recorded. results: poca (median weight was g [q ;q ( )]) were observed in , anaesthesiological procedures (incidence . ± . per , [ci . - . ]). table shows the distribution of the individual age groups, incidences and mortalities of poca. peri-operative -day mortality was per , [ci [ ] [ ] [ ] [ ] [ ] . three children died intraoperatively as a result of hemorrhagic shock, one on the picu as a result of malignant hyperthermia. days after poca, more children had died on the icu due to their underlying disease. poca is a rare event. risk factors are an age < days and an asa status ≥ iii. the main cause of peri-operative death in patients < years of age is massive hemorrhage, the -day mortality is determined by the underlying disease. in-hospital cardiac arrest -predicting adverse outcomes t partington, j borkowski, j gross northwick park hospital, anaesthesia/critical care, london, united kingdom critical care , (suppl ):p introduction: cardiac arrest occurs in . per hospital admissions in the uk. return of spontaneous circulation (rosc) is achieved in approximately half of resuscitation attempts, but rate of survival to hospital discharge is substantially lower [ ] . in our centre, post-arrest care accounts for . % of icu admissions. premorbid social function is purported to affect outcomes, but comorbidity scores are more often used for risk stratification. using a novel social function score alongside an existing comorbidity scale, we aimed to identify trends to inform management of patients at risk of deterioration. a six-month prospective observational study was conducted in a major uk hospital from october to april . for all adult inpatient cardiac arrests, medical notes were reviewed and data collected on the following domains: patient demographics comorbidities and functional status admission details post-arrest events statistical analysis was performed using student's unpaired t-test. results: cardiac arrests occurred. % were in medical patients, with the majority male ( %) and aged over ( %). % were emergency admissions, with mean duration of hospital stay pre-arrest days. in cases ( %) sustained rosc was achieved. however, seven of these ( %) were not subsequently admitted to the icu. only six patients ( %) survived to hospital discharge. pre-admission function and comorbidity were worse in patients who did not survive to discharge ( fig. ), but these were not statistically significant in view of small survivor group size. in an increasingly frail inpatient population, a substantial proportion of patients in whom circulation is restored after cardiac arrest are subsequently considered unsuitable for icu admission. given our understanding of inferior outcomes in patients with poor physiological reserve, we encourage early discussion regarding the appropriateness of cpr in selected patients, guided by social function and comorbidity. references: . national cardiac arrest audit / introduction: there are studies that determine events related to poor outcome in cardiac arrest [ ] . in our study, following parametres were determined ohca patients; age median years, asian/europe/syrian, bystander cpr, bystander aed, ems defibrillation, initial cardiac rhythm, prehospital rosc, corneal and pupillary light reflex and day survival. we determineted poor prognostic sign with post-cardiac arrest patients. in this study, we identified the causes of poor outcome in patients with ohca. this was a single-centre, retrospective study. we determined incidence and epidemiological factors including: demographics, initial cardiac rhythm. our study population were non-traumatic ohca. our icu, all ohca patient were evaluated wtih echo, and fluid, inotrope and vazopressor were added according to cardiac performance. results: during our study, patients who were admitted to intensive care unit between - were screened. of these patients were out-of-hospital arrest and of them were in-hospital arrest. development of cerebral oedema during treatment in hospital remains a poor prognostic sign. the evaluation of initial cardiac ritm is useful to predict neurological outcome in post-cardiac arrest patients. survival after ohca remains low. the evaluation of initial cardiac ritm is useful to predict mortality and neurological outcome in postcardiac arrest patients. basic life support (bls) education and training for school children is active in japan. however, the bls action by schoolchildren may be limited by school rules. this study aimed to analyse the time factors for basic life support performance and outcome in classmatewitnessed out-of-hospital cardiac arrest (ohca) and to investigate how schoolchildren act when they detect ohca. methods: nation-wide database for , school children cases with ohca and local extended database for , ems-unwitnessed ohca, both of which were prospectively collected during the period of - , were retrospectively analysed. proportion of schoolchildren-detected ohca was low in classmate cases ( . %, / ) in nationwide database and extremely low in all ems-unwitnessed ohcas ( . %, / , ) in local database. nationwide database analyses revealed that both emergency call and bystander cpr were delayed when a classmate witnessed the ohca case: median, vs. min and vs. min, respectively. classmate-witnessed cases were associated with higher incidences of shockable initial rhythm, aed use and traumatic causes. the rate of neurologically favourable outcome was . % and . %, respectively in classmate-witnessed and other cases: adjusted or; % ci, . ; . - . . of cases detected by schoolchildren in our prefecture, ( %) cases had presumed cardiac aertiology and ( . %) cases were caused by suicide attempts (hanging and fall). school children placed emergency calls as the first action only in ( . %) cases. emergency calls were largely delayed when school children dialled other numbers or left the scene to seek adult help. school children were rarely involved in bystander cpr ( %) and aed placement ( %). school children are rarely involved in entire bls. emergency calls and bystander cpr are delayed when schoolchildren act to seek help. because schoolchildren detect suicide-related ohcas, psychological care to schoolchildren involved in bls may be necessary. prognostic value of neutrophil/lymphocyte and platelet/ lymphocyte predicting cardiopulmonary resuscitation with spontaneous circulation recovery c li the affiliated suzhou hospital of nanjing medical university, suzhou, china critical care , (suppl ):p to investigate the predictive value of peripheral blood neutrophil-tolymphocyte ratio (nlr) and platelet-to-lymphocyte ratio (plr) on inhospital mortality in patients with spontaneous circulation recovery after cardiac arrest. a retrospective analysis was made of patients who recovered from cardiac arrest in our hospital from april to november and were admitted to the intensive care unit for more than hours. they were divided into survival group and death group according to the outcome of discharge.the dynamic changes and differences of nlr and plr in hours and - hours after admission to icu between the two groups were analyzed and compared. multivariate analysis and roc curve were used to explore the predictive value of nlr and plr for in-patient mortality. compared with the survival group, plr in the dead group was significantly lower within hours of admission to the intensive care department (p < . ), while nlr in - hours was significantly higher (p < . ). the nlr of surviving group was significantly lower than that of hours (p < . ), while the nlr and plr of death group were not significantly different (p < . ) from that of hours (p < . ). multivariate logistic regression analysis and roc curve showed that nlr of - h in icu was an independent risk factor for predicting in-patient mortality, and had high sensitivity and specificity in predicting death outcomes. neutrophil to lymphocyte ratio, platelet to lymphocyte ratio can help to judge the outcome of patients with cardiac arrest and recovery of autonomic circulation after cardiopulmonary resuscitation. [ , ] patients with sofa score > (vs sofa score ≤ ) had a higher free iron level ( . μmol/l vs μmol/l, p = . ) ( figure ). we found a positive correlation between free iron level at h and changes of sofa score between h and h (r= . ic [ . ; . ]). out-of-hospital cardiac arrest is associated with a significant change of plasma free iron level. free iron level at admission is associated with short term outcome. further research is warranted to better determine the significance of such changes. the optimal level of arterial oxygen in the post-resuscitation period is unknown. recent studies show conflicting results in regard to hyperoxia and its association with survival after out-of-hospital cardiac arrest (ohca) [ ] . the aim of this trial is to study the association between early hyperoxia after ohca with return of spontaneous circulation (rosc) and -day survival. observational study using data from three swedish national registers (i.e. intensive care, cardiac arrest and national patient registries after a successful resuscitation, a systemic inflammatory response occurs, and the c-reactive protein (crp) level represents the degree of inflammation [ ] [ ] [ ] . this study examined the association between increased inflammation and early-onset pneumonia (eop) in patients treated with extracorporeal cardiopulmonary resuscitation (ecpr) after out-of-hospital cardiac arrest (ohca). this retrospective study included data of patients with ohca treated with ecpr admitted to st. luke's international hospital between april and april . the exclusion criteria were as follows: age < years, therapeutic hypothermia withdrawal due to death or circulatory failure, or sepsis as a suspected cause of cardiac arrest. patients were diagnosed with eop according to clinical signs and symptoms acquired after a hospitalization period of > h and within days of admission. the crp levels were measured daily from admission to day . we studied patients with a median age of years (interquartile range: - years). furthermore, ( %) patients were males, and the median time interval from collapse to adequate flow was ( - ) min. all patients received prophylactic antibiotics, and ( %) of them had favorable neurological outcomes (cpc, - ). eop occurred in ( %) patients, with a significantly higher crp level on day than that in those without eop ( . categorizing reasons for death after ecpr is important for comparing outcomes to other studies, assessing benefits of interventions, and better define this heterogeneous patient collective. a categorizing for death after cardiac arrest in both in-hospital (ihca) and outof-hospital (ohca) arrests has been proposed in non-ecpr patients by witten et al. here, we adopt this categorization to ecpr patients. single-center, retrospective, cohort study of patients without rosc after ihca or ohca and ecpr between and . patients with survival below hours were excluded. patients were allocated to one of five predefined reasons for death. results: va-ecmo patients were included (age . ± . , . % female, % ecpr, day survival . %). reasons for death for patients with va-ecmo for shock (survival %) and ecpr ( %) were: neurological withdrawal of care ( % vs %), comorbid withdrawal of care ( % vs %), refractory hemodynamic shock ( % vs %), respiratory failure ( % vs %), and withdrawal due to presumed patient will ( % vs %) ( figure ). the differences in reasons for death among the two groups were significant (p < . ), driven by withdrawal due to neuroprognostication, comorbidity and hemodynamic instability. categorizing death after va-ecmo into five categories is feasible. there are significant difference between patients with va-ecmo for shock and ecpr. interestingly, only a quarter of patients after ecpr died due to brain damage. introduction: scarcity of potential dead brain donors and the persistent mismatch between supply and demand of organs for transplantation has led the transplant community to reconsider donation after circulatory death (dcd) as a strategy to increase the donor pool. normothermic regional perfusion (nrp) by extracorporeal membrane oxygenation (ecmo) may be the most effective method for preserving abdominal organs in dcd, especially in liver transplantation [ , ] . a pitfall of this method is its complexity and the unavailability of this resource in some hospitals, especially in regional hospitals, where potential dcd donors may exist. aim of this study is to report the use of mobile ecmo team in controlled dcd. from june to november our group has worked as a mobile ecmo team for cdcd outside our center. portable equipment included cannulation material and the ecmo device. the transplant team consisted of transplant coordinator (anesthesiologist-intensivist, ecmo operator and organ extraction supervisor), cardiac surgeon (cannulation), interventional radiologist (cannulation) and one cardiovascular perfusionist (ecmo operator). twenty-five cdcd donations were performed. characteristics of donors and organs retrieved are summarized in figure . from cdcd, livers, lungs, kidneys were obtained. the evolution of grafts and receptors was favorable at day post-transplant. mobile ecmo teams may enable cdcd in hospitals without these resources, thereby increasing the pool of donors and optimizing graft outcomes. what is the useful coagulation and fibrinolysis marker for predicting extracorporeal membrane oxygenation circuit exchange due to intra-circuit thrombus? y izutani, k hoshino, s morimoto, k muranishi, j maruyama, y irie, y kawano, h ishikura fukuoka university hospital, emergency and critical care center, fukuoka-shi, japan critical care , (suppl ):p a thrombus formation is one of the most frequent and adverse complications during extracorporeal membrane oxygenation (ecmo) support. previous studies have reported that increased d-dimer is a useful predictor of thrombus formation within the ecmo circuit. the purpose of this study was to identify coagulation/fibrinolysis markers for predicting the replacement of ecmo circuit due to intra-circuit thrombus during ecmo support. fourteen patients who underwent veno-venous ecmo for acute respiratory failure between january and december were enrolled. these patients received a total of days of ecmo support. of these, days (times) on which the ecmo circuits were replaced was regarded as the replacement group, while the remaining days were considered as the non-replacement group. the several coagulation/fibrinolysis markers were routinely measured every day during ecmo support. we compared with the levels of these markers between two group to identify the most relevant marker for ecmo circuit replacement due to thrombus. the mean duration of ecmo support was ± days, and the mean number of ecmo circuit replacement was . ± . times per patient. ddimer, thrombin-antithrombin complex (tat), plasmin-α plasmin inhibitor complex (pic), and soluble fibrin (sf) were significantly higher in the replacement group rather than in the non-replacement group (p < . , respectively). according to a multivariate analysis, sf was the only independent predictor of ecmo circuit replacement due to thrombus. the odds ratio ( % confidence intervals) for sf ( μg/ml) was . ( . - . ). the area under the curve and optimal cut-off value were . and ng/ml for sf, respectively (sensitivity, %; specificity, %). from these results, we concluded that sf may be the useful marker rather than d-dimer for predicting the replacement of ecmo circuit due to intra-circuit thrombosis. inhomogeneity of lung elastance in patients who underwent venovenous extra corporeal membrane oxygenation (v-v ecmo)-a computed tomography scan study rd di mussi , ri iannuzziello , fm murgolo , fd de carlo , e caricola , na barrett , lc camporota , sg grasso università degli studi di bari "aldo moro", department of emergencies and organ transplant, bari, italy; università degli studi di bari "aldo moro", bari, italy; department of adult critical care, guy´s and st thomas´nhs foundation trust, king´s health partners, london, uk critical care , (suppl ):p in patients with acute respiratory distress syndrome (ards), nonaerated, poorly aerated, and normally aerated regions coexist to variable degrees in lung parenchyma. the recruitment maneuvers aim to reopen collapsed lung tissue. in a theoretical point view, this strategy may also prevent the normal aerated lung tissue hyperinflation [ ] . the objective of our study was to evaluate lung characteristics in terms of hounsfield units (hu), volume and elastance before and after a recruitment maneuver. in patients with severe ards who underwent v-v ecmo, computed tomography scans (ct-scans) at cmh o of continuous positive airway pressure (cpap) and cmh o were performed. the same ct image was selected at the two different levels of pressure. the distribution of lung opacities, in terms of hu, was classified using the "ucla" colour coding table (osirix image processing software, geneva, switzerland). correspondent lung regions of about voxels were selected. the quantitative analysis, in terms of volume air (vair) was performed with maluna software (version . ; maluna, goettingen, germany). elastance was calculated as the pressure(cmh o)/ vair (ml) ratio. results: see figure . lung inhomogeneity occurs also after recruiting maneuvers. our data confirm that the elastance of recruited lung regions is higher than the elastance of the normal aerated lung regions at low positive end-expiratory pressure (peep) (baby lung). on the contrary the "baby lung" frequently develops hyperinflation. the unpredictable pattern of distribution of volume after recruitment maneuverers may explain the controversial role of peep during the ards treatment. . formal recommendations on target, timing, and rate of at supplementation are lacking. we conceived this study to evaluate the effect of prolonged at supplementation in adult patients requiring veno-venous ecmo for respiratory failure on heparin dose, adequacy of anticoagulation and safety methods: before ecmo start patients were randomized to either receive at supplementation to maintain a functional at level between and % (at supplementation group) or not (control group) for the entire ecmo course. anticoagulation was provided with unfractionated heparin following a standardized protocol [ ] . the primary outcome was the dose of heparin required to maintain the ratio of activated partial thromboplastin time between . and . secondary outcomes were the adequacy of anticoagulation measured with anti-factor xa and the incidence of hemorrhagic and thrombotic complications and amount of blood products fig. b) . conclusions: this retrospective analysis was not able to show a survival benefit for additive pp to ecmo support in general. early initiation of pp could be an important factor for improving survival in this setting and should be considered in a randomized controlled trial for further evaluation. cause-specific mortality during extracorporeal membrane oxygenation, a single center review of medical records m panigada, d tubiolo, p properzi, g grasselli, a pesenti fondazione irccs ca´granda ospedale maggiore policlinico, intensive care unit, milano, italy critical care , (suppl ):p introduction: mortality during extracorporeal membrane oxygenation (ecmo) settles around % and the occurrence of bleeding during ecmo is associated with a high mortality rate. however, cause-specific mortality is rarely reported, probably due to the difficulty of its classification. the purpose of the study was to evaluate the agreement between two expert icu physician in the classification of the cause of death of patients supported with ecmo for either respiratory or cardiac support. methods: two intensive care unit (icu) expert staff physicians independently reviewed the entire medical records of all ecmo patients who died before icu discharge from january to september at fondazione irccs ca' granda, milan. they were asked to choose the cause of patient's death among six categories. in case of disagreement, a third expert adjudicated the case. the two reviewers were also asked whether, in their opinion, bleeding during the last hours contributed to death. elso definition of major bleeding [ ] during the last hours was also recorded for each patient. results: two-hundred and two patients were supported with ecmo of whom ( . %) died. most of these patients (n= , . %) died during ecmo. interrater agreement for cause-specific mortality between the two expert physicians was substantial (k . , se . , p< . ) of the discordant cases were categorized as refractory respiratory failure and as multiorgan failure and septic shock respectively. the distribution of cause-specific mortality is shown in figure . major bleeding (elso) was present in ( . %) patients, only in ( . %) of them bleeding contributed to death according to the reviewers. patients treated with early pp while ecmo showed a superior survival to patients treated with late pp or without pp while ecmo. optimal cut off value for duration of ecmo initiation to first pp was calculated using roc-analysis (auc = . ) and the youden-index. highest sensitivity and specificity for beneficial survival were achieved for a beginning of pp in < . days. (log rank= . ). pp: prone positioning p non-invasive mechanical ventilation in veno-venous extracorporeal membrane oxygenation j rilinger, v zotzmann, x bemtgen, pm biever, d duerschmied, c bode, dl staudacher, t wengenmayer heart center freiburg university, department of cardiology and angiology i, freiburg, germany critical care , (suppl ):p introduction: veno-venous extracorporeal membrane oxygenation (ecmo) support can be combined with a variety of different non-invasive ways to deliver oxygen to the patient's lung. several positive effects might be linked to this so called "awake ecmo". so far there is little evidence about indications and outcome of this approach. we report retrospective registry data on all ards patients treated with ecmo support at a university hospital between / and / . in a systematic review of medical records, we distinguished between patients with invasive mechanical ventilation (imv) from the initiation of ecmo therapy (imv group) and patients that received any kind of non-invasive oxygen supply (non-imv group). a total of patients could be analysed. ( . %) patients received non-imv ecmo support. patients receiving non-imv ecmo therapy showed severe underlying pulmonary disease and immunosuppression (fig. ) . these patients had higher rates of lung fibrosis, long-term oxygen therapy, pulmonary hypertension, renal insufficiency and immunosuppression (p< . ). of patients ( %) required imv during the hospital stay in average . ± . [ . - . ] days after ecmo initiation. reasons were hypoxia despite of ecmo, insufficient ecmo-flow, insufficient protective reflexes or patient agitation. patients with initially non-imv ecmo support showed a numerical but not significant lower icu and hospital survival ( . % vs. . %, p= . ). non-imv ecmo support was applied in patients with severe underlying pulmonary disease and/or immunosuppression. in a high proportion of patients the ventilation regime had to be switched from non-invasive to invasive. survival in this very selected cohort was low. in this retrospective analysis no evident benefit for a noninvasive ventilation strategy could be found. the high proportion of patients who switched from non-imv to imv therapy underlines the need for rigorous patient selection. intra-hospital transportation on extracorporeal membrane oxygenation (ecmo) -a single centre experience in ireland. z siddique, s o´brien, e carton, i conrick-martin mater misericordiae university hospital, department of critical care medicine, dublin, ireland critical care , (suppl ):p the objective of this study is to evaluate intra-hospital transportation of patients on extracorporeal membrane oxygenation (ecmo). it is a retrospective analysis of prospectively collected database, performed as part of ongoing quality improvement initiatives. the setting of this study is an -bed, combined surgical and medical adult intensive care unit (icu) located in a -bed hospital that serves as the national referral centre for cardiothoracic surgery, heart & lung transplantation and ecmo in ireland. we reviewed months of data (from to ) regarding patients admitted to our critical care unit who required intra-hospital transfer for diagnostic and/or therapeutic interventions. we also compared the data to available local guidelines. results: patients were transported on ecmo on a total of occasions; the most common indication being ct brain (table ) . ecmo cannulation sites were peripheral in patients, patients were centrally cannulated. median time from start of the transfer until the patient was returned to icu was minutes (range: - ). the ecmo console was placed on a dedicated ecmo trolley apart from two occasions where it was placed on the patient's bed. number of staff required for transport was between to ; with an icu consultant as team leader. ecmo specialist nurses were always present on the transport team. transfers were during normal working hours with happening on a weekend. a total of complications occurred during the transports, of underlying pulmonary disease or status of immunosuppression in ecmo patients without invasive mechanical ventilation which was significant and were not. the significant complication encountered was ventricular tachycardia in a v-a ecmo patient which required electrical defibrillation. no adverse events related to transport were seen following return to icu. in this single-centre study, we have demonstrated safe intra-hospital transport of ecmo patients. the use of local guidelines, appropriate personnel and performance during normal working hours is recommended. a novel approach for flow simulation in ecmo rotary blood pumps a supady , c benk , j cornelis , c bode , d duerschmied heart center freiburg university, cardiology and angiogiology i, freiburg, germany; heart center freiburg university, department of cardiovascular surgery, freiburg, germany; fifty technology gmbh, freiburg, germany critical care , (suppl ):p introduction: extracorporeal membrane oxygenation (ecmo) is used increasingly in critically ill patients suffering from acute respiratory failure, cardiogenic shock or cardiac arrest. however, this therapy can have deleterious side effects such as bleeding or clotting complications and hemolysis. these complications are particularly caused by physical stress acting upon the blood components while passing through the ecmo system, especially within the rotary pump. we here present a novel approach to simulate blood flows through rotary blood pumps used in current ecmo systems in order to better understand the genesis of these complications. geometries of the xenios dp (xenios ag, heilbronn, germany) rotary pump were reconstructed by ct-scans and manual measurements using computer-aided design (cad). the computational fluid dynamics (cfd) simulation was performed using the software preon-lab (fifty technology gmbh, freiburg, germany), which implements a mesh-free lagrangian method requiring minimal preprocessing of the cad data. the geometries are introduced to the simulation model as tessellated surfaces. five operating points have been specified by the rotation of the centrifugal fan and the corresponding inflow and outflow of blood. the blood is approximatively modelled as a newtonian fluid with a density of kg/m . preonlab allows detailed assessment of the blood flow while passing through the rotary pump including analysis of local flow rates, pressure gradients and shear stress acting upon the blood. dead zones in the fluid flow can be detected which gives reference points for optimizations of the pump design. for the first time, we demonstrate a novel approach for flow simulation in an ecmo rotary pump ( figure ). this approach may help better understand hemodynamics within the extracorporeal system to define optimal operating points or re-design components aiming to limit hemolysis, coagulation disorders and bleeding in seriously ill patients. one-year experience of bedside percutaneous va-ecmo decannulation in a territory ecmo center in hong kong km fong, sy au, pw leung, kc shek, hj yuen, sk yung, hl wu, so so, wy ng, kh leung queen elizabeth hospital, intensive care unit, hong kong critical care , (suppl ):p when veno-arterial extra-corporeal membrane oxygenation (va-ecmo) support can be terminated, arteriotomy wounds of the patients of are traditionally closed by open repair in the operation theaters. lots of manpower are involved and timeslots in operating theaters are scarce. transport of the critically-ill is risky. successful va-ecmo decannulation using percutaneous device called proglide has been reported and our group had adopted and modified this approach [ ] . methods: this is a retrospective study analyzing the one-year experience of bedside va-ecmo decannulation. our institution is a -bed tertiary ecmo referral center in hong kong. our first bedside decannulation was performed in november , and since then, this practice had replaced the traditional open repair, unless contraindicated. data from november to october were analyzed. in the study period, patients received va-ecmo. survived to decannulation and received bedside percutaneous decannulation. their median age was ( - ). the default arterial catheter size was fr, with fr in cases and fr in one. five ( %) failed percutaneous closure and they were subsequently surgically repaired without extra corporeal life support (ecls) continues to be associated with high mortality rates. our ability to predict outcome prior to initiation ecls remains limited. here we take a single cell rnaseq approach in an effort to identify novel immune cell types that are associated with-and may contribute to-survival on ecls. whole genome transcriptomic profiles were generated from~ , peripheral blood monocytes obtained from patients at the time of cannulation for veno-arterial ecls (va-ecls). within each subpopulation, differential gene expression analysis was performed to identify new markers associated with survival. findings were validated in a additional cohorts by flow cytometry. surviving patients had significantly higher proportions of cd + nkt cells (cd + /cd + /cd -/cd + ) that were cd + (p = . , fdr < . ) ( figure ). to validate this observation, we performed fc analysis of a second cohort of patients. for each patient, we quantified the proportion of cd + nkt cells that were cd + . using the median proportion as the cutoff, we again found that a high proportion of cd + cells among cd + nkt cells was predictive of hour survival (p= . ). we noted that while high levels of cd + cells among the cd + nkt cells was protective in this cohort of va-ecls patients, this relationship did not hold for patients with sepsis. as only a few the va-ecls patients were septic, we analyzed a third cohort of septic ecls patients. we observed that high levels of cd + cells among the cd + nkt populations was not protective in this population. the proportion of cd + nkt cells that are positive for cd is predictive of survival among patients undergoing va-ecls for noninfection related indications. introduction: the use of calcium sensitizers has grown enormously in the last decade, probably due to their interesting pharmacodynamic properties. levosimendan (ls) is frequently administered in patients under mechanical circulatory support. we performed a retrospective evaluation of patients treated with ls prior to weaning from mechanical support. this evaluation was combined with a review of the literature. a query of our icu patient data management system revealed patients receiving ls prior to or during vad/ecls support. outcome data were obtained from the patients medical records. of our patients, % was successfully weaned off ecls. fourteen patients ( %) died before being discharged of whom while on ecls support. of the weaned patients, died afterwards. of the converted patients needed subsequent veno-venous ecls support for right ventricular support after the implantation. survival to discharge ratio for the whole group was %. more detailed demographic results can be found in table . a pubmed search using the terms "(ecmo or ecls) and ls and weaning" resulted in publications which dealt specifically with weaning of ecls support. several weaning approaches are available, however poor outcome has remains a problem. some recent studies show a possible beneficial effect of ls infusion prior to weaning from ecls. however most of these studies are retrospective or observational at best. because ls is primarily reserved for the most severe cases, outcome interpretation is difficult. overall weaning success ranges from %- % and variation is very dependant of inclusion criteria. the calcium sensitizer ls can be used when weaning off patients from ecls, certainly given its low incidence of complications. future, large randomized trials are however needed in order to confirm this strategy. cardiogenic shock is well described in newly diagnosed pheochromocytoma, and crisis may be precipitated by hemorrhage into tumour. v-a ecmo represents a rescue therapy in a subset of these patients refractory to medical management, facilitating cardiac recovery and subsequent definitive surgery. consent to publish: written informed consent for publication was obtained from the patients. during a spontaneous breathing trial respiratory mechanics can worsen, and respiratory muscle effort can increase, leading to respiratory muscle fatigue, pump failure, hypercapnia and an unsuccessful weaning from mechanical ventilation. this case report discusses the possibility of applying extracorporeal co removal (ecco r) to reduce respiratory muscle effort in a liver transplant recipient who already failed three weaning attempts from mechanical ventilation. the ecco r membrane lung was integrated into a conventional renal replacement therapy circuit and blood flow was increased from to ml/min. measurements of respiratory mechanics (including esophageal pressure, as shown in fig. ) were used to assess the reduction of respiratory effort before and during the application of ecco r. was delivered through a fr-double-lumen-cannula; ml/min blood-flow with lt oxygen sweep-gas-flow and aptt . - baseline were maintained (iv-heparin). in all cases respiratory and metabolic parameters improved without complications ( figure ). ecco r-crrt facilitated extubation ( out imv pts). in out of pts at risk of niv failure, it avoided imv. treatment mean duration was ± hours, mean lenght of icu stay was ± days. all patients survived to the treatment, nevertheless patients died due to irreversible multiple mof. in our aecopd series prismalung®-prismaflex® facilitated weaning from imv and avoided intubation in patients at risk of niv failure without complications. these positive results may be related to minimal invasiveness of the low-flow device used and may constitute the rationale for a larger randomized controlled trial. consent: written informed consent for data publication has been obtained. extracorporeal the primary outcome findings from the supernova trial [ ] demonstrated that the use of extracorporeal carbon dioxide reamoval (ecco r) allows a reduction in tidal volume (tv) to ultraprotective levels (≈ ml/kg predicted body weight or pbw) during mechanical ventilation in ards patients without significant increases in the arterial partial pressure of carbon dioxide (paco ). unfortunately, it was not feasible to directly measure ecco r rates during the trial. we used a mathematical model of whole-body oxygen (o ) and carbon dioxide (co ) transport and biochemistry [ ] to calculate ecco r rates that permit a fit to the data reported for hemolung (alung technologies) and ila (novalung)/cardiohelp (getinge) devices in the supernova trial [ ] . the mathematical model was calibrated under baseline conditions where patients were mechanically ventilated at a tv of ml/kg pbw in the absence of an ecco r device; the o consumption rate, co production rate and pulmonary shunt fraction were adjusted to match the measured baseline arterial partial pressure of o and paco . assuming all baseline parameters were fixed, tv was then reduced to . ml/kg pbw and the mathematical model predicted the ecco r rate to the change in the paco level. model predictions for the devices are shown in table . these predictions suggest that ecco r rates for ila/cardiohelp devices were approximately twice those for hemolung devices during the supernova trial. these results may be useful to evaluate the expected performance of novel ecco r devices. efficiency and safety of a system crrt plus ecco r to allow ultraprotective ventilation protocol in patients with acute renal failure f maldarelli despite renal function replacement techniques (crrt), a patient who develops acute renal failure(aki) in intensive care unit (icu) has a mortality rate of - %. this risk is partly due to the adverse effect of aki on other organs than the kidney. respiratory complications are frequently associated with the development of aki. new machines combining crrt with a carbon dioxide removal membrane (ecco r) allows the setting up of an ultra-protective ventilation ( ml/kg of predicted boby weight (pbw)) to reduce any lung damage from mechanical ventilation (mv). the reduction in tidal volume (vt) is associated with a decrease in lung damage partly triggered by aki. we evaluated the efficacy of a combined system crrt+ecco r to reduce the vt to ultraprotective values in patients with acute respiratory failure and aki. ards is a syndrome with high morbidity and mortality. an emerging treatment option is ecco r, but the benefit its remains unclear. we assess different degrees of ecco r and varying dead space (ds) on ventilator settings in order to minimize mechanical power. we calculated mechanical power as ( ) power=rr*{Δ〖vt〗^ *[ / *el+rr*( +i:e)/( *i:e)*r]+ Δvt*peep} (el: system elastance, r: airway resistance, peep: positive end expiratory pressure, i:e: inspiratory to expiratory ratio). we calculated the combination of respiratory rate (rr) and tidal volume (vt) ("optimal rr" and *optimal vt*) leading to minimal applied power for a stable carbon dioxide elimination of ml/min (vco ) for two scenarios: ) variation of physiological ds from to % of vt at a fixed rate of eccor . ) variation of ecco r of either , , or ml/min at a fixed physiological ds of %. the alveolar ventilation (va) necessary to eliminate the vco was calculated as ( ) va= (-vco *σ_co *r*t*( +k_c ))/(vco /q-p_vco *σ_co *r*t*(( +k_c ))/ ) σco : co solubility in blood, r: gas constant, t: temperature. pvco : venous partial pressure, kc: function of ph ( . for a ph of . ), q: blood flow [ l/min]). increasing ds from to % increases the minimal mechanical power from . to . j/min, primarily caused by an increase of optimal vt ( - ml). optimal rr was only slightly increased ( . - . /min, figure panel a). for varying ecco r removal, necessary ventilation ranges from . to . l/min. this predicts a minimal power between . and . j/min with an unchanged optimal vt ( - ml) and an increasing optimal rr ( . to . /min ( figure panel b)). in order to minimize mechanical power, increasing shunt or co production should be met with increases in rr while increases in ds should be met with increases in vt. our results indicate that during ecco r, mechanical power and thus risk for lung injury can be minimized with higher vt compared to conservative ventilation strategies. validity of empirical estimates of physiological dead space in acute respiratory distress syndrome jd dianti, eg goligher, as slutsky university of toronto, interdepartmental division of critical care medicine, toronto, canada critical care , (suppl ):p increased physiological dead space fraction (v d /v t ) is a hallmark of the acute respiratory distress syndrome (ards) and has been shown to predict ards mortality. v d /v t is also important in estimating the reduction in tidal volume (v t ) and driving pressure (Δp) with extracorporeal co removal (ecco r). v d /v t can be measured with volumetric capnography but empirical formulae using the patient's age, weight, height, gender and paco have been proposed to estimate v d /v t based on estimates of co production (v co ). the accuracy of this approach in critically ill patients, however, is not clear. secondary analysis of a previously published trial [ ] in which v d /v t and v co were measured in ards patients. estimated dead space fraction (v d,est /v t ) was calculated using standard formulae. agreement between methods was evaluated by bland-altman analysis. the predicted change in Δp with ecco r was evaluated using both measured and estimated alveolar dead space fraction (v dalv /v t ). results: vd,est/vt was higher than measured vd/vt, with a low correlation between the (r = . ). vco was underestimated by the predicted approach (table ) , accounting for % of the error in estimating vd/vt. the expected reduction in Δp with ecco r using vdalv/ vt was in reasonable agreement with the expected reduction using introduction: acute respiratory distress syndrome (ards) is a common condition in critically ill patient. however neuromuscular blockers (nmb) result controvertial in early treatment of ards [ ] . we ought to search systematically and realize a meta-analysis on the matter. an electronic search of randomized clinical trials in adult patient treated with early neuromuscular blockers compared without neuromuscular blockers in ards. the primary objective of the analysis was the mortality at to days. secondary endpoints included mechanical ventilation free days, icu acquired weakness and barotrauma. the search obtained studies for the analysis [ ] [ ] [ ] [ ] [ ] [ ] (figure ). the early use of neuromuscular blockers in ards showed no increase in mortality, but the results should be taken with caution. there was no differences in mechanical ventilation free days. barotrauma is less with the use of nmb. ultrasound is fairly sensitive in the detection of lung infiltrates in patients with hematologic malignancies. in patients with pneumonia requiring intensive care (icu) admission, we hypothesise that abnormal right ventricular (rv) function is associated with an increased -day mortality. rv dysfunction in critically ill patients has a well-known association with adverse outcomes [ ] . however, its impact on mortality in patients with pneumonia has not been directly studied. patients admitted to the queen elizabeth hospital birmingham icu between april and july with a diagnosis of pneumonia who had a formal cardiologist tte were included. abnormal rv function was defined by either depressed function, dilated size or moderate to severe risk of pulmonary hypertension (phtn). abnormal lv function was defined by an lv ejection fraction £ % or grade ii or more diastolic dysfunction. patients with a clinical suspicion of pulmonary embolism were excluded. the primary outcome was -day mortality. continuous data is presented as median (iqr). categorical data is presented as % and analysed using a chi-squared test. results: patients were admitted to icu with pneumonia, of which ( %) had a tte. patients were % male, had a median age of ( - ) and -day mortality of %. abnormal rv function was present in % (n= ), with % depressed, % dilated and % with moderate to severe risk of phtn. rv dysfunction was associated with an increased -day mortality compared to normal rv patients ( % vs. %, p< . ). lv function was abnormal in % (n= ) and was not associated with a higher -day mortality compared to normal lv patients ( % vs %, p = . ). rv dysfunction was associated with a higher -day mortality than lv dysfunction ( % vs %, p = . ). conclusions: this is one of the first studies to demonstrate that abnormal rv function is associated with an increased mortality in icu patients with pneumonia. interestingly, abnormal lv function was not associated with an increased mortality. rakuno gakuen university, anesthesiology, hokkaido, japan critical care , (suppl ):p we previously reported a simple correction method of estimating pleural pressure (ppl) by using central venous pressure (cvp) and that it can be used to estimate ppl and transpulmonary pressure in pediatric patients with respiratory failure. however, it remains unknown that this method can be applied to patients with various levels of chest wall elastance and/or intravascular volume. the objective of this study is to investigate whether our method is accurate in various conditions of chest wall elastance and intravascular volume. the study was approved by the animal care and use committee of rakuno gakuen university. ten anesthetized and paralyzed pigs ( . ± . kg) were mechanically ventilated and subjected to lung injury by saline lung lavage. each pig was subjected to different intravascular volume and different intraabdominal pressures; in each condition, the accuracy of our method was tested. specifically, airway flow, airway pressure (paw), esophageal pressure (pes), and cvp were recorded in each condition, then changes in pes (Δpes) and Δppl calculated using a corrected Δcvp (cΔcvp-derived Δppl) were compared. cΔcvp-derived Δppl was calculated as κ × Δcvp, where κ was the ratio of the Δpaw to Δcvp during the occlusion test. means and standard deviations of the two variables that reflect Δppl (Δpes and cΔcvp-derived Δppl) in all pigs with all conditions were . ± . and . ± . cmh o. the bland-altman analysis for the agreement between Δpes and Δcvp showed a bias of - . the activity and functionality of the diaphragm are difficult to measure in patients ventilated in intensive care. ultrasound can be a useful tool for monitoring diaphragm muscle activity during different ventilation modes. few data currently exist on diaphragm muscle activity in critically ventilated patients [ ] . our goal is to evaluate the respiratory muscular work of the diaphragm with different settings of the respirator by means of an ultrasound scan. the ultrasound assessments of the diaphragm were performed with a mhz linear probe at the apposition zone. we measured the thickening of the diaphragm with the respiratory acts, through the thickening fraction (thickening fraction, tf), defined as:tf = (tdimax -tdimin / tdi min)% tdimax: diaphragm thickness at the end of inspiration (maximum thickness) tdimin: diaphragm thickness at the end of expiration (minimum thickness). ventilatory support was divided into classes: -spontaneous breathing (sb) or continous positive airway pressure (cpap); -pressure support ventilation (psv) with low pressure support ( - cmh o); -psv with high pressure support (> cmh o); -controlled mechanical ventilation (cmv). a total of assessments were performed in patients. the evaluations were all possible at the right hemidiaphragm, while on the left they were not possible in % of the cases. the median tf (iq range) of the ventilation classes was respectively: % ( - %) in sb / cpap; % ( - %) in low-psv; % ( - %) in high psv; and % ( - %) in cmv. the kruskal-wallis test confirms a significant difference between the groups (p < . ). the ultrasound of the diaphragm can be a valid tool for monitoring respiratory muscle activity during mechanical ventilation. introduction: extubation failure is defined as reintubation after hours of extubation in mechanically ventilated critically ill patients. it is associated with morbidity and mortality. the aim of our study was to assess reintubation rates in a busy district general hospital and evaluate the impact of high flow nasal oxygen therapy (hfno) on reintubation rates. we performed a retrospective observational study looking at patients admitted to our bedded level critical care unit ( patients a year) for a period of years between st november and st october . we included patients over years of age who were mechanically ventilated and length of stay was greater than hours. exclusions were age < years, tracheostomy and patients requiring ventilation for < hours. data was collected from ward watcher, a sicsag database and electronic patient records. our study failed to show any impact of hfno on reducing extubation failure. further work is needed to develop a standardized approach to weaning and to consider routine application of noninvasive ventilation to reduce reintubation rates [ ] . fig. (abstract p ) . the bland-altman analysis for the agreement between Δpes and cΔcvp-derived Δppl in various conditions. low: low intravascular volume, normal: normal intravascular volume, high: high intravascular volume, abd-: without an abdominal compression band, abd+: with an abdominal compression band oral endotracheal intubation is common to critically ill patients in intensive care unit. oral care for an intubated patient is important to maintain the moisture of oral mucosa. also, the securement method of oral endotracheal tube developed from cloth tape to commercial tube holder. training powerpoint and video for microteaching was prepared to train up icu nurses to perform the new practice. demonstration and re-demonstration was arranged to assess skills of every nurse. afterwards, each nurse answered a quiz to evaluate the understanding of oetth and its special techniques in application. questionnaire was designed to collect the feedback from all nurses too. the result showed there was nurses ( %) out of nurses achieved full marks in the post-quiz which demonstrated their full understanding of the use of oral ett holder and its nursing care. about the feedback from nurse, % of nurses claimed that they were confident in using the new oetth in clinical setting after training. % of nurses agreed in time-saving of nursing care routine with the use of an oetth. however, only % of nurses agreed that the oetth is effective in prevention of oral mucosa injuries and another % of nursing staff disagreed on its function in improving the patient's oral care. in conclusion, some of the nurses did not agree the prevention of oral mucosa injuries by the new securement method with oetth while some nurses welcomed the new oetth as more easy and effective in oral care to intubated patients. execution of percutaneous dilatational tracheostomy using the standard laryngeal mask airway for ventilation: a prospective survey study g gagliardi , v gagliardi , c chiani , g laccania , f michielan aulss -veneto, anesthesia and intensive care, adria, italy; aulss -veneto, university of padua, adria, italy; aulss -veneto, anaesthesia and intensive care, adria, italy; aulss -veneto, anaesthesia and intensive care, padua, italy critical care , (suppl ):p we fulfilled a survey study dealing with bronchoscope-guided percutaneous dilatational tracheostomies (pdt), using the classic laryngeal mask airway (lma) for the airway management [ ] . the aim was to verify the safety and the effectiveness of the aforementioned procedure methods: we performed an observational prospective survey study enrolling patients hospitalized in the intensive care unit. before performing the tracheostomy, the endotracheal tube has been replaced by the laryngeal mask airway. arterial blood gases, ventilation pressures and tidal volumes have been monitored, registered and compared. the median peak inspiratory pressure has been detected stable in all patients. furthermore, during the ventilation with the laryngeal mask, the tidal inspiratory and expiratory volume difference observed between before and after the bronchoscope positioning, has shown a statistically significant variation. finally, in all cases etco , spo . , pao , and blood ph values persisted within the normal range. the standard lma provides for a reliable airway management and allows an effective ventilation while performing the pdt. once positioned in the supraglottic zone, the lma does not need to be moved throughout all the pdt performance, avoiding risks of displacement, glottic harm and airway device damage, and permitting an easy handling of the bronchoscope, which gives an appropriated visualization of the trachea and a more efficient aspiration. in consequence to the large internal diameter of the lma tube, ppeak has continued to be stable in all patients, providing for minor resistance and inspiratory work. eventually, no late complications, such as tracheal stenosis and infections, have occurred. tracheostomies are the most common surgical procedure performed on critically ill patients. randomized control trials comparing tracheostomy timing in intensive care patients have been equivocal. in order to perform non-urgent tracheostomy in our icu, consent is required from the patient or a formal guardian appointed ad hoc by the courts. since tracheostomies are practically the only elective surgery performed in the critically ill, icu requested guardianship almost always indicates a clinical decision to perform tracheostomy. as appointing a guardian and arranging a tracheostomy takes about a week, the decision to appoint a guardian offers a unique "intention to treat" opportunity to evaluate outcomes in patients for whom tracheostomy is planned. we performed a retrospective analysis over years on patients for whom guardianship was sought excluding those requiring urgent tracheostomy and those with a do-not-resuscitate order. patients were divided according to outcome (tracheostomy, extubation or death prior to tracheostomy) and compared. guardianship was sought for ventilated patients. a decision to withhold tracheostomy was made for patients, who were excluded, leaving patients for analysis. tracheostomy was performed for / ( %) patients, / ( %) were extubated and / ( %) died while waiting for tracheostomy (from nonairway related reasons). tracheostomy was performed on mean ventilation day ± . comparing extubated patients to those who had tracheostomy (table) shows similar demographics, but significantly lower mortality and hospital length of stay. a significant proportion of patients initially planned for tracheostomy were successfully extubated. despite demographic similarities, mortality in this group was significantly lower than for patients undergoing tracheostomy. for a selected subgroup of possibly difficult to characterize patients, delaying tracheostomy may be beneficial. figure ). ptis were analysed by speciality and by outcome. complications occurred in cases (incidence . %). there were cases of subcutaenous emphysema, pneumothorax (occuring d post procedure) and case each of stoma and suture site infection. there was unplanned cannula change within days of insertion. % of cases had cuff inflated on discharge from icu. handover of care was suboptimal; follow up care plans were documented in % of cases. a supervising consultant was present for all ptis. there was a trend of increased insertion by consultant and increased reliance on theatre, with corresponding decrease in the number inserted by trainees. pti in our training icu appears safe with low incidence of complications and good senior support for tracheostomy insertion. emphasis must continue on training junior intensivists in pti. transition of care beyond icu requires further work where currently there is suboptimal handover of care and safety netting for non-icu colleagues. supplemental oxygen administration is ubiquitous in the critical care environment, yet evidence is mounting for the deleterious effects of hyperoxia [ ] . concerns over the adverse effects from hypoxaemia often exceed those of hyperoxaemia in developing world settings, and inconsistent availability of blood gas monitoring may limit judicious oxygen titration. the aim of this project was to audit oxygen delivery practice and introduce qi measures to avoid excess oxygen delivery in a tertiary icu in lusaka, zambia. a prospective snapshot of ventilatory parameters were recorded for critically ill patients over a -week period, including positive end expiratory pressure (peep), fio , and time-course spo . systematic education was provided through group and one to one tutorials to empower nursing and medical staff to titrate oxygen safely and appropriately. repeat data collection was then performed over weeks. initially / patients ( %) were over-oxygenated, as defined by fio > . and spo consistently > %. / patients with an fio of > . had peep ≤ cm ( %). no patient had a pao recorded in the past hours. education was provided as well as implementation of unit protocols above all patient beds documenting a stepwise approach to titration peep and fio . post intervention fewer patients were over-oxygenated: / ( %) had fio > . and spo consistently > %, and / with an fio > . ( %) had a peep ≤ cm. in addition, / ( . %) had a pao recorded within hours. this qi project has shown that nurse engagement and systematic education to titrate fio and peep can be achieved in a resource poor setting and may decrease the incidence of hyperoxia in critically ill patients. availability of blood gas monitoring and knowledge of interpretation was a major barrier to oxygen titration tracheal intubation (ti) in adult burn patients might be unnecessary in to % of cases [ , ] . in pediatric burn patients, there is little data on both the rate of ti and the rate of early extubation [ ] . it has been common practice for a child with a facial burn and/or a suspected airway injury to be intubated early due to the risk of losing airway patency. however this risk should be mitigated against the potential risks of ti and mechanical ventilation in children. therefore the aim of this study was to describe the airway status of child burn victims taken in charge of in our pediatric burn intensive care unit. focused on patients arriving with ti, we investigated the rate of early extubation. in addition we compared non intubated patients with those with prolonged ti. this retrospective study described a cohort of patients hospitalized between and . data was retrospectively recorded from the patient's paper clinical chart. the mean age of our patients was . ± . years [mean±sd] with an average burn area of ± %. % had scald burns and % had facial burns. % of the children were admitted in the burn icu with ti. for % of them, tracheal tube was removed within the first hours after admission. the probability of prolonged ti increased independently with the burned skin area (bsa) (p < . ), the presence of facial burns (p = . ), and in case of flame burns (p = . ) ( figure ). among patients with more than % bsa, % were intubated more than h. among patients with less than % bsa, . % were intubated more than h. according to our retrospective data, it seems appropriate to intubate children with % and more bsa, while for patient with less than % bsa, it might be relevant to seek guidance from physician of the nearest burn center. under % bsa, ti seems rarely required. an analysis of the predictive applicability of initial blood gas parameters for the need for intubation and the presence of inhalation injury in patients with suspected inhalation injury c pirrone , m chotalia , t mangham , r mullhi , k england , t introduction: we hypothesise that initial blood gas parameters have a good predictive applicability in detecting the need for intubation and the presence of inhalation injury in patients with suspected inhalation injury. to the best of our knowledge, this has not been directly studied in the literature. patients with suspected inhalation injury admitted to the icu at queen elizabeth hospital, birmingham between april and may were included. the initial blood gas parameters analysed were pao (kpa), paco (kpa), ph, carbon monoxide level (cohb; %) and pao /fio (pf) ratio. receiver operator characteristics (roc) for these parameters were plotted against the need for intubation for more than hours and the presence of inhalation injury as detected by bronchoscopy and laryngoscopy. area under the curve (auc) for each parameter was calculated. results: patients were admitted with suspected inhalation injury to the icu. % were intubated for more than hours. of patients who were intubated, % had inhalation injury as indicated by bronchoscopy or laryngoscopy. table outlines the auc for initial blood gas parameters in detecting the need for intubation for more than hours and the presence of inhalation injury. ph was the parameter with the most prominent auc, with reverse correlation indicating fair accuracy. no clear inflection point was identified, although all patients with ph < . required intubation and had inhalation injury. paco had a fair predictive applicability in detecting the need for intubation. pf ratio, pao and cohb had poor accuracy. conclusions: initial blood gas parameters had a broadly poor predictive applicability for the need for intubation and the presence of inhalation injury in patients with suspected inhalation injury. severe acidosis (ph < . ) was the most useful blood gas parameter. clinicians should be cautious in using blood gas parameters alone to inform intubation decisions. lung cancer surgery is associated with a high rate of pulmonary complications including ards and mandates lung protective ventilation strategies [ , ] . such strategies include non-intubated video assisted thoracic surgery (nivats) with spontaneous breathing [ ] . currently neither data on respirator settings nor on gas exchange have been reported for applying the latter. this data constitutes a prerequisite for meaningful evaluating the respiratory consequences of non-intubated spontaneous breathing during lung cancer surgery. the aim of this case series was for the first time providing such data from lung cancer surgery including pneumonectomy. during a month period patients without contraindications [ ] scheduled for video assisted thoracic surgery (vats) for non-anatomical and anatomical lung resection including one pneumonectomy (px) were offered non-intubated spontaneous breathing. all patients gave informed written consent to the procedure as well as for analysis and publication of data. anaesthetic management included target controlled infusion of propofol and remifentanil, laryngeal mask airway, and pressure support ventilation. we present early data that early trials of cuff deflation within hours of tracheostomy insertion can be achieved using a standardized protocol. its impact on length of stay, duration of ventilation and patient-centered outcomes needs to be investigated in larger multi-centre trials. preventing underinflation of the endotracheal tube cuff with a portable elastomeric device. a randomized controlled study je dauvergne , al geffray , k asehnoune , b rozec , k lakhal hopital laënnec -chu de nantes, service d´anesthésie-réanimation, nantes, france; hotel-dieu -chu de nantes, service d´anesthésieréanimation, nantes, france critical care , (suppl ):p the management of the endotracheal tube cuff pressure (p cuff ) is routine practice for critical care nursing staff. underinflation could lead to ventilator-associated pneumonia [ ] whereas overinflation exposes to tracheal damage [ ] . multi-daily check and adjustment is recommended to ensure that p cuff lies between and cmh o [ ] . to automate this task some devices exist but may be inconvenient, bulky and/or ineffective. their use is not supported by guidelines. a portable elastomeric device could be appealing for p cuff automated regulation. this prospective randomized controlled study tested whether the tracoe smart cuff manager tm reduced the rate of patients undergoing ≥ episode of underinflation (p cuff < cmh o), as compared with routine manual p cuff adjustment. monocentric, randomized controlled study. patients with acute brain injury and receiving mechanical ventilation were prospectively allocated to one of the two arms: manual reading and adjustment of p cuff at least every h (routine care) or adjunction of the smart cuff manager tm (intervention). this study was approuved by an institutional review board. among randomized patients (routine care in , smart cuff manager tm in ), measurements were performed in h. with routine care, a higher rate of patients experienced at least one episode of underinflation ( . vs. . %;p< . ). episodes of underinflation episodes ( % vs. %;p< . ) and manual adjustments ( % vs. %;p< . ) were more frequent with routine care. for overinflation, there was no between-arms difference (p> . ). the adjunction of continuous p cuff control with the tracoe smart cuff manager tm reduced the incidence of p cuff underinflation as compared with manual intermittent adjustments. overinflation was not promoted by this device. direct laryngoscopy as a technique for tracheal intubation is a potentially lifesaving procedure that healthcare professionals in a variety of fields are taught. however, this skill is challenging to acquire and difficult to maintain. poorly performed intubation technique can lead to potentially serious complications [ ] . the intersurgical iview video laryngoscope is a new intubation tool which may have advantages over direct laryngoscopes, such as the macintosh, in the hands of novice personnel. a prospective randomized counterbalanced trial of medical students, who did not have previous airway management experience, was conducted. each student received brief didactic teaching,following this, participants were directly supervised performing laryngoscopy and intubation using the macintosh and iview devices in an alternating pattern. students were permitted up to three attempts to successfully intubate under four conditions, three laryngoscopy conditions using alaerdal intubation trainer and one using a laerdal simman manikin. there was no significant difference in the success rate of intubation or time to intubation between the two devices. the iview outperformed the macintosh in time to intubation in the normal airway in the final scenario, once students gained experience with both devices. no significant difference was found in the number of optimisation manoeuvres, or intubation attempts between groups. areas where the iview outperformed the macintosh included severity of dental trauma and participants' perception regarding ease of use ofthe device. the iview may prove to be a useful teaching tool for novice personnel who are acquiring the skills of tracheal intubation. patients with a primary pulmonary pathology were more likely to respond to aprv. this association has not been described before and warrants further multi-centre exploration in a larger patient group. introduction: airway suctioning is common during mechanical ventilation, using either an open endotraqueal suctioning or closed endotracheal suctioning (ces). closed circuits were developed to prevent arterial desaturation and atelectasis associated to ventilator disconnection. however, ces may cause substantial loss of lung volume. the purpose of this study was to investigate the effects of a compensation method to prevent the loss in aeration during ces. the suctioning technique was performed for seconds, negative pressures limited at mmhg. closed suction catheters with fr (halyard health, georgia, eua) were used. electrical impedance tomography (eit) monitoring and arterial blood gas were collected. a nihonkoden mechanical ventilator (nkv , california, eua) was applied, having a newly developed algorithm for suctioning which overcomes any pressure loss during suctioning (inlinesuction-app). when activated, the app delivers pcv ventilation, adding cmh o of end-expiratory pressure above peep, and delivering driving pressures of cmh o. results: pigs ( ± . kg) with injured lungs and mechanically ventilated. we tested the aspiration procedures using low peep= cmh o, or high peep=± . cmh o with v t o), whereas maintenance of compliance was observed when the app was on (from . ± . ml/cmh o to . ± . ml/cmh o. blood gas in a representative animal showed a drop in pao when app was off (from , to mmhg after min, and to mmhg after min) ( figure ). with app on the pao changed from (pre-suction), to ( min), to mmhg ( min). the new nksoftware, delivering pcv ventilation during suctioning, could prevent atelectasis and functional loss associated to the procedure. tyrosine kinase inhibitor: an effective tool against lung cancer involvement responsible for acute respiratory failure in icu y tandjaoui-lambiotte patients with advanced-stage non-small-cell lung cancer have high mortality rates in the intensive care unit (icu). in the last two decades, targeted therapies have changed the prognostic of patients with lung cancer outside the icu. the fast efficacy of targeted therapies led some intensivists to use them as rescue therapy for icu patients. we performed a national multicentric retrospective study with the participation of the grrroh (groupe de recherche en réanimation respiratoire en onco-hématologie). all patients with non-small-cell lung cancer admitted to the icu for acute respiratory failure between and were included in the study if a tyrosine kinase inhibitor was initiated during icu stay. cases were identified using hospital-pharmacies records. the primary outcome was overall survival days after icu admission. results: thirty patients (age: +/- years old) admitted to a total of icus throughout france were included. seventeen patients ( %) were nonsmoker. adenocarcinoma was the most frequent histological type (n= , %). most patients had metastatic cancer (n= , %). epithelial growth factor receptor mutation was the most common oncologic driver identified (n= , %). during the icu stay, ( %) patients required invasive mechanical ventilation, ( %) catecholamine infusion, ( %) renal replacement therapy and one ( %) extracorporeal membrane oxygenation. eighteen patients ( %) were discharged alive from icu and ( %) were still alive after days (see figure) . moreover, patients ( %) were alive one year after icu discharge. despite a small sample size this study showed that, in the context of lung cancer involvement responsible for acute respiratory failure, the use of tyrosine kinase inhibitor should not be refrained in patients with severe condition in icu. the burned patient is one of the most complex patients whith a very high mortality. those patients with inhalation injury have a worst prognosis, typically associated with respiratory complications. the aim of our study is to evaluate the mortality of burn patientes with inalation injury in a critical burn unit. a prospective, observational and descriptive study was conducted over a period of years. inhalation injury was defined with these criteria (≥ ): history of injury in an enclosed space, facial burns with singed nasal hair, carbonaceus sputum and stridor. if they were intubated it was diagnosed by bronchoscopy. demographic data, tbsa, absi, baux score, apache ii, sofa, mechanical ventilation (mv), complications, length of stay, hospital course and mortality data were collected. results: burns patients were admitted. % ( patients) had inhalation injury. mortality among patients with inhalation injury was , % ( patients). most patients were men and those who died were older and with higher severity scores (fig. ) . we found no significant differences between groups in the need for mv ( % vs. %) or in the percentage of tracheostomy performed ( . vs. . ). however, patients who died had more respiratory complications like ards, and also shock, renal failure and need of renal replancement therapies although infectious complications were similar in both groups. there was no statistically significant difference in volume used during initial resuscitation in the different groups. patients with inhalation injury who died had higher severity scores at the begining. although there were no differences in the need for mv patients who died had more respiratory complications as well as shock, renal failure and need of rrt, but no infectious complications.the volume used during inicial resuscitation, that was always related to the prognosis, was similar in both groups. further studies are needed to see if this greater initial severity corresponds to the degree of inhalation. aerogen, medical affairs, galway, ireland; aerogen, science, galway, ireland critical care , (suppl ):p patients with acute exacerbations such as asthma are prescribed aerosol therapy from presentation in the emergency department to progression through to the intensive care unit. however, the variability in dose delivery to the lung across the possible patient interventions is not well characterized. here, we assess the predicted lung dose of a bronchodilator in a simulated spontaneously breathing adult patient via both facemask and nasal cannula, and via tracheostomy during mechanical ventilation. a standard dose of . mg in . ml salbutamol was aerosolized using the aerogen solo nebulizer (aerogen, ireland). for facemask testing, the nebulizer was used in combination with the aerogen ultra with lpm supplemental oxygen flow. for nasal cannula testing, the nebulizer was used in combination with the airvo system (fisher and paykel, nz) system at both and lpm gas flow rate. tracheostomy-mediated ventilation was assessed in combination with a hme, with the nebulizer placed between the hme and the tracheostomy tube. international standard iso adult breath settings (vt ml, bpm , i:e : ) were used across all tests, and generated using a breathing simulator (asl , ingmar medical, usa) or mechanical ventilator (servo-u, maquet, sweden). the dose delivered to the lung was assessed using a capture filter at the level of the trachea, with drug mass determined using uv spectrophotometry at nm and interpolation on a standard curve. the results of testing are illustrated in figure . the bronchodilator dose delivered to the simulated patient was seen to be relatively consistent between progressive interventions, except during high flow therapy, with the more clinically relevant lpm gas flow rate having a profound effect on the dose. these results may go some way towards explaining how different patient interventions can affect aerosol dose. the the mechanical ventilation (mv) have been identified as an independent factor indicating a worse prognosis for lung cancer patients [ ] . this study was conducted in order to assess the results of noninvasive mechanical ventilation (niv) and/or invasive mechanical ventilation (imv) modalities in lung cancer patients admitted to the icu with acute respiratory failure (arf). in this study, lung cancer patients with respiratory failure who were admitted to the icu between january and december were evaluated retrospectively. results: patients were included in the study. the mortality rate was . %. patients had niv. imv was applied to patients. in the first hours, of the patients who were initially treated with niv were administered imv. the duration of hospital stay, diagnosis of pneumonia and mortality rate were found to be significantly lower in patients treated with niv alone (p≤ . , p= . , p= . ), but glaskow coma score (gcs) was significantly higher in this group (p≤ . ). the mortality rate was similar between the patients who were initially treated with imv and those who were treated with imv in the first hours. charlson comorbidity index (cci) and mv duration were significantly higher in patients who died (p= . , p= . ), but gcs was significantly lower in this group (p= . ). in the linear regression model for the likelihood of mortality, ccl≥ and unsuccessful niv increased the mortality rate by . ( . - . ) and . times ( - . ) respectively (p= . , p= . ). niv has been an effective modality for respiratory support in most lung cancer patients presenting with arf. however, failed niv seems to be a factor for increased mortality. therefore, the choice of respiratory support modality to be applied in this patient group should be decided by considering the gcs, cci and etiology of arf. the interaction between ventilator settings and the occurrence of acute kidney injury is not fully elucidated. this study aimed at investigating the effect of stepwise increase in peep level on the risk of acute kidney injury as evaluated with the renal resistivity index (rri).the primary outcome is to investigate whether increased levels of peep could lead to increase rri and whether rri could predict the occurrence of aki. methods: patients mechanically ventilated for at least hours and without aki at admission were included in the study. rri was calculated at icu admission. posterolateral approach was used for kidney ultrasound. the peak systolic velocity (v max ) and the minimal diastolic velocity (v min ) were determined by pulse wave doppler, and the rri was calculated as (v max -v min )/v max . the exam was performed modifying the peep levels: , and cm h o in random order for minutes. occurrence of aki was defined within days according to kdigo criteria. sixty-four patients were enrolled in the study and incidence of aki was / ( %). demographical and clinical characteristics are reported in table . increase in peep showed a significant increase in rri from peep to peep (p< . ) and from peep to peep (p= . ) ( figure ). the area under the roc curve of rri to predict aki was . at peep , . at peep and . at peep (all p< . ). the youden index analysis showed an rri> . as the best cut off for aki with a sensibility of % and a specificity of %. patients with rri> . were / ( %), / ( %) and / ( %) at peep ,peep and peep respectively. patients ventilated with a peep value associated with rri> . had higher incidence of aki ( / vs / , p< . ). the application of peep can increase intrarenal vascular resistance,which is associated occurrence of aki; peep level should therefore be balanced taking into account the rri. the rri seems able to predict occurrence of aki in mechanically ventilated patients. alveolar and respiratory mechanics modifications produced by different concentrations of oxygen in healthy rats subjected to mechanical ventilation with protective ventilatory strategy d dominguez garcia , r hernandez bisshopp , jl martin barrasa , d viera camacho , a rodriguez gil , j arias marzan , s garcia hernandez high oxygen can damage tissues [ ] . in this study, we analyze the histological and pulmonary mechanics modifications that can occur when identifying different inspiratory oxygen fractions (fio ) in lungs of healthy rats during protective mechanical ventilation. we use sprague-dawley rat. groups were designed, each with animals, the tidal volume ( ml/kg), peep ( cmh o) and respiratory rate ( rpm) were kept constant, changing the fio between the groups. four groups were established: fio . , . , . and . after hours, the lungs were removed for histological study and obtaining the wet/dry index. the histological modifications studied were: alveolar septa (as), alveolar hemorrhages (ah), intraalvelolar fibrin (if) and inflammatory infiltrates (ii). each parameter was rated from to [ ] . peak pressure (pp) and pulmonary compliance were monitored every minutes. different statistical tests will be used to analyze the data. results: references to the damage produced in the as, ah, if, ii and the global histological pattern were identified in the groups with the highest fio and there was more damage (p < . ) ( figure ). the wet/dry index rose significantly as the oxygen concentration increased (p = . ). in the groups to which a fio of . and was administered, the pp selected specific values with respect to the baseline intake from the first minutes, an aspect that was not appreciated in the other groups (p < . ). regarding pulmonary compliance, it will be seen that, in the fio . and groups, it decreased from the first minutes, finding differences with respect to the other groups (p < . ). conclusions: mechanical ventilation applied for hours in healthy animals produces disorders that are more pronounced as oxygen concentration increase. fio greater than or equal to . should be avoided without clinical justification. introduction: patients requiring prolonged acute mechanical ventilation (pamv, defined as + days on mv) are sicker and incur disproportionate morbidity and costs relative to patients on short-term mv (stmv, < days of mv). we quantified specific clinical outcomes among patients requiring pamv vs. stmv in a contemporary database. we conducted a multicenter retrospective cohort study within~ hospitals in the premier database, - . using icd- -cm and icd- codes we identified pamv and stmv patients, and compared their baseline characteristics and hospital events. because of the large sample size, we omitted hypothesis testing. a total of , patients met the enrollment criteria, of whom , ( . %) received pamv. at baseline, patients on pamv were similar to stmv with regard to age (years: . ± . pamv vs. . ± . stmv), gender (males: . % pamv vs. . % stmv), and race (white: . % pamv vs. . % stmv). pamv group had a higher comorbidity burden than stmv (mean charlson score . + . vs. . + . ). the prevalence of each of the indicators of acute illness severityvasopressors ( . % vs. . %), dialysis ( . % vs. . %), severe sepsis ( . % vs. . %), and septic shock ( . % vs. . %)was higher in pamv than stmv, as were hospital mortality and combined mortality or discharge to hospice (figure ), extubation failure ( . % vs. . %), tracheostomy ( . % vs. . %), development of c. difficile ( . % vs. . %), and incidence density of ventilator-associated pneumonia ( . / , patient-days vs. . / , patient-days). conclusions: over / of all hospitalized patients on mv require it for days or longer. pamv patients exhibit a higher burden of both chronic and acute illness than those on stmv. commensurately, all clinical outcomes examined are substantially worse in association with pamv than stmv. identifying the readiness of patients recovering from critical illness for liberation from invasive mechanical ventilation (imv) is not always straightforward [ ] . the scottish intensive care society (sics) trainee audit conducted a scotland-wide study to understand current practices relating to liberation from imv. data were prospectively collected on patient demographics, indication for intubation, spontaneous breathing trial (sbt) practices, physiological markers, icu outcome and icu los. all patients > years ventilated with imv for > hrs from the st nov. - th nov. were eligible for inclusion. exclusion criteria included extubation for end-of-life, death whilst intubated and presence of tracheostomy. logistic regression was performed to detect factors associated with extubation failure (ef). results were analysed via excel and stata v. . . patient benefit and privacy panel approval was granted. total population of patients were included: ( %) male and median apache score (iqr - ). ef at first attempt occurred on occasions ( . %), median icu los of days (iqr - ), mortality rate . %. the cohort successfully extubated first time had a median icu length of stay of days (iqr - ) and mortality rate of . %. methods of sbt and extubation outcomes detailed in table . no sbt prior to extubation had higher odds of ef (or . , ci . - . , p= . ); patient ventilation for < days had a three times higher odds of ef (or . , ci . - . , p= . ). these were independently associated with ef on multivariate analysis conclusions: we found a reintubation rate of . % in scottish icus. type of sbt most commonly used is divergent from the methods advocated in the literature. the lack of sbt and early extubation attempt was associated with failure, which in turn was associated with longer icu los and higher mortality. in patients undergoing prolonged invasive ventilation we hypothesise that abnormal right ventricular (rv) and left ventricular (lv) function are associated with increased -day mortality. whether changes in lv or rv function could aid in the prognostication of these patients has not been directly studied. patients admitted to the queen elizabeth hospital birmingham icu between april and july who were intubated and ventilated for more than days and had a formal transthoracic echocardiogram (tte) whilst in icu were included. abnormal rv function was defined by the presence of depressed function, dilated size or moderate to severe risk of pulmonary hypertension. abnormal lv function was defined by the presence of lv depression (lv ejection fraction £ % or grade ii or more diastolic dysfunction) or a hyperdynamic lv (formally mentioned in tte report). patients who had a neurological cause for prolonged ventilation were excluded. the primary outcome was -day mortality. categorical data is presented as % and analysed using a chi-squared test. continuous data is presented as median (iqr). results: patients required prolonged ventilation, of which ( %) had a tte. patients were aged ( - ), were % male and had a % -day mortality. the median ventilator days were ( - ) and % required a tracheostomy. abnormal rv function was present in % (n= ) and was associated with an increased -day mortality compared to normal rv function ( % vs. %, rr . [ . - . ], p< . ). lv function was abnormal in % (n= ) and was associated with an increased -day mortality compared to normal lv function ( % vs %, rr . [ . - . ], p < . ). abnormal rv function had a trend towards an increased mortality compared to abnormal lv function ( % vs %, rr . [ . - . ], p = . ). in this study, abnormal rv and lv function were present in a quarter of patients undergoing prolonged ventilation and were associated with an increased mortality. introduction: tidal volume delivered by mechanical ventilation (mv) in sedated patients is distributed preferentially to ventral alveoli, causing overdistention and associated collapse in dorsal alveoli, driving volutrauma, atelectrauma and ventilator-induced lung injury [ ] . temporary transvenous diaphragm neurostimulation (ttdn) stimulates diaphragm contraction [ ] . when used in synchrony with mv, ttdn encourages increased dorsal ventilation due to the change in pressure gradients with diaphragm contraction, mimicking a more normal physiological pattern. this may improve gas exchange and reduce injury. a pilot study was conducted using kg pigs undergoing mv in a mock icu. deeply sedated subjects were provided lung-protective volume-control ventilation at ml/kg. ttdn diaphragm contractions were delivered in synchrony with inspiration on every second breath, reducing the ventilator pressure-time-product by - % during mv+ttdn breaths. tidal volume distribution was recorded in each condition using electrical impedance tomography, and compared to never-ventilated, spontaneously breathing subjects (nv). results: dorsal ventilation changed from % during mv breaths to % during mv+ttdn breaths, compared to % in the nv group (p= . ). ventral ventilation changed from % during mv breaths to % during mv+ttdn breaths, compared to % in the nv group (p= . , figure ). conclusions: ttdn diaphragm contraction used as an adjunct to mv yields a more physiological pattern of volume distribution. this translates into less overdistension in the ventral areas and less atelectrauma in the dorsal areas and reduces ventilator-induced lung injury. this technology introduction: by measuring the pes and its derivatives, we can measure the relationship that exist between the diaphragmatic excursion and the oscillation of the esophageal pressure curve: pswing (ps) so we infer that, just as with the pes, the variations of it might be related to a weaning failure [ , ] . however, no nominal value exists in the bibliography to predict the test result. patients who meet with the inclusion criteria start the weaning process through a test of minutes of spontaneous ventilation, t-tube (tt). and also the respiratory rate (rr) and the tidal volume (tv). from this analysis, an average ps (aps) is determined for each moment of the test (aps , initial and aps , final.).a quotient was obtained in relation to these variables using the value previously obtained (quotient dtv/dps x . a total of patients were included (n= ).regarding the evolution during tt, (n= ) ( %) were successful, while (n= ) ( . %) failed when analyzing a rate that relates the variables tv and ps, a quotient was obtained in relation to these variables using the value previously obtained (quotient dtv/dps) for patients who were successful and who failed, (dtv/dps)/ successful patients presented a value of . while those of the failure group presented a value of . , (or , - p= . ) ( table ) . when presenting the relationship between tv and ps through the quotient (dvt/dps)/ , it is observed a tendency to have a higher quotient among patients who failed versus those who did not fail. the process of weaning from mechanical ventilation imposes an additional workload on the cardiovascular system, which may result in impaired myocardial function, increase in left ventricular filling pressure and respiratory distress. among surgical patients, those undergoing heart surgery are particularly susceptible to cardiac dysfunction induced by weaning because of inadequate cardiovascular reserve. the aim of our study was to depict the pathophysiological changes assessed by echocardiography during the steps of weaning and to identify possible predictors of weaning failure (wf). we enrolled consecutive patients undergoing isolated coronary artery bypass grafting in our institution. data were obtained by intraoperative transesophageal echocardiography before sternotomy (t ) and by transthoracic echocardiography at the beginning of weaning (t ) and at the time of extubation (t ). wf was defined as deferral of planned extubation or respiratory failure needing reintubation or non-invasive mechanical ventilation within hours. results: wf occurred in patients ( . %) and involved manifestations of respiratory distress in ( . %). we found a significant association between left ventricle outflow tract-velocity time integral (lvot-vti) and ventricular-arterial coupling measured at t and wf, with lvot-vti emerging as the best predictor of wf with an area under roc curve of . ( figure ); an optimal cutoff value of cm provided % sensitivity and % specificity. significant increase in e/e' measured at t ( . vs . , p . ) suggested a cardiac etiology of respiratory distress in patients who failed the weaning trial. our study showed that serial assessment of hemodynamic parameters by means of echocardiography is feasible in cardiac surgical patients and can provide insight into pathophysiological changes during weaning. although these preliminary data need to be confirmed in a larger population sample, lvot-vti emerged as a promising predictor of subsequent wf. compliance with guidelines for respiratory therapy in preclinical emergency medicine g jansen, n kappelhoff, s rehberg protestand hospital of the bethel foundation, anaesthesiology, intensive care and emergency medicine, bielefeld, germany critical care , (suppl ):p introduction: current guidelines on pre-hospital emergency ventilation are based on the guidelines for lung protective ventilation in the intensive care unit. the present survey was designed to determine the accordance of actual pre-hospital emergency ventilation by german emergency physicians (gep) with these recommendations. recommendations include a respiratory rate (rr) between - /min, a tidal volume (vt) between - ml/kg, a maximum pressure (pmax) < mbar and a positive end-expiratory pressure (peep) of mbar. an anonymous web-based questionnaire encompassing questions was sent to gep from september to december of . gep were asked to specify their level of education, their preferred ventilation settings and the usually chosen parameters employed to guide mechanical ventilation. statistical analysis was performed using the ch²-test with a significance level ≤ . . % of the questionnaires were completed ( / ). % of the participants were trainees (tr), % consultants (co). as target parameters for guidance of ventilation, % of the tr and % of the co use capnometry. the vt controlled % of the tr and % of the co on the basis of body weight. % of the tr and % of the co reported to control oxygenation using spo . table shows our analysis of the given answers. there were no statistically significant differences between the groups. deviations from the guidelines of pre-hospital emergency ventilation settings are common and mainly concern the use of a guidelinecompliant peep. in addition, recommended target parameters for guidance of ventilation were not applied in a significant proportion of gep. prospective observational study including ltx recipients admitted to our icu from february to january , who underwent a spontaneous breathing trial (sbt) using a t-piece for minutes. clinical variables and arterial blood gas samples were recorded before starting sbt and after minutes on the t-piece. diaphragmatic excursion (de) and thickening fraction (dtf) were also assessed using ultrasound(us) after minutes on the tpiece. us-dd was defined as de< mm or dtf< . of at least one hemidiaphragm. patients who successfully completed a sbt, defined according to clinical criteria,were extubated. extubation failure was defined as the need for reintubation within h. results are expressed as medians (iqr) or frequencies (%). ltx recipients were admitted to the icu, of whom underwent an sbt. were male, and the median age was y. main indications for ltx were interstitial lung disease ( . %), copd and cystic fibrosis. were bilateral ltx, and and were left and right unilateral ltx respectively. patients were extubated after sbt and required reintubation within h. presented us-dd, though there were no differences between patients who succeeded and those needing reintubation. in contrast, patients who succeeded showed higher pao /fio after minutes on the t-piece (table ) . similarly, higher reductions in deltapao /fio after minutes on the t-piece were observed in patients who failed. oxygenation after sbt performed using a t-piece may predict extubation failure in ltx recipients with successful sbt. us-dd was not associated with the need of reintubation. descriptive study about the relationship between self-extubation episodes and patient-ventilator interaction s nogales , introduction: to evaluate the relationship between self-extubation and patientventilator interaction, among other physiological variables, in order to predict and to prevent these events. self-extubation (se) are quality indicators in patients under invasive mechanical ventilations (imv) and are related with mortality [ ] . planned secondary analysis of a prospective data base of clinical and physiologic signals of patients receiving imv. we included se episodes ( - ) with continuous record of ventilator and monitor signals (bclink bettercare®). we analysed demographic data, physiological parameters (peripheral oxygen saturation spo , heart rate hr, respiratory rate rr and media arterial pressure map) and patientventilator interaction (asynchrony index ai, ineffective efforts during expiration iee and double cycling dc). we studied a period of hours prior to the se episode. we used the wilcoxon non-parametric test and for a proper analysis a linear mixed effects model. we included episodes of se, mean age ± years, %men, apache ii at admission ± , , ± , days under imv until the episode, reintubation rate . %, icu stay , ± , days, icu mortality %. at the time of the se, % were under sedation, % with physical restraint. the % were in weaning. we observed a trend to increase in spo , rr, hr, map and asynchronies in the -hour period prior to se episode. we compared these variables from this period with a -hour period before and we observed a statistically the data presented in this study show that our results are in accordance with the literature with favorable mortality and early postoperative complication rates and support that this procedure is an excellent alternative for surgery in the elderly patients. it is reported that patients with pulmonary hypertension (ph; systolic pulmonary arterial pressure (spap)≥ mmhg)) have frequent cardiac complications after transcatheter aortic valve implantation (tavi). ph often gets worse in some patients despite the normal cardiac function after tavi. no studies have ever examined prognosis after tavi in patients with or without worsening of ph. therefore, we retrospectively examined the frequency of mid-to long-term heart failure and cardiac death in patients with and without deterioration of ph after tavi. among patients who underwent tavi at our hospital between february and march , we analysed patients with ph (spap≥ mmhg) before surgery. spap was measured in transthoracic echocardiography before and within week after tavi. patients were divided into two groups according to whether spap worsened/ did not change or improved after tavi. we examined the frequency of admission due to heart failure or cardiac death (death caused by heart failure, angina, or myocardial infarction) during the period of years after tavi. ph worsened or did not change after tavi in patients, while it improved in patients. the left ventricular ejection fraction measured within week after tavi showed no difference between the two groups ( . ± . % vs . ± . %, p= . ). the worsened/ no change group was higher in frequency of admission due to heart failure (logrank; p< . ) and cardiac death (logrank; p< . ). despite successful treatment for as by tavi, the frequency of heart failure and cardiac death was higher in patients who did not show improvement of ph after tavi, even in the absence of cardiac function decrease. vigorous intervention for ph worsening after tavi may be helpful to improve prognosis. the there are several different anti platelet drugs that can be used to treat acute cardiac events. currently there are no effective markers that can assess how these drugs modify coagulation profile and quality. a new functional biomarker that measures fractal dimension (df ) and clot formation time (tgp) has been developed [ ] . df quantifies clot microstructure whereas tgp is a real-time measure of clotting time. we aimed to validate df and tgp in st elevation myocardial infarction (stemi) and assess the effect of two p y inhibitors which have different pharmacological mechanisms: clopidogrel and ticagrelor. we prospectively recruited stemi patients in the emergency setting. venous blood samples were collected hours after admission, following treatment with either ticagrelor or clopidogrel, in accordance with the local guidelines at the time. the blood samples were tested using the df and tgp biomarker, platelet aggregometry, clot contraction and standard markers of coagulation. results: patients received clopidogrel and received ticagrelor. the df for clopidogrel was higher than ticagrelor ( . ± . vs . ± . , p= . which corresponds to a decrease in clot mass of % figure ) and the tgp was reduced ( ± sec vs ± sec, p= . a % reduction in time). the results of the study suggest that clopidogrel is less powerful in its effects on clotting characteristics compared to ticagrelor. blood from patients receiving clopidogrel formed quicker and denser clots. this would suggest the risk of secondary events or stent occlusion is lower in those patients on ticagrelor, highlighting that df and tgp may be important in identifying patients at risk of future thrombotic events, the study is ongoing and will investigate the long term outcome in these patients. introduction: new onset atrial fibrillation (noaf) during critical illness frequently resolves prior to discharge. however long-term risks of noaf (i.e. heart failure, ischemic stroke and death)remains high [ ] . previous studies noted that nearly half of noaf cases did not have diagnosis recorded [ ] . addressing this may reduce post critical illness mortality by increasing af surveillance post intensive care (icu) discharge. retrospective data was collected from an electronic health record for icu admissions over a month period from a biomarker is defined as a measurable indicator of some biological state or condition. combined with a good clinical evaluation, they can enable an early and safe diagnostic, thus a faster management for the patient. cardiac biomarker testing is not indicated in routine in the emergency department (ed) because of low utility and high possibility of false-positive results. however, current rates of testing are unknown. the aim of our study was to evaluate the importance of measuring cardiac biomarkers especially troponins, d-dimer, and btype natriuretic peptide in our daily practice, and to identify the latest recommendations for a better use of these biomarkers in the diagnostic and therapeutic approaches. we conducted a prospective observational study, over a months periods performed in the ed of the university hospital center ibn rochd, casablanca, morocco, including all patients admitted during our study period and having a blood test for at least one biological marker. the dataset was analyzed by spss statistics . . a total of patients was enrolled. troponins were tested in . % patients (high sensitive in . % and troponin i tni in . %), ddimer in . %, bnp % and nt pro bnp in . % of cases. the diagnostic impact was significant in . % of cases for troponins, . % of cases for d-dimer and . % for bnp. the therapeutic impact was considered important in . % cases for troponins, . % for ddimer and . % for bnp. cardiac biomarkers have an important role in the ed, not only do they confirm the diagnosis (including the role of troponins in acs) but also eliminate others (with a strong negative predictive value of d-dimer for thromboembolic disease) and prove the cardiopulmonary origin of acute dyspnea (the significant place of bnp in confirming the diagnosis of acute heart failure). a multicenter study on the comparison of inter-rater reliability of a new and the original heart score among emergency physicians from three italian emergency departments the heart (based on history,ecg,age,risk factors,troponin) score is a valid tool to stratify the acs in chest pain. but some reports suggest that its reliability could be low for heterogeneity in the assignment due to the subjective interpretation of the history. we used the chest pain score for the "history". in this study we compare the reliability of the new heartcps and original heart. this is a multicenter retrospective study conducted in italian ed between july and october using clinical scenarios. ten physicians were included after a course on heart and heartcps score. we used scenarios which included clinical and demographic data. each participant independently assigned scores to the scenarios using the heart and heartcps. we tested the interrater agreement using the kappa-statistic (k), the confidence intervals are bias corrected ; we used stata/se . statistical software . a p-value of < . defines statistical significance. the overall inter-rater reliability was good for heart and heartcps: kappa = . (ci %; . - . )and , (ci %; . - . ); with good agreement among all the class of risk for heartcps but moderate in the medium class for heart . we found significant differences of inter-rater reliability among the senior and junior physicians who used the heartcps:k= . (ci %; . - . )and . (ci %; . - . ). heartcps score increased its history inter-rater reliability specially among the junior physicians from k= . (ci %; . - . ) to k= . (ci %; . - . ).the junior physicians seem to be more reliable than senior with the heartcps:k= . ( . - . ) vs k= . (ci %; . - . ). the heartcps showed inter-rater reliability better than original heart among the medium class of risk and the junior group. it could be proposed to young doctors to stratify the acs risk of chest pain. limit: we used scenarios rather than real patients. a hybrid approach as treatment for coronary artery disease: endo-cabg or pci first, does it matter? introduction: the aim of this study is to discuss the short-term results of a hybrid approach combining minimally invasive endoscopic cabg (endo-cabg) with a percutaneous coronary intervention (pci). to bypass the disadvantages and potential complications of conventional cabg via median sternotomy, we developed the endocabg technique to treat patients with single-and multi-vessel coronary artery disease (cad). this procedure is performed with three -mm thoracic ports and a mini-thoracotomy utility port ( cm) through the intercostal space. this technique can be combined with pci: the hybrid approach. the sequence of the procedures (endocabg followed by pci or vice versa) may result in different outcomes. from / to / data from consecutive patients scheduled for a hybrid technique at jessa, belgium, were prospectively entered into a customized database. this database was retrospectively reviewed. subgroup analysis was performed to compare outcomes of patients who first received endocabg with patients who first received pci. a p-value < . is considered significant, a p-value < . is considered as a trend toward significance. four patients underwent revision surgery and patients died within the first days. in patients the left anterior descendens artery (lad) was grafted with the left internal mammary artery (lima), the right coronary artery (rca) was the most stented vessel using pci. patients first treated with pci received more units of fresh frozen plasma after endocabg compared to those who were first treated with endocabg (p= . ). there was also a trend toward significant more transfusion of packed cells in this small subgroup (p= . ). the hybrid approach is a feasible technique as a treatment option for patients with multi-vessel cad. if cabg follows the pci, patients are more likely to receive transfusion. a possible explanation could be the need for dual antiplatelet therapy prior to surgery in this group, but this needs further investigation. prognostic difference between troponin elevation meeting the mi criteria and troponin elevation due to myocardial injury in septic troponin t (ctnt) elevation in critically ill patients is common and is associated with poor outcome. using common assays, - % of patients in the icu will have elevated troponin level. our aim was to determine whether there is any prognostic difference between troponin elevation meeting the mi criteria (rise and fall more than % together with echo and ecg new abnormalities) and troponin elevation due to myocardial injury in septic patients. we enrolled patients with sepsis and mean sofa score , respectively in which ctnt level was measured more than once and analyzed there ecg and echo findings. patients were classified into three groups:definite mi (rise and fall ctnt ≥ % and contemporaneous changes on ecg and/or echo),possible mi (rise and fall ctnt ≥ % and no other findings),myocardial injury (ctnt rise less than %) results: data from patients were analyzed ( % female; mean age . (sd . )). a total of patients had at least one elevated ctnt more than . mkg/l. in ( %) of patients ctnt level rised more than % from the first elevated measurement. ( %) of patients met mi criteria considering new ecg and echo findings. the overall mortality rate in all patients was . %.the mortality rate didn't differ significantly in three groups: in the definite mi group . %, in the suspected mi group %, in the non mi ctnt elevation group , %, p= , . coronary angiography was performed in ( %) of patients from the definite mi group,pci was performed in ( %) of patients. the mortality rate in the invasive group was not significantly lower comparing to the nonivasive group % vs , %, p= , . bleeding complications were significantly more frequent in the definite mi group % vs % and % respectively conclusions: ctnt level elevation is associated with poor outcome regardless coronary or non coronary injury. myocardial revascularization may be beneficial in patients with sepsis and definite mi, but it is also associated with increased bleeding risk. diagnostic interest of "marburg heart score" in patient consulting the emergencies department for acute chest pain chest pain is a common reason for emergency department visits, although this primarily refers to acute coronary syndrome (acs), this symptom may be frequently related to other non-ischemic etiologies. the aim was to validate the marburg heart score as a tool to exclude coronary artery disease in emergency department patients with nontraumatic acute chest pain. methods: a prospective, observational, descriptive and analytic cohort study conducted in the emergency department, from february st to march st, , collecting patients consulting for nontraumatic acute chest pain, the "marburg heart" score was calculated for all these patients. telephone contact was made after weeks to look for an ischemic cardiovascular event. we included patients. the mean age was +/- years, the sex ratio was . . the majority of the patients ( . %) consulted directly to the emergency department, . % were referred by a primary care physician. the median time to consultation after the onset of chest pain was hours. high blood pressure was the most common risk factor ( . %), followed by smoking ( %), diabetes ( . %) and dyslipidemia ( . %). thirty-five patients ( . %) had already coronary heart disease, ecg was pathological in . % of patients, patients had an acs with st segment elevation. at six weeks, . % of the patients had an acute coronary event. according to the patients' answers on the questions of the marburg heart score. the area under the roc curve of this score was . with a negative predictive value of . %; the "marburg heart score" is a simple, valid and reproducible clinical score with a discriminatory power to rule out the diagnosis of coronary artery disease from the first contact with the patient presenting for chest pain in emergencies. the abdominal aortic aneurysm (aaa) surgery is a complex procedure in elderly patients with high cardiovascular risk. anesthesiological techniques should play special attention to the volume status during cross-clamping as well as to the blood loss. goal directed fluid therapies (gdt) in aaa surgery in elderly patients decrease the perioperative morbidity and mortality [ ] . aim of this study is to investigate administration of fluid-based on either a gdt approach or a control method (fluid administered based on static preload parameters and traditional hemodynamic) in all phases of aaa surgery and especially in the phase of clamping and de-clamping. a total of patients asa iii, randomly scheduled for elective, open aaa surgery were included in this clinical trial. they were randomly assigned to two groups i -gdt with targeting stroke volume variation (svv) and ii -control group where fluids were administered at the discretion of the attending anaesthesiologist. in both these groups hemodynamic parameters, central venous pressure (cvp), temperature, blood loss and diuresis were registered during the operation and hours postoperatively. each group was assessed for postoperative complications. gdt group received less fluids and had a higher cardiac index (ci) ( . ± . vs. . ± . l/minute per m , p < . ) and stroke volume index ( . ± . vs. . ± . ml/m , p < . ) than the control group. there were significantly fewer complications in the intervention than control group ( vs. , p = . ). gdt fluid administration enables less use of fluids, improved hemodynamic and fewer postoperative complications in elderly patients undergoing aaa surgery. ultrasonography is a valid diagnostic tool, used to measure changes of muscle mass. the aim of this study was to investigate the clinical value of ultrasound-assessed muscle mass, in patients undergoing cardiothoracic surgery that present muscle weakness postoperatively. for this study, consecutive patients were enrolled, following their admission in the cardiac surgery intensive care unit (icu) within hours of cardiac surgery. ultrasound scans, for the assessment of quadriceps muscle thickness, were performed every hours for days. muscle strength was also evaluated in parallel, using the medical research council (mrc) scale. of the patients enrolled, ultrasound scans and muscle strength assessment were performed in patients. the muscle thickness of rectus femoris (rf), was slightly decreased by . % ([ %ci: - . ; . ], n= ; p= . ) and the combined muscle thickness of the vastus intermedius (vi) and rf decreased by . % ([ % ci: - . ; . ], n= ; p= . ). patients whose combined vi and rf muscle thickness was below the recorded median values ( . cm) on day (n= ), stayed longer in the icu ( ± vs ± hours, p = . ). patients with mrc score ≤ on day (n= ), required prolonged mechanical ventilation support compared to patients with mrc score ≥ (n= ), ( ± vs ± hours, p = . ). the use of muscle ultrasound seems to be a valuable tool in assessing skeletal muscle mass in critically ill patients after cardiothoracic surgery. moreover, the results of this pilot study showed that muscle wasting of patients after cardiothoracic surgery is of clinical importance, affecting their stay in icu. prediction of cardiac risk after major abdominal surgery s musaeva, i tarovatov, a vorona, i zabolotskikh, n doinov kuban state medical university, anesthesiology and intensive care, krasnodar, russia critical care , (suppl ):p the aim is to assess the incidence of cardiovascular incidents in major abdominal surgery [ ] using the revised lee index. a study was conducted of elderly patients who underwent major abdominal surgery in the krasnodar regional clinical hospital no. under combined anesthesia. in the preoperative period, the risk of cardiovascular incidents was assessed using the revised lee index and the functional status was assessed by met. depending on the lee index, groups were identified: group (n = ) -low risk (index value - ), group (n = ) -intermediate risk (index value - ); group (n = ) -high risk (index value> ). we estimated the incidence of critical incidents in groups: hypo-, hypertension, arrhythmias, and bradycardia. in the general population, cardiac risk was . ± . points; functional status - . ± met. the greatest number of critical incidents was recorded in patients with high risk ( . %), the smallest -in patients with low risk ( . %), in patients with intermediate risk - . % (n < , between groups according to chi-square criterion). in the structure of critical incidents, hypotension was most often encounteredin ( %) patients, while some patients revealed several incidents from the circulatory system (n = ). overall, the lee scale showed good prognostic ability (auroc = . ) in predicting hemodynamic incidents. the revised lee index is a useful tool to help assess the risk of cardiovascular incidents and determine patient management tactics in the perioperative period. postoperative cognitive dysfunction (pocd) remains an unresolved problem due to lack of consensus on its etiology and pathogenesis. some believe that pocd is the result of the direct toxic effect of general anesthetics on the nervous system. others claim that surgical trauma activates proinflammatory factors that induce neuroinflammation. wistar rats were allocated into groups: -minor surgery (n= ), major surgery group (n= ). after days of handling and habituation rats undergone surgery under isoflurane general anesthesia ( vol.%). group rats underwent laparotomy with gentle gut massage followed by wound closure. rats in group undergone left side nephrectomy. starting from the th postoperative day spatial memory in rats was studied in morris water maze which is a cylinder metal pool with a diameter of . and a height of . m filled with water (temp. ± o c) up to half. it has a platform with a diameter of cm and a height of cm below the water level. testing was preceded by a training stage, which included sessions daily for days. thus, rats developed spatial memory to the location of the platform. on the th day of the study test stage was conducted to assess spatial memory: rats were launched from points into maze without platform and data were recorded for seconds at each session. time spent on the target quadrant (ttq) and the number of target area crossings (tac) were registered. a second test was conducted days after the first test to evaluate long-term spatial memory. the duration of surgery and anesthesia did not differ significantly between groups. there was a significant difference between groups in average ttq and tac in test (table ). in test minor surgery group showed better results but they were less significant. major surgery is associated with a more pronounced deterioration of spatial memory in rats in early postoperative period compared to minor surgery. cardiac inflammatory markers in icu patients with myocardiac ischemia after non cardiac surgery (a pilot study) p manthou , g lioliousis , p vasileiou , g fildissis national kapodistrian university of athens, athens, greece; national kapodistrian university of athens, general thoracic hospital´´sotiria´´, athens, greece; national kapodistrian university of athens, university of athens, athens, greece critical care , (suppl ):p patients with known coronary artery disease have higher perioperative risk for myocardial ischemia [ , ] . mortality is frequent following cardiac ischemia in the intensive care unit (icu) after non-cardiac surgery. the first group includes patients admitted to the intensive care unit for post-operative follow-up without myocardiac ischemia in the first hours. the second group includes patients with myocardiac ischemia postoperatively and needs intensive care monitoring. cardiac risk assessment was made with the lee index,hemorrhagic risk assessment with the has-bled bleeding score and thrombotic risk assessment with cha ds -vasc score. postoperatively, pathological test values such as bnp, troponin, crp, calcitonin were estimated. the sequential organ failure assessment (sofa) systeme was used to assess sepsis. the nursing activity score (nas) scale was used to measure the workload of various nursing activities in the icu. according to the pilot study, the sample consists of patients. . % had myocardial ischemia. the lee index was significantly higher in patients with myocardial ischemia. the duration of hospitalization, the high dose of vasoconstrictive drugs, the length of stay in the icu, the duration of mechanical stay and the nursing workload were higher in patients with myocardial ischemia. ck-mb and troponin levels differed significantly between the two groups. creatinine, bilirubin and bnp during the hours were significantly higher. patients with myocardial ischemia had significantly higher mortality. cardiac risk assessment, has-bled score and cha ds -vasc score in combination with cardiac enzymes such as troponin could predict myocardiac ischemia in severely ill icu patients. introduction: according to the literature an airway complication followed thyroid gland surgery are: difficult trachea intubation, tracheomalacia, postextubation stridor and bleeding [ , ] . most common cause of death was problem with respiration and airway obstruction [ ] . subsequent hypoxia could require emergency airway and even tracheostomy [ ] . aim of our study was to determine the most common of airway complications and their association with type of surgery in our region. the retrospective cohort study included pts., ( women, men) was performed in odessa regional hospital, oncology centre odessa. there were three types of patients: with euthyroid goiter - ( %), polynodos goiter - ( %) and thyroid cancer - ( %) ( table ) . airway complications were diagnosed after trachea extubation based on indirect laryngoscope, presence of stridor, desaturation. the pearson's criteria was calculated. the ratio of airway complications after thyroid surgery was . % ( pts). the main reasons of airway complications in thyroid surgery included: laryngeal edema - pts ( . %); recurrent laryngeal nerve injury - pts ( . %) and postoperative bleeding pts ( . %). thyroid gland cancer and polynodosal goiter associated with laryngeal edema and recurrent laryngeal nerve injury (pearsen criteria were . -moderate and . consequentially). it's may require more attention from the anesthetists after extubation and readiness for an urgent airway. serum iron level and development of multiple organ dysfunction syndrome in patients in the perioperative period s tachyla mogilev regional hospital, department of anesthesiology and intensive care, mogilev, belarus critical care , (suppl ):p recently there has been attention of researchers to the problem of perioperative anemia. it was found that it increases the risk of death and postoperative complications. threatening complication is multiple organ dysfunction syndrome (mods). the objective was to determine the level of serum iron in the perioperative period in patients with endoprosthetics of large joints, and with the presence of mods in abdominal surgery. a prospective cohort study was conducted in patients, including men and women, age . ± . years. two groups were identified: st (control) -patients after endoprosthetics of large joints (n = ), nd (main) -patients in abdominal surgery with the presence of mods (n = ). the presence of mods was established based on the criteria for the sccm / accp conference. serum iron was monitored using an au analyzer (usa). the study identified several stages: st -before surgery, nd - st day after surgery, rd - rd day, th - th day, th - th day. when studying the indicators of serum iron, its significant decrease (p < . ) in the postoperative period was established. in the st group: st stage - . ( - . ) mmol / l, nd stage - . ( . - . ) mmol / l, rd stage - . ( - . ) μmol / l, stage - . ( . - . ) μmol / l, stage - . ( . - ) μmol / l. in the nd group: st stage - . ( - ) mmol / l, nd stage - . ( . - . ) mmol / l, rd stage - , ( . - . ) μmol / l, stage - . ( . - . ) μmol / l, stage - . ( . - ) μmol / l. moreover, in both groups, iron increased at the th stage against the nd stage (p < . ). when comparing the level of iron between the groups, significant differences were found (p < . ) at the nd, rd and th stages. in patients in the postoperative period, a decrease in serum iron is observed, the level of which rises by the th day, but does not reach the initial values. this decrease is more pronounced in patients with the presence of mods after abdominal surgery. kidney and pancreatic graft thrombosis happened in . % and . %, respectively, and bleeding in . %. forty-one ( . %) developed at least one infection during hospital stay. infection during icu was found in . % and main pathogens were gram negative bacilli sensible to beta-lactam. after icu, the incidence of multi-drug resistant pathogen was . %, predominantly gram negative bacilli. fungal infection was lower %. all-cause hospital mortality rate was . %. infectious complications are the main cause of morbidity and mortality following spk transplantation. the administration of broadspectrum prophylactic antibiotics are leading to the appearance of multi-drug resistant pathogens. knowing local microbiological flora may be helpful, allowing more adequate antibiotic prophylaxis. introduction: cardiopulmonary bypass (cpb) is associated with thrombotic complications. occurrence of thrombosis after cpb is % which takes the third place between cpb-associated complications. our study determined preoperative predictors of thrombosis in children with congenital heart defects. patients with congenital heart diseases in age up to months days (median age - , months, youngest age - days after birth, oldest - months days), underwent cardiac surgery with cpb, were enrolled in this study. all patients were divided into two groups: st -without thrombosis, nd -with thrombosis. protein c, ddimer, von willebrand factor and plasminogen plasma levels were assessed directly before surgery. thrombotic cases were proven by performing doppler ultrasound or mri. thrombotic complications were diagnosed in children ( %). between all thrombotic complications ischemic strokes were diagnosed in % ( cases), arterial thrombosis in % ( cases), intracardiac thrombus in % ( cases) and mechanical mitral prosthetic valve thrombosis %( ). receiver operating characteristic (roc) curves are created for the listed indicators. area under the curve (auc) for protein c , (sensitivity(sn)- %, specificity(sp) - %), d-dimer is , (sn - %, sp %), for plasminogen activity - , (sn %, sp %) and for von willebrand factor level - , (sn %, sp %). an roc curve was created for all three indicators, the auc was . (sn - %, sp - %). these parameters can be recommended as predictors of thrombosis in children after cardiac surgery. cpb is related with a large number of life-threatening complications. in our work, preoperative predictors of thrombosis were identified. based on this data, it is possible to create thrombosis risk scale change the tactics of the anaesthetic approach, the prevention of thrombosis in the postoperative period. further studies are needed to identify other possible predictors of thrombosis. introduction: abdominal ischemia occurs in % of patients submitted to aortic aneurysm repair. its early diagnosis requires an elevated index of suspiction, particularly in more severe patients. we hypothesized that earlier increase and higher levels of c-reactive protein (crp) may help to predict intra-abdominal ischemia. we performed a retrospective study of patients admitted to the intensive care department (icd) after abdominal aorta aneurism surgery. we included all patients admitted during a two-year period, that survived for more than hours. primary outcome was splanchnic ischemia assessed by abdominal ct-scan. we also evaluated the presence of bacteremia, abdominal compartment syndrome and icd mortality. association between inflammatory parameters and ischemia was evaluated by multivariate logistic regression. introduction: crp (c-reactive protein) has been shown to be a useful biomarker in identifying complications after major abdominal surgery. gastrectomy is a high-risk surgical procedure that requires post-operative critical care support to monitor for complications which are predominantly infective in nature. the aims of this study were to determine whether there is a relationship between post-operative crp levels and patients who developed post-operative infective complications. a retrospective analysis was performed on patients undergoing elective gastrectomy for gastric cancer at a single centre between september and july . post-operative crp levels for each day following resection were analysed for all patients. roc curve analysis was used to determine which post-operative day (pod) gave the optimal cut-off. of patients included, the majority were male ( . %), mean age was . years and . % had node-negative disease. a total of patients ( . %) had an infective complication, which includes those who experienced an anastomotic leak. crp levels on post-operative day gave the greatest auc for the gastrectomy group ( . ). crp cut-off of mg/l was significantly associated with infective complications (or . , % ci . - . , p= < . ) and gave a sensitivity of % and specificity % (ppv %, npv %). more patients with a crp > on post-operative day experienced an infective complication ( % vs %, p = < . ) or a leak in particular ( % vs %, p = . ). a crp level of less than mg/l on pod may be useful to predict the development or exclude the likelihood of such infective complications in this group of patients prior to clinical signs (ppv %, npv %). this may prompt and facilitate decision-making regarding early investigation and intervention or prevent inappropriate early discharge from critical care, whilst providing more assurance in identifying those who could be stepped down to ward level care. vasoplegia is commonly observed after cardiopulmonary bypass surgery (cpb) and associated with high mortality. chronic use of reninangiotensin aldosterone system inhibitors (raasi) is associated with its incidence and ensuing need for vasopressor support after cpb. renin serves as marker of tissue perfusion [ ] . we examined the role of renin in the setting of raasi exposure and vasopressor needs in the peri-cpb period. prospective observational study of adult patients undergoing cpb, aged . ± . years ( men, women). blood was collected ) post induction, pre-cpb; ) min post cardioplegia, and ) immediately post bypass. vital signs and perioperative medications were recorded. as control, blood was collected from men and women aged . ± . , not diagnosed with lung disease and not prescribed any raasi. baseline plasma renin in cpb patients tended to be higher than in control subjects (mean= . pg/ml± . vs. . pg/ml ± . , respectively, p= . ). minutes into cpb, mean renin was increased from baseline ( . pg/ml± . , p= . ), and remained elevated immediately post cpb ( . pg/ml± . ). patients using raasi prior to cpb tended to have a larger increase in renin post cpb (delta= . pg/ ml± . ) vs. those not previously on raasi ( . pg/ml± . , p= . ). renin was elevated in patients requiring vasopressor support in the hours post cpb vs. those not requiring pressors ( . pg/ ml± . vs. . pg/ml± . p= . ). in those prescribed raasi and requiring pressors post cpb, there was a tendency toward greater renin increase than those not requiring pressors postoperatively ( . pg/ml± . vs. . pg/ml± . , p= . ). this study suggests a trend toward higher renin levels, particularly during cpb, in patients prescribed raasi, and a positive association between renin and postoperative vasopressor needs. we speculate that increased renin levels may predict postoperative vasoplegia. cardiac surgery is associated with perioperative blood loss and a high risk of allogenic blood transfusion. it has been recognized that high blood product transfusion requirement is associated with adverse clinical outcomes. guidelines on patient blood management therefor aim at reducing blood loss and blood transfusion requirements in cardiac surgery. as there remains controversy about the advantage of minimal invasive techniques on blood loss an transfusion requirements, we wanted to investigate if the average blood loss and transfusion requirement in minimal invasive endoscopic coronary artery bypass graft surgery (endo-cabg) differ from conventional technique. we assessed the influence of pre-operative anticoagulant medication for blood loss. estimated average blood loss after conventional cabg is ml (+/- ) and transfusion requirement , units packed red blood cells . we performed a retrospective cohort study of our cardiac surgical database. from / / to / / , we collected data from patients undergoing endo-cabg. we analyzed blood loss, transfusion as well as pre-operative use of anti-coagulants as a risk factor for blood loss. we found that mean total blood loss in endo-cabg does not differ from conventional cabg, nonetheless mean transfusion requirement was lower in our cohort. use of direct oral anticoagulant is aossciated with increased blood loss and transfusion requirements (table ) . total blood loss is not influenced by minimal invasive technique for cabg (endo-cabg). an explanation for the lower transfusion requirements is the use of a minimal extracorporeal circulation, which is known to reduce the risk of transfusion. another important factor is the implementation of a standardized transfusion-protocol based on available evidence. reducing transfusion requirements is an important component in improving patient outcome after cardiac surgery and is related to multiple factors in perioperative care of our patients. retinal microvascular damage associated with mean arterial pressure during cardiopulmonary bypass surgery v shipulin retinal perfusion corresponds to cerebral perfusion and it is very sensitive to hemodynamic disturbances [ , ] . we investigated the association between retinal microvascular damage and hemodynamic characteristics in patients undergoing coronary artery bypass grafting surgery (cabg) with cardiopulmonary bypass (cpb). methods: patients with coronary artery disease and systemic hypertension were examined. ophthalmoscopy and optical coherence tomography were performed before and - days after cabg. the hemodynamic parameters during cpb were analyzed. results: ( %) patients had changes in the retinal vessels and in the ganglionic fiber structure on - day after surgery: in % of patients the foci of ischemic retinal oedema appeared, in % the decrease of the thickness of ganglionic fiber were observed. these changes may be associated with intraoperative ischemia of the central retinal artery. in ( %) patients the mean arterial pressure (map) during cpb was increased up to mmhg. in ( %) of them the association between map and foci of ischemic retinal oedema were revealed. the ischemic retinal changes were observed significantly more often if the delta of map during cpb was over then mm hg compared with the patients where the delta of map was less than mm hg (p= . ). this is probably due to an intraoperative disorders of the myogenic mechanism of blood flow autoregulation in the retinal microvasculature in patients with coronary artery disease [ ] . the level of map up to mm hg during cpb is associated with retinal blood flow impairment and the foci of ischemic retinal oedema. delta of map more than mmhg was associated with the foci of ischemic retinal oedema and decreased ganglionic fiber thickness in % of cases. atrial fibrillation after cardiac surgery: implementation of a prevention care bundle on intensive care unit improves adherence to current perioperative guidelines and reduces incidence introduction: atrial fibrillation after cardiac surgery (afacs) is a very frequent complication affecting - % of all patients. it is associated with an increase in morbidity, mortality and hospital and intensive care unit (icu) length of stay. we aimed to implement an afacs prevention care bundle based on a recently published practice advisory [ ] , focusing on early postoperative (re)introduction of β-blockers. baseline afacs incidence and β-blocker administration practices in our centre were audited for all patients undergoing valve surgery or coronary artery bypass graft (cabg) during a weeks period. the afacs prevention care bundlean easy to follow graphical toolwas subsequently introduced to the cardiac icu by a multidisciplinary team and audited following a model of improvement approach. after exclusion of patients with preoperative af, differences between pre-and post-implementation groups were compared with chisquare and fisher's exact tests for categorical, and one-way anova for continuous variables, using spss. a total of patients were analysed. patient and surgery characteristics did not differ between groups. significantly more patients received postoperative β-blockers after bundle implementation ( . % pre-vs . % post-bundle, p= . ) with a higher proportion on day ( . % pre-vs % post-bundle, p< . , figure ). the incidence of afacs was significantly reduced from . % to . % (p= . ), with a particularly marked reduction in the age group - years and for isolated aortic valve and cabg surgery. there was no significant reduction in hospital length of stay for this cohort. introduction of an afacs prevention care bundle using a graphical tool improved adherence to current guidelines with regards to early β-blocker administration and significantly reduced afacs incidence. future care bundles should include preoperative interventions and might reduce hospital length of stay. in neonates with univentricular physiology, there is a delicate balance between pulmonary and systemic circulations, with a tendency towards generous pulmonary blood flow, and a risk of systemic underperfusion. preoperatively, the use of hypoxic gas mixture (hm) has been advocated as a therapy to increase pvr, with the aim of improving systemic oxygen delivery. it is a therapy which has been routinely initiated in our institution in the setting of signs of pulmonary overcirculation. we performed a retrospective analysis of all patients in our institution who underwent a norwood procedure and who received hm preoperatively. we compared peripheral saturations, arterial blood gas analysis, serum lactate, regional cerebral and renal saturations and invasive blood pressure, prior to, and then , and hours after hm was commenced. between and (inclusive), patients underwent the norwood procedure. patients received preoperative hm. average fio was % during administration of hm. average peripheral saturations were . % prior to hm, and dropped to . % at hours, and % at and hours after initiation (p < . ). there was no change in any of the measured markers of systemic oxygen delivery, including regional cerebral and renal saturations, lactate, urine output or blood pressure. there was an association between an extended period of hm (> hours) and the need for pulmonary vasodilator therapy post norwood procedure. hypoxic gas mixture in patients with parallel systemic and pulmonary cicrculations causes desaturation and hypoxia. it does not lead to an increase in systemic perfusion and thus an improvement in systemic oxygen delivery. its ongoing use in this fragile population should be considered. introduction: analgesia in the critical patient, and especially in the neurocritical patient, is a basic goal in all therapeutic practices. patients in the icu are frequently administered prolonged and/or high doses of opioids. multiple serious complications due to the use of infusion of opioids at large doses has been described. to reduce high doses of intravenous opioids, multimodal forms of analgesia can be used. prospective observational study of the use of tapentadol enteral and buprenorphine in transdermal patches, at low doses, for the control of pain and its effect on reducing the use of fentanyl infusion in high doses on patients admitted to neuro icu of indisa clinic during consecutive years ( - ). enteral tapentadol (through ng tube) mg/ hours, was considered in patients who required intravenous fentanyl in continuous administration. buprenorphine was also added at low doses ( ug/hr) in a weekly transdermal patch, in cases of neurosurgical spine patients, fractures and long-term neuropathic pain. pain was controlled on behavioral pain scale (bps) and visual analogical scale (vas) scores, according to the conditions of each patient. their hemodynamic, gastrointestinal complications and the appearance of delirium episodes according to cam-icu scale were recorded. results: patients received tapentadol. of them also received transdermal buprenorphine. all managed to maintain adequate level of analgesia, not requiring fentanyl at doses greater than . ug / kg / hr. distribution by diagnoses: neurotrauma patients, guillain barre , spine surgery , hsa , hice , malignant ischemic acv . complications: gastric retention patients ( %), hypotension ( %), acute hypoactive delirium ( . %), acute hyperactive delirium ( %). no drug interactions were found. the introduction of enteral tapentadol and buprenorphine patches in neurocritical patients was safe and resulted in a decrease in the use of endovenous opioids and its adverse effects. we hypothesized that changing the pain management for our post cardiac surgical patients to an assessment-driven, protocol-based approach using fast acting and easily titratable agents will significantly improve patient satisfaction by reducing pain intensity in the first h after surgery as suggested by society of critical care [ ] guideline. we prospectively assessed and ( . vs . ) consecutive patients before and after introducing our pain management protocol. the nursing and medical team received rigorous training on the guideline as well as the correct assessment using appropriate pain scores measured at least hourly (numeric pain score, ≥ is timing of beta-blocker (re)initiation versus incidence of afacs before and after prevention care bundle implementation, per post-operative day and for postoperative days - (insets) moderate to severe or critical care observation tool, > is moderate to severe). we introduced a multimodal approach with a combination of fast acting iv, long acting oral opiates, regular paracetamol and rescue iv boluses for difficult to control situations and we created a prescription bundle on our electronic prescribing record. among other variables we assessed hours spent in moderate to severe pain in the first h after surgery and compared to the data collected before the guideline was introduced. we analysed patients from and from . baseline characteristics were similar between the two groups. in only . % of the patients spent less than hours and . % spend more than hours in moderate to severe pain. the data showed significant improvement in that . % of patients spent less than hours and only % patients who spent more than hours in moderate or severe pain. (p < . , chi square) ( figure ). only % of the patient needed rescue medications. % of time was the protocol inadequate necessitating other approach. introducing an assessment driven, stepwise, protocolized pain management significantly improved patient satisfaction by reducing pain intensity in the first h on our cardiothoracic intensive care unit. introduction: proximal femur fractures are most common fractures in the elderly and associated with significant mortality and morbidity, with high economic and social impact. perioperative pain management influence outcomes and mortality after surgery with early mobilization being possible [ , ] . the goal of the study was to compare the efficacy and safety of the compartment psoas block for perioperative analgesia in elderly patients with proximal femur fractures. the randomized controlled study was held in medical center "into-sana" (odesa, ukraine) from january till july . patients with proximal femur fractures and older than years were included in the study. they were randomly allocated to groupscompartment psoas block group (bupivacaine analgesia was started as soon as possible before surgery and prolonged during and after surgery with additional ischiadicus block before surgery) and general (inhalational) anesthesia with systemic analgesia perioperatively. results: patients were included in this study. perioperative compartment psoas block was associated better pain control, decreased opioid consumption, better sleep quality, earlier mobilization after surgery, decreased incidence of opioid-associated vomiting/nausea and myocardial injury. there were no difference in the incidence of hospital acquired pneumonia and delirium. perioperative compartment psoas block is effective and safe for perioperative analgesia in elderly patients with proximal femur fractures, and is associated with better pain control and decreased complications incidence. parenteral olanzapine is frequently used in combination with parenteral benzodiazepines for hospitalized patients with severe agitation. the fda issued a warning for increased risk of excessive sedation and cardiorespiratory depression with this combination based on post-marketing case reports with overall limited quality of evidence [ ] . the purpose of this study is to evaluate the safety and efficacy of concomitant parenteral olanzapine and benzodiazepine for agitation. this retrospective chart review evaluated agitated patients who received concomitant parenteral olanzapine and benzodiazepine within minutes from / / to / / . the primary end points were rate of respiratory depression requiring mechanical ventilation and hypotension requiring vasopressors. the secondary end points were percentage of patients requiring additional sedatives for agitation during the same time frame, cumulative dose of olanzapine and benzodiazepine (midazolam equivalent) received, and rate of cardiac arrest and death. a total of patients were included with notable baseline characteristics: median age of years old, % with a history of substance abuse, and % with a history of psychiatric illness. for the primary outcomes, . % of patients required mechanical ventilation and % required vasopressors. additionally, . % patients received additional sedating agents to control agitation. refer to table for more details. no cardiac arrests or deaths were observed. concomitant use of parenteral olanzapine and benzodiazepine within minutes for the treatment of agitation appears to have a small risk of respiratory depression without significant hypotension. hip fracture is very common in the elderly,it causes moderate to severe pain often undertreated. ficb is a simple safe method, easy to learn and use. the aim of our study is to assess the efficacy and safety of preoperative ficb compared with intravenous analgesia for elderly patients with femoral fracture and hip surgery in terms of opioid consumption and perioperative morbidity methods: after informed consent obtained, patients - yo asa i-iii with hip fracture were randomized to receive either an us guided ficb( ml of ropivacaine , %) or a sham injection with normal saline ' before surgery. both groups were operated under general anesthesia. postoperative analgesia was done according to vas: vas - mm, paracetamol g iv at h, vas - mm, ketoprofen mg iv at h, vas> , morphine , mg/ kgbw iv. the primary outcome was the comparison of vas score at rest over the first 'following the procedure, at the end of the surgery and at h intervals for h. the secondary outcome were the incidence of the cardiovascular events, of the ponv and of the confusion episodes, the amount of morphine consumption for h results: at baseline, ficb group (a) had a lower mean pain score than the sham injection group (b). the same difference was observed over h of follow-up (p< . ). there was a significant difference between the two groups in total cumulative iv morphine consumption at h and in the incidence of ponv and confusion episodes ( figure ). ficb provides effective analgesia for elderly patients suffering from hip fractures, with lower morbidity and lower opioid consumption compared with intravenous analgesia. pain assessment in chronic disorders of consciousness patients with ani monitoring e kondratyeva, m aybazova, n dryagina almazov national medical reseach centre, minimally conscious research group, st petersburg, russia critical care , (suppl ):p pain and suffering controversies in doc to be debated by the scientific, legal and medical ethics communities. methods: ani (anti nociception index) monitor was used to assess pain in patients with chronic disordersof consciousness (doc) age range to years - in vegetative state/ unresponsive wakefulness syndrome (vs/uws) and minimal consciousness state (mcs). average age: in mcs group , ± , and , ± , in vs/uws group. neurological status was assessed using crs-r scale. the average score on the crs-r scale was ± . in vs/uws and . ± . in mcs. pressure on the nail phalanx was used as a pain impulse. ani and nociception coma scale was evaluated before the application of pain stimulus, immediately after and past minutes. prolactin level was measured before the pain stimulus application and minutes after. ani less than indicates pain, - hypoalgesia, severe pain. the mean value of the ani in mcs patients: before the pain stimulus . ± . , after the pain stimulus application ± . and minutes later . ± . . prolactin level in mcs patients before pain . ± . ng/ml; after pain . ± . ng/ml (p> . ). prolactin in vs/uws patients before pain . ± . ng /ml, after pain . ± . ng / ml (p> . ). conclusions: ani monitor revealed that vs/uws and mcs patients react equally to the pain impulse. prolactin dynamics showed poor statistical mean and can not be consider as a marker of nociception in this group of patients. it is possible that the level of pain impulse was insufficient neuroendocrine response activation or the increase of prolactin level occurs in the long term (more than minutes). in all patients the total hip arthroplasty tha is one of the most common major surgical procedures associated with significant postoperative pain that can adversely affect patient recovery and could increase morbidity. effective perioperative pain management allows an accelerated rehabilitation and improve the functional status of these patients. multimodal analgesia mma combines analgesics with different mechanism of action which by synergistic and additive effects enhance postoperative pain management and reduce complications. the aim of our study is to assess if perioperative association of very low dose of ketamine, a potent nmda antagonist and dexamethasone, by antiemetic and antiinflammatory properties could decrease opioid consumption and postoperative morbidity of patients with tha. after informed consent, patients scheduled for primary hip joint replacement surgery aged - yo asa i-iii were prospective randomized in two groups. both groups were operated under general anesthesia fentanyl/sevoflurane. supplementary, patients in group a received mg iv dexamethasone and mg at h and ketamine mg iv bolus at induction and mg/h iv during surgery. postoperative analgesia was done according to vas, - mm paracetamol g iv at h, - mm ketoprofen mg iv at h, vas> mm morhine , mg/kgbw iv. we recorded perioperative opioid consumption, the number of intraoperative cardiac events, vas score at the end of surgery and at h, the incidence of ponv and persistance of chronic pain at months. we obtain a significant less pain score at the end of surgery p< . in group a, no significant difference at h, a significant less chronic pain at months, a fewer npvo and cardiovascular events in group a, p< . ( figure ). a multimodal approach with very low doses of ketamine and dexamethasone could be efficent in the treatment of pain for elderly patients with hip arthroplasty, decreasing postoperative side-effects and reducing chronic pain persistance. introduction: treatment in an intensive care unit (icu) often necessitates uncomfortable and painful procedures for patients. chronic pain is becoming increasingly recognized as a long term problem for patients following an icu admission [ ] . throughout their admission patients are often exposed to high levels of opioids, however there is limited information available regarding analgesic prescribing in the post-icu period. this study sought to examine the analgesic usage of icu survivors pre and post icu admission. methods: patients enrolled in a post-intensive care programme between september and june . intensive care syndrome: promoting independence and return to employment (ins:pire), is a -week multicentre, multidisciplinary rehabilitation programme for icu survivors and their caregivers. patients' level of analgesia was recorded pre-admission and upon attending ins:pire, their level of prescribed analgesia was categorized using the word health organisation (who) analgesic ladder [ ] . results: . % of patients (n= ) were prescribed regular analgesia preadmission; this increased to . % (n= ) post-admission, representing a significant absolute increase of . % ( % ci: . % - . %, p< . ) in the proportion of patients who were prescribed regular analgesia pre and post icu. in addition, pre-admission, . % (n= ) of patients were prescribed a regular opioid (step and of the who ladder) compared to . % (n= ) post-admission, representing an absolute increase of . % ( % ci: . % - . %, p< . ). this study found a significant increase in analgesic usage including opioids in icu survivors. follow-up of this patient group is essential to review analgesic prescribing and to ensure a long term plan for pain management is in place. introduction: pain, agitation, and delirium (pad) are commonly encountered b patients in the intensive care unit (icu). delirium is associated with adverse outcomes, including increased mortality and morbidity. clinical guidelines suggest that routine assessment, treatment and prevention of pad is essential to improving patient outcomes. despite the well-established improvements on patient outcomes, adherence to clinical guidelines is poor in community hospitals. the aim of this quality improvement project is to evaluate the impact of a multifaceted and multidisciplinary intervention on pad management in a canadian community icu. a pad advisory committee was formed and involved in the development and implementation of the intervention. the -week intervention targeted nurses (educational modules, visual reminders), family members (interviews, educational pamphlet, educational video), physicians (multidisciplinary round script), and the multidisciplinary team (poster). an uncontrolled, before-and-after study methodology was used. adherence to pad guidelines in the assessment of pad by nurses was measured weeks pre-intervention and weeks post-intervention. data on patient-days (pd) and pd were available for analysis during the pre-and post-intervention, respectively. the intervention significantly improved the proportion of pd with assessment of pain and agitation at least times per -hour shift from . % to . % and from . % to . %, respectively ( figure ). proportion of pd with delirium assessment at least once per -hour shift did not significantly improve. a multifaceted and multidisciplinary pad intervention is feasible and can improve adherence to pad assessment guidelines in community icus. quality improvement methods that involve front-line staff can be an effective way to engage staff with pad. oversedation introduction: sedation is a significant part of medical treatment in icu patients. a too deep sedation is associated with a longer time of mechanical ventilation, lung injury, infections, neuromuscular disease and delirium, which can lead to a longer duration of icu hospitalization, as well as an increase of morbility and mortality. many patients spend a considerable amount of time in a non-optimal sedation level. a continuous monitoring system of the sedation level is therefore necessary to improve clinical evaluation. our goal was to evaluate the incidence of non-optimal sedation (under and over sedation) comparing the parameters expressed from ngsedline with clinical evaluations and to correlate oversedation and the incidence of delirium. we have studied a cohort of patients admitted to the icu of spedali civili of brescia university hospital requiring continuous sedation for more than hours. in addition to standard monitoring, the patients have been studied using next generation sedline (masimo). sedation depth was evaluated through rass scale and the presence of delirium was evaluated with cam-icu scale. we collected data from adult patients. our data showed high incidence of oversedation. of our patients had a sr> and had a psi level< . a logistic regression analysis was performed and it showed statistically significant association between incidence of delirium and the age of the patients (p . ). the association between delirium incidence and suppression rate time was at the limits of statistics significance (p . ) and was statistically significant for non neurocritical patients (p . ). our study didn't show an association between delirium and the total time of sedation. non-optimal sedation is an unsolved problem in icu, affecting lot of patients, with a major incidence of over-sedation compared to under-sedation. our study shows an association between sr levels and the incidence of delirium. predictors of delirium after myocardial infarction, insights from a retrospective registry m jäckel, v zotzmann, t wengenmayer, d dürschmied, c von zur mühlen, p stachon, c bode, dl staudacher heart center freiburg university, department of cardiology and angiology i, freiburg, germany critical care , (suppl ):p delirium is a common complication on intensive care units. data on incidence and especially on predictors of delirium in patients after acute myocardial infarction (mi) are rare. by analyzing all patients after acute mi, we aim to identify incidence and potential risk factors for delirium. in this retrospective study, all patients hospitalized for acute mi treated with coronary angiography in an university hospital in were included and analyzed. incidence of delirium within the first days of care attributed to the mi and was defined by a nudesc score ≥ , which is taken as part of daily care three times a day by especially trained nurses. this research is authorized by ethics committee file number / . results: patients with acute mi (age . ± . years, stemi, mortality . %) were analyzed. delirium occurred in ( . %) patients and was associated with a longer hospital stay ( ± . d vs . ± . d, p< . ). patients with delirium were significantly older than patients without ( . ± . vs. . ± . years, p< . ) and had more often preexisting neurological diseases ( . % vs. . %, p< . ) and dementia ( . % vs. . %, p< , ). multivariate logistic regression analysis suggested that odds ratio for delirium was higher in patients after resuscitation or . ( % ci . - . ), preexisting dementia or . (ci . - ) and in patients with alcohol abuse or (ci . - ). while maximum lactate was also connected to delirium or . (ci . - . ), infarct size or type had no effect on the incidence of delirium. in patients with mi, delirium is frequent. incidence is associated with clinical instability and preexisting neurological diseases rather than infarct size. incidence and risk factors of delirium in surgical intensive care unit ma ali, b saleem aga khan university, anaesthesia, karachi, pakistan critical care , (suppl ):p introduction: delirium in the critically ill patients is common and distressing. the incidence of delirium in the icu ranges from % to %. although delirium is highly common among intensive care patients, it is mostly underreported. to date, there have been limited data available related to prevalence of delirium in surgical patients. in a study published in , the risk was observed % in surgical and trauma patients [ ] . the purpose of this study was to find out the incidence and associated risk factors of delirium in surgical icu (sicu) of a tertiary care hospital. we conducted prospective observational study in patients with age more than years and who were admitted to the surgical icu for more than hours in aga khan university hospital from january to december . patients who had preexisting cognitive dysfunction or admitted to icu for less than hours were excluded. delirium was assessed by intensive care delirium screening checklist icdsc. incidence of delirium was computed and univariate and multivariable analyses were performed to observe the relationship between outcome and associated factors. delirium was observed in of patients with an incidence rate of . %. multivariable analysis showed that copd, pain > and . ] were also the strongest independent predictors of delirium while analgesics exposures was not statistically significant to predict delirium in multivariable analysis. delirium is significant risk factor of poor outcome in surgical intensive care unit. . there was an independent association between pain, sedation, copd, hypernatremia and fever in developing delirium delirium is an acute mental syndrome which may cause negative consequences if it is misdiagnosed [ , ] . the aim of this study was to determine the incidence of delirium in different intensive care units and reveal the risk factors. the study was performed with patients hospitalized in intensive care units of anesthesia, neurology and general surgery departments. written informed consent was obstained from patients or relatives. delirium screening test was performed twice daily with camicu (confusion assessment method for the icu). patients who met the study criterias, were evaluated for the possible risk factors of delirium and the data was recorded daily. patients were reevaluated after the treatment. the incidence of delirium was . %. delirium was found to increase with the length of stay (p < . ). the mean age of the patients with delirium was . . this was higher than the patients without delirium ( . ) (p< . ). visual impairment (p< . ), hearing impairment (p= . ), educational status (p= . ), hypertension (p= . ), mechanical ventilation (p = . ), oxygen demand (p= . ), midazolam infusion (p= . ), propofol infusion (p= . ), infection (p < . ), sofa (p = . ), apache ii (p < . ), nasogastric catheter (p= . ), aspiration (p < . ), number of aspirations (p< . ), enteral nutrition (p< . ), albumin (p= . ), steroid (p= . ), hypercarbia (p= . ) hypoxia (p= . ), sleep disturbance (p< . ) were found risk factors for delirium. oral nutrition (p< . ) and mobilization (p= . ) were found to prevent delirium development. various factors are important in the development of delirium. these risk factors should be considered in reducing the incidence of delirium in intensive care units. ). an unplanned and brutal stop of alcohol consumption, as it can occur during icu admission, may lead to an alcohol withdrawal syndrome (aws). the most severe clinical manifestation of aws is described as delirium tremens (dt). there are no current guidelines available for aws treatment in icu. the study's aim was to describe the clinician's practices for dt treatment and the outcome of dt in icu patients. observational retrospective cohort study in two icus of a universityaffiliated, community hospital in france. patient diagnosed for dt during their icu stay, as defined by dsm-v classification, were enrolled in the study. results: patients with dt were included between and . benzodiazepines was administered to % of the patients in order to prevent an aws. as associated measures, vitamin therapy was administered to % of the patients and % had an increased fluid intake (mean . l+/- . ). concerning the curative approach of aws, the treatment's heterogeneity was notable. there was a high frequency of treatment's association ( % of the patients), every patient had benzodiazepines and the use of second line treatments such as neuroleptic, alpha- agonist, propofol was variable ( figure ). complications of dt were the following: need for mechanical ventilation due to unmanageable agitation or acute respiratory distress ( % of the patients) self inflicted injuries such as pulling out of central lines, tubes, surgical drain ( %) falls ( %). seizures ( %). delirium tremens is a severe complication of an untreated aws, which can lead to serious adverse events in icu. the current lack of evidence concerning the management of aws in icu probably explains the heterogeneity of treatments. given the potential severity of aws in icu, further evidences are required to optimize care of aws in icu patients. the incidence and related risk factor of delirium in surgical stepdown unit s yoon , s yang , g cho , h park , k park , j ok , y jung asan medical center, nursing department, seoul, south korea; asan medical center, seoul, south korea critical care , (suppl ):p step down units (sdus) provide an intermediate level of care between the icu and the general medical-surgical wards. the critically ill patients who are in recovery after long-term intensive care or who require monitoring after acute abdominal surgery are admitted to sdus. delirium in critically ill patient is common and leads to poor clinical outcomes. it is, however, preventable if its risk factors are identified and modified accordingly. to determine risk factors associated with delirium in critically ill patients to admitted surgical sdu at asan medical center. this is retrospective study conducted on critically ill patients who were admitted to the sdu from september to april and able to express themselves verbally. delirium status was determined using the short-cam tool. data were analyzed by spss . software, using t-test, fisher's exact test and logistic regression. the incidence of delirium was . %( of patients) and hypoactive delirium( case, . %) was the most commonly assessed, followed by hyperactive delirium( case, . %), mixed type( case, . %). risk factors associated with developing delirium identified from univariate analysis were age(p= . ), admission via icu (p= . ), tracheostomy (p= . ), chronic heart failure (chf) (p= . ), invasive hemodynamic monitoring (p= . ), heart rate (p= . ). after adjusted in multivariate analysis; factors those remained statistically significant were old age (rr we identified risk factors consistently associated with incidence of delirium following admitted to surgical sdu. these factors help to focus on patients at risk of developing delirium, and to develop preventive interventions that are suitable for those patients. patients with sepsis frequently develop delirium during their intensive care unit (icu) stay, which is associated with increased morbidity and mortality. the prediction model for delirium in icu patients (pre-deliric model) was developed to facilitate the effective preventive strategy of delirium [ ] . however, the pre-deliric model has not yet been validated enough outside europe and australia. the aim of this study is to examine the external validity of the pre-deliric model to predict delirium using japanese cohort. this study is a post hoc subanalysis using the dataset from previous study in nine japanese icus, which have evaluated the sedative strategy with and without dexmedetomidine in adult mechanically ventilated patients with sepsis [ ] . these patients were assessed daily throughout icu stay using confusion assessment method-icu. we excluded patients who were delirious at the first day of icu, were under sustained coma throughout icu stay and stayed icu less than h. we evaluated the predictive ability of the pre-deliric model to measure the area under the operating characteristic curve. calibration was assessed graphically. of the patients enrolled in the original study, we analyzed patients in this study. the mean age was . ± . years and patients ( %) were male. delirium occurred at least once during their icu stay in patients ( %). to predict delirium, the area under the receiver operating characteristics curve of the pre-deliric model was . ( . to . ). graphically, the prediction model was not well-calibrated ( figure ). to predict delirium in japanese icus, we could not show the well discrimination and calibration of the pre-deliric model in mechanically ventilated patients with sepsis. introduction: delirium is a serious and common complication and in some cases it treatment is difficult. aim of the study was an evaluation of the prevalence, structure of delirium and efficacy of dexmedetomidine and haloperidol sedation in geriatric patients after femur fracture. after local ethic committee approval case-records of geriatric patients with femur fracture in the period from to in the institute of traumatology and orthopedics in astana were analyzed. patients was divided for groups: in dpatients with delirium treated by i/v dexmedetomidine ( . - . mkg/kg per hour), in g group patients with delirium treated by i/v galoperidol ( . - . mkg/kg). delirium was assessed by rass at day of permission and every day at a.m. the prevalence, structure of delirium and efficacy of sedation were analysed. results: by anthropometric and gender characteristics of the group did not differ. the average age in the d-group with delirium was . ± . years old, which was comparable to the g-group - . ± . years old (p = . ). all study participants had similar comorbidities. delirium in all patients debuted at . ± . days, with an average duration of . ± . days. the effect of dexmedetomidine was better and expressed in % decrease in the duration of delirium in compare to haloperidol (p < . ). dexmedetomidine provided a more controlled and safe sedation compared with haloperidol. the average consumption of narcotic analgesics in the subgroup with dexmedetomidine was two times less than in the subgroup with haloperidol. thus, the average consumption of trimeperidine hydrochloride in patients of group d was . mg versus . mg in group g (p = . ). in gerontological patients with femur fracture treatment delirium by dexmedetomidine was more effective in compare with haloperidol. when using dexmedetomidine, the consumption of narcotic analgesics in postoperative period was % less than with haloperidol. live music therapy in intensive care unit mc soccorsi , c tiberi , g melegari , j maccieri , f pellegrini , e guerra intensive care units (icu) are not comfortable for patients, relatives or next of kin. in the last years many news approaches were described to implement the humanization of medical treatments. the positive effect of music therapy in icu is well described, especially reducing delirium risk [ ] . the aim of this paper is describing the effect in patients and their family of a music live performance in icu. after ethical committee approval (procedure aou / , italy) for three months (november -january ) patients in icu were treated twice a week with live music therapy performed by coral vecchi-tonelli of modena, italy (fig. ). data were collected all awake and conscious patients. vitals parameters, gcs, raas and cam icu were collected before, during and after the treatment, at every performance. after the treatment a feedback questionnaire were given to patients and to next of kin. results: subjects were enrolled in the research with mean age of . years old, delirium rate before the treatment was . % later . %, raas does not show any difference. over % of patients were satisfied, and relatives felt less anxiety. we recorded also a satisfaction also in relatives not enrolled. the study does not demonstrate a delirium risk reduction for the small sample and the length treatment, anyway it was recorded a low delirium rate. the safety and the potential effect of music therapy are well known, surely the research underlines the feeling of patients and their next of kin: icu is the most stressful setting for admitted patients and its humanization is a current topic for medical literature. live performances could be an entertainment moment and probably create a moment of an interaction among patients, their family and medical and nurse: icu become more human. the high level of satisfaction push us to continue this experience. introduction: patients undergoing medical procedures benefit from distraction techniques to reduce the need for drugs alleviating pain and anxiety. this study investigates if medical hypnosis or virtual reality glasses (vrglasses) as adjuvant method reduces the need for additional drugs. in a prospective, randomized, interventional trial, patients undergoing procedures were stratified in four age groups, and randomly assigned into three arms by means of a closed envelope system. all patients received standard care for pain before the procedure; the control group received further drugs for pain and stress as indicated by the visual analog scale (vas; threshold / ) and comfortscore (threshold / ), two index groups received either medical hypnosis or vr glasses as a plus before and during the procedure. vas and comfort were scored continuously and analysed with the kruskal-wallis test. patients, parents and healthcare providers scored their satisfaction at the end. of included patients to years old, % were female. regardless of age, pain and comfort scores were similar before and at the start of the procedure (vas . - . ; comfort - . ), but as of one minute after starting the procedure, both vas and comfort reduced significantly more in both index groups compared to the control (p< . ), remaining far below the threshold for both pain and stress ( figure ). there was no advantage of one index group over the other (p= . ). there were no adverse effects. patients in the vr group were more satisfied than in the standard group (p= . ) or in the hypnosis group (p= . ). there was no significant difference in satisfaction of parents or healthcare providers. from the very start of the intervention, the application of either medical hypnosis or vr glasses significantly reduces pain and anxiety in patients undergoing medical procedures. more studies are needed but both are promising safe adjuvant tools to standard pharmacological treatment. music to reduce pain and distress due to emergency care: a randomized clinical trial ne nouira, i boussaid, d chtourou, s sfaxi, w bahria, d hamdi, m boussen, m ben cheikh mongi slim academic hospital, emergency department, tunis, tunisia critical care , (suppl ):p recent clinical studies have confirmed the benefits of music therapy in managing pain and improving quality of care in the emergency department. the aim wasto evaluate the impact of receptive music therapy on pain and anxiety induced by emergency care methods: a randomized controlled study in patients consulting the emergency department. two groups: the music therapy group; patients needed venous sampling, peripheral venous catheter or arterial catheter. will bless ten minutes music therapy by headphones and a second control group of patients with the same care without music therapy. consent was requested from all participants. the level of pain caused by the act of care was assessed by visual analogic scale. heart rate, blood pressure and the mood of the patient were assessed before and after emergency care. we assessed patient satisfaction, adverse events. patients admitted to the emergency room, patients with communication difficulties and non-consenting patients were not included results: two hundred and forty patients were included randomized in both groups, with music therapy and without music therapy, the results showed comparable characteristics between the two groups: demographic data, pathological history, and initial clinical presentation. after the session of music therapy a difference was noted in the evaluation of the mean vas who was in the group with music of . ± . versus . ± . in the control group p< . ci % [- . ; - . ], and the mean of diastolic blood pressure which was , mmhg in the first group against . mmhg for the control group p = . ci % [- . ; - . ]. as for the mood, the patients were more smiling after the act of care in the group music therapy. all patients were satisfied with their experience and % recommend this therapy to their relatives . music therapy may reduce pain and anxiety in patients during emergency care. the music therapy is the intervention of music and/or its elements to achieve individual goals within a therapeutic.the music has proved to have positive physiological and psychological effects on patients [ ] . patients admitted to the intensive care unit (icu) experience anxiety and stress even when sedated, negatively influencing recovery [ ] . methods: two groups are established, a music therapy group (mg) and a control group (cg). the first one undergoes music therapy interventions, it consists of -minutes sessions of live music. patients of the gc will receive the usual treatment established by the service protocol for weaning management and the data are collected during the same time interval. data collection includes mean arterial pressure (map), heart rate (hr), respiratory rate (rr), oxygen saturation (sao ) and temperature (t). a total of patients were recruited, of which patients had to be excluded for meeting any of the exclusion criteria (n= ). of which (n= ) were randomized in the gm and the rest to the gc (n= ) ic %. regarding delirium in gm ( . %) presented a positive cam-icu, while in the cg were ( . %) (p= . ). when analyzing the variables in the cg and gm, it was observed that there were no differences with respect to hr, rr and map variable ( figure ). according to the results, we can say that music therapy as a nonpharmacological strategy for management of anxiety and delirium in patients of critical care units, might be an useful tool for the management of patients in weaning of mechanical ventilation introduction: coagulopathy and basopenia are common features of anaphylaxis, but the role of coagulopathy in anaphylaxis remains uncertain. the aim of this study is to evaluate the association between coagulopathy and clinical severity or basopenia in patients with anaphylaxis. we conducted a single-center, retrospective study of patients with anaphylaxis about their coagulopathy. levels of fibrin degradation products (fdp) and d-dimer were analyzed with the cause of anaphylaxis, clinical symptoms, medications and outcomes. we also studied the levels of intracellular histamine as a biomarker of basophil degranulation in the peripheral blood in relation to fdp and ddimer. in total, sixty-nine patients were enrolled to the study, and the levels of intracellular histamine were analyzed in patients. the symptoms included respiratory failure (n= ), shock (n= ), abdominal impairment (n= ), and consciousness disturbance (n= ). thirty-two patients needed continuous intravenous vasopressors for refractory shock. the increase of fdp was significantly associated with consciousness disturbance (p= . ) and refractory shock (p< . ). the increase of d-dimer was also significantly associated with refractory shock (p= . ). there was no correlation between the levels of intracellular histamine and either of fdp or d-dimer (p= . and p= . , respectively). the increase of fdp and d-dimer were associated with severe symptoms of anaphylaxis, while they were not correlated with intracellular histamine. these results suggest that anaphylaxis is closely associated with coagulopathy in a mechanism which is different from basophile degranulation in anaphylaxis. cardiac manifestations of h n infection in a greek icu population e nanou , p vasiliou , e tsigou , v psallida , e boutzouka , v zidianakis , g fildissis agioi anargiroi hospital, attiki, greece; agioi anargiroi hospital, icu, attiki, greece critical care , (suppl ):p introduction: cardiovascular involvement in influenza infection occurs through direct effects on the myocardium or through exacerbation of pre-existing cardiovascular disease [ ] . the aim was to study cardiac manifestations in all pts admitted to the icu with severe influenza's attack. clinical, laboratory, electrocardiographic, echocardiographic and hemodynamic data were retrospectively recorded in all pts admitted to the icu due to influenza infection (winter -spring ). diagnosis was established by pcr on bronchial aspirates the next days after admission. myocardial injury was defined by troponin levels > pg/ml ( fold uln). left ventricular systolic dysfunction was defined as ef < % and was characterized as either global or regional. hemodynamic monitoring by fig. (abstract p ) . comparison between mg and cg transpulmonary thermodilution method (picco) was recorded in pts with shock (norepinephrine > . μg/kg/min). values are expressed as mean±sd or as median (ir). results: nine pts ( males) with a mean age . ± . years, apache ii ± . and sofa score . ± . were assessed. icu admission was due to ards ( ) and copd exacerbation ( ) . icu los was . ± . days and mortality rate was %. no history of vaccination or coronary heart disease was referred. results are shown in table . levosimendan was administered in pts with severe cardiogenic shock. in all survivors, shock and indices of myocardial dysfunction subsided till discharge. coronary angiography was performed in pt showing no abnormalities. mortality was attributed to septic shock and multi-organ failure. myocardial involvement, though common in influenza pts admitted to the icu, didn't contribute to a dismal prognosis. the cardioprotective effects of levosimendan could be related to the modulation of oxidative balance. we aimed to examine the effects of levosimendan in patients with cardiogenic shock or with ejection fraction (ef) lower than % on cardiac systo-diastolic function and plasma oxidants/antioxidants (glutathione, gsh; thiobarbituric acid reactive substances, tbars). in patients undergone coronary artery bypass grafting or angioplasty, cardiovascular parameters were measured at t (before the beginning of levosimendan, . mcg/kg/min), t ( h after the achievement of the therapeutic dosage of levosimendan), t (at the end of levosimendan infusion), t (at h after the end of levosimendan infusion), t (at the end of cardiogenic shock). the same time-course was followed for plasma gsh and tbars measurements. we found an improvement in cardiac output, cardiac index and systolic arterial blood pressure. ef increased from mean % to %. a reduction of central venous pressure and wedge pressure was also observed. moreover, indices of diastolic function were improved by levosimendan administration (e/e' from to ; e/a from > to < ) at early t . it is to note that an improvement of gsh and tbars was observed early after levosimendan administration (t ), as well ( figure ). the results obtained have shown that levosimendan administration can regulate oxidant/antioxidant balance as an early effect in low cardiac output patients. the modulation of oxidative condition could be speculated to play a role in exerting the cardio-protection exerted by levosimendan in those patients. table . early administration of vasopressors and their use in the emergency department was associated with survival in septic shock. this seemed to be independent of median map recorded in the ed. we excluded all the traumatic or post-myocardial infarction forms. out of patients, the tuberculous etiology was identified in cases ( , %), mean age was years, , % were men. patients reported a tb contact in their environment, had a medical history of pulmonary tb. after pericardiocentesis, the liquid was citrine yellow in cases and hematic in patients, no patient underwent surgical drainage in our serie. mycobacterium tuberculosis was found in the expectorations in cases and ada was positive in patients. hiv serology was negative in all our patients. a months anti bacillary therapy with isoniazid, rifampin, pyrazinamide, and ethambutol was initiated in all our patients with a good evolution in cases, deaths, chronic constrictive pericarditis, small pericardial effusion and lost to follow-up. althought cardiac tamponade is rarely caused by tuberculosis, this condition remains common in endemic countries such as morocco and affect younger population, hence the importance of a better knowledge of its prevalence and and multidisciplinary management and more importantly the treatment of the underlying cause using combined antibacillary medication that has shown satisfying results. . the main perceived limiting factor is the absence of a standardized didactic program, followed by mentor's availability in residents' perception and by mentor's experience in consultants' one. pocus teaching is present although not optimal and not homogenous in italian acc residency schools. standardisation of residents' ultrasound curriculum is suggested to improve ultrasound teaching. the study included a convenience sample of critically ill patients with supradiaphragmatic cvcs and a cxr for confirmation. us is used for direct confirmation of the guidewire in the internal jugular (ijv) or subclavian (scv) vein and visualizing the guidewire in the right atrium. to evaluate for pneumothorax, "sliding sign" of the pleura was noted on us of the anterior chest. results: patients have been included, % of the catheters have been placed in the scv and % in the ijv. it was possible to confirm the position of the cvc tip for . % ( correct, incorrect cxr) of (figure ). overall, it was not possible to identify the guide in the right atrium cases ( false negatives, of them due to the presence of defibrillator leads). regarding the case where an incorrect position was seen on cxr it was also detected on ultrasound: us of the inserted vein and a negative tte confirmation. in all cases it was possible to exclude a pneumothorax by us. these results show that bedside ultrasound might be a feasible technique to confirm the cvc positioning. it is important to note that the level of the operator's expertise is significant when assessing the feasibility of this method. we only had a limited sample size and the occurrence of only one misplaced catheter. these preliminary results need to be confirmed on a larger scale. central venous catheter (cvc) misplacement occurs more frequently after cannulation of the right subclavian vein compared to the other sites for central venous access. misplacement can be avoided with ultrasound guidance by using the right supraclavicular fossa view to confirm correct guidewire j-tip position in the lower part of the superior vena cava. however, retraction of the guidewire prior to the cvc insertion may dislocate the j-tip from its desired position, thereby increasing the risk of cvc misplacement. the aim of this study was to determine the minimal guidewire length needed to maintain correct guidewire j-tip position throughout an us-guided infraclavicular cvc placement in the right subclavian vein. methods: adult intensive care patients with a computed tomography scan of the chest were retrospectively and consecutively included in the study. the distance from the most plausible distal puncture site of the right subclavian/axillary vein to the junction of the right and left brachiocephalic veins (= vessel length) was measured using multiplanar reconstructions. in addition, measurements of the equipment provided in commonly used - cm cvc kits were performed. the minimal guidewire length was calculated for each cvc kit. the guidewires were up to mm too short to maintain correct j-tip position throughout the cvc insertion procedure in seven of nine commercial cvc kits. four of these are shown in table . when us guidance is used to confirm a correct guidewire j-tip position, retraction of the guidewire prior to the cvc insertion must be avoided to ensure correct cvc-tip positioning. this study shows that most of the commonly used - cm cvc kits contain guidewires that are too short for cvc placement in the right subclavian vein. the reliability of lung b-lines to assess fluid status in patients with long period of supine introduction: ultrasound-guided cannulation is usually done using either longitudinal or transverse approach. the oblique approach utilizes advantages of both these approaches allowing visualization of the entire course of needle including tip and lateral discrimination of artery from vein [ ] . the reported incidence of the complete overlap of femoral vein by the femoral artery is - percent [ , ] . we describe the use of the oblique approach for successful cannulation of such a femoral vein which is not possible by usual approaches (figure ). endothelial cells play a pivotal role in the atherogenic process. endothelial cell dysfunction (ed) is the main risk factor for cardiovascular diseases such as hypertension, coronary heart disease (chd) and peripheral occlusive disease (pod). these diseases significantly increase the risk for perioperative complications. therefore, identifying patients with ed is important and should influence our prospective perioperative strategy. however, sensitive tools to diagnose ed are still missing and do not belong to our standard of care. aim of this study was the validation of a new non-invasive method to detect ed and a correlation with a set of established an new endothelial biomarkers. the cohort includes preoperative patients without anamnestic relevant cardiovascular disease and patients with known peripheral occlusive disease (pod). we used non-invasive endopat® technology from itamar-medical to measure ed by changes in vascular tone before and after occlusion of the brachial artery and calculate a reactive hyperemia index (rhi). in addition, we measured established markers and alternative biomarkers potentially indicate vascular diseases such as substrates and products from the no-metabolism l-arginin, asymmetric/symmetric dimethylarginine (adma/sdma), von-willebrand factor (vwf) and sphingosine- -phosphate (s p). rhi was able to identify patients with pod. rhi was significant lower in patients with clinical signs and symptoms of pod (p< . ). among other markers adma was significant higher in pod patients compared to controls and correlates with rhi. the pad technology is a helpful non-invasive functional test to measure ed and seems able in identify patients with vascular disease. in future, a combination of anamnesis, new diagnostic tools and biomarkers may further increase our sensitivity in identifying risk-patients. single-lumen fr and triple-lumen fr peripherally inserted central catheters (piccs) for cardiac output assessment by transpulmonary thermodilution s d´arrigo achieving effective critical care in low-and middle-income countries is a global health goal [ ] , which includes the provision of effective point of care ultrasound [ ] . we sought to establish zambia's first focused critical care echocardiography training programme in a bedded icu at university teaching hospital, lusaka. the programme was accredited by the uk intensive care society fice programme, with teaching adapted for local disease patterns such as tuberculous pericardial effusions. parasternal, apical and subcostal windows were used to assess ventricular dysfunction, hypovolaemia, pleural effusion, alveolar interstitial syndrome and pneumothorax. zambian doctors working with critically ill patients received an intensive one-day course, followed by mentored scanning at the bedside. teaching was delivered by visiting fellows from the uk who are accredited in echocardiography and experienced ultrasound educators. patients with abnormal mean ci or hr suffer from increased hospital mortality. abnormality of mean svi was not associated with mortality. these data support accurate measurement of ci as a hemodynamic target and the normal range defined for ci. since ci also carries the hr information, ci seems to be the more important target than svi. our data cannot necessarily be interpolated to less invasive and less precise measurements of ci. an evaluative study of the novelty device with the function of auto-aspirating and pressure indicator for safety central venous catheterization ly lin, wf luo, cy tsao national taiwan university hospital, taipei, taiwan critical care , (suppl ):p previous studies have shown that . % of cvc attempts resulted in arterial punctures that were not recognized by blood color. to overcome the problem, our team has developed a concept of pressure detecting syringe that can indicate the artery puncture [ ] . based on previous research, different springs, the actuator of the design, have been evaluated to optimize the proposed device and reduce the risk of cvc procedure. tested devices -the inner-spring is set between the pressure indicator and plunger (fig. a ). three springs are tested. test condition -blood samples were simulated by glucose solution with absolute viscosities of and mpa-s. different blood pressures were applied to simulate the artery and vein (fig. b) . the response time (rt) is defined as the time required to show the indicating signal (is) which is the movement of the piston from the position in fig. b : a - to a - . the rt is strongly influenced by spring (fig. b) but every design can show the is when pressure is higher than mmhg, the assumed minimum artery pressure. the rt of s , the strongest spring design, is about s in the mmhg-pressure and high viscosity condition. during our tests we found the user can realize the is before the position be fully changed from fig. ib : a - to a - . thus, we believe the s rt, the worst case, is still acceptable. we also found the weak spring force may lead to difficulty to empty the syringe because the spring must to overcome the blood pressure and the friction between the piston and barrel. as a result, it was difficult for s to absolutely empty the syringe even if the blood pressure is only mmhg. the spring will be compressed as fig. b : a - and fail to push the piston when pushing the plunger forwardly, which is not acceptable in clinical use. the results indicate the feasibility of using the device to facilitate cvc and we believe the s or s are more suitable for the future application. introduction: models using standard statistical features of hemodynamic vital sign waveforms (vs) enable rapid detection of covert hemorrhage at a predetermined bleed rate [ ] . by featurizing interactions between vs we can train powerful hemorrhage detectors robust to unknown bleed rates. waveforms (arterial, central venous, pulmonary arterial pressures; peripheral and mixed venous oxygen saturation; photoplethysmograph; ecg) of healthy pigs were monitored min prior and during a controlled hemorrhage at ml/min (n= ) and ml/min (n= ). two sets of vs features were extracted: statistical features [ ] and maximal pairwise cross correlations between pairs of vs within a s lag over various time window sizes ( s, s, s, s); and normalized with pre-bleed data of each given animal. for each feature set, a tree-based (ert) model [ ] was trained and tested in a one-animal-out setting to mitigate overfitting on the ml/min cohort, and another trained on the ml/min and tested on the ml/min cohort. we evaluated models with activity monitoring operating characteristics curves [ ] that measure false alert rate as a function of time to detect bleeding. models using cross-correlations show no significant deterioration of performance when applied to detect bleeding at different rates than trained for, while standard models require s longer on average to detect hemorrhage at % false alert rate in the previously unknown setting ( figure ). correlations between vs data encode physiologic responses to hemorrhage in a way independent of the actual bleed rates. this enables training effective hemorrhage detectors using only limited experimental data, and using them in practice to detect bleeding that occurs at rates other than used in training. we validated a dataset of data lines containing hemodynamic variables and treatment options. we selected nine hemodynamic variables as inputs. furthermore, data were collected regarding underlying conditions: heart failure, septic shock, renal failure or respiratory failure or a combination. we applied datastories regression on the dataset (turnhout, belgium, www.datastories.com). six different interventions were analyzed as kpi: administration or removal of fluids, increasing or decreasing inotropes and increasing or decreasing vasopressors. finally, we elaborated and challenged predictive models to generate a decision algorithm to predict each kpi. we first looked at how each hemodynamic parameter impacts the prediction of each kpi individually and performed a standard correlation analysis as well as a more involved analysis of the mutual information content between each kpi and all other hemodynamic parameters individually. confusion matrix and variable importance was obtained for each kpi. the baseline hemodynamic parameters were: gedvi ± ml/m , evwli . ± . ml/kg pbw, svv . ± %, mbp . ± . mmhg, hr . ± . bpm, ci . ± . l/min.m . the results of the regression analysis identified the different variables of importance for each of the different interventions ( fig a) . based on these results the hemodynamic variables (hr, mbp, gedvi, elwi, ci, svv) were used to develop the final hemoguide prediction model ( fig b) . the hemoguide app can be used to advise physicians with respect to basic therapeutic decisions at the bedside or as an educational tool for students. with the collection of new data, the accuracy of the system may grow over time. the next step of the project is to develop a more-sophisticated suite: the icu cockpit. feedback function contributes to accurate measurement of capillary refill time r kawaguchi , ta nakada , m shinozaki , t nakaguchi , h haneishi , s oda chiba university, department of emergency and critical care medicine, chiba, japan; chiba university, chiba, japan critical care , (suppl ):p capillary refill time (crt) is well known as an indicator of peripheral perfusion. however, it has been reported to have an intra-observer variance, partly because of manual compression and naked-eye measurement of the nailbed color change. we hypothesized that a we developed a novel portable crt measurement device with an oled display that feedbacks weather the strength of the nailbed compression is enough and counts the time. we settled the target strength and time as n and seconds according to the study we reported before [ ] . examiners measured crt with and without the feedback function. the pressing strength and time during the measurement were evaluated. there was a significant difference among the pressing strength and time between the crt measurement using the device with and without the feedback function (strength: p< . ; time: p< . ). furthermore, intra-examiner variance was significantly reduced with the feedback function (strength: p< . ; time: p< . ). in all measurements without the feedback function, % was outside the optimal strength while the measurements with the feedback function % achieved the targeted range. without the feedback function, % could not reach the optimal time, while % with the feedback function did. in total, % of the measurements could not achieve the optimal pressing strength and time. the feedback function for crt measurements, guiding examiners to an optimal pressing strength and time, fulfilled the required measurement conditions and reduced intra-examiner variance. our novel portable device would assist an accurate crt measurement regardless of personal work experience. introduction: the aim of the study was to detect the difference of conjunctival microcirculation between septic patients and healthy subjects and evaluate the course of conjunctival microcirculatory changes in survivors and non-survivors over a hours period of time. this single-centre prospective observational study was performed in mixed icu in a tertiary teaching hospital. we included patients with sepsis or septic shock within the first hours after icu admission. conjunctival imaging using idf videomicroscope as well as systemic hemodynamic measurements were performed at three time points: at baseline, hours and hours later. baseline conjunctival microcirculatory parameters were compared with healthy control. a total of patients were included in the final assessment and analysis. median apache ii and sofa scores were ( - ) and ( - ) respectively. ( %) were in septic shock, ( %) required mechanical ventilation. patients were discharged alive from the intensive care unit. we found significant reductions in all microcirculatory parameters in the conjunctiva when comparing septic and healthy subjects. we found a significant lower proportion of perfused vessels and microvascular flow index (mfi) of small vessels during all three time points in non-survivors compared with survivors. in nonsurvivors we observed no significant changes in conjunctival microcirculatory parameters over time. however, survivors had significantly improved mfi of small vessels at second and third time points compared to first time point. microcirculatory perfusion in conjunctiva was altered in septic patients. over hours evaluation survivors in comparison with nonsurvivors had better microcirculatory flow with incremental improvement of microvascular flow index. healthy pigs were centrally cannulated for veno-arterial ecmo and precision flow probes were placed on the pulmonary artery main trunk for reference. ml boluses of iced . % saline chloride solution were injected into the ecmo circuit and right atrium at different ecmo flow settings ( , , , l/min). rapid response thermistors of standard pa-catheters in the ecmo circuit and pulmonary artery recorded the temperature change. after calibration of the catheter constants for different injection volumes in the ecmo circuit, the distribution of injection volumes passing each circuit was assessed and enabled calculation of pulmonary blood flow. analysis of the exponential decay of the signals allowed assessment of right ventricular function. calculated blood flow correlated well with true blood flow (r = . , p < . , figure panel a, individual measurements organ congestion is susceptible to be a mediator of adverse outcomes in critically ill patients. point-of-care ultrasound (pocus) is widely available and could enable clinicians to detect signs of venous congestion at the bedside. the aim of this study was to develop prototypes of congestion scores and to determine their respective ability to predict acute kidney injury (aki) after cardiac surgery. this is a post-hoc analysis of a prospective study in patients for which repeated daily measurements of hepatic, portal, intra-renal vein doppler and inferior vena cava (ivc) ultrasound were performed before surgery and during the first hours after cardiac surgery [ ] . five prototypes of venous excess ultrasound (vexus) scores combining multiple ultrasound markers were developed (figure ). the association between each score and aki was assessed using timedependant cox models as well as conventional performance measures of diagnostic testing. a total of ultrasound assessments were analyzed. we found that defining severe congestion as the presence of severe flow abnormalities in multiple doppler patterns with a dilated ivc (> cm), corresponding to grade of the vexus c score, showed the strongest association with the development of subsequent aki compared with other combinations of ultrasonographic features (hr: . there is an increasing awareness on the consequences of fluid administration in patients leading to the development of methods that evaluate the effects of fluids loading on the cardiocirculatory system. however, most of methods used in the clinical practice investigate the effects of fluids on the cardiac function, instead of investigating those on the determinants of venous return. besides volume of fluids, the determinants of fluid loading are the blood volume distribution and the availability of vascular bed. in this study we aimed to test non-invasively the effects of fluids administration on the venular compartment in the skeletal muscle. in addition to the mean systemic filling pressure (msfp), we calculated changes in the stressed and unstressed volumes (vs, vu) and the venular bed availability. we enrolled critically ill patients in our intensive care unit. we assessed volumes and pressures by the near infra-red spectroscopy on the forearm using graded venous occlusions in steps of mmhg from to mmhg. the msfp, vu and vs were measured as previously reported (microcirculation ; : - ). the vascular bed availability was measured by changes in the volume recruited from the occlusion maneuvers. all the measures were done at baseline and after a fluid load ranging from to ml. values were expressed as median and interquartile range. wilcoxon test was used to compare data and a p< . was considered as significant. introduction: hypotension is a common side effect of general anesthesia (ga) and is associated with organ hypoperfusion and poor perioperative outcome [ ] . post-induction hypotension (pih) is caused by the depressant cardiovascular effect of anesthetic drugs and could be amplified by hypovolemia. the aim of this study was to assess the ability of two echocardiographic fluid responsiveness markers to predict pih: the inferior vena cava collapsibility index (ivc-ci) and the velocity time integral change (Δvti) after passive leg raising. sixty patients > years of age and scheduled for elective surgery were included. ivc-ci and Δvti were measured before ga induction. anesthesia protocol, fluid infusion and vasopressor administration were standardized in all patients. pih was defined as a mean arterial pressure (map) < mmhg or a relative decline from pre-induction value of at least % within minutes of ga induction. receiver operating characteristic (roc) curve analysis was used. the optimal cutoff was selected to maximize the youden index (sensitivity + specificity − ). the measurement of ivc-ci and/or Δvti were unsuccessful in seven patients ( . %). pih occurred in patients (incidence %). the areas under the roc curves ( figure ) preload responsiveness might be detected by the changes of cardiac index (Δcimini) induced by a "mini-fluid challenge" (mini-fc) of ml or even by the changes (Δcimicro) in response to a "micro-fluid challenge" (micro-fc) of ml. however, the smaller the fluid challenge, the larger the "grey zone" of diagnostic uncertainty. we tested whether ( ) micro-and mini-fc monitored by calibrated pulse contour analysis detect preload responsiveness and ( ) adding ml when the result of a micro-fc is within the grey zone improves diagnostic accuracy. in patients with circulatory failure, we infused ml saline over s followed by ml over s. we measured Δcimicro and Δcimini by the pulse contour analysis (picco ). preload responsiveness was defined by an increase in ci (Δciplr) during a passive leg raising test ≥ %. diagnostic uncertainty was described by calculating the grey zone after bootstrapping. Δcimicro were larger in responders than in non-responders ( . for the micro-fc, the area under the receiver operating characteristic curve was . ± . (threshold %), while it was . ± . for the mini-fc (threshold %). for the micro-fc, the grey zone ranged from . % to . % and included ( %) patients. for the mini-fc, it ranged from . % to . % and included ( )% patients, among which were already in the grey zone of the micro-fc. when evaluated by pulse contour analysis, micro-and mini-fc reliably detect preload responsiveness but with a large diagnostic uncertainty. it seems that adding ml more fluid to a micro-fc when its result is within the grey zone does not improve the diagnostic accuracy. the study is ongoing. the starling-sv bioreactance device (cheetah medical) reliably detects passive leg raising (plr)-induced changes in cardiac index (Δci). we tested whether it can also track the small and short-time Δci induced by the end-expiratory occlusion (eexpo) test, and whether shortening the time over which it averages cardiac output ( s in the commercial version) improves the detection. in mechanically ventilated patients, during a -sec eexpo, we measured Δci (in absolute value and in percentage) through calibrated pulse contour analysis (ci pulse , picco device) and starling-sv. for the latter, we considered both ci starling- provided by the commercial version and ci starling- obtained by averaging the raw data over s. we calculated the correlation between Δci pulse and both Δci starling- and Δci starling- , and the area under the receiver operating characteristic curve (auroc) to detect preload responsiveness, defined by a plr test. when considering absolute values, the correlation coefficient r between Δci pulse and Δci starling- was . (p= . ), which was lower than the one between Δci pulse and Δci starling- (rr comparison). when considering percentage changes, no correlation was observed between Δci pulse and Δci starling- . conversely, the correlation coefficient between Δci pulse and Δci starling- was . (p= . ), but it was lower than the one obtained for absolute values (p= . for r comparison). eexpo-induced Δci starling- , both in absolute values and in percentage, detected preload responsiveness with aurocs of . (sensitivity %, specificity %) and . (sensitivity %, specificity %), respectively. shortening the averaging time of the bioreactance signal increases the reliability of the starling-sv device to detect eexpo-induced Δci. moreover, the accuracy of the method is increased when absolute rather than percentage changes of ci are considered. fluids are among the most prescribed drug in intensive care, particularly among patient with circulatory failure. yet, very little is known about their pharmacodynamic properties and this topic has been left largely unexplored. there is a lack of strong scientific evidence in current guidelines for fluid administration in shock. several factors may impact the hemodynamic efficacy of fluids among which the infusion rate. the aim of this study was to study the influence of fluids administration rate on their pharmacodynamics in particular by studying mean systemic pressure (p ms ). we conducted a prospective observational study in patients with circulatory failure to compare two volume expansion strategies. when a patient required a fluid bolus, ml of normal saline were administered and several hemodynamic parameters were recorded continuously: cardiac output (co), arterial pressure (ap), mean systemic pressure (p ms ). infusion rate was let to the discretion of the attending physician and a "slow" and a "fast" group were determined based on the median of the infusion time. fluids effect was measured by the area under the curve (auc), maximal effect (e max ) and time to maximal effect (t max ) for each hemodynamic variable. results: p ms auc was higher in the "fast" group compared to the "slow" group (p= . ). we observed a shorter t max and a higher e max for p ms in the "fast" group compared to the "slow" group (p= . and . respectively). regarding co, t max was also shorter in the "fast" group (p= . ). auc and e max were similar between the two groups. fluid effect dissipated within minutes following the end of fluid infusion for every patient in both groups. the decreasing slope from maximal effect was comparable in the groups, for p ms and co alike. the effect of a ml fluid bolus in septic shock patients vanished within one hour. a faster infusion rate increased maximal effect and shortened the delay to reach it. study is ongoing. fluid management in the control arm of sepsis trials aa anparasan, ac gordon, mk komorowski imperial college london, department of surgery and cancer, london, united kingdom critical care , (suppl ):p in the past, high-volume intravenous fluid resuscitation in severe sepsis and septic shock was common. more recently, concerns over the harmful effects of this practice have led some clinicians to adopt less liberal fluid strategies. we sought to analyse temporal trends in fluid administration in the control arms of recent adult sepsis trials and assess any correlation with patient severity and mortality. a literature search was conducted to identify relevant randomized controlled trials that reported fluid administration published post . we recorded outcomes: total amount of iv fluid administered in the control arms of these trials between hospital admission and hour and hour following trial enrolment, mortality rates at the latest reported time point and apache-ii score at admission. we computed the pearson correlation coefficient and linear regression between study dates and the outcomes. we identified relevant trials [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , which recruited a total of , patients in their control arms, from to . the temporal analysis revealed no obvious trend in the in the total volume of iv fluid given by hour following trial enrolment (correlation p= . ) ( figure ). however, the total volume of fluid given by hour decreased significantly over the period of interest (r=- . , p= . ). in parallel, we observed a decrease in mortality (r=- . , p= . ) but there was no evidence of decrease in illness severity over time (p= . ). we found that in published rcts over the last two decades, the amount of intravenous fluid given to patients with sepsis in the initial hours did not appear to change, however less intravenous fluid was given over the first three days. upcoming large rcts will test the safety and efficacy of restrictive fluid administration approaches in sepsis. clinical practice guidelines recommend prompt intravenous (iv) fluid resuscitation for pediatric sepsis, including an initial fluid bolus of ml/kg [ ] . however, recent evidence is conflicting as to the effectiveness, volume, and consequences of aggressive fluid resuscitation in septic children. therefore, we sought to determine the epidemiology of early iv fluid resuscitation in an integrated health system, specifically at community hospital emergency departments (ed). we studied a retrospective cohort of pediatric patients (ages > month to < years) with sepsis identified in electronic health record data at community eds in southwestern pennsylvania from to . sepsis was defined as ) suspected infection (combination of fluid culture collection and administration of antibiotics and ) organ dysfunction (pediatric sofa score ≥ ) within hours of suspected infection. fluid bolus therapy was defined as electronic documentation of administration of . % normal saline iv bolus within hour of the time of sepsis onset. results: among , patients with pediatric sepsis, ( %) received iv fluid bolus therapy within hour of time of sepsis onset. the volume of fluid administered ranged from ml/kg to ml/kg (figure , panel a), corresponding to a median volume of ml/kg (iqr - ml/kg). patients who received ≥ ml/kg of fluids (n = , %) were younger (mean age years, sd vs. years, sd ; p< . ), more often had blood cultures collected during evaluation ( % vs. %, p= . ), and were more often transferred to another facility ( % vs. %, p< . ) when compared to patients who received < ml/kg of fluids (n = , %). mean fluid bolus volume within hour of time of sepsis onset by hospital ranged from ml/kg to ml/kg (figure , panel b) . in a cohort of community emergency departments, % of septic children received intravenous fluid boluses within one hour, and of those, only one half received volumes concordant with guidelines. (figure ). a wide range of fluid balance exists in septic shock patients cared for in icu. trends of serum albumin in septic and non-septic critically ill introduction: the link between hypoalbuminaemia and poor outcomes in critical care is well established [ ] . limited data are available on serum albumin trends during critical illness [ ] . in this study we assessed trends in serum albumin for up to days in both septic and non-septic critically ill patients. we retrospectively examined the records of adult patients admitted to critical care at the royal liverpool university hospital between and . we then excluded patients who did not have albumin data available for the first days, leaving us with patients. patients ( . %) had sepsis, and of these patients had died by day . of the non-septic patients ( . %), patients had died by day . albumin levels were collected for days from admission to critical care, in addition to other demographic and biochemical data. statistical analysis was performed using repeated measures analysis. septic patients had lower serum albumin than non-septic patients throughout the day period (p< . ). we observed a decrease in albumin by day in all groups, with levels increasing over the subsequent days. there was no difference in daily serum albumin between non-septic patients who survived or died. this is the first study, to our knowledge, to compare albumin trends in septic and non-septic critically ill patients over days. further research is needed to elucidate the optimal recipients and timing of albumin therapy. introduction: burn injury is characterized by marked inflammation, capillary leakage, and profound hemodynamic alterations. early albumin resuscitation is avoided fearing a paradoxical fluid escape into the interstitium. on the other hand, administration of crystalloids in massive amounts causes tissue edema and fluid extravasation, which deteriorates tissue perfusion by increasing oxygen diffusion distance. albumin administration could reduce the amount required to maintain hemodynamic stability in this population. we investigated whether albumin improves tissue perfusion and microcirculation by reducing tissue edema. this is an observational study conducted in the burn unit of maasstad hospital, rotterdam. patients with burns higher than % of total body surface area (tbsa) were included in the study. sublingual microcirculation was measured at admission (t ), (t ), and (t ) hours after burn injury. total vessel density (tvd) and functional capillary density (fcd) were analyzed. fluid management was calculated according to the modified parkland formula. albumin ( %) infusion was started hours after the burn insult. a total of nine patients were recruited between january and december . patients were included in the study after . ± . hours of the insult with a mean tbsa of ± %. the amount of crystalloid infusion was ± ml and ± ml at t and t ,respectively. within the first h (t ) ± ml albumin was given. tvd decreased from . ± . at t to ± . at t (p< . ) (figure ) introduction: spontaneous bacterial peritonitis (sbp) accounts for ≥ % of the bacterial infections that occur in patients with cirrhosis, and sbp has a high mortality rate ( % to %). albumin infusion has been shown to improve the outcome of sbp. the aim of this study is to examine the impact of albumin infusion on hospital length of stay (los) for cirrhotic patients with sbp. we utilized a nationwide electronic health record data set (cerner health facts®) to extract real-world data on adult patients (≥ years old) with cirrhosis and sbp who received antibiotics and admitted between january , , and april , . international classification of diseases (icd- / ) codes were used to identify cirrhosis and sbp. we used laboratory data for calculation of the model for endstage liver disease sodium (meld-na) score and vital signs data for calculation of the quick sepsis related organ failure assessment (qsofa) score at baseline for each encounter. a generalized linear model was used to assess the relationship between albumin infusion and hospital los. results: there were , encounters that identified patients with sbp and cirrhosis, of which , survived hospitalization. albumin was infused within hours of admission ('early albumin') in % (n= ), after hours in % ('late albumin', n= ), and not administered in % ('no albumin', n= ). meld-na was higher at presentation in early albumin cases versus late-or no-albumin cases (mean . and . ). unadjusted los was lower in patients receiving early albumin ( . days versus . days). risk-adjusted analysis demonstrated that early albumin led to a . % reduction in los ( % ci . %- . %, p = < . ). in these real-world data, albumin infusion within hours of admission in patients with cirrhosis and sbp was associated with a shorter hospital stay despite more severe illness. early albumin may not only improve clinical outcomes but may also reduce the costs of hospitalization in cirrhotic patients with sbp. early albumin use in patients with septic shock is associated with a shorter hospital stay: real-world evidence in the united states introduction: septic shock is among the most common critical care illnesses and incidence is rising, with mortality in excess of %. septic shock predisposes patients to multiple organ failure. while albumin is effective in management of circulatory dysfunction in septic shock, its utilization in this population is understudied in the us. we evaluated the impact of albumin utilization on hospital length of stay (los) among septic shock patients. we used a nationwide electronic health record data set (cerner health facts®) to extract real-world data on adult patients (≥ years old) with severe sepsis or septic shock, admitted between january , , and april , , identified by international classification of disease (icd- / ) codes, and receipt of antibiotics and vasopressors. we calculated the charlson comorbidity index (cci) and the acute physiology score (aps) at baseline. a generalized linear model was used to examine the association between albumin and hospital los, especially accounting for the timing of albumin infusion. we identified , unique visits for septic shock patients that survived to discharge. albumin was infused within hours of admission ('early albumin') in %, after hours ('late albumin') in %, and not administered in %. both cci and aps were higher, at presentation, in early albumin cases than late-or no-albumin cases (mean: . and . , and . and . , respectively). unadjusted los was slightly lower in patients receiving early albumin ( . days versus . days). a risk-adjusted analysis demonstrated that early albumin was associated with . % shorter los ( % ci . %- . %, p = . ). albumin infusion within hours of admission was associated with a shorter length of hospital stay. early albumin infusion may lead to better outcomes and reduced costs in patients with septic shock. further research is being conducted to assess other potential benefits of early albumin administration in this patient population. every new septic event follows by hemodynamic instability may lead sequentially to decreased organ perfusion, multiple organ failure. acute renal failure is recognized clinical feature during sepsis (up to - % in all cases). furthermore, urine output close monitoring is a cornerstone diagnostic clinical tool in each septic critically ill patient. in present study, we analyzed the dynamic minute-to-minute changes in the urine flow rate (ufr) and also the changes in its minute-to-minute variability (ufrv) during new septic event in critically ill patients. demographic and clinical data were extracted from the of critically ill patients who were admitted to the icu and developed new septic event (followed by fever and leukocytosis) and analyzed. a foley catheter was inserted into the urinary bladder of each study patient. the catheter was then connected to electronic urinometer, a collecting and measurement system which employs an optical drop detector to measure urine flow. the urine flow rate variability (ufrv) is defined and calculated as the change in ufr from minute to minute. results: ufr and ufrv both decreased significantly immediate after new septic episode until beginning fluid resuscitation (ppvalues < . ) (figure ) . statistical analysis by the pearson method demonstrated a strong direct correlation between the decrease in ufr, ufrv and the decrease in the map (r= . , p= . ; r= . , p= . ) ( figure ), and heart rate (r= . ,p=< . ) since systemic pressure starts to drop. ufrv and ufr demonstrated good clinical response to fluid administration despite the fact that systemic blood pressure did not improve (figure ) . we consider that dynamic changes in ufrv and ufr could potentially serve as a more sensitive signals ofclinicaldeterioration during the new septic event in critically ill patients.we also suggest that those parameters mightbeable to identify the optimal end-point of fluid resuscitative measures in septic critically ill patients. diminished urinary output (uo) is largely used as marker of acute kidney injury (aki) in critically ill patients. we aimed to explore the role of urinary output on incidence and mortality of aki developed during icu admission. the study population consists of all patients admitted between and to one of the dutch icus included in the nice database with an icu length of stay of at least hours, having daily measurement of creatinine and uo. only patients without renal replacement therapy that have a serum creatinine lower than . mg/dl ( . μmol/l) or a uo above . ml/kg/h on the day of the index icu admission were considered at risk for aki. patients were followed during their icu stay and classified according to the highest kdigo criteria reached based on creatinine alone (model ) and creatinine plus uo (model ) using icu admission serum creatinine as baseline. in both models, patients were classified as: no aki, renal impairment at the first day of icu admission, aki stage , aki stage , and aki stage . we identified , patients ( % male, mean age years, median icu-los days). of those, . % of patients had renal impairment at the first day of icu admission. among the remaining patients, . % in model and . % in model were classified as having no aki, . % and . % as aki stage , . % and . % as aki stage , and . % and . % as aki stage , respectively. survival at -day markedly differed according to the aki classification model used (figure) . similarly, adjusted hrs for -day mortality differed among patients with and without aki compared to patients with renal impairment at the first day of icu admission ( figure ) . among patients admitted to the icu % had renal impairment at the first day of icu admission. our findings suggested that uo plays an important role both on aki incidence and mortality and should be carefully interpret in the clinical setting especially in aki stage classification. introduction: acute kidney injury (aki) mostly attributed to renal tubular damage, has a high morbidity and mortality outcome [ ] , so a sensitive tool to assess the degree of tubular affection is needed for early detection and management of this condition. we investigated the ability of furosemide stress test (fst) (one-time bolus dose of mg/kg or . mg/kg if on prior furosemide-intake) to predict progression to akin stage-iii in critically ill subjects with early aki. we studied subjects; consecutive patients in group i receiving fst and consecutive patients in group ii receiving standard medical management for aki; patients ( . %) and patients ( %) met the primary endpoint of progression to akin-iii in groups i and ii respectively. patients with progressive aki had significantly lower urine output following fst in the first hours (p< . ). the area under the roc curves for the total urine output over the first hours following fst to predict progression to akin-iii was . (p = . ). the ideal-cutoff for predicting aki progression during the first fig. (abstract p ) . thirty-day survival according to aki classification model and model . hazard ratios (hrs) for -day mortality adjusted by sex, age, type of admission, apache iv score, sofa score at day of admission (excluded renal sofa score) for patients with aki classified with model and model fig. (abstract p ) . clinical correlation between urine flow rate variability (ufrv) and ufr and mean arterial blood pressure over new septic event (black arrows) and and after initial fluid resuscitation (red arrows). note: the ufrv and ufr decreased progressively in parallel with the falling mean arterial blood pressure and, than, rose again after the administration of fluids hours was a urine volume of less than milliliters with a sensitivity of . % and specificity . % group receiving fst. on the other hand, statistically significant hypotension, hypo-(kalemia, phosphatemia and magnesemia) occurred in group i. the fst in patients with early aki could predict liability for progression of aki, however it should be performed under adequate monitoring. introduction: ischemia-reperfusion (ir) causes renal dysfunction and damage. ir induces renal tubular injury triggered by hypoxia and hyperoxia, mediated by oxidative stress and inflammation. furosemide inhibits na + -k + - clcotransporter in the thick ascending limb of the renal medulla to decrease na + reabsorption, reducing oxygen consumption. we investigated if furosemide could improve renal oxygenation, function and damage by reducing o consumption and oxidative stress after ir. methods: wistar albino rats were divided into groups, with in each group; sham-operated control (c), control + furosemide (c+f), ir and ir+f. after anaesthesia (bl), min supra-aortic occlusion was applied to ir and ir+f groups followed by min (t ) and hours of reperfusion (t ). furosemide μg/kg/h infusion was simultaneously administered to c+f and ir+f after ischemia. systemic hemodynamic, renal blood flow (rbf), renal vascular resistance (rvr), renal oxygen delivery (do ren ), renal oxygen consumption (vo ren ), creatinine clearance (ccr), sodium handling, urine output (uo), cortical (cμo ) and medullar (mμo ) microvascular oxygenation were measured. results: rbf was reduced in ir ( . ± ) and ir+f ( . ± ) at t (p< . ) but it was further reduced in ir+f ( . ± ) (p< . ) at t compared to c and c+f. rvr was increased in ir ( ± ) and ir+f ( ± ) at t compared to c. rvr was normalized in ir ( ± ) but not in ir+f ( ± ) at t compared to c (p< . ). cμo and mμo did not differ between groups after ir insults (figure ). tissue o was reduced at the medulla, but not at the cortex in ir+f group compared to ir. do ren and vo ren were reduced in ir ( ± and ± ml/ min) and ir+f ( ± and ± ) at t (p< . ). pc was higher in ir+f ( . ± . ) compared to ir . ± . (p< . ). vo / tna + was increased in ir+f compared to ir. no change in ccr and uo was observed. furosemide after ir causes further impairment of renal perfusion, energy utilization and renal oxygenation resulting in renal damage. acute renal failure induced by hypoxemia: incidence and correlation study a trifi , h fazzeni , a mehdi , c abdennebi , f daly , y touil , s abdellatif , s ben lakhal la rabta hopital, medical intensive care unit., tunis, tunisia; la rabta hopital, tunis, tunisia critical care , (suppl ):p introduction: acute renal failure (arr) is a common complication in icus and usually caused by hypoperfusion. arf induced by hypoxemia is a concept rarely reported in icu. its incidence and pathogenesis are not well understood. we aimed to study the relationship between hypoxemia and the occurrence of arf. retrospective cohort study including patients with hypoxemia whatever its etiology between january and august . patients with chronic renal failure were excluded. arf was defined and ranked according to the kdigo criteria . arterial blood gas, urea, creatinine and clearance were reordered on the first, third and seventh days of evolution. results: patients were included and groups were obtained: group of hypoxemic patients with arf (arf+, n= ): versus group of hypoxemic patients without arf (arf-, n= ). the incidence of hypoxemie-induced arf was therefore %. clinical characteristics were comparable in both groups with a mean age of ± and a sex ratio of . . the comparative study showed in arf+ group: a lower ph ( . . ], p = . ). the most significant correlation was showed with mdrd clearance at day and p/f ratio at day (rho = . , p = . ). multivariate analysis found that septic shock and non invasive ventilation in hypoxemic patients were the factors related to arf with respectively or= . , % ci= . - . , p= . and or= . , % ci= . - . , p= . . overall mortality was % (n= ) and arf was an independent factor of mortality: or= , and % ci= . - . , p = . . hypoxemia-induced arf is a common complication associated with excess mortality. our study suggests that renal function is correlated with the degree of hypoxemia and that this correlation is rather distinct hours from hypoxemia. in preclinical models of sepsis, we have previously demonstrated that activation of amp activated protein kinase (ampk) using metformin, improves survival and organ function. thus, ampk activation is a potential therapeutic target in sepsis, and we hypothesize that exposure to metformin during sepsis is associated with decreased aki and mortality methods: retrospective analysis of a -hospital cohort of adult icu patients with type diabetes mellitus (t dm) who presented sepsis. we investigated if exposure to metformin during the hospitalization was associated with reduced -day mortality and aki. we used : propensity score matching (psm), propensity score stratification (pss) and propensity score weighting (psw) based on the probability to be exposed to metformin using covariates. for psm an exact match for insulin, amputation, cardiovascular diseases, retinopathy, charlson index, egfr, hba c, and apache iii, were used. sepsis was defined using sepsis criteria, and aki as kdigo stage or . from , patients, we found diabetic adults exposed to metformin during hospitalization and , who were not. metformin exposure during hospitalization is associated with decreased -day mortality and aki in septic adult patients with t dm. these findings suggest that metformin may constitute a potential therapeutic strategy in sepsis, and the potential role of ampk activation as a protective mechanism. however, studies are needed to confirm this association and the specific mechanisms of action. introduction: acute kidney injury (aki) may occur up to % in the intensive care unit (icu). predicting aki recovery may allow for risk stratification of patients, patient and family counseling, and early post-discharge renal care planning. however, predicting aki recovery at an early stage remains a challenge. methods: this is a retrospective study of the epanic multicenter randomized controlled trial database [ ] , which was split into development (n= ) and validation (n= ) cohorts, and patients experiencing aki stage and/or renal replacement therapy (rrt) in the icu were included [ ] . aki recovery was defined as being alive, without any stage of aki, and without need of rrt at hospital discharge. a logistic regression model with backward feature elimination was developed. the model performance was assessed by discrimination, calibration, and net benefit analysis, and internally validated with ten-fold cross validation. only the results in the development cohort are reported. of the patients who developed aki , patients ( . %) recovered from aki. the multivariable model selected age, bilirubin, heart rate, mean arterial blood pressure, surgical diagnostic group on icu admission, mechanical hemodynamic support on icu admission, suspected sepsis on icu admission as aki recovery predictors. the model had a mean area under the receiver operating characteristic curve (auroc) of . (standard deviation (sd) . ), mean calibration slope of . (sd . ), and mean calibration-inthe-large of < . (sd . ) (figure ). at the classification threshold that maximized sensitivity and specificity, mean net benefit with respect to treat-none was . (sd . ) and mean net benefit with respect to treat-all was . (sd . ). by using the routinely collected clinical data, the developed prediction model can fairly identify patients with a higher chance of aki recovery at hospital discharge. introduction: acute kidney injury (aki) is a frequent complication in critically ill patients and is associated with increased morbidity and mortality. sepsis is one of the most common cause of aki. a prospective study was conducted over months (january -june , ).we included patients with septic shock at admission or at any time during hospitalization.the aki staging was based on kdigo criteria.patients were divided into two groups, a group with aki (aki+) and a group without aki (aki-).then we compared the baseline characteristics, laboratory and physiologic data. patients with aki (aki+) were subdivided according to their prognosis. were enrolled patients. the mean (sd) age was . (± ) years.sex ratio was . . fifty-two ( %) patients developed aki.sapsii and sofa score in admission were higher in patients with kidney injury [ vs points (p= . ), . vs points ;(p= . )] respectively.the serum lactate level was significantly higher in (aki +) group patients during the first day of septic shock [ . ± . mmol/l (aki+)vs . ± . mmol/l(aki-);(p= . ) ] and its clearance was lower [( ± . % (aki +)vs ± %(aki-);(p= . )]. a significant difference was observed in c reactive protein level [ ± mg/l (aki +) vs ± mg/l (aki-) ; (p= . )].among (aki+) patients, kadigo iii was observed in . % of cases.nineteen ( . %) patients received hemodialysis.a normal kidney function was recovered in . % of cases.aki+ patients had a higher occurrence in disseminated intravascular coagulation ( vs patients, p= . ),acute respiratory distress syndrome ( vs patients; p= . ) and cardiac dysfunction ( vs patient, p= . ).mortality was higher in aki group ( % vs %; p= . ). the development of septic aki was associated with poor outcomes and prognosis.a better understanding of sepsis induced aki pathway will enable us to develop targeted therapeutic protocols.newer tools,permitting aki early detection, may make these therapies more fruitful. this study aims to show that contrast procedures do not significantly increase the risk of renal injury and should not be deferred. traditionally ciaki is the most important cause of in-hospital renal failure after nephrotoxic drugs and shock. problem is also the non-uniform definition of ciaki proposed by three different initiatives (akin, esur and kdigo). akin, being the most rigorous, defines ciaki as an increase in serum creatinine > . mg/dl or > % of baseline within hours. a retrospective observational single-centre cohort study analyzed patients who underwent a contrast procedure with iomeron . the first group underwent a ct pulmonary angiography (ctpa), and the fig. (abstract p ). internally validated model performance: (top row) roc curve; (middle row) calibration curve; (bottom row) decision curve second a coronary angiography with pci. no patient was previously prepared (raas blockade removal, crystalloid administration etc). we studied demographics, history of ckd and comorbidities and their impact on the ciaki by the akin criteria. a total of patients were divided into two groups (ctpa and pci). ctpa group ( m, f) all had acute pe and the pci group ( m, f) were treated for acs. the mean age was and years respectively. ckd was more prevalent in the pci group ( pt vs. pt) possibly explained by the more advanced atherosclerotic disease. advanced chd (nyha iii/iv) was found in pt (pci) vs. pt (ctpa) while diabetes and shock were equally distributed ( pt and pt) in both groups. the mean amount of contrast was significantly higher in the pci group ( . ml vs. ml). the mean creatinine/egfr measured before and after contrast in the ctpa group was . the goal of this study was to determine whether changing the body mass (bm) with fat-free mass (ffm) in cockcroft-gault (cg) formula could provide a more accurate prediction of aki in obese patients undergoing cardiac surgery. in this retrospective study, we reviewed institutional data of patients who underwent elective cardiac surgery in a tertiary referral university hospital. baseline patient creatinine value was collected and gfr was estimated using the mdrd, ckd-epi and cg formulas. cg formula was further modified by replacing the bm with ffm derived from the bioelectrical impedance analysis. postoperative aki was defined by kdigo creatinine change definitions. accuracy of the egfr values to predict the aki was calculated with roc-auc analysis. all the calculations were performed in different categories of bmi. figure ). the egfr is a poor predictor of aki in obese patients undergoing cardiac surgery. the ffm modified cauckraft-gault formula yield more accuracy in this specific group. retroaki: a ten-year retrospective study of acute kidney injury in intensive and progressive care units introduction: acute kidney injury (aki) is a frequent condition in intensive care units (icu) and progressive care units (pcu), affecting % to % of the patients, depending on the studied population and aki definition. aki has been identified as an independent risk factor of icu mortality and development of chronic kidney desease. the objective of this study was to describe the incidence of each aki stages as defined by kdigo definition (with evaluation of urine output, serum creatinine and initiation of renal replacement therapy (rrt)), in a mixed medical and surgical population of patients hospitalized in icu and pcu over a -year period ( - ). we included all patients who stayed more than hours in icu or pcu of edouard herriot hospital from may to january . data used to classify the patients were the urine output over a sixhour period, serum creatinine and the need for rrt, according to kdigo classification results: , hospital stays were analyzed. median icu/pcu length of stay was days [iqr: . - . ]. among icu patients, % had at least one aki episode graded , or and % had at least one severe episode (stage or ). among pcu patients, % had at least one episode of aki and % a severe episode of aki. patients had an average of . episodes of aki per stay. table represents the incidence of maximal aki stage during one stay. we found that urine output was the more frequent criteria to make diagnosis of aki stage or whereas rrt was more frequent for aki stage . this retrospective study reports a more important aki incidence in our icu/pcu than in previous studies. the difference could be fig. (abstract p ) . when comparing auc in different categories of bmi, the mcg appeared to be the only statistically accurate formula in patients with bmi - . explained by the difficulty to collect urine output from conventional database. serum creatinine and the use of rrt are often the only two criteria used to define and classify aki. these results confirm the high incidence of aki in icu and pcu and the importance to make an early aki screening of patients for whom preventive nephroprotective actions are needed. introduction: icu-patients with acute kidney injury (aki) requiring renal replacement therapy (rrt) are at risk for infections [ , ] . in this study we evaluated the incidence of infection in icu patients with and without less severe aki. finally, impact on outcomes was explored. this is a retrospective study on the pdms (protection data management system) of the adult icus of a university hospital. aki was assessed on kdigo criteria (creatinine (scr) and urine output), during the first -d of icu stay. infection was validated in the pdms by a team of icu specialists. results: during a -year period, a total of subjects were enrolled. aki was diagnosed in . % of patients during icu stay. aki patients were older ( vs. y, p= . ), had higher saps ( vs. , p< . ), and had more urgent icu admission ( % vs. %, p< . ). more aki patients had mechanical ventilation ( % vs. %, p< . ) and vasopressors on d- ( % vs. %, p< . ). aki stage , , and was present in . %, . % and . % of patients. more aki patients had infection ( % vs. %, p< . ) and increasing aki stages were associated with higher infection rates (aki- : %; aki- : %, aki- : %, aki- : %, p< . ) (figure ). we observed - times higher mortality in aki patients with infection, and a stepwise increase of mortality with increasing aki stages. after correction for infection and other confounders we found that all aki stages were associated with in-hospital mortality (ors aki- : . , aki- : . , aki- : . , all p< . ). over half of aki patients experienced an episode of infection and increasing aki severity was associated with higher infection rate. aki patients with infection had marked higher mortality, suggesting that infection was an important driver of outcome. however, after adjustment, aki stages had strong association with hospital mortality. several new biomarkers have been introduced to improve early diagnosis of acute kidney injury (aki). "nephrocheck" (nc; astute medical, usa) is a bedside test calculating "akirisk" (product of urinary concentration of the cell cycle arrest-markers timp- and igfbp ). several studies suggest the usefulness of nc in selected populations. however, the value of early routine measurement of nc is unclear. methods: therefore, we compared the prediction of a combined endpoint (cep: death < days and/or requirement of renal replacement therapy rrt) by nc within h of icu admission (nc ) and h later (nc ) with admission values of serum-creatinine, bun, cystatin c, urinary ngal, apache ii and sofa (roc-analysis). as a secondary endpoint we investigated the additional value of pathological measurements of nc ≥ . critically ill patients showed increased relative uce in the first days of icu admission, which may be attributed to higher protein catabolism. increased relative uce was associated with arc and both had no effect on -day mortality. introduction: this study compared epidemiology, short-and long-term outcomes for patients with community-acquired (ca) and hospital-acquired (ha) acute kidney injury (aki). we retrospectively analyzed all episodes of aki over a period of . years ( - ) on the basis of routinely obtained serum creatinine measurements in , patients whose creatinine had been measured at least twice and who had been in the hospital for at least two days. we used the "kidney disease: improving global outcomes" (kdigo) criteria for aki and analyzed the first hospital admission. a total of were admitted in hospital and fulfilled the inclusion criteria. average observation period per patient was days. the incidence of ca-aki among included hospital admissions was . % compared with an incidence of . % of ha-aki, giving an overall aki incidence of . %. patients with ca-aki were younger than patients with ha-aki ( vs . y) and had significantly less comorbidities, including preexisting cardiac failure, ischemic heart disease, hypertension, diabetes. patients with ca-aki were more likely to have stage aki ( , vs , %, p< . ) and had significantly shorter lengths of hospital stay than patients with ha-aki ( vs d, p< . ). those with ca-aki had better survival than patients with ha-aki (figure ; p< the evidence base for management of fluid removal during renal replacement therapy (rrt) is limited. a recent international survey revealed the extent of practice variation worldwide [ ] . our aim was to summarise the responses from europe-based healthcare professionals who participated in the survey. the international self-administered, cross-sectional, internet-assisted, open survey was disseminated between january and january via website links and emails to members of different critical care societies. results: participants from european countries completed the survey of whom ( %) were intensivists and ( %) worked in university-based hospitals. persistent oliguria / anuria was the most common indication for fluid removal ( % responders). the parameters which guided fluid removal included hemodynamic status ( % responders), cumulative fluid balance since admission ( % responders), and -hour fluid balance ( % responders). % of participants reported using crrt with a median net ultrafiltration rate ml/hr (iqr - ml/hr) for hemodynamically unstable and a rate of ml/hr (iqr, - ml/hr) for hemodynamically stable patients. only % of practitioners checked net fluid balance hourly ( % nurses, % physicians). new hemodynamic instability, defined as new onset or worsening tachycardia, hypotension, or need to start or increase the dose of vasopressors was reported to occur in % fig. (abstract p ). long-term survival patients (iqr . - . ). different strategies to re-gain hemodynamic stability were used. (figure ) main barriers to fluid removal were patient intolerance ( % physicians, % nurses) and interruptions in fluid removal ( % physicians, % nurses). the majority of participants agreed that guidelines and protocols would be beneficial. the practice of fluid removal during rrt is very variable across european countries. nurses and doctors identified a need for evidencebased protocols and clear guidelines. introduction: kidney disease improving global outcomes (kdigo) guidelines suggest the use of anticoagulation in continuous renal replacement therapy (crrt) [ ] . the effectiveness of the anticoagulation is important because replacing the hemofilter and tube interrupts crrt and increases total therapy time. regional citrate anticoagulation (rca) and unfractionated heparin (ufh) are most commonly using methods for crrt anticoagulation [ ] . the aim of this study was to investigate the efficacy, safety and metabolic differences of the patients in icu who underwent crrt and anticoagulation method changed from ufh to rca for different reasons. after ethics committee approval ( - / ) patients who underwent crrt between - at bursa uludag university hospital icu have been investigated and patients who underwent crrt by both rca and ufh included in the study. we divided patients in two groups (rca, ufh), demographic data (sex, age), sofa score, creatinine, urea, mean filter life time (flt) and ultrafiltration flow (uf), platelets, electrolytes (na, k, ca, mg), lactate, nahco and ph of groups at beginning and ending of first rca and ufh hemodialysis collected. we used t-test and bootstraps statistic tests. in agreement with other studies [ , ] , flt and uf was statistically significant lower in ufh group (table ) . there was no statistically significant difference in efficiency (urea and creatinine decrease), ph, lactate, nahco level, platelets count and electrolytes between two groups. to our knowledge, there are no studies comparing these two anticoagulation methods in the same patients. small number of patients and retrospective evaluation are limitations of the study. our results suggest that the implementation of rca method is safe and effective as ufh method with longer flt and uf. regional citrate anticoagulation during crrt in liver failure mj jain, pk kumar g, dg govil, jk kn, sp patel, ms shafi, rh harne, dp pal, sm monanga medanta the medicity, critical care, gurugram, india critical care , (suppl ):p continuous renal replacement therapy (crrt) with regional citrate anti-coagulation (rca) is increasingly being used as a treatment modality in critically ill patients. there is limited experience of use of citrate anticoagulation patients with acute liver failure and acute on chronic liver failure who pose a tough challenge of being at a higher risk for bleeding. an institutional protocol was formulated for use of commercially available citrate solutions and the same was studied to assess filter life and safety of citrate in liver disease. the primary objective was to assess safety of citrate anticoagulation in liver disease. this study was a single centre, prospective, non-randomized, single arm, observational study. all adult patients, with acute liver failure and acute on chronic liver failure requiring crrt were included. blood ionized calcium levels of . to . mmol/l was targeted throughout the therapy and total to ionized calcium ratio of less than . was maintained. rca was stopped if the ratio was more than . for consecutive assessments. incidence of citrate accumulation and toxicity were assessed. average filter life was also assessed. metabolic parameters, electrolytes and strong ion gap were followed till hours after completion on crrt. a total of patients were included in the study. nineteen patients of acute on chronic liver failure and patients of acute liver failure underwent crrt with rca. baseline average serum bilirubin, lactate and inr were . mg/dl, . mmol/l and . respectively. the average filter life was hours minutes. citrate accumulation took place in (n= ) patients and rca had to be stopped for ( n= ) patients due to the same. none of the patients had evidence of citrate toxicity. citrate anticoagulation was well tolerated in patients with acute liver failure in patients with or without pre-existing chronic liver disease on crrt. introduction: the intention of this study is to highlight the levels of citrate load for the general population that increases the risk of citrate complications (insufficient trisodium citrate delivery; net citrate overload and citrate accumulation) [ ] . this was a prospective data collection between february and march in a fourteen bedded critical care unit. eleven consecutive episodes of crrt were collected (a new episode characterized if crrt was discontinued for hours and above). one episode was excluded due to short duration (less than hours). patients undergoing rca-crrt received either a fixed or ml/kg/h effluent dose protocol. median patient age was , male %. average time on crrt was . days ( - ). % of the patients had complications, although % were minor ( figure ). all of the patients with net citrate overload had citrate loads of . mmol/h or above. the main risk factors were found to be shock and liver impairment which occurred in % of cases of which % developed complications. a fixed dose effluent protocol to standardise practice can potentially lead to a higher risk of minor complications. in our experience this is likely due to a lack of appropriate monitoring for rca-crrt complications. despite this, our complication rate of citrate accumulation is in line with that reported in literature. citrate loads in our ml/kg/ hr protocol were . % higher than our ml/kg/hr protocol and strongly related to higher complication rate that worsened in patients with risk factors for poor citrate metabolism. introduction: there is no optimal timing of continuous renal replacement therapy (crrt) in acute kidney injury (aki); however, it is based on volume overload, azotemia, hyperkalemia and severe metabolic acidosis [ ] . an important reason for metabolic acidosis in aki is increased unmeasured anions (ua) [ ] . delta-ph-ua (Δph ua ) detects the degree of metabolic acidosis caused by ua and is calculated by using 'the partitioned ph model' [ ] . in this study, we investigated whether Δph ua was a predictor to start crrt in patients with aki. the study was designed as a multicentric, prospective, observational study in . patients who were ≥ years old and diagnosed with aki [ ] were included. the moment aki was diagnosed, arterial blood gas, albumin, magnesium, inorganic phosphorus, urea, creatinine and Δph ua values were recorded. all patients were divided into two groups as crrt(-) and crrt(+) which consists of patients performed crrt due to traditional criteria. fig. (abstract p ) . incidence of complications introduction: continuous renal replacement therapy (crrt) is labor intensive and requires advanced nursing knowledge and skills. however, % of registered nurses (rn) are less than -year post-registration experiences in our unit. also there is an increasing demand of crrt from crrt days in to crrt days in . the obstacles for crrt in our department, includes variation of regimen, complicated workflow and insufficient training of nurses. a continuous quality improvement project is carried out to standardize the regimen, enhance workflow and provide structured training to nurses in the intensive care unit, to enhance nursing competence. methods: introduction: sepsis and septic shock is a leading cause of mortality in the intensive care unit. we tried to evaluate a novel hemoperfusion cartridge through a retrospective evaluation of patient's data in our centre. we used it as an adjuvant therapy in our patients with sepsis and septic shock due to varied causes. the aim of this study was to evaluate the efficacy of therapeutic hemoperfusion cartridge (hc-foshan biosun medical ® ) in the management of patients with sepsis. we retrospectively analysed data of group (n= sepsis) and group (n= sepsis+hemoperfusison; sepsis treated with hemoperfusion cartridge) admitted between to . group had received hemoperfusion cartridge as adjuvant therapy along with standard of care. demographic data, procalcitonin [ ] and leukocyte levels before and after therapeutic cytokine removal and duration of hc were recorded. while the mean duration of cvvhdf was . hours, the duration of hemoperfusion cartridge (application was . ± . hours). among patients who survived patients were administered hemoperfusion cartridge within hours of icu admission. there was a significant reduction in scores like apache and sofa score post hemoperfusion cartridge therapy procalcitonin and leucocyte levels after therapeutic hemoperfusion cartridge were found significantly lower than the pretreatment values (respectively p= . , p= . ). retrospective analysis showed significant reduction of vasopressors, and improvement in map in group . therapeutic hemoperfusion cartridge with cytokine removal applied with cvvhdf in septic patients have positive contributions to provide survival advantage. removal of activated leukocytes and endotoxin from the blood is a complex therapeutic effect of the device for removing endotoxin. in the main group ( patients with abdominal septic shock) after surgery, the traditional treatment was supplemented with two sessions of endotoxin removal ( hours each with an interval of hours) using "alteco lps adsorber" (sweden). the control group consisted of patients with a similar diagnosis and only traditional treatment. results: % of white blood cells were adsorbed in lps adsorber. among them, granulocytes ( %) were maximally extracted, then cd + monocytes (cd + mo) ( %), hla-dr + mononuclear cells ( %), monocytes ( %). il- , il- , procalcitonin (pct) were not adsorbed. the -day mortality rate in the main group was % and was lower compared to the control group - %. during monitoring, in the main group hours after the first removal of endotoxin, a decrease in the initially increased amount of activated cd + mo by . times, as well as functionally mature defensin + granulocytes (def + gran) by . times was observed. il- , il- , and pct decreased by . ; . ; and . times, respectively. during this period, the control group showed an increase in cd + mo and def + gran, while il- , il- did not change, and pct increased . times. a day after the second removal of endotoxin and then days later, the main group of il- , il- , and pct continued to decline. in the control group, only il- decreased after days, the rest continued to grow. the cellular adsorption of endotoxin-bound cd + mo and mature def + gran is an important part of the mechanism of action of the endotoxin removal device. does the endotoxin adsorption of pmx column saturate in hours? preliminary study c yamashita in the euphrates trial, the polymyxin b-immobilized fiber column (pmx) hemoperfusion (hp) had no significant effect on -day mortality. endotoxin (lps) burden by endotoxin activity assay > . may exceed μg [ ] , so the dose and duration of pmx-hp could be insufficient to lower the lps burden. to confirm this issue, we experimented in a closed-circuit with h continuous lps addition, and pmx can adsorb > μg [ ] . further, lps concentration became constant within h in the single lps spike test for determining pmx-hp duration [ ] . to prove our hypothesis that the single lps spike test reflects the adsorption equilibrium, and not saturation, we added lps intermittently to reaction. methods: lps ( ng/ml) was mixed with ml deactivated fetal calf serum as a reflux solution, as previously described [ ] ; this concentration is much higher than that observed in septic patients. we created a closed circuit that incorporates pmx- r at / th the amount of an adult pmx and performed pmx-hp at ml/min for h. lps was added in two shots (post h: ng, ng/ml; post h: ng, ng/ml). lps was measured using the limulus amebocyte lysate test at , . , , , , and hr. after an initial decrease between and h, lps concentration did not decrease between and h after pmx-hp initiation. post lps pulse addition at h, it increased and then decreased till h. futher, it did not decrease between and h, but it increased and then decreased again after lps pulse addition post h (figure ). lps adsorption rates were . , . , and . % at , , and h, respectively. conclusions: lps adsorption capacity of pmx- r was maintained even after two additional shots of lps, suggesting that the constant lps concentration in the previously reported lps spike test might be indicative of adsorption equilibrium rather than saturation. a coohort study included patients admitted to three intensive care with sepsis / septic shock ( sepsis criteria ) and aki ( akin score). all patients were submitted to cvvhdf with the oxiris filter (baxter, usa) . the main clinical data, il , procalcitonin, endotoxin ( eaa ) and sofa score were evaluated at basal time ( t ) and at the end of the treatment ( t ). all data are expressed as mean ± sd or median and iqr . anova test was used to compare the changes in the time. results: patients were submitted to rrt with the oxiris filter for ± hours . patients had aki stage , patients aki stage and patients had aki stage. at t all groups had an high vasopressor fig. (abstract ) . lps concentration in lps pulse addition test support to maintain map ≥ mmhg. il , procalcitonin eaa and sofa total were also elevated with no difference between the groups. at t creatinine improved better in aki ( p< . vs. t ) and in aki ( p< . vs t ) then in aki group. map increased in aki ( p< . vs t ) and aki ( p < . vs t ) , but not in aki group. il , procalcitonin decreased more in aki ( p < . vs t ) then aki . at t sofa total was higher in aki then aki ( p< . ) and aki ( p< . ). conclusions: aki and aki stage patients submitted to bp with the filter oxiris respond better then aki stage patients . -this transalte in a better clinical course. -crrt with oxiris filter is useful in septic patients with aki, but aki stage septic patients represent an high risk group. a non-interventional, multicenter, non-randomized patient registry for multiple organ dialysis with the advos system multiple organ failure is a challenging problem in the icu. as an advanced dialysis system, the advos procedure can eliminate watersoluble and protein-bound substances, regulate the acid-base balance as well as fluid and temperature. in , a national registry was established to collect data under "real-life" conditions of patients treated with advos without any trial-specific interventions (drks id: drks ). methods: data from / to / from german hospitals (university hospitals in hamburg-eppendorf, mainz, essen, and klinikum weiden) were analyzed. clinical parameters, treatment settings and adverse events were documented. the -and -day mortality rates were compared with extrapolated rates based on the sofa score. results: patients with a median age of years (iqr - ), of whom ( %) were male, were evaluated. patients had a median sofa score of (iqr: - ) before the st advos treatment, which is associated with an expected mortality of %. the number of failing organs was (iqr - ): cardiovascular ( %), lungs ( %), liver ( %), kidneys ( %), coagulation ( %) and cns ( %). treatments with a median duration of (iqr: - ) hours were evaluated. were discontinued, of which ( %) were due to a device error. adverse events were documented, were related to the device (all due to clotting and recovered without sequelae). significant removal of protein-bound (bilirubin: . vs . mg/dl) and water-soluble toxins (bun vs and creatinine . vs . mg/dl). in addition, improvement in acid-base balance was observed: ph ( . vs. . ), bicarbonate ( . vs. . mmol/l) and base excess (- . vs. . mmol/l) ( table ) . -and -day mortality rates were % and %, respectively. in a cohort of patients with multiple organ failure, we observed an improvement in the expected mortality rate, especially if the advos procedure was applied early. adverse events are comparable to other dialysis therapies in intensive care patients. introduction: acute kidney injury (aki) due to ischemia-reperfusion affects onethird of the patients in cardiac surgery. we investigated the potential role of cyclosporine (csa) to prevent postoperative aki and mitigate inflammatory response to extracorporeal circulation (ecc). methods: double-blind, randomized, placebo-controlled single-center study. patients (n= ) scheduled for elective cardiac surgery were randomized to , mg/kg csa or placebo before the surgery. the primary objective was to assess the role of csa to reduce the incidence of postoperative aki. the secondary objective was to study csa induced changes in the inflammatory response to ecc. results: all enrolled patients were analyzed. postoperative aki was more pronounced in the cyclosporine group compared to placebo. or= . ( . - . ), % ci. the cytokine production in response to ecc was not affected by cyclosporine (figure ) . in patients undergoing cardiac surgery, a single preoperative dose of csa does not prevent the postoperative decrease in renal function. csa does not alter cytokine release in response to extracorporeal circulation. elevated post-ecc levels of pro-inflammatory cytokine il- are associated with kidney dysfunction and may be predictive. new generation adsorbent such as oxiris r was introduced as novel technique in renal support for critically ill patients [ ] . septic shock patients require decatecholaminization strategies emphasizing blood purification to remove catecholamine-producing mediators and evacuate overload fluid in interstitials. our -year-old female patient, admitted to icu after surgery with history of ovarium cancer. her septic shock was worsened with ards, hypercoagulable state and aki. vasopressors were set. patient was controlled with mode simv ,ps ,tv ml,peep ,fio %. renal support was implemented by diuretic and cvvh started on the second day. at first,regular adsorbent was used, post-filter mode was set, and periodic fluid removal target was ml/h. but after hours, no significant changes observed. oxiris r added and after hours passed, requirements of vasopressors reduced, tidal volume increased, hemodynamic parameters stabilized, urine production increased. it was continued for days and patient was recovered. our patient had fallen into inadequate cars stage in which not able to counter septic effects on vital organs (figure ). renal would be primary target for filtration and monitoring tool. adsorbent consisted of an and polyethyleneimine was useful to purify blood from endotoxins conjoined with slower filtration. continuous yet cautious process in cvvh evacuate fluid and mediators while maintain steady hemodynamics. biomarkers could not be evaluated due to limited resources, but improving parameters could be signs that showed recovery process had already took place. advanced hemofiltration is a privilege. implementing and enhancing it with new generation adsorbent would increase survivors by extracting unnecessary fluids and eliminating catastrophic endotoxins and mediators. consent to publish: written informed consent for publication was obtained from the patient. analysis of retrospective cohort study data of patients (pt) treated for dka at icu of kaunas clinics during - has been carried out. serum kalemia, glycemia; hypokalemia, hypoglycemia episodes; rate of insulin interruption for hypo-and normoglycemia during ketoacidosis; use of nah co for ketoacidosis, and los in icu were analysed. spss . was used for statistic calculations. traits evaluated as significant at p < . . at the beginning of dka treatment in totally hypokalemia ( . ± . mmol/l) was recorded in / pt ( . %). due to ignoring of blood ph ( . - . ( . ± . ) kalemia was falsely misinterpreted as "normo-" or "hyper-" . - . ( . ± . mmol/l) in / pt ( . %), thus disregarded so complicated by obvious hypokalemia additionally in / pt ( . %). in hypokalemia los in icu was . ± . vs . ± . h, p < . . insulin use has caused hypoglycemia ( . - . ( . ± . mmol/l)) in / pt ( . %), los in icu . ± . vs . ± . h, p < . .insulin use was interrupted in case of normoand hypoglycemia with still persisting ketoacidosis in / pt ( . %), los in icu was found to be . ± . vs . ± . hr, p < . . nah co was given for symptomatic treatment of ketoacidosis during first h of dka in / pt ( . %) with stable hemodynamic: hco - buffer has increased ( . ± . - . ± . mmol/l), p < . , but it didn't control ketoacidosis, and los in icu was . ± . . vs . ± . h, p < . . hypokalemia, hypoglycemia, precocious interruption of insulin use were recorded as complications of dka treatment. all of them have prolonged los in icu. symptomatic treatment of ketoacidosis with nah co had no effect on it, and prolonged los in icu as well. a growing interest exists about co derived parameters in shock management. central venous-arterial pco difference (p cv-a co ) is strictly related to cardiac output; central venous-arterial pco difference to arterial-central venous o content difference ratio, p cv-a co / c a-cv o , has been proposed as anaerobic metabolism when it's > . mmhg/ml [ ] . to evaluate p cv-a co /c a-cv o reliability in detecting anaerobic metabolism, we analyzed it in consecutive patients affected by mala admitted to our icu, considering these patients as a prevalent anaerobic metabolism model. we calculated, by douglas formula, central venous-arterial co content difference to arterial-central venous o content difference ratio, c cv-ca co /c a-ccv o , as a respiratory quotient surrogate. we performed arterial and central venous blood gas analysis simultaneously at admission, we calculated p cv-a co , p cv-a co /c a-cv o and c cv-a co /c a-cv o and we recorded scvo . we verified relationship between p cv-a co /c a-cv o and scvo and arterial ph, arterial lactates, sofa score at admission and c cv-a co /c a-cv o by linear regression analysis. pcv-aco /ca-cvo greatly increases in mala ( . ± . ). pcv-aco / ca-cvo (fig. ) shows significant co-variation with ph (r = . ; p= . ) and sofa score at admission (r = . ; p= . ). pcv-aco / ca-cvo has poor agreement with ccv-aco /ca-cvo (r = . ) and disagrees with it in identifying anaerobic metabolism, in our series, in fact, ccv-aco /ca-cvo is, in patients, < like an aerobic rq value. pcv-aco /ca-cvo shows better agreement with ph, sofa score and lactate level than scvo . in our series, p cv-a co /c a-cv o is good illness and acidosis severity marker, but it seems to be affected by ph value in accord with haldane effect [ ] . p cv-a co /c a-cv o , in our study, doesn't seem to be a reliable anaerobic metabolism marker nor a rq surrogate. it is thought that early administration of basal insulin to patients with diabetic ketoacidosis (dka) may improve outcomes. small studies have shown trends towards decreases in time to closure of anion gap (tcag), rates of rebound hyperglycemia following discontinuation of intravenous (iv) insulin, rates of hypoglycemia, intensive care unit (icu) length of stay (los), and hospital los [ ] [ ] [ ] [ ] . this was a single-center, retrospective chart review of our institution's dka protocol between january and august . patients that received early basal insulin within hours of initiation of iv insulin and before closure of the anion gap (ag) were compared to those that did not receive early basal insulin. the primary outcome was median tcag. secondary efficacy outcomes include: time on iv insulin infusion, time to de-escalation of level of care, hospital los, and re-elevation of ag. secondary safety outcomes included incidences of hyperglycemia, hypoglycemia, and hypokalemia. a total of patients were identified meeting inclusion and exclusion criteria. median tcag was longer in the experimental group ( vs. hours, p < . ). incidence of re-elevation of ag and incidence of hyperglycemia were lower in the experimental group. other outcomes were similar (figure ). early administration of basal insulin to patients with dka resulted in a longer tcag with a lower incidence of re-elevation of ag and hyperglycemia. early administration of basal insulin appears to be safe with respect to hypoglycemia and hypokalemia. glycaemic control continues to be a challenge in critically ill patients. stress induced hyperglycaemia has been associated with increased morbidity and mortality [ ] . conversely, patients receiving intensive glucose control have a higher risk of death [ ] . a quality improvement project was designed to develop a comprehensive insulin protocol that recognized pre-existing diabetes and reduced hypoglycaemia. data was collected prospectively in all adult patients admitted to the rah intensive care unit (icu) between october and august from the national icu audit database and electronic patient records. daily figures were collected for numbers of hypoglycaemic episodes (< mmol/l), "in range" ( - mmol/l) blood sugar measurements and patients with a pre-existing diagnosis of diabetes. data was collected and analysed using microsoft excel. results: patients were identified; patients ( . %) had pre-existing diabetes. a total of blood sugar measurements were reviewed; ( . %) were "in range" and hypoglycaemic episodes ( . %) occurred. there was no significant correlation between number of diabetic patients and measurements within range. of note, there was an increase in number of measurements per patient in the second half of the time period ( vs ). the development of this protocol has improved glycaemic control in our icu. there are considerably fewer episodes of hypoglycaemia and a large proportion of blood sugar measurements are in range. we hope to continue data collection and interrogate the prevalence of pre-existing diabetes further to reduce glycaemic variability. the optimal management of blood glucose levels for critically ill patients remains unclear. hypoglycemia, hyperglycemia and glycemic variability are associated with mortality. the time in targeted blood glucose range (tir) has been suggested to correlate with mortality depending on the status of antecedent glycemic control, but it has not been verified optimal tir and whether there is an optimal disease-specific tir. a retrospective observational study was performed at a single center. in the present study, we enrolled all critically ill patients admitted in intensive care unit from january to october. patients with diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome and patients who had < blood glucose readings were excluded. gathered information included, in part, demographics, comorbidities, severity of illness scores, diagnosis at admission, length of icu stay and hospital discharge status. the primary outcome was -day mortality. we analyzed to find the optimal tir for critically ill patients. several tirs were each tested for correlation with mortality. a total of , patients, . % of whom had diabetes, were studied. tir to mg/dl (or, . ; %ci, . - . ), tir to mg/ dl (or, . ; %ci, . - . ) and tir to mg/dl (or, . ; %ci, . - . ) > % was independently associated with mortality in critically ill patients respectively. the optimal tir did not differ depending on diagnosis at admission. in this retrospective evaluation, tir to mg/dl > % was independently associated with mortality in critically ill patients, especially those with good antecedent glucose control. these findings have implications for the design of future trials of intensive insulin therapy. the prevalence of chronic dysglycemia (diabetes and prediabetes) in patients admitted to swedish intensive care units (icus) is unknown. we aimed to determine the prevalence of such chronic dysglycemia and asses its impact on blood glucose control and patient-centred outcomes in critically ill patients. in this retrospective, observational study, we obtained routine glycated hemoglobin a c (hba c) measured in patients admitted to four tertiary icus in sweden between march and august . based on previous diabetes history and hba c we determined the prevalence of chronic dysglycemia (prediabetes, undiagnosed diabetes and known diabetes). we compared indices of acute glycemic control in the icu and explored the association between chronic dysglycemia and icu-associated infections, mechanical ventilation, renal replacement therapy, vasopressor therapy, and mortality within days. of patients, ( %) had chronic dysglycemia. of these patients, ( %) had prediabetes or undiagnosed diabetes and fig. (abstract p ) . results ( %) had a known diabetes diagnosis. during icu stay, patients with chronic dysglycemia had higher average blood glucose, spent less time in target glucose range, had greater glucose variability, and were more likely to develop hypoglycemia than patients without chronic dysglycemia. chronic dysglycemia was associated with greater need for renal replacement therapy (odds ratio . , % ci . - . ) and increased -day mortality (hazard ratio . , % ci . - . ) after adjustment for simplified acute physiology score . in contrast, chronic dysglycemia was not associated with mechanical ventilation, vasopressor therapy, or icu-associated infections. in four tertiary swedish icus, measurement of hba c showed that / of patients had chronic dysglycemia (prediabetes or diabetes). chronic dysglycemia was associated with marked derangements in glycemic control during icu stay, greater need for renal replacement therapy and with increased mortality at days. case report: modern antidiabetic therapie causes ketoacidosis am heiden, m emmerich krankenhaus bad oeynhausen, institut für anästhesie, bad oeynhausen, germany critical care , (suppl ):p the modern antidiabetic class of sglt -inhibitors, that are known to reduce the risk for cardiac events [ ] , are increasingly used in the last few years. a -year old male patient with diabetes mellitus suffered days after colectomy surgery from abdominal pain and nausea. the patient had an antidiabetic therapy with empaglifozin that was paused until day after surgery (nutrition start on day , weaning on day ). methods: this is a case report of one male patient seen in the icu setting. daily blood values including arterial blood gases, vital parameters and clinical status of the patient were observed and evaluated. the blood gases showed this metabolic acidosis: ph . ; pco . mmhg, bicarbonate mmol/l, be - . mmol/l, lactate . mmol/l, glucose mmol/l. a ketonuria despite normal blood glucose values was noticed, so that the diagnosis of ketoacidosis was clear. after analyzing the possible causes we found out, that empaglifozin in times of catabolism and fasting can cause this severe symptomatic. we terminated the therapie with empaglifozin and under the treatment with insulin the symptoms disappeared within days and the patient could be discharged from the icu on day after surgery. after one episode of ketoacidosis the therapy with sglt -inhibitors should lifelong never be started again. we recommend that intensivists should be aware of the modern sglt -inhibitors because of the shown severe complications and the increased use of this medication. consent to publish: written informed consent for publication was obtained from the patient. while obesity confers an increased risk of death in the general population, numerous studies have reported an association between obesity and improved survival among critically ill patients. this contrary finding has been referred to as the obesity paradox. this retrospective study uses two causal inference approaches to address whether the survival of non-obese critically ill patients would have been improved if they had been obese. the study cohort comprises , adult critically ill patients hospitalized at the intensive care unit of the ghent university hospital between and . obesity is defined as a body mass index of ≥ kg/m . two causal inference approaches are used to estimate the average treatment effect in the untreated (atu): a naive approach that uses traditional regression adjustment for confounding and that assumes missingness completely at random, and a robust approach that uses super learning within the targeted maximum likelihood estimation framework and that uses multivariate imputation of missing values under the assumption of missingness at random. obesity is present in . % of patients. the in-hospital mortality is . % in non-obese patients and . % in obese patients. the marginal associational risk difference for in-hospital mortality between obese and non-obese patients is - . % ( % confidence interval (ci) - . % to . %, p= . ). the naive approach results in an atu of - . % ( % ci - . % to - . %, p= . ), whereas the robust approach yields an atu of - . % ( % ci - . % to . %, p= . ). a robust causal inference approach that may handle confounding bias due to model misspecification and selection bias due to missing data mitigates the obesity paradox, whereas a naive approach results in even more paradoxical findings. the robust approach does not provide evidence that the survival of non-obese critically ill patients would have been improved if they had been obese. bowel management within an icu environment is often difficult. recent data collection from an intensive care unit at the rvi identified either loose stool or constipation on > % of patient days. it was postulated this could be improved with a more tightly controlled bowel management regimen. to test this hypothesis a step-wise bowel protocol was created and introduced. data was collected in the month period following its implementation with the following aims: ) assess effectiveness of the protocol ) further observe the reasons for loose or constipated stool on an diarrhea is an important problem in each critically ill pateints [ ] . we aimed to investigate the frequency and management of diarrhea in our icu. in this study patient retrospectively reviewed, in our icu between . . - . . . patients were divided into two group as diarrhea "positive" and "negative". patients with diarrhea had fluid or loose stools or more times a day. each diarrhea period of the patients with diarrhea was examined separately and compared with the group without diarrhea. nutritional status, enteral product formulation, leukocyte, neutrophil, albumin values, gastric sparing, antibacterial and antimycotic use, los in hospital and in icu were compared. in diarrhea positive group, on the day of hospitalization, laxative and/or enema administration, toxin a in stool, nitrogen balance before and after diarrhea, enteral product change in diarrhea, probiotic, metronidazole or oral vancomycin use were examined. the incidence of diarrhea was . %. the most common diagnosis of icu admision was respiratory failure ( - %) in both groups. diarrhea occurred in two days after laxative and/or enema treatment. enteral nutrition was higher in both groups (≥ %). nasogastric tube feeding was significantly higher in the diarrhea group (p= . ). there was no difference between nutritional product formulation and diarrhea development (p> , ). antibacterial use was high in both groups ( %); however, teicoplanin use was significantly higher in the group diarrhea negative group (p= . ). the los in icu, and hospital was higher in diarrhea group (p< . ). no difference in mortality rates (p> . ). many factors may cause diarrhea in icu, and diarrhea may adversely affect patient treatment and increase morbidity. we think that preventive methods are as important as the treatment of diarrhea. the use of parenteral glutamine is studied in number of rcts and systemic reviews (heyland d , wischmeyer p ), while there is a lack of data about the use of enteral glutamine. the aim of our study was to determine the effect of enteral glutamine supplementation on the incidence of hospital infections and death. design: retrospective cohort study. inclusion criteria: males and females > years of age, tbsa burned %- %, nasogastric intubation.patients were divided in two groups: glutamine group (n= ) and control group (n= ). in the study group enteral glutamine was administered to the patients for days after admission to the icu. baseline characteristics were well balanced between groups. no significant difference was found between groups on patients' age, sex, tbsa, need for mechanical ventilation and rate of inhalation injury. primary outcome was all-cause mortality. secondary outcome was rate of nosocomial infections (skin and skin structure infections (sssi), lower respiratory tract infections, urinary tract infections, bacteremia, sepsis). mortality rate was ( %) and ( %) in the glutamine group and the control group, respectively, p= . . rate of nosocomial infections was ( %) in the glutamine group and ( %) in the control group, respectively, р= . . rates of sssi, lower respiratory tract infections, urinary tract infections and sepsis did not differ significantly between the groups: ( %) and ( %), p= . ; ( %) and ( %), р= . ; ( %) and ( %), р= . ; ( %) and ( %), р= . , respectively. rate of bacteremia was significantly different between the groups: ( %) in the glutamine group and ( %) in the control group, p= . . retrospective design is a significant limitation of our study. enteral glutamine supplementation may reduce the incidence of bacteremia in burn patients, but has no influence on the incidence of other nosocomial infections and mortality. further large clinical trials are needed. with outcomes were assessed with multivariable logistic regression and cox proportional hazard analyses, adjusted for baseline risk factors and randomization. in sensitivity analyses, models were further adjusted for key regulators of ketogenesis to assess whether any effect was direct or indirect. late pn increased plasma hb as compared with early pn, with maximal effect on day (p< . for day to and for the "maximal effect" day in the patients). adjusted for baseline risk and randomization, plasma hb associated with a higher likelihood of earlier live weaning from mechanical ventilation (p= . ) and of earlier live picu discharge (p= . ). as plasma hb replaced the effect of the randomization, the hb effect statistically explained these benefits of the randomization. further adjustment for key regulators of ketogenesis did not alter these findings. plasma hb did not independently associate with the risk of infections and mortality. withholding early pn increased ketogenesis in critically ill children, an effect that statistically mediated part of its clinical benefits. critical care patients are prone to frequent feeding interruptions for various reasons including feeding intolerance. these interruptions can lead to adverse outcomes. the aim of the study was to determine the reasons for and the duration of interruptions of enteral nutrition (en). single-center observational, cross-sectional study in a -bed mixed icu of a tertiary hospital. duration: months. patients, aged . years old (± . ), that stayed in the icu > hrs and were fed with en were included. anthropometric data, bmi, time of initiation of prescribed en, type of en formula, daily calories delivered were recorded. energy intake was calculated according to espen guidelines ( kcal/ kg bw/day). the causes for and duration of interruption were reviewed from the patient's chart. apache ii and mnutric score was calculated for all patients. mnutric score ≤ was used to diagnose malnutrition. all patients included in the study were endotracheally intubated. apache ii was . ± . . % of patients had increased risk of malnutrition. icu stay was . ( . ± . ) days, and the in-hospital mortality was %. there were episodes of en interruptions over a median icu stay of . days. median . interruptions/patient. the most common reason for en interruption was gastric residual volume monitoring followed by diagnostic and therapeutic procedures (figure ). other reasons include surgery, intolerance and/or delayed feeding and extubation. the median lost feeding time was . hours/ day ( . - . ) for all causes, while the mean loss of total energy intake was kcal/day (± )/day. average body weight of the patients was kg (± ). caloric deficit was calculated at kcal/day or % of the prescribed caloric goal. the results of this study showed that interruptions can lead to substantial caloric deficit, malnutrition and adverse events. an interruptionminimizing protocol could be useful in order to reduce the missing hours and to improve the clinical outcomes. relationship of goal-directed nutritional adequacy with clinical outcomes in critically ill patients pc tah there are controversies surrounding the effects of optimal nutritional intake on clinical outcomes in critically ill patients. this study aimed at investigating the relationship of goal-directed energy and protein adequacy on clinical outcomes which includes mortality, intensive care unit(icu) and hospital length of stay (los), and length of mechanical ventilation (lomv). this was a single centre prospective observational study. nutritional requirements were guided by indirect calorimetry and -h urinary urea.nutritional intake was recorded daily until death, discharge, or until day of icu stay. clinical outcomes were collected from patient's hospital record. the relationship between the two groups (< % and ≥ % of overall nutritional requirement) with mortality outcomes was examined by using logistic regression with adjustment for potential confounders. terlipressin, despite being one of the main treatments for acute variceal bleeding, may lead to severe hyponatremia due to its antidiuretic activity.we aimed to identify risk factors for development of hyponatremia during terlipressin treatment. retrospective study of patients admitted to acute intermediate care unit for hypertensive upper gastrointestinal bleeding due to chronic liver disease who received terlipressin(december -decem-ber ).hyponatremia was defined as a decrease in na serum levels ≥ meq and severe hyponatremia as > meq within days of treatment. we studied patients, . % male, mean age of . years (sd . ). alcohol-related liver disease was the most frequent etiology. hyponatremia occurred in patients ( . %). serum na Δbetween - and - meq and serum na Δ>- meq occurred in . and . %, respectively (table ) . severe hyponatremia occurred in patients ( . %) and symptoms were reported in two cases (status epilepticus and altered mental status). patients with higher baseline levels of na were more susceptible to terlipressin-induced hyponatremia and a longer length of stay was observed in patients with serum naΔ>- meq ( . vs . days, p< . ). the prevalence of hyponatremia in our study was lower than previously reported.higher serum na at admission and aih as etiology of cirrhosis were predictors of terlipressin-induced hyponatremia. neither the cumulative dose of terlipressin nor the duration of treatment appear to be related to the development of hyponatremia a Δ h-[na] > mmol/l was associated with larger hazards of mortality ( figure ). an increase in serum sodium in the first hours of icu admission is independently associated with a higher mortality in patients admitted with mild hyponatremia, normonatremia, and hypernatremia. based on our findings, it is possible that mild hyponatremia may be a protective mechanism in critical illness, which questions common practice of routinely correcting serum sodium when it is too low. introduction: acute liver failure (alf) represents a life-threatening organ dysfunction associated with increased mortality and liver transplantation represents the only definitive treatment. the aim of this study was to assess the effects of renal replacement therapy in combination with hemoadsorption in alf patients. twenty-nine patients with alf admitted to the intensive care unit (icu) of fundeni clinical institute were included in the study. after icu admission, consecutive session of hemoadsorption in combination with continuous veno-venous hemodiafiltration were applied. number of organ dysfunctions and sirs criteria were recorded at icu admission. the following data were recorded before and after the hemoadsorption therapies: glasgow coma scale, pao /fio , creatinine, -hours urine output, bilirubin, leucocyte and platelet count, heart rate, mean arterial pressure and vasopressor support, c-reactive protein and procalcitonine. clif-sofa score was calculated before and after the therapy. icu length of stay and -days outcome were noted. the mean age in the study group was ± years. the median number of sirs criteria was [ , ] and the median number of organ dysfunctions was [ , ] . the use of hemoadsorption was associated with a decrease in creatinine (from . ± . to . ± . mg/dl, p= . ), bilirubin (from . ± . to . ± . mg/dl, p= . ) and platelet count ( ± / ul to ± /ul, p= . ). we also observed a decrease in clif-sofa score from . ± . to . ± . (p= . ). overall mortality was . % (n= ). six patients ( . %) underwent liver transplantation with % -days survival. the use of hemoadsorption in patients with alf is associated with improvement in liver and kidney functional tests and may represent a new therapy in bridging these patients to liver transplantation. introduction: impairment of intestinal mucosal barrier function is the initiating factor of sepsis. in order to explore the effect of lactic acid bacteria on intestinal barrier function impaired by sepsis, it is necessary to establish sepsis and lactic acid bacteria ecological models. however, how to construct these models is still unclear. co-cultures with a gradient of lactic acid bacteria and caco- cells were constructed. the symbiotic state was observed under an inverted microscope and lactate dehydrogenase (ldh) toxicity tests, transepithelial electrical resistance(teer) tests and western blots were used to determine effective concentrations of lactic acid bacteria in monolayer cell models. lipopolysaccharide (lps) was used to treat cells, and cell counting kit- , quantitative reverse transcription pcr(rt-qpcr) and enzyme linked immunosorbent assays (elisa) were used to determine the appropriate concentration for sepsis models. the number of living cells decreased significantly when the moi(number of lactic acid bacteria/cell number) reached ( figure , panels a, b). the release of ldh indicated that damage to cells began to increase when the moi exceeded (panels a, b). at an moi of . , resistance values began to increase over time, whereas resistance values began to decrease when the moi reached (panel ). as the number of lactobacilli increased, the expression of tight junction protein increased and then decreased (panel a, b, c). in sepsis model experiments, the cell survival rate began to decrease once the concentration of lps exceeded ^ ng/ml (panel ). rt-qpcr results showed that ng/ml lps significantly increased inflammatory cytokines (panel ), and elisa results consistently showed that tnf-α and il- increased significantly when lps concentrations reached ng/ml (panel a, b). it is feasible to construct a cell monolayer model of lactic acid bacteria and lps. the appropriate moi of lactic acid bacteria is . and the optimal concentration of lps is ng/ml. introduction: sepsis is associated with high mortality and morbidity. as the severity increases, physiological parameters such as ph changes are one of the most notable features in metabolic acidosis secondary to high lactate. currently there is no point of care test other than blood gas measurement that could detect these ph changes. this is challenging especially in prehospital environment. the aim of this study is to develop a novel rapid point of care testing using a sensor to detect ph change in blood. sensors were produced by screen printing graphene and silver electrodes and functionalizing the graphene working electrode with an active layer of melanin. a preclinical sensor model was produced by adding lactic acid to a citrated plasma sample thus altering its ph over a clinically relevant range. the ph sensors were exposed to modified plasma, recording any changes in the voltage. the relationship between the voltage potential and plasma ph was established using weighted least squares regression. a ph dependent change in the measured voltage, with respect to the ph of the solution, was observed with a sensitivity of - . mv/ph +/- . over a physiologically relevant ph range between ph . and ph . . in this first phase proof of concept study a low cost, ph sensor was fabricated and demonstrated to be effective in measuring the ph of the plasma. this is the first time that such a sensor has been demonstrated and validated to work in this preclinical model of acidosis. the technology demonstrated here is a promising candidate for a point of care test whereby abnormal blood ph levels can be detected and monitored outside of a laboratory environment in a rapid manner. further studies are now underway to detect this change in whole blood. (figure ) . over one year only a small proportion of patients (n= , %) were classified as 'intermediate high' risk and potential candidates for reperfusion therapies. the revised national early warning score (news) with modified glasgow prognostic score (mgps) is superior to the news for predicting in-hospital mortality in elderly emergency patients t mitsunaga jikei university school of medicine, emergency medicine, tokyo, japan critical care , (suppl ):p the national early warning score (news) was developed in the ukto identify the risk of death. the previous study showed that the modified glasgow prognostic score (mgps) correlate with frailty in elderly patients [ ] . the aim of this study is to evaluate the predict value of the revised news with mgps for in-hospital mortality (in days) in elderly emergency patients. this study is secondary analysis and was carried out in jikei university kashiwa hospital, in japan, from april to march . the acute medical patients aged and older were included. the news was derived from seven physiological vital signs. the mgps was derived from c-reactive protein (crp) and albumin. discrimination was assessed by plotting the receiver operating characteristics (roc) curve and calculating the area under the roc curve (auc). the aucs for predicting in days in-hospital mortality were . for revised news with mgps and . for the original news. the auc of the revised news with mgps was significantly higher than that of the original news for predicting in-hospital mortality (p < . ) (figure ) . our single-centred study has demonstrated the utility of the revised news with mgps as a high predictor of acute phase in-hospital mortality in elderly emergency patients. the diagnostic performance of the five main emergency department (ed) triage systems has been shown to be poor in distinguishing acute coronary syndromes (acs) from mild severity diseases in chest pain patients. these ed triage systems are either clinically-based, being more sensitive or ecg-based, more specific [ ] . the goal of the study was to evaluate if incorporation of cardiovascular risk factors (cvrf) into ecgbased triage could increase his diagnostic performance. cecidoc is a prospective, observational, single-center study in an academic hospital. all consecutive adult patients admitted for acute chest pain were included. we compared the ecg-based french triage system [ ] to a modified system upgrading patients with a normal ecg but significant cardiovascular risk from a low acuity triage score (waiting period before medical assessment of max. min.) to a high acuity triage score (waiting period before medical assessment of max. min.). the final diagnosis was determined after a -day follow-up. we predefined as being adequate a high-acuity triage score (level or ) for acs and a low-acuity score (level , or ) for mild severity diseases. a total of patients was enrolled over a -month period (age . ± . ; m/f ratio . ). triage scores of patients ( . %) with acs were compared to patients ( . %) with mild severity diseases. taking into account cvrf, the sensitivity of the triage system increased from to % whereas the specificity decreased from to %. area under the roc curve (auc) went from . to . (fig. ) . for chest pain triage at ed, addition of cardiovascular risk factors into ecg-based triage increases his diagnostic performance. approximately % of patients presenting to hospital with an intentional overdose require admission to an intensive care unit (icu) [ ] . there are currently no uk guidelines regarding the optimal use of ct head scans (cth) in this patient cohort [ , ] . this study aims to determine whether we should be performing ct head scans in obtunded patients with suspected overdose requiring admission to intensive care. we performed a retrospective search of the icnarc database for plymouth university hospital trust, looking for patients admitted to the icu with overdose or self-poisoning as a primary diagnosis. patients were identified and of these patients required intubation due to obtundation(gcs< ). there were males and females with an average age of years old. the median length of stay on the unit was day. of the patients has a past medical history of mental illness, and overdosed on prescribed medications. the average gcs recorded on admission was . of the ( %) patients had a cth on admission, of which were part of a trauma scan. were known overdoses and were suspected overdose as per the cth request form. the main rationale behind those requests were to exclude additional intracranial injury. none of those cth showed any signs of acute pathology (figure ) . in this retrospective study, obtunded patients with suspected or known overdose with no history of apparent trauma or injury do not benefit from cth. in the absence of a history of trauma or focal neurological signs our conclusions are that cth provides limited value in the management of these patients. the audit was carried out to objectively investigate the problems associated with technique of folley catheterization in emergency department and indoor units of internal medicine wards [ ] . introduction: cellular and molecular mechanisms, epigenetic aspects of acute clozapine poisoning are studied insufficiently. the aim of this study was to identify morphological and epigenetic alteratons in brain neurons during acute exposure to clozapine combined wit ethanol. the experiments were carried out on male wistar rats weighting - g (n= ). group i (control) received . % nacl solution enterally; group iiclozapine mg/kg in . % nacl solution; group iiiclozapine mg/kg in % ethyl alcohol. after hours euthanasia was performed. autopsy included withdrawal of brain samples for histological examination (n = ) and for determination of global dna methylation level (n = ). the global dna methylation level ( -mc%) was determinated by fluorimetric method. inter-group comparisons were made by kruskal-wallis test. histological examination of paraffin sections of brains stained with hematoxylin and eosin was performed by light microscopy. in acute сlozapine poisoning and its combination with ethanol morphological changes in neurons of the cerebral cortex were detected. in acute сlozapine with alcohol poisoning an increase of global dna methylation level was observed. probably the identified changes have a common pathogenesis which will be clarified in our further studies. there is limited information available regarding the prevalence of adder bites and the complications of envenomation. nhs data suggests there are adder bites annually in the uk with the last fatality in [ ] . we performed an audit into adder bites in south west wales to identify the number attending our emergency departments, their management and clinical course as well as any environmental factors that predict increased likelihood of being bitten or the severity of the bite. a retrospective study of adder bites attending emergency departments in south west wales was undertaken (jan to aug ). measurements included were patient demographics, clinical presentation, type of treatment (conservative vs anti-venom) and outcome. results: patients were included, age range - years ( figure ). the majority of bites occurred in sand dunes ( . %) and all bites were on extremities. anti-venom was administered to . % ( / ) of patients. there was a significant positive association between the use of anti-venom and the length of hospital stay (r = . ; p= . ) and a significant negative correlation between the anti-venom use and both diastolic and systolic blood pressure (p= . and . respectively p= . ). all patients fully recovered. in this study, we demonstrated that with a full clinical assessment on presentation it is safe to decide whether anti-venom is required. the current guidelines are safe and effective in the treatment of adder bites. μmol/l, for pao < . kpa and > . kpa, platelets < * ^ /l and > * ^ /l, and bilirubin > μmol/l. in our population of adult ed patients, the thresholds of vital values associated with increased -day mortality were very close to routinely used values, and most of the thresholds were included in the lowest urgency level in triage and risk-stratification scoring systems. the workload in the emergency room: direct assessment by the therapeutic intervention scoring system- and indirect assessment by the nasa task introduction: the number of emergency room admissions continues to increase each year, which increases the care workload of the emergency department staff, who should to use its theoretical and practical knowledge in order to provide quality care in difficult working conditions. the aim of our study was to assess the emergency room staff workload its impact on health workers and patients and to suggest an improvement strategy to decrease this workload. a prospective, monocentric cohort study with descriptive and analytic approach over one month (december ) conducted at the emergency department of an academic hospital. the workload endured by the emergency room staff was evaluated by the nasa task load index and on patients by the therapeutic intervention scoring system- . there were cumulative days of hospitalization in consecutive patients admitted to the emergency room. the average age was ± years. the average length of stay at the emergency room was about ± h. the average tiss- score was . ± . . factors associated with important care workload were: age ≥ years, diabetes, more than comorbidities, the use of intravenous antibiotics; the use of vasoactive drugs and the use of mechanical ventilation; a high tiss score was predictive of emergency room mortality. in the indirect assessment of the care workload, medical and paramedical staff were interviewed, % of them were under years old with a sex ratio of . . a high level of mental and physical workload was expressed by ed staff with considerable level of frustration; the ed staff suggested mainly to improve the working conditions, communication and to redefine tasks "who does what". our study had shown a significant workload in the emergency room, a process to reduce this workload is being implemented medical simulation is a modern teaching tool increasingly used in specialties such as anesthesia, emergency medicine and obstetrics. however, it's not widely used in specialties like cardiology, althought cardiovascular emergencies are very frequent. the purpose of our study was to assess the effectiveness of simulation-based medical education in the management of cardiovascular emergencies among moroccan graduate students. we conducted a prospective, observational, multi-centrer study including the students of three moroccan universities from the th to the th year of medicine who underwent phases: first a pre-test, then a theoretical and practical training on cardiovascular emergencies after which the students were separated in two groups, one undergoing the medical simulation training (group ) and one who didn't (group ), followed by a theoretical then a practical post-test on resusci anne and simman®. at last, the students were asked to answer a satisfaction survey. the reform procedure in the tunisian army consists in repairing the physical damage and deciding on the applicant's ability to continue working. terrorism increases the impact of the co-morbidity generated and the socio-economic consequences that result from it. the purpose of this work was to study the epidemiological, clinical and evolutionary profile of terrorist injuries, to specify the rates of consequent partial permanent disability (ppi) and the possibilities of returning to work. descriptive retrospective cross-sectional study of reform files on military personnel injured during anti-terrorist operations from fig. (abstract ) . changes in total bcpr rate in family-and friends-witnessed ohca cases with dispatcher-assisted instruction during -week period after the day of disaster during three years january to september . the data collection was carried out on the basis of a collection form. our wounded were male, % of whom belonged to the army. the average age was years and months ± . . half of our wounded were troopers. infantry and special forces were the most exposed military units. half of the accidents were recorded in the kasserine region ( cases). chronic post-traumatic stress disorder (cptss) was found in injured, followed by amputations in injured. the after-effects were psychological in %, physical in % and mixed in % of our injured. the ppi rate ranged from % to % in . % of injuries.. more than half of the injured had returned to their professional activity, % were put on reform for health reasons. our results showed that the esptc was the most recorded sequel, and that the ppi rate was significant in a quarter of our injuries. in our series, a third of our wounded were put on reform for health reasons. to state the importance of initial care and adequate and rigorous follow-up to recover a greater number of war wounded. introduction: the rapid response system (rrs) has been shown to decrease hospital mortality [ ] . the japanese coalition for patient safety has set a major goal for hospitals to more widely implement the rrs. however, prevalence and actual circumstances of use in acute care hospitals (including small scale hospitals) in japan are as yet not well-known. web-based questionnaires were sent to acute care hospitals (of scale beds-or-larger) of prefectures in western japan. each participant hospital selected a certain department which answered the questionnaire. the rrs included the medical emergency team (met), the rapid response team (rrt), and the critical care outreach team (ccot). we investigated the presence and circumstances of in-hospital emergency calls, rrs and other systems, and then illuminated issues to be solved. our study suggests that delays in patient transfer to the icu after rrt activation in the wards were associated with slower physiological improvement.these findings support further and larger studies. blood and blood products use in intensive care unit m akcivan, s bozbay, o demirkiran istanbul university cerrahpasa, anesthesiology and intensive care, istanbul, turkey critical care , (suppl ):p blood and blood product (bp) transfusions are frequently used in intensive care units (icu) [ ] . it is important to know transfusion epidemiology and the effect of adverse transfusion reactions and their effect on mortality and morbidity.we aimed to investigate the blood and bp transfusions in the icu. blood and bp transfusions in icu, between - were reviewed retrospectively. we evaluated each transfusion as a data and examined the pre-and post-transfusion laboratory values, demographic data, cause of icu admission and comorbidities. results: patients who underwent transfusion in the icu, and transfusion data from these patients were included. the most frequent cause of hospitalizations were respiratory failure and sepsis. the rate of patients transfused in the five-year period decreased from . % to . %. the hemoglobin threshold before transfusion decreased from . g / dl to . g / dl. a total of transfusion reactions were observed and the most common transfusion reaction was febrile non-hemolytic reaction. the most commonly transfused product was red blood cell suspension. transfusion reactions were found to be slightly higher in men than women in young age group(< y) (p = . and p= . , respectively). transfusion reactions were found to be more frequent in emergency transfusions (p < . ). the number of transfusions was significantly lower in patients with apache ii score < (p < . ). the need for transfusion was found to be higher in patients with hematological malignancy (p < . ). it was observed that as the mean number of transfusions increased the mortality is also increased (p < . ). transfusion therapies are the treatments that are vital but have a serious mortality and morbidity risk. in particular, intensive care patients should be considered in detail because of their specific features. restrictive transfusion practices have positive results. association between anemia or red blood cell transfusion and outcome in oncologic surgical patients. figure a) . the association between rbc transfusion and adverse events also remained after adjustment (or . [ . - . ] ; p < . ) ( figure b) . in oncologic surgical critically ill patients, there was an independent association between anemia (even moderate anemia) or rbc transfusion and patient outcomes. our findings highlight the need for further research to determine the optimal transfusion strategy in surgical oncologic patients. transfusion impaired skin blood flow when initially high e cavalcante dos santos, w mongkolpun, p bakos, al alves da cunha, c woitexen campos, jl vincent, j creteur, fs taccone erasme hospital, intensive care department, brussels, belgium critical care , (suppl ):p red blood cell transfusion (rbct) increases global oxygen delivery (do ) and may improve microcirculation. however, the effects on blood flow have been found to be conflicting. we studied icu patients with stable hemodynamic status (mean arterial pressure (map) ≥ mmhg for at least hours) and without active bleeding, who received a rbct. skin blood flow (sbf) was determined (periflux system , perimed, index finger; perfusion unit, pu) together with map, heart rate (hr), hemoglobin (hb), lactate levels and scvo before and after rbct. sbf was measured before rbct (t ) and after (t ) for each min. according to previous data indicating the lowest sbf value found in noninfected icu patients was pu, all patients were analyzed according to the baseline sbf (i.e. < pu -low sbf vs. ≥ puhigh sbf). the relative change of sbf (Δsbf) was calculated after rbct and the responders were defined by the function of > %. results: icu patients were studied. rbct was associated with increases in map and scvo but no change in sbf. at baseline, scvo was lower in the responders than in the non-responders (p= . ) and lower in patients with low sbf than in the high sbf (p= . ). there was no difference in hb, map, and lactate, between the patients with low and high sbf. after rbct, map rose in the responders (p< . ) and in the non-responders (p= . ), sbf (p< . ) rose in patients with low sbf, and sbf (p= . ) decreased in patients with high sbf. there was a negative correlation between baseline scvo (r= - . , p< . ) or baseline sbf (r= - . , p< . ) and the relative increase in sbf after rbct. rbct increases skin blood flow only when it is impaired at baseline. severe immune dysregulation is associated with adverse outcomes and is common in intensive care unit (icu) patients [ ] . erythropoietin-stimulating agents (esas) have both anti-apoptotic and immune-modulating properties [ ] . despite potential benefit, both the safety and efficacy of these agents remains unclear [ ] . here we evaluate the impact of esas on morality at hospital discharge in critically unwell adult patients admitted to the icu. we conducted our search strategy in accordance with a predetermined protocol. the use of ffp is associated with an increased incidence of complications such as acute respiratory distress and infections, and the rate of complications increased with the quantities of ffp transfused [ ] . pcc contain several important coagulation factors and it has been suggested that they could replace ffp. this has been shown mainly in case reports or series in which coagulation factor deficit was detected by using poc viscoelastic tests in trauma [ ] or traditional hemostatic tests in obstetric patients [ ] . multicenter observational study of the safety and efficacy of the prothrombin complex concentrate. a survey of anesthetists was conducted in maternity hospitals at various levels of care in the russian federation. data has been collected and processed. as a result, patients were analyzed. pph was determined as a volume of blood loss more than ml during vaginal delivery or cs. the most significant risk factors for pph were: preeclampsia or arterial hypertension and a history of postpartum hemorrhage. . % had no risk factors for pph. it was determined that the use of prothromplex iu decreased the number of patients with transfusion ffp - ml/kg by . % and increased the number of patients without transfusion by . %, compared with patients without use of prothromplex iu (figure ). no complications were detected. the use of pcc safety and efficacy reduce use of ffp during pph. the full analysis included patients on either hfc (n= ) or cryoprecipitate (n= ). the intraoperative and postoperative changes in etp and fibrinogen concentration are shown in table . for fibtem a (intraoperatively) and fibrinogen concentration (intraoperatively and postoperatively), the mean numerical values appeared higher with hfc than cryoprecipitate. fxiii (hfc: . %, . %; cryoprecipitate: . %, . %, at baseline and hr after surgery start), fviii and vwf were maintained throughout surgery in both treatment groups. this was also the case for laboratory tests activated partial thromboplastin time, prothrombin time and platelet count. the forma- coagulation parameters analyses showed broad overlaps between hfc and cryoprecipitate, with satisfactory maintenance of the clot quality parameters, fxiii concentrations and thrombin generation parameters. the study group includes men and women with a mean age of , vs. . years (p= . ) admitted with the diagnosis of multiple trauma. we found a directly proportional and highly significant statistical correlation between base excess and fibrinogen level diagnosed using the mcf/fibtem parameter(r= . , p< . )and an inverse proportional correlation between lactate level and fibrinogen level (r= - . , p= . ). in the roc analysis that uses as a variable the level of base excess and as a criterion of classification the fibrinogen deficit (mcf/fibtem< mm) it can be observed that at a value of be<- mmol/l, we can diagnose a fibrinogen deficit with a sensitivity of . % and a specificity of . % (auc= . ,p< . ). lactate appears to be inferior to the excess base (figure ) , but still has a good diagnostic power, a value of . mmol/l has a sensitivity of . % and a specificity of % (auc= . ,p< . ). the difference between the two roc curves ( . ) is statistically significant (p = . ). both base excess and serum lactate can be used to diagnose fibrinogen deficiency with the mention that base excess appears to have a higher sensibility and specificity ability. based goal-directed algorithm. this approach requires further clinical validation. we conducted a retrospective study comparing transfusion strategies in patients with major trauma between and . we retrieved demographic data and blood products administered from patients with at least one red-blood cell (rbc) transfusion. primary outcome was a reduction of rbc administration. secondary outcomes were mortality, icu length of stay and acute kidney injury. we included patients admitted in the icu due to severe trauma (sapsii: . ± . ), and mainly after emergent surgery ( . %). they featured a mean age of . ± . y, were predominantly male ( . %) and % were in shock. in the first hours of hospital admission a mean of . ± . rbc units were administered. most patients received a fibrinogen-based protocol (fbp) ( %), with an average of ± g of fibrinogen and ± fresh-frozen plasma (ffp) units, versus ± g of fibrinogen and ± ffp units in the ffp group. the fbp was associated with a decrease administration of rbcs in the first hours (r = - . ; p < . ), even after adjustment for severity (p= . ) and for tranexamic acid use (p = . ). it was associated also with a decrease of platelet transfusion (p= . ). fibrinogen-based protocol was not associated with a decrease in mortality, acute kidney injury or noradrenaline dose. treatment of tic in past years has progressively changed to a goaldirected fibrinogen-based approach. in our population, the use of fbp lead to a reduction of rbc administration in severe trauma patients. prospective, multicenter, randomized study comparing administration of clotting factor concentrates with a standard massive hemorrhage protocol in severely bleeding trauma patients the objective of this study was to assess the ability of the quantra® qstat® system (hemosonics) to detect coagulopathies in trauma patients. many level trauma centers have adopted whole blood viscoelastic testing, such as rotational thromboelastometry (rotem®, fig. (abstract ) . study treatment plan instrumentation lab) for directing transfusion therapy in bleeding patients. the quantra qstat system is a cartridge-based point-of-care (poc) device that uses ultrasound to measure viscoelastic properties of whole blood. and provides measures of clot time, clot stiffness and a test of fibrinolytic function. methods: adult subjects were enrolled at two level trauma centers which use a rotem based protocol to guide transfusion decisions. study protocols were approved by the site's ethics committee. for each subject, whole blood samples were drawn upon arrival to the emergency department and again, in some cases, after administration of blood products or antifibrinolytics. samples were analyzed on the quantra (at poc) in parallel to rotem delta (in lab). a total of patients were analyzed. approximately % of samples had a low clot stiffness (cs) values suggestive of an hypocoagulable state. the low stiffness values could be attributed to either low platelet contribution (pcs), low fibrinogen contribution (fcs), or a combination ( figure ) . additionally, % of samples showed evidence of hyperfibrinolysis based on the quantra clot stability to lysis parameter. samples analyzed on standard rotem assays showed a lower prevalence of low clot stiffness and fibrinolysis based on extem, fib-tem results. the correlation of cs and fcs vs equivalent rotem parameters was strong with r-values of . and . , respectively. this first clinical experience with the quantra in trauma patients showed that the qstat cartridge detected coagulopathies associated with critical bleeding and may be useful for directing blood product transfusions in these patients. ability to perform testing at poc may provide additional clinical advantage. the objective of the study was to describe the conditions of use of fibryga® g, a new, highly purified, human fibrinogen (hf) recently granted a temporary import authorization for use in congenital and acquired fibrinogen deficiencies in france. observational, non-interventional, non-comparative, retrospective study conducted in french hospital centres using fibryga®. data from patients with fibrinogen deficiency having received fibryga® from december to july were retrieved from their medical files. indications, modalities, efficacy and safety outcomes were recorded. indications encompassed non-surgical bleeding (nsb) either spontaneous or traumatic, including post-partum hemorrhage (pph), bleeding during surgery (sb) or administration to prevent bleeding during planned surgery. treatment success was defined as control of the bleeding or hemoglobin loss < % for bleeding treatment and as absence of major perioperative hemorrhage for pre-surgical prevention. this analysis included patients aged , ± . years and % were male. all presented an acquired fibrinogen deficiency requiring administration of hf. indications were nsb (n= , . %) including ( . %) pph, sb (n= , . %), and prevention of sb (n= ; , %). cardiac surgeries were the main procedures associated with treatment and prevention of sb. mean total doses of fc were . ± . g, . ± . g and . ± . g for nsb, sb and prevention of sb. success rates were . % ( %ci . - . %), . % ( %ci . - %) and . % ( %ci . - %) respectively. for pph, mean dose of hf was . ± . g with a success rate of . % ( %ci . - %). overall, tolerance was good. fibrinogen concentrate fibryga® is mostly used for bleeding control. in one third of patients, hf was administered preventively to avoid bleeding during surgery. use of fibryga® was associated with favourable efficacy outcomes. functional testing for tranexamic acid effect duration using modified viscoelastometry t kammerer , p groene , s sappel , p scheiermann , st schaefer ruhr-university bochum, institute of anaesthesiology, heart and diabetes center nrw, bad oeynhausen, germany; ludwig-maximilans university, department of anaesthesiology, munich, germany critical care , (suppl ):p tranexamic acid (txa) is the gold standard to prevent or treat hyperfibrinolysis [ ] . effective plasma concentrations are still under discussion [ ] . in this prospective, observational trial using modified viscoelastometry we evaluated the time-course of the antifibrinolytic activity of txa in patients undergoing cardiac surgery. methods: patients were included. modified viscoelastometry (tpa-test) was performed and txa-plasma-concentration, plasminogen-activatorinhibitor- (pai- ) and pai-antigen-plasma-concentrations were measured over h. additionally, in vitro dose-effect-curves from blood of healthy volunteers were performed. data presented as median with interquartile range (q /q ). results: txa plasma-concentration was increased compared to baseline (t : μg ml - ) at every time-point with a peak concentration min (t ) after application (p< . ; see fig. a ). lysis was inhibited from min (lysistime tpa-test : p< . ; lysisonsettime tpa-test :p< . ). maximumlysis tpa-test was decreased at t (t : % ( / ) vs. t : % ( / ); p< . ). of note, after h some patients (n= ) had normalized lysis whereas others (n= ) had strong lysis inhibition (ml< %;p< . ) up to h. high and low lysis groups differed regarding kidney function (cystatin c: . mg l - ( . / . ) vs. . mg l - ( . / . );p= . ) and active pai- ( . ng ml - ( . / . ) vs. . ng ml - ( . / . );p= . ). in-vitro, txa concentrations > μg ml - were effective to inhibit fibrinolysis. in our trial, after h there was still completely blocked lysis in patients with moderate renal impairment. this could be critical with respect to postoperative thromboembolic events [ ] . here modified viscoelastometry could be helpful to detect the individual fibrinolytic capacity. introduction: peri-operative coagulopathy correction based on viscoelastic hemostatic assays (vhas) and single-factor coagulation products has changed the paradigm of bleeding management in cardiac surgery [ ] . in a retrospective study, we analysed patients with emergency surgery for thoracic acute aortic dissection (taad), before and after the introduction of fibrinogen concentrate in clinical practice. data were collected from paper and electronic records. the study was approved by the institutional ethical committee. patients were included in the analysis, operated in , before fibrinogen concentrate was approved for human use, and in - . therapy was guided by a rotational thrombo-elastometry (rotem) algorithm. exclusion criteria were non-compliance with the institutional protocol and intra-operative death. we investigated allogeneic blood transfusion (abt), fibrinogen use, peri-operative bleeding (pob), surgical reexploration and post-operative complications (poc). the groups were similar in gender, age, body weight, additive euro-score and aortic cross-clamp time. fresh frozen plasma, cryoprecipitate and red blood cell transfusion were lower in the fibrinogen group, but not platelet transfusion (table). , % of patients in the study group received fibrinogen concentrate and median dose was g (iqr - ). day postoperative chest tube drainage and surgical reexploration were significantly lower. there were no differences in stroke, renal replacement therapy, mechanical ventilation time and icu stay. in patients with taad surgery, rotem-guided algorithms which include fibrinogen concentrate are associated with less (pob), surgical re-exploration and abt. further research is needed to document the role of vhas and concentrated factors in reducing (poc). andexanet alfa (aa, portola pharmaceuticals, san francisco, ca) represents a modified factor xa agent which is approved antidote for apixaban and rivaroxaban. andexanet alfa may also neutralize the anti-xa effects of betrixaban and edoxaban. this study aims to compare the relative neutralization of these four anti-xa agents by andexanet alfa in different matrices. andexanet alfa was diluted at mg/ml. apixaban (a), betrixaban (b), edoxaban (e) and rivaroxaban (r) were diluted in ph . , . m tris buffer (tb), blood bank plasma (bbp) and in % albuminated buffer (ab) at . - . ug/ml. anti-xa activities of all four agents were measured in three systems and the reversibility indices of aa were profiled. the reversibility index (ri ) of anti-xa effects by aa was determined at - ug/ml. each of the four agents produced varying degrees of inhibition of anti-xa at . - . ug/ml, the ic ranged . - . ug/ml in bbp, . - . ug/ml in ab and . - . ug/ml in tb. andexanet alfa produced a concentration dependent reversal of all four anti-xa agents. in the bbp, the ri values for a ( ug/ml), b ( ug/ml), e ( ug/ml) and r ( ug/ml). in the ab, the ri values for a ( ug/ml), b ( ug/ml), e ( ug/ml) and r ( ug/ml). in the tb, the ri values for a ( ug/ml), b ( ug/ml), e (> ug/ml) and r ( ug/ml). each of the four anti-xa agents exhibit varying degrees of matrix independent anti-xa potencies in different systems, the collective order follows edoxaban > apixaban > betrixaban > rivaroxaban. andexanet alfa produced matrix dependent differential neutralization of the anti-xa effects of these agents. individualized dosing of andexanet alfa may be required to obtain desirable clinical results. the diagnostic and prognostic value of thromboelastogram (teg) in sepsis has not been determined. this study aimed to assess whether teg is an early predictor of coagulopathy [ , ] and is associated with mortality in patients with sepsis. in total, patients with sepsis on intensive care unit admission were prospectively evaluated. we measured teg and conventional coagulation tests(ccts)on preadmission and observed for development of , days and , , days respectively. multivariable logistic regression was utilized to determine odds of icu/hospital mortality. the parameter of teg (maximum amplitude, reaction time; ma/r ratio) was calculated to evaluate sepsis-induced coagulopathy. the admission patients were divided into three groupsma/r group(ma/r= - mm/min); ma/r group(ma/r> mm/min)and ma/r group(ma/r< mm/min). in our cohort of patients with severe sepsis, coagulopathy defined by ma/r ratio was associated with increased risk of icu/hospital mortality. introduction: blood sampling for coagulation assessment is often carried out in either arterial or venous samples in the intensive care unit (icu). there is controversy as to the accuracy of this method due to the inherent differences in physicochemical properties as well as the underlying effects of individual diseases in arterial and venous blood. clot microstructure has shown to be a new biomarker (fractal dimension-d f ) which encompasses the effects of diseases in all aspects of the coagulation system [ , ] . in this study, we compared the effect of all these factors in venous and arterial blood to see if there is a difference in the clot microstructure and quality. patients admitted to a tertiary intensive care unit and busy teaching hospital were recruited. arterial and venous blood was sampled from an arterial line and central venous catheter in situ from the same patient. standard markers of coagulation (pt, aptt, fibrinogen, full blood count), rotational thromboelastometry (rotem), whole blood impedance aggregometry and measured clot microstructure (d f ) were measured on both arterial and venous samples. no significant difference was observed in standard laboratory markers, rotem and platelet aggregation between arterial and venous blood. there were no differences in the fractal dimension (d f ) between the arterial and venous blood samples (d f . ± . vs . ± . respectively, p= . ). samples from patients with critical illness give comparable results from either arterial or venous blood despite their underlying pathophysiological process or treatment. this confirms blood for coagulation testing can be taken from arterial or venous blood. clinicians in the emergency setting use a wide range of hemostatic markers to diagnose and monitor disease and treatment. current methods rely on the anticoagulant effect of citrate on whole blood prior to laboratory analysis. despite the well-recognized modulatory effects of citrate on hemostasis, the use of anticoagulated blood has clear analytical advantages, including repeat sampling and storage. however by altering the physiological state of the blood reproducibility and accuracy of the test is affected. recent studies have shown the potential of a novel functional biomarker of clot formation: fractal dimension (d f ), that may give an improved diagnostic accuracy. in this study we assessed the potential of this new biomarker in scientifically measuring the effects of recalcification of citrated samples. methods: healthy volunteers were included. unadulterated and sodium citrate samples of blood were taken from each volunteer. citrated samples were recalcified using ( m cacl ). in the study we compared unadulterated whole blood d f results to citrated d f results and repeated the citrated d f experiments times for each sample over a hour period to ascertain reproducibility. the d f of citrated blood was significantly lower than that of unadulterated blood ( . ± . vs . ± . , p< . ). the results of the citrate samples when tested times over hrs gave a coefficient of variation of . %. for the first time we show that a functional biomarker of clot microstructure, d f , can precisely quantify and measure accurately the direct effect that the addition of the anticoagulant sodium citrate has on whole blood clot microstructure. the study also shows that the test is reproducible and has potential utility as a biomarker of acute disease in the emergency setting in citrated blood. this procedure now needs to be evaluated in a group of acute disease states. in this study, we analyzed the hematological abnormalities of dengue patients by thromboelastography (teg) at initial and -hour of fluid resuscitation. methods: this is a cross-sectional study evaluating teg readings of dengue patients with different severities presenting to the emergency department. laboratory confirmed dengue patient (positive ns antigen or igg/igm) was consecutively sampled. teg readings were taken at presentation and after -hour of fluid resuscitation. twenty dengue patients with varying severity had a median reaction time (r), α -angle, k time, maximum amplitude (ma) and lysis % (ly ) of . min, . ο , . min, . mm and . % respectively. mean fibrinogen was normal before and after fluid infusion. there is a non-significant reduction in ma with prolongation of other teg parameters between different dengue severities. there is a statistically significant reduction of α-angle and ma between pre and post -hour fluid resuscitation (p= . and p= . ). normal fibrinogen with low ma, which signifies a weak clot strength, may indicate either a platelet reduction, platelet dysfunction or both. reduction in ma and α-angle post fluid resuscitation is an alarming finding. this is in contrast with previous teg studies although none of it used normal saline exclusively, studied initial fluid resuscitation in emergency department settings or studied a subject with dengue. a bigger study, especially in severe dengue is needed to validate our findings. agreement between the thromboelastography reaction time parameter using fresh and citrated whole blood during extracorporeal membrane oxygenation with teg® and teg® s m panigada, s de falco, n bottino, p properzi, g grasselli, a pesenti fondazione irccs ca´granda ospedale maggiore policlinico, intensive care unit, milano, italy critical care , (suppl ):p the r (reaction time) parameter of kaolin-activated thromboelastography (teg) may be used to assess the degree of heparinization of blood during ecmo. a teg analysis is usually performed on two types of samples: fresh (f) or citrated-recalcified (c) whole blood. teg® can perform the analysis on c and f whole blood, the new teg® s (haemonetics corp., ma, usa) only on c whole blood. aim of the study was to compare the response of r to heparin using the two types of samples and two teg devices methods: during a three months period at fondazione irccs ca' granda -policlinico of milan, teg was performed (using teg ® and teg s® with and without heparinase, an enzyme that degrades heparin) on consecutive ecmo patients (as part of the gatra study, nct ) and in consecutive non-ecmo patients in whom a teg was requested for clinical purposes. bland altman analysis and lin's concordance correlation coefficient were used to assess agreement results: a total of paired samples were taken ( in-ecmo and off-ecmo). ecmo patients received . ( . - . ) iu/kg/h of heparin. among non-ecmo patients, of them did not receive any dose of heparin, two of them a very low prophylactic dose ( . and . iu/ kg/h, respectively), and one of them . iu/kg/h of heparin. using teg® , r was - . (- . ; . ) min shorter on c compared to f blood in patients receiving heparin (this difference disappeared using heparinase) and only - . (- . ; . ) min shorter in patients notreceiving heparin. r was - . (- . ; . ) min shorter using teg® s (which performs the analysis only on c blood) than teg® on f blood (figure ) . when evaluating the effect of heparin using teg, clinicians should be aware that results obtained using citrated-recalcified or fresh whole blood are not interchangeable. using citrated-recalcified blood to perform teg might lead to underestimation of the effect of heparin trauma patients are at high risk for venous thromboembolism (vte). the east guidelines recommend low molecular weight heparin (lmwh) for vte prevention and antixa monitoring after initiation of the medication or after adjusting doses in certain populations [ ] . studies have shown standard enoxaparin dosing of mg every hours may result in low antixa levels [ ] . this study aims to evaluate the efficacy of a pharmacist-lead protocol for adjusting enoxaparin dosing based on antixa levels in trauma patients. this single center retrospective chart review included adult trauma patients admitted from / / to / / . per protocol, patients with body mass index (bmi) ≤ kg/m were initiated on enoxaparin mg twice daily, and patients with bmi > kg/m were initiated on enoxaparin mg twice daily. peak antixa levels were drawn to hours after at least the third dose of enoxaparin with a goal therapeutic range of . - . iu/ml. the primary objective was time in days to goal peak antixa level. secondary objectives include vte occurrence, bleeding attributed to lmwh, and dosing regimens utilized. subgroups were analyzed based on body mass index (bmi). of patients identified, patients met inclusion criteria. median time to therapeutic antixa level was days (iqr - ). of patients fig. (abstract ) . agreement between teg® s and r teg® on citrated recalcified and fresh whole blood with bmi ≤ kg/m , patients ( . %) were dosed initially per protocol and / patients ( . %) met goal antixa level at first check (table ) . of patients with bmi > kg/m , patients ( . %) were dosed initially per protocol and / patients ( . %) met goal antixa level at first check. our results indicate the protocol is safe due to lack of bleeding attributed to enoxaparin, but less than % of patients achieved goal antixa level at first check. however, despite low rates of achieving goal antixa level, vte rates also remained low. introduction: most patients in the icu are given prophylactic anticoagulation with a fixed dose of mg once daily of enoxaparin (clexane) if cct is normal and mg if cct is low. studies on non icu patients have shown that afxa is below desired range for venous thromboembolism (vte) prevention. in the icu, many factors might influence afxa levels including weight, creatinine clearance (cct), shock and other medication. atxa activity was not yet reported in a big mixed icu population with variable morbidity. our study hypothesis is that enoxaparin is underdosed in most cases and routine afxa activity should be monitored in all icu patients. preventive enoxaparin ( mg qd) was given to all patients unless therapeutic dose was needed or contraindication existed. levels of afxa activity were taken hours after the rd dose. therapeutic vte preventive effect was defined as afxa activity of . - . . patient data was collected from medical files. the study is still ongoing, preliminary results were analyzed for patients. of patients ( %) had afxa activity below normal (subtherapeutic). weight and cct were negatively correlated with afxa activity (figure ). mean weight in the subtherapeutic afxa was significantly higher than the therapeutic group ( . vs. . respectively, p= . ). cct in the subtherapeutic afxa was significantly higher than the therapeutic group ( . vs. . respectively, p= . ). the normal cct group (> ) had significantly more patients with subtherapeutic afxa ( vs , p= . ). in our icu, % of the patients receive insufficient vte prophylaxis. overweight patients and patients with normal cct should probably receive higher enoxaprin dose. afxa activity should be routinely monitored in icu patients. in this study we use a new bedside biomarker to test its ability to measure anticoagulation effects on patients who present with acute first time deep vein thrombosis (dvt). dvt requires oral anticoagulants to prevent progression to potentially fatal pulmonary embolism and recurrence. therapeutic efficacy monitoring of direct oral anticoagulants (doac) including rivaroxaban is problematic as no reliable test is currently available. advances in hemorheological techniques have created a functional coagulation biomarker at the gel point (gp) which allows quantitative assessment of: time to the gel point (t gp ), fractal dimension (d f ) and elasticity (g') [ , ] . the prospective observational cohort study measured t gp , d f , g', standard coagulation and cellular markers in first time dvt patients at three sample points: pre-treatment and approximately and days following mg bd and mg od rivaroxaban respectively. strict inclusion and exclusion criteria applied. results: dvt patients (mean age years [sd± . ]; male, female) and non-dvt patients were well matched for age, gender and co-morbidities. mean t gp on admission was s (sd± . s) and . s (sd± . s) for dvt and non-dvt respectively. doac therapy significantly increased t gp to . s (sd± . s) after days, and subsequently increased to . s (sd± . s) at days as shown in table . d f , g' and standard hemostatic markers all remain within the normal range. conclusions: t gp demonstrates its utility in determining the anticoagulant effect of rivaroxaban. the significant difference in t gp between males and females needs further exploration. localized stasis as a result of transient provoking factors appears not to generate a systemic strength fig. (abstract p ) . correlation of anti factor xa activity with patient cct and weight. anti fxa activity value below . (red line), was considered "non-effective prevention" introduction: trauma remains the leading cause of death all over the world. to better exploit the trauma care system, precise diagnosis of the injury site and prompt control of bleeding are essential. here, we created a nursing protocol for initial medical care for trauma. the aim of this study was to evaluate the impact of protocoled nursing care for trauma on measures of quality performance. this was a retrospective historical control study, consisted of consecutive severe trauma patients (injury severity score > ). people were divided into two groups: protocoled group (from april to march ) and control group (from april to march ). we set the primary endpoint as mortality for bleeding. the secondary endpoints included time allotted from arrival to start of ct scan and surgery, administration rate of several drugs (sedations, painkillers, preoperative antibiotics, and tranexamic acid). for the statistical analysis, continuous variables were expressed as median (interquartile range) and were compared by wilcoxon rank sum tests given a nonnormal distribution of the data. we included patients in the study: in the control group before the introduction of the protocol, in the protocoled group. as a primary endpoint, the mortality for bleeding was similar between two groups ( % in the control group and % in the protocoled group). as a secondary endpoint, the time to ct initiation [group a ( - ) min vs group b ( - ) min; p < . ], and emergency procedure [group a ( - ) min vs group b ( - ); p < . ] were shortened by the protocol introduction. furthermore, the administration rates of sedations, painkillers, preoperative antibiotics, and tranexamic acid were increased in the protocoled group compared with the control group. although the mortality as a patient-oriented outcome was not affected, improved quality of medical care by nursing protocol introduction may be suggested in this analysis. this single-institutional prospective study included patients with uprf who were admitted to the trauma surgical intensive care unit (tsicu) and survived until discharge to home between and . we evaluated the activities of daily living after the discharge using physical and mental component scores of sf- ® and defined physical dysfunction (pd) as physical function (pf-n) score of or less. we divided the patients in the pd (n= ) and control (without pd, n= ) groups and compared the groups. the patients had experienced blunt injuries, including falls ( %) and pedestrian injuries ( %). the mean age was . years (men: . %); the median injury severity score was (interquartile range: - ); and the mean length of tsicu stay was . days. the average period from the injury until the survey was . months. there was no difference between the pd group and the control group in the patient characteristics, fracture type, pelvic fixation, and complications. at the time of the survey, the pd group had significantly more painful complaints than the control group (pd: . %, c: . %, p < . ), and had more physical and mental problems. the sf- ®subscale score showed a significant positive correlation between physical function and body pain, mental health respectively. the percentage of those who were able to return to work was not different in both groups (pd: . %, c: . %). in the multivariate analysis of pd, only age (odds ratio: . , % ci: . - . , p = . ) was relevant. long-term pd was observed in % of patients with uprf. the elderly were particularly prominent, and there was an association between pain and mental health. cells (rbc) this can lead to inhibition of oxygen transport function and development of hypoxia. currently used methods for analyzing the state of rbc either do not have sufficient accuracy or require lengthy analysis and expensive equipment. the use of a simpler and more informative electrochemical approach to assessing the state of rbc is very promising. electrochemical measurements in rbc suspensions (~ • cells / l) were carried out in a special electrochemical cell [ ] in the potentiodynamic mode in the potential range from - . to + . v using the ipc pro mf potentiostat (kronas, russia); optical measurements were performed using an eclipse ts inverted microscope (nikon, japan), a cfi s plan fluor elwd x / . lens (nikon, japan); rbc morphology was recorded in real time using a ds-fi digital camera (nikon, japan). when examining rbc of patients with severe multiple trauma a decrease in the ability of rbc to change their shape during electrochemical exposure was observed, indicating a decrease in deformability, which can lead to a disruption in the oxygen supply to tissues. at the same time, with the stabilization of the patient's condition a restoration of the ability of rbc to change morphology was detected which in turn could have a positive effect on the rheological characteristics of the blood (fig. ) . the results of the analysis of red blood cells using electrochemical changes in their morphology can be used as an additional method for the diagnosis of critical conditions. severe trauma should be treated immediately. whole-body ct (wbct) is widely accepted to improve the accuracy of detecting injuries. however, it remains the problem of time-consuming. therefore, we focused on the scout image taken in advance of wbct. detecting major traumatic injuries from a single scout image would reduce the time to start treatment. a previous study suggested that even specialists could not easily find chest and pelvic injuries using wbct scout image alone. in this study, we aimed to develop and validate deep neural network (dnn) models detecting pneumo/hemothorax and pelvic fracture from wbct scouts. we retrospectively collected anonymous wbct scouts together with their clinical reports at the osaka general medical center between january , , and december , . we excluded incomplete, younger than years old, postoperative, and poorly depicted images. the part of this dataset from january , , until december , , was used for validation and the rest for training dnn models. pneumo/hemothorax detection model and pelvic fracture detection model were trained respectively. accuracy, and areas under the receiver operating characteristic curves (aucs) were used to assess the models. the training dataset for pneumo/hemothorax contained images (mean age years; % female patients), and for pelvic fracture consisted of images ( years; %). the validation dataset for the former contained images ( years; %), and for the latter consisted of images ( years; %). the models achieved % accuracy and an auc of . for detecting pneumo/hemothorax, % and . for pelvic fracture. our results show that dnn models can potentially identify pneumo/ hemothorax and pelvic fracture from wbct scouts. increasing the number of samples, dnn model could accurately detect severe trauma injuries using wbct scout image. clinical information system (cis) is a computer system used in collecting, processing, and presenting data for patient care. it can reduce staff workload and errors; help in monitoring quality of care; track staff's compliance to care bundles; and provide data for research purpose. however, the transition from paper record format to electronic record involves changes in all kind of workflow in icu. therefore, an effective, efficient and evaluative rollout plan was required to minimize the risk that might arise from the new practice. methods: . small groups training were provided. a working station with different case scenarios were set up for practices. . individual tutorials were conducted to clarify questions. emphasis on patient care was always top priority. . contingency plans were available in case of server breakdown and power failure. downtime drills were conducted to prepare the staff in emergency situations. . step-by-step transition from paper record to electronic format was gradually carried out. a plan was discussed among cis team with clear dates and goals. . new items in cis were first reviewed and amended in team meeting until consensus was made; then were promulgated to all staffs during handover before implementation. fig. (abstract p ) . the effect of therapy on the electrochemically induced change in the morphology of red blood cells in patients with combined trauma . staff compliance and outcomes were then monitored; further review and amendment would be possible if necessary. cis roll-out plan was smooth. all staffs were able to integrate cis into the daily routine. the contingency plans were well acknowledged. new items were followed as planned. ongoing enhancement in cis was put forward on nursing orders, handover summary, and integration with inpatient medication order entry (ipmoe) system. with emerging benefits cis brings along, our staff has more time to devote to direct patient care. human input in data interpretation and clinical judgment on top of cis play an irreplaceable role in patient care. the daily request for laboratory tests in intensive care units is a common practice. although common, this strategy is not supported, since more than % of the exams requested with this rationale may be within the normal range [ ] . misconduct based on misleading results, anemia, delirium and unnecessary increase in costs may happen [ ] . we have developed a strategy to reduce laboratory tests without clinical rationale. observational retrospective study, from july to june . the number and type of laboratory orders requested, the epidemiological profile of hospitalized patients, the use of advanced supports, the average length of icu stay and the impact in outcomes such as mortality and hospital discharge at a private tertiary general hospital in the city of rio de janeiro / rj -brazil were analyzed. a strategy was implemented to reduce the request for exams considered unnecessary. approximately , patients underwent icu during this period. the epidemiological profile and severity of patients admitted to the unit were similar to those observed historically. there was a significant reduction (> %) in the request for laboratory tests and there was no negative impact on outcomes such as mortality, mean length of stay and no greater use of invasive resources. over the period evaluated, the estimated savings from reducing the need for unnecessary exams were approximately $ , per year. the rational use of resources in the icu should be increasingly prioritized and the request for routine laboratory tests reviewed. a strategy that avoids such waste, when properly implemented, enables proper care, reducing costs and ensuring quality without compromising safety. evaluating the medication reconciliation errors in icus after implementing a hospital-wide integrated electronic health record system a rosillette, r shulman, y jani university college hospital, centre for medicines optimisation research and education, london, united kingdom critical care , (suppl ):p introduction: medication errors in intensive care unit (icu) are frequent [ ] and can arise from a number of causes including transition of care. our aim was to investigate the impact of an integrated electronic health record system (ehrs) on medication reconciliation (mr) errors occurring at critical steps: during the transition from an icu to the hospital ward and from the ward to hospital discharge. the objective was to examine the influence of icu admission on long-term medication. we performed a monocentric study in icus of a university-affiliated hospital using drug chart and medical notes review to identify mr errors before, during and after icu admission. data were collected retrospectively from ehrs for consecutive patients discharged from the icu between june- july , and who were newly initiated on specific drugs of interest. results: drugs of interest were initiated in icu. many of these were continued after hospital discharge as shown in table . there was appropriate discontinuation of all the antipsychotics newly initiated in icu. other than anticoagulants, there was no reason documented for continuation of the initiated drugs. the planned durations were documented more often after hospital discharge than icu discharge for the following drug classes (% of patients with a plan after icu discharge to the ward; % after home discharge): antibiotics ( . %; . %), and steroids ( . %; . %), but less so for analgesics ( . %; . %), insomnia ( . %; . %), and gastroprotective drugs ( . %; . %). our study has shown that medications initiated in the icu can be inadvertently continued at icu and hospital discharge due to failure in documenting indication or duration. systems are required to deprescribe icu only drugs at discharge or communicate a plan for ongoing treatment. introduction: the surviving sepsis campaign advocates the use of care bundles to guide the management of sepsis and septic shock [ ] . our study aim was to assess compliance with a locally introduced sepsis pathway and to review intensive care unit admission outcomes. we carried out a prospective audit of patients admitted to the icu at royal surrey county hospital with a diagnosis of sepsis between / / and / / , assessing compliance with local sepsis bundle delivery, outcome of icu admission and degree of associated organ dysfunction. results: patients were identified, male ( . %), with a mean age of . ( - ). mean st hour sofa score on icu was . ( - ). % of patients required vasopressors, with % requiring noradrenaline > . mcg/kg/min, and % requiring an additional vasopressor/ inotrope. % required niv, % invasive ventilation and % rrt. icu mortality was %, in-hospital mortality %, mean icu stay days ( - ), and mean length of hospital stay days . in the presence of septic shock mortality was % with post-resuscitation lactate > , versus % in patients with no vasopressor requirement or lactate < (p< . ). the sepsis bundle was delivered in one hour to patients ( %). where the bundle wasn't completed, antibiotics were delayed in % of cases and blood cultures weren't taken in %. where the bundle was fully delivered, unit mortality was % vs. % where it was not (p< . ), but there was no significant difference in hospital mortality ( % vs. %, p> . ) or rates of vasopressor requirement, niv, ippv or rrt. there is room for improvement in timely delivery of the sepsis bundle in our hospital and various measures are being instituted. though there was no significant difference in hospital mortality, icu mortality was significantly lower in patients when the bundle was fully delivered. surviving sepsis campaign recommends h and h sepsis resuscitation bundle for sepsis. the study was done to assess the feasibility of the guideline and the compliance to sepsis- recommendations at an emergency department. prospective interventional study was conducted during one year. were involved in the study all sepsis cases with a qsofa ≥ . were assessed a composite of six components (measurement of serum lactate, obtaining blood culture before antibiotic administration and provision of broad-spectrum antibiotic before the end of h and provision of fluid bolus in hypotension, attainment of target central venous pressure assessed by cardiac ultrasonography, target lactate to normal level before the end of h ). time base line was the first medical contact at triage zone. secondary outcomes of study were the mortality rate and length of stay at intensive care unit (icu). were involved in the study, patients (mean age ± years, sex ration , ). pulmonary infections were the main cause of sepsis ( %) and urinary tracts infections ( %). at h components were achieved in % of cases [lactates ( %), blood culture ( %) and provision of antibiotics ( %)]. at h components were executed in % of cases (fluid provision achievement in %, ultrasonography assessment in % and normal lactate target achieved in %) (figure ). the reliability-adjusted rate for completion of the hours and hours bundle was at %. patients compliant to composite bundle got the mortality benefit (odds ratios = . , % [confidence interval, . - . ]). the study, however, did not show any benefits of mean intensive care unit (icu) length of stay. faisability of - h bundle ratio was at %. it has shown a significant improvement in adaptation and mortality benefit without reducing mean hospital/icu length of stay. more adapted procedures are needed to improve results targeting full compliance of patients to the - h bundle sepsis management. patterns and outcome of critical care admissions with sepsis in a resource limited setting m edirisooriya maddumage , y gunasekara , d priyankara national hospital of sri lanka, medical intensive care unit, colombo , sri lanka; sri jayawardenepura general hospital, department of critical care, nugegoda, sri lanka critical care , (suppl ):p introduction: paucity of epidemiological data is a major barrier in expansion of critical care services, especially in resource limited settings. we evaluated the patterns and the outcome of critically ill patients with sepsis admitted to a level medical intensive care unit in sri lanka. a retrospective cohort study was performed to describe the characteristics and outcome of patients with sepsis, admitted to a medical intensive care unit. sepsis is defined according to sepsis definition. we examined critically ill patients admitted over a period of months. sepsis was the commonest presentation, accounted for . % of all admissions. mean age was . ± . years. septic shock was present in . % on admission. pneumonia ( . %) was the commonest cause, while leptospirosis ( . %) and meningoencephalitis ( . %) accounted for fig. (abstract p ) . sepsis - h bundle components (% of goals achievment) second and third commonest causes of sepsis respectively. the sofa score on admission ( . ± . vs . ± . , p< . ), occurrence of aki ( % vs . %, p< . ) and the length of icu stay ( . days vs . days, p < . ), were significantly higher in sepsis than in patients without sepsis. icu mortality in sepsis (n= ) did not show a significant difference to nortality (n= ) in those without sepsis ( % vs %, p= . ). patients with leptospirosis had a mean sofa score of . , however the mortality ( . % vs %, p = . ) was similar to others with sepsis. in contrast, mortality related to sepsis was significantly high ( %, p< . ) in the packground of immunosuppression (n= ). respiratory failure secondary to pneumonia was the commonest cause of critical care admission with sepsis. sepsis related icu mortality was high in the background of immunosuppression. introduction: training in placement, and the subsequent safe confirmation of position, of a nasogastric (ng) tube, relies on clinicians completing an e-learning module at our trust. feeding through an incorrectly placed ng tube is a 'never event,' associated with significant morbidity and mortality [ ] . analysis of these incidents reveal that the misinterpretation of chest radiographs, by medical staff, who had not received competency-based training, is the most frequent cause [ ] . e-learning has revolutionized the delivery of medical education [ ] , however, there are barriers to its use [ ] . we hypothesized that, by taking e-learning content, and delivering it face-to-face, we would improve training rates, and thus patient safety. a questionnaire was completed by critical care doctors, concerning their knowledge of the existence of the e-learning module, whether they had completed formal training in ng tube placement, and how confident they were, on confirming correct positioning, using a point likert scale. all clinicians underwent training in the interpretation of ng placement, using chest radiographs. after the session they were asked to re-appraise how confident they felt. results were compared using paired t tests. confidence improved in all, rising from a pre-test average score of . (sd= . ), to post-session . (sd= . ), p=< . . prior to the intervention, % of the doctors were aware of the trust guidelines, but only % had completed the training. after the session, % were aware of the guidelines, and % had completed the training (figure ) . conclusions: e-learning is a useful tool, but has its limitations. by using course content, delivered with more traditional learning methods, we im-proved the number of appropriately trained clinicians, and thus the safe use of ng tubes in our unit. a systematic review of anticoagulation strategies for patients with atrial fibrillation in critical care a nelson, b johnston, a waite, i welters, g lemma university of liverpool, liverpool, united kingdom critical care , (suppl ):p there is a paucity of data assessing the impact on clinical outcomes of anticoagulation strategies for atrial fibrillation (af) in the critical care population. this review aims to assess the existing literature to evaluate the effectiveness of anticoagulation strategies used in critical care for atrial fibrillation. only studies contained analysable data. anticoagulated patients had a lower mortality at days and days post admission to critical care, however there was an increased incidence of major bleeding events compared to the non-anticoagulated population. thromboembolic events were comparable in both cohorts. data from current literature is scarce and inferences regarding the effectiveness of anticoagulation in patients in critical care with af requires further investigation and research. every new admission to the icu prompts a handover from the referring department to the icu staff. this step in the patient pathway provides an opportunity for information to be lost and for patient care to be compromised. mortality rates in intensive care have fallen over the last twenty years, however, % of patients admitted to an icu will die during their admission [ ] . communication errors contribute to approximately two-thirds of notable clinical incidents; over half of these are related to a handover [ ] . nice have concluded that structured handovers can result in reduced mortality, reduced length of hospital stay and improvements in senior clinical staff and nurse satisfaction [ ] . a checklist was created to review the information shared and to score the handover. this checklist was created with doctors and nurses and is relevant for handovers between all staff members. information was gathered prospectively by directly observing handovers on the icu. there is a notable discrepancy in the quality of handovers of new patients ( figure ). this is true of handovers between doctors, nurses and a combination of the two. it is also true of all staff grades. whilst a doctor may have reviewed the patient prior to their arrival, % (n= ) of patients weren't handed over to a doctor. the most commonly missed pieces of information were details of the patient's weight ( %, n= ), their height ( %, n= ), whether the patient has previously been admitted to an icu ( %, n= ) and whether the patient has any allergies ( %, n= ). the handover of new patients to the icu is often unstructured and important information is missed. this can be said for all staff members and grades, and for handovers from all hospital departments. post intensive care syndrome-family (pics-f) describes new or worsening psychological distress in family and caregivers after critical illness but remains poorly studied within specialist groups [ ] . we aim to define the degree of pics-f within our tertiary referral cardiothoracic centre and map change over the course of months. caregivers attended a -week multi-professional clinic alongside patients. peer support was facilitated through a café area and a caregiver group psychology session was offered with individual appointments if required. caregiver surveys were completed including: caregiver strain index; hospital anxiety and depression scale (hads); and insomnia severity index. patients also completed hads questionnaires. repeat surveys were completed at and months. results: over cohorts, caregivers attended, of which were spouses ( %), children ( %), and others ( %), with caregivers completing surveys at months. patients' median apache score was (iqr - . ) and median icu length of stay was days (iqr - . ). most admissions were from scheduled operations ( %). severe caregiver strain was present in / ( %) with changes to personal plans ( %) the most common sub category. hads demonstrated caregivers ( %) with anxiety and ( %) with depression. caregiver anxiety exceded that of patients', only reaching fig. (abstract p ) . each handover was scored according to the information accurately given to icu staff similar levels at months, while depression remained static ( figure ). median number of nights with 'bothered' sleep was (iqr - . ) and % of caregivers expressed problems with sleep. conclusions: significant psychological morbidity in caregivers from our tertiary cardiothoracic centre is in keeping with the general icu population [ ] . caregiver strain was reduced suggesting higher levels of resilience. future work should address mental wellbeing, particularly anxiety, to minimise the effects of pics-f. burnout syndrome is an illness that has increasingly affected health professionals. it is characterized by great emotional stress, physical and mental exhaustion and depersonalization of the individual. more serious cases can lead to job loss or even suicide. the described work identifies the burnout level of the multidisciplinary team through a specific questionnaireburnout syndrome is an illness that has increasingly affected health professionals. it is characterized by great emotional stress, physical and mental exhaustion and depersonalization of the individual. more serious cases can lead to job loss or even suicide. the described work identifies the burnout level of the multidisciplinary team through a specific questionnaire methods: application of a questionnaire suitable for the multidisciplinary group in november . the same was answered by professionals among physicians and nursing team. there was no identification of employees. after analysis of the results it is observed that % of the group presents initial burnout, % with the syndrome installed and about % with characteristics of greater severity. main factors found were: mental and physical exhaustion during the work day, the level of responsibility existing in the activity and the perception of disproportionate remuneration by work performed. all interviewees presented some degree of burnout or high risk to develop it. the most severe cases should be traced through occupational medicine and anti-stress measures with reorganization of work performance should be discussed in order to reduce the prevalence of this syndrome. introduction: burnout affecting the psychological and physical state of healthcare workers is recognized in the last years. burnout has been shown to affect the quality of care. whilst some risk factors have been identified, there are gaps within the literature related to mental health and burnout. the aim of this study is to measure levels of burnout across icu units in the metropolitan setting. to determine the level of burnout we used surveys, the maslach burnout inventory human services survey (mbi-hss) and the centre for epidemiologic studies depression scale (ces-d). with the mbi-hss we analysed different variables of burnout; exhaustion, cynicism and emotional exhaustion. basic demographic data and information regarding workout schedules were collected. we studied prevalence and contributing risk factors using and analysing the outcomes of the self-scoring questionnaires. analysis was performed using descriptive statistical analysis. there were respondents, % scored the threshold for depressive symptoms on the ces-d depression scale. interestingly, % (ci . - . %) of those meeting the score for depressive symptoms identified as having frequent restless sleep compared with % ( . - . %) from those not meeting. gender did not affect depressive symptoms % of females and % of males met the threshold. with the mbi-hss for exhaustion the mean was . (sd . ) which is a high level of exhaustion, the second variable cynicism the mean score was . (sd . ), which was considered high. the final variable was emotional exhaustion the mean was . (sd . ), this is considered moderate levels of emotional exhaustion. fig. (abstract p ) . hospital anxiety and depression scale (hads) scores for patients and caregivers at baseline, months, and months there was high prevalence of burnout in icu in all different categories as well as depressive symptoms. age and gender had no affect on burnout. interestingly, we identified that sleep and shift variables were linked to increased burnout. following the implementation of a fully integrated ehrs on march at our university-affiliated hospital we conducted a prospective study in icus by analysing pharmacists' contributions during data collection periods of days at , , and weeks post implementation. a pharmacists' contribution was defined as contacting the physician to make a recommendation in a change of therapy/ monitoring [ ] . the types of contribution were: a medication errorrectification of an error in the medication process; an optimizationproactive contribution that sought to enhance patient care, and a consult -reactive intervention in response to a request. a panel of experts composed of a senior pharmacist, a consultant, a nurse, and a pharmacy student assessed the impact of each contribution, scoring low impact, moderate impact or high impact. there were pharmacist contributions recorded in the periods. of these, ( . %) were medication errors, ( . %) were optimizations, and ( . %) was a consult ( table ) . % of the contributions were assessed as having medium impact, % as high impact and % as low impact. in general, the consultant assessed fewer contributions as having high impact compared to other members of the panel, with contributions assessed as high impact by the consultant versus by the senior pharmacist. implementing an ehrs in combination with contributions of clinical pharmacists can prevent medication related issues. interestingly the types of incident did not change over time. introduction: most icu's are noisy and may adversely affect patients outcomes and staff performance [ ] . who reports that the noise level in hospitals should not exceed db at daylight and db at night. the aim of this study is to evaluate the noise levels in intensive care unit, to apply awareness training to intensive care staff in terms of noise and to compare the noise levels before and after education. noise measurement areas are separated into points including patient bedsides, nurse desk, staff desk, wareroom, corridor and entrance of intensive care unite. measurements were performed times per day. after day, awareness training were given to staff in terms of harmful effects of noise. after the training, noise measurements were repeated during days. after total days the measurements were terminated. noise was measured with incubator analyzer (fluke model: bio-tek serial no: ). the mean noise values before and after the training were not statistically different from the mean average noise values (p> . ). when the time of measurement were compared, the noise levels were higher between - hours to other measurements before and after the training statistically (p= . ). seventeen different noise measurement areas were compared in terms of noise level, there was no statistically significant difference (p> . ). the differences were examined at the same hours between before and after training. contrary to expectations, noise levels were found to be higher after training statistically (p< . ). all of noise measurements were higher than the threshold values that who recommended. increased noise levels in critical care units may lead to harmful health effects for both patients and staff. our results suggest that much noise in the icu is largely attributable to environmental factors and behavior modifications due to education have not a meaningful effect. critical care medicine has focused on continuous, multidisciplinary care for patients with organ insufficiency in the face of lifethreatening illness. despite significant resource limitation low income countries carry a huge burden of critical illness. available data is insufficient to clearly show the burden and outcomes of intensive care units in these developing countries [ ] . the objective of our study is to evaluate the morbidity and outcomes of patients admitted to the intensive care unit of a tertiary university hospital in hawassa, ethiopia. this was a prospective observational study. data was registered and analysed starting from patient admission to discharge during a month period beginning september . data regarding demographics, sources of admission, diagnosis, length-of-stay and outcomes were analysed. the total number of patients admitted to the icu was , with patients dying over a one year period. the highest admission was from emergency medical unit, % and the lowest source was from pediatrics department, %. out of these, . % were males. the mean age was years ( - ). the most frequent aetiologies of morbidity in the admitted patients were traumatic brain injury ( . %), acute respiratory distress syndrome ( . %) and seizure disorder ( %). average median length of stay was . days (interquartile range: . - . ). the overall mortality rate was . %. the top four causes of death in the icu were respiratory illness at % followed by sepsis with multiorgan failure at %, trauma ( %) and central nervous system infection ( %). infection morbidity and mortality remains very high and needs institution of aggressive preventive strategies. the increase in frequency of trauma patients need to receive due attention. sepsis causes a high number of deaths, though overtaken by respiratory illnesses. improving the overall system of icu may achieve better outcomes in resource limited countries. introduction: icu mortality has been widely studied in the literature in relation to outcome index that primarily value organic failure [ ] . however, early mortality, in the first hours of admission has been little documented in the literature. the aim of this study is to analyze factors related to early mortality in icu. retrospective study at a second-level hospital. time of study was months. patients who died in icu were included, patients were classified according timing of dead, including those who died within the first hours of icu admission. the variables analyzed were age, sex, comorbidity, charlson index, apache ii, need for supportive treatments, more frequent admission diagnosis, origin and support treatment limitation decisions. the statistical study was carried out using the spss statistical program. patients were included during the study period, ( . %) died within the first hours of admission. no differences in the needs of support treatments were observed, more than % of patients received mechanical ventilation and vasoactive therapies. table shows characteristics of patients. half of icu deaths occur within the first hours of admission. severity at icu admisison was the main factor related with early mortality. severe stroke and coronary disease were the most frequent causes of early deaths in icu. in august the royal college of anaesthetists published guidelines on care of the critically ill woman in childbirth and enhanced maternal care [ ] . approximately babies are born across the area covered by leicester university hospitals that includes two large maternity units and is part of the uk ecmo network. this audit sets out to assess current practice and form a basis for future planning, which will likely be representative to most major obstetric centres. a retrospective audit of all patients admitted to 'intensive care units' in leicester over a month period following publication of the guidelines. the focus was on patients admitted to general adult intensive care and excludes all patients cared for in 'enhanced obstetric care' units. simple standards were proposed relating to accessibility, resuscitation, follow up and multi-disciplinary learning. in total women were identified with a broad range of diagnosis. the intensive care services are split across hospitals and we found this led to a number of problems. the presence of trained staff to resuscitate a newborn were easily accessible, no steps to provide necessary equipment pre-emptively were present in any centre. none of our critical care units had a plan for perimortem section. on-going reviews by the obstetric and midwifery teams were very variable. contact with the infant and breastfeeding support was also poor. despite the large number of deliveries significant work needs to be done in order to come in line with the new national guidelines for critically ill woman in childbirth. clearly defined pathways around escalation of care, resuscitation of both the mother and baby, integrating care of the mother and the infant in the first few days of life, and multidisciplinary learning events are being produced de novo in response to these guidelines, some of which will be illustrated in the associated poster. interprofessional collaboration scale [ ] . data were analyzed with ibm spss . results: it was found that cooperative attitudes with an average score of to are considered to be of average significance. interprofessional cooperation at an average score of , states that the level of cooperation is high and the quality of working life averages to , suggesting that it is very good. as far as professional satisfaction is concerned, nurses are happy, content and satisfied with their work, despite workload and burnout conclusions: interprofessional cooperation at the icu of the general hospital of larissa is high, but satisfaction from wages, resources, working environment and conditions is low. in addition, the results showed that improvements in hospital communication between staff, has a positive impact on the quality of professional life (table ) . contrasting with previous reports, decreased admissions per unit population in older and oldest age groups, and those with high comorbidity, suggest resource constraints may have influenced admission discussion and decision-making over the -year study period in wales. further investigation is warranted. icu discharge into weekends and public holidays: an observational study of mortality n mawhood, t campbell, s hollis-smith, k rooney bristol royal infirmary, general intensive care unit, bristol, united kingdom critical care , (suppl ):p introduction: up to a third of in-hospital deaths in icu patients occurs following ward stepdown [ ] . discharge time seems to be associated with in-hospital prognosis, but meta-analyses have not shown a difference in weekday compared to weekend discharge [ , ] . however, papers that examined discharge 'into' out-of-hours days, particularly on fridays, have found differences [ ] . our aim was to assess whether discharge from icu 'into' out-of-hours (ooh -weekends and public holidays) is associated with in-hospital mortality or re-admission to icu, and whether these patients were seen on the wards ooh by medical staff. all adults discharged from the general icu to a ward at the bristol royal infirmary in december - were included. in-hospital mortality rates were assessed for each day, with 'into weekdays' defined as sunday to thursday and 'into ooh' friday, saturday and the day before a public holiday. a subset of patients with data on readmission rate to icu was also examined. all available notes from patients discharged into ooh in were reviewed. the study included patients with a subset of with readmission data. sets of notes were reviewed from patients discharged into ooh (figure ). the in-hospital mortality was significantly higher in patients discharged into ooh ( . % vs . %, p= . ). within the subset, ooh was associated with in-hospital mortality or readmission to icu ( . % vs . %, p= . ), though readmission rate alone was not ( . % vs %, p= . ). of patients discharged into ooh, once on a ward % were reviewed by a specialty doctor but . % were not seen. this is the first study to examine icu discharge 'into' ooh days including public holidays. we found increased hospital mortality in ooh, similar to other studies [ ] . up to a fifth of high-risk icu stepdown patients were not reviewed by a doctor on ooh days. exploring the experiences of potential donors' family members (fm) in a follow up clinic is crucial to analyze the effects of organ procurement (op) on the bereavement process, to gain insight on the reasons of family refusals (fr), and to improve family care during op. a mixed-method study involving fm at and months after patients' death was developed and approved by local ethics committee. fm of potential donors after brain (dbd) and cardiac death (dcd) treated in careggi teaching hospital, florence (italy) were eligible if adult and consenting. invitation letters were sent to the entitled months after death and those who actively responded were involved in an encounter with a multidisciplinary group including a clinical psychologist, two nurses and two cultural anthropologists with expertise in op. organ replacement procedures such as ecmo (extracorporeal membrane oxygenation), lvad (left ventricular assist device) and dialysis are routinely used to treat multi-organ failure (mov). globally transplantation programs struggle with increasing organ shortage. patients (pts) with mov are a potential source for procurement. however, outcome data after kidney transplantation (ktx) from such donors are sparse. we retrospectively studied the cadaveric ktx at the charité berlin in and identified donors with ongoing organ replacement procedures. donor and recipient risk factors were assessed. overall patient and graft outcomes were analyzed at months post-transplant. a total of kidneys were transplanted. we identified ktx from donors with mov ( following cardio-pulmonary resuscitation, with acute renal failure - on dialysis) (figure ). in donors, a venoarterial ecmo was implanted during ecls-resuscitation. one donor needed a veno-venous ecmo due to ards, and donor had a lvad implanted due to cardiac failure. the donor age was ± . years (yrs). in addition, donors had at least one cardiac risk factor. the kidney donor risk index averaged . (sd ± . ) and s-creatinine prior to ktx was . (sd ± . one way to expand the potential donor pool is donation after circulatory death (dcd), and a strategy to reduce the complications related to the ischemic time is the use of normothermic regional perfusion (nrp) with extracorporeal membranous oxygenation (ecmo) [ , ] . we compare the use of standard nrp with an effective adsorption system inflammatory mediators (cytosorb®) in the regional normothermic reperfusion phase via regional ecmo, that involves a reduction in cellular oxidative damage, assessed as a reduction in levels of proinflammatory substances. we report a case series of dcd-maastricht iiia category donors, treated in ecmo with nrp, to maintain circulation before organ retrieval, in association with cytosorb® in patients. during perfusion, from starting nrp (t ), blood samples are collected times, every minutes (t , t , t ). during treatment with cytosorb®, lactate levels progressively decrease, ast and alt increase less than without cytosorb®, as sign of improvement in organs perfusion ( figure ). nrp with cytosorb® might help to successfully limit irreversible organ damages and improve transplantation outcome [ ] . development and implementation of uniform guidelines will be necessary to guarantee the clinical use of these donor pools. introduction: shock is a common complication of critical illness in patients in intensive care units (icus), who are undergoing major surgery. this condition is the most common cause of death in postsurgical icus. nowadays, there are different icu scoring systems for predicting the likelihood of mortality, such as apache or sofa. nevertheless, they are used rarely because they also depend on the reliability and predictions of physicians. in these sense, gene expression signatures can be used to evaluate the survival of patients with postsurgical shock. methods: mrna levels in the discovery cohort were evaluated by microarray to select the most differentially expressed genes (degs) between groups of those that survived and did not survive days after their operation. selected degs were evaluated by quantitative real time polymerase chain reactions (qpcr) for the validation cohort to determine the reliability of the expression data and compare their predictive capacity to that of established risk scales. introduction: this study evaluates the prognostic ability of frailty and comorbidity scores in patients with septic shock. the -day mortality rate of individual medical conditions are also compared. the burden of comorbid illness and frailty is increasing in the critical care patient population [ ] . outcomes from septic shock in patients with chronic ill-health is poorly understood. interstitial lung disease is a group of diseases associated with poor prognosis in the intensive care unit despite major improvement in respiratory care in the last decade. the aim of our study is to assess factors associated with hospital mortality in interstitial lung disease patients admitted in the intensive care unit and to investigate the long-term outcome of these patients. we performed a retrospective study in an intensive care unit of teaching hospital highly specialized in interstitial lung disease management between and . a total of interstitial lung disease patients were admitted in the intensive care unit during the study period. overall hospital mortality was %. two years after intensive care unit admission, / patients were still alive ( %). one hundred eight patients ( %) required invasive mechanical ventilation of whom % died in the hospital (figure ). acute exacerbation of interstitial lung disease was associated with hospital mortality (or= . [ . - . ] ), especially in case of acute exacerbation of idiopathic pulmonary fibrosis. multiorgan failure (invasive mechanical ventilation with vasopressor infusion and/or renal replacement therapy) was associated with very high hospital mortality ( / ; %). survival after intensive care unit stay of patients with interstitial lung disease is good enough for not denying them from invasive mechanical ventilation, except in case of acute exacerbation for idiopathic pulmonary fibrosis patients. if urgent lung transplantation or extracorporeal membrane oxygenation are ruled out, multiorgan failure should lead to consider withholding or withdrawal life support therapies. Αgi is a malfunctioning of the gi tract in icu patients associated with prolonged mechanical ventilation, enteral feeding failure and high mortality risk. the wgap of esicm proposed a grading system for agi. four grades of severity were identified: agi grade i, a selflimiting condition; agi grade ii (gi dysfunction), interventions are required to restore gi function; agi grade iii (gi failure); agi grade iv, gi failure that is immediately life threatening. the aim was to evaluate the feasibility of using agi grades i and ii as predictors of malnutrition and -year mortality in critically ill patients methods: single-center retrospective cohort study in a tertiary university hospital ( - ). agi grade iii and iv patients were excluded. Αnthropometric data, gi symptoms (vomiting,diarrhea), feeding intolerance, gastric residual volumes and abdominal hypertension were recorded. daily prescribed caloric intake was calculated using a standard protocol and daily achievement of caloric intake was recorded. mnutric score was calculated for all patients. a score ≤ was used to diagnose malnutrition. patients ( % men, mean age years) that stayed in the icu for > hours were included in the study. % were at high nutritional risk. -year mortality was %. the prevalence of agi ii was %. age, gender, bmi, mortality and energy intake did not differ significantly between patients with agi ii and those with agi i (table ) . logistic the study aimed to assess the effects of icu admission on frailty and activities of daily living in the ≥ 's population at -months. a prospective observational study with data used as a subset of the vip- trial [ ] . research ethics committee approval from the mater misercordiae university hospital (mmuh). inclusion criteria -≥ years of age and acute admission to icu from may to july . data collected on consecutive patients. frailty and activities of daily living (adl) were assessed using the clinical frailty score (cfs) and the katz index of independence in activities of daily living (katz). results: csf pre-admission frailty was present in % of patients, increasing to % at months ( figure ). % of survivors at -months had a cfs score increase by ≥ point. pre-frail and frail cfs patients suffered an average -point deterioration in their instrumental activities of daily living (iadl). % of katz patients were fully functional preadmission, deteriorating to % at months. % of patients declined by adl at months. % of the deceased were deemed fully functional initially. we demonstrate an association between an icu admission event and enduring functional decline at months. icu admission resulted in patients acquiring on average . new iadl limitations despite their initial cfs. this is echoed in a study by iwasyna et al. who also showed similar deteriorations in iadl and cognitive impairment [ ] . katz benefits may be best used in describing functional decline. % of patients developed at least one new limitation. however, the cfs takes into account iadl's and thus may be more sensitive in predicting the functional outcomes of an icu event at months. frailty: an independent factor in predicting length of stay for critically ill t chandler, r sarkar, a bowman, p hayden medway maritime hospital, critical care, gillingham, united kingdom critical care , (suppl ):p frailty has attracted attention in the healthcare community in recent years, as it is associated with worse outcomes and increased healthcare costs [ ] . our objective was to study the impact of frailty as recorded by clinical frailty scale(cfs) to prospectively evaluate the effect of frailty on hospital length of stay (los). a retrospective analysis of consecutively admitted critical care (cc) patients' data (jan' -oct' ) was performed. electronic health records were used to collect demographics, cfs and clinical outcomes. statistical analysis was performed using stata. students t-test, simple and multiple (adjusted for age, disease severity/icnarc score) linear regression were used for comparison between groups and to see group effect. we excluded extreme outliers (los> days; n= ). frailty was defined as cfs> . out of the patients (male %), ( %) were emergency admissions, the rest elective (table ) . ( %) were non-frail. the mean los were days (d) ± and d± (p< . ) in the frail and non-frail patients respectively. for emergency patients, los were d(± ) and d(± ) for the groups, (p< . ). for elective patients; los were d(± ) and los d(± ), (p= . ) for frail and nonfrail respectively. after adjusting, los was significantly higher in frail patients by days ( %ci , ; p< . ), by days ( %ci , ; p= . ) and by days ( %ci , ; p< . ) for total cohort, elective and emergency admissions respectively. the los was days higher in frail than non-frail (p< . ) for cc survivors. frailty was associated with significantly increased los in this cohort, independent of age and illness severity. hospital capacity planning should take this into consideration when modelling bed allocation fig. (abstract p ) . clinical frailty score -month trend robust clinical governance requires analysis of patient outcomes during an icu admission [ ] . on one adult icu weekly mortality meetings are used for this purpose and aid multidisciplinary reflections on individual patient deaths. however, such reviews run the risk of being subjective and fail to acknowledge themes which may relate to preceding or subsequent deaths. this paper describes a new mortality review process in which: a) reviews are structured using the structured judgement review (sjr) framework [ ] ; and b) themes are generated over an extended period of time to create longitudinal learning from death. the sjr framework has been developed by nhs improvement for the new medical examiner role, looking at inpatient deaths. we adapted this to better suit the icu creating a novel review structure. this involves explicit judgement comments being recorded, and the use of a scoring system to analyse the quality of care during the patient's stay with a focus on elements of care delivered on the icu. tabulation of this information allows analysis over time, identifying trends across all patients, and in specific subgroups. this framework has been rolled out at the st george's cardiothoracic icu weekly mortality meetings. themes that have emerged include parent team ownership, delayed palliative care referrals and inadequate documentation of mental capacity. this will continue as part of a three-month trial and following review of this trial may be extended to other critical care units in the trust. this system allows greater insight into patient deaths in a longitudinal fashion and facilitates local identification of problems at an early stage in a way that is not possible within the traditional mortality review format. the nature of the process means that key areas for change can be identified as a routine part of the clinical week. [ ] . in this study, we evaluated three distinct machine-learning methods for predicting possible patient deterioration after surgery. the data was collected retrospectively from the catharina hospital in eindhoven. this dataset contained all the surgeries conducted in the hospital from up to . the variables in this dataset were tested on their ability to differentiate between patients with a normal recovery versus patients with an unplanned icu admission after being admitted to the ward. the dataset contained variables related to either the preoperative screening, surgery or recovery room. all variables were tested for statistical significance using a univariate logistic regression (lr), from which a subset of statistically significant (p< . ) variables was created. these variables were used to train three different types of models, namely, the lr, support vector machine (svm) and bayesian network (bn). the network structure of the bn was designed using expert knowledge and the probabilities were inferred using the data. the three models were validated using five-fold cross-validation, resulting in the following areas under the receiver operating characteristic curve: . ( . - . ) for lr, . ( . - . ) for svm and . ( . - . ) for bn (fig. ) . the results indicate that machine learning is a promising tool for early prediction of patient deterioration. the bn was included because it permits incorporating clinical domain knowledge into the learning process. however, its performance resulted inferior to the lr and svm. in future work, we will investigate alternative domainaware methods, and compare the performance with that of the clinical experts. intensive care unit (icu) admission decisions of patients with a malignancy can be difficult as clinicians have concerns about unfavourable outcomes, such as mortality [ ] . a diagnosis of a malignancy is associated with an almost -fold increased likelihood of refusal of icu admission [ ] . recent large long-term mortality studies of patients with a malignancy admitted to the icu are scarce. therefore, our aim was to compare mortality of patients with either a hematological or a solid malignancy to the general icu population, all with an unplanned icu admission. all adult patients registered in a national intensive care evaluation registry with an unplanned icu admission from to were included. subsequently, we divided these patients into cohorts: cohort (all patients with a hematological malignancy), cohort (all patients with a solid malignancy), and cohort (a general icu population without malignancy). as primary outcome, we used -year mortality, and as secondary outcome, icu and hospital mortality. we included , ( . %) patients in cohort , , ( . %) patients in cohort and , ( . %) in cohort ( table ). the year mortality of patients of cohort , , and was . %, . % and . %, respectively (p< . ). age, comorbidities, organ failure, and type of admission (i.e. surgical or medical) were positively associated with -year mortality in all cohorts (p < . ). one-year mortality is higher in both patients with a hematological malignancy and patients with a solid malignancy compared to the general icu population. in addition, several factors were positively associated with -year mortality, i.e., age, comorbidities, medical icu admission, and organ failure. future research should focus on predictive modelling in order to identify patients with a malignancy that may benefit from icu admission. introduction: drug abuse is associated with immunosuppression in multiple mechanisms. despite that, the only study retrospectively reviewing drug abusers in the icu demonstrated less infections and better outcomes. we compared matched patient populations in order to fully understand whether drug abuse is a risk factor for infection and a predictor of poorer prognosis as is perceived by most physicians. we hypothesized that the drug abusers admitted to the icu will fare as good as or better than non-abuser icu patient populations. methods: this is a prospective study done between the years - on the entire patient population of the detroit medical center. after the drug abuse population was identified, controls were matched according to age and admission icu units. patients charts were reviewed and data regarding baseline demographics, infectious complication and outcome was extracted. data was retrospectively collected for drug abusers and matched controls. comorbidities and hospital admission diagnosis were significantly different between the two groups. disease severity scores were significantly higher in the drug abuser's patient group (dapg) on admission and during the icu stay. dapg had significantly more organ failure: more need for ventilation ( . % vs . % in the dapg (p< . )), more ards ( % vs . %, p= . ), more renal failure ( % vs . %, p= . ) and more need for renal replacement therapy ( . % vs . %, p< . ) .they had longer hospital length of stay (los). there was no difference in icu or hospital mortality. multivariable modeling did not find drug abuse to be an independent risk factor for hospital mortality, icu mortality (hosp: or = . , p = . ; icu: or= . , pp = . ), but was a risk factor for a longer hospital los (me= . , p < . ). drug abuse is not an independent risk factor for mortality or icu los. drug abusers should be evaluated like other patients based on baseline comorbidities and disease severity. this is a small audit which although it did not include general icu still reflects the need for encouraging clinicians and patients to speak freely regarding escalation plans. medical decsions is clinician led however this audit was carried by nursing staff as we have a duty to be advocate for our patients involvement in medical care [ ] . a retrospective analysis of independent risk factors of late death in septic shock survivors c sivakorn , c permpikul , s tongyoo (fig. ) . the pap and katz scales seem to be adequate for predicting mortality of critically ill patients admitted to a medical icu. this finding may help in the elaboration of future icu mortality scoring systems, as well as in more rational use of resources. however, further multicenter studies are needed to better elucidate these results. adherence this last group was chosen because of its experience and specific training in the field of bioethics as a control group or reference. a total of respondents participated in the study. . % were emergency physicians, . % intensivists, . % emergency nursing, . % icu nursing, . % resident doctors, . % medical students and . % other professions. we observed variability in the responses observed not only between different groups of professionals but even within the same group reflecting the difficulty in decision making. variability was observed regarding decisions in end of life ethics conflicts. a high degree of similarity with the group of master in bioethics was observed in the responses issued by medicine students. the barriers and facilitators to framing goals of patient care (gopc) and factors motivating decision making is relatively unexplored [ , , ] . a three part survey of physicians at an australian hospital in a culturally and linguistically diverse suburb ( table ) . identification of levels of confidence and barriers and facilitators to gopc discussion and decision making was the main outcome measure. factors influencing decision-making was analysed through scenarios. results: out of eligible participants responded; female, male, clinical experience - years. level of confidence was ranked between "somewhat confident and very confident." all but one respondent had six months of icu experience. no differences in the level of confidence among physician groups. barriers and facilitators were identified; poor prognosis and patient or family request were most common facilitators; conflict between treating teams and the patient/surrogate and language barriers were most common barriers. factors driving gopc decision-making included clinical, value judgement, communication, prognostication, justice and avoidance. numerous barriers and facilitators were identified. factors driving decision making did not just consider clinical factors; conflict and we aimed to investigate physician-related factors contributing to individual variability in end-of-life (eol) decision-making in the intensive care unit (icu). qualitative study with semi-structured interviews with specialists in critical care, (experience - years) from swedish icus. data was analyzed in accordance to principles of thematic analyses. most of the respondents felt that the intensivist's personality played a major role in eol decisions (table ) . individual variability was considered inevitable. views on acceptable outcome: respondents experienced that the possible outcome for patients was interpreted very differently and subjectively among colleagues, and what seemed an acceptable patient-outcome for one doctor, was not acceptable for another. values: most of the respondents were well aware that they might be affected by their own values and attitudes in the decision-making process. interestingly, several respondents mentioned that they thought that patients that were marginalized by society, especially drug-abusers could be at risk for receiving decisions to limit life sustaining treatments (lst) more often than others. none of the respondents thought that their own religious beliefs played any part in decision making. fear of criticism: among the less experienced respondents there was a clear sense of fear of making a questionable assessment of the patient's medical prognosis. there was a fear for criticism from colleagues that were not directly involved in the decision-making, and may have made another decision. this created a wish among younger respondents to defer or avoid participating in decision-making. physician-related, individual variability in eol decisions primarily consisted of differing views on acceptable outcome, values and fear of criticism. can (figure ). within each quartile of sofa score, mortality was highest in patients with pneumonia and peritonitis and lowest in patients with cellulitis (see figure ). the sepsis- consensus definition identified organ dysfunction as the hallmark feature of sepsis [ ] . in developing sepsis- , the sequential organ failure assessment (sofa) score was chosen for its prognostic value and relative ease of implementation clinically [ ] . we propose an update based on epidemiologic data from two intensive care databases that more effectively captures organ dysfunction in the context of sepsis- . using the mimic-iii (exploration) and e-icu (validation) databases, we extracted patients with suspicion of infection to form the study cohort. the predictive power of each sofa component was assessed using the area under the curve (auc) for in-hospital mortality. a logistic model with the lasso penalty was used to find an alternative statistically optimal score. results: by utilising alternate markers of organ dysfunction (e.g. lactate, ph, urea nitrogen) we demonstrated a significant improvement in auc for several versions of the new score, sofa . ( figure ). the sofa score can be updated to reflect current advances in clinical practice. using epidemiologic data, we have shown that substitution of existing components with more powerful measures of organ dysfunction may provide an improved score with greater predictive power. moreover, sofa . exhibits equivalent ease of implementation, but better reflects organ dysfunction in the context of sepsis- . introduction: risk of acute organ failure (aof) in cancer patients(pts) on systemic cancer treatment isunknown. however, % of non-hematologic and % of hematologic cancer pts will need admission to intensive care unit (icu). ipop-sci- / is a prospective cohort study designed to ascertain the cumulative incidence of aof in adult cancer pts. single centre prospective cohort study with consecutive sampling of adult cancer pts admitted for unscheduled inpatient care while on, or up to weeks after, systemic cancer treatment. primary endpoint was aof as defined by quick sofa. six months accrual expected an accrual of pts to infera population risk aof with a standard error of %. between / and / pts were on systemic anticancer treatment, had unscheduled inpatient care and were eligible for inclusion and were included. median age was years, % were male, % had adjusted charlson comorbidity index (cci) &gt; and hematologic cancers accounted for % of pts. the cumulative risk of aof on hospital admission was % ( %ci: - ); and of aof during hospital stay was % ( %ci: - ). aof was associated with older age, cci &gt; ,hematologic malignancy, shorter median time from diagnosis and &gt; prior line of therapy. on admission, % of pts were considered not eligible for artificial organ replacement therapy (noaort) and % of pts who developed aof while inhospital were judged noaort. overall, ( %) of aof pts wereadmitted to icu, . % for aort. median follow up . months (min ; max ). inpatient mortalitywas %, with icu mortality rate of %, with median cohort survival . months ( %ci: . - . ). on multivariate analysis, aof was an independent poor prognostic factor (hr . ; %ci . - . ). risk of aof in cancer pts admitted for unscheduled inpatient care while on systemictreatment is %, and risk of icu is %. aof in cancer pts was an independent poor prognostic factor. a severity-of-illness score in patients with tuberculosis requiring intensive care u lalla, e irusen, b allwood, j taljaard, c koegelenberg tygerberg academic hospital, internal medicine, division of pulmonology and icu, cape town, south africa critical care , (suppl ):p we previously retrospectively validated a -point severity-of-illness score aimed at identifying patients at risk of dying of tuberculosis (tb) in the intensive care unit (icu). parameters included septic shock, human immunodeficiency virus with cd < /mm , renal dysfunction, ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (pao :fio ) < mmhg, diffuse parenchymal infiltrates and no tb treatment on admission. the aim of this study was to validate and refine the severity-of-illness score in patients with tuberculosis requiring intensive care. we performed a prospective observational study with a planned post-hoc retrospective analysis, enrolling all adult patients with confirmed tb admitted to the medical intensive care unit from february to july . descriptive statistics and chi-square or fisher's exact tests were performed on dichotomous categorical variables, and t-tests on continuous data. patients were categorized as hospital survivors or non-survivors. the -point score and the refined -point score were calculated from data obtained on icu admission. results: forty-one of patients ( . %) died. the -point scores of nonsurvivors were higher ( . +/- . vs . +/- . ; p= . ). a score ≥ vs. < was associated with increased mortality ( . % vs. . %; or . ; %ci, . - . ; p= . )( table ) . post-hoc, a pao :fio < mmhg and no tb treatment on admission failed to predict mortality whereas any immunosuppression did. a revised -point score (septic shock, any immunosuppression, acute kidney injury and lack of lobar consolidation) demonstrated higher scores in non-survivors ( . +/- . vs. . +/- . ; p< . ). a score ≥ vs. ≤ was associated with a higher mortality ( . % vs. . %; or . ; %ci, . - . ; p< . ) ( table ) . the -point severity-of-illness score identified patients at higher risk of death. we were able to derive and retrospectively validate a simplified -point score with a superior predictive power. chronic critical illness remains a scientific challenge, from its conceptualization to its impact on patient prognosis [ ] . we evaluated the long-term evolution of icu survivors by identifying the real burden of prolonged critical illness on survival, quality of life and hospital readmissions. we conducted a prospective cohort in brazilian hospitals including icu survivors with an icu stay > h. we compared the patients diagnosed with chronic critical illness with the other patients. telephone follow-up at and months. quality of life was measured by the sf- questionnaire. it was observed that % of patients had some definition of chronic critical illness. chronic critically ill patients had higher mortality at months (p= . ). this difference is mainly due to higher intrahospital mortality (p= . ). mortality after hospital discharge was similar between groups. there was no difference in hospital readmission rate at months. various scores are developed to predict pulmonary complications such as ariscat for patients at-risk of postoperative pulmonary complication [ ] and lips for patients at-risk of lung injury [ ] . the aim of this study was to compare these scores with ours for predicting pulmonary complications in mechanically ventilated patients in sicu. this prospective observational study was conducted in sicu at a university hospital. adult patients admitted to sicu and required mechanical ventilation > hours were included. primary endpoint was the composite of pulmonary complications including pneumonia, ards, atelectasis, reintubation, and tracheostomy. multivariate analysis was performed to identify risk factors of pulmonary complications and the predictive score was developed. the roc analysis was performed to compare power of ariscat, lips and our newly developed score for predicting pulmonary complications. outcomes in intensive care units have been reported to be better in higher-volume units [ , ] . we compared outcomes for high-risk patients between low and higher volume units. audit data from irish icus is analysed and reported by the intensive care national audit & research centre (icnarc) in london. icnarc report risk-adjusted mortality rates in all patients and in low-risk patients(predicted mortality rate < %) for each unit, using the icnarch- model to predict the risk of death. we used this data to calculate the proportion of high-risk patients(predicted mortality > %) in each unit, the mortality rate for high-risk patients, the riskadjusted mortality rate and we compared the overall risk-adjusted mortality between low and high volume units. the median number of annual new-patient admissions among participating units was ; units below this were defined as lowvolume and those above as high-volume units. the proportion of all admissions to each unit who were high-risk ranged from % to %(mean %). unit mortality rates for high-risk patients ranged from % to %. the ratio of observed to expected mortality(standardized mortality ratio -smr) for high risk admissions in each unit ranged from . to . (mean . ). in fig. introduction: adl weakening is often seen after intensive care and called postintensive-care syndrome (pics). this is also seen in even outside icu and proposed to be called post-acute-care syndrome (pacs), especially in elderly patients. in patients with infection, sofa score is famous for predicting in-hospital mortality, but there are no tools for predicting adl weakening during admission. to search for risk factors for adl weakening during admission other than the age, we conducted a retrospective observational study. the subjects were surviving patients with infection, aged from to who were admitted to our department from april , to may , . information of basic characteristics, laboratory data on admission and adjunctive therapies were extracted from our database. we use barthel index (bi) as adl evaluation, and the bi at discharge were evaluated by nurses. we stratified patients by bi at discharge of over or not, and investigated factors that predicted it. we compared each factor between groups, and perform a logistic regression analysis with those that had a significant effect clinically or statistically. despite improved outcomes of intensive care unit (icu) patients, sleep deprivation remains a major concern after icu discharge. multifaceted causes make it difficult to treat and understand [ ] . not many studies have explored sleep deprivation beyond icu. this is evidenced by findings from a recent systematic review [ ] which included studies with only one study [ ] reporting sleep deprivation beyond icu. the aim of this paper is to present findings of sleep deprivation beyond icu from a larger study that examined the experience of critical illness in icu and beyond in the context of daily sedation interruption. hermeneutic phenomenology was used to conduct the study. participants aged years and above who fulfilled the enrolment criteria were enrolled into the study. the cohort comprised male and female participants. in-depth face to face interviews at two weeks after discharge were conducted and repeated at six to eleven months. interviews were audio taped, transcribed and thematically analysed. significant statements were highlighted and categorized for emergent themes. six participants continued to experience sleep deprivation up to eleven months after icu. two cited dreams about icu, three could not explain why they continued to fail to sleep and one stated that he continued hearing icu alarms in the silence of the night. sleep deprivation continues beyond icu due to nightmares, delusional memories and unexplained reasons. further research is needed to establish causes of sleep deprivation and explore ways to promote sleep in critical illness survivors after icu discharge. frailty is being increasingly seen as an independent syndrome. frail patients now account for an increasing proportion of hospital and critical care admissions [ ] . we aimed to compare frailty and mortality in our intensive care unit. clinical frailty score (cfs) was incorporated within the electronic health record (ehr) . we performed this retrospective analysis on the data collected between jan' and oct' . the predictor and outcome for this study were frailty and hospital mortality respectively. all demographic data, acute physiology score, critical care and hospital outcome data were automatically collected in the ehr and recorded. we used a cut off of cfs> and above to define non-frail and frail respectively. chi-squared test, simple and multiple logistic regression were used. adjustment was done for icnarc score and age. total number of patients was , of which ( . %) died in hospital. within the patients< years (n= ), ( %) were recorded as frail or vulnerable. the number of elective and emergency admission were ( %) and ( %) respectively. in the frail and nonfrail, mortality rates were % and . % (p< . ) respectively, with odds ratio of . ( % ci . , ; p< . ) ( age is a well-known risk factor for critical care (cc) outcome and is incorporated into many prognostic tools; however, this has been criticized for assumption of normal physiology for young at baseline. in recent years, frailty in cc prognostication has been of interest, with meta-analysis correlating worsening outcomes with increasing frailty [ ] . in this study, we compared the effect of frailty versus age for determining hospital survival for critically ill patients. we conducted a prospective cohort in brazilian hospitals including survivors of an icu stay > h. we compared chronic critically ill patients (icu stay> days) and the other patients. we performed psychological and functional presential assessment in patients within hours of icu discharge and by telephone at and months. the prevalence of chronic critically ill patients was %. regarding outcomes, chronic critically ill patients had a higher incidence of depressive symptoms than other patients in the immediate post-icu discharge (p = . ), as well as a higher incidence of muscle weakness (p < . ). however, in subsequent evaluations, we found no difference between groups regarding psychological symptoms -depression, anxiety and post-traumatic stress. higher functional dependence was observed in critically ill patients, but without difference in the quality of life score, both in the physical (p = . ) and mental (p = . ) domains. chronic critically ill patients, when compared to patients with stay> h, have a higher incidence of depressive symptoms at icu discharge. this difference disappears in the follow up. chronic critically ill patients present higher levels of functional dependence but without repercussions on quality of life scores. introduction: activation of the inflammatory response after cardiac arrest (ca) is a welldocumented phenomenon that may lead to multi-organ failure and death. we hypothesized that white blood cell count (wbc), one marker of inflammation, is associated with one-year mortality in icu treated ca patients. we used a nationwide registry with data from five academic icus to identify adult ca patients treated between january st and december st . we evaluated the association between the most abnormal wbc within hours of hospital admission and one-year mortality. we accounted for baseline risk of death using multivariable logistic regression (adjusted for age, gender and h sequential organ failure assessment [sofa] score). a total of , patients were included in the analysis. of those patients , ( %) were alive one year after ca. we plotted wbc against baseline risk of death and through graphic examination of a locally weighted scatterplot smoothing (lowess) curve found the lowest risk of death to be associated with a wbc of (e /l) ( figure mrps were identified by a specialist icu pharmacist during this programme and classified by their significance on a scale of one to four. logistic regression was used to determine if demographic factors were associated with the occurrence of a clinically significant mrp -a significance score of two or above (figure ) . the adjusted model included age, icu los, hospital los, apache ii, number of days of renal replacement therapy, number of days of ventilation, the number of medications prescribed at icu discharge, and the who analgesia classification at ins:pire. there were increased odds of having a clinically significant mrp for hospital los (or results: · % (n= ) of patients required at least one pharmacy intervention. the median number of interventions required per patient was one (iqr - ); the maximum number was six. mrps were recorded in this cohort. the most common intervention was clarifying duration of treatment (n= ), followed by education (n= ), and correcting drug omissions (n= ). the bnf drug class most frequently associated with mrps was neurological (n= ), which comprises analgesics (n= ) and psychiatric medications (n= ) ( figure ). this was followed by cardiovascular medications (n= ), gastrointestinal medications (n= ), nutritional medications (n= ), and others (n= ). many icu survivors experience mrps. the most common class of mrp was neurological, reflecting the high incidence of chronic pain and psychiatric illness in this population following discussion with icu staff, ward staff and fy doctors, a formal standardized handover system was introduced. this involved a verbal handover to the appropriate fy by an icu doctor and the patient drug chart to be rewritten in icu at the time of handover. the next change was to display posters on the wards to alert staff that the medical team are to be contacted when a patient comes to the ward from icu and to ensure the drug chart is completed. the baseline data showed a median time delay of hours, with one patient waiting hours for a drug chart. following the interventions the median time delay has decreased to hours within months as demonstrated in figure . the changes have received positive feedback from icu staff, ward staff and fy doctors. the aim of reducing the time delay by % has been achieved with the median time delay now hours. this has improved patient safety by significantly reduced delays in medications and through the introduction of a standardized handover. this has also provided an opportunity for junior doctors on the wards to seek clarification regarding medications and the clinical management plan for the patient. this has established a communication channel between icu and the wards making patient care safer and more effective. telemonitoring outside the icu is scarce. but with innovative wearables measuring respiratory and heart rate wirelessly, culture on intrahospital telemonitoring should definitely change. however, culture has been known to be one of the most crucial success factors in innovation, especially in health care. human design thinking is a promising tool in health care innovation but rarely used in a multidisciplinary team to initiate an innovation culture and stimulate sustainable collaboration. the aim of this study was to initiate a pilot project with a multidisciplinary team to start using wearables for early warning score (ews) on a clinical ward. human design thinking was used to write a value proposition on wearables in clinically admitted neutropenic hematologic patients in an academic center. a multidisciplinary team was performed to cover all disciplines involved in the technical, clinical and administrative parts of the project. a vendor was chosen based on its product specifications in relation to the present hospital monitoring infrastructure. in design thinking sessions, critical appraisal of multiple telemonitoring factors was performed by sub teams and a canvas projectplan was constructed. the project team was formed of registered nurses, physicians, itspecialists, electronic health record consultants; a critical care physician was appointed as project leader. the main critical factors were: unseamlessly transmitting of both heart and respiratory rates including appropriate movements filtering to the nurse's smartphones direct uploading into electronic health record with automated ews calculation nurse driven protocol on ews follow up. philips healthcare with their intellivue guardian wearable biosensor was the chosen vendor ( figure ). design thinking in a multidisciplinary health care team could positively influence the innovation culture. scientific evaluation of this wearable will focus on both nurse's acceptance and data storage and is expected in the summer of . severity, readmission and lengh of stay were lower in patients receiving discharges directly to home. it seems like a safe way to discharge low-risk short stay patients. it seems to save resources and reduce costs, as well as the need for hospital beds. however, futher estudies are needed to actualy evaluate this safety. forty-four cultures were analyzed with eplex ( figure ). complete agreement with conventional diagnostics was observed in / cases. no false-positive results were observed, yielding a sensitivity and specificity of % and % respectively for target pathogens. time to result was, on average, . h faster with eplex compared to conventional diagnostics. antimicrobial therapy could have been optimized in patients based on the eplex result, but treatment was only changed in one case (e.coli ctx-m+) receiving meropenem . h before the antibiogram was available. the eplex blood culture panels provide high accuracy and significantly faster results. the current implementation offers substantial potential value at a minimal cost, and is a feasible approach to -h/ days blood culture diagnostics in many hospital settings. however, efforts to increase adherence are needed. the rapid increase of extended spectrum β-lactamases (esbl)-producing pathogens worldwide makes it difficult to choose appropriate antibiotics in patients with gram-negative bacterial infection. cica-beta reagent (kanto chemical, tokyo, japan) is a chromogenic test to detect beta-lactamases such as esbl from bacterial colonies. the purpose of the study was to reveal whether cica-beta reagent could detect esbl-producing pathogens directly from urine rather than bacterial colonies to make a rapid bedside diagnosis of the antibiotic susceptibility of gramnegative pathogens. we conducted a prospective observational study from july to october . patients were eligible if they were performed urinary culture tests and gram negative pathogens were detected at least + from their urine samples. the urine sample was centrifugated at x g for min. the supernatant of sample was re-centrifugated at x g for min and the pellet was mixed with cica-beta reagent. the test was considered positive when the enzymatic reaction turned from yellow to red or orange. (fig. ) . the bundle approach could be an effective strategy to prevent hospital-acquisition of drug-resistant pathogens in icus. fig. in the aspect-np trial, c/t was noninferior to mem for the treatment of habp/vabp. we evaluated outcomes from that study in the subgroup of pts failing current antibacterial therapy for habp/vabp at enrollment. methods: aspect-np was a randomized, controlled, double-blind, phase trial in which mechanically ventilated pts with habp/vabp received g c/t or g mem every h for - days. pts with > h of active gram-negative antibacterial therapy within h prior to first dose of study therapy were excluded, except those pts failing current treatment (i.e. signs/symptoms of the current habp/vabp were persisting/worsening despite ≥ h of antibiotic treatment). primary and key secondary endpoints, respectively, were -day all-cause mortality (acm) and clinical response at test of cure (toc; - days after end of therapy) in the intent to treat (itt) population. pts failing current antibacterial therapy for habp/vabp were prospectively categorized as a clinically relevant subgroup. at baseline, failing current therapy for habp/vabp was reported in / ( %) c/t and / ( %) mem itt pts, mostly piperacillin/ tazobactam ( %), rd/ th-generation cephalosporins ( %), fluoroquinolones ( %), and aminoglycosides ( %). baseline demographic and clinical characteristics in this subgroup, including prior therapy regimen, were generally similar between treatment arms. there were greater proportions of patients with esbl+ enterobacterales ( %) and pseudomonas aeruginosa ( %) in the c/t arm than the mem arm ( % and %, respectively). lower -day acm was seen with c/t than mem, as evidenced by % confidence intervals for treatment differences that excluded zero ( figure ); statistical significance cannot be assumed because subgroup analyses in this study were not corrected for multiplicity. conclusions: c/t was an effective treatment for habp/vabp pts who had failed initial therapy. catheter-related blood stream infection (crbsi) is common serious infections and associated with increased mortality in intensive care units (icu). one of the most important strategy to prevent crbsi is to minimize the duration of central venous catheterization. we built a medical team consisting of doctors, nurses and pharmacists in icu to discuss whether patients needed central venous catheter (cvc) in terms of monitoring hemodynamics and administering drugs, and recommend catheter removal to attending physicians every day in april . the purpose of this study is to evaluate whether our team-based approach could shorten the total duration of catheterization and reduce crbsi. this was a retrospective historical control study conducted from april to october in the icu of a tertiary care hospital in japan. every patient admitted to the icu during the study period was eligible if they were inserted cvc. patients were divided into groups: conventional (from april to march ) or intervention (from april to october ). we set the primary endpoint as onset of crbsi. the secondary endpoints included the duration of central venous catheterization, the length of icu stay and hospital mortality. crbsi was defined as bloodstream infection in patients with cvc, not related to another site. we included patients: in the conventional group and in the intervention group. the reduced, though nonsignificant, tendency of crbsi was observed in the intervention group [hazard ratio, . ( % confidence interval, . - . ; p = . )]. the intervention group was significantly associated with reduced duration of central venous catheterization ( days vs days; p < . ). no difference was observed in the length of icu stay and in-hospital mortality between groups. the team-based approach to assess cvc necessity could shorten the duration of central venous catheterization and might reduce crbsi. introduction: empiric antibiotic therapy decisions are based upon a combined prediction of infecting pathogen and local antibiotic susceptibility, adapted to patients' characteristics. the objective of this study was to describe the pathogen predominance and to evaluate the probability of covering the most common gram-negative pathogens in icu patients with respiratory infections. methods: data were collected from multiple us and european hospitals as part of the smart surveillance program ( ). mic (mg/l) testing was performed by broth microdilution, with susceptibility defined as follows for p. aeruginosa & enterobacterales: ceftolozane/tazobactam results: hospitals from countries provided gram-negative respiratory isolates from patients located in an icu in the us ( %), eastern europe ( %) and western europe ( %) in . the most common pathogens isolated were p. aeruginosa ( %), k. pneumoniae ( %), e. coli ( %), and a. baumannii ( %). among enterobacterales, % ( / ) were esbl positive. figure provides the probability of covering the most common respiratory gram-negative pathogens from icu patients. co-resistance between commonly prescribed first line β-lactam antibiotics is common: when nonsusceptibility (ns) of one agent was present, susceptibility to other βlactams was generally < %. ceftolozane/tazobactam provided the most reliable in vitro activity in both empiric and adjustment prescribing scenarios compared to other β-lactam antibiotics. ceftolozane/tazobactam ensured a wide coverage of the most common gram-negative respiratory pathogens demonstrating high susceptibility levels and provided the most reliable in vitro activity in both empiric and adjustment antibiotic prescribing scenarios. further studies are needed to define the clinical benefits that may translate from these findings. evaluation of compliance of icu staff for vap prevention strategies on the outcome of patients a kaur fortis hospital, critical care, mohali, india critical care , (suppl ):p ventilator-associated pneumonia is the most common nosocomial infection diagnosed in adult critical care units. it is associated with prolonged duration of mechanical ventilation, increased icu stay and increased mortality. it continues to be a major challenge to the critical care physicians despite advances in diagnostic and treatment modalities. the primary objective of the study was to determine the compliance of icu staff towards vap prevention bundle and secondary objective was to determine the incidence, risk factors and outcome of vap patients. single center, prospective, observational study carried out from february to july . patients mechanically ventilated for more than hours and satisfying the inclusion and exclusion criteria were enrolled in the study. vap was diagnosed using the cdc criteria and clinical pulmonary infection score. vap preventive strategies were employed and compliance of icu staff was assessed. a total of patients were admitted to icu over the set time period and out of them patients were ventilated for more than hours. among them only patients fulfilled the inclusion and exclusion criteria and were enrolled in the present study. excellent compliance was observed in head end elevation, sedation vacation, stress ulcer prophylaxis, and heat moist exchanger filter use, good compliance in oral care and hand hygiene and moderate to poor compliance in subglottic suctioning. the incidence of vap was . % with a vap rate of . / ventilator days. there was a significant correlation between primary diagnosis, hemodialysis, massive blood transfusion and development of vap (p< . )). mean duration of ventilation (p< . ) and mortality (p< . ) were highly significant in vap patients. conclusions: improvement in compliance towards vap bundle and reduction of risk factors can help decrease incidence of vap and related morbidity and mortality. preventive strategies are effective in reducing ventilation-associated pneumonia (vap) in adults [ , ] . in paediatric population there are no data about vap prevention, so we introduced a new bundle (vap-p) based on the available evidence for adults. this was designed as a before-after study. we enrolled all patients admitted to -bed medical-surgical paediatric icu at gemelli hospital in rome, requiring mechanical ventilation for at least hours. patients with pre-existing tracheostomy were excluded. vap-p has been introduced since in order to improve quality of assistance. our bundle consisted in twice a day oral hygiene with chlorhexidine swab, daily check of oral bacterial colonization and aspiration prevention. comparison was made with an historical group including patients admitted before vap-p introduction (since to ). all data about demographics, antimicrobial therapy, icu stay and treatments, were collected. results: patients were included ( after and before vap-p introduction). ( %) events of vap were recorded in vap-p group compared to ( %, p= . ) vap-p group had less vap per days of mechanical ventilation ( / compared to . / p= . ). multivariate analysis yielded an or of . ( %ci . - . ) for vap incidence after bundle introduction. mortality rate was slightly reduced in vap-p group ( . %vs . % p=ns). patients who developed vap required more days on mechanical ventilation and had higher mortality rate ( vs days p< . and %vs % p= . , respectively). our vap-p seems effective in reducing vap incidence in critically ill paediatric population. introduction: ceftolozane/tazobactam (c/t) is a new antibiotic against mdr gramnegative bacteria infections, whose target population are the critically ill patients. even though / g dose safety administered as a hour-infusion has been already assessed, these patients can be under renal replacement therapy (rrt) and suffer changes in their volume of distribution (vd) that may affect antibiotic concentrations. the objective was to determine concentration reached by g c/t ( hour infusion) in septic patients on rrt (cvvhdf) and interdose behavior. we have used rrt machine prismaflex with oxyris filter and m . hplc-uv method was used for simultaneous quantification of c/t. study population consisted of three obese critically ill patients with sepsis, on cvvhdf while receiving g c/t every hours. samples were taken of prefilter, post filter blood and effluent, min before infusion and , and hours after the end of it. we found great interpatient variability with the lowest cconcentration values in the patient with more hemodynamic instability using oxyris filter. even though cmax was less than reported in healthy subjects, we found similar values of auc and t ½ in comparison with healthy population studies. cmax of t was also compromised in comparison with values reported in healthy subjects, but with higher auc and t ½. cvvhdf contributes to c/t clearance. m filter showed the least clearance and higher values of auc and t ½. extraction rate was similar in all patients and filters (figure ) . cmax achieved may be impaired because of the varying vd caused by obesity and rrt, but not affecting the antibiotic characteristics and behaviour. we conclude that because of the variety of clinical conditions, c-concentration is compromised particularly in hemodynamically unstable patients. however, the small sample doesn´t let us extrapolate these results. the extended infusion seems to be adequate to achieve the interdose antibiotic concentration. the use of biomarkers in sepsis is useful for early diagnosis and prognosis. the desired marker should be sensitive, specific, fast and accurate. procalcitonin (pct) measurement is approved by the fda even its efficacy is still under question. the determination of alfatorquetenovirus (ttv) could be a useful marker [ ] . we analyzed samples from patients admitted to icu with clinical suspicion of sepsis. analytical data of c-reactive protein (crp), neutrophils and procalcitonin were collected. the sofa and apache ii scales were calculated and patients stratified according to these values in good and poor prognosis. ttv quantitative determination was carried by using a quantitative crp . we calculated area under the curve (auc) of ttv plasma levels as a function of time. the statistical analysis involved u-mann-whitney and spearman test, using chi for qualitative variables. results showed a not significant (ns) inverse relationship between the ttv auc and the patient proinflammatory level. a tendency (ns) was found between poor prognosis and the pct median values and crp being higher in the poor prognosis.group. a trend showed lower ttv dna count related to worse prognosis. an inverse relationship was found between pct and crp values and the ttv copies /ml plasma, ns correlation in the case of pct. there was a clear trend between the neutrophils´expansion and the regression line slope, obtained between ttv loads in the first two study steps. fig. (abstract p ) . patient pk/pd measurements value> . ), suggesting that the adsorptive mechanism wasn't primarily mediated by plasma protein. ha was saturated after adsorption of a total of . ± . mg of van. the adsorptive kinetics showed an exponential reduction of van mass that reached a plateau after minutes of circulation. in our study, simulating in vivo conditions of hp using ha during sepsis, a rapid and clinically relevant removal of van has been shown. after hours of hp, we suggest to assess van plasma concentration and a loading dose of van should be considered. however, not knowing the potential interactions with other drugs, further in vivo studies are warranted to confirm these findings. assessing the volume of blood taken for blood culture and culture positivitydo we need to take less blood? it is commonly accepted that larger blood culture (bc) volumes (bcv) increase the yield of true positive cultures, and optimally cc of blood should be obtained per set ( bottles). only scarce data exists on the matter of optimal bcv. it is unknown what is the minimal volume that is acceptable for bc. the objective of this study was to determine the association between bcv and the rate of positive bc. blood taken for cultures in bd bactec plus aerobic/f negative bottles was collected from icus and acute care floors at hospitals at the dmc over months. blood volume was estimated automatically from blood background signal data in the bd bactec fx instrument. cultures were analyzed for each bottle. data was summarized for every month as the average volume and number of cultures taken and rate of positive bc for every unit. units were classified according to unit type (icu, medicine, surgery, mixed, emergency department (ed), organ/bmt or "other" which did not fit the previous categories) and analyzed as a group. a total of cultures were taken in units. there is a positive association between bv and positive bc rate for ed and "other" units (irr= . , p= . for the ed, irr= . , p< . for "other" unit). all other units had no association between bv and positive bc rate (figure ). secondary analysis, excluding pediatric units, gave very similar results. when comparing bv between unit types, the ed and "other" unit had significantly lower bv ( . ml in the ed and . ml in "other" unit compared to . ml in the icu, . ml in surgery, . ml in mixed and . ml in bmt). the correlation between bv and positive bc rate is probably limited to units taking very low bv for cultures. units taking volumes above ml show no improvement in positive bc rate when higher volumes are taken. better prospective studies should be done to further establish the minimal bcv needed and spare unnecessary blood loss to hospitalized patients without compromising bc yield. de-escalating antibiotics in sepsis with the use of t mr in a bed greek university icu c vrettou, e douka, i papachatzakis, k sarri, e gavrielatou, e mizi, s zakynthinos st icu department, university of athens, evangelismos general hospital, icu, athens, greece critical care , (suppl ):p in septic patients, the early use of appropriate empiric antibiotic therapy reduces morbidity and mortality. de-escalation refers to narrowing the broad-spectrum antibiotics once the pathogen and sensitivities are known. t magnetic resonance (t mr) is a novel method of detecting eskape pathogens. we aim at investigating if using t mr technology can expedite de-escalation of broad spectrum antibiotics. this is a prospective observational study conducted in our -bed university icu. inclusion criteria were critically ill patients age> y.o., with newly diagnosed sepsis and clinical suspicion of eskape bloodstream infection. a sample for t mr and a blood culture (bc) sample were collected simultaneously from the patients enrolled. the t mr bacteria panel test was run according to the manufacturer's guidelines and the bcs were processed according to the hospital standard procedures. we recorded clinical data and administered antibiotics. results: patients were included in the study. mean time to culture positivity was hours while mean time to t mr result was . hours. in patients the results of t mr were in concordance with the bcs. in the remaining cases, the bcs were negative while the t mr detected one or more eskape pathogens. there were no false negative results. de-escalation in at least one drug was applied to patients ( . %). no escalation was applied to patients ( . %) and antibiotic escalation in ( . %). conclusions: t mr provides a quicker detection time that could shorten the time to targeted therapy. in our population this corresponded to early (within - h) antibiotic de-escalation in approximately / of the included patients. antibiotic stewardship in icu. a single experience l forcelledo , e garcía-prieto , l lópez-amor , e salgado , j fernández dominguez , m alaguero , e garcía-carús the increasing antibiotic resistance in microorganisms urged interventions such as the antibiotic stewardship programs in icu focused on reducing the inappropriate use of antibiotics by improving the antibiotic selection, the dosage, administration route and length as well as improving clinical outcomes and reducing antibiotic resistance. retrospective study where antibiotic consumption was analysed and measured in days of therapy (dots) between and in a medical-surgical icu of a university hospital where a multimodal educational program was established. specific training in infectious diseases in critically ill patients, periodic clinical and formative sessions fig. (abstract p ) . correlation of blood culture positivity rate with blood culture volume by unit type were performed for icu staff and specific leaders within the icu staff designated. results: patients were admitted to icu. there was a reduction of , % in dots (figure ), reduction in antimicrobial resistance rates ( , in , , in [days of resistant microorganism/ patientdays]) without an impact in icu global mortality ( , % in , , % in ). the resistant bacteria registered were acinetobacter baumannii, s. aureus mr, blee and carbapenemase-producing enterobacteriaceae, pseudomonas aeruginosa mr and clostridium difficile. the safe in antimicrobial consumption was € ( % reduction). the icu stay decreased from , days ( ) to , ( ) , with no variation in mean apache ii ( , ) . the bigger decrease in antibiotic consumption was in colistin related to the reduction in resistance bacteria, in special acinetobacter baumannii, in linezolid and in piperacilin/tazobactam, even more remarkable in due to shortage of supplies which meant an increase in meropenem. the application of an antibiotic stewardship program in icu succeeded in reducing antibiotic consumption, antibiotic resistance and costs without an impact in clinical outcomes like mortality or icu stay. clinical outcomes of isavuconazole versus voriconazole for the primary treatment of invasive aspergillosis: subset analysis of indian data from secure trial p kundu, s kamat, a mane pfizer limited, medical affairs, mumbai, india critical care , (suppl ):p the secure trial was designed to compare the safety and efficacy of isavuconazole (a) versus voriconazole (v) for primary treatment of invasive mould disease caused by aspergillus and other filamentous fungi. the present analysis is aimed at comparing the indian subset of patients with that of the overall trial population and to ascertain any similarity or difference in the primary efficacy endpoint and safety/tolerability in these two groups. in secure trial, patients in one group received (i) & another patients received (v). the indian subset had patients. we have done a qualitative analysis as the sample size of the indian subset was small. non-inferiority of (i) to (v) in terms of all cause mortality from first dose to day was assessed in overall patients. the treatment difference between (i) and (v) group in the indian subset of patients was analyzed. proportion of patients who had to discontinue treatment due to teaes was analyzed. the all-cause mortality in the overall trial population met noninferiority margin (table ). in the indian subset, it was higher for (i) than (v). there was a lower incidence of ocular, hepatobiliary, skin & subcutaneous tissue disorders in the (i) treated patients (see table ). in indian subset, the above adverse events were less in the (i) group, but statistical inference could not be done due to small sample size. however, similar trend of less number of patients discontinuing therapy due to teaes in the (i) treated patients was seen in the overall patients & the indian subset. the all-cause mortality in the indian subset was higher in the (i) patients. a trend similar to the overall population regarding safety parameters favoring (i) was seen in the indian patients. considering the significantly higher prevalence of ia in india, suitably powered study design is necessary to draw definitive conclusions on the non-inferior efficacy & better safety & tolerability of (i) over (v) in patients of ia. introduction: ventilator-associated pneumonia (vap) is one of the most frequent healthcare-associated infections, correlated with increased mortality,extended hospital stay and prolonged mechanical ventilation. considering the latest outbreak of multiresistant a. baumannii infections in the critically ill patients with vap, there is a growing concern regarding challenges of the antibiotherapy in these patients. although ceftazidim-avibactam is considered to have limited effects on a. baumannii, it is reported to have a synergic activity in combination with other antibiotics. we performed a retrospective, observational study which included icu patients diagnosed with vap(cpis > ). oxa a. baumannii was isolated from the tracheal secretions using a rapid molecular diagnostic platform(unyvero a system). patients were divided in two groups according to the antibiotherapy:group a meropenem + colistin and group b meropenem + colistin + ceftazidim-avibactam.statistical analysis was performed using graphpad applying t-test and kaplan-meier curves, having the in-hospital mortality as primary outcome and days of mechanical ventilation and hospital stay as secondary outcomes. mean age(y.o) in group a was and in group b and in both groups mean charlson comorbidity index was points. survival percent was higher in the group treated with ceftazidim-avibactam ( % vs %, p = . )- (fig. ) . length of stay was significantly decreased in group b ( . days vs days in group a, p = . ). number of days under mechanical ventilation was also decreased in the ceftazidim-avibactam group ( vs ) but the data was not statistically significant. in light of the important thread of multiresistant a. baumannii and the lack of therapeutic measures, the synergistic activity of ceftazidim-avibactam use in combination with other antibiotics may be a promising approach to lower the mortality and hospitalization in critically ill patients diagnosed with vap. impact of patient colonization on admission to intensive care on and days mortality g dabar , c harmouch , e nasser ayoub , y habli , g sleilaty , j infections caused by multi resistant bacteria are a major health problem, especially in icus, and it may be associated with high mortality rates. colonization precedes infection in most instances; therefore it may be a marker of a poor outcome. we tried to determine the impact of colonization on mortality at and days in a population of patients admitted to one medical and one surgical icu in the same institution. medical records review over three years - of all patients admitted to one surgical et one medical icu at hotel dieu de france hospital staying more than h. colonization to resistant bacteria was defined as mrsa, esbl, mdr, and vre. all patient received a nasal and rectal screen on icu admission, in intubated patients tracheal aspirate was considered as colonization in the absence of clinical respiratory tract infection. demographics, apache, sofa, immunosupression, charleston comorbidity index, length of stay, mechanical ventilation, hospitalization and antibiotic use in the previous month were collected. mortality at and days was assessed through medical records or phone call. pearson chi-square was calculated for the association of colonization and mortality at and days, and subsequently odd ratio was estimated. introduction: critically unwell patients have been observed to respond unpredictably to traditional intermittent dosing (id) schedules of vancomycin, likely due to the complex physiological derangements caused by critical illness. continuous infusion (ci) of vancomycin has been suggested to overcome such problems by allowing more regular therapeutic drug monitoring and subsequent effective dose titration [ ] . this study conducted at a tertiary intensive care unit, reports our experience following implementation of a continuous vancomycin infusion protocol. prospective data was collected over two consecuative periods of three months, initially capturing plasma levels for id (target level of - mg/l) followed by reviewing plasma concentration levels in a ci protocol (target level of - mg/l). patients recieving renal replacement therapy were excluded. a total of intermittent vancomycin prescriptions were administered and dosing levels observed. in the three month ci period, patients received ci vancomycin and levels subsequently checked. the ci protocol resulted in increased blood sampling ( samples in ci group vs. samples in id cohort). two non serious incidents were reported in the ci cohort relating to preparation of vancomycin. both groups had a comparable median time to therapeutic range ( hours). however, ci vancomycin group had a greater proportion of first samples outside the desired therapeutic range ( %vs %) (figure ). as the therapy continued, ci vancomycin demonstrated a greater propensity towards consistent therapeutic levels than that observed with id. % of patients on a ci regime achieve the desired target levels compared to % in the id cohort (fig. ) . it was positive for single or multiple microbes in ( . %) and ( . %) samples respectively. single or multiple resistance genes were detected in ( %) and ( %) samples respectively. bfpcr was positive only for bacteria in ( . %), virus in ( . %) and for both in ( . %) cases. influenza a was found in ( . %) cases. the most common organisms in community and hospital acquired pneumonia were streptococcus pneumoniae ( / ) and a. baumannii ( / ) respectively. bacterial cultures were concordant with bfpcr in / ( %) of positive cases. decisions to change antibiotics could be taken earlier based on bfpcr (p< . ) than if were based solely on culturesboth in culture positive ( . ± . vs . ± . hrs) and negative cases ( . ± . vs . + . hrs) where antibiotics would have remained unchanged. based on bfpcr antibiotics were escalated in ( %) patients and teicoplanin ( / ) was most often stopped. bal bfpcr were obtained significantly earlier, identified more organisms and bacterial resistance than culture reports and lead to more frequent and earlier antibiotic changes. severe community-acquired pneumonia (scap) is a frequent cause of hospitalization and mortality. ceftaroline is efficacious for treatment of cap (port risk class iii or iv). most severe patients were excluded from the clinical trials, so the efficacy of ceftaroline in these kind of patients is unknown methods: this is a health record-based retrospective before-after study in a tertiary care hospital. all scap patients admitted in icu between november and february receiving ceftaroline were included. control group included patients with same inclusion criteria but receiving ceftriaxone. propensity scores to adjust for potential baseline differences between groups were performed. levofloxacin or azythromicin were administered in both groups. primary outcome was the change in sofa score over the first h and secondary were days of mechanical ventilation, respiratory failure at h, need of rescue antibiotics, length of stay and mortality results: there were patients in ceftaroline group and in ceftriaxone group. baseline characteristics were similar except from more intubated patients in ceftaroline group (figure ). there were less respiratory failure at h in patients with ceftaroline treatment (- . % vs. - . %; p , ), but no differences in other organ failures, mortality, days of mechanical ventilation or los. there were more need of rescue antibiotics in ceftriaxone group ( . % vs . . %; p , ). we found more streptococcus pneumoniae isolation in ceftaroline group ( ( . %) vs ( . %); p = . ); more empiric use of oseltamir ( ( . %) vs ( . %); p = . ), but no more influenzae infections ( ( . %) vs ( . %); p = . ). s. aureus was detected in patient in ceftaroline group and in in ceftriaxone group. introduction: acute respiratory failure (arf) due to pulmonary infections is a usual cause of intensive care unit (icu) admission. immigration patterns and iatrogenic immune-suppression have made tuberculosis (tb) a common disease in western europe. severe tb requiring icu care is rare. nevertheless, mortality associated with active tb and arf is poor [ ] . adult patients with tb admitted to icu from - were identified retrospectively. diagnosis was based on: positive cultures of sputum, bronchial aspirates or bronchioalveolar lavage fluid. demographic characteristics, reasons for admission, hiv status, anti-tb treatment and mortality were recorded. total of patients with tb were admitted to icu. mean apache ii score was , ± , . sixteen were male. mean age , ± , years. eight ( %) were hiv-positive, ( %) diabetes mellitus type , ( %) chronic liver disease. six ( %) had other causes of immunesuppression. main causes for icu admission were arf due to non- mycobacterium tuberculosis pathogens in %, acute liver failure in %, septic shock due to non-respiratory cause in %. overall, % were on anti-tb treatment at time of admission. tb involved the lung parenchyma in all patients. pleural involvement was present in % and lymph node in %. extrapulmonary sites were present in %: urogenital, gastrointestinal, bone marrow. pathogens identified in over-infections: % gram positive coccus, % gram negative bacilli, % fungal, % mdr-pathogen. one patient hiv-positive suffered arf due to pneumocystis jiroveci. overall, % died during icu stay. besides its latent evolution, mortality of tb patients admitted to icu is extremely high. arf due to over-infection seems to be the main cause for icu admission and mortality. better preventive approach of these patients may improve their outcome. introduction: human african trypanosomiasis (hat) is rarely encountered by critical care clinicians, but is an important differential for fever in the returning tropical traveler. late disease is characterized by seizures, fever and multi-organ failure [ , ] . we present an anonymized case presenting from an endemic area in zambia referred for tertiary critical care management. the patient was too obtunded to give informed consent and his relatives could not be contacted despite extensive efforts. a middle-aged man with no past medical history from rural zambia presented to a local clinical officer post with fever and arthralgia. he was treated twice with anti-malarial medication without resolution of symptoms. two months later he was admitted febrile and obtunded to a local hospital with worsening confusion. he was transferred hours by ambulance to our facility in lusaka, which is the only public tertiary critical care unit in zambia results: gcs on arrival was e m v without localizing neurology. microbiology investigations were negative, including for toxoplasma, cryptococcus, hiv or malaria. the patient suffered a generalized seizure followed by a sustained gcs of and was admitted to the icu for invasive ventilation and seizure control. peripheral blood smears demonstrated trypanosomes consistent with hat secondary to trypanosoma brucei rhodesiense. he was commenced on melarsoprol but rapidly deteriorated, with signs of melarsoprol-induced arsenic encephalopathy and subsequent tonsillar herniation. his death was confirmed by neurological criteria. conclusions: icu management of fulminant hat involves supportive neurocritical care plus melarsoprol, a toxic arsenic compound with common side effects of hepatotoxicity and dysrhythmia. arsenic encephalopathy occurs in % of late hat, with a fatality rate of % [ ] . early diagnosis is associated with a % survival rate in developed world travelers repatriated from endemic areas [ ] . lithium chloride to prevent endothelial damage by serum from septic shock patients (in vitro study) a kuzovlev the aim of the study was to investigate into effectiveness of lithium chloride (licl) as agent that prevents damage to the monolayer of endothelial cells under the action of serum from multiple trauma patients with septic shock. methods: serum from pts with septic shock (sepsis- ) and healthy donors was withdrawn. monolayer of ea.hy endothelial cells were incubated for hrs at °c with healthy person's serum and with septic patient's serum without licl and with it at concentrations of . mmol, . mmol, mmol, mmol. licl was added hour before the change of serum. after incubation cells were washed and fixed with % paraform solution and permeabilized with % triton x- solution. fixed cells were stained with primary antibodies to vecadherin and then incubated with secondary antibodies conjugated with oregon green fluorescent dye as well as with phalloid red and hoechst dye . images were processed by fluorescence microscope and imagej . p and metavue . programs. western blotting was used to detect antibodies to ve-cadherin, claudin and gsk- beta. statistics included mann-whitney test and chi-square test. incubation of a monolayer of endothelial cells with % serum of septic shock patients led to loss of ve-cadherin contacts and decrease of claudine. preincubation with licl . mmol did not prevent dismantling of claudine, actin, ve-cadherins; . mmol licl prevented it (p> . ), but at higher concentrations ( mmol, mmol) almost completely protected endothelial monolayer from destruction of intercellular contacts (p< . ). serum had almost no effect on the phospho-gsk- β level after min, min, min and hr, but caused a significant ( %) decrease in its level after and hrs. licl ( mmol) caused a significant increase in phospho-gsk- β already mins and up to hrs after exposure. licl prevents septic damage to the monolayer of endothelial cells in vitro in a gsk- beta mediated way. introduction: the autonomic nervous system (ans) controls both heart rate and vascular tone, which are known to be impaired during septic shock (ss) . acute inflammation is presumed to increase arterial stiffness of large arteries in experimental studies [ ] . the objectives of this work are to verify if standard ss resuscitation modulate mechanical vascular properties and to verify if alterations in these vascular properties and ans activity are correlated. a protocol of fecal peritonitis septic shock and standard resuscitation (fluids and noradrenaline) was applied on pigs. the arterial blood pressure waveform was recorded in the central aorta and in the femoral and radial arteries. the characteristic arterial time constant tau was computed at the three arterial sites, based on the twoelement windkessel model [ ] . the total arterial compliance (ac) and the total peripheral resistance (tpr) were also estimated. baroreflex sensitivity (brs), low frequency (lf, . - . hz) spectral power of diastolic blood pressure, and indices of heart rate variability (hrv) were computed to assess ans functionality. results: septic shock induced a severe vascular disarray, decoupling the usual pressure wave propagation from central to peripheral sites, as shown by the inversion of pulse pressure (pp) amplification, with a higher pp in the central aorta than in the peripheral arteries during shock. the time constant tau together with ac and tpr were independently decreased. a decrease in brs, lf power, and hrv describe an ans dysfunction. after the administration of fluids and noradrenaline, both vascular and autonomic dysfunction persisted and these were found to be significantly correlated. measures of mechanical vascular function and ans activity could represent an useful end-point to guide further clinical investigations and refine our understanding of ss mechanisms, especially under medical treatment. introduction: lipopolysaccharide (lps), is a component of gram-negative bacteria known for its activation of the host immune system. the phospholipid transfer protein (pltp) has previously been shown to promote the binding of lps to lipoproteins, to limit inflammation and to lower mortality following injections of lps or bacterial infection. the aim of the present study was to investigate the role of pltp and lipoproteins in the detoxification of lps from the peritoneal cavity. injection of lps intra-peritoneally (ip) ( mg/kg) to wild type (wt) and pltp knocked-out mice (pltp-ko) (n = per group). mass concentration and activity of lps were quantitated by lcmsms analysis of -hydroxymyristate and lal bioassay, respectively. lipoprotein fractions in plasma were separated by ultracentrifugation (n= vs n = ). following intra-peritoneal injection, clearance of intra-abdominal lps was faster and plasma neutralization was more efficient in wt than in pltp-ko mice ( figure ) . indeed, lps found in plasma of wt mice was proportionally less active, sustaining a higher capacity for wt mice to neutralize lps (figure b) . quantitative dosage of lps in portal blood, minutes after ip injection, revealed that plasma lps associates rapidly with the lipoprotein fraction (hdl plus ldl), and in higher proportions as compared to pltp-ko mice ( [ - ] % vs [ - ] %, respectively; p < . ). in line with previous studies, these observations now indicate that, lps readily associates with lipoproteins in a neutralizing process pltp mediated. finally, even with a heavy lps load ( mg/kg), the bulk of lps was still found in the lipoprotein fraction ( [ - ] %), suggesting that lipoproteins plus pltp in wt mice have a high capacity to detoxify intraperitoneal lps. in a model of peritonitis, lipoproteins and pltp were found to constitute key playors for peritoneal clearance and neutralization of lps. it emerges as a key pathway for the resolution of the inflammatory response in peritonitis. introduction: autotaxin (atx, enpp ) is a secreted enzyme present in biological fluids that catalyses the production of lysophosphatidic acid (lpa). lpa is a bioactive phospholipid evoking various cellular responses in most cell types. upregulated atx levels have been reported in various chronic inflammatory diseases. given the established role of lpa in the inflammatory response, we investigated a possible role for the atx/lpa axis in lps-induced endotoxemia. methods: lps was injected intraperitoneally ( mg/kg) in mice producing % atx levels (atx df/+ , heterozygous null mutant mice), in mice producing - % reduced atx levels upon inducible inactivation (r creer t /enpp n/n mice) and in mice expressing - % increased atx levels (enpp -tg mice). kaplan-meier survival analysis was performed. atx activity was measured using the toos activity assay. results: atx df/+ mice that produce almost % reduced serum atx levels show increased survival compared to their littermate controls. for the inducible inactivation of atx, enpp n/n targeted mice were crossed with the r cre-er t mice and tamoxifen induction enabled temporal control of floxed gene expression. r creer t /enpp n/n mice were more protected against lps-induced endotoxemia compared to control mice. enpp -tg mice overexpressing autotaxin and showing a -fold increase in plasma levels do not display improved survival rates compared to control group. conclusions: atx participates in systemic inflammation, as reduced atx levels in circulation decrease lethality of mice from caused by lps. the excess amount of circulating atx does not exacerbate the systemic inflammatory response to lps. introduction: pneumonia (pn) is a prevalent and severe infectious lung disease. host genetics plays an essential role in the pathogenesis of infectious diseases including pn [ ] . the aim of the study was to analyze the variability of genes associated with neutrophil activation in pneumonia. to identify differential expressed genes (degs) in communityacquired (cap) and hospital-acquired pneumonia (hap) dataset «genome-wide blood transcriptional profiling in critically ill patients -mars consortium» (gse ) from gene expression omnibus was analyzed (logfc≥ . , fdr-corrected p-value< . ). degs associated with neutrophil activation were selected according to gene ontology go: («neutrophil activation»). with the use of gtex portal and blood eqtl browser, we searched for esnps (expression single nucleotide polymorphisms) in whole blood for neutrophil activation genes differentially expressed in cap/hap. these esnps were further analyzed for their association with pn via the global biobank engine (gbe). a total of degs from gse correspond to go: genes ( up-and down-regulated) of which genes were common to cap and hap. functional enrichment of degs based on disgenet detected top- diseases associated with these genes (fdr-corrected p-value< . ): myeloid leukemia, chronic; sepsis; asthma; lung diseases; allergic asthma. for these genes esnps common to gtex portal and blood eqtl browser were identified. more than half of all variants were located on the second chromosome and influenced the expression of tnfaip and il rap genes. among all esnps we identified variants associated with pn in the gbe (table ) . we identified genes related to neutrophil activation, genetic variability of which was associated with pneumonia. sepsis was induced in wild-type c bl mice (n= ) and cse knockout mice (n= ) by i.p. injection of cfu/mice mdr p. aeruginosa. similar experiments were repeated after cyclophosphamide induced neutropenia. survival was recorded for days. mice were sacrificed for determination of bacterial load and myeloperoxidase (mpo) activity as a surrogate marker of myeloid cell recruitment. cytokines were measured in serum by legendplex inflammatory panel. total leukocytes from mice spleens, with or without pretreatment with the h s donor gyy , were incubated with x cfu/ml mdr p. aeruginosa. bacterial clearance was recorded. we observed a significant decrease in survival of cse -/mice as compared to cse +/+ mice ( % vs. %; p: . ). this survival advantage was eliminated in neutropenic mice ( % for both groups, p: . ). cse -/mice had increased pathogen load in the liver ( . ± . vs . ± . , p: . ) and lung ( . ± . vs . ± . , p: . ). mpo activity was lower in cse -/mice in the liver ( ± vs ± , p: . ) and lung ( ± vs ± , p: . ). cse +/+ mice had increased serum levels of il- ( . ± . vs . ± . of cse -/-, p: . ); mcp- ( . ± . vs . ± . , p: . ) and gm-csf ( . ± . vs . ± . , p: . ). phagocytic activity of leukocytes from cse -/mice was reduced compared to cse +/+ mice. this deficit was eliminated after gyy pretreatment (fig. ) . deficiency of host-derived h s leads to increased susceptibility to mdr p. aeruginosa infection due to an inefficient neutrophil chemotaxis and neutrophil mediated phagocytosis. acknowledgement funded by the itn horizon marie-curie european sepsis academy introduction: neuroinflammation often develops in sepsis along with increasing permeability of the blood-brain barrier (bbb), which leads to septic encephalopathy [ ] . the barrier is formed by tight junction structures between the cerebral endothelial cells [ ] . we investigated the expression of tight junction proteins related to endothelial permeability in brain autopsy specimens in critically ill patients deceased with sepsis, and analyzed the relationship of bbb damage and measures systemic inflammation and systemic organ dysfunction. case series included all adult patients deceased with sepsis in the years - with brain specimens taken at autopsy available. specimens were categorized according to anatomical location (cerebrum, hippocampus, cerebellum). the immunohistochemical stainings were performed for occludin, zo- and claudin. patients were categorized as having bbb damage if there was no expression of occludin in the endothelium of cerebral microvessels. results: % ( / ) developed multiple organ failure before death. . % ( / ) had septic shock. the deceased with bbb damage had higher sofa maximum scores ( vs. , p= . ), and had more often procalcitonin levels above ( % vs. %, p= . ). bbb damage in cerebellum was more common in cases with c reactive protein above mg/l as compared with crp less than ( % vs. %, p= . ). absence of zo- expression in cerebral meningeal samples associated with bbb damage ( % vs. %, p= . ). positive blood cultures (n = ) were associated to absence of zo- expression in cerebellar glial cells ( % vs. %, p= . ). in fatal sepsis, damaged bbb defined as loss of cerebral endothelial expression of occludin ( figure ) is related with severe organ dysfunction and systemic inflammation. loss of zo- in endothelial cells associates with bbb damage, and sepsis contributes to zo- loss in cerebellar glial cells. oxylipins are oxidative breakdown products of cell membrane fatty acids. animal models have demonstrated that various vasoactive oxylipin pathways may be implicated in septic shock pathophysiology but these have been poorly studied in humans. oxylipin profiling was performed on serum samples collected on enrolment to the vanish (vasopressin vs. norepinephrine as initial therapy in septic shock) trial. samples were analysed with liquid chromatography-mass spectrometry. patients were followed up until days. results: samples were collected from of ( . %) patients on inclusion to the trial and ( . %) had died by days. non-survivors were found to have higher levels of a number of oxylipins including: , -dihydroxyeicosatrienoic acid (dhet) (p< . ), , -dhet (p= . ), (s)-hydroxyeicosatetraenoic acid (p= . ), -hydroxyoctadeca-pentaenoic acid (p= . ) but lower levels of the precursor eicosapentaenoic acid (p= . ). when corrected for multiple comparisons with the benjamini-hochberg test, only , -dhet remained significant (p= . ). although there was a difference in median , -dhet levels between survivors and non-survivors, many values were below the level of detection (n= / ( . %)). as such, we also analysed - -dhet as a binary variable (figure ). patients with detectable , -dhet were more likely to die (hr . [ % ci . - . ], p< . ) and have a higher median lactate (p = . ) and total sofa score (p< . ) than those patients where baseline , -dhet was undetectable. our study suggests the oxylipin , -dhet may be associated with septic shock severity and -day mortality. these results are consistent with the known vasodilatory actions of this class of oxylipin. more work is needed to confirm its exact role in septic shock and whether this pathway is amenable to therapeutic intervention. introduction: activation of neutrophils is a mandatory stage and a sensitive marker of systemic inflammatory conditions that can lead to the development of multiorgan failure. the aim of the study was to investigate into the antiinflammatory effects of lithium chloride on human neutrophils in vitro. study was carried out on neutrophils isolated from the blood of healthy donors. % of neutrophils were activated by mkm fmlp, % -by ng/ml lipopolysaccharide (lps); then their activity was evaluated by fluorescent antibodies to cd b and cd b degranulation markers. intact and activated neutrophils were treated with a solution of lithium chloride ( mmol). immunoblotting was used to assess gsk b activity in neutrophils. mann-whitney criterion and p< . were used for statistics. results: lithium chloride mmol decreased the level of expression of cd b on intact neutrophils by % (p= . ), cd b by % (p= . ). fmlp increased cd b expression on neutrophils by . times (p= . ), cd b by . times (p= , ). addition of lithium chloride solution to fmlp activated neutrophils reduced the expression of cd b (p= . ) and cd b (p= . ). lps increased cd b and cd b expression by . times (p= . , p= . , respectively); addition of lithium chloride reduced the expression of cd b (p= , ) and cd b (p= . ) on neutrophils. fmlp led to a dephosphorylation of gsk- b by % (p< . ), lithium chloride increased its phosphorylation by % (p < . ). adding lithium chloride to activated fmlp neutrophils restored the level of gsk- b phosphorylation by % compared to controls (p< . ). lithium chloride modulates the inflammatory activation of neutrophils by bacterial components through the phosphorylation of gsk b in neutrophils. human host immune responses to lipopolysaccharide: a comparison study between in vivo endotoxemia model and ex vivo lipopolysaccharide stimulations using an immune profiling panel dm tawfik introduction: sepsis, a leading cause of mortality among critically-ill patients in the icu, recently recognized by the who as a global health burden. patients that suffer from sepsis exhibit an early hyper-inflammatory immune response which can lead to organ failure and death. in our study, we assessed the immune modulations in the human in vivo endotoxemia model and compared it to ex vivo lipopolysaccharides (lps) stimulation using transcriptomic markers. methods: eight healthy volunteers were challenged with intravenous lps in vivo. in parallel, blood from another volunteers was challenged with lps ex vivo. blood was collected before and after hours of lps challenge and tested with the immune profiling panel (ipp) prototype using the filmarray® system. the use of ipp showed that markers from the innate immunity dominated the response to lps in vivo, mainly markers related to monocytes and neutrophils. comparing the two models, in vivo and ex vivo, revealed that most of the markers were modulated in a similar pattern ( %). some cytokine markers such as tnf, ifn-γ and il- β were under-expressed ex vivo compared to in vivo. t-cell markers were either unchanged or up-modulated ex vivo, compared to a down-modulation in vivo. interestingly, markers related to neutrophils were expressed in opposite directions, which might be due to the presence of cell recruitment and feedback loops in vivo. the majority of ipp markers showed similar patterns of expression post-lps challenge in both models, except for several markers related to neutrophils and t-cells. the ipp tool was able to capture the early immune response in the human in vivo endotoxemia model, which is a translational model mimicking immune host response in septic patients. introduction: serum levels of tyrosine kinase receptor mer and its ligand gas predict mortality in septic patients in the intensive care unit. however, whether their early measurement at emergency department (ed) presentation also predicts mortality and organ failure still needs to be clarified. in this multicentre observational study, septic patients admitted to italian eds were included [ ] . at ed presentation blood samples were taken for routine biochemical analyses and serum mer and gas measurement. urinalyses, blood gas analyses and chest x-ray were routinely performed. mortality at and days, as well as the presence of organ damage such as acute kidney injury (aki), thrombocytopenia, pt-inr derangement and sepsis-induced coagulopathy (sic) were evaluated according to baseline levels of mer and gas . in conclusion, neither mer nor gas are early predictors of mortality in septic patients at ed presentation. however, mer independently predicted the development of sic, thrombocytopenia and pt-inr derangement in this population. glycocalyx shedding correlates with positive fluid balance and respiratory failure in patients with septic shock n takeyama, y kajita, t terajima, h mori, t irahara, m tsuda, h kano aichi medical university, department of emergency and critical care medicine, aichi, japan critical care , (suppl ):p endothelial hyperpermeability would play a major role in septic shock related organ failure. the aim of this study is to clarify the relationship between glycocalyx shedding and respiratory failure, sofa score, plasma angiopoietin (ang)- level and patient survival. methods: plasma samples were collected from septic shock patients from admission to icu discharge and healthy volunteers. plasma syndecan (syn)- and ang- were measured and clinical data was also collected. septic shock patients were classified into groups according to the time-course change of syn- levels. excess syn- (> ng/ml) during to days and remaining high following to days were assigned to group i. excess ang- during to days and decreased following to days were assigned to group ii. moderate increase (< ng/ml) during to days were assigned to group iii. results: plasma syn- levels are positively associated with increased ang- levels (r = . , p= . ), suggesting that ang- is involved in endothelial hyperpermeability. fluid balance and ventilator-free days (vfd) are significantly increased in group i as compared with group iii. sofa score, apache ii and patient outcome does not show any differences between groups i, ii, and iii. the positive correlation between glycocalyx shedding and fluid balance indicates plasma syn- may be a valuable marker for endothelial hyperpermeability. the negative correlation between glycocalyx shedding and vfd indicates plasma syn- may be a valuable marker for respiratory failure. the plasma level of syn- for prognosis and organ failure excluding ards in patients with septic shock requires further investigation. serial procalcitonin measurements in the intensive care unit at hiroshima university hospital k hosokawa, s yamaga, m fujino, k ota, n shime hiroshima university hospital, department of emergency and critical care medicine, hiroshima, japan critical care , (suppl ):p introduction: serum procalcitonin (pct) is a promising biomarker for differentiating bacterial infections from other inflammatory states. moreover, including serial pct measurements in the management of acute respiratory infection reduces the duration of antibiotic therapy without increasing the mortality. however, limited real-world information is available regarding the use of pct in intensive care units (icus). we extracted and analysed data from january to december , from all the orders and results of pct measurements in the icu ( beds) at hiroshima university hospital. a total of , pct measurements from icu patients were included. in patients, pct was tested ≥ times during a single icu stay. serial pct measurements showed a fade-out pattern ( [ %] patients), a second day-peaked decrease pattern ( [ %] patients), and a series of negative patterns ( [ %] patients). compared to patients who demonstrated the fade-out pattern, those who demonstrated the second day-peaked decrease pattern had higher mortality rates ( % vs. %, p < . ). approximately one-third patients in the icu who had decreasing serial pct values demonstrated the second day-peaked decrease pattern. since this group of patients had poorer survival, further studies are needed to clarify the association between a late rise in pct levels and delayed therapeutic intervention. the research was performed on full-term newborns; no clinical signs of bacterial infection were diagnosed. on the , , days the plasmà concentration of il- ß, il- , il- , tnf-α, g-csf, sfas, fgf, no was determined by capture elisa; cd cd , cd cd , cd cd , cd , cd , cd , hla-dr, cd , cd , cd cd , lymphocytes in apoptosis -immunophenotype analysis. by applying the statistical cluster population analysis of the immunological criteria under study we have evaluated the feasibility of sepsis diagnostics at the admission to the intensive therapy unit. the diagnostic rule for sepsis has been formulated by applying the "decision tree" approach to the "r" statistic medium. the cluster analysis confirms the presence of two clusters (presence of absence of sepsis: these two components explain the . % of the point variability). the diagnostic rule for the early diagnostics of sepsis is as follows: disease develops providing during the first hours cd ≥ . %, no≤ . mkmol/l or cd ≤ . %, cd ≤ . %, cd ≥ . % or cd ≤ . %, cd ≤ . %, cd ≤ . % and lymphocytes annexinv-fitc+pi-≥ . %. newborns featured the confirmed sepsis development. the accuracy of this diagnostics amounts to . %; sensitivity to . %; specificity to . %; diagnostic false positive share to . %; diagnostic false positive share to . %; positive result accuracy to . %; negative result accuracy to . %. the aggregate determination of cd , cd , annexinv-fitc+ pi-, cd and the plasma concentration of no enables the pre-clinical diagnostics of sepsis development. efficacy of pancreatic stone protein in diagnosis of infection in adults: a systemic review and metaanalysis of raw patient data j prazak , p egimann , i irincheva , mj llewelyn , d stolz , lg de guadiana-romualdo , r graf , t reding , hj klein , ya que fig. (abstract p ) . impact of h lactate and bio-adm values in patients with elevated lactate level at admission. the green curve in the left km-plot illustrates data from patients with events; the red curve patients with events. the green curve in the right km-plot illustrates data from patients with events; the red curve patients with events. of note, differences in numbers between admission (n= ) and h (n= ) is related to initial mortality introduction: adrenomedullin (am) is a peptide synthesized in vascular endothelial cells and cleared by the lungs. the use of am as an inflammatory biomarker and his predictive value has been studied in critically ill patients, but not yet in veno-venous extracorporeal membrane oxygenation (ecmo). the purpose of this study was to describe the plasmatic levels of am in patients supported with ecmo for acute respiratory failure methods: am (normal values < . nmol/l) was measured at time points: immediately before (t ), -h (t ) and -h after (t ) ecmo initiation and immediately before (t ) and -h (t ) after ecmo removal, in consecutive patients with severe respiratory failure supported with ecmo enrolled in the gatra study (nct ) at fondazione irccs ca' granda -policlinico of milan. data are reported as median ( th - th percentile). statistical analysis was performed using logistic and random effects regression models (to account for repeated measurements within individuals) results: a total of measurements were taken in consecutive patients. am (nmol/l) decreased along the course of ecmo: t = . ( . - . ), t = . ( . - . ), t = . ( . - . ), t = . ( . - . ), t = . ( . - . ) (mean diff.= - . , %: ci - . , - . ). am was lower in patients with viral compared to bacterial ards (mean diff.= - . , %ci - . , - . ) (figure ). am was higher in more severe patients (sofa>= , n= ) compared to less severe patients (sofa< , n= ): . ± . vs . ± . nmol/l, respectively p< . . basal values of am could not predict mortality at days (or= . , %ci: . - . ) after conditioning for sofa score and respiratory failure etiology conclusions: am plasmatic values seem to be higher in more severe patients and in patients with bacterial ards. am decreased along the ecmo course but could not predict mortality in our group of patients fig. (abstract p ) . plasmatic adrenomedullin during ecmo heparin binding protein (hbp) is released from activated neutrophils upon stimulation of b integrins. this pro-inflammatory effect generates the hypothesis that it can be a sepsis biomarker for patients admitted at the emergency department (ed) methods: the prompt study (clinicaltrials.gov nct ) took place at the ed of six greek hospitals. participants were admitted with suspected acute infection and at least one vital sign change. hbp was measured by an enzyme immunosorbent assay in plasma. sepsis was diagnosed by the sepsis- criteria. the primary study endpoint was the sensitivity for the diagnosis of sepsis. outcome prediction was the secondary endpoint. a total of patients were enrolled; had sepsis. the most common infections among patients without and with sepsis were upper respiratory tract infections in . % and . %; community-acquired pneumonia in . % and . %; and acute pyelonephritis in . % and . %. median hbp was . and . ng/ml respectively (p: . ). following analysis of the area under the curve (auc) it was found that the best discriminatory cut-off for sepsis was . ng/ml. the comparative diagnostic performance of hbp versus qsofa score is shown in figure . the odds ratio for sepsis with hbp above . ng/ml was . (p: . ). at the same cut-off point the sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) for the prediction of early death after hours was %, . %, . % and % respectively. hbp is more sensitive but less specific than qsofa for the diagnosis of sepsis in the ed. the rule-out prediction of early death seems the great merit. chronobiological and recurrence quantification analysis of temperature rhythmicity in critically ill patients introduction: rhythmicity and complexity of several circadian biomarkers, such as melatonin, cortisol and temperature have been found to be modified by critical illness. we examined the potential alterations of core body temperature (cbt) fluctuations and complexity in three groups (n= ): patients with septic shock upon icu admission (group a, n= ), patients who developed septic shock at icu hospitalization (group b, n= ) and controls (group c, n= ). the hourly, average cbt was computed for h upon icu admission and discharge in groups a and c, as well as during septic shock onset in group b. cosinor analysis of cbt curves was performed leading to the estimation of mesor (mean value), amplitude (the difference between peak and mean values) and acrophase (phase shift of maximum values in hours). complexity of cbt signals was evaluated with recurrence quantification analysis (rqa). no significant alterations in any circadian feature within groups were found, except for amplitude. controls exhibited increased entry cbt amplitude ( . ± . ) compared to groups a ( . ± . , p < . ) and b ( . ± . , p < . ). higher entry cbt amplitude in groups b and c was related with lower saps ii (r = - . and - . , p < . ) and apache ii scores (r = - . and - . , p < . ) respectively, reduced icu and hospital stay in group b (r = - . and - . , p < . ) and entry sofa score in group c (r = - . , p < . ). recovery cbt time series appeared more periodic in relation with icu entry, for all groups. a more random cbt signals pattern upon results: among . . individuals, . received inpatient treatment for sepsis. % had severe sepsis. % of sepsis and % of severe sepsis patients had an explicitly coded hai. the proportion of hai was higher in patients that received icu-treatment than in patients without icu-treatment ( % in icu/ % in non-icu sepsis, % in icu/ % in non-icu severe sepsis patients). tab. shows the foci of explicitly coded hai. nosocomial pneumonia was the most common hai in all patient groups. clabsi occurred more frequently in icutreated patients; % were affected. cauti and c. diff infections were more common among non-icu-treated sepsis patients. more than one quarter of non-icu-treated sepsis patients had a c. diff infection. hai are common causes of sepsis and pose a significant healthcare burden. the proportion of patients affected and the distribution of foci differ between non-icu-and icu-treated sepsis patients with important implications for sepsis management within hospitals. impact of sepsis protocol triggered by ramathibodi early warning score (rews) in ipd sepsis on clinical outcomes s matupumanon , y sutherasan , d junhasawasdikul , p theerawit sepsis is now early identified and managed during triage in the emergency department. however, there is less focus on the effect of patients' management at the ward level. we aim to evaluate the impact of the implementation of the sepsis protocol on clinical outcomes in in-patients with new-onset sepsis. we conducted a prospective observational cohort study among adult medical patients admitted to the general wards in a university hospital. a -month pre-protocol period (august to august ) was assigned to a control group, and a -month protocol period (september to october ) was allocated to a protocol group. an in-patient sepsis protocol comprised nurse-initiated sepsis protocol by ramathibodi early warning score (rews)≥ plus suspected infection, prompt antibiotic, lactate measurement, and fluid resuscitation was implemented. (table ) . the implementation of in-hospital sepsis protocol was associated with significant improvement in patients' outcomes, namely lactate measurement, starting antibiotic within hr, fluid management, and the shorter length of icu stay. icu routine nursing procedures interfere with cerebral hemodynamics in a prolonged porcine fecal peritonitis model sl liu , dc casoni , w z'graggen , d bervini , d berger , sj jakob routine nursing procedures (np) can interfere with blood pressure and cardiac output and may therefore alter cerebral hemodynamics in critical illness. this may be risk factor of sepsis-associated encephalopathy. methods: sedated and mechanically ventilated pigs were randomized to fecal peritonitis or controls (n= , each). after hours of untreated peritonitis, the animals were resuscitated for hours (resuscitation period). np [assessment of sedation (as), tracheal suctioning (ts), change in body position (cp), lung recruitment maneuver (rm)] were performed at baseline and h, h, h and h after start of rp. systemic and cerebral hemodynamics and o saturations were recorded continuously. shock is the most common cause of death in the postsurgical icu, including septic shock and hypovolemic shock, reaching the - % mortality in septic shock. the inadequate response of the immune system to the infection triggers a potent inflammatory cascade, where the c-reactive protein (crp) is an essential key in the amplification and maintenance of this cascade. the gene encoding to crp is located on the proximal long arm of human chromosome ( q ). the gt polymorphism in the promoter sequence of crp gene (rs ) has been associated with invasive pneumococcal disease. thus, we analyze the relationship between rs polymorphism and the risk of developing septic shock in postsurgical patients. an observational, retrospective and single-center study was conducted on a sample of caucasian patients undergoing major abdominal surgery, of which one part developed septic shock and another part developed systemic inflammatory response syndrome, who were used as control. the rs polymorphism was analyzed by vasoactive medications are commonly used in sepsis treatment but may correlate with peripheral ischemia and the well-publicized complication of limb and digit loss. yet, the association between limb and digit threat and the intensity, duration, and pattern of vasopressor exposure are unknown. we studied adults ( - ) at hospitals in an integrated health system who met criteria for sepsis- . we identified the time to clinically apparent limb or digit threat using clinical adjudication among those with vasopressor-dependent sepsis (i.e. > hour of vasopressors at sepsis onset) who had a surgical evaluation within -days of sepsis onset. we defined daily vasopressor intensity as to vasopressors administered. then, we created a time-dependent model for threat with mortality as a competing risk with a weight function to estimates the varying contribution of vasopressors over time. we determined the subdistribution hazard (sh) ratio of threat for various patterns of vasopressor exposure and intensity, adjusted for age, baseline risk factors, and sequential organ failure assessment (sofa) score at sepsis onset. of , adults with sepsis, , ( %) were vasopressordependent (age, [iqr, - ]; , [ %] males; max sofa score, [sd ] ). of these, , ( %) died and ( . %) had evaluations for limb or digit threat [iqr, - ] days after sepsis onset. the model-based weight function showed the contribution of vasopressors to threat was stable over time ( fig a) . overall, a unit increase in cumulative vasopressor exposure was associated with risk of threat (sh ratio, . [ %ci, . - . ], p<. ). for various patterns of vasopressor exposure, greater intensity associated with increased risk of threat ( fig b) . compared to constant exposure, an increasing and peak pattern associated with the greatest sh (fig c) . cumulative vasopressor exposure was associated with an increased risk-adjusted hazard of limb or digit threat following sepsis. fig. (abstract p ) . relationship between vasopressor exposure and limb or digit threat following vasopressor-dependent sepsis. panel a demonstrates the estimated contribution of daily vasopressor intensity prior to surgical evaluation for limb or digit threat, with mortality as a competing risk. panel b and c explore the relationship between threat and both cumulative vasopressor exposure and the pattern of exposure following sepsis onset. (b) the maximum cumulative vasopressor exposure was associated with the highest risk of limb or digit threat (shr . ) when compared to reference exposure pattern (shr . , reference). (c) increasing (shr . ) and peak (shr . ) patterns of cumulative exposure were associate with an increased sh of limb threat, while a decreasing pattern was associated with a lower risk (shr . ) when compared to constant intensity (shr . , reference). abbreviations: shr: subdistribution hazard ratio proportion of encounters transitioning from phenotype at presentation within hrs, by arrival phenotype assignment and probability of membership. (c) tsne plots for α-type, ß-type, y-type, and ∂-type, with core (dark), marginal (light), and non-members (grey) in plots on the left and core, marginal, non members, and transitioning members (black) on the right fig. (abstract p ). isolated microorganisms critical care references: . wertz et al. critical care explorations : e the process investigators choosing wisely guidelines for the provision of intensive care services, version . ics structured patient handovers references: . care of the critically ill woman in childbirth the proqol manual: the professional quality of life scale:compassion satisfaction, burnout & compassion fatigue/secondary trauma scales references: . shimabukuro-vornhagen a et al. ca the code: professional standards of practice and behaviour for nurses, midwives and nursing associates p introduction: the aim of this study was to compare factors associated with the icu mortality for vap due to multidrug-resistant (mdr) klebsiella spp. in case of monobacterial (mo) vs polibacterial (po) origin. methods: retrospective data analysis of patients treated in icu with mdr klebsiella spp. strains as pathogens of vap during three year period was carried out. results: data of patients were evaluated. mo vs po of mdr klebsiella spp. vap cases was found to be ( . %) vs ( . %), p = . . the icu mortality was / ( . %) in mo, and / ( . %) in po one, p = . . statistical significant differences of survivors vs non-survivors in mo and po vap due to mdr klebsiella spp. were found in medians of neutrophilosis p introduction: we study the population structure and resistome of mdr enterobacterales and pseudomonas aeruginosa isolates, c/t-susceptible or -resistant, recovered from low respiratory, intraabdominal and urinary tract infections of icu patients of portuguese hospitals (step study results: in e. coli, two vim- producers were found (st -b -h -o :h -ctx-m- and st -c-h -o :h ) (c/t-mic= . / - / mg/l). a kpc- -st -cladev-h -o :h ( / mg/l) was also detected. the most frequent esbl-e. coli clone was st cpr klebsiella pneumoniae ( patients), candida spp. ( patients). the comparison subgroup consisted of patients with bacteremia caused by non-escape pathogens. we evaluated the days of mechanical ventilation, duration of antibiotic therapy (amt), icu length of stay (los), hospital los and mortality (table ). results: mortality in patients with bacteremia caused by non-eskape pathogens was . %, candida spp vancomycin mass removal over minutes of hemoperfusion using ha . bars refer to vancomycin mass (mg): blue (experiment ) and red (experiment ) bars using blood while green (experiment ) bar using balanced solution. yellow dashes are mean mass values of the three experiments (with standard deviations) and yellow line represents the reduction curve over time table (abstract p ). results. * p-value versus non-eskape subgroup mechanical ventilation p translational value of the microbial profile in experimental sepsis studies sp tallósy , a rutai , l juhász , mz poles , k burián , d Érces , a szabó , m boros invasive hemodynamic monitoring and blood gas analyses were performed on anesthetized animals between - h of sepsis. the respiratory, cardiovascular, renal, hepatic and metabolic dysfunctions were evaluated with the species-specific sequential organ failure assessment (sssofa) score, the microbial profile was determined with selective media and maldi-tof ms in the initial inoculum and in the abdominal fluid taken h after sepsis induction. results: strong correlation was found between the initial dose of the inoculum (cfu) and the sssofa scores for organ dysfunction (rats: r = . , p= . ; pigs: r= . , p = . ) p introduction: pancreatic stone protein (psp) has shown promise as a biomarker of infection however, its diagnostic potential has not been systematically evaluated. we performed a systematic review and meta-analysis of available data on psp to evaluate its value for detecting infection in adults and determining a plasma or serum threshold value. methods: the pubmed and cochrane library database were searched for studies on psp in adult patients and their raw data were analyzed to estimate the best psp cut-off value that could detect infected patients using the youden's index. the cut-off sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) were computed and compared to those for procalcitonin (pct) and c-reactive protein (crp). finally, we explored the potential value of a model combining all three biomarkers to detect infection. results: from a total of potentially eligible published studies, containing patients were included in quantitative analysis. among them, patients suffered from a clinically confirmed infection. the median appropriate statistical tests were used using spss . cd was expressed as % age of neutrophils expressing positivity. results: sixty patients were analyzed. all parameters were compared between survivors and non survivors. demographics were comparable. most common source of sepsis was lungs and majority were admitted due to medical reason. non-survivors had significantly increased number of days with septic shock. at day median values of all the biomarkers and the sofa score were significantly higher in the nonsurvivor group (p< . ). there was a decreasing trend of all biomarkers and sofa score amongst survivors. on multivariate logistic regression analysis, increased cd and crp levels between baseline and day , increased days with septic shock and increased sofa references: introduction: we characterized the association of c-reactive protein (crp) with extracellular vesicles (evs) in plasma from sepsis patients and assessed a commercial crp adsorbent (pentrasorb, pentracor, hennigsdorf, germany) to deplete free and ev-associated crp. in addition, we characterized the potential pro-inflammatory effects of ev-bound crp on monocytes and endothelial cells monocytes and human umbilical vein endothelial cells (huvecs) were stimulated with isolated evs ( , g, min) monocyte il- secretion was quantified by elisa; the activation of huvecs was assessed by their expression of icam- and e-selectin using confocal microscopy. results: septic plasma (n= ) contained . ± . mg/l crp vs. . ± . mg/ l for healthy controls (n= ). both, total evs and crp + evs were significantly elevated in septic plasma as incubation of septic plasma with pentrasorb resulted in depletion of free crp ( . ± . mg/l before vs. . ± . mg/l after adsorption) as well as in a significant reduction in crp evs from crp-depleted septic plasma induced significantly lower il- levels. huvec icam- or e-selectin expression, however, did not increase upon stimulation with septic evs. conclusions: treatment of septic plasma with pentrasorb efficiently removes free crp and detaches crp from the ev surface, resulting in reduced proinflammatory effects flow cytometry confirmed the association of monocytes with platelets and platelet-derived evs as well as the uptake of evs by monocytes. conclusions: storage of isolated monocytes induces a shift towards cd expressing proinflammatory monocytes, which seems to be mediated by residual platelets and platelet-derived evs. it remains to be clarified whether evs released from activated platelets can also trigger a shift towards proinflammatory, intermediate monocytes in vivo ethical approval was provided by ucl research ethics committee ( / ). paired parametric analyses were performed and data displayed as mean +/- % ci. results: plasma calprotectin concentration began to increase . hours after endotoxin administration, was significantly higher than baseline by hours ( . ng/ml vs. ng/ml, p < . ), peaked at hours (mean ng/ml, figure ) and normalized by hrs. calprotectin peaked earlier than comparator soluble mediators (procalcitonin hrs, crp, hrs) and exhibited % sensitivity; all participants demonstrating a minimum -fold increase from baseline (mean . x). calprotectin displayed greater baseline variability (sd . ng/ml) than either crp or procalcitonin. conclusions: our results indicate the potential of plasma calprotectin as a biomarker for bacterial infection. it increases earlier and peaks more rapidly than standard biomarkers. whilst higher baseline variability was observed p a multicenter randomized controlled study on landiolol for the treatment of sepsis-related tachyarrhythmia: subanalysis of the j-land s study o nishida kagoshima university graduate school of medical and dental sciences, department of emergency and intensive care medicine methods: we analyzed a retrospective cohort of electronic health records from adult sepsis patients at upmc hospitals from to . we defined sepsis- by i.) suspected infection (e.g., administration of antibiotics or body fluid culture) & ii.) organ dysfunction (e.g., or more sofa points) in the first hours of care. data were organized by hour and included vital signs, lab values, and treatments (e.g., total hourly iv fluids (ml) and norepinephrine equivalent dose). for each hour we describe, i.) available data elements, ii.) presence of sepsis- , and iii by hour , most patients had vital signs ( %; n= , ), basic labs ( %; n= , ), fluid cultures ( %, n= , ), while serum lactate was completed in % (n= , ) conclusions: early sepsis care patterns are variable. iv fluids were given during early hours, when uncertainty about sepsis was greatest, while vasopressors were administered after sepsis- elements were present. p effects of abdominal negative pressure treatment on splanchnic hemodynamics and liver and kidney function in a porcine fecal peritonitis model sl liu department of intensive care medicine splanchnic hemodynamics and laboratory parameters were measured at baseline (bl, start of rp), and h, h and h after start of rp. two/three-way rm-anova or mixed-effects analysis, and student t tests were performed. results: npt in controls had no effect. after sepsis induction, mean arterial pressure (map) decreased by ( - ) mmhg, cardiac output (co) by . ( . - . ) l/min, and arterial lactate increased by . ( . - . ) mmol/l. sepsis and resuscitation was associated with increasing hepatic and renal arterial flows (p≤ . , both), and increasing prothrombin time npt in sepsis resulted in numerically less noradrenaline administration ( . ± . ug/ min/kg in sepsis with npt vs. . ± . ug/min/kg without npt, p= . ) and positive fluid balance ( . ± . ml/h/kg with npt vs. . ± . ml/h/kg without, p= . ). conclusions: in our experimental fecal peritonitis model, npt did neither impair splanchnic hemodynamics nor abdominal organ function. whether npt helps to reduce noradrenaline and volume administration in abdominal sepsis should be evaluated in further studies. p association between a c-reactive protein gene polymorphism (rs ) with the risk of develop septic shock in postsurgical patients of major abdominal surgery p martínez-paz valladolid, spain; hospital of medina del campo notably, the three groups received a comparable pro kg dose of acetaminophen. no difference was found between groups in term of toxic effects. patients carrying the cyp a p showed a more pronounced effect on body temperature in respect of wt and ugt a p °c respectively, but it does not reach statistical significance (fig. b). only % of the patients reach a temperature < °c at t and only % < . °c. conclusions: polymorphisms in enzymes involved in the metabolism of acetaminophen are relatively common. cyp a p seems to lead to higher peak plasmatic concentration and a slightly increased efficacy in fever control panel a: variations of acetaminophen plasmatic levels after minutes (t ) and hours (t ) after administration of an iv dose of g of paracetamol in wt patients and patients carrying mutation; panel b: body temperature variations in wt patients and patients carrying mutations clinical research, investigation, and systems modeling of acute illness (crisma) center, department of biostatistics we determined phenotype cohesiveness using probability of assignment at presentation, defining core members as ≥ % and marginal as < % probability. we determined how members transitioned to other phenotypes over hrs using t-distributed stochastic neighbor embedding (tsne) plots and determined the odds ( %ci) of transition. results: we studied , adult sepsis encounters (median age c) the odds of ever transitioning from presenting phenotype increased significantly for marginal members vs publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank the department of education of the basque government (piba - ) and the university of the basque country upv/ehu (ppg / , giu / ) for their financial support. a great disaster affects the family-and friend-performance of bcpr by diminishing the willingness of family and friend bystanders to follow the instruction provided by dispatchers. the experimental method ifitem could be an alternative of fibtem in cases when internal coagulation pathways assessment is prioritized (i.e. heparinized patients on extracorporeal supports). patients undergoing limitation of life-sustaining therapy had lower karnofsky scale scores. therefore, this scale may be useful to guide end-of-life decisions in the future, but further studies with larger number of patients are needed. readmission after discharge home from critical care: a qualitative study c robinson , f nicolson , p mactavish , t quasim , jm mcpeake nhs greater glasgow and clyde, nhs greater glasgow and clyde, glasgow, united kingdom; university of glasgow, nhs greater glasgow and clyde, glasgow, united kingdom critical care , (suppl ):p readmissions to acute care occur in a high number of critically ill patients within days of hospital discharge [ ] . biomedical drivers such as frailty and pre-existing co-morbidities have been identified as drivers for readmission. however at present there is limited data on the influence of social problems on readmission. this study, using a grounded theory approach, sought to understand from a patient/caregiver perspective what the drivers for readmission to acute care were. ethical approval was granted from the west of scotland research ethics service ( /ws/ ). a grounded theory approach was used to explore from a patient and caregiver perspective what the drivers for readmission are [ ] . using a clinical database, we identified those patients who had an icu admission ≥ days who were readmitted to acute care within days of hospital discharge. the researcher attended the ward and after discussion with the direct care team conducted a semi-structured interview with patient and/or caregiver. the interview was recorded and transcribed verbatim. the transcripts were analysed to generate initial codes, followed by the development categories and sub-categories. theoretical sampling was undertaken. results: participants were interviewed. ( . %) were patients and ( . %) were caregivers. the themes that have emerged from the data were: pain and polypharmacy; lack of social support and/or isolation; strained relationships with primary care providers and information provision across the patient journey. subsequent theory development is underway to understand how this learning could help reduce readmissions in future. in conclusion, both social and biomedical drivers are likely to contribute to acute care readmission in this group. future interventional work is required in order to identify modifiable factors to reduce this burden for patients and the healthcare service. frailty has shown to have prognostic relevance for patients with critical illness. since a wide range of tools has been described to screen for frailty, we aimed to describe the association of two frailty screening tools, the clinical frailty scale (cfs) score and the modified frailty index (mfi) in critically ill patients. we performed a post-hoc analysis of a multicenter cohort of patients admitted to six canadian intensive care units (icu) between february and july . frailty was identified using the clinical frailty scale (cfs) and the modified frailty index (mfi). concordance of the frailty screening tools was evaluated with partial spearman rank correlation and intraclass correlation (icc). discrimination and predictive ability of the tools for hospital mortality, -year mortality, hospital readmission and adverse events were compared using concordance statistic (c-statistic) and calibration plot adjusting for age, sex, sequential organ failure assessment (sofa) score and icu admission source, respectively. the cohort included patients. prevalence of frailty was . % ( % confidence interval [ci] . %- . %) with the cfs and . % ( % ci . %- . %) with the mfi. concordance between the two tools was low [(icc of . ; % ci . - . ) and partial correlation coefficient of . ( % ci . - . )], even after adjustment. hospital and -year mortality were greater for frail compared to non-frail patients using of both tools. similarly, both tools found frail patients were less likely to be living independently after hospital discharge, and more likely to be rehospitalized when compared to non-frail patients. while the cfs and mfi show low concordance, both showed good discrimination and predictive validity for hospital mortality. both tools identify a subgroup of patients more likely to have worse clinical outcomes. the post-intensive care syndrome (pics) is a myriad of physical, psychiatric and cognitive disorders secondary to critical illness, leading to a decreased quality of life and an important socioeconomic burden. this study aimed to identify if the conformity to a pics prevention bundle was able to reduce the incidence of the syndrome at icu discharge. all patients admitted to the icu from january st to december st were included. the conformity to each of the ten components of the pics prevention bundle was assessed daily, and the patients were evaluated for anxiety, depression, cognitive dysfunction, muscular weakness, mobility impairment and nutritional risk at icu discharge and at a -to- -months follow-up consultation. the patient cohort was divided in terciles according to bundle conformity for the analysis. results: from the enrolled patients, ( %) were evaluated at icu discharge, and ( %) attended to the follow-up consultation. there was no difference in baseline characteristics between the cohorts. there was no correlation between the prevalence of pics at discharge and bundle conformity during icu stay ( % vs. % vs %, p . ), though there was a decrease in nutritional risk and days in mechanical ventilation (table ) . after to months there was a reduction on the prevalence of any kind of pics, mobility impairment, muscular weakness and nutritional risk. the patients that developed pics were older and had a higher simplified acute physiology score iii at icu admission. a higher adhesion to a pics prevention bundle was not able to prevent the occurrence of the syndrome. post intensive care syndrome (pics) is well recognized following general icu care [ ] . intensive care syndrome:promoting independence and return to employment (ins:pire) is a multidisciplinary complex intervention designed to address pics [ ] . with a paucity of evidence on pics after cardiothoracic intensive care, we aim to evaluate pics and the feasibility of the ins:pire intervention in this population. those attending the clinic received weeks of intervention including individual appointments with icm nurse, physician, pharmacist, and physiotherapist. a café area facilitated peer support alongside psychology group sessions. primary outcome was quality of life measured by eq- d- l. further surveys included: pain, mental health, and selfefficacy. questionnaires were taken at baseline, and months. results: over cohorts, patients attended, % male, median age years (iqr - ), median apache score of (iqr - . ), and median icu length of stay was days (iqr - ). a total of ( %) patients completed surveys at one year. scheduled admissions represented % of those attending. mean euroqol eq-vas score was / (sd +/- ) at baseline increasing to / (sd +/- ) by year (table ) . those with problems in at least one domain of eq- d- l fell from % at baseline to % at -year with the breakdown shown in table . severe problems were seen in % falling to % at year. hads demonstrated an anxiety or depression rate of %. brief pain inventory identified patients ( %) with ongoing chronic pain. mean self-efficacy was / (sd +/- ) at baseline and / (sd +/- ) at year. cardiothoracic intensive care patients have ongoing and persistent features of pics with significant effects on health-related quality of life. further, the ins:pire multi-professional complex intervention is feasible within this specialist group. screening approach might be implemented whenever screening of the total icu population is not deemed feasible. influenza is an acute viral illness with a significant financial burden. point of care testing for influenza is available and has demonstrated accuracy [ , ] , the current gap in knowledge is the question around the opportunity cost of influenza testing. if poct is financially a less costly test this could free up scarce resource. the study adopts a cost minimisation approach. the point of care test is the roche cobas® liat® machine which can detect flu a/b and is compared with the west of scotland specialist virology centre's established in house multiplex real time pcr assay.the model was developed using microsoft excel and has arms comparing analysis of the above mentioned tests. the model estimates that the total cost of poct per patient tested is £ . compared with £ . for lab testing ( figure ). this is a saving of £ . per patient when poct is used. the result swings in favour of the lab test when poct specificity falls to . %. if the lab could provide the result of influenza testing within hours the result would swing in favour of lab testing. zanamivir which will potentially be used increasingly in the intensive care setting can more than double the difference between the tests in favour of poct. this research suggests that poct offers potential cost savings in the icu setting. this is the case as long as poct specificity is higher than a threshold of . % and the lab take longer that hours to return the result. the sensitivity analysis should allow for external validity given the usual variations in icu practice. the aim of the present study is to describe the demographic, clinical, microbiological aspects and the outcome of patients with intensive care unit-related (icu-related) bacteremia. moreover, we aimed to study the patient outcome in association with colistin susceptibility. retrospective, single-center study in a -bed icu for months, from / / to / / . icu-related bacteremia was defined as bacteremia in patients with icu stay > hours or icu readmission (first admission ≥ month before). only the first episode of bacteremia was considered. the primary outcome was -day mortality. data regarding clinical, demographic and outcome characteristics were retrieved from the patient files. the hospital's ethics committee approved the present protocol. moreover, the patients with bacteremia due to colistin-resistant pathogens were compared with the patients affected by colistin sensitive microbes. forty episodes of gram-negative icu bacteremia were collected during the aforementioned period in patients ( . % male) with a mean age and apache ii of . ± . years and ± . , respectively. the event had taken place at an average of . days. the responsible isolates were resistant to carbapenems in . % of the episodes. the majority of the events were due to a single isolate ( %). acinetobacter baumannii and klebsiella pneumoniae presented the majority of the implicated microbes ( % and . %, respectively). the crude -day mortality was %. finally, we could not detect any difference in mortality between the colistin sensitive and the colistin-resistant pathogens ( figure ). the present study denotes that, in a setting of extremely drugresistant pathogens with limited treatment options, gram-negative bacteremia in the icu is associated with increased mortality. image : characterization of resistance mechanisms affecting ceftolozane/ tazobactam in enterobacterales and pseudomonas aeruginosa icu isolates using whole genome sequencing (step study) m hernández-garcia , cc chaves , jm melo-cristino , ds silva , ar vieira , mp f. pinto , jd diogo , eg gonçalves , jr romano , rc cantón hospital ramón y cajal-irycis, microbiology department, madrid, spain; introduction: clostridium difficile infection (cdi) is the main cause of hospital acquired diarrhoea [ ] . the aim of this study was to compare characteristics of cdi during yr and . a retrospective observational study was carried out in lithuanian university of health sciences hospital -the largest teaching facility of tertiary care in country. according to department of infection control records, patients (pt) with (w.) diarrhoea and the first positive stool test for c.difficile toxin a/b were included. age, charlson comorbidity index (cci) score, profile of hospital department (medical (md), surgical or icu) where cdi was diagnosed, type of cdi (healthcare-associated (ha), hospital or community-acquired) and rate of risk factors (rf) have been estimated in both and . ibm spss . ; pearson's chi-square, fisher's exact tests were used for statistics. p < . was statistically significant. results: in total pt from , from were enrolled. in n= ( %) pt were ≥ yr old, in -n= ( %), (p= . ). in cci> was estimated in n= ( %) pt in comparison of n= ( %) in , (p= . ). in n= ( %) of cdi cases were ha, in -n= ( %), (p= . ). in n= ( %) of cdi were diagnosed in md in comparison of n= ( %) in , (p= . ). in weeks prior to cdi n= ( %) pt have been admitted to hospitals, n= ( %) have been treated w. antibiotics, n= ( %) -w. ppis, n= ( %) -w. h antagonists, n= ( %) -w. immunosupressants in comparison of n= ( %), n= ( %), n= ( %), n= ( %) and n= ( %) in , respectively, (p> . ). overall rate of cdi cases among in-hospital patients increased tenfold by yr and . in , more elderly patients had cdi and severe comorbidities were less frequent in comparison with . in , more cases of cdi were hospital-acquired and have occured in medical departments. rate of risk factors of cdi remained unchanged.these results indicate a possible relationship between ttv dna count and immunological alteration. the ttv quantitative determination could be useful as a proinflammatory marker in sepsis, with some benefits: low cost, easy determination and good correlation with immune system functionalit. it will be necessary to perform a larger study to check our hypothesis and to establish a ttv level threshold that may allow to anticípate the disease prognosis. introduction: acute kidney injury (aki) is a serious complication in sepsis and associated with high morbidity and mortality. the combination antimicrobial regimens with vancomycin (vcm) and broad-spectrum betalactams (bsbl), such as piperacillin tazobactam and cefepime, have been identified as potentially nephrotoxic combinations, but existing studies have not provided sufficient evidence. the aim of this study was to evaluate detailed association between the combination antimicrobial therapy and the risk of aki in septic patients. this investigation was a post hoc analysis of prospective nationwide cohorts enrolling consecutive adult patients with sepsis in intensive care units in japan. in this study, progression of aki was defined as one or more elevation of renal sub-score in sequential organ failure assessment score from day to day . we regarded anti-pseudomonal penicillins, fourth generation cephalosporines, and carbapenems as bsbl. multivariable logistic regression analysis including a two-way interaction term (vcm x bsbl) was performed to assess the add-on effects of each antimicrobial agent on the progression of aki. the final study cohort comprised patients with sepsis. among them, received vcm without bsbl, received bsbl without vcm, received both vcm and bsbl, and received other type of antimicrobials. the administration of vcm was associated with an increased risk of aki in patients with bsbl [odds ratio (or), . ( . - . ); p= . ]. however, the tendency was not evident in patients without bsbl [or, . ( . - . ); p= . ]. the interaction effect on the progression of aki between vcm and bsbl were statistically significant (p for interaction= . ). the regression model including two-way interaction term suggested that the combination of vcm and bsbl might synergistically increase the risk of aki in patients with sepsis. increasing resistance to carbapenems due to carbapenemase productionone of main actual problems of antibacterial resistance in burn icu. production of several types of carbapenemases (kpc, ndm and oxa- ) is common in k. pneumoniae strains. carbapemenase production is a marker of extreme antibacterial resistance. the aim of our study was to investigate the epidemiology of nosocomial infections caused by producing kpc, ndm and oxa- k. pneumonia strains in burn icu. total of patients with nosocomial infections caused by carbapenem resistance strains of k. pneumoniae were included in the study, from whom had lower respiratory tract infection, had skin and skin structure infection. initial identification of isolates was performed in laboratory by automatic microbiological analyzer. for all of k. pneumoniae isolates presence of bla ndm , bla oxa- and bla kpcgenes were examined by pcr method. baseline characteristics of patients: me (iqr) of age - ( ; ) years, me (iqr) of tbsa - ( ; ) percent, me (iqr) of icu los - ( ; ) days. inhalation injury was diagnosed in ( . %) patients. total of patients died, mortality rate was . %. all patients were diagnosed with nosocomial infection caused by k. pneumoniae. from k. pneumonia strains ( . %) were found to be producing kpc, ( . %)producing ndm and ( . %) -producing oxa . only ( . %) carbapenem resistance k. pneumoniae isolates were not producing carbapenemases. from patients infected by oxa producing k. pneumoniae patients died, mortality rate was %. from patients infected by oxa or ndm producing k. pneumoniae patients died, mortality rate was . %. from patients infected by non-carbapenemase producing k. pneumonia no one died. carbapenemase producing strains are widely spread among carbapenem resistance strains of k. pneumoniae in burn icu. mortality of patients infected by producing oxa or ndm k. pneumoniae strains reaches . %. the rationale for blood purification as adjunctive therapy during sepsis involved the capacity in removing endogenous and exogenous toxins, but currently no recommendations exists [ ] . a critical point may be the potential interaction with antimicrobial therapy, which remains the mainstay of sepsis treatment. the aim of our study was to investigate the vancomycin (van) removal during blood purification using an in vitro model of hemoperfusion (hp) with ha cartridge (jafron, zhuhai city, china), most widely used in china and actually available in europe. this is an experimental study. three independent experiments were performed: we injected mg of van in ml of whole blood from healthy donors (experiment and ) or in ml of balanced solution (experiment ) in order to assess membrane saturation. a closed-circuit (blood flow of ml/min) simulating hp ran using ha . samples were collected from arterial line at , , , , , , , , minutes; van plasma concentrations were measured and removal was evaluated using mass balance analysis. differences in mass removal was assessed using kruskal-wallis test. results: figure shows van mass at each timepoints. we observed no difference between in blood and in balanced solution experiments (p- the aim of this study is to determine if routine bbv testing in the icu contributes to the discovery of undiagnosed bbv infections. icu patients may require renal replacement therapy (rrt). sharing rrt equipment carries a risk of bbv transmission, which mainly relates to hepatitis b (hbv), hepatitis c (hcv) and hiv. since , all glasgow royal infirmary icu patients undergo routine bbv screening, with rrt machines allocated for patients with specific bbv statuses. routine bbv testing is beneficial to both the individual and society. hcv is a pertinent health issue in scotland. the scottish government aims to eliminate hcv by and is researching innovative and costeffective methods to identify undiagnosed infections. this single-centre retrospective observational study examined prospectively collected clinical data from icu admissions. proportions were compared using a two-proportion z-test and a logistic regression model was carried out to determine if deprivation quintile was independently associated with the seroprevalence of bbvs. the bbv seroprevalence in the cohort studied: . % (hbv), . % (hcv), . % (hiv). the seroprevalence of hbv in the cohort studied was similar to that of scotland (p= . ), but the seroprevalence of hcv (p< . ) and hiv (p= . ) were statistically significantly higher than that of scotland. due to the small number of reactive test results for hbv and hiv, the relationship between deprivation and bbv seroprevalence was explored for hcv only. the only independent variable associated with a reactive anti-hcv test result was "current or previous illicit drug use" (adjusted odds ratio of . ; % confidence interval of . - . ; p< . ). this study shows that routine bbv testing in the icu is useful in discovering new bbv infections. this is the first observational study focusing on the value of routine bbv testing in an icu setting to our knowledge. continuous infusion vancomycin protocol is a safe, acceptable and effective alternative to intermittent dosing of vancomycin in critical care. ceftaroline is an efficacious treatment in patients with severe cap, admitted in icu. it relates to earlier resolution of respiratory failure and less rescue antibiotics. we need an adequately pragmatic trial to confirm our findings organ dysfunction in scrub typhus, incidence and risk factor a sarkar , a guha , r dey [ , , , , ] . its preads by bite of larval stageof thromboculid mites or chigger [ ] . clinical features may include fever, headache, myalgia, lymphadenopathy, eschar, skinrash. it may also cause pneumonia, renal failure, shock, meningoencephalitis, multiple organ failure [ , ] . our study aims to discuss the incidence of organ dysfunction in a comprehensive way taking the overall population of patients with identified scrub typhus infection. there is lack of data in eastern india regarding the incidence and risk factors of developing multiorgan dysfunction syndrome (mods) in scrub typhus. in this retrospective study we studied the incidence of various organ involvement and the risk factors associated with the development of mods in scrub typhus. we collected data from december to november in tertiary care hospital at kolkata. we have included all patients who are having fever, scrub typhus igm antibody positive, age more than years. sofa score was used in evaluating patients with mods. exclusion criteria involves patient who are having coinfectional ong with scrub typhus. in a cohort (n= ), patients with multiorgan dysfunction syndrome was seen in patients ( . %), the mean age in group of patients with mods was . +/- . years (mean+/-sd). in group of patients with mods, fever duration in days was of +/- . days (mean+/-sd), interval from treatment to defervescenc in days was . +/- . days (mean +/-sd). among patients with mods, hematologic involvement was seen in patients ( . %), hepatic involvement was seen in patients ( . %), renal involvement was seen in patients ( . %), neurologic involvement was seen in patients ( %), respiratory involvement was seen in patients ( . %), cardiovascular was seen in patients ( . %), icu shifting was necessary in patients ( . %), mechanical intubation was needed in patients ( . %) in multiorgan dysfunction syndrome patients. hospital mortality in patients with mods was patients ( . %). no mortality was seen in patients without mods. other parameters were evaluated among patients with mods. they include eschar in patient ( . %), seizure in patients ( . %), hepatoslenomegaly in patients ( . %), leucopenia in patients ( . %), leucocytosis in patients ( . %), thromnbocytopenia in patients ( . %),decreased hemoglobin in patients ( . %), transaminitis in patients ( . %). the risk factors associated with the development of mods are platelet counts, bilirubin, transaminitis, glasgow coma scale, time interval from treatment to defervescence, hemoglobin, total leucocyte count and fever duration. scrub typhus is an important cause of acute febrile illness in this part of the country and is frequently associated with organ dysfunction. however, the overall mortality is low which is similar to other studies done before [ ] . score at baseline were significant (p< . ) predictors of mortality.highest area under the roc curve was obtained for number of days with septic shock ( . ) followed by increased cd between baseline and day ( . ). though serial pct levels significantly increased amongst non-survivors, it did not predict mortality. serial level of biomarkers in icu patients may predict mortality. larger trials are needed to confirm the results. plasma strem- levels were retrospectively measured at day - , - and - in septic shock patients from the immunosepsis cohort (nct ), included between / and / , using a validated elisa method. the associations between strem- , mhla-dr, -day survival status, and occurrence of icu-acquired nosocomial infection (ni) were assessed. neither strem- nor mhla-dr levels at d / were associated with the occurrence of icu-acquired ni. however, -day mortality was significantly higher in patients with d - strem- value superior to the median ( . % vs . %, p= . ; median= pg/ml). a significant inverse correlation was found between mhla-dr at d - and strem- at d - (sp - . , p< . ) and at d - (sp - . , p< . ). at d - , when stratifying patients based on strem- ( pg/ml) and mhla-dr ( ab/c), patients combining elevated strem- and low mhla-dr presented with significantly higher day mortality ( . % vs . %, p = . , chi-squared test) and ni incidence ( . vs %, p= . ) compared with patients with low strem- / high mhla-dr. this study shows for the first time that trem- pathway activation is associated with septic shock-induced immunosuppression, as shown by an inverse correlation between strem- at baseline and mhla-dr expression at d - . persisting high strem- values and low mhla-dr expression in septic shock patients are significantly associated with higher rate of icu-acquired infection and mortality. introduction: sepsis mortality remains high [ ] . the surviving sepsis campaign (ssc) recommends to guide resuscitation on normalization of lactate levels [ ] , however this is debated [ ] . we have shown that plasma levels of bio-adrenomedullin (bio-adm) were associated with patient outcome during sepsis [ ] . we therefore aimed to evaluate the added value of bio-adm to lactate measurement in the adrenoss cohort. this is a post-hoc analysis of the adrenomedullin and outcome in severe sepsis and septic shock (adrenoss) cohort study. the adre-noss study is a prospective observational study conducted in twenty-four centers and included septic patients [ ] . we studied the relationship between the association of initial evolution of lactate plasma levels and bio-adm level at h and outcome in patients for whom both markers were available at admission and one day later (" h"). bio-adm levels below pg/ml were considered as low, and high if greater than pg/ml [ ] . in patients with high lactate levels (> mmol/l) at admission (n= ), lactate normalization (< mmol/l) at h was associated with better outcome than in patients with persistently high lactate at h ( day mortality . % vs . % respectively, hr . [ . - . ], p< . ) ( figure ). among patients with decreasing lactate, high and low bio-adm levels at h identified patients with different outcomes ( day mortality % vs % for low vs high bio-adm respectively, hr . [ . - . ], p< . ). high and low bio-adm levels at h also differentiated outcome of patients with persistently elevated lactate (hr . [ . - . ], p< . ). in patients with low initial lactate, neither lactate or bio-adm had no added prognostic. our data suggest that measurement of bio-adm in addition to lactate may help physicians to refine risk stratification and therefore to guide resuscitation during sepsis. the effect of fluid replacement in sepsis, severe sepsis and septic shock in first hrs in clot quality and microstructure s pillai , g davies the inflammatory response in sepsis can lead to a spectrum of coagulation system defects [ ] . sepsis and severe sepsis is associated with a hypercoagulable state where the clot microstructure is known to be a tight and highly elastic clot, which is potentially resistant to fibrinolysis ( figure ). conversely, septic shock is associated with a hypocoagulable state where the clot microstructure is loose and structurally weak. the study aim to investigate the effect of fluid resuscitation and replacement in clot microstructure over hours. methods: patients ( sepsis, severe sepsis and septic shock) were included in the study. all these patients received standard fluid replacement therapy with crystalloids. blood samples were collected at hours, hours and hours. clot microstructure, standard markers of coagulation and inflammatory markers were measured. in sepsis group following fluid administration, the d f reduced initially and then remained stable ( . - hours, . - hours, . - hours, normal d f range . ± . ). in severe sepsis group, the d f reduced initially, then increased ( . - hours, . - hours, . - hours) and in septic shock, the df was very low to start with and there were only slight increase with fluid administration ( . - hours, . - hours, . - hours). the hypercoagulable state and clot quality in both sepsis and severe sepsis group improved with fluid resuscitation, however despite an early improvement in clot quality, ongoing fluid resuscitation resulted in markedly reduced functional clot with very low clot strength and functionality. this study demonstrates that d f as a marker of clot quality and function may have potential in fluid and component replacement in critical illness and injury. this study analyses the prognostic ability of white blood cell count (wbc), neutrophil:lymphocyte ratio (nlr) and c-reactive protein (crp). hypo-and hyperimmune responses have been associated with increased mortality from septic shock [ ] . patients with septic shock (sepsis . ) admitted to queen elizabeth hospital birmingham, between december and july were included. the primary outcome was -day mortality. data was tested for normality and presented as median (iqr) and analysed using a mann whitney u test. categorical data was presented as % and analysed using a chi-squared test. a p value of < . was used to determine significance. a multivariate binary logistic regression analysis was conducted using age, apache ii, charlson comorbidity index, performance status, and initial lactate as covariates. a hosmer lemeshow test of > . indicated good fit. results: patients were admitted with septic shock. the majority ( %) were male, with a median age of ( - ) and a -day mortality of %. on day , wbc was lower in patients who died compared to patients who survived ( [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] patients who died of septic shock had a lower wbc, nlr and crp response early on compared to survivors. this may represent early immunoparesis that allows infection to propagate unchecked. however, this was not independently associated with mortality when confounding factors were accounted for. a specific metabolite of mitochondriaitaconic acid is formed upon proinflammatory activation. the attempts of various researches to find the itaconic acid in peripherical blood of patients with sepsis were unsuccessful [ ] . some phenylcarboxylic acids (phcas) are known to be microbial metabolites and sepsis biomarkers; they also affect the mitochondrial functions [ ] . concentrations of phcas (phenyllactic, p-hydroxyphenylacetic, phydroxyphenyllactic acids) and mitochondrial metabolites (succinic, itaconic acids) in serum samples from patients on the st day of diagnosis of sepsis and serum samples from patients with late stages of sepsis (sepsis- ) were measured by gas chromatographymass spectrometry; control group - donors. results: itaconic acid was found in low concentrations ( . - . μm) only at early stage of sepsis. the multiple increase in levels of phcas and mitochondrial metabolites were detected in patients with late stage of sepsis in comparison with early stage and donors, p< . . increased succinic acid (up to - μm) concentration is the result of succinate dehydrogenase inhibition by microbial metabolism intermediates (phcas), which was confirmed by in vitro experiments in isolated mitochondria (fig. ) . itaconic acid may be a promising marker in early stage of sepsis, which needs to be proved. prediction of severe events in clinical sepsis is challenging. for such prediction we aimed to compare the novel biomarker calprotectin in plasma, with routine biomarkers. in a prospective study, blood samples were collected from consecutive patients who triggered the sepsis alert in the emergency department in our hospital. c-reactive protein (crp), procalcitonin, neutrophils, and lymphocytes were analysed according to routine practice. p-calprotectin was analysed using a specific particle enhanced turbidimetric assay (gentian diagnostics as). the composite endpoint, which was termed severe event, was defined as death or admission to the intensive care unit (icu)/high dependency unit (hdu) within hours from arrival. the study included patients with written informed consent, of whom were considered to have infection (defined as obtained blood culture and subsequent antibiotic therapy for at least days or until discharge or death), and had no infection. seventy-four patients ( %) with infection developed a severe event. mean pcalprotectin was . mg/l (standard deviation (sd) . ) among patients with infection and . mg/l (sd . ) among patients without infection (p= . ). in patients with infection mean p-calprotectin was . mg/l (sd . ) among those with and . mg/l (sd . ) among those without a severe event (p= . ). analysis of area under the receiver-operating characteristic (roc) curve for prediction of severe events showed superiority for p-calprotectin compared with procalcitonin and neutrophil-lymphocyte-ratio, both regarding all sepsis alert cases and regarding the patients with infection (p< . for all comparisons), fig . in addition, there was a trend toward superior performance compared to crp (p= . and . ). in sepsis alert patients, p-calprotectin was elevated in those who subsequently developed severe events. p-calprotectin was superior to traditional biomarkers for prediction of severe events. introduction: rapid diagnosis of acute infections and sepsis is critical in emergency departments (eds). current tests have slow turnaround times, low sensitivities, and/or signals from contaminant or commensal organisms. empirical antimicrobial treatment may result in severe adverse events and contributes to antimicrobial resistance. diagnostics to distinguish bacterial from viral infections and noninfectious etiologies support clinicians in efforts toward antimicrobial stewardship. in a prospective, non-interventional study in the eds of sites in greece (prompt study nct ), we evaluated hostdx sepsis, a host response test for suspected acute infections and suspected sepsis. hostdx sepsis measures human mrna targets and employs advanced machine learning to differentiate patients with bacterial and viral infections, and noninfectious etiologies. adult patients presenting with suspected acute infection and at least one vital sign change were enrolled. whole blood rna was quantified using nano-string ncounter. predicted probabilities of bacterial and viral infection were calculated (bvn- algorithm). patients were adjudicated in a retrospective chart review by independent infectious disease specialists blinded to hostdx sepsis results. among patients adjudicated as bacterial ( ), viral ( ), noninfected ( ), or indeterminate ( ) the area under the receiver operating characteristics (auroc) of hostdx sepsis for predicting bacterial vs. viral/non-infected patients was . , and auroc for viral vs. bacterial/non-infected patients was . (fig. ) . our results indicate that hostdx sepsis distinguishes bacterial from viral infections and other etiologies with high accuracy. hostdx sepsis is currently developed as a rapid point-of-care device with a turnaround-time of less than minutes. hostdx sepsis may therefore assist ed doctors in making appropriate treatment decisions earlier, towards the ultimate goal of antimicrobial stewardship. we studied the diagnostic value of a leukocyte deformability assay that rapidly quantifies the immune activation signatures of sepsis in an undifferentiated population of adults presenting to the ed. ed clinicians must balance the benefits of early intervention against the risks of indiscriminate use of resource-intensive interventions. there are no currently available rapid diagnostics with acceptable performance to achieve this balance. we prospectively enrolled adult patients within hours of presentation with signs of suspicion of infection in two eds in the usa. edta-anticoagulated blood was drawn and analyzed using deformability cytometry [ ] . procalcitonin (pct) levels were also measured. patients were retrospectively adjudicated for sepsis- by physician committee using the entire medical record. diagnostic performance characteristics and receiver operating curves were used to examine the diagnostic performance of the assay as well as pct. of the patients enrolled, . % were adjudicated as septic. the leukocyte deformability assay demonstrated % sensitivity, % specificity, and % negative predictive value for a single cutoff. the auc was . ( figure ). pct with a cutoff of . ng/ml had % sensitivity, % specificity, and % negative predictive value. the auc for pct (as continuous variable) was . . the leukocyte deformability assay of immune activation signatures demonstrated superior diagnostic performance for sepsis when compared to pct. the assay's diagnostic performance and rapid turnaround time of minutes may positively impact patient outcomes while minimizing indiscriminate use of valuable resources in the ed. it is already known in literature that high levels of midregional proadrenomedullin (mrproadm) are related with organ disfunction in infections despite of source and pathogens [ ] . similarly, microcirculatory impairment has been reported in sepsis. we examine the correlation between microcirculatory disfunction and mrproadm as a sign of early organ failure. we included consecutive adult patients with suspected infection, sepsis or septic shock admitted to our intensive care unit (icu) as first hospital admission with an expected icu stay of > hours. mrproadm was measured daily during the first five consecutive days and sublingual microcirculation was assessed with incident dark field (idf) technology at t , t , and t . we collected information on saps ii, apache scores, and sofa score for each timepoint. results: ten patients had septic shock, sepsis and infection. three patients died during icu stay. a mrproadm clearance of % or more between t and t was found associated with the improvement of mfi (mann-whitney u test, median increase . % versus . %, p= . ) (figure ) . a mrproadm > . nmol/l at the icu admission was associated with a worse sofa score at all the timepoint. moreover, mrproadm levels at admission was found significantly related with icu mortality (auc . [ . - ]; p= . ). mrproadm shown no relation with absolute value of mfi. the study shows a good correlation between the clearance of the biomarker and the improvement in mfi. moreover, our results support previous findings on the prognostic value of mrproadm in terms of sofa and icu-mortality. clinical performance of a rapid sepsis test on a near-patient molecular testing platform r brandon , j kirk , t yager , s cermelli , r davis , d sampson , p sillekens , i keuleers , t vanhoey immunexpress, seattle, united states; immunexpress, immunexpress, seattle, united states; biocartis nv, biocartis, mechelen, belgium critical care , (suppl ):p the purpose of this study was to clinically validate a new, rapid version of the septicyte™ assay on a near-patient testing platform (biocartis idylla™). septicyte™ lab is the first-in-class sepsis diagnostic to gain fda-clearance but has a complex workflow and a turnaround time (tat) of~ hours. the assay in idylla™ cartridge format is called septicyte™ rapid. septicyte™ lab was translated to the biocartis idylla™ near-patient testing platform and analytically validated. for this study, . ml of peripheral blood paxgene tm solution from previously collected patient samples was pipetted directly into the cartridge and inserted into the idylla™ reader. patients were part of an independent cohort (n= ) from intensive care units located in the usa and europe. septicyte™ rapid results were reported as a septiscore™ between and with higher scores representing higher probability of sepsis. assay performance determined included technician hands-on-time (hot), assay tat, failure rates, and area under roc curve based on comparison to retrospective physician diagnosis. average hot was minutes, and average tat was minutes. clinical samples could be processed immediately with septicyte™ rapid and did not require hour pre-incubation of paxgene blood, greatly improving tat. correlation of septiscore™ values between lab and rapid, based upon a subset of samples run on both platforms, was very high (r > . ). estimated roc auc performance for discriminating sepsis from non-infectious systemic inflammation (nisi/sirs) was similar to that previously reported for septicyte™ lab. this is the first demonstration of a validated, fully-integrated, rapid, reproducible, near-patient, immune-response sepsis diagnostic, providing actionable results~ hr, to differentiate sepsis from non-infectious systemic inflammation / sirs. accuracy of septicyte™ for diagnosis of sepsis across a broad range of patients r brandon , k navalkar , d sampson , r davis , t yager immunexpress, seattle, united states; immunexpress, immunexpress, seattle, united states critical care , (suppl ):p the purpose of the study was to demonstrate sepsis diagnostic performance of the biomarkers of septicyte™ in subjects other than critically ill adults, and in hospital locations other than icu. septicyte™ lab was the first immune-response sepsis diagnostic assay to gain fda-clearance (k ) and, as part of gaining this clearance, clinical validation was performed on adult patients admitted to intensive care (icu) only [ ] . we therefore performed an in silico analysis across a broad range of patients using the septicyte™ host immune response biomarkers and algorithm. peripheral blood gene expression data, including public and private datasets, were chosen based on quality, annotation, and clinical context for the intended use of septicyte™. multiple comparisons were performed within datasets to better understand the diagnostic performance in certain cohorts including healthy subjects. diagnostic performance was determined using area under curve (auc). results: table shows some characteristics of the selected datasets and patients, including number of datasets (n= ) and comparisons (n= ), number of cases (n= ) and controls (n= ) used in comparisons, patient category and hospital location. septicyte™ aucs for the three groups of adults, adult / pediatric and pediatric / neonates were . , . , and . respectively, which is similar to that previously reported ( . - . ) [ ] . these results suggest that the septicyte™ signature has diagnostic utility beyond adults suspected of sepsis and admitted to icu. this signature has now been translated to the near-patient testing platform biocartis idylla™ (as septicyte™ rapid) which promises rapid (~ hour) diagnosis of sepsis in a broad patient population following further validation. introduction: especially extracorporeal cardio pulmonary bypass (cpb) is known to induce severe inflammation. postoperative inflammation is associated with a sepsis like syndrome including endothelial barrier disruption, volume depletion and hypotension. sphingosine- -phosphate (s p) is a signaling lipid regulating permeability and vascular tone. in septic humans decreased serum-s p levels could be identified as marker for sepsis severity. we addressed three main issues: ( ) are serum-s p levels affected by cardiac surgery? ( ) are potential alterations of serum-s p levels related to changes of acute-phase proteins, s p sources or carrier? ( ) is the invasiveness of the surgery a factor that may influence serum-s p levels? methods: elective major cardiac surgery patients were prospectively enrolled in this study. serum samples were drawn pre-, post-procedure and on day and day after surgery. we analyzed s pand its potential sources: red blood cells (rbc) and platelets. we further quantified levels of other inflammatory markers and documented other clinical parameters. median serum-s p levels in all patients before the procedure were . (iqr . - . ) nmol/ml. serum-s p levels decrease after surgery, whereas all other inflammatory markers increase. serum-s p levels dropped by % in the on-pump and % in the off-pump group. changes of serum-s p levels are associated with s p sources and carriers: albumin, hdl and vwf:ag activity. patients with a full recovery of their serum-s p levels after surgery compared to their individual baseline presented with a lower sofa score (p> . ) and shorter icu stay (p< . ). serum-s p levels are disrupted by open heart surgery and levels might be negatively affected by endothelial injury or loss of s p sources. low serum-s p levels may contribute to prolonged icu stay and worse clinical status. future studies may investigate the beneficial effects of s p administration during cardiac surgery. the aim of study is to measure and correlate the expression of ncd , mhla-dr, pct (procalcitonin) and qcrp (quantitative creactive protein) to predict development of sepsis and its outcome. in this tertiary centre based longitudinal cohort study, a total patients were enrolled in whom sepsis was suspected on the basis of clinical diagnosis and supported by lab investigations. they were divided into two groups sepsis/case and non-sepsis/control. disease severity in icu was assessed by sequential organ failure score (sofa). blood samples for routine lab investigations and biomarkers were taken at the time of admission in icu before administration of first dose of antibiotics at time d /d . assessment of biomarkers was done simultaneously with tlc at d /d , d and during follow up of patients till their final outcome. there was no significant (p> . ) mean change in pct, qcrp, sofa, ncd , mhla-dr from day to day , however, mean change was higher among cases than controls.on comparison of mhla-dr between the groups across time periods, mhla-dr was significantly (p= . ) lower among septic patients than controls at both day and day . all biomarker correctly predicted cases among different percentage of patients with different sensitivity and specificity. there was no significant (p> . ) association of mortality with the study biomarkers except for pct. in our study, diagnostic value of pct in differentiating sepsis from non-sepsis was similar to ncd among all biomarkers studied. no advantage of ncd or mhla-dr was found over pct in diagnosis and correlation with disease progression and mortality. introduction: aqp is a water channel protein contributing to astrocyte and immune cells migration, blood-brain barrier maintenance and cell survival [ ] [ ] . aqp genetic variants represent biomarkers associating with outcome after traumatic brain injury and intracerebral hemorrhage [ ] [ ] . linking aqp genetic polymorphism to the course of sepsis has not been studied. methods: study cohort included icu patients diagnosed according to sepsis- consensus. aqp rs polymorphism was studied by analyzing pcr products in a % agarose gel using an aqp specific polynucleotide tetraprimer set. data were analyzed by log rank test (medcalc . . ), and odds ratios/hazard ratios were computed. statistical significance was determined by fisher test (ft) or mann-whitney test. results: of sepsis patients had the minor mutation a for snp rs located within the regulatory ' region of the aqp gene. septic shock occurred more frequently in homozygotic carriers of aqp c allele vs. patients with aa or ca genotype: or= . ( %ci: . - . ), p= . (ft). lethality in septic shock patients, n= , significantly increased compared to sepsis patients with no shock, n= ( % vs. %, p= . , ft). maximum sofa values were significantly lower in patients with minor allele a compared to cc carriers of ( . vs. . , respectively, p= . ). in post-surgery group of patients, carriers of ac or aa genotypes had significantly increased survival compared to patients with cc genotypes: chi-square= . ; hr= . ( %ci: . - . ) for lethality; p= . (figure ) . association of minor allele a of aqp snp rs with survival in sepsis patients seems secondary to linking the snp to decreased development of multiorgan failure and septic shock that contribute to mortality. validation of presepsin as a biomarker of sepsis in comparison to procalcitonin, il- and il- v chantziara , f kaminari , c sklavou , s fortis , p kogionou , s perez , a efthymiou saint savvas hospital, icu, athens, greece; saint savvas hospital, cancer immunology and immunotherapy center, athens, greece critical care , (suppl ):p sepsis is an everyday challenge for the intensivist and biomarkers are useful tools for identification and treatment of this syndrome. we sought to validate presepsin as a biomarker of sepsis in comparison to pct(procalcitonin) and interleukins (il- ,il- ). we enrolled patients, men and women average age ( . - ) years old, apache ii ( . - . ), saps ii ( . - . ), sofa ( . - ). patients were septic on admission (according to surviving sepsis campaign: international guidelines for management of sepsis and septic shock: ), had a septic episode during their hospitalization in the icu while patients never endured sepsis. we measured presepsin, procalcitonin, il- , il- during sepsis and on remission. results: all septic patients had increased values of presepsin, pct, il- and il- during sepsis with a cutoff value for presepsin pg/ml, while the values of these biomarkers were significantly decreased during remission or in comparison to non-septic patients(presepsin p = . , pct p≤ . , il- p≤ . , il- p= . . all patients who were not septic survived while among septic patients died ( % mortality). presepsin correlated significantly with pct, il- and il- (p< . ). presepsin is a valid biomarker of sepsis and correlates significantly with all the other values of pct, il- and il- . clinical sepsis phenotypes are proposed at hospital presentation. these phenotypes, biomarker profiles, and outcomes are not yet reproduced in prospective data. even less is known about the biologic mechanism the drives these distinct groups. thus, we sought to validate clinical phenotypes and to determine markers of innate immunity, coagulation, tolerance and tissue damage in a prospective cohort. we prospectively studied patients with sepsis- criteria within hours of presentation at hospitals in pennsylvania ( - ) using automated electronic alerts. using clinical variables, we predicted phenotypes (α, β, γ, δ) for each patient using euclidean distance anchored to published seneca phenotype centroids. discarded blood was analyzed in a subset (n= ) for markers of innate immunity (e.g. il- , il- ), coagulation (e.g antithrombin iii, eselectin), tolerance (e.g. ho- , igfbp ), and tissue damage (e.g. serum lactate, bicarbonate) results: among patients, α-type was present in ( %), β-type in ( %), γ-type in ( %) and δ-type in ( %, figure a ). on average, β-type was older and more comorbid (mean , sd yrs; mean elixhauser . , sd . ) with renal dysfunction (median creatinine . [iqr . - . ] mg/dl, p< . all). the δ-type had more acidosis (mean hco - . , sd . meq/l), higher serum lactate (median . [iqr . - . ] mmol/l, p < . both) and inpatient mortality ( %, figure b) . the γand δ-type had greater markers of innate immunity and abnormal coagulation (e.g il- , icam p< . both), while markers of increased tissue damage (lactate) and poor tolerance (ho- ) were present in δ-type, compared to α-type (figure c) . the distribution and characteristics of clinical sepsis phenotypes were reproduced in a prospective validation cohort. similar to the seneca study, distinct biomarker profiles of tissue damage, innate immunity and poor tolerance were present for the δ-type. the effect that neoadjuvant chemotherapy and hyperthermic intraperitoneal chemotherapy (hipec) may have in the postoperative kinetics of biomarkers remains unknow. some studies demonstrate that neoadjuvant chemotherapy and hipec do not invalidate the use of inflammatory markers in postoperative patient monitoring, but none have compared biomarkers kinetics between patients who underwent hipec or only cytoreduction surgery. our main purpose was to identify a difference pattern in c-reactive protein (crp). we conducted a single-center observational study from january to november , including all patients who underwent cytoreductive surgery with or without hipec. crp was measured daily until seven post-operative day. we compared patients with and without hipec. a total of patients were included, were female. mean age was yrs ( - ). no clinical and demographical differences were observed between groups. no documented infection was found. after surgery crp increased markedly in both groups. crp time-course from the day of surgery onwards was significantly different in hipec patients ( . ± . mg/dl vs . ± . mg/dl; p= . ). multiple comparisons between hipec and non hipec patients were performed and crp concentration was significantly different on the th and th pod (figure ). no differences were found in other biomarkers (leucocytes and platelets) neither in body temperature. after a major elective surgical insult crp levels markedly increase independently of hipec. serum crp time-course showed a higher pattern in hipec patients despite no infection detected. decreased thrombin generation potential is associated with increased thrombin generation markers in sepsis associated coagulopathy d hoppensteadt , f siddiqui , e bontekoe , r laddu , r matthew , e brailovsky , j fareed. introduction: sepsis associated coagulopathy (sac) is commonly seen in patients which leads to dysfunctional hemostasis in which uncontrolled protease generation results in the consumption of clotting factors. the purpose of this study is to determine the thrombin generation potential of baseline blood samples obtained from sac patients and demonstrate their relevance to thrombin generation markers. baseline citrated blood samples were prospectively collected from patients with sac at the university of utah clinic. citrated normal controls (n= ) were obtained from george king biomedical (overland park, ks). thrombin generation studies were carried out using a flourogenic substrate method. tat and f . were measured using elisa methods (seimens, indianapolis, in) . functional antithrombin levels were measured using a chromogenic substrate method. the peak thrombin levels and auc levels were lower in the sac patients in comparison to higher levels observed in the normal plasma ( table ). the sac group showed much longer lag time in comparison to the normal group. wide variations in the results were observed in these parameters in the sac group. the f . and tat levels in the sac group were much higher in comparison to the normal. the functional antithrombin levels were decreased in the sac group. these results validate that thrombin generation markers such as f . and tat are elevated in patients with sac. however, thrombin generation parameters are significantly decreased in this group in comparison to normal. this may be due to the consumption of prothrombin due to the activation of the coagulation system. thus, persistent thrombin generation with simultaneous consumption of clotting factors such as prothrombin contributes to the consumption coagulopathy observed in sepsis patients. introduction: procalcitonin (pct) is used in the icu as an inflammatory marker to monitor bacterial infections and guide antibiotic therapy. whether pct can predict bacteremia and therefore could prevent expenses attached to bloodcultures is unknown . we investigated whether pct can predict the outcome of blood cultures in the icu and reduce expences. a single centre observational cohort study was performed in a dutch community teaching hospital . adult patients who were staying in the icu and were suspected of bacteremia were included. simultaneously with drawing of blood cultures, samples for pct measurement were obtained. expenses for pct measurement and bloodcultures were calculated. in the study period of one year, a total of patients were included. three patients were excluded because of incomplete data. out of the included patients, ten patients had positive blood cultures. there was a significant difference in pct levels between patients who had positive bloodcultures versus patients with negative bloodcultures ( . ng/ml vs . ng/ml) ( figure ). the negative predictive value for negative blood cultures is % when pct is below ng/ml, there was no difference in crp levels between the two groups ( mg/l vs mg/l, p= . ).a set of negative blood cultures in our centre costs euros. positive blood cultures however costs significantly more depending on the micro-organisms found. pct only costs . euros per measurement. so when blood cultures are omitted when the pct level is below ng/ml, a cost reduction of % can be achieved. a pct value below ng/ml is a good predictor of a negative blood cultures in icu patients suspected of bacteremia. pct guided bloodculture management in these patients could lead to a significant cost reduction introduction: level of cfdna in plasma is a promising prognostic candidate biomarker in critical illness [ ] . oxidized cfdna (ocfdna) have not been studied as a biomarker although its functional role in cellular stress have attracted attention of researches [ ] . the goal of our study was to assess the early prognostic value of plasma cfdna/ocfdna for sepsis in a nicu setting. the cohort included nicu patients diagnosed with stroke, intracerebral hemorrhage (ich), anoxia, encephalopathy. cfdna was isolated from day plasma and stained with picogreen. oxidized dna was determined using dna immunoblotting with anti- -oxo-desoxiguanosine antibodies. genotyping of allelic variants of the tlr rs gene was performed using a pcr and designed allele-specific tetraprimers followed by electrophoretic separation of the products statistics was performed by the fisher test and mann-whitney test. results: sepsis was diagnosed by sepsis- criteria in patients ( . %). average nisu staying was , ± , days. circulating dna plasma levels on day predicted the future sepsis development (figure ): or for cfdna was . ( %ci: . - . ), p< . ; or for ocfdna was . ( %ci: . - . ), p= . . power of both performed tests with alpha= . : . . log rank test demonstrated better predictive value of cfdna vs. ocfdna (figure) . concentrations of cfdna, but not ocfdna, on day significantly positively correlated with maximum sofa values during hospitalization, day and pre-outcome leukocyte count and neutrophil-to-lymphocyte ratios in a limited cohort of nisu patients with tlr rs cc genotype and not in other patients with genotype tlr ct+tt. increased level of plasma cfdna better then ocfdna predicts sepsis development in nisu. further studies are warranted to clarify the fig. (abstract p ) . pct values in patients with positive blood cultures and patients with negative blood cultures possible utility of tlr rs polymorphism determining for sepsis risk stratification early on nisu admittance. admission was related with higher severity of illness and extension of icu stay for all groups. reduced cbt fluctuations upon icu admission was found to more severely ill patients with worse clinical outcomes, while the more periodic cbt patterns were correlated with high cbt rhythmicity and better outcome. the impact of sex on sepsis incidence and mortality have been elucidated in previous studies, and sex is increasingly recognized as one key factor in sepsis [ ] . some studies indicate that women have better immunologic responses to infections [ ] . later investigations assume this advantage is linked to immune modulating genes located on the x-chromosome [ ] . the purpose of this study is to reveal sex differences in incidence of and mortality of sepsis in a large population-based cohort. methods: adult participants in the hunt study ( - ) were followed from inclusion through end of . incident bloodstream infections (bsi) from all local and regional hospitals in nord-trøndelag county were identified through linkage with the mid-norway sepsis register, which includes prospectively registered information on bsi used as a specific indicator of sepsis. we estimated age-adjusted cumulative incidence of first-time bsi and compared the risk of a first-time bsi and bsi mortality in men and women using age-adjusted cox proportional hazard regression. during a median follow-up of . years individuals experienced at least one episode of bsi, and died within days after a bsi. cumulative incidence and cumulative mortality curves are shown in fig. a introduction:the proportion of hospital-acquired infections (hai) among sepsis patients is unknown in germany. systematic differences in hai foci between sepsis patients with and without icu treatment are insufficiently described. retrospective cohort study based on nationwide health claims data of the german statutory health insurance aok. incident inpatient sepsis cases were identified in / among insured persons > y without preceding sepsis in months prior to index hospitalization. sepsis was defined according to explicit sepsis icd- -codes (incl. severe sepsis/septic shock). hai were defined based on specific icd- -codes for surgical site infection, catheter- introduction: elevated renin is associated with an increased risk of death in patients with vasodilatory shock (vs). recent data show that patients with vs and elevated renin levels have improved survival when treated with angiotensin ii (ang ii) + standard care (sc) vs placebo + sc. patients with acute respiratory distress syndrome (ards) can develop angiotensin-converting enzyme (ace) defects that can lead to elevated renin levels and insufficient endogenous ang ii production. we hypothesized that patients with severe ards and elevated renin shock would have improved survival when treated with ang ii + sc vs placebo + sc. in the randomized, placebo-controlled, double-blind athos- study, patients with severe vs receiving > . μg/kg/min of norepinephrine or the equivalent were randomized to intravenous ang ii (n= ) or placebo (n= ). in a post hoc analysis, we assessed the subset of patients with elevated renin (defined as a renin level greater than the median value of the overall athos- population) and ards (defined by a pao /fio ratio < ) at the time of randomization. survival to days was compared between the ang ii group (n= ) and the placebo group (n= ). in patients with elevated renin and ards, baseline age, acute physiology and chronic health evaluation ii score, and blood pressure were similar in the ang ii and placebo groups. the median serum renin level was . pg/ml (iqr: . - . ) compared to the normal range for serum renin: - pg/ml. a significantly higher proportion of patients receiving ang ii survived to day compared to those in the placebo group ( % vs %; p= . ). elevated renin identified patients with vs and ards who were most likely to gain a survival benefit from ang ii. elevated renin is likely caused by an ace defect and may describe an important subset of patients with a biotype that responds well to ang ii therapy. introduction: elevated renin levels have been shown to be associated with an increased risk of death and more severe acute kidney injury (aki) in patients with vasodilatory shock (vs). recent data show that patients with vs and elevated renin levels have improved survival when treated with angiotensin ii (ang ii) + standard care (sc) vs placebo (pbo) + sc. we hypothesized that vs patients with severe aki and elevated renin levels would have improved survival and enhanced renal recovery with ang ii treatment. in the randomized, pbo-controlled, double-blind athos- study, patients with severe vs received > . μg/kg/min of norepinephrine or the equivalent and were randomized to intravenous ang ii + sc (n= ) or pbo + sc (n= ). in a post hoc analysis, we assessed the subset of patients with elevated renin (defined as a renin level greater than the median value of the overall athos- population) and severe aki (defined as those with aki requiring renal replacement therapy [rrt] at baseline). survival and renal recovery were assessed in patients treated with ang ii + sc (n= ) and pbo + sc (n= ). in patients with elevated renin and severe aki, baseline age, acute physiology and chronic health evaluation ii score, and blood pressure were similar between ang ii + sc vs pbo + sc. the median baseline serum renin level in the whole group was . pg/ml (iqr: . - . ; normal range for serum renin: - pg/ml). a significantly higher proportion of patients receiving ang ii + sc vs pbo + sc survived to day ( % vs %, respectively; p= . ). ang ii recipients also had a higher rate of discontinuation from rrt by day ( % vs %; p= . ). in this study, elevated-renin shock patients with aki treated with ang ii + sc gained a survival benefit and earlier discontinuation from rrt compared to those receiving pbo + sc. elevated renin is likely caused by an angiotensin-converting enzyme defect and may identify those patients with a biotype that responds well to ang ii therapy. most clinical trials conclude the ineffective use of anticoagulation for sepsis-induced coagulopathy [ ] . however, post hoc analyses of randomized control trials report positive results [ ] , suggesting anticoagulation is effective in specific populations exhibiting coagulopathy. further, anticoagulants should be administered in the early phase [ ] ; however, methods for precisely predicting the progression of sepsis-induced coagulopathy are not established. this study aimed to create and evaluate a prediction model of coagulopathy progression using machine-learning techniques. we performed a subgroup analysis of data from a retrospective cohort study involving adult septic patients in japanese institutions from january to december and used the japanese association for acute medicine disseminated intravascular coagulation (dic) score as a dic severity index test. the predictive ability of Δdic ([dic score on day ] -[dic score on day ]) was evaluated using various statistical methods. using variables available at the outset, we compared the predictive ability of random forest (rf) and support vector machine (svm) with that of multiple linear regression analysis. a total of adults with sepsis were included in the analysis. the root mean square error in Δdic score for the multiple linear regression analysis model was . compared with values of . and . for rf and svm, respectively. thus, the rf method predicted the progression of sepsis-induced coagulopathy more accurately than multiple linear regression analysis. conclusions: rf, a machine-learning technique, was superior to multiple linear regression analysis in predicting the progression of sepsis-induced coagulopathy. this prediction model might enable us to use anticoagulation in an early phase. this study examined the efficacy and safety of landiolol, an ultrashort-acting β -blocker, for treating sepsis-related tachyarrhythmia, according to patient background characteristics. the j-land s study (japiccti- ) was conducted in patients with sepsis, diagnosed according to the sepsis- criteria, and tachyarrhythmia (atrial fibrillation, atrial flutter, or sinus tachyarrhythmia). the patients had a mean heart rate of ≥ beats/min and required catecholamine administration to maintain a mean blood pressure of ≥ mmhg. the efficacy endpoint was the percentage of patients whose heart rate could be controlled within - beats/min at h of registration. the safety endpoint was the incidence of adverse events within h of registration. subgroup analyses of efficacy and safety were performed after stratifying the patients according to various patient background characteristics. a total of patients were randomized, to landiolol and to the control group. the efficacy endpoint, percentage of patients with a heart rate of - beats/min at h of registration, was significantly higher in the landiolol group ( . % vs . %; mantel-haenszel test: p = . ). the incidence of adverse events was . % and . % in the landiolol and control groups, respectively, and there was no difference between the two groups. most adverse events were related to sepsis or septic shock. the subgroup analyses showed that no patient background characteristic clearly affected the efficacy and safety of landiolol. landiolol is a well tolerated and effective therapeutic agent for controlling heart rate in patients with sepsis-related tachyarrhythmias; its safety and efficacy were not affected by the patient background characteristics investigated. tissue oxygenation monitoring in sepsis r marinova, at temelkov umhat alexandrovska, anesthesiology and intensive care, sofia, bulgaria critical care , (suppl ):p near-infrared spectroscopy (nirs) was proposed as a concept in the end of th century. this method offers noninvasive monitoring of oxy-and deoxyhemoglobin in tissues.nirs could be measured on the thenar or forehead within few santimeters of the skin. it was first applied as a monitoring in cardiovascular surgery. patients with sepsis have changes in the microcirculation which are important target for therapy. invasive monitoring of oxygen delivery and consumption has been used in patients with sepsis but as every invasive technique such a monitoring hides risks. nirs offers a noninvasive method for tissue oxygenation monitoring (sto ) and could be useful in patients with sepsis and septic shock. the aim of the study is to compare noninvasive tissue oxygenation monitoring with hemodinamic monitoring and lactate values in patients with sepsis methods:the study includes critically ill patients in icu of umhat alexandrovska, sofia. of the patients fullfil the criteria for septic state. the other patients do not have sepsis. in both group of patients are measured tissue oxygenation with invios monitor, mean arterial pressure, oxygen saturation in mixed venous blood and lactate values during h after icu admission. patients with sepsis are reported with significantly lower values of tissue oxygenation, compared to patients without sepsis. the values of tissue oxygenation correlate well with the mixed venous blood oxygenation, mean arterial pressure and lactate values but not significantly with apache scores. conclusions: nirs when used for tissue oxygenation monitoring correlates well with the hemodinamic monitoring and lacate values in patients with sepsis and could be used as an noninvasive monitoring for guiding teurapeutic strategies. tissue oxygenation monitoring has no linear correlation with the severity of illness in patients with sepsis and could not be reccomended as a guidance in the early ressuscitating stage of sepsis. further investiganions in these field are needed.the sequenom´s massarray platform and a recessive inheritance model was selected (cc vs tt/ct). the possible association between the cc recessive form of the rs polymorphism and the septic shock risk was analyzed, demonstrating a statistically significant relationship (p= . ) between both conditions. among patients who developed septic shock, . % presented a recessive inheritance pattern while . % showed the ct/tt genotype. on the other hand, those patients with the recessive form of the rs polymorphism were selected and a statistical analysis was performed comparing those patients who developed septic shock from those who did not develop it, obtaining a statistically significant relationship (p= . ) between the presence of the recessive form of polymorphism and the likelihood of developing septic shock. the recessive form of rs polymorphism is a risk factor for septic shock in post-operative patients of major abdominal surgery. introduction: sepsis remains one of the major causes of morbidity with mortality rates as high as % worldwide, representing significant clinical challenge to confront highly intangible therapeutic needs. rnabased structures are emerging as versatile tools encompassing a variety of functions capable to bypass the current protein-and cellbased therapies. rna aptamers act as disease-associated protein antagonists. here, the effects of an aptamer, apta- , were evaluated in animal models that mimic systemic inflammation in humans. high dose of lps endotoxin was used to induce systemic inflammation in mice and in non-human primate animal models. apta- was administered intravenously in two doses post lps infection. animals were monitored and blood samples collected up to hours after apta- administration. healthy-and lps-only treated animals served as control groups. complex analyses of clinical parameters, hematology, serum biochemistry, inflammation and tissue damage markers were performed. results: apta- increased survival of endotoxin challenged animals up to % in a dose-dependent manner and exerted profound effects on wellbeing and recovery of healthy eating habits. administration of apta- led to delayed coagulation and enhanced fibrinolysis; maintained the complement cascade activated while preventing it from further amplification. expression of pro-inflammatory cytokines was reduced while anti-inflammatory increased. endogenous pro-inflammatory molecules (damps), secreted from injured cells, were preserved at healthy level in animals treated with apta- . systemic inflammation and sepsis lead to severe dysregulation of several arms/axis of innate immune response. our studies showed that apta- affects various components of this system and restores the organism's control over its dysregulated immune response. thus, apta- might be a promising potential therapeutic candidate to treat life-threatening conditions such sepsis. several preclinical studies demonstrated beneficial effects for methane (ch ) administration in various inflammatory conditions. our aim was to investigate the consequences of post-treatment with inhaled ch in a clinically relevant intra-abdominal sepsis model. anesthetized minipigs were subjected to fecal peritonitis ( . g/kg, - x cfu i.p.; n= ) or sham-operation (sterile saline i.p; n= ). invasive hemodynamic monitoring with blood gas analyses was started between - hours, organ dysfunction parameters (pao /fio ratio; mean arterial pressure; lactate, bilirubin, creatinine; urine output and platelet counts) were determined according to a modified porcinespecific sequential organ failure assessment (ps-sofa) score system, the perfusion rate (pr) of sublingual microcirculation was measured by incident dark field illumination imaging. the animals were divided into non-treated septic or septic shock groups (n= - ) and ch treated septic or septic shock (n= - ) subgroups, ch inhalation started from the th hr ( . % ch in normoxic air; ml/min). despite the standardized induction, heterogeneous severity of organ damage was evolved. in septic and septic shock groups the median values of ps-sofa score reached ( . - . ) and ( . - ), respectively. septic shock was characterized by significant elevations of creatinine and bilirubin levels, while the platelet count decreased (from to * /l). inhalation of ch increased the sublingual pr by % in the septic group, the creatinine and bilirubin levels were decreased by % and %, respectively. ch post-treatment significantly decreased the ps-sofa score (to ; . - . ) and resulted in lower values in septic shock group (to ; . - . ). methane post-treatment effectively influences sepsis-related end organ dysfunction. up to a severity threshold it may be a promising additional organ protective tool. evaluation of sepsis awareness among various groups in turkey: a survey study s erel, o ermis, Ö nadastepe, l karabıyık gazi university school of medicine, anesthesiology and intensive care, ankara, turkey critical care , (suppl ):p introduction: sepsis is a common life-threatening condition in critically ill patients [ ] . public awareness is important for early recognition of sepsis and improvement of outcomes [ ] . we aimed to evaluate sepsis awareness among different groups of people. methods: prospective paper-based surveys were issued between st july and st august to patients, the relatives of the patiens, hospital staff and general public who gave consent to participate in the study. the questionnaire included ten questions about demographic informations, occupational informations of hospital stuff and sepsis awareness. a total of participated in the survey. of these participants, ( . %) were patients, ( . %) were relatives of patients, ( . %) were physicians, ( . %) were medical students, ( . %) were nurses, ( . %) were other hospital stuff and (% . ) were other people. of these participants, ( . %) had heard of the word "sepsis". ( . %) responded correctly regarding the definition of sepsis. ( . %) of the participants heard the word "sepsis" during their education, but only ( %) heard it through the media. in the groups of high school graduates, university graduates and postgraduates, the rate of hearing the word sepsis and correctly identifying sepsis is significantly higher than the primary school graduates or illiterate groups. (p< . ). physicians, nurses and medical students were heard of the word "sepsis" significantly more than other groups (p< . ). physicians and medical students responded more accurately to the definition of sepsis than other groups (p< . ). public awareness of sepsis is limited compared to healthcare workers. increasing public knowledge of sepsis through education and through media may contribute to raising public awareness and improving outcomes. the association between clinical phenotype cohesiveness and sepsis transitions after presentation jn kennedy , eb brant , km demerle , ch chang , s wang , dc angus , cw seymour key: cord- - luzvzsu authors: guo, hainan; zhao, yang; niu, tie; tsui, kwok-leung title: hong kong hospital authority resource efficiency evaluation: via a novel dea-malmquist model and tobit regression model date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: luzvzsu the hospital authority (ha) is a statutory body managing all the public hospitals and institutes in hong kong (hk). in recent decades, hong kong hospital authority (hkha) has been making efforts to improve the healthcare services, but there still exist some problems like unfair resource allocation and poor management, as reported by the hong kong medical legislative committee. one critical consequence of these problems is low healthcare efficiency of hospitals, leading to low satisfaction among patients. moreover, hkha also suffers from the conflict between limited resource and growing demand. an effective evaluation of ha is important for resource planning and healthcare decision making. in this paper, we propose a two-phase method to evaluate ha efficiency for reducing healthcare expenditure and improving healthcare service. specifically, in phase i, we measure the hkha efficiency changes from to by applying a novel dea-malmquist index with undesirable factors. in phase ii, we further explore the impact of some exogenous factors (e.g., population density) on hkha efficiency by tobit regression model. empirical results show that there are significant differences between the efficiencies of different hospitals and clusters. in particular, it is found that the public hospital serving in a richer district has a relatively lower efficiency. to a certain extent, this reflects the socioeconomic reality in hk that people with better economic condition prefers receiving higher quality service from the private hospitals. the hospital authority (ha) is a statutory body established under the hospital authority ordinance in , which manages all the public hospitals and institutes in hong kong (hk). the strategic priorities of hong kong hospital authority (hkha) are to (i) allay staff shortage and high turnover; (ii) better manage growing service demand; (iii) ensure service quality and safety; (iv) enhance partnership with patients and community; (v) ensure adequate resources to meet the service demand; and (vi) enhance the corporate governance. hkha has built a world-class public healthcare infrastructure that handles around % of secondary and tertiary medical needs in hk. although hkha has been providing excellent and affordable public healthcare to citizens, it suffers from some problems like long waiting time and low service quality. in order to overcome these limitations, it is important for ha policy makers to evaluate the healthcare efficiency of hospitals, locate the bottlenecks within public healthcare service system, and establish countermeasures accordingly [ , ] . efficiency measurement is an effective way to evaluate the performance of target configuration in healthcare. since the goals of healthcare services are always multiple, conflicting, intangible, and complex, it is difficult and intractable to set up an overall measurement of performance. regarding the multiple inputs and outputs, data envelopment analysis (dea) has been recognized as an effective nonparametric model to assess the relative efficiencies of a set of decision-making units (dmus) [ ] . particularly, in recent decades, dea has been widely applied to improve the productivity of healthcare-related fields in many countries [ ] [ ] [ ] [ ] , such as the united states [ ] , japan [ ] , china [ ] and india [ ] . as discussed in [ ] , dea is more suitable for managerial decision-making, which makes it the best choice to evaluate the efficiencies of hkha hospitals. in dea model, efficiency score is closely related to the quantities of inputs and outputs. an ideal scenario with the highest efficiency is producing the most outputs (e.g. the number of treated patients) using the least inputs (e.g. healthcare expenditure); and such inputs and outputs are called desirable factors. however, the maximum quantities of desirable outputs are usually bounded, given the limited desirable inputs. the reception of the patients beyond the hospital capacity will generate a congestion problem, even resulting in some unexpected mortality. a high patient mortality rate not only reflects a poor medical quality, but also may cause a dispute. thus, the mortality rate of patient, as an undesirable output, is expected to be lower. the measurement of hospital efficiency might be biased if the undesirable factors are ignored. in order to integrate undesirable factors into modeling, one straightforward idea is applying inversion transformation on the value of undesirable factors [ ] . however, the transformed values are usually negative, making it difficult for dea modeling. to circumvent this difficulty, one solution is adding a constant to the transformed undesirable factors to keep them positive [ ] [ ] [ ] . however, the determination of this constant has a significant impact on dmu ranking and classification. another widely used transformation is the reciprocal transformation [ ] [ ] [ ] , but the computation complexity of this nonlinear transformation is much higher. färe and grosskopf [ , ] propose an alternative approach which handles the undesirable factors by using a directional distance function. however, the form of direction vector could affect the dmu ranking. thus, it is a critical issue to design an appropriate transformation function. in some cases, an improper transformation may generate the inverse result as it is expected. to avoid the transformation problem and preserve the original data, liu and sharp [ ] treat the undesirable inputs as desirable outputs and vice versa, based on the physical relationship between the input and output. it has been proved as an effective approach which considers computing the operational efficiency by maximizing the undesirable inputs and desirable outputs and minimizing the desirable inputs and undesirable outputs, simultaneously. this idea is further extended by [ ] , where a unified model with several different dea approaches dealing with undesirable inputs or outputs is proposed. besides, it is suggested that the weighted additive model [ ] can be applied to handle the problem with undesirable inputs or outputs. in [ ] , a slacks-based measure (sbm) is proposed, in which the unit invariant, monotone, and reference-set dependent properties are analyzed in details. the proposed sbm model outperforms ccr, bcc and russell model in efficiency evaluation, where both the slacks for the input and the output are calculated. in [ ] , a more generalized slacksbased dea model with undesirable factors considering preference is proposed, which combines the advantages of all the factors stated above and makes several dea models unified. the proposed method also outperforms some state-of-the-art dea models on different databases of real applications. in this paper, we focus on evaluating the healthcare efficiency of hkha from to by applying the malmquist index [ ] based on the updated dea model developed by [ ] . the malmquist index can be well applied to track the specific position corresponding to each hospital and to examine changes in productivity and quality [ ] [ ] [ ] [ ] . the empirical results reveal that the ha hospitals with low efficiencies may be caused by unfair resource allocation and inefficient resource utilization. additionally, in the context of healthcare measurement, we have found only sparse literature considering the exogenous factors [ , ] , as they are usually beyond the managers' control. for example, population density and median monthly income could not be reduced in the same way as the healthcare expenditures. in this study, we apply the tobit regression model to explore the impact of these exogenous factors. the experimental results reflect an interesting phenomenon that the ha hospitals serving in the richer clusters have the comparatively lower efficiency values in hk, since people with higher income prefer to accepting treatment from the private hospitals due to the better service quality. dea has been recognized as an effective nonparametric model to assess the relative efficiencies of a set of dmus which consume multiple inputs to produce multiple outputs [ ] . dea models evaluate the relative efficiency of dmus by creating a production frontier using the best practice of observed data. a dmu is to be rated as fully efficient on the basis of available evidence if and only if the performances of other dmus does not show that some of its inputs or outputs can be improved without worsening some of its other inputs or outputs. after more than thirty-five years of development, research related to dea is still growing at a very fast rate. liu et al. [ ] has summarized that during the period to , around , more dea-related papers have been published, in addition to the existing , collections before as reported by liu et al. [ ] . in this section, we first introduce a novel generalized and slacks-based non-oriented dea model, and then, combine it with the malmquist index. gsbup (generalized slacks-based dea model with undesirable factors considering preference) [ ] is a non-oriented dea model, in which the undesirable inputs are regarded as the desirable outputs and vice versa, according to the physical relationship between them [ ] . the preferences of different factors for dmus are integrated into the model in terms of the multiplicative weights. the combination of both orientations is proposed to avoid dealing with different results calculated in an input-oriented or an output-oriented manner under variable return scale environment. assume that there are n dmus to be evaluated, and each dmu j (j = , , . . ., n) is assumed to consume m desirable inputs x d ij ði ¼ ( ) can be transformed into equalities by introducing the slacks as follows: thus, eq ( ) can be transformed as below: where "Á" denotes the element-wise multiplication between vectors, . . . ; g q Þ r q þ , and θ ¼ À θ ¼ ðy ; y ; . . . ; y k Þ r k þ . in order to take di, do, ui, and uo into account simultaneously, and to integrate efficiency and slacks into a scalar measure, the gsbup model is developed by applying the transformation approach mentioned above: where ω i , μ r , σ l , and ν h ( i, r, l, h) denote the preferences of di, do, ui, and uo, respectively, the decision variables are α i , β r , γ l , and θ h ( i, r, l, h), which also contain the slacks of all the factors. in order to evaluate the relative efficiency of dmu ¼ ðx d ; y g ; x i ; y b Þ, we solve the above [gsbup] model. this process is repeated times for = ( , , . . ., n). once gsbup identifies the efficient frontier, it can improve the performance of inefficient dmus by either increasing the current do (or ui) levels or decreasing the current di (or uo) levels. thus, the objective of [gsbup] is to minimize the ratio of the weighted efficiency summation of the dis and uos to that of the dos and uis. the details of the linear programming (lp) problem of gsbup is given in appendix a we use two definitions and one theorem to further illustrate the properties of gsbup. theorem . though dmu is gsbup-inefficient, its projecteddmu is gsbup-efficient relative to the original set of n dmus. proof. see appendix b. dea-based malmquist productivity index, developed by [ ] , provides an evaluation of productivity change over time. to describe the gsbup-based malmquist productivity method, let ðx d;t , y g;t ; x i;t ; y b;t Þ denote the input and output levels for a dmu j at any given point in time t. from time t to t + , dmu 's technical efficiency and empirical production frontier may change. the calculation of malmquist index requires two single period and two mixed period evaluations according to gsbup-dea model ( ), shown as follows: Þ to the frontier at time t + , i.e., calculating Þ to the frontier at time t, i.e., calculating then, the malmquist productivity index is defined as follows (the calculation of each period is shown in appendix c): where m measures the productivity change between periods t and t + . productivity declines if m > , remains the same if m = and improves if m < . the m can be divided into two components, the change of technical efficiency (tec) and the movement of the frontier (fs) in terms of a specific dmu : similarly, tec > , tec = and tec < indicates that technical efficiency declines, remains unchanged and improves, respectively. and the value of fs > indicates regress in the frontier technology; while fs < means progress in the frontier technology; naturally, fs = indicates no shift in the frontier technology. in this section, we first analyze the hkha data, and then discuss the measurement results of hospital efficiency in hk from to by applying malmquist index based on gsbup-dea. it is expected that the results are helpful for hkha policy makers to control healthcare costs and improve healthcare efficiency while ensuing the service quality requirements. to ensure patients in hk receive a continuum of high quality healthcare within the same area, table lists the specific hospitals in each cluster, which are also the dmus evaluated in this study. note that the evaluation of dea performance highly depends on the selection of factors because the discriminatory power may be reduced when the dimensionality of the production space increases [ ] . in this study, by reviewing the relevant literature, consulting with hk healthcare professionals and considering data availability and the parametric restrictions, two dis (i.e., the number of full-time equivalent staff and the number of beds), one ui (i.e., inpatient discharge rate), dos (i.e., total patient length of stay, total ed attendances and total outpatient attendances), and one uo (i.e., crude mortality rate) are selected for each dmu, as listed in table . all the data are collected from the hospital authority statistical report [ ] . as can be observed in table , regarding the inputs of medical resources, there is a continuous increase of investment in both human resources and bed among hospitals. however, it is worth noting that except for the dis, all the other factors (e.g., the utilization of bed, total patient attendances, and mortality rate) reach the peak values in , especially the mortality rate, which is due to the outbreak of severe acute respiratory syndrome (sars) [ ] . in addition, the surge of patient attendances in is mainly caused by the winter influenza season and avian influenza (h n ). table shows the curde mortality rate of each ha hospital from to . the crude mortality rate refers to the standardized hospital death rate covering inpatient and day patient deaths in ha hospitals during a year. the standardized death rate, as a standard statistical measure for temporal comparison, is calculated by applying the ha age-specific hospital death rate in the target year to the "standard" population in mid- . we observe that the pok oi hospital, ruttonjee hospital & tang shiu kin hospital, caritas medical centre, north district hospital and yan chai hospital rank top regarding the value of crude mortality rate. the high crude mortality rates can be due to the facts that: (i) pok oi hospital provides the elderly care for the people whose health condition and dependency level are beyond the coping we use the data in as an example to illustrate the statistical characteristics of the specific input-output factors. it is observed in table that the median value of each factor is significantly different from the average value. furthermore, the standard deviation values are large and the maximum can be times larger than the minimum, indicating that the resource utilization levels and resource allocation of the clusters are seriously unbalanced. thus, the analysis of hkha hospital efficiency and the exploration of the influencing factors are of crucial importance for the policy makers. the correlation coefficients between all the input-output factors are given in table . it is observed that there ia a significantly positive correlation between the dis and dos, satisfying the "isotonicity" production process that dos do not decrease by increasing the dis. crucially, the mortality rate of patients has a significantly positive relationship with the dos, which suggests that an increase in patient attendances is accompanied by an increase in patients' death rate. in addition, the mortality rate of patients has a negative correlation with the amount of medical resources, which suggests that properly increasing the medical resources can relieve a poor service quality in a certain degree caused by resource limitation; while too many resources can increase the fiscal burden of government. thus, it is a trade-off problem that how to determine the resource allocation. evaluation of gsbup-dea model. we evaluate the resource efficiency of hkha in each year by applying the lp of gsbup-dea model ( ) . the efficiency scores for all the hospitals during - are listed in table . according to definition , the efficient dmus' d à table that there are only % hospitals have higher efficiency values than the average, . , which reveals the fact that there exists unfair resource allocation, inefficient resource utilization and poor management in hkha. for example, pok oi hospital has relatively lower efficiency in the earlier years, because it had no ed service before . queen mary hospital is regarded as one of the best hospitals in hk, but it faces the over-investment problem which lowers the efficiency value. returns to scale (rts) is the variation or change in productivity which describes the outcome from a proportionate increase of all the inputs. in dea, an increasing return to scale (irs) occurs when the output increases by a larger proportion than the inputs. conversely, a decreasing return to scale (drs) occurs when the proportion of output is less than the desired increased input during the production process. in table , the last column displays the ha hospitals' rts in . it reveals that if hkha policy makers can properly increase the input of medical resources for the inefficient hospitals with irs (i.e., tung wah eastern hospital and pok oi hospital), these hospitals will achieve a higher service level than they expected. notably, if hkha policy makers continue to increase the hospital scale for the inefficient hospitals with drs (i.e., queen mary hospital and prince of wales hospital), it will be an uneconomic production process and even introduces unnecessary fiscal burden to the government. we take the year as an example, table shows the specific input-output factors, efficiency values and rts status of each cluster. we find that kwc receives the most patient attendances; while kec receives the least ones. in practice, hkha allocates the medical resources for each cluster based on the patient attendances. thus, hkha should allocate the most medical resources for kwc and the least medical resources for kec. however, this kind of method ignores the effect of medical case complexity of the patients. in fact, it is more reasonable to consider allocating the resources based on the complexity of the medical cases than purely on the patients' amount. in addition, the last column of table declares that the rts status of kwc is drs, indicating that the hkha should reduce its medical resource inputs. table displays the slacks of each cluster measured by gsbup, which is able to further validate the idea mentioned above. it is observed that the s d− of hkec and hkwc with irs is almost equal to zero; while their s g+ are not null, which means that the inefficient clusters with irs are mainly caused by the inefficient resource utilization. on the other hand, the inefficient hospitals with drs are mainly caused by the unfair resource allocation. this phenomenon can guide the hkha policy makers to better control healthcare costs and improve healthcare efficiency under the service quality requirements. considering all the slacks, the updated clusters' efficiency scores based on gsbup-lp model can be calculated, as shown in the last column of table . the efficiency values of the comparison are displayed in fig . it is observed that all the clusters' efficiencies are improved significantly, which further demonstrates that it is necessary to change the ideas for the medical investment standard. evaluation of malmquist productivity change index. table reports hkha hospitals' productivity change during the period - . we observe that from to , all the productivities of hospitals have made significant improvement. there are two major reasons: (i) sars outbreak and (ii) health services fees' reformation. the first diagnosed patient with sars was on february and the disease had widely spread in hk within just two weeks. the peak of the epidemic started from march , and there was a rapid influx of infected residents in ha hospitals, particularly the united christian hospital which was soon overwhelmed. therefore, its productivity improves by . %, particularly, the tec and fs improve by . % and . %, respectively (see table ). on march , the government and ha decided to designate the princess margret hospital, due to its specialty in treating infectious disease, to receive sars patients after diverting all its existing patients to other hospitals. thus, its fs only improves by . %. however, since the government intensified a strong technical support to the princess margret hospital for resisting sars, its tec improves by . % during - (see table ). besides, the speed of the patient flow increase was unexpected. the additional manpower from other hospitals was deployed to princess margret hospital for help, which is to reduce the medical resources input equivalently for the other hospitals. with the contribution from other hospitals to share the workload, the designation of princess margret hospital officially ended on april . furthermore, with the assistance of the necessary operational and information technology systems, a revised public hospital fees structure was implemented at the beginning of together with an enhanced waiver mechanism to better provide the available public resources to those in need. along with the soaring sars attendances, there is improvement in tec for almost all the hospitals. not surprisingly, the hkha hospital productivity regresses from to , since sars has been gradually defeated during this period, and the patient attendances decrease a lot. in the periods, - and - , the hkha average productivity has generally increased except st. john hospital, tung wah eastern hospital and north district hospital, which are not the core and mainstream hospitals in hk. in particular, the st. john hospital provides health services for the citizens living on the cheung chau island, which is a geographically isolated place. tung wah eastern hospital and north district hospital were once voted as the one with the highest emergency surgery mortality rates, therefore, their average tec declines by . % and . % during - (see table ). in addition to the observations stated above, it is indicated in table that the productivity and fs of pok oi hospital improve a lot during - , as it has provided ed services since . in phase i, we have measured the hkha efficiency changes from to by applying the gsbup-malmquist index. in phase ii, we will further explore the impact of some exogenours factors on hkha efficiency by tobit regression model. the hk healthcare system is composed of two sectors: a private track and a government sponsored public track. citizens can access the public healthcare system at facilities operated by the ha. insurance is not necessary for the eligible. however, the public system is geared toward emergency care, which means that if an attending nurse deems a case to be not critical, patients may sometimes spend hours waiting to see a doctor. thus, the citizens with good financial condition sometimes prefer to choose the private hospitals for their efficient and high quality services. private healthcare, however, generally is more expensive than the public healthcare system which mainly comes from the out-of-pocket household payment and commercial medical insurance pay-out. according to the world factbook in , the gini index of hk for households rose from . in to . in , while that for economically active individuals increased from . in to . in . the rising gini index of both household and individual income are often regarded as the evidence of income inequality. therefore, household income inequality has risen naturally because of the population composition change (e.g., more non-working elderly or single-parent household than those in the past) [ ] . it is well known that hk is one of the most densely populated areas in the world, with an overall density of around people per square kilometer. at the same time, hk has one of the world's lowest birth rates- . per woman of child-bearing age in , far below the replacement rate of . . it is estimated that . % of the population will age over in , rising from . % in . therefore, we consider from the aspects of economy, geography, education and demography to further explore the influence of exogenous factors. table provides the details of these factors, which are collected from the hong kong census and statistics department [ ] . the most widely used method to model the dea scores against exogenous factors is tobit regression, which is suitable when the dependent variables are either censored or corner solution outcomes [ , , ] . it is validated in [ ] that the tobit regression model is powerful in representing the second stage in dea models. the relationship between exogenous factors and cluster efficiencies can be described by the following model: where hace it describes the ith cluster's efficiency in the tth year. the symbol denotes the corresponding exogenous factor's value in the ith cluster of tth year. (β , β , . . ., β ) are the unknown coefficients, and it * n( , σ) are the independent and identically normally distributed residuals of the observations. in this study, we use the maximum likelihood estimation toolbox in r [ ] to obtain the tobit regression results, as presented in table . firstly, the poverty situation of persons with disabilities has a positive influence on ha hospital efficiency; while median monthly domestic household income and education level affect the environmental efficiency negatively. since the median income of each cluster has almost no relationship with population density (i.e., correlation coefficient = . ), the empirical results reveal an interesting phenomenon: the public hospitals that serve in a richer district, has a relatively lower efficiency in hk, since people with higher degree of education and income prefer to accepting higher quality service from the private hospitals. secondly, the proportion of population aged over and ha hospital efficiency has a negative correlation, because the elderly are more likely to suffer from life-threatening diseases. many elderly patients are physically too weak to see the doctors. moreover, one out of three elderly hk residents lives under poverty or disabilities, so they are usually unable to take good care of themselves once in sick. in other words, the aged population might increase the complications and the mortality rate. therefore, the aged population have a negative correlation with the ha hospital efficiency. thirdly, the proportion of patients come from the other clusters takes a positive correlation with the efficiency. the ha hospitals in hk are divided into seven clusters according to their geographical locations so that the healthcare service is evenly distributed across hk. although the patients are expected to receive the same level of medical care, wherever they abide in, the quality of medical care are various across different locations. thus, some patients abiding in the relative poverty districts may try to receive the better treatments from the other districts' hospitals, such as queen mary hospital, belonging to the hkwc. these types of patients will increase the workload of some hospitals, which is validated by the regression results. finally, the land area has no significant influence on ha hospital efficiency while population density has a weak positive influence. for example, new territories has the largest land area in hk, while its population density is the lowest. kowloon has the highest population density, at the same time, most of the poor with disabilities abide in this cluster. in addition, the land area and population density of hong kong island lie in the middle, but the citizens are relatively richer. in conclusion, the geography factor has no significant influence on ha hospital efficiency. in dea model, efficiency score is closely related to the quantities of inputs and outputs. an ideal scenario with the highest efficiency in a healthcare setting would be treating the most patients using the least healthcare expenditure. however, the reception of the patients beyond the hospital capacity will generate a congestion problem, even resulting in some unexpected mortality, where a high patient mortality rate not only reflects a poor medical quality, but also may cause a dispute. thus, it is regarded as an uo and is expected to be as low as possible. on the other hand, the in-patient discharge rate is a powerful indicator to represent whether this hospital could provide a good quality of service, which is expected to be as high as possible, as an ui. moreover, the measurement of hospital efficiency might be biased if the undesirable factors are ignored. by integrating the gsbup-dea model and malmquist index, this paper examines the resource efficiency of hkha based on the panel data from to . then, through the tobit regression model, some exogenous factors' influences are tested. the empirical results show that the hkha hospital efficiencies of each hospital and cluster are significant different. in general, the healthcare efficiency of hospitals belonging to the kec and ntwc are significantly higher than the other hospitals, which has a close correlation with demographic composition, geographic condition and economic position. by analyzing the evaluation of productivity change over time, we observed that the sars outbreak has a strong impact on the hospital efficiency. in addition, we found an interesting phenomenon that the public hospital serving in a richer district with high population density has a relatively lower efficiency, as hk people with better economic condition prefer to accept higher quality service from the private hospital. in recent decades, hkha has been making efforts to improve the healthcare services, but there still exist some problems like unfair resource allocation and poor management, as reported by the hong kong medical legislative committee. one critical consequence of these problems is low healthcare efficiency of hospitals, leading to low satisfaction among patients. in conclusion, we provide two suggestions on how to improve the hkha hospital efficiency in the future: (i) according to the original resource allocation system, the hkha policy makers need to properly increase the input for the inefficient hospitals with irs, such as tung wah eastern hospital and save some investment for the inefficient hospitals with drs, such as tung wah eastern hospital prince of wales hospital. (ii) it is necessary to change the medical investment standard. it may be better to consider patient attendance and hospital current efficiency simultaneously. such a new system can solve the problem of unfair resource allocation effectively. in the future, we will consider the patient service quality and use idea (imprecise data) models to help hkha policy makers find the technology backward hospitals. to further improve the efficiency in resource utilization and meet the need of growing healthcare demand due to aging population, the internal resource allocation system should be personalized and modernized at an individual level by involving heterogeneity of patients need. thus, we will also attempt to investigate the simulation methods for resource optimization by integrating heterogeneous factors at individual level in our future works. by applying the charnes-cooper transformation, [gsbup] can be transformed into a linear programming. suppose t (t > ) is a scalar variable, let: the linear programming of [gsbup] can be transformed as follows: suppose (λ à ;α à ;β à ;γ à ;θ à ) is an optimal solution of eq ( ) . according to definition , the constraints of eq ( ) can be transformed as follows: because we have known that â à i a à i ,ĝ à l g à l ! ,b à r b à r ! , and ŷà h y à h ( i, l, r, h). thus, is a feasible solution of eq ( ), and then we can get an inequality function as follows: because â à i ,ĝ à l ! ,b à r ! , and ŷà h ( i, l, r, h), in order to satisfy the inequality eq ( ), there must be (α à , β à , γ à , θ à ) = ( , , , ) . thus, we can demonstrate that the projection,dmu ¼ ðx d ;ŷ g ;x i ;ŷ b Þ is gsbup-efficient, according to definition . in a similar way, using t + instead of t for the models ( ) and ( ) incorporating quality into data envelopment analysis of nursing home performance: a case study a location-allocation model for service providers with application to not-for-profit health care organizations a survey of dea applications health-care 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squares and tobit in second stage dea efficiency analyses second stage dea: comparison of approaches for modelling the dea score r: a language and environment for statistical computing we thank dandan yu, the associate director of information center of the first affiliated hospital of dalian medical university for sharing suggestions from the perspective of hospital manager. we thank the anonymous reviewers and the department editor for their constructive comments and suggestions, which have greatly improved the exposition of this paper. key: cord- -rqdeac h authors: wilcox, elizabeth s.; chimedza, ida tsitsi; mabhele, simphiwe; romao, paulo; spiegel, jerry m.; zungu, muzimkhulu; yassi, annalee title: empowering health workers to protect their own health: a study of enabling factors and barriers to implementing healthwise in mozambique, south africa, and zimbabwe date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: rqdeac h ways to address the increasing global health workforce shortage include improving the occupational health and safety of health workers, particularly those in high-risk, low-resource settings. the world health organization and international labour organization designed healthwise, a quality improvement tool to help health workers identify workplace hazards to find and apply low-cost solutions. however, its implementation had never been systematically evaluated. we, therefore, studied the implementation of healthwise in seven hospitals in three countries: mozambique, south africa, and zimbabwe. through a multiple-case study and thematic analysis of data collected primarily from focus group discussions and questionnaires, we examined the enabling factors and barriers to the implementation of healthwise by applying the integrated promoting action on research implementation in health services (i-parihs) framework. enabling factors included the willingness of workers to engage in the implementation, diverse teams that championed the process, and supportive senior leadership. barriers included lack of clarity about how to use healthwise, insufficient funds, stretched human resources, older buildings, and lack of incident reporting infrastructure. overall, successful implementation of healthwise required dedicated local team members who helped facilitate the process by adapting healthwise to the workers’ occupational health and safety (ohs) knowledge and skill levels and the cultures and needs of their hospitals, cutting across all constructs of the i-parihs framework. health workers (hws) are in short supply worldwide. it is estimated that by , the global health workforce will be short approximately million workers, primarily in low-and middle-income countries (lmics) [ ] . in high-risk settings, where disease prevalence is high and health systems are stretched to provide basic health services, hws are at an elevated risk of contracting infectious diseases such as hepatitis, human immunodeficiency virus (hiv), tuberculosis (tb), and novel emerging threats from occupational exposure, including covid- . they also suffer stigma and discrimination at work, in their communities, and at home from bearing these increased risks. effective coverage by the health workforce depends on availability, accessibility, acceptability, and quality of hws [ ] . one of the top three factors reducing supply, along with migration and retirement, is the "risk of violence, illness or death" [ ] . strategies to address the hw shortage ought to therefore include protecting hws by promoting their health and safety at work, particularly in high-risk settings. international organizations have developed tools to improve the occupational health and safety (ohs) of hws. one of these is healthwise, a participatory, quality improvement tool, jointly developed by the international labour organization (ilo) and the world health organization (who) [ ] . in , a tripartite group consisting of workers', employers', and governments' representatives, as well as specialists from the ilo and who, convened and agreed on a framework for improving the ohs of hws. based on principles from the original work improvement in small enterprises (wise) training program created by the ilo, healthwise was then developed to help support the implementation of this framework [ ] . healthwise aims to improve working conditions, performance, and workplace safety through training and empowering hws with the ability to identify workplace hazards and areas requiring improvement in their work environments and to conduct processes for developing and implementing low-cost solutions to address them. healthwise consists of two workbooks, one for participants and one for trainers, with content organized into eight modules (figure ). the workbooks are available online in five languages. as with addressing the supply of hws, the availability of the tool is only part of the solution. it is also important to understand the implementation of healthwise and to improve upon implementation processes to maximize the tool's potential. novel emerging threats from occupational exposure, including covid- . they also suffer stigma and discrimination at work, in their communities, and at home from bearing these increased risks. effective coverage by the health workforce depends on availability, accessibility, acceptability, and quality of hws [ ] . one of the top three factors reducing supply, along with migration and retirement, is the "risk of violence, illness or death" [ ] . strategies to address the hw shortage ought to therefore include protecting hws by promoting their health and safety at work, particularly in high-risk settings. international organizations have developed tools to improve the occupational health and safety (ohs) of hws. one of these is healthwise, a participatory, quality improvement tool, jointly developed by the international labour organization (ilo) and the world health organization (who) [ ] . in , a tripartite group consisting of workers', employers', and governments' representatives, as well as specialists from the ilo and who, convened and agreed on a framework for improving the ohs of hws. based on principles from the original work improvement in small enterprises (wise) training program created by the ilo, healthwise was then developed to help support the implementation of this framework [ ] . healthwise aims to improve working conditions, performance, and workplace safety through training and empowering hws with the ability to identify workplace hazards and areas requiring improvement in their work environments and to conduct processes for developing and implementing low-cost solutions to address them. healthwise consists of two workbooks, one for participants and one for trainers, with content organized into eight modules ( figure ). the workbooks are available online in five languages. as with addressing the supply of hws, the availability of the tool is only part of the solution. it is also important to understand the implementation of healthwise and to improve upon implementation processes to maximize the tool's potential. implementation science is growing in the field of global health. madon and colleagues [ ] called on researchers to (i) "develop theoretical models and new analytic methods that apply to resource poor settings" such as areas where hws are in short supply, (ii) build capacity and strengthen research institutions in lmics in regard to implementation science, in part to learn from valuable local knowledge and insights that influence implementation processes, and (iii) increase collaboration with governments, non-governmental organizations, and communities to incorporate research into implementation processes in order to improve upon them. implementation science is growing in the field of global health. madon and colleagues [ ] called on researchers to (i) "develop theoretical models and new analytic methods that apply to resource poor settings" such as areas where hws are in short supply, (ii) build capacity and strengthen research institutions in lmics in regard to implementation science, in part to learn from valuable local knowledge and insights that influence implementation processes, and (iii) increase collaboration with governments, non-governmental organizations, and communities to incorporate research into implementation processes in order to improve upon them. this paper overviews the implementation of three healthwise modules in seven hospitals (designated the letters a through g) in mozambique, south africa, and zimbabwe. using the integrated promoting action on research implementation in health services (i-parihs) framework (described in "research methods" below), it aims to better understand the enabling factors and barriers to the implementation of healthwise in these hospitals and, considering previous implementation science research, to discuss how these might be leveraged or overcome in future implementations of healthwise. an existing north south partnership involving researchers and technical teams from canada and south africa [ ] was expanded to include team members from mozambique and zimbabwe due to plans and interest to implement healthwise in those countries. this enabled a comparison of its implementation in different contexts. the three countries are in close proximity in the southern african region and represent high-risk settings where the ohs of hws is at different stages and resource levels and has yet to be fully given the importance that it is due. according to world bank classifications based on gross national income (gni) per capita, mozambique is a low-income country (gni per capita of us$ ), south africa an upper-middle-income country (gni per capita of us$ ), and zimbabwe a lower-middle-income country (gni per capita of us$ ) [ ] . total health expenditures per capita (and as a percentage of gross domestic product) from reflect this trend, with mozambique spending us$ . ( . %), south africa us$ . ( . %), and zimbabwe us$ . ( . %) [ ] . mozambique, south africa, and zimbabwe are amongst high burden countries with regard to tb, tb and hiv co-infection, and multi-drug resistant tb [ ] . in , the incidence of tb per , people was in mozambique, in south africa, and in zimbabwe. the total prevalence of hiv among their populations aged - was . % in mozambique, . % in south africa, and . % in zimbabwe [ ] . a planning meeting with representation from all countries was held in zimbabwe in february . at this meeting, it was decided that the focus would be restricted to specific, related priority areas: biological hazards and infection control (module ) and discrimination, harassment, and violence (module ). over the following eight months, local team leads sought any necessary local, provincial, and national approvals and selected hospitals in which to implement healthwise. a total of seven hospitals participated: three in mozambique, two in south africa, and two in zimbabwe. implementation refers to the ensuing activities, including the introduction of healthwise, by training groups of hws at participating hospitals and the activities carried out by participants from this point through to the final capstone meeting. observation focused on if and how participants used healthwise in their hospitals and included the activities conducted by research team members, such as focus groups and questionnaires, to inquire into the enabling factors and barriers to its uptake and resultant activities. implementation was observed over months, beginning with three training-of-trainers (tot) workshops (one per country) in october and november . the three-day program was developed and carried out by local team members. in brief, the focus of day was on introducing healthwise and modules and . the focus of day was on module . day was devoted to developing healthwise action plans (activities to be carried out by trainees in their health facilities). throughout, participatory training techniques, including role plays and an interactive exercise on the topic of stigma [ ] , were demonstrated, which might be useful for participants to help engage workers and disseminate new information in their workplaces. following the training, participants were expected to create healthwise teams and based on the healthwise principle of finding simple, low-cost solutions to workplace issues within their local contexts, carry out healthwise activities in their hospitals. based on budgets determined by the action plans, a small amount of project funds was made available for healthwise activities. additional practical training sessions were held in mozambique in july and in zimbabwe in february . the healthwise teams trained during the tot workshops conducted walk-through assessments with the lay hws in one or more departments, helping to identify hazards and how they might be mitigated with low-or no-cost solutions. one year after the tot workshops, six follow-up workshops were held (one per hospital, with hospitals a and c in mozambique combined). during these workshops, participants presented on healthwise activities that had taken place in their facilities to date and participated in focus groups on the perceived enabling factors and barriers to implementing healthwise. participants were asked to individually brainstorm their own lists of enabling factors and barriers and to then read these out one-by-one and explain them to the group. questions and discussion were encouraged. participants in mozambique and south africa also completed an anonymous questionnaire. due to resource constraints within the hospitals, these questionnaires were unable to be administered in zimbabwe. shortly after the follow-up workshops, one representative from each hospital from all three countries attended a dissemination meeting in south africa to present on their progress implementing healthwise. the research focus of the project culminated in a final meeting in may in zimbabwe ( figure ). one representative from each hospital presented on healthwise activities that had taken place to date and provided feedback on the implementation process and preliminary findings from the research. available for healthwise activities. additional practical training sessions were held in mozambique in july and in zimbabwe in february . the healthwise teams trained during the tot workshops conducted walk-through assessments with the lay hws in one or more departments, helping to identify hazards and how they might be mitigated with low-or no-cost solutions. one year after the tot workshops, six follow-up workshops were held (one per hospital, with hospitals a and c in mozambique combined). during these workshops, participants presented on healthwise activities that had taken place in their facilities to date and participated in focus groups on the perceived enabling factors and barriers to implementing healthwise. participants were asked to individually brainstorm their own lists of enabling factors and barriers and to then read these out one-by-one and explain them to the group. questions and discussion were encouraged. participants in mozambique and south africa also completed an anonymous questionnaire. due to resource constraints within the hospitals, these questionnaires were unable to be administered in zimbabwe. shortly after the follow-up workshops, one representative from each hospital from all three countries attended a dissemination meeting in south africa to present on their progress implementing healthwise. the research focus of the project culminated in a final meeting in may in zimbabwe. one representative from each hospital presented on healthwise activities that had taken place to date and provided feedback on the implementation process and preliminary findings from the research. a multiple-case study, in which each hospital was treated as a single case, was used to examine the enabling factors and barriers to the implementation of healthwise [ ] . within the case study, thematic analysis, "a method for identifying, analysing and reporting patterns (themes) within data", was used [ ] . the integrated promoting action on research implementation in health services (i-parihs) framework was employed in this study [ ] . the i-parihs framework was published in , based on an earlier iteration from [ ] and continues to be developed and refined. the framework describes four constructs related to implementation: (i) the 'innovation', or new knowledge informed by evidence-based research, that is being introduced; (ii) the 'recipients', or the individuals and teams who are involved in or affected by the implementation; (iii) the 'context', referring to three levels of local, organizational, and external health system settings in which the innovation is being implemented; and (iv) 'facilitation', or the strategies and actions performed by the facilitator(s) to enable implementation in response to the innovation and its recipients within their given context. the earlier version was classified as an explanatory framework that specified the relationship between the constructs [ ] and while the integrated version maintains these linkages, the i-parihs framework is also descriptive as it breaks-down the constructs to further describe characteristics important to implementation. descriptive and explanatory frameworks are used to understand factors that might have positively or negatively influenced implementation processes [ ] and given a multiple-case study, in which each hospital was treated as a single case, was used to examine the enabling factors and barriers to the implementation of healthwise [ ] . within the case study, thematic analysis, "a method for identifying, analysing and reporting patterns (themes) within data", was used [ ] . the integrated promoting action on research implementation in health services (i-parihs) framework was employed in this study [ ] . the i-parihs framework was published in , based on an earlier iteration from [ ] and continues to be developed and refined. the framework describes four constructs related to implementation: (i) the 'innovation', or new knowledge informed by evidence-based research, that is being introduced; (ii) the 'recipients', or the individuals and teams who are involved in or affected by the implementation; (iii) the 'context', referring to three levels of local, organizational, and external health system settings in which the innovation is being implemented; and (iv) 'facilitation', or the strategies and actions performed by the facilitator(s) to enable implementation in response to the innovation and its recipients within their given context. the earlier version was classified as an explanatory framework that specified the relationship between the constructs [ ] and while the integrated version maintains these linkages, the i-parihs framework is also descriptive as it breaks-down the constructs to further describe characteristics important to implementation. descriptive and explanatory frameworks are used to understand factors that might have positively or negatively influenced implementation processes [ ] and given its continuing evolution, the i-parihs framework was chosen to explore the implementation of healthwise. it ought to be noted that several tools have been developed based on the original parihs framework to more thoroughly assess the context construct, including the context assessment for community health (coach) tool, specifically for use in lmics [ ] . while the dimensions described therein were considered during this analysis, they are captured in the more recent i-parihs framework and the characteristics of the latter were therefore used. data were drawn from dissemination and capstone meeting presentations (powerpoint presentations), focus group transcripts (word documents generated from audio-recordings), and open-ended responses to completed anonymous questionnaires (paper and electronic pdf copies). using an inductive approach, three focus group transcripts, one from each country, were first open coded to generate a list of enabling factors and barriers. these codes were then compared and categorized according to the i-parihs constructs and characteristics to generate a draft codebook. the remaining three focus group transcripts were then coded using the draft codebook. some characteristics were subsequently removed or combined to refine the constructs and characteristics to those listed in tables - , which are the themes and sub-themes for the final codebook. using this codebook, all data were coded using nvivo and excel to better understand the enabling factors and barriers to the implementation of healthwise. this study was approved by the behavioural research ethics board, university of british columbia, canada (h - , h - ), the research ethics committee, university of pretoria, south africa ( / ), and the medical research council of zimbabwe, zimbabwe (mrcz/a/ ). participants who were involved in the follow-up workshop focus groups, questionnaires, and dissemination and capstone meetings were provided with written information about the research objectives and processes prior to their involvement and individual informed consent was obtained. participation was voluntary and individuals were informed of their right to withdraw from the study at any time. all data was collected anonymously or de-identified before analysis to protect confidentiality. the seven participating hospitals ranged in size from to beds and from approximately to workers. in all hospitals, the workers were predominantly female. characteristics of the seven hospitals are presented in table . results for the four constructs-innovation, recipients, context, and facilitation-are presented below, with quotes that help to reflect what was an enabling factor or barrier in the implementation of healthwise in each of the participating hospitals in mozambique, south africa, and zimbabwe. it is important to note that not all constructs or characteristics were explicitly mentioned by participants at each of the hospitals. this absence does not necessarily mean that a specific characteristic was or was not an enabling factor or barrier; while this could be the case, it could instead indicate that further questioning on specific characteristics of interest may be warranted in future studies. where a characteristic is designated as both an enabling factor and barrier (ef/b) within the tables, further information on how the implementation of healthwise was helped or hindered is provided in the ensuing description. the innovation construct included characteristics related to healthwise, the intervention being implemented. three of the seven characteristics of the innovation construct from the i-parihs framework were mentioned; whether they were enabling factors and/or barriers in each of the hospitals is shown in table . table . innovation construct characteristics and whether they were enabling factors (ef) and/or barriers (b) to the implementation of healthwise in each participating hospital (a-g). "clarity" about healthwise-what the tool was and why and how it was going to be used-was a key enabling factor in nearly all of the hospitals: "when personnel have been trained and they know . . . what is expected of them and what is going to be done, they are more cooperative than when they do not know" (hospital e, focus group). the "relative advantage" of healthwise-how it would be of benefit compared with existing interventions-particularly that the tool aimed to benefit workers and their working environment (as opposed to being focused solely on patients), helped to spur the implementation of healthwise in one hospital in mozambique and one hospital in south africa where the "anticipated positive results/effects of [the] healthwise project" (hospital d; capstone meeting) were an enabling factor. "observable results" were also mentioned as enabling the implementation of healthwise by one hospital in each country. in opposition, one barrier of the innovation construct, mentioned by all the hospitals in mozambique, was a lack of clarity or "lack of knowledge about exactly what to do" (hospital a, questionnaire). for some hospitals, there was also an inability to raise awareness about healthwise among hospital staff: "...we did not have much time to publicize this project to colleagues to understand what it was all about" (hospital b, focus group). one hospital in south africa echoed this lack of clarity and awareness, as represented by one comment of "supervisors not understanding the project" (hospital e, questionnaire). the recipients construct included characteristics related to the individuals and teams involved in, or affected by, the implementation of healthwise. the characteristics of the recipients construct and whether they were enabling factors and/ or barriers in each of the hospitals are shown in table . the "time, resources, support" characteristic from the i-parihs framework was split into four: "project funding", "human resources", "material resources", and "personal protective equipment (ppe)" to better capture their different impacts on the implementation of healthwise. two characteristics from the i-parihs framework, "values and beliefs" and "presence of boundaries", did not emerge during this analysis. table . recipient construct characteristics and whether they were enabling factors (ef) and/or barriers (b) to the implementation of healthwise in each participating hospital (a-g). "motivation", or the "willingness of staff to participate in healthwise activities" (hospital c, capstone meeting), was mentioned as an enabling factor by hospitals c and f, where workers "showed much interest in this program" (hospital f, focus group). a lack of external incentives was mentioned as a barrier by both zimbabwe hospitals f and g, where "there is in most cases lack of incentives for trainers to keep their motivation high" (hospital f, dissemination meeting). lack of clear "goals and expectations" related to the implementation of healthwise was mentioned as a barrier by the three mozambique hospitals a, b, and c, where there was "difficulty of perception of some professionals about the objectives of the project" (hospital b, dissemination and capstone meetings) as well as "failure to comply with agreed deadlines" (hospital a, dissemination meeting). on the other hand, having clear "goals and expectations" was an enabling factor for both hospitals d and e in south africa and for hospital g in zimbabwe. goals came in different forms, such as an "attainable objective that was set by the team member" (hospital d, focus group), as well as "an action plan that served as our guiding point of reference" (hospital e, focus group). individual "skills and knowledge" related to ohs was both an enabling factor and barrier mentioned by hospitals a, b, and c in mozambique, depending on whether recipients were perceived as having or lacking ohs knowledge. there was some overlap with the culture characteristic in the context construct, which was discussed to a greater extent in zimbabwe and south africa. lack of "project funding" was mentioned as a barrier by all but one hospital in mozambique. "lack of resources for implementation" (hospital a, dissemination meeting), "financial constraint" (hospital e, questionnaire), and "lack of funding for full implementation of healthwise" (hospital f, capstone meeting) were some of the ways that this barrier was mentioned. since this initially proved to be a major constraint, it was addressed by local team members in all three countries through communication and practical training sessions that helped to redirect workers towards no-cost solutions. for example, a patient consultation room was rearranged to improve ventilation and reduce the risk of workers being exposed to airborne pathogens and, in the same area, ripped flooring that created a fall hazard was cut out and removed, as opposed to being replaced with new flooring (figure ). workers involved in the practical training sessions expressed that "the search for solving problems that do not require financing was a great gain" (hospital a, focus group). where funding for larger project activities was available, it was an enabling factor. hospital c in mozambique was able to draw from external funding sources to begin construction of a new tb consultation and testing unit and laboratory when the old infrastructure was identified as a hazard by the healthwise team. one hospital in zimbabwe, which used project funds to purchase some equipment for their training sessions, indicated that the "allocation of funds" (hospital f, dissemination meeting) was an enabling factor to implementation in their hospital. "human resources" were a barrier mentioned by all hospitals except a and c in mozambique. all hospitals seemed to experience some degree of staff shortages, "when the departments are so shortstaffed, they are reluctant to take part in some of the activities and to attend some of the meetings" (hospital e, focus group); turnover, "staff movement, some people are exiting the system, others might be on night duty, you know, on leave" (hospital d, focus group); overwhelming "workload from the department" (hospital d, focus group); and lack of time, "we always have quite demanding tasks that we do every day, our jobs are quite demanding, so the lack of time maybe is one of the major barriers to the implementation" (hospital f, focus group). "material resources", including the availability of reference, training, and other materials for the practical application of healthwise were mentioned by all participating hospitals. where material resources were available, they were an enabling factor; where they were unavailable, they were a barrier. there was also an issue with the "scarcity of surgical medical material with an emphasis on personal protective equipment" (hospital b, capstone meeting) mentioned by the three hospitals in mozambique, however there were indications from one hospital in each south africa and zimbabwe that the process of implementing healthwise was helping to secure "some improvements in procurement e.g. availability of appropriate ppe for linen bank staff and food services personnel and respirators" (hospital e, capstone meeting) and that "if we procure that [ppe] then it will be, the healthwise program will be effective" (hospital g, focus group). where active and engaged, the "local opinion leaders", referring to the existing ohs teams or newly created healthwise teams, were an enabling factor. this was particularly the case at both hospitals in south africa, where ohs teams were in place before the implementation of the project. one was commended as a "knowledgeable, skilled, reliable and committed ohs team" (hospital d, capstone meeting) and the other as a diverse "healthwise team comprising of members from different departments e.g. hr [human resources], staff development, cleaning, ipc [infection prevention and control] and linen bank" (hospital e, capstone meeting), which helped contribute to their success. the smaller hospital in zimbabwe also noted their "dedicated healthwise champions" (hospital g, capstone meeting). the barrier was due to "peripheral involvement of medical doctors and the nurses' representative member" (hospital f, capstone meeting), again indicating that engagement of diverse teams was one of the keys to successful implementation. "collaboration and teamwork" were mentioned as enabling factors or, where lacking, as barriers by the three hospitals in mozambique. similar to the motivation characteristic or the willingness of the workers to engage in the healthwise project, this characteristic referred to the involvement and inclusion of workers. hospitals a and c felt that there was both "good participation and adherence from employees" as well as that "there must be greater involvement of employees in the healthwise project" (hospital a/c, focus group). "existing networks", referring to collaboration and communication within and between hospitals, was generally an enabling factor mentioned by six of the seven hospitals. communication, figure . before (not shown), the physician's desk was positioned next to the window, with the patient to their right. after, the patient is positioned next to the window and the physician is seated on the opposite side of the desk, allowing the air to flow from the door outside. ripped flooring has been removed. "human resources" were a barrier mentioned by all hospitals except a and c in mozambique. all hospitals seemed to experience some degree of staff shortages, "when the departments are so short-staffed, they are reluctant to take part in some of the activities and to attend some of the meetings" (hospital e, focus group); turnover, "staff movement, some people are exiting the system, others might be on night duty, you know, on leave" (hospital d, focus group); overwhelming "workload from the department" (hospital d, focus group); and lack of time, "we always have quite demanding tasks that we do every day, our jobs are quite demanding, so the lack of time maybe is one of the major barriers to the implementation" (hospital f, focus group). "material resources", including the availability of reference, training, and other materials for the practical application of healthwise were mentioned by all participating hospitals. where material resources were available, they were an enabling factor; where they were unavailable, they were a barrier. there was also an issue with the "scarcity of surgical medical material with an emphasis on personal protective equipment" (hospital b, capstone meeting) mentioned by the three hospitals in mozambique, however there were indications from one hospital in each south africa and zimbabwe that the process of implementing healthwise was helping to secure "some improvements in procurement e.g., availability of appropriate ppe for linen bank staff and food services personnel and respirators" (hospital e, capstone meeting) and that "if we procure that [ppe] then it will be, the healthwise program will be effective" (hospital g, focus group). where active and engaged, the "local opinion leaders", referring to the existing ohs teams or newly created healthwise teams, were an enabling factor. this was particularly the case at both hospitals in south africa, where ohs teams were in place before the implementation of the project. one was commended as a "knowledgeable, skilled, reliable and committed ohs team" (hospital d, capstone meeting) and the other as a diverse "healthwise team comprising of members from different departments e.g., hr [human resources], staff development, cleaning, ipc [infection prevention and control] and linen bank" (hospital e, capstone meeting), which helped contribute to their success. the smaller hospital in zimbabwe also noted their "dedicated healthwise champions" (hospital g, capstone meeting). the barrier was due to "peripheral involvement of medical doctors and the nurses' representative member" (hospital f, capstone meeting), again indicating that engagement of diverse teams was one of the keys to successful implementation. "collaboration and teamwork" were mentioned as enabling factors or, where lacking, as barriers by the three hospitals in mozambique. similar to the motivation characteristic or the willingness of the workers to engage in the healthwise project, this characteristic referred to the involvement and inclusion of workers. hospitals a and c felt that there was both "good participation and adherence from employees" as well as that "there must be greater involvement of employees in the healthwise project" (hospital a/c, focus group). "existing networks", referring to collaboration and communication within and between hospitals, was generally an enabling factor mentioned by six of the seven hospitals. communication, expressed as "the exchange of information among workers and from workers to patients; reciprocal information sharing" (hospital a/c, questionnaire) was key, as was the "easy implementation and dissemination of information to colleagues" (hospital b, dissemination and capstone meetings). one participant from south africa mentioned that "hr has been absolutely amazing. having a member of hr in our healthwise team was the best thing" (hospital e, focus group), due to the improved communication between departments and with management that enabled more project activities to receive approval and take place. finally, the "collaboration between [hospital a] and [hospital c] -exchanged experiences and helped to overcome difficulties that were encountered" (hospital a/c, dissemination meeting) was particularly helpful. the barrier in this regard was "poor communication" (hospital d, capstone meeting). "power and authority" were identified as enabling factors for hospitals a, c, and g. this generally related to workers feeling empowered to take charge of their own health and safety. during the focus group, one participant mentioned the idea of greater ownership over their own safety: "for me the project came to change my way of thinking... i realized that i am able to improve . . . my safety in the workplace and not wait for the bosses to come to control something within the sector, and so it was positive for me" (hospitals a/c, focus group). this sentiment was shared by a participant in zimbabwe: "...when we started it was your program but now slowly it is becoming our program so if everyone is involved at that level then we are going to succeed" (hospital g, focus group). these feelings also manifested as achievements; at hospital c in mozambique, one team member used material from module , which was not part of the initial training, and worked and negotiated with management and the local municipality to more routinely dispose of waste that piled up on the hospital grounds. a "lack of authority to implement certain activities" (hospital e, capstone meeting) was a barrier mentioned by one hospital in south africa. the context construct included characteristics related to the setting in which the innovation was to be implemented. characteristics related to the local and organizational levels from the i-parihs framework were combined as these were difficult to piece apart and included six characteristics. the external health system level included three of five characteristics from the i-parihs framework, leaving out "policy drivers and priorities" and "incentives and mandates". identified enabling factors and/or barriers in each of the hospitals are shown in table . "senior leadership and management support" was an enabling factor mentioned by all seven hospitals through comments such as "support from the management... and the participation of those in charge of the sectors" (hospital b, focus group), "buy-in from senior management" (hospital d, focus group), and "management acceptance of the program" (hospital g, focus group). "lack of support from some middle managers" (hospital d, capstone meeting) where, for instance, heads of departments were at times not willing or able to release workers from their duties to participate in healthwise activities, was a barrier in hospitals d, e, and f. elements of the "culture" characteristic were mentioned by five of the participating hospitals. where workers were perceived to have greater "commitment to work", with descriptions such as "strong workforce" (hospital g, focus group), this was designated as an enabling factor. in mozambique, "one of the barriers [was] that information [had] to be oral" since workers were "not in the habit of stopping to read" (hospital b, focus group). here, there were overlaps with the willingness of workers to participate and learn and the degree of teamwork and collaboration described in the recipients construct above. where difficulties were raised in regard to "knowledge application", this was designated as a barrier. in the two hospitals in south africa, a "lack of safety culture; lack of knowledge about the importance of ohs matters and the healthwise program" (hospital e, capstone meeting) was discussed as a barrier, referring to the idea that workers have ohs "knowledge but they are not interested [in applying it]" (hospital e, focus group). "negative hospital staff attitudes" (hospital d, capstone meeting) and "resistance to change" (hospital b, questionnaire) were also perceived as a barrier in several hospitals. one hospital in zimbabwe that had expanded the services of their regular staff wellness clinic as part of the implementation of healthwise also mentioned "fear to uptake services . . . due to fear of stigma and discrimination" (hospital g, capstone meeting). competing "organizational priorities" and programs were mentioned as a barrier by hospitals d, f, and g. hospital a seemed to have priorities and programs that served to support, instead of compete with, healthwise activities, indicating "reinforcement of the ongoing ipc activities; synergies have been built among healthwise and ipc" (hospital a, dissemination meeting). in regard to "structure and systems", infrastructure was a barrier mentioned by all hospitals. infrastructure was generally older and difficult to change and participants seemed to feel that "some infrastructure hinders the proper functioning of the project" (hospital a/c, focus group), such as the "lack of ramps to move trolleys" (hospital b, dissemination and capstone meetings) at one hospital in mozambique and that "buildings were not constructed in such a way that they allow for proper ventilation" (hospital f, focus group) at one hospital in zimbabwe. hospital g expressed that the "infrastructure . . . might not be ideal but we are going to work with what we have" (hospital g, focus group). "lack of a specific project space" (hospital a/c, focus group) was mentioned by one hospital in mozambique, while in south africa, both hospitals perceived the lack of a dedicated ohs clinic "where you can see your employees when they are sick" (hospital d, focus group) or "lack of equipment at our ohs clinics" (hospital e, questionnaire) as barriers as well. institution size, specifically in relation to the number of workers trained on healthwise, was also a barrier specifically mentioned by hospital f in zimbabwe. regarding "history of innovation and change", resistance to change was mentioned as a barrier by participants at hospitals a, b, c, e, and g. one participant from south africa indicated that "anytime there is a new project there will always be resistance . . . because people are used to the norm of how they usually do things" (hospital e, focus group) and another from mozambique indicated that "resistance to change on the part of some colleagues was a challenge in the past" (hospital b, questionnaire). "evaluation and feedback processes" were perceived to be both enabling factors and barriers to the implementation of healthwise. improvements to reporting procedures were an enabling factor in hospital a, demonstrated by the increased "willingness of staff to communicate accidents in the workplace" (hospital a, capstone meeting), however "lack of understanding and knowledge of procedures, e.g., incident reporting procedure" (hospital d, capstone meeting) and "poor reporting of incidents" (hospital e, capstone meeting) remained barriers elsewhere. lack of feedback was a barrier mentioned by hospitals b, d, and e. hospital b indicated the "need to find a way to get worker feedback" (hospital b, focus group) and hospital d felt that "if you don't give feedback to the unit . . . it may compromise participation at the later stage" (hospital d, focus group) . in regard to external context, existing ohs "regulatory frameworks" were mentioned as an enabling factor by the two hospitals in south africa, such as the existence of an "occupational health and safety act that we need to adhere to" (hospital d, focus group) . the "instability of the health system environment" was mentioned as a barrier by hospital f in zimbabwe, where significant political and socioeconomic changes and challenges occurred during the course of the project. having good "inter-organizational networks/relationships", particularly with trade unions that play more prominent roles in south africa, was mentioned as both an enabling factor and, where lacking, a barrier by hospitals d and e. the facilitation construct included characteristics related to the strategies and actions performed by the facilitator(s) to enable implementation by adapting healthwise in response to the workers who were asked to use it within the contexts of their hospitals and countries. two characteristics and whether they acted as enabling factors and/or barriers in each of the hospitals is shown in table . table . facilitation construct characteristics and whether they were enabling factors (ef) and/or barriers (b) to the implementation of healthwise in each participating hospital (a-g). at least one hospital in each country declared that the "healthwise trainings" were key enabling factors to the implementation of healthwise-that the tool would not have been implemented solely based on the workbooks being available. in the hospitals in mozambique, an identified barrier was that the "training time was too short" (hospital a/c, focus group) and was therefore insufficient to support the implementation process. the practical training sessions in mozambique and zimbabwe also helped participants with relatively less ohs experience better identify workplace hazards and solutions: "...what helped was a second meeting [implementation training]... when we realized what in theory we had to do in practice" (hospital a/c, focus group). ongoing "communication and support from the research team" was an enabling factor in five of the participating hospitals. the research team was available, however participants at the different hospitals reached out to varying degrees. in the hospitals in south africa, one member of the research team was more accessible to participants and was therefore able to more quickly answer questions and on occasion, help to troubleshoot issues that arose. at the same time, key participants at hospitals a and f in mozambique and zimbabwe, respectively, were also more engaged and would reach out more often if queries or problems arose and would, in turn, receive desired engagement. for instance, one worker expressed that "we had a permanent contact with the team that trained us . . . i would email him, and he would respond quickly" (hospital a, focus group). the research team was therefore accessible, however was used in different ways and amounts by participants at each hospital. where "continued interaction between the hospital and the research team" (hospital f, dissemination meeting) took place, it was perceived as an enabling factor. many programs and tools available for health facilities focus on measuring and improving patient health, quality of service, and safety culture and have been reviewed in several publications [ , ] . the few that have been developed and studied related to hws include online infection control tools [ ] and a seasonal influenza vaccination rate improvement tool [ ] . healthwise is a widely available quality improvement tool that addresses a variety of ohs concerns encountered in health facilities, containing information and activities that are particularly suitable to areas with few resources and little ohs experience. while it has been piloted in several countries, including in senegal, the united republic of tanzania, and thailand, and has since been implemented in the united states [ ], china [ ] , and the gambia, few publications and reports discussing or evaluating these experiences are publicly available. this paper is therefore one of the first to detail the implementation of healthwise and provide an analysis of enabling factors and barriers encountered in different lmics during the process. applying the i-parihs framework enabled an identification of key enabling factors as characteristics of the "recipients" and "context" constructs and included the willingness of workers to engage in implementation, the presence of diverse teams that championed the implementation process, and supportive senior leadership. barriers were reported in all constructs and included a lack of clarity about how to use healthwise, insufficient funds, stretched human resources, older buildings, and lack of incident reporting infrastructure. overall, successful implementation of healthwise called for dedicated local research and technical team members who helped facilitate the process by adapting healthwise to the workers' ohs knowledge and skill levels and the cultures and needs of their hospitals, cutting across all constructs of the i-parihs framework. healthwise was well-received in all participating hospitals, demonstrating the importance of the innovation itself. workers in hospital a seemed especially interested in a tool that was aimed at their own needs as opposed to solely those of patients. in the majority of hospitals, even those that did not mention it explicitly, there was difficulty in fully understanding healthwise and how to use it, as well as how to spread awareness regarding its implementation throughout the hospital. the anticipated benefits or the results that were being observed over the course of the implementation spurred several hospitals forward. the research team felt there was room to improve the messaging related to healthwise, and future implementations might further explore how information related to the innovation impacts the implementation process. questions could explore what factors made healthwise more acceptable, such as its development by the ilo and who, the quality or contents of the materials, and its fit within existing hospital practices and values in order to explore additional aspects of the innovation construct. healthwise activities were accomplished in all hospitals due to the active efforts of healthwise recipients, the individuals and teams who were overall key to the implementation. barriers described in this study, including staff shortages, high workloads, and limited material resources, have been identified among common barriers to evidence implementation across clinical areas in lmics [ ] . despite these issues, workers possessed a wealth of knowledge related to their hospitals and colleagues and therefore knew best when it came to implementing healthwise. while participants at hospitals in mozambique and zimbabwe mentioned feeling empowered and taking ownership over healthwise, more might have been done to help all teams recognize earlier on that their local insights and initiatives were what would make healthwise more successful. literature on team innovation and implementation points to the need for varied team composition to promote creativity and action [ ] . where teams were more diverse, particularly where members helped link frontline workers to management, more activities seemed to receive approval and were able to move forward. having established ohs teams in both hospitals in south africa, along with the accompanying knowledge and skills, also enabled them to accomplish a variety of tasks. it seemed that healthwise was a catalyst to the implementation of available ohs policies and allowed workers to take ownership of their own health and safety, with the ohs professionals providing oversight. the importance of opinion leaders-"people who influence the opinions, attitudes, beliefs, motivations, and behaviors of others" [ ] -has been shown in other examples of successful implementation processes and was similar here [ ] . promoting collaboration and exchange between sites that are implementing the same innovation might be interesting to explore, since this was an enabling factor for hospitals a and c who worked together in mozambique and was of particular interest to participants in zimbabwe who expressed a desire to visit other sites and learn from them during the implementation process. implementing healthwise in hospitals in different countries enabled the exploration of several characteristics of the context construct, which in these low-resource settings were more often barriers to the implementation of healthwise rather than enabling factors. context has repeatedly been discussed as an important factor in regard to implementing various interventions, one that deserves more thorough definition and analysis [ ] . findings from this study may help to better identify which characteristics are most important to the implementation of healthwise and, to some degree, other similar projects in lmics. in terms of the context construct, local and organizational factors were more often discussed than external health system ones. while senior management were supportive of the project in all hospitals and welcomed its implementation, middle management were perceived as a barrier at several sites. engaging more actively with middle management to explore strategies that would have allowed workers to be involved in healthwise activities, such as being relieved from their duties for a short time on a regular basis-perhaps one hour per week-to examine and improve their working environments, while also ensuring that their tasks remained fulfilled and that their departments ran smoothly, might have been one way to overcome this barrier. taking time to explain the longer-term potential of healthwise to the departments might have been another. the resistance by middle management highlighted the importance of communication and consultation across all levels of the hospital and all stakeholders when introducing new interventions to protect hws. birken and colleagues [ ] developed a theory of the role of middle management in healthcare innovation implementation. engle and colleagues [ ] expanded on this theory and found that middle management in organizations with "high change potential" promoted bidirectional communication and independent thinking and overall supported staff to facilitate implementation. emphasizing the goal of working within limits-of older infrastructure, inadequate human and material resources due to hiring freezes and health budgets, and manual incident reporting-might also have helped to avoid some blockages in the implementation process. also, given limited data collection and reporting procedures and mechanisms, understanding what type of feedback would have been attainable and useful might also have been helpful, as would have been pointing out synergies with existing organizational priorities and programs and external system regulatory frameworks and legislation. for the most part, workers were enthusiastic and engaged, although some negative attitudes and resistance to change were mentioned. a study by bergström and colleagues [ ] that examined the organizational context construct of the earlier parihs framework found that hws' commitment to their work, or an "individual's devotion to the organization," had an impact on the implementation of knowledge translation interventions in uganda. change was less likely where commitment levels were lower and a shortage of human resources contributed to lower levels of commitment. this indicates that where human and possibly other resources are a barrier, organizational culture might need to be addressed and improved for implementation to be successful, particularly in low-resource settings. there is important interplay between constructs, particularly between "recipients" and "context". for instance, incentives that contribute to the motivation of participants and project funding for specific equipment and activities might be more effective in some contexts than others. a systematic review by liu and colleagues [ ] found a range of macro, meso, and micro level context factors that influenced the types and impacts of incentives on the recruitment and retention of hws in multiple countries. in our study, participants from zimbabwe, where macro level political and socioeconomic factors were straining the country, mentioned that incentives might have been helpful for full participation. they were also initially focused on needing project funding to move forward with any activities and hospital f was the only facility to indicate that the allocation of funds enabled the implementation of healthwise. while our study did not specifically study the effects of externally funded projects, we got the impression that some participants were expecting extra incentives to motivate their participation. we acknowledge, however, that the local conditions and previous experiences with externally funded projects might contribute to this seeming dependency and expectation in lmics. harvey and colleagues [ ] conducted a concept analysis of facilitation and presented the role of the facilitator as one of "supporting people to change their practice". this healthwise study used appointed facilitators, external to the hospitals, who focused on building capacity in ohs in order to enable change, all which fit within the defining characteristics of facilitation that they describe. hospital a, b, and c in mozambique considered the healthwise trainings useful, but too short, compared with hospitals d and g in south africa and zimbabwe, respectively, which alluded to them only as enabling the implementation of healthwise. all tot workshops were conducted in english; in mozambique, simultaneous audio translation using headsets and all materials, including the healthwise manuals, were available in portuguese. additional time may have been warranted due to the language difference, since interpretation demanded a slower pace and longer explanations. for hospitals a, c, d, e, and f, where participants communicated with the research team, this was perceived as an enabling factor. the process of communication, including tools for translation, ought to have been made clear to participants and questions encouraged, particularly following the tot workshops to help the initial implementation gain momentum, as opposed to waiting six months for check-in meetings. overall, the actions carried out by local team members were key to the implementation of healthwise. other studies have demonstrated the critical role of external facilitators and shown links between the different constructs of the parihs framework. a study by ellis and colleagues found that "good facilitation appears to be more influential than context in overcoming the barriers to the uptake of [evidence-based practice]" [ ] . this experience helps to show that the roles of the facilitators were key and that improved facilitation across the different constructs could enhance the implementation. for example, facilitators could emphasize both the knowledge and practical aspects of the tool, improving its clarity; they could adapt the training based on workers' levels of knowledge and skills in regard to ohs; they could demonstrate how the tool fits within the workplace in relation to the hospital's mission and to other programs and priorities, and help participants advocate for its implementation to improve both worker and patient safety and to better align with existing ohs legislation. a key strength of this project was the existing north-south partnership, which enabled the collaboration between multiple countries, one in the global north and three in the global south [ ] . according to landau [ ] , "international research partnerships enact and expose the inequalities, structural constraints, and historically conditioned power relations implicit in the production of knowledge". caution is needed and care must be taken to mitigate factors that could exacerbate inequalities and inequities. in this study, local research partners and team members were instrumental in initiating, carrying out, and sustaining the project. one specific measure that was taken was to provide as much direct budget control to the southern partners as the funder permitted. some limitations were related to administrative issues, such as delays securing approvals from multiple countries and facilities. data collection instruments ought to also have been piloted, particularly following translation to portuguese, and streamlined to avoid overburdening participants. this may also have helped to reduce the missing data from incomplete questionnaires; as it stands, further research is required to fully understand the more nuanced aspects of certain constructs, particularly context, where responses were not specific or detailed enough to comprehend how minor differences affected implementation. understanding how healthwise-related changes affected the ohs of hws was a desired yet difficult-to-capture aspect of this study, particularly due to insufficient existing incident reporting procedures and data collection systems at the participating hospitals. therefore, while we were able to describe some improvements that were made, we were limited in assessing ohs outcomes and focused instead on enabling factors and barriers to implementation. as a final reflection on our experience, it is worth noting that the research team initially intended to participate as mere observers to the implementation of healthwise, to understand how a standalone tool to improve the health and safety of workers, introduced via a single training session, was implemented in different hospitals in different countries. this hands-off approach was also used to discourage dependency on local teams, whose resources and time are limited, and on international funds, of which there are less and less. however, the capacities of the countries to implement healthwise were limited by their differing knowledge and skill levels in regard to ohs; while hospitals in south africa had workers who specialized in ohs and existing committees, hospitals in mozambique and even more so in zimbabwe needed to start with more basic training. implementation was also limited by resources, which were undeniably scarce in all three countries, but again, especially so in mozambique and zimbabwe, as well as by the expectation that external funds were the solution. the team gradually increased their level of facilitation, providing additional practical training and encouraging larger hospitals to start small by focusing on one department instead of being overwhelmed by the whole hospital. this shows that in some contexts, a standalone tool is insufficient and a more robust toolbox that addresses the need to build capacity in implementation science is needed. future work is focused on developing and testing preparation strategies and materials that might make it easier for individuals and teams who are keen to improve the ohs of their health facilities to do so independently using healthwise. documenting experiences implementing healthwise and other tools, including any adaptations made, and making these available via publication or central repository ought to also be encouraged. the effort to develop tools for protecting hws must be accompanied by comparable attention to the way in which these instruments are implemented in settings of need. our study of the implementation of healthwise in seven hospitals in the southern african region provides clear documentation of how a variety of enabling factors and barriers can influence success. building on methods, such as the application of the i-parihs framework which we pursued, a valuable evidence base can be built to support efforts for ensuring that improved work environments for hws are part of strengthened health systems. with this vision, future implementations ought to focus on areas such as providing clarity about the tool and helping participants to develop clear goals and expectations based on their ohs knowledge and skill levels and on the amount of resources and time available to them. securing support from senior leadership and middle management and assembling a dedicated and diverse healthwise team would also be beneficial. emphasizing the need to work within existing constraints and find no-or low-cost solutions is also key in resource-poor areas. future research might focus on examining construct characteristics in further detail and on testing ways to overcome obstacles, as well as on what additional materials might help to create a toolbox, as opposed to a standalone tool, to enable facilities to implement healthwise on their own. promoting and improving the health and safety of hws at work is part of the solution to increasing recruitment and retention of these essential workers and curbing current and projected shortages in the global health workforce. human resources 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implementing evidence-based practice: linking evidence to action the context assessment for community health tool-investigating why what works where in lowand middle-income settings safety culture in healthcare: a review of concepts, dimensions, measures and progress strategies for improving patient safety culture in hospitals: a systematic review collaboration between infection control and occupational health in three continents: a success story with international impact improving influenza vaccination of healthcare workers by means of quality improvement tools low-and middle-income countries face many common barriers to implementation of maternal health evidence products translating team creativity to innovation implementation: the role of team composition and climate for innovation identifying opinion leaders to promote behavior change the role of clinical opinion leaders in guideline implementation and quality improvement a critical examination of representations of context within research on population health interventions uncovering middle managers' role in healthcare innovation implementation what roles do middle managers play in implementation of innovative practices? health care manag knowledge translation in uganda: a qualitative study of ugandan midwives' and managers' perceived relevance of the sub-elements of the context cornerstone in the parihs framework analysis of context factors in compulsory and incentive strategies for improving attraction and retention of health workers in rural and remote areas: a systematic review getting evidence into practice: the role and function of facilitation from workshop to work practice: an exploration of context and facilitation in the development of evidence-based practice communities of knowledge or tyrannies of partnership: reflections on north-south research networks and the dual imperative this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we would like to acknowledge the dedicated health workers who participated in the implementation of healthwise at each of the participating hospitals. we would also like to acknowledge the in-kind contributions from team members and staff at the international labour organization and the national institute for occupational health for their time and expertise in ohs. sincere thank you to ana tina titos mutola jemuce, jonathan ramodike, and shamiso muteti fana for their contributions to this project. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord- -aj yknky authors: ortiz posadas, martha r. title: medical technology management in hospital certification in mexico date: - - journal: healthcare knowledge management doi: . / - - - - _ sha: doc_id: cord_uid: aj yknky mexican health policy is promoting the quality of health services by hospital certification meeting the nmx-cc standards family, which is the mexican equivalent of the iso standards family. these standards can help both product- and service-oriented organizations achieve standards of quality that are recognized and respected throughout the world in developing a quality management system (qms). mexican health policy is promoting the quality of health services by hospital certification meeting the nmx-cc standards family, which is the mexican equivalent of the iso standards family. these standards can help both product-and serviceoriented organizations achieve standards of quality that are recognized and respected throughout the world in developing a quality management system (qms). in hospital certification, one important aspect to beevaluated is the availability of technical supplies. in this sense, the incorporation of technical support services into healthcare organizations has become very important. that is why many hospitals in mexico, both public and private, have incorporated into their organization a biomedical engineering department (bed) with the purpose of integrating all engineering and management processes for assurance of the optimal use of all technological supplies in the hospital, helping in the quality of health services provided to patients. the purpose of this study is to show how the medical technology management done by the bed at the hospitals contributes both to health services quality and as an element required for certification. in general, it describes several projects developed in different hospitals (public and private) with different health levels in mexico city. each of them contributed to the certification of different clinical processes. iso standards are voluntary. as a nongovernmental organization, iso has no legal authority to enforce their implementation. some iso standards (mainly those concerned with health, safety, or the environment) have been adopted in some countries as part of their regulatory framework, or are referred to in legislation for which it serves as the technical basis. such adoptions are sovereign decisions by the regulatory authorities or governments of the countries concerned; iso itself does not regulate or legislate. however, although iso standards are voluntary, they may become a market requirement, as has happened in the case of the iso qmss. by qms we understand a management strategy that is characterized by: a focus on process management; a focus on quality, based on the participation of all members in the organization; getting profit through client satisfaction and providing benefits to all members in the organization and in the society. for governments, international standards provide the technological and scientific bases underpinning health, safety, and environmental legislation. for consumers, conformity of products and services to international standards provides assurance about their quality, safety, and reliability. for customers, the worldwide compatibility of technology that is achieved when products and services are based on international standards brings them an increasingly wide choice of offers, and they also benefit from the effects of competition among suppliers [ ] . in this sense there are some important quality management principles: customer focus, leadership, involvement of people, process approach, system approach to management, continual improvement, factual approach to decision making, and mutually beneficial supplier relationships. in particular, the process approach (from procedures to processes) is based on the following principles: • identifying processes needful for the qms; • demonstrating the ability of processes to achieve planned results and monitor, measure, analyze, and improve them; • developing information on characteristics and trends of processes; • top management reviewing process performance and improving effectiveness; • greater effectiveness when activities and resources are managed as a process; • more customer focus; • more cost effective; • meeting business objectives, the term iso refers to a set of quality management standards. this approach is based on the development of a qms that meets the new quality standard, in order to control or improve the quality of your products and services, to reduce the costs associated with poor quality, or to become more competitive, or because your customers expect you to do so, or because a governmental body has made it mandatory. you then develop a quality management system that meets the requirements specified by iso : . ., f --- in mexico, the iso family have been translated by the "spanish translation task group," providing the mexican standards nmx-cc, a set of standards to assist any organization with implementing a management quality system. in this study we just use the following mexican standards: • nmx-cc- -imnc- . quality management system. concepts and vocabulary [ ] . this describes the fundaments and specifies the terminology for theqms. • nmx-cc- -imnc- . quality management system. requirements [ ] . this specifies the requirements for the qms for any organization which needs to demonstrate its capability to provide products that comply with the legal and their clients' requirements, in order to improve their clients' satisfaction. the national crusade for quality in health services is a government policy developed by the health ministry of mexico. its purpose is to lead to more effective medical services in all mexican health institutions [ ] . this policy proposes elevating qualityin health servicesand standardizing it throughout the country. to achievethis purpose, the policyhas been developed through statements. one of theseconcernsthe certification of organizations and individuals. this actionhelps public and private institutions improve the satisfaction of both the personnel and the customers (patients). it reduces heterogeneity in the quality level among different typesof healthservice,whetherpublicor private,throughout the country. in addition,the population will gain an improvedperception about the qualityof services with veridical information, which allows people's trust in the health system to be raised. likewise, it will look to incorporating the population in supervision of quality health services. manyhospitalsin mexicocityhavebeenworking to complywiththe requirements of themexicanstandards nmx-ccin orderto becomecertificated. this procedure certificates each clinical service (in an individual way), which is consideredas a process by the standard. in this sense, hospitals must develop the required documentation for all procedures related to each process, including clinical, technical, and administrative aspects. with regard to technical aspects, the department generally in charge of the medical technology management at a hospital is the bed. its main functions are medical equipment maintenance (preventive and corrective), medical equipment assessment, training, security, and risk management. however, the most important function that demandsmostof the technical personnel'stime is medicalequipment maintenance [ ] . it is clear that all these activities have the objective of assuring optimal functionality of the available medical technology at the hospital. in this way, the technology management turns into a fundamental element in hospital certification, andthus all the servicesandprocedures relatedto medicaltechnology management provide by the bed must also comply with the mexican standards family nmx-cc. in what follows, we will describe some projects developed in different hospitals in mexico city related to different clinical services (processes) where the bed developed severalmanualsabout specific proceduresfor medicalequipment management in order to contributeto the certification of these services. project [ ] was developed in a secondary care private hospital with beds. this hospital had implemented a guaranty quality program, based on the nmx-cc- -imnc- standard. it was developed specifically for the managementof radio-diagnostic equipment. this programincludesprocedures concerning physical inspection and equipment functionality according to the manufacturers' technical specifications, as well as quality control tests. afterwards, the tests were applied according to the mexican official norm nom- -ssa- related to technical specifications for diagnostic medical equipment that uses x-rays. preventive maintenance tests were developed. these included physical, mechanical, and electrical aspects for monitoring the most significant functionality parameters in the equipment, in order to assure their stability as a function of time. quality tests were also developed. these evaluate functionality parameters with the objective to get a reference value (control value). these parameters were: focal point, exposure time, performance, field coincidence, center coincidence, fuzzy alignment, exposure rate for conventional fluoroscopy, and dose in breast tumor radiation. both preventive maintenance and quality tests were applied to items of radio-diagnostic equipment (which included x-ray, cat,mastograph, and fluoroscopy equipment) at the hospital during three consecutive weeks. failures were detected in some equipment, and the optimal functionality of other equipment was probed. project [ ] was developed in a -bed private hospital that decided to implement a qms based on the nmx-cc- -imnc- standard. the purpose was to assure the quality of the health services provided to their patients. the hospital developed a quality manual that provides information about the quality plans. these plans are documents that specify the facilities and activities necessary to realize the health processes in an effective way. on the other hand, the hospital's bed has the function to maintain the medical equipment in optimal condition. that is why the objective of this study was to develop a quality plan (based on nmx-cc- -imnc- ) containing the process related to this activity, in order to support the implementation of a qms and the certification of three specific health services at the hospital, namely pathology, clinical laboratory, and blood bank. moreover, this quality plan also provides the necessary information to enable the technical personnel to carry out the maintenance process on the medical equipment. first, we identified three processes related to maintenance. ( ) revision routines, which corresponds to visual and functionality inspection of hospital facilities and medical equipment done in a scheduled way. this requires diagnostic instrumentation, simulators, and noninvasive tests, such as fluids level analysis, temperature, and pressure tests. ( ) preventive maintenance, which is defined as a programmed serial inspection of functionality, security, and calibration realized in regular periods. the purpose is to avoid failures in medical equipment and enable hospital facilities to operate at optimal levels of efficiency. ( ) repair, which covers activities such as spark replacement, component adjustment, reconditioning, etc. whose purpose is to restore the normal function, performance, and security of the equipment in the least possible time. it is important to say that the equipment maintenance could be done by technical personnel from the hospital bed or by externaltechnicalpersonnel,dependingon the technical complexity of the equipment. thequalityplandeveloped in thisstudy' containsthegeneralprocedureto realize each process witha flow diagramshowingthe graphicsof the process.likewise, it points out the registerform (service order,revisionprocess,etc.) requiredin each case. project [ ] was developed in a private hospital with beds. it has a surgical area consistingof surgical rooms.fiveof these have endosuites, surgical suites designed to create the optimal operating environment for the surgeon, staff, and, most importantly, the patient.todayit is themost versatileroomdesign,andserves a large number of minimally invasive procedures (endoscopy, laparoscopy, and arthroscopy) [ ] .the system'sfunctions andimagesaredisplayedon multifunction flat-panel monitors, which are also capable of showing images. the purposeof this study was to developa procedures manualaboutthe use and management of the medicaltechnology utilizedin minimallyinvasive surgeriesat the hospital, in order to provide information about the adequate management of the equipment to the technical personnel from the dib and adequate use of this equipment for the medical personnel, as well as to contribute to the certification of the surgicalprocess. the procedures were generated by clinical·and technical information. the methodology for obtainingand organizing these procedures is described below. . identification of the types of minimally invasive surgery done in the hospital. they were classified into fivemedicalcategories: gynecology, general surgery, thoracic,orthopedics, and otorhinolaryngology. . identification of the medical technology used in each surgery. six technology sets were defined, according to the medicalcategoriesidentified. in the case of orthopedics, this requires two different technology sets, i.e. one for shoulder surgeryand other for knee surgery. . weconsulted technicalmanuals with the purpose of obtainingthe technical specifications of the equipment, as wellas the manufacturers'recommendations for the use and management of the equipment. . fourteen technical schedules were developed with the next information: (a) description of the equipment(including alarms); (b) physical inspection procedure; (c) management of the equipment (washing, sterilization (if necessary), warehoused, andcare); and (d) warnings and precautions. this information was incorporated in the procedurein order to provide the technical elements about the functionality of the equipmentto the technicalpersonnel from the bed. . six generic procedures about the use and management of electronic devices and medical equipment used in each minimally invasive surgery identified were elaborated. it is important to say that biomedical engineering helps the physician in all the procedures related to the minimally invasive surgeries done at the hospital. in this sense, the procedures included in the manual will be an instrument for technical and medical personnel for learning the adequate used of the medical technology, and so the optimization of the resources and the technical capability of the hospital. the procedures developed here are actually incorporated into the documentation of the management quality system of the hospital. this system provides the regulation for optimal functionality of all services (medical and administrative) from the hospital. project [ ] was developed at the national health institute in its infectious diseases research center (cieni). the center works with the human immunodeficiency virus, mycobacterium tuberculosis, influenza virus (h nl) and the sars corona virus. it has three laboratories designed with the necessary bio-safety standards, levels bsl and bsl . the laboratory equipment has two kinds of contact with the infectious agents, namely direct and indirect. for example, pipettes have direct contact and c incubators have indirect contact because the virus is in petri boxes. that is why the technology requires specific management and control. the objective of this study was to develop preventive maintenance procedures for the laboratory equipment present in this center, involving aspects about risk management and quality control. the importance of these kinds of procedure is that activities related to the maintenance and the sanitation procedures attending bio-safety should decrease the biological risk for technical personnel. in this sense, the partial goals of this study were to provide to the technical personnel from the bed the bio-safety procedures necessary for minimizing biological risk during the execution of work: • a complete preventive maintenance procedure for each specific piece of equipment. • technical and quality specifications required during the execution of the maintenance procedures and equipment calibration. • minimization of equipment failure, assuring continuous operation of the equipment and extending its useful time. • contribution to the certification process of severalclinical and research laboratory processesat the centerby complyingwiththe mexican standardmx-nmx-cc. there were piecesof equipmentselected: ( ) two doors sterilizer, ( ) analytical digitalbalance,( ) extraction bench,( ) laminarflux bench,( ) centrifugeand micro-centrifuge, ( ) refrigerated centrifugeand ultracentrifuge, ( ) laser diffraction particle-size analyzer, ( ) c incubator, ( ) microscope, ( ) pipettes, ( ) digital potentiometer, ( ) refrigerator, ( ) ultra-freezer. the procedures were structuredas follows: . introduction. this includesgeneralinformation about the featuresof the different research laboratories at cieni. . general and security rules. these providethe securityprocedures requiredfor access to the center and for equipmentmaintenance. . procedure for preventive maintenance. each procedurecontains the following information: maintenance periodicity, security procedures (the securityequipment requiredfor doing it), maintenance procedure(including generalexternal cleaning, external inspection, internal cleaning, internal inspection, lubrication, spare parts replacement, calibration, revision of electrical security, and full functionality tests). . equipment, toolsand spare parts. this section provides information about the tools and spare parts necessaryfor carrying out preventive maintenance on the equipment, as well as consumables for the operationand calibration. . quality control. some actionsrecommended for qualitycontrol were included, such as: a daily registerof parameters (temperature, pressure,humidity, etc.) in order to monitortheir fluctuations; instrumentation necessary for maintenance, certificated by the mexicanentity of accreditation [ ] . . registrationform. thisformincludesgeneraldataabouttheequipment(generic name, trademark, model, serial number, inventory number, and the clinic area whereit is placed),periodicity of themaintenance, the reportof thefunctionality tests, electrical security, and calibration. furthermore, there three appendices were incorporated: ai. cleanersand lubricators, a . disinfectors' substances, and a • proceduresin accidentcases [ ] . this study had described four different projects related to medical technology management developed by bedsindifferenthospitalsinmexicocity. the primary objective of all these projects was to provide knowledge about the maintenance procedures and quality control tests to the technical personnel to carry out their jobs and to contribute to the certification process by the nmx standards for the clinical services at the particularhospital. this study shows the importance of having documented procedures related to the management of medical technology in order to optimize the technical facilities available in the hospital, as well as for the certification. in mexico, hospital certification is a new process, and projects developed in this way will be very important in the hospital environment in order to guarantee the quality of the clinical services provide. overview of the iso system sistemas de gesti n de la calidad-fundamentos y vocabulario sistemas de gesti n de la calidad-requisitos funciones de los departamentos de ingenierfa biomedica en instituciones de salud publica y privada en mexico programa de garantfa de calidad para el servicio de radiologfa del hospital mocel. proyecto terminal. licenciatura en ingenierfa biomedica plan de calidad de mantenimiento basado en iso - para el departamento de ingenierfa biomedica del hospital angeles mocel procedimientos de uso y manejo de la tecnologfa medica relacionada con las cirugfas de mfnima invasion en el hospital santa fe manual de procedimientos de mantenimiento y prevenci n de riesgos para equipo del centro de in-vestigaci n en enfermedades infecciosas del iner entidad mexicana de acreditaci n (ema) emergency care research institute (ecri), health devices inspection and preventive maintenance system key: cord- -qt worsl authors: nan title: abstract date: - - journal: virchows arch doi: . /s - - -z sha: doc_id: cord_uid: qt worsl nan bladder cancer has served as one of the most important sources of information about the events that underlie the development of human solid malignancies. although "field effects" that alter the entire bladder mucosa appear to initiate disease, tumors develop along two distinct biological "tracks" referred to as papillary and non-papillary that present different challenges for clinical management. more recently, whole organ mapping combined with genomic platforms have identified a novel class of candidate tumor suppressors (forerunner genes) that localize near more familiar tumor suppressors but are disrupted at an earlier stage of cancer development. these studies suggested three steps for the involvement of the model tumor suppressor locus, rb , in tumor development. in the first step, one allele of forerunner (fr) gene and rb is inactivated by deletions. in the second step, homozygous inactivation of the fr genes is accomplished by hypermethylation or mutations. the inactivation of fr genes is associated with the initial clonal expansion of preneoplastic urothelial cells. in the third step, the contiguous tumor suppressor, rb , is inactivated by a mutation, which is associated with clonal evolution into carcinoma in situ progressing to invasive cancer. furthermore, we have discovered that aggressive muscle-invasive tumors express molecular markers characteristic of a developmental process known as "epithelial-to-mesenchymal transition." emerging evidence indicates that urothelial cancers contain subpopulations of tumor-initiating cells (cancer stem cells), but the phenotypes of these cells in different tumors may be heterogeneous, raising questions about whether or not the two major subtypes of cancer share a common precursor. pathology as a medical specialty has been around for about a century and a half, even though the interest in understanding disease, the focus of pathology as an academic discipline, has inspired physicians since the dawn of mankind. understanding disease remains the primary focus of pathology. in the practice of diagnostic pathology, this knowledge, notably through its morphological expression, is applied to the diagnosis of disease through the examination of cells and tissues. relatively new in this field is the notion of pathology as 'the science behind the cure'. this phrase, coined by the pathological society of great britain and ireland, refers to a widening of the scope of pathology: 'understanding disease' continues to be applied to diagnosis and classification, but now also to conceiving of new ways to treat and of new diagnostic tools assisting the physician in choosing the appropriate treatment. targeted therapy, the target being a molecular pathway involved in the pathogenesis of the lesion, along with biomarkers that are predictive for response to treatment, are in the forefront of pathology. targeted drugs that require 'companion' diagnostics, a combination also called 'theranostics', are reshaping the practice of pathology. it is this paradigm shift in pathology that makes it one of the most exciting medical specialties of today. i would love to be a resident in pathology again. the prospects for this mother of disciplines in modern medicine have never been as bright. is this entirely new? certainly, the molecular revolution with 'high-throughput' technologies, array diagnostics such as 'mammaprintr' and 'deep sequencing' to name just a few technologies we have had to become familiar with, have had and will continue to have in the years to come a profound impact on the way we practice pathology. but guiding the surgeon's hand or the pen of the oncologist in prescribing drugs has been a primary responsibility for pathologists ever since examination of cells and tissues was being applied to the practice of medicine. prognostic factors have interested pathologists long before the onset of the molecular revolution. grading and staging of neoplastic disease based upon morphological characteristics remains the mainstay of stratification of patient groups for treatment optimization. and predictive value is not limited to molecular markers: small cell carcinoma of the lung, to name just one example, will not be treated surgically, but chemotherapy is effective, even though as a rule not to the extent that the patient can be cured. we dispose of numerous morphological parameters that are prognostic and predictive. that pathological parameters have predictive value is therefore nothing new. this has become more so with the discovery that steroid hormone receptor expression predicts the response to anti-hormonal treatment and that her /neu amplification predicts the response to her /neu antibodies in breast cancer. it has become clear that the type of c-kit mutation in a gist predicts whether or not the patient will respond to a tyrosine-kinase inhibitor (imatinib), which dose of the drug would be appropriate or which second-generation inhibitor might be used. k-ras mutations will tell the oncologist that the patient will not respond to egfr inhibitors in the form of small molecules (gefatinib) or monoclonal antibodies (cituximab). the latter is also a striking example of the limitations of many of the tools that we dispose of: the k-ras mutation status will tell us who will not respond to the therapy, but not who will. based upon detailed knowledge of the molecular characteristics of many types of cancer, pharmaceutical companies are now developing a host of new drugs and more often than not are teaming up with pathologists to develop diagnostic tests that might predict which patient groups might profit from the new drug. this should not become a hype, the type of buzz that went around the h n pandemic which in hindsight was not justified by what happened in the field. let us remain modest. first of all, the number of diseases for which the combination of new drug and predictive molecular test exists remains limited. secondly, the impact of this new and promising approach to final outcome should keep us modest. for colorectal cancer, new therapies have pro-longed survival, but not cured more patients. thirdly, expectations that we will be able to predict at the level of the individual patient what the best therapy would be and how the disease will respond or progress is an illusion. 'individualized' medicine is still based upon studies on large patient groups with as outcome parameters that with a certain level of probability will indicate what might happen. a lot remains to be studied and developed. this implies also a new role for pathology. we should team up with clinical trials, using this context to conduct biomarker studies that can be implemented in daily practice. we should collaborate with drug developers to get to the desired 'companion' diagnostic tools. for pathology, exciting times indeed. breast lesions mimicking malignancy z. varga* *switzerland cell types arising normally in the breast can occasionally exhibit peculiar overgrowth or nuclear features mimicking malignant cells and thus representing potential diagnostic pitfalls. myoepithelial cell hyperplasia can reach an extensive mass and imitate lobular neoplasia or ductal carcinoma in situ with pagetoid spread. ductal epithelial cells with apocrine phenotype can appear, with highly worrisome nuclear features making the distinction between a high-grade ductal carcinoma in situ and a banal apocrine change at times quite challenging. the evidence of a preserved myoepithelial layer is a commonly accepted morphological criterion for noninvasive processes in the breast. the distinction between adenosis, highly differentiated ductal carcinomas and cancerisation of the lobules through in situ ductal carcinoma can be easily done by decorating myoepithelial cells in immunohistochemical reactions. an important exception to this rule is, however, the benign microglandular adenosis, which completely lacks the outer myoepithelial layer. intraductal epithelial proliferations can be quite florid in their extension. the question whether they represent atypical hyperplasia resp. ductal carcinoma in situ or appear simply within the scope of a florid intraductal hyperplasia occurs often in daily diagnostic service. the use of a distinct and technically reliable diagnostic panel (e-cadherin, basal cytokeratins, hormone receptors, her immunohistochemistry and in situ hybridisation, collagen iv reaction, ki- , s- and myoepithelial markers) can clear the situation in most of these difficult cases and thus can lead to the correct diagnosis. immunohistochemical differentiation of intraductal breast lesions w. p. olszewski* *center of oncology, dept. of pathology, warsaw, poland objective: immunopathological methods, particularly immunohistochemistry (ihc), are now routinely used in all invasive breast carcinoma cases as part of the evaluation of predictive factors (er, pgr, and her ). other ihcdetected antigens are used for the determination of invasiveness (e.g. p and sma), searching of primary (e.g. gcdfp and mammaglobin) or in scientific field as surrogates of genetic subtyping (er, pgr, her , egfr, lmwck, hmwck). increasing breast cancer screening on one hand and advanced surgical methods of biopsy (e.g. core biopsy, vacuum-assisted core biopsy) on the other produce a growing number of pathology material in which pathologists must diagnose on the basis of scarce tissue. most of these cases are noninvasive. however, the spectrum of possible therapies for noninvasive lesions includes observation on one side and mastectomy with radiotherapy on the other. method: therefore, determination of the exact nature of intraductal breast lesions has to be precise and sure. it generates the use of ihc antibodies in intraductal breast lesions. results: in some cases, results of such approaches create new entities. an example of such situation is differential diagnosis between clis and dcis. in a small number of cases, the interpretation of obtained stains (e-cadherin and ck be ) adds entities like positive hybrid lesion and negative hybrid lesion. conclusion: the aim of the lecture was the presentation of increasingly used ihc antibodies in intraductal breast lesions and its correlation with histological features of usual ductal hyperplasia, atypical ductal hyperplasia, lobular neoplasia, ductal carcinoma in situ, and columnar lesions (ccc, ccc+atypia, cch, cch+atypia) . the other topic is ihc expression of surrogates of genetic subtyping in carcinoma in situ. low-grade and high-grade breast cancer pathways i. ellis* *united kingdom tnm g. cserni* *hungary background: the tnm, i.e. the tumour node metastasis classification of malignant tumours, is about years old and was last updated in . although the oncology and pathology communities are expected to use this modified version from , the breast working group and the organizing committee has considered including a brief review of the topic in keeping with the educational aspects of the intercongress meetings of the european society of pathology. method: the lecture will briefly summarize the basic concepts of the tnm classification in general and will focus on the new aspects which are of interest to pathologists dealing with breast cancer specimens. some former proposals to modify the tnm will also be discussed, including the european institute of oncology proposal to abolish the present categories and replace them with coded prognostic data reporting and the replacement of the nodal categories based on the number of involved lymph nodes by categories based on the lymph node ratio (proportion of involved and examined nodes). results: na. conclusion: the tnm has been criticized for not providing enough prognostic information to guide treatment. however, it must be kept in mind that the tnm was not devised for making treatment decisions solely on the basis of the information it provides but for reporting the anatomic extent of disease in a categorical format. tnm still fulfils this aim. no system is perfect, and tnm is not an exception to this. should we use it, let us use it as correctly and uniformly as possible. wednesday, september , . - . , aula duża b gastrointestinal stromal tumours results: gist is defined as kit or pdgfra-driven mesenchymal tumor of the gi-tract, with a characteristic set of histologic features (spindle cell or epithelioid), and generally by immunohistochemical positivity for kit (cd ). dog /ano is a helpful additional marker for the positive identification of gist. current prognostication is based on mitotic activity, expressed as mitotic figures per high-power fields in an area of mm and on tumor size. different criteria are applied for gastric and intestinal gists because the latter, even with the same parameters, have a more malignant behavior. in the differential diagnosis of gist, one has to consider the following facts: wide histologic variation (especially in gastric gists), the fact that gists are the most common mesenchymal tumor in the gi tract and whole abdomen, and occurrence of gists virtually anywhere in the abdomen and rarely in distant peripheral metastatic sites. tumors that have to be considered in the differential diagnosis especially include true smooth muscle tumors, glomus tumor, gastrointestinal schwannoma, clear cell sarcoma, synovial sarcoma, desmoid, inflammatory fibroid polyp, inflammatory myofibroblastic tumor, and the newly described plexiform fibromyxoma and gastroblastoma. conclusion: detailed histologic examination supported by immunohistochemistry and kit/pdgfra mutation analysis will yield optimal diagnostic accuracy. clinical significance of kit and pdgfra mutations in gastrointestinal stromal tumours, inflammatory fibroid polyps and mucosal malignant melanomas j. lasota* *usa gists are the most common mesenchymal neoplasms of the gastrointestinal tract and represent a morphological and biological continuum from small, microscopically detected benign tumors to large sarcomas. kit or platelet-derived growth factor receptor α (pdgfra) oncogenic mutations are a typical molecular feature of gist. kit and pdgfra genes map to chromosome q and encode highly homologous transmembrane glycoproteins. activation of kit regulates important cell functions, including proliferation, apoptosis, chemotaxis and adhesion. imatinib mesylate that specifically inhibits abl, kit, and pdgfra receptor tyrosine kinases has been successfully used in the treatment of clinically advanced, unresectable, and metastatic gists. majority of kit exon mutants respond well to imatinib, while kit exon mutants are less sensitive to imatinib and require more aggressive treatment. also, tumors with the pdgfra asp val substitution, which corresponds to imatinib-resistant kit asp val mutation reported in human mastocytosis, are resistant to imatinib. although many patients benefit from imatinib treatment, resistance often develops due to secondary kit or pdgfra mutations or kit locus amplification. sunitinib mesylate, a multi-targeted inhibitor of kit, pdgfrs, vegfrs, flt , and ret receptor tyrosine kinases and other kinase inhibitors have been used for the treatment of imatinib-resistant gists. the type of secondary kit mutation can indicate response to sunitinib treatment. kit mutations were identified in mucosal mms and pdgfra mutations in gastric and intestinal ifps. although the presence of kit mutation does not necessarily correlate with kit expression in mm, an inhibition of kit receptor tyrosine kinase might still be beneficial in the treatment of selected cases. the histopathology of primary non-scarring and scarring alopecias may be complex. the reason for this is that often, the scalp biopsy provided is inadequate, and the clinical history and pattern of the alopecia are not provided to the dermatopathologist. increased diagnostic yield may be achieved by the combined use of transverse and vertical sections. this requires good communication between the dermatologist performing the biopsies, the dermatopathology laboratory and the dermatopathologist. common forms of scarring alopecias include the lymphocytic, (discoid lupus erythematosus, lichen planopilaris, central centrifugal cicatricial alopecia, pseudopelade of brocq), the neutrophilic, (folliculitis decalvans, dissecting folliculitis), and the mixed, (acne keloidalis) entities. among the non-scarring alopecias are androgenic alopecia, telogen effluvium, alopecia areata, trichotillomania and traction alopecia. in all cases of primary alopecia, a multi-team approach involving the dermatologist for adequate tissue sampling, the laboratory for appropriate laboratory processing and the dermatopathologist, together with pertinent clinical information affords the best opportunity of arriving at the correct diagnosis. graft versus host disease: an update d. massi* *university of florence, dept. of critical care medicine, italy our current understanding of histopathological features of cutaneous graft versus host disease (gvhd) is largely based on experience gained during decades of ablative hsct, in which day was regarded as the temporal cutoff for the separation of acute vs. chronic gvhd, and traditionally, acute and chronic gvhd were considered to be distinct histopathological entities. acute gvhd in the skin has been generally described as an interface dermatitis, with vacuolar basal alteration, dyskeratotic (apoptotic) keratinocytes in the epidermis and/or adnexal structures, scant dermal lymphoid infiltrate, and lymphocytic satellitosis. in contrast, chronic gvhd has commonly been reported as either lichenoid or sclerodermoid gvhd, characterized by homogenization of dermal collagen bundles, with little or no epidermal involvement. at variance with this dichotomic picture, histology of cutaneous gvhd following reduced intensity conditioning regimens is protean, displaying a variable constellation of histopathological alterations. these changes frequently blur the distinction between clear-cut clinical gvhd categories, as known in the classical ablative hsct setting. sampling errors and other technical issues may occur and may significantly affect the number of false negative cases. the utility of skin biopsies varies according to the pathologist's experience and to the prevalence of gvhd. clinicians' overall perception is that undertreatment of gvhd is much worse than overtreatment of patients without gvhd. therefore, early immunosuppressive therapy in patients with a skin eruption often precedes the results of the histopathological analysis. the pathogenesis and pathology of gvhd will be illustrated by elucidating the selective epithelial targets in the afferent stage and cellular response in the efferent stages. method: our practice in a large cancer center sees drug eruptions in the context of cancer treatment and must often be evaluated within a differential diagnosis with graft versus host disease on our bone marrow transplant service. results: with the advent of specific, targeted therapy for cancer, a new spectrum of interesting and unusual drug eruptions has emerged related to the mechanism of action of these agents. conclusion: this presentation will focus on the unique cutaneous effects arising in association with targeted therapy for cancer. wednesday, september , . - . , aula Średnia b background: the adult onset of nephrotic syndrome has been reported to be associated with underlying cancer in about % of cases. it is believed that the glomerular injury in many instances is due to the deposition of immune complexes in the glomerular capillaries. on the other hand, the course of illness in many cancer patients is complicated by infections, which may also be involved in the pathogenesis of glomerular injury. the malignancy is usually found simultaneously with, shortly before, or within a short time after the diagnosis of glomerulopathy. the glomerular lesion of paraneoplastic nephrotic syndrome usually presents as membranous nephropathy in patients with solid tumors, particularly adenocarcinomas of the lung and gastrointestinal tract. minimal change disease is strongly associated with hodgkin's lymphoma, and the most common lesions observed in patients with chronic lymphocytic leukemia are membranoproliferative glomerulopathy and membranous nephropathy. extracapillary crescentic glomerulopathy, iga nephropathy and focal segmental glomerulosclerosis are rarely associated with neoplasia. method: we present six cases of nephropathies associated with malignancies: lung, gastric and colon cancer, as well as hodgkin's lymphoma and chronic lymphocytic leukemia. all patients were over the age of and were presenting nephrotic syndrome. results: membranous glomerulopathy, minimal change disease and membranoproliferative glomerulopathy were established on the basis of light microscopy, immunofluorescence and electron microscopy. the renal lesions in paraneoplastic nephropathies did not differ from idiopathic forms of glomerulopathies. the clinical and morphologic spectrum of plasma cell dyscrasia continues to expand. while in the most advanced stage of this disease patients are diagnosed with overt multiple myeloma, at the opposite end of the spectrum, mgus is more typical. not infrequently, the underlying disease is clinically silent or can be associated with renal symptoms that prompt further investigation and thus underscore the role of renal pathologists in the early detection of the underlying process. while light chain cast nephropathy affecting distal tubules and light chain amyloid or non-amyloidotic lcdd are well recognized, in recent years, attention has focussed on the pathology affecting the proximal tubules and interstitium. proximal tubulopathy associated with an underlying plasma cell dyscrasia may be very subtle and associated with the formation of crystals or only with light chain restriction detectable in the lysomes within proximal tubules. interstitial nephritis may be associated with a rather nonspecific morphology, and only an enhanced index of suspicion may lead to the discovery of an associated light chain restriction. thus, renal pathologists are in an advantageous position to diagnose the underlying process at an early stage. therefore, it is critical to perform a full investigation of the kidney biopsy, including immunofluorescence studies that employ testing for immunoglobulin light chains, as well as electron microscopy. renal pathologists should be alerted particularly by biopsies that yield seemingly nonspecific or non-diagnostic results. investigations with congo red stain, careful evaluation of immunofluorescence studies, and electron microscopic analysis of organized and related deposits are necessary. non-hodgkin lymphomas and ptld in renal biopsies a. c. feller* *germany cytostatic drug and radiation-associated renal lesions h. regele* *austria malignant tumors might impair renal function in multiple ways. in addition to a direct impact of the tumor or its derivatives like light chains in the case of multiple myeloma, renal injury might also be a consequence of therapeutic interventions. certain cytostatic drugs (especially platin-based compounds), but also irradiation, are long known to cause renal tissue injury. the damage might affect both the tubulointerstitial space and the vasculature. in addition, it was shown that recently introduced biological agents might lead to additional patterns of drug-induced injury. blocking the action of vegf in order to interfere with tumor-induced neoangiogenesis might for example cause renal thrombotic microangiopathy. in my talk, i will discuss the histological patterns of injury caused by the different treatment modalities and the underlying pathogenic mechanisms. the knowledge of these mechanisms might help prevent renal damage. background: the morphological presentation of lung problems in infants and children is not always pathognomonic for a specific diagnosis. basic patterns are not always easily recognized and may be different from the adult situation, even with the same classifying diagnosis. method: as lung neoplasms are seldom seen in children, this overview will focus on non-neoplastic lung disease. results: a main category is interstitial lung disease. the main adult patterns of interstitial disease can also be observed in children, although uip, dip and nsip are rather rare and not always with similar aetiology (e.g. desquamative interstitial pneumonia, associated with smoking in adults). the distribution of the interstitial changes is in those cases similar to adults, but morphological presentation may be different because of a different lung structure. some interstitial patterns are specific for childhood: for example, chronic pneumonitis of infancy, pulmonary interstitial glycogenosis (formerly cellular interstitial pneumonitis) and neuroendocrine cell hyperplasia of infancy, but even so, these are not always easy to discern form the other patterns. if a (wedge) lung biopsy is taken at late stage or only from the most severe abnormalities, a characteristic pattern may be obscured by nonspecific common final pathway changes like fibrosis. conclusion: all diffuse lung diseases in infancy can be caused by many etiologic factors. this means that although there are several hallmarks that can aid in making a proper pathological diagnosis, similar as in adults, proper clinical and radiological information is essential. objective: tobacco and cigarettes are implicated in multisystemic carcinogenesis due to carcinogenic components that induce maintained inflammation, endocrine deregulation and genetic alterations in continuum. as ambience influence acts through a multifactorial behaviour gathering smoking, obesity and dietary mistakes, being sedentary, alcoholism, sexual promiscuity, toxic addition and general pollution, the isolated influence of smoking is reinforced. smoking-related non-tumoral lung diseases comprise copd, rb-ild, dip, acif/ibip, hx (langerhans cell histiocytosis), sarcoidosis (not consistent), eosinophilic lung, constrictive and lymphocytic bronchiolitis, emphysema together with sub-pleural and interstitial fibrosis uip-like or nsip-like, as well as possible combinations of all these diseases and patterns. smoking also increases or exacerbates infections (tp and other bacterial pneumonias, varicella pneumonia and influenza), pulmonary hemorrhage and pneumothorax and vascular walls fibrosis. conclusion: as smoking-related interstitial lung disease (srild) has been proposed to encompass clinical and radiological coordination, it means that molecular pathology achieves its role to define therapy as it is being tried in cancer. despite observed morphology, it is possible to localize the defence response along the bronchial-bronchiolar-alveolar pathway as epithelial and mesenchymal cells develop particular ways of adaptation, either by emt and met. as inflammation stands through fibroblasts, cellular mtor and macrophage activation, also epithelial hyperplasia and metaplasia, install both at bronchial and pulmonary stem cells pool. smoking-related lung diseases are not consistent with a spectrum but rather with expertise to report delicate inflammatory changes in morphology that diverge to interstitial (and vascular) incapacities and/or to pre-neoplastic epithelial lesions and bronchial-pulmonary carcinoma. pitfalls in interstitial pneumonias h. popper* *medical university of graz, institute of pathology, austria interstitial pneumonias can be classified into uip, dip, nsip, op, and dad. whereas dad as an acute interstitial pneumonia is easily separated and diagnosed, due to the presence of alveolar damage and hyaline membranes, the other entities might cause problems in diagnosing. the most important distinction is between uip and the other entities because uip is a rapid progressive and deteriorating disease with a high mortality rate. usual interstitial pneumonia is histologically characterized by the presence of fibroblastic foci, cystic changes called honeycombing, areas of fibrosis and scars, and a temporal heterogeneity, which results in areas of early inflammatory changes, late changes, and also areas of uninvolved lung parenchyma. the disease usually starts from the lung periphery in a patchy distribution pattern. the lower lobes are usually more affected than the upper lobes. the disease starts with tiny lesions where the surface epithelium is destroyed. underneath myofibroblasts are proliferating and the stroma is changed into a myxoid stroma composed of acidic mucopolysaccharides. these lesions are called fibroblastic focus. this repair process is accompanied by a regeneration of pneumocytes, which usually undergo metaplastic changes (bronchiolization, cuboidal metaplasia, stem cell proliferation). finally, this process results in fibrosis. several fibrotic areas might finally confluent into a scar tissue. fibroblastic foci are not only seen in alveolar septa but also in bronchioles and small bronchi. scarring in these airways results in the obstruction of the airways, and the periphery of these airways undergoes a cystic dilation, accompanied by metaplasia of the epithelium; again, bronchiolization and metaplasia, even squamous metaplasia, can occur. mucus produced by the epithelium cannot escape, and therefore, the cystic spaces increase in size, being finally visible at ct magnification. these cystic air spaces form the honeycomb lesions. in uip, fibroblastic foci can be seen in the different stages of development: early stages with lots of myxoid matrix, immature collagen, and many proliferating myofibroblasts and old stages with lots of mature collagen and fibrocytes. honeycomb lesions may present in a florid stage where some fibroblastic foci can be seen within the cysts, or older lesions with lots of mucus, or old lesions with secondary bacterial pneumonia overlying uip. also, the scars can be old, devoid of inflammatory infiltrates, or younger with scattered fibrocytes and lymphocytes. this together forms the temporal heterogeneity of uip. fibroblastic foci are often used as the dominant and even sole diagnostic criterion for the diagnosis of uip. this can result in an incorrect diagnosis since other interstitial diseases can also present with fibroblastic foci. in the presentation, we will review several cases presenting with fibroblastic foci, which can closely mimic and might give rise to an incorrect diagnosis of uip. pitfalls in drug-induced lung pathology b. murer* *italy the role of pathologists in translational research for patients and industry m. dietel* *universitätsmedizin charité, berlin, germany background: due to continuous technical developments and new insights into the complexity of many diseases, e.g. cancer, molecular pathology is rapidly growing gaining center stage in the clinical management of tumors and pharmaceutical development of new anti-cancer drugs. activated signaling components are the targets for the newly developed inhibitors, e.g. small molecules (gefitinib, erlotinib) and therapeutic antibodies (panitumumab, cetuximab). however, the application of the compounds in clinical trials has revealed promising results only when predictive procedures have been available for determining which patients will benefit from targeting therapy, so-called eligibility or predictive tests, e.g. her in breast cancer, kras and egfr mutations in colorectal cancer and non-small cell lung cancer. for the pharmaceutic industry, predictive tissue-based assays are of increasing importance in the development of new targeted drugs. fda and emea stressed this issue several times during the process of approval, and pathology based analyses will become an essential factor in drug development. conclusion: for pathology, the situation to become a partner in the clinical decision, which drug shall be given to the patient and which assay can be made available for a new, is a chance and a challenge in one. the issues to be solved are: ( ) morphology, in particular immunohistochemistry and in situ hybridization, must become measurable, e.g. by virtual microscopy. ( ) the molecular assays must be done absolutely reliably and be reproducible. ( ) quality control, i.e. ring trials/round robin tests, must be passed by all active labs. if these challenges (and some others) are met, molecular pathology is facing an excellent development. the role of biobanking and translational research for the pathologist f. carneiro* *ipatimup, porto, portugal among biobanking initiatives, tumour banks play a pivotal role in biomedical research. the general aim of a tumour bank is to acquire neoplastic and control non-neoplastic samples in standardized conditions for research (basic, clinical or translational) . a tumour bank is a vital new resource for cancer research providing high-quality, wellcharacterized tissue. it is possible for pathologists to collect fresh tissue prospectively during their routine dissection procedures. in this way, the specimens can be optimally sampled and stored for both diagnosis and research purposes. ideally, specimens are sampled immediately after surgery, prior to fixation, to ensure optimal preservation of proteins and nucleic acids. retrospective collection of tumour tissue for study and banking purposes is feasible also because in most countries, pathology laboratories have been legally obliged to file, for at least some years, the formalin-fixed and paraffin-embedded samples that were analyzed. over the last decade, tumour banks acquired a pivotal role in translational research in the field of oncology, providing tools for the evaluation of new predictive factors; evaluation of the value of a known target in a new entity; search for new therapeutic targets; validation of new diagnostic markers; and implementation of new diagnostic procedures, namely development of tissue-based diagnostic tests for guidance of therapy with new drugs introduced in clinical practice. in this scenario, it is a priority to emphasize the central role that pathologists play in translational research, specifically in tumor banking, by the establishment of a bridge between clinicians and basic researchers. limits and perspectives for standardization of tissue processing g. bussolati* *italy the paper by pupo and colleagues is a well-conducted study on the role of the gasotransmitter hydrogen sulphide in angiogenesis. the increased effect of hydrogen sulphide in tumor-derived endothelial cells and its possible effect as a vegf second messenger are of interest in the field of tumor angiogenesis. criticisms: (a) it would be important to show the specificity and non-toxicity of hydrogen sulphide synthesis inhibitor on endothelial cells. ( ) experiments using the cystathionine lyase inhibitor alone on tec proliferation and cytotoxicity are required. ( ) standardization and controls of methods for molecular analysis in archive tissues g. hoefler* *medical university of graz, institute of pathology, austria background: formalin-fixed paraffin-embedded (ffpe) samples represent the vast majority of tissue specimens available from tissue archives, available routine diagnostics, as well as research purposes. these tissues vary among institutions with respect to pre-fixation time, formalin fixation time, concentration and buffer systems used. therefore, it is of utmost importance to standardize the methods for molecular analyses to obtain consistent and comparable results. method: the first and maybe the most important step is the isolation of nucleic acids (dna, rna) from ffpe samples. in a recent multi-centric study performed by european laboratories of the impacts group, the results obtained by different laboratories varied significantly, even when the same commercial kit was used. the dna extraction protocols used by the laboratories ranged from homemade protocols with and without purification steps to commercially available kits. the extractions were performed using the same ffpe specimens. results: for array applications or tests that require accurately determined dna input, silica-based adsorption columns for dna recovery are recommended. for rna extractions, the best results were obtained for chromatography column-based commercial kits, with respect to quantity and quality. quality testing resulted in the successful amplification of -to -bp pcr products from most tissues. modifications of the protocol, especially with regard to proteinase-k digestion, led to significant improvements, also for the performance of commercial kits. the results emphasize the need for standardization and control of methods for molecular analysis in archive tissues to allow the generation of valid and comparable results in both diagnostic and in research settings. approaches to the development of a european network of archive tissues g. stanta* *university of trieste, a.c.a.d.e.m., italy ffpe tissues taken from patients are stored, sometimes for a very long time, in the pathology archives. with this material, it is possible to do very important translational research. any strategy is possible, such as that of large number analysis or rare entity collections. there is the necessity to transform our pathology biorepositories into a biobanking network. this can be done through a european organization that could be developed within the esp and starting from the "impacts" groups, which gained a large experience in molecular analysis validation and standardization of this kind of tissues. a european archive tissue biobank network depends on the willingness of the pathologists to participate, considering that this can significantly improve the diffusion of molecular methods, translational research and consequently acceleration of clinical application of molecular methods among pathologists. this can be done by a voluntary and collaborative participation of pathologists in specific projects, as scientific collaborators. the pathology archives will always be clinical biorepositories, and their function is going to change into a biobank function after accepting participation in a specific project, with the anonymization of the personal data of the patients. the networking system is based on low-cost activities with an easy governance and management of the biobanking system and with guarantees of protection of human material and data. qualification, education and training will be implemented by the network organization and with the collaboration of the esp. with cisplatin mg/m every weeks for four cycles, followed by mastectomy and then conventional chemotherapy. surgery occurred weeks after the final dose of cisplatin. the excised breast tissue and lymph nodes were examined for the presence of residual disease. pathologic complete response was determined by a review of surgical specimens. results: forty patients were enrolled in the study. twentyfour patients had tumors of > cm and patients had positive lymph nodes at diagnosis. thirty-seven patients completed four cycles of cisplatin and three patients completed two cycles. clinical complete response was observed in patients ( %). pathologic complete response was observed in patients ( %). conclusion: platinum-based chemotherapy is effective in a high proportion of patients with brca -associated breast cancers. clinical trials are warranted to determine the optimum treatment for this subgroup of breast cancer patients. clinical outcome of ovarian cancer in respect to polymorphism of low-penetrance genes e. grzybowska*, k. tcza, j. pamua-piat, s. jdru, e. telka, z. kosza, b. zema *centre of oncology-msc memoria, dept. of molecular biology, gliwice, poland objective: we wanted to analyze the influence of modifying genetic factors on the risk of brca(+) and brca(−) breast and ovary cancers and on clinical parameters as the age of onset and survival. method: the study includes three hundred forty-eight anonymous healthy women (control group), persons with ovary cancer, persons with breast and ovary cancer (case group). the patients under study developed breast cancer prior to ovary cancer. rflp and asa pcr were used to analyze mutations in brca genes and polymorphisms in pgr, mdr and tp genes. results: the presence of allele t of pgr significantly decreased the risk of second malignancy (breast cancer; or= . , p= . ). heterozygote ct of mdr gene c t and genotypes ag and at of g t/a were at lower risk of developing ovary cancer. genotype ct of c t polymorphism had protective effect against developing the second malignancy, while allele tt increased the risk of breast cancer. carriers of allele c for tp arg pro polymorphism had a significantly lower risk of developing ovarian cancer (or= . , p= . ) the best survival was found for patients carrying germline mutation in brca gene; the worst survival was observed for the group of patients with breast and ovary cancer and without germline mutation in brca gene. alleles of tp arg pro significantly modified the survival of the group of patients who were diagnosed with breast cancer prior to ovarian carcinoma. the worst survival was connected with rare allele c. conclusion: polymorphic variants of pgr, mdr and tp genes under study modified more the clinical course and the risk of second malignancy than the risk of developing ovary cancer alone. dna testing for high risk of cancers b. górski* *poland genetics of colorectal cancers r. scott* *discipline of medical genetics, school of biomedical sciences, newcastle, australia the study of rare inherited conditions with high penetrance that predispose to colorectal cancer has significantly advanced our knowledge of the genetic basis of disease and represents a paradigm that has served to better understand the molecular mechanisms that underlie the development of disease in persons who have no apparent genetic predisposition. inherited predispositions to colorectal cancer can be divided into essentially two groups: those that present with a premalignant phenotype (such as familial adenomatous polyposis (fap) and the hamartomatous polyposis syndromes) and those like hereditary non-polyposis colorectal cancer, lynch syndrome and muir-torre syndrome. for predispositions where the underlying genetic basis of the disease is known, much has been learned about disease penetrance and the expected spectrum of disease as increasing numbers of mutation carriers are characterized. this has lead to the reclassification of some defined syndromes as a result of the inherited predisposition being identical. improved knowledge about disease penetrance has also resulted in a number of questions being raised with respect to what factors influence disease expression in patients known to harbour a mutation in a colorectal cancer susceptibility gene. of particular interest are additional genetic factors (termed modifier genes) that have been correlated with disease manifestation. more recently, the focus of attention has shifted from familial aggregations of disease where there is a well-defined inherited component to population studies aimed at identifying common low-penetrance disease alleles that are associated with small affect sizes. these studies are significant not only because they are identifying genetic factors associated with colorectal cancer risk but also potential modifier genes that are important in modulating disease expression in persons who harbour a genetic predisposition. eosinophil functions have been associated for a long time with effector activity in adaptive immune responses during parasitic infections and inflammatory processes in allergic manifestations as well as in mucosal responses. the production by eosinophils of a vast array of cytokines as well as their expression of innate receptors and mediators confer to eosinophils a unique contribution both in inflammatory and adaptive responses but also in immunoregulation and innate immunity. eosinophils are customary inhabitants of the gastrointestinal tract, except for the oesophagus. beneficial function of intestinal eosinophils was their ability to defend host against helminths. however, eosinophil accumulation in the gastrointestinal tract is a common feature of numerous gastrointestinal disorders, including inflammatory bowel diseases, intestinal vasculitis, gastroesophageal reflux disease and food allergy. primary eosinophilic gastrointestinal disorders, defined as disorders that selectively affect the gastrointestinal tract with eosinophil-rich inflammation of unknown etiology, include eosinophilic esophagitis, eosinophilic gastroenteritis and eosinophilic colitis and are occurring with increasing frequency. decrease in the rate of parasitic infections in the developed world is associated with a rise in atopic/ allergic disorders and increased hypersensitivity responses to allergens and may represent a driving factor towards the recruitment and activation of gut eosinophils in those disorders. although the pathogenesis of those disorders is still poorly understood, new findings on gastrointestinal eosinophil proliferation and migration mechanisms involving il- and eotaxins provide a rationale for specific disease therapy. the present review will summarize knowledge on the physiology of gut eosinophils and will illustrate some aspects of eosinophilic disorders of the gastrointestinal tract. gastro-oesophageal reflux disease (gerd) and eosinophilic oesophagitis (ee) are the two main non-tumoral diseases involving the oesophagus and can develop in both children and adults. the former, the more frequent, is present in up to % of the western population. it is the consequence of a massive flow of gastric contents back into the oesophagus, leading to symptoms or organ damage. eosinophilic oesophagitis, first reported in and defined as a specific clinicopathological entity in , is characterized by eosinophilic infiltration of the oesophagus. its cause or causes are unknown despite its frequent association with an allergic setting. in , a consensus meeting of the american gastroenterological association institute and the north american society for paediatric gastroenterology, hepatology and nutrition recommended diagnostic criteria for ee. despite this increased knowledge of both pathologies, gerd and ee present considerable clinical and pathological overlap. their distinction remains, however, crucial as their clinical outcome and treatment modalities are quite different. the pathologist has to be aware that the diagnosis cannot be based solely on pathological features. the aim of this presentation was to provide pathologist both clinical and histological diagnostic clues in order to propose the most accurate diagnosis and treatment. eosinophilic enterocolitis a. driessen* *the netherlands eosinophilic gastro-enterocolitis, consisting of eosinophilic gastroenteritis (eg) and eosinophilic colitis (ec), belongs to eosinophilic gastrointestinal disorders whose diagnosis is based on gastrointestinal symptoms, an eosinophilic infiltration in the gut and the exclusion of secondary causes of eosinophilia (collins mh , furuta gt , shifflet a . eg and ec are both rare entities. eg is a predominantly benign disease occurring at any age (peak incidence, third-fifth decade). it may affect any part of the gastrointestinal tract, most commonly the stomach ( - %) and small intestine ( - %). ec is more uncommon, involving the colon and less frequently the rectum. symptoms vary in function of the affected layer of the wall: mucosa ( - %): abdominal pain, diarrhea; muscular layer ( - %): intestinal obstruction; serosa ( - %): ascites. the ethiopathogenesis is not fully clear, but is sometimes related to a food allergy. diagnosis requires a panendoscopy with biopsy. histologic examination may, however, be hampered by the patchy distribution of the mucosal inflammation and the presence of a normal mucosa in association with muscular/serosal involvement. in this case, a full-thickness biopsy may be necessary for diagnosis. microscopic features are the presence of numerous eosinophils in the lamina propria, extending into the epithelium (crypt abscesses) and the submucosa, associated with architectural abnormalities. in mural or serosal eg/ec, eosinophils are predominantly situated in the muscular or peritoneal layer. differential diagnosis includes other disorders with eosinophilia, e.g. inflammatory bowel disease, celiac disease, parasitic infection, vasculitis. several treatment modalities have been described in literature, such as restriction diets, corticosteroids or antihistamines. surgery is restricted to the resection of stenosed segments in mural enterocolitis. systemic eosinophilic disorders and the gi tract a. hoorens* *uz brussel, dept. of pathology, belgium secondary eosinophilic disorders, including infectious, inflammatory, hypersensitivity and neoplastic illnesses, always require exclusion before making the diagnosis of eosinophilic oesophagitis/gastroenteritis/colitis, particularly in case of peripheral blood eosinophilia. parasite infections are well known to present with eosinophilia of the gastrointestinal mucosa. a drug-induced aetiology should also always be considered. gastrointestinal eosinophils may be a feature of connective tissue disease, especially scleroderma, and can accompany vasculitis in polyarteritis nodosa and churg-strauss syndrome. with very pronounced peripheral eosinophilia, hypereosinophilic syndrome (hes) with gastrointestinal involvement, clonal eosinophilia and lymphocytic variant hypereosinophilia should be considered. hes is defined as eosinophilia (≥ . × /l) for at least months, no known cause of eosinophilia, and evidence of organ involvement. the gastrointestinal tract is affected in %. when only the digestive tract is involved, it may prove difficult to distinguish hes and eosinophilic gastroenteritis. involvement of the intestinal tract in hes has been associated with limited prognosis and, in some, a fatal outcome. eosinophilic infiltration of the gi tract in hes should be distinguished from eosinophilic infiltration of the gi tract in lymphocytic variant hypereosinophilia where eosinophilia is associated with phenotypically abnormal and/or clonal t lymphocytes. clonal eosinophilia is characterized by neo-plastic proliferation of eosinophils as part of an underlying myeloid malignancy and can accompany any one of the myeloid malignancies. two distinct subcategories of clonal eosinophilia are recognized: chronic eosinophilic leukaemia, nos and myeloid/lymphoid neoplasms with abnormalities involving pdgfra/pdgfrb or fgfr . accurate diagnosis of all these conditions requires the correlation of endoscopic and biopsy findings together with a careful clinical examination. gi eosinophilia in paediatrics m. walker* *united kingdom eosinophils are powerful innate immune cells home to the gastrointestinal tract and play a major role in both host immunity to luminal pathogens and maintenance of homeostasis of intestinal epithelium in the normal gastrointestinal tract (git) . normal numbers at different git sites are defined in children. however, if in excess, eosinophils may play a key role in the pathogenesis of disease of the git, including primary eosinophilic gastrointestinal disease (egids). data from the world wide web-based registry of egids show that these have a strong genetic and allergic component, % having coexistent atopic disease, % food sensitisation and % with a family member with similar disorders. the most studied egid in children is eosinophilic oesophagitis; symptoms include feeding intolerance and gerd symptoms. endoscopy shows a characteristic linear furrowing, and histological features include ≥ eosinophils/ hpf (peak count). there is a male preponderance and an allergic and genetic component. around - % of children are affected by food allergy, most commonly cow's milk allergy and egg and peanut allergies which may manifest as eosinophil-induced gi disorders. eosinophilic gastroenteritis is manifest as allergic eosinophilic gastroenteritis, allergic proctocolitis and food protein-induced enterocolitis syndrome (fpies) . eosinophilia is also seen in helminth infection, inflammatory bowel disease, coeliac disease and graft vs. host disease where eosinophil density can correlate with disease severity. recent work has implicated duodenal eosinophilia in functional conditions, particularly paediatric dyspepsia, with success in treatment aimed at the eosinophilmast cell axis. parasites and eosinophils in the gi tract g. de hertogh* *uz leuven, dept. of pathology, belgium background: human endoparasites belong to four groups: the protozoa and the nematodes, cestodes and trematodes. about protozoan and helminthic species can cause gastrointestinal (gi) pathology. eosinophils are frequently associated with the lesions present in these conditions. method: pubmed-based review of the associations between gi parasites and eosinophils. results: protozoan parasites may be located on the mucosal surface or in the bowel wall in an intra-or extracellular position. eosinophils can be increased in blood and tissues, notably with isospora belli. dientamoeba fragilis infection may even masquerade as allergic colitis. invasive amoebiasis (entamoeba histolytica) on the contrary has been associated with a decreased number of tissue eosinophils. worms may be observed in the egg, larval or adult stage buried in or attached to the bowel wall. helminthic infections are classically associated with blood and tissue eosinophilia, which can be limited to the place of attachment of the organisms. the number of eosinophils in biopsies can be very high and even suggestive of primary eosinophilic enteritis, e.g. in trichuriasis, anisakiasis and enterobiasis, and with ancylostoma caninum and angiostrongylus infections. alternatively, chronic inflammation with eosinophilia may be confused with ulcerative colitis or crohn's disease, the latter especially if granulomas are present (as with schistosoma mansoni infection and more rarely in strongyloidiasis, anisakiasis and enterobiasis). conclusion: eosinophils are involved in the defense against many protozoan and helminthic gi parasites. the resulting histological picture may at times be confused with other disorders such as primary eosinophilic enteritis and the idiopathic chronic inflammatory bowel diseases. the diagnosis of invasive melanoma is straightforward in most cases. it is based on the recognition of a malignant junctional, in situ component in addition to an invasive dermal component. classical diagnostic criteria are established mainly for superficial spreading melanoma, being the most common melanoma subtype. the morphological spectrum of melanoma is, however, wide, and distinction from both melanocytic naevi as well as non-melanocytic tumours may be challenging in individual cases. in particular, some benign melanocytic naevi may show concerning histological features overlapping with those of melanoma, resulting in significant potential for overdiagnosis. melanocytic lesions notoriously difficult to separate from melanoma include dysplastic naevi, naevi of special sites, halo naevi, recurrent naevi, mitotically active naevi and deep penetrating as well as blue naevi. nonmelanocytic tumours may mimic melanoma by recapitulating a junctional in situ as well as a dermal invasive component showing similar cytological and architectural features, including epithelioid, spindle cell, small cell or desmoplastic differentiation, in addition to immunohistochemical expression of the so-called melanoma markers such as s , hmb- and melan a. these tumours may be of epithelial, haematolymphoid as well as mesenchymal lineage ranging from benign to outright malignant. awareness of the critical entities in the differential diagnosis of melanoma and their differentiating features and diagnostic clues is important to avoid misdiagnosis, especially as the treatment modalities and clinical behaviours may differ significantly. a. batistatou* *greece molecular studies of melanocytic lesions are necessary in order to identify additional prognostic and predictive biomarkers and establish the pathways of relevance for targeted therapy. the advent of biotechnology has also enabled the utilization of molecular testing as a diagnostic adjunct in the microscopic evaluation of difficult melanocytic lesions. Τhe molecular multistep process of melano-magenesis has been correlated to the clark model for melanoma development. the first step of melanocytic hyperplasia and nevus formation has been linked to constitutive activation of the erk-mapk pathway as a result of somatic mutations of braf or n-ras (or h-ras or gnaq). the development of cytologic atypia (dysplastic nevi) is related to alterations in cell growth, apoptosis and dna repair; inactivation of cdkn a; and pten pathways and tp . radial growth phase has been associated with decreased differentiation and deregulated expression of mitf, as well as deficiency in the p ink a-rb pathway. alterations in cell adhesion, such as reduction/loss of e-cadherin, increase of n-cadherin, αvβ integrin, mmp- and increased expression of osteopontin are associated with the development of radial growth phase and metastatic melanoma. alternatively, some melanomas (including acral and mucosal) arise de novo and harbor mutations/ amplifications of kit and amplifications of cyclin d or cdk genes. other less frequent, pathogenetic pathways have also been proposed. in the near future, distinct molecular signatures of gene expression may be useful in identifying melanocytic lesions as melanomas or nevi. for melanomas, refined classification systems based on molecular analysis could provide more accurate prognostic markers and enable targeted therapy. novel targeted therapies in melanoma and the pathologists' role in therapeutic selection a. lazar* *usa background: when melanoma metastasizes, it is a deadly disease with unsatisfactory treatment options. it has become clear that melanoma is composed of multiple genetic subsets of disease that have different oncogene additions and thus distinct therapeutic vulnerabilities. method: many clinical trials and application of targeted therapies outside of the trial setting depend on melanoma subtype and the genetic features of an individual case. pathologists are absolutely critical in this area of testing and in therapeutic selection to enable precision medicine. results: targeted therapies based on the molecular genetic features of individual melanoma cases is beginning to drive targeted therapy selection and can greatly enrich the rate of response to particular treatments. conclusion: this lecture will focus on the genetic features of melanoma currently most relevant to treatment and how testing drives therapeutic selection. in the very near future, such testing will be employed for treatment in virtually all cases of metastatic melanoma. nephron number as determined during nephrogenesis may be one determinant of renal disease and hypertension in later life. various genetic and epigenetic factors, but also maternal or environmental causes, are known to influence nephron number. an involvement of the kidney in the development of hypertension has been postulated for a long time and supported by experimental studies in rats and sheep. brenner and colleagues supposed a direct association between nephron number and blood pressure in humans. their so-called brenner hypothesis postulated that any reduction in nephron endowment leads to hyperfiltration of the remaining glomeruli, followed by glomerular enlargement with glomerular and then systemic hypertension, resulting in glomerulosclerosis, thereby establishing a vitious circle. in line with this theory, an association of low nephron number and development of hypertension was shown in different animal models as well as in two autopsy studies in humans. keller et al. found in caucasian patients with essential hypertension a significantly lower number of glomeruli per kidney than in matched controls. in parallel, mean glomerular volume was more than twice as high in hypertensive patients as in normotensive control patients, indicating compensatory glomerular enlargement. these results were confirmed in a caucasian american population, whereas in african americans, there was no association between glomerular number and blood pressure. the pathomechanisms linking low nephron number and hypertension are only partly understood. among others, inappropriate activation of the renin-angiotensin system, impaired tubular salt handling leading to salt and volume retention, or post-glomerular structural changes have been discussed. the new classification of lupus nephritis: a critical reappraisal a. halon* *wroclaw medical university, poland background: systemic lupus erythematosus (sle) is the prototype of human autoimmune multisystemic disease and has a wide spectrum of clinical manifestations, of which renal failure is the most common and severe. about - % of patient with sle suffer from lupus nephritis (ln), and it is one of the major causes of morbidity and mortality. ln manifests as diverse patterns of immune complexmediated renal disease involving all tissue compartments: glomerular, vascular and tubulointerstitial. iga nephropathy is a disease of a diverse course and outcome. there were several attempts to create a morphological classification that would serve as a tool efficiently defining the potential responsiveness to the immunosuppressive treatment as well as prognosis in individual cases. the last of these proposals, the oxford classification of iga nephropathy, was published in july . the aim of our study was to compare the utility of few functioning classification systems, including oxford and hass classifications and japanese histological grading, as well as our own morphological index of biopsies with iga nephropathy. on the basis of data collected in polish renal biopsy registry, we selected iga nephropathy cases that were characterized by at least years of post-biopsy follow-up, as well as satisfactory tissue material for light microscopy evaluation. microscopical grading was performed by a group of experienced nephropathologists. the lecture will be devoted to the results and conclusions of this study. the myofibroblast. from wound healing to neoplasia. with special emphasis on tissue fibrosis and fibrocontractive conditions. twenty-five years of reflexions w. schürch* *canada the myofibroblast (mf) was discovered in in electron micrographs from experimental granulation tissue. this cell was shown to share features of fibroblasts and smooth muscle cells, hence its name. in due course, it was found to be the principal cell to effect wound contraction, i.e., wound healing. this unique cell was later defined at the histologic, ultrastructural, immunohistochemical, biochemical and pharmacological levels. for the surgical pathologist, the mf is best defined by its ultrastructure. immunohistochemical studies demonstrate a heterogeneous pattern of cytokeletal phenotypes regarding actin isoforms and intermediate filaments. five immunophenotypes were identified. ultrastructural features that define the mf include: (a) stress fibers, i.e., bundles of microfilaments with interspersed dense bodies; (b) well-developed cell-to-stroma attachment sites, i.e. fibronexi, intercellular intermediate and gap junctions; and (d) abundant production of extracellular matrix. mfs have been observed in normal tissues, in granulation tissue and in several pathologic settings which will be discussed in detail. numerous cells can modulate into a mf phenotype: foremost, the local resident fibroblasts, followed by pericytes, vascular smooth muscle cells, liver perisinusoidal stellate cells, kidney mesangial and tubular epithelial cells, bone marrow stromal cells and mesothelial cells. for the development of the mf phenotype, a two-stage model was proposed. following tissue injury, complex changes in the microenvironment occur with the release of cytokines and the concerted action of a permanent feedback between intra-and extracellular tension, transforming progenitor cells into proto-mfs and then into differentiated mfs. three types of pulmonary preneoplastic changes (ppc) are accepted: squamous dysplasia and carcinoma in situ (sd/ cis), atypical adenomatous hyperplasia (aah), and diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (dipnech). sd/cis are associated with the development of squamous cell carcinoma (scc). aah is a pre-invasive lesion for adenocarcinoma (adc), and dipnech may progress to carcinoid. recently, adenocarcinoma in situ (ais, formerly bronchioloalveolar carcinoma (bac)) was included among ppc. pathogenesis of scc and adc is a multistep and multicentric process involving the transformation of the normal bronchial mucosa and alveolar lining cells through a continuous spectrum of lesions. the sequence of ppc for scc includes: hyperplasia > metaplasia (sm) > sd > cis > scc; for adc, it is hyperplasia > aah/ bac > adc; and for carcinoid, it is dipnech > tumorlet. numerous genetic and molecular abnormalities occur in the very early stages of lung carcinogenesis, including hyperplasia and metaplasia and even in normal-appearing bronchial epithelium. it is not known which genetic changes are the most important or at what stage the process is irreversible. sm and hyperplasia can be either a repair or a reactive and reversible process of injured bronchial epithelium. it is found in purely inflammatory settings. these reactive processes usually do not progress to dysplasia and carcinoma. that is, morphology is a gold standard in the diagnosis of both reactive and ppc, and no ancillary studies can be used as a diagnostic aid. the strict histologic criteria are used to assist in the recognition and grading of mucosal lesions. handling the problematic pleural biopsy in suspected mesothelioma cases s. anttila* *huslab jorvi, dept. of pathology, espoo, finland the most challenging diagnostic problems in pleural biopsies include distinguishing between benign mesothelial hyperplasia and epithelioid malignant mesothelioma and between reactive pleural fibrosis and sarcomatoid or desmoplastic mesothelioma. in addition, sometimes rare tumor types, such as lymphohistiocytoid malignant mesothelioma or epithelioid hemangioendothelioma, may mimic reactive processes. the first question to be considered when handling a problematic pleural biopsy is: is the biopsy material adequate and representative as can be judged from clinical, imaging and thoracoscopic findings? if in doubt, a new biopsy should be recommended. the distinction between benign and malignant mesothelial proliferation can be made on morphological grounds only, although immunostains, e.g., for ema and desmin, may favor either a benign or malignant lesion. the most reliable criterion of malignancy is invasion. immunostains for broad-spectrum cytokeratins may aid in recognizing invasion both in epithelioid and spindle cell lesions. in spindle cell lesions, cytokeratins also help recognize the growth patterns of spindle cells. in reactive pleural fibrosis, a layer of cytokeratin-positive cells may be seen parallel to the pleural surface, whereas in sarcomatoid or desmoplastic mesothelioma, the pattern of spindle cells is haphazard or storiform. negativity of immunostaining for cytokeratins in a spindle cell lesion should not automatically lead to a conclusion of a benign process as, e.g., sarcomas and about a quarter of sarcomatoid or desmoplastic mesotheliomas are cytokeratinnegative. correlation of histological and immunochemical findings with clinical and imaging findings is of utmost importance for a correct diagnosis without unnecessary delay. these rare tumours stem from mononuclear phagocytes or antigen-presenting dendritic cells. the latter belong to different cell lineages (either haematopoietic or mesenchymal). histiocytic sarcoma (hs) affects adults and is characterised by an aggressive clinical course in most instances. hs more often occurs at extranodal sides and consists of pleomorphic, atypical, large cells that are cd + , cd + , lysozyme + , cd + , cd r + , and hla-dr + . partial expression of s- is recorded. tumours derived from langerhans cells (lc). they maintain the phenotypic profile (s + , cd a + , langerin + ) and ultrastructural features (birbeck granules + ) of lc. they include lc histiocytosis and lc sarcoma. the former represents a well-known entity, more commonly observed in children: its behaviour varies according to the stage. the latter is a very aggressive disease of adulthood with overt cytological atypia and dismal prognosis. interdigitating cell sarcoma (idcs) is a very rare neoplasm of adulthood that cannot be differentiated from follicular dendritic cell sarcoma morphologically, both being composed of oval fusiform cells growing in fascicles, storiform pattern or °whorls. the diagnosis is based on s- and vimentin positivity in the absence of other lineage markers. follicular dendritic cell sarcoma (fdcs) occurs in adults and more often presents in the lymph node, at times within the context of castleman disease. in % of cases, it has an indolent behaviour. hodgkin lymphomas (hl) consist of two main categories, classical hl (chl) and nodular lymphocyte predominant hodgkin lymphoma (nlphl). the latter occasionally shows large diffuse areas. in particular in small biopsies, this generates a difficult differential diagnosis of t cell/ histiocyte-rich large b cell lymphoma (thrlbcl). immunohistochemistry with a large panel of antibodies may be of help, but cannot solve all problems, and clinical aspects should always be taken into account as well. in view of the important clinical (therapeutic and prognostic) consequences, such cases should also be evaluated by an expert hematopathologist. the second problem is the distinction between chl and primary mediastinal large b cell lymphoma (pmbl) or diffuse large b cell lymphoma (dlbcl) nos. there may be various situations: a mediastinal mass with a synchronous composite chl and pmbl with divergent morphology and immunophenotype. this situation may be more frequent than thought since usually, only a small sample from the mediastinal mass is taken. both lymphomas may also develop metachronously. the coincidence of both lymphoma types is explained by the fact that both lymphomas likely have a common (thymic) origin. indeed, they share many genetic and molecular features as well. more difficult to understand and diagnose are the cases that arise outside the mediastinum with mixed features of chl and dlbcl-nos and cases of otherwise chl that strongly express cd and/ or other b cell markers. in such cases, other diagnoses should be considered as well, such as ebv + dlbcl of the elderly. several cases will be discussed during the session. peripheral t cell lymphomas: a new frontier s. pileri*, c. agostinelli, p. p. piccaluga *bologna university, dept. of haematology and oncology, italy peripheral t cell lymphomas (ptcls) account for about % of lymphoid tumours worldwide. almost half of them show such a morphologic and molecular variability as to hamper any further classification and to justify their inclusion in a wastebasket category termed "not otherwise specified (nos)". the latter corresponds to neoplasms with aggressive presentation, poor response to therapy and dismal prognosis. conversely to b cell lymphomas, ptcls have so far been the object of a limited number of studies aiming to elucidate their pathobiology and identify novel pharmacologic approaches. herewith, the authors revise the most recent contributions on the subject based on the experience they gained in the extensive application of microarray technologies. ptcls/nos are characterised by the erratic expression of t-cell-associated antigens, including cd and cd , recently proposed as targets for ad hoc immunotherapies. they also show variable ki- marking, rates > % heralding a worse prognosis. gene expression profiling (gep) studies reveal that ptcls/nos derive from activated t lymphocytes, more often of the cd + type, and bear a signature composed of genes and related products that play a pivotal role for cell signalling transduction, proliferation, apoptosis and matrix remodelling. this observation seems to pave the way to the usage of innovative drugs, such as tyrosine kinase and histone deacetylase inhibitors whose efficacy has been proven in ptcl primary cell cultures. gep does also allow better distinction of ptcl/ nos from angioimmunoblastic t cell lymphoma, the latter being characterised by follicular t-helper lymphocyte derivation and cxcl , pd and vegf expression. the south saharan african countries are low-resource settings where the histological diagnosis of diseases and consequently the correct managing of the patient are difficult to obtain. telepathology allows doctors working in remote locations to obtain a definite diagnosis through the transmission of tissue specimen via remote telecommunication. in particular, the "virtual slide" system allows capturing a visual image of an entire slide of a specimen which is then forwarded to another location for diagnosis. association pathology beyond borders (apof) in , in a small rural hospital in zambia, to supply to the lack of pathology skilled personnel, started a project to train local staff to become technicians, able to prepare histological and cytological slides and to screen conventional pap smears. the two zambian technicians signed out negative pap smears, and in the presence of abnormal findings, they took pictures of significant diagnostic fields. then the images were sent through internet to experts in italy who, on a rotating roster, were responsible of the final diagnosis. since , the technicians were also able to prepare histological slides from the surgical specimen: digital images of the slides were taken through a scanner and saved in a database in a local server. through a satellite connection and a made-to-measure archival software and web site, pathologists in italy were able to examine the specimen, record their diagnosis and transmit it directly to zambia. in low-income countries where no other possibilities are available, telepathology seems to be a reliable and secure diagnostic tool. leave a mark: organizational models in building and managing a pathology service in developing countries p. giovenali* *ospedale s. maria, della misericordia, perugia, italy the main aim of the ngo association pathologist beyond borders (associazione patologi oltre frontiera, apof) is the improvement of activities related to anatomical pathology in developing countries to raise the health standard in those areas through the performing of histological and cytological diagnoses for therapeutic and preventive purposes, such as screening programs. an essential part of every project managed by apof consisted in the construction and organization of new pathology services or in the implementation of already existing laboratories. while taking into account every particular local environment, needs and available resources, apof decided to export the same models that have proven effective in our context: the technical histological and cytological process, from the surgical sampling to the final report, was set in detail trough precise guidelines with the inclusion of procedures dedicated to process control. similar guidelines were used to update and adjust the diagnostic parameters according to international consensuses. the allocated funds were mainly used for the purchase of equipment and consumables and for the organization of updating courses dedicated to the technical and medical staff. in places where no skilled personnel were available, longer and more in-depth classes were organized for local staff, both in the place or in italy. the staff, once trained, passed also an examination to obtain an official and specific degree. the main purpose of this kind of management was to build a reliable system that could then be directly managed by local staff at the end of the project. the great debate about screening models in developing countries: matching needs and opportunities s. guzzetti* *ospedale evangelico valdese, asl to , turin, italy although in the developed world the importance of the correct diagnosis is appreciated as a critical issue, this is still an evolving concept in some of the developing countries, especially in africa. in particular, there are striking differences in the turnaround time for histopathological diagnosis, in the accuracy of diagnosis that has a profound impact on patients' management and ultimate outcome. the current problems in practice of lymphoid/lymphoma diagnosis include-basing treatment decisions on fine needle aspiration cytology in a large proportion of cases, poor quality histology in a minority of cases where biopsies are performed, complete lack of immunohistochemistry and other supportive investigations, and lack of an update on the current criteria for the diagnosis of various lymphoid pathologies. in africa, a majority of the laboratories still use the working formulation for clinical usage, a lymphoma classification from the early s which is based on morphology alone and does not include many entities recognized in the last years. without accurate diagnosis, any research project and effective patient management cannot be instituted. though there are no magic answers for an issue of this magnitude, on which other aspects are critically dependent, twinning between institutions in the developed countries and developing countries seems to be the most likely longterm approach. examples of twinning approach to childhood cancer diagnosis and treatment have been africa. these programmes have led to improvements in the diagnostic accuracy through capacity building and joint research projects with both direct and indirect technology transfer. the role of apof in low-resource settings: present and future projects for the development of surgical pathology in developing countries v. stracca-pansa* *italy in the last years, the cancer issue in most african countries is more and more dramatic. the who afro and the resolution of the th world health assembly made cancer one of the health priorities in developing countries and pushed african countries to formulate national cancer control programmes. once considered a disease of the rich, the pendulum has swung dramatically, and some % of new cancer cases in the next decade will be in the developing world. many poor countries are unable to cope with the accelerating burden of cancer. the essential purpose of the breast cancer pathology report is to communicate pathologic findings that aid in prognostication and guide the selection of appropriate local and systemic treatment for patients with breast cancer. to be clinically useful, the content of the report must change as new prognostic and predictive factors are validated and others become obsolete. in , the list of useful featuresthose which are grounds for specific therapeutic actions-is relatively short: the anatomic extent of disease in the breast and axilla (ajcc/uicc stage), the specimen margin status, and measures of certain cancer cell proteins (hormone receptors, her- /neu) that predict the likelihood of response to specific adjuvant therapies. histological subtype, carcinoma grade, the presence of lymphatic tumor emboli, the finding of paget disease in a mastectomy specimen are also often reported, but do not inform specific treatments the way that stage, margin status and predictive markers do. in patients with node-negative, estrogen receptor-positive breast cancer, the pathologist selects a paraffin-embedded tumor sample for the oncotype dx assay, which is used to predict the risk of recurrence in patients treated with tamoxifen and may addend the recurrence score to the surgical pathology report. the breast cancer pathology report in is vital to appropriate breast cancer treatment, but can be expected to evolve. in order to assure the quality of pathology in all of sweden, the swedish society of pathology has instituted organspecific quality assurance and standardization groups. these groups consist of dedicated pathologists from many subspecialty areas and are called kvast groups. they meet regularly and their principal work is to formulate and maintain a document with guidelines which has a common framework for all the organ-specific groups. our group prepares the guidelines for breast pathology. the mandatory sections in all the guidelines include clinical background information, instructions to clinicians as how to handle the specimens, what information is needed on the requisition form, gross description, analyses, what information must be reported by the pathologist (gross and microscopic), recommended classification system, administration and miscellaneous. sweden has a national cancer strategy programme emphasizing a patient perspective by focusing the patient process instead of piecing the treatment process together through independent specialities, as has been done previously. in , a group of breast cancer clinicians established a national quality register for breast cancer patients called inca which also include a pathology section. in collaboration with the swedish breast cancer group and the breast kvast group, another group called sweqa works with quality assurance programmes of the biomarkers used in routine pathology; estrogen and progesterone receptors, her status, and histologic grade. the guidelines for breast pathology will require the breast pathologists to participate in the breast cancer patient process by focusing on the standardisation of requisition and pathology reports and quality assurance of biomarkers. working on national guidelines: hungarian guidelines g. cserni* *hungary background: all pathologists feel that the establishment of pathological diagnoses is somewhat subjective. writing national guidelines is useful in order to achieve better consistency in reporting at the level of a geographic area, hungary. as not all countries have their national guidelines on breast reporting, it was thought useful to provide some examples of how guidelines can be constructed and/or adopted. method: the text of the hungarian guidelines on breast pathology reporting was written by a committee of pathologists with expertise in breast pathology. the basis of the new text was a consensus document from years ago. this was rewritten, circulated, and modified several times, and the updated text, ready for wider discussion, was put on the web (internet) along with four other texts (diagnostic radiology/imaging including nuclear medicine; surgery including reconstructive surgery; radiotherapy; and systemic therapy). the url allowing access to the texts was widely circulated on discipline-specific web sites. a consensus conference was organized for live discussion, and written comments were also welcome both from the writing committee members of the other texts and from the wider medical community (the other texts were discussed similarly to allow better congruence). all relevant comments were incorporated and the pre-final text was discussed at the consensus conference. the writing committee finalized the text on the basis of the relevant comments discussed at the conference. the pathology guidelines were scheduled for publication with the other texts in the national oncology journal, magyar onkologia (hungarian oncology). results: na. conclusion: na. working on national guidelines: polish guidelines e. chmielik *, w. p. olszewski, j. rys *oncology institute, dept. of pathology, gliwice, poland objective: the pathologists from the three major oncology centers have worked out the guidelines for breast cancer pathology reporting. method: the proposed report was mainly based on the european and american guidelines as well as on the seventh version of tnm classification and was prepared in cooperation with radiologists and surgeons. guidelines of the pathological reporting of breast cancer were accepted by the multidisciplinary board of the main national specialists representing different medical professions such as pathology, oncologic surgery, medical oncology, chemotherapy and radiotherapy, and afterwards, they were described in the supplement of the polish journal of pathology ( , vol , issue ) the guidelines include the rules of interpretation of needle core biopsies and other diagnostic procedures, as well as the recommendations of gross description and processing of surgical specimens depending on the type of surgical treatment. especially, pathology report of breast carcinoma after neoadjuvant chemotherapy was proposed. special techniques used for diagnosis of breast lesions, their performance and interpretation are also included. results: finally, the histopathological evaluation form of breast cancer has been proposed. in a year after the supplement publication, it is planned to conduct a survey to find out the practical use of those guidelines. on the basis of both the answers to those questions and medicine-based evidence, polish guidelines are going to be compiled. the transplant nephrologist decides to biopsy a given patient on the basis of clinical symptoms and laboratory data. the renal pathologist then makes a histological diagnosis which allows an evidence-based approach to specific therapy, which again will be decided on by the clinician. renal transplant diagnoses generally fall into one of five categories: preexisting donor-related diseases, rejection, drug toxicity, infection, recurrent or de novo renal diseases. although many diagnoses are typically encountered during a certain phase after transplantation, clinical information alone will often not suffice to differentiate between diagnoses, which require a totally opposite treatment regimen. the timing of the biopsy is most important to achieve a successful treatment and to avoid irreversible damage to the transplant. the rule of thumb at our center is to biopsy early in delayed graft function if there is a change in serum creatinine of more than . mg/dl or there is a newly diagnosed or increased proteinuria. sufficient biopsy material, adequate workup including c d and sv immunohistochemistry, and an experienced pathologist are the other prerequisites. a close collaboration between nephrologist and pathologist with regular case discussions not only helps understand the viewpoint of the clinical/pathological partner but will also aid in patient management. pathology in zero-hour biopsies and clinical consequences: hungarian and polish experience a. perkowska-ptasinska*, e. kemeny *poland at the university of szeged, hungary, we carried an original clinicopathological study to assess what type of vascular changes-if any-are associated with late graft dysfunction. we examined in zero-hour biopsies the frequency and severity of nonspecific morphological lesions semiquantitatively. the wall thickness/lumen (w/l) ratio of each artery present in the biopsy was determined by morphometry. among the arterial changes studied, only the intimal fibroelastosis (ife) of moderate degree (frequency, . %) revealed a significant correlation with serum creatinine at months (p< . ). in ife, there was also a significant correlation with the frequency and severity of tubular atrophy and interstitial fibrosis (p< . ). by morphometry, a significant association was found between the mean w/l ratios of arteries and the degree of ife (p< . ). according to hungarian experience, donor kidneys with a moderate degree of ife do indeed have a higher risk of late graft dysfunction. the analogically defined polish retrospective study revealed that the presence of arteriolar hyalinisation in the implantation biopsy was associated with more profound reduction of gfr at rd, th and th months after transplantation in those patients who experienced episodes of an acute rejection (p= . ) within first post-transplant months. this suggests that donor-derived arteriolar hyalinisation predisposes to more severe acute rejection-associated graft damage. new techniques for the identification of hla antibodies g. boehmig* *austria background: it has become evident that antibody-mediated immunity plays a critical role in acute and chronic allograft rejection. according to the banff scheme, serological alloantibody detection represents one of the major diagnostic criteria for antibody-mediated rejection (amr). the design of sophisticated diagnostic tests for prediction and monitoring of amr has become a major goal in transplant medicine. method: an important innovation has been the establishment of solid phase hla antibody detection using flow cytometry, elisa or luminex technology. in this context, luminex-based bead array technology represents an attractive strategy for a detailed analysis of anti-hla reactivity patterns. salivary and mammary glands share an identical ductuloacinar architecture, and thus, it is not surprising that lesions and tumours arising in both organs share considerable histologic similarities. salivary-type tumours are well known in breast; in contrast, breast-like lesions are rarely described in salivary glands. one of the commonest breast conditions, benign fibrocystic disease, was not thought to have a salivary counterpart, but recently, sclerosing polycystic adenosis (spa) was described as a distinctive neoplastic lesion of the major salivary glands. although spa has many histologic similarities to its mammary counterpart, it represents a true neoplastic condition characterized by clonality, focal dysplasia, and a tendency to recur. up till now, secretory carcinoma (sc) has been considered to occur only in the breast. recently, we published a series of salivary gland tumors with histomorphological and immunohistochemical features reminiscent of sc of the breast. this is an unusual, hitherto undescribed, distinctive salivary gland tumor, with some morphological features of both salivary acinic cell carcinoma (acicc) and mammary sc, characterized immunohistochemically by strong vimentin and s- protein positivity. microscopically, the tumours exhibit a lobulated growth pattern, and they are composed of microcystic and glandular spaces with abundant eosinophilic homogenous or bubbly secretory material, which is positive for pas, mucicarmine, muc , muc , and mammaglobin. the decision to undertake the sequencing of the entire human genome stemmed from many sources, in particular rrenato dulbecco's seminal article in science ( ; : - . extraordinary technical advances were required to facilitate this, but few could have predicted the attendant conceptual revolutions. since the publication in of the first draft of the human genome (and the parallel reports of the sequences of many other genomes), our view of the complexity of the organisation and regulation of genomes has increased. the encode project (genome res ; : - ) further highlighted the extraordinary diversity of transcription and demonstrated that the protein coding regions are but a fraction of the transcriptome. the importance of non-coding regions in genome regulation has become manifest, and the diversity of splicing events was previously unsuspected. the previous drip of new information has become a torrent, and 'next-generation' sequencing technologies promise to increase this driving cost of sequencing entire genomes to sub-$ , levels. the timescale of generating data similarly collapses to a mere fraction of that required even years ago. the information load will be immense and new approaches will be needed to deal with the impact of this on clinical decision making. the consequences for these developments are perhaps unfathomable at present, but we are challenged to find ways to take advantage of these developments lest pathology be bypassed by other disciplines. central to this will be educational programmes at the undergraduate and postgraduate level to 'future proof' tomorrows clinicians, including pathologists. new approaches to molecular classification of lymphomas l. leoncini*, s. lazzi, g. de falco, c. bellan, a. onnis, v. mourmouras *university of siena, italy background: the era of molecular diagnostics of lymphoid malignancies started with the cloning of the immunoglobulin and t cell antigen receptor genes. southern blot analysis was applied in clinical laboratories to establish clonality of lymphoid proliferation. this was followed by the cloning of a number of translocation breakpoints in the more common lymphomas. method: the advent of polymerase chain reaction provided an alternative to southern blot analysis as it is simpler and faster. in addition, the amount of clinical material required is much smaller, and it can be performed on archival paraffin-embedded materials. results: gene expression (ge) analyses by use of microarrays (mas) have become an important part of biomedical and clinical research. the resulting data may provide important information regarding pathogenesis and may be extrapolated for the diagnosis and prognosis of non-hodgkin lymphoma (nhl)( ). this genomic technology has revealed that existing diagnostic categories of nhl comprised multiple molecular and clinically distinct diseases. in addition, gene expression profiling studies may lead to the identification of novel targets for the development of new therapeutic agents for nhl. conclusion: more recently, the discovery of a novel class of small non-coding rnas, the micrornas, has opened a new scenario in understanding the regulation of gene expression. mirnas control gene expression at the posttranscriptional level, and deregulation of their physiological function has been revealed to be crucial in cancer. mirna expression profile can be obtained by microarray and is even more informative than gep as a few mirna alterations can specifically identify a tumor (histo) type. egfr mutation analyses in nsclc-experiences of a nationwide ring trial in germany m. dietel* *universitätsmedizin charité, berlin, germany background: since non-small cell lung carcinoma (nsclc) is being predominantly diagnosed at advanced stage, the option of a curative therapy no longer exists in most instances. roughly speaking, the first therapeutic standard measure to treat nsclc consists of a platinumbased chemotherapy, reaching a response rate of - %. recently, new substances have been introduced to treat nsclc, i.e. erlotinib (tarceva®) and gefitinib (iressa®). both inhibit the epidermal growth factor receptor (egfr ). results: for the egfr-inhibitors, it is possible to predict tumor response by egfr mutation analyses. this is the reason why the emea has approved iressa treatment only after such analysis, which has to be performed pretherapeutically. the test has to be done by pathologists who ( ) should reconfirm the diagnosis on an h&e slide; ( ) he then should identify and mark the tumor area, ( ) followed by manual microdissection to assure that at least % of the material is indeed nsclc. ( ) results: molecular tests and gene expression profiles that purport to predict patient outcomes and drive therapeutic decisions are currently favored by oncologists. however, ihc is the only laboratory venue that supplies molecular morphology that may be directly visualized and interpreted. in addition to diagnostic ihc, theranostic and genomic applications are also now in the menu of the pathologist. conclusion: pathologists must be able to emphasize the molecular morphology of ihc and how it can supply theranostic and genomic information in addition to diagnostic applications. our ihc challenges include standardization of the total test and the ability to quantitate results for patient care. most common laboratory pitfalls in ihc s. nielsen* *aalborg hospital, dept. of pathology, denmark most common laboratory pitfalls in ihc immunohistochemistry (ihc) is a well-established technique and used daily in virtually all departments of surgical pathology as a diagnostic, predictive and prognostic tool. however, ihc is an assay influenced by multiple parameters and the final result is highly dependent on the choice and performance of these variables. in the protocol setup for ihc, both the preanalytical, analytical and post-analytical parameters will affect ihc staining, and it is of utmost importance to be familiar with these technical aspects in order to use ihc as a diagnostic tool. in the pre-analytical phase, fixation still is the key element for a reliable result, and it is essential that fixation is standardized with respect to the choice of fixative, time to and time in fixative in order to get consistent results and to avoid false negative or false positive reactions. the implementation of new tissue processing techniques based on, e.g. modified reagents, can also affect the staining result. regarding the analytical phase, the three key elements are: ( ) appropriate epitope retrieval, ( ) a sensitive and specific primary antibody, and ( ) a robust detection system. in external quality programs for ihc, it has been shown that most errors in ihc are related to epitope retrieval and/or the primary antibody. to validate the performance and consistency of ihc, it is necessary to use internal and external controls. especially the use of multi-tissue blocks containing tissues with different levels of the antigen is superior to single control blocks. most common interpretation pitfalls in ihc j. klos* *norway background: the real frequency of interpretation pitfalls in immunohistochemistry is difficult to assess and may vary greatly between laboratories and pathologists. the risk of misinterpretation increases with the greater use of immunostaining as an integral part of theranostic workup, the increasing number and varying quality of available antibodies, as well as the rapidly expanding body of information regarding the complexity of ihc profiles of tumours. growing clinical expectations for pathological evaluation are an additional challenge. method: the presentation will address the most important elements regarding the correct interpretation of immunostaining using aaaspin as a simple algorithm for safer approach. results: a-adequate antibody panel: selection of antibodies is often a consequence of considered differentials, but results of immunostaining may also influence the choice of antibodies in subsequent analyses. a-antibody clone: the spectrum of reactivity and cross-reactivity should be known. according to the banff classification, antibody-mediated renal allograft rejection (abmr) is defined by circulating donor-specific antibodies (dsa), c d deposition in peritubular capillaries (ptc), and histologically detectable graft injury. these diagnostic criteria had primarily been developed and validated in biopsies from patients with early post-transplant dysfunction. results from studies in patients without clinically detectable graft dysfunction, however, cast doubt on the universal applicability of these criteria. in my talk, i will address the following issues: ( ) c d deposits but no abmr? findings in protocol biopsies from patients with stable renal function indicate that c d deposition is not necessarily always associated with renal dysfunction. the low predictive value of c d in these patients might be due to the accommodation of grafts and highlights the fact that the diagnostic impact of c d strongly depends on the clinical context. ( ) abmr but no c d? complement activation likely is not only of diagnostic importance but also part of the pathogenesis of abmr. results from gene expression profiling studies in human graft biopsies and from animal models, however, suggest that there also might be complement-independent mechanism of abmr. especially the lesions of chronic rejection might at least in part result from antibodymediated complement-independent endothelial injury. ( ) are "atypical" staining patterns of diagnostic relevance? c d can, in addition to the diagnostically relevant linear deposition in ptc, also be found in other locations and different staining patterns. it, however, appears that these other/additional staining patterns are of limited diagnostic value, at least for the detection of ambr. during gestation, several microorganisms can infect the foetus and damage the developing nervous system, leading to severe neurodevelopmental sequelae. the acronym torch was introduced to refer to these organisms including toxoplasmosis, other microorganisms, rubella, cytomegalovirus and herpes simplex virus. torch infections share similar clinical features: the maternal infection is regularly asymptomatic, the clinical presentation of infected fetuses and neonates is quite identical, and, sometimes, a clinically silent infection in the neonatal period will be responsible for permanent neurological deficits occurring later in infancy. extensive immunization programs, in developed countries, have led to an impressive decrease of congenital rubella syndrome, and the development of strategies of prenatal diagnosis and antimicrobial therapies has improved the management of congenital infections. despite these significant advances, torch infections remain a worrying cause of vision loss, hearing loss, and neurological disabilities in both developed and developing countries, and new syndromes have emerged such as congenital infections due to human immunodeficiency virus (hiv) and the human parvovirus b . in addition, in the two last decades, growing evidence has supported the hypothesis of a significant association between choriamnionitis and cerebral palsy: brain lesions would result from a production of cytokines through a mechanism of toxicity. a wealth of literature has summarized current knowledge concerning epidemiology, microbiology, diagnosis and the management of congenital infections. in this presentation, we will focus on the neuropathological features of the most frequent intrauterine infections and underscore the invaluable contribution of neuropathological studies in understanding the pathogenesis of developing brain lesions. development and functions of the dura mater w. squier* *united kingdom the dura is more than just a fibrous covering for the brain; it has other functions, including control of venous outflow and uptake of csf. dural development is not complete at birth; it undergoes considerable remodelling in early life. the meninges develop from primitive mesenchyme derived from the neural crest. the dura has two leaflets, the outer periosteal and the inner meningeal which forms the falx and tentorium. between them are the venous sinuses, which drain the entire venous outflow of the brain. bridging veins are few and carry high blood flow. a muscular sphincter at their junction with the dura regulates blood flow when intracranial pressure increases. a venous plexus, most extensive at birth, is found in the posterior falx, tentorium and the parasagittal regions. arachnoid granulations develop at months of postnatal life. originally thought to be responsible for drainage of csf, they more likely monitor csf homeostasis and pressure. fluid channels in the dura may represent a system for the uptake of csf. in early life, blood may reflux into these channels from the venous sinuses, causing intradural bleeding which is common in immature infants. dural bleeding causes symptoms such as seizures and vomiting difficulties and is associated with age-related imaging changes in the underlying brain parenchyma. we do not yet understand the pathophysiology of these observations. mitochondrial encephalomyopathies (me) represent a heterogeneous group of diseases, secondary to respiratory chain dysfunction, impaired atp production and energy crisis in the affected cells. me could be associated with defective nuclear (ndna) or mitochondrial (mdna) genome, resulting in autosomal or maternal inheritance, respectively. although multiple organ involvement is very common, the most affected are tissues with high oxidative metabolism such as cns, myocardium and striated muscle. myoclonus epilepsy with ragged red fibres (merrf), mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (melas), leber's hereditary optic atrophy (lhoa), kearns-sayre syndrome and leigh's disease represent the classical examples of me. precise phenotype/genotype correlations are very difficult due to the presence of overlap syndromes and atypical cases. the topography of lesions in the cns determines symptomatology and varies in these conditions. morphologically, me are characterized by variably expressed mitochondrial abnormalities such as intra-mitochondrial crystalloid inclusions and ragged red fibres (rrf) in muscle biopsies, as well as selective neuronal loss in different cns structures, laminar cortical necroses, microinfarctions and spongy degeneration in the grey or white matter. however, the common and diagnostically useful feature is the presence of cox-negative fibres, abnormal ultrastructure of muscle mitochondria and variably expressed vascular abnormalities. although clinicopathological correlations are often problematic, the involvement of small caliber vessels may explain many focal cns manifestations, while multisystem disease is very likely secondary to mitochondrial dysfunction in the neuronal component. results: kuru in the fore language means to shiver or to shake from fever and cold. ritualistic endocannibalism (eating of the relatives as a part of a mourning ritual, but not as an alimentary habit) was practiced not only in the kuru area but in many surrounding eastern highland groups which never developed kuru. the most striking neuropathologic feature of kuru was the presence of numerous amyloid plaques. conclusion: we may also speculate what would happen if kuru had not been discovered or did not exist. the infectious nature of creutzfeldt-jakob disease would probably not have been suspected until the beginning of the variant creutzfeldt-jakob disease (vcjd) outbreak in the uk. creutzfeldt-jakob disease and gerstmann-sträussler-scheinker disease would have remained for decades as obscure neurodegenerations of merely academic interest. the familial forms of creutzfeldt-jakob disease would not have benefited from prnp gene analysis, but only later would have been studied by linkage analysis and reverse genetics probably. the whole field would have probably remained of only arcane interest to veterinarians until the bse epidemic began to exert its devastating effect. the discovery of vcjd would have been delayed as no surveillance would have been initiated for creutzfeldt-jakob disease. and, perhaps most importantly, the sea change in mentality that has led to the conception of 'protein misfolding diseases', including not only the neurodegenerative but also an increasing number of nonneurological disorders, would have been delayed by decades. cell autocannibalism in central nervous system. the role of autophagy in neurodegeneration and nervous system tumours b. sikorska* *poland background: autophagy is a process by which subcellular constituents and organelles are targeted for degradation in lysosomes. in macroautophagy, proteins and organelles are sequestrated into a double membrane-bound vacuole called autophagosome, formed by the er membranes, under the direction of various proteins including map-lc (a microtubule-associated protein, light chain ). in addition to maintaining cellular homeostasis, autophagy may also contribute to cell damage. recently, autophagy was reported to be involved in many pathological processes including neurodegeneration, inflammatory processes and cancer. the role of autophagy in neurodegeneration is not only in removing protein aggregates but also in inducing the neuronal death. method: autophagy in human neurodegenerative diseases and tumours of the cns was studied using electron microscopy, immunohistochemistry and confocal laser microscopy. results: the presence of autophagy in prion diseases and other neurodegenerative disorders was shown. the extent of autophagy in tumours varied depending on histological type and malignancy. conclusion: although the role of autophagy in neurodegenerative diseases remains unknown, at least three hypotheses must be taken into consideration: ( ) removing protein aggregates, ( ) one of the ways of neuron death, and ( ) formation of spongiform change in prion diseases. the role of autophagy in cancer seems to be dual: on one hand, there is a growing body of evidence supporting the idea that autophagy may represent a tumor suppressor mechanism by reducing intratumoral necrosis, restricting oxidative stress and limiting chromosomal instability; on the other hand, autophagy may be an important process used by tumor cells to escape various types of stress and even therapeutic agents. advances in biology of gliomas w. biernat* *medical university of gdansk, dept. of pathology, poland objective: gliomas are the most common neoplasms of the central nervous system. the treatment of gliomas has been slowly changing for a few decades, and understanding of the glioma biology makes an important basic for the introduction of new treatment modalities. method: the most unfavorable prognosis concerns the group of diffuse gliomas which, due to the infiltrative growth, cannot be cured by surgery. the most common type of diffuse glioma is glioblastoma; this tumor may develop de novo (without preceding lower grade precursor lesion) or as a consequence of progression of malignancy. results: the molecular pathways most commonly seen in primary and secondary glioblastomas have been described, but recently, a new marker, isocitrate dehydrogenase (idh ), was defined as mutated early in the development of low-grade gliomas. the gene encoding this protein is located on chromosome q . idh catalyzes oxidative carboxylation of isocitrate to alphaketoglutarate. nicotinamide adenine dinucleotide phosphate (nadph) is the result of this reaction. idh is somatically mutated in low-grade gliomas and glioblastomas. on the other hand, alterations of the erk/mapk intracellular pathway occur in circumscribed gliomas, e.g. pilocytic astrocytoma. conclusion: all these informations suggest that differential utility of these markersand will be presented. toward "fingerprinting" of brain tumours based on the synchrotron radiation x-ray fluorescence, fourier transform infrared microspectroscopy (ftirm) and discriminant analysis d. adamek*, m. szczerbowska-boruchowska, m. lankosz *medical college krakow, dept. of neuropathology, poland objective: the neuropathologic diagnosis of brain tumours remains burdened by their well-known heterogeneity and difficulty to eliminate subjectivity in diagnosing. method: synchrotron radiation-based techniques were applied to biochemical micro-imaging of brain tumours of different types and various grades of malignancy. the specimens were cryosectioned, mounted on appropriate sample supports and freeze-dried. synchrotron radiation x-ray fluorescence was used for elemental analysis of samples. the level and distribution of p, s, cl, k, ca, fe, cu, zn, br and rb was determined. the biomolecular composition of neoplastic tissues was determined by fourier transform infrared microspectroscopy (ftirm). the composition of the tissues was used to construct a diagnostic classifier for brain tumours using discriminant analysis (da). results: it was found that cu, s, cl, k, and zn are the elements of the highest importance for the discrimination of tumor grade, as well as the tumor type. elemental analysis allowed % accordance with histological type and grade of tumor. the da applied to infrared absorption spectra indicated that lipids, amide i and amide ii, as well as phosphate group are of the highest importance for the discrimination of tumor type and tumor grade. the model obtained allowed differentiation between all investigated tumours and control samples as well as correct group classification in %. conclusion: it is difficult to speculate on the meaning of our findings with the biochemical perspective; however, the da based on elemental and biomolecular composition of tissue may be a potentially valuable method assisting the recognition and maybe grading of brain tumours. ( ) they are benign in the majority of cases; and ( ) the diagnosis of malignancy is based on cytologic features (papillary carcinoma) or on the presence of invasion of the tumor capsule or of blood vessels (follicular carcinoma). the common occurrence of benign thyroid nodules mandates an effective method for preoperative screening. the diagnosis of papillary thyroid carcinoma, by far the most common thyroid malignancy, is based on the identification of specific cytologic features. therefore, fine needle aspiration biopsy (fnab) has easily emerged in the past years as the most accurate and cost-effective tool, indeed a true cornerstone, for the preoperative management of thyroid nodules. standardized terminology to report diagnoses is highly recommended and is being implemented worldwide. the type of genetic alterations in thyroid cancer and the very nature of fnab samples make them ideally suited for molecular analysis. on the other end, the importance of intraoperative frozen section diagnosis has been constantly decreasing over the years as a direct consequence of the widespread application of fnab. it is now usually performed with cases that are suspicious after fnab and may be useful in some cases with indeterminate cytologic diagnosis. how to separate follicular adenoma from follicular carcinoma and follicular variant ptc? m. sobrinho-simoes* *portugal background: the differential diagnosis between fa, fc and fvptc is, at present, the most frequent reason for any consultancy practice on thyroid tumours. we will review this differential diagnostic problem taking into consideration that it only concerns the encapsulated type of fvptc. the poorly circumscribed/infiltrative types of fvptc, as well as the multinodular/diffuse type, do not create any major diagnostic doubts and are easily diagnosed, putting together the pattern of growth and the nuclear features. method: if one sticks to the differential diagnosis of fa, fc and encapsulated type of fvptc, the histopathological diagnostic hints are two: invasiveness (vascular invasion rather than pure capsular invasion) and presence of ptcnuclear features. results: we will discuss what to do whenever such histopathologic findings are not clear-cut enough to support a definitive diagnosis. we will review, in this context, the diagnostic value of immunohistochemical markers of differentiation and/or proliferation and that of molecular markers in a retrospective study of cases of well-differentiated carcinomas of the thyroid that have given rise to metastases and/or to local, clinically aggressive recurrences. the results obtained in this study will be used to determine the best diagnostic options and to support the conclusion that most, if not all, follicular tumours and welldifferentiated tumours of uncertain malignant potential, as well as minimally fc without vascular invasion and noninvasive encapsulated type of fvptc, carry a good prognosis even when treated by lobectomy alone. angioinvasive well-differentiated carcinoma, widely invasive follicular carcinoma, solid variant of papillary carcinoma and poorly differentiated carcinoma: from diagnosis to prognosis m. volante* *university of turin, clinic and biol. sciences, orbassano, italy malignant thyroid tumors are generally divided into welldifferentiated and undifferentiated (anaplastic) carcinomas, the former usually having a low malignant clinical behavior and good prognosis, and the latter being almost all very aggressive and rapidly fatal. diagnostic criteria rely on the recognition of cytological characteristics (i.e. nuclear alterations specific for papillary carcinoma), architectural patterns (i.e. papillary, follicular, solid, trabecular, insular or diffuse), high-grade features (i.e. increased mitotic index, necrosis) and invasive properties (i.e. vascular and/or capsular invasion). all of the aforementioned features are alternatively used as diagnostic hallmarks of specific histotypes, as peculiarities of specific variants, or as markers of aggressiveness, and their recognition is therefore essential to classify and stratify prognostically each individual tumor. the presence of vascular invasion is essential to recognize the malignant nature of a follicular tumor, but its extent is the major prognostic parameter in follicular carcinoma and draws a line between minimally invasive and widely invasive forms that are characterized by distinctive clinical outcomes. necrosis and high mitotic index usually occur in aggressive cases of papillary thyroid carcinoma, but together with the presence of solid/insular/ trabecular growth patterns represent the diagnostic features of poorly differentiated carcinoma, a specific tumor entity that shows a clinical behavior intermediate between welldifferentiated and undifferentiated carcinomas. at variance, the presence of a solid growth pattern in an otherwise typical papillary carcinoma depicts its solid variant, which is more often encountered in children and radiation-exposed individuals but has a clinical behavior usually similar to its conventional counterpart. as indicated by the world health organisation (who), histological grading is a way of predicting the biological behaviour of neoplasms. especially in neuropathological settings, tumour grade is often the key factor determining therapeutic decisions. clinical, radiological, macroscopic, histological and ultrastructural factors may already be summarized in a diagnosis that very well reflects the biology of the respective tumour entity, at least to a certain degree, but usually not in a personalized manner. this is exactly the stage where molecular biology comes into play. in recent years, much effort has been made on molecular characterization of brain tumours as there is an urgent need for specific and sensitive, highly reproducible tumour markers with a prognostic as well as predictive value. state of the art in modern neuropathology therefore ranges from basic immunohistochemical profiling, evaluation of genetic susceptibility, comparative genomic hybridization (cgh) approaches, fluorescence in situ hybridization (fish), screening for genetic hallmark mutations, evaluation of mrna expression of specific growth factor receptors, assessment of promoter methylation status and gene expression profiling to loss of heterozygosity (loh) analyses. the challenge now for pathologists confronted with brain tumours is to integrate knowledge derived from the latest molecular biological methods into the established panel of pure morphology-based investigations. objective: skeinoid fibres are globular brightly eosinophilic pas-positive extracellular collagen deposits seen commonly in gastrointestinal stromal tumours (gist) of the small bowel. ultrastructurally, they display similarity to "skeins of yearn", hence the name. however, hyaline globules are occasionally encountered in leiomyomatous gi neoplasms and may be mistaken for true skeinoid fibres leading, to an erroneous diagnosis of gist. method: we analyzed histologically and immunohistochemically well-characterized true smooth muscle neoplasms of the gi tract for the presence of hyaline globules and examined representative examples of them from formalin-fixed and deparaffinized tissue by electron microscopy. results: pas-positive intracellular and interstitial hyaline globules were detected in all benign paucicellular leiomyomas of the muscularis mucosae (n= ) and the muscularis propria (n= ) irrespective of tumour size and site, and rarely also in the adjacent muscularis propria, but in none of the leiomyosarcomas (n= ) and cellular leiomyoma (n= ). similar to surrounding tumour cells, hyaline globules expressed desmin, alpha-sma and h-caldesmon, but were negative for cd and cd . the mostly ovoid-shaped structures displayed at ultrastructural examination variably oriented bundles of filaments with a diameter of approximately - nm. at the periphery of these inclusions, altered filamentous material was recognized in different stages of degeneration with variable condensed matrix and occasional peripheral condensation suggestive of calcification. true skeinoid fibres were not detected. conclusion: the above findings are consistent with a multistep degenerative phenomenon affecting individual smooth muscle cells in paucicellular gi leiomyomas. awareness of this finding should prevent misinterpretation as gist, particularly in small biopsies. pseudotumours of the kidney j. lloreta-trull* *hospital del mar, dept. of pathology, barcelona, spain several clinicopathologic entities are grouped under the concept of pseudotumour: all of them usually result in a mass effect, therefore mimicking a neoplastic process grossly and sometimes microscopically. in the kidney and the urinary tract, the diseases most often presenting as a pseudotumour are malakoplakia and xantogranulomatous pyelonephritis. in fact, both of them can be considered inflammatory pseudotumours, i.e. inflammatory processes producing a mass effect. a more restrictive use of the term inflammatory pseudotumour applies to a subset of lesions that was initially known as myofibroblastic inflammatory pseudotumour and is currently referred to as inflammatory myofibroblastic tumour. ultrastructural examination reveals the pathogenesis of malakoplakia as a defect in the mechanisms of lysosomal extrusion from histiocytes. thus, the profusion of secondary lysosomes constitutes an optimal milieu for the deposition of calcium salts in typical michaelis-gutmann bodies. on the other hand, the foamy histiocytes of xantogranulomatous pyelonephritis are characterised by a profusion of myelin bodies due to the predominant phospholipid composition of the lysosomes, resulting from chronic destruction of renal tissue and bacterial degradation. inflammatory myofibroblastic tumour is a true neoplastic lesion with myofibroblastic differentiation and a prominent inflammatory background. this is an important differential diagnosis for both malakoplakia and xantogranulomatous pyelonephritis that may have an extensive myofibroblastic component. similar to its crucial role in kidney tumours, electron microscopy is a useful adjunct in the diagnosis of renal pseudotumours and has been essential in the elucidation of their pathogenesis. friday, september , . - . , sala wystawowa b objective: infectious complications have essential value at the conditions caused by primary and secondary immunodeficiencies, including connected with a hiv or immunosuppression therapy. laboratory diagnostics of opportunistic infections in conditions inadequate formation of antibodies is directed on revealing of antigenes of the activator. method: one hundred fifty samples of washing waters of bronchial tubes are investigated at diagnostic or medical bronchoscopy of patients (children and adults) with acute lymphoid ( . %) and myeloid ( . %) leukemia, chronic lymphoid and myeloid leukemia, hodgkin's and non-hodgkin's lymphomas. patients have been surveyed in different terms after transplantation of a bone brain. cytologic preparations were painted h&e, ziehl-neelsen and pas, ich. the cellular structure, condition epithelial cells, a degree of expressiveness and character macrophages activity epithelial and non-epithelial cells, a degree of expressiveness and character inflammations and also the presence of specific activators were estimated. results: data obtained by us testify to the prevalence bacteria ( . %) and viruses ( . %), inflammatory processes in respiratory ways. the changes connected with specific (tumoral), mycoses (aspergillosis, zygomycosis, a candidiasis) and pneumocystosis were less often observed by defeat. in one сase, it was documented as mycobacteriosis. in . % of cases of pathological changes, it is not revealed; in . % of cases, the changes connected with natural return development of pathological process were observed. conclusion: carrying out complex research of a biological material for the definition of character and a degree of expressiveness of pathological process and also the proof of a role of the infectious agent in the development of pathological process is expedient. diagnosis of infections in fine needle aspiration (fna) in immunocompetent and immunocompromised patients b. bode* *universitätsspital zürich, institute of zytology, switzerland fine needle aspiration (fna) is a well-established method for the evaluation of the aetiology of superficial and deep masses. an infectious process has to be considered as a differential diagnosis in all cases, especially in the setting of immunosuppression (hiv infection, transplantation, chemotherapy, inborn defects). fna allows a rapid distinction between neoplastic and inflammatory/infectious lesions. a wide range of pathogens including various viruses (cmv, ebv), bacteria (grampositive cocci, actinomyces, spirochetes, mycobacteria), fungi (aspergillus, cryptococcus) and parasites (toxoplasma, echinococcus) may be identified cytologically. infectious agents may be visualised either direct in standard stainings (cmv, fungi), in special stainings (mycobacteria) or immunohistochemically (spirochetes), either on direct smears or in cell blocks. molecular methods (in situ hybridization, pcr with sequencing) applied to fna specimen help identify and often subtype the pathogen if required (ebv, mycobacterium tuberculosis vs. atypical mycobacteriosis). fna is a particularly convenient method for fresh, sterile sample collection for microbiological examination with culture and drug resistance studies, playing an important role in treatment decision, e.g. in therapy of multiresistant tuberculosis. in some infectious diseases, the final diagnosis may be made by serology following indirect cytological hints in a fna specimen (e.g. toxoplasmosis, hiv). interestingly, infectious agents have been identified as aetiologically relevant factors in several tumor types (ebv in burkitt lymphoma or lymphoepithelial carcinoma, hhv in kaposi sarcoma, hpv in oropharyngeal carcinoma), so that the identification of the pathogens in fnas may play an important role in the precise diagnosis of some neoplasias. usefulness of oral cytopathology in the diagnosis of infectious diseases in immunocompromised patients p. hofman* *france background: cytology is an accepted and widely employed diagnostic methodology used in the early diagnosis of oral cancer. however, the diagnosis of many other specific clinical conditions of the mouth can be made from examination of smears, in particular infectious diseases. method: in recent years, the spectrum of infectious diseases of the mouth has changed. firstly, oral infections observed in immunocompromised patients have dramatically increased owing to the widespread implementation of solid organ and bone marrow transplantation and in the increasing prevalence of hiv infections. secondly, while the occurrence of many oral lesions has decreased significantly since the advent of highly active antiretroviral therapy, the incidence of oral warts has increased. results: in this regard, cytology can be used as a rapid, noninvasive, inexpensive and simple routine procedure in diagnosing infectious diseases of the mouth. the role of the cytopathology laboratory is diagnostic, i.e., to suggest or identify the presence of an infectious agent. however, exogenous structures that can mimic a variety of pathogens can pose a serious challenge. conclusion: the contaminants can be distinguished from microorganisms by their haphazard arrangement and lack of internal structure. moreover, the absences of acute or chronic inflammation, of macrophages or multinucleated giant cells with or without granulomas, and the absence of necrosis are features that should alert the cytologist to the possibility of contamination. finally, ancillary methods can be developed from cytological samples, which increases the specificity and the sensitivity for the diagnosis of infectious diseases in mouth. the the essentials in making a pathology diagnosis a. batistatou* *greece pathology is the discipline concerned with understanding the nature of human disease. pathologists' interpretations of tissue lesions become data, guiding decisions for patient management. cognition, the sum of processes by which the visual input is transformed, reduced, elaborated, stored, recovered and used, is very important in pathology. looking through the microscope at the stained tissue section (global impression and focal search) leads to perception of forms and colours. various regions are examined under low and high magnifications. then the pathologist puts the observed pieces of the colourful puzzle in place. an experienced pathologist proceeds promptly to pattern recognition and probably to diagnosis, while a novice takes more time, usually by not focusing on the significant areas but rather via an exhaustive search of the whole slide. non-verbalized pattern recognition consists of short sequences which result from conversion of longer series of specific features. alternative cognitive methods are diagnostic algorithms and the hypothetico-deductive strategy. experienced pathologists perceive each case as a whole, constituted by parts varying in importance and relevance. and while novices prefer to use analytic reasoning strategies, which are conscious and controlled, experts often use implicit reasoning, which is unconscious and automatic and relies largely on tacit knowledge. pathologists have faith in the analysis of morphology whose power has been appreciated even in the current molecular era. the use of virtual microscopy has a great advantage over the exchange of static images for diagnosis and training since it also allows for the initial steps to diagnosis, i.e. search, detection and perception. pathology diagnoses were asked for in the context of quality control of cervical cytology and dermatopathology. conclusion: in patient care, the dutch pathologists profit from the historical pathology diagnoses dating back to . for quality control of the lcpl, the diagnoses of other pathology laboratories of the hospitals where the patients of the general practitioners were operated provided by the palga are of paramount importance. in , the palga system will also be employed for the nationwide evaluation of the early detection of cervix, breast, and colon carcinoma. virtual microscopy in routine diagnostic procedure of pathology m. dietel* *universitätsmedizin charité, berlin, germany background: virtual microscopy (vm) is now widely applied in pathology. many studies underline the diagnostic security, the technical robustness as well as the versatility of this method. the standardization organizations dicom, hl and ihe call virtual slides as whole slide images (wsi) now and integrate the technology into their standardization strategy. in contrast to the increasing application in educations, the virtual microscopy is far from routine use in surgical pathology. this goes back to several reasons concerning technical and personal requirements: costs (scanning devices and storage), scanning time (between and min for a biopsy and between and min for a surgical specimen) and speed of virtual microscopes in comparison to conventional microscopy. results: caching and prefetching may speed up image loading, the bottleneck in virtual microscopy. the positive effects of different prefetching and caching technologies which depend on the user's behaviour will be discussed. further, the process of secondary diagnostic was evaluated using the "t. konsult pathologie" service of the professional association of german pathologists within the german breast cancer screening program. conclusion: in summary, it could be shown that the safety of diagnostic on wsi is comparable to the conventional diagnostic based on glass slides and a classical microscope. discrepancies go back to problems with the difficulty of the case itself and not to technical problems with virtual microscopy. virtual microscopy in teaching pathology in pomeranian medical university a. kram*, w. domagała *pomeranian medical university, szczecin, poland objective: microscopy is an important way of understanding the morphologic basis of diseases, and a slide seminar is part of the pathology program in medical schools worldwide. virtual pathology which allows seeing the entire digitized microscopic slide on the computer screen has been introduced recently. here, we share our experience in using digitized slides in teaching pathology and also discuss student's survey results. this has been the first implementation of a complete virtual pathology course for students of medicine in poland. method: two hundred twenty-four virtual slides for pathology course for medical students were produced by the use of aperio scanscope cs scanner and hosted in spectrum database. starting from the year , a group of polish-and english-speaking students used glass slides and microscopes in the first year and then virtual slides in the second year. at the end of the second year, on completion of the pathology course, the students were given a questionnaire to evaluate both systems. results: eighty-five percent of students preferred the screen over the microscope. continuous and easy access to virtual slides via the internet was indicated as one of the major advantages of virtual microscopy. some technical problems having an adverse impact on learning efficacy were noted. conclusion: the move to virtual microscopy and computer-assisted pathology teaching appears to be well received by students and enhance their learning ability in the field of pathology. objective: since years, there is an increase of incidence and mortality of adenocarcinoma as compared to epidermoid carcinoma. this increase is particularly notable for women younger than years. adenocarcinoma equals one fourth of cancers of the cervix in some countries like the uk where there is an organized screening program. method: the bethesda terminology has introduced for the first time the cytological diagnosis of adenocarcinoma in situ, the glandular counterpart of high-grade squamous intraepithelial lesion (hsil). results: it is a rare lesion that corresponds to % of abnormal pap smears and . % of all pap smear diagnoses. adenocarcinoma in situ is characterized by periphery radial arrangement of feather-shaped nuclei, cigar stack-shaped pseudostratified strips, rosettes images, hyperchromatic nuclei with granular structure and clean background without necrosis. on the contrary, invasive endocervical adenocarcinoma is characterized by papillary groups, lost of cellular cohesion, polymorphism of the nuclei with one or two prominent nucleoli and tumoral diathesis with dirty background, cellular debris and fragmented red blood cells. the bethesda terminology has maintained the grey zone for glandular cells abnormalities not well defined, included in the diagnosis of atypical glandular cells of endocervical, endometrial or undetermined. conclusion: the efficacy of cytological screening for detecting ais will lead to the increase of the rate of detection of ais. this will have an impact on the incidence and mortality of invasive adenocarcinoma in the coming years. the protective effect is beginning to be seen only recently for women younger than years in australia and in england. squamous lesions of the uterine cervix j. bulten* *radboud university, dept. of pathology, nijmegen, the netherlands cervical cancer is a major cause of death in women and the second most frequent cancer throughout the world, accounting for almost % of all malignancies in women. in this course, an overview is presented of the precursors of squamous cell carcinoma, its mimics, microinvasive carcinoma and cervical squamous cell carcinoma. the cin terminology (cervical intraepithelial neoplasia, grades - ) of richart is most widely used for cervical cancer precursors. nowadays, it is evident that cin is not a continuum, but reflects merely a low-grade entity (koilocytosis, flat condyloma and cin ) and conversely a true intraepithelial neoplastic process (cin - and carcinoma in situ). in diagnosing cin, hpv testing is not recommended. on the contrary, post-treatment hpv testing can predict treatment failure and thus residual cin. in grading cin and to differentiate cin from its mimics as atrophy, immature metaplasia or reserve cell hyperplasia immunohistochemistry (mib and p ) can be applied. due to preceding biopsies, microinvasive carcinoma is frequently overdiagnosed. colposcopy, cytology and immunohistochemistry are not very helpful in diagnosing microinvasive growth. as the diagnosis of (micro-)invasive growth has great clinical implications, cervical excision biopsies or cones should be totally embedded and serially sampled. there are three types of invasive growth, and the invasion depth should always be measured between the last cell of the deepest invasive focus perpendicular to the (expected) site of origin. finally, the several types of squamous cell carcinoma and its mimics are presented. , and unfavorable prognosis (alveolar rhabdomyosarcoma). immunohistochemistry can be used to separate between embryonal and alveolar rms. ap and pcadherin are almost exclusively expressed in alveolar rms, whereas egf receptor and fibrillin are found in embryonal rms. in addition, the myf- expression of alveolar rms is usually much stronger than in embryonal rms. genetic changes have been found for both embryonal and alveolar rms. most alveolar rms have a balanced reciprocal translocation, t( ; )(q ;q ). a smaller subgroup of alveolar rms has a t( ; ) translocation. two other translocations, a t( ; )(q ;p ), which generates a fusion protein composed of pax and ncoa , and a t( ; x) resulting in a fusion protein pax /afx, have been described in single cases. in embryonal rms, a loss of heterozygosity (loh) on chromosome p . has been shown. the involved gene or genes have not yet been clearly identified, but several interesting genes are located in this area like the myod gene, the igf- gene, the ldh (muscle subunit) gene, and the wt gene. a possible imprinting of this gene has also been postulated. infantile fibrosarcoma and malignant fibrous tumours r. alaggio* *anatomia patologica, scienze diagnostiche e terapie, padova, italy background: fibroblastic/myofibroblastic lesions account for % of pediatric soft tissue tumours and include benign neoplasms, reactive, pseudoneoplastic proliferations and, rarely, malignant tumours. the malignant lesions, registered in the italian protocol rms- , are reported to define their clinicopathologic and molecular features. method: forty-eight patients with fibrosarcoma (congenital and adult) were reviewed (table) . four cases, originally diagnosed as cifs, with negative etv -ntrk transcript, were reclassified as composite fibromatosis (two), undifferentiated sarcoma (one) and rhabdomyofibrosarcoma (one) and excluded from this study. results: see some of these lesions are genuine benign neoplasms; others have a reactive nature. nodular fasciitis is a fibroblastic/ myofibroblastic proliferation mostly seen in the subcutaneous tissue, morphologically presenting a loose and culture-like growth pattern. proliferative fasciitis (and proliferative myositis) is, likewise, nodular fasciitis, a fibroblastic/myofibroblastic proliferation with the presence of large ganglionlike cells. myositis ossificans is a benign and reactive lesion. fibrous hamartoma of infancy is a relatively common benign tumour of early childhood which presents three components: fibrocollagenous tissue, immature-primitive mesenchymal cells and mature fat tissue. myofibroma/myofibromatosis is a benign tumour observed in newborns and children within the first years of life, as well as in elderly patients. fibromatosis colli is a rare benign lesion typically seen in the sternocleidomastoid muscle in infants. microscopically, it is a proliferation of fibroblasts in between the muscle fibres forming a "scar-like" pattern. juvenile hyaline fibromatosis is a very uncommon, non-neoplastic lesion. fibroma of tendon sheath is a benign (possibly reactive) lesion related to tendons. calcifying aponeurotic firbroma is the tumour more frequently seen in children. gardner fibroma is an uncommon benign tumour mostly seen in infants, children and adolescents. calcifying fibrous tumour is a rare benign tumor more frequently observed in children and young adults. background: a standard clinical terminology like snomed ct is important not only for pathology information systems but also to integrate these systems with many other hospital information systems (his, pacs, departmental systems, encoding, database patients) and primary care information systems. method: snomed ct includes two hierarchies (morphologic abnormality and disorder) with similar terms. a snomed ct implementation was designed taking into account both the difference between these hierarchies and the relationship between terms located in different hierarchies. this is especially necessary in the postcoordination of clinical expressions and the creation of subsets. results: the january edition of the subset of pathology, which distributes the college of american pathologists (cap), contains , terms, but this subset needs to be improved to give it a clinical use. in sescam, , morphological concepts and specimen concepts were selected to create a minimum basic set for use in pathology information systems. snomed ct is also used in the sescam telepathology portal (project serendipia), developed according to the ihe-anatomic pathology initiative and dicom supplement- for medical imaging. conclusion: a snomed ct implementation strategy should not only include a list or subset of terms, but it must also consider the efficient use of relationships between terms and concept hierarchies, a mechanism for extension and update, and a plan for the coexistence or migration of legacy snomed ii codes. latest developments in data storage devices applicable for virtual slides j. görtler* *belgium structured reports in tumor pathology-how and why g. haroske* *germany objective: among all medical documents, pathology reports are often highly critical for patient care. in terms of information technology and knowledge engineering, presently, these reports are widely lacking adequate structure to support their usage in knowledge retrieval technologies for medical decision making, research, epidemiology, quality management and medical education. method: by means of literature surveys and by a questionnaire sent to vendors of pathology management systems (pms), the degree of structure in pathology reports in pms sold in germany was analyzed and compared with user needs expressed by pathologists. results: pathology reports are widely displayed, stored and exported as free text, identifiable by human beings, but without "observation identifiers" of a coding system not readable by a computer. a few systems allow textual information to be structured in sections partly identified by coding systems as snomed ct, etc. within the sections, the information is still unstructured. at the very beginning are attempts to structure the report as a list of coded items based on templates, which are controlled for identifiers, version, and the underlying concepts and representations. this is by far the most granular structure for computer readability and knowledge engineering. conclusion: there are very different opinions about the aim and degree of structured reporting. although standardization efforts have led to a series of reporting minimum requirements in tumor pathology, their implementation in structured data entry systems is still lacking. tools for data mining in routine pathology will be decisive for all important progress in pathology informatics at all. experiences of virtual microscopy in tma application g. kayser* *germany how to scale image information in virtual slides? k. kayser*, s. borkenfeld, j. görtler, g. kayser *heidelberg, germany objective: the application of virtual slides requires unequivocal definition and scaling of image information. scaling of image information offers the evaluation of diagnosis and content-based image retrieval (cbir). method: theory in principle-image information can be extracted with or without knowledge of its content. knowing its content (for example organ, potential diseases), we can segment biological meaningful objects (nuclei, membranes, etc.) and measure their features (size, gray values, derived parameters). the obtained results can be scaled and associated with the underlying disease. in reverse, knowing the applied algorithms and the object (and structure) features, cbir can be applied. without predefined knowledge, basic image information is mapped on spatial image units (pixels), called texture. they can be quantified by the application of stochastic geometry: each biological meaningful object is composed of so-called primitives (points, fibers, rings, plateaus). their mapping on an object can be used to detect knowledgeindependent content and scalable image information. results: object-and structure-based ( ) and the texturebased ( ) algorithms have been implemented and applied on more than , images obtained from h&e-stained glass slides of different organs (colon/rectum, lung, pleura, thyroid) in search for disease-significant areas (fields of view) and disease classification. the accuracy of the methods in field of view selection was computed to > %, that of prospective disease classification > %. hyperplastic lesions of the appendiceal mucosa are classically divided into two groups: diffuse hyperplasia and localized polyps. localized lesions were usually diagnosed as hyperplastic polyps, but some of these lesions are now better classified as sessile serrated adenomas. both diffuse hyperplasia and polyps are in most cases incidental findings on appendectomy specimens (performed for appendicitis or systematically sampled in a colectomy specimen). however, these lesions are significantly associated with colon adeno-carcinoma, and therefore, their discovery in an appendectomy specimen is an indication of further examination to exclude colorectal neoplasia. diffuse mucosal hyperplasia extends to more than one half of the circumference of the appendiceal mucosa. it exhibits elongated crypts with serrated architecture. the epithelium is composed of columnar cells alternating with large goblet cells in various proportions. the crypt bases are not serrated and are lined by regular cells with no atypia. hyperplastic polyps are supposed to be rare in the vermiform appendix. they are localized lesions, with a histological aspect similar to the corresponding colorectal lesions. similarly to diffuse mucosal hyperplasia, they are characterized by a serrated architecture restricted to the upper part of the crypts and by the lack of any dysplastic features. when lesions associate hyperplastic serrated features in one area and adenomatous (tubular and/or villous) features in another, they are designated as mixed adenomatous and hyperplastic polyps, as tumours of the colon and rectum. however, it is probable that at least part of these mixed lesions represent hyperplastic serrated polyps that have progressed to dysplasia. sessile serrated adenoma (or sessile serrated polyp or serrated polyp with abnormal proliferation) is a more recently described type of colorectal polyp with a serrated architecture. they occur frequently in the right colon, and although they resemble to hyperplastic polyps, they are characterized by subtle architectural and cytological features, especially dilation and serration of the basal part of the crypts. they can be dysplastic or not. the relative frequency of sessile serrated adenomas and other serrated lesions of the appendix is not well established, but it is highly probable that many appendiceal lesions previously designated as diffuse hyperplasia or hyperplastic polyp represent cases of sessile serrated adenomas. both types of lesions have been proven to show decreased expression of mlh and mgmt in a majority of cases and also braf mutation in a significant proportion of cases. these genetic and epigenetic alterations are similar to those observed in sessile serrated adenoma of the colon, which is now considered as a precursor lesion for a subgroup of colorectal cancer. the differential diagnosis of serrated lesions of the appendix also includes adenomas of colorectal type (more often showing villous architecture when compared to colorectal lesions) and low-grade mucinous neoplasms, often referred to as cystadenomas. adenocarcinoma, mucinous neoplasm of the appendix and pseudomyxoma peritonei a. jouret-mourin* *cliniques universitaires st luc, brussels, belgium primary adenocarcinoma of the appendix is unusual. some resemble typical colonic adenocarcinoma in their appear-ance and behaviour, but others are well-differentiated neoplasms or adenoma-like that may be associated with the pseudomyxoma peritonei syndrome without distant metastases. this pathological spectrum is confused because of terminological inconsistencies and the large variety of diagnostic criteria. therefore, there remains a "grey area" between benign and malignant lesions. some authors have recently proposed a new terminology based on the biological potential of the different lesions. lowgrade appendiceal mucinous neoplasm (lamn) is defined as a subset of lesions that have low-grade cytological atypia and minimal architectural complexity. these lesions penetrate into or through the appendiceal wall often on a broad front, without overt invasion and may be associated with pseudomyxoma peritonei. consequently, such lamn category includes the old terms of "tumours of uncertain malignant potential, "pseudomyxoma with adenoma-like histology" and the "low-grade mucinous adenocarcinoma" which can also produce pseudomyxoma. invasive mucinous adenocarcinoma (maca) includes a destructive invasion of the appendiceal wall with high-grade atypia, complex proliferation (i.e. cribriform pattern), desmoplastic stroma, signet ring cells differentiation or undifferentiated tumours. lymph node metastases occur lately, but peritoneal spreading is more frequent. some recent publications have demonstrated that protein immunoexpression profiles offer predictive factors of adverse clinical outcomes, which should further facilitate the classification of appendiceal mucinous neoplasms. appendiceal mucinous tumours can occur in patients who have suffered long-standing ulcerative colitis, familial polyposis and hnpcc syndrome. most of them show microsatellite instability probably given the high frequency of serrated precursor. pseudomyxoma peritonei syndrome is defined as the presence of abundant mucinous material on the peritoneal surface. this entity should be retained as a clinical term. besides exceptional cases of pseudomyxoma reported in association with mucinous carcinomas at other sites, all cases of pseudomyxoma peritonei are related to appendiceal rupture with subsequent transcelomic spread of tumoral cells. some authors have proposed that the same terminology should be used for the appendiceal primaries and the peritoneal lesions since lamn lesions confined to the appendix have the same appearance as those that have spread to the peritoneum. in addition, any tumour capable of producing pseudomyxoma peritonei should be considered as adenocarcinoma. therefore, the classification of pseudomyxoma perotonei includes low-grade and high-grade mucinous adenocarcinoma. the acellularity of the extra-appendicular mucin, based on extensive sampling, must be described in the pathological report because of its prognostic implications. mixed mucus-secreting and endocrine tumours of the appendix j.-y. scoazec* *hospices civils de lyon, hôpital edouard herriot, france vermiform appendix is one of the most frequent sites of mixed endocrine-exocrine tumours in the gastrointestinal tract. one histologic type of mixed mucus-secreting and endocrine tumor is specific for the appendix: this distinctive tumour is known as goblet cell carcinoid. the others are mixed endocrine-exocrine carcinomas raising the same problems of diagnosis and management than in the other digestive locations. goblet cell carcinoid is a highly distinctive clinical and histological entity. in contrast to the much more common pure neuroendocrine tumours of the appendix, which are usually discovered incidentally in young patients, goblet cell carcinoids present a peak of incidence in the fifth decade and are usually symptomatic. at macroscopic examination, goblet cell carcinoids present a very particular pattern of growth, resulting in the thickening of the whole appendicular wall and in a marked reduction in the calibre of the lumen, in the absence of visible tumour mass. this aspect is due to the predominant infiltration of the deepest part of the mucosa and the submucosa by tumour cells, which result in their fibrosis and thickening. at a higher magnification, tumor cells are grouped in small nests formed by large cells, with an abundant, pale, mucus-laden cytoplasm and an eccentric nucleus. these cells are strongly reactive with alcian blue and pas stainings. small endocrine cells are closely intermingled with mucus-laden cells; they are usually difficult to identify by conventional stainings; they are much more easily demonstrated through the immunodetection of endocrine and neuroendocrine markers such as chromogranin a and synaptophysin. finally, some amphicrine cells, with a combination of exocrine and endocrine markers, may be present. the number of endocrine cells admixed with mucus-laden cells is highly variable from one case to another and even from one region to another in the same tumour. there is no minimal amount of endocrine cells required for the diagnosis of goblet cell carcinoid, which is achieved by the combination of a typical macroscopic aspect, the presence of characteristic mucus-laden cells and the demonstration of even a few endocrine cells intermingled with the predominant mucus-producing population. from the molecular point of view, goblet cell carcinoids frequently harbour loss of heterozygosity in q, q and q. goblet cell carcinoids carry a high risk of peritoneal dissemination, but a low risk of distant metastasis. their prognosis is therefore much poorer than that of typical neuroendocrine tumours of the appendix: the -year survival is only % instead of %, all stages included; even for patients with localized disease, it is % instead of %. importantly, the tnm classification of goblet cell carcinoid must follow the criteria used for the staging of appendicular carcinomas, not those recently proposed for appendicular "carcinoids". mixed endocrine-exocrine carcinomas of the appendix combine an exocrine component, usually corresponding to a mucus-secreting adenocarcinoma of variable differentiation and an endocrine component, which may be well or poorly differentiated. the diagnosis of mixed tumour must be made with caution, only if the endocrine component is clearly neoplastic and represents at least % of the whole tumour. the prognosis and treatment are those of the most aggressive component. electron microscopy has been relatively surpassed by immunohistochemistry in pathology, especially for the diagnosis of neoplastic processes. however, its use is mandatory in neurodegenerative and neuromuscular disorders of non-neoplasic origin. ultrastructural examination has been proven to be useful in the following issues: ( ) to understand the physiopathology of muscle disorders. muscular dystrophies are produced by mutations in genes codifying proteins located at different subcellular levels. ultrastructural alterations have been observed at the level where the defective protein is expressed, i.e. plasma membrane alterations in dysferlinopathies, caveolinopathies and sarcoglycanopathies, or nuclear envelope membrane defects in emery dreifuss muscular dystrophy and laminopathies. ( ) to identify structures not visible with light microscopy. this is the case of intranuclear inclusions in oculo-pharyngeal muscular dystrophy, in inclusion body myositis, or tubulo-reticular inclusions seen in several autoimmune disorders and in aids. ( ) to determine the origin of specific anomalies depicted with light microscopy. ultrastructure of tubular aggregates, nemaline bodies, central cores or paracrystalline mitochondrial inclusions has been crucial to define the origin and organization of such changes at the subcellular components of the muscle fiber. ( ) to study in depth lysosomal storage disorders. the identification of different types of inclusions in neuronal ceroid lipofuscinosis according to the phenotype-genotype form of the disease has been especially useful, and so it was for the diagnosis of late-onset forms of glycogenosis type ii, fabry disease or others. in conclusion, electron microscopic examination is crucial to identify the subcellular structural involvement in some muscle disorders and to understand the underlying pathological mechanisms. electron microscopy of peripheral nerve a. vital* *bordeaux university hospital, dept. of pathology, france objective: electron microscopic examination (eme) of a peripheral nerve biopsy (pnb) is particularly valuable to assess the type of nerve fiber lesions, endoneurial deposits and storage materials. method: a well-done pnb, as well as a reliable methodology for fixation and embedding of specimens, constitute a prerequisite for an informative eme. results: if most cases of hereditary peripheral neuropathies are now diagnosed by molecular biology, nerve lesion analysis can direct the search for mutations in specific genes. prominent "onion bulb" formations are associated with pmp duplication. "tomaculae" correspond to pmp deletion, but can also be observed in certain cases of p mutation. other p mutations are mainly associated with irregularly uncompacted myelin lamellae. discrete "onion bulb" formations in association with "pseudo-onion bulb" formations surrounding clusters of regeneration are much suggestive of connexin mutation. abnormal mitochondria point to a mitofusin gene mutation. ultrastructural evidence of macrophageassociated demyelination is very supportive in atypical cases of inflammatory demyelinating polyneuropathy. in some cases of paraproteinemic neuropathy, myelin lamellae may exhibit a regular spacing corresponding to the presence of immunoglobulin m. in others, granular immunoglobulin deposits are identified in the endoneurium. occasionally, the endoneurial deposits have the tubular ultrastructure of a monoclonal cryoglobulin. the presence of osmiophilic lamellar inclusions in schwann cells points to treatment intolerance. at last, eme of a pnb may help in the diagnosis of a hereditary storage disease. conclusion: eme can be decisive to establish the etiological diagnosis of a peripheral neuropathy and must be supported by a reliable methodology. electron microscopy of metabolic storage diseases i. ferrer* *hospital universitari de bellv, institut neuropatologia, spain metabolic diseases of the nervous system in infancy constitute a very complex group of variegated diseases with particular clinical, morphological, biochemical and genetic characteristics. diagnosis of such disorders usually demands the collaboration of different specialists, methods, and skills. this is particularly important in order to avoid unnecessary probes and superfluous additional suffering related with inappropriate complementary examinations and visits. in recent years, molecular and genetic studies have facilitated a correct diagnosis during life, and improvements in therapy have permitted the application of new therapeutic tools in some cases. morphological visualization of determinate lesions in skin, conjunctival, appendicular and, rarely, rectal mucosa, is extremely useful to support a clinical diagnosis. lipidosis, mucopolysccharidosis, mucolipidosis, polyglucosan storage diseases and glycogenosis affect several cell types outside the central nervous system, including axons and schwann cells, endothelial cells, pericytes, smooth muscle fibres, sebaceous and eccrine glands and ducts, and striate muscle. deposits are usually too small to be visible with an optical microscope. yet electron microscopy permits the observation of lysosomal inclusions filled with specific inclusions and deposition of abnormal material in different cells. in addition to metabolic diseases, other degenerative diseases affecting the nervous system in which the diagnosis is mainly based on key pathological markers are also subject to electron microscopy analysis during life. nuclear neuronal inclusion body disease and infantile neuroaxonal dystrophy, among others, can be diagnosed by means of appendicular (or rectal) biopsies and by examining the nerve terminals and skin and conjunctiva, respectively. this presentation will cover a range of sinonasal inflammatory diseases, focussing on those where an improved understanding of pathogenesis illuminates diagnostic histopathology. the categorisation of sinonasal fungus-related diseases is important for prognosis and treatment. fungi are common airborne allergens and can be cultured from the nasal secretions of most healthy individuals. the diagnosis of fungal sinusitis relies on the histological recognition of fungi in sinus tissue, although the morphology of fungal hyphae is of limited value in distinguishing between fungal species. invasive fungal sinusitis is almost always encountered in patients whose immune system is compromised and is associated with necrosis and vascular invasion by fungi. noninvasive fungal sinusitis includes sinus fungal balls and allergic fungal sinusitis, a disease characterised by socalled allergic mucin and scanty fungal hyphae. the pathogenesis of chronic rhinosinusitis involves a complex interplay between environmental factors and genetically influenced immune responses; eosinophils may be seen in both allergic rhinosinusitis and in patients with no evidence of allergy. the differential diagnosis of inflammatory polyps will be discussed. pathologists should be aware of the many sinonasal diseases that may include a component of granulomatous inflammation including mycobacterial infection, cocaine-induced midline destructive disease and wegener's granulomatosis, and of the value of ancillary investigations such as autoantibodies in their differential diagnosis. autoimmunity to type ii collagen is involved in relapsing polychondritis, a multisystem disorder in which destruction of the cartilages of the nose, ears and upper airway is prominent. classification and diagnosis of sinonasal adenocarcinomas i. leivo* *haartman institute, dept. of pathology, helsinki, finland salivary gland-type sinonasal adenocarcinomas can occur in the sinonasal tract, and they resemble the corresponding tumours in salivary glands. the most common types are adenoid cystic carcinoma and adenocarcinoma, not otherwise specified. intestinal-type sinonasal adenocarcinomas mimic the histological appearances of intestinal adenomas, carcinomas, or rarely even the normal intestinal mucosa. occurrence of the intestinal-type sinonasal adenocarcinoma has been associated with long-term exposure to hardwood (beech, oak) dusts. in the woodworking industry, these tumours can be , times more common than in the general population. the average exposure time is years. histologically, the most common appearances resemble colonic adenocarcinomas. if the resemblance is striking, the rare possibility of a metastasis from the gastrointestinal tract should be considered. similar to colonic adenocarcinomas, intestinal-type sinonasal adenocarcinomas stain for ck , cdx- , and muc , but they also stain for ck . thus, the differential diagnosis between a primary intestinal-type sinonasal adenocarcinoma and a metastatic colonic adenocarcinoma cannot be based on histomorphology or immunophenotype alone. then, the recommended approach is colonoscopy. the intestinal-type sinonasal adenocarcinoma is a high-grade malignancy. however, the prognosis of patients with hardwood dust exposure is better than in sporadic tumours. in addition, papillary growth patterns relate to a more favourable outcome. low-grade sinonasal adenocarcinomas have not shown occupational or environmental associations. histologically, they are papillary or glandular, with a single layer of uniform epithelial cells. cytologically, they are bland, but malignancy is revealed by the complexity of architecture and invasive growth. lowgrade sinonasal adenocarcinomas do not express intestinal immunophenotypic markers. background: computer-assisted microscopy (cam) offers proven solutions in immunohistochemical assessments, sharing digital slides with collaborators in different places, storing and organize pathological and clinical data and research. method: we initially developed an in-house system for the creation of digital slides and for remote diagnoses on frozen sections, suggesting that digital pathology would become the new standard in surgical pathology. in our institution, we adopt cam using the aperio scanscope xs for several applications: results: ( ) detection and semiquantitative measurement of equivocal her immunoreactivity and of ki in breast cancer-our data on over cases with comparison between cam and human evaluation and with fish analysis strongly support its feasibility and reliability in routine practice; ( ) to store and analyze tissue microarrays with all associated experimental and follow-up data, permitting fast access to adjacent sections and comparing stains across multiple slides; ( ) to store clinical-pathological data of patients for discussion in multidisciplinary meetings and courses. conclusion: in our opinion, cam provides a unique opportunity for image visualization and analysis, archival and retrieval, which in the near future will probably replace the usual microscopy in routine practice. bibliography . objective: an automated method for immunohistochemical assessment of ki- proliferation index was developed and evaluated. using an open source image manipulation tool, imagej, a macro called ihcj was created for the assessment of immunohistochemistry stainings. the performance of the ihcj macro was evaluated in a tissue microarray series of breast cancer specimens from , patients. the specimens were stained with an anti-ki- antibody, counterstained with hematoxylin and digitized. the ki- proliferation index was calculated both visually and automatically with the ihcj macro ( fig. ) . the prognostic value of the ki- proliferation index was evaluated in uniand multivariate survival analyses. results: in a univariate survival analysis, the hazard ratio of distant recurrence during a median follow-up of . years for the automated ki- medium area fraction was . during the past years, we have completed a transition of the basic and oral pathology practical courses from light to virtual microscopy. after a pilot feasibility study, the entire training set of glass slides was digitized and located on webmicroscope server. giving access to the web, computers have become perfect companions of the students. the study material consists now of over fully digitized slides covering entities in basic pathology and entities in oral pathology. digitized slides are linked with still macro-and microscopic images, organized with clinical information into virtual cases. we undertake a comprehensive evaluation of this new approach at the end of every academic year. in these surveys, students rate the software, the quality of the images, handling of the images, and effective use of virtual slides during the time of the practical. satisfaction surveys demonstrate a steady improvement over the past years as various student suggestions were implemented. an overwhelming majority of our students considered using digitized slides at their convenience as highly desirable. overall, the quality of the images was rated as very good. however, due to the limitation of resolution of few primary scans, we have rescanned these slides at × objective and a , × , -pixel camera to alleviate these problems. our students and faculty consider the virtual microscope as a significant improvement. the administrators of our department consider virtual microscopy as innovative and costeffective because there is no longer the expense of the maintenance and replacement of microscope and glass slides. a web-based examination system for students using webmicroscopy for learning oral pathology j. szymas*, m. lundin, j. lundin *university of medical sciences, dept. of clinical pathology, poznan, poland we have developed and evaluated a user-friendly online interactive teaching and examination system for pathology courses. already in , at the end of the first course, students take a multiple-choice question exam (one correct answer per question). every exam question is linked with a proper virtual slide and the time for the answer is unlimited. this examination system uses advanced html features, and the web browser that can handle frames, javascript and cookies is required. setting the screen to a resolution of , × or higher and decreasing the size of the menu bars if necessary is helpful in viewing the digitized histological slide and the question at the same time. specific instructions about answering the questions are also given at the beginning of the examination. a score is generated for questions which are correctly answered. the scores are accumulated until the student decides to quit the web browser. in the last years, an overall % concordance rate has been achieved on practical examination based on virtual slides connected with multiple-choice questions per student. the online practical examination system was evaluated by the students using a questionnaire. students were asked to reply to a survey to evaluate the usefulness of digitized slides for practical examination. all students preferred the online examination to a traditional microscope and paper-and-pencil examination and all felt that the quality of digitized slides was superior to that of classical glass slide and allowed to make a more accurate diagnosis (rating . out of ). use of gray level co-occurrence matrix in detecting corresponding fragments and evaluating quality of virtual slides s. walkowski*, j. szymas *poznan university of technology, faculty of computing science, poland virtual slides may be acquired using various scanners, produced by different companies. pathologists who examine digital images captured by different scanners may subjectively assess their quality. in this work, an algorithm which may objectively compare the quality of virtual slides is proposed and implemented. in the first step, the algorithm selects some fragments of the slide captured by one scanner. then, it finds these fragments in virtual slides acquired by scanning the same glass slide using other devices. this is done by creating overviews of the whole slides (by zooming them out) and calculating gray level cooccurrence matrices (glcm) for each selected fragment and for the overviews of other slides using windows of adequate size. comparing some of the haralick features of the matrices (especially measures related to orderliness) allows estimating the positions of the fragments in other virtual slides. detected areas, in original resolution, are used to calculate glcm and its haralick features again. this time, measures for evaluating the quality (like contrast) are used. aggregation of the calculated values allows comparing the relative quality of the virtual slides. this method is tested on two sets of ten virtual slides. they were created by capturing the same set of glass slides using two different devices: robotic microscope axioscope (zeiss) equipped with axiocam hrc ccd camera and deskscan (zeiss) with standard equipment. acquired images were stitched and converted by specialized software based on advances in aerial and satellite imaging. color/image quality standardization in whole slide imaging y. yagi* *usa conclusion: vancb in breast lesions assisted the therapeutic decisions. a close interdisciplinary approach assured optimal results ( ). careful initial clinical-radiologic-pathologic correlation should dictate clinical management of equivocal fibroepithelial lesions diagnosed on core biopsy e. resetkova*, c. albarracin, e. arribas, n. sneige *mdacc, dept. of pathology, houston, usa objective: equivocal fibroepithelial lesions (fel) diagnosed on core biopsy (cb) may prove to be either fibroadenoma (fa) or phyllodes tumor (pt) at excision, due to which their management is controversial. method: ( ) to study the outcome of patients with fel on cb over a -year period at our institution. consensus on initial patient's clinical management was reached during a multidisciplinary conference based on correlation of clinical data, radiology, and pathology. ( ) to examine if any clinical, radiologic or histologic parameters could predict final classification, we retrospectively reevaluated imaging findings (mammography and sonography) as well as multiple histologic criteria (e.g. pattern, stromal cellularity, stromal atypia, mitosis, etc.) on cb and correlated these with diagnosis at excision. results: ( ) of excised lesions, were classified as pts, as benign cfels and as fas. in patients with no excision, no evidence of disease progression was observed ( ± months, mean ± sd). fels with indeterminate or suspect imaging findings, larger size, and an equivocal comment such as "cannot rule out pt" in the pathology report were excised more frequently (p= . , p= . and p= . , respectively). ( ) final diagnoses did not correlate with retrospective evaluation of any clinical data, imaging findings or histologic parameters. conclusion: careful initial clinicopathologic and radiologic correlation may select majority of clinically significant lesions for proper surgical management. follow-up may be an appropriate alternative for a subset of patients, given a good correlation. no radiologic or histologic parameters or clinical data on their own are distinctive enough to predict final classification of fels. objective: inconclusive results of the role of topoisomerase a (topa a) in breast carcinoma biology and therapy are partially due to numerous thresholds of positivity measured by immunohistochemical (ihc) analysis. in the presented study, different criteria found in literature of the subject were compared with results of topa a ihcevaluated material ( cases). in our study, we have the possibility to evaluate topa a in breast cancer cells using two methods (immunohistochemistry (ihc) and fluorescence in situ hybridization (fish)) in all cases. as a part of a broader study, we also were able to correlate the results of topa a in in situ carcinoma, benign lesions and breast tissue without pathological changes. we have also analyzed other prognostic and predictive factors as well as clinical outcome. method: using ihc and fish methods, we compared the percentage of stained cells, strength of nuclear stain, presence of co-expressed cytoplasmatic and membranous stain, amplification of topa a gene and also response to anthracyclin-containing chemotherapy from clinical data. results: analyzing the obtained data, we set our own cutoff points. we assumed that the best correlation both with genomic aberrations and other data listed above, which we considered important in this study, is when both the percentage and strength of stain are taken into account. in our study, a cutoff point for positive topa a status evaluated by ihc method is at least % of carcinoma cells with strong ( +) nuclear stain or at least % of carcinoma with intermediate ( +) nuclear stain. conclusion: the presented criteria as defined above correlate with amplification (ratio ≥ . ) and response to objective: the expression of tyrosine kinases in endometrial stromal tumors is controversial. several sporadic responses to imatinib have been observed in metastatic endometrial stromal sarcomas (ess). we therefore aimed to perform a retrospective analysis of possible molecular targets in ess: c-kit, pdgfra and egfr. method: paraffin blocks from patients with previous diagnosis of low-grade ess and high-grade endometrial sarcomas from nine different institutions were examined and reviewed. exons , , , and of the c-kit gene and exons and of the pdgfra gene were amplified by pcr and sequenced. the incidence and distribution of the kit, pdgfra, cd and calponin expression were examined by immunohistochemistry, and egfr amplification was assessed by fluorescence in situ hybridization (fish). results: no mutations in c-kit and pdgfra genes were detected. we observed several polymorphisms: i i, exon ( / ); v v, exon ( / ); p p, exon ( / ); and one case with a double polymorphism v v/ g g. overexpressions of kit, pdgfra, cd and calponin was detected in ( %), ( %), ( %) and ( %) cases, respectively, whereas amplification for egfr gene by fish was not detected. conclusion: expression of kit in cases of ess is infrequent and always weak. pdgfra expression was observed in % of the cases studied. we did not observe any mutations of c-kit and pdgfra or amplification of the egfr gene. so it is unlikely that patients with ess can benefit from therapies with anti-egfr and/or c-kit tyrosine kinase inhibitors. uterine tumors resembling ovarian sex cord tumors. a study of five cases e. bakula-zalewska*, a. nasierowska-guttmejer, a. daska-bidziska, m. bidziski *institute of oncology, dept. of pathology, warsaw, poland objective: uterine tumours resembling ovarian sex cord tumours (utrosct) cause confusion with respect to nomenclature as well as diagnostic difficulties. these tumours belong to the group of low-grade malignant neoplasms, and their clinical course likely depends on the percentage of the sex cord-like component. morphologically, they can be divided into two groups: those with < % sex cord-like areas (type ) and those with more than % (type ). method: five patients with primary utrosct underwent treatment in the cancer center, warsaw, between and . biopsies or excisions from all tumours were examined microscopically and immunohistochemically (ih). treatment and follow-up were correlated to histopathological diagnosis. results: patients ranged from to years of age and tumour size from to cm. tumours contained % to % of sex cord component (two tumours of type and three of type ). by ih examination, the sex cord-like component was keratin-positive in all five cases, while the stromal component was positive for cd and negative for h-caldesmon. in addition, pgr positivity was found in all cases, while sma, ckae / and inhibin was positive in three. four patients were treated with gestagens in addition to surgery. no recurrences were noted in any of these four patients over a -to -year period of follow-up. conclusion: a correct subclassification of sarcomas of utrosct type is of crucial importance since most patients with these rare neoplasms respond well to gestagen therapy and have a good prognosis compared to other endometrial stromal sarcomas. cd expression in serous invasive ovarian cancer and serous ovarian borderline tumors w. pokieser*, s. hauptmann *wilhelminenspital wien, dept. of pathology, austria objective: cd is a cell surface glycoprotein that plays a critical role as adhesion molecule for the guidance of migration of neuronal cells during embryofetal development. it is also expressed on adult neuroendocrine cells, hematological neoplasms, as well as in various carcinomas. method: in this study, we retrospectively investigated the expression of cd in a series of serous ovarian carcinomas and serous borderline tumors and analyzed the significance of this marker with regard to patient outcome. neuroendocrine cells were determined by immunohistochemical positivity of highly specific chromogranin a. patients were treated homogenously by use of radical surgery and combined chemotherapy (carboplatin and taxol) in the case of carcinoma and of surgery alone for borderline tumors. follow-up data were available for all patients. results: sixty-seven cases ( %) of invasive carcinomas, but only of ( %) borderline tumors, were positive for cd (p> . ), indicating that this phenomenon is significantly more present in invasive lesions. cd expression in the borderline tumor was accompanied by the presence of single scattered chromogranin a-positive neuroendocrine tumor cells, whereas in serous ovarian carcinomas, coexpression was only seen in less than a quarter of cases. conclusion: our results demonstrate that cd positivity is much more frequently found in serous ovarian carcinomas than in serous borderline tumors; however, expression of cd had no prognostic effect. on the other hand, cd should not be used as a marker for neuroendocrine differentiation in serous neoplasm. because of different chemotherapies in neuroendocrine ovarian carcinomas, specific neuroendocrine markers like chromogranin a or synaptophysin are recommended in these cases. are the cancer-testis (ct) antigens reliable markers of stem cells in squamous cell carcinoma of vulva? j. sznurkowski*, a. zabrocki *medical university of gdadsk, dept. of gynaecological oncology, poland objective: vulvar cancer represents - % of all gynecological malignancies. squamous cell carcinoma is a predominating malignancy at this site as it accounts for approximately - % of vulvar cancers. analyses of humoral and cellular immune responses to autologous cancer determined cancer-testis (ct) antigens as potential targets for immunotherapy. as their expression has been identified in a variety of malignant neoplasms, they appeared as potential candidates for target therapy, i.e. t cell-mediated immunotherapy of cancer. method: seventy-six patients with verified histopathological diagnosis and full clinical history were included into the study. the slides were incubated with the monoclonal antibody against mage-a , mage-a and ny-eso- . all statistical analyses were performed with the statistical software statistica . the expression of ny-eso- was revealed in one case. the expression of mage-a and magea- was identified in % and % primary tumors, % and % lymph node metastases and % and % local recurrences, respectively. cytoplasmatic expression of these antigens was identified in suprabasal and squamoid cells of scc ( fig. objective: the objective was to investigate the expression of c-kit protein in salivary gland carcinomas and to correlate it to prognosis. method: immunohistochemistry for c-kit protein was performed in carcinomas using formalin-fixed paraffinembedded sections. for the evaluation of reactivity of tumor cells, a combination of the cytoplasmatic and/or membranous staining and the percentage of positive cells were applied. only cases without any staining pattern were considered negative. for prognostic correlation, univariate disease-specific survival curves were calculated by the kaplan-meier method and distributions were compared using the log-rank test. results: of all cases, only six were c-kit-negative, including three low-grade mucoepidermoid carcinomas, two carcinomas ex pleomorphic adenoma and one salivary analogon of secretory mammary carcinoma. the group of ( %) positive tumors was dominated by nine adenoid cystic carcinomas (all but one revealing strong reaction), followed by five acinic cell, three each mucoepidermoid and salivary duct carcinoma, two carcinomas ex pleomorphic adenoma and five other tumors, in all of which positive staining ranged from % to %, with the immunoreaction varying from weak to strong. diseasespecific survival in c-kit-negative (n= ) carcinomas did not differ from that in positive (n= ) cases (χ = . ). conclusion: of all salivary gland carcinomas, only adenoid cystic carcinoma was regularly associated with c-kit expression. immunoreactivity in other subtypes, considering our as well as published data, greatly varies. c-kit expression harbours no significant prognostic information. results: aspirates were cellular showing groups with stroma and single cells. groups had a variable configuration with two major forms. some were large, three-dimensional and puzzle-like, with little ramifications. cells were densely packed and intimately related to metachromatic stroma. others were of medium size with prominent prolongations consisting of an inner core of hyaline stroma surrounded by tumoral cells. ten cases showed cylindromatous stromal structures. seven aspirations were cystic. stroma was homogeneous with non-fibrillary morphology. neoplastic cells showed a variable morphology from small, basaloid to larger ones with epithelioid morphology. moderate pleomorphism was seen in five cases. there were two misdiagnosis of acinic cell carcinoma, and two cases were considered as suspicious of malignancy. after a revision of these cases, two showed features of bca, while in the remaining two, the suspicious of malignancy persisted because of minimal amount of stroma, predominant epithelioid cell morphology and cellular density. conclusion: bca shows characteristic features that allow in many cases a precise diagnosis. it may be difficult to differentiate from epithelial-rich pleomorphic adenoma, and in these cases, a diagnosis including both possibilities seems preferable. in our series, the absence of stroma was responsible for the misdiagnosis with acinic cell carcinoma in two cases. objective: pheochromocytoma and paraganglioma are rare tumors arising from chromaffin cells. almost % of them are part of typical familial syndromes: von hippel-lindau disease (vhl), neurofibromatosis type (nf ), multiple endocrine neoplasia type (men ) and type (men ), pheocromocytoma-paraganglioma syndromes (pgls; sdhb, sdhc, and sdhd) and a newly described syndrome related to tmem gene mutations. recently, sdhb immunohistochemical analysis has been proposed as a promising molecular marker for succinate dehydrogenase mutation-related neoplasms (i.e. pgls). method: all cases of reported pheochromocytomas (n= ) and paragangliomas (n= ) between and were retrieved from the archives of the department of pathology of padova university. ffpe specimens were genetically characterized for familial syndromes. syndromic cases and a control group were semiquantitatively ( , +, +) evaluated for sdhb immunohistochemical expression. results: out of cases, cases showed sdhd (n= ), tmem (n= ), ret (n= ), men (n= ), vhl (n= ), or nf (n= ) germline mutations. the other six sporadic cases were evaluated as control. the three sdhd-mutated cases showed either negative (n= ) or + (n= ) sdhb immunostaining. completely negative staining was also observed in a sporadic case. a strong sdhb immunoreaction was observed in and a weak immunoreaction in four of the remaining cases. conclusion: sdhb immunohistochemical analysis, even not pgl-specific, can be used to triage genetic testing in pheochromocytoma/paraganglioma patients. further multiinstitutional studies should investigate the diagnostic power of this remarkable novel diagnostic tool. objective: inhibition of dipeptidyl peptidase- (dpp- ) activity by sitagliptin has been shown to improve glycemic control in patients with type diabetes mellitus (t dm) by prolonging the actions of incretin hormones, but the real impact of low-dose sitagliptin treatment on pancreatic lesions is almost unknown. this study aimed to evaluate the effects of sitagliptin on the biochemical and histological (pancreatic) parameters of zucker diabetic fatty (zdf, fa/fa) rats, an animal model of t dm. method: diabetic (fa/fa) zdf male rats were treated with vehicle or sitagliptin ( mg/kg body weight per day) during weeks (n= each). the following parameters were assessed: serum glycaemia, hba c, insulin and lipid profile; serum and pancreas oxidative stress (mda) and endocrine and exocrine pancreas histology, estimating and rating inflammatory infiltrate, fibrosis, vacuolization and congestion in a semiquantitative score ranging from (minimal) to (severe and extensive damage). results: sitagliptin in diabetic zdf rats promoted beneficial effects on dysglycaemia, dyslipidaemia, inflammatory profile and pancreatic oxidative stress. endocrine and exocrine pancreas presented a reduction/amelioration of fibrosis severity, inflammatory infiltrate, intra-islet vacuolation, and congestion vs the vehicle-treated diabetic rats. conclusion: the favourable biochemical profile promoted by sitagliptin in the diabetic rats, together with protection against endocrine and exocrine pancreatic lesions, might represent a further advantage of low doses of sitagliptin in the management of t dm. objective: several studies have suggested an increase in the incidence of right-sided colorectal carcinomas (crc). if the crc right shift is true, it is also likely that the incidence of right-sided advanced adenomas (rsaa) should increase in time. method: two large endoscopic datasets (retro and pbp) have been compared. retro contains data from the department of gastroenterology between and . pbp covers data from the polish national colorectal cancer screening program ( ) ( ) ( ) ( ) ( ) . only patients with ad-vanced adenomas who underwent total colonoscopy were included into the analysis. advanced adenoma was defined as: villous or tubulo-villous, adenoma with high-grade neoplasia or ≥ -cm lesion. two definitions of proximality were applied. the first defined right colon is proximal to the splenic flexure and the second, additionally, the descending colon. a logistic regression analysis was used to compare the incidence of rsaa between groups, adjusted for patients' age and sex. results: two hundred and , patients with advanced adenomas were found in two datasets, respectively. both groups differed significantly according to age and sex. to adjust for possible confounders, the multivariate model was fitted. conclusion: there was no statistically significant increase in the proportion of patients with rsaa between both groups when adjusted for patients' age and sex. objective: the aims of this study were to characterize the immunological microenvironment of tumour buds and evaluate the prognostic effect of immune markers and their ratios with tumour budding stratified by mismatch repair (mmr) status. method: paraffin-embedded tumour blocks from patients with colorectal cancer were cut in series and double-immunostained for ck with anti-cd , -cd , -cd , -cd , -cd , -cd , -cd , -foxp , -granzyme b, -mast cell tryptase, -cd , and -tia- and stratified into mmr-proficient and -deficient cases. tumour buds, immune cells and the ratio of immune cells/tumour buds was obtained. results: mmr-deficient tumours showed significantly less tumour budding (p< . ) and greater amounts of cd + , cd + , and granzyme b + cells (p< . ). high amounts of cd + , cd + , cd + , cd + , foxp + , granzyme b + and cd + were linked to improved survival (p< . ). prognostic effects differed between proficient and deficient tumours. marker/budding ratios showed stronger relative risks of death when compared to most markers alone. in lymph node-negative patients, high marker/budding ratios of cd (hr, . ( . - . )), cd (hr, . ( . - . )), cd (hr, . ( . - . )), foxp (hr, . ( . - . )) and granzyme b (hr, . ( . - . )) were independently linked to improved outcome. conclusion: marker/budding ratios for cd + , cd + , foxp + , granzyme b + and cd + are stronger prognostic features than the assessment of immune markers alone. these ratios are independent prognostic factors, particularly in lymph node-negative patients. moreover, our findings underline the considerable confounding effect of mmr status in the evaluation of immune response in colorectal cancer. human crypt stem cell dynamics in juvenile polyposis (jps) and peutz-jeghers (pjs) patients d. langeveld*, f. morsink, v. de boer, j. offerhaus, w. de leng *umc utrecht, dept. of pathology, the netherlands objective: pre-tumour progression is a process that precedes the adenoma-carcinoma sequence; colorectal mucosa appears normal, but cell kinetic and stem cell abnormalities suggest the existence of molecular alterations. pre-tumour progression can be made visible by studying methylation patterns, or tags, in stem cells of the crypt. shibata et al. ( ) showed higher crypt methylation heterogeneity in normal-appearing colonic crypts of familial adenomatous polyposis (fap) patients compared to normal crypt mucosa of non-fap colons. this indicates enhanced stem cell survival, which may be a predictive marker of increased neoplastic outgrowth since longer lived stem cells have the potential to gain more mutations. the objective of this study was to investigate stem cell survival in juvenile polyposis syndrome (jps) and peutz-jeghers syndrome (pjs), a biomarker predictive of pre-tumour progression. method: dna was isolated from laser-microdissected crypts of normal colonic jps and pjs tissue and agematched controls. dna was bisulphite-converted and methylation tags were created by amplifying the cpg islands in the csx gene. sequence analysis of this pool of methylation tags allows characterisation of the heterogeneity among the different tags recovered from multiple stem cell pools. objective: lymph node metastasis is an important prognostic factor in esophageal cancer. vascular endothelial growth factor c (vegf-c) and vascular endothelial growth factor d (vegf-d) are considered to induce both lymph node metastasis and lymphatic involvement in various cancers related to lymphangiogenesis. in many types of cancer, podoplanin (d - ) immunostaining has recently been used to detect lymphatic vessel invasion (lvi), but invasion detected using d - immunostaining for a predictor of nodal metastasis was controversial. we examined the relationship between vegf-c, vegf-d and lvi and clinicopathological features in patients with esophageal cancer who underwent esophagectomy. method: vegf-c, vegf-d and podoplanin expression was examined using immunohistochemical staining in surgically resected tissues. differences in categorical data were assessed by a chi-square test or fisher's exact test. results: podoplanin expression was observed in the endothelial cells of lymphatic channels. none of podoplanin-positive vessels were blood vessels. intratumoral lymph vessels were small and collapsed, while peritumoral lymphatic vessels with lvi were dilated and large. the expression of vegf-c and vegf-d protein was recognized in the cytoplasm of cancer cells, but not in the nucleus. we found that peritumoral lvi significantly correlated with lymph node metastasis (p= . ), pathologic stage (p= . ), tumor depth (p= . ) and tumor size (p= . ). the expression levels of vegf-c and vegf-d were associated with lvi. conclusion: vegf-c, vegf-d and peritumoral lvi may play an important role in lymphangiogenesis and the process of lymphatic metastasis of esophageal cancer. objective: for several anatomical localisations of extranodal marginal zone lymphoma of malt type (emzcl), an association with chronic inflammation caused by microbiological agents (e.g. helicobacter pylori in the stomach) has been described. in the lung, a link between lymphomagenesis and a defined causative organism is still missing. method: a comprehensive diversity survey using s rdna library construction followed by restriction fragment length polymorphism (rflp) analysis, sequencing and phylogenetic tree construction was employed on nine cases each of balt lymphoma and control lung tissues (normal fetal lung, pneumonitis, cancer). this highly sensitive method, hereafter termed "sharp-screening", allows for the identification of the entire bacterial population in the tissue in a cultivation-independent manner. following the results of sharp screening, an alcaligenaceae-specific pcr assay was employed on additional balt lymphoma cases and control lung tissues. results: in eight of the nine cases of balt lymphoma, bacteria of the alcaligenaceae family (alcaligenes, achromobacter, akiw ) were detected, whereas none of the control cases showed the presence of these clades. the subsequently performed alcaligenaceae-specific pcr assay detected bacteria of the alcaligenaceae family in of the independently investigated balt lymphoma cases and in only one of control lung tissues. conclusion: s rdna library construction in combination with rflp screening and phylogenetic analyses (sharp-screening) is a novel, molecular and cultivationindependent tool for the analysis of the microbial environment in chronic inflammation processes. betaproteobacteria of the alcaligenaceae family may be associated with and possibly involved in the lymphomagenesis of balt lymphomas. objective: diffuse large b cell lymphoma (dlbcl) is the most common type of non-hodgkin lymphoma. recently, major advances in the molecular characterization of dlbcl have been made through gene expression profiling studies that provided more insight into the biological heterogeneity within dlbcl. one of the identified molecular subgroups has been termed the "b-cell receptor (bcr)/proliferation cluster" due to the increased expression of bcr signaling cascade components including the spleen tyrosine kinase (syk), which has emerged as an important therapeutic target within tumors of this subgroup. in fact, a recent clinical trial with a syk inhibitor on uncharacterized dlbcls has shown promising results, but only in a subset of patients. method: we employ a novel quantitative tissue-based immunohistochemical (ihc) methodology using markers of activated bcr signaling to assess the activity of the bcr pathway in formalin-fixed paraffin embedded primary dlbcls. results: antibodies to phosphorylated forms of lyn, syk, btk, blnk and akt as well as foxo antibody represent attractive ihc markers to evaluate the activation of bcr signaling and comprise the basis of a biological signature of activated bcr signaling in dlbcl. conclusion: we report on the development of a quantitative tissue-based immunohistochemical (ihc) methodology employing activation-specific antibodies against multiple components of the bcr signaling pathway that will assess the activity of the bcr pathway in formalin-fixed paraffinembedded primary dlbcls. this approach will identify the subset of patient tumors that are actively signaling through the bcr pathway and, therefore, will predict therapeutic responsiveness to targeted inhibition of bcr signaling. enteropathy-associated t cell lymphoma: a clinicopathologic study focussing on prognostic factors and the frequency of defective t cell receptor chains p. czapiewski*, p. fisch, a. schmitt-graeff *medical university of gdansk, dept. of pathology, poland objective: enteropathy-associated t cell lymphoma (eatl) is a rare highly aggressive t cell neoplasm divided into type i (cd − , cd − ) and type ii (cd + , cd + the presence of intra-tumoral neutrophils is an independent prognostic factor in early-stage non-small cell lung carcinomas m. ilie*, v. hofman, c. butori, c. marquette, n. vénissac, j. mouroux, p. hofman *chu de nice, lpce, france objective: cancer-related inflammation has emerged as the seventh hallmark of cancer. in the tumor microenvironment, inflammatory cells, including neutrophils, influence almost every aspect of cancer initiation and progression, including tissue invasion and metastatic potential. however, the influence of intra-tumoral neutrophils in non-small cell lung carcinoma (nsclc) progression is currently unknown. this study was conducted in order to correlate the number of tumor-associated neutrophils (tans) and the prognostic of stage i nsclc. method: immunostainings on stage i ( t n and t n ) nsclc included on tissue microarrays were performed with anti-myeloperoxidase and anti-cd b anti- results: the patients comprised ten women and one man (mean age . ± . years, age range - years). immunofluorescence microscopy showed intense linear staining for igg and c along glomerular and distal tubular basement membrane in all patients. by light microscopy, irregular diffuse or focal extracapillary crescentic glomerulonephritis was found in all patients, associated with necrosis of varying extent in nine. the percentage of crescents was % to %. extraglomerular necrotizing vasculitis of small arteries was present in six patients, and in one, elastica destruction indicative of previous vasculitis was observed. an assessment of the age of histopathologic lesions showed lesions of varying age in all biopsies. active lesions were predominant in four and chronic in three, while active and chronic lesions of equal distribution were seen in four biopsies. conclusion: all our patients with coexisting anti-gbm antibodies and anca were older and all had renal histopathologic lesions of varying age, active and chronic. these results confirm a hypothesis that anti-gbm antibody production may start after injury to the glomerular basement membrane by anca. renal amyloidosis secondary to behçet's disease: clinicopathologic features of cases k. kosemehmetoglu*, d. baydar *ankara ataturk eah, dept. of pathology, turkey objective: amyloidosis is a rare complication of behçet's disease (bd). we describe ten patients with bd and renal amyloidosis. method: kidney biopsy slides were culled from the archives and reviewed. intensity and relative distribution of amyloid deposition in renal compartments were noted. glomerular deposits were classified as hilar (pattern i), mesangial nodular (pattern ii) and mesangiocapillary (pattern iii). chronic tubulointerstitial damage was graded from to ( %, -< %, -< % and ≥ %). amyloid typing was performed by immunohistochemistry. clinical information was gathered from hospital records and computer-based patient data system. results: all patients were male. their age ranged from to . full-blown nephrotic syndrome was present in six cases. duration of bd before diagnosis of amyloidosis differed from to months (mean ), and mean follow-up period was . months. immunohistochemical typing revealed aa amyloid in all ten. four cases showed glomerular-dominant and two cases vascular-dominant amyloid deposition; the rest were co-dominant glomerular and vascular. the frequencies of glomerular amyloid patterns were % for hilar, % for mesangial nodular and % for mesangiocapillary. hilar pattern was associated with vascular-dominant amyloid deposits. severe proteinuria correlated with the presence of mesangiocapillary pattern. grade iii chronic tubulointerstitial injury was detected in three cases. patients were treated with steroids and/or different immunosuppressives. among them, two progressed to endstage kidney failure, one showed remission, two were lost to follow-up, and rest had persistent proteinuria. conclusion: renal amyloidosis in bd has a diverse pathology in terms of preferential location of amyloid deposition and its intensity. patients follow variable clinical courses accordingly. objective: kras is an oncogene that is commonly mutated in various malignancies. mutations in kras are associated with lack of response to anti-egfr treatment in colon and lung carcinomas, and patients must undergo genetic testing to be eligible for treatment. several genetic tests for kras mutation analysis exist, but most are either too expensive or lack the sensitivity to identify a mutation if the percentage of tumor cells in the sample is small. the purpose of the present study was to develop a novel kras mutation detection method that is both cost-effective and sensitive. method: we designed a locked nucleic acid (lna)containing probe that inhibits the amplification of wildtype kras, thereby giving an advantage to mutated kras in pcr reaction (pcr clamping). the sensitivity of this method was evaluated using serial dilutions of plasmids containing wild-type and mutated kras fragments. the method was further evaluated on archived tissue samples of colon carcinoma and compared to direct sequencing and high resolution melting (hrm) methods. results: lna-based probe successfully inhibited the amplification of wild-type kras. the method enabled the detection of as little as % mutated dna in the sample analyzed. the method was superior to direct sequencing when the percentage of malignant cells in the sample was % or less. there was % correlation between the results of pcr clamping and hrm. objective: a newly discovered gene, jk- (fam b), located in chromosome p . plays an important role in the molecular pathogenesis of esophageal cancer. this study aims at examining the role of this gene in colorectal tumors by analyzing the differences in gene mrna expression in both benign and malignant colorectal tumors. the study was performed on colorectal adenocarcinoma, benign adenoma and nonneoplastic colorectal tissues. gene expression levels were determined using real-time pcr. the expression levels were calculated as a ratio of the ct value for jk- to gapdh and expressed as inverse ratio. results: the jk mrna was detected in all colorectal tissues. the mean inverse ratio for jk- gene in adenoma samples was . ± . , which was significantly higher than in non-tumor samples which was . ± . (p= . ). on the other hand, cancer samples had a mean inverse ratio of . ± . , which was significantly lower than in non-tumor tissues (p< . ). the under-expression of the gene in cancer suggests that loss of gene expression may promote tumor progression, that it may act as a tumor suppressor gene, or that it relates to certain genetic events in tumor pathogenesis. however, over-expression of jk- in adenoma samples may indicate that jk- has a functional role in dysplastic benign colon tumors, a function that is disrupted once the tumor progresses to a more invasive form. wednesday, objective: invasive breast carcinoma represents are characterized by invasion of adjacent tissues and a marked tendency to metastasize to distant sites. in order to determine specific prognostics factors, we established histopathologic, immunohistochemical and morphometric profiles of these types of carcinoma. method: in our study, we investigate cases diagnosed with invasive breast carcinoma in which we established microscopic characterization, immunohistochemical profiles (expression of proliferation markers, steroid receptors and her ) and computer-assisted morphometric profiles by determining the mean values for nuclear area, cellular area and n/c ratio with lucia net software. the distribution of markers and histological grade among types of carcinoma was statistically analyzed using the χ test. results: the histological type of invasive carcinoma was: . % ductal carcinoma, % mixed ductal and lobular carcinoma, and . % lobular carcinoma. according to histological differentiation, % was g , % was g and % was g . immunohistochemical expression of er was positive in % and negative in %, for pr was positive in % and negative in % and the expression of her was positive in % and negative in %. ki was intensely positive in %, moderately positive in % and intensely positive in %. p was positive in % cases and negative in % of cases. morphometric analysis revealed that mean nuclear area and n/c ratio increase are concordant with grading, but mean cytoplasmatic area has no characteristic variation. conclusion: the expressions of proliferation markers correlate with carcinoma grading. poorly differentiated and triple-negative carcinoma (er, pr and her ) with intense expression of proliferation markers and increase mean nuclear area have negative prognosis. objective: mapping tumour cell protein networks in routinely processed clinical samples, like formalin-fixed and paraffin-embedded (ffpe) tissues, will be critical for realizing the promise of personalized molecular therapy as only a subset of patients will respond. therefore, techniques being able to detect the entire spectrum of deregulated pathways in tumors before, during, and after treatment are required to assess success or failure of targeted therapies. the aim of our study was to monitor protein networks in ffpe breast cancer tissues with special emphasis on epidermal growth factor receptor (her )mediated signaling pathways to identify and validate new disease markers in order to predict response to current treatments. method: using a recently developed technology for the extraction of full-length proteins from ffpe tissues, we analyzed molecules involved in her -related signaling by reverse phase protein microarray (rppa) in a series of ffpe breast cancer patients. to this end, we evaluated > commercial antibodies for specificity in lysates from ffpe breast cancer samples in western blots and rppa. results: we found her (r's= . ), the egfr (r's= . ) and the receptor of upa (r's= . ) correlating with her . however, we could not demonstrate any significant correlation between her expression and clinicopathological parameters. conclusion: our results uncover molecules linked to her signaling and cancer progression. thus, these finings provide possible new targets for cancer treatment and may assist in optimal patient selection. objective: the pi k/akt/mtor pathway has a fundamental role in signal transduction, and its alterations are of pathogenetic role in human cancer, including breast carcinomas (bc). several drugs may interfere with the altered activation of this pathway, including the recently developed mtor inhibitors. however, few data are available concerning mtor levels in human breast cancer. method: the aim of the present study was to analyze the immunohistochemical expression of mtor and p s k in a consecutive series of bc, with long-term follow-up which had been studied for er, pgr, her , p and mib expression and for pi k and akt mutations. results: mtor and p s k expression were positively associated (p = . ), but were not related to other molecular markers with the exception of high p s k being associated with pi k mutations (p= . ). in the whole series of cases, mtor and p s k are not associated with clinical outcome. however, high mtor are associated with prolonged dfs and os in node-positive cases, in st. gallen high-risk group, and in patients treated with chemotherapy. high p s k expression was associated with prolonged dfs and os in st. gallen high-risk group. conclusion: our data show that mtor and p s k are promising biomarkers in bc whose level of expression may be of prognostic value. objective: lymphangiogenesis occurrence and the biomechanisms in lymph nodes are still unknown. the immunohistochemical application of the usually known lymphatic markers vegfr- , lyve- , prox- , and podoplanin was explored to study lymphatic vessels in tumour metastasis and non-metastatic lymph nodes of breast cancer cases to understand the metastization pathway. method: lymph nodes without and with metastases from cases of invasive breast cancer were selected. serial sections were immunostained for vegfr- , lyve- , prox- , and podoplanin using immunohistochemical protocols in accordance with the respective recommendations. the microanatomical distribution of each antibody in the lymph node, different cell type expression, adjacent mesenchymal structure positivity and neoplastic cell positivity were validated and reported as negative and positive (with the cutoff +, ++, +++ for the neoplastic cells). results: no markedly or obvious staining was obtained for lymphatic vessels. positive staining of metastatic neoplastic cells, lymphoid cells of germinal centres and node pericapsular fatty tissue has been observed. immunostained neoplastic cells revealed a predominant subcapsular and perihilar location. conclusion: the applied primary antibodies were unsuccessfully used as lymphatic markers. the spread of neoplastic cells expressing these markers may have acquired particular characteristics to develop lymphatic dissemination until reaching lymph nodes. lymphangiogenesis in breast cancer continues without demonstration in lymph nodes, while the fatty tissue can be implicated in epithelial mesenchymal transition (emt). this thesis turned up by the proximity of the positive neoplastic cells to the mesenchymal components of surrounding lymph node tissue as adipocytes were immunoreactive. objective: there is a significant percentage of patients with metastatic breast cancer and her receptor overexpression that do not respond to therapy directed with trastuzumab. in these patients, overall survival and diseasefree time are significantly shorter. several mechanisms that explain the resistance to therapy with trastuzumab have been reported. this paper aims to address the study of alterations in one of the signalling pathways of her related trastuzumab in response to breast cancer in order to incorporate into the clinical routine of other predictive biomarkers of response to therapy. method: the study comprised cases of metastatic breast carcinoma with her overexpression (herceptest +) or gene amplification (fish). all patients were treated with trastuzumab. the assessment of pten and pakt expression was based on staining intensity and percentage of stained cells. results: our series showed a statistically significant association between a positive expression of pten and a reduced expression of pakt (p = . ). the positive expression of pten was associated with a better treatment response rate (p = . ). it was also noted that the reduction of pten was associated with a shorter time of progression (p= . ) and a lower overall survival (p= . ). pakt overexpression was associated with a lower overall survival (p= . ). conclusion: our study shows that immunohistochemical expression of pten and pakt could be used as both prognostic and predictive biomarkers in breast cancer. objective: vascular endothelial growth factor (vegf) has been shown to play a major role in tumor angiogenesis in many studies. this study aimed at evaluating the relationship between vegf expression and lymph node metastasis in patients with invasive ductal carcinoma (idc) of the breast. method: in a case-control setting, we evaluated specimens of idc in patients with and without axillary lymph node metastasis. the immunohistochemistry staining was employed for evaluating the expression of vegf in the specimens of both groups. the rate of positive specimens was then compared between the groups. the relationship between the vegf expression and the size and grade of tumors were assessed. results: eighty women with idc of breast, cases with axillary lymph node metastasis and controls without any evidence of axillary lymph node involvement, were enrolled. there were ( %) and ( %) cases with positive expression of vegf in the case and control groups, respectively (p= . ). the mean size of tumor was significantly higher in patients with positive expression of vegf ( . ± . cm vs . ± . cm, p= . ). the current study showed that there is no significant relation between the rate of expression of vegf in cases of idc of the breast and the axillary lymph node metastasis; however, there may be a relation between vegf and the size of the tumor. abnormal membrane cytoskeletal cross-linker ezrin cellular distribution is associated with clinicopathological features in invasive breast cancer a. halon*, p. donizy, l. halon, r. matkowski *wroclaw medical university, poland objective: ezrin is member of the erm (ezrin/radixin/ moezin) protein family which acts as a membrane organizer and linker between the plasma membrane and cytoskeleton and plays a key role in the control of cell morphology, adhesion, polarity, motility and cell survival. the aim of the present study was to elucidate the clinical significance of subcellular expression pattern of ezrin in patient with invasive breast cancer (bc). method: immunohistochemistry for ezrin monoclonal antibody was performed on paraffin-embedded specimens from patients with bc. immunoreactivity was semiquantitatively scored according to remmele immunoreactive score (irs). results: expression patterns of ezrin were divided into cytoplasmic ( , . %), membranous ( , . %), nuclear ( , . %) and apical ( , . %). cytoplasmic pattern was the only one observed in cases ( %) and mixed immunotopography in the others. there were significant positive associations between apical and membranous ezrin localization and favorable tumor characteristics and lack of lymph node metastases. cytoplasmic ezrin staining was associated with adverse clinical outcome. lack of apical ezrin was likely to present with bone metastases in the absence of visceral disease. membranous ezrin localization was correlated with good prognosis both for csos (p= . ) and dfs (p= . ). a multivariate analysis demonstrated that membranous ezrin distribution is an independent prognostic factor (p= . ). conclusion: the switch of ezrin localization from the apical and the membrane to the cytoplasm is correlated with dedifferentiation and adverse features in bc. cellular ezrin distribution contributed to discriminating between patients with lymph node and distant metastases and those with better prognosis. objective: epidermal growth factor receptor (egfr) is a tyrosine kinase growth factor receptor expressed in a variety of human cancers and related with poor prognosis. recently, the astounding development of molecule-targeting drugs such as anti-egfr-targeting drug has attracted considerable interest of oncologists. the objective of this study was to evaluate the expression of egfr in breast carcinomas and its possible relationship with different clinical-pathological parameters. method: one hundred and seventeen breast carcinomas were included in this study. using a standard immunohistochemical technique, the expression of egfr, her , and hormone receptors was investigated. in addition, haematoxylin and eosin-stained sections of these tumors were studied for several morphological parameters. results: egfr-positive expression was detected in nine tumors ( . %). expression of egfr was positively associated with high histological grade (p= . ), highgrade comedo-type necrosis (p= . ), high degree of stroma lymphocyte infiltration (p= . ), pushing tumor margin (p= . ), and hormone receptor-negative her negative status (triple-negative phenotype, p= . ). no significant difference of egfr expression according to age was recognized. conclusion: egfr expression is more often present in the group of triple-negative breast carcinomas, and its expression is associated with features of poor prognosis. egfr expression might be important as a potential target for molecular therapy in breast cancer. objective: the purpose of the study was to assess morphometric parameters of nuclei and nucleoli in invasive ductal breast carcinomas and to compare them with axillary lymph node status. method: histologic sections from tumors were stained with methyl green-pyronin y and measurements were made using a computerized image analysis. the following seven parameters were evaluated: the nucleolar area, long-to-short nucleolar axis ratio, nucleolar shape parameter assessing the degree of nucleolar roundness, the nuclear area, long-toshort nuclear axis ratio, number of nucleoli in the nucleus and the percentage of the nuclear area occupied by nucleoli. results: a statistically significant association between a nuclear area, long-to-short nuclear and nucleolar axis ratio and bloom-richardson (b-r) histologic grade of breast tumors was found in relation to the axillary lymph node status. in b-r grade tumors, the nuclear area was significantly larger in tumors with negative versus positive axillary lymph nodes (p< . ). long-to-short nuclear and nucleolar axis ratios were higher in b-r grade tumors with negative versus positive lymph nodes (p< . ), i.e. the shape of nuclei and nucleoli of tumor cells from node-negative cancers was more elliptic as compared to node-positive ones. objective: the urokinase-type plasminogen activator (upa) and its main inhibitor pai- facilitate migration and invasion of cells in physiological and pathological contexts. both factors are clinically applicable predictive markers in node-negative breast cancer patients used to stratify patients for adjuvant chemotherapy. besides their classical functions within the plasminogen activation system, these factors are shown to play important roles in cell signaling, thus providing new possibilities to interfere with cancer progression and metastasis. although such networks are well described in cell culture systems, their analysis in tissues was hindered because protein extraction and direct analysis was possible only from fresh or frozen material, which may be not available in routine laboratory setting. method: we extracted proteins from formalin-fixed paraffin-embedded tissues, being the main source of archived patient samples in pathology institutes worldwide, by a new protocol developed in our laboratory and analyzed the extracts for interactions of upa and pai- with molecules belonging to signaling cascades relevant in cancer progression in a collective of breast cancer patients using protein microarrays. results: a substantial correlation of upa with erk and stat expression was ascertained, while pai- correlates with akt activation and egfr-related signaling. statistical analysis of upa and pai- protein expression did not reveal a significant correlation of upa or pai- with staging, grading or age of the patients. objective: breast cancer is one of the most common human neoplasms accounting for approximately one quarter of all cancers in females. in young women, the risk is low, but because of the density of breast tissue, by the time a lump can be felt, the cancer is often advanced. fine needle aspiration of breast lesions is routinely performed in our hospital. we reviewed our archives and found the cases of breast cancer in women under years old. method: between january and march , fine needle aspirates in breast lesions were performed in our institution. the aspiration was done using a -gauge needle. conventional and thinprep smears were prepared. estrogen and progesterone receptor studies were part of the routine workup of a breast cancer as well as other markers (c-erb-b , p , e-cadherin, gcdfp- ). results: one hundred and fifty-eight of the cases were carcinomas. ten of these patients were under years old (mean age . ). in eight of these patients, cytology correctly diagnosed seven ductal and a tubular carcinoma. in two cases, the cytologic diagnosis was suggestive of carcinoma, and the excisional biopsy revealed a lobular and a mixed carcinoma. conclusion: it is mandatory in young women that a breast lesion be identified using mainly ultrasound and fine needle aspiration, which are simple and well-tolerated diagnostic tools. however, mammogram may also be recommended for younger women when a family history of breast cancer or other risk factors exist. mgmt protein expression as a potential prognostic marker in breast cancer j. objective: sentinel lymph node biopsy (slnb) is rapidly becoming the standard of care in staging the axilla for early-stage, clinically node-negative breast cancer. this audit reviews the laboratory handling and pathological reporting of sentinel nodes (sns) across kent and has been performed at the request of the kent cancer network breast disease oriented group (dog). method: a retrospective analysis of consecutive breast sn cases from each of the five kent hospitals was carried out. all reports and slides of positive sns were reviewed. detailed structured questionnaire-based enquiries to lead breast pathologists were made. data were entered in microsoft excel and analysed in relation to the standards. all aspects of the pathology service were examined, including macroscopic data (number of sns/case, dimensions, sampling and slicing details) and microscopic data (performance of levels and immunohistochemistry, tnm staging and snomed coding). results: one site was unaware of radioactivity guidelines while another was unaware of national guidelines. twenty-eight percent to % of sns were bisected longitudinally and levels were sparingly used, except at site. tnm staging and snomed coding in the reports were variable. conclusion: this audit demonstrates a substantial variation in sn handling and reporting practice across kent. since the quality of the pathology service in breast cancer is of paramount importance, it is imperative that a standardised approach is achieved in the handling and reporting of sns. to achieve this, recommendations have been made and agreed upon, the success of which will be measured in a reaudit next year. objective: background: the study analyzes the positivism of the p protein and the oncoprotein c-erbb and their implication in the appreciation of prognostic invasive mammary carcinomas. method: in invasive mammary carcinomas, we have realized the immunohistochemical determination of the p protein with the avidine-biotine complex method (abc) using the dako p mouse monoclonal antibody (dilution : ). in invasive mammary carcinomas, we have determined immunohistochemically the c-erbb oncoprotein with the dako rabbit polyclonal antibody, human anti-protein c-erbb (dilution : ). the tumoral tissues were fixed in % formaldehyde and included in paraffin. results: out of invasive mammary carcinomas, ( %) have been p -positive, and out of carcinomas, ( . %) overexpressed the c-erbb oncoprotein. in the studied casuistic, we did not remark any connection between the p expression and the overexpression of c-erbb . conclusion: the presently best-known mutant gene in invasive mammary cancer seems to be the p tumor suppressor gene. we did not remark any connection between the p protein expression and the tumors' sizes, patients' ages, the clinical stage of the disease and the overexpression of c-erbb . the usage of the c-erbb status (her- /neu) in patients suffering invasive mammary carcinomas is a predictor of therapy response. objective: there are only a few entities in the breast which show a chondroid differentiation. the differential diagnosis varies from the harmless choristoma to the also benign pleomorphic adenoma, to the syringioma and phylloides tumour with uncertain dignity to the high malignant metaplastic carcinoma. the differentiation between these different neoplasias is essential for the patient because of the following therapeutical procedures and the prognostic outcome. the final diagnosis in a mammary punch biopsy may be difficult or impossible because of the small specimen and the heterogeneity of the tumour. method: our specimen is taken from a -year-old female. with mammography, new polymorph calcifications were found in the left breast. the results were classified as birads and surgical excision was recommended. one month after mammography, a stereotactic wire-marked diagnostic excision was performed. results: in histological examination, a chondroid proliferation appears with a beginning metaplastic ossification and two small foci of spindle cells and myxoid appearance. no suspicion for malignancy was found in the whole specimen. a chondroid choristoma in the left breast was diagnosed. in mammographic control months later, no calcifications were detectable. so the tumour was totally removed. conclusion: a choristoma of the breast is very rare. in literature, it is described as choristoma (tavassoli ) or as true chondroma (rosen and oberman ). the secured demarcation between the differential diagnosis is only possible at the in whole removed and nearly totally examined tumour. a chondroid differentiation in a mammary punch biopsy should be classified in the category b . a diagnostic excision should be always performed. objective: vascular tumors of the breast are very uncommon, consisting of variants of hemangioma and angiosarcoma. although angiosarcoma related to chronic lymphoedema is the most frequent, it only represents . % of breast tumors. usually, primary angiosarcoma involves young pregnant females, with only six cases occurring in males reported to date. epithelioid angiosarcoma is very unusual; their presence in males has been reported only once before in a young patient. method: this is the second case report of an epithelioid angiosarcoma in a male breast but the first one of poorly differentiated type. it developed in a -year-old patient, unrelated to hormonal dysfunction or treatment. results: the tumor located in the breast parenchyma had a -cm diameter and solid firm multinodular grey colour areas admixed with cystic spaces with hemorrhagic content. microscopically, the tumor was composed of mainly polygonal epithelioid tumor cells with abundant eosinophilic or pale cytoplasm and pleomorphic nuclei, arranged in solid areas and admixed with few spindle cells. less than % of the tumor was composed of more differentiated areas. the tumor cells in both solid and cystic areas were positive for cd and vimentin but negative for cd , er, pr, hmb- , and s- protein. pan-ck was positive in both epithelioid and spindle tumor cells. conclusion: immunohistochemistry is very useful in order to establish a correct diagnosis; factor viii, cd and cd can be used singly or in combination, although they may be lost in high-grade tumors. epithelial markers may be also positive in epithelioid angiosarcoma. wednesday, september , basement the semiquantitative immunohistochemical evaluation of the lymphangiogenesis density at cutaneous melanoma and its correlation with the sentinel lymph node status p. buzrla* *faculty hospital ostrava, institute of pathology, czech republic objective: lymphangiogenesis is a predictor of the sentinel lymph node status at cutaneous malignant melanoma. the aim of our investigation was the immunohistochemical semiquantitative evaluation of the lymphangiogenesis density and its correlation with the sentinel lymph node status. the file comprises patients with cutaneous melanoma, of them having the positive sentinel lymph node. the results of the investigation are partially in harmony with another study. method: for this investigation, the files of patients with cutaneous melanoma radically excised and the sentinel lymph nodes were extirpated. the lymphangiogenesis density was immunohistochemically evaluated using cd and d - (podoplanin). the localization of the lymphangiogenesis in cutaneous melanomas was determined and the lymphatic vessels were counted in mm . after that, we evaluated the correlation between the lymphangiogenesis localization and the invasion depth according to clark, following the correlation of the lymhangiogenesis density with the sentinel lymph node status. results: lymphangiogenesis was dominant in the peritumorous localization of cutaneous melanomas. the lymphangiogenesis density and its localization have no influence upon the lymph node status. the correlation of the depth invasion with the lymph node status was not confirmed. the results of the lymphangiogenesis localization are according to other study papers. we did not confirm the correlation between the lymphangiogenesis density and the sentinel lymph node status. it is necessary to extend the set of investigated patients with cutaneous melanoma and to use the lyve- antibody. the extension of the count of patients with cutaneous melanoma and using other antibodies such as lyve- are necessary in consecutive evaluations. objective: melanoma is a malignant tumor of the neural crest-derived cells named melanocytes. it is an aggressive neoplasm due to its high rate of proliferation and invasion. disruptions in the cellular signaling pathways promote melanoma development and progression. aberrant notch activation has been related to a variety of human neoplasms. we investigate the potential involvement of notch signaling in melanoma development and progression. for this purpose, we analyzed the expression of three essential components of the notch pathway: notch , adam and adam /tace. method: melanoma samples from seven patients were tested and compared with normal skin samples. immunofluorescent staining was performed on -μm-thick cryosections. primary antibodies were applied and incubated overnight at °c. to detect the primary immune reaction, we used fitc-labeled goat anti-mouse secondary antibodies. the samples were examined using light and uv microscopy. for the western blot technique, the western-breeze kit was used. results: notch expression in normal skin was detected in the epidermis and also in hair follicles, sweat glands, sebaceous glands and blood vessels. melanoma cells showed moderate to high levels of expression of notch . adam expression was detected in the epidermis and also in hair follicles. in some melanoma samples, adam over-expression was observed. tace/adam expression was detected only in the epidermis. western blot analysis confirmed the presence of these proteins in cytoplasmatic and nuclear lysates. conclusion: we observed that the notch signaling pathway is activated in melanoma cells. critical members of the notch pathway are potential therapy targets. objective: amelanotic melanoma is a subtype of cutaneous melanoma characterized by little or no pigment on visual inspection; it represents - % of all melanomas. the lack of pigment makes it a great mimic of other benign and malignant lesions, a fact that can mislead the correct diagnosis. method: the study included a group of cases of amelanotic melanomas, aged - years. most of the tumors were thinner than mm breslow and clark levels i to iv. the diagnostic was formulated based on special coloration for the melanic pigment (masson-fontana) and using immunohistochemical techniques (hmb- , vim, s- ). the simultaneous positivity of these markers has shown the melanic aspect of the tumor. bcl- , ki- and p- was performed by standard immunohistochemical staining using monoclonal antibodies. results: bcl- expression was positive in % cases; ki- expression was positive in most of the cases, values between % and %; and p- expression was positive in most of the cases, values between % and %. conclusion: our frequency detection is not related with the size of the tumor, depth, ulceration or mitotic activity. most lesions present expression of bcl- in % of the cases and were associated with good prognosis; p- expression is between % and % and was associated with poor survival. although ki- expression is between % and %, it is not related with the prognosis. it was suggested that p- and bcl- expression could be useful in predicting the biological behaviour. neoplastic embolisations were identified in two cases of the study group. objective: desmoplastic melanomas represent an extreme degree of fibroblastic or myofibroblastic metaplasia accompanied by abundant collagen synthesis. those tumors are in general associated with high incidence of recurrence and metastasis and a poor prognosis. method: a patient p.c., male, years old, presents at the clinical exam a right calcaneo-plantar ulcero-proliferative and multinodular lesion ( / , / , cm), with a few months' course; there is local discomfort and functional impairment. clinical diagnostic was that of kaposi sarcoma and for the histopathology was sent a cutaneous specimen of / / cm that contains the lesion. the specimens were examined using basic histological techniques and immunohistochemistry with antibodies anti-s protein, anti-cd , anti-desmin, melan a, hmb- and pan ck. results: microscopically, it was identified as tumoral proliferation with spindle cells, uniform nucleus, some of them hyperchromatic, prominent nucleoli, some tumoral cells with brown melanic pigment and a rich mitotic activity. immunohistochemical expression was intensely positive for s protein and melan a and negative for hmb , desmin, cd , pan ck, associated with focal lymphocytic inflammatory infiltrate. tumoral proliferation includes adnexal structures of the skin and is ulcerated. the histopathological aspects lead to a desmoplastic melanoma. in spite of the large excision margins sidewise and in the depth, the tumor has reappeared locally after months from excision and treatment, with inguinal ipsilateral metastasis. conclusion: the presented facts suggest a more close attention to the clinical and histopathological differential diagnosis of the tumoral cutaneous lesions in the lower limb extremities. this could influence the surgical therapeutic act. was /nmc. histological exam of skin biopsies revealed in dermis a significant proliferation of irregular, small vascular channels, covered by a single layer of atypical endothelial cells. these channels were predominately arranged around preexistent mature vessels and adnexal structures. they were placed parallel to the epidermis and were marked by cd antibody. with this antibody, we observed that majority of these vessels were intermediary vessels whose proliferation could be suppressed by anti-angiogenic therapy. based on clinical, histological and immunohistochemical aspects, diagnosis of kaposi's sarcoma in early stage was made. chemotherapy was initiated (haart scheme) for months. after this treatment, skin plaques have disappeared and serum level of cd increased at /nmc. conclusion: it is very important to recognize early phase of kaposi's sarcoma and to initiate the treatment in order to improve prognosis of this lesion in hiv-infected and also immusdepressed patients. the objective: skin cancers are one of the most common human malignancies. although the prognosis of these patients has improved in the last decades, there is still a need for novel treatment modalities and prevention from recurrence after the treatment of skin tumors. p is a tumor-inhibiting gene which is believed to be defective in many malignant situations. ki is a non-histonic protein which mainly interferes with the proliferation and has many controlling effects during the cell cycle. this study aimed at evaluating p and ki- expression in skin epithelial tumors by immunohistochemical method. method: in a descriptive setting, biopsy samples- basal cell carcinomas (bccs), ten squamous cell carcinomas (sccs), eight keratoacanthomas (kas) and two tricoepitheliomas (tes)-were immunohistochemically evaluated for p and ki expression during a -month period. the incidence and expression rate of these two variables were separately reported in each group of samples. objective: the coexistence of anti-neutrophil crescentic glomerulonephritis with membranous glomerulopathy is very rare. little is known about the clinical course, treatment and outcome of patients with concurrent coexistence of these nephropathies. method: we present the case of a -year-old man with rapidly progressive renal failure, anti-neutrophil perinuclear antibodies positivity, pulmonary infiltrates and vasculitis. results: the patient was admitted to the pulmonary department due to febrile state, weakness and weight loss. physical examination revealed fine crackles over the left lung, leg edema, and vascular skin lesions on inferior extremities. urinalysis showed proteinuria and hematuria with many rbc casts, and in a -h urine collection, the proteinuria of g was observed. serologic workup was positive for p-anca, negative for c-anca, ana, and anti-gbm antibodies and showed normal levels of c and c . hcv, hbv and hiv infection were excluded. in lab tests, the rapid increase of serum creatinine from . to . mg/dl over weeks was observed. chest ct revealed pulmonary infiltrates of left lung upper lobe. the patient underwent a kidney biopsy which showed necrotizing crescentic glomerulonephritis and membranous glomerulopathy. in light microscopy examination, glomeruli with necrotic lesions and cellular crescents were seen. electron microscopy revealed epimembranous and intramembranous deposits. the patient was treated with steroids; cyclophosphamide and seven plasmapheresis were performed with improvement in renal function. on -year follow-up, his proteinuria had decreased to mg/day and his creatinine had stabilized at . with egfr of ml/min. objective: in the last years, the study of predictive and prognostic markers of non-small cell lung carcinomas (nsclc) has been a continuous challenge. it is well known that the imbalance between akt and pten expressions plays an important role in cell proliferation, angiogenesis and tumor cell invasiveness in various solid malignancies. the aim of our study was to analyze the akt and pten expressions in primitive non-small cell lung carcinomas and, also, in their metastases. method: we have examined akt and pten immunohistochemical expressions in primitive non-small cell lung carcinomas with different stages and in ten metastatic nonsmall cell lung carcinomas: brain, adrenal glands and lungs. results: akt expression was higher in metastatic than in primitive non-small cell lung carcinomas, while pten was over-expressed in % of all tumors. there were no obvious associations between tumor stage and akt/pten expression. there were no correlations between pten over-expression and akt expression. conclusion: akt activation may play an important role in tumor cell invasiveness in non-small cell lung carcinomas, but pten suppressor gene may not be involved in akt activation. objective: the role of mirnas in cancer is a rapidly emerging area of investigation. expression profiling has identified mirna signatures in cancers that associate with the diagnosis, staging, progression, prognosis, and response to treatment. mirnas are ideal biomarkers in ffpe tissue because unlike mrna, mirna integrity is affected very little by formalin fixation. previous studies have shown that mir- overexpression correlated with poor prognosis in nsclc patients. in this study, we investigated the expression of mir- in primary carcinoma and metastasis and near non-tumor parenchyma. method: ffpe samples from surgical specimens and biopsies of seven pulmonary adenocarcinomas and five squamous cell carcinomas and respective metastasis together with normal lung tissue (alveolar and bronchial) from the same case; it was imperative to separate these well-characterized areas by lasercapture microdissection (lcm) prior to rna analysis. results: the expression level of mir- by qrt-pcr was significantly higher in tumor tissues than in adjacent normal tissues (p= . ). the overexpression in the metastasis samples compared to adjacent normal tissue was almost statistically significant (p= . ). conclusion: mir- was overexpressed in tumor tissues relative to adjacent non-tumor tissues. we found an increase in mir- expression in primary carcinoma and metastasis in pulmonary adenocarcinomas when compared with mir- lower expression in squamous cell carcinoma. despite the small sample studied, further investigation may indicate the therapeutic and prognostic relevance of this determination as previous studies suggest that mir- acts as an oncogene and has a role in tumorigenesis through the regulation of tumour suppressor genes. objective: routine diagnosis and prognostic methods may also be useful to add data to clinical information in advanced primary carcinomas if conveniently explored. the evaluation of the potential of h nmr spectroscopy for providing biochemical information of the different histological types and for discriminating between tumour and pulmonary parenchyma as well as biochemical information about different histological types was tried as a preliminary approach. method: small frozen samples of pulmonary tumours were collected together with macroscopically normal parenchyma from surgical specimens before histological classification and mirror tissue was ffpe. paired cases were directly analysed by high-resolution magic angle spinning (hrmas) h nmr spectroscopy ( mhz). the spectral profiles obtained were subjected to multivariate analysis: principal component analysis (pca) and partial least squares regression discriminant analysis (pls-da) with the predictive ability of the statistical models. results: tumor and control tissues were clearly discriminated in the pls-da model with high level of sensitivity ( % of tumor samples correctly classified) and % specificity (no false positives). the metabolites giving rise to this separation were mainly lactate, gpc, pc, taurine, glutathione and udp/utp (elevated in tumors), and glucose, phosphoethanolamine (pe), acetate, lysine, methionine, glycine, myo-and scyllo-inositol (reduced in tumors compared to control tissues). furthermore, pls-da allowed carcinoids to be discriminated from adenocarcinomas and epidermoid carcinomas. conclusion: this preliminary study raised the nmr profile between the different histological types of bronchialpulmonary carcinomas through multivariate analysis and scaled metabolic profiles that may be delineated to improve clinical decisions in future. objective: the rna binding protein hur can stabilize and/or regulate the translation of target mrnas affecting cellular responses. the expression of hur is increased in several cancers, and cytoplasmic immunoreactivity was found to be closely related to poor outcomes. method: we analyzed, by quantitative immunohistochemistry, the expression of hur in lung adenocarcinoma of mixed histologic type from stage i and ii patients. moreover, we evaluated the level of hur expressed both in the nucleus and cytoplasm of tumor cells (t-hur) and evaluated the impact of nuclear/cytoplasmic ratio (n/c) on clinical outcome. results: both t-hur and n/c were not associated with age, tumor diameter and histopathological grading, whereas high t-hur and low n/c were associated with lymph node involvement at presentation. cox's regression analysis, using either t-hur or n/c as continuous covariates, showed that high t-hur and low n/c were associated with the risk of death and metastasis. the plots of the estimates, at -year follow-up, of metastasis-free and overall surviving as a function of t-hur and n/c levels, showed that the increase of t-hur and the decrease of n/c were associated with an increase of risk. in the multivariate analysis, both t-hur and n/c retained an independent prognostic significance relative to metastasis-free and overall survival. conclusion: in conclusion, these data indicate that the over-expression of hur in lung adenocarcinoma cells is an independent prognostic marker of a poor clinical outcome. moreover, the cytoplasmic localization of hur expression is more relevant than the nuclear one for the tumor cell behavior. objective: the eml -alk fusion gene has been detected in - % of non-small cell lung cancers. we evaluated the incidence, prognosis and the characteristics of alkrearranged non-small cell lung cancers and the optimal diagnostic modality to detect alk rearrangements in routine clinical practice. method: seven hundred seventy-nine surgical specimens of non-small cell lung cancer from two institutions were analyzed. to identify alk rearrangements, immunohistochemistry and fluorescent in situ hybridization (fish) examination were performed and compared. the clinicopathologic characteristics of tumors with and without alk rearrangements were analyzed. egfr and kras mutations were determined by dna sequencing. results: we identified ( . %) non-small cell lung cancer with alk rearrangements within our cohort by immunohistochemistry. forty-three ( . %) of the eml -alk tumors were adenocarcinomas. alk rearrangement was associated with never smoking (p< . ) and female (p < ). patients in the eml -alk fusion gene in adenocarcinoma had no effect on progression-free survival and overall survival. immunohistochemical results were correlated with fish results. conclusion: the patients most likely to harbor eml -alk are never smokers with adenocarcinoma. but eml -alk was not an independent prognostic factor. immunohistochemical staining for alk could be used as a screening method to detect alk gene rearrangement. objective: lung cancer is one of the most common malignant tumors worldwide, with a growing incidence. in romania, lung cancer has a prevalence of % and an incidence of %; in terms of deaths from cancer, it ranks first place in males and fourth place in females. method: we analyzed the malignant lung tumors from january to february using information obtained from observation sheets of thoracic surgery clinic and the database of the pathology department of the university emergency hospital bucharest. distribution of cases was followed depending on age, environment, gender, living and working conditions (smoking, toxic, radiation), tumor stage and histological appearance. the analysis of these data shows that most lung tumors occurred in the fifth decade of age and is more common in men. regarding histological type and age, the most common tumors were moderately differentiated squamous carcinomas (the decade iv, v, vi and vii). four patients were hospitalized for another disease (inguinal hernia, uterine fibroma) and were subsequently transferred to the clinic for thoracic surgery for specialist treatment. conclusion: physical examination, identifying the factors contributing to lung cancer appearance and its diagnosis in early stages, as well as an adequate communication between specialists, may contribute to the decrease of mortality as well as socioeconomical costs. objective: lung damage in emphysema has been traditionally attributed to an imbalanced proteases/antiproteases, especially in α -antitrypsin deficiency (aatd). however, activation of lymphocytes with organisation in lymphoid follicles (lfs) seems to play a crucial role in disease pathogenesis. the aim of this study was to quantify the number and distribution of lfs in native lungs from patients transplanted for emphysema. method: we compared two groups of patients with either aatd (n= ) or normal levels (aatn, n= ). bronchiolar, perivascular and parenchymal lfs were evaluated on sections immunostained with anti-cd .results were expressed as lf number per square centimeter of examined tissue and, for bronchiolar lfs, as percentage of airways with lfs. results: lfs, almost absent in normal lungs from donors, were frequent in subjects with severe emphysema both with and without aatd. lf total number was increased in aatd patients as compared to aatn, and this was mainly due to a higher number of parenchymal lfs (median, range: , - vs , - lfs/cm , p= . ). perivascular and bronchiolar lfs were numerically increased in patients with aatd ( , - vs , - lfs/cm ; , - vs , - %), but did not reach the levels of statistical significance. conclusion: lf number is increased in patients with end-stage emphysema, particularly in those with aat deficiency. these results extend our knowledge of disease pathogenesis, suggesting that lymphocyte activation is a crucial event even in aatd-related emphysema, and the excessive lung damage observed in these patients may trigger the persistence of the immune response, possibly with autoimmune mechanisms. objective: (lyg) is a rare angiocentric lymphoproliferative process predominantly affecting the lung. the diagnosis of this condition is often difficult as the physical signs, history, chest x-ray, and routine laboratory investigations are usually nonspecific. nevertheless, it is important to establish a tissue diagnosis as this lymphoproliferative disorder can be refractory to treatment and even progress to overt lymphoma. method: one case of pulmonary lyg in a -year-old nigerian man of ibo extraction treated in our centre in and followed up for a year is presented. the difficulty in making diagnosis is highlighted and treatment modality discussed. results: our patient received two courses of cyclophosphamide and prednisolone before defaulting. there was evidence of some remission, even though incomplete, following the first course of chemotherapy (fig. ) . however, his representation a year later with evidence of relapse was a pointer to the ongoing process of the lesion. whether this case had progressed to lymphoma was difficult to say as he declined a readmission and further investigation. conclusion: a subset of angiocentric lymphoproliferative process including lyg shows clinical response to cytotoxic chemotherapy and steroid when commenced early, as is partly true here. lymphomatoid granulomatosis should be considered in long-standing nodular pulmonary lesion and pleural effusion of uncertain aetiology. immunohistochemical study about pathogenesis of acute respiratory distress syndrome g. simona*, i. jung, l. azamfirei, d. demian, r. solomon, b. grigoroiu *umf, dept. of pathology, targu-mures, romania objective: despite modern treatments, the prognosis of acute respiratory distress syndrome (ards) remains unfavorable and its pathogenesis is not explained enough. in few recent studies, the pathogenetic and prognostic role of vascular endothelial growth factor (vegf) and its receptors was investigated in ards, but the obtained results were controversial. method: we have compared the immunohistochemical expression of cd , vegf-a and its receptors (veg-fr and vegfr ) in normal lung (n= ) and also in early and late ards (within h, respectively, after days). cases with ards were necroptic cases (n= ), and also lung biopsies (n= ). labvision antibodies were used. serum level of vegf was also determined. results: in normal lung, all antibodies marked the endothelial and alveolar cells and also macrophages. in early ards, the intensity of vegf decreased in both endothelial cells and alveolocytes, but increased in hyaline membranes (hm) after - days. vegr marked the preserved alveolar cells and vegfr marked alveolar macrophages. hm were negative for both receptors. in late ards, down-regulation was more prominent for all antibodies. serum level of vegf was up-regulated at the same time with decreasing vegf intensity in lung cells, and also with hm appearance. all dyed patients presented hm, independently by phases of ards. cd marked alveolar macrophages and sometimes hm. conclusion: the formation of hm in ards showed an unfavorable prognosis. strong intensity of vegf and the inconstant presence of cd in hm proved that both destroyed alveolar cells and macrophages are responsible for vegf production, but the increased serum level of vegf also proved its serum extravasations in hm. optimalization of flow cytometric assessment of tnf in alveolar macrophages using multiparametric analysis e. stránská*, p. mandáková, m. vašáková, r. matej *university hospital motol, dept. of pathology, praha, czech republic objective: alveolar macrophages (ams) contribute to the pathogenesis of different lung diseases by producing proinflammatory cytokines. within the frame of the project, which is mainly concerned with cytokine expression in bronchoalveolar lavage fluid (balf) of patients with idiopathic pulmonary fibrosis and chronic obstructive pulmonary disease, we optimized the flow cytometric (fc) examination of tnfα expression in ams. the aim was to determine spontaneous tnfα production, the production during the culture and after stimulation with lipopolysaccharide. furthermore, we focused on antibody selection since ams displayed high level of autofluorescence. method: we examined balf obtained from control patients. tnfα production was assessed immediately after balf delivery, after -h stimulation with lipopolysaccharide (monensin, protein transport inhibitor was added after h of incubation) and also after incubation with monensin only. simultaneously, various concentrations of lipopolysaccharide were tested ( . , and μg/ml). fc detection of ams was simplified using multiparametric analysis, a combination of optical parameters along with the expression of surface markers cd and cd . results: concentration of μg/ml of lps was found to be optimal for ams activation, although all tested concentrations are suitable. the high background autofluorescence of ams can be efficiently reduced by the use of antibody conjugated with long-wave emitting fluorochrome, e.g. apc. objective: the aim of the present study was to contribute to the understanding of the importance of evaluating bone marrow biopsy (bmb) by computer-assisted digital image analysis (cia). moreover, the intention was to investigate the frequency of marrow fibrosis in multiple myeloma (mm) and to correlate it with plasma cell infiltration during the follow-up of patients. method: bone marrow biopsy from patients diagnosed with mm were analyzed at the time of diagnosis and reevaluated after the completion of the therapy. the percentage of plasma cells was estimated on immunohistochemically stained paraffin sections with anti-cd and ig light chains by alphelys spot browser integrated system. the fibrosis was analyzed according to the european consensus on grading bone marrow fibrosis. results: plasma cell percentage at the time of diagnosis ranged from % to % (median %) and in follow-up from % to % (median %). increased fibrosis, which appeared to be restricted to areas of severe plasma cell infiltration, was seen in % of bmb at first diagnosis. in a follow-up study, the percentage of plasma cell infiltration decreased in of , increased in of and remained nearly equal in of mm patients. all patients with disease progression after first-line therapy had increased fibrosis in bmb. the degree of fibrosis correlated with plasma cell percentage, clinical stage and response to therapy. conclusion: in all cases of mm, a bmb is essential at diagnosis as it helps identify a subset of myeloma patients with increased marrow fibrosis and response to therapy. objective: lymphoma is the commonest haematological malignancy in the developed world. we undertook an audit of all laboratory reports from the pathology department of beaumont hospital that confirmed or suspected a diagnosis of lymphoma over an -year period, assessing the following: incidence of lymphoma by age at presentation and gender, site of presentation, type of lymphoma diagnosed, number of cases utilising immunohistochemistry, number of cases where bone marrow staging was performed and the results. method: six hundred forty-seven cases were retrieved from the laboratory database where the histology report provided a definitive diagnosis of lymphoma or strongly suspicious for lymphoma. seventy-seven were diagnosed as hodgkin's lymphoma and diagnosed as non-hodgkin's lymphoma, with cases strongly suspicious for lymphoma. results: the study showed an average age of . years at presentation, with incidence of lymphoma increasing with age and peaking at an age range of - years, reducing thereafter. the highest incidence of hodgkin's lymphoma occurred in the age ranges - and - years. incidence of lymphoma was similar in both genders. b cell lymphoma had the highest incidence, followed by hodgkin's lymphoma. three hundred thirty-one cases had a nodal site of presentation, were extranodal, with the remaining from uncertain site (site labelled, for example, mediastinal mass). brain was the most common extranodal site with cases. immunohistochemistry was performed in % of cases. six percent of cases had bone marrow involvement. conclusion: the incidence of lymphoma for years in beaumont hospital is mostly consistent with the epidemiology established by the who. objective: mpns consist of polycythemia vera (pv), essential thrombocytosis (et), and primary myelofibrosis (pmf). though a number of clinical and diagnostic factors have been determined, the current classification in mpns is still not satisfactory. all mpns are characterized by jak tyrosine kinase (v f) mutation related to the deregulation of intracellular signalling pathways, e.g. ras-erk and pi k-akt, while bcl negatively regulates the pi k-akt pathway. the aim of our study was to attempt to indentify the presence and distribution of erk and bcl expression as factors which might distinguish each mpn. method: expressions of erk and bcl were investigated (immunohistochemistry with envision and dab) on trephine samples in pv, et and pmf patients. anti-erk antibodies were directed to the epitope corresponding to a site near the c-terminal of these molecules. bcl antibodies bind an epitope located between amino acids - of human bcl . finally, sections were studied under light microscope and evaluated using a semiquantitative method. results: there were similarities and differences in terms of erk expression among three mpn disorders. there was a widespread occurrence of anti-erk in the cytoplasm as well as in the nucleus. observed differences concern the levels of expression of this antigen in the nucleus. objective: there is a wide overlap of symptoms and signs among gastrointestinal (gi) graft versus host disease (gvhd) and other gi diseases (infections, drug toxicity, etc.). the diagnosis is based upon histologic and endoscopic findings. accurate diagnosis is important as it determines a specific treatment and contributes significantly to the morbidity and mortality of post-allogeneic stem cell transplant (sct) patients. persistence of gi symptoms despite initial treatment is frequent, and ulterior histologic evaluation may be helpful to address therapy. method: we performed a retrospective study of patients with persistent diarrhea despite treatment based on the first biopsy diagnosis in order to determine the diagnostic value of serial gi biopsy evaluation in sct patients. simultaneous microbiologic analyses of stools and cmv antigenemia monitoring were performed. results: of the first rectosigmoid biopsies, ( %) were diagnosed as gvhd, two ( %) as gvhd with cmv infection, four ( %) as non-cmv infection, and five ( %) as normal or unspecific. second gi biopsies were diagnostic of active gvhd in six ( %) cases, gvhd with cmv infection in four ( %), regenerative changes post-gvhd in eight ( %), cmv infection in three ( %), and normal or unspecific in eight ( %). in out of ( %) patients, the histologic findings of the second biopsy were different compared to the first biopsy, leading to a therapy change in ( %) patients. conclusion: our results showed a reliable diagnostic value for serial gi histologic evaluation that could impact on the therapeutic decision in patients with persistent diarrhea after allo-sct. thymoma with subtotal loss of keratin expression: a potential diagnostic pitfall p. adam* *medical university of tübingen, institute of pathology, germany objective: the differential diagnosis between thymoma and t lymphoblastic lymphoma poses major difficulties in small needle biopsies since both entities contain immature and highly proliferating t cells. one essential diagnostic criterion favouring thymoma is the demonstration of increased numbers of cytokeratin-positive epithelial cells. we describe a series of type b /b thymomas with substantially reduced cytokeratin expression. method: eight thymoma cases were analyzed for the expression of various cytokeratins and other epithelial markers (panck ae / , ck , ck / , cam . , ck / , p , beta-catenin, e-cadherin). as controls, type b and b thymomas and thymic carcinomas arranged on a multi-tissue histoarray were analyzed. results: with regard to cytokeratin expression, three b thymomas were completely negative for panck, ck , ck / and cam . . with regard to the other epithelial markers, seven of seven cases showed a strong nuclear expression of p and strong membranous staining for e-cadherin and beta-catenin. analysis of control cases on a multi-tissue array showed the expression of panck, ck , ck / , cam . and ck / in %, %, %, % and %, respectively. the other epithelial markers p , e-cadherin and beta-catenin were found in %, % and %. conclusion: loss of cytokeratin expression in type b /b thymomas is a potential diagnostic pitfall in the differential diagnosis with t lymphoblastic lymphoma and can be expected in - % of cases. interestingly, thymomas with loss of keratin expression seem to upregulate e-cadherin and beta-catenin. an unusual uterine tumour with signet ring cell features s. rossella*, m. fiche, c. achtari, n. ketterer, l. de laval *chuv lausanne, dept. of pathology, switzerland objective: lymphomas with signet ring cell features are rare, as is uterine dissemination of lymphomas. we report an exceptional case of a uterine tumor combining these two characteristics. method: a -year-old female was diagnosed in with localized nodal grade follicular lymphoma (stage ia). she received local radiation therapy, experienced total remission, and did well until when a systematic ct scan evidenced a pelvic anterior-lateral mass. total enlarged hysterectomy was performed. results: the anterior uterine wall contained a . -cm fish flesh well-delineated mass corresponding to a mostly diffuse and focally nodular proliferation of medium to large cells with extensive signet ring cell changes. tumor cells were cd -, cd -, bcl -, and bcl -positive with a low proliferation rate (< - %); cd underlined a focal follicular architecture. the vacuoles were pas-negative and did not stain for immunoglobulin; ultrastructural analysis revealed nonspecific degenerative vacuoles. no lymph nodes were identified isolated from the surgical specimen. objective: upregulation of the embryonic notch signaling pathway has been observed in several different malignancies, among which is pancreatic ductal adenocarcinoma (pdac). for lack of a receptor-specific blocking antibody, less specific methods were used to suppress notch signaling in earlier research. with use of a receptorspecific monoclonal blocking antibody against the notch receptor (n -ab), we determined the exact effects of notch receptor inhibition on different pdac cell lines. method: after confirming active notch signaling, n -ab activity and specificity were tested with immunofluorescence and qrt-pcr. cells were treated with n -ab and different assays were performed to establish the effects of notch receptor inhibition on growth rate and colony forming potential. in vivo experiments were performed: mice were injected with treated or untreated cells subcutaneously and tumor growth was monitored. results: treatment with n -ab did not influence the growth rate of the cells. colony forming potential did decline upon treatment with notch -ab, although this decline was only twofold. in vivo experiments did not show any differences between the untreated and treated group. conclusion: although notch receptor inhibition did diminish anchorage-independent growth in pdac, this effect was much less profound than previously reported. no effect on growth rate was observed upon treatment with n -ab, which conflicts with the general statement that notch receptor inhibition results in a decline in growth rate. notch should still be looked upon as a potential treatment target, but further determination of the different components of the notch pathway and their role in tumorigenesis seems advisable. objective: due to adverse side effects, efforts are made to reduce the time of daily lateral electrical surface stimulation (less) therapy in the treatment of idiopathic scoliosis in children and adolescents. method: studies were carried out on ten male rabbits, new zealand purebred, aged . months, with b.m. of , - , g. animals were divided into two groups (n= ): ( ) short-term less was applied for h daily during months and ( ) control group without less, but with other experimental parameters as in group . stimulation was performed with scol- (elmech). clinical, macroscopic and microscopic observations were performed. results: similar growth of b.m. was observed in the rabbits from both groups during the first months of the experiment. in month , a slightly smaller increase was observed in the animals from group than in those from group . the mean mass of the suprarenal glands in the stimulated rabbits was . ± . g, while those from the group were . ± . g. a microscopic examination revealed hypertrophy of zona fasciculata with visible overgrowth of glandular cells in rabbits from group . the results of clinical observations as well as morphological lesions indicate the presence of adaptive stress in rabbits stimulated with short-term less. objective: basal cell carcinoma (bcc) is considered a skin cancer with long evolution and low metastatic risk. method: we selected for presentation three cases with bcc operated between and , with a special history and evolution. results: the first case ( -year-old female) developed a small occipital tumour, incompletely explored and excised in another surgical department. we performed ten serial excisions (soft tissue and invaded bone) during years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and used complex reconstructive techniques (local/muscular/free omentum flaps). the second case ( -year-old male) had a neglected frontal tumour invading the orbital region; during a period of years, we performed three excisions and reconstructed the region with skin graft and temporal flap, trying to save the eye. finally, we had to excise the invaded eyeball and we used frontal flap for reconstruction ( ) . the third case ( -year-old female) had a small bcc on the left buttock, which was excised in correct limits and reconstructed with a skin graft ( ). fiveyears later, a new ulcer appeared. the patient neglected the tumour during a period of years. the bcc progressively invaded with a buttock, the upper third of posterior left thigh and the left gluteus maximus muscle, inducing severely altered general status and anemia. we performed a wide excision (including the muscle) and we reconstructed with a fascio-cutaneous flap and skin grafts ( ). conclusion: bcc can be a cancer with a high local aggressivity if the patient or the surgeon underestimates it. objective: eyelids represent a special location of the basal cell carcinoma (bcc) due to the proximity of the eyeball. the aim of this study was to review the clinical and histopathologic features and outcomes of eyelid basal cell carcinomas. the clinical records and histopathologic specimens of patients with eyelid basal cell carcinomas were reviewed and analyzed retrospectively. the main outcome measures are clinical characteristics, lesion size, histologic subtypes, severity of peritumorous inflammation, recurrence rate and prognostic features. results: the most common histologic subtypes were infiltrative, nodular, and basosquamous basal cell carcinomas. of the patients, . % were previously recurrent. recurrent basal cell carcinomas were larger, with longer duration of lesion. basosquamous basal cell carcinomas were more likely to have prior recurrences, larger lesion size, and the highest rate of orbital invasion. perineural invasion was most frequent in morpheaform and basosquamous subtypes. peritumorous inflammation differed between subtypes and was highest in the superficial subtype. the recurrence rate was . %. conclusion: the outcomes were worse than previously reported due to the delay in treatment. the prognostic factors associated with secondary orbital invasion are previous recurrences, aggressive histologic subtypes, longer duration of lesion and larger lesion size. histological assessment of small bowel hypoperfusion lesions in the pig a. l. oliveira*, d. ferreira, h. vala *agrarian superior school, viseu, portugal objective: authors propose the use of a quantitative morphological assessment for helping in studies concerning intestinal hypoperfusion. the method was applied to small intestine mucosa stained with standard hematoxylin and eosin in pigs that underwent severe hypotension due to acute hemorrhage. method: six large white pigs underwent total intravenous anesthesia with propofol and remifentanil. arterial blood ( ml/kg) was passively removed from the femoral artery over min. volume was replaced using ringer lactate in group and hydroxyethyl starch / . in group , with a delay of min after bleeding. onehour after the volume replacement, pigs were euthanized and small intestine samples were taken for histopathological examination. parameters were classified using two specific scales (chiu ; Çetin ; kaplan ) . mucosal loss (ml) percentage and crypt/ interstitium ratio were obtained (faleiros ). results: inflammatory infiltrate was present in all animals, varying from grade to grade . hydropic cellular degeneration and epithelial detachment were more pronounced in duodenum and more noticeable in group . in group , ml percentage was . ± . % in duodenum, . ± . % in jejunum and . ± . % in ileum. in group , ml percentage was . ± . in duodenum and ± % in the other intestinal segments. in the whole small intestine was . ± . % in group and . ± . % in group . crypt/interstitium ratio did not present significant differences between the groups. conclusion: quantitative morphological assessment may be useful in quantifying the degree of mucosal lost in small intestine stained with hematoxylin and eosin from pigs submitted to acute severe bleeding. results: case : the tumor in the thoracic aorta was found at autopsy. histologically, the tumor consisted of isolated atypical cells, suggesting sarcoma. immunohistochemically, tumor cells were positive for cd . the same atypical cells were seen in the intrarenal arteries as emboli accompanied with vasculitides. case : autopsy revealed lymphoplasmacytic lymphoma (lpl) involving kidneys. and more, amyloid deposition in the lungs and mpo-ancaassociated crescentic glomerulonephritis, i.e. mpa, were noted. conclusion: aortic angiosarcoma is an extremely rare lesion, and it is known that the tumor often causes distal emboli and presents vascilitis syndrome. the second case was diagnosed as lpl, mpa and amyloidosis. mpa is known to occur in some patients with malignancy. it has been reported that some malignancies produce vasculitidesinducing factors. in our cases, such factors produced by malignant cells might induce vasculitides. monoclonal antibodies in the diagnostic of spinal metastases g. kropczydski* *zabrze, poland the skeletal system is the third most frequent seat of metastases, and metastatic tumours are the most common bone malignancies. the diagnostic workup of spinal metastases begins with the identification of the primary neoplastic site. the aim of the study was to determine the utility of monoclonal antibodies in the diagnostic workup of spinal metastases. materials and methods: this is a retrospective analysis of patients whose histopathologic examination confirmed the presence of neoplastic foci in the spine. samples of metastatic tumours of patients whose primary tumour sites had not been identified were subjected to an immunohistochemical analysis based on monoclonal antibodies and assays for antigens associated with tumours most often producing bony metastases. results: the monoclonal antibodies and assays were shown to be useful aids for the identification of the histology and location of the primary tumour in patients in whom routine histological assessments had failed to determine the histological type of tumour. conclusions: the length of survival of patients with malignant spinal metastases is influenced by the type of neoplasm and locally radical surgery combined with palliative radiation therapy. in many cases, effective immunohistochemical workup can contribute to halting the progression of the tumour by enabling qualification for appropriate surgical and oncological treatment. origine and frequency of pulmonary bone fragment embolism: an autopsy study n. willi*, t. thiesler, p. ochsner, g. cathomas *kantonsspital liestal, institute of pathology, switzerland objective: pulmonary bone fragment embolism (pbfe) is a rare event observed at autopsy. pulmonary bone marrow embolism (bme) is more common, but both types of embolisms are considered to have little clinical relevance. the aim of this study was to analyze the frequency of pbfe and bme and correlate these events with clinical findings. method: in an autopsy cohort, the frequency of embolic particles of pbme and bme was evaluated by reanalyzing all pulmonary h&e-and elastin-stained (evg) sections. results: in a total of , autopsies, ( . %) pbfe and ( . %) bmes were detected. compared to bme, pbfe were significantly more common in patients with osteomyelitis [ of ( %) versus of , p< . ). in contrast, bme was more common in patients with costal fractures ( of versus of , p< . ), but no patient showed both types of embolism. in addition, pbef and bme were observed in patients with bone metastasis and orthopaedic devices. the highest density ( . particles per square centimeter) was observed in a patient who died immediately following femoral medullary nailing, presenting with the clinical picture of pulmonary thromboembolism. conclusion: in the autopsy cohort analyzed, an incidence of ‰ for pbfe was considerably higher as previously reported and pbef showed a strong correlation with osteomyelitis, and the application of orthopaedic devices and extensive pbfe may lead to death. bme are correlated with rib fracture, but no association between pbfe and bme was observed, suggesting a different pathogenetic mechanism. ( )). results: we performed correct oncological excision in % of the cases; ten patients with bcc needed re-excision. in the same surgical stage, we reconstructed the defect using local flaps for patients ( . %), local flaps and skin grafts for six patients and skin grafts only in the seven cases with mm. the main techniques used were: frontal or temporal flaps for the orbital /nasal regions, naso-genian or fan flaps for the lips and cervico-facial flaps for the cheek. when necessary, full-thickness skin grafts taken from preor retroauricular donor zones were performed ( cases). after surgery, all the patients were examined by the oncologist; only patients diagnosed with squamous cell carcinoma or malignant melanoma accepted the excision of the local regional lymph nodes. conclusion: correct tumoural excision in the face is difficult to perform. the skin graft is the best reconstruction technique from the oncological point of view, but to respect the aesthetic and functional rules, we have to perform flaps. indian ink vs tissue marking dye: a quantitative comparison of two widely used macroscopical staining tool k. kosemehmetoglu*, g. guner, d. ates, e. soylu *ankara ataturk eah, dept. of pathology, turkey objective: the evaluation of the surgical margins is a major concern in surgical pathology and marking of surgical margins with substances; indian ink and tissue marking dyes are widely used. as there is no systematic study comparing tissue marking dyes and indian ink, the most common substances used for the purpose, this study was conducted to compare the two. method: unit price, penetration into the tissue, the spreading area of one drop of dye on tissue paper, brightness under the microscope and the intensity of colors on image analysis program were compared for each of the five colors of rotring's indian ink and thermo-shandon's tissue marking dyes applied on reduction mammoplasty specimens. results: indian ink seemed to be slightly less smudgy than tissue marking dye. indian ink tended to remain on the surface and showed less tissue penetration compared to tissue marking dye with respect to all colors, except yellow. blue color of thermo-shandon and yellow color of both rotring and thermo-shandon had the deepest penetration in fatty tissues. red color of rotring was lost nearly totally after processing. rotring has revealed comparable results to thermo-shandon; even the black and green colors of rotring were more intense. on the other hand, thermo-shandon was better when red, blue and yellow colors are concerned. conclusion: rotring's indian ink is proven to be just as effective as thermo-shandon's tissue marking dye and bares majority of the characteristics of a perfect staining substance, which are easily applied, quickly fixed, durable and cheap, contain no potential contaminants, is worksafe, would not smudge/stain surrounding tissues, and look bright under the microscope without obscuring the view. objective: during the development of anatomy since the fifteenth century, a phenomenon of anatomical museums appeared. method: we present a short history of this phenomenon in europe and give insight into the form of acquisition and exhibition of the preparations. results: the prototypes were "curiosities of nature" collections with one of the first founded by aldrovandi in bologna (sixteenth century). the next famous and focused on the human body were the collections of f. ruysch in the netherlands (seventeenth century). he was performing autopsies in public and after that presented preserved parts or whole bodies and osteological preparation sets as artistic dioramas in a special exhibition house. his collection, sold to peter the great, created the foundations for kunstkamera in sankt petersburg. in the eighteenth century, teachers in surgical and anatomical schools (beginning of anatomopathology) realized the educational power of such collections. museums like the one by h. fragonard in paris, france and hunterian in glasgow were established. the next big collection-narrenturm in vienna-had many exhibits obtained from algemeine krankenhaus. the first typical anatomopathological museum was created by r. virchow in berlin (nineteenth century). virchow's motto was "no day without a preparation". in polish universities, l. bierkowski (cracow) and a. bielkiewicz (vilnius) founded such museums. that time in all europe, anatomopathological collections became popular, gathering preparations: osteological, wet (alcohol, formaldehyde, other preservatives), dry and mummified. the fall of phenomenon started in the second half of the twentieth century. nowadays, we face the era of digitalisation of images but, on the other hand, collections of "plastinated bodies". the ethical and legal aspects become more important. results: macroscopic examination revealed the absence of traumatic lesions and the presence of cardiomegaly, threeelectrode pacemaker inserted in the right ventricle, anomalously coloured myocardium, lung oedema and congestion, chronic stasis liver and cerebral oedema. microscopic examination showed lesions of severe cellular acute cardiac rejection (grade r) in a heart with graft vascular disease. conclusion: the medico-legal autopsy allowed the confirmation of a death of natural cause ( ); the exclusion of infection and neoplasia-frequent and severe causes of morbidity in the heart-transplanted population ( ); the documentation of graft vascular disease, which is related to the time span after transplantation ( ); and the diagnosis and characterization of the acute rejection ( ) as adequate cause of unexpected death, without prodromic signs and symptoms. finally, it allowed the correlation of acute rejection and the suspension of immunosuppressive therapy by the patient-data obtained through the family ( ). all these conclusions may provide information about death causes of the heart-transplanted population dying outside the hospital, which will complement that of transplanted inpatient deaths. objective: sudden death is a possible major complication of congenital cardiac malformations. method: the authors report the case of a -year-old male that unexpectedly died at work while performing a minor effort task. he was apparently healthy, apart from the occurrence of very rare "epileptic attacks". a medico-legal autopsy was performed. results: the autopsy-in the setting of a forensic postmortem examination-revealed heart malformations that are consistent with ebstein's disease of the tricuspid valve, associated (as seldom may occur) to mitral valve dysplasia and patent foramen ovale. the relevance of this case lies upon three facts: ( ) the rarity of the pathological entity, ( ) the survival of the victim until the adult age without surgical intervention and ( ) the fact that the symptomatic announcing event was sudden and unexpected death. objective: the clinical use of doxorubicin (dox) is limited by dose-related cardiotoxicity. one-electron redox cycling of the quinone moiety has long been known to form reactive oxygen species. tirapazamine is a relatively new cytostatic compound most efficient in areas of hypoxia, however under aerobic conditions causing significant oxidative stress. aim: the aim of this study was to assess morphological changes in the myocardium of rats treated with doxorubicin and tirapazamine and evaluate changes in plasma level of a cardiac damage marker, ctni. method: rats were weakly treated i.p. with . mg/kg b.w. of doxorubicin and or mg/kg b. w. of tirapazamine for weeks. control group was given saline. samples of myocardium and plasma were taken a week after last dose. tissue samples were stained with hematoxylin and eosin, van gieson method and selye method and examined under light microscope. results: myocardium of rats receiving a combination of doxorubicin and lower dose of tirapazamine exhibited similar changes as rats administered with doxorubicin solely. animals treated with doxorubicin and higher dose of tirapazamine displayed vacuolization of sarcoplasm, wavy cardiomyocytes and fuxin-positive areas in selye method as well as signs of minor interstitial fibrosis. all described alterations in this group were accompanied by significantly higher levels of plasma ctni. conclusion: both drugs caused cardiac changes in rats, including necrosis, mononuclear infiltrations and minor fibrosis. combination of doxorubicin and higher dose ( mg/kg) of tirapazamine seems to have a synergic effect on changes in myocardium. objective: disturbed glucose metabolism, particularly in diabetes, is an important factor leading to the formation of advanced glycation end products (age). the amount of age and its distribution in the cardiocytes of a diabetic myocardium and in cardiopathies is not yet well understood. studies were performed to assess age deposits in cardiocytes in chronic heart failure. method: the diabetic groups consisted of autopsy cases with diagnosed diabetes, hearts explanted during transplantation with ischemic cardiopathy and diabetes, and eight hearts from dilated cardiopathy with diabetes. the two non-diabetic groups comprised hearts explanted from non-diabetic subjects: with ischemic cardiopathy and with dilated cardiopathy. the control group consisted of samples from healthy heart donors. immunohistochemical localization of age was applied, and a semiquantitative scale was used. results: positive staining was present in both cardiopathic groups with diabetes ( % of cases), then gradually decreased to % in diabetes, nearly % in cardiomyopathy, and to % in the control group. negative staining seemed to be characteristic of control group and nondiabetics, whereas granular and diffuse staining pattern (mixed pattern) was most frequent in diabetic groups. the semiquantitative results supported an increased age accumulation in cases with cardiomyopathy and in diabetes. age staining showed no significant correlation with patient age, bmi or diabetes duration. objective: desmoplastic small round cell tumor (dsrct) is a rare malignant serosa-related tumor involving mostly the pelvic and abdominal cavities, but very uncommon in the paratesticular region. dsrct affects young adults, mainly men, and is classically associated with a bad prognosis. method: we report the case of a -year-old man admitted to the hospital for a progressive enlargement of the right hemiscrotum with a -month history. a preoperative diagnosis of testicular tuberculosis was set and consecutively a right high orchiectomy was performed. at macroscopy, the testicular parenchyma showed no abnormal areas, but the tunica vaginalis was irregular and diffusely enlarged by a whitish to gray firm tumoral mass. microscopically, the tumor consisted of nests of small, round to spindle cells, with scant cytoplasm, surrounded by a mild desmoplastic stroma. an immunohistochemical study was performed for the differential diagnosis. results: immunohistochemically, the tumor cells were positive for ae /ae and nse and negative for lca, chromogranin, synaptophysin and cd antibodies. positivity and a very peculiar staining aspect were noticed with desmin antibody: perinuclear and dot-like, suggesting a dsrct. fluorescence in situ hybridization (fish) was accomplished, demonstrating ewsr rearrangement, which in this immunophenotypical context pleads a diagnosis of dsrct. conclusion: the awareness and the knowledge of dsrct in the paratesticular area are needed for a correct diagnosis. the differential diagnosis of this tumor with other malignancies involving this region is mandatory as it has a different clinical management. comparison of prognosis of gastrointestinal stromal tumors depending on a primary site and a type of mutation w. michej*, p. rutkowski *cancer centre instytute, dept. of pathology, warsaw, poland objective: majority of primary gists originate from the stomach (g) or small bowel (sb). the aim of the study was the analysis of the pathologic and molecular factors influencing the patients' prognosis after resection of primary gists, deriving from the stomach and intestinum, omentum (ng). method: in our department, a group of registered prospectively primary gists cd (+) comprising g-gists ( . %) and ng-gists ( . %) was analyzed; molecular examination was also made using pcr. surgeons from our institute compared our results, observing diseasefree survival (dfs). results: median size of g-gists as compared to ng-gists was significantly lower ( vs. . cm,) and g-gists were characterized by lower mitotic activity (median, / vs. / hpf). in g-gist, the most common detected mutations were exon kit ( %) and exon pdgfra, but in ng-gist exon and kit. prognosis of g-gists was significantly better as compared to ng-gist: -year dfs rate, % vs. %. in ng-gists, the following factors showed negative impact on dfs based on analysis: mitotic index > / hpf, primary tumor size > cm, pathological subtype: spindle. the high prognostic significance of ajcc staging system classification in g-and ng-gists was confirmed also in multivariate analysis. conclusion: reliability of ajcc risk classification after resection of primary gist was confirmed. patients with primary gist, originating from the stomach, have better prognosis as compared with gists located in other places. in both groups, primary tumor size and mitotic activity are still the most important prognostic factors. objective: malignant peripheral nerve sheath tumors (mpnst) are highly aggressive sarcomas which may be encountered either sporadically or in the context of the inherited tumor syndrome, neurofibromatosis type (nf ). epidermal growth factor receptor (egfr) overexpression has been reported in mpnst, which has been implicated in their pathogenesis. we present three cases that have different pathogenetic origins. method: the first patient was a -year-old woman who received radiotherapy to the axillary region following radical mastectomy for breast cancer years ago. she presented with a mass in the axillary region that has been growing during the last . years. second case was a -year-old man who was admitted with a . -cm mass in the right anterior femoral region. the tumor was low-grade and consisted of cartilaginous heterologous component. third case was a -year-old man with congenital café-aulait spots and soft tissue swellings all over his body. he was admitted for soft tissue swellings in the left axilla and in the neck region and years ago, respectively. both of the lesions were diagnosed as plexiform neurofibroma. currently, the patient attended with -cm mass in the gluteal region. pathologic diagnosis was consistent with mpnst. results: the first and the third cases showed a higher egfr expression than the second case. conclusion: we aimed to describe the morphological features and discuss the clinical background and different pathogenetic origins of these three cases with mpnst. the role of egfr overexpression was also evaluated in this case series. results: the cases reviewed belonged to different subtypes of sarcoma, with leiomyosarcoma of greatest incidence ( %). the most affected age at presentation was - . gender distribution was almost equal (m/f : ). the majority ( %) of cases were located in the trunk. ten commonly used immunohistochemical markers were identified, with vimentin being the most common ( %). over surgeons were responsible for the care of these sarcomas. less than half the cases were graded at diagnosis. of those graded, % were high grade, % intermediate grade and % low grade. the size at presentation ranged from to cm (mean . cm). conclusion: soft tissue sarcomas are a widely diverse group of uncommon tumours. we confirmed that our incidence rates are comparable with those published in the usa, with leiomyosarcoma being the most common subtype. of note is that over surgeons were involved in the management of these cases over years. this would suggest a need for a nationalized specialist centre with surgeons experienced in the treatment of these rare tumours. objective: calcifying aponeurotic fibroma is a rare soft tissue tumor of children and adolescents. these lesions are presented as slow-growing painless masses that usually affect the distal part of the extremities. they are locally aggressive tumors that infiltrate the surrounding muscle and fascia. recurrence rate is over %, but malign transformation is very rare. we report a -year-old boy with calcifying aponeurotic fibroma. method: we present a -year-old boy with non-movable firm mass on his leg. it was represented as a × . -cm diameter mass which surrounded the peroneal tendon with an infiltrating contour on x-ray and mri. fibroblastic proliferation areas, dense collagenous stroma, calcification and osteoid matrix were observed histopathologically. the tumor infiltrated peripheral muscle tissues and surrounding vessels and nerves. there were no mitotic figures and evidence of atypia. overall, histopathologic and radiologic features exhibited the same characteristics of calcifying aponeurotic fibroma. conclusion: calcifying aponeurotic fibroma is a locally aggressive tumor with a high rate of recurrence. especially in young patients, those under years of age had higher risk of recurrences. very few cases of malignant transformation have been reported. surgical total excision is suggested if ever possible and is the mainstay of the treatment approach. however, it is not possible in most of the cases because of its locally infiltrative behaviour. differential diagnoses include aggressive fibromatosis, nodular fasciit, fibrosarcomas, monophasic synovial sarcoma and some other malignant spindle cell tumors. surgical management should be conservative; excision and re-excision, if necessary, are preferable to radical or mutilating surgical procedures to maintain the function of the extremity. elastofibroma dorsi: case report. clinicopathological findings s. papaemmanouil* *g. papanikolaou general hosp., dept. of pathology, thessaloniki, greece objective: elastofibroma is a tumor-like lesion of soft tissue characterized by a large number of coarse, enlarged elastic fibers and fatty tissue. its usual location, in the scapular area, deep in the latissimus dorsi and rhromboid muscles, led to the name "elastofibroma dorsi". most of the elastofibromas are usually asymptomatic, unilateral and occur mainly in middle-aged and elderly women. clinically, these lesions may simulate an aggressive soft tissue tumor. method: design: a -year-old woman presented with a slow-growing subcutaneous mass in the right lateral chest wall. ct scan revealed an ill-defined solid mass, lying deep within the latissimus dorsi. the diagnosis of elastofibroma was suspected and the patient underwent a simple excision of the mass. the surgical specimen consisted of a poorly circumscribed mass, measuring × × cm, with gray-white cut surface and elastic consistence. the sections were examined with h+e and elastic stains and followed by immunohistochemical study for a-sma, cd , and h-caldesmon. results: the lesion was composed of a mixture of collagenous stroma, few spindle cells, mature adipose cells and large coarse eosinophilic elastic fibers, which stain with verhoeff-elastica and masson-trichrome. the spindle cells were positive for cd and negative for a-sma and h-caldesmon. the microscope findings confirmed the preoperative diagnosis. conclusion: elastofibroma is an unusual benign lesion cured by simple excision. the irregular elastic fibers may be the result of abnormal elastogenesis. the familial occurrence supports a genetic predisposition to this lesion. the most important differential diagnosis consideration is desmoid fibromatosis. objective: soft part sarcoma (sps) represents a difficult working area, either for the pathologist and the oncologist. prognostic factors are limited in these tumors, and the search for clinically relevant molecular markers is relatively incipient. we have proposed the present study based on previous results by our group on differential gene expression of soft tissue tumors, which showed significant overexpression of the top a gene in sarcomas. as top a is coded by a gene sited in chromosome , we have also included her- -neu. survivine was also included as previous studies have shown a significant correlation with survival in sps. our aim was to evaluate immunohistochemical protein expression of the three genes and also assess the gene copy numbers of top a and her- -neu by fish analysis in sps in order to verify the existence of prognostic value on these parameters. method: paraffin-embedded tissues from patients with sps were included in the study. results: analysis of multiple parameters showed that combined immunohistochemical expression of top a and survivine were significantly associated with overall survival among sarcomas. this association was also valid when only high-grade sarcomas were analysed. there was no correlation between gene amplification and protein expression of top a, or with her- -neu. objective: the inflammatory amelioration of affected joints was characterized by aa-pas and herovici methods in a k/bxn mouse model of spontaneous chronic arthritis that shares many similarities with rheumatoid arthritis (ra) and was used to study the potential of cd + t cell depletion with monoclonal antibodies (mab) to stop and reverse experimental arthritis progression. method: five groups of mice (including control) were treated with specific anti-cd mab (yts and yts . ) with and without thymectomy. cd + t cells from the blood and articular infiltrate of k/bxn mice were characterized for cell surface phenotypic markers and for cytokine production. affected joints were submitted to routine decalcification and paraffin inclusion. results: mice receiving anti-cd mab improved the arthritis score days after treatment. recovery of the cd + t cells was associated with a new increase of the arthritis score after days. thymectomized and anticd mab-treated mice improved arthritis score permanently. anti-cd mab-treated animals normalized the serological levels of tnf-a, ifn-, il- and il- , and histological analysis showed an absence of inflammatory infiltrate. conclusion: to the best of our knowledge, it was shown for the first time that k/bxn mice activated and effector memory cd + t cells are present in the peripheral blood and joints and that they play an important role in arthritis maintenance since treatment with specific anti-cd mabs significantly improved disease signs, supported by histological observations. these results document that cd + t cells should be regarded as major players in the k/bxn model of experimental arthritis alongside cd + t cells and b cells. method: a -year-old woman presented with postmenopausal bleeding. the diagnosis was mixed mullerian tumoral proliferation in the probe cüretage material. later on, total abdominal hysterectomy and bilateral salpingo-oopherectomy was performed. macroscopically, the specimen had a . × × -cm polypoid mass in the uterine cavity. microscopically, there was a tumoral proliferation of swollen epithelioid cells that formed sex cord-like tubular formations and showed trabecular and insular patterns. one-layered columnar cells laid the endometrial glands peripherally of this proliferation. the neoplastic cells had mild hyperchromatism and pleomorphism and mitosis. there was no necrosis. ki- proliferation index was - %; the neoplastic cells were positive for vimentin, estrogen receptor, progesterone receptor, smooth muscle actin and bcl- , but negative for pancytokeratin, cd , hmb- and alpha-inhibin immunohistochemically. results: by the help of these findings, we reported the case as 'pecoma-like epithelioid-type endometrial stromal sarcoma', though hmb- was negative, but the morphological findings were similar. conclusion: we present the case here because of its rareness and to discuss it with the description of additional cases; more insight into their behavior and predictive morphological parameters may be achieved. intestinal-type adenocarcinoma in a background of mature cystic teratoma of the ovary: case report e. kimiloglu sahan*, s. tettkurt, n. erdogan, y. t. ayanglu, u. kafrinoglu *taksim training hospital, dept. of pathology, istanbul, turkey objective: mature cystic teratoma of the ovary, frequently called a dermoid cyst, is the most common of all ovarian neoplasms and represents the majority of benign ovarian neoplasms in women < years of age. malignant transformation of mature cystic teratoma of the ovary occurs in approximately % of all cases. patients found to have malignant transformation in a mature cystic teratoma are likely to be postmenopausal. adenocarcinoma has been reported to occur in . % of cases of mature cystic teratoma. method: the operation of total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed on a postmenopausal woman of years. in the macroscopical sections of the ovary, there were multiple cysts which had . cm of greatest diameter. there were sebum-like material and hair in some of these cysts. microscopically, there was a malignant proliferation of epithelial type that formed tubular, cribriform and polyadenoid formations. the cells of this proliferation were large and pleomorphic and had a high mitotic index. there was necrosis widely. columnar epithelium was lying in the cystic spaces. there were lipid-laden macrophages and histiocytic multinuclear cells, lymphoplasmositer inflamatuar cell infiltration around them. there were hair follicles focally. immunohistochemically, tumor cells were positive for cytokeratin and cdx- diffusely and negative for cytokeratin . results: the diagnosis was intestinal-type adenocarcinoma in a background of cystic teratoma. endoscopically and colonoscopically, there was no tumor in intestines. conclusion: although gastrointestinal epithelium is found in mature cystic teratoma, intestinal adenocarcinoma is uncommon in the ovary. because of its rareness, we present the case here. objective: cervical carcinoma metastasises mainly via the lymphatics. attempts to correlate the expression of various lymphatic markers with lymph node metastasis have provided contradictory results. we investigated the expression of lymphangiogenesis-associated molecules in human cervical squamous cell carcinoma (scc). method: the expression of vegf-d, prox- and d - were evaluated by immunohistochemistry in paraffinembedded tissue samples from cases of invasive cervical scc. correlations with tumour grade, figo stage, lymph node metastases, lymphatic emboli and inflammation were also examined. results: cytoplasmic and/or nuclear vegf-d expression in the tumor cells was found in of ( %) cases and correlated significantly with ln metastasis (p= . ), lymphatic emboli (p= . ) and figo stage (p= . ). d - and prox- were expressed in the lymphatic endothelium, while in of (%) cases, nuclear staining for prox- in the tumor cells was also observed. there was a significant correlation between d - peritumoral lymph vessel density (lvd) and the presence of lymphatic emboli (p= . ) as well as between both intratumoral and peritumoral prox- lvd and the degree of inflammation (p< . ). a significant correlation of vegf-d expression with peritumoral d - and prox- lvd (r= . , p= . and r = . , p = . , respectively) was also noticed. our results indicate that vegf-d seems to be implicated in lymphangiogenesis and in the progres-sion of cervical scc, and d - may be a useful diagnostic tool in the assessment of lymphatic emboli. inflammation also probably plays a critical role in promoting lymphangiogenesis. objective: the protein p (ink a) is overexpressed in cervical lesions associated with high-risk human papillomavirus (hpv) subtypes and , but not in low-risk hpv subtypes and or non-hpv-associated cervical lesions. distinction between low-and high-grade cervical lesions is very important for the management of patients with cervical intraepithelial neoplasia. in this study, we wanted to determine the usefulness of p (ink a) expression in biopsy specimens with indistinct initial histologic diagnosis (cin - ) . method: we applied immunostaining for p (ink a) in consecutive cervical biopsy specimens with equivocal initial histologic diagnosis (cin - ) during the period between january , and december , . results: diffuse positive expression in the lower third of epithelium was found in % ( / ) of cervical biopsies; in % ( / ), the positive expression extended to two thirds of the epithelium, suggesting the diagnosis of cin . fifteen biopsy specimens ( %) were negative or only focally positive for p (ink a), indicating the diagnosis of immature squamous metaplasia. conclusion: the data support the routine use of p (ink a) immunohistochemical evaluation of cervical biopsy specimens for better discrimination of negative, low-grade and high-grade cervical lesions. cervical adenocarcinomas concomitant with cin or squamous cell carcinoma lack gastric phenotype y. wani*, k. notohara *kurashiki central hospital, dept. of pathology, japan objective: uterine cervical adenocarcinoma with gastric phenotype was recently proposed and shows an aggressive clinical course. the aim of the study was to examine whether the gastric phenotype is present in cervical adenocarcinoma in situ (ais) or invasive adenocarcinoma (ac) concomitant with cervical intraepithelial neoplasia (cin) or invasive squamous cell carcinoma (sc). method: fifteen cases of cervical glandular neoplasms concomitant with cin or sc were retrieved from kch files and subclassified by ais+cin (n= ), ac+cin - (n= ), ac+cin (n= ), ac+sc (n= ). of those, ac and sc were independently present and the so-called adenosquamous carcinoma was excluded. in addition, no cases of minimal deviation adenocarcinoma were observed. we evaluated the presence of gastric morphology based on the criteria previously described by kojima et al. (ajsp ) . in immunohistochemistry, the staining of muc and hik was performed and scored as negative; < %, focal; % to < %, diffuse; % or more. ( ) cd expression is increasing in hyperplastic processes and ec, but there are no differences of cd in atypical hyperplasia and endometrial carcinoma. ( ) pten protein expression in eh and ec was variable, but with tendency towards its diminution in cystic glands, atypical hyperplasia and ec. the association between neoplasia of the endometrium and others benign genital lesions: independent or similar mechanism? m. sajin* objective: schwannoma of the uterus is a benign but very rare neoplasia. we report a case of uterine schwannoma occurring in a -year-old woman with a recent history of abnormal uterine bleeding. method: the curettage material was routinely processed and stained with h&e. in addition, immunohistochemistry was performed with antibodies against s -protein, sma, cd , caldesmon, melan a, hmb , cd and mib- . results: in histological investigation, very few preexisting non-neoplastic glands and a tumor with dense fibrillary matrix was seen. the nuclei were oval to bipolar and cells showed no borders. few psammoma bodies were seen in the tumor, also incipient verocay bodies. the tumor cells were intensely positive for s- protein; no reaction with all other antibodies was seen. less than % of tumor cells were positive for mib- . the histopathology and the immunohistochemistry in this case revealed an exceedingly rare example of a uterine (subendometrial) schwannoma. expression of pten, ß-catenin and estrogen receptor in endometrial hyperplasia: an immunohistochemical study s. wojtylak*, b. pieczynska, k. klonowska, a. zawrocki, w. biernat *medical university of gdansk, dept. of pathology, poland objective: type i endometrial carcinomas with endometrioid and mucinous morphology develop in the patients with chronic hyperestrogenism. these tumors show frequent pten ( - % of cases) and β-catenin mutations ( - % of cases). method: the study group consisted of cases of endometrial hyperplasia (eh) and cases of endometrial atypical hyperplasia (eah). as a control group, cases of anovulatory cycle endometria (ace) were selected. the immunohistochemical analysis was performed on the endometrial curettings by means of tissue microarray. for the objective evaluation of analysed proteins, expression h scores (percentage of positive cells) have been used. conclusion: expression of analysed proteins significantly distinguishes endometrial hyperplasia from disordered endometrial proliferation. the most extreme level of abnormal expression of the studied proteins was seen in atypical hyperplasia, confirming its close relationship to endometrial carcinoma. analysis of pten and β-catenin expression may be a useful adjunct in small endometrial biopsies from patients with suspected precursor states for endometrial carcinoma. objective: cotyledonoid-dissecting leiomyoma of the uterus (cdlu, also known as sternberg tumor) is an extremely rare variant of smooth muscle neoplasm. less than cases of cdlu have been reported so far. cdlu is characterized by alarming distinctive gross appearance suggestive of a malignant neoplasm, but paradoxically universally benign clinical behavior. although the histopathological picture of cdlu was well described, there are few if any data which may explain extrauterine overgrowth of the tumor. method: four previously not described cases of cdlu were submitted to histopathologic examination and selected immunohistochemical assays (p , ki , bcl- , wt- , p ). results of immunohistochemical stainings were compared to those previously reported in benign and malignant uterine smooth muscle neoplasms. results: the age of patients with cdlu ranged from to years (median years). grossly, all the tumors were exophytic and composed of irregular nodular protrusions. median diameter of tumors was cm (range - cm). microscopically, the cases were composed of smooth muscle fascicles dissecting the extratumoral myometrium and forming swirled nodules, similarly to previous cdlu reports. nuclear p expression was seen in < % of tumor cells. ki- proliferative index in all cdlu cases was below %. bcl- was expressed focally in a single case and diffusely in three other cases. wt- diffuse nuclear expression was seen in all cases. all cases were p -negative. conclusion: p /ki- /bcl -/wt- /p immunohistochemical expression patterns in cdlu resembled those previously reported in uterine usual type leiomyomas and did not explain the distinctive gross appearance of these tumors. objective: epithelial ovarian carcinoma (eoc) is subdivided into five histological subtypes: serous, mucinous, endometrioid, clear cell, and transitional. the differential diagnosis between these subtypes is mostly unproblematic, but is getting difficult in poorly differentiated tumors. the aim of the present study was to establish an immunohistochemical marker panel in a series of unequivocal highly differentiated eocs that simplify the differentiation in difficult eocs. method: we performed an immunostaining study in a small series of highly differentiated eocs ( cases). after examining the cases with markers, we identified antibodies as useful markers (ca - , cd , ca cd , cd v , cd h, claudin , egfr, fak, opn, p , p , and pr). the percentage of the antibody-marked tumor cells per tumor was observed counted. the f test was used to determine differences between the means of percent expressions of the antibodies. for predicting the histological subtype from the antibodies data, a multinominal logistic regression model was performed. we additionally accomplished a leave-one-out method cross-validation experiment to mimic real-life situation of predicting an unknown histological type. results: in % of the cases, the initial multinomial regression model (using all observations) was able to predict the correct subtype. however, this number reduced to % in the leave-one-out experiment. conclusion: the match of % correct predictions in the full data set is in agreement with another publication ( %) using a similar panel. however, the low number of correct predictions in the leave-one-out experiment affirms that this is no valid panel to distinguish the histological types of eocs by immunohistochemistry. objective: teratomas usually manifest as masses in descended or undescended testes, in extratesticular tissues where germ cells tumors occur and in ovary in females. teratomas are germ cell tumors composed of an array of tissues derived from two or three embryonic layers in any combination. method: our report presents two cases of immature teratomas. the first patient is a -year-old man admitted in surgical department of county hospital of constanta for increased size in the left testicle in last months, and the second case is a -year-old girl hospitalized in the same department for retroperitoneal tumoral mass. ct scan shows in both cases testicular and ovarian mass with nonhomogeneous structure, surrounded by liquidian areas. results: histological exam revealed in both situations immature teratoma with mesenchymal, epithelial adenocarcinoma and neuroepithelial features and mature zones with condroid tissues. there are no specific immunohistochemical markers for teratoma, but individual antibodies can be used to identify particular tissues. in both cases, chromogranin, synaptophysin and afp were positive. there was no correlation found for the rest of ihc markers used for these cases, markers that were positive or negative (plap, beta-hcg, cd , s ). prognosis was favorable after surgery on the young man, but the young woman was given chemotherapeutical support. conclusion: immature teratomas are rare germ cell tumors. the incidence in children is % to % of ovarian and testicular tumors. in both cases, the ihc confirms immature teratoma diagnosis. immature intestinal type of glands were positive for afp, and neuroepithelial structures were positive for chromogranin and synaptophysin that sustain immature teratoma. objective: vascular tumors of the ovary are rare, with only lymphangiomas published in the literature so far. they are usually asymptomatic and represent an incidental finding. histologically, most lymphangiomas are of cavernous type and do not exceed - cm in diameter. we report two unusually large lymphangiomas measuring and cm in diameter, respectively, both of them presenting with ultrasonographical images of malignancy due to the large size and multicystic appearance. method: patients were and years old, respectively, the latter with a clinical history of pregnancies and associated leiomyoma and endometrial polyp. the former was operated for a large pelvic cystic mass which was on microscopic examination diagnosed as a borderline serous tumor of the left ovary. results: macroscopically, they were poorly defined multicystic tumors that on cut section were dramatically reduced in size (deflated), oozing a clear, thin fluid. microscopically, there was an anastomosing network of empty-appearing cystic spaces that were lined by flattened cuboidal cells without atypia. immunohistochemically, their vascular nature was demonstrated as the cells lining the cystic network were positive for cd , cd and d - (podoplanin) and negative for epithelial markers. conclusion: lymphangiomas are benign masses and their histogenesis is uncertain. they may represent a reactive process occurring after impaired or blocked regional lymphatic drainage related to conditions such as chronic follicular salpingitis, radiation therapy or various neoplastic processes. one of our cases lacked any association and the other one was associated with a surface, noninvasive tumour. we thus conclude that our cases are likely to be true neoplasms. placental mesenchymal dysplasia (pmd) with mosaic triploidy and chorangiomas presenting as a partial hydatidiform mole (phm) j. stanek*, m. khalequzzaman *cincinnati children's hospital, dept. of pathology, usa objective: phm may show radiologic, gross, and histological features overlapping with pmd. pmd with aneuplodies has been reported, but not with a mosaic triploidy. method: a , -g male fetus without hemihypertrophy or congenital malformations was born at weeks gestation. the -g dysmature and focally hydropic placenta showed varicose dilatation of focally thrombosed chorionic vessels, and two translucent thin-walled septal cysts grossly suggestive of phm. the stem villi showed myxoid stromal change. there was no trophoblastic hyperplasia or pseu-doinclusions. the chorionic and stem vessels were dysplastic. two . -and . -cm glut- positive capillary chorangiomas were found. results: ,xxy/ ,xy karyotype was revealed by fish. amplification of three microsatellite loci on chromosome p . showed that the predominant cell line was ,xy. there was no evidence of paternal isodisomy of beckwith-wiedemann syndrome. conclusion: this unique pmd case with mosaic diandric triploidy and chorangiomas was grossly suspicious for phm because of the presence of thin-walled translucent "hydatid" vesicles admixed with placental tissue. however, a large for gestational age and dysmature fetus without anomalies and characteristic gross and microscopic placental findings were diagnostic of pmd. the distinction between phm and pmd is clinically valid as phm can be complicated by persistent gestational trophoblastic disease or trophoblastic tumors. the presence of diandric triploidy is not automatically equivalent to phm. objective: the biological role of phosphorylation of the p protein in tumour cells is still investigated. the study evaluated p protein overexpression, p phosphorylated at serine (ser ), serine (ser ), and expression of bax, cas proteins in ovarian neoplasms and their association with clinicopathological parameters. method: the expression of analyzed proteins was examined on malignant and benign ovarian neoplasms using immunohistochemistry. results: differences between the expression of studied proteins in benign and malignant ovarian neoplasms were significant (p< . ). p -ser phosphorylation was associated with advanced stage (p= . ). p protein overexpression was associated with poor differentiated tumour (p= . ), while the differences between cas expression were observed in moderate and poor tumour grade (p= . ). the correlations between bax/p -ser , cas/p -ser and p -ser expression were found in ovarian carcinomas (p< . ). p /cas-positive cancers were associated with poor differentiated (p= . ) and advanced tumours (p= . ). p /bax-positive cases were found in poorly differentiated cancers (p= . ). these immunophenotypes revealed phosphorylation of p at ser and in . % of cases. conclusion: our results suggest that the expression of p protein phosphorylated at ser might depend on the morphological maturity of tumour cells. the revealed associations between bax, cas and p protein phosphorylated at serine and expression indicate that phosphorylation of p protein at ser and might play a role in the regulation of apoptosis-related protein expression in ovarian carcinomas. experimental model of female hormonal sterility received by influence on a bitch rat of long constant illumination s. abuzaid*, i. kuzmina, g. gubina-vakulik, n. kolousova *national medical university, kharkov, ukraine objective: female hormonal sterility is successfully treated. the experimental model of this morbid condition of ovaries is necessary for the approbation of various methods of treatment of female hormonal sterility. in this connection, we have estimated histologically the structural changes of ovaries of a rat after the long maintenance in the conditions of constant illumination. method: two groups of females vistar rats at the age of months are generated: control group (Сgr), six individuals, and basic group (Вgr), six individuals. rats of Вgr within months were contained in the conditions of constant illumination and rat Сgr in other premise, in conditions of usual change of day and night. ovaries are studied histologically. results: the ovary of rats Вgr has reduced dimensions. absence of normal follicles of any degree of maturing and yellow bodies, presence of cystically variated follicles, a considerable quantity of atretic follicles, and presence of white bodies are microscopically observed. it is possible to assume that constant illumination of animals causes stimulation of the production of serotonin and inhibition of the production of a melatonin by a cone-shaped gland. in the beginning, there is a stimulation of a hypothalamus-hypophysial-ovarian axis and then exhaustion of compensatory mechanisms and development of hormonal sterility. objective: the expression of p protein is associated with a high risk of hpv infection. the purpose of this study was to evaluate if overexpression of p ink a protein can be a useful biomarker to detect dysplastic cells in cervical smears of women with normal colposcopic findings but hgsil cytology. method: cases were retrospectively searched in cytology data of the past years. one hundred thirty-nine cervical smears from patients with hgsil were reviewed by two cytologists. the colposcopic results concerning those cases were also obtained from the records. forty-three of ( . %) women had no pathologic colposcopic findings. immunocytochemistry for p was performed on all cases with normal colposcopy and hgsil cytology. the immunocytochemical staining results were estimated and classified into four grades: , ( - % positive cells), ( - % and patchy), (> % and diffuse). results: the p protein expression was not observed in two cases ( . %), whereas it was strong and diffuse in nine patients ( . %). strong and patsy p expression was detected in patients with hgsil cytology and normal colposcopy ( . %). rare positive cells ( - % cells with nucleus stained with anti-p antibody) were present in cervical smears ( . %). conclusion: colposcopy with guided biopsy detects approximately two thirds of cin cases (gage et al., national cancer institute, usa, ) . increased expression of p ink a reflects the increasing expression of viral oncogenes in dysplastic cervical cells. p ink a is a specific biomarker to identify hgsils, so it could be a useful adjunct for the reevaluation women with hgsil cytology and normal colposcopy in order to correct the underdiagnosed hgsils and prevent delay in therapeutic managements. objective: prior to the introduction of computer-assisted screening in the netherlands, it was agreed upon to first validate this method with an a priori agreed upon uniform protocol for validation. aim was a kappa value of . or higher. method: a validation sample set was made of anonymized routine screen samples, enriched for abnormalities (to %). two screeners from one laboratory scored these with either computer-assisted screening or conventional thin-layer cytology. slides were scored dichotomously independently for either mode of screening as either within normal limits or outside normal limits. the procedure was supervised by an external quality pathologist. after a pilot (n= ), the 'set' was transported to other laboratories for the application of a similar protocol. all scores were computed from six different laboratories (n= , ). results: this nationwide validation study required on average weeks in the participating laboratories. first two kappa scores were . ( % ci . - . ) and . ( % ci . - . ) for the two techniques. after months, four additional laboratories had accomplished the validation procedure. cumulative kappa score for six laboratories was . ( % ci . - . , n= , ) all average scores were above the preset norm of . . conclusion: a nationwide validation protocol could be accomplished without complications. the results showed good agreement between computer-assisted screening and conventional screening on thin-layer technique. the validation protocol allows for the implementation of computerassisted screening in programme-based screening in the netherlands since detection rates will not alter in a significant manner. diagnosis of malignant mesothelioma by fine needle aspiration cytology m. almeida*, p. campos *hospital santa maria, patologia morfologica, lisbon, portugal objective: cytopathologic descriptions of mesotheliomas are limited. this study shows the results of fine needle aspiration (fna) cytology in ten cases of malignant mesothelioma. method: material was obtained by ct-guided fine needle aspiration (fna). smears were stained with giemsa and papanicolaou stain, and cell block sections, when done, were stained with hematoxylin and eosin. immunocytochemical (icc) studies were done in smears/cell block using adenocarcinoma markers (cea, ema, cd , ck and ttf ) and mesothelial markers (calretinin, wt , ck / ). results: all mesotheliomas except three of peritoneal origin were from the pleura. there were nine epithelial malignant mesotheliomas (emm) and one sarcomatous mesothelioma (smm). all mesotheliomas except three of peritoneal origin were from the pleura. there were nine epithelial malignant mesotheliomas (emm) and one sarcomatous mesothelioma (smm). in fna, all emms were highly cellular, with a large number of small sheets, and tridimensional clusters with smooth or lobulated contours as well as single cells. the cells were round to polygonal with abundant cytoplasm and well-defined cell borders and the nuclei were predominantly centrally located, round to oval, medium to large with fine chromatin and small but prominent nucleoli; occasional binucleation was noted. the smm showed malignant spindle-shaped cells with scant, ill-defined cytoplasm singly and in loose clusters, in a bloody background. immunocytochemical staining on the smears/cell block were positive for calretinin, ck / ,ck and wt and negative for cd ,cea and ttf . conclusion: cytologic findings coupled with immunocytochemical studies and in combination with radiologic information and clinical history are highly accurate in the diagnosis of malignant mesothelioma. solid pseudopapillary tumor of the pancreas diagnosed on endoscopic ultrasound-guided fine needle aspiration material a. demir*, r. sadik, p. saksena *sahlgrenska university hospital, dept. of clin. pathology and cytology, gothenburg, sweden objective: solid pseudopapillary tumor (sppt) of the pancreas is a rare, low-grade, epithelial neoplasm that is usually discovered incidentally in young women. method: we present a -year-old woman with × -cm round tumor in the caput pancreatis. endoscopic ultrasound-guided fine needle aspiration (eus-guided fna) was performed. smears were stained with giemsa and mc manus. cell block was used for eosin, mc manus and immunohistochemical stainings. results: cell-rich smears showed single cells and aggregates of uniform cells forming branching papillary clusters with delicate myxoid fibrovascular cores. the nuclei of the cells were round or oval; nucleoli were small or inconspicuous. cytoplasms were usually vacuolated. intra-and extracytoplasmic myxoid globules were noticed. tumor cells showed diffuse positivity for cd , progesterone receptor and cd and focal positivity for synaptophysin and ae /ae . chromogranin a, ck / , ck , tag were negative. ki showed low (< %) positivity. the case was diagnosed as sppt based on morphological and immunohistochemical features, which was confirmed on the surgical material. conclusion: distinguishing sppt from other pancreatic tumors, especially pancreatic endocrine tumors, can be challenging. clinical setting, cytomorphologic features, and immunostains of the cell block help distinguish sppt from pancreatic endocrine tumors, acinar cell carcinoma, and papillary mucinous carcinoma. the objective: most countries, including greece, have adopted the triple assessment approach to breast diagnosis, with fnac as the first-line pathological investigation with the exception of microcalcifications. the majority of european countries use similar reporting systems for breast fnac (c -c ), in keeping with the european guidelines for quality assurance in breast cancer screening and diagnosis. method: in order to explore current practice in our hospital, we reviewed breast fnas within a -year period, collected and interpreted by both the cytopathologists and less by the surgeons, where no clinical data were available. results: there were a total of cancers ( %), of which were diagnosed by fna ( as c and as c ). overall, were diagnosed as c ( . %), as c ( . %), as c ( . %) and as c ( . %). of the c , were confirmed histologically (mastectomy specimens), whereas in patients, there was no feedback information. there was one false positive case concerning two separate fibroadenomas, one of which in the mammary tail, sent to the lab as axillary lymph node. in the c category, there were carcinomas, two fibroadenomas, one fibrocystic disease, and had no confirmatory biopsy. in the c category, there were six carcinomas (four ductal, one lobular, one metaplastic), two columnar cell change and one fat necrosis. our results confirm the accuracy of fna in the diagnosis of malignancy and show the major importance of a multidisciplinary approach and knowledge of the clinical and radiologic data by the interpreters of the fnas. benign renal tumors mimicking malignancy in fine needle aspiration biopsy samples: report of three cases h. gutnik*, m. strojan fležar, z. ovcak, j. pižem *medical faculty ljubljana, institute of pathology, slovenia objective: fine needle aspiration biopsy (fnab) is a wellestablished method to diagnose renal tumors. however, it is challenging to diagnose rare benign renal tumors with unusual cytomorphology mimicking malignant tumors. we report three such cases. method: all three kidney tumors were discovered by ultrasound examination, and ultrasound-guided fnab was performed. the first case was a multicystic renal tumor in the right kidney of a -year-old woman. the second case was an atypical cyst in the left kidney of a -year-old man. the third case was a solid tumor in the left kidney of a -year-old woman. results: case : papillary-like structures and macrophages, supplemented by immunocytochemistry, rendered a diagnosis of renal carcinoma, papillary type, while disregarding stromal fragments. histological diagnosis was a mixed epithelial and stromal tumor (mest). case : similar morphology led to the same cytological diagnosis as in the first case with subsequent histological diagnosis of a cystic nephroma. case : small groups of severely atypical cells were suspicious of a malignant tumor, possibly a metastatic one. the histological diagnosis was juxtaglomerular tumor, confirmed immunohistochemically and by electron microscopic examination only after additional clinical data about unexplained arterial hypertension from the age of were obtained. conclusion: cytologic samples of cystic renal tumors should be evaluated cautiously, including the possibility of mest/cystic nephroma group of tumours. the case of juxtaglomerular tumour shows the utmost importance of reporting the relevant clinical data to the pathologist. objective: in some meningiomas, primarily with a large vascular supply, preoperative embolization is performed a few days before surgery in order to soften the tumor and minimize intraoperative bleeding. post-embolization histological changes consist mainly of necrosis, ischemic cellular changes, vascular fibrinoid necrosis and increased proliferative index. these changes may result in overgrading. we have found no description of such changes in the cytological literature. method: we reviewed cases of meningiomas with prior embolization. in of them, relevant cytological changes induced by embolization were present. cytological material was obtained during intraoperative consultation, either by scrapping or squashing of tissue samples. on histology, all of them were grade i meningiomas and showed intravascular embolic material. results: cytology revealed relevant cellular dissociation with frequent single cells. ischemic cellular changes were a common finding and consisted of cell shrinkage, nuclear piknosis and ill-defined cytoplasmic limits. ischemic changes were better appreciated in single cells. eight cases showed histiocytes and neutrophils. confluent areas of necrosis were seen in one case. none of the cases showed cellular atypia or significant mitotic activity. embolic material was seen cytologically in four cases. of the embolized meningiomas, nine of them showed no significant cytological abnormalities. conclusion: embolization of meningiomas induces cytolomorphological changes that may be relevant in some cases. greater cellular dissociation and ischemic changes, as well as inflammation, may result in a worrisome cytological image. when faced with such changes, the pathologist should always consider the possibility of embolization, avoiding overgrading or misdiagnosis. the statistical comparison of different parameters was made using mann-whitney u test and spearman rank order correlation, with the aim of establishing statistically relevant differences and spearman correlation coefficients (r) between glucose in blood and periodontal disease, ageand sex-related, the length of the diabetes disease, the cytological periodontal stage and the length of the periodontal disease, age-related. results: the statistical calculation has revealed important differences of the blood glucose between the cytological periodontal stages and (p< . ), and (p< . ), and and (p> . ). in a similar way, there were also differences between stages and (p< . ), and (p> . ), and and (p< . ). conclusion: the neutrophils that have been drawn by the presence of bacteria or by the erosion areas of the oral and gastric mucosa can promote an increased gravity of the epithelial lesions, suggesting a particularity of the microbial infection at the diabetic patient who has hyperglucidic stress with the modification of the cellular and humoral immunity in the background. objective: treatment of malignant peritoneal effusions is generally palliative; therefore, quality of life issues, as well as the risks and benefits of the therapeutic options, become more critical. cytomorphologic examination alone provides only limited sensitivity for the detection of metastatic carcinoma cells in many cases of serous effusions. early diagnosis and management of peritoneal metastases from cancer patients represent new directions of researches. method: the current study was aimed at differentiating peritoneal liquids encountered in available cases, chosen to show both biochemical patterns (benign and malignant) and in this way to achieve a diagnostic value of the biochemical method. a panel of biochemical markers (tp, alb, ldh, tc, gl, tl, tg, aa, alp, u, tb, db, ast, alt, mg, fe, k) were determined from the resulted supernatant after centrifugation in blood and peritoneal fluid using automatic and semi-automatic biochemistry analyzer. results: thus, of all measured parameters, the highest accuracy in the differential diagnosis between malignant and the benign cases (cirrhosis) was obtained by measuring peritoneal effusions tc ( %), peritoneal fluid ldh ( . %) and saag ( %). conclusion: it is concluded that a suitably chosen panel, consisting of the best specific markers found, can be of great value for the initial differentiation and subsequent guidance in the diagnosis. abbreviations: tp total proteins, alb albumin, ldh lactate dehydrogenase, tc total cholesterol, gl glucose, tl total lipids, tg trglycerides, aa alpha amylase, alp alkaline phosphatase, u urea, tb total bilirubin, db direct bilirubin, ast aspartate aminotransferase, alt alanine aminotransferase, mg magnesium, fe iron, k potassium, pe/s effusions/serum ratio, saag serum-ascitic albumin gradient, sag serumeffusion gradient. objective: hyalinizing trabecular tumor (htt) is an unusual type of thyroid follicular neoplasm that may represent a major diagnostic problem in routine thyroid practice. method: we present the case of a -year-old woman in which a fine needle aspiration (fna) was performed for a . -cm unique nodule, incidentally discovered in the left thyroid lobe. a hemi-thyroidectomy was performed as the aspiration specimen was reported suspicious for papillary thyroid carcinoma (ptc). macroscopically, the nodule was light tan and well circumscribed. in microscopy, it had prominent trabecular architecture and cytological features strongly suggesting a ptc: nuclear enlargement with particularly abundant nuclear grooves and cytoplasmic invaginations. an intratrabecular abundant, homogenous and eosinophilic hyaline material was also noticed. immunohistochemistry, including anti-thyroglobulin, anti-ttf , anti-hbem , anti-ck and anti-mib antibodies, was performed. results: the tumor cells were strongly positive for thyroglobulin and ttf and were negative for hbem , ck- and chromogranin. a characteristic membranous and peripheral cytoplasmic staining was noticed with mib antibody. conclusion: despite the cytological aspect, a diagnosis of htt was made based on the well-circumscribed character of the tumor and the negativity for hbem and ck- . moreover, the unique reactive pattern of mib was an important clue to the diagnosis. careful evaluation is needed in such cases in which cytological criteria are too obviously suggesting a ptc. the differential diagnosis is essential because unlike ptc, htt is considered a benign tumor and has a different behavior and therapeutic approach. objective: thyroid nodules are a common clinical problem and the fine needle aspiration (fna) has become a standard procedure for their clinical triage. its widespread use allows a better selection of patients in need of surgical treatment. method: four thousand three hundred fifty-nine fna were performed between and , always by the same pathologist using a -gauge needle and a cameco suction device. at least three aspirations were carried out, and three to five slides were obtained for each nodule. they were immediately fixed in alcohol and stained with hematoxylin-eosin or with papanicolaou. the cytological diagnosis was classified in four categories: inadequate, benign, suspicious and malignant. six hundred thirty-eight cases had a histological follow-up. the benefits of the cytologic diagnosis were estimated by statistical analysis (epiinfo software version . . ). results: the sensitivity of fna was . % and the specificity . %. there were . % false negative and . % false positive findings. the p value was < . , considered extremely significant. the main causes of diagnostic errors were sampling errors, similar cytological features for different entities, failure to recognize the follicular variant of papillary carcinoma, and coexistence of non-neoplastic and neoplastic processes in the same gland. conclusion: although the sensitivity and the sensibility does not attain %, fna proves to be the most reliable and cost-effective method for distinguishing benign from suspicious or malignant thyroid lesions. limitations of the method included false negative, non-diagnostic and indeterminate or "suspicious" results. nevertheless, the routine use of fna reduces the rate of unnecessary surgery for thyroid nodules. objective: medullary (mtc) and papillary thyroid carcinoma (ptc) have always been considered different from each other, in their cell origin, histopathological features and incidence. we describe one rare case with simultaneous multicentric ptc, classic or oncocytic type, in one lobe and "composite thyroid carcinoma" with mixed features of mtc and ptc in the other one. these tumors were associated with graves' disease. method: surgical specimens were routinely processed, paraffin-embedded, and he-, van gieson-and grimeliusstained. immunohistochemical study included antibodies anti-cytokeratin (ck ), chromogranina (cga), thyroglobulin (tg), calcitonin (ct), and hbme . results: in the right lobe, there were two, tan brown, nodular lesions measuring . and . cm, respectively, consisting of ptc oncocytic type with follicular and focal papillary pattern and a classic variant of ptc. in the lower pole of the left lobe, a grayish nodule of . cm, with trabecular, follicular and focal papillar architecture was detected, presenting small tumor cells, pleomorphic nuclei and occasional cytoplasmic pseudoinclusions. tumor cells showed intense positive expression for tg, ck and moderate reactivity for cga and ct. hbme was focally positive with membrane staining along lateral and abluminal surfaces. conclusion: our case report emphasizes the role of detailed histopathological analysis, especially when thyroid nodules harbor various aspects, and the use of immunohistochemistry in the identification of rare types of thyroidian neoplasm. this case might be explained by the possibility of activating a common tumorigenic pathway for both follicular and parafollicular thyroid cells or a common stem cell. thyroid metastasis of clear cell renal cell carcinoma: a series of three cases l. bejan* *emergency county hospital, dept. of pathology, târgu mures, romania objective: thyroid metastases are extremely rare, the kidney being the most frequent primary tumor site. method: we report three cases of thyroid metastasis of clear cell renal cell carcinoma (cc-rcc), one of them being the primary manifestation of a renal tumor and the other two with a previous -and -year, respectively, history of renal neoplasm. the first case, a -year-old man, was admitted to the hospital with an initial diagnosis of bilateral goiter, while for the other two, a -year-old man and an -year-old woman, the discovery was incidental. results: on gross examination, white grayish illcircumscribed solid nodules were described in the right lobe (one nodule, first case), in the left lobe (two nodules, second case) and in both lobes (multiple nodules, third case). all three cases presented similar microscopic tumoral aspects: a solid architecture, polygonal cells with abundant clear or eosinophilic cytoplasm, distinct cell borders and moderately enlarged nuclei with proeminent nucleoli. since the microscopic aspect did not correspond to any primary tumor of the thyroid, immunohistochemistry was performed. in all cases, the tumor cells stained positive for cd and negative for thyroglobulin, supporting the diagnosis of a thyroid metastasis of cc-rcc. conclusion: thyroid metastases of cc-rcc are uncommon and may represent the first sign of a yet undiagnosed asymptomatic renal tumor or a metastasis from a tumor surgically removed years before (up to years). in setting a correct diagnosis, immunohistochemical studies together with the medical history are extremely important. primary angiosarcoma of the thyroid gland. a case report k. bednarek-rajewska* *poznan, poland objective: primary angiosarcoma of the thyroid is a rare and controversial entity most commonly seen in patients from the alpine regions with a long-standing history of colloid goiter. purpose: we describe a case of primary, poorly differentiated angiosarcoma in a -year-old male who presented with a rapidly enlarging thyroid mass and mild dysphagia during the preceding month. method: a ct scan of the neck revealed a large tumor mass in the upper pole of the left lobe of the thyroid measuring . × . × cm extending into the surrounding adipose tissue and infiltrating the left internal jugular vein. lymphadenopathy was identified in the left submandibular region and lower neck. cytomorphologically, the aspirate was cellular, with variably cohesive clusters of atypical spindle cells and necrotic masses. thyreoidectomy procedure was performed. histologically, the tumor was composed of spindle, polygonal and epithelioid cells with vesicular nuclei and prominent nucleoli growing in solid sheets and occasionally forming cleft-like vascular spaces filled with erythrocytes. extensive necrosis was present. mitotic activity was mitoses/ hpf. immunohistochemical stains showed tumor positivity for cd , vimentin, factor viii, wt- , m-act and cd . conclusion: the prognosis in primary angiosarcoma of thyroid is generally poor especially if the tumor penetrates the capsule of the thyroid or if there are metastases present. the patient developed further metastases in the cervical lymph nodes within few weeks after thyroidectomy despite radio-and chemotherapy. due to the rapid progression of the disease, the patient was scheduled for palliative radiotherapy. the patient succumbed to the disease months after diagnosis. objective: pheochromocytoma can be defined as a paraganglioma of the adrenal medulla and has been called the " % tumor" because approximately % are bilateral, % are extra-adrenal, % occur in children, and % are malignant. aim: in this report, we described the histopathological aspects of pheochromocytoma in correlation with immunohistochemical reaction. method: the study group included cases of pheocromocytoma diagnosed by the chromaffin reaction, he and van gieson's reaction. immunohistochemistry included monoclonal antibodies: chromogranin a, neuron-specific enolase and s protein. results: the patients have encapsulated, usually soft, and, on section, yellowish-white to reddish-brown tumors. the larger tumors had areas of necrosis, hemorrhage and cyst formation. histopathologically, the tumor cells are characteristically arranged in well-defined nests (zellballen) bound by a delicate fibrovascular stroma, which may contain amyloid. the cells vary considerably in size and have a finely granular basophilic or amphiphilic cytoplasm. the nuclei, usually round or oval with prominent nucleoli, may contain inclusion-like structures. lipid accumulation may develop in the cytoplasm and lead to confusion with adrenal cortical tumors. giant, hyperchromatic nuclei are common and are not an expression of malignancy. chromogranin a and nse were positive. sustentacular cells form a peripheral coat around the "zellballen" and were strongly reactive for s protein. conclusion: all our cases were benign, although % of pheochromocytomas are malignant and have a marked tendency to metastasize to skeletal system, particularly the ribs and spine. the sustentacular cells are more numerous in pheochromocytomas associated with men than in sporadic cases. primary carcinoid tumor of gallbladder c. comingle*, Ü. sekmen, g. altaca, b. bilezikçi *baskent university, faculty of medicine, istanbul, turkey objective: primary carcinoid tumor of gallbladder is a rare neoplasm. they usually present as a polypoid lesion. method: we report an incidentally found carcinoid tumor of gallbladder located in the cystic duct occurring in a -year-old male patient detected in cholecystectomy material. results: histopathologically, in cystic duct, an incidental neoplasm measuring mms in maximum diameter was detected, which was grossly unremarkable. the tumor constituted glandular structures. it was not invading muscular layer. immunohistochemically tumor was positive for synaptophysin. patient is alive and well after months. conclusion: definite diagnosis of carcinoid tumor of gallbladder is usually made on histopathological examination after surgery. our case is unique in that it was found incidentally, which was grossly unremarkable. it seems so that surgery alone is a reliable definite management for these small carcinoid tumors. objective: accurate identification of kras mutations has great importance for target therapy. reproducibility and cheapness of different methods are crucial to be safely applied in colorectal routine diagnostic setting. method: one hundred twelve ffep specimens, previously studied by arms/scorpions real-time pcr (therascreen, roche, italy) designed as reference method, were in parallel analysed by other two methods: restriction fragment length polymorphism-pcr (ampli-set-k-ras, bird, italy) and pcr/reverse hybridization tests (k-ras stripassay, viennalab, austria), respectively, called methods a and b. the methods were compared considering the results, costs, and working times. regarding kras genotype, selected samples were: wild type (wt), mutated in codon , and in codon . results: six of wt samples showed mutation on codon : three were false positives of method a and three of method b. two of samples mutated in codon resulted also positive on codon by method b. since method a is based on cleavage action of the restriction enzyme, we have increased both restriction enzyme concentration and digestion time, abolishing the false positives. on the contrary, there was no way of acting on method b. conclusion: although method a does not define the codon mutation type and is time-consuming, it leads to the same results of the reference method operating our slight methodological modifications. method a resulted cheap ( % of the reference kit price), useful and reproducible for routinely kras testing in colorectal target therapy. work was supported by fondazione cassa di risparmio di puglia, italy. objective: colorectal carcinoma (crc) is a worldwide common malignancy; young patients represent a third of all cases, with a rise over the last years. fifteen percent of crc have microsatellite instability (msi) due to alterations in mismatch repair (mmr) genes. familiar msi cases ( %) have germline mutations. sporadic msi crc ( %) have hypermetilated mlh- promoter. braf v e mutation exclusively occurs in sporadic msi crc. immunohistochemistry detects msi cases with high concordance with microsatellite analysis. the objective was to compare histopathology and patterns of expression of mmr proteins and braf v e mutation in patients below and over years old and determine if age is a risk factor for defective mmr protein expression and braf mutations. method: one hundred six patients < years were retrieved. age, sex, location, histologic type, tnm, infiltration and metastatic lymph nodes data were collected. mlh and msh immunohistochemistry and braf rt-pcr mutation was performed in < years and patients > years as control group. student's t, χ and logistic regression analysis were carried out. results: medullary and mucinous types were more frequent among young patients and intestinal type in older patients (p= . ). no differences were noticed regarding clinicopathological stages between groups. mmrp expression was absent more frequently in < and msh was negative in . % of these patients. no braf mutations were detected in any group. conclusion: we found an association between young age and defective mmr expression (or . ). msh lack of expression is more frequently due to a germline mutation. the fact that none of our patients had braf mutation could be partly due to the small sample size or alternate v e or k-ras mutations. objective: angiogenesis plays an important role in the progression of colorectal cancer (crc). evidence from preclinical and clinical studies indicates that vascular endothelial growth factor (vegfa) is the predominant angiogenic factor in crc. vegfa is expressed in approximately % of crcs, with minimal to no expression in normal colonic mucosa. therefore, the aim of this study was to analyze the prognostic impact of vegfa amplification in crc. method: vegfa gene amplification was evaluated in a large series of sporadic crc resections (n= , ) by fish analysis using the tissue microarray technique. spectrum green-labeled probes originated from the fish clone rp - g were used together with spectrum orange-labeled probes for the respective centromere as a reference. the vegfa amplification status was compared to relevant clinicopathological features. results: vegfa amplification was detected in patients ( %) and was significantly associated with higher t stage and higher tumor grade, presence of vascular invasion, right-sided location (p < . ) and b-raf mutation (p= . ). additionally, vegf amplification was associated with worse survival in univariate (p < . ) and multivariable analysis (p< . ; hr ( % ci), . ( . - . )). conclusion: vegfa amplification seems to highlight a small subset of crcs with aggressive phenotype. therefore, fish analysis of vegfa could represent an alternative evaluation system for identifying patients with poorer clinical outcome who could be candidates for anti-vegfa therapies. objective: k-ras oncogene is frequently mutated in colorectal cancer and is currently established as a predictive biomarker for anti-egfr targeted therapy. b-raf is a serine/threonine kinase of the ras/raf/mek /erk signal transduction pathway which is mutated in a subset of k-ras wild-type patients with colorectal cancer. the aim of this study was to examine the mutational status of k-ras and b-raf genes in correlation with tumor clinicopathological characteristics. method: dna was extracted from microdissected formalin-fixed paraffin-embedded tissues. three hundred forty-four cases were screened for k-ras and b-raf mutations at codons and and exon respectively using high-resolution melting analysis, sequencing and/or pyrosequencing. statistical analysis was performed using stata for windows. results: k-ras mutations in codons and were present in out of cases. the most frequent types of mutation were pg d and pg v at codon and pg d at codon . b-raf mutations in exon (pv e) were present in . % of analyzed samples. b-raf mutations were observed in a marginally higher frequency in women, whereas k-ras mutations were positively correlated with patients' age. moreover, there was a higher prevalence of b-raf mutations in low-grade carcinomas (p= . ). conclusion: the detected mutation frequency as well as the prevalence of specific mutation types is in accordance with previous studies. the observed correlation of b-raf mutation with tumor grade implies its importance as a marker of tumor aggressiveness. the applied methods (hrm and pyrosequencing) were proven to be sensitive, fast and accurate for mutation detection in a clinical setting. objective: aberrant activation of the phosphatidylinositol- -kinase (pi kinase)-akt pathway is frequently observed in a wide range of cancers such as breast, colorectal, ovarian and lung. several components of this pathway such as pi k and akt can constitute potential therapeutic targets, and many small molecule inhibitors are in development on early clinical trials. the aim of this study was to examine the possible significance of somatic point mutations in pik ca and akt genes as biological markers or therapeutic targets in primary urothelial bladder carcinoma. method: one hundred twenty-two urinary bladder cancer specimens were screened for activating mutations in exons , of the pik ca gene as well as in exon of akt gene by pcr-sscp and high-resolution melting analysis. mutations were identified for pik ca gene with sequencing and for akt gene with pyrosequencing and statistical analysis was performed. results: four different mutations were detected in exon of pik ca gene ( . %). the mutations were identified as p.a t, p.a v, p.h r and p.g r. one out of cases was mutant in exon of pik ca gene ( . %, p.e k). the akt p.e k mutation was identified in out of bladder tumours ( . %). statistical analysis did not reveal any correlation with clinicopathological parameters (p> . ). conclusion: mutations in pik ca gene are quite frequently observed in bladder cancer, implying their importance as potential targets for anticancer treatment. on the other hand, mutations in akt gene are not a common event in this type of cancer. analysis of dna integrity, morphology, antigenicity with different preservation methods in brain tissue a. saetta*, g. agrogiannis, p. korkolopoulou, a. gavriil, n. kavantzas, e. patsouris, e. michalitsi, a. stamatelli, n. prekete, e. palliou *university of athens, st dept. of pathology, greece objective: due to the potential carcinogenicity of formaldehyde, its replacement by substitute fixatives is recommended and could increase the possibility for application of molecular biology approaches. the aim of this study was to examine dna preservation, morphology and antigenicity of brain tissues after fixation with a formalin-free fixative in comparison with formalin-fixed tissues as well as frozen ones. method: calibrated specimens from six different areas (frontal, parietal, occipital lobes, hippocampus, cerebellum and basal ganglia) of brains from elderly individuals (age > ) were fixed for h in two different fixatives (formalin, formalin-free fixative-rcl ) at room tempera-ture. tissues were stained with hematoxylin-eosin for histological examination and their antigenicity was determined by immunohistochemistry. the integrity of dna extracted from the samples with formalin fixation or formalin-free fixation was compared with that of cryosections with gel electrophoresis and the bioanalyzer. furthermore, pcr-pflps and real-time pcr (high-resolution melting analysis) were performed in order to assess the suitability of the extracted dna for downstream molecular pathological applications. results: immunohistochemistry with antibodies against bamyloid and tau did not reveal any significant differences in reactivity for both fixatives. on the other hand, dna extracted from frozen samples was of comparable integrity with that from formalin-free fixation. amplification efficiency for short dna fragments ( - bp) was similar between all preservation methods; however, long fragments ( bp) could not be amplified from formalin-fixed tissues. the formalin substitute fixative used in this study provided good histopathological quality, and also the extracted dna performed better at the subsequent molecular biological procedures. objective: the molecular mechanisms underlying the development of esophageal cancer remain elusive. the aim of this study was to examine the simultaneous presence of alterations in two main signal transduction pathways, ras/raf/mek/erk and pi k/akt, which are implicated in carcinogenesis. the prognostic significance of perk expression was also investigated. method: genomic dna was extracted from paraffinembedded tissue blocks ( squamous-cell, adenosquamous cell and adenocarcinomas). additionally, in cases, tumor cells were collected using laser microdissection in order to minimize contamination with stromal and normal cells. we searched for somatic mutations in kras, b-raf, egfr, akt- and pik ca genes by performing high-resolution analysis and pyrosequencing. the expression of activated erk protein was assessed by immunohistochemistry. results: k-ras mutation at codon was detected in one lasermicrodissected adenocarcinoma out of specimens ( %), whereas no mutations were found in exon of b-raf gene, in exons and of egfr gene, in exon of akt- gene and in exon of pik ca gene. perk nuclear expression was positively correlated with disease grade and stage and nuclear staining intensity with grade. furthermore, perk cytoplasmic immunopositivity was correlated with tumor grade. conclusion: mutations in k-ras gene are not frequently detected in esophageal cancer, but do exist. the lack of mutations in b-raf, egfr, akt- genes implies that these may not play an important role in the pathogenesis of esophageal cancer. the correlation of perk nuclear expression with stage and grade implicates perk as a marker of local tumor aggressiveness. objective: mutation analysis in ras/raf signaling pathway plays a key role in treatment decision in patients with metastatic colorectal cancer (mcrc). at this time, several methods are available for kras mutation detection; there are also commercially available kits, but validated methods and standardized testing procedures are still lacking. method: genomic dna was extracted from formalin-fixed paraffin-embedded (ffpe) tumor tissues after the evaluation of material by pathologists. for mutation analysis of kras gene, we used three methods: direct sequencing, allelic discrimination and high-resolution melting (hrm). results: we tested tumor samples (primary tumors and metastasis) from patients with mcrc. we identified kras mutation in of ( %) patients using allelic discrimination, while hrm detected mutations in of ( %) patients. due to low burden of tumor cells in two cases and limited sensitivity of sequencing, only patients were evaluated by this method. out of them, four ( %) patients showed positivity. we performed sensitivity testing: allelic discrimination ( % of mutant dna), hrm ( %) and sequencing ( %). conclusion: allelic discrimination is a convenient, fast and sensitive method designed for the detection of specific mutations. test costs are proportional to the number of tested mutations since a specific assay has to be used for each mutation. sequencing has a limited application due to low sensitivity, while hrm represents a sensitive, rapid and cost-limited methodology, but displays higher rate of false positive results if dna is in poor quality. this technique is suitable for routine screening; however, precise identification of mutations is not possible. therefore, a combination of at least two methods is highly recommended. objective: mgmt repairs dna damages and act as a tumor suppressor gene in normal cells, preventing dna mutation. several different approaches for mgmt immunohistochemical (ihc) testing have been used, resulting in a not universally accepted standard. we evaluated the ihc expression of mgmt using five different primary antibodies in invasive breast carcinomas in order to establish the most reliable marker for this protein. the results of immunostaining were compared to qrt-pcr, used as a parameter of reliability of gene expression. method: cases were randomly selected to build a tissue microarray. the five primary antibodies to mgmt were provided by: mt . (neomarkers, genetex and santa cruz), spm (santa cruz) and mt . (zymed). heatinduced antigen retrieval in citrate and the advance™ (dako) detection system were used. ihc was visually analyzed by microscope and automated analyzed by software applied to digital slides. qrt-pcr was performed in all tumors for transcript expression quantification. results: antibody spm (santa cruz) showed the highest sensitivity (p< . ), and antibody mt . (santa cruz) showed the least sensitivity (p< . ). antibody mt . (zymed) showed higher levels of cytoplasm staining, which was not observed in the other antibodies tested (p< . ). qrt-pcr results showed that . % of the samples showed hypoexpression of mgmt when compared to normal breast (p< . ). spm (santa cruz) was the only antibody which showed a positive and significant correlation with the results obtained by qrt-pcr (p= . ). conclusion: this antibody seems to be reliable and effective for research and clinical practice in breast cancer. (supported by fapesp and cnpq). objective: mgmt repairs dna damages and act as a tumor suppressor gene in normal cells, preventing dna mutation. several different methods for mgmt immunohistochemical (ihc) testing have been used, resulting in no universally accepted standard. we evaluated the ihc expression of mgmt of five different primary antibodies in invasive breast carcinomas. method: fifty-nine breast carcinomas were randomly selected for a tma construction. five different primary antibodies against mgmt were used for the ihc study: clone mt . (neomarkers, genetex and santa cruz), spm (santa cruz) and mt . (zymed). heat-induced antigen retrieval in citrate and advance™ ihc detection system were used. ihc was visually analyzed by microscope and automated analyzed by software applied to digital slides. qrt-pcr was performed in all tumors for transcript expression quantification. results: antibody spm (santa cruz) showed the highest sensitivity (p< . ), and antibody mt . (santa cruz) showed the least sensitivity (p< . ). antibody mt . (zymed) showed higher levels of cytoplasm staining, which was not observed in the other antibodies tested (p< . ). fifty-nine samples ( . %) showed hypoexpression of mgmt when compared to normal breast evaluated by qrt-pcr (p< . ). spm (santa cruz) was the only antibody which showed a positive and significant correlation with the results obtained from qrt-pcr (p= . ). conclusion: antibody spm (santa cruz) presented to be the most sensitive and specific antibody for the ihc evaluation of mgmt. this antibody seems to be of reliable and effective use for research and clinical practice in breast cancer. mgmt as a potential prognostic marker in breast cancer j. cirullo-neto*, k. carvalho, l. kagohara, e. olivieri, d. carraro, i. cunha, j. vassallo, f. soares, r. rocha *cancer hospital a c camargo, são paulo, brazil objective: mgmt repairs dna damages, via alkylation, by removing a methyl group from the o position of guanine. it acts as tumor suppressor gene in normal cells and prevents dna mutation. we evaluated mgmt expression in breast tumors, correlating it with other prognostic factors. method: sixty-four cases of invasive breast carcinomas were randomly selected for a tma construction. immunohistochemistry (ihc) was performed for mgmt and also for er, pr, her , ki , p , p , e-cadherin, ck and ck for luminal and basal phenotype classification. ihc was evaluated following the guidelines for each marker most recommended in the literature. fluorescent in situ hybridization (fish) was performed in those cases considered + in order to assess her gene amplification status. qrt-pcr was performed in frozen tissue from our tumor bank for all cases in order to evaluate mrna expression of mgmt. results: fourteen cases were triple-negative ( . %), and among those, seven cases were basal-like carcinomas ( . %). twenty-five cases ( %) were luminal-like type a, four cases were ( . %) luminal-like type b, and one case ( . %) was her -like type. mgmt showed significant lower expression in the basal-like tumors when compared to the luminal-like ones (p= . ). basal-like phenotype tumors presented higher positivity for p and ki than the luminal types (p= . and p= . , respectively). positive p and high ki tumors showed significant lower expression of mgmt (p= . and p= . , respectively). conclusion: mgmt assessment by ihc or molecular biology techniques may represent an important prognostic factor in breast cancer. objective: the col a gene codifies a protein expressed during cartilage and osteomorphogenesis which is present in the setting of several types of infiltrating malignant desmoplasia. our team generated a monoclonal antibody against procol a which was tested for infiltrating ductal pancreatic carcinoma versus chronic pancreatitis differential diagnosis and infiltrating ductal carcinoma of breast versus sclerosing adenosis differential diagnosis. method: to investigate its usefulness in order to assess the presence of invasion in bronchioloalveolar lung carcinomas (bac), we carried out immunostaining with the monoclonal antibody anticol a in a series of nine bac and six lung adenocarcinomas with bronchioloalveolar pattern. the results show lack of staining in seven of nine bac, whereas all six adenocarcinomas with bronchioloalveolar pattern did stain (significance, p= . ). conclusion: our conclusion is that the monoclonal antibody anticol a could be a useful marker of invasion in bac when invasion is doubtful. objective: poly(adp-ribose) polymerase- (parp- ) is a nuclear enzyme that plays a role in dna repair, differentiation, proliferation, and cell death. the polymorphisms of parp- have been associated with the risk of various carcinomas, including breast, lung, and prostate. we investigated whether parp- polymorphisms are associated with the risk of non-hodgkin lymphoma (nhl). method: subjects from a korean population consisting of nhl patients and controls were genotyped for five parp- polymorphisms (asp asp, ala ala, lys lys, ivs + a>g, and val ala) using highresolution melting polymerase chain reaction (pcr) and an automatic sequencer. results: none of the five polymorphisms were associated with overall risk for nhl. however, the val ala polymorphism was associated with reduced risk for nhl in males [odds ratio (or), . ; % confidence interval (ci), . - . for cc genotype and or, . ; % ci, . - . for tc genotype], with a trend toward a gene dose effect (p for trend, . ). asp asp (p for trend, . ) and lys lys (p for trend, . ) polymorphisms revealed the same trend. in an association study of parp- haplotypes, haplotype acaac was associated with decreased risk of nhl in males (or, . ; % ci, . - . ). the present data suggest that val ala, asp asp, and lys lys polymorphisms and the haplotype-acaac in parp- are associated with reduced risk of nhl in korean males. objective: the orphan leucine-rich repeat containing gprotein-coupled receptor lgr (gpr /hg /fex) is a novel marker for adult stem cells in small intestine, colon and hair follicles. it is suspected to have a pivotal role in cell proliferation and tumor formation and seems to be a potential therapeutic target. lgr expression is poorly investigated and neither its function in stem cells nor during tumor formation is known. method: our aim was to identify a lgr antibody with a high specificity among different providers (epitomics®, mbl®, sigma®, biosite®, abgent®) for screening selected human formalin-fixed and paraffin-embedded (ffpe) tissue samples by automated immunohistochemical staining. for proving antibody specificity, in situ hybridization with a crna probe of lgr is carried out on the same tissue samples used for immunohistochemistry. as positive control, we generate a lgr expressing human keratinocyte cell line (hacat) by retroviral transduction. results: the lgr antibody from epitomics® stains the outer root sheath of human hair follicle in anagen, whereas sigma-aldrich®'s anti-lgr antibody recognizes lgr in the inner root sheath. nerve tissue is completely negative using the epitomics® antibody, but contrarily, the anti-lgr antibody from mbl® shows strong staining of purkinje cells as well as of other nerve cells in the cortex and spinal cord. the sigma-aldrich® antibody also shows slight nerval staining, but nuclear. anti-lgr antibodies from biosite® and abgent® are all-around negative under the tested conditions. conclusion: all antibodies were optimized but the ihc results are quite incoherent; therefore, further investigations need to be done. objective: glioblastoma multiforme (gbm) and anaplasic astrocytoma (aa) are astrocytic neoplastic entities of the central nervous system that appear in adults, with high biological and clinical aggressiveness. despite the definition of new neoplasm genetic subgroups, the most relevant information in the prognostic of the patient still comes from factors as patient age, localization and size of the tumour, oedema and mass shifting. metabolic phenotyping may provide new information for a better management of this disease. method: we collected molecular profiles based on hrmas spectra for high-grade glioma biopsies ( gbm and aas). the amount of human tumor tissue analyzed for each subject ranged from to mg. all samples were analyzed by post-hrmas histopathology to assess the tissue integrity and double validate histological diagnosis. results: two major metabolic groups were detected, which included and samples, respectively. most aas were located in the same group. the phospholipid patterns and the glutamine/glutamate metabolic relatives seem to be the most relevant contribution to this grouping pattern. conclusion: hrmas provides high-resolution glioma molecular profiles. one of the groups detected, which include most aa samples, seems to reflect a less aggressive type of tumor. metabolic discrimination between these subgroups includes the levels of some metabolites which can be seen by mrs 'in vivo'. objective: hpv is one of the best-known etiologic agents for squamous epithelia-related neoplastic lesions including the cervix, larynx and skin. in recent years, some of nonsquamous epithelia-driven tumors like stomach, colon and lung adenocarcinomas were reported to be containing hpv. the prevalence of hpv in gastric adenocarcinomas, which is reasonably related to chronic gastritis and gastric intestinal metaplasia, is varied between % and % in large-scale studies. regardless of being 'passenger' or 'driver', to show hpv prevalence in chronic gastritis with metaplasia, the well-known two predisposing lesions of gastric cancers was our aim in the present study. method: dna extracted from formalin-fixed paraffinembedded gastric biopsies of cases was tested for hpv-dna by pcr assay. consensus primers were used. the presence of a -bp fragment was accepted as hpv positivity. results: eight out of biopsies were found hpv-dnapositive ( %). conclusion: hpv may accompany gastritis and metaplasia. hpv deserves more studies for pre-neoplastic and neoplastic gastric lesions to enlighten the 'passenger-driver' dilemma. objective: adamantinoma of long bones (alb) and osteofibrous dysplasia (ofd) are rare, osteolytic primary bone tumours of uncertain origin. to investigate the nature of the proliferating fibroblastic stromal cells in alb and ofd and to determine cellular mechanisms of osteolysis in these tumours, we carried out cell culture and molecular studies on two cases of alb and two cases of ofd. method: alb and ofd cells were cultured on coverslips and dentine in the presence and absence of macrophage colony-stimulating factor (mcsf)-primed cd + monocytes + mcsf + receptor activator of nuclear factor kappa b ligand (rankl). cultures were examined for the osteoclast formation markers tartrate-resistant acid phosphatase (trap), cd and lacunar resorption. alb and ofd cells were examined for osteoblast markers (mineralisation nodule formation, alkaline phosphatase). results: few cultured alb and ofd stromal cells expressed epithelial markers (epithelial membrane antigen [ema] and cytokeratin). ofd cells expressed osteoblast markers. cultured alb and ofd stromal cells showed no ultrastructural evidence of epithelial differentiation. alb and ofd cells were not capable of lacunar resorption, but co-cultures of alb or ofd stromal cells and monocytes resulted in the formation of multinucleated trap + and cd + cells capable of lacunar resorption. our findings indicate that ofd and alb stromal cells express epithelial and osteoblast markers. these cells support osteoclast formation from mononuclear phagocytes via a rankl-dependent mechanism, which may contribute towards the aggressive bone destruction associated with this tumour. objective: supratentorial primitive neuroectodermal tumor (spnet) is an embryonal tumor usually developing supratentorially in children or young adults and composed of undifferentiated or poorly differentiated neuroepithelial cells. it is a relatively rare tumor in middle-aged people and extremely rarely develops after radiotherapy. we report an extraordinary case of spnet in a -year-old female that developed years after radiotherapy of oligoastrocytoma. results: a -year-old female was regularly followed after treatment of oligoastrocytoma of the left frontal lobe. the tumor was subtotally resected and treated with radiotherapy years ago. the patient has persistent mild aphasia and mild right hemiparesis. ct performed due to increased incidence of headaches revealed a cystic lesion of the left frontal lobe, cm in diameter, located below the previous tumor. the recurrence of oligoastrocytoma was suspected; however, the diagnosis of spnet was rendered. conclusion: long survival in patients successfully treated for primary brain tumors may yield in independent treatment-induced primary malignancies of the central nervous system. objective: the interaction between different proteins plays an important role in the metastatic ability of brain tumor cells. the purpose of this study was to evaluate the expression of mmp- , mmp- , cd v , and ki- in gliomas of different grades of malignancy and correlate the expression between the studied proteins in tumors. method: expression of mmp- , mmp- , cd v , ki- was evaluated on formalin-fixed paraffin-embedded tissue blocks divided into: glioblastomas multiforme (n= ), anaplastic astrocytomas (n= ), anaplastic oligodendrogliomas (n= ) and normal brain tissue (n= ) using immunohistochemistry. results: mmp- , mmp- , cd v and ki- expression was found in . %, . %, . %, . % of gliomas, respectively.mmp- immunopositivity was significantly higher in glioblastoma multiforme than anaplastic astrocytomas (p= . ). no immunoreaction for all proteins was found in normal brain tissues. mmp- , mmp- , cd v , ki- immunoreactivity was significantly higher in glioblastomas when compared with anaplastic gliomas (p= . ). in gliomas, the percentage of positive cells and the intensity of the immunostaining were proportional to the degree of malignancy. positive correlations between ki- and mmp- (p= . ), mmp- and mmp- (p= . ), mmp- and cd v (p= . ) were found in malignant brain tumors. objective: gliomas are most common among primary brain tumors, and glioblastomas (gbl) are most fatal among gliomas. surgical operation concomitant with chemoradiotherapy is adopted to treat gliomas. temozolomide (tmz) is a new oral cytotoxic agent with less myelosuppression. epigenetic silencing of o -methylguanine-dnamethyltransferase (mgmt) by promoter methylation is associated with improved survival in gbl treated with tmz. in this study, we investigated mgmt promoter methylation in gliomas treated with concomitant chemoradiotherapy (ccrt) following operation. method: in cases of gliomas including gbl, six anaplastic astrocytomas (aa) and three anaplastic oligo-dendrogliomas (ao), formalin-fixed, paraffin-embedded archival samples were used to evaluate the methylation status of mgmt promoter via methylation-specific pcr. results: mgmt promoter methylation was detected in cases ( . %) of gliomas. mgmt promoter methylation was detected in . % of gbl, in . % of aa, and in . % of ao. gbl with methylation had significantly more prolonged overall survival (mean . months) compared with unmethylated gbl (mean . months, p= . ). methylated gbl also had more prolonged progression-free survival (mean . months) compared with unmethylated gbl (mean . months, p= . ). conclusion: the frequency of mgmt promoter methylation in korean glioma patients was similar to those in western countries. these data indicate that mgmt promoter methylation is prognostically significant in gbl given ccrt. mgmt promoter methylation status is considered to be a valuable predictive factor in the routine clinic for gbl. histopathological examination showed a mixed glioneuronal tumor composed of oligodendrocyte-like cells constituting neurophil-like islands, astrocytic cells and neurons scattered in glial tissue. immunohistochemically, glial tissue was gfappositive and neurophil-like areas and big neurons were synaptophysin-positive. in astrocytic component ki- , the proliferation index was below %. p was negative. results: consequently, the final diagnosis was spinal cord glioneuronal tumor with rosetted neurophil-like islands-who grade . these cases can be confused with oligodendrogliomas, astrocytomas and ependymomas. oligodendrogliomas are distinct with their molecular genetic features. conclusion: our case is unique in that it is the youngest reported patient having this tumor located in the spinal cord. proliferative activity in all subtypes of the glioblastoma b. jarosz*, m. jarosz, r. rola, t. trojanowski *lublin, poland objective: glioblastoma is the most malignant and the most frequent primary brain tumour in adults. it accounts for - % of astrocytic tumours. the tumour has two variants: giant cell glioblastoma and gliosarcoma. the purpose of the study was to show the differences between values of the mib- proliferative indexes of glioblastoma, giant cell glioblastoma and gliosarcoma. method: surgical specimens from patients were formalin-fixed, paraffin-embedded immunostained using mib- antibody. next, proliferative index (pi) was calculated. analysis of variance (anova) was used to test the hypothesis that mean values of mib- pi were equal for each diagnosis group. the mean values of mib- pi were as follows: glioblastoma, . % ( . - , %); giant cell glioblastoma, . % ( . - . %) and gliosarcoma, . % ( . - . %), but there were no statistically significant difference in the mib- pi mean value between diagnostic groups. we observed that proliferative activity shows regional variation and was the most prominent in glioblastoma with small cells. in giant cell glioblastoma, it was much lower. because of the absence of significant differences of mib- pis in our study, in the future, the study will be repeated on cases in each group of that tumour. the extracellular matrix and diffusion barriers in the focal cortical dysplasias of brain-an immunohistochemical study j. zamecnik*, l. vargova, a. homola, p. marusic, p. krsek, k. kuncova, e. sykova *charles university, dept. of pathology and mol. m, prague, czech republic objective: changes in the geometry and composition of the extracellular space (ecs) may influence the epileptogenesis in focal cortical dysplasias (fcd) of the brain. method: tissue ecs volume and geometry (the geometrical factor "tortuosity", reflecting various ecs diffusion barriers) were studied in cortical samples of patients surgically treated for epilepsy, including nine patients with fcd type i and of six patients with fcd type ii, by realtime iontophoretic method. consequently, the samples were subjected to immunohistochemical analysis of the composition of the extracellular matrix (ecm) and morphology of the gfap + glial cell processes. results: in both fcd type i and fcd type ii, the tortuosity of the ecs was significantly increased: . ± . and . ± . , respectively; control = . ± . (mean ± sem). the ecs volume fraction was not significantly changed. when compared to controls, no significant changes in ecm composition were noted in fcd type i. however, we observed an increase in gfap + glial processes in both types of fcd and pathological accumulation and distribution of some ecm molecules (tenascins c and r, hyaluronate, chondroitin sulphate, reelin) in the ecs of fcd type ii. conclusion: the ecs of fcd has increased tortuosity, reflecting the increase of diffusion barriers in the ecs due to gliosis and pathologic accumulation of some ecm molecules. we propose that disturbed extrasynaptic transmission, mediated by the diffusion of neuroactive substances through the ecs of such cortex, represents another factor of epileptogenicity in fcd. support: iga mzcr ns - and mzofnm . hemangiopericytoma of the pineal body: case report s. uyar bozkurt*, n. comingle, b. oz *marmara university, istanbul, turkey objective: hemangiopericytomas are rare mesenchymal neoplasms that presumably derived from pericytes. although hpc mas generally attached to the cranial and spinal dura, intraparenchymal and intraventricular rare tumors have been reported. method: a -year-old male patient presented with headache, nausea and blurred vision months ago. cranial mri revealed contrast-enhanced lesion × cm in diameter in pineal gland location. given the findings of the preoperative imaging studies, the lesion was consistent with parenchymal tumors of the pineal gland. a right occipital craniotomy and resection of the lesion was performed. histologically, the tumor was composed of clusters of monotonous, closely packed, small neoplastic cells. nuclei are oval to round with granular chromatin and inconspicuous nucleoli. mitosis was rare and necrosis was not found. stroma contained dilated, slit-like vascular channels lined by flattened endothelial cells. reticulin stain showed increased reticulin network of investing group of neoplastic cells. neoplastic cells were diffusely immunoreactive with bcl- , but were negative with epithelial membrane antigen, chromogranin, synaptophysin, pgp . , s- protein, and cd . a mib- labeling index was %. results: a diagnosis of hemangiopericytoma was made based on light microscopy and conventional histochemical and immunohistochemical studies. differential diagnosis included pineal parenchymal tumors and meningiomas. the present case provides one unique example of a rare entity to the diverse spectrum of the pineal region neoplasms encountered in neuropathology. objective: neurofibroma is the most frequent neurogenic tumor in the first year of life. it is a benign proliferation of schwann cells, perineurial cells, and fibroblasts, which may occur in association with neurofibromatosis type or sporadically. the most common sites of laryngeal involvement are the aryepiglottic folds and the arytenoids, areas of the larynx rich in terminal nerve plexuses. clinical findings: a -year-old girl presented with airway obstruction and stridor with a progressive nature since birth. direct laryngoscopy: laryngeal tumoral mass, located in the supraglotic area. complete surgical excision was performed. method: all anatomical pieces were fixed in % formaldehyde solution, paraffin-embedded, cut and stained (hematoxylin-eosin and van-gieson). results: macroscopically: -cm whitish multinodular mass, firm consistency, myxoid cut surface microscopically: the submucosal nerve fibers were expanded in a plexiform pattern, infiltrating between the submucosal glands due to a proliferation of small, delicate, wavy, spindle cells with markedly elongated, wavy nuclei with pointed ends and coarse collagen fibres, embedded in a myxoid matrix. immunohistochemistry: positivity of the nervous fibers for cd and s protein. act was negative in the nervous fibers and positive in the blood vessels. ki was negative. histopathology diagnosis: plexiform neurofibroma of the larynx. conclusion: neurofibroma of the larynx is a rare condition that should be considered in the differential diagnosis of children presenting with a submucosal laryngeal mass even without the other clinical signs of nf or nf . it has a high rate of recurrence or residual disease due to the possibility of malignant transformation. objective: brain lesions are highly heterogeneous both clinically and morphologically. the morphological study of these lesions is based in their cellular characteristics, different tissue organization patterns, vascular network, collagen distribution, presence of calcium, etc. mr imaging of excised tissue samples may provide valuable information about lesion structure and microarchitecture, increase the diagnosis specificity and help for better tissue characterization. method: fifteen brain lesions biopsies from the hospital clinico universitario de valencia were fixed with formalin and embedded in a gel matrix for minimizing motion artifacts. mr microscopy images and optical microscopy images were obtained for all of them. mr microscopy images included t , t , t * and dwi. images were subsequently analyzed by hierarchical clustering. results: mr microscopy of brain biopsies shows high resolution and quality. major histological findings (for example, healthy, vascular, proliferative or necrotic tissue) exhibit differential mr parameters values (t , t and diffusion coefficient among others). hierarchical cluster analysis of these parameters revealed different mr patterns correlating with relevant histopathological and immunohistochemical features. conclusion: mr microscopy provides functional, microstructural and biophysical information complementary to that obtained by conventional histopathology. our approach and findings may help in multidisciplinary groups for better integration of histopathology and mri in brain lesion diagnosis. interaction of vesicular monoamine transporter (vmat ) and neuromelanin pigment among the midbrain dopaminergic neurons in man p. pasbakhsh*, d. german *tehran university of, medical science, iran objective: neuromelanin (nm) pigment accumulate with age catecholaminergic neurons in man, and ventral substantia nigra dopaminergic neurons that are most vulnerable to degeneration in parkinson's disease (pd) contain the greatest amount of this pigment. in vitro data indicate that nm pigment is formed from the excess cytosolic catecholamine that is not accumulated into synaptic vesicles via the vesicular monoamine transporter (vmat ). method: using semiquantitative immunohistochemical methods in human postmortem brain, we sought to examine the relationship between the contents of vmat and nm pigment. the immunostaining intensity (isi) was measured for vmat in two regions of the midbrain dopaminergic cell complex. the isi of the cells was related to the density of nm pigment within the cells. we also measured the isi for tyrosine hydoxylase (th) and examined the noradrenergic neurons in the locus coeruleus (lc) in brain -- years of age. objective: human mitochondrial diseases have a relatively high incidence, multiple genetic causes and quite diverse clinical, biochemical and morphological phenotypes requiring a multidisciplinary approach for diagnosis. the study of protein aggregation in muscle fibres in these disorders may offer new insights on their complex pathogeny. method: we studied morphological aspects of the "ragged red" fibres-targeting our interest on the types and location of different protein aggregates. we selected diagnostic muscle biopsies from seven unrelated patients and used histological, histochemical, enzyme histochemical, ultrastructural and immunohistochemical techniques. results: the expression of cytoskeletal, transsarcolemmal, sarcomeric, chaperone type and nuclear proteins revealed that "ragged red" fibres and "ragged red" regions of the fibres accumulate diverse proteins, of which desmin, alpha b crystallin, as well as n-cam, dysferlin and heat shock protein appear to be regular ones. none of our cases had any accretion of plectin, actinin, beta and gamma dystroglycan. other proteins showed variable expression. conclusion: as the list of members in the "protein aggregate myopathies" family is constantly enlarging, the study of protein accumulation in mitochondrial myopathies is of clear interest for the future. note: zurac objective: prostate biopsy is performed to detect carcinoma in those at high risk on the basis of elevated psa and abnormal digital rectal examination. re-biopsy is often performed following an initial atypical diagnosis or rising psa. method: all histopathological reports of prostate biopsies at beaumont hospital, dublin, during the time period january to january were analysed. a total of , reports were retrieved and the data were recorded and analysed. results: all prostate biopsies were grouped into initial biopsy (no previous biopsy recorded) and repeat biopsy (at least one previous biopsy recorded). multiple report parameters were recorded for each biopsy including diagnosis, number of cores taken, number of positive cores and gleason grade, and these were compared for the two groups. in the original biopsy group, all biopsies reported as atypical (but not meeting criteria for carcinoma) were further analysed for changes on follow-up biopsy. in the repeat biopsy group, repeat biopsies performed for increased psa and for previous atypical diagnosis were analysed separately and compared. conclusion: repeat prostate biopsy is often performed for persistently elevated or rising psa and previous diagnosis of atypical changes. our study assessed the likelihood of finding carcinoma in a follow-up biopsy performed for these two reasons. our study also compared the biopsy adequacy and extent and grade of carcinoma found in both initial and repeat biopsies. the findings are significant in determining the likely clinical course and appropriate management of patients with atypical diagnoses and elevated psa. objective: since atypical adenomatous hyperplasia (aah), post-atrophic hyperplasia (pah) and proliferative inflammatory atrophy (pia) of the prostate demonstrate both overlapping histological features and generality of biological properties with prostatic intraepithelial neoplasia (pin) and atypical small acinar proliferation (asap), these processes were proposed in probable precancerous lesions of the prostate. method: we studied the cytological features with the use of morphometry. the expression of amacr and cocktail hwc+p was estimated with the use of immunostaining. for the image analysis, the software wsif imagej and imagescope was used. results: bc layer was fragmented in most of cases pah, pia, aah. the bc loss in pah-pia was % and % accordingly and was below that in pin- %, aah- %, and asap- %. analysis of cytological features and nucleolus frequency showed that pah-pia was similar to pin-asap and above that in aah. prominent nucleolus was identified in atrophy, precancerous lesions and pca. frequency of prominent nucleolus in pah ( % cases, % in cases) and pia ( % and % accordingly) was below that in pin ( % and %), asap ( % and %) and pca ( % and %). amacr expression was moderately strongly positive in precancerous lesions and pca and weakly positive in other groups. area of amacr expression in pin and asap was above that in aah, pah, pia and below that in cases pca. objective: presentation of rare lesions of the prostate. method: a -year-old man, with psa , underwent a needle biopsy of the prostate. a histological examination of biopsique carrots showed an infiltrating tiny lesion within adipose periprostatic tissue at the level of one biopsy of the left lobe nodule. the lesion consisted of little irregular glands and solid nests of atypical cells psa − and ck + , and ck + . we proposed a diagnostic of a metastasis/infiltration of unknown primary origin, likely from the urinary tract. this was confirmed by a cystoscopy revealing a tumor which had a histologic appearance of a choriocarci-noma, finally classed as a poorly differentiated urothelial carcinoma with a choriocarcinoma differentiation. results: the second case concerns a -year-old patient with decompensated cirrhosis admitted to the hospital for a gastroenterology bilan. rectal examination revealed an enlarged prostate. the hemostase was necessary after a core needle biopsy of the prostate. the histological examination demonstrated a highly vascular tumor composed of chief and sustentacular cells arranged in an alveolar pattern. immunohistochemical study confirmed a paraganglioma. there were no signs of malignancy; however, we did not observe any prostatic parenchyma at the tumoral level. conclusion: many significant non-epithelial tumors may arise in the prostate gland; although they are rare, their recognition by the pathologist is essential as their treatment and prognosis are quite variable. the core needle biopsy allows for a diagnostic of a variety of tumors, and one should not ignore, in spite of the absence of clinical symptoms and complementary information, the risk of metastatic lesion in the prostate. latent prostate cancer in association with benign prostatic hyperplasia after the chernobyl accident in ukraine a. romanenko*, a. chekalova, p. harkonen, a. vozianov *institute of urology, kiev, ukraine objective: tumor volume is a powerful predictor of patient outcome in prostatic adenocarcinoma. preoperative assessment of prostate cancer tumor volume is still a big challenge. the present study attempted to identify the most predictive biopsy variables for final tumor volume in radical prostatectomy specimens. method: we reviewed prostate needle biopsies in patients who subsequently underwent radical prostatectomy. the preoperative data collected were: psa, preoperative ultrasound, total prostate volume, number of positive biopsies, total percentage of cancer in the biopsy and gleason score. prostatectomy specimens were entirely embedded and mounted whole. tumor volume was measured using the grid method. preoperative data were compared with final tumor volume in radical prostatectomy specimens by univariate and multivariate analysis. results: the number of positive biopsies (p< . ), total percentage of cancer in the biopsy (p< . ) and gleason score (p< . ) were significant predictors of tumor volume on linear regression analysis. psa value (p= . ) and preoperative ultrasound total prostate volume (p= . ) were not significant predictors of tumor volume. on multivariate logistic regression analysis, we designed a model to predict final tumor volume. this model contains all the predictors mentioned above and significantly correlates with final tumor volume (p< . ). conclusion: preoperative data (gleason score, number of positive biopsies and total percentage of cancer in the biopsy) can be used to predict the volume of prostate cancer with acceptable accuracy. these variables must be mentioned to the clinician in order to help in the therapeutic decision. "negative" histopathology (stage pt ) in a radical prostatectomy specimen after a preoperative diagnosis of prostatic adenocarcinoma m. ligaj*, k. sikora, r. sosnowski *warsaw cancer center, dept. of pathology, poland objective: in rare cases, histologic assessment of the entire radical prostatectomy specimen (rps) after a positive biopsy does not reveal residual tumour. we analyze the incidence of "vanishing prostatic carcinoma" in our institution and present algorithm of pathologic workup of "negative" rpss. method: among rpss from patients treated for prostatic adenocarcinoma (january -december ), ten cases ( . %) showed no residual carcinoma despite complete sampling. a five-step protocol of additional pathologic workup included: ( ) preoperative biopsy review; ( ) "second look" review of the rps; ( ) immunohistochemistry ( betae , p ) performed on suspicious foci; ( ) deeper levels of each block with pin high grade and/or of blocks with areas where cancer was seen in the biopsy; and ( ) block-flipping of regions specified above with deeper levels. results: cancer diagnosis had been made in transurethral resection (turp) specimen (two patients) and core biopsy (eight patients). the turp cases were excluded on the assumption of complete pre-prostatectomy carcinoma resection. biopsy review (protocol step ) confirmed prostatic carcinoma in seven core biopsy specimens ( . %). in one case, diagnosis of adenocarcinoma made in another institution was not confirmed. steps - revealed residual carcinoma in a further four rps. despite full workup, no residual tumour was seen in three rp specimens ( . %). all three "negative" cases had undergone mab prior to rp and showed no clear evidence of residual carcinoma. conclusion: "vanishing prostate carcinoma" is a rare phenomenon, with higher incidence after neoadjuvant hormone therapy. extensive histologic workup of rp specimen reduced the rate of pt rp after a positive core biopsy from . % to . %. objective: large cell neuroendocrine carcinoma (lcnec) of the urinary bladder is a rare tumor with only a few cases reported. the diagnosis is based on the criteria established in lung tumors. we report the clinical and histological data of six patients with lcnec in urinary bladder. method: the clinical charts and histological slides of six patients with the lcnec diagnosis in urinary bladder from a single institute were reviewed. the diagnosis was confirmed by the use of immunohistochemistry with at least two positive neuroendocrine markers (synaptophysin, chromogranin and/or cd ). results: all patients were male. their age ranged from to . the most frequent clinical presentation was gross hematuria. their histology had overlapping features with urothelial carcinoma and was difficult to differentiate without immunohistochemistry. the most useful features were extreme hypercellularity ( / ), lack of exophytic papillary component ( / ), nuclear molding ( / ), finely stipled chromatin ( / ) and exuberant mitotic rate (most > /hpf) with innumerable apoptotic figures. in three cases, there were foci of admixed invasive or in situ urothelial carcinoma, in one case admixed adenocarcinoma. all tumors were infiltrative to muscularis propria at the time of diagnosis, except the most recent one which did not have muscle sampled in resection. distant metastases were found in liver, spleen and bones of one patient. three patients underwent radical cystoprostatectomy; all patients received adjuvant or neoadjuvant chemotherapy, and one was given additional radiotherapy. conclusion: distinction between lcnec and urothelial cancer is important because of likely different therapeutic options. lcnecs are highly aggressive tumors with at least pt disease at diagnosis. objective: bladder cancer's incidence is increasing worldwide. to improve the results of current bladder cancer treatments, new drugs are being tested in single use or in associations. gemcitabine is metabolized to the active diphosphate and triphosphate, which is integrated into the dna and causes cessation of dna polymerization. sirolimus inhibits mtor protein kinase. our aim was to study and compare the effect of gemcitabine and sirolimus in bladder cancer chemically induced in mice. method: n-butyl-n-( -hydroxybutyl) nitrosamine was administered to icr male mice in drinking water for weeks. one group was treated with gemcitabine ( . mg/kg, i.p.) and the other with sirolimus ( . mg/kg, i.p.). all animals were killed at the end of the experiment. results: animals not treated showed a higher incidence of neoplastic and pre-neoplastic lesions than animals treated ( % simple hyperplasia, % nodular hyperplasia, dysplasia %, cis % and invasive carcinoma % objective: the accurate diagnosis of poorly differentiated invasive carcinomas in transurethral resection (tur) specimens using only h&e-stained sections continues to be a challenge for the pathologist. the aim of this study was to evaluate and select an optimal immunohistochemical (ihc) panel of antibodies to establish the urothelial or prostatic origin of poorly differentiated tumors in tur specimens. method: ihc was performed to detect cytokeratin (ck) , ck , high-molecular-weight ck (hmwck), p , prostate-specific antigen (psa) and p s/amacr in cases of poorly differentiated invasive tumors: poorly differentiated prostatic adenocarcinomas (gleason score ≥ ) and high-grade urothelial carcinomas. the youngest patient was while the oldest was years of age. results: the sensitivities for labeling prostate cancers were: psa ( %), amacr ( %), ck ( %), ck ( %), p ( %), and hmwck ( %), while urothelial highgrade carcinomas demonstrated the following rates of positivity: hmwck ( %), ck ( %), p ( %), ck ( %), amacr ( %), and psa ( %). co-expression of ck / was noticed in % of the urothelial carcinoma cases, but it lacked in prostate carcinomas. objective: the authors evaluated the possible influences of ageing on the morphology of testicular intralobular interstitial tissue (tiit). method: the studied material consisted of surgical samples of testicular tissue from cases with orchiectomy for prostate adenocarcinoma. tissue samples were fixed in neutral buffered formalin embedded in paraffin, stained with hematoxylin-eosin and goldner trichrome and immunomarked for cd . images were acquired and measurements were performed with a specialized image analysis software after previous calibration. the assessed parameters were tiit amount (p-tiit) and intralobular vascular network (ivn). ten fields were randomly selected for each case, with × objective. mean p-tiit (mp-tiit)/field, mp-tiit/case and mp-tiit/age group were determined. regression line (rl), slope (m) and significance test for slope (p) were determined in order to assess the correlation of tiit amount changes with ageing. results: intralobular septae showed variable amount of collagen fibers, from simple linear fibrillary assemblies to marked thickening with obvious septal enlargement. the latter were seen mostly in the outer region of the lobules, but without any significant spread. tiit amount had a mean value of % of intralobular parenchyma. rl showed a discrete decreasing trend with ageing (m=− . ) confirmed by "p" value (p= . ). arteriolar wall presented degenerative changes with limited extension and variable intensity. peritubular and intramural capillaries were present in all age groups. endothelial cells revealed no significant changes. objective: angiomyolipoma is a rare neoplasm composed of varying admixtures of blood vessels, smooth muscle cells and adipose tissue. there is a strong association with tuberous sclerosis. we describe the first case report of multifocal renal angiomyolipoma developed on tuberous sclerosis and associated with endometriosis. method: imaging studies in an asymptomatic -year-old woman, affected by tuberous sclerosis with tsc gene mutation, revealed a partially solid and cystic mass measuring cm involving the left kidney and a solid mass measuring . cm in the right kidney. results: the surgical specimen consisted of two left nephron-sparing procedures and one at the right side with firm, pale nodules measuring . , . and . cm. the tumors were composed of spindle and epithelioid cells with an abundant pale eosinophilic or clear cytoplasm with round nuclei, mild atypia and low mitotic activity. rare islands of adipose tissue were observed. in the two left tumors, the predominant smooth muscle cells were associated with some foci of endometriosis. the spindle and epithelioid cells were immunoreactive with hmb and smooth muscle actin. the estrogen and progesterone receptors were positive in stromal and epithelial cells of endometriosis. the spindle cells of angiomyolipoma were positive with progesterone receptors. conclusion: multifocal pecoma of the female genital tract associated with diffuse endometriosis was described by froio et al in , but to our knowledge, this is the first case report of renal angiomyolipoma associated with endometriosis. this association represents a supplementary proof of potential role for hormones in the pathogenesis of angiomyolipoma. translocation-associated renal cell carcinoma ( objective: gastric malt (mucosa-associated lymphoid tissue) lymphoma is closely related with helicobacter pylori (hp) colonization and represents a multistage process from gastritis to lymphoma. for the differential diagnosis of malt lymphoma and reactive inflammation, wotherspoon proposed a histomorphological scoring with two intermediate categories, grades and . genetic studies (ig clonality and/or translocations and chromosomal aberrations) have not brought so far definite arguments to confirm or discard lymphoma in these problematic scores. objective: in gastric adenocarcinoma, overexpression of her has been correlated to tumour location and histologic type and varies considerably in the few published studies, probably due, at least in part, to the racial heterogeneity of patients included. the aim of the present study was to investigate the immunohistochemical expression of her protein in gastric adenocarcinomas of greek patients who live in the area of epirus. method: a total of primary gastric adenocarcinomas were retrieved from the archives of the department of pathology ( men and women). they were all located in the stomach, away from the oesophageal-gastric junction. forty-eight were intestinal type, diffuse type and mixed (lauren classification). immunohistochemical analysis of samples was performed using the polyclonal rabbit anti-human c-erb- oncoprotein (dako) antibody on paraffin sections. her scoring was performed according to published consensus panel recommendations. results: overexpression of her (ihc + and +) was detected in eight adenocarcinomas ( . %). specifically, score + was assigned to five cases ( . %, four intestinal type, one diffuse type) and + to three cases ( . %, two intestinal type, one diffuse type). score + was detected in ten cases ( . %, eight intestinal type, one diffuse type and one mixed), and in cases ( %). in two cases with score +, adjacent dysplastic epithelium was noted, which was also +. the results of the current study are comparable with those of the literature, indicating that assessment of immunohistochemical expression of her in gastric adenocarcinomas could lead to the stratification of patients, the goal being the optimal personalized treatment. the prognostic value of her- /neu expression in gastric cancer patients from lower silesia in poland a. halon*, p. donizy, l. halon, r. matkowski, j. rudno-rudzinska, w. kielan, j. rabczynski *wroclaw medical university, poland objective: overexpression of her- /neu was most widely explored in breast cancer. her- positivity is reported as - % in gastric cancer (gc). the aim of the study was to assess the prognostic significance of her- in gc patients from lower silesia, the southwestern region of poland. method: immunohistochemistry (ihc) for her- monoclonal antibody was performed on paraffin-embedded specimens. ihc expression of her- was evaluated using the remmele scale (irs) and standardised herceptest modified for gc. results: the status of her- protein expression was observed as the following: ( ) objective: breakage or degradation of extracellular matrix (ecm) and basement membrane (bm) is a critical step in tumor progression. matrix metalloproteinases (mmps) and their tissue inhibitors (timps) take important roles in these processes acting in a coordinated manner to form an integrated system. the aim of the study was the evaluation of mmp- , mmp- , timp- and timp- expression and the correlation with clinicopathological parameters and survival in gc. method: formalin-fixed paraffin-embedded tissue sections from gastric cancers were studied for the expression of mmp- , mmp- , timp- and timp- protein by immunohistochemistry. objective: amacr plays role in beta oxidation of branched fatty acids. it is expressed in several neoplasms like prostatic, hepatic and thyroid cancers. it is also believed to be expressed in gastric carcinoma (gc), particularly in better differentiated and less advanced lesions. the aim of the study was to assess amacr expression in gc and its correlation with clinical and histological prognostic factors. objective: brunner's gland hyperplasia is a rare lesion, with fewer than cases having been reported in the literature. it is considered to be a hamartoma, developing from the submucosal glands, usually in the first or second part of the duodenum. most of the lesions described were polypoid and < cm in greatest diameter. often, there is an association with peptic ulcer disease. method: we report the case of a -year-old man who presented with abdominal pain, vomiting and upper gastrointestinal bleeding. the anamnestic data showed chronic ulcer disease. he also was anaemic, with a slight raise in blood eosinophilia. results: the radiological examination of the upper gastrointestinal tract revealed pyloric stenosis due to a polypoid mass measuring cm. preoperative diagnosis of the mass could not be established. the mass was excised and at the same time a vagotomy with pyloroplasty (finney) was performed. brushing cytology of the surgical specimen revealed a great number of aggregated brunner's glands without any atypia, as well as many lymphocytes. a frozen section was negative for malignancy. the histologic diagnosis was that of diffuse nodular brunner's gland hyperplasia (hamartoma) accompanied by lymphocytic infiltration. the rate of cellular proliferation was low. during the postoperative period, there were no complications. a subsequent gastroscopy showed no pathologic findings, and the patient is well at present. conclusion: our case is reported because of its rarity and the difficulties in preoperative diagnosis. the literature is also reviewed. objective: in the differential diagnosis of gist, associated mesenchymal lesion represents an additional challenge. method: a -year-old woman with intestinal occlusion at surgery showed an ileal invagination on polypoid mass of cm and an ileal suberosal nodule of cm. results: the polypoid lesion, ulcerating the mucosa and growing in the muscular wall with subserosal hourglass-like expansion, showed a monotonous hypocellular mesenchy-mal proliferation (cd + , cd − ) with prominent vascular network in myxoid inflammatory stroma. considering the peculiar degenerative, inflammatory pattern of the polyp due to ischemia and the existence of a subset of gist c-kit negative, differential diagnosis was gist (c-kit − ) or inflammatory fibroid polyp (cd + ). after a careful review of the clinical and immunohistochemical and pathological findings, final diagnosis was inflammatory fibroid polyp (ifp). the minor nodule showing a spindle cell proliferation (cd + ) was diagnosed as gist. to our knowledge, no other studies report ifp and gist occurring synchronous in the ileum. conclusion: the correct definition of these lesions is crucial: defining both tumors as gists, prognostic and therapeutic assessment becomes poor (multiple familial or advanced metastatic gist). the recent discovery of pdgfr mutation (the mutually exclusive mutation of wild-type ckit gists) in the ifp questions his reactive nature and raises the possibility of a neoplastic process. then, the questions arising are whether the two tumors represent a fortuitous coexistence or involve the same carcinogenic agents on the same gene (located in the chromosome q) and if the proliferation can be inhibited by sti . objective: melanoma is a rare tumor of the anorectal area and accounts . % to . % of all anal tumours and approximately % of all primary melanomas. besides the positivity with conventional melanocytary immunohistochemical markers s , hmb , melan a are primary anorectal melanomas positive also with marker cd and negative with monoclonal antibody cea. the primary anorectal melanoma is a typical braf mutation (exon + ) and the allelic loss nf associated with neurofibromatosis. method: the melanocytary lesion of a -year-old woman in the anorectal canal was examined with immunohistochemical antibodies: s , hmb , ck ae /ae , cd and monoclonal cea (dako), and fish method with the use of combined sound vysis preb /lsi myb/lsi ccnd /cep (abbot, usa). results: our examination stated positivity with s , hmb , melan a and sporadic positivity with cd and negativity with monoclonal antibody cea. further, amplification of the gene rreb (locus p ) and ccnd (locus q ) was found. the results of our analysis confirm genetic abnormalities associated with melanoma, and our immunohistochemical analysis prefers primary melanoma before metastatic melanoma of the anorectal canal. objective: tumor budding or dedifferentiated single cells/small clusters at the invasive front of colorectal cancer is a histological feature highly predictive of lymph node and distant metastasis and an independent prognostic factor. we hypothesized that the evaluation of tumor budding could complement k-ras analysis to improve the individualized prediction of response to anti-egfr-based therapies in metastatic colorectal cancer (mcrc) patients. method: forty-three patients with mcrc treated with cetuximab or panitumumab were entered into this study. according to the recist criteria, patients had stable or progressive disease (non-responsive, nr), while patients had a partial response (pr). tumor buds were evaluated from whole tissue sections stained for pan-cytokeratin, evaluated in the densest region using a × objective, and "high-grade" tumor budding was defined as buds/highpower field. results: tumor buds and k-ras mutation both correctly classified % of patients. all patients with k-ras mutation (n = ) or high-grade tumor budding (n = ) were nr, of which four patients had both features. all pr were k-ras wild type with low-grade tumor budding. combined, the predictive value of k-ras and tumor budding was %. additionally, high-grade tumor budding was significantly related to worse progression-free survival (hr ( %ci), . ( . - . , p = . )). method: inter-institutional and interdisciplinary cooperation (of pathologists, geneticians, molecular biologists and oncologists of all three centers) during the last months based on mutual exchange of ideas, materials and laboratory protocols and common meetings and seminars. in the centres, the following three methodical options were tested-sequencing, rt-pcr (therascreen®) and snapshot multiplex analysis-and the results of the examinations were retested using another method to verify specificity and sensitivity of the testing. results: k-ras mutations were present in . % of the cases, seven adenocarcinomas and one liver metastasis. egfr was positive in ten cases in tumor cells and in seven cases in the vessels. immunohistochemical overexpression of ras protein was detected in samples. the relationship between the positivity of the k-ras mutation and the positive immunohistochemical reaction for egfr and the ras protein did not reach statistical significance. conclusion: there were no significant correlations between the mutational status of the k-ras gene and the ihc reaction for egfr and ras p protein, proving once more the major role of molecular analyses in colorectal carcinoma anti-egfr therapy. objective: hepatic pedicle triad occlusion is often used to prevent bleeding during hepatectomy despite the ischemia and reperfusion liver injury iatrogenically induced. this study aimed to estimate the impact of selective clamping of the hepatic artery (scha) in hepatocellular function. method: ( ) forty wistar rats were divided into four groups: three groups were subjected to a scha ischemia period for min: (a (n= ) submitted to a continuous scha; b (n= ) underwent an intermittent scha for min with min of reperfusion; c (n= ) underwent an intermittent scha for min with min of reperfusion)) and group d (n= ) without scha. ( ) determination of liver blood markers and hepatic extraction function (hef) using m tc-mebrofenin days before and after surgery. ( ) isolation of hepatocytes from the biopsy performed after surgery to evaluate oxidative stress (dcfh -da), characterization of cell death (annexin-v/propidium iodide) and assessment of mitochondrial membrane potential (jc- probe) by flow cytometry. results: ( ) there was significant increase of blood markers before and after scha, but without differences between groups (ns). ( ) hef maintained normal values without differences between groups (ns). ( ) there were no significant differences in viability and in the type of cell death, as well as in the production of reactive oxygen species between groups (ns). the scha compared to previous studies performed by us where total hepatic pedicle triad was clamped shows an increase of cell viability with a decrease of hepatocyte necrosis and/or apoptosis. scha is a potential alternative to decrease preoperative bleeding, maintaining hepatocellular function. objective: the selective portal vein clamping (scpv) is a potential alternative to decrease preoperative bleeding, maintaining hepatocellular function. this study aimed to evaluate the effect of scpv in hepatocellular function. method: ( ) fifty-two wistar rats were divided into four groups: three groups of animals were submitted to a scpv ischemia period for min (a (n= ) was submitted to a continuous scpv, b (n= ) underwent an intermittent scpv for min with min of reperfusion, c (n= ) underwent scpv for min with min of reperfusion)) and group d without scpv (n= ). ( ) determination of liver blood markers and hepatic extraction function (hef) using m tc-mebrofenin days before and after surgery. ( ) isolation of hepatocytes from the biopsy performed after surgery to evaluate oxidative stress (dcfh -da), characterization of cell death (annexin-v/propidium iodide) and assessment of mitochondrial membrane potential (jc- probe) by flow cytometry. results: ( ) mortality: a- %, b- %, c- % and d- % (p< . ). ( ) there was a statistically significant increase of the ast values (p< . ) and ldh (p< . ), but without differences between groups (ns). ( ) hef significantly decreased (p< . ), but without differences between groups (ns). ( ) there were no significant differences in viability and in the type of cell death or in the production of reactive oxygen species between groups (ns). conclusion: the scpv compared to previous studies performed by us where total hepatic pedicle triad was clamped shows an increase of cell viability with a decrease of hepatocyte necrosis and/or apoptosis. however, scpv above ' should be avoided given the high mortality observed. oxidative stress and liver morphology of rats received doxorubicin and tirapazamine e. korobowicz*, i. syroka, j. dudka, a. korga, r. gieroba *uniwersytet medyczny w lublini, katedra i zakbad patomorfologi, poland objective: tirapazamine (tpz) selectively kills hypoxic tumor cells. doxorubicin (dox) is one of the most effective drugs against a wide variety of cancers. it is widely accepted that oxidative stress is involved in dox organ toxicity. tpz, similarly to dox, is activated to tpz free radical by the action of several nadphdependent reductases and generate reactive oxygen species. nadph is also an essential cofactor for glutathione-dependent enzymes that constitute major cellular defenses against oxidative damage. aim: the aim of the study was to evaluate oxidative stress and liver morphology changes in rat that received tpz in addition to dox administration. method: male wistar rats were treated i.p. with dox ( . mg/kg b.w.) and tpz ( or mg/kg b.w.) weekly for weeks. sevendays after the last treatment, animals were killed and liver samples were analyzed for nadph, mda, gsh levels and histopathological changes. blood samples were analyzed for alt, ast activities and bilirubin concentration. results: anova test revealed significant higher levels of nadph and mda in liver in group receiving a higher dose of tpz with dox vs. dox group. there were no differences between group tpz+dox vs. dox of liver gsh concentration and plasma alt activity, but levels of gsh and alt in all these groups were significantly higher compared to control. microscopically, hydropic degeneration, necrosis, inflammatory cell infiltration and vascular lesion were observed in tpz+dox group. conclusion: tirapazamine causes oxidative stress in liver of rats receiving dox. this study suggests enhanced toxicity by tpz in rat livers which received dox. the influence of tetraiodothyronine-supplemented diet on selected redox equilibrium markers and liver morphology in rats treated with doxorubicin e. korobowicz*, a. korga, j. dudka *uniwersytet medyczny w lublini, katedra i zakbad patomorfologi, poland objective: the toxicity of doxorubicin results from reactive oxygen species generation. ros production depends on tissue-specific enzymatic performance. liver is an organ that is characterized by very intensive activity of these enzymes. as a result, redox equilibrium disorders may appear. moreover, changes in thyroid hormone concentrations are accompanied by ros production. thus, disorders in iodothyronine hormones status may result in the intensification of doxorubicin-induced oxidative stress. aim: the aim of this study was to evaluate the influence of dox and t -associated treatment on selected redox equilibrium markers and histopathological evaluation of the liver. method: rats were treated with dox (. mg/kg, i.p.) once a week for weeks. apart from dox, thyroxin was simultaneously given in drinking water . and . mg/l, respectively. the concentration of lipid peroxidation products-malondialdehyde (mda) and total glutathionewere measured in liver homogenates. liver morphology was evaluated in h+e and pas diastase staining. results: higher levels of mda in liver of all tested groups and at the same time in rats treated with dox plus t lower concentrations of total glutathione compared to control were observed. morphological evaluation of liver did not show any symptoms of necrosis and steatosis, but a decrease in glycogen content in dox+t group compared to dox treatment was noticed. conclusion: thyroxin supplementation causes redox equilibrium disorders and oxidative stress in liver of rats receiving dox. the study revealed the normalizing influence of thyroxin on glycogen deposits that were observed after doxorubicin treatment. objective: dysadherin is a cancer-associated cell membrane glycoprotein that inhibits cell-cell adhesion. in many types of cancer, dysadherin is related to decreased e-cadherin expression, promotes metastasis and is an independent predictor of poor patient survival. dysadherin expression in human hepatocellular carcinoma (hcc) has not been studied to date. method: we studied by immunohistochemistry hcc (grade i, ; ii, ; iii, ; and iv, ) from patients (m/f . , mean age . range - years) with monoclonal antibodies specific for dysadherin (clone ncc-m ) and Εcadherin (clone /e-cadherin). immunostaining of inflammatory and endothelial cells was used as internal positive control for dysadherin (dys) expression. results: non-neoplastic hepatocytes and cholangiocytes were dys-negative. in neoplastic cells (nc), dys-specific immunostaining was mainly membranous, while some cases showed additional nc cytoplasmic positivity. the majority of hcc ( / , . %) had - . % dys (+) Νc, . % ( / ) showed - % (+) Νc, while % ( / ) had > % (+) Νc. dys expression was negatively correlated with e-cadherin expression (p< . ), while a positive statistically significant correlation was observed between strong dys immunostaining (> %+Νc) and tumour grade (p< . ). there was no correlation with tumour size, vascular invasion or other clinicopathological parameters examined. conclusion: normal hepatocytes and cholangiocytes do not express dysadherin. in hcc, increased dysadherin expression is observed in approximately one third of the cases; it is more extensive in high-grade tumours and is related to decreased e-cadherin expression. klippel-trenaunay syndrome with clinical presentation as metastatic liver disease: a case report s. stadlmann*, d. lenggenhager, r. a. kubik-huch, j. h. beer, g. singer *kantonsspital baden, institute of pathology, switzerland objective: klippel-trenaunay weber syndrome (ktws) is a rare congenital malformation characterized by hemangiomata, varicose veins and bone and soft tissue hemihypertrophy. ktws can include additional vascular and lymphatic system abnormalities in various organs, but involvement of the liver is rare. we report a case of ktws simulating metastastic liver disease. method: a -year-old male with ktws presented with a tumor mass in the right abdomen. ultrasonography revealed a -cm cystic abdominal tumor and additional hypodense lesions in liver segments i, ii, and viii. a ct scan additionally showed multiple hypodense lesions in the spleen, peritoneum, lung, right scrotum, soft tissue and enlarged abdominal lymph nodes, highly suspicious for metastatic disease. results: laboratory data values were: gammagt u/ l (normal - ), ldh u/l (normal - ), albumin g/l (normal - ), and alpha feto-protein . μg/ l (normal < ). histopathology of the cystic abdominal tumor mass showed a complex vascular malformation of lymphangioma-hemangioma type. evaluation from two different tumorous liver lesions revealed nodular hepatic tissue separated by fibrous septa with reactive ductules and atypical vessels, consistent with multiple focal nodular hyperplasia (fnh) in the setting of ktws. conclusion: the spectrum of ktws can include arterial and lymphatic system abnormalities beyond the classical manifestation. our findings support the concept that multiple fnh characteristically occurs in a syndromic form and is induced by an irregular blood supply in the liver, with localized hyperperfusion leading to reactive nodular proliferation of liver tissue. microscopic evaluation of metaplastic and dysplastic changes in the mucous of the gallbladder d. lacka*, a. nasierowska-guttmejer *csk mswia, zaklad patomorfologii, warsaw, poland objective: in the intra-and extrahepatic biliary ducts, precancerous changes such as hyperplasia, metaplasia and dysplasia are diagnosed. in the gallbladder, cholecystitis chronica is diagnosed often with a disregard of the features of hyperplasia and metaplasia. generally accepted markers of precancerous changes of the gallbladder and biliary ducts are still to be found. aim: the aim was to define the accumulation of tp protein and mib activity in hyperplasia, metaplasia and dysplasia of the mucous membrane of the gallbladder. method: the material comprises gallbladders operated by laparoscopy and fixed in formalin. specimens were embedded in paraffin. in the microscopic sections with hyperplasia, metaplasia and dysplasia immunohistochemical stainings for tp and mib were done along with mucycarmin and pas with alcian blue stainings (mucous presence). results: the histopathologic diagnosis revealed cases ( %) of chronic calculous cholecystitis, cases of acute inflammation and secen cases of cancer. hyperplasia, metaplasia or dysplasia were found in cases ( . %) with chronic inflammation and accounted for hyperplasia without metaplasia- cases, pseudopyloric or intestinal metaplasia- cases, dysplasia- cases. mucous stain-ings confirmed the presence of pseudopyloric and intestinal metaplasia, which helped distinguish them from adenomyosis focuses. ihc confirmed the accumulation of tp protein and proliferative activity in metaplasia and dysplasia of the mucous membrane. conclusion: mucous stainings and positive tp and mib reactions suggest that metaplasia and dysplasia of the mucous membrane of the gallbladder can be classified as intraepithelial neoplasia changes. more research should be done. objective: we aimed to investigate the relationship between the findings in total or partial hepatectomy specimens. method: one hundred six cases were collected who had total transplantation or partial hepatectomies because of liver cirrhosis (lc), hcc or other hepatic disorders from the archives. then, clinical, histopathologic features and serologic findings of the cases were reviewed. the relationship between the histopathologic features and endoscopic, clinical and serologic results were investigated statistically using comparison tests. results: for the last -year period, data from patients who underwent transplantation or hepatectomy were collected. ninety-five had total, ten had partial hepatectomies, and one had metastasectomy. after the gross and microscopic examination, cases were diagnosed as lc, had hcc, three had parasitic cystic disease and ten had other unusual diseases. among lc cases, had hepatitis b virus (hbv), seven had hepatitis c virus (hcv), three had mixed virus etiology, six were alcoholic and were due to other causes. among lc patients, had hcc. fourteen cases were found to have one, seven had two and had more than two tumors. twenty-two of the hccs were located in the right, while nine had tumors in the left and right; one case had tumors in the right, left and caudate lobe. the results demonstrated that the most common hepatic disorder was cirrhosis due to hbv in the hepatectomy specimens and hcc seen in one third of them. studies with follow-up and response to therapy will form the basis of our future projects. objective: solid pseudopapillary tumor of the pancreas (sptp) represents - % of pancreatic tumors, it affects young women, and surgery is the treatment of choice. histologic features include loosely cohesive, relatively uniform polygonal cells surrounding delicate capillarysized blood vessels. most tumors are positive for betacatenin, cd , progesterone receptors and neuroendocrine markers. mutations in the beta-catenin gene are frequent. although considered benign, they are currently classified as low-grade malignant epithelial neoplasms. method: a -year-old woman presented with abdominal pain. a tumor in the pancreatic head with liver metastasis is diagnosed by tc. fine needle aspiration cytology is diagnostic of sptp. we reviewed four more cases of sptp. results: all five tumors occurred in women < years old that presented with abdominal pain or asymptomatic. tumors ranged from . to cm. four were located in the tail and one in the pancreatic head. all patients underwent surgery with negative margins. one patient had hepatic and nodal metastases as well as lymphatic and perineural invasion. all tumors were positive for cd and cd , three for progesterone receptors. none of the patients presented tumor recurrence ( months to years). conclusion: solid pseudopapillary tumor of the pancreas should be included in the differential diagnosis of pancreatic masses. surgery is usually curative and should also be attempted in rare cases with an aggressive behaviour. despite the characterization of the morphologic and molecular features of this enigmatic neoplasm, more work is needed to uncover its cell of origin and true histogenesis. objective: serous cystic neoplasms (scn) are rare pancreatic tumors. the aim of the study was to describe histopathological characteristics of scn diagnosed in a single center during a -year-long period. method: pathological reports including macro-and microscopic descriptions of scn cases as well as routine slides were retrieved from institutional databases and retrospectively reevaluated. only cases with available original slides were included in the study. results: several clinicopathologic scn subtypes were distinguished: serous microcystic adenomas ( . %), five serous oligocystic and ill-demarcated adenomas ( . %) and a single case of microcystic adenoma coexisting with multiple serous cysts in von hippel-lindau patient ( . %). there were females ( . %) and six males ( . %). median patients' age was years (range - years). fifteen cases ( . %) were localized in the head of the pancreas, ( . %) in the pancreatic body, and five ( . %) in the tail. median tumor diameter was . cm (range - cm, the diameter of three tumors was not known). eleven cases ( . %) were diagnosed in pancreaticoduodenectomy specimens, six ( . %) in middle segment pancreatectomy specimens, and four ( . %) in distal pancreatectomy specimens. six cases ( . %) were enucleated, two cases ( . %) were diagnosed in open biopsy and two ( . %) cases were found during autopsy. conclusion: scn is found in middle-aged or older patients, mainly women. scn may be localized in each pancreatic segment and grow to large masses. the reasons for preferential existence of scn in females remain unknown. p , ki- , cd expressions in gastrointestinal and pancreatic neuroendocrine tumors and the evaluation of these tumors with clinicopathological and prognostic parameters e. kimiloglu sahan*, n. erdogan, s. ceylan, i. ulusoy *taksim training hospital, dept. of pathology, istanbul, turkey objective: gastrointestinal and pancreatic neuroendocrine tumors (gepnets) originate from the cells of the diffuse endocrine system. their molecular genetic mechanism of development and progression is complex and remains largely unknown. the purpose of this study was to review the gastrointestinal and pancreatic neuroendocrine tumors and to investigate these tumours with an emphasis on their clinicopathological characteristics. postoperative period. another patient survived for years and died of unrelated cause. conclusion: pa occurs infrequently in young patients. although some cases are diagnosed early and may be treated with potentially curable surgery, long-term survivals are rather exceptional. granulomatous pancreatitis in a patient with lada type diabetes mellitus v. mandys*, m. kheck, m. andel * rd faculty of medicine, dept. of pathology, prague, czech republic objective: the aim of this presentation was to demonstrate an unusual case of granulomatous pancreatitis discovered in a patient suffering from the lada type diabetes mellitus. method: samples of pancreatic tissue obtained during the postmortem examination were processed by a routine histological technique. the slides were stained with h&e, trichrome and van gieson method. immunohistological methods were used to detect markers of endocrine cells of islets of langerhans and of macrophages. results: a -year-old female patient suffering from diabetes mellitus lada type, generalized atherosclerosis and hypertension died due to pulmonary embolism. lipomatosis of pancreatic tissue was observed during the postmortem examination. histologic examination of pancreatic tissue discovered multiple small non-caseating epithelioid cell and giant cell granulomas replacing the islets of langerhans. conclusion: to our knowledge, our case represents the first description of non-infectious granulomatous pancreatitis associated with diabetes mellitus of lada type. objective: evaluation of crohn's disease (cd) activity is crucial to optimize therapeutic strategies. differentiation between inflammatory and fibrostenotic lesions is decisive since the former are treated with drugs, while the latter require surgery. cd activity is based on a combination of clinical, biochemical, endoscopic and radiologic findings, which cannot reliably distinguish between both entities. in patients with refractory symptoms, therapy decisions rely heavily on histologic diagnosis. method: preoperative mr imaging was performed in cd patients undergoing elective bowel resection. mr evaluated wall thickness, pre-and post-contrast wall signal intensity, relative contrast enhancement, presence of edema, and luminal stenosis. matched histological sections of the mr images were stained with hematoxylin and eosin (he). evaluation of wall and submucosa thickness, percentage of inflammatory and fibrous components in the mucosa and submucosa (masson's trichromic and reticulin stains), submucosal edema, and vascularity (cd stains). results: cases assessed as inflammatory by he had higher early post-contrast signal intensity by rm than fibrostenotic cases (p= . ). submucosal thickness correlated with early fibrosis (reticulin, p= . ), but only a trend with high vascularity (cd ). fibrostenotic cases had submucosal thickness inversely correlated with early signal capture and with relative contrast enhancement. mucosal inflammation was inversely correlated with submucosal fibrosis and thickness (p= . ). established fibrosis (trichromic) had no delayed signal capture (p= . ). conclusion: there is a good correlation between histologic and mr findings. mr may reliably differentiate between inflammatory and fibrostenotic lesions, and it may have an important role as a new pre-surgical biomarker in the management of cd. the role of standard endoscopic biopsy in diagnosis of gastric gastrointestinal stromal tumors managed in the holycross cancer centre, kielce, poland, in years - w. rezner* *holycross cancer centre, dept. of neoplasm pathology, kielce, poland objective: intramural character of growth makes gastrointestinal stromal tumor (gist) difficult or impossible to access by endoscopic biopsy forceps, and therefore, the diagnostic yield of the biopsy does not exceed %, even with the use of special techniques. the aim of the study was to evaluate the role of standard endoscopic biopsy in preoperative assessment of gastric gists. method: from among cases of all gastric gists managed in our institution in the years - , we selected cases where standard forceps biopsy from subepithelial mass was obtained. we excluded five cases with no subepithelial mass visible endoscopically and two cases of small incidental gists in patients operated for other neoplasms. biopsies diagnosed as negative for gist were analysed retrospectively with serial sectioning and immunostains including, where appropriate, cd- , cd- , sma, s- and calponin in search for neoplastic tissue which could have not been apparent in original he-stained slides. results: none of the biopsy samples analysed retrospectively contained neoplastic tissue. material which enabled histopathological and immunohistochemical diagnosis of gist was obtained in out of cases. mucosal ulceration was present in all cases of diagnostic biopsies and in out of non-diagnostic biopsies. conclusion: no gist tissue was originally missed in biopsy material, so the diagnostic yield of standard endoscopic biopsy in diagnosis of gastric gists approached one third of the cases. immunohistochemical markers utilized in differential diagnosis between primary ovarian carcinoma from metastatic colorectal carcinoma a. iliesiu*, m. aschie, m. anca, n. anca, i. poinareanu, a. chisoi, p. corici, v. sarbu, i. aschie *clinical emergency hospital, dept. of pathology, constanta, romania objective: colorectal adenocarcinoma is the most common tumor that metastasizes to the ovary and is often difficult to distinguish from primary ovarian mucinous carcinoma. an immunohistochemical marker cdx- was found to have a diagnostic value in establishing the gastrointestinal origin of metastatic tumors. obtaining the correct diagnosis is difficult but crucial to treatment and prognosis. method: in our study realized in clinical county emergency hospital constanta, we evaluated the immunohistochemical expression of cdx and also the expression of cytokeratin , cytokeratin , cea, muc in cases representing ovarian adenocarcinoma and metastatic colorectal adenocarcinomas involving ovaries. results: searching the tumor registry and pathology database of our hospital, we found that the median age of the study group was years (range, - ). metastatic colorectal adenocarcinoma were almost always negative for muc ( . %), often negative for ck ( . %), focal or diffuse positive for cdx ( . %), diffuse positive for ck ( . %), focal or diffuse positive for muc ( . %), and diffuse positive for cea ( . %). almost all of the primary ovarian carcinomas lacked immunoreactivity for cdx- . in contrast, metastases to the ovary from colorectal primaries showed cdx- immunoexpression. conclusion: cdx- is a useful marker for differentiating primary ovarian carcinoma from carcinomas metastatic to the ovary. ck , ck , cdx and muc ihc staining is a useful adjunctive diagnostic tool to differentiate metastatic colonic tumours from primary ovarian tumours, in addition to clinical history and gross and microscopic findings. multicystic mesothelioma-a case report j. jeruc* *faculty of medicine, institute of pathology, ljubljana, slovenia objective: multicystic mesothelioma or multilocular peritoneal inclusion cyst is a rare tumor with a predilection for pelvic surfaces of the peritoneum. most frequently, it occurs in women of reproductive age who have a history of previous pelvic surgery or infection. results: a -year-old man with no significant past medical history presented with abdominal pain lasting days in the ileocecal region. despite normal white cell count, acute appendicitis was suspected and the patient underwent surgery, during which a multicystic mass measuring . cm in the longest diameter was found. cysts were thin-walled, translucent, with a smooth outer surface, and mostly filled with clear and some with hemorrhagic fluid. histologically, they were lined by a single layer of cuboidal polygonal and focally hobnailshaped cells with small uniform nuclei without mitotic activity. cells stained positive for cytokeratin, calretinin and wt- , but were negative for endothelial markers, cea and estrogen and progesterone receptors. the loose connective tissue between cysts was infiltrated by lymphocytes and granulocytes. the diagnosis of multicystic mesothelioma was made. threemonths after surgery, the patient is doing well. conclusion: the majority of investigators considers this entity to be an unusual type of mesothelial neoplasm that has a tendency to recur locally and may rarely transform into a conventional mesothelioma. some, however, consider the lesion to be a non-neoplastic reactive mesothelial proliferation. multicystic mesothelioma has an indolent course, but approximately one half of cases recur. the differential diagnosis includes malignant mesothelioma, cystic lymphangioma, pseudomyxoma peritonei and mesenteric and omental cysts. collagen iv expression, as staining of the continuous basement membranes of vessels, varied from % in lr gists to % to % in ir and hr tumors, respectively. gamma's correlation test revealed correlation between microhemorrhages and grade (r= . , p= . ), tumor necroses and p (r= . , p= . ), tumor necroses and collagen iv (r=− . , p= . ) and vegf and collagen iv (r=− . , p= . ). conclusion: this study showed that both high p expression and the presence of tumor microhemorrhages are possibly related with unfavorable prognosis. in addition, we found that a tumor necrosis was correlated with a p and collagen iv. smooth muscle tumors with cd /cd positivity cells s. rjabceva* *belarusian medical academy, dept. of pathology, minsk, belarus objective: immunohistochemically, smooth muscle cells are characterized expression of sma and desmin. the aim of this study was to describe the clinicopathological and immunohistochemical features of smooth muscle tumors (smt) with cd /cd positivity cells. method: eleven cases diagnosed as smt were examined by both light microscopy and immunohistochemistry (ihc). i used ihc markers such as cd , cd , smooth muscle actin, desmin, vimentin, nse and s . results: the patients (m/f= : ), with age ranging between and years (mean = . ), had smt. a tumor size varied from . to cm (mean = . cm). tumors were localized in the esophagus ( / . %), stomach ( / . %), colon ( / . %), retroperitoneum ( / . %) and in the pelvis ( / . %). histologically, tumors are composed of elongated or ovoid cells with pale nuclei and eosinophilic cytoplasm which is distinctly fibrillar. immunohistochemically, cells of smt were positive for sma ( %), desmin ( %), vimentin ( %) and nse ( . %), but they were negative for cd , cd and s . i found that the scattered cells of the tumors were characterized by the expression of cd ( / %), cd ( / . %) and s ( / . %). these cells were located diffusely or focally in the smt. the immunophenotype of these cells was similar to immunohistochemical features of the interstitial cells of cajal or the gastrointestinal stromal tumor (gist). conclusion: although the scattered tumor cells revealed cd positivity, the histological finding was similar to smt and was different from gist. smt colonized by cd /cd -positive cells should not be confused with gists. updates of tnm classification: for the better or worse? b. karabulut*, a. m. sonmez, d. turan, n. kursun, a. ensari *ankara university med school, turkey objective: for the prognostic evaluation of tumours, the tnm classification is updated periodically. the use of this classification for colorectal cancer (crc) has caused some problems in the assessment of metastatic lymph nodes. in this study, we have investigated the effect of the updates on metastatic lymph node interpretation and, hence, staging. method: h&e slides of cases of crc were reevaluated microscopically to assess the number of metastatic lymph nodes according to the criteria of tnm , tnm and tnm . clinical parameters such as gender and age of the patients, tumour location, grade, and stage were retrieved from the patients' files. mann-whitney, kruskal-wallis, wilcoxon signed ranks and multiple comparison tests were used for statistical analysis. results: there were men ( . %) and women ( . %) with a mean age of . years (ranging from to ). the tumour was located in the right colon in cases ( . %) and cases in the left colon ( . %). there were three grade ( . %), grade ( . %), and grade tumours ( . %). the number of metastatic lymph nodes was significantly higher in grade tumours compared to grade tumours in tnm , tnm and tnm . according to tnm , significantly more metastatic lymph nodes were determined than tnm and tnm (p< . and p < . , respectively), whereas tnm revealed significantly more metastatic lymph nodes in comparison to tnm (p< . ). conclusion: our results show that there is significant variation between updates of tnm in terms of metastatic lymph node yield which will inevitably cause variation in the tnm classification. objective: metastatic lesions to the mandible are rare, comprising < % of all malignancies. an -year-old woman presented with a painful swelling in the right mandible growing progressively for months. method: computed tomography (ct) showed intraosseous expansile and destructive lesion in the corpus of the right mandible × mm in size expanding to the soft tissue laterally. after administration of contrast material, moderate enhancement was seen throughout the mass. the biopsy showed stromal tumor immunopositivity for cd . the patient had a medical history of ileal tumor resection years ago at another institute which was diagnosed as gastrointestinal stromal tumor (gist) and classified as intermediate risk group for potential of malignancy. results: the mandibular tumor was considered as a metastatic gastrointestinal stromal tumor. no tumor was seen on positron emission tomography (pet)/ct other than the mass in the right mandible. the histopathology of the ileal tumor was seen and the diagnosis was confirmed. imatinib treatment was started at a dose of mg daily. resection of the mandibular mass was planned by plastic and reconstructive surgeons. conclusion: liver and peritoneum are usual metastatic sites for gastrointestinal stromal tumors. to the best of our knowledge, metastasis of ileal gastrointestinal stromal tumor to the mandible has not been previously reported in the english literature. objective: warthin's tumor is the second most common neoplasm of the parotid gland accounting for - % of parotid neoplasms. however, parotid gland is an extremely rare site for extrapulmonary tuberculosis. objective: the purpose of this study was to assess the immunohistochemical (ihc) status of androgen receptor (ar) in various salivary gland cancers. the study group consisted of cases of primary salivary gland cancers from patients (f/m= : , age - years). these were adenoid cystic carcinomas (adcc), adenocarcinomas nos (adc), mucoepidermoid carcinomas (mec), acinic cell carcinomas (acc), carcinomas ex pleomorphic adenomas (caexpa), salivary duct carcinomas (sdc), basal cell adenocarcinoma (bcac) and large cell neuroendocrine carcinoma (lcnec). ihc reactions with monoclonal mouse antihuman androgen receptor antibody (dako, clone ar ) were done on -μm-thick sections cut from representative archival paraffin block. in each positive case, the revealed strength of ar expression was assessed as total score (ts) according to allred score. results: the ar expression was found in five adc nos, four caexpa, four sdc, four acc, three mec, and one adcc and bcac, and calculated ts ranged from three to eight points. ts had eight points in six cases, seven in three cases, six in one case, five in three cases, four in two cases and three in four cases. conclusion: ar expression was found in of ( %) primary salivary gland cancers. the strength of ar expression differed in various salivary gland cancers, and it was most frequent in caexpa ( / ) and sdc ( / ) and less frequent in adc ( / ) and acc ( / ), whereas only found incidentally in others. mena expression in normal and neoplastic salivary glands g. simona* *umf, dept. of pathology, targu-mures, romania objective: recently, studies revealed that human orthologue of murine mena (mammalian ena), an actin regulatory protein involved in the control of cell motility and adhesion, is modulated during breast, colon and pancreatic carcinogenesis. in our previous studies, we observed that mena was modulated during colon and cervix carcinogenesis. in this study, we analysed mena expression in lesions of salivary glands (sg). previous studies regarded only maspin expression in these lesions, a protease inhibitor which is increased in benign tumors but decreased in sg carcinomas. method: we have analyzed mena expression in normal sg (n= ) and also benign (n= ) and malignant (n= ) lesions of sg. for the immunohistochemical staining, we used the murine mena antibody, provided by bd biosciences. mena expression was quantified in cytoplasma of tumor cells. results: all normal sg and their benign lesions were mena-negative. it included ten pleomorphic adenomas and ten warthin's tumors. ductal adenocarcinomas (n= ), independently by their histological grade and also carcinomas with acinary cells (n= ) and squamous carcinomas (n= ), were positive. no difference of mena intensity in positive cases was observed. all lymphomas (n= ) were mena-negative. conclusion: this is the first study in literature about mena expression in sg tumors. our results prove that mena plays a role in carcinogenesis of different organs, including sg, but the exact mechanism is not yet known. in accordance with different previous studies about maspin expression in sg lesions, it seems that these two antibodies are reversely correlated. future studies are necessary in order to elucidate their role in sg tumors. secondary tumors of the salivary glands a. c. faur* *university of medicine, 'v babes' timisoara, romania objective: secondary tumors of salivary glands are rare and constitute about % of all malignant salivary neoplasm. method: a study has been carried out for years on cases of salivary gland tumors, and only one case of salivary metastatic lesion was diagnosed. a -year-old female with a history of a right temporal malignant melanoma was admitted at the plastic surgery department of county hospital of timisoara. sixmonths after the surgery, the patient returned to this clinic with a rapidly growing mass in the right temporal region and right preauricular region. a × -cm diameter tumor was excised with adjacent lymph nodes. a superficial parotidectomy was performed also, preserving the facial nerve and its branches. formalin-fixed paraffin-embedded tissue samples were cut at μm and stained using hematoxylin and eosin (he). results: on he stain, the periparotid and temporal region lymph nodes were infiltrated by malignant melanoma cells. the parotid tissue also had metastatic lesions. the metastatic malignant melanoma lesion consisted of epithelioid neoplastic cells with cytologic and nuclear atypia, large nucleoli, atypic mitotic figures and abundant melanin pigmentation. necrosis and hemorrhage were also seen. conclusion: the parotid gland and its lymph nodes are possible sites of metastasis from head and neck tumors, especially squamous cell carcinoma or melanoma. the rarity of salivary secondary tumors prompted us to report this case. objective: primary intraosseous mucoepidermoid carcinoma of the jaws is a rare lesion accounting for < % of all mucoepidermoid carcinomas reported in the literature. it is a neoplasm of adult life and affects females twice more frequently than males. histologically, it is a low-grade carcinoma usually affecting the mandible. the radiologic presentation is that of uni-or multilocular lesions. their origin still remains controversial. method: we report the case of a -year-old female who presented with a painful swelling in the left maxilla of month's duration. there was no history of previous surgical intervention. clinical examination revealed an ulcerated swelling. cervical lymphadenopathy was absent. results: the radiological examination showed a unilocular compact lesion in the maxilla, not unequivocally diagnostic of malignancy. surgical excision of the lesion together with a small part of the maxilla was performed. grossly, it was a solid mass of relatively soft and only focally bony consistence measuring . cm. on brushing cytology of the surgical specimen, groups of mucous cells without any significant atypia intermingled with aggregates of squamous cells. the histologic diagnosis, confirmed by histochemical and immunohistochemical methods, was that of low-grade mucoepidermoid carcinoma of the maxilla. the postoperative period was uneventful. the patient is on regular follow-up and is disease-free after years. conclusion: our case is reported because of its rarity, and at the same time, the literature is reviewed and speculations about the pathogenesis of mucoepidermoid carcinomas are attempted. odontogenic myxoma (om) in the maxilla: a case report and review of the literature s. papaemmanouil*, n. pastelli *g. papanikolaou general hosp., dept. of pathology, thessaloniki, greece objective: odontogenic myxoma is an intraosseous tumor of the jaws, relatively benign with locally aggressive behaviour. most of the oms are slowly growing with no symptoms. large tumors cause painless expansion. it occurs in patients over the age of and is mostly located in the mandible. method: a -year-old man was presented with a progressively enlarging mass in the maxillary area. the imaging findings revealed a large, rather wellcircumscribed tumor mass in the body of the maxillary bone. the mass was excised by peripheral ostectomy. results: the gross examination revealed a grey-white mass with translucent mucinous appearance measuring × . × cm. the sections were examined with h+e and mucin stains and followed by ihc study for mib- (ki- ). the morphologic, histochemical and ihc data were consistent with an odontogenic myxoma. conclusion: our study comments on the imaging findings of macroscopic and microscopic features and the differential diagnosis of this tumor. the current literature is reviewed. objective: the role of interactions between mmp- , mmp- and kai protein expression as markers involved in aggressive behaviour of tumours is still under investigation. the study aimed to evaluate and compare mmp- , mmp- and kai expression in primary oral squamous cell carcinomas (oscc) and adjacent marginal normal squamous cell epithelium and to estimate their association with each other in relation to clinical variables. method: mmp- , mmp- , and kai expression was evaluated on primary oscc (n= ) and adjacent marginal normal tissues (n= ) using immunohistochemistry. results: significant differences between mmp- and kai expression was found in oscc and marginal normal tissue (p= . , p= . , respectively). in normal tissue, mmp- , mmp- expression was found in basal cell layers and also frequently was observed in stromal tissues with inflammatory component. kai protein was not observed in stromal tissues. no significant differences were observed between mmp- , mmp- , kai expression and tumour grade and stage. inverse correlation between mmp- and kai expression was found in oscc (p= . ). kai -negatve/ mmp- -positive cases were observed mainly in high tumour grade and in advanced stage of tumours. conclusion: inverse correlation revealed between kai protein and mmp- expression in oscc could affect the function of kai suppressor protein and influence the metastatic potential of the tumour cells. our results suggest that accumulation of mmp- and mmp- in the surrounding tissue may enhance local invasion in oscc. expression of mmp- and pten in laryngeal squamous cell carcinoma-biological predictors? m. bodnar*, p. burduk, w. kazmierczak, a. marszalek *collegium medicum, bydgoszcz, poland objective: reliable predictors of laryngeal squamous cell carcinoma (lscc) biology are still missing. the aim of this study was to investigate two newly discovered factors (mmp- and pten) in lscc patients with correlation to the stage of the disease. method: we used specimens from surgical resections selected from patients and divided into controls ( samples) and lscc ( samples). we used standard immunohistochemistry for mmp- and pten expression studies with envision system and dab as a chromogen. antigen expression was classified as followed: -no positive cells, -< %, - - %, -above % positive cells. all results were statistically evaluated using mann-whitney u test and anova, with statistical significance at p< . . results: in patients with lscc, the expression pten was detected in the cytoplasm of % tumor cells and % stromal area (p< . ) while in controls only in % of stromal area (p< . vs lscc). pten expression was decreased in tumor cells in n+ vs n cases ( % vs %). in lscc, mmp- was found in . % of the tumor cells, but in % of stromal area (p< . ). there was no mmp- expression in controls, while expression level ( - scale) was higher in tumor cells versus stromal compartment. mmp- stromal expression in n and n+ cases was % versus % of the area, respectively. conclusion: we might conclude that decreased pten expression in tumor cells predicts lymph node involvement, which then is accompanied by decreased expression of mmp- in stromal area in the main lesion. mucosal large cell neuroendocrine carcinoma (mlcnec) of the head and neck regions: a new clinicopathologic entity k. kusafuka*, m. abe, y. iida, t. onitsuka, t. nakajima *shiuzoka cancer center, pathology division, nagaizumi, japan objective: large cell neuroendocrine carcinoma (lcnec) is well known as a subtype of lung cancer, but it is extremely rare in the head and neck regions. our objective was to establish mucosal lcnec (mlcnec) as a new entity in the head and neck regions. method: we reestimated surgically resected specimens of the primary mucosal carcinoma in the head and neck regions, including basaloid squamous cell carcinoma, during - . the immunostainings for neuroendocrine (ne) markers such as cd , chromogranin-a and synaptophysin were performed. in the cases which were positive for two or three ne markers, we re-diagnosed as "mlcnec". results: only eight cases ( . %) were re-diagnosed as mlcnec. all cases were male and their mean age was . years. three cases occurred in the tongue base, four cases in the larynx and one case in hypopharynx. although seven cases showed numerous regional lymph node metastases, only one case showed death of disease. histologically, mlcnec showed the sheet-like, trabecular, organoid pattern growth of relatively large basaloid cells in which the central necrosis, rosette formation, peripheral palisading, and high mitotic figures were sometimes seen. immunohistochemically, mlcnec indicated to be positive for two or three ne markers. only three cases of mlcnec were immunopositive for ttf- , whereas all cases except one case were only focally immunopositive for p . all cases showed high proliferating activity. conclusion: we propose that mlcnec can occur in the head and neck regions and is a new clinicopathological entity. the prognosis of mlcnec remains unclear. objective: massive ovarian edema is an unusual cause of ovarian enlargement in young women. it is due to the accumulation of edema fluid and in some cases is associated with mature cystic teratoma. the patients are young (average age), with present abdominal pain, menstrual abnormalities or evidence of hypergonadism. the ovarian enlargement is unilateral in % of cases. method: we report a case of a -year-old girl with tumor of the left ovary. grossly, the enlarged ovary's greatest dimension was × cm ( , g), composed of solid mass with large gelatinous and hemorrhagic foci. paraffin sections from samples were stained with heeo and immunostained for vimentin, s protein, sma, desmin and cd . results: histological findings were identical in all slides. ovarian stroma cells were scattered within abundant edematous fluid, and in some foci, hypocellular stroma surrounded follicles. in the cortex, follicles were dilated in fibromatous stroma with rare luteinized cells. cd confirmed the presence of many vessels with thrombi composed of fibrin-causing hemorrhagic necrosis. in some areas of necrosis, we found foci of dystrophic calcification suggesting an older process. conclusion: massive ovarian edema is a lesion which can be misdiagnosed as a neoplasm. the cause is unclear. it has been attributed to intermittent torsion of the ovarian pedicle and interference with its lymphatic drainage. the fibromatosis and massive edema represent two ends of the same disorder. objective: intimal fibroplasia is a variant of fibromuscular dysplasia (fmd), a non-inflammatory and nonatherosclerotic arterial segmental disease, resulting in narrowing of the lumen. fmd of coronary arteries is a rare pathology associated with cardiac and sudden death occurring during infancy, childhood and young adulthood. method: we describe the case of a female infant born prematurely (gestational age + / ) presenting a mild supravalvular aortic stenosis associated with an atrial septal defect and cardiac valvular dysplasia. during the first weeks of life, she developed a progressive obstructive cardiomegaly and she died at day of a cardiogenic shock. results: the autopsy confirmed a marked cardiac hypertrophy and the aforementioned congenital cardiac anomalies. histologically, we observed a myxomatous thickening of the aortic, pulmonary and mitral valves and a significant segmental intimal fibroplasia of all coronary arteries, producing subtotal obstruction of the right coronary artery. the myocardium presented multiple areas of infarction of various ages and foci of interstitial fibrosis with calcifications. sampling of the aorta and its major branches showed mild to moderate intimal fibroplasia of the aorta, celiac trunk, superior mesenteric and left renal arteries. the pathogenesis of fmd is unclear: mural ischemia, hormonal, genetic and mechanical factors have been suggested. this case supports the theory of a congenital origin and emphasizes the importance of an extensive examination of coronary arteries when performing autopsy in paediatric patients as fmd is a segmental disease, and it must be considered in the etiologic differential diagnosis of cardiac and sudden death in paediatric age. increased amount of chorionic disc extravillous trophoblasts (evt) in placental hypoxia j. stanek* *cincinnati children's hospital, dept. of pathology, usa objective: increased amount of evt in the maternal floor was found in preeclamptic placentas. this analysis intends to retrospectively prove that the evt is increased in the whole chorionic disc also in other than preeclampsia clinical conditions at risk for fetal and placental hypoxia. method: frequencies of clinical and placental parameters of consecutive cases with more than five cell islands per full-thickness paracentral section of grossly unremarkable placenta (study group, sg) were compared to all remaining , placentas (control group, cg). results: the numbers of placental septa/cell islands were statistically significantly (p< . ) higher in the sg than in the cg in association with preeclampsia, chronic hypertension, diabetes mellitus, oligohydramnios, intrauterine growth restriction, induction of labor, cesarean sections, low -min apgar score, small placentas, placental infarction, massive perivillous fibrin deposition, decidual arteriolopathy, diffuse placental hypoxia, microscopic chorionic pseudocysts, and maternal floor clusters of multinucleate trophoblastic giant cells. the reverse was seen in the premature rupture of membranes, perinatal mortality, abnormal umbilical cord, acute chorioamnionitis, chronic villitis of unknown etiology, and histological placental meconium staining. conclusion: the amount of chorionic disc evt is increased in association with clinical conditions and placental lesions known to be associated with hypoxia, but is decreased in "non-hypoxic" clinical conditions and placental lesions. counting the placental septa and cells islands can serve as a surrogate test of placental hypoxia, not only in preeclampsia. pseudo-torch and the cerebro-costo-mandibular syndrome j. stanek*, a. oestreich *cincinnati children's hospital, dept. of pathology, usa objective: while the posterior rib gaps and pierre robin sequence are well documented, components of the cerebrocosto-mandibular syndrome (ccms), the "cerebral" part thereof is more variable, including mental retardation in survivors, hydrocephalus, severe hypoplasia of frontal and occipital lobes, abnormal olfactory bulbs, cerebral heterotopias, or gliosis. method: this is a case report of unusual brain findings in ccms, to our knowledge found for the first time at postmortem examination. results: because of fetal hydrops and congenital anomalies found on prenatal ultrasound, a -week pregnancy was terminated to reveal a fetus with multiple rib gaps, dysmorphic facial features, prominent micrognathia, higharched palate, club feet, dysplastic organ of corti, incomplete visceral rotation, pseudoglandular transformation of the pituitary gland, mucosal eosinophilia of the stomach and intestines, microcalcifications of liver, and extensive, diffuse, predominantly perivascular and not only periventricular brain calcifications. there was no laboratory evidence of intrauterine infection either clinically or by in situ hybridization. conclusion: this case illustrates a not yet described pseudo-torch, congenital infection-like, presentation of the ccms with extensive brain calcifications and mucosal eosinophilia of the gastrointestinal tract. extensive brain calcifications were described in other genetic syndromes such as baraitser-reardon syndrome, aicardi-goutieres syndrome, and mitochondrial encephalopathies, but not the ccmc. calcium metabolism can have genetic background in the ccms and explain cerebral dysfunction in at least a subset of the syndrome. objective: alveolar capillary dysplasia (acd) with or without misalignment of pulmonary veins (mpv) is an uncommon congenital cause of persistent pulmonary hypertension of the newborn characterized by a lack of alveolar and vascular development. most are sporadic, but familial acd/mpv has been reported, linked to the gene foxf on chromosome q . -q . . it is universally fatal and diagnosis is entirely dependent on the pathological examination of surgical lung biopsy specimen. four cases of acd, three with mpv, are reported. method: the four neonates were full term, without associated congenital anomalies. they were admitted to the paediatric intensive care unit for hypoxia and severe pulmonary hypertension unresponsive to maximal cardiorespiratory support, including high-frequency ventilation, inhaled nitric oxide and extracorporeal membrane oxygenation. results: surgical lung biopsies performed in three cases and postmortem lung examination in one case showed pathological findings of acd, characterized by poor capillary apposition and density and medial arterial hypertrophy. these lesions were associated with misalignment of pulmonary veins in three cases. the four infants died of refractory hypoxemia during the first months of life. conclusion: these observations emphasize the importance of considering acd with or without mpv in all newborn infants who present a persisting severe pulmonary hypertension without anatomical cause. histological diagnosis based on early surgical lung biopsy may prevent from using costly, invasive and ineffective treatments and procedures such as extracorporeal membrane oxygenation. a case of complete trisomy : autoptic, cytogenetic and radiologic findings e. gradhand*, s. becker, c. richter, d. wand, c. kunze, s. hauptmann *medizin. universität halle, institute of pathology, germany objective: an autopsy of a female fetus of the + nd gestational weeks was performed after an induced abortion due to multiple intrauterine malformations suspecting a chromosomal disorder. method: prior to the autopsy, the -g female fetus was extensively x-rayed. we performed an autopsy including histological examination of all organs. cytogenetic analysis was performed using both chorionic trophoblast and tendon fibroblasts. results: the fetus was characterized by pronounced global hydrops, craniofacial dysmorphy and malformations of both hands and feet. we found a complex cardiac malformation, unilobular lungs, dysmorphic liver and spleen, malrotated and doubled right kidneys, and an aplasia of the left kidney. the parenchymatous organs showed inconspicuous histomorphological architecture. in the cerebrum, no corpus callosum was found and immature neuronal rosettes in both optical nerves were detected. xray showed vertebral clefts, a slight hypertelorism, skeletal dysplasias of both hands, and confluent frontal and occipital fontanelles. cytogenetics turned out a complete trisomy (gtg-banding). conclusion: we present radiological, autoptic and cytogentic findings in a case of a very rare chromosomal aberration which mostly occurs as a mosaic or partial trisomy . this chromosomal abnormality usually induces early abortion. therefore, a fetus with trisomy and a gestational age of + weeks is very uncommon. we found multiple malformations of the skeleton and organs, mostly located in the midline. holoprosencephaly with cyclopia: presentation of two fetuses with multiple congenital malformations and investigation of sonic hedgehog (shh) expression p. papanastasopoulos*, j. coulouras, p. aroukatos, m. repanti, e. farri-kostopoulos, h. papadaki *general hospital agios andrea, dept. of pathology, patras, greece objective: holoprosencephaly is the commonest forebrain developmental anomaly occurring in of , live borns. sonic hedgehog is the major gene implicated in holoprosencephaly. method: two fetuses of -week and -week pregnancies, terminated due to multiple congenital malformations, were autopsied, and paraffin-embedded tissue sections were examined microscopically. shh expression was investigated immunohistochemically in orbital and cns sections. results: twenty-seven-week fetus: karyotype xx; alobar holoprosencephaly, true cyclopia, proboscis formation, pituitary gland anterior lobe agenesis, atretic anus and vagina, hypertrophic clitoris, female internal genitalia, right hand oligosyndactyly, left-sided overriding fourth and fifth toes, ventricular septal defect, hypoplastic left heart complex, truncus arteriosus, asplenia, irregular liver lobation, left kidney agenesis, right kidney cystic dysplasia, hypoplastic right ear auricle, external auditory meatus atresia. thirty-two-week fetus: karyotype xy; alobar holoprosencephaly, synophthalmia, proboscis formation, hypoplastic right heart complex, patent foramen ovale, ostium secundum defect, tricuspid valve and pulmonary artery atresia, pulmonary arteries analogous branching from the aorta. no teratogenetic factors and consanguinity were reported. histological examination revealed scattered rosette-like structures in areas of dysplastic retina in both cases. immunohistochemical expression of shh was negative. conclusion: the absence of shh immunostaining suggests a potential causative role in the pathogenesis of the above phenotypes. even though both karyotypes were normal, the authors could not exclude the possibility of the existence of chromosomal alterations not detectable by routine karyotypic analysis. finally, to our best knowledge, the above phenotypes do not seem to match any known clinical syndromes, and we therefore consider their origin unknown at present. the impact of nutritional colourant tartrazine (e ) on morphological state of thymus of rat descendants i. goryanikova*, i. sorokina *lugansk state medical university, dept. of pathomorphology, ukraine objective: synthetical colourant of yellow colour tartrazine (e ) whose application is prohibited in some countries of eu got widespread use. the aim of the work was the assessment of influence tartrazine to thymus of infant rat descendants month from birth from mothers who had been taking tartrazine during gestation and feeding. method: it was histologically discovered that density of cortical and medullar thymocytes was much higher than in the control group. mitosis is often diagnosed in the subcapsular zone. the most part of thymocytes of this zone is apoptosis amenable, cells with low concentration of dna in the nucleus, with the sings of dystrophy and necrosis often met. thymus medullary substance generally consists of fine lymphocytes. the small bodies of thymus, which are situated in medullary substance, are few in number and fine. results: immunohistochemical investigation with mca defined the signs of thymocyte-interrupted maturation of depletion of cd and cd population and macrophage ed and b lymphocytes cd ra amount rising. conclusion: thymus morphological specification of infant rats with tartrazine intoxication (during month) indicates frank hyperplasia of thymus lymphoid with underlying maturation retention, and component lymphocyte immunological differentiation points to antigenic activation, which influenced the test animals. objective: pleuropulmonary blastoma (ppb), a rare tumor arising during fetal lung development, can be part of an inherited cancer syndrome. about % of children with ppb have a family history of cystic nephroma and rhabdomyosarcoma. it is related to dicer mutations on q and consists in malignant mesenchymal cells and cysts lined by benign epithelium. method: we report our experience in a paediatric pathology center. two girls of and months presented pulmonary lesions, the first purely cystic and the second purely solid, corresponding histologically to early type i and type iii ppbs. results: the first patient underwent an upper lobectomy with an unremarkable postoperative outcome. the second patient presented a thoracic relapse years after initial treatment consisting in upper lobectomy, pre-and postoperative chemotherapy. tumoral karyotype revealed complex clonal chromosomal aberrations, dominated by interstitial q , q deletion and trisomy . no familial history of neoplasia. she is disease-free years after presentation. conclusion: ppb must be taken into account in the evaluation of cystic and even solid pulmonary lesions in children under years. a correct histologic diagnosis is needed to identify early ppb, which may be difficult to differentiate from congenital pulmonary airway malformation (cpam), to appropriately manage patients and to identify an inherited predisposition to ppb. recent data showed that dicer on q , a gene implicated in mirna synthesis, plays a crucial role in lung development. loss of dicer alters mirna-dependent regulation of diffusible growth factors that induce mesenchymal cell proliferation. results: pi ki ranging - % (median %) and topo a ranging - % (median %) were lower in children older than months (> m, p= . and p= . , respectively). the two markers were strongly interrelated (r= . ). higher ki- and topo a correlated with higher mki and adrenal location and inversely with increasing tumor differentiation. the cutoff values of pi ki ≥ % and topo a ≥ % correlated with fatal outcome of the disease. in the subgroup of patients, > m significant correlations between higher values of both pi markers and metastatic stage, unfavorable histology, high mki, mycn amplification, and adrenal localization were observed. at cutoffs ki ≥ % and topo a ≥ %, the markers predicted long-term unfavorable outcome by kaplan-meyer analysis. cox regression analysis indentified pi (assessed jointly as ki ≥ % + topo a ≥ %) as the independent prognostic factor. conclusion: ki and topo a pi markers have prognostic significance and clinicopathological correlations in nb. we propose to include pi to the standard histological assessment protocol of nb tumors. we decided to test the hypothesis that fatal cases of influenza occur mainly in association with important comorbidities as was stated based in previous studies. method: we included in our study patients with fatal ah n influenza. during autopsy, we largely sampled vital organs-brain, lungs, heart, liver, kidney, lymphoid organslymph nodes and spleen and any other diseased organ. results: in our group, sex ratio was male/female = . : ; patients were and years old (mean age . ). nine women were pregnant/parturient ( . %). other patients presented obesity, malignant neoplasia, diabetes mellitus, cardiac diseases and tuberculosis. we analyzed the prevalence of these comorbidities in the general population (see table) . however, patients did not have any comorbidities or any known cause of immunosuppression. conclusion: our study group was heterogeneous with a large age distribution and different associated diseases. we identified new risk factors for fatal outcome in ah n patients (obesity and/or pregnancy) and exclude other diseases as risk factor for severe evolution (diabetes mellitus). we have to emphasise that in half of the cases, there were no comorbidities or special status to actuate the severity of the disease. these findings are reinforcing the statement that the novel influenza has a different behavior than common influenza. objective: we present the first case reporting the exceptional association of whipple's and crohn's disease. method: a -year-old man developed since diarrhea, abdominal pain, weight loss, and polyarthralgia. endoscopy showed aphthous ulcers in terminal ileum and colon. histology revealed a rich collection of epithelioid granulomas in the lamina propria with chronic inflammation. a diagnosis of crohn's disease (cd) was given and steroid therapy was administered. diarrhea and abdominal pain quickly subsided. perduring a severe weight loss, a gastroduodenal endoscopy was performed. oedema with whitish spots in the duodenum was observed. histology demonstrated lymphangiectasia and an infiltration of pas positive foamy histiocytes in the lamina propria. immunohistochemistry for tropheryma whipplei was positive. results: whipple's disease (wd) diagnosis was made and an antibiotic therapy was given. in respect to symptomatic improvement, persistence of the bacterium was demonstrated in the following performed gastric and duodenal biopsies. immunohistochemistry in previous ileal and bowel specimens was positive in the ileum. conclusion: in wd, the macrophages seem to be of central importance in the development of the disease. this infection shares with cd the pathogenetic hypothesis that a defect in cellular immune response contributes to the development of the disorder. evidences also suggest that bacteria play a role in the onset and perpetuation of cd. this case strengthens the immunological hypothesis in the pathogenesis of the disorders. the functional defect of the macrophages caused by wd can explain the amazing number of granulomas in crohn's-affected specimens. the double immunological defect due to cd and cd may contribute to the lack of eradication of the bacteria. objective: the aim of the study was to analyze the experience obtained during pathological diagnosis using digital microscopy and telepathology. method: there were microscopic examinations performed over the internet using a dynamic digital microscope nicon-coolscope, scanners aperio-scanscope and olympus dotslide, between january and march . the study included intraoperative studies, cytology specimens and oligobiopsies. the specimens were prepared and sent electronically by four cytotechnicians and assessed by five pathologists. all diagnoses were verified through routine, light microscopy assessments. results: in cases of intraoperative, frozen sections studies as well as oncologically positive cytological diagnoses, above % agreement was noted between the diagnoses made due to evaluation over the internet and the routine assessment. the agreement of % was achieved in cases of benign lesions and the assessment of bronchial surgical margins. conclusion: ( ) the efficiency of histological slide examination by sending digital images via the internet in cases of intraoperative frozen sections during thoracic surgery or to confirm "positive" results is comparable to the traditional assessment in a light microscope. ( ) application of this method enables surgeons at the hospitals which do not have a readily available pathologist to perform the surgical procedures. objective: optimum diagnosis of glomerulopathies requires light microscopy, immunofluorescence and electron microcopy. in fact, electron microscopy has a confirmatory role in glomerular diseases. in this study, the value of electron microscopy in the diagnosis of glomerulopathies in children was investigated. method: the contribution of electron microscopy to the final diagnosis was graded as necessary-diagnosis could not be reached without it; supportive-it increased the level of confidence in the final diagnosis; and noncontributorythe diagnosis does not need electron microscopy for confirmation. results: one hundred thirty-four cases of renal biopsy with some clinical data are reviewed. the contribution of electron microscopy to the final diagnosis was necessary in cases ( %), supportive in cases ( %) and noncontributory in cases ( %). conclusion: it is concluded that ultrastructural study was an essential tool in the study of renal biopsy in childhood glomerulopathies, suggesting that electron microscopy still remains a useful tool in the diagnosis of glomerular disease. ki- , p , p kip- , p and bcl- proteins were ihc-investigated in bph from all patients. results: the incidences of lpc (gleason score ), chronic prostatitis, proliferative inflammatory atrophy (pia) and prostatic intraepithelial neoplasia (pin) were . %, . %, %, and . % in group and . %, . %, . %, and . % in group , respectively. greatly elevated levels of p , ki- , and bcl- associated with decreased levels of p kip- and p in areas of pia and less lpc and pin in group compared with group patients were obtained with statistically significant differences. conclusion: our study suggests that chronic long-term low-dose radiation exposure might result in the increase of chronic inflammation, and it is now found to be associated with increased incidences of pia and pin in bph accompanied by p , p kip- , and bcl- alteration, which in turn could lead to prostate carcinogenesis. mixed peripheral ductal prostatic adenocarcinoma in radical prostatectomies: a five-year experience in a small spanish community hospital c we performed immunohistochemistry to characterise the expression of the immunoreactivity for synaptophysin, chromogranin, p , ki and cd . results: mean age of the patients was . ± . . thirteen ( . %) of the patients were males and eight ( . %) of the patients were females. the method of statistics we used was spss . . according to spearman's correlation test, there was a good correlation between ki- expression and tumor type (p< . , r = . ). also, there was a good correlation between p expression and tumor type ck and ki- immunohistochemical staining in gastroenteropancreatic neuroendocrine tumours of ( %) were g , of ( %) were g , and of ( %) g . four pancreatic tumours and six gi tumours had distant metastases. of the four pancreatic tumours, two were g , one was g , and one was g ; two stained diffusely with ck , while the remaining two showed weaker staining. three metastatic gi tumours were g and three were g ; allred score for ck was - in five of six ( %) pancreatic adenocarcinoma (pa) is a very rare lesion in young patients. patients in the age of or younger reported previously constituted < % of all patients with pa. the clinical and histopathological data concerning these patients are therefore scanty. the aim of the study was to describe characteristics of young patients with pa treated and diagnosed in a only cases with available original slides were included in the study. results: there were ( . %) cases of pancreatic ductal adenocarcinomas (not otherwise specified), two ( . %) cases of adenocarcinoma associated with intraductal papillary mucinous neoplasm and a single ( %) case of adenosquamous carcinoma. twenty ( . %) patients were males and ( . %) were females. median age of patients was . years (range - ). twenty-one ( . %) patients were treated with pancreaticoduodenectomy, three ( . %) with distal pancreatectomy, and two ( . %) with total pancreatectomy. in seven ( . %) patients, pa was diagnosed in open surgical biopsy specimen (the majority of these patients were treated with palliative surgery) objective: we analysed a series of upper gastrointestinal (gi) adenocarcinomas treated by neoadjuvant chemotherapy (ctx) between and , which all were consistently worked up and evaluated by a standardized tumor regression grading system (trg) in our institution. method: one hundred eight esophageal adenocarcinomas (ea), adenocarcinomas of the esophagogastric junction (aej) and gastric carcinomas (gc) treated by a cisplatin/ -fu-based ctx were included. trg was determined using a four-tiered system based on the estimation of the percentage of residual tumor in relation to the previous tumor bed. results: in total, patients ( %) had a complete tumor regression (trg a) and patients ( %) had a subtotal regression (trg b, - % residual tumor). partial tumor regression (trg , - %) was observed in cases ( %); patients ( %) had minimal or no regression (trg , > %). tumor regression was significantly associated with post-treatment ypt, ypn, ypl category, r status and survival (p< . ) and was shown to be an independent prognostic factor for survival (p= . ). some characteristics relating to the tumor site were, in particular, the higher frequency of total or subtotal tumor regression in ea and aeg (p< . ) and the association of pretherapeutic tumor grading and lauren's classification with tumor regression (p= . ) in gc. conclusion: we present our year's experience of a highly standardized evaluation of upper gi adenocarcinomas after neoadjuvant ctx demonstrating highly objective and prognostic relevant information from a very large collective. we recommend the implementation of a standardised trg system in every pathological report of these tumours. objective: fibroelastotic changes (fec) of the gastrointestinal tract (git) are rare lesions. only cases have been reported in the literature. their role as an own entity is unclear and is not generally accepted. method: after initial recognition of an elastotic lesion in a hemicolectomy specimen, special attention was paid to amorphic accumulations in h&e-stained slides of git specimens. elastica-van-giesson staining was performed to verify the elastotic origin. results: within years, a total number of polypoid lesions were collected. one lesion was found in the ileum and six lesions occurred in the stomach. the remaining cases were colon specimens. in five cases, fec were associated with neoplastic lesions. in cases, however, the accumulation of elastotic fibres was the only histomorphological finding. one patient received intensive short intervals surveillance because of a highly suspicious endoscopic finding in the stomach. in two cases, a clinical relevant stenosis was caused by a submucosal thickening of the bowl wall with massive accumulation of elastotic fibres. right hemicolectomy was performed in both cases. conclusion: fibroelastotic changes are not as exceedingly rare as thought before. they are the only histological finding in a certain number of polypoid lesions in the git. expression of p , vegf and collagen iv in gastrointestinal stromal tumors and its relationship with clinicopathological parameters s. rjabceva*, y. rogov, i. dulinez, m. vozmitel, a. krilov *belarusian medical academy, dept. of pathology, minsk, belarusobjective: gastrointestinal stromal tumors (gists) have a spectrum from minimal indolent tumors to sarcomas. the aim of this study was to assess the expression of p , vegf and collagen iv in gists and to establish immunohistochemical correlations with clinicopathological parameters. method: twenty-four cases diagnosed as gist were examined by both light microscopy and immunohistochemistry (ihc). we used ihc markers such as p , vegf and collagen iv. all tumors were classified by the risk grade system by miettinen et al. results: of the tumors, / . % were classified into low risk grade (lr), / % in the intermediate risk (ir) and / . % in the high risk group (hr). focal necroses ( %, % and %, respectively) and microhemorrhages ( . %, % and %, respectively) were present in gists of all groups. a p expression was correlated with a high risk grade (r= . , p= . ). gists of all groups showed vegf expression ( . %, . % and %, respectively).objective: novel influenza is an acute viral infection of the respiratory tract caused by type a influenza virus, affecting by now the entire world. although the illness is mild and self-limited in a great majority of cases, few patients may have a severe clinical course eventually leading to death. method: we studied necroptic tissue samples from patients submitted over a -month period from a total of , positive cases identified in romania since the outbreak of this type of influenza. data collected included demographic and clinical information. results: most of the patients ( . %) were adults between and years (median age, . years), male/female ration . : . the vast majority of the cases revealed diffuse alveolar damage, interstitial pneumonia and bronchopneumonia, all of them associating severe cytopathic effect in the bronchial and alveolar epithelial cells; cases presented pulmonary ischemic lesions. more than half of the cases ( . %) presented myocardial interstitial inflammatory infiltrate with full-blown picture of myocarditis in patients. of the patients, . % had lymphocytic depletion in lymphoid organs. lymphocytic meningitis, meningothelial hyperplasia, acute tubular necrosis, and liver steatosis were identified in some cases. objective: hpv dna has been identified in almost all cervical cancers, and women with active hpv infection (hpvi) express e /e oncogenes. as only a small proportion of infections progress towards cancer, it is important to distinguish transient hpvis from persistent or progressive ones. method: one hundred ninety-six samples were tested by conventional pap smear, hpv-dna test and typing, e /e -mrna expression from hpv types , , , , . kstatistic value was used in order to identify possible significant associations. results: pap-smear: negative (neg), ( . %); atypical cells of undetermined significance (ascus), ( . %); low-grade squamous intraepithelial lesion (lsil), ( . %); high-grade squamous intraepithelial lesion (hsil), ( . %). one hundred ninety-two of samples ( . %) were positive to the hpv-dna test and of ( objective: etiology of multiple sclerosis (ms) includes the virus infection which plays probably an important cofactor role in the pathogenesis of disease. clinical and morphological analysis of the cases of chronic herpetic meningoencephalitis (chme) and ms permitted to discover two cases of a combination of diseases: man, age years (onset of ms since years), and woman, age years (onset of ms since years). results: autopsy revealed the small plaques in white matter of brain and cord and some foyers of necrosis in frontal lobe and brain stem. the histological signs of chronic inflammation were established in both cases. leptomeninges and brain were infiltrated by lymphocytes and macrophages (perivascular cuffs). the progressive lesions of cortical neurons and proliferation of macroglial cells were constant histological findings. etiological diagnosis of chme was established on the base of typical intranuclear viral inclusion types i and ii in the cells of brain as well as on the revealing of hsv antigens in histological slice. laminar nonischemic necrosis was found in the cortex of frontal and parietal lobes. in the brain stem, necrosis appeared as the small foci of destruction of nervous tissue. in one case, laminar necrosis were detected in white matter of hippocampe. conclusion: thus, the morphological investigation on the light microscopic level permits correctly to recognize the combination of ms and chme. key: cord- - qfecv h authors: velasquez, t.; mackey, g.; lusk, j.; kyle, u. g.; fontenot, t.; marshall, p.; shekerdemian, l. s.; coss-bu, j. a.; nishigaki, a.; yatabe, t.; tamura, t.; yamashita, k.; yokoyama, m.; ruiz-rodriguez, j. c.; encina, b.; belmonte, r.; troncoso, i.; tormos, p.; riveiro, m.; baena, j.; sanchez, a.; bañeras, j.; cordón, j.; duran, n.; ruiz, a.; caballero, j.; nuvials, x.; riera, j.; serra, j.; rutten, a. m. f.; van ieperen, s. n. m.; der kinderen, e. p. h. m.; van logten, t.; kovacikova, l.; skrak, p.; zahorec, m.; kyle, u. g.; akcan-arikan, a.; silva, j. c.; mackey, g.; lusk, j.; goldsworthy, m.; shekerdemian, l. s.; coss-bu, j. a.; wood, d.; harrison, d.; parslow, r.; davis, p.; pappachan, j.; goodwin, s.; ramnarayan, p.; chernyshuk, s.; yemets, h.; zhovnir, v.; pulitano’, s. m.; de rosa, s.; mancino, a.; villa, g.; tosi, f.; franchi, p.; conti, g.; patel, b.; khine, h.; shah, a.; sung, d.; singer, l.; haghbin, s.; inaloo, s.; serati, z.; idei, m.; nomura, t.; yamamoto, n.; sakai, y.; yoshida, t.; matsuda, y.; yamaguchi, y.; takaki, s.; yamaguchi, o.; goto, t.; longani, n.; medar, s.; abdel-aal, i. r.; el adawy, a. s.; mohammed, h. m. e. h.; mohamed, a. n.; parry, s. m.; knight, l. d.; denehy, l.; de morton, n.; baldwin, c. e.; sani, d.; kayambu, g.; da silva, v. z. m.; phongpagdi, p.; puthucheary, z. a.; granger, c. l.; rydingsward, j. e.; horkan, c. m.; christopher, k. b.; mcwilliams, d.; jones, c.; reeves, e.; atkins, g.; snelson, c.; aitken, l. m.; rattray, j.; kenardy, j.; hull, a. m.; ullman, a.; le brocque, r.; mitchell, m.; davis, c.; macfarlane, b.; azevedo, j. c.; rocha, l. l.; de freitas, f. f. m.; cavalheiro, a. m.; lucinio, n. m.; lobato, m. s.; ebeling, g.; kraegpoeth, a.; laerkner, e.; de brito-ashurst, i.; white, c.; gregory, s.; forni, l. g.; flowers, e.; curtis, a.; wood, c. a.; siu, k.; venkatesan, k.; muhammad, j. b. h.; ng, l.; seet, e.; baptista, n.; escoval, a.; tomas, e.; agrawal, r.; mathew, r.; varma, a.; dima, e.; charitidou, e.; perivolioti, e.; pratikaki, m.; vrettou, c.; giannopoulos, a.; zakynthinos, s.; routsi, c.; atchade, e.; houzé, s.; jean-baptiste, s.; thabut, g.; genève, c.; tanaka, s.; lortat-jacob, b.; augustin, p.; desmard, m.; montravers, p.; de molina, f. j. gonzález; barbadillo, s.; alejandro, r.; Álvarez-lerma, f.; vallés, j.; catalán, r. m.; palencia, e.; jareño, a.; granada, r. m.; ignacio, m. l.; cui, n.; liu, d.; wang, h.; su, l.; qiu, h.; li, r.; jaffal, k.; rouzé, a.; poissy, j.; sendid, b.; nseir, s.; paramythiotou, e.; rizos, m.; frantzeskaki, f.; antoniadou, a.; vourli, s.; zerva, l.; armaganidis, a.; riera, j.; gottlieb, j.; greer, m.; wiesner, o.; martínez, m.; acuña, m.; rello, j.; welte, t.; atchade, e.; mignot, t.; houzé, s.; jean-baptiste, s.; thabut, g.; lortat-jacob, b.; tanaka, s.; augustin, p.; desmard, m.; montravers, p.; soussi, s.; dudoignon, e.; ferry, a.; chaussard, m.; benyamina, m.; alanio, a.; touratier, s.; chaouat, m.; lafaurie, m.; mimoun, m.; mebazaa, a.; legrand, m.; sheils, m. a.; patel, c.; mohankumar, l.; akhtar, n.; noriega, s. k. pacheco; aldana, n. navarrete; león, j. l. Ávila; baquero, j. durand; bernal, f. fernández; ahmadnia, e.; hadley, j. s.; millar, m.; hall, d.; hewitt, h.; yasuda, h.; sanui, m.; komuro, t.; kawano, s.; andoh, k.; yamamoto, h.; noda, e.; hatakeyama, j.; saitou, n.; okamoto, h.; kobayashi, a.; takei, t.; matsukubo, s.; rotzel, h. b.; lázaro, a. serrano; prada, d. aguillón; gimillo, m. rodriguez; barinas, o. diaz; cortes, m. l. blasco; franco, j. ferreres; roca, j. m. segura; carratalá, a.; gonçalves, b.; turon, r.; mendes, a.; miranda, f.; mata, p. j.; cavalcanti, d.; melo, n.; lacerda, p.; kurtz, p.; righy, c.; rosario, l. e. de la cruz; lesmes, s. p. gómez; romero, j. c. garcía; herrera, a. n. garcía; pertuz, e. d. díaz; sánchez, m. j. gómez; sanz, e. regidor; hualde, j. barado; hernández, a. ansotegui; irazabal, j. m. guergué; spatenkova, v.; bradac, o.; suchomel, p.; urli, t.; lazzeri, e. heusch; aspide, r.; zanello, m.; perez-borrero, l.; garcia-alvarez, j. m.; arias-verdu, m. d.; aguilar-alonso, e.; rivera-fernandez, r.; mora-ordoñez, j.; de la fuente-martos, c.; castillo-lorente, e.; guerrero-lopez, f.; lesmes, s. p. gómez; rosario, l. e. de la cruz; pertuz, e. d. díaz; hernández, a. ansotegui; romero, j. c. garcía; sánchez, m. j. gómez; herrera, a. n. garcía; ramírez, j. roldán; sanz, e. regidor; hualde, j. barado; león, j. p. tirapu; navarro-guillamón, l.; cordovilla-guardia, s.; iglesias-santiago, a.; guerrero-lópez, f.; fernández-mondéjar, e.; vidal, a.; perez, m.; juez, a.; arias, n.; colino, l.; perez, j. l.; pérez, h.; calpe, p.; alcala, m. a.; robaglia, d.; perez, c.; lan, s. k.; cunha, m. m.; moreira, t.; santos, f.; lafuente, e.; fernandes, m. j.; silva, j. g.; rosario, l. e. de la cruz; lesmes, s. p. gómez; herrera, a. n. garcía; romero, j. c. garcía; pertuz, e. d. díaz; sánchez, m. j. gómez; sanz, e. regidor; echeverría, j. g. armando; hernández, a. ansotegui; hualde, j. barado; podlepich, v.; sokolova, e.; alexandrova, e.; lapteva, k.; kurtz, p.; shuinotsuka, c.; rabello, l.; vianna, g.; reis, a.; cairus, c.; salluh, j.; bozza, f.; torres, j. c. barrios; araujo, n. j. fernández; garcía-olivares, p.; keough, e.; dalorzo, m.; tang, l. k.; de sousa, i.; díaz, m.; marcos-zambrano, l. j.; guerrero, j. e.; gomez, s. e. zamora; lopez, g. d. hernandez; cuellar, a. i. vazquez; nieto, o. r. perez; gonzalez, j. a. castanon; bhasin, d.; rai, s.; singh, h.; gupta, o.; bhattal, m. k.; sampley, s.; sekhri, k.; nandha, r.; aliaga, f. a.; olivares, f.; appiani, f.; farias, p.; alberto, f.; hernández, a.; pons, s.; sonneville, r.; bouadma, l.; neuville, m.; mariotte, e.; radjou, a.; lebut, j.; chemam, s.; voiriot, g.; dilly, m. p.; mourvillier, b.; dorent, r.; nataf, p.; wolff, m.; timsit, j. f.; ediboglu, o.; ataman, s.; ozkarakas, h.; kirakli, c.; vakalos, a.; avramidis, v.; obukhova, o.; kurmukov, i. a.; kashiya, s.; golovnya, e.; baikova, v. n.; ageeva, t.; haritydi, t.; kulaga, e. v.; rios-toro, j. j.; perez-borrero, l.; aguilar-alonso, e.; arias-verdu, m. d.; garcia-alvarez, j. m.; lopez-caler, c.; de la fuente-martos, c.; rodriguez-fernandez, s.; sanchez-orézzoli, m. gomez; martin-gallardo, f.; nikhilesh, j.; joshi, v.; villarreal, e.; ruiz, j.; gordon, m.; quinza, a.; gimenez, j.; piñol, m.; castellanos, a.; ramirez, p.; jeon, y. d.; jeong, w. y.; kim, m. h.; jeong, i. y.; ahn, m. y.; ahn, j. y.; han, s. h.; choi, j. y.; song, y. g.; kim, j. m.; ku, n. s.; shah, h.; kellner, f.; rezai, f.; mistry, n.; yodice, p.; ovnanian, v.; fless, k.; handler, e.; alejos, r. martínez; romeu, j. d. martí; antón, d. gonzález; quinart, a.; martí, a. torres; llaurado-serra, m.; lobo-civico, a.; ventura-rosado, a.; piñol-tena, a.; pi-guerrero, m.; paños-espinosa, c.; peralvo-bernat, m.; marine-vidal, j.; gonzalez-engroba, r.; montesinos-cerro, n.; treso-geira, m.; valeiras-valero, a.; martinez-reyes, l.; sandiumenge, a.; jimenez-herrera, m. f.; helyar, s.; riozzi, p.; noon, a.; hallows, g.; cotton, h.; keep, j.; hopkins, p. a.; taggu, a.; renuka, s.; sampath, s.; rood, p. j. t.; frenzel, t.; verhage, r.; bonn, m.; pickkers, p.; van der hoeven, j. g.; van den boogaard, m.; corradi, f.; melnyk, l.; moggia, f.; pienovi, r.; adriano, g.; brusasco, c.; mariotti, l.; lattuada, m.; bloomer, m. j.; coombs, m.; ranse, k.; endacott, r.; maertens, b.; blot, k.; blot, s.; amerongen, m. p. van nieuw; van der heiden, e. s.; twisk, j. w. r.; girbes, a. r. j.; spijkstra, j. j.; riozzi, p.; helyar, s.; cotton, h.; hallows, g.; noon, a.; bell, c.; peters, k.; feehan, a.; keep, j.; hopkins, p. a.; churchill, k.; hawkins, k.; brook, r.; paver, n.; endacott, r.; maistry, n.; van wijk, a.; rouw, n.; van galen, t.; evelein-brugman, s.; taggu, a.; krishna, b.; sampath, s.; putzu, a.; fang, m.; berto, m. boscolo; belletti, a.; cassina, t.; cabrini, l.; mistry, m.; alhamdi, y.; welters, i.; abrams, s. t.; toh, c. h.; han, h. s.; gil, e. m.; lee, d. s.; park, c. m.; winder-rhodes, s.; lotay, r.; doyle, j.; ke, m. w.; huang, w. c.; chiang, c. h.; hung, w. t.; cheng, c. c.; lin, k. c.; lin, s. c.; chiou, k. r.; wann, s. r.; shu, c. w.; kang, p. l.; mar, g. y.; liu, c. p.; dubó, s.; aquevedo, a.; jibaja, m.; berrutti, d.; labra, c.; lagos, r.; garcía, m. f.; ramirez, v.; tobar, m.; picoita, f.; peláez, c.; carpio, d.; alegría, l.; hidalgo, c.; godoy, k.; bakker, j.; hernández, g.; sadamoto, y.; katabami, k.; wada, t.; ono, y.; maekawa, k.; hayakawa, m.; sawamura, a.; gando, s.; marin-mateos, h.; perez-vela, j. l.; garcia-gigorro, r.; peiretti, m. a. corres; lopez-gude, m. j.; chacon-alves, s.; renes-carreño, e.; montejo-gonzález, j. c.; parlevliet, k. l.; touw, h. r. w.; beerepoot, m.; boer, c.; elbers, p. w. g.; tuinman, p. r.; abdelmonem, s. a.; helmy, t. a.; el sayed, i.; ghazal, s.; akhlagh, s. h.; masjedi, m.; hozhabri, k.; kamali, e.; zýková, i.; paldusová, b.; sedlák, p.; morman, d.; youn, a. m.; ohta, y.; sakuma, m.; bates, d.; morimoto, t.; su, p. l.; chang, w. y.; lin, w. c.; chen, c. w.; facchin, f.; zarantonello, f.; panciera, g.; de cassai, a.; venrdramin, a.; ballin, a.; tonetti, t.; persona, p.; ori, c.; del sorbo, l.; rossi, s.; vergani, g.; cressoni, m.; chiumello, d.; chiurazzi, c.; brioni, m.; algieri, i.; tonetti, t.; guanziroli, m.; colombo, a.; tomic, i.; colombo, a.; crimella, f.; carlesso, e.; gasparovic, v.; gattinoni, l.; neto, a. serpa; schmidt, m.; pham, t.; combes, a.; de abreu, m. gama; pelosi, p.; schultz, m. j.; katira, b. h.; engelberts, d.; giesinger, r. e.; ackerley, c.; yoshida, t.; zabini, d.; otulakowski, g.; post, m.; kuebler, w. m.; mcnamara, p. j.; kavanagh, b. p.; pirracchio, r.; rigon, m. resche; carone, m.; chevret, s.; annane, d.; eladawy, s.; el-hamamsy, m.; bazan, n.; elgendy, m.; de pascale, g.; vallecoccia, m. s.; cutuli, s. l.; di gravio, v.; pennisi, m. a.; conti, g.; antonelli, m.; andreis, d. t.; khaliq, w.; singer, m.; hartmann, j.; harm, s.; carmona, s. alcantara; almudevar, p. matia; abellán, a. naharro; ramos, j. veganzones; pérez, l. pérez; valbuena, b. lobo; sanz, n. martínez; simón, i. fernández; arrigo, m.; feliot, e.; deye, n.; cariou, a.; guidet, b.; jaber, s.; leone, m.; resche-rigon, m.; baron, a. vieillard; legrand, m.; gayat, e.; mebazaa, a.; balik, m.; kolnikova, i.; maly, m.; waldauf, p.; tavazzi, g.; kristof, j.; herpain, a.; su, f.; post, e.; taccone, f.; vincent, j. l.; creteur, j.; lee, c.; hatib, f.; jian, z.; buddi, s.; cannesson, m.; fileković, s.; turel, m.; knafelj, r.; gorjup, v.; stanić, r.; gradišek, p.; cerović, o.; mirković, t.; noč, m.; tirkkonen, j.; hellevuo, h.; olkkola, k. t.; hoppu, s.; lin, k. c.; hung, w. t.; chiang, c. c.; huang, w. c.; juan, w. c.; lin, s. c.; cheng, c. c.; lin, p. h.; fong, k. y.; hou, d. s.; kang, p. l.; wann, s. r.; chen, y. s.; mar, g. y.; liu, c. p.; paul, m.; bougouin, w.; geri, g.; dumas, f.; champigneulle, b.; legriel, s.; charpentier, j.; mira, j. p.; sandroni, c.; cariou, a.; zimmerman, j.; sullivan, e.; noursadeghi, m.; fox, b.; sampson, d.; mchugh, l.; yager, t.; cermelli, s.; seldon, t.; bhide, s.; brandon, r. a.; brandon, r. b.; zwaag, j.; beunders, r.; pickkers, p.; kox, m.; gul, f.; arslantas, m. k.; genc, d.; zibandah, n.; topcu, l.; akkoc, t.; cinel, i.; greco, e.; lauretta, m. p.; andreis, d. t.; singer, m.; garcia, i. palacios; cordero, m.; martin, a. diaz; pallás, t. aldabó; montero, j. garnacho; rey, j. revuelto; malo, l. roman; montoya, a. a. tanaka; martinez, a. d. c. amador; ayala, l. y. delgado; zepeda, e. monares; granillo, j. franco; sanchez, j. aguirre; alejo, g. camarena; cabrera, a. rugerio; montenegro, a. pedraza; pham, t.; beduneau, g.; schortgen, f.; piquilloud, l.; zogheib, e.; jonas, m.; grelon, f.; runge, i.; terzi, n.; grangé, s.; barberet, g.; guitard, p. g.; frat, j. p.; constan, a.; chrétien, j. m.; mancebo, j.; mercat, a.; richard, j. c. m.; brochard, l.; soilemezi, e.; koco, e.; savvidou, s.; nouris, c.; matamis, d.; di mussi, r.; spadaro, s.; volta, c. a.; mariani, m.; colaprico, a.; antonio, c.; bruno, f.; grasso, s.; rodriguez, a.; martín-loeches, i.; díaz, e.; masclans, j. r.; gordo, f.; solé-violán, j.; bodí, m.; avilés-jurado, f. x.; 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pierce, c.; nadel, s.; ramnarayan, p.; azevedo, j. r.; montenegro, w. s.; rodrigues, d. p.; sousa, s. c.; araujo, v. f.; leitao, a. l.; prazeres, p. h.; mendonca, a. v.; paula, m. p.; das neves, a.; loudet, c. i.; busico, m.; vazquez, d.; villalba, d.; lischinsky, a.; veronesi, m.; emmerich, m.; descotte, e.; juliarena, a.; bisso, m. carboni; grando, m.; tapia, a.; camargo, m.; ulla, d. villani; corzo, l.; dos santos, h. placido; ramos, a.; doglia, j. a.; estenssoro, e.; carbonara, m.; magnoni, s.; donald, c. l. mac; shimony, j. s.; conte, v.; triulzi, f.; stretti, f.; macrì, m.; snyder, a. z.; stocchetti, n.; brody, d. l.; podlepich, v.; shimanskiy, v.; savin, i.; lapteva, k.; chumaev, a.; tjepkema-cloostermans, m. c.; hofmeijer, j.; beishuizen, a.; hom, h.; blans, m. j.; van putten, m. j. a. m.; longhi, l.; frigeni, b.; curinga, m.; mingone, d.; beretta, s.; patruno, a.; gandini, l.; vargiolu, a.; ferri, f.; ceriani, r.; rottoli, m. r.; lorini, l.; citerio, g.; pifferi, s.; battistini, m.; cordolcini, v.; agarossi, a.; di rosso, r.; ortolano, f.; stocchetti, n.; lourido, c. mora; cabrera, j. l. santana; santana, j. d. martín; alzola, l. melián; del rosario, c. garcía; pérez, h. rodríguez; torrent, r. lorenzo; eslami, s.; dalhuisen, a.; fiks, t.; schultz, m. j.; hanna, a. abu; spronk, p. e.; wood, m.; maslove, d.; muscedere, j.; scott, s. h.; saha, t.; hamilton, a.; petsikas, d.; payne, d.; boyd, j. g.; puthucheary, z. a.; mcnelly, a. s.; rawal, j.; connolly, b.; mcphail, m. j.; sidhu, p.; rowlerson, a.; moxham, j.; harridge, s. d.; hart, n.; montgomery, h. e.; jovaisa, t.; thomas, b.; gupta, d.; wijayatilake, d. s.; shum, h. p.; king, h. s.; chan, k. c.; tang, k. b.; yan, w. w.; arias, c. castro; latorre, j.; de la rica, a. suárez; garrido, e. maseda; feijoo, a. montero; gancedo, c. hernández; tofiño, a. lópez; rodríguez, f. gilsanz; gemmell, l. k.; campbell, r.; doherty, p.; mackay, a.; singh, n.; vitaller, s.; nagib, h.; prieto, j.; del arco, a.; zayas, b.; gomez, c.; tirumala, s.; pasha, s. a.; kumari, b. k.; martinez-lopez, p.; puerto-morlán, a.; nuevo-ortega, p.; pujol, l. martinez; dolset, r. algarte; gonzález, b. sánchez; riera, s. quintana; Álvarez, j. trenado; quintana, s.; martínez, l.; algarte, r.; sánchez, b.; trenado, j.; tomas, e.; brock, n.; viegas, e.; filipe, e.; cottle, d.; traynor, t.; martínez, m. v. trasmonte; márquez, m. pérez; gómez, l. colino; martínez, n. arias; muñoz, j. m. milicua; bellver, b. quesada; varea, m. muñoz; llorente, m. 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gommers, d.; ince, c.; marca, l.; xini, a.; mongkolpun, w.; cordeiro, c. p. r.; leite, r. t.; lheureux, o.; bader, a.; rincon, l.; santacruz, c.; preiser, j. c.; chao, a.; chao, a. s.; chen, y. s.; kim, w.; ahn, c.; cho, y.; lim, t. h.; oh, j.; choi, k. s.; jang, b. h.; ha, j. k.; mecklenburg, a.; stamm, j.; soeffker, g.; kubik, m.; sydow, k.; reichenspurner, h.; kluge, s.; braune, s.; bergantino, b.; ruberto, f.; magnanimi, e.; privato, e.; zullino, v.; bruno, k.; pugliese, f.; sales, g.; girotto, v.; vittone, f.; brazzi, l.; fritz, c.; kimmoun, a.; vanhuyse, f.; trifan, b.; orlowski, s.; albuisson, e.; tran, n.; levy, b.; chhor, v.; joachim, j.; follin, a.; champigneulle, b.; chatelon, j.; fave, g.; mantz, j.; pirracchio, r.; diaz, d. díaz; villanova, m.; aguirregabyria, m.; andrade, g.; lópez, l.; palencia, e.; john, g.; cowan, r.; hart, r.; lake, k.; litchfield, k.; song, j. w.; lee, y. j.; cho, y. j.; choi, s.; vermeir, p.; vandijck, d.; blot, s.; mariman, a.; verhaeghe, r.; deveugele, m.; 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møller, m. hylander; moraes, r. b.; borges, f. k.; guillen, j. a. v.; zabaletta, w. j. c.; ruiz-ramos, j.; ramirez, p.; marqués-miñana, m. r.; villarreal, e.; gordon, m.; sosa, m.; concha, p.; castellanos, a.; menendez, r.; ramírez, c. sánchez; santana, m. cabrera; balcázar, l. caipe; escalada, s. hípola; viera, m. a. hernández; vázquez, c. f. lübbe; díaz, j. j. díaz; campelo, f. artiles; monroy, n. sangil; santana, p. saavedra; santana, s. ruiz; gutiérrez-pizarraya, a.; garnacho-montero, j.; martin, c.; baumstarck, k.; leone, m.; martín-loeches, i.; pirracchio, r.; legrand, m.; mainardi, j. l.; mantz, j.; cholley, b.; hubbard, a.; frontera, p. ruiz; vega, l. m. claraco; miguelena, p. ruiz de gopegui; usón, m. c. villuendas; lópez, a. rezusta; clemente, e. aurensanz; ibañes, p. gutiérrez; aguilar, a. l. ruiz; palomar, m.; olaechea, p.; uriona, s.; vallverdu, m.; catalan, m.; nuvials, x.; aragon, c.; lerma, f. alvarez; jeon, y. d.; jeong, w. y.; kim, m. h.; jeong, i. y.; ahn, m. y.; ahn, j. y.; han, s. h.; choi, j. y.; song, y. g.; kim, j. m.; ku, n. s.; bassi, g. li; xiol, e. aguilera; senussi, t.; idone, f. a.; motos, a.; chiurazzi, c.; travierso, c.; fernández-barat, l.; amaro, r.; hua, y.; ranzani, o. t.; bobi, q.; rigol, m.; torres, a.; fernández, i. fuentes; soler, e. andreu; de vera, a. pareja rodríguez; pastor, e. escudero; hernandis, v.; ros martínez, j.; rubio, r. jara; torner, m. miralbés; brugger, s. carvalho; eroles, a. aragones; moles, s. iglesias; cabello, j. trujillano; schoenenberger, j. a.; casals, x. nuvials; vidal, m. vallverdu; garrido, b. balsera; martinez, m. palomar; mirabella, l.; cotoia, a.; tullo, l.; stella, a.; di bello, f.; di gregorio, a.; dambrosio, m.; cinnella, g.; rosario, l. e. de la cruz; lesmes, s. p. gómez; romero, j. c. garcía; herrera, a. n. garcía; pertuz, e. d. díaz; sánchez, m. j. gómez; sanz, e. regidor; hualde, j. barado; hernández, a. ansotegui; ramirez, j. roldán; takahashi, h.; kazutoshi, f.; okada, y.; oobayashi, w.; naito, t.; 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forni, l. g.; venn, r.; londoño, j. gonzalez; cardenas, c. lorencio; ginés, a. sánchez; gubianas, c. murcia; sánchez, e. clapes; sirvent, j. m.; panafidina, v.; shlyk, i.; ilyina, v.; judickas, s.; kezyte, g.; urbanaviciute, i.; serpytis, m.; gaizauskas, e.; sipylaite, j.; sprung, c. l.; munteanu, g.; morales, r. c.; kasdan, h.; volker, t.; reiter, a.; cohen, y.; himmel, y.; meissonnier, j.; banderas-bravo, m. e.; gómez-jiménez, c.; garcía-martínez, m. v.; martínez-carmona, j. f.; fernández-ortega, j. f.; o‘dwyer, m. j.; starczewska, m.; wilks, m.; vincent, j. l.; torsvik, m.; gustad, l. t.; bangstad, i. l.; vinje, l. j.; damås, j. k.; solligård, e.; mehl, a.; tsunoda, m.; kang, m.; saito, m.; saito, n.; akizuki, n.; namiki, m.; takeda, m.; yuzawa, j.; yaguchi, a.; frantzeskaki, f.; tsirigotis, p.; chondropoulos, s.; paramythiotou, e.; theodorakopoulou, m.; stamouli, m.; gkirkas, k.; dimopoulou, i. k.; makiko, s.; tsunoda, m.; kang, m.; yuzawa, j.; akiduki, n.; namiki, m.; takeda, m.; 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kim, k. s.; xini, a.; marca, l.; lheureux, o.; brasseur, a.; vincent, j. l.; creteur, j.; taccone, f. s.; beane, a.; thilakasiri, m. c. k. t.; de silva, a. p.; stephens, t.; sigera, c. s.; athapattu, p.; jayasinghe, s.; padeniya, a.; haniffa, r.; santiago, a. iglesias; sáez, v. chica; ruiz-ruano, r. de la chica; gonzález, a. sánchez; kunze-szikszay, n.; wand, s.; klapsing, p.; wetz, a.; heyne, t.; schwerdtfeger, k.; troeltzsch, m.; bauer, m.; quintel, m.; moerer, o.; cook, d. j.; rutherford, w. b.; scales, d. c.; adhikari, n. k.; cuthbertson, b. h.; suzuki, t.; takei, t.; fushimi, k.; iwamoto, m.; nakagawa, s.; mendsaikhan, n.; begzjav, t.; lundeg, g.; dünser, m. w.; romero, d. gonzález; cabrera, j. l. santana; santana, j. d. martín; padilla, y. santana; pérez, h. rodríguez; torrent, r. lorenzo; kleinpell, r.; chouris, i.; radu, v.; stougianni, m.; lavrentieva, a.; lagonidis, d.; price, r. d. t.; day, a.; arora, n.; henderson, m. a.; hickey, s.; costa, m. i. almeida; carvalho, j. p.; gomes, a. a.; 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curiel-balsera, e.; rivera-fernandez, r.; lesmes, s. p. gómez; rosario, l. e. de la cruz; hernández, a. ansotegui; herrera, a. n. garcía; sanz, e. regidor; sánchez, m. j. gómez; hualde, j. barado; pascual, o. agudo; león, j. p. tirapu; irazabal, j. m. guergue; pérez, a. gonzález; fernández, p. alvarez; amor, l. lopéz; albaiceta, g. muñiz; lesmes, s. p. gómez; rosario, l. e. de la cruz; hernández, a. ansotegui; sanz, e. regidor; sánchez, m. j. gómez; calvo, s. aldunate; herrera, a. n. garcía; hualde, j. barado; pascual, o. agudo; león, j. p. tirapu; corona, a.; ruffini, c.; spazzadeschi, a.; marrazzo, f.; gandola, a.; sciurti, r.; savi, c.; catena, e.; ke, m. w.; cheng, c. c.; huang, w. c.; chiang, c. h.; hung, w. t.; lin, k. c.; lin, s. c.; wann, s. r.; chiou, k. r.; tseng, c. j.; kang, p. l.; mar, g. y.; liu, c. p.; bertini, p.; de sanctis, f.; guarracino, f.; bertini, p.; baldassarri, r.; guarracino, f.; buitinck, s. h.; van der voort, p. h. j.; oto, j.; nakataki, e.; tsunano, y.; izawa, m.; tane, n.; onodera, m.; nishimura, m.; ghosh, s.; gupta, a.; de gasperi, a.; mazza, e.; limuti, r.; prosperi, m.; bissenova, n.; yergaliyeva, a.; talan, l.; yılmaz, g.; güven, g.; yoruk, f.; altıntas, n. d.; mukherjee, d. n.; agarwal, l. k.; mandal, k.; palomar, m.; balsera, b.; vallverdu, m.; martinez, m.; garcia, m.; castellana, d.; lopez, r.; barcenilla, f.; kaminsky, g. e.; carreño, r.; escribá, a.; fuentes, m.; gálvez, v.; del olmo, r.; nieto, b.; vaquerizo, c.; alvarez, j.; de la torre, m. a.; torres, e.; bogossian, e.; nouer, s. aranha; salgado, d. ribeiro; brugger, s. carvalho; jiménez, g. jiménez; torner, m. miralbés; vidal, m. vallverdú; garrido, b. balsera; casals, x. nuvials; gaite, f. barcenilla; cabello, j. trujillano; martínez, m. palomar; doganci, m.; izdes, s.; besevli, s. guzeldag; alkan, a.; kayaaslan, b.; ramírez, c. sánchez; balcázar, l. caipe; santana, m. cabrera; viera, m. a. hernández; escalada, s. hípola; vázquez, c. f. lübbe; penichet, s. m. marrero; campelo, f. artiles; lópez, m. a. de la cal; santana, p. saavedra; santana, s. ruíz; repessé, x.; artiguenave, m.; paktoris-papine, s.; espinasse, f.; dinh, a.; el sayed, f.; charron, c.; géri, g.; vieillard-baron, a.; marmanidou, k.; oikonomou, m.; nouris, c.; dimitroulakis, k.; soilemezi, e.; matamis, d.; ferré, a.; guillot, m.; teboul, j. l.; lichtenstein, d.; mézière, g.; richard, c.; monnet, x.; pham, t.; beduneau, g.; schortgen, f.; piquilloud, l.; zogheib, e.; jonas, m.; grelon, f.; runge, i.; terzi, n.; grangé, s.; barberet, g.; guitard, p. g.; frat, j. p.; constan, a.; chrétien, j. m.; mancebo, j.; mercat, a.; richard, j. c. m.; brochard, l.; prīdāne, s.; sabeļņikovs, o.; mojoli, f.; orlando, a.; bianchi, i.; torriglia, f.; bianzina, s.; pozzi, m.; iotti, g. a.; braschi, a.; beduneau, g.; pham, t.; schortgen, f.; piquilloud, l.; zogheib, e.; jonas, m.; grelon, f.; runge, i.; terzi, n.; grangé, s.; barberet, g.; guitard, p. g.; frat, j. p.; constan, a.; chrétien, j. m.; mancebo, j.; mercat, a.; richard, j. c. m.; brochard, l.; kondili, e.; psarologakis, c.; kokkini, s.; amargianitakis, v.; babalis, d.; chytas, a.; chouvarda, i.; vaporidi, k.; georgopoulos, d.; trapp, o.; kalenka, a.; mojoli, f.; orlando, a.; bianchi, i.; torriglia, f.; bianzina, s.; pozzi, m.; iotti, g. a.; braschi, a.; lozano, j. a. benítez; sánchez, p. carmona; francioni, j. e. barrueco; ferrón, f. ruiz; simón, j. m. serrano; spadaro, s.; karbing, d. s.; gioia, a.; moro, f.; corte, f. dalla; mauri, t.; volta, c. a.; rees, s. e.; petrova, m. v.; mohan, r.; butrov, a. v.; beeharry, s. d.; vatsik, m. v.; sakieva, f. i.; gobert, f.; yonis, h.; tapponnier, r.; fernandez, r.; labaune, m. a.; burle, j. f.; barbier, j.; vincent, b.; cleyet, m.; richard, j. c.; guérin, c.; shinotsuka, c. righy; creteur, j.; taccone, f. s.; törnblom, s.; nisula, s.; vaara, s.; poukkanen, m.; andersson, s.; pettilä, v.; pesonen, e.; xie, z.; liao, x.; kang, y.; zhang, j.; kubota, k.; egi, m.; mizobuchi, s.; hegazy, s.; el-keraie, a.; el sayed, e.; el hamid, m. abd; rodrigues, n. j.; pereira, m.; godinho, i.; gameiro, j.; neves, m.; gouveia, j.; e silva, z. costa; lopes, j. a.; mckinlay, j.; kostalas, m.; kooner, g.; dudas, g.; horton, a.; kerr, c.; karanjia, n.; creagh-brown, b.; forni, l.; yamazaki, a.; ganuza, m. sanz; molina, j. a. martinez; martinez, f. hidalgo; freile, m. t. chiquito; fernandez, n. garcia; travieso, p. medrano; bandert, a.; frithiof, r.; lipcsey, m.; smekal, d.; schlaepfer, p.; durovray, j. d.; plouhinec, v.; chiappa, c.; bellomo, r.; schneider, a. g.; mitchell, s.; durrant, j.; street, h.; dunthorne, e.; shears, j.; caballero, c. hernandez; hutchison, r.; schwarze, s.; ghabina, s.; thompson, e.; prowle, j. r.; kirwan, c. j.; gonzalez, c. a.; pinto, j. l.; orozco, v.; patiño, j. a.; garcia, p. k.; contreras, k. m.; rodriguez, p.; echeverri, j. e. title: esicm lives : part three: milan, italy. – october date: - - journal: intensive care med exp doi: . /s - - - sha: doc_id: cord_uid: qfecv h nan months is better than cole's formula. therefore, we conducted a retrospective analysis to investigate our hypothesis. methods: the ethics committee of our hospital approved this retrospective study. we included consecutive patients aged < years who underwent tracheal intubation under general anesthesia in our hospital from august to october . we collected the following data from the anesthesia records: age in months, height, weight, type of a tracheal tube, and id and od of tracheal tube. patients who were intubated using a cuffed tracheal tube or had incomplete data were excluded. we developed a regression formula for calculating id and od based on age in months and calculated the coefficient of determination r by using a regression analyses. a difference of . mm in the actual and predicted tube size was considered clinically permissible. then, we compared the rate of a clinical permissible estimation of the cole's formula and our new formulas used by multiple comparison analysis and a p value less than . was considered statistically significant. results: a total of pediatric patients received general anesthesia during the study period. of these, patients were excluded because they did not meet the inclusion criteria. finally, we included patients for this analysis. the regression formula for predicting id by based on age in months was id = . × age in months + . , and the coefficient of determination r was . . the regression formula for predicting od based on age in months was od = . × age in months + . , and coefficient of determination r was . . the rate of a clinical permissible estimation of our id and od formulas were significantly higher than that of the cole's formula ( %, % and %, respectively; p < . ). conclusions: our results showed that the prediction of id based on age in months is more useful than that using cole's formula. in addition, estimation of od based on age in months might be more rational because od varies according to the type of the tracheal tube used. these results should be confirmed in a future prospective study. introduction: survival among out-of-hospital cardiac arrest (ca) relies primarily on bystanders and their knowledge of basic life support (bls) manouvers [ ] . many medical societies and organizations recommend teaching bls at schools as part of the educative program [ ] ; being this a reality in north european countries, but not yet an education standard issue in others including spain. moreover, less is written about the perception of ca and cardiopulmonary resuscitation (cpr) among the general population, and even less in school age. objectives: describe the perception and knowledge about ca and cpr among a teenager school population in barcelona, spain. methods: prospective, descriptive study carried out between - and - among teenagers school population, based on surveys before and after bls -cpr classes. during this period , th classes were held, in different schools in barcelona. before attending the class , each pupil was asked to answer a survey with questions related to previous knowledge of sudden death, ca, and cpr, and their attitude towards them. the class consisted on a threehour theorical and practical instruction based on the european resuscitation council guidelines, adapted for laypersons. practices were held with an instructor (ratio instructor:pupil : [ ] [ ] [ ] , with the little anne mannequins (laerdal®). after the class, a new survey (post intervention) was distributed, with questions related to the new concepts and skills learnt, the attitude toward ca and cpr. results: we have instructed pupils ( . (± . ) years, . % female). the . % had heard about sudden death and ca before the class. regarding starting cpr: % said they were not capable of doing it, and . % suggested they would be able to do cpr but in a wrong manner. in a ca scene . % would contact the emergency service and start cpr, . % would call and wait, and . % would only do cpr. after attending the classes . % declared had understood the theorical concepts and practical skilles taught; . % would changed positively their attitude towards cpr; and . % would be prone to start maneuvers. conclusions: cpr and ca remain a well known issue among teenager population in barcelona, as long as being an interesting topic. nevertheless they do not feel capable of starting maneuvers. the concepts taught during the class were easy to learn , and after the intervention the majority were prone to start cpr. this population is adequate to teach cpr. introduction: to meet the need of patients family members and staff we started to guide visiting children at our adult icu in the st elisabeth hospital (ez) in tilburg years ago. to do so we developed a guidance leaflet for parents with practical instructions and information. additionally, practical advice is given, such as what to say to the child and what to expect when visiting. the leaflet is subdivided in developmental stages. furthermore we developed a book "mees op bezoek", in which a child visits his father at the icu. pictures show what children can expect, which helps prepare the child for visiting at home. an instruction box is present at the icu with icu materials such as an iv catheter, a pulse oximetry or a tracheal tube. these materials give children a tactile experience of the icu. the box is divided in two parts; the second part contains guidance materials for when a patient may die. pedagogical staff are available to support parents, children and staff. if there are more profound problems a referral to our children's psychologist is possible. we made some improvements to our waiting area to make it more appealing to children. we instructed and educated our nurses and doctors on how to use these materials and how to guide children. we recently merged with the twee steden hospital in tilburg (tsz), in this hospital there was no program to guide children. with the merger we also wanted to introduce our "child as a visitor program" at the icu on location tsz. we wanted to know if there were differences of opinion between the nursing staff on guidance of children. introduction: critically ill children are underfed early in their pediatric intensive care unit (picu) stay and this may contribute to worse outcomes. acute kidney injury (aki) occurs in % of all picu admissions and the risk of acute and chronic malnutrition is high in these patients with aki, and the presence of malnutrition in the context of aki has been associated with more severe clinical deterioration and organ dysfunction. critically ill children with aki are at high risk of underfeeding. objectives: to evaluate the effects of protein feeding on the resolution of aki. methods: this is a retrospective study of critically ill children admitted from / - / to the picu. patients with a diagnosis of end stage renal disease requiring renal replacement therapy or had received a kidney transplant were excluded. nutritional status assessed by weight and height who z-scores after admission and caloric and protein intakes calculated from i.v. fluids and parenteral and enteral nutrition for the first days of admission. energy and protein needs estimated by schofield and a.s.p.e.n., respectively. aki was defined by prifle (creatinine only) and persistent aki was defined as patients who did not resolve their aki during the first eight days of picu stay. introduction: sedation and analgesia are important components of postoperative management of neonates who underwent cardiac surgery. excessive or inadequate sedation may have a significant adverse effect on patient outcome. objectives. we aimed to determine which drug regimen would be most effective with less side-effect and better outcome. methods: from march till march we conducted a randomized controlled prospective study in neonates with congenital heart disease who underwent arterial switch operation in our clinic. inclusion criteria: ) gestational age more than weeks, ) birth weight over g, ) age -up to days, ) absence of concomitant diseases and surgical complications. patients were randomized into cohorts: patients ( %) were given infusion of dexmedetomidine with morphine boluses (study group) and patients ( %) were randomized to the standard regimen -infusion of morphine with diazepam boluses (control group). results: in both groups there were no differences in pre-and intraoperative indexes, duration of mechanical ventilation, sympathomimetic support, and time of infusion of dexmedetomidine/ morphine. in study group time of icu stay - . h -was significantly shorter than in control group - h (p- . ). onset of peristalsis and start of feeding in study group was earlier than in control group - st vs -d day (p- . ) and -d vs . -day (p- . ), respectively. in the control group there were more patients who had complicated feeding (start after -d day, bloating or vomiting) - ( %) vs ( %) in the study group. we did not observe any decrease of mean blood pressure and heart rate in the study group as it could be expected. conclusion: use of dexmedetomidine with morphine hydrochloride boluses for postoperative sedation and analgesia is effective and facilitates feeding process in neonates, leads to earlier onset of peristalsis and start of feeding, decreasing icu stay. impact of positive end expiratory pressure on cerebral hemodynamic in paediatric patients with post-traumatic brain swelling treated by surgical decompression s.m. pulitano' , s. de rosa , , a. mancino , g. villa , , f. tosi , p. franchi , g. conti introduction: asthma exacerbation is one of the most common diagnoses seen in the pediatric ed. several adult randomized controlled trials have shown that administration of high concentration oxygen leads to rise in carbon dioxide and increases admission rates. however, there are no studies in the pediatric population comparing the effects of high concentration oxygen versus titrated oxygen therapy in asthma exacerbation. objectives: we evaluated the effects of transcutaneous carbon dioxide (tpaco ) in high concentration oxygen therapy versus titrated oxygen therapy to maintain saturation between to % in pediatric patients with acute asthma exacerbation in the ed. methods: children to years with previously diagnosed asthma with moderate to severe asthma exacerbation (asthma score > ) were randomized to high concentration oxygen therapy ( % oxygen via face mask at > l/min.) or titrated oxygen therapy (titrated up from % via a blender continuously) to maintain saturations between to % while receiving their nebulized treatments. exclusion criteria included disorders with hypercapnic respiratory failure, unconscious patient, history of congenital heart disease, pregnancy, history of smoking or using sedatives and depressants. asthma therapy was provided per the ed physician. asthma score, tpaco , pefr (age > years) were measured at the start of the study and every minutes for the first hour then every minutes until disposition decision. the primary outcome was increase in tpaco with high concentration oxygen therapy. secondary outcome included rate of admission to the hospital. results: patients were enrolled with mean age of . years. % were males and % had poorly controlled asthma with mean asthma score of . . there were patients enrolled in the high concentration oxygen group (hcot) and patients in the titrated oxygen group (tot). the minute tpaco were not statistically different( . ± . hcot v. . ± . tot,p = . ); whereas, the minutes tpaco was statistically different( ± . hcot v. . ± . tot, p = . ). the minutes tpaco was . ± . hcot v. . ± . tot, p = . . at minutes, % of the patients had a rise in tpaco in hcot v. % in the tot(p = < . ), and at minutes % had a rise in tpaco in hcot v. % in the tot(p = < . ). the asthma score was similar in the two groups at minute ( . ± . hcot v. . ± . tot, p = . ); whereas, the minutes asthma score was lower in the tot( . ± . hcot v. . ± . tot, p = . ). the rate of admission to the hospital was . % in hcot v. . % in the tot. conclusions: high concentration oxygen therapy in pediatric asthma exacerbation leads to significantly higher carbon dioxide levels. it also causes rise in carbon dioxide from the baseline which increases the asthma scores and rate of admission. introduction: in critically ill patients, temperature measurement is a routine important care task and can lead to important decisions. rectal temperature and bladder temperature are now used as a continuous body temperature measuring method in the pediatric intensive care, but these practices have several disadvantages including the patient´s discomfort, the risk of organ injury and the inaccurate measuring caused by the sensor position. a new temperature monitoring system m tm spot-on tm (spoton) is a non-invasive zero-heat-flux thermometer designed to estimate core body temperature from the skin surface. although the usefulness and accuracy of spoton system in adult patients have been demonstrated, there are no reports on pediatric intensive care patients. objectives: the aim of this study was to evaluate the effectiveness of a new temperature measurement system attached to the forehead, and compare it to rectal temperature sensors in terms of correlation and accuracy. methods: pediatric patients weighing less than kg, who were managed in our icu during the period from february to march , were enrolled in this study. core temperature was measured and recorded at every minute from the both thermistor of a rectal thermal probe and with spoton in these patients. the data when the forehead sensor or rectal probe was taken out for nursing care was excluded from statistical analysis. results: sets of data of children (mean bw g) were examined retrospectively. in all patients, spoton showed higher than the rectal temperatures. the spoton temperature was analyzed to be . degrees ( % limits of agreement of ± . ) higher temperature than the rectal one with a moderate correlation(r = . ). discussion and conclusion: rectal temperature measurement is the gold standard method for pediatric patients in icu despite several complications of rectal injury. our children´s study demonstrated the slightly higher temperature in the spoton than rectal temperature with a substantial correlation. one possible explanation could be that the abundance of brain blood flow of children affected the results. our study concluded that spoton system could be used as a highly reliable noninvasive core body temperature measurement for small pediatric patients. introduction: viral bronchiolitis (vb) remains one of the leading causes of hospitalization in early childhood. despite the heavy burden of vb on the healthcare system, little is known about the incidence of acute respiratory distress syndrome (ards) in this cohort of patients. in , the pediatric acute lung injury consensus conference (palicc) published guidelines for the definition, management and research in pediatric ards (pards) ( ) . objectives: to study the incidence and prevalence of pards in vb and to study the association between pards and specific picu outcomes such as incidence of mechanical ventilation, noninvasive ventilator settings length of picu stay in this group of patients. methods: this is a retrospective single center observational cohort study that examined children - years of age admitted to the picu with vb and respiratory failure (rf) from - . palicc criteria were applied to define pards. clinical and demographic data was collected. patients with a diagnosis of congenital heart disease or pre-existing chronic lung disease were excluded. data was expressed as median with iqr ranges. test of bivariate association were performed using mann whitney u test and chi square test. a two tailed p value of ≤ . was used to denote statistical significance. results: out of patients with rf, with vb met study criteria. eighty of these ( %) patients admitted for vb met the criteria for pards or at risk for pards. out of these patients, ( %) met criteria for pards and ( %) met criteria for "at risk of pards". median age was ( , ) months and the median weight was . ( . , . ) kgs. most common etiology for vb was respiratory syncytial virus (rsv) % followed by rhinovirus ( %). there was no statistically significant difference in age, weight, and etiology of vb in patients with pards and those "at risk of pards." patients with pards had longer hospital and picu length of stay (los) and more likely to receive diuretics compared to those "at risk for pards" ( ( , ) vs ( , . ) , p = . ; ( , ) vs ( , . ), p < . ; and % vs %, p = . respectively). nineteen ( / , %) patients with pards received invasive mechanical ventilation with a median duration of ventilation of ( , ) days. conclusions: almost a quarter of children with vb developed pards or were at risk of pards. the presence of pards in children with vb was significantly associated with longer picu and hospital los compared to those "at risk of pards". children with vb are a high risk group for the development of pards. introduction: mean platelet volume(mpv) seems to be a marker of platelet activation and may be related to severity of illness. changes in mpv and platelet count(plc)could be used for disease prognosis and mortality in icu patients. we hypothesized that mpv changes and plc could be used as prognostic tools in pediatric surgical intensive care units(psicu). objectives: to study the association between mpv changes and mortality and morbidity in psicu. also to study the relation between plc and psicu mortality and morbidity. methods: this descriptive observational study was conducted on consecutive pediatric surgical patients who admitted to psicus at cairo university hospitals starting from / - / / .after approval by research ethics committee,informed consents were obtained from parents and pediatric cases aged from month- years and stayed for > h were enrolled.mpv and plc were obtained and recorded at baseline(preoperative values),on the day of icu admission(day ), st , nd , rd , th and th days.to measure daily mpv changes; (Δmpv) was constructed and computed where Δmpv = ([mpvday(x) − mpvday ( )]/mpvday( ) × %. pediatric index of mortality(pim)score was calculated on day and the pediatric logistic organ dysfunction(pelod)score was recorded daily. results: patients who developed icu complications (fever, sepsis, pneumonia, required mechanical ventilation, needed vasopressors or blood transfusion); showed higher Δmpv compared to non complicated cases (fig. ) . this association was statistically significant on days (p value = . ), (p value < . ), (p value < . ) and (p value = . ) of icu stay but it´s insignificant on day (p value = . ).according to receiver operating characteristics(roc) curve analysis, the sensitivity of Δmpv to detect complications on day was . % but its specificity on day was . %.patients who developed icu complications showed lower plc compared to non complicated cases (fig. ) .this association was statistically significant on days (p value < . ), (p value < . ) and (p value < . ) but it was insignificant on day (p value = . ), (p value = . ) and (p value = . ). on other hand, the sensitivity of plc to detect complications day was . % but the specificity was . %, while the sensitivity of plc to detect complications day was . % but the specificity day was %. conclusions: mpv dynamics and plc have prognostic roles and could be used in determining several complications in critically ill pediatric surgical patients. plc is a more specific and sensitive tool to detect complications than mean mpv dynamics. introduction: limited information exists regarding the association between functional status at icu admission at and outcomes. objectives: we hypothesized that initial functional status assessment as well the amount of physical therapy delivered would be associated with outcomes in icu survivors. methods: we performed a retrospective cohort study in one boston teaching hospital on , adults who received critical care from to and survived hospitalization. all patients had a formal evaluation by a physical therapist in the week prior to icu admission and at hospital discharge. the exposure of interest was functional status determined by a licensed physical therapist based on the functional mobility sub scales of the functional independence measure. all patients received physical therapy to improve functional performance. the primary outcome was -day all-cause mortality. we used logistic regression to describe how -day mortality differed with functional status at icu admission. negative binomial regression was utilized to describe how functional status at hospital discharge differed with functional status at icu admission, the extent of physical therapy received and hospital length of stay. results: the cohort was % male, % non-white and had a mean age of . years. % of the cohort had sepsis, % had acute kidney injury, % had respiratory failure and % were surgical cases. the median [iqr] hospital length of stay was [ , ] days. the -day mortality rate was . %. functional status at icu admission was robustly associated with -day mortality. in a logistic regression model adjusted for age, gender, race, surgical patient type, deyo-charlson index, acute organ failure, sepsis, length of stay and the extent of physical therapy received, the second lowest and lowest quartiles of functional status at icu admission was associated with a . in critically ill patients, decreased functional status at icu admission is associated with increased -day mortality. increased intensity of physical therapy is associated with improved mortality outcomes. both functional status at icu admission and the intensity of physical therapy contribute to functional status determined at hospital discharge. introduction: patients admitted to critical care are shown to lose significant muscle mass, with the degree of muscle loss as high as % in the first week for those in multi organ failure (puthucheary, ) . early rehabilitation has been demonstrated as a safe and effective method of improving functional status at the point of critical care discharge and reducing both icu and hospital length of stay (mcwilliams et al., ) , although the specific impact of this on muscle mass has not been reported. objectives: this study aimed to analyse the impact of enhanced physiotherapy incorporating early mobilisation on the rate of muscle decline for patients admitted to critical care. methods: patients admitted to a large uk teaching hospital during the trial period and ventilated for ≥ days were included in the study. patients were randomised to either enhanced physiotherapy or standard care groups as part of a larger rct. baseline measurements were taken on the day of recruitment and then repeated at critical care discharge. muscle mass was measured using ultrasound to calculate cross sectional area of quadriceps and biceps. to ensure validity , measures were taken and the average of these taken as the final value. all scans were reviewed for agreement by therapists trained in muscle ultrasound. results: patients were included in the analysis. patients in the enhanced physiotherapy group mobilised earlier and achieved a higher level of mobility at the point of critical care discharge (see table .) all subjects demonstrated a reduction in muscle mass of both quadriceps and biceps over the course of their critical care stay. the extent of muscle loss was however lower in those receiving the enhanced physiotherapy, although this did not reach statistical significance (quads % vs %. p = . ; biceps % vs %, p = . ). conclusions: a programme of enhanced physiotherapy appeared to be associated with a lower rate of muscle loss in both biceps and quadriceps in comparison to standard care. an appropriately powered rct is required to assess these findings. introduction: survivors of critical illness experience a range of impairments after intensive care, including physical, cognitive and psychological compromise. the provision of information using a diary to describe the intensive care unit (icu) experience is one strategy that has been proposed to improve psychological health. objectives: the purpose of this study was to explore similarities and differences in patients' and relatives' perceptions of information containing strategies, including icu diaries, to assist recovery after critical illness. methods: an exploratory mixed-methods study was undertaken in an australian tertiary hospital with general icu patients admitted for ≥ days and their relatives. semi-structured interviews were conducted - months after icu discharge. transcripts were analysed using content analysis. results: twenty-two patients and relatives consented to participation and completed interviews prior to reaching data saturation. patients were usually male ( %) and aged ± years. patients raised similar themes to relatives, although with diverse opinions. themes of wanting to have a diary kept and considering they would find a diary helpful were consistent across a majority of participants, although with a minority expressing a desire to 'move on' and would not have liked a diary kept. differences between patients and relatives arose in the areas of the purpose, content, ownership and timing of delivery of a diary. patients viewed the diary as a therapeutic tool while relatives considered it as an information sharing mechanism, including as a mechanism to demonstrate to the patient 'how sick he really was' and 'what he put us through'. possibly as a result of these differences, patients considered that ownership of the diary rested with them while some relatives envisaged shared ownership. patients were more likely to note that the diary should not be provided to them until some weeks after icu while relatives considered an early time point soon after icu discharge to be appropriate. patients were more likely to raise concerns about the potential negative impact of information sharing strategies including diaries and return visits to the icu. conclusions: patients and relatives expressed common themes related to information sharing strategies after icu, but with some important differences. differences in purpose, content, ownership and timing of delivery of a diary suggest there is a need to consider whether the same intervention meets the needs of both groups of stakeholders. introduction: in the intensive care unit (icu) several patients are disturbed in their cerebral function due to their critical illness and medication, leading to discomfort, agitation, restlessness, pain and delirium. rocking chair mobilization therapy (rcmt) is a chair with good seating comfort which gives rhythmic movements. rocking chair studies have shown concrete results to improve patient satisfaction, balance and well-being in patients who suffered from dementia ( ) . however, no studies have evaluated the value and the effect of rcmt for critically ill patients in the icu. objectives: the purpose of the study was to evaluate whether rcmt could be used in the rehabilitation of critically ill patients in the intensive care. the focus was to explore the impact of rcmt on critically ill patients comfort, pain, agitation and delirium. methods: the evaluation took place in a medical/surgical icu in denmark in the period from may to july . patients ≥ years, who were physically stable and had the ability to be mobilized to chair could participate in the evaluation. the rcmt session lasted minutes.each session with rcmt was evaluated by registration of patient consciousness (richmond agitation and sedation scale (rass)), pain (numeric rating scale (nrs) - or by critical-care pain observation tool (cpot)), delirium (cam-icu) before and after the session. patient comfort was assessed by the patients as well as by the nurses during the session. results: sessions with rcmt were evaluated. males and females, age between and years, participated in the evaluation. the results showed a decrease in patient agitation level and an increase in patient consiousness. patients´with rass > decreased from before the session to after the session. patients with rass ≤ − decreased from before the session to after the session. a decrease in delirium where patients were assessed cam-icu positive before the session and patients after the session. a decrease in pain where six patients scored nrs > before the session compared to one patient after the session and patients had cpot scores > before the session compared to patients after the session. assessment and evaluation of comfort by patients themselves and by the nurses, who cared for the particular patient, showed that rcmt was associated with a high degree of patient relaxation and comfort. conclusions: promising results gives reason to recommend rcmt for critically ill patients in the icu, as an alternative holistic nonpharmacological intervention to stimulate patients´bodily awareness and enhance patient comfort and rehabilitation. introduction: critical illness and immobility in the intensive care unit (icu) lead to a loss of muscle mass and reduced exercise capacity for many years following hospital discharge. [ ] nutritional management of the critically ill is challenging and most nutritional studies are focused in this period. nutritional recommendations are for a high protein diet to minimise muscle breakdown and support protein synthesis during rehabilitation. nevertheless, during the rehabilitation period little is known of patients' protein intake and physical functioning. objective: to investigate physical functioning, frailty and dietary protein intake after months of icu discharge. method: our icu is recognised as a therapy rehabilitation centre and the only icu member of the uk rehabilitation outcomes (uk-roc). patients cognitive and physical functioning is assessed as part of their rehabilitation therapy with the functional independence measure (fim) score [ ] . the fim contains items on motor ( ) and cognitive ( ) functions that are scored on a -point ordinal scale based on the amount of assistance a person requires to perform specific activities. the fim scores on icu discharge and also on return to the rehabilitation clinic after months were assessed. in addition, frailty was assessed based on a scale ranging from very fit to very severely frail, terminally ill [ ] and patients were asked to complete a protein food frequency questionnaire. results: twenty patients were assessed. data are reported as mean and (standard deviation). patients were male % and . years ( . ). paired t tests of the changes in fim scores from discharge showed significant increments; . ± . (p = . ) and . ± . (p < . ) for motor and cognitive scales respectively. nevertheless, patients reported that they were "vulnerable to moderately frail" in the frailty scale. dietary intake was also inadequate with a protein intake of . g/kg ( . ). objectives: physiotherapy rehabilitation is a recognised component of icu care. the intensive care society -core standards recommends that rehabilitation is 'at a level that enables the patient to meet their rehabilitation goals for as long as they…are able to tolerate it'. in order to investigate and measure the terms 'tolerate' and 'level', physiological measurements and their relationship with self-perceived exertion and tolerance were analysed. methods: the project was registered with guy's & st.thomas' nhs foundation trust, clinical audit group, (project no. ). a convenience sample, of icu patients undergoing active physiotherapy led rehabilitation, were observed between july and september . a modified exertion scale was used to measure patients' perceived effort. patients also rated tolerance of the session using a tolerability scale, created based on the exertion scale. sessions were timed, heart rate, blood pressure and oxygen saturation were monitored and the cardiovascular impact of the session measured using heart rate reserve (hrr). results: nine rehabilitation sessions were observed; mean length of minutes (range - ). minimum target hrr (> %) was achieved, but not sustained, by patients, while peaked within a normal target hrr ( - %). of the patients, were able to use the tolerability scale and the exertion scale. there did not appear to be a relationship between hrr and either perceived scale measurements. there did appear to be a link between perceived exertion and perceived tolerability with of the patients scoring within points. conclusions: reported perception of exertion and physiological markers could both indicate the 'level' patients are working at. we were able to measure effects of rehabilitation on heart rate. the majority of patients were able to use exertion and tolerance scales. however, the change in heart rate was not great enough to suggest a training effect, despite their exertion scores implying high effort levels. to fulfil the icu society recommendations, a good understanding is needed of how hard patients are working during rehabilitation. further research is needed to determine why there may be disparity between heart rate and patient-reported measures of exertion; and if either is a useful guide for exercise prescription with icu patients. introduction: critically ill patients are at risk of developing deconditioning, muscle atrophy and functional impairments long after hospital discharge. there is evidence demonstrating benefits of mobilization in critically ill patients -improved functional outcome and reduced icu and hospital length of stay. however, there is limited information about how these advances are translated to clinical practice. objectives: to obtain a baseline data on patients who are eligible for mobilisation in icu and how many of these patients are optimally mobilised in icu. this would enable us to undertake a clinical practice improvement project (cpip) using the plan-do-study-act (pdsa) implementation strategy to optimise mobilisation in at least % of all eligible icu patients. methods: setting. -bedded intensivist led closed surgical icu. the mobilisation team composed of physiotherapists, bedside nurses and respiratory therapists who worked along with an intensivist. prospective audit conducted to collect data on the patients who met the eligibility criteria of mobilisation over a -month period. cpip team results: our audit revealed that at baseline, only % of all eligible patients were optimally mobilised. rca revealed a total of barriers and through multi-voting and pareto-charting, we identified the top barriers to change. key barriers identified were: . mobility not being a part of the daily review routine . staff were unsure of the eligibility criteria . lack of knowledge the benefits of optimal mobilisation in the critically ill. the team proposed following strategies to overcome the barriers: . combined icu multi-disciplinary handover rounds with the lead consultant asking the question "can this patient be mobilised?" for every patient reviewed. . providing a bedside decision-making algorithm on eligibility criteria, displayed within visibility of staff's work area. . undertake sharing session with ground staff on the importance and benefits of optimising mobility of the critically ill. conclusions: our audit revealed that less than half of eligible patients received early mobilisation. our cpip -a quality improvement initiative identified barriers in translating knowledge into clinical practice. through various tools of cpip, we identified the key barriers and strategies to overcome these barriers and thereby achieving the goal of optimising mobilisation in icu patients. introduction: bed rest and immobility during critical illness may result in profound physical deconditioning. the multidisciplinary team in intensive care includes physiotherapists, who are responsible for performing diagnoses and procedures for critically ill patients, such as ventilation, respiratory monitoring and assessments of musculoskeletal, neurological, metabolic and cardiovascular diseases, and for the prevention and treatment of the effects of prolonged immobility. objectives: to evaluate the influence of physiotherapy on quality indicators in the intensive care unit of the sagrada esperança clinic in luanda, angola. methods: a retrospective before-after study was designed to assess some quality indicators within the intensive care unit between july and september , where there were no physiotherapists specially trained for respiratory care, and from january to march , where the physiotherapists integrated a multidisciplinary team. the quality indicators analyzed were: the average duration of mechanical ventilation, prevalence of ventilator associated pneumonia and the rate of ventilated patients with non-invasive ventilation. the study population comprised patients for and for . in this study the patientsć ategorization was made by age, sex, pathology and also according with the patient classification systems saps and sofa. the statistical analysis used the systems spss version for a % significance level. results: the results obtained after analyzing the two homogeneous groups according to age, gender, type of admission and severity influencing the physiotherapy care in icu quality indicators, in the sagrada esperança clinic, highlights the decrease of the average number of days with mechanical ventilation but it is not observed a significant relation between physical therapy and this indicator (p = : ). furthermore, it is also observed a decrease ventilator associated pneumonia, and a significant relation between this indicator and the respiratory physiotherapy. last, there is a strong relation between the increase on the number of patients without invasive ventilation and physiotherapy (p = . ). conclusions: in this study it is demonstrated the respiratory therapy influences in some quality indicators, namely regarding the reduction of ventilation associated pneumonia and the promotion of non-invasive ventilation in the icu of the cse. introduction: the incidence of candidemia has increased in icu patients ( ) . in addition, there are differences in epidemiology among different countries. we have previously shown an increased proportion of nonalbicans candida species in our icu ( ) . objectives: to identify the variables associated with candidemia due to non-albicans candida species, as well as with fluconazole-resistant strains in a multidisciplinary icu. methods: all icu patients with candidemia were prospectively studied over two time periods ( - and - ) . demographics, illness severity, clinical and laboratory variables were recorded. sofa score value on icu admission subtracted from the value on the day of candidemia occurrence was defined as delta sofa. patients with c. albicans candidemia were compared to those with non-albicans candidemia. also, patients with fluconazole-resistant candidemia were compared to those without fluconazole resistance. results: among patients with icu-acquired candidemia, in patients candidemia was due to c. albicans and in patients to non-albicans species. c. parapsilosis was the most common ( %) followed by c. albicans ( %). the median time from icu admission to candidemia onset was and days for c. albicans and nonalbicans respectively, p = . . similarly, the median time for candidemia due to fluconazole sensitive isolate was days and days for fluconazole resistant, p < . . resistance to fluconazole was % and % in c. albicans and in non-albicans species respectively, p < . ).presence of shock on candidemia day (or . ; ci: . - , p = . ) and the delta sofa score (or . ; ci: . - . , p = . ) were independently associated with candidemia due to c. albicans. independent risk factors for fluconazole resistant isolates were the length of icu stay before the development of candidemia (or . ; ci: . - . , p = . ) and the presence of shock on candidemia day (or . ; ci: . - . , p = . ). previous fluconazole exposure ( patients) was not associated with fluconazole resistance. conclusions: this study confirms the predominance of non-albicans candida species, in our icu patients with candidemia, with high prevalence of fluconazole resistance. early onset of candidemia and the presence of shock were most likely due to c. albicans whereas late onset was associated with fluconazole-resistant non-albicans species. these findings may be of value for empiric antifungal treatment selection. introduction: invasive aspergillus infections are well-known complications of immunocompromised states, chronic obstructive pulmonary disease and haematopoietic stem cell transplant. bacterial coinfection is well described in influenza literature but there is scarce data on invasive aspergillosis complicated severe influenza infection. objectives: the aim of this study is to describe the clinical and demographic characteristics of patients with aspergillus isolation in severe influenza a(h n ) pneumonia. methods: prospective, observational, multicenter study conducted in spanish icus from to . all individuals with severe primary influenza a(h n ) pneumonia requiring invasive mechanical ventilation were included in the study. influenza a(h n ) patients without coinfection were compared with those with aspergillus isolation in respiratory samples. all serotypes were confirmed using rt-pcr at icu admission. patients´demographic, clinical, radiologic features, laboratory values, icu and hospital length of stay (los) and outcomes were recorded. discrete variables are expressed as counts (percentage) and continuous variables as medians with th to th interquartile range (iqr conclusions: the mortality rate was significantly higher in h n patients with aspergillus isolation in respiratory samples. diagnosis of invasive aspergillosis in critically ill patients in the post-influenza era must be re-evaluated. clinical studies should be conducted in order to know the clinical significance of aspergillus isolation in respiratory samples in intubated patients with primary influenza a(h n ) pneumonia. methods: this prospective, monocentric, study performed over months assessed the value of a twice weekly dosage of fungal biomakers (candida serology iga, igm, igg, ß-d-glucan (bdg) and mannan antigens) in icu patients after lt. proven/probable/possible infection was defined according to the eortc/msg criteria. colonisation was defined by presence of candida sp in respiratory samples without any sign of invasive infection. the study was approved by the ethical committee. results are presented as means. results: we analysed icu patients after lt. % had a candida sp colonisation while an invasive infection was proven in ( %) patients. candida albicans was cultured from % of the pulmonary samples. % of the invasive infections were related to c. glabrata. results of biomarkers dosages are presented in the table. positive candida igg serology was observed in % of the cases. mortality rate at -months after lt was % in the immunised patients versus % in nonimmunised patients. an invasive candidiasis (ic) was present in % of the immunised patients versus % in non-immunised patients. at least one bdg dosage was positive in % of the cases. bdg dosage value decreased after surgery, reaching a non-significant value after the th day. in proven ic, bdg measurements reached concentrations > pg/ml, days before initiation of antifungal treatment. no patient had positive mannan antigen measurement. conclusions: a twice weekly dosage of bdg seems to be useful in the decision making process for early initiation of antifungal therapy in lt patients. the cutoff for a significant value of bdg needs to be defined. pre-transplantation assessment of candida igg serology could help to identify patients at risk of post-operative fungal infection. introduction: the antifungal (af) therapy strategy (pre-emptive vs culture based treatment) in intensive care unit is a matter of debate [ ] . the necessity to not delay the initiation of the af in invasive candidiasis (ic) must be balanced with the cost and risk of selecting resistant pathogens when af are prescribed too widely. burn patients are at risk of ic because of the frequent use of antibiotics and immunodeficiency. objectives: to evaluate our antifungal (af) therapy strategy in suspected or proven ic in terms of prognosis and risk factors of ic. methods: observational, descriptive, retrospective study conducted from june to september in the saint louis hospital burn unit. inclusion criteria: patients treated with pre-emptive (severe sepsis or septic shock with candida sp colonization) or curative (proven, pic) af. the outcome was the pic (candidemia and/or positive peritoneal sample). clinical characteristics, organ supports, af treatments and outcome were collected and compared between pic and suspected ic (sic). the results are presented in median (iqr) or n (%). results: patients were admitted during the study period including with a total body surface area (tbsa) > %. treated with af including pic ( %). in those patients: age ( - ), tbsa ( - ), sapsii ( - ), absi ( - ) and sofa ( - ). renal replacement therapy ( %), mechanical ventilation ( %), parenteral nutrition ( %). inhospital mortality = % ( % sic vs % pic, p = . ). patients with pic ( %) were treated before the ic diagnosis ( because of filamentous infection before the pic). the delay between admission and af treatment initiation was days. patients characteristics, organs supports were not significantly different between pic and sic at the treatment initiation except for the sapsii (pic ( - ) vs sic ( - ), p = . ). patients ( %) received an echinocandin as a first-line treatment. ( . - . ) sites were monitored for candida colonization the week before treatment initiation. patients with pic had higher colonization index than those with sic ( % vs %, p = . ) and a candida score significantly higher ( vs ( . - . ) respectively, p = . ). a semiquantitative estimation of the fungal inoculum had no predictive value. conclusions: in this study, the majority of pic were treated after diagnosis confirmation. only / ( %) patient treated preemptively did declare a pic. the outcome was not different when the treatment was initiated after confirmation. the results of this study highlight the difficulty to identify patients at highest risk of ic, and question the strategy of preemptive treatment in this population. objectives: we wanted to determine whether pct guided antibiotic rationalisation could reduce fungal colonisation and antifungal usage. methods: we undertook a retrospective observational study at a nine bedded icu department in the united kingdom. we collected data on all patients admitted to the unit in the year prior and post the introduction of pct guided rationalisation of antibiotics. we used the pharmacy database to assess the use of antibiotics, correcting for changes in costs over this time. we used the microbiology database to assess the rate of patients colonising fungal species and those requiring treatment. results: since the introduction of pct, the average expenditure on antibiotics per icu admission fell . % (p . ). the rate of icu patients colonised with a fungal species fell from . % to . % (p < . ). the incidence of patient's prescribed systemic antifungal therapy fell from . % to . % (p < . ). conclusions: we demonstrated a significant reduction in patients colonised with fungal species and those requiring anti-fungal therapy since introducing pct guided rationalisation of antibiotics. a prospective randomised controlled trial is required to assess whether this equates to improved patient outcome. ), median days. c. albicans was the most commonly isolated species (sp) ( , %), candidemia was the most common diagnosed infection. the sp isolated in blood cultures (bc) were: , % c. albicans, , % c. haemulonii, . % c. parasilopsis. we had + bc for trichosporon asahii. catheter -related infection by c. albicans, c. parasilopsis, and candida haemulonii was diagnosed in patients. positive urine samples were found mostly for c. albicans . %. the most frequently factors associated with fungal infection were: > than days in the icu . %, urinary catheter . %, broad-spectrum antibiotic exposure . %, indwelling central venous catheter (cvc) . %, feeding tube . %, total parenteral nutrition . %, invasive mechanical ventilation . %. to highlight an association with acinetobacter baumannii in . % of our patients. doctors chose fluconazole in . % as a first line of therapy. an antibiogram was performed and the susceptibility was confirmed. icu mortality rate, . %. conclusions: in our environment, c. albicans continues to be the species that causes the largest number of invasive candidiasis. prolonged stay in the icu is an important risk factor to develop fungal infections. even with the particular features of a burn patient, their complexity, and the negative impact of each infection; fluconazole keeps having an important role in the treatment as a first line. the effect of introduction of daily chlorhexidine bathing on healthcare-associated infections and acquisition of multi-drug resistant organisms e. ahmadnia introduction: it has been suggested that daily bathing with chlorhexidine impregnated cloths may significantly reduce the acquisition of multi-drug resistant organisms (mdros), incidence of central line associated bloodstream infections (clabsis), and the development of intensive care unit (icu) acquired bloodstream infections [ ] . however, more recent data have failed to support daily bathing of critically ill patients with chlorhexidine for these purposes [ ] . objectives: to determine if the implementation of a daily chlorhexidine bathing regimen affects acquisition rates of mdros, the incidence of clabsis, and icu bacteraemias. methods: a quality improvement project was conducted at a bedded adult critical care unit within a uk university hospital (incorporating major trauma, medical, and surgical patients). during the year control period (december to november ), all patients were bathed using soap and water. during the subsequent intervention period (december to november ), all patients were bathed using % chlorhexidine impregnated cloths (clinell, gama healthcare). the acquisition of mdros, incidence of clabsis and icu bacteraemias were recorded during these periods ( months pre-and months post-chlorhexidine for clabsis, one year for the other outcomes). results: the study covered patient bed days ( pre-and post-introduction of chlorhexidine bathing). there were an identical number of mdro acquisitions in each group ( ), giving rise to an mdro acquisition rate per bed days of . in the control group compared to . in the chlorhexidine group (p = . ). clabsi incidence per bed days was higher in the control group compared to the chlorhexidine group ( . vs . ; p = . ). the incidence of significant bacteraemias per bed days was similar in the the two groups ( . before and . during chlorhexidine bathing; p = . ), but the incidence of bacteraemias due to skin commensals per bed days was lower in the chlorhexidine group ( . vs . ; p = . ). conclusions: at our large university hospital icu with a heterogeneous patient population, the introduction of routine daily chlorhexidine-impregnated cloth bathing appears to significantly reduce the incidence of bacteraemias due to skin commensals and demonstrates a non-significant reduction in clabsis. given the uncertainties surrounding diagnosis in the icu, the effect seen may be of benefit in reducing the use of antibiotics to cover for these skin commensals -both in terms of antibiotic stewardship and health economics. introduction: the current cdc guideline published in for the prevention of intravascular catheter-related infections recommends skin preparation with a greater than . % chlorhexidine with alcohol solution before cvcs or acs placement and with dressing changes, which was changed from % chlorhexidine recommended in the guideline. however, few studies investigated the superiority of % chg over either . % chg or % pvi for the prevention of catheter colonization as cdc guideline recommends. objectives: efficacy comparison of three antiseptic solutions [ % aqueous povidone-iodine (pvi), and . % and . % alcoholic chlorhexidine gluconate (chg)] for preventing intravascular catheter colonization. this was a open-label, multicenter, prospective, randomized controlled trial conducted at icus in japan. the intravascular catheters included central venous catheters (cvcs) and arterial catheters (acs). patients aged > years of age undergoing cvc and ac insertion in icu were randomized to receive one of three antiseptic preparations pre-insertion. catheters were removed when no longer necessary or if catheter-related infection was suspected. after catheter removal, distal tips were cultured using semi-quantitative/ quantitative techniques. catheter colonization and catheter-related bloodstream infection (crbsi) incidences were compared. results: while a total of catheters were randomized, several catheters were excluded due to withdraw of their informed consent and lack of cultured catheters after randomization, and ( %) catheters were included in the full analysis ( . % chg n = , . % chg n = , and % pvi n = ). the median catheterization duration was . days ( % ci: . - . days); no significant intergroup differences were observed (p = . ). catheter-tip colonization incidence (per catheter days) was . , . , and . events in % pvi, % chg, and . % chg groups, respectively (p = . ). catheter colonization risk was significantly higher in the % pvi group. no significant intergroup differences crbsi probability were observed introduction: spontaneous intracerebral hemorrhage (ich) is the most fatal stroke subtype worldwide caused by spontaneous vascular rupture due to hypertension or amyloid angiopathy. an accurate prediction of ich outcome would assist both families and physicians to decide therapies and monitorization at an early stage. objectives: to evaluate the relationship between the hematoma volume and location with mortality and functional outcome in patients with spontaneous ich. methods: we performed a prospective observational study, included patients admitted in icu with spontaneous ich. we determined hematoma volume at admission with kothari modified formula (axbxc/ ) and divided them in two groups according the location as infratentorial or supratentorial. we collected gcs, sofa, apache ii and graeb at admission, medical history and complications during the first week in the icu. we established modified rankin scale (mrs: poor outcome > ) and glasgow outcome scale (gos, poor outcome < ) at icu discharge. we used %, mean (sd) and median (minimal/maximum). t-student and χ (p < . ) were used for the univariable analysis. we conducted a multivariable analysis for mortality with binary logistic regression ( % ci, or) p < , . roc curve was determined for the volume of hematoma associated with mortality (ic % p < . ). results: we enrolled patients. % were men, mean age (± . ) years. global mortality was . %. . % were supratentorial and . % infratentorial. mean apache ii (± , ) and gcs . (± , ) and median sofa ( - ) and hematoma volume , cc . there were no significant differences between the two groups (infra and supratentorial) except ich volume (p . ) and length of stay (los)-icu (p . ). in the univariable analysis worse outcome with mrs was related with the volume of the hematoma (p , ) but not with gos (p , ). variables associated with mortality: gcs (p . ), apache ii (p . ), graeb (p . ), sofa (p . ), los-icu (p . ) and ich volume (p . ). after the multivariable analysis we determined hematoma volume was an independent risk factor for mortality (or , ; % ci , - , ; p . ). according the location we obtained a significantly association with mortality in the supratentorial group (p , ). we performed a roc curve of this group and obtained an auc , ( % ci , - , ; p . ) with cutoff point of , cc . conclusions: hematoma volume and los-icu are greater in supratentorial ich. the hematoma volume is associated with a worse outcome at icu discharge and a supratentorial ich volume above . cc is related to higher risk of mortality. introduction: aneurysmal subarachnoid hemorrhage (sah) is an acute cerebrovascular event, which leads to devastating consequences, high mortality and is an important cause of neurologic disability among survivors. incidence is reported between to / and mortality rates vary widely, ranging from to % among different authors. many complications associated with sah, such as delayed cerebral ischemia or hydrocephalus, also play a role in the poor functional outcome in survivors. paulo niemeyer state brain institute is a reference and high-volume center for sah, located in rio de janeiro, brazil, receiving patients from all over the state. objectives: the aim of the study was to describe the characteristics of patients with sah admitted to the icu, as part of a large prospective ongoing study, and to evaluate the factors associated with outcome. methods: from july to march , every patient admitted to the icu with aneurysmal sah, years and older was enrolled in the study. data were collected prospectively during hospital stay. the primary endpoint was mortality and dichotomized functional outcome, (poor outcome defined as modified rankin scale - ) at hospital discharge. results: a total of patients were included. the median age was ( - ), patients ( %) were female. demographic characteristics are presented in tables and . twenty-nine patients ( %) were treated by clipping, and patients ( %) were hydrocephalic and needed an evd. an intracranial pressure monitor was inserted in patients ( %). nine patients ( %) developed sepsis or septic shock during icu stay and pneumonia was present in ( %) patients. rebleeding was diagnosed in patients ( %), vasospasm was present in ( %) patients, post-surgical deterioration was diagnosed in ( %) patients and ( %) patients developed dci. twenty-two ( %) patients were mechanically ventilated. hospital mortality was % ( patients); and patients had unfavorable ( %). in univariate analysis, factors most frequently seen in patients with unfavorable outcome were rebleeding ( % vs %, p = . ), vasospasm ( % vs %, p = . ), post-surgical neurological deterioration ( % vs %, p = . ), dci ( % vs %, p = . ) and pneumonia ( % vs %, p = . ). although not statistically significant, there was a trend towards the association between sepsis/septic shock ( % vs %, p = . ) and unfavorable outcome. conclusions: sah is associated with high morbidity. neurological complications such as rebleeding, vasospasm, post-surgical neurological deterioration and dci, as well as clinical complications (eg. pneumonia) were associated with unfavorable outcomes. therapeutic interventions to prevent neurological and systemic complications may have an impact on clinical outcomes. introduction: the management of patient into the icu after been submitted to a cns resection is an important challenge. surgery is indicated for diagnosis, to reduce tumor bulk and to manage raised intracranial pressure. primary brain tumors are classified based on their cellular origin and histologic appearance. the most common malignant brain tumor is glioblastoma multiforme, this group have a poor prognosis. objectives: the goal was to make a descriptive analysis about the evolution of patient submitted in the icu for postoperative control following a surgical resection of intracranial tumors. methods: a retrospective and observational study was conducted on all elective consecutive surgical procedures for tumor resection admitted into the icu. we analyzed variables related with the tumor, predisposing pathology, surgical data and evolution in the icu. we considered as an unfavorable evolution the death into the first month after the intervention or the decrease in two points or more of the canadian´s scale score (css). is a comparative study analyzed by student´s t-test, anova of one factor and pearson´s chi-square test. comparative study expressed by: mean difference, relative risk and confidence intervals at %. results: we analyzed patients over of years ( - ) . of the total, . % are high-grade gliomas, . % low grade gliomas, , % meningiomas , . % metastasis and . % other type of tumors. average age is . years (sd . ), it is significantly lower in the low-grade gliomas, and in the group of other tumor types compared to other groups. . % are men , the most common in men ( . %) and meningiomas and other tumors in women ( . % and . % respectively) gliomas. . % are supratentorial location. average size is . ml (sd . ) . the average score in the preoperative karnofsky scale is . (sd . ) . the average income apache is . points (sd . ). an unfavorable evolution is observed in . % of patients ( . % per patient died and . % decline in the css) after one month , with no differences between different types of tumors. the percentage of deaths in the first month is higher in those undergoing surgery for metastasis ( . %, rr . , ci . to . ) . mortality at two years of intervention is . %, being higher in sifnificativamente undergoing metastasis ( %; relative risk . , ci . to . ) and high-grade gliomas ( . %; relative risk . , ci . to . ). conclusions: patients undergoing brain tumors have a significant risk of poor outcome , which is significantly higher in metastatic patients from the first month of intervention and in patients undergoing high-grade gliomas at two years. introduction: nosocomial infection (ni) is still an issue in neuroritical care. objectives: we analysed ni in a preventive multimodal protocol in patients with acute brain disease. method: we performed a -year prospective observational cohort study in patients (pts) with acute brain disease admitted to an eight-bed adult neuro-intensive care unit (nicu). we defined our preventive multimodal protocol as: ) keeping a hygienic and epidemiological regime including isolation of pts with multi-drug resistant bacteria ) correct antibiotic policy, and ) regular microbiological screening. there were ( . %; wound . %, respiratory . %, urinary . %, bloodstream . % and other . %) pts with ni. we compared ni group pts with the control group of pts and searching predictors of ni in univariete analysis. we did not find differences in age (p = . ), male (p = . ), weight (p = . ) or body mass index (p = . ), but there were more stroke pts and fewer tumour pts (p < . ). ni pts stayed in nicu longer (mean . vs . , p < . ), on admission had lower glasgow coma scale (mean . vs . , p < . ), higher therapeutic intervention scoring system (tiss, p < . ), acute physiology and chronic health evaluation ii (p < . ), and crp (p < . ); in the nicu they had higher crp (p < . ) and nicu mortality (p < . ); on discharge they had worse glasgow outcome scale (p < . ) and higher tiss sums (p < . ). ni pts had more accesses, which were strong predictors of ni: artery (odds ratio [ conclusions: our study confirmed that nosocomial infection is associated with worse outcome and higher cost, and that accesses are still risk factors in a preventive multimodal protocol. the predictive value of emergency triage codes on the outcome of aneurysmal subarachnoid hemorrhage introduction: outcome of patients with aneurysmal subarachnoid hemorrhage (sah) was associated in different studies with different variables (baseline illness severity, physical status, treatments, complications), but the relationship between outcome and triage assessment in the emergency setting has never been evaluated. emergency triage in italy is carried out with color codes: red (immediate life-saving intervention needed), yellow (urgent intervention needed), green (delayed intervention is sufficient), white (not urgent). objectives: to study the relationship between triage severity codes assigned to patients with sah in an italian emergency setting and the outcome expressed as modified rankin score (mrs) at hospital discharge (good outcome for mrs ≤ , poor outcome for mrs > ). methods: a retrospective clinical study included patients with aneurysmatic sah admitted to emergency departments of bologna catchment area, and then to intensive care unit (icu), from january to january . aneurysm coiling or clipping was performed after neuroradiological diagnosis and clinical stabilization, excluding patients too ill to benefit. intensive care treatment was carried out according to current practical guidelines. demographic, clinical and interventional data, complications, severity scores and outcome scores were recorded. the following parameters were considered in univariate analysis: age, sex, clinical condition on arrival in the emergency department (triage code, gcs, wfsn scale, vomiting and seizures) aneurysm clipping or coiling and other neurosurgical interventions, hydrocephalus, vasospasm, cerebral infarction (ct scan), fever, sepsis, acute respiratory failure with p/f ≤ , cardiovascular complications (hypotension requiring vasopressor therapy, acute cardiomyopathy, arrhythmias requiring treatment); the outcome variable was modified rankin score > at hospital discharge. results: poor outcome (mrs > ) was observed in % of triage green codes, % of yellow codes, % of red codes. the univariate analysis showed the statistically significant (p < . ) association with mrs > for the following variables: triage red code, wfsn scale > , acute respiratory failure, cardiovascular complications, sepsis. on logistic regression analysis, the red code assigned in the emergency department, cardiovascular complications and sepsis were associated with poor outcome. conclusions: the severity of general clinical conditions after subarachnoid hemorrhage needing immediate life-saving intervention, feature labelled "red code" in the emergency triage, was associated with poor outcome (mrs > ), while the other triage codes did not show any significant correlation with outcome. cardiovascular complications and sepsis during hospital stay were other variables associated with mrs > . evaluation of intracerebral hemorrhage (ich) score in patients admitted in intensive care by supratentorial brain hemorrhage l. perez-borrero introduction: intracerebral hemorrhage is a stroke subtype with high mortality and significant disability among survivors. objective: to evaluate in our area the intracerebral hemorrage (ich) score in patients with spontaneous supratentorial brain hemorrhage. methods: multicenter prospective observational study in three hospitals in andalusia (spain). we studied all patients with supratentorial brain hemorrhage admitted to the regional hospital of malaga (between to introduction: within the clinical importance of the sah, there are factors described in the scientific literature that speak of an unfavorable evolution of the disease. our hypothesis is based on trying to demonstrate if only one therapeutic intervention could alter the significance of these factors. objectives: analyze the sociodemographic, laboratory findings, clinical and radiological factors that influence prognosis at months in discharged aneurysmal sah patients treated with endovascular intervention. methods: we performed a retrospective longitudinal observational study of all patients who were diagnosed with an aneurysmal sah in icu services of hospitals between march st and november th . they were treated by endovascular intervention. after being discharged from icu and after months of neurologic follow-up. patients were divided into two groups, one formed by those who presented a favorable outcome (ef) and the other by those who didn´t (ed). the variables studied were age, sex, hbp, dm, smoking and dyslipidemia. at the time of admission po , pco , leukocytosis, hyperglycemia and hypertension was determined as well as sodium, magnesium and chlorine plasma levels. the clinical status of patients on admission was assessed using the hunt-hess and wfns scales. the severity of sah was determined by ct using the fischer scale. the aneurysm was located by four vessel angiography. the time between the sah clinic presentation and the procedure was recorded, as well as if aneurysmal occlusion was complete or not. as for the complications, we took into account the presence of fever, hydrocephalus, vasospasm and infarction. results: for the study, patients who underwent acute endovascular sah treatment using coils, were selected. female sex was the predominant sex % vs . % between ed and ef, respectively. the age group most frequently found was between and years ( % for ed and % for ef). logistic regression analysis determined as associated with a worse outcome factor: hyperglycemia on admission(or . , % ci . - . , p = . ), clinical status on admission determinated by hunt-hess (or . ci . - %, p = . ) and wfns scales (or . , % ci . - . , p = . ). the presence of fever on admission also has proven to be a poor prognostic factor (or . % ci . - , p = . ). conclusions: clinical factors for aneurysmal sah patients treated with endovascular procedure that have shown relation with the clinical outcome at six months are: poor clinical grade on admission, hyperglycemia and fever. these data are similar to those found in the literature and support the idea that the therapeutic decision (surgical or endovascular) is not the determining factor for the evolution of these patients, however, the ones mentioned above could be. background: conflicting results have been obtained by studies attempting to assess the risks of ischemic stroke in patients with venous thromboembolism, while the long-term risk of stroke in survivors of venous thromboembolism remains unexplored. objective: we evaluated whether the risk of ischemic stroke in patients hospitalized with venous thromboembolism is higher when compared to the general population. methods: one million patients from national health insurance beneficiaries in taiwan were sampled. there were , patients who had been hospitalized with diagnosis of venous thromboembolism and , unexposed subjects. all adult patients were followed from january to december to evaluate if ischemic stroke was diagnosed. cox regression models were applied to compare the hazards adjusted for potential confounders. results: after controlling for age, gender, urbanization level, socioeconomic status, diabetes, hypertension, coronary artery disease, hyperlipidemia, history of alcohol intoxication, malignancies, congestive heart failure, atrial fibrillation, smoking, peripheral artery disease and charlson comorbidity index, the adjusted hazard ratio of ischemic stroke was significantly increased in patients with venous thromboembolism ( . ; % ci, . - . ). a subgroup analysis based on patients who survived longer than months in the cohort also revealed higher hazard ratio in the patients with venous thromboembolism. ( . ; % ci, . - . ). conclusion: the possible risk of ischemic stroke is significantly higher in patients hospitalized with venous thromboembolism than in the general population. introduction: status epilepticus (se) is a common neurological emergency with considerable associated health-care costs, morbidity and mortality. , se is defined as a prolonged seizure or multiple seizures with incomplete return to baseline. , the overall mortality of se is around % with convulsive status epilepticus representing about - % of all cases. status epilepticus severity score (stess) is a prognostic score that relies on four outcome measures (age, history of seizures, seizure type and extent of consciousness impairment) determined before treatment institution that ranges between and . objective: evaluation of stess as a prognostic measure of functional impairment, neurologic motor deficits and -day mortality. methods: retrospective observational study of patients with se admitted at a general intensive care unit (icu) from to . age, gender, saps ii/iii, type of se, length of stay, number of anti-epileptic drugs, duration of se, functional impairment, neurologic motor deficits and -day mortality were collected through the icu informatics database -picis®. data is presented as mean ± sd and we used logistic regression to correlate stess with study variables. statistical analysis was performed using xstat ®. results: sample included patients, , % male, age , ± , years, saps ii , ± , , saps iii , ± , , icu length of stay , ± , days and hospital length of stay , ± , days. convulsive se represented , % of cases. stess score`s mean was , ± , . se lasted more than day in , %. electroencephalogram was performed in , % of the patients. , % of the patients needed two or more anti-epileptic drug for se. at hospital discharge , % had functional impairment and , % had neurologic motor deficits. mortality was , % at days. there was a correlation between stess and mortality (or = , ; roc = , ), functional impairment (or = , ; roc = , ) and neurologic motor deficits (or = , ; roc = , ). the number of antiepileptic drugs and se duration had no correlation significance. conclusions: we found an excellent correlation between stess and mortality in our study. besides this, we also found this score to be a good prognostic tool for functional impairment and neurologic motor deficits. we consider our main limitations the sample size and lower mortality. despite we recommend using stess as an outcome predictor. introduction: in order to determine optimal airway protection measures in early postoperative period after fossa posterior surgery (pfs), it is important to carry out a prognosis of neurological dynamics based on the preoperative neurological exam. we have designed neurological evaluation scale (nes). objectives: our study was aimed at determining the potential of nes to predict brain stem deterioration in early postoperative period after pfs based on the assessment of the preoperative neurological status. methods: the prospective study was carried out during the period from december to june and included patients operated for fossa posterior tumors (fpt). to be included in the study, patients had to be over years old and operated for fossa posterior non infiltrative paraxial tumors. we examined all patients before and after the operation, immediately after the extubation in icu. nes provided complex neurological assessment with an emphasis on the brain stem function. postoperative nes points were subtracted from the preoperative points -ab-criterion (abc). positive abc corresponds to intensification of neurological deterioration. negative or zero abc corresponds to neurological improvement. all neurological symptoms were grouped in nes blocks according to their relation to cns. results: we divided all patients in two groups depending on their abc, which revealed that the patients with positive abc had reliability less nes points before operation compared to the patients with negative or zero abc. we found out the frequency of occurrence of each nes block for inclusion in the full neurologic status. we discovered that caudal stem affection occurred more frequently in the patients with more nes points. we evaluated the probability of neurological impairment or regression of neurological symptoms depending on abc with sensitivity , % and specificity %. we created a prognostic model, which could predict the discharge from clinic outcome on the basis of the nes blocks points assigned during the early postoperative period. conclusions: we revealed neurological features of postoperative period in patient after fps. our data could predict neurological outcomes, and be useful in optimization tactic of airway protection. and those who died ( . ± ; . ± and ± . ± vs ; . ± and . ± respectively) but difference was not significant. an inverse correlation between inflammatory biomarkers (pct, crp and il- ) and igm endocab was detected. il showed a higher correlation, but without statistically significant differences. icu mortality rate was %. conclusion: igm endocab were detected in septic shock caused by gpb, it could be explain by a bacterial translocation. patients with major endotoxaemia have higher consumption of antibodies and therefore lower levels of igm endocab that is associated with a worse prognosis. the relationship between the neutrophil/lymphocyte ratio and mortality in the severe sepsis patients y. conclusions: sp compliance is below recommended but the mean hobe reaches the lower limit of the recommendation. the factors affecting sp compliance differ according to the method used for data collection and include other factors than patient's clinical condition. politics targeting to increase its compliance should address various areas of care such as team and professionals, resources and equipment and re-consider clinical indications for sp. the project was funded by the °national award of nursing research from marques de valdecilla hospital (spain). gained to collect staff opinions and anonymised patient data. ed, or and icu professionals were surveyed following a pilot to determine options, ranking and scoring criteria a priori where needed. anonymous patient data from intubated patients who were cared for in the ed, or and icu within their first hours were collected. this included physiological observations and supportive care standards around a, b and c. results: the most striking differences in staff opinion involved the preferential use of artificial colloid-based fluid resuscitation in sepsis ( % ed staff; % or staff; % critical care staff); the value and significance of recording end tidal co ( % ed staff; % or staff; % critical care staff); and the potential preferential use of flowdirected fluid boluses rather than pressure-directed fluid boluses in critically ill patients ( % ed staff; % anaesthetic staff; % critical care staff). when observing supportive care standards the largest differences were in the use of stress ulcer prophylaxis (only prescribed in critical care); patient positioning (head-up: % patients in cc; % in ed); the recording of sedation level ( % ed; % anaesthetic; % critical care) and the recording of ventilator parameterstidal volume, peak pressure and et-co -( % ed; % anaesthetic; % critical care) . finally, in respect to patient pathophysiology, all groups were under ventilated and over oxygenated. mean arterial pressure was most divergent from baseline in the ed. however, changes in pathophysiology were related to interventions (fluid boluses, analgesia, surgical interventions, inotropes, pressors) rather than location. despite the divergent views regarding the relative value of flow monitoring, observed fluid boluses were predominantly triggered by pressure changes in all three locations. conclusions: differences in staff attitudes; application of standards and patient pathophysiology were identified between care locations. the influence of variation in resources and professional composition of teams (nurses:doctors) on these results requires further work. it remains uncertain whether more uniform approaches would improve patient outcomes. lung comet score (lcs) for evaluation of extravascular lung water (evlw) in intensive care unit (icu) patients undergoing renal replacement therapies (rrt) a. taggu methods: a prospective observational study was conducted on patients in icu needing rrt. exclusion criteria were age < years, pregnant, amputees, cardiac pacemakers, pre-existing lung diseases and ascites. lung comet score as per validated technique , bia measurements and baseline data were collected pre and post dialysis. lung comet score and other covariates were fitted into a regression model using bia as the standard test. based on bia delta hydration relative (hs rel), patients were divided into normohydration and hyperhydration using a cut-off of %. results: a linear regression model in predialysis state showed that only lcs could significantly predict lung water (const . , coef. . , p value . ). in the postdialysis state lcs perfectly predicted lung water (const . , coef., . ; p value . ).bland altman plots showed good agreement between lcs and hydration status (bia) pre and post dialysis. the lcs > nearly perfectly predicted hydration status in both pre and post dialysis states. conclusions: lung comet score is a good surrogate of evlw and reliably predicts reflects hydration status pre and post dialysis in icu patients. introduction: treatment withdrawal in intensive care is common ( ) . whilst significant research attention has focused on how treatment is withdrawn and what information is communicated to families ( ) introduction: micro-aspiration of subglottic secretions is considered a major pathogenic mechanism of endotracheal tube-associated pneumonia (etap), either postoperative pneumonia or ventilatorassociated pneumonia. endotracheal tubes (ets) with taper-shaped cuffs have been proposed to provide a better seal of the extraluminal airway, thereby preventing micro-aspiration and possibly etap. objectives: to perform a systematic review and meta-analysis to assess the efficacy of ets with taper-shaped cuffs in the prevention of etap. methods: a systematic search of medline, embase and central/ cctr was conducted in march . eligible trials were randomized controlled clinical trials (rcts) comparing taper-shaped cuffs with standard, cylindrical-shaped cuffs in intubated patients. all studies reporting the incidence of etap were included. inclusion of trials was irrespective of publication status, date of publication or language. random-effects meta-analysis calculated the risk ratio (rr) and % confidence interval (ci) for the incidence of etap between both groups using the mantel-haenszel method. results: three rcts, given a total of patients, met the inclusion criteria. one trial was published as a conference abstract only ( ), while the others were published in full ( , ) . none of the trials was blinded for the intervention. patients were allocated to the intervention arm and to the control arm. etap episodes occurred in the intervention group and in the control group. the pooled rr for the incidence of etap was . ( % ci, . - . ; z = . p = . ). conclusions: the use of endotracheal tubes with taper-shaped cuffs did not show to reduce the incidence of etap. however, the number of available studies is small, and there is an inherent risk of bias due to the unblinded designs. background: understaffing of icu's can have serious adverse consequences both for patients and for nurses, and therefore it is important to have an adequate number of nurses on the ward. nurses however are in short demand and resources are scarce. being able to predict the nursing workload for a certain group of patients may help to allocate nursing capacity as efficiently as possible and thus to reduce costs, without endangering the patients safety and nurses' health. nas is a validated tool for the measurement of nursing workload in an intensive care unit. goal: this study was conducted to investigate whether it is possible to predict the nursing workload for a homogeneous group of patients, admitted after an in or out of hospital cardiac arrest and to assess the effects of baseline characteristics, vital parameters and admittance time on this workload. method: we performed a retrospective analysis of nas scores of all ihca and ohca patients admitted to our icu from october until september during the first hours of stay. the nas was recorded per patient per nursing shift. we furthermore recorded patient characteristics and vital parameters. results: during this period patients, males and females, were admitted to the icu after cardiac arrest. the mean age at admission was . years (sd = . ). the mean nas at admission was . (sd = . ). patients admitted in the evening shift had a significantly higher nas compared to patients admitted in the night shift ( . ; sd = . vs . ; sd = . (p = . )), but no significant difference was found with the day shift (mean nas day shift: . ; sd = . ). after admission the workload decreased in all patients by a mean of . points (sd = . ; p < . ). a higher sofa score, a higher peep and a lower ph at admittance resulted in a higher nas score on average over time (p < . ). conclusions: the nursing workload at admission of patients after cardiac arrest is fairly predictable, with no clinically significant difference between shifts , necessitating a nurse-to-patient ratio of at least : . after the first shift it is almost always possible to decrease the nurseto-patient ratio to : . the nas was influenced by severity of illness. these results can be used to assess the needed nursing staff for the treatment of these patients for the first days after admittance. introduction: major trauma and severe sepsis are both leading causes of admission to the resuscitation rooms in emergency departments across the world. despite obvious differences in precipitating mechanism, there are surprising similarities between subsequent pathophysiology: both disorders lead to disorders of the macrocirculation, microcirculation and host inflammatory response ( , ) . objectives: here we compare the baseline epidemiology, pathophysiology, operational and clinical management of intubated resuscitation room patients with these two critical illness syndromes (major trauma/septic shock). the results will be used to facilitate the design and planning of a study to test the feasibility/effectiveness of advanced monitoring systems (thromboelastography, oesophageal doppler flow monitoring, echocardiography, and microcirculatory monitoring) in the resuscitation room management of critically ill patients with these conditions. methods: institutional approval was gained to collect anonymised patient data over a -month period from a mixture of written and electronic records. where appropriate, significance was tested by mann whitney u (sigmaplot . ). results: patients, intubated pre-hospital or in ed resus, were identified with trauma or sepsis diagnoses. trauma patients were commoner (n = ; %) and more likely to be intubated prehospital ( / ; . % vs / ; %). lactate profiles were similar in the two groups at start and end of resus episode ( figure ). patients with major trauma were more hypertensive but equally tachycardic when compared with patients with severe sepsis/septic shock. patients with septic shock/severe sepsis (median minutes vs minutes) spent longer in resuscitation room, but received less documented consultant-level review ( . % vs . %). imaging of major trauma patients was with ct ( / ; %) and ultrasound ( / ; . %) in contrast to septic patients ( / ct; . %; / , % us). icu and hospital mortality was higher in patients with sepsis ( . % vs . %), but death in resus only occurred in the trauma population. only two patients, both with facial trauma, would have had a relative contraindication to the proposed advanced monitoring. conclusions: this novel preliminary work has highlighted some important differences between the epidemiology, outcomes, pathophysiology and clinical/operational management of intubated patients with severe sepsis versus major trauma. these will influence the conduct and outcome measures of any trial of advanced monitoring in this setting. however, contraindications to any of the advanced monitoring technologies being considered were rare and no obvious barriers to the planned study of advanced monitoring were identified. introduction: in our -bedded gicu, demand for beds has increased while recruitment of icu trained nurses has decreased. there is enduring evidence of links between workload and stress [ , ] , with high levels of burnout reported in icu nurses [ ] . there has been a shift towards measuring what makes people positive and engaged [ ] , rather than why people reach the extreme state of burn out. it is important to understand factors that affect work engagement to develop strategies that enhance nurse retention and improve the quality of icu patient care. objectives: to examine the impact of an education initiative for novice icu nurses on work engagement for the icu nursing staff and organisational resource use. methods: a pre -post design was used to collect data from all icu nurses at the start of the education programme and at months following he intervention. work engagement was measured using the self-report item utrecht work engagement scale (uwes) [ ] with an open question to capture staff experiences. organisational impact was measured using levels of sick leave, % staff turnover, use of agency nurses and staff recruitment. results: fifty three icu nurses completed the pre-intervention survey ( % response) and completed the post-intervention survey ( % response). respondents had reasonable years of icu experience (mean . , sd . ) and time in current post (mean . , sd . ). internal consistency for the uwes was high (alpha . ). levels of work engagement (mean [sd]) increased ( . , [ . ] vs . [ . ]) but did not reach significance and remained in the 'average' band as judged by the scale authors [ ] . when examined by senior and junior nurses, the increase was similar. organisational measures showed decrease in sick leave, turnover, agency use and increase in recruitment of experienced icu nurses. qualitative feedback was positive, with perceptions of improvement in unit morale due to time being invested in the individual and reduced stress and workload for shift leaders. conclusions: providing education for the newest icu recruits can have benefits for the whole icu team. however, it is important to examine how work engagement might be further improved. the incidence of silent aspiration on intensive care n. maistry royal brompton and harefield nhs foundation trust, rehabilitation and therapies, london, united kingdom intensive care medicine experimental , (suppl ):a introduction: the incidence of dysphagia on intensive care is an area of growing research. dysphagia is associated with aspiration pneumonia and increased icu bed days. in general, speech and language therapy (slt), makes recommendations based on the results of a clinical bedside swallowing evaluation, despite the unreliability of this method . this is largely due to the difficulty accessing gold standard assessment methods such as videofluoroscopy (vf) and fibreoptic endoscopic evaluation of swallowing (fees) . referral for these assessment methods are based on a local defined criteria. this study evaluates the incidence of silent aspiration identified by vf and fees in a bedded tertiary cardio-respiratory intensive care unit. objectives: to determine the incidence of silent aspiration, defined as "aspiration before, during, or after swallowing in the absence of cough or visible signs of choking and distress ," in icu patients assessed by vf or fees between july and june . method: data was retrospectively reviewed for month period from all icu referrals made to slt for swallowing evaluation. all patients received a clinical bedside swallowing evaluation. the results are presented as percentages and counts for patients receiving vf and fees that silently aspirated. results: a total of patients were referred for swallowing assessment and % ( / ) had a vf or fees. there were males and ages were . ± . years. in this group, patients had videofluoroscopic assessments and patients had fees. in the vf group % silently aspirated whilst in the fees group the values were %. patients ( %) silently aspirated during objective assessment, impacting on how and when oral feeding was commenced. conclusion: this study suggests that silent aspiration is highly prevalent in this population group. consequently, vf and fees should be part of standard routine assessment in the management of critically ill patients. delerium related incidents at the icu and nursing aspects a. van introduction: at the icu of vu university medical center (vumc) nurses are frequently confronted with delirium , . delirium is known to be present in - % of mechanical ventilated patients and - % in non-ventilated patients. immediate consequences are falling incidents or for patients to remove tubes and iv lines that are necessary for treatment. in literature, this is stated as a result of treatment, but often data is missing. consequences of removal are increased risk of complications , prolonged mechanical ventilation, los and increased morbidity/mortality . objectives: to measure the frequency of removing tubes, lines and falling incidents related to delirium. methods: a multidisciplinary focus group was formed ( ) in order to properly diagnose, prevent and/or treat delirium due to the high prevalence. the first steps were increasing awareness and implementing the cam-icu score. to clarify delirium-related incidents a one year period was set in which the dedicated senior nurse informed and trained the nursing staff regarding delirium and potential risks. to register delirium-related incidents a modified report button was built in the epr (metavision, imd soft) and used beside the regular incident reporting system . results: after one year, individual patient incidents were reported concerning falling or tube or iv line removal. this included gastric tubes, airway tubes, iv/cvc/arterial lines, other lines and fall incidents. in % of the cases the patient was diagnosed with delirium. out of patients received medication or were fixated before the incident despite a % cam-icu registration rate. because the focus group doubted about underreporting nurses were interviewed if the results corresponded with their experience. they were unanimous that there was hardly any underreporting. discussion: despite therapy or fixation delirium-related incidents occur on a weekly basis at our icu, causes harm and increases nursing workload. although the incidence rate is presumed to be low, there is no feeling of satisfaction. further improvement is necessary due to the high risks for the patient. therefore, we need to be able to diagnose incidents faster so we can start treatment sooner. although the cam-icu score was implemented, compliance is insufficient. increasing compliance is the first step to further improvement. the follow-up question is whether delirium-related injury can be reduced when cam-icu compliance improves. second step is to investigate the effectiveness of our fixation protocol. prospective study to determine the predictors of extubation success a. taggu introduction: timely extubation is crucial in critically ill patients. traditional indices like rapid shallow breathing index are considered as accurate during the spontaneous breathing trial. multiple other proposed parameters like diaphragm thickness, fluid balance and cardiac indices have been shown to predict succesful extubation in the recent years. objectives: to assess the reliability of the parameters in predicting successful extubation. methods: a prospective observational study done on adult patients eligible for extubation as decided by the attending intensivists. exclusion criteria: pregnant and tracheostomised patients. along with baseline parameters, following measurements were taken pre and post extubation. . cardiac parameters including simpsons method for ejection fraction, e/a, e/e' (lateral) for diastolic function, tapse and tad for right ventricular function. all recordings were taken just before extubation and within six hours post extubation. . just before extubation,high frequency linear ultrasound probe was used to measure the right sided dt at the zone of apposition (zoa) between th to th intercostal spaces in mid-axillary line.the change in dt fraction(Δdtfrac_pre%) was calculated as dt(end-inspiration)-dt(end-expiration)/dt (end-expiration)x .rsbi was simultaneously recorded. . fluid balance hours were recorded. figure ) . we found no significant difference on mortality when limiting the results just to trial employing cvvh at hemofiltration rate lower or higher then ml kg − h − . conclusions: blood purification with cvvh might be associated with a significant reduction in mortality when performed in patients with sepsis or ards. this is the first meta-analysis suggesting beneficial effects of cvvh on mortality and we could suppose that the beneficial effects of cvvh in these inflammatory conditions could arise from the immunomodulatory properties of hemofiltration. further high-quality randomized controlled trials adequate powered for mortality are needed to clarify the impact of cvvh on these inflammatory conditions. the authors declare no support or funding and no potential conflict of interest. we defined extreme hyperbilirubinemia as a state of total bilirubin above mg/dl and selected all patients whose serum total bilirubin increased above mg/dl at least once during their stay in the intensive care unit. we investigated the overall clinical course of the patients and compared the differences between one group with normalization of total bilirubin (recovery group) and the other group without normalization (non-recovery group). furthermore, we evaluated the association between prognosis and various clinical factors, including the peak total bilirubin levels, increasing rate of total bilirubin (vi), results of laboratory analyses related to hepatic function, and clinical features at the time of extreme hyperbilirubinemia. these data were analyzed using chi-square test and cox and logistic regression analyses. introduction: propofol is widely used in critical care sedation due to its pharmacological properties which allow serial neurological examination ( ) .hypo tension is a common side effect of propofol infusion, which affect patient outcome. introduction: propofol is a common intravenous drug used during anesthetic induction and sedation because of its rapid onset and short duration. its downfall, however, is that patients experience injection pain so severe that they recall induction as the most painful part of the sedation process. among numerous reports in efforts to decrease propofol injection pain, the most effective combination of drug and non-drug intervention evaluated through a quantitative systematic review revealed to be pretreatment with . mg/kg lidocaine in combination with a tourniquet for venous occlusion. the majority of these reports conclude that a single method is insufficient in eliminating propofol injection pain. objectives: we evaluated the effect of heated carrier fluids ( °c) in decreasing propofol injection pain. methods: a randomized controlled clinical trial was conducted in patients (asa or ), ages to . patients were allocated into groups (n = ) each. group w received ml of heated carrier fluids for minutes prior to mg/kg propofol injection; group l received ml of heated carrier fluids for minutes prior to lidocaine pretreatment and mg/kg propofol injection: and group c (control group) received ml of room temperature fluids prior to mg/kg propofol injection. propofol injection pain was evaluated using the verbal pain score (vps). results: group w and l showed significant reduction in the incidence and severity of injection pain compared to group c (p < . ). vps was significantly lower in group w (p = . ) and l (p = . ) compared to group c. there was no statistical difference between group w and group l (p = . ). there was statistically significant difference in mean blood pressures measured after mg/kg propofol injection among groups. conclusions: both heated carrier fluids and combination of lidocaine pretreatment effectively reduced propofol injection pain. objectives: we conducted a prospective cohort study to clarify the epidemiology and the nature of aes in surgical inpatients in japan. methods: the japan adverse event (jet) study was a prospective cohort study which had evaluated aes and medical errors (mes) at tertiary care hospitals. the medical and surgical wards were stratified according to hospital and whether they were medical or surgical wards, and study wards were randomly selected. intensive care units (icus) were all included. we included all adult patients aged > = years old who were admitted to any of the selected study wards ( medical, surgical, and icus) over a -month period. the primary outcome of this study was the epidemiology and the nature of aes and mes in the patients who had operation during the study period. trained nurses placed at each participating hospital reviewed all charts daily on weekends, along with laboratories, incident reports, and prescription queries to collect any potential event. they also collected the characteristics of the patients in the cohort. independent physician reviewers evaluated all potential events and classified to whether they were aes or mes, as well as to their classification, severity and preventability. introduction: whereas the importance of low tidal volume to avoid ventilator-induced lung injury (vili) in patients with ards is well known, several uncertainties still exist regarding how to set positive end-expiratory pressure (peep). many approaches have been considered, but no one showed a clear effectiveness in terms of outcome. recently a ventilator strategy using esophageal pressure to estimate the transpulmonary pressure has been proposed by talmor and colleagues . although they found an improvement in arterial oxygenation, it was not explored whether the increase in oxygenation was due to lung recruitment. objectives: the aim of this study was to assess whether the peep set to maintain a positive end-expiratory transpulmonary pressure (p l ) is associated with an increase in lung recruitment estimated by lung ultrasound score (lus) . methods: patients with moderate and severe ards were enrolled. for the first hours, peep was set according to the acute respiratory distress syndrome network standard-of-care recommendations (phase a). it was then adjusted according to measurements of esophageal pressure for the following hours (phase b) to maintain a positive p l at the end of expiration. the primary end point was the improvement in lung recruitment assessed with lung ultrasound. [ ] no data are available on the relationship between opening pressures and disease severity. objectives: to describe lung recruitment as a function of the transpulmonary pressure in mild, moderate and severe ards. methods: ards patients underwent a low-dose end-expiratory ct scan at peep cmh o and three end-inspiratory ct scans at the plateau pressures reached starting from peep cmh o, cmh o and cmh o. in each of the ct slices, lung profiles were manually delineated, excluding hilar structures. thereafter, quantitative analysis of ct scan images was performed and the gas and tissue fractions were computed. we defined the recruitability as the difference of not inflated tissue between and cmh o, that we arbitrarily assumed to be the "full recruitment". [ ] the grams of recruited tissue were computed across the pressure intervals at which the ct scan were performed, as the differences of not aerated tissue. airway and esophageal pressures were continuously measured and transpulmonary pressure was computed as: driving airway pressure (cmh o) -(esophageal plateau pressure (cmh o) -esophageal end-expiratory pressure at peep (cmh o) [ ] . results: thirty-three patients were studied, with mild, with moderate and with severe ards, according to the berlin definition. [ ] as reported in the table and fig. , the amount of tissue which can be opened between and cmh o was %, % and % respectively in mild, moderate and severe ards). mild ards patients nearly completed recruitment at approximately cmh o transpulmonary pressure while in moderate and severe ards recruitment continues up to cmh o transpulmonary pressure. conclusions: at the clinically recommended plateau pressure of cmh o, in severe ards, up to / of the lung tissue recruitable at cmh o, stays always closed. beyond contributing to the gas exchange impairment (depending on the perfusion), these "always" collapsed regions may also act as stress risers at their interface with aerated regions, though they are theoretically protected from the mechanical ventilation. introduction: extracorporeal membrane oxygenation (ecmo) is a rescue therapy for patients with acute respiratory distress syndrome (ards) by providing additional oxygenation, and removing carbon dioxide thus permitting less injurious mechanical ventilation settings that have been shown to protect the lungs from additional injury. objectives: to evaluate associations between distinct ventilator settings during ecmo, and outcome of ards patients. methods: individual patient data analysis of observational studies in adult ards patients receiving ecmo for refractory hypoxemia. multilevel multivariable logistic regression models and cox-proportional hazards models were used to determine which settings and parameters had an independent association with the primary endpoint all-cause mortality. results: nine studies with patients were selected ( figure ). initiation of ecmo was accompanied by significant decreases in tidal volume, positive end-expiratory pressure (peep), plateau pressure (pplat), and driving pressure (Δp = pplat -peep), respiratory rate and minute volume (figure ), and resulted in higher pao to fio ratios, higher arterial ph and lower paco ( figure ). higher age, lower body mass index, and higher lactate were associated with all-cause mortality after multivariable adjustment. Δp, both before and during the first three days of ecmo, demonstrated an independent association with all-cause mortality ( conclusions: in this series of ards patients receiving ecmo for refractory hypoxia, Δp and fio were the only ventilatory variables that had an independent association with outcome. these findings indicate the potential for improvement in the management of patients with ards undergoing ecmo. lungs were analysed for wet-to-dry ratio, bal protein, static compliance, spo and histology. to detect the timing of injury, rats received evans blue dye (ebd- mg/kg iv) at the initiation and were euthanized immediately before lung deflation or at , , or min afterwards ( /group). terminal bal analysed for ebd absorbance. ultrastructural impact was studied by electron microscopy on lungs sampled from rats euthanized before deflation, and at and min after deflation. hemodynamic data was obtained by echo performed at baseline (peep cmh o), immediately before and after deflation, and at mins after deflation. rv pressure was measured with a millar catheter. results: wet-to-dry ratio ( . ± . vs . ± . ; p = . ) and bal protein ( . ± . vs . ± . ; p = . ) was higher; and static compliance ( . ± . vs . ± . ; p = . ) and spo ( ± . vs ± . ; p = . ) were lower in intervention vs control. histology revealed collapse, hemorrhage and neutrophil accumulation in the intervention group. bal evans blue demonstrated that microvascular leak was absent before deflation and was maximal by min of deflation. ultrastructural analysis showed that sustained inflation caused minimal swelling of epithelium and endothelium before deflation; deflation resulted in major cellular and interstitial edema, and endothelial injury. hemodynamic data showed that rv and lv were under-filled during inflation. upon deflation, rv output, pulmonary vascular resistance, rv systolic transmural and diastolic pressures increased precipitously. rv/lv ratio increased progressively. conclusion: sudden deflation after sustained inflation with peep causes protein leak, inflammation, hypoxemia, reduced compliance, endothelial injury and rv failure. the mechanism appears to be endothelial injury resulting in microvascular leakage, pulmonary hypertension and rv failure. significance: deflation injury may be an important entity to prevent when using sustained inflation manoeuvres and may explain -in partwhy several important rcts in ards have been negative. low dose steroids reduce short term mortality in septic shock patients: results of an individual patient data meta-analysis r. introduction: previous research has suggested that the use of low dose steroids may be beneficial during septic shock. however subsequent inconsistent results explain the lack of consensus amongst doctors around the world about whether treatment with low dose steroids does improve the overall recovery and survival in patients with septic shock. we hypothetize that the lack of consistent evidence on the effect of low-dose steroids on short term mortality may be related to underpower. treated for septic shock. objectives: the primary objective of the present study was to estimate the effect of three different therapeutic regimens (hydrocortisone alone, hydrocortisone plus fludrocortisone, neither hydrocortisone nor fludrocortisone) on -day mortality in patients treated for septic shock using an individual patient data meta-analysis. methods: individual patient data meta-analysis including the major recent randomized controlled trials comparing early lowdose short course hydrocortisone and fludrocortisone to placebo (ger-inf ( )), hydrocortisone alone to placebo (corticus ( )) or hydrocortisone to hydrocortisone and fludrocortisone (coiitss ( )) in septic shock patients. the primary outcome measure was all cause -day mortality. secondary outcomes measures were day mortality, resolution of organ dysfunction (as measured by the time to reach a sequential organ failure assessement score < ), time to vasopressor and mechanical ventilation discontinuation, intensive care unit and hospital lengths of stay as well as the rate of superinfection. treatment effect on the primary outcome was quantified using relative risk and estimated using targeted maximum likelihood estimation. results: a total of , patients were enrolled in the trials. when compared to the placebo, hydrocortisone + fludrocortisone significantly reduced -day mortality (rr = . , %ci = . - . , p < . ). hydrocortisone + fludrocortisone was also superior when compared to the placebo and hydrocortisone pooled together (rr = . , %ci = . - . , p = . ). hydrocortisone + fludrocortisone significantly decreased -day mortality (rr = . , %ci = . - . , p < . ) in the nonresponders, while it was associated with an increase in -day mortality in the responders (rr = . , %ci = . - . , p = . ) ( figure ). hydrocortisone + fludrocortisone was also superior when considering secondary outcomes such as vasopressor discontinuation or lengths of stay. conclusions: in this individual patient data meta-analysis including the major randomized controlled trials on the subject, we found that an early short course of low-dose hydrocortisone and fludrocortisone decreases -day mortality and improves recovery from organ failure in septic shock patients non responding to a corticotropin stimulation test. introduction: statin therapy during intensive care unit (icu) stay has been associated with a reduction in all-cause hospital mortality in some studies. this association was especially noted in septic patients. however, potential benefit needs to be validated in randomized, controlled trials. objectives: the purpose of this study was to compare the effect of simvastatin plus standard therapy on mortality and total icu length of stay (los) to that of standard therapy alone in critically ill septic patients. methods: a prospective randomized, open label, controlled pilot clinical trial was conducted on patients diagnosed with sepsis/severe sepsis as defined by the american college of chest physicians (accp). hundred patients met the study criteria and were randomized into two groups; a standard group who received standard treatment and simvastatin group who received the standard treatment plus mg simvastatin. primary outcomes were days icu mortality and total icu los. plasma c-reactive protein (crp), total creatine kinase (ck) and liver enzymes [alanine aminotransferase (alt) and aspartate aminotransferase (ast)] were measured as secondary outcome measures. results: a total of patients completed the study. simvastatin was well tolerated, with no increase in adverse events between the two groups. total icu los was significantly lower in the simvastatin group. however, the number of patients with days icu mortality in the simvastatin group was lower compared to standard group; but survival failed to reach statistical significance. similarly, plasma creactive protein failed to reach statistical significance between the two groups conclusions: treatment with simvastatin mg in patients with sepsis/severe sepsis is safe and associated with an improvement in number of deaths and icu los but without subsequent improvement in survival. the use of anapnoguard system in intubated critically ill patients a randomized controlled study introduction: the anapnoguard system (ag) (hospitech respiration ltd., petach-tikva, israel) is an innovative respiratory guard system that continuously monitors and controls the cuff pressure by measurements of co levels above the cuff, and allowing simultaneous rinsing and aspiration of subglottic secretions. objectives: to determine the safety and clinical efficacy of ag system compared with usual care in critically ill patients. methods: prospective, single centre, open-label, randomized, controlled feasibility and safety trial. sixty patients, without pneumonia, were randomized to be intubated with the ag tube and connected to the system (n = ) or with a conventional tube (n = ) combined with subglottic secretion drainage and manually control of tracheal cuff pressure (p cuff ). primary outcome was the rate of adverse events. other outcomes included the rate of mechanical complications, the level of icu staff satisfaction, the incidence of ventilator-associated pneumonia (vap), the quality of p cuff control, and the amount of ss drained. results: out of patients enrolled in the study, were included in the analysis ( per each group). both groups were similar at randomization in demographic characteristics, icu admission diagnosis, main comorbidities and severity of illness. no device-related adverse events occurred in any of the two groups. no differences were detected using ag system vs conventional tubes in terms of post- introduction: during sepsis, intrinsic stress responses may become maladaptive and contribute to poor outcomes. targeted intervention with β-blockade to 'de-stress' such patients may be beneficial. we developed a -h rodent model of fluid-resuscitated faecal peritonitis in which mortality (occurring between and h) can be predicted at h by a low stroke volume (auroc . ), and where survivors are clinically improving by study end. [ ] objectives: to investigate the impact of β-blockade on outcomes in predicted survivors and nonsurvivors of faecal peritonitis. methods: instrumented, fluid resuscitated, male wistar rats ( - g) had sepsis induced by intraperitoneal injection of faecal slurry ( . ml/kg). at h, under brief isoflurane sedation, echocardiography was performed to differentiate predicted survivors from nonsurvivors based on a stroke volume cut-off of . ml. rats in each prognostic group were then randomised to receive either esmolol ( μg/kg over min followed by μg/kg/min infusion) or matching placebo ( . % nacl) until h. animals were observed for up to h, and time of death was recorded. the study was powered to detect a mortality reduction in predicted nonsurvivors from % to % with esmolol, with a power of . and type- error of . . results: rats were randomised after prognostication to receive either esmolol or placebo. at h, predicted survivors and nonsurvivors were clinically indistinguishable (both groups appeared only mildly unwell), though predicted nonsurvivors (stroke volume < . ml) had lower cardiac output ( ± vs. ± ml/min), higher heart rate ( ± vs. ± bpm) and blood pressure ( ± vs. ± mmhg) and more haemoconcentration (haemoglobin . ± . vs. . ± . g/dl) (all p < . ). survival was significantly improved by esmolol in predicted nonsurvivors (p = . ), but worsened in predicted survivors (p = . ). conclusions: mortality was approximately halved in predicted nonsurvivors by esmolol, but doubled in predicted survivors. early prognostication appears key in identifying the subset(s) of animals (and, potentially, patients) who might benefit from additional treatment, while avoiding iatrogenic harm in those that would naturally survive. mechanisms by which esmolol impact upon mortality are under investigation. introduction: endotoxins (lipopolysaccharides, lps) have become interesting targets in extracorporeal therapies. lps is a major constituent of the outer cell wall of gram-negative bacteria and strongly triggers inflammatory responses in humans at concentrations as low as ng/kg body weight. although the elimination of lps is promising for the supportive therapy of sepsis and liver failure, endotoxin neutralization using endotoxin adsorbents is controversial. objectives: we could recently show that endotoxin inactivation by low-dose polymyxin b (pmb; ng/ml) could be applied for endotoxin inactivation in blood [ ] . aim of this study was to establish an adsorbent-based system which combines constant pmb release for endotoxin inactivation and effective cytokine adsorption during extracorporeal treatment. methods: we established an adsorbent-based pmb release system which ensures a constant pmb level in plasma during extracorporeal therapies. a polystyrene-divinylbenzene based cytokine adsorbent (cg c) with nanostructured pores was coated with a defined amount of pmb by hydrophobic interactions. the endotoxin inactivation and cytokine adsorption was tested in an in vitro model using fresh donated blood which was stimulated with ng/ml lipopolysaccaride from e. coli. results: in plasma or blood an equilibration between the free and bound form of pmb will lead to a constant pmb level in plasma. the pmb release experiments in plasma clearly show that the adsorption and desorption is a function of the ratio pmb concentration: adsorbent surface. furthermore the pmb release depends on the protein concentration of the plasma. it makes a big difference whether the pmb coated adsorbent is used in plasma or in fractionated plasma where the hydrophobicity is much lower. the experiments suggest that the pmb coating of the cg c adsorbent doesn´t influence the cytokine removal which can take place in parallel. the ability of lps inactivation by the pmb coated cg c adsorbents was similar to pmb which was infused directly into the plasma. conclusions: our in vitro model shows that the combination of cytokine removal and controlled pmb release by the same adsorbent results in a strong suppression of inflammatory effects in blood. objective: management of hemodynamically stable pulmonary embolism (pe) with right ventricular (rv) dysfunction is still controversial. the objective of our study is to evaluate the effectiveness of local intraarterial thrombolysis (lit) in this group of patients and analyze its complications. patients and methods: prospective study (january -december ). patients included had been diagnosed of pe by computed tomography (ct), were hemodynamically stable [systolic arterial pressure (sap) > mmhg] and had a clinical suspicion of rv dysfunction (biventricular quotient in ct > or elevated levels of troponin i), that was confirmed afterwards by the presence of at least one of the following findings in the echocardiogram: subjective alteration of rv contractility, rv basal diameter (four chamber view) > mm, tricuspid annular plane systolic excursion (tapse) < mm or estimated systolic pulmonary artery pressure (spap) > mmhg. lit was done with a urokinase infusion (bolus dose of . ui followed by a perfusion of . ui/h) administered thru a pulmonary artery catheter, placed with radiological guidance, using an antecubital puncture. patients received simultaneous systemic anticoagulation with unfractionated heparin. after - h of treatment, and before ending the urokinase infusion, a radiological control was done using angiography or ct. within the seven days after lit, patients underwent a follow-up echocardiogram. statistical analysis was performed with student´s t test for parametric paired data, wilcoxon´s test for non parametric and stuart-maxwell for qualitative values. results: eighty-seven patients were included and their general data are detailed in fig. . mean treatment time was , ± , h. ninety percent of patients experienced a radiological improvement ( . % a complete/almost complete resolution and, . % a significant improvement). only , % didn´t improve radiologically. the evolutions of the different rv parameters studied are shown in fig. . minimum fibrinogen and platelet values where , ± , mg/dl and x ± . x cells/mm . eighteen patients ( , %) suffered form hemorrhagic complications that, in cases, where puncture site hematomas and, in six occasions ( , %) required an early interruption of the treatment. three patients ( , %) received a blood cell transfusion of ≤ blood units. mean icu and hospital stays where ± , and ± , days. all patients survived. conclusion: in our group of patients, lit rapidly improved the function and decreased the hemodynamic strain of the rv, while being associated with a low incidence of major complications. introduction: atrial fibrillation (afib) is associated with higher shortterm mortality in critical illness, but it is still uncertain whether afib independently contributes to unfavorable outcome. objectives: the aim of this study was to test the hypothesis that afib during critical illness is independently associated with increased in-hospital and long-term risk of death. methods: the frog-icu study was a prospective, observational, multicenter cohort study designed to investigate outcome of critically ill patients. heart rhythm was assessed at inclusion and during icu stay with digital ecg recordings. among patients who had any afib during icu stay, newonset and recurrent afib were diagnosed in patients without and with previous history of afib, respectively. primary endpoints were in-hospital and -year mortality. covariate adjusted logistic regression models and cox proportional hazards models were used to evaluate the association between afib and in-hospital mortality or -year mortality, respectively. in-hospital mortality was adjusted for independent covariates (age, gender, simplified acute physiology score (saps ii), treatment with inotropes or vasopressors, serum lactate level, high-sensitive troponin i, b-type natriuretic peptide), -year mortality was adjusted for covariates (age, gender, saps ii, history of congestive heart failure, treatment with inotropes or vasopressors, serum lactate level, c-reactive protein and serum creatinine). results: the study included critically ill patients. the study population consisted of patients for whom data about heart rhythm during icu stay was available. afib occurred in patients ( %). newonset afib (n = ) had higher in-hospital mortality ( %) compared to no afib ( %, p < . ) or recurrent afib ( %, p = . ). newonset afib showed increased in-hospital risk of death after multivariable adjustment compared to no afib ( introduction: the incidence of the supraventricular arrhythmias is increased in septic shock patient, and it is associated with worse short and long term prognosis. objective: to test that propafenon could be a feasible antiarrhythmic in the absence of contraindications. methods: patients with septic shock who received antiarrhythmic drugs for supraventricular arrhythmias were included over months. the patients were divided into the three groups according to antiarrhythmic agent: amiodarone (group ), propafenon (group ) and metoprolol (group ). in the first h the type of arrhythmia, dosages, cardioversion rates, demographic, haemodynamic, laboratory parameters were recorded. mortality was compared between the groups and between the cardioverted vs those remaining in acute and chronic arrhythmias. clinical studies; presumably due to an impairment of myocardial oxygenation and ventricular filling. a randomised control trial of heart rate (hr) control in septic shock showed an increase of survival for the patients receiving esmolol . an animal study observed a similar improvement of survival and an increase in left ventricular (lv) contractility when esmolol was associated with norepinephrine (ne) . however beta-blockers therapy in sepsis is still debated considering its negative inotropic side effect. ivabradine, a pure bradycardic agent, blocking selectively the if channels in the sinus node, could represent a safer option for hr control. objectives: compare the hemodynamic tolerance of hr control either with intravenous (iv) ivabradine or esmolol perfusion, in a large animal model of septic shock. methods: we used a closed chest swine model of fecal peritonitis. analgesia and sedation were provided by sufentanil and sevoflurane. hemodynamic monitoring included arterial blood pressure (abp); continuous cardiac output (cco); lv maximum rate of pressure (dp/dtmax) and lv elastance (e-lv); mixed venous oxygen saturation (svo ) and arterial lactate (lac). after the development of septic shock, fluid resuscitation was started and animals were randomised in groups of pigs: ivabradine (ivb), esmolol (esm) or control. ivabradine was administered with an iv bolus of , mg/kg that could be repeated at , mg/kg, aiming an hr between and beats per minute (bpm). continuous iv perfusion of esmolol was started at mg/kg/h and adapted to reach the same hr range. after hours of hr control, a fixed dose of , mcg/kg/ min ne was introduced in all groups. results: all animals developed an hyperdynamic distributive shock, including tachycardia above bpm. hr control between and bpm was successful in both ivb and esm groups. ivb administration didn't affect abp, cco, dp/dtmax, e-lv, svo or lac. esm perfusion tended to decrease abp, cco and svo ; e-lv and lac were unaffected but dp/ dtmax decreased markedly. under ne perfusion, e-lv was similar in all groups but dp/dtmax was lower in esm group. conclusions: in septic shock, hr control with an iv administration of ivabradine doesn´t alter global organs perfusion and cardiac function. esmolol perfusion, in order to achieve the same goal, reduces lv dp/dtmax and didn´t enhance lv contractility in association with ne. introduction: patients in critical care settings are often at risk of developing hypotension, which can lead to poor outcomes such as increased morbidity and mortality. current hemodynamic parameters for monitoring such hypotension often exhibit pronounced changes only when the hypotensive event is already occurring or when it is too late. we have developed a hypotension probability indicator (hpi™) to predict hypotensive episodes based on machine learning techniques. the hpi™ model was trained on~ icu and or patients. the objective of this study is two-fold: ) to test the accuracy of hpi™ to predict events on a completely independent test data set of icu patients, not used in the development of the algorithm; and ) to compare timing of interventions in response to an event to the timing of detection of an event by hpi™. methods: data used in this study came from the mimic ii mit research database. arterial pressure waveforms of patients were analyzed for hpi™ and then tested for event detection and prediction accuracy. all features of the hpi™ as well as other hemodynamic parameters for comparison were calculated using flotrac (edwards lifesciences, irvine, ca). a hypotensive event was defined as any time period where map < mmhg for at least minute. an roc analysis was performed to assess auc, sensitivity, and specificity of the hpi™ to identify an event during the event, and , , and minutes prior to the start of event. next, clinical records of the patients were reviewed for any drug or fluid interventions during start of event to minutes after an event and the elapsed time from start of event to intervention time was calculated. a drug or fluid intervention was defined as any bolus or iv infusion start. in addition, the time at which hpi™ probability of event > . prior to the start of an event was also calculated for comparison. data are presented in median [ - th percentiles]. conclusion: in conclusion, hpi™ can accurately detect an event up to minutes prior. hpi™ may serve as a useful addition in the care of critically ill patients by potentially facilitating earlier intervention either in response to an event or serve as a decision support and direct a physician's attention to potential oncoming events when hpi™ is high. this statement is valid for both in-hospital as well as out-of-hospital cardiac arrest. regardless of the location of the cardiac arrest, there are at least four factors that appear to be of major importance for survival. the first is the time from collapse to delivery of treatment; the second is the quality of cardiopulmonary resuscitation (cpr); the third is the patient's co-morbidity and the fourth is the aetiology of the ca and the presenting rhythm. the present study will focus on the first three parts of the chain of survival, time from collapse to call/cpr/defibrillation. objectives: to describe the number of survivors following inhospital cardiac arrest (ihca) in sweden during one year and, based on estimations and assumptions, calculate the potential number of additional lives saved following improvements in the chain of survival. there was a strong inverse relation between delay to call for the rescue team and delay to treatment and survival. if delay from collapse to a/call and, b/start of cpr were reduced to < minute in patients with a longer delay than that and if c/time from collapse to defibrillation was reduced to < minutes among those with a longer delay than that: a/ ; b/ ; and c/ further lives could potentially be saved. we speculate that about additional lives (one per hospital beds each year) could theoretically be saved by improved adherence to guidelines regarding the first three components in the chain of survival in swedish hospitals yearly. conclusions: in , approximately patients (four per hospital beds) were successfully resuscitated following ihca in sweden. there was a strong negative relation between collapse and call for rescue team/cpr/defibrillation and -day survival. with reduced delay times a further lives (one per hospital beds) could theoretically be saved each year in sweden. the study was supported by grants from the laerdal foundation of acute medicine in norway (jh) and the scientific council of halland (fh). prophylactic versus clinically-driven antibiotics in comatose survivors of out-of-hospital cardiac arrest -a pilot study s. results: proportion of patients on antibiotics was significantly greater from day to in prophylactic group while there was no difference on days to . peak c-reactive protein in prophylactic group was significantly smaller ( ± vs. ± mg/l; p = . ). there was no difference in peak white blood cell count ( . ± . vs. . ± . ; p = . ), procalcitonin ( . ± . vs. . ± . microg/l; p = . ) and cd . except for positive mini bal on day ( % vs. %; p < . ), there was no significant impact on other microbiological samples and x-ray signs of pneumonia ( % in each group). use vasopressors/inotropes ( % in each groups), duration of mechanical ventilation ( . ± . vs. . ± . days), tracheal intubation ( . ± . vs. . ± . days), icu stay ( . ± . vs. . ± . days), survival ( % vs. %) and survival with good neurological outcome ( % vs. %) were also comparable. conclusions: tracheobronchial aspiration was documented in more than a quarter of comatose survivors of ohca using bronchoscopy on admission. in the absence of aspiration, prophylactic antibiotics reduced peak crp and the incidence of positive mini-bal on day and had no significant impact on other introduction: survival to discharge after in-hospital cardiac arrest (ihca) is poor ( − %) and has not improved despite developments in modern medicine. data on the aetiology of in-hospital cardiac arrests is very limited, and conducted studies include ihca patients resuscitated in emergency departments, intensive care units and high dependency units. objectives: to determine the underlying causes of ihcas occurring on general wards and investigate, whether the aetiology is independently associated with six months survival. methods: a prospective observational study between - in a finnish university hospital. we included all adult ihca patients on general wards who were attended by icu´s medical emergency team. definite aetiology was determined from the autopsy records and medical records. no autopsies were conducted solely for study purposes. the local ethics committee approved the study protocol (approval no: r ). results: the cohort consisted of patients, of which ( %) were male. median age of the patients was ( , ) years. altogether ( %) ihcas were monitored/witnessed, first rhythm was shockable in ( %) cases and ( %) patients survived six months. autopsy was conducted in ( %) cases. aetiology was determined as cardiac in events, of which were due to acute myocardial infarction and due to acute myocardial ischaemia without infarction. congestive heart failure was the third most prevalent reason in cardiac sub cohort ( ). altogether ihcas were considered non-cardiac; most common causes were pneumonia ( ), exsanguination ( ), pulmonary embolism ( ) and peritonitis ( ). cardiac ihcas were more commonly preceded by subjective symptoms (e.g. chest pain, respiratory distress) than non-cardiac ihcas ( % vs. %, p = . ), while objective vital dysfunctions preceded ihcas as often in both sub cohorts ( % vs. %, p = . ). in a multivariate logistic regression model monitored/witnessed event, shockable primary rhythm and low age-adjusted charlson comorbidity index score were factors independently associated with -day survival, but the aetiology (cardiac vs. non-cardiac) was not. conclusions: aetiology of ihcas on general wards is cardiac in % of the events. ischaemic reasons for ihcas were twice as common as shockable primary rhythms in this study. subjective symptoms and objective vital dysfunctions often precede general ward ihcas. however, neither the aetiology nor the presence of antecedents, but low comorbidity, observed arrest and shockable primary rhythm are factors associated with a favorable outcome. reducing in-hospital cardiac arrest by implementation of innovative early warning information system in a tertiary medical center introduction: in-hospital cardiac arrest (ihca) is a common and high-risk issue with less than % surviving to hospital discharge. most patients show signs of clinical deterioration in the hours before ihca. as a result, the development of vital signbased early warning system was designed to detect early signs of clinical deterioration before ihca attack in order to trigger early intensive care. objectives: in this study, we investigate the impact of the implementation of an innovative early warning information system on the rate of ihca and survival rate in ihca patients. methods: a multidisciplinary team among intensivists, cardiologists, emergency physicians, and nursing staffs in a tertiary medical center was organized since may . the key interventions include automatic national early warning score (news) calculating information system, nurses and physicians computer-based reminding alarm if news ≥ or more than highest scores among previous measurements, real time early warning screen saver and electric board, in service education and early warning monitor team. all patients admitted between january and january were enrolled. total , patients were divided into three groups: pre-interventional group from jan to april (n = , ), interventional group from may to june (n = , ) and post-interventional group from july to jan (n = , ). the definition of in-hospital cardiac arrest is the number of in-hospital cardiac arrest per thousand admitted patients. we compared the rates of ihca, hours survival rate and discharge survival rate in ihca patients among these groups. results: the rate of in-hospital cardiac arrest improved from . ‰ in pre-interventional group, to . ‰ in interventional group and to . ‰ in post-interventional group (p < . ). the hours survival rate in ihca patients increased from . % in pre-interventional group, to . % in interventional group and to . % in postinterventional group (p < . ). the discharge survival rate in ihca patients also increased from . % in pre-interventional group, to . % in interventional group and to . % in post-interventional group (p < . ). conclusions: the study demonstrated that implementation of early warning information system and innovative strategies could attenuate the rate of ihca, hours survival rate and discharge survival rate in ihca patients. introduction: although prolonged unconsciousness after cardiac arrest (ca) is a sign of poor neurological outcome, limited evidence shows that a late recovery may occur in a minority of patients. objectives: we investigated the prevalence and the predictive factors of delayed awakening in comatose ca survivors treated with targeted temperature management (ttm). methods: retrospective analysis of the parisian region out-of-hospital ca registry ( - ). in adult comatose ca survivors treated with ttm, sedated with midazolam and fentanyl, time to awakening was measured starting from discontinuation of sedation at the end of rewarming. awakening was defined as delayed when it occurred after more than h. results: a total of patients ( % male, mean age ± years) were included, among whom awoke. delayed awakening occurred in / ( %) patients, at a median time of h (iqr - ) from discontinuation of sedation. in / ( %) late awakeners, pupillary reflex and motor response were both absent h after sedation discontinuation. in multivariate analysis, age over years (or . , % ci . - . ), postresuscitation shock (or . [ . - . ]), and renal insufficiency at admission (or . [ . - . ]) were associated with significantly higher rates of delayed awakening. conclusions: delayed awakening is common among patients recovering from coma after ca. renal insufficiency, older age, and postresuscitation shock were independent predictors of delayed awakening. presence of unfavorable neurological signs at h after rewarming from ttm and discontinuation of sedation did not rule out recovery of consciousness in late awakeners. grant acknowledgment none note: this abstract has been previously published and is available at [ ] . it is included here as a complete record of the abstracts from the conference. introduction: viral infections play a key role in preventable deaths of children globally, and can be antecedents to bacterial pneumonia and sepsis. diagnosis of viral infection is often problematic due to non-specific clinical presentation. we developed a host immune response gene expression signature to distinguish systemic inflammation due to viral infection vs. bacterial or noninfectious causes. objectives: to define and validate the host immune response gene expression signature against multiple independent datasets. methods: four public geo datasets describing transcriptomic responses to viral infection were used to identify biomarkers, ranked by auc, which could separate affected from unaffected subjects. biomarkers that also responded (auc > . ) to non-viral causes of systemic inflammation were removed. remaining biomarkers were then ranked for performance in other geo transcriptomic datasets for viral infection; those with mean auc > . were retained. next, a greedy search was applied to the merged ( + ) viral geo datasets to identify the best combinations of biomarkers for discrimination of viral infection. the signature was then validated using independent datasets. results: a -gene signature (comprised of isg , il , oasl, adgre ) had auc . across the merged ( + ) viral geo datasets. this signature was validated in additional geo datasets covering a wide variety of viral pathogens including a time-course study of respiratory syncytial virus (rsv) in children (fig ) , and in two independent datasets of our own: adults from the emergency department (fig introduction: using a tourniquet to temporary cut off blood supply to the arm (remote ischemic preconditioning -ripc) has been shown to result in myocardial protection and reduced incidence of aki in patients undergoing cardiac surgery. however, a recently performed large multi-center trial in cabg patients showed no beneficial effects on clinically relevant endpoints [ ] . animal studies have shown an`early window of protection' in the - hours after ripc as well as a`late window of protection` - hours after ripc. several mechanisms have been suggested to mediate the protective effects of ripc, of which attenuation of the immune response is an important candidate, although this has hitherto also only been shown in animal studies [ ] . objectives: to determine the effect of single and repeated ripc, thereby investigating both the early and late windows of protection, on the inflammatory response during endotoxemia, a standardized, controlled model of systemic inflammation in humans in vivo. methods: we performed a randomized controlled study in healthy non-smoking male volunteers. subjects were assigned to either the single-dose ripc group, multiple-dose ripc group, or the control group (n = per group). the single-dose ripc group received dose of ripc, consisting of cycles of -minute ischemia of the arm followed by minutes of reperfusion just before administration of ng/kg lipopolysaccharide (lps). the multiple-dose ripc group received one dose of ripc per day on the days before the endotoxemia experiment day, and dose just before lps administration. results: lps administration resulted in a typical increase in body temperature, flu-like symptoms, and hemodynamic changes, with no differences between groups. administration of lps resulted in a sharp increase in plasma levels of the proinflammatory cytokines tnf-α, il- , and il- as well as the antiinflammatory cytokine il- . no differences in plasma levels of these cytokines were observed between the different groups ( figure ). conclusions: in the present study, we demonstrate that ripc does not affect the in vivo inflammatory response induced by administration of endotoxin in humans. these results implicate that ripc does not exert direct anti-inflammatory effects and that the previously observed protective effects are mediated through other mechanisms. furthermore, the absence of immunomodulatory effects of ripc in the present study tempers expectations of using ripc as an immunomodulatory treatment strategy in patients. introduction: sepsis-induced immune alterations are associated with secondary infections and increased risk of death ( ). mesenchymal stem cells (mscs) have been described as a novel therapeutic strategy for the treatment of diseases related to inflammation and tissue injury with their potent modulatory effects on immune system ( ) . objectives: in this study, we evaluated the immune-modulatory effects of human dental follicle mesenchymal stem cells (hd-mscs) on lymphocytes which are isolated from peripheral blood samples of sepsis and septic shock patients. methods: according to the international sepsis definitions conference ( ), patients divided into two groups as sepsis (group i, n = ) and septic shock (group ii, n = ). peripheral blood mononuclear cells (pbmcs) were isolated from venous blood samples of group i, group ii and healthy subjects named as group iii, n = . anti-cd /cd pbmcs were co-cultured with df-mscs, ifn-g stimulated df-mscs and with no mscs about hour. cd + cd + foxp + t cells levels (treg), lymphocyte proliferation and apoptosis were evaluated with the flow cytometry. results: df-mscs and ifn-g induced df-mscs cultures significantly supressed proliferation in sepsis group when compare to septic shock group(p < , ). conclusions: mscs demonstrate their effects on immune system by increasing the number and activity of regulatory t cells (treg) ( ) .in our study, mscs suppressed lymphocyte proliferation and apoptosis but increased the rate of treg cells in sepsis cocultures. this effect was more obvious with ifn -g stimulation. these responses were not seen in septic shock patients´blood samples and might be explained with anergy. our findings revealed that df-mscs application has immunoregulatory effects in sepsis. this approach opened a new area to work how will mscs be used to reduce organ dysfunctions and mortality in the clinical practice. introduction: inhibition of mitochondrial complex i is described in human and animal sepsis. , this may be responsible, at least in part, for the decrease in mitochondrial functionality seen in sepsis. we have recently demonstrated that the mitochondrial uncoupling agent, dinitrophenol (dnp) failed to increase body temperature and oxygen consumption (vo ) in septic rats, as was seen in healthy controls. this suggests that uncoupling is active in sepsis and can contribute to fever. we further postulated that the blunted effects of dnp in sepsis may be related in part to upstream mitochondrial inhibition. objectives: to determine if complex i inhibition by metformin in healthy rats can prevent the increment in temperature and oxygen consumption (vo ) by dnp, and thus mimic the pattern seen in sepsis. methods: vo was measured in awake, cannulated male wistar rats (approx g body weight) in metabolic cages (oxymax, columbus instruments). sepsis was induced with an intraperitoneal injection of faecal slurry at time . sham control animals received no slurry. fluid resuscitation ( ml/kg/h crystalloid) was started at hours and continued throughout the whole experiment. half the septic and sham animals were treated with an iv infusion of metformin ( mg/kg) between hours - . at and hours, all animals received iv dnp ( mg/kg). arterial blood gases, echocardiography and core temperature were measured at times , and , and and hours (i.e. before and after the two doses of dnp). mean arterial pressure was recorded continuously. wilcoxon rank sum test was used to compare groups and two-way anova to compare changes in continuous variables from baseline between groups. p values < . were considered statistically significant. results: pretreatment with metformin completely prevented the increase in temperature and vo induced by dnp in sham animals at hours and reflected that seen in non-metformin treated septic rats ( figure ). the reduction in myocardial contractility (stroke volume and vmax) seen in the septic animals treated with dnp was prevented by complex i inhibition at h. metformin was metabolically well tolerated, with no increase in blood lactate. conclusions: inhibiting complex i with metformin prevents the uncoupling effect of dnp in sham animals. this mimics the pattern seen in septic animals and confirms that both complex i inhibition and pre-existing mitochondrial uncoupling could be active in septic rats. objectives: the inflammasome is a multiprotein complex that stimulates cytokines release such as interleukin- β (il- β) and il- , involved in the inflammatory response. our aim is to quantify the state of activation of the inflammasome complex in septic patients, as well as to study possible differences in the cytokines levels in sepsis and septic shock, its temporary evolution, and its prognostic value. methods: prospective study including patients admitted to the icu with sepsis or septic shock during months. on days , and , il -β serum levels and real-time expression of nlrp inflammasome (nucleotide-binding oligomerization domain, leucine rich repeat domain containing protein and pyrin) were determined by elisa and real time-pcr respectively. demographic variables, severity scores on icu admission (apache ii and sofa), sepsis focus and mortality were collected. statistical analysis: t-student, kruskal-wallis and u-mann-whitney test as appropriate. results: there were included patients (severe sepsis and septic shock ). overall mortality was % ( patients). the levels of il- β on day ( . ± . vs . ± . pg/ml; p < . ) and nlrp inflammasome ( . ± . vs . ± mrna arbitrary units; p < . ) were significantly higher in septic shock patients than in sepsis, with no differences in the following days set ( and ). the il- β and nlrp inflammasome levels decreased significantly on days and compared to first day (p < . ), without differences between survivors and deceased patients. conclusions: in septic patients, inflammasome activation complex occurs, with higher levels detected in septic shock. decreased levels of il- β and nlrp inflammasome in septic process have been observed during evolution, actually without relation with mortality. introduction: according the consensus conference on weaning from mechanical ventilation, intubated patients should pass a spontaneous breathing trial (sbt) to assess their readiness to be extubated. objectives: to characterize patients who are extubated without any sbt and to compare them to patients who had at least sbt during their weaning period. methods: the prospective multicentre observational wind (weaning according new definition) study was performed from april to august . ventilation and weaning modalities were daily assessed until discharge in all intubated patients admitted to the participating icus. we defined ) weaning attempt (wa) as a spontaneous breathing trial (sbt) or an extubation (with or without sbt), ) successful weaning as an extubation without death or invasive mechanical ventilation within days. variables are presented as mean ± standard deviation, median [interquartile range] or number (percentage). comparisons were made using chi test, exact fisher tests, student t-test or wilcoxon rank sum test as appropriate. all statistical tests were two-sided and p value ≤ . were considered significant. results: among the patients included, patients had at least wa comprising patients whose first wa was a sbt and who had another type of first wa. these patients with no sbt had a total of wa: ( . %) planned extubation without sbt, self-extubations ( . %), wa while tracheostomized ( . %) and sbt after their first wa ( . %). the majority of patients with self-extubation had a successful weaning not requiring reintubation ( . %). almost a quarter (n = ) of the patients who were extubated without any sbt had a decision of withholding or withdrawing invasive mechanical ventilation, representing . % (n = ) of the deceased patients. we then excluded patients with a decision of limitation and patients with a self extubation to compare patients who had a planned extubation with or without sbt as first wa (table ) . patients with no sbt were younger, less severe and were more often admitted for unplanned surgery: they had an easier weaning with a lower (but non significative) rate of reintubation, a shorter duration of invasive mechanical ventilation and a shorter length of stay in the icu. conclusion: patients who are extubated without sbt seem to belong to three different groups: self-extubation, terminal extubation and patients in whom physicians anticipate an uneventful weaning and extubation. among the patients with a planned extubation and without any limitation decision, clinical judgment regarding weanability appears to be effective as this group of patients had a good outcome with a low reintubation rate. this study benefited of a grant of the non-profit association départementale des insuffisants respiratoires (adir) of the haute normandie, france introduction: decrease in diaphragmatic maximal relaxation rate (mrr) occurs early in the process of diaphragmatic fatigue and well before the diaphragm fails as a force generator; its measurement would, therefore, be especially valuable in icu patients during a weaning trial. however, the use of oesophageal pressure catheters for that purpose impedes wide clinical use. on the contrary, m-mode sonography, allows non-invasive, real-time measurement of the speed of the diaphragmatic motion. objective: purpose of our study was to investigate a possible correlation between diaphragmatic mrr traditionally acquired with transdiaphragmatic pressure (pdi) catheters (mrr-pdi) and an echo equivalent mrr (mrr-echo) acquired during different breathing conditions. methods: the slope of mrr was measured from the initial steepest part of the descending pdi curve simultaneously with the slope of the initial steepest descending part of diaphragmatic excursion with m-mode sonography. the protocol entrained four consecutive stages: i) breathing spontaneously during t-piece trial, ii) breathing spontaneously with performance of sniff-like maneuvers, iii) breathing with resistances of cmh o/l, and iv) breathing with resistances of cmh o/l with performance of sniff-like maneuvers. statistical comparisons between slope recordings from the two methods were performed with pearson correlation, while bland and altman plots were obtained in order to demonstrate reliable agreement between methods at each different breathing condition. results: a total of separate breaths during the four previously reported breathing conditions from six icu patients were recorded. table summarizes the slopes measured from mrr-pdi and mrr-echo as means ± standard deviations (sd), and their linear correlations with p values. statistical significant correlations were observed in all four stages; i) pearson correlation coefficient r = . , p < . , r = . , ii) r = . , p < . , r = . , iii) r = . , p < . , r = . , and iv) r = . , p < . , r = . . bland and altman plots demonstrating differences of measurements against means, as well as confidence intervals (means of differences ± sd) were obtained for each breathing condition. graph represents the bland and altman plot for spontaneous breathing with sniff-like maneuvers without resistances. high r indexes, indicating high agreement between the two methods were noted: i) . , ii) . , iii) . , and iv) . . the results of our study suggest a statistical significant correlation and reliability between diaphragmatic mrr measured from pdi tracings and the assumed diaphragmatic relaxation rate calculated from simultaneous m-mode sonographic recordings. clinical studies are required to confirm the potential of this non-invasive index of diaphragmatic mrr to be used as a predictor for weaning success. grant acknolwedgement none declared. introduction: high flow nasal cannula oxygen therapy (hf oxy) has been recently shown to decrease re-intubation rate, as compared with low flow oxygen therapy (lf oxy). [ ] , [ ] objectives: to assess the effects of hf oxy as compared with lf oxy on diaphragmatic electrical activity (eadi), respiratory rate (rr), tidal volume (vt) and gas exchange in the post extubation period. our hypothesis was that hf oxy, as compared with lf oxy, would improve gas exchange and decrease eadi. methods: patients underwent a crossover study immediately after extubation. each patient was submitted to three consecutive steps of hour each, according to an on-off design: ) hf oxy; ) lf oxy; ) hf oxy. oxygen fraction was maintained stable throughout the study. the eadi was continuously monitored through eadi cathether (maquet, solna sweden). the heated and humidified hf oxy was delivered through nasal cannula at flow rates of - l/min, (f&p, auckland new zealand). results: rr remained similar throughout the study, vt was significantly higher during the lf oxy step as compared with the hf oxy steps. oxygenation significantly improved during the hf period, whereas paco remained unchanged throughout the study (table ). eadi was significantly higher during lf oxy ( figure ) conclusions: since the eadi is correlated to work of breathing, our physiological data suggest that hf oxy significantly reduces wob while improving oxygenation in the post extubation period. further studies are required to define if diaphragm unloading may explain the favourable results of hf oxy in clinical trials. introduction: i non-invasive mechanical ventilation (niv) has been seen to play a major role in decreasing intubation rates in patients with severe exacerbation of chronic obstructive pulmonary disease and congestive heart failure. unsuccessful niv has been found to be independently associated with increased mortality in patients with arf. the niv failure and their impact on mortality in patients with inlfuenza infection is unknown. objectives: ) to describe non-invasive ventilation failure (nivf) rate, ) to identify risk factor for nivf using chaid (chi-square automatic interaction detection) and ) to determine if nivf is associated with icu-mortality. methods: secondary analysis in , patients with influenza requiring mechanical ventilation(mv). three groups were considered: ) patients with niv who failed (group a); ) patients with niv who succeeded (group b); and ) patients with invasive mv (group c). cox analysis was used to assess survival. risk factors for nivf were obtained using chaid. conclusions: niv failure is frequent and independently associated with icu-mortality in patients with influenza. chaid analysis might be a promising tool to assist in clinical decision-making. introduction: acute kidney injury (aki) after liver transplantation is a common complication with an incidence of approximately % [ ] , resulting in high morbidity and mortality. to increase the possibilities to prevent or treat aki after liver transplantation, it is essential to increase the knowledge on changes in renal physiology after liver transplantation. objectives: the aim of this study was to gain insights into renal perfusion, filtration and oxygenation in the immediate postoperative period in patients undergoing liver transplantation and to compare these data to those obtained from a group of patients undergoing major surgery with no postoperative renal impairment. methods: informed consent was obtained preoperatively from twelve patients with normal renal function accepted for liver transplantation. glomerular filtration rate (gfr) was measured preoperatively by plasma clearance of cr-edta. the patients were studied after liver transplantation in the icu in the immediate postoperative period, sedated and mechanically ventilated. systemic haemodynamics and renal variables where obtained during two -min periods. renal blood flow (rbf) and gfr were measured by the renal vein retrograde thermodilution technique and by renal extraction of cr-edta (=filtration fraction, ff), respectively. arterial (a) and renal vein (rv) blood samples were taken for measurements of arterial (cao ) and renal vein (crvo ) oxygen contents. renal oxygen consumption [rvo = rbf x (cao -crvo )], renal oxygen delivery (rdo = rbf x cao ) and renal oxygen extraction [ro ex = (cao -crvo )/cao )] were calculated. sixty-three patients undergoing uneventful cardiac surgery with no postoperative renal impairment served as controls. results: cardiac index ( %) and systemic oxygen delivery index ( %) were higher and systemic vascular resistance index was lower (− %) in the liver transplant group compared to controls (p < . ). rbf was % higher and renal vascular resistance was % lower compared to controls (p < . ). in the liver transplanted group, gfr was % lower compared to the preoperative value (p = . ), accompanied by a % increase in serum creatinine (p < . ). after surgery, when compared to controls, gfr and ff was % and % lower, respectively (p < . , p < . ), and rvo and ro ex were % and % higher, respectively, in the liver transplanted patients (p < . , p < . ). conclusions: despite the hyperdynamic systemic circulation, gfr is considerably reduced immediately after liver transplantation, most likely caused by a post-glomerular renal vasodilation decreasing upstream glomerular filtration pressure. renal oxygenation is impaired after liver transplantation due to the high rvo , which was not met by a proportional increase in rdo . introduction: acute kidney injury is common in critically ill patients and associated with increased short and long-term mortality. most published studies have focussed on patients with severe aki. little is known about the long-term outcome of patients with less severe aki. our objective was to determine the outcome of patients with different stages of aki at and years after admission to the intensive care unit (icu). we retrospectively analysed the data of all adult patients admitted to a multi-disciplinary icu in a teaching hospital in the uk between march -may . patients with chronic dialysis dependent renal failure were excluded. patients were categorised according to their maximum stage of aki during stay in icu as defined by the serum creatinine criteria of the kdigo classification. apache ii and sofa scores were used to describe severity of illness on admission to icu. in patients with > admission to icu, we only included the first admission in the analysis. results: data of adult patients were analysed of whom % had aki during their stay in icu. patients with any degree of aki had a higher mortality at and years but they were also sicker on admission to icu. conclusions: any stage of aki during critical illness is associated with an increased risk of mortality at and years. mortality is highest in patients with aki ii and iii. more work is necessary to explore the relationship between aki and long-term outcome and to identify independent risk factors for mortality. introduction and objective: observational studies of intensive care unit (icu) patients with acute kidney injury have shown a negative correlation between accumulation of fluids and survival [ ] . it is unknown whether rapid removal of accumulated fluids is feasible and beneficial. therefore we wish to perform a pilot trial of forced fluid removal vs. standard care in critically ill patients with high-risk acute kidney injury and severe fluid overload. methods: the ffaki-trial is a pilot, multicenter, randomized clinical trial recruiting adult intensive care patients with high-risk acute kidney injury and fluid overload defined as > % of ideal bodyweight. to reduce the signal-to-noise ratio we only wish to include patients with a high baseline risk of persistent renal failure. baseline risk will be calculated using a newly developed model, the renal recovery score (rrs), to predict the chance of recovering renal function within days. in-and exclusion criteria are shown in tables and . patients are randomized to either forced fluid removal or standard care for the entire icu stay. forced fluid removal is done by infusion of furosemide and/or fluid removal with continuous renal replacement therapy. the fluid removal rate is adjusted times daily to achieve a therapeutic goal of net negative fluid balance ≥ ml/kg/h. physiologic tolerance to fluid removal is continually evaluated according to predefined criteria of hypoperfusion: lactate ≥ mmol/l, mean arterial pressure < mmhg or mottling beyond the edge of the kneecaps. in case of hypoperfusion, fluid removal is suspended until all criteria have been resolved for a minimum of hour. the flow chart for the experimental ffaki-treatment is seen in figure , , . the primary outcome is cumulative fluid balance days after randomization. by inclusion of patients we are able to detect a difference of . l between groups (α = . and β = . renal recovery score ≤ %. fluid overload defined as a positive fluid balance ≥ % of ideal body weight. able to undergo randomization within hours of fulfilling the other inclusion criteria introduction: enhanced recovery pathways have been a focus for patient optimisation of morbidiy and mortality in the post-operative patient. significant mortality improvement was seen following the implementation of the emergency laparotomy pathway quality improvement care (elpquic) bundle with an adjusted risk of death from . % to . % ( ). the first national emergency laparotomy audit (nela) has since been published demonstrating a -day mortality of % and recommending access to pathways that identify need to escalate care ( ) . however acute kidney injury (aki) in critically unwell patients remains a major source of mortality, of up to %, and morbidity ( ). it is not yet clear whether enhanced recovery pathways, specifically those that utilise early goal directed therapy, affect the incidence of aki. objectives: to determine if there was a difference in incidence of combined aki pre and post implementation of an enhanced recovery protocol, one that had already demonstrated a significant mortality benefit. methods: a subgroup analysis of the data gathered via the elpquic bundle was performed ( ). we obtained buy-in from the participating centres and requested an extrapolation of values from their raw data. if required further data was obtained via the hospital's electronic path system. all data was reviewed by a second investigator. we defined the baseline creatinine as the best available preoperative creatinine from the past year. the data recorded included creatinine at baseline, post-op, worse recorded creatinine between day and day , make , p-possum and -day mortality data. ckd stage was identified via mdrd equation with age, gender and baseline creatinine. patients with aki were stratified according to kidgo stages of akin. primary outcome was the incidence of aki in each of combined pre and post elquic patient population. secondary outcome included the stage specific incidence of aki. results: there was no significant difference between the cumulative incidence of akin pre and post elquic implementation on day post-op ( . % vs . %, p = . ) or day post-op ( . % vs . %, p = . ). conclusion: this multi-centre cohort subgroup analysis demonstrates that the implementation of a quality improvement care bundle does not affect the incidence of aki. this is in contrast to the clear mortality benefit that such a care bundle has provided and provides stimulus to discover what factors may yet improve aki, and so further improve these patients outcome. introduction: it is now well documented that critically ill patients are exposed to stressful conditions and experience discomforts from multiple sources. improved identification of the discomforts of patients in intensive care units (icus) may have implications for managing their care, including consideration of ethical issues, and may assist clinicians in choosing the most appropriate interventions. objectives: the primary objective of this study was to assess the effectiveness of a multicomponent program (mcp) of discomfort reduction in critically ill patients. the secondary objectives were to assess the sustainability of the impact of the program and the potential seasonality effect. methods: we conducted a multicenter, cluster-randomized, controlled, single (patient)-blind study involving french adult icus. the experimental intervention was the implementation of the mcp including the following steps: identification of discomforts, immediate feedback to the healthcare team, and implementation of targeted interventions under control of local champions who received monthly feedback and organized monthly meetings with their healthcare team. all icus started with a -month period with no intervention, and then they were randomized to one of two groups: icus with mcp implemented during a -month period (experimental group) and icus without any programm during the same period (control group). to assess the sustainabilty of the impact of the mcp, the study was completed with a second -month period during which the mcp was no longer applied in the experimental group. the primary endpoint was the monthly overall score of self-reported discomfort from the french -item questionnaire on discomforts in icu patients (iprea) (range from to , the lowest possible level of discomfort to the highest). the secondary endpoints were the scores of each item of iprea. results: at the end of the -month period, taking into account the clustering design, the monthly overall discomfort score was lower in the experimental group ( parents were asked to consent to being contacted months after discharge, at which point they were asked to complete the pedsql, a generic measure of quality of life. the pedsql enables a total score, physical health summary score and psychosocial health summary score to be calculated, with possible scores ranging from - and higher scores equating to better quality of life. results: parents of children aged - . years (median age: . years; ( %) males), the majority of whom had had an emergency picu admission due to sepsis (n = , %) or respiratory problems (n = ; %), completed the pedsql months after discharge from picu. for the group overall the total score was . (sd . ), physical health summary score was . (sd . ) and psychosocial health summary score . (sd . ). babies aged - months (n = ) had total scores (m = . , sd = . ) comparable to those of healthy norms (m = . , sd = . ). however older children in all age groups had lower total scores than healthy norms. whilst % ( / ) of babies had scores of more than one standard deviation below the score of healthy norms, which is recognised as being of clinical significance, this rose to % ( / ) of children aged - years and % ( / ) of children aged - years. of note is that children ( %) aged - years had been admitted to picu for reasons related to trauma or neurological concerns whereas no child aged - months had been admitted for those reasons. conclusions: children who have had an emergency admission to picu are at risk for impaired quality of life months after discharge. the risk appears to be greater for children of years and older which is likely to be at least partly attributable to the underlying reason for their admission. evaluating quality of life outcomes in the longer term after picu discharge is warranted and identification of potential risk factors will enable interventions to be targeted to optimise outcomes after an emergency admission to picu. introduction: cognitive dysfunction is an important long-term complication of critical illness associated with reduced quality of life, increase in healthcare costs and institutionalization. delirium, an acute form of brain dysfunction that is common during critical illness has been shown to be associated with long-term cognitive dysfunction( ). objectives: the aim of this prospective cohort study was to estimate the prevalence and severity of cognitive dysfunction in survivors of critical illness and to evaluate if delirium duration is an independent determinant of the severity of cognitive dysfunction. methods: included were all adult patients admitted to a -bed medical surgical icu over a -month period(from march to february ).we excluded patients with preexisting cognitive dysfunction; those that in the evaluation by the psychologist on admission to the icu had evidence of impaired cognition through the mini mental state examination and patients who could not be reliably assessed for delirium owing to blindness, deafness or language deficit and patients for whom informed consent could not be obtained. after at least months of hospital discharge patients were assessed for cognition using a validated battery of tests including: )the digit span, forward and backward; ) the rey auditory verbal learning test (ravlt); ) the clock drawing test (cdt); ) the verbal fluency test; and the mini mental state examination. we classified patients as having mild or moderate impairment if they had either two cognitive test scores . standard deviation (sd) below the mean or one cognitive test score sd below the mean; we classified patients as having severe cognitive impairment if they had or more cognitive test scores . sd below the mean or two or more cognitive test scores sd below the mean. results: enrolled in the clinical trial were patients and patients were eligible for the cohort (fig. ) . four hundred and thirteen patients were tested ( - ) months after discharge. table shows demographic and clinical data of these patients. cognitive impairment was identified in ( . %) patients; ( . %) had mild or moderate and ( %) severe cognitive dysfunction (table ) . eleven( . %) patients with delirium for days or more presented severe cognitive dysfunction. in logistic regression analysis the duration of delirium for days or more was not an independent predictor of cognitive dysfunction(p = . ). conclusions: this investigation in an unselected population of critically ill medical and surgical patients demonstrates that cognitive dysfunction is a frequent and severe long-term complication in survivors of critical illness. on the other hand, unlike other studies we couldn't demonstrate that the duration of delirium is an independent determinant of cognitive impairment. table positive determinants of the evolution of the eq-index were time and admission glasgow score (p . and . respectively) while age, duration of mv and weakness were negatively associated (p . , . and . ) ]. eq-eva paralleled eq-index changes. conclusions: after icu discharge, patients suffered frequent longterm consequences that negatively affect their hrqol. alterations in mobility, daily activities and personal care exhibited the greatest deterioration. prevalence of pain, anxiety and depression was high even before icu admission, aggravated after -year post-discharge ( % of patients) duration of vm was the only intra-icu variable that affected hrqol. pre-icu conditions as age and the extent of neurological injury and, after icu, time and weakness, were also independent determinants. the present study was supported by the argentinian society of critical care (sati) introduction: diffuse axonal injury (dai) is a common event following traumatic brain injury (tbi), which is likely related to worst long term outcome. diffusion tensor imaging (dti), a magnetic resonance imaging (mri) technique that investigates white matter integrity, is recognized as a useful tool to quantify dai extent in tbi and possibly predict outcome. few studies explored whole brain longitudinal changes of dti-derived parameters in single subjects following tbi. methods: patients with severe tbi underwent brain mri including dti ( directions, b = , voxel size x x ) - weeks and year after trauma. age-matched healthy controls underwent the same dti protocol. we used region of interest (roi) automated analysis (www.mristudio.org) covering the entire brain to quantify white matter integrity. the roi fractional anisotropy (fa), mean diffusivity (md), axial diffusivity (ad) and radial diffusivity (rd) were extracted. abnormalities were defined as dti values more than standard deviations below or above the mean values of controls for each roi. results: tbi patients with a median age of (iqr - ) and a median gcs score of (iqr - ) were included. had diffuse injury according to marshall classification. regions with increased md and reduced fa were more than expected in both early and late scan (p < . binomial test), while ad and rd abnormalities were less common. more than % of the patients had increased md in the early scan in the frontobasal girae, corona radiata and thalami; in late scans md abnormalities were larger and more diffuse, affecting also all frontal and temporal girae and corpus callosum. fa was frequently reduced in the corpus callosum, internal capsule and fronto-basal girae in early scan, while in late phase reductions were similar but more widespread, also including the central girae, cerebellum and inferior longitudinal fascicles. the number of regions with abnormal md increased over time (p < . mann-whitney), whereas for fa it was not statistically different. an inverse correlation between the number of roi with altered md at early scan and outcome evaluated with gose was found (p < . , spearman r). the present results indicate that early alterations of mean diffusivity and fractional anisotropy persist or worsen (for md) at year after tbi, suggesting an ongoing loss of white matter integrity and gliosis. the more frequently affected regions were the frontal girae, corpus callosum, corona radiata, inferior longitudinal fascicles and cerebellum. the number of roi with early abnormal mean diffusivity is inversely correlated with outcome. all patients underwent ssep, aep and tms the day before operation. after operation, all patients were delivered to icu intubated and mechanically ventilated. patients demonstrated full recovery from anesthesia with regaining consciousness, passed spontaneous breathing test (sbt) and gained points on cst without deficiency. these patients had none or low level of dysphagia and were successfully extubated after operation. these patients formed st group. patients had a neurogenic dysphagia and formed nd group. we performed ssep, aep and tms on all patients immediately after admission to icu. results: we revealed no clinical or electrophysiological points that could have predicted neurogenic dysphagia before operation. in our research, we found the ep values which were different for the first group and for the second group. the aep and tms data were not informative. we found instrumental the ssep values that reflected perioperative cct dynamics, lat p , amp n , auc n -n , auc n -n . these ssep values were used to create a prognostic rule through logistic regression and roc-curves. as a result, we were able to predict neurogenic dysphagia in early introduction: eeg monitoring during the first hours robustly contributes to the prediction of either poor or good outcome in comatose patients after cardiac arrest [ ] . quantitative eeg (qeeg) measures can be useful to visualize evolution of the eeg over hours. we recently proposed the cerebral recovery index (cri), an index based on a combination of five qeeg measures grading the severity of hypoxic brain damage on a scale from zero to one to facilitate prognostication [ ] . objectives: to evaluate the prognostic accuracy of a revised cri, after optimalization by the use of a random forest classifier instead of a manually chosen feature combination and the addition of four qeeg measures, resuscitation parameters and patient characteristics. methods: in this prospective cohort study, consecutive comatose patients after cardiac arrest were included in two intensive care units. continuous eeg was recorded during the first three days. outcome at months was dichotomized as good (cpc - ) or poor (cpc - ). nine qeeg measures were extracted: alpha to delta ratio, signal power, shannon entropy, delta coherence, regularity, the number of burst/min, mean and max burst correlation, and fraction of burst correlation > . . these measures were combined with patient characteristics and resuscitation data, including sex, age, initial heart rhythm, in-versus out-of-hospital-cardiac-arrest, and presumed cause of cardiac arrest. patients were randomly divided over a training and a validation set of respectively and patients. within the training set, a random forest classifier was fitted for each hour after cardiac arrest. based on results in the test set, two thresholds were chosen: one for predicting poor neurological outcome and one for predicting good neurological outcome. subsequently, the revised cri was evaluated in the validation set. results: poor outcome could reliable be predicted with the revised cri (with % specificity) in the validation set with a sensitivity of and % at respectively and hours after cardiac arrest. good neurological outcome could be predicted with a sensitivity of and % at a specificity of and %. conclusions: here we show that a combination of qeeg and clinical measures, extracted and combined by a random forest classifier, provides reliable, objective prognostic information. this revised cri can be used for the prediction of both poor and good neurological outcome, thereby poor outcome can be reliable predicted (without false positives) with relatively high sensitivity. the revised cri is expressed as a single index between and , which can be used in real time at the bedside, even by professionals who are not trained in eeg interpretation. introduction: continuous electroencephalography (ceeg) allows real-time monitoring critically-ill patients neurophysiology and to detect non-clinical seizures in comatose patients, delayed cerebral ischemia after subarachnoid haemorrhage, and guide therapies for status epilepticus. the application of ceeg is still limited because it requires awkward analysis by experienced neurophysiologists of huge amount of eeg tracings. quantitative eeg (qeeg) techniques, i.e.amplitude integrated eeg (aeeg) and density spectra array (dsa), have been developed to simplify the complexity of eeg interpretation, to allow rapid evaluation of cerebral background electrical activity and the power spectrum of the eeg frequencies derived from raw data eeg. these developments offer the potentiality to transform an instrument interpreted by neurophysiologist afterwards in a monitoring tool useful to icu staff. objectives: to test the hypothesis that eeg-nonexpert neurointensivists can obtain real-time reliable information from qeeg after training under the supervision of an in-house neurophysiologist. to describe the implementation of qeeg monitoring in neurointensive care units. methods: the implementation occurred in sequential phases. ceeg was recorded using surface electrodes according to the international - system, on a bipolar longitudinal montage in patients with brain injury. qeeg-naïve neurointensivists, after a short training from a neurophysiologist followed by daily supervision for the study period, were subjected to a baseline test evaluating aeeg and dsa traces. each panel consisted of raw eeg data and qeeg tools: the color density spectral array (dsa), amplitude integrated eeg (aeeg) and the burst suppression rate (bsr). after this evaluation, daily qeeg evaluation was performed by the neurointensivists and reviewed by the neurophysiologist. results: from july to april we monitored patients ( ± years, male) admitted for brain trauma ( %), stroke introduction: it has been noted the importance of job satisfaction in healthcare services and the consequences resulting therefrom, such as increasing the quality of care services provided and satisfaction of their users. objectives: to develop a model of influence of human resource management directed to the quality management and organizational excellence in the organizational results, from the perspective of healthcare staff. methods: we carried out a research study, of a transversal nature, whose study population were a total of ( , % physicians, , % nurses and , % nurse assistants) icu staff. a personal questionnaire was used to measure, through likert scales of points, the application of human resource practices of high commitment (hr), the quality of service provided to the patient (quality), the satisfaction with the capacity of the service (capacity), the personal satisfaction with the work done (satisfaction) and the affective commitment with the organization (commitment). results: the measure models of these five constructs were validated by confirmatory factorial analysis, whose results were satisfactory. the measurement model of hr is a second order construct which is introduction: in the period between - , a successful implementation project was finished aimed at strict blood glucose level (bgl) regulation in the intensive care unit (icu) [ ] . we hypothesized that glucose control would afterwards slack and that implementing other measures to modify behavior would be required to regain adequate glucose control. methods: a prospective study was performed in a -bed mixed medical-surgical icu of a university affiliated teaching hospital. all bgl values were extracted from the icu database in years following the implementation project until december . following the project, bgl targets were set at a range of - mg/dl, nurses' instructions for keeping bgl values in target were not changed. after . years, an automated warning system was implemented in the patient data management system that triggered a centrally placed monitor with feedback about the need for obtaining a bgl value, based on the actual value compared to the previous one. the primary outcome measure was mean bgl. secondary endpoints were sampling frequency, bgl within predefined targets, incidences of severe hypoglycemia, and hyperglycemia. the analysis was restricted to patients with at least two blood glucose measurements. these indicators were analyzed over the course of time using the xmr control chart, a tool belonging to statistical process control. results: data of patient admissions were evaluated, which corresponded to , bgl measurements. the bgl sampling interval (figure ), mean bgl and percentage of severe hypoglycemia all increased after introducing nurses' instruction and decreased significantly after monitoring feedback (p < . ). percentage of severe hypoglycemia events, which is associated tosafety, decreased with some delay after nurses' instruction and remained unchanged ( . % on average) and stable after introducing monitoring feedback. percentage of "in range" measurements of both normoglycemia ( - ) and protocol recommended ( - ) decreased after nurses' instructions and then increased after feedback monitoring. mean of per patient's standard deviation as a measurement of variability remained unchanged and stable after nurses' instruction and even decreased after monitoring feedback. conclusion: even after successful implementation of a bgl control system, behavior changed within months with inherent worsening of bgl control. an automated warning monitor in a central location was able to restore bgl control in the icu. using objective: the overall objective of this research program is to use the kinarm to define the neurocognitive phenotype of icu survivors (i.e. required invasive mechanical ventilation and/or vasoactive agents for hemodynamic support). this group is compared to healthy age-and gender-matched controls, as well as active control groups. these active control groups were patients ) pre-and ) post-cardiac surgery, and ) patients postcardiac arrest. methods: participants performed tasks on the kinarm that ranged from simple sensorimotor tasks to more complex executive tasks. for each task, - performance metrics were recorded. these metrics were compared to a normative database of age-and gendermatched controls and z-scores were generated. a composite score for each task was generated using a score derived from maholanobis distance, with increasing scores representing worse performance. cluster analysis was applied to these performance metrics using euclidian distance. (fig. ) . conclusions: serial mlt measurements significantly underestimate muscle wasting in critical illness and are not related to development of muscle weakness. in comparison, changes in rf csa reflect changes in 'gold standard' methods of assessing muscle mass, and are related to loss of muscle mass and function in critically ill patients. there is significant evidence that electronic prescribing can significantly reduce the errors, however implementation of it is a long term project and is not feasible in attempt to improve medicines safety over short period of time. therefore we aimed to improve safety of a current paper based system. multidisciplinary intervention was chosen as this approach has been previously demonstrated to reduce medication errors on icu . objectives: evaluate effect of multidisciplinary intervention to improve medicines safety. methods: over the course of months following interventions were introduced: development and implementation of new icu specific iv infusion chart, prescription checks during nursing handover, introduction of daily pharmacy handover and on-site feedback, additional medicines training for current staff and new medicines safety induction module for new-starters. outcome data was based on monthly spot audits carried out by pharmacy staff. comparison is made between quarter and quarter after the start of intervention. chi-square test was used to compare the two datasets. results: there were prescriptions analysed in q and in q . we observed a five-fold reduction in prescription validity errors from . % to . % (p < . ). and nearly ten-fold reduction in administration of medicines against non-valid prescriptions from . % to . % (p < . ). pre-printed icu specific iv infusion chart eliminated errors related to variable dilutions, choice of diluent, incorrect or inconsistent infusion rates. month-by-month trends are presented in figure . conclusion: multidisciplinary intervention has resulted in significant improvement in medicines safety. introduction: the concept of frailty has been defined as a multidimensional syndrome characterised by the loss of physical and cognitive reserve that predisposes to adverse events. the prevalence of frailty amongst the critically ill is unknown, however it is probably increasing. this audit aimed to look retrospectively at our admissions to intensive care, to categorise them into frail or non frail, and evaluate how frailty correlated with icu length of stay and mortality methods: a retrospective case note review of all patients admitted to intensive care over a six month period in the victoria infirmary and then queen elizabeth university hospital in glasgow. classification of frail or non-frail was done using a combination of the clinical frailty score (cfs) and edmonton frailty scale. [ , ] . once classified into frail and non-frail we looked at icu outcome, length of stay, apache, weight on admission, lowest albumin and admission haemoglobin and compared the frail population to the non-frail population. results: two hundred and eighty four patients were admitted to intensive care in this time period. of those, were over the age of years. of the patients, patients were deemed to be frail, and were deemed to be non-frail using the cfs. approximately % of the patients admitted to intensive care are over the age of . there was no significant difference found in mortality, icu length of stay or hospital stay, apache or weight between the two groups. [see table ] conclusions: we know that the utilisation of intensive care resources by older people is rising. our data shows that almost % of those admitted to icu are over the age of . interestingly, there is no significant difference between the non frail and frail groups of patients admitted to intensive care. this may be because of small sample size. the length of stay of the frail patient is shorter and this may be because as intensivists we are better at treatment limitation in this group of patients. no difference in overall mortality suggests that the patients we deem suitable for intensive care who are frail do as well as the non-frail cohort as the selection process for admission has been adequate. patients deemed to be frail are more likely to be dependant on care if they survive, with % requiring some sort of support on discharge. most studies show that frailty is associated with increased mortality so it is indeed interesting that this audit has shown no difference between the two groups. figure shows a significant increase in admissions among the elder groups along the five-year periods. the severity scores increased significantly as shown in figure (p < . ). icu lenght stay also decreased significantly (table ) introduction: in our intensive care medicine (icu) department we used a database (gespac) with uniform and quality data for all admissions from to , which allows us to study the evolution of severity scales and the clinical activity by age and type of patient. objectives: to describe the effectiveness of severity scales used in our icu over years by age and type of patient. methods: a retrospective, single-center and descriptive study was conducted from to . all patients admitted consecutively were included. patients with lenght of stay less than hours were excluded.the severity scales we analyzed were mpm , mpm , saps , apacheiii. patients were divided in groups of age by quartiles (< years, - years, - years, > years). the type of patient was classified in medical and urgent or scheduled surgery. we used descriptive statistics. qualitative variables are expressed as percentages and quantitative variables are expressed as means and standard deviations (± sd) and roc curves for the analysis of discrimination. we used spss v . results: we included patients, were men ( %), mean age was . years (sd . ). icu mortality was . %. in figure we show curve roc corresponding to the severity scales for all patients, mpm has a significantly worse discrimination respect to the other scales. mpm , saps and apache iii have a similar behavior. in table we show the severity scales effectiveness by age groups. in table we show the severity scales effectiveness by type of patients. we observed a decrease of effectiveness of severity scales over time, however this effectiveness remains optimal in all the severity scales except for mpm . introduction: we implemented a critical care epr using the quadramed system on the th sept . our objective was to evaluate whether the epr had improved the quality of our documention and the responsiveness of our notes. methods: we evaluated the patient record from hospital days prior to the implentation of the epr and hospital days months after using and refining the system. results: the proportion of completed nursing risk assessments did not change after implementation of the epr. they depend on the user to shedule their completion. safety checks for arterial and cvc lines were well established and changed little. there was an improvement in the percentage of shift checks completed when they were automatically sheduled. the system provides a date, time and audit trail for each entry. the user traceability in the medical notes increased. the presence of the author´s name improved from % to %, the date from % to %, the time from % to %, and signature from % to %. legibility improved from % to %. the proportion of entries with a contact number dropped from % to %. the nursing care plans in the paper notes were better completed than the medical notes, but still improved. the presence of the nurse´s name increased from % to %, the date from % to %, the time from % to % and the signature from to %. legibility was % in both groups. the quadramed system provides automatic calculations of early warning scores and fluid balances.the more complicated the calculation, the greater the improvement. integration of data: · the increase in data points that cross populate is: + · the allergy advice populates all the sheets compared to an average of on paper (excluding the drug chart). · the average number of scheduled events (that instruct staff to perform functions) has gone from to . conclusions: . the largest improvement came in the accessibility of the notes. they can now be accessed within one minute from any pc in the trust. previously a standard time to deliver notes was two days, reducing to one day in an emergency. . correct filing of the epr notes and the search facility reduced the average time to complete the audit by minutes per patient. . the user audit trail and traceability improved in both medical and nursing paperwork, more so in the former. this is explained by a baseline of lower documentation standards in the medical group. . the typed out notes are now legible. . there was a large improvement in the quality of data calculations that are now up to %. . there was a large increase in the number of scheduled events, but this these only lead to an improvement in documentation when they were automatically scheduled by the computer. there was no improvement when user scheduling was required. we noticed very high levels of satisfaction regarding the professional care (frequency of communication, physician skill and competence, understanding information, honesty and facilities of getting information) and overall with care. satisfaction was even higher when we considered the usefulness of the ecp. every respondents supported it as a complement to daily information but it was only supposed to replace verbal information in , %. % did not access the website because of sufficient verbal information or cultural or age-related difficulties. the access was mostly via computer ( , %) followed by smarthphone ( , %). particularly desired were daily updates, an established timetable and more detailed information. there were no statistically significant differences in the need of web access among families living near the hospital and not or prior experience with icu familiar admission. conclusions: ecp appears to decrease the level of anxiety of families, improves perceived quality and can help to combine patient care with their work and personal responsibilities without replacing the daily evolution provided by physicians. introduction: neuroimaging shows promise for determining early prognosis after cardiac arrest (ca). nevertheless, conventional mri sequences, as t -weightened sequences, are currently considered not precise enough to detect brain structural anomalies in this context, and therefore are supposed to be unable to accurately predict outcome . objectives: we hypothesize that the combined use of cortical thickness measurement and subcortical grey matter volumetry could provide an early and accurate in vivo assessment of the structural impact of cardiac arrest (ca), and therefore could be used for longterm neuroprognostication in this setting. methods: prospective study undertaken in five intensive critical care units affiliated to the university in toulouse (france), paris (france), clermont-ferrand (france), liège (belgium) and monza (italy). high-resolution anatomical t -weighted images were acquired in anoxic coma patients ( +/− days after ca) and matched controls. patients were followed up one year after ca. cortical thickness was computed on the whole cortical ribbon and deep grey matter volumetry was performed after automatic segmentation . brain morphometric data was employed to create multivariate predictive models using learning machine techniques ( figure ) . results: patients displayed significantly extensive cortical and subcortical brain volumes atrophy compared to controls. a dissociated vulnerability to anoxic insult was observed: subcortical volumes were related to ca duration and cortical thickness values were linked to the time to mri acquisition ( figure ) the accuracy of a predictive classifier, encompassing cortical and subcortical components has a significant discriminative power (auc = . ). the anatomical regions which volume changes were significantly related to patient's outcome were: frontal cortex, posterior cingulate cortex, thalamus, putamen, pallidum, caudate, hippocampus and brainstem ( figure ) conclusions: these findings are consistent with the hypothesis of pathological disconnection within a striatopallidal-thalamo-cortical mesocircuit induced by ca and pave the way for the use of combined brain quantitative morphometry in this setting. clinical and electrophysiological correlates of absent somatosensory evoked potentials after post-anoxic brain damage: a multicentre cohort study conclusions: our data confirm that bilateral absence of n reflects severe post-anoxic cerebral damage and therefore frequently correlates with concordant clinical and eeg signs of poor outcome. however, our study also identified a subset of patients with discordant signs, in whom clinical examination and/or eeg were reactive despite bilaterally absent n . our findings raise further questions on outcome prognostication after ca and underline the importance of multimodal assessment in this setting. the response time threshold for predicting favorable neurological outcomes in patients with bystander-witnessed out-of-hospital cardiac arrest introduction: it is well established that the period of time between when a call in made to emergency medical service (ems) to the point when ems arrive at the scene (i.e., the response time) affects the survival outcomes in out-of-hospital cardiac arrest (ohca) patients. however, the relationship between response time and favorable neurological outcomes remains unclear. we therefore aimed to determine a response time threshold in bystander-witnessed ohca patients that is associated with positive neurological outcomes and to assess the relationship between the neurological outcomes and response time in ohca patient. methods: this study was a retrospective, observational analysis of data from , episodes of bystander-witnessed ohca between and in japan. we used classification and regression trees (carts) and receiver operating characteristic (roc) curve analysis to determine the threshold of response time associated with favorable neurological outcomes (cerebral performance category or ) one month after cardiac arrest. results: both carts and roc analyses indicated that a threshold of . min was associated with improved neurological outcomes in all bystander-witnessed ohca events from cardiac origin. furthermore, bystander cardiopulmonary resuscitation (cpr) prolonged the threshold of response time by min (to . min). the adjusted odds ratios for favorable neurological outcomes in ohca patients who received care within ≤ . min was . ( % confidential interval: . - . , p < . ). conclusions: a response time ≤ . min was closely associated with favorable neurological outcomes in all bystander-witnessed ohca patients. bystander cpr prolonged the response time threshold by min. methods: patients with established out-of-hospital cardiac arrest (ohca) who underwent cardiopulmonary resuscitation with subsequent return of spontaneous circulation were retrospectively enrolled. two hundred and eight dic patients diagnosed by the japanese association for acute medicine (jaam) dic criteria were divided into two subgroups with hyperfibrinolysis ( ) and without hyperfibrinolysis ( ). the definition of hyperfibrinolysis was made by a fdp level > μg/ml. platelet count, global markers of coagulation and fibrinolysis were measured times after admission to emergency department (t , - ; t , - ; t , - ; t , - hr). the outcome measure was the hospital all-cause mortality. results: patients with hyperfibrinolysis had higher dic, sirs, and sequential organ failure assessment (sofa) scores associated with higher prevalence of mods, leading to a higher mortality rate of . % in comparison to patients without hyperfibrinolysis ( . %). stepwise logistic regression analyses confirmed that dic, sofa scores, and lactate levels are independent predictors of patient death. hyperfibrinolysis also predicted patient death. tissue hypoperfusion (as indicated by lactate level) is a main determinant of hyperfibrinolysis. receiver operating characteristic curves showed a significant discriminative performance of dic scores for patient death. kaplan-meier curves showed that dic, especially dic with hyperfibrinolysis, significantly affected patient death. conclusions: dic with the fibrinolytic phenotype during the early phase of post-cpr more frequently results in sirs and mods, and affects the outcome of ohca patients. hypoxia/ischemia during cardiac arrest and cpr are considered to be the cause of increased fibrin(ogen)olysis. the association between tracheal intubation during pediatric inhospital cardiac arrest and survival l.w. andersen , , t. introduction: tracheal intubation is common during pediatric inhospital cardiac arrest, although the relationship between intubation during cardiac arrest and outcomes is unknown. objective: to determine if intubation during pediatric in-hospital cardiac arrest is associated with improved outcomes. methods: this was an observational study of prospectively collected data from united states hospitals participating in the get with the guidelines -resuscitation registry. we included pediatric patients (age < years) with index in-hospital cardiac arrest. we excluded patients who were receiving invasive mechanical ventilation and/or had an invasive airway in place at the time chest compressions were initiated. the exposure was tracheal intubation during the cardiac arrest. the primary outcome was survival to hospital discharge. secondary outcomes included return of spontaneous circulation and neurological outcome. a favorable neurological outcome was defined as a score of - on the pediatric cerebral performance category score. patients being intubated at any given minute (from to minutes) were matched with patients at risk of being intubated within the same minute (i.e. still receiving resuscitation) based on a timedependent propensity score calculated from multiple patient, event, and hospital characteristics. modified poisson regression with adjustment for matching and clustering were then performed to obtain risk ratios. results: patients were included. of these, ( %) were intubated during the cardiac arrest. in the time-dependent propensity score-matched cohort (n = ), survival was lower in those intubated compared to those not intubated during cardiac . ], p = . ) between those intubated and not intubated during cardiac arrest. the association between intubation and decreased survival remained in the majority of our sensitivity and subgroup analyses conclusions: tracheal intubation during in-hospital pediatric cardiac arrest was associated with decreased survival to hospital discharge. these findings challenge the present resuscitation paradigm for pediatric in-hospital cardiac arrest. introduction: substantial proportion of patients who suffered cardiac arrest do not respond to conventional cardiopulmonary resuscitation. recently, extracorporeal cardiopulmonary resuscitation (ecpr) has been introduced as a potentially life-saving procedure in refractory cardiac arrest. objectives. the aim of our study was to evaluate the relation between ecpr survival, lactate levels and blood ph. methods: eligible patients for this analysis had to undergo ecpr after at least ten minutes of unsuccessful cardiopulmonary resuscitation with a minimum of three defibrillation attempts. for extracorporeal life support (ecls) we used cardiohelp system (maquet, germany) or levitronix centrimag blood pump (levitronix, usa). lucas ii system (physiocontrol, sweden) was used for chest compressions during ecls insertion and cannulas were placed with percutaneous puncture under fluoroscopy or ultrasound control. blood lactate and ph levels measured before ecls insertion and after hours were used for this study. results: we analyzed data from patients treated with ecpr for refractory cardiac arrest. the mean age of our patients was years ( - ). out-of-hospital cardiac arrest occurred in patients, patients suffered from in-hospital arrest. thirty-day mortality in our group was % and % of patients recovered with good neurological outcome. percutaneous coronary intervention was performed in ( %) patients. baseline value of lactate was . ± . mmol/l, initial ph . ± . . in comparison with survivors, patients who died had significantly higher initial lactate levels ( . ± . vs. . ± . ; p < . ) and lower baseline ph ( . ± . vs . ± . ; p < . ). moreover, survivors had significantly lower lactate levels after hours. conclusions: ecpr represents virtually the last chance to survive refractory cardiac arrest. the levels of blood lactate and ph are significantly associated with clinical outcomes of ecpr. introduction: post-cardiac arrest survivors treated with therapeutic hypothermia (th) remain comatose after rewarming. in contrast to survivors without th, neurological prognostication is imprecise due to a persistent sedative effect [ ] . objectives: we aimed to evaluate clinical signs and findings that could predict neurological recovery and determined the optimal time for prognosis. methods: we retrospectively reviewed database of post-arrest patients treated with th in our hospital from to . cerebral performance category (cpc), neurological signs and findings in eeg and brain ct were evaluated. neurological recovery was scored as favorable neurological outcome, namely normal cerebral function(cpc ) and moderate disability(cpc ) or unfavorable neurological outcome, namely severe disability(cpc ), vegetative state(cpc ) and death(cpc ). neurological signs and findings in eeg and brain ct, which possibly predicted neurological recovery, and the optimal time to evaluate neurological status were analyzed. results: th was performed in post-arrest patients. approximately % ( / ) of th-patients survived and % of the survivors had favorable neurological outcome. findings predicting unfavorable outcome at discharge were lack of pupillary response and/or gag reflex after rewarming, and the absence of at least one of the brainstem reflexes, no eye opening or motor response worse than pain withdrawal (m ≤ ) on the seventh day. (table ) myoclonus and seizure could not be used to indicate poor prognosis. one of survivors with myoclonus had full recovery and % of the survivors with seizures regained consciousness upon discharge. findings of eeg and brain ct showed that the patients with burst-suppression eeg pattern or brain swelling became vegetative or died, but the prognostic values of these findings were inconclusive. conclusions: our study showed that the simple neurological signs helped predict short-term neurological prognosis of comatose survivors undergoing th. the most reliable signs which determined unfavorable outcome were the lack of the pupillary light response and gag reflex. the optimal time to assess prognosis was either at to hours or days after return of spontaneous circulation. physicians can use these neurological signs to evaluate the prognosis of postcardic arrest survivors treated with th. objectives: procalcitonin (pct) and presepsin are biomarkers associated with severe infections. we asked, if they could be used to reflect the severity of the post-cardiac arrest syndrome and to predict poor outcome. a significantly greater increase in procalcitonin from admission to h was observed in patients with eventual poor outcome compared to those with a favorable one (p < . ). presepsin levels were on average constantly higher in patients with poor outcome but did not show any statistically significant changes in repeated measures analysis of variance. conclusions: plasma procalcitonin may be a useful tool for the evaluation of long-term outcome of out-of hospital cardiac arrest patients at the icu. on the contrary, presepsin did not provide clinically relevant additional predictive value in the study setting. introduction: prognosis of cardiac arrest survivor is mainly determined by ischemic brain injury. post-cardiac arrest state is characterized by elevated circulating cytokines and hemodynamic instability, called as a sepsis-like syndrome. in many critical ill diseases such as acute pancreatitis and sepsis, a low serum level of high-density lipoprotein (hdl) and apolipoprotein a- (apoa ) were associated with poor outcomes. objectives: in this study, we examined whether a serum level of hdl and apoa at intensive care unit (icu) admission is associated with a neurologic outcomes in cardiac arrest survivors. methods: this study was a retrospective observational study conducted in a single tertiary urban hospital icu. all admitted patients following cardiac arrest were screened during from march to december . patients younger than years and without admission lipid panel were excluded. neurologic outcome was determined by hospital discharge cerebral performance categories (cpc). good neurologic outcome was defined as cpc and . note: this abstract has been previously published and is available at [ ] . it is included here as a complete record of the abstracts from the conference. we analyzed all patients admitted on hospital ward that were assisted by the ihca team. patients admitted less than hours on ward and patients not eligible for resuscitation were excluded. demographic data (age and gender) were collected. we analyzed the type of patient (medical or surgical), the schedule in which the ihca happens (weekdays from hours am to hours pm and the rest, every day from hours pm to hours am, weekend and holidays), ihca witnessed, the ihca team time reaction, ihca established or not at ihca team´s arrival, return of spontaneous circulation (rosc) and hospital mortality. statistics:qualitative variables are expressed as percentages and compared using the x -test; quantitative ones are expressed as means and standard deviations (± s.d), and analyzed using student´s t-test. multivariate logistic regression was performed, with hospital mortality as the dependent variable. the level of significance was placed at p < . . the statistical analysis was performed using specific software ( ibm spss statistics for windows, version . . armonk, ny: ibm corp). results: patients were assisted by the ihca team and patients were included. in figure we described the characteristics of the study population. the beginning of cardiopulmonary resuscitation (cpr) maneuvers were immediate on ward, according to ihca protocol. the arrival of ihca team was less than minutes in all cases. table shows an assosciation between hospital mortality and the capability of anticipation of ihca situations (schedule, witness, pre-cardiac arrest …). table shows the persistence in the multivariate analysis of the relationship of these factors with the hospital mortality. conclusions: the number of activations of ihca team is remarkable, mortality of these patients is very high despite being patients on ward without a bad expected outcome. the improvement in the factors associated with the capability of anticipation of ihca situations (schedule, witness, pre-cardiac arrest …) could lead to an improvement in the prognosis of ihca. , and vessels with diameter smaller than μm were defined as small vessel. serum level of endothelial cell specific molecule- (endocan) was measured at specific time points. the hemodynamic parameters, the inotropic equivalent score, and prognosis of the patients were recorded. results: patients were iinvestigated in this preliminary report. they were equally divided into two groups (survival and nonsurvival) according to -day mortality. the baseline patient characteristics were not significantly between the two groups. the perfused small vessel density and proportion of perfused vessels at h were higher in the survival group than in the non-survival group. the endocan level were higher in the non-survival group than in the survival group, but the difference was not significant. conclusions: our results revealed that the perfused small vessel density were higher in the survival group than in the non-survival group. it encourages further studies to investigate whether aiming to improve microcirculation can improve outcomes in patient with venoarterial ecmo life support system. demographic data, sedation and vasopressor dose were recorded. enteral feeding was started as soon as possible. the cumulative grv was recorded up to a maximum of days, with a cut-off value of ml used to define intolerance to enteral feeding (ief). all data is presented as median(p -p .) statistical analysis was performed by stats . with mann-whitney u test and chi-square test. results: data from patients were recorded. baseline demographic data were similar in the groups. the average grv and the doses of midazolam were the highest in patients with vv ecmo, while the number of days with ief and the doses of na were the highest in the va ecmo group (table ) . overall, grv and number of days with ief tended to be higher in survivors (n = , grv ( - ), days with ief ( - )) than in non-survivors (n = , grv ( - , days with ief ( - )). conclusion: early enteral feeding is feasible during ecmo, in spite of impairments of gastrointestinal function potentially related to sedation and/or vasopressor treatment. extracorporeal membrane oxygenation for refractory cardiogenic shock in patients with peripartum cardiomyopathy a. chao results: six patients with confirmed ppcm were found. two ( %) patients died of neurological consequences (cerebral infarct and hypoxic encephalopathy) and their left ventricular (lv) ejection fraction remained about %. one patient underwent heart transplantation. the other three patients weaned off ecmo and their lv function began to improve on day . they were discharged uneventfully. conclusions: ecmo can provide an effective and simple treatment for critical ppcm with a satisfactory result. patients supported by ecmo whose heart function did not begin to recover on day and had neurological complications had a poor prognosis. introduction: the use of venoarterial extracorporeal membrane oxygenation (va-ecmo) for prolonged cardiopulmonary resuscitation (cpr) and severe cardiogenic shock after cpr has widely increased ( ). bleeding complications, due to necessary therapeutic anticoagulation and cpr/sirs induced coagulopathy are common ( ) . targeted temperature management (ttm) has shown positive effects on neurological outcome after cpr. although optimal target temperature is not exactly known, ttm remains a recommended approach in patients after cpr ( ). objectives: to determine the incidence of bleeding complications in patients after cpr, who are on va-ecmo and treated with ttm (target temperature °c) simultaneously. methods: we conducted a retrospective observational study from jan to dec and extracted relevant clinical data from electronically medical records. outcomes of interest were d-mortality and incidence of bleeding complications within hrs of cpr. demographic data, (anti-)coagulation status and need for transfusion were also analyzed. results: a total of patients received va-ecmo during the study period of which patients ( , %) underwent cpr before ecmo. of these, patients ( %) were treated with ttm. the median age was yrs (range - yrs) and patients were male ( %). sofa score on admission was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . patients received cpr mainly because of either acute myocardial ischemia (mi) ( ; %) or malignant dysrhythmias not attributable to acute mi ( ; %). ecmo implantation was performed within hrs ( . - hrs) of cpr and ecmo duration was . hrs ( - hrs). ttm was implemented within hrs ( - hrs) of cpr and the duration of simultaneous treatment with va-ecmo and ttm was . hrs ( - hrs). introduction: during initial resuscitation of patients with shock, last consensus recommend to target a mean arterial pressure of at least mmhg. however, there is no recommendation for the mean arterial pressure target in in the particular setting of extra corporeal cardio pulmonary resuscitation patients in the first hours following a refractory cardiac arrest. objectives: therefore, we conducted an experimental study to assess the effects of two different levels of mean arterial pressure for macrocirculatory, microcirculatory and metabolic functions. methods: randomized animal study in university research laboratory. in fourteen male pigs, a myocardial infarction was induced by a surgical ligature of the inter-ventricular coronary artery, triggering a refractory ventricular fibrillation. after twenty minutes of standardised cardiopulmonary resuscitation, extra corporeal life support was initiated to restore the circulatory flow. then, animals were randomly allocated to a high mean arterial pressure group (high map, - mmhg) or to a standard mean arterial pressure group (standard-map, - mmhg). evaluations at baseline, just before and six hours after ecls initiation were focused on ) lactate, ) amount of fluid infused and ) microcirculatory parameters (sidestream darkfield imaging, renal and liver functions). results: the two groups were similar at baseline and also at time of ecsl initiation including for the lactate levels ( objectives: the goal of our study was to assess the factors associated with percutaneous cannulation success or failure during ca. methods: this was a prospective observational monocentric study conducted between may and february including all consecutive patients with ca (no return to spontaneous circulation after minutes of cardio-pulmonary resuscitation) and an indication of ecls (low-flow below minutes). femoro-femoral cannulation ( fr for arterial cannula and fr for venous cannula, maquet®) was performed using the seldinger technique under ultrasound (us) guidance. patient characteristics, physician's a priori about cannulation conditions (ranging from (expected very easy) to (expected very difficult)) and us measures of femoral vessels diameter were recorded. the primary endpoint was the time to ecls initiation (icu admission -ecls running) and was analyzed using a stepwise multivariable linear regression. as a secondary analysis, we also explored the differences between the patients with a time to ecls initiation < min and all others (> minutes or cannulation failure conclusions: our data suggests that the level of care patients receive does not affect baby being with its mother. however, level patients are admitted to a general critical care unit and not captured in this review. the results also suggest that maternal well-being is affected by and/or affects whether baby is with her, however the % confidence intervals overlap. the above data does not take into account babies being in special care baby units and therefore not able to join their mothers at their bedside (this data will be recorded in the future). when this data is recorded it is expected that a high proportion of babies who are able to be at their mother's bedside during amc will be there. the introduction: high levels of job satisfaction are associated with decreased turnover intention, burnout incidence and absenteeism among health care professionals. moreover, turnover and burnout negatively impact on quality of care and healthcare costs. as the intensive care unit (icu) represents a highly complex and stressful environment, prevention of conflicts among team members as well as improvement of communication and job satisfaction can as such reduce burnout risk. objectives: this study explores the relationship between communication -and job satisfaction and the impact on burnout and turnover intention among icu nurses. %, / ). an average job satisfaction of . / was found. . % ( / ) had a score ≤ on job satisfaction, indicating significant dissatisfaction. icu nurses were most satisfied with the trust received from their supervisor ( . %) and least with the information about accomplishments and/or failures of the organization ( . %). . %, ( / ) had a low, . % ( / ) an average and only . % ( / ) a high turnover intention. % of the icu nurses had an indication for burnout. . % of the nurses had a low experience of their personal accomplishment. conclusions: in this survey icu nurses had a reasonable job satisfaction. they are most satisfied with the trust received from supervisors. despite a low indication for burnout risk, a quarter of icu nurses report low personal accomplishment. this may represent a particular focus for both preventive and interventional actions, which should preferably be developed through and in conjunction with the supervising staff. introduction: in the swiss diagnosis related groups ((swiss)-drg)) was implemented in intensive care units (icu). its impact on hospitalizations has not yet been thoroughly examined. we compared the number of icu admissions according to clinical severity and referring institution, screened whether implementation of swissdrg affected admission policy, icu length-of-stay (los) or icu mortality. methods: retrospective single center cohort study conducted at the university hospital zurich, switzerland between january and end of . demographic and clinical data were retrieved from a quality assurance data base. conclusions: drg introduction had not affected icu admissions policy, except for an increase of in-house patients with a low clinical severity of disease. drg had neither affect icu mortality nor icu los. interactive gaming as part of mobilisation programs is feasible in the icu, but specific explanation about the usefulness of these games to patients is crucial for improving motivation and engagement t. introduction: in recent years, light sedation has gained attention as part of standard daily care in the intensive care unit (icu). consequently, patients are increasingly engaged in their rehabilitation process. particularly early mobilization is associated with shorter time on the ventilator, shorter icu length of stay and better survival [ ] . interactive gaming may be a challenging way of engaging the patient in his own rehabilitation program. few data are available for the use of these interactive games in the icu envirnoment as part of daily routine physiotherapy, although one study showed that it was safe [ ] . we developed a trolley with a wii (tm) device that can be easily used when the patient is mobilized in a chair. we hypothesized that this would be associated with increased motivation to participate in interactive gaming by our patients. methods: the wii device was used with different games. participating patients were offered to play games of their own choice as part of the mobilisation program to improve their strength and coordination. no extensive explanation about the potential usefulness of these interactive games was given to the patients. after finishing the games, a specific survey was administered addressing motivation and affects on mental health. scores were obtained using a likert scale (range - ). results are shown as median and interquartile range {p -p ] results: at the time of abstract submission, participating patients had finished a cycle of games. some of the patients liked to use the wii device, particularly because a choice in games made it more interesting to use. other patients, however, felt they were required to participate. tennis, bowling and boxing were most frequently used. the use of the wii was programmed in the daily mobilization schedule together with a physiotherapist, or just with the attending icu nurse. in general, patients were not that enthusiastic about the wii-games (median score [ - ]), were not convinced that playing these games improved their well-being (median score [ ] [ ] [ ] [ ] ), and most felt that they did not have a choice but to participate (median score [ ] [ ] [ ] ). conclusion: interactive gaming with the wii-device is feasible in icu patients. however, thorough explanation of the potential usefulness of these games is required to engage and motivate patients to participate. methods: descriptive and retrospective study. we include all patients admitted in icu during (previous to rrt establishment) and (year of rrt establishment), and who were discharged to the ward. we analysed the icu and hospital mortality in both groups. results: in we admitted patients ( , % from the ward and , % from the other places like emergency, other icu or other hospitals), with a icu mortality of , % and hospital mortality of , %, with a hospital mortality after icu discharge of , %. in we admitted patients ( , % from the ward and , % from the other places), with a icu mortality of , % and hospital mortality of , %, and a hospital mortality after icu discharge of , % (p = . ). conclusions: after the first year of rrt establishment in our hospital, we appreciate that the continuation of patients after icu discharge, decrease the hospital mortality ( , % versus , %, p = . ). the number of patients admitted in icu from the ward decrease in ( , % versus , %), maybe because we did a previous assessment of this patients, with a stabilization in the ward and avoiding the icu admission. objectives: to identify outcomes and prognostic factors in hm patients admitted over -years to a general intensive care unit in a specialist haematology centre. (figure ). patients with - organ failures had significantly worse outcomes than those with - organ failures (p < . ) or . [ . - . , ci %]. median apa-che ii, sofa and saps ii scores were , and , respectively. median apache ii (p < . ), sofa (p < . ) and saps ii (p < . ) scores were greater in those ventilated for - days vs. ≥ days. conclusions: apache ii scores and mortality were greater than described in similar hm populations. given the severity of critical illness in our cohort, we suggest that admission to icu earlier in the acute illness may improve outcomes. poorer outcomes were observed in those with > organ failures and in ventilated patients. the survival of / rd of patients on icu for ≥ days to hospital discharge suggests that -day trials of icu in hm patients are unlikely to reliably distinguish between survivors and non-survivors. background: dedicated intensive care unit (icu) physician staffing was associated with a reduction of icu mortality in the general medical and surgical icu. however, limited data were available on the role of a cardiac intensivist in the cardiac intensive care unit (ccu). we compared the clinical outcomes in adult patients admitted to ccu before and after implementing the cardiac intensivist-directed care. methods: we enrolled , consecutive patients admitted to a ccu at samsung medical center, from january to december . in january , ccu was changed from a low-intensity staffing model to highintensity staffing model which managed by a dedicated cardiac intensivist. we divided eligible patients into low-intensity group (n = ) and highintensity group (n = , ). the primary outcome was ccu mortality. results: high-intensity group had significantly lower ccu ( . % vs . %; p < . ) and hospital ( . % vs . %; p < . ) mortality compared to the low-intensity group. the decrease in ccu ( . % vs . %; p = . ) and hospital ( . % vs . %; p = . ) mortality in high-intensity group were consistent in (low-intensity group , high-intensity group ) patient with profound cardiogenic shock treated with extracorporeal membrane oxygenation. kaplan-meier survival curve showed significant higher cumulative survival rates in highintensity group at year follow-up (log rank test, p < . ). ccu ( . % vs . %; p = . ) and hospital re-admission rate ( . % vs . %; p = . ) were decreased as well after conversion to highintensity although these results were not statistically significant. conclusions: dedicated cardiac intensivist was associated with reductions of ccu mortality in patient with cardiovascular disease requiring critical care. introduction: opioids are commonly given to alleviate pain and distress in patients admitted to the intensive care unit (icu) patients or undergoing major surgery. previous studies have shown that patients who are already taking opioids prior to surgery or icu admission are more likely to experience an extended duration of opioid use postoperatively or post-discharge ( ). however, it is unknown whether patterns of opioid usage differ between patients who are admitted to the icu and those undergoing a surgical procedure. objectives: the objective of this study was to describe opioid use in critically ill patients before and after icu admission and to compare it with preoperative and postoperative opioid use in a surgical population. methods: retrospective review and comparison of adult patients admitted to the icu or undergoing surgery at a tertiary care center between january , and december , . we divided the populations based on their degree of opioid use into "non-user", "intermittent", and "chronic" opioid users as previously described ( ). we assessed opioid use at months prior to icu admission or surgery, at discharge, and monthly for months thereafter. patients admitted to icu who had surgery were categorized under the icu population. to assess for risk of monthly chronic opioid use, a cox-proportional hazards model was postulated that allowed for recurrent events to account for patients irregularly requiring opioids over the course of the study period. the model showed that the risk of chronic opioid use was . times greater for those with prior chronic opioid use compared to patients who were non-users. there was no difference in risk of chronic opioid use between the icu and surgery group. conclusions: our findings suggest that icu and surgical patients have similar risk of prolonged chronic opioid use post-discharge. chronic opioid use prior to icu admission or surgery is the strongest predictor of chronic opioid usage at and after discharge. a single-centre cohort study of national early warning score (news) and blood gas derived biomarkers in patients with acute medical illness introduction: empirical combination antibiotic therapy for treatment of severe sepsis is a matter of debate. the proposed rationale for using a combination of two or more different antimicrobials is several fold. first, it allows for a broader empirical coverage with a higher likelihood of targeting the causative organism. second, it may decrease the development of resistance to the antibiotics used. third, a combination of active drugs potentially cause a synergistic effect increasing the efficacy of bacterial eradication. the surviving sepsis campaign recommends combination therapy in some patient populations and certain type of infections but the quality of the evidence supporting empirical combination antibiotic therapy is weak and does not include high quality randomised clinical trials (rcts). objectives: to assess benefits and harms of empirical mono-vs. combination antibiotic therapy in adult patients with severe sepsis in the intensive care unit (icu). methods: we performed a systematic review according to the cochrane collaboration methodology, including meta-analysis, risk of bias assessment and trial sequential analysis (tsa). we included rcts assessing empirical mono-antibiotic therapy versus a combination of two or more antibiotics in adult icu patients with severe sepsis. we exclusively assessed patient-important outcomes, including mortality. two reviewers independently evaluated studies for inclusion, extracted data, and assessed risk of bias. risk ratios (rrs) with % confidence intervals (cis) were estimated and the risk of random errors was assessed by tsa. results: thirteen rcts (n = , ) were included; all were judged as having high risk of bias. there was no difference in mortality (rr . , % ci . - . ; p = . ) or in any other patient-important outcomes between mono-vs. combination therapy. in tsa of mortality, the z-curve reached the futility area, indicating that a % relative risk difference in mortality may be excluded between the two groups. for the other outcomes, tsa indicated lack of data and high risk of random errors. conclusions: this systematic review of rcts with meta-analysis and tsa demonstrated no differences in mortality or other patientimportant outcomes between empirical mono-vs. combination antibiotic therapy in adult icu patients with severe sepsis. the quantity and quality of data was low without firm evidence for benefit or harm of combination therapy. introduction: de-escalation antibiotic in sepsis is associated with reduced costs and bacterial resistance. however, often it is not done. objectives: we designed this study with the primary objective to evaluate the prevalence of de-escalation in patients with severe sepsis or septic shock in an academic public hospital in south brazil. secondarily we evaluated antibiotic adequacy and cultures positivity. methods: we analyzed prevalence of de-escalation, antibiotic adequacy and culture positivity in severe sepsis and septic shock patients in an intensive care unit. results: of the patients included, de-escalation could have been performed in % of cases ( patients), but was implemented in only % of cases ( patients). among patients who received deescalation, half was for antimicrobial spectrum narrowing. the mortality was not different between patients with or without de-escalation ( . % versus . %, p = . ). empirical antimicrobial therapy was adequate in % of cases. pathogens were isolate in % of all cultures and . % of blood cultures. conclusion: the rate of empiric antibiotic adequacy was high, reflecting active institutional policy of monitoring the epidemiological profile and institutional protocols of antimicrobial use. however, the antimicrobial de-escalation could have been higher than reported. de-escalation did not impact mortality. there are few data in the literature regarding the care of severe sepsis patients in developing countries. this data can contribute to adequate treatment in this scenario. introduction: despite recent advances, appropriate initial amikacin dose in critically ill patients is still challenging. relationship between pharmacokinetic/pharmacodynamic (pk/pd) parameter peak concentration (cmax)/minimum inhibitory concentration (mic) in critically ill patients is not clear. objectives: we assessed the impact of amikacin pharmacokinetic and pharmacodynamic parameters on clinical and microbiological outcome in these patients. methods: observational prospective study. adult patients (> years) admitted to an intensive care unit (icu) with a gram negative documented infection and treatment with amikacin were included (study period: september -april ). amikacin blood samples were taken to hours after treatment started. amikacin concentration were determined using indiko® (thermo fisher scientific), and drug adjustment were based on the recommendations given by the pharmacokinetics unit (pharmacy service). clinical response, defined as sign and symptoms presented at the moment of infection diagnosis (fever, chest radiography alteration, infection biomarkers elevation and hemodynamic instability), was evaluated. ji-square and u-mann whitney test were used to compare results between treatment responders and notresponders. . mean initial dose was mg (sd: , )/day, equivalent to . ( . ) mg/kg/day. with that dose, patients ( , %) reached a cmax/mic value higher than . final treatment response was higher for those patients with amikacin cmax/mic value > ( , % vs , %; p = . ). no significant differences were reached in early treatment response (initial h) ( , % vs , %;p = , ) or days mortality ( , % vs , %;p = , ). cmax/mic values was not associated with toxicity-related treatment discontinuation ( , vs , ; p = , ). conclusions: initial cmax/mic value is associated with clinical response in those patients treated with amikacin. high initial amikacin dose may be necessary to optimize pk/pd parameters. method: in a bed mixed icu from october , to september , nosocomial infections (pneumonia, urinary tract infections, catheter-related bacteremia (crb) and secondary nosocomial bacteremia) were prospectively collected. envin-helics diagnostic criteria were applied. etiology, inflammatory response to infection, antibiotic treatment (atb t) and treatment modifications according to culture results, were analyzed. sdd was applied to all admitted patients requiring endotracheal intubation over hours. for each groups categorical variables were summarized as frequencies and percentages and number in means and standard deviations (sd) or median with interquartile ranges (iqr).percentages were compared, as appropriate, with the fisher´s exact test or x test and medians with the wilcoxon test for independent samples. for those variables that were associated with de in the univariate analysis were entered into a logistic multidimensional analysis. the model obtained was expressed by p-values and odd-ratios, which were estimated by confidence intervals at %. a hypothesis test was considered statistically significant when p-value was less than . . results: ninety patients ( , %) had atb de and did not. there were no significant differences in demographics or type of admission in both groups (fig. ) . mortality was lower in patients receiving de antibiotic (atb) ( , %, p: . ). in the multivariate analysis, icu mortality and urinary tract infection were the only variables found significant (fig. ) de was performed in out of ( , %) with crb and in out of ( , %) who had nosocomial pneumonia. the atb t was inadequate in out of infections ( , %). targeted therapy was performed in out of patients ( , %) and in out of infections, at least once occasion ( , %). finally, atb were targeted prescribed. in all studied patients with de, this was performed in patients once, in patients twice and in patients three times. the number of antibiotics used was and atb de was performed in occasions. frequency of atb used and of theirs de is shown in fig. of note, meropenem was de in , %. conclusions: patients who received atb de compared to those that did not had a significant lower icu mortality. the factors independently associated to de were icu mortality and urinary tract infection. inadequate atb t in our icu occurred in . % of nosocomial infections. atb de was performed in patients. targeted therapy was applied to , % of infections. the most commonly used antibiotics were meropenem ( , %), levofloxacin ( . %) and piperacillin-tazobactam ( , %). meropenem, was de in , %. introduction: antimicrobial prescription represents a major challenge for clinicians in the daily practice especially in certain difficult clinical scenarios. thus, in critically ill septic patients, prompt and adequate antimicrobial therapy reduces morbidity and mortality objectives: we set out to assess the impact on in-hospital of antibiotic de-escalation in patients admitted to the icu with severe sepsis or septic shock. methods: collaborative study enrolling patients admitted to the icu with severe sepsis or septic shock from two different cohorts. the first one, a spanish prospective and observational cohort and the second one, a multicenter non-blinded, randomized and non inferiority trial conducted in france. severity was estimated by the use of the predicted mortality rate at icu admissionfor every included patientby implementing the likelihood of death logit formule defined according to the apache ii and saps ii scores criteria and taking this cuantititative variable into account as a confounder factor in the regression model. de-escalation was defined as discontinuation of an antimicrobial agent or change of antibiotic to one with a narrower spectrum once culture results were available. to control for confounding variables we performed a multivariatebinomial logistic regression analysis adjusted by wald test. results: nine hundred and one patients with severe sepsis or septic shock at icu admission were treated empirically with broadspectrum antibiotics. eight hundred and seventeen patients were evaluated ( died before cultures were available). de-escalation was applied in patients ( . %). we found no differences in hospital long of stay between de-escalation group comparedto those who did not received it. we also found a significant lower hospital mortality in de-escalation group in front of the others ( . vs. . %; p < . ). by multivariate analysis (adjusted by severity scores-apache and saps), factors independently associated with in-hospital mortality were age (odds-ratio [or] . ; % confidence interval [ci] . - . ), and sofa score at icu admission (or . ; % ci . - . ), whereas de-escalation therapy was a protective factor (or . ; % ci . - . ) as well as urinary focus (or . ; % ci . - . ). analysis of the patients with etiological diagnosis revealed that the factors associated with mortality were age and sofa and conversely de-escalation therapy was a protective factor (or . ; % ci . - . ) conclusions: de-escalation therapy for septic critically ill patients is a safe strategy associated with a lower mortality. efforts to increase the frequency of this strategy are indeed justified. introduction: at the population level, both vancomycin and aminoglycosides are known to be nephrotoxic. the risk of nephrotoxicity might even be higher when combining the agents together ( ). nonetheless, in septic patients, the benefit in terms of sepsis control may outweight the risk of nephrotoxicity. thus, being able to appraise the risk/benefit ratio at the patient level would be of great interest to better tailor individual treatment. objectives: capitalizing on recent statistical innovations in personnalized medicine, our goal was to develop a patient-centered estimation of the impact of the association vancomycin/aminoglycosides on the kidney function. methods: our data come from a cohort study performed between and in the departments of anesthesia, critical care and cardiovascular surgery at a french teaching hospital. this study included all consecutive patients operated for an acute endocarditis ( ). the primary endpoint was postoperative evolution of the kidney function as evaluated by the akin score (stade : elevation in serum creatinine (srcr) ⩾ . μmol/l or ⩾ , xbaseline; stade : elevation in srcr ⩾ xbaseline; stade : elevation in srcr ⩾ xbaseline or creatinine ⩾ μmol/l with increase > μmol/l or need for rrt). the impact of vancomycin/aminoglycosides on kidney function was estimated using targeted maximum likelihood estimation on a risk difference (rd) scale. the association between patient characteristics and the individual effect of the drugs on the kidney function was estimated using conditional recursive partitioning (ctree). results: patients were included in the study. their baseline characteristics are described in table . at a population level, we confirmed the strong association between vancomycin + aminoglycosides and the risk of kidney dysfunction (rd = . , %ci: . - . , p < . ). however, at the patient level, this effect was very variable and could be predicted based on patients characteristics (r = . ) (figure ). conclusions: the individual impact of vancomycin + aminoglycosides on kidney function may be very different than the overall effect at the population level. innovant statistical approaches may be used to identify patients in whom this drug combination is safe, and others in whom it may seriously threaten kidney function. introduction: catheter-related bloodstream infection (crbsi) is one of the most frequent nosocomial infections in critically ill patients, resulting in a significant increase of morbidity and mortality. that is why it is essential to detect crbsi precociously so that optimal treatment can be initiated as soon as possible. objective: our objective is to evaluate the effectiveness of rapid non-invasive tests that may allow clinicians to detect colonisation of the central venous catheter (cvc) as a source of bloodstream infection in critically ill patients, permitting catheter withdrawal and the initiation of early goal-directed antibiotic therapy. methods: over the course of eight months, we selected for evaluation those critically ill patients admitted to our icu who developed fever (> °c) without source, to whom the clinician in charge decided to withdraw the cvc. before extraction, we obtained a skin smear at the insertion site, in addition to a catheter-hubs smear. we sent both smears, along with the catheter tip and blood cultures, to the microbiology laboratory. these results indicate that our test has a negative predictive value of %. to evaluate the degree of association between our test and the gold standard, we calculated the contingency coefficient, which resulted in , out of a maximum , (p < , ). this shows the strong validity of the combination of skin and catheter-hub cultures as a diagnostic method for cvc colonisation. conclusions: the combination of skin and catheter-hub cultures is a rapid and very effective method for detecting the colonisation of cvc as a possible source of bloodstream infection in critically ill patients. while a negative result, which can be obtained within h, would prevent the need for cvc withdrawal, a positive result would not only enable the removal of the likely source of infection, but it would also allow for, if the intensivist deemed it necessary, the initiation of early goal-directed antibiotic therapy. this would mean, in more than % of cases, starting optimal treatment at least hours prior to the diagnosis of crbsi from blood cultures. results: introduction: piperacillin/tazobactam (ptz) is a β-lactam-β-lactamase inhibitor combination with a broad spectrum of antibacterial activity. βlactams are time-dependent antibiotics and their effectiveness is in association with the duration of free drug concentrations over the minimum inhibitory concentration (t > mic) of organisms. prolonged infusion has a pharmacokinetic (pk) advantage compared to intermittent bolus dosing, a continuous infusion lower dose of g ptz may be as effective as a higher dose of intermittent bolus ptz. objectives: in this study we intend to evaluate the continuous infusion of / grams of ptz along with a loading dose of / , grams in patients admitted in a tertiary icu. methods: between october and december eight patients had piperacillin plasma concentration monitored during treatment with continuous ptz infusion in a monocentric prospective observational study. patients received a loading dose of / , grams of ptz followed by infusion of / grams, reconstituted in ml sodium chloride , % and transferred to braun space infusion system®. the pump had a flow rate of ± ml/h. blood was always extracted from the contralateral arm to the infusion, over hours at predetermined times. serum piperacillin/tazobactam concentrations were determined using an hplc method ( ). after extraction, samples ( μl) were injected into a xbridge c column (waters, spain) and were scanned by an uv detector at nm with gradient elution. mobile phase was composed by acetonitrile and a solution of tetrabutylammonium bisulfate ( g/ l). penicillin g was used as internal standard (sigma aldrich, spain). results: patients have been examined ( men and women). the average age was ± , the weight was ± kg, the creatinine clearance ± ml/min and the apache ii score , ± , . the mean concentrations of ptz in serum are represented in the next figures. conclusions: in this icu patient group, our results suggest that continuous infusion of ptz at / g per day is sufficient to obtain therapeutic plasma-concentrations in critical care patients with infections caused by ptz sensitive bacteria with a mic lower than mg/dl. however, in our group there were three patients with levels of mg/dl, which are not sufficient for bacteria with mic lower than mg/dl; these three patients are neurocritical. in conclusion, further studies in this are needed, especially studies regarding the association between piperacillin therapeutic drug monitoring and clinical outcome. introduction: ultrasound guided internal jugular vein cannulation is recommended technique in current anaesthesia and intensive care practice. however, classic short axis view has inherent problem of needle visualization during venous access. in contrast, medial oblique view may enhance needle visibility during venipuncture and decrease overlap between ijv and carotid artery and thereby increase the safety of us guided ijv cannulation ( ) ( ) . objectives: to compare the safety and efficacy of medial oblique view and in-plane technique as compared to short axis view and out-of-plane technique during us guided ijv cannulation. methods: two hundred patients aged between - yrs of either sex and american society of anesthesiologists' physical status i-ii who were undergoing any surgery under general anaesthesia requiring an internal jugular vein cannulation, enrolled for this prospective randomized controlled trial. three patients were excluded due to us machine malfunction. in patients of group m, ijv cannulation was performed with medial oblique probe position and in plane approach. in patients belonging to group s, ijv cannulation was done in out of plane approach with the us probe in short axis position. primary outcome was needle and guide-wire visibility during procedure. results: needle visibility (entire needle tract and needle tip) was significantly higher during ijv puncture in medial oblique probe position ( of patients in group m versus of patients in group s; p = . ). guide wire visibility during insertion was also higher when medial oblique probe position was used ( of in group m versus out of ; p = . ). first insertion success rate for ijv puncture, incidence of posterior wall of ijv puncture and time to cannulation were similar both the groups. no serious complications such as carotid artery puncture, haematoma formation and pneumothorax were reported. conclusions: medial oblique view may increase safety of us guided ijv cannulation in comparison to short axis view by increasing needle visibility during puncture. resuscitation "philosophy" shifted from being heart oriented towards brain oriented since its delay may increase neurological deficits . recent studies are highlighting the role of the bystander-cpr as a critical variable affecting ocha neurological outcome. , objectives: two step prospective interventional observational study to assess the role of the bystander-cpr in affecting neurological outcome in our ohca population. introduction: there is a clear rationale for monitoring microcirculatory behaviour during shock since it is the anatomical location of oxygen and substrate exchange, and may not correspond to global haemodynamics. and yet despite over a decade of research and technological advances such monitoring has not reached clinical bedside utility. analysis of the data is performed offline and too time consuming for clinical use. there is an urgent need for a system to assess the microcirculation at the bedside. we present a novel -point grading system (the point-of-care microcirculation (poem) scoring system) that can be used at the bedside (using sublingual microcirculatory monitoring). objectives: to assess the inter-user variability of the novel poem scoring system amongst doctors and nurses who may use such technology for clinical practice, and to benchmark poem scores against traditional offline computer analysis. methods: the poem score is an ordinal scale from (worst) to (best), and calculated based on assessment of individual video clips. online calculator found at: www.poemscore.com. thirtytwo naïve study participants from two uk teaching hospitals (birmingham and london) participated in a standardised -hour interactive training session in how to assign poem scores based on microcirculatory video clips from sublingual incident dark field (idf) videomicroscopy imaging. they were then asked to assign scores for different video sequences (each of varying clinical status, played in a random order). they were blinded to clinical status. inter-user consistency and agreement were assessed using intra-class correlation coefficient (icc) analysis. blinded expert poem scores were also validated against offline computer analysis of the same clips using traditional microcirculatory parameters, and the time taken to assign each was recorded. results: raters showed good inter-rater consistency (icc . , % ci . , . ) and agreement (icc . , % ci . , . ) for assigned poem scores. expert poem scores correlated well with offline analysis but took far less time to assign (mean times of minutes versus minutes; p < . ). conclusions: a new -point ordinal scale of microcirculatory function has been tested amongst 'front line' emergency physicians and nurses at two large uk teaching hospitals, and has minimal inter-user variability, even after just hour of training. poem scores take a matter of minutes to assign, and correspond well to computer-analysis variables. we present for the first time a bedside microcirculatory grading system that is quick, reliable, and gives potentially meaningful clinical parameters that might guide resuscitation. prospective randomised trials utilising goal directed therapy using the poem score are required to test its reallife clinical utility. introduction: vocal cord palsy is a known postoperative complication following cardiothoracic surgery. , . although the incidence is relatively low its existence cannot be ignored and thus its identification necessary in order to avoid any further complications and maintain patient wellbeing. this study aims to look at the incidence of vocal cord palsy following cardiothoracic surgery in a tertiary referral centre and highlight the importance of the speech and language therapist's role in working with this cohort. objectives: to measure the incidence of vocal cord palsy post cardiac and thoracic surgery and to identify the consequent effects. methodology. a retrospective analysis, within a tertiary cardiothoracic centre. data for all patients who underwent either a cardiac or thoracic surgical procedure between december and april and were referred to speech and language therapy (slt) was collected. vocal cord palsy was identified by fibreoptic endoscopic evaluation of swallowing (fees) or bronchoscopy. results: a total of patients were seen by the slt. patients with vocal cord palsy were identified by fees and bronchoscopy; % and % respectively. six patients assessed presented with vocal cord palsy; patients were post cardiac surgery ( / ) and post thoracic surgery ( / ). the consequence of vocal cord palsy was dysphonia in all the patients and dysphagia in two thirds of patients. the median duration that patients experienced dysphagia was days (range - days) and dysphonia was days (range - ). conclusion: this review highlights the high prevalence of vocal cord palsy post cardiothoracic surgery. vocal cord palsy led to high levels of dysphagia and dysphonia. early identification of these is imperative to ensure patient safety and optimise recovery and quality of life. ) . . % were over years old at the moment of the surgery. figure shows previous cardiac clinical history figure shows other relevant comorbidities. it was first surgery in . % of the patients. , % of the cases were valvular surgery (with or without cabg); , % were isolated cabg; , % thoracic aortic surgery; , % were other surgeries (congenital disease surgery, post ami complications, pericardiectomy). tables and summarizes the results of the application of sf- questionnaire in the patients interviewed in the follow up in the comparative analysis we found worse qol in women than men (p = , ), and a negative correlation between age and qol (p = , ). women in our study were significantly older than men (p = , ). we found no differences between the type of surgery and the postoperative qol, or between surgery or extracorporeal circulation duration and qol. there was a relationship between nyha degree during the follow up and the sf health score prognostic scores showed an inverse relationship with qol, but with a low correlation; pearson coefficient − , (euroscore), − , (saps ). conclusions: in our study, involving hospitals in andalusia (south spain), , % of cardiac surgery patients didn´t show any activity limitation or only a slight limitation before years of follow up. perceived quality of life decreases as age increases or worsens the functional status of the patients. conclusion: concsultation for the severely ill cases in the wards take very much time of the intensivits. it was seen that consultation request was mostly emergent and due to respiratory problems and sepsis. maybe we need another system like rapid response team for decrease the insivists work and decrease the mortality amd morbidity. the limitation of the beds in icu is one of the most important problem, and there must be more empty beds for inhospital emergencies. an external validation study of the qsofa score to predict inhospital mortality in medical patients with infection and derivation of a new enhanced score using automatically available variables: news-hazard l. introduction: sepsis has recently been redefined as´life-threatening organ dysfunction caused by a dysregulated host response to infec-tion´. it is one of the leading causes of mortality internationally. earlier identification of sepsis means more timely management, reduced length of hospital admission, and prevention of septic shock; ultimately reducing sepsis associated mortality. ( ) there is currently no standard diagnostic test for sepsis. distinguishing sepsis from alternative, uncomplicated infections is pertinent to ensuring an appropriate clinical approach. systemic inflammatory response syndrome (sirs) criteria have been used since to define sepsis (sepsis . ). however they have been found to lack sensitivity or specificity. the quick sequential organ failure assessment score (qsofa) is an emerging initial assessment method that uses three simple bedside criteria to measure organ dysfunction; altered mental status, respiratory rate ≥ and systolic blood pressure ≤ mmhg. the aim is to facilitate earlier recognition of sepsis outside of itu by prompting the clinician to think, and adequately screen for sepsis. in cases, the diagnosis of pneumococcal meningitis by culture or pneumococcal crp in csf was confirmed. in all cases, pneumococcus antigen was positive. therefore, there were no false negatives. in cases pneumococcal meningitis was not diagnosed, being the final diagnosis a non-pneumococcal bacterial meningitis or another pathology. in all cases, pneumococcus antigen was negative. therefore, there were no false positives. in conclusion, in our sample of patients, the sensitivity and specificity of the test for s. pneumoniae antigen in csf was %. the ppv and npv were also %. conclusions: in our series, the sensitivity and specificity of the test for s. pneumoniae antigen in csf by immunochromatography ( binaxnow® test ) was %. the vpp and vpn were also %. these results are similar to those reported previously in the literature. knowing the reliability of this fast, simple and inexpensive test, will allow to remove unnecessary isolation and to establish a more specific treatment and a better prognoses of the disease. evaluation of sensitivity and specificity of different criteria using for diagnosis of burn sepsis and without these (group № , n = ). logistic regression was performed to identify the independent factors for the prediction of early death ( days and less). we examined sensitivity and specificity with area under the receiver operating characteristic curve (roc auc). results: there were no significant differences between two groups for demographics, burn size, inhalation injuries. fatal outcome came early in the group № (mean icu length of stay , days vs days, p < , ). organ dysfunction at day was significantly higher in the group № (mean sofa , vs , ; p < , ). there were no significant differences in aba, fsbi and cdbs between two groups, and the highest auc were for cdbs by the day (auc , % ci , - , vs , % ci , - , and , % ci , - , for cdbs, aba and fsbi, respectively). sirs criteria were significantly higher in the group № , auc was , ( % ci , - , ) but specificity and sensitivity was too low (for sirs criteria is , % and %, respectively). independent factors for early death include: more than % immature neutrophils at the day , sofa more than by the day , thrombocytopenia less than by the day . conclusion: patients without specific pathomorphological signs of sepsis have more severe organ dysfunction, greater number signs of systemic inflammation and earlier fatal outcome. diagnostic model of sepsis by chinese experts has more sensitivity and specificity for diagnosis of burn sepsis confirmed by autopsy. immature neutrophils count, thrombocytopenia and sofa score are stronger risk factors for early death. the value of neutrophil to lymphocyte count ratio in diagnosing blood-stream infection s. involved microorganisms: s. pneumoniae and n. meningitidis in communitary abm, s. epidermidis and gram-negative bacilli in nosocomial abm. when comparing both groups, only we observed difference in the c-reactive protein at admission ( ± , in nosocomial abm vs , ± , in communitary, p , ). there were differences with other variables but were not statiscally significant. so, we observed a higher mortality in nosocomial abm group but the difference was not statistically significant (p , ). global icu mortality was % ( ) and hospital mortality was , % ( ). conclusions: the demographic and bacteriological profiles of patients with acute bacterial meningitis have changed in the last years mainly due to the expansion of neurosurgical procedures. still has a high morbidity and mortality. the detection of microbial dna but not cultured bacteria is associated with increased mortality in patients with suspected severe sepsis -a european multi-centre observational study m. introduction: sepsis is a leading cause of worldwide mortality. blood culture results poorly discriminate the mortality risk in critically ill patients with sepsis. here we aimed to determine whether the detection of microbial dna in the blood stream of patients with suspected sepsis was associated with mortality. we performed an analysis of data collected during the rapid diagnosis of infections in the critically ill (radical) study ( ) . patients were considered eligible for this study if they developed suspected sepsis and were either in or were referred for treatment to one of nine intensive care units (icus) in six european countries. when initial blood cultures were taken for clinical indications an additional blood sample was obtained for a culture-independent polymerase chain reaction/electrospray ionization-mass spectrometry (pcr/esi-ms) assay. the results of the pcr/esi-ms test were not communicated to the treating clinicians. results: of the patients analysed in the original study outcome data, blood culture results and pcr/esi-ms results were available for patients (table ) objectives: to evaluate if a "bundle" consisting of a sirs and organ failure (sof)-triage, flow chart response and alert system, and a sirs/ sepsis training course for all wards nurses improved clinical observations, lead to fewer patients developing severe sepsis, decreased length of stay in the high-level care (los) and increased survival. methods: a before and after intervention study in one emergency and community hospital within the mid-norway sepsis study catchment area. all patients with confirmed blood stream infection (bsi) and evidence of sepsis have been prospectively registered continuously since . the severity of sepsis, observation frequency of vital signs, treatment data, los and mortality were retrospectively registered from the patients' medical journals until end . results: the pre-intervention group was patients with confirmed bsi from jan to dec (n = ) whilst the postinterventions group was recruited between nov to dec (n = ). the nurses' observation frequency of vital signs increased in bsi patients with and without severe organ failure comparing these periods. the post-intervention group had, in average, . days shorter los. patients admitted without severe organ failure in the post-intervention group had a lower probability of developing severe organ failure ( . , % ci . - . ) than the pre-intervention group. adjusted for differences in disease severity the post-intervention group also had higher odds of surviving days (or . , % ci . - . ). conclusion: a sepsis specific triage-, flow chart alert and treatment system was an effective tool to increase ward nurses recognition and early treatment of patients with confirmed bsi. in addition to increased survival, the shorter los is important from a hospital perspective in term of resource utilization. this study was supported by the liaison committee between nord-trøndelag hospital trust and nord university introduction: the endotoxin activity assay (eaa™; spectral diagnostics inc., toronto, canada) is a rapid in vitro diagnostic test of the neutrophil's reaction to endotoxin and reflects the endotoxemia ) . recently, eaa is used to confirm endotoxemia such as in the euphrates (evaluating the use of polymyxin b hemoperfusion in a randomized controlled trial of adults treated for endotoxemia and septic shock) trial study in north america ) . however, eaa has not been routinely used to diagnose sepsis, yet. objectives: our hypothesis is eaa is useful to diagnosis for new definition's sepsis due to gram-negative infection. methods: the present study is a single-center retrospective observational analysis. of all adult patients in whom eaa was measured at our medico-surgical icu from july to july , patients with new definition's sepsis in were included in this study. new definition's sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection which is identified with total sofa score of or greater ) . patients were divided into two groups, ) with gram-negative organisms in some cultures and ) with no gram-negative organisms in any cultures. age, sex, body temperature (bt), wbc, crp, procalcitonin (pct), sofa score, and eaa values were compared between two groups. values are expressed as mean ± sd. data was analysed by chi-square test and unpaired students t-test. p values less than . were considered significant. results: five hundred and twenty seven patients ( men and women; mean age . ± . years) were studied. there were ) patients with gram-negative infection and ) patients with no gram-negative infection. eaa values and sofa score were statistically significant differences between gram-negative infection and no gram-negative infection ( . ± . vs. . ± . , p = . , . ± . vs. . ± . , p < . , respectively). pct was different but did not reach to statistically differences between two groups ( . ± . vs. . ± . , p = . ) and age, sex, bt, wbc were no significant differences between two groups. patients and methods: mechanically ventilated patients with severe sepsis/septic shock, treated in icu, were included in this prospective observational study. exclusion criteria were mechanical ventilation for more than hours prior icu admission and brain death. clinical and laboratory data were recorded, on a daily basis. thrombocytopenia was defined as a plt below x /μl. thrombocytopenia was considered as mild ( x /μl ≤ plt < x /μl), moderate ( x /μl ≤ plt < x /μl), or severe (plt < x /μl) depending on plt counts. serum levels of ifnγ, il- , icam, vcam, and soluble urokinase plasminogen activation receptor (supar) were estimated by using luminex xmap technology. results: fifty-six out of ( %) patients enrolled in the study were thrombocytopenic at the time of admission in icu. the overall incidence of thrombocytopenia during icu hospitalization was %, while mild, moderate, and severe thrombocytopenia developed in ( %), ( %), and in ( %) respectively. patients with severe thrombocytopenia had higher apache score, higher serum icam, il- and supar levels, higher incidence of bacteremia and higher probability to present with septic shock as compared with patients with normal platelet counts. moreover, severe thrombocytopenia was associated with statistically significantly higher hospital mortality. patients with severe thrombocytopenia showed significant higher serum icam (p < . ), il- (p = . ), and supar (p < . ) levels respectively, as compared to patients with normal platelets count, or patients with mild or moderate thrombocytopenia. in multivariate analysis, higher apa-che score, thrombocytopenia, and higher serum supar levels were statistically significantly associated with a higher risk of icu mortality. enrolled patients were stratified in different groups according to their apache ii score (apache ii > ), plt counts (plt ≤ . ) and serum supar levels (supar > . ). in multivariate analysis, this new scoring system remained the only and most significant factor associated with statistically significantly increased icu mortality [or = . , ( % ci, . to . ), p < . ]. conclusion: severity of thrombocytopenia in severe sepsis and septic shock parallels the severity of inflammation and subsequent endothelial dysfunction and is associated with higher mortality. the and il- α, were measured and compared between immediately before the first pmx-dhp therapy, before the second pmx-dhp therapy and after pmx-dhp therapy. human cytokine elisa plate array i (chemiluminescence) are used the plate which of cytokine capture antibodies are coated on wells respectively. each cytokine value is shown as relative light units of luminescence. values were expressed as mean ± sd. data were analyzed by wilcoxon signed-ranks test. a p < . was considered as statistically significant. results: all results were provided in about hours after starting this assay. one measurement of all cytokines costed $ . . tnf-α and mcp- values were significantly decreased between immediately before and after the second pmx-dhp therapy ( . ± . vs. . ± . , . ± . vs. . ± . , p < . , respectively). il- , il- and mcp- were also significantly decreased between before the second and after pmx-dhp therapy ( . ± . vs. . ± . , . ± . vs. . ± . , . ± . vs. . ± . , p < . , respectively). there were no statistically significant differences between before and after pmx-dhp therapies in other cytokines. the present study has some limitations because of a retrospective analysis and numbers of patients. however, human cytokine elisa plate array i is a fast and low-cost assay compared with the previous elisa method. and several cytokines are evaluated with one sample at the same time. this assay could be useful especially for the clinical research because small volumes of sample allow to several cytokines' information at the bedside. introduction: critical illness-acquired myopathy in rats is characterized by homogeneous muscle atrophy ( ). conversely, histological abnormalities are heterogeneous: oxidative muscles show patchy alterations (myofascitis, necrosis), while glycolytic types demonstrate normal patterns. akt and mtor are key proteins of the anabolic pathway, leading to myocyte growth when activated. conversely, ampk and foxo are key proteins of the catabolic pathway, leading to myocyte atrophy when activated. whether anabolic or catabolic pathway activation is dependent on skeletal muscle type (i.e. oxidative and glycolytic) during critical illness is unknown. objectives: to characterize activation of the anabolic and catabolic signalling pathways in a long-term rat peritonitis model by skeletal muscle type. methods: male wistar rats were followed for up to weeks after intraperitoneal injection of the yeast cell wall constituent, zymosan or n-saline. soleus (oxidative, slow twitch muscle), and gastrocnemius (mixed glycolytic-oxidative, fast twitch muscle) were harvested from both zymosan and control groups at , and days after the insult. expression of phospho-(p-) and total proteins were assessed by western blots. expression of akt, p-akt (p-threonine , active form), mtor, p-mtor (p-serine , active form), ampk, p-ampk (pthreonine , active form), foxo , and p-foxo (p-threonine , inactive form) were assessed at all time points. results: weight loss was not statistically different in soleus versus gastrocnemius in the zymosan group (− ± % versus − ± %, p = . ) at day . gastrocnemius displayed a decrease in p-akt at day , and an increase of p-akt and p-foxo at day . soleus displayed an increase of p-akt, p-ampk, and p-foxo at day , and an increase of p-ampk, and p-foxo at day . results are detailed in the table . conclusions: in a rodent model of long-term peritonitis, both oxidative and glycolytic muscles display little change in the anabolic signalling pathway. ampk (an autophagy activator) is activated while foxo , (an autophagy and ubiquitin-proteasome system activator) is inhibited up until day in oxidative but not glycolytic muscle. introduction: esophageal pressure (p es ) guided setting of peep has been described in ards patients either to avoid expiratory alveolar collapse or to promote maximum inspiratory recruitment . the proportion of ards patients that may benefit from maximum recruitment strategy and its effects regarding dead space (v d /v t ), shunt, driving pressure (dp), transpulmonary driving pressure (tpdp) and expiratory transpulmonary pressure (tpp exp ) remain unclear. methods: we included moderate and severe ards patients under mechanical ventilation and paralyzed, in the first hours after reaching ards criteria. patients were monitored with esophageal balloon catheter and ventilated with express study settings for hour after recruitment maneuver. then peep was modified to obtain an inspiratory transpulmonary pressure (tpp insp-p ) based on p es between and cmh higher peep in group b led to higher plateau pressure and tpp insp-p , positivation of tpp exp without increase in v d /v t (p = . ), shunt (p = . ), dp (p = . ), tpdp (p = . ) or oxygen stretch index (p = ). however agreement between tpp insp-p and tpp insp calculated from respiratory motion equation and chest wall elastance (tpp insp-e ) was weak with band-altman bias (tpp insp-e -tpp insp-p ) = . ± . [ %ci − ; ]. conclusions: p es measurement in moderate to severe ards patients distinguishes groups of patients in whom peep appears to be taylorized without side-effects. however physiologic studies should assess reliability of transpulmonary measurement based on either p es or chest wall elastance. introduction: to optimize mechanical ventilation different targets are used including tidal volume (tv), peak and mean airway pressure and peep. however, prevention of alveolar collapse not only depends on intra-pulmonary, but also on the extra-pulmonary pressure (epp). epp can be estimated by measuring esophageal pressure (ep). ventilator strategies aiming at optimized trans-pulmonary pressure tpp (difference between intra-and extrapulmonary pressure: tpp = tip-tep) have been shown to improve outcome. tpp-guided ventilator setting might be useful in patients with liver cirrhosis and ascites. however, the impact of paracentesis on tpp is poorly investigated. objectives: to investigate the impact of high volume paracentesis (hvp; ≥ ml) on tpp and on other parameters of pulmonary and circulatory function. methods: analysis of hvp-procedures in patients ventilated with the avea viasys ventilator (carefusion, usa) capable to measure ep via an esophageal tube. haemodynamic monitoring with the picco- -device (pulsion medical systems se, feldkirchen, germany) was available during measurements. intra-abdominal pressure iap was determined by intra-peritoneal (iap_p) and intra-vesical (iap_v) pressure measurement. high grade esophageal varices had been excluded endoscopically before measurement of ep. statistics: spss . results: male, female patients, aetiology of cirrhosis alcoholic (n = ), viral ( ) and cryptogenic ( ) . age ± years, apache-ii ± , sofa ± , meld ± . paracentesis of ± ml resulted in marked increases in inspiratory ( . ± . vs. . ± . ; p < . ) and expiratory (− . ± . vs. - . ± . cmh o; p < . ) tpp. in parallel inspiratory ( . ± . vs. . ± . cmh o; p < . ) and expiratory ( . ± . vs. . x ± . cmh o; p < . ) ep significantly decreased. paracentesis resulted in decreases in iap_p ( . ± . vs. . ± . mmhg; p < . ), iap_v conclusions: paracentesis markedly increases inspiratory and expiratory tpp in parallel with a decrease in iap. increased iap before paracentesis resulted in markedly decreased inspiratory and endexpiratory tpp despite ventilation according to the ardsnet guidelines. to avoid decreased end-expiratory tpp and alveolar collapse in patients with increased iap, paracenteses and/or higher peep-setting should be used. iap and its changes markedly confound cvp, but neither gedvi nor ci. introduction: if the proportional assist ventilation(pav) level is known, then muscular effort can be estimated from the difference between peak airway pressure and peep (△p) during pav. namely, p mus, peak, aw = (p aw, peak -peep) x ( -gain)/gain. pressure time product estimated from airway (ptp aw ) = p mus, peak, aw x inspiratory time/ x respiratory rate [ ] . objectives: validation of this hypothesis by using the esophageal pressure time product calculation. methods: eleven mechanically ventilated patients who received esophageal pressure monitoring under pav were enrolled. patients were randomly assigned to seven pav assist levels ( - %, pav means % pav gain) for minutes. maximal muscular pressure (p mus, peak, es and p mus, peak, aw ) and pressure time product (ptp es and ptp aw ) estimated from △p and esophageal pressure were determined from the last minute of each pav level. results: pav significantly reduced the breathing efforts of patients with increasing pav gain (ptp es . ± . at pav vs. . ± . cmh o•sec/min at pav , ptp es, peepi . ± . at pav vs. . ± . cmh o•sec/min at pav , p < . ). p mus, peak, aw overestimate p mus, peak, es in pav of low gain (pav ) and underestimate in pav of moderate to high gain (from pav to pav ). linear regression analysis revealed that the slope ptp es, br (ptp es per breath)/p mus, peak,es for ptp es, peepi is . (r = . ), for ptp es is . (r = . ), and ptp aw, br (ptp aw per breath)/p mus, peak, aw for ptp aw is . (r = . ). conclusions: adjustments should be made when extrapolating ptp aw into ptp es . an additional % should be added when extrapolating ptp es from p mus, peak, aw and an additional % should be added when extrapolating ptp es, peepi from p mus, peak, aw , assuming p mus, peak, es and p mus, peak, aw are equal. introduction: airway occlusion pressure is a noninvasive measure of motor neural output. if the airway is occluded, the change in pressure in the pleural space and at the airway open, both are equivalent objectives: we studied the similarity of effort and work of breathing measure with pesophageal (peso) at regular cycles, versus inadvertent airway pressure (paw) occluded during end-expiration (paw_occl). methods: esophageal, airway pressure and airway flow, sampling hz, were registered in patients during weaning time, with levels of sedation ramsay , at pressure support ventilation (psv) with differents levels of assistance (high: - cmh o, medium: - cmh o, low: - cmh o). respiratory effort was quantified using pressure-time product (ptp/min) with esophageal and occluded cycle (figure ), and wob_occlusion, using the occlusion pressure with the flow of preceding, not occluded, cycles ( figure ). the work of breathing esophageal referent (wob_peso, j/l)) is obtained from integral of peso versus differential of volume. also we are calculated Δ peso and Δ paw_occl as additional parameter. for all data, the bland-altman analysis and linear regression was applied. the results are expressed as mean ± sd, the comparison was made by t-test. results: a total of paired measures were obtained. the mean comparison of the respiratory effort and work did not show showed statistical differences for all data, except for low assistance (table ) . a good correlation between both measures methods was observed for ptp and wob (r = , and , ; respectively). the mean bias was for ptp and wob: , (± , ) cmh o*sec/min and , (± , ) j/l, respectively; and the % limits of agreement were − , to , cmh o*sec/min and − , to , j/l, respectively; this indicates wide dispersion. conclusions: airway occlusion pressure is a noninvasive procedure that could be useful to assess the effort and work of breathing patients during mechanical ventilation. introduction: chest wall elastance (ecw) is thought to increase in prone (p) as compared to supine (s) position in ards patients ( ) ( ) ( ) . this makes respiratory system elastance (ers) not reflecting lung elastance (e l) . little is known about the changes of ecw, e l and lung resistance (r l ) when moving the patient from the supine to the prone position via the lateral (l) position ( ) ( ) . objectives: the goal of present study was to measure ecw, e l and r l in ards patients in s, l and p position during the proning procedure. methods: ards patients intubated, sedated and paralyzed with an indication of p positioning were included. mechanical ventilation was delivered in volume controlled mode with constant flow inflation. end-inspiratory pause of . sec was set during the breathing cycles. ventilator settings were unaltered during the procedure. airway and esophageal pressures and airflow were continuously measured during minutes in s, then during minute in l and minutes in p. the side for the lateralization was that selected by routine practice (in the opposite side from central venous line). prone positioning was performed manually by caregivers. ecw, e l and r l were obtained by fitting the first order equation model to flow and pressures signals. values are expressed as mean ± sd. results: fifteen patients ( males) of ± years, saps ± and sofa ± were included ± days after ards criteria ( moderate and severe) were met. tidal volume averaged ± . ml/kg predicted body weight, peep ± cmh o, fio ± %, pao /fio ratio ± mmhg. the cause of ards was pneumonia in cases, undetermined in cases. side positioning was the right in and the left in patients. the results are shown in the table . conclusions: during prone positioning in ards patients, as compared to s we observed an increased r l and e l in l and increased ecw in p. introduction: driving pressure of respiratory system (Δp) is defined as the difference between plateau pressure (pplat) and total positive end-expiratory pressure (peeptot) measured after endinspiratory and end-expiratory occlusion, respectively, on airway pressure signal. Δp has recently been shown as a strong predictor of mortality in patients with acute respiratory distress syndrome (ards) ( ) . most of the studies involved in this demonstration measured pplat . sec after onset of endinspiratory pause according to the arma trial ( ) and used peep set on the ventilator (peepvent) instead of the peeptot. this does not take into account slow decay of airway pressure after endinspiratory occlusion and instrinsic peep, respectively. objectives: the aim of the study was to compare Δp when pplat was measured at different times after end-inspiratory pause and whether peeptot or peepvent were used. our hypothesis was that Δp was *p < . versus supine **p < . versus supine higher with pplat measured at . and peepvent than with any other combinations of pplat and peeptot. methods: a retrospective analysis of patients with ards in whom respiratory mechanics was measured. most of the patients had recordings at two levels of peepvent. data were analyzed with acqknowledge software. pplat was measured at . , and seconds after end-inspiratory pause. peeptot was measured after a -sec end-expiratory pause. the low-peep and high-peep measures pertained to peepvent ≤ cmh and peepvent > cmh , respectively. the primary outcome was the comparison of Δp calculated as pplat . sec -peepvent : Δp reference versus Δp computed as pplat sec -peeptot: Δp physiologic . the values are expressed as mean ± sd and are compared by using signed rank test for paired values, anova for repeated measures and bland-altman. results: twenty-three patients were analyzed. Δp reference was significatively higher than Δp physiologic in low and high peep groups: . (± . ) vs . (± . ) cmh o (p < − ) and . (± . introduction: end expiratory lung volume (eelv) is reduced in ventilated patients especially in patients with acute respiratory failure (arf). recruitment maneuvers and different levels of peep are used to restore eelv and to improve oxygenation. however; no matter how useful is the value of eelv in clinical practice his bedside measurement at baseline, at different levels of peep and after recruitment maneuvers is cumbersome. we measured the eelv with two techniques and we noted the technical problems and pitfalls. methods: we measure the eelv in patients with arf at two levels of peep ( and cm h o) with two techniques. with a dilutional nitrogen wash in and wash out method using the carescape r ventilator (ge) and by measuring the expired lung volume after a sudden release of peep to zero peep (zeep). specifically after min of stabilization at each level of peep we performed an expiratory hold and we decrease the ventilator frequency to zero to obtain sufficient time for a complete expiration. therefore, by releasing the expiratory hold we permit the return of the lung to his passive lung volume at zeep(passive frc).the expired volume was calculated by the integration of the expiratory flow. we call this volume Δeelv. correlation and agreement fig. (abstract a ) . variation of driving presure at low peep between the two methods with the bland and altmann analysis were performed. results: mechanically ventilated patients were studied. at zeep eelv was low ( ml) % of the predicted. good correlation was found between the two methods ( ± and ± ml respectively) when eelv was measured at cmh o of peep(r = o. , p < . ). on the contrary at cmh o of peep a wider variability and less agreement was noticed between the eelv values( ± vs. ± , r = . , p < . ). technical problems with carescape were spontaneous breathing attempts or asynchrony in the patient-ventilator interactions leading to instable vo -vco measurements. on the contrary with the release of peep method high expired volumes from peep to zeep induced high expired flow exceeding the lit/sec, thus affecting the linear sensitivity of the ventilator's pneumotachograph. conclusions: the measurement of the eelv remains a precious parameter for the ventilatory management of the icu patients but his measurement is still far away to be accurate by both techniques at bedside. low end-expiratory trans-pulmonary pressure is associated with lung collapse p. somhorst, d. introduction: the open lung concept aims to reduce lung injury due to cyclic opening and closing of alveoli. finding the 'optimal' peep to maintain an open lung proofs difficult and patient-specific. we hypothesize that targeting positive trans-pulmonary pressure (ptp) at end of expiration (ptpee) may prevent collapse. we used electrical impedance tomography (eit) clinically to optimize peep, visualizing over-distention and collapse. objectives: to show the association between collapse and low ptpee, as visualized by eit. methods: we retrospectively analyzed data of ten patients with acute respiratory distress syndrome (ards) who underwent measurement of the ptp and eit due to clinical considerations. a peep trial was performed to identify optimal ventilator settings. esophageal pressure (pes) was measured using endo-esophageal pressure balloons (cooper surgical, germany, or sidam, italy). the ptp was calculated as the continuous difference between the airway pressure and pes. eit was measured at the th/ th intercostal space (dräger, germany) and analyzed using specialized software (dräger, germany). collapse is defined as a local decrease in ventilation after a reduction in peep; over-distention is a local decrease in ventilation after an increase in peep. results: collapse was associated with a lower ptpee at lower peep levels. for most patients ( / ), collapse occurred when ptpee was ≤ cmh o. collapse was also present at a peep level of cmh o. inversely, we showed that collapse and over-distention can occur simultaneously (fig. ) . the ptpee was strongly correlated to the peep level (r = . , p < . ; corrected for each individual patient). the overall regression is shown as a dashed line. conclusions: for most ards patients, collapse did not occur when ptpee was above + cmh o. in addition, peep increase in order to prevent collapse may induce over-distention due to heterogeneity in the ventilation distribution in each patient. introduction: medical experts recommend keeping plateau pressure below cm h o to avoid ventilator-induced lung injury in patients with acute respiratory distress syndrome (ards). transpulmonary pressure (ptp), the difference between alveolar and pleural pressure, has been measured as a surrogate for plateau pressure for lung protective strategies. however, placement of an esophageal balloon catheter is required to measure esophageal pressure. objectives: we investigated the relationship between ptp and ventilator waveform parameters according to the strength of spontaneous breathing effort. methods: eight patients (four patients with ards and four with non-ards) mechanically ventilated with avea® were included in this study. an esophageal balloon catheter (avea® smartcath® esophageal balloon) was placed to measure esophageal pressure. we evaluated the relationship between Δptp (difference between inspiratory and end expiratory ptp) and peak inspiratory flow, or ti ratio (percentage of time until peak negative esophageal pressure to total inspiratory time). spontaneous breathing effort was categorized as strong or weak and was analyzed with inspiratory waveform using voxr data management software. results: although there was no significant relationship between Δptp and peak inspiratory flow (r = . , p = . ), a significant correlation was found between Δptp and ti ratio (r = . , p = . ). median Δptp and ti ratio were significantly higher in patients with strong spontaneous breathing effort compared with those with weak breathing effort ( . vs. . cmh o, p = . , and . vs. . , p = . , respectively). in patients with strong spontaneous breathing effort, median Δptp was higher in the ards group compared with the non-ards group ( . vs. . cmh o, p = . ). conclusions: measuring ti ratio and ventilator waveform parameters may be helpful to estimate ptp. appropriate sedatives, analgesics, or muscle relaxants may be required to limit ptp in cases of higher ti ratio in patients with ards. in vivo calibration of the esophageal balloon catheter: a simplified procedure f. introduction: a calibration procedure has been recently proposed to obtain reliable esophageal pressure (pes) measurements in mechanically ventilated patients [ ] . this procedure helps optimizing esophageal balloon filling and removing esophageal artifacts, but is timeconsuming. objectives: to test accuracy of a simplified procedure, designed according to average values of esophageal elastance (ees) and minimum appropriate filling volume (vmin) previously observed [ ] . methods: in patients under pressure controlled ventilation, pairs of end-expiratory and end-inspiratory calibrated pes values (pes,cal) were obtained with the standard procedure, consisting in measure of ees and detection of vmin and vbest (filling volume associated with the largest tidal swings of pes): pes,cal = pes -ees * (vbest -vmin). "simplified" calibrated pes values (s-pes,cal) were also obtained with a simplified procedure based on detection of vbest and on the assumptions that ees = cmh o/ml and vmin = ml: s-pes,cal = pes -(vbest - ). we used the nutrivent catheter (sidam, italy), equipped with an esophageal balloon that is cm long and has a ml nominal volume. results: in the conditions tested, vmin was . ± . ml, vbest . ± . ml and ees . ± . cmh o/ml. at optimal filling volume (vbest), difference between pes and pes,cal was . ± . cmh o (range . - . ). s-pes,cal strictly correlated with pes,cal (r = . ; p < . ); difference between s-pes,cal and pes,cal was − . ± . cmh o (figure ) . conclusions: when optimal filling of the esophageal balloon is adopted in mechanically ventilated patients, absolute values of pes are affected by significant esophageal artifact. a simplified calibration procedure seems to be adequately accurate in removing this artifact and suitable for clinical use. introduction: mechanical ventilation unloads the inspiratory muscles in case of high work of breathing to prevent development of muscle injury and patient discomfort. on the other hand, over-assist is associated with disuse atrophy and patient-ventilator asynchrony. two indices for assessing respiratory muscle effort have recently been published. patient-ventilator breath contribution (pvbc) index provides an estimation for the percentage of the total work of breathing performed by the patient related to the total work of breathing (patient + ventilator). neuromuscular efficiency (nme) or pressureelectrical activity index (pei) expresses how much pressure the inspiratory muscles generate (pmus) for each microvolt of diaphragm electrical activity (eadi). objectives: the aim of the current study was to assess the repeatability of both pvbc and nme and investigate how these indices changes in time in ventilated icu patients. methods: we included mechanically ventilated adult icu patients with a dedicated naso-gastric feeding tube for assessing diaphragmatic emg activity (eadi catheter). pvbc and nme were calculated at inclusion, after , and hrs and repeated times each with a -minute interval. pvbc was calculated by (tidal volume no assist/ eadi no assist)/(tidal volume assist/edi assist). nme was calculated by measuring change in airway pressure divided by amplitude of the electrical activity during end expiratory occlusion (delta paw/edi). results: the repeatability coefficient (rc) of pvbc and nme was % and . cm h o/uv respectively. median pvbc at t = was % and decreased until % at t = . in the same period, the mean nava level decreased ( . until . ) and mean eadi peak increased ( . until . uv). five patients had a pvbc index > %; four of them had a calculated pressure support (mean eadi peak x nava level) < cmh o. the median nme was . conclusions: we showed a repeatability of % for pvbc and . cmh o/uv for nme. this means that the absolute difference between two repeated measurements lies between this value with a probability of %. for example, with a calculated pvbc of % it is expected that % of the subsequent measurements will be between - %. nme was much more heterogeneous which indicates that neuromechanical coupling changes during icu stay in an unpredictable manner. pressure developed by the diaphragm in our patients appears within physiological limits. use of sigmoid regression for determining the optimal balloon volume in esophageal pressure monitoring: a bench and clinical feasibility study introduction: esophageal pressure (p es ), which has been used as a substitute for pleural pressure, is commonly measured by catheter with air-filled balloon. the accuracy of measurement depends on the proper balloon volume (v b ). assessment of optimal v b is difficult in clinical settings because the surrounding pressure of the balloon cannot be directly measured. in the present study, we introduced a sigmoid fitting method for determining the optimal v b . objectives: to assess the accuracy of optimal v b measured by sigmoid fitting and to evaluate the feasibility of this method in clinical practice. methods: six randomly selected esophageal balloon catheters (cooper catheter, cooper surgical, usa) were tested in a bench model with the lung and the pleural cavity during simulated mechanical ventilation. the balloon was progressively inflated in . ml increments from to . ml, and pressure in the balloon pressure (p b ) and in the pleural cavity (p c ) were measured. balloon transmural pressure (p tm ) was calculated as p b -p c . balloon pressure-volume was fitted by a sigmoid regression: v b = a/[ + e -(p-b)/c ], where a = the vertical distance of the upper asymptote, b = the pressure at the midpoint between zero and a, and c = the pressure range with the greatest volume change ( figure a shows a sample curve). the optimal v b was predicted by zero p tm and zero (p b -b). bland-altman´s analysis was used to assess the accuracy of the optimal v b predicted by p tm and p b . the balloon catheter was introduced into lower third of esophagus in patients with mechanical ventilation, and the balloon was inflated as the same sequence as that in the bench study. p es and v b were also fitted by the sigmoid regression ( figure b shows a sample curve) and the optimal v b was predicted by zero (p es -b). at each v b , dynamic occlusion test was performed, and ratio of changes in p es and airway pressure (Δp es /Δp aw ) was calculated. results: in the bench study, the best-fit coefficient r of sigmoid regression ranged from . to > . with a median (interquartile range, iqr) of . ( . , . ). the natural logarithmically transformed bias (and lower to upper limit of agreement) in optimal v b predicted by p tm and p b was − . (− . to . ). in the clinical study, v b tests were performed. r of sigmoid regression ranged from . to > . with a median (iqr) of . ( . , . ). the optimal v b was . ( . , . ) ml. the b value (r = . , p < . ) and predicted optimal v b (r = . , p = . ) significantly correlated with respective p es measured at the v b with the best Δp es /Δp aw ratio. conclusions: in the determination of balloon pressure-volume response, the performance of nonlinear sigmoid fitting was excellent in introduction: the use of more physiological tidal volumes ( - ml/ kg of ideal body weight) during general anesthesia can minimize the risk of lung injury but may be associated with increased atelectasis. a recent meta-analysis has suggested that high driving pressure and peep level changes that result in an increase of driving pressure are associated with more postoperative pulmonary complications ( ). there is no consensus, however, on how to tailor the level of peep to best suit each patient. objectives: our primary objective is to evaluate the variability of peep titrated by eit in healthy patients submitted to elective abdominal surgery. our secondary objective is to compare the consequences on lung mechanics and on the formation of atelectasis during abdominal surgery in two groups: titrated peep or peep of cmh o. methods: forty patients will be allocated into two groups: laparoscopic (n = ) or open surgery (n = ). after induction of anesthesia and neuromuscular blockade, and before insufflation of abdominal cavity, all patients will be submitted to a recruitment maneuver (rm) in pressure-controlled ventilation mode for two minutes followed by a decremental peep titration starting at peep of and diminished in steps of cmh o. optimal peep is defined as that with the best compromise of atelectasis and overdistention as measured by eit. patients in each subgroup will be randomized to one of two ventilatory strategies during intraoperative period: ( ) peep chosen by the peep titration procedure (titrated peep); ( ) peep set at cm of h o (peep ). a chest ct will be performed one hour after extubation. a density range of − to + hounsfield units (hu) was used to define atelectasis. results: thirty nine patients have been recruited. the median of titrated peep was (iq - ) (table ) . a weak correlation between bmi and titrated peep (r = . ) is shown in figure . lung compliance was significantly lower and driving pressure was significantly higher at baseline, with peep = and before rm, when compared to same measures using titrated peep during peep titration (table ) . during surgery, compliance (p < , ) and driving pressure (p < , ) were also significantly different between peep and titrated-peep group ( figure ). lung collapse evaluated through lung ct after extubation presented less non-aerated lung tissue in patients submitted to mechanical ventilation under eit-titrated peep. conclusions: in this sample of patients, the individualized value of peep titrated by eit had a great variability. peep titrated by eit was able to reduce both lung collapse and driving pressure. introduction: lung protective ventilation strategies could improve clinical outcomes in patients undergoing surgery. these strategies did not include specific goals for oxygenation. there is increasing recognition of potential harmful effect of hyperoxia in critically ill patients. however, little is known about current oxygen management during surgery. objectives: to describe current oxygen administration during general anesthesia in japanese hospitals. methods: a multicenter cross-sectional study was conducted. we screened all consecutive adult patients (≥ years) who received general anesthesia from to september or from to november at the participating hospitals (each participating hospital could choose whichever was more convenient). ventilator settings and the corresponding vital signs were collected hour after the induction of general anesthesia. we investigated the prevalence and risk factors for excess oxygen exposure ( . ± . . ± . . ± . ± . driving pressure with titrated peep (cmh o) . ± . . ± . ± . . ± . fig. (abstract a ) . driving pressure background:. acute kidney injury (aki) is common and is associated with significant morbidity and mortality after liver transplantation (lt). although the creatinine value is highly specific to estimate renal dysfunction, an inadequate sensitivity of creatinine level is demonstrated, particularly in early stage aki. cystatin c is founded to be a stronger predictor of the risk of cardiovascular events and death than creatinine. we aimed to determine whether pretransplant serum levels of cystatin c predict -day major cardiovascular events (mace) and all-cause mortality in lt recipients with normal serum creatinine values. methods: between may and october , consecutive lt recipients (mean age: years; % male; % living-donor lt) who have pretransplant creatinine level < . mg/dl were retrospectively evaluated. the -day mace was a composite of troponin i > . pg/ml, arrhythmias, congestive heart failure, death, cerebrovascular accidents. results: there was a . % -day mace event and . % of lt recipients were dead during a median of . years follow-up. mean values of cystatin c and creatinine were . ± . mg/dl and . ± . mg/dl, respectively. the risk for a -day mace event increased significantly with increasing quartiles of cystatin c; hazard ratios ranged from . to . for the highest versus the lowest quartile (p < . for trend). the kaplan-meier curves showed that the highest quartile (cystatin c > . mg/dl) had a significantly worse survival rate than the lowest quartile (cystatin c < . mg/dl) (logrank p = . ). however, pretransplant creatinine level showed neither increasing mace event rate nor worse survival rate with increasing quartiles of creatinine values (p = . for trends, log-rank p = . , respectively). conclusions: our results demonstrate that pretransplant cystatin c levels were significantly and progressively associated with -day mace and all-cause mortality in lt recipients with normal serum creatinine values, in contrast, the creatinine levels were not significant and gradual predictor of adverse clinical outcomes. were decreased (p < . ), and prevalence of postoperative aki was increased (q : %, q : %, q : %, q : %, respectively, p < . ). odds ratios for aki ranged from . to . for the highest versus the lowest quartile (p < . for trend). on the multivariate logistic analysis, low map was an independent risk factor of the postoperative aki (p < . ), after adjusting factors of age, sex, body mass index, diabetes, hypertension, creatinine, qtc interval, meld score, b-type natriuretic peptide, beta blocker uses, intraoperative red blood cell uses, postreperfusion syndrome, and cyclosporine uses. conclusions: our results demonstrate that pretransplant low map was significantly and progressively associated with the postoperative aki in lt recipients with normal serum creatinine values, therefore, our findings may assist in determining the optimal perioperative management of patients to prevent postoperative aki. introduction: patients undergoing cardiac surgery often develop, in the post operative period, pulmonary impairment and abnormalities gas exchanges ( ) . lung ultrasound (lus) examination may detect main pulmonary abnormalities at the bedside of the patient ( ). to increase bronchial drainage and help lung reaeration, physiotherapy treatment is daily applied starting from the first day after cardiac surgery. objectives: our study was to evaluate if physiotherapy treatment was able to induce changing in lung ultrasound pattern in the postoperative patients. compared total loss of aeration, before and after treatment, we identified a significant increase of rearation after physiotherapy (p = , ) evaluated with wilcoxon test. conclusions: our results confirm an elevate rate of loss of aereation in patients after cardiac surgery. physiotherapy may induce increase of reareation when evaluated with lus even thought it is not able to reduce consolidation. introduction: the therapy of malignant liver diseases has changed over the last years. during this period the frequency of liver resection has increased with great improvement in morbidity, mortality and long-term survival. [ ] thereby, the duration of liver transection and the amount of perioperative blood loss are of great importance for postoperative recovery time and therefore they are measures for choosing the optimal resection method. [ ] furthermore, the release of cytokines, chemokines, and stress hormones correlates with postoperative infection and organ dysfunction [ ] . to minimize cell damage and limit apoptotic cell death the so called heat shock response is initialized by various body cells as countermeasure to increased stress levels [ ] . moreover, pittet et al. showed a positive correlation between the small heat shock protein (hsp ) serum levels and survival after severe trauma. [ ] objectives: measurement of hsp could give an insight about pathological mechanism and their counter regulations of the liver. furthermore the hsp serum level should be correlated with the transection speed of the two resection methods cusa and stabler. . immediately after collection, samples were aliquoted, snap frozen and stored at − °c until further analyzation. to quantify hsp in serum commercially available elisa kits from r&d (duoset ic) have been used according to the manufacturer's protocol. furthermore the duration of transection and the resection surface expressed as cm /s were recorded. results: during surgery a significant increase in hsp levels was detected in patients undergoing stabler hepatectomy or cusa resection (n = , p < . ). during postoperative icu stay, hsp concentrations decline to levels comparable before surgery. the transection speed was significant faster in patients undergoing stapler resection compared to the cusa method (p < . ). the mean length of icu stay after liver resection was in both groups days. conclusions: our data show increased levels in serum of hsp , which might reflect the body's countermeasure to increased systemic stress levels during hepatectomy. moreover the hsp levels are in both groups equal high during surgery even though the resection conducted with the stabler is significant faster than cusa. introduction: performing laparoscopic surgery using carboxipneumoperitoneum usually accompanied with a moderate increase of the concentration of carbon dioxide at the end of expiration, as well as higher peak airway pressure that easily manages to compensate by the correction of ventilation parameters. in the postoperative period marked a fairly long recovery of baseline respiratory function associated not only with the post-operative pain, but with the restriction of the lung as a result of intraabdominal hypertension. objectives: assess the impact of prolonged pneumoperitoneum during laparoscopic surgery on respiratory function and to follow the dynamic of its rehabilitation. the study included patients ( men and women) in the age of . years (min , max ), operated in moscow municipal hospital № . the volume of surgical procedures: gastric resection (n = ), gastrectomy (n = ), pancreatoduodenal resection (n = ), hemicolectomy (n = ), resection of the sigmoid colon (n = ), anterior resection of rectum (n = ). depending on the surgical access patients were divided into two study groups: st -basic -(n = ) group -laparoscopic procedures, nd -control -(n = ) group of traditional laparotomy. all patients were under equal anesthesia during surgery: combined general anesthesia (sevoflurane + fentanil) and epidural infusion of . % ropivacaine solution, as well as myoplegia; postoperative multimodal analgesia: nonsteroidal anti-inflammatory drugs, antispasmodics, epidural analgesia. a study of respiratory function was carried out in four stages: -before surgery, - nd, - th, - th day after surgery. results: in patients of both groups to the second stage of study determined a significant reduction of volume parameters of respiratory function (vc, fvc, fev, fev , mef, mvv etc.). for example vc decreased in patients of group by % against the initial values, and % of patients in group (dynamics presented in the diagram). similarly changes in vc there is a decrease of all volume parameters: fev for the second phase decreased by . % in group and % in group ; mef decreased by . % and . % in the first and second groups, respectively. however, in addition to a statistically smaller decrease in the absolute values of volumetric parameters of respiratory function in the st group, we found them more intense recovery. conclusions: reducing the volume indicators of respiratory function after extensive laparoscopic surgery is less than after similar in volume laparotomy. recovery of acquired restrictive respiratory disorders is more intense and after laparoscopic surgery. at the same time in either group studies we have not observed a complete rehabilitation the initial levels of respiratory parameters, even after days after surgery. introduction: critically ill patients sometimes need laparoscopic surgery. it has been reported that steeped head-down position could increase intracranial pressure during robotic surgery. but we don´t know whether mild trendelenburg position and carbon dioxide pneumoperitoneum cause intracranial hypertension. we conducted a prospective observational study. objectives: the aim of our study was to investigate the change of optic nerve sheath diameter (onsd) in head-down position during carbon dioxide pneumoperitoneum. methods: we included patients scheduled to undergo laparoscopic gynecological surgery. exclusion criteria were ocular disease and central nervous system diseases. onsd were measured mm sagittal behind the globe we assessed onsd after tracheal intubation (t baseline), after pneumoperitoneum and trendelenburg position (t ) and every minutes (t , t , t , t ). anesthetic management were standardized. results: twenty seven patients were enrolled in this study. four patients were excluded from analysis because it was difficult for us to measure onsd. the degree of head-down angle was . ± . . onsd is significantly higher than baseline after pneumoperitoneum and trendelenburg position ( figure ). conclusions: carbon dioxide pneumoperitoneum and trendelenburg position increased intracranial pressure even if the head-down angle was mild. introduction: monitoring the anticoagulant effect of unfractionated heparin (ufh) is mandatory. this monitoring can be done by the mean of the activated partial thromboplastin time (aptt) or by anti-xa levels measurements. compared with anti-xa levels testing, aptt is more frequently impacted by preanalytic variables and biologic factors (increased levels of acute phase reactants, consumption coagulopathy) often encountered among critically ill patients. we studied the agreement of both tests results in unselected critically ill patients. objectives: to study the agreement of both tests results in unselected critically ill patients. methods: aptt and anti-xa levels were simultaneously monitored in patients treated by continuous intravenous infusion of ufh. blood samples were drawn into sodium citrate tubes (greiner bio-one sas, france). aptt was measured with triniclot automated aptt reagent (tcoag, ireland) and anti-xa levels with bio-phen heparin (lrt) (hyphen biomed, france) . an aptt of - times the control and anti-xa levels between . - . iu/ml were defined as therapeutic. results: forty-four patients (mean age . ± . years; mean sap-sii . ± . ) were included. reasons for admission were medical in , surgical in . the indications for ufh therapy were atrial fibrillation ( ), venous thromboembolism/pulmonary embolism ( ), thrombophilia ( ), acute coronary syndrome ( ), arterial thrombosis ( ). paired measurements of aptt and anti-xa were performed on page of samples. linear regression analysis was used to evaluate the relationship between aptt and anti-xa. the correlation between aptt and anti-xa levels was low (r = . ) concordant aptt and anti-xa values were observed in ( . %) data pairs. aptt was discordantly high in ( . %) data pairs and discordantly low in ( . %) ones. considering anti-xa as gold standard, monitoring anticoagulation treatment by aptt leads to a high risk of misdosing. aptt is frequently impacted by biologic factors. although less commonly, anti-xa levels can also be influenced by biological cofounders. poor correlation between aptt and anti-xa could result from lterations in fii and fviii activity. conclusions: use of aptt and anti-xa levels to guide heparin therapy may lead to different estimates of ufh concentration in the same patient. both aptt and anti-xa have limitations when used for ufh monitoring and may not accurately assess anticoagulant status. further investigation (using thromboelastometry or thrombin generation assays) could be useful to determine the optimal anticoagulation testing protocol in critically ill patients. note: this abstract has been previously published and is available at [ ] . it is included here as a complete record of the abstracts from the conference. introduction: the severe capillary leak-induced respiratory and renal failure limit large-volume resuscitation with crystalloids and blood components. the combined use of low volumes of crystalloids and "damage control resuscitation" (dcr), a blood product resuscitation goal of a : : ratio of packed red blood cells (prbc), fresh frozen plasma (ffp) has recently been applied to obstetric patients in hemorrhagic shock. another important consideration is the association of ffp with the risk of transfusion-related acute lung injury (trali), a major cause of death after transfusion. this risk is not present with the use of prothrombin complex concentrate (pcc) as the antibodies responsible for trali are removed during the manufacturing processes. methods: our research involved patients with massive bleeding after cesarean section. patients were divided into groups: st group contained patients as a treatment of massive bleeding with coagulopathy was scheduled pcc in a dose of ml/kg ( iu/kg), packed red blood cells (prbc). nd group ( patients) received fresh frozen plasma (ffp) in a dose of ml/kg and prbc. basic infusiontransfusion therapy was administered according to the protocols of hemorrhagic shock treatment in obstetrics. evaluation of the functional state of the hemostasis system was carried out using lowfrequency pyezoelectric thromboelastography (lpteg) on admission to hospital and every hours after the patient´s admission until normalization of hemostasis state. results: according to lpteg indicators obstetric patients with massive bleeding has a statistically significant abnormality in all parts of hemostatic system: platelet aggregation -intensity of contact coagulation (icc), the coagulation -intensity of coagulation drive (icd), clot maximum density (ma) and fibrinolytic activity -index of retraction and clot lysis (ircl introduction: both anaemia and transfusion of red cells (as defined by who criteria) ( ) have been associated with adverse outcomes, and the potential for anaemia to be a marker of a greater disease burden is frequently raised in discussion. cohort studies of patients aged > years demonstrate that anaemia is associated with increased mortality ( ) . anaemia is also associated with a variety of morbidities in older people, being linked with an increase in hospitalisation, poorer physiological, physical and cognitive function, development of alzheimer´s and parkinson´s diseases, depression, falls and hip fracture rates. we aimed to investigate whether anaemia was associated with adverse outcomes, increased lengths of stay and increased overall mortality in our icu cohort. we also thought it would be interesting to know if there was a difference in haemoglobin level depending on the specialty in which the patients were admitted -hereby defining the physiology of their anaemic process. methods: we conducted a retrospective review of all patients over the age of years that were admitted to the victoria infirmary, glasgow between / / and / / using the wardwatcher national database. we looked at admitting specialty (medicine or surgical), haemoglobin at admission, length of stay and hospital mortality. results: patients were included in the analysis, however full data set was available for patients. the patients were more predominantly male with similar numbers in the medical and surgical groups. medical patients were slightly younger, but with higher physiology scores and mortality. there was no statistical difference between length of stay in intensive care between the two groups. medical patients had a higher admission haemoglobin but this did not trend with outcome or length of stay. (see table ) conclusions: interestingly, and not as expected, it seems that admission haemoglobin to intensive care is not associated with outcome in the elderly population. it is noteworthy that discussion continues in the literature regarding the definition of anaemia in this age group as the population used to generate the who criteria did not include any over ´s. admission haemoglobin levels did not seem to correlate with apache, length of stay or outcome. however, the medical patients with more likely chronic anaemic state had higher apache-ii scores, were younger with higher mortality than the surgical admission who were older, had better outcomes but were more significantly anaemic on admission to intensive care. introduction: because of the substancial morbidity and mortality provoked by massive bleeding, a protocol to guide treatment of this event in each hospital is required. objectives: the aim of this study was to determine whether implementation of the massive transfusion protocol (mtp) was associated with a change in clinical practice or mortality. conclusions: the number of patients is greater in post-mtp group and apache score is lower in the same group since we are warned of these patients at an early stage. there were no differences in clinical practice regarding the administration of blood and hemostatic products.no change in mortality could be documented using the protocol. we have not found any statistically differences probably in part due to the sample size. introduction: discontinuation of life sustaining treatments (lst) is an accepted approach for certain icu patients. there are different ways of limiting lst, and while terminal extubation (te) is one of them, it may lead to dyspnoea and respiratory distress, which can be regarded as morally troublesome. table shows the characteristics of the patients included. conclusions: denial of admission to an intensive care unit due to lst decisions was associated with a high morbidity and mortality. mortality, apache ii and charlson index were significantly lower in the group of patients refused admission to an icu with a non invasive treatment recommendation. introduction: donation after circulatory death (dcd), refers to the procurement of organs from patients whose death is diagnosed and confirmed after circulatory arrest. in the netherlands the timeframe for dcd to proceed is set at two hours. a considerable number of potential donors after circulatory death are lost because they do not die within the specified timeframe after withdrawal of life-supporting treatment (wlst). identification of those dying within hours after wslt results in efficient utilization of the organ procurement teams, hospital resources and above all fulfillment of family expectations. objectives: the aim of this study is to determine factors predicting time to cardiac circulatory death after wslt within hours. methods: in this single-center study we retrospectively evaluated potential and actual dcd iii donors. patients younger than years of age, and clinically brain dead patients in whom relatives requested a dcd procedure, were excluded. univariate logistic regression analyses were performed to establish the effect of different predictors. results: only ( %) converted into actual donor partly due to the fact that cardiac death did not occur within hours. univariate analysis showed an association between the following predicitors and death within introduction: family refusal of organ donation from dbd (donors after brain death) is a limiting factor of the whole donation process and plays an important role in shortage of organs available for transplantation. although croatia is a state with presumed consent when it comes to dbd (donors after brain death) organ donation, family is always informed about the possibility of organ donation after it is verified that the deceased is not registered in the non-donor registry. if the family objects organ donation, their decision is always respected. objectives conclusions: main reason for refusal of organ donation in our hospital is unknown wish or opposition of the deceased person. no family refused donation due to fear of organ trafficking which is an encouraging fact. although refusal rate in our hospital is %, which is higher than croatian average of %, we could not clearly identify contributing factors. we also could not confirm the hypothesis that additional education of transplant coordinators lowers refusal rate. a more detailed prospective evaluation is needed in order to further reduce refusal rate in our hospital. impact of brain injury (bi) and bi with brain death ( the course was aimed to spanish health professionals (nurses and doctors), with a total duration of . hours. it consisted of a small theoretical introduction followed by several workshops, which included: donor after circulatory death management protocol through high fidelity simulator, family interview, preservation and perfusion procedures with extracorporeal membrane oxygenation in animal models. the students sat a pre-course self-assessment -question test to evaluate their knowledge about cdcd. at the end of the course they filled out a survey, offering their opinion on different sections: content, usefulness, documentation and educational support, organization, duration and overall assessment. the score ranged between one, the most negative value, to . average score was analyzed. a survey was sent to students working in different hospitals to evaluate the impact of the course in the cdcd programs at their hospitals. results: students completed the course, their characteristics are in table . students did the pre-course test, with an average score of . points. filled out the survey, results plotted in table . feedback trough the after-course survey was received from students. % of the students worked at hospitals without a cdcd program, established after completing the course. % of these students considered that the course contributed to the development and implementation of cdcd program. all professionals who worked at centers where there was already a cdcd program felt that the course contributed to its improvement. conclusions: despite the fact that there was a high knowledge on the subject among the students, they showed interest and enjoyed the course. the course had a high impact because it helped improving and developing cdcd programs in several hospitals. we believe that this course, based on high-fidelity simulaton training, has been one of the factors that has promoted controlled donation after circulatory death in spain in the last years introduction: the demand for donor lungs thoroughly exceeds the supply.this situation and the application of a strict group of selection criteria, has made donor lung shortage a major problem. to overcome this scarcity, some studies have examined the possibility of using lungs from older donors with mixed results [ ] [ ] [ ] [ ] objective: using as a starting point the favourable clinical evolution of a recipient of a year old lung, we reviewed all of our donors from the last years that were dismissed strictly because advance age (> years) methods: retrospective (feb -jan ) and descriptive study. all donors of a spanish tertiary hospital were analysed. we selected all patients excluded for donation and reviewed their contraindication to serve as lung donors. demographic data and comorbidities, reason for icu admission, icu length of stay, respiratory parameters, days of mechanical ventilation, respiratory cultures and antimicrobial therapy were collected. results: during the period studied we identified potential donors that translated into real donors and only of them ( , %) served as lung donors. after analysing the ( , %) patients that were not considered as lung donors, we identified ( , %) that had been dismissed strictly because advance age. all patients studied were brain death donors. demographic data and comorbidities, reason for icu admission and icu length of stay are detailed on figure .last mean po /fio recorded was , ± (peep , ± , ) and last mean pco recorded was , ± , mmhg. median days of mechanical ventilation were ( - we recorded the main characteristics of the donors, the most important periods in the process and the evolution of liver receptors admitted to the icu. results: patients were admitted. the mean age was , ± , . most were male ( / ). reason for icu admission more frequent: haemorrhagic stroke ( ) . the icu stay until list decision was , ± , days. the cares at the end of life (list) were performed in the first four patients in the uci, and another patients in the operating room, intervening in all of them intensivists who had participated in the previous treatment. the time from extubation to significant hypoperfusion of organs (sbp < mmhg) was minutes, the time to cardiac arrest was , minutes, and to the beginning of the cold perfusión was , minutes. liver transplants were performed without complications in the icu, and the icu stay was days ( , ). the higher alt level was ± , . of the liver transplants are well and with functioning organ today (one died in hospital ward unexpected cardiac arrest). kidneys were obtained from these donors. the maastricht iii donors provide valid organs for transplantation and the intensivists play an important role both in the detection as in the development of care at the end of life. the first transplants had long functional prolonged warm ischemia, which has been reflected in graft function, but the performing of list in operating room, the ultrafast extractions and the presence of the receptor in the hospital are improving the viability of organs, so the results of the last donors are better. thus, maastricht iii donors must be considered today as an additional source of organs for transplantation. ( ), cisatracurium was administered at a constant and high posology without monitoring the depth of neuromuscular blockade. objectives: to assess if the monitoring of the train-of four (tof) and the management of cisatracurium posology by nurses according to an algorithm can ensure an effective neuromuscular paralysis and allow to decrease cisatracurium consumption during ards methods: we conducted a prospective study in medical icus. all the patients with a pao /fio < for more than hours and requiring a continuous perfusion of cisatracurium were included. neuromuscular blockade was monitored by a tof at the adductor pollicis. nurses followed an algorithm of adaptation of cisatracurium posology depending on the tof with an aim of / . the initial posology was based on the maximal doses recommended in anesthesiology and on the patient ideal body weight. this posology was increased and a bolus done each time that the tof was > . the interruption of nmbas was decided by physicians. the initial and final posology and the daily consumption of cisatracurium, the need of performing boli, the results of tof and the occurrence of adverse events such as patient/ventilator asynchrony were noted. effective cisatracurium consumption was compared to the theoretical posology that would have been administered if the patient had been treated according to the acurasys study protocol (i.e. , mg/h). we also evaluated the economic impact of the reduction of cisatracurium consumption. introduction: sepsis-associated acute respiratory failure is frequent, occurs early and is associated with significant mortality. with the increasing use of noninvasive techniques, timing of intubation can vary and may lead to a difference in outcome. objectives: the objectives of this study were ) to draw on practitioners' current practice and perspectives to understand and identify practice variation in intubation and ) to develop an explanatory theoretical model that demonstrates the relationship of various factors contributing to practice variance. methods: between march and july , using a grounded theory approach, we conducted semi-structured interviews with providers involved in intubation and audio recorded them. the interview guide focused on clinicians' perspectives on and practices of intubation in patients with sepsis and impending respiratory failure. results: eighteen interviews were conducted with intensivists, fellows, nurse-practitioners, respiratory therapists and registered nurses. intubation perspective and practice varied dependent on three domains: patient's characteristics, clinician's characteristics, and organizational structure. patient factors included nature of acute illness, underlying comorbidities, clinical presentation, and patient's values. clinician factors included background, training, experience and practice style. system factors included of standardized policies and protocols, hierarchy and team dynamics. although most clinicians agreed that intubation is needed in case of persistent respiratory distress, altered mental status, or shock, they disagreed on when to initiate it. in different contexts, intubation could be considered as preemptive (prophylactic), therapeutic ('just in time'), and as a rescue. assessment, reassessment, and time-limited trial off noninvasive techniques matter. based on these results, we propose a model regarding intubation in sepsis consisting of the steps in the decisional process, a classification of the categories of timing of intubation, and decisional context factors that impact the timing of intubation. conclusions: in patients with sepsis-associated acute respiratory failure, variability of intubation was a natural phenomenon and appeared case-driven. intubation timing should be adjusted based on explicit consideration of each patient situation, their fitness, the cadence and trajectory of their respiratory failure, the team's proficiency in providing noninvasive and invasive ventilator support, and emphasis on clear, frequent closed-loop communication of the treatment plan and rationale within the entire critical care team. ( ) . objectives: to determine the efficacy of rhtm in septic patients with severe respiratory failure. methods: we performed sub-analysis of a retrospective observational study (japan septic disseminated intravascular coagulation study, j-septic dic study), which was conducted in intensive care units in japan. among septic patients enrolled in this original trial, we selected septic patients with severe respiratory failure and compared patients based on rhtm treatment (rhtm group and control group). propensity score analysis was performed between two groups. outcome was the number of ventilator free days. results: patients (rhtm, n = , control, n = ) were analyzed in this trial. after adjusting for baseline imbalances by propensity score analysis, vfds increased significantly in rhtm group (rhtm group: . ± . days vs. control group: . ± . days, p = . ). conclusions: in this analysis, rhtm improved outcomes in septic patients with severe respiratory failure. we need further evaluation. results: during the study period, totally ards patients with pathologic diagnosis of dad were eligible for analysis. these patients were divided as mild (n = , . %), moderate (n = , . %) and severe ards (n = , . %) by berlin definition and the hospital mortality rate were not significantly different between these three groups ( . %, . % and . %, p = . ). according to the etiology, these dad patients were divided into known etiology group (n = , . %) and unknown etiology group (n = , . %), and the hospital mortality rate had no significant difference ( . % vs . %, p = . ). the known etiology group had higher percentage of male and lower pao /fio ratio than unknown etiology group ( . % vs . %, p = . ; . ± . vs . ± . , p = . ). the multivariable logistic regression revealed sequential organ failure assessment (sofa) score at the time of open lung biopsy was the only predictor of hospital mortality (odds ratio . , % confidence interval . - . ; p = . ). in terms of glucocorticoid treatment, there was no significant difference in glucocorticoid use, timing from ards to glucocorticoid use, dose and duration between survival and nonsurvival patients. conclusions: for the ards patients with dad, sofa score was the predictor of hospital mortality but glucocorticoid treatment did not improve the survival rate. introduction: ventilator associated pneumonia (vap) is a known complication of mechanical ventilation. aspiration of oropharyngeal secretions results in infection that leads to significant morbidity, mortality and cost . use of sub-glottic secretion drainage (ssd) devices have been shown to decrease both the incidence of vap and intensive care unit (icu) days , . there have been safety concerns associated with use of ssd devices and herniation of tracheal tissue into the suction port . a study in sheep showed significant tracheal injury associated with continuous suction . human studies have shown conflicting results regarding the risk of tracheal injury , . objectives: to determine the risk of tracheal injury using an ssd device versus a standard endotracheal tube. methods: patients undergoing tracheostomy in the icu were enrolled in the study. patients were intubated in the icu, operating or emergency room, pre-hospital, or referring hospitals. intubation conditions and duration of intubation were documented. at the time of tracheostomy, a bronchoscopy was performed and the presence and degree of tracheal injury were noted. patients were followed to hospital discharge and decannulation, otolaryngology consults, and discharge or death were recorded. results: patients were intubated with a malinckrodt evac ssd device and were intubated with a standard endotracheal tube. patients were found to have a tracheal injury ranging from mild erythema to severe ulceration; / ( %) in the evac group and / ( %) in the standard group (rr - . ; % ci . to . ). / ( %) patients were reported to have injury at the site of the suction port; were reported to have mild edema and erythema and had mild to moderate ulceration. of the patients with tracheal ulceration at the suction catheter port, were decannulated successfully without further complication and patient died prior to termination of mechanical ventilation. conclusions: there was no significant difference in the risk of tracheal injury with ssd devices compared to standard endotracheal tubes. the degree of injury was similar in both groups. a small introduction: vap rates in brazil are higher than those listed in europe and eua.no municipal hospital moyses deutsch since implemented the protocol, applied the five strategies to reduce vap, however we maintained vap density with little reduction and we never zero target . objectives.objective of the study was to examine the effect of healthcare improvement ventilation bundle institute in addition to focusing on three strategies : oral decontamination with chlorhexidine (odc), the head elevation and awakening daily in the incidence of vap in a unit intensive care. methods: the study was conducted in a -bed, medical-surgical icu. criteria for nosocomial pneumonia are those from the cdc. strategy was to implement the ihi's ventilator bundle , focused and optimized in the first three the goals were the icu team adhesion of % achieved in six month after bundle implementation and % after one year of follow up. these measures included five strategies to prevent ventilator-associated pneumonia: - °elevation of the head of the bed, -adequate sedation level (rass − a − ), -oral decontamination with chlorhexidine . %, -dvt/pe prevention and -peptic ulcer prophylaxis . from january on, the icu nursing staff and ict performed a daily checklist in order to observe the five issues accomplishment. if any item was found to be inadequate it was promptly corrected. results: in january and december , adhesion to the whole bundle was % and % respectively. vap density was proportionally lower to bundle adhesion in the same period, per ventilation/day and respectively. in we achieved zero vap in both semesters. conclusions: initial vap rates were extremely high even for brazilian benchmarks. although we could not implement expensive technologies like continuous aspiration of subglottic secretions, icu team and ict efforts were crucial for satisfactory results, as well the administrative board support, which turned this issue an institutional priority. our goals are to reduce even more, implementing ''ventilator bundle-getting to zero'' program, maintaining a continuum effort to sustain these results. introduction: ventilators-associated pneumonia (vap) and its prevention is a significant concern for ventilated patients in the acute care. objectives: to determine if the knowledge and awareness of "ventilator bundle" helped in the prevention of ventilator associated pneumonia in the patients admitted to hospital. methods: a prospective observational study that evaluated vap rates from august through october were evaluated. all the adult medical patients who were intubated and ventilated in medical wards from august through october in the year were included in the study. during the period of june to july the staff nurses were educated and made aware about the problem of vap and the use of ventilator bundle in helping to prevent this vap. patients who expired within hrs of admission, who were transferred to intensive care unit within hrs, and those who were diagnosed with pulmonary embolism or metastasis were excluded from this study. intervention. the concept of "ventilator bundle' was introduced after educating the nursing staff and the medical personnel through group discussions."chula ventilator bundle" is a package of evidence -based interventions that include: ( ) clean equipment and environment; ( ) hand hygiene and elevation of patient's head of bed to - degrees; ( ) use . % chlorhexidine as a part of oral care every hour; ( ) labor over weaning and extubation each day; ( ) aspiration precaution protocol. measurement. demographic data was collected from the patient data files. vap was diagnosed when it met the (clinical non-invasive) diagnostic criteria. incidence of vap and protocol compliant were calculated. results: a total of were on mechanical ventilator for a vary period of - days. average age was . ± . with . % of male. introducing the concept of "chula ventilator bundle to prevent ventilators-associated pneumonia" significantly reduced the vap rate per ventilator days from % to % in the medical group ( medical wards). it significantly reduced the incidence of oral cavity problem ( . ± . vs. . ± . , p = < . ). ventilator bundle compliance was . %. conclusions: however, ventilator bundle compliance was less than %, introducing the concept of "chula ventilator bundle" helped us to reduce the incidence of vap and the incidence of oral cavity problem. grant acknowledgment quality improvement center, king chulalongkorn memorial hospital introduction: patient-ventilator asynchrony is a mismatch between patient and ventilator inspiratory and expiratory time. it is associated with prolonged duration of mechanical ventilation (mv), increased need for tracheostomy and increased mortality. five main patterns of asynchrony are described, without universal agreement on definition. studies on patient ventilator asynchrony have quantified asynchrony at heterogeneous time points and during periods of various durations. in addition, most of these studies were of single centre type. objectives: the aim of the present study was to evaluate the factors associated with and the prognosis impact of asynchrony, according to two methods of quantification: visual inspection of airway flow and pressure signal and a computerized method integrating electromyographic activity of the diaphragm (eadi) as a maker of patient inspiratory time at the early phase of weaning. methods: ancillary study of a multicentre, randomized controlled trial comparing neurally adjusted ventilator assist to pressure support ventilation at early phase of weaning. airway flow, pressure and eadi were recorded during minutes , , and hours following inclusion. asynchrony were quantified according to two methods: ) "flow-and-pressure" based on the visual inspection of the flow and pressure signals ) "eadi-based" with analysis of the eadi signal in addition to the flow and pressure signals. asynchrony index (ai) was calculated as the number of asynchronous breaths divided by the total number breaths multiplied by . results: patients mechanically ventilated for days ( - ) were included, men ( %), aged ( - ) years, saps ii ( - ), % were mechanically ventilated for de novo hypoxemic respiratory failure. prevalence of ineffective efforts was higher with flow-and-pressure method than with eadi-based method. auto-triggering, doubletriggering, premature and late cycling were more frequently observed with eadi-based method than with flow-and-pressure method. ai and the total prevalence of asynchrony were significantly lower with the flow-and-pressure method than with the eadi-based method (table ) . no significant difference in term of gender, age, saps , charlson score or length of mv prior to inclusion was observed with severe asynchrony (ai > %) severe asynchrony was not associated with difference in term of hospital length of stay, duration of mv and day- mortality. icu length of stay determined by the flow-and-pressure method was shorter in patients with ai ≥ % ( ( - ) vs ( - ), p = . ). conclusions: the prevalence of patient ventilator asynchrony varies according the methods and definitions used to quantify asynchrony, which suggests the need for a consensus statement in asynchrony's definition. patient ventilator asynchrony was not associated with a poorer outcome. introduction: tracheostomy is a frequent procedure in intensive care units, in the us over the past decades utilization rose substantially, driven by surgical patients [ ] . the optimal timing for tracheostomy in critically ill patients remains a topic of debate. objectives: to analyse tracheostomy utilization and trends in an intensive care unit (icu) and to determine the impact of tracheostomy timing (early vs late) in critically ill patients on duration of mechanical ventilation, icu stay, overall hospital stay and mortality. methods: retrospective study including all critically ill patients who underwent tracheostomy in an icu from to . the sample was stratified in two groups, according to time of invasive mechanical ventilation until tracheostomy: early tracheostomy (≤ days) and late (> days). results: over the study period a total of tracheostomies were performed, representing , % of the admissions in the icu. tracheostomy was more common in medical patients ( . %). mean time until tracheostomy was days. there was no tendency in tracheostomy rates and timing over the years. early and late tracheostomy groups did not differ significantly by gender, age, sofa score and type of admission. in the early tracheostomy group there was a statistically significant reduction in the length of invasive mechanical ventilation ( days vs days, p < . ) and icu stay ( days vs days, p < . ), with impact in icu and hospital mortality. conclusions: early tracheostomy was associated with reduction in invasive mechanical ventilation days and icu stay, with possible implications in long term morbidity and health care costs. reinforcing that tracheostomy timing should be considered in the decision process, when evaluating risks and benefits. introduction: development of critical care medicine has been decreasing mortality of critical illness. however, - % of survivors suffer functional impairment or icu-acquired weakness (icu-aw). in order to address interventions in icu-aw, it is essential to know when icu-aw developed in addition to its incidence and risk factors. objectives: to assess the onset of icu-aw and its incidence and risk factors in the icu of tokushima university hospital. methods: prospective observational study. critically ill adults were enrolled when they were mechanically ventilated at least days. patients younger than years old, with neuromuscular diseases, central nervous system disorders, and pregnancy were excluded. after we determined feasibility of communication, medical research council (mrc) sum score was measured as soon as possible. when mrc score was less than , we diagnosed patient as icu-aw. basic profiles, underlying diseases, apache ii score, administration of neuromuscular blocking agents (nmba) and corticosteroids, and laboratory data were recorded. introduction: severe traumatic brain injury (stbi) remains as the most significant medical and social problem due to high prevalence and mortality, primarily among young and employable population. the leading problem of intensive care of stbi is the prevention and elimination of intracranial hypertension (ich). one of the methods of ich elimination is mechanical ventilation as a component of complex therapy. among the various methods and modes of mechanical ventilation high-frequency jet ventilation (hfjv) is particularly distinguished, which is enduring "the second birth". in hfv transpulmonary pressure and the pressure in airways is much lower than one during traditional methods, the negative pressure in pleural cavity is maintained during inspiration phase and spontaneous breathing. objectives: comparative assessment of efficacy of different modes of mechanical ventilation in patients with stbi. methods: we studied the cerebral perfusion during various modes of mechanical ventilation in patients with stbi. mean age was ± . the general status in admission was severe, glasgow coma score was ± . all patients had traditional intensive care with different modes of respiratory support: controlled mechanical ventilation -cmv (n = ); synchronized intermittent mandatory ventilation -simv (n = ); hfjv (n = ). the efficacy of all modes were assessed by arterial blood gases analysis (sao - - %, pco - . - . mmhg). intracranial pressure were measured invasively and was ± mmhg. all patients regularly had clinical and neurological examination, control of laboratory tests (common blood count, arterial blood gases, arteriovenous gradient of o (avdo ) and oxygen saturation in jugular vein (sjo ). cerebral hemodynamics was studied by transcranial dopplerography. the registered parameters were mean linear velocity of cerebral blood flow (vm), pulsatile index (pi) and overshoot coefficient (oc). results: there were significant differences in parameters of cerebral hemodynamics in various modes of respiratory support: cmv: vm - . most patients found mobilisation to be a positive experience and the beginning of their recovery. however, mobilization was described as a difficult component of the care, mainly due to pain, tiredness and dizziness. almost all patients commented on the benefits of participation in physiotherapy, which was verified by physical improvements and progression in their abilities. although most improvements discussed were physical, two patients also described the psychological benefits that occurred in the sessions. they reported that the physiotherapists 'built them up' and encouraged them. one patient described a mind shift that occurred once she had mobilised out of the bed. she described it as being able to see what she was capable of. it was described as a precious and muchneeded service, without which some patients felt they may not have survived or recovered as quickly. methods: this retrospective study was performed in a -bed medical icu in spain from to . all patients admitted to the icu during this period were included in the study. cci patients were defined as those with more than days of icu stay. data were collected in ways: review of a prospectively elaborated database, review of electronic records, and telephone survey evaluating the functional status of survivors, one year after their discharge from the icu. results: during the study period, patients ( females − %) were considered cci. the characteristics of these patients are shown in table . all the studied patients needed prolonged mechanical ventilation (median days), defined as > hours/day of ventilator support for > consecutive days. the follow-up period is drawn in figure . the in-icu mortality was %. in the first year, patients ( %) were alive. most patients improved their quality of life over a year, with approximately % of them displaying some help for dressing or to performing the transfer of themselves. symptoms of anxiety and depression improved during the first year, being present in up to % (of the patients), but in % if we refer to the presence of nightmares or hallucinations. % these patients were transferred (discharge) to a rehabilitation center and % needed hospital readmission within the follow-up period. conclusions: for cci patients in-hospital mortality rate is still high after discharge from the icu. however, more than one third of them are alive one year after their hospital stay and in an almost independent condition. efforts focused on early specific therapeutic strategies after icu admission to prevent the progress of the acute disease towards chronic critical illness and to improve the outcome must be explored. [ ] [ ] [ ] [ ] . at icu, . % had delirium, . % needed blood transfusion and . % renal replacement therapy. patients worsened in all parameters of the five dimensions of the eq- d after -days: the extreme problems level increased in the mobility dimension from . % at icu to . %, self-care from . % to . %; usual activities from . % to . %; pain/discomfort from . to . and anxiety/depression from . % to . %. the dependence observed in the katz index worsened in days when . % of patients were dependents before icu admission increasing to . % after days. about family members, . % were spouses and . offspring, their mean of age was . ± . years and . % had previous experience of icu. we observed that they presented more symptoms of anxiety ( %) and depression ( . %) at icu when compared days after ( . %) and ( . %), symptoms of anxiety and depression respectively. conclusions: the most common eligibility conditions of cci were sepsis followed by mechanical ventilation. we observed a great mortality on days and among survivors a worsen quality of life with more dependence in their activities of daily living. we also observed that family members suffered more while in icu stay. introduction: tracheostomy is a favored alternative option for providing prolonged mechanical ventilation and safety airway used for more than years. despite its numerous advantages, tracheostomy may have severe complications as being an invasive method for presenting respiratory tract patency. besides, the tracheostomized patients usually have prolonged icu stay, high mortality and morbidity arise from concomitant comorbidities. objectives: the aim of the study was to evaluate the frequency, patient characteristics, complications and the prognosis related with our percutaneous tracheostomy practice. methods: hospital electronic records and icu files of the patients with percutaneous tracheostomies performed in our bed anesthesiology icu were evaluated between january and december . ethic consent was obtained from local ethic committee. the patients who were discharged with home type mechanical ventilator or their relatives were contacted by phone for getting information about their health status or related complications. (tables and ) . conclusions: the blood serum sodium levels at admission, especially hypernatremia, may also be used as an independent predictor of outcome in the surgical critically ill patients. introduction: who estimates that the worldwide dengue fever incidence is about tens of thousands of cases every year. as taiwan is situated in the high risk subtropical region, dengue fever has virtually become a seasonal infectious disease. climate warming, demographic movement and the higher probability of increase in intermittent rainfall in recent years have added many factors unfavorable to dengue fever prevention. years of prevalence and the emergence of different types have also caused the risk of mortality for dengue fever to become relatively high.of the total , confirmed dengue fever cases in , there were deaths (with a mortality rate of . per thousand), marking the largest outbreak over nearly one decade in taiwan. objectives: analysis was conducted on the confirmed severe cases of dengue fever or dengue hemorrhagic fever reported to this hospital over the period between july and september , in terms of gender, age, history of chronic diseases, warning signs and diagnostic criteria for severe conditions. methods: retrospective case study was also conducted to identify risk factors in dengue fever and dengue hemorrhagic fever as well as predictors of death among dengue fever cases for statistical analysis. results: according to the results, those susceptible to infection concentrated on older people aged over (with an average age of ); in total cases had chronic diseases (with an average rate of . %), among which hypertension and diabetes constituted the majorities; and based on symptoms, fever accounted for . % while gastrointestinal bleeding was the most common at . %. of the cases, there were deaths, with an average apache ii score of . and an average mortality rate of . %. conclusions: this study shows that patients with chronic diseases aged over will have times higher risk of death if infected with dengue hemorrhagic fever. it is therefore suggested that older people aged over and patients with chronic diseases who are infected with dengue hemorrhagic fever must be closely monitored in clinical practice to pinpoint the best time for treatment and effectively reduce mortality rates. to sum up, effective use of knowledge about risk factors and prognostic factors in dengue hemorrhagic fever can help epidemic prevention organizations to focus their limited resources on high risk groups and increase the effectiveness of prevention. cardiorespiratory instability risk escalation patterns: an association study with risk factors and length of stay l. chen (fig. ) . % of them belong to "late onset" types whose risk escalated ≤ minutes before cri onset, but with different initial rr levels (low, medium and high). % of patients belonged to "early onset" type with gradual escalating risk starting about hours before overt cri, and % falling into a "persistently high" type. the mean rr during the first hours of sdu stay are . , . and . for "late onset" types; . for "early onset" type, and . for "persistently high" type, comparing with baseline rr of . for cri negative patients. the mean rr derived in the first -hours after admission is strongly associated with risk escalation patterns observed (p-value < . ), specifically, patients of "persistently high" type were more likely to have higher mean risk levels at sdu admission . risk escalation patterns were not significantly associated with age, cci or sdu los. however, they are significantly associated with hospital los (p = . ). conclusions: there is potential "risk stratification value" of vs collected during initial hours of sdu stay in predicting the cri risk escalation patterns later on, which may in turn predict hospital los. these insights may guide monitoring resource allocation for cri management. - . ] mmol/l and most of patients were on vasopressors therapy. coronary angiography was performed in / ( %) patients with a cardiac cause; continuous renal replacement therapy was initiated in out of the patients ( %) developing acute kidney injury during the icu stay. patients showed a full neurological recovery during the icu stay ( %) but only were still alive with intact neurological function at months ( %); / after ohca ( %) and / ( %) after ihca. eight patients ( %) with irreversible brain damage had organ function suitable for donation and were eventually explanted. conclusions: ecpr provided acceptable survival rate with good neurologic recovery in refractory cardiac arrest. these patients underwent several additional therapeutic interventions, which, in case of irreversible brain damage, could stabilize extra-cerebral organ function and potentially provide some available organs for donation. post-resuscitation treatment with inhaled argon improves outcome even after a prolonged untreated cardiac arrest in a porcine model introduction: after the initial success of cardiopulmonary resuscitation (cpr), the majority of patients die, mainly due to postresuscitation (pr) cardiac failure and ischemic brain damage. inhaled argon has shown neuroprotective effects in a porcine model of cardiac arrest (ca) of short duration. objectives: to investigate the effect of post-resuscitation treatment with inhaled argon on outcome in a preclinical porcine model of prolonged untreated ca and cpr. we hypothesized that argon would ameliorate post-resuscitation neurologic dysfunction. methods: the left anterior descending coronary artery was occluded in pigs ( ± kg), and ventricular fibrillation (vf) was induced. after min of untreated vf, cpr, including mechanical chest compression, ventilation and adrenaline administration, was performed for min prior to defibrillation. following successful resuscitation, animals were subjected to hr ventilation with (a) % argon - % o (n = ) or (b) % n - % o (n = ). hemodynamics were continuously monitored and systolic myocardial function (i.e. ejection fraction (ef), shortening fraction (sf)) was assessed by echocardiography. serial blood samples were obtained for blood gas, serum neuron specific enolase (nse) and plasma high sensitive cardiac troponin t (hs-ctnt) assays. animals were observed up to hr for assessment of survival and neurological recovery (cerebral performance categories (cpc) scale). results: twenty animals were successfully resuscitated and enrolled in the study (table ) . ventilation with argon did not have any detrimental effects on respiratory gas exchange during the hr ventilation (table ) . animals receiving argon showed a significantly lower heart rate and higher mean arterial pressure and stroke volume compared to controls during the hr of observation (table ) . animals treated with argon presented also a significantly better recovery of systolic myocardial function, as represented by the higher sf at hr compared to controls (table ) . nine of the resuscitated animals in the argon group survived for h in comparison to out of in the control group. animals treated with argon presented a significantly better neurological recovery (cpc . ± . ) in contrast to animals in the control group ( . ± . , figure ). lower circulating levels of hs-ctnt (median: ng/ml vs. ng/ml, p < . ) and nse (median . ng/ml vs. . , p not significant) were observed in the animals ventilated with argon compared to controls. conclusions: in this severe model of ca, post-resuscitation treatment with argon allowed for improved hemodynamics, myocardial function and neurologic recovery, without detrimental effects on respiratory gas exchanges. munich, germany, which is staffed with physicians working at a university hospital in the specialities anaesthesia or surgery. ( ) test if there is a difference between specialists and residents in pain treatment of trauma patients. methods: after ethics committee approval, retrospective analysis of the protocols of our prehospital emergency service location in munich, germany of - . statistical calculation was done using logistic regressions with stata (college station, tx, usa). results: documented trauma cases. trauma cases could be assessed for frequency of oligoanalgesia, which was present in of these cases (see figure , dashed frames), leading to an relative frequency of % of cases. there was no difference in frequency between residents and specialists (table ) . relatively more trauma cases where handed by specialists, while documentation of pain was better in residents (table ) . documentation of pain, however, was insufficient, since pain assessment at hospital admission was documented in % of possible cases of oligoanalgesia only. conclusions: frequency of oligoanalgesia in trauma patients seems to vary in different systems, since it was much lower in munich compared to switzerland ( % vs. %, respectively). there are several possible explanations: data from swizerland was from an air resuce service while our data is from a ground based system. second, in our system possibility of treatment by a specialist was much higher ( % residents in switzerland). third, documentation in our system was inadequate. theoretically, frequency of oligoanalgesia could increase up to % if all cases without adequate pain documentation were counted as oligoanalgetic. to assess appropriate numbers improvement in documentation is essential. of the attempted resuscitations were immediately unsuccessful, resulted in rosc ( sent to icu for post-resuscitation care, whilst remained on the ward). at hours (both in icu) were still alive. defibrillation was attempted in cases. intubation was attempted on occasions. in ( %) of the resuscitation attempts cpr was the only intervention reported while ( %) received more than vial of adrenaline, or defibrillation, and or intubation. interviewees reported that in ( %) of these patients they were 'not at all' or only a 'little bit surprised' by the patient having a cardiac arrest (fig ) . they further described the chances of a successful outcome as 'unlikely or very unlikely % of the time and likely or very likely only . % of the time (fig ) . conclusions: perspectives of junior doctors interviewed suggest many cardiac arrests were not a surprise and that the probability of rosc following attempted resuscitation was unlikely. there is high incidence of patients receiving cpr attempts before death in hospitals across sri lanka with dnar practices remaining uncommon. outcomes remain poor, with rosc after cardiac arrest being . % and survival at hrs . %. of the unsuccessful resuscitation attempts, defibrillation and or repeated adrenaline was reported in . % of cases. introduction: pro-coagulatoric effects after cardiac arrest and consecutively appearing microthromboses have been considered major contributors to morbidity and mortality after cpr [ ] . in contrast, recently published data suggest that - % of patients after out-ofhospital cardiac arrest (ohca) present with hyperfibrinolysis during and after cpr [ ; ] . the interpretation of these inconsistent observations remains unclear and complicated, because of methodological differences and lacking analytical approach in the underlying studies. fibrinolytic activation might be the physiological reaction to restore perfusion after hypoperfusion due to microthromboses. this leads to the question, if the duration of no-flow (time without chest compressions) after cardiac arrest influences the level of coagulation activation and subsequent fibrinolysis during cpr. objective: to investigate the influence of a delayed onset of cpr on the extent of fibrinolysis and the function of the coagulation system measured by rotational thrombelastometry (rotem). methods: after approval of the local authorities (nds. laves, approval g - ) cardiac arrest was induced in anaesthetized female göttingen minipigs via rapid ventricular overpacing resulting in ventricular fibrillation (vf). in order to simulate a bls-cpr in animals (cpr-group), chest compressions (cc) and ventilation were started after min of vf ( : -ratio, fio = . ). in order to simulate consecutive als-cpr, continuous cc ( min − ) and ventilations ( min − , fio = . ) were started minutes later. no cpr was started in the remaining pigs (non-cpr-group). blood samples for a complete rotem analysis (rotem delta® analyzer, tem int. gmbh, munich, germany) and laboratory analyses were taken before induction of vf (baseline) and , and min after vf. all parameters were investigated for normal distribution (shapiro-wilks-test). statistical significance of differences (p < . ) was investigated using the unpaired t-test (normal distributed parameters) and the mann-whitney-u-test (notnormal distributed parameters). results: figure summarizes laboratory and rotem results. in no group maximum lysis increased significantly after cardiac arrest ( figure ). maximum clot firmness (mcf) in fibtem analyses decreased significantly in both groups (figure ), but plasma fibrinogen levels (measured using the clauss method) remained stable. introduction: perception and knowledge of hospital staff involved in an emergency evacuation of hospitalized patients is usually low. this is especially remarked in an icu due to the complexity of moving patients who depend on invasive monitoring and organ support due to acute illness. objectives: to analyze the differences between different members of icu staff about their perception and knowledge of self-protection and evacuation plans. methods: a quantitative, descriptive and cross-sectional study was carried out by a fully structured and self-administered survey in public and private icu staff through a total sample of participants. they were asked to complete a questionnaire about their perception and knowledge of self-protection and evacuation plans in the icu. this study pretended to analyze the differences between participants, taking into account their demographic and occupational characteristics and their level of satisfaction and commitment to their jobs. results: on a rating scale from to , icus workers perceive that their preparation and knowledge were too low to meet a possible emergency that could require an evacuation, although they were aware of the need to make an update. however, they state that the different icus where they work do not have these plans, and, consequently, they do not feel prepared to act in an emergency situation, even though they think this type of situation may occur. the significant differences (p < , ) were observed when levels of satisfaction and commitment to their jobs were high. the results of this study showed that there is a need for more knowledge in the area of emergency training. this should be the basis for the development of educational programs and also promoting awareness of icu staff on self-protection and evacuations plans. integrating nurse practitioners and physician assistants in the icu: results of a national survey r. kleinpell rush university medical center, chicago, united states intensive care medicine experimental , (suppl ):a introduction: an increasing number of intensive care units (icus) are integrating advanced practice providers (app) including nurse practitioners (nps) and physician assistants (pas) to meet workforce demands to care for acute and critically ill patients. although these roles are established ones, limited information is known about the specific care models used in icu settings. this information is crucial in objectively evaluating the effectiveness of app roles. objectives: to address this gap, a national survey was conducted targeting nps and pas, including those working in icu settings. methods: a web-based survey was used to assess domains including role components (i.e. direct care management; care coordination; performing procedures; education; quality assurance; research); role responsibilities (i.e. practice autonomy, prescriptive authority, credentialing and privileging delineations) unit-level organization (i.e. physician staffing models, components of the multidisciplinary care team); and hospital organization (i.e. academic status, bed size, location, payer-mix). results: a total of apps responded to the national survey including nps and pas. the respondents reported working in a variety of settings including hospitals, clinics, urgent care centers and specialty practice sites. a total of reported working in an icu setting. of these, reported / coverage of acnps and pas in the icu. main role components included patient care management as part of the multiprofessional icu team; teaching to patients, families and healthcare staff; involvement in quality improvement and research initiatives and administrative components such as committee work. specific aspects include conducting history & physical exams, ordering and interpreting diagnostic test/labs; providing care coordination, performing specialty procedures such as wound care or other specialty care. major areas of impact that were identified included continuity of care, improving evidence based practice care, reducing hospital length of stay, preventing hospital readmissions and promoting patient, family and staff satisfaction. the results of the study provide information from a large national sample of nps and pas that identifies the comprehensive care components of the role as well as areas of impact, highlighting the value of app care. globally, this information can be useful to other countries who are considering use of nps and pas in the icu. national health care resources. with icu beds, the reserves of the system are often overwhelmed. the responsibility for a rational management and distribution of these costly resources burdens the admitting intensivist. intensivists not using protocols expressed a strong desire ( %) to introduce protocol based criteria for admission. conclusions: the most important factors influencing decisions about admission (or refusal of admission) in the icu are bed availability and prognosis of the underlying disease. socioeconomic and religious criteria are clearly of marginal significance. drug abuse and severe psychiatric disease do not emerge as compelling causes of biased decisions. it appears that the intensivist's decisions are largely individualized, as application of admission protocols is limited among the icus. however, the responses documented in this survey strongly indicate that introduction of such protocols would be welcome by a majority of our colleagues. conclusions: it is essential that non-cardiac surgery should be delivered in the most appropriate clinical setting. in scotland, adults with moderate to complex congenital cardiac disease are managed by the scottish adult congenital cardiac service (saccs), based at the golden jubilee national hospital (gjnh), near glasgow. [ ] existing guidelines have established when patients should have elective non-cardiac surgery performed at gjnh. however, many surgical specialties are not routinely available at gjnh, the bed occupancy rate is high and with an increasing saccs population there is a need for appropriate patients to receive optimal care at their base hospital. additionally, urgent and emergency non-cardiac surgery ought to be performed at the base hospital. while nitric oxide is a core cardiac therapy we have shown that it is scarce in scotland and unfamiliar to many icus. there is a need for a national discourse and consensus to ensure that nitric oxide is more widely available as part of a bundle of optimal cardiac critical care. this should include education, material resources, clinical guidelines and perhaps cardiac critical care outreach services to support general icus. introduction: scarcity of intensive care unit (icu) beds has long been a problem. among other things, it increases the work load of emergency department (ed), contributing to its crowding and probably to worst care, jeopardizing outcomes. despite the plausibility of this premise, studies aren't consensual about the impact on outcome of delayed icu admission from ed. hospital de são joão is a portuguese tertiary care center. ed receives around adult admissions per year, and is spatially organized according to manchester triage priorities. emergency room (er) receives patients from the street and all patients from other areas of the ed that need critical care. it is staffed by trained personnel and is equipped with level iii icu material. intensive care department is composed by level iii and level ii icu beds objectives: assess if there's a link between time spent in ed and outcome of patients admitted to level ii and/or iii icu beds. methods: this is a retrospective study analysing older than years old patients admitted to icu from ed from st january to st december . we excluded patients transferred from other hospitals. demographic and clinical data was collected from records. we selected hospital outcome (dead, alive, transferred), hospital length of stay, icu length of stay, vital status at and days after admission and ed and er duration as outcomes. simplified acute physiologic score (saps) ii and sequential organ failure assessment (sofa) were calculated by considering the worst values in the first hours of hospital admission. we performed a descriptive analysis, with median and interquartile ranges presented for continuous variables and proportions for categorical variables. for analysis of subgroups we did a chisquare or mann-whitney test. statistical analyses were done on ibm-spss (version ). a p-value of < , was considered significant. results: adults were assisted in ed in this period, with a median length of stay of minutes. were admitted to icu beds, which accounts for , % of all adults cared for in ed. around % of patients admitted in icu were treated in the er at some point of their ed care. patients admitted to icu stayed around minutes in ed. the more severe the disease, the least time spent (p = , ). patients treated in er were significantly more likely to be admitted quickly in icu (p < , ). taking in consideration the time spent in the ed, we found an opposite relation with global outcome, meaning that patients staying longer periods in ed had lower icu mortality and lower length of stay in icu. there was no association with hospital mortality. conclusions: time spent in ed had no negative impact on outcome. however, given the fact that the majority of patients admitted to icu beds were cared in a devoted area with trained staff and full level iii equipment, we hypothesize that what might impact the most on outcome is provision of early critical care. determination of icu bed requirement using resampling k.k. introduction: planning for icu-bed provision, with a statistical confidence level, required the average number of critically-ill patients, their average icu length of stay (los), and the fluctuation/variance of these two parameters. the actual icu bed occupancy would under-estimates the variance, as icu could never exceed its full capacity. with an under-estimate, the predicted icu bed requirement would be inaccurate, with a tendency of under estimation. objectives: estimate the bed requirement to cover . % of time, by resampling of admission/discharge entries in , for the two busiest icus in hong kong (~ admissions/year each) methods: we assumed that the chance of an icu admission was identical in a period of four weeks before and after a certain date. based on this assumption, a computer simulation of icu admissions was performed as if the year happened again. in brief, we pooled patients admitted on a particular date in , and those admitted on the same day of week in the previous four and subsequent four weeks. then patients were randomly selected from the pool to simulate icu admission on that particular date. a mechanism (not described here) was in place to handle the public holidays. the hourly icu occupancy was calculated using the actual icu los of the selected patient. re-sampling for the whole year was repeated times to provide the estimates required. results: the actual hourly medians of icu occupancy were % and %. they were close to that obtained using resampling ( % and %). as predicted, the distributions of the actual occupancy were skewed to left, indicating a negative bias on the variance estimates. the observed standard deviations of the two icus' occupancy were . % and . % respectively. after resampling, the distributions became more symmetrical, and had higher standard deviations of . % and . % (both p = . ). the . percentile occupancy in reality were % and %, while that from resampling were significantly higher at % and % (both p = . ). this corresponded to three or four additional icu beds in each icu. conclusions: in conclusion, using a simple and conservative assumption, resampling could provide valuable insight for icu bed planning. introduction: the number of available intensive care unit (icu) beds are limited while the request for the beds are high. thus rationing the admission to icu is necessary especially in developing countries where the resources are limited. also models are needed to estimate and re-estimate regularly, shortage in the number of icu beds in any hospital. in the current study we tried to design a model for estimating shortage in the number of intensive care beds in a developing country tertiary university hospital after an initial delphi consensus study. objectives: designing a model for estimating shortage in the number of icu beds in a hospital. methods: initially the standard indications for icu triage were extracted from the literature. four intensivists were served as steering committee and the initial questionnaire were further prioritized by experts with three rounded delphi method and formed a standardized checklist for icu triage. indications were considered as critical, important, and all indications. then a cross-sectional study being performed during a -month period from august to september for all admissions to nemazee hospital, a tertiary healthcare center affiliated to shiraz university of medical sciences. cardiac, transplantation and pediatrics patients were excluded from the study, as to be studied separately. the checklist were filled every day by an observing physician and any indications for icu admission were marked in the questionnaire. decision making for requesting icu admission were performed by the specialized physicians of each ward regardless of the results of completed checklists.the results were further assessed according to the mentioned criteria and the reliability and viability was calculated. finally assuming that there was no available icu bed-days, the required icu bed-days were compared with the total icu bed-days of the hospitals, to estimate the shortage of icu beds. results: totally patients were admitted and studied.the required bed-day regarding critical indications, important indications, and all indications for icu admission was , , and . by comparing the required bed-days with available bed-days of the hospital, beds were calculated as shortage of icu beds. the results of the current study indicate that our center has deficiency in the number of icu beds. it seems that a checklist is not only useful for prioritizing patients but also it is useful for estimating the required number of the icu beds.the actual number of shortage is greater as three group of patients were not included. transfer delay from intensive care unit: retrospective analytical study in an indian tertiary care hospital s. k introduction: there lies scarcity of intensive care unit (icu) beds in every tertiary care hospitals, and on top of it delayed transfer of patients from icu to wards is further increasing the burdensome. numerous factors affect in making delayed transfer, which in itself is a risk factor for patient related morbidity and mortality, especially the after hour transfers. objectives: the aim of the study was to analyze the hours of transfer delay and their effect on readmission rates in the icu. methods: we conducted a retrospective study of patients transfer from our icu to the wards over last one year (jan-dec' ).data collected from the icu database by the secretarial staff during the study period and divided into following categories of transfer delays: results: there were patients admitted to our icu during the study period of which patients were shifted to the wards. the average delay in shifting was around . hours ( - . hrs).delayed transfer of more than hrs was found in % patients and the percentage of after-hours transfer was % of the total transfers. there were readmissions into the icu within hrs of shift out among patients transferred in after hours as against in patients transferred during routine hours. conclusions: prevalence of delayed discharge from icu was significant, especially the after hour discharges, which has got an impact on readmission rate as well. discharge delay should be considered as an important quality indicator for critically ill patients to decrease the morbidity and mortality in icu patients. further studies are warranted to identify factors associated with delayed discharge. introduction: critical illness (ci) and stay in an intensive care unit (icu) are known to induce physical and functional changes. bone is often forgotten in survivors. limited published data reported an altered bone metabolism in case of prolonged icu stay [ ] and a decreased in bone mineral density (bmd) in the year following icu admission [ ] . clinical impact of these changes is still not well described. objectives: our retrospective study aimed to assess incidence of any new bone fractures (bf) two years after a severe ci. methods: patients admitted in our icu during were screened. adults > years (y) old with an icu length of stay (los) > days (d) were included. lost to follow-up were considered exclusion criteria. patients who died in icu or who died during the follow-up period (fup) with an icu los ≤ d were also excluded. demographic data, medical objectives: pulmonary arterial hypertension (pah) is associated with reductions in health-related quality of life (hrql). the patient care still played an important role in improvement of hrql, even though more drug therapy was identified in recent decade.. in this study, we investigated to provide quality care for patients with pulmonary arterial hypertension via multidisciplinary care model. methods: a multidisciplinary team was organized.in a tertiary medical center, including intensivists, cardiologists, pulmonologists, cardiac surgeons, rheumatologists, chest surgeons, rehabilitation physicians, psychologist, pharmacologists, hospice care physicians, nutritionist, social workers and nursing staffs. the key interventions include home based rehabilitation therapy, hours hot line care, pah care nurse training program, hospice care information and consultation, phychological care and autogenic training, prompt pah referral system, social care connections, on-line self pah risk assessment system, on-line and innovative mobile apps patient instructions, facebook patient care group and ourdoor pah patient education program. the pah patients were divided into three groups: pre-interventional group from may to dec , interventional group from jan to june and post-interventional group from july to feb . hrql was measured using the short form health survey (sf- ) in all enrolled subjects. results: the average physical compartment scale of sf- , including physical functioning; role limitations due to physical health, pain and general health improved from ± in pre-interventional group, to ± in interventional group and to ± in post-interventional group (p < . ). the average mental compartment scale of sf- , including role limitations due to emotional problems, energy/fatigue, emotional well-being and social functioning, improved from ± in pre-interventional group, to ± in interventional group and to ± in post-interventional group (p < . ). conclusions: the study demonstrated multidisciplinary care model could improve hrql of patients with pulmonary arterial hypertension. blood pressure management with urapidil for patients with aortic dissection is associated with less esmolol usage than nicardipine j.-c. zhou sir run run shaw hospital, intensive care medicine, hanghzou, china intensive care medicine experimental , (suppl ):a introduction: acute aortic disease is a common but challenging entity in clinical practice. titration the blood pressure and heart rate to a target level is of paramount importance in the acute phase regardless of whether the patient will undergo a surgery or not eventually. in addition to the initially intravenous β-blockers, parenteral infusion of nicardipine and urapidil are the most common used antihypertensive therapy currently in mainland china. however, few empirical data was available with respect to the different effect on patients' outcome of the two antihypertensive strategies, especially given the deleterious reflex tachycardia of vasodilators which may increase force of ventricular contraction and potentially worsen aortic disease. objectives: to evaluate the difference of the abovementioned two antihypertensive strategies on the outcome of patients with aortic disease. methods: all patients with new diagnosed aortic diseases presented to our hospitals from january , to june , were retrospectively reviewed. the antihypertensive strategies and their association with patients' outcomes were evaluated with logistics regression. results: a total of patients with new diagnosed aortic disease were included in the study. of them, patients received urapidil while patients received nicardipine antihypertensive therapy. patients with nicardipine were more quickly to reach the target blood pressure level than those treated with urapidil (median vs mins, p = . ). after adjustment for patient demographics, comorbidity, involved extend of aorta, interventional strategies, antihypertensive therapy with nicardipine (with urapidil as reference) for patients with aortic disease was significantly associated with high esmolol cost (or: . , %ci: . - . , p = . ) and longer icu length of stay (or: . , %ci: . - . , p = . ). however, there was no significant correlation between nicardipine use and icu mortality (or: . ; %ci, . - . , p = . ). conclusions: although nicardipine achieved the target blood pressure level more quickly than urapidil for patients with aortic disease, it was associated with more esmolol use and longer icu length of stay. introduction: postoperative bleeding is one of the most common complications of cardiac surgery. excessive perioperative bleeding continues to complicate cardiac surgery with cardio-pulmonary bypass (cpb) in spite of improvements in extracorporeal oxygenation and surgical techniques. even bleeding after cardiac surgery has variable causes, we thought the applying isth scoring system may be able to predict the postoperative excessive blood loss in patients after cardiac surgery with cpb. objectives: the aim of present study was to examine the effectiveness of international society on thrombosis and hemostasis (isth) scoring system in patients with cardiac surgery. methods: the medical records of patients undergoing elective cardiac surgery using cpb between mar. and feb. were retrospectively reviewed. these demographic and clinical characteristics, perioperative laboratory findings, and postoperative complications were assessed using computerized databases from our institution. isth score was calculated in icu and patients were divided with overt dic group and non-overt dic group. results: among patients with cardiac surgery, patients with overt dic group (n = ) or non-overt dic group (n = ) were enrolled. mean dic scores at icu admission was . ± . (overt dic group) and . ± . (non-overt dic group) and overt dic was induced in % ( / ). overt dic group had much more ebl for hrs (p = . ) and maintained longer time of intubation time (p = . ) conclusions: in spite of limitation of retrospective design, management using isth score in patients after cardiac surgery seems to be helpful for prediction of the post-cpb excessive blood loss and prolonged tracheal intubation duration. renal failure, . % vs %, p ≤ , ; respiratory failure, . % vs . %, p ≤ , ; mechanical > h . % vs . %, p ≤ . ventilation. the variables that reached statistical significance in the multivariate analysis as predictors of mortality were apache ii or . ( % ci . - . ), p = . , euroscore or . ( % ci , - . ), p < . ; acute respiratory failure or . ( % ci . to . ), p = . ; acute renal failure or . ( % ci . - . ), postoperative bleeding or . ( % ci . to . ), p < . conclusions: mortality in this group is similar to other series, being patients with more comorbidities, with the highest score in the euro-score and apache ii and more often subjected to mixed surgery. the euroscore, apache ii, respiratory failure, renal failure and postoperative bleeding, predict higher mortality. methods: we measured rea as ratio of pulmonary pressure at the dicrotic notch (dypap) and stroke volume (sv) [ ] and rees as ratio of the difference between mean pulmonary artery pressure (mpap) and wedge pressure (pcwp) and end systolic volume (resv) (mpap-pcwp/resv) [ ] after the induction of anaesthesia (t ) via pulmonary artery catheter (swanganz f and vigilance ii monitor by edwards lifesciences), after weaning from cpb (t ) and h after in icu(t ) in patients. results: measure of rvac has been demonstrated feasible in all four patients undergoing cardiac surgery. as expected all the patients were found uncoupled (rvac > ) before surgery, immediately after weaning from cpb rvac worsen and in icu it was restored to the basal. conclusions: in this preliminary analysis we demonstrated the feasibility of measuring rvac in critical patients undergoing cardiac surgery, to our knowledge this is the first report in this field. as expected rvac is very much influenced by cpb although further investigation is needed to confirm the utility of this technique to monitor the right heart in such patients. introduction: detection of tissue hypoperfusion is paramount in the management of va ecmo. arterial to pulmonary artery co difference has been demonstrated to be an early marker of hypoperfusion in the shock patient [ ] and during hypothermic cardiopulmonary bypass [ ] , objectives: in this report we investigated the accuracy and feasibility of mixed venous to arterial co difference as an early marker of perfusion mismatch during va ecmo. methods: in a patient treated with va ecmo for refractory cardiac arrest due to acute myocarditis we performed serial measurements of pulmonary artery to arterial co difference as well as svo , map, urine output and lactate level. results: during reduced perfusion periods, assessed by elevated lactacidemia (> mmol/l) we observed high > co difference which is concordant to literature [ ] . during episodes of reduced systemic perfusion, demonstrated by increase of serum lactic acid we were able to early detect hemodynamic derangement (avg minutes) by identifying elevated (> mmhg) co difference. conclusions: this case report underlines the importance of pulmonary artery to arterial co difference as an early marker of hypoperfusion if compared to lactate level in the intensive care unit. to our knowledge this is the first report on venous to arterial carbon dioxide difference in va ecmo. further investigation is needed to confirm those preliminary results. introduction: many studies have shown clinical benefits from sdd for critically ill patients. however, there is still doubt concerning the emergence of antimicrobial resistance in the long term. previously no evidence to support this view was found but long-term effects of sdd on antimicrobial resistance on the unit level is understudied. , objectives: to determine the incidence of antimicrobial resistance in aerobic gram-negative potentially pathogenic micro-organisms (agnbs) to the components of sdd and frequently used i.v. antibiotics on icu-level over a year period with unchanged antibiotic policy. methods: this is a single-center observational cohort study in a dutch -bed adult intensive care unit in a teaching hospital. all consecutive patients admitted to the icu between january and december were included when at least one culture was taken during icu-admission. data on all cultures taken during icu stay were collected from the hospital database. susceptibility testing was performed following the guidelines of the 'clinical and laboratory standards institute' (csli) until and 'the european committee on antimicrobial susceptibility testing' (eucast) from until . incidence rates of antimicrobial resistance to tobramycin, ciprofloxacin, polymyxin b or cefotaxime were calculated per year. only icuacquired resistant pathogens were selected by excluding resistant pathogens in cultures taken on day -day . patients at risk were defined as all admissions with a length of stay longer than days. differences between the incidence in the first and last year of the study were tested using chi-square test. results: data of . cultures was analyzed containing . agnbs. the number of admissions with a length of stay more than days was . in admissions newly acquired resistance to cefotaxime was found, in to polymxin b, to tobramycin and to ciprofloxacin. figure presents incidence rates per year. in - date of discharge to the ward was unknown and therefore incidence rates could not be calculated for these years but absolute numbers were comparably low. there was no significant difference in incidence of icu acquired resistance in cefotaxime (χ = . , p = . ), polymyxin b (χ = . , p = . ), tobramycin (χ = . , p = . ) and ciprofloxacin (χ = . , p = . ) between and . conclusions: the incidence of newly acquired agnb resistant to cefotaxime, polymyxin b, tobramycin and ciprofloxacin continues to be low during a year unchanged antimicrobial policy of sdd. the increase in resistance in the society may impact these numbers and should be studied. results: overall, icu and h mortality rates were and %. . % of the pts ( / ) became infected in the early postoperative period. (icu and h mortality rate and % respectively). crpk infections were present in pts ( . % of the entire series, . % of the infected pts). sarcopenia ( % vs %, p = . ) and meld ( + vs + , p = . ) were significant preoperative risk factors. icu and h mortality rates were % and % in crpk pts, % and % in non -crkp infected pts respectively : while icu mortality was not different (p = . ), h mortality was significantly higher in crkp pts (p = . icu vs h, ci . - . ). if compared to non -crkp pts , crkp pts were more often in septic shock ( % vs %, p = . ) and more frequently underwent crrt ( % vs % p = . ). intraabdominal infections were largely represented ( %) among crkp pts. blood loss and transfusion needs, early gratt dysfunction and reolt were more represented in infected vs non infected pts. however, no differences were found when crkp and non-crkp transplanted pts were compared. conclusions: crkp infections are on the rise also in italy. post olt mortality is high and strategies able to control crkp are urgently needed to be implemented. introduction: the prevalence of antibiotic-resistant pathogens in icu conditions makes it difficult to treat these infections, and treatment becomes impossible in some cases. acinetobacter baumannii is important infectious agent icu patients, which effective antibiotic therapy is currently limited. objectives: we aimed to determine the range of a.baumannii associated infections among icu patients, to summarize the level of resistance to antimicrobial drugs, and provide an overview of strategies to prevent the spread of resistance. methods: a prospective microbiological study of the prevalence and antibiotic resistance of a.baumannii strains isolated from adult icu patients hospitalized to the tertiary hospital after cardiac surgery from to . results: a total of isolates from icu patients were included to the study. . % of the isolated strains ( ) were gram-negative, among which . % ( ) of a.baumannii isolates. strains of a. baumannii showed a high level of resistance to the iii generation cephalosporins ( . % to ceftazidime, . % to cefotaxime, . % to ceftriaxone). resistance to carbapenems was at %. investigation of antimicrobial activity of ciprofloxacin showed the resistance in . % of strains, to levofloxacin - . %. the lowest level of resistance recorded to doxycycline - . % and polymyxin - . %. conclusions: rapid microbiological diagnostics (including the results of antibiotic resistance), strict adherence to infection control, the appointment of an effective regime of antibiotic therapy, optimization schemes appointment of antibiotics, all of which are the most important priorities for the effective fight against a. baumannii associated infections in icu patients. in order to reduce the emergence and spread of drug-resistant strains in the icu, it is strongly recommended to carry out microbiological monitoring and optimization of the use of antibiotics in each hospital. therefore local resistance surveillance programs have the greatest value in the development of appropriate therapeutic recommendations for specific types of patients and infections. introduction: acinetobacter spp. are opportunistic, nosocomial pathogens that may colonize the surfaces in intensive care units. their tendency to harbor multi-drug resistance and to develop resistance mechanisms to commonly available drugs make their treatment a challenge. carbapenem resistance, and newly reported colistin resistance has led to a search for new treatment options. there are in vitro studies which report synergistic effect with rifampicin in combination therapies. objectives: we aimed to present and discuss the results of our patients who were infected with either panresistant ( patients) or only tigecycline susceptible ( patients) acinetobacter spp. and were treated with rifampicin combination regimens. methods: patients reported to be infected with colistin resistant acinetobacter spp. and treated with rifampicin combination regimens upon decision of the responsible teams were traced from the intensive care unit (icu) records between the years and retrospectively. their demographic data, liver function tests, icu and hospital outcomes were recorded. results: there were a total of patients, were women. mean age was . . in patients pulmonary site was the source. nine patients had positive blood cultures. mean sofa score at the start of therapy was . ; all were intubated, and ( %) were on vasopressor therapy. combination regimens comprised of at least antibiotics and all regimens included rifampicin and tigecycline. at the end of first week, mean sofa score was . . of these ( %) survived to hospital discharge. patients who were lost had higher initial and follow-up sofa scores. initial and follow-up liver enzymes and renal function tests were similar to their basal values in patients who survived; unlike the patients who were lost. when lost patients were re-evaluated: the first patient had irreversible lung fibrosis due to bleomycine; in the second patient; combination treatment was delayed until days after the cultures were performed; the third patient had been admitted to icu with acute renal failure and acute respiratory distress syndrome, after autologous stem cell transplantation for multiple myeloma. conclusions: when the importance of accurate antibiotic choice is taken into account for treatment success; rifampicin combinations may be considered as an appropriate treatment option for infections caused by colistin resistant acinetobacter strains. introduction: carbapenem resistant enterobacteriacae (cre) emerged in recent years as one of the most challenging group of antibiotic resistant pathogens. polymyxins are considered as the last resort for the treatment of infections with carbapenem resistant gram negative bacilli (gnb). inadequateor extensive use of colistin leads to emergence of colistin resistance, increasing mortality and morbidity and necessitating prudent use of alternative antibiotics. fosfomycin, a phosponic acid derivative which acts by disrupting bacterial cell wall synthesis, is a broad spectrum antibiotic. it is available as sodium/disodium formulation for intravenous use and is showing promising result against multi drug resistant(mdr)/pan drug resistant (pdr) pathogens. methods: a total of eight colistin resistant (mic ≥ ) gnb were isolated from icu patients with nosocomial mdr infections during a period of one year. all eight isolates were klebsiella pneumonia. among these isolates five were from blood and three from endotracheal aspirate. all the isolates were sensitive to fosfomycin in vitro. all of these patients had multiple co-morbidities with recent history of colistin exposure. intravenous fosfomycin was given as a combination therapy. results: among the five bacterimic patients, three recovered completely from sepsis. one patient took discharge against medical advice and the only one bacterimic patient who died during the course of therapy was later on diagnosed to have azole resistant fungemia as super infection. the patient with ventilator associated pneumonia also responded well after initiation of fosfomycin therapy. average duration of antibiotic therapy in all these cases was ten days. conclusions: based on the evidence of clinical experience and available studies, intravenous fosfomycin therapy may be considered as the last option for the treatment of mdr gnb infection where there is documented colistin resistance and where there is literally no other choice of antibiotic therapy. the success of the therapy is encouraging in selected group of patients. further research on intravenous fosfomycin use specially against mdr pathogens and on the effectiveness and safety of the drug in the treatment of patients with such infections may be warranted. introduction: patients at the intensive care units have an increased risk of infection due to their underlying diseases or conditions, impaired immunity, and exposure to multiple invasive procedures (surgery, mechanical ventilation, central venous catheters, artherial catheters, urinary tract catheters). multidrug-resistant organisms infection has become a public health problem and has been associated with increased morbidity, mortality, and costs. objectives: to analyze the principal features of postsurgical patients with colonization or infection by multidrug-resistant organisms, acquired before the admission at the intensive care unit. methods: retrospective observational study, descriptive, case series, collected from / / to / / in a -bed hospital, with a -bed polyvalent intensive care unit in fuenlabrada, madrid, spain. the hospital is attached to resistance zero project, with screening at admission and every week in all patients (pharyngeal, rectal, nasal, wounds and bronchial suction). postsurgical patients have been identified with multidrugresistant organisms isolation in screening in the first hours of admission to the intensive care unit. studied variables: age, sex, adjusted charlson comorbidity index, barthel index, apache ii, saps , days of hospitalization prior to icu, days of antibiotic treatment administered before icu, previous days of parenteral nutrition, prealbumin, surgical wound infection, multigrug-resistant organisms identified sample. statistical analysis: spss . categorical in frequencies and percentages, mean and standard deviation or median and interquartile range. analysis kolmogorov smirnov, shapiro wlik and qqplot to normality. confidence intervals (ci) % by t student for normal variables, boot stramp to not normal. results: in months we identified postsurgical patients with multidrug-resistant organisms in screening at the admission or before the admission to the intensive care unit. multidrug-resistant organisms identified: pseudomonas aeruginosa ( . %), esbl enterobacteriaceae ( . %), mrsa ( . %), stenotrophomonas maltophilia ( . %). isolated on: surgical wound ( . %), bronchial suction ( . %), peritoneal fluid ( . %), exudates monitoring ( . %), blood ( . %). antibiotic therapy: carbapenem ( . %), piperacilina-tazobactam ( . %). conclusions: in our study the risk of prior acquisition of multidrugresistant organisms at the admission to the intensive care unit in postsurgical patients was characterized by long hospital stay, high comorbidity and dependence, malnutrition, prolonged use of broadspectrum antibiotic, parenteral nutrition and surgical wound infection. introduction: the emergence and dissemination of klebsiella pneumoniae carbapenemase (kpc) is of great concern. outbreaks have been reported in different types of intensive care units (icu). in brazil, there have been reports of kpc since . we recently experienced a large outbreak at our hospital. risk factors for kpc colonization and outcome of icu patients are still to be determined. objectives: to study the differences between patients who acquired from those who did not acquired kpc during their stay in the icu, focusing on risk factors and outcomes. introduction: patients with a prolonged weaning represent a small part of the total icu population but this prolonged state has many implications on their later recovery and can highly impact health expenditures. objectives: to better characterize patients with prolonged weaning and assess factors associated with their survival. methods: the prospective multicentre observational wind (weaning according new definition) study was performed from april to august . ventilation and weaning modalities were daily assessed until discharge in all intubated patients admitted to the participating icus. we defined ) weaning attempt (wa) as a spontaneous breathing trial (sbt) or an extubation (with or without sbt), ) successful weaning as an extubation without death or invasive mechanical ventilation within days. we considered patients as having a prolonged weaning if weaning was not terminated at days following their first wa. conclusions: in this multicentre international prospective cohort, . % of the patients entering the weaning process had a prolonged weaning with a high mortality rate of . %. the only baseline factor associated with death were previous immunodeficiency and chronic cardiac failure. these patients highly impact the icu workload as they receive mechanical ventilation for a median duration of days and their median length of stay in the icu is days. patients with a prolonged weaning spend a long icu time after the end of weaning without mechanical ventilation raising the issue of the need for specialized units. introduction: ineffective efforts (ie), defined as the inability of patient's inspiratory effort to trigger a ventilator-delivered breath, is a commonly encountered asynchrony, and has been reported to adversely affect patient outcome , , . the incidence of ie depends on several factors, including patient population, ventilator settings, and the observation period, which in most studies so far was limited , . objectives: aim of this study was to investigate the incidence of ineffective efforts, using continuous recordings, in critically ill patients mechanically ventilated only on assisted mode and their potential effects on patient outcome. methods: adult critically ill patients hospitalized in the icu of the university hospital of heraklion on mechanical ventilation for > h were enrolled. patients were studied when they were on assisted ventilation for > hour and expected to remain on assisted ventilation for the next hours. patients were studied again on the rd and th day if they remained on assisted ventilation. continuous h measurements were obtained using a monitor validated to identify ineffective efforts (pvi monitor) . the output of pvi monitor data was processed before analysis to optimize data quality and re-sampled to a time-series with the number of ies calculated in uniform intervals of secs while preserving the total number and duration of ies . the ie index was calculated as previously described. because ie occurred in clusters, the concept of ie event was introduced, to describe variable periods of time containing ie > % of breaths. ie events were characterized by their duration and power (number of ie) . introduction: the neural timing during mechanical ventilation can be obtained from conventional airway flow tracing, or invasive esophageal and gastric signal; however, it is difficult clinical practice and could be imprecise. the first derivative of airway flow signal show line segments with distinctly different slopes and with welldefined the inflections points, therefore this closely indicate the respiratory times, it can be calculated easily. objectives: to evaluate the accuracy of the derivative of the flow signal (df) as method for measurement of the respiratory times compared with esophageal-gastric signals. introduction: providing appropriate levels of pressure support (ps) at the bedside is challenging. physicians should avoid both over-support, which increases the risk of lung trauma, muscle atrophy and prolonged weaning; and under-support, which increases the risk of patient discomfort and respiratory muscle fatigue. the latter can be determined by the using the tension time index of the inspiratory muscles (tti es ) derived from measurement of esophageal pressure. tti es values higher than . indicate fatiguing patient effort. the beacon caresystem (mermaid care, denmark) advises on level of ps using physiological models of lung mechanics, pulmonary gas exchange, respiratory drive, acid-base status and muscle function; along with clinical preference functions quantifying the risk of muscle atrophy, patient stress, and lung trauma. mathematical models are tuned to measurements allowing advice to be patient specific. objectives: this study investigates the variation of tti es and other indices of respiratory muscle function induced by an increase/decrease of the level of ps, and whether the consequent advice proposed by the beacon system results in appropriate patient effort. methods: ten patients with acute respiratory failure residing in an icu in ferrara, italy, have currently been included for this analysis. an esophageal balloon was inserted and its correct position determined by the occlusion test. the advice of the beacon system was followed for an hour from states of over-and under-support defined as % and % of baseline ps. the level of peep was kept constant throughout the study. data were analysed in terms of tti es and esophageal pressure developed in the first ms of an occluded inspiration (p . ) results: the baseline tti es values of . ± . were consistent with absence of fatiguing effort in all patients but one. as expected, reducing/increasing the level of ps resulted in tti es and p . increase or decrease, respectively. in patients the reduction of ps was associated with impending muscle fatigue. the levels of ps proposed by the beacon system resulted in tti es of . ± . , slightly higher than obtained by the treating physician, but always below the values indicating muscle fatigue, a part from the patient in which the tti es indicated fatigue at baseline. of note, this new value of tties was not associated with a significant variation p . , which implies that the proposed level of ps was not associated with an increased respiratory drive or higher transpulmonary pressure conclusion: these initial results indicate that beacon caresystem responds appropriately to over-and under-support avoiding muscle fatigue and excessive p . . the use of vo level changes as a predictor for weaning success in the mechanically ventilated patients introduction: experimentally, hyperchloraemia may induce vasoconstriction of the renal afferent arterioles and tubular dysfunction, potentially resulting in acute kidney injury (aki). the clinical implications of these findings are not well established, especially in septic patients. objectives: to investigate whether chloride serum and urinary concentrations as well as chloride load, output, balance and urinary anion gap are associated with the development of aki in septic patients. methods: retrospective analysis of an institutional database including all patients admitted to the intensive care unit (icu) for severe sepsis and septic shock from january to june . inclusion criteria were length of stay in the icu ≥ hours and complete data available on serum and urinary samples for at least days. patients were excluded if they had anuria on icu admission, continuous bladder irrigation, if they were on hemodialysis (of recent onset and chronic) and if they were kidney-transplanted. demographics and data on outcome were also analysed from the database. we collected chloride levels on daily blood (bcl) and urinary (ucl) analyses; chloride load (cl) was calculated by considering the amount of chloride present in the iv fluids administered daily to the patient, while chloride balance (cb) was calculated as: cl -co, where co is chloride output (ucl * daily urine output). creatinine clearance (crcl) was calculated on -hr urinary collection. aki was defined according to standard criteria. conclusions: most of septic patients developed aki and this complication was associated with a significant reduction in renal chloride elimination. the impact of such findings on the management of fluid therapy in this setting remains to be further evaluated. introduction: plasma interleukin (il- ) is associated with acute kidney injury (aki) in sepsis. il- receptor (il- r) is not expressed in the kidney. circulating il- in a complex with soluble il- r (sil- r) activates ubiquitously expressed transmembrane signal transducing glycoprotein on renal epithelial cells. this il- trans-signaling is associated with mortality in experimental sepsis. objectives: to study il- trans-signaling in patients with sepsis in a clinical intensive care setting. methods: in septic patients showing first organ failure at intensive care unit (icu) admission ± hours, we measured plasma il- and sil- r at admission and hours later. our primary endpoint was aki during the first five icu days by kdigo criteria. mann-whitney's, spearman's correlation and chi square tests were used. results: plasma il- was significantly higher in patients with aki at h (p = . ) and h (p < . ). plasma il- correlated with kdigo stage at h (r = . , p = . ) and h (r = . , p < . ). plasma sil- r did not differ between aki and non-aki groups. using cut-off values of pg/ml of il- and pg/ml of sil- r at h (detected by youden method), the combination of low il- and low sil r was associated with non-aki (p < . ). conclusions: combination of low il- and low sil- r in plasma is associated with decreased incidence of aki, suggesting that il- transsignaling contributes to septic aki. . % for the non-aki group (or = . ; % ci, . - . , p < . ). multivariate analysis indicated that the bpv was well associated with aki (adjusted or = . ; % ci, . - . , p < . ) while the mean blood pressure was not (adjusted or = . ; % ci, . - . , p = . ). conclusions: elevated blood pressure variability is associated with increased risk of aki in septic patients. this understanding may be helpful to develop requirement for stabilising blood pressure in the bp management of septic patients. introduction: acute kidney injury (aki) is a frequent and serious complication of sepsis in intensive care units (icu). according to acute kidney injury criteria (akin), the most current diagnostic criteria for aki is an abrupt (within hrs.) reduction in kidney function currently defined as an absolute increase in serum creatinine of more than or equal to . mg/dl, or . fold from baseline or a reduction in urine output (documented oliguria of < . ml/kg per hr. for > hr.). by time of occurrence of these criteria actual kidney insult has occurred & probably this leads to late intervention for kidney protection &/or renal replacement therapy (rrt). so early prediction of aki by using biomarkers like urinary angiotensinogen could help patients to benefit from a quicker and more appropriate therapy. urinary angiotensinogen appears quite promising due to its reported correlation with the intrarenal angiotensinogen and angiotensin ii levels which play a major role in molecular mechanisms of aki. objectives: the aim of this work was to evaluate the role of urinary angiotensinogen as a possible predictor of aki in patients with severe sepsis. methods: the study was carried on adult patients who were admitted to the department of critical care medicine, at the alexandria main university hospital and who suffered from severe sepsis. patients were categorized into two groups according to aki development; non aki group which consisted of patients (group i), and aki group which consisted of patients (group ii). patients were excluded if they have chronic kidney disease, already started rrt, received angiotensin convertase enzyme inhibitors (acei) or angiotensin receptor blockers (arbs), or septically shocked. urinary angiotensinogen and creatnine were withdrawn once from each patient on the day of admission to calculate urinary angiotensinogen/creatinine ratio (uancr, ng/mg). akin staging was assessted daily for seven days. results: there was a significant difference between the two studied groups regarding uancr ratio on admission (p < . ), whereas this introduction: acute pancreatitis with organ dysfunction is termed severe acute pancreatitis (sap) and complex sap if local complications develop (such as infected pseudocyst). we receive tertiary referrals of complex sap patients to our unit, who often have multiple ct scans. muscle wasting is known to occur in critically ill patients ( ) and can be quantified by measurement of the cross-sectional area (csa) of para-spinal muscles at the third lumbar vertebral level on ct imaging. aki is one of the most common causes of death in sap patients ( ) and is a risk factor for developing ckd ( ). kdigo guidelines suggest using creatinine changes to detect aki ( ) but creatinine changes may be inaccurate in the presence of musclewasting (myopenia) ( ). objectives: to utilise measurements of l para-spinal muscle csa (l mcsa) from complex pancreatitis patients between april -december and compare these to changes in plasma creatinine during their icu stay. methods: patients were identified from our icu patient database (wardwatcher software) and additional clinical details including creatinine/egfr level on ct-scan days, were acquired from electronic databases. images were exported from our pacs system as dicom files and analysed using imagej software (ref) in duplicate by two independent users, average values were used. for patients who had no renal-replacement therapy (rrt), between-scan l mcsa and creatinine change were paired and analysis was with excel (ms) and graphpad (prism). results: patients met inclusion criteria. patients had ≥ ct scans in icu, enabling serial estimation of l mcsa. / ( . %) patients did not have rrt in icu. there was no statistically significant difference in overall (start to end of icu) % change of l mcsa between patients who did/did not have rrt. there was also no correlation between overall (start-to-end of icu) % creatinine change and % change/day l mcsa: r = − . , p = . . for between-scan data (n = ): the median (iqr) % creatinine change/scan was − . % (− . to − ) and the % l mcsa change/ scan was − . % (− . to − . ). however, there was no correlation between % l mcsa change and % creatinine change between scans ( r = − . , p = . ). conclusions: l mcsa (relating to lean muscle mass) was shown to decrease in complex severe acute pancreatitis (sap) patients. however, there was no correlation with change in l mcsa and change in creatinine. this suggests that normal/stable creatinine values may be falsely reassuring in the context of muscle mass loss (myopenia) and ongoing aki could be under-diagnosed. acknowledging myopenia and interpreting creatinine value in context is therefore vital. introduction: continuous renal replacement therapy (crrt) is the most common therapy in critical ill patients with acute renal failure, having circuit coagulation as the most frequent complication. the crrt circuit requires careful anticoagulation to avoid coagulation and bleeding complications. critically ill patients with acquired antithrombin (at) deficiency, may have a shorter filter lifespan. objectives: evaluate the relation between the modification of at levels from baseline and circuit survival during ccrt. we would like to determine the existence of an at critical level, related to the risk of the clotting filter. methods: we started an observational study with prospective data collection in a university hospital. from october to april , patients were included, with filters in total. we measured the level of at activity at the beginning (basal at), daily, and at the moment of circuit coagulation. we divided the patients in two groups depending in their at´s basal level (< % or > %). then, we observed the percentage of change in at from baseline, and we divided the patients in tertiles to obtain three comparable groups. the main outcome measure was filter lifespan of first circuit and the correlation with at´s levels. results: low at´s basal level (< %) has significant association with longer filter life span (p = . ). we obtained three groups according to a percentage changes of ± % in at from baseline. one group declined the at´s basal level ( % decrease), other had little changes (between % decrease and % increase) and the last one had an increase ( % increase). the group which presented the highest percentual increase showed the largest median survival time to circuit coagulation ( hours; % ci: - ). we observed a significant association (p = . ) between the greater percentage change in at from baseline, and a larger time intervals to circuit coagulation. conclusions: the circuit lifespan shows a narrow correlation with evolution of at´s levels since the start of crrt until filter clotting. at measurement should be considered an essential factor during crrt. calcium supplementation was required with filters ( %) in patients ( %). in these patients, the median supplementary calcium dose (in addition to replacement fluid ca) was . mmol/hr ( . - . ). of those were initiated with calcium with only requiring further calcium in the next filter and did not ( patient who started on calcium only used filter). one patient in the citrate group was discontinued for alkalosis. no patients were discontinued for hypocalcaemia. conclusions: post dilution rca, using replacement fluid which contains calcium, in patients with a relative contraindication to heparin, reduces need for post filter calcium supplementation and provides acceptable filter life. mortality risk factors in continuous renal replacement therapy in a university hospital from colombia c. introduction: acute kidney injury (aki) occurs in more than % of critically ill patients, % need renal replacement therapy, preferring continuous therapies. however mortality seems not to change with this technology. the research available focus on the right time to start therapy, but only evaluating renal dysfunction characteristics. objectives: to identify mortality risk factors at the start of continuous renal replacement therapy (crrt) for acute kidney injury and early mortality risk factors in this patients. methods: a cohort study was performed in patients over years old with aki who required crrt in the intensive care unit of a university hospital in bogota colombia between and . the crrt was provided with aquarius® edwards® technology, polyethersulfone membrane of . and . m (aquamax®) and replacement fluids with lactate (premixed®). modality selection were guided by the hospital guideline. sample size calculation was estimated selecting cases (death) for each variable associated with mortality. a description of demographic and clinical variables was performed, bivariate analysis with mortality and early death defined as death within hours of onset of crrt, and finally we proceed to perform a multivariate prediction analysis. we considered statistically significant p value < . . results: a total of patients required crrt during the period, ( . %) patients were excluded, (age under years old, incomplete data and chronic kidney disease on dialysis). the mean age was . years (± . ), . % men. the most frequent cause of aki was sepsis in . % of cases. a total of crrt days were conducted with a median of days per patient (range - ). mean charlson comorbidity index was . (± . ), apache ii score . (± . ), total non-renal sofa had a median of (range - ) at the time of starting therapy. the hospital mortality was . % and early mortality was . %. in multivariate analysis: age (p = . ), sofa (p = . ), days door-support (p = . ) and the presence of hypotension (p = . ) were independent risk factors for hospital mortality with an area under the curve of . . for early death lactic acid levels (p = . ), glucosa (p = . ) and age (p = . ) were independent risk factors with an area under the curve of . . conclusions: patients with aki on crrt have high mortality. age, multiple organ dysfunction, hypotension and time door-support were independent mortality risk factors. low levels of glucose and high lactate at onset of crrt are independent risk factors of early death. pediatric formulas for the anesthesiologist the role of bystanders, first responders, and emergency medical service providers in timely defibrillation and related outcomes after out-of-hospital cardiac arrest: results from a statewide registry kids save lives-training school children in cardiopulmonary resuscitation worldwide is now endorsed by the world health organization (who) acute skeletal muscle wasting in critical illness enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: a quality improvement project pdf . nice quality standard (qs ) stroke in adults the sentinel stroke national audit programme (ssnap) interventions to improve the physical function of icu survivors core standards for intensive care units icu early mobilization: from recommendation to implementation at three medical centres revista brasileira de terapia intensiva invasive pulmonary aspergillosis is a frequent complication of critically ill h n patients: a retrospective study isolation of aspergillus in three h n influenza patients. influenza other respir viruses grant acknowledgement supported by fucap and ciberes effect of daily chlorhexidine bathing on hospitalacquired infection chlorhexidine 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observational cohort study the mortality risk of over hydration in haemodialysis patients ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. time course for resolution sufficient sleep quality easily measured: a multicenter centre study in dutch icus rd international symposium on intensive care and emergency medicine using nursing activities score to assess nursing workload on a medium care unit nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care unit: a literature review nursing activities score in the intensive care unit: analysis of related factors. intensive and critical care nursing organisation and management of intensive care : a prospective study in european countries impact of performance obstacles on intensive care nurses' workload, perceived quality and safety of care and quality of working life burnout syndrome in critical care nursing staff work engagement: an emerging concept in occupational health psychology diagnostic accuracy of clinical swallow assessment for oropharyngeal aspiration: a systematic review the cruelest lies are often told in silence critical review: is the endoscopic swallowing assessment (abstract a ). lactate (sepsis vs trauma) jaundice in the intensive care unit cooling techniques for targeted temperature management post-cardiac arrest thermoregulatory catheter-associated inferior vena cava thrombus ivtm intravascular temperature management catheter specifications prediction of postoperative pulmonary complications in a population-based surgical cohort lung ultrasound: routine practice for the next generation of internists relevance of lung ultrasound in the diagnosis of acute respiratory failure* assessment of hemostasis after plasma exchange using rotational thrombelastometry (rotem) prevention of pain on injection of propofol: systematic review and meta-analysis prevention of pain on injection with propofol: a quantitative systematic review mechanical ventilation guided by esophageal pressure in acute lung injury ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia ards definition task force endotracheal tubes cuff pressure control: does the co matter? minerva anestesiol incidence and outcome of in-hospital cardiac arrest in the united kingdom national cardiac arrest audit delayed awakening after cardiac arrest: prevalence and risk factors in the parisian registry diaphragm ultrasound as a new index of discontinuation from mechanical ventilation critical ultrasound journal ventilator-induced diaphragm dysfunction: time for (contr)action! the course of diaphragm atrophy in ventilated patients assessed with ultrasound: a longitudinal cohort study critical care effect of postextubation high-flow nasal cannula vs conventional oxygen therapyon early non-invasive ventilation treatment for severe influenza pneumonia use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy the first patient report of the national emergency laparotomy audit acute kidney injury enhances outcome prediction ability of sequential organ failure assessment score in critically ill patients médecine intensive et réanimation development and validation of a questionnaire for quantitative assessment of perceived discomforts in critically ill patients the emotional and cognitive impact of unexpected simulated patient death the efficiency of instructional conditions: an approach to combine mental effort and performance measures long-term cognitive impairment after critical illness satisfacción laboral de los profesionales sanitarios de un hospital universitario: análisis general y categorías laborales the nurse satisfaction, service quality and nurse retention chain: implications for management of recruitment and retention grant acknowledgement am: moulton foundation hospital/kcl the very elderly admitted to icu: a quality finish? crit care med a global clinical measure of fitness and frailty in elderly people cognitive, functional, and quality-of-life outcomes of patients aged and older who survived at least year after planned or unplanned surgery or medical intensive care treatment outcome of elderly patients with circulatory failure. int care med understanding and reducing disability in older adults following critical illness mechanical ventilation in a cohort of elderly patients admitted to an intensive care unit preferences of current and potential patients and family members regarding implementation of electronic comunication portalls in intensive care units caring for the family of the critically ill patient the carina as a radiological landmark for central venous catheter tip position duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests duration of prehospital resuscitation efforts after out-of-hospital cardiac arrest neurologic prognosis after cardiac arrest magnetic resonance imaging markers of parkinson´s disease nigrostriatal signature disruption of posteromedial large-scale neural communication predicts recovery from coma james mcdonnell foundation, the belgian american education foundation, university milano bicocca. fig. (abstract a ). study flowchart intensive care medicine experimental neurological prognostication after cardiac arrest strategies for improving survival after in-hospital cardiac arrest in the united states: consensus recommendations: a consensus statement from the cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved -day clinical outcomes in patients with st-segment elevation myocardial infarction complicated with profound cardiogenic shock the current use of impella . in acute myocardial infarction complicated by cardiogenic shock: results from the uspella registry mechanical circulatory support in cardiogenic shock cardiac transplantation research database group, long-term outcomes of cardiac transplantation for peripartum cardiomyopathy: a multiinstitutional analysis cardiopulmonary resuscitation with assisted extracorporeal life support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in countries in europe and the united states nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial feasibility and observed safety of interactive video games for physical rehabilitation in the intensive care unit: a case series is admission to the intensive care unit associated with chronic opioid use? a -year follow-up of intensive care unit survivors survival to icu discharge in ventilated patients intensive care medicine experimental modified early warning score with rapid lactate level in critically ill medical patients: the views-l score impact of matrix-assisted laser desorption ionization time-of-flight mass spectrometry on the clinical management of patients with gram-negative bacteremia: a prospective observational study. clinical infectious diseases : an official publication of the infectious diseases society of america impact of rapid organism identification via matrix-assisted laser desorption/ionization time-of-flight combined with antimicrobial stewardship team intervention in adult patients with bacteremia and candidemia. clinical infectious diseases : an official publication of the infectious diseases society of america impact of rapid identification of acinetobacter baumannii via matrix-assisted laser desorption ionization time-of-flight mass spectrometry combined with antimicrobial stewardship in patients with pneumonia and/or bacteremia. diagnostic microbiology and infectious disease an international cross-sectional survey of antimicrobial stewardship programmes in hospitals continuous infusion of beta-lactam antibiotics in severe sepsis: a multicenter double-blind, randomized controlled trial hplc determination of plasma free and total tazobactam and piperacillin effectiveness of polymyxin bimmobilized fiber column in sepsis: a systematic review crit care predicting functional impairment in brain tumor surgery: the big five and the milan complexity scale *p. ferroli the "medial-oblique" approach to ultrasoundguided central venous cannulation-maximize the view, minimize the risk medial-oblique" probe position for ultrasound-guided internal jugular vein cannulation: a crossover study improving survival from sudden cardiac arrest: the "chain of survival" concept practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the quality standards subcommittee of the american academy of neurology association of bystander interventions with neurologically intact survival among patients with bystander-witnessed out of hospital cardiac arrest in japan performance of the revised atlanta and determinantbased classifications for severity in acute pancreatitis rational fluid therapy for sepsis and septic shock what do recent studies tell us? review article surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock fluid type and the use of renal replacement therapy in sepsis: a systematic review and network meta-analysis. int care med the third international consensus definitions for sepsis and septic shock fernández-ortega regional university hospital in málaga rapid diagnosis of infection in the critically ill, a multicenter study of molecular detection in bloodstream infections, pneumonia, and sterile site infections grant acknowledgement supported, in part cytokines and signaling molecules predict clinical outcomes in sepsis the application of esophageal pressure measurement in patients with respiratory failure mechanical ventilation guided by esophageal pressure in acute lung injury ecmo criteria for influenza a (h n )-associated ards: role of transpulmonary pressure mechanical ventilation guided by esophageal pressure in acute lung injury fig. (abstract a ) grant acknowledgment national cheng-kung university hospital grant a assessment effort and work of breathing by airway occlusion pressure versus esophageal pressure hospital universitario reina sofia, intensive care unit airway occlusion pressure effects of the prone position on respiratory mechanics and gas exchange during acute lung injury effects of prone position on alveolar recruitment and oxygenation in acute lung injury prone position reduces lung stress and strain in severe acute respiratory distress syndrome lateral positioning of ventilated intensive care patients: a study of oxygenation, respiratory mechanics, hemodynamics, and adverse events the effect of lateral position on oxygenation in ards patients : a pilot study the open lung concept of mechanical ventilation: the role of recruitment and stabilization selecting the 'right' positive endexpiratory pressure level esophageal and transpulmonary pressures in acute respiratory failure spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model: high transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury relationship between activation of the sympathetic nervous system and renal blood flow autoregulation in cirrhosis hepatorenal acute kidney injury and the importance of raising mean arterial pressure a fig. (abstract a ) rotational thrombolelastometry produces potentially clinical useful results within min in bleeding emergency department patients: the deuce study thrombelastography and rotational thromboelastometry early amplitudes in trauma patients with clinical suspicion of severe injury a prospective study of anaemia status, haemoglobin concentration and mortality in an elderly cohort a experience with a hospital-wide implementation of a massive transfusion protocol: before and after a references . experience with a massive transfusion protocol in the management of massive haemorrhage rodríguez villamizar hospital universitario puerta de hierro majadahonda recommendations for end-of-life care in the intensive care unit: a consensus statement by the american college of critical care medicine end-of-life care practices in patients dead as a result of a devastating brain injury and organ donation in spain prediction of potential for organ donation after cardiac death in patients in neurocritical state: a prospective observational study causes of family refusal for organ donation development of the croatian model of organ donation and transplantation evaluation of organ procurement in an area under the influence of a training program grant acknowledgment none. a non-heart beating donor program: seville's experience l. martin-villen , the variables analyzed were: total number of queries activation, of pd, of eligible donors (ed) and of real donors (rd). rd attendance times were registered and we defined out-of-hospital time (from cardiac arrest to hospital arrival), inof-hospital time (from hospital arrival to cannulation onset), cannulation time (beginning of cannulation to perfusion onset) and perfusion (from perfusion onset to the first organ removal). we registered number and type of valid organs and tissues, number of family members or judicial negative, number of non-real-donors (nrd) and its causes regarding attendance times, the median time was (icr - ) minutes for out-of-hospital, (icr - ) minutes for in-of-hospital, ( - ) minutes for cannulation and ( - )minutes for perfusion controlled donation after circulatory determination of death in spain rodriguez villamizar puerta de hierro hospital, intensive care unit, majadahonda, spain correspondence: j. veganzones ramos -puerta de hierro hospital the use of lung donors older than years: a review of the united network of organ sharing database marginal donor lungs: a reassessment liberalization of donor criteria may expand the donor pool without adverse consequence in lung transplantation the human organ transplant act. legislative acts and guidelines, ministry of health amendment of the human organ transplant act lebrón-gallardo regional university hospital in málaga grant acknowledgment this work was funded by the innovation awards from the department of medicine recombinant human soluble thrombomodulin in sepsis-induced disseminated intravascular coagulation: a multicenter propensity score analysis a successeful strategy to reduce ventilator getting started kit: prevent ventilator associated pneumonia. cambridge ma: institute for healthcare improvement umr_s and hôpital pitié-salpêtrière, respiratory division and medical icu trends in tracheostomy for mechanically ventilated patients in the united states outcome of patients with cirrhosis requiring mechanical ventilation in icu the impact of organ dysfunction in cirrhosis: survival at a cost? does intermediate care improve patient outcomes or reduce costs abbreviations: tbs, tracheobronchial secretions aki, acute kidney injury hd, hemodialysis a patient perceptions of physiotherapy in icu: a qualitative study m dimensionamento da equipe de enfermagem da uti-adulto de um hospital ensino -rev. eletr. enf critérios para admissão de pacientes na unidade de terapia intensiva e mortalidade patient acuity rating: quantifying clinical judgment regarding inpatient stability identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the modified early warning score the epidemiology of chronic critical illness in the united states impact of chronic critical illness on the psychological outcomes of family members tracheostomy procedures in the intensive care unit: an international survey percutaneous tracheostomy: a yr prospective evaluation of the single tapered dilator technique can outcomes of intensive care unit patients undergoing tracheostomy be predicted? respir care safety and complications of percutaneous tracheostomy in a cohort of mixed icu patients prognostic consequences of borderline dysnatremia: pay attention to minimal serum sodium change. crit care are the dysnatremias a permanent threat to the critically ill patient? a explore the dengue-related risk factors and death factors in dengue hemorrhagic fever epidemic in taiwan diabeted with hypertension as riak factor for adult dengue hemorrhagic fever in a predominantly dengue serotype epidemic: a case study characteristics of dengue epidemics in taiwan modelling risk of cardio-respiratory instability as a heterogeneous process grant acknolwedgment nih ninr r nr during two years, we included all patients with more than days of stay in a medicalsurgical icu. previous informed consent , we collected demographics data, baseline functional status (barthel scale), mortality intrauci, at hospital and one-year of hospital discharge chronic critical illness a comparison between -dimentional speckle tracking & color-tissue doppler imaging for the assessment of left ventricular global longitudinal systolic strain and strain rate in outcome prediction of sepsis grant acknolwedgment italian ministry of health, italy (convenzione n. /gr- - ); and fondazione sestini exclusion criteria: do not resuscitate order. protocol: data were collected anonymously according to the utstein style. follow-up: months long using registry office and telephonic interview. data: age, sex, cerebral performance category (cpc good moderate disability, severe disability, unconscious), site of cardiac arrest, presumed etiology, initial rhythm (shockable or unshockable), witnessed event, monitored, cpr started within minute. primary end points: return of spontaneous circulation (rosc), survival to hospital discharge and cpc - . secondary end points: months survival and cpc - . statistics: numerical data are expressed as mean ± standard deviation or median (interquartile range), as percentage if ordinal data. chi-square test for ordinal data and t student's test for numerical data were performed. p significant if < . . results: cardiac arrests, cpr was carried out in cases ( %) secondary end points: . % alive at months; . % of them with cpc - . conclusions our experience reflects some aspects common with other european countries: less monitored events as well as more frequent cardiac arrests in unmonitored wards . rrt allowed a reduction of cardiac arrests thus reducing their incidence without modifying mortality incidence and outcome of in-hospital cardiac arrest in the united kindom national cardiac arrest audit epidemiology and outcomes of in-hospital cardiopulmonary resuscitation in the united states effectiveness of rapid response teams on rates of inhospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis national intensive care surveillance, quality secretariat building, castle street hospital for women correspondence: a. beane -network for improving critical care systems and training (nicst), colombo, sri lanka intensive care medicine experimental fig. (abstract a ) fig. (abstract a ) authors thank tem international for providing a rotem analyzer for the study. references . the consort extension for cluster trials mcf fibtem & plasma fibrinogen references . extracorporeal membrane oxygenation for ards in adults cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with inhospital cardiac arrest: an observational study and propensity analysis critical care in resource-restricted settings on behalf of the task force for mass critical care. evacuation of the icu. care of the critically ill and injured during pandemics and disasters: chest consensus statement icu fire evacuation preparedness in london: a cross-sectional study fire on an intensive care unit caused by an oxygen cylinder national questionaire survey on what influences doctors; decisions about admission to intensive care the faculty of intensive care medicine/the intensive care society acute care toolkit . high-quality acute care. royal college of physicians united kingdom; golden jubilee national hospital, department of anaesthesia there is a need for general (non-cardiac) intensive care units (icus) to facilitate more elective and emergency surgery for these patients. inhaled nitric oxide, a selective pulmonary vasodilator, may be required for this purpose. objectives: we wished to determine the availability of inhaled nitric oxide in general scottish icus we excluded tertiary paediatric, cardiothoracic and neuro-critical care units. an online survey was distributed followed, if necessary, by a telephone survey. caldicott guardianship approval was not required. results: four ( %) general icus had nitric oxide immediately available adult congenital heart disease (grown-up congenital heart disease) audit of critical care in scotland scottish adult congenital cardiac service a references . triage of patients consulted for icu admission during times of icu-bed shortage a then performed a cross-sectional survey by visiting each facility, and determining characteristics for each facility critical care in low-income countries functional compromise reflected by sarcopenia, frailty, and nutritional depletion predicts adverse postoperative outcome after colorectal cancer surgery sarcopenia is a predictor of outcomes in very elderly patients undergoing emergency surgery oudemans-van straaten hm, beishuizen a. low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients acetate-versus lactate-based balanced colloids used as priming solutions for cardiopulmonary bypass: an experimental pilot study h. cauwenberghs , a. de backer , h. neels , i. deblier correspondence: h. cauwenberghs -zna middelheim general hospital methods: following irb approval, male non-diabetics gave consent and were randomly assigned to receive either succinylatedgelatin g (geloplasma®) in meq na+, meq k+, meq cl-, meq mg++, meq lactate (sid ) or succinylated gelatin g (isogelo®) meq na+, meq k+, meq ca, meq cl-, meq mg++, meq acetate and bonferroni corrected. results: demographics were comparable. acid-base variables changed similarly throughout without significant differences between groups (sig shown in figure ). by contrast, glucose levels rose very significantly in the lactate group and persisted post cpb (figure ). oncotic pressure, diuresis, osmolarity and oxygen uptake did not differ between groups. discussion. concerning acid-base variables and secondary endpoints the perioperative period stewart's textbook of acidbase pl effects of intravenous solutions on acid-base equilibrium: from crystalloids to colloids and blood components seric pro-adrenomedullin levels in low cardiac output syndrome (lcos) after cardiac surgery we measured am at time-points (t -t ): before surgery; at admission; h and h after surgery. continuous data were showed as average (sd) and categorical ones in percents. comparisons were performed with kruskall-wallis and anova tests. the roc approach was used to assess the predictor capacity of am. all analyses were performed with stata . the ethical committee approved the study. results: patients were included. the average of age was ± . years, and were women . %. the median (iqr) for euroscore was ( - ). comorbidities were hypertension ( %), diabetes mellitus ( %) and atrial fibrillation ( . %). on-pump surgery was performed in the % and the coronary bypass was the most frequent ( %). the incidence of low cardiac output syndrome was %. am levels (mmols/l) were: . ± . (before surgery) postoperative pro-adrenomedullin levels predict mortality in thoracic surgery patients consensus on circulatory shock and hemodynamic monitoring. task force of the european society of intensive care medicine canadian cardiovascular society position statement on the management of thoracic aortic disease guidelines for the diagnosis and management of patients with thoracic aortic disease early and midterm outcomes following surgery for acute type a aortic dissection importance of blood pressure control after repair of acute type a aortic dissection (abstract a ). pro-adm levels t -t bleeding complications associated with cardiopulmonary bypass prospective validation of the international society of thrombosis and haemostasis scoring system for disseminated intravascular coagulation towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation hospital regional, intensive care, malaga, spain; hospital serrania, ronda, spain; hospital regional, intensive care, málaga, spain; hospital infanta margarita, intensive care, cabra, spain; hospital virgen del rocio, intensive care we analyze differences in the postoperative incidence of af in both groups. results: cohort of patients, mean age . ± . years. . % was elective surgery. euroscore . ± . points. icu mortality was . %.prior to surgery, . % and . % taking statins present a history of af. . % postoperative af episode presented. the patients treated before surgery with statins had af . % vs . % (p = . ) the sample was divided among the patients who died and those who do not. demographic variables, prognostic scales,type of surgery,early complications, icu stay and mortality were compared.the variables that reached statistical significance in the univariate analysis were analyzed in multivariate logistic regression. data expressed as mean and standard deviation, percentage, mean difference, odds ratio and corresponding confidence intervals. statistical significance level of p < . . results: a total of patients were analyzed, ≥ years ( . %) of which died( . %) predictors of postoperative complications in octogenarians undergoing cardiac surgery a ventricular assist devices, transfusion and health-related quality of life %,median rbc transfused ventricular assist devices and increased blood product utilization for cardiac transplantation. stone ml et all bleeding complications and blood product utilization with left ventricular assist device implantation. schaffer jm et all after completion of cardiac surgery. the patients were divided into two groups: aged < and age ≥ years. association analysis of demographic, clinical, therapeutic factors and complications during icu stay. univariate analysis using chi square (fisher if applicable) and t student. data expressed as percentages, means, estándar desviation (sd), mean differences (dm), odds ratio (or), and confidence intervals % (ci %) results: a total of significant differences in cardiac arrest cardiac surgery in octogenarians: a case series outcomes and cost of cardiac surgery in octogenarians is related to type of operation: a multiinstitutional analysis aortic valve replacement with and without coronary artery bypass graft surgery in octogenarians: is it safe and feasible? short-and long-term outcomes in octogenarians after coronary artery bypass surgery diagnosing and treating the failing right heart matching dicrotic notch and mean pulmonary artery pressures: implications for effective arterial elastance. the american journal of physiology university hospital of pisa, department of anaesthesia and critical care medicine, cardiothoracic and vascular anaesthesia venous-to-arterial co differences and the quest for bedside point-of-care monitoring to assess the microcirculation during shock model of pco gap during hypothermic cardiopulmonary bypass central venous o( ) saturation and venous-to-arterial co( ) difference as complementary tools for goal-directed therapy during highrisk surgery patients: closed-vs. opensystem the closed-system pivc was composed of catheter with inteof pivcs, the incidence of bacterial colonization and pivcs-related complications (phlebitis, extravasation, catheter occlusion and hematoma) were recorded. the protocol of the study was approved by the irb of tokushima university hospital. results: ninety-one closed-system pivcs and open-system pivcs were evaluated. the median indwell time did not differ between the closed-and open-system pivcs (median were identified from the database of the microbiological laboratory of the hospital and were included in this study as cases. demographic data, severity of illness, risk factors for colistin-resistance (described in previous studies), clinical management and hospital outcome of all cases were recorded. mdr -resistant to at least one agent from different classes. pdr -resistant to all classes. results: of kp ( . %) and of ec ( . %) isolates were colistin resistant. of ( . %) of kp and of ec ( . %) isolates were colistin resistant colistin-resistant isolates of klebsiella pneumoniae emerging in intensive care unit patients: first report of a multiclonal cluster risk factors associated with the isolation of colistin-resistant gram-negative bacteria: a matched case-control study combination antibiotic treatment versus monotherapy for multidrug-resistant, extensively drug-resistant,and pandrug-resistant acinetobacter infections:a systematic review in vitro synergistic activity of tigecycline and colistin against xdr-acinetobacter baumannii woodlands multispeciality hospital references . combatting resistance in intensive care: the multimodal approach of the spanish icu "zero resistance" program. garnacho montero et als during a kpc outbreak in the -bed icu of a tertiary university hospital in rio de janeiro, brazil. all patients admitted to the icu were included in the study and classified as case (kpc yielded from any biological material, either considered as colonization or infection) or control (all other patients who did not have kpc isolation). both groups were compared according to demographic data, comorbidities, sepsis diagnosis, type and time of life support, sofa and saps iii scores at icu admission, length of stay (los) at icu and hospital, and hospital costs, icu and hospital mortality. results: patients were admitted during the studied period. patients had kpc samples isolated from different biological material conclusions: during a kpc outbreak in the icu of an academic tertiary hospital in rio de janeiro, the isolation of kpc associated with colonization or infection was associated with greater icu and hospital los, more requirements of life-organ support, higher icu and hospital mortality rates impact of carbapenem resistance on the outcome of patients' hospital-acquired bacteraemia caused by klebsiella pneumoniae first report of kpc- -producing klebsiella pneumoniae strains in brazil attributable mortality rate for carbapenem-resistant klebsiella pneumoniae bacteremia zero resistance" (rz) program was swabs (nasal, pharyngeal, axillary and rectal) were routinely performed to all patients admitted, besides diagnostic cultures when needed. furthermore, we analysed other pathological variables and comorbidities. the difference between groups of mrb was made by chi-square test for qualitative variables and the kruskal-walls test for the continuous ones. statistical significance was set at p < . . results: admitted. in patients were identified one or more mrb ( in total). patients ( , %) were esbls carriers, ( , %) mrsa, ( , %) p aeruginosa, ( , %) acinetobacter spp and ( %) others mrb carriers. in cases ( , %) the presence of a mrb caused infection. nasal swabs detected % of mrb carriers ( % of all mrsa), pharyngeal swabs % ( , % of mrsa), axillary swabs % ( % of mrsa, % of acinetobacter), and rectal swabs % ( % of esbls, , % of acinetobacter). in cases ( %) just the axillary swab was positive, and in cases ( %) the rectal was the only swab able to detect a mrb. diagnostic cultures (blood, urine, bronchoaspirate, surgical wound and others) detected mrb in less than %. the checklist did not detected neither colonization nor infection by mrb in ( %) patients ( % mrsa, , % acinetobacter, % of esbls). all patients with p aeruginosa had rf, but one. there was no statistical significance between groups of mrb and other comorbidities. conclusions: the surface cultures realized at admission detected % of mrb not detected by diagnostic cultures ):e . a enteral paramomycin to eradicate colistin and carbepemenase resistant microorganisms in rectal colonization to prevent icu multiresistant nosocomial infections university hospital of gran canaria dr. negrín, pharmacy department hospital of getafe, intensive care unit microbiology unit, section biology pathology and health products ) received catecholamines and ( %) were immunocompromised. icu mortality was . % and did not differ between esbl carriers and non-carriers. the rate of esbl colonization at admission and esbl acquisition were . % and . %, respectively. escherichia coli was the most frequently observed bacteria. the results of the univariate analysis for esbl acquisition are presented in table . in multivariate analysis, igs-ii and icu length of stay were strongly associated with esbl acquisition (table ). discussion and conclusion: the observed rate of esbl carriage on admission was comparable to other rates in french icus ( %). despite the unfavourable twin-bed architecture of our icu, the incidence of esbl acquisition was . % which was actually lower than transmission rates previously published in other icus. esbl acquisition was strongly associated with icu length of stay and severity score at admission. this study is fully consistent with previous ones challenging the geographic isolation in a non-epidemic setting and suggests that environmental contamination may not play a substantial role in the transmission of esbl-pe wipo was diagnosed with lus if, on at least one upper or lower part of both sides, the lus profile moved from a (normal) to b (interstitial oedema) or from b to "b+", where b+ consisted in at least a doubling of the b lines number. the reference diagnosis of wipo was established on other criteria by experts blind for lus. results: wipo occurred in ( %) sbt. among cases with wipo, the lus profile did not change during sbt in one case, changed for lus signs of pulmonary oedema in cases (true positives) and changed but without typical lus signs of wipo in one case university hospital of lausanne, intensive care and burn unit saint michael's hospital and keenan research centre, interdepartmental division of critical care a introduction: many different tools are found to predict weaning success us) assessed excursions of the right hemi-diaphragm could be a useful measurement for prediction success in weaning from mechanical ventilation (mv us was performed after patient met weaning criteria (according to local protocol) and it was decided to discontinue mv. patients with neuromuscular disorders and diaphragmatic paralysis were excluded. measurements were performed once on pressure support ventilation (ps ≤ cmh o, peep ≤ cmh o). the right hemi-diaphragms of patients were evaluated by m-mode ultrasonography (esaote mylabgamma ac - mhz convex probe). the average diaphragm excursions value (de avg ) was estimated from sequential measurements. the rapid shallow breathing index (sbi), dynamic compliance (c dyn ), minute ventilation (m v ) and spontaneous tidal volume (v t spont) were obtained from the ventilator (servo i , maquet) table ) with best de avg cut-off value . mm (sensitivity % , specificity %). conclusions: our findings suggest that right hemi-diaphragm excursions assessed with m-mode ultrasonography is more accurate predictor of weaning success than other common weaning criteria weaning from mechanical ventilation diaphragm dysfunction assessed by ultrasonography: influence of weaning from mechanical ventilation a cycling-off guided by real-time waveforms analysis (intellisync+): pilot study on next-generation psv anesthesia and intensive care methods: in patients under psv, intellisync + was compared to to default setting, ets opti decreased cycling delay and unassisted efforts at ps basal, but these favorable effects were not maintained at ps + . further optimization (ets opti ) decreased cycling and trigger delay but did not affect unassisted efforts. when intellisync + was activated, cycling delay was shorter and values of trigger delay and unassisted efforts were at least as low as with optimized settings of ets. table summarizes the results obtained in the conditions tested. conclusions: bedside optimization of ets guided by waveforms on the ventilator screen improved pvi. increase of pressure support level worsened pvi and mandated re-optimization of ets a characteristics and factors associated with prolonged weaning. a sub-analysis of the wind study g upres ea irib saint michael's hospital and keenan research centre, interdepartmental division of critical care objectives: to determine a predictor of weaning success with a faster reaction time than respiratory rate & pulse rate. methods: patients ( male, female) on mv > days were included in our study diagnosed with sepsis (n = ), pneumonia (n = ), pancreonecrosis (n = ), obesity hypoventilation syndrome (n = ), intestinal obstruction (n = ). oxygen consumption (vo ) monitoring in different stages of mv support reduction was recorded using e-covx evaluation of mortality over time in patients receiving mechanical ventilation the use of mechanical ventilation in intensive care unit in russia: national epidemiological survey ruvent- a prospective, blinded evaluation of indexes proposed to predict weaning from mechanical ventilation a randomized, controlled trial of the role of weaning predictors in clinical decision making cpf) using ventilator built-in flow-meter to predict extubation success: a single centre study f. gobert , , h inclusion criteria were: age > years, intubation > h, no withdrawal decision of life supporting care, eligible for scheduled weaning trial and then scheduled extubation, mechanical ventilation from evita xl ventilator (dräger, germany) and patient's agreement to participate. once daily checked criteria for weanibility were present, patients were switched to a standardised pressure support ventilation (inspiratory pressure = cmh o, peep = cmh o, fio = . ) for h (if no chronic respiratory failure-crf), h (if crf) or h (if neuromuscular crf). the procedure of cpf measurement was explained to the patient, who was encouraged to cough as strong as possible just before extubation. cpf measurements were done by freezing ventilator screen and scrolling the cursor to the maximal value of cpf during expiration and tidal volume (tv) in preceding inspiration. three measurements were averaged. early extubation success rate was defined as the proportion of patients who were alive and not reintubated h after scheduled extubation. median values were compared by using non parametric tests. diagnostic performance of cpf and tv was assessed by using area under curve (auc) of the roc method. after having defined cut-off values for cpf and tv, we described the performance of a test combining cpf and tv values to predict the early extubation outcome. results: during the study period, patients were admitted to our icu of who were intubated and patients included (fig ). between the patients who succeeded and the patients who failed extubation, median cpf was − . l/min and − . l/min, respectively (p = . , fig a), median tv . l and . l, respectively (p = , , fig b), and auc averaged . and . , respectively (fig a). bi-dimensional analysis showed a synergistic effect of cpf and tv to predict early extubation success (fig b). the combination of thresholds (cpf < − l/min and tv > . l) grant acknolwedgment the study has been supported by the sigrid juselius foundation, päivikki and sakari sohlberg foundation the third international consensus definitions for sepsis and septic shock acute renal failure in critically ill patients: a multinational, multicenter study relation between mean arterial pressure and renal function in the early phase of shock: a prospective, explorative cohort study grant acknolwedgment this study is supported by the national key technology r&d program of china conclusions: in patients with chronic renal impairment who undergo cardiovascular surgery requiring cpb, a lower level of preoperative shp is independently associated with higher risk of paki. a urinary angiotensinogen as a possible predictor of acute kidney injury in severe sepsis s we aimed to compare the incidence of aki according to rifle (risk, injury, failure, loss of kidney and end-stage kidney disease united kingdom intensive care medicine experimental ):a introduction: cytokine elimination during continuous hemofiltration (chf) depends largely on the character of the filter membrane a references ( ) (kidney disease outcomes quality initiative. kdigo clinical practice guidelines for acute kidney injury antithrombin supplementation for anticoagulation during continuous hemofiltration in critically ill patients with septic shock: a case-control study acquired deficit of antithrombin and role of supplementation in septic patients during continuous veno-venous hemofiltration the influence of venovenous renal replacement therapy on measurements by the transpulmonary thermodilution technique effect of the venous catheter site on transpulmonary thermodilution measurement variables the influence of haemodialysis on haemodynamic measurements using transpulmonary thermodilution in patients with septic shock: an observational study when drugs disappear from the patient: eliminaiton of intravenous medication by hemodiafiltration cardiac arrest in intensive care unit: case report and future recommendations omni® (b. braun, melsungen, germany), a new third generregional citrate anticoagulation. we collected patients' characteristics, filter life time, circuit pressures, interruption of therapy duration and reasons (alarm types), achieved and targeted renal dose, metabolic parameters (serum creatinine and potassium levels and arterial base excess). in addition, we adminof total therapy time) in cvvhd-citrate mode. mean achieved renal dose was . ml/kg/hr corresponding to % of the targeted dose in cvvh-heparin mode and . ml/kg/hr corresponding to % of the targeted dose in cvvhd-citrate mode. in both rrt modes, excellent metabolic control and adequate fluid balance were achieved. overall, the interface, design and ease of use were evaluated by users as excellent. conclusions: crrt in both cvvh and cvvhd modes could be provided using omni® in a safe and efficient way in ten critically ill patients. users provided positive feedback regarding therapy setup, management and user interface. a intermittent haemofiltration outside itu led by the intensive care team. experience at a tertiary cardiothoracic centre s following modification of the aquarius haemofilter (nikkiso), we designed and implemented a protocol for rca with stand alone citrate administration pre filter (acd-a (acid citrate dextrose formula-a) containing mmol/l of citrate) and post dilution cvvhf using calcium containing replacement fluid (accusol containing . mmol/l ca) and, when needed, supplementary calcium depending on systemic ica. the protocol can deliver or mls/kg/hr of crrt. we compare the efficacy of this new protocol, which we have initially implemented in patients with a relative contraindication to heparin, to a historical cohort of patients who received crrt with prostacyclin and or pre-dilution cvvhf but would not have been contraindicated for rca. we also present relevant biochemical data. methods: a prospective audit of the first adult critically ill patients receiving rca with post dilution cvvhf. crude comparison was made with a historical group of consecutive critically ill patients who received crrt without heparin prior to the introduction of the rca protocol. patients were excluded from the rca protocol and the comparison if they had, severe acute liver injury. data is presented as median (range) with non parametric analysis and filter survival as a kaplan meier for the event´filter clotting´and censored for medical cessation or technical failure. results: there were filters used in patients who received rca and in in the comparison group respectively. one patient ( filters) from the rca group was excluded from the filter survival analysis due to a triglyceride level of . mmol/l, causing repeated filter failure epidemiology of acute kidney injury in critically ill patients: the multinational aki-epi study conclusions: there is no relationship between copd patients, bmi, age and extubation failure. this new formula combine parameters, dtf*rsbi, as a good parameter for extubation.methods: we used the administrative claims data of all diagnosis procedure combination (dpc) hospitals in japan from april , to march , , and retrospectively reviewed the number and outcome at discharge of patients who were on ecmo support. results: we identified , patients who received ecmo support during the -year study period. the average age was . , and only . % of the patients were under years old. the most common diagnosis was acute coronary syndrome, followed by cardiac arrest and pulmonary embolism. the overall survival rate at discharge was . % [ %ci . - . ]. among the , acute care dpc hospitals, ecmo support was provided in hospitals ( . %), and therefore the annual ecmo patient volume per hospital was . , which is much lower than international standards for ecmo centers. adjusted odds ratio for discharge alive stratified by annual ecmo volume per hospital were . [ %ci . - . ] and . [ %ci . - . ] for medium ( hospitals treating to patients) and high volume centers ( hospitals treating or more patients), respectively, compared with low volume centers ( hospitals treating or less patients). conclusions: ecmo support was administered to many adult cardiac patients, and provided in a substantial proportion of acute care hospitals in japan. no significant patient volume effect for survival discharge was found. funding from the american nurses association impact grant is gratefully acknowledged. history and icu related data were analyzed. basal fracture risk before ci was calculated using the frax tool (https://www.shef.ac.uk/frax). in january , referent family doctors were contacted by phone to check out new bf occurred during the years after icu discharge. data are expressed as median (min-max) or percentages. unpaired data were compared using mann-whitney test (p < . = significant). results: from the patients admitted in , had an icu los ≤ d, were < y, died in icu or died after an icu los ≤ d and were lost to follow-up. we analyzed patients who were alive in january and patients who died outside icu during the fup after an icu los > d. regarding alive patients ( % males), admission was mainly related to cardiovascular, respiratory and neurological failure, or trauma. age was ( - )y, simplified acute physiologic score (saps ii) was . ( - ), icu los was ( - )d. according to the frax tool, the -y probability of major osteoporotic bf (major frax risk) was . ( - )%. nine patients ( men) developed bf in . ( - ) months after ci, equivalent to a % risk of new bf y after ci. a context of fall at home was noted in every case. age, icu los and saps ii of these patients were not statistically different from non-fractured patients. their major frax risk was ( - )%, significantly higher than non-fractured patients (p = . ). finally, among the dead patients, only one y man experienced hip fracture at the th month after ci. conclusions: present incidence of new bf in the y following severe ci with a prolonged icu stay is similar to previously published data [ ]. patients who experienced new bf after ci had a higher frax risk than the non-fractured patients. influence of ci or icu stay on bf risk is thus questioned. however, to be relevant, our results need to be compared to a control population: this work is ongoing. conclusions: we detected a rise in pro-adrenomedullin levels after cardiac surgery. the results suggest that am could be useful for lcos prediction. more data are necessary to confirm the role in the prediction of relevant outcomes. conclusions: the icu stay and early complications evaluated not differ between the two groups , except for acute renal failure and higher mortality, despite the use of shorter times in cardiac surgical in octogenarians. there is a progressive decrease in coronary artery bypass surgery in recent years in this group probably in favor of percutaneous techniques.high-risk patients who require intensive perioperative management,should be identified to reduce the incidence of postoperative complications.conclusions: previous renal replacement treatment and the colonized patients' long stay at icu increase the transformation of the vre colonization into vre infection. strategies to reduce the duration of icu stay of vre-colonized patients are the main objects to controlling vre infection rate. identification of sirs/sepsis signs by ward nurses reduces -days mortality in patients with sepsis m. torsvik , l.t. gustad , , i.l. bangstad , l.j. vinje , j.k. damås , , , e. solligård , , , a. mehl , , nord university, faculty of health science, levanger, norway; nord-trøndelag hospital trust, levanger hospital, internal medicine, levanger, number of patients had ulceration at the site of the suction port but did not suffer any complication as a result. drainage of pleural effusion with small bore tube in mechanically ventilated patients s.j. lee , y.s. cha , w.-y. lee correlate with decannulation failure but future studies are necessary in this field. objectives: to weight all sharps containers in a cardiac intensive care over a one-week period. to then review the financial implications of the cost of this waste. to review ways to redistribute this waste.methods: all closed sharps containers were weighed. research the cost implications of different waste types from the waste management team within the trust. look into ways of reducing this waste. results: a total of items where weighed, totaling . kg, costing £ . . this can be broken down in six l chest drain boxes, weighing . kg, costing £ . . four l sharps bin, weighing . kg, costing £ . . l sharps bin, weighing . kg, costing £ . , and thirty-nine l sharps bins, weighing . kg, costing £ . . this would take eight weeks to produce a tonne. producing around . tonnes a year costing £ , . . compared to other types of waste: sharps containers: £ per tonne clinical waste: £ per tonne domestic waste: £ per tonne recycling: £ per tonne clinically objects that aren't sharps are placed in sharps bins, for example arterial blood gas syringes, this item could be put into a clinical waste bin. while this suggests education is needed there are other methods to reduce sharps bin wastage. these include: having needle only sharps bins, and solidifying chest drain bottles post removal.conclusions: this cardiac intensive care unit produces a volume of high-cost waste. a large proportion of this waste can be redistributed to other types of waste. this could make the unit more efficient, and reduce it's environmental burden. this audit suggests that it should be looked at other types of waste and other departments in the same manner on other units. in the bloodstream infection density related to hemodialysis catheter in the hospital moyses deutsch was . , which represents patient in its entirety. due to this high rate, it was necessary to review all related process through institutionalized and supervised practice, minimizing the risks of hemodialysis procedure and maintenance of the catheter, in order to directly reduce the length of hospital stay, morbidity and hospital costs. objectives: objective of this study was to evaluate the application of strategies according to ihi to reduce infection of the bloodstream related to cvc hemodialysis. methods: the study was conducted in a -bed, medical-surgical icu. criteria for infection catheter related bloodtream infection are those from the cdc. strategy was to implement the permanent education of employees, highlighting the importance of prevention of infections;training of new employees as the hemodialysis routine and safe and aseptic techniques; optimize other measures that can reduce the risks, such as early removal of invasive devices.raise awareness of nursing staff about the importance of their role in the prevention of infection, such as maintenance of the catheter with use of aseptic techniques; disseminate monthly for teams infection rates; make benchmarking with other services; the goals were the icu team adhesion of % achieved in six month after bundle implementation and % after one year of follow up. from june on, the icu a effect of therapeutic hypothermia on mitogen activated protein kinase pathway in the brain tissue of a swine cardiac arrest model y. c objective: to investigate the change in mitogen-activated protein kinase pathways in the brain tissue after therapeutic hypothermia in swine cardiac arrest model. design. prospective animal study setting. university animal laboratory subjects. male domestic pigs (n = ) interventions: after the return of spontaneous circulation by cardiopulmonary resuscitation following min of no flow time induced by ventricular fibrillation, pigs were randomly assigned to one of four groups (sham, normothermia, hr of therapeutic hypothermia, hr of therapeutic hypothermia). therapeutic hypothermia (core temperature - °c) was maintained and the pigs were then rewarmed for hr. at hr after the return of spontaneous circulation, the pigs were sacrificed and brain tissues were harvested. measurement and main results: we measured the tissue levels of p , jnk, and erk pathway expressions in swine brain hippocampus of the four groups. the phosphorylated p to p ratio and phosphorylated jnk to jnk ratios were significantly increased in all of the intervention groups, relative to the sham group. but the phosphorylated erk to erk ratio was increased only in the therapeutic hypothermia groups (p-value = . in the hr of therapeutic hypothermia group and p-value = . in the hr of therapeutic hypothermia group, both compared to the sham group). conclusions: normothermia activated the p and jnk pathway. and did not activate the erk pathway in ischemia-reperfusion injury after cardiac arrest. therapeutic hypothermia, however, did not attenuate the activation of the p and jnk pathways, but activated the erk pathway, which seemed to be dose dependent with the duration of therapeutic hypothermia. effect of permissive hypercapnia on outcome of cardiac arrest in a porcine model of cardiopulmonary resuscitation g. babini , g. ristagno figure ). pigs in the hypercapnic group showed a trend towards longer survival. etco and pco were significanlty higher in the hypercaninc group compared to the normocpanic one (table ). ph and po trended to be lower in the hypercapnic group during the hrs of observation. hypercapnia was associated with significantly higher mean arterial pressure during the post-resuscitation (pr) period ( lesser neuronal degeneration was seen in the frontal cortex in the hypercapnic group compared to the normocapnic one (figure ) . neurological recovery was equivalent in the two groups ( figure ). conclusions: permissive hypercapnia after resuscitation was associated with better mean arterial pressure and lesser neuronal degeneration in pigs. grant support. laerdal foundation for acute care, norway introduction: pain is the main indication for utilisation of the physician staffed prehospital emergency service in germany. data from switzerland showed that oligoanalgesia (inappropriate treatment of pain with nrs > ) is common in trauma patients. objectives:( ) determination of the frequency of oligoanalgesia in trauma patients at our prehospital emergency service location in objectives: assessment of characteristics and outcomes of patients who suffer cardiopulmonary arrest resuscitated in a tertiary hospital, inside and outside intensive care unit, according to utstein style.methods: a prospective cohort study was performed according to utstein style. every arrest occurred in the hospital "virgen de las nieves" (granada, spain) for a period of years (july/ -june/ ) were included. all arrest occurred in all areas of the hospital were included, except those in operating rooms and anesthesia recovery room (not attended by the resuscitation team) and those commenced in the prehospital setting. we also excluded patients in whom no resuscitation attempt was made or those suspended either by existence of a living will, by orders dnr or considered futile. the variables were grouped according to the location (inside or outside the icu). chi test was performed when the dependent variable was qualitative and a t-student test when it was quantitative.results: during this period a total of patients suffered at least one episode of arrest and they were resuscitated. most frequent sex was male ( . %) with a median age years ( . ± . years; interquartile - years). the cardiac origin was the most common aetiology ( . %). the icu was the area most frequent location ( . %). when comparing the characteristics of icu arrests with the rest of the hospital, significant differences were observed. it was most likely to have a shockable initial rhythm (χ : . ; p = . ), younger age ( , ± , vs , ± , years; t = , ; p = , ), shorter interval to defibrillation ( , ± , vs , ± , min; t = , ; p = , ), shorter period until start of resuscitation ( , ± , vs , ± , min; t = , ; p < , ) and shorter total duration ( ± , vs , ± , min; t = , ; p < , ). however, no differences were found in coronary aetiology, sex, recovery of spontaneous circulation and hospital survival ( . % vs . % in icu).conclusions: despite higher frequency in initial shockable rhythms and lower intervals until defibrillation and resuscitation in the icu, no differences were found in initial recovery or hospital survival. delayed onset of cardio-pulmonary resuscitation (cpr) does not induce hyperfibrinolysis in a piglet model of ventricular fibrillation -a pilot study in göttingen minipigs n. introduction: pulmonary arterial hypertension (pah) is a disease with gradually increased pulmonary vascular resistance and pressure, often leads to right ventricular (rv) failure and death. excessive proliferation of pulmonary arterial smooth muscle cells (pasmcs) is regarded as the major cause of the remodeling of pulmonary artery, whereas the underlying mechanism is largely unclear. caffeic acid phenethyl ester (cape) is the main component of propolis, which is known as a versatile compound of antimitogenic, anticarcinogenic and anti-inflammatory potentials. objectives: to investigate the effects of cape on the improvement of the hemodynamic function in pah animal model and to explore the underlying mechanisms in in vitro pasmcs. methods: animal model of pah symptom was induced in - grams sprague-dawley rats by subcutaneous injection of monocrotaline (mct, mg/kg). weeks later, the mct-induced pah rats received intraperitoneal administration of cape with various dosages of or mg/kg once per day, for further weeks. hemodynamic functions, including rv systolic pressure (rvsp) and fulton index, were measured before sacrifice. the lung tissues were harvested for examining the vascular remodeling of pulmonary artery. to investigate the molecular mechanisms, in vitro cultured human pasmcs challenged with either % oxygen level or recombinant human pdgf ( ng/ml), followed by the treatment of cape in or mm. the change of expression level and phosphorylation of the cellular signaling molecules, including erk, akt, nf-kb, or hif- a, were analyzed by semi-quantitative pcr and western blotting, respectively. results: in mct-induced pah rats, cape significantly improved the hemodynamic values of rvsp, fulton index, and attenuated the severity of pulmonary vascular remodeling. furthermore, the administration of cape critically reduced the expression levels of hif- a, nf-kb and pdgf molecules in the lung of mct-induced pah rats. in vitro assay showed that an increased expression level of hif- α and pdgf genes in hpasmcs was observed under hypoxia or pdgf stimulation, which was significantly suppressed following cape treatment. for chemical inhibition, we indicated that cellular signaling molecules erk, akt and nf-kb were involved in the up-regulation of hif- a and pdgf genes, which were responsible for the proliferation of hpasmcs exposed to hypoxia or pdgf stimulation. in addition, cape also significantly promoted the number of apoptotic cells and the number of cell arrested in g phase of hpasmcs by tunel assay and sa-b-galactosidase staining, respectively. conclusions: we showed evidence that the natural compound cape could provide therapeutic benefits on the reversal of experimental pah rats. importantly, the results further indicated that the hif- a-mediated pdgf expression is a positive feedback mechanism underlying the pathogenesis of pah, which was regulated by the akt/erk/nf-kb signaling. right ventricular arterial coupling after cardiac surgery: a preliminary report p. introduction: right ventriculo-arterial coupling (rvac), defined as the ratio of end-systolic elastance (rees) to pulmonary arterial elastance (rea) is considered a sensitive method to assess right heart performance [ ] . objectives: in this study we aim to identify the feasibility of measuring rvac in hemodynamic deranged patients undergoing complex/ emergency cardiac surgery using cardiopulmonary bypass (cpb) as an experimental model of further hemodynamic impairment. objectives: this study aims to determine the frequency of the vre colonization and the transformation into infection and the risk factors, which lead to infection. methods: the patients who were hospitalized for at least hours in tertiary mixed type icu between and and had vre colonization and vre infection during or following their hospitalization were included in the study and their medical records were examined retrospectively. vre rectal swab sample was taken from each patient at his arrival and once a week afterwards. when negativity was detected in the rectal swab sample, which had been taken total times successively from those with positive vre; that patient was considered vre negative. their demographic data, apa-che ii scores, invasive procedures, treatments (corticosteroid, antibiotics, etc.), nutrition types, laboratory results and icu outcome were recorded. results: vre colonization was detected in of patients ( . %) admitted to icu. vre infection developed in of vre-colonized patients ( . %). among these infected patients; it was (n = ) . % primary bloodstream infection, (n = ) % urinary tract infection, (n = ) % . pneumonia. in vre colonized patients ( . %) and infected patients ( %), the most frequent factor was e. faecium. in % of the vre-colonized patients, vre became negative in their stay at icu. previous renal replacement treatment was significantly higher in statistical terms in the vreinfected group ( . %) when compared to vre-colonized group ( . %) (p < . ). in the vre-infected group, colonization with vre lasted longer than week in patients ( . %) were determined. demographic data, apache ii scores, treatments, nutrition types, previous antibiotic usage and types, invasive procedures, laboratory results and icu outcome were similar between the vre-colonized and infected patients.objective: to assess the value of enteral paramomycin to decontaminate patients with rectal colistin and/or carbepemenase resistant microorganisms colonization to prevent the development of icu nosocomial infections methods: all consecutive patients admitted to the icu from october to september , expected to require tracheal intubation for longer than hours, were given sdd with a -day course of intravenous cefotaxime, plus enteral colistin, tobramycin, nystatin in an oropharyngeal paste and in a digestive solution. oropharyngeal and rectal swabs were obtained on admission and once weekly. rectal swabs colonized by colistin and/or carbepemenase resistant microorganisms were treated with enteral paramomycin gram every hours a day, in order to eradicate them and prevent nosocomial infections. categorical variables were summarized as frequencies and percentages and the continuous ones as medians and interquartile ranges (iqr) or means and standard desviations. statistical significance was set at p ≤ . . results: we applied paromomycin treatment to colonized patients with rectal colistin resistant microorganisms. all of them had colonization by extended spectrum beta-lactamases (esbls). also, all of them but two were klebsiella pneumonia. out of these two, one patient was colonized by enterobacter spp and other one by escherichia coli. demographic data and type of admission are shown in fig. . forty out of ( , %) of the studied patients the rectal swab became negative. five out of the patients were colonized by carbapenemases producing microorganisms and one of these died with persistent multirresistant rectal colonization. only out of the patients that negativized the colonization received concurrent susceptible iv antibiotics. only of the paromonycin treated patients developed a mediastinitis infection due to one of the treated microorganisms. finally, patients died in the icu. conclusion: our data show that enteral paramomycin is effective in treating rectal colistin and/or carbepemenase resistant microorganisms colonization allowing clinicians preventing the development of icu nosocomial infections. introduction: diaphragmatic thickness increases as lung volume increases towards tlc. it has been shown that in healthy subjects, diaphragmatic thickness, increases as lung volume increases, above . of the vital capacity (vc). in mechanically ventilated patients, different levels of peep are used to improve oxygenation. there is no information about the diaphragmatic thickness when in icu patients, lung volume increases with peep towards tlc. methods: in patients with acute respiratory failure (arf) and lower lobe atelectasis detected by lung echo, two levels of peep ( and ± cmh o) are used to increase lung volume and to improve oxygenation. end expiratory lung volume (eelv), and diaphragmatic thickness was measured at baseline (zeep) and at the two levels of peep. eelv was measured with a nitrogen indirect dilution method and diaphragmatic thickness at the zone of apposition with echography using a mhz linear probe. statistical analysis was performed by one way anova and normal distribution by colmogorof-smyrnof test. results: patients ( m and f) with a mean age of ± were studied. diaphragmatic thickness at baseline was , cm and eelv at ml ( %) of the predicted ( ml). at the intermediate and high level of peep diaphragmatic thickness did not change significantly ( . and . cm, respectively, p = . ) and eelv increased at % ( ml) and % ( ml) of the predicted. the increase in lung volume induced by peep was at % and % of the predicted vc ( ml). mean pao /fio ratio did not change significantly conclusions: mechanically ventilated patients for arf have a severe reduction in their eelv or frc. the use of peep reestablishes partially the eelv, but not to his normal levels(predicted frc). despite high levels of peep, diaphragmatic thickness remained constant because the increase in eelv never attained the % the vital capacity.introduction: the majority of patients entering the weaning process from mechanical ventilation (mv) in the intensive care unit (icu) will have a short and simple weaning (sw) successfully terminated within hours, while other may take up to one week (difficult weaning) or longer. studies have shown that using a sedation or a weaning protocol could reduce the length of mechanical ventilation and the weaning duration. objectives: to describe factors associated with sw and particularly assess if sedation and weaning protocol are associated with the proportion of patients having a sw. methods: we used the data from the wind (weaning according new definition) study, a prospective multicenter observational study performed in france ( icus), spain ( icus) and switzerland ( icu) from april to august . ventilation and weaning modalities were daily assessed until discharge in all intubated patients admitted to the participating icus. we defined ) weaning attempt (wa) as a spontaneous breathing trial (sbt) or an extubation attempt (with or without sbt), ) successful weaning as an extubation without death or invasive mechanical ventilation within days. we considered patients as having a sw if weaning was successfully terminated within h following their first wa. having a protocol for sedation or for weaning (or both) was asked to each center. quantitative and qualitative variables are presented as mean (standard deviation), median [interquartile range] or number (percentage) as appropriate. comparisons of proportions were made using chi or exact fisher tests and continuous variables were compared using student t-test or wilcoxon rank sum test as appropriate. we performed a multivariable analysis of factors associated with sw by means of a logistic regression, forcing both sedation and weaning protocols in the final model. all statistical tests were two-sided and p values of . or less were considered significant. results: among the patients included, patients entered the weaning process and we only kept in the present analysis the patients who did not have any decision of withholding or withdrawing mechanical ventilation. among these patients, ( %) had a sw and ( %) had a weaning duration longer than hours. main clinical characteristics are shown in table . conclusions: in this study of patients with a daily assessment of the weaning process, hospitalization in an icu using a sedation protocol or a weaning protocol (as declared by the center) was not associated with a higher proportion of patients having a simple and short weaning. admission for planned surgery, younger age, lower sofa score at admission and shorter duration of ventilation before any weaning attempt were associated with a higher proportion of simple and short weaning. this study benefited of a grant of the non-profit association départementale des insuffisants respiratoires (adir) of the haute normandie, france. introduction: during weaning from prolonged ventilation overload of diaphragm as main breathing muscle should be avoided. clinical criteria are used for determining the end of the spontaneous breathing trial (sbt) in the context of a discontinuously concept for weaning. in addition the patients subjective feeling of breathing exhaustion plays an important role. in incommunicable patients lacks this possibility for feedback.continuous monitoring of diaphragm electrical activity could give information of respiratory muscle effort during sbt. objectives: in tracheotomized patients undergoing prolonged weaning the relationship between the protocol-based definition of the end of a sbt and the course of the electrical activity of the diaphragm (eadi) should be examined. methods: prospective observation study conducted in a beds intensive care unit in an early rehabilitation clinic. patients that were not communicable because of stroke ( ), cerebral hypoxaemia ( ), traumatic brain injury ( ) have been included. using an eadi-catheter usually applied in nava (neurally adjusted ventilatory assist)-ventilation, peak of diaphragm electrical activity (eadi peak) was continuously recorded minutes before disconnection from ventilator up to minutes after reconnection. the weaning protocol contained two possibilities for terminating of the sbt: reaching clinical signs of ventilation exhausting or reaching a previously fixed time limit. results: median duration of mechanical ventilation at study start was days and days at successful weaning ( / patients, died). sbt have been recorded, terminated because of exhaustion, by time limit. median duration over all was minutes (exhaustion: / time limit: ). with multiple regression analysis, the relationship between the duration of the sbt and the eadi peak was examined. looking at all sbt, which were terminated due to exhaustion, shows that the duration of the sbt has a highly significant impact on eadi ( p < . ). the mean increase of eadi peak was . μv (absolute) and . (relatively). in sbt terminated because the time limit has been reached, there was no significant correlation between the time and course of eadi peak. conclusions: continuous recording of the electrical diaphragmatic activity during weaning of prolonged ventilation in incommunicable patients can be used as supplementary parameter in monitoring the respiratory function. introduction: patient-ventilator asynchronies are associated with poor outcome. it was suggested that bedside analysis of ventilator waveforms may help detecting different types of asynchrony and setting properly the ventilator [ ] . objectives: to test accuracy of a "waveform" method, based on specific signs on airway pressure (paw) and flow curves, in detecting spontaneous respiratory activity and asynchronies in patients under pressure support ventilation (psv).methods: recordings ( min each) of esophageal pressure (pes), paw and flow were obtained in obstructive ( %) and restrictive ( %) patients under psv with clinical evidence of poor patient-ventilator interaction. tracings of breaths were visually analyzed for detection of spontaneous respiratory activity both with pes (reference method) and without pes (waveform method) by different operators. breaths were defined as assisted, unassisted or autotriggered, and assisted breaths as delayed triggered, early cycled or delayed cycled. the waveforms method was applied in a selection of tracings ( min, breaths) by different operators for assessment of inter-rater agreement. results: the reference method detected autotriggered ( . %), unassisted ( . %) and assisted ( . %) breaths; among assisted breaths, delayed triggered ( . %), delayed cycled ( . %) and early cycled ( . %). table shows sensitivities and specificities ( % ci) of the waveform method in evaluating patient-ventilator interaction. the waveform method detected the start of patient's inspiration and expiration with a bias of − and − ms and a precision (± . sd) of and ms respectively. absolute agreement among operators was almost perfect for unassisted breaths, strong for delayed triggered, delayed cycled and early cycled breaths, and weak for autotriggered breaths. conclusions: the waveforms method is a reliable, accurate and reproducible method to assess patient-ventilator interaction and could help optimal setting of the ventilator. automation of this method may allow continuous monitoring of ventilated patients and/or improved breath triggering and cycling.methods: we studied a group de mechanically patients during the weaning time, at pressure support ventilation (psv) with different levels of assistance (high - cmh o, medium - cmh o, low - cmh o). esophageal, gastric, airway pressure, and airway flow were registered, samplig hz. we determined the phase difference (Φ) relationships between the neuronal times obtained from derivative flow versus esophageal or gastric signal respect to machine cycle, by calculating the phase delay, dividing by the cycle time of ventilator* °. times (t) definitions: t = onset inspiratory effort, t / = effort maximum. data were analyzed by descriptive statistical methods and are expressed as mean ± sd, medians, interquartile range (irq, - % quartile), and coefficient of variation (cv). the comparisons were performed by mann-whitney test. the relationships between measurement methods was examined using single linear regression and bland-altman analysis. results: patients were studied. for all data angle phase Φ median (irq): t : , (− , to , ), t / : − , (− , to , ). the mean comparison of t and t / between pes and df did not showed statistical differences for any level of support, and correlation r > , . the cv for all data at the t of pes and df: % and %, respectively; and for the t / of pes and df: % and %, respectively; without differences between levels of assistance. table below show results from bland-altman analysis. figure show representative tracing of df with well-defined inflection points (arrows) at t and t / , as the onset inspiratory flow and transition from inspiratory to expiratory flow. conclusions: the derivative of flow signal is useful to measure with accuracy neuronal and cycling times, it´s more homogeneous and precise than obtained for esophaeal or gastric pressure for all levels of assistance. the derivative of flow signal is a non-invasive signal which can be calculated easily and useful by conventional ventilator. introduction: sepsis has been defined as organ dysfunction as a result of the inappropriate host response to infection. [ ] renal function is often injured at the early stage of sepsis. [ ] autoregulation, which plays an important role in maintaining an adequate renal blood flow against changes in blood pressure, could be impaired during sepsis, [ ] thus resulting in aki if blood pressure fluctuates greatly. objectives: to investigate if there is any relationship between blood pressure variability (bpv) and aki in septic patients. methods: clinical data of patients admitted to our bed medical icu between / and / were reviewed. continuous records of blood pressure were analysed. blood pressure variability was calculated as the coefficient of variation (cv) of mean arterial pressure in the first h of admission. aki was defined by the kdigo definition according to creatinine change and urine output criteria. [ ] results: adult patients with sepsis (age: . ± . years old; apache ii score: . ± . ; male: . %) who stayed at icu for more than three days were identified. aki was presented in ( . %) of them (stage : n = ; stage : n = ; stage : n = ). the bpv was . ± . % for the patients with aki versus . ± . % for the others (p < . ). icu mortality was . % for the aki group compared to difference was not statistically significant regarding creatinine level on admission (p = . ). moreover, there was a positive correlation between uancr ratio on admission with akin staging and creatinine level of the all studied patient in the follow up days. the cutoff value of uancr on admission to predict later occurrence of aki during icu stay was . ng/mg: at this level, ( . % sensitivity and . % specificity). conclusions: urinary angiotensinogen is a new promising biomarker in early prediction of aki in patients with severe sepsis. acute kidney injury in patients with severe sepsis or septic shock: a comparison between the "risk, injury, failure, loss of kidney function, end-stage kidney disease" (rifle), acute kidney injury network (akin) and kidney disease improving global outcomes an st and polymethyl methacrylate (pmma) membranes have strong adsorption capacity. cytokines play important roles as the main mediators affecting critically ill patients. however, differences in the cytokine elimination by specific membranes during chf have not yet been fully investigated. objective: the objective of this study was to determine the elimination of cytokines by an st and pmma membrane filters during chf in a pig sepsis model. methods: piglets (n = ) weighing - kg were anesthetized and administered μg/kg endotoxin. the baxter sepxiris (an st membrane) and the toray hemofeel . w (pmma membrane) were used as hemofilters. samples were taken at , , , and hours after endotoxin administration, and the inlet plasma, outlet plasma, and filtrate concentrations of tnf-α, il- β, il- , and il- were measured. clearance values were calculated for each cytokine. results: endotoxin administration induced increases in the inlet plasma concentrations of all cytokines measured. the an st membrane filter showed higher adsorption and clearance of il- than the pmma membrane filter at hours after endotoxin administration (an st: . ± . ml/min; pmma: − . ± . ml/min; p < . ). however, the pmma membrane filter showed higher adsorption and clearance of il- β than the an st membrane filter. il- did not appear in the filtrate of the pmma membrane filter, while il- was not eliminated in the filtrate of the an st membrane filter. in addition, the filtrate concentration of tnf-α increased after its plasma concentration decreased with the pmma membrane filter. conclusions: shiga et al. previously reported the efficacy of cytokine absorption by an st membrane filters during continuous hemodiafiltration, and matsuda et al. reported the efficacy of cytokine absorption by pmma membranes. however, the cytokine absorption efficacy by these two membrane filters had not been directly compared. the results shown here confirm that there are differences in cytokine adsorption by the an st and pmma membrane filters. introduction: continuous renal replacement therapy (crrt) in intensive care is a cornerstone in the supportive treatment arsenal. its influence on thermodilution cardiac output measurements, and the possible influence of central venous dialysis catheter(cvdc) position, has been studied but the results are of uncertain clinical impact ( ) ( ) ( ) . there have been case reports describing the possibility of direct aspiration into a cvdc of drugs given in adherent central venous catheter(cvc) ( , ) . objectives: the aim of this study was to investigate if different positions of central lines influence infused noradrenaline during continuous renal replacement therapy (crrt) in an experimental animal model. methods: ten anesthetized piglets received a cvc in the right jugular vein and two cvdcs (one via the same jugular vein as the cvdc and the other through a femoral vein). after randomization the crrt was started in either one of the cvdcs and a nitroprusside infusion was started in an auricular vein. the dose was titrated until the mean arterial pressure (map) was mmhg and then kept constant during the rest of the experiment. after reaching the intended blood pressure an infusion of noradrenaline was started and titrated with the goal of increasing the blood pressure to a map of mmhg during minutes. after a washout period the crrt circuit was changed to the other cvdc and the experiment was repeated. results: the median dose of noradrenaline with the crrt in the jugular vein was . (iqr . ) and in the femoral vein . (iqr . ) μg/kg/min (p = . ). conclusions: during crrt, the noradrenaline dose needed to reach a target blood pressure in hypotensive piglets was twice as high with the cvc and cvdc close together, compared with cvc and cvdc on opposite sides of the diaphragm. this suggests that there is a possible clearance of noradrenaline and that the clearance is affected by catheter positioning a first evaluation of omni, a new device for renal replacement therapy p. schlaepfer , , j.-d. durovray , , v. plouhinec , c. chiappa , r. bellomo , a.g. schneider introduction: due to the lack of conventional dialysis facilities in our centre, intermittent renal replacement therapies (irrt) are led and performed by the itu team. this team comprises a group of specialist outreach nurses with the support of intensivists. irrt are performed nocturnally by itu nurses in level areas according to our hospital policy. objectives: to describe the use and results of irrt in level areas in patients that have left itu with established aki. these therapies are directed and performed by specialist intensive care nurses with the support of the itu medical team. methods: retrospective observational study that included those patients admitted to level areas at harefield hospital during that were transferred to level areas still requiring irrt. demographic variables were collected, along with the indication and duration of irrt and results. results: patients were admitted to harefield hospital level areas during , of which patients required continuous renal replacement therapies (crrt). this population included patients admitted after cardiac and thoracic surgery, heart or lung transplantation, mechanical circulatory devices, out of hospital cardiac arrests (oohca) and medical admissions from the cardiology or cardio-thoracic surgical wards. demographic variables were collected, along with the indication and duration of crrt. of those patients still required intermittent renal replacement therapies at their discharge to a level area. of them ( . %) were male and the group was a median age of . years. of them ( %) were hypertensive and ( %) were diabetic. as shown in figure , the most frequent reason for admission to intensive care was cardiac surgery ( . %, patients), followed by lung transplantation, heart transplantation and medical admissions from the transplantation ward. the reasons for admission to intensive care in the general crrt group are also shown in figure . the most frequent indication for initiation of crrt was metabolic acidosis ( . %, patients), followed by a combination of uraemia and fluid overload ( . %, patients), uraemia ( . %, patients) and fluid overload ( . %, patients) as shown in figure . the median time of rrt was days days whilst the median time of filtration in the general rrt group was days. the in-hospital mortality (after discharge from itu) was . % and was . % in the general crrt group. no complications were associated with the use of intermittent renal replacement therapies in level areas. conclusions: the group of patients that required intermittent renal replacement therapies beyond their discharge from itu had longer itu and hospital lengths of stay. these therapies were performed safely in level areas by the itu team, allowing these patients to leave level areas to continue their care. key: cord- -o e na authors: nan title: scientific session of the th world congress of endoscopic surgery, jointly hosted by society of american gastrointestinal and endoscopic surgeons (sages) & canadian association of general surgeons (cags), seattle, washington, usa, – april : poster abstracts date: - - journal: surg endosc doi: . /s - - - sha: doc_id: cord_uid: o e na nan purpose: to evaluate the efficacy of single-incision laparoscopic surgery for totally extraperitoneal repair (sils-tep) of incarcerated inguinal hernia. patients and methods: clinical setting a retrospective analysis of patients undergoing sils-tep for incarcerated hernia from may to august at kinki central hospital was performed. exclusion criteria sils-tep was contraindicated for the following conditions in our hospital: a history of radical prostatectomy; a small indirect inguinal hernia in a young patient; and unsuitable for general anesthesia. surgical procedure laparoscopic abdominal exploration through a single, . -cm, intraumbilical incision was performed. the incarcerated hernia content was gently retracted from the hernia sac into the abdominal cavity. in some cases, simultaneous manual compression on the incarcerated hernia from the body surface was required. if no bowel resection was needed, a standard sils-tep using mesh was performed following laparoscopic abdominal exploration and incarcerated hernia reduction. if bowel resection was required, inguinal hernia repair using mesh was not performed to avoid postoperative mesh infection, and two-stage sils-tep was performed - months after the bowel resection. results: fourteen patients ( men, women) with irreducible inguinal hernias, including with unilateral hernias and with bilateral hernias, underwent surgery. the patients' median age was years (range, - years), and median bmi was . kg/m (range, . - . kg/m ). of the patients, had acute incarceration, and had a chronic irreducible hernia. seven patients with acute incarcerated hernias underwent emergency surgery, and two of the seven patients needed singleincision laparoscopic partial resection of the ileum, followed by two-stage sils-tep. twelve patients, excluding two patients who required single-incision laparoscopic partial resection of the ileum, underwent laparoscopic exploration with hernia reduction followed by sils-tep. one case of chronic incarceration out of the twelve patients who underwent sils-tep after hernia reduction required conversion to kugel patch repair. the median operative times were min (range - min) for unilateral hernias and min (range - min) for bilateral hernias. the median blood loss was minimal (range - ml). the median postoperative hospital stay was day (range - days). the median follow-up period was months (range - months). a seroma developed in % ( / ) of patients and was managed conservatively. no other major complications or hernia recurrence were noted during the follow-up period. conclusions: sils-tep, which offers good cosmetic results, could be safely performed for incarcerated inguinal hernia. objective: introduction of mis in pediatric age group has been proved feasible and safe. there is considerable evolution with introduction of a number of invovation in mis pediatric inguinal hernia repair. high ligation of sac is the basic premise of surgical repair in pediatric inguinal hernias. there are different mis techniques broadly grouped into intracorporeal or intracorporeal with extracorporeal component namely the suturing. every techniques has its own complications. the main objective of our study was to focus on different anatomical pointers which can lead inadverent complications mainly bleeding and recurrence. methods and procedures: prospective review of hernias ( male and female) ( months- years) performed laparoscopically between september and june . under laparoscopic guidance, the internal ring was encircled extraperitoneally using a - non-absorbable suture and knotted extraperitoneally. data analyzed included operating time, ease of procedure, occult patent processus vaginalis (ppv), contralateral inguinal hernia, complications, cosmesis and recurrence. results: sixteen right ( %), left ( %) and bilateral hernia ( %) were repaired. five unilateral hernias ( . %), all left, had a contralateral ppv that was repaired (p= . ). mean operative time for a unilateral and bilateral repair were . ( - ) and . min ( - min) respectively. one hernia repair still recurred ( . %) even with all precautions and another had a post operative hydrocoele ( . %). one case ( . %) needed an additional port placement due to inability to reduce the contents of hernia completely. because of our techinique we could not find any adverent peroperative bleeding. there were no stitch abscess/granulomas, obvious spermatic cord injuries, testicular atrophy, or nerve injuries. conclusion: the results confirm safety, efficacy and cost effectiveness of laparoscopic inguinal hernia repair. during our per-operative analysis we focus to address the anatomical landmark to minimize future recurrence and peroperative surgical complications. we identified and named a point as j. point at the tip of triangle of "doom". that is most important point to address peroperatively. there is high chance of recurrence if that point is not encircled well or inadequately circled because of fear of iliac vessels injury. we aslo concluded that 'water dissection technique' is effective techniques in un-experienced hand and in early stages of laparoscopic hernia repair to prevent inadvertent iliac vessels injury. medstar georgetown university hospital, georgetown university school of medicine, introduction: incisional hernias following abdominal surgery can be associated with significant morbidity leading to decreased quality of life, increase in health care spending and need for repeat operations. patients undergoing gastrointestinal and hepatobiliary surgery for malignant disease may be at higher risk for developing incisional hernias. identifying these risk factors for incisional hernia development can help decrease occurrence. this will be the largest multi-institutional study looking at incidence of symptomatic hernia rates for major abdominal operations including colectomy, hepatectomy, pancreatectomy, and gastrectomy. methods and procedures: an irb-approved retrospective study within the medstar hospital database was conducted, incorporating all isolated colectomy, hepatectomy, pancreatectomy, and gastrectomy procedures performed across hospitals between the years of to . all patients were identified using icd- and icd- codes for relevant procedures and then subdivided into either having benign or malignant disease. exclusion criteria comprised of patients who had concomitant organ resection, or those undergoing organ transplant. data validation was performed to verify the accuracy of the data set. the rate of symptomatic incisional hernia rates (ihrs) were determined for each cohort based on subsequent hernia procedural codes identified and repairs performed. descriptive statistics and chi squared test were used to report ihrs in each group. results: during this -year span, a total of , major abdominal operations were performed at all institutions, comprising of , colectomies, , hepatectomies, , pancreatectomies, and gastrectomies. malignancy was the indication for surgery in , ( . %) colectomies, ( . %) hepatectomies, ( . %) pancreatectomies, and ( . %) gastrectomies. ihr in each cohort for benign vs malignant etiologies, respectively, are as follows: ( . %) vs ( . %) in colectomy (p= . ), ( . %) vs ( . %) in hepatectomy (p= . ), ( . %) vs ( . %) in pancreatectomy (p= . ), and ( . %) vs ( . %) in gastrectomy (p= . ) patients. conclusion: symptomatic incisional hernia rates following major gastrointestinal and hepatobiliary surgery ranges from . to . %. there was no significant increase in hernia rates in patients undergoing surgery for malignancy. patients undergoing colectomy for benign disease had a high incidence of symptomatic ihrs. introduction: prosthetic infections, although relatively uncommon, are a major source of cost and morbidity. the study aimed to evaluate the influence of mesh structure including the polymer type and mean pore size on bacterial adherence in a mouse model. methods: three commercially available hernia meshes were included in the study. for each mesh type, a cm square was surgically placed intraabdominally in mice. one mouse served as a control while an enterotomy was made in the subsequent mice to introduce a bacterial load onto the mesh. after hours the meshes were harvested. the inoculated meshes were then plated on agar plates and bacterial counts were counted after hours. the bacterial counts were compared between the various mesh types. results: the mean bacterial adherence was increased in the large pore mesh was colonies, for the small pore mesh was colonies, and in the biologic mesh group it was colonies. conclusions: through the use of a mouse model, the influence of mesh type and pore size on bacterial adherence was evaluated. meshes that have larger pores with a lower prosthetic load and the biologic mesh interestingly had lower early bacterial colonization after hours following an enterotomy. further evaluation with a longer incubation time could be helpful to determine the effect of bacterial colonization of mesh. hrishikesh salgaonkar, raquel maia, lynette loo, wee boon tan, sujith wijerathne, davide lomanto; national university hospital, singapore laparoscopic repair of groin hernias is widely accepted approach over open due to lesser pain, faster recovery, better cosmesis and decreased morbidity. however, there is still debate on its use in large inguino-scrotal hernias, recurrent hernias and history of lower abdominal surgery anticipating adhesions and difficulty in dissecting extensive hernia sac. retrospective analysis of prospectively collected data was done of patients undergoing laparoscopic repair of large inguino-scrotal, incarcerated groin hernia, recurrent cases after open or laparoscopic repair and history of previous lower abdominal surgery. between january to july , patients with large inguino-scrotal hernias, recurrent hernia, history of lower abdominal surgery, incarcerated femoral hernia underwent laparoscopic inguinal hernia repair. patient characteristics, operating time, surgical technique, conversion rate, complications and recurrence up to months recorded. patients had large inguino-scrotal hernia, recurrent hernia ( previous open, previous lap) , history of lower abdominal surgery ( lscs, appendectomy, prostatectomy, midline laparotomy), incarcerated femoral hernia, meshoma removal. patients underwent total extraperitoneal (tep) repair, transabdominal pre-peritoneal (tapp), needed conversion to open. mean operation time was min for unilateral and min for bilateral hernia. seroma formation seen in patients, minor wound infections treated conservatively. we conclude that the laparoscopic approach can be safely employed for the treatment of complex groin hernias; surgical experience in laparoscopic hernia repair is mandatory with tailored technique in order to minimize morbidity and achieve good clinical outcomes with acceptable recurrence rates. mesh fixation in ventral incisional hernia is a topic of ongoing debate. permanent and absorbable tacks are acceptable and widely used methods for mesh fixation. the purpose of this study was to compare outcomes of permanent tack fixation versus absorbable when used alone or with suture fixation in laparoscopic incisional hernia repairs. a retrospective review of all patients undergoing laparoscopic ventral hernia using tack fixation (absorbable/permanent) alone or in conjunction with suture fixation was queried from the ahsqc database. outcome measures included hernia recurrence rate, pain, quality of life, wound related issues, and hospital length of stay. propensity match scoring was performed to compare patients undergoing tack only fixation versus tack and suture fixation with a p-value of . considered significant. a total of patients were identified after propensity match scoring with who underwent repair with permanent tacks alone or with sutures and who underwent repair with absorbable tacks alone or with sutures. following matching there were no differences in bmi, age, hernia width/length, or baseline pain/ quality of life. there were no significant differences found in outcome measures including recurrence rates, pain and quality of life outcomes at days, months, and year, surgical site infection (ssi), and postoperative length of stay (p[ . ). there was a significant increase in any post op complication in the permanent tack fixation group compared to the absorbable tack fixation group ( % vs %, p. ) which is likely due to the increase in surgical site occurrences noted in the permanent tack fixation group ( % vs. %, p. ). based on this large data set, there are no significant differences in postoperative outcomes in permanent versus absorbable fixation in laparoscopic hernia repair except in surgical site occurrences. further study is needed to evaluate but at the present time, there is no convincing evidence that one type of fixation is superior to another in laparoscopic ventral hernia repair. introduction: inguinal hernia repair is the most common procedure in general and visceral surgery worldwide. laparoscopic transabdominal preperitoneal mesh hernioplasty (tapp) has been also popular surgical method in japan. single incision laparoscopic surgery is one of the newest branches of advanced laparoscopy, and its indication has been spread to not only simple surgery such as cholecystectomy, but also complex surgery. we report our experience with single incision laparoscopic tapp (s-tapp) for japanese patients with inguinal hernia. case description: a consecutive series of patients ( male, female) who underwent s-tapp during june to september in a single institution. twenty eight of the patients had bilateral inguinal hernia. the mean follow-up was days. the average age of the patients was . ± . years. establishment of the ports: a -mm vertical intra-umbilical incision is made for port access. one -mm optical port and two -mm ports were placed side-by-side through the umbilical scar. surgical procedure: the procedure was carried out in the conventional fashion with a wide incision in the peritoneum to achieve broad and clear access to the preperitoneal space, and an appropriate placement of polypropylene mesh ( dmaxtm light, bard) with fixation using the tacking device (absorbatack®, covidien). the hernia sac is usually reduced by blunt dissection, or is ligated and transected with ultrasound activated device. the peritoneal flap is closed by one suture with - pds and the - tacks using absorbatack®. discussion: in one patient, we encountered a large sliding hernia on the right side having sigmoid colon as content of the sac, which required conversion to the conventional laparoscopic procedure. there were nine recurrence cases after surgery of laparoscopic or anterior approach, and two cases after prostatectomy. there was no intra-operative complication. the mean operative time was . ± . min, and blood loss was minimum in all cases. the average postoperative stay was . ± . days. there was one recurrence case ( . %) months after the surgery. there was no severe complication after the surgery, but there were seromas ( . %) and one hematoma ( . %). two patients had blunt tactile sense in the area of the lateral femoral cutaneous nerve ( . %), which improved in two months. conclusion: our results suggest that s-tapp is a safe and feasible method without additional risk. moreover, cosmetic benefit is clear. however, further evaluation for postoperative pain and longterm complications compared to standard laparoscopic tapp mesh hernioplasty should be required. manuel garcia, md, daniel srikureja, md, marcos j michelotti, md, facs; loma linda university health introduction: prosthetic mesh use has become standard practice during ventral hernia repair to reduce the risk of recurrence. the ideal mesh is macro-porous which favors rapid cellular ingrowth and tissue integration, has limited tissue reactivity, low profile and weight, and has high tensile strength to add resilience to the repair. additionally, the material is expected to have good handling characteristics. currently, there is a wide variety of options for mesh. biosynthetic material (poliglycolic acid/trimethylene carbonate -pga/tmc) has been shown to behave well in terms of early vascularization and ingrowth as well as adequate long term tissue generation. gore® synecor® biomaterial is a composite mesh including two layers of absorbable biosynthetic material (pga/tmc) with one tridimensional non-absorbable macro-porous knit of dense ptfe mesh. it has shown good vascularization and ingrowth at days in animal examination. however, there is still no evidence of long term behavior of this mesh in human tissue. we present the first histologic analysis of this mesh year after placement in a human. objective: to perform a histologic analysis of the gore® synecor® biomaterial one year after placement in the human body. methods: after incidentally finding incorporated gore® synecor® mesh in a patient with prior ventral hernia repair year ago, during open bilateral inguinal hernia repair, a sample of mesh was taken and sent to pathology lab for analysis. tissue healing, vascularization, and ingrowth of the composite mesh were analyzed. results: histologic findings significant for a biomaterial consistent with a knitted ptfe material surrounded by mature fibrovascular tissue and foreign body inflammation consistent with expected healing response for this time frame. no evidence of any other biomaterial (pga/tmc) or evidence of infection. conclusion: gore® synecor® biomaterial has shown to be well integrated into appropriately healed tissue, with pronounced vascularization and ingrowth. the pga/tmc layers have been seen to be completely absorbed and replaced by collagen. these findings, in a human months sample, replicate what had been shown in animal specimens. method: from to , patients came to hospital with renal paratransplant hernia. they were evaluated for this study. the following data were collected from their records: age, gender, weight, age at graft rejection, surgical complications, treatment method and the treatment results with composite ptfe mesh. results: for laparoscopic repair of incisional hernia after renal transplant, the median interval between kidney transplantation and developing of incisional hernia was (range to ) days. predisposing factors were obesity, age over fifty years, and female gender. in six patients, hernia was large, and the repair was performed with using composite ptfe mesh. one patient had developed serous collection in surgical site, which was managed successfully with multiple punctures. hernia recurrence or infection was not noted in these patients during to months follow-up periods. conclusion: incisional hernia is not a rare entity after kidney transplantation. predisposing factors, such as obesity, age over years, and female gender have a role in its development. repeated surgeries in kidney recipients can increase the risk of incisional hernia. managing this complication by laparoscopic approach is a safe and effective method. sujith wijerathne, raquel maia, hrishikesh salgaonkar, wee boon tan, lynette loo, davide lomanto; national university hospital, singapore introduction: a femoral hernia is a less common type of hernia. it is estimated to account for less than % of all abdominal wall hernias. only about in every groin hernias are femoral hernias. they are found more commonly in females due to wider shape of pelvis. laparoscopy by offering magnification and better vision provides us the opportunity for clear visualization of the myopectineal orifice. laparoscopy seems to be a safe and feasible approach for femoral hernia repair in an asian population. case description: between and , consecutive patients with femoral hernia who underwent laparoscopic hernia repair were prospectively studied. patient demographics, hernia characteristics, operating time, conversion rate, intraoperative, postoperative complications and recurrence were measured. discussion: total of femoral hernias were repaired, on right and on left groin. this included patients with bilateral and unilateral hernia. concomitant obturator hernia were found. there were male and female patient. no conversion was reported. one patient had injury to bowel at the mm port entry site, without contamination, identified and managed immediately. patients developed seroma, all were managed conservatively except one who needed aspiration. peri-port bruising was noticed in patients and patients had hematoma. one patient with hematoma underwent excision of the organised hematoma. of the hematoma patient was on aspirin pre-operatively. no wound infection, chronic groin pain or recurrence was documented during follow up till date. conclusion: laparoscopic repair offers accurate diagnosis and simultaneous treatment of both inguinal and femoral hernia with minimum morbidity and good clinical outcomes. better visualisation and magnification gives us an opportunity to identify occult hernias which can be repaired during the same setting, thereby reducing the chance of recurrence and possible need for second surgery. laparoscopic repair has become the procedure of choice for the treatment of the majority of groin hernia at our institution. introduction: totally extraperitoneal (tep) repair that does not require peritoneal incisions is a good procedure that involves minimal visceral damage. however, balloon-or camera-assisted blunt dissections that are performed in a haphazard manner do not follow precise dissection of the fascia layer. furthermore, they have a disadvantage in that they are difficult to understand anatomically. we therefore developed a novel preperitoneal approach to resolve this issue. methods: a -mm trocar is inserted into the rectus abdominis sheath cavity after a small incision is made below the umbilicus and the posterior rectus sheath is exposed. a -mm trocar is inserted cm towards the pubic bone from the umbilicus. using forceps from this position, narrow branches that enter the posterior rectus sheath from the inferior epigastric vessels are dissected, thereby broadly exposing the anterior surface of the posterior rectus sheath. the third mm-trocar is inserted near the lateral margin of the rectus abdominis. on the outside, local anesthetic is injected beneath the posterior rectus sheath and the preperitoneal cavity is separated in fluid so that the peritoneum is not injured during posterior rectus sheath incision. a small incision is made to the posterior rectus sheath or attenuated posterior rectus sheath at one finger width higher than the expected upper margin of the prosthetic mesh. due to the effects of local injection, a sharp incision to the fascia can be made with an electric scalpel. utilizing this mechanism, the posterior rectus sheath aponeurosis and the lining transverse fascia and superficial preperitoneal layer are individually identified. once the preperitoneal cavity is reached, the peritoneal margin is determined in the lateral direction, and the peritoneum that is pulled due to pneumoperitoneum is separated from the preperitoneal fascia on the outside from the cranial side towards the deep inguinal ring. on the inside, the pneumoperitoneum pressure pushes the peritoneum inferiorly, leading to enlargement and increased visibility of the posterior rectus sheath deep fascia, which is dissected one layer at a time from the outside. the umbilical prevesical fascia is dropped inferiorly, and the dissection of the preperitoneal cavity necessary for mesh deployment is performed. results: by individually dissecting each fascia using emphysema through pneumoperitoneum and enlargement through local injection, the method for reaching the preperitoneal cavity could be successfully completed by following the dissection of the fascia layer without proceeding with the operation blindly, thereby resulting in the elimination of intraoperative bleeding and postoperative hematoma. introduction: in the field of abdominal wall reconstruction, the utility of drain placement is of debatable value. we present outcomes evaluating drain placement vs no drain placement at the time of robotic transversus abdominis release (rtar) technique with placement of mesh in the retromuscular position, a currently understudied subject. methods: retrospective review of a prospectively maintained hernia patient database was conducted identifying individuals who received either drain placement or no drain placement during abdominal wall reconstruction via the rtar technique from august to june at a single high volume hernia center. perioperative data and postoperative outcomes between the two groups are presented with statistical analysis for comparison and quality of life (qol) measures assessed using the carolina comfort scale. results: thirty-five patients were identified for this study, of which had drains placed intraoperatively in the retromuscular position at the conclusion of rtar (drn) and underwent rtar without the placement of draining devices (nd). the drn cohort had a mean bmi, defect area, mesh area, and operative time of . , cm , cm and minutes, respectively, compared to . , cm , cm , and minutes in the nd group. all cases utilized medium weight macroporous polypropylene synthetic implantable mesh materials in both the drn and nd subgroups. there were no reported postoperative complications, including no development of hematoma, seroma, or surgical site infections in either group. hernia recurrence was not identified in either the drn or nd cohorts through a mean follow up of days ( . months). there were no statistically significant differences in postoperative qol outcomes. conclusion: our series review suggests that the use of intraoperative drains may not afford any benefits with the rtar technique when mesh is placed in the retromuscular position. additional postoperative management associated with drain care may be unnecessary. surg endosc ( ) :s -s background: appendectomy is one of the most common operations performed during emergency surgery. although laparoscopic appendectomy (la) has become the treatment of choice, there is still a debate regarding the use of la for treating complicated appendicitis. in this retrospective analysis, we aimed to clinically compare la and open appendectomy (oa) for treating complicated appendicitis. methods: we retrospectively identified patients who underwent an operation for complicated appendicitis at our hospital; these patients were operated on between and july . [editor ] in total, patients underwent conventional appendectomy and patients were laparoscopically treated. outcomes included operation time, blood loss, length of hospital stay, and postoperative complications. logistic regression analysis was performed to analyze the concurrent effects of various factors on the rate of postoperative complications. objective: small bowel perforation has conventionally been dealt with open exploration, which frequently leads to many wound-related complications. wound infection is the major reason for increasing morbidity in these patients and delay recovery. laparoscopic surgery has various benefits over open surgery like, smaller wound, lesser pain and faster recovery. the aim of this study was to relay the advantages of minimally invasive surgery (mis) to patients with small bowel perforation to decrease postoperative wound complications and duration of hospital stay. methods: it is a retrospective study, including patients with small bowel perforation from to . of these , had traumatic etiology, had typhoid-related perforation and the remaining had a duodenal perforation. of them were male, and the average age was . years. only patients who presented within hours of perforation were included in the study. laparoscopic exploration was done on introducing camera from -mm infraumbilical port after intraperitoneal carbon dioxide insufflation. the remaining two -mm working ports were then introduced depending on the site of perforation once identified. the perforations were then repaired using intracorporeal single-layer suturing using polydioxanone - suture. the peritoneal cavity was given thorough lavage and abdominal drain placed in the pouch of douglas. fecal contamination was found in all the patients. a total of patients underwent conversion to open surgery due to inability to find the site of perforation laparoscopically. of the operated patients, patients developed port-site infection, and there were no major postoperative complications in the -week follow up period. conclusion: we conclude from our study that laparoscopic intervention in early small bowel perforation is a safe approach with favorable outcomes, especially with regards to wound complications, that are a major factor in increasing the morbidity in such patients postoperatively. laparoscopic approach leads to early discharge and recovery postoperatively. with the emerging era of laparoscopic surgery, leading to its easy accessibility, more patients can advantage from this technique when they arrive in emergency with intestinal perforation. s surg endosc ( ) :s -s introduction: pneumatosis intestinalis (pi), or gas in the bowel wall, can be seen on various imaging modalities. the pathophysiology behind pi is unclear. one theory proposes a mechanical cause (e.g. small bowel obstruction) while another proposes a bacterial etiology. management of pi in adults is difficult as often there is a benign clinical course. however, when paired with specific clinical features such as hepatic portal venous gas (hpvg) on imaging, the course of management changes as the suspicion of bowel ischemia increases. hpvg alone has been associated with a high mortality rate and a poor prognosis. management in this case becomes surgical. case presentation: we present a case of -year-old latino male who presented to the emergency room with abdominal pain and altered mental status. focused physical examination revealed a non-rigid abdomen, no rebound tenderness, no guarding, and diffuse tenderness only to deep palpation. ct scan of the abdomen and pelvis demonstrated moderate portal venous gas in the right and left hepatic lobes, an upper midline dilated small bowel loop with pneumatosis intestinalis, and a moderately distended stomach with gas and fluid. laboratory studies revealed metabolic acidosis and a lactic acid level of . mmol/l. due to these findings, bowel ischemia was suspected, and the patient was taken to the operating room for a diagnostic laparoscopy. the laparoscopy was converted to an exploratory laparotomy due to extensive adhesions. intraoperatively, there was no small bowel compromise and no identifiable transition point. extensive lysis of adhesions and repair of iatrogenic enterotomy were performed. patient tolerated the procedure well, clinically improved, and was discharged from the hospital. discussion: this case illustrates the difficulty in management of a patient with pneumatosis intestinalis and, specifically, hepatic portal vein gas seen on ct imaging. hpvg has traditionally been a harbinger of morbidity and mortality, but exploratory laparotomy revealed only diffuse abdominal adhesions and the absence of bowel ischemia despite high clinical suspicion. background: ventral hernia repair is one of the most common surgical procedures facing the general surgeon. there is little consensus as to the best surgical technique for complex scenarios. often these patients have complicating co-morbid conditions such as radiation therapy, that has an inevitable effect in the abdominal wall structures, which can lead to non-traditional repairs. case report: we present a case of a year-old female who underwent a tah/bso and right hemicolectomy which was complicated by wound dehiscence. she underwent primary repair and adjuvant whole pelvis radiation for her squamous cell carcinoma. subsequently, the patient developed acute obstructive symptoms do to a stricture within her small bowel and a large ventral hernia measuring cm with non-reducible abdominal contents below the level of the fascia more prominent in the suprapubic area. the patient's bmi was . . various considerations are important in planning a surgical repair in a previously irradiated field with loss of domain which include, minimal dissection, and the use of an atraumatic surgical techniqueque with either external oblique release or transversus abdominis muscle release (tar). we chose a a tar, as it provides wider myofascial release and dissection below the arcuate line towards the space of retzius and bogros allowing for a larger sublay mesh placement. also it avoids the need of skin flaps reducing the risk for wound complications in under-perfused tissue. the tar was performed successfully and there were no intraoperative and postoperative complications. her follow-up at months revealed no wound complications or hernia recurrence. conclusion: for patients with compromised tissue and loss of domain a tar technique may be useful when reconstructing complex abdominal wall hernias. it provides the core principals of hernia repair such as primary fascial closure, wide mesh overlap, and finally it provides a reliable approach for the under-perfused tissue without need of skin and soft tissue flap creation. outcomes in the management of cholecystectomy patients in the setting of a new acute care surgery service model: impact on hospital course larsa al-omaishi, bs, william s richardson, md; ochsner medical clinic foundation introduction: the acute care surgery (acs) model, defined as a dedicated team of surgeons to address all emergency department, inpatient, and transfer consultations, is quickly evolving within hospitals across the united states due to demonstrated improved patient outcomes in the non-trauma setting. the traditional model of call scheduling consisted of one senior attending and one senior resident on call per -hour shift. attendings were responsible for consults, previously scheduled operations, as well as clinic time. multiple recent studies have shown statistically significant improvements in several parameters of patient care by using acs including but not limited to . time from emergency department to surgical evaluation . time from surgical evaluation to operating room . operative time . percent laparoscopic . length of hospital stay . intra-operative complications (blood loss, perforation rates) . post-operative complications (fever, infection, redo) . cost. one study demonstrated a statistically significant cost savings for the acute care surgery model with respect to appendectomies, but not cholecystectomies. study design: a retrospective analysis of patients who underwent cholecystectomy in the setting of non-traumatic emergent cholecystitis was performed to compare data from two cohorts: the traditional model and the acs between january , and dec , at ochsner medical center, a -bed acute care center in new orleans. parameters gathered included . time from emergency department to surgical evaluation . time from surgical evaluation to operating room . operative time . percent laparoscopic . length of hospital stay . intra-operative complications (blood loss, perforation rates, conversion to open) . post-operative complications (fever, infection, redo). demographics were also collected including age, weight, height, ethnicity, asa, etc. inclusion criteria included: age[ and having undergone cholecystectomy between jan , and december , . exclusion criteria included choledocholithiasis, gallstone pancreatitis, ascending cholangitis, gangrenous cholecystitis, septic complications precipitating further procedures and delays, or researcher discretion. results: patients were initially identified as having undergone cholecystectomy within the allotted time period [ - , - , - , - ] . were excluded due to one of the reasons above. median patient age was years old and the average patient encounter was . days. conclusion: the acs model is better suited to manage emergent non-traumatic cholecystectomies than the traditional call service at our institution, as evidenced by several parameters. s surg endosc ( ) :s -s he nailed it background: nail guns are powerful tools and are widely used. injuries with these devices may be devastating due to the significant force they can deploy. patients and methods: we herein report a first case of a self inflicted abdominal injury with a nail gun. results: a year old male with history of coronary artery disease, type dm and early signs of dementia attempted to refill a nail gun. he lodged the device against his right abdomen while the air hose was still attached and then accidently fired nails into his abdomen. after he unsuccessfully tried to pull the nails out he drove himself minutes to our emergency room. he was hemodynamically stable on arrival; pain control was achieved, antibiotics were given and he received tetanus immunization. ct-scan showed the two foreign bodies penetrating from the ruq with one reaching the transverse colon. on emergency laparoscopy, the nails were found to have penetrated the thick omentum and the puncture site of one nail into the colon was identified. the omentum was resected off the colon and the right colon was completely mobilized. no additional injuries were found. the entrance area of the nails was then used to create a loop colostomy. the postoperative course was initially uneventful but the patient developed a severe posttraumatic inflammatory reaction of the fat tissue in the right upper quadrant and had to be readmitted for pain control and antibiotics were again administered. he recovered and was discharged with a plan for laparoscopically assisted colostomy closure after weeks. discussion: to the best of our knowledge this is the first reported isolated colonic injury by a nail gun. given the tremendous force of the device with unknown collateral damage to the surrounding tissue it was decided to manage the accident with a laparoscopic assisted colostomy using the entrance point of the nails for fecal diversion. introduction: it is difficult to diagnose obturator hernias by routine physical examination. obturator hernias are frequently complicated by ileus and the diagnosis is often first made from abdominal ct. obturator hernias are difficult to reduce, and often necessitate emergency surgery. they are common in elderly people, and they often had bad general condition. so it was high in the death rate. at our hospital, we first attempt to reduce the hernia from the body surface under ultrasonographic guidance. after relieving the strangulation, we perform radical operation electively in patients who are for possible for surgery under the general anesthesia. we perform laparoscopic repair for obturator hernias. obturator hernias are often complicated by other types of hernia. in these cases, we perform total repair. herein, we present a review of the patients who underwent surgery for obturator hernia at our hospital. methods: we review the data of cases of obturator hernia encountered by us from february to december . we performed total repair in three of the cases. however, it is difficult to procure a mesh that would be adequate for all the defects (inner inguinal ring, femoral ring, obturator). no single mesh can fit, because the inguinal and pelvic curves present opposing curves near the obturator. therefore, we placed two pieces of mesh available at our hospital ( d max [bard] and onlay sheet of kugel patch [bard] ) together in the patientswe could successfully cover all the defects using these two pieces of mesh and could fit the mesh to the pelvic shape by devising an appropriate connection between the meshes. results: we reviewed a total of operated cases for obturator hernia. the hernia was bilateral in cases, and complicated by other hernias in cases. we first determined the appropriate approach for the repair. we performed total repair in cases. they were no complications and no cases of recurrence. conclusion: our approach to the repair of obturator hernias was very useful. we can use the exact area and shape of the mesh needed in individual patients by this method. we show the method of shaping the mesh to fit the pelvic form. demin aleksandr, do, ajit singh, do, noman khan, do; flushing hospital introduction: internal hernias are known complications that are well documented to involve peterson's defect. in bariatric patient's post gastric bypass there is a high index of suspicion for internal hernias as well as a low threshold to operate. there have been some debates around the closure of the potential peterson's space with several studies advocating closure versus some which show that there is no difference in the rate of symptomatic internal hernias. we present a case of an unusual cause of small bowel obstruction due to internal hernia caused by a cecal volvulus. it is an atypical presentation however the patient was triaged and brought to the or within hours of admission. although it is rare there have been reports of internal hernias caused by other structures like congenital bands or natural potential spaces. there have been reports of unusual presentations of the cecum herniating through the foramen of winslow. the anatomical rearrangements after bypass create potential areas where an internal hernia can occur. in this case a bowel resection was undertaken due to the anatomical variation of the cecal bascule and cecal volvulus due to high rate of recurrence of this cecal pathology. majority of internal hernias do not require bowel resection especially when detected earlier and prompt surgical exploration is undertaken. mortality as direct consequence internal hernia is extremely rare. however late diagnosis of internal hernias can lead to catastrophic gut loss and may require lifelong tpn and/or visceral transplantation or autologous reconstruction. conclusion: careful history and physical of our bariatric patient can elicit the signs and symptoms of internal hernias and prevent the morbidity and mortality that can come with the complications of this condition. unusual presentations and causes are reason for prompt diagnosis and complete exploration. shingo ishida , naotsugu yamashiro , satoshi taga , koichi yano ; shinkomonji hospital, shinmizumaki hospital symptomatic cholelithiasis is common disease performed with laparoscopic cholecystectomy (lc). we will hesitate to operate if the patient is pregnant in the third trimester. pregnant patients undergoing laparoscopic surgery have been reported increasingly. however, most case reports are confined to patients in the first and second trimester. we report a patient who underwent lc in the third trimester and review the relevant literature. a -year-old woman in the third trimester ( w d) of pregnancy was seen in the emergency department of our hospital with a history of upper abdominal pain. there was no problem in the course of pregnancy. the result of the examination proved to be attack of gallstone colic. she was hospitalized the same day and underwent lc the next day. the base of pregnancy uterus was cm above the navel. we needed to consider the surgical approach, for example inserting the first trocar under left hypochondrium. operative duration was minutes. she complained abdominal distension at postoperative day (pod) and but there was no abnormality in the fetus. she was discharged on pod . after that she gave birth to a healthy baby. lc in third trimester of pregnancy was safely performed with obstetrics back up. weekday or weekend hospital discharge: does it matter for acute care surgery? ibrahim albabtain , roaa alsuhaibani , sami almalki , hassan arishi , hatim alsulaim ; kamc, background: hospitals usually reduce staffing levels over weekend. this raises the question of whether patients discharged over a weekend may be inadequately prepared and possibly at higher risk for adverse events post-discharge. the aim of this study was to assess the outcomes of common acute care surgery procedures for patients discharged over weekend, and identify the key predictors of early readmission. methods: this retrospective cohort study was conducted at a tertiary care hospital between january and december . surgical procedures included were cholecystectomy, appendectomy, and hernia repairs. patients' demographic, co-morbidities, complications, readmission and follow-up details were collected from the electronic medical records. predictors and post-operative outcomes associated with weekend discharge were identified by multivariable analysis using univariable and multivariable logistic regression models controlling for potential confounders. results: a total of patients were included. overall median age was years (iqr: , ). the majority of patients were female (n= , . %). patients ( . %) underwent a cholecystectomy, ( . %) an appendectomy, and ( . %) hernia repairs. weekend discharge was . % vs. . % of weekday discharge. patients discharged during weekend were younger ( . vs. , p-value. , mean) . post-discharge -day follow-up visits were significantly lower in the weekend discharge subgroup ( . % vs. . %, p-value . ). overall, -day readmission rate was . % (n= ), and did not differ between those of weekend and weekday discharge (or= . , % ci . - . ). conclusions: patients discharged on weekends tended to be younger in age and less likely to have chronic diseases. patients discharged over the weekend were less likely to follow up compared to weekday discharge patients. however, the readmissions rate did not differ between the two groups. intrauterine device (iud) migration out of the uterine cavity is a serious complication. its incidence in the us has been reported to be about . % annually. previously published systematic review supports the use of laparoscopic surgery for elective removal of migrated iucds from the peritoneal cavity. we present the safety and efficacy of the laparoscopic approach to this complication in the acute care setting. depicted is an otherwise healthy year old female with no previous surgical history who presented to the ed with worsening abdominal pain for one week with no associated symptoms. on physical exam, patient was non toxic. abdomen was moderately distended with guarding and rebound tenderness to palpation, no rigid. patient had been seen shorlty prior to ed admission by her obgyn and recent work up with abdominal/pelvic x-ray and ultrasound has revealed a misplaced iud in the transverse position (side ways). pregnancy test was negative. based on patient clinical presentation and recent radiologic findings, we decided to proceed with diagnostic laparoscopy. after systematic review of cavity, the foreign body was found to be incorporated within the greater omentum. we procceded, laparoscopically with omentectomy+foreign body removal. there were no perioperative complications, patiet was discharged on the following day. the use of laparoscopy in elective iud retrieval within in the abdominal cavity has been considered standard of care in surgical management to date. this poster demonstrates its use as an effective approach for safe removal of intra-abdominal foreign bodies also in the acute setting. symptomatic inguinal and umbilical hernias in the emergency department: opportunity lost? andrew t bates, md, jie yang, phd, maria altieri, chencan zhu, bs, salvatore docimo, jr., do, konstantinos spaniolas, md, aurora pryor, md; stony brook university hospital introduction: patients with symptomatic inguinal and umbilical hernias often present to the emergency department (ed) when their symptoms change or increase, usually not requiring emergent surgery. however, little is known about how often these patients present prior to eventual repair and whether they undergo surgery at the initial presenting institution. the aim of this study was to assess the clinical flow of patients presenting in the ed for inguinal and umbilical hernia. methods: all patients presenting to eds in new york state from to with symptomatic inguinal and umbilical hernias were identified using the new york state longitudinal hospital claims database (sparcs). patients were followed for records of hernia repair and subsequent inpatient and outpatient visits up to . results: , patients presenting to the ed for symptomatic inguinal hernia were identified. . % ( , ) of ed presentations resulted in inpatient admissions. , ( . %) had repair later and their average time from ed presentation to inguinal hernia repair was (± ) days. . % of patients who did not have subsequent surgery had only one ed visit. of those that underwent interval repair, . % had only one ed visit prior to surgery. for those patients with only one ed visit before repair, . % had repair at a different hospital, as opposed to . % if multiple ed visits were made. , umbilical hernia patients presenting to the ed were identified. . % ( , ) resulted in inpatient admission. , ( . %) had interval repair, with the average time from ed presentation to umbilical hernia repair being (± . ) days. % of patients who did not record of later repair presented to the ed once. of those patients who underwent repair, . % did so after one ed visit. for those patients with only one ed visit before repair, . % had repair at a different hospital, as opposed to . % if multiple ed visits were made. conclusion: a majority of patients with symptomatic inguinal and umbilical hernias that present to the ed do so once with no subsequent follow-up or repair. for those patients that undergo interval repair, a significant portion willnopt for surgery at other hospitals. a significant proportion of patients with acutely symptomatic inguinal/umbilical hernias who undergo interval repair after a previous ed visit, will opt for definitive surgery at another hospital facility. this represents a missed opportunity for continuity of care for providers and healthcare systems. nikhil gupta, dr, himanshu agrawal, dr, arun k gupta, dr, dipankar naskar, dr, c k durga, dr; pgimer dr rml hospital, delhi introduction: peritonitis is the inflammation of the serous membrane that lines the abdominal cavity and the organ contained therein and is one of the most common infections, and an important problem that a surgeon has to face. reproducible scoring system that allows a surgeon to determine the severity of intra-abdominal infections are essential to prognosticate the patient. this study was done to compare apache ii scoring and mpi score to assess prognosis in perforation peritonitis. methods: all patients admitted with hollow viscus perforation from st november till st march was included in the study. it was a cross sectional observational study. apache ii and mannheim peritonitis index (mpi) scoring systems were calculated in all the patients in order to assess their individual risk of morbidity and mortality. the outcome variables were studied postoperatively -post-operative wound infection, wound dehiscence, anastomotic leak, respiratory complications, duration of hospital stay, need of ventilator support and mortality. the inferences were drawn with the use of appropriate tests of significance. results: the study comprised of patients. neither apache ii nor mpi could predict postoperative wound infection. the mean apache ii score of subjects included in the study was . ± . with range of to and the mean mpi score of subjects included in the study was . ± . with range of to . apache ii was able to predict postoperative respiratory complications, post-operative need for ventilatory support, hospital stay duration and mortality while mpi was able to predict post-operative wound dehiscence, post-operative respiratory complications, post-operative need for ventilatory support and mortality. neither apache ii nor mpi could predict postoperative anastomotic leak and postoperative wound infection. conclusion: mannheim peritonitis index is a useful and simple method to determine outcome in patients with peritonitis. mpi is comparable to apache ii in assessing the prognosis in perforation peritonitis and can well be used in emergency setting in place of apache ii scoring when time is a definite constraint. microrna- and the prognosis of human carcinomas: a systematic review and meta-analysis chengzhi huang, mengya yu; guangdong general hospital (guangdong academy of medical science) muhammad nadeem , julian ambrus, md , steven schwaitzberg, md , john butsch, md ; university at buffalo, introduction: mitochondria is a small energy producing structure of a cell. mitochondrial myopathy (mm) is mixed disorder clinically, which can affect various systems besides skeletal muscle. mm starts with muscle weakness or exercise weakness. mm patients have decreased skeletal muscle mitochondrial function than the healthy person, because of weakened intrinsic mitochondrial function and decreased mitochondrial volume density. no one has studied the mm role in gerd and constipation so far. this study is aimed to see effects of mm on the gastrointestinal system specifically gastroesophageal reflux disease (gerd), gall bladder issues, and constipation. methods: between may and june , mm diagnosed patients at buffalo general hospital were included in this retrospective study. we assessed their demeester score for gerd and wexner's constipation questionnaire for constipation. demeester score[ and constipation score[ were set points for gerd and constipation respectively. data was analyzed by using spss version . mitochondrial enzymes were assessed by using their muscle biopsy report. results: out of ( . % female, . % male) mitochondrial myopathy patients, . % and . % were suffering from gerd and constipation respectively. . %, . % and . % patients had gall bladder issues, obstructive sleep apnea (osa) and fatigue respectively. mm gerd patients ( . % female, . male) had mean demeester score . (sd: . ) more than normal although . % patients were on gerd medications and . % patients had nadh cytochrome c reductase, cytochrome c oxidase and citrate synthase abnormal mitochondrial enzyme in mm associated gerd but . % mm patients had abnormal cytochrome c oxidase enzyme only. mm along with constipation had mean wexner's constipation score . (sd: . ) more than the normal although . % were taking enema, medications or digital assistance. % patients had cytochrome c oxidase and nadh cytochrome c reductase enzymes were abnormal in those patients. . % mm associated gall bladder issues patients had cytochrome c oxidase abnormal. . % mm associated gerd and constipation patients had gall bladder issues. conclusion: in this present study, we found that mm had effects on gastrointestinal system causing gerd, constipation and gall bladder issues. gerd, constipation and gall bladder problems are common in mm patients even patients are taking medications for gerd and constipation. cytochrome c oxidase, citrate synthase and nadh cytochrome c reductase are the most commonly impaired mitochondrial enzyme in mm patients and mm associated gerd, constipation and gall bladder issues patients. objectives: gulf war illness (gwi) is a chronic, multisymptom illness marked by cognitive and mood dysfunction and disrupted neuroendocrine-immune homeostasis affecting % of gw veterans. after + years, useful treatments are lacking and its cause is poorly understood, although exposures to pyridostigmine bromide and pesticides are consistently identified among the strongest risk factors. previous work in our laboratory using an established rat model of gwi identified persistent elevation of microrna- (mir- ) levels in the hippocampus whose gene targets are involved in cognition-associated pathways and neuroendocrine function, suggesting that mir- inhibition is a promising therapeutic approach to improve the complex symptoms exhibited by gwi. the purpose of this study was to identify broad effects of mir- inhibition in the brain by profiling the expression of genes known to play a critical role in synaptic plasticity, glucocorticoid signaling, and neurogenesis in gwi rats administered a mir- antisense oligonucleotide (mir- inhibitor). methods and procedures: nine months after completion of a -day exposure regimen involving gw-relevant chemicals and stress, rats underwent intracerebroventricular infusion of mir- inhibitor (n= ) or scrambled negative control oligonucleotide (n= ) and were implanted with -day osmotic pumps delivering . nmol/day. intranasal delivery of oligonucleotides was performed on additional rats (n= per group; daily for days) to determine whether mir- inhibition is achievable using a noninvasive procedure. hippocampi were harvested and quantitative pcr arrays were used to profile the expression of focused panels of genes important for ) synaptic alterations during learning and memory, ) signaling initiated by the glucocorticoid receptor (known mir- target), and ) neurogenesis. hippocampi were also analyzed by quantitative pcr to examine expression levels of endogenous mir- . results: upregulation ([ . fold change, p. ) of synaptic plasticity genes, glucocorticoid signaling genes, and neurogenesis genes was observed in the hippocampus of gwi rats infused with mir- inhibitor compared to scrambled control, consistent with a significant reduction (p\ . ) in mir- levels detected in rats receiving mir- inhibitor. altered gene expression and a reduction in mir- levels were not observed in rats after intranasal delivery. conclusion: mir- antagonism in the hippocampus upregulates the expression of several downstream targets involved in synaptic plasticity, glucocorticoid signaling, and neurogenesis and is a promising therapeutic approach to improve cognition, emotion regulation, and neuroendocrine dysfunction in gwi. further testing is being pursued to discover the optimal dose for intranasal administration to test viability of this option for ill gw veterans. nikhil gupta, dr, ananya deori, dr, arun k gupta, dr, dipankar naskar, dr, c k durga, dr; pgimer dr rml hospital, delhi background: the ultrasonic dissector, commonly known as the harmonic scalpel, has been in use for achieving haemostasis in surgery for almost yrs. its advantages in breast surgery, especially in the dissection of axilla, have been a matter of debate as previous studies have shown inconsistent results. this study compares the outcomes of the ultrasonic dissector in axillary dissection with that of the conventional electrocautery. methods: patients who were undergoing mrm and bcs with axillary dissection from november till march were included in the study. patients were randomized into two groups, group a undergoing axillary dissection with ultrasonic dissector and group b with electrocautery. the operative time, intra-op bleeding, post-op pain, post op drain volume, hospital stay and any other complications were noted in the two groups. results: the numbers of patients in both groups were each. group a had a significantly shorter operative time, both for axillary dissection ( . min vs. . min, p. ) and the total duration ( . vs. . min, p= . ). the blood loss was significantly less in group a, as measured by the mop count. there was significant reduction in the total post-op drainage volume, which resulted in fewer days of drain in-situ and the total number days stayed in the hospital. there was no significant change in the post-op complications such as haematoma, seroma, flap necrosis, oedema, etc. conclusion: with the use of ultrasonic dissector, the operative time, blood loss and the axillary drainage was significantly reduced. the axillary drainage in turn, reduced the hospital stay. there was no significant difference in terms of complications like haematoma formation, seroma formation, skin flap necrosis or oedema. for the statistical analysis, χ or fisher's exact tests to compare proportions and the nonparametric mann-whitney u test for analysis of values with abnormal distribution were used. discussion: the study included patients. all preoperative laboratory indicators were elevated. the laboratory tests do not demonstrate any statistical significance between these two groups. the group of the patients without stones in the cbd diagnosed by ioc was also divided in patients with diameters. ?mm and with diameters≥ . ?mm of the cbd. also in these two groups, the statistical analysis of the laboratory tests does not demonstrate significant difference. all patients underwent ioc. ioc showed stones in / patients ( . %) . a comparison of patients with and without stones at ioc showed similar mean times from hospitalization to surgery ( . background: housed in a high volume tertiary referral center, our division receives a large amount of transfers and referrals from outside institutions for patients who require completion cholecystectomies. in this study "completion cholecystectomy" refers to patients that meet one of three criteria: . previous subtotal cholecystectomy, . previously aborted cholecystectomy, or . previous cholecystectomy with incidental finding of cancer on pathology. traditionally, exploration of a reoperative field in the right-upper quadrant mandates an open approach due to dense adhesions and inflammation. over the past few years, we have found that robotic-assisted surgery has allowed us to perform these completion cholecystectomies in a minimally invasive fashion. methods: case logs and operating room billing logs were reviewed from to to identify all robotic-assisted cholecystectomies performed at our institution. review of all reports identified completion cholecystectomies. all additional variables including demographics, operative variables, and postoperative outcomes were determined from manual chart review of all consultation notes, operative reports, anesthesia records, progress notes, discharge summaries, and postoperative office visits. results: of the identified robotic-assisted completion cholecystectomies, patients had a previous subtotal cholecystectomy, patients had an aborted cholecystectomy, and patients had an incidental finding of t gallbladder carcinoma on pathology. fifteen patients ( %) underwent preoperative ercp either for choledocolithiasis or to determine biliary anatomy. average time from original procedure was months with . % of previous procedures performed in an open approach. average or time was . minutes, average ebl was . cc, and average length of stay was . days. one patient ( . %) was readmitted within days for nausea that resolved with antiemetics. three patients ( . %) had minor postoperative complications (clavien-dindo grade or ) which resolved with pharmacologic therapy. no patients suffered a -day mortality. all cases were completed in minimally invasive fashion without a conversion to an open procedure. conclusions: although rare, completion cholecystectomies present a challenging surgical scenario. although traditionally performed in an open approach, we have had success in recent years at our institution with a robotic-assisted approach to completion cholecystectomy. we feel that the robotic approach offers certain advantages in a hostile, reoperative field which allows us to perform these procedures in a minimally invasive fashion with no conversions to an open procedure to date. previously limited to case reports, this report of procedures represents the largest case series of robot-assisted completion cholecystectomies to our knowledge. s surg endosc ( ) :s -s background: percutaneous cholecystostomy tube (pct) has been used as a bridge treatment for grade ii-iii moderate to severe acute cholecystitis (ac) to "cool" the gallbladder down over several weeks and allow the inflammation to resolve prior to performing interval cholecystectomy (ic) and removal of the pct, often laparoscopically. the aim of this study was to assess the impact of timing of ic after pct on operative success and outcomes. methods: a retrospective review of electronic medical records of patients who were treated for ac with a pct, and subsequently underwent ic at our institution between january to december was performed. the patients were divided into three groups (n= each), based on the duration of the pct prior to ic, and these groups were comparatively analyzed. a comparative sub-analysis of clinical outcomes between patients who underwent surgery within the first week vs. third week or later after pct was also performed. results: a total of patients met the study criteria. each group had patients. there were no statistically significant differences between the groups in regards to age, gender, bmi, imaging findings, and indications for cholecystostomy tube placement. overall, there was no statistically significant difference in outcomes between performing ic within the first weeks, - weeks and [ weeks after pct placement. the length of stay, overall morbidity, clavien-dindo grade of complications and mortality were similar between the time intervals. however, a sub-analysis showed that patients who underwent ic within the first week of pct placement had statistically significant higher mortality rate (p= . ) compared to those who underwent ic[ weeks of pct placement. the two patients who died in our sample had ic within a week after pct placement. even though there was a statistically significantly higher morbidity rate in those who had ic[ weeks after pct, the clavien-dindo grade of these complications was lower than. conclusion: delaying ic to [ weeks after pct placement for ac is not associated with any improvement in patient morbidity, length of stay or rate of conversion from laparoscopic to open cholecystectomy. cholecystectomy within the first week of pct placement is associated with higher mortality rate than after weeks likely due to associated sepsis. introduction: the effect of intraoperative bile spillage during laparoscopic cholecystectomy (lc) on operative time (or time), length of stay (los), postoperative complication rates, and day readmission rates was analyzed. laparoscopic cholecystectomy is the gold standard operation for gallbladder disease in the united states. number of studies have shown that same day discharge in elective laparoscopic cholecystectomy is feasible and safe. bile spillage during this procedure can be a common occurrence in teaching institutions, however, data on the effects of operative outcomes is lacking. methods: this is a retrospective study analyzing all of the laparoscopic cholecystectomies performed at the brooklyn hospital center (tbhc), both emergent and elective, from to . patient data was collected on demographics, comorbidities, bile spillage, operative findings, complications, los, and day readmission rates. statistical analysis was performed using imb spss statistics v. . covaried analysis of variance (ancova) was performed on continues variables and significance levels were calculated. pearson's chi square significance level was calculated for all binomial variables. results: of the patients who underwent lc during this time period, intraoperative bile spillage was encountered in patients. interestingly, bile spillage was significantly more likely to be seen in elective cases over acute cases ( . % vs . %, p. ). there was a statistically significant increase in or time in cases where intraoperative bile spillage was encountered vs. cases where no bile spillage was encountered ( vs. min, p= . ). there was a significant increase in rate of conversion to open procedure when bile spillage was encountered ( . % vs. . %, p. ). drain placement rates increased, not surprisingly, when bile spillage was encountered ( . % vs. . %, p. ). there was no statistically significant difference in los between cases with bile spillage and cases without ( . days vs. . days). there was no significant increase in complication rate or day readmission rates. conclusions: intraoperative bile spillage significantly increases or time, conversion to open procedure, and drain placement. however, there was no significant effect observed of intraoperative bile spillage on length of stay, complication, and day readmission rates. thus, intraoperative bile spillage appears to have little clinical significance on surgical outcomes. however it may have an impact on overall healthcare costs. larger prospective studies evaluating the effect of intraoperative bile spillage on los, or time, complication rates, and day readmission rates are needed to analyze these effects further. tariq nawaz, md; rawalpindi medical university study design: prospective and observational study. place and duration: from january, to july . surgical unit ll, holy family hospital, rawalpindi. patients and methods: thousand patients with a diagnosis of cholithiasis were included. exclusion criteria are patient younger than year and older than year. calot's triangle dissection was done meticulously. cystic artery and hepatic artery anomalies and variations were observed and analyzed on spss . results: the age varies from to years. on the basis of distributional variation the cystic artery was single in % cases, branched in % cases and absent in % cases. on positional variations the cystic artery was superomedial to the cystic duct in % cases, anterior in % cases, and posterior in % cases and low lying in % of the cases. on the basis of length variation results showed that ( %) cases had a normal cystic artery. a short cystic artery was found in ( %) cases and a long cystic artery was present in ( %) cases. other arterial variations are of hepatic artery i.e moynihan's hump ( %) and and right hepatic artery present in calots triangle in % conclusions: for the safety of laparoscopic cholecystectomy one should be well aware of the anatomical variations of the cystic and hepatic artery. keywords: cholelithiasis, cholecystitis, laparoscopic cholecystectomy. as small as it gets: micro-invasive laparoscopic cholecystectomy using only two mm trocars and a needle grasper background: the majority of surgeons use four ports including for laparoscopic cholecystectomy (lc). multiple efforts have been made to reduce number and size of ports. left upper quadrant (luq). patients and methods: of lcs performed from / - / , ( %) were done using three instruments including cases in which trocars and the teleflex needle grasper were used. in cases only two mm trocars were (left upper quadrant (luq) and umbilicus) with the minigrasper being placed between the two. the gallbladder (gb) serosa was incised on both sides and a window was created behind the gb midportion and widened towards fundus and infundibulum. cystic artery (ca) and cystic duct (cd) were dissected out obtaining the critical view and after the last fundus adhesion was cut, ca and cd were secured with clips or endoloop. results: median age of women and men was . (range . - . ) years. lc was done for acute cholecystitis (n= ), chronic cholecystitis (n= ), biliary dyskinesia (n= ), choledocholithiasis (n= ). three patients had an ercp with bile duct clearance prior to the lc. in one case a keith needle was used to suspend the gb fundus for better exposure. twelve patients had additional procedures together with their lc (wedge liver biopsy ( ), lysis of adhesions ( ) , umbilical hernia repair ( ) , mesenteric/lymphnode biopsies ( ) . median or time was (range - ) minutes. the specimen was removed through the luq port site in patients. there were no vascular or bile duct injuries in this series. % of cases were done as outpatient procedures, % of patients required hours observation only three patients were hospitalized for medical reasons. conclusion: in selected cases with either small stones or biliary dyskinesia, lc with only two mm ports and a needle grasper is possible. the teleflex minigrasper can completely replace a port based grasper. introduction: the standard treatment for lithiasic acute cholecystitis remains the laparoscopic cholecystectomy despite the timing of surgery is still controversial. the aim of this prospective study is to evaluate the advantages and limitations of early laparoscopic cholecystectomy in a district hospital. methods and procedure: all patients undergoing laparoscopic cholecystectomy at the surgical department of "carlo urbani" hospital in jesi (italy) from may to september were consecutively enrolled. clinical data such as gender, age, bmi, comorbidity, previous abdominal surgery, previous acute cholecystitis were collected. subsequently, the patients were arranged in two groups according to the timing of intervention (early versus elective surgery). for each group, we compared data concerning surgery, such as operative time, intraoperative and postoperative complications, length of hospital stay and cost analysis. results: this study is a part of an ongoing research. so far, we collected laparoscopic cholecystectomies. ten ( %) of them were admitted with acute cholecystitis and were operated during the hospital stay (group a). group b included patients scheduled for elective surgery (n= ; %). the two groups were comparable with respect to clinical data. conversion to open approach was performed in cases, all of them in group b. mean surgical time was . ± . minutes in group a and . ± . minutes in group b (p= . ). no significant differences in intraoperative and postoperative complications rates were seen in the two groups, just a few in both of them. mean overall length of hospitalization was . ± . days in group a and ± . days in group b (p= . ), whereas the difference in length of postoperative hospitalization was not statistically significant. due to the extended hospitalization for group a, the cost increase as compared to group b was statistically significant, too. conclusions: early laparoscopy is comparable to delayed laparoscopy in terms of postoperative hospitalization and complications in the management of acute cholecystitis. a longer hospital stay among patients scheduled for immediate surgery may be associated with a more time-consuming diagnostic work-up before surgery. however, in future research we expect to enhance our cost analysis with more data regarding the costs incurred in the first hospitalization reserved to nonoperative treatment of group b inpatients with acute cholecystitis. s surg endosc ( ) introduction: with improvements in healthcare access and technology, admissions of octogenarian population with acute cholangitis (ac) are increasing. octogenarians are vulnerable to inferior outcomes. there is no study to evaluate factors predicting outcomes of ac in octogenarians. the aim of our study is identify factors predicting outcomes, and to evaluate the quick sequential organ failure assessment (qsofa) score and tokyo guidelines (tg ) severity grading for octogenarian patients with ac. methods: a retrospective review of octogenarian patients admitted with ac from january to december was performed. demographic profile, clinical presentation and discharge outcomes were studied. systemic inflammatory response syndrome (sirs), qsofa and tg severity grading scores were calculated. mortality is defined as death within days of admission or in hospital mortality. statistical analysis was performed using spss version . results: there were a total of patients admitted for ac, of which ( %) were octogenarians. majority (n= , %) were female, with a mean age of (range - ) years. majority were secondary to gallstones (n= , %), and ( %) were due to malignancies. ( %) and ( %) patients fulfilled sirs and qsofa criteria of severity respectively. ( %) and ( %) of patients had a tg severity grading of moderate and severe respectively. nine ( %) patients required inotropic support in the emergency department (ed) and ( %) patients were admitted to critical care unit (ccu). ( %) patients underwent endoscopic retrograde cholangiopancreatography (ercp) and ( %) underwent percutaneous transhepatic biliary drainage (ptbd) for biliary decompression. patients underwent index cholecystectomy. length of stay was . (range - ) days and -day mortality of %. multivariate analysis performed showed that an abnormal glasgow coma score (p= . ) and malignancy (p. ) predicted -day mortality. the use of ed inotropic support predicted ccu admission (p= ). a positive blood culture (p= . ), presence of malignancy (p. ), use of ed inotropes (p= . ), and index cholecystectomy (p= . ) predicted a longer length of stay. qsofa (p. ) and tg severity grading (p= . ) were predictive of -day mortality. sirs criteria did not predict -day mortality. conclusion: reduced consciousness and malignancy predicted -day mortality in octogenarian patients with ac. qsofa and tg severity grading system is superior to sirs criteria in predicting mortality of octogenerians with ac. our group has performed needlescopic grasper assisted silc (nsilc) to overcome these problems. we evaluate the technical feasibility, safety and benefit of nsilc versus three-port laparoscopic cholecystectomy (tplc). methods and procedures: this prospective randomized control study was conducted to compare the advantages if any between the nsilc and tplc. one hundred and forty eight patient were randomized into two groups, with one group underwent n slic ( patients) and a control group underwent tplc ( patients). basic information about the patient and diagnosis was collected. the surgical outcome that was composed with critical view of safety (cvs) time, major procedure time and total operation time, and the comparison of postoperative complication was made. result: nsilc group was consisted of male ( . %) and female ( . %), and tplc group was consisted of male ( . %) and female ( . %) (p= . ). the average age of nsilc group was . ± . years old, and tplc group was . ± . years old (p= . ). cvs time of tplc group was shorter than silc group (nsilc: . ± . min, tplc: . ± . min, p= . ), major procedure time (skin incision to gb removal from liver bed) of tplc group was shorter than nsilc group (silc group: . ± . min, tplc: . ± . min, p= . ). however, there was no significant difference in postoperative complication (nsilc: , tlc: , p= . ). conclusion: although cvs time, major procedure time, and operation time of silc were longer than tplc, overall clinical results were similar. nsilc is feasible and safe surgical procedure in patient with benign gallbladder disease. introduction: management of malignant biliary obstruction not amenable to surgery is usually by means of ercp or pthc. however, on occasions, these routes are not accessible and the alternate decompressive technique of percutaneous cholecystostomy (pc) has to be adopted. the aim of this study was to evaluate the efficacy and outcomes of pc in a highly selected series at a tertiary referral center. methods: we retrospectively reviewed all patients that had undergone pc from to . data collected included baseline demographics, comorbidities, details of pc placement and management, etiology of mbo, and post-procedure outcomes. the charlson comorbidity index (cci) was calculated for all patients at the time of pc. results: four hundred and eight patients underwent pc placement of which patients including ( %) males and ( %) females, with malignant biliary obstruction. the mean age at the time of pc placement was . ± . years of age, and the mean cci was . ± . for all patients. of mbo in all patients was due to pancreatic malignancies (n= ), cholangiocarcinoma (n= ), primary hepatic malignancies (n= ), secondary hepatic tumors (n= ), and ampullary carcinoma (n= ). pc tube complications were reported in ( %) patients. mean number of tube exchanges was . ± . . mean duration from pc tube placement to death was ± . days. total deaths were recorded. conclusion: pc placement appears to be a viable option in mbo in elderly and frail patients. in this cohort, pc may be a potential definitive management to improve quality of life. melanie boyle, daivyd palencia, philip leggett; houston northwest medical center background: there are very few studies assessing the relationship between gastroesophageal reflux and biliary disease. this is surprising as they share presenting symptoms as well as risk factors, particularly obesity. our group previously produced a review of patients in our practice who had undergone some type of reflux procedure. conclusions showed that the prevalence of gallbladder disease in our severe reflux population is much higher compared to that found in the general population. our goal of this study is to expand on that data to include a larger sample size to investigate the incidence of biliary disease in our reflux population and decide if this should influence our pre-operative algorithm for anti-reflux surgery patients. methods: we expanded on our previously performed retrospective review of patients that underwent laparoscopic fundoplication for reflux disease. we previously reviewed data from to . we are now looking at data from to . our expected sample size will include approximately patients, of which have currently been reviewed. our previous study included only . the surgery preformed was either a toupet or nissen fundoplication, and one underwent a dor. demographic data, imaging studies, and pathology results were reviewed. results: we looked at whether each patient who underwent antireflux surgery had a prior cholecystectomy either remotely or recently, underwent concomitant cholecystectomy, or had no biliary disease in their workup. the groups had similar age and were predominantly women. we once again demonstrated that the prevalence of gallbladder disease in our severe reflux population is much higher than the general population. when approaching a patient with gastroesophageal reflux disease, attention should be paid to gallbladder symptomatology as well. we recommend that it may be beneficial to include gallbladder ultrasound in pre-operative workup for antireflux surgery so that concomitant cholecystectomy can be performed if indicated. steven schulberg, do, jonathan gumer, do, matt goldstein, vadim meytes, do, george ferzli, md; nyu langone hospital -brooklyn introduction: acute cholecystitis is a common surgical disease with roughly , cholecystectomies performed in the us annually. the current dogma revolves around the " hour rule" advocating early cholecystectomy if within the window, and if beyond hours, conservative treatment and interval operation. in patients beyond the hour window, as well as with multiple comorbidities, advanced age, and other complicating factors, cholecystostomy has become an acceptable treatment as a bridge to interval cholecystectomy. while this has become an appropriate treatment modality, it does not come without its own set of complications. we aim to evaluate the rate of complications in our institution. methods: this is a retrospective review of all patients at our institution who underwent cholecystostomy placement between and . we evaluate the comorbidities, readmission rate, overall rate of complication associated with cholecystostomy tubes, and eventual definitive cholecystectomy. results: our cohort includes patients, % of whom were male, with a mean age of . we had an overall complication rate of . %, including tube dislodgements, leaking tubes, and misplaced tubes. all cause readmission rate was % and only % of patients who had cholecystostomy drains underwent interval cholecystectomy. conclusion: there has been much interest in treatment of acute cholecystitis in patients with multiple comorbidities. in review of our data, a surprisingly large number of patients had mechanical complications involving the cholecystostomy drain. in an era focused on decreasing readmission rates and their associated costs, drains carry a high risk of malfunction which will in turn, lead to increases in these two metrics. while there is more work to be done in the evaluation of early cholecystectomy versus cholecystostomy in this subgroup of patients, we suspect that early cholecystectomy in the medically optimized patient will lead to reduced length of stay and hospital costs as well as increased patient satisfaction. does selective use of hepatobiliary scintigraphy (hida) scan for diagnosis of acute cholecystitis, following equivocal nondiagnostic gallbladder ultrasonography, affect outcomes fahad ali, ba, amir aryaie, md, eneko larumbe, phd, mark williams, md, edwin onkendi, md; texas tech university health sciences center introduction: acute cholecystitis (ac) is diagnosed by characteristic gallbladder ultrasonographic findings (high specificity, low sensitivity). hepatobiliary scintigraphy (hida) may be needed to confirm ac (higher sensitivity and specificity). the aim of this study was to assess the impact of the current selective use of hida scan for sonographically equivocal cases of ac on outcomes. methods: a retrospective chart review of patients treated for ac at our institution ( / to / ) was performed. patients were divided into groups: the ultrasound only group (us-only) and the ultrasound-hida group (us-hida). timing of us and hida, and intervention for ac since presentation to emergency room (er), and their impact on outcomes were analyzed. ac severity was graded per the tg -tokyo guidelines. results: a total of patients were analyzed. the groups were statistically similar with regards to age, body mass index, asa class ii, iii and iv, extent of leukocytosis at presentation and liver functions test levels at presentation. in the us-only group, diagnostic ultrasound was obtained sooner, [median of (interquartile range, iqr . - . ) hours] from presentation to the er compared to the us-hida group, ) hours], p= . . hida was obtained after a median delay of . (iqr . - ) hours from a nondiagnostic ultrasound. majority of patients ( %) in the us-only group had mild (tg grade i) to moderate (tg grade ii) ac, while % of the us-hida group had moderate (tg grade ii) to severe (tg grade iii) ac (p= . ). despite this, more patients in the us-hida group ( %) had a "normal" non-diagnostic ultrasound compared to the us-only group ( . %), p. . seven patients in the us-hida group had no intervention due to normal hida scan ( ) , ac misdiagnosis due to liver cirrhosis ( ) , and severe medical comorbidities ( ) . more patients ( %) in the us-only group underwent laparoscopic cholecystectomy, compared to % in the us-hida group (p= . ). between the two groups, there was no significant differences in -day morbidity, mortality and reoperations. however, the length of stay was longer by a median of . days in the us-hida group (p= . ). conclusion: patients with moderate to severe ac are more likely to need hida scan due to a "normal" non-diagnostic ultrasound, have a delay in diagnosis, not have intervention for ac due to severe medical comorbidities and have lower chance of laparoscopic cholecystectomy. the length of hospital stay is significantly longer for these patient by a median of . days. introduction: benign gallbladder disease is commonly treated with laparoscopic cholecystectomy (lc). gallbladder cancer (gbc) is a rare malignancy characterized by high invasiveness and poor survival. in our institution, all gallbladder specimens are routinely sent to pathology, to rule out gbc. the purpose of our study was to assess the efficacy for routine histopathology of gallbladder specimens after cholecystectomy (cly) for all gallbladder disease. methods and procedures: after obtaining approval from our institutional review board, a retrospective review was conducted on all patients who underwent cly from june of to may were included in the study. the data obtained include gender, age, american society of anesthesiologist score (asa), body mass index (bmi), comorbidities, length of stay (los), radiological imaging and pathology results. independent t and chi-square tests were performed using ibm® spss® software. results: there were cly performed at our institution, of which ( %) were lc. females composed of ( %) patients and the median age was . ( %) gallbladder specimens were found to be cancerous. ( %) gallbladder specimens were benign. majority ( %) were chronic cholecystitis, ( %) were acute cholecystitis and ( %) were gangrenous cholecystitis. ( %) were found to be acalculus cholecystitis and ( %) were cholelithiasis. ( %) were found to be adenomyositis, and other. conclusion: in our institution, less than % ( ) of all gallbladder specimens were found to be cancerous. it would decrease cost and work load if gallbladder specimens are selectively sent to pathology. emanuel a shapera, md we sought to determine clinical factors associated with recurrent cholangitis in two las vegas community hospitals to aid providers in management of this disease. methods and procedures: retrospective, multi-center study. over ercps were analyzed between and . patients were identified as having multiple ( ) admissions for cholangitis per tokyo criteria. univariate and multivariate analysis was conducted. results: patients with a significantly (p. ) higher albumin level on admission ( . ) were discharged home more often than patients discharged to a facility or hospice ( . ). on multivariate analysis, non-home discharge was associated with lower albumin level at admission (p= . ) and greater maximum temperature prior to decompression (p= . ). increased hospital stay was associated with lower albumin level at admission (p= . ). a majority ( / ) of recurrent episodes involved stent placement, exchange or removal. patients ( %) had either biliary malignancy, gallbladder or both. blood cultures were drawn in % of all episodes and positive in %, e coli being the most common pathogen isolated. all patients had low hdl levels ( - , mean ) . conclusions: high fevers and poor nutritional status was associated with increased length of hospital stay and fewer home discharges. tumors, gallbladders and malfunctioning stents contribute substantially to morbidity. close follow up for indicated gallbladder removal, stent management and nutritional optimization is critical to reduce the burden of this disease. we compared the surgical method in neonate choledochal cyst between oec and lec. the perioperative and surgical outcomes that were reviewed included age, operative time, postoperative hospital stay, time to diet, and surgical complications. the patients were followed up for months (range, - months) . results: there was no difference in range of bile duct excision and manner of roux-en-y hepaticojejunostomy between oec and lec groups. there was no intraoperative complication in both groups and no open conversion in the lec group except one case which was ruptured choledochal cyst. the median age of oec and lec groups were days (range, - ) and . days (range, and median body weight at the time of operation were . kg (range, . - . ) and . kg (range, . - . ) , respectively. the median operative time was minutes (range, - ) in oec and . minutes (range, in lec groups and there was no significant difference between oec and lec groups (p= . ). intraoperative bleeding was minimal in both groups. the postoperative hospital-stay, time to start diet, and time to return to full feeding had no significant differences in both groups. after discharge, of ( %) oec patients experienced readmission due to cholangitis and ileus, while there were none in the lec group. conclusions: this study revealed that lec had better prognosis compared to oec. lec provided an excellent cosmetic result. so we suggest lec could be the treatment of choice for neonatal choledochal cyst. this is a small series, therefore future studies will have to include a larger number of patients and evaluate long-term follow-up. keywords: choledochal cyst, laparoscopy, neonate. laparoscopic narrow band imaging for intraoperative diagnosis of tumor invasiveness in gallbladder carcinoma: a preliminary study yukio iwashita, hiroki uchida, teijiro hirashita, yuichi endo, kazuhiro tada, kunihiro saga, hiroomi takayama, masayuki ohta, masafumi inomata; oita university faculty of medicine introduction: determining tumor invasiveness before operation is one of the most important unsolved issues in the management of gallbladder cancer. we hypothesized that the assessment of irregular vessels on the gallbladder wall may be useful for detecting subserosal infiltration. we present an initial report on the clinical usefulness of laparoscopic narrow band imaging (nbi) for the intraoperative diagnosis of tumor invasiveness in gallbladder carcinoma. methods: thirteen patients with gallbladder cancer were included in this study. patients with tumors located in the liver bed and those with definitive invasion observed on computed tomography findings were excluded from this study. gallbladders were observed using nbi and the microvasculature was evaluated. according to previous reports of endoscopic nbi, we defined four findings as positive: vessel dilatation, tortuousness, interruption, and heterogeneity. the nbi findings were compared with postoperative pathological findings. the study protocol was approved by the institutional review board of the oita university. results: the serosal surface of the tumor site and its microvasculature were successfully observed in all patients. laparoscopic nbi detected at least one abnormal finding in seven patients, and postoperative pathology showed subserosal infiltration accompanied by vessel invasion. on the contrary, six patients with no positive nbi findings showed mild or no subserosal infiltration and no vessel invasion. conclusions: our study indicated that laparoscopic nbi may be useful for diagnosing subserosal infiltration accompanied by a vessel invasion. shuichi iwahashi, mitsuo shimada, satoru imura, yuji morine, tetsuya ikemoto, yu saito, hiroki teraoku; department of surgery, tokushima university introduction: laparoscopic cholecystectomy (lap-c) is the standard operation for the benign diseases. we have reported reduced port lap-c (rpl-c) was safely and comparable method to sils-c and conventional lap-c (sages ) . in this time, we examined the utility of rpl-c containing the post-operative adverse event. procedures: the adjustment is the benign illness including the cholecystolithiasis, and advanced obesity and the cases of the inflammation remaining have been excluded. the incision is put and cut open the abdomen to the umbilical region, and camera port was inserted. we used mm flexible scope. mm forceps for holding of the gallbladder bottom and left hand of operator were inserted directly with no port. methods: rpl-c has been introduced in this department since july, . we performed cases of lap-c, containing sils-c and american style conventional lap-c, and we performed rpl-c has been performed already cases. we compared the patient background and the operation factor between rpl-c, sils-c, conventional lap-c. operators were young surgeons, they were not specialists of gastroenterological surgery or endoscopic surgery. results: the difference was not admitted in the age, gender, the physique, and the disease, and the difference was not admitted in hospital stay after the operation (rpl-c:sils-c:conventional lap-c= . ± . days: . ± . days: . ± . days) and the amount of blood loss (rpl-c:sils-c:conventional lap-c= . ± . ml: . ± . ml: . ± . ml) and operation time (rpl-c:sils-c:conventional lap-c= ± min: ± min: ± min). and surgical wound after rpl-c was cosmetically acceptable. regarding as the post-operative adverse event, there were no patients of bile duct injury. conclusion: in the patients on reduced port lap-c, there were no bile duct injuries of postoperative adverse event. reduced port lap-c is safely for young surgeons and comparable method. introduction: acute cholangitis is an ascending infection of the biliary tree secondary to obstruction and can be severe if proper intervention and treatment are not performed in a timely fashion. the most common management of cholangitis with ductal obstruction due to choledocholithiasis is intravenous hydration, empiric antibiotic therapy, endoscopic retrograde cholangiopancreatogram (ercp) with sphincterotomy and stone extraction with or without stent placement, followed by a delayed laparoscopic cholecystectomy. we present the case of a patient with blood clot obstruction of a common bile duct (cbd) stent after ercp with sphincterotomy and stone extraction. case presentation: a year old male presented to the emergency department with jaundice, right upper quadrant abdominal pain, truncal pruritis, nausea, vomiting, and fever. biochemical analyses and liver profile demonstrated an elevated white blood cell count, hyperbilirubinemia, and elevated liver enzymes consistent with cholestasis. biliary ultrasound demonstrated multiple gallstones and dilation of the cbd with a distal obstructing calculus. he proceeded to ercp where biliary cannulation was achieved, sphincterotomy performed, and a large amount of sludge and pus was drained. an mm stone was removed from the cbd by balloon sweep with completion cholangiogram demonstrating no filling defects. a stent was then placed in the cbd with adequate flow. following the procedure, the patient continued to have increasing hyperbilirubinemia. a repeat ercp revealed a large blood clot and continued bleeding at the previous sphincterotomy that resolved with epinephrine injection. the former stent was visualized in the proper position, removed with a snare, and found to be fully occluded with blood clots. after retrieval of additional clots, a new stent was placed with adequate return of bile. the patient recovered with resolution of his symptoms and hyperbilirubinemia with laparoscopic cholecystectomy. discussion: cholangitis is characterized by charcot's triad of right upper quadrant abdominal pain, fever, and jaundice due to an ascending bacterial infection of the biliary tree coinciding with obstruction of biliary flow most commonly from gallstones. cholangiography via ercp with associated sphincterotomy, stone extraction, and stenting is both diagnostic and therapeutic. while debated by endoscopists, stent placement has shown to reduce recurrent biliary complications, decrease length of hospital stay, and lessen morbidity. although pancreatitis is the most common cause of hyperbilirubinemia post-ercp, stent occlusion secondary to stones or blood clots should be considered to effectively treat patients. proper hemostasis is important in any procedure and close patient follow-up should be performed to prevent further complications. sarrath sutthipong, md, panot yimcharoen, md, poschong suesat, md; bhumibol adulyadej hospital background: choledochal cyst (cc) is a rare disease, characterized by dilatations of the extra-or/ and intrahepatic bile ducts. ccs occur most frequently in asian and female populations. cc is associated with biliary lithiasis and considered at risk of malignant transformation. todani's classification dividing cc into types is the most useful in clinical practice. the current standard treatment is complete cyst excision with roux-en-y hepaticojejunostomy and cholecystectomy for the extrahepatic disease (todani type i and iv). in this report we present our experience using a total laparoscopic technique to treat adult patients with cc in -year period. methods: a retrospective review of the records of the patients above years who underwent laparoscopic cyst excision and roux-en-y hepaticojejunostomy in our hospital between january and may was carried out. the data included the clinical presentation, investigation, perioperative details and complication. the type of cc was classified according to todani's classification. results: seven cases of cc were reviewed, females and male with mean age years (range - years). these included cases of todani type ib and cases of type a. the predominant symptoms were chronic abdominal pain and jaundice. a case of both pancreatitis and cholangitis were also seen. investigations included ultrasound with mrcp in cases and ercp in case. the mean operative time was hours and minutes ( hours minutes to hours range) with mean intraoperative blood loss ml (range - ml). all the resected specimens showed chronic inflammation. malignancy was not seen in any patients. the early postoperative complications included bile leakage with intra-abdominal collection in patients, which were managed conservatively (evidenced by clinical status and imaging study), re-operation was not required. the median duration of hospital stay was days (range - days). there was no perioperative mortality. all patients were followed up at , , and months postoperatively, late complication were not detected during each visit. conclusion: in our opinion, laparoscopic cyst excision and hepaticojejunostomy could offer more feasible and safe methods of treatment for ccs in adult patients with potentially less postoperative morbidity, a shortened length of stay and a lower blood loss when compared to the preferred open approach. however, we would need to study this on a larger sample of patients to report the efficacy and safety of laparoscopic approach. endoscopic trans-papillary gallbladder drainage (etgbd) in acute cholecystitis: a single center experience arun kritsanasakul, chotirot angkurawaranon, jerasak wannapraset, thawee rattanachu-ek, kannikar laohavichitra; rajavithi hospital background: surgery is the mainstay of treatment for cholecystitis, however, it may not be safe or feasible in some circumstances such as severe cholecystitis or cholecystitis in extremely high-risk patients. gallbladder drainage may be an appropriate alternative or a bridging option prior to cholecystectomy. endoscopic trans-papillary gallbladder drainage (etgbd) has been proposed as a modality that is feasible and effective in cholecystitis. objective: the primary outcome of this study is to evaluate the effectiveness of etgbd. the secondary outcome is to evaluate the safety, early experience outcomes, and complications of this procedure. methods: retrospective medical records review between january -december from a single tertiary referral hospital center, rajavithi hospital, bangkok, thailand. a total of patients who was diagnosed with cholecystitis and underwent etgbd. the procedure was performed at the endoscopic suite under light sedation via total intravenous anesthesia. the patient demographic data and procedures were collected. the technical success of etgbd was defined as decompression of the gallbladder by successful cystic duct stent placement. the clinical success was defined as resolution of symptoms and/or improved laboratory data or ultra-sonographic findings. results: a total of patients underwent etgbd. among these patients, were high risk for surgery due to age or comorbidity, had concomitant jaundice and was failure of medical treatment. both technical and clinical success of etgbd was achieved in of cases ( %). the two patients that did not achieve technical success were due to failure to cannulate guidewire through cystic duct and the other had trans-cystic guidewire perforation that needed surgical intervention. there were two intra-operative complications ( %). one was the patient who had trans-cystic guidewire perforation and another had anesthesia-related complication (hypoventilation requiring endotracheal intubation). there were no -day mortality. conclusion: endoscopic trans-papillary gallbladder drainage is an alternative treatment modality for patients with cholecystitis who are at high-risk for surgery and or those who are unsuitable for percutaneous gallbladder drainage. the technique is feasible, however, careful case selection and high endoscopic skill is needed. julia f kohn, bs , alexander trenk, md , woody denham, md , john linn, md , stephen haggerty, md , ray joehl, md , michael ujiki, md ; university of illinois at chicago; northshore university healthsystem, northshore university healthsystem introduction: subtotal cholecystectomy, where the infundibulum of the gallbladder is transected to avoid dissecting within a heavily inflamed triangle of calot, has been suggested as a method to conclude laparoscopic cholecystectomy while avoiding common bile duct injury. however, some case reports have suggested the possibility of recurrent symptoms from the remnant gallbladder. this retrospective case series reports a minimum of two-year follow-up on patients who underwent subtotal cholecystectomy within one four-hospital system. methods: a retrospective chart review database containing randomly selected cholecystectomies, all of which occurred between and , was reviewed to identify all instances of subtotal cholecystectomy. charts for these patients were reviewed through / , including any documentation from other providers, including primary care. results: six patients who underwent subtotal cholecystectomy with a remnant of infundibulum left following surgery were identified. surgical approach and the choice to perform subtotal cholecystectomy were dependent on the attending surgeon; all decisions were made intraoperatively. there was an average of months of follow-up for these patients within our institution. discussion: this case series adds six cases to the literature surrounding long-term outcomes in patients who underwent subtotal cholecystectomy. although one patient was lost to follow-up, no patient had recurrent biliary colic or other complications arising from the remnant gallbladder. this may be encouraging to surgeons who feel that subtotal cholecystectomy with an infundibular remnant is the safest way to proceed with cholecystectomy in patients with severe inflammation. objective: this study aims to evaluate the utility and efficiency of icg as an alternative to routine intraoperative cholangiogram in patients undergoing cholecystectomy. introduction: common bile duct injury is an uncommon, but serious complication associated with laparoscopic cholecystectomy. current guidelines state that when used routinely intraoperative cholangiogram (ioc) can decrease biliary injury, however it is not routinely used due to increased time of operation, and inaccessibility of equipment. indocyanine green (icg) has been found to be effective for identification of biliary anatomy during cholecystectomy, however has not yet been widely adopted. we aim to assess if icg is able to overcome the obstacles of ioc, while still effectively assessing biliary anatomy. methods: we performed a retrospective analysis of laparoscopic cholecystectomies performed in a single institution from january to september . elective and emergent cases were included. we stratified patients into icg and non-icg groups. patients who had concomitant procedures performed were excluded. we analyzed patient demographic information, as well as bmi, asa classification and comorbidities in both groups. our primary outcome was operation time (skin to skin), and laparotomy conversion rate. secondary outcomes were effectiveness of icg in visualizing biliary anatomy, and cost. results: patients were included in our study, in the non-icg arm and in the icg arm. both groups were similar in background. there were no statistical differences in patient demographics, asa classification, bmi, or comorbidities. there was no statistical difference in operation time ( . vs . minutes; p. ) or conversion rate ( . vs %; p. ). icg was able to delineate biliary anatomy in % of the patients. the cost of a mg/vial kit of icg is approximately $ . conclusion: the use of icg does not increase operating time during laparoscopic cholecystectomy. icg is an inexpensive and effective tool used to delineate biliary anatomy without the inherent burden and limitations of ioc. benefsha mohammad, md , michele richard, md , steve brandwein, md , keith zuccala, md ; danbury hospital, danbury hospital department of gastroenterology, introduction: obesity is a prevalent issue in today's society, which has increased the number of gastric weight loss surgeries. this presents an anatomical challenge to biliary disease requiring endoscopic retrograde cholangiopancreatography (ercp). in gastric bypass patients, traditional ercp via the mouth in these patients is technically more challenging, requiring a longer endoscope with a reported success rate of less than %. a solution is laparoscopic assisted ercp (la-ercp) via gastrostomy. this minimally invasive technique has become increasingly more prevalent and safe. we present our experience with la-ercp at our teaching community hospital in a large cohort of patients. methods and procedures: retrospective chart review was performed on all patients with a history of prior laparoscopic gastric bypass surgery who underwent la-ercp from april to april . the procedure was performed by two different general surgeons and one gastroenterologist. a pursestring suture and transfacial stay sutures were used to bring the gastric remnant to the abdominal wall. a gastrostomy was then created and accessed by the duodenoscope to perform the ercp. biliary sphincterotomy, papillary or biliary dilation, lithotripsy, stent placement, and/or stone removal were performed as indicated. we observed the incidence of postoperative outcomes, including acute pancreatitis, reoperation, post-procedure infection, pain control, hospital re-admission and bile leak. results: thirty-two patients met inclusion criteria. six patients were male and twenty-six were female, with mean ages of (std dev ) and years (std dev ), respectively. indications for la-ercp included suspected choledocholithiasis ( / ), cholangitis with choledocholithiasis ( / ), acute pancreatitis ( / ), abdominal pain with abnormal lft ( / ), cholangitis with cholecystitis ( / ), and bile leak ( / ). la-ercp was successfully performed in all thirty-two patients. biliary cannulation, sphincterotomy and stone extraction were performed on / patients, and one patient underwent sphincterotomy and stent placement for bile leak after recent laparoscopic cholecystectomy. one patient developed acute pancreatitis with elevated pancreatic enzymes which resolved after conservative treatment. one patient required a second la-ercp for stent replacement due to a persistent bile leak. the median length of stay was days (range - days). conclusions: la-ercp is a safe and feasible alternative to open surgery, and can be safely implemented at community hospitals with adequately trained providers. obesity is a growing burden on society, increasing the incidence of weight loss surgery. our large study proves that in this minimally invasive era, la-ercp provides gastric bypass patients a safe alternative with less pain and increased satisfaction. ahmed elgeidie, elsayed adel; gastrointestinal surgery center background: endoscopic sphincterotomy (es) is an effective therapeutic procedure for common bile duct (cbd) stone clearance but it carries a substantial risk of recurrent stones at long-term outcome. aim of the study: to evaluate the rate of cbd stones recurrence after primary complete endoscopic clearance, and to identify the risk factors of recurrence. methods: between january and december , patients with cbd stones who underwent successful es and complete stone clearance were studied retrospectively. recurrent cbd stone, was defined by the confirmation of the presence of cbd stone at least months after previous complete cbd stone clearance by es. the risk factors for recurrent cbd stones and mean time interval between initial es and stone recurrence were analyzed. results: in total, patients we included. the median follow up period was months. recurrent cbd stones appeared in / ( . %) patients after a median time interval of ( - ) months following es. stone recurrences were observed on multiple occasions in patients ( . %). on the univariate analysis, the significant risk factors related to recurrent cbd stone were male sex (p= . ), previous history of cholecystectomy (p= . ) multiple cbd stones (p= . ), large cbd stone (p= . ) the presence of periampulary diverticulum (p= . ) and stone crushing using mechanical lithotripsy (p= . ) conclusion: recurrence of cbd stones is an identified long-term risk after es and stone clearance. background: laparoscopic cholecystectomy during advanced pregnancy is challenging due to the limited intraabdominal space. patients may be at increased risk for developing trocar site hernia. case report: a year old hispanic female in her th week of pregnancy came to the er with acute right upper quadrant pain. due to lack of accessibility she had poor prenatal care. she had mildly elevated amylase but normal lfts and ultrasound showed some gallbladder wall thickening suggestive for acute cholecystitis and no dilated biliary duct. fetal ultrasound was normal. she was admitted to the hospital and started on antibiotics, obstetrics was consulted. her amylase peaked at [ u/l but then normalized and indication for laparoscopic cholecystectomy was made. mrcp and ercp were not performed as it was assumed that the patient had passed a stone. five mm trocars were placed in the luq and the umbilicus and a teleflex minigrasper between the tow. the uterus was found at the umbilical level. the gb was pulled out and the serosa was incised on both sides and a window was created behind the gb midportion and widened towards infundibulum and fundus. there was gb wall thickening and edema. the critical view was obtained and the cystic artery and duct were clipped and divided. the common bile duct appeared normal and no ioc was done. the specimen was retrieved through the luq port site using a mm endobag after dilatation to . cm due to the presence of two large stones. the port site fascia was closed using a suture passer. the postoperative course was uneventful and both mother and baby were well at the two weeks follow up. discussion: in case of biliary pancreatitis during pregnancy, lc should be performed and if ultrasound shows a normal biliary system and amylase/lipase normalize, mrcp/ercp and ioc may be avoidable to protect the baby. lc with two ports is feasible during pregnancy. removal of the specimen through a lateral abdominal wall site may help prevent an umbilical port site hernia in this patient population. s surg endosc ( ) :s -s introduction: splenic abscess is a rare, potentially lethal condition, with autopsy studies showing incidence rates between . - . %. mortality rates ranging from to % making early diagnosis and prompt intervention vital. several case reports have documented post surgical splenic abscess, most notably after laparoscopic sleeve gastrectomy. to the best of our knowledge, there has not been any reported cases of splenic abscess arising after laparoscopic cholecystectomy. it is important to remember this disease process for expeditious targeted treatment in future cases. case presentation: a year-old female with past medical history significant for cholilithiasis, hypertension, and hyperlipidemia presented to the emergency department (ed) with a chief complaint of abdominal pain for two days. labs and imaging were obtained which confirmed the diagnosis of choledocholithiasis and pancreatitis. ercp was performed which showed a . cm stone causing obstruction, with several other smaller filling defects. the stones were removed after sphincterotomy. post procedurally, the patient underwent an uncomplicated laparoscopic cholecystectomy on hospital day (hd) # . post operatively, the patient had persistent leukocytosis peaking at . thousand on postoperative day (pod) # . a ct scan was performed which showed a rim-enhancing splenic collection measuring . . cm suggestive of an abscess. interventional radiology was consulted and aspirated ml of purulent fluid. cultures grew out klebsiella pneumoniae and enterobacter cloacae complex, and the patient was discharged home on zosyn. discussion: laparoscopic cholecystectomy has become the cornerstone in treatment of symptomatic biliary colic and acute cholecystitis. of the many recognized complications of laparoscopic cholecystectomy, splenic abscess has not yet been reported in current literature. the nonspecific signs and symptoms of splenic abscess make clinical diagnosis difficult. the classic triad of fever, palpable spleen and left upper quadrant pain are only seen in about two-thirds of patients. ct scan has been shown to be the most sensitive imaging modality for diagnosis of splenic abscess. current treatment options for splenic abscess are broken down into two subsets: percutaneous and surgical intervention. percutaneous treatment includes image guided aspiration with or without placement of drainage catheter. surgical intervention can be either laparoscopic or open and includes drainage of abscess with splenectomy or splenic conservation. the best treatment option remains unclear, and there is lacking prospective data demonstrating which modality is superior. introduction: laparoscopic subtotal cholecystectomy is widely accepted as a safe alternative to the conventional laparoscopic cholecystectomy in case of acute cholecystitis with frozen calot's triangle. the remnant stump of the gallbladder may be either sutured or looped. however, there are limited studies comparing the outcomes of the two techniques. the present study is aimed at comparing loop and suture closure of the gall bladder stump. methods: a retrospective analysis of our prospectively maintained database revealed that between january and december . patients underwent laparoscopic subtotal cholecystectomy for acute cholecystitis, chronic cholecystitis or empyema gallbladder with frozen calot's triangle. the decision to use endoloop or sutures for stump closure was made intra-operatively after dividing the gallbladder through the infundibulum. a no. sized drain was kept in all the cases. the patients were discharged with drain in situ, and were reviewed on post-operative day during which an ultrasound was done and drain removed if the progress was satisfactory. the intra-operative and post-operative data between the two groups were recorded and analyzed. results: endoloop closure was performed in patients and suture closure using . ethibond was done in patients. three patients from the sutured group had post operative bile leak among which one patient underwent endobiliary stenting. the other were managed conservatively while the drain had to be retained for weeks. two patients in the endoloop group were detected to have retained stone in the remnant gallbladder cuff among which one had recurrent cholecystitis requiring laparoscopic completion cholecystectomy. none of the patients had bile duct injury or surgical site infection. mean post operative stay was . + . days, did not significantly vary between the groups. suturing needed more surgical expertise and had prolonged operative time than endoloop ( + min versus + min, p= . ). conclusion: suture or loop closure of the remnant gallbladder after subtotal cholecystectomy are equally effective. suturing the stump may be associated with increased incidence of biliary leak while endoloop may have higher incidence of retained gallstones. the choice between the two may be made intra-operatively based on the surgeon's expertise and preference. background and aim: in recent years, due to the spread of laparoscopic cholecystectomy, bile duct injury as its complication has been reported at a certain frequency. current surgical treatments include ) suturing and closing the injured part laparoscopically during surgery, ) transitioning to laparotomy and closing the suture, ) inserting a tube such as t-tube under the laparotomy, ) bile duct-intestinal anastomosis under the laparotomy, etc. are taken into consideration. regardless of which treatment method, it is not a definite ideal treatment. we have developed a bioabsorbable material (caprolactone: lactic acid ( : ) polymer reinforced with polyglycolic acid fiber and designed to be absorbed in about weeks). at this conference, we would like to talk about the current state and problems of development of minimally invasive therapy for biliary damaged area using bioabsorbable materials we developed. method: in order to overcome the problem of the current bile duct injury cure method, we have been developed, a) a method of closing a perforation part endoscopically from the luminal side of a bile duct (a covered stent using a bioabsorbable material in the damaged part), b) develop a method of closing the biliary duct injury under the laparoscope from the outside of the bile duct (adhering the bioabsorbable sheet to the bile duct perforation using a biocompatible adhesive). results: experimental results of suturing the bioabsorbable material in the biliary duct in surgery of laparotomy were able to regenerate the bile duct without stenosis in the damaged area. however, various adhesives were tried to bond the sheet of this bioabsorbable material and the native bile duct under the endoscope, but at the moment, there is no glue that will allow the sheet to be adhered readily and reliably where there is moisture to a certain extent. a tool for delivering the sheet from the bile duct into the injured part is under development and good results are obtained at present. conclusion: it is possible to regenerate the bile duct without constriction using a bioabsorbable material. it is difficult to laparoscopically adhere to the injured part of the bile duct, but we hope that it will be possible in the near future to develop further adhesives. s surg endosc ( ) , - kg/m (c) and more than kg/m (d). we made a . -cm longitudinal skin incision within the umbilicus. a wound retractor and a surgical glove were applied at that incision. we used the three -mm ports technique. after retracting the gallbladder upward, the cystic duct and artery were divided and identified using pre-bending forceps through the flexible port and laparoscopic coagulating shears (lcs). the cystic artery was dissected using the lcs and the cystic duct was also dissected after clipping. the gallbladder was freed from the liver bed using the lcs, and the specimen was retrieved from the umbilical wound. results: there were conversions to open laparotomy in cases ( . %) and requirement of additional ports in ( . %). the mean age (years), operation time (min), blood loss (ml) and postoperative hospital stay (days) in group a, b, c and d were . , . , . and . (p= . [), . , . , . and . (p= . ), . , . , . and . (p= . ) , and . , . , . , and . (p= . ), respectively. there was a significant difference in age only. the complications were bile duct injury in one case ( . %) and pneumothorax in two ( . %). conclusion: obesity had no influence of surgical outcomes for performing silc. introduction: recent studies have reported mixed outcomes when comparing surgeon case volume and laparoscopic cholecystectomy (lc) outcomes. formal minimally invasive surgical training (mist) has been shown to be associated with shorter post-operative length of stay (los), but no difference in major adverse events such as bile leak, bile duct injury, intra-abdominal abscess formation, and death. we aim to determine -day rates of major adverse events after lc in a university hospital setting, to identify significant associated risk factors, and to determine if mist or surgeon volume are associated with differences in los and major adverse events. methods: we conducted a single-center retrospective review of , cholecystectomies performed over a seven-year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . characteristics and outcomes were compared using chi squared or rank sum tests. multivariable regression modeling was used to determine independent associations with the two main outcomes, major adverse events and los. results: we identified , adults who underwent lc during the study period, with a median age of , and % women. about % (n= ) of patients had a los[ day and . % (n= ) were re-admitted within the first days after surgery for any reason. within days of lc, . % (n= ) of patients suffered from one or more major adverse events. this includes . % (n= ) of patients with bile duct injury, . % (n= ) of patients with bile leak, . % (n= ) of patients with intra-abdominal abscess, and . % (n= ) of patients died for reasons related to their procedure or post-operative recovery. table shows the characteristics of the patients and procedures with a comparison of the patients with an adverse event versus those without one. in univariate analysis, high annual surgical volume ( + cases/year) and procedure urgency were found to be significant predictors of adverse events and los, however, mist was not. in multivariable analysis, controlling for significant univariate predictors, urgent or emergent cases were associated with a -fold increase in odds of an adverse event (or= . introduction: laparoscopic cholecystectomy is an extremely common procedure in the united states, with over , cases performed annually. despite the procedure's overall safety, there has been some evidence that tobacco use is associated with increased risk of wound infection after lc. this retrospective chart review sought to examine whether tobacco use is associated with increased complications following laparoscopic cholecystectomy within a high-volume healthcare system. methods: after irb approval, of approximately , cholecystectomies performed within one four-hospital system between and were randomly selected, and patient charts were retrospectively reviewed. pre-, intra-, and postoperative data were collected, including all complications within days. tobacco use cohorts were defined as follows: never, former (any historical tobacco use), and current (active tobacco use within year of surgery) per the acs nsqip surgical risk guidelines. following preliminary data analysis, multivariable logistic regression models were generated to identify whether tobacco use was predictive of outcomes of interest. of the cases analyzed, patients ( . %) were never smokers; . % were former smokers, and . % were current tobacco users or had quit less than months prior to surgery. there were surgical site infections, one wound dehiscence, one port site hernia, three common bile duct injuries, and medical complications requiring prolonged hospitalization or readmission within days. current tobacco users were significantly more likely to undergo urgent surgery (following emergency admission or direct admission to the hospital) than former or nonsmokers. however, there was no difference between cohorts for prolonged duration of surgery, conversion to an open procedure, surgical site infection, wound dehiscence or hernia, common bile duct injury, or other medical complication. there was no significant difference between cohorts when all postoperative complications were pooled. conclusions: there does not appear to be a significant difference in -day surgical outcomes or complications in active tobacco users vs. former or non-users. although studies in other surgical settings have indicated a possible reduction in complications if patients abstained from smoking prior to surgery, this may not be beneficial in laparoscopic cholecystectomy. moreover, as current tobacco use appears to be associated with higher rates of urgent surgery, these patients may not be able to stop smoking prior to an elective procedure. prospective studies to further clarify whether there is any benefit towards tobacco cessation prior to lc may be valuable. , [ , [ respectively ( - ) , cyfra were . , . , . respectively ( - . ) . afp and cea were negative. as for this patient, he is of high risk of hepatobiliary system diseases. introduction: thymoma is one of the rare tumor entity benign or malignant arsisng from the epithelial cells of thymus gland, frequently associated with neuromuscular disorder myasthenia gravis. so, we are presenting this rare case of thymoma with myasthenia gravis in our institute. methods: we operated a single patient of thymoma in a case of myasthenia gravis by video assissted thoracoscopic approach. results: operative time- min, intraoperative blood loss − ml, post operative analgesia requirement in form of nsaids is for days, no ventilatory support required post operatively, with follow up reduction in achr ab from nmol/l to nmol/l and reduction in symptoms in form of reduced ptosis. conclusion: thoracoscopic thymectomy is feasible and safe in terms less operative time, less post operative pain and analgesia requirement and no post operative ventilatory support requirement. carter c lebares, md, stanley j rogers, md; ucsf background: duodenal fistulas are uncommon but morbid complications of acute necrotizing pancreatitis. if percutaneous drainage fails, surgical correction via roux-en-y diversion or pancreaticoduodenectomy can be required. while self-expanding metal stents have been tried, complications like migration and perforation have limited such use. endoscopic transmural stents have successfully treated fistulas of the stomach, particularly post-sleeve gastrectomy. here we present a case of endoscopic transmural stents used to treat a non-resolving duodenal fistula following acute necrotizing pancreatitis. methods: under general anesthesia, using a standard adult gastroscope, the fistula was identified in the second portion of the duodenum (fig. ) . a flexible-tipped guide wire was used to identify the fistula tract and two fr cm double pigtail biliary stents were deployed ( fig. ) with positioning verified under fluoroscopy. two weeks later these were removed and a single stent deployed into the visibly smaller tract (fig. ). two weeks after that, the single stent was removed and contrast medium was injected under fluoroscopic visualization, demonstrating resolution of the fistula (fig. ) . case: this patient is a year old woman with hypertension and congenital hearing loss who underwent a cholecystectomy for biliary colic and subsequent ercp with sphincterotomy for retained stone. this was complicated by acute pancreatitis which progressed to severe necrotizing pancreatitis with infected retroperitoneal necrosis. percutaneous drainage yielded initial improvement but a persistent moderate collection ( cc per day) lead to the identification of a fistula in the second part of the duodenum. repositioning and exchange of percutaneous drains over weeks did not hasten resolution. endoscopic transmural pigtail stents were tried after visualization of a large ( - mm diameter) fistula tract. stents were utilized as described in methods, with a total of three endoscopic interventions, at week intervals, resulting in resolution of the fistula as evidenced by contrast injection into the duodenum under fluoroscopy and subsequent ct scan with oral contrast. the patient's symptoms resolved and she was tolerating a normal diet. she remained thus at month follow-up. conclusion: this case demonstrates the benefit of endoscopic transmural stents for the resolution of duodenal fistulas, expanding the utility of this technique to address leaks and fistulas of the upper gastrointestinal tract. further study is warranted to clarify the timing and adjuncts to optimize the use of this promising approach. totally laparoscopic alpps combined with the microwave ablation for a patient with a huge hcc hua zhang; department of hepatopancreatobiliary surgery, west china hospital, sichuan university introduction: associating liver partition and portal vein ligation for staged hepatectomy (alpps) is a novel technique for resecting hepatic tumors that were previously considered unresectable due to the insufficient future liver remnant (flr) which may result in postoperative liver failure (plf). the procedure has been accepted and modified in many medical centers worldwide. but reports about the laparoscopic alpps were rare. this study aimed to report a totally alpps combined with microwave ablation for a patient with huge hcc and confirm the feasibility of laparoscopic alpps. methods: a -year-old man had complained of -year history of right upper abdominal pain, and the syndrome was worsened in recent month. abdominal enhanced computed tomography (ct) imaging revealed a cm solid mass in right lobe of liver with non-uniform and unclear boundary, the right posterior branch of the portal vein was invaded. in addition, a small lesion was simultaneous found in left lateral lobe of liver. the tumor was evaluated as unresectable due to the flr was only ml ( %). we decided to perform the laparoscopic alpps procedure. first stage including microwave ablation of the lesion in left lobe, cholecystectomy, ligation of the portal vein and transection of liver parenchyma. the second stage was done days later and consisted of laparoscopic right hemihepatectomy. results: the two stages were underwent by laparoscopy successfully. the operation duration was and minutes, respectively. estimated blood loss was and ml. the hospitalization time in intensive care unit was and days. there was no need for transfusion in both stages. the patient was discharged days after the second stage and the total hospitalization time was days. recovery of the patient was uneventful in addition to the incision infection after the second stage which recovered with conservative management. the patient did not show any signs of liver failure. the ct scan before the second stage showed an enlargement of left lobe, the flr was ml ( . %). there was no signs of residual liver disease in the ct scan days after the operation. the patient showed no signs of recurrence or liver failure in the following up period of six months. conclusion: totally laparoscopic alpps combined with microwave ablation is safe and feasible for the multiple hcc which was not resectable. the hypertrophy of remaining liver was fast and can achieve an adequate volume in a short time. introduction: chronic pancreatitis is a benign, irreversible inflammatory disorder characterized by the conversion of the pancreatic parenchyma into fibrous tissue. initial management should be conservative, surgery is applied in case of failure of medical treatment. the development of minimally invasive techniques has made it possible to perform these highly technical procedures in a laparoscopic manner. materials and method: we have the history of patients with and years with chronic pancreatitis and pancreatic lithiasis of difficult handling but intractable pain to those who decided to surgical management. we performed the procedure under general anesthesia, epidural analgesia catheter was placed. neumoperitoneum technique of cali, at mmhg and approach using a mm umbilical port, working ports of and a of mm port,. the pancreas was exposed by a section of the gastrocolic ligament with a mm ultrasonic scalpel, with cephalic retraction of the stomach, opening of a smaller sac and approaching the transpavity of omentum. the ventral surface of the pancreas was exposed from the neck. an incision was made in a pancreas body with a monopolar hook. primary pancreatic duct lumen was identified and the incision was extended longitudinally from the neck to the tail of the pancreas ( cm). roux's y loop was prepared cm from the treitz ligament, with a jejunum section with a mm stapler, roux's loop was transmecoscopically retrocollic, closing the gap of the mesocolon with monocryl. a -cm jejunum-jejunal anastomosis was performed with endo-gia stapler and closure of enterotomy with - polypropylene intracorporeal suture. jejunal (roux) isoperistaltic loop was placed longitudinally at the opening of the main pancreatic duct, and enterotomy was performed with monopolar in antimesenteric segment. the intracorporeal pancreatico and jejunum anastomosis was performed using a lower and an upper plane, with single points of total thickness with ethnobond - . closed drains were placed towards each anastomosis. this procedure was performed in the patients reported. operative time - min complications none operative time - days minimal bleeding drains no retired in both cases at days year follow-up of patients improved pain\ conclusions: minimally invasive surgery is a fundamental tool for the approach and management of patients with biliopancreatic pathologies. the establishment of multidisciplinary groups, offer an excellent alteranativa in the integral management of the patients. surg endosc ( ) gallbladder anatomy is highly variable, and surgeons must be prepared to identify anomalies of form, number, and position. variants include gallbladder agenesis, diverticulum, duplication, bilobed, multiseptate, phrygian cap, ectopic, and hourglass gallbladder. the hourglass gallbladder has been described from the earliest days of cholecystectomy, as morton described a congenital case in , and else thoroughly described the acquired and congenital strictures leading to the hourglass deformity in . we describe a case of an hourglass gallbladder found during one-step endoscopic retrograde cholangiopancreatography (ercp) and laparoscopic cholecystectomy. this year old male presented to an outside hospital with one day of nausea, and constant, severe, epigastric pain that radiated to his back. he endorsed a history of similar pain several times in the past. his abdomen was soft, nontender, and without murphy sign. laboratory evaluation revealed total bilirubin . mg/dl, alkaline phosphatase u/l, ast u/l, alt u/l, and no leukocytosis. ct abdomen and pelvis revealed cholelithiasis, distal choledocholithiasis, intra-and extra-hepatic ductal dilation, and a . centimeter left liver hemangioma. he was transferred for management of choledocholithiasis, and an abdominal ultrasound revealed cholelithiasis, without gallbladder wall thickening or pericholecystic fluid, and a . millimeter common bile duct without choledocholithiasis. he was taken to the operating room for a one-step ercp and laparoscopic cholecystectomy. upon laparoscopy, dense adhesions to the gallbladder were found. after initially attempting to obtain the critical view of safety, we then embarked on the retrograde "top down" dissection. this isolated a spherical structure measuring . . centimeters. two very thin tubular structures were identified, clipped, and transected after we found they were too small to place a cholangiocatheter. the common bile duct appeared to be pulled anteriorly by surrounding inflammation, though this was later found to be the proximal segment of gallbladder. the intra-operative ercp identified a remnant gallbladder with cholelithiasis and no extravasation of contrast. given the unusual anatomy, we completed the operation, ordered a post-operative ct liver and mrcp, and consulted a hepatopancreatobiliary surgeon. a small remnant gallbladder was identified on ct liver, though not on mrcp. completion laparoscopic cholecystectomy with intraoperative cholangiogram and ultrasound was performed on hospital day . this hourglass gallbladder variant likely occurred secondary to chronic fibrosis from cholecystitis, leading to a proximal and distal gallbladder lumen. in anatomic uncertainty, the "top down" dissection, intraoperative cholangiography, ct liver, and expert consultation are safe methods to avoid iatrogenic injury. introduction: endoscopic entero-enteral bypass could change our approach to small bowel obstruction in patients with prohibitively high operative risk. magnetic compression anastomoses have been well-vetted in animal studies, but remain infrequent in humans. isolated cases of successful use in humans include treatment of biliary strictures and esophageal atresia. while endoscopic gastro-enteric magnetic anastomoses have been described, the associated multicenter cohort study was terminated due to serious adverse events. since then, the technology has evolved and recently our own institution reported results of the first in-human trial of magnetic compression anastomosis (magnamosis), deployed through an open approach. here we present the first case of endoscopic delivery of the magnamosis device and the successful creation of an enteroenteral anastomosis for chronic small bowel obstruction in a patient with prohibitively high operative risk. methods: the magnamosis device has previously been approved by the food and drug administration (fda) for use in clinical trial. our institutional review board approved emergency compassionate endoscopic use of the device in this patient due to a non-resolving small bowel resection and prohibitively high operative risk. case: this is a year old man with advanced liver disease, chronic obstructive pulmonary disease, and history of emergent right colectomy with end ileostomy for cecal perforation. he presented with multiple acute on chronic episodes of small bowel obstruction with a stable transition point in the distal ileum, radiographically estimated at centimeters proximal to the ileostomy. endoscopic evaluation through the ileostomy revealed a traversable obstruction with proximally dilated small bowel. the magnets were delivered via endoscopic snare under fluoroscopic guidance and positioned in adjacent loops of bowel on either side of the obstruction (image ). by days post-procedure, healthy villi were visible through the central portion of the mated magnetic rings (image ). by days the magnetic rings were mobile and the anastomosis was widely patent allowing easy passage of the gastroscope (image ), and the patient's symptoms were completely resolved. the rings passed through the ileostomy days post-procedure. at month follow up, the anastomosis was unchanged (image ). conclusion: this case demonstrates the benefit of an endoscopically created magnetic compression anastomosis in a patient with small bowel obstruction and high operative risk. further studies are indicated to evaluate the use of this technique in similar patients or those with malignant obstruct, ion. desiree raygor, md, ruchir puri, md; university of florida health jacksonville cholecystectomy is one of the commonest operations in general surgery [ ] . occasionally chronic cholecystitis can lead to a small contracted gallbladder. this diagnosis can be misleading as it may represent congenital agenesis of the gallbladder [ ] . a -year-old female with a past history of pancreatitis presented with a three day history of right upper quadrant pain associated with nausea and vomiting. upon exam she exhibited tenderness in the right upper quadrant. her leukocyte count and liver function tests were within normal limits. ultrasound revealed a poorly visualized, contracted gallbladder without stones and a dilated common bile duct (cbd). cholescintigraphy revealed non visualization of the gallbladder after two hours, which was suggestive of acute cholecystitis. decision was made to proceed with a laparoscopic cholecystectomy. the abdomen was entered by an open hasson technique and standard trocar placement for a cholecystectomy was performed. on initial inspection, the gallbladder was not readily visible. a structure appearing to be the cbd was present and was mobilized circumferentially (fig. ) . a gauge butterfly cannula was utilized and multiple cholangiographic images were obtained (fig. ). no cystic duct or gallbladder was identified which was suggestive of congenital agenesis of the gallbladder. the patient did well postoperatively, and was discharged home on postoperative day two. the patient's symptoms resolved and she continues to be pain free one month postoperatively. congenital agenesis of the gall bladder is a rare disorder. a high index of suspicion is required especially in the setting of a small contracted gall bladder. if preoperative imaging is inconclusive then diagnostic laparoscopy should be the next step. cholangiogram should be performed routinely to confirm the diagnosis and to rule out an ectopic gall bladder. conversion to open does not offer any distinct advantage, and laparotomy should be avoided if possible given its associated morbidity. there are many reports upper abdominal major arterial aneurysms. however, an aneurysm of left inferior phrenic artery had never been reported. a -year-old woman with liver cirrhosis associated with hepatitis b viral infection was referred to department of surgery for treatment of aneurysm of left inferior phrenic artery. she underwent trans-arterial chemoembolization (tace) for treatment of hepatocellular carcinoma three times, previously. on months after last tace, mm sized highly enhancing nodular lesion of gastric fundus was found on follow-up abdomenpelvis computed tomography (a-p ct). one year later, the size of this lesion increased to mm, and an aneurysm was diagnosed. she underwent angiography and attempted embolization with an aneurysm of the left inferior phrenic artery, but access failed. we performed a laparoscopic vessel ligation. she recovered with no complication and discharged on the th postoperative day. s surg endosc ( ) :s -s yousef almuhanna, vatsal trivedi, fady balaa; university of ottawa a years old female, g and weeks pregnant, was brought to the hospital by ems, after being found on the floor in her toilette surrounded by vomitus and urine. mother-inlaw, who happens to be at the house that time, have heard severe retching followed by a loud bang sound. firefighters have found no pulse and therefore started cpr. return of spontaneous circulation was achieved, yet unfortunately, she had arrested again minutes prior to arrival to er. pocus assessment showed large rvot, and therefore tpa was started on the assumption of pulmonary embolism. upon arrival of blood work, it was found that her hemoglobin had dropped from to . fast was repeated showing moderate to severe amount of free fluid in the morrison's pouch and pelvis. she was then taken to the operating theatre, had undergone laparotomy showing liver segment ii injury. pringle's maneuver and aortic clamping did not control the bleed, therefore finger fracture and venous clips were used to temporary minimize the bleed, and head to interventional radiology suite. after multiple attempts to control the bleed, and the massive transfusion, she vital signs were not maintained, and had arrested afterwards. sarrath sutthipong, md, chumpunut chuthanan, md, chinnavat sutthivana, md, petch kasetsuwan, md; bhumibol adulyadej hospital, bangkok, thailand background: mesenteric panniculitis (mp) is a rare, benign and chronic fibrosing inflammatory disease that affects the adipose tissue of the mesentery of the small bowel and colon. the specific etiology is unknown and no clear information about the incidence. the diagnosis is suggested by ct and is usually confirmed by surgical biopsy. treatment is based on some selected drugs. surgical resection is sometimes attempted for definitive therapy, although the surgical approach is often limited. we reported a case of the mp diagnosed with ct and surgical biopsy by laparoscopic approach. case report: -year-old woman with months history of chronic abdominal pain, mainly localized in the sub-epigastrium, intermittent and mild. she had anorexia but no weight loss or change in bowel habits. no history of medical illness or surgery. the physical examination was unremarkable, except for palpation of ill-defined mass about cm at mid-abdomen, firm, smooth surface with mild tenderness. the laboratory profile and tumor marker were normal. ct of the abdomen, which showed focal heterogeneous enhancement of the mesenteric fat with stranding ( . . cm) with multiple internal subcentimeter lns in the supraumbilical area, which was probably inflammatory in origin and suggestive of mp. f-fdg pet/ct showed faint fdg uptake in multiple mesenteric lns. the patient was subsequently underwent diagnostic laparoscopy with biopsy. intra-operative finding showed a fat-like surface of yellowish mass at mesentery of jejunal segment, incisional biopsy was performed laparoscopically. the histology showed adipose tissue with areas of fat necrosis, fibrosis, foamy macrophages infiltration and predominant chronic inflammation, no evidence of malignancy. ihc studies (including cd , s- , cd and cd ) were performed and the result was compatible with reactive process. treatment was started with mg prednisone once daily and planned for follow-up with repeated ct scan. discussion: mp involves the small bowel mesentery in over % of cases. the diagnosis is made by pathologic findings: fibrosis, chronic inflammation and fatty infiltration. the differential diagnosis is broad and has been associated with malignancies such as lymphoma, well-differentiated liposarcoma and melanoma. the imaging appearance varies depending on the predominant tissue component. a definitive diagnosis is biopsy but open biopsy is not always necessary. no data of laparoscopic biopsy, which has been reported previously. treatment has been reserved for symptomatic cases with a variety of drugs. our case was started on oral corticosteroid treatment and waited for responsive evaluation. background: laparoscopic appendectomy is the gold standard for treatment of acute appendicitis. stapled closure of the appendiceal stump is often performed and has been shown to have several advantages. few prior cases have been reported demonstrating complications from free staples left within the abdominal cavity after the laparoscopic stapler has been fired. case report: a previously healthy year old female initially underwent laparoscopic appendectomy for acute uncomplicated appendicitis during which the appendix and mesoappendix were divided using laparoscopic gastrointestinal anastomosis (gia) staplers. her initial postoperative recovery was uncomplicated and she was discharged home the same day. the patient returned to the emergency department on postoperative day with one day of sharp mid-abdominal pain, obstipation, and emesis. her abdomen was distended and mildly tender but not peritoneal. she was afebrile but was found to have a leukocytosis of . . ct demonstrated twisted loops of dilated small bowel in the right lower quadrant with two transition points, suggestive of internal hernia with closed loop bowel obstruction. diagnostic laparoscopy was performed through the three prior appendectomy incisions. an adhesion was noted between the veil of treves and the mesentery of a more proximal loop of ileum caused by a solitary free closed staple, remote from the staple lines, resulting in an internal hernia containing several loops of ileum ( fig. ). the hernia was reduced, and the small bowel was noted to have early ischemic discoloration. the adhesion was lysed by removing the staple from both structures to prevent recurrence. through the remainder of the procedure, the compromised loops of bowel began to peristalse and the color normalized. the procedure was concluded without resection. the patient recovered on a surgical floor and was discharged home on postoperative day one. conclusion: gastrointestinal staplers are commonly used secondary to ease of use and low complication rate. it is not uncommon to leave free staples in the abdomen during laparoscopy as retrieval can often be more difficult and time consuming. our case is only the second in the literature reporting an internal hernia with closed loop bowel obstruction as a complication of retained staple. choosing the most appropriate size staple load, to reduce the number of extra staples after the fire, and removing as many free staples as possible can prevent potentially devastating complications. video-assisted thoracoscopic pulmonary wedge resection in a patient with hemopytsis and intralobar sequestration: a case report mary k lindemuth, md, subrato j deb, md; the university of oklahoma health science center case report: a -year-old male with history of noonan's syndrome, bronchitis, and asthma presented with acute hemoptysis. while chest x-ray was unremarkable, a computed tomography angiogram of his chest was significant for intralobar pulmonary sequestration in the right lower lobe. the aberrant pulmonary artery originated from the abdominal aorta, immediately proximal to the celiac axis, and coursed through the hiatus in the retroperitoneum. flexible, fiberoptic bronchoscopy revealed blood within the right lower lobe bronchus with no appreciable source. a right video-assisted thoracoscopic approach was taken for wedge resection of the sequestration. twoportal technique was utilized with the patient on single lung ventilation. the sequestration was easily identified; the anomalous pulmonary artery coursed directly to a large, focal area of hemorrhage noted within the lower lobe pulmonary parenchyma, as seen in image [rectangle marking the aberrant artery and oval marking the sequestration]. pathologically, the specimen was noted to be benign lung parenchyma with bronchiectasis and abundant, acute hemorrhage. discussion: pulmonary sequestration (ps) is a rare, congenital bronchopulmonary foregut malformation. literature describes the incidence of ps to be only . - . % of all pulmonary malformations. as ps is most frequently diagnosed during childhood, the occurrence of diagnosis during adulthood is estimated to be less than per , adults. two types (intra-and extralobar) are described, with intralobar sequestration most common and contained within the normal visceral pleura. both types have aberrant systemic arterial blood supply, most frequently from the thoracic aorta. likewise, both types are nonfunctioning lung tissue, as there is no direct communication with the bronchopulmonary tree. the most common presentation is pneumonia, and often patients will have had recurrent symptoms before diagnosis. it is rare to present with hemoptysis, which is understood to be secondary to elevated capillary pressure within the sequestration and then communication through the pores of kohn. while endovascular embolization of the aberrant pulmonary artery has been described as a safe alterative for surgical intervention, the subjects of these studies have primarily been children and long-term outcomes are unknown. the definitive treatment of ps continues to be surgical intervention. the surgeon should strive to leave as much normal lung parenchyma as possible. video-assisted thoracoscopic resection is well tolerated by patients when compared to thoracotomy. however, it is vital for the surgeon to be aware of the potential risk of life-threatening hemorrhage secondary to the sequestration having systemic blood supply that must be controlled and ligated. case report: a years-old female patient with history of an increased mass and weight loss of kilograms in months, associated with vomiting and nausea for eight months. abdominal ultrasound showed an irregular cyst, without solid projections and without signs of flow in doppler, measuring cm. investigation continued with ct scan that showed a large homogeneous cystic lesion with no septum in the abdominopelvic region, possibly mesenteric, measuring . . cm. a laparoscopic approach for resection of the cyst was then performed. the surgery was performed with a patient in the dorsal decubitus, using three trocars: one in the umbilical region ( -mm) for the camera, and where the pneumoperitoneum was created by the hasson open technique under direct vision; and another two located in the epigastrium ( -mm) and in the right upper quadrant ( -mm) . in addition to the mesenteric cyst, a simple cyst in the right ovary and a solid nodule with a lipomatous characteristic of approximately cm in the abdominal cavity were visualized. total resection of the mesenteric cyst with periprancreatic fibrous tissue was performed. the cyst was punctured and its contents fully aspirated. resection of the right ovarian cyst was also performed. at the end of the procedure the mesenteric and ovarian cysts, the nodule, part of the omentum, and the peripancreatic tissue were removed through the -mm trocar at the umbilicus. patient had no further complications, being discharged four days after the procedure. histopathologic result showed a serous cyst in the right ovary, serous cyst in peripancreatic mesentery with chronic inflammatory process and signs of calcification; no signs of malignancy were observed in any specimen. we aimed to present the succesul therapeutic approach utilizing laparoscopy for safely removing a gastrointestinal stromal tumor. depicted is a year old jehova's witness female who presented to the emergency department for evaluation of bitemporal headache and dizziness and found with profound anemia with hemoglobin . and hematocrit . upon arrival to ed. the patient refused blood transfusion as her religious beliefs, jehovah's witness, preclude her from taking blood products. as part of her work up, endoscopy was performed and revealed a large, approximatelly cm, prolapsed, ulcerated, nodular lesion with active bleeding in the cardia of the stomach. this was temporized but the friable tissue, with no single identifiable lesion for clip placement, left the patient at high risk for re-bleeding. she was taken to the operating room and laparoscopic partial gastrectomy with intraoperative esophagogastroduodenoscopy were succefully perfomed, with minimall blood loss and no intra operative complications. patient was discharged on post op day . we present the case of a -year-old male with a history of morbid obesity with an initial bmi of . , who underwent an elective laparoscopic single anastomosis duodenal-ileal bypass with sleeve gastrectomy (sadi-s). postoperatively he developed an anastomotic leak at the duodeno-ileal anastomosis that would not resolve despite reoperation. he was then converted to a roux-en-y gastric bypass (rygb). postoperative imaging failed to reveal any signs of anastomotic leak and the patient was discharged tolerating an oral diet. he returned to the emergency department days later with a cm sub-hepatic collection arising from the duodenal stump from the surgical conversion. interventional radiology percutaneously drained the collection and found a connection between the cavity and the duodenum. using this connection, a percutaneous decompressive duodenostomy drain was successfully inserted into the duodenum using a guidewire through the abscess cavity along with an extra-enteric drain placed within this cavity. the collection was obliterated and the duodenal leak was controlled successfully with percutaneous drainage, bowel rest with parenteral nutrition and broad-spectrum intravenous (iv) antibiotics. the patient was reintroduced to a bariatric clear diet after a week of bowel rest and the abscess drain was then discontinued during the same hospital admission. the patient was discharged with the percutaneous duodenostomy tube which was removed in clinic days later, after the patient tolerated capping trials and imaging failed to reveal any further collections, oral contrast extravasation or distal obstruction. in this article we analyze notable imaging from the case and review current literature on the different management options for a duodenal stump blowout. we also discuss the basics of the sadi-s procedure and conversion of a sadi-s procedure to a rygb. keywords: anastomotic leak, duodenal stump blowout, sadi-s, duodenostomy tube. pancreatopic heterotopia is often an incidental finding on autopsy, but in some cases can lead to abdominal pain, obstruction, or intussusception. we present a case of pancreatic herterotopia mimicking an internal hernia on radiologic imaging. a year old female with seven month history of chronic abdominal pain treated for low back pain and recurrent urinary tract infections. she was found to have a computed tomography (ct) scan concerning for internal hernia and labs consistent with acidosis. she was taken for a laparotomy and did not have an internal hernia, but an exophytic mass in the proximal jejunum. the mass was resected and a stapled side to side jejunojejunostomy was created. on pathologic review, the specimen was found to be pancreatic heterotopia. her post operative course was complicated by an ileus, but was discharged post op day three. at her two week follow up she had minimal incisional pain and at one year follow-up she had resolution of her left upper quadrant abdominal pain. prior to this report, pancreatic heterotopia has never been described as presenting on ct scan as an internal hernia. although uncommon it should remain in the differential when evaluating a patient presenting with abdominal pain and radiologic evidence of obstruction or internal hernia. case report: a -year-old male patient who was diagnosed with high blood pressure at years-old and presented tetraparesis and intense asthenia for six months. blood tests showed hypokalemia, hypernatremia, and suppressed renin activity. ultrasound of the urinary tract was normal. ct scan of the abdomen showed a hypodense nodule with regular margins, measuring . . cm with a density of hu in the non-contrast phase and heterogeneous uptake after the injection of the contrast in the left adrenal gland. thus, the diagnosis of hyperaldosteronism secondary to the left adrenal nodule was confirmed, and surgical resection was indicated. the procedure was performed with the patient in the right lateral decubitus. two -mm and one -mm trocars were used on the left flank, as well as the -mm portal for the camera in the lower right quadrant under direct vision. the pneumoperitoneum was created by the hasson open technique in the transumbilical incision. the procedure consisted of the dissection, isolation and electrocautery of the left renal capsule and the left adrenal region with ultrasonic device, as well as the periadrenal vessels, adjacent lymph nodes and periadrenal and adrenal fat tissue. the surgery was uneventful and the patient had no further complications, being discharged the next day. histopathologic result showed a completely excised adrenocortical adenoma. conclusions: the hybrid minimally invasive approach proved to be safe and effective for this procedure, and the known advantages of minilaparoscopy such as less trauma, better visualization, better dexterity, better aesthetics, and reduced hospital stay were observed. s surg endosc ( ) background: coccidioidomycosis is a fungal infection endemic to the southwestern united states, central america and south america. coccidioides is ubiquitous in many of these endemic regions, with near % seroconversion in some communities. two-thirds of these mycotic infections may be asymptomatic. the most common presentation of coccidioidomycosis consists of "flu-like" symptoms or pneumonia. less than five percent of symptomatic cases progress to disseminated coccidioidomycosis which may involve any organ system. very rarely infection may include the peritoneum. we report a case of coccidioidomycosis with peritoneal involvement in an immunocompetent individual. case: a -year-old male presented to the emergency department with progressive abdominal pain. he was seen and treated for pneumonia in the emergency department one week prior. the patient worked outdoors in arizona and was otherwise healthy with a family history of malignancy and blood disorders. fever, leukocytosis and ascites on computed tomography scan prompted a diagnostic laparoscopy which revealed peritoneal granulomas positive for coccidioides. the patient was treated outpatient with fluconazole. discussion: since this is the th reported case of peritoneal coccidioidomycosis to our knowledge. the patient described in this case report was an otherwise healthy -year-old male; this is incongruent with many of the previously recorded cases which involved disseminated disease in immunocompromised patients. the patient's family history of malignancy and blood disorders suggests a potential underlying genetic predisposition that could account for this abdominal presentation. possible mutations include genes coding for the interleukin- β receptor and the signal transducer and activator of transcription which have been implicated in increased coccidioidomycosis susceptibility. peritoneal infection presents a unique challenge in diagnosis. in these cases coccidioidomycosis may not be suspected due to nonspecific symptoms and imaging, the infrequency of this extra-pulmonary manifestation and clinical characteristics that mimic the presentation of tuberculosis and malignancy. abdominal infections have been misdiagnosed as appendicular abscesses, iliopsoas abscesses, adnexal abscesses and pancreatic masses. consequently, the diagnosis of peritoneal coccidioidomycosis is often made after laparoscopic exploration of the abdomen and histopathology, as it was in this case report. conclusions: coccidioidomycosis incidence is on the rise in endemic areas and it often falls on the surgeon to make the diagnosis in extra-pulmonary cases. the peritoneal subset of coccidioidomycosis should be considered in endemic areas when a young, otherwise healthy patient presents with abdominal pain. failure to recognize the possibility of coccidioidomycosis may lead to unnecessary treatments and procedures. indocyanine green cholangiography to detect anomalous biliary anatomy steven d schwaitzberg, md, gabrielle yee, ms; university at buffalo jacobs school of medicine introduction: common bile duct injury is the most feared complication of cholecystectomy. imaging with indocyanine green (icg) is a safe and effective technique to detect biliary anatomy in open, laparoscopic and robotic surgery. several studies report detecting aberrant biliary anatomy with the use of icg in laparoscopic cholecystectomy with high success rates. by identifying the cystic duct-common hepatic duct confluence before dissecting calot's triangle, icg allows surgeons to perform "virtual" cholangiography at the start of procedures to identify either normal anatomy or possible anatomic variants. it is clear that icg use is an effective tool to achieve the critical view of safety. however, no reports have suggested icg cholangiography as the last operative step in cholecystectomy to identify hidden biliary anomalies and avoid postoperative bile leak complications. case report: we report a novel use of icg cholangiography in visualizing anomalous biliary anatomy prior to closing, thus avoiding potential bile duct leakage. in our case, icg cholangiography was used to fluoresce the common hepatic duct, common bile duct and cystic duct. the cystic duct was transected, and the gallbladder was removed using electrosurgery. at the completion of the gallbladder removal, the liver was elevated to inspect the clips on the cystic duct and artery. at this point, near infrared imaging was reinitiated, and a small mm structure was noted to fluoresce next to the cystic artery. this structure was identified using white light and subsequently clipped. discussion: the use of icg in this context after the completion of the cholecystectomy facilitated the identification of a small hepatocystic or aberrant duct, which would have likely leaked bile sometime in the postoperative period. based on our experience, we recommend one additional routine near infrared viewing to identify small structures or potential leaks at the completion of cholecystectomy. improved visualization of the extrahepatic biliary anatomy by icg has the potential to translate into improved clinical outcomes. solitary fibrous tumors (sft) are uncommon fibroblastic mesenchymal neoplasms that display a wide range of histologic behaviors. these tumors, which are estimated to account for % of all soft tissue neoplasms, typically follow a benign clinical course. however, it is estimated that - % of sfts are malignant and demonstrate aggressive behavior with local recurrence and metastasis up to several years after surgical resection. we report a case of sft arising from the stomach, which is an exceptionally rare finding and has been reported only six times in the literature. additionally, this tumor was associated with dedifferentiation into undifferentiated pleomorphic sarcoma. to our knowledge, there are no documented cases of a malignant sft arising from the stomach to demonstrate dedifferentiation into an undifferentiated pleomorphic sarcoma. a -year-old male presented to the emergency department with vague complaints of right-sided flank pain. the patient had a history of nephrolithiasis and underwent a ct abdomen. this scan revealed a large heterogeneous mass in the left upper quadrant. the patient underwent endoscopic ultrasonography with fine needle aspiration of the mass, which stained strongly for cd . gastrointestinal stromal tumor (gist) was the favored diagnosis as it is by far the most common mesenchymal neoplasm of the stomach, especially cd positive spindle cell neoplasm. accordingly, the patient began treatment with imatinib; however, after four weeks of therapy, there was no significant radiologic regression. a second biopsy was performed and the specimen was sent for stat immunohistochemistry, which revealed diffuse strong nuclear positivity. a diagnosis of solitary fibrous tumor was provided. surgical resection of the tumor was performed, which measured . cm. the patient was to undergo surveillance imaging every to months post-operatively. surveillance scan showed solitary metastatic disease in the left lateral segment of the liver. he underwent left lateral segmentectomy with an uneventful recovery. our case was complicated by diagnostic dilemma with gist, highlighting the challenges of diagnosing and characterizing sfts. dedifferentiation, or the abrupt transition from a classic sft into a high-grade sarcoma, is a particularly concerning finding in our case, as it is associated with a worse prognosis than classic malignant sft. the stat marker by immunohistochemistry is very specific for sft and may have aided in the diagnosis earlier. therefore, it is imperative to keep solitary fibrous tumor, albeit exceedingly rare, in the differential diagnosis of mesenchymal neoplasms of the stomach. appendiceal diverticulitits is an uncommon pathology that can clinically mimic acute appendicitis. some radiographic distinctions have been reported, but final pathologic examination of the surgical specimen is required to confirm the diagnosis. symptoms are often more mild, which can lead to a delayed diagnosis, and increases the risk of severe complications such as perforation. a year old female presented with a three day history of right lower quadrant pain. she described the pain as constant and radiating to the left lower quadrant. associated symptoms included nausea and vomiting, and decreased appetite; she denied fevers or diarrhea. the patient had no significant past medical history, and surgical history was significant for a total nephrectomy for living donor kidney transplant to her mother. on physical exam she was tender in the right lower quadrant with rebound and a positive rosving's sign. all laboratory results were unremarkable, and she was hemodynamically stable. ct scan was performed and demonstrated a dilated fluid filled appendix with surrounding inflammatory change without abscess or free intra-peritoneal air. she was subsequently admitted to the hospital, made npo, started on iv antibiotics, and was taken to the operating room where she underwent an uncomplicated laparoscopic appendectomy. post-operatively, her hospital course was unremarkable. pathology revealed acute suppurative appendicitis secondary to an acutely inflamed appendiceal diverticula, consistent with a final diagnosis of acute appendiceal diverticulitis. appendiceal diverticulitis should be considered in patients presenting with acute right lower quadrant abdominal pain. although some consider appendiceal diverticulitis a variant of acute appendicitis, it is important to distinguish between the two diagnoses. appendiceal diverticulitis has a higher rate of complications, including perforation, and is associated with a higher risk of neoplasm, particularly mucinous adenomas and carcinoid tumors. appendectomy should be performed in all cases in order to obtain appropriate pathological examination and rule out coexistent neoplasms. laparoscopic appendectomy is a safe and appropriate approach to treatment of appendiceal diverticulitis. upper gi endoscopy and biopsy showed a gastrointestinal stromal tumor (gist) in the stomach. a videolaparoscopic partial gastrectomy was then proposed. the surgery was performed with the patient in the right lateral decubitus. two -mm minilaparoscopic trocars, a -mm conventional trocar for an ultrasonic instrument and a -mm trocar in the umbilical region for the camera were used. pneumoperitoneum was created using the hasson open technique under direct vision. trans-operatory endoscopy was perfomed to identify the tumor easily. initially, the ultrasonic device released the large omentum, and, then, the tumor was resected in the body of the stomach. the gastric wall was manually sutured with a - vicryl, and the tumor was removed in an endobag through the -mm incision in the umbilicus. the surgery was uneventful, with a total time of minutes. the patient had no further complications, being discharged two days after the procedure with good clinical conditions. histopathological result showed a free margins gist. conclusion: the minimally invasive approach proved to be safe and effective for this procedure. the known advantages of video-surgery such as less trauma, better visualization, increased dexterity, better esthetics, and less postoperative recovery time were confirmed. the upper gi endoscopy contributed to improve the safety and efficacy of the procedure, allowing a more precise resection of the gist, as well as the intragastric review of the suture line at the end of the surgery. background: portal vein thrombosis (pvt) is a rare post-operative complication, which has been associated with a wide range of precipitating factors. most commonly described associated conditions include; cirrhosis, bacteremia, myeloproliferative disorders and hypercoagulable states. pvt most frequently occurs as a complication after hepatobiliary surgery, and although possible, very few cases have been documented occurring after laparoscopic surgery of the gastrointestinal tract. herein, we describe a case of pvt in a patient who underwent elective laparoscopic right hemicolectomy and was treated successfully at our center. case: a year-old female with past medical history of depression, migraines and endometriosis underwent an uncomplicated laparoscopic right hemicolectomy at our facility, for recurrent rightsided diverticulitis. she had suffered previous episodes of diverticulitis and desired definitive surgical treatment. her hospital course was uneventful and she was discharged to home on postoperative day . on post-operative day , she presented to the emergency department complaining of severe abdominal pain, back pain and nausea. computed tomography of abdomen and pelvis revealed pvt. she was initiated on therapeutic anticoagulation with heparin. hematology was consulted for hypercoagulable workup. further investigation revealed that she had a family history of a brother who had had a lower extremity deep venous thrombosis, with negative hypercoagulable workup. she had also previously been taking leuprolide and conjugated estrogen and medroxyprogesterone for her endometriosis. she was ultimately found to have a heterozygous prothrombin g a gene mutation. her anticoagulation was bridged to coumadin and she was discharged home. she has recovered as expected, without any further complications. discussion: although more common in patients with cirrhosis after hepatobiliary surgery, pvt is a rare complication that can occur after virtually all types laparoscopic surgeries, including elective right hemicolectomy. patients may be completely asymptomatic, or present with a broad spectrum of symptoms including; severe abdominal pain, fever, diarrhea, or gastrointestinal bleeding. physicians should be aware of this possible complication, since early diagnosis and treatment is imperative to prevent life-threatening complications, such as intestinal ischemia and perforation. a detailed medical and family history is imperative, and all patients with post-operative pvt should undergo complete hypercoagulability workup. this is a case of a year old male with a previous history of a redo-hiatal hernia years prior who presented with two episodes of upper gastrointestinal bleeding with no identifiable source noted on both endoscopy and angiography. during his second admission, initial hemoglobin was . g/dl and endoscopy performed showed massive amount of blood in the stomach. continuous oozing was seen originating in the fundus area but no clear source could be identified. empiric epinephrine was injected to the area but failed to achieve hemostasis. angiography was also negative. repeat endoscopy performed showed no active bleeding, however, distention of the wrap into the gastric cavity was observed. the patient re-bled and was taken to the operating room emergently after failed attempt at endoscopic control. the patient underwent proximal gastrectomy after intra-operative gastrostomy and exploration was unable to identify a bleeding source. the patient was left with an open abdomen and in discontinuity while resuscitation was performed in the surgical intensive care unit. he subsequently underwent a roux-en-y reconstruction and gastrostomy tube placement via the distal gastric remnant. upper gastrointestinal series performed demonstrated absence of leak, and the patient was started on a liquid diet supplemented with tube feeding. his recovery was uneventful and he was discharged home in stable condition. pathology revealed gastric ischemia at the base of the wrap making it impossible to visualize through endoscopy. on reviewing the literature, gastric ulcers and ischemia have been previously described. incidence was up to % and their onset of presentation ranged from the early post-operative period up to years. most were located in the lesser curvature. the exact pathophysiology for its occurrence is not completely understood. factors hypothesized include technical aspect of the fundoplication causing inappropriate tension, vessel disruption and ischemia, and injury to the vagus nerve affecting gastric emptying which was thought to increase gastrin secretion. treatment includes medical management with proton pump inhibitors; however, few cases describe antrectomy with inclusion of the bleeding ulcer. our case presents failed medical and endoscopic management. we recommend take down of the fundoplication in hemodynamically stable patients to completely evaluate the gastric mucosa, identify, and address the source of bleeding. otherwise emergent cases will require staged gastrectomy including the wrap followed by roux-en-y reconstruction. acalculous cholecystitis associated with a large periampullary duodenal diverticulum: a case report peng yu, md, phd, austin iovoli, aaron hoffman, md; department of surgery, suny buffalo, kaleida health system, buffalo, ny introduction: periampullary diverticulum (pad) could compress common bile duct (cbd), and consequently cause obstructive jaundice and cholangitis as few publications have documented. here we first report an acalculous cholecystitis associated with a pad-related cbd obstruction. case: the patient was a -year-old female with a past surgical history of laparoscopic sleeve gastrectomy who presented at the emergency room with upper abdominal pain and vomiting for one day, associated with leukocytosis and left shift. serum total bilirubin raised up to . mg/dl on hospital day (hd) . ct, ultrasound, and mrcp images confirmed a distended, wall-thickening gallbladder with pericholecystic fluid, and a significantly dilated cbd at . cm of diameter ( fig. ) , without cholelithiasis or choledocholithiasis. ercp was unable to be completed due to the post-gastrectomy anatomy and the failure in cannulation into the ampulla which embedded in a large foodimpacted pad (fig. ). on hd , the patient underwent a diagnostic laparoscopy and an intra-operative cholangiogram which confirmed a mildly inflamed edematous gallbladder, and a . . cm large pad with a narrow neck that was distorting the distal cbd (fig. ). since the patient's bilirubin level had been improving, we decided to only do a laparoscopic cholecystectomy. intraoperatively an anatomic variation of the cystic artery encircling the cystic duct ( fig. ) was also identified. postoperatively the patient recovered well during the thereafter inpatient course and at the postoperative -week outpatient follow-up. the pathology of the excised gallbladder confirmed cholecystitis without cholelithiasis. discussion: lemmel's syndrome is defined, in the absence of cholelithiasis or other detectable obstacle, by obstructive jaundice due to pad. since lemmel described this duodenal-diverticulum-obstructive jaundice in , there still have been very few cases reported or investigated. to date there is no report describing the association of acalculous cholecystitis with lemmel's syndrome. this patient's mild acalculous cholecystitis probably attributed to the biliary obstruction and consequent gallbladder hydrops. her symptoms could be from either acalculous cholecystitis or intermittently worsening biliary obstruction. in this case, the contribution of the anatomic variation of the cystic artery is unclear. in the future, if this patient's symptoms recur, the treatment plans for her will be sphincterotomy, removal of the impacted food in the pad, or diverticulectomy. accidental fish bone ingestion masquerading as acute abdomen aim: to report a case of fish bone ingestion masquerading as acute abdomen. case report: a years old female patient presented with complaints of severe abdominal pain since days. there was no history of associated nausea or vomiting, fever or altered in bowel habits. on examination patient had tenderness and guarding localized to the right iliac fossa. blood investigations revealed raised inflammatory markers. ultrasound whole abdomen and contrast enhanced computed tomography (cect) were normal. patient was managed conservatively but in view of persistence of symptoms a triple puncture diagnostic laparoscopy was performed on day of admission. omental inflammation with soapy appendix was found and appendicectomy was performed. on further assessment a foreign body was also found in the ileum which was removed and identified as a fish bone. patient had a satisfactory post operative recovery and was discharged in stable condition. discussion: acute abdomen due to fish bone ingestion is not a very common occurrence. unfortunately the history is often non-specific and these people can be misdiagnosed with acute appendicitis & other pathologies. ct scans can be useful to aid diagnostics. it is however not fully sensitive in detecting complications arising from fishbone ingestion. conclusion: any patient with acute abdomen, with non-specific history and normal imaging may still benefit from a diagnostic laparoscopy. discussion: this patient presented with a bowel obstruction, partial cecal necrosis and neuroendocrine carcinoma. literature suggests that cecal necrosis in the majority of cases is caused by a vascular event, occlusive or non-occlusive. the patient had atherosclerosis and an underlying malignancy which can be associated with prothrombotic states and contributes to an overall risk of thrombosis. the cecum can sustain ischemic ischemic injury in the presence of severe or prolonged hypotension. most frequent causes being decompensated heart failure, hemorrhage, arrhythmia or severe dehydration, only of which was present in this patient. the midgut neuroendocrine tumor is generally located in the terminal ileum, as a fibrotic submucosal tumor cm or less. mesenteric metastases are often larger than the primary tumor and associated with fibrosis which may entrap loops of the small intestine and cause bowel obstruction. this may eventually encase the mesenteric vessels with resulting venous stasis and ischemia in segments of the intestine as seen in this patient. conclusion: cecal necrosis is a rare entity, but its incidence increases with age. isolated cecal necrosis may manifest as a ct-negative appendicitis or a small bowel obstruction in the absence of past surgical history. s surg endosc ( ) laparoscopic transection of the falciform and triangular ligament successfully released the entrapped loop with successful reperfusion by the end of the surgery. in the absence of any prothrombotic comorbidity, the patients were discharged asymptomatic without further anticoagulation. to date only few similar cases have been reported, and most of them described in neonates and pediatric patients. to our knowledge, this cases reporteds in the elderlys. in this patients laparoscopic approach was both diagnostic and therapeutic with the transection the ligament. roberto javier rueda esteban , andres mauricio garcia sierra , felipe perdomo ; universidad de los andes, fundacion santa fe this is a patient´s rare case of spontaneous splenic rupture associated to chronic myeloid leukemia as an uncommon complication. the case report and review of the relevant literature on symptomatology and clinical management is presented. emphasis is made about the importance of including splenic rupture as differential diagnosis for acute abdominal pain, especially in a patient with neoplastic hematopathology, since early treatment increases patient survival and prognosis. esophagectomy is a complex operation associated with serious immediate complications and long term chronic complications. gastric ulcers are a common chronic complication after esophagectomy with gastric conduit reconstruction. these are rarely complicated by significant bleeding or perforation. we report a case of delayed diagnosis of a fistula forming between a gastric conduit and right bronchial tree years after esophagectomy. this was successfully treated using multiple therapeutic approaches including endoscopic localization and resection through a right thoractomy. to the best of our knowledge, our patient is the only survivor from a chronic gastric conduit bronchial fistula. a year old male with type diabetes mellitus, dyslipidemia, asthma and smoking history presented years after an ivory-lewis esophagectomy for a gastrointestinal stromal tumor (gist) with a chronic cough starting years after his esophagectomy followed by multiple episodes of hematoptysis over the next years. the patient was known to have ulcers in his gastric conduit with a massive bleed year after his esophagectomy. repeat endoscopy revealed two large chronic ulcers that had increased in size based on comparison of pictures from endoscopies to years after his esophagectomy despite maximal medical management. the patient presented to numerous specialists at tertiary care centers in canada and the united states. ultimately, in a clinic the patient was observed to cough immediately after the ingestion of water, but not solids leading to a provisional diagnosis of a gastrobronchial fistula. a barium swallow failed to show a fistula (fig. ). however at endoscopy, instillation of saline directed at an ulcer immediately induced a cough, but this was not reproduced when the saline was directed away from the ulcer. the fistula was ultimately demonstrated by placing a wire through the ulcer and visualizing it bronchoscopically in the right superior segmental bronchus . in an effort to pursue a minimally invasive approach two attempts were made to close the fistula with over-the-scope clips (otsc). unfortunately, the patient's symptoms persisted. a wire was placed through the fistula and delivered through the patient's mouth and endotracheal tube. a right thoracotomy allowed access to the conduit, which was opened and the fistula localized using the wire. the fistula was resected and the bronchus closed. at twelve month follow up the patient did not have a recurrent cough or hemoptysis while tolerating a full diet. introduction: roux en-y gastric bypass (rygb) is one of the initial and most studied weight reduction procedures and remains the gold standard for comparison in bariatric surgery clinical outcomes. although rygb is an effective procedure for weight loss, it has been less popular over last several years because of increased morbidity compared to the more utilized vertical sleeve gastrectomy (vsg). early complications of rygb include bleeding, perforation, or leakage. late complications include internal hernias, small bowel obstruction, anastomotic stenosis, marginal ulcers, and gastrogastric fistulas. case report: a -year old female with a past medical history of morbid obesity, diabetes mellitus type , hypertension, gerd, peptic ulcer disease, cholelithiasis, liver dysfunction with ascites, asthma, and a past surgical history of rygb ( years ago) presented to our institution with acute on chronic abdominal pain associated with nausea, vomiting, dysphagia, inability to eat and maintain hydration, and an additional weight loss of about lbs. over the last year. in addition, the patient was a chronic opioid and nsaid user, had an extensive smoking history, and had not followed with her surgeon for years. at the time of presentation, the patient weighed lbs (bmi: . ), had normal vital signs, and appeared cachectic. an upper gastrointestinal study followed by an upper endoscopic examination demonstrated complete obliteration of the gastrojejunal anastomosis and revealed a -cm long gastrogastric fistula originating from the distal end of the gastric pouch to the lesser curvature of the excluded stomach. after conservative measures were initiated to hydrate and metabolically stabilize the patient, the decision was made to proceed with diagnostic laparoscopy and surgical placement of a gastrostomy tube to the gastric remnant. the patient was discharged after tolerating a full liquid diet and gastrostomy tube feedings, for plan of future revision of gastrojejunostomy when optimal nutritional status is achieved. conclusions: late complications of rygb occur at a rate of - %. major risk factors for anastomotic complications include non-compliance, smoking, and opiate and nsaid abuse. though abdominal pain, anastomotic stenosis, marginal ulcers, and fistulas are relatively common late complications of rygb, complete obliteration of the gastrojejunal anastomosis has not been well described in the literature. this case demonstrates the importance of long term follow up post rygb for early diagnosis of late complications and brings attention to this rare, but possible sequele that can arise in patients after rygb. contrast radiograms and upper endoscopic photographs will be presented. introduction: retroperitoneal sarcoma represents approximately - % of all sarcomas and less than . % of all neoplasia. radiotherapy and chemotherapy still do not represent valid therapeutic alternatives; therefore complete surgical resection is the only potential curative treatment modality for retroperitoneal sarcomas. the ability of complete resection of a retroperitoneal sarcoma with tumor grading remains the most important predictor of local recurrence and disease-specific survival. in a patient with a large fibrosarcoma and associated hypoglycemia, assays for insulin-like activity (ila) were found to be high in the extract of tumor tissue, while insulin was not detected in significant concentration neither in the same extract nor in his serum. laparoscopic surgery represents an alternative technique for radical resection of such tumors as a minimally invasive rather than traditional surgery. only few cases were reported in the literature. introduction: roux-en-y gastric bypass (rygb) is a frequently performed bariatric procedure, of which internal hernia (ih) is a known complication. we discuss a rare finding of occult gastric remnant perforation as a result of an obstructed ih in a post bypass patient. methods: we present a case report of a single bariatric surgeon's experience at a tertiary care hospital. literature review of pubmed confirms the unique presentation and operative findings in our patient, as few similar cases have been published. a -year-old male s/p rygb years ago presented to the ed with right upper quadrant pain, nausea, vomiting, and a leukocytosis of , . bmi was . ; weight was lbs. workup included an abdominal ultrasound showing gallbladder distention without signs of cholecystitis. liver function tests were normal. further imaging included a ct scan, remarkable for a paraesophageal hernia (peh) containing the gastric pouch, and an elevated left hemidiaphragm. the scan showed no evidence of ih or bowel obstruction. an upper gi series was additionally obtained, which was also negative for small bowel obstruction. due to unclear etiology for this patient's symptoms or source of leukocytosis, diagnostic laparoscopy was planned. results: intraoperative findings were significant for ih containing dilated small bowel with twisted and incarcerated omentum through the jejunojenunostomy site, as well as a distended gallbladder without acute inflammation. ih was reduced and closed without bowel resection. cholecystectomy was completed. subsequent inspection of the diaphragmatic hiatus revealed uncomplicated herniation of the gastric pouch. in attempts to dissect the left diaphragmatic crus, a large pocket of purulent material was encountered below the left diaphragm in the region of the remnant stomach fundus. methylene blue test and intraoperative endoscopy did not demonstrate any connection to gastric pouch. the purulence was attributed to an occult remnant stomach perforation related to distal obstructed ih. a drain was left in the abscess and the peh was not surgically addressed. patient was discharged on postoperative day . he has not suffered any further complications or recurrent complaints. conclusion: gastric perforation following rygb is an uncommon complication resulting from ih. this diagnosis was missed by preoperative imaging and was only found after thorough laparoscopic investigation. surgeons should maintain a high clinical suspicion of ih in post rygb patients with otherwise unexplained abdominal symptoms, fever, and leukocytosis, even in the absence of confirmatory diagnostic testing. threshold for operative exploration in this clinical setting should remain low. alejandro garza, md, robert alleyn, md, jose almeda, md, ricardo martinez, md; utrgv obesity is an epidemic condition worldwide carrying significant morbidity and mortality. surgical therapy is the only proven effective method to sustain weight loss. among the different surgical procedures gastric bypass is the most effective. during this surgery, most of the stomach is excluded from the upper gastrointestinal tract which makes future evaluation of the same very challenging. this could potentially lead to delay in diagnosis of any pathology in the bypass stomach. gastric cancer is the th most common cause of cancer and cause of cancer death in the united states. we present a case report of a patient who underwent a roux-en-y gastric bypass and went on to developed adenocarcinoma in the gastric remnant year after her surgery. she underwent an exploratory laparotomy, extended antrectomy, subtotal gastrectomy including the gastro-colic ligament, and incidental appendectomy. pathology showed grade undifferentiated adenocarcinoma that penetrated the visceral peritoneum with clear margins. there was angiolymphatic invasion and perineural invasion along with metastatic carcinoma in out of lymph nodes. introduction: polyarteritis nodosa (pan) is a systemic transmural inflammatory vasculitis that affects medium-sized arteries. inflammation of the vessel wall and intimal proliferation creates luminal narrowing which can lead to stenosis and insufficiency. the same inflammatory process causes disruption of the elastic lamina leading to aneurysm formation and possible spontaneous rupture with life-threatening bleeding. multifocal segments of stenosis and aneurysm formation are characteristically identified as a "rosary sign" or "beads on a string". unlike other vasculitides, pan does not involve small arteries or veins, and is not associated with anti-neutrophil cytoplasmic antibodies. we present the case of a year old female with a significant intra-abdominal bleed that was explored and repaired primarily. she was subsequently found on angiogram and postmortem pathology to have findings consistent with pan. case presentation: year old female who presented to the emergency department with abdominal pain followed by hemorrhagic shock and found to have a ruptured left hepatic artery aneurysm during exploratory laparotomy. this aneurysm was suture ligated with a successful outcome. a mesenteric arteriogram was performed the following day and demonstrated lesions consistent with pan including aneurysms of the left gastric branches, right and left hepatic arteries, and beaded appearance of the iliac artery. however, days after hospital discharge she developed massive pulmonary embolism from which she did not recover. postmortem examination confirmed rupture of the left hepatic artery aneurysm in addition to gross anatomical and histological findings consistent with pan. discussion: polyarteritis nodosa is a systemic inflammatory vasculitis that causes intimal proliferation and elastic lamina disruption. this multifocal disruption of the vessel results in aneurysm formation alternating with stenosis creating a characteristic "rosary sign" on imaging. spontaneous rupture of these aneurysms is rare and almost always fatal due to life-threatening hemorrhage. with acutely ruptured aneurysms, prompt diagnosis, aggressive resuscitation, and hemostasis through transarterial embolization or surgery is paramount for patient survival. while acute rupture of an aneurysm as the result of pan is exceedingly rare, it must be considered as a differential diagnosis in the setting of acute abdominal pain and hemodynamic instability. in a patient known to have a medical history of pan and aneurysm formation, routine monitoring and disease progression should be followed. introduction: , surgeries are done annually in the us for small bowel obstruction, which is most commonly caused by intraabdominal adhesions, malignancy, and hernias. . to . % of small bowel obstructions are due to paraduodenal hernias. paraduodenal hernias carry a % lifetime risk of incarceration with a mortality of to %. case report: the patient is a year old male who presented with severe upper abdominal pain for one day. he was passing flatus and had had a bowel movement the previous day. on examination, the patient was tender over the upper abdomen. computed tomography (ct) scan with iv contrast showed a mesenteric swirl sign. the decision was made to perform diagnostic laparoscopy with possible small bowel resection. intraoperatively, a mesenteric defect was noted posterior and to the right of the duodenum, through which bowel was herniating. the herniated bowel and its mesentery were edematous. the defect was sutured closed, taking seromuscular and mesenteric bites through the stomach, jejunum, and mesentery. the patient had an uneventful recovery postoperatively and was discharged on postoperative day . he returned on postoperative day with periumbilical pain which resolved with conservative management. he was followed up weeks postoperatively and was doing well. discussion: paraduodenal hernias are the most common internal hernias. they are seen more often in males. they are caused by failure of the counterclockwise rotation of the prearterial segment of the embryonic midgut in weeks to of embryonic development. paraduodenal hernias usually present with chronic intermittent abdominal pain, weight loss, nausea, and vomiting. they may present acutely with symptoms of bowel obstruction. peritoneal signs are often not appreciated due to retroperitoneal position of the hernia. ct scan of the abdomen often shows clustering of bowel loops, which cannot be displaced on repositioning the patient. if imaging is equivocal, diagnostic laparoscopy may be undertaken. surgical correction consists of reducing the bowel, resecting nonviable segments, and either closing the defect or opening the sac laterally into the general peritoneal cavity. in summary, paraduodenal hernias are a rare cause of bowel obstruction and as such present a challenge in diagnosis and early intervention. diverticulosis of the appendix is a rare disease found in . - . % of appendectomies, first described in . the clinical presentation may be acute inflammatory with or without appendicitis or it may be an incidental finding in an uninflamed appendix. the congenital type is rare and it has all the bowel wall layers. it most frequently represents as pseudo diverticulum which lacks the muscularis layer. the pathogenesis of appendiceal diverticula is not completely elucidated. its symptoms are similar to and often misdiagnosed for that early acute or chronic appendicitis. while appendectomy is curative for both entities, it is important to distinguish diverticulum of the appendix from appendicitis as it is four times more likely to perforate and may be a sign of an underlying neoplasm. we reported a very rare giant pseudo diverticulum of the appendix in a -year-old male presenting with chronic abdominal discomfort for months. abdominal x-ray showed abnormal gaseous finding. physical exam was significant for a soft rubbery mass in the periumbilical region. blood work revealed slight elevation of c-reactive protein. preoperative ct and mri showed a -centimeter-large cavity composed of thin wall, located at the tip of the appendix with peri appendicular fat stranding. in the concern of pending obstructive symptom and chronic abdominal pain, we decided to perform the resection laparoscopic. the soft mass arose from the tip of the appendix. there were dense adhesions between the appendix, mesentery, and sigmoid colon. after adhesiohedlysis, laparoscopic appendectomy was performed with endogia. the specimen was extracted through a small incision without spillage. hospital course was uneventful and the patient was discharged on post-operative day . the pathological finding was consistent with a pseudo diverticulum of the appendix which lacked muscularis layer and the inner wall of the cavity was lined with a scattered cubital epithelial layer in the continuity with the appendiceal mucosal membrane. here we report a successful laparoscopic resection of an extremely rare giant chronic pseudo diverticulum of the appendix. yvette farran, ms, jorge a miranda, ms, benjamin clapp, md, elizabeth de la rosa, md; texas tech university health sciences center introduction: sigmoid colon intussusception is rarely encountered and given its vague symptomatology diagnosis and management can be difficult. the treatment of an intussusception in adults is different than in children. lipomas as the causative etiology for intussusception are encountered up to . % of the times and up to %- % of the patients require surgical resection for treatment. methods: this is a case report about a year old male that presented with two weeks of worsening abdominal pain and distention. physical exam was only pertinent for abdominal pain on light palpation, guarding and moderate distress. ct scan of abdomen and pelvis demonstrated a lipomatous mass causing complete obstruction of the sigmoid colon with intussusception. this was managed with laparoscopic sigmoidectomy. the patient had an uncomplicated post-operative period and was discharged on post-operative day . pathology of the lipomatous mass confirmed a benign lipoma. discussion: intussusception is rarely encountered in clinical practice in adults and constitutes % of all cases. lipoma induced sigmoid intussusception with complete obstruction is rare. symptoms can be non-specific as in this case. this case report highlights the importance of timely diagnosis and treatment of an intussusception in adult patients. ct scan is the gold standard for diagnosis and often shows a "target sign". other imaging techniques like ultrasound have shown adequate results but remain less effective than ct scan. the treatment in adults is not a reduction by enema like in pediatrics but rather resection of the lead point. this can be appropriately done with a laparoscopic technique in most cases. conclusion: colonic intussusception is rare. surgery is the only treatment for an intussusception in adults since the lead point needs to be removed, and can be attempted safely with a laparoscopic approach. surg endosc ( ) :s -s joshua smith, md, kern brittany, md, amie hop, md, amy banks-venegoni, md; spectrum health case report: year-old female with no significant past medical history presents with a -year history of nocturnal cough that had worsened over the past months and had associated regurgitation. she underwent esophagogastroduodenoscopy (egd) that showed a tortuous esophagus and tight lower esophageal sphincter that required dilation. she received an upper gastrointestinal (ugi) contrast study that showed a dilated, tortuous esophagus with 'bird's beak' tapering, consistent with achalasia, as well as a large epiphrenic diverticulum measuring cm. esophageal manometry confirmed "pan-esophageal pressurization" consistent with type ii achalasia. given her symptoms in the presence of these findings, she elected to proceed with surgery. she underwent laparoscopic, trans-hiatal epiphrenic diverticulectomy, heller myotomy and dorr fundoplication. extensive dissection allowed for approximately cm of retraction down from the chest and we were able to come across it with a single blue load of a mm linear cutting stapler. post-operatively, she tolerated the procedure well with immediate improvement in her symptoms. her ugi on post-operative day showed no evidence of leak, she tolerated a soft diet and was discharged home. she was seen at -week and -year follow-up appointments with complete resolution of symptoms. discussion: epiphrenic diverticula in the presence of achalasia has an occurrence rate of %. large diverticula ([ cm), are even more rare with only a handful of case reports in the literature. historically, thoracotomy or, more recently, thoracoscopic approaches are required for resection. however, thoracic approaches are associated with a % increase in morbidity, namely due to staple line leak and the resulting pulmonary complications. only a single case report exists on our review of the literature that demonstrates successful trans-hiatal laparoscopic resection without post-operative complications of a diverticulum of this size. the shortest documented length of hospital stay postoperatively for similar cases is days, while the average is - days or longer for those with complications. our patient was able to go home on post-operative day after a normal ugi and was tolerating a soft diet. not only does this case show that a large epiphrenic diverticulm can be successfully resected via the trans-abdominal laparoscopic approach, this case makes the argument that patients undergoing any minimally-invasive epiphrenic diverticulectomy and myotomy, with or without fundoplication, may be successfully managed with early post-operative contrast studies and dietary advancement, thus decreasing their length of hospitalization and overall cost of treatment. kazuma sato, shunji kinuta, koichi takiguchi, naoyuki hanari, naoki koshiishi; takeda general hospital background: situs inversus totalis (sit) is a rare congenital condition in which the abdominal and thoracic organs are located opposite to their normal positions. few cases of laparoscopic surgery for gastric cancer with sit have been reported. we report a case of laparoscopic distal gastrectomy with d lymph node dissection performed for gastric cancer in a patient with sit. case description: an -year-old woman was admitted to our hospital for treatment of gastric cancer that was diagnosed by esophagogastroduodenoscopy (egd) at a local clinic after she experienced anemia and nausea. egd identified an irregularly shaped gastric ulcer located at the anterior side of the lesser curvature of the antrum. a biopsy revealed a moderately differentiated adenocarcinoma. she was then diagnosed with sit by chest radiography and abdominal computed tomography (ct). the abdominal ct showed that all organs were inversely positioned and that the wall of the antrum had thickened; it also showed the lymph nodes in the lesser curvature of the stomach, without distant metastasis or an abnormal course of vascularity. the patient was clinically diagnosed with t n m stage iiia gastric cancer according to the japanese classification of gastric carcinoma. a laparoscopic distal gastrectomy with d lymph node dissection in accordance with the japanese gastric cancer treatment guidelines as well as a roux-en-y anastomosis due to an esophageal hiatal hernia were performed. the surgery was safely and successfully performed, although it required more time than usual because the inverted anatomic structures were repeatedly examined during the surgery. the postoperative course was positive, and the patient was discharged on postoperative day without any complications. the final stage of this case was pt bn m stage ia. currently, the patient is doing well without recurrent gastric cancer. conclusion: gastric cancer with sit is an extremely rare occurrence. we experienced a case of laparoscopic distal gastrectomy with d lymph node dissection performed for gastric cancer in a patient with sit. we simulated the operation for sit by viewing left-right reversed ordinary surgical videos. the abdominal ct angiography with a three-dimensional reconstruction helped reveal any variation and confirmed the structures and locations of vessels before the surgery. the operation could safely be performed following the standardized surgical technique by reversing the surgeon standing position and trocar position. sternum or chest wall resection is performed for a variety of conditions such as primary and secondary tumors of the chest wall or the sternum. sternum reconstruction has been a complex problem in the past due to intraoperative technical difficulties, surgical complications, and respiratory failure caused by the chest wall instability and paradoxical respiratory movements. advances in the fields of surgery and anesthesia result in more aggressive resections. nowadays neither the size nor the position of the chest wall defect limits surgical management, because resection and reconstruction are performed in a single operation that provides immediate chest wall stability. chest wall resection involves resection of the ribs, sternum, costal cartilages and the accompanying soft tissues and the reconstruction strategy depends on the site and extent of the resected chest wall defect. here i'll present, the youngest ever case reported, years old girl with rhabdomyosarcoma involving the sternum. i will present the management challenges and the reconstruction options. introduction: neuroendrocrine malignancies constitute . % of all cancers. the gastrointestinal tract is the commonest site, followed by the lung. the last decade has seen a steady increase in their incidence. this is a case series of twenty five such tumours and their clinicopathological characteristics. materials and methods: twenty five patients with neuroendocrine tumours of the gastrointestinal tract were studied with reference to their demographic and clinicopathological characteristics. apart from routine pathological examination, these tumours were also checked for e cadherin expression as an independent marker of aggressive disease. results: the age of our patients ranged from to years. we had female and male patients, contradicting a female preponderance in literature. the vast majority of the tumours we encountered were from the stomach and duodenum, with and patients, respectively. two tumours were at the gastroduodenal junction, two from the appendix, small intestine and pancreas, each, and one each from the rectum and gall bladder. this is in contrast to literature that shows that neuroendocrine tumours of the git most commonly arise from the appendix and small bowel, followed by the rectum, stomach and duodenum. two of these tumours were functional. the diagnosis was confirmed by immunohistochemistry staining for chromogranin a and synaptophysin. grading was done using who criteria that takes into account the mitotic count, ki index and necrosis. of our cases were grade i. further, immunohistochemistry for e cadherin showed that absence of expression correlated with more aggressive clinical behavior. out of twenty five patients were operable at presentation and standard resections depending on the organ of origin with adjuvant therapies were given as required. could only be given palliative care. the functional tumours were treated with radiolabelled somatostatin analogues following uptake studies. conclusion: as neuroendocrine tumours are relatively rare, information about them is not as abundant as with other malignancies. absence of e cadherin expression is associated with more aggressive disease. more studies are required that document the pathological characteristics and clinical behavior in order to offer well rounded treatment protocols that treat not only the primary, but also the generalized effects of the secretions produced by them. targeted chemotherapy is gaining prominence, but more specific drugs directed at the plethora of receptors these tumours express, could potentially revolutionize treatment. ( ) . unfortunately there are no publications from denmark. we would like to present first to our knowledge reported case of double gallbladder in denmark. double gallbladder is a rare anomaly with a prevalence of : in autopsy studies, described first by boyden in ( ) . there are several classifications of double gallbladder that are based on relation between gallbladder, cystic duct and common bile duct ( , ) . non-specific symptoms and inadequate imaging are possible causes of lack of awareness of the condition. removal of all gallbladders, preferably laparoscopic with special attention to the biliary anatomy, is recommended ( ). method: case report with review of the literature. a -year-old female patient of polish origin was hospitalized due to upper right quadrant pain. on admission clinical manifestations and paraclinical abnormalities of pancreatitis were present. ultrasound scanning of the abdomen showed bile stones, ultrasonic manifestations of acute cholecystitis and normal intra-and extrahepatic bile ducts. because of elevated liver enzymes mrcp was performed and showed double gallbladder, double cystic duct and signs of pancreas anulare. scheduled ercp confirmed bile stones in cbd, double gallbladder with double cystic duct, h-type according to harlaftis classification ( ) . because of minor retroperitoneal perforation second ercp was needed for removal of all stones. the patient was then scheduled to laparoscopic cholecystectomy with perioperativ cholangiography. conclusion: anatomical variations of the gallbladder such as double gallbladder are rare and often remain unnoticed. they are most often identified because of clinical manifestations symptoms, diverse imaging studies, during surgery or autopsy. as most of them are not expected, they can contribute to complications during surgery. careful preoperative imaging is very important to prevent accidental bile duct injury. looking at the number of case reports, double gallbladder seems to be slightly more common than expected. the interesting question is whether a gallbladder discovered during an unrelated radiological investigation in a patient that previously underwent a cholecystectomy can represent undetected case of double gallbladder. we would like to present a review of the literature as well as images from mrcp, ercp and laparoscopy. michael jaroncyzk, md, courtney e collins, md, ms, vladimir p daoud, md, ms, ibrahim daoud, md; st. francis hospital; hartford ct introduction: several decades ago, surgical training was saturated with procedures to treated peptic ulcer disease. since the introduction of histamine- blockers and proton pump inhibitors, these procedures have dwindled significantly. however, there are still instances where patients require surgical intervention for peptic ulcer disease. perforation is one of the indications for surgery. the surgical options to treat a perforated peptic ulcer are numerous. one of the most common options is a graham patch. we are presenting a case of a patient with a perforated ulcer that did not have available omentum for the repair. methods and procedures: recently, a -year-old female with a past history of an open total abdominal hysterectomy and bilateral salpingo-oophorectomy presented as an outpatient with chronic lower abdominal pain. she underwent a work-up and imaging that did not reveal any pathology. at diagnostic laparoscopy, she had diffuse lower abdominal adhesions, which were lysed. she was discharged on the same day, but presented to the emergency department two days later with severe abdominal pain and fevers. the work-up revealed tachycardia, diffuse abdominal tenderness with peritoneal signs, leukocytosis and a large amount of free air on imaging. she was emergently brought to the operating room for a diagnostic laparoscopy. during laparoscopic exploration, the lower abdominal cavity appeared normal for a recent lysis of adhesions. attention was turned to the upper cavity to find the pathology. bile-stained free fluid and peri-gastric exudates were identified, but no perforation was visualized. intra-operative endoscopy revealed the site of perforation in the antrum on the lesser curvature. a biopsy was performed and the decision was made to perform a graham patch. however, the omentum was already densely involved with the lower abdominal cavity from the enterolysis. due to the close proximity of the falciform ligament, it was mobilized laparoscopically and the pedicle was used as a graham patch. the patient recovered without any additional issues. the biopsy was reported as a chronic gastric ulcer. conclusion: surgical history has given us many options to treat peptic ulcer disease that are not nearly as common as they were decades ago. perforated ulcers can be managed laparoscopically and graham patches are a common choice for repair. however, the lack of the omentum for a proper pedicle flap can pose a problem in some patients. we have shown in this patient that a falciform pedicle flap can be successfully used as a substitution. laparoscopic management of boerhaave's syndrome after a late presentation: a case report and literature review tahir yunus, hager aref, obadah alhallaq; imc background: boerhaave's syndrome involves an abrupt elevation in the intraluminal pressure of the oesophagus, causing a transmural perforation. it is associated with high morbidity and mortality. having a nonspecific presentation may contribute to a delay in diagnosis and results in poor outcomes. treatment is challenging, yet early surgical intervention is the most important prognostic factor. case presentation: we present a case of a thirty-two-year-old male with a long medical history of dysphagia due to benign oesophagal stricture. he presented with acute onset of epigastric pain after severe emesis. based on computed tomography scan, he was diagnosed with boerhaave's syndrome. presenting with signs of shock, mandated immediate surgical exploration. for which he was taken for laparoscopic primary repair with uneventful postoperative recovery. the golden period of the first hours of insult still applies for cases of oesophagal perforation. the rarity of these cases makes a comparison between the various treatment methods difficult. our data support that the use of laparoscopic operative intervention with primary repair as the mainstay of treatment for the management of oesophageal perforation. lipomas of the gastrointestinal tract are rare benign soft tissue tumors that are often discovered incidentally. these lesions are often asymptomatic, but have occasionally been reported to have clinical significance as will be described in this case report. a year old male initially presented to his primary care physician's office with a three week history of vague intermittent abdominal pain. his pain was located in the mid epigastrium and was associated with mild nausea. past medical history was significant for hyperlipidemia and a right-sided goiter, and he denied any previous surgeries. outpatient work up revealed a microcytic anemia, intermittent melena and hemoccult positive stools. the patient was referred to hematology and gastroenterology. endoscopies revealed gastritis, and small internal and external hemorrhoids. he underwent an outpatient ct scan which demonstrated a . . cm mass within the lumen of the jejunum causing long segment non-obstucting intussusception. subsequently, the patient was referred to surgery and underwent a diagnostic laparoscopy. at the time of surgery, an approximately twelve centimeter segment of proximal jejunum was identified intussuscepting into a distal limb. this segment was attempted to be reduced laparoscopically, however there was significant mesentery within in the intussusceptum and the segment could not be safely reduced. therefore, the section of bowel was delivered through a small periumbilical incision. the intussusceptum was then able to be manually reduced from the intussusception. at this point a large mass was palpated inside the lumen of the jejunum. a small bowel side to side, functional end to end resection and anastomosis was preformed. the bowel was returned to the abdomen and the abdomen was re-insufflated. the remainder of the small bowel was run and no additional lesions were identified. final pathology revealed a . . . cm submucosal partially obstructing lipoma with ulceration at the tip. the patient recovered uneventfully and was discharged home on the second post operative day. this case report describes a submucosal jejunal lipoma that was acting as a lead point for intermittent non-obstructing small bowel intussusception, while simultaneously causing a microcytic anemia due to ulceration at the tip of the lipoma. laparoscopic assisted reduction and small bowel resection is a safe and effective treatment for gastrointestinal tract lipomas that are unable to removed endoscopically. percutaneous endoscopic gastrostomy (peg) is an alternative to laparotomy for open gastrostomy tube placement to provide enteral nutrition for those who are unable to pass nutrition orally. despite being less invasive, the procedure is not without its complications, one of which includes the formation of a gastrocolocutaneous fistula. the case describes a year old female who presented with a peg placed months prior with reports of leakage of tube feeds from the gastrostomy site. as there was concern for possible ileus or obstruction, an upper gi series was completed which seemed to indicate dislodgement of the g-tube. the g-tube was replaced and a follow-up gastrograffin study was repeated which now indicated that the g-tube was within the lumen of the colon. soon thereafter fecal matter was noted to be draining around the g-tube site; however, patient was without clinical signs of peritonitis. the patient was managed non-surgically as she was a poor surgical candidate with multiple prohibitive co-morbidities. the g-tube was removed bedside by cutting it flush at the skin level with the anticipation that the remainder of the tube would be excreted with bowel movements. the decision was then made to attempt closure of the gastric fistula endoscopically which was accomplished with hemoclips. a follow up upper gi study hours later showed no extravasation of contrast through the gastric fistula. the colocutaneous fistula had self-resolved over the next couple days as well. placement of the peg tube through the transverse colon can present with varying ill effects including diarrhea, pneumoperitoneum, peritonitis, gram negative pulmonary infection or feculent vomiting with the formation of a gastrocutaneous fistula. treatment historically for a gastrocolocutaneous fistula has been exploration and excision of the fistula tract with resection of the involved colonic segment. however, there currently is no gold standard for the management of, and really ranges from conservative management to surgical and is dependent on the presenting symptoms. if the peg becomes dislodged with resultant spillage from the colon with resultant peritonitis, surgical exploration is needed with removal of the g-tube and repair of the stomach and colon. on the other hand, non-surgical management has been suggested in management of a well-established fistula. fistula closure may be spontaneous; however, can be inhibited due to delayed gastric emptying or leakage of gastric secretions through the fistula. endoscopic clipping of the fistula tract employing the hemoclips is a treatment option. median arcuate ligament syndrome (mals) is a rare etiology of abdominal pain caused by narrowing of the celiac artery at its origin by the median arcuate ligament with relative hypoperfusion downstream. patients suffer from post-prandial abdominal pain, abdominal pain associated with exercise, nausea, and unintentional weight loss. diagnosis is historically made by demonstrating elevated celiac artery velocities and respiratory variation on dynamic vascular studies. standard of care for mals patients is laparoscopic celiac artery dissection with release of the median arcuate ligament. at our institution, we have encountered fourteen patients (eleven female, three male) diagnosed by elevated peak velocity in the celiac artery by duplex ultrasound in conjunction with ct angiogram, mr angiogram, arteriogram, or multiple modalities. all but one patient had multiple diagnostic imaging modalities, with the most common being ct angiogram; eight patients had invasive imaging. the mean age at presentation was . years in men and . years in women. on average, male patients presented with a longer duration of symptoms, . years (range - years), as compared to women, . years (range - years). symptoms were fairly consistent between genders and included nausea, emesis, abnormal bowel habits, early satiety, post-prandial pain, and weight loss. all male patients reported at least two symptoms, most commonly nausea and post-prandial pain. in female patients, % reported having three or more symptoms. notably, post-prandial pain was universal among men and women, while weight loss was exclusive to female patients as reported by %. pre-operative peak velocities were recorded in all but one patient, with mean values more elevated in female patients as opposed to male patients, cm/s versus cm/s. post-operative duplexes were obtained in seven patients; pooled data show a mean change of negative cm/s for an average of cm/s after decompression. in all cases, the celiac artery trifurcation was visualized and noted to have a distinct change in artery caliber after division of the ligament. in total, % of patients reported significant improvement with return to normal diet and healthy weight gain post-operatively. of the three without complete resolution, two were diagnosed with motility disorders and one was lost to follow-up. our experience demonstrates that laparoscopic release of the median arcuate ligament in patients with significant flow limitation of the celiac artery on dynamic and anatomic imaging can be a successful treatment option for patients with recalcitrant pain and gastrointestinal dysfunction with no alternative diagnosis. matthew a goldstein, ma, kirill zakharov, do, sharique nazir, md; nyu langone brooklyn adhesions are fibrotic bands that form between and among abdominal organs. the most common cause of abdominal adhesions is previous surgery in the area as well as radiation, infection and frequently occurring with unknown etiology. these bands occur among abdominal organs, commonly the small bowel, and can lead to obstruction or remain asymptomatic, akin to the patient discussed here. congenital abdominal adhesions are rare and have received little attention in research and field of study. the patient described in this case is a -year-old female with a past medical history of morbid obesity, bmi of , hypertension and no past abdominal surgical procedures. the patient presented in august for bariatric surgical consultation and was ultimately taken for an attempted laparoscopic sleeve gastrectomy. upon entering the abdomen, significant adhesions were encountered and an additional attending was called to assist in identifying the stomach. the splenic flexure was found to be plastered to the diaphragm and the descending and transverse colon were adhered to the anterior surface of the stomach. additionally, small bowel adhesions encased the area between the right and left hepatic lobes as well as the caudate lobe. after extensive enterolysis, the pylorus remained the only identifiable portion of the stomach. the patient also demonstrated significant hepatomegaly and a wedge resection was performed. the amount of adhesion and matting of the small and large bowel obscured the view of the stomach and the procedure was deemed too dangerous and terminated. this case represents the uncommon scenario in which an abdomen with no prior surgical history presents with extensive, obscuring adhesions. one such recent study describes the influence of cytokines and proinflammatory states as contributors to obstruction and malrotation in children, but this patient demonstrated no significant history. further investigation is needed to determine potential etiologies of symptomatic and non-symptomatic congenital adhesions among bariatric patients who fail conservative treatment. today the patient is doing well and the surgical team will attempt to complete the procedure in the coming months. laparoscopic spenulectomy: an interesting case report riva das, md , daniel a ringold, md , thai q vu, md ; orlando health, abington jefferson health introduction: spenules, or accessory spleens, are a rare disease entity. most often, they are asymptomatic, and found incidentally during radiographic workup for an unrelated problem. torsion can cause a splenule to not only become symptomatic, but also confound the results of usual diagnostic studies. case description: a -year-old female patient with history of uncomplicated hypertension, hyperlipidemia, hysterectomy, cholecystectomy, spinal surgery, and partial left nephrectomy, presented to the hospital with a two-week history of intermittent left upper quadrant abdominal pain. she denied any similar episodes in the past, or any associated symptoms. further investigation with a ct scan of the abdomen and pelvis showed an acute inflammatory process in the left upper quadrant in same location as some colonic diverticulosis, as well as a . cm soft tissue mass. this indeterminate soft tissue mass was described as having decreased attenuation compared with the spleen. differential diagnosis for this mass included malignancy, an atypical splenule, or an infectious/inflammatory mass. an mri was recommended for further evaluation, but did not reveal any additional significant findings. nuclear medicine liver/spleen scintigraphy was performed, which showed no focal activity associated with the indeterminate left upper quadrant mass, therefore making it unlikely to reflect a splenule, and making malignancy the diagnosis of exclusion. following a period of observation with analgesia, intravenous antibiotics, and bowel rest, her abdominal pain did not resolve, and the decision was made to proceed with operative exploration. diagnostic laparoscopy revealed an approximately cm spherical mass in the left upper quadrant located just below the inferior aspect of the spleen. the superior aspect of the mass gave rise to a vascular pedicle, which upon tracing, seemed to originate from the splenic hilum. this pedicle was easily ligated, and the mass removed. pathology revealed an extensive infarcted hemorrhagic nodule with organizing thrombus and attached thrombosed artery, consistent with an infarcted splenule due to torsion along its own axis. the patient had an uncomplicated postoperative course. discussion: this case report demonstrates the unusual presentation and workup of a patient that was ultimately diagnosed with an infarcted splenule, despite imaging findings that did not correlate, and may even have confused her diagnosis. scintigraphy, which is normally the gold standard for diagnosing and localizing accessory splenic tissue, was in this case unrevealing, due to inability of the tracer to traverse the torsed vascular pedicle. operative exploration was both diagnostic and therapeutic. patients which was treated with antibiotics suggested by culture and sensitivity report and local wound care. one patient died due to sepsis at presentation. conclusion: chikungunya virus was found circulating in rodents in pakistan as early as . duodenal ulcer perforation which is a common surgical emergency in our part of the world usually presents with pinpoint perforation in ant wall of first part of duodenum unlike in already diagnosed cases of chikungunya disease where a slit like duodenal perforation is noted in the anterior wall of first part of duodenum. literature and consensus relate this perforation with the excessive use of nsaids due to usual presentation of arthritis in chikungunya disease but the unusual presentation is still to be answered. introduction: bouveret's syndrome is a rare form of gallstone ileus in which an impaction of a gallstone in the duodenum results in a gastric outlet obstruction. gallstone ileus accounts for approximately - % of all cases of small bowel obstruction. the terminal ileum is the most common location for a calculus to cause obstruction followed by the proximal ileum, jejunum and duodenum/stomach respectively. open and laparoscopic surgery has previously been the mainstay of treatment for bouveret's syndrome, however with the advent of new endoscopic techniques and instruments there has been increasing success in endoscopic management. this case report looks at a patient with a gastric outlet obstruction from a gallstone, and discusses the current literature regarding diagnosis and management. case: year old male presented with several day history of epigastric abdominal pain and multiple episodes of nonbloody, nonbilious emesis. he had previously been diagnosed with cholelithiasis, however had refused surgery at that time. on admission the patient was found to have a leukocytosis of . . an ultrasound was performed in which the images were limited due to pneumobilia. a subsequent ct scan revealed pneumobilia, and a large cm gallstone impacted in the first portion of the duodenum causing a gastric outlet obstruction. the patient underwent failed endoscopic attempts at removal and ultimately required a laparotomy, enerotomy with stone extraction. discussion: bouveret's syndrome is a rare variant of gallstone ileus. with newer endoscopic techniques and electrohydraulic lithotripsy, there has been increasing success with endoscopic retrieval of the impacted gallstones. there is some controversy in regards to the need for definitive operative management. stone extraction, without cholecystectomy and fistula repair, has been shown to have less postoperative complications as well as lower mortality rates compared to when a cholecystectomy and fistula repair has been performed. total mesorectal excision (tme) with neoadjuvant chemoradiotherapy (nacrt) is standard treatment for rectal cancer, which has resulted in a decrease in local recurrence. however, nacrt has shown no significant overall survival and some adverse effects mainly caused by radiation therapy. recently, the usefulness of neoadjuvant chemotherapy (nac) has been reported. we retrospectively assessed the efficacy and safety of the neoadjuvant mfolfoxiri compared with nacrt followed by laparoscopic surgery. a total of patients undergoing laparoscopic surgery for lower rectal cancer (clinical stage: ii or iii) from july to february in our department were retrospectively evaluated. patients underwent nac, and patients underwent nacrt. the following data were collected: pathological complete response (pcr), histological grade, down staging, radial margin (rm) and postoperative complications. histological grade was defined as follows: tumor cell necrosis or degeneration is present in less than one third of the tumor area (grade a), between one and two thirds (grade b), more than two thirds but viable cells remain (grade ), and complete response (grade ). these two groups were demographically comparable. down staging did not differ between the two groups. histological grade (?grade b) and pcr were significantly higher in the nacrt than in the nac group (p. ). rm had no significant difference in both groups, but tended to be able to secure negative rm in the nac group ( % vs. . %, p= . aims: increasing evidence suggest that cme may improve overall and disease free survival in colon cancer. our aims were to investigate the safety and efficacy of single incision laparoscopic cme colectomy (silcc) compared to multiport cme laparoscopic colectomy (mpclc) providing the first meta-analytical evidence. methods: pubmed, scopus and cochrane library were searched. studies comparing the silcc to mpclc in adults with colon adenocarcinoma were included. the studies were critically appraised using the newcastle ottawa scale. statistical heterogeneity was assessed with x and i . the symmetry of funnel plots was examined for publication bias. results: one randomized and four case control trials were included ( silcc vs sl introduction: obesity has been associated with increased morbidity following total proctocolectomies with ilealpouch anal anastomosis (tpc-ipaa). however, the incremental added risk of increasing obesity class is not known. the aim of this study was to evaluate the additional morbidity of increasing obesity class for tpc-ipaa. methods: after ethics board approval, the acs-nsqip database ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) was accessed to identify patients who underwent elective tpc-ipaa. body mass index (bmi, kg/m ) was classified as normal ( . - . ) , overweight ( . - . ), obesity class-i ( - . ), obesity class-ii ( - . ) and obesity class-iii (≥ ). primary outcomes were overall surgical site infection (ssi) and organ-space infection (osi). secondary outcomes were -day major morbidity and length of hospital stay (los aim: in curatively intended resection of sigmoid and rectal cancer, many surgeons prefer to perform ligation of the root of the inferior mesenteric artery (ima), high tie, because of oncological reasons. however, ligation of the ima has been known to decrease blood flow to the anastomosis. there are few reports of patients undergoing the reduced port laparoscopic approach (rps) including single-incision laparoscopic approach (sils) even among those undergoing laparoscopic lymph node dissection around the ima with preservation of the left colic artery (lca). our objective was to evaluate the quality of this procedure regarding application of rps for the treatment of sigmoid and rectal cancer. methods: the feasibility of this procedure was evaluated in consecutive cases of rps for sigmoid and rectal cancer. a lap protector (lp) was inserted through a . cm transumbilical incision, and an ez-access was mounted to lp and three -mm ports were placed. almost all procedures were performed with standard laparoscopic instruments using a flexible scope (sils). a mm port was inserted in right lower quadrant mainly in rectal cancer surgery (sils + ). our method involves peeling off the vascular sheath from the ima and dissection of the ln around the ima together with the sheath. results: lymph nodes around the ima were dissected with preservation of the lca in cases (group a). the ima was ligated at its root in cases (high tie, group b). in group a, patients were treated with sils and patients were treated with sils+ . in group b, patients were treated with sils and patients were treated with sils+ . median operative time was . , and . min for group a, and b, respectively. the operative time was significantly longer in group a. estimated blood loss was . and . g, and mean numbers of harvested ln were . , and . . none of the other operative results of groups a and b were different statistically. in this series, there was only one anastomotic leakage in group b. conclusion: our method allows equivalent laparoscopic lymph node dissection to the high tie technique. the operative time tends to be longer, however this procedure has a possibility to reduce an anastomotic leakage. introduction: the routine mobilization of the left colonic flexure in colorectal surgery is still a matter of debate. we present our surgical approach with data. this technique may increases the surgical expertise/confidence when the surgical maneuver is necessary. up to % of all splenectomies are for surgery-related injuries; % of those splenic injuries are treated by splenectomy. the iatrogenic splenic injury rate during colorectal surgery is . %. iatrogenic splenic injuries create: increased risk of mortality/morbidity, extended operative time/patient in-hospital stay and increased healthcare costs. risk factors for iatrogenic splenic injury are: advanced age, adhesions, underlying pathology. obesity is not a risk factor. it is debated if the left colonic flexure mobilization is a risk factor for splenic injury. the ligament over-traction is the most frequent damage mechanism. the most dangerous surgical manuever is the spleno-colic ligament surgical dissection. moreover, laparoscopy descreases by almost , times the splenic injury risk. some surgeons are reluctant to routinely take down the splenic flexure. materials and procedures: robotic left colonic/rectal cases with routine splenic flexure mobilization technique have been performed: left colectomy (n= ), rectal surgery (n= ), transverse-colectomy (n= ) and pancolectomy (n = ). conversion rate , %, ebl\ ml, postop-leak ( . %) and % iatrogenic splenic injuries. results: in our approach, there are pathways that need to be mastered for the splenic flexure mobilization:a) medial to lateral dissection (underneath the inferior mesenteric vein); b) lateral to medial (from the lateral peritoneal reflection); c) access to the lesser sac with omental detachment from the transverse colon; d) access to the lesser sac with the gastrocolic opening, following the inferior border of the pancreas. the dissection should be closer to the colon rather than to the spleen. in our experience the routine mobilization of the splenic flexure may have some advantages: a) better (without tension) distal anastomosis formation; b) better perfusion of the proxiaml stump; c) wider oncological dissection; d) no need of going back to the flexure when the proximal stump is too short; e) mastering a surgical manuver useful in other procedures (e.g. distal pancreasectomy). the theoretical drawbacks of routine splenic flexure mobilization can be:a) longer operative time, which is on average increased by minutes; b) risk of splenic injuries, in our experience, no splenic injuries have been registered. conclusions: technical accuracy with cautious dissection/visualization can reduce iatrogenic splenic damages rate. laparoscopy decreases splenic injury rate. robotic surgery may have the potential to further reduce this complications. our data suggest that the routine mobilization of the splenic flexure, has more advantages than drawbacks and it can reduce the iatrogenic splenic injury rate. more trials are needed in order confirm our findings. introduction: the robotic stapler with the endowrist™ technology (intuitive surgical, inc.) includes a larger range of motion and articulation compared to the laparoscopic device, and may provide some benefits in difficult areas like the pelvis. to date, few studies have been published on the application of robotic endowristed stapling. we present our preliminary experience using the robotic stapler in low anterior rectal resection (larr) with total mesorectal excision (tme) for rectal cancer. methods and procedures: between march and september , patients underwent elective robotic larr with tme and primary colorectal anastomosis within the eras program. patient demographic, intra-operative data and post-operative outcomes were compared between the endowrist™ robotic stapler group (rs group) and the laparoscopic stapler group (ls group). results: the two groups were homogeneous in terms of demographic and clinical characteristics. thirteen ( males) and patients ( males) were included in rs and in ls group, respectively. seven patients received preoperative chemoradiation in rs group, in ls group. there was no difference in intra-operative blood loss and total operative time. the median number of stapler fires for patients in rs group and in ls group was (range, - ) and (range, - ), respectively. loop-ileostomy was fashioned in patients in rs group ( . %) and patients in ls group ( . %). the days mortality was nil. two cases of anastomotic leaks have been detected in rs group ( . %), cases ( . %), occurred in ls group, all treated conservatively. the mean length of postoperative stay was . ± . days in rs group, . ± . days in ls group. conclusions: in our preliminary experience the application of robotic stapler during larr with tme has shown to be safe and feasible with acceptable morbidity. even if our case series is pretty small, fewer stapler fires were required in the rsg compared to lsg. we believe that the robotic stapler might lead to a more precise firing during pelvic surgery: it can explain the trend toward a decreased number of fires, that has been well documented in literature to be related to a lower risk of anastomotic leak. further high quality studies are required to confirm these findings. background and objectives: the present study was aimed at investigating the safety and feasibility of laparoscopic ultra-low anterior resection (l-ular) with total mesorectal excision (tme) and transanal specimen extraction for rectal cancer located at lower one-third rectum, and specifically understanding the oncological outcome of the operation. patients and method: a prospective designed database of a consecutive series of patients undergoing laparoscopic ultra-low anterior resection for rectal malignancy with various tumornode-metastasis (tnm) classifications from to at the texas endosurgery institute was analyzed. in this study ultra-low anterior resection is defined as low anterior resection for the malignant lesion at distal / of rectum. results: ultralow anterior resections were completed laparoscopically with tme and transanal specimen extraction. the operating time for the surgery was . ± . minutes, and estimated blood loss during the procedure was . ± . ml. the length of the lesion from the anal verge measured with intraoperative colonoscopy ranged from . cm to . cm, and shortest distance of colorectal anastomosis from the anal verge is cm. since diverting ileostomy was routinely installed after l-ular, none was found to have anastomotic leakage, however patients developed anal stenosis within -month follow-up. therefore the overall rate of postoperative complication is . %. moreover patients were reported to have local recurrence in -year followup with the rate of . %. conclusions: l-ular is safe and effective procedure for the rectal cancer at distal / rectum with comparable local recurrence and postoperative complication rates, thereby suggesting l-ular can be considered as a procedure of choice for rectal cancer at very low location in the rectum. for rectal cancer, however, local full-thickness excisions are fraught with high local recurrence rates -even if limited to early and best selected lesions. this corroborated observation is likely caused by a combination of missed nodal disease and direct implantation of tumor cells into the mesorectum, which upstages even early t lesions to at least a t lesion. the treatment of choice for invasive adenocarcinoma consists of an oncological total mesorectal resection, possibly with other modalities. rectal tumors of uncertain behavior can present a treatment dilemma between over-treatment vs under-treatment. concept: if the nature of a lesion is not certain or if contradictory results have been obtained, we propose a superficial local excision as a mucosal excisional biopsy to establish the diagnosis while avoiding interference with subsequent definitive treatment modalities by preserving the integrity of the external rectal wall and mesorectum. a benign final pathology concludes the treatment, whereas a detection of invasive cancer will be managed with a subsequent oncological resection. methods: this is a case report of a -year-old woman found to have a . cm villous lesion in the mid to distal rectum without proven or disproven invasive cancer. a tems-guided mucosal resection of the rectal mass at cm above the anal verge was performed whereby the lesion was dissected off the underlying muscularis. results: with preoperative discrepant erus and mri staging ut - vs ct lesion, a technically successful mucosal resection of the large rectal mass was carried out. pathology revealed a tubulovillous adenoma without high grade dysplasia or malignancy and a complete resection. conclusion: tems mucosal excisional biopsy of rectal tumors of uncertain behavior allows for a less invasive diagnostic approach that may (a) be definitive treatment if the lesion is proven benign, or (b) confirm the need for more aggressive treatment without having burned any treatment bridges or upstaged an early tumor by violating the mesorectal plane. an oncologic resection with appropriate (neo-)adjuvant chemotherapy can be carried out while preventing the potential for tumor seeding at initial operation. background: adequate visualization of the entire lumen of the large bowel is essential in detecting pathology and establishing diagnoses during colonoscopies. patients are provided dietary instructions and medications in order to achieve adequate bowel preparation. given the extensive amount of preparation required, some patients may be unable to adhere to the prescribed routine, resulting in rescheduling or repeat procedures and misallocation of limited resources. a number of previous quality-improvement efforts have been implemented to ensure adequate preparation prior to colonoscopy. objective: the objective of this study was to develop and assess the feasibility of a novel smart phone application in the delivery of bowel preparation instructions. methods: a novel smart phone application was developed to deliver bowel preparation instructions to patients undergoing colonoscopy for the first time. patients were included in the pilot phase of this project if they were undergoing a colonoscopy for the first time. we included patients who had access to a smart phone, had not previously had a bowel preparation for any reason. we excluded patients with a previous diagnosis of inflammatory bowel disease or colorectal cancer. patient surveys were administered at the time of colonoscopy. patients were questioned regarding the completeness of bowel preparation and adherence to bowel preparation instructions. patient questionnaires were completed to ascertain the ease of use of the smart phone application and any concerns that arose. quality of bowel preparation was assessed by the colonoscopist using the validated ottawa bowel preparation score. this is the pilot study results for the "coloprep" trial (nct ). results: a total of patients were enrolled in the pilot phase of this study. patient satisfaction, adherence to instructions and ease of use of the smart phone application were ascertained. bowel preparation, as assessed by the colonoscopist, was reported. conclusions: this study assessed the feasibility of using a novel smart phone application for delivery of bowel preparation instruction. this pilot study is the initial phase of a randomized controlled trial to compare smart phone application vs. written instructions in the delivery of bowel preparation instructions. the . median follow-up was months. there were no statistically significant differences found in clinical features and laboratory findings between the two groups. no statistically significant difference was found regarding the overall success rates and the complication rates between the conservative and the surgical arms (success rates: . % and . % (p= . ) and complication rates: . % and . % (p= . ), respectively). however, surgical treatment was better than conservative treatment in preventing recurrent diverticulitis (recurrence rates: % and . % (p= . ), respectively). conclusion: conservative management with bowel rest and antibiotics is a safe and effective treatment for right-sided colonic uncomplicated diverticulitis and may be considered as the initial option. on the other hand, laparoscopic diverticulectomy is also safe, effective and adequate. surgery is advocated to decrease the recurrence rate. introduction: it has been hypothesized that the structural and functional changes that develop in the defunctioned segment of bowel may contribute to the development of postoperative ileus (poi) after loop ileostomy closure (lic). as such, longer intersurgery interval between ileostomy creation and lic may increase poi. methods and procedures: after institutional review board approval, all patients who underwent lic at a single institution between - were identified. the primary endpoint, primary poi, was defined as either a) being kept nil-per-os on or after postoperative day for symptoms of nausea/vomiting, distension, and/or obstipation or b) having a nasogastric tube (ngt) inserted, without postoperative obstruction or sepsis. secondary endpoints included length of hospital stay (los) and non-poi related morbidity. patients who left the operating room with a ngt, had a planned laparotomy with a concomitant procedure at the time of lic, had a total proctocolectomy as their index operation, or had secondary poi, were excluded. patients were then divided into two groups based on timing from the index operation to lic (\ months vs. objective: fecal incontinence can be a debilitating problem significantly diminishing productivity and quality of life. sacral neuromodulation has emerged as a first line surgical option treatment in patients with fecal incontinence. though its efficacy has been rigorously evaluated in adult populations there is scant data available for its use in the pediatric pateints with fecal incontinence. this case study discusses the management of fecal incontinence in a pediatric patient with a history of hirschsprung's disease utilizing sacral nerve stimulation. methods: our patient is a -year-old female with a history of hirshsprung's diagnosed in infancy and treated surgically with coloanal pull through at the age of who presented with complaints of fecal incontinence. the patient was wearing pads daily, noting frequent uncontrolled bowel movements as well as having frequent missed days of school due to these symptoms. despite maximal medical management and pelvic floor physical therapy the patient continued to have - episodes of fecal incontinence daily. a ct scan with rectal contrast was used to establish her postoperative anatomy. anal manometry showed low rest/squeeze pressures, absent resting anal inhibitory reflex, and abnormal sensation. furthermore, during balloon expulsion testing the patient failed to pass device. the patient was deemed a candidate for stage testing with sacral nerve neuromodulation. during follow-up, the patient was noted to have resolution of her episodes of fecal incontinence and the second stage was completed. the patient continues to note % continence and dramatic improvement in her quality of life. conclusion: in this patient with a history of severe fecal incontinence due to hirschsprung's disease, sacral neuromodulation has had a significant impact on her quality of life. post-operatively she continues to have marked improvement in her symptoms with - bowel movements a day with no recurrence of fecal incontinence. the use of sacral neuromodulation is a promising treatment for fecal incontinence in the pediatric population. future research investigating the longterm efficacy of this treatment modality in the pediatric population is needed. cases of bowel obstruction caused by colorectal cancer recurrence and progression were excluded. surgical cases ( . %) were considered to be early bowel obstruction and ( . %) were classified as late bowel obstruction. left hemicolectomy (n= , . %) was a significantly more frequent procedure in early bowel obstruction, and abdominoperineal resection (n= , . %) was significantly more common in late bowel obstruction (p. ). both early and late bowel obstruction included adhesive small bowel obstruction (n= ), internal hernia (n= ), and strangulation obstruction (n= ). internal hernia (n= ) and strangulation obstruction (n= ) occurred after left hemicolectomy and abdominoperineal resection, respectively. there is no apparent relationship between surgical procedures and adhesion regions (abdominal wall, intestinal tract, and pelvic cavity). the incidence rate of postoperative small bowel obstruction remained low, and laparoscopic colectomy had been safely performed. however, countermeasures are needed because of the high frequency of both early and late bowel obstruction which occurred after left hemicolectomy and abdominoperineal resection, respectively. improved utilization of resources as an improvement introduction: nowadays, treatment decisions about patients with rectal cancer are increasingly made within the context of a multi-disciplinary team (mdt) meeting. the outcomes of rectal cancer patients before and after the era of multi-disciplinary team was analyzed and compared in this paper. the purpose of the present study is to evaluate the value of discussing rectal cancer patients in a multi-disciplinary team. methods and procedures: in our health institute, weekly mdt conferences were initiated in january . meetings were attended by surgeons, radiologists, radiation and medical oncologists and key nursing personnel. all rectal cancer patients diagnosed and treated in - in the general surgery division of the "carlo urbani" hospital in jesi (an, italy) were included. then, the data from rectal cancer patients in were evaluated, before the adoption of mdt and in year , after the adoption of meetings. datasets regarding demographics, tumor stage, treatment, and outcomes based on pathology after operation were obtained. during an mdt discussion patient history, clinical and psychological condition, co-morbidity, modes of work-up, clinical staging, and optimal treatment strategies were discussed. a database was created to include each patient's workup, treatments to date and recommendations by each specialty. ''demographic variables'' consisted of age at diagnosis, sex, body mass index, comorbidities, american society of anesthesiologists physical status classification system, clinical stage and pathological stage. other analyzed variables included baseline carcinoembryonic antigen (cea), the type of imaging, use of neoadjuvant chemo-radiation, restaging following neoadjuvant therapy, distance from the anal verge, operation type and use of adjuvant chemo-radiation. ''outcome variables'' consisted in a comparison for each group between clinical and pathological stage. results: sixty-five patients were included in this study: thirty patients in (pre-mdt) and thirty-five patients in . demographic variables did not differ significantly between groups. preoperative clinical stages with baseline preoperative cea and postoperative pathological stage were analysed, too. thanks to the mdt and the increased use of the neoadjuvant therapy, a statistically significant difference in reduction of the stage between the clinical and pathological stage in the patients of the mdt group was verified. conclusions: the vast majority of rectal mdt decisions were implemented and when decisions changed, it mostly related to patient factors that had not been taken into account prior to the adoption of multi-disciplinary team. analysis of the implementation of team decisions is an informative process in order to monitor the quality of mdt decision-making. purpose: in japan, lateral pelvic node dissection (lpnd) is the standard treatment for locally advanced lower rectal cancer. there are few reports of patients undergoing single-incision plus one port laparoscopic (sils+ ) lpnd even among those undergoing laparoscopic lpnd. the aim of this study is to describe our initial experience and assess the feasibility and safety of sils+ lpnd for patients with advanced lower rectal cancer. methods: a lap protector (lp) was inserted through a . cm transumbilical incision, and an ezaccess was mounted to lp and three -mm ports were placed. a mm port was inserted in right lower quadrant. a single institutional experience of sils+ lplnd for rectal cancer are presented. inclusion criteria was indications for lld were lower rectal cancer with t - , or t - rectal cancer with metastasis of lateral lymph node, as described by the japanese society for cancer of the colon and rectum (jsccr) guidelines for the treatment of colorectal cancer. perioperative outcomes including operative time, operative blood loss, length of stay, postoperative complications, and histopathological data were collected prospectively. introduction: endoscopic stenting with a self-expandable metallic stent (sems) is widely accepted procedure for malignant colorectal obstruction. we assessed the safety and efficacy of insertion of a sems followed by elective surgery as 'bridge to surgery (bts)' in our institute. methods: this study was a retrospective study in our institute. the data was collected from medical charts from january to june . results: a total of consecutive patients underwent radical surgery for colorectal malignancy during this period. in this series, patients ( . %) were diagnosed malignant colorectal obstruction and intended to a bts. the stent was successfully placed in patients and all the patients were planned to undergo radical surgery. the failed patients underwent stoma creation ( patients) and hartmann's procedure. the technical success rate was % and the clinical success rate was %. the median time from sems to surgery was days ( - days) . open and laparoscopic surgery was performed in and patients, respectively, except for one patient refused radical surgery because of a great age. the tumor could be resected in patients (bts patients) with primary anastomosis. however, diverting stoma creation was needed in patients and decompression rectal tube was placed in patient. the entire patient laparoscopically was no conversion to open surgery. there was no anastomotic leakage in bts patients. the median duration of postoperative hospital stay was days ( - days). the overall postoperative complication was % ( / ) including bowel obstruction and anastomotic stricture. the median follow-up period was days. during the follow-up period, patients were relapsed peritoneal dissemination, ovarian metastasis, and liver and pulmonary metastases, respectively. former patients were diagnosed stage iva at the time of primary surgery. one patient died from sudden death. conclusions: our data suggested that routine use of sems insertion was safe and effective procedure for malignant colorectal obstruction as a bts. moreover, laparoscopic procedure was useful procedure in bts patient. the short-and long-term surgical outcomes were also acceptable. introduction: serpin e , also known as plasminogen activator inhibitor- (pai- ) is an inhibitor of urokinase type plasminogen activator (upa) and tissue-type plasminogen activators (tpa ). pai- plays a role in the regulation of angiogenesis, wound healing, and tumor cell invasion; over expression has been noted in breast, esophageal, and colorectal cancer (crc). pai- is also a potent regulator of endothelial cell (ec) proliferation and migration in vitro and of angiogenesis and tumor growth in vivo. the plasminogen/plasmin system plays a key role in cancer progression by mediating extracellular matrix degradation and tumor cell migration. surgery's impact on plasma pai- levels is unknown. this study's purpose was to measure plasma pai- levels before and during the first month after minimally invasive colorectal resection (micr) for crc. objectives: retroflexion in the rectum at the end of a colonoscopy is a requirement for a complete endoscopic evaluation. retroflexion helps to visualize and detect polyps which would be missed otherwise. currently new endoscopes are available which can do retroflexion in the caecum. aim: our study aims to compare the rate of polyp detection rate in cecum and ascending colon with and without retroflexion in cecum. methods: this is a single center, single operator, retrospective study. a total of two hundred patients were involved. a single center irb waiver was obtained. patients were divided into two groups based on the presence/absence of retroflexion in caecum during their colonoscopy. the data was obtained from records. group a (n= ) had colonoscopy without retroflexion in caecum group b (n= ) had colonoscopy with retroflexion in caecum inclusion criteria: patients undergoing screening colonoscopy between the age of and . results: group a: total of patients were screened. a total of polyps were detected in group a. number of cecal polyps were ( . % of total polyp count). number of ascending colon polyp were ( % of total polyp). on analyzing the pathology % of the cecal polyps were tubular adenoma, % hyperplastic polyps % and % lymphoid aggregate. number of ascending colon polyps were , of which % were tubular adenoma, % tubular adenoma and % tubulovillous adenoma group b: total of patients were screened. a total of polyps were detected. number of cecal polyps detected were ( . % of total polyp count). number of ascending of ascending colon polyps were ( %). on analyzing pathology, % cecal polyps were tubular adenoma and % were sessile serrated. out of the ascending colon polyps % were tubular adenoma, % sessile serrated, % tubulovillous and % hyperplastic polyp. side events: two mass lesions were noted in both group a and b. there was incomplete colonoscopy in group a and b. conclusion: this retrospective analysis reveals a small increase in polyp detection in the cecum with retroflexion, especially in detecting sessile polyps which have more malignant potential. however, a large multicenter analysis will be required to validate the above observation. background: while uncommon, rectal prolapse is a disabling condition affecting older females. in a small subset of patients, concomitant organ prolapses with or without incarceration can lead to significant morbidity. as the field of laparoscopy has evolved, minimally invasive surgical options for rectal prolapse have led to improved quality and reduced morbidity for patients suffering this debilitating disease. methods: the - acs-nsqip databases was queried for patients undergoing a traditional or minimally invasive rectopexy based on cpt codes ( , , , and ) . emergent cases and patients with preoperative infections or inflammatory states were excluded. the primary outcome of interest was a -day postoperative composite morbidity score. statistical analysis incorporated multivariate analysis and binomial logistic regression with p. holding significance. results: these inclusion and exclusion criteria identified patients undergoing traditional ( ) and minimally invasive ( ) rectopexy for prolapse between and . patients undergoing traditional rectopexy were older (p. ), had a higher body mass index (p= . ), more comorbid conditions (diabetes, copd, hypertension) and less functional independence (p= . ). patients undergoing a traditional rectopexy had a higher composite morbidity incidence of . % vs. % for minimally invasive rectopexy (p. ). specifically, minimally invasive rectopexy patients had a . % reduction in wound complications (p= . ) and a shorter hospital stay ( . days vs. . days, p . ) compared to a traditional rectopexy. readmission rates were also . % lower in the minimally invasive group (p= . ). after controlling for the differences in the cohorts, a minimally invasive approach was a significant protective factor against the incidence of -day postoperative morbidity (or . , p. ). conclusion: a minimally invasive rectopexy has improved -day postoperative morbidity compared to a traditional rectopexy and should be strongly considered for the treatment of rectal prolapse. objectives: the short-term safety and efficacy of a self-expandable metallic stent (sems) placement followed by elective surgery, "bridge to surgery (bts)", for malignant large-bowel obstruction (mlbo) have been well described. the aim of this study was to investigate the risk factors for postoperative complications and optimal interval between sems placement and surgery in patients with mlbo. methods: retrospective examination of patient records revealed that the bts strategy was attempted in patients with mlbo from january to march in our institution. two of these patients were excluded because they had undergone emergency surgery for sems migration; thus, patients with mlbo who had undergone sems placement followed by elective surgery were included. of these patients, eight had developed postoperative complications (clavien-dindo grading≥ii) (postoperative complication: poc group) whereas patients had no such complications (no poc group). results: univariate analyses showed that the factors of asa score, number of lymph nodes resected, interval between sems and surgery, and preoperative albumin concentration were associated with postoperative complications. multivariate analysis identified only the interval between sems and surgery as an independent risk factor. furthermore, a cut-off value of days for interval between sems and surgery was identified by roc curve analysis. conclusions: an interval of ≥ days from sems placement to surgery is an independent predictive factor for postoperative complications in patients undergoing elective surgery in a bts setting. thus, an interval of over days is recommended for minimizing postoperative complications. haseeb kothar, ronan cahill; mater misericordiae university hospital current clinical advances in operative near-infrared visualisation of cells, tissues and structures are predicated on the use of commercial available near-infrared cameras to excite and visualise emission energy from non-selective, approved compounds (predominantly indocyanine green (icg)). it is expected that new generation compounds wholly selective for specific cellular components are now needed for further advance and a variety of molecular targets have been proposed and are being developed primarily for oncological imaging purposes. recent publications have however suggested icg itself is retained within malignant tissue differently to its uptake and clearance from surrounding non-malignant tissue which is important for two reasons. firstly, it exploits and makes visual the increased vascular permeability and disordered clearance associated with carcinogenesis which is a common endpoint of a variety of mediators including but not limited to vegf. this raises the useful option of targeting downstream effects of cancer compounds on a metabolic basis as opposed to tagging individual cell or antigen components. this means that a single agent could be used to target a variety of cancers rather then needing a specific one for each specific sub-type as well as obviating the issue of cancer cells heterogeneity even in a single cancer deposit. second, it is very likely that some or all of the "localisation" effect of proposed selective compounds may well be due to a similar phenomenum rather then cell-specific binding and may make distinction from other areas of similar metabolic behaviour (ie inflammatory regions) difficult. the crucial step-advance for such agent development so may well relate to timing of compound delivery and "visualisation window" at the region of interest rather then highly selective oncocellular-targeting. to illustrate this in more detail, we have been examining the tissue-specific effects and actions of near-infrared excitation in patients (n= ) with localised malignant colorectal primaries receiving an aliquot of icg before such examination at the time of resection. icg can be selectively apparent in the colorectal primary minutes after its systemic administration likely due to altered vascular dynamics. additional dose-related work has shown that early administration ( - minutes before examination) does not give useful information related to tumour fluorescence. interestingly none of these patients had fluorescence seen within their regional lymphatics but none also had malignant lymph nodes associated with their large primaries on pathological examination. however, this procedure is not usually performed in laparoscopic apr for its technique difficulty, which may lead to increased rates of complications ( fig. ) . here, we compared the feasibility and peri-operative outcomes of the laparoscopic apr with and without pelvic peritoneum closure (ppc) for lower rectal cancer. introduction: there are reports of increased operative duration, blood loss and postoperative morbidity, caused by difficulties in obtaining good visualization and in controlling bleeding when laparoscopic resection is performed in obese patients with colon cancer. purpose: the aim of this study was to investigate the impact of obesity on perioperative outcomes after laparoscopic colorectal resection performed by various operative methods in our department. patients and methods: we conducted a retrospective analysis of patients with colorectal cancer who underwent laparoscopic surgery between january to december . right colectomy was performed in patients, sigmoidectomy in patients, and low anterior resection in patients. the surgical outcomes were compared between non-obese (body mass index [bmi]\ kg/m ) and obese (bmi ? kg/m ) patients. results: right colectomy cases: the amount of blood loss was significantly increased in the obese group compared with the non-obese group, but operation time did not differ significantly between the groups. there were no significant differences between the two groups in the rate of postoperative complications and duration of post-operative hospitalization. sigmoidectomy cases: there were no significant differences between the two groups in operation time and amount of blood loss. even though the preoperative asa score and the rate of postoperative complications were higher in the obese group, the mean postoperative hospital stay did not differ significantly between the two groups. low anterior resection cases: there were no significant differences between the obese group and the non-obese groups in operation time, amount of blood loss, rate of postoperative complications, and duration of post-operative hospitalization. discussion: although there are some reports of increased operative times in obese patients, the operative procedure was not extended in any of the present study patients. the amount of blood loss was significantly increased in the obese group compared with the non-obese group when right colectomy was performed. among the patients undergoing sigmoidectomy, the postoperative rate of complications was higher in the obese group; however, the preoperative asa status was also higher in the obese group than non-obese group, indicating that factors other than obesity may be involved. conclusion: we concluded that laparoscopic colorectal resection appeared to be safe and feasible in both obese patients and non-obese patients. however, bmi may not accurately reflect the amount of visceral fat present. background: for the complete rectal prolapse (basically longer than cm), we thought sling rectopexy was most reasonable to hang up and fix the rectum, which drooped down and prolapsed due to the relaxation of supporting tissue. we considered ripstein method had enough fixed power of rectum to sacrum. however, complications of rectal stenosis, constipation, mesh infection and mesh penetration were reported. therefore, we modified ripstein method to conquer such complications. aim: a prospective study beyond the randomized control trial (rct) between our modified ( introduction: the results of the japan clinical oncology group (jcog) study suggested that total mesorectal excision (tme) and lateral lymph node dissection (llnd) could become the standard treatment for lower rectal carcinoma. however, llnd must also be performed laparoscopically if surgery for lower rectal carcinoma is to be carried out as a completely laparoscopic procedure. transanal tme (tatme) is expected to provide better results than the conventional tme, both oncologically and in terms of pelvic function, and its use has recently been spreading in japan. we started performing laparoscopic tatme+llnd in our department in july and here report the short-term outcomes. subjects and methods: we used laparoscopic tatme+llnd to treat men and women with ct or deeper rectal carcinoma in whom the inferior margin of the tumor was on the anal side of the peritoneal reflection. this was a retrospective study of short-term postoperative outcomes. surgical procedure: laparoscopic surgery was started simultaneously by two teams, one working transabdominally and the other working transanally. the transabdominal team performed the standard proximal llnd and mobilization of the splenic flexure via five ports. they then dissected the bilateral lateral lymph nodes, mainly in the obturator (# ) and internal iliac (# ) groups. during this time, the transanal team performed laparoscopic tatme. finally, both dissection layers were connected and the cancer was excised. results: six patients had clinical stage ii and two had clinical stage iii lower rectal carcinoma. all the patients underwent preoperative chemotherapy with s- +l-ohp. five underwent a sphincterpreserving surgery, and three underwent rectal amputation. the mean operating time was minutes (range, - minutes), and the mean amount of hemorrhage was g ( - g). the mean number of lymph nodes dissected was , and r resection was performed in all the cases. the mean length of hospital stay was days, and a postoperative complication of clavien-dindo grade iii or higher occurred in one patient (anastomotic failure). conclusions: laparoscopic tatme+llnd performed by two teams simultaneously is an extremely useful procedure that not only reduces operating time, but also is less invasive than laparoscopic surgery. it may also be effective for improving curative nature, nerve preservation, and anal function. objective: in laparoscopic appendectomy, the base of the appendix is usually secured by applying a roeders knot. the aim of this study was to compare the advantages of using staplers and hem-olocks for securing the base of the appendix. method: the study included patients between age of to years with acute appendicitis randomly divided into two groups. in the first group, the base of the appendix was secured using roeders knot. in the second group, mesoappendix was not dissected and was included in the endostapler jaws. the primary outcome was overall morbidity. secondary outcomes were total duration of surgery, total length of stay and ease in difficult cases. result: no morbidity was recorded in any group. the time of the operative procedure was significantly longer in the cases with roeders knot than in the stapler group (p. ) as mesoappendix was not dissected in the later. cases with unhealthy base were progressed to laparoscopic quadricolectomy. apart from the ease of applying a stapler, cases of second group with gangrenous base were easily tackled using endostapler, avoiding the need of a hemicolectomy. conclusion: all forms of closure of the appendix base are acceptable, but endostapler technique apart from providing a secure base, reduces operative time and is an essential tool in cases of gangrenous base. introduction: accurate staging is essential to estimate the prognosis of patients with colorectal cancer (crc) and lymph node evaluation is key to determine it. in non-metastatic crc, the number of harvested lymph nodes is the strongest prognostic factor for outcome and survival. additionally, it is thought that a higher lymph node yield may be representative of a higher quality of surgical care. due to the importance of the association between lymph node evaluation and outcome in crc, it is necessary to evaluate factors which may affect lymph node harvest. introduction: hatmann's procedure is commonly done in treating complicated diverticulitis, negleccted rectal trauma with sepsis and sometimes malignancy. the traditional techniques to restore the intestinal continuity after hartmann's procedure were for many years the standard of care in these operations, but in fact they carry many morbidity and even mortality and failure. laparoscopic techniques is not only carry the advantage of minimal invasive surgery, but also of better visualizationn and magnification. the aim is evaluating the outcome of using the laparoscope in reversal of hartmann's procedure as regard feasibility and safety. patients and method: forty patients were subjected to laparoscopic reversal of hatmann's procedure in tanta university hospital, there ages ranged between to years, the time elapsed after the original operation ranged from months to years, excluding advanced malignany. conversin occurred in cases due to extensive adhesions and bleeding. results: no mortality, or major morbidity in our study and only single leak treated by covering ilestomy. conclusion; laparoscopic hartmann's procedure is feasible, promising tehnique with minimal morbidity. background: minimal invasive surgery has been well established in the elective colorectal surgery and it has been proven better clinical outcome compared with open surgery. in the emergent setting, laparoscope is used mostly in the colecystectomy, appendectomy but laparoscopic emergent colorectal surgery is limited for it's complexity and difficulity. the aim of this study was to envaluate the feasibility of laparoscopic emergent colorectal surgery. methods: this study is prospective collected, observational single center study of patients undergoing laparoscopic emergent colorectal surgery from to . the patient demographics, surgery indication and detail, complication, clinical outcome and hospital stay were collected and analyzed. results: there are total emergent colorectal operations and patients were managed with minimal invasive method. among these laparoscopic emergent surgery, there are male patients and female patients. mean age of the patients was . years (range - years). the main indication for operation: perforation . % ( / ), leakage after elective colorectal surgery . % ( / ), obstruction . % ( / ), ischemia colitis . % ( / ,), bleeding . % ( / ). there are cases in asa , cases in asa , cases in asa . the qsofa score for sepsis: cases was , cases was , cases was , case was . there are cases undergoing laparoscopic lavage with diverting stomy, cases were hartmann procedure, cases were anterior resection, cases were right hemicolectomy, cases were perforation repair, cases were redo anastomosis. there are cases coversion to open method including cases were due to bowel adhesion, cases were due to bowel distension, case was due to severe shock status. mean operative time is . minutes. the overall mortality rate was . % and major complication rate (clavien-dindo grade above ) was . %. re-operation rate was . %. the mean hospital stay was . days. conclusions: this study presents evidence of an initially clinical outcome in emergent laparoscopic colorectal suregry. in the absence of large case series, the benefits of a laparoscopic approach should befall to at least a minority of these patients. confocal laser endomicroscopy (cle) can provide real-time observation of the cell structure and tissue morphology. in our study, we aim to assess the situation of anastomotic perfusion using cle. method: the experimental rabbits were separated into two groups: group a (good anastomotic perfusion, n= ), group b (poor anastomotic perfusion, n= ). the partial colectomy and anastomosis was performed for group a and b. then detection for anastomotic perfusion using cle was carried out after the surgery. during the continuous scanning, we counted the number of blood cells that cross over the certain point of anastomotic stoma in the same period. results: assistant with fluorescein sodium, the blood vessels are highlighted. we can see significant difference of imaging effect between group a and group b. the average number of blood cells are . /min of group a and . /min of group b (p. ), which has significant difference. conclusion: cle can allow real-time observation of the blood flow of anastomotic stoma in vivo. therefore, it is feasible to assess the anastomotic perfusion using cle in colorectal surgery. cigdem benlice, ahmet rencuzogullari, james church, gokhan ozuner, david liska, scott steele, emre gorgun; cleveland clinic background: intraoperative colonoscopy (ioc) is an adjunct in colorectal surgery (crs) especially in patients with malignancies in order to detect location of the primary or synchronous lesions as well as assessing anastomotic integrity. however, effects of intraoperative colonoscopy on short term outcomes during crs is a concern. this study aims to evaluate safety and feasibility and post-operative outcomes of intraoperative colonoscopy in left-sided colectomy patients for colorectal cancer patients by using the nationwide database. patients and methods: patients undergoing elective left-sided colectomy with low pelvic anastomosis without any proximal diversion for colorectal cancer were reviewed from the american college of surgeons national surgical quality improvement program (acs-nsqip) proceduretargeted database ( ) ( ) ( ) according to their primary procedure current procedural terminology (cpt) code. subsequently, patients who underwent intraoperative colonoscopy were identified from concurrent cpt codes and divided into two groups based on the simultaneous intraoperative colonoscopy. demographics, comorbidities, -day postoperative complications were evaluated and compared between the groups. multivariate logistic regression was conducted adjusting for significant factors between the groups. results: a total of patients were identified and ioc was performed for ( . %) patients. objective: laparoscopic ileostomy commonly performed for the patients with colorectal obstruction due to cancer, peritonitis with perforation of colon or the other reason. reduced port surgery is a novel technique that may be performed when considering minimally invasive surgery and desiring a cosmetic benefit. the aim of this study was to evaluate safety and feasibility of reduced port laparoscopic ileostomy for the patients with advanced colorectal cancer before chemotherapy. methods: between july and august , patients who underwent reduced port laparoscopic ileostomy were included ( male and female, age: years old. the outcomes were evaluated in terms of operation time, intraoperative blood loss and perioperative complications. sugical procedures: the patients were placed in the supine position and the operator stood left side. an access device with the wound-protector (ez access, hakko, nagono, japan) was inserted on the future ileostomy site in the right lower abdomen, inserting two of -mm trocars, maintaining pneumoperitoneum at mmhg with carbon dioxide. a -mm trocar was inserted in the left lower abdomen. a -mm flexible laparoscope was inserted from access device port. after exploring abdominal cavity, ileum end was identified. then the marking using dye was put on the ileum of cm proximal from the ileum end. the ileum marked by dye was grasped, and extracted through the access devise. then a blooke ileostomy was created. results: reduced port laparoscopic ileostomy was performed for patients with colorectal obstruction due to cancer before chemotherapy. the mean operative time was minutes, the mean blood loss was . ml. three patient received one additional port. there were no intraoperative complications. five patients ( . %) experienced postoperative complications (two of deep surgical site infection, one of pneumonia, one of outlet obstruction and one of renal dysfunction). there were no other intraoperative or postoperative complications. conclusion: reduced port laparoscopic ileostomy is a safe and feasible procedure for the patients with advanced colorectal cancer before chemotherapy. methods: we performed elective lcr on patients for primary colorectal cancers between june and june . seventy-two patients were excluded in this study following reasons: patients underwent multiple organ resection, and colorectal cancer was diagnosed with stage iv in patients. accordingly, patients were eligible for comparative analysis, with in group po (post operation) and in group c (control). in group po, past operative procedures were as follows: appendectomy ( %), digestive tract ( %), hepato-billiary-pancreatic ( %), gynecologic ( %), urologic surgery ( %), and others ( %). results: there were no significant differences between two groups in asa (grade≤ : vs. %, p= . ), bmi ( introduction: the treatment of rectal cancer requires highly skilled practice by the entire multidisciplinary team. important aims of treatment are: to reduce the risk of residual disease in the pelvis, with lower morbidity and to preserve good sphincter function. the tata procedure is transanal transabdominal radical proctosigmoidectomy with coloanal anastomosis. this technique was first developed in by dr. gerald marks to avoid a permanent colostomy for low-lying rectal cancer. this study reports the long-term results of tata procedure for low rectal cancer. methods and procedures: a prospective study was on patients with low rectal cancer between april and july in a tertiary referral university-affiliated center specializing in laparoscopic surgery. all resections were carried out by a team of dedicated colorectal surgery and standard protocol was used for all pre-and-post-operative care. all the patients underwent total mesorectal excision. results: consecutive patients ( male, female, mean age ) underwent tata procedure, of them ( , %) after neoadjuvant radiochemotherapy. the mean operation time was min (range - ) and the mean estimated blood loss was ml (range - ). the overall incidence of morbidity was , % ( / ) and the mean hospital stay was , days. the mean follow-up period was , (range, - ) months with a recurrence rate of , % ( / ), overall estimated -year survival , % and the disease-free survival rate , %. conclusion: laparoscopic total mesorectal excision with tata procedure is safe with excellent local recurrence and disease-free survival rate. jacek piatkowski, md, phd, marek jackowski, prof; clinic of general, gastroenterological and oncological surgery introduction: more than years ago, laparoscopic technique was considered to be a fully accepted surgical method for treatment of rectal cancer. the following years are a further search for a new surgical method that reduces invasiveness and improves treatment outcomes. it seems that such a method is transanal total mesorectal excision. the aim of this study was to evaluate the new method of rectal cancer surgery (tatme) after years of its use. methods: radicality of treatment (r resection, local recurrence), outcome of surgical treatment and quality of life of patients after surgery were evaluated. results: in the period from . . . - . . . patients ( men, women) were operated in the clinic. in cases the indication for surgery was lower and middle rectal cancer and in cases high grade dysplasia. all patients underwent laparoscopic rectal proctectomy with transanal access (tatme). in all cases, complete oncological radicalization (resection r ) was obtained. the average operation time was minutes. we had used two teams approach (cecil approach) with laparoscopic sets -abdominal and perineal starting at the same time. in the postoperative course, patients had signs of anastomosis leak ( of them required reoperation). the follow-up period is - months. none of the patients had any recurrence of cancer. conclusions: . transanal tme for rectal cancer surgery is an alternative method to conventional laparoscopic surgery. . in a large proportion of patients with lower and middle tumors, the rectum can avoid abdomino-perineal resection with permanent colostomy. background: the double stapling technique (dst) has widely spread colorectal anastomosis especially for anastomosis after low anterior resection. as for the colorectal cancer treatment, heald reported total mesorectal excision (tme) in , and has been accepted as the standard technique for rectal resection due to the decreased local recurrence rate and improved functional results. with advent of dst, there is a background that it has become possible to preserve anus, even in the case with the lesion at lower rectum. laparoscopic surgery for colon cancer was introduced in the s, and has had promising results including long-term outcomes. according to the spread of laparoscopic surgery, laparoscopic surgery had been applied to the rectal resection, with technical difficulty. one of the reasons for the difficulty is that the high rate of anastomotic leakage, a critical adverse effect of low anterior resection (lar). thus, risk factors for anastomotic leakage were widely discussed, including technical factors such as pre-compression and number or firing. the decisive difference in conventional lar and laparoscopic lar in dst, is the stapler used for transection of the rectum. the laparoscopic staplers which are currently available are thought to be not ideal, and there is little evidence of specific specifications of stapler for laparoscopic surgery. materials and methods: all method described in this study was approved by the institutional ethical review committee. we reviewed the colon and rectal wall thickness according to histological examination using h&e staining of distal margin of resected specimen of the patients who conclusions: rstc for severe acute uc is at least as safe as the laparoscopic approach. although the robotic cohort had more comorbidities, major postoperative complications, readmissions, and reoperation rates were less when compared to lstc. rstc was also associated with an earlier return of bowel function and shorter length of stay. a prospective study with larger numbers is needed to see if the superiority of robotic versus laparoscopic approaches is reproducible. s surg endosc ( ) introduction: complete mesocolic excision (cme) has been advocated based on oncologic superiority, but is not commonly performed in north america. furthermore, many data are limited to case series with few comparative studies. therefore the objective was to systematically review studies comparing the short-and long-term outcomes between cme and non-cme colectomy for colon cancer. methods: a systematic review was performed according to prisma guidelines of medline, embase, healthstar, web of science, and cochrane library. studies were only included if they compared conventional resection (non-cme) to cme for colon cancer. quality was assessed using the methodological index for non-randomized studies (minors). the main outcome measures were short-term morbidity and oncologic outcomes. study eligibility, data extraction and quality assessment was performed by two independent reviewers, and disagreements resolved by consensus. weighted pooled means and proportions with %ci were calculated using a randomeffects model when appropriate. results: out of citations, studies underwent full-text review and met the inclusion criteria, of which were unique series. mean minors score was . (range - ). the mean sample size in the cme group was (range - ) and (range - ) in the non-cme group. in the unique studies, included only right-sided resection, and . % ( % ci . - . ) of the remaining were right-sided colectomies. of the studies that reported surgical approach, . % ( %ci . - . ) of cme were performed laparoscopically. there were papers reporting plane of dissection, with cme plane achieved in . % ( . - . ). mean or time in cme group was minutes (range - ) and in non-cme group minutes (range - ). perioperative morbidity was reported in studies, with pooled overall complications of . % ( %ci . - . ) for cme and . ( %ci . - . ) for non-cme resections. anastomotic leak occurred in . % ( %ci . - . ) of cme versus . % ( %ci . - . ) in non-cme colectomies. cme surgery consistently resulted in more lymph nodes retrieved, longer distance to high tie, and specimen length. there were studies that compared -or -year overall or disease-free survival, or local recurrence. only studies reported statistically significant higher disease-free or overall survival in favour of cme. local recurrence was lower after cme in of reported studies. conclusions: the quality of the current evidence is limited and does not consistently support the superiority of cme. more rigorous data are needed before cme can be recommended as the standard of care for colon cancer resections. gilberto lozano dubernard, md, facs, ramon gil-ortiz, md, gustavo cruz-santiago, md, bernardo rueda-torres, md, javier lopez-gutierrez, md, facs; hospital angeles del pedregal introduction: to assess the feasibility of a single-stage colorectal laparoscopic re intervention without ostomy. colonic laparoscopic interventions on patients that previously underwent a minimally invasive procedure, constitutes the current boundary in the management of the acute colorectal pathology. that includes, patients with fecal peritonitis due to diverting procedures already treated surgically. the outcome of our patients could significantly improve if the surgical procedure is performed in one time, with no stoma. method and procedures: from september to june , one hundred thirty-two patients underwent colorectal laparoscopic surgery. five of these patients developed complications: three perforations due to colonoscopy and two due to dehiscence of the anastomosis. these five patients underwent a second laparoscopic procedure that included resection and anastomosis. no stoma required. results: all five patients underwent a second laparoscopic procedure due to an anastomosis leak. no stoma was required. the procedure consisted on resection of the previous anastomosis, re anastomosis, abdominal lavage, aspiration and drains placement. all of them supported with parenteral nutrition. there were no surgical complications. only one patient developed pneumonic symptoms that were solved. conclusion: the reported results, regarding no conversion rate, nor mortality, on our series of patients, suggest that single stage laparoscopic re intervention is feasible, despite fecal peritonitis. introduction: total mesorectal excision is known to be a gold standard surgical procedure for the rectal cancer. subsequently complete mesocolic excision (cme) is recognized as an essential surgical procedure for the colon cancer. the transverse colon is relatively minor location for colon cancer. variety of vessels and mobilization of splenic flexure and dissection close to pancreas make operations for the transverse colon cancer complicated. laparoscopic transverse mesocolic excision in our hospital is presented. method: laparoscopic surgery is conducted with five trocars under the lithotomy position. inferior mesenteric vein is cut after dissection of the descending colon with medial approach. the lower edge of pancreas is exposed near the inferior mesenteric vein and is dissected along toward the tail of pancreas. the splenic flexure is mobilized with lateral approach and the dissection between transverse mesocolon and the lower edge of pancreas is continued in the direction to the pancreas head. coming to the exposure of superior mesenteric artery and vein, the origin of middle colic artery and vein are cut. the transverse mesocolon is separated from the pancreas head and the duodenum with preserving the gastrocolic trunk of henle and the right gastroepiploic vein. the hepatic flexure is mobilized and cme for the transverse colon is finished. this method, the 'tail to head of pancreas' approach, we called, was performed from september . this method is well performed with one series of surgical view, and seems to be a simple procedure as cme with central vascular ligation for the transverse colonic cancer. there were no intraoperative complications, and one postoperative pancreatitis with grade ? of clavien-dindo classification of surgical complications. conclusion: our method, the 'tail to head of pancreas' approach, with transverse mesocoloc excision is simple, safe and feasible. the introduction: anastomotic complication after stapled anastomosis in colorectal cancer surgery is a considerable problem. there are various types of anastomotic complication and they have different severity. this study was aimed to evaluate the impact of intraoperative colonoscopy on detection of anastomotic complication, and its effectiveness in treatment of anastomotic complications after anterior resection (ar) and low anterior resection (lar) for colorectal cancer intraoperatively. methods: from dec. to jul. , a total of patients who underwent anastomosis between sigmoid colon and rectum after colorectal resection were reviewed retrospectively. intraoperative colonoscopy was performed routinely since december in our hospital after anterior resection and low anterior resection. to identify effectiveness of intraoperative colonoscopy, we compared postoperative complications with non-intraoperative colonoscopy group during previous months. intraoperative colonoscopy was performed after anastomosis to visualize the anastomosis line and to perform an air leakage test. if anastomotic defect and moderate bleeding were found in intraoperative colonoscopy, it was managed by means of reinforcement suture or transanal suture repair. we used logistic regression to analyze anastomotic complication between two groups with or without intraoperative colonoscopy. results: of the patients who were performed intraoperative colonoscopy after ar (n= ) and lar (n= ), abnormal findings including bleeding and air leak were found in patients ( . %). among those, cases were observed without any procedure, additional procedures were performed in patients ( . %, transanal suture ( ), lembert suture ( )). postoperative complication was developed in patients; patients had anastomosis bleeding ( . %), patients had ileus ( . %), patient had pneumonia ( . %), patients had minor complication ( . %, acute urinary retention, chylous drainage, laparoscopic port site bleeding). among patients who had anastomosis bleeding, patients were treated by endoscopic clipping, patients were cured by conservative treatment. there was no postoperative anastomotic leakage. the cases of ar and lar were and in non-intraoperative colonoscopy group, there was no significant difference between two group (p= . ). the proportion of laparoscopic surgery was . % and . % on intraoperative colonoscopy and non-intraoperative colonoscopy group, respectively, there was significant difference statistically (p= . ). however, there was no significant difference in anastomotic complication rate between two groups. (rr= . , % ci, . - . ). conclusions: although there was no significant difference in postoperative anastomotic complication rate between two groups, intraoperative colonoscopy may be valuable method for decreasing postoperative complication by visualizing anastomosis line and performing additional procedure. conclusion: it was suggested that lymph node dissection of both middle and left colic regions is necessary for splenic flexure colon cancer, because lymph node metastasis was recognized in both region. surg endosc ( ) :s -s the aims: laparoscopic right hemicolectomy became the standard of care for treating cecum, ascending and proximal transverse colon cancer in many centers. most centers use laparoscopic colectomy with extracorporeal resection and anastomosis (lc). single-incision laparoscopic colectomy with intracorporeal resection and extracorporeal (sc) remains controversial. the aim of the present study is to compare these two techniques using propensity score matching analysis. methods: we analysed the data of patients who underwent laparoscopic right hemicolectomy with lc or sc between december and december . the propensity score was calculated from age, gender, body mass index, the american society of anesthesiologists score, previous abdominal surgery and d lymphnode dissection. short-term outcomes were recorded. postoperative pain was evaluated using a visual analogue scale (vas) and postoperative analgesic use as outcome measure. results: the length of skin incision in the sc group was significantly shorter than in the lc group: median (range) ( . - ) cm verses ( - ) cm (p= . ). the vas score on day and day after surgery was significantly less in the sc group than in the lc group: median (range) ( - ) verses ( - ) on day (p= . ) and median (range) ( - ) verses ( - ) on day (p= . ). significantly fewer the number of requiring analgesia in the sc group on day and day after surgery: median (range) ( - ) times verses ( - ) times on day (p= . ) and ( - ) times verses ( - ) times on day (p= . ). there were no significant differences in operative time, intraoperative blood loss, the number of lymph nodes removed and postoperative courses between the groups. conclusions: sc for right colon cancer is safe and technically feasible. sc reduces the length of skin incision and postoperative pain compared with conventional lc. patients were divided into the following groups: cephalo-medial-to-lateral approach group (cml group, n= ) and medial-to-lateral approach group (ml group, n= introduction: laparoscopic technique has been widely used in the treatment of colorectal cancer, while playing its minimally invasive advantages, but also achieved a good effect of radical oncology. however, t colorectal cancer is not recommended laparoscopic surgery. methods: retrospectively collected pt colorectal cancer data from to in guangdong general hospital, all cases were undergoing radical surgery. results: a total of cases were enrolled in the pt group, including cases of laparoscopic group, cases of open group, conversion rate was . %. there was no difference in baseline data (age, sex, bmi, asa, etc.)(p. ). there was a significant difference between the two groups (p. ) in blood loss, postoperative complications and postoperative recovery index. in the pathologic t a/b, combined-organ resection, postoperative recurrence, the laparotomy group had more cases, and there was a statistically significant difference between the two groups (p\ . ). the -and -year overall survival rates were . % and . % for the lap group and . % and . % for the open group (p= . ). meanwhile, the -and -years disease-(p= . ). iiic stage, lymph node status, ca - and adjuvant chemotherapy were independent prognostic factors affecting overall survival. the age, pt a/b, iiic stage, ca - and adjuvant chemotherapy were independent influencing factors of disease-free survival. conclusions: laparoscopic surgery for pt colorectal cancer surgery, it is not only in the play of its minimally invasive but also obtained with the similar long-term effect. but we need more multicenter, prospective, and large sample clinical studies to validate our findings. introduction: lymph node (ln) retrieval after surgery is important. in the present study we evaluated the efficacy of the fat dissolution technique using fluid containing collagenase and lipase to avoid staging migration after laparoscopic colorectal surgery. methods: seventeen patients who underwent laparoscopic ln dissection for colorectal cancer were evaluated. first, unfixed lns within the resected mesentery were explored by visual inspection and palpation immediately after the operation by the surgeon, which is the most common practice in japan. subsequently, the fat dissolution technique was used on remnant fat tissue, and the lns were evaluated again. the primary endpoint was whether the second assessment increased the number of lns evaluated. results: the median number of lns identified at the first and second assessments was and , respectively, resulting in a significant increase in the total number of lns evaluated ( vs. , p\ . , paired t-test). one positive node was identified among all the additional lns identified ( . %; / ). although staging was not altered in any patient, the second assessment resulted in an increase in the originally insufficient number of lns evaluated (\ for stage ii) in three patients, whose treatment may be altered. tumor cells detected after the fat dissolution technique were stained with carcinoembryonic antigen and cytokeratin- . conclusion: using the fat dissolution liquid on remnant fat tissue of the mesentery of the colon and rectum enabled identification of additional lns. this method should be considered when the number of lns identified is not sufficient after conventional ln retrieval, and may avoid stage migration. aim: the aim of this study is to evaluate the pathological resection margin after laparoscopic intersphincteric resection for low rectal cancer. method: from to , there were eight laparoscopic intersphincteric resection cases for low rectal cancer. we evaluated the clinicopathological findings and the positivity of pathological resection margin. results: the median distance from the anal verge to the tumor was mm (range, - ), and the median diameter of the tumor was mm (range, - ). there was no case with neoadjuvant therapy. the estimated tumor depth were ct in cases ( . %) and ct in cases ( . %), and the actual tumor depth were ptis in cases ( . %) and pt in cases ( . %) and pt in cases ( . %). the median distal resection margin was mm (range, - ). pathological resection margin, such as the proximal, distal and circumferential margin was negative in all cases ( %). there was no mortality, but morbidity occurred in two cases (one case of anastomotic leakage and one case of small bowel obstruction). no recurrence nor distant metastasis was observed in the follow up period. conclusion: there was no positive resection margin case in the series. our patient selection, indication and the technique were considered to be precise and appropriate. introduction: the fistulas of the intestine to the vagina or the bladder include a highly morbid entity, with several functional limitation and loss of the quality of life, its diagnosis is complex and more than its treatment, which include a wide range of possibilities that go from the simple derivative colostomy in search of the spontaneous closure of the fistula, under the complete correction of the pathology with resections, anastomosis and mini-vasive reconstructions. give to know our experience in the minimally invasive treatment of whole vaginal and whole vesicial fistules by laparoscopic via, for the last years. results: a total of patients were operated in this period, women and men, all those by laparoscopic via, with intestinal resection, in thick intestine cases, in one small intestine and in another case with the commitment of the two, everyone restriction and intestinal anastomosis and in no matter were colostomy, primary closures of the fistula in patients were required, conversion to open surgery in a case and there was no recurrence, patients had prolonged hospitalization for localized infections, a requirement reintervencion for revision. a patient suffried a umbilical eventration for the extraction site, which was corrected one year after laparoscopy. conclusion: minimally invasive surgery in patients with this type of pathology becomes an excellent strategy for the integral management of these patients. group work guarantees good results. robbie sparks, dr, ronan cahill; mater misericordiae university hospital background: precise preoperative localisation of colonic cancer is a prerequisite for correct oncological resection. effective endoscopic lesional tattoo is vital for small, radiologically unseen tumors planned for laparoscopic resection but its practice may be imperfect. methods: retrospective review of consecutive patients with preoperative endoscopic lesional tattoo who underwent laparoscopic colonic resection identified from our prospectively-maintained cancer database with supplementary clinical chart and radiological, histological, endoscopic and theatre database/logbook interrogation. results: patients ( males, mean age years, median bmi . kg/m , left sided lesions, screen detected, benign polyps, % conversion rate). in operations ( %) tattoo visibility was documented with tattoo absence noted in ( . %) although tattoo was identifiable in the pathological specimen in four. in those with "missing tattoos", six of the lesions were radiologically occult and in three the tumor was found in a different colonic segment then had been judged at colonoscopy. four patients had on-table colonoscopy and five were converted to laparotomy ( % conversion rate, p. ). mean postoperative length of stay was . (range - ) days. one patient's segmental resection contained only benign pathology requiring a second operation to remove the cancer. on univariate analysis, time between endoscopy and surgery (but not patient age, gender, bmi, endoscopist or surgeon seniority, tumor size or location) was significantly associated with absence of tattoo intraoperatively (p= . ). conclusion: recording related to tattoo is variable but definite lack of gross tattoo visualisation significantly impacts the procedure. the mechanism of tattoo absence is multifactorial needing careful consideration but solvable. the aim of the present study was to perform a systematic review of the literature to determine the role of antibiotics in the management of acute uncomplicated diverticulitis (aud). diverticular disease is the most common disease of the large bowel and poses a significant burden on healthcare resources. in the united states alone, the cost of diverticular disease has been estimated to be over $ billion making it the fifth most important gastrointestinal disease economically. the use of antibiotics in the management of aud, however, is primarily based on expert opinion as current high-quality evidence is lacking. recent studies have not only questioned the optimal type and duration of antibiotic regimens, but whether antibiotics provide any benefit in the treatment of aud. conclusions: antibiotic use in patients with acute uncomplicated diverticulitis is not associated with a reduction in major complications, readmissions, treatment failure, progression to complicated diverticulitis, or need for elective and emergent surgery. however, it increases the length of hospital stay. given the risk of selection bias in included studies, further randomized trials are needed to clarify the need for antibiotics in uncomplicated diverticulitis. laparoscopic para-aortic lymph node resection for colorectal cancer aim: we want to highlight the feasibility of a sigmoidectomy using total laparoscopic with a transanal extraction of the specimen. methods: it is a -year-old female patient, obese (bmi= kg/m ) to the antecedents of laparoscopic cholecystectomy and chronic constipation. she was treated three months ago for a sigmoidal diverticulitis complicated with a pelvic abscess. the evolution has been favorable under antibiotic therapy and percutaneous drainage of the abscess. the colonoscopy showed a multiple diverticula located between and cm from the anal verge. prophylactic sigmoidectomy was performed laparoscopically using trocars ( mm supra ombilical, mm fid and mm right flank). the specimen was extracted transanally, thus avoiding a pubic incision. the steps of the intervention were: -mobilisation of left colon -closing of distal left colon stump -rectal stump lavage -opening on the rectum -transanal introduction of the anvil -specimen transanal extraction -closing og rectal stump -colonic positioning of the anvil -coloractal anastomosis. results: the intervention was minutes. no perioperative incidents. the liquid regime was authorized on the night of the intervention. the operating procedures were favorable with an exit to j post operative. the anapath examination of the surgical specimen confirmed the presence of sigmoidal diverticula. conclusion: laparoscopic sigmoidectomy with transanal extraction of the specimen for benign desease is a seductive technique with satisfactory results. it avoids a pubic incision with its parietal and aesthetic complications. chengzhi huang; guangdong general hospital (guangdong academy of medical science) background: colorectal cancer (crc) is one of the most common malignant diseases over the world. of the causes of the death of crc, metastasis to liver or lung are the major factors. however, there is still lack of precise tumor biomarker that precisely predict the clinical outcome of crc. the salt-inducible kinase (sik ) encodes a serine kinase of amp-activated protein kinase (ampk) family, which may play critical roles in tumorigenesis and tumor progression. this study aimed the study the expression and clinical significance of sik and crc patients. methods: the expression of sik protein was measured by western-blot and analysis of immunohistochemistry. sik mrna expression in cancerous tissue was measured by rt-pcr. results: the expression level of sik was correlated with the following factors: tumor invasion (t stages), lymph node metastasis, clinical stages (tnm) and tumor location. the down-regulated sik implies poor clinical outcome measured by kaplan-meier analysis (p-value. ), and may act as an independent risk factor of crc patients. background: surgical specimens for resected colon cancer vary in quality and there remains no universally accepted technique to guide resection margins. a minimum of lymph nodes provides some quality assurance, however this remains a crude marker of optimal oncological surgery. a tool to precisely identify lymphatic drainage within the mesentery could improve the oncologic quality of resection and better guide adjuvant treatment through more optimal mesenteric lymphadenectomy. while fluorescence imaging (fi) has been described to identify nodal disease in several other cancers, feasibility and best practices have not been established in colon cancer. we describe a novel technique of fi using indocyanine green (icg) to identify lymphatic spread and potentially guide optimal mesenteric lymphadenectomy in colon cancer. methods: three consecutive patients with colon cancer undergoing a laparoscopic resection had peritumoral subserosal injection of icg for fi after extracorporealization of the mobilized specimen. three concentrations of icg were injected − mg/ ml, mg/ ml, and mg/ ml. a total of ml was given for each patient. using a modified laparoscopic camera, the icg was excited by light in the near-infrared (nir) spectrum, for real-time visualization of the lymphatic drainage. the main outcome measure was identification of lymphatic drainage. results: three patients with right-sided primary colon cancer were evaluated. all three patients had successful identification of the lymphatic drainage pattern along the mesentery. the most successful protocol was ml (concentration mg/ ml) subserosal injection at points within close proximity ( cm) of the tumor with a -gauge needle, then waiting minutes for complete mapping. no intraoperative or injection-related adverse effects occurred with -day follow-up. the median lymph node yield was . all specimens had tumor-free margins. conclusion: from this small series, fluorescence imaging with icg is a potentially safe and feasible technique for identifying mesocolic lymphatic drainage patterns. this proof of concept and protocol will lead to future studies to examine the utility of fluoresence imaging to guide more precise surgery in colon cancer. introduction: anastomotic leakage in colon/rectal surgery is a dangerous event with an occurance rate ranging from to %. the associated mortality rate is between - %. the white-light intraoperative subjective surgical assessment (the most frequently used approach) underestimates the actual anastomotic leakage rate. intraoperative tissue perfusion assessment by indocyanine green (icg)-enhanced fluorescence has been reported in multiple clinical scenarios in laparoscopic/ robotic surgery, as well as for for bowel perfusion assessment. this technology can detect microvascular impairment, potentially preventing anastomotic leakage. we reviewed the literature and present our data to evaluate the feasibility and usefulness of icg-enhanced ?uorescence in the intraoperative assessment of vascular peri-anastomotic tissue perfusion in colorectal surgery. methods and procedures: a pubmed literature narrative review has been performed. moreover, out of a total of robotic colorectal cases, we retrospectively analyzed icg-enhanced fluorescence robotic colorectal resections ( left colectomies- rectal resections- right- transverse- pancolectomy). results: after icg-technology use, the biggest (n[ ) case-series showed a rate of . - % of cases in which they changed the level of resection based on icg. icg technology may variably reduce the anastomotic leak rate from to %. however, the threshold values to define the actual sub-optimal perfusion are still under investigation. in our experience, out of icg cases performed: the conversion, intraoperative complication, dye allergic reactionand mortality rates were all %. post-op surgical complications: case of leak ( , %) and sbo for incarcerated hernia ( . %). in cases, with normal white-light assessment, the level of the anastomosis was changed after icg showed ischemic tissues. despite the application of icg, anastomotic leak has been registered. conclusions: icg-enhanced ?uorescence may intraoperatively change the white-light assessed resection/anastomotic level, potentially decreasing the anastomotic leakage rate. our data shows that this technology is safe, feasibile and may prevent anastomotic leakage. however, the decision making is still too subjective and not data driven. at this stage icg, beside being a promising technique, doesn't have high level of evidence (most of the reports are retrospective). some randomized prospective trials with an adequate statistical power are needed. a precise injection dose and timing standardization is required. the main challange is to develop a method to objectively obtain a real-time intensity assessement. this may provide objective metric tresholds for an intraoperative evidence/data-based surgical decision making. introduction: according to the world health organization, colorectal cancer is the rd most commonly diagnosed cancer in the world. one of the main risk factors for the development of colorectal cancer is obesity. obesity is seen to increase the risk of colorectal cancer by % in women per kg/m and % in men per kg/m . bariatric surgery is one of the treatments that is considered to achieve and sustain a significant amount of intentional weight loss in patients. considering that fact that bariatric surgery decreases obesity, this intentional weight loss would seem to provide a favorable outcome in terms of diagnosis and prognosis of colorectal cancer. a systemic review of the literature was conducted via pubmed to identify relevant studies from january through may . the main outcome for this study is to assess whether patients who underwent bariatric surgery (restrictive and malabsorptive procedures) had an increased or decreased risk of colorectal cancer. all studies included in this meta-analysis are retrospective cohort studies. results were expressed as standard difference in means with standard error. statistical analysis was done using fixed-effects meta-analysis to compare the mean value of the two groups between bariatric surgery and non-surgery in patients with colorectal cancer. (comprehensive meta-analysis version . . software; biostat inc., englewood, nj). results: four out of studies were quantitatively assessed and included for meta-analysis. among the four studies, , underwent bariatric surgery and , did not undergo bariatric surgery. there is a significant decrease ( . ± . ; p= . ) in the risk in patients developing colorectal cancer in patients who underwent bariatric surgery compared to those who didn't get surgery. conclusion: bariatric surgery patients appear to have a decreased risk of colorectal cancer compared to patients who did not have bariatric surgery. guh jung seo, hyung-suk cho; department of colorectal surgery, dae han surgical clinic, gwangju, south korea introduction: the incidence of rectal carcinoid tumors is increasing due to the widespread use of screening colonoscopy. endoscopic mucosal resection (emr) is a useful method for small rectal carcinoid tumors (≤ mm) because of its simplicity, quick procedure and low complication rates. we aimed to describe our experience and evaluate the outcomes of emr for rectal carcinoid tumors. the patients enrolled in this study were patients with small rectal carcinoid tumors who underwent emr using a submucosal injection technique of epinephrinesaline mixture between august and october . all medical records, including characteristics of the patients and tumors, complications, were retrospectively reviewed. results: the patients were men and women, with a mean age of . years (range, - years). en block resection was performed by emr in all cases. the endoscopic mean size of tumors was . mm (range, - mm). the pathologically measured mean size of the resected specimens was . mm (range, - mm). the mean size of resected carcinoid tumors was . mm (range, . - mm). the tumor shape was submucosal tumor in and polyp in . histological examination revealed that cases had resection margin positive of tumor and case had undetermined resection margin of tumor. of the patients, patients underwent endoscopic treatment and patients underwent transanal excision. no residual tumor was found in additionally removed tissue. there were cases with emr-related complications: early postprocedural bleeding and postpolypectomy syndrome. there was no significant bleeding requiring blood transfusion or perforations. conclusion: endoscopic mucosal resection is considered to be a relatively safe and useful method for treatment of small rectal carcinoids in selected patients. background: disturbance of sexual function after an operation for rectal cancer has often occurred. the relationship between autonomic nerves and arteries in pelvis was examined. methods: clinical studies of male patients with resected rectal cancer were performed using snap gauge method, penile-brachial index and evoked bulvo-cavernous reflex. in canine experiments, pelvic splanchnic nerve (psn) electric stimulation, arterial flow measurement, corpus cavernosum pressure measurement and muscle strip study using drugs were evaluated. results: in clinical studies of male patients, transection of the hypogastric nerve (hgn) and the sympathetic trunk did not affect the erectile function in the postoperative course. in animal experiments transection of these nerves did not affect the increase in inner pressure of the penis cavernosum. in postoperative cases in which only one side of the lower grade branches of the psn (s ) were preserved, the erectile function was preserved. in animal experiments in which the psn of one side was disturbed, the ipa flow of the same side decreased, while the flow of the other side increased. we have evaluated the role of adrenergic components in the psn on the erectile function in the dog. the effect of norepinephrine hydrochloride on canine vascular smooth muscle was examined in vitro. vascular smooth muscle strips from the ipa relaxed longitudinally. electrical stimulation of the psn increased blood flow in the ipa and also elevated the cavernous pressure. these increases were blocked in part by phentolamine, but not by propranolol or atropine. the effects of cholinergic and adrenergic agonists and antagonists on mechanical responses were also examined in muscle strips obtained from various arteries in the intra-pelvic region including the ipa. norepinephrine induced contraction in the iliac artery and relaxation in the ipa, and both the contraction and relaxation responses were blocked by phentolamine but not by propranolol. these findings suggest that in the dog, α-adrenergic components projected through the psn may contribute to penile erection. conclusion: blood flow in the ipa was controlled significantly by the same side psn, but compensatory by the other side psn. it is also conceivable that the erectile function through the psn is controlled by the sympathetic nerve, not by the parasympathetic nerve. in postoperative cases in which only one side of the lower grade branches of the psn (s ) were preserved, the erectile function was preserved. introduction: currently, neoadjuvant chemo-radiotherapy (ncrt) followed by low anterior resection or abdominoperineal resection are the standard treatments for locally advanced rectal cancer. ncrt can improve resecability, achieve better sphincter preservation and reduce local recurrence. although total mesorectal excision is the standard treatment for advanced rectal cancer, recent trends in minimally invasive treatments led to an increase in local excision or "watch and wait" in patients with an excellent response to ncrt. the purpose of this study, part of an ongoing research, is critically evaluating the feasibility of "non-operative treatment" for rectal cancer in a district hospital. methods and procedures: a total of patients with rectal cancer, who where treated with ncrt from january to august at "carlo urbani" district hospital in jesi (italy), were retrospectively reviewed. all patients had histologically-confirmed primary adenocarcinoma of the rectum located within cm from the anal verge. the involved patients completed ncrt and had no recurrence disease, distant metastasis, synchronous malignancies. they were classified according to the mandard's tumor regression grade (trg) into two clusters: group a (trg - ) and b . results: the average age of people is . and were male. five patients underwent abdominoperineal resection and % fell within group a. six patients had lymph nodes involved. four patients suffered relevant complications, such as wound complication, anastomotic leak, operative reintervention and death. univariate analysis showed that the main predictors of tumor regression were the absence of lymph-nodes involvement from initial imaging (p. ), normal initial carcinoembryonic antigen level (p. ) and tumor downstaging in imaging (p. ). in addition, most relevant complications occurred to elderly patients although they observed a good clinical response. besides, % of patients were found to be complete pathologic responders upon examination of the surgical specimen. conclusions: the oncologic feasibility of non-operative management for the patients with complete clinical response after ncrt has been growing, but some studies have suggested lack of oncologic safety in these patients. the patients with a complete clinical response expect good survival, but they may still harbor residual disease. no consensus on "watch and wait" policy in the field of rectal cancer was obtained, yet. our data did not entirely support this policy although it might be the best strategy, based on the predictors of tumor regression, to avoid the complications associated with surgery in elderly patients with significant medical comorbidities and fear of a permanent stoma. introduction: conventional incision laparoscopic surgery procedure for rectal cancer is widely accepted as a successful alternative to laparotomy now, bestowing specific advantages without causing detriment to oncological outcome. evolving from this, single-incision laparoscopic surgery (sils) has been successfully utilized for the removal of colonic tumors, but the literature lacks sufficient data analyzing the suitability of sils for rectal cancer especially for total resection mesorectal excision (tme), particularlyon oncological outcome. we report the short-term clinical and oncological outcomes from a large cases retrospective analysis of observational study of sils for tme procedure of rectal cancer. methods: rectal cancer patients who underwent transumbilical single incision laparoscopic tme surgery were recruited in the current study. short-term perioperative clinical parameters and oncological outcomes were observed and all patients were followed up after surgery. then summarize the preliminary application results. results: operations were accomplished successfully with single incision laparoscopy, patients were converted to multiport approach, and was converted to laparotomy, no diverting ileostomy was performed. the average operative time was ( . ± . ) min, with an average blood loss of ( . ± . ) ml, the median postoperative hospital stay was ( . ± . ) days. all patients received a r resection and the surgical margin were conformed negative in all cases, the median number of harvested lymph node is ( . ± . ), the specimens met the requirement of tme. there were postoperational complications, no operation-related mortality or postoperative anastomotic leakage was observed. no patient appeared recurrent in a median follow up of months. conclusions: total mesorectal excision surgery for rectal cancer can be safely performed using transumbilical single incision laparoscopic technique, with acceptable short-term clinical and oncological outcome. surg endosc ( ) background: any surgical trauma induces an inflammatory response, which is considered as a negative factor in the general immune response, specially in malignant disease. the c-reactive protein (crp) is an acute phase protein often used as a marker of surgical trauma. stent treatment has been used as a treatment option for colonic obstruction in palliative cases for many years, and also as a bridge to surgery in selected cases. in a pilot study we compared the inflammatory response after acute stent treatment or surgery for malignant colonic obstruction. method: we compared two consecutive series of treatment of acute malignant colonic obstruction, stent treatment or emergency surgery during - . all patients were admitted with acute colonic obstruction due to colorectal cancer. choice of treatment was based on attending senior colorectal surgeons' preference, patient comorbidities and disseminated disease was considered. patient age, crp, time to first defecation and length of stay was recorded. results: a total of patients were identified in a retrospective analysis. patients had acute stent treatment and had acute surgical treatment for colonic obstruction, all due to colorectal cancer. median age was y ( - ) with no difference between the groups. there was no difference in metastatic disease between the groups. median time until first defecation after treatment was significantly shorter for the stented patients ( h ( - )) compared with those operated ( h ( - )) (p, ). median hospital stay was also shorter in the stent group, days ( - ), versus days ( - ) in the surgical group (p= , ). crp did not differ between the groups before treatment. both treatments resulted in increased crp levels at postoperative days and , but the crp levels were significantly higher in the surgical group than in the stent group at both time points (pod p= , , pod p, ) conclusion: acute stent treatment in colonic malignant obstruction seems to induce a less pronounced inflammatory response compared with surgery, as shown by a significantly reduced increase in postoperative crp resulting in shorter time to first defecation and a shorter hospital stay. introduction: meckel's diverticulum is the most common congenital abnormality in newborns, present in about - % of them. diagnostic of meckel's diverticulum requires a high index of suspicion, and even with the use of modern imaging technologies, they are often diagnosed intraoperatively. what to do when an asymptomatic diverticulum is found incidentally during surgery for other causes is a matter of discussion. objective: the aim of this article is to report symptomatic and asymptomatic incidentally found cases seen in a fourth-level hospital in colombia. the reports of the histopathologic examinations carried out in the hospital in the last years were reviewed searching for those containing meckel's diverticulum in their diagnosis. patients were divided in asymptomatic and symptomatic groups. the asymptomatic group was defined as patients who were operated for a different indication and a meckel's diverticulum was found incidentally. morbidity was divided in early and late complications after the initial surgery. results: from january to june , a total of pathology reports included the diagnosis meckel's diverticulum. a total of adult patients were retrieved. all of those patients with meckel's diverticulum a total of patients were symptomatic, being sbo the most common complication and required the surgical remove incidentally. conclusion: the correct approach of the patients with diverticular pathology allows the early identification and the appropriate management of the surgical complications that can be presented. robert j czuprynski, md, grace montenegro, md; saint louis university hospital presacral masses are a rare entity, with an incidence of . % and can be classified in several categories, including inflammatory, neurogenic, congenital, osseous and miscellaneous. in this case, a neuroendocrine tumor was identified with concern for iliac chain lymphatic and gluteal metastasis. the patient underwent abdominoperineal resection, excision of presacral mass, lymph node biopsy and omental flap. final pathology returned as a grade ii neuroendocrine tumor arising from a tailgut cyst. a year old female with a ten year history of recurrent perianal, ischiorectal and deep postanal abscesses presents with a presacral mass biopsy proven well-differentiated neuroendocrine tumor. octreotide scan demonstrated avidity for presacral mas as well as left intergluteal lymph node and two internal iliac lymph nodes. chromogranin a, neuron-specific enolase and serotonin markers were all negative. the patient was taken to the operating room and underwent abdominoperineal resection, resection of presacral mass and internal iliac nodes with an omental flap. neuroendocrine tumors arising from tailgut cysts of the presacral space are rare in nature. in a retrospective study from great britain, four of thirty one tailgut cysts had malignant transformation, so it is generally recommended to resect the cysts. in this case, the patient's tumor was a moderately differentiated, grade ii with extensive lymphovascular and perineural invasion. there are no prospective studies showing neoadjuvant therapies in neuroendocrine tumors of the presacral space. according nccn guidelines, patient is currently asymptomatic with low tumor burden. recommended treatment at this time is observation with surveillance tumor markers every - months or octreotide. anastomotic leakage has been commonly regarded as one of the toughing postoperative complications in laparoscopic mid/low rectal cancer surgery, attenuating the short-term clinical benefits. the left colic artery (lca) has been routinely central-ligated in dissection process to guarantee the oncological effects, which may potentially attribute to the postoperative ischemia-induced anastomotic leakage in the patients with left-colic vessel variation, e.g. bypass or absent of riolan arch. however, no specific study focuses on the surgical benefits of lca preservation compares to conventional ones. herein, we conduct a single center randomized controlled trial, demonstrating that lca-preserving technique shows significant reduction rate of postoperative leakage as well as overall complications comparing to the traditional central-ligation group. no difference in survival rate and recurrence in short term is found between the two groups. the lca-preserving strategy is proven to be repeatedly safe and feasible, potentially reduce the risk of anastomotic leakage with comparable short-term outcomes. further investigation is required for both the oncological safety and long-term prognosis for this innovative technique. background: three-photon imaging (tpi), which was based on the field of nonlinear optics and femtosecond lasers, has been proved to be able to provide the -dimensional ( d) morphological feature of living tissues without the administration of exogenous contrast agents. the purpose of this study is to investigate whether tpi could make a real-time histological d diagnosis for colorectal cancer compared with the gold standard hematoxylin-eosin (h-e). methods: this study was conducted between january and august . a total of patients diagnosed as colon or rectum carcinoma by preoperative colonoscopy were included. all patients received radical surgery. the fresh, unfixed and unstained full-thickness cancerous and the corresponding normal specimens in the same patient, were immediately prepared to receive tpi after surgery. for d visualization, the z-stacks were reconstructed. all tissue went through routine histological procedures. tpi images were compared with h-e by the same attending pathologist. results: the schematic diagram of tpi is shown in fig. a . peak tpi signal intensity excited at nm was detected in living tissues. the field of view (fov) was µm and the imaging deep was µm in each specimen. in normal specimens, glands lined regularly and characterized as a typical foveolar, which was comparable to h-e images ( fig. b and d ). in cancerous specimens, irregular tissue architecture and shape were identified by tpi, which was also validated by corresponding h-e images ( fig. c and e ). tpi images can be acquired with a view of d visualization. based on rates of correlation with pathological diagnosis, the accuracy, sensitivity, specificity, positive predictive value, negative predictive value were %, %, %, %, . %, respectively. conclusions: it is feasible to use tpi to make a real-time d optical diagnosis for colorectal cancer. with the miniaturization and integration of colonoscopy, tpi has the potential to make a real-time histological d diagnosis for colorectal cancer in the future, especially in low rectal cancer. erica pettke , abhinit shah , vesna cekic , daniel feingold , tracey arnell , nipa gandhi , carl winkler, md , richard whelan ; mount sinai west, columbia university introduction: alvimopan (alvim) is a peripherally acting µ-opioid receptor antagonist used to accelerate gastrointestinal functional recovery postoperatively (postop) after bowel resection. the purpose of this retrospective study was to compare the time to first flatus and bowel movement (bm) as well as length of stay (los) following elective minimally invasive colorectal resection (crr) in a group of patients (pts) who received alvimopan perioperatively (periop) vs a group that did not get this agent. methods: a data review from to from irb approved databases was carried out. operative, hospital and office charts were reviewed. routine use of alvim for elective crr cases was stared in . besides gi data, preoperative comorbidities and day postop complication rates were assessed. the results with periop alvim were compared to a no-alvim group. the students t and chi-square tests were used. results: a total of pts underwent elective crr. alvim was administered periop to pts ( %). the breakdown of indications between groups were similar. alvim pts were younger ( . vs. . years old, p= . ) and, as regards comorbidities, less likely to have heart disease (cad . % vs . %, other heart disease . % vs . %) but were otherwise similar. the rate of laparoscopic-assisted (alvim, . %; no alvim, %) and hand assisted or hybrid operations (alvim, . %; no alvim, %) were similar. alvim pts had significantly earlier return of flatus ( . vs . days) and first bm ( . vs . , p. for both) than the no alvim group. there was also a trend toward a shorter los ( . vs . days, p= . ) for the alvim group. overall complication rates were similar, however, alvim pts had lower rates of post-operative ileus ( . % vs . %, p. ), sssi's ( . vs %, p= . ), and blood transfusion ( . vs . %, p= . ) than the no alvim group. conclusion: the two groups compared were largely similar (most co-morbidities, indications, crr type) with the differences in age and cardiac issues noted. the impact of the higher rates of sssi's, blood transfusion, and mi in the no alvim group on gi function is unclear. pts who received alvim periop had an accelerated return of bowel function, decreased postoperative ileus and shorter length of stay. these results suggest that alvim is effective in reducing the postoperative ileus but further study is warranted. background: laparoscopic total proctocolectomy (tpc) is selected for minimally invasive surgical treatment of familial adenomatous polyposis (fap) and ulcerative colitis (uc). our policy of tpc is no diverting ileostomy for fap and creating ileostomy for ibd because most of the patients received steroid therapy. objective: we examined the outcome of laparoscopic tpc according to disease of fap and ibd (uc and crohn's disease). methods: twenty-three consecutive patients who underwent laparoscopic tpc between april and march were examined. the patients were divided into fap group and ibd group. results: seven patients of fap and patients of ibd (uc , crohn's disease ) underwent laparoscopic tpc or total colectomy. among them, patients (fap , ibd ) were cancerassociated cases. the procedures of the fap group was tpc with iaca in patients and hals total colectomy with ira in patient. the procedures of ibd group were tpc with iaca in patients, tpc with iaa in patients, total colectomy with ira in patients, of which hals cases. the mean operative time and blood loss were minutes, . g in the fap group and minutes, . g in the ibd group, respectively. diverting ileostomy was constructed in patients of only uc group. early complications of fap group were observed in cases (postoperative ileus , anastomotic leak with conservative treatment ), and those of ibd were observed in cases (ileus , anastomotic leak with conservative treatment , abdominal abscess , wound infection ). the median postoperative hospital stay was days in the fap group and days in the ibd group. complications requiring reoperation were cases (fap : intestinal obstruction, ibd : inflammation of stoma-closure site). no cancer recurrence and mortality were observed. one case of fap underwent additional transanal mucosal resection due to new lesion of adenoma. conclusions: laparoscopic total proctocolectomy for fap and ibd was performed safely, especially less complications occurred in fap patients without diverting ileostomy. in addition, followup of remaining mucosa is important in iaca and ira patients. treatment of complex anal fistula has always been a nightmare for surgeonsby conventional means. even the lowest and simple looking fistula at times comes out to be a complex one with high incidence of recurrence above %. most of the availability diagnostic including mri is nit conclusive and many a times the surgeon remains in a state of confusion as to what is going to come at the operation table. the conventional treatment modalities also usually leave the patient wounded needing almost to weeks to heal with a risk of sphincter damage and a high risk of recurrence. we would be presenting the technical details and results of our series of cases of complex anal fistula treated by video assisted endoscopic therapy. jun higashijima, phd, mitsuo shimada, professor, kozo yoshikawa, phd, takuya tokunaga, phd, masaaki nishi, phd, hideya kashihara, phd, chie takasu, phd, daichi ishikawa, phd; department of surgery, the university of tokushima background: one of the important causes for anastomotic leakage (al) in anterior resection is an insufficient blood flow of the stump. the hems (hyper eye medical system) and spies (laparoscopic icg system) can detect the blood flow of fresh organ intraoperatively by injection of indocyanine green (icg). and thermography also can evaluate the bloodflow less invasively. the aim of this study is to evaluate the usefulness of icg system and thermography in laparoscopic anterior resection. patients and methods: this study retrospectively included patients who underwent laparoscopic anterior resection for colon cancer with double stapling anastomosis procedure. blood flow evaluation of oral stumps was performed with measurement of fluorescence time (ft) using hems and spies. and bloodflow was also evaluated by thermography. result: evaluation by icg system: in all cases, the al rate was . % ( / cases). over ft cases, the al rate was %, higher than that of under s cases and these patinets need additional management, covering stoma or additional resection. and in border cases, ft * sec, al rate is . %, higher than under s cases. in these borderline cases, if covering stoma was performed in patinets with more than three well known risk factors, the al rate reduced to . % and false positive was . %. and under s cases, they need no additional management. evaluation by thermography: in residual intestine, the temperature was siginificantly higher than resected intestine ( . vs . ?, p. ). and the temperature in ft under s cases was significantly higher than over ft over s cases ( . vs . ?). the temperatue and ft was tended to be oppositely correlated (r = . ). conclusion: both icg system and thermography may be useful to avoid anastomotic leakage. introduction: some patients who undergo neoadjuvant chemoradiation therapy (crt) for rectal cancer achieve a pathologic complete response (pcr) in which no tumor cells are discovered during pathologic analysis of the resection specimen. achievement of pcr is correlated to improved prognoses relative to non-pcr counterparts. such correlations are not well established in the context of a community-based hospital. the study sought to examine response rates, recurrences, and survivals in locally advanced rectal cancer patients and compare patient outcomes to those achieved at major academic institutions. methods and procedures: a single-center retrospective chart review was performed at a local, community-based hospital. study population consisted of patients with locally advanced rectal cancer treated with neoadjuvant crt followed by surgical resection. patients with a history of metastasis, inflammatory bowel disease (ibd), hereditary cancer syndromes, concurrent or prior malignancy, and emergent surgery were excluded. results: patients ( . %) achieved pcr in the test population. across both groups, mean age (p =. ), gender (p=. ), and ethnicity (p=. ) were found to be comparable. mean interval between crt and or (p=. ), pre-op stage (p=. ), number of nodes (p=. ), radiation dose (p=. ), tumor location (p=. ), and days of follow-up (p=. ) presented statistically insignificant differences between groups. at years, non-pcr patients ( . %) had a recurrence with zero recurrences in the pcr group. -year mortality presented non-pcr patients ( . %) compared to pcr patient ( . %). conclusion: a multidisciplinary approach to rectal cancer consisting of standardized preoperative treatment and surgical resection can achieve patient outcomes and survival similar to those of larger academic institutions, even in the context of a community-based hospital. objective: the aim of this study was to assess safety and feasibility of total mesorectum excision (tme) within the holy plane based on embryology for rectal cancer. methods: prospectively collected data of consecutive patients with rectal cancer who underwent tatme from november to august were enrolled. surgical outcomes including tme completeness, operative time for tme completion, blood loss, complications, pathological findings and length of hospital stay were assessed. surgical procedure: after performing ractal lavage, self-retaining anal retractor was set, and anal dilators were used for an atraumatic introduction of the transanal access devise (gelpoint path). three of -mm trocars and one of -mm trocar were inserted through the gelpoint path in a quadrant shape. then the gelpoint path was introduced through the anal to rectum. after rectosigmoid colon was temporally clamped using an atraumatic endo bulldog clip, pneumoperitoneum was maintained at mmhg with carbon dioxide via an air seal platform. a purse-string suture using a polypropylen with -mm rounded needle was performed clock-wise to tightly occlude the rectum with a cm margin distal to the tumor. after irrigation with saline and marking dissection line with tattooing the rectal mucosa distal to the mucosal folds, a mucosal transection of rectum was initiated. then a full-thickness rectal transection was performed circumferentially. after dissection of rectococcygeal muscle at o'clock and rectourethral muscle in the anterior wall, circumferential sharp dissection within the holy plane was performed. dissection proceeded between the endopelvic fascia and the prehypogastric nerve fascia in the posterior plane, between the denonvilliers's fascia and the anterior mesorectum in the anterior plane, and between pelvic nerve and the mesorectum with recognition of the neurovascular bandle in the lateral plane. then the dissection connected to the abdominal plane via laparoscopic team with working together until tme completed. results: tme completion performed in ( . %) patients. thirty five ( . %) patients had negative of circumferential resection margin. mean of tme completion time and blood loss were min and g, respectively. one ( . %) patient had an intraoperative complication and ( . %) patients had postoperative complications. no other complications occurred. the length of hospital stay was days. conclusions: tatme within the holy plane on based on embryology is a safe and feasible procedure for rectal cancer. abstract: acromegaly is a debilitating condition marked by excessive production of growth hormone. this leads to disfiguration, cardiopulmonary complications, and increased risk for cancer. with up to a two-fold increased risk of developing colon cancer and worse prognosis for diagnosed patients, earlier and more frequent screening has been recommended. we present a case of a -year-old hispanic male with acromegaly who presented to our hospital with hematochezia and weight loss. a near-obstructing rectal adenocarcinoma with metastasis to the liver was discovered. after completing neoadjuvant chemoradiotherapy, he underwent laparoscopic low-anterior colon resection and simultaneous open hepatic trisegmentectomy. in this case report, we review the literature and current guidelines in screening this high-risk group of patients. introduction: in this study, we discovered that in cme for laparoscopic right hemi-colectomy starting at the ileocolic vessel and proceeds along the superior mesenteric artery (sma) achieved a better oncologic outcome compared with the conventional ones proceeding along the superior mesenteric vein (smv). methods and procedures: patients admitted to a shanghai minimally invasive surgical center were included from september to january and were randomly divided into two groups: study group (n = ) and conventional group (n = ). operation time, blood loss during surgery, liquid intake time, postoperative hospital stay, postoperative complications within days after surgery, specimen length, and number of lymph nodes harvested as well as the positive lymph node rate were observed and studied. results: there was no statistical difference between the two groups with the exception of number of lymph node dissected and the positive lymph node rate for stage iii colon cancer. the study group had more lymph node retrieved and also a higher positive rate compared with the conventional group. the mean number of lymph node retrieved of study group was . ± . , while the conventional group was . ± . (p. ). and the positive lymph node rate for study group was . %, the conventional group was . %. conclusion: when performing the laparoscopic right hemi-colectomy, dissecting the lymph node along with the left side of sma could be achievable and there were no differences of surgical outcomes compared with the conventional ways, while there was a higher number of lymph nodes dissected and positive rate probably leading to a better oncologic outcome. aims: we describe laparoscopic surgery for rectal cancer using needlescopic instruments performed at our department. methods: from to , cases of rectal cancer underwent surgery using needlescopic instruments: cases at rectosigmoid colon, at upper rectum, and at lower rectum. an umbilical camera port ( -mm) and two needlescopic instruments (endorelieftm) were directly punctured into the assistant surgical site. we started with port sites. in low rectum cancer cases, we kept the good pelvic visualization to lifting the peritoneum of the bladder onto the ventral side using the lone star retractor staystm. results: the median age was years ( - years), with males and females, and body mass index was . kg/ m ( - kg/m ). anterior resection was performed in cases, low anterior resection in cases, intersphincteric resection in cases, abdominoperineal resection in cases, hartmann's procedure in cases, and lateral lymph node dissection in case. in addition, one case of t b (bladder) was converted from laparoscopic to open surgery. however, there were no cases in which needlescopic instruments were replaced with conventional forceps. moreover, intraoperative complications related to the forceps were not observed. conclusions: in rectum cancer surgery, needlescopic instruments leave a small postoperative wound; healing is rapid and the cosmetic result is excellent. surgical safety is comparable to that using conventional forceps. there is no problem with the rigidity of needlescopic instruments. however, where the shaft is curved, operative control requires attention to mobility and directionality. in low rectum surgery, use of needlescopic instruments is limited due to the curvature of the shaft during the dissection of the anterior rectum wall, but it is possible to maintain a good field of view by using auxiliary equipment. therefore, more cases could be considered for surgeries using needlescopic instruments with the help of auxiliary equipment. introduction: anastomotic leaks are devastating complications of colorectal operations that lead to significant morbidity and potential mortality. inadequate tissue perfusion is considered a key contributor to anastomotic failure following colorectal operations. currently, clinical judgment is the most commonly used method for evaluating adequate blood supply to an anastomosis. more recently intraoperative laser angiography using indocyanine green (icg) has been utilized to assess tissue viability, particularly in reconstructive plastic surgery. this technology provides a real-time evaluation of tissue perfusion and is a helpful tool for intra-operative decisions, particularly in deciding to revise an intended colorectal anastomosis. our study aimed to determine if there is a statistical significance in colorectal anastomotic leak or abscess rate using icg compared to common clinical practice. methods and procedures: patients undergoing left-sided colorectal operations, between march and february , were retrospectively reviewed. patients' colorectal anastomoses were evaluated using icg angiography (icga) to qualitatively assess tissue perfusion (icg group). peri-operative and post-operative outcomes, including anastomotic leak and abscess rates, were compared to patients who had colorectal operations without icga (control group). the primary outcomes of intra-abdominal leak rate and intra-abdominal abscess rate were compared using exact chi-square tests. the secondary outcomes of -days or return, mortality, and readmission rate were compared using chi-square tests. all statistical analyses were performed using sas software. results: two leading indications for surgery included malignancy (n = ) and diverticulitis (n = ). the majority of patients either had a low anterior resection (n = ) or sigmoidectomy (n = ). all operations were primarily minimally invasive. no statistically significant difference was seen between the two groups in regards to patient demographics, rate of proximal diversion (p = . ), and splenic flexure mobilization (p = . ). patients in the icga group were more likely to have high ima ligation than in the control group ( . % vs. . %, p-value. ). of the icga group, of the patients underwent additional colonic resection while of the did not undergo additional colonic resection. there was no statistically significant difference in primary or secondary outcomes between the two groups. conclusion: icg angiography has become a helpful adjunct in determining adequate perfusion to an intended colorectal anastomosis. this data is unable to support any difference in patient outcome utilizing this technology over surgeons' visual and clinical assessment. our results may contribute to larger studies to determine if there is a true difference in anastomotic leak or abscess rate using this technology. objective: to investigate the feasibility and surgical strategy of complete mesocolic excision (cme) with completely medial access by "page-turning" approach (cmapa) for the laparoscopic right hemi-colectomy. the cmapa is a modified medial approach of cme, which focus on the exploration of surgical plane instead of the recognition of vessels. surgical procedures: ( ) start point: the anatomy projection of ileocolic vessel; ( ) expose the whole trunk of smv to the level of inferior edge of pancreas before ligating any branches, for the purpose of high tie and verifying their location; ( ) enter the intermesenteric space (ims) and right retrocolic space (rrcs) with cranial and right extension through transverse retrocolic space (trcs); ( ) complete mobilize the mesocolon and remove the tumor en-bloc. see figure ? . clinical outcome: from september to march , there were patients underwent cmapa in shanghai ruijin hospital. the average operation time was . ± . minutes, average blood loss was . ± . ml, number of lymph node was . ± . , average specimen length was . ± . cm, flatus time was . ± . days, fluid intake time was . ± . days and average hospital stay was . ± . days. the overall complications rate was . % ( / ). compared to traditional medial approach of cme performed in our center, the blood loss, operation time and hospital stay were significantly reduced by performing cmapa for laparoscopic right hemi-colectomy. conclusion: the advantage of the cmapa ( ) to avoid the laparoscopic "leverage effect" and "tunnel effect". ( ) to make the branches of superior mesenteric vessels more easily recognized. ( ) to offer surgeons an alternative route entering the trcs, ims and rrcs. ( ) to avoid repetitive flipping of the colon complying with the "no touch" principle, and to lower the requirements of assistants. figure : anatomy and surgical planes concerning cmapa. aim: we have reported a possibility of "one-stop shop" simulation for liver surgery by mri using gadoliniumethoxybenzyl-diethylenetriamine pentaacetic acid (eob-mri) (emerging technology, sages )., which is characterized by ( ) one-time examination, ( ) no-radiation exposure, ( ) demonstration of liver vasculatures including biliary tract, ( ) diagnosis of tumors, ( ) volumetry and ( ) estimation of liver functional reserve in each segment. the aim of this study is to investigate usefulness of "one-stop shop" simulation for liver surgery using eob-mri. methods: accuracy of liver vasculatures: d-reconstruction of dynamic eob-mri imaging was done by synapse vincent software (fujifilm medical co., ltd., japan), using a manual tracing method. visualization of hepatic vessels in eob-mri was compared with that in dynamic ct in patients. assessment of liver functional reserve: the standardized signal intensity (si) of each segment was calculated by si of each segment divided by si of the right erector spine muscle. the standardized total liver functional volume (tlfv) was calculated by ∑ [k= to ] (standardized si of segment (k) volume of segment (k)) divided by body surface area. the following formula of resection limit was established using normal liver cases ( % of the liver is resectable) and unresectable cirrhotic patients such as recipients of liver transplantation ( % of the liver is resectable). the estimated resection limit (%)= % (the standardized tlfv of the patient - )/ , . this formula was validated using other patients who underwent hepatectomy. results: accuracy of liver vasculatures: the liver simulation by eob-mri succeeded in demonstrating hepatic vasculatures including biliary tract, diagnosis of hepatic tumors, and volumetry without any radiation exposure. regarding the vessel anatomy at hilar area, biliary tract was more clearly visualized in eob-mri. regarding the hepatic artery, right and left hepatic arteries were well visualized in all cases, however, small-sized middle hepatic artery was visualized in only one out of patients. assessment of liver functional reserve: as a result of validation of the patients, one patient having resection volume with over the resection limit died of liver failure, however, the other cases within their resection limits did not suffer from liver failure. conclusion: "one-stop shop" liver surgery simulation could contribute to safety of liver surgery such as laparoscopic hepatectomy, because of no radiation exposure, accurate assessment of anatomical variations especially biliary tract, and helping decision making of resection volume. showing key steps of the procedure to be viewed. the in-studio program was hosted by an education specialist from the science center and a surgical resident from our institution, with laparoscopic instruments available for manipulation by participants. participants then viewed a video highlighting the roles of all healthcare providers involved in the specialty to be featured, including nurses, physicians, dietitians, psychologists, technologists, etc. live questions and answers were then encouraged between students and surgeons during the surgery broadcast. the program also expanded from high schools to vocational-technical colleges and nursing schools. results: during the - academic year there were sessions presented to schools, with student participants. by the - year this increased to sessions presented to schools, with participants. in sum, throughout the first years of the program, there were schools attending, with a total of , participants. of polled high school participants, % of responders acknowledged considering a career in healthcare after this experience. conclusion: over years, our program has grown steadily in popularity such that schools from several counties attend and regularly return, and we have been asked to expand the program to create a surgical summer camp for students interested in science and technology. live broadcast surgery in an elective, minimally invasive format provides unique visibility and access to surgical procedures for student audiences and promotes future interest in healthcare careers. surg endosc ( ) :s -s p improving trainees' self-assessment through gaze guidance introduction: effective learning to become competent in surgery depends on a trainee's ability to accurately recognize their strengths and weaknesses. however, a surgical trainee's self-assessment is poorly correlated with expert assessment. this study aimed to improve self-assessment by the visual gaze guidance provided through telestration in laparoscopic training. we hypothesized that visual conveyance of where to look or perform actions on the laparoscopic video enhances the trainees' awareness of the gaps in their skills and knowledge. methods and procedures: a lab-developed telestration system that enables the trainer to point or draw a free hand sketch over a laparoscopic video was used in the study (fig. ). seven surgical trainees ( surgical fellow, research fellow, pyg- and pyg- ) participated in a counterbalanced, within subjects controlled experiment, comparing standard guidance with telestration-supplemented guidance. the trainees performed four laparoscopic cholecystectomy tasks -mobilizing cystic duct and artery, clipping the duct, clipping the artery, and cutting the duct and artery, on a laparoscopic simulation. performance assessment, adapted from the global rating scale (grs) instrument, was completed by the trainers and trainees at the end of each task. the mean self-assessment scores were compared with the trainers' scores by the linear mixed model, where the trainees' performance indicated by the trainers' scores was control. the assessment alignment was evaluated by spearman's rho. results: the trainers' scores were significantly lower than the self-assessment scores in the standard guidance, while the scores of the trainers and trainees were much more similar (fig. ) . the correlation between the trainers' and trainees' assessment in telestration guidance was high (r= . , p. ), compared to the standard guidance (r= . , p= . ). the correlation comparison for each grs criterion shows a significant increase (p= . ) in the assessment alignment for depth perception in telestration guidance (r= . , p. ), compared to the standard guidance (r= . , p= . ) (fig. ) . the visual gaze guidance improved the alignment of assessment between the trainer and trainees, especially for the assessment alignment in depth perception. for visual gaze guidance to become an integrated part of the training, further work needs to be conducted to understand how gaze guidance change the nature of the training process. applying to surgical residency: what makes the best candidates? yann beaulieu, beng, louis guertin, md, frcsc, ariane p smith, md, margeret henri, md, frcsc, facs; university of montreal objective: while quotas for canadian surgical residency programs are at their lowest point in ten years, the number of canadian graduating medical students is at an apogee. this year, only spots in surgical residency programs were available for students applying to carms. undergraduate medical students individually collect anecdotal information regarding what influences admission to their surgical subspecialties of interest, as scarce literature covers the topic. we thus surveyed surgeons and residents to analyze the relative importance of modifiable factors and innate attributes in the selection of new surgical residents. methods: an electronic survey was sent to all surgeons and surgical residents affiliated with the university of montreal. participants were asked to specify their surgical subspecialty, their status, their level of experience and whether they were an active member of a residency selection committee. the subjective importance of predefined application elements and candidate qualities was assessed using -point likert-type items. results: of the surgeons and residents to whom the survey was sent, ( . %) and ( . %) completed the survey. evaluations of elective rotations and evaluations of core rotations were considered very important by . % and . % of responders respectively. regarding letters of recommendation, the content was rated very important ( . %) more often than the notoriety of the author ( . %). networking with key surgeons was considered the least important element to prioritize with % of negative assessments. with regards to the fundamental qualities of surgical candidates, the extremes were "clinical judgement" with . % and "innate technical ability" with . % of responders rating them very important. no significant differences in responses were observed between staffs and residents, between members and non-members of selection committees, between different levels of surgical experience and between surgical subspecialties. conclusion: clinical judgement and performance in core and elective rotations along with strong personalized letters of recommendation should be prioritized by medical students aiming for a surgical career. kazuhiko shinohara, phd, md; school of health science, tokyo university of technology background and objective: many types of training devices had been proposed since the early days of endoscopic surgery. however, they are too expensive for daily training of novices. we developed a simple and economical training device made of frozen fruit and agar. material and methods: to make this device, g of agar powder was added to ml of boiling water and boiled for min. the solution was then poured into a stainless steel tray containing frozen blueberries and lychees and refrigerated for h. basic maneuvers required during endoscopic dissection and resection of a tumor with laparoscopic forceps and electrosurgical devices were then performed using this agar model in a conventional laparoscopic training box. results: using this model, endoscopic dissection and enucleation of a tumor with an electrosurgical device could be practiced repeatedly with minimal expense and preparation. background: situs inversus totalis (sit) is a rare congenital anatomy and a challenging condition for laparoscopic surgeries because standardized strategy to overcome such anatomical difficulties. mirror-reversed video images of laparoscopic surgeries for patients with normal anatomy could help to develop surgical strategies for patients with sit. we had a chance to evaluate this idea with a treatment of a patient of early gastric cancer, and describe the surgical results of the case. patient and methods: seventy-two-year-old women with a history of sit was referred to our department for the treatment of early gastric cancer, and laparoscopic distal gastrectomy with d + lymphadenectomy was scheduled. a video record of the same surgery for a patient with similar physical attribute performed before then was retrieved, and was edited with a computer into full length, totally mirror-reversed images of the surgery. designated operator and assistant simulated the operation using the video several times before surgery. results: laparoscopic distal gastrectomy was performed with d + lymphadenectomy while the operator was on the left side of the patient and the assistant on the other side, being opposite positions as usual. laparoscopic b- reconstruction was followed using "delta anastomosis" technique reported by kanaya et al. total laparoscopic procedures were completed with the operation time of minutes and the blood loss below measurable limits. no appreciable complications were observed after surgery and the patient was discharged on postoperative day . no recurrence of the disease was detected until years after surgery, conclusion: although further validation is unlikely because of a rare incidence of this anatomy, the same technique would be recommended for one of the preoperative preparations for similar cases. background: surgical simulation is thought to provide a basis for improvement of resident surgical skill training, in the safety of a simulation setting. it is unclear whether surgical skills learned in a simulation curriculum actually contribute to the improvement of surgical skills when transferred to the or. methods: a ten question online survey was sent to attending surgeons and residents. the questionnaire focused on domains: confidence, independence, transferable skills, improvement of skills/knowledge and time spent on the simulation curriculum. evaluation data was collected and anonymously analyzed. background: minimally invasive surgery poses a unique learning curve due to the requirement for non-intuitive psychomotor skills. programmes such as the fundamentals of laparoscopic surgery (fls) provide mandatory training and certification for many residents. however, predictors of fls performance and retention remain to be described. this single-centre observational study aimed to assess for factors predicting the acquisition and retention of fls performance amongst a surgically naïve cohort. methods: laparoscopically naïve individuals were recruited consecutively from preclinical years of a medical university. participants completed five visuospatial and psychomotor tests followed by a questionnaire surveying demographics, extracurricular experiences and personality traits. individuals completed a baseline assessment of the five fls tasks evaluated by fls standards. subsequently, participants attended a -minute training-course over week one and two on inanimate box trainers. a post-training assessment was performed in week three to evaluate skill acquisition. participants were withdrawn from laparoscopic exposure and retested at four onemonth intervals to assess skill retention. introduction: bipolar energy can cause thermal injury to adjacent organs when used improperly. sages fuse curriculum provides didactic knowledge on principles and best practices for safety, but there is no hands-on component to practice these skills. the objective of this study is to compare the effectiveness of the vest™ bipolar training module in addition to the fuse curriculum. methods and procedures: the study was a mixed design with two groups, control and simulation. after a pre-test that assessed their baseline knowledge, the subjects were randomized to two groups. both groups were given a min presentation, reading materials from the fuse manual and an online didactic module on bipolar energy. the simulation group also practiced on the simulator for one session that consisted of five trials on the effect of activation time on thermal damage and the importance of providing a margin of safety by sealing short gastric vessels. after one week the performance of both groups was assessed using a post-questionnaire. one week after the post-test both groups performed sealing of vessels on an explanted porcine mesentery with vessels perfused. their performance was videotaped and their activation times were recorded. a total safety score was calculated by assessing the proximity of the location of activation to the intestine by two independent raters. wilcoxon -signed rank and mann-whitney u tests were used to assess difference within and between groups. results: a total of residents ( in each group) participated in this irb approved study. median test scores for both groups increased (simulation, p= . and control, p= . ). no difference was found between the two groups in their pre-test (p= . ) and post-test (p= . ) scores indicating learning. the median total activation time for control group was higher ( . s) compared to simulation ( . s) but was not statistically significant (p= . ). there was a moderate agreement between two raters for margin of safety (kappa= . , p. ). total safety scores showed no difference between the two groups (p= . ). conclusions: subjects with simulation training had lower activation time compared to control. training for margin of safety requires more simulation refinement. small sample size and variations in the explanted models contributed to variability in data but even with small sample size, simulation training along with the fuse curriculum trended towards being more beneficial than the fuse curriculum alone. the general, that aims to build educational infrastructure and standardize training and education in laparoscopy throughout mexico. ilap participants engage in didactic and hands-on modules in educational theory, laparoscopic techniques, and simulation based education (sbe), and then develop and implement a -day sbe course for local trainees. the purposes of this study were to understand the existing educational environment at a single institution in mexico and measure the changes in perceptions, attitudes, and engagement in surgical education after an intensive training course. methods and procedures: all faculty and of general surgery resident participants completed a survey that contained items designed to assess the existing educational environment at a large, public hospital in mexico. using a -point likert scale, residents self-rated the quality of faculty feedback and the learning environment within their institution ( =strongly disagree, = neutral, =strongly agree). faculty rated their perceptions of the same educational themes. upon completion of a faculty-lead simulation course, residents rated the educational environment during the course. faculty provided additional qualitative feedback. descriptive analyses were performed. irb-exemption was obtained through lurie children's hospital. results: discordance existed in perceptions of the existing educational environment. the greatest disparity between resident and faculty perceptions included "faculty provide sufficient feedback in the operating room" ( % vs. %), "faculty promote an active learning environment" ( % vs. %), and "residents may ask questions without fear of negative evaluation" ( % vs. %). faculty and residents agreed with "residents are sometimes afraid to speak up in the operating room for fear of retaliation" ( % each). post-course evaluations (n= ) revealed universal improvement in all educational themes during the simulation course. qualitative feedback revealed most faculty plan to incorporate open communication and safe learning into their practice. residents were equally positive, with % optimistic that they will see changes within the educational environment. conclusions: significant discordance exists in resident and faculty perceptions of the educational environment at a large teaching hospital in guadalajara, mexico. after participation in the ilap course, residents noted demonstrable change in the faculty approach to education and feedback, and both faculty and residents expressed optimism for increased engagement in education. the immediate successes of the ilap initiative should be followed over time, as the ultimate measure of success is sustainability and scalability throughout mexico. background: laparoscopic anterior resection is technically challenging and the learning curve is long. well-designed formative assessments can provide trainees effective and constructive feedback, an important element in efficient learning. previously reported assessments for laparoscopic colorectal procedures were developed for summative assessment. we aimed to develop a formative assessment tool to evaluate competence and provide trainees with effective feedback in laparoscopic anterior resection. methods: the assessment tool was developed by an expert panel from mcgill university affiliated hospitals. the procedure was deconstructed into a series of sequential steps including general domains, surgical principles, injury prevention and technical skills specific to laparoscopic anterior resection. the tool contains discrete items with global rating scales for each step of the operation; each domain was scored using a -point likert scale, with anchors for scores of , and . each operation was assessed through direct observation in the operating-room by the attending, a trained observer, and trainees themselves. intraclass correlation coefficients (iccs) were calculated to estimate interrater reliability for ( ) attending surgeon and trained observer, ( ) attending surgeon and self-assessment, and ( ) trained observer and self-assessment. internal consistency was measured using cronbach's alpha. comparison between training levels was done using mann-whitney u-test. the global operative assessment of laparoscopic skills (goals) was also used to assess trainees' general laproscopic skills. spearman's correlation was used to determine association between goals and this procedure-specific tool. overall usefulness of this tool was evaluated using a cm visual analog scale. results: in this pilot study, fourteen operations, performed by experienced surgeons and trainees were assessed. the icc between ( ) attending surgeon and observer was . ( % ci . to . ) ( ) observer and self-assessment was . ( % ci . to . ), and ( ) attending surgeon and self-assessment was . ( % ci - . to . ). the internal consistency of the items was excellent (cronbach's α= . ). there was a significant difference in median total score between experienced surgeons and trainees ( . ± . vs. . ± . ; p= . ). there was strong correlation (r= . ) between goals and this procedure-specific score. overall usefulness of this assessment tool was rated as . ± . . all assessments were completed in about minutes. conclusions: we present a new procedure-specific formative assessment tool for laparoscopic anterior resection and provide preliminary evidence of its reliability and validity. this formative assessment tool could be used for constructive feedback and tracking performance in competencybased surgical training. cullen introduction: one of the key challenges to the proliferation of endoscopic submucosal dissection (esd) in the west has been a lack of training platforms. therefore, the virtual endoluminal surgery simulator (vess) is being developed as a training tool for esd. the aim of our study is to inform the design of vess using cognitive task analysis (cta), which is a human factors engineering framework to describe practitioners' mental models and cognitive processes and incorporate insights into the simulator's design. methods and procedures: cta-based interview questions were developed to probe the cognitive challenges and strategies employed at each stage of the esd procedure. six esd practitioners were interviewed for varying lengths of time. two of these interviews were conducted simultaneously during an observation of a training workshop where the cta participants were instructors (total observation time was five hours, and interview time was * minutes). another interview was conducted during observation of esd procedures (total observation time was hours, and interview time was * minutes). participants had varying levels of experience in esd, with of them being 'super-experts' (exclusively esd exponents), an 'expert' and a fellow. a cta of the data is currently being conducted to systematically inform design of functionalities in the simulator. results: analysis of our data highlights a few prominent themes at each stage of esd: goals, challenges (e.g., avoiding perforation of muscularis); points of decision-making (e.g., partial or full incision for boundary demarcation); skills involved (e.g., dissection); and ambiguity (e.g., unclear lesion boundaries). participants also described risks associated with each stage of esd and strategies to prevent or overcome the same. conclusions: qualitative data for a cta were collected through observations and interviews of esd practitioners. preliminary analysis has indicated prominent themes to consider in the design of the training simulator. the next step in the study is to conduct a full-scale cta of esd based on the current data. the ultimate benefit of the cta would be to incorporate the results into informing the design of vess in a way that is compatible with the mental models of esd trainees, thus enhancing the fidelity and effectiveness of the simulator. background: colonoscopy is an important diagnostic and therapeutic procedure in the management of colonic disease; achieving competence during residency is an integral part of performing high-quality colonoscopy in-practice, regardless of specialty. there is debate and controversy however, regarding what, if any, number of procedures achieves said proficiency. furthermore, there is significant heterogeneity in the current guidelines and studies published to-date on the definition of competence in colonoscopy. objective: to determine individualized learning curves as an alternative to 'number of procedures' for assessing colonoscopy competence. methods and procedures: this is a multi-institutional prospective cohort study involving eleven surgical trainees (novice endoscopists). the main outcome, colonoscopy competence, was assessed by determining the independent colonoscopy completion rate (iccr), the number of procedures required to reach % independent colonoscopy completion and polyp detection rate. individual and overall iccr were calculated using moving average analysis. conclusions: while a benchmark for a minimum number of procedures may be necessary to allow supervisors to adequately assess performance, it is difficult to determine what number is optimal. there appears to be significant heterogeneity in both overall number of colonoscopies completed by each resident, as well as the mean iccr and the number of procedures required to reach the current benchmark for competency. the use of learning curves allows real-time tracking of progress and training tailored to the individual, as we move forward in the era of competency-based medical education. background: with the growing popularity of robotic-assisted surgery, new methods for evaluation of technical skill are necessary to determine when a surgeon is qualified to perform an operation independently. current evaluation methods are limited to point likert scales which require a degree of subjective scoring. surgeons in training need an objective method of evaluation to view progress and target areas for improvement. one method of objectively evaluating surgical performance is a cumulative sum control chart (cusum). by plotting consecutive operative outcomes on a cusum chart, surgeons can view their learning curve for a given task. another method of objective evaluation is the dv logger®, or "black box," which records objective measurements directly from the da vinci® system. methods: we followed two hpb fellows during dry lab simulation of robotic-assisted hepaticojejunostomy reconstructions using biotissues to model a portion of a whipple procedure. we simultaneously recorded objective measurements of dexterity from the da vinci® system and performed cusum analyses for each procedural step. we modeled each variable using machine learning (a self-correcting and autoregressive modeling tool) to reflect the fellows' learning curves for each task. statistically significant objective variables were then combined into a single formula to create an operative robotic index (ori). results: variables that significantly improved over the course of the simulation included completion time (p= . ), economy of motion in arm (p= . ), number of times head was removed from the console (p= . ), total time left master manipulator was active (p= . ), total time right master manipulator was active (p. ), and total time that any arm was active (p\ . ). the inflection points of our cusum charts and plots of objective variables both showed improvement in technical performance beginning between trials and [ fig. and fig. ]. the operative robotic index showed a strong fit to our observed data and improved with additional trials (r = . ). [ figure ]. conclusions: in this study we identified objective variables recorded by the da vinci® system which correlated with the technical dexterity of fellows during a robotics dry lab. we broke a complex procedure down in stepwise fashion with cusum analyses to determine targets for improvement. using variables which correlated with the improved performance of the fellows, we effectively modeled the learning curve with the creation of an operative robotics index (ori). this study successfully models the learning curve of novice robotic surgeons using a novel combination of objective measures. georg wiese, md, paula veldhuis, steve eubanks, md, facs, scott w bloom, md, frcsc, facs; florida hospital institute for surgical advancement introduction: robotic surgery is a specialized skill which requires time and resources to master. in a general surgery residency program that seeks to train competent surgeons in both open, laparoscopic and endoscopic techniques it is difficult to see where adding robotic training will be of benefit and at what cost this will be to the remaining surgical skills. we therefore sought to ascertain robotic surgery's current role in the training of new general surgeons by soliciting the opinions of current general surgery program directors on the role of robotic surgery at their respective institutions. methods: an irb approved survey was created and sent to general surgery program directors across the country to assess how robotic surgery training is being integrated into current surgical training. the survey was sent via email to publicly available email addresses from the acgme website of program directors. it was voluntary in nature and consisted of questions regarding current status of robotic training in residency as well as future goals. results: overall response from our pd survey were at % of the surgical programs with addresses available via acgme, though responses continue to be submitted at the time of this abstract. approximately % of all respondents are from independent, university based programs. % felt that robotics was an emerging skillset important for residents to master versus % feeling that it was more appropriate for fellowship. all respondents noted that robotic surgeons were present at their institution, % within the core faculty, and % indicated that they were actively recruiting robotically trained surgeons. additionally, % of programs indicated that residents were exposed to robotic surgery, % of these on core general surgery rotations. % of respondents indicated that they had a formal robotic training curriculum with % of programs taking measures to integrate robotics into the future curriculum though % lacked specific milestones for such training. finally, opinion was evenly divided among respondents as to whether one could sign off on residents to perform robotic assisted cases upon completion of pgy year with % agreeing with that statement and the remainder indicating some additional training would be necessary. conclusions: our study highlights the emerging field of robotic assisted mis surgery and its increasing role in residency training. it is evident from the data, that robotic surgery is a growing part of residency experience. importantly, however, milestones were significantly lacking for determining resident progress in robotic training. introduction: in chile, medical students have the opportunity to undertake a month-long medicine elective (me) in a community hospital, primary care center or emergency department within the country at the end of their first clinical year. due to the lack of opportunities to practice suturing in the first years, students usually do not have an optimal performance in this type of medical procedure during the me. simulation training programs in suturing improve technical skills, selfconfidence and patient safety in the medical internship. the objective of this study is to evaluate the impact of implementing a simulated suture training program earlier in the medical curriculum, before the me. methods: we conducted a prospective, randomized controlled trial with medical students at the end of their first clinical year. they were randomized into two equal groups. the intervention group received an intensive suture training program consisting in one theory class, four practical sessions and effective feedback from an expert surgeon. the control group did not receive training, remaining with the classic opportunistic learning approach during the me. after the me, all students undertook an electronic survey. statistical analysis was performed on the answers of both groups. per protocol analysis was applied. results: there were no statistical differences between groups in terms of age and sex. four students did not complete the training program. one student in the control group did not reply to the survey. higher self-confidence with regards to suturing was reported in the intervention group in comparison with the control group [ / ( %) vs / ( %), p, ]. also, a greater student desire to carry out suture-related procedures was reported in the intervention group than the control group [ / ( %) vs / ( %), p, ]. in addition, a lower rate of overseeing physician intervention was reported in the intervention group [ / ( %) vs / ( %), p, ] ( table ) . a greater number of patients requiring sutures were treated by the intervention group than the control group, with a median of patients ( - ) against ( ) ( ) ( ) ( ) . the intervention group performed a higher number of sutures with a median of ( - ) vs ( - ), with a statistically significant difference (p, ) in both cases (fig. ) . conclusion: a simulated suture training program prior to the me generates a positive impact on medical students by improving self-confidence and desire to attend patients that require sutures. this leads to a higher rate of both exposure to suture techniques and suture execution. introduction: measuring performance in the operating room (or) is challenging. performance is a multifaceted construct a complex interaction of many behaviors and actions that reflect an individual's knowledge and skill. no assessment tool to date provides an expertise-based, comprehensive evaluation of the various aptitudes necessary to excel in the or, especially with respect to advanced cognitive skills. using qualitative methodologies, we previously defined behavioral themes that guide surgeons' behaviors, decisions, and actions, within a universal framework of domains that reflect intra-operative performance. the purpose of this pilot study was to use this framework to derive a comprehensive assessment tool and to obtain evidence for its validity as a measure of intra-operative performance. methods: an assessment tool was developed by a panel of surgeons and surgical trainees based on the five-domain model of intra-operative performance: ) psychomotor skills; ) declarative knowledge; ) interpersonal skills (two items); ) personal resourcefulness, and ) advanced cognitive skills (ten items). all items were rated on an ordinal scale of (inadequate) to (expert) and equally weighted. surgical residents and surgeons from a single academic center were evaluated on their performance during standard general surgery operations, for example, open inguinal hernia repair and laparoscopic cholecystectomy. for residents, there were evaluators -the attending surgeon and an observing surgeon. attending surgeons evaluated their own performances and were also assessed by observing surgeons. internal consistency, inter-rater reliability, and correlation of total scores with training level (junior residents, senior residents, staff surgeons) were calculated. likert scale questionnaires were administered to evaluate the tool's usability, feasibility, and educational value. results: fifteen subjects ( junior residents, senior residents, surgeons) participated. the total score on the assessment demonstrated significant differences between training levels ( figure) . inter-rater reliability was high (interclass correlation coefficient= . ), as were internal consistency between each domain score (cronbach's alpha= . ), internal consistency amongst items in the advanced cognitive skill domain (cronbach's alpha= . ), and internal consistency amongst items in the interpersonal skills domain (cronbach's alpha= . ). all assessments required less than five minutes to complete. overall, evaluators agreed that the assessment tool was easy to use, was comprehensive, and should be used routinely throughout training to track performance and provide formative feedback. conclusion: in this pilot study, we developed a comprehensive assessment tool for intra-operative performance and provide preliminary validity evidence for the score. surg endosc ( ) introduction: the purpose of this study was to evaluate the validity of our developed system for assessing suturing skills in laparoscopic surgery (fig. ) . we have updated numbers of participants and a comparison method compared with the last year report. methods and procedures: fig. shows our developed computerized system for objective assessment of suturing skills by using a laparoscopic intestinal suturing model, e-lap. the system includes a new artificial intestinal model that mimics living tissue and pressure-measuring and image-processing devices. each examinee performs a specific skill using the artificial model, which is linked to a suture simulator instruction evaluation unit. the model uses internal air pressure measurements and image processing to evaluate suturing skills. five criteria, scored on a five-grade scale, were used to evaluate participants' skills ( fig. ) . the volume of air pressure leak was determined by the volume of air inside the sutured artificial intestine. for example, for the criterion "air pressure leakage", the approximate midpoint of the acceptable range was grade . values lower than the minimum acceptable value received lower grades and those above the midpoint of the acceptable range higher grades. we enrolled surgeons who participated a simulator competition event at the th annual meeting of the japan society for endoscopic surgery (jses houston methodist hosptial, baylor college of medicine introduction: the sages flexible endoscopy course for minimally-invasive surgery (mis) fellows has been shown to improve confidence and skills in performing gi endoscopy. this study evaluated the long-term retention of these confidence levels and investigated how fellows have changed practices within their fellowships as a result of the course. methods: participating mis fellows completed surveys six months after the course. respondents rated their confidence to independently perform sixteen endoscopic procedures ( =not at all; =very). while the pre-and post-course surveys identified anticipated endoscopy uses and barriers to use, the -month follow-up survey evaluated actual usage and barriers to use in each fellow's practice. respondents also noted participation in additional skills courses and status of fundamentals of endoscopic surgery (fes) certification. comparison of responses from the immediate postcourse survey to the -month follow-up survey were examined. mcnemar and paired t-tests were used for analyses. results: twenty-three of ( %) course participants returned the -month survey. % had passed the fes skills examination and % had attended another flexible endoscopy course. no major barriers to endoscopy use were identified. in fact, fellows reported less competition with gi providers as a barrier to practice compared to their original post-course expectations ( % versus %, p. ). in addition, confidence was maintained in performing the majority of the endoscopic procedures, although fellows reported significant decreases in confidence in independently performing snare polypectomy (− %; p. ), control of variceal bleeding (− %; p. ), colonic stenting (− %; p. ), barrx (− %; p. ), and tif (− %; p. ). fewer fellows used the gi suite to manage surgical problems than was anticipated post course ( % versus %, p. ). fellows without fes certification reported loss in confidence to independently perform barrx (− %; p. ) and colonic stenting (− %; p. ), and also a % decrease in the use of gi suite to manage surgical problems (p. ) fellows who passed fes noted no significant loss of independence, changes in use, or barriers to use. % of fellows made additional partnerships with industry after the course. % stated flexible endoscopy has influenced their post-fellowship job choice. % would recommend the course to other fellows. the sages flexible endoscopy course for mis fellows results in long-term practice changes with participating fellows maintaining confidence to perform the majority of taught endoscopic procedures six months later, and over % reporting that flexible endoscopy influenced their career choice. additionally, fellows experienced no major barriers to implementing endoscopy into practice. the materials and methods: at our center, we formulated a laparoscopic mentorship program where a senior consultant was paired with a particular trainee resident for a period of weeks. consultants & residents were a part of the study. the or schedules were rearranged to accommodate these pairs. an evaluation of the residents' views was performed prior to the study and once at its completion, using a simple questionnaire with each parameter scored between & . results and discussion: continuous, consistent evaluation by a consultant over an extended period of time allowed them to assess their assigned resident's laparoscopic skill set. all pairs observed an increased frequency of errors being noticed & improved upon. the consultants stressed upon shedding undesirable operative habits. there was a significant improvement in residents' scores at the end of the short study. conclusion: we found that the short-term mentorship program was easy to incorporate within our or schedule and was well received by the participants. continuous short rotations under senior consultants appear to allow residents to not only fully observe and imbibe correct operative techniques, but also helps shed unfavorable habits. we are currently amid the second cycle of our study & looking forward to the results at the end of this academic year. introduction: colorectal cancer is one of the most common cancers in the united states. endoscopic submucosal dissection (esd) is an emerging minimally invasive technique that allows complete en-bloc resection and a much lower recurrence rate at long-term follow-ups. however, performing colorectal esd is technically demanding since the colorectal wall is thin and constantly moving, and potentially higher rates of complications (e.g., bleeding and perforations). hence, an adequate training for colorectal esd is needed to acquire basic proficiency with minimum complications. objectives: a virtual reality (vr)-based simulator with visual and haptic feedback for training in colorectal esd is being developed, which the aim to allow trainees to attain competence in a controlled environment with no risk to patients. in this work, a newly developed application of the virtual simulator that promotes the endoscopists to perform and assess technical skills in esd is developed. training tasks are built based on physics-based computational models of human anatomy with tumors. methods: the main modules of the vr-based simulator for colorectal esd involve: ( ) rendering; ( ) haptic interface; ( ) physics-based simulation; and ( ) performance recording and assessment metrics. the rendering engine allows surgical tasks to be performed in the three-dimensional virtual environment. haptic feedback mechanisms allow users to physically feel the interaction forces. physics-based simulation technologies are employed to enable the complicated simulation for performing virtual surgical tool-tissue interactions. the simulator can also collect learners' performance data to offer feedback based on the built-in metrics. results: four training tasks involving marking, injection solution, circumferential cutting, and submucosal dissection are designed to practice skills with different surgical tools. the marking task aims to identify the lesion. the injection solution task minimizes the risk of bleeding and perforation to protect the muscularis. in the circumferential cutting task, the objective is initial incision of the lesion with the surgical tools. the objective of the dissection task is to remove the tumor from the connective tissue of the submucosa under the lesion. conclusions: the vr-based simulator enables realistic esd tasks to provide a possibility for developing, validating and objectively evaluating the performance metrics in colorectal esd training, and offers an opportunity to rise up the learning curve before application to patients. background: the virtual translumenal endoscopic surgery trainer (vtest) simulator is a virtual reality system that was designed to train the hybrid-notes technique. transfer of skill acquired while training on the vtest was measured in a near-real cholecystectomy procedure staged in the easie-r model. methods: sixteen medical students were divided randomly and evenly into groups: control, training. all subjects performed the cholecystectomy procedure on the vtest simulator to establish a baseline (pre-test). the training group received training sessions, over a period of consecutive weeks, consisting of trials per session or as many trials as can be accomplished in one hour, whichever was achieved first. at the end of the training period, all subjects performed one trial on the vtest simulator (post-test), and again to weeks later (retention test). two months after that, subjects performed the hybrid-notes cholecystectomy procedure on an easie-r model. performance with the easie-r simulator was video-recorded, and three tasks within the cholecystectomy procedure were isolated for evaluation: clipping, cutting, and dissecting the gallbladder. objective performance measures, such as time and error, were extracted from the videos by two independent reviewers, while subjective performance was scored by four expert surgeons who were blinded to the training conditions. expert reviewers used a modified version of the operative performance rating system by the american board of surgery and the objective structured assessment of technical skills (osats) tool. results: there was no difference in task completion time between the control and training groups, (t( )= . , p =. ) in the cutting and clipping tasks. however, there was a significant difference in the number of errors, t( )=- . , p=. . there was no difference in subjective performance between the training groups for the clipping and cutting tasks. in the gallbladder dissection task, however, there was a statistical significance in "instrument handling" based on one of the surgeons' ratings (t( )= . , p=. ), and a statistical significance in "time and motion" based on another surgeon's rating (t( )= . , p=. ). conclusions: results indicate that weeks of training on the vtest simulator did not allow the subjects to transfer their learned skills equally to the near-real environment, even though they retained the skills when tested for retention. this new insight suggests that modification of the training method for different types of surgical skills may be warranted to optimize their transfer to the real environment. examining conclusions: this study provides evidence to suggest that for bariatric surgeons, experience and skills acquired in performing non-bariatric surgery may not translate to improved outcomes in bariatric surgery. as seen in this study, improvement in bariatric surgical outcomes is likely more dependent on experience specifically performing bariatric procedures. as there may be no benefit acquired from performing surrogate procedures, this may have implications in the design of subspecialty training programs and for accreditation purposes. . a universally adjustable cellphone holder was used where smartphones could be placed inside the fls box in order to capture the task from a similar angle as the onboard camera. residents were able to use their own smartphones to record their performance on each of the five fls tasks in high definition (hd) quality. after each practicing session, they would upload their videos to a designated folder on a password-protected computer in the simulation lab. this folder was linked to a cloud-based storage system that fls instructor had exclusive access. the faculty was able to review each video in the next hours and provide immediate feedback to the residents via email, over the phone or in-person. the video library of performance also allowed the instructor to track the progress of the residents and whether they reached proficiency level in all five tasks to take the fls examination. this program was offered to all surgical trainees. results: utilization of simulation lab to practice fls tasks increased significantly across all postgraduate years after implementation of this model. six residents took the fls examination. the passing rate of the residents remained the same ( % before and after) but their scores in fls manual skills improved significantly compared to the group prior to implementation. the residents evaluated this change positively and reported that the use of videos and immediate feedback by faculty was a valuable intervention in their learning experience. conclusions: the smartphone cameras are readily available and can be used for telementoring. incorporation of telementoring in standard proficiency based fls training can promote self-directed learning and improve the access to experts for immediate feedback as a crucial element of effective training in acquisition of laparoscopic skills. background: it is important that making individual procedures a language, and an objective qualitative evaluation for the laproscopic training. recently, task training and the sham operation using the virtual simulator are carried out for medical students as the basic laparoscopic maneuver training, but there are few reports of objective qualitative evaluation for the training. in this study, we investigated rubric evaluation as the qualitative evaluation for laparoscopic training. materials and methods: one hundred and six students in th grade of tokushima univ. were participated. basic laparoscopic task training (gummy band ligation, beads transfer, delivery of beads, gauze excision) with training box and sham laparoscopic cholecystectomy with virtual simulator were performed. task execution time and rubric evaluation which includes the evaluation standard that became a language for each maneuver were performed before and after basic task training and sham operation. the group who are bad at laparoscopic maneuver was decided by time exceeded in tasks more than two from before practice. relationship between the group who are bad at laparoscopic maneuver and the group which self-evaluation was higher in a rubric evaluation was investigated. results: in basic task training, average task execution time in all students was shortened after practice compared with before practice, but investigated individual, students exceeded in more than two tasks. rubric evaluation in basic task training showed no difference between self-evaluation and evaluation by tutor before and after practice. in sham laparoscopic cholecystectomy, all students and tutor showed high score by rubric evaluation after practice compared with before practice. some students showed higher score than tutor, especially in part of extension of operation field by elevation of the gall bladder, exposure of triangle of calot, and exposure of cystic duct. students who showed high score by self-evaluation in many maneuver of sham laparoscopic cholecystectomy also exceeded in more than two basic tasks. conclusions: as rubric evaluation showed the point of the maneuver is made a language definitely, it was useful for an objective qualitative evaluation for laparoscopic training. pre introduction: bariatric surgery candidates have the opportunity to research bariatric surgeons and hospitals prior to scheduling their elective surgery. pre-operative information sessions are important tools for bariatric surgeons to provide patient education while increasing their patient population. online education is becoming increasingly popular, but its utility over in-person education is uncertain. our objective was to compare patients attending the two most commonly used educational formats: online (webinars) and in-person (seminars) and determine which were more likely to undergo bariatric surgery. methods: we conducted a retrospective cohort study of , patients who attended pre-operative information sessions from january to december by reviewing data maintained by the obesity, prevention, policy and management (oppm) database from our institution. the patients were divided into two groups: those who attended an in-person session (n= ) and those who attended an online session (n= , ). the proportion of patients who went on to have bariatric surgery was compared between the two groups. to categorize the study sample, patient demographics, surgeon providing the information session, and procedure performed were compared between groups. multivariate logistic regression model was applied to compare the effectiveness of in-person session and online session. results: of , patients analyzed, % attended online information sessions ( % female, mean age ). the remaining % attended in-person information sessions ( % female, mean age ). analysis found that . % of patients who attended online information sessions went on to have a bariatric surgical procedure, while . % of patients who attended in-person sessions went on to have a bariatric surgical procedure. after controlling for differences in age and gender, results of multivariate logistic regression analysis indicate that patients who attended inperson sessions were % more likely to have a bariatric surgical procedure than patients who attended an online session ( introduction: knot security is the ability of knots to resist slippage as force is applied, and the optimal number of throws to ensure a secure knot improves efficiency and outcome. the literature on the accepted number of throws per type of suture material has been largely anecdotal, often referring to throws for silk, for polyglactin (vicryl), five for polydioxanone (pds), and six for polyproprolene (prolene). we report a pilot knot-tying study of four suture types to determine optimal numbers of throws. materials and methods: four senior general surgery residents (pgy- and above) and four attending surgeons participated. participants viewed a standardized instructional video and a one-handed knot-tying tutorial. they were instructed to tie one-handed knots, beginning each knot with two throws in the same direction, and square the third and subsequent throws in the opposite direction. each surgeon tied knots, using differenttypes of - suture material: silk, polyglactin, polydioxanone, and polyproprolene. suture types were evaluated using , , , or throws. the participants were randomized to both suture type and order of throw numbers. the knots were then tested on the f.a.s. t knot tester (sawbones, vashon island, wa) for slippage (insecure knot) or breakage (secure knot). generalized estimating equation (gee) analysis was used to determine optimal throw number. results: knots were individually tested on the knot tester for slippage and recorded as % slipped (see table) . the percentage of slipped knots varied by participant and ranged from to %. generalized estimating equation analysis suggested that the only significant variable when determining knot security was number of throws (p= . ), not suture type or participant training level. the optimal number of throws for - silk, polydioxanone, and polypropylene was five, whereas six throws was optimal for polyglactin. conclusion: knot security is dependent on the number of throws placed, and these optimal numbers were higher in our study than the commonly accepted number of throws. evaluation of take introduction: laparoscopic skills can be learned using portable simulators and these skills are transferrable to the operating room. several training regions within the uk have therefore developed and delivered home-based laparoscopic training programmes for junior surgical trainees. although performance improved in some, overall engagement has been poor. similar results have been observed in north america. the aim of our study was to uncover the reasons for poor engagement with home-based simulation with a view to developing a future, more successful, programme. methods: this was a qualitative study utilising focus groups. interviews were undertaken with key stakeholders involved in various laparoscopic home-based simulation programmes through the uk. training equipment comprised the eosim portable simulator paired with online training tasks. the tasks were similar to those used in the fundamentals of laparoscopic surgery programme (fls). basic metric feedback was provided (eg time to complete task). a total of individuals were interviewed, including surgical trainees, consultant trainers, training directors and programme faculty. this generated approximately hours of data which was coded using nvivo software. a basic thematic analysis was performed. results: trainees cited multiple competing professional commitments as a barrier to engaging with home-based simulation. they tended to focus on scoring 'points' which contributed toward career progression rather than tasks which were interesting, or associated with personal development. this approach is perpetuated by the surgical training system, which rewards trainees with points for publications and exams, but not for operative skill. this leads to conflict between trainers and trainees, the former expecting trainees to instead focus upon developing their technical abilities. trainees were unsatisfied with metric feedback and wanted individual feedback from consultant trainers (attending equivalent). trainees generally perceived consultants as lacking interest toward the programmes and training in general. however, some consultants were in fact unaware of the programmes being delivered and others felt lacking in confidence to deliver necessary training to trainees. conclusions: our findings are widely generalizable and have implications for any institution delivering a similar programme. as a means of improving engagement, the the inception of scheduled simulation study days, providing trainees with the opportunity for personalised feedback from consultants, has been suggested. equipping trainers with the necessary competencies to deliver training can be achieved by ensuring attendance at the necessary professional development courses. tackling the 'box ticking' culture is more challenging and may involve a move toward restructuring the current surgical training scheme. introduction: to provide evidence for the face and content validity of a hybrid active-shooter team training simulation and the impact of a hybrid curricular model on learner's engagement and performance. the following study was conducted because hospitals are increasingly threatened by active-shooter incidents, and no active and noticeable training is currently available to train hospital staff members. methods: thirty-five volunteers (medical students, residents and other allied health providers) from the university of minnesota affiliated medical centers were randomly selected and divided into control and experimental groups. the control group (n= ) was given a traditional lecture-style presentation. the experimental group (n= ) participated in the hybrid curriculum which included augmented reality, kinesthetic simulation, and debriefing components. following both curriculum styles, nasa task load index (tlx) surveys were completed by each group member. a final active shooter simulation experience was presented and evaluated by active-shooter trained raters using a checklist of critical actions from the department of defense. a post-simulation nasa tlx survey and post-test were provided. to assess face and content validation of a hybrid team-training simulation exercise to prepare healthcare personnel in the event of a hospital-related active-shooter crisis, a -point likert-scale survey determined the realism, utility, and applicability of this type of training while engagement and performance during the simulation were measured using a nasa-tlx survey and contrasted with the rater's evaluation. our study provided evidence to support the face and content validation of an active-shooter simulation team training curriculum as a useful adjunct to health care institutional safety planning. we demonstrated that this type of training requires an optimal level of cognitive activation to increases learner's engagement and performance. we concluded that the hybrid design of our curriculum was successful in delivering these optimal levels of cognitive stimuli by producing engaging team training simulation experience capable of motivating our learners to acquire the tactical skills and life-preserving behaviors consistent with better survival opportunities during a hospital related active-shooter crisis. the introduction: the virtual electrosurgical skill trainer (vest) provides surgeons and trainees with a hands-on approach to learning the best practices in electrosurgery. it is comprised of five modules covering tissue effects, stray currents, bipolar tools, monopolar tools and or fire safety. the module in this study teaches the origins of stray currents and shows the learner how they can cause damage to non-target tissues via direct and capacitive coupling. the aim of this study was to assess learning using the vest system. methods: the irb approved study followed a single group pretest-posttest design and was conducted at the sages learning center. thirty-eight subjects participated and out of these, % were attending surgeons while the rest were medical students, residents and fellows. % of subjects had prior fuse exposure, while the remaining had none. subjects were asked to complete a five-question multiple choice questionnaire before and after using the simulator. it assessed their knowledge in topics such as direct coupling, capacitive coupling and insulation failure. participants then used the simulator to complete three tasks. first, the subject used direct coupling to seal a vessel and observed the desired effects and potential pitfalls. in the second task the subject was immersed inside the peritoneal cavity and was directed to use the active electrode to observe how the activation of energy can cause capacitive coupling. in the third task the subject practiced evaluating the insulation of electrosurgical tools for defects. wilcoxon's signed rank test was used to differentiate between pre-and post-test scores, and the mann-whitney u test was used to differentiate between the groups of subjects as a function of fuse experience. results: the median score on the pre-simulator assessment was % and the post-simulator median score was % (p = . ). there was no statistically significant difference in pre-assessment scores between attending surgeons and the others (p= . ). subjects with prior fuse exposure scored significantly higher on the pre-module assessment compared to those that had no prior fuse exposure ( % vs %, p= . ). in the post-assessment their median scores were % and %, respectively (p= . ). conclusions: the vest simulator module successfully increased the overall participants' knowledge of coupling in electrosurgery regardless of level of surgical experience. participants with prior exposure to the fuse curriculum had increased knowledge on this topic at baseline as compared to participants without any fuse exposure. introduction: the objective of this study was to assess the reliability of a modified notechs rating scale for the evaluation of medical students' non-technical (nt) skills. the importance of physician nt skills for the safe care of patients is receiving increasing attention in the literature. tools to assess nt skills such as notechs that addresses communication, situation awareness, cooperation, leadership, and decision-making have been shown to be valid and reliable. despite its importance, the assessment of nt skills of medical students, our future physicians, has received little attention. methods and procedures: twenty-seven medical students participated in of acute care simulated scenarios, each approximately minutes long. video recordings of student performance were reviewed and assessed using a modified notechs rating tool adapted for these scenarios with input from a team of clinicians, nurses, and human factors specialists. the rating scale ranged from to , representing very problematic behavior (e.g., not vocalizing concerns or decision process) and representing model behavior (e.g., identifies future problems and remains calm to unexpected events). two reviewers rated all videos independently on the notechs domains and specific subscales. student scores in each nt skill domain and interrater reliability were assessed. results: a summary of the scores of each notechs domain is shown in table . the highest overall average score of a participant was . while the lowest was . . the intra-class correlation (icc; two-way random model) was . , and the cronbach's α coefficient was [ . . the lowest icc agreement was in the situation awareness domain ( . ) while the highest agreement was in leadership ( . ). conclusion: medical student nt skills during acute care simulated scenarios vary significantly using a modified notechs assessment. this newly developed tool provides a framework for educators to evaluate medical students' nt skills during simulation training. it further identified domains where students scored lower, such as situation awareness, and could be targeted for education. the moderate icc, between the . - . range, shows that further refinement of the tool is needed to reliably assess the constructs. future steps to obtain validity evidence include additional raters and applying the tool in non-simulated settings. introduction: a general misperception of the real concept of robotic surgery seems to be revealed in our clinical practice. despite its introduction almost years ago, robotic surgery is still related to many myths and beliefs. before designing a trial to see if these false awareness could impact on outcome, we measured this misperception by a survey. moreover we tested if medical school is able today to give to the future doctors a necessary knowledge about robotic surgery. with the same survey we explore the feelings about the introduction of the artificial intelligence in medicine and the perception of the consequences of a larger use of technology in medicine. methods and procedures: a multiple choice survey was designed and anonymously administered via the platform surveymonkey (http://www.surveymonkey.com). a total of questions were selected from the research team and included in the survey. the questionnaire was divided in three parts: the first was to get information on participants' population; the second asked specific questions about robotic surgery; the third focused on technology use in medical education. results: we received and analyzed questionnaires, of which totally filled. many undergraduates consider robotic surgery as "experimental", will prefer open surgery on themselves and see a risk for robotic surgery in damaging the patient-surgeon relationship. this situation is better for medical students, but still a great diffidence were encountered. % of ug consider robotic surgery as "experimental" vs only . % of ms (q ). most thought robotic surgery had been used for only years or less (q ). . % of ug and . % of ms gave the right answer (p=. ). almost % of ug see robotic surgery as a risk in damaging the patient-surgeon relationship. this is not seen among ms (q ) (p=. ). % of ug are fearful of robots used to operate them. this fear is significantly reduced among medical students (p=. ). ug were less familiar with the indications and uses for robotics. ms gave a correct response more frequently (q , . % vs . %, p= . ). conclusions: our results indicates that nowadays, the robotic surgery is related a lot of misperceptions and a generally low level of information. this general picture is partially mitigated during the medical school, but the level of knowledge is still low. a big effort seems mandatory in clarify every technical aspect and an ethic debate about robotics, technology and ai as part of medical curriculum is advisable. background: learning theory states that a certain level of physiological stress or cognitive activation is required to achieve optimal task engagement and performance by the learners. our study will seek to determine if a hybrid team training curriculum inclusive of a task-oriented interactive virtual environment could help achieve the optimal level of cognitive activation required to result in a higher task engagement and performance. methods: a total of thirty-five medical professionals from the university of minnesota participated in several team training simulations. participants were randomly selected to an experimental and control groups. the experimental group (n= ) was exposed to a hybrid team training module, consisting of a task-oriented augmented reality phase followed by a second and third phase consisting of a kinesthetic simulation scenario and debriefing, respectively. the augmented reality phase presented the trainees to an interactive -degree image of the same clinical room where the simulation would take place allowing for ''situated-learning'' to take place. during the learning phase, trainees were encouraged to interact and communicate with each other while completing the tasks allowing for ''social-learning'' to effect. the control group (n= ), educational component consisted of a traditional audiovisual lecture-style introductory presentation, a simulation, and debriefing. after completing their respective educational components, each group completed a nasa task load index survey to assess the cognitive load experience of the individual educational models. subjects were then exposed to a final simulation (test simulation) similar in content and structure to the initial simulation. this was followed by a second nasa tlx survey. raters evaluated both group level of engagement and performance using a validated checklist of critical actions. results: the experimental groups showed higher weighted overall nasa cognitive load index scores than the control group (p= . ) prior to the test simulation. the weighted nasa score remained elevated in the experimental participant groups following the test simulation, whereas in the control group the post-simulation nasa assessment revealed a decrease in cognitive load (p= . ). expert raters using a validated checklist determined that . ± . % of the experimental (hybrid curriculum) group and . ± . % of the control group appeared to be more engaged and performed better during the simulation. conclusions: pre-simulation task-oriented augmented reality learning environments designed to incorporate situated, and social learning virtual experiences can provide the optimal level of cognitive boost that can result in a higher participant engagement and performance during team training simulation scenarios. introduction: despite the huge importance of laparoscopy, medical students have a brief contact with this surgical specialty during medical school in brazil. usually, they get in touch with this specialty during the surgery clerkship in the last years of medical school. therefore, few students perform clinical research or develop interest for this area during graduation. objective: to awaken the interest in laparoscopy of medical students early in medical school, improving the development of clinical research projects, and to prepare new generations of minimally invasive surgeons. discussion: the academic league of videolaparoscopy was created in under the guidance of dr. gustavo carvalho from the university of pernambuco, brazil. an academic league is a group of medical students who are guided by a tutor to develop three areas: research, teaching, and clinical practice. every year new students join the league after being selected with a multiple question test and an analysis of the curriculum vitae. the students are stimulated to participate in laparoscopic procedures as observers, learning about the techniques and instruments. moreover, there are minimally invasive surgery lectures and courses during the year. general surgery residents can also be part of the program as tutors. they are encouraged to present lectures, and to assist with research projects. medical students participated of this program in years. % pursued a surgical specialty after graduation. % did minimally invasive surgery as a fellowship. conclusions: the students who participate in several activities provided by the league have an increased interest in pursuing the path to become a laparoscopic surgeon. background: surgical education is an active and adaptive process of developing knowledge, technical and non-technical skills. the rise of social media has created a paradigm shift in surgical education, with online learning platforms offering exposure to real-time content, expert instruction, and global collaboration. while these disruptive technologies evolve, their influence on surgical education has not been investigated. our goal was to evaluate the growth and impact of an online surgical education model-the advances in surgery (ais) channel. our hypothesis was that utilization and engagement with the platform continues to grow, providing novel methods of measuring successful education. methods: assessment of the platform's membership demographic, user activity, and engagement was performed from inception in to quarter . the ais channel uniquely provides free, high quality, innovative content from elite surgeons in scheduled and continuously available formats across colorectal, bariatric and endocrine surgery service lines. users login to access content, with demographics, time spent, and content accessed recorded as measures of active account utilization and engagement. the main outcome measures were overall membership trends, utilization patterns by region, content type, and surgical specialty for the platform. results: users were predominately male ( . %), surgeons ( . %), and ranged in age from to years ( . %). the main surgical subspecialty represented was colorectal ( . %). active account usage/weekly recurrence was . % ( % industry benchmark), with users engaged for a mean minutes/session (excluding live events). since inception, steady exponential growth was seen across several dimensions. registered users and unique ip addresses increased from over , and , in to over , and . million in , respectively. the number of countries represented increased to reach across continents. at present, over live surgeries and live congresses have been broadcast from countries, with over , surgical videos available on demand to facilitate surgical education. the greatest engagement is seen with live surgical broadcasts. conclusion: our analysis demonstrated proof of concept for a unique, online surgical education model to provide effective surgical education. success was validated through the increase in overall users, sustained active account usage, and global penetration. user preferences for live surgical broadcasts were seen. knowing the utilization and preference patterns, the platform can continue to evolve and enhance the learners' experience. with this growth and penetrance, there is the potential to globally improve patient outcomes and the quality of care provided. background: a realistic simulator for transabdominal preperitoneal (tapp) inguinal hernia repair would enhance the surgeons' training experience before they enter the operating theater. the purpose of this study was to evaluate the efficacy of d-printed tapp simulator in evaluating preoperative skill before entering operative theater. methods: surgeons in our institution were enrolled in this study. they performed simulation tapp and the performance score was measured using tapp check list. the tapp simulator allows for the performance of all procedures required in tapp. the correlation between post -graduate years (pgys), age, experienced a number of laparoscopic surgery (more than , less than ), experienced number of tapp and the performance score was evaluated. results: strong correlation between experienced member of tapp inguinal hernia repair and the performance score was evaluated in this study (r= . ). however, the correlation between pgy, age and score was weak ( introduction: as the field of laparoscopic surgery grows, the need for standard measures of complex laparoscopic surgical skills is apparent. fundamentals of laparoscopic skills (fls) testing is required to complete general surgery residency, but there is no standard metric to convey expertise in advanced laparoscopic procedures. in an effort to develop a standardized assessment of laparoscopic suturing expertise, a group of experts was surveyed using delphi methodology to reach consensus on observed laparoscopic suturing skills reflective of performing at an expert level. methods: expert laparoscopic surgeons participated in serial surveys via redcap (research electronic data capture). experts included surgeons who perform[ /year laparoscopic procedures that involve intra-corporeal suturing, obtained from the authors' personal and professions networks. using a point likert scale, participants were asked to agree/disagree if different observed laparoscopic suturing skills indicate performing at an expert level. these skills were chosen from prior assessment instruments in the literature and the authors' previously published work. tasks were considered to meet criteria for consensus and eliminated from the next round of the survey after reaching % consensus as "strongly agree." results of the previous round of surveys were shared with participants at the start of the next round. the predefined endpoint for the delphi was set as maximum of rounds, reaching % consensus on each skill, or if[ % of initial respondents fail to return for subsequent surveys. results: after the first round of the delphi survey, respondents met inclusion criteria. preliminary data demonstrated skills that reached consensus ([ % of respondents chose "strongly agree"): forehand suturing, avoiding tissue trauma, having a technically acceptable final product (ie. tight closure), and tying a secure knot at the end of suturing. items did not approach consensus (\ % of respondents chose "strongly agree" or "agree"): alternating hands for each throw while tying, never missing a target when grabbing needle/suture, alternating direction of throws when tying, and backhand suturing. data from all four rounds of surveys as well as the final draft of the assessment instrument will be available at time of presentation. conclusion: preliminary data of this delphi study allowed us to reach consensus amongst a group of expert laparoscopic surgeons on the characteristics of expert laparoscopic suturing, which will allow creation of a comprehensive assessment tool for this domain. validation of such a tool will help advance the surgical field towards true competency-based credentialing and promotion. the study was designed to assess the knowledge of scp among european surgeons (specialists and residents). additionally, surgeons' opinion on usefulness of each of the rules of scp was gathered. the data were analyzed in terms of differences between residents and specialists. this is to set ground for and an educational program and increase the safety of elective laparoscopic cholecystectomy by minimizing the occurrence of cbdi. methods: the data on the knowledge of scp and opinion on usefulness of its rules were gathered in form of an anonymous questionnaire distributed among participants of several surgical conferences in poland. the questionnaire then asked about the surgeon's experience in terms of cholecystectomies performed and the number of complications in form of cbdi. it then listed the scp rules and asked the surgeon about their opinion on usefulness of each of the rules on a -point scale. gathered data were subject to statistical analysis and a comparison between specialists and residents was performed. the study has been registered in the clinicaltrials.gov-nct . , although these numbers are still low. significant differences in the mean usefulness score between residents and specialists were observed in regard to two rules: rule was found more useful by residents (mean score , vs. , , p= . ), whereas rule was found more useful by specialists (mean . vs. . , p= . ). the awareness of the sages safe cholecystectomy program in poland is still low and needs to be promoted. both surgical residents and specialists consider the rules of scp to be useful during surgery, although there are slight differences in the usefulness scores between the groups. an educational program to promote and further implement the scp should be established. introduction: transanal total mesorectal excision (tatme) has attracted substantial interest amongst colorectal surgeons throughout the world. technical challenges of the technique however have been acknowledged by early adopters and this may underpin the early reports of visceral injuries which occurred during the perineal phase. evidence from previous surgical training programs suggest that a structured proctorship programme can shorten the learning curve, operative time and most importantly reduce major complications. the aim of this study was to report on the first national pilot training initiative which was developed in the uk to ensure safe introduction of this technique. methods: a pilot training programme for the uk has been established in partnership with the healthcare industry, and supported by the association of coloproctology of great britain and ireland. the programme consists of three phases: (i) development of a consensus process on the optimum training curriculum of tatme from all relevant stakeholders, including experts, early adopters, and potential learners, to guide the training of this technique (ii) piloting of this training curriculum and (iii) assessment and quality assurance mechanisms to monitor training and measure outcomes. results: a cohesive multi-modal training curriculum has been developed providing clear guidance on case selection, supporting multi-disciplinary and multimodal training including online modules, dry-lab, purse-string simulators, cadaveric training and formal clinical proctoring programme. the uk pilot programme opened for applications in may and, after a rigorous selection process, the initiative was launched in september with trainers mentoring consultant colorectal surgeons from five centres. the selection of learners was based on suitable case volume and prior experience in laparoscopic rectal surgery. objective assessment tools were applied to an unedited video of a laparoscopic rectal surgery case for each applicant. for the selected centres, access to the ilapp tatme app was provided to access educational content including operative video footage, prior to attending a bespoke cadaveric workshop. each learner will then benefit from a structured, centrally organised and funded proctorship programme at their own institutions. a global assessment score form has been specifically designed to monitor training and a formal accreditation process will be used to sign off each learner using competency assessment tool. data on the cadaveric workshop and initial outcomes of the clinical mentorship will be presented at the conference. conclusion: a competency-based pilot training programme for transanal total mesorectal excision has been launched in the uk to support safe introduction of this technique. practicing on a fls trainer box is effective but requires large amount of consumables and is scored subjectively. the purpose of this study is to evaluate the face validity of the intracorporeal suturing task on a virtual fundamentals of laparoscopic surgery simulator (virtual fls). we hypothesize that the virtual fls will demonstrate face validity. methods and procedures: after a video demonstration and a practice period, twenty-three medical students and residents completed an evaluation of the simulator. the participants were asked to perform the standard intracorporeal suturing task on each of the virtual fls and the traditional fls box trainer. the presentation order of the devices was balanced. the performance scores on each device were calculated based on time (seconds), deviations to the black dots (mm), and incision gap (mm). the participants were then asked to finish a -question questionnaire regarding the face validity of the simulator. participants answered questions with ratings from (not realistic/useful) to (very realistic/ useful). a wilcoxon signed ranks test was performed to identify differences in performance on the virtual fls compared to the traditional fls box trainer. results: responses to of the questions ( . %) averaged above a . out of . those questions that rated the highest were the degree of realism of the target objects in the virtual fls compared to the fls ( . ) presently, most training methods for thoracoscopic esophagectomy use live porcines; this presents several problems including cost, long preparation times, and ethical issues. these problems further prevent frequent training. currently, no alternative models for thoracocopic esophagectomy training. we report, for the first time, the development and use of a non-biomaterial training model for thoracoscopic esophagectomy. methods: we collaborated with sunarrow co., ltd. (tokyo, japan) to develop the training model. we created organ models for esophagus, trachea, bronchus, aorta, vagus nerve, recurrent nerve, bronchial artery, lymph node, vertebrae, azygos vein, and thoracic duct, and filled the models with a polyvinyl alcohol hydrogel. the gaps between organs were filled with a filler material mimicking connective tissue. we chose a synthetic resin that closely mimics the characteristics (rigidity or elasticity) of each organ. after each organ was fixed, the model was covered with a filler to create a pleural membrane to allow training in peeling operations. in addition, because a patient plate was attached to the rear of the training model, excision with an energy device was possible and more closely simulated surgical conditions. results: using the training model resulted in a highly satisfactory level of experience in three trainees. the trainees were able to learn anatomical positions and sequence of surgical procedures, including endoscope handling. centre for rural health, aberdeen university introduction: as doctors become expert in a complex procedure, they develop automatic nuances of performance that are difficult to explain to a peer or a trainee (so called 'unconscious competence'). traditional methods which aim to allow sharing of expertise have limitations: concurrent reporting alters the flow of the task at hand while retrospective reporting is subject to bias and often incomplete. iview expert is a technique validated in the aerospace domain which externalises an expert's cognitive processes, without disrupting the task at hand. the aim of this project is to assess the feasibility of adapting the technique to medical training. methods: this was an observational case study in which an expert endoscopist wore a head mounted camera to capture a complex procedure (colonoscopy). captured video was reviewed during a facilitated debrief which externalised the expert's cognitive processes. the debrief was recorded and formed an audio commentary. the video and accompanying audio commentary formed a learning package which was watched by a specialty trainee. the technique differs from standard procedural videos in that it provides a more detailed insight into cognitive processes of the expert. this is achieved through the debrief, which encourages reflection upon kinaesthetic (head movement) as well as auditory and visual cues, resulting in a higher level of experiential immersion. questionnaires examined acceptability and educational value of the technique using likert scales and free text answers. quantitative data were presented using basic descriptions in terms of agreement with statements. qualitative data from free text responses were coded in order to identify key themes. results: the expert agreed that wearing the camera was acceptable and did not interfere with the procedure, nor usual decision making processes. qualitative analysis revealed the debrief process to be associated with a high level of experiential immersion: "as if they were there". both the expert and the trainee strongly agreed that the process was educationally valuable and that they learned something new. qualitative analysis demonstrated that the technique revealed useful and unique nuances of the procedure. the intervention could represent a powerful adjunct to existing training methods, especially amongst more experienced practitioners. we are currently undertaking a larger study involving a greater range of procedures with more learners. introduction: endoscopy is an important skill for general surgeons to possess. however, there is lack of training within surgery residency programs. we implemented a one-day endoscopic surgery course with the aim of improving the confidence of surgical residents in performing endoscopic procedures. we also aimed to examine the effect of the exposure to this course on self-reported confidence in performing endoscopic procedures. methods and procedures: the fundamental of endoscopic surgery course at texas tech university health science center is a one-day course consisting of both didactic training and lab training. the didactic part of the course is taught by attending physicians and focuses on the basics of endoscopy, management of upper and lower gastrointestinal (gi) bleed, and techniques to perform a variety of gi endoscopic procedures on swine esophagus and stomach explant. the lab portion of the course allows residents to perform different endoscopic surgical procedures with the attending physicians providing guidance. residents from pgy- to pgy- participated in the course. a -item questionnaire that measured the self-reported confidence in performing several endoscopic procedures on a - likert scale was administered before and after the course. results: twenty-two participants successfully completed the training and the questionnaires. a significant improvement was observed in the overall confidence in performing a variety of endoscopic procedures ( . ± . , p. ). the improvements remained significant even after controlling for the years of postgraduate surgical training (p. ). conclusion: the one-day fundamental of endoscopic surgery course enabled residents to be more confident with endoscopic procedures. overall, the residents felt that the course was helpful and would like to attend more than one session per year. this course should be held, at least, annually to allow the general surgery residents to become even more confident with this important skill. by being more confident in their surgical endoscopy skills, they will ultimately be able to provide better care for patients. introduction: a course evaluation study on the effectiveness of improving laparoscopic skills of surgical residents using swine models was evaluated through a self-report questionnaire administered before and after course completion. the purpose of the training is to provide surgical residents opportunities to practice and advance their laparoscopic proficiencies. methods and procedures: participating residents in all post-graduate year levels (pgy through pgy , n= ) were provided anesthetized pigs with which to perform a variety of simple to complex laparoscopic cases. prior to training, residents were given a questionnaire composed of eleven questions requiring the subjects to rate their confidence in performing various laparoscopic procedures on a - likert scale. after completion of the course, an identical questionnaire was distributed with two additional questions relating to the overall impact of the course. all statistical analyses were conducted using r statistical software (version . conclusion: overall, one-day hands-on training using swine models improved resident's skills, confidence, and understanding of laparoscopic surgery. the information acquired through the questionnaire emphasized the importance of providing a laparoscopic training course as a standard requirement at all medical institutions. allowing opportunities for surgical residents to practice their laparoscopic skillset will not only help in their individual academic advancements, it will allow them to provide optimum care for their patients. background: learning laparoscopy is difficult and many educational tools including simulation training are required. feedback plays a crucial role for motor skill training but require expert tutors and its time consuming. e-learning increases knowledge acquisition through a more interacting multimedia experience and reduces de costs of learning. in the last decade multiple applications (apps) have been developed for mobile medical training. a new ios app was developed using specially designed educational videos that explain the main technical aspects in advanced laparoscopy through simulation training. the aim of this study is to present the first results of its incorporation in a surgical simulation lab as a complement of effective feedback. methods: twenty-five consecutive residents were trained in our simulation lab through a session validated training program for the acquisition of advanced laparoscopic skills needed for the performance of a laparoscopic hand-sewn jejuno-jejunostomy. every session had written instructions and a basic tutorial video. the app consist two main sections, the first one explains the essential techniques needed for intracorporeal suturing and the second is a complete walkthrough of the validated training program. the trainees were divided in two groups, the first was trained without using the app (napp) and the second group was trained using the app (yapp). both groups of trainees could ask for feedback anytime they needed. trainees were assessed before and after the training program using validated rating scales and the number of necessary tutor-feedback sessions were registered. finally the yapp group answered a survey about the strengths and weaknesses of the app for learning advanced laparoscopic skills. results: twenty-five residents completed the training program; yapp and napp. both groups finalized their training with no statistical significant differences in their scores (p: . ). the number of tutor-feedback needed to complete the training in the yapp vs napp was of [ ( - ) vs ( - ) (p. )] respectively. in the questionnaire all participants considered that the app was effective for learning advanced laparoscopy. over downloads have been registered since the app was published in the apple app store in . we present a novel smartphone app that guides laparoscopic training using simulation-based educational videos with very good results. the use of app guided learning reduces de need of expert tutor feedback reducing the costs of simulated training. jemin choi, young-il choi; kosin university gospel hospital purpose: laparoscopic appendectomy (la) has been widely performed for acute appendicitis. in addition, minimally invasive surgery such as la is common surgical technique to the surgical residents. however, single incision laparoscopic surgery (sils) is a challenge to inexperienced surgical residents. we described our initial experience in teaching sils procedure for appendectomy in our medical center. methods: twenty nine cases of single incision laparoscopic appendectomy (sila) were performed by single surgical resident and cases of la were performed by surgical residents and boardcertified surgeons. a study was reviewed retrospectively. ( ) clinical stressors (i.e., vitals of patient coding). we developed a stress simulator testbed by integrating an fls box trainer with a linux computer, running custom c++ code. the code generated various stressor conditions, while recording sensor data from the trainer and human operator. we tested groups of participants in an irb approved trial including: novices (non-medical students), intermediates (medical students), and experts (pgy residents and fellows). the study consisted of subjects performing the peg transfer and the pattern cut six times (baseline, four randomized stressors, posttest). after each task, the nasa-tlx survey was administered to determine the overall workload of that stressor condition. an analysis of variance was conducted to identify significant trends in terms of stressor type. results: when compared to baseline nasa-tlx scores, the intermediate group had the greatest changes in overall workload than novices and experts (p= . ). additionally, the change between baseline and post-test workload was significantly lower than for the environmental, negative evaluative, and clinical stressors (p= . ). for pattern cutting, subjects reported a significantly lower perception of failure (p= . ) in both the positive evaluative (mean= . ) and post-test conditions (mean= . ), yet, though not statistically significant (p= . ), the measured accuracy in the task during the positive evaluative condition was actually worse ( . %), second only to the pre-test accuracy ( . %). the best accuracy for pattern cutting across all expertise levels was % for the post-test followed by . % in the negative evaluative condition. these results are interesting as they show that despite perceived improvements in performance with a positive feedback condition, performance actually degrades and is better in the negative feedback condition, which is perceived to be more difficult. these results were not found in the peg transfer task, which is arguably an easier task. conclusion: from the evidence gathered in the study, it is clear that there is a correlation between distractors and performance. further analysis is needed to identify the relationship between the type of stressor, and inherent difficulty of the tasks, in terms of which type of stressor best improves learning and outcomes. surg endosc ( ) each received credentials to perform diagnostic and therapeutic ercp from their respective hospitals in nevada, minnesota, and idaho. one continues to teach ercp to general surgery residents, and another taught the skill to fellows in an advanced endoscopy fellowship. all three continue to use ercp in their practice ( to times per month), as they each specialized in a field that utilizes ercp routinely. choledocholothiaisis is the most frequent indication, though ercp is also performed for iatrogenic biliary duct leaks, traumatic biliary or pancreatic duct leaks, chronic pancreatitis, and malignancy. conclusions: training in esophagogastroduodenoscopy and colonoscopy is required for general surgery residents, but the addition of ercp to select residents' training enables them to completely manage their patients' surgical disease. the training of select general surgery residents in this skill has been successful, evidenced by the continued use of ercp in the practices of three residents who completed this training program at our institution. the decision to train residents in this skill should be left to individual program directors and department chairs. we recommend that residents selected for this additional training should plan to practice in specialties where ercp can be implemented. conclusion: same-day discharge after nissen fundoplication and hiatal hernia repair is feasible for select patients. one major challenge for same day discharge is the current insurance provisions required for hospital reimbursement. within the parameters of this study, bmi and asa score did not differ between discharged and admitted patients, while older age and increased procedure duration were associated with need for admission. premkumar anandan, ms, facs; bangalore medical college and research institute introduction: minimal access surgery is an imperative element of enhanced recovery program and has significantly improved the outcomes. enhanced recovery program (erp) synonym "fast track" surgery "was first conceived by dr henrich kelhet. largely described for colorectal surgery and reported to be feasible and useful for maintaining physiological function and smooth the progress of recovery. most of the patients who present for surgical emergency are not adequately prepared and many are not in normal physiological state. the feasibility of enhanced recovery programs protocol in such emergency minimal access surgery remains indistinct. this study was designed to validate an enhanced recovery program in patients who undergo emergency minimal access surgery. introduction: pathways for enhanced recovery after surgery (eras) have been shown to improve length of stay and postoperative complication rates across various surgical fields, however there is a relative lack of evidence-based studies in bariatric surgery. the objective of the current study was to determine if starting a bariatric full liquid diet on postoperative day (pod) zero was associated with shorter length of stay (los) for patients who underwent laparoscopic sleeve gastrectomy (lsg) or roux-en-y gastric bypass (rygb). methods: retrospective review of a prospectively collected dataset was conducted at a single institution before and after implementation of a new diet protocol for lsg and rygb. postoperative diet orders were changed from full liquid diet on pod to pod . length of stay and -day readmissions were reviewed from june to august . independent samples t-tests were used to compare continuous variables and chi-squared tests for categorical variables before and after diet change was implemented. patients were excluded if they were undergoing revision surgery, were discharged directly from pacu, or had significant intraoperative complications or required reoperation within the same admission. introduction: data suggests value in using tap (transversus abdominis plane) neural blockade in abdominal surgical procedures. we deploy tap blockade using liposomal bupivacaine via ultrasound (us) as part of a narcotic sparing pain management pathway for patients undergoing abdominal surgery in our rural community setting. our goal was to evaluate adequacy of postoperative discomfort and the success in avoiding narcotic usage. methods and procedures: records of patients undergoing abdominal surgical procedures performed by one surgeon over an month period were reviewed under irb approval. patients taking narcotics prior to the procedure (except for discomfort due to the condition being surgically treated) were excluded from analysis, as were those admitted to the hospital for postoperative treatment. us guided lateral tap blocks were performed by the surgeon using mg of liposomal bupivacaine and mg of bupivacaine in the or prior to the incision. unilateral block was performed for unilateral procedures (e.g. inguinal hernia) and bilateral for laparoscopic or midline procedures. incisional sites were treated with a field block of mg of bupivacaine. prescriptions for medications included , mg of acetaminophen qid and mg of naproxen sodium tid for days. a prescription for tramadol ( to mg prn up to times daily; tablets with no refill) was given. patients were seen in followup two weeks postoperatively. data (following standard scales/metrics) for patient-reported-outcomes e.g. pain, nausea-vomiting, & fatigue will be analyzed with the above data and the analysis with conclusions will be presented & discussed. federico sertic, md, ashwin gojanur, dr, ahmed hammad, md; guy's and st thomas' hospital introduction: the aim of this project is to assess the quality of post-operative pain relief in colorectal surgery and identify patients in whom pain management has not been effective, in order to improve the quality of post-operative care. effective management of post-operative pain has long been recognised as important in improving the post-operative experience, reducing complications and promoting early discharge from hospital. standards: all patients should be pain free at rest, % of elective patients should be told about what analgesia they will have post-operatively, % of patients should be satisfied with their pain management and % of patients should feel staff did everything they could to control their pain. methods and procedures: questionnaires were given to patients on the day prior to discharge. questions about pre-operative and post-operative pain experience were asked. data regarding post-operative analgesia were collected from medication charts and medical notes. data were collected over a period of two months (august/september ). range of procedures: elective laparoscopic abdomino-perineal-excision-of-rectum with igap flaps, elective laparoscopic right hemicholectomy, laparotomy+bowel resection/stoma formation ( elective, emergency), elective repair of parastomal hernia, appendicectomy ( laparoscopic elective, laparoscopic emergency, laparotomy emergency) and elective reversal of ileosomy. pain scores ( - ): immediately post-operative pain, day post-operative pain, post-operative pain after day and pain on moving/coughing/straining. results: mean immediate post-operative pain score was . ( % of patients with score +), mean day post-operative pain score was . , mean post-operative pain score after day was . , mean pain score on moving was . ( % of patients with score +), mean pain score on coughing/ straining was . ( % of patients with score +). % of patients were satisfied with their post-operative pain management and felt that the staff had done everything they could to manage their pain. % of patients were not aware of their post-operative analgesia regimen and % did not know how regularly they could request analgesia. conclusions: effective management of post-operative pain is a key part of post-operative care and an important component of enhanced recovery programmes. patient satisfaction with pain management has been found to correlate with received pre-operative information. increasing ward nurses' and acute pain teams' knowledge is important in improving patients' pain experiences. interestingly, those patients who had a background of long-term opioid requirements reported that they were satisfied with their pain management. methods and procedures: a patient undergoing a standard ultrasound guided ql block by an anesthesiologist established the baseline anticipated response, and procedure time. the procedure, performed under sedation preoperatively, required over minutes. for this study, patients undergoing laparoscopic colorectal surgery were administered a lateral ql block (modified ql ) under ultrasound guidance by the operating surgeon. ml of a mixture ( ml injectable liposomal bupivacaine suspension, ml . % bupivacaine hydrochloride and ml normal saline) was injected bilaterally, after induction, skin preparation, draping, and prior to the operation. postoperative narcotic use and pain vas scores were documented. results: six patients were administered a bi-lateral ql block intraoperatively. procedures were: laparoscopic sigmoid colectomies, one end ileostomy reversal, laparoscopic completion proctectomy with ileal pouch anal anastomosis, and a laparoscopic descending colectomy. of the narcotic naïve patients, mean pain vas on post op days , and were . , . and . respectively within a multimodality pain management/enhanced recovery program, where standing orders prompting narcotic administration by nursing staff is pain vas . all were discharged on pod or without narcotic prescriptions. two of the patients were chronic narcotic users, and they were discharged on their baseline narcotics, i.e. without additional narcotics. all intraoperative blocks were performed in less than minutes. conclusion: a novel, surgeon-administered lateral ql block under ultrasound guidance, is feasible and provides post-operative pain control. patients are discharged home on no/baseline narcotics. a randomized controlled trial is being constructed based on these striking findings. keywords: lc-laparoscopic cholecystectomy, ga-general anaesthesia, sa-spinal anaesthesia. nikhil gupta, rachan kathpal, dr, arun k gupta, dr, dipankar naskar, dr, c k durga, dr; pgimer dr rml hospital, delhi introduction: cholecystectomy have shown some advantages when done under spinal anaesthesia (sa) and associated with less intra operative and post -operative morbidity and mortality. laparoscopic cholecystectomy (lc) under regional anaesthesia alone included patients with coexisting pulmonary disease, who are deemed high risk for ga. the aim of the present study is to assess the efficacy and safety of laparoscopic cholecystectomy under sa. materials: this prospective, interventional study was conducted on patients with chronic calculous cholecystitis attending general surgery out-patient department of our institution. results: in our study, intraoperative complications recorded were hypotension, bradycardia, intra op shoulder tip pain, bleeding from the liver bed, bile spillage, post-op pain and vomiting. % patients had intraoperative pain, % had shoulder tip pain, . % had bradycardia, . % had hypotension, . % had bile spillage and . % had bleeding. laparoscopic cholecystectomy under spinal anaesthesia should be promoted more even in developing countries but we need to establish well evaluated safety guidelines that could be followed faithfully for minimizing the risk of complication. background: the "opioid crisis" has taken over headlines with increasing public attention brought to the drastically increasing rates of addiction to prescription narcotics. in , the american society of addiction medicine reported million americans with an addiction to prescription pain relievers and a four-fold increase in overdose related deaths. in a medical setting, increased opiate use is associated with increased rates of delirium, ileus, urinary retention, and respiratory depression. these risks are increased in the obese/bariatric population. transversus abdominis plane (tap) block is a safe and effective approach to achieve optimum pain control. it reduces the use of opiates in patients undergoing major abdominal surgery. however, there is currently no data in the literature examining its use in the bariatric population. our study examines the use of liposomal bupivacaine for tap block in patients undergoing laparoscopic sleeve gastrectomy (lsg). methods: sixteen patients undergoing lsg with tap block were compared with historical cohort of sixteen patients undergoing lsg without tap block (standard group). the primary outcome measured was post-operative in-hospital opiate use (morphine equivalents). statistical analysis was performed using student's t test for continuous variables and fisher's exact test for categorical variables. results: both groups were well matched in regards to bmi, age, and asa class. there was a significant decrease in the post-operative use of opiates with the use of the tap block ( . mg in the tap block group vs. mg in the standard group; p . ). there was no difference in the mean length of stay between the two groups. there was an increase in the mean operative time with use of the tap block ( minutes in the tap block group vs. minutes in the standard group; p. ) conclusions: the use liposomal bupivacaine for tap block provides substantial analgesia, allowing for significant reduction in post-operative opiate use in our bariatric patients. this can be an important adjunct in pain control for the bariatric population and aid in post-operative complication risk reduction. introduction: the objective of this study was to identify variation in weight and demographics in the distribution of pre-operative clinical characteristics between super obese females compared with males who were about to undergo bpd/ds surgery. as the american obesity epidemic increases, morbidly obese patients have become integral to every surgical practice; they are no longer limited to bariatric surgeons. every clinical insight helps the surgeon to optimize outcomes when operating on and managing these medically fragile individuals. in this context, however, clinically and statistically significant differences in demographics, body mass, and in the distribution of weight-related medical problems between super-obese women and men are unknown. introduction: a transversus abdominis plane (tap) block is an ultrasound-guided injection of local anesthetic in the plane between the internal oblique and transversus abdominis muscles to interrupt innervation to the abdominal skin, muscles, and parietal peritoneum. currently there are incongruent findings on the benefit of this regional anesthetic to surgical patients, particularly the obese population. we hypothesized the addition of a tap block in an enhanced recovery pathway (eras) for bariatric patients would decrease opioid use and shorten hospital length of stay. methods: a retrospective review of all patients who underwent bariatric surgery at a single institution from january to december was performed. patients were identified as: no tap block (no tap), tap blocks that were performed after induction either pre-surgery (pre-tap) or post-surgery (post-tap). the primary outcome was time to first opioid (min) and total morphine (mg) equivalents in pacu. objective: prolonged postoperative ileus increases hospital length of stay and therefore impacts healthcare costs. although many surgeons recommend ambulation in the postoperative period to hasten return of bowel function, little evidence exists to support this practice. our hypothesis is that early ambulation does reduce the time to return of bowel function after intestinal surgery. methods: a subset of patients undergoing intestinal surgery from an ongoing, prospective trial evaluating perioperative physical activity was analyzed. preoperatively, patients wore an activity tracker for a minimum of three days to establish a baseline activity level, measured by daily steps. postoperatively, steps were recorded for days. patients were included in this study if they underwent an operation on the small bowel, colon, or rectum. resolution of postoperative ileus was defined as the postoperative day when patients were noted to meet all of the following criteria on review of nursing documentation: passing flatus, stooling or having ostomy output, and tolerating a regular diet without intravenous fluids. "early" postoperative activity was defined as the average number of daily steps during the first two postoperative days. discussion: these results suggest the patients who received an intraoperative block laparoscopically were more likely to be able to spend less time in the post anesthesia care unit and be discharged home the same day. based on these results, additional process improvement ideas will be implemented in an attempt to improve outcomes. riley d stewart, md, msc, frcsc, james ellsmere, md, msc, frcsc; dalhousie university division of general surgery introduction: oropharyngeal and gastrointestinal (gi) perforations from bbq brush bristles are being reported in the literature with increasing frequency. media attention to this problem has increased awareness by the public. most commonly, bbq bristles lodged in the gi tract can be removed endoscopically or pass without complication. rarely, surgical intervention is required for removal of the bristle or drainage of an associated abscess. we report a case of gastric perforation by a bbq bristle leading to a pancreatic abscess. case report: a -year-old male presented to a regional center with epigastric pain and malaise. his medical history included: hypertension, dyslipidemia, gerd, and smoking. his surgical history included: a tonsillectomy, excision of bronchial cleft cyst, and an umbilical hernia repair. on presentation, his laboratory investigations where unremarkable aside from an elevated white blood cell count. investigations including an abdominal x-rays and an abdominal ultrasound were unremarkable. he was initially treated with a proton pump inhibitor for presumed peptic ulcer disease. he returned to the local emergency room, no better than before. a ct scan was arranged which demonstrated a foreign body at the pylorus consistent with a bbq bristle and a peripancreatic fluid collection (figs. & ) . a gastroscopy failed to identify the bristle. he was admitted, placed on iv antibiotics and referred to our center. despite several days of antibiotics prior to arrival, the collection size on repeat ct scan had increased and the patient had ongoing pain. we repeated the endoscopy with a side viewing endoscope. the perforation was identified posteriorly at the pylorus. the bristle had migrated into the peripancreatic space. the perforation was cannulated with a jagtome. fluoroscopy was used to confirm the position of a wire in the fluid collection (figs. & ) . pus was drained from the collection into the stomach by placement of a french pigtail catheter (fig. ) . the patient was discharged pain free the following day. the patient was asymptomatic at weeks' follow-up. a repeat ct scan showed resolution of the abscess and safe migration of the bristle and stent out of the gi tract (fig. ) conclusion: to our knowledge, this is the first reported transgastric endoscopic drainage of a peripancreatic abscess caused by a bbq bristle gastric perforation. this case is a demonstration of the ever-expanding role of therapeutic endoscopy in a surgical practice. andrew w white, md, carl westcott, md; wake forest baptist medical center introduction: endoscopic balloon dilation of the gastroesophageal junction (gej) is generally limited to mm in diameter. in many stenotic or spastic disorders of the gej mm is just not big enough. larger balloon sizes are available ( and mm), although these are deployed under fluoroscopy without endoscopy. thus, these larger dilations are often not feasible at the time of the diagnostic endoscopy because different facilities and/or equipment are needed. also, fluoroscopic mm balloon dilations are associated with a percent perforation rate. to address these shortcomings we present an experience with a retroflexed "against the scope" balloon dilation of the gej. in detail, the gej is visualized while retroflexed and a balloon is then placed through the scope. the gej is cannulated next to the scope and deployed. please see the attached image for example. methods and procedures: a retrospective chart review was performed for a single surgeon during the past five years. we identified those who had retrograde dilations and evaluated the indications, repeat dilations, complications and symptomatic response. results: a total of retrograde dilations were performed on patients with gej related dysphagia. the average age was . years. of dilations were with a mm balloon while other dilations used as small as a mm balloon. dilations were performed for persistent dysphagia after cardiomyotomy between and days after surgery. other indications for dilation were dysphagia after fundoplication ( / ), dysphagia after paraesophageal hernia repair ( / ) and achalasia during pregnancy ( / ). patients required a total of repeat retrograde dilations at an average time of days after previous dilation. there were instances reported where the dilation did not improve symptoms. there was mucosal breakdown noted in instances although there were no perforations. bleeding was noted in instances although this was always minimal and selfresolving. conclusions: retrograde endoscopic dilation is safe and effective in this small series. the mm balloon against a mm scope gives a mm diameter, but a different shape and a decreased total circumference. there is a possible added safety advantage given that the balloon is inflated under visualization. it can be inflated in steps or stopped if it appears too aggressive. in addition these larger dilations were provided at the time of the initial diagnostic egd without extra equipment. more studies are needed to compare retrograde endoscopic dilation to other methods of management of gej stenosis. introduction: robot-assisted surgery allows surgeons to perform many types of complex laparoscopic surgical procedures. more and more patients are treated with this sophisticated system. however, all the instruments used in the currently available surgical robot system is rigid. therefore, there exists a limitation in the extent of reach to the deeper surgical fields. in order to overcome this difficulty, we are developing a novel flexible endoscopic surgery system (fess) which has flexible single port platform of cm in diameter, independently controlled endoscope and instruments, open architecture that is compatible with existing flexible devices and a magnified d hd camera that has sensors of both rgb and infrared. furthermore, the system is smaller and would be more cost-effective than existing robotic surgical system. a preliminary experiment was performed in surgical procedures using porcine model to evaluate effectiveness and feasibility of fess. methods and procedures: experimental protocols were approved by the animal research committees of our institution. we used a female swine of kg. an assistant forcep lifted up the fundus of gallbladder to create good visualization of surgical field. the cystic duct was ligated by laparoscopic clip device from assistant port. blunt dissection was performed by pushing the forceps and sharp dissection by monopolar electrocoagulation. results: the fess accomplished the dissection of the gallbladder from the liver bed successfully. two mm forceps had enough grasping and dissecting force and dexterity. the gallbladder was removed from single port site easily. conclusions: this experiment showed that it is feasible to intuitively operate single-site cholecystectomy with fess. in order to realize a pure fess procedure, an additional novel device to create good visualization of the surgical field is necessary for the fess platform. a prototype has already been developed for evaluation in securing the surgical field. the optimal working range, or "sweet spot" of fess is not relatively large. in addressing this issue, the feature of easy setup is being improved to enable more efficient positioning and shifting of the sweet spot for the surgical field. this mechanism could enhance the expansion of procedures suitable for fess. the target procedures of fess are those specifically suitable for single port surgery, such as transanal surgeries and transcervical mediastinoscopic surgeries. intraluminal procedures and natural orifice translumenal surgery (notes), which are not considered suitable for rigid surgical robot, are also good applications of fess. regression of anal and scrotal squamous cell carcinoma (hpv related) with imiquimod index patient is a year old hiv positive homosexual man with anal-scrotal condylomas (ain) initially resected in , then treated with radiation in for recurrence. recurred in with changes severe enough to ''…consider diagnosis of invasive squamous cell carcinoma…''. patient elected trial of imiquimod % cream three times per week to defer recommendation of abdominoperineal resection. imiquimod has no antiviral effect but stimulates interferon and cytokines to suppress hpv subtypes and , among other immune effects. no data exists as to systemic effects of imiquimod. after three months of therapy, lesions had largely regressed with only one specimen showing ''…concern for squamous cell carcinoma in situ…''. patient has elected to continue treatment pending further biopsy. this report is typical of a number of other reports of small numbers of cases of neoplasia regression with imiquimod % cream to include melanoma-in-situ, basal cell cancer of skin and other cutaneous malignancies as well as vin. a second female patient, years old, hiv+ with hpv lesions (ain ) including urethral lesions, is being treated with vulvar application of imiquimod to determine if urethral lesions will regress. there is no fda-approved indication for mucosal application of imiquimod. biopsies are pending at completion of six month trial of imiquiimod. surg endosc ( ) introduction: training in flexible endoscopy remains a critical skill for surgeons, as therapeutic endoscopy procedures continue to evolve and to supplant standard surgical operations. the role of endoscopy across surgical subspecialties is shifting, as endolumenal procedures (like per-oral endoscopic myotomy and endolumenal bariatric interventions) have become commonplace. while surgical residency minimum case volumes are mandated, little is known about the volume of endoscopic procedures surgical fellows participate in. we aimed to characterize the volume of flexible endoscopy cases logged by surgical subspecialty fellows as a measure of endoscopic platform use by surgeons. methods: operative case logs for fellows enrolled in post-graduate training programs participating in the fellowship council were de-identified (no patient or program specific information) and provided for analysis. the case log is an online, mandatory, self-reported collection of all surgeries, procedures and endoscopies performed during fellowship year. all cases listed within the category of "gi endoscopy" in which the fellow designated their role as "primary" surgeon for the procedure were further sorted based on subcategory and linked to the year of fellowship graduation. rigid endoscopy, trans-anal endoscopic procedures, and those in which the fellows roll was "first assistant" were excluded. introduction: complex pancreatic and duodenal injuries due to trauma continue to present a formidable challenge to the trauma surgeon with a described mortality of - % and morbidity of - %. duodenal fistula formation subsequent to failure of attempted primary repair is associated with significant morbidity and mortality. we present the first reported series of four patients with complex trauma-related duodenal injuries who had failure of primary repair which were managed with duodenal stenting. we compared outcomes to a matched case control cohort of patients with trauma related duodenal injuries. the aim of this study is to document our experience with enteral stents in patients with complex duodenopancreatic traumatic injuries. methods: a retrospective review at a level i trauma center identified patients who underwent endoscopically placed indwelling covered metal stents after failure of primary duodenal repair in the form of high output duodenal fistulas. a matched case control cohort was identified including patients with duodenal fistulas who were not treated with stents. drainage volumes were collected and classified according to source and phase of intervention (i.e. admission to fistula diagnosis, to stent insertion, after removal, and until discharge). results: there was a decrease in the mean combined drain output of ml/day (p= . ) after stent placement. when comparing the sum of all output sources, there was a statistically significant difference across phases (p= . ) and "after removal" was significantly less when compared to the reference phase (p= . ). there was also a change in the directionality of the slope for the sum of all drain outputs with an increase of ml/day prior to stent placement compared to a decrease of ml/day (p= . ) after stent placement. the stenting group demonstrated a decrease in mean drain output ( ml/day vs ml/day, p= . ) and increase in distal gastrointestinal output ( ml/day vs ml/day, p= . ). one patient in the stent group required later operative repair. all other patients in the stenting and control group had resolution of their fistulas over time. there were late mortalities in the control group. the stent treated patients demonstrated diversion of approximately ml/day of enteral contents distally. while all patients eventually healed their fistulas, the stent treated patients demonstrated an accelerated abatement of drain outputs when compared to the control cohort, but did not reach statistical significance. indwelling enteral-coated stents appear to be an effective rescue method for an otherwise inaccessible duodenal fistula after failure of primary repair. kevin l chow, md, hassan mashbari, md, mohannad hemdi, md, eduardo smith-singares, md; university of illinois at chicago introduction: esophageal trauma represents an uncommon but potentially catastrophic injury with a reported overall mortality of up to %. the management of iatrogenic and spontaneous perforations have been previously described with well-established guidelines which have been mirrored in the trauma setting. esophageal leaks are the most feared complication after primary surgical management and present a challenge to salvage. there has been increasing reports in the literature supporting the use of removable covered metal stents to treat esophageal perforations and leaks in the non-trauma setting. we present the first reported case series of four patients presenting with external penetrating trauma induced esophageal injuries, complicated by failure of initial primary surgical repair and leak development, successfully managed with the use of esophageal stents. materials and methods: a retrospective review was performed at a level i trauma center identifying four patients who underwent endoscopically placed removable covered metal stents, either by a surgical endoscopist or an interventional gastroenterologist, after failure of primary surgical repair of esophageal traumatic injuries. demographic information, hospital stay, additional interventions, complications, imaging studies, iss scores, and outcomes were collected. results: our cohort consisted of patients with penetrating injuries to the chest and neck with esophageal injuries ( thoracic and cervical esophageal injuries) managed with esophageal stenting after leaks were diagnosed following primary surgical repair. their initial esophageal injuries included grades , and . leaks were diagnosed on average post-operative day . two patients underwent an additional attempted surgical repair and subsequent leak development. esophageal stents were placed under endoscopic and fluoroscopic guidance within days of leak diagnosis. there was resolution of their esophageal fistulas with all patients resuming oral intake (averaging days after stent placement). three patients ( %) required further endoscopic interventions to adjust the stent due to migration or for dilations due to strictures. mortality was %, all patients survived to be discharged from the hospital with average icu length of stay of days. conclusion: the use of esophageal stenting has progressed over the last few years, with successful management of both post-operative upper gastrointestinal leaks as well as benign, spontaneous, or iatrogenic esophageal perforations. while the mainstay of external penetrating traumatic esophageal injuries remains surgical exploration, debridement, and repair with perivisceral drainage; our case series illustrates that the use of esophageal stents is an attractive adjunct that can be effective in the management of post-operative leaks in the trauma patient. results of the ovesco-over-overstitch technique for managing bariatric surgical complications introduction: since , the preferred method of enteral access has been the percutaneous endoscopic gastrostomy tube (peg). accidental removal is a common complication associated with excessive cost and possible significant morbidity. removal prior to days is considered ''early removal.'' early removal has more significant risk associated with it, and can necessitate emergent operation to prevent peritonitis and sepsis. some patients, who do not exhibit signs of peritonitis, may be simply observed. for these patients, peg replacement would typically be delayed - days to ensure closure. this delay results in prolonged npo status and worsened nutritional status. presented below is a case of early accidental removal followed by endoscopic clip closure, and immediate peg replacement. case report: a -year-old male presented after a large left middle cerebral artery infarct. a peg placement was completed without complication. eleven hours after the procedure the patient had pulled the peg tube out of the abdominal wall. at this time the patient appeared to have no abdominal pain and no signs of peritonitis. twelve hours following the accidental removal of his peg tube, the patient was taken back to the endoscopy suite, and an egd was performed. the previous peg site was identified and appeared closed and ulcerated. the mucosal defect was closed with two endoscopic metallic clips. a peg tube was then placed at an adjacent site. the following day, the patient was restarted on trickle feeds and advanced to regular tube feeding over a period of hours. since that time, his peg has been functioning well. discussion: we propose that in the case of early accidental peg removal, the patient should be examined first for evidence of peritonitis. if initial physical exam and radiographic investigation do not reveal peritonitis or significant pneumoperitoneum, the patient should undergo urgent repeat endoscopy. at this time, the gastrotomy can be closed endoscopically via metallic clips and peg can be replaced immediately. tube feeds can be initiated after a - hour period of dependent drainage with serial abdominal exams. introduction: since its inception in , poem has become a viable procedure for the treatment of achalasia and esophageal dysmotility disorders. however many institutions are in the beginning stages of implementing the procedure into their programs. in view of training, we report the successful ability to dissect and identify common landmarks during a poem procedure performed by trainees under supervision in a high volume poem center. methods: posterior poem procedures performed by trainees with experienced proctor guidance during the period between february to july were evaluated for the frequency of identifying the perforating vessels, the presence of sling fibers, and position on the lesser curvature of stomach evaluated by double scoping method during the creation of the tunnel and myotomy for procedure. results: all poem procedures were successfully completed by trainees (gi and surgery fellows). the average length of procedure was minutes. indication for procedure included patients with type achalasia ( %), with type achalasia ( %) and des ( %). average length of myotomy for all procedures was . cm. during these procedures or perforator vessels were identified in ( %) of patients, sling muscle was identified in patients ( %) of patients. myotomy extended to anterior lesser curvature of stomach on double scope exam in % of patients. no patient had a serious complication requiring intervention. conclusion: trainees performing a posterior poem procedure were able to correctly dissect and identify the sling muscle and/or perforating vessels in approximately % and % respectively of procedures. however the myotomy position was correctly placed in all procedures. this indicates that while ideally the sling fibers and perforating vessels should be identified, a correctly positioned myotomy can still be successfully performed by trainees without identification of these landmarks. introduction: gastroparesis is a rapidly increasing problem with sometimes devestating patient consequenses. surgical treatments, particularly laparoscopic pyloroplasty, have recently gained popularity but require general anesthesia, advanced skills and create risk of leaks. peroral pyloromyotomy (pop) is a less invasive alternative but is technically demanding and not widely available. we propose an hybrid laparo-endoscopic collaborative approach using a novel gastric access device to allow a endoluminal stapled pyloroplasty as an alternative treatment option for functional gastric outlet obstruction. methods and procedures: under general anesthesia six female pigs (mean weight kg) had endoscopic placement of or mm intragastric ports (taggs, kansas, usa) using a technique similar to percutaneous endoscopic gastrostomy. a mm laparoscope was used for visualization. endoflip (crospon, inc., galway, ireland) was used to measure cross sectional area (csa) and compliance of the pylorus before intervention, immediately after and at week survival. pyloroplasty was performed using a mm articulating laparoscopic stapler (dextera microcutter). after removing the taggs ports, the gastrotomies were closed by either endoscopic clip, endoscopic suture or suture under laparoscopic vision. the animals were survived for week. after - days, a second laparo-endoscopic procedure was performed to verify healing of the pyloroplasty as well as intraluminal dimensions. at the end of the protocol, animals were euthanized. results: six endoluminal linear stapled pyloroplasty were performed. the mean operative time was min. in all cases, this technique was effective in achieving optimal pyloric dilatation. median pyloric diameter (d) and median cross-sectional area (csa) pre-pyloroplasty were mm ( . - . mm) and . mm ( - mm ). after the procedure, these values were increased to . mm ( . - . mm) and . mm ( - mm ) respectively (p= . the quality of endoscopic examination depends on the quality of endoscopic equipment, experience of the endoscopist and preparation of the patient. contemporarily electronic endoscopes make feasible to transfer image directly to external device which is subsequently linked to computer network and can be transferred further. dynamic image viewed in real time is more accurately interpreted by a physician than a static one. the possibility of simultaneous voice contact makes teleconsultation sterling. the aim of this study was to present our own experience regarding endoscopic teleconsultations. materials and methods: analysis enrolled examinations performed in endoscopic centers located in lesser poland district and in denmark. consultations took place in real time, consulting physicians had more than years of experience in endoscopic procedures and over colonoscopies and therapeutic procedures performed. there were teleconsultations via standard internet connection mb/s. endoscopic centers were equipped with olympus and series linked to video card. each card had its own ip address, and the image was accessible through internet login from anywhere. consulting physicians used computers connected to internet for tracing the image synchronously and giving advice. results: teleconsultations were undertaken in . % of all endoscopic procedures. teleconsultations concerned difficulties in endoscopic image interpretation in cases and decisions regarding further treatment in cases. the consulting physician solved all problems concerning proper endoscopic image interpretation. in cases the elective procedure was rejected. the elective treatment was continued in remaining cases. patients had a complication of polypectomy that was endoscopically treated. conclusions: the opinion of independent consulting physician in difficult clinical cases regarding endoscopic procedures helps to understand the endoscopic image in real time and implicates a decrease in complications after endoscopic procedures. michelle ganyo, md, robert lawson, md; naval medical center san diego introduction: a presacral phlegmon is a contained collection of infected fluid and inflammation within the bony pelvis, posterior to the rectum and anterior to the sacrum, that usually arises as a complication of surgery, malignancy, inflammatory bowel disease, ischemic colitis or perforated viscous. symptoms include low-back pain, pelvic pain and fevers. antibiotics and supportive therapy are the mainstay of treatment. however, if abscess develops, drainage is required usually by trans-gluteal percutaneous and/or surgical methods, both of which are associated with significant morbidity and mortality. endoscopic ultrasound (eus) -guided drainage of perirectal and presacral abscesses is a well described minimally-invasive approach that permits clear definition of anatomy, real-time access to the abscess and creation of an internalized fistula through placement of one or more transluminal stents. however, to date there is no published report describing endoscopic treatment of the more complicated, clinically challenging presacral phlegmon. here we present a case of a symptomatic presacral phlegmon recalcitrant to medical management that was successfully treated with an endoscopically placed retrievable, transmural, lumen-apposing metal stent. case report: this is a case-report of a -year-old, post-partum female who presented with fevers and recurrent lower back pain radiating to her rectum and vagina. her spontaneous vaginal delivery was notable for a second-degree laceration that was primarily repaired at the time of delivery months prior to presentation. her past medical history was otherwise unremarkable. radiographic imaging revealed several perirectal and presacral abscesses that were considered too small for percutaneous drainage. iv antibiotics were started and the largest abscess was targeted for eusguided aspiration. unfortunately, her pain became constant and progressed in severity. a follow-up mri a week later revealed a -cm presacral phlegmon. results: colonoscopy revealed a luminal bulge in the rectum but was otherwise normal. to permit drainage and multiple sessions of endoscopic necrosectomy, a mm lumen-apposing metal stent (lams) was placed transrectally under eus-guidance into the presacral phlegmon. endoscopic debridement with forceps and copious irrigation was performed. over the following weeks the patient reported purulent rectal drainage and resolution of her fevers and pain. repeat endoscopy revealed a normal rectum and no sign of the stent. a follow up mri showed a -cm area of heterogenous tissue in the presacral area. conclusions: although not previously described for management of a presacral phlegmon, lams appears to be a safe and effective, minimally-invasive treatment option. introduction: flexible endoscopy has evolved to include multiple endoluminal procedures such as anti-reflux procedures, pyloromyotomy, and mucosal and submucosal tumor resections. however, these remain technically demanding procedures as they are hindered by the state of flexible technology which has difficult imaging, limited energy devices, no staplers, and cumbersome suturing abilities. an alternative approach is transgastric laparoscopy, which for almost decades has been shown to be a good procedure for pancreatic pseudocyst drainage and full-thickness and mucosal resection of various lesions. we propose to expand the indications of transgastric laparoscopy by using novel endoscopically placed transgastric laparoscopy ports (taggs, kansa, usa) to replicate endoscopic procedures such as endoluminal antireflux surgery. methods and procedures: under general anesthesia female pigs (mean weight . kg) had endoscopic placement of mm-intragastric ports (taggs, kansas, usa) using a technique similar to percutaneous endoscopic gastrostomy. a mm laparoscope was used for visualization. endoflip, (crospon, inc., galway, ireland) was used to measure cross sectional area (csa) and compliance of the gastroesophageal junction (gej) before and after intervention. laparoendoscopic-assited suture plication of the gej was performed using - sutures (polysorb®). once the taggs ports were removed, the gastrotomies were closed by using endoscopic clip. at the end of the protocol, animals were euthanized. results: five laparoendoscopic-assited sewing plication were performed. the mean operative time was , min (endoscopic evaluation: . min, tagss insertion: min, endoflip evaluation+ gej plication: , min, gastric wall closure: min). in all cases, this technique was effective in achieving adequate gej plication. median gej diameter (d) and median cross-sectional area (csa) pre-plication were . mm ( . - . mm) and . mm ( - mm ). after the procedure, these values were decreased to . mm ( . - . mm) and . mm ( - mm ) respectively (p= , ). median distensibility (d) and median compliance (c) pre-plication were . mm /mmhg ( . - . mm /mmhg) and . mm /mmhg ( , - , mm /mmhg). after the procedure, these values were decreased to , mm /mmhg ( . - . mm /mmhg) and . mm /mmhg ( . - . mm /mmhg) respectively (p= , ). no intraoperative events were observed. conclusion: a hybrid laparoendoscopic approach is a feasible alternative for performing intragastric procedures with the assistance of conventional laparoscopic instruments; especially in cases where the location of the intervention limits the access of standard endoscopy or where endoscopic technology is inadequate. further evaluation is planned in survival models and clinical trials. introduction: due to previous manipulation or submucosal invasion, colonic lesions referred for endoscopic mucosal resection (emr) frequently have flat areas of visible tissue that cannot be snared. current methods for treating residual tissue may lead to incomplete eradication or not allow complete tissue sampling for histologic evaluation. our aim is to describe dissection-enabled scaffold assisted resection (descar): a new technique combining circumferential esd with emr for removal of superficial non-lifting or residual "islands" with suspected submucosal involvement/fibrosis. methods: from to , lesions referred for emr were retrospectively reviewed. cases were identified where lifting and/or snaring of the lesion was incomplete and the descar technique was undertaken. cases were reviewed for location, prior manipulation, rates of successful hybrid resection and adverse events. results: lesions underwent descar due to non-lifting or residual "islands" of tissue. patients were % m, % f, and average age (sd ± . yrs). lesions were located in the cecum (n= ), right colon (n= ), left colon (n= ) and rectum (n= ). average size was mm (sd ± . mm). previous manipulation occurred in / cases ( % biopsy, % resection attempt, % tattoo). the technical success rate for resection of non-lifting lesions was %. there was one delayed bleeding episode but no other adverse events. approximately % of patients have been followed up endoscopically to date with no evidence of residual adenoma. conclusions: descar is a feasible and safe alternative to argon plasma coagulation and avulsion for the endoscopic management of non-lifting or residual colonic lesions, providing en-bloc resection of tissue for histologic review. further studies are needed to demonstrate long-term eradication and for comparison with other methods. results: patients underwent fully covered stent placement procedures. indications for stent placement were leak in patients ( sleeve; bypass) and stricture in patients ( bypass, sleeve). five patients had stent migration. three required surgical removal, one patient endoscopic repositioning and one passed the stent per rectum. all eight patients with enteric leak successfully underwent stent placement in conjunction with diagnostic laparoscopy and drainage. all but one of these patients developed an enteric leak perioperative to index procedure. the average duration of stent treatment in these patients was days ( - days). of the patients treated for a stricture, patients ( sleeve, bypass) failed treatment and required subsequent definitive operative revision. average length of time of stent treatment in these patients was days (range, - days) and five had severe intolerance. conclusions: endoscopic stent placement of leak may require multiple procedures and carries the risk of migration; however, this therapy seems to be an effective treatment. failure rates are higher with strictures and are not as tolerated by patients. background: colonoscopy is the most commonly performed endoscopic examination worldwide and is considered the gold standard for colorectal cancer screening. the quality of examination and endoscopic treatment is affected by a number of factors that are verified by recognized parameters such as cecal intubation rate and time (cir, cit), withdrawal time, adenoma detection rate (adr) and polyp detection rate (pdr). advanced endoscopic imaging improves accurate recognition of the nature and variety of pathologic lesions, while the endoscope tips, third eye retroscope and wide-angle endoscopy allow detection of lesions located on the proximal side of the intestinal folds. the aim of the study was to assess the suitability of wide-angle colonoscopy for the detection of colorectal lesions and to analyze the functionality of a special endoscope series regarding cir, cit and withdrawal time. introduction: leak is an uncommon but serious complication of gastrointestinal surgery. when identified post-operatively, percutaneous drains are used to manage abscesses and prevent further peritoneal contamination. if drain position is suboptimal, however, the consequences of persistent leak may necessitate a formal surgical intervention in a hostile abdomen. in select situations, we have utilized natural orifice transluminal endoscopic surgery (notes) methods to enter the abdominal cavity and place/reposition drains under direct endoscopic visualization a part of our comprehensive endoscopic management algorithm for leaks. methods and procedures: a prospectively collected database was queried for patients who had undergone transluminal endoscopic drain repositioning (tedr) as part of multimodal endolumenal therapy for leak (including interventions like defect closure, enteral feeding access, or endolumenal stent placement). inadequate drainage was identified pre-procedurally by undrained fluid collections in conjunction with clinical signs of sepsis. translumenal access was obtained via the leak site and carbon dioxide insufflation was used in all cases. the peritoneal cavity was surveilled and cleared of gross debris by irrigation and suction. intraabdominal drains were located endoscopically and fluoroscopically, grasped with an endoscopic snare or grasper and repositioned adjacent to the leak site to ensure better drainage. results: four patients ( female), average age (range - ), average body mass index (range - ) were managed with tedr as a component of endoscopic treatment of full-thickness gastrointestinal leak. two patients developed leak following revisional bariatric surgery. one patient had an acutely dislodged gastrostomy tube with intraperitoneal leak after multiple laparotomies recently closed with a granulating vicryl mesh. one patient developed a leak at an esophagojejunostomy following total gastrectomy. three patients had adequate drainage after the initial tedr, while one patient required tedr on two occasions. all patients had improved drainage demonstrated by resolution of clinical signs of sepsis and resolution of fluid collections. drains were removed as clinically indicated. conclusion: intraabdominal drains are an essential element in the management of full-thickness gastrointestinal leaks, but are not always able to be adequately positioned percutaneously. transluminal endoscopic drain repositioning via a gastrointestinal defect is a viable option to avoid surgical intervention in an otherwise hostile field and is a novel practical notes application. background: epiphrenic diverticula (ed) arise from increased intraluminal pressures, often secondary to achalasia or another underlying esophageal motility disorder which causes "pulsion" physiology. ed are traditionally thought to contribute to patients' symptoms of regurgitation and dysphagia, and are frequently resected at time of heller myotomy and fundoplication done for treatment of the primary motility disorder. ed excision carries significant risks (staple line leak, pulmonary complications, mortality), and little is known regarding patients with ed and esophageal motility disorder who undergo surgical myotomy without ed resection. the goal of this study was to compare outcomes of patients with ed and esophageal motility disorder who did and did not undergo diverticulectomy at time of myotomy and fundoplication. methods: retrospective analysis of prospectively collected database from to was performed. patients with diagnosis of ed undergoing surgical treatment of symptomatic esophageal motility disorder were included. all patients underwent laparoscopic heller myotomy with toupet fundoplication by a single surgeon at a tertiary referral hospital. patients were stratified according to whether ed was excised or not excised at time of primary surgery. patient-reported symptoms were obtained from pre/post-operative clinic evaluations and mailed surveys during the follow-up period. independent samples t-test and fisher's exact test were used to compare continuous and categorical variables respectively. results: ed was identified in patients prior to surgery. primary diagnoses included achalasia (n = ), nutcracker esophagus (n= ), and diffuse esophageal spasm (n= ). ed was excised in five patients ( . %) and not excised in ten patients ( . %), with no significant difference in frequency of preoperative dysphagia ( % vs. %, p= . ) or regurgitation ( % vs. %, p= . ) between groups respectively. reasons for non-resection included ed was too proximal (n= ), patient/surgeon preference (n= ), and small ed size (n= ). the resection group did not experience any leaks and there were no mortalities in either cohort during the follow-up period. at mean clinic follow-up of days, there was no difference in frequency of residual dysphagia in patients who did or did not undergo ed resection ( % vs. %, p= . ) and neither cohort reported residual regurgitation symptoms. conclusions: this study suggests that leaving ed in place during surgical treatment of an esophageal motility disorder may achieve similar rates of postoperative symptom control. while ed excision in this study did not cause significant excess morbidity, ed resection introduces risk of leak and requires more extensive surgery that may not provide significant benefit to patients. introduction: median arcuate ligament syndrome (mals) has been described in the literature as presenting with a constellation of symptoms including nausea, vomiting, weight loss, and post-prandial epigastric pain. while many of these symptoms are consistent with foregut pathology, a cohort of patients with mals presenting with delayed gastric emptying has not been described in the literature. in this study we report on the possible association of mals with delayed gastric emptying. methods: cases of mal release were collected between and . eight patients were identified who presented with mals and underwent subsequent mal release. all patients underwent laparoscopic or robotic surgery. patients were compiled into a retrospective database and their demographic, symptomatic, imaging, and outcomes data were analyzed. background: laparoscopic fundoplication (lf) is often performed to treat paraesophageal hernia and/or gerd. care is taken to select the right patients for the operation. some patients may not improve, and others experience dysphagia or bloating after surgery. factors associated with patient satisfaction after fundoplication would be helpful during the patient selection process. methods: a retrospective review of a prospectively collected database was performed. queried patients underwent lf from to . non-elective operations and fundoplications after heller myotomy were excluded. of this cohort, patients were included only if they responded to a two-year postoperative quality of life survey. surveys were distributed preoperatively, at three weeks, at one year, and at two years. the surveys include the reflux severity index, gerd-hrql, and dysphagia score. the gerd-hrql asks about patient satisfaction with their current state ( = dissatisfied, = somewhat satisfied, = very satisfied). the cohort was divided according to their answer to this question at two years. demographics and preoperative factors were compared between the groups with kruskal-wallis and fisher's exact tests. univariable and multivariable ordinal logistic regression was performed to identify preoperative symptoms associated with satisfaction at two years. scores on the surveys over time were were also analyzed. results: a total of patients were included in the analysis (dissatisfied = , somewhat satisfied = , very satisfied = ). the only significant demographic or preoperative difference was a high number of paraesophageal hernias in the 'very satisfied' cohort (p = . ). on univariable regression, younger age and paraesophageal hernia predicted satisfaction. several variables negatively predicted satisfaction with an or \ . multivariable regression, controlled for age and hernia type, identified throat clearing, post-nasal drip, and globus sensation as preoperative symptoms less likely to result in patient satisfaction (p = . , . , and . , respectively). subgroup analysis of patients with paraesophageal hernias revealed that patients with bloating preoperatively are less likely to be satisfied at two years. survey scores over time showed all groups improving over three weeks, but while satisfied patients continued to improved, dissatisfied patients symptomatically worsened over time. conclusion: this study confirms previous reports stating atypical symptoms of gerd are less likely to improve after lf. it also shows individuals with paraesophageal hernia tend to do quite well, unless they report bloating preoperatively. patient-centered analysis such as this can be useful when discussing postoperative expectations with patients, and may reveal opportunities to individualize operative approach. objective: the study was performed to assess whether sutured crural closure or mesh reinforcement for hiatal closure yields better results with regards to symptom resolution and recurrence post-operatively. material and methods: a prospective randomized controlled trial was carried out at grant medical college and sir j. j. group of hospitals, mumbai, india. patients were randomized to receive either sutured repair or mesh reinforcement of hiatal closure. outcomes of interest were symptom resolution, quality of life scores and recurrence in the postoperative period. results: patients were recruited for the trial ( -sutured repair, -mesh reinforcement). the two groups were comparable in terms of demographic profiles, symptom severity and findings at esophagogastroscopy and manometry in the pre-operative period as well as size of the hiatal defect measured intra-operatively. post-operatively the mesh repair group had significantly better symptom resolution in terms of early satiety, chest pain and regurgitation (p\ . ) while with respect to heartburn, dysphagia and post-prandial pain there was no significant difference between the improvements demonstrated. improvement in quality of life scores after either procedure was not significantly different. recurrence was higher in the suture repair group ( vs , p. ). recurrence lead to poorer symptom severity scores as well as quality of life scores and one patient underwent re-operation. the change in the symptom severity score from baseline after the procedure at months in the subgroup population. conclusion: mesh reinforcement results in a reduced rate of recurrence and offers excellent symptom control in the short-term without a rise in complications when compared to sutured repair for the closure of hiatal defects in laparoscopic hiatal hernia repairs. material and methods: in a period from to , patients underwent laparoscopic resection ( -gastric resection, -duodenal resection), using different techniques. all patients were investigated with upper gi endoscopy, eus and abdominal contrast-ct, which allows us to get the complete evaluation of tumor, including size, location, type of growth and the gi layer. based on the findings the decision on the type of resection was made. the majority of resections were wedge or partial resections, performed using endoscopic steplers or using ultrasound scissors followed by double-suturing of gatro/duodenotomy. in the cases of tumor location on the posterior gastric wall we mobilized the the greater curvature to get a direct approach to the tumor with extraluminal growth. in the cases with intraluminal growth we used transgastric approach with small , cm incision on the anterior gastric wall for endoscopic stepler. technically the most complex procedures were in the cases of tumor location close to anatomically narrow places and muscle sphincters (gastroesophageal junction, pylorus, duodenal bulb, duodenal flexure), with high risk of stenosis and dysfunction of anatomical sphincters. in such cases we used «lifting-technique» in which we dissect serous and muscle layers circumferentially around the tumor making partial enucleation of lesion followed by total resection preserving almost all normal tissue with minimal suturing and deformity at the site of surgery. ( : ), mean age was . years (sd ± . ), patients ( %) had mis. the type of reconstruction was predominantly with a "pull-up" technique (n = , . %) followed by the kirschner-akiyama procedure (n = , . %), stapled gastroplasty was performed in patients. all the anastomosis were performed at the level of the neck and only one of the patients had a stapled anastomosis, mean operative time was min (sd ± min) including resection of the specimen. primary neoplasms were predominantly hypopharynx (n = , . %), distal esophagus (n = , %), cervical esophagus (n = , . %) and thoracic esophagus (n = , . %). histologic types were mainly squamous cell carcinoma (n = , . %) and adenocarcinoma (n = , . %). mean of hospitalization days was . (sd ± . ). no complications were observed in patients and major complications (dindo-clavien ≥iiib) were found in patients. anastomotic leak was present in patients ( . %) and perioperative mortality ( days) was . %. progressive shift to laparoscopic surgery was evidenced through the years ( - : . %, - : . % and - : . %; p = . ) and reduction in major complications (p = , ) was observed. anastomotic leaks (p = , ) and perioperative mortality (p = . ) did not show significant differences in the present study. conclusions: results in our center show that major complications decrease with time after application of minimally-invasive surgery and no differences in anastomotic leaks and mortality were seen. current data has lead us to abandon open total esophagectomy as a first-choice procedure. introduction: minimal invasive three-fields esophagectomy for minimal invasion is the surgical standard for oncological procedures and benign diseases. cervical dissection has a risk of to % in some series, of, lesion or paralysis of the rnl, but the standard in mckeon approach is %. a high level of suspicion is needed because this type of lesion has an impact on postoperative evolution and the hospital stay. main: to describe three cases of rnl post esophagectomy paralysis in three planes by least invasion. methods: in a period of years, january to june , esophagectomies for bening disease were performed. three patients ( males female) with diagnosis of terminal achalasia and stenosis secondary to caustic ingestion consulted at the minimal invasion service fundcacion valle del lili. they were schedualed for minimal invasive three fields esophagectomy, one patient without complications and early discharge ( postoperative day) but occasional dysphagia, the other two required early reintubation after de surgery with ards, patient requiered tracheostomy, the second patient could be extubated after days but with occasional dysphagia. all three had mild hoarseness after surgery. the patient who required tracheostomy was decannulated at days without complication. results: the three patients underwent endoscopy without complication in the cervical anastomosis stenosis or disorder in the emptying of the gastric tube, swallowing study without alteration and laryngoscopy with paralysis of the left vocal cord. these patients went to speech therapy with total paralysis recovery at months corroborated with laryngoscopy, without dysphagia or hoarseness. conclusion: rnl innervates the larynx and upper esophageal sphincter, therefore lesion or paresis causes symptoms such as hoarseness, dysphagia, difficulty swallowing, aspiration, difficulty in coughing, pneumonia and ards. injury has a predecessor factor in pulmonary complications and prolongation of the hospital stay. % of these patients may require some surgical procedure to restore the function of rnl. noninvasive monitoring of the laryngeal nerve decreases the risk of injury. philip case report: multiple esophageal diverticula associated with achalasia introduction: achalasia is well defined disorder of increased lower esophageal sphincter tone ( ). epiphrenic esophageal diverticulum are a rare disorder believed to result from increased intraesophageal pressure often in conjunction with a motility disorder causing functional outflow obstruction. they are a pulsion-type pseudo-diverticulum with mucosal bulging most frequently from the right posterior esophageal wall ( ) . we present a very rare case of achalasia associated with multiple esophageal diverticula successfully treated with laparoscopic heller myotomy with dor fundoplication. case presentation: a year old woman presented with years of dysphagia, chest discomfort, regurgitation, and weight loss. esophagoscopy showed a patulous esophagus with multiple esophageal diverticula (figure ). barium esophogram demonstrated esophageal diverticula in the distal esophagus and delayed clearance of esophageal contrast (figure ). high resolution monometry revealed a hypertensive mean les, an aperistaltic body on of wet swallows, and panesophageal pressurization in of wet swallows -consistent with type ii achalasia by chicago classification ( ). we performed a laparoscopic heller myotomy with dor fundoplication. the myotomy was extended cm above the gasgtroesophageal junction and cm onto the gastric cardia. an anterior diaphragmatic defect with a moderate type hiatal hernia was repaired with two sutures, ensuring to not impinge the esophagus (figure ). at weeks post operatively the patient reports excellent results. her dysphagia and chest discomfort have entirely resolved. her eckhardt score improved from seven preoperatively to one post operatively. discussion: type ii achalasia is successfully treated in the majority of cases with laparoscopic heller myotomy and partial fundoplication ( ). however, esophageal diverticula typically require both myotomy as well as diverticulectomy for successful treatment ( ) . there is little experience with the surgical management of multiple esophageal diverticula. we propose a two stage surgical approach for these patients. we reason that the risk of esophageal leak or stenosis in the case of multiple esophageal diverticulectomies out weighs the proposed benefit. indeed epidemiologic studies indicate that the majority of esophageal diverticula are asymptomatic ( ) . in the event the patient remains symptomatic after myotomy a second stage operation with diverticulectomies would be possible. this single experience suggests that diverticulectomy may not be necessary in the case of multiple diverticula associated with achalasia. instead, treatment may be directed at relieving the functional obstruction responsible for the symptoms by performing laparoscopic heller myotomy with dor fundoplication. takahiro kinoshita, md, facs, masanori tokunaga, md, akio kaito, md, masahiro watanabe, md, shizuki sugita, md; national cancer center hospital east, japan objective: the optimal surgical approach for siwert type ii cancer is still controversial due to the anatomical complexity of the region. potential advantages of laparoscopic transhiatal approach have not been fully investigated. methods and procedures: we retrospectively analyzed consecutive patients with siewert type ii cancer who underwent laparoscopic transhiatal resection. indication of surgery is patients with siewert type ii cancer with less than cm esophageal invasion. regarding the extent of resection, basically proximal gastrectomy with the lower esophageal resection was selected, aiming at preservation of gastric reservoir function. in terms of reconstruction after proximal gastrectomy, double-tract method was performed. intraoperative peroral endoscopy was routinely employed for determination of the appropriate resection level of the stomach. esophagojejunostomy was employed by overlap method using a mm linear stapler. in order to obtain a wider operative field in the lower mediastinum, the diaphragmatic crus was dissected to widen the esophageal hiatus. results: in patients ( males and females), median operation time was minutes, and estimated blood loss was g. the rate of surgical morbidity was %, and that of anastomotic leakage was %. there was no mortality. the mean length of proximal margin was mm, and no positive margin was recorded. the -and -year overall survival rate was . % and %, respectively. conclusions: laparoscopic transhiatal resection for siewert type ii cancer is technically challenging, but appears feasible and safe when performed by an experienced surgical team. a largescale prospective study is necessary for final conclusion. introduction: mesh use for reinforcement of primary crural closure is controversial. synthetic mesh use poses a risk of erosion but there is no evidence that non-synthetic mesh is useful to minimize the risk of hernia recurrence. we evaluated a fully bioresorbable mesh made from poly- -hydroxybutyrate (p hb) for crural reinforcement after para-esophageal hernia (peh) repair. the aim of this study was to evaluate the safety and efficacy of p hb mesh at the hiatus in patients undergoing peh repair. this was a review of prospectively collected data on consecutive patients that had repair of a peh with reinforcement of the crural closure with p hb mesh. to be considered a peh at least % of the stomach was herniated into the chest. a collis gastroplasty or crural relaxing incision was added for short esophagus or crural tension when necessary. routine follow-up consisted of esophagogastroduodenoscopy (egd) at months for patients that had a collis gastroplasty and a barium upper gi study (ugi), high resolution manometry (hrm) and ph test in all patients at months. a hernia of any size identified during objective follow-up testing was considered a recurrence. overall, there was a significant difference in mean measured tension between the three subjective suture ratings by the surgeons. however, there was substantial variability and overlap amongst the surgeon's ratings (figure) . the tension necessary to approximate the crura during peh repair can be objectively measured and as expected increases progressively with anterior movement up the hiatus. while there was some correlation between a surgeon's subjective assessment of the tension necessary to bring the crura together and actual measured tension, there was wide variability and imprecision from one stitch to another. objective tension measurement may provide a more reliable assessment of when excessive force is being used to re-approximate the crura and potentially improve peh recurrence rates. ahmed introduction: paraesophageal hernia repairs are increasing in prevalence, and unfortunately carry a high recurrence rate. consequently, reoperation is expected to increase in frequency. published data on the outcomes of recurrent paraesophageal hernia (rpeh) repair is very limited. because of the technical difficulties of revisional surgery, we hypothesize that laparoscopic revisional paraesophageal hernia repairs are associated with high perioperative morbidity and poor patient outcomes. methods: all rpeh repairs performed by the foregut surgical service at our institution from to were reviewed. patients were included if their index operation was a true pehr (initial type hiatal hernia repairs were excluded, as well as multiply recurrent hernias). demographics, medical and surgical history, and operative notes from the index surgery were reviewed. details from standardized pre-operative symptom assessment, objective testing and operative details for the revisional surgery were collected. patients were routinely offered month post-operative upper gastrointestinal contrast evaluation. postoperative outcomes included a standardized symptom assessment and results of objective testing at any time after surgery. results: twenty six patients were identified who underwent repair of rpeh. demographic, operative and perioperative data was available for all patients (table ) . twenty four patients underwent followup symptom evaluation (two were lost to follow-up after the initial hospitalization). sixteen patients underwent follow-up objective testing by radiographic evaluation with contrast, endoscopy or both. these subgroups were used to calculate symptomatic and objective outcomes (table ) . conclusion: reoperative laparoscopic surgery for recurrent paraesophageal hernias is technically challenging as evidenced by long operative times. despite this, perioperative outcomes at a high volume center are good, with low morbidity and no mortality. importantly, symptomatic outcomes for this difficult problem are excellent. introduction: hypotension of the lower esophageal sphincter (hles) and the presence of hiatal hernia (hh) have both been associated with gastroesophageal reflux disease (gerd). the exact likelihood with which a hles or a hiatal hernia predict gerd continues to be defined. we hypothesize a synergistic interaction in those with hles and hh in predicting gerd as defined by a positive ph study. methods and procedures: between and , consecutive patients presenting to a surgical practice with symptoms most concerning for gerd, without prior antireflux surgery were evaluated by high resolution manometry (hrm), esophagogastroduodenoscopy (egd), videoesophagography (veg) and an ambulatory ph study. hles was defined as residual les pressure of\ mmhg, hh was defined as having been noted and measured by the radiologist, these were further categorized into any hh, - cm, [ - cm background: while clinical outcomes have been reported for antireflux surgery, there is limited data on postoperative outpatient encounters and their associated costs. the aim of this study is to evaluate the utilization of healthcare and its associated costs during the -day postoperative period following antireflux surgery. methods: we analyzed data from the truven health marketscan® research databases. patients ≥ years with an icd- procedure code or cpt code for antireflux surgery and a primary diagnosis of gerd during - were selected. only patients with continuous enrollment six months prior to the date of surgery and -days after surgery were analyzed. patients with a diagnosis of esophageal cancer or achalasia during the six-month period prior to antireflux surgery, a length of stay [ days following index procedure, a capitated plan, or patients who underwent emergency surgery were excluded. outpatient endoscopy was defined using icd- and cpt codes, and related readmission was defined by clinical classification software. introduction: the development of postsurgical gastroparesis following nissen fundoplication is poorly understood. in this study, we analyze the development of gastroparesis requiring intervention and other subsequent procedures following fundoplication and paraesophageal hernia (peh) repair procedures in the state of new york. methods: using a comprehensive state-wide administrative database (sparcs), we examined all in-patient and outpatient records for adult patients who underwent fundoplication or peh repair as a primary procedure for the treatment of gerd between the years of - . patients with an initial gastroparesis diagnosis were excluded from the analysis. through the use of a unique identifier, each patient was followed until for the subsequent diagnosis of gastroparesis or reoperation. surgical procedures for the treatment of gastroparesis included pyloroplasty, pyloromyotomy, or gastroenterostomy procedures. multivariable logistic regression models were used to identify independent predictors for having subsequent reoperation. results: a total of , patients were analyzed. this included , fundoplication patients ( . %) and , ( . %) with peh repair. in the fundoplication group, ( . %) patients had a follow-up diagnosis of gastroparesis or secondary procedure. ( . %) of the patients who underwent a primary peh repair procedure had a follow-up procedure or gastroparesis diagnosis (table ) . mean time to follow-up procedure or diagnosis was . years for the fundoplication group and . years for the peh repair group. the majority of the follow-up procedures in the fundoplication group were revisional procedures (fundoplication or peh repair) (n = , . %), while ( . %) patients were newly diagnosed with gastroparesis and/or underwent a secondary procedure for its treatment. conclusion: fundoplication and peh repair procedures have a relatively low post-operative incidence of gastroparesis following initial procedure for treatment of gerd. secondary fundoplication or peh repair was more commonly performed compared to any of the surgical procedures for gastroparesis for both procedures. further analysis of association with subsequent procedures is needed. during this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. if the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. if the reflux was observed intensely up to cervical esophagus, the position was returned to head high position for the safety and the case was assigned to severe category. the anti-reflux surgery was considered in the moderate and severe categories. results: we have performed laparoscopic nissen procedure in cases. the mean operation time was min. the outcome was assessed by reflux test performed on - postoperative day, and the results showed the reflux was disappeared in every cases. median follow-up period of this study was months ( - months). in cases ( . %) ppi was restarted before months after the anti-reflux surgery. in cases ( . %) ppi was restarted after the anti-reflux surgery during the whole follow-up period of this study. the bmi of the patients had no relationship to the needed restart of ppi. to evaluate the degree of esophagitis objectively before and after the anti-reflux surgery we designed "the esophagitis score". in this scoring method, a number from - was assigned according to the degree of esophagitis along with the la classification. the results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the ppi restarted group (p. ). discussion: the number of gerd patients who needed anti-reflux surgery seems to be so high. to extract the patients who needed it remarkably is important. the anti-reflux surgery is most effective for the patients who really have the obvious reflux. reflux test is feasible because of its convenience and visual effects for the patients. the results of the laparoscopic nissen fundoplication were good and satisfied by the patients mostly. surg endosc ( ) :s -s introduction: fundoplication at the time of giant paraesophageal hernia repair is controversial. the proposed advantages are better reflux control and lower recurrence. disadvantages include fundoplication specific complications, might be unnecessary and may not decrease recurrence. we retrospectively reviewed giant paraesophageal hernia repairs (peh) with two point gastropexy in the fundus and body, and no antireflux procedure. data collected is postoperative gerd symptoms, postoperative proton pump inhibitors (ppis) therapy and recurrence. methods: a retrospective review of patients who underwent repair of giant peh from to december of . giant was defined as a hernia with % or more of the stomach above the diaphragm. follow up consisted of upper gi (ugi) study one year postoperatively and reflux symptom questionnaire. patients were followed every months in the surgery clinic and a ppi wean was initiated at the second postoperative visit. the primary outcome we evaluated was discontinuation of ppis. in addition, we utilized a standardized reflux scale and recurrence rates collected. chi-squared was used for statistical analysis. background: gastroesophageal reflux disease (gerd) is a highly prevalent disorder with a multitude of treatment options ranging from lifestyle modifications and medical management to surgical options. despite the numerous treatments available, there is still debate over which approach is most appropriate and effective for patients. this study aims to examine the effect of robotic hiatal hernia repair (rhhr) with the novel addition of esophagopexy in patients with gerd. methods: a single institution, single surgeon, prospectively maintained database was used to identify patients who underwent rhhr with a partial fundoplication and concomitant esophagopexy for gerd from november to july . patient characteristics, operative details and postoperative outcomes were analyzed. primary endpoint was resolution of subjective gerd symptoms and discontinuation of proton pump inhibitor (ppi). recurrence of hiatal hernia was a secondary endpoint. results: eleven patients were identified meeting the inclusion criteria (rhhr + esophagopexy) with a mean follow-up of . weeks ± . weeks. in regards to the rhhr, % underwent a partial fundoplication and the additional % underwent a re-do wrap. this patient cohort was . % female with a mean age of . ± . years. preoperative esophagogastroduodenoscopy (egd) was performed in % of patients with the study showing a hiatal hernia in . %, gastritis in . % and esophagitis in . % of patients. manometry was performed in . % of the patients showing % of these patients with esophageal dysmotility. esophagograms and ph studies were performed preoperatively in . % and . % of patients respectively. preoperatively, % of patients had a documented diagnosis of gerd and were taking a ppi and/or h blocker. after rhhr with esophagopexy, . % of patients had resolution of their gerd symptoms while . % (n = ) remained symptomatic. however, one of two patients reported a subjective decrease in symptom severity following the procedure. despite resolution of symptoms, . % remained on ppis. another % switched to h blockers and one patient discontinued all antisecretory therapy. none of the patients experienced recurrence of their hiatal hernia. conclusion: based on our data, rhhr with esophagopexy results in resolution gerd symptoms in over % of symptomatic patient. in patients with hiatal hernias and gerd, rhhr with esophagopexy does lead to resolution of symptoms, however, the majority of patients remained on ppis. long-term follow up is needed to investigate whether these patients are able to discontinue ppis and remain symptom free. chaya shwaartz, nadav zilka, mustapha siddiq, yuri goldes, md; sheba medical center, israel background: d gastrectomy for gastric carcinoma is a well-established procedure in patients undergoing surgery for gastric cancer and is the standard of care in our institution. reduced pain, early ambulation, and better cosmetics are some of the benefits of minimally invasive surgery for early gastric cancer. we aimed to describe our experience in laparoscopic d gastrectomies undertaken by a single surgeon in our institution. methods: this is a single-center retrospective review of prospectively collected d gastrectomies performed by a single surgeon. between november and february , laparoscopic subtotal/total gastrectomies were performed at sheba medical center, a tertiary center for forgut cancer. clinicopathological characteristics of the patients, surgical performance, postoperative outcomes and pathological data were collected. results: forty-five patients underwent laparoscopic gastrectomy. of these, had subtotal gastrectomy and had total gastrectomy. the median age in our series ( - ). most of the patients in our series had early gastric cancer (t - ) ( %). the mean average of dissected lymph nodes was ± . the mean operative time was ± . the postoperative complications, classified using the clavien-dindo classification. severe complications ([ cd iiia) rate was %. conclusions: laparoscopic d gastrectomy for invasive gastric cancer is safe and feasible when carried out in high-volume centers by an experienced surgeon as part of a multidisciplinary team with careful case selection and appropriate high-quality postoperative support. minimally invasive management of diaphragmatic hernias after esophagectomy: a case report introduction: esophagectomy is a common treatment for both benign and malignant pathologies of the foregut. hiatial paraconduit hernias are rare complications following esophagectomy. in this study, we review our experience with these rare diaphragmatic hernias. methods: a retrospective analysis of all patients presenting with hiatial hernia after esophageal resection at the university of oklahoma health science center between and was performed. data was abstracted from the medical record for evaluation and included demographics, symptoms, repair techniques and outcomes. no patients were excluded. results: a total of ten patients were identified to have paraconduit hernias. during this time interval, there were a total of esophageal resections performed. all patients had esophagectomy for malignant disease. seven of the patients have undergone surgery. two patients are asymptomatic and are being followed at their request, and one patient is pending elective correction. of the seven patients who underwent surgery, the median age was , with males and two females. six of the seven patients underwent minimally invasive ivor lewis esophagectomy and one had an open mckeown procedure. the median time from esophagectomy to hernia repair was months, with range from month to months. the most common presenting complaint was abdominal pain and nausea. one patient was noted to have a paraconduit hernia on postoperative day and taken to surgery for repair during the hospitalization. there was one death in a patient who presented with necrosis of the small bowel. the remaining patients all had laparoscopic approach. one patient required a hand port to reduce incarcerated colon and one patient was noted to have a cecal perforation during port closure requiring repair. all patients had herniated colon, with small intestine or pancreas herniation noted in three. repair was performed by reducing the viscera, a left phrenic relaxing incision, closure of the hiatus around the conduit and then closure of the diaphragmatic defect with mesh. at median follow up of months, there are no recurrences. conclusion: hiatal paraconduit hernias are becoming a frequent finding among survivors of esophageal cancer surgery. our study demonstrates that there is a propensity for patients who undergo minimally invasive esophagectomy to develop these hernias. the vast majority of patients can undergo laparoscopic repair. our recommendation is to perform a diaphragmatic relaxing incision and liberal use of mesh. early results appear to be favorable regarding recurrence. aim: there have been several reports illustrating the safety and efficacy of various surgical techniques in performing laparoscopic esophagojejunostomy (ej). this study aims to compare two established methods of ej anastomosis -circular stapling with purse-string suture ("lap-jack") and linear stapling technique -in laparoscopic total gastrectomy. methods: patients diagnosed with gastric cancer underwent intracorporeal ej anastomosis in laparoscopic total gastrectomy from january, to october, . cases used the circular stapler with purse-string "lap-jack" method, and patients used the linear stapling method for ej anastomosis. were matched using propensity scores, and retrospective data for patient characteristics, surgical outcome, and post-operative complications was reviewed. the two groups showed no significant difference in age, bmi, or other clinicopathological characteristics, and there was no conversion to an open procedure. after propensity score matching analysis, the linear group had significantly shorter operating time ( . ± . vs . ± . , p≤ . ) and more sufficient proximal margin ( . ± . vs . ± . , p = . ). no significant difference was found in estimated blood loss, retrieved lymph node, hospital stay, and time for first flatus. there was no postoperative mortality. early postoperative complication of the circular and linear group occurred in ( . %) and ( . %, p = . ) patients respectively. ej leakage occurred in ( . %) cases from each groups, with ( %) case from both group needing radiologic or surgical intervention. no other significant difference in early complication was found. late complication was observed in ( . %) cases (circular = linear = , p = . ) with ej anastomosis stricture in the linear group, but there was no statistical significance. conclusion: both circular stapling and linear stapling techniques are feasible and safe in performing intracorporeal ej anastomosis during laparoscopic total gastrectomy. linear-stapling technique had more sufficient proximal margin and shorter operating time. there was no significant difference in anastomosis related complication between the two groups. masahiro watanabe, masanori tokunaga, akio kaito, shizuki sugita, takahiro kinoshita; national cancer center hospital east, gastric surgery division background: although the current standard treatment for advanced gastric cancer (agc) is open gastrectomy, laparoscopic gastrectomy (lg) is increasingly performed, especially in the east. however, it is a technically demanding procedure, and the feasibility remains unclear. the aim of the present study was to clarify the feasibility of lg for agc. patients and methods: the present study included patients who underwent lg for agc between and . the indication of lg has gradually expanded in our institute, and is currently any stage gastric cancer except for gastric cancer obviously invading adjacent organs or gastric stump carcinoma. we retrospectively reviewed short-and long-term surgical outcomes of the patients. results: male/female ratio was : , and median age (range) was ( - ) years. distal gastrectomy was most frequently performed ( %), followed by total gastrectomy ( %). median operation time and intraoperative blood loss was ( - ) minutes and ( - ) g, respectively. clavien-dindo grade iii or more complication rate was . %. with a median followup period of months, the -year recurrence free survival rates of pstage ii and iii patients were % and %, respectively. conclusion: the outcomes of lg for agc are satisfactory, provided that an experienced team performs the surgery. introduction: the present study aims to evaluate the predictive value of indocyanine green (icg) for the detection and prevention of anastomotic leak following esophagectomy. anastomotic leak is a highly morbid and potentially fatal complication of esophagectomy. ensuring adequate perfusion of the gastric conduit can minimize the risk of postoperative leak. intraoperative evaluation with fluorescence angiography using icg offers a dynamic assessment of gastric conduit perfusion, and can guide anastomotic site selection. methods: a search of electronic databases medline, embase, scopus, web of science and the cochrane library using the search terms "indocyanine/fluorescence" and esophagectomy was completed to include all english articles published between and august . articles were selected by two independent reviewers based on the following major inclusion criteria: ( ) esophagectomy with gastric conduit reconstruction; ( ) use of fluorescence angiography with indocyanine green to assess perfusion; ( ) age ≥ years; ( ) sufficient outcome data for the calculation of leak rates and ( ) sample size ≥ . the quality of included studies was assessed using the quality assessment of diagnostic accuracy studies- . results: our literature search yielded potential studies, of which studies were included for meta-analysis after screening and exclusions. there were eleven prospective and three retrospective studies. the pooled anastomotic leak rate when icg was used was found to be %. pooled sensitivity and specificity for leak detection were . ( . - . ) and . ( . - . ), respectively. when studies involving intraoperative modifications were removed, pooled sensitivity and specificity were only marginally changed to . ( . - . ) and . ( . - . ), respectively. the diagnostic odds ratio was found to be . ( . - . ) across all studies and . ( . - . ) when intraoperative interventions were excluded. only three trials included a control group, giving a sample size of . in studies with a comparator group, icg was associated with an % reduction in the risk of anastomotic leak [or: . ( . - . )]. conclusions: in non-randomized trials, the use of icg as an intraoperative tool for visualizing vascular perfusion and conduit site selection, is promising. however, poor data quality and heterogeneity in reported variables limits cross-study comparisons and generalizability of findings. randomized, multi-center trials are needed to account for independent risk factors for leak rates and to better elucidate the impact of icg in predicting and preventing anastomotic leaks. objective: robotic assistance for bariatric surgery represents a novel application of a rapidly emerging technology. its safety and efficacy remains primarily characterized by smaller, singleinstitution studies. in this investigation, the influence of robotic assistance on short-term perioperative outcomes is contrasted with the more established primary multi-port laparoscopic approach for patients undergoing roux-en-y gastric bypass (rygb), using data from a national bariatric database. methods: a retrospective analysis of , robotic-assist and , laparoscopic rygb patients from the metabolic and bariatric surgery accreditation and quality improvement program national database were reviewed for differences in patient characteristics and short-term outcomes. on bivariate analysis, variables associated with primary outcomes of -day reoperation, readmission and reintervention were imputed into multivariate analyses to determine independent significance. results: robotic-assist bypass patients were older (p\. ), had a higher prevalence of comorbidities and had concomitant operations more frequently performed during surgery (p\. ). on bivariate analysis, robotic-assist patients had a higher rate of readmission than laparoscopic patients ( . % vs. . %; p=. ), but no differences in -day reoperation ( conclusion: robotic-assistance does not confer an increased rate of morbidity and mortality after rygb, and represents a feasible surgical modality for the surgeon willing to adopt the technology and accept its limitations. alicia m bonanno, md, brandon tieu, md, farah husain, md; oregon health and science university introduction: marginal ulcer is a common complication following roux-en-y gastric bypass with incidence rates between and %. most marginal ulcers resolve with medical management and lifestyle changes, but in the rare case of a non-healing marginal ulcer there are few treatment options. revision of the gastrojejunal (gj) anastomosis carries significant morbidity and mortality with complication rates ranging from to %. thoracoscopic truncal vagotomy (ttv) may be a safer alternative with decreased operative times. the purpose of this study is to evaluate the safety and effectiveness of ttv in comparison to gj revision for treatment of recalcitrant marginal ulcers. methods and procedures: a retrospective chart review of patients who required surgical intervention for non-healing marginal ulcers was performed from st september to st september . all underwent medical therapy along with lifestyle changes prior to intervention and had preoperative egd that demonstrated a recalcitrant marginal ulcer. revision of the gj anastomosis or ttv was performed. data collected included operative time, ulcer recurrence, morbidity rate, and mortality rate. statistical analysis was performed using t-test and fischer's exact test. results: a total of fifteen patients were identified who underwent either gj revision (n= ) or ttv (n= ). there were no -day mortalities in either group. mean operative time was significantly lower in the ttv group in comparison to gj revision ( . ± vs. . ± minutes respectively, p= . ). recurrence of the ulcer was not significant between groups and occurred following gj revisions and ttv. overall complication rate was not significantly different with % in the gj revision group and % in the ttv group. complications included anastomotic leak ( gj), anastomotic stricture ( gj), aspiration ( ttv), dysphagia ( gj and ttv), and dumping syndrome ( gj). conclusions: our results demonstrate that thoracoscopic vagotomy may be a better alternative with decreased operative times and similar effectiveness. however, further prospective observational studies with a larger patient population would be beneficial to evaluate complication rates and ulcer recurrence rates between groups. we present a case of a -year-old female with a history of thyroid cancer who initially presented to an outside hospital complaining of reflux, abdominal pain, early satiety, and -pound unintentional weight loss. endoscopy demonstrated a cm pre-pyloric mass; with initial biopsies of the mass demonstrating only gastric mucosa. endoscopic ultrasound and fna of the lesion also failed to elucidate its pathology. due to the pyloric location of the mass and inability to rule out invasive malignancy, we recommended a robotic-assisted transgastric submucosal resection with possible distal gastrectomy. intraoperatively we found a -degree circumferential pre-pyloric exophytic sessile tumor. frozen sections suggested a benign papillary tumor therefore we proceeded with submucosal resection. the resulting mucosal defect and gastrotomy were closed primarily with absorbable suture. final pathology showed the tumor to be a tubulovillous adenoma with high grade dysplasia arising against a background of intestinal metaplasia. the resection margins were negative for dysplasia. the postoperative course was complicated by a minor leak which did not require operative intervention and subsequent gastric outlet narrowing which required endoscopic dilation and feeding tube placement. however, the patient has recovered well and has advanced to diet as tolerated. gastric adenoma has a prevalence of . - . % in the western hemisphere. the risk of carcinomatous transformation in gastric adenomas is related to size, degree of dysplasia, and villosity. gastric adenomas are considered precancerous lesions. pre-operative pathologic diagnosis of dysplasia is often elusive as biopsies will often miss or under-grade the lesion. guidelines advocate for complete resection with either endoscopic submucosal dissection or surgical resection depending on surgeon preference and local expertise. endoscopic resection has been shown to be safe and efficacious in the removal of adenomas with good long-term outcomes. in this case the pathology of the lesion was unclear after multiple unsuccessful biopsies and required a surgical diagnosis to rule out invasive malignancy. management of gastric adenomas, while rare, may require a multidisciplinary approach between surgical endoscopy, minimally invasive surgery, and surgical oncology to achieve local control in an oncologically sound manner. we show that transgastric submucosal resection can be achieved in a minimally invasive fashion using robotic assistance. objective: parahiatal hernia is a rare type of diaphragmatic hernia with incidence of . - . %. para-hiatal hernias arises lateral to the left crural musculature adjacent to but separate from the oesophageal diaphragmatic hiatus. in view of its rare occurance and little clinical suspicion, it is almost never diagnosed clinically. the current case report is intended to depict the clinical profile of an intraoperatively diagnosed para-hiatal hernia and feasibility of laparoscopic repair of parahiatal hernias. method: laparoscopic fundoplication is frequently performed at grant medical college and sir j. j. group of hospitals, india. during one such case intraoperatively para-hiatal hernia was diagnosed. discussion: primary or true parahiatal hernias occur as a result of a congenital weakness and secondary defects follow hiatal surgery. the primary treatment of para-hiatal hernia is mesh-plasty. this is coupled with fundoplication in cases of large hernia and those symptomatic for gastroesophageal reflux disease. laparoscopic repair of these uncommon hernias is safe, effective and provides all of the benefits of minimally invasive surgery. conclusion: due to its rare occurrence, knowledge about this condition among laparoscopic surgeons is important to avoid diagnostic dilemma. knowledge about its management aids intraoperatvely to avoid performing incomplete procedure. introduction: extended indications of endoscopic resection for early gastric cancer (egc) have been widely accepted. according to current japanese guidelines, additional gastrectomy with lymph node dissection (lnd) is recommended for patients proven to have potential risks of lymph node metastasis (lnm) on histopathological findings. on the other hand, the frequency of lnm in these patients is exteremely low. the aim of this study was to elucidate the accurate risk of lnm based on the number of risk factors (rf) for possible lnm, and to compare the stratified risk of lnm with predicted risk from additional radical resection. methods and procedures: we enrolled egc patients who did not meet absolute or extended indications of endoscopic resection, and investigated the risk stratification of lnm according to the total number of lnm rfs described below; ( ) sm , ( ) lymphatic vessels invasion, ( ) undifferentiated adenocarinoma and [ mm in diameter, and ( ) [ mm in diameter and ulcer formation. we compared the stratification risk to the surgical risk that was calculated based on the japanese national clinical database (ncd) risk calculator in patients with additional gastrectomy after esd. results: the total number of lnm rfs and frequency of lnm were significantly correlated ( / rf; . %, rfs; . %, rfs, . %, rfs, . %; p. , fischer exact test). the estimated frequency of lnm was found to be lower than the predicted value of in-hospital mortality rate based on ncd in . % of / rf-patients who underwent additional gastrectomy with lnd after esd. the present study suggested that some patients must be over-indicated for additional gastrectomy with lnd, and no additional surgical treatment or less invasive surgery, such as local lnd (sentinel node navigation surgery or lymphatic basin resection), might be indicated for some patients with low number ( / rf) of lnm risk factors after esd. aims: laparoscopic proximal gastrectomy has been applied for early gastric cancer in upper third. we previously reported outcomes of laparoscopic total gastrectomy in managing this condition. in this study, we applied this modified technique for upper third early gastric cancer with double tract reconstruction. it is expected that our technique could be useful for treating these cases. methods: from april of to june of , consecutive patients with upper third early gastric cancer were assigned to undergo surgical treatment with proximal gastrectory at our hospital. we had cases of total gastrectory for upper third early gastric cancer in the same study period. background: laparoscopic total gastrectomy for remnant gastric cancer is much more difficult than common laparoscopic total gastrectomy due to severe adhesions to adjacent organs, displacement of anatomical structure. purpose: the aim was to analyze cases of laparoscopic total gastrectomy for remnant gastric cancer at the department of surgery of juntendo university urayasu hospital between november and april . method: we analyzed outcome and feasibility of laparoscopic total gastrectomy surgery for remnant gastric cancer. and we compared with laparoscopic total remnant gastrectomy ( cases) versus laparoscopic total gastrectomy ( cases) in our hospital. results: in the previous laparoscopic surgeries. we performed laparoscopic distal gastrectomy in cases, laparoscopic proximal gastrectomy in pcases, and open distal gastrectomy in cases. all cases were performed laparoscopic total gastrectomy with r-y reconstruction. case of them had been converted to open surgery due to severe adhesions. the mean operative time was min and the mean blood loss was ml. there were no intraoperative complications, and there were postoperative complications as a pancreatic fistula and a bowel obstruction. however, there were no intra-operative complications more than grade according to the clavien-dindo classification. the mean postoperative hospital stay was . days. all cases were without recurrence. thus, there were no significant differences in operative time, bleeding volumes, intra and postoperative complications and hospital stay compared with laparoscopic total gastrectomy. conclusions: laparoscopic total remnant gastrectomy can be performed with similar short-term outcomes to laparoscopic total gastrectomy, and may be feasible and safe procedure, and can become an option of therapeutic strategy. although this study was not powered to show lower recurrence rates with synthetic absorbable as compared to biologic, the . % recurrence rate is consistent with other series utilizing this mesh. it is interesting to note the difference in time to recurrence. these results suggest that while synthetic absorbable mesh may result in lower recurrence rates, recurrence seems to occur earlier. the results also suggest that deconditioning (lower bmi), and difficult cases and/or recovery may predispose to recurrence. these findings can help inform lf mesh selection and predict which patients are at higher risk of recurrence. introduction: little discussion of gastroparesis (gp) following laparoscopic paraesophageal hernia repair (lphr) has been reported in the literature. we wished to examine the incidence in our institution, and identify potential risk factors for development of gastroparesis following lphr. methods and procedures: a single institution retrospective chart review was preformed using cpt codes corresponding to paraesophageal hernia repair and fundoplication to identify patients undergoing laparoscopic paraesophageal hernia repair over a five year period ( / / - / / ) by three surgeons. emergency procedures and reoperations were excluded. in total, patients undergoing non-emergent first time lphrs were identified. size of the hiatal defect was identified when able, via either measurement between the diaphragmatic crura on ct or by medical record documentation. data obtained included sex, age, hernia type, mesh usage, and existence of specific comorbidities associated with gastroparesis. presence of gastroparesis was identified either by documentation of diagnosis via clinical judgment, or by results of gastric emptying nuclear medicine studies, with timing being no longer than months from date of surgery. independent students t-test and fisher exact test were used to determine statistical differences between the groups. results: patients undergoing non-emergent first time lphrs were identified. of these, we were able to obtain the size of the hiatal defect in patients. patients overall were diagnosed with gastroparesis, with an overall incidence of . %. when comparing all patients who developed gastroparesis to those who did not, only females comprised the group which did develop gastroparesis ( males/ females with gp, males/ females without gp, p= . ). age was also found to be greater in the group which developed gastroparesis. for patients in which the size of the hernia defect was identified, the average age was years older in the group diagnosed with gastroparesis ( step under laparoscopic view, left part of the lesser omentum was cut with preserving the hepatic branch of vagus nerve. the right crus of the diaphragma has been dissected free from the soft tissue around the stomach and abdominal esophagus. in this step the fascia of the right crus should be preserved and the soft tissue should not been damaged to avoid bleeding. after cutting the peritoneum just inside the right crus, the soft tissue was dissected bluntly to left side. then the inside margin of the left crus of the diaphragma was recognized from the right side. in this part of the procedure, laparoscope uses trocar (a), the assistant uses trocar (b) to pull the stomach to left lower side and the operator's right hand uses trocar (c). step the branches of left gastroepiploic vessels and the short gastric vessels were divided with ultrasonic coagulation and dissection device. the left crus of the diaphragma was exposed and the window at the posterior side of the abdominal esophagus was widely opened. in this part of the procedure, laparoscope uses trocar (a) at the beginning of dividing left gastroepiploic vessels, trocar (b) when dividing short gastric vessels. step the right and left crus are sutured with interrupted stitches to reduce the hiatus. from the right side, the fundus of the stomach is grasped through the widely opened window behind the abdominal esophagus. then the fundus of the stomach is pulled to obtain a degree ''stomach-wrap'' around the abdominal esophagus (fundoplication). using - non-absorbable braided suture, stitches are placed between both gastric flaps. purpose: laparoscopic gastrecomy has been widely adopted as the treatment of choice by many countries and institutions. internal hernia is a well-known complication after rouxen-y gastric bypass in the field of bariatric surgery. however, there were only a few reports of internal hernia after gastrectomy in gastric cancer patients. the purpose of this study was to analyze the incidence and clinical features of internal hernia after gastric cancer surgery in a high-volume center. method: , gastric cancer patients who underwent curative gastrectomy at seoul national university bundang hospital between january and december were retrospectively reviewed in this study. internal hernia was classified into two types, mesenteric hernia and petersen's hernia. result: patients who underwent distal gastrectomy (dg) with reconstruction by billroth ii, rouxen-y gastrojejunostomy and uncut rouxen-y gastrojejunostomy, total gastrectomy (tg) with esophagojejunostomy, and proximal gastrectomy with double tract reconstruction (pg dtr) with esophagojejunostomy and gastrojejunostomy had potential space for internal hernia. among these patients, ( . %) were determined as internal hernia by computed tomography and patients ( . %) underwent surgical treatment of internal herniation. two patients were conservatively managed. all patients suffered from abdominal pain and / ( %) patients showed nausea and vomiting. the median interval between the initial gastrectomy and surgery for internal hernia was days. mesenteric hernia was observed in cases and petersen's hernia in cases. since we started closing the mesenteric and petersen's defects from may of , there were only cases ( %) observed afterwards but there were cases ( %) before closure of the defects. conclusion: internal hernia after gastrectomy is likely underreported. although we analyzed patients with internal hernia, there might be more patients with mild symptoms who were managed conservatively by their own. a high degree of suspiciousness for internal hernia should be maintained in patients presenting symptoms like nausea, vomiting and abdominal pain after gastrectomy with potential space for internal hernia. with our experience, closure of the mesenteric and petersen's defect is helpful in reducing internal hernia. however, due to low incidence, a multicenter retrospective study is necessary. introduction: the increased incidence of anemia in patients with a hiatal hernia (hh) has been clearly demonstrated, as has resolution of anemia after hh repair in these patients. despite this, the implications of preoperative anemia on postoperative outcomes have not been well described. in this study, we aimed to identify the incidence of preoperative anemia in patients undergoing hh repair at our institution and sought to determine whether preoperative anemia had an impact on postoperative outcomes. methods and procedures: using our irb-approved institutional hh database, we retrospectively identified patients undergoing hh repair between january and april at our institution. we identified all patients with anemia, defined as serum hemoglobin levels less than mg/dl in men and mg/dl in women, measured within two weeks prior to surgery, and compared this cohort to those that had normal hemoglobin values preoperatively. specific perioperative outcomes analyzed included: estimated blood loss (ebl), operative time, need for blood transfusion, failure to extubate postoperatively, intensive care unit (icu) admission, postoperative complications, length of stay (los), and -day readmission. results: we identified patients undergoing hh repair, of which had preoperative bloodwork available for review. the average age was years and the majority of patients were female ( %, n= ). most were treated electively ( %, n= ) and with a minimally invasive approach ( %, n= ). patients ( . %) had preoperative anemia. compared to patients without anemia, patients with anemia had increased rates of failed extubation postoperatively ( . % vs. . %, p= . ), increased icu admissions ( . % vs. . %, p= . ), increased need for perioperative blood transfusions ( . % vs %, p= . ), and increased rates of postoperative complications ( . % vs. . %, p. ). although mean los ( . days vs. . days, p . ), mean operating time ( mins vs. mins, p= . ), and ebl ( ml vs ml, p= . ) were greater in the anemic group, they did not reach statistical significance, and there was no significant difference in -day readmission rate ( . % vs . %, p= . ). conclusions: anemia diagnosed on preoperative bloodwork appears to be associated with increased failure to extubate postoperatively, need for icu admissions, need for perioperative blood transfusion, and increased overall complication rate after hh repair. however, we found no significant difference in los or -day readmissions between anemic and non-anemic patients. since the majority of patients in this analysis underwent elective repairs, these results would support the preoperative treatment of anemia in patients undergoing hh repair. few studies have compared the procedures' long-term effectiveness with none looking beyond years. this study sought to characterize the efficacy of laparoscopic toupet versus nissen fundoplication for types iii and iv hiatal hernia using a telephone survey. methods and procedures: with irb approval, a review of all laparoscopic hiatal hernia repairs with mesh reinforcement performed over seven years at a single center by one surgeon was conducted. patient demographics and perioperative characteristics were recorded. hiatal hernia was classified per published sages guidelines as type iii or iv using operative reports and preoperative imaging. patients with type i or ii or recurrent hiatal hernia and patients receiving concomitant procedures were excluded. the gerd-health related quality of life survey was administered by telephone no earlier than months postoperatively. patients responded to items concerning symptom severity using a -point scale ( =no symptoms to =symptoms are incapacitating to do daily activities). symptoms surveyed included heartburn ( items), difficulty swallowing ( item) and regurgitation ( items introduction: as the thoracic esophageal carcinoma has a high metastatic rate of upper mediastinal lymph nodes, especially along the recurrent laryngeal nerve (rln), it is crucial to perform complete lymph node dissection along the rln without complications. although intraoperative neural monitoring (ionm) during thyroid and parathyroid surgery has gained widespread acceptance as the useful tool of visual nerve identification, the utilization of ionm during esophageal surgery has not become common. here, we describe our procedures focusing on a lymphadenectomy along the rln utilizing the ionm. methods and procedures: we first dissect ventral and dorsal side of the esophagus preserving the membranous structure (meso-esophagus), which contains tracheoesophageal artery, rln and lymph nodes. we next identify the location of the rln which runs in the meso-esophagus using ionm before visual contact. after that, we perform lymphadenectomy around the rln preserving the nerve. this technique was evaluated in consecutive cases (neural monitoring group; nm) of esophagectomy in prone positioning, and compared with our historical cases (conventional method group; cm background: laparoscopic hiatal hernia repair, particularly large type and type hernias, is associated with high recurrence rates. various use of overlay mesh reinforcement have been described in an attempt to improve outcomes. unfortunately, overlay use of biologic mesh continues to result in high recurrence rates, and more effective repairs employing permanent mesh raise serious erosion concerns and are therefore rarely used. we theorize that employing an interlay technique with permanent mesh (positioned between both crura) will help enhance crural closure and improve rates of hiatal hernia recurrences with minimal risk of erosion. methods: we reviewed all patients who underwent a laparoscopic hiatal hernia repair from april to august by a single surgeon from a prospectively maintained database at a tertiary care referral center (n= ). patients who underwent surgery for achalasia with concurrent hiatal repair were excluded. during this time frame, a new interlay technique of polypropylene mesh was employed upon suture closure of the crura. outcomes of repair were retrospectively reviewed. recurrence of hernia was identified by positive work up of patient's symptoms (new onset dysphagia, gerd, pain). results: a total of consecutive laparoscopic hiatal hernia repair were reported in a period of months. interlay polypropylene mesh was utilized in all repairs. patients were majority females ( . %), had a median age of and had a mean bmi of . . eleven ( . %) patients were redo repairs. majority of patients received a nissen fundoplication (n= , . %) followed by a toupet fundoplication (n= , . %). median length of stay after surgery was day. median follow up was days (range: - days). there were zero reported recurrences. conclusion: laparoscopic hiatal hernia repair with interlay polypropylene mesh appears in the short term to be a safe and durable technique to reduce the incidence of hiatal hernia recurrences. further studies are needed to assess more long term outcomes of this novel technique. zia kanani , melissa helm , max schumm , jon c gould, md ; introduction: laparoscopic fundoplication remains the current gold standard surgical intervention for medically refractory gastroesophageal reflux disease. studies suggest that on average - % of patients undergo reoperative surgery due to recurrent, persistent, or new symptoms. the primary objective of this study was to characterize the long-term symptomatic outcomes of primary and reoperative fundoplications in a clinical series of patients who have undergone one or more fundoplications. methods: patients who underwent laparoscopic primary or reoperative fundoplication between and by a single surgeon were retrospectively identified using a prospectively maintained database. patients undergoing takedown of a failed fundoplication and conversion to roux-en y gastric bypass (for morbid obesity, severe gastroparesis, or or more prior failed attempts) were excluded from the current analysis. all procedures were performed laparoscopically. patients were asked to complete the validated gerd-health related quality of life (gerd-hrql) survey prior to surgery and postoperatively at standard intervals to assess long-term symptomatic outcomes and quality of life. gerd-hrql composite scores range from (highest disease-related quality of life) to (lowest diseaserelated quality of life, most severe symptoms conclusions: patients who need to undergo reoperative fundoplication have more severe gerd-related symptoms at years post-op compared to patients undergoing primary fundoplication. however, good outcomes and morbidity rates of laparoscopic reoperation that approximate that of a primary fundoplication are possible in the hands of an experienced surgeon. adenocarcinoma of duodenum: surgical or endoscopic treatment? introduction: it is well known that the adenocarcinoma of the duodenum (adc) is a quite rare lesion infact represents % of cancer of the small bowel and % of these are localized in the periampullary area: % affect the sub-papillary tract and only % the supra-papillary segment of the duodenum. the adc may arise from duodenal polyps (familial polyposis, or gardner's syndrom or be associated with coeliac disease). until now the treatment was the pancreatoduodenectomy (for anatomo-surgical reasons and for the possibility of regional lymphonode resection). infact in my series of of such procedures, where performed for duodenal cancer. in this last years patients with adc of supra-papillary segment of the duodenum underwent endoscopic submucosal dissection (esd). the purpose of this study were to check the feasibility of the esd in treating such cases. in our experience this kind of endoscopic operation was feasible with high complication rate; perforation in cases ( . %); and bleeding occurred in case ( . %). all the complications were successfully treated endoscopically and the long-term outcomes was favorable. consitering the high rate of complications, the difficult and long procedure, the compliance of patients (c ), the general anesthesia, a very very skilled endoscopist is needed. conclusions: the esd represent a new endoscopic approach enstablished in clinical practice: end is performed following the intraluminal path ( rd space) wich, unlike the others, remain virtual and has to be created by dissecting and expanding the tissues layer between the mucosa and the muscolaris propria allowing the endoscope to gain access. the benefit of esd for treating the adc of the supra-papillary segment of the duodenum, according to our experience, must be validate in the future; a pre-operative pet-tac scan examination must be performed in order to demostred the lesion of the duodenum and if there is any limphatic involvement and no infiltration of the head of the pancreas. yoontaek lee, md, sa-hong min, md, young suk park, md, sang-hoon ahn, md, do joong park, md, phd; seoul national university bundang hospital purpose: this study summarizes the single institution experience of laparoscopic gastrectomy in advanced gastric cancer and evaluates the postoperative morbidities and long-term oncologic outcomes. methods: a total of , laparoscopic gastrectomy for advanced gastric cancer were performed at seoul national university bundang hospital between may and may . the characteristics of patients, surgical techniques, postoperative morbidities, and long-term oncologic outcomes were retrospectively reviewed using electronic medical records. results: patients required conversion to open surgery. the reasons of conversion to open surgery were advanced stage (n= ), intraoperative bleeding (n= ), adhesion due to previous abdominal operation (n= ), small abdominal cavity (n= ), associated disease (n= ), and intraoperative pleural injury (n= ). the mean hospital stay was . days for distal gastrectomy, . days for total gastrectomy, . days for proximal gastrectomy, and . days for pylorus preserving gastrectomy. the mean number of collected lymph nodes was . for distal gastrectomy, . for total gastrectomy, . for proximal gastrectomy, and . for pylorus preserving gastrectomy. the rates of postoperative complications of grade ii or more were . %. there was one case of postoperative mortality due to delayed bleeding after discharge. old age was the only independent predictor of surgical morbidities. background: intrathoracic gastric volvulus is a life-threatening condition of paraesophageal hernia. the therapeutic is a challenge because in acute volvulus it may lead to gastric strangulation and necrosis. most patients are elderly and with a significant associated medical illness which has higher morbidity and mortality of major surgery. we present a laparoscopic surgery is safe in paraesophageal hernia with acute intrathoracic gastric volvulus in a high-risk patient. case presentation: an -year-old woman with underlying of diabetes mellitus and hypertension was transferred from an outlying hospital with anemia, dysphagia, urinary tract infection and aspiration pneumonia. she had severe recurrent emesis after admission. ct scan of the chest and abdomen revealed a large esophageal hiatal hernia, and most of the stomach was in the inferior mediastinum with organoaxial gastric volvulus. endoscopy revealed flat pigmented spot gastric ulcer which compatible with cameron lesion and twisting of gastric folds without evidence of ischemia. the endoscopic reduction was unsuccessful. a laparoscopic surgery was performed and the herniated stomach was successfully reduced. the hernial sac was excised. the crura were approximated and reinforced with composite mesh. nissen fundoplication was performed along with gastropexy of the greater curve of the stomach to the abdominal wall. there was no perioperative complication. she tolerated enteral diet on a postoperative day . she had an uneventful recovery and discharged in weeks after treatment of her associated medical illnesses. she had no relapse of previous symptoms at her six-month follow-up assessment. discussion: endoscopic reduction of acute gastric volvulus may be the first option in a patient with severe comorbidities. however, if there is evidence of ischemia or failure of endoscopic reduction, surgical treatment should be considered. laparoscopic reduction and gastropexy may be a lessinvasive and viable alternative to the more aggressive surgical procedure but definitive surgery with repair hiatal hernia can be done in a selected patient. conclusion: minimally invasive treatments of acute gastric volvulus with paraesophageal hernia, either endoscopic or laparoscopic offer the option for reducing morbidity and mortality in elderly with significant comorbidities. the definitive laparoscopic surgery can be accomplished successfully and safely when it is performed with meticulous attention to the surgical technique and perioperative care. reid fletcher, md, mph, emily ramirez, rn, alfonso torquati, md, philip omotosho, md; rush university medical center introduction: the objective of this study was to evaluate the impact of an enhanced recovery after surgery (eras) program on post-operative length of stay following laparoscopic sleeve gastrectomy. eras programs have been demonstrated to improve outcomes and decrease length of stay in multiple surgical disciplines however relatively little has been published regarding the impact of eras programs in bariatric surgery. methods: an eras program for all patients undergoing bariatric surgery was implemented in february at a single institution. we retrospectively reviewed all patients undergoing laparoscopic sleeve gastrectomy between february and august . as a pre-eras historical control, we also reviewed all patients undergoing laparoscopic sleeve gastrectomy between january and december . baseline patient characteristics, additional concomitant operative procedures as well as -day readmission and complication rates were reviewed. logistic regression analysis was used in univariate and multivariate models to identify factors that predicted early post-operative discharge. data analysis was completed using stata se software (statacorp lp; college station, tx). results: eighty-five patients underwent laparoscopic sleeve gastrectomy after implementation of the eras program while patients were included in the pre-eras control group. there were no statistically significant differences in the baseline characteristics between the two groups and there were no differences in the rate of concomitant procedures performed. there was a statistically significant decrease in post-operative length of stay following implementation of the eras program from . it has been reported that laparoscopic redo surgery is effective for recurrent gerd and/or hiatal hernia after surgery. however, there has been very few reports from japan. we report an initial experience of laparoscopic surgery for japanese patients with recurrent gerd and/or hiatal hernia. among patients who had undergone laparoscopic fundoplication in our hospital from to , patients with recurrent gerd/hiatal hernia underwent redo surgery. preoperative work-up included upper gi series, endoscopy, ct, h ph-impedance and manometry. the patients consisted of women and men with a mean age of . years. the interval from the initial surgery was . months ( days- months). the types of initial fundoplication were nissen: , toupet: , anterior: . the types of recurrence were sliding hernia: and paraesophageal hernia: . one patient with recurrent sliding hernia had poor gastric motility. laparoscopic redo surgery was performed on patients. redo surgery included crural repair with mesh reinforcement: , refundoplication: (nissen-nissen: , nissen-toupet: , toupet-toupet: , toupet-lateral: ) and reduction of the incarcerated paraesophageal hernia: . additional procedure included mesh reinforcement: and pyloroplasty: . open partial gastrectomy was performed for one patient with incarcerated and strangulated hernia. operation time was min. patients was converted to open surgery. oral intake was started on the st pod and postoperative stay was . days. two patients recurred after redo surgery, one of whom underwent re-redo surgery. during the surgery, ivc was injured but rescued by open surgery. eleven patients had good outcome and patients required ppi after redo surgery. our morphological fundoplication score significantly improved after redo surgery. symptom score and acid exposure time were also significantly improved after redo surgery. laparoscopic redo surgery for recurrent gerd and/or hiatal hernia after surgery is safe and effective, although attention should be paid during surgery to avoid injury of the adjacent organs. surg endosc ( ) introduction: cameron ulcers (cu) are linear erosions or ulcerations in the gastric mucosa at the level of the diaphragmatic hiatus in patients with a hiatal hernia (hh) and are frequently associated with anemia. perioperative outcomes of patients with cu undergoing hh repair are not well described. we sought to identify the incidence of cu in patients undergoing hh repair at our institution and determine whether the presence of cu impacted postoperative outcomes. methods and procedures: using our irb-approved institutional hh database, we retrospectively identified patients undergoing repair between january and april . we identified all patients with cu found on preoperative esophagogastroduodenoscopy (egd). we compared patients with and without cu to determine if they differed in terms of preoperative anemia (defined as hemoglobin levels less than mg/dl in men and mg/dl in women). lastly, we compared outcomes between the cu group and the non-cu group, focusing on need for perioperative blood transfusion, failure to extubate postoperatively, intensive care unit (icu) admission, postoperative complications, length of stay (los), and -day readmission. conclusions: the presence of cu on preoperative egd is associated with increased rate of preoperative anemia, increased los, and increased icu admission after hh repair. although the cause of anemia in patients with hh is commonly attributed to cu, only % of cu patients were anemic, indicating that differences in outcomes may not only be attributed to a higher incidence of anemia in cu patients. the implications of cu in patients undergoing hh repair need to be further elucidated. laparoscopic heller myotomy as treatment for achalasia objective: aim of this stud was to review our experience with laparoscopic heller dor myotomy. disphagia constitutes the main symptom. diagnosis is performed by means of esophageal manometry. materials and method: over a period of years, patients were treated with heller myotomy plus dor fundoplication laparoscopically. all patients had lost weight, and there was a prevalence of females with an average age of . twenty five patients had chagas disease. they were all assessed with serial x-rays, endoscopy, esophageal manometry, and their symptoms were assessed with a - score, being the most severe. results: there was no conversion or mortality. in patients the mucosa was perforated during myotomy. the mucosa was sutured without altering the result of the treatment. average hospital stay was hours. one patient had to be reoperate because of esophageal perforation with peritonitis. sixty patients were followed up with manometric control and ph-probe testing, and only % of those had pathologic reflux. conclusions: laparoscopic treatment of achalasia is possible and reproducible, while reducing the morbility of laparotomy with relieve of patients symptoms. introduction: stent treatment in the gastrointestinal tract is emerging as a standard therapy for overcoming strictures and sealing perforations. we have started to treat patients with perforated duodenal ulcers using a partially covered stent and external drainage achieving good clinical results. stent migration is a serious complication that may require surgery. pyloric physiology during stent-treatment has not been studied and mechanisms for migration are unknown. the aims of this study were to investigate the pyloric response to distention mimicking stent-treatment, using the endoflip, investigating changes in motility patterns due to distention at baseline, after a pro-kinetic drug and after food ingestion. methods: a non-survival study in five pigs was carried out, followed by a pilot study in one human volunteer. a gastroscopy was performed in anaesthetized pigs and the endoflip was placed through the scope straddling the pylorus. baseline distensibility readings were performed at stepwise balloon distention to ml, ml, ml and ml, measuring pyloric cross sectional area and pyloric pressure. measurements were repeated after administration of a pro-kinetic drug (neostigmin) and after instillation of a liquid meal. in the human study readings were performed in conscious sedation at baseline and after stimulation with metoclopramide. results: during baseline readings the pylorus was shown to open more with increasing distention, together with higher amplitude motility waves. reaching maximum distention-volume ( ml), pyloric pressure increased significantly (p= . ) and motility waves disappeared. after prokinetic stimulation pyloric pressure decreased and motility waves increased in frequency and amplitude at , and ml distentions. after food stimulation pyloric pressure stayed low and motility waves showed increase in amplitude at distentions of , and ml. during both tests the pylorus showed higher pressure and lack of motility waves at maximum probe distention of ml. similar results were found in the human study. the pylorus seems to acts as a sphincter at low distention but when further dilated starts acting as a peristaltic pump. when fully distended, pyloric motility waves almost disappeared and the pressure remained high, leaving the pylorus open and inactive. stent placement in the pylorus results in pyloric distention, possibly changing motility. this study indicates that a duodenal stent placed over the pylorus should have a high radial force in the pyloric part in order to dilate the pylorus and diminish the contraction waves, this might reduce stent migration. introduction: cutting-edge technology in the field of minimal invasive surgery allows the application of singleincision laparoscopic surgery on gastric cancer. however, single-incision distal gastrectomy (sidg) is still technically difficult due to limited range of motion and unstable field of view-even in the hands of an experienced scopist. solo surgery using a passive scope holder may be the key in allowing sidg to be safer and efficient. we report our initial experience of consecutive cases of solo sidg. methods: prospectively collected database of patients clinically diagnosed as early gastric cancer who underwent solo sidg from october until july were analyzed. all the operations were held by a single surgeon and a scrub nurse. a passive laparoscopic scope holder was controlled by the surgeon to fix the field of view. results: the mean operation time (sd) was . (± . ) min, and the average estimated blood loss was . ± . ml. average body mass index was . ± . kg/m . the median hospital stay (range) was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) days, and the mean number of retrieved lymph nodes was . ± . . there was no conversion to multiport or open surgery. early postoperative complication occurred on % with three delayed gastric emptying, two postoperative pneumonia, one pancreatitis, and one wound complication. conclusion: solo sidg using a passive scope holder allows sidg to become more feasible by providing a stable field of view. there were no peri-operative deaths in either group. in the elective group, age was not an independent risk factor for complications (or . , % ci . - . ). conclusions: the incidence of major complications and mortality in this series were much lower than those previously reported for elective lpehr, while morbidity after emergency repair remains high. the paradigm of watchful waiting for elderly and/or minimally symptomatic patients with giant peh should be revisited. the impact of vagal nerve integrity testing in the surgical kamthorn yolsuriyanwong, md, eric marcotte, md, mukund venu, bipan chand, md; loyola university chicago, stritch school of medicine background: thoracic and gastric operations can cause vagal nerve injury, either accidentally or intended. the most common procedure, which can lead to such an injury, includes fundoplication, lung or heart transplantation and esophageal or gastric surgery. patients may present with minimal symptoms or some degree of gastroparesis. gastroparetic symptoms of include nausea, vomiting, early satiety, bloating and abdominal pain. if these symptoms occur and persist, the clinician should have a high suspicion of a possible vagal injury. investigative studies include endoscopy, esophageal motility, contrast imaging and often nuclear medicine gastric emptying studies (ges). however, ges in the post-surgical patient have limited sensitivity and specificity. if a vagal nerve injury is encountered, subsequent secondary operations must be planned accordingly. methods: from january to august , patients who had a previous surgical history of a foregut operation, with the potential risk of a vagal nerve injury, had vagal nerve integrity (vni) test results reviewed. vni test was measured indirectly by the response of plasma pancreatic polypeptide to sham feeding. the data collected and analyzed included age, gender, previous surgical procedures, clinical presentation, results of vni testing and the secondary procedure planned or performed. vni testing was compared to other testing modalities to determine if outcomes would have changed. results: eight patients ( females) were included. the age ranged from to years. two patients had prior lung transplantation and six patients had prior hiatal hernia repair with fundoplication. seven patients presented with reflux and delayed gastric emptying symptoms. one lung transplantation patient had no symptoms but his lung biopsy pathology showed chronic micro-aspiration with rejection. the vni testing results were compatible with vagal nerve injury in patients. according to these abnormal results, the plans for nissen fundoplication in patients were modified by an additional pyloroplasty and the plans for redo-nissen fundoplication in patients were changed to redo-nissen fundoplication plus pyloroplasty in patient and partial gastrectomy with roux-en-y reconstruction in patients. the operative plans in patients with a normal vni test were not altered. all patients that had secondary surgery had improvement in symptoms and or improvement in objective tests (ie signs of rejection). conclusion: the addition of vni testing in patients with previous potential risks of vagal nerve injury may help the surgeon select the appropriate secondary procedure. . we present a single-center experience with a "myotomy first" approach for all patients, regardless of diverticular size. the hypothesis is that cardiomyotomy alone will provide satisfactory symptom abatement in some patients. and mis cardiomyotomy causes minimal scarring, so a staged mis diverticulectomy is feasible at a later date if diverticular retention/stasis continues. in order to discuss this treatment algorithm we present our experience with cardiomyotomy alone for patients with epiphrenic diverticula. methods: the electronic medical record was queried for patients with esophageal diverticula who were managed with cardiomyotomy and dor fundoplication alone. pre and post-operative reflux/dysphagia questionnaires were gathered; imaging studies, operative data, complications and follow up were reviewed. results: from march of until the present, patients with esophageal diverticula were treated using the "myotomy first" approach. intraoperative esophagoscopy was done to internally visualize the elimination of the inciting spastic esophageal muscle. preoperatively, all patients complained of regurgitation, followed by dysphagia in ( %) and weight loss ( %). postoperatively, dysphagia and weight loss resolved in all subjects. regurgitation symptoms resolved in ( %) patients. the average size of the diverticula was . cm , the range was - cm . post operative esophagream's showed persistent diverticual, however most had decreased in size. there were no perioperative complications, average length of stay was . days and there were no icu admissions or returns to the or. the average length of follow up for these patients was days where all patients reported being satisfied with their results and none of them have yet desired to pursue diverticulectomy. discussion: a "myotomy first" approach resulted in excellent short term symptomatic control. none of the have retained or re-experienced symptoms of diverticular retention worthy of surgical intervention. in the age of laparoscopic surgery, an esophageal epiphrenic diverteculectomy should be staged. this step wise approach seeks to assure surgical necessity for a morbid endeavor. surg endosc ( ) :s -s the background: the two-stage oesophagectomy (ivor-lewis procedure) remains the mainstay of curative surgery for oesophageal cancers in the uk. gastro-oesophageal anastomotic leak is a potentially devastating complication of this procedure affecting perioperative morbidity and mortality. although the leak rates have improved over the years, it still remains widely variable. intraoperative reinforcement of gastro-oesophageal anastomosis with an 'omental wrap' has been proposed as a measure to reduce anastomotic leak rates. there is some data to suggest that this additional technique reduces anastomotic leak. we reviewed our single institution data to assess if the omental wrap indeed had a 'cocoon' effect in maturing the anastomosis and reducing leak rates. methods: data for all cancer oesophagectomies (ilog) performed in our institute since april - was retrospectively analysed from a prospectively maintained database. the patients were categorised into two groups. masafumi ohira; department of gastroenterological surgery, hokkaido university graduate school of medicine background: in laparoscopic surgery, both surgical technique and adequate support and traction by an assistant are highly important. this study assessed the impact of the first assistant on shortterm outcomes of laparoscopic distal gastrectomy (ldg) and laparoscope-assisted distal gastrectomy (ladg). methods: patients who underwent ldg or ladg for gastric cancer at our hospital, between november and august , were included. ldg and ladg cases of billroth i reconstruction, performed by a single surgeon accredited in endoscopic procedures, were analyzed. the cases were categorized into the following groups according to the first assistant's postgraduate years (pgy) of experience: group a, - years; group b, - years; group c, - years; and group d, [ years. short-term outcomes were compared between the groups. results: we examined cases. operative time was significantly longer in group a than in group b (p= . ). no significant differences in operative time were found between groups b, c, and d. the cases were recategorized into groups as follows: group a, the young assistant group (group y, n= ), and groups b, c, and d, the senior assistant group (group s, n= ). significant differences in operative time and method of anastomosis (circular stapler or delta anastomosis) were observed between the groups (p= . and p= . , respectively), but no significant differences in complication rates were found (p= . ). the unadjusted analysis revealed that the group, method of anastomosis, and body mass index (bmi) were significant factors associated with longer operative time. multivariate linear regression analysis with stepwise model selection using akaike's information criterion (aic) revealed that bmi and group were significant factors associated with longer operative time (p= . and p= . , respectively). multivariate analysis using these variables and the method of anastomosis confirmed the significance of bmi and group for longer operative time, but no significance was found in the method of anastomosis (p= . , p= . , and p= . , respectively). conclusions: our study showed that operative time tended to be longer when the first assistant had experience of less than pgy, but the morbidity did not increase. as with the operator, the first assistant needs adequate training to ensure a smooth operation. steven g leeds, md, marc ward, md, brittany buckmaster, pa, estrellita ontiveros, ms; baylor university medical center at dallas background: gastric contents can reach beyond the esophagus into the larynx and pharynx causing an increasingly prevalent disease called laryngopharyngeal reflux (lpr). magnetic sphincter augmentation (msa) has been used as an alternative treatment for gerd with good success, but there is no data to support its use in lpr. methods: forty-five patients with msa implants for symptomatic relief with both gerd and lpr symptoms were examined. all patients experienced at least one typical gerd symptom as well as at least one extra-esophageal symptom. this was assessed using the gerd-hrql which is questions graded - on each question, and reflux symptom index (rsi) which is questions graded - on each question. patients filled out questionnaires preoperatively, one month postoperatively (early follow up), and at months to year postoperatively (late follow up). the responses on the gerd-hrql were clustered into questions inquiring about heartburn ( ), dysphagia ( ), and regurgitation ( ) like all surgical fields there is a push towards standardization of the post operative course while maintaining safe practices. other surgical fields have streamlined recovery processes in an effort to standardize care and minimize costs. laparoscopic hiatal hernia repair is a complex procedure, but with experience and a team approach, this operation can become a streamline process. methods: a retrospective review was done for over laparoscopic hiatal hernia repairs at a single institution. aspects of post operative care such hospital floor, nursing ratio utilized, pain medication, diet advancement, use of foley catheters and length of hospital stay were tracked. statistical analysis was done to compare utilization of resources as years went on along with complications and readmissions. results: a total of hiatal hernias were performed between and . improvements were noted in nearly every field over time, including faster foley removal, decreased length of hospital stay, decreased use of patient controlled analgesics (pcas) and faster advancement of diet. furthermore these patients are now treated on a surgical floor rather than the intensive care unit or step down with a higher nurse to patient ratio, decreasing hospital cost. there were no changes in complications, reoperations or readmissions over the course of the study. conclusions: cost, length of stay and so called "advanced recovery pathways" are all the rage in the surgical literature. anytime a procedure and its post operative course can become less of a "major undertaking" and more routine, the more streamline it becomes. this comes from making a standard protocol that deescalates treatment based on what is actually needed. nearly every aspect of post operative care was simplified; length of stay and cost to the hospital was decreased while no additional complications or readmissions were accrued. the foundation of a formalized advanced recovery pathway will be implemented from these factors which were studied. background: the obesity epidemic continues to worsen. bariatric surgery remains the most effective way to achieve weight loss and resolution of comorbidities. laparoscopic sleeve gastrectomy has become the most common bariatric operation due to excellent efficacy and low morbidity and mortality. the most common complication of sleeve gastrectomy is gastroesophageal reflux disease (gerd), which can adversely impact the quality of life and lead to additional esophageal complications. recently, esophageal magnetic sphincter augmentation (linx®) has become an acceptable alternative to fundoplication for certain patients with gerd. the use of linx® in patients who previously underwent laparoscopic sleeve gastrectomy was described in a case series in . the known complications of these devices include dysphagia, need for endoscopic dilation, and device erosion. the complication profile of linx® in the setting of sleeve gastrectomy has not been reported heretofore. methods: we present a case of a patient with prior sleeve gastrectomy who received a linx® device one year after her bariatric operation due to severe gerd refractory to medical management. initial evaluation demonstrated a hypotensive lower esophageal sphincter and hiatal hernia, but no evidence of stricture or twisting. soon after linx® implantation, the patient developed progressive dysphagia and worsened reflux. repeat evaluation showed esophagitis, a moderate stricture with angulation at the incisura, and a large amount of retained food. discussion: the patient was recommended conversion to roux-en-y gastric bypass, but was deemed to be a poor candidate due to heavy smoking. thus, laparoscopic removal of the linx® device was performed with hiatal hernia repair and gastric stricturoplasty. post-operative fluoroscopic evaluation revealed improvement in the stricture, but persistent gastroesophageal reflux. the patient experienced a significant improvement in her symptoms of dysphagia, nausea, and vomiting. however, once smoking cessation is achieved, she may still need a conversion to roux-en-y gastric bypass in order to address persistent gerd. conclusion: conversion to roux-en-y gastric bypass remains the standard approach to treatment of gerd post sleeve gastrectomy. new approaches to this problem, including placement of linx®, are promising but have not been evaluated for long-term safety and efficacy in the setting of prior bariatric surgery. careful diagnostic evaluation prior to placement of magnetic sphincter augmentation device should be routinely undertaken. postoperatively, close long-term follow up is imperative, particularly in patients with prior sleeve gastrectomy. presence of linx® in a patient with prior bariatric surgery may lead to worsening symptoms if complications of initial operation are present. kazuto tsuboi, md , nobuo omura, md , fumiaki yano, md , masato hoshino, md , se-ryung yamamoto , shunsuke akimoto, md , takahiro masuda , hideyuki kashiwagi, md , norio mitsumori, md , katsuhiko yanaga, md ; fuji city general hospital, shizuoka, japan, nishisaitama-chuo national hospital, saitama, japan, the jikei university school of medicine, tokyo, japan background: esophageal achalasia is one of the primary esophageal motility disorders, and the patients suffer from dysphagia, vomiting and chest pain. timed barium esophagogram (tbe) is a convenient method to assess esophageal clearance, which we usually performed before and after surgery. meanwhile, laparoscopic heller-dor operation (lhd) has been considered worldwide as a gold standard for the surgical management of esophageal achalasia. the aim of this study is to examine the effect of preoperative clearance rate at the lower part of the esophagus on surgical outcomes in patients with esophageal achalasia. patients and method: between august and april , patients who underwent lhd at our institution were extracted from the database. out of patients, patients met our inclusion criteria; such as the patients who underwent lhd as an initial operation with complete evaluation with preoperative esophageal clearance by tbe. these patients were divided into three groups by the degree of esophageal clearance (group a: clearance rate \ %, group b: %? clearance rate \ %, and group c: %? clearance rate). patients' background, pre-and post-operative symptom scores, and surgical results were compared. before and after surgery, the standardized questionnaire was used to assess the degree of frequency and severity of symptoms (dysphagia, vomiting, chest pain and heartburn). moreover, satisfaction with operation was evaluated using the standardized questionnaire. statistical analysis was performed by using krasukal-wallis test or chi-square test, and p-value less than . was defined as statistically different. results: their mean age was . years and of them were male ( . %). one hundred and sixty-eight patients ( . %) were in group a, ( . %) in group b, and ( . %) in group c. the maximum width of the esophagus in group c was smaller than that in other groups (p= . ). as to the pre-operative symptom score, the frequency score of dysphagia was significantly lower in group c (p= . ), whereas the severity score of chest pain was significantly higher in group c (p= . ). surgical outcomes including the incidence of mucosal injury were not different among the groups. moreover, the patient satisfaction with lhd was excellent regardless of preoperative esophageal clearance. conclusion: preoperative clearance rate at the lower part of the esophagus in patients with esophageal achalasia did not affect the surgical outcomes of lhd, but the characteristics of preoperative symptoms in patients with poor esophageal clearance was low dysphagia and high chest pain. surg endosc ( ) ( . cm . cm) was made by dissecting between submucosal and muscular layers at the anterior remnant gastric wall. after creation of the double flap, the posterior esophageal wall ( cm from the edge) and the anterior gastric wall (superior edge of the mucosal window) were sutured for fixation, and . cm from the inferior edge of the mucosal window was opened, and the wall of the esophageal edge and the opening of the remnant gastric mucosa were sutured continuously. the anastomosis was fully covered by the seromuscular flaps with suturing. in latg, roux-en-y reconstruction was performed through a small incision using a circular stapler. introduction: the purpose of this study was to clarify the long-term and short-term outcomes of consecutive patients who underwent thoracoscopic esophagectomy in the prone position using a preceding anterior approach for the resection of esophageal cancer at a single institution. this method was established to make an esophagectomy easier to perform and to achieve better outcomes in terms of safety and curativity. methods and procedures: we retrospectively reviewed a database of patients with thoracic esophageal cancer who had undergone a thoracoscopic esophagectomy (te, patients) or an esophagectomy through thoracotomy (oe, patients) between january and august . to compare the long-term outcomes of te and oe, we used a propensity score matching analysis and a kaplan-meier survival analysis. to analyze the short-term outcomes of te, patients were chronologically divided into three groups: a first period group ( patients), a second period group ( patients), and a third period group ( patients). as for thoracoscopic procedure, the esophagus was mobilized from the anterior structure during the first step and from the posterior structure during the second step. the lymph nodes around the esophagus were also dissected anteriorly and posteriorly. the intraoperative factors, the number of dissected lymph nodes, and the incidence of adverse events were compared among the three period groups using a one-way anova or chi-square test. results: one hundred and twenty-three patients from each group, for a total of patients, were completely selected and paired. background: it is also difficult to anastomose using circular stapler in the narrow neck field. to overcome the problem we modified circular stapling for anastomosis. gastric juice reflux is frequently observed at the esophagogastric anastomosis. we develop and report trapezoidal tunnel method to reduce the incidence reflux. ( ) patients one hundred thirteen cases ( in left lateral and in prone position), with esophageal carcinomas underwent vats-e, respectively. esophago-gastric anastomosis is performed for cases by modified circular stapling and cases by trapezoidal tunnel method. ( ) methods at first the patients are fixed at semi-prone position and esophagectomy is performed in prone position that can be set by rotating and ports are used at the intercostal space (ics). esophagectomy and the l.n. dissection are performed with pneumothorax by maintaining co insufflation. esophago-gastric anastomosis is performed as following, i) trapezoidal tunnel method sero-muscular layer of anterior wall in the near top of gastric conduit is peeled from submucosal layer after parallel horizontal incision of sero-muscular layer, and then trapezoidal tunnel of sero-muscular layer is created. the edge of the proximal esophagus is drawn into the tunnel and esophago-gastric submucosa anastomosis is performed. to wrap anastomosis distal side of parallel line is closed. ii) modified circular stapling at first the circular stapler is introduced into the gastric conduit and joined to an anvil, and close a little. and then a joined anvil is placed into the proximal esophagus and secured by means of a pursestring suture. the gastric conduit opening is closed by a linear stapler. purpose: mesh utilization and its impact on postoperative hernia recurrence following paraesophageal hernia repair remains a polarizing topic. this analysis evaluates the recent trends in laparoscopic paraesophageal hernia repairs and analyzes the impact of operative time on postoperative morbidity. methods: the - acs-nsqip database was queried for primary cpt code for laparoscopic paraesophageal hernia repair with and without mesh ( / ). only elective cases performed by a general surgeon were included. operative time was grouped into quartiles ( - , - , - , - min) and statistical analysis was performed using anova univariate with post-hoc testing and multivariate regression modeling controlling for age, diabetes, renal disease and weight loss. this analysis was powered to detect a greater than % difference in outcomes based on mesh utilization. the outcomes of interest were composite morbidity scores and readmission rates within days of surgery. results: the database identified a cohort of , laparoscopic paraesophageal hernia repairs performed between and . average patient age was years and average patient body mass index was . mesh was utilized in % of cases per year and did not change over the study period (p= . ) however mesh utilization was %, %, %, and % within operative time quartiles - respectively (p. ). postoperative morbidity and readmission rates for each operative time quartile were . %, . %, . %, and . % (p. ) and . %, %, . %, and . % (p= . ), respectively. post-hoc testing indicated statistically significant differences in postoperative morbidity and readmission rates between quartiles and / . multivariate regression analysis documented operative time as a risk factor for postoperative morbidities and readmission, even after controlling for covariates. mesh utilization was only significant for a reduction in the rate of venous thromboembolic complications (or . , p= . ) but did not impact other morbidities or readmission rates. conclusion: this analysis suggests that patients with higher operative times have increased postoperative morbidity and readmission while mesh utilization does not impact postoperative outcomes, after accounting for the longer operative time of a paraesophageal hernia repair with mesh. introduction: gastroparesis is a chronic gastric motility disorder defined by delayed gastric emptying and symptoms such as nausea, vomiting, bloating and abdominal pain. surgical options for refractory gastroparesis include pyloroplasty, gastric stimulator insertion, and gastrectomy. the palliation from a pyloroplasty and gastric stimulator may be synergistic, however concerns remain regarding the possibility of stimulator infection when performing both procedures simultaneously. we present our initial experience of combined laparoscopic pyloroplasty and insertion of gastric stimulator. methods: gastroparesis patients diagnosed by solid gastric scintigraphy or endoscopic evidence of retained food after prolonged npo status who underwent combined laparoscopic heineke-mikulicz pyloroplasty and gastric stimulator insertion between july and july were reviewed. patient demographics, pre-and post-operative symptom scores and outcomes were collected. results were analyzed using statistical tests as appropriate. p value . were considered significant. results: seven patients underwent the simultaneous pyloroplasty and gastric stimulator insertion. six patients ( %) were idiopathic and one patient ( %) was diabetic. one patient was male and six patients were female. charleen yeo, enming yong, danson yeo, kaushal sanghvi, aaryan koura, jaideepraj rao, myint oo aung; tan tock seng hospital introduction: gastric cancer is one of the most common cancers in the asian population, with recent literature supporting the laparoscopic approach in early disease. however, the minimally invasive approach in advanced disease is still controversial. the outcomes of laparoscopic gastrectomy in the elderly have also not been extensively studied. we aim to evaluate our institution's short term outcomes of laparoscopic versus open gastrectomy for gastric cancer-with particular focus on advanced disease and elderly patients. methodology: we prospectively collected the data of all patients who underwent gastrectomies for stomach cancer from to . all patients underwent a partial or total gastrectomy with d lymphadenectomy. the decision for open or laparoscopic approach was decided between surgeon and patient. we excluded patients who underwent palliative resection. all patients were followed up for at least one year post-operatively. introduction: it was an eye-opener when the lancet brought the attention about global surgery. it is estimated that the deaths due to lack of access to surgery is far greater than deaths due to malaria, tuberculosis and hiv/aids put together. there is greater need to stress the importance in developing countries. there is a responsibility at the medical schools to enlighten students about this necessity and arouse interest in concept of global surgery. the students or surgical residents in the future are a great resource to solve this major problem. the first step would be to educate surgical residents. we need to assess the existing awareness about global surgery problem among surgical residents. we can plan a program to train the next generation surgeons. methods and procedure: all the surgical residents in our institution (victoria hospital, bangalore, india) were enrolled for this study. a total of residents were enrolled. a multiple-choice questionnaire regarding global surgery was designed. the received questionnaire was analyzed to assess the depth of knowledge about global surgery. there were multiple choice questions (mcq) and an option was provided at the end for feedback and suggestion to improve the global surgery in our country. each question carried one mark. score more than was considered the cutoff for pass and those students were termed 'informed'. results: ( . %) students cleared the cut off score of and were termed 'informed'. among this group ( %) residents scored marks. ( . %) students did not cross the cut off and were termed 'non-informed'. among these ( . %) students scored marks and did not know anything on the topic. students provided relevant suggestions and opinions to improve global surgery issue. conclusion: there is a great lacuna in knowledge about global surgery among surgical residents. we need to plan a program integrating global surgery in the syllabus of surgical training. the awareness among residents would arouse interest and participation in the future. introduction: minimally invasive surgical techniques (mists) could have tremendous applications and benefits in resource poor environment. these include but are not limited to short hospital stay, reduced cost of care, and reduced morbidity, especially related to post operative infections. there is growing interest in mists in most low and middle income countries (lmic) but its adoption has remained limited largely due to high cost of initial set-up, lack of technological backup and limited access to training among others. one of the most limiting factors is the maintenance of the vision system. an affordable laparoscopic set-up as an example will therefore go a long way in improving access to mists. methods and procedures: a common zero-degrees mm scope is attached on the camera of a low price smartphone (samsung galaxy j , samsung®, seoul, south korea). two elastic bands are used to fix the scope right in front of the main camera on the smartphone. the device is covered with sterile transparent drapes (tegaderm®, m corporate, st. paul, mn, usa). a light source is connected with a fiber optic cable for endoscopic use. the image can be seen in real time on a common tv screen through an hdmi connection to the smartphone, with a sterile drape. holding the vision system through the scope would guarantee to keep the camera in place without issues. to operate in full screen the vision was digitally zoomed at . , without losing quality (that is more related to the intensity of the light). as a collateral project we built a low cost simulator training box with the same camera to train the surgeon, obtaining a high fidelity and affordable simulation setting. results: we were able to perform the tasks of the fundamentals of laparoscopic surgery curriculum using our vision system with proficiency. in a pig model, we performed a tubal ligation to simulate an appendectomy and we were able to perform basic laparoscopic suturing. no major issue were encountered and small adjustment only were required to have an acceptable, stable and clear view. conclusion: there is growing interest in minimally invasive surgeries among surgeons in lmic, but its adoption has remained limited due to reasons such as high cost of initial set-up, lack of technological backup and limited access to training among others. an affordable laparoscopic camera system will therefore go a long way in improving access to mis in such settings. open. there were no deaths or bile duct injuries in our series. two patients undergoing laparoscopic approach were converted to open ( . %). complications, los, and gender were similar between the two groups. the laparoscopic group were significantly younger and had a significantly longer operative duration (table) . long term outcomes were not available for analysis. laparoscopic and open cholecystectomy appear safe in the setting of short term surgical missions. neither group suffered major complications. both had similar immediate outcomes. los for both groups was surprisingly similar and shorter than larger series which may possibly due to patient selection. given similar immediate outcomes and large burden of disease, the open approach should be considered. however, this cost may be extracted in terms of greater pain or longer recovery time for patients, which may outweigh the benefits. further data is needed to study pain, long term outcomes, and return to work. introduction: minimally invasive surgery relies on optimal camera control for the successful execution of operations. one disadvantage of laparoscopic surgery is that camera control is dependent on a surgical assistant's interpretation of visual cues and ability to predict the next field of focus in addition to verbal commands from the operating physician to provide the optimal view. robot-assisted minimally invasive surgery provides the operating surgeon the advantage of dictating their field of view. this study aims to utilize a video processing algorithm to determine the incidence of improperly centered field of view in laparoscopic vs. robot-assisted surgery. methods: in this study, recordings of minimally invasive resection of rectal cancer ( laparoscopic and robot-assisted surgery) were evaluated. recordings were input into matlab® video processing to generate single frames at each second interval. a single reviewer would indicate the pixel which best determined where the camera should be centered based on positioning of instruments, current action (dissection/hemostasis/traction) depicted in the frame, and previous review of recordings. pixel locations were recorded for subsequent analysis. centered views were determined as those with the identified centered position pixel lying within the center quadrant when frames were split into a uniform grid. in addition, distance of each point to the absolute center of the frame was calculated based on the pixel's x and y positions. results: individual operation data was analyzed for percent of centered pixel locations and pixel distance from the center pixel of the frame. robot-assisted surgery demonstrated higher percentage of centered views over laparoscopic surgery ( . ± . vs. . ± . ; p. ). robot-assisted surgery also demonstrated shorter distances to frame center than laparoscopic surgery ( . ± . vs. . ± . ; p. ). conclusion: robot-assisted surgery aims to resolve conflicts of cooperation that occur between surgeon and assistant in laparoscopic surgery by enabling manual visual control of the operative field by the operating surgeon. this study demonstrates that by eliminating such conflicts, optimal surgical view is more frequently obtained. surg endosc ( ) background/objective: valveless laparoscopic insufflator systems are marketed for ability to prevent loss of abdominal collapse and desufflation during laparoscopy. however, community surgeons raised concern for possible entrainment of room air, including oxygen ( ), with these systems. this study seeks to quantify o and non-medical air entrainment by a laparoscopic valveless cannula system to understand the risk of intraoperative air embolism. a communityuniversity collaborative was created to design a model and test this hypothesis. methods: an artificial abdomen was developed and calibrated to equivalent compliance and intraoperative volume of an average adult abdomen. it was connected to a flow meter, oxygen concentration sensor, and commercially available laparoscopic valveless cannula system. background: further advance of near-infrared (nir) imaging capability into greater clinical usefulness will be helped by the development of new targetable agents. to avoid issues related to dose timing and contamination, compounds that become fluorescent only at the site being targeted would be a significant advance. here we build on earlier laboratory work to show step-wise advance of the agent towards clinical trialling. methods: a novel agent (nir-aza) was tested in ex vivo colorectal specimens using two commercially available systems to determine characteristics in biological tissue. it was then trialled in a large animal cohort (n= ) to determine its performance for both intestinal perfusion assessment and lymph node mapping (both stomach and colon) using again a commercially available optical imaging system and including a direct comparison with indocyanine green. results: the novel agent was easily detectable in biological tissue in the near infrared wavelength relevant to commercial instrumentation both as a local depot tattoo and as a lymphatic tracing agent. porcine model trialling again showing excellent detection and tracking characteristics both in the circulation and in gastrointestinal tissue with clear tracking to relevant lymph nodes within minutes evident with the latter. while these studies were non-survival, there was no evidence of local tissue or systemic system toxicity in any case. direct qualitative and quantificative comparison between in situ nir-aza and icg at both intestinal and lymph basin regions showed similar levels of fluorescence. conclusion: the trial compound underwent successful testing indicating proof of earlier projected potential. this is encouraging for further work to advance to first in human testing. introduction: enhanced imaging systems have been developed to alter laparoscopic camera output to facilitate visualization during laparoscopic surgery using several novel imaging modes: clara mode reduces overexposure and reflections while brightening darker areas of the image; chroma mode intensifies color contrast to more clearly delineate blood vessels; and a combined chroma-clara mode. the ies also allows the surgeon to change imaging modes throughout the procedure as needed to facilitate different portions of the operation. we hypothesized that this technology would enhance visualization of critical structures during laparoscopic cholecystectomy (lc) compared to standard laparoscopic imaging. methods: videos and still images from an ies (karl storz endoscopy) were assessed in patients undergoing lc using the four imaging modalities. three time points were assessed: ) after adhesions were taken down but before any other dissection; ) after partial dissection of the hepatocystic triangle; and ) after establishment of the critical view of safety (cvs). seven surgeons blinded to the imaging modalities ranked each modality from (best) to (worst) for each of time points ( dissection points for cases). structures identified on achievement of the cvs were also analyzed. all statistics were performed using spss. rank data was analyzed with the friedman and wilcoxon signed rank tests. results: the median ranks of the chroma and chroma-clara imaging modalities (median [iqr] [ ] [ ] [ ] vs ( - ), p= . ) were not significantly different from each other, but both ranked significantly higher than the clara and standard modalities (median rank [iqr] [ ] [ ] and [ ] [ ] , respectively, p. ). individual surgeon preferences varied; four surgeons preferred chroma-clara, two preferred chroma, one preferred clara, and none preferred the standard mode. in addition, the cystic artery and cystic duct were visible in all cases after achieving the cvs, but the common bile duct was visible in only % of cases. conclusion: enhanced imaging system technology provides modalities that were significantly preferred over standard laparoscopic imaging on retrospective review of still and video images during lc. enhanced imaging modalities should be evaluated further to assess their impact on outcomes of lc and other laparoscopic procedures. introduction: cholangiocarcinoma is often diagnosed at an unresectable stage. endoscopic stent placement is generally performed to release the tumor-induced biliary obstruction. however, stents misplacement and migration, tumor tissue ingrowth and cholangitis are relatively frequent complications. energy-based techniques (radiofrequency ablation and photodynamic therapy) have been proposed as alternatives or in addition to the stent placement, showing controversial results. the use of laser sources in the ablation of the biliary wall has not been investigated so far. this study aims at the evaluation of the optimal power and exposure time to achieve a controlled circumferential intraluminal laser ablation of the common bile duct (cbd). methods: through a laparotomy access, the cbd of pigs was exposed and a small choledocotomy was made. a confocal endomicroscopy (ce) scanning (cellvizio) was performed through the choledocotomy, after injection of ml of sodium fluorescein. the . mm diameter circumferentiallyemitting diode laser probe ( nm wavelength) was introduced in the cbd. laser ablation was performed at w during s (n= ) or s (n= ). the power setting was predetermined on preliminary ex-vivo tests on porcine liver specimen. local temperature control was monitored through a fiber bragg grating, embedded in the laser probe. ce scanning was then repeated. the extent of the ablation was measured on hematoxilin-eosin and nadh stained slides. results: the diameter of the probe was too small to enable a single-shot circumferential ablation. there were no full-thickness perforations. after s from turning laser on, the temperature at the application site reached a plateau with minimal oscillations, and remained at mean values of . ± . °c during both and min. histology revealed that the mucosa ablation, at the contact areas, induced a consistent cellular necrosis (nadh-). ce scanning provided real-time images with a specific aspect of the post-ablation mucosa, including an alteration of the normal glandular structure and a general lack of enhanced imaging. the local application of a circumferential laser source induced a precise and safe mucosa ablation with a long-standing increase in temperature in the cbd, in this experimental trial. however, there is a need of an adapted probe, better fitting the diameter of the cbd to enable a single-shot circumferential treatment. goutaro katsuno, md, phd , yasuhiko nakata, md, phd , nobuyuki kubota, md, phd , teruo kaiga, md, phd , takao mamiya, md , masahiro yan, md , naoaki shimamoto, md , shuichi sakamoto, md, phd ; department of gastrointestinal and minimally invasive surgery, mitsuwadai general hospital, introduction: recently major developments in video imaging have been achieved for performing complete mesocolic excisions (cme) or total mesorectum excisions (tme). indocyanine green (icg) fluorescence imaging is already contributing greatly to making intraoperative decisions for keeping an intact visceral fascial layer, making suitable mesentery division lines and identifying anastomotic perfusions. the aim of this study is to present our experience with laparoscopic procedures for colo-rectal cancers using icg fluorescence imaging (lap icg-fi). patients and methods: we usually use the near-infrared (nir) laparoscopy (stryker corporation, michigan, usa) for lap icg-fi. [indocyanine green fluorescent imaging] visualization of lymph flow: icg ( . mg/ . ml) was injected into the submucosal layer around the tumor at points with a -gauge localized injection before the lymph node dissection. visualization of blood flow: after complete colorectal mobilization, the mesocolon was completely divided at the planned proximal or distal transection line. indocyanine green was injected intravenously and the transection location(s) and/or distal rectal stump, if applicable, were re-assessed in fluorescent imaging mode. results: we experienced lap icg-fi cases with colo-rectal cancer patients. tumor was located at the rectum in of them, at the sigmoid colon in , at the transverse colon in , at the descending colon in , at the ascending colon in , and at the cecum in . tnm stage was -i in patients, ii in , iii in , and iv in . the median (range) age of the patients was ( - ) years with a median (range) bmi of . ( - . ) kg/m . the lymph flow was visualized in patients ( %) intraoperatively. however, a high-quality intraoperative icg lymphangiogram was achieved in patients ( %). in high-quality lymphangiogram, the lymphatic ducts and lymph nodes were clearly visualized in real time, and this proved useful in keeping an intact visceral fascial layer as well as in making a suitable mesentery division line even in the bmi[ patients. a high-quality intraoperative icg angiogram was achieved in all patients. anastomotic perfusion was satisfactory in all cases. in patients ( . %), the use of nir+icg resulted in revision of the proximal colonic transection point before formation of the anastomosis. there were no postoperative anastomotic leakages. no injection-related adverse effects were reported. conclusion: lap icg-fi is a simple, safe and useful tool to help us complete lap cme or tme and check real-time anastomotic tissue perfusion. introduction: recently, the spread of laparoscopic surgery as a standard treatment and the development of information & communication technology have yielded abundant video data of laparoscopic procedures. these data have been accumulated and we can access them anytime, anywhere. however, the direction of how to use the abundant video data are still unclear. conventionally, surgical procedures have been performed based on surgeon's subjective decisions and skills, so called "tacit knowledge". for the purpose of objective analysis of laparoscopic procedures in video data, automatic recognition of surgical tools and understanding of surgical workflow must be the first critical step. we used convolutional neural network (cnn) which is the current trend in machine learning and computer vision tasks. methods: using video database of laparoscopic sigmoid colectomy in our institute, we performed annotation of tools and phases in every frame of the operating videos. for the tool detection, we annotated bounding boxes for both left and right tools in the videos. furthermore, phase annotation was performed by watching the videos in consultation with laparoscopic surgeons. the laparoscopic sigmoid colectomy operation passes through phases; -placement of ports and preparation, -dissection of retrorectal space, -medial approach to ima, -isolation and division of ima, -medial-to-lateral retromesenteric dissection, -lateral mobilization of left colon, -rectosigmoid mobilization, -division of mesorectum, -rectosigmoid resection and anastomosis, -finishing. we used cnn architecture to perform surgical tool detection and workflow recognition. results: we totally labeled tools used in the procedures of laparoscopic sigmoid colectomy and successfully developed tool detection system by cnn. as for surgical workflow, average times of phase - were . , . , . , . , . , . , . , . , . , . min, respectively. workflow recognition system using cnn was also successfully developed, while we needed to extract pure operating scenes in advance for efficient recognition outcomes. we've developed tool detection and phase recognition systems using cnn. we need more datasets to improve the detecting ability for future clinical uses. introduction: surgical environments require special aseptic conditions for direct interaction with the preoperative images and surgical equipment, which hampers the use of traditional input devices. we presented the feasibility of using a natural user interface (nui) for gesture control combined with voice control to directly interact in a more intuitive and sterile manner with the preoperative images and the integrated operating room (or) functionalities during laparoscopic surgery. in this study, efficiency and face validity of using this nui for medical image navigation and remote control during the performance of a set of basic tasks in the or will be assessed. methods and procedures: twenty experienced laparoscopic surgeons participated in this study. they performed basic tasks in the or focused on the interaction with a medical image viewer (osirix; pixmeo) and with the functionalities of the integrated or (or ; karl storz). these tasks were carried out by means of traditional manual interaction, using a computer keyboard and mouse and a touching screen, and using a gesture control sensor (myo armband) in combination with voice commands. this nui is controlled by the tedcube system (tedcas medical systems). time required to complete the tasks using each interaction method was recorded. at the end of the tasks, participants completed a questionnaire for face validation and usability assessment. results: the use of the nui required significantly less time than conventional manual control to show preoperative studies and information for surgical support. however, the interaction with the medical image viewer was significantly faster using the traditional input devices. participants evaluated the nui as an intuitive, simple and versatile tool that improves sterility during surgical activity. seventy-five percent of the participants would choose the gesture control system as a method of interaction with the patient's preoperative information during surgery. conclusions: the presented gesture control system allows surgeons to directly interact with preoperative imaging studies and the functionalities of an integrated or during surgery maintaining the aseptic conditions. for the traditional manual interaction, it is necessary to take into account the possible reaction time and displacement time of the technician to execute the surgeon's requests. a more personalized medical image viewer is required and with higher integration with the capabilities of the presented gesture control system. emma k gibson, bs, jacqueline j blank, md, timothy j ridolfi, introduction: following a generous left hemicolectomy an anastomosis between the transverse colon and rectum may be required. extensive mobilization and retroileal routing is sometimes necessary to create a tension-free anastomosis. retroileal routing is a technique in which a window is created in the ilieocolic mesentery. the colon is routed through this window, beneath the ileum, prior to entering the pelvis. retroileal routing is uncommon and there is no data on this technique when performed in using a hand-assisted laparoscopic technique. the aim of this study was to review our experience with hand-assisted laparoscopic left sided colon resections including retroileal routing of the proximal colon to the rectum. methods and procedures: we performed a retrospective review of a single surgeon's experience with hand-assisted laparoscopic left sided resections over a seven-year period from - . indication for operation, basic demographics, bmi, procedure time, short-and long-term morbidity, and mortality were recorded. results: a total of patients underwent a hand-assisted laparoscopic left sided resection with a colorectal or coloanal anastomosis. of these, underwent hand-assisted laparoscopic procedures with retroileal routing of the proximal colon. in each case, operations included a midline hand port incision and two mm ports in the lower abdomen. the indications for operation were diverticular disease and neoplasm in nine and four patients respectively. procedures took an average of . ( - ) minutes to complete. postoperative morbidity included intubation for co retention in one patient and a rll effusion in another patient. there were no anastomotic leaks and there were no -day or -day mortalities. conclusion: retroileal routing of the colon following left hemicolectomy occurs infrequently. a hand-assisted laparoscopic approach appears to be a safe and efficient in these technically challenging cases. objective: approximation of the diaphragmatic crus pillars is a key step in hiatal hernia repair. the dogma of successful hernia repair requires tension free approximation of tissue. there are no techniques described to measure tension across the crus closure. aim of this study is to describe a novel technique for measuring the tension exerted on crural sutures and report initial findings. methods: data was collected at institutions by the same surgeon. after hiatus dissection was complete the crus defect was measured both anterio-posterior and transverse dimension. the crus closure sutures were placed posterior and then lateral to the esophagus. the initial suture is started posteriorly with a figure of eight fashion (# ). with each subsequent stitch placed anteriorly (# and # ) or laterally (l , l ) till adequate hiatus closure is achieved. we measured tension on each suture placed as follows. conclusions: the autolap system provides improved image stability, staff interactions, and enhanced ergonomic comfort for the surgical team. it also offers cost-savings from decreased staffing requirements for hospitals that routinely use staff camera holders. the system set up of - min was less variable after cases, representing the learning curve. in addition, our approach identified problems with the system that require improvement by the manufacturer. notably, we identified significant ergonomic problems for human camera holders, which has been previously described and can be addressed by this device. background: gastric leaks continue to be a troubling predicament for physicians and patients alike. they are especially concerning after bariatric surgery. electrolyte abnormalities and dehydration continuously pose a life threatening problem in these patients. methods: this is an irb approved retrospective review of our experience with a biologic tissue mesh plug closure of gastric leaks. our interventional radiology colleagues percutaneously accessed the perigastric collection with a wire and a straight catheter was guided through the gastric wall defect and advanced over the wire until it was intraluminal. the surgeon then placed an endoscope down to the level of the gastric defect. the wire was then retrieved by the endoscope achieving percutaneo-oral wire access. the biologic tissue matrix was then measured and cut to a square and inverted into a cone like structure with a flat straight piece on the open end. the cone patch was then secured to the wire with braided polyglactin suture loop. the wire was then withdrawn back through the gastric defect pulling the plug and patch into position and placement was confirmed by endoscopy. results: we attempted closure of a gastric leak arising after bariatric surgery in six patients. five underwent successful deployment while one had premature disconnection of the plug from the wire and could not be deployed. the five who had successful deployment had immediate success and within days resumed enteral intake of liquids and resolution of the leak. two of the six patients additionally underwent covered stent placement to stent a stenotic area at the incisura angularis from the esophagus to the antrum. this stent was typically removed - weeks later. there were no complications related to the procedure or the plug. only one patient has undergone repeat endoscopy to evaluate the status of the plug. in that patient an ulcer at the plug site was visualized one month after the procedure. three months later endoscopy showed the clean ulcer had shrunk to half of the original ulcer size. conclusion: this novel minimally invasive technique utilizing ir and endoscopic placement of a biologic mesh plug into gastric leaks after bariatric surgery has been highly successful in treating chronic and subacute gastric leaks. we recommend that these endoscopic techniques be used to close gastric defects prior to operative intervention. introduction: laparoscopic surgery has spread worldwide and become a standard procedure among many abdominal surgical fields. the incidence of postoperative adhesion, which is a typical postoperative complication, is considered low compared with that after laparotomy, but once complications develop, such as adhesion-induced intestinal obstruction and chronic abdominal pain, the low-invasiveness of laparoscopic surgery may decrease markedly. while we have previously used a sheet-type absorbable barrier to prevent adhesion, it requires a technique in many cases when it is applied in the abdominal cavity. in this study, we used a spray-type absorbable barrier, which is considered simple to apply, as an adhesion-preventing absorbable barrier following laparoscopic surgery. subjects and methods: a spray-type absorbable barrier for prevention of adhesion (ad spray type l®) was applied to the dissected surface, port region, and beneath the small incised wound in patients who underwent laparoscopic surgery of the large intestine after february . the nozzle is long ( mm in length) and the angle of the tip is adjustable to some extent, so that the spray could be applied easily to the target region, even in areas in which it would be difficult to secure a work space, by rotating the shaft and finely adjusting the angle of the tip. in order for the barrier to remain in the target region, this preparation must remain viscous after application. discussion: approaches for the insertion and affixing of a conventional sheet-type absorbable barrier for the prevention of adhesion has been reported previously by various researchers. the adhesion-preventing absorbable barrier used in this study was a spray type with a long nozzle, which may have been useful because it made the laparoscopic application easy. however, its application requires some experience and time for preparation compared with the use of the sheet type, which could be disadvantageous. further accumulation of cases, including evaluation of prevention of adhesion after use of the adhesion-preventing absorbable barrier may be necessary. christopher g yheulon, md, priya rajdev, md, s. scott davis, md; introduction: evidence has demonstrated that biosynthetic glue for laparoscopic inguinal hernia repair results in decreased pain. however, the two glue sub-types (biologic-fibrin based; synthetic -cyanoacrylate based) have never been compared. this study aims to assess the outcomes of those subtypes. method and procedures: a systematic review of the medline database was undertaken. randomized trials assessing the outcomes of laparoscopic inguinal hernia repair with penetrating and glue fixation methods were considered for inclusion and data analysis. thirteen trials involving patients were identified with eight trials utilizing fibrin and five trials utilizing cyanoacrylate. results: there were no differences in recurrence or wound infection between the glue subtypes when compared individually to penetrating fixation alone or indirectly to each other. there was a significant reduction in urinary retention with fibrin glue when compared to penetrating fixation (or . , % c.i. . - . ). no studies utilizing cyanoacrylate analyzed urinary retention as an outcome. there were non-significant trends in reduction of hematoma and seroma for both glue subtypes when compared to penetrating fixation (or . , % confidence interval . - . ). conclusions: glue fixation in laparoscopic inguinal hernia repair reduces the incidence of urinary retention and may reduce the rate of hematoma or seroma formation. as there are no differences in outcomes when comparing fibrin or cyanoacrylate glue, surgeons should choose the glue that is available at the lowest cost at their respective institution. however, improvement of the optical system is necessary to further utilize this advantage. we are developing an optical lens system covering the range from macroscopic to microscopic. methods: we developed a handheld prototype created by combining the objective lens system of an optical microscope and a telescope lens. a feasibility study using a porcine model was conducted. macroscopic observation was done at a distance followed by microscopic observation in contact with tissue. first, we observed the operative field macroscopically. we then observed the serosa of the small intestine microscopically, and effects of blood flow occlusion were studied. results: ( fig. and fig. ) the same visual field as ordinary laparoscopy was achieved during macroscopic observation, while using microscopic observation it was possible to observe the complex peristaltic movements of the intestine. the minute blood vessels of the visceral peritoneum and larger, deeper blood vessels were also observed. when the mesenteric vessels were occluded, changes in peristaltic movement were seen directly. congestion in blood vessels in the deep layers of the serosa was observed. improvement in peristalsis and congestion were confirmed by restoring blood flow. this system enables direct visual observations not possible with conventional optics. this system can be utilized in both laparoscopic and open surgery. the microscopic visual information obtained by this system may help with intra-operative decision making and serve to facilitate safe and precise surgery. introduction: accurate, real-time visualization is critical for efficient, effective and safe surgery. although optical imaging using near-infrared (nir) fluorescence has been used for visualization of anatomic structures and physiologic functions in open and minimally invasive surgeries, its efficacy and adoption remain suboptimal due to the lack of specificity and sensitivity. herein, we report a novel class of compounds, which are exclusively metabolized in liver or kidney, rapidly excreted into to biliary or urinary systems, and emitted two different nir fluorescence spectrums. methods: novel, water-soluble heptamethine cyanines; compound x (biliary) and compound y (urinary), unreactive towards gluthathione and the cellular proteome were synthesized, and visualized using real-time, dual-color nir imaging device. sprague-dawley rats (n= ) and yorkshire pigs (n= ) were used to demonstrate and validate its usefulness, distributed into a control group (icg; rat n= , irdye cw rat n= ), a biliary group (compound x; rat n= , pig n= ), a urinary group (compound y; rat n= , pig n= ), and dual-labeling group (compound x&y; rat n= , pig n= ). each rat and pig received one or two of the compounds at optimized dose of . -mg/kg intravenously, fluorescence signals and bio-distributions were monitored and recorded over time. the target to background ratio (tbr) was calculated in each target systems and compared to assess sensitivity and specificity. results: compound x was rapidly cleared from liver within min after intravenous injection while the fluorescence signals in biliary system lasted up to h both in rats and pigs. compound y showed significant renal excretion up to h and the urinary signals remained up to h. they were both highly specific to target organs with tbr values of . (biliary), . (urinary) and . (cf. icg) at peak signals. these new compounds have approximately - times higher quantum yields than icg and . - . times higher specificity to kidney and liver than irdye cw. one-way anova showed significant differences between control, biliary, and urinary group (p. .) dual-labeling results also showed a complete separation of these two metabolic systems (p= . ) and a real-time display of these two systems were clearly visualized with pseudo-colored labeling inside the animal body. conclusion: we report a new generation of organ-specific, real-time fluorescent markers for intraoperative visualization, navigation and potential geo-fencing. these new compounds have significantly higher quantum yields and higher specificity to visualize kidney and/or liver than any currently available reagents. background: porcine models have been widely accepted for gastrointestinal surgery studies, due to their similarities to human anatomy, histology and physiology. devices such as laparoscopic staplers have been widely used in bariatrics and are currently the cornerstone of bariatric. there are currently few published articles regarding surgical stapler testing in porcine models by means of a survival design. the purpose of this study is to present a new model for stapler testing in porcines. we present the following study in which we asses a novel stapler's feasibility and safety, and its compatibility to currently used stapler reloads. this novel stapler, the aeon™ endoscopic linear stapler (lexington medical inc., billerica, ma. pending fda approval), has been previously tested in-vitro and in-vivo by the lexington medical engineering department in matters of mechanical function, staple line bursting pressure, staple formation and hemostasis. duffy et al. used this instrument for small bowel anastomoses in a two-week survival study in porcine models. methods and procedures: four porcine animal model was used under iacuc protocol for a -day survival study held at the fiu (doral, fl, u.s.a) research facility. all animals underwent sleeve gastrectomy using the novel stapler handle, combined with the endo gia™ (medtronic, mansfield, ma) mm-staple reloads in two of the animals and aeon™ mm-staple reloads in the remaining two. no reinforcements or oversewing of the staple line was done. these procedures were performed by two bariatric surgeons. animals were monitored perioperatively by the facility staff as per protocol. the animals were euthanized at day . post-mortem assessments were done blindly. gross evaluation and comparison of the gastric tube and their staple lines was done, as well as patency, strictures, and staple line integrity. results: stapler function was equivalent with both reload brands, no technical issues were encountered. - firings were used per animal. no intraoperative complications related to stapler function ensued. no postoperative complications were encountered. all animals survived the full length of the study- days. all sleeves were patent, no strictures or bowel obstruction were present. conclusions: in an animal survival study, a follow-up period of weeks appears to be a good benchmark for stapler testing. the use of the novel stapler for gastric resections appears feasible and safe. further studies such as microscopic examination of the staple lines, might help confirm equivalence, safety and feasibility of these products for the sleeve gastrectomy procedure. jason m samuels, md , peter einersen, md , krzysztof j wikiel, md , heather carmichael , douglas m overby , john t moore , carlton c barnett , thomas n robinson, md , teresa s jones , edward l jones, md ; university of colorado denver, denver va medical center introduction: the purpose of our study was to evaluate the impact of smoke evacuation devices on operating room fires caused by surgical skin preps. surgical fires are rare but preventable events that cause devastating injuries. alcohol-based surgical skin prep serves as the fuel for a fire ignited by electrosurgical instruments. we hypothesized that increasing air exchanges near the tip of the active electrode will reduce the concentration of alcohol thus reducing the incidence of surgical fires. methods: a standardized, ex vivo model was created with a cm section of clipped, porcine skin. surgical skin preparations tested: % isopropyl alcohol with % chlorhexidine gluconate (chg-ipa) and % isopropyl alcohol with . % iodine povacrylex (iodine-ipa). based upon previous studies, a high-risk situation was replicated with immediate energy activation in the presence of pooled alcohol-based prep. the site was draped to simulate a small surgical procedure with approximately square cm exposed. (figure ) a standard and smoke evacuating electrosurgical pencil was activated for s on w coagulation mode in the presence of % oxygen. a standard wall suction was also tested with the tip held cm from the tip of the electrosurgical pencil. a chi-square test was used to compare differences between groups. results: surgical fires were created in % ( / ) of the tests with the chg-ipa and % ( / ; p= . ) of the tests with iodine-ipa. continuous wall suction did not change the incidence of fire. the smoke evacuation electrosurgical pencil significantly decreased the incidence of fire when compared to the standard pencil and continuous wall suction for both preparations (table ) . with chg-ipa, the smoke evacuation electrosurgical pencil decreased the frequency of fire by % (figure , p. ). similarly, when using iodine-ipa, the electrosurgical pencil with integrated smoke evacuation demonstrated a % decrease in fires (figure , p. ). conclusion: alcohol-based skin preps fuel surgical fires. the use of a smoke evacuator electrosurgical pencil reduces the occurrence of surgical fires. elimination of alcohol-based preps and the use of smoke evacuation devices decrease the risk of operating room fires. brian bassiri-tehrani, md, netanel alper, md, jeffrey s aronoff, md, yaniv larish, md; lenox hill hospital ureteral stents have historically been used in pelvic surgery when anatomical or clinical considerations warrant urological expertise to aid in identifying the ureters. in the colorectal and gynecologic surgery literature, prophylactic ureteral stents appear to increase the ability to detect ureteral injuries while not being shown to prevent such injuries. with the increasingly widespread use of laparoscopy and the robotic platform in complex colorectal and pelvic surgery, the utility of stents remains unclear. one of the limiting factors regarding the use of ureteral stents in minimally invasive surgery is the lack of tactile feedback; the inability of the surgeon to directly palpate the stents. one proposed method to overcome this deficiency has been the use of lighted ureteral stents. increased operating time, increased cost, and need for specialized equipment are potential drawbacks of lighted stents. an alternative to using lighted stents in minimally-invasive surgery is to directly inject indocyanine green (icg) into the ureters after cystoscopy-guided placement of ureteral stents. intraoperative visualization of the ureters is acheived by using either the pinpoint endoscopic fluorescence imaging system in laparoscopy, or firefly integrated with the robotic platform. it is hoped that the risk of inadvertent ureteral injuries during colorectal and pelvic operations will be minimized using this technique, due to improved visualization of the ureters throughout the procedure. in this case presentation, we describe a novel use of icg in a patient undergoing a laparoscopic surgery for resection of a . . . cm pelvic mass abutting the bladder, sigmoid colon and left ureter. preoperatively, there was concern that the mass would be intimately adherent to, or even invading, the bilateral ureters based on ct scan findings. after ureteral injection of icg, visualization of both ureters was easily achieved at the time of operation, and the procedure proceeded with careful and safe dissection of the mass with visualization of the ureters at all times. though there is a paucity of studies evaluating the use of icg in the laparoscopic modality, this technique was safe, easy to employ, inexpensive and very useful to visualize the ureters intraoperatively. indeed, larger studies with appropriate sample sizes would help to further validate this novel use of icg. university of colorado -denver, va eastern colorado healthcare system introduction: operating room fires are "never events" that expose the patient to the risk of devastating complications. our group has previously demonstrated that alcohol-based surgical skin preparations fuel operating room fires. manufacturer guidelines recommend a three-minute delay after application of alcohol-based preps to decrease the risk of prep pooling and surgical fires. the purpose of this study was to evaluate the efficacy of the three-minute dry time in reducing the incidence of surgical fires. methods and procedures: a standardized, ex vivo model was used with a cm section of clipped, porcine skin. alcohol-based surgical skin preparations tested were % isopropyl alcohol (ipa) with % chlorhexidine gluconate (chg) and % ipa with . % iodine povacrylex (iodine-ipa). nonalcohol-based solutions included % chlorhexidine gluconate and % povidone-iodine "paint." an electrosurgical ''bovie'' pencil was activated for seconds on watts coagulation mode in % oxygen, both immediately and minutes after skin preparation application, with and without solution pooling. results: no fires occurred with immediate testing of nonalcohol-based preparations ( / ). alcohol-based preps created flames on immediate testing in % ( / ) of cases when pooling was present. without pooling, flames occurred in % ( / ) of cases on immediate testing. after a -minute delay, there was no difference in the incidence of fire when pooling was present ( / vs. / , p [ ) . similarly, there was no difference when pooling was not present ( / vs. / , p= ). (table ) conclusions: alcohol-based surgical skin preparations fuel surgical fires. waiting minutes for drying of the surgical skin prep did not change the incidence of surgical fire (regardless of whether there was pooling of the prep solution). the use of nonalcohol-based skin preps eliminated the risk of fire. introduction: laparoscopic port sites are associated with a significant incidence of long-term hernia formation. in addition, closure with closed loop suture may lead to increased post operative pain thereby limiting patient mobility. the development of novel trocar closure systems could offer a pathway towards quality improvement and warrants investigation. we performed a randomized controlled trial comparing a novel anchor based system (neoclose®) versus standard suture closure. methods: a prospective randomized controlled trial of patients undergoing port site closure following robotic assisted laparoscopic sleeve gastrectomy or gastric bypass was completed ( with neoclose® device and with standard laparoscopic suture closure). each patient had both the camera port and stapling port closed ( port sites in each group). primary outcome measures included the incidence of hernia ( week ultrasound), time for port site closure, and depth of needle penetration. secondary outcome measures were analog pain scoring at post op day , week and week . results: physical exam as well as ultrasound evaluation showed no hernias in either group at weeks. when compared to suture closure, the neoclose® device was associated with shorter closure times ( . ± . versus . ± . s, p. ) and needle depth penetration ( . ± . versus . ± . cm, p\ . ). the neoclose® device was associated with decreased pain at week after the operation (analog pain score . ± . versus . ± . , p. ). no difference in pain scoring was observed on post operative day or at week . conclusions: trocar site closure with the neoclose® device is associated with decreased closure times and needle depth penetration. no difference in the incidence of hernias was identified very early after operation. the neoclose® device led to decreased pain week after trocar closure which is potentially secondary to decreased tension when compared to closure with closed loop suture. long term hernia data ( year) is pending with patients scheduled for follow up physical exams and ultrasounds. federico gheza, md, mario a masrur, md, simone crivellaro, md; uic introduction: robotic instruments provides a better ergonomics during suturing compared to standard laparoscopy. minimally invasive procedures with limited need of few suture may benefit from an economically affordable device able to overcome some limitations of laparoscopic suturing. flexdex surgical recently obtained the fda approval for human use of its articulated laparoscopic needle driver. the official training provided by the company (available at https://flexdex.com/register-for-training) is a h basic dry lab. the training curriculum as well as the accreditation process is not well structured. no literature is available today on this matter. our goal was building a dedicated training, to allow a safe and predictable early use in humans. methods and procedures: the training module design and implementation was done in our minimally invasive laboratory. in the preliminary phase we define with a small group of residents and research specialists a short list of mandatory concepts to detail showing the instrument. a simple suturing task was then performed by the same group with the new device, laparoscopically and with the robot, available in our lab for training only. a more complex task, based on a dedicated self-designed high-fidelity model of urethral anastomosis was then proposed, exploring different options (one flexdex only vs two flexdex, surgeon vs assistant holding the camera). lastly, we applied the new device in animals to evaluate the usefulness of including simple tasks or entire procedures in the training curriculum. results: we were able to define a multilevel, adaptable training module including a basic information session, a dry lab with inanimate low-and highfidelity models and a pig lab. subjects with different level of expertise (medical student, resident, fellow, expert and very expert surgeon) were involved to have an extensive feedback. however, our main focus was to design a training module for laparoscopic and robotic surgeons, to safely introduce the flexdex in their practice. the only outcome for this preliminary work was collected through a "post exposure" survey. the expert surgeon that did the entire training was able to give feedback after his first application of the device in humans as well. conclusions: flexdex is a promising device, available in the united states in approved facilities only. a minimally invasive lab with high laparoscopic and robotic training experience is the ideal setting to build a curriculum. a first adaptable, multilevel, original, high-fidelity training is proposed to be validated with further studies and could be implementable for accreditation purposes. surg endosc ( ) :s -s augmenting spatial awareness in laparoscopic surgery by immersive holographic mixed reality navigation using hololens objectives: endoscopic minimally invasive surgery provides a limited field of view, thus requiring a high degree of spatial awareness and orientation. because of a d field of endoscopic view, a surgeon's spatial awareness is diminished. this study aims to evaluate the efficacy of our novel surgical navigation system of immersive holographic mixed reality (mr) using a head-mounted smart glass display hololens to enhance spatial awareness of the operating field in laparoscopic surgery. the authors describe a method of registering and overlaying the preoperative mdct imaging localization of tumors, vessels, and organs onto the real world in the operating theatre through holographic smartglasses in augmented reality (ar). methods: in this study we included laparoscopic gi, hpb, urology, and gynecologic surgeries using this system. we developed a ct-based patient-specific holographic mr surgical navigating application using hololens, that is a pair of see-through monitors built-in head-mounted display. by reconstructing the patient-specific d surface polygons of tumors, vessels, and organs out of the patient's mdct, mr anatomy was displayed on the see-through grasses three-dimensionally during actual surgery. the hololens features an inertial measurement unit which includes an accelerometer, gyroscope, and a magnetometer for environment understanding sensors, an energy-efficient depth camera, a photographic video camera, and an ambient light sensor. results: the accurate surgical anatomy of size, position, and depth of the tumors, surrounding organs, and vessels during surgeries could be measured using build-in dual infrared light sensors. the exact location between surgical devices and patient's anatomy could be traced on the pair of mr smart-glasses by satellite tracking. the gesture controlled manipulation by surgeons' hands with surgical groves was useful for intraoperative anatomical references of tumors and vascular position under sterilized environment. it allowed the user to manipulate the spatial attributes of the virtual and real anatomies. this system reduced the length of the operation and discussion time. this could support complex procedures with the help of pre-and intra-operative imaging with better visualization of the surgical anatomy and spatial awareness with visualization of surgical instruments in relation to anatomical landmarks. conclusions: the immersive holographic mr system provides a real-time d interactive perspective of the inside of the patient, accurately guiding the surgeon. this helps spatial awareness of the surgeons in the operating field and has illustrative benefits in surgical planning, simulation, education, and navigation. enhancing scene visualization is a feasible strategy for augmenting spatial awareness in laparoscopic surgery. francisco miguel sánchez margallo, phd , juan a. sánchez-margallo, phd , andreas skiadopoulos, phd , konstantinos gianikellis, phd ; minimally invasive surgery centre, cáceres, spain, university of nebraska at omaha, university of extremadura, spain introduction: new handheld devices have been developed in order to address the technical limitations and ergonomic issues present in laparoscopic surgery. the aim of this study is to analyze the surgeon's performance and ergonomics using the radius r drive instruments (tubingen scientific medical, germany) during the execution of laparoscopic cutting and suturing tasks. methods and procedures: three experienced laparoscopic surgeons performed both an intracorporeal suturing task and a cutting task on a box trainer. both tasks were repeated three times. a maryland dissector and a pair of scissors were used for the cutting task. for the suturing task, a maryland dissector and needle holder were used. conventional laparoscopic instruments and their equivalent r drive instruments were used. the order in the use of the type of instruments was randomized. execution time and surgeon's ergonomics were assessed. for the latter, surface electromyography (trapezius, deltoid and paravertebral muscles) and the nasa-tlx index were analyzed. for the cutting task, the percentage of the area of deviation from the cutting pattern (% of error) was assessed. the suturing performance was assessed by means of a task-specific validated checklist. results: surgeons required more time to perform both laparoscopic tasks using the r drive instruments. the use of both instruments had a similar percentage of deviation from the exterior part of the cutting pattern. however, the deviation from the inner part was significantly higher using the r drive instruments (conv: . ± . % vs r drive: . ± . %; p\. ). needle driving was scored lower using the r drive instruments, but quality of knot tying was similar to conventional instruments. the use of r drive increased the muscle activity of the trapezius muscles bilaterally for both laparoscopic tasks. this muscle activity also increased for the left deltoid muscle during the cutting task. surgeons stated that the use of r drive instruments leads to a higher mental and physical workload when compared to traditional laparoscopic instruments. conclusions: despite the novel and ergonomic design of the r drive laparoscopic instruments, the results of this study suggest that an improvement in surgical performance and physical workload is required prior their use in an actual surgical setting. further studies should be done to analyze the use of these instruments during other laparoscopic tasks and procedures. we believe that surgeons need a longer and comprehensive training period with these laparoscopic instruments to reach their full potential in laparoscopic practice. background/objectives: d printing has been shown to be a useful tool for preoperative planning in various surgical disciplines. however, there are only several single case reports in the field of liver surgery. this is because of problematic visualization of anatomy, difficulties in methodology and-most importantly-high costs limiting implementation of d printing. the goal of this study is to evaluate the utility of personalized d-printed liver models as routinely used tools in planning and guidance of laparoscopic liver resections. materials and methods: contrast-enhanced computed tomography images of consecutive patients who underwent laparoscopic liver resections in a single centre were acquired and processed. proper segmentation algorithms were used to obtain virtual models of anatomical structures, including vessels, tumor, gallbladder and liver parenchyma in stl (stereolithography) format. after processing files, models in parts were subsequently printed with desktop ultimaker + (ultimaker, netherlands) d printer, using polylactic acid filaments as printing material. all parts were matched together to create a mold, which was later casted with transparent silicone. models were delivered to surgical teams prior to the surgery as well as used in patients' education. results: up to now, six full-sized, transparent, personalized liver models were created before laparoscopic liver resections and used as a tool for preoperative planning and intraoperative guidance. usefulness of these models has been evaluated qualitatively with surgeons. operative data was obtained for each patient and it will be used for quantitative analysis in further study phases. costs of one model varied between $ and $ and whole process of development took approximately days in every case. conclusions: d-printed models allow precise planning in complex cases of minimally invasive liver surgery by providing high-quality visualization of patient-specific anatomy. implementation of this technology might potentially lead to clinical benefits, such as reduction of operative time or improvement of short-term outcomes. having said that, more data is needed to decisively prove these hypotheses. introduction: modern laparoscopic graspers may risk inadvertent injury to tissues, and have been shown to produce crush and puncture injuries. in addition, the force transmitted to the tissues by grasper handles can be highly variable, dependent on the orientation and amount of tissue engaged by the grasper. we have developed a novel vacuum-based laparoscopic grasper designed to reduce tissue injury from grasping. the aim of this study is to compare the incidence and severity of tissue trauma caused by vacuum-based graspers versus standard compressive graspers while manipulating tissue. we performed an in vivo surgical porcine study to assess gross and histologic tissue injury after grasping trials. grasping trials were divided equally between two adult porcine models; samples of small bowel were grasped with a standard atraumatic laparoscopic grasper (aesculap double-action atraumatic wave grasper) and were grasped with our novel vacuum grasper with varying vacuum head designs ( for head a, each for heads b and c). following grasping, the porcine model was allowed to dwell for hours prior to harvest. gross injury was graded as follows: ) no injury, ) ecchymosis only, ) serosal injury, ) seromuscular injury, and ) perforation. histologic injury was graded as follows: ) serositis, ) partial-thickness injury to the muscularis propria (mp), ) full-thickness mp injury, and ) full-thickness mp and mucosal injury. mann-whitney u test was performed to compare both gross and histologic injury scores between the groups. results: on gross assessment, no samples were noted to have injury more severe than ecchymoses following grasping. the vacuum grasper was found to cause more ecchymosis (median= ) than the compressive laparoscopic grasper (med.= , u= , p. ). on histologic assessment, the compressive grasper caused significantly more severe injury (med.= ) compared to the vacuum grasper (med.= , u= , p= . ). subgroup analysis showed that heads a (med.= , u= . , p= . ) and b (med.= , u= , p= . ) caused significantly less injury compared to the compressive grasper. head c (med.= , u= . , p= . ) also showed less injury but did not reach statistical significance. conclusion: this study demonstrates that our novel laparoscopic vacuum grasper produces less tissue trauma than standard compressive graspers. vacuum-based grasping is a viable alterative for reducing inadvertent tissue injury in laparoscopy. minimally invasive surgery centre, cáceres, spain, university of nebraska at omaha, university of extremadura, spain introduction: the aim of this study is to analyze the surgeon's performance, workload and ergonomics using an ergonomically designed handheld robotic needle holder during laparoscopic urethrovesical anastomosis in an animal model, and comparing it with the use of a conventional laparoscopic needle holder. methods and procedures: six experienced surgeons performed an urethrovesical anastomosis in a porcine model using a handheld robotic needle holder and a conventional laparoscopic axialhandled needle holder (karl storz gmbh). the robotic instrument (dex®, dextérité surgical) has an ergonomic handle and a flexible tip with unlimited rotation, providing seven degrees of freedom. the use of the surgical instrument was randomized. for each procedure, an expert surgeon evaluated the surgical performance in a blinded fashion using the global operative assessment of laparoscopic skills rating scale. besides, the quality of the intracorporeal suture was assess by a validated suturing-specific checklist. the surgeon's posture was recorded and analyzed using the xsens mvn biomech system based on inertial measurement units. the surgeon's workload was evaluated by means of the nasa task load index, a subjective, multidimensional assessment tool. the patency of each anastomosis was assessed using methylene blue. results: all urethrovesical anastomoses were completed without complications. only one anastomosis with the robotic device failed the patency test. surgeons showed similar surgical skills with both instruments, although they presented greater autonomy with the conventional instruments (p =. ). for the suturing performance, the use of the robotic device led to an increase in the number of movements during the needle driving and lower tendency to follow its curvature during the withdrawal maneuver (p=. ). the level of workload increased with the robotic device. however, the surgeon's satisfaction with the surgical outcome did not differ using both instruments. the use of the robotic instrument led to similar posture of the shoulder and wrist and better posture of the right elbow (p=. ) when compared to the conventional instrument. conclusions: the use of the robotized needle holder obtained similar results for the surgical performance and surgical outcome of the urethrovesical anastomosis when compared to the conventional instrument. we consider that aspects such as the surgeon's autonomy, dexterity in driving the needle and workload could be improved with a comprehensive training with the new device. inertial sensors can be an alternative for actual and crowded surgical environments. surgeons acquired a better body posture using the novel robotic needle holder. surg endosc ( ) :s -s introduction: temporal and spatial tissue temperature profile in electrosurgical devises, such as ultrasonic scissors and bipolar vessel sealing system, was experimentally measured, and the incidence of postoperative complications after thoracoscopic esophagectomy was assessed according to the electrosurgical devises used. methods and procedures: experiment of thermal spread: sonicision (sonic) was used for ultrasonic scissors and ligasure (ls) was used for bipolar vessel sealing system. each device was activated in order to cut porcine muscle at room temperature. temperatures of both the device blade and porcine tissues beside the device were measured using a temperature probe. each experiment was performed at least three times. room temperature was degrees. clinical analysis: the patients who underwent thoracoscopic esophagectomy with -field lymph node dissection in the prone position were selected in the study. incidence of postoperative complications after thoracoscopic esophagectomy was compared according to electrosurgical devises. bronchoscopy was used for diagnosis of recurrent laryngeal nerve paralysis (rlnp). sonic and ls was employed in and patients, respectively. material: we compared consecutive cases using d laparoscopic surgery versus cases of d conventional laparoscopic surgery from january to june . all surgical procedures were performed by experienced laparoscopic surgeons using d (einsteinvision system) and hd conventional laparoscopic optic. d-laparoscopic surgery offers the depth perception of the surgical field that is lost with the conventional ( d) laparoscopic surgery, and in many series is reported to be better in terms of surgical performance. outcome measures was operation time, surgical performance, blood looses, complications and surgeon satisfaction with the procedure. results: cholecystectomy was the most frequent surgery performed with cases ( %); hernia surgery cases ( %); fundoplication cases ( %), appendectomy cases ( %), left colon excison with colo-rectal anastomosis cases( %), and other cases ( %) wich included ovarian cyst excision, liver biopsy, prostatectomy and pediatric surgery. we compared each d procedure with a standard laparoscopy case performed by the same surgeon during the time of the study. d vs d surgical procedures outcome measures are shown in table . we found better results in operation time, surgical performance and less blood looses in favor of three-dimensional laparoscopy (. ). conclusion: d laparoscopy reduces operation time related to better performance during the procedure. depth perception facilitates dissection, intracorporeal knotting, mesh placement and colo-rectal anastomosis. surgeons reported better surgical performance and comfort during d laparoscopy; there were any reported side effects such as headache or dizziness. background: social media (some) uniquely allows international collaboration, with immediacy and ease of access and communication. in areas where surgical management is contentious, this could be a valuable tool to frame the current state, propose best practices, and possibly guide management in a rapid, cost-effective, global scale. our goal was to determine the ability to use twitter-a some platform-as an alternative surgical research tool. methods: twitter was used to host an online poll on a pre-selected controversial topic with no current consensus guidelines-pathological complete response in rectal cancer. an influential colorectal surgeon published the survey "t n rectal cancer undergoes a complete response" on two separate occasions. both polls were open for duration of three days. two methodologies were tested to increase exposure and direct towards relevant participants: first, tagging several worldwide experts, then using the well-established hashtag #colorectalsurgery and publishing during an international surgical conference. the main outcome measure was the feasibility, validity, reproducibility, and methods to further participation of a twitter survey. results: the tweet polls were posted three weeks apart. there was no cost and the time required for the process was three minutes, demonstrating the feasibility. providing three closed options to select from facilitated validity. the poll's anonymity limited knowledge of the participant's qualifications, but public comments and "retweets" came from surgeons with experience ranging from trainee to department chair. a robust volume of respondents was observed. the st post received votes, "likes", "retweets", and comments from a diverse international group ( countries). all tagged members participated in the forum. the nd received votes, "likes", "retweets", and comments. the results were reproducible, with the majority favoring option on both occasions ( % and %, respectively; p= . ). treatment recommendations, their rationale, and open questions were identified in the thread. conclusions: some can be used as a research tool, with valid, reproducible, and representative survey results. while exposure was comparable across the two methods, tagging specific members guided experts to provide more opinions than using conference and specialty hashtags. this could expand awareness, education, and possibly affect management in a transparent, cost-effective method. the anonymous nature of respondents limited the ability to make conclusions, but interest and opinion leaders for further study can be easily identified. this demonstrates the potential for some to facilitate international collaborative research. background: despite the technological advancement of a minimally invasive approach to pylorus -preserving pancreaticoduodenectomy (pppd), the morbidity is still high. among the many complications, postoperative pancreatic fistula (popf) is reported in high incidence rate, which varies from researcher to researcher, and a fistula risk score (frs) has been developed to predict the popf. the aim of this study is validate the fistula risk score in minimally invasive approach of pppd and find the other meaningful parameter for prediction of popf. method and materials: from january to august , laparoscopy attempted right-sided pancreas resection was performed on patients including robotic reconstruction in the division of hepatobiliary and pancreas at yonsei university health system. among them, patients were excluded due to total pancreatectomy (n= ), open conversion (n= ), pancreaticogastrostomy and hybrid manual anastomosis (n= ), non-measurable drain and missing datas (n= conclusions: fistula risk score is significant prediction factor of popf including biochemical leaks. in addition to the previously known frs variables, our data showed that bmi is an important predictor of popf with clinical relavancy in a minimally invasive approach of pppd. laparoscopic hemi-hepatectomy for liver tumor satoru imura, hiroki teraoku, yuji saito, shuichi iwahashi, tetsuya ikemoto, yuji morine, mitsuo shimada; tokushima university introduction: with progress of surgical technique and devices, laparoscopic liver resection became a realizable option for patients with liver tumor. major liver resection such as anatomical left or right hemi-hepatectomy has also been introduced in many centers. herein, we evaluate surgical results of laparoscopic hemi-hepatectomy for liver tumor. patients and methods: until march , consecutive patients who underwent laparoscopic or laparoscope-assisted hemi-hepatectomy (left: , right: ) were reviewed and the surgical data such as operation time, blood loss, postoperative complications were analyzed retrospectively. results: of the patients underwent left hemi-hepatectomy, cases were primary liver cancer, cases were metastatic tumor, and cases were benign tumor. pure laparoscopic surgery was performed in cases. the mean blood loss was ( - ) ml, mean operating time was ( - ) minutes and mean postoperative hospital stay was ( - ) days. the rate of postoperative complications was . % (wound infection; n= ). all right hemi-hepatectomy was performed by laparoscope-assisted method. of the patients underwent right hemi-hepatectomy, cases were primary liver cancer, cases were metastatic tumor, and cases were benign tumor. the mean blood loss was ( - ) ml, mean operating time was ( - ) minutes and mean postoperative hospital stay was ( - ) days. the rate of postoperative complications was . % (biliary stenosis; n= ). the patients with hepatocellular carcinoma were followed up for a median of ( - ) months. recurrence occurred in cases and none of them had died at the time of follow-up. conclusion: laparoscopic hemi-hepatectomy is a safe and effective procedure for the treatment of benign and malignant liver tumors. ibrahim a salama, professor; department of hepatobiliary surgery, national liver institute, menoufia university abstract background: iatrogenic biliary injuries are considered as the most serious complications during cholecystectomy. better outcome of such injuries have been shown in cases managed in a specialized center. objective: evaluatation of biliary injuries management in major referral hepatobiliary center. patients and methods: four hundred seventy two consecutive patients with post-cholecystectomy biliary injuries were managed with multidisciplinary team (hepatobiliary surgeon, gastroenterologist and radiologist) at major hepatobiliary center in egypt over years period using endoscopy in patients, percutaneous techniques in patients and surgery in patients. results: endoscopy was very successful initial treatment of patients ( %) with mild/moderate biliary leakage ( %) and biliary stricture ( %) with increased success by addition of percutaneous (rendezvous technique) in patients ( . %). however, surgery was needed in ( %) for major duct transection, ligation, major leakage and massive stricture. surgery was urgently in patients and electively in patients. hepaticojejunostomy was done in most of cases with transanastomatic stents. one mortality after surgery due to biliary sepsis and postoperative stricture was in cases ( . %) treated with percutaneous dilation and stenting. conclusion: management of biliary injuries was much better with multidisciplinary care team with initial minimal invasive technique to major surgery in major complex injury encouraging for early referral to highly specialized hepatobiliary center. introduction: simple liver cyst is the solitary non parasitic cystic lesion of the liver. teatment of symptomatic liver cyst varies from simple aspiration to hepatic resection. each treatment has its own merits and associatied complications. laparoscopic unroofing (fenestration) offers the best balance between efficacy and safety. polycystic liver disese (pcld) treatment by this method are less clear because of high failure rate. liver resection though more effective carries higher risks. treatment of hydatid disease are controversial. materials and method: simple cyst may be asymptomatic and picked up as incidental findings on ultrasound examination for other abdominal complaints. few cyst have symptoms of mass effect or with complication effect due to haemorrage, rupture, infection. on examination liver is palpable. compression over bile duct give rise to jaundice. the commonest symptoms are pain, early satiety, nausea and vomiting. simple cyst are more common in female after years of age. the cyst located antriorly inferiorly and laterally are the ideal case. investigation like ultrasonography is important. it will helps us to detect the cyst nature, will help to differentiate bet ween simple cyst from poly cystic liver disease, from neoplastic liver. in endemic area of hydatid liver disease serological test is mandatory. ct scan is important regarding details information about to localise the cyst, to identify the liver tissue arroud the cyst, relationship of cyst with the nearby vital structures, number of cyst, calcification and carcinomatous changes in its wall. aspiration of cystfluid, biological and cytological examination to rule out the presence of infection, biliary communication and malignancy. recently, ca - estimation is helpful for the differentiating the simple cyst from the cystadenoma or carcinoma. for jaundice patient ercp is impotant to locate the intraductal polyp causing the biliary obstruction or cyst causes the compression of the biliary tree. for bleeding in cyst mri is helpful. carcinoma at epithelial lining may occur. result: laparoscopic de-roofing (fenestration) less radical procedure ensures adequate drainage of cyst content into the peritoneal cavity. the cyst wall can be removed using harmonic scalpel so smoked produced and fogging of lens can be minimized. the interior surface inspected with care to exclude neoplastic growth and biliary communication. whole operative procedure, duration of postoperative recovery, hospital stay is much shorter in this procedure. large cevron incision can be avoided. no recurrence in two years follow up period. liver resection and total cystectomy theoretically minimizes the recurrence risk but invoke the a real risk of postoperative complications and death. conclusion: careful case selection and meticulous surgical skills are the two major determinants of the outcome. in the llr group, the first port was placed with an alexis® wound retractor (applied medical, usa) and free access® (top corporation, japan) at the abdominal defect made by previous sc. an additional or trocars were placed as needed. results: all patients in the llr group were treated using the laparoscopic approach. there were no other significant differences in patient background and characteristics. operative duration was similar for these groups. blood loss, complication rate, and hospital stay in the llr group were significantly decreased compared with the olr group. conclusion: in concurrent liver resection and sc, the open approach may require multiple large incisions, but the laparoscopic approach can complete procedures with a stoma wound and a few port wounds. additionally, use of a platform on the wound for sc enhances safety and efficacy for dissection of intraabdominal adhesions and a clear operative view. primary hepatic lymphoma: the importance of liver biopsy diego t enjuto , carlos ortiz , laura casanova , jose luis castro , pablo sánchez , jaime vázquez , norberto herrera , benjamín tallon , carmen jimenez ; hospital severo ochoa, hospital san rafael, hospital henares primary hepatic lymphoma (phl) is a very uncommon lymphoproliferative malignancy. it accounts for only . % of all extranodal non-hodgkin lymphoma and . % of all cases of non-hodgkin disease. the diagnosis is made when there is only liver involvement or when there is minimal non-liver disease. bone marrow, spleen, or hematologic affection should be excluded to confirm the diagnosis. we present our experience with two phl's that were correctly diagnosed thanks to laparoscopic liver biopsy. -year-old male admitted because of a -month history of right upper quadrant pain and nonmeasured weight loss. liver function tests and cholestasic enzymes showed normal values. serologic tests showed negative results for both hbv (hepatitis b virus) and hcv (hepatitis c virus). ct (computed tomography) scan showed three intrahepatic lesions in segments v, vi, and vii. ct-guided fine needle did not reach the diagnosis so a laparoscopic hepatic biopsy was performed. the final diagnosis was burkitt-like lymphoma. chemotherapy with r-chop (rutiximab, cyclophosphamide, adriamycin, vincristine, and prednisone) modality was started and completed after cycles. it is currently years since the patient was diagnosed and there are no clinical or radiological signs of recurrence. -year-old male who complained of diarrhoea and abdominal pain. chronic hb infection with no viral charge was detected. ultrasound showed heterogeneity of the whole left hepatic lobe and an mri was performed. a ten by segen centimeters lesion occupying the left hepatic lobe enhanced in arterial phase was seen suggesting adenoma. laparoscopic hepatic biopsy was completed to reach a definitive diagnosis. non-hodgkin lymphoma follicular type has just been confirmed with the histology and immuno-histochemistry. chemotherapy with r-chop should be started in the following weeks. phl's diagnosis is hard to achieve. fine needle biopsies are frequently negative because of the large area of necrosis. surgical biopsies are sometimes indispensable to get enough tissue to reach the diagnosis. phls are sometimes misdiagnosed as hepatocellular carcinoma because of its relation to hcv meaning a major hepatic resection. that is the reason why we consider that all diagnostic measures should be undertaken to rule out a different type of tumor. surgical resection is normally not needed in phls; as they are chemosensitive lesions. surgical options usually add unnecessary morbidity and mortality to these patients. chemotherapy standard treatment for phl consists on r-chop combination. pancreatic neoplasm enucleation -when is it safe? case report and review of the literature elaine jayne buckley , k molik , j mellinger ; siu-som, hshs pediatric surgery introduction: solid pseudopapillary tumors are rare neoplasms accounting for - % of pancreatic malignancies with a low risk of recurrence and metastasis. pancreatic malignancies are less common in pediatric populations, though small case series have identified that pseudopapillary tumors comprise between and % of pediatric pancreatic neoplasms. as these tumors have a low risk of metastasis, the mainstay of treatment has remained surgical excision. several surgical approaches have been described from extensive resections such as pancreaticoduodenectomy to local enucleation. we present a case of enucleation of a large pseudopapillary tumor from the pancreatic head complicated by pancreatic fistula. a literature review was performed given the rarity of this tumor to review surgical approaches, to compare complications and long-term outcomes, and to identify specific strategies to decrease the risk of pancreatic fistula. case description: a year-old female presented with months of abdominal pain. computed tomography identified a right upper quadrant mass felt to be consistent with a lipoma. follow up ct at months suggested the mass was more likely a gastrointestinal stromal tumor (gist), and surgical resection was recommended. enucleation of the mass was chosen in view of a wellcircumscribed appearance, clear operative tissue planes, and concern for long-term morbidity of a more extensive resection given the patient's young age. pathology demonstrated an . cm pseudopapillary tumor with negative margins. her post-operative course was complicated by a grade b pancreatic fistula, managed with nutritional support, external drain maintenance, and endoscopic stenting. the patient achieved healing of the pancreatic fistula after four months. results: our literature review demonstrates no difference in recurrence, mortality or morbidity between types of surgery. pancreatic fistula contributed to the majority of postoperative morbidity in all cases. recommendations for enucleation include small ( - cm) tumors with between and mm margin from the main pancreatic duct. techniques identified to minimized post-operative pancreatic fistula include preoperative imaging of the duct anatomy, preoperative pancreatic stent placement, and intraoperative ultrasound to identify the pancreatic duct. some literature supports preservation of pancreatic parenchyma, particularly in younger patients, to reduce endocrine and exocrine dysfunction given the low rates of recurrence and metastasis with this rare neoplasm. conclusion: our case demonstrates complications of enucleation of a large pseudopapillary tumor with successful multidisciplinary post-operative management. with the risk reduction strategies identified, we suggest that enucleation may be considered for pseudopapillary tumors in younger patients to preserve pancreatic parenchyma and long-term pancreatic function. introduction: recent advancements in minimally invasive techniques led to increased effort and interest in laparoscopic pancreatic surgery. laparoscopic distal pancreatectomy is a widely accepted procedure for left-sided pancreatic lesions. in other cases, the adoption of laparoscopic pancreaticoduodenectomy has been hindered by the technical complexity of laparoscopic reconstruction. hybrid laparoscopy-assisted pancreaticoduodenectomy (hlapd) in which pancreaticoduodenal resection is performed laparoscopically, while reconstruction is completed via a small upper midline minilaparotomy, is combines the efficacy of open approach, and the benefits of laparoscopic approach. the purpose of this study is to report our experience of hlapd and to define the learning curves. methods: patients with benign and malignant periampullary lesion underwent hlapd by a single surgeon between july and may were retrospectively reviewed. the clinicopathologic variables were prospectively collected and analyzed. the learning curve for hlapd was assessed using cumulative sum (cusum) and risk-adjusted cusum (ra-cusum) methods. results: the most common histopathology was pancreatic ductal adenocarcinoma (n= , . %), followed by intraductal papillary mucinous neoplasms (n= , . %), ampulla of vater cancer (n= , . %), and common bile duct cancer (n= , . %). the median operation time was min (range, - min) and the median estimated blood loss was ml. based on the cusum and the ra-cusum analyses, the learning curve for hlapd was grouped into four phases: phase i was the initial learning period (cases - ), phase ii was the technical stabilizing period (cases - ), phase iii was the second learning period (cases - ) and phase iv represented the second stabilizing period (cases - ). there was a statistical difference in terms of surgical indication between phase ii and iii (p= . ). conclusions: hlapd is a technically feasible and safe procedure in selected patients. this procedure has benefits of both open and minimally invasive procedure, and could be a stepping-stone for transition from open to purely minimally invasive pancreaticoduodenectomy. in silico investigation of the background: wilson's disease is a rare autosomal recessive genetic disorder of copper metabolism, which is characterized by hepatic and neurological disease. the gene atp b (on chromosome ) leads to wilson's disease is highly expressed in the liver, kidney, and placenta and encodes a transmembrane protein atpase (atp b), which functions as a copper-dependent p-type atpase. methods: here, the rare codons of atp b gene and their location in the structure of atp b protein was studied with rare codon calculator (racc) (http://nihserver.mbi.ucla.edu/racc/), atgme (http://atgme.org/), latcom (http://structure.biol.ucy.ac.cy/latcom.html) and sherlocc program (http://bcb.med.usherbrooke.ca/sherlocc.php). racc server identified arg, leu, ile, and pro codons as rare codons. results: results showed that cyp a gene have single rare codons of arg. additionally, racc detected two rare codons of leu, single rare codons of ile and rare codon of pro. atp b gene analysis in minmax and sliding_window algorithm resulted in identification of and rare codon clusters, which shows the difference features of these algorithms in detection of rcc. analyzing the d model of atp b protein show that arg residue constitute hydrogen bonds with glu and glu that with mutation of this residue to ser this hydrogen bonds were disrupted and may interfere in the proper folding of this protein. moreover, the side chain of arg don't forms any bond with others residues that with mutation to thr form new hydrogen bond with the side chain of arg . these addition and deletion of hydrogen bonds effects on the folding mechanism of atp b protein and interfere with the proper function of the atp b position. his forms the hydrogen bonds with the his and it seems that this hydrogen bond close together two region of this protein and it seems that has a critical role in the final folding of atp b protein. conclusions: computational study of diseases such as wilson's disease and involved genes (atp b) help us in understanding of disease's physiopathology and finding new approaches for detection and treatment. pancreatic stump leak and fistula formation are significant causes of morbidity in patients undergoing distal pancreatectomy (dp), with incidence of % to as high as % in a large systematic review. we present a case of a year old female, four months status post distal pancreatectomy and splenectomy for pseudopapillary neoplasm of pancreatic tail. patient presented to our institution with day history of left upper quadrant pain and general malaise. differential diagnosis on admission was abdominal wall abscess vs incarcerated incisional hernia. physical exam was positive for severe tenderness to palpation over a * cm cm non reducible mass in left upper quadrant with surrounding skin erythema. patient underwent a diagnostic laparoscopy and intraoperative findings revealed extensive adhesions to the anterior abdominal wall and a loop of small bowel was found adhered to the previous incision site in left upper quadrant. upon further dissection we entered a large cm cavity with saponified caseous material. the saponified material and thick tan fluid were evacuated into an endocatch bag and two large bore jackson pratt drains were left within the cavity. further examination showed that the small intestine was normal with no signs of obstruction or ischemia. fluid studies and cultures were sent and showed yeast like organisms and negative for acid fast bacillus. we report an unusual presentation of a distal pancreatectomy stump leak in the formation of an intra-abdominal saponified fluid collection four months after the primary procedure. given the high incidence of pancreatic stump leak and fistula formation after distal pancreatectomy, much effort has been made to identify factors associated with higher incidence of leaks and their usual and unusual presentations, which will be reviewed in this report. initial concerns regarding healthy donor's safety and graft integrity, need for acquiring surgical expertise in both laparoscopic liver surgery and living donor transplantation (ldlt) have delayed the development of laparoscopic donor hepatectomy in adult-to-adult ldlt. however, decreased blood loss, less postoperative pain, shorter length of stay in hospital, and excellent cosmetic outcome have well been validated as the advantage of laparoscopic hepatectomy. hence, the safety and feasibility for laparoscopic donor should be further investigated. we present initial experiences and safety for totally laparoscopic living donor right hepatectomy. in cases who received elective living donor right hepatectomy for adult-to-adult ldlt, totally laparoscopic approach was applied from may up to august . the anatomical variation of portal vein was not considered as an exclusion criteria, but all donors were with type i portal vein variation. the bile duct anomaly was preoperatively evaluated with magnetic resonance cholangiopancreatography (mrcp) and was never excluded for totally laparoscopic approach. d conventional rigid º rigid laparoscopic system was used in cases and the remaining cases used d flexible laparoscopic system. in about %, hepatic duct anomalies (type , a, b) were identified. the operation time was from hours to hours. and the time for the graft removal was within minutes. the hepatic duct transection was performed under operative cholangiography via a cystic duct and the patency of left hepatic duct was also confirmed by operative cholangiography. however, during postoperative period, bile leakage was identified in only case and resolved after the biliary stent insertion by ercp. during operation, there was no transfusion and the inflow control like pringle maneuver was not used at all. v or v were reconstructed in cases and large right inferior hepatic vein was prepared for anastomosis in cases. all grafts were removed through the suprapubic transverse incision. most donors were discharged at days after hepatectomy. during the short-term follow-up period in the donors except this case, complications were not identified. conclusively, totally laparoscopic right donor hepatectomy in elective adult-to-adult ldlt can be initially attempted after enough experiences of laparoscopic hepatectomy and ldlt. however, the true benefits of totally laparoscopic living donor right hepatectomy should be fully assessed through various experiences from multi-institutes. background: the role of neoadjuvent chemotherapy on the treatment of pancreatic cancer remains widely controversial. studies have evaluated its effect on resectability and survival; however, few have studied the consequence of neoadjuvent therapy on surgical outcomes and complications. methods and procedures: a retrospective analysis was performed utilizing the targeted pancreas module of the national surgical quality improvement project (nsqip) for patients undergoing pancreaticoduodenectomy. neoadjuvent therapy was defined by chemotherapy and/or radiation in the -days before surgery. patient demographics, operative characteristics, and -day outcomes were compared amongst patients undergoing neoadjuvent chemotherapy, radiation, chemoradiation, and no neoadjuvent therapy. both univariable and multivariable analysis were completed. results: pancreaticoduodenectomy was completed in , patients. , patients had no neoadjuvent therapy; underwent both chemotherapy and radiation; underwent chemotherapy alone, and underwent radiation alone. there were no differences in demographics or comorbidities. no difference in -day mortality was found; however pancreatic fistula formation was affected by neoadjuvent therapy. neoadjuvant radiation increased fistula formation (or: . , % ci: . - . ) while neoadjuvent chemotherapy (or: . , % ci: . - . ) was protective. conclusion: neoadjuvent therapy significantly impacts surgical outcomes following pancreaticoduodenectomy. given that pancreatic fistula formation can delay post-operative chemotherapy, it may be reasonable to refrain from neoadjuvent radiation therapy for patients with resectable and borderlineresectable disease. the influence of thickest background: the use of stapling devices for distal pancreatectomy remains controversial, due to concerns about the development of postoperative pancreatic ?stula (popf). pancreas thickness might be associated with popf, but suitable thickness of stapler remains also inconclusive in view of reducing popf. methods: we routinely use thickest endo gia™ reloads with tri-staple™ (covidien, north haven, ct) for pancreas closure during laparoscopic left side pancreatectomy (lp) since . we compared short term surgical results of the consecutive ten patients underwent lp using new stapler (ns) and patients with lp using other type of stapler (os) focusing on popf. results: no patients developed clinically relavent (cr)-popf in ns group and two patients ( . %) with os group experienced cr-popf. however, there was no difference of cr-popf between two groups. pancreas thickness on stapling point were not different between two groups ( . mm vs . mm, p= . ). in ns group, patients ( . %) developed a popf, whereas in os group, patients ( . %) developed a popf. there was also no difference of popf between groups. conclusion: the gia™ reloads with the thickest tri-staple™ allows effective prevention of cr-popf after distal pancreatectomy. however, there was no advantage over thinner stapler for lp. introduction: single-incision laparoscopic hepatectomy (silh) has been showed feasible and safe in experienced hands for selected patients with benign or malignant liver diseases. there were only small series reported and most of the procedures were minor liver resections. we herein present our experience of silh during a period of months. methods and procedures: consecutive patients underwent silh which were performed by two experienced laparoscopic surgeons with straight instruments. patient characteristics and surgical outcomes were analyzed by reviewing the medical charts. results: the patient age was . ± . ( - ) years with male predominance ( patients, . %). six patients ( . %) had liver cirrhosis proved by pathologic examinations. nine procedures ( . %) were indicated for malignancy. four major hepatectomies (over two segments) and nine minor ones were performed including seven anatomical resections. the abdominal incisions were para-or trans-umbilical except one which was along the old operative scar at lower midline, while most of them (n= , . %) was within cm in length. inflow control was carried out by either individual hilar dissection or extraglissonian approach instead of pringle maneuver. the operations were all accomplished successfully without additional ports or open conversion. the operative time was . ± . ( - ) min and the estimated blood loss was . ± . ( - ) ml. five ( . %) patients encountered complications and four of them were classified as clavien-dindo grade i. the postoperative length of hospital stay was . ± . ( - ) days. there was no mortality. conclusion: silh can be performed safely and efficaciously for selected patients with benign and malignant liver diseases including cirrhosis. not only minor but also major liver resections are feasible. this innovative procedure provides low postoperative pain and fast recovery. before adopting this demanding technique, surgeons should be familiar with both single-incision laparoscopic surgery and laparoscopic hepatectomy. better outcomes after the learning curve could be anticipated. background: laparoscopic distal panreatectomy (ldp) has been replacing the open procedure for benign or malignant diseases of the pancreas. however, it is often difficult to apply ldp for pancreatic ductal adenocarcinoma (pdac) because its aggressive invasion to adjacent organs or major vessels. objectives: the objective of this study was to report our experiences for laparoscopic extended pancreatectomy with en-bloc resection of adjacent organs or major vessels for left-sided pdac. methods: we reviewed data for all consecutive patients undergoing ldp for left-sided pdac at asan medical center (seoul, south korea) between april and december . the patients who underwent laparoscopic extended panreatectomy with en-bloc resection of adjacent organs or major vessels were included in analyses. results: of total patients, underwent laparoscopic extended pancreatectomy. there were male and female patients with a median age of . years. resected adjacent organs or vessels were as following: stomach in , duodenum in , colon in , kidney in , superior mesenteric vein in , and celiac axis in . median operative duration was minutes, and median length of hospital stay was days. pathological reports revealed the following: a median tumor size of . cm, the tumor differentiation (well differentiated in , moderately differentiated in , and poorly differentiated in ), t stages (t in , t in , and t in ) , and n stages (n in and n in ). r resection was achieved in patients, and most r resection were tangential retroperitoneal margins. postoperatively, clinically relevant postoperative pancreatic fistula was occured in patients, and there was no -day mortality. median overall survival was . months and year survival rate was . %. conclusions: although laparoscopic surgery has limitations in treating extensive diseases, some selected patients can be applicable for laparoscopic extended pancreatectomy with acceptable complication and survival rates. who underwent hepatic resection was included. these patients were divided into llr or olr. demographics, tumor characteristics, recurrence rates and over-all survival were compared between the groups. results: patients were included and grouped into llr (n= ) and olr (n= ). the average tumor number was ± for both groups, while the mean tumor size was . cm and . cm for the llr and olr group, respectively. when compared with olr, llr had lower post-operative complication rates ( . % vs . %, p= . ) and shorter hospital stay ( vs days, p= . ), although the difference was not statistically significant. overall, recurrence-free and disease-free survival was comparable between llr and olr. introduction: single port surgery has been described since with cholecystectomy, colectomy, gastrectomy, and others. nevertheless, few cases are still reported in field of hbp surgery. herein, we report single port pancreatic surgery developed from our previous experience. we had started single port surgery in , since then we have done more than cases of single port surgery using surgical glove port including cholecystectomy, appendectomy, and colectomy. because we consider this experience should develop to pancreatic surgery, cases of single port staging laparoscopy for potentially resectable and borderline resectable pancreatic cancer and cases of single port plus one port distal pancreatectomy (spop-dp) have been done in our institution. single port staging laparoscopy for pancreatic cancer. resectability was proved in ( %) out of patients while patents had unresectale factor such as small liver and peritoneal metastases that was not able to detect pre-operatively. the length of hospital days were . ± . days and the days to chemotherapy were . ± . days. single port plus one port distal pancreatectomy (spop-dp) spop-dp starts with . cm skin incision on umbilicus. subsequently, a wound retractor is installed at umbilical wound. then, a non-powdered surgical glove ( . inches) is put on the wound retractor through which three -mm slim trocars and one -mm trocar are inserted via each finger tips. a semi-flexible laparoscopic camera is inserted via the middle finger port. -mm port is used when laparoscopic us, mechanical stapler, endo intestinal clip or retrieval bag were needed. an additional -mm port is inserted at left subcostal lesion mainly used for surgeon's right hand instrument. gastric posterior wall is fixed to abdominal wall by suture instead of manual retraction. pre-compression before transection of the pancreas was done using endo intestinal clip before firing. discussion: as we have seen in these two decades, surgery has dramatically been changed by laparoscopic surgery or robotic surgery. nevertheless, because of technical difficulty and relatively high post-operative complication rate, introduction of reduced port surgery to hbp surgery has just started. spop-dp using endo intestinal clip, glove port and gastric wall hanging method is feasible. but its advantage is not clear so far, multicenter rct is highly desired to clear the benefit of reduced port surgery for pancreas. introduction: scoring systems (ss) are an essential pillar of care in acute pancreatitis (ap) management. we compared six ss (acute physiology and chronic health examination (apache-ii), bedside index for severity in ap (bisap), glasgow score, harmless ap score (haps), ranson's score and sequential organ failure assessment (sofa) score) for their utility in predicting severity, intensive care unit (icu) admission and mortality. methods: ap patients treated between july and september were studied retrospectively. demographic profile, clinical presentation and discharge outcomes were recorded. predictive accuracy of six ss was assessed using areas under receiver-operative curve (auc) with pairwise comparisons. results: patients were treated for ap. twenty-two ( . %) patients were excluded for insufficient data. / ( . %) were male and mean age was . ( - ) years. most common aetiology was gallstones ( . %). mean length of stay was . ( - ) days. ( . %) patients had severe ap, ( . %) required icu admission and ( . %) died. table below shows positive predictive value (ppv), negative predictive value (npv) and auc of six ss in predicting outcomes. pairwise comparisons revealed ranson's (p. ) and sofa (p. ) scores were superior than other ss in predicting all three outcomes. auc of sofa was greater than ranson's score in predicting severity (p. ), but similar in predicting icu admission (p= . ) and mortality (p = . ). conclusion: sofa score is superior to classical ss in predicting severity, icu admission, and mortality in ap. introduction: necrotizing pancreatitis is often a devastating sequelae of acute pancreatitis. historically several approaches have been described with variable outcome. open necrosectomy is associated with higher morbidity ( %) and mortality ( %). endoscopic necrosectomy often is tolerated well but associated with stent migration and multiple procedures. video-assisted retroperitoneal debridement is tolerated well but associated with severe bleeding if adjacent blood vessels are injured during the procedure leading to severe complications. methods: in our series, we perform a step up approach by involvement of a multidisciplinary group consisting of general surgeons, gastroenterologists, infectious disease physicians, critical care internalist, interventional radiologist and nutritional services to formulate a management plan. the necrotized pancreas is initially drained with an ir guided drain, fluid cultures sent for microbiology and treatment with appropriate antibiotics if deemed necessary. the drain is gradually upsized to a fr sized drain to form a well-defined tract for surgical debridement; a preoperative ct scan of the abdomen with iv contrast to access the location and proximity of the vasculature around the necrotized pancreas. a collaboration with the interventional radiologist to discuss possible ir embolization of splenic artery prior to surgical debridement. the patient would then undergo video assisted retroperitoneal pancreatic necrosectomy and a sump drain left in-situ at the pancreatic fossa. post-operative management in the surgical icu would be lead by the critical care internalist. results: three patients were managed by this multidisciplinary approach with excellent outcomes. one patient underwent preoperative ir embolization followed by surgical debridement; second patient underwent embolization immediately following debridement; one patient did not require any embolization but had ir on standby if needed to intervene. post-operatively all three patients recovered well. they all were tolerating good oral intake and were discharged to rehabilitation facilities. conclusion: our preliminary experience demonstrates that an early multidisciplinary plan by various subspecialties can result in a pragmatic and successful approach to this potentially catastrophic condition. introduction: liver resection with preservation of as much liver parenchyma as possible is called parenchymal sparing hepatectomy (psh). psh has been shown to improve overall survival by increasing the re-resection rate in patients with colorectal liver metastases (crlm) and recurrence. the caudal-cranial perspective in laparoscopy makes the cranial segments ( , a, , and ) more difficult to access. the objective of this systematic review is to analyze feasibility, safety, morbidity, and oncologic outcomes of laparoscopic psh. methods: a systematic review of the literature was performed. medline/pubmed, scopus, and cochrane databases were searched. a search strategy was published with the prospero registry. a systematic review was conducted on all cases reported, they were categorized by area of resection and quantitative meta-analysis of operative time, blood loss, length of hospital stay, complications, and r resection was performed. results: of the studies screened for relevance, studies were selected. because interventions or endpoints were noncontributory or reporting incomplete, were excluded. only publications remained, reporting data from patients who underwent laparoscopic psh. the highest oxford evidence level was b and selective reporting bias was common due to single center and noncontrolled reports. among them, ( . %) resections were in the cranial segments ( . %), a ( . %), ( %), and ( . %), which previously would have required laparoscopic hemi-hepatectomies or sectorectomies. the most common tumor type was crlm ( %) and the second most common tumor type was hepatocellular carcinoma ( %). feasibility of laparoscopic psh was %, conversion rate was %, and complications were seen in % of cases. no perioperative mortality was reported. no standardized reporting format for complications was used across studies. meta-analysis revealed a weighted average operating time of minutes, estimated blood loss of cc, and length of stay of days. r resections were achieved in % of cases. conclusion: laparoscopic psh of difficult to reach liver tumors are feasible with acceptable conversion and complication rate, but relatively long operating times and relatively high blood loss. in future studies, data on long term survival and specific tumor type recurrence should be reported and bias reduced. yangseok koh , eun-kyu park , hee-joon kim , young-hoe hur , chol-kyoon cho ; chonnam national university hwasun hospital, chonnam national university hospital purpose: laparoscopic surgery has become the mainstream surgical operation due to its stability and feasibility. even for liver surgery, the laparoscopic approach has become an integral procedure. according to the recent international consensus meeting on laparoscopic liver surgery, laparoscopic left lateral sectionectomy ( conclusion: this study showed that laparoscopic lls is safe and feasible, because it involves less blood loss and a shorter hospital stay. for left lateral lesions, laparoscopic lls might be the first option to be considered. keywords: laparoscopy, left lateral sectionectomy. outcome analysis of pure laparoscopic hepatectomy for hcc and cirrhosis by icg immunofluorescence in.-a propensity score analysis introduction: in laparoscopic hepatectomy, the surgeon cannot use their hand to palpate the liver lesion and estimate margin of resection. the use of icg immunofluorescence technique can show up the liver tumour and has the potential to facilitate a throughout assessment during the operation. method: between and , there were patients undergone pure laparoscopic liver resection for hcc in our hospital. patients had undergone surgery by the conventional laparoscopic approach. patients had laparoscopic hepatectomy with additional icg immunofluorescence augmented technique. the surgical outcome was compared with propensity score analysis in a ratio of : . result: patients had icg immunofluorescence assisted laparoscopic hepatectomy (group ). patients using conventional laparoscopic liver resection with propensity-matched were selected for comparison (group ). the median operation time was minutes vs minutes p= . , the median blood loss was ml vs ml (p= . ). additional tumours were identified by icg technique. patients had suspicious lesion picked up by icg technique but proven to be benign pathology on frozen section examination. the sensitivity of tumour detection by group was %. % r resection was achieved in group and group respectively. hospital stay was days vs days (p= . ), post-operative complication was ( %) vs ( . %) (p= . ) none of the patient developed icg related complication. conclusion: in the current study, the new technique showed equally good short-term outcome when compared with conventional laparoscopic hepatectomy. icg immunofluorescence augmented reality is a promising technique that might facilitate easier identification tumour during laparoscopic hepatectomy. surg endosc ( ) :s -s taking the training wheels off: transitioning from robotic assisted to total laparoscopic whipple introduction: there is a substantial learning curve to performing minimally invasive pancreatoduodenectomy (mis-pd) for surgeons who are trained in open pd. the learning curve to transition from robotic assisted pd (rapd) to total laparoscopic pd (tlpd) is not well established. methods: mis-pds performed between january and june performed by sc as a surgeon or co-surgeon were included for analysis. mis-pds were performed using a robotic assisted technique prior to august , and tlpds were performed subsequently. rapds performed prior to were excluded to limit the comparison to rapds after the initial learning curve. demographics, clinical and pathologic outcomes, operative and post-operative outcomes were compared. results: a total of rapds and tlpds were scheduled during the study period. there was no statistically significant difference in age, body mass index, or prior abdominal surgery. median time from initial clinic consultation to surgery was days for the rapd group versus days in the tlpd group (p= . ). conversion to laparotomy was required in of patients ( there were no operative complications or mortality. the mean hospital stay was ± . hours. there was no postoperative jaundice, bile leak, intra-abdominal collections or mortality. conclusion: when surgery is indicated for difficult acute calculous cholecystitis, laparoscopic subtotal cholecystectomy with control of the cystic duct is safe with excellent outcomes. however, if the critical view of safety can't be achieved due to obscured anatomy at calot's triangle, conversion to open surgery or cholecystostomy must be performed to prevent bile duct injury. scott revell, md , joshua parreco , rishi rattan, md , alvaro castillo, md ; u. miami -jfk gme consortium, university of miami, miller school of medicine introduction: over the last two decades the increasing incidence of benign liver tumors has led to the expanded need for clinicians to make therapeutic decisions regarding the utilization of open, minimally invasive and ablative techniques. the purpose of this study was to compare outcomes of the management of benign liver disease based on operative approach and pathology. methods: patients aged years or older who underwent liver surgery for benign liver tumors from to were identified in the nationwide readmissions database. patients were compared based on liver pathology, resection versus ablation, and an open versus laparoscopic/robotic approach. the outcomes of interest were in-hospital mortality, prolonged length of stay (los) [ days, and readmission within -days. univariable analysis was performed for these outcomes and multivariable logistic regression was performed using the variables with a p-value . on univariable analysis. results were weighted for national estimates. results: there were , patients undergoing surgery for benign hepatic tumors in the us during the study period. the most common pathology was benign neoplasm ( . %) followed by hemangioma ( . %), and congenital cystic disease ( . %). resection alone was performed in . %, ablation alone in . %, and resection with ablation in . %. a laparoscopic/robotic approach was used in . % of cases. the overall mortality rate was . %, a prolonged los was found in . %, and readmission within days occurred in . %. an increased risk for mortality was found with hemangioma (or . , p= . ) and congenital cystic disease (or . , p= . ). resection with ablation was associated with an increased risk of prolonged los (or . , p. ), while a laparoscopic/robotic approach was a protective factor for prolonged los (or . , p. ). patients treated with ablation alone were at decreased risk for readmission (or . , p. ). omar m ghanem, md , desmond huynh, md , tomasz rogula, md ; mosaic life care, cedars sinai, introduction: laparoscopic sleeve gastrectomy is the most commonly weight loss procedures performed worldwide. as such, there is great diversity in the techniques utilized. this study aims to identify and categorize the differences in techniques and assess the need for guidelines in this field. case description: surgeons were surveyed on the techniques they employ on biweekly basis using the international bariatric club facebook group. the survey included sleeve staple line reinforcement, preoperative work up, intraoperative hiatal dissection, bougie size, distance from pylorus to distal staple line, and intraoperative leak testing. surveys were conducted between may and july . each survey was active for weeks after which data was collected. participants were required to select a single answer per question. discussion: when surveyed on staple line reinforcement (n= ), surgeons used no reinforcement, over-sewed, buttressed, clipped as necessary, over-sewed as necessary. for preoperative work up (n= ), utilized routine endoscopy, routinely obtained upper gi series, routinely obtained both endoscopy and upper gi, and employed endoscopy or upper gi series only in patients who were symptomatic. for hiatal dissection (n= ), surgeons dissected the hiatus routinely, dissected only when obvious hernias intraoperatively, dissected only if the hernia was detected on preoperative work up, and dissected in the setting of gerd symptoms. for sleeve caliber sizing (n= ), bougie \ f was used by surgeon, bougie size f, f, f were utilized by , bougie size f and f were utilized by , bougie[ f were used by , and gastroscopes ( f) were used by . with regards to distance from pylorus to where the sleeve staple line was initiated (n= ), participants started \ cm away from pylorus, between and cm, and started [ cm from pylorus. finally, for preferred intraoperative leak test during sleeve (n= ), methylene blue was used by surgeons, air leak test by , used both, and opted for none. conclusion: this study characterizes the wide varieties in the techniques used during sleeve gastrectomy. a great number of variations exist in every parameter surveyed; however, there is little evidence comparing the effectiveness and safety of these variations. in this setting, further randomized controlled trials are necessary and should be used to construct guidelines to best optimize outcomes in this extremely common and necessary operation. yen-yi juo, md, mph, yas sanaiha, md, yijun chen, md, erik dutson, md; ucla introduction: bariatric surgeries are commonly performed in accredited centers of excellence, but no consensus exists regarding the optimal readmission destination when complications occurred. our study aims to examine the impact of care fragmentation on post-operative outcome and evaluate its causes and consequences among patients undergoing -day readmission after bariatric surgery. methods: the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) database was used to identify patients who experienced -day unplanned readmission following bariatric surgery. non-index readmission was defined as any readmission occurring at a hospital other than the one where initial surgery was performed. primary outcome was -day mortality after surgery. logistic regressions were used to identify risk factors for nonindex readmission and to adjust for confounders in the association between non-index readmission and -day mortality. results: a total of , patients were identified as experiencing -day unplanned readmission following bariatric surgery, among whom ( . %) were non-index readmissions. occurrence of postoperative complication during initial hospitalization was the most significant risk factor for non-index readmission (or . , % ci . - . , p= . ) in our multivariate logistic regression. the three most common reasons for readmission were similar within the two comparison groups, including nausea/vomit, abdominal pain and anastomotic leakage. similar proportion of patients underwent reoperation among the two comparison groups ( . vs . %, p= . ). even after adjusting for occurrence of complications, being readmitted to a non-index facility was still associated with a . -fold odds of -day mortality ( % ci . - . , p\. ). conclusion: non-index readmission significantly increases the risk of -day mortality following bariatric surgery. patients were more likely to visit a non-index facility if complications occurred during their initial hospitalization. further patient education is required to re-inforce the importance of continuity-of-care during management of bariatric complications and guide patient's decision making in choosing readmission destinations. introduction: sleeve gastrectomy has become the most performed bariatric surgery. removing part of the stomach causes weight loss by restricting food intake and regulating the production of incretins, particularly ghrelin. however, prognostic factors to weight loss after sleeve gastrectomy have been difficult to find. the goal of this research was to study the correlation between the volume of resected stomach and weight loss. methods and procedures: volume of resected stomach of patients undergoing sleeve gastrectomy was measured. a standard laparoscopic technique was used. calibration was performed tightly around a fr bougie, and stapling started - cm from the pylorus. the standardized technique for measurement involved insufflation with a g catheter with saline solution to a pressure of cm h o immediately after removal of the specimen. resected stomach's volume, gender, age, bmi, height and % of total weight loss (%twl) at months and year were prospectively recorded. correlation between variables was analyzed with pearson's test and linear regression models. conclusion: removed stomach was larger on men than women and its size slightly correlated to height. however, volume of resected stomach did not seem to have an incidence on short termweight loss. gastric size should not be considered as a prognostic factor for weight loss in patients undergoing sleeve gastrectomy. revisional bariatric surgery after initial laparoscopic sleeve gastrectomy: what to choose salman alsabah, eliana al haddad, ahmad almulla, khaled alenezi, shehab akrouf, waleed buhamid, mohannad alhaddad, saud al-subaie; amiri hospital introduction: bariatric surgery has been shown to produce the most predictable weight loss results, with laparoscopic sleeve gastrectomy (lsg) being the most performed procedure as of . however, inadequate weight-loss may present the need for a revisional procedure. the aim of this study is to compare the efficacy of laparoscopic re-sleeve gastrectomy (lrsg), laparoscopic roux-en-y gastric bypass (lrygb) and gastric mini-bypass surgery (mgbp) in attaining successful weight loss following initial lsg. methods: a retrospective analysis was performed on all patients who underwent lsg at amiri and royale hayat hospital, kuwait from to . a list was obtained of those who underwent revisional bariatric surgery after initial lsg, and their demographics were analyzed. introduction: the aim of this study is to identify potential risk factors or early indicators, specifically related to perioperative blood pressure, and its association with perioperative hemorrhage in the bariatric population. laparoscopic bariatric surgery in the united states has been steadily increasing over the past several years. between and , the annual number of cases has increased by %. although rare, hemorrhagic complications (hc) occur at a rate of - % and can lead to significant morbidity and mortality. by identifying factors which may place a patient at higher chance of hc, surgeons can potentially mitigate those risks. these modifications could reduce morbidity and limit the requirement of transfusions or reoperations. methods and procedures: a retrospective case-control series was performed to include all patients who underwent either laparoscopic sleeve gastrectomy (sg) or laparoscopic roux-en-y gastric bypass (gb) in at a single bariatric center of excellence. a total of patients were identified with perioperative hc. each patient was matched : for procedure, body mass index, and medical comorbidities. peak systolic, diastolic, and mean arterial pressures were compared between groups at time of admission, intraoperative, and during remainder of initial hospital stay. welch's t-tests were used for comparison between groups. results: a total of procedures were performed with de novo sg, and de novo gb. revisional bariatric cases were excluded from the study. hc occurred in ( . %) total patients, gs and gb. four patients required operative treatment for hc, were treated laparoscopically and required laparotomy. the mean diastolic pressures at time of arrival on day of surgery was higher in patients who develop hc (p= . ) and mean peak diastolic pressure intraoperatively was lower in patients who develop hc (p= . ). there was no statistical difference in peak systolic or mean arterial pressures throughout the hospital stay. conclusions: bariatric surgical patients with elevated preoperative diastolic blood pressures are at an increased risk of postoperative hc. additionally, decreased peak diastolic blood pressures may be an early indication of an hc in bariatric patients. introduction: bariatric surgery in the adult population is recognized as one of the most effective treatments for obesity and its comorbidities. nonetheless, the safety, efficacy, and substantial outcomes of bariatric surgery in young adults are still not well documented. the aim of our study is to evaluate the safety and efficacy of laparoscopic sleeve gastrectomy (lsg) in young adults (\ years old) versus older adults (≥ years old). methods: we retrospectively reviewed all patients who underwent bariatric surgery at our institution from to. propensity score matching was used in order to balance covariates, matching for common demographics and comorbidities between the younger patient population (\ years old) and the control group ([ years old). all tests were two-tailed and performed at a significant level of . . statistical software r, version . . ( - - ) was used for all analyses. results: of patients, . % (n= ) met our inclusion criteria after matching. we found . % (n= ) patients under years old and . % (n= ) patients greater or equal to years old (control group). we observed that our younger population distribution was predominantly caucasian and female, . % (n= ) and . % (n= ) respectively. the mean age was . ± . years with a preoperative body mass index (bmi) of . ± . kg/m in the younger group compared to . ± . years and a bmi of . ± . kg/m in the control group. diagnosis of diabetes and hypertension were present in . % (n= ) and . % (n= ) of our younger group, respectively. no statistical significance was found when assessing the percentage of bmi loss (% ebmil) at and months follow-up as shown in table . when comparing the % ebmil at months follow-up, the younger group had . % more ebmil than the control group (p= . ). when assessing post-operative complications we observed no statistical significance. conclusions: bariatric surgery is equally effective and safe in young adult population demonstrating a significant better %ebmil at months following bariatric surgery. following prospective studies are needed to elucidate the resolution and behavior of comorbidities in a younger bariatric population. minimally invasive conversion of sleeve gastrectomy to rouxen-y gastric bypass for intractable gastroesophageal reflux disease: short term outcome background: surgical management recommendations for intractable gastroesophageal reflux disease (gerd) after sleeve gastrectomy (sg) remain controversial. this case series demonstrates our experience with treatment of post-operative intractable gerd using minimally invasive conversion of sg to roux-en-y gastric bypass (rygb). patients and methods: this is a retrospective review of a prospective data registry (mbsaqip) from jan through sept . eleven patients, female and male, were evaluated. of the surgeries, were laparoscopic, assisted with xi da vinci robot, and assisted with si da vinci robot. all patients presented with intractable reflux on high dose ppi. three had a history of aspiration pneumonia. ± . %, respectively. one was omitted due to pending results. conclusion: several solutions exist for operative management of intractable gerd after sg including redo-sleeve gastrectomy, combined gastrectomy with fundoplication, conversion to gastric bypass or anti-reflux procedures such as linx. reports remain small in series and require further study to evaluate the consistency of results. we found minimally invasive conversion of sg to rygb is a highly effective and safe option for treatment of intractable gerd. setthasiri pantanakul, chotirot angkurawaranon, ratchamon pinyoteppratarn, poochong timrattana; rajavithi hospital background: obesity is an important health problem affecting more than million people worldwide. esophageal dysmotility is a gastrointestinal pathology associated with obesity; however, its prevalence and characteristics remain unclear. esophageal dysmotilities have a high prevalence among obese patients regardless of gastrointestinal symptoms. objective: to identify the prevalence of esophageal motility disorder in asymptomatic obese patient. materials and methods: prospective study was performed between june and march . a total of of morbid obese patients who visited the bariatric and metabolic clinic at rajavithi hospital (bangkok, thailand) underwent preoperative evaluation with high resolution esophageal manometric test with manoscantm eso (smith medical). tracings were retrospective analysis and reviewed according to chicago classification criteria for esophageal motility disorders. results: among asymptomatic obese participants, twenty five of them were female. the mean age was . ( - ) years old. most of the participants were classified as class three obesity or over. the mean bmi was . kg/m . no hiatal hernia was found and the anatomy of esophagus was normal in all patients. the mean irp was . mmhg. twenty-one patients ( . %) demonstrated high irp over normal limit ([ mmhg) . four patients demonstrated premature contraction (dl\ . second). hypercontractile esophagus was identified in patients and ineffective motility disorder was found in patients. two patients were diagnosed as distal esophageal spasm (des). two patients were compatible with type achalasia and patients ( . %) have esophageal outflow obstruction. none of the patient demonstrate incomplete bolus clearance even high irp or abnormal motility. conclusion: this study reveals a high prevalence of esophageal dysmotility in asymptomatic thai obese patients. the most common abnormality were esophageal outflow obstruction and ineffective motility. the chicago classification of esophageal motility disorder may not suitable among obese population. sitembile lee, ms , chike okolocha , aliu sanni, mdfacs ; philadelphia college of osteopathic medicine ga campus, eastside bariatric and general surgery introduction: roux-en-y gastric bypass (rygb) is the most popular bariatric procedure performed worldwide, accounting for % of all bariatric procedures. however, in patients with a body mass index (bmi) ≥ kg/m (super-super obese) the rygb procedure can be technically challenging. this has led to the adoption of a single-stage treatment such as one anastomosis (mini) gastric bypass (oagb/mgb) in the super-super obese patients. proponents of the oagb/mgb claim the clinical outcomes are comparable to the rygb. the aim of this study is to compare the outcomes of the two procedures by examining the literature. methods: a systematic review was conducted through pubmed to identify relevant studies from to with comparative data on rygb versus oagb/mgb on super-super obese populations. the primary outcome was the percentage excess weight loss (%ewl). other outcomes include operative times, complication rates and length of hospital stay. results were expressed as standard difference in means with standard error. statistical analysis was done using randomeffects meta-analysis to compare the mean value of the two groups (comprehensive meta analysis version . . software; biostat inc., englewood, nj introduction: obesity is becoming more prevalent in patients with inflammatory bowel disease (ibd). the obese body habitus increases the complexity of surgeries that are often needed to treat ibd. some surgeons may delay definitive surgical treatment because of obesity. little data exists on bariatric surgery in the obese patient with ibd. methods: we retrospectively identified patients who had known diagnosis of ibd who underwent bariatric surgery from to . demographics and post-operative outcomes were assessed. results: patients were identified: with ulcerative colitis (uc) and with crohn's disease (cd). of the uc patients, none of the patients had surgery for uc and only one was on a biologic. of the uc patients, had adjustable gastric band (agb), had gastric bypass and had sleeve gastrectomy. one patient with agb had it replaced for slip and subsequently removed for dysphagia. uc preoperative bmi average was . . postoperative bmi was . with excess weight loss (ewl) of %. average follow up was months. of the cd patients, patients had ileocolic resections and one had total proctocolectomy with end ileostomy. one was on remicade and one on mp. of the cd patients, had agb, had gastric bypass and had sleeve gastrectomy. one agb patient had conversion to gastric bypass because of dysphagia and poor weight loss. a second abg patient had band removal because of dysphagia. cd patients' preoperative bmi average was . . postoperative bmi was . with average ewl of %. average follow up was months. overall, agb patients had % ewl, sleeves % and gastric bypass %. two uc patients had post-operative flares, one immediately post op and one month post-operative. four of the band patients had dysphagia, with one replacement, two removals and one conversion to bypass. there were no leaks, intraabdominal infections, fistulas or wound infections. conclusions: uc patients appear to have higher excess weight loss compared to crohn's patients; ewl % compared to % but was not statistically significant. agb had poor results in both uc and cd patients. sleeve gastrectomy and gastric bypass results in effective weight loss for obese patients with ibd. gastric bypass in ibd patient is controversial, but may be appropriate in the right clinical setting. introduction: previous studies suggest that modest preoperative weight loss is associated with improved weight loss following bariatric surgery. however, there remains a need to investigate factors which may successfully predict preoperative weight loss among bariatric patients. methods and procedures: this analysis included patients who underwent laparoscopic roux-en-y gastric bypass (rygb), sleeve gastrectomy, or gastric banding at an academic medical center in california. data were measured at patients' consult and preoperative clinical visits. preoperative weight loss outcomes were categorized as follows: no weight loss, lost weight, or gained weight. associations between categorical sociodemographic and surgical characteristics and preoperative weight loss outcomes were assessed using the chi-square test of association. associations between continuous measures and preoperative weight loss outcomes were assessed using anova. a sub-group analysis was completed among participants who lost weight prior to bariatric surgery. wilcoxon-rank-sum and kruskal-wallis tests were used to evaluate associations between patient characteristics and the number of pounds lost. results: patients (n= , ) were predominately ages - ( %), female ( %), white ( %), and privately insured ( %). patient race was significantly associated with weight loss outcomes (p = . ): whereas % of white patients lost weight prior to surgery, only % of black patients lost preoperative weight. among privately insured patients, % lost weight. in contrast, % of patients insured by medi-cal/medicaid lost weight (p= . ). on average, lower baseline excess body weight was associated with no weight loss. patients who lost preoperative weight (n= , ) were included in the sub-group analysis. male sex (p\. ), black race (p. ), undergoing laparoscopic rygb (p= . ), no previous abdominal surgeries (p= . ), upper tertile baseline weight (p. ), waist circumference (p\. ), percent body fat (p\. ), bmi (p. ), excess body weight (p. ), and systolic blood pressure (p= . ) were associated with more pounds lost. conclusions: this study demonstrates various associations between sociodemographic and clinical patient characteristics and preoperative weight loss. given previous literature indicating the positive relationship between preoperative and postoperative weight loss following bariatric surgery, the results of this study suggest an opportunity to improve preoperative weight loss among specific groups. yen-yi juo, md, mph , usah khrucharoen, md , yijun chen, md , yas sanaiha, md , peyman benharash, md , erik dutson, md ; background: besides rate and extent of weight loss, little is known regarding factors predicting interval cholecystectomy following bariatric surgery, which are important factors in a surgeon's consideration during decision-making regarding whether to perform prophylactic cholecystectomy. in addition, no previous studies have quantified the incremental costs associated with ic. we aim to identify risk factors predicting interval cholecystectomy (ic) following bariatric surgery and quantify its costs. methods: a retrospective cohort study was performed using the national readmission database - . cox proportional hazard analyses were used to identify risk factors for ic. linear regression models were constructed to examine associations between cholecystectomy timing and cumulative hospitalization costs. background: patient-reported outcomes after bariatric surgery are important in understanding the longitudinal effects of surgery. the impact of hospital practices and surgical outcomes on followup rates remains unexplored. objective: to assess the effect of hospital-level practices and -day complication rates on -year follow-up rates of a standardized patient-reported outcomes survey. methods: bariatric surgery program coordinators in a statewide quality improvement collaborative were surveyed in june about their practices for obtaining patient-reported outcomes data one year after surgery. hospitals were ranked based on their follow-up rates between and (accounting for overall performance and improvement). univariate analysis was used to identify hospital practices associated with higher follow-up rates. multivariable regression was used to identify independent associations between -day outcomes and follow-up rates after adjusting for patient factors. results: overall, follow-up rates improved from ( . %± . ) to ( . %± . ) though there was wide variability between hospitals ( . % vs . % in ) . coordinator survey response rate was %. sixty-one percent of all surveyed coordinators perceived that surgeons prioritize high follow-up rates. when asked how long were their patients followed for, % of coordinators noted their programs provided lifelong follow-up. patient reminders about the -year survey were used by % of programs, mostly during clinic visits ( %). most programs ( %) had implemented strategies to improve follow-up rates, such as handing out the survey ( %) during clinic visits. follow-up providers included surgeons ( %), nurse practitioners ( %), and/or registered dietitians ( %). patient disinterest ( %), loss to follow-up ( %), survey length ( %), and lack of staff/ resources ( %) were the factors most commonly perceived as barriers to high follow-up rates. when compared to programs in the bottom quartile of follow-up rates, those in the top quartile were more likely to hand out the survey to patients during clinic visits ( % vs . %; p= . ) and had lower rates of risk-adjusted severe complications ( . % vs . %; p= . ), readmissions ( . % vs . %; p= . ), and reoperations ( . % vs . %; p= . ). conclusions: hospitals vary considerably in their -year follow-up rates when seeking patientreported outcomes data after bariatric surgery. there were also significant differences in programspecific practices for obtaining these data. hospitals with higher -year follow-up rates were more likely to physically hand surveys to patients during a clinic visit and had lower -day severe complication, readmission, and reoperation rates. improved -year patient-reported outcomes follow-up after bariatric surgery may be a proxy for higher quality perioperative care. david merkle , kazim mohommed , danielle r rioux , dilendra weerasinghe, md, facs ; nova southeastern university, herbert wertheim college of medicine, bariatric surgery is gaining popularity not only for its weight loss benefits, but also for its metabolic effects. we present a -year-old female patient with symptoms of neuroglycopenia, occurring -years post roux-en-y gastric bypass surgery. during one of her syncopal episodes, her blood sugar was noted to be mg/dl. continuous glucose monitoring demonstrated post prandial hypoglycemia, averaging episodes per day, with a maximum of episodes in one day. upon further evaluation, the lab results of the hba c, chromogranin a, somatostatin, and urinary sulfonylurea levels were all normal, with the c-peptide level within the upper limit of normal. ct scan of the abdomen and pelvis did not show any obvious masses in the pancreas, and since the chromogranin a level was normal, it lead to the empiric diagnosis of nesidioblastosis by exclusion. we placed the patient initially on medical management which included a carbohydrate restricted diet of g per meal, eating - small meals per day, and taking mg of acarbose three times per day. overall, symptoms have improved, and she has - episodes per month, compared with about episodes per day. we will also present the data with regards to other invasive treatment options, which are available when medical treatment options have failed, such as gastric bypass reversal versus distal gastrectomy. vertical banded gastroplasties (vbgs) were a common bariatric procedure in the s but have largely fallen out of favor due to unsatisfactory weight loss and a relatively high incidence of longterm complications such as dysphagia and severe gastroesophageal reflux disease (gerd). one of the ways to address these undesirable effects is to convert to a roux-en-y gastric bypass (rygb). the aim of this study was to assess the safety and efficacy of vbg-to-rygb conversion. outcomes of vbg revisions performed at an academic center between and were reviewed. of the vbg revisions, gastrogastrostomies were created in two patients, two underwent a planned -stage conversion, and vbgs were converted to rygbs. patients were operated on an average of years after their initial vbg. presenting symptoms were weight regain (n= , . %), dysphagia (n= , . %), or severe gerd (n= , . %). fourteen patients ( %) had a gastric staple line dehiscence. of the vbg to rygb conversions, were laparoscopic, were converted to open, were open, and were robotic-assisted. average operative time and length of hospital stay were . minutes and . days, respectively. within the first months post-operatively, twelve ( %) patients required readmission directly related to surgery, while eight ( %) visited the emergency department. eight patients ( %) required at least one unplanned operation due to complication(s) during the entire follow-up: small bowel obstruction (n= , at -week, -months, and -months), necrosis/leak of remnant stomach requiring remnant gastrectomy (n= ), tracheostomy for prolonged respiratory failure (n= ), bleeding (n= ), anastomotic leak (n= ), and hemothorax requiring vats (n= ). four patients ( %) had a contained perforation that was medically managed and five ( %) developed a gastrojejunal anastomosis stricture requiring endoscopic intervention. one patient ( . %) developed pulmonary embolism. there was no mortality directly related to surgery. complete resolution or improvement of gerd/dysphagia was appreciated in all patients in the short term follow-up. patients who presented with weight regain had a mean bmi loss of . ± . points in the median follow-up time of . months up to a year after conversion to rygb. in summary, reoperative bariatric surgeries after vbgs are complex, requiring longer operative times and length of stay. our study found % risk of severe complications requiring reoperations, compared to the previously cited % in short and long-term complications. conversion of vbg to rygb provides excellent relief of severe gerd and dysphagia and is a viable option for significant weight reduction. introduction: bariatric surgery is a safe and effective treatment for severe obesity and its comorbidities. however, concomitant splenectomy is sometimes required due to uncontrolled bleeding during the surgery. limited literature exists regarding the effects of concurrent splenectomy on outcomes of bariatric surgery. this study aimed to determine these outcomes. methods: adult patients with obesity who underwent primary, elective laparoscopic roux-en-y gastric bypass (lrygb) or laparoscopic sleeve gastrectomy (lsg) with concomitant splenectomy were identified from the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip, ) and national surgical quality improvement program (nsqip, (nsqip, - datasets. using propensity scores (based on baseline variables), patients who underwent primary bariatric surgery were matched : to a control group (primary lrygb/lsg without concomitant splenectomy) and thirty-day postoperative outcomes were compared. continuous variables and categorical variables were categorized as medians with interquartile range (iqr) and counts with percentages, respectively. background: several previous studies have suggested a correlation between weight loss and age after bariatric surgery. objective: the aim of our study is to further address age as a preoperative factor to determine the amount of weight loss after bariatric surgery. materials and methods: we performed a retrospective analysis of outcomes of a prospectively maintained database of , obese patients who underwent either sleeve gastrectomy (sg) or roux-en-y gastric bypass surgery (rygb) at our hospital between and . we analyzed the -month, -month, and -year postoperative percent total body weight loss (%tbwl) of obese patients who underwent bariatric surgery based on their preoperative age. results: the average age of patients included in the study was years old with a range of - years. an inverse relationship between preoperative age and postoperative weight loss was observed. younger patients achieved a higher % tbwl than older patients at the -month, -month, and -year postoperative follow-up. the average %tbwl for all patients at the -month, -month, and -year postoperative follow-up periods were . %, . %, and . %, respectively. at the -year follow-up, for every decade increase in age (above the average age of ), patients lost % less tbwl. conclusion: in our study, younger patients tend to lose a greater amount of %tbwl than older patients after bariatric surgery. results: patients participated in the survey. the median age was yo (iqr: - ) and . % were females. the following responses were encountered when asked about the importance of surgery-related factors: the study population indicated the following responses regarding expectations from magnetic surgery compared to conventional laparoscopy: there was no significant evidence of different responses by demographic groups. additionally, . % of the population indicated that a surgeon performing magnetic surgery should be more skillful than a surgeon performing conventional laparoscopy. conclusion: this study represents the first report of bariatric patient's perception regarding surgery-related factors. notably, nearly % of the cohort indicated that cosmesis after surgery is an important factor, whereas the responses regarding the rest of the factors were indicated as expected. the bariatric population included in this study had a positive perception of magnetic surgery. furthermore, the population perceived that this technique is associated with better outcomes, better cosmetic results, and higher surgeon dexterity. introduction: although much is known regarding medical outcomes of metabolic surgery, less is known regarding quality of life outcomes. we hypothesized that the collection of patient-reported outcomes (pros) could help us understand quality of life in this patient population. we chose to primarily use patient reported outcomes measurement information system (promis) instruments because of their broad applicability, low cost, and ability to use computer-adapted technology to survey. methods: we implemented the routine collection of pros as part of clinical care in december, . patients were offered tablets in clinic, and were asked to complete the surveys at most of their visits. we used computer-adapted technology to decrease the length of time needed to survey. we collected the following promis instruments: depression, pain interference, physical function, and satisfaction with social roles. we also collected the gerd-hrql, a general health question, and a current health visual analog scale (vas). we retrospectively reviewed our results from december through september . results: our response rate was % over the last year of collection. in total, assessments were completed by patients. the mean scores in our total patient population were as follows: vas , gerd-hrql , general health , depression , pain , physical function , and social roles . for promis instruments, the mean for the national population is , with as the standard deviation. for the depression and pain scores a higher score is worse, while a higher score indicates better quality of life for social roles and physical function. conclusions: routine collection of patient reported outcomes can be implemented in a metabolic surgery clinic. health-related quality of life appears to be decreased in this patient population compared to the general public. further work is ongoing to learn about postoperative trends, as well as differential effects of metabolic procedures. the effect of peri-operative antibiotic drug class on the resolution rate of hypertension after roux-en-y gastric bypass and sleeve gastrectomy. results: in total, rygb and sg were included in our analysis. no significant differences were found between cefazolin and clindamycin regarding hypertension resolution rates after sg. there was a significant difference in the resolution of hypertension after rygb with the use of prophylactic clindamycin or cefazolin. as shown in figure , patients who underwent rygb and received clindamycin had a significantly higher rate of hypertension resolution compared to cefazolin. this effect started at weeks post-operatively ( . % vs . % respectively, p= . ) and persisted up to the -year ( . % vs . % respectively, p= . ). we found no significant differences in patient age, sex, number of pre-operative hypertensive medications, pre-operative bmi, or %bmi change after year to account for the significant effect of antibiotic choice on hypertension resolution. conclusion: this study represents the first clinical report to suggest an impact of the type of antibiotic administered at the time of rygb on co-morbidity resolution, specifically hypertension. future studies will be needed to confirm that the mechanism of action for this novel finding is due to the differing modifications of the gastrointestinal microflora population based on the specific peri-operative antibiotic administered. introduction: laparoscopic adjustable gastric band with plication (lagbp) is a novel bariatric procedure which combines the adjustability of the laparoscopic adjustable gastric band (lagb) with the restrictive nature of the vertical sleeve gastrectomy (vsg). the addition of plication of the stomach to lagb should provide better appetite control, more effective weight loss, and greater weight loss potential. objective: the purpose of the study was to analyze the outcomes of lagbp at months. setting: this is a retrospective analysis from one surgeon at a single private institution. methods: data from all patients who underwent a primary laparoscopic lagbp procedure from december to june were retrospectively analyzed. data collected from each patient included age, gender, weight, body mass index (bmi), and excess weight loss (ewl). results: sixty-six patients underwent lagbp. the mean age and bmi was . ± . years and . ± . kg/m, respectively. all patients were beyond the -month postoperative mark. no patient was lost to follow-up. the patients lost an average of % and . % excess weight loss (ewl) at months ( . % follow-up) and months ( . % follow-up), respectively. also, the patients lost a mean bmi of . kg/m and . kg/m at months and months, respectively. the total number of fills during the study period was , and the mean fill volume was . ± cc. dysphagia was the most common long-term complication. the mortality rate was %. conclusions: lagbp is a relatively safe and effective bariatric procedure. in light of recent studies demonstrating poor outcomes following lagb, lagbp may prove to be the future for patients desiring a bariatric procedure without resection of the stomach. the median interval between (lrygb) and reoperation is months in group a and months in group b. the median percentage of excess weight loss (%ewl) is % vs %, respectively (p= . ). patients % ( in group a) were admitted in an emergency with an acute abdomen pain. ct scan was performed in patients % and has shown signs of occlusion in all cases. the most common symptoms were abdominal pain and vomiting. the surgery was performed by laparoscopy in patients % and by laparotomy or conversion in patients %. in all cases internal hernia was reduced and closed all defects. in only one patient in (group a) small bowel at jja was resected. there was no mortality and one patient had pneumonia with acute respiratory distress which was treated medically. conclusions: the closure of mesenteric defects at (lrygb) by tight non-absorbable continued sutures is recommended because it is associated with a significant reduction in the incidence of internal hernia. introduction: laparoscopic roux-en-y gastric bypass (rygb) is a common and effective form of bariatric weight loss surgery. however, a subset of patients will fail to achieve the expected total body weight loss (tbwl) greater than % after months or experience significant weight regain despite dietary, psychiatric, and behavioral counseling. although alternative procedural interventions exist for operative revision after suboptimal rygb weight loss, laparoscopic adjustable gastric banding (lagb) provides an option with short operative time, low morbidity, and effective results. we have previously demonstrated that short-term ( -month), and mid-term ( -month) weight loss is achievable with lagb for failed rygb. the objective of this study is to report the long term year outcomes of lagb after rygb failure. methods and procedures: a retrospective review of prospectively collected data before and after rygb when available, and before and after revision with lagb was performed. background: saline filled intragastic balloons have become a common outpatient procedure for the treatment of obesity. acute dilation, ischemia and necrosis of the stomach has been described in the medical literature. gastric necrosis from acute gastric dilation is a rare but life-threatening condition, which requires timely diagnosis and management. we present a case of partial gastric ischemia with necrosis hours following placement of a saline filled intragastric balloon. postoperative complaints of bloating, nausea and vomiting are common complaints following placement of saline filled intragastric balloons and can lead to a delay in diagnosis. early diagnosis and management is essential in avoiding this life threatening complication. case report: a year old woman, bmi , comorbid conditions of diabetes mellitus underwent uncomplicated placement of a saline filled intragastric balloon for treatment of obesity. hours after placement the patient complained of cramping and bloating. hours following placement the patient developed vomiting and presented to an emergency room for evaluation. she was found to have blood glucose exceeding and a severely dilated stomach with pneumotosis on ct evaluation. ng tube decompression and icu management of the severe hyperglycemia was initiated. removal of the intragastric balloon was delayed - hours until an appropriate endoscopic retrieval kit could be obtained. endoscopic retrieval was performed without incident and near complete necrosis of the gastric mucosa was noted. the antrum was the only area spared. hours after retrieval a laparoscopic evaluation of the stomach revealed full thickness necross of the entire fundus and greater curve. indocyanine green (icg) fluorescent dye was used to assess vascular integrity of the remaining stomach and to define lines of resection. resection of the greater curvature was performed using icg florescent dye to ensure that the angle of hiss was viable and well perfused. the patient had a full recovery and subtotal gastrectomy was avoided. conclusions: spontaneous gastric distension exacerbated by gastric outlet obstruction following placement of a saline filled intragastric balloon can occur. unrecognized this condition can lead to ischemia, necrosis and perforation of the stomach. appropriate evaluation of patients following placement of intragastric balloons is essential. recognition of this condition can be delayed due to the complaints of cramping, bloating and vomiting which are typical following placement of saline filled intragastric balloons. untreated, gastric ischemia and necrosis can lead to early perforation which is associated with a high mortality rate. introduction: morbid obesity has become a growing health risk in the united states with up to % of americans suffering with obesity. bariatric surgery remains the best treatment for morbid obesity. the recent use of laparoscopic sleeve gastrectomy (lsg) as a single stage procedure has met with great success because of its quick learning curve and minimal postoperative complication rates. however, there are concerns if the lsg is an effective procedure for long-term weight loss. although criticized at first, the mini-gastric bypass (mgb) surgery has become a great option for morbidly obese patients because of the ability to lose weight with minimal post-op complications. the aim of this review is to assess the outcomes of lsg as it compares to mgb for the management of morbid obesity. introduction: we hypothesize that a jejunoileal anastomosis and partial diversion using magnamosis, a novel magnetic compression device, is technically feasible and will improve insulin resistance and metabolic syndrome similarly to patients who underwent bariatric surgery. metabolic surgery has demonstrated improvements in various parameters including insulin resistance, triglyceride levels, and cholesterol. it may be technically feasible to perform a less-invasive operation through partial diversion, and thereby stimulate an increase in incretins from the l-cells of the ileum to glean these benefits. methods and procedures: we performed a laparotomy and jejunoileal partial diversion using magnamosis in five rhesus macaques with induced insulin resistance through dietary modifications. after surgery, weight was monitored and a metabolic laboratory evaluation was performed weekly. timed tests were performed at baseline and again at and weeks postoperatively for triglyceride levels, glp- , insulin, glucose, and bile acids. the primates were followed for weeks prior to euthanasia. results are represented as mean±sem and all p-values were calculated using a two-sample students' t-test. introduction: many studies concerning individuals seeking bariatric surgery indicate a higher prevalence of psychiatric disorder in this population, both before and after surgery, however results are not conclusive. the aim of this study was to investigate changes in psychiatric health after gastric bypass surgery. methods: patients within the catchment area of the department of psychiatry of the south alvsborg hospital, operated with gastric bypass surgery during - were identified through the scandinavian quality registry (soreg). patients files were examined and psychiatric diagnoses and alcohol/drug abuse were recorded preoperatively and with a follow up time of years. results: a total of operated patients were identified. of these patients had been in contact with the psychiatric department before or after surgery. patients had attempted suicide preoperatively, but no attempts were made postoperatively, all women. patients attempted suicide postoperatively without a previous history of suicidal attempts, men woman. four patients with a preoperative history of alcohol abuse were identified, all women. these individuals did not seem to abuse alcohol/drugs postoperatively. postoperatively patients with an alcohol/drug abuse were identified, men, women. none of them had a former history of abuse. of the patient performing suicidal attempts postoperatively, men woman, had a postoperatively emerging alcohol/drug abuse. conclusion: preoperatively known alcohol/drug abuse or suicidal attempts do not seem to predispose for postoperative abusive problems or suicidal behavior. preoperative identification of individuals prone to alcohol/drug abuse or suicidal attempts seems difficult. introduction: in the past, our group has popularized models for gastric bypass, sleeve and gastric imbrication. there are currently no models to predict weight loss following single anastomosis duodenal switch. surgeons who offer this procedure are left to guess based on their limited experience how their patients will do following surgery we have developed a simple office based algorithm to predict weight loss following this procedure. method: patients met the criteria for this study. these patients underwent surgery at a single institution from june to december . non-linear regression analysis was performed to interpolate weight loss at one year. a multilinear regression was run to determine the significant variables. a model was then constructed to predict weight loss after single anastomosis duodenal switch. results: bmi, htn, gender, and the interaction between htn and dm were found to affect weight loss. the model achieved a r value of . and the average error of prediction in the model was . %ewl. conclusion: today too many surgical practices offer procedures tailored to surgeon instead of the needs of the patient. using our models predicting postoperative weight loss can be a straightforward process using easily gathered data. all surgeons should be doing this currently in their own practice to allow patient to choose targeted healthcare interventions based on patient's personal goals. surg endosc ( ) introduction: there is a long-standing practice of testing anastamosis both in upper and lower gi surgery. post-operative leaks in bariatric surgery are an uncommon but serious compilation increasing morbidity and risk of mortality. the present study looks at the practice of performing an intra-operative leak test during roux-en-y gastric bypass (rygb) and sleeve gastrectomy (sg). methods and procedures: the study was divided in two independent phases of six months and months. data was collected from all patients undergoing sg, rygb or revision rygb within those two periods. to confirm the integrity of the staple line all patients underwent a methylene blue and air test intra-operatively. this was followed by a gastrograffin swallow the morning post procedure. results: total number of patients in the study was . there were four positive intraoperative tests. one patient was a primary rygb and three patients were undergoing revision rygb. all were reinforced and subsequent recovery and gastrograffin swallow showed no leak. one revision rygb had an undetected small bowel injury distal to jejuno-jejunostomy that was not identified on intraoperative or next day imaging. we used multivariate statistical analysis to study our population sample and classified the impact of each factor or their combination with the use of principal component analysis. we used systematic clustering to identify subpopulations that have significant differences in statistical distribution. result: the main determinant of total operative time was the surgeon and the level of his assistant. prior surgeries, bmi and smoking history had a statistically significant impact on the laparoscopic time (p value. ). removing the impact of various surgeons, we detected four clusters of patients based on more than patient characteristics. we noticed total or time had two different clusters: one with a standard-deviation of - min while the other had over min. conclusion: this study may have practical implications on improving scheduling. the different comorbidities of these bariatric patients helped to stratify patients into these main cluster groups. better predictability on length of operative procedure can lead to more efficient use of or time and staff, thus ultimately leading to savings for the hospital. in addition, we used automated noninvasive tracking methods to identify phases of bariatric procedures that will allow more accurate estimated or time to efficiently schedule cases. the smart or, which is equipped with multiple noninvasive sensors, allows for error free tracking and monitoring without human interference. objectives: successful outcomes after bariatric surgery (bs) require a comprehensive educational program (cep) focused on post-surgical dietary and lifestyle changes. at our institution, patients must comply with a -week life-after-surgery program prior to surgery. since many patients are not able to participate in-person, an online cep was created to improve accessibility. to evaluate comprehension, a -question test is administered at the last preoperative visit to participants of both classes. the primary objective of this study is to evaluate the effectiveness of online versus inperson cep in terms of comprehension and post-operative weight loss. methods: patients who underwent bs from august -may were retrospectively reviewed at a single institution. all patients who underwent the in-person or online cep, completed the -question test, and had post-operative follow-up for at least months were included. baseline demographic, operative, and weight data were obtained using the electronic medical record. background: body weight loss after bariatric surgery is affected by several factors. diabetes status or preoperative body mass index (bmi) would affect the body weight loss after surgery. age and sexuality may also be the predictor. furthermore, the malabsorptive procedure is considered more effective for body weight loss than the restrictive procedure alone. we investigated the contribution of preoperative background data and procedures to the body weight loss after surgery. methods: this was a multicenter, retrospective study to validate the efficacy of bariatric surgery for morbidly obese patients in japan. patients underwent sleeve gastrectomy (lsg) or lsg with duodenal-jejunal bypass (lsg/djb) in each institution from january to december , and whose bmi was kg/m or more at the first visit were included in this study. we investigated the percent excess body weight loss (%ewl) at months after surgery. univariate and multivariate analyses were done to evaluate the predictive factors of body weight loss. we defined that %ewl more than % as well response (wr background: despite its known safety and efficacy, bariatric surgery is an underutilized treatment for morbid obesity in the united states. objective: our goal was to identify factors associated with failing to proceed with surgery despite being considered an eligible candidate by a bariatric surgery program. methods: this is a retrospective study that includes all patients (n= ) who attended a bariatric surgery informational session (bis) at a single center academic institution in . eligible candidates were identified after clinical evaluation and multidisciplinary candidacy review (mcr). we compared patients who underwent surgery to those who did not (i.e. dropped out) by evaluating patient-specific, insurance-specific, and bariatric surgery program-specific variables. univariate analysis and multivariable regression were performed to identify risk factors associated with failing to undergo surgery among eligible candidates. introduction: the elderly are a special subset of the population due to their limited physiological reserve with aging. revisional bariatric surgery is becoming more common with increase in primary bariatric procedures. data on safety, weight loss, and metabolic effects of revisional bariatric surgery in elderly is limited. the aim of this study was to assess the safety and efficacy of revisional bariatric surgery in the elderly. methods: clinical data of all elderly patients ( years and above) who underwent elective revisional bariatric surgery at an academic institute between and were reviewed. demographic data, perioperative variables, and postoperative outcomes were studied. results: a total of patients were identified with a female predominance ( : ). mean age was ± . years. mean bmi at the time of revisional surgery was . ± . kg/m . the primary indication for revisional surgery included management of postoperative adverse events (n= , . %) and weight recidivism (n= , . %). in patients with postoperative complications, the most common indications for revisional surgery were dysphagia (n= , . %), marginal ulcer (n= , . %), gastric outlet obstruction (n= , . %), and fistula formation (n= , . %). the most common type of revisions included conversion of vertical banded gastroplasty to roux-en-y gastric bypass (rygb, n= ), revision of rygb (n= ), conversion of adjustable gastric banding to sleeve gastrectomy (sg, n= ), and sg to rygb (n= ). two out of seven ( . %) patients with -day postoperative readmissions had serious complications that required reoperation. one of them underwent small bowel resection for ischemia and the other had thoracotomy for hemothorax evacuation developing secondary to a gastropleural fistula. while there was no mortality over the first days postoperatively, two patients died months after surgery due to infectious complications. in the median follow-up time of (interquartile range, - ) months, mean weight and bmi changes of − . kg and − . kg/m were observed. twenty-three ( . %) patients had diabetes at time of revisional surgery. a mean reduction of . mg/dl in fasting blood glucose and . % in glycated hemoglobin were noted between baseline and last follow-up. conclusion: revisional bariatric surgery in elderly is associated with high complication rates. our data indicate that revisional bariatric surgery can potentially alleviate symptoms and resolve complications of primary bariatric surgery. elderly patients should have their risk stratified and weighed against the benefits of surgery. anne-marie carpenter, bs, alexander l ayzengart, md, mph; university of florida introduction: bariatric surgery is the most effective treatment for morbid obesity. of all available procedures, laparoscopic sleeve gastrectomy (lsg) is now the most popular worldwide. common complications of lsg include gastroesophageal reflux, stricture, and staple-line leak. although rare, portomesenteric venous thrombosis (pmvt) and liver retractor-induced injuries are increasingly reported. we present a case of isolated left portal vein thrombus after routine lsg that was likely caused by prolonged compression of left liver lobe by the nathanson retractor. case presentation: a -year-old female with a bmi of and biliary colic due to cholelithiasis underwent lsg with hiatal hernia repair and cholecystectomy. she tolerated the procedure without complication and was discharged home on the following day. on postoperative day , she presented to the emergency department with fever and epigastric pain. contrast ct revealed an isolated filling defect within the proximal left portal vein; abdominal doppler demonstrated an acute thrombus occluding the left portal vein with normal flow in the main and right portal veins. the patient was treated with a -month course of therapeutic anticoagulation with lovenox. a complete hematologic workup did not uncover any hypercoagulable conditions. the patient recovered well and remained asymptomatic at her follow-up visit weeks after operation. discussion: pmvt is a rare surgical complication with multifactorial etiology. in bariatric surgery, evidence suggests lsg elicits more frequent pmvt compared with roux-en-y gastric bypass. a systematic review cited the incidence rate of pmvt as . - % after lsg. the mechanisms are thought to be due to pneumoperitoneum, procoagulant obese state, manipulation of portomesenteric venous system during division of the gastrocolic ligament, and postoperative dehydration. liver retraction is paramount during laparoscopic bariatric surgery to provide adequate visualization of the upper stomach and diaphragmatic hiatus. most methods of liver retraction produce significant pressure on the liver parenchyma by compressing it against the diaphragm. three types of liver injury have been documented in literature: minor congestion, traumatic parenchymal rupture, and delayed liver necrosis. uniquely, we propose an additional type of injury-left portal vein thrombosis due to compression of left liver lobe with the nathanson retractor. conclusion: the case described herein represents the first documented report of isolated left portal vein thrombosis after lsg. this is a unique presentation of retraction-related liver injury causing pmvt by mechanical compression of liver parenchyma. as surgical procedures increase in duration, intermittent release of liver retraction should be performed at regular intervals. introduction: up to % of patients experience internal hernia (ih) after laparoscopic roux-en-y gastric bypass (rygb). studies have shown that antecolic roux limb orientation, and closure of the mesenteric defect reduce, but do not eliminate, the incidence of ih. we hypothesize that despite operative differences, ih occur more frequently in patients who experience significant weight loss. this study aims to determine whether those patients who present with ih following rygb experience greater than % excess body weight loss (ebwl). methods: a retrospective chart of all patients who underwent ih repair following rygb at our institution between sept and sept was performed. all applicable cpt codes to encompass ih repair were reviewed (n= ). patients with ih repair after rygb were identified. results: of the patients, were female. the mean pre-rygb weight was lbs (sd± . ), bmi . kg/m (sd± . ). all procedures but one were performed in an antecolic configuration; the other retrocolic-antegastric. fifteen cases were laparoscopic and two were open; nine had the jejunal mesenteric defect closed, eight did not. the average weight loss from the time of rygbp to ih presentation was . lbs (sd± . ) and %ebwl from rygb to the nadir weight was % (sd± ). when evaluated by t-test, there was no statistical difference in bmi at the time of program initiation, rygb, or ih presentation, as well as number of pounds lost, %ebwl, or time to ih presentation, when comparing patients for whom the mesenteric defect was closed or not. average time from rygb to ih presentation was . years (range - days) . conclusion: in our limited cohort of patients who have presented with internal hernia after rygb, there was an average of % ebwl. this is greater than the average expected %ebwl at our institution and others, suggesting that ih may occur in patients with greater weight loss at a higher frequency. mesenteric defect closure did not appear to have any influence in this limited cohort, suggesting that weight loss is a stronger factor in ih development. we plan a more extensive evaluation in a larger cohort of patients to determine if greater %ebwl is a predictor of ih formation in patients undergoing rygb. introduction: introduction of enhanced recovery after surgery (eras) pathways has led to early recovery and shorter hospital stay after laparoscopic roux-en-y gastric bypass (lrygb) and laparoscopic sleeve gastrectomy (lsg). this study aims to assess feasibility and outcomes of postoperative day (pod) discharge after lrygb and lsg from a national database. methods: patients who underwent elective primary lrygb and lsg and were discharged on pod and were extracted from metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) dataset. a : propensity score matching was performed between cases with pod vs pod discharge, and the -day outcomes of the propensity-matched cohorts were compared. high risk patients were excluded from the analysis. purpose: the aim of this study was to evaluate a large volume, multi surgeon bariatric surgery center producing the largest sample size to date proving efficacy (% weight loss) and safety of sleeve gastrectomy following band removal in one or two step procedures. methods: all patients undergoing conversion of lagb to lrygb ( ) and lsg ( ) regardless of one step vs two step conversion from january to january were included. a retrospective analysis of our prospectively maintained database was performed to compare outcomes in patients undergoing conversion to lrybg vs lsg after lagb to identify the outcomes. introduction: the purpose of the study was to describe the use of intraoperative indocyanine green (icg) fluorescence angiography to identify the blood supply patterns of the stomach and gastroesophageal junction (gej). we hypothesized that identifying these vascular patterns may help modifying the surgical technique to prevent ischemia-related postoperative leaks. methods: patients underwent laparoscopic sg and were examined intraoperatively with icg fluorescence angiography at an academic center from january to september . prior to the construction of the sg, ml of icg was injected intravenously and pinpoint® technology was used to identify the blood supply of the stomach. afterwards, the sg was created with attention to preserving the identified blood supply to the gej and gastric tube. finally, ml of icg were injected and pinpoint® technology was used again to ensure that all the pertinent blood vessels were preserved. results: patients successfully underwent the procedure with no complications. the following blood supply patterns to the gej were found: the incidence of overall accessory blood supply to the right-side dominant pattern was more common than expected. in about half of the cases where an accessory vessel was found in the gastrohepatic ligament, the blood flow was toward the stomach (and not the liver). furthermore, the incidence of accessory blood supply from the left side was found in % of the cases. % of patients had both the left side accessory and accessory gastric artery pattern. in these particular patients, if a concurrent hiatal hernia repair is performed, these accessory blood supplies are at risk of being injured if care is not taken to preserve them, rendering the gej relatively ischemic. conclusion: icg fluorescence angiography allows determining the major blood supply to the proximal stomach prior to any dissection during sleeve gastrectomy so that an effort can be made to avoid unnecessary injury to these vessels. background: morbid obesity, a common medical concern with significant health risks, has a prevalence of . % among u.s. adults. bariatric surgery provides effective weight loss for morbidly obese patients with improvement in their comorbid conditions. traditionally, routine intraoperative drain placement (idp) and postoperative esophagram (ugis) were thought to identify early postoperative complications. recently, these interventions have been scrutinized for their effectiveness. we hypothesized that idp and postoperative ugis do not alter outcomes in bariatric surgery and only increase hospital length of stay (los). methods: two cohorts, each consisting of patients from either or were analyzed from our institution. in the cohort, all patients had idp and an ugis on postoperative day , prior to starting a clear liquid diet. in the cohort, no patients had idp or ugis, but instead were started on a clear liquid diet on postoperative day , in the absence of vomiting. all patients in each cohort underwent either a laparoscopic sleeve gastrectomy or a roux-en-y gastric bypass. a retrospective study was performed to analyze whether there was a significant difference in postoperative complications, length of stay, and operating room time between these two cohorts. those who underwent t dm remission were less likely to be vdd at all time points. the rates of vdd appear to be slightly higher in rygb at each time points. the rates of macrocytic anemia, microcytic anemia and hypoalbuminemia were low and varied depending on surgical procedure, with no relevant increase following surgery (see figure ). conclusions: vitamin d deficiency is prevalent among diabetic patients with obesity presenting for bariatric surgery. the postoperative management was successful in addressing vdd following surgery; those who experienced t dm remission after surgery were less likely to be vdd. further prospective studies are needed to explore this relationship. surg endosc ( ) :s -s introduction: it is well known that morbid obesity is strongly associated with high blood pressure. cardiovascular risk reduction is a well studied and described result of bariatric surgery. the objective of this study is to quantify hypertension resolution in patients who underwent bariatric surgery at our institution. methods: we retrospectively reviewed all the patients who underwent either laparoscopic sleeve gastrectomy (lsg) or laparoscopic roux en y gastric bypass (lrygb) at our institution between and . we selected those patients who were on antihypertensive medical treatment and had a -month follow-up. hypertension resolution was defined as the interruption of any blood pressure medications within the follow-up period. we compared the patients who had resolution of hypertension (group ) with patients who did not (group ), based on demographics, comorbidities, and outcomes. chi-square and student t-test were used for categorical and continuous variables respectively. results: out of patients, ( . %) patients met the inclusion criteria, out of which, ( . %) had a complete resolution of hypertension within months. the patient population included in group was predominantly female n= patients ( . %), diabetic (n= , %), with a mean bmi of . ± . kg/m , a mean age of . ± . years, and a preoperative systolic blood pressure mean of ± . mmhg. the most common procedure performed was lsg with n= ( %). comparison between group and group based on age, gender, bmi, and diabetes showed no statistically significant difference. estimated bmi loss % at months, type of procedure and % ebmil showed no statistically significant difference between the groups. conclusions: rapid weight loss is associated with a drastic reduction of blood pressure. besides weight loss, we did not identify a clear correlation between risk factors when we compared patients who had resolution of hypertension with patients without resolution. further prospective studies should be done for better understand these findings. the mount sinai hospital, university of chicago introduction: for many patients, hiv has transformed from a life-threatening illness into a manageable chronic disease. reflecting trends in the general population, obesity is increasingly prevalent among hiv-positive patients. surgical intervention has shown the greatest effectiveness in treating obesity. it is unknown, however, whether physician attitudes reflect the changing trends in obesity care for hiv-positive patients. methods and procedures: medical students from the first, second, and fourth years of training were invited to participate in an irb-approved survey, handed out during didactic sessions, which was designed to assess their knowledge and attitudes regarding bariatric surgery in hiv-positive patients. self-reported demographic information of respondents was also collected. the outcome of interest was the proportion of correct responses. univariate and multivariate regression analyses were performed. results: surveys were completed by medical students. demographic covariates included the following: age, sex, race, bmi, and year of training. age, sex, race, and bmi were not statistically significant in the multivariate model. however, in both univariate and multivariate models, each additional year of training was associated with a significant increase in the proportion of correct responses (multivariate model beta coefficient= . , p. ). conclusions: obese and hiv-positive patients suffer from well-documented stigma in health care. these findings suggest that medical training corrects common misperceptions of obese and hivpositive patients, and may lead to a better understanding of the appropriateness of bariatric surgery for hiv patients. whether these attitudes are predictive of referral practices remains to be seen. introduction: obesity is a common problem worldwide with numerous associated comorbidities and is associated with an increased risk of developing some cancers. despite bariatric surgery being associated with a risk reduction for cancer development, some will develop cancer after surgery and little is known about complications which might arise during multimodality cancer treatment. here we report the case of a year-old female who developed an unusual giant marginal ulcer (mu) post laparoscopic roux-en-y-gastric bypass (lrygb) while receiving systemic chemotherapy for an early stage breast cancer. case report: in summary, a year-old female with a preoperative bmi of kg/m had an uncomplicated lrygb one year prior to her presentation. she was a non-smoker, was abstinent of alcohol and did not use nsaids, steroids or other ulcerogenic medications. eight months post procedure with a bmi of . kg/m she was diagnosed and treated with bcs plus slnb for a pt n m er/pr +ve her −ve breast cancer. one week following her third cycle of docetaxel and cyclophosphamide, she presented with two days of melena, small volume hematemesis and abdominal discomfort. the patient was resuscitated with prbc, started on a ppi infusion and had free air ruled out on a cxr. upper endoscopy was complete showing a giant mu at the gastrojejunal anastomosis, biopsies ruled out malignancy and h. pylori. subsequent ct abdomen/pelvis identified contrast extravasation from the anastomosis confirming a free perforation. broad spectrum antibiotics were started and a diagnostic laparoscopy complete. a graham patch repair utilizing omentum and abdominal washout were complete with placement of surgical drains. the patient was supported with parenteral nutrition while npo. diet was advanced after an upper gi series on post operative day showed no ongoing leak. the patient was discharged on post operative day , recovered and although further chemotherapy was discontinued she completed whole breast radiotherapy. conclusion: leaks and hemorrhage are early postoperative complications that are not seen intraoperatively in our experience. furthermore, endoscopy significantly increases mean operative time. routine use should be left to the discretion of the surgeon but should not be considered an essential step of the sleeve gastrectomy. the objective of the study: surgical site infection (ssi) following bariatric surgery contributes to patient morbidity and additional use of health care resources. we investigated whether a ssi quality control initiative in the form of a refined preoperativeantimicrobial protocol affected the rate of ssi following laparoscopic roux-en-y gastric bypass (lrygb). we reviewed all lrygb procedures performed between june and december at a single bariatric surgery centre of excellence. two preoperative antimicrobial protocols were compared. patients undergoing surgery prior to february received g of cefazolin whereas patients undergoing surgery after february , received a new antimicrobial protocol consisting of g cefazolin, mg metronidazole and ml oralchlorhexidine rinse. the primary outcome was day ssi including superficial ssi, deep incisional ssi and organ/space infection as defined by the centre for disease control. clinic charts and provincial electronic medical records were reviewed for emergency department visits, microbiology investigations and physician dictations diagnosing ssi. outcomes were assessed using a students t-test. results: two hundred seventy six patients underwent lrygb of which received the refined antimicrobial protocol and received cefazolin. the refined antimicrobial protocol significantly decreased the rate of deep incisional ssi compared to cefazolin (n= , . % vs n= , . %; p\ . ). the refined antimicrobial protocol resulted in an insignificant overall reduction in the rate of superficial ssi (n= , . % vs n= , . %; p[ . ) and organ/space infection (n= , . % vs n= , . %; p[ . ) respectively. conclusions: a preoperative antimicrobial protocol using cefazolin, metronidazole and chlorhexidine oral rinse appears to reduce the rate of ssi following lrygb. this protocol may be most effective to prevent deep incisional ssi. additional patient cases or alternative study design including a randomized control trial is required to better understand the efficacy of this protocol. background: for many years, the roux-en-y gastric bypass (rygb) was considered a good balance of complications and weight loss. according to a several short-term studies single anastomosis duodenal switch or stomach intestinal pylorus sparing surgery (sips) offers similar to weight loss to rygb with fewer complications and better diabetes resolution. however, no one has substantiated complication and nutritional differences between these two procedures over the midterm. this paper seeks to substantiate previous studies and compare complication and nutritional outcomes between rygb and sips. methods: a retrospective analysis of patients who either had sips or rygb from to . complications were gathered for each patient. nutritional outcomes were measured for each group at , , and years. regression analysis was applied to interpolate each patient's weight at , , , , , , and months. these were then compared with t tests, fisher exact tests, and chi squared tests. results: rygb and sips have statistically similar weight loss at , , , , and months. they statistically differ at and months. at months, there is a trend for weight loss difference. there were only statistical differences in nutritional outcomes between the two procedures with calcium at and years and vitamin d at year. there were statistically significantly more long term major complications, minor complications, reoperations, ulcers, small bowel obstructions, nausea, and vomiting with the rygb than sips. conclusion: with comparable weight loss and nutritional outcomes, sips has fewer short and long-term complications than rygb and better type diabetes resolution rates. introduction: the purpose of this study is to determine the risk factors that contributed to increased postoperative complications, as noted in prior studies within the publicly funded insurance population undergoing bariatric surgery. methods and procedures: data was collected via a retrospective review of the medical records of patients who underwent laparoscopic roux en y gastric bypass or laparoscopic sleeve gastrectomy from to at a single institution. for each patient, data was collected in the following categories: baseline demographics, insurance status, medical comorbidities, immediate complications, re-admissions and associated complications, and follow up out to years. results: a total of patient charts were reviewed, patients were categorized as private insurance and patients were categorized as public insurance. there was no statistically significant difference in mean patient age (private . years vs public years), sex (male:female %: % for both groups), or bmi ( vs ). there was a statistical significance in relationship status in the categories of single ( % vs %), married ( % vs %) or living with a partner ( % vs %), as well as employment status ( % vs %). when comparing comorbid conditions preoperatively there was no difference except for diabetes which was less common in the private insurance group % vs %. readmission rates for complications were significantly different as well at % vs % with public insurance patients having increased complication rates and readmissions. there was no difference in follow up percentages at each time point for the two groups. interestingly postoperative bmi was significantly different in the two groups until year out ( vs ) when the difference disappears. conclusions: our current data set confirms prior research that documented higher complication rates in public insurance patient populations without differences in long term results in regards to weight loss. it also shows that the public insurance group is possibly at higher risk for complications and readmissions postoperatively due to the lack of social support at home given that a much higher percentage of them are single or divorced, and lack employment. it is likely that this lack of support at home prompts more frequent readmissions and associated complications. introduction: gastric bypass has been an acceptable treatment for the morbidly obese patient, with proven efficacy on weight loss and remission of co morbidities, especially diabetes (t dm). laparoscopic sleeve gastrectomy (lsg) is gaining momentum as an alternative procedure for the morbidly obese patient. the aim of this study is to assess the resolution of t dm by examining hba c, bmi, fat %, and % excess weight loss in t dm patients in our lsg patients. methods: we performed a retrospective chart review of t dm patients before and after lsg, analyzing hga c, bmi, % weight loss, fat %, and diabetic medications. data was analyzed by using spss version . paired t-test was applied to see the significance of bmi, weight, fat % and hba c before and after the procedure. introduction: gastroesophageal reflux disease (gerd) is a known risk following laparoscopic sleeve gastrectomy (lsg), with up to % of patients affected by the disease postoperatively. of these patients, an unknown number progress to medically refractory gerd. due to their postsurgical anatomy, these patients have limited options for intervention. while endoluminal therapies are available, surgical revision to roux-en-y gastric bypass (lrygb) has become an accepted revisional treatment. despite this therapeutic option, many payors deny coverage for this treatment. in this study, we report outcomes of revision of lsg to lrygb and difficulties in obtaining insurance approval for the operation. methods: we conducted a retrospective review of all patients who underwent a revisional bariatric operation at a single institution between january and august . we analyzed all patients who underwent conversion of lsg to lrygb. we collected data on -day mortality and morbidities, pre-and postoperative antacid use, and the insurance approval process. results: within the study period, we identified patients undergoing revisional bariatric surgery. seventeen patients had undergone conversion of lsg to lrygb. all of these patients underwent revision due gerd refractory to maximal medical therapy. the average body mass index was kg/m , and our average operative time was minutes. one patient required laparoscopic cholecystectomy within days due to acute cholecystitis, and another patient required reoperation for control of staple line bleeding. there were otherwise no -day morbidities or readmissions. fifty nine percent stopped all antacid medication by six months, and % stopped by months. of the % percent of patient still on proton pump inhibitor therapy, none of those patients complained of reflux symptoms. of non-medicare patients, % were initially denied insurance coverage for revision. only one plan accounted for all initial approvals. twenty five percent of denied patients eventually paid out of pocket, and the remaining % ultimately secured coverage after an appeal process. with no significant differences in mortality or hospital stay. significantly shorter operative times were observed in the adolescent group ( . ± vs . ± , p. ). in univariate analysis blood transfusions and vte rates were significantly lower in the adolescent group but there was no difference after risk-adjusted logistic regression analysis. analysis of readmission data showed lower rates in adolescents compared to young adults ( . % vs . % p= . ). however, adolescents are more frequently readmitted secondary to gallstone disease ( . % vs . %, p. ). the most common reason for readmissions in both groups was nausea and vomiting with fluid/electrolyte depletion, followed by abdominal pain. conclusion: adolescent bariatric surgery is feasible and safe, with outcomes similar to that of young adults. lsg is currently the most common bariatric procedure performed in adolescents which is reasonable given the relative lack of co-morbid conditions within this group. nausea and vomiting are the most common reason of readmission in both groups, but gallstone disease is significantly higher in adolescents, suggesting that this population should be carefully screened for gallbladder disease preoperatively. further studies regarding long-term results are needed to elucidate long-term outcomes, such as the durability of comorbidity resolutions in adolescent patients. introduction: revision bariatric surgery is always considered to be associated with higher complication rates. there is currently controversy in the literature regarding one stage and two stage revisions. methods: the present study is ongoing longitudinal prospective analysis of data of revision surgery in a single unit. the revision surgery was offered after initial failed or complicated gastric band, sleeve gastrectomy and roux-en-y gastric bypass (rygb). results: there were forty-two individuals who had revision bariatric surgery. the age of the cohort of patients ranged from twenty-six to seventy-five years. thirty-three were females and nine males. all patients who were hypertensive or diabetic at the time of their initial bariatric operation had a relapse of their co-morbidity prior to their revision surgery. the two stage revisions patients had their band removed at another facility, had a compilation from the band itself or did not wish for revision surgery initially. of the two failed bypasses one had a large pouch and very short limbs. the other had a gastro-gastric fistula and ultra short limbs. there were no deaths in this study. one patient who underwent one stage revision of a gastric band to bypass had an iatrogenic small bowel injury that required a second operation. amelioration of diabetes and hypertension was seen in all who had relapsed. weight loss was good in all patients except for the those undergoing revision from short limbed to long limbed bypass. conclusion: there is enough evidence that revision surgery is feasible, and can ameliorate metabolic co-morbidities after failed band and sleeve. two staged surgery is not necessarily safer compared to one stage revision. in the present study an inadvertent iatrogenic injury occurred in one stage revision group but is not true reflection of increased complications. the association between preoperative endoscopic esophagitis and post operative gerd in sleeve gastrectomy patients samer elkassem, md; medicine hat regional hospital introduction: gerd is a common complication after sleeve gastrectomy (sg). the purpose of this study is assess the relationship between pre-operative findings of endoscopic esophagitis and postoperative gerd in sg patients. the hypothesis of this study is that patients with pre-op esophagitis are more likely to have gerd post-op than patients with no esophagitis pre-op. methods: a retrospective review of sg patients who had pre-operative endoscopy and followed prospectively for at least one year was preformed. patients were divided into two groups based on pre-op endoscopic findings: those with no findings of esophagitis (ne), and those with endoscopic esophagitis, including barretts (ee). patients were followed for at least one year, and assessed for usage of a proton pump inhibitor (ppi) usage. the two groups were compared using both student t-test and chi square test. results: a total of patients did not have any findings of esophagitis on pre-op endoscopy (ne group), and patients had findings of endoscopic esophigitis (ee). there was no difference in preoperative demographics and post-op weight loss at one year (table i) . follow-up ranged from one to years post-op. the dependency on ppi usage and de novo reflux are shown in table ii . introduction: patients with "super-super obesity", defined as a bmi≥ , are at higher risk of weight-related health problems and might benefit more than others from metabolic and bariatric surgery. however, these benefits need to be weighed against the potential for increased operative and perioperative risks. accurate data regarding these patients is critical to guide procedure choice and informed, shared decision-making. the metabolic and bariatric surgery accreditation and quality improvement program (mbsa-qip) is a national accreditation and quality improvement program, which captures clinically-rich specialty-specific data for the majority of all bariatric operations in the united states. this is the first analysis of the mbsaqip participant use file (puf) focusing on this at-risk subpopulation. introduction: sleeve gastrectomy represents one of the most common surgical procedure used in bariatric surgery. the most feared complication following laparoscopic sleeve gastrectomy is the leak that occurs at the staple line. one method to reduce the risk of leak is the use of reinforcement material at the suture line. in this study, the efficacy of sutures and fibrin glue in the prevention of staple leak has been compared retrospectively. materials and methods: a total of patients undergoing lsg between october and august at the medical faculty of firat university were retrospectively assessed using the hospital database system records. results: there were males ( %) and ( %) females, with a mean age of years (range: - y), and body mass index of kg/m . while no reinforcement material was used in patients ( %) at the suture line, reinforcement sutures or fibrin glue were used in ( %) and ( %) patients, respectively. postoperative leak occurred in patients ( . %), and ( . %) of these had no use of reinforcment material for leak prevention, while additional sutures or fibrin glue had been used in patients, one in each group ( . %). one patient died due to leak and the consequent development of sepsis ( . %). discussion: lsg is increasingly more frequently used in bariatric surgery practice. however, an increase also occurs in the rate of complications. a discrepancy exists in the published literature regarding the benefit of reinforcment the suture line on the risk of leak risk. in our patient series, patients without the use of additional material in the staple line had a significantly increased risk of leak. conclusion: despite some controversy, strong evidence exists on the effectiveness of fibrin glue in the prevention of leaks in patients undergoing laparoscopic sleeve gastrectomy. background: laparoscopic bariatric surgery has been performed safely since . in a persistent search for fewer and smaller scars, single port and acuscopic surgery or even notes have been implemented. the goal of this study is to analyze the safety and feasibility of using a low cost incisionless liver retraction compared to a standard laparoscopic retractor for sleeve gastrectomy. methods and procedures: candidates for sleeve gastrectomy that fulfilled nih criteria for bariatric surgery were selected. those younger than and/or with prior upper-left quadrant surgery were excluded. all patients signed written consent. patients were randomized : to either a standard port technique with a fan-type liver retractor through a mm port (group a); or a port technique with the liver retracted by a polypropylene suture passed through the right crura and retrieved at the epigastrium with the use of a fascia closure needle (group b). all surgeries were performed by the same surgeon. surgery length from insertion of first port to withdrawal of the last was the primary endpoint. anthropometric data, % of pre-surgical total weight loss (%ptwl), visualization of the surgical field, complications inherent to liver retraction and postoperative morbidity were recorded. background: comprehensive web and hospital based preparative patient education allow the morbidly obese patients to understand weight loss surgery, its benefits, the necessity of follow up and the risk of weight regain. while the inhouse seminars provide a face-to-face interaction with the bariatric program staff, the online seminars are easily accessible and more cost effective. the primary objective of this study is to compare demographics and weight loss surgery outcomes between patients who participated in the online vs in-house preparative seminars. methods: after obtaining institutional review board approval, a retrospective chart review was performed involving patients who underwent bariatric surgery between january and december at a tertiary care center. the patients were divided into two groups based on their choice of educational seminar, online or in-house, prior to their initial consult with a surgeon. data was collected on age, type of insurance, length of stay (los), longest follow up and change in bmi to assess weight loss. results: one hundred and eighteen patients were included in this study. eighty patients attended in-house seminar while completed online seminar. the various types of surgery (laparoscopic gastric bypass, sleeve gastrectomy, and band) were similarly represented between the two groups. there was no difference in the type of insurance policy between the groups. patients who elected to take the in-house seminar were on average years older than those who chose the online course, which was statistically significant (p. ). there were no differences in los, longest follow up after surgery, and weight loss at months between the groups. conclusions: based on mbsaqip registry data, patients age or over did not have higher odds of a -day readmission compared to younger patients after lsg or lrygb. rates of -day readmission, reoperation, and death were similar, but rates of complications (e.g. pneumonias, unplanned intubations) were higher in the older group. bariatric surgery in the elderly should therefore be performed only after careful and patient-centered selection processes. introduction: revisional bariatric surgery has become more common in recent years. it is to address short and long-term complications of primary bariatric surgery as well as the issue of weight regain. the aim of this study was to retrospectively analyze the indications for reoperation and short-term outcomes in our institution. methods and procedures: between and , patients who underwent bariatric surgery in our center were included in a prospectively collected database. demographic data, primary and revisional bariatric procedures, reasons for revisions and outcomes were recorded and reviewed retrospectively. results: a total of patients underwent bariatric surgery at our institution and % of these (n= ) were revisional bariatric surgery. we identified groups of patients according to their primary procedures: adjustable gastric band (agb), roux-en-y gastric bypass (rygbp), vertical band gastroplasty (vbg), and sleeve gastrectomy (sg). of the patients, ( %) had abg as primary procedure. of those, % had their band removed due to food intolerance and severe dysphagia and % had a conversion to either rygbp or sleeve gastrectomy (sg) due to weight recidivism. in the rygpbp group (n= ), % of the patients presented with late complications. of these, % had an acute presentation (small bowel obstruction, internal hernia, or perforated marginal ulcer) requiring emergency surgery. only % patients needed gastric bypass takedown due to severe hypoglycemia. weight recidivism was noted in % of the patients that necessitated either revising the anastomosis, trimming of the gastric pouch or gastrogastric fistula takedown. in the vbg group (n= ), % of the patients experienced weight recidivism that required conversion to rygb and % of the patients required the vbg to be taken down due to obstructive symptoms. in the sg group (n= ), % of the patients experienced early complications needing a second procedure. weight recidivism was found as the most common reason for conversion ( %) to rygbp. twenty nine percent of the patients in this group underwent conversion to a rygbp due to severe de novo gerd. introduction: our aim was to systematically review the literature to compare weight loss outcomes and safety of secondary surgery after sleeve gastrectomy (sg), particularly between roux-en-y gastric bypass (rygb) and biliopancreatic diversion with duodenal switch (bpd-ds). sg was originally developed as the first part of a two-stage procedure for bpd-ds. however, it is now the most common standalone bariatric surgery performed in the united states. the majority of sg are done as the sole bariatric operation but in %, a second operation is necessary, due to insufficient weight loss, weight regain or reflux. the most common second-stage operations are rygb at % and bpd-ds at %. there are a few small case series comparing rygb to bpd-ds as a secondary surgery after sg. these studies suggest that after failed sg, bpd-ds results in greater weight loss but higher early complication rates than rygb. we had one mortality, related in part to supra-therapeutic anticoagulation perioperatively. one patient underwent successful heart transplantation and additional patients were reactivated on the transplant list. conclusion: laparoscopic sleeve gastrectomy is effective in advanced heart failure patients for meaningful weight loss, reactivation to the transplant wait list, and ultimately cardiac transplantation. however, this complex population carries a high perioperative risk and close multidisciplinary collaboration is required. more data is needed to best optimize perioperative management of these patients. the introduction: bariatric surgery is a highly effective treatment for severe obesity. while its effect on improvement of the metabolic syndrome is well described, its effect on intrinsic bone fragility and fracture propagation is unclear. therefore, the aims of this systematic review of the literature were to examine ( ) the incidence of fracture following bariatric surgery, ( ) the association of fracture with the specific bariatric surgical procedure ( ) conclusion: it appears that the overall risk of sustaining a fracture of any type after undergoing bariatric surgery is approximately percent after an average follow up of . years. the greatest risk of fractures is associated with the bpd, with the rygb being the most favorable. fractures following bariatric surgeries tend to follow osteoporotic and fragility patterns. post-operative supplementation of vitamin d, calcium and weight bearing exercises need to be optimized, and long term follow-up studies will be needed to confirm that these interventions will indeed reduce fracture risk following bariatric surgery. background: the effect of sleeve gastrectomy on gastroesophageal reflux (gerd) remains controversial. it is currently common practice to perform a hiatal hernia repair (hhr) at the time of the sleeve gastrectomy, however, there are few data on the outcomes of gerd symptoms in these patients. the aim of this study was to evaluate the effect of performing an esophagopexy hiatal hernia repair on gerd symptoms in morbidly obese patients undergoing robotic sleeve gastrectomy (rsg). methods: a single institution, single surgeon, prospectively maintained database was used to identify patients who underwent rsg and concomitant esophagopexy for hiatal hernia repair from november to july . patient characteristics, operative details and postoperative outcomes were analyzed. primary endpoint was subjective gerd symptoms and recurrence of hiatal hernia. results: thirty-seven patients were identified meeting the inclusion criteria (rsg+hhr+esophagopexy) with a mean follow-up of . over the past years there have been several bariatric surgeries cancelled secondarily to abnormal pre-operative test results within eastern health. these surgeries are often cancelled the day before their scheduled surgery, which does not provide sufficient time to book other patients. the end result is that the or gets underutilized and the bariatric surgery waitlist grows. prior to any major surgery patients are often subjected to a routine screening process, which includes a history and physical along with diagnostic screening tests and screening blood work. a preliminary analysis was done of the first patients through the bariatric surgery program at eastern health assessing the coagulation study results and outcomes. analysis showed that out of the first patients % were found to have a history of bleeding, % were using anticoagulants preoperatively, another % were noted to have a family history of bleeding. in the preoperative blood work that was done, % were found to have an elevated ptt/ inr for which hematology ended up being consulted in % of the patients. overall this did not change the preoperative management of these patients and they went on to have their surgery. intraoperatively patient was noted to have excessive bleeding and this was found not be associated with any preoperative elevation in their coagulation studies or family history of bleeding disorders. post operatively there was bleeding in patient which required transfusion, however this too was found not to be associated with any preoperative elevation in their coagulation studies or family history of bleeding disorders. overall this initial analysis showed no difference in operative management or delay in surgery secondarily to abnormal preoperative assessment findings. further analysis of a larger population of the bariatric surgery program patients is needed in order to determine whether any changes should be made to the preoperative assessment protocol. introduction: patients undergoing bariatric surgery frequently present with various obesity-related psychiatric comorbidities, including depression. furthermore, previous literature has demonstrated a positive association between depression and cardiovascular disease, and obesity serves as an independent risk factor for cardiovascular disease. however, the relationship between preoperative depression and cardio-metabolic risk factors following bariatric surgery remains unknown. methods and procedures: this retrospective analysis utilized data obtained from patients (n= , ) who underwent bariatric surgery at a single academic medical center in california. patients underwent either laparoscopic roux-en-y gastric bypass or sleeve gastrectomy. using medical record data, patients were preoperatively categorized as follows: not depressed, history of depression but not currently on anti-depressive medication, and history of depression and presently taking anti-depressive medication. patient demographic characteristics were obtained preoperatively. clinical and biochemical risk factors for cardiovascular disease were evaluated preoperatively and and months following bariatric surgery. anova, kruskal-wallis, and chisquare tests were applied where appropriate. results: in this sample, % of patients were not depressed, % had a history of depression but were not taking anti-depressive medication preoperatively, and % had a history of depression and were taking anti-depressive medication preoperatively. at baseline, depressive history was positively associated with female sex (p\. ), older age (p\. ), white race (p\. ), medicare insurance (p\. ), previous abdominal surgery (p\. ), length of stay (p\. ), requiring an inferior vena cava filter (p=. ), total cholesterol (p\. ), and triglycerides (p =. ). on average, patients with a history of depression taking anti-depressive medication weighed less than patients with a history of depression not on medication and patients without depression preoperatively (p=. ) and (p=. ) and (p=. ) months after surgery. after six months of follow-up, preoperative depressive history was positively associated with total cholesterol (p=. ), triglycerides (p\. ), hba c (p=. ), and fasting serum concentrations of insulin (p=. ). after months of follow-up, preoperative depressive history was positively associated with higher levels of total cholesterol (p=. ), ldl cholesterol (p=. ), and triglycerides (p= . ). conclusion: a history of depression prior to surgery was associated with higher levels of total cholesterol and triglycerides at baseline and and months postoperatively. after months, preoperative depressive history was also associated with higher levels of ldl cholesterol. this study suggests that, on average, bariatric patients with comorbid depression have worse lipid profiles prior to-and up to one year after-bariatric surgery relative to counterparts without depression. yen-yi juo, md, mph, yas sanaiha, md, erik dutson, md, yijun chen, md; ucla introduction: anastomotic leak is one of the most morbid complications of roux-en-y gastric bypass (rygb), yet its risk factors are ill-defined due to the rarity of the complication. we aim to identify both patient-and operative-level risk factors for anastomotic leak after rygb using a national clinical database. methods: a retrospective cohort study was performed using the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) database. all adult patients who underwent laparoscopic or open rygb were included. multivariate logistic regression models were used to identify patient-and operative-level variables associated with development of anastomotic leakage. clinically relevant anastomotic leakage is defined as those that required readmission, intervention, or reoperation. introduction: hyperammonemia secondary to ornithine transcarbamylase (otc) deficiency is a rare and potentially lethal disorder. the prevalence of otc deficiency is reported to be : , to : , in the general population. otc deficiency has been reported in patients presenting with neurological symptoms after roux-en-y gastric bypass (rygb), and less than cases have been reported in the literature. the aims of this study are to examine the apparent incidence of this uncommon disorder in patients after bariatric surgery and to examine potential predictors of mortality. methods and procedures: this is a single center, retrospective study in a large, urban teaching hospital of postbariatric surgery patients who developed hyperammonemia from january to august . elevated plasma ammonia with an elevated urinary orotic acid level is accepted as consistent with a diagnosis of otc deficiency. all patients in our program are instructed on a post-operative diet containing grams/day of protein. descriptive and correlative statistics are calculated for all variables. results: between january and august , bariatric surgical procedures were performed at this single medical center. seven women with neurological symptoms had plasma ammonia levels above the upper limit of normal range. their average bmi is kg/m . two patients underwent vertical sleeve gastrectomy (vsg), underwent vsg with duodenal switch, and underwent rygb. all patients were hospitalized. the mean peak plasma ammonia level is umol/l (range: - ). the mean urinary orotic acid level is . mmol/mol creatinine (range: . - . ). there were patients with no orotic acid level checked, secondary to demise. no patient had clinical features or findings of progressive hepatic failure. there are four mortalities ( . %). serum folate and peak lactic acid levels are predictors of mortality with p-values of . and . respectively. the apparent incidence of otc deficiency is : in post-operative patients. conclusions: in our post-operative population, hyperammonemia results in a high mortality. its apparent incidence, secondary to otc deficiency, amongst bariatric surgery patients is higher than that reported in the general population. since otc deficiency is identified after multiple bariatric surgical procedures, further investigation will be important to examine potential mechanisms for its development which may include a genetic predisposition (possibly triggered by nutritional deficiencies), upper gut bacterial overgrowth (supported by elevated serum folate levels), or preexisting, subclinical hepatic dysfunction. introduction: the use of closed suction drains is associated with poor outcomes in many anastomotic operations and routine use is not recommended. in this context, intraoperative drain placement for primary bariatric surgery remains controversial. recent studies demonstrate that drains confer no benefit to patients; however, data are limited to descriptive single center experiences with low sample size. in order to characterize this practice gap, and implement evidence based recommendations, we sought to evaluate the use of closed suction drain and outcomes following primary bariatric cases using the mbsaqip registry. methods: we used data from the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) public use file for patients who underwent a non-revisional laparoscopic roux-en-y gastric bypass (rygb), laparoscopic sleeve gastrectomy (lsg), or laparoscopic adjustable gastric banding (lagb). we excluded patients with asa status greater than or conversion to an open procedure. we analyzed demographics, preoperative comorbidities, procedure type for patients who did and did not undergo drain placement. adjusted rates of postoperative complications and mortality were then compared based on receipt of postoperative drain placement. results: of the , included patients who underwent laparoscopic bariatric surgery, , ( . %) underwent intraoperative drain placement. drains were more often placed in patients who underwent lrygb, were older, had higher preoperative bmi, had higher preoperative asa status, and had more comorbid conditions. after patient level risk adjustment, there was no difference in rates of leaks requiring intervention ( . % versus . %, p= . ) or mortality ( . % versus . %, p= . ) for patients with and without drains. in patients who underwent drain placement, there were higher rates of transfusion ( . % versus . %, p. ), reoperations for bleeding ( . % versus . %, p= . ), all reoperations ( . % versus . %, p. ), and surgical site infections (ssi) ( . % versus . %, p. ). conclusion: our analysis demonstrates that nearly one quarter of all laparoscopic bariatric surgery patients undergo drain placement. we found that drain placement is more common in preoperatively higher risk patients and following higher complexity procedures as suggested by associated increased rates of transfusion and reoperations for bleeding. we found no benefit to drain placement in terms of interventions for clinically significant leaks or mortality. finally, patients who underwent drain placement were more likely to develop ssi suggesting routine placement is not without risk. although further prospective studies are warranted, our analysis demonstrates that drains have the potential for harm with minimal protective benefit for patients after primary bariatric surgery. sleeve gastrectomy ( % n= ) and laparoscopic roux-en-y gastric bypass ( % n= ) were the two types of surgeries done in our population. the risk of developing atrial fibrillation was calculated preoperatively and found a -fold higher risk in females and -fold greater risk in males when compared with the ideal risk for each category. at months follow-up the preoperative risk was . ± . % with an absolute risk reduction of . % corresponding to a relative risk reduction of . % with males having a more significant change at months follow-up. these findings and the electrocardiographic changes at months follow-up are better described in background: the sleeve gastrectomy (lsg) is the most popular procedure worldwide to treat obesity. among those that are obese, gerd has a prevalence of . percent. many surgeons do not perform lsg in these patients because only . percent of symptomatic patients showed resolution of gerd-like symptoms after concomitant sleeve gastrectomy with hiatal hernia repair. many surgeons perform the gastric bypass on gerd patients with hiatal hernias because they believe its superior for the resolution of gerd. when they do this they overlook the many long term complication associated with gastric bypass. also, many patients do not want the gastric bypass under any circumstances. surgeons need to be open to finding better way to reduce the high recurrent rates of gerd after lsg. materials and methods: this is a single institution, multi-surgeon, retrospective study involving morbidly obese patients in a prospectively kept data base from january of through july of . these patients all had gerd with preoperatively identified hiatal hernias on egd. all patients were dependent on anti-reflux medications. there were ( . %) males and ( . %) females. bmi ranged from to . hiatal hernias measured from cm to cm. all lsg patients received a primary crural closure, with or without gore bio a mesh placement, at least weeks prior to the sleeve gastrectomy. post-operatively, patients were interviewed for gerd symptomatology and anti-reflux medication dependency. results: of the patients, ( . %) patients had resolution of gerd-like symptoms and off all anti-reflux medications after the staged hiatal hernia repair and sleeve gastrectomy. patients ( . %) had improvement of gerd but still dependent on anti-reflux medication. patients ( . %) had no resolution or improvement of gerd. there was one post-operative complication of laryngospasm with pulmonary edema status post extubation. there were no mortalities in the series. conclusions: in this study, staged hiatal hernia repair, at least weeks prior to sleeve gastrectomy, doubled the published rate of gerd resolution from % to %. % showed improvement in symptoms at one year. this rate is comparable to gerd resolution after gastric bypass. this may be an alternative approach to hiatal hernias in the morbidly obese patient with gastroesophageal reflux disease who do not want a gastric bypass. background: bariatric surgery is a common procedure in general surgery. gastric bypass has been performed laparoscopically for over two decades and multiple techniques are described. the circular stapled anastomosis, one of the earliest methods for gastrojejunostomy, is performed in two ways: a transoral method to introduce the anvil and a transabdominal approach developed later. the former technique requires passing the anvil of the circular stapler through the mouth, down the esophagus, and into the gastric pouch. in the latter method, a gastrotomy is made, the anvil is introduced, and the gastrotomy is stapled off, creating the gastric pouch. this study aims to objectively compare the two methods of circular stapled gastrojejunostomy in terms of surgical site infection (ssi) rate. methods: a retrospective chart review of patients undergoing laparoscopic roux-en-y gastric bypass with one of two surgeons at a bariatric center of excellence in an academic hospital from january introduction: laparoscopic sleeve gastrectomy (lsg) has become the most commonly performed procedure in the treatment of morbid obesity, but there is significant variability in its performance. from national database analysis, more restrictive sleeve construction, based on smaller bougie size, has not correlated with greater weight loss. we hypothesize that bougie size is not reflective of actual restriction, or that sleeve restriction does not correlate with weight loss. we performed qualitative and volumetric analysis of immediate post-sleeve contrast studies to determine the association of sleeve restriction with post-operative weight loss and complications. methods: between and , patients underwent immediate post-sleeve contrast studies. based on standardized vertebral body height assessment by preoperative chest radiograph, sleeve diameter at intervals (including the narrowest point) was measured in mm, and the volume above the narrowest point of the sleeve was calculated. sleeve shape was assumed as dual-tiered or simple truncated cone based on morphology. sleeve restriction, morphology and volumetric analysis were associated with clinical outcomes including complications, post-op symptoms, and weight loss at months. background: variability in surgical technique resulting in narrowing at the incisura angularis, twisting along the staple line, and retention of the gastric fundus has been implicated in increased gastroesophageal reflux disease (gerd) following laparoscopic sleeve gastrectomy (lsg). standardizing creation of the sleeve based on anatomic landmarks may help produce more consistent sleeve anatomy and improve outcomes. methods: a retrospective review of all patients undergoing lsg from january to november at a single institution specializing in bariatric surgery was performed (n= ). patients underwent either traditional lsg with use of a f suction bougie to guide creation of the sleeve (n = ) or anatomy-based sleeve gastrectomy (abs, n= ). abs was performed using a gastric clamp to maintain predetermined distances from key landmarks ( cm from gastroesophageal junction, cm from incisura angularis, cm from pylorus) during stapling. patient demographics, perioperative characteristics, and post-operative outcomes were compared using chi-square and student's t-tests as required. helicobacter pylori (hp) is prevalent in up to % of the population worldwide with increased rates observed in the bariatric population. bariatric surgery has seen a rapid expansion over the last years with the growing rates of severe obesity. higher hp rates are thought to be associated with increased rates of postoperative complications including increased marginal ulceration and leak rates. accordingly, some bariatric centers have adopted routine pre-operative screening and hp eradication programs. yet, while hp correlation with gastritis and malignancy has now been well defined, its impact on patients undergoing bariatric surgery remains unclear. background: the risk of developing a hiatal hernia in the obese population is . fold compared to patients with a bmi \ . most hiatal hernias after bariatric surgery are asymptomatic and when symptoms are present they may be difficult to differentiate from overeating or maladaptive eating habits. the aim of this study was to define the risk and symptoms associated with a hiatal hernia in the post-bariatric surgery cohort. methods: a retrospective review of prospectively collected data for patients who underwent laparoscopic hiatal hernia repair who previously had primary roux-en-y gastric bypass (rygb) or sleeve gastrectomy (sg). data collection spanned a five-year interval ( / - / ). preoperative and follow up data were collected from medical records and questionnaires in the clinic or by telephone. variables obtained include age, gender, psychiatric history, pre-index procedure bmi, pre-hiatal hernia repair bmi, post-hernia repair bmi, pre and post operative symptoms, and associated morbidity. all hiatal hernia repairs were done laparoscopically, with posterior cruroplasty after circumferential hiatal dissection. results: we identified patients with a symptomatic hiatal hernia who had previously (range: - years) underwent bariatric surgery. fourteen rygb patients presented at a mean of . years compared to sg patients who presented at a mean of . years after index procedure. diagnosis was by a combination of ugi ( %), ct scan ( %) and egd ( %). mean follow up was . months (range: - months). laparoscopic hiatal hernia repair was successfully performed in all patients with % mortality. dysphagia and regurgitative symptoms markedly improved in [ % of patients however, nausea, vomiting and abdominal pain were not changed in - % of patients ( figure) . conclusion: hiatal hernia following bariatric surgery is a rare but important cause of bloating manifested as nausea and vomiting, abdominal pain, regurgitation or reflux, and food intolerance or dysphagia (barf)-and should be further evaluated with imaging or endoscopy when present. laparoscopic repair of hiatal hernia is warranted and results in resolution of symptoms in the majority of symptomatic patients. mid-term outcomes of sleeve introduction: obese patients suffer from multiple organ comorbidities which contribute to a shortened lifespan. one of the effects of obesity is thought to be pseudotumor cerebri, which is secondary to increase in intracranial pressure (icp) in the absence of an obstruction. over the past two years, we have measured icp after insufflating with a laparoscopy device. we found that icp increases dramatically and it correlates with the amount of insufflation in the abdomen. over the years, there have been studies in obese patients and intra-abdominal pressure. these studies have shown that some obese patients have an intra-abdominal pressure of - mmhg. increasing intraabdominal pressure is thought to escalate intracranial pressure (icp). the objective of this pilot study was to observed change in icp after the raising intra-abdominal pressure. method: in this retrospective chart review preliminary study, pressure in each of the patients either normal pressure hydrocephalous or high pressure hydrocephalous receiving a ventricle shunt were measured by manometer. once the shunt was placed into the ventricle, we attached a manometer to measure the opening pressure. after we accessed the abdominal cavity using the standardoptiview technique, we created a pneumoperitoneum. after achieving an intraabominal pressure of mmhg, were measured the icp using the manometer. spss software version was used for data analysis. paired t-test was applied on icp before and after the procedure. introduction: postoperative bleeding represents an infrequent, yet serious complication after bariatric surgery. differences in the rate of postoperative bleeding reported for the two most common weight loss procedures-laparoscopic roux-en-y gastric bypass (lrygb) and laparoscopic sleeve gastrectomy (lsg)-are ostensibly confounded by patient and surgeon specific preoperative, intraoperative and postoperative factors, in particular, by the utilization of staple line reinforcement or oversewing. with this understanding, we aim to use a large national database to definitively characterize differences in bleeding rates between lsg and lrygb. conclusions: after appropriate risk-matching, lsg patients have a reduced likelihood of a postoperative bleeding event compared to those undergoing lrygb. this difference is likely more pronounced with intraoperative securing of the staple line via oversew, buttress or an alternative method. these findings from a large national database represent an important consideration for surgeons and patients alike when evaluating the appropriate bariatric operation. background: bariatric surgery has shown to be the most effective treatment, with documented improvement in obesity-related comorbidities. the type of health insurance coverage plays an important role in the access to bariatric surgery, but might also affect postoperative outcomes. the objective of this study is to determine whether there is a difference in outcomes based on the type of insurance months after bariatric surgery. methods: we retrospectively reviewed all the patients that underwent bariatric surgery at our institution from to . we divided the patients into two groups, based on the type of insurance, private (group one), and public (group two). we compared demographics and months outcomes between the groups, using t-test for continuous variables and chi-square for categorical variables. we also compared months estimated bmi loss between different private insurances using anova. introduction: bariatric surgeons are now performing primary and revisional procedures on the extremes of age. there is controversy surrounding the safety and effectiveness of bariatric surgery among older age groups compared to younger age groups. to address this knowledge gap, we designed a study assessing short-term bariatric surgery outcomes among various age groupings across a large national database. methods and procedures: de-identified patient data across from the mbsaqip registry was used. age groupings were organized into young, middle-aged, and older adults (in years) as follows: \ , - , and [ , respectively. the following -day outcomes were evaluated between all possible pairwise age groupings: mortality, surgical site infection (ssi), and readmission; logistic regression was used to compare outcomes between age groupings controlling for primary vs. revisional index operation, patient factors, and procedure factors. a p value of . was deemed statistically significant. results: a total of , patients were identified (age range: to [ ); % (n= , ) underwent primary bariatric operations while % (n= , ) underwent revisional cases. older adults had significantly worse outcomes than middle-aged and younger adults, respectively, for over comparisons across all outcomes; in contrast, younger adults had significantly worse outcomes than middle-aged adults for only comparisons across ssi and readmission. for primary bariatric cases, older adults had significantly higher mortality rates than middle-aged and younger adults, respectively, in the following categories: asa , laparoscopic sleeve gastrectomy (lsg), or laparoscopic roux-en-y gastric bypass (lrygb). for revisional cases, older adults had significantly higher mortality rates than middle-aged and younger adults, respectively, in the setting of female gender, caucasian race, or asa . regarding ssi, older adults undergoing primary lrygb had significantly higher organ space infections compared to younger adults. in addition, older adults who had revisional lrygb had significantly higher deep surgical site infections compared to middle-aged adults. following primary bariatric cases, older adults had significantly higher readmission rates compared to younger adults in the presence of male gender, caucasian race, asa , copd, or after lsg. following revisional cases, older adults had significantly higher readmission rates than middle-aged and younger adults, respectively, in the setting of pre-operative chronic steroid use. conclusions: overall, older adults had worse short-term outcomes compared to their younger counterparts following primary and revisional cases. further research is required to investigate these findings with the goal of targeting interventions to improve outcomes among bariatric surgical patients. background: the obesity epidemic in the united states has been accompanied by surge in bariatric surgery. nearly , bariatric procedures were performed in the us in , % of which involved roux-en-y gastric bypass (rnygb). while rnygb has proven an effective tool in combating obesity, it also alters a patient's anatomy in a way that makes traditional ercp a difficult, if not impossible option for interrogating the common bile duct. one way to approach the post-rnygb patient with obstructive jaundice is to access the peritoneal cavity via a laparoscopic/ robotic approach followed by direct cannulation of the gastric remnant with a laparoscopic port, allowing passage of an endoscope. the aim of this study was to evaluate our single center experience with minimally-invasive transgastric ercp (tg-ercp) from to . methods: we compiled a list of all patients who underwent laparoscopically or robotically assisted tg-ercp at our institution from - . we then examined patient demographics, procedural details, postoperative outcomes, and success rate, with success defined as cannulation of the ampulla, clearance of obstruction if present (stones/sludge/stenotic ampulla), and completion imaging of the biliary and pancreatic ducts. results: patients were included in the study. cases were performed robotically ( %), and laparoscopically ( %). ercp was successful in cases ( %). all unsuccessful attempts were aborted when the endoscopist was unable to pass the scope through a tight pylorus. median time of operation was minutes ( minutes if concomitant cholecystectomy was performed, minutes if not). median length of stay after operation was days (range - days). median estimated blood loss (ebl) was ml. post ercp pancreatitis occurred in patients ( . %), and was mild and self limited in all cases. patients had postoperative bleeding requiring transfusion. both of these had concomitant cholecystectomy. discussion: in patients with biliary obstruction and anatomy not suitable for traditional ercp, tg-ercp is a viable option. it can be performed with in a minimally invasive fashion (either laparoscopically or robotically) with a high success rate and low morbidity. as the population of patients who have undergone rnygb continues to grow, so does the likelihood of encountering one with obstructive jaundice. tg-ercp, therefore, should be thought of as an essential tool in the armamentarium of the general surgeon. introduction: primary palmar hyperhidrosis (ph) is a pathological condition of over perspiration caused by body produces an excessive amount of sweat. this disorder affects to decrease quality of life of patients. thoracoscopic sympathectomy is minimally invasive and an effective procedure to treat hyperhidrosis. different of level of sympathectomy has been debate for the best outcomes. many researchers studied about short term outcomes but no empirical research evidences long term outcomes of thoracoscopic sympathectomy in thailand. this study purposed to evaluate and compare the long term clinical outcomes between patients who underwent t and t thoracoscopic sympathectomy for ph with particular attention to patient satisfaction and quality of life. methods and procedures: sixty patients with ph underwent thoracoscopic sympathectomy. patients were divided into two groups by the level of thoracoscopic sympathectomy as t group and t group. they were investigated the improvement of sweating, compensatory sweating, satisfaction and quality of life. the long-term investigation was designed to examine clinical outcomes at before surgery, six months after surgery, year after surgery, years after surgery, and last follow up days were compared within group and between of t and t group. they were subjected to telephone interview using multiple questionnaires to investigate surgery outcomes, degree of satisfaction, and quality of life improvement. results: sixty patients responded to the telephone interview. patients demographic data and also recurrence rate of ph between t and t group was not significant different (p= . ). both groups improved severity of sweating without any statistical significant. but the t thoracoscopic sympathectomy led to significantly lower incidence of compensatory hyperhidrosis when compared with t group at back and trunk sites. the t group had higher overall satisfaction than t group with was not significantly different. long term result are followed after years. conclusions: there was no difference in decreasing severity of sweating between t and t level of thoracoscopic sympathectomy. both group equally archived patient satisfaction. but the t level of thoracoscopic significantly had lower severity of ch and better quality of life in long term period. introduction: acute pancreatitis due trauma is commonest cause of pseudocyst in pediatric age. due to limited literature available and under diagnosis by pediatricians, the true incidence of pseudocyst in - age group is not known. material and methods: retrospective analysis of pediatric age ( - years) patients who underwent laparoscopic cystogastrostomy at distric teaching hospital was done. patients data, presentation, investigations, opetation done and post operative course was studied. result: total of patients ( males & females) had mean age of . years, mean weight of kg. etiollogies included blunt abdominal trauma ( ), idiopathic ( ), gallstones ( ) . average cyst diameter was . cm. laparoscopic cystogastrostomy by transgastric approach was successfully possible in cases with no conversion. cystogastrostomy was performed using sutures in patients and ultrasonic energy device in patients. gastrotomy was closed with sutures in all cases. mean operative time was minutes. post operative imaging at months revealed no persistence or recurrence of cyst. conclusion: minimally invasive laparoscopic approach for chronic pancreatic pseudocyst in pediatric age group is safe and effective strategy and should be adopted as primary modality of treatment. introduction: videoscopic neck surgery is developing despite the fact that only potential spaces exist in the neck. gagner first described the endoscopic subtotal parathyroidectomy with constant co gas insufflations for hyperparathyroidism in . the cervical approach utilizes small incisions in the neck thus making it cosmetically unacceptable and cannot be used for lesions greater than cm. the axillary approach makes it difficult to visualize the opposite lobe. the anterior chest wall approach utilizes port access at various positions on the anterior chest wall depending on the surgeon. this technique also allows bilateral neck exploration. hence we have been able to perform total thyroidectomies with central compartment clearance for papillary carcinoma and near-total thyroidectomies for large multinodular goiters, materials and methods: three incisions subplatysmal plane pneumoinsufflation with carbon dioxide (co ) ports creating a subplatysmal palne dissection begins at the inferior pole posterior dissection clipping superior thyroid vessels specimen freed up thyroid lobectomy was performed in the twenty cases. the average blood loss was ml mean operative time was min there were no complications and no cases were converted to open. there were no cases of recurrent laryngeal nerve injury or postoperative tetany. no subcutaneous emphysema, ecchymosis or hypercarbia was observed in any patient. all patients were discharged on the second postoperative day except the first on the fifth day. in conclusion this approach seems to be safe in case of unilateral lobectomy but early to say it is superior to conventional thyroidectomy especially in total thyroidectomy. introduction: laparoscopic sleeve gastrectomy (lsg) is one of the most commonly performed weight loss surgeries. prolonged hospital admissions are associated with both increased morbidity and mortality and increased strain on the health care system; studies are now investigating the safety and feasibility of outpatient lsg. this study examined a single surgeon's postoperative admission trends for patients who underwent lsg. the patients were divided into two cohorts based on the date of surgery, and we hypothesize institutional experience has a significant impact on postoperative stay and hospital readmission rate. methods: this is a retrospective study on lsgs performed by a single surgeon in a tertiary center from - . inclusion criteria: patients [ years old, bmi [ with comorbidities or bmi [ , and patient approval by the bariatric surgical program in victoria, british columbia. patients with prior weight-loss surgery were excluded. patients were discharged home on a care plan involving: nurse and surgeon telephone follow-ups within one week post-surgery. patients were divided into two cohorts: cohort a (procedures between - inclusive) and cohort b (procedures between - inclusive). results: patients were included in this study: females ( . %) and males ( . %). the mean preoperative age was . ± . years, and the mean preoperative bmi was . ± . kg/m . the average postoperative discharge day for the population was day . ± . and the average or time was . ± . minutes. one patient in cohort b was re-admitted pod with a diagnosis of postoperative edema managed conservatively and is included in the analysis as pod . a second patient in cohort b returned to hospital (pod ) for abdominal pain and was managed conservatively as outpatient. conclusion: there was a significant difference in the average postoperative discharge day between patients in cohort a and cohort b who underwent lsg with patients in cohort b requiring a shorter average admission time. this study suggests that with increasing institutional experience and a postoperative discharge plan, patients undergoing lsg may be discharged on postoperative day one safely. surg endosc ( ) introduction: minimally invasive techniques have revolutionized the art of the surgical practice. the laparoscopic approach to cholecystectomy has become the gold standard and is the most common laparoscopic general surgery procedure worldwide. in an effort to further enhance the advantages of laparoscopic surgery, even less invasive methods have been attempted, including smaller and fewer incisions. the objective of this study was describing our results of years of needlescopic cholecystectomy. methods: since march all patients that underwent to needlescopic cholecystectomy micro-laparoscopic procedure with instruments of mm were included in this study in a prospective database and the information was analyzed. results: between march and september , needlescopic cholecystectomies have been done at texas endosurgery institute in san antonio, texas by a single surgeon. % of the patients were female. the average age was . (range of - years old). average operating time was . minutes (range of - minutes). the minute operation required laparoscopic cbd exploration, accounting for the extended time. average estimated blood loss (ebl) was cc (range of - cc). % of cases required conversion to standard mm cholecystectomy and was completed without incidents. all patients were followed up at weeks, weeks, and months after the procedure. only patient presented with a hernia at the umbilical site. otherwise no wound, bile duct, bile leak, bleeding or thermal injury complications were identified. conclusions: micro-laparoscopic procedures with mm instruments in this specific procedure of needlescopic cholecystectomy is safe and feasible, and is a cosmetic alternative to the standard laparoscopic cholecystectomy. there's still less report about thyroid cancer cases in toetva. this study reviews all cases of thyroid cancer which surgery were performed. there were cases of toetva in thyroid cancer and cases of opened thyroidectomy. objective: to review and report in terms of surgical outcome, complication, post-surgical treatment and recurrence in all cases of thyroid cancer surgery, especially in toetva technique. material and methods: from march -july in police general hospital, a total of patients underwent toetva with cases of toetva in thyroid cancer and cases of opened thyroid surgery in thyroid cancer. all patients were recorded in multiple parameters. results: this study have total of thyroid cancer cases which cases ( %) were male and cases ( %) were female, with an average age of . most clinical presentation was thyroid mass or nodule which was at cases ( . %), case ( . %) was non-toxic goiter and case ( . %) was grave disease. the clinical presentation mean time was . years ( weeks- years). there were cases ( . %) with a mass at right lobe, cases ( . %) with a mass at left lobe, and cases ( . %) with mass at both lobes. the size of thyroid mass was . ± . centimeters ( - centimeters). there were cases ( . %) had euthyroid, case ( . %) had subclinical hyperthyroid, cases ( . %) had subclinical hypothyroid, and cases ( . %) had hyperthyroid. for type of surgery, there were cases ( . %) of toetva surgery and cases ( . %) of opened total thyroidectomy. most patients at cases ( . %) didn't have any post-operative complication. and there were hypothyroid cases ( . %), transient hypocalcemia with no symptom cases ( . %), and transient hoarseness cases ( . %). after toetva surgery performed, cases ( . %) were redo completion thyroidectomy, cases ( . %) were transaxillary completion thyroidectomy, cases ( . %) were redo toetva, and case ( . %) deny for reoperation. and cases ( %) didn't have any complication after redo surgery, cases ( . %) were hypothyroid, cases ( . %) were hypocalcemia and hypoparathyroid, and case ( . %) was transient hoarseness. after did thyroidectomy, ultrasound neck shown that cases had no residual or recurrence thyroid mass, cases had residual thyroid tissue. all cases received radioactive iodine ablation. radionuclide total body scan showed no evidence of distant functioning metastasis. conclusion: three-year short-term followed up toetva in thyroid cancer has shown less complication and no recurrence cancer. objective of the study: sentinel node navigation surgery (snns) in gastric cancer has been investigated for almost two decades in an effort to reduce operative morbidity. indocyanine green (icg) with enhanced infrared visualization is one technique with increasing evidence for clinical use. we are the first to systematically review and perform metaanalysis to assess the diagnostic utility of icg and infrared electronic endoscopy (iree) or near infrared fluorescent imaging (nifi) for snns exclusively in gastric cancer. methods and procedures: a search of electronic databases medline, embase, scopus, web of science and the cochrane library using search terms "gastric/stomach" and "tumor/carcinoma/cancer/neoplasm/adenocarcinoma/malignancy" and "indocyanine green" was completed in may . all human, english language randomized control trials, non-randomized studies, and case series were evaluated. articles were selected by two independent reviewers based on the following major inclusion criteria: ( ) diagnostic accuracy study design; ( ) indocyanine green was injected at tumor site; ( ) iree or nifi was used for intraoperative visualization. the primary outcomes of interest were identification rate, sensitivity and specificity. titles or abstracts were screened after removing duplicates. the quality of all included studies was assessed using the quality assessment of diagnostic accuracy studies- . results: ten full text studies were selected for meta-analysis. a total of patients were identified with the majority of patients possessing t tumors ( . %). pooled identification rate, diagnostic odds ratio, sensitivity and specificity was . ( . - . ), . ( . - ), . ( . - . ) and . ( . - . ) respectively. the summary receiver operator characteristic for icg+iree/nifi demonstrated a test accuracy of . %. subgroup analysis found improved test performance for studies with low risk quadas- scores, studies published after and submucosal icg injection. iree had improved diagnostic odds ratio, sensitivity and identification rate compared to nifi. heterogeneity among studies ranged from low (i \ %) to high (i [ %). conclusions: the idea of snns in gastric cancer is intriguing because of the potential to limit operative morbidity. we found encouraging results regarding the accuracy, diagnostic odds ratio and specificity of the test. the sensitivity was not optimal but may be improved by a carefully planned and strict protocol to augment the technique. given the limited number and heterogeneity of studies, our results must be viewed with caution. objective: to evaluate the feasibility, cost effectiveness and safety of single incision laparoscopic surgery using routine laparoscopy instruments. method: cases of acute appendicitis and cases of symptomatic gallstone disease were included in study. cases were enrolled in study and prospective observational study was performed. ruptured appendicitis/abscess formation were excluded from study. similarly empyema gallbladder/gallbladder perforation were also excluded. results: total cases included; cases of appendicitis and cases of symptomatic cholelithiasis. mean age of appendectomy group was . ± . years and mean age of cholecystectomy group was . ± . years. in our study, mean operative time for sil appendectomy was . ± . min. post-operative fever was noted in cases ( . %). mean post-operative pain as per vas score taken after hours, on pod was . . average post op stay in hospital was . days, port site infection occurred in one case ( . %). patient satisfaction score obtained on the scale of - on one month follow up was . , while scar cosmesis score was . . in our study, cases underwent sil cholecystectomy, of which were male ( . %) and were females ( . %), and mean age of patients was . yrs. mean operative time in our study was . min, mean post-operative pain taken on pod as per vas score was . , mean post-operative hospital stay was . days, port site infections occurred in cases. post-op fever was noted in cases, post-operative patient satisfaction score obtained at month follow up was . and scar score of . on the scale of - . no case required drain placement and conversion. conclusion: sils can be performed using conventional laparoscopic instruments especially in a government setup where per capita economic burden to patient will be less. though it has more operative time, it has comparably less post-operative hospital stay, causes less pain, and has significantly more patient satisfaction regarding post-operative scar and cosmesis. since sils has more patient acceptance and satisfaction, it can be offered to all patients undergoing laparoscopic surgery. it is very useful in government setup where lower economic class of patients will also benefit, irrespective of unavailability of special instruments and financial constraints, as it can be performed using routine laparoscopic instruments. in the year we started to practice the pericardic window by laparoscopy to diagnostic of head injury hidden in precausal trauma, although lucketally for our society, this type of injury has decreased considerably, we have achieved an important number of patients and in the last year we have performed the procedure for another type of pathologies and also diversified the approach route according to the case. objective: sharing accumulated experience in years in the pericardic window practice by laparoscopy or thoracoscopy. material and methods description of cases results: during this period, we have accomplished cases of laparoscopic pericardal window with two unique ports for the diagnosis of head injury in trauma precordial, additionally there were practiced windows through traumatic trauma of which have been derived in treatment of cardiac injury on this way, without performing open approach. in another scenario, we have performed pericardial spill treatments for different causes by minimally invasive via. no complication or mortality associated with the procedure has been presented. conclusions: the pericardic window performed by a minimally invasive surgery is an effective, replicable strategy for the management of diagnosis and the medical and traumatic treatment of this pathology. patient selection is key and work in multidisciplinary groups guarantees good results. introduction: for the transabdominal preperitoneal repair (tapp) for groin hernia, single port surgery (sps) has been reported to reduce the abdominal wall damages. to reduce the length of the umbilical scar and to keep the view of triangulation, we use one needle forceps plus sps. patients and methods: from may to july , consecutive tapp patients were retrospectively investigated. there were male and female. we use two mm ports ( for the scope and for the operator's right hand forceps) through an umbilical multi-channel port and additional mm needle instrument is pierced above the pubic bone. a mm flexible scope allowed us to keep the triangular formation easily. we studied the safety and usefulness of this method from the viewpoints of operation time and the complications. results: median operation time of single side hernia ( cases) was min ( - ) and the bilateral case ( cases) was min ( - ). five cases needed one or two additional mm ports, and one case with severe preperitoneal adhesion due to the previous prostate cancer surgery was converted to open method because of the venous bleeding. other complications were spermatic cord injury and postoperative seroma that required the percutaneous puncture. umbilical scars and the pierced needle instrument scars became gradually invisible within or months. there were no incisional hernia nor wound infections in our series. these data was comparable to the conventional laparoscopic hernia repairs. conclusions: operation scars of this method had better cosmesis than the conventional tapp or sps tapp, and there were no differences between our sps-tapp with one needle foerceps and conventional method in operation time and the complication rate. our method was demonstrated as a less invasive approach for laparoscopic groin hernia repair. clinical application: fj clip is a stainless steel that can be used to hold organs in the abdominal cavity. it is available in two sizes: mm and mm. the device is short, it has a strong grasp, and it causes no or only negligible organ damage. we have used fj clip in the performance of local gastric excision (n= ), colectomy (n= ), and cholecystectomy (n= ) with no resulting difficulty. f loop plus is a g stainless steel loop-like device into which we can insert φ . mm nt alloy thread, which we draw out extracorporeally via simple puncture. laparoscopic total and proximal gastrectomy. we made a small incision at the umbilicus and inserted a -mm camera port and -mm metal cannula. we placed two (left and right) epigastric ports. retraction of the left hepatic lobe was easy with use of the -mm fj clip and a -mm penrose drain. for # lymph node dissection, we used the fj clip to grasp the upper part of the stomach, inserted the f loop plus from the upper right abdomen. for # dissection, we grasped the pyloric vestibule and pulled it leftward. for dissection of the upper edge of the pancreas, we grasped the left gastric arteriovenous pedicle and pulled it toward the abdomen. the fj clip's grasp and traction exerted on the stomach wall were strong and effective, and there was little organ damage. reconstruction (roux-y) or double tract were performed within the abdominal cavity by hand-sewn purse string suture of the esophageal stump, insertion of an anvil, and use of an automated anastomosis device. we have experienced total and proximally cases to date, but there have been no complications, and both intraoperative bleeding and operation time were within normal limits. conclusion: we believe the fj clip and f loop plus will replace conventional forceps for various tasks in reduced port gastrectomy. introduction: pulmonary anatomical resection is considered as standard treatment for early staged lung cancer. uniportal video-assisted thoracoscopic surgery (uvats) has recently showed favorable surgical outcomes, but remains technically demanding, especially in a complex procedure such as anatomic segmentectomy. needlescopic instruments facilitates complex laparoscopic surgeries with nearly painless and scarless postoperative outcomes, however, its utilization of thoracoscopic surgery were mostly for minor procedures such as bullectomy and sympathectomy. we presented our initial experience of lung cancer surgery performed by uniportal vats and additional needlescopic instruments, and we also compare the operative results with conventional uniportal vats. methods: from december to august , consecutive patients with lung cancer undergoing anatomical lung resections including lobectomies and segmentectomies were reviewed retrospectively. of these patients, patients received conventional uniportal vats (uvats), and patients received needlescopic-assisted uniportal vats (na-uvats). we compared the peri-and post-operative outcomes in these groups. results: there was no significant difference in demographic, anesthetic, or operative characteristics in two groups except for age. the mean operation time was statistically less in the na-uvats group ( . ± . min vs . ± . min, p= . ). the intraoperative blood loss was significantly less in the na-uvats group ( . ± . ml vs . ± . ml, p= . ). there were two major pulmonary arterial bleeding events and one conversion to thoracotomy in the uvats group. the hospital stay, duration of chest tube drainage and post-operative pain scale were comparative in the two groups. conclusion: under the assistance of additional needlescopic instruments, uniportal vats can be performed more efficiently and safely without compromising its benefit in less postoperative pain and early recovery. purpose: we applicated the v-loc into abdominal wall closure in single incision laparoscopic appendectomy (sila) from . the aim of our study is to present our experience of abdominal wall wound closure technique using barbed suture in sila and comparision of perioperative outcomes with conventional method of layer by layer abdominal wall closure after sila. methods: from august to june , sila was performed on patients with acute appendicitis at the department of surgery, hallym sacred heart hospital. under approval of institutional review board, data concerning demographic characteristics, operative outcomes, postoperative complications were compared between both v-loc closure group and conventional layer by layer closure procedures. in v-loc closure group, after removing the appendix, divided linear alba was closed using unidirectional absorbable barbed suture v-loc - with continous running fashon. begins at the end of incision, and coming back with reinforced running. subcutaneous closure was also done using same thread, and the subcuticular suture along incision line was performed with remaning portion of v-loc. results: the demographic data of patients's characteristics were similar between the two groups. the use of barbed suture significantly reduced the suturing time for abdominal wall closure (p= . ) compared with conventional suture. the postoperative incision length was significantly shorter in v-loc group than conventional group (p= . ). the rate of surgical site infection were similar in both group. no incisional hernia were noted in both group with median follow up periods of . months. the total costs of the procedure were comparable in both group under korean drg system. the use of barbed suture in abdominal wall closure in single port laparoscopic appendectomy is safe, and feasible method, reduces the suturing time, thereby decreasing the total operation time, and incision length with cosmetic effect. angela m kao, md, michael r arnold, md, julia e marx, paul d colavita, md, b todd heniford; carolinas medical center introduction: morgagni hernia is an anteromedial congenital diaphragmatic hernia seen in approximately in live births and rarely identified in adulthood. patients may be asymptomatic, have intermittent symptoms, or present acutely with incarceration/obstruction. given this, surgical repair is recommended, but a standardized technique has not yet been described. methods: a prospectively collected hernia-specific database was queried for all adult morgagni hernias performed at a tertiary hernia center. demographics and peri-operative data were compared. ( ) repair. the most common ( . %) method of repair included suturing mesh to the diaphragmatic portion of the defect and securing the anterior-inferior edge to anterior abdominal wall with transfascial sutures and/or tacks. four patients ( . %) underwent primary repair. average defect and mesh size was . cm and . cm , respectively. three patients ( %) underwent a concomitant paraesophageal hernia repair. mean ebl and length of stay was ml (range - ml) and . days (range - days). postoperative morbidity included transient postoperative hypoxemia ( patients) and pleural effusion ( ) . there was no mortality, mesh complications or recurrences with a mean follow-up of months. conclusions: morgagni hernias patients were more often older, obese, and women. these hernias remained unrepaired in % of patients despite their having had previous abdominal surgery. a laparoscopic or robotic approach offers an effective hernia repair with minimal complications, short hospital stay, and excellent long-term results for both elective and acute operations. mesh repair, sutured to the diaphragm and sutured/tacked to the abdominal wall, appears to be a very successful means to repair larger defects. introduction: hydatidosis is a zoonotic disease caused by echinococcus granulosus. it is endemic in the mediterranean, south america and middle east. it is a systemic disease wherein lungs are the second most common organ involved, after liver. radio-imaging plays an important role in diagnosing and determining the extent of the disease. surgical enucleation of cyst has been the classical treatment for this disease. bilateral lung involvement has been traditionally treated by median sternotomy or a bilateral thoracotomy. video assisted thoracoscopic surgery (vats) is an effective surgical approach in such settings. materials and methods: at our center, we have operated cases of pulmonary hydatidosis thoracoscopically over the past years. in all cases, area around the cyst was cordoned off with . % cetrimide soaked gauze pieces. a pericystotomy is performed with ultrasonic shears & the germinal membrane is delivered en masse into an endo-bag. an air leak test after saline instillation into the cavity, is a standard part of the procedure. for those cases with cysto-bronchiolar communications, the defect was sealed by either suturing or glue application. traditionally, bilateral cases & cysts larger than cm in size were tackled by an open approach. but, in our experience, cyst size, bilaterality & presence of complications are not contraindications for vats. all cases are administered perioperative albendazole ( mg twice a day, administered for three cycles of days each, with a gap of days in between) which helps in preventing recurrence and also takes care of any inadvertent intra-operative spillage. introduction: minimally invasive surgery (mis) is the standard approach for most of the surgical procedures performed by general surgeons. traditionally the majority of operations for trauma are performed open due to the complexity of the cases, however, trauma surgeons are expanding their armamentarium to include mis in a variety of acute procedures. we report our experience with the application of laparoscopy in a variety of trauma cases. methods: a retrospective review of trauma cases performed between / - / . during that time laparoscopic cases were performed after traumatic injury. patient demographics, injury severity (iss), injury mechanisms, the types of procedures and outcomes will be described. means and standard deviations were calculated and t test were performed. a p value of . was statistically significant. results: demographics-a total of trauma cases were performed laparoscopically during the study period. the majority were male, n= and the age was sd . obesity was documented in %, hypertension or cad was in %, and substance abuse was in %. blunt trauma was in % and penetrating %. the iss was sd . surgical procedures-the majority, %, of the procedures were completed laparoscopically. non-therapeutic laparoscopy was performed in %. repair of diaphragmatic or traumatic abdominal wall hernias were %. hematoma evacuation and control of bleeding was %. control of solid organ bleeding and repair was performed in %. intestinal repair occurred in %. for the cases that required open conversion iss was sd vs. laparoscopic cases iss was sd , p= . . outcomes: the overall length of stay was days sd . there was n= late death in a poly-trauma patient that required open conversion for complex solid organ and intestinal injuries. there was n= case of a community acquired pneumonia, and n= case of a recurrent pneumothorax. conclusions: a descriptive series of trauma operations approached with mis techniques is described. this cohort had high injury severity and a predominance of comorbid conditions. laparoscopy was successfully applied in the majority of cases for a variety of therapeutic procedures and mortality and morbidity was low. mis is safe and is gaining momentum for application in traumatic injury. objectives: laparoscopic distal gastrectomy for early gastric cancer is a standard treatment in japan described in guidelines. the surgical procedure has been shifting from laparoscopic assisted to complete laparoscopic surgery. in this study, we evaluated the outcomes and safety of the laparoscopic assisted distal gastrectomy. methods: for the marking of the oral side transecting line, the clipping at oral side of cancer lesion was performed by gastro-endoscopy before surgery. the lymph node dissection (d +/d ) is performed laparoscopically. as the dissection of the pancreatic superior region, the assistant hold the left gastric artery and keep the good view by retracting the pancreas. the common hepatic artery and proximal side of splenic artery are exposed. both sides of the left gastric artery and vein are exposed. left gastric vein and left gastric artery are cut after clipping and sealing. lymph node dissention of hepato-duodenal ligament is done and right gastric artery is cut after clipping and sealing. minor curvature of upper gastric wall is exposed (no , dissection). billroth i reconstruction by the circular stapler (cdh) is performed. through the upper median incision with cm, operator pulls out the stomach and transects the oral side of stomach with linear stapler after palpating the clips. duodenum is transected after purse string suture. gastroduodenal anastomosis is performed by cdh. results: two hundred cases were analyzed. the operation time, blood loss and the conversion to open surgery rate were minutes, ml, and . %, respectively. as postoperative complications, anastomotic failure, pancreatic fistula and postoperative bleeding were %, . % and %, respectively. the reoperation rate was %. one surgical death due to cerebral infarction was experienced. there were no patients with ppm (pathological proximal margin) positive and too much pm distance. frequency of abdominal wall incisional hernia and ileus were % and %, respectively. conclusion: although there is the disadvantage that small laparotomy can be made in the upper abdomen, laparoscopic assisted distal gastrectomy with billroth i reconstruction in our procedure is enough good from the viewpoint of the precision of proximal margin, and the incidence of serious complications. introduction: minilaparoscopy (mini) is a modality of minimally invasive surgery that attempts to produce less surgical trauma to the abdominal wall by reducing the diameter of surgical instruments to mm. searching for better outcomes in inguinal hernia repair, surgeons have looked for new and less invasive alternatives such as single-incision surgery, single-port surgery and mini. minilaparoscopic transabdominal preperitoneal hernia repair (mini-tapp) demonstrates some of the known advantages of mini general surgery procedures such as enhanced visualization, improved dexterity and great cosmetic outcome. it is safe and reproducible since it does not differ from standard laparoscopy. introduction: the celiac plexus is a structure located in the retroperitoneum, at the level of the lumbar vertebra, which is located in the prevertebral region and has sympathetic fibers. patients with advanced gastrointestinal cancer and associated pain, one of the management strategies is pain control. neurolysis of the celiac pleural by laparoscopy was first reported in humans in in patients with advanced pancreatic adenocarcinoma with excellent results. experience will be shown in the simplification of the technique for the procedure. method: neurolysis of the celiac pleura was performed in patients with advanced gastrointestinal cancer, stomach %, pancreas % liver % other %, no complications associated with the procedure, pain improvement was achieved in % of patients after process. the standardization of the technique by laparoscopy and its simplification, has made this procedure that is replicable and safe. description of the technique: patient in french position, technique of trocars, umbilical trocar mm and trocars of mm paraumbilical, staging laparoscopy is performed and sampling if necessary, is identified in the region of the lowercurvature of the stomach, the celiac trunk and the emergence of the left gastric artery are identified and cc of % alcohol diluted to the medium in the lateral fatty bearing are instilled through a pericranial under direct vision, verifying the non-arterial instillation of the alcohol. there were no complications related to the procedure. results: we report the experience of one group who underwent celiac pleura neurolysis in patients with advanced gastrointestinal cancer, gastric cancer %, pancreatic cancer %, liver cancer % and another %. the most frequent pathology report was adenocarcinoma, % of the patients were managed at hours with sustained effects, up to months of follow-up. with a significant decrease in pain medication. only patient required new laparoscopic neurolysis because of difficult-to-manage pain. the operative time of this procedure was minutes. the standardization of the technique, the use of low cost inputs, makes this type of procedure easily replicable with goodresults in pain management in cancerpatients. conclusions: mis is offered as one of the fundamental tools for the management of palliative procedures in gastrointestinal cancer. neurolysis of the celiac pleura with standardization of the technique, use of low cost elements, and the surgeon's skills make this procedure an option of management and control of pain in patients with advanced gastrointestinal cancer, is easily replicable, economical and insurance. background: the non-absorbable polymer clip offers a solution to the disadvantage of traditional metallic clip. due to its metallic property, it is not only expensive but also causes artifacts on imaging studies and often migrates into cbd. this study compares the traditional standard metallic clip with hem-o-lock used in laparoscopic cholecystectomy (lc) in regard of the safety and efficacy?. material and methods: this study includes patients who underwent lc implementing metallic clip (mc) and patients implementing hem-o-lock clips (h )?. both clips were applied to cystic duct and artery, then the gallbladder was dissected from the liver bed by diathermy. the intraoperative and postoperative parameters were collected including duration of the operation and complications?. results: the median operative time was not statistically different between the mc and the hc group ( . vs . minutes, respectively; p= . ) with no significantly less incidence of bile spillage ( vs. , p= . ) . no statistically significant difference was found in the incidence of postoperative complications between both groups ( vs. , p= . ). no postoperative bile leakage was encountered in both groups. conclusion: hem-o-lock clip provides a complete hemobiliary stasis and a secure cystic duct and artery control. its cost effectiveness is also attractive while provides efficacy equivalent to that of the standard metallic clip. introduction: most of the blunt thoracoabdominal injury patients always have multiple organ injuries. plan of definite treatment depends on the preoperative diagnosis. in isolating diaphragmatic traumatic injury without others organ injury laparoscopic approach is helpful, decrease a length of hospital stay as well as decrease a wound complication. authors describe the laparoscopic treatment of the patient who had rupture of a diaphragm from blunt trauma in an emergency setting. methods and procedures: a years old man presented with motor vehicle accident and mechanism of injury was blunt thoracoabdominal injury. he complains about chest tightness and tachycardia. complete evaluation and ct scan ware performed. stomach was herniated to the left chest and diaphragmatic ruptured was found neither others great vessels nor solid organs injury. the laparoscopic approach was desired and left diaphragm was repair by non-absorbable sutured without intraoperative complication. results: the patient has been discharged days post-operative with full recovery. chest x-ray was taken before discharge, in out-patient department weeks as well as months after discharge which shown no diaphragmatic herniation. conclusion(s): laparoscopic approach in isolated traumatic ruptured diaphragm patients is safe and should be considered. short-term outcome of laparoscopy-assisted distal gastrectomy with roux-en-y reconstruction through mini-laparotomy for gastric cancer since , we have introduced laparoscopy-assisted distal gastrectomy (ladg) with b-i reconstruction through mini-laparotomy. regarding to reconstruction, roux-en y reconstruction are also one of the choice in ladg, however, the technical feasibility has not been well documented so far. the purpose of this study was to compare the short-term outcome of ladg with roux-en-y reconstruction through mini-laparotomy compared to that of ladg with b-i anastomosis. between and , patients who underwent ladg for gastric cancer in oita university were enrolled in this retrospective study. since , the roux-en-y reconstruction has been performed as a standard method in our department. these patients were divided two groups based on anatstomosis; roux-en-y (r-y) group (n= ) and billroth i (b-i) group (n= ). baseline characteristics, operative results (including complications) and pathological results were evaluated. there were a considerably greater number of patients with advanced clinical stage and having ≥t invasion in the r-y group. estimated blood loss was lower in r-y than in b-i (p. ) and operative time was longer in r-y than in b-i (p. ). there were no significant differences in all grade intra-operative complications (p= . ). in addition, there were no significant differences in all grade post-operative complications between the two groups except internal hernia. hospital mortality was % in each group. ladg with r-y reconstruction through mini-laparotomy was technically feasible as well as ladg with b-i anastomosis. utilization of laparoscopy associated with blunt abdominal trauma: the nationwide inpatient sample - kenneth w bueltmann , marek rudnicki ; advocate illinois masonic medical center, chicago, il, university of illinois introduction: the incidence of trauma and its heavy burden upon the healthcare system remain strong. paradigm shifts in the management of these cases has, however, improved the mortality in such cases. it can be expected that improvements in management, when combined with the benefits of laparoscopy, will demonstrate positive impacts upon treatment outcomes. methods: the nationwide inpatient sample was referenced for inpatient stays for the years to . abdominal trauma cases were selected and identified as hollow (ho) or solid organ (so) type, and as blunt or penetrating. the trauma subset was then scanned for the presence of discrete laparoscopic procedures, laparotomy, and converted cases, and flagged accordingly. conclusion: utilization of laparoscopy in treatment of intraabdominal solid and hollow organs injury increases over time. although current analysis based on available hcup nis data include any procedures done during post-traumatic hospitalization, its results can lead to conclusion that minimally invasive technique is being utilized in increased fashion. introduction: single incision laparoscopic (sil) surgery is a laparoscopic procedure which leaves a single small incision in navel, and has been reported to be less invasive than and as safe and efficient as the conventional multiport laparoscopic (mpl) surgery. the long-term rate of incisional hernia after sils colectomy is unknown, and the risk factors of incisional hernia formation is not fully elucidated. methods and procedures: this is a retrospective from a prospectively collected database. the investigation took place in a high-volume multidisciplinary tertiary private hospital in japan. introduction: laparoscopic approach in the acute surgical care setting continues to be underutilized. we aim to report the successful diagnostic and therapeutic use of laparoscopy in the management of a nontoxic patient presenting with acute abdomen and to highlight the benefits of a minimally invasive approach without added morbidity. case report: presented is a -year-old male with history of cad s/p cabgx two years prior and no abdominal surgical history who presented to the ed with sudden onset severe, diffuse, abdominal pain of six-hour duration with n/v. there was no trauma to the abdomen. he had mildmoderate hypertension, but was otherwise hemodynamically stable. on examination, the patient was in severe distress and writhing in pain. fast exam was unable to be performed secondary to pain. cta of the abdomen revealed mesenteric abnormalities with associated small bowel edema in the rlq suspicious for small bowel ischemia. he was taken to the or for diagnostic laparoscopy. he was found to have an omental adhesive band to the abdominal wall with herniation of the small bowel through the small opening. approximately cm of ischemic, nonviable small bowel was resected and anastomosed intracorporeally. he tolerated the procedure well and was discharged home on post-operative day . discussion: primary omental related internal herniation of small bowel is exceedingly rare. there have been only few cases reported in the literature ( , , , ) . two were diagnosed on exploratory laparotomy, one on diagnostic laparoscopy and one at autopsy. the one who underwent diagnostic laparoscopy did not require bowel resection. in presenting this case, we hope to illustrate the role of laparoscopy in the management of acute abdominal pain due to bowel compromise. introduction: morgagni hernias are a rare finding in the adult population, and represent - % of all congenital diaphragmatic hernias. multiple approaches to these rare hernias have been described in the literature. here we present a novel technique of laparoscopic trans-abdominal repair using a combination of the endo-close device (medtronic, minneapolis, mn) and the ti-knot (lsi solutions, victor, ny.) methods: in a patient with a large left anterior diaphragmatic defect we performed trans-abdominal suturing utilizing the endo-close to perform primary closure of the defect, using the ti-knot to secure the pledged sutures along the anterior fascia. due to the size of the defect ( cm) this primary repair was buttressed with polyester mesh. in a second patient with a smaller ( cm) classic right-sided anterior diaphragmatic defect we similarly performed laparoscopic trans-abdominal suturing using the endo-close to traverse both the anterior and posterior fascia and the ti-knot to secure the sutures in order to perform a primary repair of the hernia. both patients presented had an uneventful postoperative course and no indication of recurrence at months. conclusions: morgagni hernias present unique technical challenges. in our experience the combined use of trans-abdominal suture with laparoscopic knot replacement device allowed for completion of both cases laparoscopically with minimal tension on the repairs. feasibility of concomitant laparoscopic splenectomy and cholecystectomy in situs inversus totalis: first case report worldwide ibrahim a salama, md, phd; department of hepatobiliary surgery, national liver institute, menoufia university introduction: situs inversus totalis is a rare anomaly characterized by transposition of organs to the opposite site of the body. combined laparoscopic splenectomy and cholecystectomy in those patients is technically more demanding and needs reorientation of visual-motor skills. presentation of case: herein, we report a year old girl presented with yellowish discoloration and left hypochondrium and epigastric pain diagnosed as hereditary spherocytosis (hs). the patient had not been diagnosed as situs inversus totalis before. the patient exhibit a left sided "murphy's sign" and spleen palpable in right hypochondruim. diagnosis of situs inversus totalis was confirmed with ultrasound, computerized tomography (ct) and magnetic resonant image (mri) with enlarged right sided spleen and presence of multiplegall bladder stones with no intra or extrabiliary duct dilatation. the patient underwent combined laparoscopic splenectomy and cholecystectomy as treatment of hereditary spherocytosis (hs). discussion: feasibility and technical difficulty in diagnosis and treatment of such case pose challenge problem due to the contra lateral disposition of the viscera. difficulty is the laparoscopic technique encountered in skelatonizing the structures in calot's triangle, which consume extra time than normally located gall bladder with right sided standing surgeon and the position changed to left sided standing surgeon during splenectomy. in review up to date medical literature this is the first case reported worldwide. conclusion: provided that the technique is performed by an experienced surgical team, concomitant laparoscopic splenectomy and cholecystectomy in situs inversus totalis is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder disease as in hereditary spherocytosis (hs) as changes in anatomical disposition of organ not only influence the localization of symptoms and signs arising from a diseased organ but also imposes special demands on the diagnosis and surgical skills of the surgeon. objective: to identify the preference among medical students of the following surgical approaches: open surgery, conventional laparoscopy, minilaparoscopy (mini), single incision laparoscopic surgery (sils), natural orifice transluminal endoscopic surgery (notes), and robotic surgery. methods: an online google questionnaire was filled by medical students of different years in medical school. before answering the questionnaire, they watched an online video showing the different techniques, its advantages and disadvantages. the questionnaire consisted of questions about the hypothetical situation where the participants were going to be submitted to an elective cholecystectomy and they could decide which technique they would prefer. all statistical analysis was performed using the r software program, version . . . the chi-squared test was performed for categorical variables where appropriate. a p value . was statistically significant. results: one hundred and eleven medical students answered the survey. ( . %) were female and men. most of the students were between to years old ( . %). they were in the first four years of medical school. when asked if they would consider notes or single incision even if they know that they are new procedures and with not completely established security standards, . % ( ) answered that they wouldn´t consider with no difference between gender (p= . ). when asked if only conventional laparoscopy, robotics or mini were offered, which one they would choose: % of women and . % men chose mini first (p= . ). about the factors that they would consider the most important when choosing the surgical technique, they answered safety first ( . %), followed by the surgeon´s experience with the procedure ( . %), with no statistically significant result between genders (p= . ). when asked if they would consider an open technique even with the other techniques available and compared according to their year in medical school, students closer to finishing medical school would not consider it, with a statistically significant result (p= . ). regarding the most important factors they would consider and compared by year in medical school, safety and experience of the surgeon performed best, with a statistically significant result (p. ). conclusion: among the available surgical approaches, minilaparoscopy tends to be the preference among women medical students who considered safety the most important aspect. the closer they get to the end to medical school, the less they consider the open technique. background: extension of the single incision for the purpose of specimen removal in singleincision plus one additional port laparoscopic surgery (sils+ ) can undermine the merits of sils + , either by increasing wound-related morbidity or by destroying cosmesis. methods: we retrospectively analyzed the clinical outcomes of patients underwent elective sils + anterior resection, either with transanal specimen extraction (tase, n= ) or transumbilical specimen extraction (tuse, n= ), for colorectal cancer from january to june . this study included patients with a tumor diameter less than cm, measured by preoperative computer tomography. results: both groups were similar in patient's basic information and oncologic condition. most surgical data and postoperative clinical variables were comparable between tase and tuse group, except for increasing operative time in tase ( . + . vs. ± . min, p= . ) and reducing wound complications in tase ( % vs . %, p= . ). dosage requirement of narcotic analgesics was not inferior in tase group compare to tuse group. no significant differences were observed in conversion rate, perioperative and overall morbidity between the two groups. conclusion: although sils+ with tase prolonged operative time compare to with tuse, implement of tase is expected to provide benefit of reduced wound-related morbidity in patients with a tumor diameter less than cm. medhat ibrahim, md; al-azhar university, naser city, cairo, egypt purpose: morgagni hernia (mh) is a rare condition. mh is less than % of surgically treated diaphragmatic hernias in infants. there is no specific symptom for the maorgagni hernia. open surgical repair was the golden stander before the introduction of the laparoscopic surgery in the children and infant. there are many different laparoscopic techniques for mh repair have been reported. i report laparoscopic repair of mh in five infants using primary sutures closure with inrta-corporeal knot tying and ethicon secure strap device. this study is an evaluation of the safety and efficacy of this new laparoscopic technique of mh repair in infants with it is short-term outcomes follow up. patients and methods: five infants with mhs underwent laparoscopic repair by hernia sac excision then two primary sutures, non-absorbable proline through the full thickness of the anterior abdominal wall and the posterior rim of the defect, intra corporeal sutures knot tying, ethicon secure strap device which was used to complete the colures of the defect. there was no insertion of chest tube or drain. results: five infants with mh were operated upon. there were males and female. all cases were left side mh, male-female ratio was : . intraoperative and postoperative analgesia requirement was minimal (paracetamole mg/kg/rectal suppository/ hours for the first hours). ceftriaxone mg/kg single dose at the anesthesia induction. all operations were completed laparoscopic. all infants started and tolerated oral regular feeding with in hours from surgery. none of the patients developed intraoperative or postoperative complications. the maximum follow-up was months (mean, months). all patients are in good health without recurrence or port site compilation. conclusion: this easy save technique of mh repair is reducing the operative time and postoperative hospital stay. it is minims the need of postoperative analgesia, anti biotic. the early oral feeding is also a good benefit. the introduction: transumbilical single port laparoscopic appendectomy (tspla) is the most popularized single port surgery in the world. it provides more cosmetic benefits than conventional laparoscopic surgery. however, single port appendectomy requires longer operation time and advanced surgical skills. we aimed to investigate the learning curve for tspla. material and methods: data were collected from patients who underwent tspla by single surgeon between march and february . the learning curve were analyzed using a cumulative sum control chart (cusum) for operation time and complication. results: a total of patients were included in this study. mean operation time is . ± . minutes. there was no open or multi-port conversion. based on cusum for operation time, learning curve were cases. conclusions: tspla is a safe and effective alternative procedure. the learning curve could be overcome safely without major complications. our results suggest that the cases are sufficient to achieve surgical skills for tspla. introduction: anastomotic leakage (al) is a life threatening complication after minimally invasive ivor lewis esophagectomy (tmie ile) and has diverse treatment strategies such as conservative treatment, endoscopic treatment and surgery. however, there is no consensus on which treatment strategy is best. the aim of this study was to analyse various therapeutic strategies for al and their outcomes. methods and procedures: this retrospective multicentre study was performed in three highvolume hospitals. all patients that developed al after tmie ile in the period of january -july were included. the different endoscopic (stenting, clipping and suction-drainage) and surgical treatments and their success-rate were described; success was defined as clinical improvement after primary treatment. primary endpoint was the time until oral feeding was resumed. secondary endpoints were hospital stay and the total amount of surgical, endoscopic and radiologic interventions. results: in total patients that developed al were identified; four patients received antibiotics only. in the remaining patient, endoscopic treatment was performed as primary treatment in %; % received primary surgical treatment. basic variables were similar in these groups. median postoperative day of diagnosis of al was day in the endoscopic-group and day in the surgical-group (p= . ). admission to the icu as a result of the leakage was necessary in % in the endoscopic-group versus % in the surgical-group (p. ). however, median icu-stay was significantly shorter in the endoscopic-group ( days versus days, p= . ). success-rate of the primary treatment was similar; % and % respectively (p= . ). primary and secondary endpoints were comparable for both the endoscopic-and surgical-group; median time until oral feeding was resumed was days and days respectively (p= . ), median total hospital stay days and days respectively (p= . ) and the median number of interventions was in both groups (p= . ). conclusion: endoscopic treatment appears to be a safe and efficient therapy for al after tmie ile. a patient-tailored approach based on the condition of the patient and the morphology of the leak can be adapted to avoid surgery in a selection of patients. this may prevent surgical reoperations and reduce icu admissions. background: lymph node (ln) dissection around recurrent laryngeal nerve (rln) is one of the most important and difficult procedure in esophageal cancer surgery because of high rate of ln metastasis and risk of rln palsy. especially around left rln, the surgical area is far and narrow by thoracic approach which tends to results in insufficient ln dissection. therefore, we tried to remove this ln by imaging lymphatic chain to dissect sufficient ln. surgical procedure: we perform thoracoscopic esophagectomy by semi-prone position using - mmhg thoracic air pressure. after dissection of right rln ln, middle and lower esophagus, encircle the esophagus at the level of bifurcation of bronchus and pull toward right side by tape to dissect the dorsal and left side of upper esophagus. dissect the tissue including left rln ln from trachea by pulling esophagus up to dorsal side and try to move this tissue toward dorsal side of left rln so that this rln ln tissue can recognize as the "lymphatic chain". to increase the mobility of esophagus, cut the esophagus at the level of aortic arch and pull further up this upper esophagus to dorsal side. cut the esophageal branch of rln and separate this lymphatic chain from rln. at the end of thoracic procedure, this lymphatic chain is attached to upper esophagus. after the upper esophagus has pulled out from cervical site, lymphatic chain can easily recognize at the esophageal wall. result: we performed this lymphatic chain procedure in cases. to evaluate this procedure, cases of conventional method by same prone positioned esophagectomy was used for control. there was no statistical difference between these two groups in amount of blood loss (lymphatic chain: conventional= ml: ml, p= . ), rate of rln palsy ( . %: . %, p= . ). although the thoracic operation time was extended in some degree ( min: min, p= . ), number of dissected ln was increased ( . : . , p= . ) and recurrence along left rln has been relatively fewer by this method ( . %: . % p= . ). conclusion: ln dissection around left rln would be easy and sufficient by imaging lymphatic chain. further improvement is needed to secure this procedure and further evaluation should be done to support this data. introduction: to evaluate the role of robotic assisted surgery as part of an appropriate patient work-up and treatment of ipmn and its consistency in terms of perioperative and long term results. few reports described singular minimally invasive procedures for ipmn. this study aims to describe a comprehensive, oncologically adequate treatment of ipmn in a minimally invasive unit with an extremely high robotic penetrance. methods and procedures: we retrospectively analyze our database of resected ipmn between and . this case series includes consecutive, unselected patients: all candidates with a preoperative diagnosis of ipmn were approached robotically. results: among robot assisted pancreatic resections, we identified patients with ipmn. one was excluded for having less than months follow-up, so patients were included and analyzed. they underwent duodenopancreatectomy in cases, distal pancreatectomy in cases and central pancratectomy in . all but one indications followed the most updated available guidelines (sendai from to and fukoka from to ; american gastroenterology association guidelines were used for comparison only). one patient was operated even if the guidelines were suggesting to follow up, because of a strong familiar cancer history. the final pathology for this patient was high grade dysplasia. in another patient we were inside fukoka's recommendations, but outside aga guidelines and the final pathology was adenoma in chronic pancreatitis. postoperative morbidity was . ( low grade complications, one grade a pancreatic fistula, now considered a biochemical leakage only) and mortality was zero. one conversions to open surgery occurred only: a dp in jehowah's witness with a bulky mass behind the portal vein. the mean follow up was months (range: - ), with only one loss to follow up after months for a high grade dysplasia. conclusion: in hepatobiliary pancreatic minimally invasive centers the treatment of ipmn can be grant following the same principles of major cancer centers, with comparable results. large unbiased studies are needed to evaluate if a minimally invasive approach could modify the ratio between operated and surveilled patients. reducing the use of catheters, tubes and imaging after hiatal hernia surgery significantly reduces length of hospital stay sophia s oswald, candice l wilshire, md, brian e louie, md, ralph w aye, md, alexander s farivar, md; swedish medical center introduction: historically, standard post-operative management of patients undergoing laparoscopic hiatal hernia surgery has been placement of a foley catheter and nasogastric tube (ngt) at the time of surgery with removal early on postoperative day (pod) one, at which time an upper-gastrointestinal series study (ugi) would be performed. we initiated a quality improvement project, seeking to assess if we could safely forego placement of foley and ngt along with the ugi, unless clinically indicated. our aim was to determine if this decreased overall length of stay (los), and how often and which demographic of patients needed placement of foley or ngt postoperatively. methods and procedures: we reviewed patients who had undergone laparoscopic hiatal hernia surgery between and under a single thoracic surgeon. patients were excluded for poor esophageal motility (peristalsis \ %), previous esophageal surgery, and presence of a paraesophageal hernia (peh) with over % of the stomach contained in the chest. eligible patients were further stratified into two groups: fast track and non-fast track. fast track was defined as patients who left the operating room (or) with no foley or ngt, and did not receive a routine ugi on pod one. non-fast track was defined as patients who left the or with a foley and ngt and received a routine ugi on pod one. los was measured in hours from the start of surgery to the time of discharge. results: of the patients included, were categorized as fast track and as non-fast track. the two groups were similar in terms of age, gender, bmi and asa; however, the fast track group had fewer paraesophageal hernias and shorter surgery times [table] . the hospital los, however, was significantly shorter in the fast track group, even though there were more postoperative urinary catheters utilized. no patients in fast track group needed an ngt placed or ugi ordered during initial stay. conclusion: in more straightforward laparoscopic hiatal hernia surgery, surgeons can safely forego ngt and foley placement, as well as ugi evaluation the following morning. these initiatives may translate to a quicker discharge from the ward, and may allow safe transition to performing these cases in hour ambulatory outpatient setting. further evaluation of additional interventions and patient education to decrease los are underway. the conclusion: laparoscopic surgery seems to be a safe and feasible option, with long-term benefit for primary tumor resection with metastatic colorectal cancer, but optimal treatment has yet to be defined. the canadian association of gastroenterology (cag) has implemented the colonoscopy skills improvement (csi) program across canada with a goal of improving colonoscopy quality. the programs' efficacy has not yet been formally assessed. this retrospective cohort study was performed on fourteen endoscopists practicing in a tertiary referral center who have undergone csi training between october and december . procedural data were collected before and after csi training. data were extracted from the electronic medical record (emr) and entered into spss version . for analysis. student's t-test was used to compare groups for continuous data; chi-squared tests were used for categorical data. data were collected for a total of procedures; were done before csi training and procedures since csi training. our sample size provided % power to detect a mean difference in adr improvement of %. the most common indication for colonoscopy was family history of colorectal cancer in ( . %) patients. while age ( . yrs v. . yrs, p. ) and gender ( . % male v. . % male, p= . ) were similar, they were statistically different between groups. groups were comparable in terms of indication, and completion rate ( . % v. . %). adr improved significantly after completing the course ( . % v. %, p. ). an improvement was also noted in both polyp detection ( . % v. . %, p. ) and polyp removal ( . % v. . %, p\ . ). we have seen a significant increase in adr at out institution since implementing the csi program. gastric stomach cancer is a rapid major cause of cancer-related death globally, have higher incidence in men and it is noticeable by its heterogeneity. a lot of studies have expressed out the molecular basis of this cancer, include pathogenesis, invasion and metastasis. the invention of new technologies has help to bring out several novel biomarkers that have diagnostic and prognostic value. therefore, this review centers on biomarkers for the early diagnosis, treatment and prognosis of gastric cancer, elaborate the clinical important of serum tumor markers in a patient with this cancer as well as checking the growths, prognosis together with epigenetic changes and genetic polymorphisms. a deep and rigorous search was carried out in pub med/medline using specific words; "gastric cancer", with "tumor marker". our search yielded important reports about related topic from books and articles that were published before the end of september . conclusively, scientists are utilizing time and resource to salvage this nemesis which is of global burden. classical and novel biomarkers are important for treatment as well as pre-post diagnosis of gc. major causes for this disease are cigarette smoking, infection by helicobacter pylori, atrophic gastritis, male sex, and high salt intake. the treatment of which early diagnoses is of important to the management, after pathological diagnoses by stage prognosis and metastatic setting, although the outcome proved not so good includes chemotherapy, and oral medication are oxaliplatin, capecitabine, cisplatin and -fluorouracil ( -fu). introduction: emergent appendectomy is the standard of care in usa based on tradition rooted in theory that delaying surgery allows for progression of disease and poorer outcomes. antibiotic treatment alone has been shown feasible in the treatment of uncomplicated appendicitis. in clinical practice surgical treatment can be delayed due to a multitude of medical and logistical reasons. this study evaluates the relation between timing of surgery to outcomes. methods and procedures: consecutive adult patients undergoing appendectomy in a teaching community hospital were risk stratified using the acs risk calculator. time from imaging to incision defined early and delayed groups. statistical analysis was used to determine association between risk level, timing of surgery and outcomes. results: % of patients in this study were considered high risk. average time to incision was . hours. shorter time to incision was associated with a statistically significant lower length of stay (p. ). for every hours in surgery delay, one day was added to the length of stay. no statistical difference was found between time to incision and other outcome variables of clinical complications, conversion to open appendectomy or frequency of complicated appendicitis. length of stay was longer than predicted by acs risk calculator in both high and low risk groups. a multidisciplinary, obesity-focused approach improves diagnosis of obesity-related illnesses: a new paradigm for the care of patients with obesity roderick olivas, aaron brown, md, racquel s bueno, md, cedric s lorenzo, md; university of hawaii -department of surgery introduction: patients suffering from the burden of obesity are at significant risk for medical problems that lead to premature death and disability. we hypothesize that a multidisciplinary bariatric team will be better equipped to recognize and diagnose these conditions. this study hopes to quantify that a patient focused approach leads to increased recognition of obesity-associated comorbidities, thus improving quality of care and surgical outcomes. methods and procedure: a retrospective medical chart review of patients who underwent bariatric surgery from / / to / / was performed comparing patient problem lists obtained from their primary care providers upon entry into the bariatric program, and the final problem list generated after evaluation by the program's multidisciplinary team. the total number and specific comorbidities identified before and after multidisciplinary team evaluation was analyzed with a paired t-test and manova, respectively. comparison of the number of comorbidities identified against specific patient demographics was conducted using paired t-test. results: a total of patient charts were selected and met inclusion criteria. the sample consisted of % women and % men; the mean age was . ; the mean bmi was . ; % were morbidly obese (bmi ) and % were obese . the total number of comorbidities identified after evaluation by a multidisciplinary team was significantly greater (p=. ), with the average number of comorbidities diagnosed before and after being . and . , respectively. a significant increase (p. ) in the identification of comorbidities before and after evaluation were noted for all demographics, and no disparities regarding gender, age, marital status, employment status, bmi, or ethnicity where identified. conclusion: patients with obesity unknowingly suffer from many obesity-associated comorbidities simply because their health care providers have failed to recognize the existence of these conditions. surprisingly, this include diseases that are highly associated with obesity, such as osa and t dm, for which obese patients should be screened. although the root of this dereliction is yet to be determined, insufficient obesity-focused education and inherent weight bias among providers must be considered. assessment by a multidisciplinary bariatric team resulted in the identification and treatment of an increased number of comorbidities in this patient population. increased recognition of obesity-related comorbidities improves quality of care, which can translate into improved surgical outcomes. introduction: it is known that surgical residents suffer from sleep deprivation. no recent study evaluated the type and number of calls received at night. lately, burn out, depression and suicide have been the subject of interest in studies and media because of the higher rate among the residents compared to general population. the objective of our study is to evaluate junior resident's level of fatigue and the quantity and quality of calls received during on-call nights in general surgery at chus. methods and procedure: transversal study conducted on junior residents that were on-call in general surgery at the chus between april and august , . the participants detailed all the calls received between pm and am on an database created on the application handbase and completed a daily calendar of their on-call night noting all the tasks they did every half hour (surgery/consultation/sleep). the level of fatigue was evaluated at the end of the night at am with a visual analog of sleep scale on a score over points. results: the level of fatigue / (tired) or / (exhausted) was reached in closed to % of the oncall nights. the median number of calls by night was and the median duration of sleep was only . hours. the median lenght of uninterrupted sleep was . hours by night. among the total nights and calls analyzed, % were ''not pertinent'' and % were ''reportable in the morning''. more than % of the nights had at least one call ''not pertinent'' or ''reportable in the morning'' that have interrupted the junior resident's sleep. the level of fatigue was significantly correlated to the number of calls received during the night (spearman's rho=+ . , p. ) and to the number of uninterrupted hours of sleep (spearman's rho=− . , p. ). conclusion: the level of fatigue is very high among the junior residents in general surgery. many of the calls received during the night are not pertinent or could have been delayed to the morning. our results lead us to the conclusion that interventions and recommendations should be made to raise nurses and resident's awareness about the situation to reduce the unnecessary calls and the level of fatigue of the residents. we hope that on-call resident sleep will be better preserved and that will result in fewer health issues for them (burn out, depression, suicide). without interruptions: does twitter level the playing field? heather j logghe, md , laurel milam, ma , natalie tully, bs , arghavan salles, md, phd ; thomas jefferson university, washington university, introduction: frequent interruption of women in conversation has long been noted anecdotally, and studies confirm that women are interrupted more often than men. such interruptions can diminish perceptions of authority and compromise women's self-confidence. on twitter, users cannot be interrupted in the same way they can be in live conversation. thus the platform may provide a means for women to overcome this obstacle. to determine the degree to which women surgeon leaders utilize twitter compared to their male colleagues, we examined the twitter accounts and activity of the leaders of three national surgical societies. methods and procedures: lists of surgeons holding leadership positions in three surgical societies; the american college of surgeons, the academic association of surgery, and the society of american gastrointestinal and endoscopic surgeons, were obtained and duplicate names were deleted. table details the organizations and leadership positions included. the twitter accounts of these leaders were then identified and confirmed by reviewing the accounts for surgical content. account duration was calculated from the join date. the number of tweets, accounts following, followers, and likes were recorded for each account. outliers were defined as two standard deviations from the mean. results: one hundred sixty-eight men and women surgeon leaders were identified. forty-nine percent of the men and % of the women were found to have twitter accounts. mean account durations for men and women were similar, . years and . years, respectively. outliers for total tweets ( men, women), accounts following ( men), followers ( men), and likes ( men) were excluded from analyses. almost all positive outliers were men. there were no negative outliers. overall, excluding the outliers, there were no significant differences between men and women in any metric. conclusion: among leaders in the surgical organizations analyzed, a higher percentage of women than men have twitter accounts. those with the greatest number of tweets, accounts following, followers, and likes, however, are overwhelmingly male. thus, although women in this sample were more likely than the men to have twitter accounts, men were more likely to gain influence through their accounts. increasing women's influence in this public forum may position them as much-needed role models for the current and next generations. surgical societies may help reduce the disparity in women's representation in surgical fields through education of their members on how to use social media. introduction: the aim of this study was to report the perioperative morbidity and short-term outcomes of a case series of robotic-assisted laparoscopic transabdominal preperitoneal (tapp) inguinal hernia repairs. methods and procedures: a retrospective review (january through december ) of patients who underwent either unilateral or bilateral robotic-assisted laparoscopic tapp inguinal herniorrhaphy by two attending surgeons was performed. patient demographics, perioperative morbidity, operative time, and follow-up data were analyzed. results: patient demographics are summarized in table . mean operative times for unilateral and bilateral inguinal herniorrhaphy were . ± . and . ± . minutes, respectively. mean robot console times for unilateral and bilateral inguinal herniorrhaphy were . ± . and . ± . minutes, respectively. postoperative complications included urinary retention ( . %), conversion to open repair ( %), and delayed reoperation ( . %). no major bleeding, surgical site infection (ssi), or mortality was observed. at first follow-up visit ( ± days), symptoms/signs included groin/scrotal swelling ( %), seroma ( %), groin pain ( %), burning ( %), numbness ( %), and persistent urinary retention ( %). % of patients required a second follow-up visit. two patients underwent reoperation for suspected recurrence but instead a cord lipoma was found without a hernia defect. conclusions: robotic-assisted tapp inguinal herniorrhaphy can be performed with operative times and short-term outcomes similar to those published for open technique. the robotic-assisted tapp inguinal herniorrhaphy is a safe and an efficient minimally invasive surgical option with lower ssi risk and better cosmetic results. gunnar nelson, nathan lau, phd; virginia polytechnic institute & state university introduction: the fundamentals of robotic surgery (frs) and fundamentals skills of robotic surgery (fsrs) are universal curriculums covering a range of topics to assure a high level of surgical skills for optimal patient outcomes. this assurance of skills should include management and response to adverse events. thus, we reviewed frs and fsrs to identify any gaps in educational contents pertaining to how surgical teams are trained to handle adverse events in robotic surgery. methods and procedures: we conducted a literature search through google scholar, journal of robotic surgery, and plos one on frs and fsrs from to . we reviewed articles on preparing medical professionals in handling adverse events during robotic surgeries. besides the two curriculums, we also surveyed the literature on the characteristics of the adverse events and responses of the medical team. this literature survey provided a basis for recommending additional education contents to frs and fsrs. results: in our review, the frs contains modules consisting of an introduction to robotic surgery, with cognitive, psychomotor, and team training/communication skills. meanwhile, the fsrs contains different tasks, half of which on human-machine interaction and another half on operative interaction. both curriculums appear to lack contents on managing adverse events in robotic surgery. according to fda data, , adverse events were reported per , surgeries, of which (i) % relates to broken pieces of surgical instruments falling into patients, (ii) . % pertains to burning holes in tissue from electric arching, and (iii) . % relates to unexpected operations of the instrument such as power outage and issues with electrosurgical units. thus, medical professionals should be trained to manage common adverse events in robotic surgery. for frs, augmenting the five current scenarios in the communication section with common adverse events (i.e., broken pieces falling into patients) would minimize complications under abnormal circumstances. for fsrs, the most logical method would be augmenting the operative interaction tasks with adverse events to train medical professionals. conclusion: we discovered universal curriculums on robotic surgery lack education contents for training medical professionals to manage adverse events and out of the , procedures, ( . %) pertained to device malfunction. to protect the patient's health, universal curriculums must incorporate contents preparing medical professionals in responding to adverse events, particularly device malfunctions, during robotic surgeries. introduction: this retrospective study was performed to evaluate the safety and feasibility of the new senhance robotic system (transenterix) for laparoscopic cholecystectomies. we report the first single-institutional experience utilizing this new robotic platform. methods: approximately robotic cholecystectomies were performed using the senhance robotic system. the senhance surgical system is a new robotic platform that consists of a cockpit, manipulator arm and a connection node ( figure ). this new system provides robotic surgery with numerous advantages including eye-tracking camera control system, haptic feedback, reusable endoscopic instruments, and a high configuration versatility due to total independency of the manipulator arms. patients were between and years of age, eligible for a laparoscopic procedure with general anesthesia, had no life-threatening disease with a life-expectancy of less than month and a bmi\ . a retrospective review of a variety of prospectively collected pre-, peri-and postoperative data including but not limited to patient demographics, intraoperative as well as postoperative complications was performed. cholecystectomies were performed by expert level laparoscopic surgeons. results: the standard laparoscopic technique and setup was easily applicable to the senhance robotic system for this particular surgery. operative time and perioperative complications were comparable to reports of standard laparoscopic cholecystectomies. there was no significant learning curve detected in our case series. conclusion: we report the first experience with laparoscopic cholecystectomies using the new senhance robotic system. there were no major perioperative complications and operative time was comparable to standard laparoscopic cholecystectomies well reported in the literature. this case series suggests that the senhance robotic system can be safely and easily used for laparoscopic cholecystectomies by experienced laparoscopic surgeons. background: the ergonomic benefits or robotic surgery for the health of the surgeon are widely touted as benefits of this technique, though concern remains over a perception of increased risk of injury to patients, particularly in the novice robotic surgeon. injury to the bedside surgeon and assistants due to robotic movement can also occur, though not previously reported. we describe a finger fracture to the bedside surgeon due to entrapment between robotic arms and discuss potential risks to the surgeon in robotic procedures. procedure: a distal pancreatectomy and splenectomy was performed utilizing the davinci si system (intuitive surgical, inc., sunnyvale, ca). during the operation, hemorrhage was encountered which required an instrument exchange that was delayed by self-testing failures. after the instrument was validated and advanced into the field by the bedside surgeon, the operator abruptly took control of the device to reposition. the external portion of the active arm was then rapidly and forcefully propelled laterally toward a stationary retracting arm. the bedside surgeon's hand was still engaged on the instrument being inserted and became trapped between the two arms, leading to a right middle finger crush injury. results: the bedside surgeon sustained a fracture to the distal phalanx at the insertion of the flexor tendon with significant hyperextension of the joint. there was temporary paresthesia of the fingertip. while flexor tendon function was preserved and surgery was not required, the surgeon was required to maintain continuous splinting and was unable to return to full duty for a total of weeks. the surgeon has mild residual hyperextension. conclusions: while complications to the patient have previously been attributed to the robotic platform, this case demonstrates that there are other inherent hazards to members of the operative team. as is natural with all indirect visual surgical techniques, the operator becomes intensely focused on the internal view and instruments in the field. this spatial separation is accentuated on the robotic platform as the isolated console provides a complete visual field immersion, no tactile feedback, and a disconnect between the rapid, sizeable outward arm motions need to produce small internal movements. given the need for maximum dexterity internally, the device doesn't have external proximity sensors to prevent arm-arm or arm-operator collisions. while many bedside operators report anecdotes of collisions with the device, this case reveals the forces involved at the human-machine interface can lead to more significant injuries. robtic approach to non-midline abdominal wall hernias: a single institution experience from a high volume center emily benzer, do, j. stephen scott, md, facs; university of missouri introduction: the objective of our study was to evaluate our experience with robotically repaired non-midline abdominal wall hernias at a high-volume robotic surgery program. we also will discuss the technical advantages of the use of robotic technology in repair of these unusual hernias which have typically had higher recurrence rates then midline hernias. laparoscopic approach for lateral ventral abdominal wall hernia (spigelian) and lumbar hernia has been described, however the success of robotic assisted repair for these hernias has yet to be determined. methods: a retrospective case analysis of all robotic abdominal hernia cases between june and june at an academic institution with a single high volume robotic surgeon was performed. the operative details of robotic repair of non-midline abdominal hernias, patient demographics, length of stay and smoking status were recorded and analyzed. the technical advantages of the use of robotic technology for example circumferential fixation of the mesh, ease of intracorporeal suturing, and the use of wristed instruments to gain better angles for posterior fascial release were evaluated. results: a total of cases were identified. the average age of the patients was . years (range - years) and patients were predominantly female ( %). spigelian hernias represented % (n = ) and lumbar hernias % (n= ). all patients had primary closure of their defect and patients ( %) had a posterior myofascial release performed. mesh types placed included polypropylene uncoated (n= ), polypropylene coated (n= ), and biologic (n= ). with uncoated polypropylene mesh placed had peritoneum closed over the mesh. the average length of stat was . days (range - days). there were no recurrences identified over a mean follow up period of . months (range . - . months). conclusion: robotic assisted repair of non-midline abdominal wall hernias is a viable option in the elective setting with no recurrences noted in this case series. the technical advantages of using robotic technology were identified and discussed in detail. these advantages theoretically improve outcomes in these patients however further analysis on long-term outcome and costs will have to be determined in future studies. the inguinal hernia repair has seen several critical improvements in recent times due to the implementation of new techniques, including laparoscopic repair, as well as robotic repair. with over , inguinal hernia repairs performed annually, it is important to identify the safest and most patient-friendly method. for surgeons, robotic assisted laparoscopic surgery is gaining in popularity for its dexterity and d visualization. but despite the growing interest in robotic hernia repairs, there is a scarcity of literature to support its superiority over open inguinal hernia repair. this study hypothesizes that patients who undergo robot assisted laparoscopic inguinal hernia repair will have decreased immediate post-operative pain, shorter recovery room stays, decreased narcotic requirement, and overall decreased pain at follow up compared to open inguinal hernia repair. in this study, we performed a retrospective analysis of patients who underwent either an open or robotic assisted laparoscopic inguinal hernia repair at stamford hospital, from july -july . the following characteristics were analyzed for both subsets of patients: gender, bmi, type of repair, operative time, recovery room time, immediate post-operative pain, and post-operative pain at follow up. our study demonstrated longer average operative time for patients undergoing robotic hernia repair compared to open repair, which was statistically significant (p value=. ). patients who underwent robotic inguinal hernia repair spent less time in the recovery room compared to patient who underwent open repair. in addition, patients in the robotic hernia group required less narcotics in the recovery room compared to patients who underwent open repair (p value = . ). there was no statistically significant difference between lengths of hospital stay between the two groups. this study highlights several possible advantages of robotic inguinal hernia repair, including lower post-operative pain scores, less narcotic usage required in the post-operative period, as well as shorter recovery room time. the results from this study should increase interest in investigating the superiority of robotic inguinal hernia repair. future plans for study involve comparing robotic to laparoscopic repair. in addition, we plan to continue to follow the study patients to look at additional qualitative metrics, including time to return to work and time to return to daily activities. introduction: buccal mucosal grafts (bmg) are traditionally used in urethral reconstruction. there may be insufficient bmg for applications requiring large amounts of graft, such as urethral stricture after gender affirming phalloplasty. rectal mucosa is an alternative with less post-operative pain, no impairment in eating and speaking, and larger graft dimension. laparoscopic transanal minimally invasive surgery (tamis) has been described by our group. due to the technical challenges of harvesting a sizable graft within a confined space, we adopted a new approach using the intuitive da vinci xi® system. we demonstrate the feasibility and safety of a novel technique of robotic tamis (r-tamis) in the harvest of rectal mucosa for the purpose of onlay graft urethroplasty. methods and procedures: irb approval was obtained. three female-to-male transgender adults (age range: - years) presenting with post-phalloplasty urethral strictures underwent robotic rectal mucosal harvest. the procedure was first rehearsed on an inanimate model using bovine colon. the surgery was performed under general anesthesia with the patient in lithotomy position. the gelpoint path transanal access platform was used. the rectal mucosa was harvested by the robotic instruments after submucosal hydrodissection. specimen size harvested correlated with clinical surface area needed for urethral reconstruction. following specimen retrieval, flexible sigmoidoscopy was used to ensure hemostasis. the rectal mucosa graft was placed as an onlay for urethroplasty. results: there were no intraoperative or postoperative complications. average graft size was cm (range: - cm). every case had excellent graft take for reconstruction. all patients recovered without morbidity or mortality. they reported minimal postoperative pain and all regained bowel function on the first postoperative day. all reported significantly less postoperative pain and greater quality of life in comparison to prior bmg harvests. the procedure has been refined to increase efficiency and decrease operative time by maintaining adequate insufflation, retraction of the mucosal graft, and maintaining graft integrity. conclusions: to our knowledge, this is the first use of r-tamis for harvest of rectal mucosal graft. our preliminary series indicates the robotic approach is feasible and safe. it constitutes a promising minimally-invasive technique to employ in urethral reconstruction. demonstrated feasibility and avoidance of the challenging recovery associated with bmg harvest warrants further application and long-term evaluation of this procedure. prospective studies evaluating graft success, donor site morbidity and long-term outcomes are needed. introduction: the proportion of robotic minimally invasive procedures that are being performed annually is growing rapidly, specifically in the field of general surgery. a robotic approach to minimally invasive procedures potentially confers a number of benefits ranging from a magnified viewing field to greater attenuation and translation of hand movements leading to improved stability and maneuverability. it is paramount that a robust curriculum is designed for training surgical residents in robotic techniques. the aim of this project is to assess the current state of robotic surgery training at the ohio state university, with specific regard to whether it is currently temporally effective in addition to establishing a baseline against which the robotic surgery curriculum can be compared. methods and procedures: data were obtained for cases performed at the ohio state university hospital east, between january and september of . case time, date, type, and attending surgeon were recorded and tracked for review. of the cases, were cholecystectomies, were unilateral inguinal hernia repairs, and were bilateral inguinal hernia repairs-for a total of procedures included in the analysis. chief residents were trained in two-month blocks, beginning in january of . mean console operative times for the first and second months were compared for cholecystectomies as well as unilateral and bilateral inguinal hernia repairs. results: mean console time decreased for cholecystectomies (− . %; n= ), bilateral (− . %; n= ) and unilateral (− . %; n= ) inguinal hernia repairs from month one to month two. there was a large amount of variance across training blocks, but there was a systematic improvement in operative time across the training period. average operation length was shortest for cholecystectomies (m= . min), followed by unilateral inguinal hernia repairs (m= . min), and finally bilateral inguinal hernia repairs (m= . min). discussion: this preliminary data suggests that residents are able to decrease their robotic operation time over the course of the two-month rotation. although sample sizes were relatively small for each block, the consistency of the trend supports this conclusion. further data collection will allow for more precise estimates in the future, and stronger conclusions to be drawn. these results show that rapid improvement is possible and provide motivation to establish robotic surgery curricula for general surgery residents nationally. robotic pancreas-sparing treatment of pancreatic neuroendocrine tumors: three case reports and review of the literature alessandra marano, giorgio giraudo, stefano giaccardi, desiree cianflocca, diego sasia, felice borghi; santa croce e carle hospital introduction: pancreas-sparing resections would be the ideal procedure in case of small pancreatic neuroendocrine tumors (p-nets) reducing the risk of exocrine and endocrine insufficiency. compared to standard resection, this type of surgery is safe and feasible without increasing the risk of postoperative complications except the overall rate of clinical pancreatic fistula (pf), which did not result in higher mortality or overall morbidity. robotic surgery for pnets enucleation has been rarely described but initials experiences have shown that this approach is associated with favorable outcomes. the aim of this study is to describe three cases of dv®si™ pancreatic enucleation for p-nets located in the uncinate process, in the body and in the posterior aspect of the tail of the pancreas, respectively. a brief review of the literature regarding the application of robotics for pnets enucleation is also included. methods and procedures: this study includes patients undergoing dv®si™ enucleation for pnets with a maximum diameter no more than cm and a distance between tumour and main pancreatic duct (mpd) greater than mm. at surgery, exposure of the pancreas was achieved by separation and traction of the gastrocolic and gastropancreatic ligaments. the pancreas was explored: an intraoperative ultrasound was used ensuring negative margins and leaving the mpd intact. thus, a cross-stitch through the tumour was made routinely in order to pull the tumour. enucleoresection was carried out with monopolar scissors and bipolar forceps. the tumour was placed into a specimen bag and removed from the trocar port. a drain was always left. results: median total operative time was min. no conversion neither intraoperative complications occurred. median length of stay was . days. two patients presented a pf grade a (classification isgpf) while a pf grade b occurred in case of pancreatic tail net enucleation. final pathology revealed two insulinomas and one non-functioning net of the pancreatic body. at a median follow-up of months no pancreatic insufficiency, reoperation or tumour reoccurrence was observed in all cases. the robotic approach for the treatment of p-nets is safe and feasible and, in selected cases, it may extend the indications of minimally invasive pancreatic-sparing surgery. in particular, the robotic approach provides a more precise dissection and may ensure negative margins and the mpd intact. these preliminary results are consistent with literature data about over robotic pancreatic enucleations for p-nets that shows favourable surgical outcomes, especially if compared with those of open surgery. introduction: rectal cancer continues to be a surgical challenge. new technologies must be incorporated into practice and, at the same time, oncologic surgery and overall outcomes must be improved. the use of da vinci robotic surgery systems has spread rapidly in the field of rectal cancer treatment showing several technical advantages and favorable outcome compared to laparoscopy. since the introduction of the robotic platform in our institution in , we have adopted a single-docking robotic technique for rectal resection. the aim of this study is to present our standardized technique and to analyse the clinical outcomes of the first robotic rectal procedures. methods and procedures: prospectively collected data reviewed from consecutive patients who underwent single docking totally robotic (da vinci® si™) dissection for rectal cancer resection between june and august under eras program. robotic rectal surgery was performed without changing the position of the robotic cart but only the robotic arms are repositioned between two phases: ) vascular ligation, and sigmoid colon to splenic flexure mobilization; and ) pelvic tme. results: there were men ( %) and the median age was years (range- - ). thirty-five patients had neo-adjuvant chemoradiotherapy whilst patients had bmi [ . procedures performed included anterior resection (n= ) and abdominoperineal resection (n= ). protective ileostomy was performed in patients. the median operating time was min (range- - ). there was one conversion and two intra-operative complications (one bladder lesion and one ureteral lesion, respectively). median length of stay was . days (range, , and readmission rate was %. thirty-day mortality was zero. anastomotic leak rate was %, and all patients except by one were managed conservatively. the mean lymph node harvested was (sd± . ). radial margin was negative in all patients. at median follow-up of months, there were no local recurrences. the single docking robotic technique is a safe and feasible approach for rectal surgery: in our study it has demonstrated favourable clinical outcomes and the adoption of a standardized stepwise approach was useful especially during the initial learning phase. to the best of our knowledge, this is the largest series from italy to report this standardized approach and the short-term clinical and oncological outcomes. in the complex laparoscopic surgical procedure, there is a problem such as that the laparoscope and the surgical instruments interfere with each other because multiple instruments is concentrated in one place. this problem is significantly appear in the laparoendoscopic single site surgery. therefore we suggested multi degrees of freedom (dof) manipulator with mantle tube for assisting laparoendoscopic surgery, which manipulator has two flexion and one telescopic mechanisms actuated by wire. it is possible to insert any thin surgical instruments such an endoscope the mantle tube of the multi dof manipulator, which the manipulator can let those surgical instruments access the operative field from different axis with other instruments. the use of this manipulator has two advantages, one of which is avoidance of fighting between instruments and laparoscope. the other is that become possible to ensure a satisfactory field of vision in the operative field. in this report, we assumed that this multi-dof manipulator is used as laparoendscope. in order to evaluate the performance of this manipulator, the operation time of the test in the abdominal cavity simulator (fasotec inc.) was measured. the test is a contact test to multiple-targets, which is a test that bring a forceps contact multiple-targets in the abdominal cavity simulator according to the defined pattern. as a general comparison and evaluation target for this measurement result, it is compared with the case using the same access method as the conventional rigid endoscope. in this test, the number of contacts between forceps and laparoendoscope were recorded by using electrical device. subjects (n= ) are adult men who trained the peg transfer in the above simulator. it was compared of total operating times of the test and the field of vision obtaining each device. from these results, using the suggested manipulator device rather than using rigid laparoscope a satisfactory field of vision is obtained, and it is possible to short the operating time approximately seconds, and to small the number of contacts significantly. therefore it was shown that the effectiveness using the suggested manipulator device. for this reason, use of this device is expected to facilitate the complex surgical operation. additionally, it is performed para ablative operation of swine liver tissue in the abdominal cavity simulator, as previous step of clinical test. the operative field in this test was surveyed, the refinements of this manipulator for improvement performance were described in this report. yoshiyuki usui, md, phd, ichiro akiyama, md, phd, hironori kunisue, md, phd, hideaki mori, md, phd, tetsuya ota, md, phd; okayama medical center background and methods: we have performed approximately cases of gasless endoscopic thyroid surgery since for years. this surgery was performed through a small subclavian incision and using a wire traction and inserting an endoscope. we have modified and improved our surgical techniques by inventing various surgical instruments. here we introduce four newly invented surgical instruments, chronologically. results: we made u-retractor ( ), u-trocar ( ), u-kelly forceps ( ), and u-suction tube retractor ( ). all surgical instruments were modified from conventional surgical instruments. the u-retractor was a piercing retractor, each end of which had a sharp tip and a retractor. this retractor was inserted from the -cm working port outside the body and retracted the muscles effectively. the u-trocar was reversely set from inside to outside to make the working space wider. the u-kelly forceps which had a special ratchet were made to dissect loose connective tissue around the thyroid gland avoiding injury of the recurrent laryngeal nerve. the u-suction tube retractor facilitated a wider working port and eliminated the mist created by the ultrasonically activated scalpel effectively. recent data showed no difference of operative time, hoarseness, blood loss and hospital stay between conventional thyroid lobectomy and gasless endoscopic lobectomy. conclusion: gasless endoscopic thyroid surgery has been improved in the last years. this procedure made the excision of not only benign thyroid tumors but also small thyroid carcinomas. this operation is still cost effective, because almost all surgical instruments are reusable and is a satisfactory experience to both the patients and surgeons. objective: to put forward the importance of complete (r ) resection for the treatment of retroperitoneal tumors increasing overall survey. methods: in this study; patients having the diagnosis of retroperitoneal tumors with different histopathological subtypes whom were hospitalized in emergency surgery department of istanbul medical faculty between the years of and were evaluated retrospectively. the database of the department was analyzed. operational backgrounds, histopathological results, radiological evaluations, and assesments about relapses, and overall survey were obtained from the medical archieve. results: the average follow-up time was , years. all of the patients included into the study were undergone operations. the average time of hospital stay was calculated as days. of the patients were found to have positive surgical margins in their histopathological evaluations. overall mortality rate of the study was % ( / ). we have observed a direct correlation between complete (r ) resection and disease-free survival. patients having relapses had worse prognosis in terms of overall survey ( % mortality rate). after having done the statistical evaluation, surgery was found to be the main determining factor for the assesment of overall survey. conclusion: reference to an experienced and multidisciplinary surgical center after an early diagnosis has upmost importance for the treatment of retroperitoneal tumors. surgical approach constitutes the main element in the management. overall survey is directly correlated with complete (r ) resection. novel fluorescent dyes for real-time, intraoperative, organ-specific visualization of biliary and urinary systems using dual-color near-infrared imaging ; children's national health system, nih/nci p multidisciplinary approach for management of necrotizing pancreatitis: a case series prabhu senthil-kumar university of alberta, centre for the advancement of minimally invasive surgery introduction: the objective of this study was to systematically review the bariatric surgery literature to understand how weight loss is reported. the incidence of obesity has increased globally. according to the world health organization more than million were obese in . in the last decade, bariatric surgery has been increasingly utilized as an effective treatment option for severely obese patients. currently, bariatric surgeries are among the most commonly performed operations. the primary outcome of such procedures is weight loss which has been shown to vary according to the type of surgery. however, there are different methods used to report weight loss which makes it difficult to directly compare outcomes between studies. a previous review by dixon et al. in revealed a wide heterogeneity in weight loss reporting. however, there have been no recent reviews on the reporting of weight loss in bariatric surgery. methods: a search of the medline electronic database was performed for studies published in using search terms gastric bypass/sleeve gastrectomy, weight, human, and english. articles were selected by two independent reviewers based on the following inclusion criteria: ( ) adult participant ≥ years predictive factors for excess body weight loss after bariatric surgery in japanese obese patients takeshi naitoh hypertension resolution after rapid weight loss: a single institution experience cristian milla matute reoperative bariatric surgery: analysis of indications and outcomes: a single center experience iman ghaderi objective: to observe the effects of duodenal-jejunal transit on glucose tolerance and diabetes remission in gastric bypass rat model. method: in order to verify the effect of duodenal-jejunal transit on glucose tolerance and diabetes remission in gastric bypass, twenty-two type- diabetes sprague-dawley rat model established through high fat diet and low dose streptozotocin (stz) administered intraperitoneally were assigned to one of three groups: gastric bypass with duodenal-jejunal transit (gb-djt n= ), gastric bypass without duodenal-jejunal transit (rygb n= ) and sham (n= ). body weight, food intake, blood glucose, as well as meal-stimulated insulin, and incretin hormones responses were assess to ascertain the effect of surgery in all groups. oral glucose tolerance test (ogtt) and insulin tolerance test (itt) were conducted three and seven weeks after surgery. results: comparing our gb-djt to the rygb group, we saw no differences in the mean decline in bodyweight, food intake, and blood glucose -weeks after surgery. gb-djt group exhibited immediate and sustained glucose control throughout the study outcomes with sham operation did not differ from preoperative level. conclusion: preserving duodenal-jejunal transit does not impede glucose tolerance and diabetes remission after gastric bypass in type- diabetes sprague-dawley rat model is bariatric surgery effective for comorbidity resolution in super obese patients? methods: a retrospective analysis of outcomes of a prospectively maintained database was done on obese patients with a diagnosis of at least one or more of the following comorbidities-t dm, htn, osa, or hld-at the time of initial visit who had undergone either a sleeve gastrectomy (sg) or a roux-en-y gastric bypass (rygb) at our hospital between and . the patients were stratified based on their preoperative body mass index (bmi) class: bmi methods: we retrospectively reviewed all patients that underwent laparoscopic sleeve gastrectomy (lsg) at our institution from - . common demographics and comorbidities were collected as well as creatinine, preoperatively and up to hours after surgery. the renal function was calculated using the ckd-epi formula, derived and validated by levey et al. acute kidney injury was defined as an increase in serum creatinine by ≥ . mg/dl within hours after surgery. all tests were two-tailed and performed at a significant level of . . statistical software r, version . . ( - - ) was used for all analyses. results: of the patients reviewed conclusion: the impact of laparoscopic sleeve gastrectomy in renal function is evident within the first hours after surgery. patients undergoing lsg, especially patients with baseline chronic kidney disease stage ≥ are at increased risk of developing acute kidney injury in the perioperative setting the body mass index (bmi), fasting plasma glucose (fpg), glycosylated hemoglobin (hba c), serum triglyceride, serum cholesterol and blood pressure of all patients were measured before and at months after surgery. the results were collected and analyzed. results: patients suffered from metabolic disease undertook lsg surgery successfully (a mean age of years), were male and were female. all of patients suffered from obesity and the mean bmi of them was . ± . kg/m before surgery. among them, patients had type diabetes mellitus (t dm), patients had hypertriglyceridemia (htg), patients had hypercholesterolemia (hc) and patients had hypertension. the mean bmi of patients at months after surgery was . ± . kg/m and decreased significantly (p. ). the mean excess weight loss (ewl%) of patients was . %± . %( %* %) at months after surgery. the average levels fpg, hba c of t dm patients at months after surgery were . ± . mmol/l, . %± . % methods: we retrospectively reviewed all patients who underwent bariatric surgery from to . we assessed kidney function using the chronic kidney disease epidemiology collaboration (ckd-epi) and cardiovascular risk using framingham risk score (frs) equation pre-operatively and at and months of follow-up. our population was divided into two groups: patients with ckd stage ≥ (gfr\ ml/min) and patients with normal gfr. significance. results: of the , patients reviewed, . % (n= ) met the criteria for ckd-epi glomerular filtration rate (gfr) and framingham risk score (frs) calculations. after matching, patients ( . %) were left to analyze, % (n= ) of which had a laparoscopic sleeve gastrectomy. eighty-six patients ( %) had an impaired kidney function (ckd≥ ) (group ) and patients ( %) had a normal gfr (group ). common demographics and comorbidities after matching are described in table . the mean creatinine in group was . ± . mg/dl versus . ± . mg/ dl in group (p
). glomerular filtration rate was . ± . ml/min in group and ± . ml/min in group . furthermore, when the frs was calculated at months follow-up, patients with impaired kidney function had an absolute risk reduction of . % corresponding to a relative risk reduction (rrr) of group . the percentage of estimated bmi loss was found to be similar in both groups ( . ± . and . ± . respectively p= . ). conclusions: bariatric surgery, especially lsg, has a positive impact on kidney function particularly in patients with chronic kidney disease stage or greater. despite these patients having a higher preoperative cardiovascular risk, they showed similar risk reduction when compared to patients with normal kidney function at months of follow-up the impact of socioeconomic factors and indigenous status jerry t dang only ( . %) patients underwent urgent conversion for management of complications after sg. three patients had intraoperative complications necessitating blood transfusion. fourteen ( . %) patients required readmission within days postoperatively. six patients ( . %) required surgical interventions including for gastrointestinal leak, for hemodynamic instability, for a cecal perforation, and for a small bowel obstruction. there were no mortalities within the first year of revisional surgery. in patients with bmi[ kg/m at the time of revisional surgery, at the median postoperative follow-up of (interquartile range, - ) months, a median (interquartile range, - ) kg/m reduction in bmi was observed. overall, ( . %) patients had persistent type diabetes at time of revisional surgery. improvement of diabetes was observed in patients ( . %) after conversion of sg to rygb. among patients with gerd symptoms, subjective symptomatic relief was reported at the last follow-up. conclusion: weight recidivism is the most common indication for revision of sg objective: to evaluate laparoscopic mini-gastric bypass in the treatment of morbid obesity. method: three hundred patients with a mean bmi of . . kg/m underwent a laparoscopic mini-gastric bypass between to . a laparoscopic approach with five trocar incisions was used to create a long narrow gastric tube; this was then anastomosed ante-colically to a loop of jejunum cm. distal to the ligament of treitz peri-operative and short-term follow-up results up to does age or preoperative bmi influence weight loss after bariatric surgery? one-way anova or the kruskal-wallis test was used to compare continuous data across all groups. subsequent analysis of categorical data was achieved by chi-square or fisher's exact test. statistical significance was accepted as p. . results: a total of patients ( % male) were analyzed. average age and preoperative bmi were . ( . ) years and . ( . ) kg/m , respectively. preoperative comorbidities included: diabetes ( . %), hypertension ( . %), hyperlipidemia ( . %), previous myocardial infarction ( . %), obstructive sleep apnea ( . %), chronic obstructive pulmonary disease ( . %), gastroesophageal reflux ( . %), tobacco use ( . %). the asa classes of patients undergoing sg were ii ( . %), iii ( . %), and iv ( . %). the follow up rate at , and months was . %, . %, and . %, respectively. the -day mortality and readmission rate were % and . %, respectively. the %ewl was not different among age groups at , or months for the total, male, or female cohorts. among preoperative bmi groups, %ewl was not different in any cohort at or months, but was different at months for the total cohort (p. ) and female cohort (p\ . ), and trended toward significance in the male cohort (p= . ). the highest %ewl was found to be in patients with preoperative bmi of - . there was no difference in -day mortality or readmissions among groups a crp≥ mg/dl had a sensitivity for a complication of % and a specificity of %. primary bariatric surgery patients with a post-operative complication had higher crp levels compared to those who did not ( . ± . mg/dl vs . ± . mg/dl; p= . ). there was no difference in crp levels for patients with a -day reoperation or readmission. there were no mortalities. conclusions: bariatric surgery patients with elevated post-operative crp levels are at increased risk for -day complications. the low sensitivity of a crp≥ mg/dl suggests that a normal crp methods and procedures: the patients, who formed the previously published cohort, were contacted and their charts were reviewed. follow-up visits, symptom severity scores, and any subsequent medical or surgical interventions were collected. symptoms were assessed using the symptom severity score (sss) and the gastroparesis cardinal symptom index (gcsi) questionnaires. success was defined as a sss of or less. results: out of original patients, patients ( males, females) were available for follow-up ( patients declined participation, were lost to follow-up, patient was deceased, and was excluded after undergoing esophagectomy for unrelated indication) mbbs ; grant government medical college and sir jj government hospitals methods and procedures: twenty-six nh patients with dm were prospectively randomized to undergo either lrygb or lsg. patients were followed for -years with primary end points consisting of total weight loss (twl), percent excess body weight loss (%ebw) and impact on dm as measured by fasting blood glucose (fbs) and hba c. in addition, baseline, week, and , , , , and months post-operative levels of glucagon-like peptide (glp- ), peptide yy (pyy), leptin, and ghrelin were collected. results: a total of / patients completed follow-up. the %ebw at year for lrygb and lsg were % and %, respectively. resolution of dm occurred in / patients, the remaining three subjects were in the lgs arm. pre-operative fbs in lrgyb and lsg groups, were and , respectively. pre-operative hba c in the lrygb and lsg groups, were . and . , respectively. fbs at year for lrygb and lsg were and , while hba c for lrygb and lsg were . and . , respectively. a consistent post-operative decrease in fbs was only seen in lrygb. lrygb ghrelin percentages increased at , , and months, while levels decreased in lsg. leptin percentages decreased in both groups. the ppy levels remained relatively unchanged in both groups. lrygb glp- levels increased at week, , , and months. lsg glp- trends were similar except at months where glp- levels decreased. conclusion: lrygb and lsg resulted in equivalent post-surgical weight loss and resolution of dm in the nh population video assisted thoracoscopic thymectomy (vats) has emerged as a minimally invasive alternative to the standard transsternal approach. we present herewith the surgical and neurological outcomes after vats their operative time, blood loss, conversion rate and post operative parameters like intensive care unit (icu) stay, inter-costal drainage (icd) indwelling time, hospital stay were recorded. neurological outcomes were assessed based on myasthenia gravis foundation of america (mgfa) post intervention status classification. statistical analysis was done using stata software. results: ninety patients underwent thoracoscopic thymectomy during the study period. vats was done through right approach in ( . %), left approach in ( %) bilateral approach in patients ( %) and subxiphoid approach in ( . %). there was conversion to open approach in ( . %) patients due to dense adhesions at westchina hospital of sichuan university were included. all of the operations were performed by a single skilled surgeon. we divided our patients into two groups based on whether isao was used. of them, patients received isao for lps and patients received lps without isao. surgical skills and safety were evaluated. results: there were no significant differences in preoperative patients characteristics of the two groups. significantly less intraoperative blood loss( . ± . ml vs . ± . ml; t=− . , p= . ) were observed in group of isao conclusions: isao is technically feasible, safe surgical skills for patients reveived lps, and its represents an effective method to decreased intraoperative blood loss. p modular laser-based endoluminal ablation of early cancers: in-vivo dose-effect evaluation and predictive numerical modelling giuseppe endoscopic submucosal dissection enables en-bloc removal of early gastrointestinal neoplasms. however, it is technically demanding and time-consuming. laser-based ablation (la) techniques, are limited by the lack of depth penetration control and thermal damage (td) prediction. our aim was to evaluate a predictive numerical modelling (pnm) of the td to preoperatively select the optimal power and exposure time enabling a controlled ablation down to the submucosa (sm). additionally, the ability of confocal endomicroscopy (ce) to provide information on the td was assessed at the histology, there was an increased damage depth per higher j applications. the r value at . j was . ± . , and was significantly lower when compared to energies from j (r= . ± . ; p. ) up to j ( . ± . ; p\ . ). safe m and sm ablations were achieved applying lower p settings ( . and w), at different t values, leading to an mp impairment only in and % of the cases, respectively. ce provided relevant images of the td, consisting in architecture's distortion and disappearance of the gland's contours. the predicted damage depth we also analyzed early gastric cancer patients who received lpg-ip with cm jejunal interposition. anastomosis procedure was overlap method for eshophagojejunostomy and gastrojejunostomy, feea for jejuno-jejunostomy. results: the comparison between otg/opg-ip shows no significant difference in perioperative complications and qol scores, significant smaller body weight loss in opg-ip group. lpg-ip group also shows good result in short term outcomes. consideration: as comparison in open surgery implies superiority in jejunal interposition, we have introduced lpg-ip. esophagogastrostomy after proximal gastrectomy is simple but has a risk for sever gerd symptoms, no optimal procedure for reconstruction after proximal gastrectomy has yet been established. although laparoscopic jejunal interposition is relatively complicated in procedure, we can safely perform in combination with common anastomosis techniques. conclusion: body weight loss in otg-ip group is smaller compared to otg group consecutive patients with early gastric cancer underwent solo spdg (n= ) and mldg (n= ) performed by same surgical team. solo spdg can be defined as practice in which a surgeon operates alone using camera holder. mldg usually requires two or three surgical assistants. the inclusion criteria in this study were (i) pathologic proven stage i-ii gastric cancer (ii) no other malignancy (iii) more than d lymph node dissection (iv) r surgery. one-to-two propensity score matching was performed to compensate for the differences between two groups. results: after the propensity score matching, solo spdg (n= ) and mldg (n= ) patients were selected. mean operation time ( ± . vs ± . mins, p= . ) and estimated blood loss (ebl) ( . ± . vs . ± . ml, p= . ) were significantly lower in the solo spdg group than in the mldg group. the hospital stay and the use of pain control were similar between the two groups. although the initiation of semi fluid diet was similar, the time to first flatus was earlier in the solo spdg adhesional omental hernia: a case report an unexpected cause of small intestinal obstruction in crohn's disease strangulation inguinal hernia due to an omental band adhesion within the hernia sac: a case report omental adhesion, intestinal herniation, and unexpected death in the elderly small bowel obstruction secondary to greater omental encircling band-unusual case report the median operative time was min. the median postoperative hospital stay was . d. histological examination of the tumors revealed carcinomas, adenomas, and carcinoid. complications occurred in ( %) patients, viz., ssi (two patients), pancreatic fistula (two patients), bleeding (two patients), passing failure (one patient), and cholangitis (one patient). however, no severe postoperative complications (clavien-dindo classification grade or higher) were reported in these cases. conclusion: our cases showed that duodenal tumor resection using lecs enables curability through a minimally this study aimed to compare the outcomes of tltg with those of latg by using a meta-analysis. methods: we searched pubmed, embase, and cochrane library in may, to locate prospective or retrospective studies on surgical outcomes of tltg versus latg. the outcome measures were postoperative complications such as anastomosis leakage and anastomosis stenosis, operation time, blood loss, time to flatus, time to first oral intake, and postoperative hospital stay endoscopic thyroid lobectomy: our early experience at tertiary care hospitals of lahore univariate analysis was performed followed by logistic regression to identify independent predictors for the primary outcome. results: forty-six out of ( %) patients referred for gp required jt insertion to treat malnutrition. etiology of gp included: % idiopathic, % diabetic, % post-surgical. thirty-six patients ( %) reported severe daily symptoms. twenty-five patients ( %) had successful return to oral intake while ( %) required prolonged feeding access, reinsertion of a jt or tpn initiation. on multivariate analysis patients who had a pyloroplasty (p= . , or . ) and those who were married (p= . , or . ) were found to be independent predictors of successful discontinuation of tube feedings. on subgroup analysis -hour gastric emptying time normalized after pyloroplasty (p= . ) in patients which had a successful re-initiation of oral intake while persistent gastric emptying refractory to pyloroplasty was associated with failure. the group of patients who underwent pyloroplasty did not differ in terms of demographics, marital status (p= . ) and preoperative gastric emptying (p= . ) from those who did not. gp etiology (p= . ) psychiatric conditions (p= . ) and substance abuse laparoscopic transabdominal repair of morgagni hernia rebekah macfie average procedure length was . minutes. average hospital length of stay was . days, with all patients tolerating a regular diet prior to discharge. our -day readmission rate was / ( . %). / ( . %) patients required repeat egd evaluation for either recurrence of symptoms or impacted food bolus. at week follow-up, / patients ( %) complained of dysphagia and / patients ( %) had eliminated ppi from their daily medication regimen. at month follow-up, / patients ( %) complained of dysphagia and / patients ( %) had eliminated ppis. at year follow-up, / patients ( %) complained of dysphagia and / patients ( %) had eliminated ppis. conclusion: as a recently introduced surgical option, no long-term data exists detailing the linx procedures ultimate success rates and complication profile mini-laparoscopic vs traditional laparoscopic cholecystectomy: preliminary report deniz atasoy since the introduction of minilaparoscopic cholecystectomy (mlc) in , it gained little interest that could be attributed to decreased durability of the reduced size instruments, poorer optical resolution and smaller jaws of the instrument tips. our aim was to compare the outcomes of mlc with traditional laparoscopic cholecystectomy (tlc) one developed choledocholithiasis on postoperative day one and after ercp the course was uneventful. the other patient developed choledocholithiasis and acute pancreatitis on the sixth postoperative day and was treated conservatively. the stone in the ampulla had fallen by itself without a need for ercp single-incision plus one additional port laparoscopic surgery for colorectal cancer with transanal specimen extraction: a comparative study two patients had a previous attempt of hernia repair, one with mesh. one patient did not have any immunosuppression due to hiv infection, whereas the other were on cyclosporine, tacrolimus and/or mycophenolate mofetil. there were two laparoscopic and two open cases, mean operative time was . minutes ( - ), mean blood loss was ml ( - ). mesh used were biological porcine dermis in one case, polypropylene with absorbable hydrogel barrier in three cases. mean mesh length and width were cm ( - ) and . cm ( - ) respectively. one patient underwent a component separation, though none of the patients had the fascial defect closed. there were no intra-operative complications. three patients were readmitted for hyperkalemia, abdominal pain, and seroma respectively. neither recurrences nor reoperations were reported. mean follow-up was . days ( - ) conclusion: post liver transplant incisional hernia repair is feasible either laparoscopic or in an open fashion. because of the size and location of the defect, fascial closure is unlikely achievable. the use of standard techniques and materials give a similar result of the non-transplant population. p technique of esophagojejunostomy using orvil after laparoscopy assisted total gastrectomy for gastric cancer shinichi sakuramoto there was a significant difference in mortality between the two time-periods, / patients died during - and / died during - (p= . ). those who died were significantly older ( years ( - )) than the survivors ( y ( - )) (p= . ). five of the patients who died in the previous group died without any intervention. / of those who had an acute open necrosectomy died. surgical necrosectomy correlated significantly with mortality (p= . ). the only patient who died in the recent group died without any intervention. none of the patients receiving minimal invasive drainage in this group died until now only cases in adults and fewer than cases in children have been reported in world literature, with surgical management being the only option. an innovative, minimally invasive laparoscopic excision of the abdominal sac was performed and the scrotal component was managed by jaboulay's procedure. this is probably the first case report in world literature describing laparoscopic management of hydrocele-en-bissac. case report: a year old male presented with complaints of bilateral hydrocele and swelling in right lower abdomen since one year. computed tomography of the abdomen revealed an encysted hypodense lesion with enhancing walls along the right side of pelvis, anterior to the psoas muscle and extending through the internal ring into the right inguinal region upto the scrotal sac; measuring . cm . cm suggestive of an encysted hydrocele of cord associated with hydrocele of both scrotal sacs excessive gastric resection may result in postoperative deformity of the stomach, with consequent gastric stasis in food uptake. to minimize the resection of stomach tissue, especially for lesions close to the esophagogastric junction or pyloric ring, we have developed laparoscopic wedge resection (lwr) with the serosal and muscular layers incision technique (samit) for gastric gastrointestinal stromal tumors. this samit is simple and does not require special devices. purpose: the purpose of this study was to clarify whether lwr with samit for gastric gists is technically feasible in term of short-term outcome methods: all patients who went through lsg in our department between / to / have been evaluated for bleeding complications, after implementation of anti-bleeding policy: blood pressure was controlled to mmhg during stomach resection and staple line was reinforced throughout it's length with a running - absorbable v-lock suture. drains were used selectively. results: out of patients who went through the procedure ( . %) suffered hemorrhagic complications: patients had? hb[ gr%. patients received - red blood pc's. no patients were re-operated for bleeding. patients were readmitted for infected hematoma and had ct guided drainage. one patient ( . %) suffered from leak. conclusion: implementation of anti-bleeding policy in lsg is very effective. there is no need to use expensive buttress material to achieve these results. drains can be used selectively. the impact of this policy on leak rate needs to be fifty procedures immediately prior to, immediately after, and eight months after completion of training were included for each endoscopist. data were extracted from the electronic medical record and entered into spss for analysis. student's t-test was used to compare groups for continuous data, and chi-squared tests were used for categorical data. data were collected for procedures. patient groups pre, post, and eight months after csi training were comparable in terms of age ( . yrs, . yrs, and . yrs), sex ( it's in the bag; can stoma output predict acute kidney injury in new ostomates? robert fearn colostomy output stabilised rapidly, whilst ileostomy output increased progressively throughout the first postoperative days as can be seen in chart . twelve patients ( %) developed aki during index admission. length of stay was significantly greater in the aki group at ( % ci - ) days vs ( - ) days. highest daily stoma output was non significantly higher in the aki group ml ( % ci - , ml) vs , ( - , ml) as was mean daily stoma output at ml ( - , ml) vs ml ( - ml) (chart ). seventeen patients ( %) were readmitted for any reason, ( %) specifically for aki. in total patients ( %) developed aki within three months of their stoma surgery only of whom had developed aki during their index admission. all patients who developed aki following their index admission were ileostomy patients. conclusion: acute kidney injury in new stoma patients is associated with prolonged hospital stay and readmissions with associated morbidity and healthcare costs consecutive laparoscopic bariatric operations were performed, including primary roux-en-y gastric bypasses (lrygb), primary adjustable gastric bands (lagb), primary sleeve gastrectomies (lsg) and secondary bariatric surgeries and revisions. all bariatric procedures were approached laparoscopically ( procedures were stapled and were nonstapled). the mean patient age was years ( - ), females represented % and mean bmi was . kg/m ( - ). there were no perioperative mortalities, no conversions to open surgery and no intraoperative blood transfusions. there we two major intraoperative complications (hypopharyngeal perforation- , malignant hyperthermia- ). mean hospital stay was . days ( - days). eleven patients ( . %, in gastric bypass group and one in lsg group) required -day reoperations for postoperative complications (staple line gastrointestinal bleeding- , anastomotic leak- , strangulated port site hernia- , unexplained severe abdominal pain- , intestinal obstruction- , and intraabdominal abscess- ). there were no long term ( -year) mortalities in patients that required reoperation. there was one transfer to another institution. the dynamics of further improving safety was such that there was no complication on the recent consecutive stapled procedures and the mean hospital stay was . days ( - days). detailed subgroup analyses will be provided. conclusions: with well-controlled and structured pre-, intra-, and post-operative care, laparoscopic bariatric surgery can be performed with minimal reoperations and zero mortality in a teaching institution does concomitant placement of a feeding jejunostomy tube during esophagectomy affect quality outcomes? md, facs; icahn school of medicine at mount sinai background: placement of a feeding jejunostomy tube (fj) is often performed during esophagectomy. few studies, however, have sought to determine whether concomitant placement affects postoperative outcomes of esophagectomy of these, ldg was performed patients and odg was performed . we compared elderly patients (aged years or more) with younger patients in each operative procedure. (ldg: elderly , younger ; odg: elderly , younger ) preoperative comorbidity and surgical results were analyzed. multivariate analysis was performed to detect predictive factors for postoperative complications. results: in both ldg and odg groups, the operative time and amount of blood loss did not differ, while comorbidity was more common in elderly patients than in the nonelderly, and there were fewer retrieved lymph nodes in elderly patients. the incidence of all postoperative complications did not differ between both groups in each procedure, and there were no significant differences in the time to first flatus or postoperative hospital stay. however, in terms of specific postoperative complications, respiratory complications were more frequently observed in eldery group with odg significantly (p= . ), while not with ldg group. in multivariable analysis, age was not independent predictor of postoperative complications. conclusion: odg for eldery patients requires attention particularly in postoperative respiratory complications. ldg is a safe and less invasive treatment for gastric cancer in elderly patients who have greater comorbidity. p examining the role of preoperative ineffective esophageal motility in laparoscopic fundoplication outcomes tyler hall there were no significant differences in complications or recurrence rates. preoperative quality of life measures did not vary between the cohorts nor did postoperative scores at three weeks or six months. patients with % ineffective clearance exhibited worse gerd-hrql scores one and two years postoperatively conclusion: preoperative ineffective esophageal motility was shown to result in comparable short-term quality of life following ars. however, gerd-hrql scores at one and two yearsshowed worse outcomes in patients with preoperative iem robotic surgery as part of oncologically adequate ipmn treatment: indications, short and long term results federico gheza eligible patients who had minimally invasive surgery were stratified in multiport laparoscopic and robotic cohorts, and included if they had poi/sbo after surgery. comparative analysis assessed the demographic, perioperative, and postoperative outcomes. the main outcome measures were the incidence rate, associated variables, and time to ileus/ sbo across the mis platforms. results: during the study period total patients were reviewed- laparoscopic and robotic. postoperatively, ( . %) laparoscopic and ( . %) robotic patients suffered from poi/sbo laparoscopic sbo occur significantly later after the index procedure than robotic sbo ( conclusions: the rate of poi/ sbo is considerable and comparable across laparoscopic and robotic approaches. however, there are distinct differences in the severity, time to occurrence, and impact on quality measures, such as los and readmissions between laparoscopic and robotics. this information could be an important factor in which approach the surgeon choses laparoscopic surgical procedure was standard with using laparoscopic linear stapler. responses to surgery were evaluated a month after the operation based upon the american society of hematology evidence-based practice guidelines for itp. results: there was no open conversion in this study. the mean operation time and blood loss were min and g, respectively. there was no case using blood transfusion during and after operation. with regard to complications, one patient ( %) had a postoperative pancreatic fistula that did not require percutaneous drainage. positive responses, including the complete and partial remissions, were achieved in % ( / ). the mean follow-up duration was months, and the -, -, and -year relapse-free survival rates were % for all three time points. conclusions: the present study demonstrated that ls for itp can provide good long-term outcomes two cases of conversion from sp-c to open surgery were excluded. all procedures were followed postoperatively for a minimum of months, and wound complications such as bleeding, fat lysis, infection, or hernia were recorded. patients were classified as having a wound complication or not. results: pure transumbilical sp-c was completed . %, additional trocars were used in . %, and the rate of conversion to open surgery was . %. after a median follow-up of . (range, - ) months few cases performed with hand assist, notes, or single-incision. utilization of robotics was highest for bpd/ds ( of , cases, . %). the greatest number of robotic-assisted cases were sleeve gastrectomy ( , of , , . %) and gastric bypass ( , of , cases, . %). relatively few operations were converted to a different approach (see table). operative time was longer when using robotic approaches for both sleeve ( . vs . minutes, p. ) and bypass ( . vs . , p\ . ). postoperative los was no shorter when using robotic-assistance (see table). unadjusted -day outcomes revealed slightly higher rates of readmission for both operations when using robotic-assistance (see table), and slightly higher rates of complications after robotic sleeve gastrectomy p comparision of perioperative and survival outcomes of laparoscopic versus open gastrectomy after preoperative chemotherapy: a propensity score-matched analysis adjustment for potential selection bias in the surgical approach was made with propensity score-matched (psm) analysis. perioperative and survival outcomes were compared between the lag and og groups. results: in total, patients were identified from the database. after psm analysis, patients who underwent og were one-to-one matched to patients who underwent lag in the setting of nact. these two groups had similar outcomes in terms of intra-and postoperative complications and -year overall survival. however, the lag group had a longer operation time (p= . ) and lower estimated blood loss (p= . ). moreover, compared with patients in the og group, those in the lag group had fewer days until first ambulation conclusion: the present study indicates that lag performed by well-qualified surgeons for treatment of locally advanced gastric cancer after preoperative chemotherapy is as acceptable as og in terms of oncological outcomes. p outcomes of laparoscopic antireflux surgery for gastroesophageal reflux disease: effectiveness and economic benefits kyung won seo, phd; kosin university college of medicine purpose: laparoscopic antireflux surgery (ars) is an alternative treatment option for gastroesophageal reflux disease (gerd) in the world. however, the effectiveness and economic feasibility of ars versus medical treatment is unknown. this study was performed to evaluate the effectiveness and economic benefits of ars. methods: nine patients with gerd were treated using laparoscopic ars between and . surgical results and total cost for surgery were reviewed. results: seven men and women were enrolled. preoperatively, typical symptoms were present in patients, while atypical symptoms were present in patients. one patient underwent partial fundoplication due to absent peristalsis and the other underwent nissen fundoplication. postoperatively, typical symptoms were controlled in of patients, while atypical symptoms were controlled in of patients. overall, at months after surgery, reported partial resolution of gerd symptoms, with achieving complete control. the average cost of ars for nine patients was usd. conclusion: laparoscopic ars is effective for controlling typical and atypical gerd symptoms. the cost of ars may be more economical over the long term compared to medical treatment since laparoscopic surgery is reported to affect respiration and circulation, we should take indication of lag for elderly patients into consideration carefully. indication of lag for elderly patients, however, is still controversial. the aim of this study is to assess the safety and validity of lag for elderly patients. method: medical records were retrospectively reviewed for patients who underwent lag for gastric cancer between and . in this study, patients over years of age were defined as elderly patients. patients were divided into two groups according to age; group a (age ≥ , n= ), group b (age \ , n= ). preoperative characteristics and postoperative outcomes were analyzed. two-tailed student's test and/or pearson's chi-square test were used for statistical analysis. results: there were no significant differences in male/female ratio and body mass index between two groups. number of patients whose asa physical status was ≥ , and/or performance status was ≥ did not differ total gastrectomy ( . vs . %, p= . ), proximal gastrectomy ( vs . %, p= . ). intra-operative blood loss, operating time, and number of harvested lymph nodes did not differ between the two groups. as for postoperative complications such as intra-abdominal abscess ( . vs . %, p= . ), anastomotic leakage ( vs . %, p= . ), significant difference was not observed between the two groups. in addition, respiratory and cardiovascular complication was not observed in elderly patients. incidence of clavien-dindo classification ≥grade ( . vs . %, p= . ), and postoperative hospital stay ( . vs . days, p= . ) did not differ. conclusion: short-term outcomes of lag in elderly patients were not different from those in young patients the essential role of the transcystic duct tube (c-tube) during laparoscopic common bile duct exploration (lcbde) towakai hospital introduction: laparoscopic common bile duct exploration (lcbde) is a standard surgical procedure for the treatment of common bile duct stones (cbds). however, there are some problems associated with cbd drainage after operations even if performing with the primary closure. therefore, we developed a new drainage tube, c-tube, which contributes to shorter drainage periods and reduces perioperative complications. method: c-tube is a type of bile drainage tube which is fixed to the cystic duct with an elastic band. closing the duct with an elastic band as soon as c-tube is removed prevents bile leakage from the stump of the cystic duct. the essential roles of this tube include: . assisting suturing during operations, . use during intra-and post-operative cholangiograpy, . assisting post-operative endoscopic sphincterotomy when necessary we included patients from -years prior to our intervention and compared this with patients who had follow-up after implementation. we excluded patients having revisions, gastric banding, and patients whose primary surgeon had left during the data collection period. we analyzed demographics and follow-up rates at , , , , and months. chi-square test was used to evaluate for significance, and results were corrected for multiple comparison. results: patients met inclusion criteria in the pre-intervention group, and in the postintervention group. of those, were analyzed for the year follow-up visit. the pre-intervention group had males, females, and an average age of . approximately / of the surgeries performed were sg, / were rygb. the post-intervention group had males, females, average age of . approximately half of the post-intervention cases were sg while the rest were rygb. conclusion: bariatric surgery is a useful tool in aiding weight loss and improving comorbidities. it is essential that patients receive long-term follow-up and monitoring to achieve these goals. our program now uses a system of phone call reminders for scheduled visits, as well as calls and letters for annual visits surgeon's evaluation of an intraoperative microbreaks web-app workload questions were modified nasa task load index (physical demand, mental demand, and complexity) and procedural difficulty on - ( =maximum impact) scales. primary outcomes were the impact of microbreaks on surgeons' physical performance, mental focus, pain/discomfort and fatigue with checkboxes for improved, no change and diminished. secondary outcomes were microbreaks impact on distraction level and workflow disruption using a - ( =maximum impact) scale. descriptive statistics were calculated for median and interquartile ranges (iqr) of these responses. results: seven surgeons ( male, female), with a median (iqr) surgical experience of ( . , ) years, completed ten surgical days with a median (iqr) operative duration of ( , ) minutes/surgical day. the median number of microbreaks/surgical day was . the median (iqr) for mental demand, physical demand, surgical complexity and difficulty are shown in table . following each surgical day, surgeons reported / improved physical performance situs inversus totalis (sit) is inherited in an autosomalrecessive fashion with complete abnormal transposition of thoracic & abdominal viscera. its incidence varies from in to live births. for those undergoing surgery, laparoscopic approach is preferred as it avoids inappropriate incisions. however, due to mirroring of the viscera, the surgeon faces constant visio-spatial disorientation during laparoscopy. p ''how to be a surgeon and not dying trying'' control of basic physiological parameters in perioperative phase second main variable: blood pressure (bp) with manual measurement sleeve. preoperative bp and immediate postoperative bp were measured, we were not able to measure intraoperative bp due to the lack of consent of the surgeons involved for the use of other devices different from the heart rate band. secondary variables: years from graduation, years of practice, age, body mass index (bmi), number of medical co-morbidities, number of jobs, sleeping hours the night before. we took measurements to surgeons during a laparoscopic cholecystectomy. results: the mean preoperative heart rate was . bpm. the mean minimum intraoperative heart rate was bpm. the mean maximum intraoperative heart rate was . bpm ( % with tachycardia at the surgery). the mean immediate postoperative heart rate was . cpm. the mean heart rate minutes after the postoperative phase was . cpm. at the immediate preoperative phase % of surgeons had elevated bp level (usual normotensives) articles were randomly selected and the gender of the first and last authors determined. results: of the bariatric surgery publications reviewed, only % of first authors and . % of last authors were female surgeons. even though the proportion of female authors has increased over time, this is not proportional to the increase in the number of female surgeons or surgery residents (figure ). discussion: female surgeons are under-represented in bariatric surgery research. the number of female surgeons and residents has a continuous up trend over the last few decades our survey also included the validated quick-dash (disabilities of the arm, shoulder, and hand) questionnaire for upper-limb symptoms and the ability to perform certain physical activities. the quickdash is scored into two components: disability/symptom score, and the optional work module, which represent the impact of disability on daily activities and work responsibilities, respectively. both scores range from - , with a higher score indicating greater disability. surgeons were grouped according surgical focus (open, lap, or ra), and comparisons were made between groups. surveys with more than % of responses missing were excluded. statistical analysis were done using spss . , with α= . . results: completed surveys were evaluated (open: n= , lap: n= , ra: n= ). the survey response rate was %. . % of respondents were general surgeons, and mean age was ± . years. surgeons reported an average of ± . cases performed per month ra: . %, p= . ). likewise, there were no differences in the mean disability similarly, there was a positive correlation between mean work scores and reported pain in the upper-limb for lap and ra, both p. . conclusions: this nationwide survey revealed a similar prevalence of pain in the upper-limb among surgeons performing open, laparoscopic and robotic-assisted procedures. likewise, similar disability scores were reported between the three surgical groups. older surgeons performing laparoscopic and robotic-assisted approaches reported a higher impact of upper-limb problems interfering with their daily activities, unlike open surgeons. among all surgeons who reported pain in the upper-limb, laparoscopic and robotic surgeons were more likely to report that this pain interferes with their work activities an analysis of subjective and objective fatigue between laparoscopic and robotic surgical skills practice p d laparoscopic versus robotic gastrectomy for gastric cancer: comparisons of short-term surgical outcomes lin chen, xin guo patients who underwent d-lag (n= ) or rag (n= ) for gastric cancer were enrolled. the clinicopathological factors and short-term surgical outcomes were compared with retrospectively analysis. results: the clinicopathological factors between the two groups were well matched. postoperative recovery factors including the days of first flatus, days of eating liquid diet and hospital stay were similar. the rate of postoperative complications between the two groups were with no statistical differences in the subgroups of patients with total gastrectomy, d-lag had less blood loss and shorter operative time than rag (p= . and p. ), while for distal gastrectomy, blood loss and operative time showed no statistical differences. conclusions: this study suggests that d-lag is a novel and acceptable surgical technology in terms of surgical and oncological outcomes. d-lag is a promising approach for gastric cancer therapy methods: patients underwent robotic surgery between the beginning of to first half of in turkey were included. data were obtained from a prospectively maintained database. patient, surgeon and hospital identifiers were encrypted. parameters were operation type, operation year, robotic system used (s, si, xi), hospital volume and surgeon volume. high volume robotic colorectal hospital and surgeon was defined as the caseload within the forth interquartile ( th- th) based on the median value. results: there were colorectal procedures. surgeons performed robotic colorectal surgery at hospitals. ( . %) and ( . %) procedures were performed with the s-si and xi platforms respectively. hospitals have both of the si and xi platforms. hospitals are the si, hospitals are the xi hospital currently. the number of robotic colorectal operations increased gradually by years (figure ). the median numbers of colorectal procedures were (range - ) and (range - ) per hospital and per surgeon respectively among those hvrcs, the numbers of si and xi users were and respectively. the surgeons who performed more than procedures continued to use robot in their practice except one surgeon who stopped at . only left colectomies and no right colonic resection were performed before introduction of the xi platform first robotic cases and implementation of a robotics curriculum in a general surgery residency domenech asbun armonk ny) and utilized student's t test and chi-square. we also performed a linear regression analysis to determine the effect of or time, robotic surgery, and diagnosis on operating room costs and postoperative length of stay. results: laparoscopic and robotic cholecystectomies were performed. demographic parameters (age, gender, medical comorbidities, preoperative albumin and bmi, surgical history and smoking) were comparable. primary diagnosis was significantly different (chi-square . ), driven by more acute cholecystitis in the laparoscopic group. / robotic cases and / ( . %, p = . ) laparoscopic cases were converted to open ( for adhesions, for failure to progress, and for visualization of anatomy after adjusting for or time and diagnosis, robotic surgery was associated with a $ increase in costs robotic surgery is independently associated with increased or cost, but individual hospital systems must decide if this additional cost outweighs increased robot utilization and training benefits for physicians and staff robotic abdominal wall hernia repairs: technical considerations and lessons learned inguinal hernia repairs (ihrs) comprised the majority ( . %) of cases ( . % male, mean age . , mean bmi . ). there were unilateral ihrs with an average operative time of . ± . min and an average ebl of . ml. there were bilateral ihrs with an average operative time of . ± . min and average ebl of . ml. thirteen ihrs were combined with umbilical hernias and two with incisional hernias. average operative time for combined procedures was . min and average ebl was . ml. fifty-five incisional hernias were repaired robotically ( . % male, mean age . , mean bmi . ), four of which were retrorectus and two of those required transversus abdominis release. median hernia size was cm ( - cm). mean operative time was . ± . min and average ebl was . ml. twenty-three ventral/umbilical hernias were repaired robotically ( . % male, mean age . , mean bmi . , median size . cm ( - cm), mean operative time . ± . min, average ebl . ml). one spigelian hernia (operative time min, ebl ml) and one parastomal hernia (operative time min, ebl ml) were repaired robotically. there were no major complications and only groin seroma requiring percutaneous aspiration. nine patients required conclusion: this study demonstrates improved outcomes of robotic inguinal hernia repair compared to an open or laparoscopic approach. robotic hernia repair showed overall lower -day complication and readmission rates, and shortened los. while open approach had the highest rate of opiate use we retrospectively investigated consecutive overweight gc patients (bmi≥ ) underwent distal gastrectomy with d lymphadenectomy ( for rag and for lag) performed by two surgeons. the clinicopathological and surgical features were compared between groups. the cutoff point for initial phase (phase i) and stable phase (phase ii) were determined by cumulative sum (cusum) curve of operation time. results: generally, the surgical outcomes including postoperative complication rate, duration of postoperative hospital stay and lymph nodes harvest in the overweight patients have comparable results between rag and lag groups. the cutoff determining phase i and ii according to the cusum figure for rag group was and cases for surgeon a and b, respectively. and comparison analysis showed that the operation time of phase ii rag was significantly shorter robotic-assisted transabdominal preperitoneal inguinal herniorrhaphy: a single-center experience including perioperative morbidity and short-term outcomes patient factors, treatment factors, and outcome measures were collected in an attempt to gain insight and to generate ideas to potentially improve outcomes. results: there were no operative complications. six patients ( %) had failed gastric pacemaker placement prior to intervention. nine patients ( %) reported improvement in their symptoms and overall quality of life. four patients ( %) reported no improvement in symptoms and required additional intervention for symptom control and supportive care (one underwent roux-en-y gastric bypass, three underwent laparoscopic jejunostomy feeding tube placement to maintain nutrition). conclusion: robotic-assisted pyloroplasty is a safe option that improves symptoms and quality of life in % of our patients patients were matched into cohorts by procedure type. outcomes were analyzed using unpaired t-test and fisher's exact test. results: cost data was available for patients undergoing ras or la procedures. significant increases in equipment, labor, and overhead costs resulted with ras vs. la. variable-labor and variable-overhead costs were significantly higher in la procedures. higher supply costs and longer procedure time was seen with ras in all cohorts however, total -day costs were not significantly different in any group. conclusion: ras led to significant increases in fixed clinical, operative and pathologic factors were reviewed and analyzed. results: seventy patients underwent robotic surgery for rectal cancer during the study period. the locations of tumor were upper rectum, lower rectum. the procedure were as follow, high anterior resection in , low anterior resection in , isr in , apr in patients. eight patients underwent bilateral lymph nodes dissection (llnd). the procedures were performed successfully in all cases. mean age was . years, and % of the patients were men, and the mean body mass index was . (range, . - . ) kg/m . median operative duration was ( - ) minutes. median blood loss was ( - ) ml. median postoperative stay was ( - ) days. mean harvest lymph node number was . ( - ). surgical margins were negative in all cases. there was one conversion due to bleeding during the llnd and anastomotic leakage occurred in two patients. morbidity was %. there was no mortality postoperatively in this series. conclusion: in early series of the selected patients, this technique appears to be fesible and safe when performed by surgeons skilled in laparoscopic colorectal surgery the inactive electrode was placed touching small bowel to simulate accidental thermal injury. the bowel tissue at the site of temperature change was immediately resected and examined histologically for tissue injury. student t-tests were used for all comparisons with a p-value less than . considered statistically significant. results: comparison of the laparoscopic and robotic techniques are displayed in table . energy transfer was quantified using energy leak (per ma), which in these tests averaged . degree celsius change ( % ci . - . ) at the inactive electrode. surface temperature heated to a maximum of . degrees celsius, more in the robotic system than laparoscopy but still clinically negligible. pathology results from in vivo testing showed only thermal injury to the serosa without deeper mural injury. conclusions: stray energy transfer occurs in both laparoscopic and robotic surgery in amounts that are measurable but without clinical relevance. the average change in tissue temperature is less than degrees celsius laparoscopically and less than degrees robotically. while the robotic surgery appears to transfer more stray energy, no significant bowel injuries were caused in either group. p robot assistance can improve the performance of laparoscopic extensive concomitant adhesiolysis: results from a large observational study federico gheza outcomes compared were operative time, conversion rate, overall complications, gastrointestinal (gi) related complications (wound infection, abdominal abscess, anastomotic leak, ileus and small bowel obstruction), hospital length of stay, and -day re-admission rate. two sample t-test was used and p. was considered statistically significant. results: fifty-five robotic colectomies were matched with laparoscopic counterparts based on type of operation: right colectomy (n= ), sigmoidectomy (n= ), low anterior resection (n= ), proctocolectomy (n= ), transverse colectomy (n= ), abdominoperineal resection (n= ), and total abdominal colectomy (n= ) we assessed if technical obstacles of laparoscopic suturing were decreased and if laparoscopic skills overall were improved. surgical outcomes were compared relative to our historic values; we assessed procedure time and operating room efficiency, including set up and turn-over times. results: overall, the d/flexdex system permitted a greater improvement in working speed, superior optical visualization, and better suture handling compared to standard laparoscopy. all surgeries were completed without any complications. historically, we considered laparoscopic suturing to be complicated and inefficient. we relied on tacking devices for mesh fixation, suturing was previously completed with large cumbersome straight laparascopic devices. however, with flexdex and endoeye flex d, tacking devices have been eliminated and suturing technique improved. the mean total procedure times remained comparable for inguinal and hiatal hernia surgeries, and slightly longer for ventral hernias. operating room efficiency, including mean set up and turn-over times also remained unchanged. the acquisition cost for both the olympus endoeye flex d laparoscopic imaging system we performed a cost analysis which showed an average total cost of $ , for laparoscopic sleeve gastrectomy and an average of $ , for robotic assisted. the total reimbursements were $ , for laparoscopic sleeve gastrectomy and $ , for robot assisted. this translated to an average contribution margin of $ , for laparoscopic vs $ , for robot assisted. we analyzed these differences for bypasses as well. laparoscopic bypasses averaged minutes laparoscopically vs robotically. we found an average cost of laparoscopic $ , vs robot assisted $ , , with a contribution margin of $ , laparoscopic vs $ , robot assisted. conclusions: in our study we noted increased operative times with robot assisted operations, especially bypasses which could be explained by increased use of the robotic system for difficult cases such as revisional bypasses. the impact of cost is especially important in this financial climate, and judicious use of resources becomes important when determining surgical approach average or time for rih was minutes compared to lih which was minutes. average intraoperative cost for rih was $ , compared to lih which was $ . of note, one lih was converted to open, whereas none of the rih required conversion. average los was . hours for rih compared to . hours for lih. postoperative pain at one week follow up was the same between both groups. two postoperative surgical site occurrences (sso) occurred in the lih group ( groin seromas), whereas no ssos occurred in the rih group. eleven ventral hernia repairs were examined, were robotic (rvh) and were laparoscopic (lvh). average or time for rvh was minutes compared to minutes for lvh. average intraoperative cost for rvh was $ , compared to lvh which was $ , . no procedure from either group required conversion to open. average los was . hours for rvh, and . hours for lvh. again, postoperative pain was the same at one week follow up for both groups. there were no postoperative complications noted in either cohort. conclusion: operative time and procedural costs for rvh and rih repairs were shown to be longer and more expensive when compared to their laparoscopic counterparts. however, with increased operative experience using the robotic platform, surgical time did show a decreasing trend does robotic system have advantages over laparoscopic system for distal pancreatectomy? results: a total of consecutive patients underwent minimally invasive distal pancreatectomy (ldp n= ; ra-ldp n= ). most common pathologic finding was pancreatic ductal adenocarcinomas ( cases). there was no in-hospital mortality or cases of conversion to open surgery in this study. spleen-preserving approach was performed more often in the ra-ldp ( %) than in the ldp ( . %) groups (p= . ) both groups showed no significant differences in the total number of lymph nodes, number of positive lymph nodes, tumor differentiation, tumor stage, and resection margins. conclusions: ra-ldp is a safe and feasible approach that has an advantage of performing spleenpreserving distal pancreatectomy, with perioperative and short-term oncologic outcomes comparable to those of ldp. p robot-assisted alpps technique mike fruscione right portal vein embolization was not feasible secondary to the proximity and size of the right hemi-liver tumor burden relative to the right portal vein. the pre-operative planned procedure was a right trisectionectomy and microwave ablation of the segment lesion. results: using the da vinci xi surgical system (intuitive surgical, inc.) the right portal vein was dissected, doubly-ligated, and divided. the liver parenchyma was split from the inferior edge to the dome mm medial to the falciform ligament and down to the middle hepatic vein which was preserved to maintain adequate venous outflow. the patient was discharged home on post-operative day two. on post-operative day six, ct volumetrics demonstrated a flr of %. on post-operative day seven, a second stage alpps procedure was performed where the right hepatic artery, middle and right hepatic veins and right hepatic duct were ligated and divided. segments a/b, , , and were removed. the patient was discharged home on post-operative day five they were asked to answer demographic questions and rate their comfort level ( =not comfortable, =very comfortable) with aspects of robotic surgery. paired t-tests and wilcoxon tests were used to assess whether there were changes in comfort level before and after labs, and chi-square goodness of fit tests were used to assess whether dry lab (using inanimate objects), wet lab (using a porcine model), or simulator modules were thought to be most helpful in obtaining specific robotic skills. results: the survey response rate was % (n= ). ninety-one percent of residents felt that robotic surgery is not intuitive. prior to simulation, % of residents felt inadequately prepared to safely operate on the robotic console. following simulation, % felt better prepared and more confident to participate in robotic surgery for the first patients whom we treated (the first-stage group), we invited a visiting expert from a high-volume center to perform the procedure jointly with our hospital's surgeons by using a dual console. for the subsequent patients (the second-stage group), the procedure was performed by our hospital staff alone. in this report, we describe our experience of introduction of robotassisted colectomy and discuss issues for the future. patients and methods: the operative procedure was sigmoid colectomy, low anterior resection, and intersphincteric resection. the median number of lymph nodes dissected was . . the mean operating time was minutes for the first-stage group and minutes for the second-stage group. the median console time was minutes for the first-stage group and minutes for the second-stage group, with no significant differences between the two groups. the mean operating time other than console time was minutes for the first-stage group and minutes for the second-stage group, significantly longer in the latter group. the mean amount of hemorrhage was . g in the first-stage group and g in the second-stage group. no significant differences were found between the two groups in the mean length of postoperative hospital stay. none of the patients in either group developed a complication of clavien-dindo grade iii or higher. conclusions: the use of dual console system was particularly useful for the introduction of robotassisted surgery in our hospital. for the patients whom we treated, we found almost no difference in console time between the first-and second-stage groups. the high-quality instruction received via the dual console was considered to have had a beneficial effect on the operators' learning curve. however, the operations that were set up other than console time, such as roll-in and docking, took significantly longer in the second-stage group when the proctor was not present select specimens from each trial were immediately resected and evaluated for histologic thermal injury. experiments were repeated times based to detect an expected difference of five degrees. student t-tests were used for all comparisons with significance set at . . results: stray energy transfer was higher in the single incision setup compared to the traditional setup (figure ). stray energy in the assistant grasper caused . ± . °c of temperature change in the standard configuration, and . ± . °c in the single incision configuration (p= . ). doubling energy output to w amplified the same finding robotic single-site cholecystectomy of cases: surgical outcomes and comparing with laparoscopic single-site procedure jae hoon lee incisional hernia occurred one case in each group. rssc is safe and feasible procedures. with accumulating of experience, rssc had more short operative time than sslc. comparing to sslc, rssc is relatively suitable to acute gallbladder disease and high bmi and requires a minimal learning curve to transition from traditional multiport to single-port robotic cholecystectomy. p initial experience using da vinci xi robot in colorectal surgery anna r spivak, do, john marks, md; lankenau medical center introduction: the xi robot has been developed to facilitate multiquadrant abdominal surgery. this report presents initial experience to evaluate feasibility and safety of xi robot in colorectal surgery. methods: all cases performed on xi robot were prospectively entered into a robotic database that was queried for colorectal cases performed from intraoperative complications were encountered in cases ( . %), requiring conversion to laparoscopy. none were converted to open. mean length of largest incision . cm. median ebl ml. there was no mortality. there were ( . %) immediate postoperative morbidities: postoperative abscess, bowel perforation, two postoperative bleeds, two hernias, two hematomas, smv thrombosis, small bowel obstruction. perioperative blood transfusions were required in . % of cases. there was one anastomotic leak. median time from surgery to low residue diet and discharge was days. conclusion: initial experience shows robotic colorectal resection with da vinci xi learning curve for robotic sleeve gastrectomy and roux-en-y gastric bypass: achieving equivalence to laparoscopy residents and fellows participated in an analogous fashion in both arms of the study, and patients undergoing re-operative bariatric surgery were excluded. results: a total of patients undergoing rsg (n= ) or rrygb (n= ) were included. for the overall robotic cohort, median age was (range - ), % were american society of anesthesiologists (asa) score , % were asa score , and mean body mass index (bmi) was ± with no differences between procedures. there were no conversions to open. there was one patient with portal vein thrombosis after rsg which occurred in the th rsg and one patient who underwent re-operation in the immediate post-operative period for hemorrhage at the gastro-jejunal anastomosis in the rrygb group; this occurred in the th rrygb. there were no leaks, strictures, or mortalities in either group. mean length of stay was days± for rsg with no difference based on number of procedures performed. in the rrygb group, los decreased after the first five procedures from days± to days±(p= . ). for both procedures, operative time decreased by number of procedures performed (figure). equivalence to lsg in operative time ( minutes± ) was reached after eight robotic procedures were included. the da-vinci xi® was used for the operations. age, gender, body mass index (bmi), asa score, indication for surgery, urgency of procedure, type of procedure, docking number, operation time, estimated blood loss, complications, short (≤ days) and long term ([ days) complications were evaluated. results: patients ( females) were included. median age was . median bmi was , median asa score was . total and completion rrp-ipaa were performed for and patients respectively. the indications were as follows: medical refractory uc (n= ), cancer/dysplasia (n= ), fulminant colitis (n= ), toxic megacolon (n= ), medical treatment resulting in growth retardation (n= ), medical treatment refractory bleeding (n= ). patient with toxic megacolon had an emergent operation. the median docking number was and for completion and total rrp-ipaa respectively. median operative time was minutes. median blood loss was ml. all patients had a stapled ileal j pouch anal anastomosis. all patients had a diverting loop ileostomy at the time of ipaa creation. no intraoperative complications were observed. no conversion to open surgery was needed. the median time to flatus was day. the median time to oral intake was day. patient had a laparotomy on postoperative day due to intra-abdominal bleeding. patient had a bleeding from ileostomy which was treated endoscopically. superficial surgical site infection was observed in patients. patient had a pouchitis managed with oral antibiotics. patient had an ileus responded to conservative treatment. patient had a per-anal bleeding stopped spontaneously. patient had a urinary tract infection responded to antibiotics. patients had pouchitis, patient had a perianal fistula requiring a loop ileostomy and a parastomal hernia was developed in another patient in long term follow up ) were significantly different between the two groups. , pairs undergoing primary and pairs undergoing revisional procedures were successfully matched. robotic gastric bypass was associated with a significantly longer operation length than laparoscopic gastric bypass for both primary (median difference minutes, p. ) and revisional (median difference minutes, p. ) procedures overall, there were no significant differences in anastomotic/staple line leak, -day readmission, reoperation, re-intervention, total event, and mortality rates between matched cohorts. conclusion: when controlling for patient characteristics, those undergoing primary and revisional lrygb and rrygb had no difference in early morbidity. despite the prolonged operative duration, the robotic approach was not associated with any clinical benefit or increased complications for primary or revisional gastric bypass surgery preoperative risk factors were collected. we focused on perioperative outcomes and in hospital complication rate. results: thirty-three patients underwent robot assisted giant hiatal hernia repair at our institution. patients ( %) were years and older and patients ( %) had a bmi higher then. there were no significant differences in patient characteristics between the groups. no patient underwent conversion to open or standard laparoscopy. no mortality was observed and no transfusions were needed. four patients ( %) had a complication, two of them were older than years old. three of the four patient ( %) that had a complication were obese. there were no statistical differences in mortality % and . % of them were with s-si and xi platforms respectively. the median numbers of procedures were (range - ) and (range - ) cases per hospital and per general surgeon respectively. the high volume surgeons (higher than th percentile) performed ( %) of the cases. the xi platform has been the main tool for colorectal surgery only (figure ). conclusions: while xi platform significantly increased caseload in general surgery by facilitating performance of colorectal surgery, its preference in other general surgical fields is not superior to si laparoscopic inguinal hernia repair (tapp) -first experience with the new senhance robotic system robin schmitz ; intuitive surgical inc, loma linda university medical center introduction: crohn's disease is an incurable inflammatory disorder that can affect the entire gastrointestinal tract. while medical management is considered first-line treatment, approximately % of patients with crohn's disease require surgery within years of their initial diagnosis. traditionally, surgery has been performed via an open approach with poor adoption of minimally invasive technique. the aim of this study is to demonstrate the feasibility of robotic-assisted approach as a minimally invasive option for surgical management of crohn's disease and compare the perioperative outcomes with traditional laparotomy. methods: patients who underwent elective resection of the intestine for crohn's disease by roboticassisted or laparotomy approach from to q were identified using icd- codes from premier healthcare database. all the procedures were performed by either general surgeons or colorectal surgeons. since hospital characteristics were comparable between the two cohorts before propensity-score matching, : matching was performed using patient characteristics such as age, gender, race, charlson index score and year of the surgery to create comparable cohorts. sample selection and creation of analytic variables were performed using instant health data (ihd) platform (bhe methods: we conducted a retrospective analysis of , mis inguinal hernia repairs ( , robotic, , laparoscopic) from through with data collected in the premier hospital database. patient, surgeon, and hospital demographics of robotic and laparoscopic inguinal hernia repairs were compared. the adjusted odds ratio of receiving a robotic procedure was calculated for each of the demographic factors using a multivariable logistic regression model. statistical significance was defined as p. . sas software version . was used for statistical analysis. results: the odds of a procedure being robotic increased from inguinal hernia repair is one of the most common general surgery procedures with over , performed annually in the united states. when compared to traditional open inguinal hernia repair (oihr), laparoscopic inguinal hernia repair (lihr) has been associated with faster postoperative recovery rates and lower postoperative pain. with advances in the robotic platform, robotic inguinal hernia repair (rihr) is an available technique that is currently being explored. this study examines lihr and rihr as described in literature to see if one is superior to the other. study design: search terms: ''inguinal hernia repair surgical complications including hematomas ( . %), seromas ( . %), and trocar site infection ( . %) resolved with antibiotics, with a . % postoperative complication rate. conclusion: rihr repair is a safe alternative to lihr, with fewer postoperative complications and a faster recovery time. however, operative time as well as or room time is significantly longer, which may increase overall cost laparoscopic or robotic approach were chosen on a schedule availability basis. data was collected prospectively and it involved anthropometric data, presence of type diabetes mellitus (t dm), % of preoperative total weight loss (%ptwl), surgical time, postoperative length of stay, -day complications, and need for readmission or reoperation. comparison between groups was carried on with t-test for continuous data and with chi-square test for dichotomous variables. a p lower than . was considered significant. results: overall sagb were performed, laparoscopic and robotic. a long and thin gastric pouch was created calibrated by a fr bougie and a . cm antecolic antegastric gastrojejunal (gj) anastomosis was groups (laparoscopic vs robotic) were comparable regarding age ( vs . years, p= . ), bmi ( . vs kg/m , p= . ), %ptwl ( . vs . %, p= . ) and % with t dm ( vs there were fewer men in the laparoscopic group ( . vs % there were ( . %) major complications in the laparoscopic group: bleedings from the gj anastomosis, one of which required reoperation, severe dumping syndrome, gerd requiring revision and gj stricture that underwent relaparoscopy. the only complication ( %) in the robotic group was an acute pancreatitis. readmission rate was % in both groups and reoperation rate was % for laparoscopic and % for robotic surgeries. conclusions: totally robotic sagb with manual gastro jejunal anastomosis was safe and feasible in this early experience compared to laparoscopic approach multi degrees of freedom manipulator with mantle tube for assisting endoscopic and laparoscopic surgical operations masataka nakabayashi, phd , yuta hoshito, masters student p step by step anatomic mapping during laparoscopic transabdominal adrenalectomy lateral flank approach ranbir singh steps analyzed were: right adrenalectomy: step ) mobilize liver; ) medial dissection; ) adrenal vein isolation; ) inferior dissection; ) adrenal off kidney; ) detachment. left adrenalectomy: step ) division splenorenal ligament; ) develop plane pancreas/kidney; ) mobilization medial/lateral borders adrenal; ) adrenal vein isolatoin; ) dissection adrenal off kidney; ) detachment. structures were identified as yes/no and results expressed as percentage total n of cases seen at each step. results: structures identified at each step are shown (table) incisions were made at the oral vestibule under the inferior lip. a -mm trocar was inserted through the center of the oral vestibule with two -mm trocars above incisors. the subplatysmal space was created down to the sternal notch, and carbon dioxide was insufflated at pressure mmhg to maintain the working space. parathyroidectomy was performed using laparoscopic instruments. intraoperative parathromone levels were measured minutes after excision of gland. primary end-points were the success rate in achieving the cure from hyperparathyroid state and hypocalcemia rate. secondary end-points were operating time, scar length, pain intensity assessed by the visual-analogue scale, analgesia request rate, analgesic consumption, quality of life within postoperative days (sf- ), cosmetic satisfaction, duration of postoperative hospitalization, and cost-effectiveness analysis. result: one patient experienced a transient recurrent laryngeal nerve palsy which was spontaneously resolved within month. no permanent recurrent laryngeal nerve injury was found no mental nerve injury or infection was found. conclusion: with highly sensitive localising sestamibi and ct scans, focussed exploration is the current standard of treatment. among all minimally invasive surgeries, toepva is a feasible, safe, and almost pain-free surgical option when combined with intraoperative parathormone monitoring for patients with hyperparathyroidism indocyanine green is a water soluble nontoxic compound exhibiting near infrared renal function and long-term survival. indocyanine fluorescence helps in assessing vascular flow, tissue perfusion and aberrant anatomy and thereby leads to lower conversion rates in partial nephrectomy. we aim to present our experience in patients who underwent partial nephrectomy over years. materials and methods: of the partial nephrectomies performed at our institution, were done by laparoscopic approach alone and rest by patients who underwent llr for whole hepatoma in our facility, underwent llr for a solitary hepatoma and were divided into "before standardization" (bs; n= ) and "after standardization" (as) groups (n= ). patient background, characteristics, and perioperative outcomes were compared between these groups. procedure: we chose the devices according to phases of liver transection. a soft-coagulation monopolar device was used for marking surface. an ultrasonically activated device was used for transection of the liver surface within a -cm depth. crash and sealing with biclamp were indicated for deep-phase transection. the cavitron ultrasonic surgical aspirator was used if the lesion was close to the major glisson's sheath or the major hepatic vein. results: no significant differences in the patients' background were found between the two groups. the operative durations were min ( - min) and min ( - min) in the as and bs groups, respectively, with a significant difference (p. ). the blood loss volumes were cc ( - cc) and cc ( - cc), respectively (p= . ). the lengths of hospital stay after llr were days (range, - days) and days ( - days), respectively, with a significant difference iwao kitazono, phd , kentaro gejima , hizuru kumemura , akira hiwatashi , yuichiro nasu , fumisato sasaki , akio ido , yutaka imoto ; cardiovascular and gastroenterological surgery, kagoshima university graduate school of medical and dental science, digestive and lifestyle disease, kagoshima university graduate school of medical and dental science introduction: in locally-treatable gastrointestinal tumors, laparoscopic endoscopic cooperative surgery (lecs) is a minimally-invasive technique that can avoid excessive resection of the gastrointestinal tract. objective: to share our therapeutic guidelines and surgical technique of lecs for gastroduodenal tumors. subjects: nineteen patients who underwent lecs for gastroduodenal tumors ( patients with gastric tumor and patients with duodenal tumor).[results] ) gastric tumors ( gist, glomus): . site of lesion was u ( patients), m ( ), or l ( ), . operative procedure was acquired in a stepwise manner from classical lecs ( patients) to inverted lecs ( ) to non-exposed endoscopic wall-inversion surgery: news ( ). . operative outcome revealed no postoperative complications. ) duodenal tumors ( adenoma, m cancer, ectopic pancreas): . site of lesion was bulbus duodeni ( patient), superior part ( ), or descending part ( ); . operative procedure was esd followed by laparoscopic continuous suture in a single seromuscular layer for patients with preoperatively confirmed or suspected cancer, or full-thickness resection followed by albert-lembert suture along the short axis for patients unable to undergo esd. in all cases, c-tube was placed to prevent bleeding and perforation at the site of resection due to exposure to bile; . operative outcome included successful endoscopic hemostasis upon bleeding from exposed vessel on postoperative day in patient and anastomotic leak in patient. the event of anastomotic leak resolved after days of bile drainage through c-tube and conservative therapy. compared with patients who underwent esd alone, those who underwent lecs had significantly larger diameters of resected specimens and tumors (p. ) but no significant difference in the incidence of postoperative bleeding and delayed perforation. conclusion: for gastroduodenal tumors, lecs is a minimally-invasive and safe therapeutic option as it combines advantages of both laparoscopy and endoscopy. in particular, c-tube placement for bile drainage was effective in reducing exposure of the suture site to bile as well as supporting drainage after anastomotic leak. introduction: in japan, transurethral balloon catheters (tuc) are currently inserted in most surgical patients to maintain a urine outflow route and to measure the urine output both intraoperatively and postoperatively. however, tuc insertion not only causes postoperative pain but can also lead to urinary tract infections. temporary suprapubic catheters (spc) are used in the field of obstetrics and gynecology as a method of postoperative management to avoid performing transurethral procedures. in the field of surgery, especially in laparoscopic surgery, spc also considered how it would be a useful way to reduce patient suffering. here we report our prospective study on whether an spc can be safely inserted as a substitute for tuc during laparoscopic-assisted colectomy. subjects and methods: the subjects in this study were patients who underwent laparoscopic surgery for primary colorectal cancer from to , and who would normally have had their urinary balloon catheter removed early after surgery. during surgery, an angiomed cystostomy set was installed for patients who gave their consent to participate in this study as an alternative to a urinary balloon catheter. we prospectively collected patient information including sex and age, in addition to other perioperative data, such as, time required for cystostomy, complications accompanying cystostomy, sense of discomfort or pain associated with the vesical fistula after surgery, the time of the removal of the vesical fistula, the frequency of releasing the vesical fistula, postoperative complications. results: our subjects included cases who gave their informed consent to have an spc inserted. an spc was inserted into the remaining case. the mean surgical duration was min, and the spc insertion was performed at a mean of min after the start of surgery. insertion required a mean duration of . s. the bladder of one case ( . %) was perforated, and hematuria was observed at the time of insertion in two cases ( . %), but surgery completed without any incident. six out of cases ( . %) demonstrated neither urinary urgency nor independent urination on the day the catheter was clamped. however, the clamp was released two to four times, and draining of an average of ml urine, urinary urgency, and independent urination were confirmed - days later. conclusion: spc is a procedure that avoids crossing the urethra and its associated disadvantages. here we were able to demonstrate that the procedure can be safely used in laparoscopic surgery patients.our objective is to devise methods for proper port placement to overcome the ergonomic challenges. procedure: patients with sit were operated laparoscopically in our hospital in the period of may to november , males suffering from cholelithiasis without cholecystitis and female with acute appendicitis. after thorough review of literature and proper planning, the patients were posted for surgery. for laparoscopic appendectomy, a thorough initial diagnostic survey is performed on introducing a scope through the umbilical port and confirming the exact location of the appendix. the two working ports are introduced accordingly, which is usually a mirror image of the standard port sites. the appendix was visualised in the left iliac fossa and after meticulous dissection, the appendix and mesoappendix were divided using an endostapler. the operative time was minutes and there were no intraoperative or postoperative complications.the port placement for laparoscopic cholecystectomy in such a case is trickier as the anatomical variation and the contralateral disposition of the biliary tree demand an accurate dissection and exposure of the biliary structures to avoid iatrogenic injuries. it is important to conform to the principles of triangulation during port placement. the mirror image of -port placement is convenient for left-handed surgeons. whereas, to make the procedure comfortable for right-handed surgeons, the working ports need to be shifted caudally with the surgeon standing between the patient's legs. the mean operative time was minutes and there were no minor or major intraoperative or postoperative complications.conclusion: ergonomic comfort is vital to a smooth procedure. while mirroring ports suffices for appendectomy, all other procedures require forethought for port placement. it should be noted that ambidexterity is a desirable skill in the operating room for a laparoscopic surgeon.priscila r armijo, md, chun-kai huang, phd, gurteshwar rana, md, dmitry oleynikov, md, ka-chun siu, phd; university of nebraska medical center introduction: the aim of this study was to determine how objectively-measured and self-reported fatigue of the upper-limb differ between laparoscopic and robotic surgical training environments. methods: surgeons at the sages conference learning center, and at our institution were enrolled. two surgical skills practical environments were utilized: ) a laparoscopic training-box environment (fls) and ) the mimic® dv-trainer (mimic). two standardized surgical tasks were chosen for both environments: peg transfer, and needle passing. each task was performed twice. objective fatigue was evaluated by muscle activation and fatigue, and comparisons were made between fls and mimic, for each surgical task. muscle activation of the upper trapezius, anterior deltoid, flexor carpi radialis, and extensor digitorum were recorded during practice using surface electromyography (emg; trignotm, delsys, inc., boston, ma). the maximal voluntary contraction (mvc) was obtained to normalize muscle effort as %mvc. the median frequency (mdf) was calculated to assess muscle fatigue. subjective fatigue was self-reported by completing the validated -scale score piper fatigue scale- (pfh- ) before and after practice. statistical analysis was done using spss v . , with α= . . results: this abstract represented the performance of trainees (fls: n= , mimic: n= ) as part of larger cohort of the study. for peg transfer, emg analysis revealed that mimic had a significant increase in mean muscle activation for the upper trapezius and anterior deltoid, both p\ . . conversely, practice with fls led to significantly more muscle fatigue than mimic for the same muscle groups (upper trapezius: p= . , anterior deltoid: p= . ), represented by a significantly lower mdf. similarly, for needle passing, mimic had a significant increase in mean muscle activation for the upper trapezius (p= . ) and anterior deltoid (p= . ), but practice with fls significantly induced more muscle fatigue effort for anterior deltoid (p= . ). survey analysis revealed a significant decrease in self-reported fatigue after performing fls tasks (before: . ± . , after: . ± . , p= . ), but no difference after mimic tasks (before: . ± . , after: . ± . , p= . ). conclusions: although different muscle groups are preferentially required in the performance of fls and mimic, our analysis for both surgical tasks showed practice with mimic required more activation of shoulder muscles, whereas practice with fls could lead more muscle fatigue for the same muscle groups. interestingly, surgeons reported improved or no change in perceived fatigue after the tasks, despite of having an increase in muscular activation and effort. subjective selfreport fatigue might not truly reflect the level of fatigue when trainees practice surgical tasks using fls or mimic. objective: to investigate the prevalence of musculoskeletal (msk) injuries in bariatric surgeons around the world. background: as the popularity of bariatric surgery increases, efforts into improving its patient safety and decreasing its invasiveness have also been on the rise. however, with this shift towards minimal invasiveness, surgeon ergonomic constraints have been imposed, with a recent report showing a - % prevalence of physical complaints in surgeons performing laparoscopic surgeries. methods: a web-based survey was designed and sent out to bariatric surgeons around the world. participants were queried about professional background, primary practice setting, and various issues related to bariatric surgeries and msk injuries. results: there were responses returned from surgeons from countries around the world. . % of the surgeons have had more than years of experience in laparoscopic surgery, . % in open and . % in robotic surgery. % of participants reported that they have experienced some level of discomfort/pain attributed to surgical reasons, causing the case load to decrease in . % of the surgeons. it was seen that the back was the most affected area in those performing open surgery, while shoulders and back were equally as affected in those performing laparoscopic, and the neck for those performing robotic, with . % of the surgeons reporting that this pain has affected their task accuracy/surgical performance. a higher percentage of females than males reported pain in the neck, back and shoulder area when performing laparoscopic procedures. supine positioning of patients evoked more discomfort in the wrists, while the french position caused more discomfort in the back region. only . % sought medical treatment for their msk problem, of which . % had to undergo surgery for their issue, and . % of those felt that the treatment resolved their problem. conclusion: msk injuries and pain are a common occurrence among the population of bariatric surgeons, and has the ability to hinder performance at work. therefore, it is of importance to investigate ways in which to improve ergonomics for these surgeons as to improve quality of life.introduction: the use of robotic technology is rapidly increasing among general surgeons but is not being routinely taught in general surgery residency. we aimed to evaluate our first robotic cases during which time we developed a robotic surgery curriculum incorporating residents. methods: the first robotic cases performed at our institution from - by two surgeons were analyzed. a residency curriculum was developed and instituted after the first months. it consisted of online modules offered by intuitive surgical resulting in certification, simulator training, hands on workshops for cannula placement, docking, instrument exchange, camera clutching and other introductory tasks. patient demographics, type of procedure, resident involvement, total operative and console times, comorbid conditions and complications were evaluated. unpaired t tests were performed for statistical analysis. results: females and males comprised this series with an average age of years ± . the majority of patients, % had comorbidities, with a predominance of hypertension, % and diabetes, %. the bariatric patients had an average bmi of ± . a variety of procedures were performed including hernias, foregut and bariatric. residents participated in % of cases. there were no differences in total operative and console times in cases with residents except bariatric procedures. there were complications in this series; postoperative ileus, gallbladder fossa hematoma and an enterotomy. there was one early conversion to open in a complex foregut case and no deaths in this series.conclusions: we report our initial experience of robotics in a variety of general surgery and complex foregut cases. the implementation of a robotic surgery program and residency curriculum was safe with similar outcomes related to operative times and complications. as mis expands with the application of robotics in general surgery, residency curriculums will need to be revised. further data is needed to determine residency learning curves between robotics and laparoscopy.background: robotic surgery has made a large impact in the fields of urology and gynecology. its use is significantly increasing in the fields of general and bariatric surgery. evidence remains unclear as to the clinical impact on outcomes, and significant questions remain as to the impact of cost. our goal was to evaluate the economic impact of robotic surgeries in general and bariatric surgery at our institution. methods: this study is a retrospective analysis of minimally invasive general and bariatric procedures done at a single institution from january through june . we performed a cost and reimbursement analysis of robotic versus conventional laparoscopic surgery. the cost evaluation included operative time, operating room costs, length of stay and overall hospital expenses. in addition, we looked at reimbursement and the contribution margin per cpt code. results: our study included a total of patients who underwent laparoscopic and robot assisted general and bariatric surgeries. the average time duration for laparoscopic surgeries was minutes vs minutes for robot assisted. we performed a cost analysis which showed an average total cost of $ , for laparoscopic and an average of $ , for robot assisted. the total reimbursements were $ , for laparoscopic and $ , for robot assisted. this translated to an average contribution margin of $ , for laparoscopic vs $ , for robot assisted. for general surgery we found an average cost of laparoscopic $ , vs robot assisted $ , , with a contribution margin of $ , laparoscopic vs $ , robot assisted. for bariatric surgeries we found an average contribution margin of $ , for laparoscopic vs $ , for robot assisted. conclusions: robotic surgery has been associated with higher costs and longer operative times. in this economic climate of increased cost awareness with institutions under increasing financial pressures, judicious use of resources becomes important when determining surgical approach. although cost of robot assisted surgery may decrease with time, other quality factors may be important in patient selection. although there is no clear evidence that institutions lose money with robot assisted surgery, in our experience the contribution margin is lower with robot assisted surgery as compared to conventional laparoscopy.introduction: this retrospective study was performed to evaluate the safety and feasibility of the new senhance robotic system (transenterix) for inguinal hernia repairs using the transabdominal preperitoneal approach. our series is the first experience in the field of general surgery utilizing this new robotic platform. methods: from march to september , inguinal hernia repairs in patients were performed using the senhance robotic system. the senhance surgical system is a new robotic platform that consists of a cockpit, manipulator arm and a connection node (figure ). this new system provides robotic surgery with numerous advantages including eye-tracking camera control system, haptic feedback, reusable endoscopic instruments, and a high configuration versatility due to total independency of the manipulator arms. patients were between and years of age, eligible for a laparoscopic procedure with general anesthesia, had no life-threatening disease with a life-expectancy of less than month and a bmi \ . a retrospective chart review was performed for a variety of pre-, peri-and postoperative data including but not limited to patient demographics, hernia characteristics, intraoperative and postoperative complications. results: male and female patients were included in the study. median age was . years (range - years), and median bmi was . (range . - . kg/m ). median docking time was minutes (range - minutes), and median operative time was minutes (range - minutes). two cases were converted to standard laparoscopic surgery due to robot malfunction and intraoperative bleeding respectively. one patient developed a postop seroma that did not require any further intervention. conclusion: we report the first series of laparoscopic inguinal hernia repairs using the new senhance robotic system. compared to previously published conventional laparoscopic or robotic tapp hernia repairs these data suggest similar outcomes in operative time and perioperative complications. additionally there was no significant learning curve detected due to its intuitive applicability. therefor the senhance robotic system can be safely and easily used for tapp hernia repairs by experienced laparoscopic surgeons. this is a video presentation of years old female, who presented with suprapubic pain and mass to gynecology office. she has a history of robotic hysterectomy and sbladder sling operation years ago. this was complicated with peritonitis and long icu stay, due to what she was called ''bowel injury'' but treated only conservatively with antibiotics and subsequent abscess drainages at that time. she has occasional appearing nodule and pain at the left suprapubic region. ct ordered by gynecology read as abdominal wall hernia with long sigmoid diverticuli in hernia. also there was small amount of subcutaneous air at the tip of herniated diverticuli. after antibiotic treatment and improvement, colonoscopy shows, actually the diverticuli is the limb of the sling going through the simoid and anchored in subcutaneous fat on abdominal wall ahich represents clocutaneous fistula as gets infected. clip was placed on sling and repeat imaging comfirmed that the localion of this sling fits to location of so called ''hernia'' the sling limb was resected robotically and colon was repaired with side stapling of clolonic wall. the abdominal wall defect is repaired with long term absorbable suture. as far as we have found, the presentation and treatment of this complication is unique and could not find a similar case to guide us for the plan. background: robot-assisted surgery using da vinci surgical system (dvss) is thought to have many advantages over conventional laparoscopic surgery. it was reported that the use of the surgical robot might reduce surgery-related complications, then a multi-institutional historically controlled prospective cohort study on the feasibility, safety, effectiveness and economical efficiency of robotic gastrectomy (rg) for resectable gastric cancer was conducted in japan. this study evaluated the safety of rg using dvss xi. methods: this single-center, prospective phase ii study included patients with resectable gastric cancer (umin ). the primary endpoint was the incidence of post-operative complications greater than grade iii according to clavien-dindo classification during one month after surgery. the secondary endpoints included all adverse events and completion rate of robotic surgery. results: from oct to jan , patients were enrolled for this study. the incidence of post-operative complication greater than grade iii was %. the overall incidence of adverse events was . % (grade i; . %, grade ii; . %). no patient required conversion to laparoscopic or open surgery; thus, the rg completion rate was %. conclusion: this study suggested the introduction of rg using dvss xi for gastric cancer seems to be safe and feasible. priscila r armijo, md , dmitry oleynikov, md , sages robotic task force* ; university of nebraska medical center, sages robotic task force introduction: while robotic companies continue to aggressively market and promote the use of robots in general surgery, little is known about how this technology is employed by general surgeons, and what is expected of this technology from both novice and experts in the field. the aim of this study is to evaluate the needs of general surgeons who are new to robotic surgery and the needs of established robotic surgeons. methods: the sages robotic task force survey, a one-page survey, was designed and sent electronically to all sages members. questions regarding fellowship training, area of expertise, robotic simulation and in clinical case use, services offered in the current hospital, mentorship, likelihood of switching to a different approach, and expectations for the robot were included in the survey. two groups were created based on previous use of davinci® system in a clinical scenario, or not. statistical analysis was conducted using ibm spss v. . . , using fischer's exact and pearson's chi-squared tests where appropriate. results: sages members answered the survey. surprisingly, respondents ( %) had used the davinci® in a clinical setting. among these, ( %) had additional fellowship training, compared to ( %) in the non-clinical use group, p= . . of all surgeons with additional fellowship training, the great majority ( %) had specialization in advanced gi, mis and bariatric surgery, followed by colorectal ( %). most surgeons are performing less than cases per month using the robotic system, and with the majority of cases performed using the platform being hernia repairs ( %), followed by foregut-related procedures ( %). interestingly, from all the surgeons who replied the survey, only . % are planning to switch from open procedures to its robot counterpart, whereas . % are planning to adopt robotic-assisted procedures rather than laparoscopy. conclusions: the majority of sages members who responded to the survey have used the davinci® in a clinical setting in the past. surgeons who stated they perform mainly laparoscopic procedures were likely to continue to adopt robotic techniques, whereas those who perform open hernia repair for example were not very likely to switch to robotic approach. while the use of the robot may be enabling surgeons who used to perform mostly open procedures in the urology or gynecology fields, laparoscopic skills predict robotic utilization in general surgery. hernia and foregut appear to be the most common procedures that are being utilized.aim: while conventional multiport laparoscopic splenectomy has become gold standard for some hematological or splenic diseases, reduced-port laparoscopic splenectomy (rpls) including singleincision laparoscopic splenectomy (sils) is regarded as highly challenging. herein, we describe the technical refinements for safe rpls especially for patient with splenomegaly. methods: in all cases, access was achieved via a . -cm mini-laparotomy at the umbilicus into which a sils tm port or e-z access ® with three -mm trocars was placed. a -mm flexible scope, an articulating grasper, and straight instruments were used. our rpls is characterized by the followings: a) early ligation of the splenic artery to shrink the spleen, b) application of our original "tug exposure technique," which provides good exposure of the splenic hilum by retracting (tugging) the spleen with a cloth tape, and c) safe introduction of stapler under the guidance with a flat drain into the splenic hilum. results: rpls patients ( men and women, ± years old) comprised hematological disorder (n= ), splenic disease (n= ), and liver cirrhosis (n= ). in patients ( %), rpls was successfully completed: sils in and sils plus one additional port only in patients. conversion to open surgery was necessary in patients including liver cirrhosis with remarkable collateral varicose veins around the spleen. operation time and blood loss were ± min and ± g, respectively. weight of the extracted spleen was heavier than normal and ± g (maximum g). no intra-or postoperative complication occurred. the postoperative scar was nearly invisible. conclusions: rpls might safely be performed even for splenomegaly (up to , g). however, care should be taken for cirrhotic patient with collateral veins. rpls can be the procedure of choice even in the patients with splenomegaly and who are concerned about postoperative cosmesis. the aim of this feasibility study was to evaluate laparoscopic sn biopsy for laparoscopic snns in early gastric cancer patients. subjects and methods: this study includes patients with ct n m (primary tumor \ cm) gastric cancer who underwent laparoscopic sn biopsy in conjunction with radioisotope and dye methods between jan. and jul. . first, we looked for green-dyed sns after injection of indocyanine green (icg) without near-infrared light system, and then tried to detect the radioactivity of sns using a hand-held gamma probe inserted through a small incision at the umbilical port. after the areas where sns were distributed were resected, a gastrectomy with prophylactic lymphadenectomy was performed according to the gastric cancer treatment guidelines of the japanese gastric cancer association. we looked for undetected sns in the resected specimen at the back table. results: among cases, there were ( %) in which sns were not detected in the resected specimen. there were cases in whom sns were detected in the resected specimen. in both cases, the primary tumors were located in the middle and greater curvature of the stomach. in case , laparoscopic sn biopsy identified the left ( sb) and right ( d) greater-curvature lymph node (lns) as sns, however, lesser-curvature ( ) and infrapyloric ( ) lns remained as sns in the resected specimen. in case , the left ( sb) and right ( d) greater-curvature lns were identified as sns intraoperatively, while the lesser-curvature ( ) ln remained as an sn in the resected specimen. the sns overlooked with laparoscopic sn biopsy method were detected by radioisotope only. no cases had ln metastasis, and the -year relapse-free survival rate of these patients was %. conclusions: our feasibility study of laparoscopic sentinel node biopsy for early gastric cancer showed that we should search for sns of the lesser curvature carefully even if the primary lesion is located at the greater curvature. key: cord- - u cssky authors: martin-villares, cristina; perez molina-ramirez, carmen; bartolome-benito, margarita; bernal-sprekelsen, manuel title: outcome of tracheostomies for critical covid- patients: a national cohort study in spain date: - - journal: eur arch otorhinolaryngol doi: . /s - - - sha: doc_id: cord_uid: u cssky background: the question of an optimal strategy and outcomes in covid- tracheostomy has not been answered yet. the critical focus in our case study is to evaluate the outcomes of tracheostomy on intubated covid- patients. methods: a multicentric prospective observational study of covid- patients undergoing tracheostomy across hospitals was conducted over weeks in spain (march to may , ). data were collected with an innovative approach: instant messaging via whatsapp. outcome measurements: complications, achieved weaning and decannulation and survival. results: we performed , surgical ( . %) and percutaneous tracheostomies. median timing of tracheostomy was days ( – days) since orotracheal intubation. a close follow-up of / ( . %) patients at the cut-off time of -month follow-up showed that in ( . %) patients, weaning was achieved, while ( . %) were still under mechanical ventilation and ( . %) patients had died from covid- . decannulation among those in whom weaning was successful (n = ) was achieved in ( %) patients. conclusion: to the best of our knowledge, this is the largest cohort of covid- patients undergoing tracheostomy. the critical focus is the unprecedented amount of tracheostomies: in weeks. weaning could be achieved in over half of the patients with follow-up. almost one out of four tracheotomized patients died from covid- . poor outcomes in critical patients infected with sars-cov- admitted to icus have been reported [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . in italy, [ ] % of covid- patients were still in icu weeks after admission and mortality rates have been over % in large case series [ , ] . in this pandemic scenario, with limited icus resources [ ] , tracheostomy seems to help covid- patients to get off the mechanical ventilation [ ] , reducing the respiratory effort in patients with limited pulmonary reserves, shortening the dead space and enabling the suctioning of accumulated mucous. current protocols have recommended to delay tracheostomy for at least days or longer or advocated to wait until a negative pcr [ ] [ ] [ ] . however, all recommendations are neither based on the experiences of patients infected by the sars-cov- nor in a pandemic situation with overcrowded icus lacking proper equipment for mechanical ventilation. the questions of an optimal strategy and outcomes in covid- tracheostomies have not been answered yet. covid orl esp collaborative group members and hospitals (*) are listed in the acknowledgements section. spanish otolaryngologists began tracheostomies very early in the pandemic, on march , . the rationale was to achieve fast weaning to enable incoming patients to take advantage of the released mechanical ventilation equipment. the critical focus of our case study is the unprecedented amount of tracheostomies in spain that may serve as a lesson for this and potential future pandemics. on march , the spanish covid orl group was created to share experiences in the management of upper airway during this pandemic. the group has performed a national multicentric prospective observational study on covid- critical patients undergoing tracheostomy in a total of hospitals in spain. the study prospectively collected data during seven consecutive weeks from march to may , in each participating hospital. clinical data were collected daily with an innovative approach: instant messaging via whatsapp by participants. a daily report analysed data to keep all surgeons updated. each participating hospital included: new covid- patients undergoing tracheostomy, achieved weaning and decannulation of patients (as non-identified data). also, the accumulated covid- -related mortality rate was registered. data were available for all collaborators at any given time. members of the covid orl group shared experiences in tracheostomy indications, performance and outcomes, but also in self-protection in covid- scenario. to assess the impact of tracheostomy in intubated covid- patients, the following outcome measurements were assessed on a daily basis: (a) indication of tracheostomy: conventional or emergency tracheostomy; (b) timing for tracheostomy (early < days or late > days); (c) technique: open or percutaneous tracheostomy; (d) perioperative complications; and (e) final outcomes: the number of patients in whom weaning and/or decannulation could be achieved, complications and survival. follow-up of tracheotomized patients was performed until month after the procedure. over otolaryngologists had registered on march , to participate in the covid orl messenger group. this social media platform allows the large group of ent colleagues from hospitals to exchange critical information and development of a common strategy in the pandemic. as of may , , with , icus patients confirmed by the health ministry of spain [ ] , data for covid- patients who underwent tracheostomy across hospitals in spain were available. most of tracheostomies were performed in a very short time: tracheostomies in less than months (figs. , ) . from march to april alone, during the weeks of the pandemic peak in spain, data were entered for cases. after the peak, from april to may , further cases were added. the unequal spread of covid- in spain had an impact on the number of tracheostomies in each hospital (fig. surgeons shared some technical modifications, such as a sub-isthmus tracheotomy approach or the use of electrocautery and harmonic scalpel, both used exclusively before opening the trachea. most of the endotracheal tubes were found partially or subtotally blocked with sticky secretions. only cuffed non-fenestrated tubes were used in all covid- patients. isolated cases of tracheomalacia with cuff leaking were reported. complication rate was low; hemorrhage was the notable major adverse outcome in patients ( . %). one patient died from bleeding. among other adverse events were desaturation with cardiac arrest (n = ; . %), right after opening the trachea, with ( . %) subsequent intraoperative deaths. pneumothorax after tracheostomy was reported in cases. all surgeons were able to use personal protective equipment (ppe) in all procedures. standard ppe consisted of glasses, n /ffp with an additional surgical mask placed above, two pairs of gloves and a face shield. initially, ppe with powered air-purifying respirator (parp) was available only in two hospitals. just one vital emergency tracheotomy was performed without ppe under less optimal conditions, with only double surgical mask and glasses. the surgeons who performed this procedure were asymptomatic at weeks after procedure and tested antibodies proved negative. an overview of all outcomes is listed in fig. . a close follow-up of / ( . %) patients at the time of reporting showed that in ( . %) patients, weaning was achieved, while ( . %) were still under mechanical ventilation, while ( . %) patients died from covid- . among those in whom weaning was successful (n = ), decannulation could be achieved in / ( %) at the cut-off time. on early march, , at a very critical moment of the pandemic in spain and without published data yet from initial experiences in china or italy, spanish otolaryngologists began their first tracheostomies in madrid (march, ) and barcelona (march, ) , with the onrush of more than a thousand patients in their respective overcrowded icus, which doubled its current capacity. a large group of otolaryngologists started an innovative exchange of critical information focused on tracheostomy on covid- patients under mechanical ventilation in an attempt to coordinate among themselves and to develop a common strategy. on may , the spanish health ministry confirmed , icu accumulative admissions [ ] . between march and may , the spanish covid group, encompassing hospitals, performed tracheostomies, the equivalent of . % of all registered icu patients with mechanical ventilation in spain. herein, ent departments not participating in our social media group have not been considered; therefore, the number of total tracheostomies in spain can be presumed to be even higher. to the best of our knowledge, there are no published data about such a high number of tracheostomies in covid- critical care units. the rate of tracheostomies ( . %) is similar to that reported in large cohort studies on acute respiratory distress syndrome (ards) in the lung-safe trial [ ] ; % of ards patients underwent tracheostomy in icus of [ ] . timing of the tracheostomy remains controversial [ ] . our data about the median timing for tracheostomy are days (range - days) after tracheostomy. only . % of our covid- patients ( / ) underwent tracheostomy at a very early stage within days of intubation. in the covid trach collaborative group [ ] , only % of patients underwent tracheostomy before days of intubation. in the recent literature (table ) , tracheostomy related to covid- was indicated after - days of mechanical ventilation. a systematic review of , patients from studies published by adly [ ] could show that early tracheostomy within days reduces the complications and mortality. however, most of the patients had healthy lungs, whereas critical covid- patients presented severe acute respiratory distress syndrome (ards). several ent academies have advocated to delay tracheostomies in covid- patients for days or longer after intubation, some including pcr negativity, to reduce the risk of contagion [ ] [ ] [ ] . an international consensus suggests that covid- tracheostomy should be performed after day of invasive ventilation and considered only when patients display signs of clinical improvement [ ] . in any case, all recommendations are currently based on patients not infected by the sars-cov- . also, the pressure of overcrowded icus with a high demand for equipment for mechanical ventilation had not been considered in any recommendation. this calls into question whether delaying a useful technique that potentially supports weaning and eventual decannulation has to be delayed because of a potential risk of contagion that has not been demonstrated so far. due to the type of data collection, it could not be analyzed whether early or late tracheostomy made a difference in time of rate of weaning or decannulation. no comparison was made with long-term intubated, non-tracheostomized patients. technical issues in the execution for covid- tracheostomy were highlighted after lessons learned in the sars outbreak [ ] : expert surgical teams, avoiding repeated connections and disconnections of ventilator circuits, minimal use of diathermy, stopping mechanical ventilation just before opening the trachea, closed suction circuits and negative-pressure room whenever feasible, as recommended in the consensus document elaborated later based on this experience [ ] . but in covid- pandemic, new scenarios have come up. in some centers, the onrush of cases in need of mechanical ventilation led to the creation of covid- critical care units, sometimes located far from the operation theaters and most of our tracheostomies were performed at the bed-side. in the covidtrach collaborative cohort [ ] , % of tracheostomies were performed in the operation theatre and % in intensive care. in our cohort, the decision whether to perform a surgical or a percutaneous tracheostomy depended on the experience with the latter. more open tracheostomies ( . %) were performed by the group, as were in the covidtrach collaborative cohort [ ] . complication rates in tracheostomy were low. with . % hemorrhages requiring surgical revision was the most frequent one, similarly as in other reports [ , ] or the ards-related trac-man trial study [ ] . eventually, one patient died from bleeding. among other adverse events, ( . %) intraoperative deaths right after opening the trachea occurred. poor survival rates have been published for intubated critical patients without tracheostomy infected with sars-cov- admitted to icus (table ) , with mortality rates in large case reports of - . % [ , ] . case reports about tracheostomies in covid- are scarce and with too few cases ( table ) to allow further conclusion. the overall covid- -associated mortality in our cohort at the time of reporting was . % (n = / ). in the covidtrach collaborative cohort [ ] , only % mortality rate was found; however, % (n = / ) of patients were still under mechanical ventilation at the time of completing the study. in our study, / ( . %) were still under mechanical under ventilation at the cut-off time. a review of clinical [ ] no data . % (n = ) grasseli, italy [ ] jan - , . % (n = ) arent, usa [ ] feb -march % wang, china [ ] jan - , % (n = ) huang, china [ ] dec -jan , % (n = ) yang, china [ ] no data % (n = ) zhou, china [ ] dec -jan % yao, china [ ] h post intubations . % studies about tracheostomies in acute respiratory distress syndrome (ards) patients undergoing tracheotomy, with very damaged lungs, such as covid- pneumoniae, shows a mortality rate of - % [ , ] . in this pandemic scenario, with limited icus resources [ ] , our data show that about . % (n = / . ) of patients undergoing tracheostomy get off the ventilator. the covid trach collaborative group from uk nhs reports similar weaning success rates ( %; n = / ). the results of both reports suggest that the tracheostomy could be effective in the weaning and decannulation of covid- patients, although data are preliminary yet and further studies are required. covid- recommendations on tracheostomy technique, perioperative management and self-protection have been very similar to sars outbreak protocols. sars-cov- is a new virus that has led to a pandemic, with an onrush of covid- cases that needed to be dealt with. in spain, a large group of ent colleagues from hospitals created an innovative exchange of critical information through social media platform that proved usual for exchange of information and development of a common strategy. from , patients, weaning could be achieved in % with an overall mortality of . %. nevertheless, . % still remain connected to mechanical ventilation at the cut-off time despite the long-term follow-up due to chronicity and severity of covid- disease. tracheostomy may have helped to the recovery of more than critically ill covid- patients and subsequently released more than mechanical ventilators for incoming patients, but it remains unclear whether tracheostomy influences the survival of these patients and which might be the ideal timing to perform it. further studies are required to try to clarify these issues. this study has several limitations. data were collected prospectively by an instant messaging group on-site. subsequently, data are incomplete or missing in . % of the cases. the follow-up time of month seems to be too short as at the cut-off time. . % patients were still tracheotomized and under mechanical ventilation. she has been involved in reviewing the manuscript version to be published and interpretation of results. a special acknowledge to prof. miguel arístegui md phd, head of ent-department of gregorio marañón madrid hospital for his expert comments in the manuscript. we also like to thank the spanish society of otorhinolaryngology and head and neck surgery (seorl-hns) and the clinicians and staff members of every hospital that took care of our patients with tracheostomy in the sars-cov- pandemic altahaia xarxa asistencial manresa hospital, m dolors deola-trasserra, vanessa villarraga-cova cabueñes gijon hospital, marta fernandez-pello can mises ibiza hospital ciudad real general hospital ciudad de coria hospital jorge de abajo-larriba; del mar barcelona hospital dr negrin gran canaria hospital, jesus benitez-del rosario tomas martinez-guirado infanta elena huelva hospital, jesús crovato-rojas infanta cristina badajoz hospital, tomas mogollon-cano la candelaria tenerife hospital marques de valdecilla santander hospital ntra stra sonsoles avila hospital, maria jesus velasco; palencia hospital, ignacio alonso-castiñeira puerta de europa algeciras hospital quiron ciudad real hospital san carlos madrid clinic hospital, mari cruz iglesias-moreno san juan de dios barcelona hospital coia romeu-figuerola, maria foglia-fernandez son espases mallorca hospital son llatzer mallorca hospital urduliz hospital vic hospital jose miguel sebastian; university hospitals of derby and burton nottigham (gb)* invited hospital britain intensive care national audit and research centre ( ) icnarc report on covid- in critical care characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention baseline characteristics and outcomes of patients infected with sars-cov- admitted to icus of the lombardy region characteristics and outcomes of critically ill patients with covid- in washington state clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan clinical features of patients infected with novel coronavirus in wuhan, china clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study emergency tracheal intubation in patients with covid- in wuhan, china: lessons learnt and international expert recommendations ventilator triage policies during the covid- pandemic at u.s. hospitals associated with members of the association of bioethics program directors covidtrach; the outcomes of mechanically ventilated covid- patients undergoing tracheostomy in the uk: interim report nd tracheotomy recommendations during the covid- pandemic recommendations from the cso-hns taskforce on performance of tracheotomy during the covid- pandemic informe sobre la situación de covid- en españa nº . de mayo de epidemiology and patterns of tracheostomy practice in patients with acute respiratory distress syndrome in icus across countries tracheotomy in covid- patients: optimizing patient selection and identifying prognostic indicators safety and prognosis in percutaneous vs surgical tracheostomy in patients with covid- early experience in tracheostomy and tracheostomy tube management in covid- patients recommendation of a practical guideline for safe tracheostomy during the covid- pandemic letter to the editor regarding "corona-steps for tracheotomy in covid- patients: a staff-safe method for airway management tracheostomy in the covid- pandemic anesthetic and surgical management of tracheostomy in a patient with covid- early versus late tracheostomy for critically ill patients timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review tracheostomy in the covid- era: global and multidisciplinary guidance surgical considerations for tracheostomy during the covid- pandemic: lessons learned from the severe acute respiratory syndrome outbreak consensus document of the spanish society of intensive and critical care medicine and coronary units (semicyuc), the spanish society of otorhinolaryngology and head and neck surgery (seorl-ccc) and the spanish society of anesthesiology and resuscitation (sedar) on tracheotomy in patients with covid- infection effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the tracman randomized trial this article was made possible by the generous sharing of experience by prof. jesus m culebras md phd, professor of surgery and member of the royal academy of medicine and surgery of valladolid. he has given us advice on how to organize the data collection in our patients. he also reviewed the manuscript critically for important intellectual contents. we also acknowledge author contributions cmv, cpmr and mbb develop the concept and designed the study. cmv had the responsibility of the data collection and data analysis. cmv wrote the manuscript. mbs made final corrections. all authors have revised the manuscript and gave approval for the published version. conflict of interest we have no conflicts of interest to disclose. key: cord- - xzc uc authors: nan title: esicm wednesday sessions october date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: xzc uc nan power spectrums for vt and eadi are shown in fig. (ps and nava) for a typical patient. the enlarged section highlights how changes in eadi are highly synchronized with nava ventilation, but less so for ps. table ) and complications of mechanical ventilation ( table ) did not differ significantly between the two studied groups. introduction. high tidal volumes in mechanically ventilated patients with ards lead to baro/bio-trauma and increase mortality. also, it was recently shown that ventilation with high tidal volumes is a risk factor for ''acquired ards'' in a medical population. objective. we evaluated the impact of high tidal volumes after cardiac surgery. method. we analysed the prospectively recorded data of , consecutive patients who underwent cardiac surgery from to . we predefined groups of patients based on the tidal volume delivered immediately after surgery: ( ) low: - . , ( ) ''traditional'': - . , ( ) high: above ml/kg of predicted body weight (pbw). we assessed the risk factors for organ dysfunction (prolonged mechanical ventilation, hypoxemia, hemodynamic failure and renal failure) by univariate and multivariate analysis, including the initial tidal volume in the models. mean tidal volume/actual weight and tidal volume/pbw was . ± . and . ± . in men (p \ . ), . ± . and . ± . in women (p \ . ). patients ( %) were ventilated with low tidal volumes, , ( . %) with ''traditional'' tv and ( . %) with high tv. the mean body mass index in the groups was . ± . , . ± . and . ± . respectively (p \ . ). with increasing bmi, the tidal volume/ actual weight decreased while the tidal volume/pbw increased (figure) . the percentage of women was . , . and . % respectively for low, ''traditional'' and high tv (p \ . ). high tidal volumes were associated with prolonged intubation ([ h) ( . vs. conclusion. traditional and very high tidal volumes are associated with prolonged mechanical ventilation and organ dysfunction after cardiac surgery and use of high tidal volumes is an independent risk factor. ''prophylactic'' protective ventilatory strategy should be provided in this population with inflammatory state at risk to develop ventilator induced pulmonary edema. women and patients with high bmi are more at risk to be ventilated with injurious tidal volumes. introduction. evidence shows that clinicians' non-technical skills (behavioural and cognitive skills) have a significant impact on teamworking, patient safety, efficiency of care provided and potentially patient outcomes ( ) . such skills are key for cardiac arrest teams (cats), which are multi-professional (anaesthetists, physicians and nurses) and normally function under high pressure. to date, most tools to assess nontechnical skills in healthcare have focused on surgery ( ) and anaesthesia ( ) . no validated, robust tools are currently available for assessing non-technical skills in cats. objectives. to develop and validate an observational skill-based clinical assessment tool for resuscitation (oscar). this should be psychometrically robust for use in both training and assessment contexts. methods. oscar was based on a well-validated tool for surgery (otas) ( ) and was developed in phases. six behaviours were included in the assessment: communication, cooperation, coordination, monitoring, leadership and decision-making. observable behavioural exemplars were derived for each one of these behaviours across the three cat subteams-anaesthetists, physicians and nurses (phase ). quantitative expert consensus methodology was employed to assess content and face validity and observability of the exemplars (phase ). two clinician observers used oscar to blindly rate eight cats performance in a series of simulated cardiac arrests. psychometric analyses of these ratings were used to determine observable behaviour applicability, internal consistency, and inter-rater reliability (phase ). . of oscar behaviours demonstrated high internal consistency (cronbach a = . - . ). psychometric analyses dictated removal of three behavioural exemplars (two in anaesthetic group; one in physician group) to significantly improve internal consistency. inter-rater reliability was also high (inter-observer pearson r = . - . , all p \ . ). inter-observer reliability analyses revealed a learning curve between the two observers, with significant reduction in scoring discrepancies from the first to the eighth observed resuscitations. conclusions. oscar is a psychometrically robust (reliable, content-and face-valid) tool for the assessment of teamworking skills in cardiac arrest events. the tool is feasible to use and can be employed for both training and assessment purposes. introduction. different educational methodologies are used to teach basic skills in emergency medicine. high-fidelity patient simulation offers an ideal venue for presentation of critical events that can be managed by medical students without risk to a patient. therefore full scale simulation training could be superior to paper case based seminary rounds to achieve these specific educational objectives. objectives. the aim was to compare simulation to a standard education measured by multiple choice questionnaire. after written informed consent and approval of the institutional research ethics board fifth year medical students were included in the survey. they took part in the compulsory emergency medicine curriculum of charité universitätsmedizin berlin. the students completed a basic multiple question tests on day including questions concerning the topic of ''acute coronary syndrome'' (acs). on day for the topic ''acs'' half the group was assigned a min session simulation training while half the group was assigned a min session paper case training. on day groups were reversed and the topic ''aic'' was taught in either simulation training or paper case seminary round. the test of day was repeated after each training sessions. results of the tests were evaluated using spss(tm) . the mann whitney u test was used to show any significant differences in reaching educational objectives in the test (a \ . was considered significant). there was an even distribution of men and women among the two groups. the test results showed no significant difference between the two groups on day . on day two for the topic ''acs'' the group with simulation training achieved significantly better test results. for the topic ''acs'' on day there was no difference while students received further training in acs not using a high fidelity simulator. the results were not linked to specific teachers. introduction. rapid sequence induction (rsi) involves loss of spontaneous breathing and mandates airway control. steps to reduce adverse incidents include adherence to minimum monitoring standards, appropriate drug selection, access to difficult airway equipment and presence of skilled anaesthetists. there is substantial evidence that appropriate monitoring reduces risk by detecting the consequences of errors, and by giving early warning of patient deterioration. objectives. to assess conduct of emergency anaesthesia (monitoring and drugs) for critically ill patients not in an operating theatre (or) administered by intensive care doctors. methods. prospective analysis of rsi for critically ill patients in a uk nhs acute hospital over month. or based practice was excluded. reason for anaesthesia, location, drugs administered, monitoring modalities, adverse events and access to airway equipment were recorded. results. data from patient episodes were collected: predominantly in the emergency department ( %) and intensive care unit ( %) for respiratory failure ( %), reduced consciousness ( %) and to facilitate investigations ( %) . the most common induction agent was propofol ( %); thiopentone ( %) and etomidate ( %) were less frequently used. suxamethonium ( %) was preferred for initial neuromuscular blockade. during induction most doctors used pulse oximetry, electrocardiography and blood pressure monitoring. only % used capnography. no doctor used minimum monitoring to association of anaesthetists of great britain and ireland (aagbi) standards. rescue airway equipment immediately available is shown in fig. . complications occurred in cases (fig. ) . patients that had a hypotensive episode during induction all had thiopentone or propofol used as induction agents. % of patients had a period of desaturation, and % required more than one attempt for successful intubation. in cases with complications, rescue airway equipment was unavailable in[ and % did not achieve uk minimum monitoring standards. conclusions. shortcomings during emergency anaesthesia were recorded including monitoring, access to rescue airways and physiological disturbance. procedural guidelines and training are to be developed for emergency anaesthesia; access to capnography and alternative airway equipment will be assured. these issues are unlikely to be unique to our trust and assessment of practice is recommended. introduction. critical care echocardiography (cce) is performed and interpreted by the intensivist at the bedside to establish diagnoses and guide the management of patients with circulatory or respiratory failure in the icu. competence in basic and advanced cce has been recently defined [ ] , but no curriculum to reach the required cognitive and technical skills has yet been elaborated. objectives. to assess the efficacy of a limited, tailored training program for noncardiologist residents without experience in ultrasound to reach competence in basic cce. methods. six noncardiologist residents (anaesthesiology: n = , pneumology: n = ) without previous experience in ultrasound participated to the study during two -month periods. the curriculum consisted in h of didactics, h of interactive clinical cases and h of tutored hands-on. color doppler mapping was excluded from the training. after completion of the training program, all eligible patients underwent subsequently a transthoracic echocardiography (tte) performed in random order by a recently trained resident and an experienced intensivist with expertise in cce who was used as a reference. in each patient, the resident and the experienced intensivist answered binary ''rule in, rule out'' clinical questions covered by basic cce [ ] : global left ventricular (lv) size and systolic function (eye-ball evaluation of ejection fraction), homogeneous or heterogeneous lv contraction pattern, global right ventricular (rv) size and systolic function, identification of pericardial fluid and tamponade, and assessment of both the size and respiratory variations of the ivc. in case of undetermined interpretation, the corresponding clinical question was considered not addressed. the agreement between responses to clinical questions provided by the two investigators who independently interpreted the tte study at bedside was used as an indicator of effectiveness of the tested curriculum. proportion of graduates to work within a ''critical care'' setting. the level of support available to trainees may vary with local resources but risk management and national guidelines stipulate that close supervision is provided to junior doctors in high stake decisions and procedures until deemed competent at the relevant tasks . furthermore, substantial ongoing reduction in working hours places further limitations on training; both majors can impact adversely on junior doctors service output and experience. a modified delphi method was used years ago to design a task focused single-day course on the theoretical basis of critical care and provide lab-based training in delphi identified high risk procedures and interventions . objectives. assess the impact of the course on the following: trainee confidence and the start of the ''novice'' critical care post trainee performance in comparison to peers perceived educational benefit from their training post compared to peers methods. junior doctors attending the course were enrolled in the study and matched for graduation year and medical school to junior doctors who did not attend similar training prior to commencing their post. data was collected through anonymous standardized forms on the day of the course, first day of the job, end of week , week and months into the post. trainee confidence and self perceived competence were assessed on a ten point scale. in addition, trainees were requested to maintain a log of interventions: -ultrasound guided central venous catheter insertion, -arterial catheter insertion, -ventilation problem solving. candidates attending the course demonstrated greater confidence at multiple points within their post as well as higher performance, satisfaction and educational value scores. conclusions. critical care trainees benefit from a task focused orientation to the fundamentals of critical care before commencing first post in this setting. . enrolled patients in each group. no differences in age and gender. incidence of vap-study group . % compared to control group . % p value . . vap per , hospital days: control- . % compared to study- . % p value . ; average days in icu control- . compared to study- . , p value . ; average ventilated days, control- . compared to . , p value . ; average antibiotic use in days control- . compared to study- . , p value . . introduction. nosocomial infections are the most common in-hospital complications with high morbidity and mortality. educating healthcare professionals is an important prevention measure. objective. to analyze the impact of a nurse consultant team on nosocomial infections prevention in the icu, the improvement in prevention knowledge of the nurse staff, and its impact in the application of the prevention measures in the daily practice. methodology: the nurse referent team was constituted by nurses. the study subjects were all the staff icu nurses and all the patients admitted during pre and post-intervention phases. the study was conducted in our medical-surgical icu ( beds) in phases: pre-interventional ( / / - / / ) observational. record of the accomplishment of cdc recommended variables about mechanical ventilation associated pneumonia (vap) and catheter related bloodstream infection (cr-bsi) prevention measures. interventional ( / / - / / ) eight educational meetings with the nurses staff groups to teach the most important aspects of the nosocomial infections prevention. before and after lectures every nurses answered an anonymous questionnaire about their knowledge in those subjects. a poster with the most important reminders was place in every icu patient room. post-interventional ( / / - / / ) observational. new record of the same cdc pre-interventional variables. we compared the accomplishment of these variables before and after the interventional phase as well as the number of correct questionnaire answers. statistics were made with spss software. results. during the interventional phase % of the staff nurses attended the educational meetings. the number of correct answers increased significantly after the conference ( . vs. . % p \ . ). regarding to the daily practice, we observed a significant increase in the accomplishment in most of the variables (see table below), while in of them no improve was observed and in the improvement was not statistically significant. during the study period we observed a decrease in the incidence of vap ( . - . episodes/ , mv days) and cr-bsi ( . introduction. glucose variability has been found to be associated with mortality in critically ill patients, independent of mean glucose concentration [ ] . objectives. the aim of this analysis was to assess the impact of real time continuous glucose monitoring (cgm) on glucose variability in critically ill patients receiving intensive insulin therapy (iit). methods. this is the post-hoc analysis of a prospective, randomized, controlled trial [ ] . data of patients admitted to the icu either receiving iit according to a real time cgm system (guardian Ò , medtronic, northridge, ca, usa) (n = ) or according to an algorithm (n = ) with selective arterial blood glucose measurements (simultaneously blinded cgm) for h were analysed. insulin infusion rates were guided according to the same algorithm in both groups. mean glucose and standard deviation, as a marker of glucose variability, were calculated for the first h (glumean , glusd ) and for the whole study period (glu sd ). statistical comparison of parameters between study groups and between icu survivors (n = ) and non-survivors (n = ) was performed using student's t test. results. the variability of sensor glucose during the entire study period was comparable between the real time cgm group and controls ( . ± . vs. introduction. in the gastrointestinal tract, the gut flora which comprises several hundred grams of bacteria is crucially involved in host homeostasis through their metabolic, trophic, and protective activities. however, the immediate changes in the gut flora in critical illness following severe insults are unknown. objectives. to investigate the changes in the gut flora at an early phase of severe insult in critically ill patients. methods. fifteen patients who experienced a sudden and severe insult including trauma, out-of hospital cardiac arrest, and cerebral vascular disease were studied, along with healthy volunteers as the control group. two fecal samples were acquired from the subjects by swabs of the rectum within h after admission to the emergency room (day ). samples were serially collected from patients on day , , , , , and . samples were collected from control subjects. results. total bacterial counts, especially various obligate anaerobes and total lactobacillus, significantly decreased in comparison to those of the control subjects on day . in addition, on day , the total organic acid levels of the patients were significantly lower than those of the control subjects; particularly acetic acid, propionic acid, and butyric acid. the levels of these acids remained low throughout the days period of study. the total bacterial counts did not recover to normal levels during the day study period. obligate anaerobe counts of the patients did not improve until day . total lactobacillus counts were low on day and increased gradually thereafter, but did not attain the levels found in controls. the counts of pathogens (enterococcus and pseudomonas) increased during the study period. conclusions. gut flora in critically ill patients can change drastically immediately after a severe insult, and may not recover for up to days. at the same time, the number of harmful bacteria can increase. total bacteria . ( . - . ) . ( . - . ) . obligate anaerobes clostridium cocades group . ( . - . ) . ( . - . ) . clostridium leptam subgroup . ( . - . ) . ( . - . ) . bacteroides fragilis group . ( . - . ) . ( . - . ) . bifidobacterium . ( . - . ) . (\ . - . ) . atopobium cluster . ( . - . ) . (\ . - . ) . results. mean serum (oh)d level was . ± . ng/ml. by current definitions the majority of patients ( . %) were vitamin d deficient (\ ng/ml) and . % were vitamin d insufficient (c and \ ng/dl). normal (oh)d levels ([ ng/ml) were present in . %. table provides information on clinical and laboratory findings in the three (oh)d groups. both lower (oh)d tertiles were associated with increased hospital mortality after adjustment for age, sex and saps ii. for patients both (oh)d and pth levels were available. adjusting the cox regression analysis also for pth and dialysis status increased the hr for hospital mortality to . ( . - . ) and . ( . and . ) for the two lower (oh)d tertiles. in addition tertiles of pth and serum calcium levels suggested higher mortality rates for patients in the highest pth (p = . ) and those in the lowest calcium tertile (p = . ). our results demonstrate that independent of baseline saps ii, age and sex, critically ill patients with low (oh)d levels seem to be at increased risk for hospital mortality. whether a rapid correction of vitamin d status may be beneficial in the icu setting remains to be further explored in randomized controlled trials. • the autonomic storm after brain death must be early diagnosed and treated with a standardized protocol including hormone therapy introduction. the use of filling pressures of the right atrium and left atrium is normal in the monitoring of critically ill patients undergoing mechanical ventilation. this monitoring is done through an invasive catheter placed in the superior vena cava and pulmonary artery, which is not free of complications. the ability to make measurements of these parameters in a non invasive way, makes the echocardiography an useful and essential tool when monitoring critically ill patients objectives. we focus the study on validate the reliability of noninvasive measurements by echocardiography and invasive measurement catheters of filling pressures methods. we conducted a prospective observational study relating the filling pressures, between central venous pressure (cvp) with the diameter of the inferior vena cava and left atrial pressures with the values of the ratio e/e . the filling pressure variables were only discriminated as high or low. low values were accepted when invasive measurement of cvp was \ and \ mmhg in the lap; and by echocardiography when the diameter of the ivc was\ mm and the ratio e/e \ . high values were accepted when the measurement of cvp was higher than and mmhg in lap and in echocardiography when the diameter of the ivc [ mm and the ratio e/e [ . we collected data from patients in the immediate postoperative period, under mechanical ventilation (vt - ml/kg, fio %, peep ), sinus rhythm, good cardiac function and without postoperative drug support. all of them had a central venous line and right atrium catheter as habitual monitoring of postoperative cardiac patients. we performed an echocardiography when the patient presented hypotension, with low values of cvp and lap, and we repeated the measurements after the infusion of the habitual fluid protocol ( ml hes % in - min). the data we record were: diameter of ivc and ratio e/e by echo and cvp and lap values by invasive catheters. rd esicm annual congress -barcelona, spain - - october s introduction. an attenuated cardio-hemodynamic response to dobutamine is associated with a poor outcome in established human sepsis [ , ] . establishing a sensitive method to identify early cardiac dysfunction in both experimental and human sepsis would be a useful tool to explore timesensitive mechanisms further. objectives. to assess myocardial responsiveness to dobutamine in early sepsis. methods. all procedures were in accordance with uk home office laboratory animal legislation. under isoflurane anaesthesia, male adult wistar rats underwent left common carotid and right internal jugular venous cannulation for blood sampling/continuous bp monitoring and fluid administration respectively. rats received either . ml caecal slurry (sepsis; n = ) or . ml saline (sham; n = ) ip, before fluid resuscitation ( . % saline ml/kg/h) and conscious monitoring was commenced. after h, rats were re-anaesthetized with isoflurane and transthoracic echocardiography was performed. stroke volume was optimised with saline boluses prior to an incremental dobutamine infusion ( . - mcg/kg/ min). data are presented as mean (sd); analyzed with -way anova and post-hoc tukey test. results. figure summarizes hemodynamic changes after sepsis, fluid resuscitation and dobutamine infusion. baseline parameters were similar after echocardiography-guided fluid resuscitation, with contractility and stroke volume restored in septic rats to sham values. septic rats demonstrated an enhanced chronotropic response to dobutamine compared to sham (p \ . ). both peak velocity and cardiac output were attenuated by c % in sepsis (p \ . ). in sepsis, baseline map was higher but neither sham nor septic maps were affected by dobutamine infusion. conclusions. dobutamine stress echocardiography is a sensitive, reproducible, dynamic physiological probe that reveals early cardiac dysfunction in septic rats with apparently similar baseline cardiovascular physiology. introduction. the evaluation of right ventricular (rv) function is clinically useful in patients with acute respiratory distress syndrome (ards) because the presence of rv failure has large prognosis implications. the purpose of the current study was to compare right ventricular myocardial strain imaging parameters with conventional echocardiographic indices evaluating right ventricular function during ards. objectives. we hypothesized that peak systolic strain would be more sensitive than conventional echocardiographic parameters in detecting subclinical right ventricular systolic dysfunction in patients with ards. methods. in total, patients with ards and with normal right ventricle function assessed by two dimensional echocardiography and age matched subjects under mechanical ventilation without heart or pulmonary disease were included in the present study. conventional echocardiography parameters for rv function assessment like rv fractional area change (rvfa) or the tricuspid annular plane systolic excursion (tapse) were measured and compared to tissue doppler imaging parameters with strain value obtained from the right ventricle free wall. . strain values were reduced in the rv free wall of the patients with ards compared with the control group ( . % ± . vs. . % ± . p = . ) moreover no significant difference was observed in conventional two dimensional parameters evaluating rv systolic function between these two groups of patients. in patients with ards a significant relationship was shown between peak systolic strain at basal free wall and arterial carbon dioxide tension (rho = - . p = . ) and with the end inspiratory pressure (rho = - . p = . ). conclusions. during the ards, doppler tissue imaging parameters can determine rv dysfunction that is complementary to conventional echocardiographic indices and is correlated with respiratory parameters. on doppler tissue imaging, patients with ards exhibit abnormal rv systolic function even in patients with normal rv function assessed with conventional echocardiographic parameters. objectives. studying the effect of olv on rv outflow impedance during inspiration and expiration using transesophageal echo-doppler in a trial to differentiate the rv consequence of increasing lung volume from those secondary to increasing airway pressure during mechanical ventilation. methods. thirty stable patients on mechanical ventilation because of different causes were enrolled prospectively in this single center, cross sectional clinical study. each patient was firstly subjected to conventional ventilation (cv) with volume controlled ventilation, followed by open lung concept (olc) ventilation by switching to pressure controlled mode, then recruitment maneuver applied until pao /fio [ torr. hemodynamic (mean arterial pressure ''map'', central venous pressure ''cvp'' and heart rate ''hr'') and respiratory (total and intrinsic peep, peak, plateau and mean airway pressure and total and dynamic lung compliance) measurements were recorded before, min after a steady state of cv and min after a steady state of olc ventilation. also, transesophageal echo doppler was performed at end of inspiration and end of expiration to calculate the mean acceleration (ac mean ), as a marker of the rv outflow impedance, min after a steady state of cv and min after a steady state of olc ventilation. results. during inspiration, ac mean was significantly lower during cv compared to olc ventilation (p value . ). inspiration didn't cause a significant decrease in acmean compared with expiration during olv (p value. ) but did do so during cv. in comparison to baseline and cv, olc ventilation was associated with a statistically significant higher cvp (p value . for both), higher total quasi-static lung compliance (p value . for both) and dynamic lung compliance (p value . for both). moreover, pao /fio ratio of olv was significantly higher than in baseline and cv (p value . for both). conclusions. olc ventilation does not change rv afterload during inspiration and expiration as rv afterload appears primarily mediated through the tidal volume. moreover, olc ventilation provide a more stable hemodynamic condition and better oxygenation and lung dynamics. introduction. among indices provided by the analysis of aortic blood flow through esophageal doppler, mean acceleration (acc) is supposed to reflect the left ventricular (lv) systolic function, but this has been poorly validated. in particular, acc could be influenced by loading conditions of the lv. objectives. to test whether acc actually behaves as an indicator of lv systolic function by testing if . it increased with inotropic stimulation, . it was not altered by fluid loading, . it correlated with the echographic lv ejection fraction (lvef) and it reliably tracked the changes in lvef during therapeutic intervention. in patients with cute circulatory failure (sapsii ± , age ± years, receiving norepinephrine), we administered either a volume expansion ( ml saline over min in patients) or dobutamine ( lg/kg/min in patients). we simultaneously measured acc (cardioq, deltex medical) and lvef at baseline and after therapeutic intervention. results. volume expansion significantly altered neither lvef (from ± to ± %) nor acc (from . ± . to . ± . cm/s ) while dobutamine infusion significantly increased lvef by ± % and acc by ± %. considering the acc/lvef pairs of measurements, an acc \ . cm/s predicted a lvef b % with a sensitivity of % ( % ci [ - %]) and a specificity of % ( % ci [ - %]). the changes in lvef and in acc during fluid and dobutamine administration were significantly correlated (r = . , p \ . ). conclusions. acc fulfilled the criteria required from a clinical indicator of lv global systolic function. a given value of acc allowed detecting a low lvef with a modest accuracy. by contrast, the treatment-induced relative changes in acc were reliable for tracking the treatment-induced relative changes in lvef. objectives. to compare the relationship between systolic or diastolic dysfunction at icu admission and the incidence of cardiologic complications and mortality at sixth months. methods. prospective study of forty consecutive patients diagnosed of acute myocardial infarction (ami) ( nstemi, stemi) who were admitted in the icu of university hospital puerto real (cadiz, spain) from st may to th september . studied variables: age, gender, type of ami (nstemi, stemi), left ventricular ejection fraction (lvef) by biplanar simpson's rule, diastolic function (ratio e/e of the mitral annulus included), incidence of cardiac complications (acute pulmonary oedema, atrial fibrillation with hemodynamic instability and cardiogenic shock) and mortality at sixth month. echocardiographic studies were performed with a ge vivid pro(r) by an intensivist who had performed up to doppler studies in critical patients. all studies were remeasured by a second observer in an echocardiographic workstation with no statistical difference in measured velocities. patients were classified according to their lvef in (a) preserved ([ %), (b) mildly depressed ( - %), (c) moderately depressed ( - %) and (d) severely depressed (\ %); and according to their e/e ratio in (a) normal e/e ratio (\ ) and (b) elevated e/e ratio (c ). the results were statistically analysed with chi-square test and odds ratio calculus. results. diastolic dysfunction measured with e/e ratio was associated with high incidence of cardiac complications (chi test cl % p \ . , or ). systolic dysfunction measured by lvef was also associated with more complications but with less strength of statistical association (chi test cl % p \ . , or . ). there were no significative statistical difference between lvef and e/e ratio in mortality at sixth month. conclusions. in our study, diastolic and systolic dysfunctions in patients with ami at icu admission were associated with high incidence of cardiac complications, with more strength of statistical association in patients with diastolic dysfunction. the small sample volume didn't allow us obtaining significative statistical differences in mortality at sixth months. a new method has been developed to assess global end-diastolic volume (gedv) and extravascular lung water (evlw) from a transpulmonary thermodilution curve. our goal was to compare this new method to the established method currently in clinical use, over a wide range up to extreme pathophysiological conditions. objectives and methods. anesthetized and mechanically ventilated pigs ( - kg) were instrumented with a central venous catheter and a right ( f pulsiocath, pulsion, munich, germany) and a left ( f volumeview, edwards lifesciences, irvine, ca) thermodilution femoral arterial catheter. the right femoral catheter was connected to a picco monitor (pulsion) and used to measure cop, gedvp and evlwp using the old method based on the equation: gedv = cop (mtt -dst). the left femoral catheter was connected to the new ev monitor (edwards) and used to measure coe, gedve and evlwe using the new method based on the equation: gedve = f (s /s ) coe mtt, where s and s are respectively the maximum up-and down-slopes of the dilution curve, respectively. measurements were done during inotropic stimulation (dobu), during hemmorhage (hypo), during fluid overload (hyper), and after inducing oleic acid-acute lung injury (ali). overall, cop and coe ranged from . to . and from . to . l/min, respectively. cop and coe were closely correlated (r = . ), mean bias (± sd) was . ± . l/min and %error was %. gedvp and gedve ranged from to , and from to , ml. gedvp and gedve were closely correlated (r = . ), mean bias was - ± ml and %error was %. evlwp and evlwe ranged from to , and from to , ml. evlwp and evlwe were closely correlated (r = . ), mean bias was - ± ml and %error was %. parameters over the study period are presented in the table (*p \ . intervention vs. base or hyper). introduction. fluid resuscitation is a major therapy in icu. various mechanisms are involved in the regulation of the microcirculation and the macrocirculation. objectives. the goal of this study is to assess the sublingual microcirculatory changes in response to fluid challenge in preload-responsive and non preload-responsive patients. after approval by our local institutional review board, patients in surgical icu have been included in an observational study. each patient was monitored by an arterial catheter and an oesophageal doppler. the decision of fluid infusion was taken by the physician in charge of the patient. preload-responsive patients were defined by variations in cardiac index (ci) c %. sublingual microcirculation videos were obtained using the orthogonal polarized spectral (ops) imaging technology. functional capillary density (fcd, cm cm - ) and microcirculatory flow index (mfi) were collected. the macrocirculatory and microcirculatory measurements were obtained before, during and after the infusion of ml of saline. five sublingual sites were recorded before and after the fluid resuscitation. the ventilator settings and sedative and vasoactive drugs infusion rates were kept constant throughout the procedure. results. patients were admitted in icu for acute brain trauma (n = ), hemorrhagic shock (n = ), septic shock (n = ), acute brain hemorrhage (n = ) and acute pancreatitis (n = ). the average age of the patient was ± . the mean values of ci and mean arterial pressure (map) before the fluid therapy were respectively . ± . l/min/m and ± mmhg. nine patients responded to fluid infusion (ci c %.). about the microcirculation, there was no significant difference between responders (r) and non-responders (nr) concerning the variations of mfi ( . introduction. passive leg raising (plr) was shown to discriminate hemodynamically unstable patients who will benefit from subsequent fluid administration or not. concerned by the possibility of harmful hypotension starting the plr maneuver from a °semirecumbent position, in a previous study, we found that raising patients' legs from a supine position, we were not able to predict fluid responsiveness in a heterogeneous cohort of medical intensive care unit (icu) patients. objectives. to investigate whether starting plr maneuver from a °semirecumbent position would better predict volume responsiveness without harmful hypotension in spontaneously breathing critically ill medical icu patients. methods. fluid responsiveness was tested in consecutive patients ( sepsis, respiratory failure, heart failure, others) with a mean arterial pressure (map) \ mmhg and/or a cardiac index (ci) \ . l/min/m . heart rate (hr), mean arterial pressure (map), global end-diastolic volume index (gedvi), cardiac index (ci) and stroke volume index (svi) were recorded using the picco method. patients were stable in a semirecumbent ( °) position when first measurements were taken (baseline ). for the plr maneuver, patient's bed was tilt to have the lower limbs raised to a °angle while the patient's trunk was then in a supine position. changes after min were recorded. the patient was then brought into a supine position, and heamodynamic measurements were recorded when stable (baseline ). thereafter, ml of . % nacl were administered over min. positive predictive values (ppv) and negative predictive values (npv) of the plr maneuver were calculated using a cut-off value of % increase for ci and svi and % increase for map. results. patients' median age was ( - ) years and their saps score ( - ). all patients received vasopressors and/or inotropes. baseline hemodynamics and changes after plr and fluid challenge are shown in table . results are given as median (range); n/a = not available, *p \ . versus baseline. ppv and npv for ci were and %, for svi and % and for map and %, respectively. conclusions. in our hands, plr was not useful identifying fluid responders in this heterogenous population of severely ill medical icu patients, the starting semirecumbent position being associated with a potentially harmful decrease in map. however, it was helpful to detect patients who will not benefit (or even suffer harm) from further fluid administration. recently, some studies suggested that an impaired diastolic function is a predictive factor of mortality in patient with shock. it is not already known whether fluid infusion could improve diastolic function. objectives. the aim of the study was to determine the impact of rapid fluid infusion on diastolic function. after acceptance by the local ethic committee, icu patients were prospectively included. volume expansion (ve) by ml of saline was performed by the intensivist in charge. transthoracic doppler echocardiography was performed before and after fluid infusion. stroke volume (sv), early diastolic transmitral velocity (e), early diastolic mitral annular velocity (ea) and e/ea ratio (reflect of lv filling pressure) were studied. patients were divided in groups according to their sv' increase: responders (r) (those who increased their sv by at least %) and non-responders (nr). wilcoxon rank sum test was performed to compare data before and after ve. data are presented in median (iqr) results. fifty-three ( %) patients were r and ( %) were nr. in the overall population, ea increased significantly with ve [from . ( . ) to . ( . ) cm/s, p = . ]. in the r group ea increased significantly [from . ( . ) to . ( . ) cm/s, p = . ] and e/ea did not change significantly [from . ( . ) to . ( . ), p = . ]. however in the nr group, ea did not change significantly [from ( ) to . ( . ) cm/s, p = . ] while e/ea increased significantly [from . ( . ) to . ( . ) cm/s, p = . ]. conclusions. according to these results, adequate fluid infusion seemed to enhance lv relaxation without increasing lv filling pressure while inadequate fluid infusion did not affect relaxation but increased lv filling pressure. objectives. the aim of our study is to compare the rapid variation of co measured by vigileo-flotrac Ò with doppler-echocardiography which is considered as a reference method. during the first hours of hospitalisation, we studied mechanically ventilated patients receiving norepinephrine who underwent arterial pressure monitoring via a radial artery catheter. the flotrac Ò pressure sensor and the vigileo Ò monitor were connected to the arterial line. at each fluid expansion or norepinephrine dose modification a transthoracic doppler-echocardiography was performed and co was calculated. variations for co measured by each method were compared. results are presented as median (iqr). linear regression and the bland-altman method were used for statistical analysis. methods. for the in vitro experiments blood of healthy donors was incubated (in the ratio : ) with one of the following solutions: ringer solution, ringer-lactate solution, modified gelatin (gelofusin); hydroxyethyl starch (hes) / . . after incubation, the following parameters of erythrocyte aggregation were measured: t and t -characteristic times of spontaneous erythrocyte aggregation; b-hydrodynamic strength of aggregates; i . -index of strength of the largest aggregates at shear rate . s - . rbc deformability at various shear stresses was determined by ektacytometry. in vivo study on patients with trauma treated randomly with either only crystalloids (group ; n = ), or crystalloids + hes / . (group ; n = ) or crystalloids + gelofusin (group ; n = ) over days, the same parameters as in vitro study were determined at day - . twenty healthy men and women were included as controls. for statistical analysis the statistical package spss version . was used. statistical significance was considered at p \ . . in vitro study in the final analysis effects of different colloids on rbc aggregation and deformability were considered as increasing impact (:), decreasing impact (;) and no impact (-) ( table ) . in vivo study significant microrheological disturbances were detected at day after admission. deformability index was lower in patients compared with controls ( . ± . vs. . ± . ; p = . ). simultaneously, the patients showed erythrocytes hyperaggregation compared with control (;t , ;t ; :i . , :b). in the first group (crystalloids) described violations persisted throughout the study time. in group (crystalloids + hes), the deformability was higher than in the st group, from days till the end of the study, attaining the normal range, and also higher than in the third group (crystalloids + gelofusin). in the third group, deformability index was not significantly different from group . according aggregatometrical data in the first group hyperaggregation syndrome remained the entire period of observation. hes adding (group ) decelerated aggregate formation (:t , :t ; ;i . ). in contrast, modified gelatin adding enhanced erythrocyte aggregation (;t :i . , :b). conclusions. crystalloid solutions are not able to improve microrheological parameters. hes / . increases rbc's deformability and reduced rbc's aggregability. gelofusin increases erythrocyte aggregation and no effect on deformability. introduction. trauma patients often require norepinephrine (ne) infusion and fluid challenge to keep normal blood pressure values. the reliability of dynamic predictors of fluid responsiveness during vasopressors therapy is under debate. we investigated the impact of norepinephrine (ne) infusion changes on pulse pressure variation (ppv) assessed with the mostcare system (vytech health, laboratoires pharmaceutiques vygon, ecouen, france) in intensive care unit patients. this device is a pulse contour method that provides cardiac output and fluid responsiveness variables and does not need any kind of calibration or preloaded data. methods. trauma patients ( female, male, mean age ± ) admitted to a -bed university hospital medico-surgical icu were prospectively enrolled. inclusion criteria were: mechanically ventilated patients (tidal volume [ ml/kg and constant respiratory rate); invasive arterial blood pressure monitoring; ne infusion. ppv values were recorded continuously during three different haemodynamic states: at baseline (t ), min after a . lg/kg/min ne increase (t ), min after a further . lg/kg/min ne increase (t ), min following the reduction of ne to t dosage (t ) and min after setting ne to baseline value (t ). during the study neither fluid challenge nor other vasoactive/inotropic drug changes were done. anova test was applied. results. see data in table . at t ne mean dosage was . lg/kg/min (range . - . lg/kg/min). the mean ppv was: at t . ± . %, at t . ± . %, at t . ± . %, at t . ± . %, at t . ± . % (p \ . ). conclusions. our findings demonstrated that ppv was significantly affected by changes in ne: the higher the ne dosage the lower the ppv. changes in arterial tone due to ne infusion can impair ppv reliability in assessing fluid responsiveness in trauma patients. introduction. in mechanically ventilated patients respiratory variation in the arterial pulse pressure (dpp) is a reliable predictor of fluid responsiveness . respiratory variation of pulse oximetry plethysmographic waveforms correlate to dpp and can be calculated automatically in real time (heart-lung index [hli Ò ] from hamilton medical). this prospective study evaluates the relationship between dpp and hli Ò to predict fluid responsiveness. mechanically ventilated patients were investigated; all connected to an hamilton g ventilator and ventilated in adaptive support ventilation (asv), paralyzed and none had severe cardiac dysrhythmia. were eligible for fluid expansion. dpp, hli Ò (obtained from a finger probe pulse oxymeter integrated to the ventilator) and cardiac index (ci from transthoracic echo-doppler), were obtained before and after fluid expansion ( ml/kg of hea over min). ci-responders were defined by % increase from baseline. results. out of the patients were ci-responders and had significantly higher hli Ò before volume expansion ( % ± vs. % ± , p \ . ). before fluid expansion hli Ò was correlated with dpp (r = . , p \ . , fig. ). hli and dpp were significantly correlated with change in ic induced by fluid expansion (r = . and r = . , respectively). objectives. the primary end point of this study was to evaluate the rvd of the ivc in icu patients with spontaneous breathing. methods. icu patient with spontaneous breathing and signs of hypoperfusion (oliguria, mottles, serum lactate level [ mmol/l) were eligible after the approval of the local ethics committee. we excluded patients with acute heart failure with pulmonary edema, moribund and arrhythmic patients. the trans thoracic echocardiographic (tte) evaluation was done by confirmed intensivists (level [ in echocardiography). the aortic diameter measured at the lv outflow chamber and the tvi were measured. the vena cava inferior diameters at inspiration and at expiration were measured on the sub costal view. the rvd of the ivc was defined as the (maximal ivc diameter -minimal ivc diameter)/maximal ivc diameter. these measures were realized at t , before fluid challenge, and after a fluid challenge of ml of hes % ( . / ) over min (t ). patients with an increase of tvi of more than % were considered as responders to the fluid challenge. the measures of tvi and of the rvd of the ivc were validated by an experimented intensivist and echographist (level ) after blinding the patient' name and of the times of measurement. roc curves were constructed, and the cut off was determined as the closest point of the roc curve to the ideal point (sensibility = specificity = ). the values are expressed as median and extremes. objectives. our objective was to test whether non invasive assessment by trans thoracic echocardiography of sub aortic velocity time index (vti) variation after a low volume of fluid infusion ( ml of hydroxy ethyl starch, hes) can predict fluid responsiveness. methods. sub aortic vti was measured by transthoracic echocardiography before fluid infusion (baseline) in sedated patients with acute circulatory failure and low tidal volume mechanical ventilation in whom volume expansion was planned. then, vti was recorded after ml of fluid infusion over min, and after an additional infusion of ml of hes over min. we measured the variation of vti after ml of fluid (dvti ) for each patient. receiver operating characteristic (roc) curves were generated for dvti in all patients. when available, roc curves were also generated for pulse pressure variation (ppv) and central venous pressure (cvp). , volumes (gedvi) and variabilities (svv, ppv) have been suggested to predict volume responsiveness (vr). the final classification of a patient as ''volume responsive'' is usually made by a volume challenge (vc) with an infusion of a pre-defined amount of fluid over a certain time. among many variations of vcs, the infusion of ml crystalloid over min is one of the most established. despite superior predictive capabilities of svv, ppv and gedi compared to cvp and pawp in a number of studies, they fail to predict vr in a substantial number of patients. furthermore, the use of these parameters is limited due to femoral access of the cvc (gedi; cvp) or the absence of controlled ventilation and/or sinus rhythm (svv, ppv). repeated ''exploratory'' vcs with ml/kg might result in volume overload in some patients. objectives. therefore, we investigated the usefulness of a ''small vc'' with . ml/kg crystalloid over min compared to a standard vc with ml/kg over min. in patients equipped with picco hemodynamic monitoring we performed a min vc with ml/kg of crystalloid. during the vc transpulmonary thermodilution (td) was performed at , and min to obtain td-derived ci (ci td ). additionally pulse contour ci (ci pc ) was recorded in intervals of min. introduction. the prevalence of obesity, defined as a body mass index (bmi) c kg/ m , reaches epidemic proportions. it is not only a risk factor for health problems, but also exacerbates illness progression. consequently, the number of obese patients on the intensive care unit (icu) has increased enormously. caring for obese patients can be quite challenging due to the weight and size of this person. the extent of and specific problems associated to the care of obese icu patients are unknown. the aim of this study is to identify and quantify problems nurses face in caring for obese patients on the icu. this study was performed on the icu at the radboud university nijmegen medical centre and contained two parts. in the first part a selection was made of obese patients admitted between and ; these patients were matched with normal weight patients (bmi . - . kg/m ). patients were matched on gender, age, length of icu stay and apache-ii score. all patient files were screened for the presence and intensity of problems in caring for these patients. in the second part nurses were asked in a survey to share their experiences in caring for obese patients. they were asked about the nature, frequency and intensity of the problems they faced. in total, problems were identified in the screened patient files. seventy-two problems ( . %) occurred in care for obese patients and ( . %) in care for normal weight patients. in both groups, most of the problems were related to activities of daily living (adl) such as (re)positioning in bed, transfers and personal care. surprisingly, the intensity of the problems was similar in both groups. most of the problems were moderate (hardly to solve by one person) or severe (only to solve with two persons or special equipment). moderate problems occurred in . % of normal weight patients and in . % of obese patients; severe problems . and . %, respectively. this result was also confirmed by the survey. the nurses qualified most of the problems they were asked about as moderate or severe, and the frequency of the experienced problems was much higher. from the files it appeared that in . % of the obese patients nurses had adl problems. strikingly, in the survey nurses reported that they frequently ( . %) or even always ( . %) experienced adl problems in obese patients. nurses reported and experienced more problems in daily care for obese icu patients compared to normal weight icu patients. although the intensity of the problems with obese patients did not differ from normal weight patients, the frequency in which they occur was much higher. differences between reported problems and the survey suggest an underestimation of problems that can be solved by performing a prospective study. nevertheless, based on these results, and taking into account that obesity will increase in the future, we recommend anticipating to the needs of the nurses whenever possible. introduction. worldwide the number of obese patients (bmi [ ) is increasing rapidly ( ); this also includes patients admitted to the intensive care units (icu). this raises special demands on the staff, the surroundings and the equipment ( ) . often the obese patient is not mobilised according to the clinical standard this causes complications to breathing, circulation and skin etc. furthermore the length of stay in the icu increases and the mortality rises. objectives. the aim of this study therefore was to make clinical guidelines and recommendations for mobilisation of the obese icu patient based on evidence. this will increase the knowledge and importance of mobilisation between staff and on longer term improves the daily average number of mobilisations performed with these patients. a secondary aim is that increased knowledge on this topic will improve the interdisciplinary work between the different professions based on the same overall aim. a systematic review of the literature concerning mobilisation of the obese icu patients was made in the year - . the study is still work in progress analysing the literature to make guidelines and recommendations based on evidence. furthermore evidencebased education of special trained staff in mobilisation has been conducted in january/ february to improve their knowledge of the impacts mobilisation has on the respiration, circulation and skincare etc. the education was planned to aiming at a interdisciplinary audience. results. the preliminary results shows that it is more difficult to care for and mobilise the obese icu patient, because there is lack of space, non-availability of the correct equipment, too few available staff members and a significant negative attitudes among the staff towards the obese patient. recommendations are made within airway, breathing, circulation, nutrition, pain, equipment and patient experience according to the procedure of mobilisation of the obese icu patient. the recommendation was implemented in the already performed education and resulted in a changed attitude among the participant and improved the status of mobilisation in the daily prioritization. this knowledge was obtained in the evaluationinterview conducted approximately one month after the seminar. conclusions. according to the literature mobilisation of the obese icu patient needs special attention towards a safe clinical practise based on evidence with focus on both the patient and the staff. special attention towards this group of patient is created by performing evidence based research resulting in clinical guidelines that has to be implemented through theoretical and practical education on an interdisciplinary level. nurses are constantly exposed to the pain and suffering of those in their care . the primary aim of this study was to investigate the risk of secondary traumatic stress/compassion fatigue (sts/cf-the trauma suffered by the helping professional) and burnout (bo-emotional exhaustion, depersonalization, and reduced sense of personal accomplishment), and the potential for compassion satisfaction (cs-the fulfillment from helping others and positive collegial relationships) among nurses working in icu. an additional goal was to test the relationship of these three constructs to each other. ( ) . the use of closed suction circuits has been suggested beneficial as a prophylactic measure ( ) . objectives. the aim of this study was to compare the incidence of vap and the occurrence of desaturation during suction using either oss or css. we also investigated contamination of the closed suction circuit and the occurrence of adverse events. methods. css were a new product in our clinic. all staff underwent a user course supervised by the manufacturer of the closed circuit. after this, data were collected during four periods in , month css followed by months oss which was repeated twice. during the summer period css were used without any data collection and then followed by two periods of css and oss. all mechanical ventilated patients were consecutively included. a culture of deep endotracheal aspirate and a blind microbiology brush was taken in association with the intubation, after h and every monday. after changing css and in case of extubation, the tip of the catheter was sent for culture. demographic data were retrieved from the hospital database. data were analyzed with descriptive methods. results. the incidences of vap were higher in the css group (table ) . both suction systems showed almost no desaturation during and after suctioning. positive cultures were obtained in % of all the retrieved css catheters. the microbiological flora resembled the species found in the airway cultures. there were no inter patient contamination and neither did the bronchoscopy frequency differ between oss and css patients. in the css group six adverse events were seen; three tube occlusion and three incidences with secretion clogging. conclusions. the use of a css did not prevent vap, in our study. there were no benefit with css other than maybe to protect the staff and our finding of positive culture in % of the cases is in line with earlier studies. objectives. the aim of this study was to determine which intensive care patients the nurses defined as 'difficult' and their experiences in coping with such patients. the study was carried out as a qualitative design with voluntary nurses employed in five intensive care units of a research and training hospital. the data were collected using demographic characteristics form and a semi-structured interview form. interviews with nurses were made individually and face to face. the data were evaluated by using colaizzi's phenomenological data analysis method. as a result of data analysis into two categories and two themes were identified. the categories were ( ) difficult patient definition of the nurses, ( ) the effect of difficult patients on their care, and ( ) how the nurses are affected and cope with difficult patients. the nurses listed their reasons for defining some persons as difficult as difficult physical care of the patients, and the difficulty in communicating due to dementia, agitation, alzheimer's disease or the patient's personal characteristics. the nurses said that they found taking care of patients they found difficult physically and psychologically demanding. they used methods such as finding out the patient's problem and taking appropriate measures, increasing communication with the patient and providing explanations, trying to obtain spiritual satisfaction and transferring the patient's care to another nurse when communication problems were impossible to overcome. intensive care nurses have difficulty in caring for and communicating with some intensive care patients due to the characteristics of the disease, physical/psychological factors and personal characteristics. we found that nurses continued the care of these ''difficult'' patients by focusing on solving their problems, transferring the care to another nurse when necessary or by trying to obtain spiritual satisfaction. methods. teams of three delirium experts visited ten icu's in the the netherlands in which the cam-icu was incorporated in daily practice, twice. these teams consisted of two consultants in either psychiatry, clinical geriatrics or neurology, and either a research-physician (mmjve) or a research-nurse (mvdb). based on cognitive testing, inspection of the files and dsm-iv criteria for delirium, the teams classified patients as awake and not delirious, or delirious or comatose. this classification served as gold standard to which the cam-icu as performed by the bed-side nurses was compared. a simple table was used to calculate the sensitivity and specificity. results. delirium experts performed assessments. ( %) of these patients were assessable for delirium, ( %) patients were excluded because the level of consciousness was too low, and ( %) patients were non-assessable due to other reasons. overall, we found a sensitivity of % ( % ci - %) and a specificity of % ( % ci - %). the strengths of this study include the large numbers, the multicentre design, the extensive evaluations by teams of various delirium experts and the independent assessments of delirium experts and bed-side nurses. a limitations is the time interval between the expert assessment and the administration of the cam-icu (mean min; standard deviation min). there were striking differences in implementation strategies of the cam-icu between the centres. tables , . rd esicm annual congress -barcelona, spain - - october s introduction. presence of expiratory ineffective efforts in mechanically ventilated patients is a common problem associated with increased duration of mechanical ventilation, length of stay and also a higher cost and mortality. nowadays, identification and categorization of expiratory asynchronies can only be done at the bedside with the continuous observation of the ventilator interface. nurses must be skilled to understand non appropriate situations of anomalous patient-ventilator interactions. objectives. we tested the hypothesis that after specific training nurses would acquire enough skills to detect expiratory efforts as intensive care expert physicians would do. training phase: nurses were provided with selected bibliography on patient ventilator interaction and afterwards trained by intensivists with expertise on mechanical ventilation ( h/day during days) on airway pressure, flow and volume waveforms identification and eye interpretation of early and late ineffective expiratory efforts during expiration. validation phase: airflow and airway pressure waveforms were obtained from different icu mechanically ventilated patients using and acquisition and processing biomedical signal software (better care Ò ). one thousand and seven breaths were randomly selected from a total of , , breaths. subsequently, selected breaths were blindly analyzed by trained nurses and intensivists to identify ineffective expiratory efforts. introduction. several publications indicate that manual hyperinflation is a widely used measure in the icu, but more important is the fact that there is no uniformity in the implementation of this measure. this is also on my ward. in literature there are a number of reasons given to start manual hyperinflation: abolish mucus retension, improve oxygenation and removal of atelectasis. the positive effects are improved compliance, improved oxygenation and a decrease in the number of vap's (ventilator associated pneumonia). the negative effects are a decrease in cardiac output due to high peak pressures, an increased risk of baro-/volutrauma and the risk of giving too much tidal volumes. the risk of barotrauma increase with pressures above cmh o. other side effects include the development of a pneumothorax and increased icp (intra cranial pressure). objectives. creating more awareness of the procedure with lower peak pressures as a result. methods. through literature review, clinical courses and the introduction of a pressure gauge achieve greater uniformity and awareness of the procedure. we used a flow analyzer of imt medical, a laptop with flowlab software version . . and an artificial lung to demonstrate how much pressure and volume is generated during manual hyperinflation. conclusions. compliance with bts guidelines could be improved. unsurprisingly co-morbidities were frequent, but did not seem to affect outcome. use of a pneumonia severity assessment tool was sub-optimal, however mean curb- score didn't correlate with that recommended to prompt critical care assessment. apart from functional status, we are unable currently to identify any factors in this age group which can be used to guide critical care admission decision making. conclusions. in our study the incidence of complicated pneumonia was / , patients admitted in picu. in necrotizing pneumonias the blood cultures were more positive than in non-necrotizing patients. although the surgical approach in necrotizing pneumonia is controversial, it resulted in a insignificantly lower mortality rate, comparing with non-necrotizing pneumonias. background. community-acquired pneumonia (cap) of mixed etiology has frequently been described in the literature, but its clinical significance remains unknown. the aim of this study was to describe the prevalence, clinical characteristics, and outcome of severe cap of mixed etiology in icu patients. a -year prospective study was conducted on consecutive patients with severe cap admitted to icu in whom an extensive microbiological investigation was performed. results. patients were included. a single pathogen was detected in ( . %) cases, while two or more pathogens in ( . %) cases. the most frequent pathogens' combinations were those of two bacteria ( . %) and bacterium plus virus ( . %). compared with patients with monomicrobial pneumonia, patients with mixed pneumonia were older, had higher severity score (psi) and were more likely to have previous chronic pulmonary disease (see table below). moreover, mixed cap patients showed similar clinical and analytical data at admission but increases in the frequency of respiratory distress and in length of stay and a trend to higher orotracheal intubation and mortality rates. a mixed etiology was detected in % of cases with cap requiring icu hospitalization and was associated with older age and increased severity. despite similar radiological features (n of involved lobes, pleural effusion) at admission, cap with mixed etiology showed a trend to worse clinical course and outcomes than monomicrobial pneumonia. objectives. to assess the incidence and aetiology of pneumonia in a mixed medicalsurgical icu, in order to develop local epidemiologically guided protocols to reduce antibiotic resistance selection in patients with pneumonia. methods. retrospective observational study on prospectively collected data in a mixed medical-surgical icu of a secondary care italian hospital. at our institution, epidemiological data on infections and data on antibiotic use are recorded since ; in a new electronic recording of icu infections was introduced. type of infection, germ characteristics, clinician diagnosis and antibiotic use were prospectively collected in an electronic database and retrospectively reviewed. antibiotic exposure index was calculated as each antibiotic total amount administered divided by its defined daily dose times total days of admission. between and a total of patients were admitted to our icu. pneumonia was the commonest infectious disease at admission ( cases, % of patients), and the commonest infectious complication during icu stay ( new occurrences, % of total pneumonia patients). table shows major epidemiological findings in the study population. the incidence of acquired pneumonia was remarkable: . cases every , days of mechanical ventilation. the most frequent isolated organisms were s. aureus ( patients) and p. aeruginosa ( patients). methicillin-resistant s. aureus (mrsa) accounted for % of pneumonia caused by s. aureus, and its prevalence matched closely the exposure index to vancomycin. such a high incidence of mrsa is consistent with other records in mediterranean countries. carbapenem-resistant p. aeruginosa was somewhat less of a problem ( % of pneumonia by p. aeruginosa), and was not apparently associated with antibiotic exposure, at least within the unit. conclusions. in our retrospective observational study we found a high incidence of pneumonia at our institution, as well as a high percentage of mrsa, the latter with strong relationship with exposure to vancomycin. new protocols for infection containment and antibiotic usage are urgently needed. introduction. community-acquired pneumonia (cap) carries a high morbidity and mortality. a major problem is the insufficient monitoring of cap by standard chest radiography, as the evaluation depends highly on the observer and the extent of pulmonary infiltration cannot be assessed properly ( ). objectives. the aim of our study was to compare the process of inflammation in cap measured by alveolar nitric oxide (no)-analysis ( ) in exhaled breath and the extent of the inflammatory infiltration by electrical impedance tomography (eit) ( ) in spontaneously breathing patients. after approval of the local ethic committee and obtained written informed consent patients with cap were included in the study. all patients showed an acute pulmonary infiltration in chest x-ray, pulmonary symptoms (coughing, shortness of breath), positive findings in auscultation, leukocytosis, elevated crp and a pneumonia severity index c . no analyses (analyser cld sp, eco medics, dürnten, switzerland) were performed at t (up to h after admission), t ( days after admission) and t ( days after admission. eit measurements (eit evaluation kit, dräger medical, lübeck, germany) were performed at t and t and inhomogeneity of ventilation was assessed by offline analysis. all measurements were made at beside in sitting position. data were compared by t test and regression analysis. results. there was no significant correlation between the alveolar no concentration and the extent of inhomogeneity of the local infiltration measured by eit. also during the study the time course of the inhomogeneity index was not correlated with change in exhaled no. the right/left distribution of the pulmonary infiltration in the chest x-ray and the eit measurement showed a positive correlation (p \ . ; r = . ). conclusions. pulmonary regional infiltration in cap measured by eit can not predict the actual alveolar process of inflammation in the lung. nevertheless the monitoring devices give additional information to better evaluate the time course of inflammation and the dimension of the respiratory dysfunction in diseased lung. organizing pneumonia (op) presenting as acute respiratory failure (arf) is a relatively rare disease, and was only previously specifically reported in small series [ , ] , with mortality up to %. these studies were performed before the publication of international consensus classification of idiopathic interstitial pneumonias in [ ] . objectives. to compare clinical features and prognosis of patients with op with those of patients presenting diffuse alveolar damage (dad), during arf. design: retrospective monocentric study in a university hospital conducted during an yr-period. to determine predictors of niv failure in patients who were intubated for respiratory failure and extubated directly to niv. methods. this is a retrospective analysis of prospectively collected data from january to dec . patients with respiratory failure were mechanically ventilated in a university hospital's medical intensive care unit (icu) and subsequently extubated to niv. physiological and biochemical parameters, using arterial blood gas measurements, were collected at the end of the spontaneous breathing trial and h after the application of niv. failure of niv was defined as respiratory failure requiring re-intubation within h. out of patients, . % were successfully extubated to niv. success rates were . % in patients with chronic obstructive pulmonary disease (copd) and . % in other patients (p = . ). patients who failed niv were more tachypnoeic, acidaemic and hypercapnic pre-niv, and more tachycardic, hypotensive, acidaemic, hypercapnic and hypoxaemic post-niv (p all. ). on logistic regression analysis, three physiologic parameters predicted niv failure: pre-niv respiratory rate (or . , % ci . - . per breaths increase), post-niv heart rate (or . , % ci . - . per beats increase) and post-niv systolic blood pressure (or . , % ci . - . per mmhg decrease). conclusions. physiologic parameters, including the respiratory rate pre-niv, and heart rate and systolic blood pressure post-niv, independently predict niv failure post-extubation. these parameters should be taken into account in the decision to extubate directly to niv. introduction. discontinuation of mechanical ventilation in critically ill patients is a challenging task and involves a careful weighting of the benefits of early extubation and the risks of premature spontaneous breathing trial (sbt). only a few studies have explored indices derived from both heart rate and breathing pattern variability analysis for the estimation of weaning readiness. objectives. to investigate heart rate (hr) and respiratory rate (rr) complexity in patients with weaning failure or success, using both linear and nonlinear techniques from signal processing theory. methods. forty-two surgical patients were enrolled in the study. there were who passed and who failed a weaning trial. signals were analyzed for min during two phases: despite of passing the protocol the decision to extubate was postponed in some patients. to gain insight on the physicians reasons for continuing mechanical ventilation after passing the wean screen protocol. a wean screen protocol was introduced at a mixed medical (neuro-)surgical icu of a teaching hospital in december to april . ventilation practitioners assessed ventilated patients and recorded the physicians reasons for continuing mechanical ventilation despite of passing the wean screen protocol. . patients were ventilated in this period. daily screens were performed, screens were successful. only passed wean screens resulted in extubation. the rate of extubation was %. % screens did not lead to liberation from mechanical ventilation. the extubation rate does not correspond with the findings of the abc trial with an extubation rate of %. table shows the physicians' reasons to continuing mechanical ventilation. it should be noted that all patients with an unsafe airway were patients with a glasgow coma scale (gcs) of b [intracerebral haemorrhage ( %), cerebral infections ( %), post-cpr encephalopathy ( %) and severe brain injury ( %)]. we accomplished a reduction in the use of sedatives (- % midazolam and - % propofol) and morphine (- %) ( table ). the amount of time spend on ventilators decreased, albeit not significantly (p = . ). this was probably due to the vap-ventilatorbundle (introduced last year), the heterogeneity of our cohort and the already short mv-duration. . non-invasive ventilation (niv) has been utilized in selected patients with hypoxemic arf to avert endotracheal intubation, which is related to life-threatening complications. niv has been also proposed to facilitate weaning and extubation in patients with hypercapnic arf. so far, no controlled randomized study has investigated the potential role of niv in weaning patients with hypoxemic arf. objectives. we designed this pilot study to assess safety and feasibility of niv to wean hypoxemic arf patients. twenty mechanically ventilated patients with hypoxemic arf were randomized to receive early extubation followed by niv application via helmet (helmet group) or conventional weaning through the endotracheal tube (tube group). primary outcomes were the duration of invasive mechanical ventilation and the adherence to the study protocol. secondary outcomes were protocol failure (i.e. need for re-intubation), icu and hospital mortality, rate of tracheotomy, duration of continuous intravenous sedation, weaning time, and septic complications. table . weaning through helmet by niv application following early extubation was safe and feasible. overall the adherence to the study design was %. in addition, in the helmet group, there was a significant reduction in the rate of tracheotomy and a trend toward a lower rate of protocol failure, and fewer days on invasive ventilation. there was no difference with respect to days of continuous sedation, icu and hospital mortality, weaning time and septic complications. ( ) . delirium is a common occurence on the icu and is associated with increased length of stay (los) and poor outcomes ( ) . objectives. we developed a combined daily sedation hold, delirium management, and weaning (sdw) protocol and implemented this to reduce icu los and improve outcomes. methods. a sdw protocol was implemented in . we prospectively audited all patients from january to march . delirium was measured using the icdsc. data was analysed using graphpad statistical software. results. consecutive patients were analysed. the incidence of delirium was % ( pts). of these, % ( ) had risk factors for delirium. there was no difference in onset of delirium between sexes, age, type of admission, or severity of illness. however, in patients with delirium, duration of mechanical ventilation (mv) and icu los were significantly longer and there was a trend towards increased hospital los ( conclusions. measuring the linear dependence of variables through time by k and ø may be used to determine non-linear behavior between the variables of the emmv. non-linear behavior during weaning perhaps indicates the dependency of, either the resistance or compliance of the respiratory system, on the ventilatory support (i.e. pi). accordingly, k and ø, estimated at the frequency interval form to (h) - , can provide information concerning to the dynamics of the respiratory system that can be used as a complement to determine the suitability of the mv withdrawal. objectives. to study the potential superiority of aprv on cmv in a subgroup of patients with severe ards. methods. retrospective observational study on patients severe ards who were admitted between july and january to mafraq hospital icu in uae. the diagnosis of ards was based on presence of bilateral infiltrates in cxr and p/f ratio of less than in absence of evidence of elevated left atrial pressure. all patients were managed according to ardsnet guidelines using low tidal volume cmv and iv steroids. criteria for transition to airway pressure release ventilation (aprv) included failure to wean down fio below % after h, hemodynamic instability due to high peep, and failure to maintain plateau airway pressure below cmh o. initial settings of aprv were ph , pl , th , and tl . with titration of fio as required keeping pao more than mmhg. we compared the outcome of cmv and aprv groups with special concern to the duration of mechanical ventilation, requirement for tracheostomy, and survival to icu discharge. twenty four male and females were included in the study with a mean age of years (± ). fourteen out of them fulfilled the criteria and were shifted to aprv within h of initiating mechanical ventilation. ten out of ( %) patients in the aprv arm survived to icu discharge versus out of ( %) patients in cmv group (p . ). survivors in aprv group spent significantly shorter periods of mechanical ventilation compared to survivors in cmv group ( . vs. . days p . ). while out of ( %) survivors in cmv required tracheostomy for prolonged intubation or recurrent lavage, only out of ( %) survivors in aprv group required tracheostomy tube placement (p . ). we concluded that aprv can be effectively used as rescue measure of ventilation in patients with severe ards. although our study does not show any mortality benefit of using aprv over cmv, there was a shorter ventilation days and icu stay using aprv. we strongly recommend further studies to investigate the probability of using aprv as initial mode of ventilation in this subset of patients. weaning from mechanical ventilation is a common daily procedure when caring for critically ill patients, and a lifesaving practice on which nurses are taking an increasing role with the introduction of nurse-led protocols. the literature supports that nurse-led protocols facilitate weaning and increase nurses' input in decision-making. on the other hand, decision-making is a complex function affected by the nature of the task, the decision environment and the characteristics of the decision maker. although the cognitive process of clinical decision-making has been investigated with many different methodologies, little is known about the decision environment and its impact on decisions' during the weaning process. objectives. this paper aims to address one of the factors of the clinical environment and its impact on the decisions when discontinuing mechanical ventilation. methods. this paper is part of a large comparative ethnographic study looking at nurses' input during the weaning process of mechanically ventilated patients. participant observation of critical care nurses took place in an -bedded icu in greece and an -bedded icu in scotland for months each to examine nurses' involvement in the decisions made. in-depth semi-structured interviews with the nurses followed focusing on how nurses perceived their participation in the decisions made. data from field notes and interview transcripts were analysed thematically using the qualitative data analysis software nvivo, version . inter-personal and inter-professional relationships were considered revealing influences of nurses' input in decision-making. clinicians' personality played a significant role in their involvement in decisions, whereas trust and appreciation, the sense of support and the sense of accountability were also considerable dynamics of inter-professional relationships and predisposed decision-making. clinical decision-making is a multi-dynamic process specifically in complex clinical long-term situations such as weaning. aspects of the decision environment, such as the interprofessional relationships should be acknowledged when introducing methods to enhance nurses' role in teamwork and collaborative decision-making in order to improve the weaning process of ventilated patients and their outcome. objectives. the objective of our study was to analyze the temporal trends and outcomes of two cohorts of patients ventilated with psv and pav+. a cohort of consecutive patients who were ventilated with pav+ and another cohort of consecutive patients who were ventilated with psv were compared. all patients had the same inclusion criteria (gas exchange, ventilatory mechanics, peep level, resolution/stabilization of the cause leading to invasive mv and appropriate level of consciousness). both modes were adjusted to predefined clinical criteria (psv to reach a respiratory rate about bpm and pav+ to reach a physiological inspiratory effort introduction. presence of expiratory asynchronies (ea) (ineffective efforts, cough and continued contraction of inspiratory muscles) is a common problem associated with increased duration of mechanical ventilation, longer stay, higher costs and increased mortality. because of the lack of systems that automatically detect and report ea, their identification is currently done by examining ventilator interface at the bedside or by applying dedicated algorithms in investigational conditions. validate the accuracy of linear mathematical algorithms to automatically detect ea built in a new computerized system that grabs and process data from different bedside icu monitors and mechanical ventilators. observational and prospective study in a general icu of beds. two beds were equipped with a software (better care Ò ), a technological platform responsible for data acquisition and synchronization, processing, storing-as non static and processable dicom objects-and also for integrating all this data with health information systems. by using the better care Ò platform, a total of , , breaths from consecutive adult patients were collected with at least h of mechanical ventilation. algorithm # : the ea algorithm consisted in a mathematical analysis of the airflow and airway pressure waveform variations during expiration not followed by a mechanical breath. algorithm # : designed to select , breaths out of the total number. this algorithm sorted and classified the breaths by the percentage of deviation from the expected expiratory curve. the result was , breaths covering most of the shapes the expiratory curve could have. five expert attendant physicians independently analyzed the , selected breaths and classified them as ea or not. the ea algorithm processed the same , selected breaths and assigned a percentage to each one, according to the variation in the shape and direction of the expiratory airflow and airway pressure curves. the expert criterion against the ea algorithm scores was used to construct a logistic regression model. we calculated sensitivity, specificity, positive predictive value and negative predictive value. the predictive performance of ea algorithm was evaluated using roc curves. optimal sensitivity and specificity were achieved by setting the cut-off point at a ea algorithm score of %. a variation in the shape and direction of the expiratory airflow and airway pressure curves [ % compared to the theoretical curve identified an ea with a sensitivity of . %, specificity of . %, a positive predictive power of . % and a negative predictive power of . %. introduction. near-infrared spectroscopy (nirs) in combination with a vascular occlusion test (vot) has been proposed to assess and identify metabolic and microcirculatory alterations during sepsis and shock in critically ill patients. however, to automatize repeated measurements at the bedside, this technique can potentially cause discomfort to the patient. vascular arterial occlusion performed in the finger may be a more attractive method to execute repeated measurements at the bedside because of more tolerability from the patient. we have previously showed in healthy volunteers that nirs can be used on finger to assess the sto response to vot and that min was an adequate occlusion time to provide the best curve fit for nirs dynamic variables . objectives. we aimed to investigate whether sto response to vot obtained from the finger could predict conventional sto response measurements obtained from the thenar of critically ill patients. parameters of sto response were measured with an inspectra spectrometer model (hutchinson technology inc.) equipped with a -mm or a -mm probe. the mm probe was placed over the thenar eminence and the -mm probe was place over the ventral face of the middle finger. we performed in each patient a series of two vascular occlusion tests (vot): one on the finger ( min) followed by one on the arm ( min). the measurements were obtained within h of intensive care admission and every h thereafter until day . vot-derived sto traces were analyzed for baseline, ischemic (rdecsto , %/min) and reperfusion (rincsto , %/s) parameters. we performed paired of nirs measurements in critically ill patients (age ± ; m/ f). although sto did not differ significantly between thenar and finger ( % ± vs. % ± ; p = . ), rincsto and rdecsto were statistically lower in the finger ( . %/s ± . vs. . %/s ± . , p = . ; . %/min ± . vs. %/min ± . ; p = . ). we performed bivariate linear model with correlated errors in which sto outcomes on thenar and on finger were treated as responses. the correlation was significant for sto and rincsto , but not for rdecsto (table ) . furthermore, mixed model analysis showed that thenar-sto as dependent variable could be significantly predicted by finger-sto parameters with estimation coefficient (± se) of . ± . (p = . ), . ± . (p = . ) and . ± . (p = . ) for sto , rincsto and rdecsto , respectively. correlation of sto response: finger vs. thenar a prospective randomized clinical trial performed in icu's of an university and teaching hospital during a . year period, involving septic and non-septic patients, randomized (after stratification) to hemodynamic monitoring, by picco tm or pac with both techniques allowing cardiac output and central/mixed venous o saturation monitoring. methods. hemodynamic management was guided by extravascular lung water index (evlwi) and global end-diastolic volume index (gedvi) in the picco tm group and by the pulmonary capillary wedge pressure (pcwp) in the pac group for consecutive days. primary outcome measures were ventilator-free days (vfd), for which the study was powered, and lengths of stay in icu and hospital. secondary measures were the course of cardiorespiratory parameters, fluid and vasopressor requirements, lactate levels, organ functions and mortality. in the study period, septic and non-septic patients were included. patients received a picco tm and a pac catheter. monitoring arms were comparable at baseline, although sepsis differed from non-sepsis in hemodynamics and severity of lung injury. premorbidity was greater in non-septic patients. the fluid infusions and balances did not differ between monitoring arms, except at t = h when the picco tm group had a more positive balance (p = . ). cardiac index and central venous o saturation increased more in the course of time in the picco tm than in the pac group. the decrease in norepinephrine requirements strongly tended to favor the picco tm group (p = . ). the course of lactate levels and organ failure did not differ between monitoring arms. vfd did not differ among monitoring arms. picco tm monitoring was associated with relatively fewer mechanical ventilation and icu days in sepsis but more in non-sepsis (after day ). the changes in respiratory parameters, sofa and number of catheter-related complications did not differ among the arms of the study. overall, patients ( %) died in the picco tm group before day and ( %) in the pac group (p = . ). conclusion. hemodynamic management guided by picco tm monitoring is safe and results in better tissue oxygenation than guidance by pac, without inducing pulmonary overhydration, in septic and non-septic, critically ill patients. this was associated with fewer mechanical ventilation and icu days in patients with sepsis but more days in patients with non-sepsis (after day ), partly attributable to greater cardiovascular premorbidity in the latter. the major primary and secondary endpoints, vfd and mortality, were not affected. introduction. non-invasive evaluation of endothelial function may be easily accomplished by ultrasound assessment of flow-mediated vasodilation (fmd) of the brachial artery, but this technique has not been fully explored in septic patients. objectives. this prospective study aims to investigate the role o fmd analysis on intra hospital prognosis of patients with severe sepsis and septic shock. adult patients admitted to the intensive care unit with a diagnosis of severe sepsis or septic shock (\ h of duration) were consecutively included. fmd of the brachial artery was measured upon admission and after and h using a high-frequency linear transducer ( . - mhz) according to internationally accepted protocols. a group of apparently health subjects paired for gender and age was used as controls for fmd analysis. patients were followed up to discharge or death. we studied adult patients mean age ± years, females, % on vasopressors with sepsis predominantly of abdominal or respiratory etiology ( %). apache ii risk score was ± and intra hospital mortality rate was %. fmd was similar in patients with or without use of vasopressors at baseline (p = . ). fmd in septic patients was significantly lower than in health controls ( . ± vs. ± %; p \ . ). we observed that survivors depicted a gradual improvement on endothelial function, so that h after sepsis onset fmd was significantly lower in nonsurvivors (- . ± vs. . ± %; p \ . ; time-group interaction p value = . ). conclusions. brachial fmd is altered in septic patients with hemodynamic instability and its improvement may be an early marker of favorable prognosis. introduction. change in pulse pressure variation (dpp) and respiratory variation of the pulse oxymetry plethysmogram (pop) may predict the hemodynamic effect of peep in mechanically ventilated patients [ , ] . reported comparisons [ , ] between pop variations (popv) and co or dpp are based on selection of - consecutive breaths (dpp b) during a ''stable'' period of pop. recently, a fully automatic ventilation mode (intellivent Ò , hamilton medical, switzerland) that incorporates an automatic and continuous popv calculation (hli Ò ) using a dedicated algorithm has been developed. the present study was designed to compare dpp b, dpp calculated with the algorithm as hli Ò (dppalg) and hli Ò. . . sedated icu patients ventilated with hamilton medical s ventilator (with integrated pulse oxymetry (po)) were included (age = ± years, saps ii = ± , no arrhythmia, norepinephrine: . ± . mg/h in patients, map = ± mmhg, vt = . ± . ml/kg). waveforms of po from a finger sensor and of blood pressure from a radial catheter were recorded for - h. from the waveforms, breath by breath (using respiratory flow signal), without pre-selection of stable periods and using known formula [ ] dpp b (averaging breaths without any filtering), dppalg and hli Ò were automatically obtained (matlab Ò ). dpp b was compared to dppalg ( pairs) using mann-whitney t test. pairs of hli Ò and dppalg values (see fig. below) were compared using linear regression and bland-altman method. a dppalg threshold value of % was used to generate hli Ò roc curves. results. dpp b and dppalg were significantly correlated (r = . , p \ . ), but standard deviation of dpp b were higher than the standard deviation of dppalg ( . ± . vs. . ± . %, p \ . ). dppalg and hli Ò were correlated (r = . , p \ . ), mean difference was ± %. hli Ò above % predicted dppalg above % with a sensitivity of % and specificity of % (roc: . ). conclusions. dpp b should be interpreted with caution due to the high variance of this index. in real conditions and during long time monitoring dppalg and hli Ò are in acceptable agreement and hli Ò may help estimating continuously the hemodynamic effects of ventilation. introduction. transthoracic echocardiography (tte) is supposed not to be useful in ventilated patients (pt). echocardiography is usually performed transesophageally in ventilated pt and is thought to be independent of the examiner's skills. we want to demonstrate that tte in ventilated pt could be learned even by medical students with reasonable results and that tte could add useful informations for interpretation of the hemodynamic status. objectives. in a prospective observational study consecutive patients (pt) were enrolled in a -bed medical intensive care unit of a university hospital. inclusion criteria was septic shock according to actual guidelines. transthoracic echocardiography (acuson cv , siemens, germany) was performed by a medical student in each subject on day , day and survival was reported on day . tte-examination was reduced to an apical -chamber view for interpretation of left ventricular global function and calculation of left ventricular ejection fraction (ef) with the simpson method and to a subcostal view in order to examine the diameter of the inferior caval vein (ivc) and to rule out pericardial effusion. each examination was digitally recorded and was interpreted by an experienced cardiologist. every single pt was mechanically ventilated. cardiac output (co) was measured with the transpulmonary thermodilutional technique (picco-catheter, pulsion, germany). the insertion of the picco-catheter took place due to an individual physician's decision. crp was measured as an parameter of inflammation. results. pt, mean age years ± . , male ( %), pt with known coronary artery disease ( %), pt with known dilated cardiomyopathy ( %). mean apache ii-score . ± . . pt died within days ( %). picco-catheter was inserted in pt ( %). tte could be successfully performed in pt ( %). the following values are expressed as mean values ± sd, student's t test, p \ . denotes statistic significance. ef on day . % ± . , ef on day . % ± . , p = . . ivc on day . mm ± . , ivc on day . mm ± . , p = ns. co on day . l/min ± . , co on day . l/min ± . , p = . . crp on day . mg/dl ± . , crp on day . mg/dl±, p\ . . pericardial effusion in no pt. in older pt coronary artery disease is common and ef is at the start of septic shock severely diminished. ef decreased slightly in the early course of septic shock, may be as an expression of septic cardiomyopathy. the ivc diameter did not change and may not be useful as a predictor of preload in ventilated pt. co decreased over time as the hyperdynamic circulation in septic shock is getting normalised. tte adds useful hemodynamic information and should be performed in each ventilated pt. tte could be performed in almost each ventilated pt and is easily learned even by medical students. ( , ) , which can often be caused by anaemia. in current guidelines the transfusion trigger is haemoglobin (hb) \ g/dl, but there is no recommendation for scvo ( ). objectives. the aim of this retrospective study was to evaluate the change in scvo before and after transfusion and to reveal whether co -gap reflects it. methods. over a month period hb, scvo , co -gap and o -extraction ratio (o er) were recorded before and after transfusion. data are presented as median [interquartile range], for statistical analysis wilcoxon, mann-whitney tests and pearson correlation were used as appropriate. results. out of transfusion events the scvo was measured in cases. after transfusion hb increased significantly: . [ . - . ]- . [ . - . ] g/dl, p \ . . the median scvo was %, therefore two groups were created: ''low'' (scvo \ %, n = ); ''high'' (scvo c %; n = ). hb increased significantly in both groups (p \ . ), but scvo conclusions. in the high-group the low hb levels did not cause oxygen debt, as after transfusion hb increased significantly but scvo did not, and o er and co -gap were within the normal range. our results give further support that not only the hb level should serve as a transfusion trigger, but measures of oxygen debt such as scvo and co -gap should also be considered, hence unnecessary transfusions could be avoided. introduction. intellivent Ò is a fully closed loop ventilation designed to keep the patient within target ranges of etco and spo . the system includes an automatic adjustment of peep and fio following the ardsnetwork tables [ ] . if required peep is changed by cmh o every min with a maximal possible value set by the user or depending on an automatic and continuous calculation of the respiratory variations of the plethysmogram from an integrated pulse oxymeter (hli Ò ), i.e. the higher the hli Ò the lower the maximal peep allowed by the system. the present study was designed to estimate whether changes in peep are reflected in hli Ò changes. in sedated icu patients ventilated for min in fully closed loop ventilation with intellivent Ò (hamilton medical s ventilator), episodes of significant changes in peep (c cmh o) were selected and hli Ò values within min before and after peep changes were collected. statistics were done using sigmastats with p \ . as significant. results. changes in peep and in hli Ò are shown in the table ± cmh o ± cmh o ± % ± % p \ . the correlation between change in peep and change in hli Ò is shown on the fig. . conclusions. based on these preliminary data changes in peep are reflected hli Ò changes and may help estimating continuously the hemodynamic effects of ventilation. objectives. we have tested a axis accelerometer sensor for detection of regional left ventricular ischemia. in pigs a -axis accelerometer was sutured to the left ventricular (lv) apical region in left descending coronary artery (lad) supply area accelerometer x-axis measured longitudinal-, y-axis circumferential-and z-axis radial epicardial motions. epicardial displacements were calculated from the acceleration signals and systolic displacements within ms after peak r on ecg was measured. lad was occluded for s to induce regional lv dysfunction. myocardial circumferential strain (shortening) measured by echocardiography in the lv apical anterior region was used to confirm ischemia. the ecg st-segment in lead ii was also monitored. data are presented as mean ± se. early systolic displacement at baseline was ± mm, ± mm and ± in circumferential, longitudinal and radial directions, respectively. lad occlusion induced akinesia in circumferential ( ± mm, p \ . ) and radial ( ± mm, p = . ) directions, whereas longitudinal displacement changed less to ± mm (p = . ). ischemia was confirmed by echocardiography strain, showing lengthening in systole (p \ . ). no significant changes were observer in the ecg st-segment during coronary occlusion (p = . ). introduction. there is increasing evidence to suggest perioperative complications are predictive of long term survival and that reducing them may improve survival rates . goal directed therapy has been shown to reduce mortality and morbidity perioperatively, with those unable to increase oxygen delivery perioperatively having demonstrably worse outcomes. the advent of non invasive tissue oxygenation monitors using near infrared spectroscopy has allowed further study of oxygen flux during goal directed therapy. objectives. to observe changes in tissue oxygenation during an h oxygen delivery targeted post surgical optimisation program and provide long term mortality followup of a surgical cohort of high risk patients. methods. patients undergoing high risk surgery and postoperative optimisation (targeting of oxygen delivery index of [ ml/min/m ) on the tensive care unit at a london teaching hospital were enrolled. each patient underwent a protocolised haemodynamic optimisation protocol as per our standard unit policy for h with consecutive recordings of tissue oxygenation at the thenar eminence using an inspectra monitor. additional variables relating to global and tissue perfusion were measured concurrently. patients were followed up for survival status at . years using routinely available information held within our hospital records. in hospital mortality was . % (n = ), whilst at . years this had increased to % (n = ). there was no significant difference between apii scores ( ) versus . ( ), age . ± . versus . ± . or operation type for survivors and non-survivors at . years respectively. significant differences between groups were found however for admission and mid optimisation protocol ( h) hr and sto (see table there were no significant differences in measured variables for day mortality. conclusions. there appears to be a statistical and clinical difference in hr and tissue oxygenation between the long term survivors of high risk surgery who undergo monitored postoperative goal directed optimisation. introduction. bronchoscopic bronchoalveolar lavage (b-bal) is today the gold standard for sampling of inflammatory markers in the distal airways. nonbronchoscopic bronchoalveolar lavage (n-bal) by ordinary suction catheter has been investigated as a more easily accessible method for alveolar sampling in the setting of acute respiratory distress syndrome (ards). the results, however, were disappointing, probably due to more proximal sampling by the n-bal. to investigate wether n-bal by a catheter with physical properties similar to those of the bronchoscope is comparable to b-bal. methods. b-bal and n-bal by cook's airway exchange catheter was performed with ml normal saline on opposite sides min apart at nine different occasions on anesthetized and intubated pigs. the volume of the recovered lavage was noted, after which the fluid was analyzed for albumin, total cell count, viability and differential cell count. statistical analysis was performed using wilcoxon's rank-sum test. results. n-bal yielded significantly higher albumin content than b-bal ( . ± . vs. . ± . mg/l, p = . ). in all other measurements there were no significant differences between n-bal and b-bal (recovered volume . objectives. we hypothesized that collagen synthesis and degradation are disturbed in acute respiratory failure. in the finnali-study we defined acute respiratory failure as need of noninvasive and/or invasive ventilatory support for more than h ( ). after informed consent we collected blood samples for serum procollagen propeptides i and iii (pinp, piiinp) and ictp levels at study admission, day , and . patients with all four blood samples were included in this substudy. multiple organ dysfunction (mod) was defined as two or more individual organ sofa scores of - at any day during the first week. results. the study population comprised of finnali patients ( ). the mean (sd, range) age was years ( , - ) and the majority were male %. on admission the mean sapsii score was ( , - ). patients ( %) developed mod during the first days. over time piiinp/pinp-ratio first increased and then decreased to baseline by day while pinp/ictp-ratio decreased and then decreased to baseline by day (p \ . and p = . , respectively) ( fig. ). there were no statistical differences in the ratios between patients with or without mod. conclusions. we found that in patients with acute respiratory failure the balance of collagen synthesis was towards degradation of type i collagen and production of collagen type iii. ± ng/ml in the ards group, and significantly higher than the . ± . ng/ml in the ali (not ards) group. the difference in hmgb values in the early stage between the group that died up to the by th day and the surviving group was not significant, but the hmgb values were significantly higher in the group that died until the th day and th day than in the survival group. it was concluded that differences in hmgb values in the early stage after the onset of ali (not ards)/ards are useful as outcome determining factors after days of onset. an inverse correlation was observed between the hmgb values and lung oxygenation, suggesting the possibility that hmbg is involved in the development of respiratory failure. s. shibata , g. takahashi , n. shioya , s. endo akita city hospital, anesthesiology, akita, japan, iwate medical university, emergency medicine, morioka, japan, iwate medical university, critical care medicine, morioka, japan sivelestat sodium hydrate (sivelestat) is a selective polymorphonuclear leukocyte elastase (pmn-e) inhibitor and has also been shown to be effective for pulmonary disorders associated with sirs in clinical patients. blood levels of inflammatory cytokines have been shown to be decreased in patients treated with sivelestat. however, since patients with sirs have already received other drugs, it remains indefinite whether or not sivelestat might suppress the production of cytokines. moreover, it is difficult to clarify any cells releasing cytokines. in the experiment using cells isolated from the blood, intercellular mutual actions and cytokine networks were blocked and the experiment failed to faithfully reproduce the in-vivo condition. objectives. the possibility of sivelestat suppressing the production of cytokines from granulocytes and monocytes was assessed by intracellular cytokine staining using the whole blood culture method and flow cytometry to faithfully reproduce the in-vivo condition. methods. blood samples were collected from healthy volunteers. a vehicle (control group), lipopolysaccharide (lps; lps group), or lps + sivelestat (sivelestat group) was added to the whole blood, followed by the addition of a protein transport inhibitor in each group. after incubation, they were subjected to staining of the cytokines retained in the cells by the addition of an anti-interleukin (il- ) or anti-tumor necrosis factor a (tnf-a) antibody and analysis by flow cytometry. the data were analyzed by the kolmogorov-smirnov test. values obtained [d/s(n)] result from the comparison of the fluorescence histograms of each sample with a control one. addition of sivelestat at low concentrations ( and lg/ml) significantly (p \ . ) suppressed the production of il- from granulocytes induced by a low concentration ( ng/ml) of lps. on the other hand, the granulocytic production of tnf-a induced by a high concentration of lps ( ng/ml) was significantly (p \ . ) suppressed by treatment with sivelestat at high concentrations ( and lg/ml). with regard to the monocytic production of tnf-a and il- induced by lps, there was no significant suppression of either tnf-a or il- production by sivelestat. conclusions. sivelestat, a neutrophil elastase inhibitor, suppressed granulocytic production of il- and tnf-a, suggesting the potential usefulness of sivelestat for the treatment of various morbid conditions involving il- and tnf-a in their onset. introduction. coagulation, fibrinolysis and extravascular fibrin deposition are the hallmarks of the pathogenesis of acute lung injury (ali). pai- has a central role in antagonizing fibrinolysis by decreasing the plasminogen turnover to plasmin. pai- has been suggested as a clinical severity marker of ali. in previous studies it was associated with higher mortality and morbidity in the critically ill. upar is a cell surface receptor activating the serine protease upa. increased expression of upar is found in various stages, including inflammation, tissue remodelling and malignancies, indicating poor prognosis. pai- antagonizes the proteolytic activities of upa and plasmin. objectives. we sought to evaluate the prognostic value of supar and pai- for -day mortality of patients with acute respiratory failure (arf). the finnali-study patients needed invasive or non-invasive ventilation for more than h ( ). blood samples were collected from patients at baseline and on day after baseline. healthy volunteers were also analyzed. sera were frozen at - °c until analyses. concentrations of supar and pai- in blood serum were measured by enzyme linked immunosorbent assay (elisa). data are presented as median (iqr). the prognostic value of supar and pai- for -day mortality was determined with roc analysis. in the critically ill, supar and pai- were . ( . - . ) ng/ml and . introduction. acute lung injury is a common disease in intensive care, associated to various septic or inflammatory diseases. inflammation is part of the defense mechanisms of innate immunity, occurring after tissue injury. objectives. the aim of the project was to decipher the transcriptional changes occurring after the onset of an inflammatory injury by intravenous injection of oleic acid. experimental study of the lung transcriptome after oleic acid injection. thirtysix c bl/ j mice, aged of weeks, were sacrificed at h, h , h, h, h and h after physiological serum or oleic acid injection ( ll) in the caudal vein. left and right lung were separated for mrna extraction and pathological examination. labelled cdna were hybridized on cdna nylon microarray (tagc, marseilles, france) and raw data were extracted from scanned images with bzscan software. raw data were normalized with the quantile method, and supervised analysis was conducted with significance analysis of microarray algorithm within the r statistical suite and bioconductor libraries. after the administration of oleic acid, the mice were tachypneic and prostrated. all survived during the first hours. the pathological analysis of lung tissue revealed an early inflitration of the lung tissue by polynuclear cells, as well as a pulmonary edema. these alterations were not observed after h. the time course analysis of transcriptional lung data identified a thousand genes which expression is modulated after injury. hierarchical clustering identified major groups of genes. the first one ( genes) is composed of genes transiently up-regulated between h and h after oleic acid injection. th second group ( genes) is composed of genes expressed between h and h. the third group ( genes) is composed of genes expressed at the later time points ( h- h). the functional annotation linked these signatures with keywords related to pro-inflammatory response, vascular endothelium modification and lipid metabolism, respectively. rt-pcr analysis of pro-(tnf, il ) and anti-inflammatory (il , il ) markers related the pro-inflammatory phase to the earlier time points ( h- h ) and the anti-inflammatory phase to the late points (after h). conclusions. oleic acid injection in mice induced a transient acute lung injury. this is confirmed by clinical, pathological and transcriptional modifications. the modulation of gene expression after the oleic acid injection revealed an early pro-inflammatory response, followed by an anti-inflammatory response and lipid metabolism modificiations. this model could now be used to describe the specific modulation occuring during pulmonary infection and critical injuries like acute respiratory distress syndrome. introduction. ventilator associated lung injury (vali) is influenced by tidal volumes, airway pressure and cyclic opening of alveoli during mechanical ventilation. preserved spontaneous breathing during partial ventilatory support may be protective, but it is not known whether the transpulmonary pressure generated by spontaneous breathing has the same effect on vali as if generated by the ventilator. to determine whether hemodynamics, respirtory function and vali are influenced by the amount of support provided by pressure support ventilation. after approval from the institutional animal care committee, acute lung injury was induced in anesthetized sd rats by acid aspiration. ten animals each were then ventilated with positive end-expiratory pressure cmh o in pressure control (pc), pressureregulated assist control (ac) or pressure support mode with % (ps ), % (ps ) or % (ps ) pressure support of initial distending pressure needed to maintain tidal volume. pc animals were paralyzed. after h animals were killed and vali determined. results. there were no differences in baseline characteristics. acute lung injury was characterized by a decrease of the p/f ratio from ± to ± mmhg and of the dynamic compliance from . ± . to . ± . ml/cmh o. conclusions. compared to controlled ventilation, preserved spontaneous breathing activity improved hemodynamic stability, respiratory function and lung edema clearance. the reduction in pressure support did not lead to reduced tidal volume, but transpulmonary pressure was preserved by muscular activity of the chest wall. no difference was observed between full or % of pressure support, but further reduction in pressure support resulted in increased wet-dry ratio. objectives. we studied the effects of metabolic acidosis on enzymatic and non-enzymatic no-production in hypoxic and hyperoxic lung regions in a pig model. eighteen healthy anesthetized pigs were separately ventilated with hypoxic gas to the left lower lobe (lll) and hyperoxic gas to the rest of the lung. six pigs received hcl infusion (hcl group), six pigs received n w -nitro-l-arginine methyl ester (l-name) and hcl (l-name + hcl group) and six pigs received buffered ringer's solution (control group). no concentration in exhaled air (eno), no synthase (nos) activity in lung tissue, and regional pulmonary blood flow were measured. results. metabolic acidosis, induced by infusion of hcl, decreased the relative perfusion to the hypoxic lll (q lll /q t ) from (± ) to (± )% in the hcl group (p \ . ), and from (± ) to (± )% in the l-name + hcl group (p \ . ), without any measurable significant changes in eno from hypoxic or hyperoxic lung regions there were no significant differences between the hcl and control groups for ca + -dependent or ca + -independent nos activity in hypoxic or hyperoxic lung regions. metabolic acidosis augmented the hypoxic pulmonary vasoconstriction, without any changes in pulmonary enzymatic or non-enzymatic no-production. when acidosis was induced during ongoing nos-blockade, the perfusion of hypoxic lung regions was almost abolished, indicating acidosis-induced pulmonary vasoconstriction was not no dependent. assessing and monitoring biomarkers in acute lung injury (ali) may improve knowledge of its pathogenesis, early recognition, and management and predict remote organ injury and multiple organ failure. objectives. early consents for research are difficult to obtain in patients with or at risk of ali because of the emotional burden of the severity and sudden onset of the disease. however, study samples may be obtained from left-over clinical blood draws, which are readily available if processed adequately. the aim of this study was to compare fresh and ''waste'' blood samples prospectively in a series of consecutive critically ill patients. the hypothesis is that ''waste'' blood samples if appropriately processed provides accurate and reliable results comparable to the gold-standard, which is immediate collection and processing of fresh blood samples. prospective study comparing biomarkers of epithelial injury (srage) and inflammation ( different cytokines/chemokines) in critically ill patients measured on fresh blood or waste blood, kept at degrees celsius for h. an automated system performed a daily screening of adults in the icu with an increased risk for ali (lung injury prediction score, lips) within h of admission and/or on recognition of the diagnosis of ali, using the american-european consensus conference criteria. risks factors for ali include pneumonia, sepsis, pancreatitis, shock, aspiration, high risk surgery and high risk trauma. irb approved the protocol and written consent was obtained from patients or their surrogates. statistical measurements were performed using the bland-altman analysis for correlation between fresh and waste blood sample data. between may and december , patients were enrolled. one patient was excluded due to lack of sample. samples were obtained either at one time point (n = ) or two, on consecutive days (n = ). female/male patient ratio was / . seven of the patients had ali. twenty two patients had risk for ali with a median lips score of (iqr . - . ). sepsis was the most common risk factor, present in patients. in-hospital mortality was % ( / ). the bland-altman plot (mean bias ± se, limits of agreement) showed good correlation for il- ra (- ± . pg/ml, - . to . pg/ml), il- ( . ± . pg/ml, - to . pg/ml), il- (- . ± . pg/ml, - . to . pg/ml), il- (p ) (- . ± . pg/ml, - . to . pg/ml), mcp- (- . ± pg/ml, - . to . pg/ml) and srage (- ± pg/ ml, - to pg/ml) between fresh blood and ''waste'' blood samples. in patients with ali, properly stored blood, drawn for clinical purposes, can be processed within h for research purposes. however, the stability of each biomarker of interest needs to be individually validated before using stored blood introduction. pulmonary surfactant inactivation following acute lung injury might promote alveolar derecruitment and reduce the airspace available for ventilation, making the lung more prone to ventilation-induced lung injury (vili). our aim was to test the potential for a protective effect of exogenous surfactant treatment in a model of acid aspiration and vili. methods. male c /bl mice were anesthetized, mechanically ventilated (vt ml/ kg; rr /min; peep ± . cmh o; fio . ) and immediately subjected to intrabronchial (right) instillation of . ml/kg hcl . m. mechanical ventilation went on for min. min after the acid instillation, mice were treated with exogenous surfactant ( mg of phospholipids/ml) given as bolus of ml/kg in the right bronchus (surf group). we measured oxygenation, lung compliance (measured every min throughout the experiment), macrophage inflammatory protein (mip) in broncho-alveolar lavage (bal) fluid. . pao at the end of the experiment was significantly higher in the surf than in control group ( ± vs. ± mmhg, p \ . ). although surfactant bolus caused a reduction in lung compliance measured and min after treatment, in the surf group compliance restored to ± % of the post injury level, while it decreased in control group to ± % (p \ . ). there were no differences between groups in the dosage of mip- in bal neither in right or left lung. conclusions. exogenous surfactant treatment improved lung function in a murine model of two hit lung injury. grant acknowledgment. introduction. ventilator induced lung injury significantly contributes to the mortality in patients with acute respiratory distress syndrome, the most severe form of acute lung injury. understanding the molecular basis for response to cyclic stretch and its derangement during high volume ventilation is of high priority. objectives. to identify specific molecular regulators involved in the development of ventilator induced lung injury. we undertook a comparative examination of cis-regulatory sequences involved in the coordinated expression of cyclic stretch responsive genes using microarray analysis. analysis of stretched vs. non-stretched cells identified significant enrichment for genes containing binding sites for the transcription factor atf (activating transcription factor ). to determine the role of atf in vivo, we compared the response of atf gene deficient mice to wild type litter mates in an in vivo model of ventilator induced lung injury. results. atf deficiency results in increased sensitivity to mechanical ventilation alone or in conjunction with inhaled lipopolysaccharide ( mg/kg) as determined by assessment of lung and bronchoalveolar lavage cell infiltration and pro-inflammatory mediator release, pulmonary edema and indices of tissue injury. the expression of genes containing an atf cis-regulatory region was significantly altered in gene deficient animals. atf protein expression and nuclear translocation is increased after mechanical ventilation. conclusions. atf deficiency confers increased sensitivity to mechanical ventilation alone or in combination with inhaled endotoxin. in our model, atf acts to ''counterbalance'' cyclic stretch and high volume-induced inflammation, limiting its potential to cause additional lung injury and consequently protecting animals from injurious cyclic stretch. objectives. our aim was to evaluate the role of the alveolar macrophages in a murine model of ali, by selective depletion of this type of cells from the air space achieved by clodronate administration. mice were treated (it) with ll of clodronate (clo)-or pbs (pbs)-liposomes. after h mice were anesthetized and ventilated (vt - ml/kg, rr min - , fio . ); in order to induce lung injury ml/kg of hcl ( . m) or air bolus (sham group) was instilled in the right bronchus. mice were ventilated for min, and extubated after awakening. h after injury, animals were sacrificed and broncho-alveolar lavage (bal) and blood gas analysis (fio = . ) were performed. . h after lung injury animals with alveolar macrophages depletion, showed a better oxygenation versus pbs-treated group. however, recruitment of neutrophils in bal was not statistically different between clo_hcl and pbs_hcl group. results. high levels of oc were found in patients treated by mg of ot bid. oc levels ranged from , to , ng/ml in these patients. concentrations of oc were five-to tenfold higher than concentrations reported in healthy volunteers. lesser levels were found in patients treated by mg of ot bid. nevertheless, the patient with the moderate renal failure seemed to accumulate oc (levels ranged from to ng/ml) whereas concentrations reported in the patient with a normal renal clearance were below ( - ng/ml). conclusions. ecmo seemed not to have any influence on oc concentrations while renal insufficiency seemed to be the parameter leading to oc accumulation. as ic was very low and reached even with usual dosage, increasing ot dose to mg bid appeared to be unnecessary. objectives. aim of our study was to evaluate the effect of nursing care on patients undergoing venous-venous ecmo for acute respiratory distress syndrome (ards). methods. we recorded physiological and ecmo parameters (heart rate, arterial blood pressure, mixed venous saturation (svo ), arterial oxygen saturation (spo ), body temperature and extracorporeal blood flow (bf)) before and during daily nursing in patients undergoing vv-ecmo for several days (each patient was followed on average for . days, cases in total). arterial blood gases were also collected before and after nursing care. daily nursing was performed following defined steps (sponge bath, oral hygiene, change position of endotracheal tube, elevation with scooping stretcher for sheets replacement and back hygiene, dressing replacement) in agreement with a standard protocol in use in our department. (expressed as mean ± standard deviation). all patients were affected by ards h n -related. patients were sedated with propofol ( ± mg/h) or midazolam ( . ± . mg/h) plus an opioid drug (fentanyl ± mcg/h or remifentanil . ± . mcg/kg/min or sufentanil . ± . mcg/kg/min). ramsey score before nursing was . ± . . in cases patients were paralysed. in table we summarized the adverse events observed during nursing care, divided into hypertensive or tachycardic episodes, blood oxygen desaturation, reduction in svo or reduction in bf. forty-nine sedative bolus were administered during nursing (mean request for each patient: . ± . ), always after an episode of hypertension or tachycardia (most frequently during elevation with scooping stretcher and changing position of endotracheal tube). although in cases preventive bolus of sedation were administered before nursing, in of those cases ( %), additional bolus were required. we found an inverse correlation between bf and the increase in heart rate, drop in arterial saturation and svo . despite active warming, we observed a drop of . ± . °c (p \ . ) in body temperature. nursing care may have a significant impact on physiologic parameters of patients during vv-ecmo. tachycardia, hypertension and reduction in oxygenation were commonly recorded and were not prevented by pre-nursing bolus of sedation but were attenuated in patients with higher bf. introduction. prone position has been used in cases of ards with refractory hypoxemia but some physiological effects are still unknown. prone position could increase intraabdominal pressure (iap) and could lead to acute renal failure (arf). acute kidney injury in icu is associated with increased mortality. objectives. the aim of this study was to determine whether prone position could increase intraabdominal pressure and possibly promote arf. we studied all adult ards patients who were ventilated using the protective strategy defined by ards network criteria and who needed prone position to improve oxygenation. we collected respiratory data (ventilator parameters and gas exchange) and hemodynamic variables (heart rate, systolic, diastolic and mean arterial pressure). iap was measured using the abdo-pressure tm bladder transducer following world society of acute compartment syndrome recommendations. abdominal perfusion pressure was calculated as mean arterial pressure minus iap. main renal parameters were: filtration gradient (fg), creatinine clearance, fractional excretion of sodium (fena) and urea (feurea). patients were classified according to rifle score after each manoeuvre. all data were recorded in prone and in supine position at least once per day. results. the study included patients ( male) admitted to a medical-surgical icu over a one-year period. their mean age was . ± . and length of icu stay was ± days. all patients had primary ards and had received nephrotoxics. icu mortality reached %. we recorded at least manoeuvres per patient (a, b, c). prone positioning improved pafio ratio from . ± to ± (p = . ). iap showed a small increase from . ± . to . ± . mmhg (a; p = . ), from . ± . to . ± . mmhg (b; p = . ) and from . ± . to . ± . mmhg (c; p = . ). there were no statistically significant changes in hemodynamic parameters or abdominal perfusion pressure. renal function parameters (fg, creatinine clearance, fena and feurea) showed no modification after each prone positioning. in contrast, when patients were classified according to rifle score, we observed a trend towards worsening, though this was not statistically significant. conclusions. prone positioning improved arterial oxygenation in primary ards patients and was associated with an increase in iap. however, creatinine clearance and glomerular filtration remained unchanged. percutaneous extracorporeal life support system (p-ecls) including ecmo becomes widely used in medical and surgical emergent situation, such as refractory cardiogenic shock, cardiac arrest and acute respiratory failure. patients requires highly specialized intensive care and monitoring system. we reviewed our ecls experience and tried to analyze the clinical outcomes, factors for survival and frequently faced problems during management for improving weaning and survival rate (medical vs. surgical patients). introduction. in spite of the huge efforts spent over the last years, conventional treatment of acute hypoxemic respiratory failure (ahrf) is often inadequate and alternative procedures must be instituted. icus skillful in extracorporeal membrane oxygenation (ecmo), as recently shown [ ] , may improve survival of these patients. since we developed a treatment algorithm for ahrf which encomprises: ( ) low flow venous-venous ecmo (lf-ecmo) consisting in a relatively low initial blood flow (bf, - . l/min) to maximize extracorporeal co removal while providing partial oxygenation (if needed, bf can be increased up to . - l/min to keep arterial po above mmhg); ( ) femoral-femoral percutaneous cannulation with - fr cannulas to allow free movements of the neck and increase patient's tolerance; ( ) early institution of spontaneous assisted ventilation (sb) and weaning from sedation and mechanical ventilation (mv) while on ecmo. objectives. to review our last years lf-ecmo activity. methods. study period was january - . lf-ecmo entry criteria were: potentially reversible acute hypoxemic respiratory failure, lis c , no evidence of intracranial bleeding and no absolute contra-indications to heparinization. ecmo was performed with different type of heparin coated hollow-fiber artificial lungs. . we treated patients (mean ± sd, ± . years old, % males, bmi ± , sofa . ± , oi ± ). % of these patients were placed on ecmo at other hospitals and transported to our icu by a dedicated ecmo team. ventilation days before ecmo were ± (range - ). before ecmo vt/kg was ± . and rr was ± : after ecmo beginning vt/kg was unchanged while rr decreased to ± (p\ . ). ecmo was set at bf . ± l/min, gf . ± . l/min, fio . ± . introduction. ventilating patients with acute lung injury (ali) in supine position potentially leads to an impaired pulmonary gas exchange. prone position (pp) is an attractive means to improve ventilation-perfusion (v/q) ratio [ , ] but has several contraindications and showed no improvement in survival so far [ ] . another therapeutical option is an upright position, which is easy to perform and has theoretical advantages over pp: the upward shift of the abdominal compartment is less pronounced, thus increasing thoracoabdominal compliance [ ] . however, to date regimes of an upright position did not tilt patients more than ° [ ] . objectives. we hypothesised that a °standing position (sp) during mechanical ventilation may improve respiratory function. furthermore, we aimed to determine the feasibility of a sp for h during mechanical ventilation. we studied adult patients, receiving mechanical ventilation for more than h in the intensive care unit of an university hospital. after recording baseline data, patients were placed in a °sp with the body entirely straight. further data sets were recorded during h in sp, and after patients position was readjusted to supine position. functional residual capacity (frc) increased immediately after reaching sp (p \ . ) and remained elevated after repositioning to supine position. pao /fio ratio and compliance decreased initially during sp, but increased (p \ . ) after patients were retransferred to supine position. haemodynamic variables remained stable under a moderate increase of doses of catecholamines during the study period. conclusions. changes in respiratory function during sp are probably explained by a downward shift of the diaphragm due to gravitational forces leading to an increased frc but not altering v/q ratio as demonstrated by the pao /fio ratio. after reaching the initial supine position the opening of the lung proved by the elevated frc is the predominant effect now associated with an increase in oxygenation as reflected by the pao /fio ratio due to an optimised v/q ratio. our results are confirmed in a subgroup analysis for patients meeting ali criteria. ventilating patients in sp may be a new therapeutical approach to improve respiratory function in patients with ali. ( ) . there are several clinical trials investigating the efficacy of the free radical scavenger n-acetylcysteine (nac) in ards, but its advantage remains uncertain. objectives. critically appraise and summarize all randomized clinical trials involving intravenous nac administration in adult patients suffering from ards. we included trials involving participants with ards according to the american-european consensus conference criteria ( ) regardless of the underlying cause, and where one of the groups was treated with intravenous n-acetylcysteine in bolus intravenous doses or as continuous infusion, or combination of the two, and the other group was given placebo or standard treatment. conclusions. the main finding of this meta-analysis is that intravenous nac is ineffective in reducing mortality, length of stay or duration of mechanical ventilation in ards. we also found that late administration of nac may be associated with adverse outcome. the mechanism of this potentially deleterious effect remains unclear, but dosing and timing of nac appear to be critical issues. objective. to evaluate if extubation during ecls is harmful or beneficial. a -year-old woman was admitted to our intensive care unit (icu) after removal of a left ventricular assist device. this device was implanted as bridge to recovery for postpartum cardiomyopathy and ventricular function seemed to have recovered sufficiently. however, shortly after icu admittance she developed massive left and right ventricular failure. therefore a centrally cannulated veno-arterial ecls (maquet permanent life support) was implanted as a bridge to transplant. four days later she was extubated while on full ecls support, in order to reduce the risk of ventilator associated pneumonia. while on ecls, the patient was mobilized, practiced with an ergometer and chatted with her family. three days later the patient underwent cardiac transplantation. the postoperative period was characterized by temporary pulmonary failure, due to the combination of lung edema and atelectasis. eventually she made a full recovery. discussion. ecls provides a valuable means as bridge to transplantation, bridge to bridge or bridge to recovery. with the increasing use of ecls for circulatory failure, debate about the necessity of mechanical ventilation during this treatment ensues. ecls is usually applied under deep sedation and controlled mechanical ventilation. discontinuation of sedation possibly prevents intensive care acquired weakness. extubation during ecls may provide better pulmonary perfusion due to negative intra-thoracic pressure. furthermore, the awake and extubated patient is able to mobilize and exercise which may reduce the risk of atelectasis and ventilator associated pneumonia. our patient however developed pulmonary edema and atelectasis after discontinuation of ecls. the edema was probably a consequence of reperfusion injury, due to severely decreased pulmonary flow while on ecls. an absent ventilatory drive while on ecls may have led to hypoventilation while the patient was extubated, resulting in atelectasis. an extensive medline search resulted in one other case report describing an extubated patient on ecls. intermittent non-invasive positive pressure ventilation was used to prevent atelectasis, but the patient developed pneumonia after days of ecls. our patient was successfully extubated while on ecls. however, we conclude that there is insufficient evidence to recommend or oppose extubation of patients on ecls for circulatory failure. severe ards and refractory hypoxemia were defined with a pao / fraction of inspired oxygen (fio ) ratio of b , or uncompensated hypercapnea with a ph of \ . despite receiving optimal conventional treatment. the ecmo can be used as a rescue treatment in these case. objectives. evaluation of severe ards treated with extracorporeal oxygenation (ecmo). all these ards were due to bacterial pneumonia or h n influenza. over the last year (december -january ), the recourse to extracorporeal oxygenation (ecmo) was used in ten patients with severe ards and severe hypoxemia. two groups were defined: bacterial pneumonia with ards (bp group, n = ), and h n influenza with ards (h n group, n = ). all ecmos were implanted at the bedside to facilitate intra-hospital or inter-hospital transfer, because of severe hypoxemia or hemodynamic instability making impossible patient mobilization before ecmo. results. data sets of patients of consecutive patients treated with ecmo were complete and included into analyses. we had no clinical or radiological evidence for thrombosis or clotting within ecmo-circuit with a target-ptt of s. one patient with systemic aspergillosis died because of intracranial hemorrhage. one ecmo circuit had to be replaced due to insufficient oxygenator function after days. further data are presented in tables and . conclusions. in this retrospective analysis of patients who underwent ecmotreatment, ac with low-dose heparin (target-ptt of s) was safe and without any observation of macroscopic thrombosis or clotting within the circuit. transfusion requirements and intracranial hemorrhage were low as compared with previous reports [ , ] . therefore our data suggest that it is possible and safe using ecmo-therapy with low-dose heparin. introduction. in response to h n pandemy, italy and lombardy created a national and a regional icu network, respectively, for treatment of ards patients. our hospital policlinico san matteo of pavia participated with a team for inter-hospital ecmo implantation and subsequent patient transport. objectives. description of the pavia ecmo team and activity analysis. methods. our team is composed by a cardiac surgeon, two intensivists, a perfusionist, an icu nurse, two emergency rescue technicians and a driver. all necessary aids for implantation and intensive care are ranged in three trolleys and three transport bags. equipments are firmly mounted on a two-level steel bridge connected to a spinal board. a portable ultrasonograph is also available. the ecmo team was alerted by the national call center. each mission used two ambulances, and in one case the ambulances were embarked on a hercules c j. from october to december , four patients were implanted and transported, three suffering from h n influenza (including a -kg body weight patient) and one from acute mitral valve rupture. all patients, already mechanically ventilated with maximal support, had veno-venous ecmo implanted by femoro-femoral percutaneous cannulation. the median mission duration was of . h (range - h). all patients were transported to our icu, where the median ecmo duration was of days (range - days). no major managing issue occurred during the ecmo missions, and patient hospital survival was of %. a multispecialist team with good knowledge of ecmo can provide an effective support in severe respiratory failure, with ecmo implantation in peripheral hospitals and subsequent patient transport, thus realizing a fast and safe continuum between phone call activation and admittance to the reference center. introduction. when patients with sever respiratory failure are treated with v-v ecmo the right heart sometimes fails. this is a serious complication with a high mortality. in our unit these patients have been converted to v-a ecmo, although it is not fully agreed upon in the ecmo community due to previously depressing results. objectives. to evaluate the results of conversion to v-a from v-v ecmo in case of right heart failure. retrospective analyses of all patients with severe respiratory failure, treated between and at the karolinska ecmo centre. patients who were converted to v-a ecmo due to right ventricular failure were evaluated. a total of patients ( adults, peadiatric, neonatal) were treated on v-v ecmo for severe respiratory failure. of them ( adults, peadiatric, neonatal) needed conversion to v-a ecmo due to right ventricular heart failure demonstrated clinically by multiorgan failure and verified by echo cardiography. the survival after conversion to v-a ecmo was / ( %) in the adult age group, / ( %) in the peadiatric age group and / ( %) among the neonates. conclusions. given the high risk of fatality if not treated, conversion to v-a from v-v ecmo should be considered when the right ventricle fails. patients on v-v ecmo with right ventricle heart failure have very bad prognosis. it is concluded from the present results that conversion to v-a ecmo can save some of these patients. cardiac surgery and regional hemodynamics: objectives. to test whether tapse and right ventricular systolic (sm) and diastolic (em and am) tissue doppler imaging velocities are related with pulmonary artery systolic pressure (pasp) and length of the weaning process in mechanically ventilated patients with acute heart failure (ahf). methods. rv fractional area change (rvfac), left ventricular ejection fraction (lvef), pasp, tapse, sm, em, am rv tdi velocities, early diastolic mitral e wave and e maximal tdi velocities of the mitral annulus at the lateral wall were obtained at admission by doppler echocardiography in a cohort of patients with ahf, presented with pulmonary oedema, who required positive-pressure ventilation for more than h in the intensive care unit (icu). echo-derived measures were compared between patients with and without pulmonary hypertension, whereas their association with duration of mechanical ventilation and length of the weaning process was tested with multivariate linear and logistic regression analysis. and increased e/e ratio ( . ± . vs. . ± . , p \ . ) compared with subjects with normal pasp (n = ). these variables were negatively associated with duration of mechanical ventilation (r = . , beta slope = - . for tapse, r = . , beta = - . for sm, r = . , beta = - . for em/am, p \ . ) and were proven to successfully discriminate patients with (n = ) and without (n = ) prolonged weaning ([ days of weaning after the first spontaneous breathing trial failure, p \ . for all comparisons). conclusions. we suggest that in critically ill patients with ahf presented with pulmonary oedema, low tapse and rv tdi velocities upon admission are associated with pulmonary hypertension and prolonged length of the weaning process. objectives. the aim of the study was to study changes in cerebral blood flow (cbf), as determined by tcd, during the early postoperative course of cvs and to correlate such changes with post-operative nc. we studied patients undergoing extracorporeal circulation cvs (coronary by-pass, valve replacement or both) between march and march . cbf was assessed by measuring bilateral mca flow velocities by tcd before and , and h after cvs. changes c % between consecutive tcd results were considered significant. demographic and clinical variables, co morbidities, euroscore, sofa, type and duration of surgery and type and severity of nc were also recorded. patients were assigned to groups according to cbf changes from baseline: a) changes b %; b) cbf increases c %, c) cbf decreases c %. nc were classified as major (stroke, tia and coma) and minor (delirium, encephalopathy, transient cognitive impairment). we used descriptive statistics and inference by v , anova and pearson's correlation. of the patients, were excluded ( early post-operative death and due to technical difficulties or incomplete tcd recordings). of evaluable patients, ( %) had no cbf changes (group a), ( %) had increases c % (group b) and ( %) had decreases c % after cvs (group c). a positive correlation was found between cbf changes and duration of circulatory arrest (p \ . ), maximum sofa score (p \ . ), respiratory dysfunction (p \ . ) and duration of mechanical ventilation (p \ . ). neurological complications occurred in patients ( %), of which ( %) were major and were minor ( % introduction. the sole monitoring of macrohemodynamic variables is not always sufficient in the early detection of tissue hypoperfusion, especially in cardiac surgical patients that frequently present with microcirculatory derangements. near infrared spectroscopy (nirs) is an easily applicable non invasive technique that has been used to provide an estimate of tissue oxygenation at the bed side. objective. the aim of our study was to evaluate the effect on outcome of guiding hemodynamic therapy and specifically inotrope titration in cardiac surgical patients postoperatively with nirs. methods. patients operated on with cardiopulmonary bypass were assigned, after stratified randomization (gender, euroscore-cutoff of ), to an intervention (ig) and a control group (cg). postoperatively, following cardiac intensive care (cicu) admission, after initial resuscitation according to cicu protocol, sto (%) was measured in patients of the ig in muscle sites: thenar, masseter and deltoid. if it was less than % in / sites, dobutamine was administered in incremental doses ( . lg/kg/min), with the sto (%) measured every half hour. the interventional period began upon cicu admission and lasted for h, after which both groups were treated according to cicu protocol. primary outcome measured was the oxygen consumption rate at the end of the h intervention period as assessed with nirs vascular occlusion technique. . patients were included in the study ( in the intervention group and in the control group). the groups did not differ statistically significantly regarding age, euroscore, and macrohemodynamic variables postoperatively (with the exception of cvp). microcirculatory parameters upon admission to the cicu also did not differ, excluding masseter sto (%). the oxygen consumption rate and the reperfusion rate increased in the h study period in both groups, without differing statistically significantly between the groups at any time point (cg oxygen consumption rate . ± . upon cicu admission and . ± . h later, ig . ± . and . ± . respectively) (cg reperfusion rate ± upon cicu admission and ± h later and ig ± and ± respectively). as far as outcome parameters were concerned, the groups did not differ statistically significantly in the total hours and total dose of vasopressors ± inotropes received, in the hours of mechanical ventilation, in the duration of cicu or hospital stay, and in sofa scores the days following the operation. conclusion. nirs guided titration of inotropes did not lead to a greater improvement in the microcirculation h postoperatively, or to a better outcome. the limited power of the study prevents definite conclusions on the role of nirs in hemodynamic therapy in cardiac surgery patients. objectives. to estimate the prevalence of pulmonary embolism among mv patients in icu and its association to deep vein thrombosis (dvt). in a monocentric prospective observational study, we included all the patients requiring mechanical ventilation with no previously diagnosed pe, who underwent a thoracoabdominal ct contrast scanner for any medical reason. we used a modified protocol for pe diagnosis with a -multidetector row ct scan read by two independent radiologists. the association with a dvt was explored by performing venous compression ultrasound of four limbs. objectives. the aim of this animal study was to evaluate the effect of intraabdominal hypertension on left ventricular diastolic function. after approval by an institutional animal care committee, rabbits were anesthetised before mechanical ventilation. an intraperitoneal infusion of . % glycine solution was used to increase intraabdominal pressure to mmhg. the right common carotid artery was catheterised in the neck in order to introduce a millar mikro-tip catheter (millar instruments inc., houston, usa) into the left ventricle. heart rate, arterial pressure, central venous pressure, oesophageal pressure and intraabdominal pressure were measured. the s time constant of relaxation which is considered as best index of relaxation was calculated using the derivative method ( ). all haemodynamic measurements were registered at baseline and after inducing intraabdominal hypertension. data are presented as mean (iqr) and were compared using a wilcoxon rank sum test. results. heart rate (from ± to ± beat/min, p = . ), mean arterial pressure (from ± to ± mmhg, p = . ) and dp/dt max (from , ± to , ± mmhg/s, p = . ) were not significantly modified by intraabdominal hypertension. however, the s time constant of relaxation increased significantly (from ± to ± ms; p = . ). conclusions. in this animal model, intraabdominal hypertension impairs left ventricular relaxation. these changes in the condition of the microcirculation have been related to the degree of organ dysfunction and thus patient outcome ie hospital length of stay. near infrared spectroscopy (nirs) is an easily applicable non invasive technique that has been used to provide an estimate of tissue oxygenation at the bed side. objectives. the aim of our observational study was to examine whether impaired tissue oxygenation as assessed with nirs immediately postoperatively correlates with hospital length of stay. patients undergoing a planned cardiac surgical procedure on cpb were included in the study. patients' thenar tissue oxygenation (sto %) was assessed with nirs postoperatively in the cardiac intensive care unit (cicu). results. patients undergoing cardiac surgery on cpb ( male/ female) (age: ± years, euroscore: . ± ; mean ± sd) were enrolled in the study. patients length of stay was . ( - ); median(range). the haemodynamic parameters of our patients upon admission to the cicu were: map ± mmhg, cvp ± mmhg, pcwp ± mmhg, mpap ± mmhg, ci . ± . l/min/m , svr ± dyne x s/ cm , pvr ± dyne x s/cm , hr ± bpm, hb . ± . g/dl, lactate . ± . mg/dl; (all variables expressed as mean ± sd). upon admission to the cicu all patients were mechanical ventilated, under vasopressor ± inotrope support and their central temperature was . ± . ; mean ± sd. the thenar sto % was ± ; mean ± sd. thenar sto % correlated statistically significantly with hospital length of stay (r = . , p = . ). discussion. tissue oxygenation as assessed with nirs reflects the balance between regional oxygen delivery in relation to oxygen utilization. an elevated sto in the presence of normal macrohemodynamics may reflect impaired oxygen consumption and thus an impaired microcirculation. conclusion. patients with impaired tissue oxygenation immediately postoperatively have a longer hospital length of stay. further studies are needed to confirm these results and to investigate the potential benefit from incorporating this information regarding tissue oxygenation in the treatment algorithm. objectives. the goal of this study was to compare two different sedative agents for implantation of crt-ds related to incidence of adverse events and patient's satisfaction. methods. the study included forty-two, asa iii-iv patients, undergoing transvenous implantation of crt-ds under local infiltrative anesthesia with to ml of % lidocaine. intraoperative sedation was established with intermittent boluses of midazolam ( - mg) to achieve desirable level of sedation. before the induction of ventricular fibrillation in order to test the defibrillator function of the crt-d device, patients received an additional bolus of either propofol ( . - . mg kg - , p group, n = ) or etomidate ( . - . mg . kg - , e group, n = ) targeting bis values in the range - . the incidence of apnea, hypotension, nausea, myoclonus, pain at injection site, allergic reactions as well as patient's satisfaction with anesthesia described as feel of well being were registered and compared between groups. results. in subjects ( %) no complications were recorded. myoclonus was registered in patients from e group ( %) and in none from p group (p \ . ). no patients receiving etomidate reported pain at injection site compared to patients ( %) receiving propofol (p \ . ). there was no significant difference in incidence of apnea between two groups ( vs. %, p = . ). two patients in p group ( %) and in e group ( . %) became hypotensive after delivering the hypnotic agent (p = . ). also, there was no statistically significant difference between groups considering the frequency of nausea ( % vs. %, p = . ). all the patients whom propofol had been delivered ( %) reported feel of well being and only four of them filed the same after etomidate ( %) (p \ . ). no allergic reactions and major adverse events were registered. conclusions. implantation of crt-ds and its testing can be successfully performed with administration of both propofol and etomidate as a safe procedure with low per operative morbidity and shorter complication rates. still, treating with propofol tends to be more satisfactory for the patients. introduction. ultra-short-acting b selective adrenergic antagonists are now widely used to control tachycardia and tachyarrhythmia perioperatively. among them, landiolol, a new ultra-short-acting b -blocker, has been reported to exert a more potent negative chronotropic effect with little effect on blood pressure than esmolol ( ). however, detailed mechanisms underlying different cardiovascular actions are still unknown. objectives. in this study we evaluated direct effects of landiolol on cardiac performance and single cell electrophysiology in comparison to those of esmolol. methods. the present study composed of two parts. the first part of the study used isolated guinea-pig hearts which were perfused in the langendorff mode at constant flow with oxygenated tyrode solution at °c. the coronary perfusion pressure (cpp) was continuously monitored throughout the experiment, and intrinsic heart rate (hr) and isovolumetric left ventricular contraction were measured with a thin saline-filled balloon inserted into the left ventricle. the second part of the study was to measure action potentials and ionic currents in ventricular myocytes isolated enzymatically from guinea-pig hearts. comparison of data was conducted by repeated-measure anova with post hoc test (bonferroni's correction). conclusions. esmolol had a more potent negative inotropic effect than landiolol. this effect is, at least in part, derived from shortening of apd. in addition, increase of the coronary resistance would facilitate the negative chronotropic action of esmolol in vivo. conclusions. nma moderates hpv in the conscious spontaneously breathing beagle, but not to the same degree as acz. as compared to acz, the additional methyl-group in nma may impair its capability in vivo to act on a non-ca acz-sensitive cellular receptor or channel or that both, ca-dependent and ca-independent actions of acz yield a greater effect. introduction. tee with bubble test is considered as the ''gold standard'' method to detect a pfo with right to left shunt. tcd is a non-invasive method which has been shown to be as accurate as tee for pfo detection. we conducted a multicenter trial to estimate the prevalence of pfo, the influence of the size of the heart chambers on the prevalence of pfo and the accuracy of tcd as a non invasive method for pfo detection in mechanically ventilated icu patients. one hundred icu patients ( m and f) under mechanical ventilation who needed a tee study for hemodynamic assessment were included in the study. in each patient, the presence of a pfo was detected by tee and tcd. three bubble tests with agitated haemacel Ò were performed by each method, with tee probe at and rotation and with tcd the gate of pulse wave doppler (pwd) at the m segment of the middle cerebral artery (mca). patients without temporal acoustic window to perform tcd were excluded from the study. the size of pfo was classified as grade i, ii and iii according to the number of microbubbles passing from the right to the left atrium and the number of hits (high intensity transient signals) detected with pwd in the mca (grade i: \ microbubbles or hits, grage ii: [ and \ and grade iii: more than microbubbles or hits). for each patient included in the study we measured and correlated the presence of pfo with the tidal volume (v t ), the plateau pressure (p plat ), the compliance of the respiratory system (c rs ) and the size of the right (rv) and left (lv) ventricle. results. mean p a o /fio was (min , max ), mean c rs was ml/cmh o (min , max ), mean v t was ml (min , max ) and mean p plat was cmh o (min , max ). the prevalence of pfo detected with tee was % and with tcd %. there was no pfo detected with tee and missed by tcd. tcd was more sensitive than tee in detecting pfo of grade i ( with tee, with tcd) and ii ( with tee, with tcd), while for grade iii the two techniques had equal sensitivity ( with tee, with tcd). no correlation was found between p plat , c rs , v t and the presence of pfo. on the contrary, a strong correlation was found between rv dilatation and the presence of pfo (p \ . ). conclusions. the prevalence of pfo detected by tcd is very high in mechanically ventilated icu patients and this may have important clinical implications. tcd is more sensitive than tee in detecting a small pfo. the presence of rv dilatation increases the prevalence of pfo. objectives. the aim of our study was to identify in mechanically ventilated patients for ali/ards the prevalence of pfo and to evaluate the factors that may influence the prevalence of pfo. methods. two groups of mv patients, one with ali/ards and one without respiratory failure (rf), were enrolled in the study. all patients underwent a tee study for hemodynamic assessment. in each patient three consecutive bubble tests with agitated haemacel Ò were performed at and rotation of the tee probe. the bubble test was performed through a central line in the inferior or superior vena cava (ivc, svc). a pfo was diagnosed by the presence of microbubbles in the left atrium within five cardiac cycles following the injection. furthermore, in ali/ards patients in whom a pfo was not detected at baseline mv, three consecutive bubble tests during recruitment maneuver at cmh o for s were performed. the compliance of the respiratory system (c rs ), blood gas exchange and the ventilatory settings (p plat , v t ) were recorded in both groups. o, respectively. the presence of rv dilatation was a strong predictor for the fo opening (p \ . ); on the contrary, no statistical significant difference was found between the site of injection (svc vs. ivc), the c rs , v t , and p plat and the presence or absence of a pfo. a high prevalence of pfo was found in ali/ards patients. rv dilatation seems to be the reason of this high prevalence. rv dilation may be due to the lower c rs and higher p plat of the ards patients. introduction. the clinical evaluation of arterial tone is mainly based on the calculation of total systemic vascular resistance (tsvr). however, given the pulsatile nature of arterial flow, this parameter provides an inadequate assessment of vascular tone. another approach proposed would take account of changes in pulse pressure and blood flow, relationship known as arterial elastance (ea). so, for a given stroke volume, the blood pressure generated in the circulatory system will depend on ea ( ). to assess the ability of the dynamic arterial elastance (ea dyn ), defined as the relationship between pulse pressure variation (ppv) and stroke volume variation (vvs), to predict the hemodynamic response in mean arterial pressure (map) to a increase in stroke volume (sv) in hypotensive preload-dependent patients with acute circulatory failure. we performed a prospective clinical study in a -bed multidisciplinary intensive care unit, including patients with controlled mechanical ventilation and monitored with the vigileo Ò monitor, for whom the decision to give fluids was taken due to the presence of circulatory, including arterial hypotension (map b mmhg or systolic arterial pressure \ mmhg), and preserved preload-responsiveness condition, defined as svv c %. dynamic arterial elastance (vpp/vvs ratio), arterial pulse pressure to sv ratio, map/sv ratio, tsvr and map were compared to predict a map increase c % after volume expansion (map-responders). results. at baseline, only ea dyn was significantly different between map-responders and nonresponders. ve-induced increase in map was strongly correlated with baseline ea dyn (r = . , p \ . ) and changes in ea dyn after ve (r = . ; p \ . ). the only predictor of map increase was ea dyn (auc . ± . ; % c.i.: . - ). a baseline ea dyn value [ . predicted an increase c % in map after fluid administration with a sensitivity of . % ( % c.i.: . - . %) and a specificity of % ( % c.i.: - %). conclusions. dynamic assessment of arterial elastance by pvv to svv ratio during controlled mechanical ventilation could be used to predict mean arterial pressure increase after volume loading in hypotensive preload-dependent patients. severe sepsis is one of the major reasons for intensive care unit (icu) admission and leading causes of mortality. some of these score systems have been customized for patients such as apache ii, apache iii, sasp ii and mods. this study is to assess the validity of mortality prediction systems in severe septic patients. objectives. the aim of this study was to compare and evaluate four severity scoring systems in intensive care unit (icu), including apache ii, apache iii, sasp ii and mods in severe septic patient. methods. fifty-six severe septic patients were divided into two groups. one was survival group and the other was non-survival group. besides general data, the continuous surveillance of apache ii, apache iii, sasp ii and mods were recorded by st, rd and th day. results. compared with survival group, mods was significant difference in non-survival group only in st day ( . ± . vs. . ± . , p \ . ) but apache ii, apache iii and sasp ii were significant difference through st, rd and th day(p \ . ). in seven-day comparison, p value of apache iii in non-survival group was the minimum (p = . ) and p value of mods was the maximum (p = . ). in optimal survival evaluation, it seemed that apache iii was the best (apache iii [ apache ii = saspii [ mods). conclusions. in order to evaluate the critical condition and prognosis of severe septic patients, apache iii was the best and apache ii and sasp ii were followed and mods was the worst. objectives. to assess compliance with the cem standards for management of severe sepsis across three ed sites in the west midlands. methods. data was collected retrospectively over months. patients presenting to the ed within this period were assessed for likelihood of severe sepsis by the diagnostic code given to each patient upon leaving the ed. data was analysed using a scanned copy of the ed clerking. patients' notes were assessed for sirs criteria and signs of new infection. if these criteria were met, and organ dysfunction was present, they were included in the audit. results. patients with severe sepsis were identified. of these % were documented as septic by ed staff. the cem standards of care were received in % of patients with a documented diagnosis of severe sepsis in the ed, and % of patients overall. % of patients received the 'treatment' aspects of care: oxygen, iv antibiotics (with blood culture) and iv fluids. % of severely septic patients had no documented consideration of icu referral. conclusions. early recognition of severe sepsis in the ed led to greater performance in meeting the cem standards. although % of patients received observations and % received the treatment interventions, we performed poorly in meeting the remaining cem standards. the trust has developed a severe sepsis proforma which incorporates the cem standards to accurately record the completion of each intervention. a sepsis course for staff has been launched trust wide, and a formal referral process to icu for all severely septic patients is being implemented. objectives. to observe association of body temperature (bt) and antipyretic use with mortality in the critically-ill. a prospective multi-national, multi-center observational study. consecutive patients whose icu stay were expected to be more than h were recruited from centers in japan and centers in korea. patient's bt was prospectively recorded every h until patient's death, discharge from the icu or up to days. information including patient's clinical characteristics at admission, presence of infection, and use of steroids, extracorporeal circuit, and antipyretics were recorded. ( ). while blood culture results take time, treatment for bloodstream infection should be provided swiftly, usually before results are available ( ) . prior treatment with antimicrobials increases the chances of false negative results. haste, poor technique and alteration in commensal flora may increase the chances of falsely identifying pathogens. objectives. we have investigated the utility of blood culture tests in our general critical care unit over year in terms of results yielded and actions prompted. methods. the indication for blood culture was clinician's discretion. all critical care sourced blood cultures for the period oct to sept were reviewed from the microbiology laboratory database. blood culture specimens were collected in bact/alert Ò bottles (biomerieux, durham, nc, usa ). notes review was made of the positive blood culture episodes to determine actions after the results were known. consideration was given to the source of the blood sample: clean stab versus from an intravascular device. categoric data was analysed using the chi-squared test and p value of . was accepted as significant. objectives. we hypothesized that in the emergency department of our hospital many patients with sepsis are not recognized as such. methods. in a retrospective design, patients of an age of years and older who were admitted to the emergency department during a period of months between january-april and diagnosed as having an infection were included. the diagnose infection was made on admission by the emergency department nurse. the included patients were either classified as having sepsis or not having sepsis, according to the sirs criteria. conclusions. h n infection was associated with significant morbidity and mortality. it occurred mainly in young pts with co-morbidities and was associated with severe hypoxemia, a trigger for prolonged mechanical ventilation and frequent use of lung rescue therapies. a significant delay in hospital admission and start of antiviral therapy should also be noted. admission to administration time difference between cycles was . h, with a mean reduction of . h between clinician assessment and prescription time in cycle two. we identified delays against the standard after both cycles of the audit. we demonstrated that the method of prescription should be taken into consideration when prescribing antibiotics in patients with suspected sepsis. there are a multitude of factors that could contribute to a reduction in the clinician assessment to prescription time, which may be investigated in further audits. conclusions. despite high levels of resistance among psa and ab from these icus, cfr for most carbapenem dosing regimens were above the reported susceptibility. doripenem provided greater cfr than meropenem, which was superior to imipenem against these isolates. while higher doses combined with prolonged infusions significantly improved cfr against psa, alternative therapeutic strategies will be required to address these highly resistant ab. grant acknowledgment. the passport study is supported by a grant from janssen-ortho-mcneil. introduction. drug interactions are common, and the effects of these interactions can range from innocuous to deadly. critically ill patients often receive a variety of potent drugs, including antimicrobials, making this population extremely susceptible to drug-drug interactions. therefore, physicians must be familiar not only with the antimicrobial drugs capable of producing adverse drug events, but also their potential drug-drug interactions. there are scarce data about the incidence of these types of drug interactions and the how frequently it might cause adverse events. objectives. the purpose of this study is to evaluate the incidence of potential drug interactions involving antimicrobials and the possibility to cause adverse events. the clinical pharmacist has prospectively analyzed icu prescriptions between january and december with the purpose to identify potential drug-drug interactions involving antimicrobials. the screening was done with the relief from a software (epocrates rx Ò drug reference). the interactions detected were classified in eight groups according to the affected system (neurological, cardiovascular, gastrointestinal, renal, endocrine, hematological, musculoskeletal and others) and through the type of interaction (pharmacokinetic, pharmacodynamic and others). we have identified the most common potential effects, the medications involved and have observed the incidence of adverse drug events. results. the icu admitted patients during the study period. we have analyzed physician orders with prescribed items. we have identified antimicrobial drug interactions ( different interactions) which compound % of the total drug interactions (n = ). the cardiovascular system and the pharmacokinetic interaction were the most potentially affected ( %; %). the most common medications involved were: fluconazole ( %), clarithromycin ( %), levofloxacin ( %); linezolid ( %). the clinical pharmacist has made an intervention regarding medication safety in % (n = ) and the acceptance rate by the medical icu staff was %. we have not been able to identify any adverse drug event caused by drug interaction even with our active search and the spontaneous reports. however, sub notification must be taken into consideration. conclusions. clinicians should be aware of potential drug-drug interactions when making therapy selections for critically ill patients. antimicrobial drugs are susceptible to interact with other drugs, which may increase the risk of adverse drug events. the clinical pharmacist interventions may improve clinical outcomes by optimizing medication use, monitoring potentially preventable adverse drug events and promoting information about this important issue to the icu multi-professional team. introduction. cefazolin is one of the most frequently administered antimicrobial agent for prophylaxis in ''clean'' surgery. its broad spectrum against gram + micro-organisms and its pharmacological characteristics make it an easy-to-use choice to prevent infections caused by staphylococcus aureus and coagulase-negative stapylococci. objectives. the aim of this study is the evaluation of the plasma concentrations of cefazolin administered as a prophylactic antimicrobial agent during cardiac surgery with cpb. adequate cefazolin plasma levels can maintain a tissue concentration high enough to prevent the risk of developing post-operative infections. after obtaining ethical committee approval and personal written consent, two groups of patients were enrolled in this prospective study. the first group, patients, received cefazolin, g, - min before skin incision and g adjunctive dose after h. then, three g doses were administered every h. in the second group of patients the adjunctive g cefazolin dose was given at the beginning of the cpb. blood samples were collected immediately before the first dose and every hour for the whole time of surgery, and, only in the second group, after surgery, at th, th and th hour. plasma cefazolin concentration was determined with a biological radial diffusion assay. results. plasma cefazolin was constantly higher than the mic of the most involved micro-organisms (according to clsi). in the first group, cefazolin concentration suddenly decreased after starting cpb. the g adjunctive dose immediately restored it. the earlier administration of this dose in the second group prevented this sudden fall. plasma cefazolin was maintained at effective inhibitory levels for the whole time of surgery in all patients ([ mcg/ml). during the postoperative period cefazolin decreased slowly, but inhibitory plasma levels were always maintained. the rate of cefazolin clearance was found equal to the creatinine clearance in all patients. perioperative plasma cefazolin concentration conclusions. the administration of cefazolin g every h can guarantee effective inhibitory plasma concentrations during surgery and during the first h after surgery. cpb causes a sudden fall in cefazolin plasma levels. this can be avoided administering an adjunctive g dose immediately before starting cpb. objectives. vancomycin dose regimen was adjusted based on trough plasma levels in burn patients that were distributed according to the extension total burn surface area (tbsa); also pharmacokinetics changes were compared. methods. twenty seven adult burn patients of both sexes, requiring antimicrobial therapy with vancomycin for the control of sepsis were investigated. pharmacotherapeutic follow up was performed in a serial of periods ( observations) for all patients investigated by collection of blood samples, ml each from the venous catheter as follows: st blood sample collection, h after the beginning of drug h infusion and a nd sample blood collection at the trough, immediately before the next dose. if necessary, additional sample blood collections were performed based on the laboratorial data for patients any time, for dose adjustment purpose and optimization of drug therapy. vancomycin plasma concentrations were determined by highperformance liquid chromatography. plasma curve decay was plotted, and pharmacokinetics was analyzed by one-compartment open model against the reference data reported. results. burn patients receiving the empiric dose regimen showed trough plasma level lower than the minimum effective concentration, consequently dose adjustment was required. vancomycin adjusted dose regimen showed statistical significance differences according to tbsa (p \ . ) as follows for daily dose normalized to body weight and expressed by mean ± sd: . ± . mg/kg/day were required for patients with tbsa below %, . ± . mg/kg/day for tbsa - % and . ± . mg/kg/day were required for tbsa above %. relevant changes on pharmacokinetics were observed by drug plasma clearance increased according the increase of tbsa (p \ . ), while the apparent volume of distribution and also the biological half-life remained unchanged. additionally, a weak correlation was observed between vancomycin plasma clearance and creatinine clearance (r = . ; p = . ), probably due to the contribution of the extra-renal clearance on total drug elimination. on the basis of data obtained in the present study and to prevent therapeutic failure and also to reduce the risk of bacterial resistance, dose adjustment in burn patients is recommendable based on vancomycin plasma monitoring and also on the extension of total burn surface area. introduction. the importance of early antibiotic therapy has been recently demonstrated. regarding a rapidly increasing number of obese patients, appropriate drug dosage in these patients is an important challenge of critical care since it has been shown that not only early start of antibiotics but also correct target concentrations decrease mortality. vancomycin is administered according to body weight (bw). nevertheless, little is known about the percentage of obese patients achieving pre-defined target serum levels within h after initiation of vancomycin therapy compared to patients with normal bw. objectives. therefore, it was the aim of our study to analyze the appropriateness of serum vancomycin levels in patients with a bw between and kg. vancomycin is almost entirely excreted by the glomerulus and may be responsible for nephrotoxicity [ ] . however, there is a lack of definitive evidence linking concentrations to either outcome or toxicity [ ] . few reports exist comparing intermittent dosing and continuous infusion. ingram [ ] suggested that whilst associated with a slower deterioration in renal function, there was no difference in the prevalence of nephrotoxicity. similarly, hutschala [ ] demonstrated worsening creatinine in patients following cardiac surgery with both intermittent and continuous infusion but infusion tended to be less nephrotoxic despite receiving higher doses. we wish also to report our experiences with vancomycin infusion in critically ill cardiac patients. methods. we examined retrospective data from , patients treated with vancomycin. we perform adjusted and un-adjusted analysis using sofa on the day of starting vancomycin and total dose received. to assess the differences in either an initial pulmonary or non pulmonary presentation. methods. prospective, observational, multi-center study conducted in intensive care (icu). we reviewed demographic and clinical data for all pandemic h n influenza a infections reported in the esicm h n registry. results. patients were screened from the registry. patients with completed data entry for pulmonary and non pulmonary with outcomes were identified and analysed. all patients had either suspected, probable or confirmed pandemic h n influenza a infection and were being cared for in an icu. % of the patients were male with a median age of (iqr - ) years. the admission mean saps score was ± and the apache ii score was ± . % of the patients subsequently received non invasive ventilation and % received invasive mechanical ventilation. the icu mortality rate was %. the hospital mortality was %. % of patients presented with a pulmonary presentation. % of these were admitted with ards and/or bacterial pneumonia and % with an acute bronchospastic exacerbation. % of patients were admitted to the icu with a non pulmonary presentation. the main reasons for admission in these patients were: cardiovascular instability ( %), altered level of consciousness ( %), renal failure ( %) and acute coronary syndromes ( %). patients with a pulmonary presentation were older, had a increased history of asthma or copd and were more likely to be ventilated. they had a higher mortality rate in the icu. non pulmonary presentations were more likely to suffer from chronic renal impairment. a total of episodes of pandemic influenza a (h n )v infections in critical care setting were analyzed: with bacterial pneumonia ( males and females) and with wheezing or viral pneumonia ( males and females). the mean age was (± ) years in patients with bacterial pneumonia and (± ) in patients viral pneumonia. the mean apache ii score was (± ) and (± ), with a corresponding probability of death of (± )% and (± )%. comorbidities were common, but without significant differences between the two groups (only exceptions pregnancy-more prevalent in patients without bacterial pneumonia-and dialysis dependence-more prevalent in patients with bacterial pneumonia). at icu admission shock and acute renal failure were more common in patients with bacterial pneumonia. in patients without pneumonia; severe hypoxia and ards did not presented significant differences between groups. aims. evaluation if an isocaloric beginning of artificial nutrition in critically ill medical patients is associated with increased nutritional related side effects compared to a hypocaloric start. methods. critically ill medical patients with an expected need for artificial nutrition of [ days were included into this prospective, randomized clinical study. artificial nutrition was started either isocalorically right from the beginning (group a; n = ) or hypocalorically ( % of the energy demands) followed by a stepwise increase over the next days (day : %); day : %) (group b; n = ). nutrition related side-effects were defined as the occurrence of hyperglycemia, hyperlactatemia, hypertriacylglycerolemia, upper digestive intolerance, cholestasis, or diarrhea as well as disturbances of serum electrolytes and were assessed on a daily basis. patients were randomized to receive either an artificial nutrition started isocalorically (group a) or hypocalorically followed by a stepwise increase (group b). of the patients, patients completed the study (group a: n = ; group b: n = ). the calculated, cumulative energy requirements of patients of group a and b were , ± , and , ± , kcal, respectively (p = ns). patients of group a received ± % and patients of group b ± % of the calculated energy requirements (p \ . ). the incidence of nutritional related side effects was not different comparing both groups, except for hypophosphatemia, which was more pronounced in group a. additionally, exogenous phosphate needs were higher in patients of group a. the number of interruptions of the artificial nutrition did not differ between groups. conclusions. an isocaloric start of artificial nutrition provided more energy during the first days of their icu stay than a hypocaloric beginning. there was no difference in the number of interruptions and in the incidence of nutritional related side effects, except hypophosphatemia suggesting the presence of refeeding syndrome. in studies carried on to demonstrate positive effects of glutamine (gln) that has innumerable biological features, the main point of discussion isn't whether gln has positive effects in sepsis but rather the effect difference between different administration routes. only enteral (en.) or parenteral (pn.) administration was analyzed in this respect and no studies on combined administration were performed. the primary endpoint in this study was to analyze the effects of administration of en. and pn. gln together or separately on intestinal mucosa + immune system in the experimental sepsis model. for this purpose villus atrophy, bacterial growth in blood and tissue, levels of blood gln, tnfa and il were examined. the secondary endpoint was to evaluate the different administration models in terms of cost. wistar, adult female rats were used. they were fed standard. sepsis was developed in groups (all rats) by injection of intraperitoneal(ip.) ml ( cfu/ml) e. coli. grup c (n = ):en./pn. isotonic saline ( ml/day; ml/d); grup e (en., n = ):en. gln ( . g kg - day - ) + pn. saline ( ml/d); grup p (pn., n = ):pn. gln ( . g kg - day - gln) + en. saline ( ml/d); group ep (en. ± pn., n = ):pn. gln ( . g kg - day - ) ala-gln = . g kg - day - gln) + en. gln ( . g kg - day - ); were administered. feeding of rats began h (h) after administration of ip e. coli. blood gln (with spectrophotometer), tnfa and il concentrations(with elisa) were examined at the start (baseline levels) and at - h after the experiment started. samples of tissue from mesenteric lymph node, liver, lung, blood and small intestine were collected. ala-gln = . g kg. . rates of reproduction of the strain administered were found lower for group ep than group c (p \ . ). rates of villus atrophy in ileum of group ep, p and e were lower than group c (p \ . ).plasma gln levels were found lower in groups ep and p at h, and higher at h than other groups (p \ . ). when plasma gln levels at h were compared with their baseline levels, significant increases were detected in groups ep and p and significant decreases were detected in groups c and e (p \ . ). serum tnfa and il levels were found lower for groups ep and p at and h when compared between groups (p \ . ). when serum tnfa and il levels at h were compared with their baseline levels, more distinctive increases were detected in groups c and e than other groups (p \ . ). significant positive correlation was determined between tnfa and il levels at h (p \ . ) and h (p \ . ). cost of simultaneous administration of en. and pn. gln was higher than en. administration but close to pn. administration at these doses. methods. medline and embase were searched. hand citation review of retrieved guidelines and systematic reviews was undertaken and academic and industry experts were contacted. only methodologically sound randomised controlled trials (rcts) were eligible for inclusion in the primary analysis. the primary analysis was conducted on clinically meaningful patient oriented outcomes, which included mortality, functional status and quality of life. secondary analyses considered vomiting/regurgitation, pneumonia, bacteremia, sepsis and multiple organ dysfunction syndrome. meta-analysis was conducted using the peto analytic method, which is known to minimize bias in the presence of sparse events. the impact of heterogeneity was assessed using the i metric. results. , unique abstracts were identified, resulting in the retrieval of papers for detailed eligibility review. four rcts were identified to be on topic however one rct reported excessive loss to follow-up such that an intention to treat analysis could not be conducted. analysis based on the three methodologically sound rcts demonstrated the provision of early en was associated with a significant reduction in mortality (or = . , % confidence interval . to . , i = ). no other outcomes could be pooled. sensitivity analysis including all four on-topic rcts (or = . , p = . , i = ), and a simulation analysis conducted using a different analytical method. (or exact = . , % ci . to . ), confirmed the presence of a mortality reduction. conclusions. although the detection of a statistically significant reduction in mortality is promising, overall trial size was small. the results of this meta-analysis should be confirmed by the conduct of a large multi-center trial. reference(s). results. the mean ibp was . ± . and mean igp was . ± . . correlation between the ibp and igp was significant however moderate (r = . ). analysis according to bland and altman showed a bias and precision of . and . mmhg respectively, however the limits of agreement (la) were large and ranged from - . to . mmhg. the median grv proto was ml ( - , ) and median grv classic was also ml ( - , ). correlation between the methods was excellent (r = . ). analysis according to bland and altman showed a bias and precision of - . and . ml respectively and the limits of agreement (la) ranged from - to mmhg. the median drainage time and return times were min ( . - ) and . min ( - ) for grv proto compared to min ( . - ) and min ( - ) for grv classic. a preliminary cost effectiveness analysis shows that the price of measuring grv with the classic method ranges from . € to . € per day, depending on the grv size. price of measuring grv with the gastro pv system is independent of grv size and is estimated at . € per day. the gastro pv system if priced at . € could become cost effective at grv of cc and more. conclusions. the interim results of an ongoing multicentre pilot study show that the gastro pv is a good alternative to the standard method for measuring grv. because the nurse can perform other tasks during drainage and return of the grv, and the fact that the system remains closed during measurement, this could be a major step forward in standardisation of grv measurement. furthermore it allows screening for intra-abdominal hypertension via igp estimation. acknowledgment. the gastro pv devices were provided by holtech medical, free of charge. introduction. the importance of early enteral feeding of the critically ill patient has been well documented. it is the more physiological approach, which is associated with lower rates of infectious complications. early enteral nutrition within h is recommended by the espen guidelines on enteral nutrition. a recent meta-analysis revealed that mortality and the incidence of pneumonia were significantly reduced in patients with enteral nutrition within h. parenteral nutrition may be associated with higher mortality. objectives. evaluation of a new technique for the placement of postpyloric feeding tubes by intensive care physicians. methods. prospective cohort study in critically ill patients subjected to transnasal endoscopy and intubation of the pylorus. attending intensive care physicians were trained in the handling of the new endoscope for transnasal gastroenteroscopy for days. a jejunal feeding tube was advanced via the instrument channel and the correct position assessed by contrast radiography. primary outcome measure was successful postpyloric placement of the tube. secondary outcome measures were time needed for the placement, complications like bleeding and formation of loops and the score of the placement difficulty graded from (easy) to (difficult). data are given as mean values and standard deviation. out of attempted jejunal tube placements, tubes ( %) were placed correctly in the jejunum. the duration of the procedure was ± min. the difficulty of the tube placement was judged as follows: grade : patients, grade : patients, grade : patients, grade : patients. in cases, the tube position was incorrect, and in another cases, the procedure had to be aborted. only in one patient, bleeding occurred that required no further treatment. conclusions. fast and reliable transnasal insertion of postpyloric feeding tubes can be accomplished by trained intensive care physicians at the bedside using the presented procedure. this new technique may facilitate early initiation of enteral feeding in intensive care patients. grant acknowledgment. the authors acknowledge the support of pentax, hamburg, germany, who provided the endoscope used in the study and of fresenius kabi, bad homburg, germany who provided the feeding tubes. a well-nourished condition before prolonged endotoxemia results in a better ability to adapt to endotoxin-induced metabolic deterioration of arginine-nitric oxide metabolism than does reduced caloric intake before endotoxemia ( ). the role of individual organs in the arginine-citrulline metabolism during malnutrition and sepsis is unknown and may be key to direct future interventions. to study the effects of reduced caloric intake and endotoxemia on the citrulline-arginine metabolism in the gut-liver-kidney axis. organ arginine-nitric oxide metabolism was measured by using a primedconstant stable-isotope infusion of [ n ]arginine and [ c- h ]citrulline during conditions; a -day reduced caloric intake feed regimen (starv; n = ), normal control feed regimen (co; n = ), endotoxemia alone (ce) and reduced caloric intake and endotoxemia (re) in. catheters for blood sampling were placed in the abdominal aorta, which, in combination with the catheters in the portal, hepatic and renal veins, served for metabolic measurements across the portal-drained viscera, liver and the kidneys, respectively. results. interestingly, re animals had similar citrulline appearance from the gut ( ± nmol/kg/min) compared to control and animals during ce, but higher in endotoxemia alone ( ± , p \ . ). this was related to a significantly higher no production from the gut in the re group ( , ± vs. ± , p \ . ). in the kidney arginine appearance from citrulline decreased significantly during re compared the control animals ( ± vs. ± nmol/kg/min, p \ . ). in contrast, the liver disposed more arginine in the re group compared to the other conditions, while no production was not higher. conclusions. despite reduced caloric intake prior to endotoxemia, the gut remains capable of increasing release of citrulline, although the capability of the kidney for the de novo production of arginine is severely compromised. metabolic control of the citrullinearginine metabolism in the gut-liver-kidney axis should focus on increasing de novo arginine production from citrulline. objectives. the aim of this study was to measure duodeno-caecal transit times of enteral feed in this patient group using a scintigraphic technique. a prospective observational study was performed in mechanically ventilated critically ill patients ( m, age ± yr, bmi ± kg/m , icu admission day ± , apache ii on study ± ; mean ± sd) and healthy subjects ( m, age ± year, bmi ± kg/m ). after a h fast a ml enteral feed (ensure kcal/min), labelled with mbq m tc-sulphur colloid, was infused into the distal duodenum over min. dynamic anterior scintigraphic images were recorded in min frames for min and the time of first appearance of activity in the caecum was recorded by two blinded operators (kj, ar). data were assessed using mann whitney u test and are presented as median (iqr). introduction. erythromycin, a macrolide antibiotic is widely used as a prokinetic agent in intensive care unit (icu) despite the lack of data supporting its prolonged effectiveness in enteral nutrition (en) intolerant critically ill patients. to evaluate impact on clinical outcome of erythromycin prescription as prokinetic agent in icu. all patients consecutively admitted from january through december mechanically ventilated for more than days and receiving en were included in an observational cohort study. en intolerance was defined clinically as a -hourly gastric residual volume (grv) c ml or vomiting. successful en was defined as a grv\ ml with a feeding rate c ml/h. erythromycin prescription was left to practician appreciation. objectives. this study aims at evaluating the relationship between diarrhoea and en in icu patients. methods. during month, the days with and without diarrhoea (c liquid stools/day) and the characteristics of nutritional support of all patients staying in our icu were recorded. patients staying \ h or presenting an intestinal stomy were excluded. we compared, between days with and without diarrhoea, total energy coverage and energy coverage by en as % of needs, en energy intake and en volume for each patient. needs were estimated as - kcal/kg body weight for women and men, respectively. the relationship between antibiotics, laxative treatment and diarrhoea was also analysed. results are presented as mean ± sd. comparisons were made by mann-whitney test. the risk of diarrhoea with en was calculated by odds ratio and confidence intervals (ci). the study included days of hospitalisation of patients ( ± years, bmi ± kg/m , sofa score at admission ± ). en was present in days of diarrhoea and days without diarrhoea. determining the small bowel function is of great concern in icu patients, because a malfunctioning small bowel may predispose to malnutrition and may increase the risk of sirs. a recently developed test, the citrulline generation test (cgt), measures the enterocytes' capability to convert glutamine into citrulline. the production of citrulline exclusively takes place in functioning enterocytes, therefore this conversion represents small bowel function. objectives. we aimed to define the cgt reference values in 'stable' icu-patients to assess small bowel function. secondly, we wanted to compare four different cgt methods; enteral and iv administration of dipeptiven and measurement of citrulline in both arterial and venous samples. we performed the cgt on stable icu-patients, defined as having respiratory failure but not dependent on vasopressors. they had a normal renal function and were able to tolerate enteral nutrition. a h fast was followed by administration of g of glutamine-alanine (dipeptiven Ò ) either intravenously or enterally, randomly determined. the next day the same test was performed by using the other route. after each administration of dipeptiven, citrulline levels, both arterial and venous, were measured at fixed time points using reverse-phase high performance liquid chromatography (hplc). results. nine females and males were admitted to the icu with either a medical ( ) or a surgical ( ) diagnosis. they had a mean (± sd) age and bmi of . ± years and . ± , kg/m respectively. their median apache ii score was . (iqr = . - . ). on the day the cgt was performed their median sofa score was . (iqr = . - . early post-pyloric feeding has been shown to improve clinical outcomes [ ] . commonly used methods for placing a nasojejunal tube (njt) are blind, endoscopic or fluoroscopic placement. the later two methods are relatively invasive, expensive and can cause delay to feeding, whereas blind placement is often unsuccessful. electromagnetic sensor guided njt insertion is a bedside technique able to confirm successful placement without the need for abdominal x-ray. the system incorporates a liquid crystal display and a receiver unit. the receiver is placed over the patient's xiphoid process and picks up the signal from an electromagnetic transmitter located at the tip of the feeding tube. the screen provides a visual aid to enable the operators to trace the route of the tube tip and identify its' location according to anatomical markers. objectives. we were interested to determine the suitability of electromagnetic sensor guided njt insertion especially in relation to success rate and procedure time. methods. fifty patients were referred for electromagnetic njt insertion on units at the leeds teaching hospitals. insertion time was measured from oesophageal visualisation until post-pyloric placement. various positional manoeuvres were employed along with administration of sedatives, prokinetics and air insufflation when applicable. all insertions were carried out by experienced investigators. all njt insertions were confirmed by abdominal x-ray. data collection included patient demographics, hospitalisation and procedural information. results. forty male and female patients, mean age (range - years), bmi mean ( - ), had attempted electromagnetic njt placement. patients had been hospitalised for a median of days ( - ). indication for njt insertion was either large aspirate and/or reflux ( %). seventy six percent of patients had an artificial airway and % of patients were receiving sedation. forty six percent of patients received metoclopramide and % air insufflation. thirty six percent of patients were moved into either left or right lateral position. successful post-pyloric placement was achieved in % of patients confirmed by additional abdominal x-ray. procedural time varied from to min (mean ). two of the placement failures were due to patient intolerance. conclusions. bedside electromagnetic guided njt placement technique is an acceptable method of placing post pyloric feeding tubes with a high success rate. gastrointestinal failure (gif) score has been suggested ( ). the gif score defines gi failure as the occurrence of feeding intolerance (fi) and intra-abdominal hypertension (iah) simultaneously. to compare the outcome of patients with primary vs. secondary gif. methods. all consecutive, mechanically ventilated (mv) patients treated for at least h during january to december in two icus were studied. gif was defined as gif score equal or above points according to the gif score ( ). points = fi and iah simultaneously; points = abdominal compartment syndrome (acs). fi was defined as the need to stop enteral feeding for any clinical reason (vomiting, high gastric residuals, bowel distension etc). iah was defined as mean intra-abdominal pressure (iap) c mmhg on any day. acs was defined as iap [ mmhg with the new onset organ failure. when gif developed in a patient with primary pathology in abdomino-pelvic region it was classified as primary gif, when occurred without previous pathology in abdomino-pelvic region it was taken as secondary. objectives. in this study the biochemical quality and prion safety of the pharmaceutically licensed plasma octaplaslg Ò was evaluated. the prion reduction factor achieved by western blot was confirmed by animal studies. eighteen consecutive batches of octaplaslg Ò (octapharma ppgmbh, vienna, austria) were tested on global coagulation parameters, fibrinogen levels, activities of coagulation factors and protease inhibitors, activation markers, as well as von willebrand factor multimers. in parallel studies, plasma pool was spiked with exogenous spike material, derived from brains of hamsters infected with hamster-adapted scrapie k, and a down-scale of the octaplaslg Ò manufacturing process was performed. the prp sc reduction factor for the resin was investigated in both western blot and hamster bioassay studies. a reduction factor of c . log prp sc was found for this process step by western blotting. the outcome of the hamster bioassay confirmed that the high level of removal prp sc seen during octaplaslg Ò manufacturing was equivalent to a removal of infectivity ( . log ). in octa-plaslg Ò , a parallel reduction of the s/d virus inactivation step led to significantly higher activities of plasmin inhibitor. our studies demonstrated that the same amounts of prp sc and prion infectivity bind rapidly and with a very high affinity to the chromatography resin. octaplaslg Ò has the same clinical safety and efficacy profile compared to that demonstrated by octaplas Ò over the last years, except for the increased safety margin in terms of prion disease transmission and the possible effect of a significantly increased plasmin inhibitor activity. uniplas Ò is a second generation solvent/detergent (s/d) treated, coagulation active plasma for infusion produced with an implemented prion removal step. it was developed as an alternative to the blood group specific s/d plasma products, octaplaslg Ò and octaplas Ò , in order to obtain an universally applicable (i.e. blood group independent) plasma that can be used without taking into account the blood group of the recipient. due to an initially controlled, optimal mixing of plasma of different blood groups prior to s/d treatment, in uniplas Ò , the blood group specific antibodies (anti-a and anti-b of both igm and igg type) are neutralised and/or removed by free a and/or b substances and red blood cells (rbcs) to a clinical acceptable level with very limited or no complement activation. objectives. in this study an extensive biochemical characterisation of the first uniplas Ò validation batches was performed. methods. three batches of uniplas Ò were produced by octapharmappgmbh (vienna) under production conditions in [ ] [ ] . uniplas Ò batches were tested on all important coagulation factors, protease inhibitors, activation markers, adamts and factor h levels, as well as von willebrand factor multimers. in addition, anti-a and anti-b titres of igm-and igg-type were investigated. finally, complement activation products, as well as key components of the complement system, were measured. results. in uniplas Ò batches, all coagulation factor activities were higher than . iu/ml and all protease inhibitor activities, including protein s and plasmin inhibitor, were higher than . iu/ml. uniplas Ò contained standardised levels of adamts and factor h, within the normal ranges for single-donor freshfrozen plasma. there was no activation of fvii obtained during manufacturing, thrombin-antithrombin (tat)-complex, prothrombin fragments (f + ) and d-dimer levels were within the normal ranges. anti-a and anti-b titres were within the uniplas Ò specification, i.e. anti-a igm and anti-b igm\ : as well as anti-a igg and anti-b igg \ : , respectively. uniplas Ò did not contain an increased amount of immune complexes and the manufacturing of uniplas Ò associated with more complement activation than the one seen for octaplaslg Ò . conclusions. the present study confirmed that uniplas Ò displays the same high quality and clinical efficacy as the s/d treated blood group specific plasma octaplaslg Ò , but with the additional advantage in being a blood group independent universally applicable plasma. most pts received more fluids than calculated by parkland formula ( ± . ml/kg %tbsa). interestingly, nonsurvivors received less ( . ± . vs. . ± . ml/kg %tbsa). gastric decompression, ascites drainage and the implementation of a stool protocol with rectal enemas ( interventions in pts) was able to remove . ± . l of body fluids and this was related to a significant decrease in iap and cvp and an improvement in oxygenation and urine output ( conclusions. pris is a difficult condition to diagnose and routine monitoring of the adverse effects of high-dose propofol remains sub-optimal. hypothermia has been reported to alter propofol pharmacokinetics and we propose that active cooling may increase the risk of developing pris. this may be particularly relevant in patients with tbi who are on high doses of propofol to control icp in addition to concomitantly administered catecholamines to maintain cerebral perfusion pressure. we recommend that further research is required in this area in view of the increasing use of induced hypothermia in icu. objectives. to compare differences in fluid resuscitation based on direct or indirect admissions to the london burns unit. methods. admissions to the burns unit with [ % burned surface area (%bsa) were identified over years. were excluded from analysis due to palliation or death within the first h. sets of notes were randomly selected for analysis of fluid balance in the first h period of fluid resuscitation after the burn injury. results. mean (sd) time from burn injury to arrival at the burns unit was lower for patients transferred direct to the burns hospital rather than via another hospital ( . ± . vs. . ± . min p = . ). mean (sd) error in burn size estimation was lower for patients initially treated by burns specialists versus non-burns specialists ( ± . vs. . ± . %, p = . ). all patients were resuscitated according to the parkland formula calculated at one of , or ml/kg/%bsa. the mean (sd) actual fluid volume differed from the target by . % (± . %); the lower the calculated fluid target, the greater the error between actual and planned resuscitation volumes; there was no difference in accuracy of fluid resuscitation at h between patients initially managed by burns specialists versus non-burns specialists ( . ± . vs. . ± . % respectively, p = . ). conclusions. burned patients transferred directly to specialist burns care receive a faster and more accurate assessment of their burn injury. despite this, we found no difference in fluid targeting errors at h, though this may reflect corrective fluid management on arrival at the specialist centre. echocardiography is an useful and minimally invasive tool that allows to know the heart filling pressures, also it has proven highly accurate in predicting the response to volume in critically ill patients. we try to determinate the response to fluid infusion by static variables as cvp or lap, comparing with the variation of ivc. methods. an observational prospective study with patients undergoing coronary cardiac surgery ( patients were excluded by a no presenting a good echo views), in the postoperative period under mechanical ventilation (vt ml/kg, fio %, peep ). we performed an echocardiography if the patient presented hypotension, just before the habitual fluid load protocol were started ( ml hes % in - min). we collected data before and after the infusion, and determine the responsiveness to volume if the cardiac output increased more than %. data in the report included invasive cvp and lap, and echo measures, ratio e/e', diameter and variations of inferior vena cava (ivc) and variations of stroke volume by echocardiography (Ølvot x vti lvot) and with vigileoÒ system. . the correlation between low values of cvp/lap and volume response was poor, the relationship between cvp below mmhg with increased cardiac output had a correlation (pearson correlation - . ) with a significance ( -tailed) . , and the relationship between lap \ mmhg and an increase in cardiac output had a correlation (pearson correlation . ) with a significance of ( -tailed) . . the measurement of the variation of the inferior vena cava, led us to calculated a cutoff point more sensitive to determine which patients were responders to volume. through the roc curves (sensitivity/specificity), with the area under the curve of . % (se = . %) and with a confidence interval of % (p significance of . ), resulted in a % variations of ivc with a sensibility of % and specificity of % (younden's index of . %). the same calculation, based on kraemer's quality indices (qi) gave us a % of variation in ivc, with a w = . specificity rather than sensitivity (qi . ), and with a w = . sensitivity rather than specificity (qi . ) objectives. to ascertain whether postoperative hypothermia is linked to high or low risk surgical patients. we conducted a prospective systematic analysis looking at the incidence of postoperative hypothermia in adults who underwent general anaesthesia. children age \ , pregnant women and patients undergoing regional anaesthesia were excluded from the survey. to identify the current level of doctors' knowledge on perioperative fluid management. methods. the survey was conducted at george eliot hospital, nuneaton, uk in may . questionnaires consisting of ten multiple-choice questions on basic sciences and clinical scenarios were devised by a consultant anaesthetist. these were personally distributed to doctors of all grades working in anaesthetics and the surgical specialties. doctors were asked to complete the questionnaire within min. of the questionnaires distributed, were completed. results. the mean questionnaire score varied between specialties from % in the anaesthetics department to % for doctors in surgical specialties. the mean score of registrars and fy doctors in surgical specialties was found to be and % respectively. the overall mean score was %. of all doctors surveyed, the daily maintenance water requirement was known by only %, % knew the daily maintenance sodium requirement and % knew that of potassium. the electrolyte contents of . % sodium chloride and hartmann's solution was answered correctly by % and % respectively. there is a significant deficiency in doctors' knowledge on perioperative fluid management. more emphasis on optimal perioperative fluid management is required in undergraduate and postgraduate training. increased awareness of the british consensus guidelines on intravenous fluid therapy for adult surgical patients would aid training. based on this survey, a regional online survey of junior doctors is planned to further identify gaps in perioperative fluid management training. optimal fluid management could also help to reduce prolonged hospital stay which can result from fluid-related complications. objectives. to evaluate dynamic echocardiographic parameters as predictors of volume responsiveness in surgical patients. methods. patients were included in the study after laparotomy surgery performed on the same day ( breathing spontaneously and mechanically ventilated in volume controlled mode with tidal volume of ml/kg). a fluid challenge was performed in spontaneously breathing patients by passive leg raising and infusing saline ( ml/kg). echocardiographic analysis of respiratory changes of inferior vena cava diameter (ddivc) and aortic blood flow (dabf) was performed in all patients. a threshold of % for ddivc was used for classifying patients as volume responders or non-responders. age, sex, gender, bmi, cvp, iap, map, left ventricular ejection fraction, left ventricular systolic and diastolic area, and stroke volume in all patients, as well as itbvi, ci, ppv and svv in patients were measured. a positive correlation with ddivc was established for itbvi (r = . , p = . ), iap (r = . , p = . ) and ef (r = . , p = . ). a positive correlation with dabf was not established for any variable measured. patients ( %) were classified as volume responders and ( %) as non-responders. responders had overall higher iap than non-responders ( . ± . mmhg vs. . ± . mmhg respectively, p = . ). respiratory changes of ivc diameter showed positive correlation with itbvi. so, conclusions about itbvi could be indirectly made from ddivc values in patients who are not being invasively monitored. ppv and svv did not show positive correlation with itbvi. surprisingly, we confirmed a positive correlation between ddivc and iap. we detected patients with high iap, while all the volume responders had overall higher iap. although further investigations are needed to establish how longer duration of high iap may influence ddivc, it seems that ddivc is a good parameter of volume responsiveness during first h after laparotomy surgery. unlike from other studies, we could not establish a positive correlation between dabf and any variable measured. these studies were performed in hypovolemic septic patients, so this could be the reason for such different results. more studies are needed in a larger set of patients undergoing laparotomy surgery to evaluate dabf. introduction. fluid optimization after major cardiac surgery was shown to improve patients postoperative outcome significantly. several hemodynamic parameters were proposed for the guidance of therapy but never compared in a head to head trial. objectives. in this prospective randomized trial patients scheduled for elective cardiac surgery underwent early goal directed fluid therapy guided either by stroke volume variation (svv) or by oxygen delivery index (do i). we hypothesized that while svv is easier to obtain it will not be inferior to do i in outcome parameters. methods. following ethics committee approval and signing of a written informed consent, patients were randomized in two groups to undergo either fluid optimization guided by do i or svv in the first postoperative hours in the icu following elective cardiac surgery (cabg). following a standardized egt protocol the parameters were collected by using hemodynamic monitoring based on a pulse contour analysis and a transpulmonary lithium dilution (lidco plus, lidco,uk). we compared amount and type of volume infused, need and amount of inotropic or vasopressor substances, time spent on ventilator, los in the icu and postoperative complications. statistics were evaluated by using a t test for unpaired samples. table . compared to the do i group fluid optimization using svv showed reduced ventilator times (p = . ) and less complications (p = . ) in the first days after surgery. no differences between the groups were detected concerning the type and amount of volume infused, need for inotropes or vasopressors or the los in hospital conclusions. while svv is less invasive, cheaper and easier to be obtained than do outcome was at least not inferior and even showed improvements in postoperative cardiac surgery patients. rd esicm annual congress -barcelona, spain - - october s introduction. over the years, there have been concerns over incompatibility of transfused blood with various intravenous fluids during blood transfusion, especially related to increased levels of haemolysis. it is often impractical, particularly in an emergency situation, to flush through a giving set with a so-called ''safe'' fluid prior to and after delivering blood. we wanted to investigate whether this is actually necessary and whether the usual fluids used in the perioperative period really do cause any demonstrable alteration in the composition of transfused blood. objectives. the purpose of this study was to expose packed red cells to a variety of different intravenous fluids commonly used during the perioperative period and to measure a number of parameters in the blood following their contact with each different fluid, including a blood film to examine for clumping of cells or haemolysis. a unit of a positive blood was passed through blood giving sets which were primed with various intravenous fluids. after adequate mixing of blood with fluids, samples were collected for full blood count, urea and electrolytes and blood films. one millilitre of mixed blood was taken in each bottle at a time. the intravenous fluids used in this study were normal saline, hartmann's solution, % dextrose, % dextrose, starch and gelatin. there was no significant rise in blood parameters suggestive of haemolysis. the potassium and ldh levels were not significantly different with various fluids. the haemoglobin and haematocrit levels were also comparable to one another. there was no demonstrable changes in blood parameters suggestive of haemolysis, nor were there any change in electrolyte values. this suggests that all of the fluids investigated during this study would be suitable to be used via the same giving set before and after the transfusion of pack red cells. objectives. to assess the compliance with the national guidelines in avoiding inadvertent peri-operative hypothermia in an acute district general hospital in england. we prospectively studied our local practice on maintaining normothermia in consecutive adult surgical patients { men, mean age . years, patients with asa grade ( . %), emergency surgical patients ( . %), patients with significant cardiac disease . %}. we used a questionnaire that was filled pre-operatively by anesthetic nurses, intra-operatively by anesthesiologists, and post-operatively by recovery nurses. patients were recruited from the following surgical subspecialties: general surgery ( %), gynecology ( %), trauma ( %), breast surgery ( %) and orthopedics ( %). day surgery patients were excluded. peri-operative hypothermia was defined as temperature \ °c as per the nice guidelines. results. less than half of our patients ( . %, n = ) had their temperature measured preoperatively, on whom incidence of hypothermia was . % (n = ). only one of these patients was warmed prior to induction. patients requiring emergency surgery and those with asa grade had increased incidence of preoperative hypothermia ( . % and . % respectively, p \ . ). based on nice guidelines, patients needed intraoperative forced air warming but only ( . %) patients received it. intraoperative temperature measurement was made on patients, of whom . % (n = ) were hypothermic. incidence of intraoperative hypothermia was high in surgical procedures lasting longer than min (p \ . ) but was not affected by the use of regional anesthetic techniques. patients had their temperature measured on arrival to recovery of whom ( . %) were hypothermic. patients ( . %) had their temperature measured every min (nice recommendation) and the mean time interval for temperature measurement in recovery was min. patients were still hypothermic on leaving recovery. conclusions. majority of our surgical patients did not receive adequate perioperative care on maintaining normothermia. consequently, the incidence of hypothermia was significant pre-, intra-and post-operatively. we are currently analyzing the data to investigate the effect of hypothermia on duration of recovery stay, length of hospitalization and mortality in our patients. we completed a double-blind randomized trial in patients undergoing cardiac surgery in which we compared fluid resuscitation with a hydroxyethyl starch (hes, % mw pentastarch) and saline. use of hes resulted in markedly less use of catecholamines the morning after surgery. an underlying design principle was that assessment of cardiac index (ci) is essential for a proper fluid protocol. in this analysis we examine that supposition. all subjects had pulmonary artery catheters. patients were consented preoperatively, but randomized post operatively to receive up to blinded ml boluses for predefined hemodynamic targets; ci \ . l/min/m , blood pressure (bp) set by admitting team, cvp \ mmhg, or urine output \ ml/h. hemodynamic measurements were made before and after each bolus. after the study boluses, only saline was used. results. patients received fluids, hes and saline. there were study boluses, hes and saline. of these, boluses ( %) could not be assessed for this hemodynamic analysis (but were still used for the primary outcome) because of protocol violation or missing data. of the rest, ( %) of boluses were given for a low ci; in bp and cvp were also low so that ci was the only trigger in %. a low bp was a trigger in ( %). low cvp was the trigger in ( %). only hes and saline patients required the maximum allowed blinded boluses. at the th bolus, low ci was the trigger for ( %) of hes but ( %) of saline patients. there were that could be evaluated for hemodynamic response based on four possible outcomes of cvp and ci. objectives. the aim of our study was to evaluate the predictive value of cvp with regard to gedi, and to correlate these parameters to cardiac index (ci). conclusions. volume depletion according to gedi was found in more than half the patients. the predictive values of cvp with regard to volume depletion were low gedi and its changes significantly correlated to ci and its changes, which was not observed for cvp. therefore, gedi appears to be more appropriate for volume management during mayor liver resections. introduction. regional anticoagulation with citrate is an effective and established anticoagulation strategy during crrt in critically ill patients, especially in surgical patients with a high risk of bleeding and in case of a heparin-induced thrombocytopenia ( ). however, citrate crrt could be associated with major metabolic derangements such as metabolic alkalosis, hypocalcemia, hypernatremia and citrate toxicity. objectives. the aim of our study was to investigate efficacy, safety and metabolic stability during citrate crrt in critically ill patients with acute kidney injury. methods. the retrospective study was performed in a mixed surgical and trauma icu in a university hospital. patient charts were reviewed for demographic data, the period and dosage of citrate crrt and metabolic parameters. reasons of admission, comorbidities and severity of illness were also evaluated. citrate crrt was performed using commercially available equipment and fluid solutions (multifiltrate Ò with integrated ci-ca Ò -system; fresenius medical care; germany). to maintain stable metabolic and haemodynamic conditions we used an internal standard protocol for citrate crrt. statistical analysis was performed using descriptive methods (mean, median and standard deviation) and a mann-whitney u test where appropriate. p \ . was regarded as statistically significant. conclusions. although minor metabolic imbalances were observed, none led to a termination of citrate crrt and all of them could be managed by adjustments of blood flow and dialysate rates according to a preset protocol. our findings suggest citrate crrt to be a safe and effective strategy for crrt even in patients with hepatic dysfunction. nevertheless, metabolic parameters need to be monitored regularly to avoid severe metabolic derangements. introduction. the liver is central to ammonia metabolism, being the main site of urea cycle enzyme pathways. in acute liver failure (alf) and decompensated chronic liver disease (cld) ammonia dysmetabolism results in hyperammonaemia, thought to be of central importance in the pathogenesis of hepatic encephalopathy and, in alf cerebral oedema [ ] . continuous renal replacement therapy (crrt), commonly used in critically ill patients may be an effective method of clearing ammonia. little is known of the efficacy such techniques have on ammonia clearance. objectives. to quantify the clearance of ammonia using an aquarius haemofilter (ahf) using different renal replacement doses and techniques. methods. patients with a circulating ammonia level[ lmol/l due to commence crrt were enrolled. the ahf was programmed to run in either pre-or post-dilution modes at a blood flow rate of ms/min using a . or . m filter depending on the crrt ultrafiltration (uf) dose, which included , or ml/kg/h (adjusted for ideal body weight). ml of blood and effluent fluid were collected, on ice into lithium/heparin and serum separation tubes, from pre and post filter access points and effluent tubing to calculate urea and ammonia clearance using the cordoba formula [ ] . delta whole body ammonia clearance was determined by measuring arterial ammonia at and min. ammonia measurements were performed using a pocketchem Ò blood ammonia bedside testing machine. results. patients ( alf and cld) were recruited (mean age years, sd ( ), with mean arterial ammonia lmol/l, sd ( ). min whole-body ammonia clearance was - lmol/l, p = . , paired t test). ammonia and urea clearance were correlated (r = . , p = . ); uf rate correlated negatively with filtrate ammonia (r = - . , p = . ) and positively with ammonia clearance (r = . , p = . ). filter ammonia clearance was not dependent on filter size for the standard blood flow rate. pre or post dilution modes did not affect ammonia clearance (p = . , student's t test). a constant filter size and blood flow rate achieved ammonia clearance of ml/min/m for ml/kg/h, ml/min/ m for ml/kg/h and ml/min/m for ml/kg/h (p = . , one way anova). conclusions. ml/kg/h based on ideal body weight appears to be the optimum dose of crrt for ammonia clearance when using a blood flow rate ml/min and a . m filter. filter and delta whole body ammonia clearance may be increased further using the combination of a higher dose ( ml/kg/h) with a larger filter size and higher blood flow rates. introduction. malnutrition is common in intensive care following the catabolic state induced by critical illness. patients who progress from enteral nutrition back to oral feeding are usually in an energy deficit. espen guidelines recommend increasing calorie delivery during the recovery period to cover this anabolic phase. oral nutritional supplements (ons) are widely used to facilitate calorie delivery within the hospital setting however the effectiveness of this strategy is dependent on patient compliance with the products. compliance among the elderly ward-based population has been considered ( ) however that of intensive care patients has not been reported. to evaluate compliance to ons in a mixed medical and surgical adult intensive care unit (icu) in a district general hospital. prospective observational study was conducted over a month period with data compiled from fluid chart analysis and discussions with nursing staff. all adult icu patients prescribed, or offered without prescription, an ons were included until the point they were discharged to the ward. the supplements studied, resource Ò energy, . fibre, fruit and dessert (nestlé nutrition), were selected based on their availability within the trust. patients were offered a choice of flavour. results. data was collected and analysed for patient days. a total of supplements were prescribed. of the prescribed supplements, . % were offered to patients and . % consumed. % were offered the same at nursing discretion based on clinical need and . % were consumed. resource Ò energy was the most frequently prescribed and offered product ( . and . % respectively). most common flavours selected by patients were strawberry and vanilla. resource . fibre was better tolerated ( . %) than resource energy, resource fruit and resource dessert ( . , . and . % respectively). across all products the best tolerated flavours were apricot, chocolate and coffee ( %). the highest calorie supplement, resource Ò . fibre, resulted in the best compliance in both tested flavours. compliance with ons demonstrated here is higher than previous studies ( ) partly attributable to one-on-one nursing of icu patients enabling active encouragement with feeding. nursing staff discretion had better uptake than routine prescription of ons. however, difficulties with ons still remain. interestingly in our study the highest calorie density supplement was tolerated the best and thus giving the most benefit to the patient. despite the difficulties associated with ons uptake we would recommend its regular use on icu with a drive towards the highest calorie supplements being offered. introduction. cirrhosis is a chronic disease and the patient's quality of life is affected in a negative way due to the problems like ascites, jaundice, nutrition deficiency, fatigue, activity intolerance, itching, pain, insomnia, anxiety, hopelessness, work loss and depression. objectives. the aim of this study is to examine the changes in patient's lives that diagnosed with cirrhosis of the liver disease owing to the symptoms they experienced. methods. this research is a qualitative study that has been carried out with inpatients diagnosed with liver cirrhosis in the gastroenterology clinic of a teaching and research hospital. average age of patients was (ranging - ). descriptive characteristics form and semi-structured interview form were used in the data collection. interviews with patients have been performed individually and face to face. the data were evaluated by using colaizzi's phenomenological data analysis method. as a result of the data analysis, three categories and six themes were identified. categories include: (i) problems of symptoms related to the physical limitations (ii) psychosocial issues. patients suffer mostly from fatigue and malaise ( patients), while those in the later stages suffer from, additionally, physical ailments caused by acid. inability to sleep due to anxiety and increase in tendency to sleep in advanced stages have been identified after being diagnosed. the majority of patients were identified to have undergone an anxiety besides having a fatal disease due to concern for the future, being forced to quit the job and being affected by the experiences of the patients in advanced stages. it also has been discovered that the patients had experienced social isolation because of fatigue and weakness in particular. as the result of this study it has been determined that patients with cirrhosis have mainly problems of fatigue, weakness, sleep disorders, anxiety and associated problems. rd esicm annual congress -barcelona, spain - - october s [ ] . while in patients with acute liver failure, elevation of arterial ammonia levels has been linked to cerebral complications and increased mortality, the role of arterial ammonia in hh patients is unknown. our study aims at evaluating arterial ammonia levels in patients with hh. furthermore, we wanted to elucidate the potential consequences of high ammonia levels in these patients. arterial ammonia levels were measured and documented in hh patients without liver cirrhosis who were admitted to the medical icu. icu mortality and overall day-survival were documented. cox regression was performed to describe the impact of ammonia levels on mortality. mann-whitney test was used for comparison of metric variables. results. overall median arterial peak ammonia level in our patients was lmol/l ( . - . lmol/l), whereas median arterial peak ammonia value was significantly higher in icu non-survivors compared to survivors ( ( - . ) vs. . ( . - . ); p \ . ). saps ii and sofa score were significantly higher in icu non-survivors (p \ . and p \ . , respectively). cox regression revealed that arterial peak ammonia levels were significantly associated with higher -day-mortality (p \ . ), even after adjustment for saps ii. median arterial peak ammonia levels in patients with verified brain edema were significantly higher than in patients without ( . lmol/l ( - . lmol/l) vs. . lmol/l ( . - . lmol/l); p \ . ) after exclusion of patients following cardiopulmonary resuscitation with consecutive hypoxic brain damage. our results suggest that increased levels of ammonia are associated with high mortality and can lead to brain edema in patients with hh. % of patients had a diagnosis of sepsis and % of patients were admitted under the neurosurgical team, the latter of which may have contributed to the relatively low anticoagulant use of %. systemic heparinisation was the sole anticoagulant used, but compliance with local protocols was poor with % of appts below the therapeutic range and % of infusions commenced at the wrong rate. % of filter changes were due to clotting and mean filter life was h. despite this, dose delivery was acceptable, with % of prescribed dose delivered. conclusions. as previously reported , our demographic data confirm the relatively poor outcome of patients needing crrt. we have identified areas where care for these patients could be optimised and endeavour to do this locally via improved protocol design and an ongoing educational programme. many of the components of crrt could be incorporated into care bundles, but certain aspects of treatment remain controversial which may be a barrier to their adoption. given the high numbers of neurosurgical patients in our unit, consideration should be given to the use of regional anticoagulation such as citrate. introduction and objectives. accurate prognostic indicators of patient survival in an intensive care unit (icu) help guide clinical decision making. factors known to portend poor prognosis in acutely ill cirrhotics in icu include the need for mechanical ventilation, development of shock, renal failure and sequential increase in the number of failing organs. while serum lactate is now an established marker of survival and/or the need for transplantation in fulminant liver failure, its impact on critically ill cirrhotics is less well known. methods. we retrospectively studied consecutive acutely ill cirrhotics admitted to the icu between and at the royal free hospital, a tertiary referral centre in liver diseases and transplantation. data were collected on demographic variables, aetiology of liver disease, liverspecific prognostic scores [child-turcotte-pugh (ctp), model for end-stage liver disease (meld), united kingdom model for end-stage liver disease (ukeld)], and acute illness scores [acute physiological score and chronic health evaluation (apache ii), sequential organ failure assessment score (sofa) ]. in addition, serum lactate levels at , and h were also recorded. multivariable logistic regression analysis was performed, and the discrimination ability of each of the above-mentioned scoring models in predicting icu and hospital survival of these patients was evaluated using the area under the receiver operating characteristic (roc) curve. conclusions. one third of lt recipients present a documented bacterial infection within year after surgery. we found a high prevalence of ciprofloxacin resistance and a low incidence of s.aureus witch was often resistant to methicillin. non fermentative gram negative bacilli represent % of the pathogens and should be taken in account for treatment of the most severe patients. extracorporeal liver support therapy is in its infancy but is valued as a detoxification treatment option for patients with cirrhosis who have rapid worsening of their liver function. we report the use of prometheus Ò , a new extracorporeal liver support system allowing the removal of protein bound and water soluble toxins by fractionated plasma separation and absorption (fpsa) in a patient with wilson's disease (wd) who developed rapid worsening of their liver function. a -year-old female patient, diagnosed with wd since the age of , was initially treated in an irregular pattern with penicillamine. therapy was discontinued. now, years later, she developed acute decompensated liver failure with hepatic encephalopathy with a meld . liver transplantation (lt) was the treatment option for this patient. but, in this case, the rapid and adverse evolution of the liver failure with renal failure and the unknown waiting time for a emergency liver donor in our country led us to use the extracorporeal liver support therapy. after h min of therapy we reduced the amount of bilirrubin for less than a half, we increase the urinary output and next day the patient went to liver transplant, stable, with a renal function improved. conclusions. acute liver failure due to wd is most of the time fatal without emergency lt. this case report highlights discontinuation of chelants treatment in a patient with wd. as the patient progressed to decompensated liver cirrhosis with encephalopathy, lt was the only treatment option but while we don't get a donnor, we can use, for a short period of time, an extracorporeal liver support therapy as a very useful bridge. results from two studies presented at the recent easl congress have shown that treatment with extracorporeal devices may not confer a survival advantage for severe liver failure patients, despite positive dialysis effects. however, results among a small sub-group of patients show promise like severely ill patients with hepatorenal syndrome type or a meld score over . ( ) . metoclopramide is used to stimulate the upper gi tract and seems to have no effect on colonic motility. objectives. the aim of this in vitro study was to compare the prokinetic potency of those substances. a tissue bath with guinea pig colonic segments fixed on a polyacrylic tray allows the evaluation of the transit time (tt), the time necessary for a wooden pellet to perambulate. a decrease of the tt reflects stimulation, and an increase inhibition of peristalsis. after stable peristalsis activity the effect of increasing concentrations of prucalopride, neostigmine or metoclopramide on tt were evaluated. dose response curves were constructed, two way anova (sigma stat) was used for statistics, p values b . were considered to be significant. effect of prucalopride and neostigmine on motility results. prucalopride stimulates normal peristalsis in vitro only in the highest tested concentration of lm (p \ . ). neostigmine's prokinetic effect was limited to a small concentrations range ( . lm, p \ . ), the concentration of . lm had a moderate, but not statistically significant prokinetic effect and the highest tested concentration ( lm) lead to a complete block of peristalsis (fig. ) . metoclopramide, as expected, was devoid of any effect on colonic motility. conclusions. this experimental setting is a reliable method to evaluate the effect of different substances on colonic motility in vitro. prucalopride's prokinetic activity is concentrations dependent and limited. neostigmine is well known to improve colonic motility, but it seems imperative that the drug's effective dose range be use-higher concentrations have inhibitory effect on peristalsis. objectives. robotic radical prostatectomy involves extreme changes in patient position and often associated with a longer operative time than other commonly performed laparoscopic procedures. this review discusses the anesthetic considerations in robotic radical prostatectomy while analyzing potential risk factors related to pulmonary complications. we retrospectively reviewed the medical records of all the patients who had undergone robotic radical prostatectomy at our institution. among the total patients of , aged to years, patients were capable of spontaneous respiration at the end of surgery (group i) whereas patients needed assist ventilation (group ii). the demographic characteristics, coexisting diseases, anesthesia and operation time, anesthetic agents, the amounts of blood loss, infused fluid and transfused blood products were compared between the groups. results. the mean age of the patients was . ± . years. the mean operation times were . ± . min (range, - min). age, body mass index (bmi) and asa status did not differ significantly between the two groups, whereas operation time, the amount of blood loss and the incidence of transfusion were significantly higher in the group ii. although patients with subcutaneous emphysema and atelectasis needed prolonged ventilator care for h, the incidence of atelectasis and subcutaneous emphysema was similar between the groups. conclusions. prolonged laparoscopic surgery in a steep trendelenburg position has a high possibility of postoperative respiratory insufficiency and the possible contributing factor is a long operation time. objectives. we examined the frequency of postoperative cough reflex and its effect on postoperative clinical outcome retrospectively. we examined the patients who admitted into the icu after the esophagectomy with lymphadenectomy during the period from september, , to february, . in addition to usual criteria for extubation we removed their tracheal tube if the cough reflex was identified when one milliliter of half saline was distilled into their trachea. if the cough reflex was absent until days after the operation the patient underwent tracheostomy and after that they weaned from the ventilator. results. there were patients (f/m / ), and their mean age was . ± . . cough reflex were confirmed by seventh postoperative day in patients ( %) but residual patients underwent tracheostomy because of absence of cough reflex ( introduction. the technique of laparoscopic cholecystectomy carried with carbon dioxide pneumoperitoneum may lead to adverse events in mechanical, hemodynamic and respiratory systems as a consequence of physiopathological changes such as increased intraabdominal pressure. _ it may cause hypoxemia, hypercapnia, hemodynamic instability and impairment of oxygenation. decreased functional residual capacity, ventilation/perfusion imbalance and sympathetic stimulation effects of co that is absorbed from peritoneum are basic problems. in perioperative period, application of mechanical ventilation and anesthesia should be reviewed because of these physiopathological mechanisms. in this study, we aimed to investigate the effects of cmh o peep application on etco , minute ventilation and arterial oxygenation during laparoscopic cholecystectomy operations. for this reason, the study included total patients and they were randomly divided into two groups. same anesthetic protocol was applied in both groups. for general anesthesia induction; mg/kg dose of fentanyl, mg/kg dose of propofol were administered. following this procedure endotracheal intubation was applied with . mg/kg dose of cisatracurium. patients received % o -% n o (mixture with equal amounts) with . - . mac end-tidal sevoflurane for anesthesia maintenance. before co insufflation, respiratory parameters were recorded on the respiratory apparatus adjusting etco - mmhg, respiration rate /min., inspiration/expiration rate : , vt: - ml/kg. patients were ventilated by volume controlled mechanical ventilation. heart beats, mean arterial blood pressure and peripheric o saturation (spo ), etco , minute ventilation(v) and peak airway pressure(p _ ip) values of all patients were recorded just before insufflation (t ). after recording, cmh o peep was applied to the first group (group ). peep wasn't applied to the nd group (group ). these parameters were repeated in periods such as (t ) and (t ) minutes after insufflation, preexsufflation (t ) and postexsufflation (t ) in both groups. before insufflation, respiration rate ( /min) and etco ( - mmhg) values were adjusted as planned in both groups and minute ventilation was also adjusted. at the same time, total insufflated amount of co for distending abdomen was recorded. arterial blood gas analyses were made just before induction (while patients were breathing normal room air, t ), min after induction (t ) and just before the end of the operation (t ). in our study, we found that minute ventilation to stabilize etco - mmhg was significantly increased in group in which peep was not applied (p \ . ). none enhancement was needed in minute ventilation in group and arterial oxygenation was significantly increased in group (p \ . ). aside from the cholesterol lowering effects of statins, as a class of drugs they have been shown to exert anti-inflammatory effects and have the potential to be therapeutic in neuroinflammatory disorders . we tested the hypothesis that atorvastatin improves memory retrieval post unilateral nephrectomy in a murine model. methods. c /bl mice were randomly allocated into groups (n = - /group): control plus placebo, control plus atorvastatin, nephrectomy plus placebo and nephrectomy plus atorvastatin. animals were given either a placebo ( . ml normal saline) or lg in . ml normal saline of atorvastatin by gavage once a day for days. on day all animals underwent fear conditioning training using a conditional stimulus of a db tone and an unconditional stimulus of a . ma electric shock. on day the surgical animals underwent unilateral nephrectomy, whilst the control animals received no surgery. at post-surgical day all animals were tested for hippocampal dependent memory retrieval using the fear conditioning paradigm, with freezing response to the db tone as a marker of memory retrieval. all animals were then terminated. results. surgery evoked a reduction in hippocampal dependent memory retrieval in the nephrectomy plus placebo group as measured by % freezing time (mean ± sd: ± ) when compared to the control plus placebo group ( ± ; p \ . ); a situation mimicking pocd. this change was obviated in the nephrectomy plus atorvastatin group ( ± ; p [ . vs. control plus placebo). conclusions. our data suggested that atorvastatin has the potential to improve postoperative cognitive performance in a murine model of pocd. the proven safety of the drug along with its already widespread use and cost effectiveness would permit rapid instigation of a human randomized controlled trial to explore efficacy in the clinical setting. a. puxty , r. docking glasgow royal infirmary, department of anasethetics, glasgow, uk hypotension in the post-operative period is common but guidelines recommend its prevention/treatment [ ] . epidurals are common practice following major surgery in many institutions and can prevent pulmonary complications [ ] but have also been associated with falls in blood pressure when compared to other analgesic techniques [ ] . fluids therapy is a common intervention for hypotension but fluid overload has been associated with worse outcomes in surgical patients [ ] . we decided to audit the incidence and management of hypotension in the surgical high dependency unit of a large tertiary referral hospital. to determine the incidence and management of hypotension in the surgical high dependency unit in pancreatic, upper gi and lower gi patients. we prospectively looked at patients who underwent major upper gi, lower gi or pancreatic surgery involving epidural analgesia. the first h of care from onset of anaesthesia was closely looked at with regards to fluid management, epidural management and actions taken on episodes of hypotension or severe hypotension (defined as systolic blood pressure of \ and \ respectively). each episode of hypotension was looked at to determine the actions taken at that point. of the patients looked at, were major pancreatic, lower gi and upper gi patients. ( %) had at least one episode of hypotension, with ( %) having at least one episode of severe hypotension. mean fluid in during the first h was ml, with a mean fluid balance of ml. there was no difference between the doses of epidural local anaesthetic in h between the hypotensive and non hypotensive groups (p = . ). management of hypotensive episodes was variable, but the most common intervention at episode one was fluid bolus ( %) and discontinuation of epidural was most common at episode two ( %). use of vasopressors for hypotension was very low with only two infusions being started altogether. conclusions. hypotension is very common in our high dependency unit. fluid balance in our patients was far more positive that we had expected. management of hypotension was variable. we plan to institute a protocol for hypotension and fluid administration to determine if improvements can be made. objectives. to identify predictive factors associated with the need for relaparotomy in patients with ssp. adult ssp patients undergoing laparotomy between and included within a single-center peritonitis registry (perit) were collected. patients subjected to relaparotomy were studied. we excluded patients with severe peritonitis secondary to appendicitis. apache ii and sofa score at icu admission after the initial laparotomy were recorded. variables with a p value. in a bivariate analysis were included in a multivariate logistic regression for further analysis of predictors for need for re-laparotomy. results. two-hundred forty-seven patients were obtained from perit registry. a total of patients with spp were included in the analysis. eighty seven patients ( %) required relaparotomy. median number of re-laparotomies was . most spp were associated to colon (n = , . %), small intestine (n = , . %) and biliary tract (n = , . %) perforations. cultures were positive in . % of first laparotomy: gram negative bacteria were isolated in . %, gram positive bacteria in . % and fungi in . %. hospital mortality was % (n = ). multivariate analysis is described in the table . conclusions. in obese patients scheduled for surgery, the previous use of cpap has not shown an improvement in blood gas parameters. the use of cpap in the hours before and immediately after surgery has not been associated with better postoperative oxygenation. combined icu-surgery dpt. action in these cases seem to contribute to better patient outcomes. objectives. we set out to quantify the intensive care workload and changes to that workload over the first years following the transfer of a specialist bariatric service to our hospital. a prospectively collected bariatric surgical database was cross-referenced to the itu database (ward-watcher) to identify admissions to the -bedded critical care unit of all patients who had undergone any bariatric procedure. for each patient identified; demographics, reason for admission, level of support, length of stay and outcome were recorded. data were grouped into -month periods for trend analysis. research in emergency situations and especially in resuscitation field raises important ethical and regulatory issues. the globalization of the resuscitation science through multicentric trials for example highlights the need for a more consistent approach to regulatory aspects to enable the science to grow while protecting human rights. objectives. the purpose of this analysis is to compare the different regulations approaches in emergency research in north america (canada, usa) and in europe (european directive, france). conclusions. this analysis emphasizes the lack of international standardization of regulatory measures and ethical decisions. however some countries like the us seem to advance in the democratic process by mandating additional regulatory measures (community consultation, public disclosure to the communities) prior to initiation of clinical investigation; nonetheless, there is little evidence of their effectiveness. many challenges are raised. firstly, the variability in regulations, and consequently in local board's assessments, is problematic, pleading for international regulations. secondly, the current heterogeneous ethical review process and demanding unsubstantiated regulatory measures poses a risk to all when it is not evidence based and it is applied inconsistently between countries, within a country and worse at the level of each individual hospital review board. it puts the investigator at risk for unnecessary criticism and the community at risk as it is unknown if we truly consult or inform our target communities about waiver of consent research through our current ethical and regulatory processes. globalization and evaluation of the ethical and regulatory processes are urgently needed; regulatory community has to work towards a standardized evidence-based process upon which to base regulatory decisions. introduction. in research outside the intensive care field it is known that a high score for the psychological factor ''perceived hopelessness'' experienced by healthy individuals increases risk of death several fold. objectives. the aim of this study was to examine if the score of the psychological factor ''perceived hopelessness'' may predict long term mortality (mean or high perceived hopelessness score) when assessed post icu care in former icu patients. methods. prospective, multicenter study in three mixed icu's in sweden. questionnaires, including the -item hopelessness scale, demographic data and previous illnesses, were sent months after discharge to all former adult icu patients who thereafter were followed for another years. a reference group of individuals from the uptake area of the hospitals served as controls. results. ( %) patients returned the questionnaires. the icu patients reported significantly higher mean scores in perceived hopelessness score compared with the general population, . (sd . ) compared with . (sd . ) (p \ . ), and % (n = ) of the icu patients perceived a mean or high hopelessness score compared with % of the general population (p \ . ). the icu patients who died during the follow-up period reported a significantly higher perceived hopelessness score (n = ) . (sd . ) (p \ . ) as compared with those who survived up to years after discharge (n = ) . (sd . ). in a logistic regression model the long term mortality for the icu group was found to be affected by: pre-existing disease [odds ratio (or): . ], age (or: . ) and perceived hopelessness score (or: . ). the new and interesting finding of this study is that icu patients score higher on ''perceived hopelessness'' than a control population and this increase is predictive for the post icu mortality. furthermore, the size of this effect is significant and only exceeded by pre-existing disease and age. we performed a retrospective observational study to evaluate what proportion of met calls was associated with lomt issues. to estimate the proportion of met reviews involving patients with a not-forresuscitation (nfr) order and the timing of met calls in relation to admission and death or discharge from hospital. to compare the patient characteristics and outcome for met calls associated or not associated with lomt issues. we obtained hospital research ethics committee approval. we performed a retrospective observational study involving five-year (august -april ) in a single tertiary australian hospital. we obtained information on demographics, on the met review and hospital outcome. lomt included nfr orders, not for met orders and palliative care plans. results. we analysed met reviews in patients. table and fig. summarize major findings for overall population and the two subgroups of patients with or without lomt. patients with lomt care plan were older, more likely to have medical diagnoses, were reviewed later during their hospital stay and closer to their hospital discharge or death. fewer lomt patients were admitted to icu. hospital length of stay was shorter, mortality in lomt care patients was double that of non-lomt patients. however, more % of patients with lomt were discharged alive from the hospital. conclusions. more than one third of met activations deal with lomt issues. although the mortality of these patients is high, a large proportion survives to hospital discharge. evaluation of the patient experience in intensive care (icu) frequently depends on reports from surrogates such as relatives. there is a concern regarding the validity of the surrogate opinion which might not represent the values of the incapacitated patient and treatment decisions therefore maybe biased [ ] . others have found that there is a strong preference within a population for utilizing relatives as surrogate decision-makers in the event of admission to icu and this attitude is not influenced by ethnicity, religion or education level [ ] . objectives. the objective was to measure the ability of the relative to answer on behalf of the patient. a further wish was to determine the validity of their surrogate responses. a retrospective study, which surveyed relatives of patients who had died within a critical care service during a -year period ( , ) . the item questionnaire allowed for the collection of quantitative and qualitative data with respect for each item to overcome the limitations of the quantitative format which may not be sensitive to all the issues which can surround the provision of end-of-life care [ ] . for items, relatives were asked specifically to grade their capacity to represent the patient. results. quantitative data from the items designed to test the relatives' perception of their ability to act as surrogates indicates that relatives considered they could respond to these items for % (average) of instances. when the relative did answer on the patient's behalf, the level of concordance between the surrogate (relative) and the patient's perceived opinion was % suggesting that when the relative is willing to act as surrogate the response is likely to have validity. (table ) . results from the qualitative data indicates that the low ( %) level of willingness to answer these questionnaire items reflected a reluctance to answer on behalf of a sedated or ventilated patient, rather than an inherent inability to represent the patient. conclusions. the response rate to the items vindicates concerns regarding the ability of relatives to represent the patient in icu settings and supports a need for further study. where the relative is willing to act as surrogate, concordance does exist. qualitative data clarified quantitative results and was instrumental in promoting a better understanding of the concerns of relatives who have a family member admitted to icu. . the majority of patients that died in icu were provided some kind of therapy restriction. an important conflict strains between clinical practise, bioethical principle and jurisdiction laws; the solution of this conflict is more and more urgent. therapy restriction has also important economical aspects since the number and cost of available treatments constantly increase. our survey studied therapy restriction procedures in hungary for the first time. in we performed a survey with questionnaire among intensive care physicians. questionnaires were sent out electronically to registered members of the hungarian society of anaesthesiology and intensive care. respecting anonymity we have statistically evaluated replies ( %) with t test and anova. we grouped intensive care physicians based on gender, years spent in work, religion and type of department they were working, and we compared data from these groups. intensive care physicians generally make their decisions alone, based on the patient's long-term life prospects and physical status ( . / points). they are slightly influenced by the opinion of the patient ( . ), the relatives ( . ) and other medical personnel ( . ). if the physician sees any chance of recovery but the patient or relative requests treatment restriction then . % of physicians that completed the forms would continue therapy against the will of the patient or relative. only . % would accept the patient's/relative's opinion and autonomy in such a case and would stop therapy. in fact . % of physicians would make their decisions without considering or even against the opinion of patient if they think therapy is useless. if there is no chance of recovery despite medical treatment % of physicians stop the treatment, . % would continue it without informing the patient or the relatives, . % informs the relatives but continues useless treatment irrespective of the will of the patient or relative. having analyzed the groups we found two significant differences. in case of useless treatment physicians working in university hospitals more often choose treatment restriction without informing relatives (p \ . ) then those working in non-university hospitals. physicians who declare themselves as atheist rather choose the continuation of treatment without informing relatives (p = . ). conclusions. the hungarian practise of end of life decisions among intensive care specialists is paternalistic, physicians make their decisions alone, do not consider the requests of the patient or relatives. our goal is to strengthen patient autonomy and to support their opinion by training icu physicians. on the other hand it is inevitable to define what useless medical treatment exactly is and to introduce this category in medical ethics and also in jurisdiction practise. objectives. to determine the frequency and processes of eol care at our centre. between october and december , / ( %) patients staying in the icu for more than day, underwent some form of eol care in the icu. icu staff notified investigators whenever an eol decision was made. we recorded demographic details, documentation of the eol care process in the case notes, and interviewed icu staff to determine the eol care processes involved. results. patients ( %) were male, ( %) were females. mean age was . ± years. icu stay was . ± . days, admission apache ii score was . ± . which increased to . ± . on the day of eol care decision. % patients had metastatic cancer. reasons for initiating eol care were refractory acute illness in %, advanced cancer in %, brain death in %, and lack of finances in %. eol discussions were initiated by the family in %, and by the icu medical team in % patients. families wanted to take the patient home to die. the icu consultant was involved in all discussions with the family, the primary consultants in % and primary team residents in %. nurses were involved in only patients. agreement on eolc was reached after discussion in %, discussions in %, and discussions in % of cases. documentation of the eol care process was not done in % cases. withholding of life support (wh) was practised in / patients ( %) and withdrawal of life support (wd) in %. intubation was withheld in . % patients, cardiopulmonary resuscitation in %, inotropes in % and dialysis in %. regarding wd, only / patients were extubated and the ventilator withdrawn in another / patients. inotropes were withdrawn in patients ( %). reduction of fio . without discontinuing mechanical ventilation was the commonest mode of wd, in patients ( %). all patients received morphine infusions during lols/wols. family members were present by the bedside in % cases. conclusions. wh is preferred over wd. documentation of the eol process does not occur in a significant proportion of cases. nurses are rarely involved in the eol care decision making process. legal issues may be barriers to good eolc in our icu, and perhaps in india. objectives. to know the point of view of the staff is essential to understand their beliefs, attitudes and decisions. brazilian private general icu with beds. the following items were analyzed: profile of the interviewed; their opinion about end of life questions: fear of death, fear of experience pain before death, the best place to die, advanced directives, decision-making process, therapeutic withhold of mechanical ventilation, nutrition, fluid management, antibiotics, vasoactives drugs, sedation and analgesia in patients which death is imminent and irreversible. results. about . % of our icu team answered the research (n = ). the mean age is . years (sd . ), . % of female, . % married, . % protestants and . % catholics and icu professional experience of . years (sd . ). using a visual analog scale ( , no fear to , the worst fear possible) the team pointed . as their fear of death; the fear of suffering pain before death was . . for . % of the responders, the best way to die would be with their lovely ones, no matter if at home or at hospital. only . % would prefer to die an icu. the majority of the team ( . %) would share the eol decision-making process with the family instead only by the medical staff ( . %). about . % would leave an advanced directive with their therapeutic preferences like do not resuscitation orders. the icu team agreed on the withdrawal of vasoactives drugs ( . %), antibiotics ( . %), nutrition ( . %) and mechanical ventilation ( . %) in patients out of treatment. our results showed the staff vision about their own death and their opinion about the end-of-life care issues. in developing country as brazil there is a still gap between everyday practice and the current legislation. fortunately, the debate about eol issues has increased in last years. the end-of-life discussions and decisions should begin by respect to points of view of all involved: patients, family, medical staffs with a legal support of the society's beliefs and expectations. prospective observational study conducted in greek multidisciplinary icus. we studied all consecutive icu patients who died, excluding those who stayed in the icu \ h or were diagnosed with brain death. patients comprised the study population [mean age ± (sd) years, mean apache ii score on admission ± ]. results. of patients studied, % received full support including unsuccessful cardiopulmonary resuscitation (cpr). % died after withholding of cpr, % after withholding of other treatment modalities besides cpr, and % after withdrawal of treatment. patients in whom therapy was limited had a longer hospital (p = . ) and icu (p \ . ) stay, a lower admission gcs score (p \ . ), a higher apache ii score h prior to death (p \ . ), and were more likely to be admitted with a neurological diagnosis (p \ . ). patients who received full support were more likely to be admitted with either a cardiovascular (p = . ) or trauma diagnosis (p = . ), and to be surgical rather than medical (p = . ). the most important factors affecting the physician's decision to provide full support were reversibility of illness and prognostic uncertainty; the physician's religious beliefs and legal concerns had minimal impact. the main factors guiding the decision to limit therapy were unresponsiveness to treatment already provided, prognosis of underlying chronic disease, and prognosis of acute disorder; old age was not a determinant, while economic cost and lack of icu beds seem to play no role. relatives' participation in decision-making occurred in % of cases and was more frequent when a decision to provide full support was made (p \ . ). the principal reason for not discussing end-of-life dilemmas with relatives was the fact that the family was thought not to understand ( %) advance directives were rare ( %). icus. however, in a large majority of cases, it involves the withholding of cpr only. withholding of other therapies besides cpr and withdrawal of support are infrequent. physician has a dominant role in decision-making. objectives. the primary objective of this study is to determine the prevalence of inappropriate or non-beneficial care in icu patients as perceived by their icu healthcare providers, as well as the reasons for this perception. second, we want to determine which factors are associated with the perception of inappropriate care. a descriptive survey design is used. a single-day cross-sectional evaluation of perceptions of inappropriate care among , icu healthcare providers in icu centres in european countries will take place on may th . questionnaires will be administered to icu healthcare providers (nurses, head nurses, junior and senior icu physicians) providing bedside care to adult icu patients on that particular day. in this study, inappropriate care is defined as a patient care situation that is similar to one or more of seven scenarios. these scenarios were created based on the literature and a multidisciplinary conference attended by experts in intensive care, geriatrics, and palliative care. . the cross-sectional study will take place on may th . preliminary results will be given at the esicm conference. we have designed a one-day cross-sectional study to record inappropriate or non-beneficial care in european icu's. results will be available for the esicm conference. grant since the introduction of the mental capacity act in the uk in , the impact within research in the intensive care environment has not been elucidated. since many of the patients are incapacitated and therefore unable to consent, it is now stipulated by the ethics committee that the researcher must make reasonable attempts to identify a consultee, failing this, nominate a person unrelated to the research project to be consulted. in order to comply with the mental capacity act, retrospective consent must be obtained, once the patient regains capacity. objectives. the aim of the study was to highlight the difficulties in obtaining retrospective consent, evaluate the methods used and demonstrate the adaptations made to increase retrospective consents. methods. this explorative analysis investigated the process of obtaining consent in patients enrolled in an observational study on critically ill patients. consent was obtained on admission if the patient had capacity. assent from the patient's next of kin or a legal professional representative was obtained before enrolment in patients who lacked capacity. after discharge from icu, a member of the research team re-visited these patients to explain their involvement in the research, its purpose, procedures, implications and any further participation required by the subject. at this point, the patient could consent or withdraw from the study. if the patient decided to withdraw from the study, all data collected and samples stored were destroyed. the researcher visited the patient for a minimum of two visits; firstly to explain the study; secondly to establish if the patient has retained the information and to gain retrospective consent. results. patients were recruited within the time period of which ( . %) died. in ( . %), consent was obtained on admission as the patients had capacity, ( . %) were discharged prior to obtaining retrospective consent, ( %) lacked capacity on the researcher's visits, and patient ( . %) withdrew from the study. patients ( . %) were successfully consented retrospectively. overall, the researchers performed visits to obtain from the patients for whom retrospective consent was required. conclusions. the process of recruiting patients who lack capacity within the intensive care unit is challenging and time consuming. stipulations set by the ethics committee to seek retrospective consent once the patient has regained capacity, has a major impact on research staff time and finances. detailed recommendations as well as guidelines how to assess capacity in the post-icu patient and how the assessment of capacity has to be applied to intensive care research are needed to fully comply with ethical and legal requirements. objectives. we wanted to know if patients expressed to surrogate decision makers, after icu discharge, specific resuscitation directives, and we have investigated any factors related to the patients and their illness or care process that might be associated with this. we reviewed patients admitted in the icu between december and may . a random sample of survivor patients has been defined. seven patients were excluded ( for language barrier, died, were no more reachable). fifty three patients took part in semistructured interview at - month post icu discharge. the questionnaire discussed in detail the aspects of advance directives. patients had also completed a quality of life questionnaire (euroqol d), and we calculated the eq- d visual analog scale. we reviewed medical records in icu data base: age, gender, length of stay, saps ii, bmi, length of ventilator support and central venous catheterization as well as prescription of transfusion, hemodialysis or adrenergic agonist. multivariate logistic regression was practiced to investigate any factor associated to expression of specific resuscitation directives after icu discharge. after icu discharge, % of interviewed survivors expressed specific resuscitation directives to an appropriate identified surrogate (written ''living will'' or oral statement). eq- d visual analog scale was ± . on multivariate regression analysis, only one studied variable was significantly associated to the post-icu expression of specific resuscitation directives: age (odds ratio = . , z = - . , p = . ). conclusions. after icu discharge, a majority of our patients expressed to surrogate decision makers specific resuscitation directives, especially the younger patients. our findings suggest that surviving to icu is an opportunity to specify oral or written directive, and both may help to illuminate future decision making from the patient's perspective. objectives. to explore the issues around eolc provision for cancer patients in a critical care unit through family, professional and patient experiences. to explore how a diagnosis of cancer impacts upon eolc provision for critically ill patients. a heideggerian phenomenological interview approach was undertaken, in order to gain personal experiences. families of those patients who died after decisions to forgo lifesustaining treatment (dflsts) were interviewed. patients who were seriously critically ill (apache ii [ or had received cpr) who experienced critical care were also interviewed, since patients' views about eolc provision are very rarely explored. doctors and nurses also contribute their vision for, and experiences of, eolc in a cancer critical care unit. thirty seven participants were interviewed. tensions between treating families versus treating patients impacted on timeliness of eolc. achieving a good death was possible through caring activities that made best use of technology to prevent prolonged dying. decision-making and eolc could be difficult to separate out which, in turn, affects prospects for eolc. three main themes included: dual prognostication; the meaning of decision-making; and care practices at eol: choreographing a good death. these themes outlined the essence of moving along a continuum toward patients' deaths and the impact that had on opportunities for care and a good death. conclusions. cancer affected the trajectory in unexpected ways. the trajectory could be very quick, especially in unexpected death and some newly diagnosed cancers. even in the face of a life-limiting and serious disease like cancer, death could be unexpected. the rapidity of trajectory related to cancer diagnosis, prognosis, withdrawal and patient demise significantly impacted on the potential for, and timing of, eolc. a sentiment of moving on from historical practices around critical care for cancer patients, and related poor prognoses, was overwhelmingly agreed on but important caveats in cancer prognostication remains. conclusions. these data suggest that oscillation settings of and hz provided more optimal pef/pif ratio ([ . ). our data also suggests that airway clearance using hfcwo may facilitate improved gas exchange in mechanically ventilated patients. further study is required to confirm these results grant acknowledgment. partial funding support in the form of devices was provided by hill-rom inc. a. esquinas , m. folgado , j. serrano hospital morales meseguer, intensive care unit, murcia, spain, hospital virgen de la concha, zamora, spain, hospital reina sofia córdoba, intensive care unit, cordoba, spain objectives: we hypothesized that the use of intrapulmonary percussive ventilation (ipv) could effect hypercapnia/acidosis and airway secretions control during treatment with noninvasive mechanical ventilation (nippv) in exacerbations of copd associated with bronchial secretions. prospective multicenter study. the study was performed in the medical icu of spanish university hospitals members of the spanish ipv working group. we enrolled copd exacerbation patients with secretions and the need for nippv in icu. criteria of exacerbations of copd are: a respiratory frequency c /min, a pao [ mmhg and ph b . . we define two ipv strategies as complementary treatment during nippv to evaluate the effects of ipv. strategy group i: nippv at first line and combination of ipv in early periods without nippv in spontaneous breathing and ph c . . strategy group ii: first line of ipv with mouthpiece/face mask and oxygenation previous to the application of nimv with ph \ . . in both groups daily sessions ipv were applied by for min/ day by mouthpiece or face mask during stay in icu. nippv was applied with bipap ventilator (respironics) and face mask with bipap mode. cardiopulmonary monitoring, clinical and arterial blood gases were evaluated. therapy was considered as successful when patients did not need nippv support and clinical and arterial blood gases returned to baseline. results. patients with copd exacerbation were admitted in icu for nimv, age ± years, male ( %) were excluded for severe hypoxemia (pao :fio b ) associated with pneumonia ( / ) and cardiac insufficiency ( / ). fifty patients were enrolled in the study. -up tilt-table rehabilitation better than sitting in a chair for ventilated adults in intensive care in terms of improving lung function? j. manners , a. thomas , s. boot , g. mandersloot barts and the london school of medicine and dentistry, london, uk physiotherapy intervention is a fundamental part of the patient stay in an intensive care unit (icu) and treatment is often aimed at maintaining/improving respiratory function. physiotherapists use the upright posture to elicit these improvements and sitting in a chair and standing with a tilt-table are commonly used interventions. to date there are no published reports comparing the efficacy of these interventions in ventilated subjects. • to compare the effects of these two positioning techniques employed with icu patients. • to measure changes in respiratory rate, tidal volume and minute volume during these positioning interventions. • to measure functional residual capacity during positioning interventions. • to measure the change in metabolic demand during positioning interventions. methods. convenience sampling of ventilated subjects meeting the inclusion criteria was employed. subjects acted as their own controls undergoing sitting in a trauma chair and standing on a tilt table at degrees in random order on the same day. respiratory rate (rr), tidal volume (v t ), ventilation (v e ) and oxygen consumption (vo ) were measured at minute intervals during baseline and intervention for min. functional residual capacity (frc) was measured once at rest and following each intervention. measurements were recorded using the ''e-covx'' module for the ''ge carestation ventilator''. results. subjects were recruited. no adverse events occurred during interventions. significant increases from baseline rr (p \ . ), v e (p \ . ) and vo (p = . ) occurred during the tilt table intervention. there was an increase in frc during tilting of . l which failed to reach significance. significant increases from baseline rr (p \ . ), vo (p = . ) and a decrease in v t (p = . ) occurred with the chair intervention. conclusions. these interventions are safe in a critical care population. increased muscular activity associated with upright interventions elicited expected elevations in vo . the tilt-table produced an increase in v e driven by an increased rr at the expense of v t . v e was not elevated during chair sitting despite an increased vo and was accompanied by an unexpected decrease in v t. introduction. uk guidelines about rehabilitation after critical illness highlight the need for outcome measures to determine patient progress and efficacy of treatment [ ] . there is no consensus about the most appropriate measures of patient function. the austoms [ ] tool was designed by therapists in australia to measure activity and function across nine scales assessing structural and functional difficulties and ability to perform activities. scales are split into four domains (impairment, activity limitation, participation restriction and distress/wellbeing) and scored from to with . intervals allowed. acceptable inter-rater variation is defined as an absolute difference of . . austoms has not been appraised in patients recovering from critical illness. objectives. to prospectively determine the inter-rater reliability of the austoms physiotherapy scales in adult patients who had undergone cardiothoracic surgery and required critical care admission for over days. methods. the therapy (physiotherapy and occupational therapy) team underwent a h teaching session using the austoms handbook prior to commencing the trial. austoms was then used over eight consecutive weeks during the weekly therapy goal setting meeting. each week a patient was selected to be scored using the most appropriate functional scales. the clinical history was presented to the team by the therapist leading the patient's care. therapists were then asked to independently score patients across the four domains for each scale. reasons underlying differences in scores were explored by group discussion. the difference between the th and th centiles of the initial scores was calculated for each domain as a measure of inter-rater variability. results. - therapists were present at each meeting. respiratory function and musculoskeletal movement related function were the most common scales used. the mean difference between th and th centiles was greater than . (± . ) for all domains. none of the scales/domains showed consistent inter-rater reliability over the week period. overall the activity limitation domains of each scale showed the least inter-rater variance of scores. clinical experience of therapist did not appear to influence scores. conclusions. the austoms outcome measure showed poor inter-rater reliability when evaluated over an week period on our intensive care unit. further work is ongoing to evaluate the ability of austoms to reveal changes over time when scored by therapists. introduction. uk guidelines on the rehabilitation of patients after critical illness highlight the importance of establishing and reviewing individualised rehabilitation goals for all patients that are at risk of developing physical and non-physical morbidity [ ] . our institution's practice is to create objective goals that are smart-specific, measurable, achievable, realistic and timed [ ] . objectives. the aim of this audit was to prospectively collect data regarding the setting of rehabilitation goals in a group of patients admitted to a cardiothoracic intensive care unit. methods. all consecutive patients admitted under the intensive care team in november were included. data regarding the timings of initial physiotherapy assessment, goal setting, and concomitant sedation were collected using a structured questionnaire completed by the treating physiotherapist. results. patients were admitted under the critical care team. patients were assessed by a physiotherapist within h of admission. of these , had smart goals set within a median of days of initial assessment (range - days). there was a correlation between level of consciousness and the number of days taken to set goals. patients who were fully conscious or drowsy on initial contact (n = ) had a smart goal set in a median of days. by contrast patients who were sedated/paralysed on initial assessment (n = ) had goals set in a median of days. initial goal setting did not include other therapists or the family. goals fell in to categories, range of movement, hoisting out to chair for periods of time, sitting on the edge of the bed, transferring out to the chair by standing and mobility goals-i.e. walking set distances. the maximal interval between reviews of the patients' goals was days. most patients had smart goals defined and regularly reviewed. however, despite physiotherapy assessment within h of admission, there was often a delay in setting these objective goals. the need for continuous sedation acted as a barrier to explicit setting of goals. the results emphasised the need to improve patient and family/carer involvement with initial goal setting in order to be compliant with uk standards. objectives. investigation of ems effects on muscle strength and exploration of issues in relation to handgrip dynamometry in icu patients. one hundred seventy two consecutive patients with apache ii score c , were randomly assigned to the ems (n = , age: ± years, apache ii: ± ) or the control (n = , age: ± years, apache ii: ± ) group. ems sessions applied daily in muscles of both lower extremities. the strength evaluation of various muscle groups of the upper and lower extremities was made clinically upon awakening with the mrc scale, ranging from to (normal strength) for each group. the same scale was also employed in the diagnosis of cipnm (mrc \ / ). a subgroup of these patients also performed handgrip dynamometry. results. fifty seven patients (ems: , control: ) were finally evaluated. ems patients scored higher than controls (p b . ) in wrist flexion, knee extension, ankle dorsiflexion and right side hip extension, while they tended to perform higher in all other muscle groups (p: . - . ) ( table ) . grant acknowledgment. this project has been co-financed by e.u. and the greek ministry of development. background. secretion removal is major aim of respiratory physiotherapy in intensive care. manual hyperinflation provides a tidal volume to the lungs that is greater than baseline. it is effective in secretion clearance and is frequently used [ , ] . there is a limited evidence that addressed the effects of combining rib-cage compression and suctioning on oxygenation, ventilation, and airway-secretion removal in mechanically ventilated patients [ ] . objectives. the aim of this study was to investigate the effects of manual hyperinflation administered in combination with expiratory rib-cage compression on lung compliance, gas exchange, and secretion clearance in mechanically ventilated patients. methods. twenty-two intubated, mechanically ventilated, and hemodynamically stable patients were studied. the patients received manual hyperinflation, with or without expiratory rib-cage compression, with a minimum -h interval between the two interventions. manual hyperinflation with or without expiratory rib-cage compression was performed for min before endotracheal suctioning. respiratory mechanics and hemodynamic variables were measured min before (baseline) and then and min after the interventions. arterial blood gases were determined min before (baseline) and min after the interventions. secretion clearance was measured as sputum weight. the two measurements were obtained on the same day. results. no significant differences were observed in gas exchange and secretion clearance between the two interventions (p [ . ). in each case, static lung compliance and tidal volume improved significantly at min post-intervention (p \ . ), whereas at min postintervention, only static lung compliance had improved significantly above baseline (p \ . ). our results suggest that the addition of expiratory rib-cage compression to manual hyperinflation does not improve lung compliance, gas exchange, or secretion clearance in mechanically ventilated critically ill patients. recently, there has been an interest in mobilization of acutely ill patients who are in an intensive care unit (icu). in the literature, the major safety issues while mobilizing critically ill patients has been outlined. cardiac reserve [(cr) (% of age predicted maximal heart rate)] and respiratory reserve [(rr), ratio of partial pressure of oxygen in arterial blood to the inspired fraction of oxygen (pao /fio )] are the important factors that can affect the ability to tolerate the mobilization. patient who has rr more than and cr lower than % is considered to have sufficient reserve to tolerate mobilization [ , ] . objectives. the aim of this study was to compare the effects of mobilization on respiratory and hemodynamic parameters in patients with sufficient and insufficient respiratory and/or cardiac reserve. mobilization events are divided into two groups (sufficient, insufficient) according to the pre-mobilization cr (sufficient, \ %; unsufficient, [ %) and rr (sufficient, [ ; insufficient, \ ). heart rate (hr), systolic/diastolic/mean arterial blood pressure (sbp, dbp, mabp), respiratory rate (rsr) and percutaneous oxygen saturation (spo ) were recorded from the monitor. respiratory and hemodynamic parameters were collected just prior to the mobilization, just after the completion of the mobilization when the patient had been returned the supine position and min of the recovery period and compared between the groups. a total of abdominal surgery patients ( male, female) received mobilization treatments in icu. the mean age was . years, mean body mass index (bmi) was . kg/m , mean apache ii score was . and mean icu stay was . days. mobilization events included ( %) sitting on the edge of the bed, ( %) standing, ( %) walking to chair and sitting in the chair. % ( ) of mobilization events had insufficient rr and % ( ) of mobilization events had sufficient rr. . % ( ) of mobilization events had insufficient cr and . % ( ) of mobilization events had sufficient cr. all respiratory and hemodynamic parameters were found similar in sufficient rr and insufficient rr group at all stages of the mobilizations (p [ . ). spo was higher, while hr and rsr was lower at all stages in sufficient cr group compared to insufficient cr group (p \ . ). resting hr and cr may affect the safety of mobilization, for this reason it is important to consider respiratory and hemodynamic parameters prior to and while mobilizing the icu patients. introduction. obesity is a chronic disease and a major health problem. obesity in critically ill patients is associated with a prolonged duration of mechanical ventilation and intensive care unit (icu) length of stay [ ] . objectives. the aim of this study was to investigate the effects of mobilization on respiratory and hemodynamic parameters in the critically ill obese patients. [ . kg/m )] were included as soon as their cardiorespiratory stability allowed mobilization protocol. mobilization was defined as sitting in the bed, sitting on the edge of the bed, standing, walking to chair and sitting in the chair. heart rate (hr), systolic/diastolic/mean arterial blood pressure (sbp/dbp/mabp), respiratory rate (rr) and percutaneous oxygen saturation (spo ) were recorded from the monitor. respiratory and hemodynamic parameters were collected just prior to the mobilization (supine position), just after the completion of the mobilization when the patient had been returned the supine position and min of the recovery period. all parameters were compared with initial values. the ratio of partial pressure of oxygen in arterial blood to the inspired fraction of oxygen (pao /fio ) was calculated from the arterial blood gas samples before and after the mobilization. introduction. the use of respiratory therapy for patients with a variety of lung disease is a standard in medical care [ ] , including in the intensive care unit (icu) setting [ ] . in this context, it is widely accepted the routine use of physical therapy in several situations in the intensive care, such as the care of critically ill patients not requiring ventilatory support, assistance during the postoperative recovery and the assistance to critically ill patients requiring ventilatory support [ ] . at present definitive recommendations cannot be made regarding the use of respiratory physiotherapy for decreasing relevant clinical outcomes in critical ill patients requiring mechanical ventilation. objectives. this study aimed to determine the impact of providing chest physiotherapy on the duration of mechanical ventilation, intensive care length of stay, intensive care and hospital mortality in mechanically ventilated patients. single-centre, randomized, controlled trial in a university hospital general intensive care unit (icu). were included in the study patients aged more than years, admitted to the icu needing mechanical ventilation for longer than h. physiotherapists provide group intervention (p) with the intensity and frequency of therapy they felt appropriate based on their assessment of the likely treatment benefit. control patients (group c) only received suctioning, decubitus care and general mobilization. results. primary outcomes were icu and hospital mortality regardless of the cause of death. secondary outcomes were length of icu and hospital stay, length of mechanical ventilation, weaning and extubation failure. patients in the p group more frequently achieved parameters to start weaning, but there were no significant differences between p and c groups on weaning and extubation failure, length of mechanical ventilation and length of icu stay. there was fewer hospital, but not icu, mortality in the p group. conclusions. we demonstrated that respiratory physiotherapy decrease hospital mortality and suggest that this effect was, in part, secondary to the effect of the intervention on weaning from mechanical ventilation. introduction. critical illness can cause diverse cerebral dysfunctions ranging from unconsciousness to minor cognitive impairments (mci). severe cerebral dysfunction, as delirium, is known to affect outcome after critical illness but it is uncertain whether minor impairments affect mortality or morbidity [ ] . objectives. the primary aim of this study was to estimate the incidence of mci in a group of general icu survivors immediately after icu stay and three and months after discharge. secondary we wanted to explore if type of cerebral dysfunction after icu discharge affected mortality and morbidity. methods. patients admitted to our general icu were included prospectively. we included patients. / ( %) were delerious and / ( %) were not delerious but had mmse \ after icu stay. of the patients with mmse c , were possible to classify as having mci or not. / ( %, % ci: - %) were found to have a mci after icu discharge. on and months these numbers were respectively: % ( % ci: - %) and % ( % ci: - to %) there was an increased risk of both death and being institutionalised at both and months regarding delirious patients and patients with mmse \ compared to patients with mmse [ . no such differences were found regarding patients with or without mci. (tables and ) . conclusions. the incidence of mci after critical illness is high on discharge but drops on and months after. severe cognitive impairments affect mortality and morbidity, but minor cognitive impairments do not. objectives. this study analyzes mid-term survival and risk factors associated with survival of patients undergoing cardiac surgery in son dureta hospital. methods. patients were consecutively operated from november to december . patients who were discharged alive from hospital were followed until december . we did kaplan-meier survival analysis and logistic regression study of variables associated with mid term mortality. results. in-hospital mortality was . % ( % ci: . - . %). information was available on , ( %) of , patients who survived until hospital discharge. at the end of the follow-up period, observed mortality was . % (ci %: . - . %). survival probability at , and years of follow-up was , and %, respectively. the mean time of follow-up was . years (range . - . ). patients c years showed a lower survival rate than patients \ years of age (log rank \ . ). age c years, history of severe ventricular dysfunction (ef \ %), diabetes mellitus, preoperative anemia and hospital stay were independently associated with mid-term mortality. conclusions. mid-term survival of patients alive after hospital discharge was very satisfactory. mid-term mortality varied according to age and several preoperative chronic diseases. a closed-ended questionnaire was developed by the nurse congress commission of the société de réanimation de langue française (srlf). an invitation to complete it online was sent by email to caregivers registered on the srlf push-list. results were analyzed by icu or by respondent. results. caregivers working in icus completed the questionnaire ( % were nurses, % were doctors, % were nurse's aides, % worked in adult icus and % in pediatric icus). % of adult icus (n = ) had unrestricted policy but % had a visiting time of less than h per day. at the opposite, % of pediatric icus (n = ) had unrestricted policies. % of the respondents working in icus with a visiting time \ h per day considered very useful or essential to enlarge visiting periods but % of them considered this enlargement as unhelpful. at the opposite, % of the respondents working in icus with unrestricted policy found very useful or essential to reduce visiting periods. % of caregivers working in icus with unrestricted policy but only % of caregivers working in other icus thought that an unrestricted policy was able to improve often or systematically the relations with families. moreover, only % of caregivers working in icus with unrestricted policy but % of caregivers working in other icus thought that an unrestricted policy disturbs the organization of care. % of respondents found very useful or essential to give information in a dedicated room whereas it was often or systematically done in only % of icus. identically, % of respondents found very useful or essential to give information to proxies with the patient's nurse whereas it was often or systematically done in only % of icus. some cares were often or systematically programmed for family participation in % of pediatric icus but in only . % of adult icus. indeed, proxies often or systematically participated in nursing in % of pediatric icus but never in adult icus. at the opposite, proxies often or systematically participated in tracheal aspirations in only % of pediatric icus and in . % of adult icus. conclusions. more than half of respondent's adult icus are closed but caregivers working in icus with unrestricted policy perceive it favorably. some improvements are also expected by caregivers on the use of dedicated rooms for information and on the participation of nurses in meetings with families. finally, participation of families to care is not a practice of french adult icu caregivers. methods. included: patients with dysfunction of two or more organs in the first h, admitted and discharged from icu during . excluded: neurocritical and politrauma patients. contact year following discharge; questions were asked concerning symptoms related to a period in intensive care that presented following discharge and which were not present prior to admission. in the case that the patient was not contacted, the next of kin was asked. results. patients included. general characteristics during admission to icu: % male; age . ± . years; sofa* ± . ; apache** ii . ± . ; apache** iv ± . ; length of stay in icu: . ± . days; . % were on invasive mechanical ventilation and . % on non-invasive mechanical ventilation. data collection was carried out over ± . months, on average months (range: - months). . % ( patients) had died at the time of contact. the person contacted was the patient in . % of the cases, the spouse in . % and immediate family (patient's parent/child/sibling) in . % of the cases. . % had difficulty sleeping following discharge from icu with an average time since discharge of . ± . months; . % suffered feelings of sadness and difficulty in finding enjoyment which had persisted for . ± . months; . % had experienced difficulty in concentrating over an average of . ± . months; . % had suffered some form of memory loss after discharge over an average period of . ± . months; . % presented with asthenia over an average of . ± . months; . % had arthromyalgia over a period of . ± . months; . % had experienced changes in appetite over an average of . ± months; . % had changes in intestinal habit over an average of . ± months; of which . % had diarrhoea, . % constipation, and . % both symptoms; . % presented with headache over a period of . ± . months; . % had tremors, that had not previously been present, over an average of ± . months; . % had experienced reduced vision, over an average period of . ± . months; . % presented with speech/ language problems, over an average period of . ± . months; . % exhibited newly presenting changes in micturition, over ± . months. another less frequently occurring symptom was loss of hearing ( . %). conclusions. severely ill patients that are admitted to icu frequently present with ''residual'' symptomatology following discharge, most notably arthromyalgia and asthenia. many of these conditions persist for months. intensive care unit (icu) readmission rates range from to %, in spite of initial recovery from critical illness. previous researches report that the revised acute physiology and chronic healthy evaluation (apache ii) score at either admission or discharge is an important predictor for readmission after icu discharge. however, there are a few papers concerning the association of discharge apache ii score with readmission after discharge from surgical intensive care unit. objective. we compared the ability of the discharge apache ii score with that of the admission apache ii score in predicting readmission, especially early readmission within h, after discharge from icu. conclusion. this study showed that both discharge apache ii score and admission apache ii score are useful predictors for readmission after icu discharge, but discharge apache ii score is only independent factor in predicting early readmission within h after icu discharge. introduction. health related quality of life (hrqol) is decreased in former icu patients. in research outside the intensive care field it is well known that the psychosocial factors, coping strategies and perceived hopelessness affect hrqol. however, the influence of coping and hopelessness on hrqol after intensive care is unknown. objective. the aim of this study was to examine how coping strategies and perceived hopelessness among former icu patients compares to corresponding in a reference group. we also evaluated the effect of coping and hopelessness and icu related factors on hrqol. methods. prospective, multicenter study in three mixed icu's in sweden. patient demographics, length of stay, apache ii score, reason for admission and time on ventilator were collected for all adult patients. questionnaires, including the coping instrument pearling-schooler mastery scale (pms), the -item hopelessness scale, sf- , demographic data and previous illnesses were sent months after discharge from hospital to the patients. the reference group (n = , ) was a random selection of persons from the same catchment area as the study patients. . ( %) icu-patients, - years, returned the questionnaires. the patients reported significantly lower mean scores in coping . (sd . , p \ . ) and higher perceived hopelessness . conclusions. this study indicates that coping strategies and perceived hopelessness are important for the hrqol of previous icu patients. however, the magnitude of these effects are smaller than that of pre-existing diseases. introduction. mortality on a medical intensive care unit (icu) is estimated to occur in about % of patients. its association with age, severity of illness and comorbidities is well established. for other diseases like coronary artery disease it has been shown that pre-existing depression is a risk factor for worse outcome. the role of depression regarding the outcome of icu patients has not been investigated so far. we studied the association between pre-existing depression and mortality in medical icu patients and present preliminary data of this ongoing study. objectives. assessment of a possible association between mortality of icu patients and prevalent depressive mood at time of icu admission. the primary endpoint was -day mortality. methods. prospective cohort study. all patients admitted to a medical -bed icu in a university hospital, older than years, were eligible. postoperative patients and patients who had an expected length of stay below h (survey) were excluded. patients whose cognitive function allowed appropriate comprehension and response answered the hospital anxiety and depression scale (had). prevalent depressive mood at admission was defined by a score c in the depression dimension. all other patients were assessed by observer rating by next-ofkin. in this case the hammond scale, a validated instrument for observer rating of depressive mood (cut-off c ), and a modified version of the had for observer rating (cut-off c ) were used. in addition apache ii, saps ii, sofa, age, sex, comorbidities, reason for admission, length of icu stay and ventilator days were recorded. . by now patients had complete follow up data. of these patients ( %) were classified to have depressive mood at icu admission. in total patients had died by day ( %). the -day mortality was % ( / ) in patients with depressive mood and % ( / ) in patients without (p = . ). patients with and without depressive mood did not differ with respect to age, sex, apache ii, saps ii or sofa score at admission. multiple logistic regression analysis with -day mortality as the dependent variable revealed that prevalent depressive mood at the time of icu admission was an independent risk factor for mortality (table ) . conclusions. pre-existing depressive mood is an independent risk factor for mortality in medical icu patients. introduction. some classical post-icu discharge predictors of death are described, such as age, severity of disease and level of nursing care [ ] . besides these factors, some laboratorial data at icu discharge are potential predictors of post-icu death. objectives. the aim of this study was to investigate whether standard base excess (sbe), ph, lactate, hemoglobin level, creatinine, platelets, leukocytes and albumin at the icu discharge as well as the % decrease on c-reactive protein concentrations (crp [ %) from the day pre-icu discharge to the day of icu discharge may be useful predictors of in-hospital outcome. patients discharged from the icu after at least h of stay were retrieved from our prospective collected data base. a multivariate analysis was performed using a backward-lr binary logistic model taking in-hospital death as a dependent variable and the cited data as independent variables. results. patients were retrieved. the average age was ± years old, mean apache ii score was ± , and the main causes of admission were septic syndromes and respiratory failure. the in-hospital mortality after icu discharge was %. the icu length of stay was ± days. at the time of icu discharge ph was . ± . , sbe was - . ± . mmol/l, lactate was . ± . mmol/l, hemoglobin . ± . , creatinine was . ± . g/dl, albumin was . ± . g/dl, platelets was , ± , /mm , leukocytes was , ± , cells/mm and the number of patients who lowered crp at least % were ( % conclusions. this study demonstrated that sbe, lactate, hemoglobin and albumin concentrations on the day of icu discharge are independent predictors of in-hospital mortality. moreover, the reduction on crp levels above % in the last h of icu stay is a strong predictor of better in-hospital clinical outcome. we suggest that these variables together with the clinical judgment may be taken into account on the icu discharge decision process. readmissions to the intensive care unit (icu) are usually associated with increased morbidity and mortality, and they may evidence the quality of patients' care. the risk for icu readmission varies across studies, and is generally analyzed just before icu discharge, leading to deviation of icu team and patients' daily goals. early prediction may improve the care for patients in risk for icu readmission, and help developing mechanisms for its prevention. objectives. to analyse risk factors for readmission in intensive care unit looking at the first h data after unit admission. methods. the first intensive care unit admission of patients was analyzed from january to december in a medical-surgical unit. readmission to the unit was considered those during the same hospital stay or within months after intensive care unit discharge. deaths during the first admission were excluded. demographic data, acute illness and comorbidity prognostic scores, and use of mechanical ventilation were submitted to uni and multivariate analysis for readmission. numeric variables were expressed as median or percentage. conclusions. age, medical admission, sofa score and respiratory-and/or sepsisrelated admission are early associated with increased icu readmission risk. objectives. the aim of this study was to examine patient perceived hrqol in former icu patients that die in the period from month up to years after discharge from intensive care unit and the hospital. methods. prospective, multicenter study in three mixed icu's in sweden. questionnaires, including hrqol (sf- ), demographic data and previous illnesses, were sent out six, , and months after discharge to all former adult icu patients. data for this study were only collected among those dying before the months post-icu follow-up. of the patients who returned the questionnaires ( . %) died, ( . %) between and months, ( . %) between and months, and ( . %) between and months. the most frequent admission diagnoses were respiratory problems n = ( . %) and gastrointestinal diseases n = ( . %). examining hrqol in the former icu patients the following observations were made: (see fig. ). a pronounced and quantitatively large decrease in hrqol is seen for the surviving patients with pre-existing disease as compare to the previously healthy survivors. although already at a very low value further decreases in hrqol for the patients dying before years post icu is significantly less as compared to the icu patients with pre-existing disease that survives. the decrease is mainly in physical function, role physical function and role emotional function (marked in the figure). conclusions. yes, health related quality of life is extensively affected, mainly in the dimensions physical function, role physical function and role emotional function. importantly, in these two affected physical dimensions a shorter time to death increases such a decrease. the finding further stresses the importance of pre-existing diseases for the final hrqol outcome of former icu patients. introduction. despite initial recovery from critical illness requiring icu admission, many patients remain at risk of subsequent deterioration and death [ ] . recent studies have shown readmission rates ranging between and % [ ] ; this population had mortality rates six times higher and were eleven times more likely to die in hospital [ ] . . to calculate the readmission rate in our mixed icu unit over a months period . to identify risk factors associated with readmission into the icu . to study the outcomes of these readmissions methods. a retrospective observational study, data was collected from an icu computer database (metavision) and analysed manually results. the total number of admissions in this period was , average patient age was ± with . % being males. readmissions constituted . % of the total admissions with . % of those readmitted within h of their initial discharge. % of the initial discharges from the unit were made out of hours i.e. unplanned, presumably due to heavy demand on beds. readmissions were particularly associated with patients discharged to surgical wards . % and the hepatobiliary hdu . %, the latter might reflect the proportion of that particular patients population received. . % of the readmissions required to stay h or less in icu. the overall mortality of the patients requiring more than one admission in this months period was . %. there is an urgent need for expanding icu services in our hospital, i.e. extra beds, staff, outreach teams, etc in addition to investing in nursing capacity building especially in surgical wards. we agree with others studies that compared with the general population, icu survivors report lower hrqol. moreover, a relationship between several factors like sepsis, renal failure, sofa (first and second day score), critical illness polyneuropathy, mechanical ventilation, sedation time, previous psychiatric history and blood products transfusions were found in our study population. conclusions. according to our data, subclavian vein was the most common insertion site used, especially as nd and rd placement and was related with the lower incidence of becteremia episodes. although the risk of placing a cvc for inflection complications is against the risk for mechanical complications, we have to improve our cvc policy, preferring the subclavian or the jugular site of insertion, in order to minimize the infection risk for a nontunneled cvc. objectives. objectives for this study were to determinate the frequency and the risk factors associated with bos. secondarily, we searched several variables as civil status, age, sex, work seniority as potential risk factors. inclusion criteria were to work in critical care unit (ccu) the hospital clínico universidad de chile (hcuch). this unit included subunits: intensive care unit (icu), middle care unit (mcu). the mbi Ò instrument was applied between april to july of . all staff of ccu were asked to response the instrument. as previously reported, bos was defined with high ee, high dp and low pa. risk of bos was anything of the three dimensions positive for bos. we gave information on specifics objectives and the schedule of a future intervention programme. for analysis, comparisons were made based on student t test, chi-square test with yates corrections or fisher exact test as corresponded. for all tests we used confidence interval % with p \ . . a total of mbi Ò tests that included all sub-units in ccu. this is a % of all personal working in the ccu. bos was found in . % of cases. women ( %), unmarried ( %), with an average of age . years old. ( - years old) and with a work seniority younger than years ( %). ee is high ( . %), for nurse and paramedical personals. dp was . and . % to middle level, for nurse and medical doctor, and low pa in % for paramedical personal, with longer work seniority (more than years). risk factors were female gender, unmarried status, childless, middle aged ( - years old) and recent start in the job (stay younger than years). introduction. burnout is a prolonged response to chronic emotional and interpersonal stressors on the job, and is defined by three dimensions: exhaustion, cynism (depersonalization), and inefficacy. icu physicians are exposed to several stress factors and are particularly predisposed to this syndrome. to describe the prevalence of burnout syndrome among intensivists and its relation to their quality of life. methods. an epidemiological cross-sectional survey conducted to evaluate all adult icu physicians in salvador, ba (brazil), from october to december . the quality of life and burnout syndrome were evaluated respectively by the whoqol-bref instrument and the maslach burnout inventory (mbi). burnout was classified into low, moderate and high levels for the three studied dimensions, according the mbi classification, and it was defined by the presence of a high level in at least one dimension. the quality of life was evaluated in four domains: physical, psychological, social relationships and environment, graduated from to , with higher scores denoting higher quality-of-life. [ ] ) has been successfully used to measure nursing workload on an intensive care unit over a -h period. in contrast to intensive care, the nursing care workload on mc is not evenly spread over a twenty four period, but tends to vary between shifts. objectives. the aims of this pilot study were ( ) to assess the fitness of nas as an accurate reflection of nursing workload on an mc unit. ( ) to determine the nursing work load, per patient, per h shift. prior to the commencement of the study all thirty one nurses taking part received instruction in the content and registration of nas. at the end of each h shift, each nurse retrospectively scored their patient(s) using nas. this consists of a check list containing twenty three items giving a possible score between and , where equates to . full time equivalent (fte) intensive care nurse. the nas were entered in to a database and the average scores, per patient, per shift were calculated. three hundred patients were retrospectively scored over a -month period in october and november . not all patients were scored on all three shifts as some patients had been transferred out of the unit before shift end. in addition any incorrectly completed forms were discarded and excluded from the study. methods. this multicenter pilot study included doctors working at (pediatric) intensive care units (icu). subjects were randomly assigned to two groups: one was first tested during day, then during night, while the other was tested in reverse order. the d test of attention [ ] was used to assess attentional performance. total performance (tn-f) score, standardized for age and level of education, was used to express attentional performance. subjective, -to- scores were gathered in two questionnaires. results. figure displays standardized total performance scores of doctors. measured attentional performance showed high intra-and interpersonal variability and did not differ between both shifts (p [ . ). in contrast, doctors expected alertness to be decreased ( . ± . and . ± . (mean ± sd) on subjective -to- scale during day and night shifts, respectively; p \ . ) and the chance of making errors to increase (from . ± . to . ± . (mean ± sd); p \ . ) during night shifts. conclusions. physicians working at icu are aware of the risk of making errors during night shifts. however, we showed that doctors perform equally during night and daytime when confronted with a short-time challenging task. consequently, a discrepancy between measured attentional performance and expected alertness was observed. these results suggest nocturnal alertness might be comparable to daytime during short-lasting tasks that elicit a high level of stress and motivation (e.g. testing, medical emergency). further research is needed to elucidate if longlasting (routine) tasks reflect decreased sustained attention and contribute to medical errors. we studied physicians, the majority of whom were male ( %). mean age and time since graduation were . and years, respectively. high levels of emotional exhaustion, depersonalization, and reduced personal accomplishment were found in . , . , and . %, respectively. prevalence of burnout syndrome, defined as a high score in at least one dimension, was . %, while prevalence was . % for all three dimensions. in conclusion, burnout syndrome was common in this sample of icu physicians. aims. our goal was to assess the physician's opinion about potential competencies of a triage nurse. a representative cross sectional study design was applied with self-fill-in questionnaire about physician's attitude related to skills of triage nurses. the questionnaires were distributed between september and november in (out of ) eds. in this survey physicians' questionnaires were processed. chi-square and student-t test was used for comparison of variables. p values less than . were considered statistically significant. results. . % of physician would support the special training of triage nurse. . % of physician suggests that the nurses use the patient's physical examination regularly in eds. the full time (ft) emergency physician significantly would reduce the basic competencies of nursing (e.g. dressing, feeding of patient, p = . , and p \ . , respectively) than parttime (pt) emergency physicians. significantly greater part of the ft physician would widen the competency of triage nurses in the field of physical examination of nervous system (p \ . ) and cardiovascular system (p = . ) than the pt physician. conclusion. hungarian emergency physician would widen the competency of triage nurse, but only half of physician would like to that nurses apply physical patient examination in practice. the full time physician would give more competencies for triage nurse than part time ones, but the final field of competency will be depended on other factors. healthcare-associated infections (hcai) are estimated to affect . million people worldwide, causing longer hospital stay, increasing hospital costs and excess mortality [ ] . hand hygiene represents the single most effective way to prevent healthcareassociated infections. compliance with hand hygiene amongst healthcare workers (hcw) has been demonstrated to be quite low at % [ ] . to quantify the degree of compliance to hand hygiene norms in the icu and to assess the short term success of strategies to improve hand hygiene compliance. setting. bedded medical-surgical icu in a tertiary care centre. design. prospective observational. method. unobtrusive observer (single person). observed over sessions of h. the compliance was calculated as :number of times the staff performed hand hygiene/number of hand hygiene opportunities. the number of hand hygiene opportunities was based on the who tools [ ] : before touching a patient, before clean/aseptic procedures, after body fluid exposure risk, after touching a patient and after touching patient surroundings. introduction. icu delirium represents a form of brain dysfunction that in many cohorts has been diagnosed in - % of patients receiving mechanical ventilation. delirium is a common but complex clinical syndrome characterized by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course and is associated with poor outcomes. and yet, it can be diagnosed and treated. in the uk, reporting of delirium is generally considered to be poor. in light of updated nice guidelines on delirium due out this year, specialist clinical assessment will soon become gold standard as a means of diagnosing and reducing the prevalence of this condition in the icu setting. nice recommends that cam-icu (confusion assessment method) be used by healthcare professionals who are trained and competent in the diagnosis of delirium. on our -bed unit, we are currently implementing cam-icu assessments to be performed twice daily (at the commencement of each nursing shift) as well as rass (richmond agitation and sedation scale) scoring on an hourly basis for all patients. objectives. to implement training of all our icu nursing staff in the use of cam-icu and rass scoring. to periodically validate and reinforce earlier training, so as to improve assessment and reporting of delirium. methods. our 'delirium group' comprising both nursing and medical staff, taught cam-icu and rass to staff members using multimedia presentations in small groups and/or individual teaching sessions over weeks. scoringofcam-icu andrasswassubsequentlyauditedon occasions post training. discrepancies were discussed and post-audit retraining provided where necessary. results. the following audit and validation data were generated on our unit as documented in table . no statistical analysis was undertaken. we anticipate focusing on the challenges encountered and strategies used in managing this change in our icu practice. methods. the factors causing resistance to change based on multisource data. qualitative technical methods were used: brainstorming and focal groups. the data collection elaboration was created by the collaboration of icu nurse, quality department nurse and external reviewers. finally, the main factors were classified in different categories. each category was scored by to according to gravity and prevention possibility. finally, priority was given to more serious and easier prevention problems. results. the most serious problems for icu professional was the historical factors. the easier solution problems were ''the lack of information'' and all evaluators were agree with it. we arranged the factors in order to the next classification (tables and ). discussion. all investigators were agreed with the low importance of problems with payments and low prevention probability of low organisational flexibility, so they were agreed on not to work about them. the icu professionals were more pessimistic and have lower confidence in prevention possibilities but they showed more confidence about the capacity to learn new skills. they weren't worried about resistance to do experimental things. probably, historic factors play an important role in this pessimistic attitude. on the other side, quality and safety experts have more experience in prevention programs and they put all their trust in its. after doing the analysis, we chose the ''lack of information problem'' to plan prevention activities. we consider it is a serious and real problem but at the same time, easy of prevent. conclusions. the implementation of the patient safety program in the icu means a real cultural change. the priority analysis could help to plan strategies in order to avoid the program failure. objectives. we concerned about whether medical personnel could recognize management of the cuff of artificial airway or not. we asked to doctors and nurses working in intensive care unit of konyang university hospital, daejeon, republic of korea. we asked questions with contents of questionnaire that was composed of methods of set initially, maintenance and appropriate pressure of cuff. results. of medical personnel replied to us. most of them had worked in intensive care unit, so they had placed of artificial airway. . % of them used manometer to adjust the cuff. we could find that nurses had more cognition compared to doctors for it ( vs. %). only . % of doctors described pressure of the cuff in medical record. of medical personnel replied that they knew the appropriate range of cuff pressure. % ( / ) of them replied that the range of cuff pressure was kept with - mmhg and % ( / ) was - mmhg. % of nurses in the icu knew that range of cuff pressure was - mmhg. most of them knew complications of high and low pressure of the cuff. . % of medical personnel monitored the cuff balloon during receiving mechanical ventilation and they used manometer to adjust it. % of nurses knew that the cuff should be adjusted continuously, but % of doctors did. interval measuring the cuff pressure was % of once a day, % of three times a day, % of more than four times a day conclusions. most of the medical personnel knew to keep appropriate cuff balloon to prevent various complications of artificial airway. they had insufficient cognition about maintaining the cuff balloon and appropriate level of cuff pressure. that was more prominent in doctors than nurses interhospital transfer is occasionally required as a consequence of limited therapeutic options or because of a need for a higher intensity of medical care that cannot be given in rural intensive care units. along with the potential benefit for the to be transferred patient, transport may also lead to hemodynamic and pulmonary deterioration. in order to minimize additional risk of interhospital transport of critically ill patients, a mobile intensive care unit with a specialized retrieval team was established in our university hospital-based intensive care unit. from march , transport of the critically ill patients in our adherence region are performed by micu. objectives. in this prospective audit adverse events and patient stability during micu transfers were assessed and compared to our previous data on transfers performed by standard ambulance [ ] . results. interhospital transfers over a -month period were evaluated. systolic blood pressure, glucose and haemoglobin were significantly different at arrival compared to departure, although never significant values for major deterioration were reached. an increase of total number of variables beyond threshold at arrival was found in % of patients, percent exhibited a decrease of one or more variables beyond threshold and thirty percent showed an equal number of trespassed thresholds. there was no correlation between the patients status at arrival and the duration of transfer or severity of disease. icu mortality was %. compared to standard ambulance transfers of icu patients performed in , there were far less adverse events: . vs. %, which in the current study were merely caused by technical (and not medical) problems. although mean apache ii score was significantly higher, patients transferred by micu showed less deterioration in pulmonary parameters during transfer than patients transferred by standard ambulance. conclusion. transfer by micu imposes less risk to critically ill patients compared to transfer performed by standard ambulance and has therefore resulted in an improvement of quality of interhospital transport of icu patients. introduction. previous studies in adult intensive care units (icus) reported rates of pre-mortem to post-mortem discrepancies ranging between and % depending on the population studied. and, most of them were retrospective studies, which included small number of patients. to compare clinical and pathological diagnoses and to determine the types of errors in a large and multidisciplinary icu-patient population. we conducted a prospective study of all consecutive autopsies performed on patients who died in the icu of the hospital universitario de getafe, madrid, spain, between january and december . the diagnostic errors were classified in two categories: class i errors that were major misdiagnoses with direct impact on therapy, and class ii diagnostic errors which comprised major unexpected findings that probably would not have changed therapy. conclusions. this study found significant discrepancies between clinical diagnoses before death and post-mortem findings. this reinforces the importance of the post-mortem examination in detecting otherwise unexpected diagnoses and improving the quality of care of critically ill patients. introduction. unplanned extubation is associated to a high risk of reintubation end correlates with increased risk of nosocomial pneumonia. on the other hand, reintubation significantly increases morbidity and mortality in critical ill patients, increasing the incidence of ventilator associated pneumonia (vap) rate and makes the airway management risky. objectives. the aim of our study was to test the rate of unplanned extubation as well as the reintubation rate in our icu, in order to evaluate the efficiency of our airway and weaning time protocols. methods. during a nearly year's period, patients admitted to the icu, mean age: . years, mean apache ii score: . , mean los: . days, with predicted and actual mortality: . and . % respectively. from these, were intubated and included retrospectively in our study. patients were extubated, while the others either underwent bedside percutaneous tracheostomy or died. we concerned that the number of days of mechanical ventilation were about equal to the number of days of intubation. reintubation was defined as the need to reintubate during the first h after extubation. we recorded four episodes of unplanned extubation. three of them caused by malfunction of the tube due to secretions and airway obstruction and one of them was undesired extubation caused by the patient himself. the total number of days of intubation was , , mean ± sd: . ± . , min: , max: days. therefore the rate of unplanned extubation was . %, while the standard limit is below %. the total number of reintubations was , while the total number of scheduled extubations was . therefore, the reintubation rate was . %, while the standard limit is below %. conclusions.the recorded rate of unplanned extubation was low in our icu patients, below the acceptable limit, assuming that our sedation and airway management policy is effective. on the other hand, the recorded rate of reintubation was high in our study, above the acceptable limit. although a low rate of reintubation might indicate excessively long mechanical ventilation times, this did not recorded to our study. nevertheless, our data suggest that we have to improve further our weaning time protocols, making the extubation procedure safer, and avoiding risk factors for vap. . pvs such as inappropriate enrollment of patients with a contraindication to the study treatment may lead to excess harm in the active intervention group [ ] and failure to deliver the study intervention according to the study protocol may underestimate true treatment efficacy [ ] . full reporting of pvs may aid in the interpretation of rct results however there are no published reviews on this topic [ ] . objectives. to determine reporting rates for key types of pvs and to investigate study characteristics that may be related to reporting. publications were excluded because they were subgroup or economic analyses of a previously published rct [ ] , not a rct [ ] , not published in the target journal [ ] , systematic reviews [ ] , or other reason [ ] . median trial size was participants (range: to , ). / ( %) of rcts were single centre, / ( %) were industry funded and / ( %) reported negative findings. overall / ( %) of rcts reported some form of pv, these included: / ( %) patient compliance; / ( %) discontinuation of study intervention due to safety; / ( %) study intervention-related researcher error; / ( %) inappropriate enrollment and; / ( %) technical errors in randomisation. multi-centre rcts may be more likely to report study intervention-related researcher errors ( % of multi-centre trials vs. % of single centre trials, p = . ). academic trials were less likely to report discontinuation of study intervention due to patient safety ( % of academic trials vs. % of industry trials, p = . ) and were less likely to report technical errors in randomization ( % of academic trials vs. % of industry trials, p = . ). conclusions. multi-centre trials are accepted to be organizationally complex. on-site education may be required to reduce errors in study intervention delivery attributable to the research team. it is possible the apparent excess harm attributable to industry trials is a reporting artifact however, if it is real, it must be addressed. additional research is required to investigate patient safety-related pvs and technical randomization errors, which may be lower in academic trials. to determine the occurrence of harmless incidents and ae related to physician's competences in icus, disclosing their potential risk factors. conclusions. this prospective study was essential to identify the proportion of our icu admissions affected by md-inc and md-ae, disclosing their nature. our md-ae rates, affecting more than % of admissions, were higher than those described in prior general studies, including not only icus. among the detected md-ae, hypoglycemic episodes not related to insulin administration predominated, indicating important deficiencies regarding nutritional support. severity on admission and length of stay were important risk factors for the occurrence of at least one md-ae. a systematic measurement and analysis of unintended events (ue) have been recommended for patient safety and improvement of quality of care in critically ill patients. however, a spontaneous reporting system may be inefficacious in intensive care unit (icu) because of a poor data collection, particularly by physicians staff. objectives. the aim of this study was to evaluate the reliability of a staff spontaneous event report by comparison with events collected by an external observer in a surgical intensive care unit (icu). to facilitate the reporting and the analysis, we identified a series of events with a serial number and a colour code related to their for each of the following macro-phases: icu bed booking, admission procedures, patient stay, discharge and emergency procedures. a specific structured form including ue's code and colour, date and hour of the event and type of patient has been prepared and proposed to staff -week for each month after a proper phase of education. the report was voluntary and anonymous and the data collected during the morning shift from september to december have been compared to those collected from an external observer. in the studied period, healthcare staff reported ues: % collected by nurses, % occurred during the morning shifts and % were classified as moderate or severe. the rate of ue in the morning shift was ues per patient days. the external observer identified events in morning shifts with an incidence of ues per patient days. the violation of isolation rules for patient with multi-drug resistant bacteria infection both by icu staff and surgical consultant was the ue observed more frequently by the staff ( %) and by the external observer ( %). conclusions. the above data indicated that: . in our icu the incidence of ue is very high, particularly for compliance to isolation of infected patients and . the spontaneous reporting system under-estimated largely the real incidence of ues. introduction. importance of renal assessing in intensive care unit (icu) patients is unquestionable for a correct drug dosing, fluid requirements or decisions for renal replacement therapies. serum creatinine (sc) is a very common biochemical parameter in clinical practice for assessment of renal function. many equations have been designed to estimate creatinine clearance based on sc, but their capacities for providing a correct estimate of glomerular filtration rate (gfr) are suboptimal. this is even worse in critically ill patients due to malnutrition and/or immobilization. in clinical practice, despite its limitations, h-urine creatinine clearance (crcl h ) is used as a reference method to determine gfr. data show that cystatin-c could be promising as an endogenous filtration marker in icu settings. objectives. to assess in a medical icu population whether the arnal-dade formula of cystatin-c clearance (cc) developed from serum cystatin-c (scc) shows better predictive performance of gfr than sc-based formulae, as regards to patients' renal function: crcl h c ml/min . m or crcl h \ ml/min . m . results. all formulae showed notable bias from the reference method. interestingly, all equations based on sc-values clearly overestimated crcl h (cg: . %; mdrd: . %; fv-mdrd: . %), whereas cc showed underestimation of these crcl h (cc: - . %). in the crcl h c ml/min . m group (n c = ; patients), cc showed the best correlation indexes (cc-crcl h ; r = . , r = . ), the second most biased (- . %) and the worst precision ( . %). in this group, mdrd was the least biased (- . %) and the most precise ( . %). in the crcl h \ ml/min . m group (n \ = ; patients), cc was the worst correlated with crcl h (r = . , r = . ), in contrast to mdrd (r = . , r = . ). in terms of precision, mdrd showed again better results than cc: . % vs. . %, respectively. conclusions. in our icu population, cc did not demonstrate a clear improvement on the remainder sc-based formulae in either of the two groups according to crcl h . however, in a patient with high mdrd values and suspicion of low gfr, cc could be useful as guidance before obtaining the definitive confirmation by crcl h . introduction. there are well established and robust techniques for measuring and categorizing renal function in people with chronic kidney disease (ckd). a number of rapid bedside estimates of renal function have been devised incorporating routine daily measurements, such as serum creatinine, in combination with demographic data (e.g. cockroft-gault, the mdrd series). the addition of serum cystatin c measurements to some equations may also improve accuracy of estimation. the current and accepted categorical classification of acute kidney injury (aki: akin/rifle) has been useful epidemiologically but does not provide a continuously variable measure of severity of aki which would be valuable for both clinical management and research. objectives. previously published abstracts have suggested a role for egfr in describing renal function in the critically ill but a more comprehensive analysis was needed. methods. ( male) (mean age range - ) critically ill patients with aki were recruited. a h creatinine clearance ( crcl) (previously validated as a measure of renal function in critically ill patients) was measured and simultaneous blood sampling was done for creatinine, urea, albumin and cystatin c. various equations used to estimate gfr were compared to crcl with regression and bland-altman analysis. all patients had a crcl of\ ml min per . m introduction. epithelial-mesenchymal transition (emt), a key process in tissue development and repair, has also been identified as a major mechanism in fibrogenesis. the cytokine tgfb has been shown to induce transformation of epithelial cells into matrixforming and smooth muscle actin (sma)-expressing myofibroblast (mf) via emt. the other prerequisite is an injury-induced loss of intercellular contact, including adherens junctions (ajs). the classical experimental method to induce aj disruption is the uncoupling of e-cadherin-mediated contacts by low calcium medium (lcm). this concept has been termed as the two-hit model of emt ( ). b-catenin, a scaffold protein of the aj, released by cell contact injury, can act as a transcription factor and has been shown to facilitate emt. however, the mechanism whereby cell contact injury promotes emt is not understood. our recent studies have shown that smad , one of the main signal transducers of the tgfb pathway is a strong inhibitor of epithelial sma expression, by interfering with myocardinrelated transcription factor (mrtf) [ ] . the latter is the main driver of the sma promoter, through it association with serum response factor (srf). intriguingly, b-catenin can bind to smad . to clarify the mechanisms whereby aj injury promotes sma expression. methods. ajs were manipulated in kidney tubular cells, either by sirna-mediated downregulation of e-cadherin, b-catenin or through chemical uncoupling of ajs by lcm. protein expression was detected by western blotting and immunofluorescence microscopy, proteinprotein interactions were monitored by co-immunoprecipitation, and the activity of the sma promoter was determined by luciferase reporter assays. knockdown of e-cadherin promoted b-catenin translocation to the nucleus and induced a threefold rise in the tgfb-triggered sma expression. conversely, silencing of b-catenin strongly suppressed the two-hit (tgfb + lcm)-induced activation of the sma promoter, and inhibited sma protein and mrna expression by %. the same stimuli induced strong association of b-catenin with smad . transfection of cells with a b-catenin expression vector dose-dependently prevented the inhibitory action of smad on the mrtfinduced activation of sma promoter. moreover the active (myogenic) mrtf-srf complex was restored, as b-catenin preempted smad 's inhibitory effect on the complex. these studies define a novel mechanism whereby epithelial injury activates the myogenic program, a central process in organ fibrosis. our results imply that b-catenin, liberated from the injured ajs, facilitates the activation of the myogenic program by preventing or mitigating the inhibitory action of smad on mrtf. these hitherto unknown interactions among smad , b-catenin and mrtf represent novel targets to lessen fibrogenesis. introduction. in intensive care unit (icu) patients, kidney function is monitored by the creatinine clearance (crcl). it can be measured by two methods. urinary crcl (ucrcl) is directly measured, using the urinary and serum creatinine. but commonly crcl is estimated from serum creatinine (scr) alone, as estimated glomerular filtration rate (egfr); using equations validated in chronic kidney diseases. there is paucity of literature on validation and comparison of these methods in icu (hoste) . objectives. we compared -h timed ucrcl and egfr in the newly admitted critically ill. we also sought to ascertain the incidence of high crcl and the agreement between methods in this subgroup. conclusion. the use of rifle criteria gives a high incidence of aki in the icu setting. in this unselected population of critically ill pts, cysc seems to be superior to cre in predicting pts who will develop aki and will need rrt during their hospitalization in the icu. early identification of high risk patients may allow potentially beneficial therapies to be initiated early in the disease process, before irreversible injury occurs. introduction. the contrast-induced nephropathy (cin) is consider to be the most frecuence reason of acute renal failure in hospitalized patients. they are defined by a fixed increase ( . mg/dl) o a % rise serum creatinine level after to be exposed h to the contrast. the main complications are kidney and cardiac problems and this will lead to longer hospitalization and increased mortality. objectives. to compare cin occurrence after a injecting a iso-osmolar contrast (ioc, idixanol) or a low-osmolar contrast (loc, iohexol) to a group of patients submitted to coronary angiography, with o without percutaneous coronary intervention (pci). to establish unrelated cin markers and to evaluate the efficiency of the kidney protection protocol used in our hospital. conclusions. the loc was associated to a greater number of cin than ioc. patients who developed cin were significantly longer hospitalized. the use of point giving system that includes cin's predictors like dm, hematocrit \ %, ami, and treatment with diuretics helps us to classify cin risk and use a correct kidney protection protocol. introduction. the incidence of acute renal failure in the intensive care unit (icu) is around % of cases and is related to increase in mortality in patients who required dialysis as far as %. early detection of acute kidney injury (aki), after damage is not on set could be crucial to develop therapeutic strategies to modify the course of injury. blood and urinary concentrations of ngal are early biomarkers of aki ; to date, little information exists regarding ngal usefulness in critically ill patients. objectives. to analyze: . the capacity of urine ngal (ungal) to predict akievaluated by rifle score-in critically ill patients and, . the ungal values in patients with sirs, sepsis or septic shock. methods. ngal was measured in urine sample by an automatic analyzer device (architect ci Ò ; abbott diagnostics) at admission and h later in patients admitted to a general icu. patients were classified both by rifle score at admission and and h later and by ungal concentrations at admission. to the later classification, the cut-point for aki prediction was obtained by roc curve analysis. ungal values at admission were compared in patients with sirs, severe sepsis or septic shock. clinicians were blinded to ngal results. the study included consecutively-admitted patients ( female) with mean age . ± . years, and length of icu stay of . ± days. fifty-four sirs, severe sepsis and septic shock. thirteen patients developed rifle f score, of them at icu admission; extracorporeal renal therapies were required in cases. when patients were classified according to their rifle score at h of admission, ungal values at admission were: ( - ) ng/ml in patients with rifle , ( - ) ng/ml in with rifle r, ( - ) ng/ml in with rifle i and ( - ) ng/ml in with rifle f (p = . ). five patients were excluded, three died before h with ungal ( - , ) ng/ml and two were discharged before h with ungal ( - ) ng/ml. the area under roc curve of ungal at admission for aki prediction was . ( % confidence interval . - . , p \ . ), with an optimal cutoff value of ng/ml with % sensitivity and % specificity. forty-seven patients have ungal b ng/ml. ungal concentrations at admission were ( - ) ng/ml in patients with sirs, ( - ) ng/ml in patients with severe sepsis and ( - ) ng/ml in patients with septic shock (p = . ). conclusions. urine ngal concentrations measured at icu admission appeared as a useful predictor of aki in critically ill patients; in addition, ungal concentrations showed an increasing pattern from sirs to severe sepsis and septic shock. rd esicm annual congress -barcelona, spain - - october s introduction. two previous studies using the rifle criteria in intensive care patients have found the incidence of acute kidney injury (aki) to be and %. however, these studies used calculated basal value of creatinine in a considerable proportion of their patients, which is a possible source of error. objectives. the aim of this study was to investigate the incidence and severity of acute kidney injury in intensive care patients using true baseline creatinine values. objectives. the aim of this study was to define the status of hcy and b vitamins at admission and days of icu stay in critically ill patients, and to evaluate its relationship between them. a prospective study was done on critically ill consecutive patients with inclusion criteria: c years old, sirs and apache ii [ . hcy, b and folic plasma levels were measured by enzymoimmunoassay and enzymatic method. for b , b and b in erythrocyte. permission was obtained from an institutional ethical committee and written informed consent was asked. results. at and days of icu stay and % of patients were b deficient, respectively. and % were b deficient on both times, respectively. folic levels show significant differences between and days of icu stay. we found association between b vitamin and hcy at admission and days. no differences were found between and days hcy values. introduction. cytochrome p a (cyp a), the most abundantly expressed cytochrome p enzymes in liver, are responsible for the metabolism of over % of drugs used across several therapeutic classes. in adults, cyp a is represented primarily by the major isoform, cyp a , and a polymorphically expressed isoform, cyp a . individuals with at least one wild-type cyp a * allele synthesise functionally active enzyme while homozygotes for the * allele are functional non-expressers of the enzyme. the presence of functional cyp a increases the hepatic metabolism of cyp a substrates such as tacrolimus. ckd is known to reduce the hepatic metabolism of drugs via the cyp a enzyme system and we have shown, recently, that aki has a similar effect and that the length of time with aki is the most important variable. we hypothesise that expression of functional cyp a may reduce the impact of aki on hepatic drug metabolism as has been shown to be the case for drug interactions with the imidazole antifungals. methods. ( male) (mean age range - ) critically ill patients with no aki and varying degrees of severity of aki were recruited. midazolam concentration was measured h after intravenous administration as a probe-drug for hepatic cyp a / enzyme activity (t [midazolam] ). this is a validated method for testing cyp a activity in critically ill patients. patients were excluded if they were on any known cyp a / inhibitors. results. two patients with severe aki had unexpectedly high t [midazolam] . figure demonstrates the following: without a cyp a * allele, the rate of midazolam metabolism increased with duration of aki (r = . ; p \ . ) (solid line). patients who had at least one * allele (dashed line) were protected from the inhibitory effect that aki has on hepatic drug metabolism (significant difference between the correlation lines p = . ). if the two major outliers are removed (dotted grey line) from the * /* group (r = . ; p \ . ), the correlation lines remain statistically different (p = . ). conclusions. the presence of an allele which codes for functional cyp a protects critically ill patients from the inhibitory effect of aki on the hepatic metabolism of midazolam. thyroxine replacement therapy has become commonplace in the management of organ donors to reverse hemodynamic instability and homeostasis, yet the pharmacokinetics of thyroxine are unknown in this patient population [ , ] . since t is only available in oral form, we studied the pharmacokinetics of oral versus intravenous t to determine if oral administration is suitable. objectives. ( ) to study the pharmacokinetics of oral versus iv t therapy; ( ) to determine if oral thryoxine therapy is suitable. with ethics approval and signed consent from the substitute decision maker, patients who were determined to be neurologically dead and consented for organ donation, were randomized to receive either an oral or intravenous dose of t ( mcg/kg). all patients received an oral and iv preparation; one of which was a placebo. this study was also double blinded and randomization occurred in blocks of - . free serum levels of t and t were measured hourly until the time of organ procurement. the area under the curves (auc) were determined and compared using. results. there were patients ( males) in the oral versus patients ( males) in the iv group, with an average age of ± vs. ± , respectively. there was no significant difference at baseline or h between groups for hemodynamic variables, free t , free t or tsh levels. the only exception was map where it was higher at baseline in the oral group and there was a significant increase at h in the iv but not the oral group ( - vs. - in the oral). the auc for t was greater for the iv group ( pmol/l/ h) compared to the oral group ( pmol/l/ h). there was no statistically significant difference in any of the levels from to h between the oral and iv groups. oral bioavailability of t was %. conclusions. administration of iv t resulted in a slightly greater auc compared to oral administration. however, oral bioavailability of t in our population was very high, at %. t is currently the recommended thyroid replacement in neurologically dead organ donors. however, intravenous t is unavailable in many jurisdictions. iv t has been used as a substitute. our study shows that in this select population, oral bioavailability is high suggesting that oral t may be a reasonable alternative. further work is needed to determine whether there was a difference in the number and rate of organ retrieval in the oral versus intravenous groups. introduction. specific characteristics of metabolic derangements occurring in critical illness is domination of developing catabolic state particularly in acute necrotizing pancreatitis. as a result, we faced such a problem as developing a clinically apparent protein-calorie deficiency which is resistant to standard nutritional support. the treatment of acute necrotizing pancreatitis in chronic abuse patients is difficult to handle for the clinician and should include sufficient energoplastic supply. objectives. in our research we aimed to assess the efficacy of adding of ornithineaspartate complex in carbohydrate metabolism in chronic abuse patients with acute necrotizing pancreatitis. methods. comparable chronic abuse patients with acute necrotizing pancreatitis (control group n = , mean age . ± . ; ornithine group n = , mean age . ± . ) received early parenteral nutrition from the moment of admission to hospital with universal system ''three-in-one''. ornithine group also received ornithine-aspartate complex by parenteral administration ( g/day). on the second day the patients were admitted parenteral nutrition and tube feeding h/day. the volume of parenteral nutrition was gradually decreasing. biochemical and metabolic endpoints were measured at baseline and on th day (nitrogen balance, amino acids spectrum, plasma whole protein, transferring concentrations, glucose and insulin levels) at the clinical laboratory in all patients metabolic disturbances with protein status and carbohydrate metabolism shifts were revealed. dynamic of the whole protein, albumin/protein ratio and nitrous balance in both group showed similar tendency of metabolic improvement. dynamic of essential and nonessential amino acids concentration remained normal showing adequate energoplastic supply in both groups. glutamine concentration in ornithine group remained stable and even increased by the th day of nutritional support, while in control group glutamine concentration was decreasing, and by the th day of nutritional support it was below normal values. in ornithine group higher levels of endogenous insulin at normal values of glucose and faster fisher index improvement were detected. conclusions. administration ornithine-aspartate complex in therapy of acute necrotizing pancreatitis in chronic abuse patients, probably, may influence on disease outcome. in ornithine group duration of delirium tremens causes was ± days versus control group ( ± days). restoration of metabolic activities confirms adequate nutritional support in both groups but ornithine-aspartate complex adding provides faster improvement of protein and carbohydrate metabolism. objectives. this study was designed to evaluate the nutrition indexes including serum prealbumin level as prognostic indicators of patient recovery in critically ill patients with comparing severity scoring systems. we selected patients over years old, supplied with total parenteral nutrition (tpn) for more than days in surgical intensive care unit, ajou university hospital, suwon, korea. the serum prealbumin, albumin levels and total lymphocyte count were measured at the first, rd, , , , th days of nutrition support care by tpn. we checked apache (acute physiology and chronic health evaluation) ii score, saps (simplified acute physiology score), mods (multiple organ dysfunction score) and sofa (sequential organ failure assessment) score of patients. results. there were male patients and female patients with mean age . years. the mean day of sicu staying was . days. we compared two groups; survivor group (n = ) and non-survivor group (n = ). there were significant statistical differences in icu staying days (p = . ), apache ii score (p \ . ), saps (p \ . ), mods (p = . ) and sofa score (p = . ) between two groups. however, serum prealbumin level (p = . ), albumin level (p = . ) and total lymphocyte level (p = . ) did not showed significant difference between two groups. receiver operating characteristic curve showed low accuracy of serum prealbumin level as a prognostic factor (area = . ). prealbumin level showed correlation with albumin (r = . ), however did not show correlation with apache ii (r = - . ), saps (r = - . ), sofa (r = - . ) and mods (r = - . ). conclusions. nutrition indexes including prealbumin did not correlated with clinical outcome of critically ill patients. introduction. physical function is impaired following critical illness [ ] . anaemia is a common complication of critical illness and has the potential to influence physical function [ ] . it is not known whether anaemia affects the physical components of quality of life, the ability to carry out the activities of daily living (aodl) or the actual physical function of patients during recovery from critical illness. to determine the physical quality of life, ability to perform activities of daily living and actual physical function in a cohort of icu survivors dichotomised on the presence of anaemia at months following icu discharge. one other organ failure were recruited from a general icu population. patients with a preexisting haematological condition were excluded. baseline and characteristics of icu stay were recorded. the patients were assessed with the sf- quality of life questionnaire (pcs), the frenchay activities index (fai) of aodl recalled for pre-morbid status and at and months, and the min walk test ( mwt) for actual physical function at and months following discharge from icu. organotopic measures of haemaglobin, creatinine, serum c-reactive protein and albumin concentration were also recorded. the results were dichotomised on the presence of anaemia at months for statistical analysis. baseline characteristics were compared with student's t test. a way anova was performed on the pcs and fai score as well as comparisons with t test between each time-point. the distance walked as part of the mwt was compared with mann-whitney u test. patients who remained anaemic at months were older, had a longer icu stay and had a greater requirement for inotropes during their icu stay. the pcs score of quality of life and the fai score was significantly impaired in both groups during follow up, but there was no effect of anaemia. the results of the t tests showed that there was a significant difference between the groups at months for pcs but not for fai scores. the distances walked were severely impaired compared to the normal population ( and m at and months for anaemic group and and m for non-anaemic) in both groups was not significantly different between the two groups. the non-anaemic group did increase the distance walked significantly from to months. there was no difference between albumin, crp and creatinine concentrations between the groups. methods. this experiment was divided into two procedures. the first procedure is to choose two kinds of cell strains, including jurkat cell strain (comes from leukemia) and ccrf-cem cell strain (comes from acute lymphocyte leukemia).we cultivate this two kinds of cell strains to mature stage, then inoculate every kind of cell strain into four culture dishes, two culture dishes was stimulated by lg/ml lipopolysaccharide(study group), and the other two culture dishes serve as blank control(not stimulated by lg/ml lipopolysaccharide). eight hours later, we extracted the microrna in each culture dish. the second procedure is to use the technique of gene microarray to analysis the difference expressions of microrna. in the context of a high altitude expedition human subjects can safely be submitted to prolonged hypoxia and the resulting changes in mitochondrial function can be explored in a controlled fashion. the effect of hypoxia on immune cells-key players in the pathophysiology of sepsis-is of particular interest. to measure mitochondrial function of monocytes during prolonged hypobaric hypoxia. methods. serial blood samples were collected and oxygen saturation was measured in twelve climbers before and throughout a high altitude climbing expedition to pik lenin ( , m). measurements were performed at m (baseline) and at the altitudes of , m (day ), m (day ) and , m (day ) above sea level. pure monocytes were isolated by the use of an antibody-antigen mediated immunomagnetic cell isolation procedure and lysed for determination of activities of mitochondrial enzymes cytochrome c oxidase and citrate synthase. repeated measurements anova followed by least significant difference (lsd) post hoc test were used to compare results on different altitudes. mean oxygen saturation was ± % on , m, and decreased to ± % on , m and ± % on , m (p = . ). we observed an increase in citrate synthase activity on all altitudes compared to baseline levels (p = . ). compared to the baseline, prolonged hypobaric hypoxia induced an increase in the mitochondrial respiratory chain enzyme cytochrome c oxidase enzymatic activity only at , m (p = . ). normalization of cytochrome c oxidase enzymatic activity by citrate synthase activity (relative enzymatic activity) yielded a decrease in relative cytochrome c oxidase enzymatic activity during hypoxia on , and , m (fig. ) . expressing cytochrome c oxidase enzymatic activities as a ratio to citrate synthase is intended to act as a safeguard for potential differences in mitochondrial enrichment. conclusions. the data demonstrates that prolonged hypobaric hypoxia leads to a decrease in relative cytochrome c oxidase activity. this is due to an increase in citrate synthase activity as a marker enzyme for the mitochondrial matrix representing mass and/or number of mitochondria which is not counterbalanced by a corresponding increase of cytochrome c oxidase activity. results. glycocalyx degradation was increased in the lps-treated animals ( . lm, p \ . ) compared to controls. intracellular tissue no concentrations were two-to threefold higher in the lps-treated mice compared to controls (liver, kidney, heart, gut). the number of infiltrating mpo-positive cells increased significantly during endotoxemia. levels of both plasma arg and cit were significantly lower in lps-challenged mice than in controls, whereas plasma ornithine levels were significantly higher. conclusions. in this new developed murine sepsis model, the prolonged infusion of lps resulted in increased glycocalyx degradation and associate endothelial leakage. the enhanced no levels correlated with decreased plasma levels of arg and cit. our murine model with prolonged infusion appears applicable as a model for the human clinical situation, enabling adequate investigation of the influences of the arg-no metabolism on endothelial dysfunction in sepsis. critical illness polyneuromyopathy is a muscular weakness occurring in intensive care unit. one of the major risk factor is sepsis. an early decrease in membrane excitability was described [ ] but corresponding mechanisms are imperfectly known. tnfa is released in the first time of sepsis and could be involved in the physiopathology. objectives. the aim of our study was to investigate tnfa effects on muscular voltage gated sodium channels (nav) in an in vitro model. early effects of tnfa on nav were analysed by macro-patch clamp on muscular fibers isolated from rat peroneus longus. measurements were performed on control fibers and after addition of tnfa at concentrations ranging from . to ng.ml - . the effects of chelerythrine, a specific inhibitor of protein-kinase c (pkc), were also tested. experimentations were realised in a laboratory with permission of experimental research on animals and under the supervision of an authorized person (no - ). tnfa produced a concentration-dependant inhibition of nav currents (fig. ) . maximal inhibition ( % of control current) was observed with concentrations from ng ml - and above. this decrease was fast: % of maximum inhibition was observed in less than min. moreover, chelerythrine inhibited tnfa action on nav. conclusions. in our experimental model, tnfa induce a rapid and concentration dependant decrease of muscular nav currents like observed in chronic sepsis [ ] . as this effect is too quick to be a transcriptional one, and as it is blocked by chelerythrine, it can be assumed that tnfa action is mediated by a nav phosphorylation secondary to pkc activation. in conclusion we evidenced that tnfa reduce muscle excitability in the early stages of sepsis. further studies are needed to obtain a precise description of tnfa mechanisms. may also contribute to cell signaling and regulation of the immune response. nad(p)h oxidase in leukocytes and the vascular wall is a major regulated source of o . we hypothesized that mice deficient in the p phox (ko) component of nad(p)h oxidase would have less pulmonary inflammation than wild type (wt). we treated wt or ko mice with iv saline or lps and assessed lung injury by: . wet-dry-weight ratio; . leak of evans blue (eb) labeled albumin; and . histological score for edema. we used myeloperoxidase activity to indicate neutrophil (pmn) accumulation in lungs, and measured accumulation of macrophages and neutrophils in bronchial alveolar lavage (bal). apoptosis was assessed by tunnel staining. we also expression of icam- , an adhesion molecule, and nitric oxide synthase (nos) enzymes, enos and inos (western and northern analysis) as well as nitrotyrosine formation. results. lung injury was increased in both groups. surprisingly there was greater eb leak in ko than wt at h and a greater edema score at and h. pmn and macrophage accumulation in bal were the same in both groups at h but greater in ko mice at h. myeloperoxidase activity was similar at h post lps in ko and wt indicating that similar accumulation of pmn in the lungs. apoptosis was increased in both groups at h, but resolved in wt at h and persisted in ko. nitrotyrosine was increased in both groups but appeared higher in ko. expression of enos and inos increased in both groups but was greater in ko than wt. conclusions. in contrast to our prediction, lung injury was greater in p phox ko mice which indicates that this complex is not essential for lung injury. however, the injury was more severe and prolonged in ko mice indicating that o may regulate the inflammatory response. introduction. septic shock remains the main cause of mortality in the icu, thus a persistent challenge. recently, dna and mrna analysis by microchip and gene expression by real time pcr highlighted proteins s a , s a and their complex, known as the calgranulins, as potential key prognostic markers for this disease: those two proteins, whose expression seems to be restrained to phagocytes cells are newly recognized components in sepsis-induced inflammation. moreover, they were shown to be at significantly higher concentrations in the plasma of septic shock patients that were going to die. in the contrary, those who were to survive saw their plasmatic concentration decrease, all severity scores in between the population being the same. objectives. the aim of this study was to determine the repartition of these proteins in immune cells, their intracellular variation, at baseline and after cell activation and finally to understand the relation between their intracellular and extracellular expression. we used an in vitro model close to the immuno-inflammatory aggression that is septic shock. we stimulated in vitro for , and h whole blood from healthy volunteers using agonists found in the inflammatory storm that is septic shock (lps, fmlp, gmcsf, ifng). we also induced death cell, either using an apoptotic agonist, or by necrosis technics. we then analysed the intracellular variation of the calgranulins using flow cytometry technics. the extracellular quantification was made using elisa methods. all the statistic analysis were made using a mann-whitney test. we showed in this work for the first time that the intracellular repartition of the calgranulins is different depending on the type of cell: the complexe is the main form in the monocyte cytoplasma, whereas s a is the main intracellular form of the pmn. this repartition remains after cell activation. we also checked the absence of calgranulins in lymphocytes. after cell activation we showed that intracellular s a , s a and s a a increased, but at different levels depending on the cell and the agonist used. extracellular s a also raised after cell stimulation, but the concentration found were very low compare to those found in the plasma of septic shock patients. conclusions. together, these results suggest a different regulation depending on the form of the protein and of the cell and thus of proper distinct function of each monomer and of the complex. in the limits of our model the increased concentrations found in the plasma of patients with a septic shock can't be explained by immune cell activation. objectives. although there is no specific antidote for these potent toxins, drugs like penicillin g and silibinin have been used with conflicting evidence. we successfully managed two patients with mushroom poisoning by using silibinin and nac. methods. two members of a family, a mother years old, and her son years old were admitted to our icu h after the ingestion of wild mushrooms. they presented with abdominal cramps, vomiting, profuse diarrhea ([ /day), myalgias, confusion and agitation. the clinical examination showed severe dehydration, tachycardia, oliguria with grade i-ii hepatic encephalopathy. laboratory exams revealed elevation of liver enzymes sgpt: / u/l, sgot: / u/l. coagulation parameters were as following: prothrombin time . / . , factor v \ %/ %, factor vii \ / %. high ammonia levels were noted, reaching and ng/dl, respectively. metabolic acidosis was also present with mild renal dysfunction. the ultrasound performed in both patients showed hepatosplenomegaly. aggressive fluid and electrolyte replacement started upon admission. silibinin was given at a dose of mg/kg/day intravenously, in four divided doses, for three consecutive days, while nac was given as a continuous infusion at a dose of mg/kg for the first hour, mg/kg for the next h, and thereafter mg/kg/day for the following four days. hepatic encephalopathy, mild jaundice and renal dysfunction resolved within h, and liver function tests returned to normal within days. the patients recovered fully and were discharged to a medical ward. recent experimental and clinical studies have shown a strong protective and antioxidant effect against hepatic cell injury in amanita toxicity by the administration of nac and silibinin, either as monotherapy or as a combination therapy. although further clinical research is required to confirm their efficacy in reducing mortality and transplantation rate, nac has been used in our icu in hepatic dysfunction of different etiologies with promising results. we have recently shown that in patients with lactic acidosis due to metformin intoxication (serum drug level = ± lg/ml; therapeutic level is b lg/ml) systemic oxygen consumption (vo ) can be abnormally low despite a preserved global oxygen delivery (do ) ( ). the study, however, suffered from being retrospective. objectives. to prospectively clarify whether metformin primarily impairs vo . methods. eight sedated, paralyzed and mechanically ventilated pigs received a continuous i.v. infusion of metformin, at a rate of . g/h. the amount of metformin administered to each animal ranged from and g. the experiment always finished h after the initiation of drug infusion. use of sedative and neuromuscular blocking drugs, as well as ventilatory setting, were always kept constant. serum metformin concentration was measured at the end of the experiment, using high performance liquid chromatography (hplc). arterial ph, lactatemia, vo (indirect calorimetry) and do (computed from cardiac output measured by pulmonary artery thermodilution) were recorded hourly. data are presented as mean ± sd. statistical testing was performed using the one-way repeated measure anova and the linear regression analysis. metformin infusion produced toxic serum drug levels ( ± lg/ml; n = ). arterial ph drop from . ± . (prior to infusion) to . ± . (end of the experiment) (n = ; p \ . ) and lactatemia rose from ± to ± mmol/l (n = , p \ . ). vo progressively decreased (from ± to ± ml/min; n = , p \ . ) while do did not significantly change over time (from ± to ± ml/min; n = , p = . ). the decrease in vo was proportional to the dose of metformin administered (r . ; n = , p = . ) and to the serum drug level reached by the end of the experiment (r . ; n = , p = . ). conclusions. lactic acidosis develops during metformin intoxication in the presence of a diminished vo but in the absence of any clear evidence of inadequate do . this finding suggests that impaired oxygen utilization, rather than availability, may have a role in the pathogenesis of metformin-induced lactic acidosis. : min) . death was consequent to multiorgan failure, anoxic encephalopathy or capillary leak syndrome if ecls was performed under cardiac massage. four patients presented with documented brain death, allowing organ donation in cases. among these patients, the heart of one flecainide-poisoned patient was successfully transplanted, after normalization of ecg and myocardial function as well as toxicant elimination under ecls. prognostic factors in ecls-treated poisoned patients were as follows: qrs enlargement on admission (p = . ), saps ii score on admission (p = . ), ecls performance under massage (p = . ), arterial ph (p \ . ), lactate concentration ( . [ . - . ] versus . mmol/l [ . - . ], p = . ), as well as red cell (p = . ), fresh plasma (p = . ), and platelet (p = . ) transfusions within the first h. conclusions. to our knowledge, this is the larger series of ecls-treated poisoned patients ever reported. ecls appears to be an efficient salvage technique in case of refractory toxic cardiac failure or arrest, with a % survival rate. our series clearly demonstrate that toxic refractory cardiac failure remains the best indication with a % survival rate. objectives. aim of the study was to investigate the incidence of infections in patients treated with hypothermia while receiving sdd. in this retrospective case control study patients treated with prolonged hypothermia (cases) were identified and patients with severe brain injury were included (controls). propensity score matching was performed to correct for differences in baseline characteristics and clinical parameters. primary outcome was the incidence of infection. the secondary endpoints were the micro-organisms isolated from surveillance cultures and during infection. the demographic and clinical data indicated that the cases and controls were well matched. the length of stay in the icu and duration of mechanical ventilation were comparable between the groups. the overall risk of infection during icu stay was % in the hypothermia groups versus . % in the normothermia group (p = . ). pneumonia was diagnosed in . % of patients in both groups (p = . ). the incidence of meningitis, wound infection, bacteremia, and urinary tract infection was low and comparable between the groups. staphylococcus aureus was most frequently identified as the causative infectious microorganism in both the hypothermia ( . %) and normothermia ( . %) group (p = . ), followed by coagulase negative staphylococci ( . % in the hypothermia and . % in the normothermia patients, p = . ) gram-negative bacteria were isolated from the surveillance cultures in . % of patients treated with hypothermia and . % of patients in the control group (p = . ). colonization of the rectum with gram-negative bacteria was significantly more frequent in patients treated with hypothermia compared with normothermia ( . vs. . % respectively, p = . ). in contrast, colonization of the upper gastrointestinal tract and sputum was comparable between the groups with an incidence of . % in the hypothermia patients versus . % in the normothermia patients (p = . ). use of sdd mitigates the increased risk of infection in patients treated with hypothermia. based on the surveillance cultures, it seems that oropharyngeal decontamination is the most effective part of the sdd regimen in the prevention of pneumonia. introduction. prognostic scores specific for critical patients were developed in order to predict mortality based on physiologic and laboratorial variables. on the other hand, specific scores for burn patients are calculated taking into consideration inhalation injury, age and total burned surface area (tbsa), among others. however, scores utilized in general icu have not been evaluated in burn patients. objectives. therefore, the aim of the present work was to validate apache ii, saps as well as initial sofa in a population of patients with massive burn. these scores were compared to some specific burn patient scores, including absi (abbreviated burn severity index) and estimates of the probability of death. retrospective study employing data collected prospectively from may to february ( months) at an icu specialized in burn patients at a teaching hospital which is considered a reference centre in trauma care. all patients admitted during this period were included. one hundred and fifty-four consecutive patients were studied (male: %; female: %), with averaged age of . ± . years and a hospital stay of . ± . days. mortality rate of our sample was . %. incidence of inhalation injury was % and total burn surface area (tbsa) was the following: . % of patients had % or less; . % had - % of tbsa whereas . % showed % or more. area under curve of receiver operating characteristic (roc) of evaluated indexes is displayed on table . computerized head tomography is routinely performed as a diagnostic tool after the occurrence of neurologic deterioration in the icu adult patients. however, the ct findings in this setting are rarely reported. we hypothesized that the analysis of a series of cranial cts would help to understand the neurologic conditions of the critically ill patients and improve their management. objectives. to analyze, over a three-month period, the head ct scans performed in the adult icu in the albert einstein hospital in são paulo, brazil. methods. all cranial cts performed in the icu patients during the studied period were analyzed by two radiologists from the albert einstein hospital staff from may st to august st, , according to a pre-established protocol: . presence of acute cerebral ischemia; . presence of previous cerebral ischemia; . presence of acute cerebral hemorrhage; . presence of cerebral edema; . cerebral aneurisms; . cerebral tumors and . normal cerebral tomography. we studied ct scans from ( . %) males and ( . %) females, mean age . ± . years. the head ct findings were the following: ( ) presence of acute cerebral ischemia = ( . %); ( ) presence of previous cerebral ischemia = ( . %); ( ) presence of acute cerebral hemorrhage = ( . %); ( ) presence of cerebral edema = ( . %); ( ) cerebral aneurisms = ( . %); ( ) cerebral tumors = ( . %) and ( ) c years c , abc (assessment blood consumption) cp: c and ets (emergency transfusion score) cp: c , c years c . these scales handle the following combinations of variables for calculation: age, sex, type of admission, mechanism, blood pressure, focussed assessment for the sonography of trauma, hemoglobin, orthopedic or pelvic trauma, heart rate. mt was defined as the transfusion of units or more of packed red blood cells in the first h. we study the sensitivity (s), specificity (sp), positive and negative predictive value (ppv, npv), likelihood ratios positive and negative (lhr+ , lhr-) and area under the receiver operating characteristic curve (auroc) of different scales for the predictive power of tm validated in the literature. patients were available for analysis ( . % men, iss ± , blunt trauma . % objectives. we measured patient-reported outcome following surgical management with dc using a quality of life instrument. methods. survivors discharged between and months after severe tat were contacted after obtaining approval by our institutional irb. we excluded patients with neurotrauma. we applied self-response version euroqol questionnaire (eq- d) and visual analog scale (eq-vas: (worst health)- (best health). euroqol it is based on a descriptive system that defines health in terms of dimensions: mobility, self-care, usualactivities, pain/discomfort and anxiety/depression. each dimension has levels of response: no problems (level ), some problems (level ) severe problems (level ). results. thirty four patients were contacted. mean ± sd age was . ± . yrs, male were . % and penetrating trauma occurred in . %. mean ± sd in severity scores were: ati . ± . , iss . ± . and apache ii ± . the median time from discharge was months (iqr - months). the eq- d dimensions in which the largest proportion of patients reported severe problems were usual-activities (work, study) and pain/discomfort . % and . % respectively as shown in the conclusions. survivors of severe trauma and dc, reported acceptable quality of life with minimal limitations with social functioning. a prospective study should assess quality of life in these patients from hospital discharge and systematically over time. introduction. brain tumors surgery is one of the main causes of admittance to the nicu. it is important to know the risk factors associated to hospital mortality of patients admitted to nicu due to this reason. to identify perioperative factors associated to higher hospital mortality in a series of patients admitted to nicu immediately after a bt elective resection. methods. data of patients operated for bt elective resection and consecutively admitted to nicu at imss umae bajío were prospectively obtained. nicu bt database includes perioperative items. we divided the series in two groups: surviving and deceased patients. then, we analyzed the perioperative behavior differences between both groups. either student's t test or chi-square test was used, as it corresponded, for the analysis of differences observed between both groups. values of p lower than . were considered significant. results. the hospital mortality observed in this series of patients was . % ( / ). data of the nine variables showing significant differences between surviving and deceased patients groups are shown in table . even if hypoxic brain injury has been reported as the strongest factor affecting the poor outcome of near-drowning patients, little has been known about prognostic factors affecting the outcomes of those patients receiving mechanical ventilation. to define prognostic factors affecting the outcomes of patients mechanically ventilated after near-drowning. , white blood cell counts (or, . ; % ci, . - . ; p = . ), serum creatinine (or, . ; % ci, . - . ; p = . ), and serum lactic acid (or, . ; % ci, . - . , p = . ) were associated with favorable outcomes, respectively. however, only higher body temperature as a clinical parameter and the level of serum lactic acid as a laboratory parameter were significant predictors of favorable outcomes in multivariate analyses; the or were . ( % ci, . - . ; p = . ) and . ( % ci, . - . ; p = . ), respectively. conclusions. initial body temperature and the level of serum lactic acid were two most important clinical and laboratory prognostic factor in nearly drowned patients. the outcomes were not affected by the degree of initial hypoxemia. to determine the use of automated external defibrillators (aed) and manual defibrillators deployed in the various hospital wards (unmonitored areas) in a university hospital. a prospective study was performed according to utstein style of all cardiac arrests occurred in the hospital during the first months after the implantation of a new protocol of care for hospital cardiac arrest. because of this plan automated external defibrillators were located for hospital wards and common service areas (radiology areas, outpatients, …) where one would expect a lower incidence of cardiac arrests, according to the risk map elaborated previously. in areas of greatest risk manual defibrillators previously existed. all resuscitation attempts in these areas were analyzed, excluding the emergency department because of a separate protocol against the rest of the hospital. special attention was given to the use of aeds by wards staff before the arrival of resuscitation team. also a comprehensive volunteer training program was designed, but it began after the analyzed period was finished. results. during the first months we collected a total of pcr in hospital wards and public areas, with a median age of years and predominantly male ( patients). the most common origin was respiratory ( patients) followed by cardiac ( patients). the most frequent rhythm detected was non-shockable ( patients), only in was shockable and unknown in . before the resuscitation team arrival only two patients had been manually defibrillated and were never used the new aeds. conclusions. the aeds provided in the hospital were completely useless in the first months after placement, probably due to the lack of a comprehensive training plan associated to the population goal. methods. descriptive longitudinal study. patients were studied by encephalic death, as potential donors of organs, alerted to the network of regional transplant (cdtot), by units of intensive care, for months, in barranquilla's city. it was applied qualifying each of the variables in agreement to the vital opposing signs and biochemical tests brought in this moment. . . % of the subjects were male; the average of age was . years (±sd: . ). the values of blood sugar, sodium, osmolaridad, tonicidad, po , fc, pam, and glasgow, determined a score of , qualification that there had patient with encephalic death with the scale mbcm, as a test of certainty of the scale to diagnose encephalic death in total absence of reflections of stem. conclusions. there is recommended the application of mbcm's scale to every neurological patient by diagnosis of encephalic death in proof of certainty, in absence of others. by the high specificity of the already demonstrated scale there is recommended that scores lower than they should restate the qualification. a score of is an encephalic death in absence of reflections of stem. grant acknowledgment. clínica general del norte-cdtot introduction. prospective analysis of tracheostomies performed in patients admitted to a neurotrauma icu, the reasons for its implementation, and intraoperative complications in the first week. methods. all patients admitted to the icu of neurotrauma, which underwent a tracheostomy after admission. data were collected: affiliation, cause of admission, average stay, cause for realization of tracheostomy, tracheostomy time delay from its indication, place of performance of the procedure (icu or operating room), perioperative complications (event at transfer to operating room or during surgery: hypoxia, hypotension, arrhythmia, bleeding, premature extubation, false cannulation, cardiac arrest, pneumothorax or death), and postoperative complications in the first week (bleeding, difficulty in changing cannula, stomal infection, pneumothorax, death). introduction. the s- b protein is a brain-specific protein release from astroglial cells into the circulation after traumatic brain injury (tbi). researches indicate that the s- b serum level could be a useful indicator of tbi severity, however there is not evidence enough about the role of s- b in nonsevere head trauma. the hypothesis that s- b is a useful screening tool to detect brain injury in patients with a normal level of consciousness after a head trauma was tested. a total of patients with the diagnosis of mild tbi without decrease of consciousness (according to the gcs) with at least one neurological symptom or finding like amnesia, headache, dizziness, convulsion and vomits, were prospectively included. we recorded the clinical data on admission and a blood sample before h after tbi, for s- b inmunoluminescence analysis. a routine cranial computed tomography scan (ct) was obtained within h after the injury (categorized in normal or pathological). the diagnostic properties of s- b serum levels. lg/l, for prediction of intracranial lesions revealed by ct were tested with receiver operating characteristic (roc) analysis. seventy of the patients ( . %) were men, with a mean (sd) age of . ( . ) years (range, - years). a total of patients ( . %) had intracranial lesions. serum s- b levels were significantly higher in patients with intracranial lesions than in the remaining patients. the average value of the protein in patients without intracranial lesion was . lg/l with a ci % ( . - . lg/l), and in those with pathological findings in ct was . lg/l with a ci % ( . - . lg/l). significant differences were found between levels of s b protein and the presence of pathological findings in the ct (p = . ) (fig. ) . the roc curve analysis showed that s b protein is a useful tool to discriminate the presence of intracranial injury in ct (auc, . , % ci, . - . , p \ . ). s b analyses with a cut-off level of . lg/l showed a sensitivity % but a specificity . %. we evaluated different cut off values and in our series, the best cut off of the s b protein is at . lg/l with a sensitivity of % and specificity %. (fig. ) conclusion. determination of serum protein s- b is a useful biochemical indicator of brain damage in head trauma. our results show that an increase in the cut-off point of s- b to . lg/l increases its accuracy in the prediction of the existence of macroscopical lesions. key words. protein s- b, brain injury, minor head trauma, cranial computed tomography. critically ill patients with systemic inflammatory response syndrome frequently suffer muscle weakness due to critical illness myopathy (cim) and polyneuropathy (cip). several in vitro studies have shown that the cause of muscle weakness is a loss of membrane excitability accompanied by membrane depolarization [ ] . objectives. we investigated membrane polarization and excitability parameters in muscle and motor nerve in vivo within the first week after intensive care unit (icu) admission. methods. the study was approved by our local ethics committee. patients with sofa scores c on consecutive days underwent nerve conduction studies including direct muscle stimulation to categorize patients as icu-control, cim-(dmcmap \ mv) and/or cippatients (reduced snap amplitude) within the first days after icu admission. to assess excitability parameters we recorded stimulus-response behaviour, threshold electrotonus, current-threshold relationship and recovery cycle from abductor pollicis brevis muscle following stimulation of the median nerve [ ] . data are shown as median and %/ % percentile. conclusions. we describe for the first time that critically ill patients in general show muscle-and nerve membrane depolarization, whereas patients later suffering from muscle weakness due to cim or cim/cip feature additionally reduced membrane excitability. this suggests that membrane depolarization in critically ill patients is caused by energy failure leading to dysfunction of the na-k pump, the motor of membrane repolarisation-whereas reduced membrane excitability in cim or cim/cip needs an additional dysfunction of voltage gated sodium channels for example occurring in the presence of endotoxins [ ] . in intensive care patients with central nervous system (cns) disease, the systemic inflammatory response syndrome (sirs) criteria are often unreliable as a basis for identifying the inflammatory process. even with the presence of some infection they could be signs of the diencephalons-catabolic syndrome. diencephalons-catabolic syndrome like sirs constitutes of hyperthermia over °c, tachypnea of over per minute, tachycardia, and arterial hypertension. thus, sirs symptoms may occur after antibacterial treatment even if there is no infection or inflammation. we suggest a more precise method which could help to avoid the excessive antibacterial therapy and to control it in patients with cns disease-a procalcitonin test. objectives. reduce the use of wide specter antibiotics makes the control over antibacterial therapy in patients with cns diseases more precise; reduce the number of complications related to unnecessarily long antibacterial treatment. after obtaining the informed concern, in our investigation we included patients with different neurological disorders, who had recently transferred neurosurgical operations. all of them demonstrated sirs symptoms on different postoperative terms. when sirs symptoms occurred, we checked the level of procalcitonin in the patient's serum by a semi quantitative method on a disposable brahms pct-q system. the procalcitonin level was determined against a color scale. procalcitonin level over . ng/ml ( patients) considered a sign of infection and in such cases we prescribed antibacterial treatment , mg of selenase for - days. if the test result was negative ( patients) we repeated it in h and in cases with the same results, no antibacterial treatment was administered even if there were sirs symptoms. if pct-q test was negative patients were sedated (fentanyl . - . lg/kg/h and clonidine . - . lg/kg/h) to achieve autonomic stability and attenuate clinical manifestation of sirs. we had not observed any cases of sepsis in both groups of patients. by mince of pct, we had managed to reduce the quantity of wide specter antibiotics, used in neurosurgical patients for . %. conclusions. procalcitonin test in neurosurgical clinic let us determine the necessity of antibacterial treatment reduce the use of wide specter antibiotics, medical costs and prevent the forming of polyresistant infection. l. combe , r. appleton , c. gilhooly , j. kinsella university of glasgow, department of anaesthesia and critical care, glasgow, uk intensive care unit-acquired weakness (icuaw) is increasingly recognised as a common complication of critical illness with potentially prolonged debilitating sequelae. the estimated incidence is % in patients with sepsis, multi-organ failure or prolonged mechanical ventilation [ ] and suggested risk factors include: the systemic inflammatory response syndrome (sirs), sepsis, higher severity of illness, hyperglycaemia, renal replacement therapy and parenteral nutrition. objectives. the aims of this study were to determine the incidence, risk factors and outcomes for patients diagnosed with icuaw in glasgow royal infirmary's (gri) icu. the study was undertaken in two parts, firstly as a case-control study [matched for age (within years), sex and admission apache ii score (within points)] and secondly by comparing identified cases of icuaw to a -month cross-sectional sample ( / / - / / , patients) of gri's icu patients. data for both parts of the study was obtained from two electronic databases, wardwatcher and carevue. carevue was searched to identify patients with icuaw and wardwatcher was used to identify the controls. data collected included: patient and illness characteristics, severity of illness scoring, organ support and treatments provided, laboratory results and outcomes. minitab software was used for statistical analysis. conclusions. the incidence of icuaw was very low, we hypothesise this to be explained by the absence of systematic evaluation of patients for icuaw. the risk factors and outcomes for icuaw were consistent with some of the published literature. prospective study is now planned to systematically evaluate this condition. with increasing age, comorbidity, and socioeconomic deprivation being associated with higher risk pregnancies, there comes a potential higher risk of complications. neurological and neurosurgical complications, which can be particularly devastating during the peripartum period, include those due to medical conditions of pregnancy (hypertensive disease, sepsis, thromboembolic disease, hypoxic-ischaemic brain injury), iatrogenic complications secondary to anaesthetic or obstetric interventions, incidental illness or injury (pharmacological alterations, trauma, tumour), and deliberate self-harm and violence. objectives. to ascertain the frequency of neurocritical care admissions in the west of scotland, the nature of the admission diagnoses, the impact they have on our service (length of stay), and maternal and foetal outcome. methods. using the scottish intensive care society audit group wardwatcher patient database, female patients aged - years old who were admitted to the neurocritical care unit were identified (january -december ). we manually reviewed the electronic admission note for each of these women in order to gain diagnoses; a targeted case note analysis ensued. within the month study period there were a total of admissions to neurocritical care, of whom fulfilled the age and gender criteria; admissions ( . % of total) were for neurological complications in the peripartum period. the age range was to years (median years). three women ( %) were intrapartum ( - weeks gestation) at the time of their admission, and three were postpartum ( day- months). half of admissions were due to incidental illness or injury, a third to pregnancyrelated medical complications, and one case was iatrogenic in nature. length of stay in icu was to days (median . days). one patient sustained a residual facial nerve weakness and deafness. conclusions. this survey provided insight into the incidence and nature of pregnancyrelated pathology requiring acute referral to a regional neurosciences centre. as highlighted in other surveys, there may be many more peripartum patients with neurological complications who are cared for in general critical care units, and do not require admission to a tertiary referral centre [ ] . further work is underway to ascertain the true numbers of neurological complications of pregnancy countrywide. our approach represents a paradigm for the continuing audit of pregnancy-related critical care resource use in scotland. introduction. hypertonic saline has an osmotic effect on the brain because of its high tonicity and ability to effectively remain outside the blood-brain barrier. there may be a minimal benefit in restoring cerebral blood flow, which is thought to be mitigated through local effects of hypertonic saline on cerebral microvasculature. most comparisons with mannitol suggest almost equal efficacy in reducing icp but not compared their effects on eeg. objectives. we aimed to compare the effects of % mannitol, % or % hypertonic saline on hemodynamic parameters, intracranial pressure and electroencephalography in experimental head trauma. bilateral craniotomy were carried out in the parietal region and head trauma was applied for all rabbits. the rabbits were randomly divided into four groups. in group i rabbits were only observed. in group ii: % mannitol, in group iii: % hypertonic saline and in group iv: % hypertonic saline was administered intravenously to achieve similar osmolar load. electroencephalography, mean arterial pressure, heart rate, intracranial pressure were recorded before trauma and and min after trauma. results. increased intracranial pressure was significantly decreased by mannitol, and % hypertonic saline solutions at the end of study (p \ . ). but intracranial pressure values of mannitol and % hypertonic saline groups were lower than the other groups (p \ . ). the electroencephalography scores decreased after trauma in all groups (p \ . ). at end of the study, and % hypertonic saline groups had similar electroencephalography scores with pretrauma scores (p [ . ). the mean arterial pressure and heart rates increased after trauma in all groups (p \ . ). mean arterial pressure values were found lower only in mannitol group at end of the study (p \ . ). our study showed that when used in intracranial hypertension treatment, % hypertonic saline solution is as effective as mannitol, and preserves hemodynamic parameters, and normalizes traumatic electroencephalography abnormalities better than mannitol. objectives. to identify the causes of new onset seizures in patient admitted in medical icu. methods. all the patient admitted in icu and who had new onset seizures were evaluated. the patients were evaluated for metabolic profile. imaging (ct/mri) was done whenever needed. patients with preexisting seizure history were excluded from study. . ( males, females) patients, who had first seizure during hospitalization in icu were included. patients had generalised and one had focal seizures. patients had metabolic abnormalities. ( . %) had evidence of hepatic encephalopathy. ( . %) had only hepatic encephalopathy while rest had associated uremia, hyponatraemia, hypophosphatemia and hypomagnesemia. out of patients, who had renal failure, had evidence of uremia while rest had associated hyponatraemia or hypophosphatemia. only one patient had evidence of hypocalcemia. imaging was done in patients. ( %) had abnormal ct scan results. ( . %) had intracranial hemorrhage, ( . %) had infarct, ( . %) had brain metastasis, had evidence of hydrocephalus and one each had evidence of extradural hemorrhage and tuberculoma. csf analysis was done in ( . %) patients. ( . %) had evidence of tuberculosis and ( . %) had evidence of pyogenic infection. to study the role of various investigations and ct in evaluating these patients. all patients admitted with new onset seizures within h prior to presentation were included. all the patients were questioned and an attempt was made to assign an electroclinical syndrome to seizure. patients were evaluated for metabolic profile, neuroimaging. csf examination was done in those who had persistently altered mental status, infectious symptoms and fever. results. patients were admitted ( . % of total patients who came to emergency) with history of new onset seizures. . % patients were diagnosed to have acute symptomatic seizures and were placed in ilae category . and three patients were placed in ilae category of remote symptomatic seizures. the cause of seizures was established in ( . %) patients and remained unestablished in ( . %) patients. ( . %) patients were diagnosed to have neurocysticercosis. other important causes were acute infarct, uremia, hyponatremia, hypernatremia, viral encephalitis, post partum eclampsia, pyogenic and tubercular meningitis. alcohol withdrawal seizures were seen in . % patients. metabolic derangements were seen in ( . %) patients. computed tomography was done in patients and % had abnormal findings. mri was done in patients and had abnormalities. conclusions. neurocysticercosis was found to be most common cause of seizure activity in our part of country. though metabolic derangement can cause significant proportion of new onset seizure patients routine imaging of brain should be performed in patients with new onset seizures. work environment and organisational issues: - subjective and objective research into the working conditions and their effect on the health and safety of people working in icu, focusing mainly on the natural factors of temperature, humidity, ventilation, lighting and noise (part ) n. karachalios , e.c. katsilaki , d. sfyras general hospital of lamia, icu, lamia, greece the aim of the project is the subjective and objective investigation of the conditions of work and the relation repercussions on the health and safety of people working in the icu, focusing mainly on the natural factors that are likely to cause the sick building syndrome. for this purpose a protocol of research in two phases has been planned. the first included objective measurements, with the use of suitable equipment, of the natural factors of temperature, humidity, ventilation, lighting and noise. the second phase included the subjective estimation of the working people about their own health and conditions of their work, in the particular area of the hospital with the use of substantiated anonymous questionnaire. after the subjective and objective study and analysis of questionnaires and measurements of natural factors, we found that the medium temperature of the icu was °c. the mean relative humidity of the icu was % (highest . % and lowest . %). the mean ventilation rate of the icu was m /h (highest . and lowest \ . m /h). the mean sound pressure was . db (highest and lowest . db). the average lighting was . lux ( lux lowest and lux highest). the objective data seem to keep pace with the subjective opinions of the working people, as they were impressed in the questionnaires of subjective estimate. the objective data were compared with the subjective. the results of the research were also compared with data from the existing bibliography and current legislation, leading to a line of conclusions. ( ) insufficient and bad quality ventilation. ( ) the existing temperature of the environment contributes to the appearance of sick building syndrome. ( ) the working environment is noisy. ( ) the environment of work has problematic or insufficient lighting. ( ) the icu under study is a building area which can be characterized as ''sick'' if immediate action is not taken. background. up to % of critical care nurses test positive for (symptoms of) post traumatic stress disorder (ptsd) [ , , ] . it is assumed that these symptoms are caused by professional involvement in life-threatening events [ ] . in a sample of intensive care nurses, we investigated which work related incidents were perceived as most distressing. method. in interviews, nurses ( % female) were asked to memorize and tell about their most traumatic work related event. all interviews were recorded. after verbatim transcription, the 'most critical events' were extracted and categorized bij two independent psychologists. . none of the nurses reported major life-threatening events such as trauma-related injuries, massive bleeding or seeing patients die as their 'most critical incident'. conclusion. not the major life-threatening events but relatively 'normal work related events' under unusual circumstances are mentioned as most critical by nurses. in contrast to major life-threatening events, these 'normal events' are usually underestimated by colleagues, and thus potentially compromise peer-support. a care bundle refers to evidence based interventions and information grouped together to improve outcomes and consistency of provided care [ , ] . at the icus charge nurses and intensivists as shift leaders are responsible for daily management of unit activities. several immediately made decisions by shift leaders are made under time pressure and high information load with inadequate information. though we have evidence of structure and process based factors such as material and human resources, admission and discharge decisions or bed utilization, the support for information transfer and integration is poor in organizational decision-making concerning these factors. objectives. to identify immediate information needs of charge nurses and intensivists during the management of daily activities at the icu and evaluate how necessary this information is for their decision-making. from september to november , all charge nurses (n = ) and intensivists (n = ) of university affiliated icus providing comprehensive care in finland were surveyed with an on-line questionnaire using statements. the questionnaire was developed based on our previous observation study and statements of our survey regarded information needs related to the icu care activities. a rating scale from to (completely unnecessary-absolutely necessary) was used to assess the necessity of the information. for each statement, a response with mean or over was regarded as necessary information for immediate decisions. results. the response rate was . % (charge nurses . %, intensivists . %). the working experience varied from to years (mean . , sd . ). over % of respondents worked as a shift leader once a week or more often. statements of were valued as a necessary (mean [ or more) for immediate decision-making. absolutely necessary information (mean [ or more) for immediate decision-making were assessed related to the statements. these statements concerned isolations, mechanical ventilation, admissions and discharges, special treatments, patient's condition, and scheduled dates or times for surgery or other procedures. conclusions. both icu charge nurses and intensivists identified several information needs that are crucial for immediate decision-making during the whole icu care process. information needs of the shift leaders differed and they were strongly connected to the needs of one's professional requirements. an integrated overview and summarization of immediately needed information-a care bundle for organizational decision-making-at the icus is highly needed for icu shift leaders. the common interests of both professionals, charge nurses and intensivists, should be emphasized when new technology-based systems are developed. background. the nursing shortage is an international problem that is expected to worsen in the coming years. studies show that one of the main reasons nurses leave the profession is their dissatisfaction with their work environment. structural empowerment and nurse-physician collaboration are two elements of the nurses' work environment that are potentially related to one another according to kanter's theory ( ) . in addition, a nurse's clinical specialization has been found to influence perceptions related to these two concepts. to examine the level of perceived structural empowerment, the perceptions of nurse-physician collaboration and the relationship between these two variables, among intensive care unit (icu) nurses and general ward nurses in israel, and to compare the groups. a descriptive, correlational, comparative study design was used on a sample of icu nurses and nurses from internal medicine and general surgery wards in a large university hospital in israel (response rate %). a three section, self administered questionnaire was used to measure the study variables: the condition of work effectiveness scale-ii (cweq-ii), the collaboration with medical staff scale (cmss) and demographic-professional background. results: perceived structural empowerment was found to be moderate (m = . , sd = . , range = - ). nurses tended to agree that there was nurse-physician collaboration (m = . , sd = . , range = - , = strongly disagree, = strongly agree). a correlation was found between structural empowerment and the nurse-physician collaboration (r = . , p \ . ). a significant difference was found between icu nurses and general ward nurses on their perceptions of nurse-physician collaboration (t ( ) = - . , p \ . ; general wards: m = . , icu: m = . ). no significant differences were found between nurse specialization on perceived level of structural empowerment. conclusion. nurses in this study tended to agree that there was nurse-physician collaboration on their unit/ward. nurses who perceived themselves as having a higher level of structural empowerment, felt that there was a higher level of nurse-physician collaboration. general ward nurses had more positive perceptions about nurse-physician collaboration on their ward as compared to icu nurses. no difference was found between the two groups on the level of structural empowerment. recommendation. the findings of this study can be used as the basis for the design of interventions, aimed at enhancing structural empowerment and nurse-physician collaboration, in order to improve nurses' work environment, as one of strategy to decrease the nursing shortage. further study of additional hospitals in the country is also recommended. teams have expanded and in some hospitals h cover has been instituted. researchers are questioning the validity of outreach services and its impact on patient outcomes. as cco has been viewed as the panacea to all problems, data collection and analysis is fundamental in proving its financial and clinical benefits. objectives. this comparative study aims to evaluate retrospective data from month in and month in . data does not encapsulate patient outcomes; it will compare frequency of referrals and interventions. this data provides an indication to the extent cco has participated in the care of the acutely ill over a given time period. methods. data was collected from the d medicus database collating intervention data. analysis occurred using key interventions using excel software conclusions. whilst the validity of services has been questioned, the data itself indicates that more patients are referred and frequency of interventions has increased. various system changes occurred during this time period such as a change of mews trigger scores, the advent of h cco and courses such as alert and survive sepsis were introduced into the basic training of staff. it must be noted that the intention in the uk for cco was a service that empowered staff through education to undertake this care themselves; therefore the increase in interventions could indicate that the educational approach hasn't made progress. although the study compares interventions, an increase in the type of interventions was also noted such as ward based cco supervised cpap and establishing a picc line service. therefore this highlights the changing application of interventions. further analysis is required to look at the appropriate skills required for the delivery of safe care to the acutely ill in the ward environment. whilst ward staff are increasingly under resourced, both in skills and manpower, cco do provide the skills, knowledge and time to meet the shortfall in safe timely care. introduction. working as a critical care nurse involves situations where teamwork is essential and rapid, effective communication is of importance [ ] . the education to become a specialist icu nurse gives skills and knowledge to manage patients who are critically ill with rapidly changing conditions [ ] . experimental research is one way of contributing to the acquisition of such knowledge. to describe how icu nurses may contribute and perform in the experimental research process, an environment usually unfamiliar to them. we describe our experiences with regard to clinical contribution and our subjective evaluation of involvement in animal experimental research. method. three icu nurses in a swedish hospital were asked to participate in a research project investigating myocardial metabolism in porcine models of shock. the tasks were anaesthesia and pain management, assisting with catheter insertion and haemodynamic monitoring the pigs during the process results. although the situation was new, the nursing role and function in the team were at once similar and different to the daily work situation in the icu. one major skill learnt was the rigour of experimental measurements and sources of error, which is sometimes neglected in clinical care. being able to observe changes due to shock in a controlled setting, we improved our ability to critically 'think ahead' in anticipation of clinical deterioration [ ] . our first-hand experiences at the animal experimental laboratory allayed many anxieties and misconceptions with this type of research. conclusions. the critical care environment demands skills such as the ability to accurately define and change priorities rapidly, good communication and teamwork [ ] . we believe that the experimental research setting is one way of enhancing this ability. in these units patients condition may change rapidly and they may need close inspection as well as emergency response. early warning scoring (ews) system may make early recognition of and response to bad condition possible by observation based on systematic parameters. ews was developed as a simple scoring system to be used at ward level utilizing routine observations taken by nursing staff. ews is based on five physiological parameters; systolic blood pressure, pulse rate, respiratory rate, temperature and avpu score (alert; reacts to voice; reacts to pain; unresponsive). objectives. the aim of this study was to evaluate ews among patients admitted to pacu. methods. ews parameters were recorded four times from patients after their admission to pacu. the first record was taken during the first admission to pacu (ews ), the second (ews ) after min, the third after (ews ) and the fourth record after min. the correlation between variables like differences of four ews, patients age, the asa score, duration of operation were statistically examined. early treatment and recognition of sepsis is a stated aim of the surviving sepsis campaign [ ] but in busy clinical environments the delivery of antibiotics and fluids can often be delayed. we describe the implementation of an audit proforma, based on the survivesepsis.org [ ] resuscitation bundle, as a tool to deliver six aspects of management within h of recognition sepsis. . improve the early recognition and treatment of sepsis in acute medical patients. . provide a sustainable change in the management of septic patients . improve mortality and length of hospital stay methods. the proforma consist of six treatment management steps, based on the survivesepsis.org ''septic six'': oxygen, blood cultures, antibiotics, lactate, iv fluids, strict fluid management. it is triggered by patients satisfying two or more of the systemic inflammatory response syndrome criteria. all management steps should be implemented within h of the trigger time stated on the form. the forms are collected and analysed every month and the results are displayed for staff working on the medical admissions unit and accident and emergency. a total of forms have been collected, % diagnosed with severe sepsis. the progress on all six parameters is shown below. over the initial seven month period we have demonstrated a sustained improvement in the rapid delivery of all six of the management parameters. introduction. the early goal-directed resuscitation has been shown to improve survival in patients presenting with septic shock. a recent systematic review demonstrated the inability of central venous pressure (cvp) to predict the hemodynamic response to fluids infusion, and it should not be used to make clinical decisions regarding fluid management in critical patients. the clinical implication of this fact in septic shock is not well-known. objectives. the aim of this study is to determine if the resuscitation with fluids guided by cvp has clinical implications in patients with septic shock. post-hoc analysis of a patients' cohort with septic shock admitted in the medical intensive care unit since june to june . all of them were treated on basis of a bundle for severe sepsis management. chi-square analysis was used to compare categorical data. continuous data were compared using student's t test. we used multiple logistic regression model to assess the association between the independent variable and mortality, after adjustment for possible confusing factors (we considered variable to be confounding if the estimate of the coefficient changed by more than %). eighty-five patients were studied. % were male. their average age was ± and % had previous chronic diseases. severity scores: apache ii ± , sofa ± and % of patients had multiorganic dysfunction. infectious focus was respiratory in %. cvp mean was ± mmhg, scvo ± % and the mean amount of fluids provided was ± cc. % of patients needed mechanical ventilation. hospital-stay middle was days ( - ) and days in icu conclusions. in our patients' cohort with septic shock treated under the basis of the early goal-directed resuscitation, the volume of fluids infused was associated independently with mortality. a lower fluid administration in the resuscitation probably could be caused by the early reach of a high central venous pressure. blinding of study interventions is necessary to prevent bias in randomized controlled trials (rct). since normal saline and % albumin are packaged in bags and bottles, respectively and they have different color and texture, a blinding procedure is necessary to ensure the fluids appear identical for comparative rcts. objectives. to describe the blinding procedure and evaluate sterility and stability involved in the transfer and storage of study fluids in the precise pilot rct. a standard operating procedure for concealment, meeting pharmacy guidelines and good manufacturing practices was developed by the manufacturing pharmacist at the coordinating centre and used by all participating sites. fluids were transferred with aseptic technique into identical ml bottles under a sterile hood by the pharmacy or transfusion medicine technician then covered with an opaque wrapping. average time to transfer of study fluids from their original packaging was recorded to understand labor involved with creating each study fluid package. yellow intravenous tubing was manufactured to also conceal the fluid color. six blinded bottles of normal saline and % albumin from the participating centers were stored at room temperature for at least months. cultures of the fluids using blood culture media and/or endotoxin levels (measured by commercial assay) were obtained to document sterility of the study fluids. protein electrophoresis was used to assess albumin stability. results. transfer of the study fluids was the responsibility of the research pharmacist/ technician and blood bank at and sites, respectively. average time to transfer containers of normal saline and % albumin into bottles was ± and ± min, respectively. sterility (culture negative and/or endotoxin undetectable) of study fluids was confirmed from all bottles of normal saline and albumin that underwent testing. protein electrophoresis of albumin samples showed a single band suggesting no degradation of albumin during transfer and storage. conclusions. the standardized blinding procedure developed for transfer of study fluids in this pilot rct confirmed sterility and stability of our study fluids for months. these data are important when considering the length of allowable storage time for these study fluids. due to the resources and time involved with the transfer of these fluids for individual sites, this transfer method needs to be incorporated into budgeting and may not be feasible in the context of a large rct. grant acknowledgment. the precise pilot rct was funded by a grant from canadian blood services. covidien, singapore, singapore, yong loo lin school of medicine, national university of singapore, biostatistics unit, singapore, singapore introduction. the surviving sepsis campaign recommends a -h resuscitation bundle and a -h management bundle to improve outcomes in severe sepsis. compliance with and relevance of these recommendations to asian intensive care units (icus) are unknown. objectives. the primary objective of the present study was to assess the compliance of asian icus and hospitals to these bundles. the secondary objectives were to evaluate the impact of compliance on mortality, and the organisational characteristics of asian hospitals which are associated with higher compliance. methods. this was a prospective observational study of patients with severe sepsis who were admitted to the participating icus in july . we recorded the organisational characteristics of participating centres, the patients' baseline characteristics, and the achievement of targets within the resuscitation and management bundles. results. sixteen countries and icus participated, enrolling patients. hospital mortality was . %. achievement rates for the bundle targets were: lactate measurement, . %; blood cultures, . %; broad-spectrum antibiotics, . %; fluids ± vasopressors, . %; central venous pressure, . %; central or mixed venous oxygen saturation, . %; low-dose steroids, . %; drotrecogin alfa, . %; glucose control, . %; lung-protective ventilation, . %. compliance rates for the entire resuscitation and management bundles were . and . % respectively. on logistic regression analysis, achievement of the targets for blood cultures, antibiotics, and central venous pressure independently predicted decreased mortality. high-income countries, university hospitals, icus with an accredited fellowship programme, and surgical icus were more likely to be compliant to the resuscitation bundle. conclusions. compliance to the resuscitation and management bundles is generally poor across asia. given the resource limitations in asia, the most appropriate strategy to improve outcomes in severe sepsis may be to concentrate on ensuring early administration of antibiotics after blood cultures, and appropriate fluid therapy. cerebral oxygen desaturation predicts cognitive decline and longer hospital stay after cardiac surgery monitoring brain oxygen saturation during coronary bypass surgery: a randomized, prospective study the work is supported by departmental sources. clinical features and prognosis of organizing pneumonia pre-senting as acute respiratory failure in icu reference(s). . webster nr. ventilation in the prone position prone position in acute respiratory distress syndrome effect of prone positioning on the survival of patients with acute respiratory failure acute effects of upright position on gas exchange in patients with acute respiratory distress syndrome this study was funded by arjo international ag, florenzstrasse d metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports longterm propofol infusion and cardiac failure in adult head-injured patients mild hypothermia alters propofol pharmacokinetics and increases the duration of action of atracurium intermittent haemodialysis versus crrt for arf in the intensive care unit dialysis dose in acute kidney injury: no time for therapeutic nihilism cirrhotics admitted to icu, and when added to the liver-specific scores of meld or ukeld, improves their respective predictive value intensive care, london, uk, royal free hospital epidural anesthesia, hypotension and changes in intravascular volume intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery surrogate designation: can we trust our relatives? does chest physical therapy work? physiotherapy in intensive care: towards an evidence-based practice fisioterapia no paciente sob ventilação mecânica this research was supported by grants from the following brazilian funding agencies/programs: cnpq, capes, fapesc and unesc readmission to surgical intensive care increases severity-adjusted patient mortality physiological scoring systems and audit predicting death and readmission after intensive care discharge a case-control study of patients readmitted to the intensive care unit severity of illness and risk of readmission to intensive care: a meta-analysis a comparison of admission and worst -h acute physiology and chronic health evaluation ii scores in predicting hospital mortality: a retrospective cohort study learning from the past to inform the future-a survey of consultant nurses in emergency care assessing emergency nursing competence post-traumatic stress among swedish ambulance personel levels of mental health problems among uk emergency ambulance workers partial and full ptsd in brazilian ambulance workers: prevalence and impact on health and on quality of life ambulance personnel and critical incidents impact of accident and emergency work on mental health and emotional well being artemis health institute, director, critical care, pulmonology and sleep medicine, gurgaon, india, artemis health institute, nursing, gurgaon, india reference(s) the australian incident monitoring study in intensive care: aims-icu. the development and evaluation of an incident reporting system in intensive care adverse events in critical ill patients ministry of health and social policy communication: a key factor in the patient safety? anemia of the critically ill: acute anemia of chronic disease impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient high dose recombinant human erythropoietin stimulates reticulocyte production in patients with multiple organ dysfunction syndrome: the journal of trauma: injury, infection and critical ca to the staff of the critical care department, faculty of medicine injury severity and quality of life: whose perspective is important? quality of life and persisting symptoms in intensive care unit survivors: implications for care after discharge variations in health-related quality of life in critical patients funded in part by fogarty international center nih grant no. d tw - and clinical research institute-fundacion valle del lili glasgow coma score, use of mechanical ventilation and vasoactive agents, and the occurrence of severe sepsis (according to bone's criteria- ). the causes of admission were divided as: ischemic stroke, hemorrhagic stroke, subarachnoid hemorrhage, status epilepticus, traumatic brain injury, elective neurosurgeries, and miscellanea. the foci of infection, microbiological data and bacteremia were analyzed from septic patients. numeric data were expressed as median and interquartiles, while categorical data were calculated as percentage. univariate and multivariate (logistic regression) analysis was carried out to point factors associated with hospital mortality. results. we included patients, with median age years (iq range - ) and % were male %) patients, while it occurred during icu stay on ( %) patients. hospital mortality was associated with age, the admission cause (higher for hemorrhagic stroke, traumatic brain injury and status epilepticus), apache ii score, glasgow coma score and severe sepsis on the univariate analysis cnpq perioperative factors associated to higher mortality in patients admitted to the neurological intensive care unit (nicu) immediately after brain tumor (bt) resection saldívar umae (high-specialty medical unit no ) el bajío, imss and nicu, hraeb (high-specialty regional hospital of el bajío) anaesthesiology and intensiv care medizin anaesthesiology and intensive care unit charité universitätsmedizin-berlin, department for anesthesiology and intensive care medicine after approval of the local ethics committee, the pdr icg was measured within h post injury (day ) using the non-invasive limon system (pulsion medical systems of pdr icg to supranormal values higher sofa scores were indirectly associated with lower pdr icg values, particularly for sofa scores[ . when patients were grouped by icu length of stay (\ , c days, corresponding to the mean icu los of the german trauma registry), logistic regression analysis identified pdr icg consumables were provided by pulsion medical systems influence of apoe polymorphism on cognitive and behavioural outcome in moderate and severe traumatic brain injury genetic variation of the apoe promoter and outcome after head injury effects of apolipoprotein e genotype on outcome after ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage the association between apoe « , age and outcome after head injury: a prospective cohort study decreased cerebrospinal fluid apolipoprotein e after subarachnoid hemorrhage correlation with injury severity and clinical outcome « association of ventilation rates and co concentrations with health and other responses in commercial and industrial buildings « sensitivity to noise, personality hardiness, and noise-induced stress in critical care nurses recommended lighting level for offices » the chartered institution of « sick building syndrome, sensation of dryness and thermal comfort in relation to room temperature in an office building: need for individual control of temperature silent misery: most severe critical incidents post traumatic stress disorder in the emergency room: exploration of a cognitive model trauma exposure and post-traumatic stress disorder in intensive care unit personnel increased prevalence of post-traumatic stress disorder symptoms in critical care nurses drivers of quality in health services: different worldviews of clinicians and policy managers revealed systems thinking, system dynamics the fifth discipline: the art and practice of the learning organisation the development of system dynamics as a methodology for system description and qualitative analysis finnish funding agency for technology and innovation nursing activities score tradução para o português e validação de um instrumento de medida de carga de trabalho de enfermagem em unidads de terapia intensiva: nursing activities score (nas) nursing activities score in the intensive care unit: analysis of the related factors the self-perceived health between medical-surgical and crit-ical care nurses in hungary deutsch , i. boncz , a. sebestyen , a. olah university of pecs faculty of health sciences a longitudinal study design was used to explore the self perceived health of inhospital nurses in acute care settings (surgery, casualty, internal medicine, intensive, coronary care, emergency room) in two hungarian factors predicting team climate, and its relationship with quality of care in general practice nurse working conditions, organizational climate, and intent to leave in icus: an instrumental variable approach critical care nurses' work environments: a baseline status report quality of practice in an intensive care unit (icu): a mini-ethnographic case study vasps/intv ). medicinska fakulteten, lunds universitet critical thinking and clinical decision making in critical care nursing assessing and developing critical-thinking skills in the intensive care unit gulhane military medical academy, haydarpasa training hospital, istanbul, turkey, gulhane military medical academy technology as a catalyst to transforming nursing care devices and desire: gender, technology and american nursing surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock division of pulmonary and critical care medicine, seoul, republic of korea, peking union medical college hospital, department of critical care medicine mai hospital, intensive care department, hanoi, viet nam, king saud bin abdulaziz university for health sciences, king abdulaziz medical city, intensive care department dr soetomo general hospital, department of intensive care republic of china, ripas hospital, intensive care unit surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock the surviving sepsis campaign: results of an international guideline-based performance improvement program targeting severe sepsis great differences in compli-ance with surviving sepsis campaign bundles surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock delayed diagnosis is associated with increased morbidity, mortality and cost in the icu. as the mortality rate of severe sepsis remains unacceptably high, a group of international expert developed guidelines in , termed the surviving sepsis campaign (ssc). the ssc group has introduced the ''sepsis care bundles surviving sepsis campaign guidelines for severe sepsis and septic shock implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality improving outcomes for severe sepsis and septic shock: tools for early identification of at-risk patients and treatment protocol implementation observational, prospective follow-up. patients who were admitted into the intensive care unit in university hospital complex a coruña (chuac) during the months of hospital mortality was surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock early goal-directed therapy in the treatment of severe sepsis and septic shock associated with decreased mortality translating research to clinical practice: a -year experience with implementing early goal-directed therapy for septic shock in the emergency department improvement in process of care and outcome after a multicenter severe sepsis educational program in spain duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock delta co (pvco -paco ) as a prognostic factor in septic shock septic shock using the new device inspectra : relation to macro-and microhemodynamic and outcome c. luengo , , f. vallée , c. damoisel , m. resche-rigon among the techniques assessing microperfusion, near infrared spectroscopy (nirs) gained interest. more than baseline sto values, the reperfusion slope after a vascular occlusion test (vot) nirs parameters, especially the reperfusion slope scvo or svo ); metabolic (ph, base excess and lactate) parameters were collected. microperfusion data consisted in: nirs (baseline sto , occlusion and reperfusion slopes (%/s), automated software); skin laser doppler microflow (baseline flow (tpu), peak flow (tpu) and slope during reperfusion (tpu/s), measured during and after a min vot. survivors (s) and non-survivors ] differed between s and ns at day . macro-hemodynamic and metabolic data did not differ between s and ns plan quadriennal ea svo does not predict fluid responsiveness in critically ill septic patients supported by msm research grant: replacement of and support to some vital organs years) were studied. apache ii and sofa score at study entry were (range: - ) and (range: - ) respectively. the septic syndrome was due to sepsis (n = ), severe sepsis (n = ) or septic shock (n = ). sites of infection included the lung reference(s). . ungerstedt u: microdialysis: principles and applications for studies in animals and man the pathophysiology and treatment of sepsis management of sepsis surviving sepsis campaign guidelines for management of severe sepsis and septic shock relation between muscle na + k + atpase activity and raised lactate concentrations in septic shock: a prospective study long-term continuous glucose monitoring with microdialysis in ambulatory insulin-dependent diabetic patients whether it is worth to correct acidemia by infusion of alkaline solutions is a matter of discussion. there are a number of evidences against the use of alkalinization therapy with respect to the benefits of reversing ph and the side effects of sodium bicarbonate infusion [ ]. nonetheless, as recently shown by means of an on line survey, % of critical care physicians administer base to patients with lactic acidosis mmol/l), animals were randomized to min of: a) sustained lactic acid infusion, a + b) sustained infusion + sodium bicarbonate, o) transient infusion, b) transient infusion + sodium bicarbonate. in the transient infusion (group o and b), at randomization lactic acid was replaced with normal saline. acid-base status and lactate levels were measured over time. in a number of animals phosphofructokinase (pfk) enzyme's activity was also measured. results. following lactic acid infusion blood lactate rose unnecessary use of alkali perturb acid-base status and lactate metabolism potentially overcoming metabolic adaptive strategies. reference(s). . boyd jh, walley kr. is there a role for sodium bicarbonatein treting lactic acidosis from shock? use of base in the treatment of acute severe organic acidosis by nephrologists and critical care physicians: results of an online survey strong ions gap (sig) quantifies unmeasured blood anions and it is calculated by the difference between strong cations and strong anions (all of them, dissociated in blood plasma) retrospective, observational study of all patients with septic shock as defined by the american-european consensus, admitted to the icu from arterial blood gases, albumin, lactate and electrolytes were obtained at admittance and h later; apache and sofa score, central venous saturation and lactate comparison of acid base models for prediction of hospital mortality following trauma forty-five sepsis patients [median age, (iqr, - ) years; admission saps ii, ( - ) pts; severest multiple organ dysfunction syndrome score interaction of vasopressin infusion, corticosteroid treatment, and mortality of septic shock comparing two different arginine vasopressin doses in advanced vasodilatory shock: a randomized, controlled, open-label trial lambert university of leicester, division of anaesthesia, leicester, uk blood samples were taken: at induction of anaesthesia, at and - h post-cpb. neutrophils were isolated, mrna extracted, dna cleaned and reverse transcribed supported by a grant from the association of anaesthetists of great britain and ireland, and the british journal of anaesthesia/royal college of anaesthetists secretoneurin (sn), a neuropeptide, is specifically expressed in endocrine elevated nucleosome levels in systemic inflammation and sepsis extracellular histones are major mediators of death in sepsis rd esicm asymmetric and symmetric dimethylarginines (adma, sdma) are protein-breakdown markers; both compete with arginine for cellular transport and are excreted in urine. moreover adma, sdma, their ratio (marker of adma catabolism), arginine, interleukin- (il- ), tumor-necrosis-factor-a (tnf-a), c-reactive-protein(crp) on day , , , , and at discharge in consecutive severely-septic patients were measured sdma were higher than normal, adma/sdma ratio was halved, arginine was low. adma was related to total sofa and arginine, inversely related to il- and crp; sdma was related to saps ii, sofa, blood urea, creatinine, arginine. adma/sdma ratio was inversely in non-survivors, creatinine, il- , tnf-a, crp and adma were stable, sdma increased, adma/sdma ratio remained low figure: time course of adma and sdma blood levels (mean ± standard error) during icu stay and the last icu day protein-hmgb- levels as predictors of outcome in patients with sepsis and septic shock hmgb as a predictor of organ dysfunction and outcome in patients with severe sepsis early low dcs counts may be correlated to disease severity and could predict fatal outcome. however, little is known about dc number in other shock than septic. objectives. to evaluate and compare the circulating dcs number in patients with severe sepsis, septic or cardiogenic shock. methods. in a prospective multicentric study ( icu), consecutive immunocompetent patients with severe sepsis (ss), septic shock, cardiogenic shock were included. peripheral blood dc counts, measured by flow cytometry, were evaluated and compared between the three populations at admission and h later. correlation to disease severity evaluated by clinical scores and day mortality was studied. results. patients were included (age ± years, male, sofa d . ± . , saps ii ± ): septic shock, severe sepsis and cardiogenic shock. mortality at d was respectively , and %. patients presented a sepsis associated to cardiogenic shock. at baseline and at day , a dramatic diminution in the numbers of total dcs either myeloid (mdcs) or plasmacytoid (pdcs), was observed in sepsis (severe sepsis or septic shock) compared to cardiogenic shock patients. no difference was seen between severe sepsis and septic shock patients (fig. ). we did not observe any correlation between the number of total dcs at admission or at day and severity of illness scores dc reduced number is a valuable marker of severe sepsis in shock and is not affected by hemodynamic changes. it could not be used as a prognostic marker in severe septic patients. preliminary results from a prospective study assessing the relationship between standard laboratory coagulation and global tests of clot-formation using thromboelastography in patients with fulminant hepatic failure v the routine use of international normalized ratio (inr) to establish the coagulation status in patients with fulminant hepatic failure (fhf) may be misleading. anecdotally, fhf patients, despite a significantly deranged inr, may display a normal or even hypercoagulable state, as recently shown, albeit in an extracorporeal setting, with frequently clotted circuits, despite raised pt we prospectively studied coagulation, demographic, survival and outcome measures of fhf patients (defined by de-novo liver failure, coagulopathy-inr [ . , and encephalopathy) admitted to the royal free hospital liver and/or intensive care unit(s) (icu), a tertiary referral centre in liver diseases and transplantation we present the standard clotting tests and teg results from (of a required ) patients currently enrolled, demonstrating variable degrees of encephalopathy and coagulopathy effect of norepinephrine on cardiac output and preload in septic shock patients apparent heterogeneity in splanchnic vascular response to norepinephrine during sepsis aggressive use of high-dose norepinephrine in the treatment of septic shock norepinephrine requirement is not an independent variable to predict outcome in severe septic shock patients aim. the aim of this study was to measure the level of ptsd among hungarian ambulance workers, and explore factors which can influence it.sample and methods. hungarian ambulance workers were involved to this crosssectional study ( ambulance drivers, ambulance nurses, and ambulance team leaders: medical doctors and ambulance officers). self filling questionnaire were used for data collection, including briere's trauma symptom checklist, and socio-demographic questions. chi square test, independent t test and variance analysis were used for comparison of variables.results. the average ptsd-points of ambulance workers was . there was significant association between level of ptsd and gender: women's average , men's average ptsd-points (p = . ). there were no correlations between level of ptsd and type of settlement, location of ambulance station and level of education. those who would need psychological support (p = . ), and those who had psychologically traumatic experiences in the last years have significantly higher ptsd-points (p = . ).conclusions. hungarian ambulance workers are exposed with many effects which can lead ptsd. professional psychological support is needed in order to cope with ptsd successfully.the results were presented and discussed in our weekly meeting on patient safety and healthcare for all icu personnel. by the end of this year all the recommendations will be implemented in our icu.conclusions. we improved the safety and quality of in hospital transportation of icu patients by performing a prospective risk analysis. bow-tie is a good instrument to identify health care risks. to determine the incidence of phrenic neuropathy associated with the catheterization of internal jugular and subclavian veins, without ultrasound support, in patients admitted to an icu. a prospective study was performed by following patients admitted in the icu between october and may . a normal neurography of both right and left phrenic nerves at the moment of their admission was the main inclusion criteria. after this baseline study, a new neurography was repeated weekly (chen and resman method, sinergy medelec), during their stay and at the moment of being discharge from icu. simultaneously, all vascular subclavian and internal jugular vein catheterization were registered. a final neurography and a fluoroscopy study were performed after being discharged from hospital. results. patients were included and two hundred and ten neurographies of both right and left phrenic nerves were performed. patients did not receive any vascular punctures in the cervical region during the follow up period, acting as control group. patients underwent a total of vascular catheterization, in subclavian vein ( . %) and in internal jugular vein ( . %). a phrenic neuropathy was diagnosed in patients. this represented an incidence of % ( / ) of phrenic neuropathy per patient and % ( / ) related to subclavian and internal jugular vein catheterization. in relation to patients without phrenic nerve injury who underwent subclavian and internal jugular vein catheterization, patients affected of phrenic neuropathy had longer mechanical ventilation time ( ± days vs. ± , p = . ) and longer average stay time in icu ( . ± days vs. ± , p = . ), although these differences have not statistical significance. we did not find significantly differences related to age ( ± vs. ± , p = . ) and apache ii index ( ± . vs. . ± . , p = . ) between both groups (wilcoxon two-sample test). we performed a control neurography of case patients after being discharged from hospital. we checked the cmap phrenic nerve reappearance after weeks and months of being diagnosed its neuropathy, respectively. conclusions. we found an incidence of phrenic neuropathy of % per patient and % related to subclavian and internal jugular vein catheterization, during the follow-up period. the time of reappearance of phrenic cmaps after being detected its neuropathy points to a neuroapraxia or partial axonotmesis as pathogenic type of injury.discussion. phrenic neuropathy has to be considered in cases of difficult weaning of unclear etiology. the catheterization of subclavian and internal jugular veins should be recommended employing ultrasound support. p. merino , m.c. martin-delgado , j. alvarez , i. gutiérrez-cía , Á . alonso-ovies , syrec hospital can misses, icu, ibiza, spain, isde, Á rea de salud, madrid, spain, hospital de fuenlabrada, icu, madrid, spain, hospital clínico universitario, icu, zaragoza, spain introduction. syrec project aims to improve icu patient safety. the project includes an epidemiological study. we present the main results.objectives. to estimate the near miss (nm) and adverse events (ae) rate in spanish intensive care units (icus). we study the incidence and nature. finally, we classify and analyze its severity.methods. multicenter prospective observational cohort study. inclusion criteria: patients admitted to the participant icus during the -h observation period. during this period, nm and ae detected and reported inside and outside icu were included. only outside icus were considered when its were the reason for admission. we evaluate the kind of incident, severity and preventability. data collection studied under the distribution of frequencies.results. , patients were included. , incidents were reported in patients, were nm and ae. risk: the median risk of nm was % versus ae %. . incidents per patient admitted. incidence rate: the incident rate median was . per patients per hour icu stay, the nm of . per patients per hour icu stay and that of ae, . per patients time of stay in icu. the % of the incidents reported have been nm and % ae. this incidents causing temporary damage in the . % of occasions and in the . % permanent damage, compromised the patient's life or contributed to death. classification of incidents (table ) . conclusions. our study shows a high individual risk. our icus services present a highrisk environment. therefore we have to go into the developement of epidemiological studies depth, in order to create further strategies supporting patient safety. restore cardiovascular performance in severe lactic acidotic rats a. kimmoun , n. sennoun , n. ducrocq , b. levy , inserm u , groupe choc, vandoeuvre-lès-nancy, france, chu nancy brabois, intensive care unit, vandoeuvre-lès-nancy, france introduction. lactic acidosis during shock is responsible for myocardial failure, vascular hyporesponsiveness and a decrease in sensitivity to vasopressor agents. sodium bicarbonate is a proposed treatment to correct acidosis, although with deleterious cardiovascular effects. indeed, hypocalcemia and hypercapnia, both powerful myocardial depressants, are the main side effects of the administration of this therapy [ ] . objectives. already studied in experimental models of isolated lactic acidosis, the cardiovascular effects of sodium bicarbonate administration have never been explored after correction for hypocalcemia and hypercapnia. methods. we therefore compared, in a rat model of severe lactic acidosis (ph \ . , hyperlactatemia[ mmol/l) induced by a state of controlled hemorrhagic shock, the cardiovascular effects of: ( ) standard resuscitation plus administration of sodium bicarbonate with correction for calcemia and paco (''adapt'' group, n = ); ( ) standard resuscitation plus administration of sodium bicarbonate without correction for paco and calcium (''nonadpat'' group, n = );( ) standard resuscitation; (''stand'' group, n = ); ( ) standard resuscitation plus calcium administration (''calc'' group, n = ). evaluation at steady and shock state, min and min was focused in vivo on arterial gas and myocardial contractility (emax) by conductance catheter. ex vivo vasoreactivity was tested on mesenteric arteries ( lm) by myography. sodium intakes were equivalent between groups. results. our model displayed a profound acidosis from . to . ± . (p = . ) and hyperlactatemia from . ± . to . ± . mmol/l (p \ . ). emax decreased from . ± . to . ± . mmhg/ll p = . . in the adapt group, at min, ph was normalized at . ± . (p = . ). furthermore, emax was enhanced at ± % (p \ . ) (stand: ± %, nonadapt: ± %, calc: ± %). the cumulative dose of infused norepinephrine was significantly lower in the adapt group ± lg/kg compared to other groups (stand: ± lg/kg, nonadapt: ± lg/kg, calc: ± lg/kg, p = . ). ex vivo mesenteric vasoreactivity in the adapt group was normalized (graph ).mesenteric vasoreactivity to phenylephrine conclusions. in severe lactic acidosis, infusion of sodium bicarbonate after correction of its side effects improves myocardial function and vasoreactivity. [ ] . the prevalence and significance of -hydroxyvitamin d deficiency in the intensive care unit have not been fully determined. a recent study of an unselected group of itu patients [ ] has suggested low itu admission -hydroxyvitamin d levels are common. objectives/hypotheses to be tested. royal free hospital intensive care unit patients exhibit low circulating levels of -hydroxyvitamin d. circulating levels of -hydroxyvitamin d decrease further during the course of hospital admission. admission circulating levels of -hydroxyvitamin d affect itu morbidity and mortality methods. all itu admissions were assessed within h of presentation and patients who were deemed to have the potential to require admission for at least week were included. demographic and clinical data were obtained in a prospective manner. results were recorded from samples obtained at admission, days and days. standard itu nutrition protocols were used. no interventions were performed. results. clinical and outcome data were obtained for patients. no significant differences between apache , saps or apache scores for survivor and non-survivor groups at either itu or hospital discharge were noted. further patients await complete data analysis. % ( of for whom results were available) achieved an adequate ([ nmol/l) circulating hydroxyvitamin d level. patients ( . %) demonstrated levels within the insufficient range ( - nmol/l). patients ( . %) did not have any detectable -hydroxyvitamin d. the remaining patients ( . %) were either in the deficient ( . %, - nmol/l) or severely deficient ( . %, - nmol/l) ranges. admission -hydroxyvitamin d levels in survivors and non-survivors were compared at itu and hospital discharge. no significant differences between the four groups (p [ . , anova) were observed, indicating that in this data set, admission -hydroxyvitamin d levels do not appear to alter or determine clinical course. mean -hydroxyvitamin d levels were compared at admission, day and at day . no significant differences between the three groups (p [ . , anova) were identified. no significant differences between the mean -hydroxyvitamin d levels of the survivors and non-survivors at day or day were apparent (small numbers). admission [ , ] and patients undergoing surgical procedures [ ] . patients with neurological illness can receive significant quantities of ns, chosen primarily for its iso-osmolar properties. objectives. ns is commonly used as maintenance and resuscitation fluid by the anaesthetist, and as intravascular flushes by the radiologist during prolonged interventional neuroradiological (inr) procedures. this pilot feasibility study aimed to ascertain the effect of ns infusion on acid-base measurements in patients undergoing inr procedures under propofol-remifentanil anaesthesia. methods. we collated routine electrolyte, albumin and acid-base data of patients who underwent coil/glue embolisations of intracranial aneurysms and vascular malformations, both before and after the procedure. base excess (be) was partitioned into the effects of sodium chloride difference (na-cl), albumin, lactate and unmeasured anions (uma), using the stewart-fencl-story approach [ ] . all values are reported as medians (ranges objectives. to investigate the erythropoietic response to hight dose of a weekly schedule of recombinant human erythropoietin (rhuepo) in critically ill anaemic septic patients. a total of patients admitted to the intensive care unite (icu) were enrolled in this study, patients were randomized to receive either rhuepo or not, patient did to form the rhuepo group, did not to form the control group.results. the epo treated group of patients showed significant increase in reticulocyte count compared with baseline p \ . , as well as with the control group p \ . . the epo treated group exhibited also a significant increases in hb concentration compared with baseline p \ . as well as the control group . . all patients in the control group received rbc blood transfusion %, while only . % of the epo group did. the epo treated group showed significant decreases in their apache ii score during the study period compared with baseline p \ . as well as with the control group p \ . . the epo treated group showed no significant difference in their sofa score compared with baseline p \ . , however the control group exhibited continuous and significant increase in their sofa score throughout the study period compared with their baseline p \ . , there was no significant difference in the final outcome recovery, mortality or morbidity p . , p \ . respectively.conclusions. the administration of rhuepo to critically ill anaemic septic patients is effective in raising their reticulocytic counts, hb concentrations and in reducing the total number of units of rbcs they require. in addition there was a trend toward better in hospital clinical course, increased recovery and decreased mortality in the rhuepo group.conclusions. anaemia is common following critical illness but does not appear to affect the physical aspects of recovery during medium term rehabilitation. this may be due to an overwhelming degree of symptom burden from other complications of critical illness impairing physical function to such a degree that the effects of anaemia are negligible in the medium term. although decreases in number and function has mainly been described in skeletal muscle, also other organs seem to be affected and it has been hypothesized that mitochondrial dysfunction might be involved in the development of organ failure. to study the effect of plasma of patients with septic shock on mitochondrial function in vitro to potentially later on identify a central factor affecting mitochondria in all tissues during sepsis and leading to multiple organ failure.methods. after sacrificing - week old sprague-dawley rats, mitochondria from soleus muscle were isolated through homogenization and a series of centrifugations. mitochondrial function was assessed by measuring of oxygen consumption, using an oxygraph containing a clarke-electrode, after addition of adp. before these measurements, mitochondria were incubated with plasma from septic patients or healthy volunteers, respectively, for min. in our second series, the mitochondria were incubated with different concentrations of il- , tnf-a or buffer. respiration rates were measured in the presence of adp (state ; a measure for the oxidative capacity to produce atp) and without the presence of adp (state ; a measure for the amount of uncoupling). respiratory control ratio (rcr; a measure for the respiratory efficiency of the mitochondria) was calculated by dividing state by state activity. all measurements were related to citrate synthase activity to compensate for the amount of mitochondria. statistical differences between the groups were analyzed using a student's t test.results. adp dependent (state ) respiration was % higher and rcr % higher in the mitochondria incubated with plasma from the septic patients compared to those incubated with plasma from healthy volunteers (table) . there were no significant differences between the groups incubated with preservation buffer or the different cytokines (table) . introduction. microvascular fluid loss from the intravascular to the interstitial space generates tissue edema and is one of the major challenges in emergency and intensive care medicine. isolation of interstitial fluid (if) from skin makes it possible to study the microcirculation and proteins in this environment both during normal as well as pathophysiological conditions such as acute inflammation.objectives. by studying bio-markers from proteomic analysis by mass spectrometry in an inflammation model, we wanted to find proteomes that could be important in explaining inflammation. we have applied a recently described centrifugation method in a porcine model and compared it with implanted wicks. in nine anesthesized piglets we compared the methods and evaluated the if, by overhydrating the pigs with ml of acetated ringer's solution for h, and thereafter continuously supplemented for h according to fluid losses. if was isolated from implanted dry wicks, wet wicks and by centrifugation of excised skin. the methods were evaluated by the ability to reflect overhydration and to show the expected composition of plasma proteins in if by use of hplc. the if was also processed further with mass spectrometry to find possible tissue degradation or inflammation due to overhydration. statistics: by spss v . and graphpad instat (version . ). significance level: p = . . colloid osmotic pressure in if was significantly lowered after overhydration for all the tree methods. wet wicks p = . , dry wicks p = . , skin samples p = . . hplc of if collected with centrifugation after overhydration, identified peaks representing molecules smaller than albumin. mass spectrometry of the same if identified several proteins associated with inflammation: alpha- -antichymotrypsin and lumican, the latter a protein identified as a modulator of inflammation. we have introduced a new centrifugation method for isolation of if from the skin of pigs. by further analysis of if isolated by centrifugation we were able to distinguish proteins found only in the if of the pigs overhydrated with ringer's acetate. these proteins could be associated with an inflammatory condition in the skin caused by massive overhydration, again causing tissue degradation. identification and validation of proteomic biomarkers can be a useful tool in future treatment of inflammation in general, and in sepsis in special. objectives. to define the pattern of change in metabolites by mrs in experimental sepsis. male sd rats (weight - g) underwent cecal ligation and puncture or sham procedure (n = per group), and h after surgery were euthanized. pulmonary tissue was extracted for magic angle mrs (hr-mas) and processing by the r metabonomic package. a supervised statistical analysis of main components (mc) was performed on the processed spectra.results. the mc analysis discriminated both group (septic and nonseptic) indicating a different metabolite profile. in addition, the analysis of mc loading revealed displacement positions in the discrimination between groups with a variation in the signal intensity of %.conclusions. metabolomic analysis of pulmonary tissue by mrs is a potentially useful technique for the detection of biomarkers in sepsis.grant acknowledgment. introduction. cd + cd + neutrophils are a key subset of phagocytes associated with severe bacterial sepsis [ ] . their characteristics, and potential neuro-immunomodulation, have not been explored in humans neutrophils exposed to septic plasma from icu patients. to assess the effect of adrenergic/cholinergic neurotransmitter molecules on human neutrophil adhesion and activation markers following exposure to human septic plasma. with irb approval, neutrophils were isolated from healthy volunteers (ficoll density gradient separation) and incubated for h with either plasma from healthy volunteers or septic patients plus pathophysiological concentrations of epinephrine (e), norepinephrine (ne) or acetylcholine (ach) and nicotine (nic) to assess potential parasympathetic-related neuro-immunomodulation. flow cytometry (dako cyan) measured expression on neutrophils of cd , cd , cd antibody markers and viability. median values are shown; analyzed by anova.results. neutrophils were unaffected by ne, e, ach or nic after incubation with plasma from healthy volunteers. after incubation with septic plasma, marked neutrophil activation occurred (p = . ). however, nic reduced cd + cd + activation (* fig. a ) by % (median ( - %; th- th centiles); p = . ). nic also attenuated cd expression, suggesting reduced neutrophil adhesion (* fig. b) . neutrophil viability was similar across drug and plasma treatments. conclusions. these preliminary data suggest that nicotine attenuates both the activation and adhesion of human neutrophils exposed to human septic plasma, but does not affect viability. objectives. the aim of this study was to evaluate the potential impact of lag between sepsis initiation and start of treatment on mitochondrial respiration. methods. animals [ . ± . kg] were randomized (n = /group) to a control group (group i) and three groups resuscitated at (group ii), (group iii), and (group iv) hours, respectively, after fecal peritonitis induction. fecal peritonitis was induced with instillation of . g/kg of autologous feces via intra-peritoneal drain. resuscitation was performed according to the ssc and esicm sepsis guidelines for h. respiration of permeabilized skeletal muscle fibers and their isolated mitochondria was assessed at baseline and after , , , and h, when applicable, or before death occurred, if earlier. at the end of the experiment, also isolated brain, hepatic and myocardial mitochondrial respiration was measured using high resolution respirometry (oxygraph- k, oroboros instruments, innsbruck, austria). results. mortality ( %, each) and organ dysfunction was highest in groups iii and iv. in these two groups, different pattern of changes of skeletal muscle mitochondrial complex i-dependent respiratory control ratio (rcr) were observed (table ) . no significant differences between groups were observed for complex i-and ii-dependent rcr values of hepatic, myocardial and brain mitochondrial respiration (fig. ). there were no significant differences between the groups for any of the complexes in permeabilized skeletal muscle fibers mitochondrial respiration (data not shown). conclusions. despite the high mortality observed in groups resuscitated at later time points after induction of sepsis, end organ mitochondrial function assessed using physiological substrates was preserved. despite significant changes in skeletal muscle mitochondrial respiration efficiency in the two groups with the highest mortality, our findings do not support the view that mitochondrial dysfunction plays a major role in the pathogenesis of multiorgan dysfunction in experimental sepsis. grant acknowledgment. swiss national fund, nr: - ; stiftung für die forschung in anästhesiologie und intensivmedizin. adipose tissue is an endocrine organ which produces signalling proteins involved in inflammation and glucose homeostasis [ ] . one of these proteins, adiponectin, promotes glucose utilisation and fatty acid oxidation and thus improves insulin sensitivity via its two receptors, adipor and adipor [ ] . adiponectin expression has been shown to be reduced in type ii diabetes, obesity and endotoxaemia [ , ] . adiponectin also exhibits antiinflammatory properties [ ] . in this study, we have examined whether adiponectin and its receptor gene expression changes in murine adipocytes stimulated by lps. methods. t --l adipocytes were grown in culture media (dmem with % fetal calf serum) until confluent. pre adipocytes were differentiated with the addition of mg/ml insulin, mm dexamethasone and mm ibmx. media was changed every h. cells were treated on day with ng/ml, or mcg/ml lps (escherichia coli, sigma-aldrich). cells were harvested at and h. mrna levels were determined by rt pcr in a . ll reaction volume consisting of . ng of reverse transcribed cdna mixed with optimal concentrations of primers and probe and qpcr tm core kit (eurogentec, uk) in -well plates on a mx p detector. results. cell response to lps was confirmed using il as a reference gene. expression of adiponectin mrna was significantly reduced in cells treated with lg/ml lps harvested at h ( . fold p = . ). there were no changes in cells treated with lower concentrations of lps. there were no changes at h. r gene expression was significantly reduced following treatment with ng/ml lps at h ( . fold p = . ), but treatment with higher concentrations did not change expression. there were no changes at h. r expression levels were significantly reduced at h in the and the mcg/ml groups ( . fold p = . and fold p = . ) respectively. there were no changes at h. discussion. our results add to the evidence that changes occur in the adiponectin system during inflammation. in this model, we observed rapid reduction (at h) in adiponectin at high dose lps, r at low dose lps and r at medium and high doses. there were no changes in expression levels at h. this suggests that a rapid change in the adiponectin system may occur in response to lps but this change is not maintained at h. in a previous study, our group has shown reduced adiponectin gene expression in adipose tissue depots in lps induced endotoxaemia [ ] . it is interesting that different concentrations of lps induce different changes within the adiponectin system. further studies are needed to elucidate whether reductions in both adiponectin and its receptor may contribute to the inflammatory changes and hyperglycaemia commonly observed during sepsis including all co poisoned patients treated with hyperbaric oxygen. following parameters were seized: age, sex, date of admission, sofa, the source of the intoxication, the gravity co score, the initial clinical examination (realized by first aid), biology, the rate of hbco, the murray score and the rate of complication. results. patients were included in the study. the sex ratio was %, the mean age was ± years and the global mortality was , %. among the patients % were poisoned by smoke (s group), % by pure co (c group) and % by exhaust fumes. more than % of the exhaust fumes victims were suicide origin. this characteristic is associated with neurological impairment induce by ingested drugs. then, their neurological status is impossible to link to the co poisoning. we have therefore decided to exclude this group. the sofa score was higher in the s group compared with the c group ( . - . ; p \ . ). a co score equal to was present in versus % respectively in s versus c group (p \ . ). in the under group of patients having a co score at , % ( / ) of co poisoned patients versus . % ( / ) of smoke poisoned patients were ventilated (p \ . ). these patients were intubated either during transport or in the intensive care and none of them received hydroxycobalamine during the first aid (before intubation). the laboratory data showed in the s group a higher lactates level ( . vs. . mmol/l; p = . ) and lower initial pao /f i o ratio ( vs. ; p = . ). nine percent of the s group present a murray score at versus % for c group (p \ . ). pneumonia, shock and death were significantly more frequent in the s group (respectively . vs. . %, p \ . ; . vs. . %, p \ . ; and . vs. . %, p \ . )conclusions. as expected the smoke poisoned group has a higher mortality than pure co group (mortality % vs. overall mortality . %). at equivalent co gravity score, mortality and complications are always more frequent in the smoke poisoned group. the smoke poisoned group has a high risk of degradation. those patients require specific monitoring and support and probably early administration of hydroxycobalamine. hypothesis. at administration and maintaining higher plasma levels of at can reduce the need for inotropes in burn shock patients. we performed a retrospective cohort study of burn shock patients admitted to a single tertiary care center over years period. patients were eligible for inclusion if they were received fluid resuscitation with ringer's solution and colloid according to clinical guidelines. data were abstracted including demographic, burn injury characteristics, resuscitation fluid volume, the type of colloid and the average of plasma at levels within h after burn injury. administration of fresh frozen plasma and/or recombinant human at was defined as at administration. the decisions of at administration and inotropic support (dopamine or dobutamine) were made by the attending intensivists. primary outcome measure was the need for inotropes within h after burn injury. cox regression model was used to estimate the risk reduction by at administration and average of at levels. [ ] . argon, another member of the noble gas family has been reported previously to have a neuroprotective property [ ] . the aim of this study was to investigate whether it attenuates neuronal injury in a rat model of neonatal asphyxia. methods. seven-day-old postnatal sd rats underwent right common carotid artery ligation and then recover with their dim for h. thereafter, they were exposed to % o balanced with nitrogen for min. after h, they were treated with % argon or % nitrogen (positive control group) for min. the cohort pups without intervention served as naïve control. they were perfused days later and their brains were sectioned and stained with . % cresyl violet. microphotographs were taken from ca area of the hippocampus near - . bregma relative to adult brain at magnification. healthy cells were counted in a blind manner and their mean value was used for data analysis. results. the thickness of healthy layers in the right ca area of the positive control group was remarkably reduced compared with other groups (fig. ). quantitative analysis revealed that argon treatment significantly increased healthy cell numbers in the right ca area of hippocampus from . ± . in the positive controls to . ± . (p \ . ) (fig. ). grant acknowledgment. this study was supported by a grant from action medical research, uk. objectives. our objective was to study the mechanisms of death following high-dose citalopram administration in rats. experimental study in sprague dawley rats with intraperitoneal (ip) citalopram administration; determination of the median lethal dose (mld)using the dixon and bruce upand-down method; clinical descriptive study of citalopram-induced features and measurement of alterations in respiratory pattern (arterial blood gases and plethysmography) and biological parameters including blood lactate (scout Ò , ekf diagnostic), plasma and platelet serotonin concentrations (high-liquid performance chromatography-fluorometry); determination of the preventive activity on seizures and death of diazepam, cyproheptadine, and propranolol pretreatments with the determination of their minimal effective dose; comparisons using anova for repeated measurements followed by bonferroni post-test.results. citalopram ip-mld was determined as mg/kg in rats. seizures were significantly increased in rats receiving and % of citalopram mld versus controls (p \ . and p \ . , respectively), while death rate was only significantly increased in rats treated with % of citalopram mld (p \ . ). significant decrease in body temperature was observed after min in rats treated with doses[ % mld in comparison to controls (p \ . ). occurrence of serotonin behavioural syndrome was comparable in all groups. citalopram administration did not result in significant hypoxemia, hypercapnia, and lactate elevation, thus not supporting the hypothesis of the occurence of any significant deleterious cardiovascular effect in citalopraminduced toxicity. however, a significant moderate increase in the inspiratory time (p \ . ) accompanied with an expiratory braking was observed. a significant decrease in platelet serotonin and increase in plasma serotonin concentrations were measured (p \ . ). pre-treatment with diazepam ( . mg/kg) and cyproheptadine ( . mg/kg) of rats receiving a lethal citalopram dose prevented seizures and death, while propranolol was ineffective.conclusions. citalopram respiratory toxicity remains mild, while deaths result from seizures probably related to serotonin toxicity. our observations may be helpful to better understand and manage human citalopram poisonings. objectives. to define the population pharmacokinetics (pk) of phenytoin in the critically ill, in addition to risk factors for sub-therapeutic dosing.methods. free and total ptn concentrations were measured in serum by means of high performance liquid chromatography following microfiltration, two to three times in the first h after a loading dose. population pk modelling, including intra and interindividual variability, were determined using nonmem (r) . in the netherlands the use of diazepam is advised as first line treatment although evidence is not established and mainly provided through case-reports [ ] . to compare the effect of diazepam on mortality in (hydroxy) chloroquine intoxication to standard therapy. we performed an extensive medline search ( -april ) with a manual reference search of identified papers. (hydroxy) chloroquine intoxication studies and case reports in english, dutch or french were evaluated. patients older than years with severe intoxications, based on measured concentrations or life-threatening symptoms, were included. pooled relative risk (rr) for mortality with corresponding % confidence interval (ci) were calculated by means of a fisher exact test. our results were compared with two retrospective and one prospective study.results. there were case reports identified from which case reports met our inclusion criteria. thirteen patients received diazepam of whom two died, compared to twelve patients who did not get diazepam of whom one died. statistical analysis demonstrated that treatment with diazepam was not associated with a lower mortality rate (rr: . ci . - . ; p = . ).although pooling of case reports is debatable, these results were comparable to the retrospective and prospective studies that didn't show any benefit from diazepam in chloroquine intoxication [ , , ] . the positive effect of diazepam may have been underestimated, due to the fact that it has been given only as rescue therapy.conclusions. based on our analysis there is a lack of evidence concerning any antidotal effect of diazepam. good supportive treatment is pivotal. if the clinical manifestations of (hydroxy) chloroquine intoxications require sedation or treatment of seizures, diazepam is a good choice based on its pharmacological profile. a prospective study which compares diazepam to sedativa with similar pharmacokinetic and dynamic profile is required to prove that diazepam has any antidotal effect. introduction. brain is one of the first organs affected in sepsis and evaluation of brain function is difficult since patients are under sedation. it has been shown that mitochondrial dysfunction may play a significant role in the pathogenesis of septic encephalopathy. here we investigated inflammatory and metabolic parameters in a model of polymicrobial sepsis in mouse. methods. sepsis was induced by intraperitoneal injection of feces. animal received imipenem h after the procedure. control animals received intraperitoneal saline and imipenem after h. blood cytokines and serum lactate were measured. the animals were sacrificed by cervical dislocation. brain slices of mcm were used to measure oxygen consumption and glucose uptake.results. interleukin , mip a and interleukin b significantly raised in the first h after sepsis induction (p = . ; p = . ; p = . respectively). in h only mip a was significant higher (p = . ). lactate was elevated and h after sepsis induction (p \ . and p \ . respectively). oxygen consumption increased after h of sepsis and drops under control values h after the induction of sepsis. glucose uptake, measured by the nbdg fluorescence, was higher after h (p = . ) and h after sepsis induction.conclusion. in a murine model of abdominal sepsis, inflammatory markers, lactate production, and brain glucose uptake increased and were parallel to alterations in the mitochondrial oxygen metabolism. introduction. the royal bournemouth hospital has one of the highest out-of-hospital cardiac arrest admission rates in the uk. in , following ilcor/aha guidelines [ ] , a cooling protocol was developed for patients with return of spontaneous circulation after advanced life support for ventricular fibrillation or pulseless ventricular tachycardia. in preparation for potential new ilcor/aha guidelines in , the prospective database of outcomes for these patients was analysed.objectives. to evaluate the outcomes of therapeutic hypothermia for patients with return of spontaneous circulation following cardiac arrest. outcome data from our prospective registry of cooled patients are summarised.results. sixty-three patients were cooled in years (median age years; mode ; range - years). % survived to itu discharge and % to hospital discharge. % of these were discharged home ( % to a rehabilitation hospital before home and one patient to a long term care facility). ninety-five percent of survivors were alive at months and % alive at year with seven status results still pending. median itu length of stay was . days (range - ). six patients required temporary percutaneous tracheostomies for airway protection and weaning from ventilation. median duration from itu to hospital discharge was days (range - ).conclusions. this series is large by comparison to other uk centres. survival to hospital discharge, at months and year were better than other published results. although neurological outcomes were not formally assessed, we believe that the capacity to discharge home is a desirable patient outcome and represents the beneficial neurological effect of our cooling protocol. selection bias will have undoubtedly affected our results. however the age of our patients was higher than in published trials and in other reports is considered an adverse outcome predictor. our data would not support restricting induced hypothermia on the basis of age alone. we consider the itu and hospital lengths of stay required to discharge these patients to be long. these data were not reported in original trials. discharges may obviously be delayed for non-clinical reasons. this aside, neurological recovery progresses for months after cardiac arrest and discharge home may still prove possible if time is allowed. however, post-itu resource implications should be considered when introducing a cooling protocol. introduction. acute ischaemic stroke (ais) is the third largest cause of mortality and the leading cause of chronic disability in the industrialized world. in some parts of europe and the united states - % of patients with ais may be admitted to a neurological intensive care unit (icu) for supportive therapy with - % receiving mechanical ventilation [ , ] . there are currently no agreed uk criteria for the admission of ais patients to critical care.objectives. to review the incidence and outcome of ais in our tertiary icu over the last five years. november and november . ais was classified as thrombo-occlusive or embolic. subarachnoid haemorrhage and primary intracerebral haemorrhage were excluded. demographic and outcome data were recorded and compared against a mean value of all icu admissions.results. ais comprised . % of icu admissions during the study period. demographic data is presented in table as mean ± standard deviation or median (interquartile range) as appropriate. in % ( / ) of hospital ais admissions were admitted to icu. patients had surgical procedures including decompressive craniectomies. % of survivors had a discharge gcs of / . mortality for unselected medical admissions over the study period was %. there are differences of significance in the mortality according to the age, classified by age groups with an age cut off of years (\ years . vs. c years %, p \ . ). apart from the gcs, the rest of the variables analyzed in the ich score are not of significance; supra and infratentorial, presence of intraventricular blood neither on the divided volume over or under cc although, in the latter, a p \ . can be observed and if we only analyze the supraventricular, it comes out as significant. other analyzed data are the time of the surgery, which is not significant, the need for mechanical ventilation, which is ( . vs. . %, p \ . ), and the days of ventilation with a mortality clearly higher on those patients with\ days of ventilation ( %) and on those of shorter stay (lesser then days %).conclusions. let be remarked that the samples have been taken from patients admitted in the intensive care unit, losing a possible sample of less serious patients, and with a higher level of consciousness, what might explain why supra or infratentorial location and the volume don't come out as forecasting factors, since its likely that there are many small infratentorial outside the intensive care unit. we highlight also that the high mortality in the first few days can be caused by those patients who are admitted as donors, developing an encephalic death in the first days, conditioning also the data regarding the mortality on fewer days with ventilation. the finish up, we have to point out the fact that the presence of previous hypertension during the treatment might be a bad forecasting factor that should be deeper studied. to determine whether a delay exists between the time of diagnosis of intracranial haemorrhage and the time of reversal of anticoagulation, in patients presenting within our region. following approval by all audit and haematology departments a month retrospective analysis was performed. we reviewed consecutive patients who received reversal of anticoagulation with pcc and vitamin k having presenting with intracranial haemorrhage whilst on warfarin. time of diagnosis was obtained from the time of scan and time of pcc issue was obtained from the blood bank database. case note analysis was performed to obtain further information.results. patients were identified, in the neurosurgical centre and in peripheral hospitals. the median time from scan to issue of pcc was min. patients were reversed within min and patients waited longer than min to have pcc issued. no adverse thromboembolic events were encountered.conclusions. avoidable delay exists between ich diagnosis and pcc issue. pcc could be stored in the emergency department and a stat dose administered immediately after diagnosis facilitating rapid correction of inr. repeat audit will be required to assess safety and efficacy. objectives. the aim of this study was to compare the functional ability and muscle strength between these two groups of patients. twenty-nine patients were evaluated (m: , f: ) (age: ± years).the diagnosis of critical illness polyneuromyopathy was based on muscle strength measurement according to the medical research council (mrc) of muscle strength methodology. nine patients were diagnosed with critical illness polyneuromyopathy during their icu stay (mrc \ / ).the patients were evaluated with mrc and hand-grip dynamometry (hgd) every days until their discharge from the hospital. the fim scale (functional independence measure) was used to evaluate the functional ability ( - ).the first evaluation was done at the discharge from the hospital and the second one ± months afterwards.results. the patients who developed critical illness polyneuromyopathy had statistically significantly lower mrc ( ± vs. ± , p \ . ) and hgd at icu discharge (left ± kg vs. ± , and right ± kg vs. ± , p \ . ) compared to those who did not. the muscle strength as assessed with the mrc days after icu discharge had statistically significantly lower ( ± vs. ± , p \ . ), just as the second hgd evaluation (left ± kg vs. ± and right ± vs. ± kg, p \ . ).compared to those who did not develop critical illness polyneuromyopathy, the patients who did, had statistically lower fim values during their discharge from the hospital ( ± vs. ± , p \ . )and months afterwards ( ± vs ± , p \ . ).conclusions. the patients who developed critical illness polyneuromyopathy had significantly inferior muscle strength at their discharge from the icu. these patients also had lower functional ability. this functional ability remained defected even months after their discharge from the hospital. these initial findings are suggestive that the appearance of critical illness polyneuromyopathy affects the patients mobility after their discharge either from the icu or from the hospital and persists for several months after icu discharge. further studies are needed to evaluate the effect of this impairment on the quality of life of these patients and also to evaluate therapeutic tools for critical illness polyneuromyopathy. introduction. this poster presents a qualitative system dynamics (sd) analysis of the factors which influence the care of acutely unwell ward patients in new zealand. this systems thinking approach is commonly used in organisational research and offers a way to make sense of complex relationships between variables. this approach has previously been used in health care to demonstrate differences in mental models between policy makers and clinicians (cavana et al., ) . since the factors which influence the care of acutely unwell ward patients are complex and multi faceted the qualitative sd method becomes an ideal analytic approach (e.g. see wolstenholme and coyle, ; senge, ; vennix, ; or maani and cavana, ) .objectives. the aim of this study was to examine the factors which influence the care of acutely unwell ward patients from an organisational perspective. key objectives were to determine the enablers and barriers to care from a nursing, medical and managerial (at ward and executive level) perspective.methods. using a multiple case study approach in four wards in two new zealand hospitals, focus groups and one to one interviews were conducted with key stakeholders identified as nurses, doctors and managers. initial coding of the data generated themes. these themes were then clustered to provide variables which were mapped to generate separate causal loop diagrams (clds) for each of the stakeholder groups to provide the basis for analysis. the clds were compared for characteristics and world views. preliminary results demonstrate a difference between clinical and managerial staff in characteristics and world view regarding the factors which affect the care of acutely unwell ward patients.conclusions. the qualitative sd approach has offered a novel and helpful way to make some sense of the complexity associated with caring for acutely unwell ward patients. organizational responses that may improve care delivery to these patients should be based on frank and open discussions between staff at all levels to ensure a shared mental model as the basis for change. objectives. the aim of the study is to explain the nursing in the technologicallyadvanced intensive care units. in this phenomenologically-designed study, a face-to-face in-depth interview was performed with nurses, who were experienced for - years in the intensive care unit of cardiovascular surgery clinics. during the interviews, a semi-structured form was used. data were analysed using colaizzi's method of data analysis. the study was approved by the ethics committee of the institution.results. according to the nurses, nursing in technologically-advanced environment has three stages. these stages constituted three themes of the study: technology shock (first stage), understanding the technology-supported care (second stage), competency in technological environment (last stage). in the first stage, the nurses focus on themselves and technology; perceive the environment as frightening and complex. in the second stage, nurses gain control on technology, feel themselves safe and recognize their responsibility. in the last stage, the nurses experience anxiety related to their accountability. this anxiety may be motivating but also may be wearisome.conclusions. the nurses passes through three stages in a technologically-advanced environment. helping nurses to pass through these three stages appropriately will increase the contribution of technology to the patient care, more utilization of technology by nurses and more job satisfaction. unexpectedly, the compliance rate with the recommendations was significantly better over night. although the number of nurses is constant in the h, the number of doctors is lower and less differentiated in the night shift. in an attempt to find an explanation for these findings we looked at the patient flow and time span until the first medical observation in the different time periods and we found that over night admissions (between : a.m. and : a.m.) corresponded only to % of all admissions and were seen sooner, which might explain our findings. a. objectives. the purpose of the study was to assess whether the completion of the sepsis resuscitation bundle within the first h after icu admission, but beyond the specific time limit of the various bundle interventions, is related to an improvement in survival in patients with severe sepsis/septic shock. this was a single-center prospective observational study of patients admitted to the medical-surgical icu of an urban tertiary care teaching hospital with severe sepsis/septic shock. patients were recruited from june to november . we assessed the compliance with the different tasks included in the -h resuscitation bundle. furthermore, we ascertained within the first h after icu admission the compliance with those tasks not carried out within their specific time limits; we have called this variable ''bundle improvement at the icu''. results were stratified by the number of tasks of the bundle completed before admission at the icu, and the lag time between the beginning of severe sepsis and admission to the icu. these late completed tasks at the icu were related to hospital mortality by a cox regression model. objectives. the aims of this study were to assess the compliance rate with h bundle as defined in the surviving the sepsis campaign guidelines in patients diagnosed with sepsis regardless of severity and whether compliance affects the rate of mortality and/or hospital stay. we conducted a prospective observational study. we randomly recruited adult patients from acute admissions unit and intensive care in an acute district general hospital in england who met the diagnostic criteria for sepsis. for each patient, compliance with sepsis care bundle was obtained from medical notes. the following components of the h sepsis bundle were assessed: obtaining blood cultures, initiating antibiotic therapy, measuring serum lactate and in the event of septic shock administration of fluid therapy. conclusions. long and unacceptable delays in admission to iccu were identified despite evidence of significant organ dysfunction in many of these patients. with all bundle elements being met for only patient it is apparent that evidence based endpoints aimed at reducing mortality from severe sepsis are not being met despite all the bundle elements being practically deliverable. poor compliance with taking blood cultures prior to antibiotic administration and lack of scvo measurement are areas requiring particular attention. further work is recommended to identify potential contributing factors to non-compliance. introduction. international guidelines recommend that cardiac output measurement is required in addition to arterial pressure monitoring in patients with persistent shock after initial therapy [ ] . nevertheless, these recommendations are not supported by any comparison of arterial pressure and cardiac output for monitoring the effects of the most current treatments like fluid therapy. objectives. to evaluate in which extent monitoring the haemodynamic effects of a standardized fluid challenge with the sole arterial pressure could help for detecting the fluidinduced changes in cardiac index (ci). in critically ill patients with acute circulatory failure deemed at receiving a -ml saline infusion over min, we measured the systolic (sap), diastolic (dap), mean (map) and pulse (pp) arterial pressure and transpulmonary thermodilution ci before and after volume expansion.results. volume expansion significantly increased ci, sap, dap, map and pp by ± %, ± %, ± %, ± % and ± %, respectively. the fluid-induced changes in pp, sap and map were significantly correlated with the fluid-induced changes in ci (r = . , . and . , respectively). the changes (in %) in pp were significantly related to the changes (in %) in stroke volume for all quartiles but with different coefficients of correlation: r = . for the st quartile ( - years), r = . for the nd quartile conclusions. pp and sap were the best arterial pressure values for detecting the fluidinduced changes in ci. using the sole pp for assessing fluid responsiveness led to a non negligible proportion of false negative cases. this supports the recommendation that when a precise monitoring of fluid resuscitation is required, like in refractory shock, a direct assessment of cardiac output is required. objectives. aim of our study is to show that it is possible to reduce high catecholamines in previous improper volume resuscitated patients by forced volume resuscitation combined with active dose reduction and generate the hypothesis of an avoidable catecholamine induced circulation injury. introduction. the sialic acid content of the red blood cell (rbc) membrane decreases early in sepsis [ ] , and this alters the rbc shape and metabolism [ ] . an increased ratio of the rbc proteins band /alpha spectrin was observed in a mouse model of septic shock, suggesting a possible alteration of the rbc membrane integral/peripheral proteins ratio [ ] . as there are interspecies differences in membrane composition, these observations need confirmation in humans. we studied rbcs from patients with (n = ) and without (n = ) sepsis at icu admission and on day in the septic patients. exclusion criteria were recent rbc transfusion, hematologic diseases, cirrhosis and diabetes mellitus. procedures included screening for rbc membrane protein alterations by cryohemolysis test and separation of the rbc membrane and skeletal proteins by polyacrylamide gel electrophoresis in the presence of sodium dodecyl sulfate [ ] . comparison between groups was made by the student's t test or the mann-whitney test. a p value . was considered as statistically significant.results. the hemogram, including reticulocyte count was similar in septic and non-septic patients at icu admission. no significant difference was observed for cryohemolysis test results and the amount of the rbc proteins (table ) . objectives. our purpose was to compare a new method (patrol fr - ) with the reference method (randox tm ) during cbp. patients scheduled for coronary artery bypass (cb) and aortic valve replacement (avr) under cbp were enrolled after written informed consent in this protocol approved by local ethics committee. anesthesia protocol was standardized with systematic use of tranexamic acid. three blood samples were harvested: t = induction; t = min. after cross aorta clamping; t = h after induction. the patrol method was performed after serum exposition to a photosensibilizer agent then to a laser irradiation leading to the formation of free radicals. oxidation by those free radicals of a fluorometric sensor allowed an indirect measure of tas. this measurement in arbitrary unit (au) corresponded to area under curve compared to a control value from a pool serum. a value higher than indicated a lower capacity for the given serum to neutralize free radicals whereas a lower value indicated a higher capacity. the same sample allowed tas determination (lmol/l) with randox tm method. results were expressed as absolute numbers, mean ± sd. tas were compared with anova test; p \ . was significant.results. the seven patients ( male, female; ± years old) enrolled underwent cardiac surgery ( cb and avr) without any problem. there was no variation in tas determination with the randox tm method: t : . ± . ; t : . ± . ; t : . ± . lmol/l. conversely a two fold significant increase was measured during cpb with the patrol method: ti: . ± . ; t : . ± . *; t : . ± . au. *p \ . versus t .conclusions. oxidative stress due to overwhelming release of reactive nitrogen/oxygen species (rn/os) is held largely responsible for sepsis-induced organ failure and mortality [ ] . up-front and/or ongoing distortion of the pro-oxidant/anti-oxidant balance is likely to play an important role in this situation and in ischemia-reperfusion. therefore the patrol test which appeared to be more sensible than the randox tm method could a good tool in these cases and for evaluation of new anti-oxidant treatments in critical care medicine. these results have to be confirmed in a larger population. introduction. sepsis is the leading cause of death in critically ill patients. despite attempts to improve standardized strategies in resuscitation and treatment of sepsis, the morbidity and mortality remain unacceptably high. early diagnosis and stratification of the severity of sepsis is the key to start timely the appropriate treatment. sepsis is the systemic inflammatory response syndrome to infection; it can lead to hypoperfusion and organ dysfunction and at the cellular level to aerobic mitochondrial dysfunction. lactate is the product of anaerobic metabolism and thus may serve as a prognostic factor in this subset of patients.objectives. the authors propose to test the association of the first serum lactate at hospital admission with shock and icu mortality in patients with community-acquired severe sepsis. during the study period , patients were admitted in the unit, of those ( %) had severe community-acquired severe sepsis (cass). crude icu mortality rate among cass was %. considering the model previously described in methods and when the variables were adjusted only gender, age, saps ii, severity of sepsis and serum lactate were retained in the final model for icu mortality and saps ii nad serum lactate for shock (see table ). a first blood lactate level was independently associated with shock and icu mortality in patients community-acquired severe sepsis admitted in intensive care. objectives. the objective of this study was to test whether svo can predict fluid responsiveness in these patients. we studied patients who were monitored with a pulmonary artery catheter for severe sepsis and septic shock. hemodynamic measurements were obtained before (baseline values) and after a fluid challenge with colloids or crystalloids. responders were defined as those with a[ % increase in cardiac index (ci). no additional interventions were performed during the test. student's t test and linear correlation were used for the statistical analysis.results. mean patient age was ± years and the mean sofa score ± . mean arterial pressure was ± mmhg, cardiac index . ± . l/min/m , pulmonary artery balloon-occluded pressure ± mmhg, and heart rate ± bpm. thirty-four patients ( %) responded to the fluid challenge. responders and non-responders had similar baseline svo ( ± vs. ± %, p = . ). baseline svo was[ % in responders ( %) and in non-responders ( %). there was no correlation between changes in ci (%dci) and the baseline svo (fig. ) . sepsis is a disorder of microcirculation [ , ] . although the pathogenesis of microvascular dysfunction in sepsis is extremely complex, neutrophil activation and their interaction with endothelial cells are considered central features of sepsis-induced microcirculatory alterations. to our knowledge, however, no study evaluated the microvascular pattern of septic patients with chemotherapy-induced severe leukocytes depletion.objectives. to assess early microcirculatory response to sepsis in patients with and without drug-induced neutropenia.methods. demographic and hemodynamic variables together with sublingual microcirculation recording (ops-sdf videomicroscopy) were collected in four groups of subjects: septic shock (ss, n = ), septic shock in neutropenic patients (nss, n = ), neutropenia without inflammation (neutr, n = ) and healthy controls (crtl, n = ). except for controls, all measurements were repeated after complete resolution of septic shock and/or neutropenia (tp ). collected video-files were processed using appropriate software tool and semi-quantitatively evaluated (functional capillary density, fcd (cm/cm ); mean flow index, mfi [ ] ) [ ] . conclusions. microvascular derangements in sepsis did not differ between non-neutropenic and neutropenic patients. surprisingly, neutropenia per se without measurable systemic inflammation was also associated with alterations of the sublingual microcirculation. although we cannot exclude the role of residual neutrophils, our data could indicate that leukocytes are not the only and exclusive modulators of septic microvascular dysfunction. in addition, the role and mechanisms of microvascular changes associated with chemotherapyinduced neutropenia warrants further investigation. multiple organ failure is a leading cause of death in critically ill patients. improvements in outcome will most rely on our capacity to measure rapidly accessible biomarkers.objectives. to investigate if the time sequence of reactive oxygen metabolites (roms) production with sofa score could be prognostic for outcome. the study included critically ill patients (from september to december ) who had roms measured (hydroperoxides) during icu stay, when the diagnostic criteria for sepsis (observed n = ), severe sepsis (observed n = ) and septic shock (observed n = ) were present, - days and weeks after the diagnosis (samples n = ); on the same days, the sofa score was calculated. the plasma roms values were assayed by a diacron-italia kit, applied to an automatic instrument (olimpus au ). statistical analysis was performed used mann-whitney test and the linear regression analysis. the roms values and sofa score were inversely correlated (r = . for sepsis; r = . for severe sepsis; r = . for septic shock). the droms (the difference between the first and the last measurement of roms levels in each individual patient) was significantly different between survivors and non-survivors. clinical characteristics of the patients are presented in table . values are presented as median and interquartile rangers. a p value . was considered as statistically significant.conclusions. the plasma roms values decreased when the critically conditions rapidly evolved towards organ failures with higher sofa. to explore: (a) stress neuropeptides (acth, cortisol, prolactin, neuropeptide y (npy) and substance p (sp)) in critically ill subjects and controls, (b) potential association between levels of stress neuropeptides, disease severity and pain. a prospective correlational study, with repeated measurements and cross-sectional comparisons. fifty-three critically ill patients with diverse primary diagnoses and -age and gender-matched healthy controls were studied for days. serum neuropeptides were quantified by elisa (npy, sp) and chemiluminescence immunoassays (acth, cortisol, prolactin). pain levels were assessed by payen and puntillo scales. clinical severity was quantified by multiorgan failure scoring system (mof) and the multiple organ dysfunction score (mods). results. we observed: (a) statistically significant differences between critically ill and control subjects in regard with cortisol (p \ . ), npy (p \ . ) and sp (p \ . ) levels throughout the study. specifically, cortisol levels were higher and npy and sp levels were lower in patients compared to controls, (b) significant bivariate associations between stress neuropeptides (p \ . ), (c) statistically significant associations between acth and pain intensity levels assessed by payen (r = . , p = . ) and puntillo (r = . , p = . ) scales. there was also a constant but not statistically significant (p = . ) trend for lower sp levels in patients receiving opioids than in controls. moreover, npy levels were significantly lower in patients receiving analgesia (p = . ), (d) lower acth and cortisol levels in survivors (p \ . ) (e) at the day of least severity, a significant association between sp levels and mof was observed (r = . , p \ . ).conclusions. (a) despite the fact that npy and sp are stress neuropeptides, their levels appear to be decreased in mods patients. it is worth-exploring whether critical illness may be a state of suppressed activity of some neuropeptides, (b) the observed association between stress neuropeptide levels and survival in critical illness needs to be explore further, (c) bedside measurement of selected neuropeptides in the future may provide an estimation of pain in uncommunicative patients.hence, the study of stress neuropeptides may provide new insight for the management of the critically ill. objectives. the objective of this study was to compare septic and non-septic inflammatory process in critically ill patients with respect to paraoxonase activity, lipid profile and lipid peroxidation markers. methods. analyzed were serum paraoxonase activity, lipid profile, oxidized low density lipoproteins and conjugated dienes in critically patients with sepsis n = ), age/sex/ap-acheii matched critically ill controls with non-septic sirs (n = ) and age/sex matched outpatient controls without inflammation (n = ).results. the activity of pon was lower in septic patients ( . ± . u/ml) as well as in patients with non-septic sirs ( . ± . u/ml) compared to healthy controls ( ± . u/ml). the decrease in paraoxonase activity, high density lipoprotein cholesterol and apolipoprotein a- concentrations was closely followed by the counter increase of serum amyloid a in both groups of patients. there was no difference in paraoxonase activity between septic and non-septic critically ill patients. the concentration oxidized low density lipoproteins and conjugated dienes as markers of lipid peroxidation, were raised in both septic and non-septic sirs critically ill patients as compared with healthy controls. however there was no difference between both critically ill patient groups.conclusions. the decreased activity of paraoxonase in negative correlation with lipid peroxidation markers offers a potentially useful nonspecific marker of inflammation in critically ill patients.grant acknowledgment. objectives. in the present study, we studied the short-term and direct effects of ivig with sepsis.methods. patients was investigated. following the administration of g of ivig for h, we took blood samples immediately following ivig treatment and at h after ivig treatment. blood samples taken at h and just prior to ivig administration were used as controls. while there was no difference between h before and just prior to ivig treatment, statistically significant decreases were observed in the levels of il- after the administration of ivig. no significant changes were observed in the levels of tumor necrosis factor-a and high mobility group box- .changes in serum tnfa, il- , hmgb we confirmed the results of previous animal studies. while we reported that the administration of ivig directly reduces the levels of il- in patients with sepsis, a further prospective study of the ant-cytokine effects following ivig treatment will be conducted in the near future. objectives. to investigate the levels of nucleosome in septic patients and to determine whether nucleosome could serve as a biomarker for sepsis. sixty-four consecutive patients who were newly admitted in surgical intensive care unit at two university hospitals were enrolled in this study. whole blood samples were drawn within h of admission and on the third, fifth and seventh days. a last blood sample was drawn after recovery at icu discharge in survivors or at imminent death in the cases of non-survivors. plasma levels of nucleosome as well as cytokines il- and il- were detected by means of enzyme linked immunosorbent assay. . fifty patients were diagnosed as sepsis and the other fourteen patients were classified as controls. plasma levels of nucleosome were significantly higher in septic patients than in controls (two-way anova, p \ . ), while the levels of il- and il- were comparable between septic patients and controls. the septic patients presented the highest levels of nucleosome on the admission day, which was significantly different from the admission levels of nucleosome in controls ( . ± . vs. . ± . , p \ . ). the plasma levels of nucleosome between survivors and nonsurvivors showed no statistical significance.conclusions. plasma levels of nucleosome may serve as a valuable biomarker for sepsis.introduction. high mobility group box protein (hmgb- ) is a cytokine that can mediate inflammatory response in different conditions included rheumatoid arthritis, infections, sepsis and septic shock. hmgb- released by activated macrophages/monocytes acts as a late mediator of sepsis. studies have shown that serum hmgb- concentrations were elevated in patients with severe sepsis.objectives. in the present study, we evaluated the role of the hmgb- levels at the time of admission at the intensive care unit (icu) as predictor of outcome in patients with sepsis and septic shock.methods. forty-four patients admitted to the icu with sepsis and septic shock was recruited. serum samples were obtained at the time of admission for the determination of hmgb- levels. the results were correlated with the origin of sepsis, severity, organ dysfunction, requirements of mechanical ventilation and vasoactives, days at the icu, comorbidities and mortality at the icu and days after admission. twenty-six patients were male ( . vs. . %). septic shock was present in patients ( . %). the mortality rate at the icu was . % (n = ) and . % (n = ) at day th. hmgb- levels were . ng/ml ± . ( . - . ng/ml). hmgb- levels were significantly higher in non-survivors at the icu than in survivors ( . ng/ml ± . vs. . ± . , p \ . ). higher levels of hmgb- in serum at the admission were correlated with a higher mortality rate in the icu (p \ . ) but not at day th (p = . ). these levels were not correlated with days at the icu, requirements of vasoactives, mechanical ventilation, and apache score.conclusions. the determination of hmgb- levels at admission at the icu in patients with sepsis and septic shock is a good predictor of worse outcome and lethality.introduction. recent experimental and clinical data ( , ) support the hypothesis that costimulatory molecules, such as cd , play an essential role in the innate immune response during sepsis. expression of cd on the surface of monocytes could represent an important pathway in the modulation of the production of several key inflammatory mediators.objectives. to investigate whether the expression of cd molecule on the surface of plasma monocytes differs among the various stages of sepsis. a total of participants ( icu patients with sepsis, icu patients with septic shock and healthy controls) were included in the study (male patients . %, mean age . ± . years). inclusion criteria: icu patients on mechanical ventilation with first episode of sepsis or septic shock during current hospitalization. exclusion criteria: immunosuppression, neoplasia, autoimmune disease, cardiovascular disease. age, gender and comorbid conditions were recorded. a blood sample for quantification of cd expression was obtained at the time of enrollment (day ), and on the fifth day after the onset of sepsis; measurement was made on the same day. cd expression on the surface of plasma monocytes (on days and ) was assessed by flow cytometric analysis. statistical analysis: kruskal-wallis test to identify difference of cd expression among the groups was performed. post-hoc analysis was made by mann-whitney u test between independent groups, using bonferroni correction for multiple comparisons. roc curve analysis was used to determine the accuracy of cd in identifying patients with sepsis or septic shock. patients with sepsis had significantly higher levels of cd (day ) compared with healthy controls subjects ( . ± . vs. . ± . , p b . ). on the contrary, patients with septic shock did not show any significant difference compared with controls. a roc curve analysis for cd (day ) (auc = . , p b . ), revealed that a cut-off value of . could predict patients with sepsis with a sensitivity of % and a specificity of %.conclusions. upregulation of cd expression may reflect a protective phenomenon during sepsis. on the contrary, low cd expression could represent impaired immune function associated with more severe disease. in order to increase the cardiac output in the septic shock patients, according to surviving sepsis campaign team, norepinephrine (ne) or dopamine administration was recommended. the both agents increase the sympathetic tone which antagonize against parasympathetic activity used for gastrointestinal motility (involved gastric emptying). then, it is raised a question whether ne delayed the gastric emptying or not.objectives. this study was aimed to evaluate the gastric emptying in the septic shock patients with norepinephrine. a prospective observational study involved adult septic shock patients, who received ne continuously in icu sardjito general hospital (yogyakarta, indonesia). patients with any head pathologies (trauma, surgical procedures for tumor or bleeding), any gastrointestinal or abdominal pathologies (diarrhea, trauma, surgical procedures for cancer, peritonitis, ileus etc.), and administrations of metochlopramide or alinamin were excluded. nutrition fluids ( ml) was given passively via nasogastric tube, then after min the tube was aspirated. the volumes of aspirates were recorded in % as a gastric residue. once measurement was done with time randomly for every patient. at the measurement time were recorded the dose of ne and the vital signs.results. the gastric residues were . ± . % ( patients), . ± . % ( patients) and . ± . % ( patients) for the doses of ne of . , . and . lg/kg b.w./ min respectively. at the ne doses of . , . and . lg/kg b.w./min, all of the gastric residues were zero ( patients). the correlation between the ne doses and the gastric rescues was statistically significant (p: . ). the mean arterial pressures (map) were . ± . mmhg (ranges from to mmhg. there was no significantly correlation between map and the gastric residues.conclusions. the gastric emptying in the septic shock patients was not disturbed by administration of ne. introduction. anemia is a frequently encountered problem on the intensive care unit. several factor lead to anemia, among which are traumatic blood loss and the drawing of blood for routine laboratory tests. it's not known how this may affect innate immunity. hepcidin is a central regulator of iron homeostasis. it is induced in response to iron and inflammation and reduced in response to anemia and hypoxia. the suppression of hepcidin leads to the internalization and degradation of the iron exporter ferroportin on intestinal cells and macrophages, leading to the uptake of iron from the gut and the release of iron from the macrophages from the reticulo-endothelial system (res). these cells are central to the innate immune response and the altered iron status of these cells due to suppression of hepcidin may affect the inflammatory response of these cells. we tested the hypothesis that phlebotomy in human volunteers would lead to a suppression of the innate immune response. this abstract provides data of a pilot study carried out in subjects. to investigate the effect of phlebotomy on the innate immune response of whole blood in human volunteers.methods. three volunteers were subjected to the letting of ml of blood by phlebotomy. blood for the determination of hemoglobin and iron parameters, leucocyte count and differential, and hepcidin- was drawn at day , and after phlebotomy. further whole blood stimulation was carried out at each time point by adding . ml heparin anticoagulated whole blood to a prepared tube containing endotoxin, pam cis or rpmi as a control. final concentrations of lps and p c were ng/ml and lg/ml respectively. these tubes were incubated at °c for h and centrifuged for min at , g. the supernatant was frozen at - until the measurement of tnf-alfa and il- by elisa. cytokine production was corrected for the number of monocytes present. data are expressed as mean ± sem. hemoglobine decreased from . ± . mmol/l at baseline to . ± at day . it returned to normal at day . there were no apparent changes in serum iron levels. there was however a clear decrease in serum ferritin levels from ± at baseline to ? at day . leucocyte count and differentiation did not show any significant changes. hepcidin was clearly suppressed from to day after phlebotomy (from ± to ± ). tnf-alfa production dropped from to ng/ monocytes at day . il- production dropped from to ng/ monocytes. hepcidin levels correlated well with cytokine production (r . for tnf-alfa, r . for il- ).conclusions. phlebotomy leads to suppression of the innate immune response in whole blood. this could be a result of the intracellular decrease of iron in immune cells due to the systemic suppression of hepcidin. these findings are relevant to critical care patients that are subject to the repeated drawing of blood while their immune system is often compromised. introduction. hypothermia and hyperthermia occur in many pathological states presenting to the emergency department. both these processes are known to significantly impair coagulation pathways but as yet there is little evidence to show what affect they have on the evolving clot structure. previous studies have attempted to determine the effect of temperature on whole blood coagulation using techniques such as thromboelastometry (teg) but its ability to provide meaningful outcomes in terms of clot quality and structure remains elusive. recent studies have highlighted the potential of a new technique, gel point (gp) and fractal dimension (d f ), as a functional biomarker in haemostasis. to explore both the changes in coagulation pathways and their associated effect on clot structure and quality based on the new biomarkers, gp and df. following full ethical approval, healthy whole blood samples were obtained from individuals and tested at temperatures of °c (n - ), °c (n - ), °c (n - ), °c (n - ), °c (n - ). an oscillatory shear technique [ ] using an ar-g instrument (ta instruments) was applied to each sample. the gp, which indicates the formation of the fibrin network, was obtained for each sample using the chambon-winter gel point criterion [ ] . this method provides the basis from which d f can be determined [ ] to interpret the structural properties of the clot network. the results were compared with the standard teg analysis. firstly, results showed a significant progressive change in the clot structure by this new biomarker across the whole temperature range ( - °c). secondly, it also highlighted a significant and meaningful correlation between coagulation pathway change (time to gp, tgp) and the eventual clot outcome (fractal dimension). the tgp of the incipient clot was prolonged and the corresponding d f decreased with reduced temperature values. although, the changes in the coagulation pathway of the teg (r time) and the rheometer (tgp) correlated, the new biomarker, d f , provided additional structural data on the fibrin network formed and highlighted the relationship between coagulation pathway changes and the eventual fibrin clot structure.conclusions. in this study, we describe and quantify for the first time how temperature affects the coagulation pathways and how this impacts on the fibrin clot network, morphology and strength by using the new biomarkers, gp and d f . the potential of these new biomarkers in determining the effects of temperature change in critical illness and injury needs to be evaluated clinically. key: cord- -srt jh authors: peters, e.j.g.; collard, d.; van assen, s.; beudel, m.; bomers, m.k.; buijs, j.; de haan, l.r.; de ruijter, w.; douma, r.a.; elbers, p.w.g.; goorhuis, a.; gritters van den oever, n.c.; knarren, g.h.h.; moeniralam, h.s.; mostard, r.l.m.; quanjel, m.j.r.; reidinga, a.c.; renckens, r.; van den bergh, prof, j.p.w.; vlasveld, i.n.; sikkens, j.j. title: outcomes of persons with covid- in hospitals with and without standard treatment with (hydroxy)chloroquine date: - - journal: clin microbiol infect doi: . /j.cmi. . . sha: doc_id: cord_uid: srt jh objective: to compare survival of subjects with covid- treated in hospitals that either did or did not routinely treat patients with hydroxychloroquine or chloroquine. methods: we analysed data of covid- patients treated in hospitals in the netherlands. inclusion dates ranged from february (th) , to may (th), when the dutch national guidelines no longer supported the use of (hydroxy)chloroquine. seven hospitals routinely treated subjects with (hydroxy)chloroquine, two hospitals did not. primary outcome was -day all-cause mortality. we performed a survival analysis using log-rank test and cox-regression with adjustment for age, sex and covariates based on premorbid health, disease severity, and the use of steroids for adult respiratory distress syndrome, including dexamethasone. results: among included subjects, -day mortality was . % in subjects treated in hospitals that routinely prescribed (hydroxy)chloroquine, and . % in subjects that were treated in hospitals that did not. in the adjusted cox-regression models this difference disappeared, with an adjusted hazard ratio of . ( %ci . - . ). when stratified by actually received treatment in individual subjects, the use of (hydroxy)chloroquine was associated with an increased -day mortality (hr . ; %ci . - . ) in the full model. conclusions: after adjustment for confounders, mortality was not significantly different in hospitals that routinely treated patients with (hydroxy)chloroquine, compared with hospitals that did not. we compared outcomes of hospital strategies rather than outcomes of individual patients to reduce the chance of indication bias. this study adds evidence against the use of (hydroxy)chloroquine in hospitalised patients with covid- . the spread of sars-cov- , leading to the current pandemic of covid- , has a profound global impact on daily life, morbidity and mortality. several preliminary studies have reported that the antimalarial agents hydroxychloroquine and chloroquine, or (h)cq, alone or in combination with the antibiotic azithromycin, can have a suppressive effect on the viral replication, and might decrease the mortality of covid- - . so far, clinical studies have been hampered by confounding by indication , , , , monocentre setup , , and small numbers of included subjects . a recently published systematic review , a published randomized controlled trial and an rct only available in pre-print , suggested that hydroxychloroquine is not effective in patients admitted to hospital. side effects of (h)cq are well-known, and include fever and cardiac arrhythmias. while we are awaiting definite results from more rcts, cohort studies can provide quick closure of existing knowledge gaps. when treatment assignment in cohort studies is based on prescriber discretion, the risk of indication bias (even after covariate adjustment) remains high. however, our database of dutch hospitals contains data of subjects from hospitals that either routinely prescribed (h)cq or did not prescribe it at all, offering a unique opportunity to compare both strategies. the comparison of different treatment strategies among hospitals leads to a significant reduction of (indication) bias. the objective of this study was to compare the effect of hospital-wide covid- treatment strategies with or without routine (h)cq use on all-cause -day mortality. we used data from the ongoing covidpredict clinical course cohort containing over , persons with covid- , from hospitals in the netherlands, including two university hospitals. included in the database were all subjects admitted to hospital with positive sars-cov- pcr of nasopharynx, throat, sputum or bronchoalveolar lavage samples, or ct-scan abnormalities that were typical for covid- (co-rads and ) , without another explanation for the abnormalities than inclusion dates ranged from the first admitted case in the netherlands on february th , to may th , when the dutch national guidelines no longer advised the use of (h)cq. we excluded patients < years and patients who were transferred to or from another hospital. dosage of chloroquine base was: loading dose of mg, followed by mg twice a day for a total of days. dosage of hydroxychloroquine sulphate was mg twice daily on the first day, followed by mg twice daily on days to . among the seven (h)cq-hospitals, the timing of start of (h)cq treatment differed; three hospitals started at the moment of covid- diagnosis, four started after diagnosis but only when patients clinically deteriorated e.g., when there was an increase in respiratory rate or increase in use of supplemental oxygen. the two hospitals that did not routinely treat subjects with (h)cq (i.e., the non-(h)cq-hospitals), offered best supportive care, including oxygen therapy and potentially antibiotic therapy, according to local guidelines and prescriber discretion. participating hospitals did not routinely prescribe other experimental medication (e.g., lopinavir/ritonavir, remdesivir or steroids, see table ). subjects who were incidentally treated with these drugs were included in the study. primary outcome was -day all-cause mortality, defined as hospital mortality, or discharge to a hospice care facility. a waiver for the use of hospital record data was obtained through the institutional review board of amsterdam umc; however, patients were given the opportunity to opt out. we collected data according to the collection protocol of the world health organization. missing covariates were imputed using multiple imputation with the mice package (version . . ) and the outcomes were determined by pooling the results of imputed datasets . j o u r n a l p r e -p r o o f we performed a regression analyses and determined the pooled effect. missing data range for all covariates was less than . %, except for obesity (missing data . %) and use of corticosteroids ( . %). in the primary analysis, we compared effectiveness of (h)cq versus non-(h)cq hospital strategies, irrespective of actual individual (h)cq treatment. we performed a survival analysis using log-rank test and cox-regression with adjustment for age, sex, time in the pandemic (i.e., the number of elapsed days after march st at hospital admission),and covariates based on premorbid health (i.e., history of lung, kidney and cardiovascular disease, diabetes mellitus, obesity, and neoplasms or hematologic disease), disease severity during presentation (respiratory rate, oxygen saturation) and the use of steroids, including dexamethasone, for adult respiratory distress syndrome (ards) , . we repeated the analyses comparing actually received treatment, with (h)cq. in a secondary analysis, we used a composite endpoint (either mechanical ventilation or all-cause mortality) at days. as a sensitivity analysis, we performed a complete case analysis using inverse probability weighting of propensity scores (determined using the same covariates). we performed a subgroup analysis in (h)cq hospitals that started (h)cq directly from the moment of diagnosis versus outcomes in non-(h)cq hospitals. all statistical analyses were performed using r versions . . (r table . follow-up data were missing for ( . %) subjects. the patients with missing outcome data were included table saturation during admission were similar in both hospital groups (see table ). in (h)cq-hospitals, . % of subjects received corticosteroids for ards and . were in a study protocol of an experimental sars-cov- directed antiviral (e.g., lopinavir/ritonavir) or immunomodulatory drug trial (e.g., imatinib, anti-complement c ), versus . % and . % in non-(h)cq-hospitals, respectively. table ). when stratified by actually received treatment, the use of (h)cq was associated with an increased -day mortality (hr . ; %ci . - . , table ) in the full model. in the secondary analysis with either mechanical ventilation or all-cause mortality at days, there were no statistically significant differences between the (h)cq and non-(h)cq hospitals (crude p= . , adjusted hr . ( %ci . - . ), online supplement ). the complete analysis using propensity scores for treatment strategy and actual treatment showed similar results (see table ). an overview of the distribution of the strength of this study is that data were collected in nine hospitals, including two university hospitals, in the netherlands during the covid- epidemic. data collection was set up prospectively and the database included data on all consecutive subjects admitted to general medicine and pulmonology wards, and to intensive care units. the database was set up according to the who standards, which enabled data comparison and uniformity of data among the different participating centres. the comparison of hospital-defined treatment strategies rather than the treatment actually received led to a lower risk of indication bias compared with previous studies , , , . we roughly estimate the extend of the effect of indication bias to be the difference in outcome between the uncorrected and the corrected model. further strengths include the multicentre setup , , as mentioned above, and the relatively large numbers of included subjects . there are some limitations we need to address. although health care in the netherlands has a homogeneous setup, there was some variability in standard protocols among the hospitals that could j o u r n a l p r e -p r o o f have led to residual confounding. the two non-(h)cq-hospitals were tertiary (university) centres, whereas the (h)cq-hospitals comprised both secondary and tertiary care hospitals. before the covid- pandemic, the tertiary care hospitals and their intensive care units function as referral centres for local secondary care hospitals. since we excluded subjects transferred to and from other hospitals, the referral role of the tertiary care hospitals, including the university hospitals, was minimized. furthermore, subjects in the (h)cq hospitals were more likely to receive steroid treatment, while subjects in the non-(h)cq hospitals were more likely to receive other experimental immunomodulatory drugs. the numbers of the individual types of medication were small, making it impossible to draw conclusions from these differences. the results of the recovery trial, suggested a lower mortality in patients treated with dexamethasone . treatment with dexamethasone could therefore have resulted in a lower mortality in the group of (h)cq hospitals. we did not find such an effect, even after correction in the full model. we also used extensive covariate adjustments, using various methods to minimize influence of differences in patient population among hospitals, and the similarity in outcomes between these methods is reassuring in this regard. show a benefit of (h)cq treatment. this may be explained by the timing of the administration of the drug and its specific working mechanism. chloroquine binds in silico and in vitro with high affinity to sialic acids and gangliosides of sars-cov- . these bindings inhibit the interaction at non-toxic plasma levels with ace- receptors and could hypothetically stop the cascade from formation of pulmonary infiltrations to full blown ards and death [ ] [ ] [ ] . the antiviral activity might be more effective in the pre-clinical setting as the deterioration in the hospital is more an effect of the cytokine storm provoked by sars-cov- than an effect of the viral infection itself. this hypothesis might explain why the clinical benefit for admitted subjects was absent in our study, although we did not observe a difference in outcome among subjects treated early (at diagnosis) and among those treated later upon clinical deterioration. j o u r n a l p r e -p r o o f j o u r n a l p r e -p r o o f j o u r n a l p r e -p r o o f association of treatment with hydroxychloroquine or azithromycin with in-hospital mortality in patients with covid- in observational study of hydroxychloroquine in hospitalized patients with covid- hydroxychloroquine and azithromycin as a treatment of covid- : results of an open-label non-randomized clinical trial use of hydroxychloroquine in hospitalised covid- patients is associated with reduced mortality: findings from the observational multicentre italian corist study low-dose hydroxychloroquine therapy and mortality in hospitalized patients with covid- : a nationwide observational study of participants effect of hydroxychloroquine with or without azithromycin on the mortality of covid- patients: a systematic review and meta-analysis hydroxychloroquine in patients with mainly mild to moderate coronavirus disease : open label, randomised controlled trial effect of hydroxychloroquine in hospitalized patients with covid- : preliminary results from a multi-centre, randomized, controlled trial co-rads -a categorical ct assessment scheme for patients with suspected covid- : definition and evaluation multiple imputation by chained equations in praxis: guidelines and review clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study factors associated with hospital admission and critical illness among people with coronavirus disease a practical guide to propensity score analysis for applied clinical research dexamethasone in hospitalized patients with covid- -preliminary report structural and molecular modelling studies reveal a new mechanism of action of chloroquine and hydroxychloroquine against sars-cov- infection connecting hydroxychloroquine in vitro antiviral activity to in vivo concentration for prediction of antiviral effect: a critical step in treating covid- patients in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus (sars-cov- ) key: cord- - el tx v authors: weese, j. scott title: barrier precautions, isolation protocols, and personal hygiene in veterinary hospitals date: - - journal: veterinary clinics of north america: equine practice doi: . /j.cveq. . . sha: doc_id: cord_uid: el tx v because nosocomial and zoonotic diseases are inherent and ever-present risks in veterinary hospitals, proactive policies should be in place to reduce the risk of sporadic cases and outbreaks. policies should ideally be put in place before disease issues arise, and policies should be effectively conveyed to all relevant personnel. written policies are required for practical and liability reasons and should be reviewed regularly. although no infection control program can eliminate disease concerns, proper implementation of barrier precautions and isolation can reduce the exposure of hospitalized animals and hospital personnel to infectious agents. appropriate personal hygiene, particularly hand hygiene, can assist in the prevention of disease transmission when pathogens bypass barriers and are able to contact personnel. veterinary hospitals have moral, professional, and legal requirements to provide a safe workplace and to reduce the risks to hospitalized patients. based on experience in the human medical field and on the continual emergence of new infectious diseases, infection control challenges can only be expected to increase in the future. regular reassessment of protocols based on ongoing research and clinical experiences is required. reduce the risk of infection of hospitalized animals with pathogens from the resident microflora of hospital personnel. in human medicine, prevention of transmission of bloodborne pathogens, such as hiv, hepatitis b virus, and hepatitis c virus, from patients to health care workers (hcws) is a major concern [ , ] . the epidemic of hiv in the general population and hcws led to the development of universal precautions. based on universal precautions, infection control practices are applied to all patients, regardless of known or suspected infectious disease status, and emphasize the prevention of any contact with blood or certain body fluids [ ] . in veterinary medicine, there currently are not the same concerns about transmission of bloodborne pathogens to veterinary personnel. indeed, the attitude toward blood contamination in veterinary medicine is somewhat cavalier. nevertheless, it is critical to remember that new diseases are emerging at all times and that many of these new diseases are zoonotic. just because there is minimal concern about bloodborne pathogens of horses at this point in time does not mean that there is no risk posed by exposure to equine blood now or in the future. it is prudent to ensure that adequate precautions be taken now rather than waiting for the infection of large numbers of veterinary personnel to stimulate change, as occurred in human medicine. although the initial focus of barrier precautions in human hospitals was prevention of disease in hcws, increasing attention has been paid to the role of hcws in dissemination of pathogens in human hospitals. the dissemination of multidrug-resistant (mdr) pathogens and the severe impact of mdr infections in human hospitals have led to changes in protocols to limit the spread of these organisms within hospitals. the use of barrier precautions has been an important part of these protocols; however, the efficacy and necessity of these protocols are unclear. in the united states, the occupational safety and health administration (osha) has mandated that hcws have access to appropriate personal protective equipment. the type of personal protective equipment required for each situation has been left to the discretion of the employee and employer; however, potentially contaminated body fluids are not to reach the employee's work clothes or street clothes, undergarments, skin, eyes, mouth, or other mucous membranes [ ] . the level of barrier protection required would thus depend on the risk of contact with body fluids of concern, the potential for splashing or aerosol exposure, the volume of fluid that might be produced, and the duration of exposure [ ] . these same points are relevant in the veterinary context. veterinary hospitals need to be aware of osha or equivalent rules to provide a safe workplace and avoid potential liability. thus, the development of appropriate infection control protocols, including barrier precautions, is required. in general, consideration must be given to the route of pathogen transmission: contact (direct or indirect), droplet, airborne, common vehicle (eg, equipment, medical devices), and vector borne. standard protective outerwear includes clean coveralls, laboratory coats, scrubs, or other dedicated clothing (eg, hospital uniforms). protective outerwear should be changed whenever it is visibly soiled or otherwise contaminated with body fluids perceived or known to pose a risk (eg, feces, blood, nasal exudates, urine or uterine fluid). additionally, outerwear should be changed frequently (at least daily), because gross contamination does not need to be present for pathogen contamination to have occurred. hospital personnel should change their hospital outerwear before leaving the building; coveralls, laboratory coats, surgical scrubs, and related items should not be worn out of the hospital setting. wearing protective outerwear home increases the risk of transmission of pathogens from the hospital to the household and from animals at home to hospitalized animals. all veterinary hospitals should provide laundry services so that outerwear does not leave the building. gloves are an important component of most, if not all, barrier protocols. the centers for disease control and prevention (cdc) recommend glove use by hcws to reduce the risk of transmission of infections from patients to personnel, to prevent hcw skin flora from being transmitted to patients, and to reduce transient contamination of the skin on hands of personnel by microorganisms that can be transmitted from one patient to another [ ] . glove use has been shown to be an effective means of reducing pathogen transmission in human medicine. the use of gloves during peripheral venous catheter placement has been demonstrated to reduce the frequency of complications in human patients compared with regular handwashing [ ] . glove use has been an important part of successful infection control programs in human hospitals [ ] [ ] [ ] , although the relative effect of glove use versus concurrently applied measures is sometimes difficult to interpret. it has been suggested that universal glove use in human hospitals might be preferable for prevention of transmission of mdr bacteria, because as many as to patients may be colonized for every patient known to be infected [ ] . to the author's knowledge, there are no published standards for glove use in veterinary hospitals apart from the use of sterile gloves during surgery. examination gloves that are clean but not sterile are often used when handling wounds, infected body sites, and animals known or likely to be shedding pathogens in body fluids from orifices or on their skin; however, widespread use of examination gloves and protocols regarding glove use are not common. at the ontario veterinary college veterinary teaching hospital (ovc-vth), a policy requiring glove use for any contact with equine patients was instituted in response to nosocomial and zoonotic transmission of methicillin-resistant staphylococcus aureus (mrsa). whether this has reduced the transmission of mrsa or other mdr bacteria at the ovc-vth is under investigation. objective data are not available to help develop glove use protocols for veterinary hospitals; however, it is reasonable to recommend that gloves be worn whenever there might be contact with nasal secretions; feces; or discharge from surgical incisions, draining abscesses, or wounds. education of hospital personnel is important so that glove use does not result in less emphasis on hand hygiene. gloves may have small inapparent defects or be torn during use, and hands may be contaminated while removing gloves. hand hygiene measures should be performed immediately after glove removal. if gloves are used to handle potentially contaminated items and not immediately discarded, they are not acting as an effective barrier in preventing the spread of nosocomial pathogens to surfaces or other patients, although they may still be protecting the wearer. care should be taken to remove gloves before handling items like pens, stethoscopes, thermometers, stall surfaces, medical records, pagers, telephones, and cabinet or door handles. gloves should be changed between all patient contacts. for more than a century, gowns have been used to prevent transmission of disease to hcws and patients [ ] . gowns have most commonly been used in surgery; however, their use in hospital wards is increasing. the cdc has produced guidelines stating that ''gowns are worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from patients or items in their environment to other patients or environments'' [ ] . gowns should be worn whenever direct contact with the patient or indirect contact with the environment or patient care items may result in transmission of pathogens. a variety of types of gowns are available in terms of the degree of body coverage and the material the gown is made of. the ideal barrier gown would cover all areas of the body that might become contaminated, prevent penetration of liquids, be of adequate strength to resist tearing and puncture under normal activities, be comfortable to wear for long periods, be available in appropriate sizes for all personnel, be nonabrasive to skin, and be of acceptable cost [ ] . neither the overall effectiveness of gowning nor the effectiveness of different gowns in veterinary situations has been adequately evaluated. all these factors must be considered when choosing a gown for use in a hospital (nonsurgical) situation. in particular, the ability to resist contamination during anticipated animal contacts, ease of use, and cost are important. the most likely problem in veterinary practice is poor resistance to liquids, especially under direct contact or pressure. in equine medicine, there is a greater likelihood of high-volume contact with fluids (ie, diarrheic horse) or direct contact with patient surfaces that would have moist secretions or excretions (ie, horse with nasal discharge rubbing against personnel). these types of high-risk situations must be considered when choosing an appropriate gown. additionally, prolonged contact with potentially infectious patients, such as with -hour nursing care of neonatal intensive care unit foals, creates additional problems. if gowns do not cover the entire body (eg, gowns that do not cover the lower extremities) and hospital personnel are in prolonged contact situations with foals, the likelihood of contamination is high. full body gowns may be more appropriate in these situations. there is more evidence supporting the effectiveness of gowns in preventing disease transmission to hcws compared with the prevention of spread of nosocomial disease [ ] . some studies have failed to show any benefit of gowning in specific situations, such as newborn units and neonatal intensive care units [ ] [ ] [ ] , whereas others have reported significant beneficial effects on nosocomial disease [ ] [ ] [ ] . in particular, the use of gowns that offer little resistance to liquid penetration and those that leave the lower extremities exposed have been questioned. perhaps the main advantage of gowns in these situations is raising awareness of the potential infectious nature of the patient and encouraging the concurrent use of other appropriate infection control protocols. protective eyewear, including goggles and face shields, is used in human medicine during procedures in which sprays of blood, body fluids, and secretions may occur [ ] , and the use of these items is mandated in some instances by the osha bloodborne pathogens final rule [ ] . the use of eye protection in equine hospitals is extremely uncommon, perhaps justifiably so, considering the low prevalence of bloodborne zoonotic pathogens in horses. nevertheless, it would be prudent to consider the use of these items when spraying of potentially infected secretions may occur. normal surgical masks may be effective against the spread of large particle droplets that are transmitted by close contact and travel only short distances (up to ft) from infected patients [ ] . transmission of severe acute respiratory syndrome to hcws prompted re-evaluation of the effectiveness of normal surgical masks in the prevention of disease transmission. one study reported that wearing of surgical or n masks (but not paper masks) by staff was associated with protection [ ] . other authors have questioned the overall effectiveness of surgical masks in hospital situations [ ] . airborne transmission of zoonotic pathogens from horse to veterinary personnel is thought to be of minimal concern in most hospital settings, and mask use is uncommon in veterinary hospitals apart from surgical procedures. surgical masks might be useful for reducing transmission of mrsa. although mrsa is not considered to be spread via the airborne route, the main location of colonization of mrsa in hospital personnel is in the nasal passages, and hand-to-nose contact is frequent. thus, mask use prevents direct contact between the hand and nose, thereby decreasing hand contamination or decreasing the risk of inoculation of the nose after contamination of the hands during contact with a horse. the actual benefit of masks during short-term patient contact situations is unclear. basic barrier techniques must be used in all veterinary hospitals. clean protective outerwear must be worn by all hospital personnel. the use of other barrier techniques is much more variable and should be directed at control of specific diseases or syndromes. it is important that written protocols outlining the required level of barrier protection be available. gowns and overboots are the most commonly used items for additional barrier protection, but masks, caps, and eye protection may be required at times. in some facilities, overboots are not used but personnel are required to wear rubber boots that are easy to disinfect, and disinfection of boots is required after exiting potentially contaminated areas. determination of the required level of barrier precautions may be based on clinical findings (ie, diarrhea, fever of unknown origin, nasal discharge), farm history (eg, endemic disease, recent infectious diseases on farms), or the nature of the disease. at some hospitals, mainly those in regions where salmonellosis is of particular concern, all horses with colic are treated as if they may be shedding salmonella. common protocols for these equine patients include the use of gloves, gowns, and overboots; restriction of movement in the hospital; and provision of dedicated medical equipment (eg, thermometers, nasogastric tubes, buckets). an understanding of the incidence of pathogen shedding by certain groups within the equine population is required to define appropriate protocols. thus, ongoing active and passive surveillance of nosocomial infection rates plays a key role in determination of the appropriate barrier protocols. barrier precautions, as a whole, have been successful in controlling some outbreaks of nosocomial disease [ , ] but not others [ ] . the reasons why barrier precautions are variably effective is difficult to determine; however, nosocomial infection is a complex multifactorial process, and the individual effects of certain factors are difficult to discern. like most other infection control methods, barrier precautions are only effective if used appropriately, and poor compliance is an ever-present concern that can have a negative impact on the entire infection control program. failure of barrier techniques may involve inherent weaknesses in the items used, inappropriate selection of items, inappropriate use of items, inadequate training of personnel, or the inherent inability of barrier precautions to prevent pathogen transmission completely in all cases. it is important that barrier items do not create a false sense of security. barrier items are useful but by no means % effective at preventing transmission of pathogens. it is critical that veterinary personnel use all adjunctive infection control techniques (ie, hand hygiene) and not rely solely on barriers. the reported variability in the benefits of barrier precautions should not dissuade hospitals from implementing these protocols. the use of quarantine to prevent transmission of human or animal disease dates back to biblical times and was widespread in the middle ages [ ] , predating understanding and acceptance of the ''germ theory.'' published recommendations for isolation protocols appeared as early as [ ] . the early emphasis was on segregating certain patients in ''infectious disease hospitals,'' which continued to have high levels of nosocomial disease because of a lack of barrier precautions, asepsis, and separation of patients according to their disease [ ] . these hospitals were closed over time as better infection control practices and hospital designs were developed [ ] . isolation protocols are designed with two basic goals in mind: prevention of transmission of pathogens from infected animals to other animals, people, or the hospital environment and prevention of nosocomial infection to high-risk individuals. guidelines published by the cdc in and recommended that hospitals divide isolation precautions into a variety of categories: strict isolation, respiratory isolation, protective isolation, enteric precautions, wound and skin precautions, discharge precautions, and blood precautions [ , ] . the protocols for each category were based on epidemiologic features of diseases in the given category. in , guidelines were revised to allow for more decision making on the part of the users [ ] . hospital infection control committees were given broader powers to develop their own protocols considering the circumstances and environment specific to the hospital. category-specific guidelines were modified and consisted of strict isolation, contact isolation, respiratory isolation, tuberculosis isolation, enteric precautions, drainage/secretion procedures, and blood and body fluid precautions [ ] . further changes occurred later, largely in response to the hiv epidemic, and these earlier categories may be most relevant to veterinary hospitals at this point. in veterinary hospitals, there has been less attention paid to the development of standardized protocols for different diseases or categories. it is logical, however, that veterinary hospitals design appropriate guidelines to deal with diseases of concern in their area and hospital. most isolation protocols have been developed to limit transmission of salmonella. whether all these protocols are necessary for other pathogens, such as viral respiratory pathogens and mdr bacteria, needs consideration, as does whether extra precautions are required in some instances. at a minimum, strict isolation, respiratory isolation, contact isolation, enteric precautions, and drainage/ secretion isolation protocols based on cdc recommendations should be considered, and veterinary-specific guidelines for working with those classes should be developed. identification of the isolation status of patients is critical. this is particularly important when horses may be housed under isolation protocols implemented in the main hospital. appropriate signage should be used to make it clear to all personnel that the animal may be infectious and that additional protocols must be used. at the colorado state university veterinary teaching hospital, a color-coding system is used to indicate the infectious disease status of each patient (p. morley, dvm, phd, personal communication, ). under this system, adhesive dots are placed on the stall cards of all animals. red dots indicate animals with a known highly contagious disease. yellow dots indicate that the animal is suspected of having an infectious disease or is at increased risk of acquiring an infectious disease. green dots indicate that the animal is not suspected of carrying a relevant infectious agent and that it is not at an increased risk of acquiring an infectious agent compared with the general hospital population. this type of system is easy to apply and easy to understand and should be considered in all hospitals. additionally, more prominent signs can be used to indicate certain concerns (ie, salmonella, mrsa, rabies suspect) more clearly to all personnel. isolation units should be designed so that, apart from surgical procedures, horses rarely, if ever, have to leave the unit. stocks, examination areas, and weight scales should be available if possible. the isolation unit should be designed so that there is minimal movement of personnel and items between it and the main hospital. changing rooms with showers are ideally present in the unit. preferably, the isolation unit should be physically separated from the main hospital. in cold snowy climates, this may be problematic because of the difficulty in moving personnel, animals, and supplies. if the isolation unit is properly designed and largely self-sufficient in terms of supplies and staffing, these difficulties may be largely overcome, although there may be resistance from clinicians because of the additional effort required to evaluate animals in the isolation unit. much consideration should be given to the design of stalls in isolation units. in particular, the area of entry and means of manure disposal should be considered. anterooms containing routine supplies and medical records are commonly used. these rooms allow for containment of routine items used on the animal but can be a highly contaminated environment depending on the barrier methods used when in the stall, the method of removal of barrier items, and cleaning protocols for the stall and anteroom. if anterooms are stocked with routine items (ie, syringes, bottles of soap and disinfectant, medical records), consideration should be given to preventing contamination of these items and what to do with all items in the stall after an infectious animal is discharged. ideally, anterooms should be minimally stocked and all items disposed of when the animal leaves the hospital. any items returned to the hospital from an isolation stall should be cleaned and disinfected in the stall if possible, placed in a leak-proof bag, labeled as potentially infectious, and returned to the hospital to a designated area for further disinfection. contamination of the anteroom with manure should be avoided. ideally, there should be minimal contact of personnel with infectious animals and their stall environment. minimization of contact should not interfere with the delivery of appropriate veterinary care, however. sealed windows used as viewing sites allow for general inspection of patients without having to enter the stall or anteroom. closed-circuit televisions or web-cameras can be placed in stalls and projected to a central area for frequent remote monitoring. an added advantage of web-cameras is that remote password-controlled access from any computer can be established so that clinicians can evaluate the general appearance of the patient without even entering the isolation unit, let alone the stall. in some situations, a degree of increased barrier precautions or some physical distance from other patients when transferring a horse to the isolation unit is not indicated, practical, or desirable. examples of this would be when animals cannot be safely or effectively treated in isolation (eg, neonatal intensive care unit foals, horses with severe neurologic disease) or when the isolation unit is full. in these situations, some clinics use inhospital isolation or ''semi-isolation.'' in-hospital isolation protocols allow for an increased level of protection but are not a replacement for a proper isolation unit and should not be used solely for clinician convenience. it is critical that animals isolated within the main hospital be prominently identified, as discussed previously. protocols should be developed regarding the handling of animals, the stall, and the area around the stall. animals that are isolated in the hospital should not be walked outside their stall unless they are being moved for a required procedure. if they are moved, their feet should be picked out and scrubbed with an appropriate disinfectant (ie, . % chlorhexidine) at the time they leave the stall. one person should follow behind the horse to collect and appropriately dispose of any feces, and any areas potentially contaminated by the horse or its body fluids should be sprayed with disinfectant. people handling these horses should wear protective barrier clothing, such as full waterproof coveralls or a full-length waterproof gown, gloves, and dedicated footwear or boot covers. care should be taken to avoid clutter of potentially contaminated items (ie, barrier items, buckets, nasogastric tubes) outside the stall. the area around the stall entrance should be considered potentially infectious and disinfected routinely (at least three to four times per day). attention should be paid to the pattern of water drainage from the stall and in the area. if water runs from the stall to the breezeway or runs down the breezeway past the stall, housing of potentially or known infectious animals in the stall may be inappropriate. horses should not be able to come into direct contact with neighboring animals. barriers may be required if solid walls are not present on all sides. horses potentially carrying respiratory pathogens that can be spread via the aerosol route should not be housed in general ward areas. specific protocols should be developed for cleaning inhospital isolation stalls. these stalls should be cleaned last, personnel cleaning stalls must wear protective gear, and items used to clean the stall must be disinfected immediately after use. one of the major problems with barrier precautions is obtaining compliance by hospital personnel. ''time factors'' and ''too cumbersome'' were the most commonly reported reasons for noncompliance with barrier precaution protocols by trauma professionals in a human hospital [ ] . a similar study evaluated the use of barrier precautions during trauma resuscitations and reported that none of hcws in the study were in complete compliance with protocols for the use of barrier precautions; however, % wore gloves [ ] . the authors concluded that hcws are cavalier with respect to bloodborne diseases and that measures to encourage or force compliance are required. compliance is also of concern in isolation units in terms of admission of potentially infectious horses and the correct use of appropriate protocols. depending on the facility, there may be reluctance to admit certain moderate-risk patients to the isolation unit because of difficulties in case management, such as distance to the unit from the main hospital, time required to comply with all the isolation protocols, and the associated increased cost to the client. cost is another factor that may limit the use of barrier precautions. barrier precautions almost always involve the use of disposable items, and the cost of these items is not insignificant. at the ovc-vth, approximately us $ , is spent annually on disposable isolation gowns ($ , ), gloves ($ , ), and overboots ($ , ). although these figures are for the entire teaching hospital, most barrier items are used in caring for hospitalized equine patients. it is also important to note that glove use is required for any contact with horses in this institution, thereby explaining the use of more than boxes of examination gloves. in times of fiscal constraint, especially at veterinary teaching institutions, there may be reluctance to spend this amount of money without clearly demonstrated benefits. concerns about cost should be tempered with the consideration of the costs of nosocomial and zoonotic infections and costs of hospital closure and decontamination should major outbreaks occur. cost is also a concern with isolation facilities because they are expensive to build, maintain, and staff. isolation units should be designed so that enough stalls are present to allow contaminated stalls to be cleaned and disinfected, followed by a specific period when the stall remains empty between patients. ideally, isolation facilities should have dedicated personnel so that there is no cross-contact with the main hospital. this is not feasible in all situations, particularly in small hospitals, where the caseload does not justify full-time technical staffing. another area of concern that is difficult to quantify is the potential adverse effect of barrier precautions on patient care. if cumbersome protocols are required, particularly in busy hospitals, there may be a tendency to spend less time in direct contact with animals. in human medicine, it has been reported that certain infection control protocols may be a disincentive to enter patient rooms [ ] . in some aspects, this might be desirable, because infection control protocols should reduce personnel traffic and limit the potential for spread of pathogens. although limiting unnecessary contact is desirable, the concern is that medically required contacts may be limited and that patient care may be compromised. a recent study in a human hospital confirmed this suspicion, reporting significantly lower contact times with isolated patients, despite the isolated patients being more severely ill [ ] . results of this study clearly demonstrate that proper consideration be given to which patients to isolate and how to manage these patients to ensure proper care. of all the possible measures that can be taken to reduce nosocomial and zoonotic infection, hand hygiene is perhaps the most important, easiest to use, most cost-effective, and most underused measure [ ] [ ] [ ] . an understanding of the beneficial effects of hand hygiene dates back to the middle s and the astute observations of ignaz semmelweis [ ] . his institution of a mandatory hand disinfection program for clinicians and students resulted in a tremendous decrease in puerperal fever, which was a common cause of postpartum disease in women during that period. independently, oliver wendell holmes concluded that the hands of hcws spread puerperal fever, and he described methods for limiting the spread of disease [ ] . formal implementation of hand hygiene policies lagged tremendously, however, and it was well into the twentieth century before an emphasis began to be placed on hand hygiene. hands of hcws are thought to be the most common source of nosocomial infection; despite convincing data regarding the benefits of hand hygiene, particularly when compared with the overall dearth of other objective data regarding infection control measures, hand hygiene is still underused in the medical field. traditionally, handwashing with water and soap has been the standard for hand hygiene. the cleaning activity of soaps is from their detergent properties, which results in removal of debris from the hands [ ] . plain soaps have little if any effect on pathogens residing on the hands, however. it has been demonstrated that handwashing with plain soap fails to remove pathogens from the hands of hospital personnel [ ] . paradoxically, some studies have shown that handwashing with plain soap may increase bacterial counts on the skin [ , ] . handwashing with plain soap before intravenous catheter placement was reported to be no more effective than no hand hygiene at reducing the incidence of catheter complications in human patients [ ] . antimicrobial soaps are widely available in hospitals and have been demonstrated to be effective at reducing bacterial hand contamination. these may contain a variety of antimicrobial substances, including triclosan, hexachlorophene, povidone-iodine, and chlorhexidine [ ] . unfortunately, compliance with handwashing is typically poor. studies evaluating handwashing frequency in hcws have yielded disappointing results, with handwashing only occurring after . % to % of situations in which it was indicated [ , ] . in particular, physicians tend to have poor compliance with hand hygiene protocols [ ] . compliance with hand hygiene protocols is a major challenge for infection control programs. reasons given for poor compliance with hand hygiene include lack of time, poor access to proper handwashing facilities, and skin damage from repeated washing [ , ] . skin damage from repeated handwashing is a definite concern in hospital situations. the frequency of dermatitis can be high in personnel who wash their hands frequently. one study reported that % of nurses evaluated had clinical signs of dermatitis and % had a history of skin problems [ ] . damaged skin is of particular concern from an infectious control standpoint because it can harbor greater numbers of bacteria than normal skin. more recently, alcohol-based hand sanitizers have become popular. these products have many advantages over antimicrobial soaps, including their spectrum of antimicrobial activity, speed of activity, dermal tolerance, and ease of use. they also eliminate the chance for cross-contamination from water taps and paper towel dispensers [ ] . increasingly, hand hygiene guidelines are recommending the use of these products when gross contamination of hands is not present [ ] . most alcohol-based hand sanitizers contain % to % alcohol and may be in a gel or liquid form. recently, it has been suggested that an alcohol concentration of % or higher is desirable, and a product containing % alcohol is now available [ ] . although there are potential advantages of alcohol-based products in terms of effectiveness against microorganisms, the main advantage is ease of use. additionally, alcohol-based hand sanitizers can easily be placed throughout the hospital at minimal cost. as well, individual use bottles can be dispensed to health care providers to keep on their person for ease of use even when wall dispensers are not in the immediate area. sinks, on the other hand, are difficult and costly to add in an established facility. the use and effectiveness of hand hygiene in veterinary situations have not been adequately explored. although much of the information obtained in human medicine can be applied to veterinary hospitals, care must be taken with direct extrapolation of human studies. it is logical to assume that horses would have a higher endogenous bacterial load on their skin because of their haired coat and typical housing methods. this would translate into the potential for greater contamination of the skin on hands of veterinary personnel who handle horses compared with human health care providers. veterinarians typically wear gloves less commonly than their counterparts in the medical field, and there is a somewhat cavalier attitude taken toward hand contamination in veterinary medicine as compared with human medicine. gross contamination of hands with feces, discharge, and pus is likely more common, and access to handwashing facilities may be limited. effectiveness of hand hygiene in veterinary situations has not been thoroughly evaluated. a recent study reported that use of an alcohol-based hand sanitizer was more effective at reducing hand contamination after physical examination of horses than a -second handwash with antibacterial soap (j.l. traub-dargatz, dvm, ms, personal communication, ). this finding is important because it countered concerns that debris on the hands from animal contact might inhibit the efficacy of alcohol-based products. many facilities are now placing alcohol-based hand disinfectant dispensers widely throughout the hospital. at the ovc-vth, approximately dispensers have been placed. at some hospitals, individuals have been given small personal containers of hand disinfectant to carry around while on clinical duty. all hospitals should consider widespread placement of alcohol-based hand dispensers as part of the infection control program. the area under the fingernails tends to harbor large numbers of bacteria. hospital personnel with false fingernails have been shown to harbor more gram-negative bacterial pathogens under their fingernails before and after handwashing [ , ] . naturally long (> . in) fingernails may also affect the effectiveness of hand hygiene and harbor excessive bacteria [ ] . additionally, chipped nail polish may support the growth of larger numbers of bacteria on the fingernails [ ] . at the ovc-vth, people in animal contact positions are not allowed to wear false fingernails or nail polish and must keep their nails cut short. studies have indicated, not surprisingly, that skin underneath rings is more heavily colonized with bacteria compared with other areas on the fingers [ , ] . this may relate to a more hospitable environment for bacterial growth (eg, warm, moist, protected) and decreased exposure during handwashing. whether the wearing of rings is linked to transmission of disease is unknown and requires further study [ ] . in the interim, some facilities, including our institution, have restricted jewelry to wedding rings and wedding bands, although there has been little effort to evaluate and enforce compliance at this point. long neck chains and bracelets that could come into contact with animals are also of concern for safety (entanglement) and infection control reasons. although the risk of these items is unclear, it is reasonable to prohibit wearing of any jewelry items that could come into contact with animals. hospital personnel commonly carry cellular and wireless telephones, and these items have a high likelihood of becoming contaminated. frequently, personnel handle telephones if they are ringing regardless of the cleanliness of their hands or examination gloves. further, disinfection of telephones and pagers is rarely performed because of the possibility for damage to the telephone or pager. mrsa has been isolated from a wireless telephone in a veterinary clinic [ ] . pagers have a similar potential to become contaminated [ ] . the role of contaminated surfaces of telephones and pagers in pathogen transmission is unclear at this point but should be considered. unlike barrier materials, an additional concern about these items is that they frequently accompany personnel home and, if contaminated, could expose other individuals or animals at home. personnel training should emphasize that telephones and pagers should only be handled with clean hands. telephone covers that protect the telephone from contamination and can be routinely disinfected should be considered. personal medical items, particularly stethoscopes, have come under scrutiny as reservoirs of potential pathogens. stethoscopes have close and frequent contact with patient skin surfaces and can easily become contaminated. one study reported that % of doctors' stethoscopes had microorganisms on them, with most organisms being potential nosocomial pathogens [ ] . regular cleaning of the stethoscope bell and diaphragm with alcohol has been shown to reduce bacterial contamination significantly [ ] . stethoscopes should be cleaned at least once daily and after every contact with a potentially infectious horse. consideration should be given to providing dedicated stethoscopes for infectious cases and animals at greater risk of acquiring a nosocomial infection (ie, compromised neonatal foals). because nosocomial and zoonotic diseases are inherent and ever-present risks in veterinary hospitals, proactive policies should be in place to reduce the risk of sporadic cases and outbreaks. policies should ideally be put in place before disease issues arise, and policies should be effectively conveyed to all relevant personnel. written policies are required for practical and liability reasons and should be reviewed regularly. although no infection control program can eliminate disease concerns, proper implementation of barrier precautions and isolation can reduce the exposure of hospitalized animals and hospital personnel to infectious agents. appropriate personal hygiene, particularly hand hygiene, can assist in the prevention of disease transmission when pathogens bypass barriers and are able to contact personnel. veterinary hospitals have moral, professional, and legal requirements to provide a safe workplace and to reduce the risks to hospitalized patients. based on experience in the human medical field and on the continual emergence of new infectious diseases, infection control challenges can only be expected to increase in the future. regular reassessment of protocols based on ongoing research and clinical experiences is required. a review of single-use and reusable gowns and drapes in health care hospital infection control practices advisory committee. guideline for isolation precautions in hospitals department of labor occupational safety and health 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nurses bacterial transfer and cross-contamination potential associated with paper-towel dispensing spectrum of antimicrobial activity and user acceptability of the hand disinfectant agent sterillium gel effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers bacterial carriage by artificial versus natural nails a prolonged outbreak of pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission? microorganisms isolated from skin under wedding rings worn by hospital personnel handwashing: ringwearing and number of microorganisms isolation of methicillinresistant staphylococcus aureus from the environment in a veterinary teaching hospital pathogenic bacteria on personal pagers bacterial colonization of stethoscopes and the effect of cleaning stethoscope: a potential source of infection key: cord- - qc iur authors: chang, i-chiu; hwang, hsin-ginn; hung, ming-chien; kuo, kuang-ming; yen, david c. title: factors affecting cross-hospital exchange of electronic medical records date: - - journal: information & management doi: . /j.im. . . sha: doc_id: cord_uid: qc iur abstract adopting electronic medical record (emr) exchange may save patients’ lives and also improve their health. most electronic data interchange studies have considered commercial enterprises and necessary funding to support business activities, emr exchange focuses on saving patients’ lives. our study combined transaction cost and sociological perspectives to identify factors that affect a hospitals’ willingness to implement emr exchange. a survey was conducted with regional hospitals and medical centers in taiwan to justify the validity of a resulting model. our findings indicated that the model was valuable and determined which factors influenced the decision to implement emr exchange at these hospitals (perceived benefits, uncertainty, influence, and reciprocal investments). based on these findings, healthcare policy makers can promote emr exchange and hospitals can identify desirable partners that will form a strategic alliance to meet the dynamic challenges in the healthcare industry. during a patient's lifetime, she or he may visit many medical institutions and each may keep only a part of the treatment information for a restricted time. without access to a complete medical history, physicians are unlikely to provide proper medical care. in , the u.s. congress enacted the health insurance portability and accountability act (hipaa) to establish national standards for electronic retention and transmission of health data and national identifiers for healthcare providers, health insurance plans, and employers. in , a european union action plan for a european ehealth area was published to secure interoperability of ehealth systems that apply patient's electronic health records [ ] . taiwan implemented a universal health insurance policy in . the bureau of national health insurance (bnhi) granted a completely free choice of health-care providers and therapies to all insured citizens. consequently, patients scatter their medical records in every hospital and clinic they visit and this wastes resources through repeated examination. with electronic medical record (emr) exchange, doctors improve their diagnostic decisions and enhance patients' safety without wasting resources. in light of the e-government's success in taiwan, which has been ranked as one of the top five worldwide, the department of health (doh) was tasked with setting up the healthcare certification authority ic cards using public key encryption for medical institutes and medical staff. additionally, a survey in showed that % of taiwanese hospitals had computerized some of their patients' records and % were constructing an emr. as for the clinics, computerization of medical records had reached % [ ] . thus hospitals in taiwan have provided a good base of e-healthcare by exchanging emr. the astonishingly rapid spread, via intra-hospital transmission, of the severe acute respiratory syndrome epidemic that killed people in taiwan speeded up the initiation of the doh project of emr exchange between hospitals to track potential contagion. the doh promoted a trial of emr [ ] . however, the adoption rate of emr by hospitals was not satisfactory at the end of the trial. adopting emr exchange was not a simple activity but it was a social and economic interactive process between the healthcare organizations and their operating environment. in the medical context, emr exchange must occur between a hospital and its competitors. the exchanging transaction may cause a smaller hospital to lose its patients after adoption of emr. electronic data interchange electronic healthcare electronic health record electronic medical record social exchange theory transaction cost theory a b s t r a c t adopting electronic medical record (emr) exchange may save patients' lives and also improve their health. most electronic data interchange studies have considered commercial enterprises and necessary funding to support business activities, emr exchange focuses on saving patients' lives. our study combined transaction cost and sociological perspectives to identify factors that affect a hospitals' willingness to implement emr exchange. a survey was conducted with regional hospitals and medical centers in taiwan to justify the validity of a resulting model. our findings indicated that the model was valuable and determined which factors influenced the decision to implement emr exchange at these hospitals (perceived benefits, uncertainty, influence, and reciprocal investments). based on these findings, healthcare policy makers can promote emr exchange and hospitals can identify desirable partners that will form a strategic alliance to meet the dynamic challenges in the healthcare industry. ß elsevier b.v. all rights reserved. however, hospitals have had to take social factors into consideration to overcome any economic threat. we therefore decided to work on combining social and economic theories to identify those factors that affected the willingness of hospitals to adopt emr exchange and thus promote it to track and control potential contagion problems. the survey by the medical record institute in revealed that % of its respondents believed that sharing patients' records was essential [ ] . though the implementation of emr exchange involved much effort, hospitals' willingness to exchange emr was rarely studied. different hospital organizations have different personnel expertise and medical equipment. being responsible for patients' lives, hospitals need to consider both social and economic perspectives in making a decision to adopt emr exchange. two popular theories, social exchange theory (set) and transaction cost theory (tct), were used to provide deeper insight to the topic. set provides a foundation for studying relationships among organizations, while the tct has been applied in vertical and crossorganizational integration. both theoretical perspectives can be used as a basis for cross-hospital behavioral studies. the set arose from many different domains, blau [ ] suggested two important factors, trust and commitment, that people needed in attempting to obtain better exchange benefits. hall [ ] utilized the set to discuss information and knowledge exchange among large-scale, decentralized organizations and analyzed its suitability in the field of it. any problem involving a contract can be investigated using a transaction cost approach. tct focuses primarily on economic aspects of relationships and has been useful in explaining why firms initiate a relationship. transaction costs are made up of costs to search, evaluate, control, and redesign a relation. shortcomings of tct have been identified as emphasizing outcomes and institutional arrangements instead of processes and the environment, disregarding trust as irrelevant. however, organization theorists have challenged the assumptions underlying economic models that overlook trust and power and exaggerate the influence of opportunism [ ] . firms participating in a good relationship over time are likely to consider not only economic but also social factors in their decision to continue in the relationship. low-trust relationships often result in high transaction costs. utilizing both tct and set may provide a more comprehensive explanation and yield greater explanatory power [ , ] , providing a more comprehensive explanation of the strategic alliances of nonprofit organizations. most hospitals in taiwan form pairwise vertical relationship to perform training, academic conference/ workshop, facilitation sharing, and patient referral. these dimensions involve fairly long-term relationships which influence their satisfaction with the arrangement. hospital emr exchange contain both extrinsic and intrinsic rewards: financial, improving their health, or saving their lives. therefore, in our model both tct and set variables were included as independent variables and weighted equally to provide a complementary theoretical foundation for studying the hospital decision to adopt emr exchange. it has been increasingly used in the healthcare industry to support patient care and render assistance in the administration. one of many important changes has been the shift from paper-based medical records to computer-based processing and storage. thus hospital is were gradually modified to process and store data, information, and knowledge for all its operations. other health-related is, such as computerized physician order entry systems, laboratory, radiology, pharmacy is, and electronic record systems have been developed to provide better functionality in patients' information and medical knowledge is. the electronic record systems were particularly important since they are patient centered and a core component in integrating all health care information about a patient. with the assistance of electronic provider-based medical records, comprehensive patient information can be located and accessed rapidly. taiwan's health care records were at a level where hospitals can transmit a standard form of electronic patient records via the internet, providing text, digital, and imaged data for doctors' diagnosis and continued medical care, thus improving the quality of medical services. emr exchange is necessary when a co-treating clinician is not able to access a patient's records directly [ ] . based on the survey of shapiro et al. [ ] , % emergency physicians believed that the exchange of health information would improve clinical care. but there were % emergency physicians who thought it would be difficult to obtain relevant clinical information from external sources. emr exchange must allow hospitals and doctors with different computer application systems to interchange electronically structural data. emr exchanges contain more than text, relating to both financial and medical treatment aspects of life information. moreover, emr exchange may occur between a hospital and its competitors to help in saving a patients' life. due to the complexity and costs-sensitive issues in implementing emr exchange, an expert panel was formed to help guide the process. this panel of nine people included one medical informatics consultant, three general experts with experience in the field, and the authors. the medical informatics consultant had extensive consulting experience with emr exchanges and was a professor in the field of medical informatics at a taiwanese national university. the three general experts had all been involved in the planning and implementation of exchange projects funded by the doh; they consequently all had comprehensive experience with and knowledge of emr implementation. the expert panel critiqued our research model, checked/reviewed its completeness and discussed the suitability of our questionnaire. in the medical context, knowledge and information about handling patients is well known and methods are shared. therefore, emr exchange not only integrates the records of patients but also helps adopting hospitals increase the quality of health care while reducing costs. as a result, both transaction and social relationships occur while implementing the emr exchange; however, contracts are needed to mandate the authority and obligation of both parties. to this end, our purpose (as shown in fig. ) was to combined economic and sociological factors that could better explain the relationships. considering the possible moderating effects from both theories, son et al. [ ] reorganized two variables asset specificity and uncertainty of tct and one variable trust of set to moderate the impact of emr exchange factors on its usage. the specific emr exchange factors included power exercised of set and reciprocal investments of tct. they found only one significant but weak moderating effect of the influence of reciprocal investments on diversity. therefore, in our study tct and set were weighted equally, as complements to each other, and the variables in both tct and set were assumed to be independent variables presented separately instead of as mediators or moderators of each other. set assumes that trust and dependence affect cooperation between organizations and that trust and interdependence have been proved to affect emr exchange [ ] . as the dependence between partners can be regarded as a power relation in acquiring or exchange specific resources, young-ybarra and wiersema [ ] found that the primary consequence of dependence was the power factor that refers to all kinds of influence. chwelos et al. [ ] considered perceived benefit to be a determinant of emr adoption. we felt that these three variables (trust, influence, and perceived benefits) were all relevant in the context of emr exchange and thus, we included them in our research model. most successful cooperation involves a high degree of trust [ ] , therefore: h . . trust among hospitals affects their willingness to implement cross-hospital emr exchange. by adopting emr, an influential organization can impact its cooperating partners by using special standards, which aid in successful exchange. in other words, a firm with greater relative influence can induce desired actions from its partner firm with a relative high interest to sustain the relationship. h . . one hospital's influence can affect another hospital's willingness to implement a cross-hospital emr exchange. chwelos et al. [ ] regard perceived benefit as a determinant of emr exchange, direct benefits included operational cost and other saving in maintaining patients' health while indirect benefits emerged from the use of emr exchange. therefore, we hypothesized: h . . perceived benefits affect hospital's willingness to implement a cross-hospital emr exchange. the original three transaction dimensions of tct were: asset specificity, uncertainty, and frequency, which was focused on examining recurring exchanges and was often ignored in tct studies. reciprocal investments implied that exchange partners intended to guarantee a stable and long-term cooperative relationship. zaheer and venkatraman [ ] suggested including reciprocal investments as a factor in evaluating transaction cost. asset specificity should strengthen the cooperative relationship between suppliers and purchasers [ ] . the asset specificities in the context of emr exchange are human, physical, and temporal. human assets address the professional knowledge of medical care in patient records; physical asset refer to specialized equipment and related it; temporal assets involve the extent to which timely performance by a physician is critical. h . . asset specificity affects a hospital's willingness to implement cross-hospital emr exchange. uncertainty occurs when there is insufficient information to predict results or enhance confidence in a decision-making activity. although kwon and suh [ ] agreed that is had reduced uncertain behavior of cooperative partners, the uncertainty of the is itself was also an issue. in a medical environment, standards, such as those of digital signatures, public keys, and other authentication systems are necessary to address these issues of confidentiality and privacy. lack of standardization certainly impedes the exchange and sharing of medical data. h . . legal and technological uncertainty affects a hospital's willingness to implement cross-hospital emr exchange. reciprocal investments can serve as a credible commitment to reduce opportunistic actions. considering the reciprocal investments between hospitals in training, academic conferences and workshops, facilitation sharing, and patient referral, we formulated the hypothesis: h . . reciprocal investment affects a hospital's willingness to implement a cross-hospital emr exchange. the survey instrument was split into three parts. the sociological and transaction cost dimensions each consisted of nine questions; the third part had six questions that collected demographic information about the respondent and his or her hospital. a fivepoint likert scale was used to measure the respondent's agreement of each item, where represented strongly disagree to representing strongly agree. wordings of items were changed to fit the healthcare context and the source origin of each item in the questionnaire was taken from previous surveys, as shown in appendix a, table a. . the population of our study included accredited regional hospitals or medical centers in the official list of the taiwan doh; this included medical centers, and regional hospitals. according to the medication act of taiwan, the highest executive of a hospital must be a physician who is expert in the clinical area but may not have substantial knowledge of it and management. therefore, it adoption decision are generally made by the directors of the is department. consequently, they are always included in those project teams that identify, determine, and decide on it adoption decisions. before mailing out our questionnaire, a telephone call was conducted to obtain the names of the it executives/directors. studies have shown that by making prior calls and mailing questionnaires to the named subject, response rates can be improved. the doh gave us data on which hospitals had implemented emr exchange. a total of questionnaires were dispatched to those who had done so. the subjects had all previously received a notice of our effort from the doh and had participated in some trial stages. therefore, they understood emr exchange well and were able to answer the questionnaire. of the dispatched questionnaires, were returned for a % respondent rate. the ratio of medical centers to regional hospitals was about - ; this compared to the ratio of - according to doh; thus in our study, more a greater number of medical centers responded, presumably because the non-respondents were mainly from regional hospitals who serve a more restricted geographical area and thus have less is personnel (average two to three persons most) in their is department, and may not currently be able to implement emr exchange. approximately % of emr exchange adopters were from medical centers. among the respondents, the proportion of emr exchangers was % which is slightly different from that of the population obtained from the doh ( %); see table . among the respondents, five returns were incomplete. therefore, only were available for statistics analysis. the majority of the questionnaire respondents were male ( %), aged between and ( %). about % percent of the respondents had more than two years of experience in the is department and % were directors with over ten years of experience (see table ). mailing surveys with a return of % are generally considered satisfactory; thus the respondents to our study represent a reasonable sample of the population. prior to data analysis, the reliability and construct validity of the research instrument was assessed. the measurement of each element was first derived from theory and discussions of prior research and they were then reviewed by the expert panel. since the respondent size was less than , it was not possible to perform a factor analysis but the kaiser-meyer-olkin analysis gave sociological and transaction cost of . and . , respectively, and these were analysis results greater than the threshold of . . therefore, the factors used in our study were appropriate. the results of bartlett's test of sphericity were also significant in these two dimensions (see table ). the cronbach's a for each variable was greater than . except for types of emr exchange ( . ) in the trust construct, as shown in table a . . types of emr exchange contained text document, picture, and diagram. in order to reflect the unique perspective of emr exchange, the low cronbach's alpha was considered acceptable for our exploratory study. the discriminant analysis of the research model is shown in table . our study used the wilks' lambda value to test whether or not the means between the two groups (emr exchanger and nonexchanger) were significantly different. the value of wilks' lambda ( . ) and chi-square of . indicated that the research model had a significant effect in separating the two groups (p = . ). using discriminant loading analysis can avoid the collinear problem and thus it is relatively stable in analyzing small samples. in general, the discriminant loading has to be greater than . to be significant. among the six variables, that uncertainty, perceived benefits, influence, and reciprocal investments all were significant and had a loading greater than . ; they therefore contributed a significant influence in discriminating the two groups (see table ). both emr exchangers and non-exchangers considered trust and asset specificity as of average importance. thus they had no effect on the willingness to implement cross-hospital emr exchange; their discriminant loadings were À . and À . , respectively. the two groups thought differently about influence, perceived benefits, uncertainty, and reciprocal investments; exchangers valued them much more than non-exchangers. however, contrary to our expectations, all agreed on a lack of importance of trust and asset specificity owned by hospitals. the lack of importance of trust may be due to insurance reimbursement. in taiwan, most hospital funding is disbursed from the bnhi. therefore, even though physicians can obtain medical records from other institutions, they can perform redundant examinations of patients and still apply for reimbursements. such a situation occurs when a patient seeks a second-opinion consultation. often physicians do not fully trust the medical records of other hospitals and perform tasks to increase the revenue of their own hospital. a possible reason for the significant support for asset specificity could be the fact that emr exchange was the norm of the taiwanese medication act, which required hospitals with insufficient equipment or expertise to refer patients to others which had adequate treatment equipment. thus though each hospital competes through its emr exchangers, smaller hospitals tend to depend on their larger counterparts for assistance due to the limited medical resources and capabilities. the significant effect of perceived benefits was also confirmed. under the global budget systems of reimbursement introduced by bnhi, a revenue ceiling was set to prevent hospitals from abusing or wasting medical resources. larger hospitals could increase their revenue cap and thus, were more willing to exchange emr to meet the requirement of the reimbursement system. however, small hospitals may not have the finances needed for purchasing special diagnostic equipment. thus, large and small hospitals saw that the perceived benefits of exchanging emr and formed alliances to improve patient care. lastly, the effect of reciprocal investment was confirmed in our study. the exchangers paid more attention to reciprocal investments for cooperation and collaboration among hospitals by hiring experts, initiating training, or adjusting workflows than nonexchanger. the research model was refined and is shown as fig. . the scope of our study was limited to regional hospitals and medical centers in taiwan. is department of the hospital and they may not represent the views of other medical staff. although we had a satisfactory respondent rate, respondents might have tended to favor the technology and be more willing to mail back the questionnaire. additionally, this study used a static cross sectional approach which might not reveal the dynamics of the technology adoption processes. the relationship among emr exchangers is both cooperative and competitive by nature rather than a competitive nature for a customer-supplier relationship in business activities. the sociological perspective as well as economic perspective is important determinants for implementing the emr exchange. this study is conducted in an earlier stage of the implement of emr exchange. due to the limited adoption of emr exchange, this study can be viewed as a pilot study to provide some insights of current adoption of emr exchange. hence, this study contributes to use two theories of social exchange and transaction cost to understand the factors of emr exchange. with more adopters, future studies can be conducted to explore the moderator variables to specify when certain effects will hold or to study a mediator effect as to how and why such effects occur based on the results of this study with further refinement to both the model and the survey instrument as more hospitals adopt emr exchange. our study combined tct and set to complement each other and provide a theoretical foundation for studying a hospital's decision on implementing emr exchange. they together provided a more comprehensive explanation of the strategic alliances of nonprofit organizations. we addressed challenges that are still new to the healthcare industry and obtained promising empirical results indicating that our model could be useful in distinguishing hospitals that exchanged emr from those that did not. knowing the significant factors that influenced the decision to exchange emr by the surveyed hospitals, more exchange emr may be promoted. we therefore recommended that the government offer more incentives to increase the perceived benefits of emr exchange on the bottom line. for exchangers, better quality of customer service and communication efficiency as well as cost reduction are important. since the majority of hospital funds come from the bnhi reimbursement, stable and favor exchange bnhi policies are important to encourage hospitals to implement emr exchange. the standards, forms, and related technologies of emr exchange also play an important role. in an increasingly competitive environment, establishing an alliance with a large hospital becomes a survival strategy for a small hospital. under the current budgeting policy, costs over the bnhi ceiling may not be reimbursed. with the formation of an alliance, member hospitals can share their reciprocal, specific assets, manpower, and equipment to gain the competitive advantage as a group. thus our study provided a reference model for hospitals intending to adopt emr exchange. although, both the u.s. and the eu developed clear frameworks and norms to reduce uncertainty in medical institutes, many studies have shown that emr adoption and diffusion has been slow [ ] . nowadays more people are worried about traveling without emergency medical records in case of accident; a tiny storage device that can plug into any usb port could reduce medical risk. with more tourists crossing borders, an international exchange of emr may become necessary. exchange and power in social life inter-firm dependence, environmental uncertainty and vertical co-ordination in industrial buyer-seller relationships research report: empirical test of an edi adoption model examination of online channel preference: using the structure-conduct-outcome framework borrowed theory applying exchange theories in information science research borrowed theory applying exchange theories in information science research towards personal health record: current situation, obstacles and trends in implementation of electronic healthcare record in europe determinants of commitment and opportunism: integrating and extending insights from transaction cost analysis and relational exchange theory trust, commitment and relationships in supply chain management: a path analysis, supply chain management the impact of partnership attributes on edi implementation success electronic data interchange usage in china's healthcare organizations: the case of beijing's hospitals national survey of current development on computerized medical records with hospitals, department of health coercive strategy in interfirm cooperation: mediating roles of interpersonal and interorganizational trust sixth annual survey of electronic health record trends and usage for european commission activities in ehealth emergency physicians' perceptions of health information exchange effects of relational factors and channel climate on edi usage in the customer-supplier relationship the computerized patient record: balancing effort and benefit strategic flexibility in information technology alliances: the influence of transaction cost economics and social exchange theory relational governance as an interorganizational strategy: an empirical test of the role of trust in economic exchange she received her phd from the university of texas at arlington, usa. her research interests include decision support systems, healthcare information systems, and electronic medical records. her published works have appeared in decision support systems, industrial management and data systems key: cord- -wnd uss authors: singh, shalendra; cherian ambooken, george; setlur, rangraj; paul, shamik kr; kanitkar, madhuri; singh bhatia, surinder; singh kanwar, ratnesh title: challenges faced in establishing a dedicated bed covid- intensive care unit in a temporary structure date: - - journal: nan doi: . /j.tacc. . . sha: doc_id: cord_uid: wnd uss an intensive care unit (icu) is an organized system for the provision of care to critically ill patients that provides intensive and specialized medical and nursing care, an enhanced capacity for monitoring, and multiple modalities of physiologic organ support to sustain life during a period of life-threatening organ system insufficiency. while this availability of trained manpower and specialized equipment makes it possible to care for critically ill patients, it also presents singular challenges in the form of man and material management, design concerns, budgetary concerns, and protocolization of treatment. consequently, the establishment of an icu requires rigorous design and planning, a process that can take months to years. however, the coronavirus disease- (covid- ) epidemic has required the significant capacity building to accommodate the increased number of critically ill patients. at the peak of the pandemic, many countries were forced to resort to the building of temporary structures to house critically ill patients, to help tide over the crisis. this narrative review describes the challenges and lessons learned while establishing a bedded icu in a temporary structure and achieving functionality within a period of a fortnight. post planning and designing of the hospital, work on building the hospital commenced on june . the treatment area of the hospital consisted of four main hangars (each consisting of beds, with one hangar being designated the icu/unit/ high dependency unit), and a triage area for reception of patients (fig. , ) . all treatment areas of the hospital were connected by a concrete platform. apart from the treatment area, the hospital also contained a doctors' block, an administrative area, separate donning and doffing areas and a mortuary with the capacity to store the bodies. additional facilities available also included a liquid oxygen tank, a laboratory, radiology services including x-ray and ultrasonography, and an in-house pharmacy. all regions of the hospital were demarcated as 'red' zones (requiring donning of full complement personal protective equipment prior to entering), and 'green' zones, where freedom of movement was allowed. being a temporary set up, the frames of the hospital were made of aluminium alloy, and the sheet was made from fire-resistant poly-elastic material. the cubicles and partitions were made from octanorm® partitions. the description of the whole hospital including the technical specifications is beyond the scope of this article, which will deal primarily with the challenges faced during the operationalization of the icu. in its guidelines on icu planning and designing in india, the indian society of critical care medicine(isccm) has laid down recommendations for the setting up of an icu, including the initial planning, decisions about icu level, number of beds, icu design, equipment provision, support system recommendations, manning plans, human resource development, and environmental planning among others( ). these guidelines were developed by the isccm as a consensus document for the standards to be aspired for the provision of safe and high-quality intensive care in india and were taken as a baseline while planning the design and functionality of the icu. however, while the isccm guidelines do address resource limitations in the form of resources, size of the institution and variability across specialties and subspecialties, the j o u r n a l p r e -p r o o f designing of this icu differed at places with these guidelines due to the restrictions in place due to the disease process per se, as well as the time constraints due to the urgency of the project. in accordance with the isccm guidelines, the planning committee for the icu design and equipment provision included all the stakeholders -the architects, and engineers, the consultant intensivist, physicians, and was coordinated by an administrator to ensure smooth functioning and to ensure that everyone was on the same page. however, some difficulties were faced since a consultant intensivist was not involved during the initial (first days) of planning of the architectural design of the hospital, leading to a few points being overlooked during the initial planning, such as the integration of a shower area in the doffing zone, establishment of fire safety protocols and evacuation plan, maintenance of optimal temperature of the icu, and provision of uninterruptible power supply (ups) system and generator backup for the icu, especially the ventilators. these points were addressed subsequently, with separate shower areas being built in the doffing zones, fire safety protocols and evacuation plans being formalized, climate control of the icu is optimized, and ups and generator system is enabled. specific challenges faced concerning these points have been discussed in subsequent paragraphs. the first challenge in the designing of the icu was in deciding the level of the icu. the isccm defines three distinct levels of icu, with a level ii icu being recommended for large general hospitals, and a level iii icu (the highest tier) being recommended for tertiary care hospitals [ ] . it was also suggested that an icu comprises not more than beds in any setup. however, the fact that the structure was meant to be temporary, in addition to the urgency due to the rapid spread of the pandemic precluded such a design. the icu was consequently divided ventilators assembled in the icu (fig. ) . another challenge that we faced was that, even with robust manufacturer support, the haste at which the whole project had to be completed resulted in a few equipment glitches and faulty equipment (approximately %) being delivered. the faulty equipment was repaired post-inauguration but did not affect the functionality of the hospital since the initial days were covered by the functional equipment already available. perhaps the most specialized and maintenance reliant equipment in the hospital was to be established in the laboratory. it was realized that for organizations with a dearth of experience in laboratory design, the task of setting up a laboratory in a fortnight could prove complicated. however, an in-house laboratory with the facilities to run all basic investigations was considered essential for patient management. consequently, a private diagnostics firm was given the contract to establish a laboratory with all the basic investigations within the hospital premises. additionally, the liaison was maintained with a local diagnostics facility to conduct specialized tests. the quality control for the laboratory was done by specialists who were part of the duty contingent. the indenting procedures for drugs and other consumables in the icu also required fine-tuning and proved surprisingly difficult. the hospital had given the contract for the provision of all required consumables to a private pharmacy which, apart from maintaining an on-site pharmacy, would also liaise locally for any extra requirements should the need arise. however, the private pharmacy company did not have the requisite licenses to provide 'schedule x' drugs (strongly habit forming drugs, which have the potential to be abused -predominantly opioids); these had to be locally sourced from a sister hospital. additionally, the lack of universal nomenclature for many commonly used icu consumables resulted in erroneous materials being initially provided, which had to then be returned. however, most issues could be ironed out within the building period and did not significantly hamper icu functionality. with the project having to be completed in under a fortnight, difficulty was encountered in ensuring adequate electric supply and climate control for the hospital. electric supply was provided with a generator capable of providing . mw power. due to an oversight, the initial electrical design of the icu had only catered for three plug points per patient bed, which was inadequate and had to consequently be augmented to eight per bed. also, with the indented equipment arriving and being calibrated only three days prior to the inauguration of the hospital, load testing could not be conducted until two days prior to commencement of operation. load however, the same could not be catered due to the design and space constraints within the icu, and only two washbasins could be provided per icu partition of beds. it is well recognized that nutritional support is a cornerstone of good critical care [ ] . however, the catering services for the hospital had been outsourced to catering with limited experience in hospital diets. specific diet charts were provided to the firm, along with instructions, to ensure adequate nutrition of the admitted patients. apart from the monitoring of the nutritional value of the diets, regular patient feedback was also sought to assess the palatability of the hospital food, as this was deemed to be a significant determinant in overall patient satisfaction. the disinfection and disposal of biomedical waste (bmw) also proved to be a challenge, with extra caution needed to be exercised since improper handling of the waste could also lead to the icu was designed in such a way that it was connected to all the wards of the hospital by a common alleyway, and was easily accessible from any of these wards. this was considered essential to expedite the transfer of any patient who would deteriorate in the ward. specific logistical support remained a significant challenge, with considerable effort being needed to fine-tune the system to attain maximal efficiency. issues such as apparel size for the duty personnel, catering demands of the patient population, wi-fi connectivity issues and user unfamiliarity with the online database, all surfaced after the commencement of the functioning of the hospital. it was also found that despite extensive training and mock drills being carried out prior to accepting patients, there arose considerable confusion in certain facets relating to logistical support, and had to be proactively corrected by the administrative teams. requirements of the other collaborators. one valuable lesson learnt from the establishment of this icu was the importance of including the intensivist at the very beginning of the planning and designing process as the intensivist provides a unique viewpoint, which is often overlooked by administrators. the involvement of ground-level workers during the designing process could also help reap rewards, as they are often best placed to provide an insight into the patient perspective. the initial trends from the icu also showed that while concerns over the effectiveness of makeshift hospitals do still exist, when executed well, they have the potential to significantly augment the healthcare facilities in the event of an epidemic. however, there is a need for a more defined protocol for the establishment of a large-scale icu, which would aid significantly in the disaster response to future medical emergencies. covid- ) dashboard the indian perspective of covid- outbreak critical events in intensive care unit problems with systems of medical equipment provision: an evaluation in honduras, rwanda and cambodia identifies opportunities to nutritional and metabolic support in the adult intensive care unit: key controversies medical waste management practice during the - novel coronavirus pandemic: experience in a general hospital treatment algorithms and protocolized care critical care "normality": individualized versus protocolized care protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in critically ill paediatric patients sars-cov- causing pneumonia-associated respiratory disorder (covid- ): diagnostic and proposed therapeutic options molecular mechanism of remdesivir for the treatment of covid- : need to know the novel coronavirus disease (covid- ) pandemic: a zoonotic prospective a sars-cov- vaccine candidate key: cord- - yao a authors: chiang, wen-chu; ko, patrick chow-in; wang, hui-chih; yang, chi-wei; shih, fuh-yuan; hsiung, kuang-hua; ma, matthew huei-ming title: ems in taiwan: past, present, and future() date: - - journal: resuscitation doi: . /j.resuscitation. . . sha: doc_id: cord_uid: yao a taiwan is a small island country located in east asia. from around modern concepts of the ems were imported and supported by legislation. considerable progress has since been made towards the construction of an effective pre-hospital care system. this article introduces the current status of the ems in taiwan, including the systems, response configurations, funding, personnel, medical directorship, and outcome research. the features and problems of in-hospital emergency care are also discussed. key areas for further development in the country vary depending on regional differences in available resource and population density. an analysis of the strength, weakness, opportunity, and threats of the evolving ems in taiwan could be an example for other countries where the ems is undergoing a similar process of development and optimisation. taiwan is a small island country located in east asia. from around modern concepts of the ems were imported and supported by legislation. considerable progress has since been made towards the construction of an effective pre-hospital care system. this article introduces the current status of the ems in taiwan, including the systems, response configurations, funding, personnel, medical directorship, and outcome research. the features and problems of in-hospital emergency care are also discussed. key areas for further development in the country vary depending on regional differences in available resource and population density. an analysis of the strength, weakness, opportunity, and threats of the evolving ems in taiwan could be an example for other countries where the ems is undergoing a similar process of development and optimisation. © elsevier ireland ltd. all rights reserved. taiwan, previously named formosa (meaning beautiful island) by a portuguese explorer in , is a country consisting of a main island and some smaller islands located in east asia off the southeastern coast of china. the main island is km long and km wide, slightly larger than the combined areas of massachusetts and connecticut, or a little smaller than the netherlands. the population of taiwan was estimated at almost million in july , spread across a land area of , km , making it the th most densely populated country in the world. in fact, the population density should be even higher than estimated because of the topographic character of taiwan. a central mountain range geographically bisects taiwan from north to south which results in two-thirds of the island being covered by forested peaks. most of the population is distributed in four cities (taipei, kaohsiung, taichung, and tainan), as shown in fig. . the uneven population distribution has led to disparities in regional resourcing and has influenced the level of development of the local emergency medical service (ems) system. in the s, a basic ems system (mainly transporting sick and injured patients to hospital by ambulance) was started in taiwan. the system was delegated to police stations with neither well-coordinated communication to the hospital nor well-trained providers in pre-hospital care. although some efforts were made, the situation did not alter for the better until . in that year a formal emergency medical technician (emt) training curriculum was initiated by pioneers of emergency medicine who had studied ems abroad. this initiative was supported by the society of emergency and critical care medicine in taiwan. the year marked the beginning of modern ems in taiwan when a lot of important concepts of ems were put into legislation, the emergency medical service act. the law designated pre-hospital care as a function of fire administration at the central and local level. it also regulated essential ambulance equipment and permitted emts acting as physician surrogates to provide different levels of care based on their levels of certification. in , emergency medicine was recognized as an autonomous medical speciality by the department of health (doh) in taiwan. this landmark facilitated the further development of the ems. over the last eight years, taiwan's ems has undergone rapid development, including the implementation of off-line medical direction, establishment of national disaster response teams, and the introduction of automatic external defibrillators (aed) by emts. enabling the ems to provide fire service based advanced life support (als). new initiatives are close to introduction. these include medical directorship, public-access aed programs, and a nationwide standard for computerized reporting of out-of-hospital cardiac arrests (ohca) and major trauma. the pre-hospital care system in taiwan can be categorized into governmental or privately supported services. the governmental services are all fire-based with three levels of care providers (emt-i, emt-ii, emt-p), and are activated by a universal access number ( ). in some cities, hospital-based als teams, consisting of a physician and a nurse, participated in pre-hospital care of the critically ill but this was temporary and gradually shifted to a fire service based response soon after the introduction of qualified emt-ps into the system. however, due to the limited number of emt-ps, complete pre-hospital als only exists in some urban areas. the primary responsibility of the governmental ems system is to deliver sick and injured patients to hospital and not for secondary transportation (i.e. between hospitals or back home). in contrast to the free governmental service, the private service charges patients. most only have emt- or emt- crews in their ambulances and they play a complementary role to the governmental service by providing inter-hospital transport. for sicker patients, a physician or nurse from the transferring hospital is also required to staff the ambulance. as a local custom, privately supported ambulances also transport dying patients home from hospital because many people wish to pass away at home. the public demand for the ems is increasing. the latest data from the national fire agency (nfa) in the ministry of the interior shows a % annual increase in ems demand over the last ten years. the annual ems call volume was , in , which is equivalent to . calls per , persons per day, or approximately half of the number of ems calls seen in the united states. according to an evaluation carried out in urban taipei, the als demand was estimated at around - % of ems calls , and the average response times were . - . min, , with mean call-to-first shock times for cardiac arrest of . min. in a rural area, the average response time was found to be longer, up to . min. a bypass policy for major trauma or severe illness (e.g. stroke or acute coronary syndrome) is recommended by academic societies but not fully implemented because of insufficient coordination and uncertain accountability between the jurisdiction of the doh and nfa. land ambulances are the main transport mode in the taiwan ems. aero-medical and helicopter transport is limited to emergency events with poor access (i.e. major incidents, off-shore island inhabitants or transplant organ procurement), and requires interagency coordination. a few private companies provide efficient aero-medical evacuation but at a much higher cost. the main funding of ems operations is from general taxation. there is another important resource for public ems in taiwan: donations from taoism or buddhism temples. in many jurisdictions, ambulances are funded by donations from buddhism or taoism temples, as indeed is most ems equipment. this is in line with their obligation to charity. in return, ambulances and equipment bear the names and logos of the temples or charities to honor their contributions. in , there were a total of emts in governmental firestations in taiwan, responsible for fires and pre-hospital care. over % of them were at emt- or emt- level. in july there were only emt-ps (paramedics) across the country, and most were employed in urban areas. since the development of the ems system in taiwan was modelled on the north american paradigm, the pre-hospital care providers and their training program resemble those of their north american counterparts. the national standard training program of emt- is h to ensure competency in vital sign measurement, basic life support (bls) skills and aed operation. the curriculum of emt- level requires h of training and, in addition to the emt- material, includes ecg monitoring, application of the laryngeal mask and pasg (pneumatic anti-shock garment), and some medications, e.g. oral glucose water or intravenous saline. in addition to firemen, volunteers and crews of private ambulance companies are also required to certify as emt- s and emt- s. for entry to the emt-p course (the highest level of pre-hospital care provider), most entrants are selected from the best members of the fire-based emt- course because at present training costs are completely supported by the government. the duration of the curriculum for emt-p is h. the course content is extended to important concepts of medicine, advanced airway management, advanced cardiac life support, pre-hospital trauma life support, paediatric advanced life support, disaster man-agement, and hazmat procedures (hazard identification, action plan, zoning, managing the accident, assistance and termination). they are also required to perform two internships during the training: to practice medical skills under the tutelage of registered nurses and physicians in a tertiary emergency department and to participate in ambulance runs with experienced paramedics in the field. finally, after almost nine months of training, they must pass the examination approved by doh to get the licence. all emt levels are required to recertify by attending approved refresher courses within a prescribed period of time. in , the emergency medical service act of taiwan provided implementation of medical oversight for pre-hospital carers at all levels. physicians on the medical consulting committees (required by law) are responsible for the standards of patient care, including establishment of pre-hospital medical protocols and assistance in education of emts. however, a lack of specific tasking and full-time positions in the fire department for medical directors has resulted in the medical oversight remaining incomplete in terms of protocol revision, quality assurance, system design, and direct medical oversight. the situation improved after july when the amended emergency medical service act stipulated that local fire departments appoint an identifiable physician for medical oversight. ems dispatch in taiwan is performed by experienced fire fighters. however, there are neither formal training courses nor certification available for ems dispatchers. moreover, the standard dispatcher protocol and decision-making steps for delivering als or bls are not well-established in many systems. therefore, appropriate dispatch performance on als cases was only %, and over triage (i.e. dispatching an als team to a bls scene) was very common. besides, the numbers of dispatcher-assisted bystander cpr in ohca were also low according to data acquired in metropolitan taipei. these drawbacks indicate that a standard als dispatch protocol and dispatcher training programs should be established in taiwan. an advantage of the taiwan ems is that the system is still growing and receiving considerable attention from the public and government. during this developing process, ems researchers potentially have the chance to exam the effectiveness and outcome of many newly implemented strategies, such as als performance on cpr quality, [ ] [ ] [ ] [ ] [ ] their effect on outcome of ohca and costeffectiveness analysis. , since taiwan is located at the western pacific seismic belt near mainland china, researchers also have opportunities to evaluate the ems response to catastrophic events like earthquakes or public health emergencies like sars (severe acute respiratory syndrome). [ ] [ ] [ ] this type of research can be used to optimize the pre-hospital care system with data derived from relevant local events. to date most studies have been carried out only in metropolitan taipei. lacking a universal, well-established infrastructure in the ems, data collection for quality assurance and outcome research at the national scale remains currently unavailable. in each jurisdiction, there is an ems advisory committee for the planning and integration of pre-hospital and in-hospital emergency department care. hospital eds that are determined as capable of receiving ambulance patients are designated as ems response hospitals by law. before transporting patients to a hospital ed, ems personnel will contact the nearest ed by radio. when the destination ed is overwhelmed, ems patients may be re-directed to other nearby eds. since emergency medicine was approved as a medical specialty in taiwan, the predominant workforce in the ed are emergency physicians. based on hospital accreditation in taiwan, both doctors and nurses working in the ed are required to certify in acls, atls, or equivalent trauma training courses. some tertiary hospitals are allowed to accept registered residency and rotating trainees including student nurses and emts. the major problem of eds in taiwan is of significant overcrowding, especially among many tertiary hospitals. two systemic causes contribute to this condition: the limited patient flow and undeveloped interfacility transfer rules. under the national insurance of health (nih) for all inhabitants, the medical cost for users is relatively low in taiwan compared to other developed countries. people can seek medical care in any level of hospital they wish, with little difference in cost. political and cultural considerations make the attendance/triage of patients with non-serious problems to suitable eds impossible. solutions for overcrowding are proposed and include creation of a large holding unit, pre-established rules for admission, priority-setting and active interfacility transfer. many evidence-based life-saving strategies for severely sick patients including hypothermia for post-resuscitation care or early goal directed therapy for severe sepsis have been started in some hospitals. although restricted financial resources and overcrowded eds limit the practices above, there is a paradoxical phenomenon of the use of ecmo (extra-corporeal membrane oxygenation) in resuscitation in taiwan. one of the most notable features of tertiary eds is the widespread use of e-cpr (ecmointegrated cardiopulmonary resuscitation) for cardiac arrest and its effects on outcome. the intervention initially arose from a scientific interest in one medical centre, ntuh (national taiwan university hospital), but is now popular in many hospitals because of initial favorable outcome data, patient demands, and payments form the nih. diversity in population density and its geographical distribution heavily influence the distinct blueprints of taiwan ems development in the future. it can be divided into three models: the metropolitan, the outskirt, and the rural system, as shown in fig. . in the metropolitan model (areas marked a), both ems personnel and hospital capacity are abundant. the goal should focus on the full implementation of more evidence-based advanced prehospital interventions and area wide disaster preparedness, and improving the precision of pre-hospital triage and transport. in the rural model (areas marked c), where pre-hospital and in-hospital ems resources are limited, the emphasis should be placed on shortening the ems response time and provision of good quality bls-d care. the local public safety agencies should consider emergency healthcare services as a primary responsibility, not a role secondary to fire fighting or policing. the government should develop aero-medical capability to reduce the time to definite care for critically ill patients in these areas. public education on awareness of severe illness and bystander cpr is also helpful. for the outskirt model (areas marked b), regionalized care for conditions such as trauma or stroke should be facilitated. ems personnel should distribute the patient flow efficiently, including following the bypass rules, even cross-district, and streamlining the interfacility transfer network. beyond all regional aims above, there are two important tasks that must be emphasized in all regions. first and foremost, a universal well-established infrastructure for quality assurance is of paramount importance for the ems in taiwan so that the quality of care and the outcomes of many new integrated interventions in the ems can be evaluated. another priority would be to coordinate various components in the ems. historical events show that coordinating services across county lines is particularly challenging. ems personnel should also promote cooperation in solving problems arising from incidents that cross jurisdictional lines, such as near municipal and county border areas. the ems is unique in straddling medical care, public safety and public health. being a young system in taiwan, the ems has gained momentum in the last decade. the strength of the system is that the development process provides opportunities to integrate new interventions and to evaluate their outcomes. the weaknesses are an immature data collection system for quality assurance and insufficient coordination in the leadership of government healthcare between the doh and nfa. the geographic and demographic characteristics such as frequent natural disasters, public health emergencies and an aging population provide an opportunity to create an efficient system. ems personnel need to be able to show the benefits of their work in terms of improved patient outcomes and patient satisfaction. this will gain the respect and support of other health professionals and make the system a sustainable one. all authors declared no potential conflicts of interest in this report. central intelligence agency, us government emergency physician and the emergency medical service ministry of the interior, taiwan the demand for prehospital advanced life support and the appropriateness of dispatch in taipei ems characteristics in an asian metropolis impact of community-wide deployment of biphasic waveform automated external defibrillators on out-ofhospital cardiac arrest in taipei study of patients arriving by ambulance in taipei city three years' experience of emergency medical services in ilan county evaluation of emergency medical dispatch in out-ofhospital cardiac arrest in taipei comprehensive evaluation for quality of prehospital cpr video-recording and time-motion analyses of manual versus mechanical cardiopulmonary resuscitation during ambulance transport machine and operator performance analysis of automated external defibrillator utilization evaluating the quality of prehospital cardiopulmonary resuscitation by reviewing automated external defibrillator records and survival for out-of-hospital witnessed arrests better adherence to the guidelines during cardiopulmonary resuscitation through the provision of audio-prompts outcomes from out-of-hospital cardiac arrest in metropolitan taipei: does an advanced life support service make a difference? cost-effectiveness of different advanced life support providers for victims of out-of-hospital cardiac arrests improving surge capacity for biothreats: experience from taiwan emergency medical services utilization during an outbreak of severe acute respiratory syndrome (sars) and the incidence of sars-associated coronavirus infection among emergency medical technicians facing an outbreak of highly transmissible disease: problems in emergency department response ed overcrowding in taiwan: facts and strategies cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis the part of the future models of ems design in this work was supported by grants from department of health, taiwan: doh -td-h- - and doh -td- - . key: cord- -li pwigg authors: nan title: esicm monday sessions october date: - - journal: intensive care med doi: . /s - - -x sha: doc_id: cord_uid: li pwigg nan methods. for the present investigation, healthy male volunteers with a mean age of ± . years were recruited for a cardiovascular screening exercise stress test prior to inclusion for the study. during the lbnp protocol, the subjects were exposed to sequential increasing negative pressures of - , - , and - mmhg while resting in a supine position with their legs sealed in the lbnp chamber at the level of the iliac crest. in addition to continuous registration of cardiac output (co) and mean arterial pressure (map), sublingual perfused vessel density (pvd) ( ) and microvascular flow indices (mfi) ( ) were measured using sidestream dark-field (sdf) imaging before (t ), during (t ; - mmhg), and after (t ) lbnp. results. there were no significant differences in mean co and map in our subjects. introduction. fever management remains controversial in sepsis. control of thermal balance might improve vascular tone but fever could play a role in host defence. objectives. the aim of this multicentre randomised controlled trial was to determine primarily whether external cooling might accelerate the weaning of vasopressors in patients with septic shock. patients with septic shock treated with epi/norepinephrine infusion and fever over . °c were enrolled in centres when also requiring mechanical ventilation and sedation. patients received external cooling to reach normothermia ( . - °c) during h (n = ) or had fever respected (n = ). a goal of mmhg for mean arterial pressure was used in the two groups. a similar algorithm was used for weaning of vasopressors. the main end point was the number of patients achieving a % decrease in the initial dose of vasopressor in the two groups. shock reversal was defined by vasopressor withdrawal for at least h. at inclusion the two groups (cooling/respect of fever) were similar for age ± versus ± years, saps iii ( ± vs. ± ), sofa score ( ± vs. ± ), and body core temperature ( . ± . vs. . ± . °c). a similar number of patients received steroids and a pc before enrolment. body temperature became significantly lower in the cooling group within the h of treatment: . ± . vs. . ± . at h and . ± . vs. . ± . °c at h (p \ . ). the decrease in vasopressor was more rapid in the cooling group (fig. ). shock reversal was vs. %, p = . and in-hospital mortality was vs. % in the cooling and the respect of fever groups respectively. conclusions. these preliminary results show that treating fever using external cooling in septic shock patients allows a more rapid decrease in the dose of vasopressor without apparent adverse effect. grant acknowledgment. aphp-scr . we set up to describe the antibiotic treatment regimens prescribed for patients with severe sepsis in spanish icus and to analyze the potential therapeutic benefit of combination therapy. methods. edusepsis subanalysis, including all patients with severe sepsis admitted to the participating icus during months, in three periods between november and june . there was analyzed the time between the presentation of sepsis and the initiation of antibiotic treatment and empirical antibiotic used in terms of focus and origin of sepsis (community/nosocomial). we also studied the combination therapy compared to monotherapy, assessing the impact on outcomes of combination therapy in particular. the results are presented as frequencies (percentage) or mean ± standard deviation. results. there were included , patients with severe sepsis (age . conclusions. combination therapy is not associated with a better outcome in this large cohort of patients with severe sepsis. nevertheless, there is room for improvement since % of patients did not receive antibiotic therapy within the first h from admission, as recommended by the ssc. introduction. tracheostomies are increasingly common in hospital wards and can lead to significant patient harm. this is partly due to bed pressures in uk critical care units and the increasing use of percutaneous and surgical tracheostomies for critical care patients. commonly, hospital wards lack the infrastructure to care for tracheostomies safely. objectives. analyse tracheostomy-related critical incidents reported in the uk over a year period. we wished to identify themes and make recommendations to improve patient safety. methods. the search was conducted from st october to th september and was conducted in february to allow time for incidents to be submitted. the selected incidents were then incorporated into an access database (microsoft office ) and the description of each incident was read and reviewed. we analysed tracheostomy-related critical incidents reported to the uk national patient safety agency over a year period, identified by key letter searches. we categorized the records to identify recurring themes and then performed root cause analysis where possible. results. we identified , incidents from the npsa incident database originating from hospital wards during the study period having the defined letter sequences. of these incidents, were associated with tracheostomies; directly affecting patients with the remaining not directly affecting individual patients. in the incidents where patients were directly affected ( %) were associated with some identifiable patient harm of which ( %) were associated with more than temporary harm. in incidents ( %) some intervention was required to maintain life and in cases the incident may have contributed to the patient's death. there were cardiac arrests and respiratory arrests described in these incidents. of the incidents, involved equipment and there were blocked or displaced tracheostomy tubes described. note: an individual incident could be classified in multiple fields conclusions. we were able to identify themes in incident reports associated with tracheostomies and identify areas where care could be improved to reduce risks to patients. there were a number of recurrent problems that contributed to incident evolution or severity that would be potentially avoidable. these include: introduction. the study of computerized thoracic tomography patterns can be of great help in the diagnosis of the causes of acute respiratory failure in the icu patients. we hypothesized that the consecutive analysis of a series of thoracic cts will contribute to the management of these critically ill patients. objectives. to study, over a three-month period, the thoracic cts performed in the adult icu in the albert einstein hospital in são paulo, brazil. methods. from may st to august st, , all the thoracic cts were analyzed by two radiologists from the albert einstein hospital staff according to a pre-established protocol: ( ) presence of parenchymal consolidations; ( ) ground-glass opacities; ( ) septal thickening; ( ) atelectasis ( ) pleural effusions; ( ) pneumothorax ( ) pneumomediastinum; ( ) subcutaneous emphysema; ( ) presence of nodules; ( ) presence of masses; ( ) presence of cysts; ( ) emphysema; ( ) bronchial thickening. results. hundred and sixteen thoracic cts were performed and analyzed over the study period, from ( . %) males and ( . %) females. the mean age of the patients was . ± . years. thoracic ct analysis revealed: ( ) parenchyma consolidations: ( . %); ( ) ground-glass opacities: ( %); ( ) septal thickening: ( . %); ( ) atelectasis: ( . %); ( ) pleural effusions: ( %) ( ) presence of pneumothorax: ( . %); ( ) pneumomediastinum: ( . %); ( ) subcutaneous emphysema: ( . %); ( ) nodules: ( . %); ( ) presence of masses: ( . %); ( ) presence of cysts: ( . %); ( ) emphysema: ( . %); ( ) bronchial thickening: ( . %). conclusions. thoracic ct is a useful tool for a detailed analysis of the lung parenchyma, specially in the detection of ground-glass opacities, consolidations and atelectasis, improving the diagnostic possibilities and management of acute respiratory failure. s. wolf , , a. rieß , j.f. landscheidt , c.b. lumenta , l. schürer , p. friederich charite campus virchow, department of neurosurgery, berlin, germany, klinikum bogenhausen, neurosurgery, muenchen, germany, klinikum bogenhausen, anesthesiology, muenchen, germany introduction. extravascular lung water index (evlwi) may present a valuable marker for the severity and treatment of acute lung injury and acute respiratory distress syndrome. measured by single indicator transpulmonary thermodilution and indexed to predicted body weight, a threshold of ml/kg is currently regarded as the upper limit of normality. however, so far only critically ill patients were studied and data from subjects with normal cardiovascular function is lacking. objectives. to prospectively investigate evlwi in patients without cardiopulmonary compromise. methods. patients requiring elective brain tumor surgery were equipped with a transpulmonary thermodilution device (picco . , pulsion medical systems ag, munich, germany). triplicate evlwi measurements were performed after induction of anesthesia (time point ), before (time point ), during (time points and ) and after surgery (time point ) as well as after extubation (time point ) and before discharge from the neurosurgical icu (time point ) . data were recorded electronically and investigated with a random effect model to cope for multiple measurements per individual. results. valid measurements were performed in patients ( female/ male, fig. ). no patient showed clinical signs of over-hydration or cardiopulmonary failure and all were discharged regularly from the icu on postoperative day one. indexed to predicted body weight, females had a mean evlwi of . (sd . , range - ) ml/kg and males had a mean evlwi of . (sd . , range - ) ml/kg (p \ . ). % of the measurements in females and % in males exceeded the threshold of ml/kg. no significant differences were between the different time points of measurement (p = . ) or during anesthesia and after extubation (p = . ). conclusions. measured with single indicator transpulmonary thermodilution and indexed to predicted body weight, evlwi frequently shows values above the previously established normality threshold of ml/kg in patients without cardiopulmonary compromise. females present significantly higher values than male patients. as we are not aware of any abnormal hemodynamic profile for brain tumor patients, we propose our findings as a close approximation to normal values for evlwi. introduction. cardiovascular dysfunction is though to be common during weaning from mechanical ventilation. however, its precise incidence is unknown in this setting. in addition, the respective impact of systolic and diastolic dysfunctions on the weaning process have not been studied. objectives and methods. this is an ancillary study of the ''bnp for the management of weaning'' clinical trial. patients were ventilated with an automated weaning system as soon as they tolerated pressure support ventilation with an fio b %, a peep level b cmh o, and a total inspiratory pressure b cmh o. a total of patients underwent transthoracic echocardiography (tte) at day (initiation of weaning). in addition, serial tte were performed in a subgroup of patients to explore left ventricle filling pressures variations during daily weaning trials (low-pressure support with zero end-expiratory pressure). filling pressures were assessed using the ratio of early transmitral peak velocity (e) over early diastolic mitral annular velocity (e ). results. day tte revealed a systolic (ejection fraction \ %) or diastolic dysfunction (defined as e \ . cm/s) in half of patients. treatment during weaning included diuretics ( % of patients), vasodilators ( %) , dobutamine ( %), amiodarone ( %) and betablockers ( %). diastolic dysfunction was more prevalent in patients with difficult or prolonged weaning as compared to those with simple weaning (weaning duration \ days). serial tte revealed a greater increase in e/e ratio during failed weaning trials as compared to successful trials. conclusions. when treated, systolic dysfunction does not seem to jeopardize weaning. in contrast, diastolic dysfunction is associated with difficult/prolonged weaning. during failed weaning trials, there is a more pronounced increase in filling pressures as compared to successful trials. introduction. monitoring and determination of fluid responsiveness in a critically ill patient who presents with circulatory compromise and septic shock is essential but often, challenging and difficult. continuous haemodynamic monitoring using arterial pulse contour analysis is less invasive compared to the thermodilution method using the pulmonary artery catheter. objectives. we aim to assess the utility of stroke volume variation as measured by the flotrac Ò device (edwards lifesciences, irwine, usa) as a predictor of fluid responsiveness in patients with septic shock. we studied mechanically ventilated adult patients with septic shock in the medical intensive care unit (icu) of a university hospital. haemodynamic parameters including stroke volume variation (svv) and stroke volume (sv) were recorded using radial arterial pulse contour analysis (flotrac Ò pressure sensor versions . and . ) before and after a crystalloid fluid challenge. fluid responsiveness was defined as an increase of c % in sv after the fluid challenge. results. the sensitivity, specificity, positive predictive value and negative predictive value of a svv of c % to predict fluid responsiveness were respectively . , . , . and . %. the area under the receiver operator characteristic curve for the prediction of fluid responsiveness using svv (pre) was only . . similarly, there was no correlation between svv (pre) and the absolute change in stroke volume (spearman's rho - . , p = . ). conclusions. our study's findings call for caution with the use of svv measured via versions . and . of the flotrac Ò device to predict fluid responsiveness in patients with septic shock. further studies are now required to assess if recent software upgrades may provide more accurate svv measurements in severely septic patients. objective. our objective was to assess the recent literature with respect to cco monitor validation. in particular we wished to determine if study protocols reflected the dimension of time. we looked at four different cco monitors: vigileo tm , picco tm , pulseco tm , and oesophageal doppler (odm). human validation studies of cco monitors were sought through the ovid interface, generating over , hits. manufacturers' websites were also searched. case reports were excluded, as were abstract-only publications, letters, and studies over years old. ultimately, studies were included. a full reference list and search strategy is available from the authors. a recent article provided suggested criteria for assessment of cco monitors [ ] : this was used to generate a proforma. to check for interobserver bias, a subselection of five studies was assessed by the three authors independently; no differences were found. the authors summarised the remaining studies individually. results. results are summarised in table . w rows do not add up because some studies evaluated more than one monitor researchers have yet to address the necessity of validating cco monitors with respect to their realtime functionality. while most studies give an assessment of bias based on essentially static measurements, fewer than half document sampling time or directional change reliability. response time and response amplitude to a step change in cardiac output are important variables which may influence patient treatment; in the vast majority of studies, these have not been assessed. in this respect, all four monitors have yet to be validated. this study offers two perspectives: one, for clinicians to realise that the cco monitor in their intensive care unit may not have been as extensively validated as they think; another, for researchers, to realise that work is still to be done. initial distribution volume of glucose rather than right ventricular end-diastolic volume is correlated with cardiac output following cardiac surgery j. saito , h. ishihara , e. hashiba , h. okawa , t. tsubo , k. hirota hirosaki university graduate school of medicine, anesthesiology, hirosaki, japan, hirosaki university graduate school of medicine, division of intensive care, hirosaki, japan introduction and objectives. rational decision making for cardiovascular and fluid management in critically ill patients requires reliable assessment of cardiac preload. we have reported that initial distribution volume of glucose (idvg) measures the central extracellular fluid volume and has potential as an alternative preload variable ) . idvg can be approximated rapidly and simply in any icu using a conventional blood glucose analyzer ) . right ventricular end-diastolic volume (rvedv) has been shown to be a better indicator of cardiac preload than cardiac filling pressure ) . this study was intended to determine whether idvg, rvedv, pulmonary artery wedge pressure (pawp) or central venous pressure (cvp) are correlated with cardiac output (co) during the early postoperative days following cardiac surgery in the absence of apparent congestive heart failure. methods. twenty-nine consecutive patients who underwent cardiac surgery such as coronary artery bypass grafting (either off-pump or on-pump: n = ), valve surgery (n = ) and aortic arch replacement (either hemi or total: n = ) were studied. patients associated with excess hyperglycemia ([ mmol/l), arrhythmias or mechanical cardiovascular support were excluded from the study. a volumetric thermodilution pulmonary artery catheter for continuous monitoring of co and rvedv was placed in the operating room. immediately after cardiovascular variables were recorded, idvg was determined using the incremental plasma concentration at min after administration of glucose ( g) as described previously ) . three sets of measurements were performed; on admission to the icu and daily at a.m. on the first postoperative days. the relationship between either volumetric or static variables and cardiac index (ci) was evaluated throughout the study period. a p value. was considered statistically significant. results. all but one patients required vasoactive drugs during study period. indexed idvg (idvgi) had a moderate correlation with ci (r = . , n = , p \ . ), even though indexed rvedv (rvedvi) had a slight correlation with ci (r = . , n = , p = . ). a linear correlation was also obtained between changes in idvgi and those in ci (r = . , n = , p \ . ). however, changes in rvedvi had not a correlation with those in ci (r = . , n = , p = . ). neither pawp nor cvp had a correlation with ci (r = - . , n = and r = - . , n = , respectively). although cardiac dysfunction has a significant impact on determining co early after cardiac surgery, our results demonstrate that idvg rather than rvedv is correlated with co. idvg has potential as being an alternative indicator of cardiac preload following cardiac surgery. (spv) are reliable predictors of fluid responsiveness in controlled mechanically ventilated patients [ ] . ppv and spv are calculated using an intra-arterial catheter. it is unknown whether an arterial pressure signal obtained with the nexfin tm system [ ] using only a finger cuff can be used to calculate ppv and spv. objectives. to validate ppv and spv measured with a finger cuff. methods. after their arrival on the icu, sedated and mechanically ventilated patients after coronary artery bypass graft surgery (cabg) were included. intra arterial pressure (iap) was measured using an arterial catheter inserted in the radial artery, and non-invasively, using the finger cuff of the nexfin tm monitor (bmeye, the netherlands). we took the mean value of ppv and svv in a -min time interval before and after the administration of a fluid challenge. agreement of the ppv and spv measured by the finger cuff and from the iap signal were assessed using the method described by bland and altman. results. nineteen patients were included and twenty-eight volume challenges were analyzed, resulting in simultaneous measurements. ppv and spv measured by the finger cuff correlated with ppv and spv from iap (r = . , p \ . and r = . , p \ . , respectively), see figure . the mean bias was - . and - . % for ppv and spv respectively, and limits of agreement were - . and . % for ppv and - . and . % for spv (see figure ). there was no correlation between the bias and the mean value of the two measurement methods. the correlation between changes in ppv and spv measured by the two different methods was r = . (p \ . ) for ppv and r = . (p \ . ) for spv. conclusions. in ventilated icu patients, ppv and spv can be reliably calculated using the nexfin tm monitor. reference(s). ( ) kramer, a., et al., chest, . ( ) . ( ) eeftinck schattenkerk, d.w., et al., am j hypertens, . ( ) . introduction. the transpulmonary thermodilution (tptd) technique with integrated pulse contour analysis (picco Ò -system) enables continuous monitoring of cardiac index (ci) after calibration by tptd [ ] . this monitoring technique is applied in patients with lung failure who undergo prone positioning (pp) which has been shown to potentially improve pulmonary gas exchange [ ] . objective. we sought to determine the influence of a modified pp ( °) on the accuracy of pulse contour derived ci (pcci) without recalibration by tptd. patients: after approval by our institutional review board and written informed consent by a legal surrogate we studied critically ill patients ( #, $, age - years) who were mechanically ventilated due to acute lung injury following lung contusions or acute respiratory distress syndrome. methods. all patients were prone positioned and had received an extended haemodynamic monitoring (picco Ò , pulsion medical systems ag, munich, germany). before turning from supine position (sp) to pp, ci was measured by tptd (tptdci) and pcci was calibrated. ten minutes after positioning, pcci was read from the monitor and then recalibrated by tptd. after - h, pp was ended and measurements were performed analogously to prone positioning. volume management between the respective time points remained unchanged. linear regression analysis and bland-altman plots were used for statistical analysis. all data are given as mean ± standard deviation, range in brackets. results. the tptdci in sp was . ± . ( . - . ) l/min/m . after proning, a pcci of . ± . ( . - . ) l/min/m and a tptdci of . ± . ( . - . ) l/min/m were measured. linear regression analysis revealed a correlation coefficient of r = . (p \ . ). mean bias (tptdci-pcci) was . ± . l/min/m . immediately prior to turning back to sp, tptdci was . ± . ( . - . ) l/min/m . after re-positioning, the pcci was . ± . ( . - . ) l/min/m and tptdci was . ± . ( . - . ) l/min/m , with a mean bias of . ± . l/min/m . the correlation coefficient was r = . (p \ . ). conclusion. pcci is only marginally influenced by prone positioning and is reliable without recalibration by tptd. however, in case of greater differences a recalibration by tptd is nevertheless recommended. objectives. the aim of this study was to analyze the clinical agreement between the intermittent bolus thermodilution technique (tdco) and apco in patients with non-traumatic intracranial hemorrhage requiring intensive care. methods. this was a prospective observational clinical study in a university level icu. we studied adult patients with non-traumatic intracranial hemorrhage, who for clinical indication underwent co monitoring by the tdco (pac, . fr, criticath tm sp h td catheter, becton-dickinson, singapore). in parallel, arterial pressure waveform was applied using the radial arterial pressure curve (flotrac/vigileo tm , version . and . , edwards lifesciences, ca, usa). tdco measurements were done approximately every h and when needed. the length of data recording was depending on the need for tdco monitoring and icu stays but was no longer than days. every tdco measurements and the simultaneous apco values were recorded and included into the analysis. results. data pairs were obtained. overall, mean co was . (sd . ) l/min for tdco and . (sd . ) l/min for apco. mean bias between tdco and apco was . l/min ( fig. ), % limits of agreement . to . l/min and the percentage error %. there was a large interindividual variation in mean bias and percentage error (minimum to maximum, - . to . l/min and - %, respectively). the bias was significantly greater if patient received norepinephrine ( . vs. . l/min, p = . ) but not if patient received dobutamine ( . vs. . l/min, p = . ) . only a small correlation between the bias and the rate of norepinephrine infusion was detected (q = . ). when cardiac index of . (l/min/m ) was used as a cut off value for need for intervention, the sensitivity and specificity for apco were . ( % ci . to . ) and . ( % ci . - . ), respectively. conclusions. according to our results the second generation of flotrac Ò /vigileo Ò monitoring system underestimates the tpco and the sensitivity is poor. there is also a large interindividual variation in bias. the use of norepinephrine may provoke the error. objectives. to compare cardiac output techniques to the reference tte method, which allows accurate measurement of the aortic flow section and of velocity time integral of aortic pulsed wave doppler signal to measure co. methods. monocentric prospective study included patients requiring invasive blood pressure and hemodynamic therapeutic intervention. tte co measurement was performed with aortic diameter measured in parasternal long axis view at the the aortic leflets, and velocity time integral measured using five apical view averaged on cardiac cycles. tod co was measured only when the pac insertion was decided. tte, uscom Ò , mostcare Ò and vigileo Ò were performed in all patients. each value was the average of successive cardiac cycles with consecutive measurements. each patient could have several measures. results. mechanically ventilated patients ( ± years; sofa ± . ) were investigated allowing to obtain measurements ( under norephinephrine). diagnostics: brain injury (n = ), sepsis(n = ) and others (n = ). patient had the methods ( measurements), patients had techniques ( measurements), patients had techniques ( measurements), conclusions. all methods correlated more or less with tte co, with a slope close to identity, and a low intercept. the best correlation was obtained between mostcare Ò and tod. agreement for almost all methods was large, within an acceptable range. for the pulse contour method, mostcare is correlated better than vigileo with tte co. the arterial signal has to be accurate as possible and requires a high quality chain for measurement avoiding overdamping or underdamping to allow effective signal digitalization. introduction. the lithium indicator dilution technique is attractive in paediatric intensive care because it is non-invasive. however, it requires calibration. the reliability of cardiac output measurement data rests on the reproducibility of the calibration factor (cf). objectives. to establish the number of calibrations (= x) that are required in a paediatric patient material, if the coefficient of variation for the calibration factor does not increase by % or more by (x + ) calibrations. to establish x it is also required that % of the patients do not show an increase in cv by % or more and that % of the patients show an increase in cv by % or more at (x + ). hemodynamically stable sedated and ventilator treated children under intensive care with a body weight of - kg were included. to perform calibration, . mmol/kg of lithium chloride was injected intravenously and the concentration of lithium ions in arterial blood was analyzed by a lithium selective electrode. the calibration process was repeated times and the cf as well as lithium indicator cardiac output (lidco) were calculated. results. results from children with a mean body weight of . kg are presented below. cv was below % throughout the investigation. introduction. stroke volume variation has been shown to be a better indicator of fluid responsiveness than static indices such as cvp or paop. a limitation of dynamic parameters is arrhythmias which produces abnormal svv. beat-to-beat variations reflect altered cardiac filling times not the effects of mechanical ventilation in fluid responsive conditions. a recently developed enhanced algorithm (newsvv) helps eliminate this limitation. newsvv rejects ectopic beats using multi-parameter signal recognition and restores the respiratory variation of the signal using spline-based interpolation. objectives. to evaluate the performance of the new arrhythmia rejection svv algorithm to predict fluid responsive from patient data with frequent arrhythmias. methods. newsvv was developed from data collected in a porcine model to limit the impact arrhythmias had on svv. comparing the current standard svv (svvstd) algorithm (flotrac-vigileo system edwards lifesciences, usa) with the newsvv showed a significantly improved sensitivity and specificity. ( ) in this preliminary study sets of patient data with frequent pvcs and atrial fibrillation (afib) were ran through the new algorithm and compared to the data from svvstd. in one patient fluid boluses ( - cc platelets and packed red blood) during a period of afib caused newsvv to decrease from to % and co to increase from . to . l/min, while svvstd algorithm did not show a significant change (varying randomly between and %). a second patient had non-paroxysmal afib. svvstd showed abnormally high values ranging between and %. patient was a non-responder to fluid and had a co ranging between and l/min. newsvv showed more realistic value of % depicting a non-responder range. the third patient had periods of afib followed by normal sinus rhythm (nsr). svvstd algorithm had abnormally high svv values ([ %) during the afib. during nsr, both algorithms correlated well with svv of %. (fig. .) conclusions. the newsvv algorithm improved svv with ectopics and afib and shows promise in eliminating a limitation of svv in those conditions. further studies are needed to fully evaluate the performance in patients with arrhythmia receiving fluid challenges. rd esicm annual congress -barcelona, spain - - october s methods. mechanically ventilated pigs (median weight kg) under general anesthesia were investigated. after instrumentation, baseline values were obtained after at least h of stabilization. ''shock'' phase (simulation of aaa rupture): ( - ) ml/kg of blood was gradually withdrawn and hemorrhagic shock maintained for h. abdominal cavity was filled with warmed saline to abdominal pressure of mmhg. ''clamp'' phase: infrarenal aorta was cross clamped for min and hemodynamics was resuscitated with shed blood and fluids. ''post-surgery'' phase lasted h and pigs were subsequently sacrificed. hemodynamics was obtained at baseline, every min for first h of hemorrhage, every h until postoperative phase and every h till the end of the study. data are presented as median (iqr), appropriate non-parametric tests were used for statistical analysis. results. baseline co measured by pac was ( - ) ml/kg/min. both vigileo ( - ) ml/kg/min (p = . ) and lidco ( - ) ml/kg/min (p = . ) differed significantly. the course of co is shown in fig. , all values are presented as a difference to baseline. the median difference between pac and vigileo was ( - )% and for lidco ( - )%. study limitations: both devices were designed for co estimation in humans but we do not expect huge differences in arterial system properties in pigs. young pigs reacted to hemorrhage by severe sinus tachycardia which caused failure in some co measurements but at least pigs are presented at every timepoint. conclusions. absolute co values obtained by both vigileo and lidco differ significantly from pac. unlike lidco rapid, flotrac/vigileo was able to track changes in co during severe hemorrhage. grant acknowledgment. iga mzcr ns - and vz msm . introduction. most important role of postoperative sedation is suppressing stress of the patients in icu. urinary -hydroxy- -deoxyguanosine ( -ohdg) can be a good biomarker for oxidative stress in clinical research. the aim of this study is to assess the free radical production under sedation in icu and compare the production between with midazolam and dexmedetomidine. subjects and methods. subjects were twenty-five patients with sedation after neck malignant tumor operation and ventilated for h in icu. patients with renal failure were excluded from this study. all patients received fentanyl ( lg/kg/day), fifteen patients were with midazolam ( . mg/kg/h: m-group) and ten patients were with dexmedetomidine ( . - . lg/kg/h: d-group) we examined the concentration of urinary -ohdg by high performance liquid chromatography (hplc) method with coolaray system every morning in icu. results. the average value of urinary -ohdg of healthy human volunteer is ng/ml. the values of urinary -ohdg were less than ng/ml in the both groups and no significant differences were observed between the groups in this study. conclusions. postoperative sedation with both midazolam and dexmedetomidine were effective in suppressing oxidative stress in icu patients. poorly controlled pain in the postoperative period can lead to slow recovery and life threatening complications, especially in elderly patients. it has also been suggested that the quality of postoperative analgesia could decrease delirium incidence and reduce duration of hospital stay in the elderly patients. however, the ideal postoperative analgesia management of elderly surgical patients in intensive care units remains to be determined. since, continuous epidural analgesia provides the required level of analgesia to support early mobilization and significant reduction in pulmonary and cardiovascular morbidity in the early postoperative period, we postulated that the use of low dose of continuous epidural morphine might improve postoperative analgesia and reduce undesirable side effects in elderly patientstherefore, the present study was designed to evaluate the effects of morphine administered via epidural patients controlled analgesia and intravenous tramadol + metamizol on postoperative pain control and side effects in elderly patients after major abdominal surgery. objectives. the purpose of this study was to compare the analgesic efficacy of morphine administered via epidural patients controlled analgesia (epca) with our standard analgesic for postoperative pain treatment, intravenous tramadol + metamizol in eldery patients undergoing major abdominal surgery. methods. forty patients older than years undergoing major abdominal surgery were randomly assigned to two groups. group i received epidural morphine mg at the end of surgery and used a patients controlled analgesia device programmed to deliver morphine . mg/h, . mg per bolus. group ii received intravenous infusion of mg tramadol plus mg metamizol in ml electrolyte infusion. the patients in group ii received ml of the infusion solution as a loading dose over min (corresponding to mg tramadol plus . mg metamizol) postoperative analgesia was tested at rest on a visual analogue pain scale ( = no pain, = worst possible pain) at , , , and h after surgery. patients' satisfaction, arterial oxygen saturation, respiratory rate, episodes of nausea, vomiting, pruritus and dizziness were also noted. results. both groups obtained adequate pain relief, and there were no between-group differences in pain scores. there were no significant respiratory differences but the patients in the epidural group were more sedated. in the tramadol metamizol group patients were treated for ponv while of the patients in the morphine group showed ponv. we conclude that combination of tramadol and metamizole provided postoperative analgesia equivalent to that provided by epidural morphine in early postoperative period. the both analgesic regimens were safe and suitable for the management of postoperative pain in elderly patients. h. poon , j. hulme sandwell and west birmingham hospitals nhs trust, birmingham, uk, sandwell and west birmingham hospitals nhs trust, intensive care medicine and anaesthesia, birmingham, uk a substantial amount of patients in intensive care units (itu) receive an inappropriate level of sedation with a tendency for over-sedation. although the ideal itu sedation practice is not known, many units use a protocol-based approach incorporating best practice consensus. the use of daily interruption of sedation infusions can reduce oversedation and is included in our current guidelines. objectives. the audit assesses compliance to our current protocols for sedation scoring and adjustment of sedation infusions. provision of sedation breaks in patients sedated more than -day is evaluated. methods. retrospective review of itu inpatients' daily record charts during june and july at sandwell and west birmingham hospitals nhs trust in two -bedded itu. charts were reviewed. results. our guidelines recommend hourly sedation scoring from h to midnight and hourly scoring from midnight till h; at , and h. % of the reviewed charts did not have a recorded hourly score. % did not have hourly scores overnight. % of the charts contain ramsay score - or - ; % of the charts contain ramsay score or . per protocol, sedation infusion is stopped at ramsay score - or - but in % of cases this did not occur. a sedation bolus should be given at a score of or . % did not receive a recorded bolus. our guidelines advocate restarting a sedation infusion at a lower rate after it has stopped and the patient is less sedated and increasing the rate after a bolus is given. however, correct infusion rate adjustments were only performed in % of cases. often, rates were changed but without first stopping, or administering a drug bolus. out of sedation days, there were only true daily breaks. conclusions. there is a tendency to over-sedation in our itu; less so under-sedation. common practice deviates from protocol and there is poor documentation. scores are recorded less often than protocol: there may continuous assessment by nursing staff that is not recorded. boluses are given more often than documented on patient charts. review of the current guidance is required to address appropriate frequency of formal scoring, nurse-led compulsory sedation breaks and pharmacokinetic education about the necessity to stop or bolus before infusion rate alterations. introduction. daily interruption of sedation has been shown to decrease length of stay in icu . recent national guidance in scotland promotes dis as part of a care bundle to decrease ventilator associated pneumonia. a week retrospective first round audit was completed prior to the introduction of dis and demonstrated % of patient hours where sedation could be improved. a second round audit of current practice was therefore undertaken to assess the impact of dis on sedation levels. our aim was to identify the frequency of periods where sedation levels were undesirable and investigate any clinical reason behind these. objectives. to assess whether dis would improve sedations levels of our patients already managed with a simple sedation algorithm (sa) aiming at a ramsay sedation score level - . methods. six months following the introduction of dis, a second period of weeks was studied retrospectively where the icu daily charts were examined to look at: demographic data, sedation score, and whether dis had been successfully carried out. results. cases were identified: males and females with an average age years and similar illness severity scores to the first group. dis was carried out on patient days, omitted on days and contraindicated on a further . , patient hours were examined. ( %) were excluded due to contraindications such as refractory hypoxia, drug overdose, and end of life care. the remaining patient hours were compared to the first round group [ , patient hours with contraindications ( %)] using the mann-whitney test as shown in fig. . conclusions. we could not demonstrate any difference in sedation levels following introduction of dis on our unit. we found a large proportion of patients where dis was unsuitable. introduction. delirium, an acute and fluctuating disturbance of consciousness and cognition, is a common manifestation of acute brain dysfunction in critically ill patients, occurring in up to % of ventilated patients in the united kingdom . delirium is independently associated with more deaths, longer hospital stay, and higher overall cost . hypoactive delirium is much more common, is easily missed and is associated with a worse prognosis than hyperactive delirium . objectives. the aim of our project was to quantify the presence of delirium on our critical care unit and to survey the practice of delirium assessment within our region. we conducted a prospective audit at the critical care unit, birmingham city hospital, uk. we used the confusion assessment method for the intensive care unit (cam-icu) to assess for delirium daily on all our patients for a period of weeks. simultaneously, we conducted a telephone survey to elicit the delirium assessment practice of the other units within the west midlands region of the unite kingdom. results. we carried out our assessment on patients over a -week period, which resulted in assessments ( were on non ventilated patients and on ventilated patients). assessments could not be completed because of deep sedation or language barrier. in total we had assessments positive for delirium giving an incidence of % for those patients we could fully assess. all of the patients with a positive assessment had hypoactive delirium. the telephone survey revealed only three of the twenty units in our region routinely assessed for delirium. none of the units had a formal management protocol/guideline for delirium. conclusions. delirium is a significant problem on our critical care unit. the incidence was lower than that reported in the literature this might be because firstly we were unable to assess a number of patients due to the patients being deeply sedated, and secondly we noted many of the patients during the assessment period were high dependency patients with minimal organ dysfunction. despite a large number of recent publications on delirium and increasing awareness amongst critical care professionals most of the units in our region do not routinely assess for delirium. without regular assessment most delirium will go unrecognised and thus opportunities to instigate preventative measures and early management will be missed. methods. six patients aged - years old ( females) who all sustained brain injury with cerebral oedema alongside other traumatic damage (i.e., fractures, abdominal trauma) are hereby presented. upon admission to the icu all patients received large propofol doses ( - ml/h of propofol infusion %), in an attempt to lower cerebral metabolic demand along with vasopressors to maintain a normal mean arterial pressure. three to days following admission all patients developed metabolic acidosis (base deficit ranged from - to - mmol/l), hyperkalemia (potassium concentration ranged from . to . mmol/l), evidence of muscle cell degradation (creatine kinase and myoglobin concentrations ranged from , to , u/l and from , to , lg/l, respectively) and lipaemia (triglyceride concentrations ranged from to . mmol/l). at that time all patients were clinically stable and usual laboratory tests as well as cultures were inconclusive, hence a diagnosis of pris was suggested. results. three out of six patients developed global left ventricular dysfunction, which was documented by echocardiographic evaluation, with normal cardiac enzymes, while all patients developed acute renal failure. cardiac and renal failure were observed within - h following the manifestation of the above abnormal laboratory findings. continuous hemofiltration was initiated promptly on a daily basis in all cases, while the administration of propofol was discontinued. abnormal laboratory findings normalized within - days, while cardiac and renal function gradually ameliorated within a week, following therapy in all cases. no deaths were recorded. conclusions. the initiation of continuous hemofiltration therapy is a crucial therapeutic tool for the elimination of propofol and its potentially toxic metabolites in cases of pris and may have a beneficial effect upon survival in these cases. l. zurong , w. yichun intensive care unit of hunan province tumor hospital, changsha, china objectives. our purpose was to compare the analgesic properties, effect, and side effects of intravenous butorphanol and fentanyl during chest tube removal in cardiac surgery patients. seventy-four patients with cardiac surgery were enrolled before chest tube removal. each patient received standard doses of either fentanyl ( lg) or butorphanol ( mg) before chest tube removal in a double-blind manner. pain intensity and pain distress were measured before analgesic administration, immediately after chest tube removal, and min later pain quality was measured immediately after chest tube removal. level of sedation was measured before and min after chest tube removal. results. the fentanyl (n = ) and butorphanol (n = ) groups were identical with respect to age, race, sex, and weight. pain intensity, pain distress, and sedation levels did not differ significantly between groups. however, procedural pain intensity (mean . , sd . ) and pain distress (mean . , sd . ) scores for all were low. patients remained alert, regardless of which analgesic was administered. conclusions. if used correctly, either fentanyl or butorphanol can substantially reduce pain during chest tube removal without causing adverse sedative effects. thus, clinicians may choose either safe and effective analgesic interventions during chest tube removal. introduction. delirium is defined as an acute alteration of mental status, with either a disturbance of consciousness or a change in cognition which develops over a short period of time and fluctuates during the course of the day. reported prevalence of delirium in critical care varies widely from to %. despite this, delirium remains grossly under-recognised and is often thought to be temporary and of little consequence in critical care. it is however one of the most frequent complications and, after adjusting for age, gender and severity of illness is an independent risk factor for prolonged length of stay and mortality ( ) . current recommendations are for the assessment and diagnosis of delirium using simple validated tools ( ) . pharmacological intervention should be considered when reversible precipitating factors have been corrected. haloperidol is considered the drug of choice. objectives. the purpose of this study was to detect knowledge and awareness of delirium, attitudes and behaviours towards its assessment and pharmacological management in critical care units of two large uk teaching hospitals a -point survey was distributed to all senior medical and nursing staff employed in critical care at the leeds general infirmary and the james cook university hospital, middlesbrough. a total of questionnaires were collected after four follow up rounds via web-based survey tool ''survey monkey''. results. the survey detected a significant awareness of the problem delirium poses in icu. the vast majority ( %) of practitioners did not screen for delirium routinely. of the % who screened only in used screening tools that were appropriate, the majority lacked the knowledge of suitable methods to do so. % of respondents felt that they required tools to aid diagnosis of delirium in their unit. the pharmacological management of delirium varied significantly, with a wide range of drugs used, suggesting the need for guidance. the majority of respondents ( %) felt that they needed guidelines for treatment of delirium, % felt that guidelines would change their practice. despite an awareness of the problem delirium poses in icu, data from this survey shows a lack of knowledge of assessment and treatment. given that most respondents needed guidelines, we have developed a delirium treatment protocol and implemented the confusion assessment method for icu (cam-icu) training package for all staff in the james cook icu. following its implementation we plan to re-evaluate in the hope that the awareness of delirium can be met with the appropriate knowledge to implement a sustained change in practice. results. patients were included, male ( %), mean apache ii score ± . midazolam was suspended in % after h. maximum dose of sufentanyl was mcg/kg/h. bilirrubin and creatinin did not change from initial values and there was no effect in enteral nutrition tolerance. bis values improved % from ± to ± (p = ns) and there were less hemodynamic effects as well as less necessity of amines and sedatives. results are shown in table . conclusions. sufentanyl is an efficient and safe sedative that reduces necessity of more sedatives, amines and generates adequate sedation without renal or hepatic effects. a.s. puxty , j. kinsella , k. anderson glasgow royal infirmary, department of anaesthetics, glasgow, uk etomidate is a sedative agent often used for the induction of critically ill patients. it is, however, a controversial drug with effects on the steroid axis that have been suggested may lead to a poor outcome. so far this has only been proven in infusions of the drug. despite this some have called for its withdrawal altogether objectives. to determine the attitude of anaesthetists and icu consultants in five hospitals in a major uk city towards the use of etomidate. methods. an online questionnaire was constructed using surveymonkey (portland, oregon, usa). this was then sent out to all anaesthetists in glasgow via an e-mail link. a reminder was sent after weeks. trainees from one of the hospitals were unable to be contacted via e-mail and so hard copies of the questionnaire were sent to them. of a total of anaesthetists in glasgow (trainees and consultants), ( %) completed the questionnaire successfully. of those answering the questionnaire, . % were sho level, . % spr, . % consultants and . % sas grade. these respondents sub-specialities/specialist interest were: general ( %), pain ( %), icu ( . %), obstetrics ( . %) and cardiac ( . %). overall ( % ci - )% of respondents were concerned about etomidate's effect on steroid synthesis, although when asked about induction of an emergency laparotomy ( - )% would still use it [with ( - )% avoiding it and ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) % responding that they were never involved in emergency laparotomies]. of those using etomidate, ( - )% would avoid it in a septic patient, and a further ( - )% would give steroid cover. the most common reason for using etomidate was cardiovascular stability [ ( - )%]. other reasons given were simple dosing ( [ - ] )% and habit ( [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] )%. more than one reason was allowed. looking for differences between groups the following was found: while icu consultants reported more concern over etomidate ( vs. %, p = . ), there was no difference in etomidate usage in emergency laparotomy ( % of general vs. % of icu consultants, p = . ). trainees were more likely to have their habit changed by the recent literature on etomidate ( vs. %, p = . ). conclusions. there is concern among anaesthetists and icu consultants regarding the use of etomidate but usage has not changed markedly by most. further evidence of harm would likely need to be demonstrated before abandonment of the drug. introduction. nociception and requirement of additional analgesia before painful procedures in icu are difficult to anticipate. under anaesthesia, the direct pupil light reflex reflects the sympatho-vagal balance and remains altered by pain and sedative drugs. the pupillometry is a reproductive, non invasive method based on automated flash light device assessing pupillary variations [ ] . to study pupillometric parameters to anticipate the tolerance to painful stimuli (surgical debridement). methods. eligibility criteria: sedated patients (morphinomimetics + benzodiazepines, bps = ) in days after invasive surgery for cervical necrotizing fasciitis (cnf), complicated or not with mediastinitis, requiring a surgical debridement three times a day. clinical evaluation performed before and during debridement: heart rate (hr), mean arterial pressure (map) and behavioral pain score (bps) [ ] . pupillometric test before debridement (calibrated bright flash of one-second at lux, (neurolight, id med) with recording of pupillary parameters: minimum and maximum diameter, variation rate, latency, velocity. noxious procedure was defined as an increase of at least one point of the bps (change in facial expression, upper limb movement or ventilator synchrony). the additional analgesia was decided blindly from pupillometric values. analysis compared two groups defined on bps variation induced by the procedure: group with dbps c and group with dbps = . comparison of pupillometric parameters before procedure between the groups. results expressed as median (interquartile range, iqr), mann-whitney test, significance at p \ . . . patients with cervical cellulitis of which complicated by mediastinitis, h/ fratio = / , age years ( ), igs ( ). in this population, during the procedure, hr and map were unchanged, the bps increased significantly [from ( ) to ( ) , p = . ] but remained unchanged in patients ( %) (group = high tolerance). pupillometric parameters before procedure before procedure group (n = ) group (n = ) p conclusions. all pupillometric parameters, except latency, were discriminant for subsequent debridement tolerance with significantly lower values in the group without pain experience. the pupillometric test seemed adapted to this clinical practice for evaluation of nociception status and may help for rationalizing analgesia for short noxious procedures. introduction. delirium is an acute and fluctuating change in mental status, with inattention and altered levels of consciousness. the incidence of delirium in orthopedic patients was ranges from . to %. delirium may present before or after the patient undergoing surgical procedure and has demonstrate increasing risk, including mortality. objectives. the purpose of this study was to compare the effectiveness and tolerability of intravenous propofol versus midazolam infusions in postoperative agitation/delirium therapy with using an epidural infusion for postoperative analgesia after major orthopedic surgeries in high-risk patients with chronic renal failure. with the institutional ethic committee approval; eighty-two high-risk chronic renal failure patients (asa iii, bun [ mg/dl and serum creatinin value [ ) after a major hip or knee operations with a diagnosis of agitation/delirium were eligible for the study in the postoperative period. richmond agitation sedation scale (rass) or confusion assessment method for the icu (cam-icu) were used for sedation/orientation levels. all agitated patients had an lumbar epidural catheter was inserted preoperatively in combination with spinal anesthesia intraoperatively. after the surgery the catheter was loaded with . % mg bupivacaine at the t to l sensory levels and a continuous infusion of . % bupivacaine was commenced at - ml/h in combination with patient controlled analgesia of meperidine ( mg/bolus). for agitation/delirium therapy in group p (n = ) propofol was used with intravenous loading dose of - mg/kg in a bolus and followed by continuous infusion at - mg/kg/h and group m (n = ) midazolam was used with intravenous loading dose of . - . mg/kg in a bolus and followed by continuous infusion at . - . mg/kg/h to ensure a target of rass in + and - values. hemodynamic parameters (heart rates, systolic and diastolic blood pressures), oxygen saturation with sedation-agitation scales were monitored periodically for h. adverse events were recorded. p \ . showed statistically significant. results. the groups were demographical comparable (p [ . ). group p patients reached the target rass scores earlier in group p (p \ . ). hemodynamic values were significantly higher in group m (p \ . ). the epidural bupivacaine consumption was significantly lower in group p with a limited analgesic requirement (p \ . ) and n treatment required adverse events was seen in group p (p [ . ). conclusions. intravenous propofol infusion may be an effective and safe approach adjunct to epidural analgesia for possible postoperative agitation/delirium treatment after major orthopedic surgeries in high-risk patients with chronic renal failure. introduction. ventilator-associated pneumonia (vap) is the most common nosocomial infection among the critically ill patients admitted in the intensive care units (icus). implementation of the available international evidence-based guidelines and recommendations to prevent and manage vap into the clinical setting may not be adequate leading to suboptimal patient care and increased vap rates. objectives. to assess the implementation of selected vap prevention strategies, and to learn how vap is managed by the intensivists practicing in the indian subcontinent. methods. three hundred -point questionnaires were distributed during an international critical care conference. ( . %) were returned and ( %) questionnaires of delegates from india, nepal and sri lanka were analyzed. most of the intensivists ( . %), reported using vap bundles in their icus with a high proportion including head elevation ( . %), chlorhexidine mouthcare ( . %), stress ulcer prophylaxis ( . %), heat and moisture exchangers (hme, . %), early weaning ( . %), and hand washing ( . %) as part of their vap bundle. use of subglottic secretion drainage (ssd, . %) and closed suction systems (css, . %) was also reported by many intensivists, whereas, use of selective gut decontamination was reported by only . % of respondents. most common method for sampling used for diagnosis of vap was endotracheal suction by ( . %) intensivists, and only . % intensivists reported using protectedsample brush. gram negative organisms (pseudomonas, acinetobacter) were reported to be the most commonly isolated organisms. majority of respondents ( . %) reported using proton pump inhibitors for stress ulcer prophylaxis. majority ( . %) believed that vap contributed to increased mortality in their icus with . % treating vap with an antibiotic course lasting for - days. de-escalating therapy was considered, in patients responding to treatment, by . and . % considered adding empirical mrsa coverage and . % considered adding nebulised antibiotics in certain high risk patients. overall there was good concordance regarding vap prophylaxis among the intensivists with a majority adhering to evidence based recommendations and guidelines. even though the gap between recommended guidelines and the actual clinical practice is closing, we could identify certain issues like the choice of agent for stress ulcer prophylaxis, use of hme, ssd and css, where there still exists some practice variability and opportunities for improvement to provide better patient care. objectives. to reassess the value of individual levels and dynamic alteration of procalcitonin (pct) in predicting the outcome of ventilator-associated pneumonia(vap) patient. methods. forty adult patients with vap were studied and divided into two groups according to their outcome at day after diagnosis of vap: death and survival. serum pct levels were measured on days , and (d , d , and d , respectively) and their alteration between different days (kinetics, pct) were calculated. to control the study, acute physiology and chronic health evaluation ii (apache ii), sequential organ failure assessment (sofa), and clinical pulmonary infection score (cpis) and c-reactive protein (crp) were also recorded and analyzed. all parameters have been investigated as independent variables in relation to -day death as dependent variable. results. the increase of pct levels on day , and were significantly predictive of death in univariate analysis with area under curve (auc) and % ci of . ( . , . ), . ( . , . ) and . ( . , . ), respectively. however, kinetics of pct levels among day , and did not show a significant difference between favorable and unfavorable outcomes (p [ . ). multivariate analysis revealed that only sofa ( ) conclusions. neither pct individual levels nor their kinetics during vap course can predict patient outcome. comprehensive evaluation of patients with multiple methods, in combination with pct levels, may increase predictive accuracy in the future. grant acknowledgment. we have no competing interests. introduction. the presence of new or progressive radiological infiltrates, pyrexia, leukopenia or leukocytosis, and the presence of purulent tracheal aspirates are key features defining the presence or absence of vap. the incidence of vap is dependent upon the number of diagnostic criteria applied, and the demographics of the critical care population to which it refers. a uk government directed ''patient safety first'' campaign in the uk, has highlighted vap as a complication related to mechanical ventilation that can be reduced through the introduction of a ''care bundle''. however, benchmarking between different units has practical limitations. objectives. selective data presentation can distort the perceived occurrence of critical events in order to deliver performance targets. we compared the incidence of vap between a neurosurgical and general intensive care unit in the same hospital. a variety of denominators were applied to explore the potential for data manipulation to realise performance targets a local database of neurosurgical and general intensive care admissions, covering a month period, was analysed retrospectively results. and subjects were admitted to gitu and nitu respectively in the month period. ( %) and ( %) subjects were ventilated for more than days. table summarises the demographics and measures of performance between the two units. a p value . was considered significant. parametric and non-parametric tests were applied as appropriate. . vap is associated with not only mortality but also considerable morbidity, prolonged duration of ventilation and increased cost of hospitalisation. to determine the incidence of vap in patients ventilated at the qensiu, to calculate mv resource utilisation, and to ascertain whether vap relates to outcome in acute sci. we undertook a retrospective case note review of all patients ventilated at the qensiu during a year period. patients were identified using a local computerised database. the qensiu receives referral of patients with sci from the whole country (pop * . m). vap was defined pragmatically as deteriorating gas exchange more than h following mv, coupled with a raised crp or wcc, together with either a positive sputum sample or new infiltrates on cxr. statistics: descriptive, median (range); analytical, mann-whitney u and fisher's exact test as appropriate. death occurred in % of patients, and was significantly greater in the group who were retrospectively assigned to the vap cohort: vap vs survival of the deaths, occurred following discharge from the unit ( of whom developed a subsequent vap). conclusions. vap incidence was apparently high in this patient population ( %), particularly in comparison to the reported general icu population incidence ( - %) . this may partially reflect our pragmatic diagnostic criteria, applied retrospectively. vap was also associated with an increase in mortality following discharge in patients with sci. a modified vap bundle adapted to sci patients is being developed locally, based on recent recommendations . introduction. the implementation of a prevention programme with feedback to nurses and healthcare workers (hcw) was associated with better outcomes and increased compliance [ ] . to assess the effects of feed-back in a study based on implementing a variables care bundle to prevent vap. a multicenter and prospective study was carried out in icus. the element care bundle consisted in hands hygiene, oral hygiene, monitoring cuff pressure, sedation vacation/adjustment and avoid ventilator circuits changing. beweekly feed-back displaying posters with information was carried out to update hcw in the compliance of the prevention measures and vap incidence. a questions with open answer questionnaire was performed months after the implementation of the feed-back in all icus to assess the knowledge of the compliance measures, vap incidence, opinion of the study and improvement suggestions. results. questionnaires were obtained. the median experience in intensive care was . years (sd . - . ). % of the staff was aware of the study: . % agree that was useful, . % disagree and . % didn't know. regarding if they thought that in their units they had a high vap incidence, . % answered that they did, . % answered negatively and . % didn't know. asking about the knowledge of the prevention measures' compliance . % answered right, . % said they knew but didn't specify the percentage, . % didn't know and . % didn't answer the question. finally, about the vap incidence, . % answered right, . % said they knew but didn't specify it, . % didn't know and . % didn't answer the question. . % added comments, the most relevant was: . % of the respondents wanted more verbal information. conclusions. poster feed-back failed to improve compliance on vap care bundle due to lack of information. our survey suggests to implement other communication strategies based on direct verbal interaction to improve implementation. objectives. to compare the effectiveness of two different methods of oral dental hygiene on ventilator-associated pneumonia (vap) prevention using the cpis (clinical pulmonary infection score). methods. twenty-seven critically ill patients, aged - years were studied. patients were randomly separated in groups: group (n = ) received oral care with tooth brushing using the bass technique followed by lavage with chlorhexidine . % (chx) solution in nacl . % (chx:nacl . % = : ). hexetidine . % (hex) was used for oral lavage alone in group (n = ). demographics, sofa, apache ii, gcs and cpis scores were recorded upon patient admission. on days , , and , bal and tongue surface cultures were obtained. the endpoints taken into account were the cpis on days , , , and as well as the number and species of bacteria cultivated. a cpis c was considered positive for vap. two-way anova, t test for independent samples, mann-whitney u, pearson correlation and kruskal-wallis tests were used for statistical analysis. p \ . was considered statistically significant. patient data analysis showed that both groups were homogeneous. on days , and there were more negative tongue surface cultures in the chx group than in the hex group (p = . ). even though the cpis did not differ significantly between the groups, a strong tendency of faster and greater reduction in the chx group was observed. moreover, a continuous gradual improvement of the cpis score was recorded in both groups on days , and . the overall incidence of vap was similar in both groups: group , . % (n = ) and group , . % (n = ). the same bacteria (p \ . ) developed in both bal and tongue cultures on days (p \ . ) and (p \ . ). nevertheless, the cpis was positive for vap only in the above patients on day , while day was totally free of vap. conclusions. even though the cpis improvement was more remarkable in group , both group scores showed parallel improvement overtime, the chx group being in a slightly more propitious position. diligence in patient oral care seems to be an additional effective practice for vap prevention, independently of the method used. introduction. specific patterns of cytokine gene expression are reported to be associated with the occurrence of infection in humans [ , ] . it is unclear whether these characteristic profiles are a consequence of an established disease process or precede the infective process. objectives. our primary endpoint was to determine whether hospital acquired pneumonia was associated with differential gene expression of ifn-c, tnf a and il- family of cytokines. secondary endpoint was to identify whether alteration in gene expression preceded the clinical onset of infection. methods. consecutive patients undergoing elective thoracic surgery were recruited. hospital acquired pneumonia was diagnosed as per nnis guidelines, independent of study investigators. mrna and protein levels were analysed pre operatively, h and days post operatively. . patients had an uncomplicated recovery. patients developed hospital acquired pneumonia. il- , il- , il -p , il- -p , il- -p , tnf-a, and ifn-c mrna and protein levels of il- , il- , and ifn-c in peripheral blood were analysed before surgery, h and day post surgery. il- p mrna levels were reduced in the pneumonia group ( , ; , - , ) compared to non pneumonia group ( , ; , - , ) day post surgery (p = . ). ifn-c mrna levels were reduced in the pneumonia group ( ; - , ) compared to non pneumonia group ( ; - , ) (p = . ) day post surgery. absolute copy numbers of mrna per million copy numbers of b-actin are quoted. all values are quotes as median and th to th centile range. patients with postoperative hospital acquired pneumonia exhibit distinct patterns of cytokine gene expression. these distinctive patterns manifest before the clinical onset of pneumonia. objectives. the aim of this study was to evaluate the impact of the implementation of a ventilator bundle on the incidence of vap in our intensive care unit (icu). methods. prospective, observational study. during a year period (january - ) a ventilator care bundle based on the cdc and canadian guidelines , was applied to each patient requiring more than h of mechanical ventilation (mv). the ventilator care bundle consisted in:hand hygiene. use of barrier precautions. preference of noninvasive ventilation (niv). orotracheal intubation. semirecumbent position. continuous aspiration of subglottic secretions. manteinance of the endotracheal cuff pressure. oral care with chlorhexidine. daily sedation vacation and assessment of readiness for weaning. no scheduled ventilator circuit changes. ventilation circuit maintenance. stress bleeding profilaxis. we followed general measures for infection control:single patient room. microbiologic surveillance. monitoring and early removal of invasive devices. program to reduce antimicrobial prescriptions. for each ventilated patient the following data was registered:age, apache ii, the reason of admission, risk factors, use niv, mv duration, timing of tracheostomy, time of diagnosis of vap, microbiological data, length of stay and mortality in icu. the compliance with the bundle was registered in a check list. the application of the ventilator care bundle impact was compared with historical data. . ventilated patients were included. the median age was years. the mean apache ii was . ± . . the reason of admission was in a % medical and % surgical. the most frequent risk factors were: age [ years, emergency surgery, pulmonary disease and immunosuppression. niv was used in %. the median duration of mv was days. tracheostomy was done in . % patients with a delay of ± days. there were late-onset vap episodes and the rate of vap per , ventilator days was . . the vap were caused by candida albicans, enterobacter aerogenes and pseudomona aeruginosa. the length of icu stay was . days. mortality was % (only one patient with vap). the rate of compliance with ventilator care bundle was %. the rate of vap per , ventilator days after implementation of the bundle decreased significantly (table ) . there is currently no consensus on the diagnostic criteria for ventilator associated pneumonia (vap) which has led to significant variation in the reported incidence ( - %) . icus need a reliable and accurate diagnostic system so that the efficacy of measures to reduce the incidence of vap can be assessed, and if vap is to be considered as a quality indicator of performance. objective. to establish a process to diagnose vap that can be used for continuous surveillance and to assess the effect of new therapeutic interventions. method. potential diagnoses of vap were identified prospectively by a senior intensive care doctor and clinical data was collected to calculate a modified clinical pulmonary infection score (cpis) . each case was subsequently reviewed at a multidisciplinary team (mdt) review forum with intensive care and microbiology clinicians. the case details, modified cpis and semiquantitative microbiological culture results were used to reach a consensus view on the diagnosis. a pilot audit performed over a week period in , gave a vap incidence of % ( vaps; ventilated patients; ventilator days) . a change to our ventilator care bundle was subsequently instigated, with the addition of chlorhexidine paste to daily mouth care before repeat surveillance. result: patients were admitted to the critical care unit over days. patients were ventilated during a total ventilator days. patient episodes were identified as potential vap and discussed at the mdt forum. cases were diagnosed as vap (incidence . %) and patient diagnosed as tube associated pneumonia. the other cases were excluded either due to clinical circumstances (n = ) or absence of positive microbiology (n = ). conclusion. we have developed a process for identifying and diagnosing vap within our critical care unit that continues to be used for ongoing surveillance. collaboration between the intensive care team and the microbiology department, along with a mdt forum, has been fundamental to this process. our data highlights the difficulty in diagnosing vap and the need for multidisciplinary expertise. of the patient episodes prospectively identified as potential vap, were deemed not to be vap when clinical data and results were available for review at the mdt forum. the reduction of vap incidence between the pilot study and subsequent screening suggests benefit from the introduction of oral chlorhexidine, however we recognise other contributing factors. controversially, icus in the uk are increasingly being asked to provide data on vap incidence as a quality indicator. we believe that we have a process that is robust and allows us to accurately monitor the incidence of vap. introduction. bacterial biofilm within the internal surface of the endotracheal tube (ett) may contribute to ventilator-associated pneumonia. the gene expression pattern of those bacteria, embedded within biofilm matrix, greatly differs from their planktonic counterpart and allows survival benefits and increased virulence. to compare biofilm production capability of planktonic versus sessile methicillin-resistant staphylococcus aureus (mrsa) retrieved from within etts, and to assess whether antimicrobials can hinder those processes. ultimately, to study any change in planktonic versus sessile bacterial dna. we previously developed a model of pneumonia in pigs mechanically ventilated up to h and challenged into both lungs with mrsa. from those studies, etts of pigs, treated with placebo (n = ), linezolid (n = ) or vancomycin (n = ) were retrieved. distal and medial parts of each ett were processed ( samples). the planktonic mrsa strain, inoculated to the pigs, was compared with sessile mrsa strains, retrieved from the internal surface of the etts, in capability to form biofilm, assessed through the adhesion-to-aplaque method for gram-positive bacteria. the optical density of biofilm was measured using a microplate reader at wave length k = nm and results are proportional to the planktonic control strain (value = ). pulsed-field gel electrophoresis (pfge) was used to determine potential bacterial dna recombination. introduction. ventilator-associated pneumonia (vap) is a common complication in mechanically ventilated patients and is associated with increased morbidity, mortality and costs. treatment-related risk factors associated with vap, include prolonged duration of mechanical ventilation, lack of antiseptic techniques, improper patient's position, inappropriate cuff pressure, peptic ulcer prophylaxis, and deep sedation. objectives. the aim of this study is to evaluate the presence of these risk factors and their association with vap development in a multidisciplinary icu. one hundred and fifty-seven critically ill patients consecutively admitted to a multidisciplinary icu, were prospectively studied. forty-one of them, developed vap ( m/ f age: ± years, apache ii score on admission ± , sofa score on admission ± ). inclusion criteria were intubation \ h prior to icu admission or after h of admission. exclusion criteria included: prior hospitalization in another icu, icu stay\ h, brain death, age \ years old and pregnancy. bronchial secretions, samples from the pharynx and gastric secretions were collected from each patient times weekly (on days , and ). we also documented the known risk factors for vap; sedation depth (using the ramsay scale), cuff pressure, head-bed elevation, reintubation, ventilator circuit changes, tracheostomy, the presence of levin, deep venous thrombosis and stress ulcer prophylaxis, three times weekly per patient results. in this selected sample of patients, the incidence of vap was per , ventilation days. out of this sample, % underwent at least one endotracheal tube change, % had at least once their ventilator circuit changed, % underwent a tracheostomy, % had levin, % did not have head-bed elevation above °, % had ramsay scale or , % had cuff pressure b cmh o, % did not received deep venous thrombosis prophylaxis and all of them received h -receptors antagonists, as gastric ulcer prophylaxis. these results indicate that several risk factors for vap, do indeed apply for the cases under study and that the incidence of vap is relatively high. therefore, the implementation of preventive strategies and the reinforcement of vap bundles can result in beneficial effects on the appearance of vap, in the monitored icu. introduction. pulmonary inflammatory response and progressive ards may complicate posttraumatic ali. clrt by a motor-driven bed is used in trauma patients to improve gas exchange and to prevent from ventilation-associated complications. we investigated the effect of clrt on the inflammatory response in the posttraumatic course. to assess systemic and pulmonary cytokines (interleukin (il- , il- ), intercellular adhesion molecule- (icam- ) before and days after begin of clrt. conventionally positioned patients served as a control group. after approval by our institutional review board trauma patients presenting with ali (pao /fio \ ) were prospectively randomized in clrt (n = ) and control group (n = ). cytokines were assessed from serum (s) and broncho-alveolar lavage (bal) after admission at the icu and on day , respectively. results. the mean age was ± years and mean injury severity score was ± . pulmonary gas exchange improved significantly in clrt in comparison with conventional positioning on day . changes in cytokine levels are presented in table (median and / percentile values, * = p \ . within groups and $ = p \ . between groups, wilcoxon and mann-whitney-u test). serum il- and il- levels were reduced statistically significant on day in both groups, but this effect was significantly more pronounced in clrt-group. in bal cytokines tended to be increased in clrt and control group on day . icam- levels were increased in s and bal after days treatment. conclusions. the early use of clrt reduces the systemic inflammatory response (il- , il- ), but has no influence on regional pulmonary cytokine expression. clrt might be a helpful tool for stabilization in trauma patients with ali. objectives. the aim of this study was to compare the performance of adaptive support ventilation (asv) with and without closed loop control by end tidal co (etco ) (asvco ) to that of pressure control ventilation (pcv) and volume control ventilation (vcv) during simulated ards and to compare the ability of all modes to manage etco , tidal volume (v t ), and plateau pressure (pp) as respiratory mechanics, peep and minute volume changed. methods. asv and asvco were compared to a v t of ml/kg in vcv and pcv using the michigan instruments test lung set up with co titrated into one of the test lung chambers. the compliance of the system was set at and ml/cmh o and resistance at . cmh o/l/min. at baseline ventilation co was titrated to establish a co production of ml/kg pbw/min ( kg) or ml/min. after stabilization and data collection co production was increased to ml/ min and then to ml/min then decreased to ml/min. after each co adjustment and stabilization period data was collected. statistical analyses were performed by anova or kruskal-wallis tests where appropriate, a p value. was considered significant. overall etco level in asvco ( . ± . mmhg) was higher than in other modes (asv . ± . , vcv . ± . , pcv . ± . mmhg) (p \ . ). at the lowest compliance etco in asvco ( . ± . mmhg) was higher than in vcv ( . ± . mmhg) and pcv ( . ± . mmhg). overall v t was similar in all modes except that v t in asvco ( . ± . ml/kg) was lower than in vcv ( . ± . ml/kg) (p = . ). at the lowest compliance v t in asv ( . ± . ml/kg) and asvco ( . ± . ml/kg) were lower than in vcv ( . ± . ml/ kg) and pcv ( . ± . ml/kg) (p \ . ). overall, pp in asv ( ± . cmh o) and asvco ( . ± cmh o) were lower than in vcv ( conclusions. our high mortality in this group of patients despite improved oxygenation concurs with published data. however, potential improvements with adherence to ph and oxygenation targets could be made to ensure optimal use of hfov as a lung protective strategy. objectives. this randomized cross-over controlled study was designed to assess safety, gas exchanges, and ventilator outputs obtained with intellivent Ò as compared to adaptive support ventilation (asv) ( ) in icu ventilated patients with acute respiratory failure. methods. the study was approved by ethic committee and inform consents were obtained by next-of-kin. intubated, sedated and ventilated patients were included (age = ± years, saps ii = ± , and ali/ards and normal lungs patients, respectively). patients were ventilated using a g (hamilton medical, switzerland) with a dedicated software. asv and intellivent Ò were delivered in random order for two periods of h with half an hour of washout in between. tidal volume (v t ), peak pressure (ppeak), spo , and etco were continuously recorded. blood gas analysis and plateau pressure (pplat) were measured at the end of each period. a paired t test was used to compare ventilation and oxygenation parameters between asv and intellivent Ò period. no patient was removed from intellivent Ò for major safety issue. intellivent Ò delivered a lower mv ( . ± . vs. . ± . l/min, p = . ), peep ( ± vs. ± cmh o, p = . ), fio ( ± vs. ± %, p \ . ), vt/pbw ( . ± . vs. . ± . ml/kg pbw, p = . ), and pplat ( ± vs. ± cmh o, p = . ) than asv. static compliance, pao /fio ratio and paco were not different between asv and intellivent Ò . with both asv and intellivent Ò , v t was between and ml/kg pbw in all the patients. figure is showing the distribution of mean of individual breath by breath peak pressure during the two recording periods. conclusions. intellivent Ò delivered lower volumes and pressures than asv for equivalent results on gas exchange suggesting more efficient ventilation. introduction. during neurally adjusted ventilatory assist (nava) pressure applied to the airways by the ventilator is moment-by-moment proportional (according to a proportionality factor called ''nava gain'', unit: cmh o/lv) to the electrical activity of the diaphragm (eadi, unit: lv), as measured through a modified nasogastric tube with a multiple array of esophageal electrodes. independently from its physiological correlation with real diaphragm activity, eadi and its variations are the only variables through which different nava gains may affect patient respiratory pattern. objectives. we explored how eadi influence the effect of varying the nava gain on tidal volume and peak airway pressure. we included twelve patients recovering from acute respiratory failure. all patients, connected to a servo-i ventilator (maquet critical care, solna, sweden) able of delivering both psv and nava, underwent to a random application of increasing gains ( . - - . - - . - - cmh o/lv) during nava and increasing pressure support ( - - - cmh o) during psv. each level was maintained at least min. all changes in eadi, tidal volume (vt), and peak airway pressure (paw peak ) were referenced respect to their respective values at nava gain . . introduction. lung protective ventilation strategies is considered 'gold standard' for patients with acute respiratory distress syndrome (ards). high-frequency oscillation (hfo) has been used as a rescue measure and claimed to protect the lungs from ventilator induced lung injury ( ) . theoretically hfo should be considered early in the course of ards. objectives. we were interested to determine the time course to achieve optimal gas exchange with early hfo and its impact on the use of other adjunctive therapies; inhaled nitric oxide, prone positioning and extracorporeal oxygenation or carbon dioxide removal. after ethical approval, a total of adult patients with ards were enrolled in this prospective observational study. the oscillation (metran co. ltd, - , -chome, kawaguchi, saitama, japan) was started when fio [ . or level of peep [ cmh o were required on a conventional ventilator. hfo frequencies, cycle volume and bias flow were altered until optimal gas exchange achieved. the pattern of gas exchange was observed for the first h and other adjunctive therapies were used when required. the following parameters were recorded: duration of hfo, arterial blood gases during the first h, frequency of need for other therapies, incidence of barotraumas, and re-requirement of hfo once weaned from. a total of patients (age between - years, male:female ratio = : ) were ventilated - days with conventional ventilator before start of hfo. duration of hfo varied from to days ( median). there was a significant improvement in pao at - h (p = . ) following the onset of hfo (fig. ) . the number of patients requiring other therapies are very low; inhaled nitric oxide n = , prone positioning n = , both prone positioning and nitric oxide n = , ecmo/novalung n = . seven patients required re-hfo once weaned and another two developed pneumothoraces requiring chest drainage. conclusions. the data of this study demonstrates that significant improvement in gas exchange occurs in patients with ards following - h of hfo. early oscillation also appears to reduce the need for other adjunctive therapies. further studies of early hfo strategy are warranted. introduction. neurally adjusted ventilatory assist (nava) is a novel method for patient triggering of pressure support. instead of relying on conventional pressure or flow triggering, the peak diaphragmatic emg signal (edi) is used to precisely synchronise patient demand with ventilatory assist. although, the physiology and science underpinning nava has been described, less is known about its clinical application and efficacy ( ) . in particular, clinical superiority over conventional pressure support has not been established. objectives. here, we describe the clinical, nursing and operational lessons learnt from the introduction of nava platforms (servo-i, maquet) into a -bedded central london intensive care unit over years. in parallel we present some novel data from an observational cohort study examining the effect of nava on sedation use and ventilator days. a protocol for the safe measurement of edi in critically ill ventilated patients was developed through multidisciplinary review and discussion. a year registry of clinical lessons and adverse events from the introduction of nava was kept. in a parallel observational cohort study we examined three populations of ventilated patients (n = ) matched for apache ii, oxygenation index and compliance. group had no nava catheter; group had edi signal measured during conventional pressure support; and group utilised the edi signal to act as a neural trigger to drive ventilatory support. results. the measurement of edi was not associated with a difference in hospital mortality. there was a significant reduction in sedation use, muscle relaxation, ventilator days and icu days in patients with a nava catheter (fig. ) . however, there was no significant difference in any of these parameters with edi measurement guiding conventional pressure support versus nava. ventilator days in nava versus pressure support conclusions. in this study we show that neurally adjusted ventilatory assist can be safely and effectively be introduced into a 'non-expert' intensive care unit. we further show that reductions in sedation use and ventilator days appear to be related to the earlier introduction of sedation holds and reductions in ventilatory assist (with consequent earlier spontaneous breathing trials) in order to acquire an edi signal rather than due to an intrinsic advantage gained by improved patient-ventilator synchronisation with nava. the causes of the respiratory failure were: infections n = ; . % (immunodeficiency n = , tuberculosis n = , aplastic anemia n = , congenital cardiomyopathy n = , sepsis n = ), rsv infection-bronchiolitis n = ; . %, bronchopulmonary dysplasias n = ; . %, leukemias n = ; . %, burn-ards n = ; . %. the mean duration of hfov was . days ( h to days). the parameters of ventillation ranged: fio : - %, mean pressure: - cmh o, dp: - cmh o. the i time and hertzs ranged within the acceptable for age limits. closed suction circuit was used. we didn't notice any side effects from cardiovascular system or distension of the thorax. eadi and respiratory effort indices decrease when assistance increases in nava. nava should also theoretically allow perfect synchronization between the patient and the ventilator, and no asynchrony has been described with this mode. nava level adjustment at bedside, however, is still a matter of research. we assessed breathing pattern, respiratory effort indices, and patient-ventilator synchronization throughout a titration of nava and of pressure support ventilation (psv). we assessed breathing pattern, respiratory effort indices, and patient-ventilator synchronization throughout a titration of nava and of pressure support ventilation (psv). methods. physiological study conducted in seven patients (preliminary results) during the weaning. airway pressure (paw) and flow, esophageal and gastric pressures and the eadi were continuously recorded. for each patient, the following levels of assistance were consecutively applied: in psv: - - - - cmh o; in nava: . - - . - - . - - - - cmh o/mvolt. results are given as median and [ th- th percentiles], and tidal volume (vt) in ml/kg of predicted body weight. results. the increase from the lower to the higher level of assistance was associated with an increase in vt from . [ . - . ] to . [ . - . ] ml/kg in psv and from . [ . - . ] to . [ . - . ] objectives. we describe technical possibilities, tolerance and gas exchange with combination of oscillation device with nimv. a specific oscillator device (sensor medics, vyasis) was selected to change conventional airflow to oscillatory airflow. connected by ''t'' piece with oscillatory devicerespiratory circuit-face mask. we selected bipap ventilator (vision resp inc), facial mask. bipap mode (iap/epap cmh o) to achieve stable mechanical ventilation (t ). a progressive increment in rate of oscillation (hz) and power oscillation to achieve airflow change (t ). to evaluate the differences of peepi during the release phase, referred to mechanical pressure release from p high to p low , and the inspiratory work of breathing (wob) during p high among currently available aprv ventilators, using a lung model (ttl , mi). methods. the six aprv ventilators were evaluated in this study: ) nellcor puritan-bennett (puritan-bennett), ) evita xl (drager), ) servo i (maquet), ) avea (viasys), ) g (hamilton) and ) engstrom (ge healthcare). ventilator settings in aprv ventilators were set as follows: p high /p low cmh o/ cmh o, t high /t low . s/ . s. when evaluated peepi during the release phase, t low was diminished by steps of . s from . to . s. the inspiratory pressure-time product (ptp), as an index of wob, was directly measured under with tidal volume/respiratory rate of ml and /min. measurement for each setting was performed in a random order. three breaths were analyzed and averaged for each measurement. the results are shown in fig. objectives. to perform bench study to test the hypothesis that ett or trach can reduce the insufflated (vti) and/or exsufflated (vte) volume as provided by coflator Ò . methods. coflator Ò is connected to a pneumatic model (ttl, michigan instruments) via ett mallinckrodt . , . , . , . , . ) or trach (mallinckrodt . , . , . ) . the set up is tested in conditions of compliance (c ml/cmh o) and resistance (r cmh o/l/s): c r , c r , c r , c r . the device is set in manual mode, at the highest inspiratory flow, inspiratory/expiratory time / , s pause after expiration. three pressures are used, , and cmh o in both inflation and deflation. a baseline condition without any tracheal prothesis nor r served as reference. airflow and pressure upstream ett or trach are measured (biopac mp ). five insufflations followed each by an exsufflation are performed in each condition. the data are analyzed by using a linear mixed effects model where ett or trach, and pressure have fixed effects and c or r a random effect. the dependent variable is vti and vte. the main end-point is the slope of the relationships between vti or vte and pressure. results. the vti-pressure slope was significantly lower with any ett than baseline at both c ( fig. a and b). the same was true for trach. even though these differences were statistically significant the reduction in vti from the baseline averaged ml with etts as a whole. the vte-pressure relationships were similar for ett and trach and showed no difference from baseline at c ( figure d ). however, at c , the relationships are scattered ( figure c ). moreover, expiratory pressure of - and - cmh o were not reached for ett . , . and . and trach . and . . conclusions. ett and trach slightly but significantly change the performance of the device. however, small sized ett or trach in c condition substantially modify the efficacy of the exsufflation. these findings desserves assessment in patients for relevance. rd esicm annual congress -barcelona, spain - - october s though humidified high flow nasal canula oxygen (hfnc) has been widely studied in pediatric population, few data in adult is available and its and its precise indications and actual benefits in these patients remains unknown. two studies have shown that hfnc generates a low level of positive airway pressure contributing to decrease the work of breathing. one study has reported a favourable effect on comfort and oxygenation of hfnc as compared to venturi mask and in another preliminary one, fewer patients using hfnc went on requiring non invasive ventilation. objectives. to evaluate the efficiency of hfnc (optiflow, fisher and paykel, auckland) in critical care patients with acute respiratory failure. methods. prospective single centre study in a university hospital intensive care unit. all patients exhibiting acute respiratory failure (arf) as defined by clinical signs and/or failure of haematosis, regardless of the aetiology, were eligible. hfnc was used at a mean output of ± l/min and a mean fio of ± % throughout the study period. results. thirty-five patients were included. the mean age was . ± . years old and mean saps ii is ± . pulmonary infection was the most common aetiology of arf. hfnc was used ± days. all but one patient were discharged alive from icu. optiflow significantly reduced respiratory rate (p \ . ), heart rate (p \ . ), dyspnea score (p = . ), sus clavicular recession and thoraco abdominal asynchrony, and improved pulse oxymetry (p = . ). there was no significant difference in ph, pao , paco on arterial blood gazes performed before and , and h after hfnc use. the pao /fio ratio at and h after hfnc initiation was higher than before use of hfnc (p = . ). patients ultimately intubated exhibited a higher respiratory rate min ( . ± . vs. . ± bpm, p = . ) and min ( with an incidence of up to % in routine sonography [ ] , pleural effusion is one of the most common complications in intensive care patients. the use of bedside d ultra-sound to detect pleural effusion is fast, practicable and minimises radiation exposure [ ] . however, sonographical volumetry tends to be imprecise, and ct imagingbased volumetry is the more accurate method to quantify pleural fluid in intensive care patients [ ] . objectives. the aim of this study was to compare the accuracy of d and d ultra-sound volumetry of pleural effusion in intensive care patients. methods. icu patients designated for thoracentesis because of radiological support for pleural effusion were examined both with d and d ultra-sound \ h before and after the intervention. effusion volume was calculated with the formula ''volume [ml] = sep [mm] '' [ ] for d measurements and compared to the d volumetry by the ge d view software. the difference of volumetry before and after intervention was compared to punctured volume (gold standard). the device used for u-sound measurements was the ge voluson i. . within the group under survey (n = ), eight patients were on the respirator. mean punctured volume was ml ( ml; ml). mean absolute value of deviation from punctured volume (gold standard) was ml ( . %) for the d measurements and ml ( %) for d measurements. biggest difference between methods was found between ml and ml punctured volume. none of the methods generally measures higher volumes than the other. conclusions. the size of deviations from gold standard in both directions in d measurements suggests that the method is not reliable in predicting pleural effusion volume. d measurements are more likely to predict the right effusion volume, making the method a better diagnostic tool than d u-sound measurements. although thoracocentesis was found to be safe for mechanically ventilated patients [ ] and d volumetry may not change the therapeutic decision, which depends on high-risk patients' overall clinical condition, it could nevertheless help to avoid unnecessary interventions and thus improve patient safety. ongoing work analyses results for a group of patients with ct imaging-based volumetry of pleural effusion as gold standard. we study the utility of deltacvp changes during pressure support ventilation (psv) as an indication of respiratory effort. patients after several t-trials failures were on psv. the level of ventilatory assistance was changed in order to set the psv. no aditional interventión was used in the management of these patients. we registered data from the ventilator and beside monitor (vt, rr, p , deltacvp) in two levels of ps. optimal-ps, as the lowest support without respiratory distress and with the middle of this level -psv. the inspiratory trigger was used with the highest sensibility without autotrigger, the inspiratory ramp was changed in every patient and expiratory was flow-cycled at % of the peak inspiratory flow. results. patients n, acute on chronic respiratory failure, n, heart failure, n, recovery of acute respiratory failure. age ± years, admission apache ii ± and they needed weaning with ps after ± days with control mechanical ventilation. the respiratory mechanics in this time were cst.rs ± ml/cmh o and raw.rs ± cmh o/l/s. the ramsay score was ± ( ) ( ) ( ) ( ) ( ) . when the optimal level of ps was decreased from ± to ± cmh o, all patients showed respiratory distress, and the variables studied changed significantly: p : . ± . to . ± . cmh o, deltacvp . ± . to . ± . cmh o, vt decreased from . ± . to . ± . l and rr increased from ± to ± bpm (p \ . ). the correlation between p and del-tacvp was . (p = . ). central venous pressure swing provided information about the respiratory effort and may be useful during pressure support ventilation. introduction. the use of a tidal volume of ml/kg of predicted body weight is part of the management of patients presenting with ards ( ) and prevents ventilator induced lung injury in icu patients undergoing mechanical ventilation ( ) . the setting of tidal volume is based on patient height. height seems to be more often estimated by the icu staff than actually measured ( ). objectives. our study aimed to assess the accuracy of the visual estimation of patient height and its impact on ventilator settings. thirty-two patients admitted to a surgical icu were prospectively included in this observational study. patients had their height visually estimated by icu staff members ( doctors, nurses and nurse-assistants) and then measured. we also measured the knee height from which height can be extrapolated. we then compared the mean estimated height for each patient to the actual measured height with the use of bland and altman plots and the consequences of the measurement error on the tidal volume setting. in most patients visual estimation overestimates the actual height. the measurement errors result in an increase in the tidal volume up to + ml/kg. this remains true whatever the subgroup studied: all patients (bias: . ± . , % ci: - . ; . ), male patients (bias: . ± . , % ci - . ; . ), female patients (bias: . ± . , % ci . - . ) and whatever the type of assessor. extrapolated height from knee height results invariably in an underestimation of actual height (bias - ± . , % ci - . ; . ). our results prove that neither visual estimation nor knee height measurement are reliable surrogates for measured height. therefore, measuring patient height should be mandatory in critically ill patients in order to minimise ventilator-induced lung injury. methods. , respiratory acts were recorded in icu patients selected because of severe asynchrony with the ventilator (g , hamilton medical) during psv. by visual analysis (va) of airway pressure and flow trajectory, ineffective efforts and inspiratory/expiratory delays were detected. the results of va were compared with those provided by a new algorithm based on the automatic analysis (aa) of flow trajectory. results. va identified ineffective efforts ( % of patients acts). among , assisted acts, average inspiratory and expiratory delay was ± ms and ± ms, respectively. significant inspiratory and expiratory delay ([ ms) occurred in , ( %) and in acts ( %), respectively. automatic analysis was able to identify , of , patients acts ( %). in , cases ( %), both inspiratory muscles contraction and relaxation were detected. in acts ( %) only relaxation was identified. compared with va, inspiratory and expiratory delay of aa was ± and ± ms, respectively. aa recognized the start and the end of patient's effort before the ventilator in , ( %) and , ( %) of assisted acts. sensitivity and specificity of aa in detecting ineffective efforts, inspiratory delays [ ms, expiratory delays [ ms were and %, and %, and % respectively. the new algorithm proved to be efficient as a real-time, continuous monitoring system of patient-ventilator interaction. the advantage over traditional flow and pressure based triggers has to be tested. introduction. mechanical ventilation remains as one of the most difficult safety issues in the icu, but parameters commonly monitored by ventilators only depict the most extreme risks for patients. new computerized approaches may manage exhaustive data and may include ''intelligent'' software that mirrors expert decision making. to test the clinical usefulness of a new computerized system as a herald for clinically significant alarms and its possible impact in outcome. methods. twenty-five mechanically ventilated patients were continuously monitored in a single mixed icu in a university-affiliated hospital. we recorded age, diagnosis, pao /fio , apache ii and sofa on admission. the computerized system grabs and process data from different devices, usually a monitor and a respirator, and evaluates the most relevant events in a ventilated patient. all the algorithms were designed and validated with the clinical staff. data of ventilated patients were recorded at the icu during months and a total of , , breaths from different patients, each of them with a register of at least % of total ventilation time, were collected. data include biomedical signals (waves and trends) as well as all the clinical events detected by the system, including trapped gas at end-expiration, presence of secretions, double-cycling, asynchronies during expiration, pulse pressure variation in patients not triggering the ventilator and stress index ([ . or . ) in those ventilated with square airflow. outcome variables were icu length of stay, hospital stay and mortality. statistical analysis included multiple regression models for length of stay and mortality. [ ] [ ] [ ] [ ] [ ] [ ] [ ] , icu length of stay . days [ . - ] , hospital length of stay days . the frequency of alarms were: trapped gas at end-expiration: . %, presence of secretions . %, double-cycling . %, asynchronies during expiration . %, stress index [ . . %, stress index . . %, and pulse pressure variation . %. multiple regression analysis found pao /fio associated with length of mv and close to significance with hospital stay and mortality, but any of the computerized alarms reached yet the level of significance. conclusions. the computerized system is able to detect and review more clinically significant problems than clinical routine. however, its impact to define patient outcomes warrants further investigation. objectives. we have assessed the ability of the ventilator t-bird vs and ltv- to deliver to a lung model with ards a set tidal volume (vt) at different simulated altitudes. we used a decompression chamber to mimic the hypobaric environment at a range of simulated cabin altitudes of , , , and , m ( , , , , , feet). ventilators were tested with realistic parameters. vt was set at and ml in an ards lung model. the positive end expiratory pressures (peep) were set at and cmh o. pressure drop across the pneumotachograph was measured by a differential pressure transducer (enertec tm ). the spirometer was checked at each altitude using a calibration syringe. the inspired oxygen content (fio ) was %. respiratory rate was breaths/min. the ratio inspiratory time/expiratory time was / . the protocol included three measurements for each simulated altitude. comparisons of preset to actual measured values were accomplished using a t test for each altitude. a significant difference was defined by p \ . . the standard deviation for the three measurements obtained at each altitude was consistently less than ml. respiratory rate delivered was breaths/min in all cases. variation of peep did not change the volume delivered. the t-bird vs showed a decrease in volume delivered. comparisons of actual delivered vt and set vt demonstrated a significant difference starting at , m for a vt set of ml, at , m for vt set of ml. at these altitudes, the variations between vt set and delivered were more than %. with decreasing barometric pressure, the ltv- showed mostly an increase in volume delivered. comparisons of actual delivered vt and set vt demonstrated a significant difference at , m for a vt set of ml, at , m for vt set of ml. the delivered tidal volume remained within % of the set vt. assuming that the patient is ventilated at sea level and gas exchange is normal, the movement to altitude would result in an increase in tidal volume which might in fact represent a clinical event. conclusions. the ltv- met the trial targets in all settings, whereas the t-bird-vso did not compensate well for altitude and progressively delivered lower volumes as barometric pressure decreased. such variations between delivered and set vt suggest lack of efficacy of altimetric correction in hypobaric conditions in some devices. the ltv showed a moderate increase in volume delivered for ards lung model with increasing altitude, but maintained the delivered volume within % of the set vt up to , m. the accuracy of the vt delivery was superior with the ltv- than with the t-birdvso . oxygen therapy is commonly used to correct residual oxygenation impairment in the post-extubation period. this is usually done through a venturi mask which allows to deliver predetermined fractions of oxygen humidified with bubble humidifiers. the low humidity delivered by such devices and the use of an oro-nasal mask may, however, reduce patient's comfort, possibly resulting in mask displacement or removal and consequent oxygen desaturations. nasal high-flow (nhf) oxygen therapy allows to deliver high-flow oxygen, humidified with heated humidifiers and delivered through nasal cannulae, with the potential to improve comfort and efficacy. objectives. in patients requiring oxygen therapy after extubation, we compared nhf vs. venturi mask in terms of oxygenation and comfort. patients who were mechanically ventilated for more than h, passed a spontaneous breathing trial, and had pao /fio \ at the end of the trial were randomized to receive oxygen with nhf or venturi mask after extubation. exclusion criteria were: tracheostomy, age \ , pregnancy, or anticipated need for noninvasive ventilation after extubation. in both groups, fio was set to obtain spo between and % ( - % in copd patients). with nhf, flow rate was set at l/min. arterial blood gases, respiratory rate, and discomfort were assessed at , , , , , , and h. discomfort was assessed by asking patients to rate their discomfort with the used device by using a numerical scale from (no discomfort) to (maximum imaginable discomfort). discomfort symptoms were also assessed for the dryness of the delivered oxygen (dryness of the mouth, throat, nose, difficulty to swallow and throat pain). incidence of desaturations and interface displacement was also assessed. objectives. to evaluate the optimal humidifier water temperature when using a helmet for noninvasive positive pressure ventilation. oxygen. each was sequentially tested in the following order: using the helmet without humidification at ambient temperature, with humidification with unheated chamber water, and with humidification with the chamber water at , , and °c. at each setting, after a min stabilization period, measurements were taken. comfort level at each setting was evaluated using a visual analog scale (vas) rated zero (most comfortable) to ten (least comfortable). temperature and relative and absolute humidity inside the helmet, and vas scores statistically significantly increased as the humidification chamber water temperature increased. the lowest vas, . ± . , was obtained when water in the humidifier chamber was at ambient temperature. conclusions. for patient comfort during cpap using a helmet, the most desirable conditions are likely to obtained by humidifying without heating, that is by leaving the water in the humidifier chamber at room temperature. introduction. the physiological and clinical effects of non-invasive ventilation (niv) on acute post-operative respiratory failure are relatively unknown. the aim of this study was to determine the prediction factors for failure in the use of niv with a helmet in this context. the use of niv was assessed for a period of years, in a post-operative intensive care unit (icu). demographic data was collected, as well as arf and arterial gas readings. haemodynamic changes were assessed using picco tm technology and the clinical development of patients was recorded. all patients who developed acute respiratory failure (arf) were treated using niv as their primary care, and the two groups for the study were determined in this way, depending on whether the technique was successful, or the patients required intubation. the risk factors that determined failure in the application of niv were subsequently determined. of the patients presenting with post-operative arf treated with niv using a helmet, did not require intubation ( . %). following a multivariate analysis using logistic regression, we determined that there are four independent risk factors for the failure of niv. the primary causes of respiratory failure are as follows: acute respiratory distress syndrome (ards) and pneumonia, and in second place, the high initial evlwi (extravascular lung water index) value, as a protective factor, is the increase in the po /fio ratio after the first hour of niv application. conclusions. niv using a helmet could provide an effective alternative to conventional ventilation in selected patients with post-operative arf. -jaber s, delay objectives. analyze niv practice in emergency departments. we have development an international epidemiology survey (march ) by electronic questionnaire to know niv organization, equipment and training in emergency departments (phase i). design. international multicenter prospective. we have enrolled information from hospitals: spain ( ); italy ( ); india ( ); usa ( ); slovakia ( ); turkey ( ); germany ( ); australia( ); chile ( ); singapore ( ); finland ( ) during to analyze noninvasive practice in prehospital and emergency medicine, equipment, interfase, ventilatory modes and common clinical applications. major results during month period analysis were: noninvasive mechanical ventilation were applied in prehospital: ( ) ( . %). nimv commonly was applied follow a objective pprotocol of nimv: ( ) ( ) ( . %). global rate indication of niv were copd exacerbation ( %) and cardiac pulmonary edema ( - %). all niv applications were successful applications in emergency departments (avoid eti %) with minor complications ( . %) (skin nose lesion). equipment more relavant were (cpap devices ( %) and facial mask ( %) was more frequent, follow total face( %); nasal mask ( %); helmet ( %); type ventilary mode: cpap ventilatory mode was frequent used as first line ( % ( ) suggest niv should be started within h of not responding to the maximal medical therapy for acute type respiratory failure patients. following an earlier audit presented as an abstract at esicm ( ) , which looked at possible delays in starting niv, protocols were implemented to start niv earlier at russells hall hospital acute admissions unit. objective. the aim was to assess the delays in starting the appropriate patients on niv at admission looking at impact on adverse outcomes. method. data was collected retrospectively using bts niv audit tool. cases admitted with type respiratory failure in our hospital between january and march who needed niv were included in the audit. delay was subdivided into a) door to first arterial blood gas (abg) sampling b) abg to decision for niv and c) from decision to actual starting of niv. results. the mean time to get an abg from admission was min. cases with delay more than h skewed the data. the median time, which was more representative of the usual delay between admission and first abg, was min. our audit showed that out of ( %) patients had abg within an hour compared to out of ( %) in the last audit. although noninvasive ventilation (niv) has been widely used in patients with acute on chronic respiratory failure (acrf) due to chronic obstructive pulmonary disease (copd), series studying patients with pulmonary restriction due to morbid obesity (mo) are rare ( ) , despite the disease is highly prevalent in our environment. objectives. the aim of our study is to analyze and compare the effectiveness of niv in patients with copd and om. we analyzed all patients admitted to icu for a period of years with diagnosis of acrf due to copd or mo and treated with noninvasive ventilation. niv success was defined as the avoidance of endotracheal intubation, survival in icu and at least h on a medical ward with no signs or symptoms of respiratory failure. variables are expressed as means ± standard deviation and percentages. comparison between variables by pearson's v test and student t. we analyzed survival and hospital readmission per year (log rank test). during the study period, patients were admitted with exacerbation of copd and with mo. all patients were treated with two levels of pressure. age differs between copd and om, ± and ± years, respectively (p = . ), as well as the percentage of men, . adaptive support ventilation (asv) Ò (hamilton galileo) has been shown to result in better patient synchrony, reduced weaning times and reduced work load for the icu staff ( , ) . but, data is lacking on its efficacy, especially as non invasive ventilation (niv) due to the concern of being closed loop ventilation. also, little is known about the risk factors of late niv failure in patients who improve initially ( objectives. to assess end tidal co monitoring in patients with hypercapnic exacerbations of copd requiring niv methods. simultaneous measurement of paco and petco was performed in groups of patients. paco was measured using arterial blood gas analysis and petco was measured using non-invasive capnography. the groups were; phase a: mechanically ventilated patients post coronary artery bypass graft, used to establish the reliability of the end tidal carbon dioxide monitor in a homogenous group of previously well patients. phase b: patients with copd who did not have symptoms associated with an exacerbation, used to assess the use of a non invasive sampling device and assess the sampling method in stable copd patients. phase : patients with a hypercapnic exacerbation of copd requiring niv. capnography was monitored continuously in this group and petco values were calculated based on a mean value min before and after the arterial blood gas sample. this was to avoid any sampling error as it was impossible to isolate the exact moment of arterial puncture. agreement between the sampling methods was assessed using the bland-altman method. phase a objectives. we aimed to evaluate the possible harm of niv failure in routine practice among spanish icus. methods. we extracted patients with acute respiratory failure requiring either invasive or noninvasive mechanical ventilation in spanish icus during the -month period of the validation of the sabadell score ( ). we recorded demographic parameters and treatments received during the icu stay. patients were followed until hospital discharge or death. results. we analyzed , patients, of whom , ( %) received only invasive mechanical ventilation (imv) and ( %) received niv. niv succeeded in % of patients, but the other % required intubation. niv failure was more common in neurologic ( %) and post operatory ( %) and less frequent in coronary patients ( %). mortality was lower than predicted in niv patients ( vs. %) and similar to predicted in imv patients ( vs. %). mortality was lower than predicted in patients in whom niv was successful ( vs. %) and (similar or slightly lower than to predicted) in those in whom niv failed ( vs. %). conclusions. routine use of niv seems to confer a benefit, even when it fails and intubation is needed. reference(s tables and shows the parameters on respiratory muscles. introduction. the effectiveness of non-invasive ventilation (niv) in the setting of hypoxemia de novo remains controversial. it has been detected that patients in whom niv fails and intubation is required have a high mortality. otherwise, in patients in whom niv avoids intubation, survival rate is also high. to identify the factors involved in success or failure of niv in critically ill patients with hypoxemia de novo. we retrospectively studied all the patients admitted in our -bed intensive care unit (icu) from january to december with the diagnosis of hypoxemia de novo. do-notintubate patients were excluded. the indication of niv was at medical discretion, as well as intubation criteria. we defined the hypoxemia de novo as acute non hypercapnic respiratory failure due to a different cause from cardiogenic pulmonary edema. we defined two groups of patients: ) niv failure, patients who required intubation, and ) niv success, patients who did not require intubation. we collected demographical variables (age and gender), etiology of the hypoxemia, severity scores on admission (saps ii and sofa), glasgow coma scale (gcs), respiratory rate (rr), pulsioximetry (spo ), ph and fio , before and h after starting niv, episodes of nosocomial respiratory infection, length of stay (los) in icu and icu mortality. we compared both groups using the mann-whitney non-parametric test. p \ . was statistically significant. we studied patients ( women and men) with a mean age of ± years. the etiology of respiratory failure was: ards (n = ), pneumonia (n = ) and others (n = ). there were patients in the niv failure group ( %), and in the niv success group ( %). niv failure rate was higher when hypoxemia was due to ards (p = \ . ). objectives. this retrospective analysis aimed to assess outcomes following instigations of niv in a variety of clinical conditions. outcome data for copd/apo and non-copd/apo groups were compared. we assessed whether outcomes differed between these groups. in addition we wished to assess how outcomes varied across non-copd, non-apo conditions. objectives. the aim of this study was to compare patient's respiratory effort with three different noninvasive ventilators currently used on critical care patients and selected from a bench study. six patients treated by niv to prevent respiratory failure after extubation were included. each subject was successively submitted to a randomly assigned min-period of ps-niv with three different ventilators: bipap vision (respironics), elisée (resmed) and oxylog (dräger medical). these ventilators have different performances in a bench comparison. ventilatory settings were adjusted for the first ventilator and maintained for the followings. ps level was increased in order to obtain a tidal volume of - ml/kg of body weight (ps ± cmh o). flow, airway and oesophageal pressures were recorded. the oesophageal pressure time product (ptpoes) and tidal oesophageal swing (dpoes) were measured to evaluate patient's respiratory effort. results. no significant differences in tidal volume, respiratory rate and autopeep were found between ventilators. the dpoes and ptpoes, however, were significantly higher with oxylog as compared to bipap vision and elisée , as expected from the bench comparison. there are limited data on niv s efficacy in hypoxic respiratory failure. objective. to investigate the epidemiology and outcomes of patients administered niv as first line respiratory support in a mixed medical-surgical icu over a year period (jan -dec ), in an academic medical center. methodology. data abstraction from icu database, clinical care manager and chart review. results. surgical patients (sp) and medical patients (mp) were administered niv. the sp were % male, and had a median age of years. the mp were % male, and had a median age of years. % of sp were admitted with type respiratory failure (t rf pao \ kpa), % were admitted with type respiratory failure (t rf paco [ kpa) and the remainder were admitted with respiratory distress (rd). % of mp were admitted with t rf (pao \ kpa), % were admitted with t rf (paco [ kpa) and the remainder were admitted with rd. the median length of stay (mlos) was days for sp (range - ); the mlos for mp was days (range - ). sp were commenced on niv on average . h after admission (range - h), and remained on niv for a median of . (range - ) h. % of surgical patients required intubation, and the mortality rate was . %. mp were commenced on niv on average h after admission (range - h), and remained on niv for a median of (range - ) h. % of medical patients required intubation, and the mortality rate was %. logistic regression was applied to all datasets. among medical and surgical patients there was no correlation between the type of respiratory failure, initial blood gas or ph and the need for subsequent intubation, or risk of death. hematology patients had a mortality rate of % and accounted for % of overall deaths. oncology patients also had a % mortality rate, and accounted for % of overall deaths. amongst the mp that presented with hypoxemia, the intubation rate was % and the mortality rate was % (although not all patients that died were intubated). amongst the mp that presented with hypercarbia, the intubation rate was % and the mortality rate %. summary. niv successfully prevented intubation in more than % of patients. patients presenting with hypoxic respiratory failure were no more likely to be intubated than those presenting with hypercarbia. two-thirds of hematology and oncology patients treated initially with niv subsequently died. a microdialysis system was composed and the time delay of the system, recovery time, was introduced and tested with a fluids switching method. twelve sd rats were divided into ir or control group. myocardial ir was induced by ligating ( min) or releasing ( min) the suture underlying lad. mycrodialyisis probe was implanted into the left ventricular myocardium perfusion area to be occluded. dialysate samples were collected every min. blood samples were drawn at the beginning and at the end of the procedures. dialysate calcium concentration ([ca++]i) was detected with an atomic absorption spectrophotometer. serum calcium and ctnt were detected. recovery time for the microdialysis system was min, recovery rate was %. [ca++]i showed no changes during ischemia and descended immediately after reperfusion,reached the lowest level at min after reperfusion, then escalated slowly while keeping lower than control with significant difference. there was no difference in serum calcium at the beginning ( objectives. to evaluate the causes, incidence and impact on outcome of admission hyperlactatemia in patients admitted to a general micu. methods. data were retrospectively collected from the patient records for all adult patients admitted in the micu during the -months period. data regarding patient demographics, probable cause of hyperlactatemia, presence of shock on admission, need for organ support and icu outcome were recorded. patients were divided into two groups based on admission lactate levels: high lactate, with levels of mmol/l or more and normal lactate, with levels less than mmol/l. patients in these two groups were compared in terms of need for organ support and icu mortality. the efficacy to discriminate between survivors and non-survivors was assessed by area under the receiver operating characteristic curve (auroc). introduction. during critical illness alterations in blood flow are thought to predispose to organ dysfunction and hemodynamic therapy is often targeted at maintaining organ perfusion. however, abnormal blood flow distribution during critical illness may cause regional blood flows to correlate poorly with systemic haemodynamics ( ) . currently, our understanding of blood flow distribution during critical illness in humans has been limited by the invasiveness of established techniques for its measurement. objectives. phase-contrast mri (pc mri) represents an entirely non-invasive, contrastfree, method of measuring blood flow in major blood vessels ( , ) . we sought to apply this technique to technique to the measurement of organ blood flow in the critically ill. in a pilot proof of concept study, we measured renal and portal blood flow by pc mri critically ill humans with sepsis, multi-organ dysfunction and acute kidney injury (aki). in individuals cardiac output was measured by thermo-dilution in the icu, in the remaining patients we measured cardiac output (ascending aortic flow) and also descending thoracic aortic blood flow using pc mri techniques. we studied critically ill individuals with severe sepsis and aki. when studied, were mechanically ventilated, were on continuous haemofiltration and required vasopressors. transport and mri examinations were carried out without complication. in these patients, median cardiac index was . l/min/m (range . - . ), median renal blood flow ml/min ( - , ) and median renal fraction of cardiac output . % ( . - . ). median portal blood flow was ml/min ( - , ). descending aortic blood flow (measured in patients) ranged between and % of cardiac output (median %). conclusions. phase-contrast mri can efficiently and safely assess organ perfusion during critical illness in man. near simultaneous measurement of cardiac output enables organ blood flow to be assessed in the context of the global circulation. preliminary observations suggest renal blood flow is consistently reduced as a fraction of cardiac output in established aki. pc mri may be valuable to future investigation of organ dysfunction and vasoactive therapies in sepsis and critical illness. objectives. we were interested in the effects of the higher pco -levels on the microcirculation of infants with birh weights \ , g. data were collected from infants, who were randomized either to treatment with permissive hypercapnia or normocapnia. inclusion criteria were a birth weight between and , g, a gestational age from rd to th+ weeks, intubation during the first h of life and no malformations. the pco target range was increased stepwise and was mmhg higher in the intervention group. skin microvascular parameters were assessed noninvasively with sdf on the right arm every h during the first week of life and on the th day. results. pco (auc: ± vs. ± ) differed significantly between the two groups (p = . ). functional vessel density (fvd) was significantly lower in the intervention group on the th day of life ( ± vs. ± cm/cm ; p = . ). the proportion of small vessels increased in the control group whereas they decreased slightly in the intervention group, but did not reach stat. sig. increasing target pco lead to a temporary hyperdynamic flow in both groups. conclusions. pco -levels influence significantly the microcirculation in preterm infants. elevation of pco -levels leads to a decrease in fvd, presumably due to shunting and vasoconstriction and might cause temporarily hyperdynamic flow. methods. blood from healthy volunteers were diluted with hes, albumin %, rl or autologous plasma to obtain a final hematocrit of %. in vitro wbv measurements were made by the rheolog tm device (rheologics, exton, pa), a new viscometer with a u-formed capillary. the flow rate (determined by the rate of change in height of the columns of blood) is directly related to the pressure drop across the capillary tube. the shear rate (from , to s - ) and viscosity of the sample can be mathematically derived. results were expressed as median values (with - % intervals) and compared by anova with bonferroni correction. a p value . was considered as statistically significant. hemodilution with rl and albumin decreased significantly the wbv for all shear rate compared with autologous plasma and hes ( fig. ). conclusions. in contrast to albumin and ringer's lactate, hes and autologous plasma increased the whole blood viscosity, suggesting that these solutions may be preferred in severe hemorrhagic shock to better preserve plasma viscosity and microcirculation. we divided into two groups the randomly selected sample from the scope of patients come through open-heart operation assisted with extracorporeal support at the university of pécs: therapeutic (continuous blood gas monitoring/cdi- ) and control (intermittent sampling) group. after the retrospective data collection we carry out the analysis with (prevalence) frequency and confidence interval calculation and khi square test. results. the following accompanying diseases occurred significantly higher rate in the therapeutic group: ami (p = . ), kidney disease (p = . ), chronic pulmonary disease (p = . ), and the aggregation of the accompanying diseases showed also significantly high degree (p = . ). the long interval operations occurred significantly higher rate (p = . ) in the therapeutic group, and the times of the aorta clinch (p = . ) and the perfusion (p = . ) was also significantly longer. despite of that during the perfusion in a significantly more cases remained the rates in the normal range concerning to the therapeutic group (ph: p \ . ; be: p \ . ; pco : p \ . ), and the prevalence of the restart of the heart showed also significantly higher rate (p = . ). the continuous blood gas analyses assure reliable and the postoperative recovery assisted ecc circulation support. this assists considerably for keeping the parameters in the physiological limits even in the higher rate of the incidences of complex operations and accompanying diseases. this could contribute to lower incidence of side effects, preventing the causeless elevation of the postoperative hospital charges. objectives. describe the changes in capillary perfusion after erythrocytapheresis during severe falciparum malaria. we report two cases of severe falciparum malaria and describe the evolution of the sublingual capillary perfusion after erytrocytapheresis. the sublingual microcirculation has been studied with sidestream dark-field imaging (microscan; microvisonmedical tm , amsterdam). the device was applied on the lateral side of the tongue and the video images ( - captures of - s.) of capillary perfusion were recorded. the microcirculatory scores were analysed offline: small vessels (\ lm) density (number of vessels/mm), percent of continuously perfused small vessels (ppv%) and mean flow index (mfi). mmol/l. the capillary perfusion has improved: capillary density increased ( . /mm), the proportion of perfused vessel increased ( %) and flow was continuous in most vessels (mfi: ). clinical evolution was rapidly favourable and the patient was discharged from the intensive care unit. case . severe falciparum malaria with high parasitemia ( %) and acute renal failure. before erythracytapheresis: macrohemodynamic parameters were normal but microcirculation was reduced: vessels density ( . /mm) with % of small vessels perfused and the flow was slow in most vessels (mfi: . ). after erythracytapheresis: parasitemia decreased ( . %). sublingual microcirculation has improved with an increase in small vessels density ( . /mm) among which . % were perfused with a continuous flow (mfi: ). the patient had a good outcome. conclusions. microcirculation monitoring should be assessed specifically in some critically ill patients, even if macrocirculatory parameters are in the normal range. during severe plasmodium falciparum malaria, this monitoring could be specifically important to assess the effect of erytrocytapheresis therapy on tissue perfusion. rd esicm annual congress -barcelona, spain - - october s objective. perioperative myocardial infarction (pomi) is associated with significant mortality and morbidity in cardiac surgery. the primary objective of this prospective multicenter study is to investigate whether monitoring of coronary sinus metabolic markers can reliably predict ischemia and pomi faster than conventional monitoring. method. patients undergoing cardiac surgery were monitored perioperatively using a transjugular implanted microdialysis catheter (cma microdialysis) to study the metabolic changes of the heart. coronary sinus (sc) samples of lactate, pyruvate and glycerol were obtained continuously through -h post-operatively. pomi was defined by ckmb c u/ l and troponin t c . lg/l. a total of patients met the criteria for pomi. patients showed at least one adverse event during the postoperative course. lactate, lactate-pyruvate-ratio and glycerol levels in the sc sharply increased up to h before rise of cardiac enzymes. analyses of regression and discriminate analyses showed statistically significant (p \ . ) relationships between elevated metabolite values and the occurence of pomi. roc analysis revealed that lactate, lp-ratio and glycerol from the sc are sensitive markers to predict pomi and postoperative clinical events. conclusions. coronary sinus metabolic markers are sensitive and early predictors for the detection of perioperative myocardial infarction and severe complications in patients undergoing cardiac surgery. beginning disorder can be detected far earlier than with any existing monitoring device. perioperative red blood cell transfusions (btx) are commonly used in patients undergoing cardiac surgery to correct for anemic conditions caused by blood loss and hemodilution associated with cardiopulmonary bypass circulation and anesthesiological procedures. however, several studies have shown btx might have adverse effects on patient outcome. the goal of btx is to correct anemia and to ensure an improvement in the oxygen delivery to the parenchymal cells by the increased presence of red blood cells in the microcirculation. the aim of this investigation was to test the hypothesis that btx during onpump cardiac surgery have a beneficial effect on sublingual microcirculatory perfused vessel density, and oxygenation. methods. adult patients undergoing on-pump cardiac surgery were selected for this study. sublingual microvascular flow index (mfi), detected vessel length (dvl), and functional capillary density (fcd) were assessed using sidestream dark-field (sdf) imaging in patients. sublingual reflectance spectrophotometry was applied in patients to monitor sublingual tissue oxygen saturation. in group a, btx resulted in increased fcd and dvl as depicted in fig. . mfi for small and medium microvessels was not affected by btx (fig. ). in group b, reflectance spectrophotometry demonstrated increases in microcirculatory hemoglobin and oxygen saturation ( fig. ). the main findings suggest that leukoreduced btx improves the systemic circulation and oxygen carrying capacity of the microcirculation by increasing fcd and thereby reducing diffusion distances without increasing significantly the convection of red blood cells. this reduction in diffusion distances causes an increase in microcirculatory oxygen saturation. d.m.j. milstein , k. yürük , r. bezemer , c. ince academic medical center at the university of amsterdam, translational physiology, amsterdam, netherlands aims. anemia is a common adverse effect of oncologic diseases as is the therapeutic options required for their treatment. however, as blood transfusions are directed at correcting for anemia and intrinsic hypoxic conditions, little evidence exists claiming that blood transfusions have successfully resolved anemic challenges as storage can significantly deteriorate rbc function. the aim of this study was to investigate the influence of rbc transfusions on sublingual microcirculatory perfusion and tissue oxygenation in anemic oncology patients. methods. eight consecutive ambulatory patients scheduled to receive packed rbc transfusion bags were selected for this study. baseline sublingual microcirculation functional capillary density (fcd) was measured using sidestream dark-field (sdf) imaging prior to and after min of the completion of the last infused blood bag. sublingual mucosal oxygen saturation (sto ) was measured at the same anatomical location and time points using near-infrared spectroscopy (nirs). results. figures and capillary refill time (crt) is a generally accepted method of assessing the circulatory status of a patient. we have previously showed that using . s as the upper limit of normality in critically ill patients could discriminate patients with a more unfavourable outcome . however, this upper limit of normality was defined based on variation of crt in an adult healthy population . the best crt in critically ill patients, therefore, should still be redefined. objectives. we aimed to define the best crt as predictor of organic and metabolic dysfunction in an intensive care unit (icu) population. methods. capillary refill time was measured by applying firm pressure to the distal phalanx of the index finger for s, and a chronometer recorded the time of returning to normal colour. we performed receiver operating characteristic curve (auc) to detect the best crt consistent with severe organ and metabolic dysfunction, as evaluated by sequential organ failure assessment (sofa) [ and acidosis (lactate [ mmol/l and be\ - meq/ l), respectively. in addition, we performed logistic regression analysis using the cutoff crt as binary to investigate its estimated odds ratio (exp(b)). of patients included in the study (age ± ; male), had circulatory shock, of whom had septic shock. mean crt in all patients was . ± . . figures and show the roc curve for sofa score[ and metabolic acidosis, respectively. using the best crt value, logistic analysis revelled the following estimated odds ratio: for sofa score[ : exp(b) = . ; p = . ); for metabolic acidosis (exp(b) = . ; p = . ). roc curve for crt relative to sofa score [ roc curve for crt relative to acidosis conclusions. we found that . s is the best time to define prolonged crt in critically ill patients, and that using this crt cutoff value could discriminate patients with a more severe organ and metabolic dysfunction. introduction. impairment of microcirculation in acute situations is associated with organ failure and depends on macrocirculation but also on specific factors ( ) . micro-perfusion, assessed by tissue hemoglobin saturation (sto measurement) or micro-blood flow (laser doppler, ld) are easy to use and non invasive methods. the obtained data could be an end point in critical care resuscitation or optimization. objectives. to assess the impact on microcirculation of cardiovascular (cv) support on the basis of mean arterial pressure (map) and cardiac output (co), to evaluate when microcirculatory parameters improved or not the modifications observed in map and co. methods. observational study: measure of co, map, svco , and lactate, thenar nirs (inspectra ; hutchinson technology) baseline sto , with performance of an arterial occlusion test ( mn, mmhg) so calculate occlusion-os and reperfusion slopes-rs ( ). similarly, forearm skin blood flow velocity (ld, blf d, transonic systems) basal ld, and post-ischemic peak velocity ldmax) ( ) were measured. data were collected before and after cv optimization (fluid loading, vasoactive or inotropic drugs). patients were defined: macrocirculatory responders (r) when co increased more than % versus nonresponders (nr); microcirculatory responders (rs+) when rs increased more than % versus nonresponders (rs-). statistical analysis: nonparametric tests (wilcoxon and mann-whitney test). results. patients ( % in shock) were studied. had sepsis ( %), hemorrhage ( %), pulmonary oedema ( %), or other ( %). therapeutic optimization challenges were performed: fluid challenges ( ml, . % nacl), dobutamine c/kg/min, nitrates, diuretic, electric shock and an increase in dosage of norepinephrine. in r group (n= , %), co was increased associated with map (p \ . ), svco (p = . ) and decreased lactate (p = . ). the micro-oxygenation improved with an increase of rs ( . [ . - . ] vs. . [ . - . ]%/s, p = . ) as microperfusion did: increase in ldmax ( . [ . - . ] vs. . [ . - . ] tpu, p = . ). in the nr group, both the macro or the microcirculation did not change. since no microcirculatory differences between r and nr were observed, patients with good or poor microcirculation could not be detected. the study based on microcirculatory responses showed % of responders (rs+). in this group, baseline sto (p = . ), basal ld (p = . ) and ldmax (p = . ) increased in a large amount in association with an improved co and map (p = . and p = . ). in the rs-group, co and map were also improved (p = . and p = . ). conclusions. improvement of macrocirculatory parameters can improve microcirculation but not in all patients. improvement in microcirculation may also be a target, regardless the effects on macrocirculatory parameters. this concept has to be tested prospectively. introduction. hypothermia is regularly used for brain protection after resuscitation from cardiac arrest but its impact on cardiovascular function, however, is not well defined. objectives. the aim of this study was to evaluate the cardiovascular response to mild therapeutic hypothermia and rewarming in a large animal model. seven anesthetized, mechanically ventilated and invasively monitored sheep were cooled with a cold intravenous saline infusion, ice packs and nasal cooling (rhinochill system, benechill, ca) to achieve a core temperature of - °c (the basal temperature in sheep is around °c). after maintenance of this temperature for h, sheep were progressively rewarmed to baseline temperature. a positive fluid balance was maintained during the entire study period to avoid any hypovolemia. the sublingual microcirculation was observed using sidestream dark-field (sdf) videomicroscopy and the proportion of perfused vessels (ppv) and perfused vessel density (pvd) evaluated using a semi-quantitative method. results. during cooling, systemic and pulmonary artery pressures did not change, but cardiac output decreased significantly along with the increase in vascular resistance. left and right ventricular stroke work index decreased reflecting altered ventricular function. nevertheless, there was an increase in mixed venous oxygen saturation (svo ), reflecting a decrease in oxygen extraction. sublingual microcirculation analysis showed a significant decrease in ppv and pvd. all the variables returned gradually to baseline during the rewarming phase. conclusions. in this intact healthy large animal model, the alteration in cardiac function during hypothermia was well tolerated because of the simultaneous decrease in oxygen requirements. arterial pressure was maintained by an increase in systemic vascular resistance associated with a reduction in peripheral microcirculatory density. grant acknowledgment. *rhinochill system was supplied by benechill, inc. objectives. to evaluate consequences of hypoxemia occurence on intestinal microcirculatory perfusion in mice submitted to controlled hemorrhage. tracheotomized and ventilated balb/c mice were submitted to systemic hypoxemia (pao = mmhg) during h. controlled hemorrhage to mean arterial pressure of mmhg was associated (from th to th min). groups were constituted: hh = hypoxia and hemorrhage, hr = hemorrhage, hx = hypoxia, cl = control (neither hypoxia nor hemorrhage). a segment of ileon was exteriorized through an abdominal midline incision. it was opened along the antimesenteric border and placed on a specially designed piedestal to facilitate observation of the villi with transilluminating and epifluorescent microscopy. the bowel segment was superfused with krebs solution maintained at °c. villous perfused density (dvp), red blood cell velocity in villous tip arteriole (vart) and villous capillaries (vcap) were observed after fitc-labeled erythrocytes were intravenously administered. mice were included in each group. leucocytes adhesion to intestinal wall venules ( - lm) was observed in a separated set of experiments including also mice per group. number of adherent leucocytes (l adh ) and leucocytes flux (l fl ) were observed in each group. measurements and arterial blood gases were collected at , , min (t ). data were expressed as mean ± sem and were compared by analysis of variance (anova). introduction. despite remarkable progress in hemodynamic monitoring, clinical examination, assessment of peripheral perfusion and comparison of surface and body core temperature still are diagnostic cornerstones of critical care. infrared non contact thermometers provide accurate measurement of body surface temperatures. the picco device using an arterial line with a thermistor tip in the distal aorta-in addition to transpulmonary thermodilution (tptd)-provides continuous body core temperature. objectives. therefore, it was the aim of our study to evaluate the predictive capabilities of surface temperatures and their differences to body core temperature regarding ci, svri and parameters of microcirculation. in icu-patients body core temperature was measured four times per day using a picco-catheter (tp), a thermistor-tipped urinary catheter (tu) and an ear thermometer (te) (thermoscan; braun). additionally, surface temperatures were determined on the great toe, finger pad, forearm and forehead using an infrared non contact thermometer (thermofocus; tecnimed). furthermore capillary refill time (crt), lactate and scvo were measured and peripheral perfusion was clinically assessed (normal, pale, mottled). immediately afterwards tptd was performed to obtain ci and svri. statistics: spss . . spearman correlation. compared to tp, t forehead (- . ± . °), t forearm (- . ± . °), t finger pad (- . ± . °) and t toe (- . ± . °) were significantly lower (p \ . for all comparisons). in multivariate analysis tptd-derived ci ( . ± . l/min sqm) was significantly correlated (r = . ) to the difference ''tp-t forearm '' (p \ . ), ''tp-t finger pad '' (p = . ), crt (p = . ), scvo (p = . ) and map (p = . ). tptd-derived svri was multivariately associated (r = . ) with ''tp-t forearm '' (p \ . ) and map (p \ . ). scvo was independently correlated to the difference ''tp-t finger pad '' (r = . ; p \ . ). lactate was independently correlated (r = . ) to crt (p \ . ). the roc areas were . and . for (tp-t forearm ) and (tp-t finger pad ) to predict ''ci \ . '' and ''scvo \ '', respectively. the sensitivity, specificity and negative predictive value of ''tp-t forearm [ . °'' were , and % regarding a ci \ . l/min/sqm. .) measurement of surface temperatures using non contact infrared thermometers and comparison to body core temperature provides useful data on macro-and microcirculation. .) the differences (tp-t forearm ) and (tp-t finger pad ) were independently associated to tptd-derived ci and svri, and ci and scvo , respectively. .) crt was independently associated to lactate level. v. shilov , a. astakhov ural state postgraduate medical academy, chelyabinsk, russian federation introduction. actuality of this problem consists of different disturbances of heart rhythm and heart conductivity (from sinual bradycardia and ventricular extrasystolia till sinuatrial arrest and fibrillation of ventricles) provoked by traction of oculomotorial muscles and pressure on eyeball. this reaction is called oculocardial reflex (ocr). it is necessary to note there is no definite strategy of ocr prevention. objectives. this study was conducted to estimate the possibility of the control of haemodynamic effects of ocr. the haemodynamics and hydrobalance were investigated with electric current probe ( and khz) using monitoring complex of cardiorespiratory system and hydratation of tissues -km-ar- «diamant». data documentation was carried out at stages of evisceroenucleation: . before anesthesia and surgery; . at induction; . during the intubation; . at eyeball mobilization and oculomotorial muscles traction; . while deepening of endotracheal anesthesia by inhalative anesthetics during - min after preceding stage; . at the end of surgery, after the extubation. results. the study confirmed ocr reflex, to appear at eyeball extraction and to manifest as bradycardia, cardiac output decreasing heart productivity, but peripheric vessel resistansce does not change. monitoring-controlled gradual deepening of inhalative anesthesia during - min has restored the haemodynamic data to normal eliminated ocr vessel reactions. hydrostatic changes took place only at the end of the operation, after the extubation. it manifested ad increasing of extracellular liquid confirmed by decreasing of low-frequent impedance. intracellular liquid remained intact. it seems the most possible, hydrostatic changes of extracellular liquid to depend on crystalloid infusion in blood vessels up to , ml during anesthesia and they eliminate with hypovolemia. conclusions. thus we can conclude that vascular manifestations of hemodynamics in ocr at eyeball extraction or active oculomotorial tractions may be eliminated with gradual deepening of inhalative anesthesia and monitoring of registed date of haemodynamic and hydrobalance. probably it's necessary to optimige the anesthesia using of pterygopalatal and pterygoorbital blockade to prevent ocr before the induction as retrobulbal anesthesia may be an ocr trigger. f. corradi , c. brusasco , a. vezzani , f. altomonte , p. moscatelli university of genoa, anesthesia and intensive care, genoa, italy, ospedale maggiore di parma, anesthesia and intensive care, parma, italy, azienda ospedaliera universitaria san martino, emergency medicine, genoa, italy introduction. despite improvements in trauma care, uncontrolled bleeding is the leading cause of potentially preventable early in-hospital deaths contributing to to % of trauma-related deaths ( ) ( ) . about % more deaths occur within the second/third hour after injury due to occult major internal haemorrhage. failure to recognize this situation may in part be due to lack of sensitivity of hb/hct levels, arterial blood pressure, heart rate, respiratory rate, injury severity score and markers of hypoperfusion (lactate and base excess) in initial assessment of blood loss. to study if early changes in spleno-vascular resistance index predict the development of hypovolemic shock after trauma. a prospective observational study conducted in adult haemodinamically stable patients admitted to the emergency department because of suspected or definite severe trauma and retrospectively divided into groups depending on whether or not they developed haemorragic shock requiring blood transfusion. doppler ultrasound measurements of splenic arterial branches at ilum were obtained and splenic doppler resistance index (sdri) was recorded at admittance (within h from trauma) and related to arterial blood gas analysis (haemoglobin, base deficit, lactate, co , ph), heart rate, and outcome in the first h (intensive care unit admittance, blood transfusion, sepsis, mortality). results. statistically significant differences between patients who developed shock within h and those who did not were the following: higher sdri ( . ± . vs. . ± . , p \ . ), lower base deficit (- . ± vs. . ± meq/l, p = . ) and higher lactate ( . ± . mmol/l vs. ± mmol/l p = . ). auc's of roc analysis were significant for sdri (auc = . , ci . - . , p \ . ) and lactate (auc = . , ci = . - . , p = . ), and borderline for bd, hr, hb, and ph. by multivariate analysis, sdri at admittance resulted to be the only good independent predictor of hypovolemic shock and bleeding (p \ . ), whereas haemoglobin, base deficit, heart rate, lactate and ph were not significant. in trauma patients with stable haemodynamic conditions at admittance spleen constriction occurs very early under heavy adrenergic stimulation in response to occult bleeding and can be non-invasively detected by sdri. the present study proposes sdri as a non-invasive measurement of changes in splanchnic circulation to detect blood loss and occult hypovolemia, which may help activate early surgical or radiological intervention for patients with major trauma and guide therapy to optimize splanchnic perfusion. introduction. approximately % of patients require temporary circulatory support due to cardiogenic shock following cardiac surgery. these patients are at risk of a mismatch between oxygen delivery and demand and carry a substantial mortality and morbidity risk. mixed venous oxygen saturation (svo ) is the still the ''gold standard'' for the determination of the ratio between systemic oxygen delivery and consumption (do /vo ratio) in cardiac surgery patients. a nonivasive technique is thought to be cerebral near-infrared spectroscopy determining cerebral oxygen saturation (rso ). purpose. the present analysis aims to compare rso and svo levels in adult patients undergoing ecmo therapy for postoperative cardiogenic shock. methods. data were collected hourly for the first h post operatively. each patient was equipped with a pulmonary artery catheter (pac) for continuous determination of svo connected to a vigilance ii-monitor (edwards lifesciences, irvine, usa) and an invos monitoring system (somanetics, troy, usa) to determine rso . data were analyzed by parametric testing and bland-altman analysis. a total of patients were enclosed. all svo values were in a range between and %. in this range, the linear correlation coefficient between svo and rso was r = . (p \ . ). the correlation coefficient for svo values below % was r = . (p \ . ) and r = . (p \ . ) for svo levels equal or higher than %. bland-altmann analyses of all collected oxygenation data (n = ) revealed a bias of . % (mean % ci: . to . ) and limits of agreement ( . standard derivation) of . to - . % (upper % ci: . to . ; lower % ci - . to - . ) for the raw data of the whole group ( figure ). bland-altmann analyses of svo values below % (n = ) showed a bias of . % (mean % ci: . to . ) and limits of agreement ( . standard derivation) of . to - . % (upper % ci: . to . ; lower % ci - . to - . ). bland-altmann analyses of svo values equal or higher than % (n = ) revealed a bias of - . % (mean % ci: . to . ) and limits of agreement ( . standard derivation) of . to - . % (upper % ci: . to . ; lower % ci - . to - . ). interestingly, despite svo values [ %, we noticed events in patients with rso values less than % for more than min. all events had been associated with arterial co levels below mmhg, whereas no other changes in hemodynamic or oxygenation parameters could be determined. conclusions. this pilot study suggest for the first time that rso highly correlates with svo in patients undergoing ecmo therapy due to refractory cardiac and/or pulmonary dysfunction. therefore determining rso may be a noninvasive alternative to monitor global tissue oxygenation under this condition. additionally, it was noted that cerebral hypoxia may be present despite a svo c mmhg. rd esicm annual congress -barcelona, spain - - october results : during severe hypothermia ( °c) cardiac index (ci), stroke index, mean arterial pressure and indexes of lv contractility (prsw and dp/dtmax) were reduced. after rewarming all variables remained reduced, except for ci that returned to prehypothermic values due to increased heart rate. systemic vascular resistance (svr), lv isovolumetric relaxation time (tau) and oxygen content in arterial and mixed venous blood increased during °c, while lv end diastolic pressure (lvedp) was constant. after rewarming svr and lvedp were reduced, while tau and the blood oxygen contents normalized. troponin-t and tnf-a were constant during °c but increased after rewarming. albumine plasma concentration was reduced during °c and remained so after rewarming. conclusions. surface cooling to °c followed by rewarming caused reduction of systolic, but not diastolic lv function. there were no signs of inadequate global oxygenation throughout experiments. the posthypothermic increase in troponin-t may reflect degradation of myocyte troponins secondary to a hypothermia-induced calcium overload. the increase in tumour necrosis factor alpha together with a posthypothermic reduction of plasma albumin concentration may indicate that the cooling and rewarming initiated an inflammatory response. we studied patients, mean age . ± . years, % male. the etiology of cardiogenic shock was: % (n = ) dilated cardiomyopathy, % (n = ) acute myocardial infarction, % (n = ) acute cardiac allograft rejection and % (n = ) acute myocarditis. the duration of ecmo support was . ± . h. weaning was possible in % (n = ) and the ecmo was used as a bridge to transplantation in % (n = ). -day survival was and . % of our serie were discharged from the hospital. in cases the ecmo was withdrown as a result of a limiting treatment decision. objectives. to describe the characteristics of patients with ca and its management with moderate hypothermia using arctic sun Ò device with hydrogel patches. descriptive, observational and retrospective study of patients who suffered ca and received moderate therapeutic hypothermia ( °c) according to the protocol implemented in a coronary intensive care unit of a tertiary hospital. we collected patients from june to april , first months of this therapy in our hospital. moderate therapeutic hypothermia is applied using the arctic sun Ò device consisting of hydrogel patches applied to the skin covering % of the body surface. the device is connected to a temperature control console, measuring core temperature with an urinary catheter. we analyzed demographic characteristics, cardiovascular risk factors and other relevant comorbidities. we collected data about the ca, its initial treatment and its icu management with moderate hypothermia, analyzing length of events and systemic and neurological outcome at discharge from icu. we also collected data about the infectious complications during the icu stay. results. during this period, moderate therapeutic hypothermia was applied to patients with a mean age of ± years. . % were male. the most frequent cardiovascular risk factor was cigarette smoking, present in % of individuals. the ca cause was an ami by % of cases; however, myocardial infarction or angina was documented before the event only in . % of patients. the ca event was outside the hospital in . % of cases and the initial heart rate recorded was ventricular fibrillation in . % of cases. the average ca length was . ± min. obtaining a temperature of °c took between and h from the ca in most cases; and this temperature was maintained for an average of ± h. the average time of induction of hypothermia was . h. the re-heating was performed between . to . °c per hour, averaging h to reach temperatures of . °c. midazolam sedation was performed in all patients and severe chills required muscle relaxation with cisatracurium in . % of patients. infectious complications occurred in . % of patients, the most common site of infection was respiratory. the average stay was days. at the time of icu discharge, average gcs was and the average gos was . mortality was . % ( patients). -implementation of a therapeutic hypothermia protocol is feasible. -infectious complications are common, being respiratory ones the most observed. -the arctic sun Ò device is quick and safe for induction of moderate therapeutic hypothermia. rd esicm annual congress -barcelona, spain - - october s objectives. up to now, it is not clear, however, whether mild hypothermia influences also markers of oxidative stress and nitric oxide production. methods. eleven patients after out-of-hospital cardiac arrest were included into this study, all were treated with mild hypothermia using endovascular system thermodard xp. target core temperature °c was maintained for h, re-warming rate was set at . °c per hour, followed by normothermia of . °c. blood samples for measurement of nitrotyrosine and nitrates/nitrites were taken at admission and then every h for days. during hypothermia the levels of nitrotyrosine and nitrates/nitrites were comparable with baseline values. in re-warming period serum levels of both parameters gradually increased and in normothermia the levels were significantly higher as compared with hypothermia: nitrotyrosine . ± . vs. . ± . lm/l, p = . ; nitrates/nitrites . ± . vs. . ± . lm/l, p = . . our results revealed that during mild hypothermia in cardiac arrest survivors the levels of nitrotyrosine and nitrates/nitrites are significantly lower. these data indicate that the reduction of oxidative stress and suppressed nitric oxide production may be involved in the protective effect of hypothermia. grant acknowledgment. this study was supported by the grant of the czech ministry of health, nr. . new volumetric variables of preload, such as total end-diastolic volume index (tedvi) and active circulation volume index (acvi) and central blood volume index (cbvi), have been shown to be good predictors of fluid responsiveness. during acute changes of intravascular volume, such as hemorrhagic shock, these variables allow a more accurate intervention. objectives. the aim of our study was to investigate the changes in tedvi, acvi, cbvi in a juvenile model of hemorrhagic shock. seven anesthetized ponies ( - months of age) were studied at normovolemia (base), after blood withdrawal to mean arterial pressure (map) of mmhg (hemo), after infusion of norepinephrine to a map of mmhg (ne), and after retransfusion (resu). tedvi, acvi, cbvi were measured by ultrasound dilution (ud) technology with costatus device. data were analyzed using kruskal-wallis analysis and dunn's t test. comparison of fluid load agreement by blant altman. results. tedvi and acvi had significant change during hemo and resu status. percentage of tedvi and acvi changes agreed with percentage of blood volume removed/ infused with bias and limits of agreement (loa) % (- . , . ) and - . (- . . %) respectively. ne administration induced map and cvp significant changes, whereas tedvi and acvi remained unchanged. cbvi showed high variability and seemed to be inconsistent on the identification of the volume status. conclusions. in this animal model, tedvi and acvi were superior to cbvi in accurately reflecting hemorrhage and were also suitable to predict fluid responsiveness. ne administration did not affect the volumetric variables tedvi and acvi. ( ). objectives. we sought to identify independent predictors of post-arrest neurological recovery, and of survival to hospital discharge with neurological recovery. in the course of a pre-planned interim analysis, we analyzed the data from participants of nct . this three-center, double blind, placebo-controlled, clinical trial is ongoing (estimated enrollment = patients) and aims to asses the efficacy of combined vasopressin and epinephrine during cardiopulmonary resuscitation (cpr) and of steroid administration during and after cpr. post-arrest neurological recovery was defined as glasgow coma scale score[ documented at least once by study-independent physicians in patients not receiving sedation for at least h. we identified a total of patients who were subjected to at least one post-arrest assessment of their neurological status. subsequently, we used backward stepwise logistic regression, and assessed the following potential predictors: cause of cardiac arrest (cardiac vs. non-cardiac); area of cardiac arrest occurrence (monitored vs. non-monitored); use of therapeutic hypothermia; number of cpr cycles; mean arterial pressure and serum lactate at min following resuscitation; and patient group allocation. results. the sole independent predictor of post-arrest neurological recovery was the occurrence of the cardiac arrest in an area of monitored patient care (i.e., intensive or coronary care unit, and operating or emergency room): odds ratio: . , % confidence interval = . - . ; p = . . the sole independent predictor of survival to hospital discharge with neurological recovery was the serum lactate concentration at min after resuscitation: odds ratio: . ; % confidence interval = . - . . conclusions. the results of this preliminary analysis suggest that post-arrest neurological recovery seems to depend more on the use of pre-arrest patient monitoring rather than the employed cpr protocol. also, patients with lower, early post-arrest serum lactate concentration seem to have a better chance of surviving to hospital discharge without concurrent, severe neurological deficits. reference(s). to quantify the attribution of intra-operative defibrillation on markers of myocardial injury (ck, ck-mb, tnt and hfabp). methods. single centre prospective study in which elective cabg patients were included in a month period in . patients with valve, emergency, off-pump surgery or rethoracotomies were excluded. patients were grouped as having had defibrillation or no defibrillation during surgery. serum levels of ck, ck-mb, tnt and hfabp were analyzed in blood samples taken at arrival on the icu and at , and h after admission to the icu. levels of these biochemical markers were compared using a paired t test. results. all data presented as mean ± standrad deviation conclusions. atrial fibrillation is a common problem associated with morbidity and mortality in critically ill patients; however, evidence-based recommendations are lacking leading to variability in treatment. our audit confirmed variability and low compliance to nice in treating new af. inconsistency in using appropriate first line drugs for rate control and inadequate thromboprophylaxis reflects lack of familiarity with nice guidelines. educating itu medical staff and promoting the use of well validated, easy to remember chads scoring system might improve compliance with nice guidance. also,promoting hemorr hages scoring system for assessing risk of bleeding and carat tool to guide prescribing antithrombotics may allow itu physicians to anticoagulate more patients with af with less fear of bleeding complications. in patients with acute coronary syndromes (acs) combined antiplatelet and anticoagulant therapy is recommended in addition to percutaneous coronary revascularization. heparins and glycoprotein iib/iiia receptor inhibition can be associated with immune-mediated thrombocytopenia of clinical significance in less than %, resulting in major bleedings and increased mortality rate. to evaluate the incidence of thrombocytopenia and its impact on in-hospital complications-bleedings, reinfarctions, in-hospital heart failure and mortality in patients with acs. retrospective evaluation of patients admitted during months, fulfilling the criteria for acs: rest chest pain up to h, changes in standard ecg with or without st-elevation with or without elevated serum troponin i. serum troponin i was estimated by immunochemical method (boehringer, mannheim, germany, normal levels . lg/l). patients were treated by combined antiplatelet therapy, heparins and percutaneous coronary revascularization. platelets were estimated by automatic analyzer sysmex xe , kobe, japan (normal levels - /l). thrombocytopenia was defined as platelet count less than /l or a drop in platelet count of more than % during inhospital stay. we registered demographic, laboratory, clinical data and in-hospital mortality. we included acs patients, . % ( / ) with and . ( / ) without stelevation ( . % men, mean age . ± . years). mean admission troponin i was . ± . lg/l, platelet count . ± . /l. in-hospital thrombocytopenia was observed in . % of patients. in thrombocytopenic patients in comparison to non-thrombocytopenic ones we observed significantly increased mean age ( . ± . vs. . ± . years, p = . ) and admission serum creatinine ( . ± . vs. . ± . lmol/l, p = . ), significantly decreased admission systolic blood pressure ( . ± . vs. . ± . mmhg, p = . ) and hdl-cholesterol ( . ± . mmol/l vs. . ± . mmol/l, p = . ), significantly increased bleedings ( . vs. . %, p = . ), in-hospital heart failure ( . vs. %, p = . ), but nonsignificantly increased reinfarctions ( . vs. . %), arrhythmias ( . vs. . %) and in in-hospital mortality ( vs. . %). thrombocytopenic patients were less likely treated by percutaneous coronary revascularization ( . vs. . %, p = . ). admission thrombocytopenia in comparison to normal admission platelet count was associated with significant increase in inhospital mortality ( vs. %, p = . ) and icu-mortality ( . vs. . %, p = . ). conclusions. thrombocytopenia, observed in more than % of acs patients, was associated with in-hospital complications and mortality, especially thrombocytopenia on admission. introduction. stress cardiomyopathy, also known apical ballooning or takotsubo cardiomyopathy (tts), has been recognized for several years. this syndrome is characterized by transient systolic dysfunction of the apex or mid segments of the left ventricle (lv) in the absence of coronary artery disease. several forms of mostly physical stress may evoke this syndrome. in this case we describe a very uncommon cause for tts in an unusual situation. a -year-old woman without cardiovascular history found her husband non-responsive in bed. after resuscitation he was admitted to icu. visiting her husband, she complained of chest pains, shortness of breath and hyperventilation. physical examination revealed no abnormalities but her ecg showed deep negative t-waves in leads i, ii, iii, avf, v -v . her troponin t level was . lg/l (ref \ . ), nt-pro-bnp was , ng/l (ref \ ). ck was ng/l with ckmb of ng/l. echocardiography showed very poor lv function with the typical apical ballooning of the lv along with hyperkinesis of the basal ring ( fig. ). there was no coronary artery disease. she was admitted and treated with beta-blockers. within days, the enzymatic changes normalized and echocardiography showed improved lv function with and normalization of the apical segments. she made full recovery within weeks. discussion. icu admittance has significant impact on family members. in the acute phase of the illness, most medical attention goes to the admitted patient. especially when prognosis is poor, stress to the family may be considerable. mostly spouses and relatives with female gender are at the highest risk for depression and anxiety disorders . in contrast, little is known about the occurrence in relatives of broader physical symptoms like pain and nausea or even acute onset severe medical conditions requiring treatment. in our case the wife experienced pain, anxiety and nausea along with hyperventilation. however, the underlying disease was a severe cardiomyopathy requiring admittance and treatment. the tts cardiomyopathy is known to icu physicians in relation to subarachnoid hemorrhage, but most likely not in the context of severe emotional stress. in summary, we stress the importance for intensive care physicians to be alert to the fact that despite many diverse symptoms related to stress and anxiety, relatives can develop acute medical conditions as well. a retrospective observation study. demographic profiles, operative data and short term outcomes in the icu were reviewed in the patients who underwent beating-heart (b-h) operation. we also compared b-h operation group ( - ) and conventional cardiac arrest (c-a) operation group (before ). both groups of patients were similar with respect to preoperative demographics (age, co-morbidities, lv function). in the b-h operation group, mean age was years ( - ). preoperative mean nyha functional class was . . and the mean lvef was . %. patients underwent single valve operation, and the rests needed combined valve operation or cabg. patients were included in the c-a operation group, with mean age of years ( - ), nyha functional class of . and mean lvef of . %. in the b-h operation group, no dc shock was needed, whereas % of the patient with c-a operation needed dc shock after aortic unclamp. in the single aortic valve replacement, b-h operation group had a tendency of shorter assist perfusion time after intracardiac procedure ( . vs. . min). in the icu, inotropic support (maximum dose of dopamine) was much less ( . vs. . r) than conventional c-a operation (p = . ) and additional iabp support was not required ( vs. % in c-a operation). low cardiac output syndrome was not encountered in the b-h operation group ( vs. % in c-a operation). no major postoperative complication was encountered except ventricular tachycardia in one patient. there was no day mortality ( vs. % in c-a operation). conclusions. in our series, valve surgery on the beating-heart had a superior postoperative hemodynamics and lower associated morbidity compared to conventional cardiac-arrest operation. this procedure is recommended especially in the patients with impaired lv function. ( ) objectives. does hrt measured during daytime or nighttime predict: one-year all-cause mortality in acs?; hospital readmission within one-year? methods. secondary analysis of the immediate aim study, prospective clinical trial of patients presenting to the emergency department (ed) with symptoms of acs (n = , ): holter recordings of patients, positive for acs and admitted to the hospital, started min (median time) after arrival in the ed; -year follow up after hospital discharge in % of the sample; recordings scanned to exclude artifact and non-sinus rhythm. hrt analysis performed using research software at the washington university heart rate variability lab; hrt parameters measured: ) turbulence onset (to), which characterizes the initial rate acceleration after a ventricular premature contraction (vpcs); and ) turbulence slope (ts), which characterizes the subsequent oscillation in heart rate. results. holter recordings eligible for hrt analysis; eliminated due to unanalyzable rhythm, \ vpcs needed to calculate hrt, or recording time \ -h. patients were diagnosed with ua, with nstemi, and with stemi. patients died and were re-hospitalized during follow up. hrt measures were dichotomized into low and high-risk groups based on previously reported cutpoints: to \ % normal, to c % abnormal; ts [ . ms/beat = normal, ts b . abnormal. chi square statistics calculated. findings include: abnormal -h ts significantly associated with -year mortality [odds ratio (or) . (p = . )]; re-hospitalization significantly associated with both abnormal -h to (or . , p = . ), and -h ts (or . , p = . ); abnormal night ( - ) to and day ( - ) ts also significantly associated with -year mortality (or . , p \ . for both); abnormal daytime to (or . , p = . ) and ts (or . , p = . ) each significantly associated with re-hospitalization. conclusions. patients with acs who have a ts \ . measured over h or during the daytime are at higher risk of dying within year after hospitalization. those who either have to c % or ts b . have a greater risk of re-hospitalization. assessment during the daytime only might provide sufficient information for risk stratification. hrt measured close to acs symptom onset may aid in risk stratification. objectives. we tried to find a correlation between trs and the severity of coronary artery disease (cad) found in coronary angiography. we analyzed all consecutive patients with nsteacs admitted to intensive care unit from june to december . all patients were stratified at admission with trs. pci were performed when it were indicated. for the study we grouped patients according to trs and the severity and extend of cad. considering the trs the patients were classified into three categories: trs - , trs - and trs - and considering the results of the coronary angiography were grouped into three categories: normal angiogram, one or two vessel disease and three vessel or left main disease. we excluded patients without pci. qualitative variables are expressed as absolute value and percentage and quantitative variables are expressed as means ± standard deviation or median ± interquartile range when correspond. comparisons between groups were made with the v or fisher's exact test for categorical variables and mann-whitney test for quantitative variables. a total of patients were admitted with nsteacs during the period of the study and underwent to pci. age median were higher in patients with trs - than other groups ( . years ± . p \ . ). men percentage and in-hospital mortality were similar in all groups (pns). between groups there weren't significant differences in prevalence of diabetes, hypertension, dyslipidemia, smoking, mean first troponin i and mean highest troponin i (pns). the v for all comparisons were . (p \ . ). normal angiogram were most likely found in patients with trs - than in those with trs [ (p \ . or , % ci . - ). one or two vessel disease were found more often in those with trs - than in those with trs\ o [ (p \ . or . , . three vessel or left main disease were found more often in those with trs - (p \ . or . , % ci . - . ). conclusions. the relationship between trs and clinical outcomes (recurrent angina, acute myocardial infarction and death) is well known but its relation with the extent and the severity of cad is not well determined. in our study we found a correlation of trs with the number of vessels affected in coronary angiography, making the trs as a good predictor of the extent and the severity of cad. a.b. ratnaparkhi , j. walton freeman hospital, anaesthetics, newcastle upon tyne, uk introduction. acute onset atrial fibrillation (af) is common phenomenon in the intensive care unit. atrial fibrillation poses risk for thromboembolism. practice of commencing anticoagulation after acute onset af varies in different intensive care units. anticoagulation comes with its own side effects in the already compromised patients in the intensive care unit. this regional audit was carried out in intensive care units of the north east region of the uk. to assess the practice of use of anticoagulation after acute onset of atrial fibrillation in the intensive care units. postal questionnaire were sent to the intensive care units of the north east region of the uk including two cardiac surgical intensive care units. the questions asked were; is there a protocol in your unit? are you aware of any guidelines? if yes, which guidelines? do you commence anticoagulation for acute onset af? what do you use for anticoagulation and in what dose? after what duration of onset of af you consider starting anticoagulation? how long do you continue anticoagulation? do you commence anti platelet therapy? we also put six clinical scenarios with acute onset atrial fibrillation. the aim was to assess if the units consider stroke risk stratification for commencing the anticoagulation. one example is; how would you manage anticoagulation for a year old patient with hypertension and diabetes, presented with sepsis following pneumonia. results. we received responses from out of intensive care units. the management of anticoagulation strategy was different in different unit. two units were aware of the nice guidelines, one unit was aware of the accp guidelines and two units were aware of the other guidelines. ten units responded that they commence anticoagulation for acute onset af. commonly used anticoagulation was low molecular weight heparin. four units use anticoagulation within less than h of the onset of af. there was no fixed duration for the continuation of the anticoagulation. different units consider various factors before commencing anticoagulation. conclusions. use of anticoagulation in acute onset af varies in the different units. each unit takes into account different factors for the commencement of anticoagulation. this audit highlights the possible need for the evidence based protocol for the use of anticoagulation in acute onset af in intensive care units. objectives. to study of the clinical features and analytical features of those patients with dilated cardiomyopathy treated with ecmo as a bridge to cardiac transplantation in order to determine which parameters are useful to predict the outcome methods. a retrospective study from december to december . all patients were divided into two groups: the a group: patients who died before transplantation; the b group patients who got transplantation. several clinical and analytical characteristics are compared before starting ecmo, at and h after the onset and immediately before withdrawing (''end time'') ecmo treatment (either for transplantation or for death). qualitative variables are expressed as % and quantitative ones a mean and standard deviation (sd). chi square and t student test are used as appropriated. a p \ . denotes statics significance. there are statistically significant differences between patients who died and patients who survived to be transplantated. the presence of multiorgan failure and severe tissue oxygen hypoperfusion, and its persistence after initiated treatment, denotes a worse prognose. the study of this differences could be useful to decide which patients benefit of ecmo treatment. objectives. to measure the diagnostic contributions of routinely used (nt b type natriuretic peptide (nt probnp), cardiac troponin i (t), ddimeres (dd), c-reactive protein (crp) and procalcitonin (pct)) and new biomarkers(mid-regional pro-atrial natriuretic peptide-(mr-proanp), pro adrenomedullin (pro adm), pro endothelin (pro et) and copeptin [pro vasopressin (cp)] for diagnosing infection in patients with severe acute dyspnea. we designed a prospective study of patients admitted in the emergency department and in medical intensive care unit in a university hospital. inclusion criteria were acute dyspnea with spo b % and/or respiratory rate (rr) c b/min. patients with obvious myocardial infarction or pneumothorax were excluded. clinical-biological data were recorded and biomarkers sampled. an independent blinded expert panel classified the patients according to all the data including response to treatment and outcomes blindly to biomarkers' results. the roles of biomarkers were assessed quantitatively and then using terciles of the distribution. the contribution of the biomarkers in the diagnosis was assessed using auc-roc curves and by multiple logistic regression taking into account other clinical and biological explanatory variables. objectives. to compare differences between a group of patients with lmca treated with percutaneous coronary intervention (pci) and others with cabg. to evaluate direct results and make a long term prognosis analyzing mayor cardiovascular complications (mcc) rate. observational retrospective study that includes a total of patients with lmca submitted to ca between january and december : patients ( %) were treated with pci and compared to patients ( %) treated with cabg. in the total of the pci cases drug-eluting stents were used. we exclude patients in cardiogenic shock and those with protected left main coronary artery. results. average age of the patients was . ± . . in the pci group most of the patients were older than years. in the cabg group there was a majority of male patients ( . vs. . %, p = . ) without significant differences in the rest of demographic information. in the pci group (p = . ) there were more previous record of acute myocardial infarction (ami) and pci found, and also a greater percentage of patients with lvef\ % (p = . ). average euroscore of patients from the pci group were greater than those from the cabg group. complete revascularization was obtained more frequently in the cabg group. in the cabg group (p = . ) the number of days between diagnosis and therapeutic strategy as well as the days hospitalized were greater. in the multivariate analysis, the type of therapeutic strategy wasn t associated to mortality when hospitalize. the median follow-up period was months. according to the classification ccs (p = . ), there was no significant difference in the grade of angina. tendency to a greater restenosis of stent, greater mortality during follow-up and greater mcc without statistically significant. in the multivariate analysis surgical strategy was associated to a lower mortality during follow-up (or . objectives. our objectives were to analyze the characteristics of the patients who were done a cardiac catheterization, the differences of the procedure and the incidence of complications. methods. we randomized consecutive patients referred to the hospital for cardiac catheterization since august until october . results. among patients, the age (mean ± sd) was ± . years and more frequently male ( . %). . % were angioplasty. the radial approach was used in patients ( . %; . % with f arterial sheaths and . % with f), and the femoral approach in patients ( . %). there was no difference in the baseline characteristics of the patients. the time required for the procedure and the fluoroscopy time were longer in the radial group (p = . ). a cross over was more often necessary in the radial group ( patients, . %) due to radial artery spasm, deviousness, loop, unstable catheter or artery dissection. only one patient required cross over from femoral to radial approach ( . %) due to serious deviousness in iliac artery. the intravascular ultrasound (ivus) and rotablator always were done by femoral approach. the incidence of complications was higher in the femoral approach group ( . vs. . %, p = . ). in the radial approach group, the most important complication was wrist haematoma ( % radial artery occlusion checked with allen test), however the femoral approach complications were: inguinal haematomas ( . %), big haematomas required blood transfusions ( . %), femoral artery pseudoaneurysms ( . %), arteriovenous fistulas ( . %), retroperitoneal haemorrhages ( . %), strokes ( . %). these complications increased the hospital stay ( . ± vs. . ± . days, p = . ). conclusions. the radial approach reduces peripheral arterial complication rates and allowed earlier ambulation, so also reduces the hospital stay. however, needs higher learned time, and the size of the artery can limit several procedures (ivus/rotablator on the other hand, the development of bundle branch block after that procedure has been associated with higher rates of complete av block, syncope, and sudden cardiac arrest at long term. objectives: our aim is to describe the incidence of cardiac conduction problems after pavi and to identify possible risk factors associated with these conduction problems. patients and methods. a total of consecutive patients who underwent a pavi were included in our analysis. the indication for pavi was a severe symptomatic aortic valve stenosis in patients who were rejected or had a high risk for conventional savr. permanent pacemaker implantation was performed in case of the presence of complete heart block or symptomatic bradycardia, persisting after at least the second postprocedural day. data are expressed as mean value ± sd for continuous variables and as numbers with percentage for categorical variables. between the variables selected for predicting av block after pavi (basal valvular area, annulus diameter, valsalva sinus diameter, left and right bundle branch block), the only independent predictor was the last one (or . , % ci . ( ). implementation of care bundles have been advocated to reduce the infection rate ( ). objectives. the aim of the study was to identify the effect of the introduction of the central venous catheter (cvc) bundle on crbsi rate on our critical care unit over a threeyear period. retrospective audit on the rate of crbsi for a months period before the implementation of the cvc bundle provided baseline data. prospective audits for the corresponding months were carried out after the cvc bundle was firmly embedded in clinical practice. the data was collected based on the information recorded in our clinical information system (cis). the cvc bundle consisted hand hygiene, barrier precautions on insertion, % chlorhexidine skin preparation, using femoral site as last resort, daily review of necessity of central access, daily inspection of insertion site, use of tpn on a dedicated port and maintaining asepsis when accessing the line. robust educational program was rolled out during the implementation phase for medical and nursing staff. compulsory elements of the care bundle were recorded in our cis. we collected data on overall compliance with the bundle, mean dwell time, number of crbsis, site of infection and whether the patient left the unit with a cvc line in situ. for statistical analysis chi-square test and wilcoxon test were used. our main results are summarised in table . lines removed prior to transfer (n) we have seen a significant increase in the compliance with the bundle and it resulted a significant and sustained reduction in mean dwell time, cvc related infection rate and number of patients transferred to the ward with cvc lines (all p \ . ). the bundle resulted in bigger scrutiny for cvcs, hence the reduction in the number of lines inserted. conclusions. our data shows that implementation of care bundles can significantly and sustainably reduce the rate of crbsi on the icu in a real life setting. our previously unacceptable infection rates were reduced and now are comparable with the recently published data ( ) . evidence-based catheter-care procedures, guided by healthcare workers perceptions and including bedside teaching, reduce significantly the crbsi rate and demonstrate that improving catheter care has a major impact on its prevention. to evaluate the incidence of catheter-related bloodstream infection (cr-bsi) and of the use of central venous catheters (cvc) after an intensive improvement program aimed at reducing cr-bsi. before-and-after study in patients admitted to a -bed medical-surgical icu from january through december . in we implemented an improvement program (analysis of barriers, creation of a working group, review of protocols, and implementation of an educational program and checklist) and a set of measures to reduce cr-bsi during cvc insertion and maintenance based on provonost et al.'s model ( ) . in the postintervention period, we suspended the use of the checklist and evaluated the degree of completion of the online training module ''bacteremia zero program'' and analyzed the staff turnover rate. we have monitored cr-bsi using the ''estudio nacional de vigilancia de infección nosocomial en uci'' (envin-uci) criteria since . we calculated the incidence rate ratio of cr-bsi and cvc utilization ratio for , , and . we compared the incidence rate ratios using the epitab module from the stata program and utilization ratios using chi-square tests. results. nine cr-bsi were diagnosed in , one in , and five in . the incidence rate ratio of cr-bsi in these periods was . , . , and . %, respectively. the incidence rate ratio in the postintervention period ( . %) was significantly lower than in the preintervention period ( . %) ( . : % ci . - . , p = . .) the increase in incidence rate ratio between and was not statistically significant ( . vs. . %, p = . ). the pre-and post-intervention cvc utilization ratios were . and . , respectively (no significant differences). during the year , and for existing staff in , rotating residents, nurses (turnover rate %), and nurse's aides (turnover rate %) joined the icu. the training module was completed by % of the new nurses and none of the physicians or nurse's aides. conclusions. the program was effective; its effectiveness may be related to the intensity of the measures. a low preintervention incidence rate ratio does not preclude the usefulness of an improvement program. introduction. in the intensive care unit (icu) the bloodstream infections (bsi) related to the central venous catheters (cvcs) represent a serious clinical complication and are a substantial economic burden. although the data are still somewhat controversial, the use of antibiotic impregnated cvcs is one of the generally accepted approaches in reducing the risk of bsi [ , ] . objectives. in order to determine the efficacy of antibiotic impregnated cvcs in our clinic we evaluated retrospectively the data of the cultures of cvcs and blood obtained from patients during their stay at icu within the last years (january till august ). conclusions. surprisingly, there was no difference in the incidence of the cvc and bloodstream infections in both groups. we can conclude that the strategy of using mrimpregnated cvcs did not reduce the incidence of catheter related bsi. although earlier studies have indicated that mr-impregnated cvcs are cost saving [ ] , our data add further proof to the suggestion that the cost effectiveness of these catheters is at least uncertain. results. from all patients, ( . %) developed infection from any reason during the icu stay. patients developed crbsi, . % of the total patient number and . % of the patients who developed any infection. we recorded episodes of bacteremia due to cvc during days of cvc placement stay, . % while the standard limit is four episodes of crbsi per , days cvc placement. during the year , we chanced our practice in order to avoid as risk factors as we can, using only antimicrobial/antiseptic impregnated catheters, improving our hand hygiene and aseptic technique, using only chlorhexidine and semipermeable polyurethane dressings and making catheter replacement at scheduled time intervals as a method to reduce crbsi. the previous year the recorded crbsi incidence was . % respectively. conclusions. the incidence of intravascular catheter related infection is recorded above the standard limits for second consecutive year assuming that we have to improve further our surveillance policy. on the other hand, the incidence is recorded smaller than the incidence of the previous year according to the change to our practice, assuming that our reforming policy, although not fully effective, still is better for the prevention of intravascular catheter related infections. introduction. intravenous catheter related blood stream infection is a major factor contributing to in hospital morbidity and mortality and extending hospital stay by days and expenditure by , to , lb . the incidence of central line associated blood stream infections (cr-bsi) in our unit was audited in and a comprehensive infection prevention program that included staff education, hand hygiene, maximal sterile barrier precautions and daily assessment of the need for a central line was introduced. we are also taking part in the national audit project matching michigan. objectives. assess the effectiveness of the infection prevention programme and re-audit the incidence of cr-bsi methods. data was collected daily for a period of months. this included the number of patients with central venous catheters in the unit, the number of lines removed or re-sited, the indications for line change, the site of line insertion and incidence of line infection. the lines were reviewed daily and removed if indicated clinically (pyrexia or raised white cell count) or if not required. results. over a period of months central lines were used amounting to line days. the lines inserted were subclavian (sc)- ( . %), femoral (f)- ( . %) and internal jugular (ij)- ( . %). the percentage of lines removed for clinically suspected cr-bsi reduced in this period from to . %. the average duration of stay for the lines were sc . days, ij . days and f days which was shorter than our previous audit showed. the percentage of microbiologically proven cr-bsi also dropped from . to . % ( from internal jugular lines and one from a femoral line). conclusions. introduction of simple and cost effective practices decreased the prevalence of cr-bsi in our unit by a factor of five. daily review of lines led to earlier removal of central lines once they were no longer required. the unit being a neurointensive care unit has a greater proportion of patients in whom femoral lines are often the only option. our survey proves that with strict adherence to guidelines and following infection control protocols diligently the risk of cr-bsi from all line types can be reduced. conclusion. this study implies that the scale of crbsi may be higher than is currently recognised and that the blood culture positivity rate for crbsi is %( / ). as concurrent antibiotic therapy may reduce blood culture and cvc tip positivity, the blood culture rate of % suggests that crbsi has an inherently high blood culture positivity rate despite concurrent antimicrobial therapy. ( ). in this context, we tested the introduction of chlorhexidine(chx)-impregnated sponges ( ) ( ), acinetobacter baumannii . % ( ), serratia marcescens . % ( ), stenotrophomonas maltophilia . % ( ), escherichia coli . % ( ) jai salmonella enteritidis . % ( ) . production of extended-spectrum beta-lactamases (esbls) was detected in % of klebsiella spp. and e. coli strains, overproduction of ampc beta-lactamases was recognized in . % of enterobacter spp., while only one k. pneumoniae strain was found to produce metalloenzyme. all eight strains of p. aeruginosa were susceptible to aminoglycosides, ciprofloxacin and carbapenemaces, both strains of s. maltophilia were susceptible to ticarcillin/clavulanate and trimethoprim/sulfamethoxazole. among a. baumannii isolates, . % were susceptible only to colistin. in total, . % of isolates were susceptible to imipenem and ciprofloxacin. conclusions. gram-negative bacteremia, in particular in the critically ill, is associated with significant morbidity and mortality. significant susceptibility to ciprofloxacin and imipenem was demonstrated. empiric treatment regimens should be based on unit-specific data. ben objective. to assess whether implementation of a national safety program to prevent cvc-related bacteremia had an impact on rates of devices-associated infections acquired in icu. methods. prospective, multicenter, incidence, surveillance study of vap, crb and uti carried out from - - to - - . simultaneously, a bundle for prevention of cvcrelated bacteremia and a comprehensive safety program were introduced at the national level. infections were diagnosed according helics definitions. the follow-up was carried out until discharge from the icu or to a maximum of days. the severity was assessed by the apache ii score. the rates are expressed as incidence density (id) per , days of risk factor. rates are compared with those of previous years ( ) ( ) . introduction. acute kidney injury (aki) is one of the most dreaded complications of severe malaria. occurs as a complication of plasmodium falciparum malaria in less than % of cases, but the mortality rate in these cases may be up to % [ ] . to evaluate the incidence of aki and compare akin and rifle classification systems with regard to hospital mortality. a retrospective analysis based on medical records of adult patients with severe plasmodium falciparum malaria admitted in the general icu of clínica sagrada esperança, in luanda, angola, from january to december . criteria for diagnosis included the standard who definition for severe malaria. only changes in serum creatinine were used to define the presence of aki by both criteria. logistic regression was used to access the association of each rifle and akin with hospital mortality. data are presented as odds ratios with % confidence intervals (ci). we enrolled patients. thirty-nine ( . %) were males. the mean age recorded was . ± . . the mean apache ii score was . ± . , with a mean predicted dead rate of . %. the mean sofa score on admission was . ± . . the mean length of stay in the icu was . ± . days. rifle allowed the identification of more patents than akin as having aki ( . vs. . % there was no statistic association between corticosteroids therapy and length of icu stay less than days (p = . ), duration of mechanical ventilation less than days (p = . ), severe infection (p = . ), re-intubation (p = . ), tracheotomy (p = . ), nosocomial infections (p = . ), myopathy (p = . ) or mortality (p = . ). although there is a tendency for a higher prescription of corticosteroids in dni patients with severe infection, the difference did not reach statistical significance. the use of steroids is neither associated with a better outcome nor with a higher frequency of adverse events or side effects, namely critically illness myopathy or nosocomial infections. ozbek introduction. q fever, a zoonosis due to coxiella burnetii, is more frequent and severe in men than women, despite a similar exposure. here we explore whether the severity of c. burnetii infection in mice is related to sex differences in gene expression profiles. methods. experimental study analyzing the transcriptome of c bl/ j mice. ten females and males were sterilized at weeks of age. after weeks, males and females ( intact and castrated animals of each gender) were killed. the other series of mice were injected intraperitoneally with c. burnetii organisms and sacrificed at day one after infection. organs were aseptically excised and stabilized in rnalater. total liver rna was retrotranscribed and labelled with cy . labelled cdna were hybridized onto whole mouse genome oligo microarray k (agilent). raw signal data were normalized with the quantile method. the significance analysis of microarrays test was used to study the gene expression in uninfected and infected mice. supervised analyses were carried out with r with the library bioconductor. pca was used to visually explore global effects for genome wide trends, unexpected effects and outliers in the expression data (library made ). in another set of experiments, mice ( intact males, castrated males, intact females and castrated females) were killed at , , and days after c. burnetii infection (same protocol). liver rna was analyzed by rt-pcr to confirm microarray results. results. multiclass analysis (sex and infection) identified , modulated genes (fdr = %, |fold change| [ . ) . we found that % of the genes are specifically modulated in males or females. only % of the genes are sexindependent. castration showed that sexual hormones are responsible for more than % of this sex-specific differential expression. the reduction of gene expression modulation upon castration is seen almost exclusively in males. functional annotation of male specific signature identified groups of keywords linked to cellular adhesion, signal transduction, defensins and cytokines and jak/stat pathway. functional annotation of female specific signature identified two group of keywords linked to intracellular metabolism and circadian rhythm. these results were confirmed by rt-pcr. the increased susceptibility to infection in males may be related to the overexpression of il and stat . the modulation of the circadian rhythm in female is linked to a more efficient bacterial clearance. conclusions. this study showed for the first time that the sexual dimorphism observed in q fever is reflected by sex related gene modulation, and is under the control of sexual hormones. this study also showed that the circadian rhythm seems to play an important role in infection in mice. this work open the way for deciphering the role of sex and circadian rhythm in human infections. the author's report a p.aeruginosa sepsis with skin and heart involvement in a previous healthy woman. a years old woman without a pertinent medical history came to the hospital after days with high fever ([ . °c), vomiting and diarrhea. at admission she was in septic shock with multiple organ disfunction (hemodynamic, cardio respiratory and renal) and presented genital skin lesions (round, ulcerated, painless lesions with necrotic black eschar and erythematous margin-ecthyma gangrenosum). the laboratory tests showed bicytopenia (leucocytes and platelets), hepatic necrolysis and elevated troponin t, associated with t wave inversion in anterior leads in the ecg. the ecocardiogram showed apical dyskinesis with normal systolic function suggesting tako-tsubo cardiomyopathy. hemocultures ( ) were positive to pseudomonas aeruginosa and skin lesions biopsy showed vascular ulcers with local p. aeruginosa inflamation. results. besides the fluid challenge and supportive therapy she began empirically piperaciline-tazobactam with rapid improvement of the clinical picture. she needed vasopressors (norephynefrine and dopamine) for h. the skin lesions have resolved in days and cardiac treatment was conservative and symptomatic. the patient was discharged from the intensive care after days. conclusions. ecthyma gangrenosum although relatively uncommon, was first considered a pathognomonic sign of p. aeruginosa sepsis, but now we known that other bacterias can have the same presentation. tako-tsubo cardiomiopathy or broken heart syndrome is a stress-induced cardiomiopathy characterized by transient systolic dysfunction that mimics myocardial infarction but without coronary disease. although the unusual p. aeruginosa clinical presentation sepsis should be treated with prompt supportive measures and the most adequate antibiotic. objective. we undertook this study to determine the relative frequency of meningitis and sepsis in a paediatric intensive care and to define the clinical and laboratory features at the time of admission and the outcome of these children. we reviewed the medical records of patients with sepsis and meningitis, in our paediatric intensive care, from to . results. among these patients % had meningitis, % had sepsis, % patients had bacteraemia, and % had meningitis and sepsisage ranged from month to years old ( % were - years old. boys %, girls %. temperature at the moment of admission was in % patients greater than °c. leucocytosis was noted in % (from , to , / mm ) and leucopenia % ( , - , /mm ) % of the patients had petechiaes, % had a positive lumbar puncture and % who did not have lumbar punctures had diffuse intravascular coagulationthe species of microorganism were in % meningococcus group b, in % no organism was found, in % were pneumococcus, and meninococcus group d in %. on admission, % of our patients had seizures. the duration of hospitalization in our picu was % (average length of stay from to days) % had hemodynamic instability, and % had a normal arterial pressure. from the patients who had hemodynamic instability, needed only fluids %, and % needed fluids and inotropes % of the patients received intravenous ceftriaxonewe had no mortality. conclusion. meningitis and sepsis remain a serious problem in picu. with the existing guidelines of therapy and prognostic signs at the moment of admission in picu we have a better outcome. howitz introduction. community acute bacterial meningitis is a relatively common disease. three bacteria are responsible in most cases: streptococcus pneumoniae (adults), neisseria meningitidis (older children and young adults) and listeria monocytogenes (in the elderly, alcoholics and immunosuppressed). the mortality rate ranges between and % and is higher in case of pneumococcal meningitis ( %) due mainly to increased intracranial pressure and the intense inflammatory reaction that produces pneumococcus in the cerebrospinal fluid. objectives. to study epidemiology, aetiology, clinical and evolution in acute meningitis in the adult community in our icu. methods. retrospective and descriptive study of patients admitted to a tertiary icu with beds from january to december . a total of patients of whom were males ( . %) and women ( . %). the mean age was . years (range: - ). the apache ii at admission was determined in of the patients with an average of points, which is associated initially with a good prognosis. the glasgow coma scale was found in % of the cases the majority ranging between and with a range: - . the average stay in icu was . days. patients died ( . %). risk factors include: infections in otolaryngology: cases ( . %) alcohol: case ( . %) and states of immunosuppression: ( . %) of which: there were two diabetic patients ( . %); hiv: ( . %) were chronic treatment with corticosteroids in one case ( . %); advp: case ( . %) liver transplantation: one case ( . %) and other case cerebrospinal fluid leak ( . %). in patients (% . ) found no risk factor. the most common complication was the need for endotracheal intubation and mechanical ventilation in a . % of patients, hydrocephalus followed by . %. hearing sequelae were found in patients ( . %) and persistent vegetative state in case ( . %). the outcome was favorable and without sequelae in cases ( . %). the etiology was bacterial germs and virus in cases in . bacteria, not unknown in cases ( %). filiated of the causative agent in the majority ( . %) were streptococcus pneumoniae, followed by neisseria meningitidis in cases ( . %), listeria, staphylococcus aureus, e. coli and mycobacterium tuberculosis were isolated in one case each ( . %) . in relation to the vhs virus was found in one case ( . %) and unable to filial the rest. conclusions. community acute meningitis is a disease with low prevalence and mortality in our environment. the agent most commonly streptococcus pneumoniae, clearly associated with increased morbidity. the most frequent complication was the need for endotracheal intubation and secondly hydrocephalus. mortality was associated with longer hospital stays and lower glasgow at the beginning, but not with age. rd esicm annual congress -barcelona, spain - - october s evaluated factors: patient characteristics, signs, symptoms, abscess location, time between symptoms and hospital admission and surgery, lab results, microbiology, antibiotic therapy, apache , saps , sofa, length of icu stay, surgical re-intervention, duration of mechanical ventilation, infectious complications, critical illness myopathy (cim), renal replacement therapy (rrt), re-intubation, tracheotomy, mortality. descriptive statistics were used to analyze data. objectives. to assess ventriculitis (vg) and to study outcome and disability indices in patients admitted in icu due to cerebral hemorrhage (spontaneous or traumatic). we prospectively studied patients hospitalized due to cerebral hemorrhage in the icu of university hospital of thessaly, between and . patients were followed for median follow up of ( - ) days. on admission, the neurological status of patients was described by the glasgow coma scale; disability was evaluated at months by the rapid disability rating scale (rdrs). results. one hundred twenty-one patients ( male) were studied; median (iqr) age was ( - ) years, gcs before intubation ( ) ( ) ( ) ( ) ( ) ( ) objectives. to analyze characteristics of patients diagnosed with infective endocarditis in a third-level hospital from january until december , evaluating the echocardiography findings, the therapeutic strategy used, and both morbidity and mortality rates in hospital and during long term follow-up. observational retrospective study of consecutive patients with following duke criteria with a mean follow-up of ± months. conclusions. this study showed a low mortality of sepsis and its sequential stages in children with meningococcal disease admitted to the picu, which was probably associated with the early use of antibiotics (up to the sixth hour) and aggressive fluid esuscitation. diagnosis and treatment of infections in critically ill patients: - background. about one-third of hospital mortality in critically ill patients occurs after intensive care unit (icu) discharge. post icu deaths may arise from incomplete resolution of the primary condition or from the development of new complications. some authors have recently hypothesized that unresolved or latent inflammation and sepsis may be an important factor that contributes to death following successful discharge from the icu. aim. the aim of our study was to determine the ability of the clinical and inflammatory markers at icu discharge to predict post-icu mortality. a prospective observational cohort study was conducted during a -month period in an bed polyvalent icu. acute physiology and chronic health evaluation (apache) ii score, simplified acute physiology score (saps) ii, sequential organ failure assessment (sofa) score, c-reactive protein (crp), body temperature and white cell count (wcc) of the day of icu discharge were collected from patients who survived their first icu admission. results. during this period patients were discharged alive from the icu. a total of patients ( . %) died in hospital after icu discharge. there were no differences in clinical and demographic characteristics between survivors and nonsurvivors. c-reactive protein levels at icu discharge were not associated with hospital mortality (mean crp concentration of survivors = . introduction. early diagnosis of bacterial infection can be challenging in critically ill patients, however prompt recognition and initiation of antibiotics improves outcome. serum procalcitonin (pct) has been proposed as a more reliable marker of bacterial sepsis than white cell count (wcc) or c-reactive protein (crp), however there is no consensus in how it should be used and pct measurement has not disseminated widely into critical care practice in the uk. to identify if clinical recommendations based on procalcitonin levels are being followed. we retrospectively studied pct use between october and december . assay results were interpreted as: . ng/ml, possible local bacterial infection . - . ng/ml, possible bacterial systemic infection, moderate risk of severe sepsis . - ng/ml, likely systemic bacterial infection, high risk of severe sepsis \ ng/ml, almost exclusively severe bacterial sepsis or septic shock. , this was compared to changes in antibiotic prescribing which were identified from our local audit database and used as a surrogate marker for clinical suspicion of sepsis. to provide context we also compared this to crp and wcc trends in a larger sample from june to december . results. forty-four episodes had matched antibiotic prescribing data and pct results. a further episodes provided synchronous wcc and crp data. pct assays were typically requested on day (median, interquartile range - ). distribution of pct results pct value (ng/ml) . . - . - [ number (%) ( ) ( ) ( ) ( ) there was poor concordance between pct and both wcc and crp trends and also when wcc and crp trends were compared. pct assays did not have significant correlation with antibiotic prescribing. pct conclusions. our study suggests pct results did not influence clinical practice. pct testing may be of greater benefit if used with a protocol with guidance for clinicians based on assay levels. routine and serial quantitative pct testing protocols may also be useful to guide antibiotic initiation and duration, particularly in cases of greater diagnostic uncertainty, for example traumatic brain injury. , references. introduction. procalcitonin (pct) is a reliable marker for diagnosis of infection after cardiac surgery, except in patients who previously received antibiotics, but its diagnostic role in patients with post-sternotomy pre-sternal wound infection and mediastinitis has not been studied in detail. ( ) . objectives. this retrospective study focused on the role of pct in the differentiation between poststernotomy pre-sternal wound infection and mediastinitis. methods. all patients (n = ; age: median , - years) who underwent surgical treatment due to poststernotomy superficial pre-sternal wound infection and mediastinitis between january and september were included in the study. procalcitonin (pct), c-reactive protein (crp) and leukocyte counts were routinely measured within the last h before surgical wound revision. body temperature and hemodynamic parameters were evaluated immediately before operation. bacteriologic samples were also routinely taken intraoperatively. results. the primary cardiac operation was cabg (n = ), cabg and valve procedure (n = ) and others (n = ). time between primary operation and wound revision was in median days (range sensitivity, specificity, positive and negative predictive value for diagnosing sepsis are presented in table . roc curves and auc are presented in figure . roc curves and auc conclusions. patients with sepsis have significantly higher levels of crp, pct, il- and lbp on admission to the icu as compared to patients with sirs. pct is more usefull in differentiating between sepsis and sirs than crp, il- and lbp. b. ergan arsava , s. bilekli , n. alayvaz aslan , e. er , a. topeli hacettepe university, ankara, turkey introduction and objective. the incidence and mortality of bacterial infections significantly increase with age. aging is associated with an impaired immune response, which causes not only an increased susceptibility for infections, but also a poor inflammatory response against them. procalcitonin (pct) is an inflammatory biomarker used as a diagnostic and prognostic tool in bacterial infections. there is no data regarding the diagnostic yield of pct in elderly patient populations. in this study we sought to identify the relationship between age and the magnitude of pct response in patients admitted to the intensive care unit (icu). methods. patients, who were admitted to icu between january and december , with the diagnoses of severe sepsis, pneumonia and chronic obstructive pulmonary disease exacerbation (copde) were included into the study. patients' demographics, apache- scores, admission pct values, intensive care and hospital outcomes were extracted from a database of prospectively collected clinical data. results. we studied a total of admissions ( female/ male, mean age ± standart deviation . ± . years). median (interquartile range-iqr) apache score was ( - ); the icu and hospital mortalities were . and . %, respectively. median (iqr) admission pct levels were . ( . - . ) ng/ml in patients with severe sepsis (n = ), . ( . - . ) ng/ml in patients with pneumonia (n = ) and . ( . - . ) ng/ml in patients with copde (n = ). there was a negative correlation between age and pct levels (spearman correlation coefficient: r = - . , p = . ); the median (iqr) pct levels were . ( . - . ) ng/ml in patients\ years-old and . ( . - . ) ng/ ml in patients c years-old (p = . ). in subgroup analyses it was found that the inverse correlation between age and pct levels mainly arised from patients with severe sepsis (r = - . , objectives. we intend to define the role of pct in the initial evaluation of the patient with a suspected sepsis admitted to the icu. preliminary data from a prospective observational single centre study (polyvalent icu in a third level university hospital). the ethics committee of the centre has approved this study. we included all patients admitted to our unit with diagnosis of sepsis since june- . we measured pct (lgr/ml) at admission and at the second and third day of stay beside the routine screening for the source of infection. then we analyzed the relation of pct with culture results. chi-square and anova have been used for the analysis. (fig. ). pct at admission showed an auc of . ( . - . ) for discriminating bacterial infection. we detected higher mortality in those patients with bacterial infections and sustained high levels of pct the third day ( fig. ) (p \ . ). figure , conclusions. in the initial approach to the septic patient, pct does not seem in our experience useful as an aid in decision-making but an early decrement of serum levels can be a marker for response and for a better outcome of patients with bacterial infections. ( - ) b-d-glucan (bg) assay in early detecting ici in critically ill pts and assess its reliability on arterial blood specimens compared to venous blood specimens. methods. all pts admitted to the -bed icu of our university hospital, between th of february and th of march , harboring an arterial line for more than days and suspected to have an ici, were prospectively enrolled. from all the pts, two blood samples drawn from the arterial line and direct femoral site were simultaneously obtained and subjected to both conventional cultures and bg assay determinations. candida colonization index (cci) and candida score (cs) were also calculated. results. during the study period, from admissions, pts were enrolled. bg assays, cutaneous and mucosal swabs and urine cultures were collected. in pts bg assays resulted negative from either arterial line and femoral site. all but one did not develop ici. in pts bg assays resulted positive. four of these pts did not develop ici, whereas the other six developed ici ( fungemias and mediastinitis). the positive and negative predictive values (ppv, npv), sensitivity (se) and specificity (sp) of bg assay, cci, and cs are shown in table . among pts with ici, (median sofa score value ± . ; median saps ii value . ± . ) had at the diagnosis bg levels c pg/ml and developed septic shock; two of them died within few days. in contrast, the clinical course of pts with bg assay below pg/ml was not complicated by septic shock (median sofa score . ± ; median saps ii value ± . ) and a rapid clearance of bg levels was observed. in addition, we observed a % agreement between arterial line and femoral site bg assays (positive and negative). in particular, we detected bg levels from arterial site specimens that did not significantly differ by those obtained from femoral site specimens (p = . ). conclusions. although conventional mycological culture remains the gold standard for ici diagnosis, we showed that bg assay seems to be a diagnostic tool that may help physicians in early detecting ici. sampling blood from the arterial line was shown to give a simple and adequate specimen to be used for bg assay. further studies are in progress in order to define the role of bg as a surrogate marker for an early diagnosis of ici. objectives. to assess which marker, if any, and at which cut-off value could add diagnostic information to enhance clinical assessment in the difficult context of long-term icu-patients. methods. long-term ([ days) critically ill patients prospectively enrolled in the general icu of a university-hospital. all patients were daily assessed by the attending physician for the accp-sccm classification. c-reactive protein (crp, mg/dl), procalcitonin (pct, ng/ ml), and interleukin- (il- , pg/ml) were measured after patient's discharge on daily stored sera. an independent overall clinical evaluation after patient's discharge, aware of the clinical course but blinded against biomarker's measurement, an ''a posteriori'' accp-sccm classification, was chosen as reference standard for all comparisons. results. we studied clinical variables and biomarkers in patient-days ( patients). the day by day accp-sccm classification of the attending physician overestimated the severity of the inflammatory response to infection. discriminative ability of each biomarker for diagnosis of sepsis is shown in table . methods. icu patients ( males and females) with new onset of fever and leukocytosis within the first days of icu admission were prospectively included in the study. exclusion criteria: age \ or [ years old, heart or renal failure, hypertension, copd, pregnancy and head trauma. serial plasma samples were taken on days , and after the onset of fever for procalcitonin and bnp levels measurement. procalcitonin and bnp values were correlated with severity scores (apache ii and sofa), progression to septic shock and final outcome. statistical analysis was performed. results. patients included in the study were divided in three groups according to clinical and laboratory findings: sirs, sepsis and septic shock. procalcitonin value on days and and bnp value on days , and was significantly associated with sofa max value and with sofa value at the first day of fever, but not with apache ii. there was found no correlation between procalcitonin value on days , and and final outcome. bnp value on days and was significantly associated with final outcome (p = . and . respectively). the optimal cut-off bnp value on day was estimated to be pg/ml (sensitivity = %, specificity = %). the optimal cut-off bnp value on day was estimated to be pg/ml (sensitivity = %, specificity = %). procalcitonin value on days , and was not able to differentiate between patients with sirs and those with sepsis. also procalcitonin value on days , and was not significantly associated with progression to septic shock. bnp value on day was useful in differentiating between patients with sirs and those with sepsis (p = . ). the optimal cut-off bnp value was estimated to be pg/ml (sensitivity = %, specificity = %). bnp value on days and was significantly associated with progression to septic shock (p = . ). the optimal cut-off bnp value on day was estimated to be pg/ml (sensitivity = %, specificity = %). the optimal cut-off bnp value on day was estimated to be pg/ml (sensitivity = %, specificity = %). conclusions. in icu patients with new onset of fever during the first days of icu hospitalization, bnp value on days and seems to be a good predictor of icu mortality and progression to septic shock. also bnp value on day may be useful in differentiating between patients with sirs and those with sepsis. in our study procalcitonin value on days , and was not found useful in predicting progression to septic shock nor the final outcome. due to the small number of patients included in our research, further studies are needed to confirm these findings. objectives. as c-reactive protein (crp) is regarded a marker for both inflammation and infection we decided to analyse the pct and eo status next to every crp request of critically ill patients, during month. a two-side immunoassay (sandwich principle) for procalcitonin, using both anti-katacalcin and anti-calcitonin (see fig. a ) was used for quantitative analysis of procalcitonin with the roche modular e . pct concentrations [ . lg/l were regarded as positive. crp was measured by immunoturbidimetric analysis using the roche modular p. a positive blood culture was regarded as infection, with exclusion of the coagulase negative staphylococcus aureus since this organism doesn't induce pct expression. every crp request of the icu during month was accompanied by a pct, wbc, and eosinophil count. conclusions. pct at randomly measured at the icu doesn't seem to contribute to an earlier diagnosis of sepsis. pct measurement seems to be useful only when sepsis is suspected and a blood culture request has been summoned. however, its non-specificity for infection, as demonstrated by the high number of pct-positive, no blood-culture requested patients (concerning mostly post-cardiac arrest and post-heart surgery patients), makes it difficult to apply routinely. the recently displayed effort of various companies to market pct in combination with cd and neopterin (other potential markers of infection) supports the conclusion that not one marker by itself can substitute the golden standard of blood culture today. objectives. in this prospective observational study we sought to investigate the role of serum c-reactive protein (crp) and procalcitonin (pct) in the diagnosis and prognosis of patients admitted to the icu with suspected h n infection. all patients older than year-old, presenting with severe acute respiratory disease (cough, fever and respiratory distress) admitted to the icus of an university hospital in southeast brazil were included in this study. serum levels of crp and pct were measured at inclusion and at day , and . were also were also significantly higher (p \ . and p = . , respectively) independently from the presence or not of a co-infection. conclusions. as a conclusion, in our experience, some severe forms of influenza a/ h n with respiratory failure had elevated levels of pct and/or crp in the absence of proven bacterial co-infection. low values were unusual in the presence of co-infection but high values are not synonymous of co-infection and may be related to the severity of the disease. a large prospective randomized study is needed to assess the clinical interest of these biomarkers during the next pandemic of influenza. methods. descriptive study of pregnant with influenza a admitted in the obstetric section icu. the study period runs from september to january . during this period patients were admitted. entry criteria (%): gestosis %, complicated postoperative gynecology and obstetrics , postpartum hemorrhage , acute respiratory failure in influenza pneumonia: . , sepsis and others respiratory failure respectively, others (pregnant myocardial infarction, trauma, renal failure, arrhythmias and heart failure) . acute respiratory failure due to influenza pneumonia was assessed using severity criteria the ats/idsa (major criteria ( ) were admitted in icu cases of severe influenza pneumonia, nasopharyngeal specimens confirmed with rt-pcr positive for influenza a (h n ): pregnant in icu og, and women and men general icu. the average age of pregnant was ± years, average stay days. % were in the rd trimester and one in the nd trimester (week ). two-third pregnancy and two primiparous. the apache ii on admission ranged between and . only one patient with pre-existing disease (diabetes type ). admission due: acute respiratory failure complicating pneumonia multilobar in %, with more than days of typical symptoms (fever [ °c, malaise, myalgia, headache and respiratory symptoms), no starting oseltamivir within h symptoms. caesarean was performed at %; % in the first h of admission and one after days (week ) intrauci, posterior cerebral hemorrhage fetal death. all newborns free of viral disease. invasive mechanical ventilation (mv) in the first h in patients and did not require. required aggressive parameters %: bipap, alveolar recruitment and prone. a percutaneous tracheostomy for weaning. the average duration of mechanical ventilation: ± days complications: barotrauma (pneumothorax and a pneumomediastinum ). % required vasoactive drugs. one patient with acute renal failure that required extracorporeal clearance techniques (hdfvvc), recovering renal function, deep vein thrombosis complicated with shaldon catheter. one brain death by massive subarachnoid hemorrhage. nosocomial infections in patients, most common germ staphylococcus epidermidis catheter and candida sp in urine. initial empiric coverage with ceftriaxone and clarithromycin, as well as oseltamivir. conclusions. during pregnancy, especially in the second and third quarters, there is an increased risk of complications associated with infection by influenza a virus h n , highlighting pneumonia, with more rapid progression to severe respiratory complications. objectives. the aim of this study was to describe baseline characteristics, management and outcomes of critically ill patients with influenza a (h n ) infection who were treated at icu. we performed a retrospective observational study which included critically ill patients with influenza a (h n ) infection admitted to icu between rd november and th march . the primary outcome measure was mortality. secondary outcomes included the rate of influenza a (h n )-related critical illness and introduction of mechanical ventilation as well as intensive care unit (icu) length of stay and hospital length of stay. in the early th century, burns patients were dying of multi-organ failure due to dehydration and hypovolaemia [ , ] . the parklands formula was devised to guide fluid resuscitation and prevent multi-organ failure from occurring. however, over enthusiastic fluid resuscitation will lead to other complications [ ] . objectives. we aimed to assess the adequacy and complications of fluid resuscitation in the st h of a burns patient admitted to our icu, a tertiary centre for burns intensive care. • a retrospective medical case notes audit on all patients admitted to our icu in with [ % tbsa (total burns surface area). • st h of burns resuscitation initiated by the referring hospital and our icu compared to the parkland's formula. • statistical analysis by spss . results. patients audited. • mean duration of transfer from burn injury to our unit = . h • mean age = years, burn area %, length of stay . days • day mortality = % • % had an inhalational injury • no statistical difference between the emergency department (ed) estimation of tbsa and whiston icu. • mean iv fluids given . l but the actual predicted requirement is . l, therefore an excess of . l (p \ . ) • average urine output during this period was . ml/kg/h suggesting that this amount was adequate. iv fluids in the st h conclusions. excessive amount of iv fluids in the st h is associated with prolonged ventilation and length of stay but is not associated with increased day mortality. the mean amount of fluid required in the st h is approximately ml/kg/h which is consistent with other studies [ ] . urine output is still an accurate marker of resuscitation. there was no statistical difference between the determination of tbsa by the ed and burns surgeons, contrary to other studies [ ] . introduction. icu-acquired hypernatremia appears to be associated with mortality in the icu . to reduce iatrogenic rise of serum sodium the use of balanced colloids has been advocated. objectives. aim of this study was to establish the incidence of clinically relevant hypernatremia on our icu and to evaluate the change in incidence of hypernatremia due to the introduction of a natriumacetate based colloid solution. we performed a single centre retrospective study in a -bed mixed icu with all available medical specialities except neurosurgery. sodium measurements of all patients were analyzed during a -month period prior to and after a switch from sodium-based (s) to natriumacetate -based (na) colloids. s contains a % kda polystarch with a mmol/l na and mmol/l cl concentrations (voluven Ò ). na contains a % kda hydroxyeethylstarch with a mmol/l na and mmol/l cl concentrations (volulyt Ò ). serum sodium measurements were routinely performed -hourly. by protocol colloids were provided to a maximum of l/day, independent of bodyweight. patients with hypernatremia at icu admission were excluded. data are expressed as mean ± sd. comparison of na concentrations between groups was performed with a t test for independent samples and comparison of incidence of hypernatremia with a pearson chi-square test. results. patient characteristics and number of samples are summarized in table . after the introduction of na mean serum sodium concentration in the total icu population decreased significantly from . ± . to . ± . , p = . . the incidence of serum na[ mmol/ l decreased from . to . %, p = . . the percentage of patients with at least one na measurement[ mmol/l did not change significantly: . % (s) versus . % (na), p = . . introduction of a natriumacetate based colloid solution in stead of a sodium-based colloid solution reduces the overall incidence of clinically relevant hypernatremia; however, the number of patients with such hypernatremia did not change significantly. patients admitted to intensive care frequently have a metabolic acidosis with previous studies demonstrating an association between the degree of acidosis and outcome. hyperchloraemia is a significant cause of metabolic acidosis and there is increasing interest in the adverse consequences associated with it, which include hypotension, renal dysfunction, impaired gut perfusion and increases in inflammatory cytokines. previous studies, however, have failed to show that hyperchloraemic metabolic acidosis (hcla) has a significant effect on survival. to assess whether patients with hcla had a worse prognosis than our general intensive care unit (icu) population, and the factors associated with the development of hcla. consecutive admissions to the intensive care unit over a month period were studied. patients with a base deficit[ mmol/l and a serum chloride[ mmol/l on the same arterial blood sample during their icu admission were classified as having an episode of hcla. apache ii scores on admission, length of stay on the unit, mortality rates and reason for admission were collected. hospital survival was investigated by logistic regression analysis, controlling for illness severity (apache ii) and admission category, and displayed as a kaplan-meier curve. of patients entering the unit during the retrospective study period, had an episode of hcla, with an odds ratio of death of . ( % ci . , . ) compared with those without hcla. after controlling for apache ii score on admission, and admission category the odds ratio reduced to . but was still statistically significant (p = . , % ci . , . ). the development of hcla was significantly more associated with medical than surgical admissions with an odds ratio of . ( % ci . , . ). within the surgical admissions, the occurrence of hcla differed significantly with the urgency of surgery, with an odds ratio of . ( % ci . , . ) for emergency surgery versus elective surgery. those with hcla had a longer median duration of stay and were overrepresented in the group of patients whose length of stay was c days. kaplan-meier graph showing survival to days conclusions. the results demonstrate that hcla occurs frequently in a general icu population and is associated with a significantly worse outcome. this is in contrast to previous studies which have demonstrated acidosis secondary to lactate and an elevated strong ion gap are associated with poorer outcomes, but not hyperchloraemia. a. dumoulin , a. janssen , j.j. de waele , j. decruyenaere , e.a. hoste universitair ziekenhuis gent, gent, belgium increased creatinine clearance or hyperfiltration has been reported in icu patients. enhanced renal clearance of antibiotics in patients with hyperfiltration may result in suboptimal antibiotic serum concentrations, and so affect patient outcomes. there are only limited data on the incidence of hyperfiltration in icu patients. objectives. assess the epidemiology of hyperfiltration in a cohort of icu patients. single center retrospective cohort study, including adult patients hospitalized during the period / - / in the bed icu of the ghent university hospital, a tertiary care center. data were retrieved by a specially designed electronic alert from the electronic icu database. urinary creatinine clearance (ccr) was calculated as ( h urine volume) (urinary creatinine)/([creatinine day - + day ]/ )/time. we retrieved the initial ccr, and the minimum and the maximum ccr. hyperfiltration was defined as a ccr c ml/min. patient days with anuria were excluded from the analysis. data are reported as median (interquatile range). patients with neurological disease. several factors may interfere with water and sodium homeostasis in these patients, including factors that are also present in other icu patients. in addition, these patients may develop a syndrome of antidiuresis (siad), or salt wasting syndrome (sw). the latter by secretion of brain natriuretic peptide (cerebral salt wasting syndrome (csw)), release of atrial natriuretic peptide in volume overload, or renal salt wasting. objectives. assess the epidemiology of hypona in icu patients with neurological disease. methods. retrospective single center study. data were retrieved from electronic icu databases. inclusion criteria were age c years, hypona (\ mmol/l), and neurological disease. only the first episode of hypona was considered. siad and sw was assessed with tonicity balance on data of the preceding h in patients with urinary sodium[ mmol/l, in whom other etiologies were excluded. sw was defined as negative salt balance and negative fluid balance, and siad as positive fluid balance. to evaluate the prevalence of anaemia among patients attended at the emergency room (er) and to estimate the need of an early diagnose and efficient treatment. observational transversal trial in which days in june were randomly chosen. all patient attending to the er is included. paediatric, gynaecologic and traumatic cases fall out of this research. anaemia was diagnosed according to who criteria. comparison means statistics methods for quantitative variables and chi square for categorical variables were used. prevalence data for the entire cohort, for men and women separately and for different age bands, medical history, anaemia related medication and red blood cells data were extracted. results. patients were interned through the er channel. % men, mean age . ± . years old (median ), and , % were subject of blood analysis using classification proceedings. from the analysed . % were anaemic. . % of them were under years old, % aged from to and . % elderly patients (over years old). most frequent co-morbidity was chronic obstructive pulmonary disease (copd) (n = , . %) and most related drug aspirin (n = , . %). % of the sample had a bleed but only . % needed red blood cell transfusion. we found statistic difference in mean age, antiplatelets therapy use, bleeding episode, need for transfusion, creatinin value and hospitalisation. anaemia classification according to vcm: microcytic . %, normocytic %, macrocytic . %. conclusion. unknown anaemia detection in the er and its following treatment could be a strategy to further reduce allogeneic blood transfusion. the presence of disorders of sodium balance on icu admission could be independently associated with mortality. we decided to study if the existence of dysnatremias at the time of icu admission could be related to mortality in critically ill patients. we conducted a retrospective study in a mixed icu with a database of , adults admitted consecutively over a period of years ( - ) . most patients ( . %) had normal sodium levels ( b na b mmol/l) on icu admission. the frequencies of borderline ( b na b mmol/l), mild ( b na \ mmol/l), and severe hyponatremia (na \ mmol/l) were . , . %, and . %, respectively. the frequencies of borderline ( \ na b mmol/l), mild ( \ na b mmol/l), and severe hypernatremia (na [ mmol/l) were . , . , and . %, respectively. all types and grades of dysnatremia were associated with increased raw and risk-adjusted hospital mortality ratios. multiple logistic regression analysis showed an independent mortality risk rising with increasing severity of both hyponatremia and hypernatremia. odds ratios and % confidence interval (ci) for borderline, mild, and severe hyponatremia were . , . and . , respectively. odds ratios and % ci for borderline, mild, and severe hypernatremia were . , . , and . respectively. conclusions. this observation suggests the possible correlation of natremia on icu admission with hospital mortality and confirms that both hypo-and hypernatremia present on admission to the icu could be independent risk factors for poor prognosis in icu populations. ( ) . a relationship between mortality and delay from time of pars trigger to critical care admission for patients not requiring surgery has recently been described ( ) . objectives. this study was to test the hypothesis that in cases of emergency laparotomy, prolonged physiological deterioration pre-operatively is associated with higher hospital mortality. we reviewed notes of patients that underwent emergency laparotomy between july and february at the northern general hospital, sheffield, uk. time at which patients triggered (pars c ), time of arrival in theatre and hospital mortality were recorded. two-tailed fisher's exact test was used to test null hypotheses that a delay of more than h after pars trigger does not affect hospital mortality. . patients had an emergency laparotomy during this period. of notes retrieved by our patient record service, were incomplete. of remaining patients patients did not trigger, of whom died ( . % mortality). patients triggered, died ( . %). amongst patients that triggered, arrived in theatre within h, of whom died ( . % mortality); of the patients that arrived in theatre after h died ( . % mortality). the odds ratio of death for those with a prolonged pre-operative deterioration (n = ) compared to those without (n = ) was . ( % ci . - . , p = . ). the number needed to treat early to save one life was . conclusions. our data suggest that in cases of emergency laparotomy, those who trigger pars pre-operatively have higher hospital mortality than those who do not. specifically, our data indicate that patients triggering pars c should arrive in theatre within h of first triggering. nothing is known about the effect of the duration of icu-related therapies on acute outcome. to identify the importance of the duration of invasive ventilation and of renal replacement therapy for acute prognosis of surgical patients treated in an intensive care unit (icu). we performed a retrospective analysis of prospectively collected data of an icu patient cohort linked to a local database. adult patients (n = , ) admitted to a -bed icu at a university hospital in munich, germany, between and who had an icu length of stay of more than days and who were followed-up until the end of the acute phase after icu admission. cox-type additive hazard regression models were used to analyse linear, nonlinear or time-varying associations of therapeutic variables with survival time. duration of different invasive therapies was evaluated by constructing specific vectors, which tested potential effects of time-dependant variables on outcome after a lag time of days. . patients ( . %) were still alive at the end of the acute phase after icu admission. during the acute phase, . % of the patients required invasive ventilation, and . % a continuous renal replacement therapy. besides the underlying disease and disease severity at icu admission, the need for invasive ventilation or renal replacement therapy was associated with poorer outcome. duration of invasive ventilation shortened survival (with a lag of week), if treatment lasted for more than days (non-linear association). in contrast, duration of renal replacement therapy was unimportant for acute prognosis. conclusion. prolonged duration of invasive ventilation, but not of renal replacement therapy is inversely related to acute survival. objectives. to identify the prognostic importance of preceding invasive ventilation, renal replacement therapy and catecholamine therapy for long-term survivors after surgical critical illness. we performed a retrospective analysis of prospectively collected data of an icu patient cohort linked to a local database. adult patients (n = , ) admitted to a -bed icu between and , who had an icu length of stay of more than days, were followedup until the end of the second year after icu admission. hazard function was explored by weibull modelling and likelihood ratio tests. cox-type structured hazard regression models were used to analyse linear, non-linear or time-varying associations of therapeutic variables with -year survival time of a patient subgroup, which had survived the period of high hazard. hazard rate declined exponentially up to day after icu admission, and became constant thereafter. patients reached this stable stage of their disease forming the study population. of these patients ( . %) were still alive at the end of the second year after icu admission. underlying diseases were major determinants for long-term outcome. long-term mortality was significantly associated with the acute extent of physiological derangement during icu stay (maximum apache ii score), but was independent from the duration of preceding invasive organ support. in surgical patients with a prolonged icu length of stay, an exorbitant mortality exists for about half a year after icu admission. later on, life expectancy of surviving patients is largely determined by the underlying disease and, to a minor degree, by the acute extent of homeostatic disturbance during icu stay. the duration of preceding invasive therapies does not limit long-term survival. b. rozec , a. desdoits , k. asehnoune , c. lejus , y. blanloeil chu nantes, hôpital laënnec, anesthesia and intensive care, nantes, france, chu nantes, hotel-dieu, anesthesia and intensive care, nantes, france postoperative stroke could be an endpoint in non-cardiac surgery morbidity studies [ ] . therefore, its frequency established in old studies and considered higher than in the non surgical population remains to be estimated more precisely. objectives. the aim of this evaluation was to calculate the frequency of stroke, firstly in a prospective study, and secondly in a review of the literature. strokes diagnosed in the prospective follow-up ( days) of surgery for hip fracture was confirmed by a neurologist and a ct-scan. retro and prospective studies (except abstract) published in journals (pubmed, ovid) from to were included in the analysis. statistics:% ic , multivariate analysis (effects of population size, date of publication, type of surgery, patient age, prospective vs. retrospective studies were evaluated). results. mean pre-operative possum scores between the two groups showed no significant differences. continuous measurements taken by the odm showed a mean stroke volume increase of mls at the end of surgery (paired t test, p-value = . ). ( . %) patients following implementation compared to ( . %) prior to implementation required post-operative critical care admission. following odm implementation, critical care los was reduced from . to . days and post-operative length of stay within hospital was also significantly reduced by . days. introduction. local (skeletal muscle necrosis) and remote (lung neutrophil infiltration) ischemia-reperfusion injury (ir) have been described in animals [ ] and humans after aortic surgery. postconditioning with cyclosporina (csa) was recently shown to prevent skeletal muscle infarction in pig latissimus dorsi muscle flaps [ ] . objectives. the aim of this study was to investigate local (gastrocnemius muscle, gc) and remote (lung and liver) ir in rats exposed to aortic cross-clamping with special focus on mitochondrial respiratory chain complexes activities and reactive oxygen species (ros) production. we also investigated whether pharmacological post-conditioning with csa would be protective in this setting. methods. anaesthetized (isoflurane) and mechanically ventilated wistar rats underwent laparotomy and were randomly assigned to one of the following groups: sham (n = ), ir (n = , clamping of the infrarenal aorta for h followed by h of reperfusion), ir+csa (n = , mg/kg csa administered intraperitoneally and min prior to reperfusion). maximal oxidative capacities (vmax) and complexes i, ii and iv of the mitochondrial respiratory chain were determined using glutamate-malate (vmax) and succinate (vsucc) as substrates in the gc permeabilized fibers and freshly harvested liver and lungs isolated mitochondria. tissue superoxide anion production was assessed with dihydroethidium (dhe) in thin sections of frozen gc. data are expressed as mean±sem and analyzed with anova followed by newman-keuls post-hoc test; a p value. was considered significant. esophagectomy with gastric tube reconstruction is associated with frequent postoperative complications due to a (surgery induced) systemic stress response, provoked by the overproduction of proinflammatory cytokines. in elective postoperative esophagectomy patients, we previously showed that levels of serum crp are associated with the occurrence of postoperative complications and reduced survival. plasma ngal (pngal) and urine ngal (ungal) are early predictors of acute kidney injury, however sepsis/sirs seems to accelerate their production even in the absence of aki. objectives. we examined the role of pngal and ungal as early indicators of postoperative complications at the icu in patients undergoing elective esophagectomy surgery methods. in a prospective follow-up cohort study, data of a total of patients admitted to the icu following elective esophagectomy with gastric tube reconstruction were collected in the period from september to april . patients who developed aki at the icu were not included in this study. postoperative pngal and ungal levels were determined at consecutive time points and the relation between the course of postoperative serum pngal and ungal, development of complications and outcome of the patients was investigated. in our experience, assisted by dv robot radical prostatectomy, despite requiring longer surgery time, was shown to be safer than conventional radical prostatectomy, with a significant less blood loss during surgery, less need for blood transfusion, fewer postoperative complications, included need to reoperate, and also a shorter length of hospital stay than conventional radical prostatectomy. objectives. the aim of the study was to evaluate safety and effectiveness of m infusion, impact on fluid balance and urine output (uo) and also whether we can avoid cvc line insertion. we conducted a prospective analysis of patients (pts) treated with m who were admitted to the shdu between oct and aug . demographic data and vital parameters were collected through the individual questionnaires before ( ) introduction. an ever increasing number of patients over the age of year are being admitted to critical care units [ ] . with no marked expansion in the number of critical care beds in our hospital and in the health region as a whole, this may lead to a huge strain on the service provision, with less availability of beds to treat elective and other emergency admissions. to determine the factors that affect outcome following admission to critical care of patients aged years and above(medical and surgical). methods. ethical approval was sought but deemed unnecessary as our study was observational (non-interventional). we prospectively looked at the number of patients (age year and above) who were admitted to icu/warrington general hospital over the period of year. our unit is a modern, -bedded general icu with an annual admission rate of approximately ( level and level care). we examined data that was related to the source of admission, gender, apache scores, the use of vasopressors (including inotropes) and the need for ippv in the first h of admission. we analysed the effect that each factor had on patient mortality (applying chi-square and z tests). we followed the patients up for months post-discharge from icu. the final report produced results that showed icu, hospital and -month mortality. results. there were admissions during the period st may - th april . last set of mortality data was obtained in september . female: male ratio was : . the overall -month mortality was %. in our study, patients admitted through a&e, theatre and ward had mortality rates of , and % respectively. patients who received vasopressors (including inotropes) in the first h had a significantly lower mortality than patients who did not receive any vasopressor support ( vs. %). invasive ventilation in the first h of admission was associated with significantly higher mortality rates ( vs. %). in this patient cohort, the overall -month mortality is higher than the general icu population. factors that determine mortality include the source of admission to icu, the need for vasopressor support and invasive ventilation in the first h of admission. introduction. the optimization of oxygen delivery (do ) is an intervention with fluids and inotropics to achieve supranormal goals of do during surgery, before disturbances of perfusion occur and oxygen debt accumulates. oxygen debt is directly linked to multiple organ failure and death. we aimed to evaluate the temporal pattern of oxygen debt in the intraoperative period in patients included in two studies of goal directed therapy to supranormal values of do . oxygen debt was calculated from data obtained from high risk surgical patients included in two randomized controlled trials were analysed. , the oxygen deficit was calculated by subtraction of the basal vo value from subsequential values of vo obtained during surgery and after the icu admission. the oxygen debt was calculated by the product of oxygen deficit and time (minutes) between measurements. patients treated with supranormal goals of do ([ ml/min/m ) using fluids and dobutamine showed lower levels of oxygen debt during icu stay. the peak of oxygen debt was , ml/m at min of surgery in the control group in comparison to , ml/ m in the protocol group. in the second study, the peak of oxygen debt occurred at min in the volume group ( , ml/m ) which was significantly higher than in the dobutamine group ( , ml/m ). higher oxygen debt during peroperative period correlated with poor outcome as shown on the original studies. conclusion. the use of supranormal goals of do with dobutamine and fluids in the peroperative period results in lower oxygen debt. post-operative nausea and vomiting (ponv) is a common problem in the patients undergoing laparoscopic surgery. the release of serotonin during surgical procedure may induce ponv. we investigated if postoperative increase in plasma serotonin metabolite was associated with ponv after gynecologic laparoscopic surgery. objectives. the patients who experienced nausea after gynecologic laparoscopic surgery (ponv group, n = ) and patients who had no or mild nausea (control group, n = ) were enrolled into this study. postoperative nausea was assessed during h in post-anesthetic care unit and ondansetron was administered if needed. blood samples were obtained before anesthesia and h after surgery. plasma serotonin metabolite ( -hydroxy indole acetic acid, -hiaa) was analyzed using high performance liquid chromatography (hplc) assay. perioperative change of plasma -hiaa and the degree of nausea were compared between groups. results. the degree of post-operative nausea varied from to ( mm visual analogue scale, vas) and median value was ( - ) in control group and ( - ) in ponv group (p \ . ). average -hiaa concentration of all patients increased after surgery ( . ± . to . ± . ng/ml, p \ . ). baseline plasma -hiaa concentrations were similar between groups, however, -hiaa of ponv group increased higher after laparoscopic surgery compared with control group ( . ± . to . ± . ng/ml vs. . ± . to . ± . ng/ml, p = . ). conclusions. the patients who experienced post-operative nausea showed more increase in -hiaa concentration. ponv after gynecologic laparoscopic surgery may be associated with a peripheral release of serotonin. introduction. the intracavitary ecg method is an easy, accurate and inexpensive methodology for real time positioning of the tip of central venous catheters. in particular, when the ecg method is performed using not the guidewire but the saline-filled catheter as electrode, the methodology is completely safe and can be applied to any central venous access device (vad). we have tested a new specific device (sapiens tls, romedex) which simplifies and standardizes the ecg method; it consists of a hardware (a small box with cables connecting it to a pc and to ecg electrodes) plus a software (which can be used on any pc). we tested the sapiens tls in patients who underwent positioning of central vads ( totally implantable ports, piccs and tunnelled catheters, all inserted by ultrasound guided venipuncture). our goal was to position the tip of the catheter at the cavoatrial junction: the length of the catheter was estimated by anthropometric measurements and the correct positioning was achieved by the intracavitary ecg method during the procedure. the final position was checked by a post-procedural chest x-ray. there was no insertion-related complication. the intracavitary ecg method was easily performed in all cases. at the final x-ray control, % of all tips were correctly positioned at the cavo-atrial junction (± cm), confirming the accuracy of the intracavitary ecg method. the anthropometric measurement tended to overestimate the length of the catheter both in port insertions ([ cm in % of cases) and in picc insertions ([ cm in % and [ cm in % of cases). conclusions. the intracavitary ecg method as performed with the sapiens tls was more accurate than the anthropometric measurement in terms of correct positioning the tip of the catheter during the procedure. the sapiens tls simplified the method, by standardizing the ecg tracking, and making it easy (no need of ecg monitor, no need of ecg commuter since the sapiens tls displays simultaneously the surface ecg and the intracavitary ecg). also, the sapiens tls allows the print-out of the intracavitary ecg reading for documentation, as well as the storing of the ecg reading in a computer-based database. previous studies have shown that hypernatremia impact graft function after orthotopic liver transplant (olt). the purpose of this retrospective investigation was to determine whether differences in serum sodium values after olt influenced postoperative short-term patient outcomes. objectives. the study was aimed at exploring the incidence of hypernatremia after orthotopic liver transplantation (olt) in order to provide critical monitoring and intensive care services. clinical and sicu laboratory data were collected; serum sodium was assessed an average of three times per day. hypernatremia was defined as two daily values of serum sodium above mmol/l. from to , we analyzed patients with hypernatremia after olt. the major outcome was death in the icu after days. conclusions. in sicu, olt patients are easy to suffer from hypernatremia ( . %) and have high mortality ( . %). hypernatremia is associated with an increased risk of death in patients with olt. early active fluid infusion is crucial, besides optional continue venovenous hemofiltration (cvvh). cywinski objectives. the aim of this study was to determine the value of blood lactate sequential dosages during the first postoperative hours for the diagnosis of gd. we conducted a retrospective study on consecutive patients admitted in icu after lt, between july and june . lt with auxiliary or splited grafts were excluded so were patients with septic or cardiogenic shock occurring during the first h after lt. criteria for gd diagnosis were: sgot [ , u/l with pt \ % between d and d , or re transplantation or death between d and d . demographics and biological data (transaminases, pt, serum bilirubin) were recorded between d and d . hopital bicêtre, kremlin-bicêtre, france, hôpital saint-louis, paris diderot university, biostatistics, paris, france, hôpital hôtel-dieu, medical intensive care unit, nantes, france, hôpital gabriel montpied, nephrology and transplantation, clermont-ferrand, france, hôpital edouard herriot, medical intensive care unit, lyon, france, conclusions. in kidney transplant recipients, arf is associated with high mortality and graft loss rates. increased pneumocystis and bacterial prophylaxis might improve these outcomes. early icu admission might prevent graft loss. a. umgelter , k. lange , p. büchler , h. friess , r.m. schmid technical university of munich, transplantationszentrum münchen rechts der isar, ii. medizinische klinik, münchen, germany, technical university of munich, transplantationszentrum münchen rechts der isar, chirurgische klinik, münchen, germany introduction. the shortage of donor organs in the eurotransplant region results in late allocation at a time when liver disease is already very advanced. the severe condition of patients at that stage negatively affects outcomes of orthotopic liver transplantation (olt). to support decision-making in these situations, clinical data are urgently needed. objectives. to evaluate outcomes of liver transplantation (olt) in icu-patients with multi-organ failure due to advanced acute on chronic liver failure (aclf). methods. in our centre, patients on the waiting list for olt are not automatically excluded from the procedure, if their condition deteriorates to multi-organ failure. a consensus of the team in each individual case is based on criteria such as the previously manifested will of the patient, exclusion of current infection, absence of neurologic damage or other organ damage expected to impair the possibility of rehabilitation. we retrospectively analyzed a database comprising data from evaluation for the waiting list of all patients transplanted in our center since implementation of the meld-score for allocation. only cirrhotic patients treated on our intensive care unit before transplantation were included. patients treated on the icu before retransplant for primary graft failure were excluded from analysis. data are presented as median ( th - th percentile). wilcoxon or mann-whitney u tests were used for comparisons of paired and unpaired data, respectively. results. from january until september patients ( m, f; age ( - ) years) fulfilled inclusion criteria. cirrhosis was due to alcohol (n = ), hcv (n = ), alcohol+hcv (n = ), alpha- -antitrypsin deficiency (n = ), budd-chiari-syndrome (n = ) or cryptogenic (n = ). upon icu admission icu, apache ii scores were ( - ), sofa scores ( - ); meld ( - ). after ( - ) days on the icu, directly before transplantation, sofa scores had deteriorated in all patients to ( - ) and meld scores to ( - ). patients had renal replacement therapy and patients were on single-pass albumin dialysis. the -day-mortality was %, hospital mortality % and -year mortality %. in hospital survivors, surprisingly, sofa scores ( ( - ) vs. ( - ); p = . ) and inr ( . ( . - . ) vs. . ( . - . ); p = . ) upon admission to the icu were significantly higher than in non-survivors. there were no significant differences in age, gender, meld scores or use of extracorporeal treatment in survivors vs. non-survivors. conclusions. liver transplantation in selected cirrhotic icu-patients with multi-organ failure is not medically futile. outcome, however, is much worse than usually considered acceptable. objectives. this work tries to study the clinical profile and the results with the immediate postoperative outcome of patients suffered from pancreas-kidney transplantation (pkt) and only pancreas transplantation (pt) admitted in our intensive care unit (icu) setting. methods. prospective study during years (from to ). we recorded epidemiological, demographical and clinical data, surgical and postsurgical complications, therapy, morbidity and mortality rate, length of stay in icu, organs survival, etc. the data were expressed in mean±typical deviation, median and percentages. results. we recorded patients. table expresses some of the data. the mean age was . ± . years old male . %. pkt from unic deceased donor: %. pt: %. the mean ischemia time was . ± . h for the kidney and . ± . for the pancreas. the most frequent surgical complications were bleeding ( . %), technical difficulties ( . %) and anesthetic complications ( . %). postoperative immunosuppression consists in methyl-prednisolone, tacrolimus, mycophenolate mofetil and thymoglobulin (as our protocol recommends) and was administered to the % of the patients. prophylactic antibiotic and antiviral therapy (ampicillin, ceftriaxone, fluconazole and gancyclovir) was given to almost the % of the patients. table expresses the blood test results. the mean insulin requirements per day during the stay in icu was ( - . ) iu. table represents the complications in the icu. the first leading cause of reoperation was vascular thrombosis ( %) followed by intraabdominal bleeding ( %). conclusion. the clinical profile of this patient in our setting is a years old man, with high blood pressure, retinopathy, dialysis, pancreas-kidney transplant recipient, with unic decesed-donor. he needs no insulin or minimal requirements. the principal complication is pancreatic vascular thrombosis that frecuently leads to removal of the graft. ( ) . in a clinical practice, a specific marker to evaluate and predict ischemic-reperfusion injury in liver transplantation (olt) is not available. poor organ perfusion and high pct levels appeared to predict early graft failure only in the cardiac donor ( ) . objectives. we evaluated pct as a predictor of ischemic-reperfusion injury in liver transplantation and pdr, as a predictor of complication and graft outcome. methods. prospective study. patients (age, child-pugh score, aetiology of liver cirrhosis) undergo liver transplant. bilirubin levels and pdr ( . mg/kg of ig in a central catheter with limon system Ò , pulsion medical system, munchen, germany) was measured once a day for postoperative days (pod). on the same day, aspartate aminotransferase (ast/gpt) and alanine aminotransferase (alt/got) were measured. sofa score was as a patient severity score. serum level of pct, c-reactive protein (crp) was collected at the liver reperfusion time and from the st to the rd pod. warm and cold ischemia time was collected. statistical analysis was performed with wilcoxon, spearman tests (p \ . ). linear correlation was performed too. a small rise on pct levels were observed early after olt, with a peak in the st day after olt. it was associated neither with hepatic post-olt dysfunction nor with other non infective complications. pct increased significantly after liver reperfusion (p \ . ) and correlate with pdr on the nd pod, but not correlation were found with crp, white blood cells, or liver enzymes after olt. crp levels increased rapidly after olt. pct increasing after liver reperfusion correlated with child-pugh olt (r = . at nd pod) in the recipients. the cold ischemia time did not correlate with pct serum levels after liver reperfusion as well as the warm ischemia time. a negative correlation was found between pdr and liver function in the recipient. pdr did not correlate with child-pugh score. the cold ischemia time well correlated with ast and alt on the first day after transplant (r = . ). it negatively correlate with pdr (r = - . ) at the same time. the warm ischemia time did not correlate with pdr, ast and alt. the same results were found between pdr and liver enzymes and lactates. no correlation was found between pdr and sofa score. conclusions. pct peak in the recipient at reperfusion and early post operative was not predictive of graft dysfunction or other non infective complication. it may represent a marker of ischemia-reperfusion injury. crp levels increased rapidly after olt and it could be an expression of surgical procedure, and it doesn't correlate with pct. objectives. the aim of this prospective observational study was to describe the kinetics of ngal following renal transplantation and to assess its ability to predict delayed graft function. introduction. lung transplantation is the recognized therapy for end-stage respiratory failure. many serious medical complications have been described occurring from months to years after lung transplantation, often necessitating admission to an intensive care unit (icu), which has been associated with a high mortality. we examined the factors associated with mortality. methods. all patients admitted to the general intensive care unit between and following lung transplantation were included in this retrospective study. data was collected regarding demographic parameters, intensive care unit stay and outcome. over the study period, forty patients were admitted to the icu. the main pretransplant diagnosis was idiopathic pulmonary fibrosis followed by chronic obstructive pulmonary disease. the majority ( %) of patients required mechanical ventilation during their icu stay. the main reason for icu admission was septic shock in patients ( %) of cases. an organism was isolated from of these patients; in cases, the organism was shown to be multi-drug resistant. the icu mortality was . %. non-survivors were characterized by a higher admission sofa score (p = . ), an admission diagnosis of sepsis ( . vs. . % for all other diagnoses, p \ . ), and a requirement for mechanical ventilation (p = . ). in addition, the incidence of chronic rejection was significantly higher in the non-survivors (p = . ). conclusions. severe sepsis remains the most important factor associated with a poor outcome. new strategies are required to alter the course of this common complication of lung transplantation. (the % of the infections were respiratory) and ( %) patients presented pulmonary allograft rejection. according to our immunosuppressive protocol, we started with methylprednisolone and tacrolimus and we added mycophenolate later. the ccd length of stay was ( - ) days and the median days of mechanical ventilation were ( - ). thirteen ( %) patients died, basically due to refractory respiratory failure, multiple organ dysfunction syndrome and haemorragic shock. conclusions. in our large series of lung transplantation a remarkable incidence of complications has been observed. despite this complications, lung transplanted patients presented an excellent short term outcomes. introduction. acute kidney injury (aki) poses a massive challenge after kidney transplantation, especially when kidneys from brain dead adult donors are transplanted into small paediatric recipients. inflammation mediated by cytokines is a key event in experimental models of ischaemic aki. objectives. the aim of this study was to investigate whether remote ischaemic preconditioning (ripc) reduced the inflammatory cytokine load and apoptosis in the kidney after transplantation. methods. kidneys were harvested from eight -kg brain dead donor pigs and transplanted into two groups of -kg recipient pigs after h of cold ischaemia. in one group (+ripc, n = ) ripc was performed before the -h reperfusion period, while no ripc was performed in the other group (-ripc, n = ). non transplanted kidneys from brain dead pigs served as controls. concentrations of tnf-a, il- , il- , and il- in renal tissue were determined by an immuofluorometric assay. renal apoptosis was quantified by immunohistochemistry for activated caspase- . high concentrations of tnf-a, il- , il- , and il- were detected in renal cortex in all three groups. no statistical differences between the two transplanted groups were found for any of the cytokines. compared to controls higher cortical levels of il- (control vs. -ripc, p = . , control vs. +ripc, p = . ) and lower levels of il- (control vs. -ripc, p = . , control vs. +ripc, p = . ) were found in transplanted kidneys. no differences were detected for tnf-a or il- . transplantation significantly increased the number of apoptotic cells in both glomeruli and tubuli (control vs. -ripc, p = . , control vs. +ripc, p = . ). no difference was found between recipients, (p = . ). conclusions. in transplanted kidneys from brain dead donors exposed to h of cold ischemia and ±ripc, we found increased tubular and glomerular apoptosis, but no increase in pro-inflammatory cytokines. the levels of il- were higher in transplanted kidneys compared to controls. remote ischaemic preconditioning did not modify cytokine load or apoptosis in the kidney graft. objectives. we present the case of a patient with confirmed hit and the management of its status during the perioperative period of the cardiac transplantation. a years old patient with a cardiac myxoma was operated under heparin anticoagulation. thrombocytopenia is noted at day after surgery. an enzymelinked immunosorbent assay (elisa) was performed and since the result was positive, the treatment was changed to lepirudin. the hit was confirmed by a heparin-induced platelet activation (hipa) test. the internal jugular vein thrombosis was observed. the post operative evolution was marked by the necessity of the implantation of a ventricular assisted device. the patient was submitted to two sessions of plasmapheresis which turned the antibodies negative. the patient underwent heparin anticoagulation during the surgery time and bivalirudin as the post operative treatment. the antibodies remained negative. two months later, the cardiac transplantation was performed; heparin was used for anticoagulation during surgery. due to a restored renal function, danaparoid was used postoperatively. conclusions. hit is a serious complication of heparin therapy. the diagnosis is difficult. when hit is strongly suspected, a non-heparin anticoagulant is recommended. the choice of the anticoagulant depends on the hepatic and renal function. plasmapheresis is a solution for the antibody purging prior to cardiac surgery. objectives and methods. a nationwide qualitative study investigating their perception of the meaning of professionalism, and how they learn to behave professionally was performed. all eight dutch icm training centres participated. the moderator asked participants to clarify the terms professionalism and professional behaviour. next, participants were asked to explore the questions 'how do you learn the mentioned items?' and 'what ways of learning do you find useful or superfluous?' qualitative data analysis software (maxqda ) facilitated analysis: an inductive approach applying open, axial and selective coding principles was used. results. fellows across eight groups participated. results relating to the subtopics 'elements of professionalism' and 'teaching and learning of professionalism' are described consecutively. elements of professionalism relevant to intensivists: the elements most frequently addressed were communication, keeping distance and boundaries, medical knowledge and expertise, respect, teamwork, leadership and organization and management. medical knowledge, expertise and technical skills seem to become more tacit when training progresses, and relate to ethical, cultural and legal dilemmas originating in the specific icu context, and working as a multidisciplinary icu team member. teaching and learning professionalism: topics can be categorised into the themes workplacebased learning, by gathering practical experience, by following examples and receiving feedback on their actions, including learning from own and others' mistakes. formal teaching courses (e.g. communication) and scheduled sessions addressing professionalism aspects were also valued. conclusions. the emerging elements considered most relevant for intensivists were adequate communication skills, and keeping boundaries with patients and relatives. the specific icm context, and working as multidisciplinary icu team member substantially influenced the icm fellows' perception of professionalism. whereas medical knowledge, expertise and technical skills seem to become more tacit when training progresses, professionalism issues continue to be learned during icm training. professionalism is herein mainly learned 'on the job' from role models. formal teaching courses and sessions addressing professionalism aspects were nevertheless valued, and learning from own and others' mistakes was considered especially useful. selfreflection as a starting point for learning professionalism was stressed. the latter can e.g. be stimulated by means of assessment, structured feedback and use of portfolios, for which guidelines are now being developed within the cobatrice project. introduction: during the past decades there has been an increase in mass casualty events with changing geopolitical and climate situations. in a mass casualty event comprehensive care for the individual is expected [ ] . to meet these obligations further education in disaster medicine seems obligate [ ] . therefore the german home department responsible for mass casualties passed a concept for student education in disaster medicine [ ] . objectives. the introduction of a summer academy ''disaster medicine'' (sadm) is a first approach at charité university of berlin to establish a curriculum for disaster medicine. the sadm is sponsored by the german academic exchange service (daad) for years. the enhancement of student education in disaster medicine is supposed to raise the level of skills and knowledge of future physicians in the face of mass casualties [ ] . international participants and an interdisciplinary approach are keystones of the sadm concepts. in a globalized world international networking should enable students to exchange knowledge about the handling of mass casualties in different parts of the world. disaster medicine needs an interdisciplinary approach [ , ] . psychological aspects are always a key factor in the successful handling of mass casualties. the teaching concept of sadm consists of four parts: e-learning ahead of a week training session, emergency medicine training, disaster medicine training and excursions to evaluate already existing disaster concepts. the concept will be evaluated [ ] using a knowledge test, a skills test and a structured written interview concerning motivation and satisfaction of the students. conclusion. the support of the daad for three consecutive years allows a further evolution of this concept by integrating the evaluation results. the sadm should enable future physicians to meet the challenges of mass casualties with greater confidence and skills. educational programs are being set up to provide training and skills in these core subjects for dental care professionals. objectives. to evaluate dental practitioner (dp) skills and knowledge prior to a day continuous medical education (cme) training session, and assess training efficacy at the end of the session. methods. nine ( ) multiple choice questions concerning medical emergencies and pain treatment were handed out to dps at the beginning of cme training sessions over a year period in metropolitan france. after the day training session, the same multiple choice was taken again and collected for statistical analysis (kruskall-wallis test). examination before and after cme, p \ . we evaluated dps and obtained a % answering rate. before the cme session, the correct answer rate was below % for several items, like the european emergency telephone number or performing back blows before the heimlich manoeuver for severe choking, and below % for identifying vasovagal malaise by bradycardia, giving insulin for diabetic malaise or treating anaphylactic shock by epinephrine. more worrisome still is the fact that nearly out of dps would prescribe non steroidal anti inflammatory drugs (nsaids) during late pregnancy. the overall impact of cme was highly significant (p \ . ), showing real efficacy but correct answering rates after cme still remained between and %, which leaves room for improvement. further studies are under way to evaluate long term memorization of cme sessions in order to determine their optimal frequency. conclusions. medical skill and proficiency evaluation before cme training sessions for dps allows to target the training sessions and to evaluate their efficacy in the short run. introduction. the positive impact of immediate bedside echocardiography for rapid diagnosis and management of acute hemodynamic disturbances in the critically ill patient is well established. it is advocated that peri-resuscitation echocardiography should be an integral part of training for all intensivists. however, a major challenge for the intensive care clinician is access to appropriate echocardiography training outside of specific fellowship programmes. objectives. one suggestion to meet this training need is to combine supervised practical instruction with self-learning through the use of on-line educational tools. the internet is ideally suited to studying echocardiography as e-tutorials serve to convey theoretical principles whilst stills/video clips aid image recognition and interpretation. here we review currently available web based learning resources. methods. an online search was performed using google Ò and yahoo Ò search engines with the following key words: echocardiography, tte, toe, education, training, programme, courses, on-line, web-based, critical care. the resulting hits were screened to identify relevant sites and these were then evaluated independently by each author before an overall consensus was reached. one author had no previous echocardiography training whilst the other had passed the american national board of echocardiography perioperative transesophageal echocardiography examination. a total of sites were identified for evaluation (see table ); these are listed below with a brief description. conclusions. our search demonstrated a number of sites dedicated to facilitating echocardiography training. these varied from those which were essentially atlases, to those with a modular learning programme supported by interactive discussions and self assessment. some were targeted at the beginner seeking a basic understanding of echo whilst others were aimed at the enthusiast preparing for examinations. with growing interest in critical care ultrasound it is likely that we will see the use of such resources increasing. however echocardiography is a practical skill and it is essential that on-line learning is conducted in parallel with supervised bedside training in a process of 'blended learning'. . to determine level of supervision for trainees in the elective mri setting as compared with critical care transfers to mri. . to gain insight into the learning resources used by medical staff on mri to allow existing training to be improved. methods. two online surveys were conducted in february , with invitations to participate via e-mail. the survey population included all anaesthesia and intensive care medicine consultants in the local tertiary neurosciences centre and all trainees for these specialties in the northern ireland deanery. first year trainees were excluded. results. the response rate was % for consultants and % for trainees. in total, consultants responded with over % having no experience of mri at consultant level, even though % worked in areas where mri skills could be required. trainees completed the survey, with % having experience of mri in the elective setting, all of whom had been directly supervised by a consultant. % of trainees had experience of critical care transfers for mri, but this was in an unsupervised capacity more than % of the time. despite this, % of trainees did not feel competent to work in mri unsupervised. web based learning was found to be a poorly utilised mri training tool, particularly among consultants. conclusion. we have demonstrated a need to formalize training for mri in our institution and for trainees in the local deanery. we propose to meet this need by a combination of e-learning and experiential sessions with defined competencies. this should increase the cohort of physicians who can provide optimal care , in this unique environment and subsequently improve both service delivery and patient safety. was not a priority in health systems. following the report: ''to err is human. building a safer health system'', by the institute of medicine, which had a great impact on the media, ''patient safety'' is included as an strategic line in most health systems. training in patient safety is essential to implement safety culture and as a result improve it. for that reason we developed a training program ( courses) in for physicians and nurses from our icu. objetive. patient safety training program assessment. methods. we designed a h course ( % practical), using simulated scenarios common in icu clinical practice. we pointed out the relevance of human factors such as teamwork and communication, and its leading role in the genesis of error. we discussed a ''sentinel case'', using the root-cause analysis method, and analysed an icu process through failure mode and effects technique. adverse events reported to the department website were reviewed. participants and instructors discussed specific aspects about insertion of central venous catheter, prevention of nosocomial infection and improvement of security in the different groups of icu patients, highlighting the need for fidelity to the established protocols for this purpose. finally, participants completed a survey that assessed various aspects in a score from to . results indicated the most and least interesting aspects and suggestions for improvement were included. results. assessment surveys were analysed. participation rate was %. overall results: appropriate and clear targets, accomplished goals and utility ( . ) , appropriate content objectives and organization ( . ) , time invested in development activity and oral presentations ( . ), faculty competence ( . ) , interest and faculty adaptability to the group needs ( . ), degree of satisfaction and practices ( . ) . most interesting comments: practice of root-cause analysis ( . %), continued participation and motivation ( . %), practices with hps and group discussions ( . %), importance of human factors ( %), theory and practice good balance ( . %). least interesting comments: too condensed contents ( . %), few scenarios ( . %)suggestions: do it again( . %), enhance preventive medicine sessions ( . %), increase course duration ( . %). conclusions. overall assessment was positive. adaptability and competence of teaching staff have been the most valued aspects; too condensed contents and oral presentations were the least valued. practice of root-cause analysis ease of participation, ongoing motivation, hps scenarios and group discussions are the most appreciated activities. final comment: good acceptance has encouraged us to continue in to complete participation of all interested professionals. introduction. our intensive care unit (icu) was one of the first to initiate a humanization program in daily routine in . since then, the program suffered changes, the icu grew up in number of beds and complexity and had great renewal of the members of our interdisciplinary group. objectives. to improve our knowledge we continually re-evaluated the stress factors for the patients from our staff members' perspective, putting them in the patients place. methods. between january and march of , a research form was used with the interdisciplinary icu team. the following items were analyzed: profile of the interviewed, evaluation of the environment of the icu and the stress factors for the patients. the results were compared with the questionnaire form filled by the patients after icu discharge, as a part of our quality improvement program. results. about . % of our icu team answered the research (n = ). the mean age is . years (sd . ), . % of female, . % married, . % protestants and . % catholics and icu professional experience of . years (sd . ). our icu is noisy for . %, very illuminated for . %, easy-going for . %, organized for . %. in a preview research we found closed results. according to the team, factors that bother the patients are: noise ( . %), bed bath ( . %), loneliness ( . %), lack of privacy ( . %), anxiety ( . %), distortion of time perceptions ( . %) and fear ( . %). the patients (n = ) described as main complaints after icu discharged: distortion of perceptions of time ( . %), anxiety ( . %), sleeplessness ( . %), noise ( . %), loneliness ( . %), fear ( . %), pain ( . %)bed bath ( . %) and lack of privacy ( . %). the study showed differences of icu team opinions and the patients' complaints. when the team is placed in the patient's perspective they may experience a better view of how harmful is an icu and how much we can do to improve it. this is our daily challenge: take care with quality, respect, affection and always search for improvement. introduction. endotracheal intubation is a routine procedure to protect the airway in critical care, that is performed by a wide variety of clinicians from different specialities with different levels of experience in airway management. serious complications can result from misplacement of an endotracheal tube (ett) in a main stem bronchus. a widely recommended method for the prevention of this complication is bilateral auscultation of the lungs; but this method frequently provides only inconclusive results ( ) . other routinely used tests to verify correct endotracheal tube placement include observation of symmetric chest movements, and inserting the ett to a specific depth, but it remains unclear which of these tests detects endobronchial intubation best. objectives. we therefore designed this study to determine which bedside method has the highest sensitivity and specificity for detecting endobronchial intubation in adults and whether sensitivity and specificity increases as a function of the anesthesiologist's experience. methods. surgical patients were randomized to two study groups. in the first, the ett was fiberoptically positioned . - -cm above the carina, whereas in the second group the tube was positioned in the right main stem bronchus. first year residents and experienced anesthesiologists randomly performed only one of the following tests to verify the position of the tube: ) bilateral auscultation of the chest (auscultation); ) observation and palpation of symmetric chest movements (observation); ) estimating the position of the ett by the insertion depth (tube depth); and, ) a combination of all three mentioned tests (all three). results. patients ( female/ male) with observations by experienced and inexperienced anesthesiologists were included in the study. tube depth and all three had a higher sensitivity ( . and ) in detecting endobronchial intubation than auscultation ( . ) and observation ( . ) (p \ . ). experience increased the sensitivity only for auscultation, with % of first year residents versus % of experienced anesthesiologists detecting endobronchial intubation by auscultation correctly. the optimal ett insertion depth was found to be cm in women and cm in men. we conclude that auscultation alone is inadequate for assessment of correct ett insertion depth, and that checking for symmetric chest movements is of little use. our results suggest that the hierarchy of the methods used to assess the correct ett insertion depth should be changed and that clinicians should rely more on depth of ett insertion than on auscultation. this is especially true for physicians with less experience in airway management and in situations where auscultation is difficult or impossible. min usa) , uses a new probe measuring hemoglobin saturation at a lesser depth ( vs. mm before), with more data output ( value/ s vs. value/ . s). the new device contains automated software to compute parameters such as occlusion and reperfusion slopes of sto obtained during and after a vascular occlusion test (vot). objectives. to compare nirs parameters obtained with the devices used simultaneously in healthy volunteers and critical care patients to test if the new device gave similar results than the older one. methods. micro-oxygenation parameters were collected simultaneously with the different nirs models, one on each thenar eminence, before (baseline) and during a min upper arm (brachial artery) vot in patients ( septic shock (g ), trauma (g )), compared to healthy volunteers (hv)(g ). nirs probes were then shifted to the contra lateral thenar eminence and a second vot was performed. sto occlusion and reperfusion slopes from both devices were calculated in all groups by the same software, using linear adjustment (r c . to be valid); p \ . was considered significant. following parameters were collected in patients: saps ii and sofa scores, macrohemodynamic (heart rate (hr), mean arterial pressure (map), central venous pressure (cvp), cardiac output (co) and svo (mixed venous o saturation) or scvo ), and metabolic parameters (ph, base excess, and lactate). results. median ± iqr. patients (g and g ) did not differ for macrohemodynamic or metabolic data, except map ( ( - )mmhg vs. ( - )mmhg; p = . ). baseline nirs sto values were similar for both groups and for both devices, but were lower than in hv. during vot, reperfusion slopes were also lower in patients than in hv regardless the device used. the minimum sto during vot, occlusion and reperfusion slopes were significantly different between the devices: intraclass correlation coefficient (icc) . , . and . , respectively, and bland and altman poor agreement and large bias. conclusions. data obtained with model largely differ from those obtained with model , regardless of the studied population for both sto baseline and slopes. these differences appeared more pronounced in hv than in patients. such differences may result from muscle depth, number of data output allowing to more precise linear adjustment, or the minimum value reached during occlusion. it becomes hazardous to compare data obtained with these devices either in hv or in critically ill patients. crrt is used increasingly for the management of acute renal failure in critically ill patients. one major problem with crrt is coagulation of the filters, leading to decreased efficacy and increased costs. regional anticoagulation with citrate is an effective and established form of anticoagulation during crrt in critically ill patients ( , ) . objectives. the aim of this study was to investigate the filter life span during regional anticoagulation with citrate and regarding cost effectiveness. methods. this observational, retrospective study was performed in a mixed surgical and trauma icu in a university hospital. clinical characteristics are shown in table . citrate crrt was performed using commercially available equipment and fluid solutions (multifiltrate Ò with integrated cica Ò -system; fresenius medical care; germany). to maintain stable metabolic and hemodynamic conditions we used an internal standard protocol for citrate crrt. reimbursement for crrt is calculated on procedure related rates (according to german drg). data are shown as mean or median and standard deviation. results. f patients treated with citrate crrt from april through december were evaluated ( table ). the mean circuit lifetime of crrt for all patients was ± h (fig. ) . mean daily costs per patient were calculated as eur and mean benefit for crrt as eur (table ) . commercially available interstitial glucose sensors have already been evaluated for this purpose with promising results. however, because of the range of medications administered in the icu, potential interference with sensor performance must be characterized. to minimize the undesired offset caused by these medications, an interference rejection membrane (irm) was uniquely developed for a new subcutaneous glucose sensor for in-hospital monitoring. the novel irm was studied within the icu setting to gain a realistic picture of its performance in clinical use. objectives. acetaminophen is known to be an interfering agent for electrochemical sensors. to study the functionality of the new irm, the effect of acetaminophen on sensors worn by critically ill patients was assessed. sensor signals were characterized to identify any undesired response from the medication. methods. icu patients simultaneously wore - -day sensors that were connected to ipro tm (medtronic diabetes, northridge, ca) recorders to gather blinded sensor glucose values. patients were given acetaminophen or a mix of hydrocodone and acetaminophen during their icu stays; staff charted the exact time of each medication administration. to assess whether a signal offset would be introduced by the acetaminophen, min of sensor signals before and after medication administration were compared. the period of min was chosen based on acetaminophen's pharmacokinetic profile and the time to reach maximal plasma concentration. the normalized medians for the signal segments before and after each acetaminophen delivery were calculated. the medians formed vectors, each with elements representing signal characteristics before and after the medication deliveries. a paired t test was used to compare the vectors and assess for any effect (p \ . ) on sensor performance. across the patients evaluated for this study, acetaminophen and a mix of hydrocodone and acetaminophen were administered a total of times. one sensor was not available during a medication delivery; thus, occurrences of acetaminophen administration were analyzed. no effect on sensor signals could be identified in the instances of acetaminophen delivery. no statistically significant difference was observed between the signal segments before and after administration (p [ . ). conclusions. this study demonstrates that a novel irm effectively reduces the undesired interference of acetaminophen on a continuous glucose sensor signal during clinical use. although this analysis was focused on acetaminophen, the outcome suggests that the irm may also effectively suppress interferences from other medications administered in the icu. [ ] . however, assessing elastance requires a highly invasive vena-cava occlusion maneuver and left and right ventricle pressure/volume waveforms, which are not typically available in an intensive care unit (icu) and may raise ethical issues in regular use. a validated, lumped-parameter chamber cardiovascular system (cvs) model is used to evaluate a time-varying elastance estimate at the bedside using standard clinical measurements. objectives. to assess time-varying elastance at the bedside for the left and right ventricles using available icu data, and prove the concept on a porcine model of pulmonary embolism. five pigs had pulmonary embolism (pe) induced via injection of blood clots over h, developing full pe in stages from a healthy state. at each state several data sets were taken ( in total over pigs), measuring aortic and pulmonary artery pressure waveforms (p ao (t), p pa (t)), left and right ventricular volume and pressure waveforms (vlv(t), vrv(t), plv(t), prv(t)). at each cardiac state in inducing pe, the time-varying elastances are estimated as elv = plv/ vlv and erv = prv/vrv. these values are correlated to readily measured quantities (pao and gedv). these correlations are used to approximate time-varying elastances erv* and elv* for use in a clinically validated -chamber cvs model. note these approximations are load dependent and thus change with cardiac state. a fivefold cross validation was used to validate the model. a time-varying elastance is generated from data from pigs and used to simulate the fifth pig. simulated pv loops are compared to the originally measured pv loops to validate the approach. results. p ao (t) and elv were highly correlated over the data sets (r = . to r = . ). p ao (t) and elv, gedv and erv are also well correlated (r = . to r = . in this case we report the worldwide first use of the novel deltastream-dp -system (medos corp.) in a patient suffering from acute right heart failure due to pulmonary embolism following cardiac surgery. in a year-old male patient days after mitral valve reconstruction cardiac arrest occurred during physiotherapy treatment. after failure of restoring circulation, a short-term ecls system (lifebridge Ò ) was implanted under cardiopulmonary resuscitation by inserting cannulas in venous and arterial femoral vessels and then switched immediately to the dp -deltastream system. ct-scan revealed the diagnosis of a massive central pulmonary embolism. transesophageal echocardiography showed a dilated failing right ventricle. a thrombolytic therapy was carried out by administering mg alteplase. following ct-scan showed reduced thrombus burden. the deltastream system was carried out for h. ptt was maintained to . -fold under i.v. heparine therapy. pump blood flow was held at a maximum of . l/min ( , - , r/min) for days. despite transesophageal echocardiography showing improved left ventricular function the ecls flow was maintained for further days focussed on the improvement of right heart. further on the pump flow was reduced every h and the system could be explanted after days in now stable cardiolpulmonary situation. the patient was discharged on day at home in good state without any neurological dysfunction. overall duration of the ecls deltastream therapy was h. no system related major complication occurred during the time. even in maximum blood flow of . l/min no relevant hemolysis was measured. ldh level was only slightly elevated to - u/l. introduction. airway management has progressed dramatically in the last years but the most significant advance has been video laryngoscopy. several devices have been introduced since, the most important currently available are the glidescope Ò , c-mac Ò , mcgrath Ò , pentax airway scope Ò , airtraq Ò , among others. a common practice has been to abandon direct laryngoscope intubation (dli) after attempts and move onto advance airway devices such as video laryngoscopy which is becoming the first choice when available. although dli is successful in the majority of patients, poor glottic exposure is more likely to require prolonged or multiple intubations attempts and therefore be associated with complications such as oxygen desaturation or airway and dental injuries. in the intensive care environment an airway should always be considered a difficult airway due to scarce time to perform assessment, to make decisions and to act. should the use of video laryngoscopy be implemented as a routine for airway management in a critical care setting ? objectives. the purpose in this study was to describe for the first time the use of video laryngoscopy, specifically the vel , as a routine choice for airway management in the intensive care environment. single center, prospective observational study, from november to february , was conducted in our intensive care facility, which involved utilization of the vel for all tracheal intubations, no exclusion criteria, rapid sequence intubation (rsi) was the standard procedure. information was recorded by the operator assistant on the same day identifying timings of intubation, number of attempts, success or failure and the difficulties encountered. vel was developed in our institution in and later adopted as a standard airway management by the department of anesthesia. the device has an original mccoy blade with an attached port that holds a channel for the displacement of an optical shaft mm long, . mm in diameter with a °angle view (tekno-medical Ò germany) which is assemble to a video camera (telecandx ii, karl storz, germany), an external light source and to a -in monitor. results. there were tracheal intubations performed by operators, crash intubations and rapid sequence intubations. all intubation attempts were successful, mean number of attempts . the median time to successful intubation was s with no complications. subjective assessment post intubation showed that in all cases vocal cords were view in full, all operators manifested to feel comfortable with the handling of the apparatus but felt dependent on a assistant specially to maintain view while maneuvering the endotracheal tube. conclusions. routine airway management with vel in critical care setting is effective with a high rate of success and most important, with a positive impact for patient safety. introduction. hypovolemia is a common complication in many clinical scenarios and its detection is considered of prime importance. in previous clinical studies, tissue oxygen saturation (sto ) measured by near-infrared spectroscopy (nirs) has been explored for this purpose; however, results are disappointing. it has been suggested that the sensitivity of nirs for detection of hypovolemia might be improved when nirs is applied in combination with a vascular occlusion test (vot). nirs in combination with a vot, consisting of a -min period of arterial occlusion followed by reperfusion, allows quantification of muscle deoxygenation during ischemia (sto downslope; a measure of muscle oxygen consumption rate) and muscle reoxygenation after ischemia (sto upslope; a measure of microvascular reperfusion rate). objectives. in the present study we applied multi-site and multi-depth nirs in combination with a vot in a model of simulated central hypovolemia; lower body negative pressure (lbnp). eight healthy male subjects, with a mean ± sd age of ± years, participated in this study. the lbnp protocol consisted of a stepwise increase of lbnp from to - mmhg. stroke volume (sv), heart rate (hr), cardiac output (co), and mean arterial pressure (map) were continuously measured using near-infrared finger plethysmography (nexfin). multi-depth nirs, with probing depths * and * mm, was performed on forearm and thenar for the measurement of sto . three-min vots were performed by rapidly inflating a pneumatic cuff around the left upper arm before application of lbnp and at lbnp = - mmhg. vot-derived sto traces were analyzed for baseline, downslope, and upslope. . from baseline to lbnp = - mmhg, sv decreased from ± to ± ml (p \ . ), hr increased from ± to ± bpm (p \ . ) and co and map were maintained around baseline level. forearm sto baseline decreased significantly from ± to ± (p \ . ) and ± to ± % (p \ . ) for the and mm probing depth, respectively. forearms sto downslope, measured with the and mm probe, decreased from - . ± . to - . ± . %/min (p \ . ) and - . ± . to - . ± . (p \ . ), respectively. forearm sto upslopes remained unchanged during lbnp. vot-derived sto parameters measured on the thenar did not shown any changes as a result of lbnp. conclusions. vot-derived sto parameters measured on the forearm seem to be more sensitive to the hemodynamic changes associated with lbnp compared to sto parameters measured at the thenar. grant acknowledgment. this project was supported in part by hutchinson technologies inc. introduction. hypovolemia is a common complication in many clinical scenarios and its detection is considered of prime importance. in previous clinical studies, near-infrared spectroscopy (nirs) has been explored for this purpose; however results are conflicting due to inconsistencies in methodology with respect to nirs probing depth and site. objectives. in the present study we applied multi-site and multi-depth nirs in a model of simulated central hypovolemia; lower body negative pressure (lbnp). fifteen healthy male subjects, with a mean ± sd age of ± years, participated in this study. the lbnp protocol consisted of a stepwise increase of lbnp from to - mmhg. stroke volume (sv), heart rate (hr), cardiac output (co), and mean arterial pressure (map) were continuously measured using near-infrared finger plethysmography (nexfin). multi-depth nirs, with probing depths * and * mm, was performed on forearm and thenar for the measurement of tissue oxygen saturation (sto ). . from baseline to lbnp = - mmhg, sv decreased from ± to ± ml (p\ . ), hr increased from ± to ± bpm (p \ . ), and co and map were maintained around baseline level. forearm sto decreased significantly from ± . to ± . % (p \ . ) and ± . to ± . % (p \ . ) for the and mm probing depth, respectively. thenar sto measured with the mm probe remained unchanged, but measured with the mm probe, a decrease from ± . to ± . % (p \ . ) could be observed. conclusions. forearm sto seems to be more sensitive to (simulated) hypovolemia compared to thenar sto and the sensitivity of nirs seems to increase for increasing probing depth. grant acknowledgment. this project was supported in part by hutchinson technologies inc. introduction. sidestream dark field (sdf) is a microcirculatory imaging modality implemented in a hand-held microscope for the non-invasive bed-side visualization of the human microcirculation. despite the many studies showing the importance of microcirculatory imaging in intensive care patients the introduction of sdf imaging into routine clinical practice remains cumbersome. one of the challenges is the need for automatic analysis of the images which currently is subjective and time consuming. objectives. in the present study, we introduce a rapid automated software method for automatic quantification of microvascular density, a key microcirculatory parameter, based on sdf image contrast analysis. methods. twenty-five sequential sdf images (duration = s, resolution = pixels) were isolated from an sdf movie clip, stabilized, and averaged. subsequently, the mean ± sd gray scale intensity in a sliding pixel window was calculated and the sdvalue was assigned to the window center pixel, creating an sdf contrast image. this is a simple and rapid algorithm for vessel wall detection as a pixel window at a tissue-vessel junction will have a high sd-value due to the presence of both light tissue cells and dark red blood cells. conclusions. here, we introduce and validate a rapid automated method for quantification of microvascular density in sdf images. as this algorithm detects vessel walls rather than vessel lumen, smaller and larger vessels have similar contribution to the microvascular density assessment. a limitation, however, is that vessel diameters cannot be detected with this algorithm. the preliminary results confirm the proof of concept of the sdf image contrast analysis software, however, further research is required for its optimization. the criteria believed to be necessary for the implementation of hcs in practice were that his name would be written{ ( )}, the document dated{ ( )} and signed{ ( )}. physicians in private practice wanted date(p = . ) and signature(p = . ) more often than in institution. ( ) physicians thought that the patient must be competent at the designation' time of hcs, especially those who possess advances directives(p = . ) and a hcs(p = . ) themselves. ( ) thought the hcs should know about the patient's wishes regarding treatment and care objectives. conclusions: more than / of physicians did not know who the hcs is. more than / thought hcs useful and at least / would encourage a patient to designate one before heart surgery. about % thought that being a hcs is a too high responsibility and that the hcs could not be the best representative when needed. the potential fear this topic might induce is a barrier for this minority. introduction. the use of a daily goals chart has been shown to improve communication between the multi-disciplinary team leading to an increase in understanding of daily patient goals and a decrease in length of patient stay on the intensive care unit (icu) [ ] . we have used a daily goals chart on our icu since . we wanted to assess the value of this initiative in a general adult icu. methods. the royal cornwall hospital is a large uk district general hospital. we conducted the survey over a week period in the icu. each day, after the morning multidisciplinary ward round, the consultant in charge was asked to give the main goals for each patient. these were compared with those written on the daily goal chart, or stated by the house medical and nursing staff. they were graded as complete match ( % of consultant goals matched), partial match ( - % matched) or non match (\ % matched). results. surveys were conducted. the daily goals sheet matched the consultant completely on ( %) occasions and partially on ( %) occasions. in comparison, the combination of house medical and nursing staff had complete match on ( %) occasions and partial match on ( %) occasions. house medical staff had a % complete or partial match, house nursing staff had a % complete or partial match. overall house staff understanding of the goals set on the ward round is far better than that recorded on the goals chart. the goals related by medical and nursing staff showed differences that reflected their differing clinical priorities. combining results of all staff led to higher levels of complete match than either group independently. low levels of non-matches indicate that there is good overall understanding and communication within the team. use of daily goals charts is an effective aid to augment communication on the icu multidisciplinary ward round. objectives. to assess the effectiveness of an icu diary on post-icu psychological symptoms of patients (pts) and their families. single centre prospective study. three periods: = control ( to / ), = diary ( / to / ), = control ( / to / ). all the pts admitted c days for the first time to our medical-surgical icu were included. during the intervention period, the diary was filled both by the caregivers and the pts' relatives, without directives except for the first (medical summary) and the last (recovery wishes) ones. at icu discharge, their families were asked to fill a satisfaction questionnaire (ccfni) and the hospital anxiety and depression scale (hads), and to be contacted by phone to assess peri traumatic stress disorders [dissociation and impact of event scale-revised (ies-r)], hads at months and year after icu discharge. we excluded pts if they or their family refused to participate, were not fluent in french, or if their family was not present around the day of icu discharge. the optimal theoretical content of the diary was determined by a delphi technique involving a panel of icu and non-icu caregivers and a voluntary visitor. the content of the diaries was analysed and linked to the outcome measurements. of the admitted patients, were included. after exclusion of pts, formed the basis of the study. the content of diaries and the results of ies-r are under analysis. the year data is not yet available the saps ii at admission, icu and months post icu mortality were not significantly different between the three periods. the family satisfaction score was high and was not significantly different between the three periods. included: patients with failure of two or more organs in the first h, admitted to icu during . excluded: neurocritical and politrauma patients. contact year following discharge from; questions were asked about the patients' different perceptions during their stay in icu. if it was not possible to contact the patient, the next of kin was asked. results. patients included. general characteristics during admittance to icu: % male; age . ± . ; sofa * ± . ; apache ** ii . ± . ; apache ** iv ± . ; length of stay in icu: . ± . days; . % on invasive mechanical ventilation and . % on non-invasive mechanical ventilation. data collection was carried out over a period of ± . months, on average months (range: - months). . % ( patients) had died at the time of contact. the person interviewed was the patient in . % of the cases, the spouse in . % and immediate family (patient s parent/child/sibling) in . % of the cases. overall, . % do not have any memory of their stay in icu. for . %, the experience was unpleasant and for . % of patients the memory is very unpleasant. . % experienced fear, . % disorientation, . % a feeling of lack of hygiene, . % a feeling of suffocation/drowning (with the endotraqueal tubes, etc.), . % a lack of privacy (nudity, etc.) and . % pain during procedures. . % were very grateful for our phone interview. . % were satisfied with the staff. conclusions. in patients with high severity scores during their time in icu, less than half have memory of their stay after year. in those who do, the feeling of fear and disorientation predominates. to determine the occurrence of communication failures in clinical icus, identifying their main detection tools and disclosing their effects on patient condition. a prospective cohort was conducted in four icus of a -bed academic, tertiary-care urban hospital in sao paulo, brazil, enrolling critical ill patients older than years from july to august . communication failures were identified by daily direct observation of medical and nursing rounds and also by chart reviews. the association between communication failures and adverse event occurence was determined using multivariate logistic regression. results. among the enrolled admissions, as much as admissions ( %) were affected by communication failures, with occurrences. the vast majority of the communication problems was not registered in patient charts, and could only be identified during the medical and nursing direct monitoring. none of the identified communication failures caused patient harm. nine out of ten communication issues involved exclusively members of the multidisciplinary icu health team, patients and their relatives being seldom included in this scenario. despite communication failures are considered important adverse event risk factors, no association was identified between these two variables. conclusions. the incorporation of direct observation as a research tool for identifying untoward events was essential to the detection of communication failures in our study. almost half of the studied admissions was affected by communication flaws, most of them involving exclusively the healthcare team. nevertheless, these figures are underestimated, since the research team remained in the studied icus for no more than h a day. although patients were not harmed fortunately, the presence of these communication issues suggests the existence of important gaps in the provision of critical care. the issue regarding communication deficiencies in icus setting affecting patient safety deserves attention. relatives of patients in the intensive care unit (icu) are exposed to considerable stress . effective communication with relatives has been shown to provide support and minimise stress whilst improving their wellbeing and decision making for critically ill patients . furthermore, satisfaction is dependent on communication by a senior caregiver . no published guideline or recommendation exists for when relatives should be first spoken to, how often they should be updated, or how these conversations should be documented. to determine how well relatives of patients in the icu are kept informed and to assess the quality of documentation. we retrospectively analysed data from the metavision Ò clinical information system of patients staying over days during / / - / / on the -bed icu at the nnuh. data obtained from the 'relatives communication' page included: when relatives were first spoken to, how often they were spoken to (according to the number of entries made) and the members of staff involved in the conversations. these variables were analysed in relation to patient outcome and length of stay on the icu. . patients were analysed. communication with relatives was not documented in % of patients. % of communication was carried out by a consultant. discussions were more likely to occur with relatives of patients who died; % compared to % of patients discharged to the ward. similarly, relatives of patients who died were spoken to more frequently; % were talked to on more than one occasion compared to % of patients surviving to discharge. relatives were more likely to be spoken to with an increased duration of admission on the icu; communication occurred with only half the relatives of patients staying - days, compared to % of those staying more than days. two-thirds of relatives of patients staying more than days were not communicated with until after the fourth day of admission, although the majority of these were spoken to on numerous occasions and all were seen by a consultant. relatives of patients dying on the icu are more likely to be communicated with, and are updated more often than those of patients surviving to discharge. a delay in communication with relatives of patients staying more than days on the icu was noted, but conversations occurred more regularly and involved a consultant. we suspect that our results demonstrate a lack of documentation rather than actual communication; auditing relatives' satisfaction with communication on the icu may help clarify areas for improvement. assessment of satisfaction with the quality of care provided to patients hospitalized in intensive care units, in most cases, is transferred to the relatives of the same, given the context of the patient himself unable to speak. the diagnosis of the needs of families of critically ill patients has been the subject of several studies. aiming to assess the needs of relatives of patients admitted to the picu (polivalent intensive care unit), we conducted studies in particular through an adapted version of the questionnaire ccfni (critical care family needs inventory) developed from the adaptation made by johnson and col. ( ) and focus group. one of the needs identified in these studies was to improve information about what happens in the picu. with this in mind we designed a manual to support relatives in order to improve communication and understanding in the context of the intensive care unit. objectives. this study aims to assess the impact on the level of family satisfaction of a manual we've created. the manual is available from january to all visitors at the entrance of that unit. the questionnaire was mailed to all families who had a family member hospitalized in the picu during the year following the introduction of the manual. together followed a letter to present the study and a stamped and addressed envelope for their return. beyond the satisfaction and access to the manual or not, were collected socio-demographic data from relatives and socio-demographic and clinical data of patients. we obtained responses, representing % of all potential families. questionnaires were returned because of address failure ( . %). statistical analysis was performed using spss Ò v. . results. the satisfaction of family members who had access to the manual was better in all dimensions tested (support, comfort, information, access, trust), and with a statistically significant difference (p \ . ). this difference was clearer in the fields support (med , / . ) and information ( . / . ). conclusions. the impact of the manual on the improvement of family satisfaction was positive in the various dimensions assessed. the questionnaire of family satisfaction monitoring and understanding of information given through a manual created by us can contribute to a better understanding of the needs of families and hence for the continued improvement of service quality. johnson introduction. the burnout can be defined in its multidimensionality: emotional exhaustion, understood as a feeling of exhaustion and failure of the person to give more of herself; depersonalization, in which the person's relationship with patients and with colleagues becomes cold, distant and guided by some cynicism, lack of personal and professional completion, which may manifest itself, on one hand, by the sense of incompetence and inability to respond to requests or, on the other hand, by the sense of omnipotence. the provision of intensive care can lead to health care provider's physical, psychological and emotional exhaustion, which may develop to burnout. we notice the absence of specific studies on this syndrome, in portuguese intensive care units. objectives. the study here presented intend to identify the levels of burnout of physicians and nurses working in portuguese intensive care (adult polyvalent units in the north of the country), and to identify factors that can lead to the development of burnout in the portuguese physicians and nurses working in that setting. the methodology presented consist of application of a questionnaire for self fulfilment with items: , socio-demographic data of the study population; , experiences in the workplace; , maslach burnout inventory-general survey. for the application of methodological tools, we requested the authorization by the competent institutional bodies: the board, ethics committee and directors of services. the professionals who participated in the study were asked informed consent, whether in formal or informal. in addition, each instrument was accompanied by a cover sheet of the same. we have also done observation of the work contexts, and interviews. in this study we will focus on the results of the questionnaire. . sample: hospitals with a total of intensive care units. professionals participants in the study , physicians nurses. the mean ages of respondents , of professional experience years and of experience in intensive care were years. mbi preliminary results:distribution of levels of burnout by occupational category: at the moment, portuguese physicians and nurses who work in intensive care units seam to have medium levels of burnout, obtained through the mbi. results show higher levels at emotional exhaustion in nurses never less in general they showed higher personal and professional completion than physicians. depersonalization were higher in physicians. the results presented here underline the importance of promoting the prevention of burnout at intensive care. the development of the burnout syndrome in physicians and nurses in intensive care has serious consequences, both for themselves, or the consequences that entails for patients and their families. introduction. the hospitalization of a member of the family in the intensive care unit (icu) usually occurs in an acutely and inadvertent way, leaving little time for a family adjustment. facing the stressful situation, the family may feel disorganized, helpless and with difficulties to mobilize themselves, enabling the rise of different types of needs. the scope of those needs leads to the alleviation of tension and uncertainties that could provide to the family the stability needed to cope with the situation disease . to identify the needs of care of family members with persons admitted to the icu. methods. this is a transversal study, held in two icus (a public one and a private one) in the city of feira de santana, bahia, brazil, after approval by ethics and research committees. the relative person is understood by the person who had consanguinity ties or who was closest to the patient, who lived with him and had close relationships. relatives were interviewed when his relative was over h of hospitalization. the the brazilian adaptation of the critical care family need inventory (inefti) was used for measuring the degree of importance, once it has items distributed in five dimensions. descriptive statistics were used for analysis. the inefti reliability was satisfactory (cronbach a = . ). results. the needs of care considered most important by family members were those related to the security dimension, expressed by the items ''to know what are the chances of improvement of the patient'' ( . ± . ), ''to be informed about everything that relates to the evolution of the patient'' ( . ± . ) and ''to feel that hospital people care about the patient'' ( . ± . ). in the category information, the item ''be able to talk to the doctor everyday'' ( . ± . ) obtained more average. in the category proximity was consider more important to ''see the patient frequently'' ( . ± . ). the needs of the categories support and comfort categories showed lower scores. these results are similar to those presented by literature , , what confirms the appreciation of the family to the aspects related to the recovery of the hospitalized relative, in detriment of their own needs. conclusions. having security, information and being around its ill relative is what the families need. the security is provided by the conviction that the person receives the best care in the pharmacological, technological and human aspects, and can be perceived by the information transmitted by the team and by the proximity established in the interaction with the sick relative. a collaborative project was developed between the itu clinical staff of a large, inner city teaching hospital, palliative care clinicians and an academic department of palliative care. qualitative data collection included: (i) semi-structured interviews with staff and relatives of patients thought to be at the end of life; (ii) focus groups with staff (iii) observation of care and (iv) clinical note review. data was analysed using the framework approach to identify key themes. results. semi-structured interviews were carried out with staff and focus groups took place. a total of relatives, representing patients thought to be at the end of life, were interviewed. half the patients represented were female, with diagnoses including infection, hypoxic brain injury, malignancy and liver failure. the participants were aged - and included a range of ethnic groups and religious affiliations. non-participant observations of care took place for and clinical note review for of these patients. data from the interviews with staff describe that an existing withdrawal of treatment document was working well but could be developed further along with suggestions for amendments. the interviews with relatives, observations and review of clinical notes show key themes: communication, decision-making, patient and family needs, and symptoms and their management. through discussion at itu end of life group meetings, a consensus was reached to pilot a complex intervention comprising an amended withdrawal document; a psychosocial assessment; education and awareness-raising; palliative care team input and increased psychosocial support. the psychosocial assessment document was deemed valuable to all patients and was rolled out for all patients admitted to itu. initial evaluation shows greater staff awareness. documentation of end of life issues and the collaborative research process has improved communication between itu and palliative care staff. introduction. consumer-centric healthcare is a key component of nhs policy. when patients are critically ill, family members act as surrogates. family members alone may inform patients of events that occurred, and provide physical, emotional and socioeconomic support during rehabilitation. thus, high family satisfaction (fs) is important. the fs-icu instrument was developed in canada to quantify family satisfaction and benchmark intensive care units (icus). we have piloted and validated previously an adaptation of the fs-icu such that its language was appropriate for the uk . to date, no intervention has demonstrated improvement in the fs-icu for a critical care unit. we hypothesise that provider-driven interventions fail to recognise central issues. co-production is a framework that enables creation of parity between providers and consumers by validating both individual worth and specialised knowledge . there are no published data on the use of co-production in intensive care. we undertook to co-produce interventions targeted to improve family satisfaction. the fs-icu instrument will be used as an objective measure of their efficacy. objectives. to co-produce some interventions targeted to improve family satisfaction and to use the fs-icu instrument as an objective measure of their efficacy. methods. fs-icu questionnaire responses were used to highlight potential areas for service development. focused interviews with families provided detailed descriptions of the ''the way the icu works''. these data were used to build exercises for a workshop of service users and providers which aimed to co-produce service developments. results. fs-icu questionnaires were received over the months to april ( % response). quality and consistency of communication between icu doctors and relatives; the level of relatives' inclusion in decision-making processes; and the icu waiting room atmosphere were identified as needing improvement. four families were interviewed in detail. workshop participants included trust directors, managers, clinicians, nurses, patients and their families. proposed interventions from the workshop included: development of a non-clinical family liaison officer role with a dedicated contact number; increasing focus on managing patients' and relatives' expectations of care delivery; specific improvements to the waiting room area. intensive care patients' relatives provided a unique insight into the icu functioning that should be utilised as a resource. co-production was used to design service improvements that may not have been obvious from a provider perspective. workshop transactions were empowering for both staff members and patients' families, generating social capital that creates and improves social provider-consumer networks, now and in the future. to evaluate the degree of satisfaction of icu patients regarding their icu stay. as the result of a fund sponsored by former patients and their relatives, our dept of intensive care is able to provide a small team of assistants to welcome and accompany the relatives of icu patients. one role of this team is to collect and evaluate impressions and criticisms from patients and relatives shortly after the icu stay. we studied a convenience sample of icu patients who stayed in our multidisciplinary dept of intensive care between september and april . the evaluation included simple questions about the welcome (friendliness of the personnel, explanations), quality of care (including pain control, attention to patient needs, availability of nurses and speed of response) and comfort (temperature, light, noise). data were analyzed using non-parametric (mann-whitney) and chi tests. we collected answers from of patients ( were incapacitated, had died and declined), including unplanned admissions and patients after major surgery. more than % of the patients were very satisfied with all items, except for information provided by the attending physician ( % of patients) and the room temperature ( % of patients) (figure ). post-icu enquiries can provide valuable feed-back information that could improve the quality of care in the icu. introduction. previous research suggests that family members of critically ill patients hospitalized in the icu frequently suffer from severe anxiety. a survey conducted in our unit-a -bed, university-affiliated tertiary-care, closed, general icu with restricted visiting hours-revealed a willingness of family members to participate in a support group. such a group was recently introduced and we report on our initial experience over the last year. methods. the purpose of the support group was to provide a forum where family members could freely raise any topic related to the care of their loved one as well as to family-related issues. the meetings were held weekly in the icu and chaired by a senior nurse and the unit social worker. family members were informed of the meetings when the patient was admitted to the icu and notifications were placed in the family waiting room. all family members were encouraged to take part and to raise any topic they felt was relevant. results. since its introduction in , there has been an increase in the percentage of a family representative attending the meetings from to %. the most frequently raised issues included staff-family interaction (especially lack of empathy), lack of information regarding the patient's status and prognosis, and the lack of adequate visiting hours. in addition, other issues included technical aspect related directly to the family, in particular, overcrowding and lack of privacy in the waiting room. finally, participants wanted to learn skills in order to cope with their new and uncertain circumstance. we have noted an ongoing readiness of family members to take part in the support group. the issues raised have and will allow us to make appropriate changes and to improve the current situation. in particular, the meetings help us to identify family members at risk who require more immediate and personal attention. introduction. the soap study suggested outcomes of cancer patients admitted to icu are similar to those without cancer in contrast to other reports . we wanted to compare this with our own experience. ( ) to determine critical care and hospital outcome of patients with malignancy referred to critical care in the previous years. ( ) to identify any factors influencing treatment decisions and survival after admission. retrospective chart review of patients undergoing treatment for malignancy admitted to icu for medical or surgical reasons from may to feb . leukaemia patients were not included as they are treated at a different hospital by a different group of clinicians. demographic information, tumour/treatment related factors e.g neutropenia, preadmission status and critical care diagnoses e.g. sepsis, were collected in addition to patient outcomes. results. patients were identified ( . % of all critical care admissions). itu mortality was . % (n = ), however only . % (n = ) survived to hospital discharge (comparable overall unit mortality: - %, hospital mortality: %). hospital survivors were younger (median . vs. years), and more non-survivors had pre-existing comorbidities, sepsis, ali and required more organ support (all ns). there was no difference between the groups regarding cancer treatment. non-survivors had a longer stay in critical care and treatment withdrawal/limitation decisions were more common suggesting these were often based on lack of medical progress whilst on icu rather than diagnostic nihilism. hospital mortality in patients with malignancy is higher in our specialist centre than reported for a europe wide cohort ( . vs. % overall and % in the medical subgroup). the majority of our patients were medical and not post-surgical unlike in the soap study. this may account for the greater mortality as a larger proportion of our patients had ali, sepsis, neutropenia and required inotropes. numbers admitted to critical care are much smaller than the . % reported in the soap study, suggesting some referral and admission triaging by the oncologists and the icu team. our results are similar to single centre french (hospital survival rate . vs. . %) and brazilian studies ( . vs. %), although a majority of our patients did not receive mechanical ventilation. , a diagnosis of cancer or active treatment for it should not be the major determinant of critical care support, but the patient's general premorbid status and the extent of organ failures appear to be important factors in decision making as for any other critical care patient. figures from the soap study for non specialist centres do not appear to reflect the experience of specialist oncology centres. historically there has been a negative perception of the prognosis for patients with haematological malignancies requiring admission to the intensive care unit (icu). however, advances in chemotherapeutic regimes and haematopoietic stem cell transplantation (hsct), along with improved monitoring and supportive measures have suggested that outcomes for these patients have improved [ ] . establishing key prognostic indicators predictive of outcome may be useful in identifying patients most likely to benefit from icu therapy. the aim of this study was to describe clinical outcomes and identify prognostic factors in patients with haematological malignancy requiring admission to icu. following research approval, a retrospective cohort study was undertaken in a -bedded specialist cancer icu over a -year period (october -september . recorded patient variables included demographics, haematological diagnosis, reason for icu admission, hsct, apache ii, admission laboratory data, number of organ failure, use of invasive mechanical ventilation, renal replacement therapy (rrt) and vasopressors. the primary outcome was in-hospital mortality. key prognostic variables in determining inhospital mortality were identified using univariate and multivariate analysis. results. patients with haematological malignancies were admitted to the icu during the study period: mean age . (sd . ); . % female; haematological diagnosis ( . % leukaemia, . % lymphoma, and . % myeloma); . % emergency admissions and . % were post-hsct. mean apache ii was . (sd . ), mean number of organ failures . (sd . ), % required invasive mechanical ventilation, . % rrt and . % vasopressor therapy in the first h of icu admission. icu, in-hospital and -month mortality were . , . and % respectively. significantly higher mortalities were seen in patients who were mechanically ventilated ( vs. % non-ventilated patients p \ . ), on vasopressor support ( vs. % no vasopressor support p \ . ), neutropenic ( vs. % non-neutropenic p \ . ) and in multi-organ failure defined as c organ failures ( deaths vs. deaths in patients with b organ failure, p \ . ). univariate analysis revealed mechanical ventilation, vasopressor support, albumin \ g/l, neutropenia, platelet count \ /l and multi-organ failure were all significant with p values . , . , . , . , . and. respectively. multivariate analysis revealed that multi-organ failure was the only independent prognostic predictor of in-hospital mortality. conclusion. mechanical ventilation, apache ii, vasopressor support, albumin\ g/l, neutropenia, platelets \ /l and multi-organ failure all had a significant association with mortality; however multi-organ failure was the only independent factor that predicted poor outcome. c.y.c. michael , a. vasu , s. eillyne tan tock seng hospital, emergency department, singapore, singapore introduction. coronary heart disease is the leading cause of mortality and morbidity for both women and men. although men are affected in greater numbers, women have been shown to have worse outcomes and higher mortality. objectives. this study aims to examine gender differences in risk factors, angiographic severity, treatment and in-hospital mortality after stemi. methods. in this retrospective study, the medical records of patients with an admitting diagnosis of stemi from tan tock seng hospital, emergency department (ttsh ed) between st january and st december were reviewed. we extracted the data from the electronic records of the emergency case notes and inpatient discharge summaries. results. of the patients studied, ( . %) were women and ( . %) men. four hundred and forty-nine ( . %) patients underwent coronary angiography. one hundred and seventy ( . %) patients did not undergo coronary angiography, majority ( . %) were elderly aged c years (men . % and women . %). between women and men, there was no significant difference between the number and distribution of diseased coronary vessels (including triple vessel and left main stem diseases). regardless of age, men were frequently treated with a coronary artery stent ( . %). elderly women (aged c years) were more often treated conservatively ( %) while those younger women (aged b years) were frequently treated with a coronary artery stent ( . %). in-hospital mortality rate was significantly higher for women than men ( . vs. . %, p = . ). amongst the patients treated conservatively, elderly women had the highest in-hospital mortality when compared to the other patients (women c years . vs. women b years . %; men c years vs. men b years . %). compared to men, women were significantly older (p \ . ; % ci . - . ) , more likely to have a history of hypertension ( . vs. . %; p \ . ), diabetes ( . vs. . %; p \ . ), hyperlipidemia ( . vs. . %; p = . ), peripheral vascular ( . vs. . %; p = . ) or ischemic heart diseases ( . vs. . %; p = . ) and less likely to be smokers ( . vs. . %; p \ . ) or consume alcohol ( vs. . %; p \ . ). conclusions. elderly women who were treated conservatively had the highest in-hospital mortality during the early management of stemi. hôpital saint-louis, ap-hp, paris diderot university, hematology department, paris, france introduction. aml is considered as an oncology emergency as a proportion of patients experience life threatening complications within the first hours or days after diagnosis. early death had been shown to be statistically related to high white blood cell (wbc) and monoblastic leukemia - , with leukostasis and lysis syndrome as the most deadful events. objectives. to evaluate the relationship between timing of icu admission and outcomes in high risk aml patients at the earliest phase of the malignancy (before any chemotherapy) methods. retrospective study in a tertiary care teaching hospital. adult patients with newly diagnoses aml from to were included. patients admitted for an immediate life sustaining therapy (ventilation, vasopressors or renal replacement therapy) were excluded. patients admitted directly to the icu (early admission) were matched for age, wbc and fab subtype with patients primarily admitted in hematology ward. datasets were extracted from medical charts. results. patients were included ( early admitted to the icu and admitted first to the wards). median follow up was . months. median age was . years ( - ). fab m or m was retrieved in % of the patients. karyotype was favorable for % and poor for %. median wbc was l - . no statistical difference was seen for demographic and hematological parameters between early admitted patients and matched controls. among the patients admitted first to the wards (controls), were subsequently admitted to the icu (lately admitted) and remained in ward during the entire treatment course (never admitted). the median time between diagnostic and icu admission of this last group was ( - ) days. strikingly, patients lately admitted had more frequently dyspnea,oxygen requirement, high respiratory rate, low diastolic arterial pressure and lower first h urine output. lately admitted patients were less likely to receive the complete dose of induction chemotherapy ( vs. %) furthermore, late admission resulted in increased use of invasive mechanical ventilation ( vs. %) and vaso-active drugs ( vs. %). these differences resulted in longer stay in icu and decreased survival. conclusion. patients at the earliest phase of high risk aml who are lately admitted to the icu experience worse outcomes, with increased use of life-sustaining therapies and higher mortality, compared to patients early admitted to the icu. physiologic parameters at the time of aml diagnosis such as respiratory rate, diastolic blood pressure, spo , or oxygen need are likely to help clinicians distinguish those patients at risk of late icu admission and subsequent adverse outcomes. studies are needed to assess the right place for newly diagnosed aml with physiological abnormalities but no organ dysfunction. atrial fibrillation (af) is the most common sustained tachyarrhythmia in the community. it has a prevalence of * % in those over years of age ( ) . the chronic health consequences of chronic af are significant. it can cause impaired cardiac function, a fivefold increased risk of stroke and decreased life expectancy ( ) . af is also the commonest arrhythmia in the critically ill, though a recent systematic review ( ) was unable to recommend evidence based standards due to the heterogeneity of the studies. objectives. a retrospective cohort study to assess the impact that chronic af has on the outcome from critical illness. methods. all patients admitted with chronic af between / / and / / were identified. we recorded age, apache ii and predicted hospital mortality, actual icu and hospital mortality, past medical history, admitting diagnosis, medication, echo findings, anticoagulants given, therapy instituted, and any further events between icu and hospital discharge. the only data collected for the patients who did not develop af was their age, apache ii and predicted hospital mortality and actual icu and hospital mortality. data analysis using chi square test and mann-whitney u test were used where appropriate. results. patients were admitted to the icu over the study period, of which had a history of chronic af ( . %), the remaining results are shown in table . chronic af had a prevalence of . %, in keeping with previous studies, and the mean age in the chronic af group was significantly higher. interestingly, there was no difference in icu and hospital mortality between the groups. despite the chronic af group being older with significantly worse apache ii scores. indeed the hospital mortality ( . %) of those patients admitted with chronic af was over % less than predicted hospital mortality ( . %). why patients with chronic af are outperforming expectation is not clear. it could be that apache ii is over estimating the severity of illness in these individuals, or is there something about the way chronic af is treated that affects the response to critical illness, for example, anticoagulation therapy? one of the major outcome measurements in burns centers is still mortality after severe burns. there are many predictive factors in admission as well as factors that are related with all the course of the disease responsible for survival after severe burn. many centers have a minimum standard of burn survival or la (the body surface area that kills % of people) and also have generated computer models of death probabilities based on age and tbsa (total body surface area) burned. objectives. to evaluate the outcome of the severely burned patients treated in the burn center and to develop a predictive model for survival from major burns in albania. the medical records of all acute burn patients admitted to the burn center of the university hospital center ''mother teresa'' in tirana, albania are reviewed retrospectively. statistical analyses are conducted using spss version . logistic regression is used for the prediction of death probability for two risk variables, tbsa burned and age. based on the index of evidence the variables are grouped in significant strata, from to for each variable. logistic regression equation is: where z = , - , age - , age - , age - , age + , tbsa - , tbsa - , tbsa - , tbsa after calculating the probability of death for each record, we have done respective grouping according the mortality from - %. results. during - are admitted altogether , patients in the burn center. overall mortality in icu is . % with a significant reduction during the years, up to . in . row burn mortality is . for , persons per year. la for children is % tbsa; for adults % tbsa and for aged % tbsa. based on probability of death, we notice that older age and larger burn size are associated with a higher like hood of mortality. figure gives an overview of death probability in our burn center. conclusions. the mortality reduction speaks up for a better work of our staff toward the patients. the predictive model may assist all the burn team to identify the crucial determinants of clinical outcome to establish a real basis for treatment standards and to allow future comparisons of new treatment strategies. ( ) in mechanically ventilated (mv) critically ill patients. methods. prospective observational multicenter study during weeks in november . consecutive patients admitted to the participating icus and requiring mv for at least h were included. maximal, minimal and mean intra-abdominal pressure (iap), were recorded on day , , and . iah was defined as mean iap c mmhg/ h at least day. following risk factors were recorded if evident during the first icu day or immediately before: respiratory failure, abdominal surgery with fascial closure, damage control laparatomy, major trauma/burns, prone positioning, gastroparesis, ileus, colonic pseudo-obstruction, ascites, hemo/pneumoperitoneum, intra-abdominal fluid collection, acidosis (ph \ . ), hypothermia (core t°\ °c), massive transfusion ([ u of packed red cells/ h), massive fluid resuscitation ([ l/ h), coagulopathy, oliguria and sepsis. results. patients from icus were included; mean apache ii score on admission was . ( . ) and -day mortality %. mean number of iap measurements was . per day. iah occurred in patients ( . %). only pt ( . %) had none of the studied risk factors, nevertheless % of them still developed iah. of the patients with or more risk factors, only . % developed iah (table ) . objectives. to describe the icu admission of our hospital for serious complications of hematology patients in the last years. compare the characteristics of these patients throughout the study period. analyze mortality and their evolution from their admission to the icu. the evolution of hematologic patients has improved in recent years due to better supportive treatment, sometimes involving the use of specific treatments in the icu. a retrospective study of medical records of all patients with hematologic diseases were admitted to our icu from april until may . we excluded patients admitted for channeling central catheter, diagnostic tests and bone marrow transplants. we selected a total of patients ( % male) with a mean age of years (range - ). the main hematological diagnoses were the most common aml ( %), acute lymphatic leukemia ( %), lymphoma (non-hodgkin's lymphoma) ( %), coagulopathy ( %), myelodysplastic syndrome ( %) and myeloma multiple ( %). the principal reason for admission in the unit were: acute respiratory failure ( %), followed by sepsis ( %) and less cns and cardiac problems ( and %) respectively. as important risk factors of neutropenia and peripheral blood stem cells after transplantation. the icu mortality reached . %. the average stay was . days. conclusions. the transfer to the icu allows a high percentage of hematological patients survive severe complications and the benefit continues after discharge. the mortality of icu patients in our series has not changed over the past years, keeping both the characteristics of patients transferred. the consensus among the services of hematology and intensive care is essential to select and treat the best candidates to benefit from support in the icu and to improve current survival results. a retrospective (from to ) and prospective (from to ) analysis of obstetric patients (pregnant or postpartum admissions) admitted in our ccd was performed. results are expressed as mean (standard deviation) or frequency (percentage). chi and t student tests were used for statistical analysis according to the different variables (spss . , inc. chicago, il), accepting a p-value . as significant. results. obstetric patients were included. mean maternal age was . ( . ) years and mean gestational age was . ( ) weeks. apache ii score was . ( ) . ( . %) patients were admitted to ccd due to an obstetric cause. the main diagnosis of this group were thrombotic microangiopathies ( . %) and hemorrhagic shock ( . %). thrombotic microangiopathy included ( %) eclampsia-preeclampsia, ( %) acute fatty liver, ( %) hellp syndrome and ( %) ptt-shu. in the remaining . % ( patients) the main reason for ccd admission not related to the pregnancy was respiratory failure ( . %). from the whole population included, patients ( . %) required mechanical ventilation (mv) with a mean duration of . ( . ) days. furthermore, ( . %) patients required surgical intervention ( . % hysterectomy). the ending of pregnancy was made in patients ( . %), most cases by caesarean . % ( patients). mean length of stay in ccd was . ( . ) days. maternal mortality was . % ( patients), basically in the non-obstetric group ( vs. ) . conclusions. this is a large series of young obstetric critically ill patients with a low mortality. however, a non-depreciable part of the population included presented important morbidity. objectives. to identify the association of co-morbidities with mortality. methods. retrospective analysis of clinical process of diagnosing patients with severe sepsis/septic shock admitted to the intensive care unit (icu) in the period of november to october . we collected demographic data, co-morbidities, and mortality in the icu hospitalization. statistical tests used were student's t and chi-square. we analyzed patients admitted with this diagnosis, median age of years and females . %. in . % ( patients) appear co-morbidities, distributed as follows: hypertension . %, . % diabetes mellitus, cerebrovascular disease . %, . % chronic kidney disease; . % neoplasic disease and chronic obstructive pulmonary disease . %. the mean age ( . , p \ . ) was higher in this group. the overall mortality in the icu was . % that has not increased significantly to . % in the group with comorbidities, and the overall in-hospital mortality was . % and rise significantly to . % (p \ . ). conclusions. in our study, around - patients had co-morbidities and these facts and the age were those who contributed to higher mortality. the factors of greatest weight are those related to metabolic disease. the characterization of chronic illness in the icu is important in future larger epidemiological studies to better characterize this group of patients and the factors predictive of mortality to decrease the suffering of the patient and plan for admission to intensive care units. one year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study. introduction. despite the advances in respect to the development of objective criteria for admission of patients with hematologic malignancies to intensive care unit (icu), no evidence exists that they contributed to a reduction in the mortality, which depends from the aggressiveness of the cancer itself, its complications and even as a consequence of therapy. since the decision to admit one of these patients in icus involves a complex decision-making process, it becomes imperative to identify predictors that may help the clinician to discriminate the patients who may benefit from intensive care than those in which intensive care will be associated with just a prolongation of an agony. objectives.: to identify early prognostic factors in the admission of patients with hematological malignancy, admitted in the icu of a central university hospital. analysis of data prospectively collected and registered in a database of patients with hematological malignancy, admitted to the icu between january and december . we collected for each patient demographic and clinical data (age, sex, length of stay, origin, previous treatment, stage of disease at admission, type of malignancy and aggressiveness, organ dysfunction at admission, co-morbidities, reason of admission), general severity scores (saps ii and apache ii) and organ dysfunction scores (sofa at admission to the icu, maximum sofa score and delta sofa). specific variables were correlated with mortality at the icu and hospital discharge. results. patients ( males and females) fulfilled the inclusion criteria. the average age was ± . years ( - years). the type of hematological malignancy was acute leukemia ( . %), multiple myeloma ( . %), myelodysplastic syndrome ( . %), chronic leukemia ( . %), low grade non-hodgkin lymphoma ( . %), high grade non-hodgkin lymphoma ( . %). the average length of stay in the hospital was . ± . days. most patients were admitted from the department of hemato-oncology ward of the hospital ( . %), . % of the emergency department and . % of another hospital. the icu mortality was . %, with a corresponding hospital mortality of . %. the discriminative capacity of the severity scores, as assessed by the area under the roc curve (aroc) was . for saps ii and . for apache ii. for the delta sofa calculated for each organ dysfunction, progression of respiratory dysfunction/failure and cardiovascular failure demonstrated the best discriminative power (aroc of . ). conclusions. none of the variables showed a statistically acceptable relationship with icu or hospital mortality. the general severity indices saps ii and apache ii demonstrated a better discriminative power than the multiple organ failure scores. however, in this group of patients,it is still difficult to know objectively what factor or combination of factors may be useful in deciding the admission of the patient in an icu. recently due to new developments in interventional gastroenterology and new therapeutic options for treatment, gastroenterological and hepatological (geh) admissions to acute care settings has been decreased. for general intensive care units (icu) gastroenterological and hepatological (geh) diseases consititutes the minority of icu admissions. so we planned to find the incidence and clinical course of admissions due to geh complaints in a medical icu. objectives. main objective is to analyze clinical and epidemiological features of patients admitted to icu with geh disorders. other objectives are to analyze the mortality rate and the factors contributing mortality in these patients. and who stayed for more than h were included. the prospectively developed data including demographics, prognostic scores and clinical features of patients were analyzed retrospectively. patients with geh disorders consituted % of patients admitted to icu. one hundred thirthythree patients with an age of [ - ] years and gender of % male were included. more than half of these patients ( %) did not have any chronic geh disease. the patients were admitted most often from the emergency department ( %). the most frequent admission diagnosis was gastrointestinal bleeding ( %) followed by hepatic diseases including hepatic failure and acute hepatic encepahalopathy, biliary tract infection ( %), pancreatitis ( %) and enteric diseases including massive diarrhea and bowel obstruction ( %). on admission median apache ii and glasgow coma scores were [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , respectively. acute kidney injury (defined by rifle criteria risc, injury or failure) was found in (% ) patients. the most common rifle class was class failure ( %). during icu stay patients ( %) needed renal replacement therapy and patients ( %) received mechanical ventilation. nosocomial infection developed in ( %) patients and icu aqıired severe sepsis occured in ( %) patients. icu and hospital mortality were % and % respectively. length of icu and hospital stays were [ ] [ ] [ ] [ ] [ ] [ ] and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] days respectively. respiratory failure requiring mechanical ventilation, acute renal failure on admission and severe sepsis in the icu were found to be the independent factors determining mortality in these patients (p = . , p = . and p = . respectively). patients with geh constitued % of patients admitted to icu. they usually do not have any chronic geh disease. gastrointestinal bleeding is the most frequent admission diagnosis. respiratuar and renal failure on admission and severe sepsis occured in the icu are the major determinats of mortality in these patients. introduction. in recent years described series with hematological patients in icu, but these studies are often limited because they are retrospective, single center in a few patients divided over many years. to determine the characteristics of mortality in this group is very important to assess their management in the icu. objective. to analyze prognostic factors associated with icu mortality of patients (pts) with hematologic malignancies admitted to the intensive care unit (ptu). method. an observational, transversal, prospective, multicenter oct conducted between june and october . we conducted a descriptive analysis, chi-square, bivariate and logistic regression including variables with a value of p \ . with the sas statistical pauet to assess the factors influencing mortality in icu. we included patients from icus. the mean age was years. the apache ii at admission was . ± . ) and the first day sofa ± . . ( . - . ). the crude mortality icu was . % ( pts). we divide related mortality by infectious etiology ( %) versus other causes ( %). in univariate analysis the variables significantly associated with mortality were: males p \ . , hematology plant from . , . multiple myeloma, respiratory failure at admission . , tachycardia, . , . hypothermia, tachypnea , apache ii c , more than two organ failures . , presence of ards \ . , invasive mechanical ventilation (imv) \ . , niv . , . transfusion (of all products: red cells, platelets and plasma), acquisition intrauci infection . , days longer stay in icu . . the presence of neutropenia was not associated (p = . ) at a significantly higher mortality, or personal history, septic shock, bone marrow transplant or other reasons for admission to the icu. table describe the independent factors associated with mortality in logistic regression analysis. variables classics such as septic shock or neutropenia not associated with mortality. and the independent variables associated with increased icu mortality were: vm, ards, severity and need for transfusion of blood products. results. patients were identified. major haematology diagnoses were acute leukaemia %, nhl % and lymphoma %. mean time to icu admission was . days with % admitted within h. the commonest reasons for icu admission were respiratory failure %, sepsis % and acute renal failure %. the mean number of organs supported was . . % of patients had c organ failure. mean apache ii score was . . increasing organ failure correlated with increasing mortality. patients with or organ failure had % mortality. mean icu stay was days with % having an icu stay of less than h. icu mortality rate was . %. . % received invasive ventilation, . % failed non-invasive ventilation (niv) and required invasive ventilation, . % had niv only and % received no respiratory support. vasoactive support was given to . % and rrt to . %. invasive ventilation and niv were associated with a higher mortality; and % versus % in spontaneously ventilating patients. vasoactive support was associated with more organ failure, longer icu stay and higher mortality. rrt was associated with a higher mortality versus %. patients with a documented poor haematological prognosis had a higher mortality but also more organs supported. conclusions. from this study invasive ventilation, cardiovascular support and multiorgan failure are strongly associated with increased mortality. the need for rrt was not an independent predictor of mortality. close collaboration is needed between the specialities to allow early resuscitation and critical care support to avoid delayed admissions with multi organ failure. introduction. the prescription of stress ulcer prophylaxis (sup) in critically ill patients is relatively commonplace due to the association between physiological stress and gastrointestinal (g.i.) bleeding. however, recent guidelines recommend that only patients who are mechanically ventilated, and/or have a coagulopathy warrant prophylaxis. they also state that histamine receptor blockers (h rb's) can be used primarily for sup ( ). objectives. the aim of this audit was to compare prescription practice of sup at the itu/hdu at mayday hospital with those set out in the guidelines and to calculate the potential cost savings resulting from following these guidelines. methods. data prospectively collected from consecutive admissions to mayday hospital itu/hdu between october and november . . data was collected on patients, had a g.i. bleed on admission, and were already on sup so were excluded. of ( %) patients with major risk factors were prescribed sup, compared with of ( %) patients with no major risk factors. proton pump inhibitors (ppi's) were prescribed preferentially to h rb's; versus . the cost of sup during the audit period was £ , . if we had only prescribed it to those at high risk the cost would have been £ , . , and if we had only used h rb's the cost would have been £ . . prescribing of sup in our unit does not reflect quenot's guidelines. this not only represents an increased cost but there are increased rates of nosocomial pneumonia and c. difficile diarrhoea associated with sup ( , ) . there is little evidence showing the superiority of ppi's over h rbs in the prophylaxis of bleeds; and there is evidence of an increased rate of the aforementioned infections with ppi's as compared to h rb's ( ). we prescribed ppi's to a significant majority of our patients; however, it is our opinion that our current unit practice is not dissimilar to that of the rest of the uk. we would encourage all critical care units to review their sup prescribing as our results show that significant savings can be made with judicious prescription of these drugs. . surprisingly little is published on the cost of drug treatment for critically ill patients. critical care is expensive, mainly due to the high staff ratio, expensive equipment but also due to a significant reliance on pharmacological management, which is usually funded with a limited drug budget. objectives. to explore the relationship between drug expenditure, patient acuity and outcome. methods. data was generated by retrospective analysis of consecutive patients admitted to our bedded general adult icu/hdu in a london teaching hospital, during february . patients were excluded from analysis if they were present in icu for less than h. the first and final ccu days stay were not included so that only full days were analysed. daily drug-use per patient was manually extracted from the computerized icu management system (cis, qs, ge medical). costs of prescribed drugs, fluids and parenteral nutrition (pn) were calculated from the pharmacy computer system and analyzed using regression analysis (spss ver ). results. the patient characteristics and outcomes of the patients are described in table table patient characteristics and outcomes age ( - )* gender (male n and %) ( %) apache ii score . ( . )** tiss score/patient . ( . )** length of ccu stay (days) ( - )* ccu survival (n and %) ( . %) daily drug cost for each patient's stay £ . (£ . - . )* daily drug cost for ccu and hospital survivors n = £ . ( . - . )* daily drug cost for ccu survivors who died in hospital n = £ . ( . - . )* daily drug cost for ccu non-survivors n = £ . ( . - . )* *median (interquartile range), **mean (standard deviation) the median daily drug cost was £ . . of note, the drug cost was highest for ccu nonsurvivors compared with survivors and also compared with patients who died in hospital after ccu discharge (p = . ). multivariate regression analysis demonstrated that median daily drug cost/patient = - . + . (mean tiss score) + . (apache ii score), r = . %; i.e median daily drug cost/patient was positively associated with tiss and apache ii score explaining % of the variation in cost seen. conclusions. this is the first study to show that daily drug expenditure in all general ccu adult patients correlates with patient acuity. median daily drug costs/patient were found to be £ . . this parameter would make an interesting comparison with other units both nationally and internationally. daily drug costs can be predicted on the basis of apache ii and tiss scores. furthermore, this may be further refined to develop a quality marker of daily drug cost in relation to survivors and non-survivors. material, methods and results. all patients admitted to the icu of neurotrauma, which underwent a tracheostomy after admission. data were collected: affiliation, cause of admission, average stay, indication of tracheostomy, tracheostomy time delay from its indication, place of performance of the procedure (icu or operating room), perioperative complications (event during transfer to operating room, event during surgery: hypoxia, hypotension, arrhythmia, bleeding, premature extubation, false cannulation, cardiac arrest, pneumothorax or death), and postoperative complications in the first week (bleeding, difficulty in changing cannula, stomal infection, pneumothorax, death conclusions. tracheostomie is a simple surgical technique and . % of tracheostomíes could be safely performed in the icu, saving hours of scheduled interventions in the operating room. there were no serious event during the transfer to the operating room or during the performance of tracheostomy. tracheostomized patients in icu, had a higher incidence of hypotension during surgery, although this complication in any case was serious or required treatment with vasoactive amines. when the tracheostomy is performed in the operating room, the delay shows a tendency to be higher, although this difference is not ss introduction. the concept of tight glyceamic control in critically ill has led to the rise of number of insulin infusion protocols designed to keep the blood sugar (bs) in predefined range. at the same time monitoring practices and patients populations vary greatly between intensive care units and thus so do the results. the matter is complicated by the absence of a widely agreed common glyceamic control indicators against which protocols can be evaluated and compared ( ). to establish the quality of glyceamic control in two different intensive care units. to compare the quality of glyceamic control between two intensive care units, with different glyceamic protocols and blood sugar measurement practices. we conducted retrospective non-randomized population study comparing quality of glyceamic control in two independent and non-related intensive care units. time spend in pre-defined glyceamic range was chosen as a quality indicator for both units ( , ) . data was collected from the electronic database and point of care bs measuring devices. the frequency distribution was analyzed to establish the patient-to-patient variability and a degree of bs deviation from the target value. results. units were different in method of sampling, frequency of sampling, target for optimal glyceamic range and instigated insulin protocol. data was collected on patients ( , bs measurement) in itu and patients ( , bs measurements) in itu . mean bs was . (sd = . ) mmol/l in itu and . (sd = . ) mmol/l in itu . conclusions. the performance of both protocols were satisfactory- . and . % of the time patients spend with bs less than mmol/l in itu and itu respectively. the quality of glyceamic control on both itus is similar in terms of proportion of time spend in different glyceamic bands, with the exception of the longer time spend in a hyperglyceamic state in itu . this study confirms the notion for a need of unified approach for evaluating quality of glyceamic control for in-patient populations. with an icu mortality of . % and in-hospital mortality of . %. the median transfusion threshold was a platelet count of /l with yearly medians ranging from . /l to /l. the % of platelet transfusions complying with bcsh guidelines increased from . to . % during the year study period. the specialties with the highest platelet requirement were general surgery ( . %), haematology ( . %) and general medicine ( . %) as a % of total units transfused. the yearly median threshold for haematology patients fell from . /l in to x /l in , increasing guideline compliance from . introduction. numerous protocols (e.g. glycaemic control, hhh, renal rescue) have been introduced into icu. these protocols involve blood sampling to assess gases, haemoglobin, glucose and electrolytes. this may result in anaemia and subsequent transfusion and adverse clinical outcome ( , ) . reducing blood loss due to sampling is an important blood conservation strategy ( ) . currently, our icu processes over , blood samples per month. objectives. to study the indications for blood gas sampling in our icu and identify strategies to reduce sampling. methods. we performed a prospective, observational study over week in . the nurses completed a questionnaire per shift per patient to assess the primary and any secondary reasons for each sample. subsequent management changes, haemoglobin levels, active bleeding, and transfusion were also recorded. results. blood samples from patients and questionnaires were analysed ( % of the nursing shifts). the range was - samples per patient per h shift with a mean of . the secondary reasons showed that many samples were also being used for potassium ( %) and glucose ( %) monitoring. only % of samples changed management (potassium %, ventilatory settings %, glucose %). haemoglobin levels dropped by an average of g/dl per week per patient with no active bleeding. units of blood were transfused during the study period. conclusions. our study shows that reasons for sampling are often relatively weak and sampling is promoted by icu protocols. frequent sampling does not change management for a large proportion of samples and may cause anaemia. there are financial implications to frequent sampling-at the time of the study each sample cost £ . (€ . ) to process. each unit of blood transfused cost £ (€ ). we have considered ways to reduce sampling including changing the glucose protocol to capillary sampling, using ml syringes, increased use of end tidal co monitoring, protocol redesign and education of staff. reference(s it has been reported that tight glyceamic control is associated with net savings in terms of length of stay on the itu and critical care bed occupancy ( ) . whilst it might be true for the overall length of stay, there is as yet, an un-quantified effect of frequent blood sugar measurement on the overall available nurse-patient time ( ) . there is finite amount of nurse-patient time within any given shift and so prioritizing nursing care will be an important factor in critically ill and high dependency patients. this is specifically important for any saving to be realized from the introduction of automated blood sugar measurement devices ( ). objectives. to quantify the amount of nursing time devoted to glyceamic control on itu or post-operative critical care environment based on data from four cohort studies on quality of glyceamic control in three intensive care units. a mathematical model, which takes into account frequency of blood sugar measurements and time to take each measurement was developed. stochastic analysis was used to calculate interdependency between quality of glyceamic control and the frequency of blood sugar measurements. introduction. introduction of trans-catheter aortic valve implantation (tavi) has been the latest technological advance in minimizing surgical stress and improving the chances of high-risk patient undergoing a successful aortic valve intervention ( ) . the latest technology comes at considerable cost, which relates to both-the cost of the tavi valve and to it's delivery system. currently, there are no randomized controlled trails addressing the issue of cost-effectiveness of tavi versus surgical avr ( ) . to build a cost-effectiveness model for patients undergoing either a tavi procedure or a surgical avr based on the level of care: level (ward based care), level (high dependency unit) and level (intensive care unit) during in-hospital stay, taking into account the rate of post-operative complications in both groups. methods. tavi patients were matched against patients who had previously undergone surgical avr. the groups were matched for demographic and physiological risk factors, as well as euroscore. a decision analytical tree was constructed based on the length of stay in hospital and post-operative complications. a markov model was built and the effectiveness was measured in terms of improvement in nyha class, which was translated into the quality adjusted life years (qaly) ( ) . results. the average in-hospital cost for tavi was £ , versus £ , for the surgical avr. the cost did not include the theatre time cost. in the surgical avr group the in-patient mean cost was greater than respective cost of the tavi group due to longer overall length of stay as in-patients. patients in the avr group spent more days in level and level care as compared to the tavi group. conclusions. the shorter length of stay and reduced rate of post-operative complications in the tavi group has got the potential to substantially reduce the overall in-patient cost and offset high cost of the valve. the effectiveness arm of the models did not differ for both groups, due to the lack of published literature, and raises a need for a qaly assessment for the effectiveness of tavi. the rate of post-operative complications in surgical avr group (higher rate of stroke and need for cardiac pacemaker) substantially affected the projected long-term cost. objectives. to determine if interventions for permanent pacing (ppm) and change of generator are more efficient in small hospitals. retrospective, transversal, observational study, measured through five diagnosis related groups (drg) that make up the casemix of pacemakers from the spanish minimum basic data set in , descriptively analyzing demographic variables (age, gender), clinical (number of secondary diagnoses (nsd) and procedures (np), mortality) and management (total, preoperative length of stay, access, discharge, hospital size), defining inefficient stays exceeding days the average. a bivariate study contrasting quantitative variables and comparisons between nominal and categorical, evaluating the independent association between short stay and different covariates studied building a binary logistic regression model, introducing as independent variables those that were significant in the bivariate as well as those considered that might be associated with the dependent variable. introduction. blood products are in short supply and with an ageing population the demand is likely to increase. blood use has been shown to be declining within the surgical specialties and intensive care, however overall use has remained unchanged. this audit looks at the use of packed red cells amonsgst medical inpatients to determine appropriateness. to determine if red cell use is appropraite among medical inpatients methods. medical blood transfusions were examined between august and august . patients were selected and pre and post transfusion haemoglobins were determined along with chronicity of anaemia. transfusions with haemoglobins of c . g/dl triggered a case note review. over months , patients were transfused , units. , units ( %) were given to medical patients ( %), of which patients were reviewed receiving transfusions. average age was . in patients pre transfusion haemoglobin was b g/dl ( %) and in patients c . g/dl ( %). in the group b g/dl patients had acute anaemia and had chronic anaemia. in the group c . g/dl patients had acute anaemia and had chronic anaemia. patients were not transfused and had absent data. out of case notes only were available. patients were transfused for acute anaemia, for chronic anaemia of which patients had cardiac disease, had haematological disorders, patients had iron deficiency anaemia and patient was folate deficient. conclusions. chronic anaemia in the over s accounted for the majority of transfusions. documentation was substandard. transfusions in chronic anaemia may be reduced by up-to-date guidance on transfusion triggers and alternative strategies to the use of blood products. ( ) results. the commonest indication for pct was long-term mechanical ventilation ( %) followed by airway protection ( . %). . % patients had platelets count\ lac while . % had severe thrombocytopenia (\ , ). . % patients had an additional coagulopathy (hepatic failure and multiple organ failure), with inr [ . was present in . % and deranged aptt in . % patients. pct was safely performed in all these patients. the patients received platelets or fresh frozen plasma(ffp) before the procedure to optimize coagulation. only . % had minor bleed through stoma, which was stopped in - min requiring gauze compression. conclusions. pct under videobronchoscopic guidance has low haemorrhagic complication rate in patients with deranged coagulation profile. platelets/ffp should be transfused before the procedure in these patients. introduction. blood components transfusion is common in the critically ill patient, as in the acute bleeding or the acute illness with multiorganic failure context. as any medical intervention, it has clinical indications and associated risks. clinical guidelines have evolved in a restrictive direction, suggesting that decision should be based on particular clinical situation and not only on analytical results. objectives. understand our transfusional practice and how close it is to clinical recommendations, as a quality indicator of our intensive care unit (icu). retrospective study using the icu patients data base. the population consists of patients with more than h icu stay in . the variables analysed are sex, age, diagnostic class (medical, surgical, trauma), saps ii score, mortality, number of transfusional events (erithrocyte concentrate, platelets, fresh frozen plasma and albumin) and the concordance to our hospital clinical guidelines. results. the population is of patients, % of male gender, with an average age of years-old. the admission diagnostic is medical in % of patients, with an average saps ii score of , median icu stay of days and a mortality rate of %. % (n = ) of patients received any kind of blood component transfusion, mostly erithrocyte concentrate ( % of patients), followed by albumin ( %). the populations of transfused patients is older ( vs. years-old), has a longer icu stay ( vs. days), higher saps ii score ( vs. ) and mortality rate ( . vs. . %) . pretransfusional values are hemoglobin of . g/dl, , platelets/ul, and albumin of . g/dl. the level of concordance with recommendations is high for erithrocyte concentrate ( %), platelets ( %) and fresh frozen plasma ( %) but not for albumin ( %). conclusions. the level of transfusion is high in icu patients. the population who received transfusion has a more severe clinical condition and higher mortality rate. the level of concordance with recommendations is high with the exception of albumin, which use is still less standardized. with increasing acuity due to escalating icu bed demand, but the impact on patient safety is unclear. sdu continuous non-invasive physiologic monitoring of hr, rr, bp and spo identifies cardio-respiratory instability often unnoticed by caregivers. causes may be alarm fatigue and/or high sdu nurse-to-patient ratios which make bedside monitoring insensitive. instability may become more resistant to intervention the longer it occurs. the impact of instability duration upon sdu patient outcomes is understudied. objectives. the study purpose was to determine the impact of cardiorespiratory instability duration experienced by in-patients being cared for on a monitored sdu upon hospital length of stay (los) and hospital charges. prospective study of monitored patients on a -bed trauma sdu over weeks. noninvasive continuous monitoring data were downloaded from bedside monitors and analyzed for vital signs (vs) beyond local instability criteria: hr\ or [ , rr\ or [ , systolic bp \ or [ , diastolic bp [ , spo \ % . vs time plots of unstable patients were further assessed to judge instability as mild or serious. instability duration categorized as: none, [ ] [ ] [ ] [ ] [ ] [$ k) . relationships between instability duration and outcomes analyzed with chi-square for mild and serious instability. conclusions. there has been a marked improvement in the overall recording of sews since the previous study. it is of concern that respiratory rate was again the least well recorded parameter as this has been shown to be the best physiological predictor of impending cardiopulmonary arrest , . this may be because respiratory rate is not provided by the automated monitoring devices available on the general wards in our hospital, and must be calculated manually. it demonstrated an increase in mortality even when tiss scores were taken into account as an independent risk factor. since these publications critical care outreach and the use of early warning scores have become common place; however it was felt that time of discharge was still impacting on patient outcome. to review our post-unit mortality and readmission rate, with particular focus on the time of discharge. conclusions. our mortality and readmission data compare favourably with a recent publication. there is a clear difference in mortality related to time of discharge; however this is for evening discharges as compared to night discharges in previous papers. [ ] [ ] [ ] [ ] the time of discharge may represent logistical issues of planned discharges or early discharge decisions due to pressure for beds. overnight discharge is an uncommon occurrence in our unit; this evidence suggests that previous concern about night discharges should be extended to evening discharges. transferring critically ill patients is a challenging task in the day to day activities of the critical care team. safe accomplishment of these transfers relies on skills of the persons accompanying and the resources available. guidelines have been produced by various professional bodies [ , ] to safely accomplish these transfers. the competency document released by the royal college of anaesthetists, uk requires that junior trainees have appropriate knowledge, skills, attitude and behaviour in the principles of safe transfer of critically ill patients [ , ] . to obtain information about trainee's perspective, experience and knowledge in transfer of critically ill. a web based online survey was sent to all the anaesthetic/itu trainees in the west midlands region of the uk. results. total number of respondents were . of these, . % had less than months of anaesthetic training before undertaking a transfer. only % had formal training on transfer of critically ill patients. % of the trainee's didn't have any competency based formal assessment of their skills, attitudes and behaviour in transfer of critically ill patients. majority of them ( %) felt that every one should undergo formal training before undertaking transfers. while % of the respondents have undertaken transfers during their training, only % have experienced some form of critical incident during these transfers. more than % of these adverse events were related to equipment failures while % were due to patient deterioration. nearly % of the trainees were not aware of terms and conditions of the insurance cover for these transfers. conclusions. this survey highlights the deficiencies involved in training the trainee's for transfer and the transfer itself. the results demonstrates that majority of the trainees would prefer to attend specific transfer courses before venturing out on an actual transfer. we hence recommended the following for implementation: improvement of training process for those undertaking transfers; regular monitoring of this process; regular analysis of critical incidents and acting upon it; making the insurance compulsory for those undertaking the transfers. greek hospitals, including initial management of critically ill patients and primary care for a growing proportion of the population. the impact of ed length of stay (los) on patient outcome has not been covered adequately by existing surveys so far. objectives. the aim of this study was to determine the association between ed overcrowding and outcomes for critically ill patients. in the present study, we included medical and surgical pts that all of them were intubated promptly to ed of general hospitals of athens gr, for months. pts survived [ h were divided into groups: ed boarding \ h (group a) and ed boarding c h (group b). demographics, apache ii, diagnosis, los, and icu and hospital mortality were recorded. ed boarding time was measured in min. groups were compared using chi-square, mann-whitney, unpaired student's t tests and stepwise regression analysis. the collection of data lasted months. results. in the ed, critically ill patients with a mean age . ± . years and apache ii score . ± . were intubated. pts were males and were females with a mean age . ± . and . ± . years, and apache ii score . ± . and . ± . respectively. main diagnosis was multi trauma ( ) objectives. we sought to assess the baseline characteristics and outcomes of the patients presenting af as a cause of met call activation. using the met database of one tertiary teaching hospital, we retrospectively reviewed all patients for which the met diagnosis was atrial fibrillation. we reviewed their clinical history, immediate treatment and outcome. these data were compared to those of a control group of randomly selected met calls with patients being matched for age, gender and ward of origin (surgical or medical). objectives. to ascertain the proportion of preventable in-hospital cardiac arrests occurring at university hospital lewisham. furthermore, to identify any common predictors of poor outcome that were apparent prior to those arrests and whether these are potentially modifiable. a case note review was performed on the cohort of patients who suffered inpatient cardiac arrests and who were admitted for icu (level- ) care post-resuscitation. these patients were identified using our quarterly feedback from the intensive care national audit and research centre (icnarc) case mix program dataset between april and september . we found that half ( out of ) of our in hospital cardiac arrests resulted in death despite level- care post arrest within the audit period. of these in-hospital arrests were deemed preventable from case note review and trust cardiac arrest call audit forms when available. in addition, in the preventable sub-group an arterial blood gas sample was not obtained in out of , %. in all of these cases, the icu outreach team was not aware of the patient prior to the arrest. conclusions. in keeping with widely published data regarding survival to discharge after in-hospital cardiac arrest, the high mortality rate of % for this cohort of patients emphasises the importance of early recognition of abnormal physiology and timely intervention. with the sensitivity, specificity and validity of ews yet to be validated and no clear benefit proved from the introduction of met/outreach teams, an alternative strategy for earlier recognition of critically ill patients is needed. our data suggests that arterial blood gas sampling, an essential investigation central to the recognition of critically ill patients is being consistently overlooked and is an important factor influencing outcome. results. attended patients were , , with mean age of , years, and women represent , % of them. most demanding services were internal medicine ( %) followed by general surgery, haematology and nephrology. global data may be seen in table . with regards to admissions to the icu of these patients, table depicts the proportion between requested admissions, and refusals. introduction. tradicionally, critical care interventions are highly intensive, expensive and brief. critical illnesses and interventions that we use, can both contribute to posticu disability: catheter-related bacteraemia, polineuropathy, resistant organism, nutricional problems, complications of tracheostomy, prolonged analgesic. all these factors and a premature discharge from an ever full icu, can even have an impact on occult mortality after discharge from icu (between and %). in our unit a follow up program have been implanted. when patients are about to be discharged from icu, icu clinicians selected those considered to be recoverable but fragile enough to have poor prognosis. objectives. to quantify the workload that a after icu follow-up entails, and to determine if this program impacts on mortality posticu. prospective and interventional study carried out during a months period. at a beds medical uci of a teaching hospital in malaga icu, patients were enrolled in the follow up program. we assessed prognosis with sabadell score and severity of illness with apache ii score; and registered our interventions after discharge from icu. the final endpoint was status at hospital discharge: survivant or dead. we did interventions in patients: we changed a venous catheter ocasions ( % of patients), changed analgesic schedule times ( . %), stopped antibiotics times ( %), modified parenteral nutrition times ( %) . we searched and treated sources of sleep deprivation (delirium, anxiety or insomnio) in patients ( %); treated tracheostomy complications in patients. mortality of patients enrolled in this program was . % ( patients) even if the mean expected mortality by apache ii score was [ %. conclusions. in our study, implementation of a continued follow-up program after icu discharge in selected patients, carried out by icu staff, was associated with an important decrease of mortality. encouraging clinical results and a non-excesive workload for icu staff justify continuing this follow-up. objectives. various therapeutic protocols were used for the management of sepsis including hyperbaric oxygene (hbo) therapy. it has been shown that ozone therapy (ot) reduced inflammation in several entities and exhibits some similarity with hbo in regard to mechanisms of action. thus, we designed a study to evaluate the efficacy of ot in an experimental rat model of sepsis and to compare these effects with hbo. methods. forty male wistar albino rats were divided into sham, sepsis+cefepime (control), sepsis+cefepime+hbo (hbo), and sepsis+cefepime+ot (ot) groups. sepsis was induced by an intraperitoneal injection of . cfu escherichia coli; hbo was administered twice daily at . -atm pressure for min; ot was set as intraperitoneal injections of . -mg/kg ozone/oxygen gas mixture once a day. the treatments were continued for days after the induction of sepsis. at the end of experiment the lung tissues and blood samples of the study animals were harvested for biochemical and histopathologic analyses. results. lung tissue myeleperoxidase activities and oxidative stress parameters, and serum proinflammatory cytokine levels, il- b and tnf-a, were found to be ameliorated by the adjuvant use of hbo and ot when compared with the antibiotherapy alone group. histopathologic evaluation of the lung tissue samples confirmed the biochemical outcome. some measures indicated significantly more efficacy of ot than hbo. conclusions. our data presented that both hbo and ot reduced inflammation and injury in the septic rats' lungs; a greater benefit was obtained for ot. these findings suggest that it may be possible to improve the outcome of sepsis by using ot as an adjuvant therapy. objectives. to investigate the regularity for change of paf, tm and vwf in septic rat, and the protective effects of statins on vascular endothelium. methods. fifty-four male sd rats were randomized into simvastatin with lps group (group a, n = ) and lps group (group b, n = ) and control group(n = ). they were respectively accepted ml/kg normal saline (ns) abdominal injection for both control group and group b, ml/kg simvastatin abdominal injection for group a, then h later, total male sd rats from group a and group b were respectively accepted lps ( mg/kg weight) abdominal injection to establish sepsis model and ml/kg ns abdominal injection for control group. thereafter, detected the serum concentration of von willebrand factor (vwf), thrombomodulin(tm) and antithrombin (at-iii) at different point of time ( , , and h after lps abdominal injection) in both group a and group b by elisa, the endothelial cells from thoracic aorta was observed with electron microscope. under electron microscope scanning, endothelial cells in septic rats from group b were found disarranged. under transmission electron microscope, endothelial cells were found to be in prophase of apoptosis characterized by unclear cell membrane, thickened cellcell conjunction, disappeared desmosome and microfilament, dissolved or vacuolized organelles and agglutinated and evaporated chromatin gathering under the karyolemma, but the karyorrhexis were not found. no similar changes were found in group a. ( ) introduction. sepsis induced lymphocyte apoptosis is believed to play an important role in the pathogenesis of sepsis and in the development of the immunesuppresion observed in septic patients. lymphocyte apoptosis not only decreases the number of functional lymphocytes but may also modify the immune response towards an anti-inflammatory state. erythropoietin (epo) has recently been recognized as a multifunctional cytokine with antiinflammatory, antioxidative, and antiapoptotic properties. objectives. this study aimed to test whether epo could mitigate peripheral blood mononuclear cell (pbmc) apoptosis and whether epo could modify the dynamic changes in lymphocyte-subsets in a porcine model of acute endotoxemia. methods. twenty-eight anesthetized and mechanical ventilated pigs were randomized to one of three groups: ) epo group, epo administered h prior to endotoxemia (n = ); ) placebo group, vehicle administered h prior to endotoxemia (n = ); ) sham group, animals only anesthetized and mechanical ventilated. endotoxemia was induced by an infusion of lipopolysaccharide (lps). after h the lps infusion was reduced to a maintenance dose and the animals were fluid resuscitated. pbmc were isolated at time , , , and min of endotoxemia. apoptosis in pbmc and relevant lymphocyte subsets were assessed by staining with -amino-actinomycin d ( aad) and annexin v using multicolor flow cytometry. apoptotic lymphocytes in spleen were quantified by immunohistochemical staining for activated caspase- . endotoxemia increased the number of apoptotic mononuclear cells in both blood (p = . ) and in spleen (p = . ), but with no significant modifying effects of epo. the numbers of both cd + (t-helper) and cd + (cytotoxic) t-cells declined during endotoxemia. cd + cells, defining b-lymphocytes, demonstrated a biphasic response with an immediate decline followed by an increase in number of b-cells. the dynamic changes in the lymphocyte subsets were not modified by epo. , and reduced the number of circulating leucocytes. epo had no modifying effects on these dynamic changes. furthermore, epo did not mitigate apoptosis in pbmcs analyzed by flow cytometry or in spleen lymphocytes analyzed by immunohistochemistry. this study does not support that epo confer protection against lymphocyte apoptosis. objectives. aim of this study was to investigate the effects of combined, recombinant human activated protein c (rhapc) and ceftazidime (cef) in our established model of acute respiratory distress syndrome (ards) and septic shock methods. thirty sheep ( - kg) were operatively prepared for chronic study, and were randomly allocated either to sham, control, rhapc, cef, or rhapc/cef groups (n = each). after tracheostomy, acute lung injury and sepsis was produced in all groups, following an established protocol ( , ) , except the sham group that received the vehicle. the sheep were studied for h in an awake state and were ventilated with % oxygen. pao /fio ratio was determined intermittently. cef ( g) was administered intravenously and h post injury. rhapc was given as a continuous infusion ( mcg/kg/h), starting h post injury. the animals were resuscitated with ringer's lactate solution to maintain filling pressures and hematocrit. lung tissue was obtained during necropsy and analyzed for myeloperoxidase (mpo) using a commercially available kit. statistical analysis: two-way anova and student-newman-keuls post hoc comparison. data are expressed as mean ± sem. significance p \ . . . mpo levels (mu/mg protein) were ± in sham and significantly increased in the control group ( ± *). the rhapc ( ± *) and cef group ( ± *) increased significantly vs. sham and tended to be lower than controls, but not statistically significant. mpo levels of combined rhapc/cef ( ± *) showed no difference to sham, but were significantly lower than controls or rhapc or cef alone. conclusions. combined administration of rhapc and ceftazidime in ards associated with septic shock improved oxygenation more than cef or rhapc alone, and prevented the onset of ards. seleno-compounds, such as sodium selenite (na seo ) show conflicting clinical results in the treatment of sepsis. efficacy, as well as mechanism of action of na seo , are unclear, with prevailing opinion that it acts as an anti-oxidant. however, na seo has also oxidant properties that could have a paradoxical therapeutic role in septic shock by reducing over-activated phagocytic cells. indeed, in septic sheep, high dose na seo injection as bolus rather than continuous administration resulted in a beneficial effect on survival time, macro and microcirculation ( ). objectives. to investigate at the endothelial level the mechanism of action of a bolus injection of a high oxidative dose of na seo . in male wistar rats, lipopolysaccharide (lps, mg/kg) or normal saline were injected intraperitoneally, followed h later by either an intravenous bolus injection of na seo (corresponding to . mg/kg se) or normal saline. after h of lps, extravasation of fluoroisothiocyanate-dextran and leukocyte-endothelium interaction in venules of the cremaster muscle were quantified by intravital microscopy. results. na seo did not alter systemic haemodynamic variables as compared to lps rats. there were no intergroup differences in fluoroisothiocyanate-dextran extravasation. lps significantly decreased leukocyte rolling when compared to control animals (p \ . ). bolus injection of na seo did not alter leukocyte rolling but decreased leukocyte adhesion and extravasation levels to control values. our results in endotoxemic rats suggest that a toxic dose of na seo may have a beneficial effect of on leukocyte-endothelium interaction without a significant effect on plasma extravasation. objectives. to design a model of sepsis in pigs characterized by an unchanged q t over time. methods. after a h fasting, pigs (weight - kg) were sedated with ketamine ( mg/ kg) and midazolam ( . mg/kg) i.m. animals were tracheostomized and anesthetized (propofol mg/kg iv bolus, followed by mg/kg/h), atracurium ( . mg/kg/h) and fentanil ( lg/kg/ h). the internal jugular vein, carotid artery and pulmonary artery were catheterized for iv fluid administration and monitoring. a lumbotomy was performed and an ultrasonic blood flow and a laser-doppler microvascular flow probes were placed in the left renal artery and on the kidney surface to measure renal artery blood flow (rabf) and renal cortical blood flow (rcbf), respectively. a cystostomy was performed to collect and measure urine output (uo). sepsis was induced by the iv administration of live e. coli ( . our previous study showed that citrulline (cit) supplementation during endotoxemia improved microcirculatory flow and endothelial function, and prevented glycocalyx degradation as a consequence of increased arginine (arg)-dependent vascular nitric oxide (no) production. during sepsis the availability of arg, the substrate for endothelial no production, is tempered as a consequence of increased inflammatory no synthase (inos) activity. the reduced endothelial nos (enos) activity and vascular no production is believed to result in endothelial and vascular dysfunction. a shortage of arg availability for enos is considered the main cause of the dysfunction. previous studies have indicated cit as an important, if not exclusive, mediator for enos-derived no production. cit is a substrate for argininosuccinate synthetase, an arg-producing enzyme that co-localizes with enos in the caveolae, thus directly and exclusively supplying arg to enos. objectives. we investigated whether cit supplementation during an ongoing endotoxemia rescues the enos-derived no production in endothelial cells, thereby providing a mechanistic explanation for its positive in vivo effects. mice received a continuous intravenous endotoxin (lps, lg total) infusion for h alone or an h lps infusion with cit ( . mg total) during the last h of endotoxin infusion. after the h infusion, the mice were sacrificed, arterial blood was sampled and the carotid arteries were removed. no production in the carotid arteries was measured ex vivo with -photon fluorescence microscopy, using a fluorescent copper-based no probe. amino-acid concentrations in plasma were measured by hplc. results. both cit and arg plasma concentrations were significantly increased in the lps-cit group compared with mice treated with lps alone (p \ . ). in vivo cit supplementation led to detectable levels of no production ex vivo in carotid smooth muscle cells (smc) and endothelial cells (ec) by using the no-probe with -photon fluorescence microscopy. while ec-derived no production was absent in the carotid arteries of mice treated with only lps, the smc-related no signal was undisturbed. no production in the ec of the lps-cit group was not blocked by the inos inhibitor , w, suggesting enos to be responsible for the observed effect. furthermore, ex vivo incubation of the carotid arteries of the lps-cit mice for min with extra cit ( mg/ml) resulted in prominently increased no production in the carotid ec, whilst this effect was not observed in the carotid arteries of lps without cit treated mice. conclusions. cit supplementation during murine sepsis rescues the enos-derived no production in carotid artery endothelial cells, providing a mechanistic base for the positive effect of cit supplementation on endothelial no synthase during endotoxemia. grant acknowledgment. objectives. investigated the mechanism involved in the clearance of bacteria observed after rpaf-ah treatment in sepsis model. mice were subjected to clp model, after min, the mice were treated with rpaf-ah. the cfu counts and measured of mediators were determined. results. the numbers of bacteria (cfu) recovered in the peritoneal fluid was inhibited in rpaf-ah treated group ( . / . ), suggesting a more efficient clearance of bacteria after rpaf-ah treatment. direct incubation of s. typhimurium, e. coli and s. aureus failed to affect bacterial growth indicating lack of a direct effect of paf-ah on bacteria. administration of rpaf-ah in ccr (receptor for mcp- /ccl ) deficient mice failed to increase bacterial clearance after clp, suggesting that mcp- signaling is involved in this phenomenon. rpaf-ah treatment also failed to increase bacterial clearance in inos deficient mice and no levels were found to be elevated ( . ± . / . ± . ) in peritoneal fluid of the mice treated with rpaf-ah after clp surgery. synergism for no production was also seen when macrophages stimulated with e. coli were treated with rpaf-ah+mcp- and correlated with better bacterial killing by macrophages. peritoneal macrophages from knockout mice for mcp- , stimulated from lps+ifn inhibited no levels when compared to wt mice ( . ± . / . ± . ). this results indicating that, excessive mcp- favors macrophage production of no and hence the ability of macrophages to deal with invading bacteria. conclusions. we conclude that the increase in bacterial clearance is important for the protective effect of rpaf-ah in sepsis and that exist a signaling involving mcp- /ccl and no in this system. introduction. disturbances within the microcirculation represent an important factor in the pathogenesis of multiple organ dysfunction during systemic inflammation and sepsis [ ] . dehydroepiandosterone (dhea) has immunomodulatory effects and improves survival in several animal models of trauma, hemorrhage and sepsis but also causes potent vasodilatation [ ] . to maintain efficient microcirculation we combined dhea with sodium orthovanadate (sov), which augments vascular contraction. furthermore, sov has been identified to attenuate tissue injury and improve survival related to inflammatory response [ ] . objectives. we investigated whether the combined administration of dhea and sov has beneficial effects to microcirculation in experimental sepsis. we divided sixty male lewis rats into six groups: control group; ethanol (solvent) treated control group; dhea ( mg/kg) + ( . mg/kg) treated control group; endotoxemic group (lps mg/kg); dhea + sov treated endotoxemic group; dhea ( mg/ kg) + sov treated endotoxemic group. two hours after lps challenge we performed intravital fluorescence microscopy of the intestinal wall in order to study leukocyte adhesion and functional capillary density (fcd). tnf-a, il- a, il- and infc, gm-csf and mcp were measured at baseline and following h of endotoxemia in all experimental groups. in comparison to untreated rats subjected to endotoxemia the treatment with dhea (both dosages) and sov resulted in a significant reduced number of adhering leukocytes in intestinal submucosal venules. furthermore, the mucosal functional capillary density was significantly improved. we did not identify any changes in cytokine plasma levels. conclusions. the study demonstrated beneficial effects of combined treatment with dhea and sov within the intestinal microcirculation in experimental endotoxemia. concomitant administration of sov permitted to reduce dhea dosage and prevent potential vasodilation without affecting anti-inflammatory dhea action. . spronk pe, zandstra df, ince c: bench-to-bedside review: sepsis is a disease of the microcirculation. crit introduction. sepsis is a disease of the microcirculation and impairment of the intestinal microcirculation during sepsis may cause a breakdown of gut barrier function thus releasing bacteria and their toxins into the systemic circulation [ ] . consequently, the protection of the intestinal microcirculation represents a pivotal therapeutic target in severe systemic inflammation. cannabinoids that interact with cannabinoid receptors (cb r and cb r) have been shown to have immunomodulatory properties in in vivo and in vitro studies and the endocannabinoid system has been shown to be involved during systemic inflammation [ ] . objectives. the aim of the present study was to examine the effects of cb receptor modulation on the intestinal microcirculation in experimental sepsis (endotoxemia) using intravital microscopy (ivm). we studied four groups of animals (lewis rats, n = per group): healthy controls (con), endotoxemic animals ( mg/kg lipopolysaccharide; lps), endotoxemic animals treated with cb agonist, hu ( mg/kg iv), and endotoxemic animals treated with cb antagonist, am ( . mg/kg iv). intravital microscopy of the intestinal microcirculation was performed following h lps/placebo administration. leukocyte adhesion and functional capillary density (fcd) were measured offline in a blinded fashion. results. following h of endotoxemia, a significant increase of leukocyte adhesion in the intestinal submucosal venules (e.g., v venules: con . ± . n/mm , lps . ± . n/mm , p\ . ) was observed. capillary perfusion of the muscular and mucosal layers of the intestinal wall was significantly reduced (e.g., circular muscular layer: con . ± . cm/cm , lps . ± . cm/cm ). treatment of endotoxemic animals with the cb receptor agonist, hu , further increased leukocyte adhesion (v venules: . ± . n/mm ), whereas cb receptor inhibition by am significantly reduced leukocyte activation (v venules: . ± . n/mm ) and restored capillary perfusion (circular muscular layer: . ± . cm/cm ). conclusions. the data support the hypothesis, that cb receptor signalling is involved in the impairment of the intestinal microcirculation during sepsis. blocking cb receptor signalling reduces leukocyte activation and improves capillary perfusion in acute endotoxemia in rats. the long-term effect of modulating cb receptors in more clinical sepsis models needs further investigation. [ ] . this study compares dobutamine and levosimendan for the treatment of circulatory failure in septic shock and assesses survival benefits. objectives. in this controlled randomized doubleblinded study anaesthetized and ventilated pigs ( . ± . kg) were enrolled after approval by the local governmental commission. methods. by continuous infusion of endotoxin (escherichia coli serotype :b , sigma-aldrich; . ± . lg/kg/h) over a time period of . ± . h, septic shock was induced. hemodynamic stabilization was performed by either use of the vasopressor norepinephrine alone (control group; n = ) or in combination with levosimendan ( . lg/kg/min; n = ) or dobutamine ( . lg/ kg/min; n = ). in a setting of h of measurements and treatment heart rate (hr), map, central venous pressure (cvp), pulmonary artery pressure (mpap) and cardiac output (co) were recorded continuously and evaluated hourly. beside norepinephrine requirement and mixed venous oxygen saturation (svo ) mean survival time and survival rate within the measurement period were analysed. results. after endotoxinemia septic shock was marked by reduction of co and svo [p \ . ]. mean survival time and survival rate were superior in levosimendan treated animals ( table ). norepinephrine consumption was lowest in the levosimendan group. after h, co of surviving animals was highest in the levosimendan group and statistically different compared with the control group. comparison of parameters hr, map, cvp and mpap showed no differences between treatments. conclusions. the complementary use of the calcium sensitizer levosimendan provides potential survival advantage in endotoxemic septic shock. beside an increase in co, improvement of regional organ perfusion or protection could be an explanation and has to be shown by further analysis. reference(s methods. the study group consisted of patients with shock on vasopressor support and control group had normotensive patients. arterial and capillary samples were taken simultaneously and were tested immediately at the bedside. the results of the paired measurements were analysed as a scatter plot by bland and altman method and were expressed as a correlation coefficient. values were considered to disagree significantly when the difference exceeded %. results. mean arterial and capillary sugars (mg/dl) in study and control groups were . ± and . ± . , and . ± . and . ± , respectively. on bland-altman analysis, % in study group and % in control group were out of range (acceptable limit \ %) [ figures , ] . correlation between capillary and arterial values was less in the study group (r = . , p . vs. r = . , p \ . ). in addition, the disagreement between capillary and arterial values was more than % in % of the patients in the study group vs. % in control group (p = . ) (iso standard \ %). conclusions. capillary blood glucose monitoring can be applied reliably to patients in icu. however, caution must be exercised in patients with shock in whom arterial blood may be preferred. rd esicm annual congress -barcelona, spain - - october objectives. our primary objective was to evaluate the safety and efficacy of a single oral high dose vitamin d supplementation in an intensive care setting over a one-week observation period. methods. , iu (corresponding to . mg) of cholecalciferol (d) dissolved in ml herbal oil or matched placebo (pbo) were given enterally (via nasogastric feeding tube or swallowed) to patients with vitamin d deficiency [ (oh)d b ng/ml] in the medical icu. results. baseline characteristics including age, sex and saps ii were balanced between the two groups (mean age ± years, % male, saps ii ± ). mean serum (oh)d levels at baseline were ± ng/ml in both groups. the mean serum (oh)d increase in the intervention group was ng/ml (range - ng/ml). two patients showed a small ( ng/ml) or no response ( ng/ml) attributable to gastrointestinal dysfunction after prolonged hypoxia and gastrointestinal gvhd after allogeneic stem cell transplantation. the time course of the (oh)d response is given in figure . introduction. considerable controversy has emerged as to whether tight glucose control (tgc) is warranted in all critically ill adult patients. recently, a new blood glucose upper limit ( mmol/l) has been assessed as more appropriate. rather than blood glucose target ranges, algorithms used to achieve tgc should be numerically evaluated before initiating clinical trials (preclinical validation test). our purpose was to assess performances of tgc algorithms in realistic virtual icu patients. we compared numerically the nice-sugar algorithm (n-s) and the cgao system (cgao) used in the ongoing cgao-rea study [clinicaltrials.gov, id:nct ] . a set of virtual patients constituting the test bench was built with ) real data coming from patients controlled with cgao before starting cgao-rea and ) a non-linear pharmaco-dynamic glucoseinsulin system model where patient endogenous glucose clearance and insulin-sensitivity were time varying parameters. in order to anticipate how algorithms would manage glycaemic control in clinical settings, delayed controls and inaccuracy of glucometers were implemented. the overall performance of each algorithm over the whole stay was assessed according to standard scores. results. the percentage of time in the target range [ . - . mmol/l] with n-s was less than % for almost all patients. in insulin-sensitive patients, glycemic fluctuations and sometimes severe hypoglycemia are induced by n-s (fig. ). the mean time in the target range with cgao was about % and variability scores were significantly lower than with n-s. mean glucose and standard deviations were always lower with cgao than with n-s. a numerical test bench constituted of realistic virtual icu patients, whose features were defined from real data obtained in patients under glycemic control, enabled to determine the best algorithms candidate for further evaluation in clinical settings. according to this approach, the algorithm used to achieve tgc in nice-sugar would not have been selected for such a large clinical trial while cgao reached the first validation step in simulation. we recommend that further glucose control studies focus not only on the target range but also on the algorithmic properties. introduction. there has been much debate in recent years about the appropriate level of blood glucose for intensive care patients with proposals of different levels of glucose control using insulin infusions. one risk of intensive glucose control is hypoglycaemia and this has been proposed as a measure of quality of care given by delivering the protocol safely. the nice-sugar trial found that intensive glucose control increased mortality among adults in intensive care. objectives. the aim of our study was to record hypoglycaemia and study it's relation to insulin therapy. insulin therapy on our unit follows the recommendations of the nice-sugar trial. methods. hypoglycaemia was recorded as a blood glucose level\ mmol/l. levels were detected using the blood gas analyser (radiometer m). data was recorded at the time of hypoglycaemia to provide an explanation using the innovian system which is the paperless patient record system on our unit. data was obtained over a period of months between october and december . data recorded included adverse events which were defined as worsening shock and/or increasing inotropic support. feeding status at the time of hypoglycaemia was recorded. results. there were a total of admissions over this period and there were a total of , blood glucose measurements. incidents of hypoglycaemia were recorded, of which patients were on insulin and were not. of the patients who were on insulin, had adverse events at the time of hypoglycaemia. all these patients died within h of the adverse event. all except one was on full feed. the others had minimal feed due to poor absorption. of the patients who did not have adverse events, were discharged and one died days after the hypoglycaemic event due to worsening sepsis. of the patients on insulin, there were iatrogenic errors where feeding was stopped and the insulin was left on. none resulted in any adverse outcome for the patients. of the patients who were not on insulin therapy, had adverse events at the time. died within h of the adverse event and died days later. the remaining patients were discharged. none of the patients were on full feeding protocol. conclusions. our findings suggest that hypoglycaemia in our unit is not primarily related to insulin therapy. it is related to adverse events and possibly inappropriate feeding at the time of hypoglycaemia. hypoglycaemia, in the absence of insulin therapy, is associated with a poor outcome. use of hypoglycaemia as a quality indicator should be interpreted with caution. introduction. vitamin d deficiency seems increasingly prevalent. pleiotropic effects of vitamin d like immunomodulation and effects on muscle strength may be of special importance to critically ill patients [ ] . however, vitamin d deficiency has only been studied in small and selected groups of icu patients [ ] . objectives. to prospectively determine the prevalence of vitamin d deficiency in winter and summer and relate vitamin d status to outcome in cohorts of critically ill patients. results. vit d was measured in patients admitted in winter and patients admitted in summer (table ). mean vit d was significantly lower in winter than in summer. in winter, % was deficient, % severely deficient. in summer, % was deficient, % severely deficient. predicted mortality was higher in winter and higher in vit d deficient patients. observed mortality was lower than predicted in all groups, but not different between groups. including both vit d and season in a multiple regression analysis, winter (p = . ) and not vit d (p = . ) was related to predicted mortality. introduction. glucagon-like peptide- (glp- ) lowers blood glucose via stimulation of insulin and suppression of glucagon secretion, as well as slowing gastric emptying. we have previously shown that exogenous glp- attenuates hyperglycaemia in non-diabetic critically ill patients [ , ] . however, islet cell function in critically ill diabetic patients may be so disturbed that pharmacological doses of glp- have no effect in this group. objectives. the aim of this study was to evaluate the effect of exogenous glp- on glycaemic excursions during intraduodenal nutrient infusion in critically ill patients with preexisting type- diabetes mellitus. methods. nine critically ill, mechanically ventilated, patients with pre-existing type- diabetes ( m: f, age ± years, hba c . % ± . %, bmi ± kg/m , apache ii on day of study ± , days in icu on day of study ± ) received iv infusions of glp- ( . pmol/kg/min), and placebo, from t = - min on separate days in a randomised, double-blind, fashion. between t = - min a liquid nutrient (ensure) was infused intraduodenally at a rate of kcal/min via a naso-enteric feeding catheter. blood glucose concentrations were measured by glucometer at min intervals. data are mean±sem and comparisons are using student's t test. results. prior to the commencement of iv infusions there was no difference in blood glucose between the groups (at t- min: glp- : . ± . mmol/l vs. placebo: . ± . mmol/ l; p = . ). during fasting, glp- had no effect on glycaemia (at t = min: glp- : . ± . mmol/l vs. placebo: . ± . mmol/l; p = . ). however, glp- attenuated the overall glycaemic response to the nutrient (auc - min : glp- : , ± mmol/l.min vs. placebo: , ± mmol/l.min; p \ . ), as well as the peak blood glucose (glp- : . ± . mmol/l vs. placebo: . ± . mmol/l; p \ . ) conclusions. exogenous glp- is effective in reducing the glycaemic excursions that occur with enteral nutrient critically ill patients with pre-existing type diabetes mellitus. these data indicating that further studies using glp- , or its analogues, are warranted in this group. , , , , whilst raising concerns regarding an increased risk of hypoglycaemia. , , . locally most units adopt a protocol that reflects the practice of the original study. objectives. this study was conceived due to concerns around the safety of tight glycaemic control (tgc). our objectives were to measure adherence to our local policies and ascertain our true rates of hypoglycaemia. methods. this study was designed as a retrospective audit on four critical care units in the cheshire and mersey critical care network. each site used the same audit tool but adapted it to allow for differences in local practice and protocols. data pertaining to the prescribing and administration of insulin was collected daily over a week period (the time of data collection varied from day to day). the doctors and nursing staff were unaware of the audit and the data was collected by the ward pharmacist who suggested modifications to therapy if it was deemed inappropriate or unsafe. results. patient days worth of data was collected with blood glucoses checked in this period. % of patients receiving insulin had insulin prescribed. only % of blood glucoses were within the target range set by the local protocol. however, of all the results only . % were ''low'' as defined by the local protocol, and only . % ( / ) were hypoglycaemic episodes as defined in the greet van den berghe paper of (\ . mmol/l). conversely, . % were above the target range. in the trusts that recorded how many of these levels were[ mmol/l (a proposed alternative upper limit), the rates were and %. in response to a blood glucose the policies suggest dosage adjustments/maintenance. on only % of occasions were the adjustments made correct. insulin infusions appeared to be managed safely by nursing staff. insulin, if given, was always prescribed and hypoglycaemia (blood glucose \ . mmol/l) occurred on only one occasion. although safe, adustments often didn't follow the protocols and the patients' blood glucose were within the target range only % of the time, potentially negating many of the perceived benefits of tgc. reasons for non-compliance with the protocols was difficult to objectively establish reference(s). introduction. diabetes mellitus has been associated with an increased risk of adverse outcomes after coronary artery bypass grafting. hemoglobin a c is a reliable measure of long-term glucose control. it is unknown whether adequacy of diabetic control, measured by hemoglobin a c, is a predictor of adverse outcomes after coronary artery bypass grafting. material and method. we evaluated consecutive diabetic patients who underwent primary, elective coronary artery bypass grafting at the anadolu medical center. hba c levels of all patients with diabetes mellitus were measured and value of % or greater was used as a threshold for uncontrolled hyperglycemia. all the peroperative variables were recorded and then, statistically evaluated. the statistical analysis was realised by t test for parametric variables and chi-square test for nonparametric variables. results. there were consecutive patients that underwent elective coronary artery bypass graft surgery between january and april . among them, patients had diabetes mellitus and others not. there were no significant differences between groups regarding each adverse outcomes (table ) . although, ( . %) of total surgical site infection in patients had been seen in diabetic patients, there were also no significant differences between groups regarding the rate of infections (table ). there was no early postoperative mortality in diabetic patients. insuline treatment (iit) , by implementing a completely nurse driven protocol as in the leuven i study, to achieve tight glucose control in our -bed medical(cardio-)surgical icu and non-ventilator beds. in the last year, the benefit of iit and the possible detrimental effects of hypoglycemia on survival have been heavily debated. objectives. the goal is to analyze our daily practice in all icu patients and compare this with the intensive treated groups from the leuven , visep en nice-sugar trial. methods. we compared mean morning blood glucose levels and the percentage of patients who had a hypoglycaemia, defined as glucose below . mmol/l, from to . the frequency of control and the insulin dosage was comparable to the leuven study. enteral or parenteral feeding was started at admission. no standard intravenous glucose was used. glucose was measured with arterial blood samples on the abl flex radiometer as poct. results. in our patients, the mean morning blood glucose was higher than in the leuven study and comparable to the visep and nice-sugar. the percentage of hypoglycemia on our icu was lower in comparison with the visep and nice-sugar. this may be explained by the availability of a poct on our icu which allows quick adjustments of the insulin dosage. conclusions. effective tgc with sprint resolved organ failure faster, and for a greater percentage of patients who had similar admission and maximum sofa scores, compared to a matched retrospective conventional control cohort. these morbidity reductions mirror the reduced mortality seen with sprint. these results suggest that reduced organ failure, assessed by sofa, is a fundamental element in reduced mortality when tgc is implemented effectively. introduction. tight glycaemic control was reported to reduce mortality in selected surgical critically ill patients and lowering of blood glucose (bg) levels was recommended as a means of improving patient outcomes ( ) . however, this approach has been linked with significant risk of hypoglycaemia. recently, several studies have confirmed significant associations between variability of bg levels and patient outcomes ( ). objectives. to evaluate the association between bg variability and hypoglycaemia in a mixed adult icu. methods. retrospective analysis of the prospectively collected and stored bg measurements over a year period, during which tight glycaemic control was targeted in all patients. every day we have calculated the bg coefficient variation as expressed by sd/mean bg level. we have divided the patients into low, medium and high variability groups ( - , - and [ , respectively) . hypoglycaemia was determined if bg was below . mmol/l. for statistical analysis chi-square test and pearsons correlation test was used. results. patients were admitted over the -year period, providing daily data points. bg variability was high in daily measurements ( . %), medium in ( . %) and low in ( . %). hypoglycaemia occurred in measurement points ( . %). hypoglycaemia was observed at all points ( %) when bg variability was high vs. . % when bg variability was medium and . % when bg variability was low and this difference was statistically significant (p = . ). we observed a significant correlation between increased bg variability and hypoglycaemia (r = . , p = . ). conclusions. increased bg variability as expressed by coefficient variation is associated with hypoglycaemia, when measured daily in a mixed icu population employing tight glucose control. decreasing the variability of the bg concentration may be an important dimension of glucose management. if reducing swings in the bg concentration is a major mechanism behind the beneficial effects of glucose control, it may not be necessary to pursue lower glucose levels with the associated risk of hypoglycemia. ). there were two major outliers which may skew the results in favour of the hypothesis. if these two results are removed (fig. ) the statistical significance remains strong (n v * p \ . ; **p = . ; ***p = . )). standard multiple regression analysis found the most useful predictors of t [mid] were 'time with aki' and 'serum urea' (beta coefficient . and . (p \ . ) respectively). crcl, serum creatinine and urine output did not add further predictive statistical power. conclusions. this study demonstrates a reduction in the hepatic metabolism of midazolam associated with aki. this effect is related most strongly to the length of time the patient has suffered with aki. our results are similar to the ncepod report. even with multiple recommendations by ncepod and the national institute for clinical excellence (nice) recognition of the critically ill remains poor. detection of organ failure risk is vital to implement preventative strategies. we found a delay in aki recognition and a lack of risk assessment. observations, included in admission protocols, were recorded, but investigations outside of these, were often absent. nice suggest management should be physiologically and not diagnosis based but few patients had a documented physiological plan. we suggest improving under and postgraduate education to increase awareness of aki. this could occur as an extension to the national, acute life-threatening events recognition and treatment course. an aki admission protocol may allow identification of at risk patients and instigate appropriate monitoring, investigation and management. improved ward based fluid monitoring and management would reduce deterioration. incorporation of a physiological monitoring plan on the icu observation chart may reduce preventable aki. there was no effect in patients with extensive stroke and high severity of a glasgow score ( - points in an observational prospective study, a total of patients who admitted during months in a medical and surgical intensive care unit and didn t have any recent history of renal replacement therapy were included in the study. ( %) of all patients was in aki (acute kidney injury) group according to the akin (acute kidney injury network) definition. the mean of age in aki group was more than non-aki ( . ± . , . ± . respectively; p \ . ); and had worse condition according to apache ii (acute physiology and chronic health evaluation ii) score ( . ± . vs. . ± . ; p \ . ). the aki patients stayed longer in icu rather than non-aki patients ( . ± . vs. . ± . days respectively; p \ . ); with more mortality rate ( . vs. %; p \ . ). also the mechanical ventilation days, time of vasoacive drugs and the use of dobutamin were more in aki group (p \ . ; p = . and p = . respectively). the aki was a significant predictor for mortality using the multivariate logistic regression (or adj = . ; %ci: . - . ); and had the same sensitivity as the apache ii score in prediction of mortality (sen. = . ). objectives. the purpose of this study was to evaluate renal function in children with congenital heart disease (chd) undergoing cardiac surgery with cpb. we conducted prospective, non randomized observational study at the tertiary care university children's hospital -bed surgical icu. study protocol was approved by hospital ethics commission. the study included patients with chd with body weight from . to kg (mean . ± . kg) and age from days to years (mean age months). there were patients with ventricular septal defect (vsd), patients had atrioventricular septal defect (avsd), two had total anomalous pulmonary venous drainage (tapvd), one had tetrology of fallot (tof), one had transposition of great arteries (tga), and one had aortic stenosis, requiring ross operation. urine was collected in the postoperative period during the first h after surgery for determination of clcr. the serum creatinine (scr) level was determined by jaffé s method (cobas analyzer, roche). harrison am et al. [ ] shows that estimated creatinine clearence (clcr) using schwartz formula does not accurately predict clcr. therefore we used standard formula for clcr calculations. urine output, inotrope score, duration of aortic cross clamping and cardiopulmonary bypass was recorded. we applied rifle criteria to assess renal functions, using clcr as a variable reflecting glomerular filtration rate (gfr). objectives. evaluate whether a real-time alert of worsening of rifle class, through the physicians' dect telephone system, would affect therapeutic interventions for aki and progression of rifle class. single centre, prospective intervention study during a -month period in our bed surgical and medical icu. three study phases were compared: a . -month control phase (con ) where physicians were blinded for the electronic alerts, a -month intervention phase where electronic alerts of worsening rifle class were made available to the physicians through the dect telephone system (int), followed by a second . month control period (con ). pasw statistics was used for statistical analysis and a double sided p value of . was considered as significant. at study entry, before and after to receive antioxidant or placebo concentration the blood was drawn, to posterior determination of thiobarbituric acid reactive species (tbars), protein carbonyls, total nitrite concentration and il- . results. the use of nac+dfx decreases oxidative damage parameters. patients at antioxidant arm have, despite not reaching statistical significance, a decrease on plasma il- levels h after the start of treatment. as observed to oxidative damage parameters, il- returned to the placebo levels after the end of antioxidant administration. the nitrite levels increased h after nac+dfx, returning to placebo levels and h. the incidence of arf using the rifle criteria was not significantly different in the two arms, and this was also true to a number of secondary end points, none of which showed significant differences between the treatment arms. analyzing the subgroups of the sofa score we observed at day a worse cardiovascular sofa in the nac+dfx arm ( . ± . vs. . ± . , p = . ) and a better renal sofa in antioxidant treated patients ( . ± . vs. . ± . , p = . ). conclusions. we demonstrated that nac + dfx administration was able to decrease plasma markers of oxidative damage and to a minor extend il- plasma levels. we believe that the use of antioxidants could be an alternative adjuvant therapy to prevent arf in critical ill patients with hypothension. table were found to be independent risk factors for postoperative aki: objectives. we aimed to access prospectively whether the use of antioxindants has beneficial effects in renal function of critical-ill patients undergoing imaging studies with intravenous radio-opaque agents (ivca). patients were recruited from those hospitalized in a tertiary intensive care unit between and . inclusion criteria were: a) requirement for imaging studies with ivca b) no use of renal replacement therapy. patients were randomized to receive before and after imaging, either antioxidants (n-acetyl-cysteine , mg and ascorbic acid g and ml ns . %) (sg) or cc ns . % (cg). renal function was assessed by serum levels of creatinine and cystatin c assessed before and at , h following administration of ivca. patients were followed until discharge. systatin c was measured by elisa. conclusions. the results of this study suggest that the use of preventive antioxidant therapy may protect critical-ill patients from contrast-induced nephropathy. our preliminary results have to be confirmed in larger cohorts. acute coronary occlusion is the leading cause of cardiac arrest. because of limited data, the indications and timing of coronary angiography and angioplasty in survivors of out of hospital cardiac arrest are controversial. objectives. using data from the parisian region out of hospital cardiac arrest (procat) prospective registry, we performed an analysis to assess the impact of an invasive strategy on hospital survival. between january and december , survivors of out of hospital cardiac arrest were referred to a tertiary center in paris, france. in survivors with no obvious extra-cardiac cause of arrest, an immediate coronary angiogram followed if indicated by coronary angioplasty was performed at admission. the prognostic value of pre-hospital and in-hospital characteristics on in-hospital mortality was evaluated using logistic regression analysis. results. at least one significant coronary artery lesion was found in ( %) therapeutic hypothermia has been shown to improve survival and neurological outcome in patients who have suffered out-of-hospital cardiac arrest and in whom the initial rhythm was ventricular fibrillation (vf) [ , ] . international guidelines now recommend the use of therapeutic hypothermia as part of post-resuscitation care in patients fulfilling the above criteria [ ] . objectives. we surveyed current practice regarding the use of therapeutic hypothermia for post resuscitation care in northern ireland (ni) intensive care units. a questionnaire was devised, reviewed and agreed by each author prior to posting to the lead clinician in each of northern ireland's adult intensive care units. a % response rate was obtained. we asked about the existence of a protocol for cooling, which patients were cooled, duration of cooling, by what particular method(s) cooling was achieved and how temperature was monitored during cooling. results. out of ( %) adult icus in ni institute therapeutic hypothermia routinely as part of their post-resuscitation care. only out of the units ( %) have a protocol for institution and maintenance of hypothermia. all units that utilise hypothermia do so regardless of the initial cardiac rhythm. out of ( . %) icus target a temperature of - °c with out of ( . %) targeting a temperature of - °c. all units utilise surface cooling methods with out of ( %) also using cold intravenous fluids occasionally. out of ( %) units cool for - h, ( . %) unit - h and unit - h. all units use more than one method of temperature monitoring during cooling. all units sedate patients during cooling and out of ( . %) also routinely curarise patients during cooling. the units that do not currently use therapeutic hypothermia cited lack of resources/funding as the main obstacle to adopting this evidence based practice. conclusions. the practice of therapeutic hypothermia post cardiac arrest has been embraced by the majority of icus in ni. there appears however to be variation in the target temperature and duration of hypothermia once instituted. icus that cool patients appear to do so regardless of initial cardiac rhythm. regional protocolisation of this therapeutic modality may help standardise practice across ni icus. reference(s we compared our data with those from retrospective audit [ ] . the method of th was via surface cooling technique together with cold intravenous saline infusion but not ivcd. total patients presented with cardiac arrest: underwent th ( ooh vf/vt and ooh non-vf/vt). in , there was an overall improvement in adherence to the audit standards, as shown in table : table : table hospital survival rate of th % gcs of the survivors at icu discharge / ( %) / ( %) / ( %) / ( %) conclusions. introduction of ivcd has led to an improved compliance with local and ilcor th guidelines. although the total numbers are small, there has been an increase in the patients discharged with gcs from our icu using ivcd. there are areas that require further improvement, notably the time to reach target temperature and prevention of rebound hyperthermia. work continues on protocolised evaluation of neurologically damaged survivors. rd esicm annual congress -barcelona, spain - - october s target temperature management after out-of-hospital car-diac arrest, an international, multi-centre, randomised, parallel groups, assessor blinded clinical trial-rationale and design of the ttm-trial n. nielsen , , and the ttm-trial study group helsingborg hospital, department of anesthesia and intensive care medicine, helsingborg, sweden, lund university, department of clinical sciences, section of anesthesia and intensive care medicine, lund, sweden introduction. experimental studies and previous clinical trials suggest an improvement in mortality and neurological function with induced hypothermia after out-of-hospital cardiac arrest (ohca). previous trials have included highly selected populations and the optimal target temperature is not known. objectives. to evaluate differences in efficacy and safety with target temperature management at and °c for h after ohca of presumed cardiac cause. methods. intervention: patients will be managed with h of temperature control at versus °c according to randomisation. temperature control will be delivered with temperature management equipment at the discretion of the trial sites. to facilitate cooling, when applicable, and to stabilise the circulation all patients will be treated with ml/kg of crystalloid infusion ( °c or room temperature according to treatment arm). design. randomised trial with : concealed allocation of ohca patients to temperature control for h at versus °c with blinded outcome assessment. sample size is based on a relative risk reduction of % with a risk of type- error of % and a power of % with a % loss to follow-up. conclusion. this study demonstrated that health care professionals, despite guidelines, are hyperventilating simulated cardiac arrests patients. suboptimal ventilation was a problem across all the backgrounds investigated; although doctors performed best here, they were still found to be hyperventilating to an unacceptable level. hyperventilation has a number of deleterious physiological effects and is associated with poor outcomes. increased training, awareness and recertification may be the answer, and certainly improves short term compliance with guidelines. however, these effects may be short lived and other changes may be needed. a reasonable course of action may be the use of paediatric ( l) self inflating reservoir bags as a first line device. this simple measure may ensure delivery of more guideline consistent ventilation, independent of the level of experience. extracorporeal life support (ecls) has been proposed as the ultimate heroic rescue measure in prolonged cardiac arrest unresponsive to conventional cardiopulmonary resuscitation. ecls effectiveness in out-of-hospital cardiac arrest remains to be addressed. decision to discontinue cpr due to medical futility is based upon presumed prolonged anoxia, with existing guidelines for termination. however, even when ecls is implemented, failure to maintain stable hemodynamic conditions due to marked capillary leak frequently results in patient's death. to evaluate the usefulness of routine laboratory parameters in the decision to treat refractory cardiac arrest patients with ecls . methods. sixty-six adults with witnessed cardiac arrest of cardiac origin unrelated to poisoning or hypothermia undergoing cardiopulmonary resuscitation without return of spontaneous circulation (duration: min [ - ], median, [ - %-percentiles]) were included in a prospective cohort-study. ecls was implanted under cardiac massage, using a centrifugal pump connected to a hollow-fiber membrane-oxygenator, aiming to maintain ecls flow c . l/min and mean arterial pressure c mmhg. introduction. due to the human lifespan increasing, people are living longer. cardiac arrest (ca) in old people could be seen as a natural end of life process and cardio-pulmonary resuscitation (cpr) in this setting as a disturbance. therefore, the question of prognosis in patients has been raised when performing cpr in the elderly. data from the s found month mortality in % of patients over suggesting that cpr in elderly people could be futile ( ) . the recent progresses in the management of resuscitated patients, such as mild hypothermia, were not evaluated in patients older than years ( , ) . in a recent study, we found that age [ years was an independent pejorative prognostic factor ( ) . hence there is virtually no data of prognosis factor of elderly patients after ca. our aim was to determine the prognosis factors in patients older than years successfully resuscitated. methods. all patients admitted to icu for ca with successful rosc were consecutively included between and . ca data were prospectively entered in a registry according to utstein recommendations. patients were managed following standardized procedures. good prognosis was defined as cpc or at icu discharge. factor associated with a good outcome were identified using multivariate analysis. results. among , patients admitted for ca, were older than years. median age was . years ( - ), ca was from cardiac origin in % of patients and . % had a vt/vf initial rhythm. mean no flow (nf) and low flow (lf) were . (± . ) and . min (± . ). mean blood lactate and creatinine level at admission were . mmol/l (± . ) and lmol/l (± ). . % of patients presented post-resuscitation shock (prs) and . % were treated with hypothermia. conclusions. ca in elderly patients is associated with an in-icu % good outcome rate. this should promote the cpr in non-severely disable elderly patients with ca regardless of their age. we plan to collect the -month mortality and the functional status of survivors. introduction. post-resuscitation phase is often characterized by a ''sepsis-like'' syndrome, which may be associated with the development of organ dysfunction. microcirculatory abnormalities play a key role in sepsis-related organ failure; however no data are available on microvascular function after cardiac arrest (ca). objectives. the aim of this study was to investigate peripheral microcirculation during and after therapeutic hypothermia (th) in ca patients. methods. this prospective, observational study included patients treated by th after ca. sublingual microcirculation was evaluated using sidestream dark-field (sdf, microscan, the netherlands) videomicroscopy at hypothermia and normothermia in all patients. at least images of s each from separate areas were recorded at each time point and stored under a random number to be analyzed, using a semi-quantitative method, by an investigator blinded to time and condition. thenar oxygen saturation (sto ) was measured using a tissue spectrometer (inspectra ; hutchinson, usa). a vaso-occlusive test was performed at hypothermia and normothermia by rapid inflation of a pneumatic cuff around the arm to evaluate sto reperfusion rate, reflecting microvascular reactivity. results. compared to hypothermia, measurements at normothermia showed a significant increase in functional capillary density (fcd) from . ± . to . ± . n/mm (p = . ), the proportion of small perfused vessels (ppv) from ± to ± % (p = . ) and mean flow index (mfi) from . ± . to . ± . (p = . ). fcd and ppv values were significantly correlated with body temperature. sto reperfusion rate was largely decreased when compared to healthy volunteers, but it did not change over the study period (from . ± . to . ± . %/sec) and showed large inter-individual variability. the same was found for sto (from ± to ± %). conclusions. mild hypothermia is associated with decreased fcd and ppv in the sublingual area when compared to normothermia. microvascular reactivity is decreased but changes are unpredictable. introduction. acute posthypoxic myoclonus (phm) occurs in deeply comatose patients, soon after a hypoxic episode. it is characterized by generalized, severe body jerks with violent flexor movements, but more focal myoclonus is reported too ( ) . acute phm and status myoclonus are considered to have a poor prognostic outcome ( , ) . although the cerebral cortex is known to be the most common origin of myoclonus in ambulant patients ( ) , the origin of acute phm is uncertain ( ) . to determine whether acute phm originates from damage in cortical or subcortical structures. for this study patients with myoclonus in the first h after admission were selected from the propac ii study, a prospective cohort study including patients admitted after cpr and treated with hypothermia. exclusion criteria: pre-existing disease with life expectancy\ months and severely disability before cpr. baseline characteristics were used from the main database. additional data of eeg and ssep recordings made after rewarming were collected. eegs were evaluated for presence of epileptic activity, status epilepticus, generalized periodic discharges, burst suppression pattern, iso-electric or low voltage amplitudes and reactivity of the background pattern. data collected from sseps: n potential, giant potential (defined as a potential five times the size of a normal potential) and p /n amplitudes (done by jhk). the glasgow outcome scale (gos) was used to assess outcome after months, poor outcome was defined as a gos of - (death, vegetative state, severe disability), good outcome as a gos of - (moderate disability, good recovery). . from a total of patients included in the propacii study, ( %) patients developed myoclonus. baseline characteristics of this group: age , % male, time to rosc min, primary cardiac arrest in patients, hypoxic arrest in . ssep recordings were available from patients. n potentials were present bilaterally in % ( ) and giant potentials were seen in % ( ) of the patients with a present n potential. eegs were made, epileptic activity was seen in % ( ) and a status epilepticus in % ( ), thus % of the eegs did not show any type of epileptic activity. good outcome was seen in % of the patients, poor outcome in %. mortality was %. conclusions. the results of this study show that acute phm is found in % of patients admitted after cpr and treated with hypothermia. it did not necessarily lead to a poor outcome, but we did not have information about the type of myoclonus. the available data seem to support the idea that the myoclonus originates mainly from subcortical structures, given the low number of patients with eegs showing epileptiform activity and sseps with giant potentials, which can be seen in cortical myoclonus ( ). introduction. the international liaison committee on resuscitation, the american heart association and the european resuscitation council recommend that mild therapeutic hypothermia improve neurological outcome in unconscious adult patients with return of spontaneous circulation (rosc) after out-of-hospital cardiac arrest (ohca) due to ventricular fibrillation (vf) or ventricular tachycardia (vt). in our intensive care unit (icu) we use mild hypothermia in all patients following cpr with successful rosc regardless of initial rhythm. in this study we compared the effect of mild therapeutic hypothermia at neurological outcome and mortality between the patients who had ohca due to vf or vt and them who had ohca due to a different initial cardiac rhythm as asystole or pulseless electrical activity. the study protocol was approved by the local ethics committee on human research. a total of patients were admitted to our icu with rosc after ohca between may and december . therapeutic hypothermia was initiated after admission in icu by intravenous infusion of cold saline ( °c , ml bolus) followed by intravenous cooling device (coolline catheter, coolgard alsius corporation irvine, ca, usa). the target temperature was °c maintained for h followed by slow active re-warming over a minimum period of h ( . °c per hour). intravenous anesthesia was induced in all patients by a combination of propofol and remifentanyl with dose adjustment as needed. to prevent shivering, patients received muscle relaxation by iv administration of sisatracurium every h. the primary end point was the neurological outcome at months according to the pittsburgh cerebral performance category (cpc). secondary end point was mortality at months. prehostital cooling procedures were not applied. nine of the patients ( %) of the group of the patients who had ohca due to vf or vt had favourable neurological outcome cpc or as compared with of ( %) of the group of the patients who had ohca due to a different initial cardiac rhythm. mortality at months was % ( of patients died) in the group of the patients who had ohca due to vf or vt as compared with % ( of patients died) in the group of the patients who had ohca due to a different initial cardiac rhythm. in patients who had ohca due to vf or vt mild therapeutic hypothermia inproves the neurological outcome and reduces mortality as compared with the patients who had ohca due to a different initial cardiac rhythm. objectives. we aimed to compare therapeutic hypothermia using either surface or endovascular techniques in terms of efficacy, complications and outcome at our institution, a bedded tertiary referral icu. a local research ethics committee reviewed the proposed study and waived the need for a full ethics submission, as the study met the national criteria for service evaluation. data were collected from patients undergoing therapeutic hypothermia following cardiac arrest over a . year period by retrospective casenote review and interrrogation of the carevue (phillips uk) database. therapeutic hypothermia was initiated in the icu using iced hartmann's solution, followed by either surface (n = ) or endovascular (n = ) cooling; choice of technique was based upon endovascular device availability. the target temperature was - °c for to h, followed by rewarming at a rate of . deg h - . the mean age was ± years; % of arrests occurred out of hospital, and % were ventricular fibrillation/tachycardia. endovascular cooling provided a longer time within the target temperature range (p = . ), less temperature fluctuation (p = . ), better control during rewarming ( . ), and a lower -h temperature load (p = . ). endovascular cooling also produced less cooling-associated complications in terms of both overcooling (p = . ) and failure to reach the target temperature (p = . ). after adjustment for known confounders, there were no differences in outcome between the groups in terms of icu or hospital mortality, ventilator free days and neurological outcome. conclusions. endovascular cooling provides better temperature management than surface cooling, as well as a more favorable complication profile. the equivalence in outcome suggested by this small study requires confirmation in a randomized trial. introduction. ventricular assist devices (vads) are successfully used in patients with end stage heart failure, usually as a bridge to transplantation or recovery, but increasingly as destination therapy as well. a major threat for patients with a vad is the frequent occurrence of, mainly thromboembolic, stroke, with a reported incidence of up to %. manufacture guidelines for anticoagulation therapy are based on relatively small observational studies and common sense rather than evidence, and as a consequence anticoagulation protocols vary widely between centers. objectives. the aim of this systematic review was to provide more evidence in order to determine the optimal anticoagulation protocol to prevent stroke in patients supported with a vad. a systematic search in pubmed and embase was performed in which we included all types of vads. all types of anticoagulation drugs applied to prevent thromboembolism were included and divided in three categories; heparin, coumarins and antiplatelets. we included references with a full text available, written in english, dutch, german or french, and which described patients with a stroke or tia. our primary outcome measure was defined as the onset of any type of stroke. two authors evaluated independently the results of this search; doubtful references were evaluated by two other authors. after critical appraisal articles were selected as relevant, which include cohort studies, case-control studies and trials, totaling patients with vad support between and . the mean age was years (range - ) and the mean duration of support was days ( - ). stroke occurred in - % patients supported by vad, with an incidence of - /patient-year. the majority of strokes occurred within the first year. six types of anticoagulation protocols were used that combines drugs from one or all three categories. most protocols used a combination of all categories ( , patients with a total follow up of , days) and had an average stroke incidence of . events/patient-years. the lowest average stroke incidence was reported in studies that used only antiplatelets ( . events/patient-years) and the highest in which only heparin was used ( events/patientyears). we could not detect a decreased risk for stroke in patients with vad support when coumarines or heparin were used instead of or in addition to antiplatelets. antiplatelets should be part of an anticoagulation protocol to prevent stroke in patients supported by vad. a.m. de la torre , c. marco , d.j. palacios , a. pedrosa , i. lopez de toro , v.a. hortigüela hospital virgen de la salud, toledo, spain objectives. to analyze the difference between two groups of patients with ich considering severity, treatment, evolution and mortality. methods. description retrospective study of admitted patients between st of january of to st of december and st of january of to st of december in the icu of virgen de la salud hospital (toledo) with the diagnosis of ich. there are patients in the group of - and patients in the groups of - without any difference of age. regarding comorbidity between the two groups no differences can be found regarding the previous presence of hta, but regarding diabetes and dislipemy, we do find a higher prevalence on the second group ( . vs. . %, p \ . and . vs. . %, p \ . respectively). reviewing the presence of anticoagulated patients, no differences of significance can be found, but a trend ( . vs. . %, p \ . ). regarding the location of the hemorrhage, the most frequent is the basal ganglia ( . vs. %), existing no differences amongst the two groups. we don't find differences either in the presence of a intraventricular component, whether it is neither supratentorial nor infratentorial. there are differences between the ich score of both groups with p \ . : with a score of ( . vs. conclusions. an increase in the comorbidity can be observed in the included patients, which can be due to a better screening of these pathologies. we also find that the ich score is higher than in the - sample, which is attributed to the admittance in the icu of patients with the ultimate goal of organ donations. in the evolution, it can only be observed a longer stay in patients from the second sample, likely because they are more serious patients with a higher ich score. the analysis of the two groups has not been conclusive when it comes to assessing the improvements that might have come out in these last years, although it is necessary a deeper analysis of the data. introduction. sodium dysbalances are frequent medical complications in patients with subarachnoid hemorrhage (sah). hyponatremia is more frequent but it is associated with better outcome than hypernatremia. the aim of this study was to observe differences in outcome between hyponatremic and hypernatremic patients with sah. we performed the prospective years study in incidence of hyponatremia (serum sodium \ mmol/l) and hypernatremia (serum sodium [ mmol/l) in patients (pts) with sah. we compared the incidence of cerebral complications, glasgow outcome scale (gos) upon discharge from the neurointensive care unit (nicu) and in mortality nicu. results. there were ( %) pts with dysnatremia, more patients had hyponatremia ( , %), less hypernatremia ( , %). between these groups there were no diferences in stay in nicu (p = . ), duration of dysnatremia (p = . ), fluid intake (p = . , ml/day), daily sodium intake (p = . , mmol/day) and fluid output (p = . , ml/day). hyponatremia was more frequent on admission (p \ . ) and connected with higher diuresis (p \ . ). hypernatremic pts received more antiedematic therapy (p \ . ). hypernatremia was arised in pts with significantly lower glasgow coma scale (p = . ). these pts had more cerebral complications (p = . ), worse glasgow outcome scale upon discharge from nicu (p \ . ) and higher mortality in the nicu (p = . ). conclusion. dysnatremia is frequent in patients with sah ( %). hyponatremia occurs more often, but hypernatremia is connected with worse outcome. objectives. to analyze clinical, epidemiologic and outcome differences and to identify predictor factors of mortality at discharge from icu of patients admitted after craneoencephalic trauma (cet) according to glasgow coma scale (gcs) score. observational prospective study of patients admitted in the intensive care unit (icu) after cet. we classified the traumatic brain injury, according to gcs score of b or c points groups. we analyzed clinical and demographic data during icu stay, as well as physiological, functional and emotional data measured with paecc scale (project for the epidemiological analysis of critical patients) at discharge from icu. qualitative variables are expressed as a percentage and quantitative variables as mean and standard deviation. we used chi test, t-student and multivariate analysis as required with a maximum alpha error of %. we analyzed patients, . % male. at admission . % had gcs b . traffic accidents ( . % in gcs c and . % in gcs b ) were the most frequent cause of cet. there was a higher rate of out hospital hypotension in the gcs b group (p = . , or . , % ci . - . ). cranial computed tomography (ct) scan findings in the gcs c group were diffuse injury i and ii ( . %) after marshall classification versus . % in the gcs b group (p = . ). fewer complications were detected in patients in the gcs c vs. gcs b group ( . vs. . %, p = . , or . , % ci . - . ). icu mortality rate was significantly lower in the gcs c group than in the gcs b group ( . vs. . , p \ . ). predictors of mortality were gcs at admission (p = . ), ct findings type iii, iv and v (p = . , . and . respectively), complications (p = . ), tracheotomy (p = . ), days on ventilator (p = . ), apache ii (p = . ) and the length of icu stay (p = . ). best overall score in paecc questionnaire at discharge from icu was better in the gcs c vs. gcs b group. ( . ± . vs. . ± . , p = . ). conclusions. patients with lower gcs at admission presented higher rate of prehospital hypotension, more severe ct findings, more complications at icu, worse physiologic, functional and emotional outcome, and higher rate of mortality, than patients with gcs c . factors associated with increased mortality were coma level, type of findings in ct, complications, prolonged mechanical ventilation, length of icu stay, apache ii, and the need for a tracheotomy. objectives. the aim of our study was to estimate the influence of hyperhaes infusion on haemodynamic regulation. we examined patients with severe brain trauma (gcs score \ , sedation, artificial ventilation). the bp, stroke volume (sv) and their variability (bpv, svv) were determined by the bioimpedance method. additionally we determined the peripheral pulse (pp) and its variability (ppv) using plethysmography curve registration. special attention were paid to the p ( . - . hz) and p ( . - . hz) bands of bpv, svv and ppv, connected with volume state, breathing, and autonomic regulation, especially baroregulation. all the comparisons were made before and after min. of the infusion of hyperhaes ( ml). all patients had the autonomic dysfunction: the waves of baroregulation (p ) had low power compared with healthy. hypovolemia was moderate: sv ( ± . ) and pp ( ± . ) were slightly decreased, but bp were ± . mmhg. the bp increasing was registered as the first reaction on the infusion of hyperhaes ( ± . mmhg). the same time pp increased more then twice and became ± . , and p of ppv decreased from ± . to ± . , that reflected the improving of the volume state. although sv did not rise significantly, the increasing of p were estimated in svv, as a marker of the baroregulation restoration. conclusions. the infusion of hyperhaes in severe brain trauma not only decrease the range of hypovolemia, but restore the baroregulation as a significant part of autonomic regulation, needed for cerebral perfusion support. introduction. continuous measurement of intracranial pressure (icp) using intraparenchymal sensors has become part of the standard management of patients at risk of developing intracranial hypertension. whilst reliability has been explored previously little is published on the accuracy of depth to which the sensor is placed. a difference in sensor location has been shown to affect the reliability of icp readings and could impact negatively on patient management ( ). to determine whether icp sensors (codman, j&j) placed by neurosurgical staff were within the optimum depth of cm from the cortex. methods. consecutive patients were identified from a prospectively collected neuro icu database who had had a ct of the head (cth) performed whilst an icp sensor was in situ during . the depth of the sensor tip on cth was measured and patients were stratified according to whether they had surgery or no surgery to determine any differences between open and percutaneous placement. of the icp sensors ( %) were placed deeper than cm. the greatest incidence of deep placement was in surgical patients / ( %) and in craniotomy patients % of these were deeper than cm conclusions. this investigation has shown that the majority of patients admitted to our neuroicu have less than optimally placed icp sensors. inappropriately deep sensors appear more common in surgical patients, particularly following craniotomy. the impact of this on patient outcome is unknown and would require further study. this study has highlighted we need to implement new methods to improve the accuracy of our icp sensor placement. graduated marks on the sensor sheath during manufacture may assist accurate placement. conclusions. if icp is largely used, it remains below %. % of the cases have been monitored with at least techniques suggesting an acceptance tendency for a multimodal monitoring. among these techniques, the control of pco seemed considered important as the use of tcd to assess perfusion and vessel tone. on-going analysis of these data will provide information on the therapeutic strategy performed and the impact on outcome. introduction. raised intracranial pressure (ricp) can be evaluated sonographically by measuring the optic nerve sheath diameter (onsd). a wide variation in the threshold measurement of onsd for ricp has been reported in literature. it is likely that exaggeration of the hypoechoic edge artifact around the dura by high frequency ([ mhz) linear transducers and uncertainty over whether to measure -mm behind the papilla or behind the globe (posterior margin of sclera) could have resulted in such differences. to determine the optimal site of measurement of onsd by correlating it with ricp determined clinico-radiologically. we also evaluated if different sonographic appearances of the onsd could be used qualitatively to determine the presence or absence of ricp. methods. initially, in order to precisely delineate the anatomical dura sonographically and assess optimal cursor placement, cadaver orbital preparations were studied before and after subarachnoid fluid insufflation. scans were then done by a single sonographer using a - mhz linear transducer on healthy volunteers and patients admitted to the medical/ neurosurgical intensive care units. onsd was measured at locations; -mm behind the papillae and -mm behind the globe. in each location measurement was made within the anatomical dura and another between the echogenic margins of retrobulbar fat as described in literature. four patterns (fig. ) of the nerve sheath were identified based on the appearance of the csf space and edge artifact. ricp was diagnosed by clinically correlated computed tomography of the brain. an independent sample t test was done to correlate measurements with ricp. classification of optic nerve sheath appearances results. / ( %) scans were done on patients with ricp. all measurements independently correlated with ricp (p \ . ); albeit cut-offs differed substantially ( table ) . the presence of a type pattern (fig.) in both eyes strongly suggested ricp ( % positive predictive value) whilst its absence in both eyes ruled out ricp ( % negative predictive value). methods. three years after the introduction of the concept of bs in our icu, a questionnaire was sent to people directly involved in the nursing of critically ill patients to study the current practice during the previous month. responses were received from persons, a % response rate. ( %) persons had practiced bs. only ( %) employees used calming bath and ( %) an invigorating bath. guided oral care and guided suction was performed respectively by ( %) and ( %) nursing persons. orientative positioning was used by ( %) nurses. everybody is very satisfied with the instruction manual which can be found in each room. ( %) persons estimated to be well informed about bs. others wanted more practice course and training at the bedside. conclusion. pattern suggested an increasing interest in bs since its introduction. initial touch is well implemented. more effort is needed for continuous education and training. introduction. admittance to hospital for surgical treatment, is often linked with insecurity and anxiety for many patients. to most patients, the postoperative care unit constitutes an unknown environment, and can represent a frightening experience. research has shown that preoperative information leads to subjective outcome as anxiety reduction, and objective outcome as shorter hospital stay and less intake of pain medication. few studies, however, have addressed patients' experiences with preoperative information about the early postoperative phase. objectives. the purpose of this study was to describe patients' experiences with preoperative information about events they may experience during their stay in the postoperative unit. patients' experiences may contribute to increased knowledge about this topic. the study design was exploratory-descriptive, and a semi-structured interview based on thematic guide was used. nine patients met the inclusion criteria, and they had an average age of years. they were admitted to elective surgery for cancer and their stay in the postoperative unit varied from to . days. the interviews were conducted - days after surgery and transcribed verbatim. the data material was subjected to qualitative content analysis. results. experience with information before surgery and in the early postoperative phase, was categorized into four themes: being prepared before surgery, reactions to differing experience, discomfort and pain, management of some self-care activities and experiences with the environment of the postoperative unit. conclusions. the patients received a fair amount of information before surgery, but only limited information concerning what to expect while in the postoperative unit. the patients' information needs differed and patients with former experience with surgery were more prepared for what to expect. the patients got mainly verbal information and most of this was given the day before surgery. o.m. peters-polman , m. van roosmalen , j.e. tulleken , j.g. zijlstra umc groningen, intensive care, groningen, netherlands, arup nederland, amsterdam, netherlands, umc groningen, groningen, netherlands background. who guidelines concerning sound levels in hospitals requires a maximum of db in daytime, a nighttime sound level below db to allow good sleep quality and peak levels that do not exceed db at all times. in an icu environment, apart from being critically ill, patients are exposed to typical icu environmental noise. sleeping cycles disturbed by illness are further disrupted by care providers performing procedures and taking vital signs and alarms with delirium as a common result. we describe the acoustic environment in our mixed icu. we conducted an observational study in which we continuously measured the sound level (db), frequency and repetition of sound in our icu. we used a splnet microphone and noise monitoring system which was placed, after informed consent, at the ear level of the patient. results. noise sources are numerous and consist of human voices, doors slamming, pagers, telephones, shoes and equipment alarms. there is a round the clock continuous background noise of - db, staff conversation with levels of - db and peak levels up to - db, mainly due to alarms. these levels of sound are comparable to loud conversation at meter distance ( - db), walking along a motorway ( - db) or standing next to a roaring engine ( db). conclusion. who guidelines clearly state maximum sound levels of db in daytime, db at night and peak levels of db. the sound level in our unit is exceptionally and unacceptably high throughout day and night and requires a behavioral intervention. further research on the influence of these noise levels on our patients is necessary. objectives. this study has been achieved in order to realize the comparison of efficiency of manual and mechanical compression techniques used for the maintenance of haemostasis after femoral sheath removal. methods. this study was planned and applied as a randomized controlled trial. the study was executed at a military education and research hospital in turkey between january and march . data collecting form was prepared by the investigators after the literature examination. the form consists of questions which are evaluating the demographic data of patients, the compression time, the pain level (before sheath removal, during the manual/ mechanical compression and after the sheath removal), the complications occurring in femoral zone, the mobilization/discharge period and the problems (bruise, oedema, hemorrhage and etc.) occurring the th day after the discharge. the patients have been called up in order to evaluate the problems occurring on the th day. the persons that were applied mechanical compression have constituted the experimental group and the patients that were applied manual compression have formed the control group. the patients volunteer to participate to the study have been informed in regard with the implementing procedures before the application. descriptive statistics were shown in numbers and percentages for the variables obtained by counting and in mean ± standard deviation for variables obtained by measurement. results. the average of age is . ± . in the experimental group and is . ± . in the control group. the average of compression time is . ± . min in the experimental group and is . ± . min in the control group (p \ . ). the average of mobilization time after sheath removal is . ± . min in the experimental group and is . ± . min in the control group (p \ . ). it has been observed a lower pain level during compression and after sheath removal in patient that were applied mechanical compression in comparison to the patients that were applied manual compression(p \ . ). when the groups were compared in terms of femoral zone complications while no haematoma was observed in the experimental group, haematoma has been occurred in the . % (n = ) of the control group. conclusions. the mechanical compression provides an earlier mobilization and earlier discharge of the patient. this study shows that mechanical compression is a method as safety as the manual method in order to obtain a haemostasis a correlational survey was conducted in public hospitals located in athens. critical care nurses completed anonymous questionnaires , , yielding a response rate of %. greek critical care nurses believe that open visiting increases family's satisfaction ( . %), exhausts family members ( . %) and provides emotional support to the patient ( . %); nevertheless the effects of visiting depend both on patient and family ( . %). furthermore open visiting hampers the planning of adequate nursing care ( . %) and is not a helpful support for the caregivers ( . %) while increases their physical and psychological burden ( . %). critical care nurses' attitudes toward visiting hours were rather negative and they didn't want to liberalize the visiting policy of their unit ( . %). there was a positive correlation between nurses' beliefs and attitudes regarding visiting (r = . , p \ . , r = . , p \ . ). the factors ''working experience'', ''adequacy in staff'' and ''the number of shifts'' were found to be independently correlated and they predicted the score of the scales of the questionnaire. greek icu nurses have rather negative beliefs and attitudes toward visiting and open visiting policy. this will be a challenging barrier to overcome when imposing new flexible policies in icus . objectives. our aim was to elucidate potential mechanisms for the beneficial effects of rhapc on ali, as assessed by microarray analysis of lung tissue after sepsis induced by clp in rats. methods. sepsis (n = ) was induced in rats by clp. a sham-operated group (n = ) underwent laparotomy and closure without clp. a clp group (n = ) received subcutaneous saline ( ml/kg) and a clp + apc group (n = ) additionally received mg/kg rhapc. twelve hours postoperatively, lung tissue was preserved in mrna later until mrna isolation by promega total rna kit and analyzed using illumina beadarray. data were log variance stabilized and quantile normalized using the lumi package in r and the limma package was used for group comparisons and false discovery rate correction. data were further analyzed using panther and david. the clinical outcomes of this study showed a marked attenuation of the sepsisinduced increase in lung permeability in rats treated with rhapc . although no formal statistical significance was reached for the gene expression changes between the clp and the clp + apc groups, there was a clear attenuating effect of rhapc on the changes in gene expression caused by sepsis reflected in generally lower fold change values and fewer significantly differentially regulated genes in the clp + apc versus sham group compared to the non-treated clp vs. sham group ( vs. genes). nevertheless, there were only genes of which the fold change difference between clp versus sham and clp + apc versus sham was more than one, indicating that although there was a large difference in the number of differentially expressed genes, the difference in fold change between these genes was small. conclusions. these data suggest that the rhapc treatment of septicemic rats does not only cause a down regulation of specific pathways as argued by previous investigators, but leads to a global reduction in the inflammatory response at a mrna level. introduction. septic shock guidelines recommends the use of recombinant human activated c protein (acp) in high risk mortality patients. the aim of our study is to describe the clinical characteristics, and the outcome of patients treated with acp in our hospital. methods. retrospective and descriptive study which includes patients with severe sepsis/ septic shock treated with pca in a tertiary hospital intensive care unit (icu) over years ( - ) . we analyze epidemiological data, reason for admission, infectious focus and agent, severity scores, organ failure, complications, stay and mortality. we used chi-square analysis to compare categorical data and student's t test to compare continuous variables. conclusions. in our study most patients were admitted from emergency department, with organic failure caused by pneumonia. we haven't detected deaths related with acp complications, even in patients undergoing surgery. we found as prognostic factors for mortality: organ dysfunction, acp indication, renal failure, pao /fio relation, amount of vasopressors, bicarbonate and base deficit levels, apacheii and icu stay. objectives. to analyze changes on hemodynamics in patients with severe sepsis treated with high volume hemofiltration ( ml/kg/h) vs. patients treated with very high volume hemofiltration ([ ml/kg/h). we conducted a prospective randomized trial from january to november in patients admitted into icu with a diagnosis of septic shock in which hf was indicated. patients were randomized to one of each group of therapy. the control group received high volume hemofiltration therapy and the experimental group received very high volume hemofiltration. the hemodynamic parameters were measured at the admittance in icu and every h onwards. results. data of patients were collected ( men and women) mean age ± years old. the hemodynamic parameters registered at the admittance and during the therapy had no significant difference between the groups. the control group received hf therapy during . ± . days and the intervention group . ± . days. there wasn't any difference either in the administration of vasoactive drugs between both groups. the most significant difference between the groups was the -day survival rate, . % of the experimental group against . % of the control group (p = . ). from these results we can conclude that very high volume hemofiltration therapy should be the therapy of election because it improves the survival of patients with severe sepsis without impairing the hemodynamic parameters. we have to point out the importance of the nursing staff in the assembly and management of the equipment as well as in the patient care and thus avoiding potential complications. introduction. the use of herbal products is increasing, and may result in increased drug-herb interactions or form a potential for adverse reactions in cardiovascular surgery patients. objectives. the aim of this study was to describe the utilization patterns for herbal products in patients with cardiovascular disease. methods. this was a descriptive study which was carried out among adult patients presenting to cardiovascular surgery department for elective cardiac surgery between september and april in a research and training hospital. after giving informed consent, patients were interviewed by researchers using a structured survey instrument in the preoperative period. results. interviews were conducted with patients (mean age . ± . , range: - years), % of them were married, % were men, and % of the patients had high school or university education. the majority ( %) had coronary artery disease and most of the patients ( %) had concomitant diabetes mellitus and hypertension. the most common used drugs were anti-hypertensives, nsai's, and anti-aggregants. most patients ( %) reported the regular use of drugs. eighty-nine ( %) among the surveyed patients reported the use of herbal products. the most common used herbal products were garlic ( %), apple vinegar ( %), lavandula stoechas ( %), cratageus ( %) and ginger-honey mixture ( %). the average educational degree of herbal product users was found to be higher when compared with the others. many patients report being informed about those products from television, internet, newspapers, herbal-stores personal communications, and report the use of those products after the diagnosis is made. none of those patients have informed physicians or nursing staff about the use of those herbs. the demographic variables of patients and the herbal-product usage has failed to show a statistically significant difference (p [ . ). conclusions. the use of herbal products is common among the patients with cardiovascular diseases. health professionals should be aware of the usage of those products in order to prevent possible adverse reactions and drug-herb interactions. introduction. nurses employed in the icu operate in a complex environment, under time pressure, and with limited information available. thus, errors are inevitable and, besides their adverse consequences, they offer the potential for learning . in this concept, properly copying with errors is a prerequisite for avoiding their recurrence and improving nursing practice. objectives. our aim was to investigate how error-copying strategies are associated with constructive and defensive changes in icu nursing practice. methods. questionnaires were completed (a % response rate) from nurses employed in the icus of adults, children, and the coronary care unit of two greek hospitals, between january-june . ''ways of copying'' scale as revised by wu et al. was used for evaluating copying strategies. this includes copying subscales, each ranging between and . constructive changes in response to error included items (paying more attention to detail, keeping better patient records, reading patient notes more carefully, seeking advice, discussing with colleagues about similar situations, devoting more observation on patients, reading for covering knowledge deficiencies), while defensive changes included items (getting more worried, feeling less confident at work, being more likely not to discuss errors, being less trusting of others, thinking to leave profession.). a four-point likert scale ( - ) was used for evaluating each item, and points were summed to estimate total scores of constructive and defensive changes. . . % of participants were female and . % were registered nurses. mean (±se) age was . ± . years and mean icu experience was . ± . years. multiple linear regressions with constructive and defensive changes in practice as dependent variables and copying strategies as independent variables are summarized in table . participants were more likely to make constructive changes if they coped by seeking social support (p = . ) and accepting responsibility (p = . ). at the same time, they were more likely to make defensive changes if they coped by escape-avoidance (p = . ). reasons for high risks are e.g. sedation and analgesia, immobility, malnutrition and hemodynamic or oxygenation problems as well as poor identification or unsystematic assessment of the risks. in our unit, we performed a months retrospective review of pressure ulcer risks for all patients (n = ) using jackson-cubbin calculator. the risk point level in this instrument is and below. patients of ( %) exceeded the risk limit already in the icu admission phase. objectives. to change care practices of pressure ulcer prevention and care with action research. with the measurement tool nurses are able to identify patients at risk of developing pressure ulcers during the whole icu in-patient time, and to prevent risks of pressure ulcer in an early stage. with the assessment tool, the measurement is systematic which enables the benchmarking and have effects on material recourse planning and cost caused by pressure ulcers. the study unit is a -bed icu for adults taking care annually circa , patients with multiple disorders. firstly, the jackson-cubbin pressure area risk calculator was translated into finnish. a few changes which have an effect on pressure ulcer risk were added; weight limits were also defined with bmi values, hyperbaric oxygen therapy was added in deducted points as well as h limit for blood transfusions and limits for hypothermia from celsius or under. secondly, standardized guidelines for different risk levels were developed; if patients have a high risk specialized mattresses should be used and changes of positions and beds should be stressed. thirdly, an electronic evolution form for patient information system was planned and implemented. finally, a systematic education program for icu personnel including special lectures, material demonstrations and familiarization by the nurse responsible for wound care was started. results. after the development project and systematic education the knowledge of personnel about pressure ulcer risks and care has increased. risk points are counted once a day for every patient using the electronic form. all the mattresses at the icu have been changed to medium and high risk mattresses and are chosen for a patient related to the risk assessment points. conclusions. a reliable assessment scale, systematic measurement and continuous evaluation and education are crucial for identification of high risk pressure ulcer patient at the icus. with a systematic measurement and recognizing high risk patients we can also improve patients' quality of life and reduce the cost caused by pressure ulcers. reference(s ) is considered to be one of the main agents in gram negative sepsis. in recent years several adsorption dispositives have been designed in order to achieve low blood endotoxin levels with a theorical clinical improvement. toramyxin (polymixine b fixed to polyesthirene fibers) and alteco lps adsorber (polyethylene discs) are two of these dispositives. both are used with h sessions for several days until patient clinical improvement. • design a nursery prothocol with the most important procedures in gram negative septic shock patients with acute renal failure that undergo adsorption cartridge therapy. • evaluate initial experience in the use of endotoxin adsorption cartridges. methods. nursery prothocol with special attention to the settlement and management of the cartridge therapy, based on library references and practice guidelines. once prothocol was stablised, prospective observational study was started from january till january . inclusion criteria were: patients admitted to our intensive care department with gram negative confirmed septic shock and acute renal dysfunction requiring continuous renal replacement therapies (crrt). adsorptive cartridge were added and several parameters were studied: heart rate, mean blood pressure, vasopressor support (norepinephrine), pao / fio , and lactate. the information was analyzed in excel. results. nursery protocol was correctly applied in all patients and showed to be basic in the maintenance and early complication detection. hemodynamic improvement that allowed norepinephrine lowering dose and normalized lactate levels with no changes in pao /fio . patient (toraymyxin): years man, acute pancreatitis with septic shock. patient (toraymyxin): years man, pneumococic pneumonia and klebsiella septic shock. patient (alteco): years man, acute pancreatitis with enterobacter cloacae septic shock. patient (alteco): years woman, acute peritonitis with e. coli septic shock. results of a program to reduce catheter-related blood-stream infection in the icu: two years' follow-up a systematic review comparing the relative effectiveness of antimicrobial-coated catheters in intensive care units benefits of minocycline and rifampicin-impregnated central venous catheters which antimicrobial impregnated central venous catheter should we use? modeling the costs and outcomes of antimicrobial catheter use when is hit really hit? anticoagulative management of patients requiring left ventricular assist device implantation and suffering from heparin-induced thrombocytopenia type ii -hit happens: diagnosis and evaluating the patient with heparininduced thrombocytopenia informe del registro mami - grupo de trabajo de la sociedad europea de cardiología (esc) sobre marcapasos y terapia de resincronización cardíaca moreno millán e. variación de la estancia preoperatoria en españa según grupos de edad, sexo y modo de acceso hospitalario reference(s). . association of anaesthetists of great britain & ireland. safety guideline on interhospital transfer intensive care society: guidelines for the transport of the critically ill adult competency-based st st training and assessment. a manual for trainees and trainers. royal college of anaesthetists training and assessment of competency of trainees in the transfer of critically ill patients adverse events experienced while transferring the critically ill patient from ed to the icu a modified mccabe score for stratification of patients after intensive care unit discharge: the sabadell score surviving intensive care. edicion taurine and niacin block lung injury and fibrosis by down-regulating bleomycin-induced activation of transcription nuclear factor-kappab in mice antioxidants and sepsis: can we find the ideal approach? post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. a scientific statement from the international liaison committee on resuscitation therapeutic hypothermia after cardiac arrest: unintentional overcooling is common using ice packs and conventional cooling blankets it's well known that normobaric hyperoxia (nh) increases arterial and brain oxygen tension. however the influence of nh on intracranial pressure (icp) and cerebral metabolism in patients to investigate the dynamics of icp, jugular bulb saturation (svjo ), brain oxygen tension (pbro ) and cerebral metabolism during nh in patients with ich icp monitoring and tissue microdialysis were used in all patients, svjo monitoring -in , pbro -in . microdialysis and pbro catheters were placed in lesioned (les) and intact (int) brain tissue. icp, svjo , pbro , glucose and glycerol levels, lactate/pyruvate ratio dynamics during fio ) to ± mmhg (ð \ . ) (fio . ) and ± mmhg (ð \ . ) (fio . ) cerebral metabolism didn t change significantly, except glycerol level increase in lesioned brain tissue from ( ; ) mlmol/l (fio . ) to ( ; ) mlmol/l (fio . ) and ( ; ) mlmol/l (fio . ). fio . : glucose (int) - . ( . ; . ) mmol/l, glucose (les) - . ( . ; . ) mmol/l, lactat/piruvat (int) - . ( . icp was stable during investigation ( . ± . mmhg nh is accompanied by pao and pbro increase and doesn't influence icp and cerebral metabolism in ich patients with normal vo /do relationships effects of anesthetics oc cerebral blood flow and cerebral metabolic rate isoflurane preconditioning improves long-term neurologic outcome after hypoxic-ischemic brain injury in neonatal rats this no-profit trial has been supported by depuy/ hemedex, providing the probes. no other economical support has been received effect of equiosmolar solutions of mannitol versus hypertonic saline on intraoperative brain relaxation and electrolyte balance a comparison of % hypertonic saline and mannitol for brain relaxation during elective supratentorial brain tumor surgery hypertonic resuscitation and blood coagulation: in vitro comparison of several hypertonic solutions for their action on platelets and plasma coagulation effect of the combination of mannitol and ringer acetate or hydroxyethyl starch on whole blood coagulation in vitro no well defined threshold for transfusion or target hemoglobin (hb) level for these patients exists. objectives. to examine associations of anemia and transfusion with adverse outcomes in patients with sah, and better define hb level thresholds associated with these. methods. retrospective, observational study of consecutive patients with sah admitted to icus at mayo clinic in jacksonville and rochester, usa, over -year period. data included demographics, nadir hb, blood transfusion, ali/ards, vasospasm, radiographically confirmed cerebral infarction, apache and wfns. primary outcome was association of anemia and transfusion with death and secondary outcomes were vasospasm, cerebral infarction and ali/ards. results. we identified patients, mean age was (± ), ( %) were females. mortality was %. seventy-two ( %) of patients were transfused. ( %) patients had vasospasm and ( %) cerebral infarction. there was a strong association between transfusion and increased mortality (p = . ), vasospasm (p = . ), cerebral infarction (p \ . ) and ali/ards (p \ . ) outcome prediction in mild traumatic brain injury: age and clinical variables are stronger predictors than ct abnormalities comparison of simultaneous continuous intracranial pressure (icp) signals from a codman and a camino icp sensor therapeutic actions may correct abnormal values and perform potentially cerebral blood flow/oxygen extraction coupling. objectives. aim of this study was to describe the incidence and the type of bedside icu monitoring devices used in the management of patients with severe tbi in french icu's. methods. multicentric observational study including patients having severe tbi (glasgow coma scale (gcs) \ ) picked on scene by a mobile medical unit for pre-hospital care (samu). inclusion period: months general hospital of athens, department of intensive care unit o poder na relação enfermeiro-utente relacionamento enfermeiro, paciente e família: factores comportamentais associados à qualidade da assistência investigação qualitativa em enfermagem: avançando o imperativo humanista the experiences of families of critically ill patients in greece: a social constructionist grounded theory study. intensive and critical care nursing visiting hours policies in new england intensive care units: strategies for improvement this study was supported by a post graduate programme in nursing surviving the nursing shortage: developing a nursing orientation program to prepare and retain intensive care unit nurses clinical utility of apc-pci (activated protein c-protein c inhibitor) complex as predictors for severity and prognosis in sepsis: preliminary study republic of korea introduction. recently human recombinant activated protein c (drotrecogin alfa [activated]) has been shown to reduce mortality in severe sepsis. in severe sepsis, conversion of protein c to apc (activated protein c) is impaired due to endothelial dysfunction. apc level is related to coagulation cascade known to be important in sepsis pathophysiology. objectives. in this preliminary study, we checked apc-pci (activated protein c-protein c inhibitor) complex level to evaluate protein c activation using apc-pci elisa kit they were admitted asan medical center (seoul, korea) medical intensive care unit (icu) between sep and . , respectively. apc-pci level had no statistically difference among sepsis, severe sepsis, septic shock ( . , . , . ng/ml, p = . ). between hospital survivor group and non-survivor group there was also no difference in apc-pci level ( . , . ng/ml but apc-pci level was tended to decrease in severe sepsis, septic shock group as compared to sepsis group activated protein c versus protein c in severe sepsis endogenous protein c activation in patients with severe sepsis efficacy and safety of recombinant human activated protein c for severe sepsis septic critical patients to evaluate the experience with drotrecogine alfa (da) in septic critical patients (scp) in a analysis of scp admitted in an icu unit between december and which received treatment with da. patients were included or excluded on the approved specifications fda and emea. inclusion criteria were septic patients and apache ii score c and/or two or more organ dysfunction (od) thirty-eight patients were eligible od: respiratory %, renal %, cardiovascular %, metabolic %, hematologic %; sdra . , vmc . , vni, . , all patients received empirical antibiotic treatment in the first h according to epidemiologic characteristics. microbiology: some germens were isolated in patients ( %) mortality (%) by presumed site of infection day /day : respiratory / , abdominal / , urologic / ; skin / . average hours drug administration was h. da was administrated at % of the patients between hour and hour , the other % between hour y critical septic patient treated early with empirical antibiotics, the best standard care and da have a low mortality rate. more early da administration was associated to lower mortality the treatment of severe sepsis in france: overview of a -year survey period bichat hospital, surgical intensive care unit lariboisière university hospital, medical intensive care unit cochrane database leptin is an adipocyte-derived cytokine regulating energy homeostasis, metabolism as well as immune-inflammatory processes. leptin also has thermogenic actions and regulates enzymes of fatty acid oxidation. leptin is significantly increased in response to acute infection and sepsis and exerts direct effects on cd + t-lymphocyte proliferation, macrophage phagocytosis, and secretion of inflammatory cytokines such as il- and tumor necrosis factor (tnf) a. we measured leptin in blood of septic patients we measured leptin serum levels in septic patients leptin levels in septic patients (mw = , . ng/ml ± sem = , . ng/ ml) are significantly higher compared to healthy controls (mw = , . ng/ ml ± sem = , . ng/ml, p \ . ). serum levels of leptin were significantly higher on day (mw = , . ng/ml ±sem = , . ng/ml) and day (mw = , . ng/ ml ± sem = the aim of this multi-centre retrospective observational study was to resuscitation bundle the above preliminary data indicated that an experienced use of rhapc, when compared to other survey ( ), was associated with a reduction of serious bleeding events, a more frequent off-label use and a similar mortality rate. the concomitant adherence to evidence-based guidelines improved significantly the patient survival ) macias et al. sources of variability on the estimate of treatment effect in the prowess trial: implications for the design and conduct of future studies in severe sepsis use of drotrecogin alfa (activated) in italian intensive care units: the results of a nationwide survey acute lung injury (ali) is one of the most frequent complications of sepsis. although coecum ligation and puncture (clp)-induced sepsis is a frequently used model, we found only three microarray studies of clp-induced sepsis - , of which one looked at lung tissue . none of them had examined the effects of recombinant human myocardial transcriptional profiles in a murine model of sepsis: evidence for the importance of age molecular signatures of sepsis: multiorgan gene expression profiles of systemic inflammation sepsis gene expression profiling: murine splenic compared with hepatic responses determined by using complementary dna microarrays endothelin- in endotoxin-and sepsis-induced lung injury activated) in real-life clinical practice for management of severe sepsis in surgical patients in patients with severe sepsis and multiple organ dysfunction, major surgery is not a contraindication for early ( - h after surgery) daa administration retrospective, observational, descriptive cohort study in patients with severe sepsis and multiple organ dysfunction treated with daa the principal focus of sepsis differed between the two groups (p \ . ): in the surgical group it was the abdomen ( . %) followed by the skin and soft tissues %) followed by the urinary tract ( . %) in the perfusion period, the distribution of severe/ moderate hemorrhages in the surgical group was %/ . vs. . %/ . % in the medical group. we found no differences between groups in death from any cause at days ( . vs. . %; rr ; % ci . - . ; p = . ). nevertheless, at days overall mortality had increased in both groups, although this difference was not statistically significant: the percentage of increase with respect to the -day mortality was % in the surgical group and % in the medical group in patients with severe sepsis and multiple organ dysfunction, major surgery is not a contraindication for early ( - h after surgery) daa administration. given our findings at days, studies including a wider period from the initiation of daa administration are necessary to evaluate the cost-efficacy efficacy and safety of recombinant human activated protein c for severe sepsis recombinant human activated protein c, package labeling and hemorrhage risk reference(s). iom. to err is human incidence of adverse events and negligence in hospitalized patients matrix metalloproteinase- promotes repair after ventila-tor-induced lung injury supported by the parker b. francis foundation, physician services incorporate, ontario thoracic society and canadian lung association sepsis-induced immuno-endocrine dysfunction impact of arginine-vasopressin (avp) and apelin (apl) exogenous administrations in a rodent model because the corticotrophic pathway is disturbed during circi, with acth-cortisol dissociation, alternative physiologically nondominant pathways such as the vasopressinergic/apelinergic axis, become essential to the hpa adaptation to stress. objectives. seeking the impact of arginine-vasopressin (avp) and apelin (apl) exogenous administrations on: acth & corticosterone blood contents, and respective pituitary and adrenal gland receptor expression (v b, apj) in a rodent model of endotoxin challenge. methods. a rodent model of endotoxin (lps e. coli :b , mg/kg i/p)-induced hpa axis has been selected to study the committment of avp/apl and related receptors (v b/ apj). rats (n = ) were equipped with subcutaneous osmotic minipumps (alzet, ) containing: saline, apl- ( , , , lg), or avp ( . , lg) for h. results. without lps challenge, exogenous apl administration did not alter acth & corticosterone blood contents whereas high dosage of exogenous avp significantly increased corticosterone blood content (p \ . vs. control). lps i/p challenge induced a huge increased of blood acth & corticosterone, both culminating at . h ( -and -fold increases respectively, p \ . vs. baseline), which was normalizing at h for acth whereas corticosterone remained high. this dissociation validates the model, matchs with human observations, and suggests non acth-dependent corticosterone release after lps challenge apl administration completely reversed the above down-regulation while avp also partially restored apj pituitary expression by almost % in a dose-dependent manner, and to a lesser degree in the adrenal gland (p \ . vs. lps). selective non-peptide v b (ssr ) and peptide apl antagonists (f a) substitutions confirmed the above effects were directely mediated. conclusions. apl and avp pituitary neuronal and bloodstream contents behave differently, and blood acth & corticosterone contents were dissociated, after acute lps challenge. apl as well as avp exogenous administrations were able to reverse (partially for the later) the lps-induced apj down-regulation in both pituitary and adrenal glands. reference(s) supported by the esicm young investigator award from infection diagnosis to therapy an antimicrobial stewardship program (asp) is a method of optimizing antimicrobial prescribing, altering antimicrobial resistance, reducing costs, and improving patient care. the intensive care unit (icu) is an ideal environment for the application of an asp given the complexity of the patient population, the ecology of resistant organisms, and the fact that selection of inappropriate antimicrobials or delays to determine the impact of the introduction of an icu asp on prescribing, patient outcomes, resistance, and costs we implemented an asp in a -bed medical surgical icu of a university-affiliated hospital. the asp team used prospective audit with interaction and feedback providing suggested changes in therapy (e.g. antibiotic choice, dose, duration) on a daily basis. asp provided consultation on all icu patients not followed by the infectious diseases consult service. parameters collected included demographic data, details of antimicrobial regimens, culture results, defined daily doses (ddd)/ patient days and antimicrobial costs mean monthly antibacterial ddd/ patient-days post-asp was reduced by . % ( . vs. . , p \ . ). the implementation of the asp was associated with a . % decrease in mean monthly antibiotic costs/ patient-days ($ vs. $ ) for a total cost reduction of $ , . in terms of prescribing and resistance, the introduction of asp was associated with a reduction in the prescribing of anti-pseudomonal agents (compared with antibiotics not covering pseudomonas) (mean monthly ratio . vs. . ), mrsa vs. mssa covering antibiotics (mean monthly ratio . vs. . ) and improved susceptibility pattern for pseudomonas aeruginosa as demonstrated by increases of , and % to tobramycin, meropenem, and piperacillin-tazobactam susceptibilities, respectively. there was no difference in icu mortality rate the asp team worked collaboratively with the icu team to improve antimicrobial therapy and as a result improved overall antibiotic usage and resistance patterns of important icu microorganisms, and decreased antimicrobial costs. appropriate and judicious antimicrobial use guided by an asp is beneficial to the icu can pct and/or crp help identify associated bacterial infection in patients with influenza pneumonia? procalcitonin (pct) is a recognized marker of bacterial infection and might be a prognostic marker in lower respiratory tract infections. objectives. to determine if pct and/or c-reactive protein (crp) levels at admission in intensive care unit can help identify associated bacterial infection in patients with influenzae pneumonia. methods. a nationwide registry (reva) was set up in france during the h n influenza pandemic. levels of pct and crp at icu admission were compared between patients presenting with influenzae pneumonia associated or not with a bacterial coinfection. results. patients were included, of whom received antibiotics prior to hospitalization. of the remaining patients, ( %) had documented bacterial co-infection. the bacteria involved in the co-infections were streptococcus pneumoniae (n = , . %), staphylococcus aureus (n = , . %), streptococcus a group (n = , . %). figure shows the initial values of procalcitonin and crp. median values for both pct ( . vs. . ng/ml, p \ . ) and crp ( vs. mg/l, p = . ) were significantly higher in patients with bacterial coinfection. the area under the roc curve was . and . , respectively for pct and crp. a cutoff of[ . ng/ml for pct (sensitivity % and specificity %) best identified patients with bacterial co-infection. for crp, a cutoff of[ mg/l (sensitivity %, specificity %) best identified patients with bacterial co-infections. comparison of the h n pneumonia and bacterial pneumonia group revealed no differences except for a higher saps in the latter pro endothelin (pro et) and copeptin (pro vasopressin cp)) for diagnosing infection in patients with severe acute dyspnea. methods. we designed a prospective study of patients admitted in emergency department (ed) and medical intensive care unit (icu) in a university hospital. inclusion criteria were acute dyspnea with spo b % and/or respiratory rate c b/min. patients with obvious myocardial infarction or pneumothorax were excluded. all clinical and biological data were recorded and biomarkers sampled. an independent blinded expert panel classified the patients according to all the available data including response to treatment and outcomes blindly to biomarkers' results. the roles of biomarkers were assessed quantitatively and then using terciles of the distribution. the contribution of the biomarkers in the diagnosis was assessed using auc-roc curves and by multiple logistic regression taking into account other clinical and biological explanatory variables. results. consecutive patients ( % male, med age years, day mortality %) were enrolled. the final diagnosis was severe sepsis for ( . %) (pulmonary: n = , non-pulmonary n = ). the parameters independently associated with infection lead to a clinico-biological model with an auc = . and a good calibration (p (hlchi ) = . ) and included temperature, arterial pressure, cyanosis, stupor and coma, orthopnea, localized chest sound abnormalities, pao /fio ratio and localized infiltrate on chest x ray although new biomarkers were different between septic and non septic patients with severe acute dyspnea, only mid pro-anp may add a significant contribution. further analysis about the prognostic value of these biomarkers is ongoing grenoble university hospital and brahms diagnostic czech republic, st faculty of medicine charles university and thomayers' hospital, anesthesiology and intensive care medicine fluid management with cvp is still common despite lack of efficacy. objectives. implement stroke volume maximisation during major surgery using odm guided fluid challenges. assess impact of odm use on central venous line insertion rates. identify and overcome barriers to adoption of odm technology. methods. nhs technology adoption centre project (ntac) supported an implementation project at hospitals. the audit into central catheter use during major surgery was undertaken at manchester royal infirmary. fourteen anaesthetic consultants volunteered to champion odm use to guide targeted fluid challenges with hes / . (voluven, fresenius kabi) within a range of major surgical procedures (colo-rectal, hepatic, pancreaticobiliary, urological, reno-pancreas transplant and emergency surgery). prospective data was collected for patients who underwent major surgery between with no significant differences in preoperative risk, intervention patients had enhanced post-operative outcomes. cvc insertion reduced after anaesthetists had the opportunity to use odm to guide fluid therapy. reference(s) clinically used fluids modify in vitro phenotype and function of circulating immune cells peri-operative fluid loading, i.e. ''hemodynamic optimization'', reduces post-operative complications and hospital length of stay. mechanisms involving perfusion have been studied, but fluid could also alter phenotype and function of circulating immune cells, and consequently the systemic inflammatory response induced by surgery blood from control donors has been diluted in crystalloid fluid (isotonic saline, wsio), colloids (hydroxyethyl starch (hes kd, . %) and % albumin solution (alb)), or autologous plasma, which corresponds to clinical situations in programmed anesthesia and surgery. two dilution levels have been studied, to achieve - g/dl hemoglobin (dilution ) and - g/dl (dilution ) )* cd mono (sites/cell) , ( , ) , ( , )* , ( , ) , ( , )* , ( , )* cd b pmn (sites/cell) alb only increased ord, but not activation and adhesion markers. conclusions. wsio had clear anti-inflammatory properties, whereas colloids were more inflammatory, with a dissociation of the effects between different types of fluids. mechanisms have to be precised, especially regarding physico-chemical, immuno-inflammatory and metabolic regulations. reference(s). none. grant acknowledgment. plan quadriennal outcome-related factors federacion panamericana e iberica de sociedades de medicina critica y terapia intensiva (fpimcti) our aim was to conduct a multicenter study to evaluate the epidemiology of delirium in intensive care units (icu) a -day point-prevalence study was performed with the aim of describing in icus from countries in south and north america and spain % were admitted to the icu due to medical causes and sepsis was the main diagnosis (n = , . %). patients were sedated and only ( . %) patients could be evaluated with the cam-icu. the prevalence of delirium was . % (n = ). as compared to patients without delirium, those with the diagnosis of delirium had a higher severity of illness at admission as demonstrated by higher sofa increased use of invasive devices such as central venous catheter (p \ . ), arterial catheter (p = . ) and urinary catheter (p = . ) were more frequent in patients with delirium. on multivariate analysis, delirium was independently associated with increased icu mortality in this one-day international study, delirium was frequent in icu patients and associated with increased mortality and icu los. the main modifiable risk factors associated with the diagnosis of delirium were the use of invasive devices and sedatives the study was funded by the federacion panamericana e iberica de sociedades de medicina critica y terapia intensiva (fpimcti). the fpimcti has used in part an educational grant from hospira recent studies suggest that increased blood glucose variability (bgv) is associated with icu mortality . hypothermia is known to induce insulin resistance, thus potentially increasing bgv. no studies however have examined the effect of therapeutic hypothermia (th) on insulin requirements and bgv. objectives. to examine the effect of th on bgv and its relationship to all patients were treated with intravenous insulin (blood glucose target - mm), according to a written algorithm, with nurse-driven adjustment of insulin dose. for each patient, standard deviation of repeated blood glucose samples was used to calculate bgv. two time-points, comparable in duration, were studied: th (stable maintenance phase, i.e. - h, core temp ± °c) vs. normothermia (nt, i.e. after rewarming, stable normothermic phase, core temp ± °c). mortality and neurological recovery (glasgow-pittsburgh cerebral performance categories, cpc, dichotomized as good = cpc - vs. poor = cpc - ) were assessed at hospital discharge. statistical analysis was performed with anova for repeated measures therapeutic hypothermia is associated with increased insulin requirements and higher blood glucose variability, which in turn correlates with worse prognosis in patients with post-ca coma. strategies aimed to maintain stable glycemic profile and avoid blood glucose variability might contribute to optimize the management of th and may translate into better outcome glucose variability is associated with intensive care unit mortality therapeutic hypothermia post cardiac arrest has been shown to improve survival and neurological outcome . there are approximately , treated cardiac arrests in the uk each year with one-eighth we aimed to establish if implementation of an agreed care bundle including therapeutic hypothermia reduced mortality and improved neurological outcome patients were categorized according to initial cardiac rhythm, ventricular fibrillation/tachycardia (vf/vt) or non-vf/vt. we recorded the degree of implementation of the post cardiac arrest care bundle, comprising; coronary reperfusion, haemodynamic optimisation, control of ventilation, blood glucose, temperature and seizures. data was compared with survival to discharge and neurological function there were ihas, male (mean age . years) and female ( . years) and oohas, male ( . years) and female ( . years). the predominant presenting rhythm in oohas was vf/vt ( . %) compared to ihas which was non vf/vt ( . %). underlying co-morbidities included - °c) was achieved in % of vf/vt oohas compared to . % of vf/vt ihas. the complete care bundle was delivered to . % of oohas and . % of ihas survival rates were higher in all patients with complete bundle of care versus those with an incomplete bundle independent of location or rhythm ( . vs. . % p = . ). this improval in survival was also demonstrated in vf/vt arrests receiving the complete bundle of those patients who had a vf/vt arrest, survival with full neurological recovery (gcs on discharge) was higher in those receiving therapeutic hypothermia . versus % where therapeutic hypothermia was not achieved adherence to the post cardiac arrest care bundle led to significantly improved outcome following both vf/vt and non vf/vt arrests. there was a trend towards therapeutic hypothermia improving neurological outcome on discharge reference(s). . the hypothermia after cardiac arrest study group. mild therapeutic hypothermia to improve the neurological outcome after cardiac arrest royal sussex county hospital intensive care unit, brighton, uk for patient data h. altemimi , s. altaf , j. brown , s. al-juboori , v. jadhav queen elizabeth hospital, kings lynn, medical assessment unit, kings lynn, uk introduction. the medical assessment unit (mau) in our district general hospital (with beds) provides assessment and treatment of acute medical patients from general practice (gp) referals and the emergency department (ed). patients arriving in mau are first triaged by the nurses before assessment by junior doctors. the early warning score (ews) is an indepenently verified scoring systems used to prioritise patient assessment. appropriate referal to critical care outreach teams and intensive care units can be triggered by nurses or doctors according to the ews score. clear and seemless referal pathways and communication between those involved with acutely unwell patients is essential. objectives. to measure key performance indicators in the mau and identify specific areas for improvement. methods. retrospective audit of all admissions to medical assessment unit during week in . the following parameters were recorded for patients admitted. patient ages ranged from to : [ . of these, only were reviewed within h. . % of patients reviewed within min. conclusions. in the uk, early warning scores have been developed to trigger early review. the most sophisticated intensive care becomes unnecessarily expensive terminal care when the pre-icu system fails to refer in a timely manner. our results showed that when a patient was recognised as being unwell, they were seen rapidly by the outreach team. however, not all new admissions had their ews documented, overlooking an important opportunity to risk stratify patients before formal medical clerking. our critical care outreach team have prominent role in education to identify abnormal physiology early, and take action as appropriate. immunological host reactions are primarily believed to determine the clinical course of this disease. an overwhelming inflammatory response to microbial invasion may be involved in the pathogenesis of sirs, sepsis and multiple organ failure. it is important to block the inflammatory response and stop or alleviate sepsis injuries. immunotherapy is regarded as effective approach to improve the immunological function. objectives. immunomodulation in the critically ill is an appealing notion because of the abnormal immune responses. the aim of this study is to evaluate the immunomodulation and its mechanism to improve immune function and prognosis in sepsis. methods. experimental part:clp model were divided into three groups including sham group, control group and experimental group. control group only used antibiotic and experimental group used antibiotic plus immunomodulation. blood collection were made after clp model in , , and h. lymphocyte counting, cd +, cd + t lymphocyte and cd /cd ratio were checked. the apoptosis of lymphocyte in thymus and spleen and survival rate were checked. clinical part: prospective analysis seventy patients conformed to the enrolled standard. it was divided into two groups at random. one was control group with regular therapy, the therapy group with ulinastatin plus thymosin-a in a week. the immune index before and after therapy in the , st, rd, thday was observed. results. experimental part: lymphocyte, cd + t lymphocyte and cd /cd ratio in experimental group increased more significant than in control group (p \ . ). lymphocyte apoptosis index of thymus and spleen in control group increased more significant than in experimental group (p \ . ). h-survival rate in experimental group was higher than in control group. clinical part: cd + t lymphocyte, lymphocytes and hla-dr cd + had more significant increase in therapy group than in control group (p \ . ). twenty patients died in the control group and thirteen patients died in the therapy group (p \ . ). conclusions. immunomodulation in sepsis can improve immune function and alleviate the lymphocyte apoptosis and extend the survival time. in recent years, the antiinflammatory effects of niacin by reducing nuclear factor jb (nf-jb) activation have attracted attention. however, the protective effects of niacin on the development of acute lung injury and systemic inflammatory response during sepsis have not been studied.objectives. we performed this study to determine whether niacin attenuates acute lung injury (ali) and improves survival during sepsis and the beneficial effects of niacin are associated with the down-regulation of nf-jb pathway.methods. lipopolysaccharide (lps) at a dosage of mg/kg was injected into the tail vein to induce endotoxemia in rats. then, vehicle, low dose niacin ( mg/kg), or high dose niacin ( mg/kg) diluted in distilled water with same volume ( ml/kg) was administered once to the rats through orogastric tube, respectively. we observed the survival of the subjects. at h post-lps injection, we measured serum tumor necrosis factor-a (tnf-a), interleukin- (il- ) levels, lung cytoplasmic phosphorylated inhibitor jb-a (p-ijb-a), ijb-a, nuclear nf-jb p expressions, nf-jb p dna-binding activity, and ali occurrence.results. high dose niacin improved survival during sepsis. niacin induced dose-dependent reduction of serum tnf-a, il- levels, lung cytoplasmic p-ijb-a, nuclear nf-jb p expressions, nf-jb p dna-binding activity, and ali occurrence in endotoxemic rats. in contrast, niacin preserved lung cytoplasmic ijb-a expression dose-dependently in endotoxemic rats.conclusions. niacin attenuated acute lung injury and improved survival during sepsis in rats. the protective effects of niacin were associated with the down-regulation of nf-jb pathway. niacin can be considered as a therapeutic agent for sepsis. f. barbani , m. boddi , r. cammelli , a. cecchi , e. spinelli , m. bonizzoli , a. peris university of florence, postgraduate school of anesthesia and intensive care, florence, italy, university of florence, department of critical care medicine and surgery, florence, italy, careggi teaching hospital, anesthesia and intensive care unit of emergency department, florence, italy introduction. acute kidney injury (aki) is a frequent complication in critically ill patients. there is emerging evidence that aki can lead to chronic kidney disease and that even only partial renal recovery after aki is associated with a higher long-term mortality.objectives. we investigated whether measurement of renal resistive index (rri) by ultrasound could predict renal function recovery after aki.methods. rri has been determined in patients who had been admitted (jan -feb to our mixed intensive care unit (icu) and referral trauma center (careggi teaching hospital, florence, it) and developed aki. rri measurements were performed within h from aki diagnosis, according to rifle criteria. renal recovery was defined as the return to the normal renal function parameters.results. patients studied were ( male vs. female) with a mean age of . ± . years. aki was due to sepsis (n = ), shock (n = ), rhabdomyolysis (n = ), abdominal compartment syndrome (n = ) and major surgery (n = ). mean length of icu stay was ± days. at discharge patients showed a complete recovery of renal function, while patients had persistent altered renal function parameters or needed renal replacement therapy (rrt); mortality rate was . % ( / ) . rri measured at aki onset was significantly higher in patients with persistence of renal failure than in patients with complete renal recovery ( . ± . vs. . ± . , p \ . ). rri [ . had a sensitivity of % ( % ci - %), a specificity of % ( % ci - %) and a positive likelihood ratio of . ( % ) for persistent renal dysfunction at the discharge.conclusions. our findings suggest that doppler-based determination of rri at the onset of aki can identify those patients who are at greater risk for no complete recovery of renal function. further studies on larger populations are required to confirm these preliminary results so to promote therapies dedicated to this high risk population.conclusions. apache score on admission, hypothermia and mean arterial pressure are not statistically significant, but age approached significance at % level in ccu survival. blood sugar control is not statistically significant at % level but approached significance as p value was less than . for ccu survival. for hospital survival,age is significant at % level; apache score on admission and mean arterial pressure are significant at % level while cardiac index, hypothermia and glycaemic control are not statistically significant . in the intensive care society (ics) published a care bundle for the management of patients following cardiac arrest . the american heart association now recommends regionalisation of post-resuscitation care following out of hospital cardiac arrest (ohca), in a centre capable of providing rapid therapeutic hypothermia, h emergency angiography and percutaneous coronary intervention (pci) as necessary . objectives. the audit's purpose was to evaluate work load, treatment and outcomes of ohca on the icu following publication of the ics care bundle and inception of a h pci service in our hospital. methods. retrospective audit of ohca patients admitted to icu from / to / to examine number admitted, cause of arrest, treatment and mortality. predicted mortality from the icnarc model was used to calculated standardised mortality ratio (smr). comparison was made with an audit of ohca patients between / and / . the sample was subdivided into subgroups with cardiac and non-cardiac cause for ohca. the chi-square test was used in analysis. results. comparison conclusions. we demonstrated: . a significant increase both in the absolute number of ohca and the proportion due to cardiac causes, due in part to in-region transfers for emergency angiography/pci. . a significant increase in the use of angiography and pci, increasing use of therapeutic hypothermia and iabp. . improved survival from previous audit. . better than predicted survival, particularly in the 'cardiac' group. this audit lends support for the protocolised icu care of post-ohca patients in a regional centre able to offer h emergency pci. there is scope for increased use of cooling for arrests of all causes, and extending provision of angiography/pci to vf arrests and those of unknown cause . reference(s). . despite all the research, education and training that has gone into the field of cpr during the last years, survival rates remain bleak for the majority of patients . so, what is lost in translation? much of the problem is that what the medical community is being trained to do is not being replicated in clinical practice . given this discrepancy, along with the deleterious outcomes, we conducted a manikin-based study to assess the quality of ventilation delivered during simulated cpr, in a large uk centre. objectives. to demonstrate whether uk-based medical personal were adhering to ventilation guidelines and to see how this result varied across specialities. methods. a simulated cardiac arrest scenario was undertaken by (a- . , power- %) participants from a range of medical specialties. participants were asked to asynchronously ventilate our manikin for a period of min during which time tidal volumes (tv), minute volume (mv) and ventilation rates (vr) were recorded. to help limit outside influence, at no point during the trial was any feedback about ventilation technique or als principals discussed with the participant. results. the mean and sd across the sample population for the mv, vr and tv were . l min - (sd . ), . min - (sd . ) and ml (sd ) respectively. comparison of groups can be seen in table introduction. mild hypothermia reduces cerebral blood flow (cbf) without concurrent increase of cerebral oxygen extraction rate in the first h after cardiac arrest, indicating a lower cerebral metabolic activity with a preserved metabolic coupling.objectives. the aim of this study was to assess the cerebral blood flow and cerebral oxygen extraction in patients treated with prolonged hypothermia, as previously was performed in newborn infants with perinatal asphyxial encephalopathy . patients were included after restoration of spontaneous circulation (rosc) after asystole, pulseless electrical activity based circulatory arrest or after rosc after ventricular fibrillation based prolonged resuscitation. in this prospective observational study comatose patients after cardiac arrest were treated with prolonged hypothermia for h. after h patients were passively rewarmed. mean flow velocity in the middle cerebral artery (mfv mca ), reflecting cbf, was measured after , , , , , , , , and h after admission to the icu by transcranial doppler (tcd). jugular bulb oxygenation (sjbo ) and arterial oxygenation were measured at intervals of h. introduction. isoflurane is a volatile anesthetic known for its direct vasodilating effect on cerebral vessels, producing a cbf increase. moreover, it has been shown in animal studies that isoflurane has neuroprotective properties, inducing tolerance to ischemia when used as a preconditioning agent. at the present time, isoflurane is not used as a sedative agent in neuroicu because of the fear of an increase in intracranial pressure (icp) caused by the increase in cbf. however, sah patient at risk for vasospasm may benefit from an increase in cbf. the ischemic risk will peak at day - , leaving a window of opportunity for neuroprotection. objectives. we decided to measure rcbf during traditional intravenous sedation with propofol and during volatile sedation with isoflurane in sah patients not having intracranial hypertension. the clinical trial was approved by the hospital irb and registered on trial.gov (nct ). we enrolled sah (fisher - , wfns b ) patients, monitored with an intraparenchimal icp device and a thermal diffusion probe (tdp, hemedex) for the assessment of rcbf. an icp [ mmhg was an exclusion criteria. cerebral and haemodynamic parameters were assessed at steps:step during sedation with propofol - mg/kg/ h; step : after h of sedation with isoflurane . - % mac administered through an anesthetic conserving device; step after h of propofol re-started at the same infusion rate. in all patients sedation with isoflurane produced an increase of rcbf although not yet significant in the population (step : ± ml/ g/min; step : ± step : ± ). jugular vein oxygen saturation, sjo , was significantly higher at the end of the isoflurane step (step : ± %; step : ± ; step : ± ). icp did not change significantly and remained below the pathological threshold (step : . ± ; step : . ± ; step : ± mmhg).conclusions. the small population of this pilot study phase causes a lack in statistical significance, however our data already suggest that isoflurane induces a marked cerebral vasodilatation and an increase in rcbf compared to propofol. patients with a normal icp did not develop an intracranial hypertension. at short and long term and its correlation with severity scales, scales of quality of life and endovascular treatment m there is not a consensus about which scales should be used to define the outcome after aneurysmal subarachnoid hemorrhage. objectives. the purpose of this study was to determine the risk factors and impact on functional outcome and quality of life months after spontaneous sah due to ruptured intracranial aneurysms. methods. we performed a prospective study of patients with aneurysmal spontaneous sah admitted to our centre from july to august . diagnosis of sah was done by ct and ethiological diagnosis by brain angiography. we paid attention to previous pathological history, clinical characteristics at admission and radiological characteristics. the severity was measured by the hunt-hess (hh), wfns, graeb and fisher scales. the months outcome was assessed by the glasgow outcome scale (gos) and modified rankin scale. the basic activities of daily living were evaluated with the barthel index. moreover, patients were asked about their subsequent incorporation to their previous occupation. we divided our population into two groups depending on the clinical grade at admission (hunt-hess scale): group i, hh , or ; and group , hh or . long-term followed up continues. results. during the year of study a total of patients have been included. the mean age of patients was years with a prevalence of % in women, being arterial hypertension and smoking history the main factors of related risk. the angiography was performed in . % of the patients. an aneurysm was confirmed as the origin of the bleeding in . %. poor clinical grade at admission (hh or ) was associated with apache ii, sofa, glucose, more sah computed tomography on admission, and infection and icu stay. there is % mortality in the series. after a months period, group patients (hh or grade) had a severe disability and functional dependence to perform instrumental and basic activities of daily living (p = . ). only % of patients were able to return to their previous occupation months after the initial bleeding. scales and outcome by clinical grade at admission introduction. aneurysmal subarachnoid hemorrhage (asah) remains a therapeutic challenge due to unacceptably high levels of mortality and morbidity. for survivors of the initial insult, cerebral vasospasm and related delayed ischemic deficits are the major determinants of final outcomes. traumatic sah (tsah) occurs in as high as % of patients with tbi, and is associated with a twofold increase in risk of death. statins may be an alternative for conventional treatments of vasospasm due to their beneficial pleiotropic effects on cerebral vasomotor reactivity as well as absence of negative haemodynamic influence.objectives. the goal of our study was to examine the effects atorvastatin therapy on cerebral vasospasm after asah and tsah as well as on short term outcomes of icu patients (length of stay and severity of condition upon discharge from icu). hypertonic saline infusion is an alternative to mannitol to decrease intracranial pressure before craniotomy [ , ] . previous studies have demonstrated that both hypertonic saline and mannitol interfere negatively with various components of blood coagulation [ , ] . normal blood coagulation capacity is essential during craniotomy and, therefore, we created an in vitro model to examine the effects of hypertonic sodium chloride and mannitol solution on whole blood coagulation. fresh citrated whole blood, withdrawn from volunteers, was diluted with . , . or . % sodium chloride solution or % mannitol to make vol.% and vol.% hemodilution in vitro. the diluted blood and undiluted control samples were analyzed with thromboelastometry (rotem Ò ) using two activators, tissue thromboplastin without (extem Ò ) or with cytochalasin (fibtem Ò ). all the study solutions with the same vol.% hemodilution induced comparable decrease in hematocrit. in extem Ò analysis, alpha-angle was smaller in the mannitol group than in the . % or . % sodium chloride group after vol.% dilution (p. ). in vol.% hemodilution, alpha-angle was also more decreased, and clot formation time more delayed in the mannitol group than in the . , . or . % sodium chloride groups in extem Ò analyses (p \ . ). maximum clot firmness (mcf) in extem Ò analysis was similar with all the study solutions after vol.% dilution, but after vol.% dilution mcf was weaker in the mannitol group than in the other groups. mcf was also weaker in . % than in . % sodium chloride group after vol.% dilution. in fibtem Ò analysis, mcf was stronger in the . % sodium chloride group than in the mannitol group after both dilutions (p \ . ). a or vol.% dilution of % mannitol disturbs whole blood coagulation more than equiosmolar . % sodium chloride. this disturbance seems to be attributed to overall clot formation and strength but also to pure fibrin clot firmness. . % sodium chloride might be more favorable than mannitol before craniotomy in patients with high bleeding risk. introduction. delayed cerebral ischemia (dci) is a major complication after aneurysmal subarachnoid haemorrhage (sah), occurring in around % of patients and increasing case fatality . - -fold. induced hypertension, alone or in combination with haemodilution and hypervolemia (triple-h), is used around the world as a therapy in the treatment of dci, but its efficacy in improving outcome is not based on a randomised clinical trial. objectives. to investigate the outcome of induced hypertension versus no induced hypertension in patients with dci after aneurysmal sah. study design a multi-centre, single blinded, randomized controlled trial. study population patients admitted after recent sah with a treated aneurysm and dci based on the onset of a new focal deficit and/or a decrease of the level of consciousness of at least point on the glasgow coma scale with exclusion of other causes of deterioration, will be randomized to either hypertension (n = ) or no hypertension (n = ). interventions in the intervention group, blood pressure will be raised with norepinephrine or additional dobutamin in case of low cardiac output. when clinical improvement occurs, hypertension will be continued for h, after which the dose norepinephrine will be tapered daily, but resumed in case of clinical deterioration. when no clinical improvement occurs within h, induced hypertension will not be continued. patients in the reference group will be treated according to the standardised sah treatment protocol of the participating centre including oral nimodipine and normovolaemia without haemodilution. main outcome measurement the modified rankin scale at months after the sah, will be compared between patients who were randomized to induced hypertension and patients who were randomized to no induced hypertension. objectives. to investigate brain metabolism at different serum glucose levels.methods. six patients with aneurismal sah and vasospasm were enrolled in the study (age . ± . ; male/female / ; . cerebral microdialysis was used in all patients. microdialysis catheters were placed into ''lesioned'' (brain tissue perfused by involved artery) and ''intact'' brain tissue. glucose levels in arterial blood (glu art ) and in brain interstitial fluid were compared. we analyzed brain glucose levels, intracranial pressure (icp), lactate/pyruvate (l/p) ratio, pao , paco and cerebral perfusion pressure (cpp) at blood glucose levels b mmol/l (group i, n = ), . - mmol/l (group ii, n = ), . - mmol/l (group iii, n = ), c mmol/l (group iv, n = ). we found out tight correlation between glucose levels in arterial blood and in ''lesioned'' brain tissue (n = ; r = . ; p \ . ) and weak correlation between gluart and glucose levels in ''intact'' brain tissue (n = ; r = . ; p \ . ). pao , paco , icp and cpp were comparable between groups. glu art was . ± . mmol/l in group i, . ± . mmol/l in group ii, . ± . mmol/l in group iii and . ± . mmol/l in group iv. normal glucose levels in arterial blood (group i) were accompanied by low glucose levels in ''intact'' ( . ± . mmol/l) and ''lesioned'' ( . ± . mmol/l) brain tissue. arterial blood glucose elevation has led to significant increase in brain glucose levels. but brain glucose levels were in normal ranges during hyperglycemia. glucose levels in ''intact'' brain tissue: . ± . mmol/l (group ii), . ± mmol/l (group iii), . ± . mmol/l (group iv). glucose levels in ''lesioned'' brain tissue: . ± . mmol/l (group ii), . ± . (group iii), . ± . (group iv). we didn't find out any significant differences in l/p ratio at different blood glucose levels. however, low glucose levels in ''intact'' brain tissue (b . mmol/l; . ± . mmol/l; n = ) were accompanied by significant increase of l/p ratio ( . ± . vs. . ± . at normal brain glucose levels (c . mmol/l; . ± . mmol/l; n = )). we didn't notice any significant differences in l/p ratio in ''lesioned'' brain tissue at different brain glucose levels, opposite to intact brain tissue. l/p ratio was . ( . ; . ) at glucose levels in ''lesioned'' brain tissue b . mmol/l ( . ± . mmol/l; n = ) vs. ( . ; ) at glucose levels in ''lesioned'' brain tissue c . mmol/l ( . ± . ; n = ).conclusions. hyperglycemia is not accompanied by high glucose levels and brain metabolism impairment in ''intact'' and ''lesioned'' brain tissue in severe patients with aneurismal sah. low glucose levels in ''intact'' brain tissue are related with significant increase of l/p ratio. introduction. the national confidential enquiry into patient outcome and death report found that less than % of patients with a severe head injury received a standard of care that was judged to be good [ ] . our intensive care unit (icu) at the royal cornwall hospital, a large district general hospital, is one of the few non-neurosurgical centres in the uk to use intracranial pressure (icp) monitoring. we aimed to assess if the practice of icp monitoring in our non-neurosurgical centre was valuable and safe. retrospective audit of case notes and charts of all patients admitted with traumatic brain injury receiving icp monitoring over a year period from st january until st january . a total of patients who had icp monitoring for traumatic brain injury were identified. the codman tm strain-gauge catheter was used in all cases, ( %) were male, ( %) were female. mean age was years (range - ). median reported gcs at the scene of injury was (range - ), median gcs prior to intubation was (range - ). median apache score was (range - ). all patients were discussed with the neurosurgical referral centre. patients were monitored for a median of days (range [ ] [ ] [ ] [ ] . icp was raised in patients ( %). elevation of icp triggered the following interventions: patients ( %) received hyperosmolar agents, patients ( %) were treated with therapeutic hypothermia, patients ( %) with barbiturate coma and none of the patients received steroids. patients were transferred to a neurosurgical centre ( % of patients with elevated icp, % of total). complications comprised one minor intracranial haematoma and one monitor failure. review of documented care bundles for head-injury patients revealed: head-up tilt in %, gastric protection in %, normoglycaemia in %, early enteral nutrition in %, appropriate thromboprophylaxis in %, appropriate sedation in % and appropriate analgesia in %. % survived to hospital discharge.conclusions. in our audit the majority of patients received specific treatment for raised icp, which might have gone undetected without invasive icp monitoring. at the same time most patients were managed without neurosurgical intervention. in light of the paucity of neurocritical care beds [ ] this approach appears to help to select a suitable subgroup of patients needing transfer to a specialist centre. our data adds weight to the evidence that icp monitoring is a valuable and safe monitoring modality in a non-neurosurgical icu if used appropriately within established guidelines and in collaboration with a neurosurgical referral centre. introduction. assessment of injury severity and prediction of outcome represent major challenges following severe traumatic brain injury (tbi). objectives. this study was aimed to evaluate relationships between cerebrospinal fluid (csf) levels of purported biomarkers of tbi including glial fibrillary acidic protein (gfap), ubiquitin c-terminal hydrolase (uch-l ) and alpha-ii spectrin breakdown product (sbdp ), and partial pressure of brain tissue oxygen (ptio ) as well as brain temperature during the first h and up to days post-injury.methods. twenty-seven severe tbi patients with csf drainage and invasive monitoring (licox probe) have been studied with quantitative csf-elisa for sbdp , uch-l and gfap on admission and every h up to days. in the first h, biomarker levels decreased while those of ptio increased. all three biomarkers correlated with ptio (p \ . , p = . and p = . , respectively). after the first h, there were statistically significant changes in levels of the three markers as well as in levels of ptio (p = . , p \ . , p = . , p \ . , respectively). however, the correlation between biomarkers and brain tissue oxygenation was sustained and, for uch-l improved (p \ . ). no significant correlations between biomarker levels and brain temperature were found. the results indicate that cfs levels of sbdp , uch-l and gfap are related to ptio following severe tbi. future studies are on their way to unravel whether these biochemical markers and ptio measurement could serve the better care of the head injured. introduction. this was a pilot study to compare the cerebral neurochemical changes in patients with traumatic brain injury (tbi) who underwent conventional blood glucose level (bgl) control and intensive bgl control with continuous titrated insulin.objectives. to demostrate that intensive glycaemic control using insulin induced a decrease of cerebral glucose.methods. this prospective, randomized study was conducted in traumatic brain injury patients in a surgical and trauma intensive care unit. patients admitted over an -month period with tbi were prospectively divided into two groups according to the method used for bgl control: the intensive group consisted of patients who underwent continuous titrated insulin infusion to maintain a lower normoglycemic level of - mmol/l, and the conventional group consisted of patients whose bgl was maintained at between . and . mmol/ l using conventional sliding scale bolus subcutaneous insulin administration. data on cerebral haemodynamics, interstitial brain oxygenation (ptio ( )) and neurochemical monitoring were collected via microcatheters inserted in the penumbral region. we analyzed , cerebral microdialysis samples. in patients treated with intensive insulin therapy, there was a reduction in microdialysis glucose by % of baseline concentration compared with a % reduction in patients treated with a conventional blood glucose level control. intensive insulin therapy was associated with increased incidence of microdialysis markers of cellular distress, elevated glutamate ( ± vs. ± %, p \ . ), elevated lactate/pyruvate ratio ( ± vs. ± %, p \ . ) and low glucose ( ± vs. ± %, p \ . ), and increased global oxygen extraction fraction. cerebral microdialysis glucose was lower in nonsurvivors than in survivors ( . ± . vs. . ± . mmol/l, p \ . ).conclusions. intensive glycaemic control using insulin induced a decrease of cerebral glucose and an increase in microdialysis markers of cellular distress. in patients with severe brain injury, tight systemic glucose control is associated with increased mortality. introduction. we have previously used c-flumazenil positron emission tomography to show that selective neuronal loss in the thalamus is pervasive after traumatic brain injury (tbi) and correlates with functional outcome, findings that are concordant with previous post-mortem data. the mechanisms responsible are unclear, but may involved global hypoxia/ischaemia as well as retrograde degeneration.objectives. we hypothesised that early brain tissue oxygenation would correlate with late diffusion tensor imaging (dti) abnormalities in the thalamus, and therefore, help to provide an explanation for late neuronal loss. nine patients underwent brain tissue oximetry (pbo ) following acute tbi, using a licox pbo probe, sited in structurally normal frontal white matter. mean pbo was calculated for the duration of their intensive care admission. at a median of . months (range - days) they underwent magnetic resonance imaging, including dti. apparent diffusion coefficient adc (maps) were created, adc calculated in regions of interest in the frontal lobes, splenium of the corpus callosum and thalami, and correlated with mean pbo using spearman's rho. ethical approval was obtained from the local research ethics committee, and assent from next-of-kin was obtained in all cases.results. mean pbo was inversely related to adc in both frontal lobes (r = - . and - . ; p = . and . ), and with the adc in the thalamus bilaterally (r = - . and - . ; p = . and p = . ). in contrast, no correlation was seen between mean pbo and adc in the splenium of the corpus callosum, a common site of traumatic axonal injury (tai; p = . ).conclusions. the inverse correlation of mean pbo associated with adcs in the monitored brain region is unsurprising, but the correlations observed with contralateral regions and deep grey matter suggest that the burden of tissue hypoxia has a significant impact on secondary neuronal loss across the brain. in contrast, the lack of correlation with adc changes in an area at risk of tai suggests a less significant impact of hypoxia on the progression or maturation of tai. the correlations with measures of thalamic microstructural injury are particularly significant, since they establish a clear link between acute physiology, tissue fate in key brain regions, and clinical outcome. introduction. earlier studies have suggested that autonomic dysfunction is associated with poor outcome in traumatic brain injury (tbi).objectives. this study was performed to assess changes in baroreceptor sensitivity and heart rate variability as indices of autonomic dysfunction in relation to icu management variables during early tbi.methods. ten patients ( females/ males) with a median age of (interquartile range, iqr, - ) admitted to icu following tbi were prospectively studied for the first consecutive days. all patients were sedated and mechanically ventilated with icp monitoring in place. high fidelity signals at hz were sampled for ecg and invasive arterial pressure (radial) to monitor baroreceptor sensitivity (brs) based on three or more consecutive beats in which successive systolic pressure and rr intervals increased or decreased with the threshold set at mmhg and ms, respectively. heart rate variability (hrv) was analysed by fourier transformation in the low (lf, . - . hz) and high frequency (hf, . - . hz) domains. the lf/hf ratio and total power ( . - . hz) were also calculated for hrv. management variables included use of inotropes, vasopressors, icp, use of decompressive craniectomy, icu length of stay (los) and mortality. statistical significance was set at p \ . using mann-whitney one-way anova and spearman correlation tests. median days (and iqr) were . ( - . ) for inotropes, . ( - ) for vasopressors and . ( - . ) for icu los. brs and lf, hf, lf/hf ratio and total power were all depressed throughout early icu management with no significant changes in the first week. no significant correlations were found between brs/hrv and days on inotropes/vasopressors or icu los. four patients underwent decompressive craniectomy and one patient died while in icu. no correlation was found between these events and brs or hrv changes brs, hrv and icp data conclusions. both brs and hrv were depressed early following tbi but did not correlate to icu management variables. while autonomic dysfunction is evident early in the icu treatment of tbi, no evidence to support an association between severity of impairment and icu outcome was found in this pilot study. introduction. in neurocritical care, raised intracranial pressure (icp) is associated to a poor outcome and its detection still leads the therapeutic management of the patients suffering from head pathologies.objectives. although invasive devices are recommended to detect intracranial pressure (icp), we investigated the correlation and the reliability with non-invasive ultrasound techniques as the optic nerve sheath diameter (onsd) assessed by ultrasonography and the pulsatility index (ip) measured by transcranial doppler sonography (tcd). we included patients suffering from intracranial hypertension, sedated and mechanically ventilated and control individuals, chosen among healthy people. all the patients had icp measured invasively either by external ventricular drains (evd) or intraparenchymal catheter. everyone underwent non-invasive measurements of onsd bilaterally and simultaneous medial cerebral artery ip assessment at the side of the best window.results. onsd had a significant difference between volunteers ( . ± . mm) and patients ( . ± . mm). ip's were . ± . for the control individuals and . ± . for the patients (media icp = ± mmhg) and also revealed a significant difference. onsd strongly correlated with icp (y = . x + . , p \ . , r = . ) whereas ip had some correlation but without statistical significance (y = . x + . , p = . , r = . ). onsd was found wider (p = . ) within patients with both icp and ip abnormal. a strong correlation was found between onsd and ip (y = . x + . , p = . , r = . ). however, we could not find the best cut-off values of onsd and ip for predicting an icp [ mmhg.conclusions. ip and onsd correlated with icp with a stronger reliability results of the latter, suggesting the possibility to integrate their use in the case of icp invasive monitoring would be contraindicated or not available. we studied the effects of normothermic therapy during the acute phase of traumatic brain injury.methods. twenty patients ( males, ± years old) who were admitted in the intensive care unit due to traumatic brain injury (glasgow coma scale upon admission - , marshall scale ii to iv) were studied. if patients' core temperature was above . °c, a cool line Ò , alsius corporation, irvine, ca. usa intravascular heat exchange central venous catheter (coolgard Ò device) was inserted via the femoral or the subclavian route, in order to achieve and maintain a target temperature of °c. intracranial pressure (icp) was measured (a) invasively by means of a intraparenchymal catheter (camino, camino laboratories, san diego, ca, usa) and (b) noninvasively by means of transcranial doppler sonography (tcd), using a philips hd xe (philips medical systems; bothell, wa, usa) equipped with a mhz transducer and a mhz linear transducer. estimated icp was calculated by tcd using the equation proposed by czosnyka and colleagues and the pulsatility index (pi = vs -vd/vm) was assessed in the middle cerebral artery bilaterally. all measurements were conducted at baseline and repeatedly on a daily basis for the next days and the average values were used in the statistical analysis.results. target temperature (t: . ± . °c) was achieved within the next h of the catheter insertion. at baseline (t: . °c) pulsatility index (pimean) was . ± . , icpmean/invasive was ± . mmhg and icpmean/noninvasive was . ± . mmhg. invasive and noninvasive icp values correlated significantly (r = . , p \ . ). following ± h from the insertion of the catheter the above parameters were significantly decreased as compared to baseline values (pimean = . ± . , icpmean/invasive = ± . mmhg, icpmean/noninvasive = . ± . mmhg, respectively; all p \ . ). out of patients, progressed towards brain tamponade, remained in a persistent vegetative state and were discharged with normal consciousness and motor deficits. however, due to the small number of patients no analysis could be performed to estimate the possible impact of normothermic therapy on the survival of these patients. these preliminary results suggest that normothermia during the acute phase of traumatic brain injury may decrease icp and ameliorate cerebral blood flow. introduction. extracranial organ dysfunctions are extremely common in patients with severe traumatic brain injury (tbi). although it has been shown that development of tbiinduced multiple organ failure (mof) is associated with a poor outcome, the underlying mechanisms leading to mof after tbi have not been investigated.objectives. to investigate in vitro the effect of plasma from tbi patients developing different degrees of organ failure on human endothelial cells.methods. ten consecutive severe tbi patients were included. gcs, iss and sofa score were recorded at admission; sofa was also recorded after days. plasma samples were obtained at the same time points. adhesion of freshly isolated human neutrophils on spontaneously transformed human umbelical vein endothelial cells (ecv ) was evaluated after h in vitro stimulation with % of plasma collected from tbi patients days after admission. expression of intercellular adhesion molecule- (icam- ) was assessed by immunofluorescence. to determine the impairment of the endothelial cell barrier function, trans-endothelial electrical resistance (teer) and permeability to fitc-dextran were measured. plasma from healthy volunteers were used as control. data are expressed as mean ± sd. results from different experiments were compared by unpaired t test.results. ten male patients were enrolled, mean age ± , gcs ± , iss ± , sofa was . ± . on admission and ± . on day . plasma derived from tbi patients increased the adhesion of neutrophils on ecv cells ( ± vs. ± cells/field, p \ . ), induced a significant reduction of teer ( . ± . ohm/cm vs. . ± . ohm/cm , p \ . ) and caused a concomitant increase of endothelial permeability to dextran ( . ± . vs. . ± . %, p \ . ) compared to control (healthy plasma). a visual up-regulation of icam- expression was also observed. there was a significant correlation between delta sofa score (day -day ), calculated excluding gcs, and neutrophil adhesion on endothelial cells exposed to plasma from tbi patients (p = . , r = . ).conclusions. plasma from patients with tbi causes the increase of endothelial permeability and neutrophil adhesion, which correlates with the development of extracranial organ dysfunction expressed by sofa. these results suggest a mechanism potentially responsible for the development of mof after traumatic brain injury.grant acknowledgment. fondi universitari ex- %, regione piemonte-ricerca sanitaria finalizzata. objectives. the aim of this study is to describe indications of dc and outcomes in our unit.methods. it is a retrospective revue collecting patients who had a dc for severe icht between january and july . inclusion criteria were: icht refractory to medical management due to cerebral oedema. we define intractable icht as intracranial pression (icp) over cmh o, pupil modification, neurologic deterioration persisting more than min despite medical management or ct scan findings. exclusion criteria were imminent cerebral death, icht due to an acute hematoma, tumour, hydrocephalus and prediction of short life expectancy. objectives. historically, research has targeted problems experienced several months post discharge from critical care, namely using data from follow up clinics \ months after the critical illness. in contrast, this study aimed to review data from patients recently transferred from critical care to the wards. this data can then be compared with patients' progress after earlier rehabilitation. methods. this was a prospective, longitudinal study, involving long stay critical care patients ([ days), between april - . this cohort included all patients nursed within our itu/hdu, regardless of speciality, age or gender. all reviews took place whilst the patients were still hospitalised. the study used qualitative data, using specifically designed questionnaires which highlighted the type of long term problems our patients suffered. these were developed using data from previous informal patient interviews and the had (hospital anxiety and depression) questionnaire. the latter was considered too intrusive for the ward environment. a data base was used to list the frequency of these problems to provide quantitative data. a total of patients were reviewed over years. the qualitative data highlighted different, common morbidities, in addition to disease specific morbidities. between, april - , % of patients demonstrated at least physical or psychological problems and % displayed or more. the quantitative data showed the most prevalent morbidities were: poor mobility at %, nightmares %, loss of appetite % and insomnia %. year showed similar findings, plus global weakness at %.conclusions. this research showed significant post critical illness morbidities in this cohort which appeared to impact on the patients' recovery on the wards. the challenge for our follow up is to target support and rehabilitation whilst the patients are in critical care and then re-evaluate the results. if this expedites a return to a near normal quality of life, it will have improved the efficacy of our service and may impact on follow up care in general. . it may affect the balance of family and change their roles and responsibilities, mainly due to the separation from their relative imposed by hospitalization. this admission may also generate other discomforts to the family, as relationship problems, emergence of diseases, lack of financial resources for expenditures now installed, anxiety, depression, fear and irritability . objective. to get to know the discomfort that characterizes the changes experienced in the daily life of families who have a relative in icu. method. this is a qualitative study, conducted in a general icu of a large hospital in the city of salvador, bahia, brazil, from august to october of . nine relatives of people hospitalized for at least h in icu were interviewed. the data were analyzed by the use of procedures of analysis of grounded theory. results. the hospitalization of a family member in icu produced discomfort for her, as the uncertainty of recovery, the fear of loss and the sudden physical separation of the relative. the interaction between the huge discomfort of life threat and the separation from the relative, in turn, spawned other discomforts in the daily lives of families, expressed by two categories. the first one, having difficulties to answer psychobiological needs, meant for the family member the experience of sleep deprivation, loss of appetite and constant concern with the relative. the second one, suffering a discontinuity in the daily life, meant to the family the disruption of daily activities with the relative, irritability front other family members, removal of the routine of home, loss on work performance and studies and difficulties to enjoy the leisure and recreation.conclusion. the coping of illness and hospitalization of a relative in intensive care produced discomfort for family members, characterized by changing of the routine of the daily life and care for oneself. the family's attention is primarily directed toward the ill relative. it starts to experience the routine of a hospital and disrupts the organization of familiar and personal life, it finds itself suffering a break from daily life. the discomfort experienced by the family can be minimized by practices of the healthcare team, which provide care, information, support, safety and convenience. (fig. ). this is a unique opportunity to study the effects of nursing environment on sleep quality and quantity in icu patients. to study the effects of nursing environment on sleep quality and quantity in icu patients. a total of patients will be included in this ongoing study: ten subjects who were admitted to the old, ward-like icu (fig. ) , and ten patients who will be admitted to the new, single-room icu (fig. ) . objectives. in order to understand the family's perception of nursing care, the authors undertook this study, assessing the family satisfaction and use the results to increase the quality of care.methods. this is a qualitative study of inductive nature. data was collected along the time of the study by in-depth interviews, to six relatives of each patient, after discharge the intensive care unit. for data analysis we followed the steps of the phenomenological method, according to max van manen ( ) . results. from data analysis, the results were divided in categories: ) relative needs; ) icu environment; ) relative's feeling; ) nurses role and ) suggestions. all this categories were grouped in a central theme called ''being a relative in a general intensive care unit''. the results show that relatives of patients admitted to the intensive care unit often require complete knowledge of the medical condition of the patient, a specific area for that purpose and a comfortable waiting room. they express the need to be near the patient and participate in care. they feel fear and anger with the situation that inevitably are forced to live and think, mostly, that nurses are effective and efficient in meeting the needs of the patient and family. conclusions. it is essential to promote attitudes and behaviors that provide comfort, safety and privacy for relatives, and acknowledge that they have a role in the process of care, reinforcing their importance in decision making process.introduction. heart failure (hf) is a complex syndrome that commonly affects elderly patients in whom it has a major impact upon longevity and quality of life. it is usually associated with symptoms such as dyspnoea, fatigue, and fluid retention, and results in frequent episodes of hospitalisation.objectives. this study was planned to examine the relationship between self-care behaviors and quality of life in patients with hf.methods. this study was planned and applied as a descriptive and a cross-sectional study. introduction. the hospitalization of a relative in icu, especially when it's unexpected, is considered a too stressful experience for the family, usually compounded by the disruption of daily life. from the relative's hospitalization at the icu, the family will necessarily interact with health practices, the rationality that underlie it and institutional objects that may be a source of comfort or discomfort , .objectives. to understand the situations defined as comfort to relatives of people in critical state of health and the sense of comfort in this situation.methods. this is a qualitative study conducted in the general icu of a large hospital in the city of salvador, bahia, brazil, from june to october of . fourteen family members of persons hospitalized for at least h in icu were interviewed by a specific questionnaire. all recorded interviews were transcribed and the data were analyzed by the use of procedures to encode the data of grounded theory. seven categories expressed the experience and sense of comfort for the relatives who had a person hospitalized in the icu: ) security: confidence of relatives in technical-scientific and humanistic team and in the possibility of recovery of the person who is hospitalized, ) reception: comfort experienced by the family by being treated as a person by the professional of icu when they interact with a supportive attitude, ) information: comfort experienced by the family when it feels conscious of the reality of the health condition of their relative and to receive guidance about the unit s routine, ) social and spiritual support: comfort experienced by the receiving of help and support of the family, friends and religion, ) proximity: the comfort of being close of the relative and being able to enjoy the interaction established between them, ) convenience: comfort experienced in interacting with pleasant elements and support of basic needs of the family, offered by the environment and physical structure of the hospital; ) integration with itself and the daily: the possibility of the family member to take care of himself, to help the relative and to give continuity to the family routine as it did before the hospitalization.conclusions. the comfort is a positive, subjective and dynamic experience, which changes in time and space, which is the result of the interactions that the individual sets with himself, with those around him and with the situations he faces, without losing view that every family is unique and can experience this process in a proper way. to ascertain the perceptions of icu nurses' about the needs of families of critically ill patients methods. this is a transversal study. the data were collected in four icus in the city of feira de santana, bahia, brazil, after approval by ethics and research committees. all clinical nurses of icus were interviewed. the brazilian adaptation of the critical care family need inventory (inefti) was used for measuring the degree of importance of needs of family members, valued at increasing levels from to . descriptive statistics were used for analysis, needs with a mean score [ were defined as having the greatest importance.results. the nurses identified % of needs as important for family members. the items related to security ''to be sure that the best possible treatment is being offered to the patient'' ( . ± . ), and the information ''to talk to the doctor every day'' ( . ± . ), were pointed out as the most important, with consistent results with the literature. some needs of support ''to have general guidelines on the icu at the first visit'' ( . ± . ) and comfort ''to have a bathroom near the waiting room'' ( . ± . ) were also identified as important. however, the needs of proximity, like being close to their relative was not identified as important to the family for all nurses.conclusions. the nurses identified the need for security and information as important, however the wish that the family has to be near their relative was not considered important, as described in the literature , , . a movement of nursing towards the family can be perceived, so nurses should plan their interventions based on knowledge of the demands of the family in order to promote care for the relief of immediate distress and anguish, which will consequently encourage the recovery of the ill relative reference(s). nurse educator, realized that with an ongoing critical care nursing shortage world wide, even when retention is high, some turnover is inevitable necessitating an orientation tool to guide charge nurses in assigning new hires to critically ill patients. impetus for this clinical orientation tool arose from observations that new hires were often overwhelmed or disengaged at the bedside, and patient assignments did not consistently foster the development of critical care skills. the orientation tool reflected a staged approach to patient assignments; gradually exposing the new hire to progressive levels of complexity. embedded within the tool were guidelines specifying performance competency expected of new hires at month intervals in their first year of critical care practice. evaluation at this stage involved on the spot interviews. use of the tool began in january . since its introduction, this tool has guided patient assignments for newly hired nurses. in six cases, nurses moved through the stages more quickly than anticipated. reports from staff nurses, clinical educator, patient care coordinator and nurse manager suggest that anxiety and stress of novice critical care nurses related to the complexity of patient assignments have decreased, and that the tool's structure provides clear goals and has enhanced satisfaction with the consolidation experience. our goal was to ensure the tool facilitated an optimal learning experience, structured around orientation standards and leading to the development of confident, competent practitioners. future plans for on-going evaluation include: formal surveys with present msicu staff, and exit interviews with nurses new to critical care who have left their msicu positions prior to the introduction of the orientation tool. ( ) has previously been claimed to show an association between improvement of score (or lack of) over time and survival status ( ) . severe sepsis in patients is associated with considerable mortality. activated protein c (apc) is a mediator of the inflammatory and coagulation systems, which has shown decreased mortality in severe sepsis ( ) beyond h sofa scores showed further distinct improvement over the apc infusion period in the survivor group, whereas minimal improvement was seen in the non survivors.change in daily sofa scores conclusions. our analysis appears to agree with levy's previous findings of increasing sofa (albeit modified) scores and mortality. we, however, looked at a different treatment period, (apc infusion rather than first day of sepsis) but, nonetheless, found the same association of increasing score and mortality and decreasing score and survival. the mean age in survivor group was considerably less than that in non survivors and this age discrepancy largely accounts for the difference in mean apache score ( points) between groups. the depicted trend in sofa scores is more apparent beyond the initial h of treatment, and suggests that improving sofa scores and outcome prediction is possible beyond the previously reported h. our numbers are small, but lend support to the predictive potential of repetitive sofa scores and outcome.objectives. this real-life registry was implemented to describe clinical characteristics of patients treated with drotrecogin alfa (activated) (daa) in france and the use of this drug.methods. this national multicenter observational study, proposed to intensive care units (icus) which used daa, was conducted by data abstraction from hospital files of patients admitted in icus and treated by daa. two sets of data were obtained: a) retrospective data collected between january st, and beginning of the prospective phase in each site; b) prospective data for patients treated until november . this current analysis aimed to describe the patients retrospectively enrolled and treated between january and april . statistical analysis was mainly descriptive. conclusions. this study showed a good concordance between the target population and population treated by daa in terms of treating patients with higher disease severity. patients treated in real-life had a particularly severe sepsis as shown by the saps ii score of and high number of organ dysfunctions at time of infusion initiation. the -month observed mortality was lower than the predicted hospital mortality of % with this level of saps ii. introduction. mortality in severe sepsis is variously described, but is often up to % ( ) . activated protein c (apc), a mediator of the inflammatory and coagulation system has shown a decrease of hospital mortality from . to . % ( ) at year post apc we found that patients ( %) out of were still alive ( patients are still less than year post apc and therefore not eligible for consideration). conclusions. this study is limited in size, but demonstrates further favourable evidence to support the administration of apc for patients with severe sepsis, and appears to contradict the cochrane findings ( ) . we have shown that our hospital survival has improved since initial report ( ) . we attribute this improvement in smr to better targeting of apc to the more severely ill septic patients (as evidenced by the increased apache score).longer term survival data was also encouraging, % of our patients were alive at year, post apc. this should be considered against an initial predicted survival to hospital discharge (never mind year) of . %. we find this result very promising, it would appear that initial survival advantage with apc is in fact sustained beyond hospital discharge. objectives. medication errors reported in a self reporting medical incident system were systematically analyzed to identify root causes and obtain preventive measures methods. all medication incidents received within year in a -bed mixed icu, were analyzed by trained persons in analyzing medical adverse events. the systematic approach consisted of five steps. . description of the incident in a causal tree. . all causes were classified into the main categories according to the prisma incident analysis tool (technical failure, organization failure, human failure, patient related and non classified). . all medication errors were categories into the broad stages of medication process (prescription, transcription, preparation, dispensation and administration). . the recovery phase of all near miss were analyzed. . development of an action matrix based on the most suitable solution (equipment, procedures, information/communication, training and motivation) for each root cause. . incidents/near miss were recorded. % were medication or fluid therapy related incidents/near miss. human intervention ( %), verification ( %) and organizational/ protocol ( %) were the most common causes of medication incidents/near miss. % of all errors occurred in the administration phase and % in the prescription phase. the most suitable solution for the recorded medication errors are shown in fig. . conclusions. this systematic approach reveals that introduction of new equipment, such as a patient data management system (pdms), and improvement of the procedures are the most important actions to reduce medication errors in our icu. objectives. this study is a descriptive study which is carried out in order to determine the perspectives of newly graduate and experienced nurses on medication errors working in a military education and research hospital. methods. this study was planned and applied as a descriptive and a cross-sectional study. study was executed at a military education and research hospital in turkey between july and august . totally nurses were involved, of those were newly graduate and were experienced nurses. data collection form which has been prepared by the researches in order to determine the perspectives of nurses on medication errors consists of two parts. the first part consists of questions prepared in order to determine the ages, departments, educational levels, experiences and some informative characteristics of the nurses. in the second part there is questionnaire form on perspectives of the nurses on medication errors which was prepared by gladstone in . the study was applied after written ethical approval of the ethical committee of the military education and research hospital and application permission of the nursing department. the application was realized by surveying on volunteer nurses after making necessary explanations about the aim of the study and the application procedures to the participants. the data were analyzed using percentages, mean ± standard deviation, chisquared test and independent-samples t test. conclusions. in this study among the causes of drug errors; tiredness and exhaustion of nurses is stated in the first place. it is thought that rearrangement of working hours of the nurses, reduction of long working hours by the nursing administration will be effective on preventing drug errors. ( ). to test the basic knowledge and practical implementation of picco measurements by icu personnel. descriptive trial in which (para)medical icu personnel were asked to participate in a written or online survey ( questions based on the information found in the manual of the picco system).results. so far, persons have participated: nurses and medical doctors ( were residents in training), all of them actively working in an icu. in total, % of the respondents knew that a picco co measurement is performed intermittently by transpulmonal thermodilution and on a continuous basis by arterial pulse contour analysis. about % is convinced that a picco measurement is an invasive procedure, while in fact it is considered minimally invasive. opinions are divided upon the indications for picco measurement. some participants do not know that the measurement of extravascular lung water provides valuable additional information in pts with acute hypoxic respiratory failure and some even believe that picco can also measure pulmonary capillary wedge pressures. the basic knowledge on co calibration is insufficient: % do not know that the temperature of the injection fluid should best be below °c and only % know that the volume of the calibration fluid depends on the patients' weight. % faulty believe that the patient has to be in the supine position to perform a measurement and % is not informed on the fact that the co obtained should not differ more than % from the mean co value. only % of the respondents carry out a rapid flush test before each picco measurement and only % know that the calibration fluid has to be injected in less than s to obtain a correct measurement. finally, % believe that it is necessary to input the cvp value to calculate a correct co, although % of the respondents correctly knew what to do in case the delta t°is too small and % could correctly interpret the thermodilution curves displayed in the survey.conclusions. from these data we can conclude that a big variation exists in the knowledge on the basic principles and the practical implementation of picco measurements. some confusion exists with regard to the terminology used. we conclude that (as with any new technique) high quality education on picco measurements is necessary for icu personnel. this education can be facilitated by a good protocol, that can be implemented by nurses and doctors at the bedside to avoid human errors. a.c. beers vu university medical center, intensive care, amsterdam, netherlands health insurance companies in the netherlands sign exclusive contracts with hospitals. patients are more critical and independent. they consciously choose a particular hospital or treatment. this is why our management gave high priority to the subject of customer service in their long term policy plan.objectives. in january a project group was launched, which aimed for a number of specific improvements but also by increasing awareness and enthusiasm for customer experience amongst employees. the project is focused on the experience or perception of patients and visitors.methods. the first step was a baseline measurement by hcg (hospitality consulting group). this measurement included interviews with employees from different icu locations and an online survey that was completed by employees, next of kin and other visitors. this resulted in a high score for commitment of staff towards patients and visitors. remarkably, employees thought that aspects for example reliability, professional care and privacy would be valued higher by customers. they attach more importance to how they are received, to empathy and sympathy. respondents also mentioned other things for improvement for example better signage, improved telephone access, better information about rules and procedures, unambiguity in approach, a better visibility of staff and a pleasant and hygienic department. . several improvements such as product, behavior and environment were achieved: we employed family counsellors, developed an information folder and started a pilot for an improved name badge. we can still make improvements in awareness, behavior and addressing each other on this subject. this year we plan to come to an agreement on standards, competencies and control by means of several management training sessions and workshops for employees. we can measure changes in patient satisfaction by family evaluation surveys or an instrument called netto promotor score. the netto promotor score (nps) indicates how many respondents will recommend our ward or hospital to their family and friends. to quote fred lee: ''if a service is provided as expected, patients or visitors will not remember it, they are merely satisfied. satisfied patients will forget a service quickly, have no story to tell to their family and friends and are not really loyal to your organisation. therefore you must create an unforgettable experience, because an experience that remains in memory, is told to others.'' reference(s). critically ill medical, post-surgical, and trauma patients are at greater risk for hyperglycemia with associated increase in mortality and morbidity. tight glycemic control (tgc) has been well documented as a method to control hyperglycemia by managing blood glucose fluctuations through carefully controlled continuous insulin infusion. in order to determine the amount of time it takes within practice for nurses to implement effectively a tgc protocol within the critical care unit, we conducted a pilot time-in-motion study to elucidate the effect on workload. a time-and-motion study was carried out at a hospital located in london, uk in order to document the time associated with tgc activities. a timing workflow, used to capture the key steps involved with effective tgc implementation when utilizing blood gas analyzers for the determination of whole blood glucose (bg) and the time required to complete each step, was designed and then validated by ccu staff. ccu staff was trained on the timing workflow and mechanism. independent observers shadowed ccu nurses, observing when a blood glucose measurement was taken, which steps were completed, and the length of time required to complete each step. other data such as time of the previous bg measurement and status of the last bg test was collected for analysis purposes. during the past few years, the increased incident rate of medical errors occurring in hospitals under governing of hong kong hospital authority has contributed significant attention from the public and health care policy makers. in such a situation, promote patient safety culture becomes paramount for all health care professionals and hospital settings. interdisciplinary teamwork is important in the intensive care units. the benefits of good teamwork have been well documented in the literatures. they included fewer delays, increase in working moral, increased in job satisfactory and decreased in medical errors. in relation to patient safety, fewer errors occur when there is strong teamwork because patient care activities are planned, well organized and standardized. therefore, substantial attention should be given to decrease of medical errors and nurture patient safety culture within high-risk areas such as icus. objectives.• to examine the perception of teamwork and patient safety culture of doctors and nurses between icus and within icu • to investigate the relationship between teamwork and patient safety culture of icu doctors and nurses methods. a cross-sectional surveyed of doctors and nurses in three intensive care units with various size, level of care and staff to patient ratio of hong kong hospitals. totally icu doctors and nurses have been included in this study. a modification of safety attitudes questionnaire developed by sexton and colleagues in was adopted. results. the overall response rate was . %. there were no significant difference of perception of teamwork and patient safety attitude among studied icu's doctors and nurses. however, icu (a) and icu (c)'s doctors demonstrated more positively and showed significant different in perceptions of teamwork (p = . ; . ) than nurses. regarding patient safety attitude, icu (a)'s doctor also showed significant difference (p = . ) and rated more positively than nurses working in the same clinical area. a highly statistically significant association between patient safety attitude and teamwork was shown in the spearman rho statistics with r s ( ) = . , p = . . conclusions. the rate of agreement on teamwork and patient safety attitude were higher in icu doctors. they were more likely to perceive effective teamwork and patient safety in the working area. nurses tended to rate both items lower. as teamwork has been shown to have strongest relationship with patient safety issues, more attention should be given to improve teamwork for icu nurses. tnf is upregulated within the alveolar space early in the course of ventilator-induced lung injury (vili), and plays a major role in the pathogenesis. we previously found in knockout mice that two tnf receptors play opposing roles during vili, with p promoting but p preventing pulmonary oedema. this suggests that specific blockade of the p receptor within the alveoli is a potential therapeutic strategy for vili. domain antibodies (dabs) are the smallest antigen-binding fragments of the igg molecule, which may have advantages over complete antibodies due to their small size (short half life, enabling regional delivery) and monovalent binding (no receptor cross-linking). objectives. we tested the effects of an intratracheally (i.t.) delivered dab that binds to and inhibits the mouse p receptor (biopharmaceutical r&d, glaxosmithkline), on pulmonary oedema and inflammation during vili. methods. c bl mice were ventilated with a high-stretch protocol (plateau pressure . - . cmh o, tidal volume - ml/kg, peep cmh o, o with - % co ). immediately after the start of high-stretch, mice were given an i.t. bolus of non-specific 'dummy' dab or p -specific dab ( lg in ll) and ventilated for up to h ( -hit model). as a -hit model, ng lps was included in the dab bolus. respiratory elastance (ers) and blood gases were monitored, and bal performed at termination. in the -hit model, lung cell suspension was analysed for intravascular margination of neutrophils (pmn), and bal fluid (balf) assessed for pmn infiltration and alveolar macrophage (am) activation using flow cytometry. results. high-stretch ventilation produced deteriorations in ers and po , and high balf protein in both models. treatment with the p -specific dab substantially attenuated all of these changes in the -hit model (table ). in the -hit model, p blockade prevented deteriorations in ers and po , and significantly decreased pmn margination, intraalveolar pmn infiltration and icam- expression on ams (table ) . introduction. ventilator-induced lung injury (vili) triggers a variety of molecular responses within the lungs. however, the contribution of these pathways to lung repair has not been identified.objective. to identify the molecular mechanisms involved in lung repair after vili.methods. vili was induced in mice by ventilation using high pressures ( cmh o) without peep for min. after this, pressure was decreased to cmh o and peep increased to cmh o for h more to promote lung repair. we quantified histological damage, protein content in alveolar lavage (balf) and different molecules in lung tissue (collagen, matrix metalloproteinases- and - , tnfa, ifnc, il- , il- , mip- and lix) in the different conditions (baseline, after injury and after repair). additionally, survivors and non-survivors to the repair phase were compared. the effects of the differentially released mediators were studied in a wound model using murine alveolar cells cultured in presence of balf obtained from ventilated animals, and human alveolar cells and balf from ventilated patients. results were compared using an anova, with a significance level of p = . . . mice were studied ( at baseline, after injury and after repair). high pressure ventilation caused lung tissue injury, with significant increases in balf protein content, mmp- , mmp- , tnfa and mip- , and a significant decrease in il- . during the repair phase, tissue injury was partially reverted, balf proteins and levels of tnfa decreased, but mmps and mip- persisted elevated. mortality during the repair phase was %. survivors showed lower levels of collagen and higher levels of mmp- ( ± vs. ± units, p \ . ) and mip- ( ± vs. ± pg/mg protein, p \ . ).blockade of mmp- , but not mip- , delayed wound closure in both murine and human alveolar cells cultured in presence of balf from ventilated mice or patients respectively.conclusions. vili is partially reversible by decreasing airway pressures and increasing peep. mmp- promotes epithelial repair.grant acknowledgment. universidad de oviedo (unov- -becdoc), ficyt (cof- - ). introduction. critically ill survivors present significant long-term brain-related morbidity. excessive end-inspiratory stretch during mechanical ventilation (mv), even in healthy lungs, may promote alterations in the local and the systemic inflammatory cascade. the effects of ventilator-induced systemic inflammation on brain structures are unknown. to characterize the role of the ventilatory pattern (high vs. low tidal volume (vt)) in the development of local or systemic inflammatory response and regional neuronal brain activation in rats. brains were processed for c-fos immunohistochemistry, as a cellular marker for activated neurons, in the following regions: thalamus, cerebral cortex, amygdala, hippocampus, hypothalamus, and caudal striatum. data were analyzed using one-way anova (p \ . ). results. map and lung compliance remained stable and in the normal range in both groups. pao decreased and paco increased at h in lvt. mv animals presented high levels of systemic and lung inflammatory mediators compared with baseline levels. hvt significanly increased tnfa and il- in plasma when compared with lvt group. in the lungs mv increased il- , il- , il- b and mip- proteins, irrespective of the vt level (lvt or hvt). mcp- only increased in hvt lungs, while tnfa lung levels are similar in ventilated and non-ventilated animals. a significant increase in the number of c-fos immunopositive neurons was only found in retrosplenial cortex and thalamus in hvt animals as a sign of neuronal activation of those areas. none of these two areas were activated in lvt or in control animals. mechanical ventilation produced a moderated systemic and lung inflammation in the context of a preserved lung function. high tidal volume ventilation promoted differential neuronal activation in the brain compared with lvt animals. these findings suggest a novel cross-talking mechanism between lung and brain in the context of experimental acute lung injury.grant acknowledgment. mec bfu - /bfi, fundació parc taulí. jl-a is senior researcher program i isciii, and ciberes. ( ).in an ex vivo perfused human lung preparation injured by e. coli endotoxin, allogeneic human mscs or the conditioned medium restored normal fluid balance ( ).objectives. we wished to evaluate the potential for mscs to modulate inflammation and enhance repair after ventilator induced lung injury (vili). adult male sprague-dawley rats were anaesthetised, orotracheally intubated and subjected to injurious mechanical ventilation. following the development of vili, animals were recovered and extubated. thereafter the animals received two intravenous injections of mscs ( . million cells) or vehicle immediately post injury and at h. the extent of the inflammatory response and recovery from vili, as measured by systemic oxygenation, respiratory static compliance, lung wet:dry ratio and lung lavage inflammatory cell infiltration, was assessed at h. mscs reduced inflammation and enhanced repair following vili. msc treatment improved respiratory static compliance, reduced total lung water as assessed by wet:dry ratio, and decreased bronchoalveolar lavage total inflammatory cell and neutrophil counts, from , cells/ml to , cells/ml (ci . - . ) (fig. ). there was a trend towards better oxygenation in the msc group.conclusions. these findings demonstrate the potential of mscs to modulate inflammation and enhance repair following vili. further analysis of our work, including bal cytokine assay and histological assessment of injury, will provide insight into the utility of mscs to enhance repair in the lung. to determine the role of vagus nerve signaling in vili and establish whether stimulation of the vagus reflex can mitigate lung injury from high volume ventilation.methods. first we demonstrate that disruption of the cap reflex by bilateral vagotomy results in worsening lung injury in a mouse model of high-volume-induced lung injury. in a clinically relevant rat model of injurious ventilation following hemorrhagic shock/resuscitation (hs; model of lung ischemia/reperfusion injury), we then tested the hypothesis that electrical and pharmacological stimulation of the vagus nerve can attenuate injurious effects of vili. finally, to determine the molecular mechanisms by which stimulation of the cholinergic response mitigates vili, we exposed human bronchial epithelial cells (beas b) to cyclic stretch ( cycles/min, pka) in the presence of specific agonist or antagonist of the subunit of the acetylcholine nicotine receptor. vagotomy exacerbates lung injury from high volume ventilation in mice as demonstrated by increased wet-to-dry ratio, infiltration of neutrophils in bronchoalveolar lavage fluid and lung tissues, and increased tissue levels of interleukin- . vagotomy exacerbated while vagus stimulation attenuates lung injury in rats after ischemia reperfusion injury ventilated with either high or low volume strategies. treatment of both mice and rats with the vagus mimetic drug, semapimod, resulted in decreased lung injury. vagotomy also increased pulmonary apoptosis whilst vagus stimulation (electrical and pharmacological) attenuated vili-induced apoptosis. in vitro studies suggest that vagus-dependent effects on inflammation and apoptosis are mediated via the a nachrc-dependent effects on cyclic stretch-dependent singling pathways c-jun n-terminal kinase (jnk) and fas (tnf receptor superfamily, member ).conclusions. stimulation of the cholinergic anti-inflammatory reflex may represent a promising alternative for the treatment of vili.introduction. so far, histological data on critical illness myopathy (cim) primarily refers to muscle biopsies taken during protracted critical illness (after weeks), repeatedly describing pronounced type-ii muscle fibre atrophy.objectives. we speculate that type-ii fibre atrophy develops during early critical illness in patients with non-excitable muscle membrane which predicts cim. ( ) methods. due to their elevated risk for cim, critically ill patients with sofa scores c on of consecutive days within the first days after icu admission were eligible for inclusion into this prospective, observational study. preexisting iddm or neuromuscular disorder, pregnancy, bmi c kg/m , age \ years, or pretreatment[ days on other icu constituted exclusion criteria. surgical muscle biopsies were taken from vastus lateralis muscles between day and after first sofa c and postprocessed according to standard procedures (isopentane, liquid nitrogen, atpase/toluidineblue staining). we assessed muscle membrane excitability after direct muscle stimulation, abnormal muscle membrane excitabilty indicating cim ( ). after quantifying fibre-type specific median cross sectional areas (csa) with imagej-software, we compared fibre-type specific csa in patients with and without non-excitable muscle membrane. nonparametric tests (mann-whitney u) were used for statistical analyses, results expressed as median and ( th/ th) percentiles for continuous variables. . patients were enrolled and subsequently biopsied. patients were evaluated for muscle membrane excitability, of whom % (n = ) showed non-excitable muscle membrane. reliable csa quantification was obtainable for patients.type-ii but not type-i muscle fibre csa during early critical illness was significantly decreased in patients with non-excitable muscle membrane ( , lm compared to , lm for type-ii, p = . ; , lm compared to , lm for type-i, p = . ; n = ). furthermore, non-excitable muscle membrane was associated with significantly lower mrc scores after end of sedation ( . ( . / . ) vs. . ( . / . ) , p = . , n = ). in patients showing non-excitable muscle membrane after direct muscle stimulation we could observe selective type-ii fibre atrophy as early as within the first days after icu admission (day - after st sofa c ). our findings demonstrate that nonexcitable muscle membrane indeed is associated with a histomorphological correlate previously linked to cim. these results highlight the need to focus on early critically illness in order to investigate pathophysiological aspects of cim. bacterial sepsis is a major threat in neonates born prematurely, and is associated with elevated morbidity and mortality. little is known on the innate immune response to bacteria among extremely premature infants. objectives. identify innate immune defect in premature infants as risk factor for the development of neonatal sepsis. methods. we compared innate immune functions to bacteria commonly causing sepsis in infants of less than wks of gestational age, infants born between and wks of gestational age, term newborns and healthy adults. levels of surface expression of innate immune receptors (cd , tlr , tlr , and md- ) for gram-positive and gramnegative bacteria were measured in cord blood leukocytes at the time of birth. the cytokine response to bacteria of those leukocytes as well as plasma-dependent opsonophagocytosis of bacteria by target leukocytes were also measured in the presence or absence of interferon-c. results. leukocytes from extremely premature infants expressed very low levels of receptors important for bacterial recognition. leukocyte inflammatory responses to bacteria and opsonophagocytic activity of plasma from premature infants were also severely impaired compared to term newborns or adults. these innate immune defects could be corrected when blood from premature infants was incubated ex vivo h with interferon-c. conclusions. premature infants display markedly impaired innate immune functions, which likely account for their propensity to develop bacterial sepsis during the neonatal period. maturation of the innate immune response to bacteria can be induced by interferon-c ex vivo and represents a promising strategy to prevent neonatal sepsis. the anaphylotoxin c a impairs neutrophil phagocytosis in animals and humans with sepsis. although dependency on the phosphoinositol -kinase delta (pi kd) pathway has been identified , , greater understanding of the mechanism will allow novel therapeutic options. objectives. to test the hypotheses that c a mediates its effect on phagocytosis by impairing rhoa activation, and that similar defects will be found in neutrophils from critically ill patients. methods. the mechanism was dissected using an in vitro model of c a-mediated neutrophil dysfunction, treating healthy human donor neutrophils with c a at concentrations found in sepsis ( nm). phagocytosis was assessed by zymosan particle uptake. neutrophils exposed to zymosan were assayed for rhoa activity, a key mediator of actin polymerisation in phagocytosis . phagocytosis by neutrophils from critically ill patients was investigated, looking for correlations with a marker of c a exposure (cd , the main c a receptor) , an examination of the rhoa and actin polymerisation response to zymosan, and the ability of gm-csf to restore phagocytosis ex-vivo. results. c a inhibited phagocytosis of zymosan by healthy donor neutrophils (reducing from to %, p \ . ) and also impaired rhoa activation (figure) . blocking pi kd, using inhibitor ic , prevented the inhibition of rhoa by c a, and prevented the reduction in phagocytosis. treatment with gm-csf restored phagocytosis and rhoa activation (fig. ). neutrophils from patients with critical illness showed a strong correlation between phagocytosis and surface cd expression (r = . , p \ . ), consistent with our previous findings . patient neutrophils failed to up regulate rhoa or polymerise actin in response to zymosan, in marked contrast to cells from healthy donors (p = . and p = . respectively). ex-vivo gm-csf was able to improve phagocytosis by patient neutrophils from to %, p \ . . conclusions. these data demonstrate that c a inhibits rhoa activity through pi kd, inhibiting phagocytosis. gm-csf is able to reverse this inhibition. similar effects are seen in neutrophils from critically ill patients, providing new avenues for therapeutic intervention in critical illness. host infection triggers an innate immune response leading to a systemic inflammatory response, often followed by an immune dysfunction which impairs the lung defence mechanisms in mice and increases susceptibility to secondary p. aeruginosa pneumonia. activation of the toll-like receptor (tlr)-dependent signalling pathways influences the magnitude of the initial pro-inflammatory phase of sepsis. contribution of tlr signaling to the subsequent development of post-infective immunosuppression has been poorly studied.objectives. to investigate the relative contribution of tlr and tlr in lung defence towards p. aeruginosa in the setting of sepsis-induced immune dysfunction. we used wild-type (wt) c bl /j mice and littermates deficient for tlr (tlr ko), tlr (tlr ko) or both tlr and tlr (tlr ko). these animals were subjected to a sublethal polymicrobial sepsis (cecal ligature and puncture, clp) followed by a secondary p. aeruginosa pneumonia at day post-clp . we evaluated -day survival and the lung response and h after instillation through lung histology, quantification of protein level, cell recruitment and myeloperoxydase (mpo) activity. lung expression of tlr , tlr and tlr was assessed through quantitative rt-pcr. bacterial lung clearance was evaluated through quantitative culture of bronchoalveolar lavage fluid (balf). bacteremic dissemination was assessed through quantitative blood cultures. finally, we measured cytokines in the balf and in the whole lung. post-septic wt and tlr ko mice displayed high susceptibility (mortality rate %) towards secondary pneumonia. in contrast, post-septic tlr -deficient mice (either tlr ko or tlr ko), survived the secondary pulmonary infection (mortality rate \ %). in wt mice, clp increased lung expression of tlr , but neither of tlr nor tlr . tlr ko mice displayed improvement in lung bacterial clearance and reduction in bacteremic dissemination as compared to wt mice. with regard to pulmonary inflammation, tlr ko mice displayed decreased alveolar damage. furthermore wt and tlr ko mice displayed differences in the pulmonary release of cytokines. thus tlr ko mice exhibited increased production of tnf-a and ifn-c and a decreased production of il- .conclusions. in a model of polymicrobial sepsis followed by p. aeruginosa pneumonia, tlr deficiency improves survival by promoting efficient bacterial clearance and decreasing pulmonary inflammation. tlr -dependent mechanisms that specifically contribute to lung defence in the setting of sepsis-induced immune dysfunction are currently investigated. infection is a serious complication in critically ill patients, who can be in a state of secondary immunodeficiency due to a severe illness. apart from common nosocomial pathogens, highly unusual microorganisms may be found in these patients, i.e. pathogens whose cultivation requires specific conditions, and/or agents which are difficult to cultivate. molecular biology-based methods (pathogen-specific probes with real-time pcr detection, or universal system pcr detection with subsequent sequenation) make diagnosis faster and more accurate.objectives. i) to assess an agreement of investigation results using classical microbiology techniques and molecular biology-based methods; ii)to evaluate the clinical effect of the diagnoses based on the frequency of changes in antibiotic therapy as a direct result of molecular detection of ''pathogens'' (mpd) and to assess the effect of this change by evaluating a -day trend of inflammatory parameter concentrations i.e. of procalcitonin (pct) and c-reactive protein (crp). a total of samples (blood, bal, tracheal aspirate, urine, cerebrospinal fluid and secretions from abdomen drains and thoracic punctures) were taken from icu patients (aged - ). these were investigated simultaneously, both by classical microbiology and microbial methods, using the system of pathogen-specific probes with real time pcr for agents. each sample was tested simultaneously with the universal pcr detection system for bacteria and fungi with the subsequent sequenation.results. an agreement between the two compared examination methods was found in % of samples and disagreement in % of the samples. % of the results were classified as ''not possible to interpret''. in % of the samples, mbm detected the presence of other agents, which were not confirmed by cultivation. in % of cases, the mdp results did not contribute to the decision to change the atb. in % of cases, a modification of atb treatment followed; a change, reduction or stopping the administration of the drug. in % of cases, atb was changed without any direct connection to the results. in % of patients who underwent the change in atb treatment, a decrease in inflammatory parameters occurred (pct and crp), however, in % there was an increase. the remaining % are divided equally between those ''without any change'' and ''data not available''.conclusions. the advantage of septic-state diagnostics using molecular biology techniques, as opposed to classical microbiology methods, is the fast availability of the examination results ( - h) , and its high sensitivity and specificity. proving the presence of agents in biological material does not necessarily signify its pathogenicity. however, in combination with a thorough assessment of the clinical progression, including laboratory indicators of inflammation, it is of considerable benefit in decisions about the efficacy of antibiotic therapy. common antibiotics and the number of patients on high or low intensity crrt recruited were: ciprofloxacin ( , ) , meropenem ( , ), piperacillin-tazobactam ( , ) , vancomycin ( , ). the clearance of individual antibiotics varied approximately -and fold within a single crrt regimen for high and low flow rates, clearance, estimated using ccrt extraction ratios for the two flow rates, differed significantly: meropenem ( vs. ml/min; p = . ) and vancomycin ( vs. ml/min; p = . ). using dialysate clearances, significant differences for vancomycin ( vs. ( ) objectives. to perform a meta-analysis on incidence and outcome of intra-abdominal hypertension (iah) in different icu populations, the evolution of iap over time and the correlation with organ failure and fluid balance (fb)methods. pts admitted to icu with iap measurements (gastric or bladder) were included. data from existing databases were collected on , pts from centers ( countries [ ] . recently, it was demonstrated that % hes / . induces increased inflammation and leads to more tubular damage compared to % hes / . in an ex-vivo kidney perfusion model [ ] . we investigated whether different hes solutions lead to disturbed cell proliferation or to increased apoptosis in murine kidney cells. we performed a large cohort study on prospectively collected data over a year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . data were extracted from the cub-réa network , a french regional database in which icus from paris and its suburb prospectively record data using standardized coding methods. cancer patients with septic shock were selected through keywords including the malignancy status on one hand (''hematological malignancy'', ''cancer'', ''cancer with metastasis''), and ''septic shock'' or the combination of ''septicemia'' and ''shock'' on the other hand. extracted variables included demographic characteristics, type of malignancy, requirements for organ failure supports (vasopressor therapy, mechanical ventilation, renal replacement therapy) and severity-of-illness score (saps , , , , however, some studies have suggested little effect on morbidity or mortality. , clarification of any differences would improve pre-operative risk assessment, providing more information for the clinician and patient. it would also aid resource planning in the critical care unit. we hypothesized a proportional increase in the extremes of bmi occurring over the -year study period. we analysed data collected prospectively between april and april on patients undergoing cardiac surgery in our unit using the patient analysis and tracking system (pats Ò ) database. the patients were grouped according to bmi. for each group we calculated organ specific complication rates, re-operation and readmission rates, itu and postoperative length of stay and overall mortality. we studied the change in mean bmi of patients over the year period. in comparison with normal bmi range ( . - . ), patients with bmi range \ . had significantly increased rates of peri-operative myocardial infarction (mi) ( conclusions. both the high and low extremes of bmi range show significant increases in complication rates compared to normal bmi patients undergoing cardiac surgery. the bmi group - . shows significant increase in re-operation, readmission and mortality rates.there is a year on rear increase in the bmi group [ . this suggests a greater demand for resources particularly in the intensive care unit as the population with a higher morbidity and mortality increases. we would welcome an opportunity to present a detailed analysis of our findings. with advances in critical care medicine, more patients are surviving intensive care units stays. patients admitted to critical care may experience morbidity that affects their life after discharge . in addition to any physical morbidity, treatment in critical care may also be stressful and psychologically traumatic for patients .objectives. to describe the psychological outcome of patients surviving icu admission at months. a second end-point was to find possible relationships between patients' background and intensive care variables, post-traumatic stress and depression disorders.methods. retrospective analysis of data from icu follow-up clinic. data were collected in questionnaires (ptss- and beck inventory) during an interview at months after discharge of icu in the last years. statistics analysis: pearson's chi-square or fisher's exact test, significance for p \ . . . patients were interviewed, mean age was ± , % were male and . % were trauma victims. mean icu length of stay was ± days and sapsii score ± . . % of patients had less than years of education. concerning previous health status . % were healthy and . % were dependent for daily living activities. . % were retired. more than % had new complaints after discharge. only . % of the previously professionally active patients resumed their work and only % of the retired were able to maintain their normal activity. almost % of patients had new psychiatrics symptoms and only . % were being followed by psychiatry: % were on benzodiazepines and . % on anti-depressants. . % of the patients had symptoms suggestive of diagnosis of post-traumatic stress disorder (ptsd) having a ptss- superior to . regarding beck inventory, % were considered to have a depression, with . % having moderate to severe depression. after the interview % were oriented to a psychiatric consultation. % of depressive patients had new symptoms (p \ . ). of the previously active patients who did not resume normal activities, a significant (p \ . ) part was depressed ( . %). the same is true for the retired patients ( . %), p = . . longer hospital and icu lengths of stay were related with development of depression (p = . and p = . , respectively). patients with higher sapsii were more prone to develop ptsd. women had more ptsd than men (p = . ). patients in risk of ptsd and depression were younger (p = . ; p = . , respectively). as with depression these patients also had more new complains and did not return to work. introduction. mild hypothermia improves outcome after cardiopulmonary resuscitation (cpr). modes of action for it are manifold, though one way might be reduction of basal metabolic rate (bmr). therapeutic hypothermia was able to reduce bmr in patients with traumatic brain injury and critically ill patients with fever.objectives. in the present study we investigated the metabolic effect of therapeutic hypothermia in patients after successful cpr.methods. patients after cpr were treated with therapeutic hypothermia ( °c) for h and subsequently rewarmed with a rate of . °c per hour until °c was reached. all patients received standardized sedoanalgetic medication and neuromuscular blockers. indirect calorimetry was performed at , . and °c, as well as between . and . °c and - h after cpr. for statistical analysis repeated measures anova, linear and logistic regression were used. a linear relation between bmr and temperature was detected ( kj/m / . °c; p \ . ). therapeutic hypothermia ( °c) was associated with a reduction of bmr by ± % compared to °c. in this regard no difference was found between patients with good and bad neurological outcome (good outcome vs. bad outcome: ± vs. ± %; p = . ). concerning substrate oxidation rates only fat oxidation rate showed a temperature dependency ( g/day/ . °c; p \ . ). in contrast to protein oxidation rate (good outcome vs. bad outcome: ± vs. ± g/day; p = . ) patients with good neurological outcome had a significantly higher fat oxidation rate (good outcome vs. bad outcome: ± vs. ± g/day; p = . ) and a significantly lower glucose oxidation rate (good outcome vs. bad outcome: ± vs. ± g/day; p = . ) as compared to patients with bad neurological outcome.conclusions. in patients after cpr mild therapeutic hypothermia ( °c) was associated with a reduction of bmr by %. a linear relation between temperature and bmr was detected. fat oxidation rate was temperature dependent in contrast to protein and glucose oxidation rate. a significant difference in glucose and fat oxidation rates was found between patients with good and bad neurological outcome. objectives. our goal was to determine whether its institution after resumption of spontaneous circulation (rosc) improves survival and neurological recovery in an experimental model of cardiac arrest in rabbits.methods. ventricular fibrillation was induced in anesthetized rabbits. after -min of untreated fibrillation, cardiopulmonary resuscitation was attempted using external massage, electric shocks and intravenous epinephrine. after rosc, rabbits randomly underwent either normothermic life support (control group with conventional ventilation until weaning) or hypothermic support with rapid cooling (tlv group). in this last group, a °c hypothermia was induced by -min of tlv using a perfluorocarbon. subsequently, the perfluorocarbon was removed from the lungs and rabbits were conventionally ventilated with maintenance of hypothermia during h. rabbits were further warmed and weaned from ventilation. in both groups, hemodynamic and biochemical parameters were monitored, as well as survival and neurological recovery. after days, survivors were finally euthanized for post-mortem analyses. neurological dysfunction was assessed by a - % scoring system evaluating reflexes, postural reactions and behaviour ( %: no dysfunction; %: brain death).results. ten rabbits were randomized to the control group and to the tlv one. defibrillation was obtained using . ± . and . ± . electric shocks, respectively. subsequent rosc was observed after . ± . and . ± . min, respectively. oesophageal and tympanic temperatures were rapidly reduced in the tlv group, achieving . ± . and . ± . °c within -min versus . ± . and . ± . °c in control, respectively. in the tlv group, rabbits returned to normothermia within - h after the hypothermic episode. throughout follow-up, no significant difference in blood pressure was observed between both groups (e.g., ± and ± mmhg in control vs. tlv at h after cardiac arrest, respectively) whereas heart rate was decreased throughout hypothermia in tlv vs. control (e.g., ± vs. ± beats/min at h following cardiac arrest, respectively). lactates's concentration and epinephrine dosages were not significantly different between groups. importantly, neurological dysfunction was significantly attenuated in tlv vs. control (e.g., ± vs. ± % after h). in control, / ( %) rabbits survived throughout the follow-up and the others died or should be euthanized earlier following severe disability. in the tlv group, survival was significantly increased as / rabbits survived to the entire follow-up ( %).conclusion. ultra-fast cooling induced by tlv after rosc improves survival and neurological recovery following -min of experimental cardiac arrest in rabbits.grant acknowledgment. (ca) . th involves at least h of induced hypothermia ( - °c), mechanical ventilation and sedation. th may affect sedation through changes in pharmacology. still, no clinical studies have investigated the use of sedation during th. objective. to compare the efficacy of two sedation protocols for patients treated with th. methods. open, randomised, controlled, population based study of patients treated with th ( - c for h) after ca in two norwegian university hospitals. patients were randomised to sedation with remifentanil + propofol (rp) or fentanyl + midazolam (fm). baseline characteristics (age, sex, bmi, saps-ii) and cardiovascular variables during study drug infusion (blood pressure, heart rate, use of fluids, vasopressors and inotropic drugs) were recorded. the primary end point was defined as time from stop of sedation to extubation. results. sixty patients were randomised. one patient was withdrawn by next of kin. baseline characteristics were similar in the two groups. for two patients in the rp group, and one in the fm group, study drugs were stopped shortly after allocation due to cardiovascular instability. the rp group had lower heart rates and more patients needed noradrenaline infusions than the fm group ( . ( . ) (mean(sd)) vs. . ( ) beats/min, p = . , and vs. patients, p = . , respectively). other circulatory variables were similar. reasons to not stop sedation or not extubate after stop of sedation were; cessation of icu treatment (n = ), need for mechanical ventilation (n = ), inadequate awakening (n = ), seizures after stop (n = ), and other (n = ). sedation was stopped according to protocol in of patients. median (range) time from stop of sedation to extubation for the patients who could be extubated according to protocol was . ( - . ) vs. . ( . - . ) h in the rp and fm group, respectively, p = . . ''cerebral performance category'' on day - was similar in the two groups. conclusions. time to extubation after cessation of sedation was significantly shorter in patients sedated with rp compared to fm. however, the benefit from a short time to extubation is limited by that only one-third of the patents can be extubated according to protocol. the rp group had lower heart rates and needed more noradrenaline. no major differences were observed for outcome.grant acknowledgment. ntnu. increased blood glucose variability during therapeutic hypo-thermia and neurological recovery after cardiac arrest key: cord- - qsszns authors: huang, yao; chen, zhe; wang, yu; han, liang; qin, kai; huang, wenya; huang, ying; wang, hui; shen, pan; ba, xin; lin, weiji; dong, hui; zhang, mingmin; tu, shenghao title: clinical characteristics of patients with covid- and systemic autoimmune diseases: a retrospective study date: - - journal: ann rheum dis doi: . /annrheumdis- - sha: doc_id: cord_uid: qsszns objectives: increasing data about covid- have been acquired from the general population. we aim to further evaluate the clinical characteristics of covid- in patients with systemic autoimmune diseases (aids). methods: we included all confirmed inpatients with covid- and systemic aids in wuhan tongji hospital from january to march . we retrospectively collected and analysed information on epidemiology of inpatients and additional clinical characteristics of patients with systemic aids. outcomes were followed up until april . results: of the patients with covid- , the median age was . years and . % were male. more than half ( . %) had chronic comorbidities. the proportions of elderly, male and patients with comorbidities were significantly higher in intensive care unit (icu) than in the general ward (p< . ). ( . %) patients with systemic aids were further screened and analysed from inpatients. the median age was . years and . % were female. all patients were living in wuhan and two family clusters were found. ( . %) patient was admitted to icu and one died. ( . %) of patients changed or stopped their anti-aids treatments during hospitalisation, and of them felt that the disease had worsened after the quarantine. conclusions: older males with chronic comorbidities are more vulnerable to severe covid- . the lower proportion of covid- in patients with systemic aids needs more high-quality human clinical trials and in-depth mechanism researches. of note, the withdrawal of anti-aids treatments during hospitalisation can lead to flares of diseases. since december , accumulating pneumonia cases caused by unexplained pathogen emerged in wuhan city, hubei province, china. on january, a novel enveloped rna betacoronavirus was identified by deep sequencing analysis, which was subsequently named as severe acute respiratory syndrome coronavirus (sars-cov- ) by the coronaviridae study group of the international committee on taxonomy of viruses. the who named the coronavirus disease as novel coronavirus disease and declared it as a global public health emergency of international concern. on march, who made a further assessment that it could be characterised as a pandemic. till april, more than . million cases of covid- have been reported worldwide. several studies have reported covid- based on data from the general population, but little is known about disease-specific groups. - we retrieved inpatients who were diagnosed with covid- in two campuses of tongji hospital, tongji medical college, huazhong university of science and technology (hereinafter referred to as wuhan tongji hospital) and reported the epidemiological and clinical data of inpatients suffering from systemic autoimmune diseases (aids), providing more information on this population and relevant therapies. for this retrospective, single-centre study, we obtained the medical records and compiled data for inpatients who were diagnosed with covid- (ordinary, severe and critical cases) and admitted how might this impact on clinical practice or future developments? ► the pandemic of covid- in multiple countries highlights the demand to develop prophylactic and therapeutic countermeasures. under such circumstances, hydroxychloroquine (hcq) and chloroquine, which are widely used in aids, have entered the spotlight and aroused much controversy. it is noteworthy that if the application spectrum of hcq is expanded without enough rationale, it will increase the risk of patients with covid- , especially patients who depend on hcq for their survival. the proportion of covid- in patients with systemic aids is low, and whether it is associated with anti-aids therapies requires more high-quality human clinical trials and in-depth mechanism researches. ► the covid- pandemic has taken up substantial medical resources, however, the concern about the underlying diseases of patients with chronic comorbidities cannot be ignored. to two campuses of wuhan tongji hospital. the data cut-off for the study was april . covid- was diagnosed based on the interim guidance from national health commission of the people's republic of china. laboratory confirmation of covid- was defined as a positive result by the use of high-throughput sequencing or real-time reverse transcriptionpolymerase chain reaction (rt-pcr) assay on specimen from the lower respiratory tract. the confirmation of systemic aids was through electronic medical records, and by this means eight patients with rheumatoid arthritis (ra), three patients with systemic lupus erythematosus (sle), two patients with sjogren's syndrome (ss), two patients with ankylosing spondylitis (as), one patient with behcet's disease and one patient with polymyalgia rheumatic were included. two cases of organ-specific aids were excluded, including one patient with hashimoto's thyroiditis and one patient with pulmonary sarcoidosis. when a ventilator or continuous renal replacement therapy or extracorporeal membrane oxygenation treatment was required, the patient was admitted to the intensive care unit (icu). this study was approved by the ethics commission of tongji hospital, tongji medical college, huazhong university of science and technology (tj-irb ). written informed consent was waived by tongji hospital for emerging infectious diseases and the urgent need to collect data. we reviewed electronic clinical records at two campuses of wuhan tongji hospital and extracted demographic characteristics, epidemiological history, comorbidities, clinical symptoms or signs on admission, chest ct findings, laboratory results on admission, therapies that were prescribed for covid- as well as aids, and clinical outcomes for all inpatients with systemic aids. all radiological assessments and laboratory testing were performed for the clinical care needs of the patients. the radiological abnormality was determined based on description in medical reports. the information about aids was collected through telephone follow-up, and one patient was further confirmed as ss with ra. the classification criteria for aids were unclear, but they were diagnosed by rheumatologists, and these diseases were consistent with their description of the symptoms and corresponding elevated antibodies/mri findings. the information was obtained and collated using a standardised data collection form. two researchers (yh and zc) independently reviewed and collated the data collection form to ascertain data accuracy. acute respiratory distress syndrome (ards) was defined according to the berlin definition. coagulopathy was defined as prolonged prothrombin time by s or prolonged activated partial thromboplastin time by s. acute cardiac injury was diagnosed if serum levels of cardiac biomarkers (eg, highsensitivity cardiac troponin i) were above the th percentile upper reference interval, or if new abnormalities were presented in electrocardiography and echocardiography. hypoproteinaemia was defined as blood albumin below g/l. acute kidney injury was diagnosed according to the kdigo clinical practice guidelines. septic shock was defined according to the third international consensus definition. the quiescent stage of the disease was roughly defined as no obvious symptoms and signs of inflammatory activity, otherwise it was defined as the active stage. organ damage was defined as having a medical history, long-term symptoms such as cough and/or corresponding supplementary examination results. patients or the public were not involved in the design, or conduct, or reporting or dissemination plans of our research. a total of inpatients with covid- who were admitted to the two campuses of tongji hospital were included in this analysis, and we obtained information regarding sex, age and comorbidities (table ). the distribution of sex and age is shown in figure a . of the patients, ( . %) were admitted to the icu. the median age of the patients was years (iqr . - . ); patients in icu were older than those in the general ward by a median of years (p< . ). about . % of the patients in icu were older than years and this proportion was significantly higher than that in the general ward. a total of . % were female, and the proportion of male and female was comparable in the general ward, but in icu, the proportion of male ( . %) was significantly higher than that of female ( . %; p< . ). more than half ( . %) had comorbid conditions with hypertension being the most common ( . %, figure b ). a total of inpatients were retrieved in two campuses of tongji hospital and ( . %) patients with systemic aids were screened and analysed in this study. among these aids, on admission, the degree of severity of covid- was categorised as critical in ( . %) patient, severe in ( . %) patients and ( . %) patients developed into severe disease during hospitalisation. the median age of the aid group ( . ) was the same as the total population, but the proportion of female was significantly higher ( . %). all patients were living in wuhan, and two family clusters were found. comorbid conditions were present in . % of the patients with hypertension being the most common ( . %). common symptoms were fever ( . %), cough ( . %), shortness of breath ( . %) and sputum production ( . %); sore throat, nasal congestion and hemoptysis were uncommon. the median of length of hospital stay (lohs) was . days. most patients received antiviral therapy ( . %), antibiotic therapy ( . %) and oxygen support ( . %). one patient was admitted to icu for the administration of continuous renal replacement therapy, and she was in the uremic stage of lupus nephritis and underwent dialysis twice a week. eight ( . %) of patients received disease-modifying antirheumatic drugs (dmards), including methotrexate, leflunomide, thalidomide and hydroxychloroquine (hcq). six ( . %) of patients were treated with methylprednisolone or prednisone acetate, and of them took two tablets per day. botanicals such as tripterysium glycosides and total glucosides of paeony were prescribed in seven ( . %) patients. ten ( . %) of patients were treated with immunosuppressant (including glucocorticoids, methotrexate, leflunomide, thalidomide, hcq, tripterysium glycosides and total glucosides of paeony). ten ( . %) of patients changed or stopped their anti-aids treatments during hospitalisation. unfortunately, five of them felt that the disease had worsened after the quarantine. of the patients with severe complications, ards was the most common ( . %). moreover, the median time from onset of the disease to ards was . days (iqr . - . ). by the end of march, ( . %) patients had been discharged from hospital and ( . %) patient had died. the one death was a -year-old female. she had a history of chronic renal failure for years, sle for more than years, hypertension for - years, sciatica for years and a history of chronic gastritis and tuberculosis. she had severe pneumonia with an oxygen saturation of % on admission. the subsequent auxiliary examination indicated that she had heart failure, with a progressive increase in high-sensitivity cardiac troponin i and n-terminal pro-brain natriuretic peptide. the chest ct scan showed bilateral patchy shadowing with 'white lung' changes, bilateral pleural effusion, left ventricular enlargement, and pericardial effusion (figure j). on the th day of admission, the patient developed metabolic acidosis, frequent ventricular premature beats and was declared dead. online supplementary table s shows the chest ct and laboratory findings of patients with systemic aids on admission. abnormalities in chest ct were found in all patients. figure shows representative chest ct results of five patients with nonsevere disease (figure a-e) and five patients with severe disease (figure f-j). among the patients, the most common ct patterns were bilateral patchy shadowing ( . %) and ground-glass opacity ( . %). laboratory tests showed that most patients had decreased levels of lymphocyte counts, haemoglobin and albumin ( . %, . %, . %). elevated levels of d-dimer, erythrocyte sedimentation rate and serum ferritin were common ( . %, . %, . %). liver and renal function tests showed abnormalities in six patients, of which four were categorised as severe. all patients presented elevated c-reactive protein level. elevated levels of interleukin (il) and/or tumour necrosis factor (tnf)-α were presented in ( . %) of patients; two patients presented a lower level of il- receptor. patients with severe disease presented higher levels of infection-related biomarkers than those with nonsevere disease. five of patients presented decreased number of helper t (th) cells; two presented decreased number of both th cells and suppressor t cells and were categorised as severe. seven of patients presented decreased number of natural killer cells and all seven were categorised as severe. compared with the average lohs of tongji hospital ( . patients with severe covid- and patients with non-severe covid- regarding neutrophil count (p= . ), lymphocyte count (p= . ), haemoglobin (p= . ), d-dimer (p= . ), blood urea nitrogen (p= . ), il- receptor (p= . ) and procalcitonin (p= . ). given the very limited samples and some equivocal information by telephone follow-up, the results should be interpreted more cautiously. this is a descriptive study on the epidemiology and clinical characteristics of patients with covid- and systemic aids, and an extended report on the epidemiology of inpatients with covid- in wuhan tongji hospital. the proportion of males was significantly higher in icu than that of females, and this result may indicate that symptoms are milder in females after sars-cov- infection. the protective mechanism might be attributed to sex hormones and x chromosome, rendering females stronger antiviral immunity. notably, more than half ( . %) of patients with covid- suffered from chronic diseases with . % in the icu; hypertension ( . %) and diabetes ( . %) were the most prominent. this proportion was significantly higher than the study reported on patients, presumably because more patients with severe covid- were admitted to tongji hospital. altogether, these results suggest that older males with chronic comorbidities are more vulnerable to severe covid- , consistent with the finding of patients. we selected patients with systemic aids for further analysis, and cases were eligible from electronic clinical records. compared with the data of cases, a more compact age distribution (iqr . - . vs iqr . - . ) and more females ( . % vs . %) were presented in patients with aids. this might be because that systemic aids generally occur more often in females (table ) . disease progression in severe cases was extremely rapid and required icu admission. the time between hospital admission and acute cardiac injury was as short as day; ards was days. furthermore, one death occurred on the th day of the onset of covid- . patients with systemic aids manifested more gastrointestinal symptoms than the whole covid- population. treatment and radiographic and laboratory results were basically consistent with those reported in patients. besides, we analysed cytokine and lymphocyte subsets (online supplementary table s ), which were not included in previous studies. - from very limited cases, we did not find any difference in clinical outcomes of covid- between patients with systemic aids and other patients, including lohs, ventilation rate, icu incidence and the case fatality rate. intriguingly, the number of patients with aids ( . %) was far below our expectations, considering that aid might affect approximately %- % of the total population. [ ] [ ] [ ] generally speaking, people with chronic comorbidities are more susceptible to sars-cov- , therefore, we hypothesise whether there are protective factors for patients with aids. therapies that control detrimental immune responses in patients with aids have attracted our attention. chloroquine phosphate, tostuzumab and glucocorticoid autoinflammatory disorders are approved in the diagnosis and treatment plan of corona virus disease (tentative seventh edition). among them, chloroquine phosphate is used for conventional antiviral therapy, and the other two are used for severe diseases. it is notable that hcq, tocilizumab and glucocorticoid are recommended for the management of ra by the european league against rheumatism. according to our statistic result, ( . %) of patients used glucocorticoid and/or hcq. hcq has a similar effect to chloroquine phosphate and has higher safety. the recent publications of an in vitro and a clinical trial suggested that hcq might have an anti-sars-cov- effect. nevertheless, the validity of the clinical findings aroused much controversy because of obvious methodological flaws. quite unexpectedly, the treatment might be overinterpreted by social media, contributing to great public interest in hcq. many clinical trials using hcq for covid- as postexposure prophylaxis or therapies are under way, and the forthcoming results may shed light on this issue. although high-dose glucocorticoids may delay the resolution of coronavirus, an emergency doctor in wuhan using inhaled glucocorticoids for asthma has survived exposure to numerous patients confirmed with covid- , which enables us to speculate whether patients using low-dose glucocorticoids could prevent coronavirus infection. and certainly, these issues need to be verified by rigorous methodological clinical trials. in our study, however, there is no evidence to show what role immunosuppressants may play in the clinical outcomes of covid- . during the telephone follow-up, we learnt that more than half ( . %) patients changed or stopped their anti-aids treatments during hospitalisation because they were unaware of the consequences of drug withdrawal or were unwilling to trouble doctors. some patients stopped their anti-aids treatments for more than days (hospitalisation + weeks hotel quarantine + weeks home quarantine), which was more common among elderly people living alone. a landmark clinical study has demonstrated that the withdrawal of hcq can result in severe and even life-threatening flares of sle, such as lupus nephritis. unfortunately, five of them felt the disease had exacerbated after the quarantine, but still dared not go out to see a doctor in this special period. although the countermeasures towards covid- should be explored with extraordinary vigour and speed, it is noteworthy that if the application spectrum of hcq is expanded without enough rationale, it will increase the risk of patients with covid- , especially patients who depend on hcq for their survival. our study has some limitations. first, only inpatients with covid- and systemic aids in a single centre were analysed. it would be more thoroughgoing if eligible patients in more institutions and those who were treated at home could be included. due to the specificity of wuhan tongji hospital, our analysis might represent more severe outcomes. second, some patients had incomplete medical records and thus we could not obtain more comprehensive information. third, most information about aids came from telephone follow-up, which might not be comprehensive and objective. finally, there was insufficient evidence to speculate the effect of immunosuppressants or hcq on covid- ; more high-quality human clinical trials and in-depth mechanism researches are urgently needed to explain the relationship between them. these two decades have seen the global spread of three unprecedented coronavirus diseases: severe acute respiratory syndrome, middle east respiratory syndrome and 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the treatment of severe acute respiratory syndrome coronavirus (sars-cov- ) hydroxychloroquine and azithromycin as a treatment of covid- : results of an open-label non-randomized clinical trial a rush to judgment? rapid reporting and dissemination of results and its consequences regarding the use of hydroxychloroquine for covid- the world health organization international clinical trials registered organization registered platform post-exposure prophylaxis / preemptive therapy for sars-coronavirus- -full text view canadian hydroxychloroquine study group. a randomized study of the effect of withdrawing hydroxychloroquine sulfate in systemic lupus erythematosus the authors thank the patients who participated in this retrospective study and kindly provided their information.contributors yh and zc collected the data and performed the analysis, and yh wrote the article. yw, lh, kq, wh and yh gave advice on the study. hw, ps, xb and wl helped to analyse data. hd and mz helped to revise the paper. st solved the discrepancies and gave advice on the study.funding this article was supported by the national natural science foundation of china (no. , , ). patient and public involvement patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research. ethics approval this study was approved by the ethics commission of tongji hospital, tongji medical college, huazhong university of science and technology (tj-irb ). written informed consent was waived by tongji hospital for emerging infectious diseases and the urgent need to collect data.provenance and peer review not commissioned; externally peer reviewed. data availability statement data are available upon reasonable request by email to shtu@ tjh. tjmu. edu. cn. non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. kai qin http:// orcid. org/ - - - hui wang http:// orcid. org/ - - - shenghao tu http:// orcid. org/ - - - x key: cord- -zdxebonv authors: chen, lichin; tsao, yu; sheu, ji-tian title: using deep learning and explainable artificial intelligence in patients' choices of hospital levels date: - - journal: nan doi: nan sha: doc_id: cord_uid: zdxebonv in countries that enabled patients to choose their own providers, a common problem is that the patients did not make rational decisions, and hence, fail to use healthcare resources efficiently. this might cause problems such as overwhelming tertiary facilities with mild condition patients, thus limiting their capacity of treating acute and critical patients. to address such maldistributed patient volume, it is essential to oversee patients choices before further evaluation of a policy or resource allocation. this study used nationwide insurance data, accumulated possible features discussed in existing literature, and used a deep neural network to predict the patients choices of hospital levels. this study also used explainable artificial intelligence methods to interpret the contribution of features for the general public and individuals. in addition, we explored the effectiveness of changing data representations. the results showed that the model was able to predict with high area under the receiver operating characteristics curve (auc) ( . ), accuracy ( . ), sensitivity ( . ), and specificity ( . ) with highly imbalanced label. generally, social approval of the provider by the general public (positive or negative) and the number of practicing physicians serving per ten thousand people of the located area are listed as the top effecting features. the changing data representation had a positive effect on the prediction improvement. deep learning methods can process highly imbalanced data and achieve high accuracy. the effecting features affect the general public and individuals differently. addressing the sparsity and discrete nature of insurance data leads to better prediction. applications using deep learning technology are promising in health policy making. more work is required to interpret models and practice implementation. while ensuring the accessibility to care, some countries applied a "gate-keeping" strategy and others empowered patients with the freedom to choose their own providers. in the gate-keeping strategy, the patients first visit general practitioners (gp) for medical advice, and the gp decides whether to refer the patient to a secondary or tertiary institution. the intention of the gate-keeping strategy is to enhance efficiency, regulate cost, and reduce wait time for secondary care. however, there are some limitations to this strategy such as gps limiting the possibility of specialists responding to patient and market demands [ , ] ; further, the subsequent delayed referral can cause other problems [ ] . some countries have reformed their strategy to offer patients with the freedom to choose providers. patients are to "vote with their feet" and choose health providers who fit their preferences and needs [ ] . this strategy empowers the patients by prompting providers to compete for patients through a customer-market mechanism, such as improving their services, such as care quality, efficiency, and wait time [ , ] . however, such expectations has preconditions. patients are expected to make their choices based on sufficient information and rational decision [ , ] , which is commonly not the case. other studies report that patients have shown inadequate ability to use comparative information during provider selection [ , ] . past studies indicate that the patients' choice is a complex interrelationship between the characteristics of the patients, the providers, and the incident itself [ ] . the decision may differ based on the characteristics of individuals, the characteristics of the provider, and the condition of the incidence, which makes it difficult to evaluate in advance. however, researchers have developed several techniques to simulate and forecast the patient flow, patient volume, resource allocation, and patient choices. the gravity model, for instance, calculates the spatial interaction between a community and a hospital using population mass of the community, capacity and service mix of hospitals, and distances (or traveling time) [ , ] . the aggregate hospital choice model (ahcm) is intended to model hospital choices through the market share. based on historical data, ahcm uses time-series techniques to forecast future patient volumes [ ] . forecast and simulation techniques such as mean absolute percentage errors, autoregressive integrated moving average (arima), seasonal arima [ ] , and discrete event simulation models [ , ] have also been used previously. however, these theories have strict preconditions and partially explain the choice scenario. recently, deep learning methods have gained popularity. they capture the underlying pattern of data by transforming data into a more abstract matter and classifying them based on the latent distribution [ , ] . the deep learning approach has been proven effective and has shown excellent performance in a wide variety of applications [ , , ] , such as disease risk forecasting [ ] , vital signs classification into physiological symptoms [ , ] , image classification for diagnosis [ , ] , text-based medical condition recognition [ , ] , and clinical event forecasting [ ] . however, irrespective of the outstanding performance, the results of the deep learning technology remained a blackbox, which merely provided the results without reasons or any information that indicated how the conclusion was reached. this incapability of the deep learning method to gain trust and convince people to use its results limited its implementation in healthcare field. meanwhile, some previous studies indicate that the existing hierarchical coding scheme of electronic health recodes is not sufficiently representative [ , ] . it does not quantify the inherited similarity between concepts, and using deep learning to project discrete encodings into vector spaces may lead to a better analysis and prediction. while insurance data are the most commonly used data in policymaking, it is necessary to investigate the pattern of insurance data before applying deep learning. this study accumulates the possible features that were previously mentioned in related work on the patients' choices and aims to use deep neural networks (dnns) to generalize and predict the patients' choices. focusing on the hospital levels of the patients' choices, this study used explainable artificial intelligence (xai) methods to interpret the effecting features for the general public and individuals. in addition, this study explored the representations of insurance data by comparing the performance of model training with and without the preprocessing of changing data representations. the data used were the insurance data of the national health insurance (nhi) of taiwan. we characterized all the effecting features based on three main entities: the patient, the provider, and the incident. the characteristics of patients such as the age, gender, income, and previous medical experiences (positive and negative) were all possible features affecting the behavior of patients while accessing care [ , , ] . further, young people need relatively less care and females are more endurable than males; these facts along with the income of individuals affected the patients' willingness to visit a facility. meanwhile, studies [ ] indicated that the patients' satisfaction and loyalty were significantly related to the facility they would go to. when patients were satisfied with and loyal to a specific provider, they were less likely to change providers. continuity of care was also considered an effecting feature, which could be indicated as the duration and frequency of visiting a provider (known as density); those who visited a provider regularly were less likely to change providers. the frequency of changing providers (known as dispersion) could also be an indicator of continuity of care. the characteristics of a provider included the hospital reputation, hospital level, facilities at the hospital, and travel distances. commonly, patients considered that institutes with higher levels (secondary and tertiary institutes) possess better equipment, more skillful physicians, and higher reputations. some studies indicate that service quality affects the patients' demand [ ] , while others report that patients commonly neglect the quality indicators and prefer recommendations from associates [ ] . professionals such as gps are tempted to decide based on feedback from patients and colleagues as well as their cooperation experiences with the department or hospital, rather than official information such as quality of service or wait time [ ] . some patients even decide based on review websites [ , ] , which is another form of social approval and recommendations from others. studies [ ] also indicate that the patients' choices may change according to the condition of the incident, for example, the severity of the condition, the complication of the disease, and the number of patients with chronic disease. the health status of the patients would affect their willingness to travel distance. noncritical events and healthier patients would consider farther distance of travel and seek a second opinion. people would be tempted to go to emergency services as outpatient services are closed on weekends or holidays. people in taiwan have the freedom to choose their own providers without the referral of a gp [ , ] . under universal coverage, people do not possess the knowledge of choosing providers rationally. other than choosing physicians, people commonly consider the level of the institute. primary care service in taiwan are usually a physician of a certain specialty who owns a clinic and acts as a private practitioner [ , ] . hence, the primary care service commonly referred to clinics irrespective of specialty. a secondary and tertiary care often referred to regional/district hospitals and medical centers. people commonly consider that "large hospitals possess more skillful physicians and better medical facilities," resulting in patients, irrespective of their medical severity, swarming to medical centers [ , ] . according to a public opinion poll conducted in [ ] , although . % of the respondents agreed that for a mild condition the patient should go to the primary care service nearby instead of tertiary hospitals, % considered institutes with higher levels to possess better professional skills, and % expressed having confidence in determining the severity of their own condition. this phenomenon causes the recession of the primary care service and overcrowding of the tertiary care [ ] . consequently, tertiary facilities are overwhelmed with mild-conditioned patients and have limited capacity to treat acute and critical patients [ , ] . this also induces an increase in the cost of treating mild conditions. the "hierarchization of services," highlighted for several years, refers to visiting appropriate medical resources according to needs rather than swarming to tertiary institutes. approaches to ease such extreme unbalanced patient volume have been proposed, such as increasing copayments, strengthening referral mechanisms, limiting outpatient service volumes for tertiary facilities, and providing incentives for cooperation between different levels of providers. however, such a phenomenon still exists [ , ] . to address the maldistribution of patient volume, it is essential to oversee the choice of patients before strategy planning. this study aims to support the evaluation by providing a sophisticated tool to predict the patients' choice and provide the effecting features for them to do so. the aim of this study is to predict the patients' choices of hospital levels and interpret the reasons for the prediction. in addition, this study demonstrates the effectiveness of changing the representation of insurance data. the data used were the insurance-claims data from the two million clinical declaration files and the registry for beneficiaries files from the taiwan nhi research database (nhird), dated from january , , to december , . the data were originally sampled to ensure their representation of the population across taiwan. the files included the demographic information and visiting records of outpatients and emergency settings. some publicly announced data were added to enrich the records, including the "physician density" information that referred to the number of practicing physicians serving per ten thousand people in each region of taiwan [ ] . the national calendar was used to retrieve information on weekends and national holidays. incomplete or questionable data, such as individuals without birth date or gender (or with two genders), records without a date, birth date later than the visit date, patients without any visiting records, patients without a primary diagnosis, and incomplete information of visited hospitals were excluded. eighteen features were included in the analysis, which were characteristics of the patients, providers, and incidents. the following section will further outline the definition and calculation equation of the features. the targeted prediction outcome of this research is the four hospital levels, namely the medical center, regional hospital, district hospital, and clinic. the age, gender, low income (yes/no), total number of visits, total number of diseases, total number of chronic diseases, and four continuity indicators were included as characteristics of the patient. the age was determined according to the date of the visit. the denotation of low income was the status identified when entering the insurance. the total number of visits was the number of visiting records during the study period. the total number of diseases and chronic diseases were identified using the encoded international classification of diseases (icd) codes for each patient. the continuity indicators captured the duration, density, dispersion, and continuity of an individual while accessing care [ ] [ ] [ ] . to track duration and density of patients accessing care, the usual provider of care (upc) and least usual provider of care (lupc) were used to indicate the visiting ratio of medical institutes. the upc represented the most frequently visited institute, and the lupc represented the least frequently visited institute. the patients were required to visit the provider at least once to denote an institute as the lupc. the sequential continuity of care index (secoc) was used to calculate the change of providers, representing the dispersion of care. the continuity of care index (coci) was a single indicator that represented the continuity of care for an individual. the calculation of the continuity indicators are shown in equations ( ), ( ), ( ), and ( ), where n represents the total number of visits, n ! denotes the number of visits to the i th provider, k is the number of providers once visited, and c " is denoted as when the j th provider is the same as the (j+ ) th provider ( if not). we characterized the providers with indicators: the physician density of each region, the most frequent provider continuity (mfpc), and the least frequent provider continuity (lfpc). with reference to the patients' "vote with their feet" in choosing providers, we calculated the mfpc and lfpc to represent the patients' experiences and recommendations for each institute [ , ] . the mfpc represented the frequency of being voted as the upc, and the lfpc represented the frequency of being voted as the lupc. each patient could vote for only one mfpc and lfpc. the calculations are shown in equations ( ) and ( ), where p indicates the total number of patients, and upc ! and lupc ! indicate the i th patient who voted the provider as the upc or lupc, respectively. the incident was characterized based on five encoded features. through the encoded icd codes and treatment codes of visiting records, we identified whether a surgery was involved (yes/no), whether it was an emergency service (yes/no), whether it was considered as a severe condition (yes/no), whether the visit day was a work day (yes/no), and the disease importance rate (dir) of the target disease during that visit. the identification of surgeries and emergency services were based on the treatment codes defined by the nhird. the severity was defined based on emergency triage results. triage results rank for level to ( = resuscitation, = emergency, and = urgent) were listed as severe, and conditions that were included in the catastrophic illness announced by the nhi were also listed as severe. the date of the incident was distinguished as a work day or non-work day. to capture whether the visit of the patient was a regular or singular event, we used the dir to represent the importance of the target disease in that visit. the encoded primary diagnosis was identified as the target disease in that visit. the dir represents the ratio of importance and is calculated as shown in equation ( ), where n indicates the total number of visits of the patient, and di represents the total number of visits for disease di. we used only the primary diagnosis of the visit to identify the dir. this study used the dnn framework to train the patients' choices of hospital levels. dnn is a complex version of an artificial neural network (ann) that contains multiple hidden layers [ , ] , where every neuron in layer is fully connected to every other neuron in layer + . in a multi-layer neural network, each layer of the network is trained to produce a higher level of representation of the observed pattern. every layer produces a representation of the input pattern that is more abstract than the previous layer by composing more nonlinear operations [ , ] . the computation is shown in equation ( ) . each hidden layer computes a weighted and bias of the output from the previous layer, followed by a nonlinear active function that calculates the sum as outputs. the number of units in the previous layer is represented by and the output of the previous layer by . figure demonstrates the dnn architecture. to demonstrate the effect of changing data representations of insurance data, we designed a comparison. we used an autoencoder (ae) as the processor for the data representation change. ae is popular for processing scarce and noisy data [ , , ] . it encoded the input into a lower dimension space and then decoded the representation by reconstructing an approximate input %. the goal of the reconstruction was to minimize the mean square error of and % . equations ( ) and ( ) demonstrate the computation of the encoder and decoder, where and ′ denote the respective weights and and ′ denote the respective bias of the encoder and decoder. figure demonstrates the ae architecture. figure . autoencoder architecture xai methods enhance the interpretability of machine learning models [ , ] . this study adopted the shapley additive explanations (shap) [ ] . shap combines the desirable characteristics of other interpretation frameworks, including local interpretable model-agnostic explanations (lime) and deep learning important features (deeplift). the shap value was computed using all combinations of the input, and the average marginal contribution of a feature value over all possible coalitions was calculated. shap has the ability to interpret models globally and locally, that is, to show the general effects of features on the whole population and individuals. all features were aggregated into a visit vector. due to the imbalanced distribution of hospital levels, this study used a random undersampling strategy to sample the majority label and balance the training set. the model was trained on balanced data and tested on actual distributed data [ ] . meanwhile, to deal with numerical features with different scale levels, all the numerical values (including the age, number of diseases and chronic diseases, number of visits, number of votes as mfpc and lfpc, and physician density) were normalized between and , and the categorical features were transformed into a one-hot/dummy encoding before analysis. those indicators that were already ratio figures (values between and ) were used accordingly (including coci, upc, lupc, secoc, and dir). the data were randomly split into training data ( %) and testing data ( %). a five-fold cross-validation training strategy was used. the data processing flow is shown in figure . the proposed dnn model contained input nodes (based on input features) and hidden layers with neurons each. the rectified linear unit (relu) active functions were used for each layer. four output nodes symbolized the hospital levels. optimization was carried out by mini-batch stochastic gradient descent that iterated through small subsets of the training data and modified the parameters in the opposite direction of the gradient of the loss function to minimize the reconstruction error. the data representation changing comparison is done through the same training process, except that one is preprocessed with ae, and the other is not, as shown in figure . the ae model consisted of hidden layers; the neurons in those layers were , , , , and . the relu active function was used for the encoder (first layer) and decoder (last layer) and a sigmoid active function for the latent space conversion (the third layer). the performance indicators used here are the area under the receiver operating characteristics curve (auc), accuracy, sensitivity/recall, specificity, precision, and f score, as shown in equations ( ) to ( ) , where tp, tn, fp, and fn denote for true positive, true negative, false positive, and false negative. for a multi-class classification of hospital levels, the macro average was used to generalize the performance, which computed the metric independently for each class and then took the average to consider each class equally. the auc used the one-vs-rest scheme to demonstrate the general performance. the result also compared the shap value of the trained model, with and without ae preprocessing, to show the effect of representation change on feature importance. this study was implemented with python version . . , combined with pytorch framework . a total of , patients and , , visiting records were analyzed, where . % patients chose to go to the clinics, . % to the district hospital, . % to the regional hospital, and . % to the medical center. tables to demonstrate the information of patients, providers, and incidents. the performance results are listed in table . processing without and with ae reached an auc of . and . , respectively. therefore, changing data representations led to an increase of . in auc. the mean shap values are listed in figure , with the mfpc, physician density, and lfpc listed as the top factors. the contribution could be positive or negative. the contribution of other features, even combined together, was very less. the ae process changed the contribution ranking, shifting the physician density from the second to the third position. figure shows the interpretation analysis of individual cases. the base value represents the decision of the general public ( . ). the red color symbolizes the features that contributed positively and pushed the decision above the base value, and the blue color symbolizes the features that contributed negatively and pushed the decision below the base value. figures (a) and (b) show cases processed by the model without ae, and (c) and (d) show cases processed by the model with ae. it appears that the processing of ae enlarges the less contributing features and makes them more visible on graphics. with the outbreak of covid- , it has been highlighted that there are insufficient applications in assisting public health. exploring the patients' choices of hospital levels is the cornerstone of evaluating policies for referrals, utilization of healthcare resources, and rerouting patient volume for the hierarchization of services, and during disease outbreaks or infection control. the choice of patients was highly imbalanced. some of the features did not reflect the character of the general public, such as low continuity, visits often not involving surgery, emergency service, or the condition not being considered severe, however, the model could still predict with high sensitivity and specificity, without initially finding the best-fit features. this study tried to address the black-box problem of machine learning [ , ] using the shap value. according to our result, three features could interpret the majority of patients' choices of hospital levels: the mfpc, lfpc, and physician density. however, the features affected individuals differently. although entering the training process without previous data preprocessing is ideal, the performance of models can be improved by changing the data representation. it is straightforward that image and audio signals include disturbance and noise information, and using methods to eliminate noise leads to better predictions. structured data were encoded with existing encoding schemes that were meaningful to people. the sparsity, discrete, and scarcity of data, which is invisible to the human eye, were difficult to notice. this study demonstrated the effectiveness of changing data representations. by merely adding preprocessing in advance, all the performance indicators increased, and the shap value became less extreme, allowing less contributing features to be observed. the discipline of social economics mostly focused on clarifying the causality and the interrelationship of factors that affect patients in choosing hospitals. however, the machine learning approach attempted to seek the underlying pattern of data and predict accurately without relying on existing knowledge. the choice indicated a certain underlying trend, but not necessarily complete reasons and causalities. this study provided an alternative approach to observe the patients' choice. the prediction was based on the trajectory of the de-identified patient-visit data, commonly collected by the insurance company. hence, the model is highly achievable elsewhere as it neither involves (d) complex information that is difficult to collect nor violates patient privacy. however, this study has several limitations. distance to travel remains an important factor in choosing hospitals [ ] . although there are ways of using de-identified insurance data to project the region where patients live [ ] , such information is still based on hypothesis and cannot be validated accurately. further analysis could be done based on decisions of patients of different regions and explore different decision choices due to misallocation of medical resources. future applications using deep learning technology are promising in health policy making. a golden standard for interpreting machine learning models has not been established. the method of using the interpretation model and the generated scores can be further explored. shared decision making between patient and gp about referrals from primary care: does gatekeeping make a difference determinants of patient choice of healthcare providers: a scoping review. bmc health services research are the serious problems in cancer survival partly rooted in gatekeeper principles? an ecologic study identifying quality indicators used by patients to choose secondary health care providers: a mixed methods approach free choice of healthcare providers in the netherlands is both a goal in itself and a precondition: modelling the policy assumptions underlying the promotion of patient choice through documentary analysis and interviews. bmc health services research which factors decided general practitioners' choice of hospital on behalf of their patients in an area with free choice of public hospital? a questionnaire study. bmc health services research hospital choice models: a review and assessment of their utility for policy impact analysis the geography of hospital admission in a national health service with patient choice time series modelling and forecasting of emergency department overcrowding predicting patient volumes in hospital medicine: a comparative study of different time series forecasting methods using simulation to forecast the demand for hospital emergency services at the regional level forecasting emergency department crowding: a discrete event simulation. annals of emergency medicine deep learning for healthcare: review, opportunities and challenges a comparison of shallow and deep learning methods for predicting cognitive performance of stroke patients from mri lesion images opportunities and challenges in developing deep learning models using electronic health records data: a systematic review a guide to deep learning in healthcare assessment of deep learning using nonimaging information and sequential medical records to develop a prediction model for nonmelanoma skin cancer voice pathology detection using deep learning on mobile healthcare framework deep learning for healthcare applications based on physiological signals: a review. computer methods and programs in biomedicine dermatologist-level classification of skin cancer with deep neural networks end-to-end lung cancer screening with three-dimensional deep learning on low-dose chest computed tomography. nature medicine comparing deep learning and concept extraction based methods for patient phenotyping from clinical narratives using deep learning to enhance cancer diagnosis and classification doctor ai: predicting clinical events via recurrent neural networks deep ehr: a survey of recent advances in deep learning techniques for electronic health record (ehr) analysis. ieee journal of biomedical and health informatics deep patient: an unsupervised representation to predict the future of patients from the electronic health records choice of hospital: which type of quality matters measuring patients' healthcare service quality perceptions, satisfaction, and loyalty in public and private sector hospitals in pakistan do patients choose hospitals with high quality ratings? empirical evidence from the market for angioplasty in the netherlands the impact of web-based ratings on patient choice of a primary care physician versus a specialist: randomized controlled experiment does universal health insurance make health care unaffordable? lessons from taiwan an overview of the healthcare system in taiwan taiwan's healthcare report taiwan's single-payer success story -and its lessons for america public opinion poll report summary. , national health insurance administration, ministry of health and welfare statistics yearbook of practicing physicians and health care 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testing data sets for binary classifiers in bioinformatics using regional differences and demographic characteristics to evaluate the principles of estimation of the residence of the population in national health insurance research databases (nhird) this study was approved by the research ethics committee at national taiwan university (no. em ), and the waived informed patient consent for the data was already de-identified before analysis. the authors have no conflicts of interest to declare. key: cord- -fgvbrg d authors: ohara, hiroshi; pokhrel, bharat m.; dahal, rajan k.; mishra, shyam k.; kattel, hari p.; shrestha, dharma l.; haneishi, yumiko; sherchand, jeevan b. title: fact-finding survey of nosocomial infection control in hospitals in kathmandu, nepal—a basis for improvement date: - - journal: trop med health doi: . /tmh. - sha: doc_id: cord_uid: fgvbrg d the purpose of this study was to investigate the actual conditions of nosocomial infection control in kathmandu city, nepal as a basis for the possible contribution to its improvement. the survey was conducted at hospitals and the methods included a questionnaire, site visits and interviews. nine hospitals had manuals on nosocomial infection control, and seven had an infection control committee (icc). the number of hospitals that met the required amount of personal protective equipment preparation was as follows: gowns ( ), gloves ( ), surgical masks ( ). six hospitals had carried out in-service training over the past one year, but seven hospitals responded that no staff had been trained. eight hospitals were conducting surveillance based on the results of bacteriological testing. the major problems included inadequate management of icc, insufficient training opportunities for hospital staff, and lack of essential equipment. moreover, increasing bacterial resistance to antibiotics was recognized as a growing issue. in comparison with the results conducted in targeting five governmental hospitals, a steady improvement was observed, but further improvements are needed in terms of the provision of high quality medical care. particularly, dissemination of appropriate manuals, enhancement of basic techniques, and strengthening of the infection control system should be given priority. recently, nosocomial infections have become a global concern recognized as a major patient safety issue. they not only cause a significant burden on patients but also lower the quality of medical care. in addition, prolonged hospitalization due to nosocomial infections increases costs and unnecessary expenses for the hospital [ , ] . in the healthcare setting, particularly in developed countries, various measures including the organization of infection control teams (icts), preparation of manuals, strengthening of surveillance systems, and training of staff have been taken to assure effective control. however, it is only some decades ago that importance was attached to nosocomial infection control and effective measures were employed, even in developed countries [ ] . in developing countries, where the incidence of infectious diseases is high and environmental conditions of healthcare facilities are poor, nosocomial infections may frequently occur, and some studies have reported a high incidence at healthcare facilities in these countries [ ] [ ] [ ] . effective nosocomial infection control is crucial in the healthcare facilities of developing countries, but in actual fact, attention to it is still limited and control measures are not functioning well in many facilities. furthermore, as implementation of control measures seems to be costly and to consume resources, nosocomial infection control is often given a low priority. severe acute respiratory syndrome (sars), which originated in guangdong province, china in november , spread to more than countries. in many hospitals where sars cases were encountered, nosocomial infections also broke out, causing many casualties along with economic havoc [ , ] . it is not overstatement to say that such outbreaks have heightened awareness regarding nosocomial infection control even in developing countries. in more recent years, epidemics of novel influenza have also posed a threat of nosocomial infections [ ] . these facts made many people realize again the importance of strengthening nosocomial infection control at hospitals in developing countries. some of the authors of the present paper have been engaged in technical cooperation for nosocomial infection control with hospitals in developing countries, recognizing the importance of strengthening control measures in order to enhance the quality of medical care. between and , they have contributed to the promotion of nosocomial infection control in vietnam in collaboration with leading hospitals [ , ] . since , in response to the growing concern regarding nosocomial infections, we have focused our efforts in nepal through collaboration with tribhuvan university teaching hospital (tuth) in kathmandu city, where a technical cooperation project by japan international cooperation agency (jica) had been implemented to strengthen the hospital. following studies including those on hospitalacquired diarrheal diseases [ ] and the prevalence of multiple drug-resistant pathogens [ ] , this survey was carried out as a baseline study aiming to contribute to the improvement of nosocomial infection control at tuth and consequently in kathmandu city. the primary purpose of this study was to evaluate nosocomial infection control conditions and to prepare the basic information needed to provide technical guidance. the subjects of this survey are leading hospitals in kathmandu city (five national hospitals, nine private hospitals, and three other hospitals). the national hospitals included three general hospitals (one out of three was a university hospital; i.e. tuth), one pediatric hospital and one obstetric hospital. all the private hospitals were general hospitals, while three other hospitals included one semigovernmental hospital and two non-profit organization hospitals (these three hospitals were general hospitals). the hospitals play a crucial role in medical care in kathmandu city. a questionnaire was developed based on the form used in the previous surveys in vietnam [ ] . the form consisted of the following items: "general information of the hospitals, control system including manual and infection control committees (icc), equipment and facility preparedness, training conditions, surveillance conditions, expectation for international cooperation and current problems. the contents of each item in the questionnaire are shown in table . the questionnaire was distributed to the hospitals in october and filled out by the hospital staff members who were responsible for nosocomial infection control or the director of the hospital. the recovered data were processed using spss ver for windows. in some hospitals, to determine the actual situation of icc, manuals, current problems and awareness level of hospital staff regarding nosocomial infection control, direct observations were conducted along with a brief interview with the hospital staff responsible for nosocomial infection control or hospital di- current problems requested the hospital to describe the current problems. rector in addition to the information obtained by the questionnaire. in , a questionnaire survey was conducted at five national hospitals in kathmandu city [ ] . these five hospitals were included in this study ( ) . the results of the questionnaire were compared with those of this study ( ), including manuals, iccs, in-service training and preparedness of personal protective equipment (ppe). a comparative statistical analysis of the and results was carried out by the fisher's exact method using spss ver for windows. tuth was established in with the assistance of a grant-aid from the japanese government as the first medical school in nepal, followed by the implementation of a technical cooperation project supported by the jica from to (the corresponding author participated as a team leader). the purpose of the project was to strengthen medical and educational services at tuth. during the above period, technical guidance was conducted in the field of hospital management, clinical medicine, nursing management, laboratory management and medical education. however, nosocomial infection control was not included in the project, probably because awareness regarding nosocomial infection control was still poor in those days even in developed countries including japan. currently tuth is playing a leading role in medical care as well as human resource development in nepal as the oldest and one of the most advanced medical schools. in this study, the current situation of nosocomial infection control at tuth was investigated in detail as a basis for further improvement. during the jica project period, technical guidance was provided, not on nosocomial infection control, but on bacteriological testing as a priority subject. in this study, investigation was performed by direct observation and interviews with heads of the departments of clinical microbiology and pharmacology and doctors of internal medicines, focusing on whether bacteriological testing was utilized for implementation of nosocomial infection control, in addition to detailed observation of the hospital and the questionnaire survey. ethical approval was obtained from the institute of medicine, kathmandu, nepal prior to using the questionnaire in the target hospitals. the hospitals responded to most of the questionnaire items, but for some items, a response was obtained from only hospitals. the average number of beds in the surveyed hospitals was as follows: national hospitals; ( - ), private hospitals; ( - ), other hospitals ( - ). the average number of clinical departments was as follows: national hospitals (excluding the two specialized hospitals); . ( - ), private hospitals . ( - ); other hospitals . ( ) ( ) ( ) ( ) ( ) ( ) . tuth, which is one of the national hospitals, had beds and clinical departments. manuals for infection control were used in . % ( / ) of the hospitals (national / , private / , and other hospitals / ). however, most of these manuals were more than five years old and some of their contents were not considered suitable for recent infectious diseases and antibiotic use. the manuals at three hospitals were considered obsolete. two national hospitals had good manuals with up-todate contents. only three hospitals had manuals for novel influenza. an infection control committee (icc) was established in . % ( / ) of the hospitals (fig. ) . however, a regular icc meeting was held in only two hospitals (once a month, and every three months) and the remaining hospitals held meetings when requested. it was noted that the operations of these committees were far from adequate. no hospitals had an infection control team (ict). equipment and facility preparedness: the number of hospitals which met the standard quantity requirements for disinfectants and personal protective fig. . no hospital was equipped with a sufficient quantity of n masks and goggles. eleven and hospitals responded that n masks and goggles were unavailable, respectively. a total of . % ( / ) of hospitals responded that the preparation level for novel influenza was poor or slight. four hospitals responded that they could prepare isolation rooms to deal with novel influenza/ sars, but no hospital was equipped with negative pressure rooms. only one hospital had a plan of zoning formulated according to the risk of infection. training conditions: current training conditions are summarized in table . six hospitals (four national hospitals, one private hospital and one other hospital) were organizing training programs for their staff (in-service training). regarding future plan, five hospitals responded that they planned to conduct inservice training, and eight hospitals responded that they did not have any plans at the present time but hoped to in the future. among all the hospitals, one had already conducted a training program on sars and/or novel influenza and three hospitals intended to conduct training. surveillance conditions: bacteriological testing was regularly performed for nosocomial infection cases at . % ( / ) of the hospitals and . % ( / ) of the hospitals for some cases. surveillance of nosocomial infections according to reports from clinical departments on clinical signs such as fever, respiratory signs, diarrhea, etc. was regularly carried out in . % ( / ) of the hospitals in the survey (fig. ) . seven hospitals had a strong interest in cooperating with foreign hospitals. a particularly strong expectation was observed regarding research support, information supply, ppe provision, and guidance in constructing an effective control system (table ). among the problems observed in the study were weak icc function, few training opportunities among the hospital staff, inadequate use of antibiotics, shortage of infection control staff, shortage of doctors and nurses and their overload in daily medical practice, shortage of fundamental equipment including ppe, inadequate practice of basic tech- comparison of nosocomial infection control conditions between and at five national hospitals showed an improvement trend. particularly, preparation of ppe and disinfectants remarkably improved as shown in figure (p = . and p = . , respectively), categories in which all five hospitals met the standard quantity. in , four out of five hospitals (except for one specialized hospital) were conducting in-service training, while only one hospital was conducting such training in (p = . ). among these four hospitals, manuals were on hand and an icc was established (p = . ). the first icc in nepal was established in at tuth. since then, an icc meeting has been held once a month. a comparatively good infection control manual was prepared and has been revised according to necessity. inservice training has been conducted for most of the staff at tuth. this study showed a good situation regarding equipment preparedness including disinfectant (sufficient amount), ppe (sufficient amount of ordinary masks, disposable gloves and gowns) along with preparation of isolation rooms. however, incomplete observance of basic techniques such as standard precautions, as well as the need to further strengthen the function of icc, have been pointed out as challenges. performance of bacteriological testing was well carried out in the clinical microbiology department of tuth, and the results were passed on to the clinical side through the drug information office. however, the interview suggested that increased bacterial resistance to antibiotics was a growing issue at tuth. appropriate nosocomial infection control is a key strategy in providing high quality medical care, and effective measures are particularly required in developing countries, where the frequency of infectious diseases is high and environmental conditions of hospitals are poor [ , ] . however, nosocomial infection control is generally not given high priority, and awareness among medical practitioners is still low, a situation that jeopardizes health care functions. in this survey in kathmandu city, steady progress was observed in national hospitals in comparison with the results in . it is particularly noteworthy that awareness among staff and the level of training activities increased with an improvement in the preparedness of essential infection control equipment such as ppe and disinfectants. regarding private hospitals and other hospitals, a comparative study was not conducted using this survey, but an improvement in infection control similar to that of the national hospitals is assumed. however, further efforts to strengthen nosocomial infection control at the target hospitals are still considered necessary. the results showed that the majority of hospitals did not have an up-to-date nosocomial infection control manual, that the surveillance system was not established sufficiently, and that preparations against sars and novel influenza were poor. it is crucial to improve these fundamental systems. moreover, special emphasis should be placed on observance of basic techniques (standard precautions) such as hand hygiene, effective use of ppe and appropriate practice of disinfection [ ] [ ] [ ] . enlightenment activities, such as distribution of manuals and teaching materials and the organization of training courses for medical staff, are very useful and effective for the improvement of nosocomial infection control. an increasing number of hospitals have been establishing iccs in recent years, but the management and implementation of activities need further improvement to achieve effective control measures. hereafter, icts also need to be set up in leading hospitals. furthermore, the detailed status of nosocomial infections and their causative agents should be strictly monitored and properly utilized in clinical practice. among the targeted hospitals in this survey, tuth showed comparatively good results. bacteriological testing, supervised by the jica project, was functioning well and contributing to the surveillance of nosocomial infection based on bacteriological examination and reports from clinical departments for suspected nosocomial infection cases. however, our previous study on pathogens associated with nosocomial lower respiratory infections showed a high frequency of gram negative bacilli such as escherichia coli, pseudomonas aerginosa, acinetobactor baumanii, klebsiella pneumoniae, as well as a high multiple drug resistance rate for isolated bacteria. in addition, a high rate of extended stratum beta lactamase (esbl) producing bacteria was observed [ ] . the spread of multi-resistant bacteria reported by many developing countries is considered to be a facilitating factor in nosocomial infection [ ] [ ] [ ] . methallo β lactamase (mbl) producing bacteria, which originated from india, is also suspected to be spreading to nepal [ , ] . these findings suggest the need for more aggressive measures to tackle this global threat. the appropriate use of antibiotics based on accurate bacteriological testing, along with appropriate guidelines, is a worldwide challenge. nepal, fortunately, has not experienced a sars outbreak, and no human case of avian influenza has been reported to date. on the other hand, awareness of nosocomial infection control seems to be lagging behind countries where a sars outbreak did occur as shown in the study [ ] . when a novel influenza becomes an epidemic and human to human infection is common, nosocomial infections may easily occur as seen in the spanish influenza pandemic of - . appropriate nosocomial infection control is also considered useful for novel influenza control. special importance should be placed on setting up a foundation for appropriate nosocomial infection control in daily practice, training medical staff and establishing a control system, before nosocomial infections become a frequent occurrence. nosocomial infection control is crucial in providing high quality medical care. greater efforts should be focused on training medical staff to enhance basic techniques and establish control systems at ordinary times, not waiting until after an outbreak or epidemic. with such a foundation, it will be possible to promptly apply stringent nosocomial infection control in the event of an outbreak of novel influenza, sars or other emerging infectious disease. these measures will contribute to the reduction of unnecessary costs and can improve the financial condition of the hospital. based on the results of this survey, the authors intend to collaborate with nepalese authorities and further contribute to the improvement of nosocomial infection control. currently, our collaborative activities at tuth are related to basic studies on bacterial resistance to antibiotics and the appropriate use of antibiotics. in addition, guidance on the promotion of standard precautions and surveillance systems is currently being prepared. the results of the present survey are expected to provide baseline data for monitoring the progress of the nosocomial infection control situation at tuth as well as that in hospitals in kathmandu. in this survey, only hospitals in kathmandu city were investigated. infection control conditions are improving in these hospitals but further improvement in the software aspect is still needed to assure high quality medical care. in nepal as well as other developing countries, a significant disparity in the conditions of medical care and the health system exists between major cities and rural areas. in the future, the expansion of nosocomial infection control to hospitals in remote areas will be needed along with the implementation of guidance for hospitals in those areas. hospital-acquired infections in belgian acute-care hospital: an estimation of their global impact on mortality, length of stay and healthcare costs the cost of hospital-acquired infection and the value of infection control what can we learn from each other in infection control? experience in europe compare with the usa health-care-associated infections in developing countries paediatric hospital-acquired bacteraemia in developing countries evaluation of surveillance for surgical site infections in thika hospital canada; canadian severe acute respiratory syndrome study team. identification of severe acute respiratory sundrome in canada experience and review of sars control in vietnam and china prevention of nosocomial transmission of swine-origin pandemic influenza virus a/h n by infection control bundle report on japan-vietnam collaboration in nosocomial infection control in bach mai hospital fact-finding survey of nosocomial infection control in hospitals in vietnam and application to training programs molecular evidence based hospital acquired rotavirus gastroenteritis in nepal prevalence of nsocomial lower respiratory tract infections caused by multi drug resistance pathogens prevalence of nosocomial infection and antibiotic use at a university medical center in malaysia impact of enhanced infection control at two neonatal intensive care units in the philippines feasiblility and efficacy of infection control interventions to reduce the number of nosocomial infections and drug-resistant microorganisms in developing countries: what else do we need? importance of structured training programs and good role models in hand hygiene in developing countries testing the who hand hygiene self-assessment framework for usability and reliability acinetobacter infections: a growing threat for critically ill patients contribution of acquired carbapenem-hydrolyzing oxacillinase to carbapenem resistance in acinetobacter baumannii extended spectrum beta-lactamase (esbl) medicated resistance to third generation cephalosporins among klebsiella pneumonia in chhenai new delhi metallo-beta-lactamase (ndm- ): towards a new pandemia? the authors would like to express thanks to the hospitals in kathmandu city for their cooperation during the implementation of this study. this survey was conducted with the support of grants from the national center for global health and medicine, japan. none. key: cord- - u e q authors: nan title: selected abstracts from the th j project meeting, antalya, turkey, march - , date: - - journal: j clin immunol doi: . /s - - - sha: doc_id: cord_uid: u e q nan hans d. ochs the identification of single gene defects involving genes that play crucial roles in adaptive or innate immunity is not only important for confirming a pid diagnosis, but may contribute to optimal therapy, and contribute to genetic counseling, carrier identification and pre-natal diagnosis. to accomplish this, the diagnostician has to consider the inheritance of these disorders: x-linked, autosomal recessive, autosomal dominant and the type of mutation: loss of function, hypomorphic, dominant negative or gain of function. conventional techniques to screen for single gene mutations include flow cytometry to measure disease-specific expression of proteins (cell surface, cytoplasmic or nuclear) or to analyze relevant signaling pathways (e.g. stat b phosphorylation via the il- r; pstat via the il- receptor); and sanger sequencing of mrna or genomic dna using dye-terminator sequencing. next generation sequencing ("by synthesis") has been refined, and is being used increasingly to study families with multiple affected members with an atypical pid phenotype, or to explore consanguineous families with one member affected. whole exome sequencing requires less data analysis, compared with whole genome sequencing, but may miss intronic or regulatory elements. the challenge of whole exome/genome sequencing is to confirm that the multiple variants identified by these techniques are causative for the clinical phenotype of the study patient. however, with increasing experience, next generation sequencing will become a standard procedure for the identification of genetic defects responsible for inherited diseases, including pid. stephen jolles immunodeficiency centre for wales, university hospital of wales, cardiff, uk. immunoglobulin (ig)-replacement therapy represents the mainstay of treatment for patients with primary antibody deficiency and is administered either intravenously (ivig) or subcutaneously (scig). recent developments using a high-purity recombinant human hyaluronidase have allowed the longer term repeated use of this enzyme to facilitate the delivery of immunoglobulin and other molecules including antibiotics, local anesthetics, insulin, morphine and fluid replacement into the subcutaneous space. hyaluronidase facilitated scig (fscig) has helped overcome the limitations on the volume which can be delivered into the subcutaneous tissues by enabling dispersion of scig and its absorption into lymphatics. the rate of facilitated scig infusion is equivalent to that of ivig, and the volume administered at a single site can be greater than ml, an enormous increase over conventional scig, at - ml. the use of fscig avoids many of the systemic side effects of ivig, and has higher bioavailability than scig. over three years of safety data are now available for this approach though longer term safety data and information on anti-hylauronidase antibodies and their relevance will be required. fscig could aid several areas of patient management in both primary antibody deficiency and immunomodulatory indications. key factors influencing how it will be used in future are long-term safety data and cost-benefit analysis. date after the cd deficiency was firstly described in a turkish girl in . the patients with cd deficiency had normal b-cell differentiation in bone marrow, normal absolute number of b cells in peripheral blood and normal bcr repertoire. also, the patients had normal stimulation via the bcr, normal proliferation response upon antigen stimulation but reduced memory-b-cell compartment in peripheral blood. the cd deficiency leads to hypogammaglobulinemia and impaired antigen-specific humoral immune responses after vaccination. we had described thirty carriers in relatives of our two patients with cd deficieny and also showed that the mfi value of cd and cd expressions were lower in the carriers than in controls. during the last five years, it was also showed that the mutations of the other coreceptors of b cells such as cd and cd caused antibody deficiency. in conclusion, the description of cd deficiency reminds the importance of the molecules on b cells and contribute to identify new genetic defects (cd , cd ), and it was showed that coreceptors could affect the expressions and the functions of each other. ege university faculty of medicine, dept of pediatric immunology, izmir, turkey ig class switch recombination deficiencies are rare pids ( : , births) with normal or elevated serum igm and low igg, iga and ige levels, defective or normal somatic hypermutation, defective t/b cooperation ( %), intrinsic b cell defect ( %), susceptibility to bacterial infections begining from the first year of age (impaired b cell immunity) and lack of germinal centres in secondary lymphoid organs. we present a cd l defective case with clinical findings such as recurrent otitis media, recurrent upper and lower respiratory tract infections, sinusitis, arthritis, relapsing polychondritis , ebv-associated cervical lymphoproliferation, cmv infection, bronchiectasis, liver and spleen enlargement, multiple nodules in the liver, chronic diarrhea due to persistent cryptosporidium parvum, fungal pneumoniae, osteoporosis, and schwannoma. this case is remarkable with low igm levels and normal cd l ezpression on activated t cells although he had a novel mutation in cd l gene (a novel missense mutation in cd lg (c. c t), leading to an a. a. change from histidine to tyrosine at position (h y) at the start of the extracellular domain). in addition, we present two cases with cd deficiency with normal cd expression on b cells.both of these cases had homozygous-cd -mutation leading to a longer protein due to deletion of stop-codon. in conclusion; cd molecules although non-functional in b cells, may be normally expressed on cell surface. these cd molecules are unable to trigger signal, because cd l + il activation leads to complete lack of proliferation. evaluation of cd or cd l expression by flow cytometry may lead false results. study of cd l + cytokine (or cd + cytokine)induced b cell proliferation appears as a useful tool for these diagnosis. institute for immunology and physiology (ub ras). yekaterinburg, russia regional children clinical hospital № , yekaterinburg, russia the ural regional center of clinical immunology, which based on children clinical hospital number one (№ ) in yekaterinburg, observe patients from different territories of ural region and neighboring areas. it consists of laboratory department, consultative department, vaccination and treatment rooms, beds and boxes in special departments in the regional children hospital. the close collaboration with j-project started in . this is an example of such collaboration. in patient a. an international consilium was diagnosed a progressive neurodegenerative disease as a manifestation of primary immunodeficiency: x-linked agammaglobulinemia with b-cell deficiency. mri results: unspecified leukodystrophya rapidly progressive multifocal brain lesions with demyelinating, generalized cerebral atrophy, iii degree, signs of periventricular leukomalacia in the anterior horns of the lateral ventricles. the brain biopsy was recommended in order to clarify the nature of the defeat of the pathological process and define the role of the immune mechanisms of its development (held in the neurosurgical department with subsequent histological and immunohistochemical studies). histological and immunohistochemical study of the brain tissue of the right frontal lobe: a signs of productive meningoencephalitis in brain tissue with vasculitis, perivascular and focally moderate diffuse infiltration of mononuclear (accumulation of mononuclear cd rb+, vimentin+), most of which are cd + lymphocytes with granules of granzymeb. around -dystrophy and necrobiosis neurons, intracellular edema, small focuses of gliosis -there are isolated myeloid cells (myeloperoxidase +) and plasma cells with cytoplasmic expression of immunoglobulin light chains lambda and kappa; cells and the extracellular matrix of brain tissue expressing cd antigen and s protein. virological and bacteriological studies of brain tissue and liquor: connection of progressive degenerative changes and infectious process weren't obtained verified acknowledgments of an infectious or autoimmune process has not been received. search for a genesis of cytotoxic process in the brain continues. center for chronic immunodeficiency, university medical center freiburg and university of freiburg, germany the essential role for igg replacement therapy (iggrt) for common variable immunodeficiency (cvid) has been demonstrated in many studies and metaanalyses. while patients with "infection only" reach a nearly normal life expectancy -though still not quality -under iggrt, cvid patients with additional manifestations like inflammatory lung, bowel or liver disease, lymphoproliferative and/or autoimmune disease often require additional immunosuppressive treatment. there is little consensus on the form of immunosuppressive regimen, once steroids have failed, with possibly the one exception of rituximab treatment for autoimmune cytopenia. additional studies are essential to guide therapeutic algorithms. some of these patients suffer from late onset combined immunodeficiency (locid). as in classic forms of combined immunodeficiency, iggrt can be only a part of the treatment strategy, which needs to additionally address the cellular immunodeficiency of the patients. therefore a retrospective survey was performed on patients diagnosed with cvid who underwent hematopoietic stem cell transplantation. the results of this study are currently in revision. in summary, iggrt is the baseline therapy for cvid but does not address sufficiently the immune dysregulation in a subgroup of patients. better predictive markers have to be identified for the selection of patients for additional, potentially even definite forms of treatment in order to prevent the morbidity and mortality associated with these secondary manifestations of cvid. the first department of primary immunodeficiencies in russia was established on the basis of the institute of immunology in , when patients with pid were registered. currently, patients with pid are followed in the department of immunopathology in adults. % of pid adult patients have pid with immunoglobulin deficiency. analysis of this group of adult patients showed that the diagnosis of pid, on average has a delay of - years from the first symptoms. in % of cases, there is an infectious clinical phenotype, % -combined infectiouslymphoproliferative phenotype, % -infectious and enteropathy. the study of immunophenotyping of b-lymphocytes for the degree of maturation in this group of patients was begun. patients are currently included in this study. patients showed complete absence of b-lymphocytes, -the reduction of b-cells, patients of those have a normal amount switched memory b cells (mbc), people -a decrease amount of switched mbc. persons of the group with decreased amount of switched mbc had an expansion of transitional mbc. at present, a clear link of immunophenotypes with specific clinical phenotypes in not found, but this may be due to small sample of patients at the moment, the investigation continues. for the treatment of this category of patients only intravenous immunoglobulins are available in russia. we use drugs in various concentration of russian and foreign production. the availability of immunoglobulins for the adult patients unfortunately is not sufficient in russia, so the recommended pretransfusion level of igg is not achieved in about % of patients. our work presents the experiences of our center with the subcutaneous form of immunoglobulin therapy (scig). we have patients on such therapy. the youngest child is months old. the largest group consists of cvid patients, next-xla patients. we also substitute children diagnosed with the dgs and accompanying hypogammaglobulinemia and some children with subclasses deficiency as well as secondary hypogammaglobulinemia. in most cases we start therapy with intravenous preparates, but there have been some children to whom we proposed the subcutaneous form at the initial stage of the therapy. the main factors which made us change the mode of the drug application were adverse reactions to ivig, poor vein access and the parents`wish. the administration of scig is very rarely complicated by severe adverse reactions (the risk of their incidence amounts to about . %). even patients with serious side effects to previous immunoglobulin therapy and/or blood transfusion can be safely treated with scig. the most common side effects are local reactions but their incidence decreases during following substitutions. we can observe swelling, redness, induration, soreness. but we should remember that more severe side effects are also possible, for example: the first cvid patient presented with fever, weakness, difficulties in breathing during the following infusions. changing the brand of the drug turned out to be a sufficient method of getting rid of side effects. the second patient, also with cvid, suffered from nausea, headache, meningismus. we changed the drug brand, slowed down the infusion rate and introduced premedication with an antihistaminic drug. the third patienta girl with dgs and hypogammaglobulinemia, after having been operated on for hypoplastic left heart syndrome, responded to infusions with high fever, muscle and joint pain, skin changes (erythrodermia). we introduced premedication, changed the drug brand and slowed the infusion rate, yet without any positive effects. in two patients we observed adverse reactions after preparates at a concentration of twenty percent. there were: weakness, chills, fever, headache, and very intense pain in the place of injection. during the subcutaneous treatment of xla patients, we observe significant reduction in the number of infections and days of school absence. despite that, all our patients with xla suffer from chronic sinusitis. similar results occurred in cvid patients, but the severity of infections was the same. the use of scig results in more stable and higher igg through levels especially in xla patients. in our practice, we had only a few cases in which iv form appeared to be better than sc one. in the case of two boys with higm syndrome, we observed recurrent enthesitis of the first patient and progression of lung fibrosis of the other. ivig was better to control platelets levels in the girl with cvid and thrombocytopenia. it has also occurred that parents refuse to allow us to start subcutaneous therapy, giving two main reasons: they feel safer under frequent doctor`s control and they are afraid of making mistakes in procedures. as for the youngest children (below )their fear of needle is independent of its size, which is the third reason. in conclusion, we would like to emphasize that education programmes implemented by doctors and nurses are essential to make this form of therapy easier, safer and more satisfying for patients and their parents. despite intensive investigation into the nature of cvid, the exact molecular defect(s) and pathogenesis of disease remain unknown. our aim was to evaluate the role of t cells in the mechanisms of cvid development. additionally the impact of some innate and adaptive immunity related genes (hla, cytokine gene polymorphism, mbl genes) was investigated. based on previously observed by us constellation of shared immunogenetic profiles a comparison of t-cell phenotype of cvid patients, and elderly/young healthy individuals was performed. ten patients with cvid were enrolled ( male, female; average age - , years) presented mainly with pulmonary infections, followed by bronchoectasis and splenomegaly. our study demonstrated multiple t-and b-cell abnormalities in cvid patients such as: decreased cd +, increased cd + t cells and low cd /cd ratio, loss of naïve and early differentiated t cells, expansion of terminal effectors (cd + cd ra + cd l-) t cells, memory/effectors (cd + cd -cd -) and terminally differentiated (cd + cd +) t cells. excessive t-cell activation reflecting the prevalence of activated t cell phenotype was also detected, due perhaps to an antigen-driven process. the very low numbers of circulating mature (cd + cd +) and class-switched memory (igm-igd-cd +) b cells were pathognomic for our patients and could be used as an additional diagnostic criteria in the national guidelines. furthermore high level of nonclass switched (igm + igd + cd +) b memory cells and suppressed nk cell count was observed. decreased responsiveness to polyclonal stimuli via cd and cd pathway correlated with the loss of cd expression which was more pronounced in the treatmentnaïve cvid patients. these findings were further discussed in the context of the similarities that exist along with markers for immune senescence (lack of cd or expression of cd ). increased frequency of ifn-γ polymorphisms associated with low expression level found could indicate genetically predisposition to high activation of th lymphocytes in cvid and consequently support the concept of impaired th -type responses. in conclusion our study provided new insight into the pathogenesis of cvid. this work was partially granted by medical university sofia, grant# bcg vaccination at birth is the constant element of vaccination programmes in poland. high reactogenic bcg danish vaccine has been replaced in , by bcg moreau vaccine. frequency of disseminated bcg infection, in children with primary immunodeficiencies after bcg moreau vaccine manufactured by biomed, poland were estimated. one thousand five hundred sixty three cases of primary immunodeficiencies were diagnosed in the department of immunology, children's memorial health institute in warsaw between - . among patients with t cell predominant deficiency, group high risk of bcg infection, scid was recognized in children. mendelian susceptibility to mycobactarial diseases (msmd) was detected in four patients: ifgr deficiency and il deficiency -equally in two patients, and nemo -in one. in the group of primary immunodeficiencies regarded to be less prone to mycobacterium infections, cgd was diagnosed in , hies in patients, and xl-higm in patients. disseminated bcg infection was recognized in scid patients, of them died, because of bcg diseases. all patients with msmd developed bcg infection, one with il- deficiency died. during nearly -year-follow-up, no case of tuberculosis or disseminated bcg infection have been diagnosed among cgd , hies and xl-higm patients. early anti -tb drug prophylaxis and usage of wide range of antibiotics in therapy is crucial for cleaning of bcg infection. peter Čižnár ; julia horáková ; peter Švec ; ivana boďová ; sabina Šufliarska ; linda libai veghová ;, marieta hricová st pediatric department, comenius university medical faculty, children`s university hospital, bratislava, slovakia. transplantation unit, department of pediatric haematology and oncology, children`s university hospital, bratislava, slovakia. objectives: severe combined immunodeficiency (scid) is a group of disorders due to more than genetic defects, characterized by increased susceptibility to severe infections and early life death. the diagnosis is supported by the demonstration of low absolute t lymphocyte count variably associated with numerical defects of b and nk cells. patients are very heterogeneous regarding clinical course, immune parameters and clinical outcome. bcg (bacillus calmette-guerin) vaccine, a life attenuated vaccine was the part of slovak immunization program, administered at birth until . a comparison of clinical course of bcg exposed (bcg+) and non-exposed (bcg-) scid patients in slovakia in period of past years are given. results: incidence rate of diagnosed and treated scid in slovakia was calculated to : . , meaning , cases per year. in total cases represent ada patients, il rg deficiencies, case of complete del q and in cases genetic defect was not found by analysis of rag / , il rg, artemis, il ra, jak and ada genes. all patients were confirmed absent trec (t-cell receptor excision circles) copies in a retrospective neonatal guthrie card analysis. seven out of these patients underwent hsct, in the hsc source was a mud. favorite outcome was achieved in of them. half of our patients have been exposed to a live bcg vaccine during neonatal period. patients vaccinated with bcg faced severe complications and organ damage due to generalized skin and organ abscess formation, requiring prolonged (up to months) hospital care and complex antibiotic therapy with more than four types of anti-mycobacterium drugs, for more than years. average length of hospital care for bcg exposed patient was , months vs. , months in non-exposed group (p < , ). no statistical difference was found between the time of recognized first symptoms, and time of diagnosis in bcg + and bcg-group. the clinical presentation of non-bcg vaccinated patient differs in the initial symptoms when failure to thrive and pneumonia at months was the most common finding. post-transplantational recovery in bcg-group was less complicated. conclusions: two major improvements for the outcome for scid patients in slovakia have occurred in past years. early life vaccination for tuberculosis has been retreated and improvements in diagnostics for severe t cell defects have been made, including flow cytometry phenotyping and genetic testing within the middle european countries cooperation, the j-project. bcg and late diagnosis prolongs time for hospital care, immune reconstitution and carries severe complications, consequently it increase the costs of health care and decrease the quality of patients' life. the perspective of newborn screening for scid would be the next major step in improving the outcome of scid patients. ahmed aziz bousfiha ; leïla jeddane ; nahla erwa ; monika esser ; shereen m. reda in africa, primary immunodeficiencies are still largely undiagnosed, with no cases reported in of countries. though the african society for immunodeficiencies (asid) already organized international meetings and training schools, their impact outside the hosting country is still insufficient. at this time, only a few pid patients are reported in africa (less than patients), the majority of whom are in north africa and south africa. so, asid propose the a-project, a training program based on the j-project. some issues prevent effective training for pid in africa: diversity of languages, only a few are initiated to pid, lack of resources for travel expenses, difficulty to access to care and shading by the hiv pandemic. a-project is designed as a one-day training by an african pid expert in a small group of motivated caregivers. this project is adapted to the african context, as it only requests minimum funding and can reach more people. each a-project will be co-organized by asid and a local committee, and shall lead to some commitments to be realized by locals, in particular the establishment of a registry, a network between physicians and scientists and creation of a patient association. moreover, each a-project will be done in the medical language used in the country (english, french or portuguese). the first a-project was already done in benin, and five more are already planned for . our goal is to reach all countries where no patient were reported in years. this clinical program will raise pid awareness in africa and can potentially discover new aspects of the immunity. till very recently primary immunodeficiency diseases (pids) were not being frequently recognized in india. however, the scenario has changed over the last years or so. the indian society for primary immune deficiency (ispid) was founded in - . over the last years the ispid has organized international conferences (at new delhi and mumbai), national conferences (at chandigarh and varanasi) and continuing medical education programmes (at new delhi and lucknow). these meetings have served to act as catalysts for the cause of pids and have resulted in increasing the awareness about these conditions amongst paediatricians and physicians in our country. several centres now have the clinical skills and the technical wherewithal to perform laboratory investigations for these patients. the repertoire of tests includes nephelometery, elisa based tests and flow cytometry. facilities for molecular diagnosis of pids are also being developed at some of these centres. a lot more, however, needs to be done. the clinical phenotype of several pids in india is likely to be different from that in the west . further, the type of infections in these patients is also likely to be different. this is because of the differences in the micro-and macro-environment to which these patients exposed in developing countries. these differences have been well brought in the recent publication on chronic granulomatous disease from our centre . further, the genetic background of the indian population is diverse and several new mutations are likely to be identified amongst these patients. the indian council of medical research has taken up the lead in this regard and is proposing to set up centres for advanced research (cars) in pids - each at the post graduate institute of medical education and research, chandigarh and the institute of immunohematology, mumbai. the foundation for primary immunodeficiency (fpid), usa has also been closely involved in these efforts and has helped facilitate the development of these cars. the field of pid research in india is wide open and we are likely to witness new and exciting scientific developments in the coming years. references: . gupta s, madkaikar m, singh s, sehgal s. primary immunodeficiencies in india: a perspective. annals of the new york academy of sciences ; : - . the prevention of pid's complications, the improvement of the health care of patients with pid, the creation of the registry of the patients with pid, the implementation of the finance regulations for detection and treatment of patients with pid diseases in public health facilities, the training and professional development of medical professionals in this field. objective: to improve the detection and diagnosis of pid diseases and the life quality of patients with pid in the republic of kazakhstan. undertaken activities for realization of the project: . professor. l. marodi visited kazakhstan in october and the meeting was held in ministry of health of the republic of kazakhstan, presentations were given at the international conference held in national research center for maternal and child health, the negotiations with heads of the national medical holding' clinics and scientific center of pediatrics and pediatric surgery were held. international islamic university, kuantan pahang, malaysia. two hundred and sixty three ( ) suspected pid (primary immunodeficiencies) cases were referred to clinical immunologist led clinics in malaysia from - . patients referred were from all states of malaysia and seen at the institute of pediatric, hospital kuala lumpur and university associated hospitals in north and central peninsular malaysia the initial pid patients were seen by - pediatric immunologist between - followed by another , beginning in followed by the other in . there were ( . %) patients with at least abnormality on the immune prameter recorded and regarded as probable pid. however ( . %) were recorded as pid based on existing criteria. (who scientific committee , iuis scientific committee, primary immunodeficiency disease. ) our population were mainly children, % below years and % below year. only were above years. pid were classified as; predominant antibody deficiencies %, combined immunodeficiencies . %, other cellular immunodeficiencies . %, phagogocytic defect . %, immunodeficiency associated lymphoproliferative disorders %. our data differed from most classification where predominant antibody deficiency is most frequent as high as %, (steihm, ) . of the specific pid recorded, x linked a gammaglobulinemia (xla) , hyper igm syndrome (higm) , common variable immunodeficiencis (cvid ), selective iga deficiencies severe combined immunodeficiencies (scid) , di george syndrome (dgs) ,chronic granlomatous disease (cgd) , hyper immunoglobulin e syndrome (hige ) , primary cd deficiencies , ataxia telangiectassi % malaysia comprises of multi ethnic groups with a population of . million in . pid amongst them showed, malays at . %, chinese %, indians . % and others . % whilst the male predominate over female at a ratio of . : . family history of affected sibling or in first degree relative, or early death with suspected infant dying of infection was positive in . % which is higher than in most reports eg egypt . % (reeda ). this could be due to high consanguinity in the population. alternatively the symptomatic sibling of affected patients is more likely to be referred to the clinical immunologist. scid records the most varied organism from the positive microbiological isolate viz bacteria , fungus , virus , parasite . chromobacterium violaceum was seen in cgd patients in which deteriorated with eventual death. as in many national registries diagnostic delays remains prominent. in our series the mean diagnostic delay was o . ± . years. in comparison thailand stands at . ± . years, while france, a median of . years. malaysia remains committed to provide better diagnostic services and improved care of the pid patients through research collaboration with foreign partners with a drive for creating subspecialty training. patient groups aligned to ipopi is now closer to its formation with the creation of its protem committee ensuring that patients' interest will always be guarded aknowledgement. the authors thank all who had contributed directly or indirectly, especially medical officers, nurses, consultant pediatricians especially dr kamarul azhar, institut of pediatrics hkl, laboratory scientists especially dr shanaz murad of the imr kuala lumpur university of manchester, uk although the concept of grouping mendelian disorders associated with an upregulation of type i interferon (ifn) has not been previously recognised in the medical literature, our past and current work argues that this concept has scientific validity and clinical utility. i will discuss the possibility that such conditions can usefully be considered to represent a novel set of inborn errors of immunity, and that the recognition of diseases as type i interferonopathies will have significance for the development of targeted therapies, as well as informing our understanding of viral and retroelement biology, and the pathogenesis of some forms of autoimmunity. classic kaposi sarcoma (ks) is exceedingly rare in children from the mediterranean basin, despite the high prevalence of hhv- infection in this region. we hypothesized that rare single-gene inborn errors of immunity to hhv- might underlie classic ks in childhood. we report here autosomal recessive ox deficiency in an otherwise healthy adult with childhood-onset classic ks. ox is a costimulatory receptor expressed on activated t cells. its ligand is expressed on various cell types, including endothelial cells. the mutant ox protein was poorly expressed on the cell surface and failed to bind ox ligand, resulting in complete functional ox deficiency. the ox -deficient patient had a low proportion of effector memory cd + t cells in the peripheral blood, consistent with impaired cd + t-cell responses to recall antigens in vitro. the proportion of effector memory cd + t cells was less diminished. the proportion of circulating memory b cells was low, but the antibody response in vivo was intact, including to a vaccine boost. together, these findings suggest that human ox is important for cd + t-cell memory, but redundant for immunity to most common pathogens, with the notable and surprising exception of hhv- . the chronic mucocutaneous candidiasis disease (cmcd) is characterized by persistent or recurrent infection of skin, nails, oral, or genital mucosae with candida albicans. il- -mediated immunity has been concerned in host defense against candida on body surfaces. we have investigated nine patients with chronic mucocutaneous candidiasis disease (cmcd) and signal transducer and activators of transcription (stat ) mutations. the novel c. c > a (n k) and c. a > g (q r) mutations in the coiled-coil domain (ccd) and the c. c > t (t m) mutation in the dna-binding domain (dbd) of stat are gain-of-function (gof) for γ-activated factor (gaf)-dependent cellular responses to stat . low proportion of il- a-and il- -producing t cells, lower levels of intracellular il- a and il- by t cells and impaired candidainduced secretion of il- a and il- by leukocytes from cmc patients compared to that in healthy controls were found. the c. c > t (r w) mutation affecting the ccd and the c. c > t (t m) mutation affecting the dbd of stat and resulted in gain-ofphosphorylation and gof. these mutant alleles enhanced the cellular responses to cytokines via stat signalling pathway. these data provide further insight into the mechanism of host defense against candida. heterozygous gain-of-function stat mutation is known as a major etiology of chronic mucocutaneus candidiasis. gof mutation affecting the stat coiled-coil domen (d g) was initially discovered in -year boy with cmc. gof mutation of dna-binding domen (t m) was found in the second our patient with cmc. both patients have early manifestation of recurrent or persistent infections of the skin, mucous membranes, and nails with candida albicans. they also have skin infections with dermatophytes. patient presented from the first months of age with severe recurrent sinopulmonary infections. recurrent pneumonia and chronic bronchitis complicated by bronchiectasis, which resulted in cor pulmonale and congestive heart failure. patient suffered from recurrent hsv infection, recurrent aphthous stomatitis, has several episodes of bacterial skin infections. he also has chronic bronchitis and several episodes of pneumonia, but does not have bronchiectasis. both boys developed esophageal stricture, patient necessitating nissen fundoplication in the age of years. the patients have mild autoimmune features: uveitis (p ) and alopecia (p ). immunological investigation revealed different impairment of immune system: more severe, similar to combined immunodeficiency in p , which declines with age. the p does not have changes in lymphocyte number and immunoglobulin's, but impaired antibody production to pneumococcal antigens. western blotting performed with nuclear extracts of lymphocytes of both patients showed stronger stat phosphorylation after stimulation with cytokines ifnγ, ifnα, il- . mononuclear blood cells from both patients released much smaller amounts of il- a and il- than candida-exposed cells from healthy control. stat activation triggers transcription of interleukin (il)- which is crucial for mounting protective immune responses against fungi. several mutations affecting the stat /il- pathway have been reported, resulting in selective susceptibility to fungal (candida) infection, a hallmark of chronic mucocutaneous candidiasis (cmc). in patients with autosomal-dominant (ad)-cmc we previously reported defective th responses and identified an underlying gain-of-function (gof) stat mutation leading to hyperphosphorylation of stat . how this affects stat or leads to decreased il- remains to be determined. in patients with ad-cmc, we assessed how gof-stat mutations affect stat activation, dna-binding, gene expression, cytokine production and the effect of epigenetic modification. we show that stimulation of stat in the presence of gof-stat mutations leads to significantly reduced transcription of stat -inducible genes (rorc/il- / il- /il- /c-fos/socs /c-myc). this was not due to impaired stat phosphorylation, altered nuclear translocation nor sequestration of stat into stat /stat heterodimers. dna binding to a stat-consensus binding site construct (hsie) was intact but binding to an endogenous stat dna target was impaired. the reduced stat -dependent gene transcription could be normalized by inhibiting stat activation by fludarabine or enhancing acetylation with histone deacetylase (hdac) inhibitors trichostatin a or itf . silencing hdac , hda and hdac indicated an important role for hdac . impaired stat -dependent gene transcription likely underlies decreased th- cytokine production, susceptibility to fungal infections and other pathology seen in ad-cmc patients and could be a new target for defining novel therapeutic approaches for this potentially lethal disease. autoimmune features have been long thought as association with immunodeficiency disorders, but are now viewed as a crucial component of some diseases attributed to the breakdown of self tolerance or defects of immune regulators. it had been previously established that a single gene defect of the foxp gene (foxp in humans) caused widespread autoimmunity in both humans and mice. the clinical syndromes observed in both scurfy mice and humans suffering from ipex are similar to those observed in experimental models in which treg are selectively depleted. in , three groups demonstrated that these diseases were indeed the result of a regulatory cell deficiency. around one third of the patients with clinical manifestation closely resembling ipex syndrome, foxp is not mutated, these patients are referred to as ipex like. here we present a case; a female patient years with multiple autoimmune manifestations; dm, coeliac disease and ulcerative colitis with marked decrease in the percent of cd + cd + foxp + cells. as she has a siblings suffering from dm; the whole family was investigated. the father and the mother had % cd + cd + foxp + cells. background: hids is an autosomal recessive disease, first recognized as a separated entity at . in patients with hids, the activity of mevalonate kinase is reduced to - % of normal levels. hids is caused by mutations in the mevalonate kinase gene (mvk), located on the long arm of chromosome ( q ). it is manifested by cyclic attacks of fever initiated usually during first year of age. the frequency and severity of attacks tend to decrease later in life. materials and method: a retrospective analysis of medical history , clinical course and laboratory findings of two albanian children with periodic fever , diagnosed with hyper igd syndrome. results: case presentation : an -year-old boy admitted to the hospital because of periodic fever spikes, which occurred every - weeks and lasted - days, presented since the first year of life and coincided with the beginning of immunization. he had a tonsillectomy and adenoidectomy at the age of . the fever attacks were associated with chills, malaise, and abdominal pain without gastrointestinal signs. between attacks the patient was free of symptoms. from his family history, recurrent febrile episodes during childhood were reported to his father. physical examination showed normal findings, except for a cervical lymphadenopathy. laboratory: marked increase of erythrocyte sedimentation rate and crp. wbc-ranged from . to /mm . , high asto. serum igd was repeated several times and was always elevated (mean value: serum igd iu/ml). the mutation v i is found from the genetic examination done for gene mutations in chromosome ( q ). he repeated attacks after initial treatment with corticosteroid ,than is suggested. the second case was a four-year-old girl hospitalized five times because of prolonged fever, and diagnosed as pneumonia, tonsillitis, acute otitis media and sinusitis, treated by antibiotics. her laboratory findings were not remarkable except for increased acute inflammatory responses. serum amyloid a (saa) μg/l ( μg/l) and igd was extremely high . iu/ml. genetic examination for two mutations were negative, but reduced mevalonate kinase activity in white blood cells was demonstrated in more thorough investigations. treatment regime: colchicine conclusions: auto inflammatory syndromes always pose diagnostic and therapeutic challenges to the clinicians. the clinical description of the diversity of periodic fever syndromes is helpful in the assessment and management of these patients. although hids is predominantly identified in populations from northern european areas, it has to be considered in children with periodic fever. anastasiia bondarenko ; liudmyla chernyshova ; iryna sychova shupik national medical academy of postgraduate education, kiev, ukraine. dniepropetrovsk regional children's hospital, dniepropetrovsk, ukraine. background. aspergillus is an actual pathogen in chronic granulomatous disease responsible for about % of all infections. in - % lungs are involved and in % -cns. case. we report a case of combined loci in -years old female patient with ar cgd. the child was born from iii pregnancy, ii delivery on th week of gestation with body mass g. she received bcg vaccination at -th day of birth. at months the local inflammation in site of bcg with regional lymphadenitis developed which was treated with isoniazid for months. then bilateral purulent cervical lymphadenitis developed at , and months treated with wide spectrum antibiotics. culture from pus was negative. pcr for mycobacterium tuberculosis complex was negative. at months systemic infection without loci occurred with fever, lymphadenopathy, hepatosplenomegaly, loss of weight, progressive anemia, inflammatory changes in blood for almost months. bacteriological cultures were negative. treatment with wide spectrum antibiotics was insufficient for months. disseminated bcg infection was suspected and -compound amb treatment was started ex juvantibus with positive effect: the fever has stopped, the sizes of lymph nodes, liver and spleen have decreased, the weight of a body normalized. the child suffered from recurrent pyogenic infections, underwent disseminated salmonellosis. at the age of years blood samples were tested at the laboratory of human genetics of infectious diseases, inserm (paris, france). an absence of p phox protein expression detected by western blot conferring a complete defect in cyba due to compound of geterozigous mutations in q . at years primary tuberculosis complex of right upper lobe (mbt -) was diagnosed. at the age of during the unexplained fever multiple formations were identified in the liver, biopsy showed caseosis suspected the mycobacterial nature of lesions but mbt (-). at the age of years because of shade in the left upper lobe and ineffective standard antibiotic treatment the tuberculosis again was suspected. due to ineffective antimycobacterial treatment for months multi drug resistant tubercullosis was considered. anti-tb drugs ii line was appointed without clinical response. fever persisted. mri of brain revealed mass lesion in the left parietal lobe. because of suspected tumor the brain biopsy was done and the pus was obtained. microbiological studies revealed aspergillus fumigatus. at the same time subcutaneous tumor-like infiltrate х mm appeared on chest in a proection of lung lesions. the pus was obtained during thoracentesis. result of microbiological studies: aspergillus fumigatus. drainage of abscesses and intravenous voriconazolum led to dramatic clinical improvement and normalization of blood parameters. conclusion. features of our case is spread lesions of aspergillosis with relatively slow progression of infection. high incidence of tuberculosis in ukraine leads to a high suspicion regarding this infection. diagnosis of tb is mainly based on instrumental studies. radiological and histological differential diagnosis between tuberculosis and other infections with granulomas in cgd is difficult. high suspicion of tuberculosis led to late diagnosis of aspergillosis. great north children's hospital, newcastle upon tyne hospitals nhs foundation trust, and primary immunodeficiency group, institute of cellular medicine, newcastle university, newcastle upon tyne, uk even following the introduction of biologic disease modifying antirheumatic drugs (dmards), a small number of children suffering from severe, refractory autoimmune (ai), rheumatic and/or autoinflammatory disorders will not get into clinical remission (cr) and will potentially further suffer from multiple side-effects of combined and long-term immunosuppressive and anti-inflammatory therapies, in particular severe infections (marodi l, casanova jl. jaci ; abinun m. ped health ). whilst autologous t cell depleted hsct following the immunosuppressive conditioning regimen achieved complete clinical remission in majority of children with severe juvenile idiopathic arthritis (jia) (de kleer im et al. ann rheum dis ) , infection-related mortality remains significant (abinun m et al. mol immunol ) . therefore, following the success of allogeneic hsct in treating children with immunodysregulation, polyendocrinopathy, enteropathy, x-linked (ipex) syndrome (nademi z et al. bmt ) , we treated further children with different severe ai (alps, autoimmune lymphoproliferative syndrome (n = ); complex ai disorder (n = )), rheumatological (jsle, juvenile systemic lupus erythematosus (n = ); jia (n = )) and autoinflammatory disorders (mkd, mevalonic kinase deficiency/ traps, tnf-receptor associated periodic fever syndrome (n = ); eoc, early onset colitis (n = )). overall, of the children are alive (follow up - years), in complete and (complex ai disorder) in partial cr, original disease (alps) relapsed in , and children died ( each with alps and eoc). children had significant, but transient acute (grade - ) and chronic (limited) graft vs. host disease (gvhd), experienced multiple virus reactivation(s), and remarkably we saw significant secondary ai diseases post-hsct (transient nephritic syndrome (n = ) and cytopaenias (n = ); psoriasis, n = ; and thyroid disorders (grave's thyrotoxicosis and hypothyroidism), n = ). our data add to the positive experience and evidence acquired over the last - years (daikeler t et al. bmt ; snowden ja et al. bjh ) to propose the allogeneic hsct as a viable treatment option for the small group of children suffering from severe autoimmune disorders. the wiskott-aldrich syndrome (was) is an x-linked primary immune deficiency disorder characterized by thrombocytopenia, microthrombocytopenia, recurrent, mostly respiratory tract infections, eczema and increased risk of autoimmune disorders and malignancies. was is caused by mutations in the wasp gene which encodes wasp, a -amino acid protein. wasp plays a critical role in actin cytoskeleton organization, signalling and different functions of immune cells. we present here the results of genetic analysis of patients with was from eleven eastern and central european (ece) countries, turkey, iran and azerbaijan. clinical and laboratory information of affected males and carrier females from was families were collected. the wasp gene was sequenced from genomic dna of patients with was, as well as their family members to identify carriers. in this large cohort, we identified unique mutations including novel sequence variants. the mutations were scattered throughout the wasp gene and included single base pair changes ( missense and nonsense mutations), small insertions, deletions, and splice site defects. this study was financially supported by the tÜbİtak project s and bap project tda- - . background: chronic granulomatous disease (cgd) is a rare primary immunodeficiency disorder of phagocytes. resulting in impaired killing of bacteria and fungi. a mutation in one of the four genes encoding the components p phox , p phox , p phox and p phox of the leukocyte nadph oxidase leads to autosomal recessive (ar)-cgd. a mutation in the cybb gene encoding gp phox leads to x-linked recessive cgd. methods: we report here the results of genetically and functionally characterized patients with cgd from turkish families in turkey. results: most of the families ( %) have an ar genotype (% p phox , % p phox and % p phox ) and % have an x-linked genotype. patients with a , a and x phenotypes with oxidase null activity (dhr stimulation index of ≤ . ) were found in patients. however, in p phox deficient cases and in other ar cases with high residual oxidase activity (dhr stimulation index ≥ ) were found in patients. conclusions: residual oxidase activity is similarly lack in the x , a and a phenotype except ar cases with missense mutation. in our cohort, the percentage of ar-cgd was different from european and usa registries (in comparison with % , % and % of p phox , p phox and p phox deficient ar-cgd cases, respectively) with the higher percentage of patients with p phox ( %) and p phox -deficent ( %) phenotypes, and the lower percentage of patients with p phox -deficient ( %) phenotype. the basic difference in our results from those reported is the higher percentage of patients with ar-cgd (% ), which was lower than in the european and usa registries, probably because of the higher prevalence of consanguineous marriage in turkey. introduction: schnitzler syndrome is an autoinflammatory disorder of unknown etiology. at least some of its clinical presentation is mediated through an activation of inflammasome and release of il- , as was repeatedly demonstrated by a prominent therapeutic effect of il- blockade. recent reports bring an evidence of an important role of mitochondria in inflammasome activation and in a pathogenesis of autoinflammatory diseases. we have therefore investigated mitochondrial function and structure in patients with schnitzler syndrome. materials and methods: activity and amount of oxidative phosphorylation complexes (oxphos) were analysed by spectrophotometry, histochemistry and imunoelectrophoretic methods in fibroblast cell lines derived from skin biopsies of three adult male patients with schnitzler syndrome. ultrastructure of mitochondria, mitochondrial network and reactive oxygen species (ros) were analysed by fluorescent and electron microscopy. results: the activities and amount of oxphos complexes i, iii and iv were decreased in patients with schnitzler syndrome. interindividual differences in the degree of impairment (from severe to moderate) in analyzed mitochondrial parameters were found. content of ros, previously suggested as main inducers of inflammasome, were not significantly increased in cells with schnitzler syndrome. we, however, did find consistent and prominent changes in mitochondrial structure of all three patients. disturbed mitochondrial network and mainly abnormal, partially swelling mitochondria with unusual and sparse cristae were characteristic for all patients. we did further notice marked accumulation of neutral lipids in all tested fibroblasts. conclusion: severe structural damage of mitochondria associated with milder functional changes represented a consistent feature found in all tested schnitzler syndrome patients. along with progress in basic and clinical immunology worldwide, the knowledge and activities in the field of primary immunodeficiencies (pids) have developed during last two decades. in , a group of junior doctors and students joined seniors in this filed to establish iranian primary immunodeficiency registry (ipidr). several national and international research projects have been done so far which led to lots of publications, while improving the diagnosis of patients with pids, construction of iranian primary immunodeficiency association (ipia), and establishment of research center for immunodeficiencies were other activities which lead to better management of the patients. organizing annual meeting on clinical immunology and immunodeficiencies, celebrating pi week annually and active participation in the international congresses were all helped in to increase knowledge of physicians in the country. the overall activities in the field of pids led to an increased trend in recognition of more patients in the recent years, which was associated with decreased delay in diagnosis. based on recent report of the registry, published recently in the j clin immunol, more than new patients with pid, in addition to previously reported patients, were presented. predominantly antibody deficiencies were the most common form of disease, followed by combined immunodeficiencies, congenital defects of phagocytes, and other well-defined syndromes with immunodeficiency. the rapid progress in identification and registration of the patients with pids is important not only as of epidemiological aspect, but also as of timely diagnosis and appropriate treatment of the patients. the j project physician education and clinical research collaboration program was launched in in eastern and central europe (ece). in less than years, it has achieved remarkable success. this project aims to increase knowledge in the field of primary immunodeficiency disorders (pid), and to improve the diagnosis and treatment of patients worldwide, particularly in countries with limited economic resources, which currently report fewer such patients than expected. in most ece countries, gene sequencing, which can provide a definitive diagnosis of pid, still remains unavailable. by contrast, such technology is used elsewhere to detect the more than pid-causing genes that have been discovered in the last three decades. thus, pid awareness programs like the j project remain critically important, to improve diagnostic facilities and treatment and to promote clinical research collaboration. this paper highlights the achievements of the j project and the spread of its concepts and spirit to the countries of western asia. primary immunodeficiencis (pid ) are rare genetically determined diseases , occurring with an incidence of per inhabitants. it is heterogeneous group of disorders, from quite commonly found and usually asymptomatic iga deficiency ( in ), to a very rare diseases such as chediak -higashi ( in inhabitants). in , within the framework of a government research project no. pbz-kbn- /p / -" development , improvement and implementation of highly specialized diagnostic procedures for immune-mediated diseases", a network of cooperating national centers for diagnosis and treatment of pid, named polish working group on primary immunodeficiencies (pgr pno) was founded. as a result of joint efforts of the group as well as an implementation of three eu grants [euro-pid -nas qlrt - - ( - , euro-policy -pid sp -ct- - , euro-gene -scan ( , )] the number of centers actively working in the diagnosis and treatment of primary immunodeficiencies increased. up todate pgr pno includes pediatric centers , and since - centers for adults. development and dissemination of new diagnostic and therapeutic standards contributed significantly to the increase in detection pid. with early diagnosis of the disease -the implementation of appropriate treatment, including gamma globulin replacement therapy together with quality of life has improved. in spite of all efforts recognition of pid in poland is very rare and currently is . to , what is almost times smaller than in europe (www.esid.org). at the moment, a nationwide registry of children and adults with pid consists of patients. in september pgr -pno summarized in the annual report the current status of the substitution therapy with intravenous and subcutaneous immunoglobulin therapy in children and adults with pid in poland. on the basis of available information, half of all patients ( children and adults) were diagnosed to have antibody deficiency. these data are similar to the register of a european database esid , where the percentage of patients with pid with a predominance of antibody deficiency is more than % (www.esid.org) development and dissemination of new diagnostic and therapeutic standards as well as a national cooperation contribute significantly to the increased detection of pid. early diagnosis of the disease is followed by earlier implementation of appropriate treatment, including gammaglobulin replacement therapy together with improvement of quality of life. mutations of was were identified in was boys and in heterozygote mothers. frequently genetic damages occur in , , , exones and , intrones: deletions ( ), splice-site mutation ( ), missens ( ), insertions ( ). deletions and insertions lead to stop-codon in cases. nbs patients were homozygous for del mutation and oneheterozygote for del had delt x-cgd: deletions ( ) and nonsens ( ) mutations in different exons of cybb were observed most often. in families was performed prenatal diagnosis: x-scid- , higm - , xla- , was- , nbs- , a-t- , cgd- , xlp- , dnalig - . healthy children - . recurrent severe complicated infections developed in % of pid patients. antibody deficiencies: bacterial infections - %, enteroviral - %, tuberculosis cases, atypical mycobacteriosis - case. combined pid: bacterial infections - %, fungal - %, viral - %, opportunistic (pneumocystis jiroveci) - %, mycobacterial - % ( -complication of bcg vaccination, -tuberculosis or atypical mycobacteriosis). cgd: bacterial - % (staph.aureus, e.coli, b.cepatia, salmonella spp., klebsiella spp.), mycobacterial - % ( % bcg origin, % -tuberculosis), aspergilosis - % immune disregulation syndromes (xlp [ ] and alps [ ]): bacterial infections - %, viral - % (ebv). autoimmune violations were observed in % of all pid cases: % of combined pid, % of antibody deficiencies, % of other well defined syndromes, % of autoimmune syndromes. cytopenias developed in %, vasculitisin %, ulcer colitisin %, arthritisin %. oncology diseases developed in % of patients: mainly in nbs, a-t, was and cvid: t-and b-leukemia's, lymphomas, solid cancer. the study of primary immunodeficiency is a unique model for studying the molecular basis of immunity. question about intravital pid verification is still relevant. a regional center of clinical immunology was established in at the regional children's clinical hospital № , yekaterinburg. the regional clinical hospital № joined the center in . institute of immunology and physiology, ural branch of the russian academy of sciences carries scientific management of the center. the centre works closely with foreign counterparts in the international project j project and it has been one of the centers of jmf since . over years we formed a regional register of patients with primary immunodeficiency, comprising patients: children and adults. analysis of the regional register allows to investigate the causes of deaths in patients with pid. infectious syndrome mortality -sepsis, generalized mycobacterial infection - patients, proliferative process - patients, dominate the mortality structure. creation of specialized immunological centers permit to raise the educational level of the medical staff, precisely identify nosological forms of pid among different groups of patients, to prevent the birth of children with pid, increase the length and quality of life such patients and take part in the collaboration with international experience in the pid. introduction: the aim of this retrospective study is to determine the frequency, and demographic, clinical and laboratory features of adult cvid patients referred to our clinic. materials and methods: we retrospectively evaluated adult patients ( female (% , ), male (% , ); aged to years: median years) who were diagnosed as cvid according to esid and pagid criteria during a year period (january -march ). results: the median current age of patients was , and the median cvid diagnosis age was , years. the diagnostic delay in patients with cvid was , years (median). cvid patients presented lower levels of igm ( patients, , %), iga ( patients, , %) and igg ( patients, , %). according to lymphocyte lmunophenotypes of cvid patients, cd ( patients, , %), cd ( patients, %) and cd /cd ( patients, %) values were observed the most lower ones. discussion: we found that both of the patients with bronchiectasis showed lower levels of immünoglobulins and lower imunophenotypes of b cell than the others that do not have bronchiectasis. in our patients cd , cd and cd /cd values have got enough priority to be mentioned about an immun deficiency. in conclusion, despite recent improvements in diagnostic tools, the diagnosis of mild or moderate cvid is often delayed. however, it seems that the diagnosis of cvid is delayed especially in adulthood on account of the fact that the lack of awareness of these illnesses among the medical professionals all over the world. primary immunodeficiency disease is important in turkey because of the high rate of consanguineous marriage. the lack of awereness about immunodeficiency can cause late-diagnosis and severe complications. the objective of this study was to assess pid awereness before and after clinical immunogy education among medical students. one hundred and thirty-two questionnaires with items ( ) were distributed to seventh somestre medical students and ( %) completed questionnaires were evaluated before (first) and after (second) their education about clinical immunology courses for hours. questionnaire scores (qs) were detected as total correct answers. the mean of the first qs was . ± . and second qs was ± . (p < . ). there was no statistically difference in gender ( m and f). of questions, there were related with pid directly. the correct responses rate less than % before education were of questions. all participants corrected their responses after education. the best improvement was detected in the responses of the clinical signs related with pid. it was remarkable that the participants have known the family history related with pid excellent before education. the majority of the participants ( %) believed that a lymphocyte count of /mm was related to immunodeficiency. nbt and ch test were not found to be related with pid before education. it is also important to increase the awareness of pid among the physicians during their education in medical school and more comprehensive education in pid appears to be useful for medical students. chronic granulomatous disease (cgd) is a rare primary immunodeficiency with mutations in nadph oxidase enzyme complex which causes failure of phagocytic cells to produce superoxide and subsequent intracellular killing of microorganisms. we retrospectively analysed medical records of patients diagnosed with cgd in the last years from immunological diagnostic centres from central and eastern european countries (estonia, poland, belarus, ukraine, czech republic, slovakia, hungary, serbia and slovenia) and russia. genetic sequencing from patients' dna was performed in genetic centres in ljubljana, belarus and netherlands for mutations in known genes involved in cgd pathogenesis: cybb, cyba, ncf , ncf . we included patients with cgd in our cohort, were female. the mean age at presentation of the disease was months and at diagnosis , years. lymphadenitis ( %), dermatitis ( %), enteritis ( %), pulmonary infections ( %), liver abscesses ( %) and septicaemia ( %) were the most common clinical presentation. complications of bcg vaccination ( %) were the most common presenting infection. in total , years of followup in our cohort, the patients suffered different severe infectious episodes ( . per year). respiratory ( %), lymph node ( %) and gastrointestinal tract ( %) infections represented the most prevalent severe infections. we identified different mutations out of genes tested. in patients we identified different mutations in cybb gene, unrelated patients had the same mutation in cyba gene and in patients had typical deletion in ncf gene. in our cohort we observed high incidence of bcg infections as a presenting symptom. apart from high bcg infections patients included in our study had similar frequencies of infections and infecting microorganisms as patients described in previous series. objectives: the aim of this study is to determine the carrier rate in healthy controls from central european and balkan region. methods: we screened more than healthy subjects from countries in the region. exon and was pcr amplified and subsequently sequenced with abi prism genetic analyzer. results: heterozygous mutations were found in % of apparently healthy hungarians, % of slovenians, % of bosnians, % of serbians and in % of apparently healthy macedonians. mutations found in hungarian population were as follows: v a ( ), k r ( ). mutations found in slovenian population were: v a ( ), k r ( ) and e q ( ). mutations found in bosnian population were: v a ( ), k r ( ) and f c ( ). mutations found in serbian population were: e q ( ), k r ( ). mutations found in macedonian population were as follows: e q ( ), k r ( ) and m v ( ). conclusion: we found higher than expected carrier rate in screened populations, from % to %. it is interesting to note that more than half ( %) of detected carriers in all analyzed populations has k r mutation. progress in the field of primary immunodeficiencies (pids) is reflected in national pid registries. data from slovenian pid registry were analyzed. patients' data were collected retrospectively before and prospectively afterward. patients were classified according to international classification and updated regularly. data of patients with different pids were analyzed. interestingly, complement deficiencies are the most common, accounting for % of all entries. second most common are antibody deficiencies with %, followed by well-defined syndromes ( %), immune dysregulation ( %), neutrophil defects ( %), combined deficiencies ( %), autoinflammatory disorders ( %) and defects of innate immunity ( %). prevalence of diagnosed pids in slovenia has changed in the last years; less complement deficiencies and more antibody deficiencies were diagnosed in comparison to previous decades. the number of new pid cases has been gradually increasing, a more prominent increase has been noted in the last years. the prevalence increased most for combined immunodeficiencies, cvid and autoinflammatory disorders. the spectrum of pid entities has also widened in the last decade. three patients with scid were diagnosed and successfully treated in the last three years (incidence - : . births). high prevalence of complement deficiencies reflects early implementation of good complement diagnostic facilities and awareness among infectologists. this group of patients was prospectively collected from . combined immunodeficiencies, cvid and autoinflammatory syndromes were all probably underdiagnosed before due to lack of awareness among physicians. distribution of pid groups is more consistent with esid registry in the last five years. identification and successful treatment of scid patients in the last years is an important quality marker. bulgarian association for clinical immunology was set up in aiming to get together all specialists working in the field of clinical immunology. one of the important objectives of the association was to raise the public awareness and attract attention of specialists, national health system, government and other related societies in order to improve the diagnosis and access to treatment for children and adults with pid. efforts of immunologists led to the following results: . consensus on the diagnosis and treatment of the basic pid groups was created by the pid national working group that was established in , and specific guidelines were disseminated as well. register for pid patients has been set up in bulgaria that allowed the collection of data on the incidence and prevalence of pid and the negative effect of these conditions on the population. . educational program to improve the qualification of the physicians and provide available resources to general practitioners and raise the public awareness were introduced. collaboration with patient's organizations was developed. . treatment of pid patients has been fully covered by the public health system since march . all these steps made it possible to advance the diagnosis and management of pid in our country. pediatric pid patients care -single center experience g. petrova; p. perenovska; s. mihailova; e. naumova umhat "alexandrovska", sofia, bulgaria j-project in bulgaria started in and up to now we have elaborated programme with diagnostic criteria, well equipped laboratory, established some mutual connections with foreign colleagues, held regional meetings, conferences; created clinical standards for treatment and ensured an immunoglobulin treatment and replacement therapy. here are examples of some of the problems we face: . seven-years old boy with hypogamaglobulinaemia (normal number b-ly with abnormal function). ivig had some initial effect, but lately we noted very fast deceleration in the overall health status with possible need of lung transplantation. the case is posing a question what more could we do, could we have prevented this rapid worsening. . ten-month old girl with scid with severe bcg infection after first vaccination, referred relatively late to our center, but successfully transplanted. the case is posing a question about timing of bcg vaccination and of referral to specialized center. . nine-years old girl with unidentified immune deficiency, normal immunological follow up but clinical course as an immune deficiency with very favorable effect of ivig according the parents. the case is posing the question should we stop or should we continue ivig, despite failing to find immunological defect, based on the good clinical response. unfortunately pids are not very well recognized and sometimes the patients are referred late. sometimes poverty and lack of knowledge of patients leads to miscalculation and neglecting of their conditions by themselves, or refusal for specific tests for clarifying the diagnosis. background: although rare, primary immune deficiencies (pid) are manifested with high rate infections as well as with autoimmune and malignant disorders that are treated hardly and inefficiently. pid are not only immunological problem; they require close collaboration between immunologists, pediatricians, ent, lung and gut specialists, dermatologists, hematologists, oncologists, patients and administration. the aim of this study was to summarize the activity on registration and replacement therapy of pid patients in plovdiv region at the university hospital "st. george"-plovdiv for year ( . - . ). methodology: children with pid of humoral immunity hospitalized at the clinic of pediatrics, and adults with hereditary angioedema (hae) were included in the study using immunological and other lab tests, clinical follow up and treatment: iv and sc ig for children with pid and c esterase inhibitor (ruconest, berinert) for hae patients. results: three national workshops and a national conference on pid were hosted and organized in plovdiv since . well established university hospital immunological laboratory, detecting serum immunogloblins, blood lymphocyte populations and subpopulations and complement proteins; clinic of pediatric and genetic diseases and an information center for rare diseases and orphan drugs function in plovdiv. an expert center for diagnosis and treatment of pid was created at the university hospital. it is a team of two competent pediatricians, an immunologist and an allergist. the targets are hospitalized pid children, outpatient pid children and hae adults. the center introduced regular replacement therapy with iv and sc iv and c inhibitor, reimbursed by the national insurance. together with icrdod the experts provide education for patients and parents how to perform sc ig application as well as consultations of patients and relatives about pid.since march indicated reimbursed replacement therapy with iv ig -octagam, started regularly in hospitalized pid children with bruton hypogammaglobulinemia, cvid, omenn syndrome or igg id. these patients, aged form to years, had to hospitalizations for one year. four outpatient children with omenn syndrome or igg subclass deficiency were subjected to sc ig -gammanorm, and hae type outpatients had good response for replacement c inhibitor therapy as follows: conestat alfa (ruconest)in hae adults ( iu/ml weekly), and berinert ( u/kg b.w. weekley)in hae adult patients. conclusions: the expert pid center in plovdiv university hospital provides competent diagnosis, therapy, education and consultations for pediatric and adult pid patients from plovdiv region. the recent introduction of reimbursed replacement therapy for pid patients (hospitalized or outpatients) allows regular immunological and clinical follow up of the diseases. background: intravenous immunoglobulins (ivigs) are scarce biological products used in a broad variety of disorders. tolerance to infusions is usually good but adverse events, including some serious ones, have been reported. methodology: a cohort study aimed for detection of adverse events that occur during and following intravenous immunoglobulin (ivig) infusions at cairo university children hospitals [patients were recruited at neonatal intensive care units (nicu), pediatric intensive care units (picu), general and specialized inpatient wards ] over a time period of six months, from april through september, . the study included transfusions for different disease conditions in patients.three maltose-stabilized intravenous immunoglobulin products were administered to patients. assessments were done before, during and after the infusions. results: there were symptoms and laboratory changes of adverse events during ivig transfusions, with some patients experiencing more than one adverse reaction. adverse events were noted to occur most frequently within to h from onset of ivig infusion (n = , . %). first hour after infusion onset was the most common timing for symptoms of adverse reactions (n = , . %). patient characteristics of those with adverse reactions: adverse reactions occurred in . % of the infusions (n = ) with the majority belonging to the - years old age group (n = , . %), with variable diagnostic categories. ten patients observed during infusions ( . %) had one or more risk factors for complications, while patients observed during infusions ( . %) had no risk factors. the commonest risk factor was administration of nephrotoxic drugs (n = , . %), followed by presence of a suspected autoimmune disorder (n = , . %) and preexisting renal insufficiency (n = , . %). using regression analysis, the predicting variables for each complication were noted .for example ,fever and chills were related to infusion rate and dose whereas the predicting variables for pallor were infusion rate and presence of existing risk factors. conclusions: clinicians should be aware of the high need for special monitoring while infusing ivig to patients with primary immunodeficiency disorders, autoimmune hematological disorders and sepsis. certain diagnosis of a primary immunodeficiency disorders (pid) is most confirmedly performed by investigation of a gene defect, allowing genetic counseling and screening. molecular diagnosis helps both parents and index pid patient by carrier detection and pre-implantation testing for selecting appropriate reproductive decisions. furthermore, for confirmation of diagnosis and establishment of the inheritance pattern genetic analysis is necessary. this survey in all pid cohorts should be considered for long-term planning such as bone marrow transplantation of a pid infant at birth. the result of this testing also is important for screening of newborns and for those in specific family or ethnic groups. the prevalence of pids has been estimated to be more than / worldwide. based on the total population of iran reported in ( , , ), the expected prevalence of pids in iran would be more than , individuals. however, because of the high rate of consanguineous marriages in iran and an increased risk for development of disorders with an autosomal recessive pattern of inheritance, this prediction is likely to be an underestimation. to date, clinically diagnosed patients of pids have been reported in iran, and a definite diagnosis, defined by mutation analysis, was made in individuals. as a result, . % of the expected pid patients have been identified, and among these, . % have been diagnosed at a molecular level. the proportion of genetically definite diagnosis varied between . and % in the different disease categories. this wide spectrum might be due to unknown underlying genetic defects or modifying genes, especially in patients with predominantly antibody deficiency. on the other hand, the latter patients also had the lowest percentage of clinically diagnosed cases. croatia is a small country with inhabitants . according to expected prevalence of pids we expected approximately four hundred patients with pid. for the past few years university hospital center zagreb is the reporting center for esid registry. it is also the national center for diagnosis and treatment of pids, including haematopoietic stem cell transplantation. current pid database is running manually, with the exception of patients reported to esid registry. most of them are of pediatric age, reffered to the hospital from all over the country. the pids patients are classified according to international classification ( iuis-international union of immunological societies ). there are pids patients included in the database at the moment. the majority of them have antibody deficiency. combined immunodeficiency and well defined syndromes appear in equal distribution. other types of pids are reported in small numbers. although no consanguinity was reported, we noticed the geografic distribution of severe combined immunodeficiency patients (scid) mostly in regions, istra and podravina. it can be explained with genetic isolation. the establishment of national online pid registry is in process. the aim is to improve the diagnosis od pid specially in adult patients, who are not included in present database, with exception of the patients diagnosed in childhood. primary immunodeficiency disorders are underdiagnosed in croatia, specially in adults. establishing national pid registry will improve the physicians awareness of pids, which is particularly important for adult patients. we expected the number of diagnosed pid patients will rise. this will give the opportunity to make progress in diagnosis and treatment, and the opportunity for further epidemiological and clinical studies. another patients have well defined immunodeficiency syndromes from which: are with di george anomaly; with wiskott-aldrich syndrome; with ataxia-teleangiectasia; with hyper ige syndrome; with schimke syndrome and are with nijmegen breakage syndrome. in early nineties, two ( ) of our patients had chronic mucocutaneus candidiasis. patients are registered as x-linked scid and with xlinked lymphoproliferative syndrome (xlp). patient has chronic granulomatous disease; have severe congenital neutropenia and have hereditary angioedema. patients are with whim syndrome. patients are with anti-inflammatory disorders: has hyper ig d syndrome (hids) and have familial mediterranean fever. the j-project realization in the republic of kazakhstan allows to update the pid problem, to raise the availability of early diagnosis of pid, to improve the life quality of patients with pid by providing substitution therapy and as a result, the infant mortality and disability rate has been reduced. common variable immunodeficiency (cvid) is the most common primary immunodeficiency (pid) characterised by impaired immunglobulin production and immune dysregulation. chronic and recurrent infections and its results are typical manifestation of this disease. in addition there is a higher risk of autoimmune disorders, lymphoproliferative or granulomatous diseases and malignancies. successful management of cvid patients is based on prevention and consistent therapy of infections with sufficient immunoglobulin replacement and/or antibiotics, prevention and active screening of cvid related complications. in our study we analysed data of patients gained from medical records. these data were also input into czech pid registry and pid registry organized by esid (european organisation for immunodeficiency). we aimed at the period before diagnosis-onset of the symptoms and their characters and the course of the disease-effect of therapy, occurence of the related complications. finally, we compared our data with similar performed studies. chronic and recurrent upper and lower respiratory infections were the most frequent first manifestation of our cvid patients, but developed chronic lung disease or autoimmune disorder as well. in all patients the intravenous or subcutaneous imunoglobulin replacement therapy, eventually combined therapy with antibiotic prophylaxis, was initiated. beside chronic lung disease the most common complications were autoimmunity disorders, especially autoimmune thyroiditis, evans syndrome, trombocytopenia (itp), autoimmune hemolytic anemia (aiha). on the contrary we revealed patients with insuline dependent (type ) diabetes mellitus and cvid. only few case reports have been published with such association. successful management of cvid patients is based on a prevention and a consistent treatment of infections with sufficient immunoglobulin replcement and/or antibiotic therapy, a prevention and an active screening of cvid related complications. such approach can significantly improve the prognosis of cvid patients and the quality of their life. laura zilinskaite ; ieva bajoriuniene , ; raimundas sakalauskas ; brigita sitkauskiene , department of pulmonology and immunology, lithuanian university of health sciences, kaunas, lithuania. background. primary immunodeficiency (pid) is considered to be a rare disease. despite that it is thought that six million people may be living with a pid worldwide. in the hospital of lithuanian university of health sciences (hluhs) patients with suspected immune disorders have been diagnosed and treated since . we aimed to review the structure of pid diagnosed and treated in hluhs during the last five years. methods. data about patients with pid consulted in the hluhs was collected from the department of medical statistics. case histories of these patients were revised and patients' data was collected: onset of symptoms, type and duration of disorder, type of treatment. all patients with pid were divided into several groups according to the classification of international union of immunological societies primary immunodeficiency diseases classification committee ( ). results. there were patients with pid diagnosed in the centre. antibody deficiency was diagnosed for patients: -bruton's disease, common variable immunodeficiency (cvid) and selective immunoglobulin (ig) a deficiency. complement deficiencies were diagnosed for patients: -c esterase inhibitor deficiency and -c deficiency. another well-defined syndrome with immunodeficiency was found in six patients. the most prevalent symptom in patients with predominant igg deficiency was recurrent pneumonias which occurred at the age . ± . yrs. the mean time between the onset of symptoms and confirmation of the diagnosis was . ± . yrs. thirteen patients are on the replacement therapy with intravenous immunoglobulin. these patients had - infections/year before the treatment initiation and only - infections/year during the treatment. •pid center has successful sideproject as regional charitable public organization of invalids "society of patients with primary immunodeficiency diseases in st. petersburg" solovushka (nightingale) "". web site for patients (www.opidspb.ru) was opened due to mutual efforts of pid center staff and patients. pid center laboratory is based on spb pasteur institute central clinical diagnostics laboratory and laboratory of molecular immunology and seroepidemiology. main groups of tests perform for pid patients are: general clinical assays; flow cytometry ( -color assay on facs canto ii); humoral factors assays (ig levels, igg subclasses, post-vaccination igg levels, etc.); burst-test on flow cytometer; genetic analysis of btk, rag , rag ,was, cybb genes. despite of relatively short story of spb pid center it has a variety of completely diagnosted and successfully cured cases of pid including agammaglobulinemia with b-cell in identical siblings, wiskott-aldrich syndrome, chronic granulomatous disease (cgd), etc. introduction: the primary immunodeficiency diseases are a group of disorders caused by basic defects in immune function that are intrinsic to, or inherent in, the cells and proteins of the immune system. there are more than primary immunodeficiency diseases.. laboratory studies are necessary to determine the presence of a primary immunodeficiency diseases. the standard screening tests for antibody deficiency starts with measurement of immunoglobulin levels in the blood serum. these consist of igg, iga and igm levels. the results must be compared to agematched controls. additional studies used to evaluate patients with antibody deficiencies include measuring the different types of lymphocytes in the blood by marking those cells with molecules that can identify the different types. a commonly used test is called flow cytometry that can identify b-cells and t cells present in the circulation. methods: in in our laboratory of immunology is created the sector of examination for the pid and we measure the immunoglobulin levels with a beckman coulter immage immunochemistry system fully automated rate turbidometry and rate nephelometry method. we have determine the aged-matched levels of immunoglobulins in our laboratory. we have install also a new flow cytometer of beckman coulter company and we can determine the b cells by cd marker and t cell with cd , cd and cd marker. this examinations has been of great help in diagnosis of primary immunodeficiencies. results: in years - from the examination of children aged from - years old reported in our laboratory for immunological examination from the pediatric department of uhc mother teresa in tirana we have selected cases with disorders regarding the primary immune deficiencies. we have cases ( cases reported in - and new cases ) with nul b cell in cytoflorometry (b cd cell = %). the level of immunoglobulins was indetectable for igg , iga and igm in the moment of diagnosis. they were boys and the age at diagnosis was and years and actually they are and years treated with ivig. we have classified them as bruton (xla). we have case with low cd b-cell in circulation but only in of them we have done the immunoglobulin level. the low level of cd b cell is accompanied with different kind of hypoglobulinemies: common variable immunodeficiency cvid, with isolated iga deficiency, with igg deficiency and with both igg + igm deficiency. the immunoglobulins disorders : we have classified them according the antibody deficiencies (tab ) and we noted that the most frequent one is the deficiency of iga ( / or . % -from which iga isolated, accompanied with low igm and with low igg ) with average age at diagnosis . years old. in children in the first years of live aged from . to years old we found case with transient hypogammaglobulinemia of infancy. according this survey we can report our cases of primary immunodefiecies in uhc mother teresa of tirana with different classification conclusion: the finding are to be completed with other cases in albania and it is necessary to do the national register for pid in order to estimate exactly the prevalence of this disorders in our country. nyíregyháza-debrecen, hungary the stat mutation was confirmed in as the cause of autosomal dominant hyper-ige syndrome (ad-hies). the disease, which also mentioned in the literature as job's syndrome, is a rare primary immunodeficiency. this disease can be characterized by the following classic triad: recurrent purulent skin infections, cold abscessus which are formed in the ground of chronic ekcematoid dermatitis, pneumatocele, formation causing pneumonia and extremely high ige level. dental training interdependency as well as bone and connective tissue disorders frequently occur in the nonimmunological symptoms as multi-systemic disease. the stat protein has an important role in the area of wound healing, immunity, tumor and neovascularization. we would like to show this in case of -years old kitti whom the perinatal medical history was eventless. there is a frequent hospitalization in kitti's case history since her infancy. due to the age of three months because of serious exsiccotoxicosis, months old bilateral bronchopneumonia and pleurisy required icu care. bronchoscopy was made because of recurrent pneumonia, which excluded the bronchial malformation. lately rather otitis, mastoiditis and airway obstructive symptoms dominated the clinical picture. from serum immunoglobulins-igg is very low, whereas high levels of igewas indicated. on this basis, the diagnosis of job's syndrome was up, which is a negative stat mutations as the molecular genetic test performed demonstrated. the disease has a great clinical importance, since the risk of emergence of serious and often life-threatining complications are high. because of the prevention of disseminated infections, the early detection and the appropriate treatment are essential. in default of causal therapy, the treatment primarily concern to prevention of infections, or their aggressive antibiotic therapy. calcium and vitamin d and as well as histamine on the case of itchy skin symptoms are reccurrended to use. laboratory of molecular immunogenetics, human genetics institute, cnrs and university montpellier , montpellier, france. we performed clinical, immunological and genetic studies of hyper-ige syndrome (hies) patients from hungarian, lebanese, one russian, one polish, and one swedish families with autosomal dominant (ad) or sporadic forms of the disease to reveal cross-ethnicity of recurrent and novel mutations in the signal transducer and activator of transcription- gene (stat ). four patients from hungarian families, and one russian, and one swedish patient carried the heterozygous r w germline mutation at the dna-binding site of stat . the recurrent v m mutation affecting the src homology (sh ) domain was detected in one lebanese and one polish family, and the v del deletion located in the dna-binding domain was unveiled in another lebanese family. a novel h y mutation affecting the dna-binding site of stat in three hungarian patients from a gypsy family was also found. the segregation of this mutation with hies, restriction fragment length polymorphism analysis of stat from patients and controls and the negligible production upon il- stimulation of monocyte chemotactic protein- by the patient's blood mononuclear cells suggested that the h y mutation was disease-causing. these data suggest, that dominant negative mutations of the dna-binding and sh domains of stat cause ad and sporadic cases of hies in different ethnic groups with r w as the predominant mutation found in of the families. functional and genetic data support that the novel h y mutation may result in the loss of function of stat and leads to the hies phenotype. published in molecular immunology. : - . males with an expressed mutation in the sap (signaling lymphocyte activating molecule [slam]-associed protein) gene have an x-linked syndrome characterized by an increased vulnerability to infection with epstein-barr virus (ebv). we evaluated two related male patients with fatal infectious mononucleosis (fim) and mutation in the sap gene. sequence analysis revealed hemizygous g to a transition at nucleotide position in exon in one of the patients, and heterozygosity for this mutation in the genomic dna from his mother and maternal grandmother. this mutation resulted in asparagine instead of glycine in the sequence of the sap protein at amino acid position . to analyse the effect of this missense mutation on protein function cdna was generated by site-directed mutagenesis and cloned in pcmv-flag vector. we found that the mutant sap (sap/g d) protein was defective in protein folding as manifested by the reduced half-life compared to that of wild type sap. furthermore, the sap/g d protein was defective in binding to its philological ligands slam and b . these results suggest that defects in protein folding and ligand binding collectively contribute to the loss of function of the sap protein in patients carrying g d mutation. dedicator of cytokinesis (dock ) deficiency is an innate error of adaptive immunity characterized by recurrent viral, bacterial and fungal infections, very high serum ige concentration and a progressive deterioration of t-and b cell-mediated immunity. traditional sanger sequencing may fail to identify mutations in dock , due to overlapping large deletions in heterozygous patients. we studied the genetic and immunological features of two sisters ( and years of age) born to healthy hungarian parents. mutational analysis of genomic dna and cdna from the patients and parents by a combination of pcr and bidirectional targeted sequencing failed to identify the mutation. however, a multiple ligation-dependent probe amplification (mlpa) assay revealed two previously unknown large deletions, del - exons and del - exons, of dock in both patients. the children's mother was heterozygous for the del - exons mutation, whereas the father carried the del - exons deletion. immunoblot analysis showed an absence of dock protein from the peripheral blood lymphocytes of both patients. these data suggest that the new compound heterozygous del - exons and del - exons mutations result in a loss of dock protein function and a typical dock deficiency phenotype. our findings suggest that traditional sequencing technology may give misleading results in such cases and that mlpa may be indispensible for the definition of the large deletions frequently observed in patients with dock deficiency. we describe here a patient with invasive cryptococcus laurentii infection and the x-linked form of hyper-igm syndrome (x-higm). c.laurentii is an extremely rare human pathogen. this fungus was previously considered saprophytic and non-pathogenic to humans, but it has been isolated as the etiologic agent of skin infection, keratitis, endophthalmitis, lung abscess, peritonitis, meningitis, and fungemia. most affected individuals had a compromised immune system because of leukemia, cancer, diabetes mellitus, aids, or prematurity. repeated isolation of c.laurentii from the oropharynx of an immunocompromised patient has also been docu- the wiskott-aldrich syndrome (was) is an x-linked recessive immune deficiency disorder characterized by thrombocytopenia, small platelet size, eczema, recurrent infections, and increased risk of autoimmune disorders and malignancies. was is caused by mutations in the wasp gene which encodes wasp, a -amino acid protein. wasp plays a critical role in actin cytoskeleton organization and signalling, and functions of immune cells. we present here the results of genetic analysis of patients with was from eleven eastern and central european (ece) countries and turkey. clinical and haematological information of affected males and carrier females from was families were collected. the wasp gene was sequenced from genomic dna of patients with was, as well as their family members to identify carriers. in this large cohort, we identified unique mutations including novel sequence variants. the mutations were scattered throughout the wasp gene and included single base pair changes ( missense and nonsense mutations), small insertions, deletions, and splice site defects. genetic counselling and prenatal diagnosis were applied in four affected families. introduction: mhc-class ii deficiency is an autosomal recessively inherited combined immunodeficiency disorder characterized by less than % expression of hla-dr on b cells or monocytes. it is caused by mutation of genes (ciita, rfxank, rfx , rfxap) regulating transcription factors which controls expression of mhc-class-ii molecules on cell surface. mhc-class ii molecules are expressed on thymic epithelial cells, antigen presenting cells (b lymphocytes, dendritic cells, monocytes and macrophages) and activated t cells. these molecules are of critical importance to immunity, cd + t cell development, antibody production, tolerance induction and inlammatory response. consequently, patients present with clinical findings related to combined immunodeficiency during infancy. material and methods: medical records of thirteen patients with mhc-class ii deficiency, followed-up in ankara university, medical school, division of pediatric immunology/allergy from to , were evaluated retrospectively. findings: during study period, male and female patients were diagnosed with mhc-class ii deficiency. age of diagnosis were between months and years of age. consanguinity were present in eleven out of thirteen patients. most frequent clinical findings during initial diagnosis were failure to thrive, pneumonia and oral moniliasis. lymphopenia was absent in all of the patients, however, low serum igg level was present in all of them. except for the yo female patient with a positive family history and whose hla-dr expression was , %, hla-dr expression was % in the rest of the patients. eight patients underwent hematopoietic stem cell transplantation (hsct). two patients were lost soon after hsct due to complications and three patients died of opportunistic infections. four patients died of severe opportunistic infections without underwent hsct. results: mhc-class ii deficiency is a combined immunodeficiency and not considered a rare disease in our country. to date, only known treatment is hsct. since it has poor prognosis, hsct should be performed before development of chronic viral infections and sequelae related to infections in patients who have hla-matched sibling. fatih celmeli ; giancarlo la marca ; ines santisteban ; michael s. hershfield purine nucleoside phosphorylase deficiency (pnp deficiency) is a rare autosomal recessively inherited type of immunodeficiency. pnp deficiency constitutes about to percent of all combined immunodeficiencies. it is characterized by progressive combined immunodeficiency and neurologic findings which includes ataxia, developmental delay, and spasticity. the immunodeficiency is progressive, with normal immune functions at birth, but severe t cell deficiency with variable b cell functions presented by the age of years . the only curative treatment is the hematopoietic stem cell transplantation (hsct). here, we present a year-old girl with recurrent respiratory tract infections, short stature and spastic paraplegia. immunological, biochemically and genetics investigation revealed pnp deficiency with a t mutation in pnp gene. case report: a years-old girl was referred to our pediatric immunology clinic for recurrent sinopulmonary infections since year of age. she was full term neonate and her parents were not consanguineous. she had a history of prolonged and resistant bronchopneumonia, and an attack of generalized chickenpox complicated with pneumonia. she had also severe zona infection resolved with ulceration in cornea, one year ago. she has been suffering from frequent infections like chronic sinusitis, oral moniliasis, recurrent pneumonia and sclerosing cholangitis. she has also nonprogressive cerebral palsy, spastic paraplegia, behavioral problems and limited motor and mental retardation. there was no family history of recurrent infections or immunological disorders. on her physical examination, there was failure to thrive, (her weight and height < rd p) oral moniliasis, bilateral crepitus ralls, and splenomegaly. she has also marked spasticity with brisk reflexes in lower extremities. laboratory tests revealed lymphopenia: hemoglobin g/dl and platelets /mm wbc /mm , absolute lymphocyte /mm . the laboratory results are shown in the table. lymphocyte proliferation is lower than normal limits in response to pha stimulation (wst assay). ppd response and hiv was negative. antihbs, and antihav were negative despite vaccination. uric acid level , mg/dl. direct coombs was negative, thyroid autoantibodies were within normal limits. genetic analysis revealed homozygous missense mutation (c. g > a), which causes the a t amino acid substitution in pnp gene, in exon , which has previously been reported. additionally, a homozygous g/a polymorphic site in ivs has been detected (c. + g (ivs + g)). discussion: pnp deficiency is caused by mutations in the pnp gene at q . . this gene encodes the protein purine nucleoside phosphorylase, one of the enzymes involved in the purine salvage pathway. adenosine deaminase (ada) deaminates adenosine to yield inosine, which is then converted to hypoxanthine by pnp. pnp also converts guanosine to guanine. a number of metabolites are elevated in the plasma and urine in pnp deficiency, including deoxyguanosine and deoxyinosine. there is an intracellular accumulation of their deoxy triphosphate compounds, particularly deoxyguanosine triphosphate (dgtp). the latter is toxic to t cells, a property similar to deoxyadenosine triphosphate in adenosine deaminase deficiency. in this report, we demonstrate the clinical characteristic of the patient with late diagnosis of pnp deficiency. pnp mutations likely lead to an intense alteration of the enzyme activity which in turn, cause severe and early onset of the clinical findings. however, in our case, the clinical onset of the disease is quite late (after years) which can be explained by the residual activity of the pnp. in conclusion patients with pnp deficiency can be late onset. additionally, late diagnosis of this patient can cause severe comorbidity which limits the chance of bone marrow transplantation. di george syndrome, a disorder caused by a defect in chromosome ( q . deletion), results in the poor development of several body systems. clinical features include congenital heart defects, hypoparathyroidism and thymic hypoplasia or aplasia leading to t-cell immunodeficiency. the aim of our study is to screen and determine the incidence of di george syndrome within only one tube of blood in children with congenital heart anomalies in our population. children who were found to have a cardiac defect during routine visits in pediatric cardiology and neonatalogy departments were included into the study. cases with known genetic syndromes and newborns younger than gestational weeks of age and small for gestational age (birth weight < gr) were excluded. a total of patients were included. there were ( %) males and ( %) females. age ranged between - months ( . ± . months). parental consanguinity was % (n = ) in the study group. the majority of patients diagnosed after murmur was heard during the routine physical examination (n = , %). five patients ( %) diagnosed antenatally. remaining clinical signs on admission were as follows; respiratory distress (n = , %), tachycardia (n = , %) and central cyanosis (n = , %). echocardiagorafic examinations revealed ventricular septal defect (vsd) (n = ), tetralogy of fallot (tof) (n = ), vsd-asd (n = ), aortic coarctation (n = ), double outlet right venticle (dorv) (n = ), transposition of the great arteries (n = ), truncus arteriosus (n = ) and pulmonary atresia (n = ). pulmonary stenosis, endocardial cushion defects, total pulmonary venous return anomaly and hypoplastic left heart were the other defects. q . deletion was ascertained in ( . %) patients; these patients were diagnosed to have tof ( . %), truncus arteriosus ( . %), dorv ( . %), vsd ( . %) and vsd-asd ( . %). preliminary results of the study showed that the frequency of q . deletion is % in patients with known cardiac defects. single tube of blood is enough for flow cytometric and genetic analyses. further studies involving higher number of patients is mandatory to give sufficient information about the exact incidence of the disease. di george syndrome -where do we stand now? małgorzata pac; małgorzata skomska; ewa bernatowska department of immunology, the children's memorial health institute, warsaw, poland di george syndrome (dgs) classically comprises t-cell deficiency (due to thymic hypoplasia), hypoparathyroidism, cardiac malformations,and facial abnormalities. deletions of the long arm of chromosome at position q. are most commonly associated with dgs. syndrome is also found associated with other genetic abnormalities ( p deletions, char ge), certain teratogenic influences (retinoid acid, foetal alcoholic syndrome, maternal diabetes). the dgs phenotype is very heterogenous with variable expression of the different features including the immunodeficiency. the initial treatment emphasis is to control the hypoparathyroidism. correction of congenital heart defects (if present) is usually needed. the best treatment of the immune defects of dgs is still controversial. both hsct and transplant with fetal thymus are the option for complete dgs (cdgs). long term survival after hsct has been reported, though at a lower rate ( - %) compared to survival after hsct for scid. survival in the subgroup receiving matched sibling donor transplants was better at over %. the use of post natal human thymus was pioneered by markert at duke university and has become established as the treatment of choice for cdgs, with the result of out of treated patients survived ( %). more recently this approach has also been used in london, at gosh. . under care of cmhi there are patients fulfilling esid criteria, girls ( . %) and boys ( . %), age / - y.o. in % of them q deletion in locus d s was found. the vast majority children were diagnosed as partial dgs. none of them had significant hypogammaglobulinemia and no regular ivig therapy or antibiotic prophylaxis were required.. the mean number and percentage of cd , cd and cd lymphocytes as well as lymphoproliferative answer to pha and cd in dgs patients were slightly diminished. in many improvement of cellular immunity was observed with age. about % presented with congenital heart disease, requiring surgery, while almost % had the symptoms of hypocalcemia and hypoparathyroidism, next % -speech and learning difficulties. one child was diagnosed as cdgs. scid is a rare, inherited condition, is caused by numerous molecular defects that lead to severe compromise in the number and function of t cells, b cells, and occasionally natural killer cells. seventeen patents with scid were registered during the period from till in the children's clinical university hospital. medical charts of these patients have been reviewed. there were boys and girls. positive family history was in families. mean age at the onset of symptoms and scid diagnosis was . ± . and . ± . months, respectively. pneumonia ( %), candidacies ( %), bcg infection ( %), diarrhea ( %) were the most important infections. anemia and relative lymphopenia were in % cases , growth retardation, hypotrophy had % children . pathogens such as candida albicans ( ), mycobacterium tuberculosis complex ( ), cmv ( ) and others have been identified. totally patients died.two girls are alive ( and months post-transplant). autopsy was done in patients. we saw different changes in thymus and lymphatic nodes. artemis deficiency (n = ), t-b-scid (n = ), t-b + scid (n = ), γc deficiency (n = mutation r w in γ-chain of receptor for il- ), unspecified scid (n = ) were detected. conclusion: generalized bcg infection had % of our scid patients. (incidence of tb is still high . / population in latvia and newborns obligatory are vaccinated on the second to fifth day of life). due to possibility of absence for pid routine genetic identification in only few scid forms were identified precisely. children's hospital, university of freiburg, freiburg, germany. purpose: ipex (immunodysregulation, polyendocrinopathy, enteropathy, x-linked) is a rare x-linked recessive life-threatening disorder characterized by autoimmunity and early death. pulmonary complication related with ipex has not elucidated exactly. here, we report i.e. patients, of which died from severe pulmonary disease. methods: clinical data and laboratory findings included autoantibodies, immunoglobulin levels as well as number of t, b and nk cells were evaluated. foxp expression was performed by flow cytometry. genomic dna was isolated and all exons and exon-intron boundaries of the foxp gene were sequenced by sanger sequencing. results: patient i (pi) presented with nephrotic syndrome at years of age and then developed autoimmune hepatitis without eczema, enteropathy or high ige and died at years of age due to acute respiratory distress syndrome (ards). two cousins of pi had the same hypomorphic splice site mutation leading to normal foxp protein expression and suppressive capacity. however, they exhibited typical symptoms such as eczema, diabetes and enteropathy with eosinophilia at early age (pii, piii) and were transplanted in infancy. one of them had severe respiratory distress right after birth (piii). patient iv from another family presented with chronic diarrhea without autoimmune manifestations and died due to ards. conclusion: lung disease related to ipex syndrome has not been reported before and this entity could be a critical factor in disease outcome. severe combined immunodeficiencies (scids) are a group of primary immunodeficiencies that comprise a number of monogenic disorders characterized by a block in t cell differentiation with or without impairment of b cell and natural killer (nk) cells. without early diagnosis and treatment most children die in the first year of life. a lack or very low number of t-cell receptor excision circle (trec) detected by realtime quantitative polymerase chain reaction assay (qpcr) is consistent with t-cell lymphopenia and has repeatedly demonstrated clinical validity in population based newborn screening for scid. however, the impact of population screening will be less in communities with high consanguinity and family history of scid, in which targeted screening may be more appropriate. here, we screened high risk neonates and infants (with one or more of the following: clinical presentation and/or family history suggestive of pid, failure to thrive otherwise unexplained, lymphopenia) at cairo university hospitals. their full history and clinical examination were recorded. immunoglobulin profile and immunophenotyping of peripheral lymphocytes were performed as confirmatory tests. sixteen classical scid cases were detected, as well as another scid variants (omenn syndrome and major histocompatibility complex class ii deficiency) (totally . % of all subjects screened). the rate of consanguinity in this group was . %. secondary causes of low trecs, other than scid, in our series included: bacterial septicemia ( preterm, full-term), prematurity ( cases), one preterm with omphalocele and facial dysmorphism, one preterm with congenital adrenal hyperplasia, one full term with microvillus inclusion disease, and one full term with idiopathic tcell lymphopenia. this demonstrates that in populations with high consanguinity rates, as in egypt, targeted (non-population based) trecs assay may provide a more efficient screening strategy. case : a is a years old female, st kid of non consanguineous marriage presented with fever for months. one week after the onset of the fever red patches appeared on the face, hands, abdomen, ll. mother sought medical advice and received antibiotics, antipyretics and oral steroids for about one month with no signs of improvements regarding fever. one week later the mother noticed pallor and sought medical advice and the baby was admitted to local hospital and received one bag of blood. and then she was referred to our hospital (zagazig university hospital) where she developed acute pallor again which needed recurrent blood transfusions. dark colored urine occurred in frequent attacks with abdominal enlargement and pain, and interestingly upto this time, no improvement regarding fever, bone pain or pallor. on examination she was underbuilt (all parameters are under rd centile), pallor, tinge of jaundice, generalized skin pigmentation, generalized lymphadenopathy, nd degree clubbing and hsm investigations: cbc (pancytopenia with reticulocytopenia) -lft (increased ast with indirect hyperbilirubinemia)-kft (normal)-ldh (highly elevated u/l)-esr ( ) -fibrinogen ( . gm/ l)serum triglycerides ( . mg/dl)-ebv-vcm igm positive and igg negative -c ( . normal) -rf and ana(-ve) -serum ferritin ( ng/ml) -cd is low -bone marrow biobsy revealed dysplastic changes -l.n. biopsy revealed non specific inflammatory changes. treatment: hlh protocol with no sct prognosis: patient passed initial phase with complete resolution and waiting for bmt case : m is months old boy, nd kid of non consanguineous marriage (the st is healthy years old female) presented with fever and difficult breathing since the age of months. the fever was of gradual onset stationary course and not responding to treatment with antipyretics and antibiotics. one week later the mother noticed abdominal enlargement with red rash over the abdomen that was associated with pallor but there was no evidence of bleeding from any site, no change in the color of urine, no jaundice, no ecchymosis, no joint swelling then he is referred to our hospital (zagazig university hospital). this boy is delivered by nvd at term with no evidence of any problem either during pregnancy or delivery, he is exclusively breast fed and vaccinated as scheduled. examination: his weight was kg, length cm, and head circumference cm all are average for age, he was pale with no jaundice or cyanosis he had hsm and other systemic examination was quite well. children with pid usually are admitting to the hospitals and intensive care units of infants' pathology regional children clinical hospital № , but at a later date, in serious condition, after the development of clinical manifestations in the form of severe generalized infectious disease, or various complications including hematological. the screening technology approves children to be diagnosed in newborn period and to be observing by immunologist and hematologist for the next preventative therapy and bone marrow transplantation or hematopoietic stem cell transplantation. costs for the differential diagnosis and verification of the diagnosis before the manifestation and complications development of pid - usd. costs for the differential diagnosis and verification of diagnosis after manifestation and complications development of pid would be usd in months. economic loss prevention in pid - usd. economic loss prevention in t -lymphopenia - usd. we also should include into account the contribution to the state's economy, which will later be obtained, due to the presence of a healthy member of society. at is an autosomal recessive multisystem disorder characterized by progressive cerebellar ataxia, telangiectasia and increased susceptibility to infections and malignancies, particularly lymphomas and leukemia. laboratory immune investigations typically show decreased peripheral tcells, particularly of naïve t cells, with abnormal in vitro response to mitogens. most at patients have decreased serum iga and igg subclass concentrations. while about % of patients with at show raised serum igm concentrations during the course of the disease, it is unusual to find a high level of igm at onset. as cerebellar ataxia and oculocutaneous telangiectasia are not present at very young age, these patients are often erroneously diagnosed as hyper igm syndrome (higm). to prevent mistaking a-t patients for higm it is proposed to add dna repair disorders as a possible cause of higm. . diagnosis of at, suggested by elevated alfa-feto-protein and increased sensitivity of patients' cells to irradiation, can be confirmed by identifying a mutation in the atm gene.we report female case of at that with diagnosis of hyper igm received ivig but later they had manifestation of ataxia in the course of their disease and then had telangiectasia of conjunctiva. first case was a yrs girl that was suffered from itp and granulomatosis lesion of skin associated with hyper igm before at diagnosis. second case was a years old girl with microcephaly, sever ftt , neurodevelopmental delay , abnormal faces and hypo and hyperpigmentation lesions and anemia. with respect to these manifestation and increased afp ,nijmegan breakage syndrome was suggested. third case was suffered from hyperigm before a t diagnosis for years. we present a patient with a dock deficiency. mutations in the dedicator of cytokinesis gene (dock ) cause a combined primary immunodeficiency syndrome that is characterized by elevated serum ige levels, depressed igm levels, eosinophilia, sinopulmonary infections, cutaneous viral infections, and lymphopenia. onset of the disease was observed at -month of age with severe eczema and recurrent respiratory infections (pneumonia, bronchitis, otitis). at years of age neuroblastoma was diagnosed. from the age of years he started with severe skin infection , subsequently recurrent mucocutaneous aspergillosis was established based on skin biopsy and bacteriological studies. immunological investigations revealed persistent leukocytosis, hypereosinophilia, low level of igm and increased ige up to iu/ml. so hyper ige syndrome was diagnosed and genetically confirmed when a large deletion of the dock -gene was identified. stem cell transplantation was performed in when the patient was y.o. one year later progressive multifocal leukoencephalopathy secondary to infection by polyomavirus jc was diagnosed. but after immunosuppressive therapy with cyclosporine awas suspended our patient's condition improved: the load of polyomavirus jc on plasma showed a decrease; mri brain was essentially stable ; immunological tests showed an initial improvement of subpopulations and proliferative response to mitogens; donor chimerism % stable. Özdemir Öner ; bozdoğan sıla department of pediatrics, division of allergy/immunology, sakarya university, medical faculty, adapazarı, türkiye. background: bronchiolitis and infantile asthma are the most frequent causes for typical wheezing signs in infants. however, when a physician comes across patients with recurrent wheezing are resistant to β -agonist and anti-cholinergic therapy, known as atypical wheezing cases; he should investigate for hypogammaglobulinemia in these patients. aim: here, three cases are reported to make pediatricians aware of hypogammaglobulinemia, which is one of the reasons causing recurrent and persistent wheezing attacks during infancy and beyond. case presentations: case : month-old girl presented to us with complaining of coughing and persistent wheezing. she has been having wheezing and breathing difficulty for the last months after she got upper respiratory tract infection. her symptoms persisted even though she was using religiously nebulized salbutamol + budesonid therapy. before this episode, she had had other wheezing attacks in her past medical history beginning from months of age. in her family history, her father has asthma. physical examination revealed her breathing difficulty. ronchi as well as rales were heard on the auscultation of her lungs. at the fourth day of admission, she was given ivig mg/kg/dose. later, her symptoms did improve and not recur for the last months. laboratory findings showed normal routine biochemistry, complete blood count and sedimentation rate. chest x-ray showed normal findings. echography was normal. ph-metry for reflux investigation was normal. sweat test was normal. in the serological evaluation: low igg level for his age ( mg/dl) was detected at two different times. igg subgroups, igm ( mg/ dl), iga ( mg/dl) and ige ( ) levels were within normal. case : -month-old girl came to our outpatient clinic with complaints of coughing and wheezing. at months of age, she had urinary and upper respiratory tract infections. despite antibiotic therapy, wheezing persisted for months and wheezing severity increased and it did not respond to β -agonist therapy. thereafter, she was admitted to the hospital for days and symptoms resolved. however, she came back to hospital due to recurrence of her symptoms in days. in her family history, grandmother and her cousins have asthma. physical examination showed breathing difficulty. ronchi as well as rales were heard on her lungs. although salbutamol, ipratropium, antibiotherapy (clarithromycin) and anti-reflux therapies were given, her symptoms did not improve for weeks. at the th day of admission, she was given ivig mg/kg/dose. later, her respiratory system symptoms did not recur for the last several months. once she was evaluated for persistent wheezing attacks during admission, biochemistry, cbc, esr were normal. chest x-ray and echography were normal. in serological evaluation: low igg level for his age ( mg/dl) was detected at two different times. igg subgroups, igm ( mg/dl), iga ( mg/dl) and ige (< ) levels were normal. case : month-old boy was brought to us complaints of having frequent lower respiratory tract infections (bronchiolitis). he was experiencing recurrent wheezing attacks almost every other week for the last months. in past medical history, he was diagnosed with trisomy and hypothyroidism at the months of age. he went thru an operation for atrio-venticular septal defect. physical exam revealed dyspnea, tachypnea and wheezing. crackles were heard on the chest auscultation. abdominal, cardio-vascular and the rest of the examination were normal. when he was evaluated for frequent wheezing attacks in our outpatient clinic, routine biochemistry, cbc and esr were normal. chest x-ray showed normal findings. in serological evaluation: low igg level for his age ( mg/dl) was detected twice. igg subgroups, igm, iga and ige levels were within normal. he was given ivig mg/kg/dose. for the last three months, he did not have any lower respiratory tract infection. conclusion: the awareness of immunodeficiency among pediatricians has been greatly improved. recurrent respiratory tract infections are major infections in these patients. thi is a relatively common condition associated with infant hypogammaglobulinemia. in patients with recurrent and/or persistent wheezing symptoms during infancy and beyond, especially resistant to therapy, hypogammaglobulinemia should be excluded from possible diagnoses. background: the acquisition of new food allergy after transplantation or transplant-acquired food allergy (tafa) is usually reported in adults and rarely in children. tafa is described mainly after liver, but also after small bowel/intestinal, lung and heart transplantations. in different studies, the male/female ratio is equal. literature data suggest that children with tafa typically present within the first year after surgery and they are typically allergic to multiple foods. aim: tafa is generally characterized with allergy to multiple foods and increased level of total and/or spesific ige. here, a patient although who had normal total. ige and specific ige test results, he developed reaction to skin prick test for cow's milk is presented and his clinical presentation will be discussed. case presentation: month-old-boy came to our allergy clinic with complaints of vomiting after drinking cow's milk and skin rush on the area where contact ed with chocolate. in his past medical histroy, left lateral segment of liver (donor was his mother) was transplanted to him when he was at months. the liver donor was not recorded as having a history of allergic disease. methylprednisolone and tacrolimus immunosuppression were used after the transplantation, and tacrolimus therapy was continued for prophylaxis of chronic rejection. when he was at months, family fed the patient with cow's milk but hours later he began to vomit. he vomited five times in two hours. then, he developed constipation. rectal irrigation was used. then oral intake stopped for two days. he was thought to be having food protein induced enterocolitis. his vomiting complaints repeated after intake of formula and baby food which include grain. so he fed with special formula including short-chain peptides and free aminoacids and his symptoms improved. past medical history: extrahepatic biliary atresia was diagnosed at weeks age with conjugated hyperbilirubinemia (according to scintigraphy and biopsy results). family history: his father has penicillin allergy and his aunt has asthma. at our outpatient clinic: height and weight were within normal percentiles. physical examination reevaled normal examination findings. laboratory findings: wbc was . /mm , with % neutrophils, % eosinophils and % lymphocytes. his hemoglobin was . g/ dl , platelet count was . /mm . total ige : < and immunocap specific ige against milk, grain and other classsic foods was < . . skin prick test results: saline: x mm, histamine x mm, fresh cow's milk: x mm, other food allergens (peanut, egg, fish, soybean, wheat): x mm. conclusion: our patient seemed to have cow's milk allergy related to liver transplantation. laboratory investigations and clinical presentation of the patient did not look like typical ige-mediated food allergy, which is expected in tafa. patient history: years old male patient, the first pneumonia at the age of followed by times pneumonia attacks/year, otitis media and sinusitis. hospitalization due to respiratory insufficiency caused by bronchiolitis obliterans and diagnosed with hypogammaglobulinemia at the age of . no consanguinity. patient findings at diagnosis ( / ) had hepatospenomegaly, bilaterally cervical, supraclavicular axillar lap, osteoporosis, bronchiolitis obliterans organizing pneumonia, hyper igm, lower igg, iga, ige, low b-cell. no response to tetanus toxoid. İsohemagglutinin antib was ¼. cd ,cd l, aid, taci, baffr, icos gene mutation were negative. protein electrophoresis revealed polyclonal igm increase, immunofixation was no clonality. lymph node biopsy result was available paracortical expantion . cd (+) t and cd were positive. b lymphocyte distribution were normal. malignancy ruled out. no giant germinal centers. evaluation of bone marrow aspiration/ biopsy were abnormal localization of megakaryocytes, dismegakaryopoiesis, blasts in normal range. lymphocyte ratio % mostly consisting of cd + cells, cd + cells were rare, plasma cell ratio was %, amyloid negative. progression of patient, igm level and spnenomegaly were increased and patient had respiratory failure. splenectomy could not be done due to respiratory failure. than patient was treated with rituximab ( mg/kg/week). after rituximab therapy, lymph nodes and splenomegaly were ( cm), regressed and igm level decreased (from mg/dl to mg/dl), increased effort capacity. after month after rituximab therapy splenomegaly and igm level were progressed. splenoctomy was performed. pathological evaluation of the spleen malignancy ruled out. current igm level is mg/dl. conclusion: the most convinient scenerio for this patient would be a csr defect of unknown etiology presented as cvid. the recent litarature revealed genetic defects of some molecules operating in dna repair pathways such as msh , msh , msh , msh , mlh , rad , rad , nbs leading to csr abnormality and impaired antibody maturation. cvid is characterized by hypogammaglobulinemia, recurrent respiratory and gastrointestinal bacterial infections. good's syndrome(gs) is a thymoma-related immunodeficiency and characterized by hypogammaglobulinemia, decreased b cell and variable deficiencies in cell-mediated immunity. case: a -year old male patient presented with a palpable anterior chest wall mass. in , he was diagnosed with rheumatoid arthritis. laboratory showed hypogammaglobulinemia and all autoantibodies were negative. cd + , cd + , cd + cells were < %. bone marrow(bm) examination demonstrated low cd + b-lymphocyte and increase in cd + t cells. tuberculin skin test was positive. t-cell proliferative response was normal. immunizations with h.influenzae type-b and tetanus toxoid revealed no response. anti-b titer was low. taci, btk and icos mutattions were negative. ultrasonography showed hepatosplenomegaly. mild edema, mononuclear cell infiltration (suggested the early stages of extrahepatic biliary obstruction) were detected on liver biopsy. in the medical history, he had reported chronic sinusitis, otitis and bronchitis dating back to rd decade of life. at age , he underwent surgery for thymoma. in follow-up, the computed tomography showed soft tissue mass on the anterior chest wall and pathology was thymoma. discussion: frequent respiratory infections with encapsulated pathogens beginning at the age of , lack of opportunistic pathogen infections, presence of hepatosplenomegaly and rheumatoid arthritis, bm examination findings and successful management of infections with ivig therapy all indicated a diagnosis of cvid. the coexistence of cvid and thymoma has been reported in the literature. introduction: common variable immunodeficiency (cvid) is a primary immunodeficiency disorder characterized by impaired b cell differentiation with defective immunoglobulin production. it has heterogeneous clinical manifestations including recurrent infections, chronic lung disease, autoimmune disorders, gastrointestinal disease, and susceptibility to lymphoma. patients with this disorder have evidence of immune dysregulation leading to autoimmunity. autoimmune cytopenias are a more common presenting disorder in children and may be the initial manifestation of the disease. we want to present a patient presenting with autoimmunue hemolytic anemia and finally diagnosed as cvid. case: a years old, previously healthy female patient applied to emergency clinic with complaint of paleness, light headedness and yellow discoloration of her scleras. her history was not compatible with blood loss. she denied having melena, hemotochezia or hematuria. her mensturation history was also normal. her hemoglobin level was . gr/dl, reticulocyte count was % . , complete blood count was otherwise normal. direct coombs was (+++). for the differential diagnosis of immune hemolytic anemia, viral serology, ana and anti-dsdna were studied, but the results were normal. igg, igm and iga levels were lower than normal normal for her age. other causes of hypogammaglobulinemia were excluded. blood group was arh (+), blood isohemagglutinin were anti a(-) and anti b (-/ +). lymphocyte subsets were also studided. as the patient has reduced immunoglobulin levels with normal lymphocyte subset analysis, she presented after puberty and other defined immunodeficiency states were excluded, she was diagnosed as cvid and monthly immunoglobulin replacement therapy was planned. she had aseptic meningitis after her first ivig transfusion. the ivig preparation was changed with another trade and she did not have any problem during the following treatments. it has been one year since she was diagnosed and she did not have any other medical problems. conclusion: the diagnosis of cvid requires decreased igg, igm and iga levels are also reduced but are less valuable for diagnosis. ige level is checked to exclude other disorders. igg subclass determinations are indicated if antibody titers are decreased but immunoglobulin levels are near normal. hypogammaglobulinemia secondary to other disorders should be excluded. autoimmune conditions can be the presenting signs/symptoms in cvid. autoimmune hematologic disorders may precede, present at the time of diagnosis or develope during the course of cvid in approximately one-half of the patients with autoimmune problems. selective immunoglobuline deficiency is an uncommon dysgamaglobulinemia, in which immunoglobuline levels except igm level are normal. it can be primary or secondary to cancer, autoimmune diseases, gastrointestinal system diseases and immunosuppressive therapy. patients can be asymptomatic or have recurrent infections, asthma, angioedema, autoimmune diseases, celiac disease and bronchiectasis. allergic diatheses are the second commonest presentation of selective igm deficiency. in this presentation, we report a case with asthma and angioedema who has selective immunoglobuline m deficiency. a year old male patient who has been diagnosed with asthma for years with a well controlled asthma for years presented with labial angioedema. he had labial angioedema daily without antihistamines. he did not have any suspected food or drug allergy. he did not have family history of angioedema. physical examination was normal under antihistamine therapy. laboratory evaluation revealed a . % percentage of eosinophils. absolute lymphocyte count was , absolute neutrophil count was cells/mm . immunoglobuline e value was ng/ml, levels of immunoglobuline g and a were within normal limits for age. immunoglobulin m value was . mg/dl ( - ). anti a was / , anti b was ½ positive, antihbs was above mlu/ml. lymphocyte subsets were normal. because of the continuous usage of antihistamines, prick tests could not be done. levels of d was . , d was . ku a /l. thyroid functions, antitpo, c , c and c esterase inhibitor values were normal. antinuclear antibodies and antitransglutaminase lga was negative. immunoglobuline m value of his father was normal, immunoglobulin m value of his brother was . mg/dl ( - ). selective immunoglobuline deficiency is a rarely seen dysgamaglobulinemia. it was reported in children with asthma, but it was not reported in children with angioedema. it can have value in the clinical evaluation of patients with angioedema. cukurova university, department of pediatric allergy and immunology, adana, turkey a patient who is at age of years at present and who has been followed up at the our clinic with xla diagnosis presented with pain in his ankles and wrists and swelling of his right knee. he also was suffering from skin tightening of the lower extremities. his physical examination revealed arthitis of the right knee and sclerotic changes were detected in the skin. skin biopsy was performed and it revealed morphea (localized scleroderma). after the diagnosis of morphea and arthritis, ivig gm/kg and nsaid were applied. following the treatment skin findings and arthritis resolved, however approximately two months later liver enzymes were detected to be high in his routine control. liver biopsy performed to clarify the aetiology of elevated liver enzymes was reported as autoimmune hepatitis. in addition to ivig gm/kg, budenofalk mg/day was started. after months of treatment, his liver enzymes normalized. currently he is being treated with ivig monthly and ursofalk daily. patients with xla typically present with recurrent bacterial infections and it might be associated with some autoimmune diseases. there are not any reports indicating an associaton of autoimmune hepatitis and scleroderma with xla. bruton agammaglobulinemia is an inherited immunodeficiency disease caused by mutations in the gene coding for bruton tyrosine kinase (btk). the median age at the diagnosis of the antibody deficiency is about . years in turkey. here, we report a case of bruton disease presenting with recurrent cervical abscess at two months old infant. a -months-old boy was firstly hospitalized for the treatment of the right cervical abscess at days old. after the recurrence of swelling on the cervical area, the patient was referred to the admitted to hospital secondly. there was no consanguinity between parents and, his family history was unremarkable except four of the mother's cousins, died because of unknown etiology in infancy. on his physical examination, his weight, height andhead circumference were normal range by age. there were no visible tonsils. there was a palpable, mobile x cm mass on right upper cervical area. the molecular analysis of the causal gene for bruton's tyrosine kinase (btk gene) revealed the mutation in exon . this mutation g. delg (c. + del) leads to the changes of amino acid order in the protein with the subsequent changes in activity of btk (at the level of dna: substitution of glutamic acid (p.glu *) causes non-sense mutation leading to the formation of stop codon with premature end of dna transcription to cause stop codon. after initiating the intravenous immunoglobulin with antibiotics, the cervical mass was getting smaller in a short period, and had not observed again. neutropenia was improved within the months. this case is an important example to diagnose bruton disease in early life. it demonstrates that maintaining a high level of clinical suspicion is essential for the diagnosis of bruton disease in a child with recurrent cervical masses. elif azarsiz; neslihan edeer karaca; guzide aksu; necil kutukculer ege university faculty of medicine, department of pediatric immunology, izmir, turkey transient hypogammaglobulinemia of infancy (thi) is characterized by recurrent infections and reduced serum immunoglobulin levels. typically, thi patients recover spontaneously, mostly within - months of age, but sometimes recovery may be delayed until - years. the use of intravenous immunoglobulin (ivig) as an alternative to antibiotic prophylaxis remains contraversial also in symptomatic patients. some authors believe that ivig therapy may cause a delay in the maturation of the humoral immune system because of the interference from passively transfered antibodies. the aim of this study was to investigate the effect of ivig replacement on recovery from immunodeficiency in these patients. patients ( %) received ivig therapy while patients ( . %) showed spontaneous normalization without ivig. the percentages of patients who had more than six times the number of febrile infections in a year decreased from % to % in the group receiving ivig treatment. at admission, before being recruited to ivig therapy, serum immunoglobulin g (igg) levels and anti-hemophilus b (hib) antibody titers were found to be significantly low in cases who were selected for replacement. the percentages of patients who did not have protective levels of anti-hib, anti-rubella or anti-rubeola-igg were also significantly high in ivig cases. there was no statistically significant difference in the age at which igg levels normalized between both groups. patients in the ivig group and non-ivig group reached normal igg levels at the age of . ± . and . ± . months, respectively. in conclusion, ivig infusions do not cause a delay in the maturation of the immune system in thi patients. the very low and non-protective specific antibody responses against previously applied vaccines are important factors to consider when selecting patients for ivig therapy. zoltán ellenes-jakabffy ; ibolya kovács ; mihaela bătăneanţ ; maria cucuruz ; margit Şerban ; lászló maródi department of pediatrics, clinical city hospital oradea, romania. objective: to study the amplitude of the chronic inflammatory phenomena: atopic and autoimmune diseases, as well as their associations in pediatric sigad patients and to study the sigad patients' family history ( st degree relatives) for pids (primary immunodeficiencies). methods: retrospective analysis of the clinical and laboratory records of pediatric sigad patients diagnosed between and at the departments for pediatric immunology of the medical universities of debrecen (hungary), oradea and timişoara (romania). results: out of patients, we found out ( %) with atopic diseases, mostly with respiratory localizations (asthma and allergic rhinitis), ( , %) patients with autoimmune diseases (jia, psoriasis, celiac disease, thyroiditis etc.) and other patients without clinical symptoms of autoimmunity but constantly elevated autoantibody levels. there were patients with coexistent atopic and autoimmune diseases. regarding the family history, we identified families with multiple cases of pids : with multiple sigad, with sigad and cvid, with sigad and higms (hyper igm syndrome). conclusions: the chronic inflammatory phenomena are present in the majority of the studied sigad patients: symptomatic atopic diseases in %, symptomatic autoimmune diseases in , %, that means a cumulative %. there are comorbid associations within the atopic and autoimmune disease groups and also between the two groups. sigad is the most common primary immunodeficiency. it's prevalence is / - / . aim was to assess the prevalence of co-morbidity in patients with sigad in latvian pediatric population and the analysis of some immunological abnormalities in these patients. the study included patients - years old. medical charts have been reviewed. into account were taken the data, which were made at time of diagnosis. patients were divided into groups: st -patients with allergic disease, nd -patients with autoimmune diseases, rd -patients with infectious diseases, th -asymptomatic patients or patients with sigad unrelated diseases. patients with multiple co-morbidities of various disease groups were not placed in any of these groups. each patient group was divided by age: - years, - years - years. results. . % were boys and . % girls. sigad in . % of the cases were diagnosed before years of age (inclusive). % of the patients had co-morbidities: allergic ( %), autoimmune ( . %) or infectious diseases ( . %). patients - years old: children with infectious and autoimmune diseases have . times greater igg than healthy children or children with allergic diseases (p < , ); children with autoimmune diseases has . times more cd cells than children with allergic diseases (p < , ).; children with infectious diseases have . times lower absolute number of cd cells than children with autoimmune diseases (p < , ); patients - years old: children with infectious diseases have . times more absolute number cd cells than children with allergic diseases (p < , ). patients - years old: children with autoimmune disease have . times higher cd /cd index than children with infectious diseases (p < , ) karakina m. l. , , , tuzankina i. a. , , vlasova e. v. introduction: antiepileptic drugs are known to cause immunosupression in some cases. levetiracetam is an anticonvulsant medication used to treat epilepsy in the posttraumatic seizures. we report a rare case of hypogammaglobulinemia and b cell aplasia associated with levetiracetam treatment. case report: a -year-old female was operated for pituitary tumor with transnasal surgery and required second operation for postoperative rhinorrhea. after operation, menengitis developed and antibiotic treatment was administrated. however, there was a poor response to this treatment after one month and craniotomy was performed due to the diagnosis of "shimic menengitis". her seizures occurred as a postoperative complication and levetiracetam was initiated. after the -month follow-up, the findings of menengitis could not be controlled with antibiotherapy. she was referred to our immunology department for chronic menengitis with fever, headache and high cerebrospinal white blood cell count. results: in her clinical evaluation, it was learned that she had previously healthy. laboratory examination showed that decreased levels of igg mg/dl (normal: - ) and iga mg/dl (n: - ). peripheral blood flow cytometric analysis revealed the absence of b cells (cd + b cells; < %). t cell subsets and natural killer cell numbers were normal. neutrophil function, chemotaxis, phagocytosis and oxidative burst activity were found to be normal. isohemaglutinin titer, levels of pneumococal and tetanus specific igg antibodies were also normal. antiepileptic drug was discontinued after epileptic seizure was controlled. b cells gradually increased three weeks later and returned to normal within two months (cd + b cells: . %). conclusion: patients requiring levetiracetam should have serum immunoglobulins measured and lymphocyte subsets analysis performed if they experience recurrent or persistent infections. mustafa gulec ; fevzi demirel ; ugur musabak ; ozgur kartal ; sait yesillik ; abdullah baysan ; ergun ucar ; osman sener gulhane medical school, division of immunology allergic diseases, ankara, turkey. gulhane medical school, department of chest diseases, ankara, turkey. introduction: common variable immune deficiency (cvid) may present with several clinical manifestations involved in different organs and tissues in adults. we present a case with a history of chronic cough for more than twenty years and further diagnosed as cvid. case: a -year-old male who works in a chemistry lab admitted to our clinic with a history of frequent upper respiratory tract infections for more than years. he also had intermittent diarrhea symptoms and his respiratory symptoms have been worsened since . he had been hospitalized due to pneumonia and empyema several times. he had undergone left lower lobectomy due to bronchiectasis in . he had been admitted to intensive care unit due to worsening of his medical condition. he was further diagnosed with cvid and ivig treatment was initiated. he is currently under remission with monthly ivig treatment and without any respiratory or gastrointestinal symptoms. discussion and conclusion: cvid is a clinical disorder in which the humoral part of the immune system is affected. most frequent presenting symptoms belong to respiratory, gastrointestinal systems and skin. however, due to the organ specific physical examination and lack of awareness, the diagnosis is frequently overlooked. in our case, frequent upper respiratory infection, loss of weight, diarrhea, bronchiectasis and empyema with unknown etiology are the most informative clinical signs. medical history is the most important part of patient evaluation. immunoglobulin replacement therapy is a basic treatment in primary immunoglobulin deficiency disorders. immunoglobulin substitution can be given intravenously (ivig) or subcutaneously (scig) for patients with antibody deficiency. both of these treatments are effective in prevention and cure of infections, although differences in advers events profile and patients' quality of life can be seen. the authors describe here their experiences in switching patients from ivig treatment to scig and a few years observation of scig therapy of patients with antibody deficiencies. sirje velbri , mirja varik tallinn children's hospital, tallinn, estonia. north-estonian regional hospital, tallinn, estonia. j clin immunol ( ) : - antibody deficiencies are the most common group of primary immunodeficiencies. the main hallmark of antibody deficiencies are recurrent infections but the patients have also higher risk of autoimmune and allergic diseases. we analysed retrospectively the frequency and character of autoimmune diseases in patients ( children and adult patients) with primary antibody deficiencies. there were ana-lysed patients with xla, patients with cvid, patients with selective iga deficiency, pa-tients with iga/igg subclass deficiency and patients with isolated igg subclass deficiency. autoimmune diseases were found in patients ( , %) besides in children ( %) and in adult patients ( %). in two boys with xla there was not found autoimmune diseases but in patients with other forms of antibody deficiencies in - % of cases. autoiimmune diseases were found more often in iga/igg subclass defi-ciency ( %) than in other forms of antibody deficiencies ( - %). the spectrum of auto-immune diseases differed in adults and child-ren and in different forms of antibody de-ficiencies. immune thrombocytopenia was found in adult patients with cvid or igg subclass deficien-cy, autoimmune connective tissue disorders in iga and iga/igg subclass deficiency. in children there was found mainly thyroiditis, diabetes i type and juvenile arthritis. rostov state medical university. research institute of clinical immunology, rostov-on-don, russia. primary immunodeficiency (pi) is currently one of most important genetically determined immunological clinical pathology which is hard to manage . among different types of pis almost % of cases occurs due to a deficiency in antibodies production. injections of immunoglobulin are current standard in the management of pi. however this treatment is expensive, often is hard for patients, and frequently has limited effectiveness. substitution of immune proteins frequently is inefficient for treatment of severe infectious conditions in pi patients. we investigated maturation, activation and differentiation of immune t-cells in the dynamics of ivig replacement therapy. we observed patients with with cvid ( ) and xla ( people) over a year of regular replacement therapy. we have found that recovery of the humoral component does not affect the maturation and the differentiation of t-cells, but can reestablish activation and regulatory properties. these changes are more evident among patients with cvid, which immuneregulatory and functional potential reestablish faster. obviously, the effects tlymphocytes increase the effectiveness of replacement therapy in patients with xla, cvid common variable immunodeficiency (cvid) is one of the most frequent symptomatic primary immunodeficiencies. the diagnosis is based on significantly decreased levels of immunoglobulins, with poor or absent response to vaccines and by excluding other defined causes of hypogammaglobulinaemia. as suboptimal antibody production is mainly due to b cell defects, therefore, we aimed to study lymphocyte subgroups of cvid patients and to compare the patterns with the clinical presentation in these patients. six adult patients with cvid diagnosis were studied. lymphocyte subpopulations were determined by flow cytometry. for b-cells subgroups cd , cd , igm and igd reagents w e r e u s e d . a l l l y m p h o c y t e s w e r e g a t e d f o r f i n d i n g cd + cd + memory b cells and from this population switched (cd + cd + igd -igm -) and non-switched (cd + cd + igd + igm + ) memory b cells were counted. all patients had normal levels of total lymphocyte count and absolute counts of cd + , cd + and cd + /cd + cells were also normal in all patients. only one patient showed low levels of cd + cells levels. according to paris classification scheme the patients could divided into two subgroups: mb and mb . although almost all our cvid patients had normal number of total b cells, most of them showed reduced number of memory b cells and/or switched memory b cells. all of our patients had very low or absent level of class-switched memory b cells, therefore can be possible associated with a higher risk of granulomatous disease and splenomegaly. detailed investigation of b-cell phenotypes can better characterise cvid patients and can provide more information about possible clinical outcome. background: common variable immunodeficiency (cvid) is one of the most frequent symptomatic primary immunodeficiencies, often related to spectrum of infectious and autoimmune diseases. in cvid patients wide spectrum of gastrointestinal disorders, including infections, are frequently seen. inflammatory bowel disease, helicobacter pylori infection, giardia lamblia infection, campylobacter or salmonella infection have been reported. however, abnormal liver function test and liver disease are found in approximately % of cvid patients. case history: a -year old female patient was admitted to infectious disease department due to recurrent pneumonia and purulent rhinosinusitis. blood analysis confirmed panhypogammaglobulinaemia with impaired responses to vaccinations, elevated liver function tests and anti-hcv positivity, interpreted as old and passed infection. due to cvid intravenous immunoglobulin substitution was started. however, liver function tests remained elevated and with hcv-rna analysis high hepatitis c viral load was detected. chronic hepatitis c virus infection was diagnosed and treatment with peginterferon α- a and ribavirin was started. conclusion: our case emphasizes the need for hcv-rna and hbv-dna analysis in patients with hypogammaglobulinaemia, as the serological detection is impaired and prognosis for chronic hepatitis in immunodeficiency patients is poor. outpaitent clinic of clinical immunology and allergology, east tallinn central hospital, tallinn, estonia background: primary antibody deficiencies are the most frequent primary immunodeficiencies. recurrent respiratory tract infections may result in permanent lung damage in - % of patients, most commonly presenting with the development of bronchiectasis. we aimed to evaluate the lung function and radiographic pulmonary changes in our patients with primary antibody deficiency. material and methods: we reviewed the records of adult patients with a confirmed diagnosis of primary antibody deficiency at our clinic. patients were included in this analysis in whom ct scan was performed during the last months, comprising patients with cvid and two with igg subclass deficiency (median age years; range - years; % females). all patients were on regular immunoglobulin replacement and one of the patients was on prophylactic antibiotic at the time of analysis. mean trough levels of igg were calculated based on the results measured during the last months prior to ct scan. the spirometry was performed according to published protocols. results: all patients demonstrated normal spirometry data based on fev and fvc. two patients had slightly lower mmef rates, however, the changes were not associated with higher rate of infection nor changes in ct scan. none of our patients had bronchiectasis or atelectasis. among parenchymal changes fibrotic lines were most frequently detected. in two patients ground glass due to fibrosis was noted. mean immunoglobulin trough levels in our patients were between . - . g/l, with the median of mean trough levels of all our patients . g/l. when comparing the trough levels to lung function and ct scan results, no significant associations were seen. conclusion: no remarkable changes in lung function or chest ct scan in our patients with primary antibody deficiency were noted. as regular immunoglobulin replacement therapy could have prevented the development of permanent lung damage. rationale: patients with primary immunodeficiencies (pi) (n = ) were treated subcutaneously (sc) with immunoglobulin g (ig) preceded by recombinant human hyaluronidase (ighy) at or week intervals based on their previous intravenous ig (igiv) dose. we report data for a subset of patients aged ≥ years from the final efficacy, safety and tolerability data of a pivotal phase trial of ighy. methods: patients received igiv for months at prestudy doses and frequencies. subsequently, ig % was administered sc, at % of the weekly equivalent of the iv dose, following rhuph infused through the same sc needle at a dose of u/g igg. after a ramp up from a -to a -or -week dose interval, patients received ighy every weeks for months. the primary efficacy endpoint was the mean rate of validated acute serious bacterial infections (sbis) per patient-year during the efficacy period. results: fifty-nine patients received ighy infusions; . % were completed without administration changes due to tolerability concerns or adverse events (aes). median infusion sites/month was . . the temporally associated systemic ae rate was . /infusion (ighy) vs. . /infusion (igiv). the local adverse drug reaction rate was . /infusion. the annual sbi rate was . and . /patientyear for all infections. conclusion: in adults with pi, ighy was effective in preventing infections. the majority of patients received full -to -weekly doses of ig using a single sc site with good local and systemic tolerability. rationale: in a pivotal phase trial of facilitated-subcutaneous (sc) infusion of human immunoglobulin g (igg), %, and recombinant human hyaluronidase (rhuph ) (ighy) in patients with pi, rhuph permitted most patients to have a single-site infusion (every - -week igg dosing) with bioavailability and infusion rates comparable to intravenously administered igg (igiv). we report the final analysis of the long-term extension of the initial phase study, with a duration of up to years of treatment with ighy plus additional follow-up. methods: sixty-six patients who completed the initial phase study enrolled in the extension study. patients continued their pre-study ighy dose/frequency every - weeks. after months, some patients switched to -week dosing to evaluate effects of shorter ighy interval on trough igg levels. from the final analysis, tolerability and safety after up to years of treatment were evaluated. the ighy part of the extension study was followed by a - week observation period during which patients received igg % administered iv, or sc weekly without rhuph . results: in the extension study, patients were treated with ighy and discontinued prior to safety follow-up. following discontinuation of rhuph , patients switched to follow-up. no patients withdrew due to ighy-related reactions (adrs). no serious adrs related to ighy were reported. the maximum ighy exposure for the initial and extension studies combined was years (total exposure = . patient-years; n = ighy infusions); during this time, there were no clinically observable long-term changes in the skin or sc tissue. the rate of temporally related systemic adverse events (aes), excluding infections, was . / infusion. the rate of all local aes was . /infusion. of the ighy infusions administered in the extension study, . % had no administration changes (rate reduction, interruption or discontinuation) due to tolerability concerns or adverse events. the annual rate of all infections under ighy treatment was . /patient-year. reducing the dosing interval from to weeks (same monthly dose) resulted in a % increase in trough igg levels. thirteen patients had at least non-neutralizing anti-rhuph antibody titer of ≥ : with no associated aes; no patients had neutralizing anti-rhuph antibodies. conclusions: in the extension study, ighy was well tolerated and effective, with no serious adrs for treatment periods up to years. over a maximum -year ighy exposure (for an individual patient) in the initial phase and extension studies combined, no long-term changes in skin or sc tissue were observed. the rates of infections and adverse reactions were stable or decreased over the course of the two studies, suggesting no increased risk with continued exposure to ighy. rationale: we report interim analysis of safety, tolerability and pharmacokinetics (pk) of igsc % in patients with primary immunodeficiencies (pi) aged ≥ years in europe. methods: epoch : igsc % or intravenous ig % (igiv) administered at pre-study doses every months. epoch : igsc % administered time per week for months at epoch doses. serum igg trough levels are maintained at > g/l. the primary endpoint is validated acute serious bacterial infection (sbi) rate. results: at the interim analysis in october , patients started the study. during igsc % treatment (n = ), acute sbi episode (pneumonia, moderate in severity) was reported. the infection rate per patientyear was . (igsc %). there were no serious adverse events considered related to any treatment. the rate of local adverse drug reactions (adrs) was . /infusion and all were mild in severity; no severe systemic adrs were reported with igsc %. of igsc % infusions, only . % required slowing or interrupting the administration rate. mean serum igg trough levels were . g/l (igsc %, n = ), . g/l (igiv -week interval, n = ) and . g/l (ivig -week interval, n = ). conclusion: igsc % provided an effective and well-tolerated therapy, with no dose adjustments needed from pre-study ig dose. this study is ongoing to confirm results over months. it is well known, that intravenous immunoglobulin (ivig) is the main therapeutic modality in b-cell primary immunodeficiencies (pid), it decreases mortality and morbidity in these patients dramatically. yet, it is also well known that all ivig products are very expensive, especially considering life-time use and almost normal life expectancy in these patients, if treated correctly. irregular treatment and problems with insurance/state coverage of ivig in some countries stems from this. goal: the goal of our study was to compare medical and other costs, related to the disease in patients with humoral pids with or without ivig treatment. patients: patient with b-cell deficiencies ( % x-linked agammaglobulinemia, all genetically confirmed, % common variable immunodeficiency). the age of patients varied from to years. methods: we analyzed medical and other disease-related costs during years preceding the diagnosis (without ivig therapy) retrospectively and during years on regular ivig therapy. the costs included those incurred by the state (hospitalization, home visits, emergency calls) and by the parents (costs of drugs, private consults, etc). the state costs caused by parents missing work were also considered. for standardization purpose for calculation we used the prices for the end of . results: the patients analyzed fell into different categories: . the st group -( % of patients studied) -patients with several severe infections before therapy, some chronic conditions as a result of those. age of diagnosis varied from years to years (with average time to diagnosis years). in this group costs of ivig treatment were , times higher than before the diagnosis (fig. ). nd group( % of all). patients with late diagnosis (average time to diagnosis years), who had multiple severe infections before the ivig treatment and acquired serious chronic lung complications due to it. in this group the costs before the treatment were higher, than on ivig treatment. . very early diagnosis -within the first year of life (mostly because of preceding family history) ( %). the comparative analysis was not possible, but it was noted that these patients had no history of serious infections before of while on ivig therapy. the only additional costs, besides ivig, were related to bad venous access, requiring occasionally day in-patient hospitalization for ivig infusion. as expected, in all groups, the number of infectious episodes, the number of hospitalizations (fig. ) and doctor visits (fig. ) after beginning of regular ivig treatment dropped dramatically. we also followed patients with xla, who did not receive ivig therapy because of social aspects. both patients died from severe infections. we evaluated this fact in economical prospective: in russia one worker, who works continuously and retires at years of age brings about mln roubles into the state budget (when costs for schooling and routine medical care are subtracted). if one supposes that an xla patient have been diagnosed very early in life, did not form complications prior to therapy and was on regular ivig therapy for life, this sum equals to years on ivig. conclusions: regular ivig therapy not only leads to reduction of infectious episodes, hospitalizations, and as a result improved quality of life. in some cases it even brings down the disease-related costs, incurred by the medical system and the family, and is economically advantageous for the state. introduction: replacement of immunoglobulins is a standard therapy for patients with primary immunodeficiency disease (pidd) characterized by primary antibody deficiency (pad). this poster represents our clinical experiences of initiation of home-based treatment with subcutaneous immunoglobulin (scig) with the patients diagnosed with primary variable immunodeficiency (cvid). case report: the patient (age ) has been treated at our immuno-allergy outpatient clinic since with the diagnosis of hypogammaglobulinemia (igg, iga, igm) with normal b cell count, withsusp. cvid. with the repeated administration of intramuscular and intravenous immunoglobulins (ivig, imig) repeatedly occurred serious adverse reactions, which resulted in discontinuation of the replacement therapy. in february the health condition of the patient worsened due to recurrent bacterial respiratory infections. there was a progressive decrease of serum concentrations of immunoglobulins (igg , g/l, igm , g/l, iga , g/l). the patient was admitted to the intensive care unit of the st internal department, university hospital bratislava, for a subcutaneous immunoglobulin replacement trial. despite serious adverse reactions with previous administration of several types of immunoglobulins, there have not occurred any clinically relevant side effects. conclusion: compared with im or iv formulations and administration, for selected patients, scig is better tolerated, clinically efficacious, safe, and appreciated by the patients. background: common variable immunodeficiency (cvid) is primary immunodeficiency (pid) classically viewed as antibody deficit. although, cvid is considerd to be a humoral immunodeficiency, approximately % of cvid patients have low t-cell counts or abnormal tcell function. despite adequate immunoglobulin replacement patient morbidity and mortality is variable and a number of complications are not those typically seen in pure antibody pid e.g. xla. so, t-cell rather than b-cell phenotype could determine outcome in patients with cvid. many patients with cvid have clinical history suggestive of allergic respiratory disease, but prevalence of asthma and role of atopy have not been well established. apart from recurrent infections and their sequelae, cvid patients suffer from other disease-related complications in up to % of the cases. about % have onset before the age of years. aims: ) to present one more case of tadolescent with cvid and allergic asthma, ) emphasise ultimate need of collaborative network of primary immunodeficiency centers. case report: parents of , y boy were sure that "something was wrong" with their son and were seaking for problem solution for many years. since age , child had frequent respiratory infections. adenoidectomy and tonsillectomy were performed at age . sinuitis was diagnosed several times. boy was complaining of fatique for a long time. last several years, his main problems were fever (max c) usually lasting days till weeks, accompanying running nose, coughing, conjunctival problems; intermittently headache (lasting for a few hours till all day). oral aphtae were present almost every two weeks. he was incompletely vaccinated (bcg, and once diteper). morbilli and varicellae infections passed without complications. in jan he was diagnosed as allergic asthma in sarajevo (allergy to pollen, soya, nuts and antibiotics ("ceclor" and "pancef"). in february was admitted at children's hospital sarajevo for suspected primary mmunodeficiency. he had slightly lower levels of igg and iga (twice measured), normal ige and decreased number of t helper ly. due to suspected pid, boy was checked up in two nearest regional pid centers : hypogammaglobulinemia was confirmed (igg , , iga , , igm , , as well as deficiency of igg , igg and igg ). flow cytometry showed slightly raised concentration of lymphocites b (cd ), slightly raised number of nondifferentiated b cells. cvid was suspected but not proved. in july child visited center for primary immunodeficiencies in munchen, germany, were he was diagnosed ad probable cvid on the basis of hypogammaglobulinemia, lower levels od switch memory b cells, normal number of t-cells, positive antibodies to vaccinations and overcome infection (morbilli, varicellae). allergic asthma was additionaly confirmed in specialised pediatric pulmology hospital in germany (abnormal spirometry, normal ige, positive skin prick test, abnormal fractional exaled nitric oxid test, incipient brochiectasies due to asthma confirmed by high -resolution lung ct scan). low human immunoglobulin replacement was started ( mg/kgbw) as well as antiasthmatic therapy (inhalatory steroids, antihistaminics). excellent therapeutical response were achieved : after one , y follow up, we can confirm patient has excellent general condition, no subjective symptoms, no tiredness, no severe infections. conclusion: diagnosing cvid is challenging task and quite often could be "per aspera ad astra". there is ultimate need of collaborative work of primary immunodeficiency network aimed of diagnosing patients on time. cvid patients with history suggestive of allergic asthma, are negativne on traditional tests, additional test designed to identify allergic asthma might be conducted. common variable immune deficiency (cvid) is a heterogeneous syndrome characterized by hypogammaglobulinemia, recurrent infections, immune disregularity (autoimmunity, autoinflamation) and propensity to malignancies. in the us report, . % of cvid patients had a lymphoid malignancy, and cancers of other sorts developed in % of patients. it is not clear why cvid patients have higher risk of malignancy but chronic antigenic stimulation, chronic inflammation and increased chromosomal radiosensitivity may be the cause. cvid patients with higher igm level, reduced or absent b cell numbers, cd t cells lower than and pli phenotype have higher prevalence of malignancy. allergy and clinical immunology department of rasool e akram hospital has registered cvid patients. mean age of the onset of cvid symptoms was . years. mean diagnosis age was . years with mean diagnostic delay of years. mean follow up time was years (minimum . -maximum y). malignancy occurred in the follow up of patients ( %). one patient had two different malignancies (breast cancer and gi adenocarcinoma). malignancy risk per case was %. hodgkin's lymphoma was the most common type ( % of cancers common variable immune deficiency is a heterogeneous syndrome characterized by hypogammaglobulinemia , recurrent infections , auto immunity and auto-inflammation . more than % of cvid patients have auto immune complications and among them, auto immune cytopenia is the most common. cvid patients with higher igm levelhigher low b cellslower t reg levelslower cd /cd ratio and lower class switched memory b cells have higher prevalence of autoimmunity. allergy and clinical immunology department of this hospital has registered cvid patients. mean age of onset of cvid symptoms was . years. mean diagnosis age was . years with mean diagnostic delay of years. mean follow up time was years (minimum . maximum y). autoimmunity was detected in cases ( %) and cases ( %) had more than one autoimmunity. autoimmunity was the first symptom of cvid in percent of cases. autoimmune disorders should be considered in the follow up of cvid patients. igg is major immunoglobulin and classified subgroups as igg , igg , igg and igg . igg and igg subclasses are rich in antibodies aganist proteins such as the toxins produced by the diphtheria and tetanus, as well as antibodies aganist viral proteins. recurrent ear infections, sinusitis, bronchitis and pneumonia are common in ig g subclass deficiency. ig g is the major subclass of ig g. igg subclass deficiency is very rare. chronic eosinophilic pneumonia is one of the eosinophilic lung disease and is seen rarely. in the presence of peripheral eosinophilia and radiological pulmonary infiltrates diseases suspected. when increase in the number of eosinophils in bronchoalveolar lavage fluids and/or presence of eosinophils in lung tissue diagnosis is confirmed. according to different recording systems chronic eosinophilic pneumonia is % - of the interstitial lung disase. there is not any criteria for diagnosis but also diagnoses is confirmed with suspected findings. symptoms inludes that: )in the presence of respiratory symptoms for two weeks long )eosinophilia at alveolar lavage and\or peripheral blood ( bal fluid cytological examination > % , blood > /mm ) )radiological imaging of the lung peripheral infiltration )exclusion of the other causes of eosinophlic lung disease there is eosinophilia over /mm nearly all patients. one of third or half of patients have diagnosed as asthma. disease begin with systemic symptoms such as night sweats, weight loss, anorexia and pulmoner symptoms such as cough, shortness of breath, wheezing. patients have restrictive or obstructive findings in pft. one of third patients, especially with history of asthma, have obstruction in pft. İn the pathologic biopsy findings include; thickening of alveolar walls and accumolation of eosinophils and lymphocytes. long time used corticosteroids treatment is recomended. relaps is common when treatment is discontinued. we present the patient who has ig g deficiency, chronic eosinophlia and % eosinophils in bronchoalveolar lavage fluid. the patient improved long time used oral steroid then inhaled steroids. this was presented in terms of clinical association. case: a years old female patient who were followed due to asthma in the other center for two years, although use of combination inhaled fluticasone and salmeterol, patient was admitted with cough and sputum production. in thorax ct there were, bronchiectasis at right lower lobe, pneumonic consolidation in the right lower lobe and ground glass opacities. we detected as igg mg/dl ( - mg/dl), iga mg/dl ( - mg/dl), igm mg/dl ( - mg/dl), ige . mg/dl, igg mg/dl ( - mg/dl), igg mg/dl ( - mg/dl), igg mg/dl( - mg/dl), igg mg/dl ( - mg/dl). because eosinophilia ( cells) and symptoms continued, bronchoscopy was performed. left main bronchus was normal, right bronchus were seen dilated. purulent secretion was aspirated on rigt bronchus with flexible bronchoscopy ..in cytological examination % eosinophils was detected in bal. bronchoalveolar lavage cultures was negative. the patient was diagnosed chronic eosinophilic pneumonia and mg/ kg oral steroid was began. ivig was given up to patient; because of frequently recurrent sinopulmonary infection and patient had igg subclass deficiency. in the third month of oral steroid therapy physical examination findings and pft were improved and started inhaled steroid. conclusion: immunodeficiencies often can be seen alone. although, the pathogenesis of immundeficiencies with lung disease is not well understood and associated with interstitial lung disease. therefore, investigations must be include bronchoscopy and bronchoalveolar lavage. scid is a congenital heterogeneous group of diseases characterized by severe impairment of t,b, nk cell development and function. the hematopoietic stem cell transplanted patients with scid in the time period from to were evaluated. male/female ratio is / . median follow-up time is years ( months- years). parental consanguinity ratio was , %. mean age of onset of the symptoms was ± , months. most common clinical findings on admission were; pneumonia ( , %), moniliasis ( , %), diarrhea ( , %), dermatitis ( . %). classification according to t, b, and nk cell counts; (figure ). molecular genetic defects were determined in patients (figure ) are given. there is no difference between age groups according to occurrence of acute and chronic gvhd. death ratio increases with the increasing age. acute and chronic gvhd and number of deaths were significantly higher in peripheral stem cell transplanted patients. there is no statistically significant difference in occurrence of acute/chronic gvhd between b-and b + scid, who had been hla idantically transplanted from family donor. both groups have similar ratios of ivig treatment need after hsct. there is no statistically significant difference in occurrence of acute/ chronic gvhd between nk-and nk + scid, who had been hla idantically transplanted from family donor. both groups have similar ratios of ivig treatment need after hsct. death ratio was similar in groups. bcg dissemination in bcg vaccinated patients is significantly higher in the nk + group. the rate of complications due to severe infections is high and increases with age in patients with scid. hsct is curative, should be considered as early as possible. trec analysis for neonatal screening will give chance for early diagnosis and treatment of the patients. the hyper-ige syndromes are rare pids and are characterized by atopic dermatitis, skin abscesses recurrent pneumonias, elevated serum ige levels and sometimes mucocutaneous candidiasis. we have been evaluating and following up a group of patients with features suggestive for autosomal recessive hyper ige syndrome (ar-hies). homozygous dock mutations were identified in several of these patients. however, two siblings from a consanguineous family in this group of patients showed homozygous block in chromosome p . in homozygosity mapping which includes stk gene. sanger sequencing was performed for stk deficiency and showed a novel c. - delgata mutation in stk gene causing a premature stop codon. clinical manifestations of stk deficiency, also known as a macrophage stimulating (mst ) deficiency, stk deficiency comprise recurrent and severe viral skin infections including molluscum contagiosum and warts, fungal and bacterial infections and autoimmunity which are also the features of ar-hies. our patients's main features include autoimmune cytopenias (aiha and itp), cutaneous viral (molluscum contagiosum and mild perioral herpetic lesion), mild atopic dermatitis, seborrheic dermatitis, lymphopenia (particularly cd lymphopenia), and intermittent mild neutropenia. serum ige level was mildly high in these patients. our results indicates that patients that show clinical phenotype of ar-hies needs to be also evaluated for stk deficiency. determination of the underlying defect and reporting the patients are required for the description of the phenotypic spectrum of pids and the frequency of these diseases as well as for genetic counselling. mendelian susceptibility to mycobacterial disease (msmd) is a rare entity. patients with msmd have susceptibility to salmonella and some other intracellular microorganisms in addition to weakly pathogenic mycobacterial species. il- rβ deficiency, most common form of msmd, is caused by mutations in the il rb gene. patients who have symptoms suggestive for msmd or history of sibling death due to bcgosis were evaluated. the expression of the il- rb was detected in patients and family members by monoclonal antibodies on the lymphocyte surface by flow cytometry after the lymphocytes were stimulated in vitro with pha. mutation analyses was done by sanger sequencing. all index cases were presented either with bcg or salmonella infection. two patients, though they were bcg vaccinated had no clinical symptom, six presented with the symptoms of salmonella infections, two developed leukocytoclastic vasculitis, candidiasis was the accompanying feature in seven. recurrent leishmaniasis that necessitated subcutaneous interferon-γ and prophylactic amphotericine b therapy was present in a patient. in all patients the percentage of lymphocytes with il rβ expression was found to be less than % . prophylactic antimycrobial treatment and in severe and resistant infectious episodes if-γ therapy, should be given. many patients have associated mucocutaneous candidiasis. the prognosis is good unless the patient admits at the later stages of bcg infection. the results of our patients showed that the analysis of the surface expression of il rβ on activated lymphocytes is an effective diagnostic method which can also be used in screening of the patients with probable msmd. ataxia-telangiectasia (a-t) results from the loss of ataxia-telangiectasia mutated gene (atm) function and is a heterogeneous, multisystemic disease and characterized by accelerated telomere loss, genomic instability, progressive neurological degeneration, immunodeficiency, premature ageing and increased neoplasia incidence. even in classic a-t with ataxia and telangiectasia, the onset of clinical symptoms and the rate of progression are variable. here, we report two siblings was diagnosed as a-t with severe and early hypogamaglobulinemia, decreased cd , increased cd ro, no ataxia and telangiectasia, purulent otitis and hemophagocytosis that harbor a rare frameshift mutation of atm gene. Özdemir Öner ; bozdoğan sıla department of pediatrics, division of allergy/immunology, sakarya university, medical faculty, adapazarı, türkiye. department of pediatrics, sakarya university, medical faculty, adapazarı, türkiye. background: the acquisition of new food allergy after transplantation or transplant-acquired food allergy (tafa) is usually reported in adults and rarely in children. tafa is described mainly after liver, but also after small bowel/intestinal, lung and heart transplantations. in different studies, the male/female ratio is equal. literature data suggest that children with tafa typically present within the first year after surgery and they are typically allergic to multiple foods. aim: tafa is generally characterized with allergy to multiple foods and increased level of total and/or spesific ige. here, a patient although who had normal total. ige and specific ige test results, he developed reaction to skin prick test for cow's milk is presented and his clinical presentation will be discussed. case presentation: month-old-boy came to our allergy clinic with complaints of vomiting after drinking cow's milk and skin rush on the area where contact ed with chocolate. in his past medical histroy, left lateral segment of liver (donor was his mother) was transplanted to him when he was at months. the liver donor was not recorded as having a history of allergic disease. methylprednisolone and tacrolimus immunosuppression were used after the transplantation, and tacrolimus therapy was continued for prophylaxis of chronic rejection. when he was at months, family fed the patient with cow's milk but hours later he began to vomit. he vomited five times in two hours. then, he developed constipation. rectal irrigation was used. then oral intake stopped for two days. he was thought to be having food protein induced enterocolitis. his vomiting complaints repeated after intake of formula and baby food which include grain. so he fed with special formula including short-chain peptides and free aminoacids and his symptoms improved. past medical history: extrahepatic biliary atresia was diagnosed at weeks age with conjugated hyperbilirubinemia (according to scintigraphy and biopsy results). family history: his father has penicillin allergy and his aunt has asthma. at our outpatient clinic: height and weight were within normal percentiles. physical examination reevaled normal examination findings. laboratory findings: wbc was . /mm , with % neutrophils, % eosinophils and % lymphocytes. his hemoglobin was . g/ dl, platelet count was . /mm . background: except for antibody deficiency and complement defects, hematopoietic stem cell transplantation (hsct) is the single best curative treatment defined for primary immunodeficiency (pid) so far. in the current study, we aimed to assess the role of pid type, donor type and clinical status on hsct success rates. materials and methods: we retrospectively reviewed the records of a total of hscts procedures performed in patients diagnosed with pid between and , in ankara university pediatric allergy and immunology department. results: of the patients, had severe combined immunodeficiency (scid) and had non-scid. the survival rates following hsct, in both scid and non-scid patients were %. when classified according to the source of donor, patients who had a hla-matched sibling donor (msd) in the scid group had . % survival rate post transplantation, those who had a matched related donor (mrd) had . % and those who received a haploidentical donor had . % survival rates. in the non-scid group there were patients with haploidentical transplants ( omenn syndrome and mhc class ii deficiency) and all patients died. we assessed several potential risk factors associated with survival in scid patients. patients diagnosed over months of age with a pre-existing pulmonary infection, requiring intensive care and/or mechanical ventilation had significantly lower survival rates. conclusion: hsct is the best curative treatment for pid. our results demonstrated that hsct performed from matched family donors or even haploidentical parents is a lifesaving treatment in various types of pid's, especially in scid. introduction: in case of donor availability allogeneic hematopoietic stem cell transplantation (hsct) can be regarded as a definitive therapy for a variety of primary immunodeficiency syndromes (pids), including severe combined immunodeficiency (scid) and non-scid pids. study period: we retrospectively reviewed the hospital records of consecutive children with pid, who had allogeneic hsct in the last years, between january and january . our median follow-up time is , years ( months - , years) patients and methods: the median age of children at hsct was , months ( , months- years). boys/ girls diagnoses were based on anamnestic data, clinical findings, and immunological and genetic analysis. conditioning regimens included busulphan + cyclophosphamide, busulphan + cyclophosphamide + atg, fludarabine + melphalan or fludarabine + anti-cd in b-, t-, nk-scid cases conditioning was not used. indications for transplantation: patients' diagnoses were severe combined immunodeficiency (n = ), wiskott-aldrich syndrome (was, n = ), chronic granulomatous disease (cgd, n = ), xlinked lymphoproliferative disease (xlp, n = ), whim-syndrome (n = ), hyper igm syndrome (cd ligand deficiency, n = ), leukocyte adhesion deficiency (lad, n = ), dock mutation (n = ) transplantations: hscts for children were performed. patients were retransplanted ( pt once, pt twice, pt times), because of rejections. at the first hscts in / cases sibling bone marrow, / sibling peripheral blood, / sibling cord blood, / unrelated cord blood, / unrelated bone marrow, / unrelated peripheral blood, / haploidentical donors were used median cd count was , x /kg ( , x - , x /kg) patients engrafted on median ± day (anc > , g/l) acute gvhd occured in / cases ( pathomorphological findes: distortion of the structure of lymph nodes due to enlargement of paracortical zones and follicules was found in all patients. presumed atypical cells (makrolymphoblastes and berezovsky-sternberg-reed cells), were detected in patients overwise during follow-up for - years in these patients revealed no specific infectious and malignansy. accumulation of proliferating dn cells (a lot of mitoses) was characteristic fiture in lymph nodes and spleen of alps patients. setting of plasma cells in follicular zones in the lymph nodes was reveald in cases, and eosinophilesin , pronounced immunoblast proliferation in , sinus histiocytosisin . multiple hyperplastic follicles, extended sinuses with many phagocytizing macrophages, lymphocytic infiltration was revealed by histological examination of the spleen in all cases. immunohistochemistry findes: t-and b-cells proliferation (ki- expression), atypical location of lymphocyte populations, settings of plasma cells in all lymph node zones. in paracortical zones was found cd +, cd +, cd + cd -, cd + cd -cells in patients, cd +, cd + cells in patient; and in restricted follicular zones -cd +, cd +, hla-dr + cells in patients, cd +, cd + and cd + in patients. the presentation of a case of kimura disease in a patient with was. the was was diagnosed in year months, based on infectious syndrome, atopic dermatitis, hematological syndrome -skin hemorrhages and thrombocytopenia - * /l. after he performed often sars. regularly received ivig at mg/kg, antibiotic therapy with a positive effect -infectious syndrome stopped, controlled hemorrhagic syndrome. since there was a herpes virus infection with frequent exacerbations on the face. patient received acyclovir, valacyclovir, famvir with a temporary effect. in . on the left side of the face -periorbital region, eyelids, malar region appeared the site of soft tissue hyperproliferation - cm in diameter with a thickness of - cm, with moderate moist, painful on palpation, the left eye was closed, the lid margin ciliated dramatically thickened, deformed. in october-november was admitted in diagnostic department, massive antibiotic, antimycotic, antiviral therapy, ivig therapy. the histological study showed the angiolimphoid hyperplasia with eosinophilia without immunomorphological signs of malignant tumor growth. based on histological, immunohistochemical studies of the skin, these clinical and laboratory findings, diagnosis: mass lesion of the left face -kimura disease. patient helded courses of chemotherapy with positive dynamics: mass lesion decreased, erosive surfaces disappeared and now receives romiplostimum, acyclovir, biseptolum, ivig . g/kg time per month. under the observation there is a family k., which is unique in the deletion variants of the same region q. . and the presence of an adult patient with the di george syndrome. clinical manifestations of the syndrome in family members is differ. methods: clinical, laboratory, instrumental and genetic ( dna was isolated using a kit «qiaamp dna mini kit» and dna from dried blood spots was isolated using a commercial kit "dna-sorb-b». mlpaanalysis set salsa mlpa probemix p -b digeorge, genetic analyzer applied biosystems ). mother ( years), had few incidents of pneumonia before years. she was diagnosed ullrich-turner syndrome at age years. all childbirths by caesarean section. she has not any laboratory and instrumental findings of immunodeficiency, endocrinopathy, cardiac and thyroid abnormalities. she has deletion in the starting area of the di george region (lcr -a), including genes cltcl , hira, cdc , cldn , gp bb, tbx , txnrd , dgcr . father ( years), healthy, current smoker. the dna microstructural violations in di george region haven't been identified. son was from i pregnancy, heart defect was set prenatally, marked growth retardation. childbirth at weeks. he had unstable reduced cell parameters and hypogammaglobulinemia, the size reduction of the thymus and congenital heart disease: truncus arteriosus, dc b stage by lang. after days of life operated for congenital heart disease. during the surgical intervention the thymus wasn't found in a typical place. the postoperative period was complicated by sepsis, heart and respiratory failure. received ivig, antibiotic and antifungal therapy. he suffered from sars, severe course, the degree of respiratory failure ( months) -death. in mlpa-dna defined microdeletion disorders starting region di george (lcr -a) -from the -year-old dry blood sample (postmortem study a year old boy with bleeding, eczema and recurrent pyogenic infection was admitted to our department. the child who received treatment in hematology accidentally a few times, but has not had the effect of treatment . laboratory parameters -cd -cells- % ( ), cd -cells - % ( ), cd -cells - % ( ), cd -cells - % ( ), cd / -cells - % ( ), cd / cd - . , hla-dr- , nbt- . igg- . q /l, iga- . q / l, igm - . q / l, ige- u / ml. hb- g / l, erythrocytes- . x / l, leukosytes - . x / l, neutrophils- %, lymphocytes - % ( ), eosinophils- %, monocytes- %, metamielosytes:- %, plateletsrare was observed.normal bone marrow cells, the separation of platelets from meqakariosyt has become weak. the advantage of erythroid unordered have been observed. bone marrow puncture the mielokariosytes - . x / l, meqakariosytes - . x / l, blasts- . %, myelosytes - . %, metamyelosytes - . %, seqments - . % neutrophils-% . , eosinophils- . %, lymphocytes- . %, monocytes- . % erythroblasts- . %, pronormoblasts- . %, normoblasts- . % meqakariosytes - . %, plasmatic cells- . %.his younger brother with eczema, pyogenic infections (furunculosis) was admitted to our department. cd - % ( ) ataxia telangiectasia (a-t), is a genetic disorder caused by the homozygous mutation of the atm gene and, frequently associates with variable degrees of cellular and humoral immunodeficiency. however, the immune defects in patients with a-t are not well characterized. to our knowledge, there is no work on major lymphocyte subpopulations and recent thymic emigrants of a-t patients comparing to age-matched healthy controls. according to esid criteria, patients diagnosed as a-t and agematched healthy children were assigned to the study. both patients and healthy controls were grouped as - , - , - years and older than years. using flow cytometer, major lymphocyte subpopulations and cd + cd ra + cd + recent thymic emigrants (rte) were determined as per cent and absolute cell numbers and compared. no significant differences regarding all lymphocyte subpopulations were observed between age groups of a-t. comparing to the healthy controls, there were a decrease (in t cells, effector memory t cells, b cells, naïve b cells, switched b cells and rte) and there were an increase (in active t cells, naïve t cells and nonswitched b cells) in the absolute number and percent of some cell populations in the a-t group. findings of this study showed effector functions in some cell lymphocyte populations were decreased and could be thought that bone marrow of patients should be tried to increase the cells numbers. however, the study has an important limitation about patient and healthy population. ataxia-telangiectasia (a-t) results from the loss of ataxia-telangiectasia mutated gene (atm) function and is a heterogeneous, multisystemic disease and characterized by accelerated telomere loss, genomic instability, progressive neurological degeneration, immunodeficiency, premature ageing and increased neoplasia incidence. even in classic a-t with ataxia and telangiectasia, the onset of clinical symptoms and the rate of progression are variable. here, we report two siblings was diagnosed as a-t with severe and early hypogamaglobulinemia, decreased cd , increased cd ro, no ataxia and telangiectasia, purulent otitis and hemophagocytosis that harbor a rare frameshift mutation of atm gene. nijmegen breakage syndrome(nbs) is a rare autosomal recessive disease usually presenting at birth with microcephaly. here we present a case of nbs diagnosed at the age of twenty seven who admitted to our outpatient clinic with malaise, loss of appetite, weight loss and dyspnea on effort . she was hospitalized in another centre years before because of pneumonia, pancytopenia, generalized lymphadenopathy, hepatosplenomegaly and hypogammaglobulinemia (very low igg and iga) where she couldn't have any definite diagnosis. her past medical history was remarkable for primary amenorrhea and basal cell carcinoma excision from preaericular region when she was . she had no severe infection history before except frequent upper respiratory tract infections. her parents were consanginous and she had a brother died at months of age. microcephaly together with short stature, multiple palpable lymphadenopathies , splenomegaly and absent secondary sexual characteristics were prominent features in physical examination. direct fluorescence sequencing of the nbn gene showed a homozygous mutation in exon (c. _ delacaaa) which confirmed the diagnosis of nbs in our patient. nbs is mostly diagnosed in childhood. the delay in diagnosis was partly due to the lack of severe infections in her past medical history until she was . another factor that lead to the delay is that it is an unknown disease among physicians in turkey. the longest known survival is years in a patient who had no clinical features of nbs other than primary amenorrhea. as a result, our patient is one of the oldest patients reported in the literature presenting nearly all of the classical features of the disease and carrying the most common pathologic mutation. wiscott-aldrich syndrome (was) is a rare x-linked recessive immunodeficiency disorder characterized by thrombocytopenia, small platelets, eczama, recurrent infections and an increased risk of autoimunity and malignancy. the gene responsible for was is located in chromosome xp . -p - , which consists of exons, and encodes a -amino acid protein. in this study, we aimed to screen was gene mutations and analyze the effects of determined mutations in boys with non-classical was phenotype. ivs + g > a gene alteration in intron of was gene was identified in case , previously. so, rna isolation and then cdna synthesized was carried out. in case , after amplification of exons of was gene by pcr, the amplicons were sequenced. in this patient, g > c alteration was detected in the first base of intron . afterwards, cdna synthesized for detecting the splicing effect. based on the gel image results, cdna found to be base pairs smaller than the normal in case . in case , g > c alteration was detected in the first base of intron and then we determined multiple splicing products. two different splicing mutations (ivs + g > a and ivs + g > c) were detected in two cases with non-classical phenotype. ivs + g > a splicing mutation was stated in the literature, previously, but ivs + g > c mutation was first time identified in this study. whim is rare (< / ), heterozygous, autosomal dominantly inherited pid, caused by mutations in the gene encoding for the chemokine receptor cxcr , mapped on q locus. the altered cxcr / cxcl interaction impairs cellular homeostasis and trafficking, resulting in immunological dysfunctions with abnormal retention of mature neutrophils in the bone marrow (myelokathexis) and consecutive severe neutropenia, variable degree of lymphopenia and hypogammaglobulinemia. whim patients suffer from recurrent bacterial infections since early childhood and later on manifest a specific susceptibility to hpv infections with developing widespread warts. because of rarity of the disease, heterogeneity in clinical presentation and usually incomplete phenotype, the diagnosis is often delayed and whim syndrome is not suspected. a year old boy who is suffering from recurrent bacterial infections, often complicated with bronchopneumonia, with severe neutropenia, but also, with lower level of lymphocytes and still, normal serum immunoglobulin level is presented. he has no developed warts; neither his parents nor relatives have warts. at the age of years was unveiled the diseasecausing mutation in the cxcr gene (c. c > t; p.r x; heterozygote). severe congenital neutropenia accompanied with lymphopenia and findings of mature neutrophils in bone marrow, might be an easy approach for getting closer to the clinical diagnosis of whim syndrome. early identification is important for clinical and therapeutic management, allowing a more comprehensive follow-up and administration of appropriate therapy. we report two cases of congenital heart disease (tetralogia fallot and interruption aortic arch) with confirmed microdeletion chromosome q . by karyotype and fluorescence in situ hybridization analysis (fish). children underwent surgical correction of congenital heart defects with good postoperative outcome, although were complex. the phenotype of these patients can be extremely variable, frequently leading to clinical confusion, diagnostic delay, excess morbidity, early mortality. identification of these patients is essential for their adequate management and genetic counseling. a multidisciplinary approach is fundamental to ensure that the patient will be able to attain his or her maximal potential. the underlying cause of the juvenile periodentitis is not well understood but is now thought to be related to an abnormal immune system and to invading bacteria in the cementum of the teeth. instead painful fissures and recurrent pyogenic infections of the skin seem to be the most common medical complications. however, a number of pls patients with abscesses or pseudotumors of the liver have been described. there have been reports of pls patients with other stigmata such as growth retardation, non-symptomatic intracranial calcifications and mental retardation furthermore, coinheritance of pls and albinism type has been reported. case presentation: a yr old girl admitted to our hospital with chief compliant of skin lesions since early months of birth. in the past medical history; she had skin abscess and failure to thrive. on admission she had erythematous, shiny skin with generalized dry scaly predominantly palmoplantar hyperkeratosis and loss of teeth except four or five molar teeth. she informed that she had malformed teeth since childhood which fell off one by one. she had also poor oral hygiene non-pitting edema on lower extremities. no hepatosplenomegaly detected. family history was negative. she investigated for probable immune-deficiency with regard to skin lesions, history of skin abscess and ftt the lab finding are as following: cbc diff = normal ,crp = neg, esr = , ast = , alt = , alph = , alb = . , total pr = . , urea = , cr = . igg = , igm = , iga = , ige = . , cd = %, cd = %, cd = %, cd = %, cd = %, cd = % conclusion: according to nearly normal lab values and presenting signs such as: generalized pyogenic periodentitis, palmoplantar hyper keratosis and negative family history were attributed to a very rare autosomal recessive disorder with ectodermal dysplasia known as papillon-lefevresyndrome manifesting with palmoplantar hyperkeratosis and severe early onset of destructive periodontal leading to pre-mature loss of both primary and permanent dentitions. nijmegen breakage syndrome (nbs) is a rare autosomal recessive syndrome of chromosomal instability mainly characterized by microcephaly at birth, combined immunodeficiency and predisposition to malignancies. the disease is caused by mutations in the nbs gene, which encodes nibrin, a component of the hmre -rad -p complex involved in cellular response to dna doublestrand breaks. the aim of the present case report was to discuss two siblings with immunologically and clinically different phenotypes of disease presentation and to make an attempt to explain possible genotype-phenotype relation. the two patients and their non-consanguineous parents were clinically, laboratory and genetically investigated. for mother and father we observed no clinical presentation and no immunological abnormalities. sibling no. ( years old boy) had no history of recurrent infections and no deviation in immunological tests. sibling no. . ( month old girl) had recurrent infections since birth and iga, igg and igg deficiency as well as t-and b-cells deficiency. cytogenetic analysis revealed variable percent of spontaneous chromosomal instability which was more severe (in % of chromosomes analyzed) in sibling no. . additionally we sequenced bi-directionally ( amplicons) the dna samples from all family members to survey the germline genetic variation in the nbs gene. the del (exon ) was detected in both siblings in homozygous and in both parents in heterozygous feature. in order to explain different clinical and immunological presentation of two siblings the rest of the nbs exones were analyzed for genetic heterogeneity. no additional changes were observed. in conclusion patients with the same nbs genotype may show different phenotypes. other gene/epigenetic factors seem to play a role in phenotype modulation. omenn syndrome [mendelian inheritance (omim )] is an autosomal recessive form characterized by the presence of fatal generalized severe erythroderma, lymphoadenopathy, eosinophilia and profound immunodeficiency. objective: we studied clinical and immunological presentation of the disease manifestation and frequency c. - delaa (p.k vfs ) in rag gene among eastern slavs population. results: we collected clinical and immunological data of patients ( from belarus, -ukraine, -russia) females, males. age of omenn syndrome manifestation varied from st day of life to yr month. age of diagnosis - days to year months. in patients had classical immunological phenotype t(+/-)b-nk+, pt had tlowb + nk + with cd + tcrgd + expansion. in pts had mutation in rag gene, in had c. - delaa (p.k vfs ) in one or two alleles. at present moment in pts are alive, were transplanted, pt is prepared to bmt. conclusion: this study demonstrates that the most popular genetic abnormalities in eastern slavs children with omenn syndrome is c. - delaa (p.k vfs ) in rag gene. this information may be useful for rapid diagnostic of omenn syndrome in laboratories used sscp (single strand conformation polymorphism) before sequencing. under examination the patient particularly bright phenotype attracted attention: microcephaly, "birdlike" facial features (sloping forehead, nape, hypoplasia of brow ridges, broad nasal bridge and protruding midface, hypoplasia of the mandible). in addition, besides specific anomaly of the facial bones we noted: big ears, sparse hair and clinodactyly of the fifth fingers. clinical and immunological characteristics: the feature of the case is pancytopenia syndrome we have diagnosed at the early stages of observation and which is continued throughout the period of observation. erc - . - . x /l hb - - g/l leuk - . - . x /l neu - - % ( - cells/mcl) plt - - x /l data of immunological examination: iga - , g / l igm - , g / l igg - , g / l (other results of immunological examination are without features) the deep insufficiency of antibody production in our patient was the cause of serious, recurrent, and subsequently chronic bacterial sinopulmonary infections after years old. the results of clinical laboratory and immunological examination without significant features: erc - , - , x /l hb - - g/l leuk - , - , x /l neu - - % ( - cells/ mcl) plt - x /l iga - , g/l - . g / l igm - , g/l - . g / l igg - , g/l - . g / l (other results of immunological examination are without features) the x-linked chronic granulomatous disease (cgd) is a primary phagocytic cell deficiency characterized by severe bacterial and fungal infections of various organs. we report of a years of a male patient with xlinked cgd who presented with recurrent hepatic abscesses as the sole manifestation of the disease. phagocytic and bactericidal activities of granulocytes were studied by using microbiological assays. generation of superoxide anion by blood granulocytes was measured by the ferricytochrome c reduction test. cgd is an immunodeficiency caused by mutations in genes encoding subunits of the nadph oxidase complex. normally, assembly of the nadph oxidase complex in phagosomes of phagocytic cells leads to a "respiratory burst" essential for the clearance of microorganisms. cgd patients lack this mechanism, which results in life-threatening infections and granuloma formations. the leading cause of death are pneumonia and pulmonary abscess, septicemia and brain abscess. in neurogical manifestations various pathogens have been involved including aspergillus spp., s. prolificans, a. infectoria, salmonella and staphylococcus spp. there are only some several reports on fungal brain and spinal cord infection, aspergillus abscess resembling brain tumor, meningitis due to streptococcus and candida spp. in the past years we treated children with cgd. we present the infectological challenge of an x-linked cgd patient with brain abscess. in spite of our effort we were unable to identify its causative pathogen. empiric therapy sometimes resembles polypragmasia in cgd. to decrease mortality and morbidity from fungal infections in cgd the prophylactic use of itraconazole or voriconazole is widely recommended. a relatively new azole, posaconazole is active in pulmonary and cerebral fungal manifestations , indeed may be effective against fungi with inherent resistance to ampb or voriconazole. there was no etiological diagnosis in our case that did not respond to conventional antifungal and antibacterial treatment. based upon the findings and literature data we presume the causative agent might be some kind of moulds. we suppose the use of echinocandin and posaconazole as salvage ("prophylactic") therapy has resulted significant regression of the brain abscess. the diagnosis of chronic granulomatous disease (cgd) was verified in children during the past few years in the department of clinical immunology of regional children's hospital of chelyabinsk (russia). in our opinionin casesthe diagnosis was establishedearly enough. michael w. transferred to the neonatal pathology unit of our clinic at the age of days with vesiculopustules. take into consideration our own experience of observing children with this form of primary immunodeficiency in previous years, the child was conducted immunological examination, in particular, the test of restoration nitroblue tetrazolium by superoxide anionformed when oxygen explodes in leukocyte (nitro blau tetrasolium -nbt-test). this decision is caused by the fact that previously observed children with chronic granulomatous disease, had vesiculopustules in % at birth. the survey has revealed a complete lack of production of reactive oxygen species by neutrophils in the evaluation of nbt-test, which allowed us to suggest the diagnosis of cgd. the baby was banned vaccination against tuberculosis, and after reliever vesiculopustules the boy was discharged home. however, at the age of month the baby suffered from glandular abscess and right-segmental pneumonia. in cbc there is expressed anemia (hb g/l, erythrocytes - . x /l), leukocytosis ( x /l), accelerated esr ( - mm/h). at the age of months in the university of debrecen, medical and health science center debrecen, hungary, molecular genetic studywas conducted by prof. dr. laszlo marodi. it was revealed a mutation in c. g > a in exon of gene cybb (encoding subunit gp -phox), after that the diagnosis of cgd was finally verified. it was assigned a basic preventive antimicrobial therapy by trimethoprimsulfamethoxazole, and itraconazoleto prevent fungal infections. despite this since months the child has repeatedly and consistently suffered from bilateral groin lymphadenitis during the year, acute hematogenous osteomyelitis of the left ulna, pneumonias, purulent mesadenitis, endoperitonitis. the fact that the child aged months was diagnosed sepsisis evidence of the severity of infectious complications. clinical and biochemical blood tests were distinguished by consistently high levels of esr and the presence of leukocytosis, and also severe anemia. now the child is years months, he is undergoing treatment at the department of clinical immunology, russian children's clinical hospital (moscow) after bone marrow transplantation. case history № , christina n. from the early history we know that the girl's newborn period was uneventful. she was vaccinated against tuberculosis in the nursing home (no reaction). it was noted the formation of abscesses after vaccination against whooping cough, diphtheria and tetanus in and . months. in years months she suffered from mezootit. for the first time the girl came under our observation in the children's hospital in chelyabinsk (russia) at the age of years with right segmental pneumonia, complicated by the destruction. after further examination it was diagnosed tuberculosis of intrathoracic lymph nodes to the right with upper lobe bronchopulmonary defeat. to take into consideration given above, it was conducted immunological test that revealed a complete lack of production of reactive oxygen species by neutrophils in the evaluation of nbt-test. on the basis of the history, clinical manifestations and results of immunological examination chronic granulomatous disease was diagnosed. after fourmonth period treatment a recovery came from tuberculosis and child was transferred to outpatient monitoring. in years in this family a second daughter was born -arina n. taking into account revealed immunodeficiency of her sister, the child was not vaccinated against tuberculosis on our recommendations. a six-month-old child was conducted immunological examination, which, like her older sister, also shows a complete lack of production of reactive oxygen species by neutrophils in the evaluation of nbt-test. during the molecular genetic studies of both sisters it was identified identical mutation c. - del gt gene ncf (encoding subunit p phox). now the older girl is and her sister is years old. observing them in the dynamics neither of them do not show any life-threatening infections. thus, the recovery test of nitrobluetetrazolium by superoxide anion formed when oxygen explodes in leukocyte (nitro blau tetrasolium -nbt-test) is a fairly reliable method of early diagnosis of chronic granulomatous disease. chronic granolomatous disease (cgd) is due to defective phagocyte superoxide production leading to impaired microbial killing. it is comprised of a group of five genotypes with a common phenotype, chracterized by recurrent severe bacterial and fungal infections and tissue granuloma formation. patients with cgd often present with pneumonia, liver abscess, skin infections, lymphadenitis, osteomyelitis. a five month old boy was referred to pediatric infection unit by lymphadenitis. on the medical history, he had taken antibiotic therapy for lymphadenopathy when he was months old. the abnormal eye movement was noticed by the family and on the eye examination peripheric chorioretinal hypopigmented lesions were determined when he was months old. İn his labratory examination, viral serology were negative. his parents were not consanguineous. his mother's brother had died at years old. he had history of skin infections and osteomyelitis. his grandmother had been diagnosed as having tuberculosis lymphadenitis one year ago. on his physical examination, his growth was normal, patological findings were horizontal nistagmus, / degree systolic murmur, fistulized lymph tissue on the left submandibuler region. on the laboratory findings; he had anemia and neutropenia. immunglobulin levels and lymphocyte subtypes were normal. his respiratory burst activity was very low. chronic granulamatous disease was thougth in the patient by the clinical and laboratory findings. İt was detected gp phox mutation in the genetical analysis. he was diagnosed as having x-linked cgd. antibiotic prophylaxis (tmpsmx, flucanazol) and interferon gamma were started. he is months old now and he is on the list of match unrelated donor screening. patiens who has history of lympadenitis, skin infections and chorioretinal findings should be evaulated for the x-cgd. leucocyte adhesion deficiencies (lads) are rare autosomal recessive inherited disorders. three different forms of lads have been described so far. in lad-i, the most common leucocyte adhesion deficiency, the function of β integrin cd is lost. . while one of the first signs of the disease consist in delayed separation of the umblical cord, severe infections already start early during infancy. another feature of lad-i includes impaired wound healing. therefore, mortality during infancy is high. a fifty day old boy was referred to the hospital due to diarrhea and leukocytosis. the patient was delivered following an uncomplicated full term pregnancy. the parents were first degree cousins. father's brother and mother's uncle had died during infancy period. his umblical cord had separated on the th day. patient had applied because of diarrhea by starting in the first days of life and leukocytosis was detected ( . / mm ). on the physical examination, his body weight was gr ( th to th percentile) and his height was cm ( th percentile). there was a granuloma on the umbliculus. other systems were normal. in the laboratory examination, leukocyte count was high, immunoglobulins, respiratory burst activity, gaita analysing and culture were normal. in the lymphocyte subtype analysing, cd + b cells ratio was mildly low. cd , cd a, cd b, cd c levels were found to be very low. in the genetic analysing, it was detected two deleterious mutations in the itgb gene. patient had been diagnosed as lad- . he treated by antibiotics and then started prophylactic antibiotherapy. family screened for tissue match. his older sister was found full matched. he was referred to transplantation unit. it was applied bone marrow transplantation when he was months old. presence of delayed umblical cord separation and leucocytosis should be considered in the diagnosis of lad but these patients might have different symptoms such as diarrea. mendelian susceptibility to mycobacterial disease (msmd) is a rare entity. patients with msmd have susceptibility to salmonella and some other intracellular microorganisms in addition to weakly pathogenic mycobacterial species. il- rβ deficiency, most common form of msmd, is caused by mutations in the il rb gene. patients who have symptoms suggestive for msmd or history of sibling death due to bcgosis were evaluated. the expression of the il- rb was detected in patients and family members by monoclonal antibodies on the lymphocyte surface by flow cytometry after the lymphocytes were stimulated in vitro with pha. mutation analyses was done by sanger sequencing. all index cases were presented either with bcg or salmonella infection. two patients, though they were bcg vaccinated had no clinical symptom, six presented with the symptoms of salmonella infections, two developed leukocytoclastic vasculitis, candidiasis was the accompanying feature in seven. recurrent leishmaniasis that necessitated subcutaneous interferon-γ and prophylactic amphotericine b therapy was present in a patient. in all patients the percentage of lymphocytes with il rβ expression was found to be less than % . prophylactic antimycrobial treatment and in severe and resistant infectious episodes if-γ therapy, should be given. many patients have associated mucocutaneous candidiasis. the prognosis is good unless the patient admits at the later stages of bcg infection. the results of our patients showed that the analysis of the surface expression of il rβ on activated lymphocytes is an effective diagnostic method which can also be used in screening of the patients with probable msmd. introduction: mendelian susceptibility to mycobacterial disease (msmd, online mendelian inheritance inman ) is a rare immunodeficiency characterized by predisposition to infections caused by weakly virulent mycobacteria, such as mycobacterium bovis bacille calmette-gue´rin (bcg), environmental nontuberculous mycobacteria (ntm), and salmonella strains in otherwise healthy individuals. il- rb deficiency is the most common form of msmd and is characterized by childhoodonset mycobacteriosis with frequent recurrence. it has been found that patients with il- rb deficiencies are also prone to developing infections with nontyphoidal salmonella species with bacteremia and lymphadenopathy. here we present a girl with recurrent cutaneous leukocytoclastic vasculitis (clv) with salmonella enteritidis due to il- rb deficiency. case report: a four year old girl that had been diagnosed serologically with recurrent salmonella infections, associated with lymphadenopathy and skin eruption was admitted as having henoch-schönlein purpura. she had been vaccinated with bcg and developed left axillary lymphadenitis which spontaneously drained and had recurrent oral monilia plaque. edema and purpuric eruptions were present on the upper and lower extremities and the abdomen.multiple mobile, painful,enlarged submandibular lymph nodes of about x cm in diameter were palpable. skin biopsy showed a dense inflammatory site with eosinophils, neutrophils and fibrin in the upper dermis and dermal vessel wall,compatible with leukocytoclastic vasculitis. serological studies to assess diagnostic markers for vasculitis and infectious agents were all negative. immune work-up were unremarkable other than hypergammaglobulinemia. salmonella enteritidis was identified in blood culture. she responded dramatically to ceftriaxone treatment within a few days and lesions cleared completely. extended immunological and molecular genetic examination of the patient was carried out for il- /ifn-γ pathway defects. on the facs analysis of t cells for cell surface expression of the cytokine receptor chains, she did not express any il- rβ . discussion: in thepresent report, we describe a child with clv with salmonella enteritidis due to il- rb defi-ciency.in a large cohort of patients with il- rb deficiency, ntm, m. tuberculosis, disseminated bcg infection after inoculation with the vaccine, and salmonella infection have been described. sporadic cases with other infectious agents have also been reported. salmonella infections reported in these patients were due to extraintestinal, or septicemic, recurring infections caused by nontyphoidal salmonella species. only two il- rb -deficient patients have been identified with vasculitis due to salmonella strains; both came from turkey, where consanguineous marriages are common. kutukculer and colleagues reported the first case of s. enteritidis-associated clv. sanal and colleagues reported a clv case associated with group d salmonella infection. leukocytoclastic vasculitis is an immune complex mediated disease predominantly involving small vessels of the skin and can be associated with drugs or can be found as a component of other disease, such as infections, connective tissue disorders, and malignancies. infectious agents can cause vasculitis directly or clinically mimic primary vasculitis .multiple infectious agents have been suspected as triggering or contributory factors in the vasculitic process . several factors contribute to the primary vasculitis related to infections: a type or immune-complex reaction, cell-mediated hypersensitivity, abnormal immune regulation, and direct endothelial cell invasion by infectious agents. in our case, extensive evaluation was performed to determine the underlying vasculitis process. clinical and laboratory examinations revealed no association between vasculitis and other infections or an underlying connective tissue disease or medication. she responded well to ceftriaxone treatment, and clinical manifestations gradually resolved within a few days, providing strong evidence that improvement of the vasculitic lesions was due to elimination of the salmonella with antibiotics conclusion: our patient has one of the exceptional forms of il- rb deficiency, with recurrent clv due to salmonella enteritidis. although common presentations for salmonella infection in individuals with il- rb deficiency are lymphadenopathy and bacteremia, it can be present clinically as clv. some infections such as salmonella may be responsible for different types of vasculitis even though they are not common . in this respect, clinicians should be aware of possible infectious causes of vasculitis, and children presenting with unusual recurrent infections caused by non typhoidal salmonella, bcg, or ntm should be investigated for ifn-γ ⁄ il- pathway defects. gülez n.; genel f. dr. behcet uz children hospital allergy-immunology department, izmir, turkiye the complement system is an important part of the innate immune defense and also plays a major role in shaping the adaptive immune response. these functions are required for a good defense against infections, especially bacteria. the c deficiency is a rare disease that is associated with recurrent neisserial infections, especially meningits caused by n. meningitidis. the patient, a seven years old girl was admitted to hospital with high fever and diffuse, purple-coloured skin lesions. her symptoms gave the diagnosise meningococcal meningitis. she had also earlier been diagnosed with the same disease when she was years old. a sister to the patient had died from meningitis at years of age. she has also one older and one younger sister. there is no consanguinity between her parents. the laboratory analyses of the classical pathway measured as complement hemolytic activity (ch ) and c concentration revealed no activity and absence of c , respectively. analysis of serum from her younger sister showed the same results, while her older sister's ch and c levels were found normal. thus, our patient and her younger sister were diagnosed with hereditary c deficiency. the genetic analyses have not been completed yet. we here report the third and fourth cases of c deficiency in turkish patients. interferon-g receptor- (ifngr ) deficiency is caused by mutations in ifn-γ receptor- gene and is characterized mainly by susceptibility to mycobacterial disease. we report a boy with complete recessive ifngr deficiency, afflicted by recurrent mycobacterial diseases with m. bovis, m tuberculosis, m. avium intracellulare and m.fortuitum. genetic analysis showed a homozygous mutation ( inst) in ifngr gene leading to complete ifngr deficiency. in addition, he had atypical mycobacterial skin lesions caused by m.avium intracellulare and he developed scrotal and lower limb lymphedema secondary to compression of large and fixed inguinal lymphadenopathies. to our knowledge, the patient is the first case with interleukin- /interferon − γ pathway defect and severe lymphedema. defects in the il- / ifn − γ pathway must be considered in patients with disseminated or recurrent mycobacterial infections and in patients with severe viral infections, especially in countries where bcg vaccination is part of the national health programme. it must be kept in mind that these patients may develop granuloma-like skin lesions and severe lymphedema. hsct must be applied at the earliest time before developing organ damages. t lymphocyte/nk cells. restricted defective molecules in the circuit and recently discovered cybb responsible for autophagocytic vacuole and proteolysis have been identified in around % of patients with the mendelian susceptibility to the mycobacterial disease (msmd) phenotype. primary defects in oxidase activity in chronic granulomatous disease (cgd) lead to severe, life-threatening infections. the role of phagocytic respiratory burst in host defense against mycobacterium tuberculosis was controversial. previous studied showed that the critical role at reactive oxidants is to serve as intracellular signals for activation of microbicidal enzymes, rather than excretions a microbicidal effect perse.the role of phagocytic respiratory burst in host defense against m. tb is further supported by recent studies discovered immunological defects secondarily affecting phagocyte respiratory burst function and resulting in primary immunodeficiencies with varied phenotypes, including susceptibilities to pyogenic or mycobacterial infections. the patients with severe pid's like scid have broader diverse infections susceptibility and mycobacterial infections as well, however, common variable immunodeficiency (cvid) mostly characterized by a deficiency of immunoglobulins and recurrent sinopulmonary infections. method: we overview the clinical rate of mycobacterial disease in our pid cases and evaluate the complex cases. results: two hundred pid cases were evaluate between - in our clinic, among % of them which diagnosed as msmd nearly all presented with mycobacterial infection. % diagnosed as cgd and interestingly % of them have been experienced mycobacterial disease sometimes in their life, as disseminated bcg or late onset complications of bcg including osteomyelitis or mtb once or more than one episode through their life. also we have presented a cvid patient with disseminated tb and granulomatouse hepatitis, tb arthritis , peritonitis and a patient with lad and nontubercolouse mycobacterial infectiouse abcesses of her skin. conclusion: pid cases like cgd, msmd or cvid which are living in area's with high prevalence of mycobacterial infection could have quiet different presentations and the study of these complex cases has provided essential insights into the functioning of the immune system. despite the conventional view we have confirmed that the generation of rois by phagocytic respiratory burst may play a role in the defense of the host against m. tuberculosis by clinical evidence. goran ristic, srdjan pasic, bojana slavkovic division of clinical immunology, mother and child health care institute of serbia, belgrade chronic granulomatous disease (cgd) is a rare disease caused by mutation in any of the five components of the nicotinamide adenine dinucleotide phosphate (nadph) oxidase in phagocytes, resulting in recurrent, life-threatening bacterial and fungal infections of the affected individuals. our proband male patient presented at age of years with bilateral pneumonia and positive serology for aspergillus sp. the phorbol myristate acetate (pma) stimulated nitroblue tetrazolium (nbt) test showed no reduction ( %) in our patient and partial reduction ( %) in his mother. analysis of the cybb gene showed a deletion of nucleotide g (c. delg) exon causing frame shift mutation and early termination of translation (p.val serfs). this mutation was not previously described. at the moment of diagnosis, his mother was already pregnant, th week of gestation. fetal ultrasound showed that she was carrying a male fetus. the fetal blood sample, obtained by the percutaneous umbilical cord blood sampling, showed male karyotype and the pma stimulated nbt test showed % reduction. there were no complication during pregnancy or delivery and a healthy boy was born. the proband patient underwent allogenic hsct, his sister was the identical sibling donor. in the cases where the family-specific mutations are unknown, partial or complete gene deletions can be recognized by multiplex ligase-dependent probe amplification (mlpa) or array comparative genomic hybridization ( features of the patients with ar-hies dock- deficient and non-dock- deficient group are given in the table . all patients with dock- deficiency presented with cutaneous viral infections or early onset and severe atopic dermatitis. many have also food allergy and/or asthma. neurological complications and malignancy were seen in % and % respectively. sixty seven percent of patients had low t; %, low cd levels; %, high ige. the latter features were shared between patients with or without dock- deficiency, except atopic dermatitis which was mild when present in patients without dock- deficiency and ige levels were only mildly high or normal. we identified stk and coronin a deficiency in two siblings each among the patients who showed overlapping features with ar-hies and do not have dock- deficiency. our results showed that patients with dock deficiency have early onset and more remarkable eczema, food allergy, asthma, more marked eosinophilia, higher ige, low igm levels and development of malignancy. these features may be helpful in differentiation dock patients from patients without dock- deficiency. it seems routine lymphocyte subset study results are not helpful for this differentiation. alişan yıldıran , stephan borte murat elli , tunç fışgın ondokuz mayıs university, school of medicine, samsun-turkiye immunodeficiency center leipzig (idcl) at klinikum st. georg ggmbh, leipzig-germany hsct might be curative for some pids. our immunology and transplantation center was newly established. we retrospectively reviewed all children with pid who diagnosed and received hsct at ondokuz mayıs university or somewhere between june and december . twenty-two patients were identified. four of them were referred to us for hsct from other centers. the median age was months ( month- yr) at hsct. patients' diagnoses were scid (n = ), chs (n = ), leukocyte adhesion deficiency (n= ), mhc class ii deficiency (n= ), chronic granulomatous syndrome (n = ), hlh (n = ), was (n = ) and omenn's syndrome (n = ). seven patients received hla-matched related hsct; twelve haploidentical hsct and two matched unrelated hsct. one scid patient died just after her diagnosis. two patients developed bcgosis secondary to reactivation of pretransplant vaccination. one of them died due to hemophagocytic bone marrow aplasia, and the other has recovered. five patients had graft failure; two of them received no conditioning regimens because of general health status and the other because of cmv infection. at a median follow up of months (range - ), patients are alive, with overall survival of %. we conclude that; our clinic undertakes an important duty in our region for pid patients. also, different pid's could be seen in our region. nerological complication patient (epilepsy, brain infarct) outcome died (one with post -bmt comp., with malignancy all alive department of pediatrics and adolescent medicine department of allergology, rheumatology and clinical immunology, university children's hospital, university medical centre, ljubljana, slovenia. developed.there is no severe life-threatening complications development. we describe here a patient with invasive cryptococcus laurentii infection and the x-linked form of hyper-igm syndrome (x-higm). c.laurentii is an extremely rare human pathogen. this fungus was previously considered saprophytic and non-pathogenic to humans, but it has been isolated as the etiologic agent of skin infection, keratitis, endophthalmitis, lung abscess, peritonitis, meningitis, and fungemia. most affected individuals had a compromised immune system because of leukemia, cancer, diabetes mellitus, aids, or prematurity. repeated isolation of c.laurentii from the oropharynx of an immunocompromised patient has also been documented. invasive c.laurentii infection has not been reported in patients with any form of primary immunodeficiency disorder emphasizing the true rarity of disease due to this fungus. two groups have recently reported that dectin- deficiency due to the mutation of clec a or premature termination of the dectin- signal transduction molecule card may predispose patients to chronic mucocutaneous candidiasis (cmc). we studied the frequency of clec a mutation in healthy individuals, patients with the hyper-ige syndrome (hies), and patients with autoimmune polyendocrine syndrome type (aps- ), all aged between to years. genomic dna was isolated from peripheral blood. monocytes and monocyte-derived dendritic cells (mddcs) were used to study the phenotypic expression of dectin- . clec a gene was sequenced with the big dye terminator cycle sequencing kit. mononuclear cells (mcs) were isolated from heparin-treated venous blood. mdccs were obtained by culturing monocytes isolated by immunomagnetic cell separation assay. receptor expression was assessed by flow cytometry. secretion of il- a by mcs stimulated with killed c. albicans blastoconidia was assessed by elisa. we report here on healthy individuals with homozygous (one year-old man) or heterozygous ( men and women) tyr x mutation in the dectin- gene but no signs of cmc. dectin- levels on monocytes and mddcs were negligible in the homozygous man and the heterozygous individuals displayed intermediate levels of dectin- , between those of the homozygous man and the wild-type controls. markedly lower levels of il- a production were observed in the cells of the man with the homozygous mutation than in the control cells. levels of production of this cytokine were intermediate in heterozygotes. the frequency of tyr x heterozygous individuals was % among healthy donors and % in patients with hies and % in patients with aps . importantly, the year-old hies girl with heterozygous tyr x mutations has never had mucocutaneous candidiasis. we suggest that dectin- receptor-mediated immunity is redundant for host defense against cmc, possibly due to the involvement of multiple lectin receptors in the recognition and uptake of candida. chronic mucocutaneous candidiasis (cmc) is a heterogenous group with recurrent chronic candida infections spesifically involving nails, skin and oropharynx. several immunodeficiencies as dock- deficiency, severe combined immune deficiency, autoimmune polyglandular syndrome type (apeced), il- rβ and il- p deficiencies, card , stat- and stat- can cause cmc. we report here a years old boy, born to consaginous parents with onicomycosis, moniliasis, recurrent pneumonia, recurrent herpetic lesions, autoimmune thyroiditis and trombocytopenia. last admission was due to generalized tonic-clonic convulsion and mycotic aneurism on middle cerebral artery was detected. flow cytometry revealed cd lymphopenia, immunoglobulin values were in normal range. polymorphism on exon for aire gene (t/c heterozygot g g) and heterozygot stat mutation (c. > a; q h) were detected. various stat gof mutations (affecting the coiled-coin domain or the dna-binding domain) have been systematically associated with susceptibility to cmc. autoimmune manifestations associated with stat- mutations have been attributed to increased type interferon. the aneurism formation is not elucidated whether it's due to candida infection or vascular damage directly affected by stat- mutation. purpose: chronic granulomatous disease (cgd) is a rare genetic disease of phagocytic system. affected patients commonly present with bacterial infections associated with pneumonia, abscesses and lymphadenitis. in this study, we investigated the clinical and laboratory findings of our cgd patients. materials and methods: the demographic data (age at diagnosis, initial presenting symptoms, family history, follow-up period), mutation analysis, therapy options, complications, radiological findings and prognosis were evaluated retrospectively. results: among cgd patients, autosomal recessive form was detected in of them. the age at onset was statistically lower in x' linked cgd patients than ar form ( . ± . mo vs . ± . mo; p = . ).respiratory tract infections (sinusitis, otitis, pneumonia) and recurrent abscesses were more commonly seen at onset. microbiological culture revealed a. fumigates from lung biopsy in one patient and s.marcescens from blood specimen in other ones. bcgitis was observed in one patient and five patients received anti-tb therapy. non-infectious complications were granulomatous uveitis, recurrent pericardial effusion, skin granuloma, noduler formation in lung and brain area. conclusion: due to high rate of consanguinity, autosomal recessive inheritance was observed highly in our patient cohort. since, patients with cgd are susceptible to tuberculosis and bcg complications; initiation of tuberculosis prophylaxis is advisable in countries where bcg is still administrated at birth. key words: chronic granulomatous disease, consanguinity, bcg. acquired immunodeficiency research center, isfahan university of medical sciences, isfahan, iranbackground: defects of the immune system in primary immunodeficient diseases (pids) predispose individuals to recurrent infections. complex genetic components for susceptibility to mycobacterial disease have been suggested. natural human immunity to the mycobacteria group, including mycobacterium tuberculosis(mtb), bacille calmette-guérin (bcg) or nontuberculous mycobacteria (ntm) relies on the functional il- / -ifn-γ integrity of macrophages (monocyte/dendritic cell) connecting to key: cord- - ydvjmr authors: sekhar, laligam n.; juric-sekhar, gordana; qazi, zeeshan; patel, anoop; mcgrath, lynn b.; pridgeon, james; kalavakonda, niveditha; hannaford, blake title: the future of skull base surgery: a view through tinted glasses date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: ydvjmr abstract this article broadly outlines the potential advances in the field of skull base surgery, which may occur in the next years based on many areas of current research in biology and technology. many of these advances are also broadly applicable to other areas of neurosurgery. we ground our predictions for future developments in an exploration of what patients and surgeons most desire as outcomes for care. this leads to an examination of recent developments in the field and outlines several promising areas of future improvement in skull base surgery, per se, as well as identifying new hospital support systems needed to accommodate these changes. these include, but are not limited to advances in imaging, raman spectroscopy and microscopy, -dimensional printing and rapid prototyping, master-slave and semi-autonomous robots, artificial intelligence applications in all areas of medicine, tele-medicine, and green technologies in hospitals. in addition, we review therapeutic approaches employing nanotechnology, genetic engineering and anti-tumoral antibodies, as well as stem cell technologies to repair damage caused by traumatic injuries, tumors, and iatrogenic injuries to the brain and cranial nerves. additionally, we discuss the training requirements for future skull- base surgeons and stress the need for adaptability and change. however, the essential requirements for skull base surgeons remain unchanged, namely: knowledge, attention to details, technical skill, innovation, judgement, and compassion. our conclusion is that active involvement in these rapidly evolving technologies will enable us to shape some of the future of our discipline to address the needs of both patients and our profession. and anti-tumoral antibodies, as well as stem cell technologies to repair damage caused by traumatic injuries, tumors, and iatrogenic injuries to the brain and cranial nerves. additionally, we discuss the training requirements for future skull-base surgeons and stress the need for adaptability and change. however, the essential requirements for skull base surgeons remain unchanged, namely: knowledge, attention to details, technical skill, innovation, judgement, and compassion. our conclusion is that active involvement in these rapidly evolving technologies will enable us to shape some of the future of our discipline to address the needs of both patients and our profession. complex aneurysms and vascular lesions, and safely reconstruct the skull base to promote healing and prevent cerebrospinal fluid leakage and infections. more recent technological introductions have proceeded to revolutionize the treatment of challenging skull base pathology including the introduction of endoscopic surgery, advances in neuroimaging, radiosurgery and high energy focused radiotherapy, the perfection of vascular bypasses for replacement of major arteries and venous sinuses involved by tumors , , , and the use of skull base approaches to treat complex vascular lesions. through the establishment of organizations such as the north american skull base society, the world federation of skull base society, as well as clinical institutions focused on the refinement and teaching of skull base surgery, the knowledge and skillset necessary to properly practice this challenging subspecialty have been effectively disseminated. this long history of innovation has presently resulted in the safe and effective practice of skull base surgery. however, the discipline remains on the cutting edge of neurosurgery and many challenges have yet to be addressed. in this paper, the authors survey the many emerging technologies that appear poised to bring about the next revolution in the skull base surgery. many of the advances described in this article are generally applicable to many areas of neurosurgery. although the future is always difficult to predict, a specialist discussion of the most promising advances may help young surgeons entering the field and in turn help to shape the future. a number of techniques that may have an impact on skull base surgery are shown in table . we will focus on some but not all of these areas. patients ultimately want their surgical team to cure, control, or ideally facilitate the prevention of disease. they favor minimally invasive approaches. when possible, they want illnesses to be treated by medicines only; if further intervention is necessary, they prefer minimal surgery or radiosurgery without any tissue damage; and when it cannot be avoided, more extensive surgery without undue risk. patients rightly put a premium on minimizing morbidity, which means no damage to surrounding brain, cranial nerves or blood vessels and no cosmetic deformity. regardless of the approach, they want to minimize time away from work and family and to be treated for a reasonable cost. surgeons chose their profession to heal patients and to cure or control diseases by performing elegant operations within their limits without major complications. they want to balance this pursuit with their desire to live well and to be healthy and happy with their families. finally, they want the freedom to operate with the professional autonomy they have earned through their pursuit of highly specialized training without undue interference from the hospital administration or the government in their daily practice of medicine. the best way for surgeons to ensure that the needs of their future patients are being met is to continue to drive the innovation necessary to deliver transformative treatment options that are effective, economical and minimally disruptive. for tissue preservation and augmented diagnostic utility , . examples are shown in figure , wherein an ex-vivo skull base neoplasm has been examined by a raman fiber-optic touch probe device to determine a biochemical "fingerprint" of the specimen ( figure a and b), and by the stimulated raman scattering microscopy, in comparison with subsequent conventional tissue section stained with h&e ( figure c and d). in addition, such imaging modalities can be combined with immediate treatment. for example, laser thermal ablation is already being used in the mri suite for epileptic lesions and some brain tumors with variable results , . lasers or ultrasonic removal may also be combined with rapid intraoperative pathology for precise intraoperative tissue removal. sporadic diseases exhibit multiple mutations, unlike syndromic diseases. they require broader approaches than the treatment of syndromic diseases. immunotherapy is an approach that is being commonly used in other malignancies , using antibody-based drugs that target tumor-specific surface antigens. an example is the use of bevacizumab, an antibody that targets the the most important step in bringing novel therapeutic approaches to skull base pathology is the detailed molecular characterization of each of the pathologic entities that collectively make up "skull base tumors". such efforts are underway and will to expand as investigational techniques become more widely available and cost effective. for skull base tumors, we will need to tailor our therapeutic interventions based on disease-specific, and even patient-specific, mutational, transcriptional, or epigenetic profiles. this type of "precision medicine" will offer hope to patients for which our current treatment paradigms are inadequate. in the hospital, ai will become increasingly essential. robotics and ai will combine to influence every aspect of healthcare (see below). ai may be employed in the icu and general ward to monitor patient care in addition to providing clinical decision-making support to doctors and nurses. for instance, robotics will find increasing applications in all areas of surgery, including skull base and neurosurgery. in order to be adopted widely, a medical robot should be able to perform a task as well or better than a human, not cause any harm to the patient or the human workers, be able to adjust to the human environment, and able to be rapidly cleaned and sterilized. tasks requiring great accuracy, it is widely expected that there will be increased use of ai combined with robotics in the or in the next years. the great benefits will be for procedures which will require great precision, procedures performed through a small space, in japan, humanoid robots, specifically nurse robots and robotic assistants, are being developed due to a lack of medical personnel and caregiver resources. in the usa and other countries, such humanoid robots have also been developed for other uses. hansen robotics (hansen robotics co., hong kong, china) has created human looking and speaking humanoid robots, endowed with ai, notably those named jules and sophia. these robots have been given speech recognition skills, responses, and some other skills, but not all the elements of intelligence that are displayed by humans. humanoid robotic nursing assistants will be developed and widely used in future due to health care worker shortages, patients' desire to have x nursing assistance, and the needs created by infectious diseases wherein human-human contact must be minimized. we expect that hospitals will also use robots to replace or supplement employees such as internal delivery workers, cleaners, and other jobs inside the hospital, which require regular or rapid maintenance such as with the hospital's sewage, water, or electrical supply. cleaning of operating rooms, or other hospital rooms, which do not have patients, can be done efficiently and rapidly with ultraviolet light or other techniques, using robots , . such robots will need to be supervised by their human counterparts. but they will learn steadily with use and such knowledge can be transmitted readily to other robots like them. it is to be expected that, initially, there will be resistance to deployment of these robots, but over time, people will gradually accept them, primarily because of increased safety and lowered cost of health care. however, both of these putative benefits will need to be demonstrated scientifically. technology will transform the education of students, residents, and surgeons in the future. students will be able to study anatomy and physiology in -d, -d, and -d. the fourth dimension reflects the time-related changes in -d images (for example, carotid artery anatomy as the heart beats) along with physiology. the fifth dimension indicates three dimensional images changing in time with simulated pathology. advanced virtual reality and surgical simulations and one on one coaching by ai enabled robots will supplement traditional teacher- student learning. flexibility in adapting to quickly evolving and increasingly sophisticated systems of cognitive offloading will be critical to student success. in the future, imagination, problem solving, and the ability to work in teams with diverse members (including ai-enabled robots) will be more important than accumulation of knowledge. this is because massive knowledge storage will be available for quick recall. master ai brains will assist all of our medical work to varying degrees. this will reduce medical errors, increase work efficiency, and improve on the job learning. the educational qualifications and training for trainee neurosurgeons will be different in the next decade. mathematics, biology, physics, chemistry, and logical thinking will still form the building blocks of education in science. however, residents will also need to learn computer science, software hospitals of the next years will be very different from the hospitals today. we envision they will be smaller and closer to patients with only the most difficult cases transferred to central hospitals. all hospitals will be environmentally friendly and carbon neutral, deriving their entire energy requirements from renewable energy. this will also apply to products used in hospitals. they will be providing an enhanced and optimal healing environment for patients. for example, the patient rooms may be optimized to each patient with use of colors, plants, music, sunlight, etc. better methods of medical waste disposal will need to be developed, to avoid environmental contamination and spread of infection into communities. the future of health care workers in the age of robotics and ai in parallel with many other industries, fewer health care workers will perform manual and highly repetitive jobs and ai-enabled robots will replace some such workers. health care workers in hospitals will require greater skills and education. hospital employees will be happier, work less, and supervise robotic workers. there will be fewer radiologists, pathologists, family doctors, etc., due to robotic assistants. home visits may be made by humanoid robot (ai enhanced) exhibiting great knowledge, empathy, and no prejudice. surgeons, trainees, and other health care workers will also work collaboratively with such robots and ai since they will become commonplace. surgeons will be performing less invasive but more technically complex procedures. there will be great emphasis on master-slave robots and supervision of autonomous robots performing procedures. there will be a great role for innovators and a constant retraining for the newer procedures. with increasing use of ai and robotics, will human beings still be involved in patient care? since the patients are humans, there will always a need for human beings to care for them. however, we will see an evolutionary change in health care professionals in the next years. adaptability, cooperation in the work environment, compassion, and a special set of skills will be required of surgeons. some of these will not be obvious until the new reality emerges. the current covid- epidemic has suddenly enhanced the use of many technologies which had been developed, but not deployed on a large scale. these include tele-consultations, tele-working, different requirements for sterilization of hospitals, and home based learning. the lead author's team has also developed a low cost "home microsurgery lab" for resident trainees, and proposed this as the seventh competency in resident training in the usa . many of these changes will influence patient comfort, safety, costs of medical care, and the need for particular types of health workers. skull base surgeons and neurosurgeons of the future need to be nimble, adopting newer technologies as they become available. however, essential characteristics remain unchanged. these are knowledge, innovation, technical skill, judgement, and compassion. our active involvement in these technologies will enable us to shape some of the future. innovation will be an important requirement of future and current doctors. innovations may not be major but may be found instead in the small things impacting our day-to-day work. or they may relate to clinical surgery, basic neurosciences, workflow and efficiency, outpatient and hospital infrastructure, patient satisfaction and quality improvements. young surgeons must constantly strive to leave things better than they find them. surgeons need to be actively involved in hospital, and health care administration to guide the changes. tissue engineering to fabricate blood vessels, bone, facial tissues, etc. in conjunction with -d printing f) nanotechnology to engineer diagnostic and therapeutic particles g) rapid molecular and genetic diagnosis of tumours h) anti-tumoral antibodies, car-t cells, and checkpoint inhibitors to treat malignant tumours i) crispr cas- based genetic engineering techniques to eliminate inherited syndromes such as neurofibromatosis, von-hippel lindau's disease j) stem cell technologies to repair damage caused by traumatic injuries, tumours, and iatrogenic injuries to the brain, and cranial nerves k) master-slave, and semi-autonomous robots for use in the operating room l) humanoid robots as helpers in the operating rooms, cleaning services, food services, and nursing services in hospitals m) artificial intelligence applications for diagnosis of disease, in the hospital, and outpatient care n) re-engineered hospitals which are green, energy self-sufficient, use proper waste disposal, and adapted to the patient's needs o) new training methods for residents, and surgeons saphenous vein graft bypass of the sigmoid sinus and the jugular bulb during the removal of glomus jugulare tumors results of attempted radical cerebral revascularization for difficult skull base tumors. a contemporary series of patients. world neurosurgery shining light on neurosurgery diagnostics using 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database and web-based tool for image annotation the roboscope™ is shown with the actuator mechanism the bendable sheath presently has channels, the top two (sfe . mm)are for the two laser endoscopes, the middle two ( . mm) are for the instruments, and the bottom two ( . mm) are for suction devices. the channels can be modified to suit the surgical needs the roboscope™ with two different dimensions ( mm and mm the roboscope™ is now bent, with the tow tools in close up the karns introducer device™ for the roboscope™ is shown with a) the tulip closed, and b) the tulip open cadaveric use of roboscope™. a) shows the introduction of the roboscope™ through an opening in the skull base of a cadaver b)the remote manipulation of the controls c) the view of the structures through the laser fiber-optic endoscope (courtesy of eric seibel concept of the artificially intelligent robotic assistant, showing a) the surgeon and robotic assistant , and b) the surgeon, a human, and a robotic assistant ground truth (gt) annotation for identifying instruments in a surgical field through the neuroid dataset generated by the uw team (a) input frame (b) annotations were created using the labelme annotation tool (c) gt for distinguishing tool vs background (tissue, gauze, etc) (d) gt for locating each class of conceptualization of the android robotic nurse helper (arnh) for a patient in isolation due to an infection. the physician and the nurse are able to remotely view the patient, and all of his vitals, even sense palpation using haptic sensors, and instruct the robotic nurse helper the anrh is present with the patient continuously round the clock, and is able to sterilize itself using ultraviolet light or other methods acknowledgements: we wish to thank raja sekhar, for his review of the manuscript and the authors report no conflict of interest in this paper. key: cord- -us wwmp authors: nan title: abstracts for the ipna congress, august - september , shanghai, china date: - - journal: pediatr nephrol doi: . /s - - - sha: doc_id: cord_uid: us wwmp nan first days after the diagnosis. dwi-mri was performed without application of contrast medium and without general anaesthesia. results: dwi-mri examination confirmed the inflammatory infiltration in kidney parenchyma in all our patients ( %). on the other hand, static renal scintigraphy confirmed inflammation only in children ( %). six months later, none of the two follow-up examinations showed any signs of inflammation or scarring in children examined so far. conclusion: in conclusion, nuclear magnetic resonance (dwi-mri) imaging seems more beneficial and accurate in the diagnostics of acute pyelonephritis when compared with static renal scintigraphy. moreover, dwi-mri provides more accurate information on the extent of kidney damage. objective: to evaluate the most proper radiologic investigation algorithm in detecting high grade vesicoureteral reflux (vur) and renal cortical scarring after first febrile urinary tract infections in infants aged less than one year . methods: a total of infants aged less than one year with a first febrile urinary tract infection who completed the diagnostic follow up of renal bladder ultrasound (rbus), voiding cystourethrography (vcug) and late months technetium dimercaptosuccinic acid renal scan (dmsa) were enrolled in the study.the most proper radiologic investigation algorithm that could highly detected both high grade vesicoureteral reflux and renal scar in infants after the first febrile urinary tract infection considering high benefit, low cost, low radiation exposure were assessed. results: abnormal renal bladder ultrasound (rbus) was identified in ( . %) infants. vesicoureteral reflux (vcug) was identified in ( . %) with high grade reflux (grade and ) in ( . %) infants.abnormal renal parenchyma including renal scar was identified in ( . %) infants.the top down approach with late months dmsa scan showed high benefit in detecting all abnormal renal parenchyma including renal scars, with high sensitivity ( %) in detecting high grade vesicoureteral reflux (vur) whereas reducing the unnecessary investigation for low grade vur ( . %) and radiation exposure per patient ( . msv). conclusion: currently, there is no ideal diagnostic radiologic investigation after a first febrile urinary tract infection in infants and children.the study suggest performing the top down approach with late months dmsa scan that could detect all renal scars and highly detection of high grade vur. abstract# p-sat association between postvoid urine bladder volume and urinary tract infection in infants and children: a retrospective cohort study orpheus monakil, ivy avilla department of pediatrics, da la salle university medical, philippines objective: to determine the association between post void urine bladder volume residual and urinary tract infection(uti) in children. methods: medical records of pediatric patients aged to years old with diagnosis of urinary tract infection were reviewed. demographic data, urinalysis and urine culture results and kidney and urinary bladder(kub) ultrasound findings were tabulated and analyzed using the % confidence interval. relative risks were computed with a level of significance of p value < . . results: a total of patients were included in the study. five hundred forty-four( . %) belongs to age group < years old. majority were females with a . : male to female ratio. escherichia coli is the most common organism isolated. patients with post void urine bladder residual are at risk for having growth in the urine culture. in sub group analysis for age and sex, statistically significant results were noted among patients belonging to the - years with the rr of . , % ci ( . , . ) p-value of . and males with rr . ( % ci . , . ) p value . . conclusion: there is an association between the occurrence of urinary tract infection and the presence of post void bladder volume residual. males and those patients aged to years of age are more at risk for urinary infection. objective: to evaluate if a relationship exists between renal ultrasound and voiding cystourethrography (vcug) findings among children with uti and determine whether the renal ultrasound findings/results can serve as a guide if a procedure such as vcug is needed to be done in the patient. methods: medical records of infants and children diagnosed as having uti who underwent renal ultrasound and vcug were reviewed. demographic data, urine culture and results of imaging studies were tabulated and analyzed. kappa statistics was used to determine the agreement between renal ultrasound and vcug results. mcnemars test was utilized to determine the statistical significance of the agreement. level of significance was place at p value of < . . results: a total of patients were included in the study. thirtyeight( %) had vesicoureteral reflux. there were more females with a male to female ratio of : . while cases with reflux had a : . male to female ratio. most common chief complaint was fever. e. coli is the most commonly isolated etiologic organism from the urine. twenty( . %) patients had primary vur while ( . %) were secondary. fifty two of children had abnormal sonogram; of duplex collecting system (dcs) diagnosed during postnatal usc on objective: the aim was to evaluate the relationship of laboratory investigations, therapeutic delay time (tdt), and therapeutic response time (trt) with acute renal damage and to verify these parameters in the presence of non refluxing and refluxing urinary tract infection (uti). methods: a prospective study was conducted in children. all patients received voiding cystourethrography (vcug) and dimercaptosuccinic acid (dmsa) renal scintigraphy. statistical analyses were applied to assess all parameters with dmsa renal scintigraphy. results: abnormal dmsa renal scintigraphy was detected in / ( . %) patients. there were no significant differences in peak temperature, tdt and treatment duration. however, white blood cells (wbc) count, percentage of serum polymorphonuclear cells (%pmn) and trt had significant differences at p-values . , < . and . , respectively. the area under roc curve for wbc count, %pmn and trt was . ( %ci . - . ) at p-values . , . ( %ci . - . ) at p-values < . and . ( %ci . - . ) at p-value . , respectively. overall, the optimal cutoff value for %pmn was . with sensitivity . % ( . - . ) and specificity . % ( . - . ). the optimal cut-off value for trt was hours with sensitivity . % ( . - . ) and specificity . % ( . - . ) . in patients with no vesicoureteral reflux (vur), there was significant difference in trt at p-values . . the area under roc curve for trt was . ( %ci . - . ) at p-value . . the optimal cut-off value for trt was hours with sensitivity . % ( %ci . - . ) and specificity . % . in vur patients, there were no significant differences in tdt, %pmn and trt between normal and abnormal dmsa renal scintigraphy at p-value . , . and . , respectively. conclusion: %pmn ≥ % and trt ≥ hours predict renal damage in the first episode of uti. however, in patients with no vur, trt ≥ hours predict renal damage. dmsa renal scintigraphy in the first episode of uti should be considered in those patients. susceptibility data. knowledge of local antimicrobial susceptibility all children with the first episode of febrile urinary tract infection traditionally. nowadays it has been revealed that the presence of renal scar is more important than the presence of vur regarding renal and patient outcome. our aim was to assess the relationship between the severity of vur and the severity of dmsa scan changes which is performed in the first week of the first febrile uti. methods: children with the first febrile uti who were admitted in ali asghar children hospital were evaluated prospectively. all dmsa scans have been observed and graded by our nuclear medicine specialist without any knowledge of presence or absence of vur. renal damages in dmsa scan were classified to grades as follows: grade : normal kidney, grade : decreased uptake in one pole with intact border, grade : decreased uptake in two poles with intact borders, grade : diffuse decreased uptake with intact border, grade : decreased uptake in one pole with scar, grade : decreased uptake in two poles with scar, grade : multiple scars, grade : diffuse decreased uptake with one pole scar, grade : diffuse decreased uptake with multiple scars. then dmsa findings in patients with no vur, with low grade vur and high grade or dilating vur were compared with each other. results and conclusion: one hundred and six patients with the first febrile uti were included in this study, thus kidneys were evaluated for the presence or absence of vur and dmsa grading. the mean age of our patients was ± . years old. . % of our patients were male. . % of kidneys did not have any vur, low grade vur (grades , , ) was seen in . % of kidneys and high grade vur grades , ) was found in . % of kidneys. . % of patients with low grade vur and/or without vur had dmsa scoring. abstract# p-sat fibronection in reflux nephropathy, is it a marker of grade of reflux? nahid rahimzadeh tehran university of medical science, associated professor, tehran, iran objective: vesicoureteral reflux (vur) is one of the most common urinary tract abnormalities in patients with urinary tract infection. nowadays noninvasive diagnostic methods are suggested to recognize vur and its severity. methods: we measured urinary and serum fibronectin in children with vur. results: the mean serum fibronectin was . ± . in children with low grade vur versus . ± . in children with high grade vur (pv> . ). the mean urinary fibronectin was also . ± . in low grade vur and . ± . in high grade vur (pv> . ). thus we didn't find any association between the severity of vur and the amount of fibronectin in serum and urine of patients. we also didn't find any relationship between dmsa changes at the acute phase of uti and serum and urine fibronectin. conclusion: in contrast to some previous studies, we showed the serum and urinary fibronectin cannot preclude the severity and grade of vur and hence it is not suitable surrogate marker for imaging techniques for vur diagnosis. abstract# p-sat the use of serum procalcitonin level in the prediction of high grade vesicoureteral reflux in urinary tract infection nahid rahimzadeh tehran university of medical science, associated professor, tehran, iran objective: procalcitonin is a reliable and specific marker of bacterial infection such as urinary tract infection. some authors suggest measurement of serum procalcitonin as a predictor of vesicoureteral reflux. we investigated this association in children who admitted because of acute pyelonephritis. methods: forty eight children with the first febrile uti were included. twelve patients had low grade vur, nine patients had high grade vur ((≥ ) and twenty seven patients didn't have any vur in their imaging assessment. results: there was a significant association between high grade vur and higher levels of procalcitonin (pv= . ). the sensitivity of procalcitonin level ≥ . ng/ml was % and specificity was % for diagnosis of high grade vur. conclusion: we concluded that serum procalcitonin concentration is a sensitive and promising predictor of high grade vesicoureteral reflux. hydronephrosis, parenchymal scarring and to study the rate of resolution of vur on follow up. methods: this was a retrospective study conducted by reviewing case records of all infants and children with primary vur who had minimum follow up of years, at our nephro-urology clinic over the last years.the imaging evaluation (renal ultrasound, voiding cystourethrogram, dmsa scan) was done based on the indian society of pediatric nephrology guidelines. severity of vur was classified as mild (grade i, ii), moderate (grade ii, iii) and severe (grade v) results: of the children screened for primary vur, with complete data were included for analysis. the mean age was . ± . months with male to female ratio of . : . the age at presentation was significantly lower for moderate to severe vur as compared to mild vur (p= . ). thirty children ( %) had abnormal antenatal scans. majorities ( %) of children were diagnosed to have vur during evaluation for urinary tract infection.among patients, six had solitary kidneys and thus the total number of systems evaluated was . of these, systems had vur ( % had mild, % had moderate and % had severe vur). hydronephrosis was seen in % of patients with vur. of these, % were unilateral and % were bilateral.there was no significant difference in the presence of hydronephrosis and grade of vur. there was no significant difference in presence of scars between mild and mod-severe vur. at the end of years of follow up, complete resolution of reflux was seen in %, % and % of children with mild, moderate and severe vur respectively. conclusion: severity of vur did not necessarily correlate with hydronephrosis and parenchymal scarring. over a year follow up, complete resolution of reflux was seen in nearly % of children irrespective of the grade of reflux. abstract# p-sat growth in children with dilating vur -a follow up of the swedish reflux trial per brandstrom, sverker hansson pediatricuronephrologic center, university of gothenburg, gothenburg, sweden objective: the swedish reflux trial included children, - years of age, with vur grade - , diagnosed after uti in and prenatal urinary tract dilatation in . dmsa was abnormal at start in children ( %). the children were randomized to antibiotic prophylaxis, endoscopic injection with deflux™ or surveillance. there have been reports on growth retardation in children with vur and catch up after vur resolution. the mechanism behind these findings is unclear. the children of the swedish reflux trial constitute a high risk group with dilating vur, recurrent febrile uti and high prevalence of renal parenchymal defects. we have searched the growth pattern of these children for differences related to gender, treatment group, uti recurrence, vur grade at follow up or renal defects on dmsa. methods: height and weight z-scores, compared to standardized swedish growth charts, were registered during the year follow up in of the children in the trial and at outpatient visits thereafter in patients to the age of . years (median, range . - . ). change in height z-score between first and last visit was used to measure growth over time. results: the first and last recorded height and weight z-scores were all within normal range. there was a larger gain of height in children with renal defects compared to those without (z-score difference . vs. . , p= . ). there were no differences in growth related to gender, treatment group, vur-grade at follow up or recurrent uti. conclusion: the children of the swedish reflux trial constitute a high risk group with dilating vur, recurrent febrile uti and high prevalence of renal parenchymal defects. they have normal weight, height and height gain at follow up for up to years. there was no sign of growth inhibition in these children related to dilating vur. the larger height gain seen in those with renal defects seem to be due to their slightly shorter stature at study start, although within normal range, which could be related to more severe urinary tract and renal problems during their first - years of life. engin kose, caner alparslan, serdar saritas, cengizhan elmas, fatma mutlubas ozsan, onder yavascan, nejat aksu tepecik training and research hospital, pediatric nephrology, izmir, turkey objective: the management of vesicoureteral reflux (vur) is varied and remains controversial. conservative therapy is based on the understanding that vur can resolve spontaneously, mostly in young patients with low-grade reflux. in this study, we wanted to evaluate the spontaneousresolution rate of low-grade vur (grades i and ii) in children. methods: children with low-grade (i-ii) vur treated in our hospital from may to may were prospectively studied. patients with low-grade (i-ii) vur and those who showed normal dmsa findings were included into the study. initially, a dmsa scintigraphy was performed in all patients and those who experienced acute febrile urinary tract infection (uti) during the follow-up period. treatment success was defined as complete vur resolution. no patients were prescribed antibiotic prophylaxis. all parents were informed by being given an explanation of the clinical significance of personal hygiene methods used after urinating or defecating. our institutional review board approved to collect the data, retrospectively. statistical analysis was made by using ibm spss . software. results: the study sample comprised infants ( boys and girls) all of whom showed low-grade reflux (grades i-ii). bilateral reflux was seen in ( . %) of cases. median age at diagnosis was months (range: - months). median follow-up time was months (range: - months). the spontaneousresolution rate of reflux was . % ( out of renal units). the frequency of febrile uti was . ± . episode/year (median: . episode/year). during the follow-up no patients with febrile uti experienced scar on dmsa scintigraphy. conclusion: infants with low-grade reflux show a low risk of febrile uti and a high spontaneous resolution rate without antibiotic prophylaxis. therefore, these children should be managed primarily by conservative therapy. ji-nan sheu , , hai-lun sun , , shan-ming chen , , yu-hua chao , , min-sho ku , , pen-fen liao , ko-huang lue , pediatrics, chung shan medical unversity hospital, taichung, taiwan school of medicine, chung shan medical university taichung, taiwan objective: to assess the usefulness of procalcitonin (pct) as a marker for predicting dilating (grades iii-v) vesicoureteral reflux (vur) in young children with a first febrile urinary tract infection (uti). methods: children aged≤ years old with a first febrile uti were prospectively evaluated. serum samples were tested for pct measurements upon admission to a tertiary hospital. all children underwent renal ultrasonography (us), m tc-dimercaptosuccinic acid renal scan, and voiding cystourethrography. the diagnostic characteristics of pct test for acute pyelonephritis (apn) and dilating vur were calculated. results: of children analyzed ( boys and girls; median age, months), ( . %) had apn. there was vur in ( . %), including ( . %) with dilating vur. the median pct value was significantly higher in children with vur than in those without (p< . ). using a pct cutoff value of ≥ . ng/ml, the sensitivity and negative predictive value for predicting dilating vur were . % and . %, respectively, for pct, and . % and . %, respectively, for the combined pct and us studies, whereas the positive and negative likelihood ratios were . and . , respectively, for pct, and . and . , respectively, for the combined studies. by multivariate analysis, high pct values and abnormalities on us were independent predictors of dilating vur. conclusion: pct is useful for diagnosing apn and predicting dilating vur in young children with a first febrile uti. a voiding cystourethrography is indicated only in children with high pct values (≥ . ng/ml) and/or abnormalities found on a us. objective: to evaluate the accuracy of acute m tc-dimercaptosuccinic acid (dmsa) scan in predicting dilating vesicoureteral reflux (vur) among young children with febrile urinary tract infection (uti). methods: the medical records of children (age≤ years), presenting with febrile uti between january and december , were retrospectively reviewed. the sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio of acute dmsa scan in predicting dilating vur in young children with febrile uti were calculated. results: a total of children were included, of which ( . %) had abnormal dmsa results and ( . %) were identified as vur on micturatingcystourethrography (mcu). among all the patients, the number of dilating vur was ( . %). the rate of abnormal results on dmsa of dilating vur group was significantly higher than the rates of non-vur and low-grade vur groups (p< . ). in age< months group and age≥ months group, the sensitivities of dmsa in predicting dilating vur were . %, . % respectively, while the negative predictive value were . %, . % and negative likelihood ratio were . , . , respectively. conclusion: for children of age≤ years with febrile uti, acute dmsa scan possesses certain values in excluding dilating vur. the possibility to detect dilating vur by mcu is rather low when the result of dmsa is negative. cakut: voiding disorders abstract# p-sat mono-symptomatic and non-mono symptomatic nocturnal enuresis: a clinical evaluation mitra naseri , mehran hiradfar dr sheikh children hospital/pediatric nephrology department, mashhad university of medical sciences, mashhad, iran dr sheikh children hospital/pediatric surgery department, mashhad university of medical sciences, mashhad, iran objective: nocturnal enuresis is divided into mono-symptomatic nocturnal enuresis(mne) and non mono-symptomatic nocturnal enuresis(nmne).this study was conducted to review clinical and ultrasonography findings in enuretic children, and compare organic and functional pathologies of lower urinary tract (lut) in children with mono-mne with those who have nmne. methods: neurologically normal children with chief complaint of enuresis enrolled in the study including boys and girls, aged - years old, ( . %) with mne and ( . %) with nmne. urine analysis, urine culture and kidney bladder ultra sonography was done for all .some patients underwent voiding cystoureterography (vcug), urodynamic study (uds), or both. results: patients were divided in to groups: mne, nmne daytime incontinence and nmne +daytime incontinence. constipation, encopresis and urge incontinence were significantly more frequent in patients with nmne +daytime incontinence (p= . , . , . respectively) . bladder wall thickness was the most common us findings..one patient with mne and with nmne+ daytime incontinence had vesico -ureteral reflux(vur) )(p= . ).posterior urethral valve was reported in one patient with nmne. evidences of bladder dysfunction were noted in about half of the patients who underwent uds, with higher prevalence in cases with nmne + daytime urinary incontinence(p= . ). bowel symptoms and vur were significantly more prevalent in cases with nmne +daytime incontinence. conclusion: we recommend doing vcug in enuretic children who have daytime incontinence.in addition our study revealed that symptoms suggestive of over active bladder are not good indicators for bladder dysfunction. abstract# p-sat correspondence between urinary calcium, ca + concentration and osmolality in enuretic children agata korzeniecka-kozerska, tadeusz porowski department of paediatrics and nephrology, medical university of bialystok, bialystok, poland objective: among many factors predisposing to enuresis hypercalciuria may play an important role. hypercalciuria is be observed in patients both in patients with nocturnal polyuria and without. hence, we decided to assess urine concentration of calcium (mmol/l) and ca + (mmol/l) in patients with monosymptomatic enuresis and answer the question if patients with enuresis present calcium balance disturbances methods: the study was conducted on children ( enuretic aged median . ( . - . ) yrs diagnosed with monosymptomatic enuresis after months of unsuccessful non farmacological treatment and healthy children aged median . ( . - . ) yrs. we collected -h urine samples from all children enrolled to the study. calcium concentration, ca + , ph, osmolality of urine and additionally daily sodium excretion were estimated and compared between two groups. statistical analysis were performed using statistica ver. . (statsoft,tulsa, ok). the mann-whitney u test was used for comparisons between two independent parameters. correlations were made with spearman test. a p value of < . was considered to be statistically significant. results: there were no differences in age, gender and parameters of physical development between both studied groups and between girls and boys among groups. urinary calcium concentration in enuretic children did not differ compared to reference group ( p= . ). we found statistically significant differences in urinary ca + concentration (p= . ) and osmolality (p= . ) between both studied group. ca + in urine correlated negatively with age and parameters of physical physical development only in enuretic patients. additionally, positive correlation was found between ca + and calcium concentration (r = . ; p< . ) and between ca + and osmolality (r= . ; p< . ) in urine of enuretic children. positive correlation was also observed between ca + and daily natrium excretion (r= . ; p< . ) in enuretic children. conclusion: disturbed calcium balance may play an important role in pathogenesis of monosymtomatic enuresis. it's a need to assess calcium and natrium excretion in enuretic children. abstract# p-sat usefulness of the application of questionnaires to detect attention deficit hyperactivity disorder (adhd) and other psychiatric disorders in children with functional voiding disorders sandra gautreaux pediatric nephrology, complejo asistencial universitario de leon, spain objective: although the relationship between functional voiding disorders (fvd) and the presence of a psychological problem remains controversial, the greater frequency of adhd among children with this condition is well known. the purpose of this study was to determine the diagnostic performance of the application of questionnaires to detect adhd and other psychiatric disorders in children with functional voiding disorders in general pediatrics consultations methods: the study was conducted on children between and years of age ( males) diagnosed with fvd (patient group) and children of the same age ( males) who had no urinary symptoms (control group). the parents of these children responded to the questions in two standardized questionnaires: the strengths and difficulties questionnaire (sdq) to screen for mental health disorders and the questionnaire for the detection of adhd of the dsm-iv psychiatric disorders of american academy of psychiatry manual. the variables obtained from the questionnaire responses were compared between the two groups of children using the student's t-test for unpaired samples when variables were quantitative and the chi-square test if the variables were qualitative. it was considered significant when p< . results: no significant differences were found between the two groups in the sdq questionnaire in any of its sections (emotional symptoms, conduct problems, hyperactivity, peer problems and prosocial behavior) or global assessment test, in which only patients of each group had an abnormal result. the questionnaire for the detection of adhd, presented an altered overall result of . % and . % patients in the control group (p=ns). there were also no differences between the two groups on the results of this test concerning the inattention or hyperactivity-impulsivity sections. conclusion: the results of the application of questionnaires to detect adhd and other psychiatric disorders in children with fvd are similar to those of the general population. the routine application of this type of questionnaires to all the patients in pediatrics consultations does not seem necessary. abstract# p-sat characterization of voiding dysfunction in chidren with attention deficit-hyperactivity disorder jun yonug kim, kun hee lee, jung won lee department of pediatrics, hallym university kangnam sacred heart hospital, seoul, korea objective: attention deficit hyperacitivity disorder (adhd) has been associated with impairment of frontal inhibitory function and catecholaminergic system. adhd is diagnosed in ~ % of children. children with adhd seem to suffer from various forms of urinary problems such as nocturnal enuresis, dysfunctional voiding and diurnal incontinence. however, no data exist to confirm in korean adhd children. we investigate the clinical findings of voiding dysfunction in adhd children. methods: between october and march , a total of children ( children with adhd and the other children with upper respiratory infection as control group) were enrolled in gangnam sacred heart hospital, hallymuniversity. adhd children were diagnosed under diagnostic and statistical manual of mental disorders (dsm)-iv criteria. a comprehensive survey of voiding and defecating were administered. results: the patient group included boys and girls, and the control group boys and girls. mean age were . +/− . year in adhd group and . +/− . in control group. children with adhd had statistically significant higher incidence of enuresis (p= . ), urgency (p= . ), urge incontinence (p= . ) and constipation (p= . ). there was no significant differences in straining, intermitteny, holding maneuvers (p> . ). conclusion: children with adhd in korea have significantly higher rates of enuresis, urgency, urge incontinence and constipation than those without adhd. the psychological correlates of primary nocturnal enuresis weiran zhou, xiaomei liu, ying shen nephrology, beijing children's hospital, beijing, china objective: previous studies based on clinical samples have reported that enuresis in children is associated with behavioural problems and reduced self-esteem, anxiety, but the relationship remains controversial. this study investigated psychological correlates of enuresis in a group of children suffering primary nocturnal enuresis(pne). methods: this survey involved parents and their children with pne aged - years. clinical datas of enuresis were collected through parents' reports and individual administrations to all children. parents completed the child behaviour checklist. children completed piers harris children'sself concept scale, the screen for child anxiety-related emotional disorders (scared)and depression self rating scale for children (dsrsc) . results: of the children, are boys and are girls. are monosymptomatic primary nocturnal enuresis and, are nonmonosymptomatic. children accord with the severest form of bedwetting(>= times/week). . %(n= )children have behaviour problems and, girls get higher scores in withdraw and internalizing problems than boys. boys are more aggressive. . %(n= ) get positive results through scared. . %(n= ) get positive results in dsrsc. children with the severest form of bedwetting are likely to have more complex form of psychological problems. they have greater social problems, get higher scores in behaviour problem (p= . ) and lower scores in piers harris children's self concept scale (p= . ). but children with or without the severest form of bedwetting have no significant difference in scared . mne have no significant difference with nmne in scores of all the three children's self-evaluated scales. conclusion: most children with pne had different psychological problems. the severer the symptoms are, the more complex the psychological correlates are. these preliminary findings support the view of enuresis closely related with psychological problems. psychological problems are affected by many factors except for enuresis, so further researches need to be conducted to determine whether there is a causal relationship between psychopathology and enuresis. the current situation of treatment of primary nocturnal enuresis in children xiaomei liu, lu chen, weiran zhou nephrology, beijing children's hospital, beijing, china objective: we would like to discuss the treatment of primary nocturnal enuresis in children. methods: children, diagnosed with primary nocturnal enuresis, paid outpatient visits to beijing children's hospital from january to may , are enrolled in the study. the information of previous clinical experience, compliance and expected treatment goals are collected and analyzed. results: children, with the mean age of . ± . are enrolled. children have visited doctors before, have unsatisfied clinical experience, such as late intervention, less standardized treatment and over-treatment. . % have poor compliance with doctor's suggestion of behaviour therapy and alarm therapy. children have been suggested to take medicines such as chinese traditional medicine ddavp, but . % of them refused the suggestion anxious of the side effects or stop the usage on their own. the primary expected treatment goal of parents is to improve the symptoms, accounting for . %. excluding the underlying diseases, alleviating parents' burden, treating the symptoms of hyperactivity or inattention and avoiding adverse effects on intellectual and fertility are also included. for children, they'd like to improve the symptoms so they won't be published by parents or laughed by their fellows. most parents ( . %) preferred medicines as the first choice. . % parents and children are inconsistent with the behavior therapy (the rate of newly diagnosed and non newly diagnosed children were . %, . % respectly. χ test p> . ). ( . %) don't accept alarm therapy (the rate of newly diagnosed and non newly diagnosed children were . %, . % respectly. χ test p> . ). conclusion: children with primary enuresis need early intervention and standardized treatment. the effect of treatment largely depends on cooperation and joint participation of children and parents. this study found that the compliance of behaviour training and alarm therapy is lower than medicine. the goals of children and parents, living conditions and other factors should be fully considered in the treatment of enuresis to improve short-term remission rates and long-term cure rate of the disease. beware of the sleeping bladder in monosymptomatic nocturnal enuresis (mne) britt borg, konstantinos kamperis, birgitte mahler, soren rittig pediatrics, aarhus university hospital, skejbv, denmark objective: bladder reservoir function in children with nocturnal enuresis is assessed by maximal voided volumes (mvv) registered on frequency-volume charts. although a degree of association is evident, mvv does not always reflect the nocturnal bladder reservoir function in mne. we aimed to evaluate the nocturnal bladder reservoir function during the night in children with apparently normal mvv. methods: data from children aged - treated for mne in a tertiary referral centre was analyzed. data from children was excluded due to reduced mvv according to iccs standardization and due to lack of home recordings. the remaining were divided into two groups, based on whether mvv was above (n= ) or below (n= ) the average nocturnal urine production during wet nights (nupw) . first morning voids were not included in mvv values. results: % of the children with mne and a normal bladder capacity had an average nocturnal urine production during wet nights below their mvv, one third of these had nupw below % of mvv expected for age. these children did not differ significantly in terms of demographic characteristics, frequency of wet nights or treatment time needed to achieve dryness. urine output during dry nights was not statistical significant between the groups (p= . , mean diff.= . ml). the group with mvv>nupwet shared significantly higher mvv to mvv expected for age ratios (mean diff= . , p< . ). urine output during wet nights was lower in the group of children with mvv>nupw (diff: . ml, p< . ) . conclusion: children with mne and apparently normal bladder reservoir function during daytime may experience wet nights with urine volumes well below their mvv and mvv expected for age. the fact indicates bladder reservoir function abnormalities during sleep that is not assessed by day recordings. physicians treating children with mne should consider anticholinergic treatment. one year experience of a multidisciplinary investigation on nocturnal enuresis in a brazilian tertiary care facility objective: to characterize a cohort of children, - yrs old, with nocturnal enuresis, defined by iccs criteria on the basis of a multidisciplinary evaluation including renal, neurological, psychological and physical therapy approaches. chronic clinical conditions and genetic disorders constituted exclusion criteria. methods: after irb approval, families were invited to participate in the project through press releases, children completed quality of life evaluation through clinically validated questionnaires, followed by a one -day multidisciplinary clinical evaluation. sleep, urinary and intestinal diaries were evaluated. urinary sonography, nocturnal polysomnography, urinary and blood analysis were scheduled. results: / participants (pts)were male ( , %), mean age ± yrs. twenty two children were excluded due to noncompliance /chronic clinical conditions. / pts were evaluated. / parents of children/adolescents, answered the cbcl questionnaire, / ( %) of which resulted in scores compatible with clinical psychological conditions. monosymptomatic enuresis (moe) was diagnosed in / children ( . %). in the moe group, / pts were diagnosed with intestinal constipation; / pts with obstructive sleep apnea, / pts with hipercalciuria and / were characterized with adhd. area and velocity of center or pressure displacement (vm) were used for postural control evaluation and resulted in , ± , cm and , ± , cm.s- , respectively; / pts were also assessed for postural alignment exhibiting pelvic anteversion ( , ± , grades) and head protusion ( , ± , grades). these results corroborate with a smaller range of motion found for hip flexion ( , ± , grades) and hip extension ( ± , grades) assessed using a goniometer. conclusion: multidisciplinary evaluation of enuretic children may be the key to optimize therapy on the basis of the underlying etiology of the process abstract# p-sat weight depending dosing of desmopressin (ddavp) in nocturnal enuresis pauline de bruyne , ann de guchtenaere , charlotte van herzeele , ann raes , jo dehoorne piet hoebeke , erik van laecke , johan vandewalle paediatric nephrology, ghent university hospital, ghent, belgium department of urology, ghent university hospital, ghent, belgium objective: in children as well as in adults, a uniform starting dose of desmopressin is prescribed. this uniformity is based on the inability to detect a weight-dependent dose-concentration correlation as this correlation is probably blurred by the wide intra-and interindividual differences in plasma concentration for a fixed desmopressin dose. recently, a smaller variation in plasma concentration was shown for the oral lyophilisate formulation of desmopressin (compared to tablet formulation). therefore, this study assessed a possible correlation between weight-corrected dose and plasma concentration for both formulations. methods: children with monosymptomatic nocturnal enuresis were recruited in a tertiary centre. two tests were performed on two separate days (at two weeks interval) in identical, standardized conditions: on day desmopressin tablet μg and on day desmopressin oral lyophilisate μg was administered. plasma concentrations were measured at one, two and six hours post dosing. the nonparametric spearman's rank correlation coefficient was used for assessing the correlation between weight corrected dose and plasma concentration. results: mean (sd) age and body weight of the patients were respectively . ( . ) years and . ( . ) kg. a positive correlation between plasma concentration of ddavp was found for the oral lyophilisate formulation at hours (p-value , ) and hours (pvalue , ) post dosing. this is not the case for the tablet formulation. results are shown graphically in figure and . figure and : correlation of dose corrected by weight to plasma concentrations at and hours post dosing conclusion: to the best of our knowledge, this is the first pharmacokinetic study showing a significant dose (normalized for size) -concentration correlation for desmopressin. nevertheless, this correlation was only significant for the oral lyophilisate group. this result is clinically important as it is a strong indication for more predictable plasma concentrations for the oral lyophilisate formulation, and thus preventing elevated concentrations of desmopressin. objective: increased nocturnal urine production and/or bladder hyperactivity in primary nocturnal enuretic (ne) patients could possibly be associated with autonomic nervous system dysfunction. reports of studies on autonomic nervous system dysfunction in ne are limited. to investigate autonomic nervous system function in enuretic children by performing ambulatory blood pressure monitorisation (abpm) for hours. methods: children with primary ne were enrolled in this study and they get hour abpm. their results were compared with healthy children. urinalysis,urine electrolyte levels, urinary culture and urinary system ultrasound were carried out in all the children. they also requested to have a diary about daily fluid intake and volume of daily urine. results: the enuretic group consisted of children (m/f: / ) and the control group of healthy children (m/f: / ). the mean ages were . ± . years and . ± . years, respectively. the mean -hour bp and daytime dbp did not differ between the groups however, the mean systolic bp was significantly higher in enuretic children (p< . ). the mean nighttime systolic bp, dbp and map were significantly higher as well in the patient group. daytime bp load did not found to be elevated in both groups.elevated night time systolic bp load was observed in patients and was not observed in control group ( . % vs %) (p< . ). nighttime diastolic bp load was elevated in of patients, compared with of control subjects (p< . ). the nocturnal bp dip was significantly reduced in the patient group compared with control group for diastolic blood pressure ( . % vs . %, respectively; p= . ). patients with elevated night time bp load was found to have higher frequency of urinary incontinence per week as well as per night while compared with enuretic children with normal night time bp load (r= . , p< . ; r= . , p< . respectively). conclusion: nocturnal bp loads were significantly higher in children with enuresis. these subtle abnormalities of circadian blood pressure regulation, loss of nocturnal dip and observation of decreased nocturnal pulse rate may reflect autonomic nervous system dysfunction and pathogenesis of en. objective: bladder dysfunction and especially oab plays a major role in nocturnal enuresis, not only in the non monosymptomatic (nmne) but as well in the monosymptomatic patients (mne) . if the enuresis is related to a mismatch in nocturnal diuresis and maximal functional bladder capacity, then the bladder volume should be a major parameter, but is sofar not taken as a parameter for subtyping into nmne in the iccs standardization. maximal voided volume in a diary is the golden standard, although relation with outcome is poorly studied. methods: aim of the study was to evaluate the optimal parameter for estimation of bladder volume as maximal voided volume in a diary, during forced diuresis, bladder volume during uroflow + uroflow), correlating with cystomanometry (if indicated). studypopulation patients age to years, > / days wet, only cystomanometries. results: if we compare the data from the bladder volume against the reference frame from rittig (aarhus), then , % of patients had a mvv in diary < , % percentile demonstrating that a majority of patients had a small for age voided volume in their diary. correlation between mvvdiary, mvv forced diuresis, bladder capacity (uroflow+ residu) and cystomanometry show that there is a strong correlation between the , but especially for the last parameters (r . - . , p < . ),but results with mvv diary are worse (r . - . , p . - . ) . there is no sex or gender difference in this observation. correlation with response to therapy at year shows a superior correlation with mvv forced diuresis and during uroflow than mvv diary (p . ). since cystomanometry is only performed in refractory cases, this voided value had no correlation with clinical outcome. conclusion: bladder volume can be estimated in several ways, each with their advantages and pitfalls. our data demonstrate that the alternative non invasive methods during force diuresis and in center during uroflow correlate best to each other and to the cystomanometricvalues. but as well to the one year outcome (p . ). abstract# p-sat evaluating nocturnal diuresis (polyuria) claire debusschere, delphine guenter, sophie wouters, johan vandewalle, ann raes, joke dehoorne pediatric, nephrology, gent, belgium objective: nocturnal enuresis is more than bedwetting, but a symptom of a disorder involving multiple pathogenetic factors in circadian rhythm of diuresis/solute excretion and bladder dysfunction. where the sum of diaper weight and morning voided volume, is the standard to evaluate nocturnal diuresis (polyuria), it does not give indices about pathophysiology. the aarhus concept : in center studies during standardised intake, offers the advantage of standardized conditions, and reliability of the values, but is restricted to specific research centres in limited patients for budgetary reasons). the ghent concept : a home based hours concentration prophyle with time daytime and nighttime collections offers an alternative. this one day test was not validated against days diuresis nighttime registration, and was criticized since waking up the patient overnight might increase diuresis and solute excretion, as is demonstrated in sleep deprivation aim of the study: to validate nocturnal diuresis and solution excretion to evaluate nocturnal polyuria against days nighttime diary and days daytime diary. methods: to the study the incidence of nocturnal polyuria, and to evaluate the value of the morning osmolality in the study of nocturnal polyuria. results and conclusion: children ( m), mean age y ( - y) , h diuresis +/− ml, daytime +/− ml nighttime +/− ml, no sex difference. correlation between volumes in diary and h concentration prophyle during h (p . ), night (r . p . ) and day (p . ). only % of patients have a nocturnal polyuria (&gt; %ebv= absolute nocturnal polyuria), but up to % have a nocturnal diuresis higher than % ebv and &gt; than their mvv (relative polyuria). there is no correlation between early morning osmolality and nocturnal diuresis-rate (nocturnal polyuria). objectives, methods and results: we present a months old albanian female with fever, urinary retention and constipation. this problems has occurred one week before hospitalization. no history of trauma. life history has no remarkable data. no history of uti or constipation before. physical examination: weight and stature on centile. no respiratory problems. the big overfilled bladder was palpated. on the left sacral region, was a tumorous mass very painful and worm. perianal reflex, bulbocavernosus were weak. other reflexes were normal. there were a hard stools in the rectum. other systems examination was unremarkable. high es rate and pathological urine sed with infection indicators. other laboratory examination was unremarkable. ultrasound examination resulted with dilatation of the left kidney pyelon ( mm), distended and overfilled bladder lumen (> ml) with thin bladder wall. rectum distended and full with fecal masses.lateroposterior there is a sonolucent cystic formation with (volume ml). that cystic formation was supected for ureterocellae first. the urinary catheter and rectal clismas were done. that formation was abscess and it was drained. and two weeks after was better. voiding cystourethrogram and computer tomography was done and resulted that are no anatomical defects in the urinary tract. because of the collapsed bowels there's not good visualization of the region around the sigma and rectum. irigografy resulted: dolihosigma and suspected for hirschprung. two months later the abscess relapsed and needed drainage again. conclusion: since the abscess has repeated the next step will be biopsy. hirschprung, tailgut cysts and other presacral masses should be included in the differential for patients with recurrent abscess in the perisacral space with clinical manifestation of urinary retention and constipation. abstract# p-sat treatment failure to enuresis alarms: challenges and factors influencing adherence to treatment indra ganesan , jessica xj hooi , jasmine jy goh , yh ng , sm chao nephrology service, kk women's and children's hospital, singapore, singapore department of pediatrics, kk women's and children's hospital, singapore, singapore objective: the study aims to identify factors influencing treatment failure to enuresis alarm and the factors influencing adherence to treatment. methods: all patients aged to years referred to the voiding clinic in kk women's and children's hospital, singapore with primary nocturnal enuresis who opted for enuresis alarm treatment, over year period from - , were prospectively studied. data, via direct interview and parental questionnaire was collected on demographics, age at presentation, presence of family history, frequency of nocturnal enuresis per week and per night, on whether child awakens after wetting, or associated constipation in the child and parental perception of why primary enuresis happens. results: seventy-nine of ( %) children with primary nocturnal enuresis with complete data were included. mean age at presentation was . ± . years and ( %) were male. twenty-five children had a family history of nocturnal enuresis in a st degree relative. eighteen children had constipation. fifty-one ( %) children achieved the targeted consecutive dry nights. in the remaining children, the main reasons for treatment failure were non adherence to usage of enuresis alarms mainly due to an inability to wake up to the alarm in deep sleep ( %) and underlying neurobehavioural conditions ( %) (adhd, autism, depression and a chromosomal disorder). the only significant clinical factor predicting treatment failure was the presence of an underlying neurobehavioural condition (or . , and developmental delay . factors such as male gender, family history in first degree relatives, frequency of enuresis, arousal when wet, and the presence of constipation, were not significant. conclusion: in our population, % of children achieved nocturnal urinary continence with enuresis alarms. treatment failure of enuresis alarms is higher in the presence of an underlying neurobehavioural condition and developmental delay. non adherence to treatment is mainly due to inability to arouse from deep sleep. long-term follow-up of children with nocturnal enuresis -do enuretics become nocturics? an-sofie goessaert , bente schoenaers , olivier opdenakker , karel everaert , johan vandewalle urology, ghent university hospital, ghent, belgium ghent university, ghent, belgium pediatric nephrology, ghent university hospital, ghent, belgium objective: although an overlap between both nocturnal enuresis (ne) and nocturia is known, research on the occurrence of both conditions in one patient is lacking. this study aims to investigate the prevalence of nocturia and other urinary symptoms in patients who have suffered from ne. methods: a questionnaire was sent to patients treated more than years ago in the university hospital of ghent for ne evaluating the history and current status of enuresis and validated questionnaires on urinary incontinence (iciq-ui) and overactive bladder symptoms (iciq-oab). medical files of all subjects were analysed on the history of enuresis. all subjects were asked to sign an informed consent. results: of the ( %) subjects who completed the questionnaire, reported nocturia ( %), with a sex ratio (m/f) of / in the nocturic group versus / in the non-nocturic group, mean age is versus years old, respectively. comparing the nocturic and nonnocturic group, retrospective analysis of the history of enuresis shows an older age at which the subjects were cured ( vs . , respectively) and a higher percentage of non-monosymptomatic ne ( % vs %, respectively) in the nocturic group. no differences in past treatment for ne were found between both groups. prospective analysis shows a significantly higher prevalence (p< . ) of voiding frequency during daytime, urge and urinary incontinence in nocturics compared to nonnocturics. with an increase in number of nocturic episodes per night, the percentage of female subjects increases (p< . ) and the percentage of subjects with non-monosymptomatic ne increases as well (p< . ). conclusion: over one out of former enuretic patients develops nocturia, often accompanied by other urinary symptoms and with significant bother. cure of nocturnal enuresis does not necessarily equals cure of the urological pathology and some of the nocturic patients, who remain to suffer from bothersome symptoms, might benefit from continuous treatment for the underlying urological condition, such as overactive bladder syndrome or nocturnal polyuria. objectives, methods and results: a year old girl was admitted to our hospital due to unusual pattern of voiding. when she wanted to urinate, she was writhing in pain; she cried, became pale and sweated. since the newborn period parents have observed sudden episodes when the girl started to cry and curled up her legs. she stopped when she began to urinate. the girl's father occasionally had pains in the jaw between yawning. the girl's voiding was like parents described: when she was trying to begin urinating, she was squatting on the toilet seat, crying and became pale and sweated. when voiding occurred the girl seemed to relax. the voiding volume was small and the urinary stream was weak. all investigations results were normal. according to the clinical course we assumed that the girl had an unusual expression of paroxysmal extreme pain disorder (pepd). the diagnosis was confirmed by the detection of the heterozygous pathogenic mutation in the scn a gene, a missense mutation in exon . the same mutation was also confirmed in her father. the girl was started on carbamazepine and the pain attacks almost disappeared. pepd is a rare autosomal dominant neuropathy linked to mutation in the scn a gene which encodes voltage-gated sodium channels. abnormal pain sensitivity occurs due to changes in the properties of the channels. pepd's onset is in the neonatal period with the most characteristic clinical features being attacks of excruciating pain in the rectum, genitalia, face and limbs. in literature we did not find any citation of patients with attacks triggered by the voiding stimulus. carbamazepine has been effective in relieving symptoms but the response is often incomplete ( ) ( ) ( ) , as in our patient. conclusion: the case described is interesting because of the rare clinical expression of pepd with pain triggered by voiding. the same mutation was recently found in patients with sfn ( ) . the study of functional importance of this mutation showed that the result of the mutation is increased frequency of firing pain-signaling neurons ( ) . rita pavione rodrigues pereira , vera herminakalika koch , simone nascimento fagundes , aline rossi , juliane de oliveira marques vieira , clarice tanaka physical therapy, university of são paulo, são paulo, brazil communication disorders and occupational therapy, university of são paulo, são paulo, brazil objective: to assess the postural control in children and teenagers with enuresis compared to a control group methods: enuretic (eg) patients ( boys and girls) with mean± sd of . ± . years, ranging from to years old, and . ± . of bmi were paired with assyntomatic kids (cg) of equal age, gender and bmi. three trials of seconds were collected while standing on a forceplate at hz of frequency with standard position of feet in four different sensorial conditions: ( ) open eyes and stable surface; ( ) closed eyes and stable surface; ( ) open eyes and unstable surface, and; ( ) closed eyes and unstable surface. the analized variables were area (a) and velocity (vm) of center of pressure displacement (cop). student t-tests were used to compare variables between groups for each sensorial condition. the level of significance was % for all the analysis. results: when compared to cg, the eg revealed larger area of cop displacement in the condition ( ) (mean± sd of , ± , cm for cg and , ± , cm for eg; p= , ), and in condition ( ) (mean± sd of , ± , cm for cg and , ± , cm for eg; p= , ). no difference in vm were identified. conclusion: when compared to assymptomatic control group, the enuretics children and teenagers presented larger area of cop displacement under normal sensorial input (condition ) and when vestibular input alone was offered (condition ). the hip and spine mobility is diminished in enuretic children and teenagers rita pavione rodrigues pereira , vera herminakalika koch , monica maria ribeiro goncalves , thais de souza milhoratti , daniela castro pacheco , clarice tanaka physical therapy, university of são paulo, são paulo, brazil communication disorders and occupational therapy, university of são paulo, são paulo, brazil objective: to assess the hip and spine mobility in children and enuretic teenagers compared to a control group. methods: enuretic (eg) patients ( boys and girls) with mean ± sd of . ± . years, ranging from to years old, and . ± . of bmi were paired with assyntomatic kids (cg) of equal age, gender and bmi. the range of motion of hip flexion and extension was measured using a goniometer. spine flexibility was measured using schober e stibor test and bank of wells. student t-tests were used to compare variables between groups. the level of significance was % for all the analysis. results: when compared to cg, the eg revealed diminished range of motion of hip extension bilaterally ( ± . for eg and ± . for cg at right side; p< . ; ge . ± . for eg and . ± . for cg at left side; p< . ). no difference was found for hip flexion range of motion, however compared to cg, eg showed lower values bilaterally ( . ± . for eg and . ± . for cg at right side; . ± . for eg and ± . for cg at left side). the spine flexibility did not presente any difference for schober ( . ± . for eg and . ± . for cg; p = . ), and stibor ( . ± . for eg and . ± . for cg; p= . ) and bank of wells ( . ± . for and . ± . for cg; p= . ). conclusion: when compared to assymptomatic control group, the enuretics children and teenagers presented diminished range of motion of hip extension suggesting transversal misalignment of the pelvis. more concern about enuresis children: an epidemiological study of primary nocturnal enuresis in elementary schools in shanghai yibing zheng , yinv gong , hong xu , keli wang , , zhonghui ni , , dandan he , nephrology and rheumatism, shanghai, china xuhui health bureau, shanghai, china minhang center for disease control and prevention, shanghai, china objective: ( ) to assess the prevalence of primary nocturnal enuresis (pne) and its risk factors in children of elementary school age in shanghai. ( ) to evaluate the impact of enuresis on these children and their parents, and to identify the methods and effectiveness of managing enuresis. methods: a randomly selected cross-sectional study was conducted in four elementary schools in two districts inshanghai. the parents of these children were asked to complete questionnaires anonymously which included items about the presence and frequency of enuresis, its risk factors and its perceived impact and management. the distress caused to the family by enuresis and the outcome of any management was evaluated using a -point visual analogue scale (vas). pns was defined as an involuntary voiding of urine during sleep, with a frequency of more than two times a week for three consecutive months, in the absence of congenital or acquired defects of the central nervous system. results: a total of questionnaires were distributed. the overall response rate to the questionnaire was . %, girls . % and boys . %. the prevalence of pne declined with age from . % at years old to . % at years old. of all enuresis children, . % had daytime urinary symptoms and . % had a positive family history. . % of parents were concerned and . % were very concerned about enuresis. . % of children were worried about and . % were very worried about enuresis. only . % of pne children sought for treatment and the common strategies ( . %) were adjusting lifestyle such as restriction of water intake at night, . % used alarm clock and . % were take medication. . % of parents felt that the current treatment was effective. conclusion: we conducted a relatively scientific epidemiological survey on the prevalence of pne in two districts in shanghai. we find enuresis still has great impact on children and their parents, but only a small part of them will seek for treatment. and only half of the parents feel that the current treatment is effective. therefore, it would be desirable to create a series of standardized management and follow-up processes for enuresis children. abstract# p-sat renal manifestations of tuberous sclerosis: a descriptive analysis sophy korula , alka ekbote , naresh kumar , sumita danda , indira agarwal , swasti chaturvedi paediatrics, christian medical college, vellore, india clinical genetics, christian medical college, vellore, india objective: to describe the renal manifestations in children - years of age diagnosed with tuberous sclerosis complex (tsc) at a tertiary hospital in south india. methods: data of children with tsc who presented to christian medical college vellore hospital from january onwards, were analysed by a retrospective chart review. the cases were identified from outpatient records and underwent ultrasonography, urine analysis and serum creatinine to recognize renal involvement. results: twenty-five children with tsc were identified. two children did not imaging studies available and were excluded from the analysis. the age of included children ranged from days to years with a median of years. seventy four percent ( / ) were males. ten of the children had evidence of renal involvement ( . %). of the ten children with renal involvement, six had angiomyolipoma ( %), five had renal cysts ( %) and one had suspected renal cell carcinoma. in two children both angiomyolipoma (aml) and cysts were noted. none were symptomatic. one child was found to have proteinuria and another had reduced creatinine clearance of . ml/min/m with normal bp and urinalysis. the rest of children had no evidence of proteinuria and had normal creatinine clearance. conclusion: we conclude that all children with tsc should be screened for renal involvement and regular follow up should be arranged. abstract# p-sat sonographic growth charts for kidney length in normal korean children: a prospective observational study objective and methods: kidney length was measured by sonography in a prospective observational study of normal children from to years of age. results and conclusion: there was a good correlation between kidney length and somatic values including age, weight, and height. the rapid growth of height during the first years of life was intimately associated with a similar increase in kidney length. the values of weight and height showed good correlation with kidney length in children from to years of age. height should be considered the important factor to correlate with kidney length. for the children aged years or older, the regression equation was obtained: kidney length (cm) = . + . x height (cm). for the younger than years, the equation was: kidney length (cm) = . + . x height (cm). objective: the outcome of children with unilateral nonfunctioning mcdk. methods: children ( pts with right mcdk), afunction confirmed by renal scan, boys, mean age of years (range . month - . years), mean observation period of . years with a range of . month - . years. prenatally diagnosis was made in %. abnormalities of the contralateral kidney were found in / pts ( %) -dystopia (n= ), hydronephrosis due to ureterovesical obstruction (n= ), vacter syndrome (n= ). in pts mcdk had been removed (in period - ) . collected data include egfr (calculated by cystatin c), urine protein/creatinine ratio, microalbumin/creatinine ratio, a microglobulin (a m)/creatinine ratio, urine beta- microglobulin (b m), urine ngal, urine nag, blood pressure (bp), renal length. results: hypetrophy of the contralateral kidney (length > sds) was detected in / pts ( %) to years of age. complete involution (in %) or decrease of size (in %) of mcdk occured in the first years. hyperfiltration (defined as egfr of ml/min/ . m ) was seen in pts ( %). none of pts demonstrated decreased egfr, proteinuria (mean value of . mg/mmolcreatinine), microalbuminuria (mean value of . mg/mmolcreatinine).urine a m (mean value of . mg/mmolcreatinine), urine b m (mean value of . mg/l), urine nag (mean value of . ukat/mmolcreatinine), urine ngal (mean value of . ng/l) were in a normal range. all pts were normotensive -bp defined as < th percentile for age and gender. the combination of hepatoblastoma with renal failure due to congenital dysplastic kidneys in children is extremely rare. we report two children in renal failure since birth due to congenital cystic dysplastic kidneys. hepatoblastoma was subsequently diagnosed in both of them. methods and results: case a male infant was born at weeks gestation with an antenatal diagnosis of bilateral dysplastic kidneys and bladder outflow obstruction secondary to a prolapsing ureterocele, anhydramnios, and pulmonary hypoplasia. he underwent surgical repair of other congeniatal abnormality after birth. peritoneal dialysis was initiated at months. treatment with erythropoietin (epo) was commenced at weeks of age. case a male infant with congenital cystic renal dysplasia, bilateral vesicoureteric reflux pulmonary hypoplasia and oligohydramnios was born at weeks gestation. peritoneal dialysis was commenced at day due to anuria from birth. epo was commenced at months of age. both of them required high dose epo to maintain adequate haemoglobin. hepatoblastoma was diagnosed in both of them at - years, following an incidental finding in abdominal imaging done for different reasons. conclusion: hepatoblastoma has been reported in association with cystic renal dysplasia in children in the literature to date. none of these children had evidence of impaired renal function prior to the diagnosis of hepatoblastoma. in our report both the child were treated with high dose erythropoietin prior to diagnosis of hepatoblastoma. erythropoietin (epo) is the primary regulator of erythropoiesis through specific interaction with its receptor (epo r). epor expression has been demonstrated in common paediatrictumour cells and such expression is reported to promote tumour cell survival through release of angiogenic growth factors. angiogenesis is the primary requirement for tumour growth. epo production has been observed in patients with hepatomas and in the hepg- cell line in hepatoblastoma. we report two cases of hepatoblastoma detected incidentally in children with established renal failure and propose a putative role of epo in the development and / or progression of hepatoblastoma in this population. objective: hypercalciuria is the most common metabolic cause of renal stone. long term immobilization is associated with hypercalciuria and bone loss. the effect of short term immobilization on hypercalciuria was the main objective of this study. methods: in a prospective study all orthopedic patients less than years with pelvic fracture who were assigned for immobilization with traction were enrolled in this study. serum (calcium, phosphorous, alkaline phosphatase, sodium, potassium, uric acid, bun, creatinine)and fasting urine calcium, creatinine, sodium, potassium and uric acid were checked within hours of hospitalization and also in st, nd and rd weeks of immobilization and then after to months of mobilization. student's t-tests used for statistical analysis. results: fifty five patients male and female with the mean age of . ± . years were studied. urine calcium /creatinine (u ca/cr)* ratio before immobilization u ca/cr was . ± . . one, two and weeks following immobilization u ca/cr ratio was . ± . , . ± . and . ± . respectively.multivariate tests revealed a significant rise in u ca/cr ratio during hospital stay when this value checked before immobilization and throughout immobilization as soon as end of st week and following in nd and rd week ( objective: importance of renal biopsy(rb) in diagnosis and treatment of kidney disease is the same for children as for adults. however there are some differences between institutions in practice of this invasive method. the aim of this study is to identify the current status and complications associated with the renal biopsy of childhood kidney disease. methods: a retrospective study was conducted based on medical records from all patients who had undergone native renal biopsies with -gauge needles from april to november in our center. we analyzed the number of experiments, sex, age, indication, the types of harvest (percutaneous or open) and anesthesia (general or local), histopathological findings, and complications. results: a total of renal biopsies were performed in patients ( boys, girls). the mean age at first procedure was . years. about % of the indications for a biopsy showed moderate proteinuria and hematuria in the annual urinary screening program in japan, and approximately percent of those were refractory childhood nephrotic syndrome. open renal biopsies were practiced in only cases, and the rest of children underwent percutaneous ultrasound-guided kidney biopsies. the most procedures of patients aged or younger were executed under general anesthesia due to the non-cooperation of them. about % of the biopsy-proven kidney diseases showed immunoglobulin a nephropathy, and approximately percent of those were henoch-schonlein purpura nephritis. for the post biopsy complications, out of all performances administered hemostatic agents for moderate hematoma, but none of them required blood transfusion or surgical intervention. conclusion: we suggested that renal biopsy could be supportively performed under local anesthesia in the patients more than the upper grades of elementary school. in addition, patients aged or younger, including months, could undergo the percutaneous ultrasound-guided renal biopsies without procedural and general anesthesia complications. therefore, our results revealed that this procedure was considered safe even in infants. abstract# p-sat fifteen years review of indications and results of renal biopsy in children from a single center in egypt there were insufficient biopsies. in pathologically diagnosed specimens primary glomerulonephritis was the most common finding (n= , . %) followed by secondary glomerulonephritis (n= , . %) and end stage renal disease (n= , . %). the most common causes of primary glomerulonephritis were minimal change disease (n= , . %), diffuse proliferative glomerulonephritis (n= , . %), focal proliferative glomerulonephritis (n= , . %) and focal segmental glomerulosclerosis (n= , . %). lupus nephritis (n= , %) was the most common cause of secondary glomerulonephritis followed by hemolytic uremic syndrome (n= , . %) and amyloidosis (n= , . %). only one mortality has been reported as a complication of renal biopsy (uncontrolled bleeding). conclusion: this study introduces the first biopsy based epidemiological information of pattern of renal diseases in egyptian children from a single tertiary pediatric center in which minimal change disease was the most common histopathological finding and steroid resistant nephrotic syndrome was the most frequent indication for biopsy. results: a total of children were enrolled in the study. most of them ( %) had isolated microhematuria, and were proved mild lesion of glomeruli ( %) by renal biopsy. about % of them, however, might have progressive glomerulonephritis, such as iga nephropathy, focal segmental glomerulosclerosis, alport syndrome and so on. these asymptomatic children were found urine abnormalities due to either school urine screening study, health examination, or during diagnosis of non-renal diseases. in center a, iga nephropathy was the most case diagnosed, while in center b and c, minor glomerular abnormalities was the most case diagnosed. the difference among three centers was significant and this variation might be due to different indications of renal biopsy. conclusion: our findings confirm that urinalysis may help early detecting progressive glomerulonephritis in asymptomatic children. children with isolated microhematuria has relatively low risk of severe pathologic lesion of glomeruli, thus isolated microhematuria per se might not be suggested as indication of early renal biopsy. long-term follow-up with appropriate further examination is of great importance for these asymptomatic children. abstract# p-sat twenty-three-year review of disease patterns from renal biopsies: an experience from a pediatric renal center there were episode of peritonitis with an incidence of episode per . patient/months. the commonest organisms isolated were gram negative rods ( . %), followed by staph aureus ( . %). sixteen ( . %) were culture negative and ( . %) were fungal peritonitis. catheter removal related to peritonitis was performed in patients in whom only one patient returned back to pd. exit site infection ( episodes) and tunnel infection were reported in and patients respectively. catheter malfunction was the most common non infectious complication seen in ( . %) children. other noninfectious complications include haemorrahgic effluent ( . %) children while catheter leak, umbilical hernia and inflow pain where seen in ( . %) children each. at the end of the study ( . %) children remained pd active, ( . %) transferred to hd, ( . %) transplanted, ( . %) suspended from pd, ( . %) lost follow up and ( . %) children died. conclusion: in the setting of our country with limited resources and investment, capd is efficient and successful with complications comparable to most parts of the world. attempts to produce pd fluids locally and to train and educate health care workers will greatly improve the use of pd in developing countries. profile and response to therapy in patients with idiopathic membranous nephropathy from march to december . renal biopsies were studied for light microscopy, immunofluorescence and electron microscopy. antibodies to the m-type phospholipase a receptor (pla r), bovine serum albumin (bsa), and cationic bsa were measured by western blotting with patient sera (when available) and then detecting for both totaligg as well as specifically for the igg subclass. results: renal biopsies were performed during the study period, out of which patients had membranous nephropathy. five were secondary to sle and patients ( . %) had idiopathic membranous nephropathy. mean age at presentation was . +/- . years with % having hematuria and . % hypertension at presentation. estimated gfr was . +/- . . renal biopsy showed findings consistent with membranous nephropathy on light microscopy with with< % of the interstitium showing tubular atrophy and interstitial fibrosis. immunofluorescence studies showed granular igg and c along the peripheral capillary walls. electron microscopy showed subepithelial deposits, with formation of basement membrane spikes between the deposits. few intramembranous deposits were also present. subendothelial and mesangial deposits were not present. there were no antibodies to bsa or cationic bsa detected in any of the five sera available. one of the five patients had circulating antibodies to pla r. all patients received prednisolone, angiotensin converting enzyme inhibitors and oral calcium supplements. two patients continued to have nephrotic range proteinuria inspite of prednisolone and were started on cyclosporine. none of the patients developed any complications. conclusion: immunosuppressive therapy is beneficial in children with idiopathic membranous nephropathy. anti-pla r antibodies can be seen as early as years of age. abstract# p-sat hypercalcemic crisis and nephrogenic diabetes insipidus due to vitamin d intoxication methods: twenty-three children ( kidneys) with first uti with p-fimbriatede.coli were enrolled in the study. children were aged between few months and years. all children were treated with adequate antibiotic therapy. dmsa scintigraphy was performed in a few days after infection and control scintigraphy was performed months to months later. dmsa findings were categorised as normal, generally diminished uptake of activity, focally diminished uptake of activity and clearly pathologic with renal scars. results: the first dmsa scintigraphy immediately after infection was normal in kidneys ( . %), generally diminished activity was found in kidneys ( . %) and focally diminished activity in kidneys ( % ). renal scars were present in kidneys ( . %) . on the control scintigraphy kidneys ( . %) had normal findings. generally diminished activity were found in kidneys ( %) and focal diminished uptake in kidneys ( . %). significantly higher number of scars, in kidneys ( . %), despite of antibiotic treatment were found on the control scintigraphy (p< . ). conclusion: dmsa scintigraphy demonstrated that the infection with p-fimbriatede.coli can result in permanent renal damage, which clearly points to uti with p-fimbriatede.coli as a risk factor in renal damage. our results confirm obligatory scintigraphic follow-up of children with positive p-fimbriatede.coli infection. objective: efficacy of mannitol with furosemide was compared with that of albumin with furosemide in the treatment of diuretic resistant oedema in childhood nephrotic syndrome. methods: forty patients fulfilling the criteria for "resistant oedema" in nephrotic syndrome cases were enrolled in this descriptive cross sectional study. resistant oedema was diagnosed based on failure to achieve therapeutic response to diuretics or a weight loss of < % body weight daily. all nephrotic syndrome patients with severe oedema, age year to years of both sexes were hospitalized and were managed with fluid restriction, no added salt and bed rest. beside these mg/kg/day oral furosemide or combination of furosemide and spironolactone, were given for days to achieve desired diuresis. those patients who did not get response were divided into two groups (group-a, group-b) in consecutive fashion. the group-a study population, was with intravenous mannitol . - gm/kg/day in single daily dose over - hrs followed by intravenous furosemide mg/kg/day for days. the group-b study population was with intravenous albumin, . - gm/ kg /day in single daily dose over - hrs followed by intravenous furosemide mg/kg/day in every alternate day, total doses. conclusion: this boy presented with rhabdomyolysis, myohemoglobinuria and arf. (similar pr similar presentation can be rarely seen in human being, but often seen in dogs). blood exchange transfusion in time must be necessary for preventing "water fall effect" established, for it can eliminate inflammatory factor and toxic products such as bun, ccr, and creatinasein blood effectively. blood tranfusion in combination with azithromycin and clindamycin must be a good choice replace the "babesia-infected" rbc and eliminate pathogens in blood. beta- -microglobulinuria in human immunodeficiency virus infected children objective: to determine whether hiv infection in children is associated with increased urinary excretion of β -microglobulin, which is a marker of tubular defect. methods: a prospective observational study was done of hiv infected children attending outpatient immunology clinics to investigate urinary β -microglobulin excretion by measuring urine β -microglobulin to creatinine ratio. in addition serum sodium, potassium, urea, bicarbonate and creatinine levels were documented and urine dipstick test was done to quantify proteinuria. results: thirteen ( ) children aged months to months (mean +/- months) were enrolled. all children had normal estimated glomerular filtration rate. eleven children were on different haart regimes (see table ), one was receiving nevirapine prophylaxis and one was not on any treatment. the duration of haart use was - months (mean of +/- months). seven ( ) children were on cotrimoxazole for pneumocystis jiroveci prophylaxis and on anti-tuberculosis drugs, namely rifampicin, ethambutol, isoniazid and pyrazinamide. none received any nephrotoxic drugs. the hiv viral load was > copies/ml in children and < copies/ml in children. of hiv-infected children, ( %) had no abnormal urine protein excretion and nine ( %) had elevated urinary levels of β -microglobulin.of note only ( %) of the children with β -microglobulinuria had associated proteinuria. ten children ( %) had metabolic acidosis with the mean serum bicarbonate (co ) level of . mmol/l ( range - mmol/l). conclusion: proteinuria is believed to be the earliest finding for the diagnosis of hiv associated renal diseases. in our study β microglobulinuria and metabolic acidosis were the prominent findings suggesting that hiv induces tubular dysfunction in children without clinical evidence of renal disease. objective: acute kidney injury (aki) is an important cause of mortality in sub saharan africa because access to renal replacement therapy is limited. there are few reports on haemodialysis in childhood aki in the sub region. we therefore performed a preliminary review of data on children who received intermittent haemodialysis for aki in our centre. method: a retrospective review of case records and haemodialysis registers of children in aki who received haemodialysis in our centre from january to december . results: children, including a child aged years, received haemodialysis for aki over the period but full details were available for children and were further reviewed for this study. there were males ( . %). the children were aged - ( . +/- . ) years. the primary aetiology of aki was related to intravascular haemolysis (ivh) with massive haemoglobinuria (n= ), septicaemia (n= ), acute glomerulonephritis (n= ), malignancies (n= ), malaria (n= ), hiv (n= ) and haemolyticuraemic syndrome (n= ). the aetiology of ivh was secondary to glucose- -phosphate dehydrogenase (g pd) deficiency in patients, autoimmune haemolyticanaemia in and was unknown in the others. one of the patients with ivh secondary to g pd deficiency also had malaria. the number of sessions of dialysis ranged from to sessions per patient with a modal value of objectives, methods and results: a twelve-day old, formula-fed, full term neonate with unremarkable perinatal history was admitted for poor oral feeding and significant ( %) weight loss. physical examination was otherwise unremarkable. investigation showed normal anion gap metabolic acidosis, hyperkalemia ( . mmol/l), hyperurecemia ( . mmol/l) but normal creatinine ( umol/l). metabolic screen and other investigation was unremarkable. on further questioning parents has been feeding baby with goat milkbased formula since day . baby was switched back to normal cow milk-based formula with prompt resolution of metabolic disturbance and without recurrence of acidosis on follow-up. conclusions: goat milk is becoming increasing popular to parents because of the myths associated (organic, easier digested, hypoallergenic, better nutrient content etc). however there is good evidence suggesting against these misbelief and there are even reported morbidities associated with ingestion of goat milkbased formula. with increasing appealing but not necessarily accurate information available on the internet, what the public need is education. objective: there have been great inroads made in controlling the scourge of hiv in south africa. the national pmtct program has reduced the mtct rate to . % and children infected prior to these interventions are now on effective treatment programs. these children are now surviving longer and so we are seeing increased numbers of hiv related renal pathology presenting to our clinics. before the widespread availability of arv's in south africa these children would have been denied access to our program but now we are able to offer them crrtand a transplant. the biggest challenge facing our program is one of the social disintergration of much of our indigent population. the vast majority of our patients come from social backgrounds that are incompatible with adhering to the rigours of a chronic renal program. this is compounded when the care givers are themselves ill or when the child has a second serious illness such as hiv to deal with. methods: we would like to present our experience with admitting hiv positive children with ckd to our chronic program and will highlight the challenges that face these families and their health care providers. we will describe the social issues affecting each family and how they impact on the child's care. results: all families had serious social issues on top of having to deal with their hiv disease. all families had extreme difficulties in adhering to our program. / died as a result of non adherence and of the remaining children only is really coping well with the program. / children have no living parents and is foster care. the rest are either with a single parent or with a family relative. conclusion: the huge difficulties facing these patients is forcing us to rethink the criteria that should be applied to admitting these patients to our program. restricting the program to children with these problem seems cruel and we feel that all options should be considered before denying these children access to life saving care. abstract# most of the patients presented during autumn and winter. the incidence of apsgn has decreased in the past years in shenyang, but the proportion of the patients with acute kidney injury (aki) or nephroticrange proteinuria was increased. the proportion of children with macroscopic hematuria remained almost the same during these years. macroscopic hematuria resolved in - weeks and non-nephroticproteinuria resolved in - weeks. the treatment of apsgn patients with nephrotic-proteinuria was the same with the children with primary nephrotic syndrome and prednisone was withdrawn in - months. some aki patients have been followed up for years and no patients with chronic renal failure. all patients with microscopic hematuria at onset and % patients with microscopic hematuria after years. conclusion: the incidence of apsgn was decreased during recent years. the proportion of apsgn patients with aki or nephrotic-range proteinuria was increased. the short-term prognosis of apsgn was good and minority of the patients persisted with microscopic hematuria. abstract# p-sat analysis of clinical manifestations and prognosis in children of acute poststreptococcal glomerulonephritis objective: crescentic glomerulonephritis (gn) is characterized by severe infiltration of massive inflammatory cells into glomeruli and crescent formation. although renin angiotensin system (ras) is the key player in renal injury, the impact of direct renin inhibitor on glomerular crescent formation is not elucidated yet. methods: to examine whether direct renin inhibitor ameliorate renal injury in crescentic gn, we investigated renal injury induced by antiglomerular basement membrane (gbm) antibodies in wistar kyoto rats treated with direct renin inhibitor, aliskiren. in addition, using cultured glomerular mesangial cell (mcs) and parietal epithelial cell (pecs), we examined whether recombinant renin could induce monocyte chemoattractant protein- (mcp- ) expression and cell proliferation, respectively. results: an anti-gbm nephritis model developed progressive proteinuria and glomerular crescent formation, accompanied by increased expression of mcp- and (pro)renin receptor. interestingly, (pro)renin receptor expressed strongly in the crescent formation area in diseased glomeruli. proteinuria was significantly reduced by the treatment of aliskiren. then, aliskiren markedly ameliorated renal injury (% glomerular crescent: . +/− . %) compared to vehicle treatment ( . +/− . %). excretion of urinary protein in a group of rats treated with aliskiren were significantly reduced compared to vehicle-treated rats. aliskiren treatment markedly decreased mcp- and (pro)renin receptor mrna levels in the diseased kidney. next, primary cultured mcs stimulated by recombinant renin showed significant increases of mcp- mrna expression. furthermore, primary cultured pecs showed an increase in recombinant renininduced cell proliferation. conclusion: these data suggest that therapeutic strategy of direct renin inhibitor may prove beneficial for crescentic gn by the suppression of the ras activation and the decrease of inflammation and cell proliferation in glomerular crescent via (pro)renin receptor. an update on management of acute glomerulonephritis in children objective: to analyze the clinical effects, safety, and significance of leflunomide combined with hormone in the treatment of children with refractory nephrotic syndrome. methods: collected cases patients in our hospital in children with refractory nephroticsyndrome,and randomly divided into cases of the control group and treatment group. control group was treated with mycophenolatemofetil (mmf)andhormone,the treatment group was treated with leflunomide (let) and hormone.measured and compared the changes before and after treatment of h urinary protein excretion,tc,alt,cr,bun clinical efficacy and complications. results: the two groups after months of treatment, h urinary protein, plasma albumin, total serum cholesterol, serum creatinine and blood urea nitrogen and other indicators were significantly better than before treatment and has a statistically significant (p < . ); the overall response rate in the control group and treatment group were . % and . %. conclusion: the application of leflunomide combined with hormone treatment of children with refractory nephrotic syndrome can make the disease to be effectively alleviated, the clinical results were satisfactory, safe, and fewer complications, it is worthy of promotion. objective: post-streptococcal acute glomerulonephritis (psagn) is a familiar disease in children. misdiagnosis might occur when it is presented with atypical symptoms. here we report a -year-old girl presented with acute heart failure which was finally diagnosed comorbidity of psagn and graves' disease. methods: retrospectively review the history of the patient. the girl was admitted to our hospital with cough, shortness of breath and chest tightness, without any other obvious symptoms and history of illness. the examination of cardiac color ultrasound showed mitral insufficiency with severe mitral regurgitation and heart enlargement. other examinations also found she had hypertention, mild anomalies of urinalysis, hypocomplementemia, hypoalbuminemia, hyperthyroidism and elevated antistreptolysin o. first we diagnosed her illness as rheumatic disease. after two weeks treatment with rest, fluid and sodium restriction, controlling blood pression, diuresis and methimazole, the girl recovered very well. she had no any symptom with normal urinalysis and blood pressure, the result of reexamination of cardiac color ultrasound was normal, her hypocomplementemia and hyperthyroidism were improved significantly. finally she was diagnosed as co-morbidity of psagn and graves' disease. conclusion: psagn with atypical symptoms at presentation should be paid more attention, especially when it is also has co-morbidity. abstract# p-sat report of a child with idiopathic cryoglobulinemia idiopathic cryoglobulinemia is rare to see in child. here we report a child with typical manifestations of cryoglobulinemia. the subjected child was male, years and months, he had repeated rashes, itching, desquamation on his fingertips for more than two years, accompanied with recurrent miliary reddish rashes on the trunk and limbs for more than one year, transient arthralgia for weeks, and edema and oliguria for days before he was admitted to our hospital. he was treated as atopic dermatitis all the time. but the rashes were recurrent. erythema could be seen after desquamation. weeks before admission, he had arthralgia on the right knee, days later on left knee without swelling, both were retrieved spontaneously. x-ray of the knees revealed no abnormal. ten days before admission, edema and decreased urine output was notice without gross hematuria. physical examination in local hospital revealed blood pressure / mmhg, needlelike erythematous maculopapules in his hands and feet. urine test revealed protein g/l, rbc /ul, no casts. serum bun was . mmol/l, cr umol/l, tco mmol/l, c . g/l. he was sent to another hospital days later. there, prednisone mg per day was given. as a result, the urine output increased gradually, but serum bun and cr remained high, so he was referred to our hospital. renal biopsy indicated membrane proliferation glomerular nephritis with abundant microthrombus. the diagnosis of cryoglobulinemia was suggested. after that serum cryoglobulin and serum protein electrophoresis were tested days after prednisone was given, both were normal. etiological examinations, included hepatitis virus a, b, c, d, e, g were all negative; antibodies of hiv, syphilis, toxo, cmv, rvb, rsv, hsv, eb, adv, and rickett's organism were all negative, mp-igm : . antinuclear antibodies of sle, anca and antiphospholipid antibodies were all negative. so idiopathic cyoglobulinemia was more favored. the treatment of prednisone mg per day was continued after admission. he restored gradually. prednisone was taped down gradually. now prednisone has been stopped for more than one month, he seems well during that period of time. methods: children with hsp over years of age were enrolled in the study. they were evaluated for demographic, anthropometric, clinical and laboratory data including urinalysis, complete blood count, serum albumin, creatinine, iga levels. in addition, anti-tissue transglutaminase iga (elisa), anti-endomysium iga (ifat), antigliadin (gaf x, deaminated) iga (ifat) and anti-gliadin (gaf x, deaminated) igg (elisa) antibody levels were determined. seropositive patients were evaluated by endoscopic small bowel biopsy. the rate of cd seropositivity in hsp patients was compared to the rate in healthy turksih children by the test for the statistical significance of two percentages. results: celiac serology was evaluated in children ( male, mean age . +/- . years) with hsp. there was no patient with growth failure or having symptoms associated with cd like abdominal pain, abdominal distention or diarrhea. in addition, none of the patients had iga deficiency, anemia or hypoalbuminemia. celiac serology was positive in ( %) children. endoscopic evaluation was performed in patients and one of them was diagnosed as cd. prevalence of cd in children with hsp was significantly higher compared to healthy turkish children (p< . ). conclusions: celiac seropositivity was % in children with hsp and this rate is significantly higher than the rate in healthy children. although the number of children with hsp is small in this preliminary study, this result suggests that celiac screening may be considered in children with hsp. ( ) groups. the glomerular and tubulointerstitial lesions were scored by katafuchi criteria and oxford classification of igan,respectively. results: .the baseline data of different clincal or pathological groups were no significant differences (p more than . ),but h protienuria were significant increased in grade and groups than grade group(p less than . ). .according katafuchi critiria,the severity scores of glomerullar and tubulointerstitial lesions were positively correlated with either different clincal or pathological groups(p less than . ). .according to oxford classification, only the severity scores of mesangial hypercellularity and segmental glomerulosclerosis/adhension were positively correlated with different clinical groups(p less than . ),but the severity of mesangial hypercellularity, endocapilarity hypercellularity, segmental glomerulosclerosis/adhension,tubular atrophy/interstitial fibrosis and cellular/fibrocellular crecents were all positively correlated with different pathological groups (p less than . ). [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] were evaluated retrospectively. patients were analyzed comparing those hospitalized during the first and the second ten-year period.the long-term prognosis was evaluated in / patients ( %) with hsp nephritis followed-up for to years (mean . ± . years) based on urine analyses, serum creatinine and blood pressure measurements. results: of patients (mean age . ± . years, range - years, m: f ratio . ) with palpable purpura ( %), other symptoms were more common during the first ten-year period including arthralgias ( % vs. %, p= . ), gastrointestinal symptoms ( % vs. %, p= , ) and renal involvement ( % vs. %, p= . ). among patients ( %) with hsp nephritis, had isolated hematuria and/or non-nephrotic range proteinuria ( %), nephritic syndrome ( %) and nephritic/nephrotic syndrome ( %). hematuria and/or nonnephritic proteinuria was less common (p= . ) in the second tenyear period while the incidence of nephritic/nephrotic syndrome was insignificant (p= . ). recurrences of purpura had patients within years. patients had renal biopsy including one with % of crescents and one another with iga nephropathy diagnosed seven years after initial presentation of hsp. long-term prognosis was favourable in most patients with abnormal urine analyses in ( %), in one with hypertension but normal serum creatinine and in all with nephritic/nephrotic syndrome at disease onset. conclusion: clinical evaluation of patients with hsp nephritis treated at our institution showed a good long-term prognosis. urine and blood pressure abnormalities in followed-up patients were associated with nephritis at disease onset. -up (f-up) . egfr was estimated using schwartz formula; decline in renal function was defined as the slope of egfr over the f-up. results: % were males, with mean age at renal biopsy of . ± . y and a median f-up of . y (iq range . - . y); more than % presented with egfr > ml/min/ . m . end-stage renal disesase (esrd) was reached by % of children, % loss of initial egfr by %; % reached the combined end point (esrd or % loss of initial egfr). at renal biopsy % presented with mesangial proliferation (m ), % with endocapillary proliferation (e ), % with segmental glomerulosclerosis (s ) and % with tubular atrophy/interstitial fibrosis (ta/if; t / ). patients with segmental sclerosis and ta/if showed a significantly worse egfr slope over the f-up (s vs s p= . ; t vs t / p= . ). at univariate linear regression, clinical data at renal biopsy (egfr, proteinuria and map) were not associated with renal function decline, while data at - and - months and ta-proteinuria and map significantly predicted egfr slope.a multivariate linear regression model (including proteinuria and map at - months together with the difference of egfr at renal biopsy and at - months as independent variables) performed well in predicting egfr slope (r = . ). this model was used to derive a formula able to estimate egfr slope with good performance (mean bias between estimated and really observed egfr slope of . ± . ml/min/ . m ). conclusion: the oxford classification of igan was well applicable to this pediatric population. a formula was developed that estimates renal function decline over the f-up based on proteinuria, map and egfr loss after - years of observation, which will need a validation on other cohorts. sixteen-year experience with pediatric iga nephropathy and validation of the oxford classification as a risk predictor (m ), segmental sclerosis (s ), endocapillary proliferation (e ), and tubulointerstitial fibrosis (t or t ) was ( . %), ( . %), ( . %), and ( . %), respectively. there was no significant decrease in gfr within the entire cohort. however, five patients showed decreased renal function, and of them, two reached stage iii or iv ckd. the five patients' changes in the k/doqi ckd stage were to , to , to , to , and to . their pathological classifications were haas /m s e t , haas /m s e t with global sclerosis, haas /m s e t , haas /m s e t , and haas /m s e t with global sclerosis. in the oxford classification, global sclerosis was the only factor correlated with decreased renal function, whereas the haas classification showed no significant correlation with renal function. conclusions: global sclerosis was correlated with decreased renal function. however, in our cohort, there was no significant decrease in renal function during the follow-up period (p = . ). thus, we could not clearly correlate the haas and oxford classifications with renal outcome. the value of the oxford classification as a predictor of renal outcome remains unclear in korean children with iga nephropathy. meng-jie jiang, xiao-yun jiang, ying mo, li-zhi chen, li-ping rong pediatric, the first affiliated hospital of sun yat-sen university, guangzhou, china objective: to analyze the clinicopathological characteristics of primary immunoglobulin a nephropathy (igan) manifested as macroscopic hematuria in children. the clinicopathological characteristics of cases with primary igan manifested as macroscopic hematuria were analyzed retrospectively. according to the lasting time of macroscopic hematuria, cases were assigned to group a (no more than seven days) and cases were assigned to group b (more than seven days). results: the manifestations comprised: acute glomerulonephritis ( % in group a, . % in group b), nephrotic syndrome ( % in group a, . % in group b), hematuria and proteinuria ( . % in group a, . % in group b) and isolated hematuria ( . % in group a, . % in group b). . % cases in group a and . % cases in group b were accompanied with abnormal renal function. there was no significant difference between group a and b (p> . ). the urinary lysozyme or β -mg increased ( . % in group a, . % in group b). in group a, subclass ii was the most common histopathological type ( . %), followed by iii ( . %) and i ( . %) while the predominant histopathological types in group b were subclass iii ( . %), iv ( . %), ii ( . %) and i ( . %). none in group a and . % cases in group b showed crescent. besides, only one glomerulosclerosis was in group a while ( . %) cases of glomerulosclerosis were in group b. the difference between group a and group b was statistically significant (p< . ).no differences were found in balloon stenosis between group a ( . %) and group b ( . %), as well as the renal tubular and interstitial damage ( . % in group a, . % in group b). . % cases in group a and . % cases in group b were found with simple iga deposition in mesangial area. there was no significant difference between group a and group b (p> . ). the children with primary igan manifested as macroscopic hematuria lasting for more than seven days are easily appearing renal tubular damage, crescent formation and glomerulosclerosis. subclass iii and iv are the most common histopathological types. a case report of iga nephropathy accompanying crohn's disease akihiko shirasu , akira ashida , hideki matsumura , hyogo nakakura , tomoki aomatsu , atsushi yoden , motoshi hattori , hiroshi tamai , pediatrics, hirakata city hospital, hirakata, japan pediatrics, osaka medical college, takatsuki, japan pediatric nephrology, tokyo wemen's medical university, tokyo, japan there have been several reports of iga nephropathy accompanying crohn's disease in which the clinical course of the two diseases was linked. we recently experienced a case of iga nephropathy with deterioration of renal function complicated by crohn's disease. a - year-old boy diagnosed as having crohn's disease underwent total colectomy at the age of years. the patient was referred to pediatric gastroenterology unit at the age of , and thereafter maintained a state of remission form crohn's disease while receiving -aminosalicylic acid ( -asa). two months prior to referral to our pediatric nephrology unit, when the patient was years old, a school health examination had revealed microscopic hematuria and mild proteinuria. at that time, laboratory tests suggested deterioration of renal function. renal biopsy was performed and histological examination by light microscopy demonstrated focal segmental mesangial proliferation and moderate tubule atrophy with a diffuse interstitial inflammatory infiltrate consisting predominantly of lymphocytes. immunofluorescence assays revealed + diffuse granular staining for iga and + staining for c in the mesangium. therefore, the patient was diagnosed as having iga nephropathy and chronic interstitial nephritis. the -asa therapy was stopped considering the possibility that it had induced interstitial nephritis. the renal function of the patient has since remained quiescent for months. patients with crohn's disease who present with abnormal urinalysis findings commonly have urological complications, such as urolithiasis and urinary tract infections. however, the possibility of renal parenchymal disease including iga nephropathy should also be considered, even if there is no apparent aggregative linkage of urinalysis findings with gastrointestinal symptoms of crohn's disease. the duration of heavy proteinuria determined long-term outcome of henoch-schönlein purpura nephritis in children results: among the patients, ( . %) cases presented with hematuria and nephrotic syndrome (ns); ( . %) with hematuria and nephrotic range proteinuria (> mg/kg/ h); ( . %) with hematuria and moderate proteinuria ( ~ mg/kg/ h). the typical pathological features, such as the diffuse glomerular mesangial and endocapillary proliferation, mesangial interposition, and double contour formation, were shown in all specimens. moreover, the podocyte hypertrophy, shedding, and cytoplasmic absorption dropletswere also observed in most specimens under light microscopy. the percentage of small cellular crescents varied from . - %. patients were followed up for to years, and all had recovered. conclusion: the predominant clinical manifestation of iskdc grade vi hspn in children was ns accompanying with hematuria. the well outcome might be associated with the prompt use of steroids and/or immunosuppressive drugs at the onset of iskdc grade vi hspn with very mild glomerulosclerosis and tubulointerstitial lesion. in our future study, all patients should be followed for five or ten years, and more specimens should be observed under electron microscope to investigate whether the podocyte lesions of iskdc grade vihspn should be taken into account in the clinical pathological report and a future new histologic classification of hspn. objective: the aim of the study was to assess efficacy of immunosuppressive treatment in children with iga nephropathy (igan) and henoch-schoenlein nephritis (hsn) based on clinical manifestation and histopathological oxford (o-c) and who (who-c) classifications. the study group consisted of children with igan- and hsn - , (mean age . ± . years) , treated with azathioprine (aza) mg/kg/day - months with prednison (pred) mg/kg/day (nephrotic syndrome-ns), mg/kg/day (nephritic syndrome -nps) weeks, gradually diminished within months. it recognize clinical remission at normal renal function and absence of proteinuria at the end of treatment. in all patients we estimated: proteinuria, gfrs (calculated using schwartz's formula) at the onset of study and after months. they had performed renal biopsy on average . ± . years after the onset of illness and at the end of treatment. we were analyzed the histopathologic evaluation of renal biopsy specimens using the who-c (grade i-v) and oxford classification : (mmesangial hypercellularity, e-endocapillary hypercellularity, ssegmental sclerosis, t-tubular atrophy/interstitial fibrosis; absent = , present= ). results: in patients with igan we observed: ns- , nps- ; with hsn : ns- , nps- . after the treatment aza/pred we noted clinical remission in all children with igan and % with hsn. gfr was normal before and after treatment. at the onset of illness igan patients had: grade iii- , grade iv- according to who-c; hsn had: grade ii - , grade iii- , grade iv - ; at the end of therapy we observed positive effect in who-c only in ( %) igan patients and in ( %) hsn , without progression properly ( %) and ( %). in o-c of igan patients we observed nobody with total regression of changes, only children had m or e or s after treatment. in patients with hsn we noted total regression of changes in ( %), in other -m or e or t . conclusion: aza/pred therapy used in children with igan and hsn can make clinical remission in both groups, but histopathological regression-more frequent in hsn. oxford and who classifications are very useful for estimation of efficiency of treatment. -year follow-up of pediatric hennoch schönlein purpura with renal involvement elena tudorache , christine azema , stéphane decramer , georges deschênes , tim ulinski pediatric nephrology, armand trousseau hospital, paris, france pediatric nephrology, chu toulouse, toulouse, france pediatric nephrology, robert debré hospital, paris, france objective: the aim of this study was to determine the long-term outcome in children with hsp nephritis who underwent a renal biopsy and to identify possible correlation between disease parameters and treatment. we included retrospectively all patients with renal biopsy proven iga nephropathy related to hsp of three pediatric nephrology centres over a -year period. results: patients were included. nephrotic range proteinuria was present in % with grade ii, % with grade iii and % with grade iv lesions. renal function was impaired in %. significant proteinuria > mg/l was found in / patients years post renal biopsy, in / patients at years and in / patients at years. there was no correlation between risk for proteinuria at , , or years with initial histological lesions. there was a tendency to higher residual proteinuria in patients with nephrotic proteinuria at disease onset and also for patients who were not treated with steroid pulses at disease onset with vs. mg/l (p= . ) at three months, vs. mg/l (p= . ) at one year, vs. mg/l (p= . ) at five years, and vs. mg/l (p= . ) at ten years. there was a tendency to less proteinuria in the long term for those with early steroid pulses (< days vs. > days after proteinuria onset (p= . ).in patients with acei/arb treatment within days after renal disease onset, compared to those who were treated later (>one month), proteinuria was significantly lower at (p= . ) and months (p= . ). among control kidney biopsies, % show fibrosis of different degree unrelated to initial histology. conclusion: there is a risk to underestimate long term disease severity in patients with low iskdc classes. there is need for prospective long term studies to explore the benefit of early acei/arb and/or steroid pulses. abstract# p-sat good outcome of biopsy-proven henoch-schonlein purpura nephritis in children in shanghai single center objective: severe hsp nephritis considered a risk factor for chronic kidneys disease development especially in patients with nephrotic syndrome (ns). methods: we present our experience with tacrolimus (tac) as a steroid sparing agent for a treatment of severe hsp nephritis in years boy. our patient has been observing at the republic center of pediatric nephrology minsk for years. he presented with a typical purpuric rash with recurrences after infections. one year later during acute pneumonia macrohematuria, proteinuria ( - . g/ h) occured and ace inhibitors (iace) were prescribed. despite this, boy developed nephrotic range proteinuria ( . - . g/ h), biochemical protein g/l, albumin g/l, cholesterin , mmol/l. renal biopsie showed mesangial proliferation with iga deposits. prednisolon (pred) mg/daily with heparin failed to decrease proteinuria and activity. cyclosporin a mg/daily plus pred on alternate day were started and followed during months with positive dynamic (proteinuria , g/ h, decreased clinical and laboratory activity) after which pathogenic treatment was stopped. arterial hypertension (ag) was treated by iace. months later proteinuria ( . g/ h) and activity increased again. with the presence of ns resistance to steroids combined with hematuria and ag, medrol ( mg/daily) plus tac mg twice daily were prescribed. duration of tac therapy was months. tac was succesfully withdrawn with no rebound disease activity observed (during months). at present the patient receiving iace only. our results indicate that tac may be a promissing steroid sparing agent for treatment of severe hsp nephritis. anti-proteinuric effect of cyclosporine a treatment for iga deposit diseases objective: to evaluate the therapeutic effect of cyclosporine a (csa) on nephrotic-range proteinuria in children with immunoglobulin a (iga) deposit diseases in mesangium such as iga nephropathy (igan) and henoch-schonlein purpura nephritis (hspn). methods: fifty four children ( children with igan, children with hspn) who were diagnosed with iga deposit diseases in mesangium at renal biopsy were analyzed retrospectively. all the patients developed nephrotic-range proteinuria (> mg/m /day) for more than months. the starting dose of csa was mg/kg per day that was given in two divided doses, and the drug level was maintained between and ng/ml. the degree of proteinuria was measured before and after csa treatment. steroids were tapered off and stopped gradually after initiation of csa. results: mean duration of csa treatment was . +/- . months (range . - . months). mean follow-up duration was . +/- . yr (range . - . yr) from the beginning of csa treatment. the mean ratios of protein to creatinine decreased from . +/- . to . +/- . after csa treatment for months. thirty-two ( . %) patients achieved complete remission. renal function was preserved in all patients months after csa treatment. there were no severe complications in patients with csa treatment. conclusion: our findings indicate that csa is an effective agent to treat nephrotic-range proteinuria of iga deposition glomerular diseases such as igan and hspn and the duration of csa treatment should be at least more than months for efficacy. objective: to observe the therapeutic effects of hemoperfusion combined with corticosteroid in treating children with henoch-schonlein purpura. methods: a total of patients ( inthe hemoperfusion group (hp) and inthe control group) were included and followed up for months. both groups were treated with corticosteroids and other supportive therapy. patients in the hp group received hours of hemoperfusion each day for consecutive days. clinical features at the acute phase, relapses in a year and renal involvement at , , , months were compared. the blood levels of iga and such cytokines as, tnf-alpha-il- , il- , ltb were measured by elisa technique before and , , days after hemoperfusion. results: hemoperfusion significantly reduced the severity and duration of abdominal and joint pains. for patients with renal involvement at acute phase the hp group had quicker relief than the control (log rank p= . ). for patients without renal involvement at acute phase the hp group had less occurrences of renal involvement compared with the control during follow-ups(log rank p= . ). the rash was also alleviated after hemoperfusion though the difference was not significant. patients' levels of iga were elevated compared with the healthy control before treatment ( day ) patients'levels of cytokines also significantly increased compared with the healthy control on day , they began to decrease day after hemoperfusion and there were significant differences among those groups. less relapses were seen in the hp group compared with the control (p= . ). conclusion: hemoperfusion combined with corticosteroid was more effective than corticosteroid alone in improving extrarenal symptoms, alleviating and preventing renal involvement. the effects may be achieved by iga and cytokine reduction after hemoperfusion. the treatment of henoch-schonlein purpura nephritis in children combined with mycophenolate mofetil and corticosteroid nephritic syndrome type, cases( . %). about histological degrees, cases were in grade (mesangial proliferation, all accompanied by < % crescent formation), case was in grade (moderate to severe mesangial proliferation, accompanied by % crescent formation). treated with new therapy, cases were complete remission ( %), cases were improved, and one died. the complete remission rate of this therapy was significantly higher than that of the past treatment. objective: steroid pulse therapy (spt) has been reported to be effective for improving urinary abnormalities and preventing renal deterioration in patients with iga nephropathy. however, some patients are refractory to spt or have relapse after spt, resulting in renal impairment. the efficacy of tonsillectomy combined with spt has been discussed. the aim of our study is to evaluate the efficacy of tonsillectomy combined with spt in childhood iga nephropathy. methods: children, aged to years, who had been followed up for more than years after the first biopsy between and , were enrolled in this study. all patients received spt (methylprednisolone, ~ mg/kg intravenously times per week for consecutive weeks). patients received tonsillectomy combined with spt (group a), and patients received spt alone (group b). tonsillectomy was performed one month before or after spt. the therapy was followed by oral prednisolone and tapered off for to months, with warfarin, dipyridamole and ras inhibitor. all of patients underwent repeat biopsy. clinical features and pathological findings were retrospectively analyzed. results: the disappearance rate of proteinuria was . % for group a vs % for group b at year, and that of hematuria was % vs . % at years. for group a, all the cases which of urinary abnormalities had improved by the treatment could maintain remission, but for group b, . % of the cases had recurrence of proteinuria and . % had recurrence or did not achieve disappearance of hematuria at the last observation. histlogically, the percentage of glomeruli that showed crescents was significantly reduced in both groups. but the cases which still showed crescent formation at the second biopsy were % for group a vs . % for group b. conclusion: the differences of recurrence rate for urinary abnormalities after the treatment and disappearance rate of crescents at second biopsy may suggest that tonsillectomy can improve the long-term prognosis. objective: to observe the efficacy and security of tripterygium wilfordii polyglycosidium (twp) in treating children with severe henoch-schonlein purpura nephritis (hspn). methods: children failed to intravenous pulse methylprednisolone for days for their severe hspn entered our study and were given oral twp for - month. we evaluated the efficacy and security of twp through examinations of urinalysis, blood routine, function of liver and renal, myocardial enzyme series, level of sex hormone and electrocardiogram (ecg) before treatment, - month after giving twf and weeks after stopping medication respectively. results: proteinuria disappeared in all patients. the remission time was weeks in children, weeks in , weeks in respectively. during treatment, elevated glutamic-pyruvic transaminase and glutamic-oxaloacetic occurred in patients and returned to normal after stopping medication. abnormal findings in examination of ecg were observed in patients, one with left ventricular high voltage, another with knot parallel rhythm of the heart. after stopping medication, one patient still had t wave change in ecg. we didn't find any abnormalities of blood routine, renal function and level of sex hormone. conclusion: the twp has good efficacy and security on the treating children with severe hspn. the efficacy and side effects of glucocorticoids in treating children with henoch-schonlein purpura kai-yun liu, ling lu pediatrics, irst affiliated hospital of anhui medical university, anhui, china objective: to observe the efficacy and safety of glucocorticoid in the treatment of children with henoch-schonlein purpura. methods: patients with hsp were divided into mild and severe group according to clinical manifestations. children in mild group were given hydrocortisone sodium succinate (hcss) therapy. children in severe group were given methylprednisolone ( mp ) therapy. a follow-up record system was set up for every patient. we observed the recovery time of clinical symptoms and side effects of glucocorticoid. results: symptoms of skin rashes, joint and gastrointestinal in all children were disappeared within months of treatment. the urinalysis in of patients with renal involvement returned to normal in weeks. the other patient failed to mp therapy was given oral tripterygium and got normal urinalysis in weeks after disease onset. the body mass index (bmi) values in all children after glucocorticoid treatment were significantly higher than before treatment. after stopping medication, there was no significant difference in bmi value compared with before treatment and between two groups. during the treatment, patient in each group had ecg abnormal, and their ecg returned to normal after stopping drug. we didn't find any abnormalities of blood routine, renal function and level of sex hormone. objective: to investigate the role of th /treg imbalance in the pathogenesis of childhood henoch-schonlein purpura(hsp). and further explore the immunomodulatory affects of compound/lycyrrhizin(gl) on the th /treg deviation in hsp. methods: hsp patients were chose as gl-treated group, another patients were used as conventional therapy group. besides ( . - )ml/kg/l was enjected in l-treated group, other treatments were same, any steroid or immunosuppressants treatment was prohibited. age and sex-matched healthy children were used as healthy controls. blood samples of patients were obtained at the acute stage and after days treatment. using intracellular staining, the frequency of peripheral cd +cd -il +(th ) and cd +cd +foxp + treg cells was detected by flow cytometry all patients received methyl-prednisone pulses iv ( g/ . m for consecutives days) and subsequently oral prednisone with gradual withdrawal in six months, and mmf at dose of - mg/kg/ h for months. results: after six months of therapy all patients but one had persistent microscopic hematuria (me), only / patients had recurrent ma. patients with grade ii hspn showed significant reduction or normal proteinuria. only / patients with grade iii hspn had proteinuria still > gr/ h, / patients had proteinuria < g/ h, in / proteinuria was normal. mean period of follow-up was years. after one year, only patient had recurrent ma, patients showed persistent me. two patients with persistent proteinuria > g/ h showed a significant reduction (< g/ h in pts, normal in pt). proteinuria did not reappear in all patients.the effect persisted after years and after therapy withdrawal. no side effects was recorded. conclusion: our experience shows the efficacy and safety of mmf in hspn and has to be confirmed by larger controlled studies. the analysis of blood perfusion therapeutic effect on cases of allergic purpura cheng guo-qiang xi 'an children's hospital urology department, xi'an, shanxi, china objective: to observe the auxiliary therapeutic effect on severe allergic purpura. methods: children with severe allergic purpura were randomly divided into the control group ( cases) and the treatment group ( cases). the children of control group were treated with conventional therapy (anti-inflammatory, anti-allergic, anticoagulation and symptomatic treatment). the children of treatment group were treated with conventional therapy and blood perfusion. two groups of patients were both treated for days, and were followed up for months. the amelioration time and the regression time of clinical symptoms such as abdominal pain, bloody stool, rash, joint symptoms, visible hematuria and proteinuria, was compared in two groups before and after the treatment. the amelioration time of the clinical symptoms of children in the treatment group, such as acute abdominal pain, bloody stool, rash, joint symptoms, abdominal pain and bloody stool, visible hematuria, proteinuria, and other clinical symptoms, was shorter than the time in the control group (p < . ), and the late symptoms such as joint symptoms, abdominal pain and bloody stool iterations was also less than those of the control group (p < . ). methods: iga nephropathy model was established in male sprague-dawley rats. at week , rats in the model group were randomly assigned to either remain in the model group (n= ), or to receive treatment with rednisone (n= ), , (oh) d group (n= ), or prednisone plus , (oh) d (n= ). at week , serum interleukin- level was detected by elisa, and the level of treg cells in the blood was assayed using a flow cytometry method. results: ( ) the proteinurine and the number of blood cells in urine from rats in the model group was significantly higher than in rats in the control, prednisone, , (oh) d , and prednisone plus , (oh) d treatment groups (p < . ). ( ) serum interleukin- in the model group was significantly increased compared with control and treatment groups (p < . ), and the levels were decreased in turn in the prednisone treatment group, , (oh) d treatment group, and prednisone plus , (oh) d treatment group. in addition, the , (oh) d and prednisone plus , (oh) d treatment groups showed lower levels than the prednisone treatment group (p < . ). ( ) the level of treg cells in the model group was significantly decreased compared with the control and treatment groups (p < . ), with the levels showing a slight increase in the prednisone treatment group, a larger increase in the , (oh) d treatment group, and the greatest increase in the prednisone plus , (oh) d treatment group when compared with the model group. furthermore, the , (oh) d group and prednisone plus , (oh) d treatment groups showed higher levels than the prednisone treatment group (p < . ). conclusion: a th /treg disorder exists in rats with iga nephropathy, with the levels of interleukin- increased and the levels of treg cells decreased. vitamin d can regulate the th /treg balance and reduce the level of protein and blood in the urine in rats with iga nephropathy. objective: to explore the therapeutic effect of prednisone (pred) combined with mycophenolate mofetil (mmf) and cyclosiporin a(csa) in children with severe purpura nephritis (hspn). methods: we collected patients with severe hspn (from iskdc iiia to i) whose proteinuria symptom of nephrotic syndrome did not significantly relieve after weeks which treated with oral pred and mmf ( - mg/(kg.d)); and (or) the gross hematuria did not disappear after courses which treated with large doses of methylprednisolone. all patients were treated with oral csa - mg/(kg.d) to induce remission therapy for - months, then gradually reduced csa to - mg/(kg.d). the follow-up was - months. results: combined therapy with immunosuppressant treated a month later, gross hematuria were disappeared in all patients, patient ( %) was partial remission (urinary protein and urine erythrocyte continued to decrease %- % than before), patients ( %) were significantly remission (urinary protein and urine erythrocyte continued to decrease over % than before), -hour urinary protein was . ± . mg/kg, urine erythrocyte was . ± . × /ml. months later, patients ( %) were significantly remission, patient was complete remission (urinary protein was completely negative, urinary sediment red blood cells < /ml), -hour urinary protein was . ± . mg/kg, urine erythrocyte was . ± . × /ml. months later, patients ( %) were significantly remission, patient was complete remission, -hour urinary protein was . ± . mg/kg, urine erythrocyte was . ± . × /ml. patients were complete remission at last and the median duration of complete remission was . ± . months. patients had not been reached complete remission, which follow-up was - months. patients were relapse during withdraw or reduction, other side effects included hairy ( patients objective: increasing evidence suggest that the cosmc( -beta- galactosyltransferase-specific molecular chaperone ) might play a vital role in the pathogenesis of iga nephropathy (igan). however, the mechanism is not clear. methods: we investigated whether cosmc gene( c galt c )methylation is an important mechanism in igan in children. methods (m:f= : ) primaryigan children and (m:f= : ) healthy controls were enrolled randomly. the methylation status of the c galt c was detected using bisulfite-specific polymerase chain reaction (bsp)-based sequencing analysis. results: the male patients had obviousely high methylation percentage than the male controls(p= . ). three significant hypermethylation sites were identified in the male patients: cpg site (p = . ), site (p = . ), andsite (p = . ). in the female groups,the patients and the normal controls all had high level methylation without significance (p= . ). conclusion: methylation of c galt c might have the vital significance in the susceptibility to the male igan patients. objective: the aim of this research is to investigate the value of serum and urinary tgf-β and mmp- level, the noninvasive and easy repeatable biomarker, for assessing the severity and disease progression in igan children. methods: children with biopsy-proven igan and normal children(control group) were enrolled between july and january .(fingure )the igan group was divided into clinical groups according to their clinical features: isolated hematuria group (ih group, patients), hematuria and proteinuria group (hp group, ), and nephritic syndrome group (ns group, ). patients were divided into two groups according to their lee's pathologic classification: grade i+ii (lee's i+ii, patients), grade iii+ iv (lee's iii+ iv , ) groups. igan group was classified according to the renal function into two groups(renal failure group vs normal group). igan group was also divided into four groups according to their immunophenotype: iga( patients),iga+igg( ),iga+igm( ),iga+igg+igm( ) group. results: the level of tgf-β and mmp- inserum and urinary of the igan group was significantly higher than that in the control group (p< . ). both the level of tgf-β and mmp- inserum and urinary of the three clinical groups in the igan children were not statistically different. the serum tgf-β and mmp- levels were significantly higher in lee' s iii+ iv group compared to that in lee's i+ii group(p< . ). the difference was not statistically significant between urinary tgf-β and mmp- levels in the two lee's group.the serum tgf-β and mmp- levels of renal failure group were significantly higher than that of normal renal function group in igan children(p< . ),and the urinary tgf-β and mmp- levels of the two group were not statistically significant different. the serum and urinary tgf-β and mmp- levels were not statistically different in all immune classification. conclusion: the serum tgf-β and mmp- plays an important role in the severity and progression of children with igan. tgf-β and mmp- may be two more noninvasive and easy repeatable biomarkers to be used in evaluating the progression of igan in children. abstract# p-sat glomerular ace expression is enhanced in pediatric iga nephropathy yusuke seki, maki urushihara, takahiro tayama, takashi nagai, ariunbold jamba, shuji kondo, shoji kagami department of pediatrics, the university of tokushima graduate school, tokushima, japan objective: angiotensin converting enzyme (ace) is a homolog of ace and is thought to be a potent counter-regulator against ace activity. while renin-angiotensin system (ras) plays a critical role in the progression of iga nephropathy (igan), the role of ace has not been investigated in pediatric patients with igan. this study was performed to examine the relationship between ace expression and the development of pediatric igan. methods: we performed immunohistochemical analysis of ace and ace in kidney tissues from patients with pediatric igan and patients with minor glomerular abnormalities (mga) using specific antibodies and examined the correlation with clinical parameters and pathological findings. in addition, we elucidated the effects of various cytokines on ace expression in cultured human mesangial cells (mcs) by quantitative real time pcr and western blot analyses. results: ace expression levels in glomeruli (r = . , p < . ) and tubules (r = . , p = . ) were positively correlated with the mesangial hypercellularity score, while ace expression levels in glomeruli (r = . , p = . ) and tubules (r = . , p < . ) are not. multiple regression analysis showed that the mesangial hypercellularity score correlated with ace expression level in glomeruli and urinary protein-creatinine ratio (r = . , p < . ). in igan patients not treated with a ras blocker (ace inhibitors or angiotensin ii type receptor blockers), ace expression levels in glomeruli were significantly increased compared to patients with mga (p < . ). iga patients treated with a ras blocker did not show this increase in ace exrepssion. furthermore, ace mrna and protein expression was enhanced by interleukin- beta, a pro-inlammatory cytokine, and suppressed by transforming growth factor-beta , a pro-fibotic factor in the progression of igan. conclusion: these data indicate that ace expression in glomeruli is associated with mesangial hypercellularity in the active phase of pediatric igan. abstract# p-sat increased serum interleukin- and peripheral th cells in children with henoch-schonlein purpura nephrology (hspn) xiaoshan shao nephrology, guiyang children's hospital, guizhou, china objective: interleukin (il)- and th cells have been involved in many autoimmune diseases. the aim of this study is to investigate the involvement ofil- and th cells in the pathogenesis of childhood henoch-schonlein purpura (hspn). methods: serum and supernatant levels ofcytokines and chemokines were analyzed by enzyme-linked immunosorbent assay (elisa). using intracellular staining, the frequency ofperipheral th and th cells was studied by flow cytometry. results: children with hspn had significantly higher serum levels of il- , il- and transforming growth factor-beta than healthy controls. the il- levels in culture supernatants of peripheral blood mononuclear cells with anti-cd and cd antibody stimulation were much higher in patients with hspn ( . +/− . vs. . +/− . pg/ml, p = . ). thepatients also had more th cells ( . +/− . % vs. . +/− . %, p = . ) but not th cells in peripheral blood. moreover, il- could promote human endothelial cells to produce chemoattractants il- and monocyte chemotactic protein- . the increased frequency of peripheral th cells and serum il- levels are shown in childhood hspn that may in part contribute to vascular inflammation, suggesting cellular immunity is likely to be involved in the process of hspn. expression and significance of tgf-beta, smad , fn, ub and smurf in the renal tissues of children with iga nephropathy chen li-zhi, jiang xiao-yun, ling yi-hong, mo ying, sun liang-zhong pediatrics, the first affiliated hospital of sun yat-sen university, guangzhou, china objective: in this study, we investigated the expression of tgf-beta , smad , snon, fn, ub and smurf inthe renal tissues in children with igan, in order to explore the potential cross-talk between ubiquitinproteasome pathway and tgf-beta signaling and even their role in the progressive renal fibrogenesis of igan. methods: sixty children with igan were divided into three groups according to their clinical features: isolated haematuria group (ihgroup, patients), hematuria and proteinuria group (hp group, ), and nephrotic syndrome group (ns group, ) . patients were also divided into three groups according to pathologic grades: grade ( patients), grade ( ) and grade ( ) groups. six normal renal specimens (four was non-tumor kidney tissues from patients who had renal tumor and underwent nehprectomy, another two was healthmismatched donor renal tissues before renal transplantation) were used as the control group. the expression of ub, smurf , tgf- , smad , snon, and fn in renal tissues were determined by immunohistochemistry (two-step powervisiontm) and semi-quantitatively analyzed by the software of image-pro plus . . the degrees of glomerular and tubulointerstitial lesions were scored according to the katafuchi semi-quantitative criteria. results: the expression of tgf-beta , fn, ub and smurf inigan kidneys was significantly higher than that in the control group(pless than . ), while the increased expression of smad was only found in glomeruli but not in renal tubular interstitium(p less than . ). the highest expression of tgf-beta , fn, and ub were found in the ns and grade groups(p less than . ), smurf in the ih and grade groups(p less than . ), while the lowest expression of smad was found in the grade group(p less than . ), closely associated with different clinical and pathological groups. (p less than . ) conclusion: these results demonstrate that upp and tgf-beta /smads signaling pathway were both activated in children with igan.both upp and tgf-beta /smads signaling pathway may play an important role in the progress of glomerular sclerosis, renal tubular injury and renal interstitial fibrosis in children with igan. abstract# p-sat objective: the proteasome (ps) plays a key role in the activation of transcriptional factors, cytokines and presentation of hla-i restricted peptides. in immune mature cells, particularly dendritic cells, the ps, under the action of interferon gamma and alpha, becomes an immunoproteasome (ips), by substituting catalytic units beta , beta , beta with other low molecular weight proteins (lmp and lmp ) and an endopeptidase-like complex (mecl- ). this modification confers an optimal catalytic property for professional presentation of specific peptides to mhc class i. our group previously demonstrated that adult patients with iga-nephropathy (igan) have an increased expression of ips catalytic subunit, which correlated with the severity of renal disease.aim of this study was to investigate the switch from ps to ips in children with primary igan and with henoch-schoenlein purpura (hsp), a vasculitis sharing with igan several immune system abnormalities. methods: peripheral lymphomonocytes (pbmc) from children with igan, with hsp and healthy control subjects (hc), isolated by centrifugation gradient, were tested with real time prc (taqman) to assess quantitatively the mrna levels of ps alpha subunit (constitutive), of the active subunit of ps (beta , beta , beta ) and of ips (lmp , lmp and mecl- ). results: objective: recent studies suggest that dysregulated innate immunity plays an important role in the pathogenesis of iganephropathy (igan). interleukin- subfamily and its receptor, interleukin- receptor alpha- (il- r ), were recently identified as immunomodulators in human diseases, acting as mediators of mucosal host defense. however, the potential role of il- r in the pathogenesis of igan has not been explored. methods: in the current study, one hundred ninety four patients with igan and normal controls were genotyped for coding polymorphisms of the il- r gene and the association between the polymorphisms and igan was investigated. local expression of il- r was examined in patients with igan and healthy controls using immunohistochemistry. results: our case-control analysis showed that genotypes of rs were associated with childhood igan. individuals with the cc genotype of rs had about three fold reduced risk of igan compared with those with the gg genotype in the codominant model (p= . ) and those with the genotypes containing g allele (gg or gc) in the recessive model (p= . ).after bonferroni correction, the association between rs cc genotype and reduced risk of developing igan remained significant. furthermore, the renal expression of il- r was significantly higher in healthy controls compared with subjects with igan. conclusion: our data suggest that the cc genotype of rs polymorphism in il- r gene is associated with the reduced risk of igan, and this genetic association was supported by the higher renal expression of il- r in healthy controls compared with patients with igan. abstract# p-sat toll-like receptor gene polymorphisms contribute to development of proteinuria in childhood iga nephropathy henoch-schoenlein purpura (hsp) is the most common form of immune-mediated systemic vasculitis in children, which mainly affects skin, joints, gastrointestinal tract and kidney. the overall prognosis of hsp is favorable, but the long-term outcome is dependent on the degree of renal involvement. the incidence of renal involvement varies from to % and there have been some reports showing that nephritis might be related to an older age at onset, persistent purpura (> month), severe abdominal pain, and relapsing disease.recently, several studies have shown that galactose-deficient iga (gd-iga ) is recognized by anti-glycan antibodies, resulting in the formation of the circulating immune complexes and their mesangial deposition causing renal injury in hsp nephritis and serum galactose-deficient iga levels were highly inherited in children with hsp nephritis.regarding the treatment of hsp, one randomized double-blinded controlled study recently showed that patients with abdiminal pain or arthralgia may benefit from early treatment with prednisone, but the drug has not been proven to be capable of preventing the development of renal symptoms. however, it was effective in altering the course of renal involvementmild henoch-schoenlein purpura nephritis (hspn) generally does not require aggressive treatment due to a favorable course of the disease, but severe nephritis has a high risk of progression to end stage renal failure. although several intensive therapies, such as intravenous high-dose methylprednisolone pulse, immunosuppressive/cytotoxic drugs, fibrinolytic therapy, anticoagulants, antiplatelet agent and plasma exchange, have been used in children with severe hspn, treatment of hspn still remains controversial due to the rarity of randomized controlled studies in this field. expressions and significance of mtor, p s k and e-cadherin in glomeruli of children with iga nephropathy objective: to investigated the expressions of mtor, p s k , and e-cadherin in glomeruli of children with igan to explore the role of mtor/p s k signaling pathway in the progressive renal glomeruli fibrosis of igan. methods: seventy-two children with igan were divided into three groups according to their clinical features: isolated hematuria group (ih group, patients), hematuria and proteinuria(hp group, patients), and nephritic syndrome group (ns group, patients). patients were also also divided into three groups according to their pathologic grades: grade ii( patients), grade iii( patients) and grade iv( patients). six normal renal specimens were used as control group. the expressions of mtor, p s k , and e-cadherin in glomeruli were determined by immunohistochemistry method and the relationship between these indexes and the clinical pathology indexes were analyzed. results: the highest expressions of mtor and p s k inglomeruli were found in the ns group, both of which in tubulointerstitium were higher in grade iii and iv group than that in grade ii group and control group while the lowest expressions of e-cadherin was found in the grade iv group. the glomerular lesion level degree was positively correlated with expressions of mtor and p s k inglomeruli. the quantitative urinary protein of h was positively correlated with expressionsss of mtor in glomeruli. the concentration of serum iga was negatively correlated with the expressionss level of mtor in glomeruli. there was no significant correlation between the expressions of ang ii, mtor, p s k , e-cadherin and α-sma in igan glomeruli and their courses from duration of illness as well as iga depositional strength. conclusion: the mtor/p s k signaling pathway was actived in the children with igan and it may play an important role in the progress of renal glomeruli fibrosis in children with igan. abstract# p-sat iga from hsp patients trigger apoptosis and inhibit cytoskeletal proteins in huvec objective: henoch-schonlein purpura (hsp) is the most common form of small-vessel vasculitis in children, and its etiology is believed to be associated with immune injury. a polymorphism in the gene encoding heat shock protein - (hsp - ) is known to be associated with immune diseases. the purpose of this study was to investigate the correlation between the hsp - gene polymorphism (+ a/g) and hsp in children. the polymerase chain reaction-restriction fragment length polymorphism (pcr-rflp) method was used to detect the hsp - polymorphism in cases of children with hsp and controls, and the association of this polymorphism with hsp and hsp nephritis (hspn) was analyzed. results: in patients with hsp, the a/a, a/g, and g/g genotypic frequencies at the + a/g position of hsp - were . %, . %, and . %, respectively. in the control group, the a/a, a/g, and g/g genotypic frequencies at the + a/g position of hsp - were . %, . %, and . %, respectively. thus, the g/g genotypic frequency in the hsp group was significantly higher than that in the healthy control group (χ = . , p< . ). the frequencies of the a and the g allele were . % and . %, respectively, in the hsp group and were . % and . %, respectively, in the control group. the frequencies of the a/a, a/g, and g/g genotypes in patients with hsp were . %, . %, and . %, respectively. in hspn, the frequencies of the a/a, a/g, and g/g genotype were . %, . %, and . %, respectively. conclusion: the + a/g polymorphism in the hsp - gene is associated with hsp in children. the g/g homozygous genotype may be a genetic factor that predisposes individuals to hsp, but it is not significantly associated with the development of renal impairment. abstract# p-sat investigation of the correlation between tumor necrosis factoralpha gene polymorphism and henoch-schonlein purpura in children fei zhao , , songming huang , , huaying bao , guixia ding , ying chen , hongmei wu , aihua zhang nephrology, nanjing children's hospital, nanjing, china institute of pediatrics, nanjing medical university, nanjing, china objective: to investigate the association between serum tumor necrosis factor-α (tnf-α) gene polymorphism and the occurrence and development of henoch-schoenlein purpura (hsp) in children. the polymerase chain reaction-restriction fragment length polymorphism (pcr-rflp) method was utilized to detect and compare the genotype and allele frequencies at the tnf-α - locus in hsp child patients and non-hsp child patients. furthermore, the relationship between the genotypic and allelic frequencies at the tnf-α - locus and the susceptibility to hsp and henoch-schonlein purpura nephritis (hspn) was analyzed. results: . the g/g, g/a, and a/a genotype frequencies at the tnf-α gene (− g/a) locus in the hsp group and the control group were . %, . %, and . % and . %, . %, and . %, respectively; among them, the a/a genotype frequency in the hsp group was higher than that in the healthy control group, with a statistically significant difference (x = . , p < . ). the g and a allele frequencies in the hsp group and the control group were . % and . % and . % and . %, respectively. the a allele frequency in the hsp group was higher than that in the healthy control group, with a statistically significant difference (x = . , p < . ). . the g/g, g/a, and a/a genotype frequencies in the hsp non-renal impairment group and the nephritis group were . %, . %, and . % and . %, . %, and . %, respectively, but these differences were not statistically significant (x = . , p > . ). the g and a allele frequencies in the hsp non-renal impairment group and the nephritis group were . % and . % and . % and . %, respectively; the difference in the frequency of the a allele in the hsp non-renal-damage group and the nephritis group was not statistically significant (x = . , p > . ). conclusion: the tnf-α (− g/a) gene polymorphism was associated with hsp in children. a/a homozygosity may be a genetic predisposing factor for hsp; however, this factor was not significantly correlated with the development of kidney damage. abstract# p-sat objective: the nephrotic syndrome (ns) is characterized by proteinuria, hypoalbuminemia and generalized edema. although the pathophysiological mechanisms of ns remain unknown, studies with animal models and patients have associated the ns with changes in immune response. the present study investigated the expression of molecules related to cell activation, such as the beta- integrin (cd ) and cd on peripheral blood leukocytes and renal production of reactive oxygen species in rats with ns induced by doxorubicin. meathods: male wistar rats, - g, were divided into two groups: animals receiving intravenous injection of doxorubicin ( . mg/kg) (dox, n= ) and control animals that received saline (con, n= ). the animals were sacrificed at days , , and after injection, and hour urine and blood samples were collected for biochemical and immunological analyzes. the phenotypic analysis of leukocytes was performed by flow cytometry. the expression of cd in monocytes, cd +, cd + and nk cells and the expression of cd in monocytes were measured. in renal tissue samples, the oxidative activity was evaluated by tbars production and antioxidant activity of sod and catalase. results: the dox group animals showed significant increase in cellular cd expression and in the percentage of cytotoxic t lymphocytes, nk cells and monocytes that expressed cd as well as raised cd expression on peripheral blood monocytes when compared to the con group. the increased production of reactive oxygen species in renal tissue of dox group animals was positively correlated with the cd expression on monocytes and serum levels of creatinine. conclusion: these findings indicate a potential link between increased activation of peripheral monocytes and kidney damage in animals with ns. additional studies analyzing the effects of the blockade of integrins and co-stimulatory molecules may offer new therapeutic opportunities to treat human ns. abstract# p-sat cyclosporine a protects podocyte via upregulating the expression of cofilin- li xiaoyan, zhang xiaoyan, li xuejuan, wang xuejing, wang suxia, ding jie pediatric, peking university first hospital, beijing, china objective: podocyte foot process is dysregulated in nephrotic syndrome. the effacement of podocyte foot processes typically arises owing to perturbations in the actin cytoskeleton. calcineurin inhibitor cyclosporien a (csa) is currently used in the treatment of nephrotic syndrome. recent data suggest that the effects of csa on nephrotic syndrome are independent of its effects on the immune system. they identified that csa can stabilize the actin cytoskeleton through stabilizing synaptopodin in podocytes and thereby reduce proteinuria directly. other studies also showed that csa induced cofilin phosphorylation and promoted stress fiber generation in proximal tubular cells. however, whether the antiproteinuric role of csa is played by regulating cofilin- in podocyte has not been studied. methods: acute podocyte injury and nephrotic syndrome were induced by puromycin aminonucleoside (pan) injection in rats with or without csa. cultured podocytes were exposed to pan with or without csa treatment. cofilin- , nephrin, synaptopodin expression were determined by western blot or immunofluorescence. the cofilin- specific effect was determined using cofilin- sirna. results: csa reduced proteinuria, restored expression of cofilin- , nephrin, syanptopodin and repaired foot process effacement of pan induced nephropathy in vivo. in vitro studies showed that exposure of csa restored the expression of cofilin- and nephrin which decreased by pan. csa also repaired actin cytoskeleton impaired by pan. the protective effect of csa was disappeared partially when cultured podocytes were exposed to cofilin- sirna. objective: to find a probably mechanism of immune disorder in rsv nephropathy in rats which resembled the change of minimal change nephrotic syndrome. methods: . rsv mrnas (g, f, m , ns , ns ) and proteins (g and f) were detected with fluorogenic quantitative rt-pcr and indirect immunofluorescence assay (ifa) to find the evidence of viral persistence. . dc-sign mrna and protein were detected with rt-pcr and ifa to find the trend of its change. . the levels of il- /il- and cd /cd were measured by elisa and flowcytometry. results: the course could be divided into two stages: . first stage ( d- d) the mrna of rsv f, g, m , ns- and ns- in kidneys, lungs and spleens expressed and arrived at the highest on d, which accorded with the expression of rsv f and g proteins in ifa. the positively fluorescent luminance and mrna of dc-sign expressed stronger than that in the control, especially from d (ct kidney = . ± . ) to d (ct kidney = . ± . ). compared with the control, the secretion of il- in renal tissues was rising from d ( . ± . pg/ml) to d ( . ± . pg/ml). the expression of cd and cd in peripheral blood was lower than that in normal control. . second stage ( d- d) rsv mrna and viral proteins in the tissues were persistently expressed; it showed that partial rsv survived through immune escape. after d, the fluorescent luminance of dc-sign was gradually reduced in the three tissues. the expression of dc-sign mrna in kidneys, lungs and spleens on d (ct kidney = . ± . ) and d (ct kidney = . ± . ) was higher, except that in spleens on d (ct= . ± . ) was significantly lower than the control. the secretion of il- in tissues decreased after d ( . ± . pg/ml), but that of il- gradully increased after d ( . ± . pg/ml). although the expression of cd and cd in peripheral blood was increased gradually after inoculation, the level was still lower than that in normal control. conclusion: there was rsv persistence in rats which likely attributed to the rsv-induced immune escape. rsv interacts with dc-sign to make dcs inhibit the immune ability of cytotoxic t cells, caused t cell immune dysfunction and finally induced the immune tolerance. abstract# p-sat evaluation of the migratory and regulatory profile of leukocytes from peripheral blood in pediatric patients with idiopathic nephrotic syndrome objective: dynamic regulation of the podocyte cytoskeleton plays an important role in maintaining the glomerular filtration barrier. severe glomerular disorders are associated with perturbed organization of the podocyte actin cytoskeleton. the therapy is based on immunosuppressive agents, in particular cyclosporine a, whose beneficial effect seems also related to the stabilization of the actin cytoskeleton in podocytes. previous studies of our group demonstrated, that the mtor inhibitor everolimus (ev) might similarly involve the recovery of the actin cytoskeleton in a puromycin (pan) experimental model of proteinuric disease. methods: in the present study, inhibitory effects of ev on mtor complex (mtorc ) and − (mtorc ) were analyzed by western blotting in human differentiated podocytes. downstream of mtorc the activity of rhoa (gtpase pull-down assay) and myosin light chain (mlc) was studied. to identify further signaling pathways affected by ev, we performed affymetrix microarray expression analysis followed by verification using real-time rt-pcr. results: biochemical studies revealed a substantially decreased phosphorylation level of both mtor effector proteins mtorc (reduced p-akt) and mtorc (reduced p-p s k) by ev. objective: notch constitutes an evolutionarily conserved intercellular signaling pathway that determines cell fate in various organs. activation of notch and notch has been implicated in human glomerular diseases. notch was reported to play a critical role in development of glomerular diseases; however, a function of notch remains unclear. our aim of the study is to clarify notch pathway's contribution to developing proteinuria and glomerulosclerosis. methods: we injected either jagged antagonistic antibody (mab) or notch agonistic mab or notch agonistic mab intraperitoneally to mice with adriamycin (adr) nephropathy, a model of nephrotic syndrome and focal segmental glomerulosclerosis, and evaluated the levels of proteinuria and the ratios of sclerotic glomeruli. next, we treated cultured podocytes with adr in the presence or absence of notch agonistic mab, and we assessed the effect on cell survival and examined the pathways involved. then, we evaluated a correlation between notch activation and podocyte loss in human kidney specimen of nephrosis, minimal change disease (mcns) and focal segmental glomerulosclerosis (fsgs). results: administration of notch agonistic mab ameliorated nephrosis and glomerulosclerosis in mice with adr nephropathy, even when notch agonistic mab was administered therapeutically after the onset of nephrosis. in vitro, notch agonistic mab protected adr-damaged podocytes from apoptotic cell death. the specific knockdown of notch led to increased apoptosis in damaged podocytes. notch rescued damaged podocytes from apoptosis through akt pathway. human kidney specimens of nephrosis showed a positive linear correlation between the number of podocytes expressing activated notch and the number of residual podocytes. the glomeruli with mcns showed more activated notch and more podocytes, conclusions: whereas those with fsgs showed less activated notch and less podocytes. notch pathway has a pivotal role in preventing apoptosis of damaged podocytes. specific activation of notch may represent a novel clinical strategy for the amelioration of nephrosis and glomerulosclerosis. abstract# p-sat proliferation and apoptosis of tubular cells in initial and advanced stages of focal segmental glomerulosclerosis (fsgs) objective: to analyze processes of proliferation, apoptosis and ciliogenesis in proximal tubular cells during initial and advanced stages of fsgs associated with cystogenesis. methods: normal kidney tissues and tissues of fsgs kidneys were immunohistochemically analyzed using ki- proliferation marker and caspase- apoptotic marker. diameters of dilated and cystic proximal tubules were measured and correlated with proliferation index of tubular cells. data were analysed by the kruskal-wallis and dunn's post hoc test and expressed as mean+/−sd. significance was accepted at p< . . results: normal kidney tissue showed absence of proliferation in proximal tubules. initial stages of fsgs were characterized by intermingling areas of healthy non-proliferating proximal tubules, and pathologically changes, mildly dilated ( um diameter) proximal tubules showing proliferation index of . %. advances stages of fsgs displayed different stages of cystogenesis: while mildly dilated tubules (diameter +/− . um) contained , % of proliferating cells, their number increased to , % in cysts with diameters from +/− . um to +/− . um, and then decreased to , % in cysts with diameter +/− . um. while in the largest cysts proliferation index was lowest and the primary cilia short and distorted, in distal tubules and collecting ducts, primary cilia were extremely long and branching. apoptotic caspase- positive cells were observed within the tubular and interstitial cells. conclusion: deterioration of proliferation and apoptosis, and primary cilia formation characterizes cystogenesis in fsgs kidneys. we suggest that changes in primary cilia length might cause alterations in transfer of signaling pathways which control proliferation, differentiation and apoptosis of proximal tubules cells. advanced stages of fsgs are associated with cyst formation and increased proteinuria leading to nephrotic syndorme objective: to investigate effect of prednisone on the expression of ezrin and neph in rats with adriamycin-induced nephrosis. methods: adr model was induced by a tail intravenous injection of adr.the rats were divided into three groups, which were control group, model group and prednisone group. serum index and h urinary protein were measured at and weeks. observe pathologic changes of renal tissues at weeks. the expression of ezrin and neph in glomerulus was evaluated by immunohistochemistry respectively. results: compared with control group, at weeks, h urinary protein and total cholesterol in model group and prednisone group were significantly increased(p< . ),albumin and total protein were significantly decreased(p< . ),which indicated that the model was successfully established;compared with control group, at weeks, the expression of ezrin and neph in the model group were significantly decreased(p< . ).compared with the model group, the expression of ezrin and neph in prednisone group were significantly increased(p< . ), h urinary protein and total cholesterol were significantly decreased(p< . ),albumin and total protein were significantly increased(p< . ), renal pathology and ecm/ga were significantly increased(p< . ). conclusion: the expression of ezrin and neph were reduced in rats with adriamycin-induced nephrosis which were negatively related to proteinuria and renal pathological damage. prednisone can reduce the proteinuria and relieve the renal pathological damage by improving the expression of ezrin and neph . objective: the activation of the complement system plays an important role in various kidney diseases, such as antibody-mediated rejection or membranous glomerulopathy. the majority of the circulating complement components are produced in the liver. but in the last decade the local production of complement components by other cells is highly debated. the aim of our study was to proof the ability of human podocytes to produce and secrete complement components. methods: immortalized human podocytes were analyzed with western blot (wb), immunofluorescence (if) or/and pcr for their ability to produce components (c / c q, c , c , c , c ) inhibitors (factor h, mcp, cd , cd ) and activators (factor b, properdin) of the complement system. secretion of components was measured in the medium, and functionality of c was tested in a specific c convertase assay. stimulation of the cells was done with interferon-γ, interleukin and human albumin. results: pcr-studies revealed that human podocytes express on mrna level the components c , c , c , c , the inhibitors factor h, mcp, cd and cd , and the activators properdin and factor b. on protein levels c , c , factor b, properdin, factor h, cd and cd were detected. in immunofluorescence all the components showed either intra-plasmatic, perinuclear or peri-membranous distribution. in addition, we could show that podocytes secrete the factors c , c , c , c , factor b and factor h into the medium. the secreted c was clearly functionally active and could further enhanced by stimulation with interferon-γ. objective: to construct the eukaryotic expression plasmid and its shrna plasmids of il- of mice, and to investigate their ability of expression or inhibitory effects on il- . methods: the rna from spleen cells of bal b/c mouse was reversed to cdna, and the full-length cds fragment of il- was amplified. the target segment was cloned into the expression vector plvx-ires-zsgreen , then, the recombinant plasmid plvx-il- -ires-zsgreen was obtained. three pairs of shrna chains targeting il- gene and one pair control shrna chain were designed and synthesized, then annealed to form double strand ,and inserted into the expression vector plvx-shrna . three shrna plasmids and one control plasmid were constructed ,which were called shrna /shrna /shrna /shrnac, respectively. these plasmids were identified by restriction analysis and sequencing, and then they were transfected or co-transfected into t cells in mediation of liposome. the transcription levels of il- mrna were detected by fluorescent quantitative pcr, while expression levels of il- protein were detected by elisa. results: restriction analysis and sequencing proved that the recombinant plasmid were constructed correctly. the plasmid of plvx-il- -ires-zsg reen could expression il- ; when cotransfected with expression plasmid, il- expression levels were significantly reduced in the group of shrna /shrna /shrna as compared with the shrnac group, and the group of shrna had the least expression. conclusion: il- eukaryotic expression plasmid and its specific shrna plasmids were constructed successfully, and plasmid shrna had the best inhibitory effects. abstract# p-sat reno-protective effect of all-trans retinoic acid on adriamycininduced nephropathy mice xiaoli wang, jingjing cui, qiu li nephrology and immunology department, children's hospital of chongqing medical university, chongqing, china objective: to investigate the reno-protective effect of all-trans retinoic acid on adriamycin-induced nephropathy mice. methods: balb/c mice were randomly divided into nephrosis(a single adriamycin . mg/kg,n= ) and control(tail intravenous injection the same amount of saline,n= ). after two weeks nephrosis divided into atra-treated(intraperitoneal injection all-trans retinoic acid mg/kg, three times a week,n= ) and adr nephrosis. then, we chose five mice each group randomly after treatment weeks and weeks to collect -hours-urine, blood, kidney for detection. results: all-trans retinoic acid significantly decreased -h urinary protein excretion, serum tc and tg(p< . ). fas/fasl shows by immunohistochemistry and fluorescence quantitative pcr is decreased sifnificantly(p< . ). conclusion: all-trans retinoic acid has anti-apoptosis on adriamycin induced nephropathy mice to protect kidney damage and delay fibrosis process. abstract# p-sat molecular mechanism of ers induced by lipid accumulation in human mesangial cells (hmcs) objective: dehydroxymethylepoxyquinomicin (dhmeq) is a novel nf-κb inhibitor that potently inhibits the dna-binding activity of nf-κb, resulting in therapeutic effects for various pathological conditions. to elucidate the pathogenetic role of nf-κb in minimalchange nephrotic syndrome (mcns), we examined whether dhmeq could ameliorate the nephrosis in mice induced by puromycin aminonucleoside (pan), which is considered to be an animal model for mcns. methods: mice were injected with dhmeq or only vehicle hours before pan injection on day . mice without pan injection served as controls. the dhmeq or vehicle was injected on consecutive days. the daily urine was collected from day to day , and the urinary concentrations of albumin and creatinine were measured. some mice were sacrificed days after pan-injection, and their serum concentrations of cholesterol, total protein, albumin and il- were measured and the pathological changes of the kidneys were observed. results: pan injection without dhmeq in the mice induced albuminuria which gradually increased up to day and gradually decreased thereafter. in contrast, pre-treatment with dhmeq was associated with no significant increase in the amount of albuminuria during the first weeks. in the serological tests, pan-injection induced an increase in the cholesterol level, a decrease in the total protein, a decrease in the albumin and an increase in the il- in the serum compared to controls days after injection, but dhmeq ameliorated these changes. an electron microscopic analysis indicated an effacement of the foot processes of the podocytes in the pan-injected mice, but this was rarely observed in the pan-injected mice pre-treated with dhmeq. further immunohistochemical analysis showed that dhmeq can inhibit the pan-induced translocation of nf-κb from cytoplasm into nucleus. conclusion: these results suggest that dhmeq can be a candidate therapeutic agent for mcns, because the activation of nf-κb of podocytes may be associated with pan-induced nephrosis. knocking-down stim gene expression inhibits some podocyte molecules jingjing yan, meigui wang, siguang lu the first people's hospital, lianyungang, jiangsu, china objective: to study the effect of knocking-down stim on nephrin,podocin,cd- ap and α-actinin- in murine podocytes in vitro. methods: conditionally immortalized murine podocyte cells were cultured in rpmi medium at °c permissive condition.then the cells were shifted to non-permissive condition at °c and cultured for ten-fourteen days, and were transfected with stim small interfering rna(sirna) using transfection reagent lipofectamine .transfection efficiency was measured by flow cytometer and inhibitory effect of stim sirna was determined by rt-pcr and western blot at fourty-eight, senventy-two hours after transfection respectively. results: ( )the transfection efficiency of fam-sirna was about . %. ( )after transfection with specific sirna,the expression levels of stim mrna and protein were down-regulated by . % and . % respectively. ( ) the expression levels of nephrin,podocin and α-actinin- mrna were decreased by %, %, % respectively, whereas cd- ap showed no-change.both podocin and α-actinin- protein were decreased by %, % respectively. objective: one of the most common causes of nephrotic syndromes in children is the minimal-change-glomerulonephritis (mcgn). typically, mcgn results in foot processes effacement of podocytes. their plate-shaped flattening very likely results in dysfunction of the filtration barrier and may underlie the increase in urine albumin concentrations. notably, mcgn often disappears at the onset of puberty, thus in parallel with increasing peripheral hormone levels. this is particularly true in girls. methods: podocytes were studied by western blot analysis, immunofluorescence and by radioimmunoassay for their ability to secrete and bind estrogens. results: podocytes express estrogen receptors both, estrogen receptor alpha and beta, suggesting that increasing levels of estradiol during puberty potentially maintains and restores morphological integrity of podocytes. this protective function could be mediated by stabilization of the podocyte cytoskeleton by estradiol, as evidenced in vitro by the increase in phosphorylation of cofilin, very similar to the effects of estradiol in neurons. furthermore, we show that dissociated podocytes express aromatase, the final enzyme of estrogen synthesis, and that podocytes in fact synthesize estradiol, as evidenced by measuring estradiol content in the supernatant. conclusion: as it was shown that estrogen synthesis in cells other than those in gonads becomes stimulated during puberty, an autocrine mechanism of estrogen action could underlie decreasing frequency of mcgn at the onset of puberty. overexpression of pgc- α inhibits aldosterone-induced podocyte phenotypic changes and detachment by blocking mitochondrial dysfunction objective: to explore the role of heparanase in the pathogenesis of rat respiratory syncytial virus (rsv) nephropathy. methods: ~ g sprague-dawley(sd) rats (n= per group) were inoculated with × (plaque-forming units, pfu) rsv and sacrificed on days , , and postinoculation (rsv ,rsv ,rsv l and rsv ). five normal sd rats inoculated with dulbecco's minimum essential medium were served as normal control. the expression level of heparanase protein and mrna in kidney of each group was determined by immunohistochemical staining and real-time quantitative rt-pcr respectively. the proteinurina was measured and the relationship between the expression level of heparanase and the hour urinary protein was studied. results: rats with rsv nephropathy exhibited higher proteinuria by comparison with normal rats. there was a significant difference between each group(rsv >rsv >rsv >rsv ). compared with normal control, rats with rsv nephropathy showed up-regulated expression of heparanase protein in glomeruli. the expression level of heparanase protein in rsv and rsv group was higher than that in rsv and rsv group. there was a linear positive correlation between the expression level of glomerular heparanase protein and the quantity of urinary protein(r = . ,p< . ).compared with normal control group, the expression level of heparanase mrna in kidney f r o m r s v , rsv , rsv a n d r s v g r o u p w a s elevated(rsv >rsv >rsv >rsv ).there was a linear positive correlation between the expression level of renal heparanase mrna and the -hour urinary protein(r= . ,p< . ). the increased heparanase in kidney may be important to the loss of glomerular negative charge in glomerular basement membrane and is involved in the pathogenesis of rsv nephropathy. podocyte morphology andautophagosomes were viewed using electron microscopy. podocyte numerical density was estimated by weibel-gomez method. expressions of autophagy markers and ersassociated proteins were analyzed by western blot. results: the expression level of ers-associated protein grp was up-regulated from day to day post-injection. the results also showed that autophagosomes were massively accumulated and the autophagy marker lc was up-regulated in the models on day and . furthermore, rapamycin was given to phn rats to further explore the role of autophagy in the process of complement-dependent podocyte injury. results revealed that rapamycin, which enhanced autophagy in podocyte, could reduce proteinuria, lighten podocyte lesionsand prevent podocyte loss on day . conclusion: taken together, our results demonstrated that ers plays an important role in completment-dependent podocyte damage, and in another aspect, autophagy induced byers can alleviate injury as a protective mechanism. this provides an important basis for a thorough understanding of the role of autophagy in the process of podocyte damage and the pathogenesis of mn. abstract# p-sat the cytoprotective role of autophagy under oxidative stress in human podocyte objective: autophagy is a ubiquitous catabolic process involving selective degradation of cellular components. it shows cytoprotective effects in different cell types and helps to maintain cell homeostasis. some studies demonstrated that cell stress, generated by starvation or some chemical reagents, can initiate autophagy which responsively resists harmful stimuli at the early stage. however, little is known about autophagy in human podocytes under oxidative stress. since the apoptosis and autophagy pathways share some common molecules, we investigated the role of autophagy induced by puromycin aminonucleoside (pan) in human podocytes. methods: human conditional immortalized podocytes were treated with pan, the generation of reactive oxygen species (ros) was measured by immunofluorescence. then, autophagy was assayed by immunofluorecence staining for lc puncta and western blotting for lc . in addition, the mammalian target of rapamycin (mtor) and its substrates which play critical roles in autophagy inhibition were investigated for elucidating the mechanism of pan induced autophagy. podocyte apoptosis was assessed by flow cytometry (yo-pro- /pi and active caspase assays). to study the effects of autophagy on podocyte apoptosis, -methyladenine ( -ma) and chloroquine were used to inhibit autophagy. results: autophagy was detected in pan-treated podocytes in a dose and time dependent manner and prior to apoptosis which was accompanied with increased ros generation. lc aggregates were observed in the cytoplasm and the expression of lc ii was significantly elevated. intriguingly, phospho-mtor and its substrates (phospho-p s kinase and phospho- e-bp ) increased when the autophagy was activated. when autophagy was inhibited by ma and chloroquine, podocyte apoptosis increased significantly. conclusion: pan induced both apoptosis and autophagy in human podocytes. our results suggested that this in vitro model will be useful for the study of crosstalk between apoptosis and autophagy in podocytes. autophagy may be the adaptive cytoprotective mechanism for podocytes under oxidative stress. further studies directed at identifying the role of mtor are essential. abstract# p-sat impact of angptl knock-out on adriamycin-induced nephropathy mice objective: idiopathic focal segmental glomerulosclerosis (fsgs) is associated with recurrence after transplantation due to a circulating permeability factor or factors (n engl j med, : - , ) . we have shown the effects of fsgs plasma and its fractions on glomerular permeability in vitro and in vivo and have used state-of-the-art proteomics to identify cardiotrophin-like cytokine- (clcf ), a member of the il- family, as a candidate for the active substance. we hypothesize that a new model of fsgs can be based on the effects of clcf in mice. methods: rclcf (r&d systems) was injected intraperitoneally (ip), one dose, μg/kg, or infused by minipump for days, μg /kg/day. a construct containing clcf- was administered by electroporation. all studies were done in c bl mice. urinary albumin/creatinine, pjak , pstat , patk, and perk in peripheral blood cells (pbc) and in kidney homogenate were measured and glomerular histology was assessed. results: albuminuria was induced promptly by rclcf after either injection or electroporation. peak albuminuria occurred by days of expression and was - fold increased vs. baseline. ip administration of rclcf- increased pjak and pstat of pbc within min. and renal pjak and pstat remained upregulated for at least hours after injection. kidney pjak and pstat as well as perk/ and pakt were markedly increased after days of infusion. mesangial matrix was increased at that time. conclusion: we conclude that clcf mimics many of the renal effects of the active fraction of plasma from patients with idiopathic fsgs and may play an important role in its etiology. its relationship to other candidates such as circulating urokinase receptor (supar) is not known. a murine model based on administration or overexpression of clcf may permit us to define mechanisms of injury and to test potential therapeutic agents prior to use in clinical trials. over-expression of myo e in mouse podocytes enhance cellular endocytosis, migration, and adhesion objective: to investigate the effects of tacrolimus (fk ) on hepatocyte growth factor and transforming growth factor β in kidneys of fsgs rats. methods: establish unilateral nephrectomy combined adriamycin double tail vein injection of fsgs model in rats divided to model group and treatment group ,then treatment group rats were treated withtacrolimus weeks. the protein expression and site of hgf and tgf-β in renal of each group were assayed by western blot and immunohistochemistry after animals were sacrificed. urine protein, serum albumin, blood lipoids and kidney function were tested automatic biochemical analysis system. results compared with the normal control group , model group and treatment group rats h urinary protein excretion , serum creatinine , blood urea nitrogen , cholesterol significantly increased serum albumin significantly reduced severe renal pathological changes and tgf-β protein expression was significantly increased , and the differences were statistically significant ( p < . ) ; compared with the model group , in experiments weekend , the treated rats h urinary protein excretion , relevant serum biochemical indicators of renal pathological changes varying degree of improvement in renal tissue hgf protein expression was increased and tgf-β protein expression was decreased , the above differences were statistically significant ( p < . ). objective: the cellular mechanisms of kidney injury caused by obstructive nephropathy are interstitial inflammation, fibrosis, and apoptosis. rodent models can be used to simulate obstructive nephropathy in the human kidney. we developed shear-thinning hydrogels for the local delivery of il- to abate the progression of inflammation and fibrosis that leads to ckd. methods: injectable dock-n-lock gels were developed as previously reported (fig. ) . il- was added to the gel or phosphate buffered saline solution at a concentration of . ug/ul. study design: eight cohorts were studied ( , , days, n= ): healthy, sham operation, healthy injected with msa, healthy + gel, unilateral ureteral obstruction (uuo), uuo + il- , uuo + gel, uuo + gel/il- . ul of il- solution, gel, or gel/il- was injected into the left kidney via retroperitoneal approach days after the initial uuo or sham operation. histology: immunohistochemistry (ihc) was performed on paraffin sections to identify macrophages and apoptotic cells, and trichrome stain was used to evaluate fibrosis. cells and total area were quantified for ihc and total fibrotic area was quantified for trichrome. results: comparing the treatment groups to the untreated uuo, macrophage infiltration and apoptosis were significantly reduced at day and . by day , adding the il- via gel injection reduced macrophage infiltration more than il- alone and il- alone did not reduce apoptosis. fibrosis was decreased by day in all three treatment groups (fig. ) . conclusion: injectable hydrogels were synthesized that permit facile local delivery of immunotherapy to both healthy and obstructed kidneys. renal inflammation and scarring was reduced in an animal model of ckd by using an injectable hydrogel for drug delivery. logistic regression reveled that apd was the main parameter significantly associated with surgery treated upjo cases (roc plot was . ). a possible threshold of mm apd may be used as a cut-off value of surgery treated upjo group with a sensitivity of % and a specificity of %. conclusion: apd dilatation was the strongest predictor of surgery treated upjo. pt and renal length also significantly discriminate the two groups and correlate with apd, only with lower predictive power. our findings expand the clinical knowledge in the field of prenatal consult by highlighting a threshold of apd, which predicts the need for surgery in prenatally detected hn cases. abstract# p-sat survival and renal outcome in fetuses with lower urinary obstruction (luto) with and without intra-uterine vesicoamniotic shunting.a ten years experience of a cohort. objective: ureteropelvic junction obstruction (upjo) is the most common cause of hydronephrosis in children. the significant role of the surgical relieving of high grade obstruction is indisputable. nevertheless, the effect of pyeloplasty on the function of the involved kidney remains controversial, especially in upjo with significantly reduced relative renal function (rrf) before surgery. to evaluate the effect of pyeloplasty on the relative function of kidneys in children with upjo and decreased rrf. methods: the records of children who underwent pyeloplasty for upjo during a year period in schneider children's medical center of israel were reviewed. the study group included children who underwent pyeloplasty for upjo and had an initial rrf < %. children with bilateral upjo, solitary kidney or other genito urinary abnormalities were excluded. the control group included children with non obstructive hydronephrosis and an initial rrf< %. results: the average initial rrf in the study group was % (range - %), and the final renal function was % ( - %). in the control group, the initial rrf was % ( - %), and the final function was % ( - %). the final rrf of the study group was significantly higher comparing to the control group (p value< . ). in the subgroup of patients with upjo and initial rrf< % ( patients) the average initial function was % ( - %) and the final function was % ( - %). in the control subgroup with initial rrf< % ( patients) the initial average function was % ( - %) and the final function was % ( - %). conclusion: pyeloplasty is associated with an improvement of renal function in children with upjo and an initial rrf < %. this is also true for patients with rrf< % before surgery. our results support the need for pyeloplasty in children with upjo and reduced rrf. objective: common cause of chronic kidney disease (ckd) in children. kidney damage occurs in utero, and kidney disease progresses postnatally. the objective of this project was to identify clinical biomarkers, in particular antenatal variables, which predicted long-term renal outcome in boys with puv. methods: this was a retrospective cohort analysis. primary outcome was the development of end stage renal disease (esrd) as defined as starting dialysis or preemptive transplantation. clinical variables studied included antenatal factors, postnatal renal function, and modifiable variables. continuous data for the two outcome groups were compared, receiver-operating characteristic (roc), kaplan-meier, and logistic regression analyses were conducted to assess the robustness of each candidate biomarker as a predictor of outcome. results: in this cohort cases reached the primary outcome of end stage renal disease at a mean age of . ± . yrs. compared to those who didn't, those who progressed to esrd had younger age at diagnosis ( . ± . vs . ± . yrs, p< . ), valve ablation ( . fsgs rate was found as % in biopsied subjects. nephrotic syndrome was defined by edema, massive proteinuria (> mg/m per hour or a protein/creatinine ratio > . mg/mg), hypoalbuminemia (< . g/dl), and hyperlipidemia. remission was defined as a urinary protein excretion below mg/m per hour or a protein/creatinine ratio below . mg/mg for three consecutive days. steroid resistance was accepted as no achievement of remission in spite of treatment with prednisolone, mg/kg per day for weeks. if steroid resistance was seen, patients were also treated with cyclosporine a (csa) ( - mg/kg per day for least months) and, thereafter, if required, with cyclophosphamide(cp) ( . - . mg/kg per day for - weeks). renal failure was defined as a glomerular filtration rate (gfr) below ml/min per . m body surface area, and esrd was defined as a gfr below ml/min per . m or the necessity for any renal replacement therapy. bidirectional dna cycle sequencing analysis of entire coding exons and adjacent intronic segments of nphs gene was performed.nphs gene mutation analysis has been also performed in healthy children. results: pathogenic nphs mutations were found in patients ( %) from the totally srns children group. mutation rate was % in familial group, and . % in sporadic group. a total of mutations were determined in the nphs gene, and of which were characterized as a novel mutation presented at hgmd databank. in the mutation positive nphs group, most of the mutations were found out to harbor in exons , , and while no mutation were found in exon of the respective gene. patients with p l, r q, r x, r h, s a, a t, v g, h d, ivs + g>a, c. - inst, c. delg mutations were progressed to end-stage renal disease (esrd). also, age at onset of proteinuria (years) was . +/- . in the mutation (-) (n= ) group; . +/- . in the mutation (+) (n= ) group. for the mutation negative patients, effects of other disease causing genes involving nphs , wt , trpc , cd ap, and actn for different molecular subtypes of srns may be considered. nphs mutation screening was performed for all the patients who had proteinuria up to two years of age. as a causative srns gene, we should consider nphs gene mutation screening in early diagnosis and the follow-up of the clinical course. conclusion: in relation to homozygous or compound heterozygous nphs mutated patients who have the lack of response to standard steroid therapy we suggest to perform nphs gene mutation analysis for every child (if consent can be obtained) soon after the first episode of ns. for the newly diagnosed patients, the crucial certain determination of the causative disease gene mutation will enable clinicians to avoid redundant immunosuppressive therapeutic trials. we then performed next generation sequencing in the affected patients and in one of their unaffected relatives. exome enrichment was conducted using the agilent sureselect human all exon v + utrs capture kit. the multiplex libraries were then sequenced on an illumina hiseq instrument with a x bp read length. results: we unexpectedly identified a novel lmx b mutation segregating with the disease in the family. subsequently, we screened additional unrelated families from our international cohort of autosomal dominant fsgs and found mutations of the same residue in families. none of the probands had any sign of dysplasia of nails, patellae or elbows, iliac horns or glaucoma, or any ultrastructural changes suggestive of nail-patella-like renal lesions. lmx b encodes a homeodomain-containing transcription factor that is essential during development. a lmx b in silicohomology model suggests the mutated residue plays an important role in strengthening the interaction between the lmx b homeodomain and dna. both mutations are expected to diminish such interactions. conclusions: our data demonstrate that isolated fsgs could be due to mutations in genes also involved in syndromic forms and highlights the need to include these genes in all next-generation sequencing diagnosis approaches in fsgs. .in / patients mutations were identified by ngs (detection rate %). in / patients sequence variants were found in two different genes ( %) suggesting oligogenic inheritance. in of these patients the causative mutation was located in a gene following an autosomal dominant inheritance pattern. these patients showed a more severe form of the disease compared to affected family members who showed only the causative mutation without additional modifier variants. one additional patient of this cohort with pierson syndrome had two single heterozygous mutations in nphs and lamb , respectively (both genes following an autosomal recessive pattern of inheritance). a further patient showed two mutations in nphs and the non-neutral polymorphism p.arg gln in nphs . structural and/or functional analysis of all mutations identified in patients with mutations in two genes suggested impaired protein function of the particular gene products. conclusion: the influence of modifier genes or digenic inheritance seems to play an important role in the pathogenicity of srns. the application of ngs is therefore of special interest and highly efficient in the diagnostics of patients with srns. abstract# p-sat mutation analysis in japanese patients with congenital and infantile nephrotic syndrome objective: mutations in podocyte genes (nphs , nphs , wt , and lamb ) are associated with congenital (< months) and infantile ( - months) nephrotic syndrome (ns). the purpose of this study is to investigate the frequency of causative mutations in these genes in ns manifesting in the first year of life in japan. methods: all exons and exon-intron boundaries were investigated in consecutive, unrelated patients from regional pediatric kidney disease centers, by pcr-direct sequencing. results: we detected disease-causing mutations in . % ( of ) patients ( % in congenital and % in infantile) (table) . objective: hypercoagulability along with thrombosis are prevalent complications of nephrotic syndrome. in cases of refractory nephrotic syndrome, intracardiac thrombus, although rare, is a serious complication because of its association with morbidity and high mortality herein, we report a case of a patient with a right atrial thrombus associated with nephrotic syndrome who responded well to corticosteroid therapy and attained quick remission. case presentation: a -year-old japanese boy was referred to our hospital for a right atrial thrombus associated with idiopathic nephrotic syndrome diagnosed month ago. the patient had attained the partial remission within the days of the corticosteroid therapy initiation. he was asymptomatic otherwise at the time of admission. the patient's vitals were stable and laboratory values were almost within the normal range. an echocardiogram showed a large isolated hyperechoic mass in the right atrium, which originated from the superior right atrial wall. the mass measured × mm in diameter and traversed through the tricuspid valve in a to-and-fro motion. the patient underwent emergency surgical thrombectomy on day and anticoagulation therapy was started days after the operation. the subsequent hospital stay was uneventful, and the patient was discharged on day . objective: nephrotic syndrome features proteinuria and severe sodium retention which is implicated in ascites and edema formation. previous works realized in nephrotic rats (pan) clearly highlighted that, the increase of sodium absorption in the ccd is associated with an increase activity of the na/k atpase; sodium absorption is independent of aldosterone, activation of epithelial sodium channel enac is not necessary and sodium absorption is inhibited by amiloride. our hypothesis is that, in nephrotic syndrome, another apical sodium channel sensitive to amiloride and independent of saar pathway is implicated in sodium absorption in the ccd. methods: transcriptome of ccds from control rats (ct) and pan treated clamped rats (adx pan) was analyzed using a high-resolution quantitative and comparative analysis of gene expression. subsequently, transcriptional (rt-qpcr) and proteic expression (western blot and immunohistochemistry) of channel were analyzed. sodium handling in vivo and in vitro microperfused collecting ducts in different conditions (ph and . , apical zinc . mm and amiloride . mm) was analyzed. results: metabolic study confirmed previous results: sodium absorption and ascites were similar in pan and adxpan rats suggesting that sodium absorption in nephrotic syndrome was independent of saar. transcriptome analyses highlighted an increased expression of accn mrna only in adx pan at day . rt-qpcr confirmed an increased expression of accn only in the ccd of adx pan (about eight time compared to adx ct). subsequently, protein shows an increase expression of accn (adx pan . +/- . vs adx ct . +/- . , p . ) and immunohistochemistry on microdissecated ccd highlighted a strong apical expression of accn only in adx pan rats. schimke immuno-osseous dysplasia (siod) is a rare autosomalrecessive multisystem disorder, characterised by: disproportionate growth deficiency, defective cellular immunity, nephrotic syndrome and progressive renal disease.siod is caused by bi-allelic mutations of smarcal gene, which encodes the hepa-related protein (harp), a member of the snf family of atpases, acting as chromatin remodelers within multi-protein complexes. a -year-old patient was hospitalized in november , after detection of proteinuria ( . g/day). at our first clinical examination: height-weightgrowth retardation, thinning hair, thin and hypopigmented skin, arched palate and normal neuro-psychological development.serological examination showed proteinuria ( . g/day), hyperchol. (col tot mg/dl, ldl-col mg/dl) and lymphocyte deficiency ( . %).renal function and complement levels were normal. lymphocyte subpopulations showed a decrease of t lymphocytes and an increase of nk cells(cd + cd +).the patient had also a detour back-lumbar scoliosis and normal kidneys in size, but with reduced corticomedullarydifferentiation. we started therapy with ramipril . mg/day. the hrs urine exams performed monthly showed persistent proteinuria ( - mg/day). at the end of april , for the persistence of proteinuria, we performed renal biopsy, which showed focal and segmental glomerulosclerosis. at discharge, she started therapy with irbesartan mg/day with significant reduction of proteinuria ( mg/day). after months of therapy, thepatient did not present proteinuria and her renal function was normal. the molecular genetic study of smarcal gene revealed that patient was compound heterozygous for two mutations: a novel missense mutation in exon , inherited by mother, and a nonsense paternally-derived mutation in exon , leading to a truncated smarcal protein. our data allow us to diagnose a schimke immuno-osseous dysplasia (siod). in most patients, life expectancy is limited to childhood or early adolescence, due to the onset of stroke, infections,hematopoietic bone marrow failure and renal failure. only patients with milder and late onset forms can survive until adulthood. gain of glycosylation in integrin-alpha- causes nephrotic syndrome and lung disease objective: congenital nephrotic syndrome and interstitial lung disease is a rare multiorgan disorder, characterized by disrupted basement membrane structures. itga gene mutations were recently identified as the genetic cause of this disorder, but the disease mechanism remains poorly understood. methods: we describe a patient who presented with neonatal respiratory distress, glomerulosclerosis, proteinuria, pulmonary hypoplasia and alveolar glycogenosis, who died months after birth due to respiratory insufficiency. a genome-wide screening for deletions and duplications revealed a large homozygous region that included the itga gene. we sequenced the gene and then conductedin vitro characterization studies to investigate the effect of the variant on the protein function. results: a novel homozygous missense mutation was identified in the coding region of the itga gene, which introduces an n-glycosylation motif to the protein sequence. thereby, the mutant integrin alpha- protein becomes hyperglycosylated. functional studies demonstrated that the conformation of integrin alpha- is affected and the mutant alpha- precursor is targeted for degradation. consistent with these findings, alpha- integrin was not detected in the patient glomeruli. furthermore, integrin alpha- protein expression was absent in murine podocytes that lack endogenous integrin alpha- and transfected with mutant itga . conclusion: our findings underscore the role of the integrin alpha- beta- complex as the main regulator of podocyte basement membrane integrity. here, we show that hyperglycosylation of the integrin alpha- subunit, causing the complete lack of alpha- -beta- expression on the basement membrane, is a new pathogenic mechanism underlying congenital nephrotic syndrome and interstitial lung disease. itga mutation screening was directly implemented in dna diagnostics, facilitating early diagnosis, recurrence risk estimation, and genetic counselling. the clinical study on pkhd gene-based testing for the diagnosis of arpkd objective: in order to study the implications of pkhd gene-based testing for arpkd diagnosis in clinical practice, we performed a prospective study to apply pkhd -based genetic testing to the suspected arpkd patients. methods: suspected arpkd patients from unrelated families were detected on mutations of pkhd gene by pcr direct sequencing. these patients were evaluated by combining the testing results and their clinical materials. results: in the detected children, mutations (p s, v a, q h, l x) were novel and mutations (t m, r w, r c, n s, a v, q r, q r) were previously described. of the variants were definite pathogenic mutations. two pathogenic mutations in both chromosomes were found in out of families ( %), which greatly aid to making definite diagnoses. the families with perinatal presentation consisted of fetuses and couples. one definite pathogenic mutation (s c) was found in the wife of family no. , however, it was still difficult in conforming the diagnosis owing to lack of the pathogenic mutation from the husband. for the other families, only some potential mutations were found.two in four children with congenital hepatic fibrosis were detected two pathogenic mutations in both chromosomes, and their liver functions were obviously lower than the other two children without pathogenic mutations. conclusion: pkhd gene-based testing is an effective means for the diagnosis of arpkd, at the same time it could improve the understanding of this disease by analysing the testing results and their clinical materials. objective: to present a case of schimke immuno-osseous dysplasia (siod) which is the first to be reported from egypt. methods and results: this article presents a case from egypt with mild form of siod presented at the age of . years with disproportionate short stature, srns (focal segmental glomerulosclerosis), laboratory evidence of cellular immune deficiency and radiologic characteristics of spondyloepiphyseal dysplasia and died at the age of . years with bone marrow failure and severe pneumonia. conclusion: we emphasize that siod is to be considered in children with growth retardation, srns and bone abnormalities and that inherited nephrotic syndrome may be presented in late childhood or even adolescence and siod suspected patients even before full picture development should be closely monitored for proteinuria, hypertension, cellular immunity and opportunistic infections especially with the need to start immune suppressive therapy for nephrotic syndrome. abstract# p-sat denys-drash syndrome presenting with polycystic kidneys objective: denys-drash syndrome (dds) is characterized by a congenital or infantile nephrotic syndrome due to diffuse mesangial sclerosis, male pseudohermaphroditism and a strong predisposition to develop wilm's tumors and gonadoblastoma's. the syndrome is caused by a dominant mutation in the wt gene. we report a case of dds associated with renal cysts, which has never been described so far. we report a case of dds in a months old girl presenting with proteinuria and bilateral cortical cysts on renal ultrasound. autosomal recessive polycystic kidney disease was excluded by a normal liver biopsy. a kidney biopsy showed diffuse mesangial sclerosis. at the age of months, she developed a unilateral wilm's tumor, which was treated by heminephrectomy and chemotherapy. the renal cysts were still present on ultrasound. histological examination of a cyst (located in the resected specimen, but separate from the wilm's tumor) showed one layer of flattened epithelial cells, without any evidence of malignancy. the combination of diffuse mesangial sclerosis and a wilm's tumor pointed to the diagnosis of dds. genetic analysis showed a de novo heterozygous missense mutation c. g>a (p.asp asn) in the wt gene, previously described in patients with dds, confirming the diagnosis. because polycystic kidneys have never been reported in dds, we explored several genes responsible for these renal manifestations, such as hnf- β, pax , pkd and pkd . remarkably, we identified a heterozygous missense variant c. a>g (p.lys glu) in the pkd gene. mutations in pkd lead to autosomal dominant polycystic kidney disease (adpkd). the pathogenicity of the newly identified missense variant in our case was evaluated by different mutation prediction software programs and was classified as being 'likely pathogenic'. the same variant was found in the patient's mother, having no renal cysts on ultrasound and in the grandfather, having bilaterally renal cysts. conclusion: this is the first case of dds in combination with polycystic kidneys. we hypothesize that pkd c. a>g variant might be an incompletely penetrant allele that can cause a severe phenotype of adpkd in association with a wt gene mutation. the phosphatase and tensine homolog (pten) gene is a tumor suppressor gene located on the long arm of chromosome ( q - ). the pten protein is broadly expressed in cells throughout the body, acting as both lipid and protein phosphatases, and regulates intracellular signaling via various pathways. reduced pten protein resulting from a pten gene mutation may enhance cell proliferation, resist from apoptosis. in addition, it has became clear that, in vascular endothelial cells, pten gene abnormalities lead to increased expressions of vascular growth factors, such as angiotensin ii (ang ii), that are essential to angiogenesis. recent reports revealed a germline mutation of the pten gene to cause several syndromes with generalized, multiple hamartomatous lesions of tridermic origin. thus, the new concept of pten hamartoma tumor syndrome (phts) has been proposed. to the best of our knowledge, we describe here for the first time a case of focal segmental glomerulosclerosis (fsgs) with phts. a -year-old girl was found to have proteinuria and hematuria on health examination and referred to us for persistent urinary abnormalities. igm nephropathy were diagnosed by renal biopsy, and she started taking an angiotensin-converting enzyme inhibitor. however, proteinuria was not reduced, and an oral angiotensin ii receptor blocker (arb) was administered. proteinuria persisted and she underwent renal biopsy again, yielding a diagnosis of fsgs. despite continued oral arb treatment, proteinuria is ongoing with a urine protein-to-creatinine ratio of approximately . , and mild renal impairment. at age years, years ago, a neck mass prompted a detailed examination which revealed multiple thyroid nodules, ovarian cysts (mucinous cystadenoma), hemangiomas in the plantar and femoral regions, spinal cord lipoma, and renal nodular lesions, necessitating follow-up. subsequently, additional workup detected a pten gene heterozygous mutation (exon codon cga(arg) tga(stop)) and she was diagnosed with phts. methods: a -day-old girl, the first child of non-consanguineous chinese parents, was hospitalized due to edema, gross proteinuria, and progressive renal failure. she was delivered spontaneously at weeks of gestation with a birth weight of gand a body length of cm. during the delivery, she was experienced mild asphyxia. placental weight was large, and the amniotic fluid was meconium-stained. pregnancy was unremarkable and had included routine prenatal ultrasound evaluation. the family history of proteinuria or renal failure was negative. on admission, the findings from physical examination showed the patient had bilateral microcoria and limb hypotonia. results of serological testing for torch infections were negative. since pierson syndrome was suspected, a kidney biopsy was performed when she was aged days. meanwhile, all coding exons of lamb were analyzed by using pcr and direct sequencing. results: electron microscopy revealed some glomerular basement membranes were thick and thinning, with splitting of the lamina densa. in addition, the foot processes of podocytes were diffusely effaced, and the number of podocytes increased. two different novel nonsense mutations (trp x and gln x) of lamb were detected in the patient. these mutations were inherited from her parents respectively. conclusions: newborn with unexplained renal insufficiency or nephrotic syndrome should consider pierson syndrome. our report extends the genotypic spectrum of pierson syndrome. a familial wt mutation associated with incomplete denys-drash syndrome we report a familial wt missense mutation in exon ( c>t, r w) in three members of one family. patient , a years old boy, was born at ambiguous genitalia ( , xy karyotype), penoscrotal hypospadias and bilateral inguinal hernias. he was found proteinuria on the preoperative examination and renal biopsy showed diffuse mesangial sclerosis. patient , a years old, is the older sister of patient , who has normal genitalia. she was found proteinuria and renal biopsy showed focal mesangial sclerosis. wilms's tumor was not found in both of them. a wt mutation was detected in both the two patients and their farther. the patients are considered as incomplete dds and they can inherit mutations from their father. so, this finding will provide new evidence for a better understanding of dds and further familial studies in patients of dds are need. ying chen , songming huang , , guixia ding , , hongmei wu , aihua zhang , nephrology, nanjing children's hospital, nanjing, china institute of pediatrics, nanjing medical university, nanjing, china objective: to investigate the correlations between peroxisome proliferator-activated receptor (ppar)-α, ppar-γ, and ppar-γ coactivator- α (pgc- α) gene polymorphisms and susceptibility to primary nephrotic syndrome (pns). methods: patient genotypes were determined using the polymerase chain reaction-restriction fragment length polymorphism (pcr-rflp) technique for the pro ala and val met polymorphisms of the ppar-γ gene, the gly ser polymorphism of the pgc- α gene, and the leu val polymorphism of the ppar-α gene. the gene polymorphisms in cases of pns in children and normal controls (nc) were analyzed and compared to examine the differences in the clinical metabolism index, proteinuria, renal pathological types, and hormone treatment responses among pns children with different genotypes. results: the ppar-γ pro ala and pgc- α gly ser mutations were not associated with the occurrence, blood pressure, total cholesterol, a decrease in glomerular filtration rate (gfr), urine protein excretion at the onset of disease, renal pathological type, or hormone treatment response in children with pns. although the homa-ir values for children with the a allele did not differ significantly from those of children with the pp genotype of the ppar-γ gene, their insulin levels were decreased and their isi values were significantly increased (p= . and . , respectively). the triglycerides (tg) levels of children with the aa genotype of the pgc- α gene were significantly increased (p= . ). in addition, the ppar-γ (val met) and ppar-α (leu val) gene polymorphisms did not show any mutations in the cases of pns in children or the nc children. conclusion: the pro ala mutation of the ppar-γ gene may be correlated with a decrease in insulin secretion and an increase in insulin sensitivity and the pgc- α (gly ser) gene polymorphism may be a causative genetic factor for the triglyceride abnormalities in children with pns. the relationship between endothelin- gene polymorphisms and primary nephrotic syndrome in children objective: nphs mutations have been reported in cns. however, no hot mutation has been described in chinese family. in this study, nphs mutations were analyzed in a chinese family with two siblings died of cns. methods: genomic dna samples were extracted from peripheral blood of the proband, her parents, and unrelated normal individuals. all exons of nphs were detected by polymerase chain reaction(pcr) and direct dna sequencing. results: the proband, a -day-old girl, weighed g at birth. the placenta was one time heavier than usual. she was hospitalized with edema of legs, heavy proteinuria(+++), and hematuresis(+++). two compound heterozygous mutations were identified in exon (c. c>t, p.p s), which was detected in her father, and in exon (c. t>c, p.v a), which was also detected in her mother. these two new mutations were not found in the chinese controls. conclusion: new compound heterozygous nphs mutations (c. c>t and c. t>c) were identified in a chinese family with two siblings of congenital nephrotic syndrome, which were suggested to be the causative mutations in this family. the compound heterozygous mutations (c. c>t and c. t>c) lie between ig and ig domain which has a free cysteine residues. these mutations might cause misfolding and defective intracellular transport, with consequent absence of the mutant nephrin on the plasma membrane. abstract# p-sat sporadic myh -related disease: a case report and mutational analysis of myh gene .genetic analysis confirmed that these three cases had intron (+kts) mutation.after confirmation of fs, cytogenetic analysis showed xy in girls though phenotypically there were females.abdominal ultrasound in them showed normal uterus with streak gonads and gonadectomy was done for both and histologically reported as dysgerminoma stage i. familial girl aged entered esrd and received live related renal transplant from her mother. the sporadic girl aged years also entered end stage renal disease rapidly and died. the third was a nephrotic boy aged years with fs. he had bilateral hypoplastic testes. his chromosome was xy. renal biopsy showed mcd with igm deposits and partially responding to therapy. a six year old girl presented at the emergency department with a history of episodes of vomiting in hours. she had a history of polyuria and polydipsia with a current daily intake of liters. physical examination revealed signs of mild dehydration. plasma electrolytes revealed hyponatremia ( mmol/l), hypokaliemia ( . mmol/l), metabolic acidosis with normal anion gap ( mmol/l), hypophosphatemia ( . mmol/l), hypouricemia ( umol/l) and normal serum creatinine ( umol/l). urinalysis confirmed the na, k, ph and acid uric losses: na ( mmol/l, fractional excretion %), k ( mmol/l, ttkg ), tubular phosphate reabsorption of %, and fractional excretion of uric acid of %. cystine level in leucocytes was normal. she was discharged six days later with oral supplementation of potassium and phosphorus. laboratory studies weeks later revealed surprising findings with persistent hypokaliemia ( mmol/l), metabolic alcalosis (hco mmol/l), hypomagnesemia ( . mmol/l), and hypocalciuria (calcium/creatinine . mmol/mmol). we therefore sequenced the slc a gene and we found that she is compound heterozygous for known missense mutations (p.thr met and p.gly ser). conclusion: gs can have atypical presentations including severe polyuria; it should be suspected in case of severe hypokaliemia even in the absence of the other classical features. this case report emphasizes the need for repeated laboratory tests in unclear tubular disorders, especially outside of confusing intercurrent illness. a single basepair mutation causes cystinosis in the majority of western cape patients. conclusion: renaltube is being used by pediatric nephrologists over the world for the study of their patients with primary tubular disorders. renaltube will likely contribute to a better care of these children and to a better scientific understanding of primary tubular diseases. the creation and development of this sort of international collaborative efforts must be encouraged within the pediatric nephrology community. objective: to study molecular mechanism of hypercalcemia-induced nephrogenic diabetes insipidus (ndi) by identification of proteins in inner medullary collecting duct (imcd) responsible for this syndrome. methods: the effect on rat kidney medullary collecting duct of early onset ndi resulting from parathyroid hormone-induced hypercalcemia was studied using proteomics and phosphoproteomics in native inner medullary collecting duct (imcd) cells. imcd tryptic peptides and phosphopeptides were identified and quantified by mass spectrometry using a label-free methodology. the major findings were confirmed by selected reaction monitoring study, immunoblot, and immunohistochemistry. results: a total of , peptides corresponding to , proteins and , phosphopeptides of proteins were identified, with significant changes in abundance of proteins and phosphopeptides in early onset ndi versus vehicle controls. gene ontology terms and pathway analysis revealed that hypercalcemiaaffected proteins and phosphoproteins are associated with integrin signaling, and actin cytoskeleton organization. immunoblot and selected reaction monitoring lc-ms/ms studies confirmed the hypercalcemia-regulated proteins (agrin, arcp b, capg, erm, itgb , lamb , and lamc ) and phosphoproteins (myh , add , dync li , cgnl , aqp ). hypercalcemia induced changes in abundance of vasopressin-regulated phosphorylation of aquaporin- (aqp ) at ser and ser , but not total aqp , and decreased abundances of slc a urea transporters ut-a , ut-a , and phospho-ser -ut-a . the major findings were also identified in imcd of rats with vitamin d-induced hypercalcemia. filamentous actin aggregation was firstly demonstrated in imcd of rats with hypercalcemia-induced ndi from both pth and vitamin d. conclusions: early increasing in water excretion in response to hypercalcemia are dependent of changes in abundances of aqp phosphorylations, ut-a and its phosphorylations are consistent with prior literature pointing to key roles of the integrin signaling and the actin cytoskeleton in maintenance of collecting duct function. objective: to study molecular mechanism of hypokalemia-induced nephrogenic diabetes insipidus (ndi) by identification of proteins in inner medullary collecting duct (imcd) responsible for this syndrome. methods: the effect on rat kidney medullary collecting duct of early onset ndi resulting from hypokalemia was studied using proteomics in native inner medullary collecting duct (imcd) cells. imcd tryptic peptides were identified and quantified by mass spectrometry using a label-free methodology. the major findings were confirmed by selected reaction monitoring study, immunoblot and immunohistochemistry. results: a total of , peptides corresponding to proteins were identified with significant changes in abundance of proteins in early onset ndi versus vehicle controls.gene ontology terms and pathway analysis revealed that hypokalemia-affected proteins are associated with generation of precursor metabolite and energy and regulation of actin cytoskeleton. immunoblot and selected reaction objective: inherited distal rta (drta) is a rare condition and is almost always observed in children as a primary entity. mutations in genes encoding transporter or channel proteins operating along the renal tubule may result in a variety of functional defects. the identification of the molecular defects in drta may provide a basis for future design of targeted therapeutic interventions and, possibly, strategies for gene therapy of these complex disorders. for this reason, we evaluated mutations in slc a and atp v b genes. methods genomic dna from pediatric patients diagnosed with drta was extracted from peripheral blood samples. sequencing was performed for five exons of slc a ( , , , , ) and two exons of atp v b ( , ). all the selected exons are considered hotspots for mutations associated to this tubular disorder. results silent mutations were identified in both studied genes. the mutation c. t>c was identified in exon of slc a in one patient and the second variation (c. t>c) was found in exon of atp v b in two patients. although previously described, these silent variations are not highly frequent in the overall population. also in slc a , exon , two nonsynonymous variations were identified in the same patient (p.pro leu and p.val ile). the p.val ile variation was also found in three other patients. it has been shown that these variations are rare polymorphisms in the population, but they have already been associated to diego group erythrocyte antigen. in exon of atp v b the variation p.met ? was presented in twelve patients and the mutation p.thr ile was found in six patients. although they occur in the coding region of atp v b , these variations have been described as highly frequent in the population. dent's disease is an x -linked renal proximal tubulopathy associated with mutations in clcn (dent's type ) and ocrl (dent's type ).ocrl mutations also cause the oculocerebrorenal syndrome of lowe. we report the case of a year old boy with dent's disease associated with a novel hemizygous change, c. t>c p.(met ) in exon of ocrl. our patient presented at years of age with incidental finding of non-nephrotic range proteinuria. he had elevated urinary beta - microglobulin, retinol binding protein and hypercalciuria. he was developmentally normal and is otherwise of good general health. slit lamp examination and vision were normal. he had normal renal function but had very poor renal accumulation of mtc-dmsa on renoscintigraphy. genetic testing identified a hemizygous change, c. t>c p.(met ), in exon of ocrl, which affects the translation initiation codon. his healthy year old brother who was also found to have low -molecular weight proteinuria and hypercalciuria, is currently being investigated. to the best of our knowledge, the hemizygous change, c. t>c p.(met ?) in exon of the ocrl gene which was identified in our patient with dent's disease represents a novel variant which has not been previously reported in a dent's disease patient. abstract# p-sat enamel-renal syndrome associated to splenic and ovarian calcifications: a case report sameh mabrouk, noura zouari, houda ajmi, jalel chemli, menair tfifha, saida hassayoun, saoussen abroug , abdelaziz harbi pediatrics, university hospital of sahloul, sousse, tunisia enamel-renal syndrome (omim ) is a rare condition characterized by amelogenosis imperfecta and nephrocalcinosis.we report a new pediatric case of this rare association with the particularity of associated splenic and ovarian calcifications. this report concerns a -year-old girl, born to consanguineous parents (first degree cousins). she has no family history of nephrocalcinosis or kidneydisease. her unique brother, aged years, is in good health and has no dental or renal problems. she was first seen at the age of years in dentistrydepartment because of dental abnormalities, the diagnosis of amelogenosis imperfecta was made and the patient was further investigated. a renal ultrasound showed a bilateral medullary nephrocalcinosis. ct confirmed bilateral nephrocalcinosis which was associated to ovarian and splenic calcifications. besides this young girl has a normal growth, her puberty began at the age of years. laboratory findings including serum electrolytes, urea, creatinine, calcium, phosphate, parathormone and alkaline phosphatase were within normal ranges. on urine examination we found a hypocalciuria, with normal sodium and phosphate excretion. the patient is regularly seen in both dentistry department and pediatrics. the aim of this report is to highlight the important role of pediatricians as well as dentists in recognizing this rare and uncommon syndrome. objective: ipex syndrome, a hereditary (x-linked) immune dysregulation with autoimmune polyendocrinopathy and enteropathy, as the basic manifestations, presents a rare and severe disease. the objective of this case report is to highlight the pleomorphism of the syndrome. methods: the authors report the case of a male infant, with a family history of three male siblings affected by ipex syndrome. the patients' medical records were reviewed in order to describe the case of the youngest one. results: during the follow-up of the youngest of three siblings, who presented eczema and intestinal manifestation, without compromised pancreatic and thyroid function, different from other two siblings, it was noticed the pattern of dent's disease. we registered hypophosphatemia, hypercalciuria, glycosuria, low molecular weight proteinuria and ultrasound revealed second stage bilateral nephrocalcinosis. in this child there was no apparent glomerular involvement, as it was seen in the eldest sibling. conclusion: dent's disease is an x-linked renal proximal tubulopathy associated with mutations in the chloride channel gene clcn (xp . ), which is next to foxp gene on the x chromosome (xp . -q . ). it seems that in this sibling mutations occurred in exons of both of these genes. this case is to remind on pleomorphic potential of mutations that occur near the coding regions of the foxp gene. objective: multiple target organ defects (mtod) is a subgroup of pseudohypoaldosteronism (pha) type i and salt wasting is more severe in this form of pha i. it has a poorer outcome than the renal form, and therapy must be maintained throughout life. here, we reported an infant with mtod who had severe hyperkalemia resistant to classical treatment of pha. hyperkalemia was normalized only by peritoneal dialysis (pd). case: a month-old boy was admitted to our hospital with persistent vomiting, metabolic acidosis, and severe hyperkalemia. there was consanguinity between parents and he had a healthy sister and brother. there was no history of medication. physical examination revealed the signs of volume depletion and acidosis. results: in laboratory examination, blood urea nitrogen was mg/dl, creatinine . mg/dl, sodium meq/l, potassium . meq/l, and chloride meq/l. blood ph was . , base excess - meq/l, and hco meq/l. urinary analysis revealed low specific gravity ( ) with ph . , and normal urinary sediment. urinary sodium was meq/l, potassium meq/l, and plasma renin activity . ng/ml ( . - . ), aldosterone pg/ml ( - ), cortisol . mg/dl ( - . ), and acth . pg/ml ( - ). renal ultrasonography did not show any abnormalities. sweet-test showed high sodium waste from sweet glands ( meq/l). the patient diagnosed as mtod. severe hyperkalemia persisted and was resistant to all treatment options for pha, including high-sodium and low-potassium diet, fluid resuscitation, potassiumbinding resins, indomethacin, fludrocortisone, and hydrochlorothiazide. nutritional status of the patient was also not good, and parents did not accept gastrostomy. hyperkalemia was corrected only after pd treatment, and his nutritional status improved dramatically. conclusion: in the case of type iv renal tubular acidosis resistant to therapy, mtod could be considered as a cause of acidosis. if the classical treatment options fail to correct hyperkalemia in these patients, pd may be a reasonable choice to normalize severe hyperkalemia. gülsün gülay yılmaz erta yilmaz , pediatric nephrology, md, antalya, turkey akdeniz univercity, prof. dr, antalya, turkey tuberous sclerosis, which has an autosomal dominant hereditary disease with a high rate of spotaneous mutation, especially occupies the nervous system and many other organs like kidney, heart and lung. the case presented here was initially diagnosed as congenital heart and polycycystic kidney diasease, because of its characteristics which were quite different than expected for tuberous sclerosis. finally, it was evaluated at our pediatric department together with its dermatological and radiological aspects and defined as a tuberous sclerosis of delateddiagnosis. the case was discussed with its former and actual findings and presented as a warning for early diagnosis. abstract# p-sat the effect of bone marrow stem cells mobilization on expression of hif- α and egf in ischemia/reperfusion-induced renal injury objective: to investigate the therapeutic effects of bone marrow stem cells which has been mobilized by g-csf and stem scf on expression of acute tubular necrosis hypoxia inducible factor- a (hif- α) and epidermal growth factor (egf), and to investigate the mechanism of scf and g-csf on the treatment of ischemia/reperfusion-induced renal injury. methods: male sprague-dawley rats that are - weeks old were randomly allocated into groups (n = ineach group): control group (group a), ischemic-reperfusion group (group b), scf + g-csf + ischemic-reperfusion group (group c) and scf + g-csf + control group (group d). detection index: hif- α was measured by immunohistochemistry technique, the expression of egf and cd + cells in kidney was measured by strept avidin-biotin-peroxidase(sabc) and egf mrna by rt-pcr . results: ( ) at days postoperative, the cd + cells of group b and c was conspicuous higher than group a and d(p< . ), group c was higher than group b(p< . ). they gradually descended from days with the time prolonged. ( )at days postoperative, there was significant difference of the expression of hif- α between group a and d (p< . ). the expression of hif- α of group b and c showed higher positive reaction at days postoperative then decent to normal. at each time the expression of hif- α of group c was significant higher than other groups (p< . ). ( )the egf expression of group b and c showed higher positive reaction at days postoperative and decent to normal with the time prolonged, group b peaks at days and higher than group a, group c peaks at days, and it is the highest (p< . results: in contrast to model group, atn treated with adscs displayed: cells expressing green fluorescent protein were dectected in injured tubule in kidney . treatment group were significantly higher than model group, p< . ; renal damage is lighter; kidney damages were relative gently and histopathologic lesion scores was relative lower; while ki- positivece cells in treatment group were more than those in model group (p< . ); the expression of bax, bcl- and cell apoptotic index(ai) in treatment group was lower than those in model group , p< . , but bax/bcl- ratio was higher than those in model group. conclusion: allogenic adscs transplantation can accelerate proliferation of renal tubular epithelial cell and suppress apeptosis injury through up-regulating the ratio of bcl- / bax and down-regulating the expression of bax protein in acute kidney injury. objective: previously we showed that pretreatment with the antidepressant fluvoxamine (flu) improves postischemic survival and ameliorates functional and structural kidney damage after renal ischemia/reperfusion (ir). in heart ir injury flu is protective through activating the sigma- receptor (s r) -nitric-oxide synthase (nos) system. here we studied the intrarenal vasoregulatory effect of flu and analyzed the renal s r-nos cascade. methods: male wistar rats were were treated i.p. either with ( ) vehiculum (veh); ( ) flu ( mg/bwkg; flu); ( ) flu+ s r antagonist ne- ( mg/bwkg; fn); ( ) flu+ non-selective nos blocker l-name ( mg/bwkg); ( ) flu + selective endothelial (e) nos blocker l-nio ( mg/bwkg); ( ) flu and selective neuronal (n) nos blocker -ni ( mg/bwkg). minutes later rats were either harvested or subjected to minutes of ischemia followed by hours of reperfusion. sham-operated animals served as controls (n= /group). renal s r, akt, enos and nnos protein levels were measured, the alteration of renal capillary diameters was determined in vivo using muliphoton microscopy. results: ir induced renal vasoconstriction, which was ameliorated by flu. this increase was neutralized by all nos blockers, mostly by -ni. after ir all measured protein levels increased. s r expression was similar in all treatment groups. akt and enos levels were lower, while nnos levels were higher in the flu treated group compared to veh and fn. the acute vasodilatative effect of flu minutes after treatment was suspended by l-name and -ni and even reversed by l-nio. s r, akt and enos protein levels were elevated min after flu treatment, while nnos levels remained unchanged. discussion: pretreatment with the s r agonist flu -used chronically without notable side-effects -improves postischemic renal perfusion through the activation of s r -nos system in a time and nos isoform specific manner. based on this data one can hope to find a new therapeutic target in the treatment of renal ir damage through the modulation of the s r. methods: sd rats were randomly divided into model group, intervention group and normal group, rats in each group. intraperitoneal injection with gentamicin for days to establish renal tubular injury rat model. then the intervention group rats were transplanted with × /ml bm-mscs via tail vein. days after transplanted with bm-mscs, took blood and kidney specimen of rats for testing. serum creatinine (scr), urea (bun), malondialdehyde (mda), superoxide dismutase (sod), glutathione peroxidase (gpx), heme oxygenase - (ho- ) were detected by spectrophotometry. he staining was used to evaluate the change of renal tissue pathology, then score the renal tubular injury according to the nangaku semiquantitative scoring method. tunel method was used to detect the apoptosis of epithelial cell rate in renal tubular, while immunohistochemistry was used to detect the proliferation of renal tubular epithelial cells (pcna labeling index). results: . scr and bun of intervention group rats were lower than those in the model group, the difference was statistically significant (p < . ); . renal tubule pathological score of intervention group rats were lower than those in the model group, the difference was statistically significant (p< . ); . apoptosis ratio of renal tubular epithelial cell in intervention group rats were lower than the model group, the difference was statistically significant (p< . ); . the pcna labeling index of intervention group rats were higher than those in the model group, the difference was significant (p< . ); . the mda level was significantly reduced in intervention group rats than in the model group (p < . ); . the sod, gpx and ho- inintervention group rats were significantly increased than those in the model group (p < . ). conclusion: antioxidant factors such as sod, gpx and ho- were significant increased after bm-mscs transplanted into rats. it means that bm-mscs may have antioxidant effect to heal the renal tubular damage. the effect on regeneration and repair in renal tubular epithelial cell after injury deal with at r antagonist pd objective: to study the effect of proliferation of renal tubular epithelial cell after injury deal with at r antagonist pd ,and to explore the function and mechanism of at r in the regeneration and repair after acute kidney injury. methods: to establish the human renal proximal tubule cells (hk- cells) hypoxia /reoxygenation model. hk- cells were divided into two groups. ( ) ( ) these results suggest that the renal proximal tubule epithelial cells after hypoxia/reoxygenation can be simulated tubular epithelial cell process damage; ( ) the proliferation of renal tubular epithelial cell after injury was inhibited by pd .at r may play an important role in the regeneration and repair in the kidney by means of promoting the proliferation of renal tubular epithelial cells. ( ) arb have no significantly inhibit the proliferation of renal tubular epithelial cell after injury, suggesting that at r may not have major role in regeneration and repair after acute kidney injury. the effect and mechanism on regeneration and repair in renal tubular epithelial cell after injury by the inhibitory proliferation effect of acei and arb objective: to study the effect of regeneration and repair of renal tubular epithelial cell after injury deal with fosinopril and valsartan, and to explore the function and mechanism of acei and arb induced acute kidney injury by suppressing proliferation. objective: ischemia-reperfusion injury (iri) is a major cause of acute kidney injury (aki) and both innate and adaptive immunity contribute to the pathogenesis. t cell immunoglobulin- (tim- ) has been reported as an important regulatory molecule and plays a pivotal role in several inflammatory diseases. however, it keeps unknown whether tim- is involved in renal iri. to investigate the expression of tim- on kidney mononuclear cells (kmncs) from mice with renal iri and explored its role in the pathogenesis of renal iri. methods: the left renal pedicle was clamped in c bl mice for min, followed by reperfusion. animals were sacrificed at baseline, day , . flow cytometry was used to quantify tim- expression on kmncs ,cd + t cell,cd + t cell,foxp + tregs and cd + b cell. the levels of tnf-α, ifn-γ, il- and il- in kidney tissue were measured using elisa. results: at day , the increased expression of tim- on kmncs ,cd + t cell,cd + t cell,foxp + tregs in the injured kidney from mice with renal iri compared to those from uninjured kidney tissues and baseline (p< . ). percentage of tim- + cells in kmncs showed an inverse correlation with kidney injury score and kidney tnf-α level. similar negative correlations were found between kidney injury score and tim- levels on cd + t, cd + t cells. consistently, tim- expression on cd + t cells was further increased in mice at day . tim- expression on foxp + tregs negatively correlates with kindey tnf-α. conclusion: tim- might participate in the proceeding of renal iri by regulation on various cd + t cell subsets. tim- might be a potential new marker for assessing severity of renal iri. expression of galectin- and tim- in kidney of mice with renal ischemia reperfusion injury objective: t cell immunoglobulin- (tim- ) is a surface molecule expressed on various immune cells which plays a central role in immune regulation. identification of galectin- (gal- ) as a ligand for tim- has established that the tim- /gal- pathway has been linked to several inflammatory diseases by regulating adaptive and innate immunity. to study the expression of gal- and tim- in kidney of mice with renal ischemia reperfusion injury (iri). methods: thirty c bl male mice were randomized into renal iri groups with and without recombinant gal- . the left renal pedicle was clamped in c bl mice for min, followed by reperfusion. animals were sacrificed at baseline, day , , , after iri. gal- and tim- mrna levels in kidney tissues were determined using real-time rt-pcr. expression of gal- in kidney were detected by immunohistochemistry staining .the levels of tnf-α, ifn-γ,il- and il- in kidney tissue were measured using elisa. results: the expression of gal- and tim- mrna in the injured kidney tissues increased significantly compared with uninjured kidney tissues and baseline (p< . ). compared with the uninjured control and baseline control, the expression of tnf-α and ifn-γ increased significantly in the injured kidney. the expression of gal- and tim- mrna was positively correlated with renal il- and il- level (r= . , r= . respectively; p< . ), but negatively correlated with kidney tnf-α and ifn-γ level (r=- . ,r=- . respectively,p< . ). after recombinant gal- treatment for three days, the kidney injury ameliorated and inflammatory cytokines (tnf-α and ifn-γ) decreased. the expression of gal- and tim- in kidney tissues increase in mice with kidney iri. tim- /gal- pathway are closely related to inflammatory process in renal iri. objective: we previously found that rgc- (response gene to complement- ), a key factor in regulating cell cycle, plays an important role in dealing with epithelial-mesenchymal transition (emt). this study aimed to evaluate the effects of rgc- regulating cell cycle in renal tubular epithelial cells injury and repair. methods: ( ) objective: autophagy is a lysosomal degradation pathway that is essential for cellular stress adaptation and normal homeostasis. increased level of autophagy has been reported in the post-ischemic kidneys by static analysis. this study aimed to understand the dynamics of epithelial autophagy in kidneys following acute ischemic injury and during renal repair. methods: taking the advantage of differential ph sensitivity of rfp (pka . ) and egfp (pka . ) fluorescence, we generated a new strain of cag-rfp-egfp-lc mice to distinguish early autophagic vacuoles from autolysosomes and to monitor autophagic process in the kidneys with ischemia-reperfusion injury (iri). results: renal epithelial cells responded to nutrient deprivation with easily detectable fluorescent puncta that represented autophagic vacuoles and corresponded to lc -ii and atg protein levels. the majority of the egfp lost its fluorescence in the acidic environment of the autolysosomes where bright rfp signals remained. in normal kidneys, few egfp and rfp puncta were present in the nephron. iri led to dynamic changes in autophagic process in the proximal tubules with the number of egfp puncta reaching the peak at day and returning to the control level at days whereas rfp puncta persisted at a high level through days post injury, indicating autophagy initiation at day but autophagosome clearance at days as kidneys were recovering. since rfp puncta persisted in cells with recent autophagy, we examined ki expression and found significantly lower proliferation in cells that contained rfp puncta, suggesting that autophagic cells were less likely to divide for tubular repair. furthermore, % proximal tubular cells with mtor activation indicated by p-s kinase expression contained no rfp puncta. inhibition of mtorc activity with rapamycin caused a -fold decrease in cell proliferation. conclusion: our results highlight the dynamic regulation of autophagy in post-ischemic kidneys and suggest a role of mtor in autophagy resolution during renal repair. abstract# p-sat novel mechanisms by which heparin can regulate the vascular activity of angiotensin ii (ang-ii) and fibroblast growth factor- (fgf- ) and affect the outcome of acute kidney injury (aki) objective: critically ill children treated with extracorporeal membrane oxygenation (ecmo) and/or cardiopulmonary bypass (cpb) frequently develop hypertension, endothelial dysfunction, and acute kidney injury (aki). these patients show high serum levels of ang-ii and fgf- , and are treated with heparin to prevent clotting disorders. however, the mechanisms by which heparin may affect the vascular activity of ang-ii and fgf- are not clearly understood. we carried out this study to determine whether heparin can modulate the vascular activity of ang-ii and fgf- by affecting the rho-a, rac- , src, and pkc signaling pathways. methods: normal fvb/n mice were injected with adenoviral vectors carrying a secreted form of human fgf- or lac z vectors, and treated with heparin ( , u/kg) or control buffer (n= per group). vascular contractility was studied in pressurized isolated resistance-sized mouse mesenteric arteries, in the presence and absence of ang-ii and fgf- . the activation of the src, rho-a, rac- , and pkc signaling pathways were assessed by pull-down assays and western blots, both in vivo and in vitro. permeability changes were explored in cultured human renal glomerular endothelial cells (hrgec) using fitc-dextran. results: heparin significantly enhanced the fgf- -induced activation of rho-a and rac- in the kidney and isolated mouse mesenteric vessels. in addition, heparin antagonized the ang ii-induced contractility of isolated mouse mesenteric vessels through rho-a and pkc-dependent pathways. these changes were reverted by fgf- , and abolished by the rho kinase inhibitor y . both heparin and fgf- , acting in a synergistic manner, increased the permeability of hrec by activating the rho-a and src signaling pathways. conclusion: we conclude that heparin and fgf- , acting in a synergistic manner, can modulate the activity of ang-ii in the kidney, isolated resistance vessels, and cultured hrgec. these findings clearly identify novel mechanisms by which heparin, acting alone or in combination with fgf- , may affect the control of blood pressure, renal perfussion, and capillary permeability in critically ill children treated with ecmo and cpb. abstract# p-sat cisplatinum (cis) toxicity in immortalized human kidney (hk- ) proximal tubular epithelial cells is independent of dna strand breaks and has implications for biology and therapy of renal cell carcinoma (rcc) results: viability of huh- and hk- cells decreased similarly after ic doses of cis with morphology and mtt assays. many dna damage genes, including atm-related genes, were expressed less at mrna and protein levels in both cell types. however, p expression decreased in hk- cells. comet assays showed extensive dna strand breaks in huh- but not in hk- cells. atm promoter activity increased in only huh- cells. also, s and g /m populations were depleted by facs in huh- but not hk- cells. conclusion: hk- cells transformed by hpv e / oncogenes displayed independence from cis-induced dna breaks and atmmediated cell cycle arrest. such independence from genotoxicity will help explain mechanisms imparting resistance to chemo-or radiotherapy and invasiveness in rcc. abstract# p-sat renal neutrophil gelatinase-associated lipocalin and kidney injury molecule- expression in children with acute kidney injury on henoch-schonlein purpura nephritis yue du, jinjie guo, ling hou, yubin wu, tingting sun paediatrics, post graduate trainee, china objective: to evaluate serum, urinary and renal neutrophil gelatinaseassociated lipocalin(ngal) and kidney injury molecule- (kim- ) in children with aki on hspn by prifle or hspn with nephroticrange proteinuria. methods: we performed a prospective single-center evaluation of serum, urinary and renal ngal and kim- in a cohort of children. we recorded any relevant data including age, gender, weight, hemoglobin(hb), serum creatinine(scr), cystatine c(cysc), serum beta -mg, albumine, urine beta -mg, urine protein in all patients. each patient's estimated creatinine clearance was calculated using the original schwartz formula. blood sample and five ml of urine sample from each participating patient were collected for ngal and kim- using an enzyme-linked immunosorbent assay. analysis of proteins ngal and kim- using sabc immunohistochemical assay. results: twenty five patients were enrolled in the study. nine patients with aki-on-hspn(a-on-c) and six were done renal biopsy, sixteen patients with hspn with nephrotic-range proteinuria and ten were done renal biopsy. blood cystatinc, beta -mg , scr, ngal and kim- were increased significantly in patients with a-on-c than those with hspn, and so do urine ngal, kim- and beta -mg. there was no significant difference of proteinuria between the patient with a-on-c and the patients with hspn. immunohistochemical results showed that ngal and kim- were expressed in proximal tubule and their expression were significantly higher in a-on-c group than in hspn group. the correlation analysis showed that urine ngal and kim- were negative correlated with gfr and they were uncorrelated with proteinuria. conclusion: blood, urine and renal ngal and kim- were significantly increased in patients with a-on-c than those with hspn, and they were negative correlated with gfr. we may conclude that ngal and kim- may diagnose a-on-c patients more sensitive than scr. abstract# p-sat objective: neonatal period is an important stage in the development of renal function at the children. the frequency of renal damage in infants undergoing resuscitation is high, but non-specific clinical symptoms and low information existing survey methods impede their timely diagnosis. purpose -evaluation of diagnostic importance of determining the level of carbonic anhydrase ix (ca ) in the urine of newborns in critical states. methods: we evaluated human carbonic anhydrase ix in the urine of newborns who had asphyxia at birth and receiving treatment in the intensive care unit -the main group. the control group consisted from healthy newborns ( people). for the study used a sample of newborn urine collected at - days of age. carbonic anhydrase was determined using enzyme immunoassay kit. results: human carbonic anhydrase ix (ca ) -trans membrane protein, the main physiological function of which is to regulate the ph by the reversible hydration of carbon dioxide. the main pathogenic factor causing kidney damage of fetus is chronic fetal hypoxia. there is a single study hif-i alpha (hypoxia inducible factor-i alpha) in the blood, increased expression of which occurs during hypoxia. this is connected with damage of tubules and interstitial cells of the kidneys, their proliferation, synthesis of cytokines and extracellular matrix. in this case, activity of ca is reduced in the blood. normally, ca is missing in the urine, so its definition can be a marker of early renal dysfunction. the authentic increase of ca level in the main group was revealed in comparison with the control group ( and β -mg, , / , / / / / μg/g cr. levels of each marker were very high in nb and m children, and subsequently decreased gradually. urinary α -mg levels reduced the quickest, and became the same as at >= years old by months after birth. conclusion: renal tubular function can be evaluated in children < years old using these normal values. the most stable and useful marker from early infancy seems to be urinary α -mg. urinary biomarkers for gentamicin-induced acute kidney injury in the neonatal intensive care unit objective: gentamicin (gm) is an aminoglycoside frequently used in the neonatal intensive care unit (nicu). gm is nephrotoxic and may cause acute kidney injury (aki). serum creatinine (scr) appears to be an insensitive and unreliable marker for detecting aki. to determine whether urine biomarkers are useful for early detection of gm-induced aki in neonates in the nicu. methods: prospective, clinical, observational study. forty-six neonates ( m/ f) without pre-existent kidney disease were divided in a gm group (n= ) and a reference group (n= ). demographics, vital signs and clinical conditions were recorded. only neonates with a bladder catheter in place were included. urine samples were collected every two hours. biomarkers (gsta - , gstp - , kim- , nag, ngal) were determined. residual blood samples were used to measure scr. results: the gm and reference group were comparable for gestational age, weight and mortality. neonates treated with gm are admitted longer than neonates in the reference group. treatment with gm resulted in higher scr compared to the reference group ( . [ . - . ] vs. . [ . - . ]; p< . ). higher levels of scr correspond with higher urinary excretion of all biomarkers, especially in neonates treated with gm. the average time until the highest peak was shorter for all biomarkers compared with scr (p< . ). there was no difference in produced urine volume between the gm and the reference group. conclusion: higher scr levels correspond with higher urinary excretion of all biomarkers, especially in neonates treated with gm. gstp - seems the most useful marker for early detection of aki in neonates. seong heon kim, sang wook mun, su young kim . pediatrics, pusan national university children's hospital, yangsan, korea objective: spontaneous tumor lysis syndrome (stls) before cancer treatment is rare and develop mostly in burkitt lymphoma and non-hodgkin lymphoma. here we report a case of stls secondary to tcell acute lymphoblastic leukemia(all) which presented with renal stone and subsequent aki. methods and results: a -year-old boy was admitted to our hospital for generalized tonic clonic seizure. one month ago, he visited other hospital for episodic right-sided flank pain and evaluations revealed microscopic hematuria, hyperuricemia and stone on right uretero-pelvic junction. his blood pressure was / mmhg and he did not have any dysmorphic features and he had developed normally. physical examination showed tender hepatomegaly ( cm below costal margin) and no splenomegaly. his initial laboratory findings were as follows : bun . mg/dl, creatinine . mg/dl, uric acid . mg/dl, ldh iu/l, wbc , /ul, hb . g/d l, platelet k /u l. there was no blast on his peripheral blood smear test. emergent hemodialysis was started because of aki, hypertension and seizure. his renal function, blood pressure, uric acid and electrolyte abnormalities gradually improved with appropriate therapy after times of hemodialysis. but serum uric acid level increased again (from . mg/dl to . mg/dl), so allopurinol was added on. the cause of aki was unclear and we thought that aki presumed to be secondary to acute uric acid nephropathy caused by stls. after few days, bone marrow biopsy was done and demonstrated normocellular marrow without evidence of malignancy. after day of hospitalization, abdominal pain with hepatomegaly was getting worse than before and uncontrolled high fever occurred. % of blasts were seen on his peripheral blood smear and subsequent second bone marrow biopsy demonstrated acute t cell lymphoblastic leukemia. then, he was referred to division of pediatric hemato-oncology on our hospital and induction chemotherapy was started. conclusion: stls with aki is very uncommon initial presentation of leukemia and stls presenting with renal stone is extremely rare. in a clinical situation of marked hyperuricemia with acute kidney injury, we need to consider occult malignancy and stls. the application of serum beta- -microglobulin (beta- -mg) and cystatin c(cysc)concentration to evaluation of renal function impairment in patients withneonatal jaundice yanan xin, cairong jiang, junfeng yang, hui xu, yuan zhang the fourth hospital of baotou, baotou, china objective: to explore the application of serum beta- -microglobulin (beta- -mg) and cystatin c(cysc)concentration to evaluation of renal function impairment in patients with neonatal jaundice. methods: neonates with hyperbilirubinemia from jan. of to dec.of in pediatric department and full term infants were chosen as research object, hyperbilirubinemia divided into mild group (bilirubin< . umol/l) and moderate severe (bilirubin> . umol/l) group according to the level of bilirubin. the different of sex and age were not significant between neonates with hyperbilirubinemia and control group. serum beta- -mg, cysc, cr and bun were measured in the two groups. results: serum beta- -mg and cysc in neonates of hyperbilirubinemia were significantly higher (p< . ) than healthy neonates, meanwhile, serum cr and bun were significantly lower (p< . ) than healthy neonates. after treatment, serum beta- -mg and cysc of neonates with hyperbilirubinemia were significantly lower (p< . ) than pretreatment. however, serum beta- -mg were higher (p> . ) abeta-d cysc were significantly higher (p< . ) than normal group. but there was no significant difference between mild and moderate severe group in the level of serum beta- -mg, cysc, cr and bun(p> . ). the result implied that neonates with hyperbilirubinemia suffered for renal function to varying degrees. howerer, the damage can partially recovered after energetic treatment. clinical and pathological analysis of iga nephropathy with acute kidney injury minguang chen, xiaohua ye, qing yang nephrology, yuying children's hospital, wenzhou, china objective: to investigate the incidence, etiology, clinical pathological characteristics and prognosis in primary iga nephropathy(igan) children with acute kidney injury(aki). methods: retrospectively analysis the clinical and pathological manifestations and follow-up results of chlidren with primary igan and aki in our department from january, to jun, . results: there were cases with aki in chlidren with igan( . %), the peak serum creatinine were from . umol/ to umol/l. histological changes: with the formation of crescent in cases, diffuse endocapillary proliferation in example, cases of renal tubular injury, cases of red blood cell and protein cast, cases with acute interstitial nephritis. multivariate logistic regression analysis showed: with massive proteinuria were independent risk factors of igan in children with aki (or = . , % confidence interval was . - . , p< . ). the etiology of aki except with massive proteinuria, include: . iga nephropathy with severe glomerular damage, including crescentic glomerulonephritis and diffuse endocapillary proliferation; complicated acute interstitial nephritis; drugs causing decreased glomerular filtration rate; . renal tubular injury induced by gross hematuria. all of the patients were not on dialysis, hormone therapy in cases (including cases of methylprednisolone pulse therapy), cases combined with cyclophosphamide treatment. except cases no significant improvement, the renal functiones of all patients recovered or improved within - months after treatment. follow-up from month to years, cases had renal function improved, but were lost to follow-up and after years enter to the chronic renal failure, case with renal function loss after months and repeated renal biopsy showed glomerular sclerosis of . % during the follow-up period. conclusion: aki is not uncommon in children with igan, the causes are varied and massive proteinuria is independent risk factor among them. we should adopt different treatment strategy according to different causes and the short term prognosis is good. abstract# p-sat biopsy proven acute interstitial nephritis in children objective: biopsy proven acute interstitial nephritis (ain) is an uncommon cause of acute renal failure in children. the cause of ain most is commonly due to medications such as antibiotics or infections. we reviewed our experience of biopsy proven ain in children. the biopsy database of all native renal biopsies over a year period was reviewed. all biopsies which listed acute interstitial nephritis were selected and clinical and laboratory data were extracted from clinical records. results: cases of ain from biopsies,( . %) was identified. median age . years, range - / cases presented with acute renal failure without an obvious cause. / cases had non specific constitutional symptoms and oliguria was reported by patients. antibiotics were the most common medications implicated ( / patients) three patients were on multiple medications with one having chronic epilepsy and the other crohn's disease. five patients required short term dialysis ranging from to days. patients were treated with corticosteroids and at last follow up, had reduced gfr - ml/min/ . m . conclusion: acute interstitial nephritis is uncommon in childhood but when it occurs, antibiotics are the single commonest cause. there is significant morbidity associated with the illness with not all patients making a full recovery. abstract# p-sat acute kidney injury as presentation of burkitt's lymphoma eva greta ter haar , anne uyttebroeck , marleen renard , veerle labarque , djalila mekahli pediatric nephorlogy, university hospital leuven, leuven, belgium pediatric hemato-oncology, university hospitals leuven, belgium objective: acute kidney injury (aki) has become increasingly prevalent. approximately - % of children admitted to pediatric tertiary care centers present with this life-threatening condition. the most common causes are post-operative septic shock, organ or bone marrow transplantations and intrinsic renal disease. the latter comprises multiple disorders, but tumor invasion due to a lymphoproliferative malignancy is very exceptional. methods and results: we report two cases of aki caused by infiltration of burkitt's lymphoma. both four-year-old male patients presented with abdominal pain, nausea, vomiting, weight loss and overall weakness since a few weeks. clinical examination showed hepatosplenomegaly and impressive bilateral nephromegaly. both had malignant hypertension. blood analysis showed severe renal impairment in both patients. the first had creatinine of . mg/dl (egfr ml/min/ . m ), urea of mg/dl and uric acid of . mg/dl. the second had creatinine of . mg/dl (egfr ml/min/ . m ), urea of mg/dl and uric acid of mg/dl. lactate dehydrogenase was extremely elevated in both cases ( u/l; u/l respectively). urinary sediment was normal. ultrasound showed bilateral nephromegaly in both patients (patient :+ sd and + sd; patient : + sd and + sd, for right and left kidney respectively). mri demonstrated a homogenous renal enlargement with features of an infiltrative lesion. bone marrow was inconclusive and diagnosis of burkitt's lymphoma was confirmed by a renal biopsy. after starting chemotherapy according to the inter-b-nhl ritux protocol, both children developed a tumor lysis syndrome and required hemodialysis. at last follow-up both children still had hypertension. nevertheless, renal size and function were normalized. conclusion: lymphomatous infiltration due to burkitt's lymphoma is a rare cause of aki. however, it should be considered in a patient presenting with unexplained renal failure and bilateral nephromegaly with normal urinary sediment. renal biopsy may be needed to confirm diagnosis. abstract# p-sat does malnutrition interact with acute kidney injury in children? objective: to investigate the interaction between malnutrition and acute kidney injury (aki) assessed by prifle criteria and to assess the effects of these factors on the outcomes of pediatric intensive care unit (picu) patients. methods: prospective cohort study conducted on children. outcome variables: mortality, need for dialysis, picu free days (the number of days alive from icu discharge to day ) and ventilator-free days (the number of days alive and breathing without assistance from admission to day ). exposure variables: malnutrition on admission (who growth standards) and any change in prifle criteria during the first icu days. results: of patients (median age = iqr = months, girls) enrolled, ( %) were malnourished and ( %) developed aki. among the malnourished, / cases ( %) had aki, while this complication occurred in / ( %) of patients without malnutrition resulting in a risk ratio of . ( %ci . - . ). the days mortality rate was / cases ( %) and aki was associated with higher risk ( / versus / cases -rr= . %ci . - . ). concurrent malnutrition and aki was present in / cases ( %) producing a tendency (p= . ) to a further increased risk of death (rr= . %ci . - . ). / ( %) patients needed dialysis and malnutrition increased the risk for this outcome (rr= . %ci . - . ). aki was associated with significantly higher icu free days ( ± vs. ± ) and ventilator-free days ( ± vs. ± ) but concomitant malnutrition did not reduce either of these outcomes. conclusion: malnutrition and aki are common in children admitted to the icu and the presence of malnutrition is associated with increased risk of developing aki. the need for dialysis was increased in malnourished patients and more powered studies are demanded to test whether the tendency to higher mortality observed in patients with concomitant aki and malnutrition is confirmed. urine erythropoietin level is associated with kidney and brain injury in critically ill neonates yanhong li, jie yan, xiaozhong li department of nephrology, children's hospital affiliated to soochow university, suzhou, china objective: erythropoietin (epo) is a glycoprotein hormone produced predominantly in the kidneys. the protective effect of exogenous epo in hypoxic-ischemic brain injury has been thoroughly examined in neonates. however, the metabolism of endogenous epo in neonates remains unclear. we aimed to evaluate the concentration of urinary epo (uepo) in critically ill neonates and to identify possible clinical and laboratory variables that may be associated with uepo levels. methods: the concentrations of epo, cystatin-c, microalbumin, and α -microglobulin in the first available urine sample during the initial hours of life were measured in critically ill neonates. clinical and laboratory data were collected for each neonate. results: there was a positive correlation between uepo levels and urinary levels of cystatin-c (r = . , p = . ), microalbumin (r = . , p < . ), andα -microglobulin (r = . , p < . ). the concentration of uepo was elevated in neonates who developed acute kidney injury (aki) during the first week of life compared with those without aki (p = . ) and was also elevated in neonates with brain injury, as demonstrated by ultrasound or magnetic resonance imaging, compared to neonates without brain injury (p = . ). an increased log uepo level was associated with the occurrence of aki (odds ratio of . , p = . ) and brain injury (odds ratio of . , p = . ). conclusion: an increased urinary epo level in the early postnatal period is significantly associated with kidney and brain injury in critically ill neonates. abstract# p-sat acute kidney injury following extracorporeal membrane oxygenation support and concomitant hemofiltration -the role of diuretics objective: fluid overload (fo) is common during extracorporeal membrane oxygenation (ecmo) and can be managed by continuous hemofiltration (hf) and/or diuretic therapy. although combination therapy of hf and diuretics in particular can be most effectively for fo removal during ecmo, it may also increase the risk for prerenal acute kidney injury (aki) post-ecmo. our objective was to describe the incidence of aki post-ecmo in patients treated with ecmo and hf who received concurrent diuretics. methods: in this cohort study all neonates (≤ days after birth) treated with ecmo and concomitant hf between and were included. patients were divided into two groups based on diuretic regimen: group- , patients who received no or one single diuretic dose during ecmo and group- , patients who repeatedly received diuretics. both groups were compared using mann-whitney u test for nonparametric data and chisquare test for categorical data. aki was defined as the highest serum creatinine (scr)-based rifle class reached on post-ecmo day up to post-ecmo day (risk, injury, or failure being %, % or % of median scr reference values for age). results: neonates received ecmo support with hf, died immediately following decannulation and others were lost to followup since they were transferred back to their referring hospitals within days post-ecmo. of the patients in group- , ( %) qualified as risk and ( %) as injury. of the patients in group- , ( %) qualified as risk, ( %) as injury and ( %) as failure (group- vs. group- , p= . ). patients in group- had an increased ecmo duration (p= . ) and number of ventilator days (p= . ). no differences were observed in baseline characteristics (e.g. age at the start of ecmo, underlying diagnosis, severity of illness scoring using the pim and prism risk adjustment systems), hf flow rate, and fluid balance between both study groups. conclusion: the incidence and severity of aki immediately post-ecmo was significantly higher in patients who repeatedly received diuretics in addition to hf during ecmo. valentina sitnikova, yuliya pashkova, tatiana zvyagina, elena kulakova, alexandra nastausheva voronezh state medical academy, voronezh, russia objective: it is actually to find the new markers of kidney damage and spread them in practice. cystatine c (cys) is one of these, but there are only few data about it in children with urinary tract infection (uti) according to the age. the aim of our study was to evaluate serum concentration of cys in children with uti of different age. we investigated patients ( girls and boys) with uti from month to years among them children were under years old. methods: concentration of cys were measured by immunoenzime method (elisa) with test-system biovendor (check republic). results: the mean cys concentration in children with uti under year was . ± . mg/l, in older children it was lower: . ± . mg/l, p= . (mann-whitney). in girls before year cys concentration was . ± . mg/l and in boys of the same age it was . ± . mg/l, p> . . in girls over year cys concentration in serum was . ± . mg/l, in boys - . ± . mg/l, p> . . the results of our study showed that among children with uti serum concentration of cys was higher in children of the first year of life and did not depend on sex. probably, higher level of cys in infants connects with low glomerular filtration rate in children of this age. microalbuminuria can prognosticate outcome in the critically ill children biplab maji, surupa basu, rajiv sinha paediatrics, post graduate trainee, kolkata, india objective: microalbuminuria [albumin creatinine ratio (acr) > mg/g] increases in acute inflammatory conditions as a result of glomerular endothelial dysfunction. the study evaluated its prognostic potential in the critically ill child. methods: an ongoing prospective observational study (oct -mar ) of random urine acr (mg/g) estimated on day and day of pediatric intensive care unit (picu) admission, of a tertiary care pediatric hospital. demographic, laboratory data, vasopressor use, mechanical ventilation, length of stay, outcome and pelod scores were recorded. results: of children, children (median age . years, % male) recruited. the commonest cause of admission was pneumonia, infection associated hemophagocytic lymphohistiocytosis followed by meningitis. day acr (median . mg/g) significantly correlated with day total leukocyte count (p= . ). both day and day acr correlated with pelod scores [median ] (p= . & p= . respectively) and duration of mechanical ventilation (p= . and p= . respectively). both median day acr, and day acr were significantly different between survivors (n= ) and non-survivors (n= ) (p= . and p< . , respectively). roc curve analysis for mortality prediction revealed the highest area under curve (auc) of . for acr , followed by . for acr and . for pelod scoring (p> . , non-significant for auc comparisions) (fig. .) . a cut-off value of day acr of . mg/g had a positive predictive value of . % for negative outcome conclusion: microalbuminuria is an early inflammatory marker that correlates with organ dysfunction. significant levels reliably predict negative outcome early into intensive care admission, as accurately as pelod scores, which can help counsel patients, plan treatment and triage, and allocate resources judiciously. abstract# p-sat an unusual presentation of congenital nephrotic syndrome caused by wt mutation ann raes, sofie maebe, joke dehoorne, bert callewaert, johan vande walle pediatric nephrology, university hospital, gent, belgium objective, methods and results: a caucasian girl was admitted at the age of days because of progressive lethargy, poor feeding, oliguria en peri-orbital edema. extreme hyponatremia ( mmol/l), severe renal insufficiency (creat . mg/dl, p . mg/dl), low plasma albumin ( . g/dl), respiratory compensated metabolic acidosis (arterial ph . pco mmhg, bicarbonate . mmol/l, be - . mmol/l) and massive proteinuria ( g/l). clinical examination was normal without anomalies of the external genitals or other dysmorphic features. despite supportive therapy (sodium, bicarbonate, albumin and furosemide) she progressed to respiratory failure and renal failure with need for mechanical ventilation and peritoneal dialysis. congenital infections and thrombosis was ruled out. histological examination showed diffuse mesangial sclerosis (dms). the combination of congenital nephritic syndrome and dms on biopsy was suggestive for mutations in the wilms' tumor (wt ) gene. genetic analysis showed normal female karyotype and conformed a heterozygosity for the c. c>g or p.his gln mutation within the zinc finger domain. after a long and complicated icu episode, a stable situation with home choice peritoneal dialysis was achieved. due to the important risk for comparision of auc of pelod with acr , p= . for comparison with acr ) for the prediction of mortality in the pediatric intensive care unit. development of wilms' tumor, bilateral nefrectomy was performed and kidney transplantation will be planned. we present an unusual case of congenital nephrotic syndrome with extreme hyponatremia at presentation and fast progression to esrd, due to mutation in wt gene. several genes have been implicated in congenital nephrotic syndrome. genetic testing is mandatory and can add important information such as risk of malignancy. renal histology can play an important role in the approach for appropriate mutational screening. mutations in the wt gene are associated with denish drash syndrome and frasier syndrome, but also with isolated and sporadic steroid resistant nephrotic syndrome. in the last category the majority of patients is female, the age of onset and time to esrd is variable, although the vast majority of cases are older at presentation and time to esrd is longer than in our case. objective, methods and results: a -year-old girl, affected by b thalassemia major, was admitted for proteinuria detected at the emergency unit. fever, hyporexia and diarrhea had been present in the last three days. on physical examination she presented with decreased skin turgor and hypertension. laboratory examinations showed: hyponatremia ( meq/l), hypokalaemia ( . meq/l), hypophosphatemia ( . mg/dl), hyperazotemia ( mg/dl), reduced creatinine clearance (crcl = ml/min/ . m ) and metabolic acidosis (hco - . mmol/l). urine analysis revealed: proteinuria, glycosuria, hypercalciuria, hyperuricuria, hyperphosphaturia and aminoaciduria. she had been under treatment for five years with deferasirox (dfx) mg/kg/die. we stopped dfx and gave supplementation of potassium, phosphate, sodium bicarbonate and sodium chloride with electrolyte and renal function (crcl ml/min/ . m ) normalization in days. after one month only minimal proteinuria persisted. conclusion: in so far a fanconi syndrome (fs) has been reported in patients ( children), while mild renal insufficiency (ri) has been documented only in children. in our case dehydration seems to be responsible for the ri, while an interstitial nephritis cannot be excluded. close monitoring of renal function should be done in children on dfx. objective: to test the hypothesis that neutrophil gelatinase-associated lipocalin (ngal) and interleukin- (il- ) are early biomarkers for aki in critically ill patients and evaluate the predictive value of them in patients with established aki at inception of crrt. methods: children from picu and health examination center in guangzhou women's and children's medical center were divided into four groups: critically ill patients with aki recevied crrt group (group ), critically ill patients with non-aki recevied crrt group(group ) , critically ill patients with aki don't recevie crrt group (group ),healthy control group (group ). . ml venous blood and urine specimens were collected and was kept under - °c.from each patient in picu untill they were discharged, transferred or die . serum creatinine (scr) and urine ngal and urine il- were analyzed . results: compared with group and group , the urine ngal and urine il- increases obviously in group and group (p< . ). there is no significance of urine ngal and urine il- between group and group .(p> . ).the concentration of urine ngal increased more than times obviously days before diagnosed of aki under the akin standard with auc . (p < . ) , and the concentration of urine il- increased more than times day before aki with auc . (p < . ). the auc was . (p < . ) when they were combined. the level of urine ngaland il- at initiation of rrt were higher in in non-survivors compared to survivors. conclusion: urine ngal and urine il- are useful indicators to predict and early diagnose aki. the level of urine ngal and il- at initiation of rrt.were negative correlation with the outcome of renal prognosis and survival rate . objective: the aim of this study was to evaluate the rate of early kidney injury in infants with congenital heart disease (chd). neutrophil gelatinase associated with lipocalin (ngal) which can be measured both in serum (sngal) and in urine (ungal), is at the moment the most promising marker directed to discover early kidney injury within the glomeruli and distal and proximal tubules. less known is cathepsine l as a marker of tubule necrosis. methods: the study group consisted of patients ( boys and girls) with congenital heart disease. all patients were under years of age (mean . months). blood and urine samples were obtained during routine checkups. all patients had normal serum creatinine level at the day of collecting samples. the control group (n = ) was age-and gender-matched. levels of sngal, ungal and cathepsine were compared in whole group. the study group was divided depending on the nature of the defect (cyanotic/acyanotic) and the treatment (surgical/conservative treatment). results: chlidren with congenital heart disease had significantly higher concentration of sngal, ungal and urine cathepsine than the control group. no significant difference was observed in the urine cathepsine and urine and serum ngal level between patients with acyanotic and cyanotic chd. there were also no significant differences in patients who underwent surgery and on conservative treatment in ngal level (both in urine and serum). cathepsine level was significantly higher in group after surgical treatment. conclusion: patients with chd are at higher risk of early kidney damage. this process is independent on the etiology and nature of the defect. ngal determined in the serum and urine of these patients may be used to detect kidney injury or monitoring disease progression. urine cathepsine is more efficient marker of early kidney injury in patients after cardiac surgery. abstract# p-sat tim- expression in kidney mononuclear cells and its relationship with foxp + tregs from mice with renal ischemia reperfusion injury yamei wang, yuhong tao, li ye department of pediatrics, west china second university hospital, chengdu, china objective: foxp + tregs participate in the repair of renal ischemia reperfusion injury. t cell immunoglobulin- (tim- ) plays a pivotal role in several inflammatory diseases by modulation of foxp + regulatory t (treg) cells. to detect the expression of tim- in kidney mononuclear cells (kmncs) from mice with renal iri and analyze the relationship with foxp + tregs, to explore the role of tim- in repair of renal iri. methods: the left renal pedicle was clamped in c bl mice for min, followed by reperfusion. animals were sacrificed at baseline, day , , , after iri. tim- expression in kmncs were determined using real-time rt-pcr and flow cytometry. the percentage of foxp + treg in cd + t cells was quantified by flow cytometry. the levels of tnf-α、ifn-γ、il- and il- in kidney tissue were measured using elisa. the correlation among tim- expression, foxp + treg and cytokine level was analyzed. results: the expression of tim- expression in kmncs from injured kidney at acute stage(day ) was significantly higher than those from uninjured kidney at acute stage and lower than those from injured kidney at repair stage (day , , ). the percentage of foxp + treg in cd + t cells was up-regulated with time. compared with the uninjured kidney, the expression of tnf-α and ifn-γ increased significantly in the injured kidney at acute stage and the expression of il- and il- increased significantly in the injured kidney at repair stage. the tim- expression in kmncs at iri repair stage was positively related with the level of foxp + treg, il- (r= . , r= . respectively; p< . ), but negatively related with the level of tnf-α and ifn-γ. conclusion: the increased expression of tim- in kmncs may take part in the repair of renal iri and contribute to the development of foxp + treg. objective: (d+)hus is a critical health problem in argentina since it is the main cause of acute renal failure in children and the second cause of chronic renal failure. fecal contamination of food and drinking water by asymptomatic cattle is often the source although secondary infection through personto-person contact may also occur. occasionally in (d+) hus, the onset among affected siblings occurred within a short time of each other. to evaluate the risk and clinical severity of illness for childhood (d+)hus in siblings. methods: we retrospectively analyzed the clinical records of children with d+hus that were admitted in our pediatric department between march and december . results: (d+) hus occurred in siblings in of the families studied ( %). patients had an affected sibling with diarrhea and progressed to hus ( %). family cases: mean age: months, were girls. the mean duration of interval between hus episodes was days. second family members had prolonged oligoanuria ( vs days) and a most of them developed neurological complications. long-term renal complications were more frequent in this group, but differences were not statistically significant. conclusion: these findings emphasize the potential for extensive intra-familiar transmission of stec, especially between siblings. a second family member might also develop an even more severe hus episode, so siblings should be kept under close surveillance. objective: kawasaki disease (kd) is a common cause of systemic vasculitis in children. other than well known complications like coronary artery aneurysm, there have been few reports of this disease involvement in renal system. according to the study from wang jn et.al, % ( out of ) of the patients who suffered from kd showed renal inflammatory foci in dmsa renal spect which suggested a possibility of renal scar formation subsequent to kd. therefore, this study was performed to verify the renal inflammation following kd. methods: from march to october , patients who were diagnosed as kd at national health insurance service ilsan hospital were enrolled to the study. all of the patients underwent dmsa renal spect to evaluate renal involvement during their acute phase of kd. echocardiography was performed to assess cardiac involvement such as coronary artery aneurysm. complete blood cell counts, aspartate amino-transferase, alanin amino-transferase, albumin, c-reactive protein, and bun/creatinine were measured. also urine β microglobulin was measured to assess renal tubular function. addition to fever of more than five days of duration, of the following symptoms, rash, conjunctival injection, changes of lips or oral mucosa, erythema and swelling of hands and feet and cervical lymphadenopathy, was the diagnostic criteria for kd. results: among the patients, % showed increased white blood cell s (wbc) and % showed elevated ast/alt level. serum albumin was below . g/dl in % of the patients. all of the patients presented normal renal function test. in urinalysis, hematuria and pyuria were observed in % and % respectively. echocardiography revealed coronary artery aneurysm in % of the patients. urine β -microglobulin was elevated in %. regardless abnormal findings in urinalysis and elevated β microglobulin, no significant findings were observed in dmsa renal spect. conclusion: according to the study, mild abnormality in the urinalysis and elevated β -microglobulin were the only findings of renal involvement in kd. however there was no aggressive renal manifestation which could be detected in dmsa renal spect. objective: in this study, the question remains if ngal is a culprit or only bystander in aki due to sepsis in children. methods: twenty seven children, (m- , f- ) admitted to intensive care diagnosed with sepsis, severe sepsis or septic shock were enrolled in this study. the concentration of ngal, protein c and s, antithrombin iii and basic parameters were measured in the plasma at diagnosis and after days of treatment. results: mean creatinine concentration in septic children at admission was higher than in reference group (p < . ). there was statistically significant difference in aptt, prothrombin time, prothrombin ratio, thrombocytes count, heart rate, and systolic blood pressure between study groups in first and after days (p< . , p< . , p< . , p< . , p< . , p< . respectively). the pc concentration in the septic patients was significantly lower than those of the references (p< . ), and during intensive days treatment raised (p< . ). also protein s concentration rose during the treatment (p< . ), and was lower in septic children then reference group (p< . ). ngal concentration was significantly higher in study group on the admission day comparing with reference group (p< . ). plasma ngal was correlated at admission and after days of treatment with protein c (respectively: r=- . , p< . ; r=- . , p< . ). multivariate regression revealed that ngal was significantly predicted by creatinine (β= . , p< . ) and protein c (β=- . ; p< . ), yielding a model r = . (p< . ). conclusions: it is possible that kidney binding of pathogenic antibodies stimulates local expression of ngal, which plays a crucial role in the pathogenesis of aki. objective: the aim of the study was to assess the impact of perinatal risk factors (prfs) on serum ngal level in term neonates. methods: the study group consist of term neonates with prfs, and healthy neonatescontrol group (cg). serum ngal (elisa) was measured in samples of cord blood (cngal) and peripheral blood (pngal) taken within first days of life, and stored in - °c until elisa procedure was performed. prfs were divided into groups: . pathology of pregnancy or mother: diabetes (d) n= , infection (i) -elevated crp or wbc n= , positive vaginal culture (vc) n= , hypertension (ht) n= , others n= ; . labor pathology: instrumental delivery (id) n= , premature rupture of membranes, > hours (prom) n= , fetal distress (fd) n= ; . neonatal pathology: intrauterine infection (ii) n= , cakut n= , perinatal asphyxia (pa) n= . the results were shown as median; values of cngal, pngal were logtransformed before analysis. statistical analysis was performed with t-student, manova tests with help of statistica . statistical significance: p< . . results: in term neonates, median cngal was . ng/ml vs . ng/ml in cg. mean log cngal was significantly higher (p< . ) vs cg, pngal was ns. mean log cngal correlated positively with mean log pngal (r= . , p< . ). univariate analyzes of log ngal in neonates with chosen prfs vs neonates without particular factor showed significantly higher (p< . ) mean log cngal in id and fd group (median cngal: . vs . and . vs . ng/ml respectively), whereas in ii group significantly higher were mean log cngal and mean log pngal (median cngal . vs . ng/ml, pngal . vs . ng/ml). multivariate analysis showed that the impact of id was significant in groups: d (f= . ; p< . ), i (f= . ; p< . ), prom (f= . ; p< . ) and fd (f= . ; p< . ). conclusion: . intrauterine infection may have a significant influence on ngal in cord and peripheral blood whereas fetal distress and instrumental delivery only in cord blood. . the instrumental termination of pregnancy has an import impact on ngal level in cord blood of neonates whose mothers had diabetes or infection, with prom or fetal distress. objective: acute kidney injury (aki) is a common problem and associated with significant morbidity and mortality in neonates. pediatric-modified rifle (prifle) classification system was developed to standardize the definition of aki in children. we aimed to evaluate the performance of prifle score diagnosis, severity and prognosis of aki in term and preterm neonates. methods: in this retrospective study, charts of patients who were admitted to neonatal intensive care unit (nicu) over a year period were reviewed for development of aki. a diagnosis of aki was determined for patients ( . %) according to the prifle criteria results: of the patients included in this study, of them were girls and -were boys. mean age was . days (min-max: - ), mean birth week was . ± . weeks (min-max: - ), mean birth weight was ± gr (min-max: - gr), length of nicu stay was . ± . (min-max: - days). two hundred fifty four patients with aki were classified according to prifle criteria. ninetyeight patients ( . %) achieved an 'r' level of aki severity, patients ( . %) an "i" level, patients ( %) an "f" level, patients ( , %) an "l" level. the most common etiologies of aki -were prematurity, congenital heart disease, hypoxic ischemic injury, sepsis and usage of nephrotoxic agents. patients classified with a higher prifle score had a longer nicu stay and required a greater number of mechanical ventilation (p< . ). renal replacement therapy (rrt) was needed for patients ( . %). mortality rate was % and all deceased patients were classified as prifle 'i','f' or 'l',p < . ) conclusion: using prifle criteria in neonates with aki is an efficient way to assess the severity and prognosis of the disease. objective, methods and results: i present a case of a years albanian old boy, th centile of development. presented with abdominal pain, vomiting. four days after, was addmited in the surgery clinic for uregent apendicitectomy. wbc: . , se: /, bun: . , cre: , urine: normal. after the intervention medications that were used were: gentamycin, metronidazol, cephtriaxon, h blocators. two days after he was better. thereafter he had polyuria and frequent urinating. the fifth day he had oliguria to seventh day, when he couldn't urinate. nativ rtg of abdomen resulted normal. he was transferede to pediatric clinic-nephrology department as an akute kidney injory. he looked very sick, consious, stratified tongue, ecg: b/min, bp: / mmhg, breathing sounds were normal, periferal edemas and cold extremities. lab resultrs: cre: , bun: . , k: . , na: , egfr: . ml/min oer . m . ultrasound resulterd with urinary stasis: hydronephrosis, huge bladder. first was suspected for acute obstruction and aki couse of a medication. we changed a bladder cathether which we find out that was blocked and took out ml urine/ h. we dialysed him for three days and cre was stabilized to , when we stoped dialyse. bp was stabile, his weight droped from kg to . kg. he had proteinuria g/ h. schintigraphy was done (biopsy we couldn't do) and resulted: egfr was % less than adecuat for age, suspected for nephritis tubulointestialis. he had some toxoalergic exanthema spread to the body. repeted us resulted with ascaridosis in the gallbladder, which was treated with mebendazole and in the feces were found the parasites. imune ab were negativ, ige: positive, periferal blood smear had eosinophils, wastage of na and mg with urine. cre after four weeks was , bun: , negative proteinuria. no changes of uveitis in the eyes. importance of this case is cause this is the first case in kosova that was dialysed and has recovered and now is free of dialyse (all other cases have traveled abroad until then). conclusion: we have to think for parasites as a cause of a tubulointesticial nephritis but also of a abdominal pain or fatigue. surgery team should have a close cooperation with pediatricians, in order to identifye in time complications of the surgery. urine output in first hours after birth in relation to akin criteria saroj kumar patnaik, gaurav aggarwal, uday kumar, vempati venkateshwar, shamsher singh dalal pediatrics, command hospital air force, bangalore, india objective: applicability of akin urinary output (uo) criteria in neonates during first hours of life remains contentious since nonpassage of urine during this time has traditionally been considered 'normal'. we hypothesize that 'physiological' oliguria in first hours of life is mostly prerenal in origin related to poor fluid intake during transition and uo criteria should be applicable in the st hours of life too. we aimed a) to investigate pattern of uo in babies admitted to nicu with underlying morbidity but regulated fluid intake versus roomed-in babies in postnatal ward on breastfeeds in first hours of life; b) to relate uo till hrs of life with development of aki methods: prospectively timing of first void and hourly uo from birth till hours age was compared between consecutive postnatal ward and nicu admissions. neonates with structural malformations and requiring ventilatory/vasopressor support were excluded. outcomes-primary : time of first void after birth secondary: uo in st hrs in relation to subsequent aki results: amongst eligible postnatal breastfed babies (mean bwt . kg ; sga ; lscs born) and nicu admissions (median birthweight . kg,mean ga wks ( - wks); prematures ( < wks); sga ( elbw) recruited after informed consent, first voiding was significantly earlier for nicu babies (mean( %ci) (hrs) postnatal . ( . , . ) vs nicu . ( . , . ) hrs). nonvaginal delivery(lscs . ( . , . ) vs vaginal . ( . , . ) and normal birthweight (aga . ( . , . ) vs sga . ( . , . ) ) had a trend for earlier voiding. % babies voided within hrs of birth -more in nicu babies ( . % nicu vs . % postnatal (p< . ) (fig) .asphyxia with mas in nicu and iugr and poor feeding in postnatal ward had delayed first void beyond hours. postnatal and nicu neonates anuric in st hrs met stage i akin creatinine criteria. asphyxiated babies anuric beyond hours in nicu developed stage iii aki. conclusion: 'physiological' anuria in st hrs of life is misnomer and is related to fluid intake. most babies are nonoliguric by h; anuria > h needs investigation. akin urinary criteria should be applicable in neonates. odillha morales maglalang-reed nephrology, philippine children's medical center, quezon city, philippines objective: the precise mechanism of renal injury among dengue patients is not known. patients who have atn will usually require early dialysis. however, on admission to the hospital, it is difficult to distinguish dss patients with atn from patients with reversible prerenal causes that will respond to simple hydration. our understanding of the complex pathogenesis of tubular injury in dengue aki is very limited that until it is sufficiently increased, therapeutic strategies will continue to fail.therefore we sought to explore the limitations of serum creatinine in this setting. general objective is to determine the clinical and diagnostic factors which are predictive for the need for dialysis among dss patients at pcmc. specific objective is to determine if the following factors are predictive of the need for dialysis: decrease in estimated creatinine clearance by % or < ml/min/bsa with urine output of < . ml/kg/hr. x hours or anuria of hours, assess the usefulness of urinary sediment scoring (uss) in predicting the need for dialysis, methods: this retrospective study covered newly admitted cases of dengue shock syndrome lll and lv at the philippine children's medical center between january to december . results: data from patients were available for analysis. comparison of the demographic characteristics between patients who required dialysis and those who did not showed no significant difference as proven by all p values > . . of the differentclinical and laboratory parameters, there was a significant difference in the hr, rr, o saturation, bicarbonate and base excess as proven by all p values < . . the hr an rr were significantly higher among those who needed dialysis than those who did not o saturation, bicarbonate and base excess were significantly lower among those who needed dialysis than those who did not. the estimated creatinine clearance was significantly lower among those who needed dialysis than those who did not. urine sediment score (uss) ≥ was significantly higher among those who needed dialysis than those who did not. conclusion: our data indicate that a decrease in estimated creatinine clearance by % or < ml/min/bsa with urine output of < . ml/kg/hr. x hours or anuria of hours is not predictive of dialysis among dss-induced aki as well as other clinical and laboratory indices. but rather, relatively lower serum creatinine level among dssinduced aki who needed dialysis is associated with greater urine sediment scorecompared with those who did not. a uss ≥ correlated with atn and was predictive of early dialysis.however, estimated crea < is the only factor predictive of dialysis, since this is the only one that was positive after logistic regression. abstract# p-sat pre-operative fgf predicts acute kidney injury in pediatric cardiac surgery patients: a prospective study mark r hanudel, myke federman, barbara gales, georgina ramos, vicky campbell, kristen ethridge, mary scotti, brian reemtsen, isidro b salusky, katherine wesseling-perry pediatrics, ucla, los angeles, usa objective: fibroblast growth factor (fgf ) is a phosphaturic hormone that predicts renal disease progression in ckd. however, in the setting of aki, there is a paucity of prospective data on fgf , especially in the pediatric population. thus, we prospectively measured fgf levels in pediatric patients undergoing cardiopulmonary bypass (cpb) and assessed the ability of fgf to predict aki. methods: pediatric patients, age newborn to years, without underlying ckd, undergoing cardiac surgery requiring cpb were eligible for the study. plasma fgf levels ( nd generation cterminal, immunotopics) were measured pre-operatively and at , , , , , and hours post-reperfusion. serum creatinine was obtained at baseline and daily post-reperfusion. aki was defined by the akin criteria, estimated gfr was calculated using the schwartz formula, and cardiac surgery complexity was classified via rachs- score. results: of the enrolled patients, developed at least stage aki. gender, weight sds, height sds, baseline egfr, cardiac surgery complexity, and cpb duration did not differ between the aki group and the non-aki group. patients who developed postoperative aki were younger than those who did not. preoperative fgf levels were inversely related to age (r = - . , p = . ). pre-operative fgf levels were significantly higher in patients who developed aki than in those who did not; this remained significant upon correcting for age. post-operatively, fgf levels increased in all patients. conclusion: pre-operative fgf levels predict the development of post-operative cpb-associated aki. fgf levels increase in non-ckd patients undergoing cpb, even in patients without significant changes in serum creatinine, suggesting that fgf may be a more sensitive marker of aki than serum creatinine. non-aki pateints p value objective: improved perinatal care increased not only the survival rate but also the frequency of acute kidney injury (aki) in newborns. we aimed to determine the frequency, etiology, clinical course and mortality of aki in a third level neonatal intensive care unit (nicu). methods: medical records of all patients admitted to a nicu in western turkey during - were evaluated and those having aki within - days of life were determined. birth weight, gestational age, mode of delivery, gender, maternal morbidity, hospitalization period, accompanying morbidities and mortality of all patients; and primary disease causing aki, highest serum creatinine and prognosis of patients with aki were recorded. results: there were patients (m/f: / ) and ( , %) had aki of which % developed during - days of life mostly due to birth asphyxia, hypovolemia, cardiac disease, sepsis and urinary system anomalies. aki incidence and total mortality rate were higher in patients with birth weight < g and with gestational age < week. however, mortality in patients with aki was increased independent on birth weight ( , % in < g vs , % in > g; p= , ) and gestational age ( , % in < week vs , % in > week; p= , ). mortality tended to increase in the presence of aki independent on the underlying cause, but this was significant only for sepsis ( , % vs , %, p< , ; or , ) and cardiac diseases ( , %vs , %, p= , ; or , ) . hospitalization period was increased if aki was present ( , vs , days, p< , ). serum creatinine in deceased patients with aki was higher than those who survived ( , vs , mg/dl, p< , ). chronic kidney disease was developed in ( %) patients of whom had urinary tract anomalies and had birth asphyxia. conclusion: aki incidence in nicu was %, and % of aki developed during the first week of life. aki is associated with low birth weight, prematurity, birth asphyxia, sepsis, hypovolemia, cardiac diseases and urinary tract anomalies. mortality in patients with aki is increased independent on the birth weight, gestational age and underlying etiology. objective: cisplatin (cddp) is one of the antineoplastic agents widely used for solid tumors in adults and children. an excessive dose due to medical error causes severe nephrotoxicity, ototoxicity and myelosuppression. previous reports described the effects of plasma exchange, sodium thiosulfate, n-acetylcysteine and other interventions. however, the strategy for over-dose patients, as regards the selection or intensity of therapies and the target of cisplatin removal, remains uncertain in children. a year-old girl was admitted for headache and vomiting. she was found to have a right cerebellar tumor and underwent total extirpation of this medulloblastoma. next, we administered chemotherapy mainly using cddp. however, she developed renal insufficiency and hearing loss on the fourth day. we then realized that we had been administering cddp mg/m for days, instead of the intended day. we promptly discontinued the cddp and began plasma exchange and sodium thiosulfate administration. nonoligiric renal failure was confirmed by a urea nitrogen value of . mg/dl and creatinine level of . mg/dl. with cycles of plasma exchange and weeks of sodium thiosulfate, renal function improved and the cddp concentration decreased from . to . mg/ml. after month, the concentration was . mg/ml. we switched from cddp to carboplatin, and chemotherapy was continued for courses and then radiation therapy was added. ultimately, she had mild renal insufficiency and moderate hearing loss. we evaluated the relationship between renal function and the cddp concentration. severe renal failure and hyponatremia were observed at a cddp concentration of mg/ml or more. creatinine clearance of ml/min/ . m was maintained at a cddp concentration below . mg/ml. conclusion: in children with a cddp over-dose, plasma exchange and sodium thiosulfate administration are effective. also, monitoring of cddp concentrations is recommended in patients with acute renal failure. in over-dose patients, early severe renal failure can be prevented when the cddp concentration is reduced to less than . mg/ml with these therapies. abstract# p-sat peritoneal dialysis in children with acute kidney injury: a developing country experience om p mishra , aditya k gupta , vishal pooniya , rajniti prasad , narendra k tiwary , franz schaefer pediatrics and medicine, institute of medical sciences, varanasi, india division of pediatric nephrology, heidelberg university medical centre, heidelberg, germany objective: peritoneal dialysis (pd) is the preferred and convenient treatment modality for acute kidney injury (aki) in children and hemodynamically unstable patients. the present study analyzed the efficacy of pd in patients with aki and factors contributing to mortality. methods: the outcome of acute pd was studied in children ( males) with aki, aged month to years, at a tertiary care centre of a teaching hospital in india. results: there were patients less than year of age, patients - years of age, and patients more than years of age. per the rifle criteria, patients were classified at the risk stage; , at the injury stage; and , at the failure stage at the time of the decision to start pd. hemolytic uremic syndrome was the most common cause of aki ( . %), followed by septicemia ( . %) and acute tubular necrosis ( . %). treatment with pd was highly effective in lowering retention markers (blood urea decreased by % and serum creatinine by % during the course of dialysis therapy, both trends significant at p < . ). overall mortality was . %. deaths occurred - days after hospitalization. significantly higher proportion of non-survivors had fluid overload ( . % vs %, p= . ) and septicemia ( . % vs . % , p< . ) than survivors at presentation. the risk of mortality by multivariate analysis was higher when patients were anuric [odds ratio (or) . , % confidence interval (ci) . - , p< . ), had septicemia (or . , % ci . - . , p< . ), or severe infectious complications (or . , % ci . - . , p< ). conclusion: because of its simplicity and feasibility, acute pd is still an appropriate treatment choice for children with aki in resource-poor settings. septicemia and severity of aki are contributory factors to high mortality in pediatric acute kidney injury. outcome of acute kidney injury managed in a regional paediatric nephrology centre shivaram hegde, sabina pahari paediatric nephrology, university hospital of wales, cardiff, uk objective: this study reviewed the aetiology, treatment modalities and outcome of children with aki managed in our tertiary paediatric nephrology unit. method: retrospective analysis of referral practices, aetiology, and management of children treated for aki over the last years. children primarily treated in intensive care units were excluded. outcomes noted as complete recovery, residual renal injury, renal replacement therapy (rrt) dependency or death. they were followed up until their renal function normalised and any proteinuria or hypertension resolved. result: out of the total children aged months to years, % were under years. haemolytic uremic syndrome (hus) was the commonest aetiology in cases ( %), of them secondary to ecoli and with atypical hus. obstruction was second most common ( ) and renal function improved following relief of obstruction. supportive management sufficed in ( %) cases and ( . %) received renal replacement therapy (rrt); peritoneal dialysis being the commonest mode. most children needing dialysis were oliguric ( ). at discharge there were no deaths, patients showed complete recovery of renal function, one was dialysis dependant and renal function was improving in the rest. at months we found normal renal function in ( %) children and chronic kidney disease (ckd) stage ii in ( %) and ckd stage iii in . the dialysis dependent child underwent renal transplantation. based on the data from patients currently under follow up (for - months, mean months), ( %) children have recovered completely and have developed ckd; stage i in and stage ii in . conclusion: prognosis following aki was excellent in our patients, probably because of lack of multiorgan dysfunction. hus was the commonest cause and urgent renal imaging needed when obstruction is suspected. oliguric patients are more likely to require dialysis and need early referral to the regional unit. all cases should have long-term follow up to ensure renal recovery and detect delayed complications. clinical course and outcome of acute kidney injury (aki) due to childhood haemolytic uremic syndrome (hus): a single centre experience shivaram hegde, sabina pahari paediatric nephrology, university hospital of wales, cardiff, uk objective: clinical data, along with the management and outcome of children with aki due to hus, caused by shigatoxin-producing ecoli (stx-hus) are described. method: we analysed the data of children with stx-hus induced aki, managed in our unit over the last years. outcomes noted as complete recovery, residual renal injury, dialysis dependency or death. all patients were followed up at least for a year and further monitoring continued until their renal function normalised and any proteinuria or hypertension resolved. methods and results: stx-hus was the commonest cause of aki in our unit, accounting for of the total cases ( . %) treated for aki during this period. patients were less than years of age. all children presented with blood in stool and with oligoanuria. all showed microangiopathic haemolytic anaemia and thrombocytopenia. positive stool cultures (for ecoli ) were obtained in and had ecoli lipopolysaccharide serum antibodies. patients required dialysis (peritoneal dialysis in , haemodialysis in and both modes in ) and one child needed plasma exchange. the remaining responded to supportive management. morbidities encountered included bowel perforation ( ), hypertension ( ), seizures ( ) and diabetes mellitus ( ) and three of these children needed intensive care management. at discharge there were no deaths, none with dialysis dependency or complete renal recovery but all showing improving renal function. at months we found normal renal function in ( %) and chronic kidney disease (ckd) stage ii in and ckd stage iii in . a year old girl with an unknown myopathy presented for the third time with clinical and laboratory features of rhabdomyolysis. on day two of admission, her renal function deteriorated with decreased urine output, increasing creatinine of μmol/l and ck of , iu/l. she was commenced on haemodialysis and started on calcium supplements, as her calcium levels were . mmol/l. three week into her illness, she was symptomatic with high blood pressure of mm of hg leading to a generalised seizure. her serum calcium was . mmol/l. the ct brain did not reveal any evidence of haemorrhage or infarction. there were no other trigger factors identified for the seizure and the hypertension, apart from the hypercalcaemia. the hypercalcaemia was managed with low calcium dialysate, calcitonin and sevalamer. despite the above treatments, she continued to be hypercalcemic and developed erythematous palms and soles and an injected conjunctiva. in view of the refractory hypercalcaemia, she received two doses of intravenous pamidronate ( . - mg/kg) when the creatinine was mmol/l. following this, her calcium levels normalised to . mmol/l. her renal function improved and was discharged a week later. there was no nephrocalcinosis seen on follow up. bisphosphonates are used in children with caution, as there is little evidence on its safety and efficacy. they act by binding to the surface of calcium phosphate crystals and inhibiting osteoclast formation, aggregation and dissolution. it is nephrotoxic causing acute tubular necrosis and collapsing focal segmental glomerulosclerosis. pamidronate is usually used in children with chronic kidney disease but this was the first time it was used in a child recovering from acute kidney injury secondary to rhabdomyolysis. there were no complications with the use of pamidronate in our patient. chronic kidney disease during long-term follow-up in children treated with neonatal extracorporeal membrane oxygenation: do we need to worry? objective: acute kidney injury (aki) is a common complication in children receiving extracorporeal membrane oxygenation (ecmo) support. as aki may cause loss of a significant number of functioning nephrons, these children are at risk of developing chronic kidney disease (ckd) post-ecmo. therapeutic interventions might be needed to prevent further renal function deterioration or comorbidity of ckd in these patients. the objective of our study was to determine the prevalence of ckd during long-term follow-up (fup) of children treated with ecmo. methods: this was a cross-sectional study performed between and . all children previously treated with neonatal ecmo who visited our fup clinic at the age of , , , , and years were screened for ckd. if more check-ups were available per patient, only the latter one was used for the study. ckd screening included height (ht) and blood pressure measurements (bp), and laboratory parameters including serum creatinine (scr) (schwartz formula [ . *ht (cm)/scr (mg/dl)] or mdrd formula were used to estimate gfr) and urinary protein/creatinine (up/c) ratio. ckd was suspected in patients with hypertension (> th percentile of reference values according to height and age), abnormal egfr (< ml/min/ . m ) or proteinuria (up/c ratio > mg/mmol creatinine). patients were excluded if scr was lacking. results: to date, children visited the fup clinic. of these, ( %) were excluded because of pre-existent kidney disease and ( %) because of missing scr data. hence, children ( % female) were screened for ckd. the number of patients per fup age category was < years, between - years, and > years. bp was within normal ranges in all children. in ( %) children either an abnormal up/c ratio or egfr was observed. up/c ratio was increased (median [iqr - mg/mmol creatinine]) in ( %) children, of which was explained by low muscle mass. only ( %) children had an abnormal egfr but all > ml/min/ . m . conclusion: the prevalence of ckd and its clinical implication in children previously treated with neonatal ecmo seems to be limited. future research will focus on identifying risk factors for ckd following ecmo support. abstract# p-sat years clinical retrospective analysis in children of acute poisoning inpatient man jiang, qiu li nephrology and immunology department, children's hospital of chongqing medical university, chongqing, china objective: acute poisoning is the common critical and emergency disease in children. since childhood is the special life stage with continuous growth, clinical features are different from the adult and changes were happened in resent years. the change rules, clinical features, treatments and the outcomes of acute pediatric poisonings inpatients were investigated in this article. methods: retrospective evaluated the cases of pediatric acute poisonings admitted to the children's hospital of chongqing medical university. cases were divided into groups by ages, or divided into groups based on different origins (urban or suburban), different causes and routes of poisonings in different groups were calculated. the clinical manifestations, treatments and prognosis in acute intoxication were also studied. results and conclusion: pediatric acute poisoning mainly happened in - years old children ( . %), there was no statistical difference between genders. the common causes of poisonings were pharmacological poisoning ( . %), food poisoning ( . %), animal bites and stings ( . %) and pesticide poisoning ( . %). in the resent five years, pharmacological poisoning rose to be the top reason of poisonings, and was mainly composed by children≤ years old (p < . ),and urban children were more than children from suburban(p < . ). neurological and psychiatric drugs were the most common ( . %) in drug poisoning. rural children with animal bites and stings, pesticide poisonings and rodenticide poisonings were more than the urban children (p < . , p < . , p < . ). the main poisoning causes in - years old group and > years old group children were food poisoning ( . %) and pesticide poisoning ( objective: little is known about cardiac surgery-associated acute kidney injury (cs-aki) in children in developing regions of the world. the study aimed to determine the prevalence of cs-aki, associated factors and its impact on mortality and utilization of hospital services. methods: hospital records of children aged - years that underwent cardiac surgery (other than device closure procedures and pacemaker insertion only) at an indian hospital between and were reviewed. cs-aki was defined as a rise in serum creatinine of ≥ . mg/dl in any hours and or by urine output less than . ml/kg/hr for an -hour period in the first days after cardiac surgery. results: the study included children with a median age of year ( . - ), of which ( . %) were neonates and . % had single ventricle. about % of the children had rachs- or interventions. cs-aki occurred in children ( . %), most often in the first hours after cardiac surgery. on univariate analysis cs-aki was associated with sepsis and intra and post-operative hypotension. in-hospital mortality was -fold higher in children who developed cs-aki. cs-aki was associated with - days longer duration of mechanical ventilation, inotropic support and icu stay. conclusion: cs-aki occurs in children in developing countries but at a lower frequency mainly due to older children with less complex congenital heart disease undergoing cardiac surgery. cs-aki was associated with higher in-hospital mortality and increased utilization of hospital services. factors associated with cs-aki included intra and post-operative hypotension and sepsis. objective: data on long term effects of newborns after acute kidney injury is limited. the aim of the study was to evaluate long term effects of acute kidney injury (aki) in neonatal period. methods: inclusion criteria were as follows: oligo-anuria or plasma creatinine > . mg/dl during first three postnatal days or > . mg/dl after third postnatal day or ≥ % increase in plasma creatinine within hours during hospitalization in neonatal period. three hundred sixty children who had aki during neonatal period (between january and december ) and survived to hospital discharge were invited; of them accepted to participate. patients' characteristics during aki and during follow-up were recorded; a physical examination and laboratory studies, including acr (urine microalbumin/creatinine ratio) were performed. schwartz formula was used to estimate gfr; hyperfiltration was defined as a gfr > ml/min/ . m . hypertension was defined as blood pressure ≥ th percentile for age, gender and length. results: the mean age on evaluation was . ± . years. . - . - . % of patients. all these children were dialyzed for more than days on acute phase of the disease. at time of discharge from hospital proteinuria remained in ( . %), hypertension -in ( . %) patients. after year, years and > years period proteinuria was detected accordingly to . - . - . %, hypertension to . - . - . % of patients. after > years from the onset of disease hypertension was detected more often in the group of children who were < years old on acute phase of the disease ( % vs . %, p= . ). in the group of patients who hadn't proteinuria on the acute phase, after > years period proteinuria was observed to % of them. after year period renal impairment of various degree was observed to . %, after years -to . %, after > years-to . . on admission his mean arterial pressure was mmhg, his creatinine was . , potassium . and sodium . usual medical management for aki was initiated but even by late d he continued to be anuric with a rising creatinine. his uric acid was grossly elevated at mg/dl. dialysis was considered but as the parents were not in favour of it they were offered the option of rasburicase. rasburicase was given on late d and within hrs he started to produce urine which peaked at ml/kg/hr by d . the creatinine also showed a concomitant fall and by discharge (d ) it was . mg/dl and normalized at . mg/dl by d . uric acid was . mg/dl on d and . mg/dl on d . case : years old boy with multiple special needs was transferred from another hospital intubated, anuric and in multi organ failure (mof). creatinine was elevated at . mg/dl and uric acid was also found to be raised at . mg/dl. in view of mof along with disseminated intravascular coagulopathy (dic) dialysis was considered a risky process and parents were offered the option of rasburicase. rasburicase was given on d of admission and although the repeat uric acid was . mg/dl and he did produce ml of urine within hours no further improvement in renal parameters was noticed. dialysis (sled) was initiated on d . although the creatinine improved with sled he continued to be oligo-anuric and died of mof by d . conclusion: although rasburicase seemed to work in case , it was not beneficial in case . the exact mechanism for rasburicase is still hypothetical and the few case reports have all documented positive results. although it seemed to have worked in case , to the best of our knowledge case is the first documented case wherein it did not work. proper randomized control trial is needed before advocating rasburicase as a novel therapy for aki. results: age, sex, diagnosis, baseline and post-surgery hemoglobin, total leukocyte count, platelet count and biochemistry were recorded. baseline and post-operative, urea (mg/dl), creatinine (mg/dl), urine output (ml/kg/hr) and inotrope dose were also recorded daily. the duration of cpb was noted. post-operatively cardiac, renal, hepatic, neurological and respiratory dysfunctions were recorded. conclusion: fifteen ( . %) children developed aki stage i, one child ( . %) developed aki stage ii and four children developed aki stage iii ( %). all patients with aki had a longer stay in hospital. eight children required dialysis for aki; two required dialysis to maintain the fluid balance post operatively. none developed chronic renal impairment. using stepwise regression, younger age (< year), weight < kg, pump failure, sepsis and duration of cpb more than minutes were significant risk factor for developing aki. results: most of the patients were male, with less than days old and weighing less than kg.in the majority of cases ( %), arf was diagnosed in the first days after surgery, demonstrating influence of the procedure itself. all of them were treated by peritoneal dialysis(pd) for a mean time of hours; . % of them died. there was no statistical significant difference between age, time on extracorporeal circulation and duration of dialysis, comparing the patients who survived and the deceased ones. conclusion: acute renal failure is a common complication in children with congenital heart disease and pd is a safe dialytic method. the mortality rate is high and influenced by aspects related to the child, underlying disease, type of surgery and many other associated aspects. abstract# p-sat acute kidney injury epidemiology and associated factors in a pediatric intensive care unit. conclusion: acute kidney injury (aki) is associated with significant morbidity and mortality in pediatric patients with critical illness. the main causes associated to aki were sepsis and shock. we found no association with cardiac surgery, probably explained by the low level of complexity that is performed in our center. almost half of our patients with aki were in failure and the mortality was high as previously reported. objective: fibroblast growth factor- (fgf- ), a phosphaturic hormone involved in calcium phosphate homeostasis, appears to predict renal disease progression in adults with non-diabetic ckd (fliser, jasn ) . this study aimed to determine renal survival according to fgf- serum levels in children with ckd stage ii-iv. methods: children participating in the escape trial (age . ± yrs, gfr ± ml/min/ . m ; underlying renal disease: hypo/dysplasia ( %), glomerulopathies ( %), hereditary or other ( %)) were analyzed. all patients received fixed dose ace inhibition and were followed prospectively by -monthly examinations for up to years. the study endpoint was defined by egfr loss > % from baseline, gfr < ml or start of renal replacement therapy. fgf- levels were determined at baseline (c-terminal human fgf- elisa (immutopics, san clemente,ca,usa objective: the long-term outcome of patients born with unilateral renal agenesis (ura) and of those who underwent therapeutic unilateral nephrectomy (un) remains a topic of concern and debate. children with a solitary functioning kidney (sfk) have an increased risk of developing hypertension, albuminuria and chronic kidney disease in later life. the purpose of this study was to identify whether plasma symmetric dimethylarginine (psdma) is an useful biomarker reflecting the level of renal injury in children with solitary functioning kidney (sfk). methods: we measured circulating psdma in patients with sfk and no other urinary defects. patients were subdivided for two groups: primary sfk (psfk)-unilateral renal agenesis (ura) and secondary sfk (ssfk) after unilateral nephrectomy. the control group (c) consisted of healthy children, aged mean . ± . yrs. immunoenzymatic elisa commercial kits was used to measure psdma concentration. data analysis was performed using computer program statistica . . results: the age and sex of studied children did not differ from healthy controls (p> . ). plasma sdma levels in sfk children were higher than in healthy participants (p< . ). there was no difference in psdma concentrations between psfk and ssfk patients (p> . ). sdma plasma levels correlated significantly with c cr (r= - . , p< . ) in all participants. roc analyses performed in order to define the diagnostic efficiency of serum creatinine and psdma in identifying children with c cr < ml/ min/ . m among sfk and healthy participants revealed no difference between all two aucs (p> . ). conclusion: in children with a solitary functioning kidney increased psdma levels were observed, however the sensitivity and specificity of this marker in detecting the decrease in c cr was not better than creatinine. objective: renal osteodystrophy encompasses a variety of skeletal disorder ranging from high turnover lesions of secondary hyperparathyroidism (shpt), to low turnover lesionsof diverse etiology that are usually associated with normal or reduced pth levels. so our aim was to assess by dexa which is a precise , rapid and noninvasive procedure the degree of osteopenia in patients with crf. methods: children aged ( - . ) years, on conservative treatment and on hemodialysis were included in the study bmd of lumbar spine and wrist were measured by (dexa) and compared with age and sex matched controls. results: shows that out of patients, ( %) are osteopenic ( %) on hemodialysis and ( %) on conservative treatment, of these ( . %) had severe osteopenia as regard bmd of the spine, while dexawrist shows ( %) are osteopenic, ( %) on regular hemodialysis and ( %) on conservative iii, of these ( . %) had severe osteopenia ,correlation between z-score spine in the osteopenic group and different biochemical parameters shows non-significant correlation except -ve correlation with duration and age of the patients, while z-score wrist of the same group shows +ve correlation with bicarbonate. our result shows that group with ipth >= pg/ml are more osteopenic than those with lower ipht levels, although difference did not reach level of statistical significance p > . . conclusion: we can conclude that osteopenia is frequent in patients with crf more in the dialyzed group, with longer duration of the disease, older age and severe acidosis, irrespective of the severity of the disease. although, degree of osteopenia is not correlated with biochemical findings of (shpt) but still patients with (shpt) are more osteopenic and have lower cortical bone density. mineral and bone disorders were defined according to k/doqi guidelines. results: during the study period % of stage i-iv ckd patients and all esrd patients and renal allograft recipients had at least one type of mbd. high turnover bone disease with hyperphosphatemia, hyperparathyroidism and hypocalcemia was the most frequent type of mbd in stage i-iv ckd and esrd patient. adynamic bone disease was seen in only one esrd patient. hypophasphatemia was the most common disorder in renal allograft recipients. vitamin d deficiency/insufficiency was seen in % of stage i-iv ckd, % of esrd patients and all renal allograft recipients. all patients with stage i-iv ckd and esrd were treated with calsitriol and renal allograft recipients were treated with vitamin d supplementation. conclusion: mineral and bone disorders especially high turnerover type is common in children with ckd and esrd. although successful kidney transplantation corrects many of the metabolic abnormalities associated with the development of mbds, renal allograft recipients had increased risk of vitamin d deficiency/insufficiency. objective: calciphylaxis is a complication of chronic kidney disease that characterized by necrotic lesion in the skin and in histological examination reveals microcalcification of medium sized blood vessels. materials and methods: we report on a -month old girl with end stage renal disease due to diffuse mesangial sclerosis referred for tenckhoff catheter implantation. laboratory tests on admission were: bun = mg/dl, cr= mg/dl, uric acid = mg/dl, calcium= mg/dl, phosphate = mg/dl, alkaline phosphatase= , pth= pm/l,vitd= mg/ml. calciphylaxis process started when she received calcium gluconate iv the day before surgery and continued progressively when oral calcium carbonate and oral calcium gluconate were given. hourly peritoneal dialysis was started and all calcium containing medications were stopped. but the process continued progressively. surgical detriment of the necrotic tissue of right wrist was done. comfeel dressing had no effect and the circulation of tissue was poor. therefore the left wrist was kept as control. pamidronate . mg/kg/day prescribed for days and then once a week for weeks. after one week of starting pamidronate skin lesion began to heal, circulation improved and after six weeks all skin lesions completely recovered. as shown in figure one debridement cause skin scar on right wrist. conclusion: pamidronate is effective to stop calciphylaxis in children with advance renal insufficiency and severe calcium-phosphate imbalance. medical or surgical debridement are not suggested and lesions will recover without scar by pamidronate objective: fibroblast growth factor (fgf ) is a key player in kidney-bone axis and regulation of calcium and phosphate homeostasis. most of the recent research has focused on fgf in chronic kidney disease and there is paucity of data in healthy children. hence we initiated a study on the various biomarkers of calcium-phosphate metabolism including fgf in healthy children and present here the interim report of our findings as of now. methods: a total healthy school children and adolescents aged - years, were enrolled in this cross-sectional study, after a written consent from their parents. height, weight and pubertal staging were assessed. blood was collected and calcium, phosphate, pth and vitamin d were estimated by standard methods. plasma c-terminal fragment of fgf was quantitated using a commercial elisa kit (immutopics, usa). three day dietary recall was done to calculate mean daily calcium, phosphate and protein intake. results: of the children enrolled % were males. the mean age was . yrs, mean height was cms and mean weight was kgs. the mean blood biochemistry values of the children tested so far for ca, p, pth and vitamin d shown in table . the parameters of the children were normal for their respective ages however fgf levels were found to be lower compared to reports in literature. conclusions: from the results available as of now all of the children had normal biochemistry for their ages. the fgf levels were found to be lower than reports in the literature. whether it can be attributed to the dietary differences from the children of the west needs further investigation. testing of the entire cohort will reveal if this lower fgf is a universal phenomenon among all children in our study. on the contrary, all dxa parameters showed a decreased in their mean zscore bmd values that reached statistically significance. finally, multivariate stepwise regression analyses showed that estimated glomerular filtration rate at the beginning of the study was the best predictor of the difference in bmd z-scores measured at lumbar spine. additionally, values of ipth at the beginning of the study and the change of ipth throughout the study predicted the . % of the difference in z-score of sos measured at radius with an inverse relationship. conclusion: the use of two different techniques have shown bipolar changes of bone properties after renal transplantation. reversal of renal osteodystrophy and consequently correction of many of the underlying metabolic abnormalities, mainly normalization of ipth, strengths cortical bone as this is best illustrated by qus assessment. however, reduction in bmd, is predominantly considered as an adverse effect of steroid immunosuppression. age . yr) (group ), patients with ckd stage on pd or hemo (mean age yr, mean time on dialysis yr) (group ) and patients with ckd stages - (mean age yr, mean gfr ml/min/ . m ) (group ). ohd levels were deficient in % and insufficient in % of the group patients, % were deficient and % were insufficient in group , and % were deficient and % were insufficient in group . results: intact pth (ipth) was above the target level by different ckd stages in % of the group patients, in % of the group and in % of the group and showed an inverse correlation with ohd levels (p< . , r=− . ). there was inverse correlation with age in the complete cohort of patients (p= . , r =− . ) height standard deviation score (sds) was associated with ohd only in group (p= . , r= . ). there was direct correlation between ohd levels and gfr in group and . conclusion: our data suggest that ohd deficiency is common in pediatric renal transplant and ckd children of any stage even in an area with year-long sunshine, especially in adolescents. hyperparathyroidism was also frequent in all groups. it would be advisable to monitor vitamin d status in these patients. ) years, with ckd ( on hd, on pd and tx) mean age ( . - . ) and healthy children, mean age . ( - . objective: the aim of our study was to analyze twelve single nucleotide polymorphisms (snp) of gene lrp potentially associated with osteoporosis risk in children with routine steroidotherapy in the course of the idiopathic nephrotic syndrome. methods and results: glucocorticosteroids are important risk factors for drug induced osteoporosis. decrease in bone mineral density (bmd) and increased risk for pathological fractures are caused by direct division of steroids at the cellular level by inhibiting the replication of osteoblasts and stimulation of its apoptosis. also proven its effects on the inhibition of type i collagen synthesis. lrp is one of the wnt signaling pathway proteins coreceptors involved through the rank-rankl system in regulation of the osteoblasts function. lrp is included to the osteoporosis phenotype genes group and its selected single nucleotide polymorphisms can be responsible for bmd decrease in patients with glucocorticoid therapy. the study group was composed of children with idiopathic nephrotic syndrome, boys and girls beetwen the age of five to twelve years old , with osteoporosis and with normal bone mass density. study also included the control group consists of healthy individuals at the same age not treated with glucocorticoids. the analysis was carried out with polimerase chain reaction (pcr) and taqman molecular probe designed for single nucleotide polymorphisms (snps) nearby investigated mutations in lrp gene that can be connected with osteoporosis fenotype. odds ratio value (or) was based on frequencies of single nucleotide polymorphisms in lrp gene and its haplotype analysis. the results showed significant differences in or value among the three groups. it was also found the differences in the lrp gene structure. based on gabriel algorytm single nucleotide polymorphisms pairs analysis in children with osteoporosis and nephrotic syndrome we proved the correlation between selected snps pairs presence and decretion of bone mineral density in studied group. objective: growth hormone (gh) and insulin-like growth factors are essential for normal growth and development. chronic renal failure (crf) results in major changes in the circulating growth hormone /insulin-like growth factor (igf) system. our aim isto study: to assess clinical and laboratory parameters of growth and osteodystrophy including igf and igfbp as part of the somatotropic hormone axis in egyptian children suffering from crf on conservative therapy. methods: egyptian children ( boys and girls) with a mean age of . y ( . to . y) suffering from crf on conservative therapy and controls were included in the study. ht, wt and tsf were measured ,pubertal staging was assessed and followed up for a period of months. at the end of the follow up period serum for igf and igfbp , renal function, electrolytes, ca, p ,and alkaline phosphatase and acid base balance were measured and an x-ray of the left hand and wrist was done to determine their bone age by tanner and whitehouse. results: our study shows that children suffering from crf in egyptian conservative therapy have growth retardation with a mean ht of - . sds, a mean wt of - . sds. tsf mean was - . sds. on the average the patients had a delay of . y (+/- . ) in their bone age. their height was retarded more than their bone age with a height age/bone age of . (+/- . ). alkaline phosphatase as a markers of renal osteodystrophy is significantly correlated to the height, height age , bone age and to the ph. the mean igf sds (- . +/- . ) did not differ from that of controls while the mean igfbp sds ( . +/- . ) was significantly higher in patients with crf than in controls. height and weight were significantly correlated to igf but not igfbp . there is a significant correlation between igfbp level and the glomerular filtration rate. conclusion: the imbalance between normal insulin-like growth factor-i (igf-i) and markedly increased igfbp plasma levels plays a pathogenic role for growth retardation in children with chronic renal failure. the lower the gfr the higher the igfbp level. the latters inhibitory action may provide hope for improving growth in cases of crf by reducing the level of igfbp or displacing igf from it. objective: anemia is one of the most common complications of chronic kidney disease (ckd) and renal transplantation. this study evaluated the prevelance and the etiology of anemia in children with stage i-iv ckd, end-stage renal disease (esrd) and renal allograft recipients. methods: between and , we prospectively followed pediatric stage i-iv ckd, esrd patients and renal allograft recipients. anemia was defined according to k/doqi guidelines as hb is less than the fifth percentile of the normal, adjusted for age and sex. results: during the study period . % of stage i-iv ckd, % of esrd patients and . % of renal allograft recipients developed anemia. the mean hb levels were . +/- . g/dl, . +/- . g/dl and . +/- . g/dl in stage i-iv ckd, esrd patients and renal allograft recipients, respectively. the mean hb levels were significantly lower in esrd patients as compared to stage i-iv ckd patients and renal allograft recipients (p< . , p< . ). erythropoetine (epo) deficiency was the most frequent cause of anemia in stage i-iv ckd and esrd patients, followed by iron deficiency. in addition to epo and iron deficiency, bone marrow suppression and parvovirus infection were the causes of anemia in renal allograft recipients. erythropoietic stimulating agents were used in % of stage i-iv ckd, % of esrd patients and % of the renal allograft recipients. conclusion: although anemia is one the most common problems seen in children with ckd and esrd, the prevelance is also high in renal allograft recipients. these patients should be evaluated and treated accordingly to the underlying causes. abstract# p-sat determinants and prevalence of anaemia among preschool children in highly focussed states of india results: about more than % child is anaemic among all eag states. the prevalence of severe anaemia is . % in rajasthan followed by uttar pradesh ( . %) and madhya pradesh ( . %). those children aged to months are times significantly more likely to be severe anaemic as compare to the to months aged children. those mothers have severe anaemia, their children are also found to be severe anaemic ( times more than not anaemic mothers). mothers who are highly educated and belong to richest quintile their children are less likely to be anaemic. the finding of the study shows that demographic and socio-economic indicators play significant role in determining the prevalence of anaemia in eag states which needs focused programme to reduce the prevalence of anaemia in preschool children. abstract# p-sat impaired renal growth hormone mediated jak/stat signaling in juvenile rats with chronic kidney disease objective: linear growth retardation is a major problem in children with chronic kidney disease (ckd) and is ascribed to gh insensitivity. treatment with exogenous gh has been accepted as standard therapy in children with ckd and short stature. however, concerns have been raised in the past on the potential fibrogenic effects of gh. there is no information regarding renal ghr signaling pathway in ckd. methods and results: to investigate this pathway, surgically / nephrectomized (ckd) and pair-fed control (c) juvenile ( wk old) rats were sacrificed after weeks of ckd. serum creatinine and albumin excretion were significantly elevated (associated with glomerulomegaly and early fibrosis) while body weight and length gain were reduced in ckd rats. serum igf-i levels were decreased in ckd, even though serum gh levels were unchanged. kidney ghr mrna and protein levels were reduced and phosphorylation of jak and stat was significantly impaired. supressor of cytokine signaling (socs ) mrna was increased in association of increase in renal il mrna. renal igf- mrna was unaltered in ckd. thus, in the remnant kidney of ckd growth retarded juvenile rats there is impaired gh mediated jak /stat signaling. this defect may be due to a reduction in gh receptor expression and signaling together with an increase in socs expression. conclusion: we suggest that the insensitivity of the remnant kidney to gh may serve to protect against the potential adverse renal effects of exogenous gh in ckd patients. objective: concerns have been raised about possible adverse effects of growth hormone(gh) in short children with chronic renal diseases. six cases of short children with chronic renal diseases ckd were studied in our hospital, the microalbuminuria as a sensitive parameter of early glomerular damage was detected during the treatment of recombinant human growth hormone. the individual growth response to gh was also observed. methods: of the cases, male were , female , the onset age ranged from to years old, all were diagnosed as growth retarded children with various chronic renal diseases. the dosage of gh was . iu/kg/d. the follow-up period was from months to years. microalbuminuria was measured by a commercially available elisa kit, as a sensitive parameter of early glomerular damage in children being treated with recombinant human growth hormone. serum insulin-like growth factor igf-i concentration and igfbp were also measured before and during the treatment with gh. results: there was no statistically difference on the level of microalbuminuria compared with that of pretreatment. linear growth were . cm/month with an increment in height sds by . at the end of the first year of gh treatment. growth retardation in children with ckd is associated with normal to slightly low concentrations of (igf)-i and igfbp . objective: iron deficiency anaemia is common in chronic haemodialysis patients and is the most common factor of resistance to erythropoeitin treatment. kdoqi clinical practice guidelines and recommendations for anaemia in ckd suggest maintaining hb levels between - g/dl, tsats > % and serum ferritin above ng/ml. our unit's previous practice provided - mg/kg/week of elemental iron intravenously to our haemodialysis population and monitored blood parameters monthly. from july , we changed our practice to withhold routine administration of iv iron, unless blood parameters (monitored fortnightly) suggested iron deficiency. we assessed the change in our practice in safely reducing the frequency of iv iron administration in our haemodialysis population. methods: we included all children attending our haemodialysis unit (july ). we used %hypochromia of > %, correlating with hb level of < g/dl as a marker for initiating iv iron sucrose ( mg/kg/week) until improvement of the above parameters. serum hb and %hypochromia were monitored at the start of change-over and fortnightly thereafter. all patients received routine erythropoietin at recommended doses of between - units/kg/week. results: at initiation of change-over, there were patients with mean hb . g/dl, mean %hypochromia . % and mean tsats . %. from july -mar , four patients required iv iron therapy (mean hb . g/dl, mean %hypochromia . %, mean tsats . %). three patients had weeks and one patient had weeks of iv iron sucrose mg/kg/week to achieve normalisation of serum hb (mean . g/dl), %hypochromia (mean . %) and tsats (mean %). at time of reporting (mar ), there were patients with mean hb . g/dl, mean %hypochromia . % and mean tsats . %. two patients received transplants. conclusion: a novel change in our practice has resulted in a safe reduction of iv iron therapy in our population of children undergoing haemodialysis. from our findings, we suggest avoiding routine iron infusions in paediatrichaemodialysis, which is unlikely to have an adverse effect on the incidence of anaemia and will reduce the risk of inadvertent iron overload. abstract# p-sat reversible portal ascitis after bilateral nephrectomy in infant with polycystic kidney disease we report here on a newborn with moderate renal failure and severe hypertension due to autosomal recessive polycystic kidney disease (arpkd). antihypertensive therapy associating minoxidil, labetalol, amlodipine and lasilix were not able to control adequately blood pressure. due to massive kidney enlargement, inadequate respiratory function and inability to tolerate enteral nutrition, parenteral nutrition was initiated at months to maintain adequate calories intake. at months of life, the infant presented severe viral pneumonia complicated by cardio respiratory arrest . he required cardio respiratory resuscitation and hospitalization in icu for several days. unilateral right nephrectomy was decided after this severe complication in order to avoid similar accidents due to massive kidney volume and to improve respiratory and nutrition status. one week after unilateral nephrectomy, we noted rapid increase volume of the left kidney and important ascitis having the biological characteristics of portal hypertension. repeated aspiration of more than ml of portal ascitis was performed every day. in parallel daily perfusion of albumin for more than weeks and complete parenteral nutrition did not succeed in treating ascitis. faced to resistant ascitis and persisting difficulties in maintaining enteral nutrition and adequate respiratory ventilation , left nepherctomy was decided and performed. automated peritoneal dialysis was rapidly initiated in our anuric infant (weight after binephrectomy kgs). portal ascitis disappeared in hours with rapid normalization of respiratory ventilation and return to normal and well tolerated enteral nutrition. conclusion: to our knowledge, this is the first case reported of portal ascitis noted after palliative unilateral nephrectomy to facilitate pulmonary expansion and gastrointestinal function in arpkd. ascitis was resistant to daily albumin perfusion and repeated aspirations but was completely reversible after bilateral nephrectomy and initiation of peritoneal dialysis. early bilateral nephrectomy at months of life was probably the ideal choice to avoid many complications in our infant due to abdominal and thoracic compression by massive kidney compression. ethical considerations, therapeutic possibilities, and parent consent should be discussed in such challenging and very difficult cases. abstract# p-sat serum hepcidin levels and anemia in pediatric chronic kidney disease objective: hepcidin restricts the availability of iron from its stores for erythropoiesis resulting in a functional deficiency of iron and hyporesponsiveness to erythropoiesis stimulating agents. the objectives were to estimate the serum hepcidin in children with chronic kidney disease stage ii to iv and correlate it with hemoglobin, iron status (serum ferritin and transferrin saturation), inflammation (c reactive protein) and estimated glomerular filtration rate (egfr). methods: it was a cross sectional study. children aged to years with ckd stage - on stable dose of iron and or erythropoetin for the last weeks were included. children with anemia due to other causes, severe acute infection, chronic cardiac or respiratory conditions and those who received parenteral iron and or blood transfusion in last weeks were excluded. hemoglobin, serum ferritin, transferrin saturation, c reactive protein were assessed. serum hepcidin levels were estimated using a elisa based kit in the cohort as well as in age and sex matched normal children to estimate the levels in normal population. multivariate regression analysis was used to assess the relationship between hepcidin and hemoglobin, iron status, inflammation and egfr. results: forty children were recruited into the study. the mean age of children was . + . years. around %, % and % of children had ckd stage ii, iii and iv respectively. the mean serum hepcidinlevels in children with ckd ( . + . ng/ml) was significantly higher than controls ( . + . ng/ml). conclusion: serum hepcidin levels showed an increasing trend with decrease in egfr, but this was not statistically significant. the mean haemoglobin was . + . g/dl, the mean ferritin was . + . ng/ml , the mean transferrin saturation was . + . %. anemia and absolute iron deficiency was seen in % of our cohort and worsened with increasing stages of ckd. serumhepcidin levels did not correlate significantly with haemoglobin, ferritin or with c-reactive protein. objectives, methods and results: presenting a -year old armenian patient who developed a secondary amyloidosis on top of a familial mediterranean fever (fmf) and moved to germany years ago. at the time of the move the patient had already a terminal renal insufficiency and received intermittent hemodialysis. despite the therapy with colchicine moderate attacks of the fmf occurred with an interval of weeks and inflammatory parameters were permanently elevated. the dosage of colchicine was titrated up to mg per day. as a consequence diarrhea occurred and the dosage had to be decreased. over the course the amyloidosis progressed and affected all internal organs including heart and bowel. the combination of inflammation, uremia and amyloidosis led to malnutrition (bmi kg/m ). at the age of years the most severe colitis with peritonitis and paralytic ileus occurred. the treatment with colchicine was paused in assumption of a toxic effect. after improvement of the diarrhea but still persisting abdominal pain the colchicine treatment was slowly started again. shortly afterwards a very severe attack of the fmf developed with an accompanied cardiovascular insufficiency. the treatment with a single high-dose of methylprednisolone and the inhibition of interleukin with anakinra ( mg/kg, given after dialysis) led only to a short remission. the high-dose methylprednisolone treatment was therefore repeated three times and anakinra was given on a daily basis. since then no new attack of the fmf occurred and the combination of lowdose colchicine and anakinra improved the general status of the patient the elevated inflammatory parameters including serum amyloid a have almost normalized. objectives: invasive aspergillosis is almost exclusively occurs in immunocompromised hosts. the central nervous system (cns) is one of the most frequent sites of invaziveaspergillozis after the lungs. we report a case of invasive aspergillosis in a boy with end stage renal failure. methods and results: a -year-old boy was admitted to the hospital for abdominal pain, fewer and cough. he suffered from chronic kidney failure (crf) known for a year and he was on peritoneal dialysis for seven months. he was initially treated with iv. ceftriaxone for lobar pneumonia, intraperitonealceftazidime and cefazolin for peritonitis. the peritoneal fluid was also cultured for fungus and mycobacteria and all cultures were negative. on the seventh day, the patient complained for lower extremity weakness, and bilateral hyperactive deep tendon reflexes and positive babinski reflex were found. cranial magnetic resonance imaging (mri) was normal, but the spinal cord was compressed between c -t by a solid mass which was originated from right lung on spinal mri. computed tomography-guided tru-cut lung biopsy was performed for the solid mass. repeated peritoneal fluid culteres were also negative. two days later, when unconsiousness and convulsions were seen, intraparenchymal multiple hemorrhagic abscesses were found on his second mri. typical hyphae of aspergillusfumigatus was present in pathologic specimens and galactomannan test was positive. cerebral abscesses were evaluated as cns involvement of invasive aspergillosis. anti fungal therapy was began immediately as amphotericin b and caspofungin. the peritoneal catheter was removed and continuous veno-venous hemodiafiltration was performed. however his condition kept deteriorating and death ensued on the fourth day of anti fungal therapy. conclusion: invasive aspergillosis may rarely occur in immunocompetent patients and diagnosis may be missed or delayed due to lack of the particular clinical signs. we should be careful about diagnosis of fungal infections in patients with crf since early treatment before the invasion and dissemination of aspergillosis to adjacent tissues and/or organs offers a higher survival chance for the patient. questionnaire and to find a way to increase reliability for healthy children aged - years especially, according to iranian culture. objective: we lunch this study to compare the parent and children's behavior problem in pediatric patients suffering from ckd referring arak amir kabir hospital. methods: to perform this case control study, we recruit children with ckd and compared them with other non affected children age between to years old. the child behavior checklist cbcl / for child behavior assessment and general assessment function gaf for the evaluation of their parent's behavior were completed by the parent's data was analyzed using qualitative variables and chi-square formula. results: among patients with ckd, case . % showed behavioral problem while this figure was case . % in the control group, denoting a significant difference p- . . moreover children / % in the case group and children . % in the control group had internalizing problem p- . . children % with ckd and children . % in the healthy group had externalizing problem which was also a significant difference p- . . as a significant p- . the parent's average stress and behavior scores in case and control were . & . , respectively. conclusion: the higher prevalence of behavioral problem in the children suffering from ckd and their parent's functional impairment highlights the important of early treatment and subsequently prevention of future behavioral problem in their sibling. abstract# p-sat development in -year-old children with and without ckd objective: ckd is a pathophysiologic process with multiple etiologies, resulting in the inexorable attrition of nephron number and function and frequently leading to esrd. a number of studies have suggested that children with ckd have problem in development than other children our goal was to compare development of children with ckd with normal children within the common age range for the disease. methods: in this descriptive-analytical study, we selected children with -year-old children whom were diagnosed with ckd as our case group and studied their developmental status by ages and stages questionnaire (asq). the control group was selected from -year-old children who attended the clinic for reasons other than ckd. conclusion & application to practice: the eleven key areas of responsibility used to measure sc in a periodic evaluation demonstrated a strong correlation to the increasing extent of qpdo. additionally, as the nurses progressed to becoming expert a direct correlation to the qpdo was notable. the study became the foundation for staff training and developing a competency appraisal framework in renal nursing practice thereby promoting quality assurance procedures while attaining qpdo. objective: urinary incontinence is a child health problem that affect both the child and the family in psychological and social aspect and that leads to a decrease in quality of life of the child and his caregiver. patients with higher ckd stage had significantly lower qol score in all domains in the child-self reports, but not parent-proxy reports. whereas there was no difference between patents with stage i and stage ii. according to gender, boys had a tendency to present better qol than girls, but there was no significant difference between these two groups. age discrepancy was not a significant factor to decide qol in children with ckd. in addition, there was significant difference between parent-proxy reports and child-self reports and qol scores in the child-self reports was significantly higher than in the parent-proxy reports, especially in the domains of emotional, school functioning and psychosocial health score. conclusion: residual renal function in children with ckd is a important factor to decide qol. in addition, emotional and psychosocial support for their parents can be necessary to improve qol in children with ckd. abstract# p-sat results: the mean period of post-transplant follow-up was . +/- . years(range: . - years). in the first year of transplantation, ( . %) recipients had obesity obese patients had higher serum ggt levels than non-obese patients ( . +/- . u/l vs . +/- . u/l, p= . ). there was a positive correlation between bmi and ggt and tg levels in obese patients (r= . , and r= . , p< . respectively). patients with dyslipidemia were found to have significantly higher mean ggt level ( . +/- . u/l vs. . +/- . u/l, p= . ) and bmi ( . +/- . vs. . +/- . p= . ). we could not find any correlation between bmi, and gender, post-transplant follow-up, duration of crf, primary disease, donor status and graft loss. in the first year of transplantation, gfr was significantly lower in obese patients than non-obese recipients (p< . ) conclusion: our data has suggested that, even within its normal range, elevated serum ggt concentrations and hyperlipidemia are closely associated with obesity in transplanted patients and obesity has negative effects on graft functions. the relationship between the graft function and the serum and urine ngal in children with renal transplantation tehran university of medical science, associated professor, tehran, iran objective: the evaluation of graft function long term after transplantation is important. serum creatinine is the most common used marker for graft function in renal transplantation. the level of serum and urine ngal may predict graft function in renal transplant recipients. methods: we evaluated pediatric renal transplant recipients by measurement of serum and urine ngal, serum creatinine concurrently. the gfr of the patients was also estimated by schwartz formula. results and conclusion: the time after transplantation was - years (mean: . +/- . years). the mean serum ngal was +/- . ng/ml ( . - ) . the mean urine ngal was . +/- ng/ml ( - ). we didn't find any association between serum creatinine, gfr estimated by schwarz and serum ngal. we also didn'y find any association between urine creatinine, gfr estimated by schwarz and serum ngal. glomerular filtration rate measured by dtpa scan of fourteen patients were available. we also didn't any association between gfr measured by dtpa scan and serum and urine ngal. abstract# p-sat racial disparities in paediatric kidney transplantation in australia glomerulonephritis and late referral were more common in non-caucasian patients. among patients who did receive a transplant, caucasians had overall better hla matches to their graft and were less sensitised. conclusion: caucasian australian paediatric patients have greater access to kidney transplantation, particularly from living donors, and are likely to have the better graft survival. some racial disparities may be inevitable due to differences in kidney diseases, however further work is required to understand barriers to live donation and address disparities. abstract# p-sat cost-effectiveness of renal transplantation in paediatric and adult transplant recipients. [ . - . ] ), were associated with a lower inscription probability months after reaching esrd. the national inscription rate was % with a significant center variability (median % [iqr - ]) that remained after adjustment on patient characteristics (p< . ). preemptive transplantation rate explained % of the inter-center variability (p= . ). probability of transplantation months after inscription decreased with time of waiting list inactivity (p< . ) and with the probability of finding a compatible transplant considering patient's hla and abo groups. underweight (bmi <- sd) was associated with lower transplant probability (or . [ . - . ]). at months, % of patients were transplanted with a significant center variability (median % [iqr - ] that remained after adjustment (p= . ). conclusion: as expected patients' characteristics contribute to intercenter variability as well as centers' attitude towards the inscription of younger children, management of specific primary renal diseases and preemptive transplantation. despite national allocation rules we found a significant inter-center variability in the probability of being transplanted after inscription on the list, which was not explained by either the patient or center characteristics of our study. abstract# p-sat ten year outcomes of paediatric renal transplantation: the irish experience objective: focal segmental glomerulosclerosis is the most common cause of steroid-resistant nephrotic syndrome in children and adolescents. within years of initial presentation, - % of patients will progress to end stage kidney disease requiring kidney transplant. recurrence rate after transplantation is high and may be associated with early graft loss. methods: we analysed demographic and transplant data collected by the australian and new zealand dialysis and transplant registry (anzdata) on children and adolescents with a diagnosis of primary fsgs who were years of age or younger at the time of transplant. kaplan-meier analysis was performed to compare graft survival according to recurrence of fsgs and donor characteristics. results: during the -year period from st january to st december , transplants were performed in patients (age range - years, median years). twenty seven patients developed recurrent fsgs, with one child developing recurrent disease in grafts (overall recurrence rate %). the median time to recurrence was days, with loss of graft function in / transplants ( %). median graft survival in patients with recurrence was significantly shorter than in patients with no recurrence ( . years vs > years, respectively; p< . ). there was no significant difference in recurrence rate in recipients receiving deceased donor (dd) versus live donor (ld) transplants (p= . ) and median graft survival was significantly better in recipients with live donors ( . yrs vs . yrs for dd, p< . ) conclusion: the rate of recurrent fsgs and graft loss in this retrospective cohort study of children and adolescents transplanted within the australasian region, was similar to previously reported studies. however, in contrast to previous studies, there was no significant difference in rate of recurrence for live versus deceased donors. additionally, live donor recipients had longer median graft survival compared to deceased donor recipients. outcomes of calcineurin inhibitors conversion to mammalian target of rapamycin inhibitors in children with renal transplantation nuntawan piyaphanee, suroj supavekin, anirut pattaragarn pediatrics, siriaj hospital, bangkok, thailand objective: to study outcomes of pediatric renal transplant recipients who underwent cni elimination and conversion to mtor inhibitors. methods: we performed retrospective analysis of all pediatric renal transplant recipients who underwent cni elimination and conversion to mtor inhibitor at siriraj hospital, a tertiary care center in thailand. indications for conversion were defined. graft function prior and post conversion, history of acute rejection, and cni elimination failure were reviewed. results: nine of pediatric renal transplant recipients underwent complete cni conversion to mtor inhibitor. triple-drug regimen including prednisolone, cni and mmf/mpa was basically prescribed to the recipients. eight with tacrolimus and with cyclosporine were conversed to everolimus. mean ages at transplantation, conversion and last follow up were . ± . , . ± . and . ± . years, respectively. everolimus was initiated within months in patients. each patient due to cni induced hemolytic uremic syndrome, posttransplant diabetes mellitus, graft impairment with early onset nephrocalcinosis and graft impairment with renal artery stenosis. everolimus was initiated after months in patients due to chronic cni nephrotoxicity, chronic allograft nephropathy (can) and unfavorable graft functions with history of delay graft function. median duration from transplantation to cni conversion was . months (range . - ) and median time from conversion to the last follow-up was months (range - ). mean creatinine clearance (crcl) prior to the cni elimination was . ± . , as compared to mean crcl of . ± . ml/min/ . m at last follow up (p = . ). three patients had acute rejection (ar) before the conversion, but only patient had ar post cni elimination. there were no patients with graft loss or cni-elimination failure. conclusion: conversion from cni to everolimus was safe without increasing risk of acute rejection in pediatric kidney transplant patients who experienced early and late cni associated complications. objective: due to a severe shortage of suitable deceased-donor kidneys for children awaiting kidney transplants (kt), we have performed a series of abo-incompatible (abo-i) living kt since . historically, abo-i kt was performed using several session of plasmapheresis (pp) to remove existing anti-a or anti-b antibodies, followed by splenectomy to prevent rebound of antibodies. because splenectomy had risks of surgical complications including bleeding and pancreatic pseudocyst, we introduced a new protocol, for abo-i kt, in january . the new protocol without splenectomy utilizes the anti-cd monoclonal antibody (rituximab) and pp. this study retrospectivery examined the efficacy and safety of this protocol. methods: eight de novo abo-i kt ( males and females) were performed between january and december . the mean age at transplantation was . ± . years (range . - . years). the immunosuppressive protocol consisted of cyclospolin or tacrolimus, mycophenolate mofetil, and methylprednisolone. all patients received induction therapy with basiliximab. the preconditioning protocol included pp or double filtration plasmapheresis (dfpp) and a single dose of rituximab (average dosage mg/m ). all patients who underwent kt achieved a isoagglutinin titer less than : with - sessions of pp/dfpp treatment before transplant. results: the patients were followed for to months with a mean follow-up of months. patient and graft survival rates were %. one non-adherent patient experienced antibody mediated rejection. figure ). in the rtr who had graft loss, there was no significant difference in graft survival time ( . , . years, dsa negative vs dsa positive), grade rejection ( . , . episodes per patient), grade rejection ( . , . episodes per patient) or c d staining ( %, % patients). one patient in each group had bk virus associated nephropathy. two patients had plasma cell infiltrates on biopsy and lost their grafts within months of dsa detection. results: fifty-one kidney recipients (male cases; female cases) were enrolled in this study. the median age was years, the youngest kidney recipient was years old with a body weight of . kg). there were recipients less than equal years, including one children with congenital renal dysplasia and one with congenital renal artery malformation. about . % kidney recipients came from guangdongprovince. about to pediatric patients accepted renal transplatation each year from to , but there were in , which showed a significant increase than in each previous sigle year.the policy that children had a kidney recipients priority may contribute to this increase. the kidney donors were cadaveric kidneys( . %) and living kidneys( . %), only one patient accepted auto-renal-transplatation. all kidney recipients were survival to present with the treatment of glucocorticoid and or immunosuppressants,such as csa, fk , mmf,ect. only two patients accepted retransplatation due to losing function of the renal grafts. conclusion: renal transplantation in children increased significantly in in our hospital, and it seemed an effective treatment to children with esrd. recent adult studies have shown that low levels of immunosuppression (is) are associated with dndsa. however, limited data is available on significance of dndsa and its management in paediatric population. to assess relationship between dndsa with renal function, histological findings, immunosuppression levels and graft outcome in paediatric renal transplant recipients (rtr). in our centre, at the time of the study, dsa were tested if deterioration in graft function was found necessitating renal biopsy. methods: retrospective review of all rtrs in a single tertiary nephrology centre tested for dndsa. data collected included dndsa, histological findings, egfr as marker of renal function, baseline immunosuppression, subsequent treatment and outcome. results: / patients had dsa tested; / had dndsa detected. median time for measured of dndsa was . years post-transplant (range . - . ).histology: / biopsies in dndsa+ve subgroup had antibody mediated rejection (abmr) of which were active abmr ( were c d positive) compared to / in dndsa-ve subgroup. the following treatments were used in the dndsa+ve group: increase in is+ pulsed methylprednisolone (mp) ( patients), increase in existing is ( ), rituximab ( ), pulsed mp ( ), sirolimus added+pulsed mp ( ) . in one patient no change was made. at last follow up, in / patients with dndsa an improvement in egfr was observed. on re-testing for dndsas, / patients tested negative, / had lower and / increased levels. / had not yet had repeat dndsa testing. conclusion: despite previous reports of dndsa conferring poor prognosis, in our cohort with allograft dysfunction and positive dndsa an improvement in renal function was observed in %. however, larger prospective studies are required to further evaluate these findings. abstract# p-sat anuria since birth: does it impact outcome of kidney transplant in infants? shefali vyas, maria isabel roberti pediatric nephrology, saint barnabas medical center, livingston, usa objective: scarcity of data exists for allograft outcomes and urological problems in children with long term de functionalized bladders. however, even less is known about the outcome of infants anuric since birth and whose bladders underwent "forced rehabilitation" after a successful renal transplant. methods: in this retrospective study we compared urological events and allograft outcome in infants with esrd mainly due to urological problems. they were grouped according to the history of pre-txp urine out put: group a with urine output prior to txp and group b anuric since birth (all had visible small bladders by ultra sonogram). results: there were no significant differences regarding birth history or ethnicity . group a had boys ( %) and group b had all girls; all but one child in group b received lrd txp. all received induction followed by triple therapy (tacrolimus, steroids and mmf). group a: / had v-u reflux and / were on pd prior to txp (mean time= mos). all patients in group b were started on pd in the neonatal period (mean = . days). pre txp native nephrectomies were done in patients ( in group a and in group b). group a had acute rejections and none in group b. conclusion: anuric young infants had higher rates of post txp utis and v-u reflux, a direct consequence of their inherent small bladders. however, the year graft survival, patient survival and gfr remained excellent in anuric infants (group b )compared to young infants transplanted with higher rates of v-u reflux and dysfunctional bladders pre txp. abstract# p-sat kidney transplantation in a child with bladder dysfunction who underwent prior bladder augmentation: a case report tepecik training and research hospital, pediatric nephrology, they were divided into groups; pts with esrd on dialysis (d), / with history of kidney transplant, and kidney transplant recipients with good graft function (t). all subjects were tested for anti-hla antibody month prior to and month and months after administration of the combination vaccine of influenza a/ h n . results: among the t group, no pt tested positive for either anti-hla class i or class ii antibodies before or after influenza a/ h n vaccine. in the d group, of the pts with a history of graft failure who were sensitized before immunization; showed no change in class i & ii, one patient had mild increase in class i after vaccination, and one patient had an increase in class i by %. [figure] conclusion: none of the t pts had clinical evidence of either cell mediated or humoral rejection after the influenza a/h n vaccine. in the d group, no pt had any statistically significant increase in anti-hla antibody following vaccination. our study suggests that influenza a/h n vaccination may be safe and tolerable in pediatric dialysis pts with or without a failed kidney allograft. the effect of dipping blood pressure status on structural and diastolic heart function in renal transplant recipients mitra basiratnia , gholamhossein ajami shiraz nephrology urology research center, shiraz university of medical sciences, shiraz, iran department of pediatric cardiology, shiraz university of medical sciences, shiraz, iran objectives: non dipping has been linked to cardiovascular disease in adults, however the impact of non-dipping on cardiovascular status of the adolescents with renal transplantation has not been well established. the aim of this study was to evaluate the influence of non dipping status on left ventricular mass index and diastolic function in subjects with renal transplantation. methods: sixty six stable renal transplant patients ( females, males), aged to years (mean . ± . years) were enrolled in this study. cardiac function assessed by tissue doppler echocardiography and blood pressure measurement performed using ambulatory method. dipping was defined as at least % bp decline during the night and was calculated as (mean daytime -mean night time/mean daytime)*% . left ventricular mass (lvm) was calculated by standard dimensional directed m-mode echocardiography according to the formula of devereux and was indexed to height in meters to the . power to allow the comparison between recipients of different sizes. left ventricular hypertrophy was defined as lvmi> . g/m . in patients younger than years and g/m . in patients > years. data analysis was performed by spss- . a p< . was considered statistically significant. results: non-dipping was identified in ( %) patients. five recipients were systolic non-dippers, diastolic non-dipper, and both systolic and diastolic non-dippers. left ventricular hypertrophy (lvh) was found in . % of the renal allograft recipients. lvh was present in % of the systolic nondippers and . % of the systolic dippers (p= . ) . forty five percent of the diastolic non dippers and . % of the diastolic dippers had lvh (p= . ) . there was no correlation between systolic and diastolic dipping status and lvh, respectively (p= . , p= . ). there were no significant differences in terms of diastolic function [measured by early diastolic inflow velocity (e), e/a ratio, and early diastolic mitral inflow velocity to earlydiastolic annular velocity (e/ea)] between dipper and non dippergroups(p= > . ). conclusion: non dipping is common among renal transplant recipients, but is not always related to diastolic dysfunction and lvh. prospective longitudinal studies are required to determine the impact of dipping status on diastolic and structural heart function in renal transplant recipients. parsa yousefi chaijan, parvin soltani, farshid haghverdi, masood fazelimoslehabadee nephrology, arak university of medical sciences, arak, iran objective: nephrolithiasis in renal grafts is a relatively common phenomenon which can induce organ damage; hence early diagnosis and management of predisposing factors can preclude subsequent complications. the aim of this analytic cross-sectional study is to determine the contributory factors to nephrolithiasis after renal transplantation. method: renal-transplanted patients ( - years old) were enrolled in the study, being divided into two groups of transplanted patients suffering from nephrolithiasis (within first years after surgery) and transplanted patients free from renal stone with the same age and gender and similar gfr. data were collected and arranged in excellmicrosoft program and the statistic analysis was carried by spss v . pvalue < . were considered statistically significant. result: the studied showed that male gender (p = . ), age group of - years (p= . ), hyper cholesterolemia (p= . ), hyper triglyceridemia (p= . ), rd year after surgery (p= . ), hyperuricosuria (p= . ) , hypocitraturia (p= . ) and anemia (p= . ) were significantly more common in patients with nephrolithiasis. conclusion: it is better to evaluate hyperuricosuria and hypocitraturia in kidney donors, moreover all patients had better undergo serial sonography for early screen and management of renal stone as well as treatment for hyperlipidemia and anemia. it also seems prudent to further assess the donors of transplanted patients suffering from renal stone and possbile relation between cni & nephrolithiasis ( regardinghyperuricusuria) objective: epstein-barr virus-associated smooth muscle tumor (ebv-smt) in immuno-compromised patients has recently been reported. but there were no evidence about the treatment of ebv-smt. we report a -year-old girl treated for multiple ebv-smt by using rituximab. methods: case report results: she was suffering from end stage renal disease due to congenital nephrotic syndrome induced by wt mutation. renal transplantation (tx) was performed at the age of years, and immunosuppressive therapy was performed her. soon after performing tx, she was infected cytomegalovirus(cmv), bkv and ebv. she was reduced in amount of immunosuppresive therapy, and she recovered from viremia of cmv and bkv. her ebv titer did not become negative, but we did not perform any medication because of no symptom. four years after tx, she was pointed out cm of cholecystic polyp in a protocol abdomen ultrasonic examination. we soon performed cholecystectomy and extirpation of swelling mesenteric lymph nodes. the pathological finding of cholecystic polyp was ebv encoded small rna (eber) positive smooth muscle tumor but there was no finding about post-transplant lymphoproliferative disorder in mesenteric lymph nodes. positron-emission tomography (pet) showed accumulation of cm mass around th of thoracic vertebra and ct scan showed three small masses in the lung and one in the liver. we diagnosed her suffering multiple infection of ebv-smt. immunosuppression therapy was reduced, but there was no change about size of her tumor. rituximab was administered for keep away from repetition of tumor after proving infection of ebv only in b cells by using flow cytometry. after medication of rituximab, the ebv dna counts were normalized. ultrasonic examination detected three small masses in liver and one lymph node around main artery. but her mass around th of thoracic vertebra was disappeared and whole body ct scan detected only one small residual mass in the lung. we report a case of an ebv-smt presenting multiple infections, which was treated with rituximab. rituximab may be an effective treatment for multiple ebv-smt but careful observation is also needed for the reappearence of ebv-smt. the usefulness of monitoring of epstein-barr viral load after renal transplantation in pediatric recipients with ebv seronegative objective: the purpose of this study are to establish a protocol for monitoring epstein-barr virus (ebv) infection for identification of pediatric renal transplant recipients with a high risk of developing posttransplantlymphoproliferative disorder (ptld) and to predict the development of ptld. methods: peripheral blood mononuclear cells (pbmcs) and plasma ebv loads were measured by nested pcr (n-pcr) and real-time pcr (r-pcr) every - months after grafting in pediatric recipients who were seronegative for ebv before grafting ( with ebv-associated symptoms, including with ptld (group a); with asymptomatic persistent high ebv loads in pbmcs of > , copies/ug dna for over months (group b); and with neither ebv-associated symptoms nor persistent high ebv loads in pbmcs (group c). ebv-ctls were also measured in patients without ebv-associated symptoms. results: the ebv genome detected by n-pcr was present in plasma in ( %), ( %), and ( %) in groups a, b and c (p< . for a vs. b and a vs. c). ebv loads detected by r-pcr in pbmcs were significantly higher in groups a (p< . ) and b (p< . ) compared to group c. ebv genomes in plasma were detected by n-and r-pcr in only the cases with ptld. one patient with lymphadenitis in group a and patient in group b had ebv-dna in plasma based on n-pcr, but the viral loads using r-pcr were < copies/ml. the ctls' percentage was significantly lower in group b when ebv loads first rose above copies/ugdna. conclusion: plasma ebv loads (over copies/ml) estimated by r-pcr and ctls' monitoring may be useful to distinguish ptld from other ebv-associated diseases or asymptomatic viremia, and to avoid ptld as patients with asymptomatic persistent high ebv loads had higher ebv loads and lower percentages of ctls. abstract# p-sat risk factors for post-transplant lymphoproliferative disorder (ptld) in children with kidney transplantation (ktx) -a single center survey since the introduction of tacrolimus (tac) since pre-transplant evaluation showed complete obstruction of ivc/ iliac vein below diaphragm, she had been managed with peritoneal dialysis for years until january when she received a living donor kidney allograft from her mother. the graft was transplanted in a left orthotopic position. venous drainage was to the left ascending lumber vein. in addition, a venous bypass was made using donor ovarian vein between graft vein and splenc vein after splenectomy. such double venous drainage was working very well after transplantation. there was no surgical complication and the serum creatinine (s-cr) during the hospital stay was . mg/dl. at second month after the transplantation, she developed an increase of s-cr with edema and hypertention. however, biopsies of kidney allograft performed at nd and th month after the transplantation revealed no evidence of acute rejection. hypertention was difficult to control even with a maximum dose of calcium blocker, and a temporary increase of the s-cr up to . mg/dl was noted when angiotensin ii receptor blocker was administrated. by the ultrasonography, the maximum arterial blood flow of the kidney allograft was high enough ( cm/s) to suggest renal arterial stenosis. moreover, severe renal arterial stenosis was clearly shown for about mm length from the anastomosed site of aorta by the contrasting ct.for the treatment of artery stenosis of the kidney allograft, percutaneous transluminal renal angioplasty (ptra) was performed at th month after the transplantation. the stenotic lesion was expanded using the special dilatation balloon from . mm through . mm in diameter. because intravascular ultrasonography showed no intimal thickening of the blood vessel, a vascular stent was not placed. after the ptra, s-cr was decreased to . mg/dl, and the blood pressure became controllable by antihypertensive agents. moreover, the angiography performed months after the ptra revealed no progression of arterial stenosis. the s-cr of this patient is now stable in . mg/dl. post-transplant encapsulating peritoneal sclerosis in children: a single center experience kei nishiyama tokyo women's mdical university, pediatric nephrology, tokyo, japan objective: a substantial proportion of encapsulating peritoneal sclerosis (eps) cases develop after renal transplantation (rt), an entity known as post-transplant eps. although risk factors for eps include prolonged pd, recurrent peritonitis, decreased ultrafiltration and prolonged administration of hypertonic glucose or icodextrin, the pathophysiology of post-transplant eps is largely unknown. however it has been postulated that the use of calcineurin inhibitors (cnis) after transplantation may promote eps, as these drugs are considered profibrotic. a recent scottish study showed that the contribution of post-transplant eps might be even as much as % of the total eps patients. by contrast pediatric cases are very rare. therefore we examined the incidence of post-transplant eps in pediatric renal transplant recipients. methods: in this study, we retrospectively investigated clinical records from consecutive pediatric renal transplant recipients in our center between to , who performed pd before transplantation. clinical parameters and pd-related risk factors of eps were collected at the time of rt. transplant-related variables were also collected. eps cases who met ispd diagnostic criteria including clinical feature and either radiologic and/or histopathological confirmation were examined. results: the median duration of pd was . yr (range . to . ). twelve patients ( . %) had at least one episode of peritonitis. ten patients ( . %) were administered hypertonic glucose and/or icodextrin. the median follow-up period after transplantation was . yr (range . to . ). all patients were administered cni, and patients discontinued corticosteroid during the follow-up period. although patients had ultrafiltration failure at the time of rt, there was no case who developed post-transplant eps. conclusion: the case of eps after rt was not seen in this study. possible explanation of this result might be associated with shorter durations of pd and small sample size. since post-transplant eps is rare but carries a high mortality, caution should be paid to developing post-transplant eps even in pediatric patients with a relatively long pre-transplant duration of pd. asli kantar, kaan gulleroglu, esra baskin, umut bayrakci, zafer ecevit, hande arslan, aydincan akdur, gokhan moray, mehmet haberal pediatric nephrology, baskent university, ankara, turkey objective: viral infections remain a significant cause of morbidity and mortality following renal transplantation. although cytomegalovirus is the most common opportunisticpathogenesis in transplant recipients, numerous other viruses may affect clinical outcome. viral infections are potentially severe complications of transplantation, as they not only induce specific diseases, but they also favor the development of allograft damage, opportunistic infections and acute rejection. we evaluated the major viral infections seen following kidney transplantation and allograft outcomes in our pediatric patients. methods: we evaluated retrospectively pediatric renal transplant recipients for the occurrence of viral infections and compared outcomes among these patients. patients were divided in to two groups those who developed an infection and those who did not. inthese groups, we recorded induction therapy used at transplantation, immunosuppressive therapy given at discharge, acute rejection rate, patient and graft survival rates. results: the mean age of the patients was . ± . years. viral infection was found in patients. cytomegalovirus infections were the leading causes; ebv and bk virus were following causes in our study. any significant correlation could not be shown between viral infections and immunosuppressive therapy. we did not observe any correlation between acute rejection and viral infections. lowest gfr at th month was shown in patients with bk virus infection. a significant correlation was shown between viral infection and graftloss (r: . p: . ). conclusion: viral infections are common after kidney transplantation. patients should be monitored more carefully for provide against damage in transplanted kidney. objective: anemia is a frequent condition in kidney transplant recipients and it has a negative long term impact on graft and patient outcomes. recently it has been shown that treatment with angiotensinconverting enzyme inhibitors (acei), angiotensin ii receptor blockers (arb) and mtor inhibitors could be the leading causes of anemia in renal transplant recipients.to study the association of hemoglobin (hb) and ferric parameters with gfr, immunosuppressive drugs, acei, arb and clinical features of kidney recipients. method: hospital records of (f/m: / ) kidney recipients were reviewed retrospectively. the mean age of the study group was . ± . years. the mean follow-up was . ± . months. results: thirty six ( %) patients were found to be anemic. mean hb levels of anemic and non anemic patients were . ± . mg/dl vs . ± . mg/dl respectively. ferritin and iron levels as well as transferrin saturation index, rdw and mcv did not differ among the groups. anemia was not found to be correlated with immunosuppressive or antihypertensive drugs including acei and arb. donor status did not also have any influence on anemia. mean gfr of patients at posttransplant months and year follow-up was found to be significantly lover than patients without anemia ( . ± . vs . ± . ml/min/ . m respectively). graft loss was also found to be significantly higher in anemic patients ( % vs %, p< . ). conclusion: in this study we examined the prevalence of anemia and its risk factors in kidney transplanted patients. its incidence is quite high in our patients. we found that anemia in kidney recipients is neither related to iron status nor medications like acei, arb or immunosuppressive drugs. the major determinant of hb level, especially during the first year of transplantation is the graft function. the most important conclusion of this study is the considerable controversial impact of anemia on graft survival. there was no significant effect on blood pressure ; patients ± modigraf® administration days in the converted group. in the whole series, mean creatinine level was . ± . mg/dl throughout the observational period, and no rejection episodes were detected. blood pressure was well controlled and no proteinuria was seen. the equivalent dose ratio between modigraf® and liquid tacrolimus was . . conclusion: modigraf® appears to be a safe and sustainable way to administer tacrolimus in kidney transplanted infants. in our experience required modigraf® dose was . times the oral liquid tacrolimus one, and therapeutic levels were attained in one week. objective: prescribing of medications in paediatric practice is problematic as many drugs remain unlicensed. this is especially true of immunosuppressive medications. however, there is now a licensed product for tacrolimus called modigraf® with data available on bioavailability. we undertook a single centre prospective study of conversion to modigraf®, an oral liquid available in granule formulation ( mg and . mg) that allows for dosing according to body weight. methods: all paediatric renal transplant recipients (rtr) under the care of a single centre were considered for conversion to modigraf® from their current tacrolimus regimen. inclusion criteria included all rtr under years of age who were on tacrolimus suspension. exclusion criteria included recipients of multi-organ grafts, patients with lactose intolerance and patient choice to continue with their current suspension. patients were then seen by the multi-disciplinary team. after equivalent dose conversion, patients were monitored with blood tests one week after conversion with subsequent doses adjusted accordingly. patients continue to be monitored with blood levels over a month period after conversion with renal allograft function, renal allograft loss and side-effect profiles recorded. results: forty-three ( % of ) rtr were considered for conversion to modigraf®. the families of four patients requested to stay on their current tacrolimus suspension, three patients were deemed unsuitable due to lactose intolerance and three patients were excluded due to low doses (incompatibility with the granule dosing). thirty-three patients were then converted to modigraf® and closely monitored. after blood level monitoring one week after conversion, % ( ) patients had their doses increased due to lower than anticipated -hour trough tacrolimus levels. there was stable renal allograft function without renal allograft loss after conversion. conclusion: conversion to modigraf® immunosuppression can be safely undertaken in paediatric rtr, although regular monitoring in the immediate period of conversion is required to provide accurate immunosuppression dosing. escort trial -effects of strict control of blood pressure in pediatric renal transplant recipients -baseline characteristics of patients from a randomized controlled trial tomas seeman, jiri dusek, nadezda simankova, karel vondrak, jakub zieg dpt. of pediatrics, university hospital motol, prague, czech republic objective: arterial hypertension is a known risk factor for impaired graft survival in patients after renal transplantation (rtx). strict control of blood pressure (bp < th percentile) delays progression of chronic kidney diseases in children (escape trial). it is not known whether strict bp control has renoprotective effect also in children after rtx. the aim of this randomized controlled trial was to investigate whether strict bp control can protect kidney graft in children after rtx. methods: all children from our pediatric renal transplantation center were screened for eligibility for the study (children - years at least year after rtx, no acute rejection in the last months, egfr> ml/min/ . m , hr mean bp > th percentile using ambulatory blood pressure monitoring abpm). altogether children fulfilled the inclusion criteria. they were randomized to intensified bp control group (intens, target hr map < th percentile, n= ) or standard bp control group (stand, target hr map - th percentile, n= ). all antihypertensive drugs are allowed to reach the target bp. the study period is years. the primary endpoint is the yearly change in egfr (schwartz formula, ml/min/ . m /year), the secondary endpoints are graft failure, change in proteinuria, left ventricular mass and safety of strict control of bp. results: the baseline characteristics of the patients are given in the allelic variants. tac dose (mg/kg/day) and tac exposure normalized for dose (tac co/d) (ng/ml/mg/kg/day) were analyzed with respect to cyp a genotype and for interaction with azoles and corticosteroids, for a period of one year post-transplant. over time, tac co/d was significantly lower in recipients with a cyp a * /* genotype compared to those being homozygous for the cyp a * allele ( . +/- . versus . +/- . ng/ml/mg/kg/day, p= . ). the dose requirement was significantly higher in children with a cyp a * /* genotype compared to those being cyp * /* ( . +/- . versus . +/- . mg/kg day, p= . ). the tac co/d was significantly higher for patients receiving azoles (n= ) than those not receiving azoles (n= ) ( . +/- . and . +/- . ng/ml/mg/kg/day, p= . ) and consequently the required tac dose was lower in patients receiving azoles overtime ( . +/- . versus . +/- . mg/kg/day, p < . ). in children receiving steroids without azoles the tac co/d was significantly different between the cyp a * /* and cyp a * /* genotypes, respectively ( . +/- . vs. . +/- . ng/ml/mg/kg/day, p= . ) but the tac co/d was not different for those receiving steroid versus those not receiving steroid with cyp a * /* genotype ( . +/- . and . +/- . ng/ml/mg/kg/day, p= . ). conclusion: in conclusion, the tac dose is influenced by the cyp a genotype and drugs such as azoles, while steroids may not impact tac dose. while therapeutic drug monitoring of tac remains necessary, integrated knowledge of patient genotype and comedication use provides the opportunity to refine tac dosing in children receiving kidney transplant. abstract# p-sat basiliximab induction therapy in pediatric renal transplantation, a double blind clinical trial hasan otukesh tehran university of medical science, associated professor, tehran, iran this is an open, single center, randomized study to compare induction therapy with basilixamb with no induction therapy in children with renal living transplantation. in this trial pediatric renal transplant recipients enrolled randomly to one group with basiliximab as induction therapy and another group without basiliximab induction therapy. both group received prednisolone, cyclosporine and cellcept. we assessed graft function at months after transplant and compared this item between these two groups. in the congress the data and results of this randomized trial will be presented. abstract# p-sat legalization of the organ donation and optimal utilization of young pediatric donor kidneys into pediatric recipients in china objective: china has started to establish a new national system for organ donation and transplantation since march by the ministry of health and the red cross society of china. the aim of this study was to describe our initial experience of pediatric renal transplantation using organ donations from pediatric patients no more than years old. methods: the procedure of organ donation includes: . judgment of brain death, or circulatory death, or brain death followed by circulatory death by doctors; . organ donation informed consent form signed by family (children's parents); . approval by the hospital ethics committee; .organ donation to the red cross society and allocation by the china organ transplant response system (cotrs). the red cross society has been commissioned by the ministry of health to run this system. clinical data of children who underwent renal transplantation using organ donations from pediatric patients no more than years between september and march were retrospectively analyzed. results: the age at transplantation for these patients was . years to years and the weight was kg to kg. among these cases, donors were used aged from days to years and all diagnosed with circulatory death. recipients received en bloc kidney transplantation and the other recipients received one single kidney according to the size of both recipient and donor. the duration of follow-up after the transplantation was month to months. patient survival rate was % and graft survival rate was / ( . %, one graft loss due to the hemorrhagic complication and the other one due to the thrombosis). at latest follow-up, the median serum creatinine level was umol/l and the median egfr was ml/(min· . m ). conclusion: organ transplantation legislation is necessary to ensure the rights and obligations of donors, recipients and medical institutions. we believe young pediatric donors can be expanded further to increase the number of pediatric renal transplants. this pediatric to pediatric combination on the one hand efficiently lower the discarding ratio of the kidneys from small donor, and give more chances to the younger recipient on the other. to assess the normalization of serum (oh)d level (> ng/ml) after standard treatment dosing among primary hypertension (ph) and chronic kidney disease (ckd) methods: we enrolled patients aged - yrs we collected retrospective data on age, sex,race, cause of kidney disease, egfr, ht, wt, bmi, bp z-scores, lipid panel, (oh) d level, pth, calcium, phosphorus, magnesium, medications, type and dosing of vitamin d supplements and follow up serum vitamin d level three months post treatment. results: mean age (yrs) was ( . ± . ). white( ) prevalence of vitamin d deficiency was ( %); % had level < ng/ml. mean pretreatment (oh) d (ng/ml) was ( . ± . ) after completion of standard treatment almost % patients had (oh) d level < ng/ml; ph( . ± . ) and ckd( . ± . ). none were in toxic range. conclusion: the standard treatment dose of vitamin d doesn abstract# p-sat mineral metabolism in european children with end-stage renal disease marjolein bonthuis the netherlands pediatrics, nephrology and dialysis unit results: hypocalcaemia was found in % of hd, % of pd, and % of transplanted patients, with a mean time on transplantation of . years. hyperphosphataemia was found in % of hd, % of pd, and % of transplanted patients. pth was outside target in % of hd, % of pd and % of transplanted patients. in dialysis patients, calcium and pth were inversely associated with age; % of adolescents were hyperphosphataemic resulting in a significantly higher risk compared to - year olds (or: . , %ci: . - . ). patients transplanted pre-emptively had a lower risk of hypocalcaemia compared fgf is modulated by calcium in children under chronic peritoneal dialysis azocar , maria l. ceballos , angelica m. rojo luis calvo mackenna children's hospital human intact fgf- levels (pg/ml, immutopics) were determined through a -site elisa kit. klotho levels were determined by a solid phase sandwich elisa kit (pg/ml). descriptive statistics, univariate and multivariate analysis were performed methods: we measured serum calcium, phosphorus, intact parathyroid hormone, alkaline phosphatase (alp), -hydroxy vitamin d ( d ), , -hydroxy vitamin d ( , d ), and fgf- from children (male:female = : , mean age . years) with ckd stage i-v predialysis in korea with . - year intervals since . results: hypocalcemia was observed in . %, . %, . %, . % and . % of patients with cdk i to v (the rest is the same as above) %, . %, . %, . % and . %. d level was below fgf- (ru/ml) was . , . , . , . and . . serum p had positive correlation with alp (p < . ), ipth (p = . ) and fgf- levels (p < . ) and was inversely correlated with urine phosphorus conclusion: the prevalence of hypocalcemia, hyperphosphatemia and hyperparathyroidism increased as ckd progressed. serum ipth and fgf- increased and , d level decreased in proportion to the progression of ckd malaysia national transplant resource centre, national transplant resource centre, kuala lumpur, malaysia objective: to analyse the cost-effectiveness of paediatric and adult living related renal transplantation (lrt) and deceased donor renal transplantation (drt) the time horizon was the lifetime of transplant recipient from transplant to death. data for survival analysis was obtained from national renal registry. statistical analysis was performed using stata se version . . the costs was discounted at % p.a. results: we reviewed medical records. there were children ( lrt, drt) and adults ( lrt, drt). the paediatric recipients mean age was . +/- . (lrt) and . +/- . years (drt), whereas the adult recipients mean age was . +/- . (lrt) and . ± . years (drt). the and -year patient survival rates for both paediatric lrt and drt were % and % respectively. the and -year patient survival rate for adult lrt was . % and % respectively, whereas adult drt was . % and % respectively. mean cost per paediatric transplant at first year was rm , (lrt) and , (crt), from second year onwards was at , per year (lrt) and , per year (drt) . the total lifetime cost was rm , (lrt) and , (drt) their serum creatinine, egfr, cholesterol, ldl, proteinuria, full blood counts and liver function were profiled to compare the pre-/post-conversion changes. common adverse effects, acute rejection, opportunistic infection and need of treatment for hypercholesterolaemia and proteinuria were investigated. results: we have eligible patients with m: f = : . the mean age at renal transplantation was sirolimus was started at a mean age of . +/- . , at a mean time period of +/- . years after renal transplantation, and used for a mean duration of we observed new onset hyperlipidaemia in patients ( %) and needed statin treatment. we found significant proteinuria (spot pr/cr > . mg/mg) in ( %) patients and needed acei treatment. there was no adverse effect on blood counts and liver function. there was no opportunistic infection observed after conversion to sirolimus in the study period. there was one acute cellular rejection (ia) one month after conversion to sirolimus and responded to pulse methylprednisolone. conclusion: converting from a cni based immunosuppressant protocol for paediatric renal transplantation patients to a sirolimus based one was effective and the benefit was shown up to months post-transplantation one patient received a desensitisation regime with rituximab and plasmaexhange pre-transplant and iv immunoglobulin post-operatively. surgical complications occurred in patients; lymphocoeles, ureteric leaks and renal vein thromboses. early post-operative medical complications included hypertension ( ), pulmonary oedema ( ), seizures ( ), reaction to basiliximab ( ), sepsis ( ), acute tubular necrosis ( ), delayed graft function ( ), acute rejection ( ) and diabetic ketoacidosis ( ). primary ebv infection occurred in patients - developed ptld. there were ( %) graft failures; renal vein thrombosis ( ), acute humoral rejection ( ), acute tubulointerstitial nephritis and tacrolimus toxicity ( ), de-novo acute glomerulonephritis ( ), chronic rejection ( ) and non-compliance ( ). graft survival rates were % at one year, % at years, % at years and % at years. patient survival was % at years. conclusion: our outcomes compare well with international figures a desensitisation program for paediatric renal transplant patients in nsw one child received atg in addition. results: complications/ patient outcomes: : yo boy, donation from mother. dsa antibodies mfi . no complications. no infections. good renal function, creatinine at yrs. : yo boy, previous transplant from biological father. donation from foster father. dsa antibodies mfi . post operative complication of pseudomonas pneumonia/bronchiectasis, cmv, acute cellular rejection x . good renal function creatinine at yr. : yo boy, donation from father. dsa antibodies mfi . early e-coli urine infection. no other complications, creatinine at yr. : yo girl, recipient of liver transplants. maternal donor with positive b cell cxm and dsa mfi . no complications. good renal function four of them had subsequently increasing needs in bicarbonate and/or sodium supplementation, and f was reintroduced in of them. conclusion: f is effective in most cases of severe tubulopathy after rtx. however, side-effects can occur. further prospective studies are needed to validate this indication methods: eighty-one (f/m: / )pediatrictransplant patients were included to the study.demographic characteristics and laboratory parameters were recorded.risk factors for hyperuricemia and the effects of plasma uric acid levels at rd and t h months, st and th years on allograft outcomes were evaluated. results: mean age was . ± . years.mean follow-up time after transplant was . ± . years. hyperuricemia was detected in . % of patients. a significant negative correlation was found between th month uric acid leveland th year of gfr value (r = - . , p = . and r = - . , p = . ). a significant positive correlation between th and th months uric acid levels and th year plasma creatinine level was demonstrated conclusion: uric acid levels may have predictive value in the long term assessment of renal function.posttransplanthyperuricemia can be used as a long term prognostic marker of poor renal outcome.patients with hyperuricemia should be monitored closely for renal functions abstract# p-sat tuberculosis in paediatric renal transplant patients -single centre experience methods: retrospective descriptive folder review of tb in paediatric renal transplantation at red cross children's hospital, university of cape town from - . results: paediatric renal transplant with tb identified. male : female . ages . - . yrs(mean . ; median . ). all patients screened for tb prior to transplant polycystic kidney disease, dysplasia, chronic glomerular nephritis, unknown cause, systemic lupus erythematosis and all patients were on steroids and had recent intensification of immunosuppression. tb treatment included conventional drugs in all but case. levels of calcineurin inhibitors were affected in / patients and required increased dosing(up to times baseline) according to levels in all. rejection was seen in patients(all biopsy proven). successful treatment of tb in all patients with retention of graft. graft and patient survival % post treatment. conclusion: tb is a significant problem in paediatric renal transplants in developing countries. our series shows that with careful investigation and diagnosis of tb as well as careful monitoring of immunosuppressant levels objective: to evaluate the reliability, validity and feasibility of the persian version of the pediatric quality of life inventory (pedsql tm . tm . ) generic core scales in iranian healthy students ages - and chronically ill children ages - . methods: we followed the translation methodology proposed by developer to validate persian version of pedsql tm . tm . generic core scales for children. six hundred and sixty children and adolescents and their parents were enrolled. sample of healthy students were chosen by random cluster method between regions of isfahan education offices and chronically ill children were recruited from st. alzahra hospital private clinics. the questionnaires were fulfilled by the participants. results: the persian version of pedsql tm . tm . generic core scales discriminated between healthy and chronically ill children (healthy students mean score was . better than chronically ill children, p< . ). cronbachs alpha internal consistency values exceeded . for children self reports and proxy reports of children - years old and - years old. reliability of proxy reports for - years old was much lower than . . although, proxy reports for chronically ill children - years old was more than . , these reports for healthy children with same age group was slightly lower than . . constructive, criterion face and content validity were acceptable. in addition, the persian version of pedsql tm . tm . generic core scales was feasible and easy to complete. conclusion: results showed that persian version of pedsql tm . tm . generic core scales is valid and acceptable for pediatric health researches. it is necessary to alternate scoring for - years old objective: bisphosphonates are widely used in the management of children with steroid induced osteoporosis (sio). with the increasing use of bisphosphonates, there have been reports of abnormal radiological findings in the growing skeleton. therefore, their use in pediatric patients remains controversial. the present study was conducted to evaluate the long term follow-up results of radiographic features especially metaphyseal sclerotic lines, associated with pamidronate therapy in pediatric patients with nephropathy. methods: twenty two children with nephropathy receiving oral calcium and pamidronate (mean duration: . months, dose: mg daily) were evaluated restrospectively. all patients had soi because of chronic glucocorticoid therapy for the treatment of nephropathy. biochemical tests, long bone radiography and bone mineral density (bmd) were performed before the treatment of pamidronate and followed up several years later. the physeal growth rates were estimated by measuring the distance that the sclerotic lines moved on the radiographs during the corresponding time intervals. results: the mean follow-up period was . years. in all patients, the well-defined sclerotic lines at the metaphyseal ends were observed and progressively moved from physeal plate to diaphysis on the radiographs of long bones. the mean moving rates of the sclerotic lines was . mm per year and in twelve patients, the lines disappeared. and the mean growth rate of height was . cm per year. conclusion: our long-term follow-up results suggest that the metaphyseal sclerotic lines associated with pamidronate treatment tend to disappear without affecting the skeletal growth. bisphosphonate treatment for soi in pediatric patients with nephropathy seems to be safe although further studies for larger number of patients are needed abstract# p-sat clinical effectiveness and safety of the high dose active vitamin d therapy on severe hyperparathyroidism in children with esrd eun gu kang, su-yon kim, joo hoon lee, young seo park department of pediatrics, asan medical center children's hospital, seoul, korea objective: a potent inhibiting effect of active vitamin d on parathyroid hormone is well known, but there is uncertainty on the dose to be used in hyperparathyroidism. the aim of this study is to assess the effectiveness and safety of high dose active vitamin d treatment on severe hyperparathyroidism in children with end stage renal disease (esrd). methods: fifty-four patients underwent dialysis for more than year between may and feb in asan medical center. among them, patients who were administered high dose of active vitamin d (dose of alfacalcidol mcg/day to mcg/day) with severe hyperparathyroidism(intact parathyroid hormone (ipth) > pg/ml) were selected. changes of ipth, plasma albumin-corrected calcium, phosphorus and , (oh) vitamin d were analysed. results: fourteen patients ( boys and girls) with median age of . years ( - years) were included. the mean duration of dialysis was ± months and the median duration of the high dose alfacalcidol therapy was months( - months). the ipth level significantly decreased in patients ( %) from . ± . to . ± during the high dose alfacalcidol therapy (p< . ). serum phosphorus ( . ± . mg/dl vs. . ± . mg/dl, p= . ) and calciumphosphorus product ( . ± . mg /dl vs. . ± . mg /dl , p= . ) were not significantly changed and , (oh) vitamin d was low or normal after therapy. plasma albumin-corrected calcium significantly increased ( . ± . mg/dl vs. . ± . mg/dl, p= . ). four patients ( %) had persistent severe hyperparathyroidism despite treatment with high dose of alfacalcidol, which was controlled after kidney transplantation ( patients) or after parathyroidectomy ( patients).conclusion: high dose active vitamin d therapy controlled severe hyperparathyroidism in the most children with esrd without significant adverse events. clinical features and treatment of ckd-mbd in children with ckd i-v predialysis objective: vitamin d is known to have multiple effects on the cardiovascular system, renal function, hyperparathyroidism and growth, its deficiency is common in adults and children with chronic renal disease (ckd), but data in kidney transplant children are scarce. the aim of the present study was to investigate the vitamin d status in groups of children and adolescents with ckd and to establish the association between (oh) vitamin d ( ohd) levels, age, hyperparathyroidism, short stature, and renal function. methods: we recruited children: renal transplant patients with a functioning graft for at least months (mean age yr, mean graft abstract# p-sat the expression and significance of il- 、ip- and il- in serum and synovial fluid with juvenile idiopathic arthritis. objective: to detect the disparity of three cytokines about interleukin- (il- ),interferon-inducible protein (ip- ) and in peripheral blood(pb) and synovial fluid(sf) of patients with juvenile idiopathic arthritis (jia). method: serum concentrations of the three cytokines were measured in patients with systemic-onset jia(sjia), polyarticular jia(pjia) and healthy controls using enzyme-linked immunoabsorbent assays (elisa). patients being no marked arthritis symptom or only temporary arthralgia enrolled in probable sjia group. sf from patients with sjia, pjia were examined for cytokine levels. objective: the aim of the present study is to evaluate serum concentrations of ghrelin and leptin, and their associations with fat mass and insulin homeostasis in children undergoing chronic dialysis. methods: the study population consisted of patients on maintenance dialysis ( pd and hd) aged between - years and age-and sex-matched healthy children. serum levels of total ghrelin and leptin were measured in all patients and controls. fasting serum glucose and insulin levels were also measured in the patients; insulin resistance was estimated by the homeostasis model assessment of insulin resistance (homa-ir). nutritional status was assessed by measuring body mass index (bmi), triceps skinfold thickness (tsf) and multi-frequency bioimpedance analysis (bia). body fat mass was estimated by the bia method. results: the mean total ghrelin level was significantly higher in the patients than the controls ( ± vs. ± pg/ml, p< . ). higher total ghrelin levels in dialysis patients were significantly associated with younger age (p= . ), lower bmi-sds (p= . ) and lower bia-based fat mass-z score (p= . ). the mean leptin level was also higher in dialysis patients compared to the controls but the difference was not statistically significant ( . ± . vs. . ± . ng/ml). however, the ratio of leptin levels to fat mass was significantly higher in dialysis patients than the controls ( . ± . vs. . ± . , p= . ). serum levels of leptin in dialysis patients positively correlated with bmi-sds, tsf-z score and bia-based fat mass-z score (p< . for all). serum leptin levels also had a positive correlation with serum insulin (p= . ) and homa-ir (p< . ), and an inverse correlation with total ghrelin level (p= . ). conclusion: children on maintenance dialysis have high levels of total ghrelin that are closely related to decreased fat mass and poor nutritional status. in contrast to ghrelin, leptin is associated with increased fat mass and insulin resistance; however, these patients have inappropriately elevated leptin levels in relation to body fat mass that may be related to wasting. objective: this study investigated the influence of social support and other psychosocial factors upon mortality, adherence to medical care recommendations, and physical qol amongst hemodialysis patients. method: hd patients were examined using the qol questionnaire to determine self-reported inclinations. logistics regression through weighted k was used to analyze data. results: . % of patients reported health had interfered with their social activities demonstrating a strong associated with risk towards all-cause (sp= . ) and cause-specific mortality including cardiac diseases (sp= . ). these patients had a greater risk of withdrawing (sp= . ) from treatment, non-adherence to phosphorus (sp= . ) greater than . mg/dl and increased risk towards an albumin of less than . g/dl (sp= . ). patients reporting dissatisfied with family support ( . %) were at highest risk to non-adherence to intra-dialytic weight gain (sp= . ), shortening the dialysis session (sp= . ) and increased risk of potassium level greater than meq/l (sp= . ). however, patients reporting dissatisfied with staff support ( . %) revealed a higher risk of decreased physical qol (sp= . ). conclusion: this study demonstrated that physical qol was not only affected by medications and other laboratory work-ups but also with additional psychosocial support. the study led to the development of programs empowering patients and families to participate in their treatment plans. the program includes various counselling approaches directed to patient, families, and health team. objective: the aim of the study was to analyze health-related quality of live (hrqol) in children with chronic kidney disease (ckd) dependent on the ckd stage, treatment modality and selected social life elements in families of the patients. furthermore, potential differences between self-and parent/proxy reports and the factors influencing them were assessed. methods: ckd children (on hemodialysis-hd, peritoneal dialysis-pd and conservative treatment-ct) and their parentproxies were enrolled into a cross-sectional national study. a semistructured interview form was used to determine the demographic and social characteristics of the participants. we used the pediatric quality of life inventory (pedsql) . generic core scales to assess the hrqol in children. results: hrqol scores for all ckd groups were significantly lower in all domains compared with population norms, the lowest one being in the hd group. in ct children, hrqol did not depend on the ckd stage. children with ckd reported problems with education and emotional functioning. both parents assessed the hrqol of their children differently depending on their involvement in the care. there are differences between the hrqol scores of the children and their parents. conclusion: the hrqol in children with ckd is lower than in healthy children. this is already observed in the early stages of the disease. the disease itself influences the child's mental state. children on hd require special support on account of the lowest demonstrated overall hrqol. children's lower rating of the quality of life observed by their parents may render the patients unmotivated and adversely affect their adjustment to life in later years. it may also create conflicts between the parents and the children. objective: chronic medical illness is a significant risk factor for the development of psychiatric disorders. the aims of the study were: to investigate the level of anxiety in children with chronic kidney disease (ckd) and to identify factors associated with the presence of that emotional problem. methods: ckd children on hemodialysis (hd, n= ), peritoneal dialysis (pd, n= ,) and on conservative treatment (ct, n= ), and healthy subjects (n= ) were enrolled in the study. we used state-trait anxiety inventory (stai) for adolescents and stai-c for children. socio-demographic and physical factors were assessed. results: there was a significantly higher level of anxiety-state among hd children ( - years) compared with other groups of participants of the same age. the level of anxiety among adolescents ( - years), both anxiety-state and anxiety-trait, was significantly higher in the hd group compared with other groups, which did not differ among themselves. in the hd adolescents, there was a correlation between the anxiety-state and the duration of the disease as well as with the number of hospitalizations. pd adolescents in the mainstream education had higher levels of anxietystate and anxiety-trait compared with home schooled patients. conclusion: even though children and adolescents with ckd are at risk of developing a variety of emotional disorders, the level of anxiety among the researched group, with the exception of hd patients, was not significantly different than the level of anxiety among healthy subjects. adolescents on hd who present a high level of anxiety should undergo long-term psychological treatment. ipek akil objective: compare medication adherence and kidney graft loss rate before and after transition in a single-center cohort of pediatric patients. methods: records of the patients transplanted in our center between and were screened and patients who remained in the program by their th birthday were included in the analysis. adherence and graft function were assessed for the period of years prior and years after transition. undetectable and/or sub-therapeutic levels of calcineurin inhibitors and their level variability were used as measures of adherence. graft survival analysis was performed for the period of years before and years after transition. results: out of screened patients, were eligible and of them were transitioned (tg -transitioned group). the remaining patients were used as a comparison group (cg), of them did not reach the age of transition by the time of the analysis. the median age at transplantation was . [ . - . ] years in the tg and . [ . - . ] years in the cg, median age at transition was . [ . - . ] years. overall, there was no significant difference in adherence within tg before and after transition (p= . for low drug levels and p= . for drug levels variability); however, patients with lower pre-transition adherence (tertile i) showed improvement of their adherence following transition when compared with those with high pre-transition adherence (tertile iii), p= . . there were graft losses per . patient-years in tg vs losses per . person-years in cg (p= . ). the peak graft loss in all pediatric transplant recipients in our center (n= losses) occurred years (sd . years) prior to the transition. conclusion: at our institution, transition was not associated with worsening adherence or graft loss. this may be in part do to the fact that the transition occurred at a later age than in other institutions. a report on -years experience in the use of mtor-inhibitor (sirolimus) in paediatric renal transplantation patients with calcineurin inhibitor (cni) toxicity the management of children with end-stage renal disease (esrd) deu to congenital urological abnormalities is more problematic and difficult than in patients with esrd due to other causes. kidney transplantation in neurogenic bladder patients with small capacity and defunctionionalized urinary bladders is a challenging issue in the field of pediatric transplantation. in these patients with severe bladder dysfunction, augmentation cystoplasty can protect the transplanted kidney by reducing intravesical pressure and creating an appropriate capacity. -year-old boy who presented urinary tract infection with fever at year-old and while his investigation, stage chronic kidney disease secondary to bilateral grade reflux disease was found (blood urea: mg/dl, creatinin: . mg/dl, creatinin clerance: ml/min/ . m ). his mixiocystoureterographic and urodynamic study were showed bladder wall irregularity and trabeculation; decreased bladder capacity and compliance, respectively. at -month of followup he was putted into dialysis programme about years. thereafter, normal bladder capacity was achieved after bladder augmentation implementation. he was achieved renal transplantation from his mother, after -month of augmentation operation. now, he still got uneventfull follow-up period about months. consequently, bladder augmentation application with timely and rationally could be a chance to kidney transplantation in children with bladder dysfunction. the effect of anti-hla antibodies on renal graft functions esra baskin , asli kantar umut bayrakci , kaan gulleroglu , mahir kirnap , , feza karakayali , , aysegul haberal , , gokhan moray , , mehmet haberal , pediatric nephrology, baskent university, ankara, turkey general surgery, baskent university, ankara, turkey immunology, baskent university, ankara, turkeyobjective: the identification of suitable donor kidneys for transplant candidates with high levels of circulating antibodies against human leukocyte antigen (hla) is a major challenge and results in adverse graft outcome. methods: seventy four kidney transplanted children without any shown hla antibody in the pre-transplant period were enrolled in the study. their anti hla antibody status was checked by luminex during post transplant period and its relation with the graft function and prognosis of the patients is studied. results: mean age of the patients was . ± . years. mean follow-up time was . ± . years. pre-transplant cytotoxicity tests and pra was negative in all patients. nine ( . %) patients were found to have anti hla antibodies after kidney transplantation. mean time for the detection of antibodies was found as ± . months. patients with anti hla antibodies were similar with patients without antibodies in the terms of age, sex, hla mismatch, transfusions and immunosuppressive drugs as well as the presence of viral infections. mean serum creatinine level was found to be higher in patients with anti hla antibodies. the antibody mediated rejection rate was found to be . % ( / ) in patients without anti hla antibodies while it was . % ( / ) and remained dialysis dependent. all were dialysis dependent by months post diagnosis. time from anca gn diagnosis to kidney transplant (mean±sd) was ± months (range - months). all patients received induction therapy and maintenance immunosuppression with prednisone, mycophenolate mofetil, and tacrolimus. median duration of follow up post transplantation was . years (range . - . ). egfr at last follow up was . ± . ml/min/ . m (range . - . ). patient lost her transplant to biopsy-proven, severe acute cellular rejection due to complete non-adherence to medications after months of stable transplant function. no patient had recurrence of vasculitis. conclusion: short-term patient and allograft survival in paediatric patients with eskd secondary to anca gn is excellent despite aggressive disease, with no recurrence of vasculitis post transplant.abstract# p-sat en-bloc kidneys from infant donors less than kg transplantation into pediatric recipients at school age objective: given the shortage of donor kidneys in china, the use of grafts from deceased infant donors (weight < kg) is a potential approach to expand the donor pool. in this study, we reviewed the results of the first cohort of en bloc kidney transplantation of infant donors to pediatric recipients at school age in our center.methods: from february to march , infant en bloc kidney transplants in pediatric recipients were performed in our center. en bloc kidneys from infant donors (maastricht category iii) who died of severe congenital disease were recovered and donated to the red cross society of tianjin and allocated to our center by china organ transplant response system (corts). donor age ranged from to days with weight ranging from . to . kg. recipients included females and males with age ranging from to yr. the en bloc graft was implanted extraperitoneally in the right iliac fossa. the distal end of the donor aorta was anastomosed end-to-end to the internal iliac artery, while the donor vena cava was anastomosed to the external iliac vein. the donor ureters were implanted separately onto the bladder with double-j stents placement. after the operation, the recipients received basiliximab as an induction therapy. maintenance immunosuppression consisted of tacrolimus and myfortic. prophylactic anticoagulation with heparin was used for the first week after transplantation. results: patient survival was %. complications included delayed graft function in patient (managed by pd for one week), urine leak in , and anticoagulation-related hemorrhage in . due to discontinued anticoagulation, one graft was lost early from vascular thrombosis. of the remaining recipients, all had immediate and excellent long-term function with average creatinine of . ± . mg/dl at months follow-up (range - months). conclusion: this is the first report of en bloc kidney transplantation from infant donors into pediatric recipients in china. many improvements by our transplant teams had improved the survival of patients and grafts. based on our experience, albeit very limited, we concluded that favorable outcomes can be obtained from en bloc transplantation from infant donors. objective: to describe the rates and outcomes of renal transplantation in children with intellectual disability (id). methods: we performed a retrospective analysis of all children receiving a first kidney alone transplant in the united network for organ sharing (unos) dataset from january , to october , . recipients with definite, probable, and without id were compared using chi-square and fisher's exact tests. kaplan meier curves were constructed for patient and graft survival. results: over the study period, children with definite ( ) or probable ( ) intellectual disability underwent first renal transplant accounting for % of all first pediatric renal transplants (total n= ). children with definite or probable id did not significantly differ from other recipients on the basis of gender or ethnicity but tended to be younger. children with definite id had higher rates of structural kidney disease and lower rates of glomerulonephritis. children with id were not significantly different than children without id with respect to rate of preemptive transplant, donor source, or number of episodes of acute rejection. graft and patient survival were similar between children with definite or probable id and without id. in cox regression, intellectual disability was not significantly associated with patient or graft survival. conclusion: in this first large-scale study, % of all first pediatric renal transplants are performed in children identified as having intellectual disability. early outcomes after transplant appear to be equivalent between children with and without id. further research is needed on long-term outcomes and quality of life effects of transplant in this population. mariana guerra duarte rosa de lima, ana cristina simoes e silva, nadine marcia de faria, eleonora moreira lima pediatrics, universidade federal de minas gerais, belo horizonte, brazilobjective: the aim of this study was to evaluate the clinical course of children and adolescents undergoing renal transplantation at federal university of minas gerais between and and to identify possible factors that could interfere with graft survival. methods: a retrospective observational cohort study through analysis of medical records of patients below years submitted to renal transplant were performed. data were analyzed in spss, version . . the results were expressed by descriptive variables and survival analysis was performed using the kaplan-meier method. comparisons between subgroups were made using the log-rank test. p level was set at below %. results: we analyzed patients who underwent transplants. the mean age was . ± . years. the main causes of chronic kidney disease were cakut ( . %) and glomerular diseases ( . %). most patients were submitted to dialysis before transplantation ( . %) with a mean duration of . ± . months. deceased donor was used in . % and the average cold ischemia time was . ± . hours. dialysis after renal transplantation was performed in . % of cases. the median survival of patients , and years was . %, . % and . %. there were four deaths in this population, two after graft loss. twelve patients lost their grafts ( . %). the median survival of the graft was . years and , and years survival was . %, . % and . %, respectively. no statistical difference was detected in graft survival between the deceased versus. living donor recipients, the different age groups, the occurrence of hypertension or not, the preemptive transplantation vs. preceded by dialysis (p= . ) and those with more than three versus less than three hla mismatches. a significant reduction in graft survival was associated with cold ischemia time associated with h, need for dialysis after transplantation, early acute or late rejection and creatinine greater than mg per dl after the first year os transplantation. conclusion: in our center, graft survival was similar to that described in the literature. however, further studies are needed to address the variables that negatively impacted the results of transplantation. objective: the aim of this study is to assess whether there is an increase in anti-hla antibodies after the influenza a/h n vaccine given to pediatric pts with esrd on dialysis (d) and with kidney transplant (t). methods: pediatric pts were enrolled. mean age was . years old, % female, % male, % african american, % hispanic.objective: ptld is the most common malignancy and important complication of pediatric solid organ transplantation. the rates of pltd have been increasing through s in ktx recipients. we conducted a survey of ptld in children who received ktx since the introduction of tac. methods: from , ktx was performed in recipients at our center. among them, we analyzed data from children who had undergone ktx since the introduction of tac and retrospectively studied incidence of ptld and risk factors, including immunosuppression protocol and pre-ktx ebv serology. results: we retrieved the data of pediatric recipients since ( boys, median age at ktx . years, living ktx , pre-emptive ktx , ebv-seronegative ). among them, cases ( ebvrelated, non-ebv) of ptld were diagnosed in recipients ( . %), and all cases were ebv-seronegative at ktx. the median duration from ktx to the onset of ptld was months (range: - months). the most common presenting symptom of ptld was abdominal complaints in cases, followed by fever in , superficial lymphadenopathy in and nasal congestion in . immunosuppressants were reduced in all cases; the subsequent treatment consisted of antiviral agents + ivig ( / ), anti-cd monoclonal antibody ( / ), and anti-cd monoclonal antibody + chemotherapy ( / ). only one recipient died due to ptld. assessing the correlation between ptld and immunosuppressants in ebv-seronegative recipients (median age at ktx . years, cya , tac , mzr , mmf , il- receptor antibody ), a significantly higher incidence of ptld was associated with tac ( / ) than cya ( / ) [or . , p= . ] in multiple logistic regression analysis. we compared the incidence of ptld, median age at ktx, and rate of ebv-seronegativity in eras (a: - , b: - , c: - ) of the study period and found %/ . yrs/ % in a, %/ . yrs/ % in b, and %/ . yrs/ % in c. thus the incidence of ptld increased with the increase in ebv-seronegative recipients. conclusion: in our study, maintenance treatment with tac (compared with cya) is associated with a higher risk for developing ptld. attention should be paid to the increase in the ebv-seronegative recipients.abstract# p-sat acute graft dysfunction and encephalitis post renal transplant: the role of epstein-barr virus objective: epstein-barr virus (ebv) has been described as a rare cause of acute kidney injury and encephalitis in children. methods: we report a case of a year old renal transplant recipient who developed acute graft dysfunction and a significant neurological insult with evidence of primary ebv infection. results: the patient had been diagnosed with posterior urethral valves prenatally and received a live related renal transplant aged years. seven months post-transplant he presented fluid overloaded, oliguric, with significant uraemia and hyponatraemia. there was a history of lower urine output and sore throat days before admission with evidence of anaemia with red blood cell fragments, thrombocytopenia, mild monocytosis, raised ldh, alt and splenomegaly on presentation. haemodialysis was commenced. primary ebv infection was subsequently detected by serology and pcr.renal biopsy showed a picture of acute glomerular thrombotic microangiopathy(figure above) and acute tubular injury secondary to haemoglobinuria.scanty eber+ lymphocytes containing ebvencoded small nuclear rna were also present. within days of presentation patient deteriorated neurologically developing a reduced conscious level, dysarthria, decreased motor power peripherally and an inability to upward gaze. an mri brain demonstrated increased t signal and mild diffusion restriction in in the caudate nuclei, putamina and ventro-lateral thalami. this picture has been previously described in ebv encephalitis. there was a gradual neurological improvement and by day of admission, and doses of i.v. methylprednisolone, the patient had a full neurological recovery. the number of ebv copies has subsequently decreased on lower dose of immunosuppression. by week after presentation he was no longer dialysis dependent with creatinine -fold higher than the previous baseline. conclusion: this is the first report of acute graft dysfunction and encephalitis due to primary ebv infection in renal transplant recipient.abstract# p-sat indoleamine , -dioxygenase (ido) as a new immunological marker in kidney elisa loiacono , barbara votta , alessandro amore , licia peruzzi , maria paola puccinelli , roberta camilla , luca vergano , giuliana guido , maria elena donadi , rosanna coppo nephrology, cittàdella salute e dellascienza. regina margherita children's hospital, turin, italy nephrology, cittàdella salute e dellascienza, turin, italy nephrology, sapienza university of rome, rome, italyobjective: the enzyme indoleamine , dioxygenase (ido), induced by interferon-gamma (ifn-gamma) and toll-like receptors (tlrs) ligands in dendritic cells, degrades the essential aminoacid tryptophan (trp) to kinurenine (kyn). its activity is estimated by the ratio of kyn to trp concentration (kyn/trp).t-cell activation and proliferation are affected by trp deprivation and accumulation of kyn. therefore, activating ido during immune responses counter balances mechanism of negative feedback loop of ifn-gamma and acts as a tool to downregulate overwhelming immune activation. ido activation has been reported to be increased in acute rejection and downregulated in vitro by the immunesuppressants adopted for organ transplantation. objective: to determine the prevalence of mycophenolic acid (myfortic) use as part of the immunosuppressant regime in our current paediatric renal transplant recipients in a single tertiary paediatric nephrology centre and examine the demography of these cases. method: case note and pharmacy record review of all paediatric renal transplant recipients' history, immunosuppressant medication and current renal allograft function in january . indication for medication switch from mycophenolatemofetil to enteric-coated mycophenolic acid tablets (myfortic) was noted. data presented as median (range). results: ( male) out of a total of patients with renal transplants are currently receiving myfortic in our centre. age and time from transplant was . ( . - . ) years and . ( . - . ) years. the most common cause of end stage renal disease requiring transplantation in this subgroup was posterior urethral valves in / cases. two of these recipients had abo incompatible living related transplants. current egfr was . ( . - . ) ml/min/ . m . / patients receiving myfortic were also receiving prednisolone and tacrolimus as part of their immunosuppression regime. one patient was on tacrolimus and myforctic only (history of idiopathic intracranial hypertension). dosage of myfortic varied based on patient size from mg twice daily to mg twice daily. the indication for carrying out a medication switch from mycophenolatemofetil to myfortic was related to gastrointestinal symptoms in all cases; specifically diarrhoea in cases, abdominal pain in cases and both symptoms in cases. these symptoms improved on myfortic with renal allograft function remaining stable, however in view of neutropenia in one patient her myfortic is currently suspended and under review. we have found that enteric-coated mycophenolic acid (myfortic) was a well-tolerated alternative in paediatric renal allograft recipients who developed gastrointestinal symptoms whilst receiving mycophenolatemofetil. its usage should be considered in such patients who are able to take tablet preparations. ferretti alfonso, ilaria luongo, bruno minale, gabriele malgieri, carmine pecoraro nephrology and urology, santobono children' hospital, naples, italyobjective: uti represent one of the main complications after kt and have an important role in graft funcion impairment. this retrospective report is aimed to evaluate the incidence of uti in a group of patients attending our hospital for post transplant usual medical controls. methods and results: we incuded in our study children who underwent kt between and : m and f, mean age . +/- . . four children received a graft from a living related donor and from a deceased donor. first morning sterile urine sample to the microbiology laboratory was obtained when attending the hospital for its usual medical control or immunesuppressive drug detection levels. results: in patients ( . %) esrd was secondary to cakut. thirty-six patients ( %) presented at least one episode of uti occurred in the first months after kt, mainly in females ( . : ) . uti developed in the first period were caused mainly by gram negative bacteria ( %). e. coli was the main agent ( . %), the other uropathogens involved were: proteus ( %), enterobacter cloacae ( %), pseudomonas aeruginosa ( %), candida albicans ( . %) and klebsiella ( . %). later infections were caused mainly by candida, klebsiella, proteusansdenterobacterfaecalis. one patient at the th month post-transplantation manifested uti caused by corinebacterium urealyticum associated with concretions of baldder mucosae. eight patients ( m and f) experienced the graft loss: patients were affected by cakut and had febrile uti posttx. one patient left the second graft by a an acute deterioration of renal function during an uti by bkv. conclusion: uti in kidney transplanted children represent a main complaint as demonstrated by the high incidence ( %) in total population mainly in females. a significant role is played by primary uropathy and immunosuppression as demonstrated by the high frequency also in non uropathic patients. the role of uti in longterm outcome of kt remains controversial. factors associated with elevated pulse wave velocity in children after renal transplantation objective: even after successful transplantation children with underlying chronic kidney disease (ckd) still carry a high cardiovascular risk. this is also documented by cardiovascular death being the second leading cause of death after transplantation in this patient cohort.methods: in a cross-sectional approach renal transplant recipients at three german transplant centres were enrolled. we measured pulse wave velocity (pwv), a strong predictor for cardiovascular events, as our primary end point. in all participants we assessed classical (e.g. blood pressure, cholesterol) and non-classical (e.g. crp, pth) cardiovascular risk parameters. results: patients were ± years of age and had received their transplant ± years ago. pwv-sds adjusted to height was . ± . . in order to identify predictors of elevated pwv, we performed a univariate screen and introduced factors with a p-value below . into a stepwise forward linear regression analysis. we found that systolic blood pressure in the ambulatory blood pressure measurement and gfr independently predicted pwv-sds (table) . conclusion: our results show a large variability in aortic stiffness in children after renal transplantation. we found elevated pwv to be associated with classical as well as non-classical risk factors. the wide range of cardiovascular comorbidity seen in these patients highlights the need for individualized risk factor monitoring and management. objective: renal transplantation is the optimal treatment for end-stage renal disease in children,. however, it remains technically challenging in small recipients, especially with adult-sized graft. we report on two -year-old children, undergoing living donor kidney transplantation, and describe our management after failure to close the abdominal wall. method: both children weighed < kg and received their father's kidney. the recipient/donor weight ratios were / and / . surgical procedure was an extra peritoneal approach to the iliac fossa, with vascular anastomosis on the aorta and vena cava. they recieved intensive fluid replacement during surgery to optimize hemodynamic status and graft perfusion. after initial successful reperfusion, all attempts to close the abdominal wall (even simple skin closure or superficial muscle layer closure) led to graft hypoperfusion, diagnosed on graft colour change and doppler ultrasound. closure with resorbablevicryl?mesh gave the same results and failure. finally, we had to close with a synthetic non resorbable plate (goretex?), without skin closure.results: the first patient presented acute tubular necrosis and required continuous hemofiltration from day to . the second one had immediate diuresis and with a decrease of serum creatinine to μmol/l at day . in both cases, kidney was successfully replaced intra abdominally at day , with superficial closure of facia and skin in one child and with vicryl? mesh and skin in the second one. no effect on clinical graft perfusion or doppler parameters were observed after final closure. in patient , a limited necrotic area x cm, on direct contact with the goretex?plate, was noticed during the second surgery procedure but it remained very superficial. finally, with a follow-up of respectively year and month, recipients and grafts are doing well without any other events and a serum creatinine of - μmol/l. conclusion: in conclusion, in small patients kidney size discrepancy and tissue oedema can lead to renal allograft compartment syndrome. in this situation, goretex? plate is an option for initial wound closure and graft salvaging. objective: amr in the transplant is one of the most complicated form of rejection, which do not respond to the standard therapy. survival of the transplant exposed to amr is still low. this is a clinical report of an amr-treatment in children in our centre. methods: girls with amr after the deceased donor renal transplantation were observed of age , , , from to in our centre. all had a negative "cross-match" at the time of transplantation, the quantity of discordant antigens varied from to . for girl it was the transplantation. children had an immediate function of the graft, -delayed. induction of the immunosuppressive therapy: polyclonal antibodies and methylprednisolone, maintenance: tacrolimus, prednisolone, mmf. children had high level of preexisting antibodies (more than %) at the time of transplantation. there were morphological confirmation and decrease of the graft function for the moment of amr. the treatment of amr included: pulse therapy of methylprednisolone, polyclonal antibodies, rituximab, immunoglobulin iv. function of the graft was evaluated by the cr levels, gfr, the level of dsa.results: the cr of children was ± umol/l for the moment of developing of amr. function of the graft has been restored to satisfied: cr fall to ± umol/l, there were no proteinuria. it was noted a significant reduction of dsa i and ii class in from patients. conclusion: thus, treatment of an amr of the graft with methylprednisolone, rituximab and immunoglobulin intravenously let us achieve % -year graft and recipient survival after deceased donor kidney transplantation in children. since the risk of amrdevelopment is high in children with high levels of preexisting antibodies, addition of one-time rituximab and immunoglobulin intraveneously in therapy seems reasonable.abstract# p-sat tacrolimus granules use in kidney transplanted infants. dose and safety.ramon vilalta, enrique lara, alvaro madrid, marina munoz, sara chocron, gema ariceta paediatric nephrology, hospvalld'hebron, barcelona, spainobjective: tacrolimus in infants has been administered as an extemporaneously compounded oral liquid made by hospital pharmacy. modigraf® is a new tacrolimus formulation available as sachets containing granules ( . mg and mg), that are made up with water, prepared by parents or caregivers. modigraf® is considered at least as safe and practical than the compounded oral tacrolimus liquid. furthermore, it is easier to be stored and ready to use, and promotes patient's autonomy, preventing potential medication errors. kidney transplanted infants, de-novo and converted from oral liquid to modigraf® were evaluated to assess its safety and adequate dose. methods: after induction with basiliximab or atg, de novo's patients were treated with modigraf® associated with mmf and with tapered steroids. infants with similar immunosuppression regimen were converted from oral tacrolimus to modigraf®. target tacrolimus through level was - ng/ml. mean patients' age at transplantation was . years old, and mean follow-up period with modigraf® was ± months.results: in the de-novogroup the stable modigraf® dose needed to reach target levels was . ± . mg/kg/day. in the converted group, the initial oral tacrolimus liquid dose was . ± . mg/kg/day, whereas modigraf® stable required dose was higher: . ± . mg/kg/day (p = . ). target levels of tacrolimus were reached after key: cord- -vgjz ts authors: nan title: th international congress of the european association for endoscopic surgery (eaes) sevilla, spain, – june date: - - journal: surg endosc doi: . /s - - -x sha: doc_id: cord_uid: vgjz ts nan laparoscopic cholecystectomy is one of the most commonly performed operations worldwide. bile duct injury (bdi) is a rare but very serious complication of the procedure, with a significant impact on quality of life and overall survival. the high frequency of bdi with laparoscopic cholecystectomy was first considered to be a consequence of the initial learning curve of the surgeon, but it later became clear that the primary cause of bdi is misinterpretation of biliary anatomy. intraoperative cholangiography (ioc) has been advised by many authors as the technique reduces the risk of bdi. however, the procedure has inherent limitations and is therefore reserved for select cases. fluorescent cholangiography using indocyanine green(icg) is a novel approach, which offers real-time intraoperative imaging of the biliary anatomy. a comparative study was contacted by administering icg intravenously or intrabiliary during the operation. forty patients scheduled to undergo an elective lap. cholecystectomy were randomly divided in two groups: in group a icg was administered in a dose . mg in ml solution intravenously hour before surgery. in group b icg was injected intrabiliary in a . mg/ml solution mixed with the patient's bile. also, we observed and analysed the following parameters, liver function, b.m.i, asa score and possible complications, before and after operation. results: group a. intravenous icg was administered in patients. there was no any reaction and the extrahepatic biliary anatomy was identified well. there was no bdi or any complication related to the procedure. group b. icg was injected intrabiliary in patients during the laparoscopic procedure. in all but one patient the extrahepatic biliary tree was delineated very well. in one patient part of icg solution was injected into the gallbladder wall and this resulted in a partially confusing image. there was no bdi and no postoperative complication conclusions: fluorescence cholangiography can be used during laparoscopic cholecystectomy to obtain fluorescence images of the bile ducts following intrabiliary injection during the operation orintravenous injection h before the procedure. the later technique is more easy to perform and does not require catheterization of the biliary tree. endoscopia digestiva chirurgica, policlinico universitario ''a. gemelli'', rome, italy; ihu, strasbourg, france; camma group, icube, university of strasbourg, cnrs, ihu strasbourg, strasbourg, france; ircad, strasbourg, france; digestive and endocrine surgery, nouvel hopital civil, university of strasbourg, strasbourg, france; digestive and endocrine surgery, ihu-strasbourg, strasbourg, france aim: surgical societies are united in promoting the critical view of safety(cvs) during laparoscopic cholecystectomy(lc). nonetheless, reports have shown a discrepancy between the operative reports and the correct application of cvs, which may explain the stability of bile duct injury rates. therefore, surgeons and computer scientists at our institution are developing a machine-learning algorithm to automatize cvs assessment. however, the lack of a consistent cvs video assessment framework limits the ability to generate data to train the artificial intelligence. here we describe and test a method for cvs evaluation in videos. method: between march and july , consecutive videos of lc performed at nouvel hospital civil(strasbourg, france) were recorded. two independent reviewers assessed the achievement of cvs in the s video sequences preceding clipping of cystic duct and artery. in addition to the 'doublet view' method, a 'binary' video evaluation method was tested: each of the criteria composing the cvs( structures entering the gallbladder, clearance of the hepatocystic triangle and lower part of the cystic plate) was classified as achieved or not. if the criteria were met, then the cvs was considered achieved. inter-rater agreement for cvs and for each of the criteria was evaluated. results: twenty-two videos( fundus first and partial lc, and broken videos) were excluded from the cvs analysis. cvs elements were assessable in all but one s videos sequences( . %). after mediation, cvs was achieved in / ( . %) of lc. the cystic plate was identified in only . % of videos. inter-rater agreement using the doublet view vs. the binary method was as follows: . %(? = . ) vs. . %(? = . ) for cvs achievement, . %(? = . ) vs. . %(? = . ) for the structures, . %(? = . ) vs. . %(? = . ) for the hepatocystic triangle and . %(? = . ) vs. . %(? = . ) for the cystic plate ( fig. ) . conclusions: reliable cvs assessment is crucial to generate consistent data for machine-learning algorithms aiming at decreasing bile duct injury after cholecystectomy. our binary cvs video assessment method showed higher inter-rater reliability than the doublet view, originally described for assessment of photos. further studies are on going to validate the cvs assessment in videos and support our initial results. surg endosc ( ) the vital role of surgeries in healthcare requires a constant attention for improvement. surgical process modeling is an innovative and rather recently introduced approach for tackling the issues in nowadays complex surgeries, involving complex logistics, much technology, and large teams. surgical process modeling allows for evaluating the introduction of new technologies and tools prior to the actual development and is beneficial in optimization of the treatment planning and treatment performance in operating room. in this study, we first discuss the concepts associated with surgical process modeling, aiming to clarify them and to promote their use in future studies. next, we apply these concepts to analyze the procedure of challenging interventions, minimally invasive liver treatment (milt) methods, with the ultimate goal of improving and optimizing the treatment procedure. the procedure model of current treatment activities and planning of various milt methods and the associated techniques, are analyzed and combined into a generic procedure model of milt, which provides a firm foundation for qualitative and quantitative analysis of different milt procedures. the generic procedure model is validated by data from erasmus medical center (rotterdam, the netherlands) and oslo university hospital (oslo, norway) . the proposed procedure model is designed to be a basis for improvement of the procedure and to determine how and where the new technologies can be best, effectively and efficiently, employed in the clinical practices prior to and/or during actual development of the new technologies for milt. as a conclusion, the current work illuminates the importance of surgical process modeling for improving different aspects of treatment procedures and provides an overview of various modeling strategies that can be used to establish surgical process models. the generic procedure model of various milt methods, including laparoscopic liver resection, laparoscopic liver ablation and percutaneous ablation, is introduced and validated which is a basis for introduction of the optimized procedure model of milt objective: to determine the most appropriate time to start total laparoscopic living donor right hepatectomy (tldrh) based on the experience with laparoscopic liver resection (llr). summary background data accumulation of experience in llr is essential before starting tldrh to ensure donor safety. methods: we retrospectively reviewed data of and consecutive patients who underwent llr and donor hepatectomy, respectively, between and . operative outcomes of laparoscopic major hepatectomy (lmh) were compared between two periods based on tldrh introduction (phase i - vs phase ii . learning curve of llr was evaluated using the cumulative sum (cusum) method to determine the optimal time of tldrh introduction. conclusion: accumulating an experience of at least lmh cases is needed in low-volume lt centers before starting tldrh to ensure donor safety. introduction: the number of surgical adverse events is still too high. an important number of these adverse events occur within the operating room (or) and are in fact preventable. in order to reduce adverse events in the or, we simply need to know what went well and what can be done better. the aim of this study was to analyze and debrief a predefined selection of surgical procedures, with the use of an operating room 'black box', to identify commonly observed safety threats and resilience support events. methods: in the period - , predefined gastro-intestinal laparoscopic cases were recorded by the or black box'. the postoperative surgical team assessment record (star) questionnaire was used. the recordings were analyzed by specifically trained raters, using the systems engineering initiative for patient safety (seips) model of work system and patient safety to identify relevant safety threat and resilience support events. qualitative data analysis was used to identify the most commonly discussed events during the team debriefings. results: in only . % (n = ) of times or team members, when asked direct following surgery, indicated that they had noticed aberrations (n = ) during the case. a mean number of . (sd . ) relevant positive and negative events (e.i. aberrations) per surgical procedure were identified using the black box performance report. on average, . (sd . ) of events identified by the black box were rated as safety threats. most events discussed during the team debriefings were related to communication. conclusion: these results once again highlighting the importance of clear and closed-loop communication in the operating room. theatre staff underestimated the number of aberrations occurring in the or, when asked to retrieve from memory. postoperative structured team debriefing may be important for resolving incorrect assumptions between operating team members to avoid future unnecessary miscommunication. background: the eaes has recently published an intraoperative adverse event classification to assist the direct measurement and routine reporting of minimal access surgery interventions. we aimed to explore the clinically validity and reliability of the classification. methods: a prospective evaluation utilising case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision surgery randomised controlled trial was performed (isrctn ). enacted adverse events identified with the observational clinical human reliability analysis technique were graded with the eaes classification by two blinded, independent assessors. test-retest reliability was explored using grades previously applied during the development of the classification with intraclass correlation co-efficients calculated. clinical validity was assessed using -day morbidity events, the clavien-dindo classification and the highest eaes grade per case. results: laparoscopic cases ( h of surgery) contained error events which were all successfully categorised. excellent inter-rater and test-retest reliability was seen (icc . , % ci . - . , p \ . and icc . , % ci . - . , p \ . respectively. % of patients experienced post-operative morbidity (median event, range [ ] [ ] [ ] [ ] [ ] [ ] . labelling analysed cases by their highest eaes classification grade gave % grade , % grade and % grade procedures. % of grade cases developed a morbidity event, but this significantly increased in grade and operations ( % and %, p = . ). the number of complications and highest recorded clavien-dindo grade increased with each additional grade ( . ± . vs. . ± . vs. . ± . , p = . and median vs. vs. , p = . respectively). anastomotic leak and re-operation were correctly captured by the allocated eaes grade ( . % vs. . % vs. %, p \ . and % vs. % vs. %, p \ . respectively). there was a significant rise in length of stay observed with increasing eaes grade (median vs. vs. days, p \ . ). conclusion: in the context of major laparoscopic surgery, the eaes intraoperative adverse classification is seen to be a clinically valid and reliable assessment method. psychological medicine, nuhs, singapore, singapore aims: neurobiological feedback in surgical training could translate to better educational outcomes such as measures of learning curve. the variation in brain activation of medical students when performing laparoscopic tasks before and after a training workshop is not properly studied before and we planned to do this using functional near infrared spectroscopy (fnirs) which is a non-invasive optical brain imaging tool that measures cortical oxygenation change which is used as a marker of pre-frontal cortex activity (pfca). methods: this randomised controlled trial examined the pfc activity differences in two groups of novice medical students during the acquisition of basic laparoscopic tasks. 'trained-group' had standerdised oneto-one training on the tasks, while the 'untrained-group' had no prior trainining and was just shown a video of the tasks. the pfca was measured pre and post intervention using a portable fnirs device. primary outcome was the difference in the pfca pre and post intervention. secondary outcomes were the differences in pfca between the tasks and between the sexes. results: trained and untrained medical students with an equal sex distribution and a comparable age distribution were invovlved in the study. all students were right handed. trained group had a significantly attenuated pfca in the 'precision-cutting' (p = . ) and 'suture-insertion' (p = . ) tasks compared to the untrained group. subgroup analysis based on sex revealed significant attenuation in pfca in trained females compared to untrained females across of the laparoscopic tasks: 'pegstransfer' (p = . ), 'precision-cutting' (p = . ), 'suture-insertion' (p = . ). no significant pfca attenuation was found in male students who underwent training compared to untrained males. conclusion: a standardised laparoscopic training workshop promoted greater pfca attenuation in female medical students compared to males. this suggests that female and male students respond differently to the same instructional approach. these results may have implications for surgical training and education such as a greater focus on one to one surgical training for female students and use of pfca attenuation as a form of neurobiological feedback as a measure of learning curve in surgical training. robot assisted versus laparoscopic advanced suturing learning curve e. leijte , i. de blaauw , c. rosman , s.m.b.i. botden surgery, radboudumc, nijmegen, the netherlands; pediatric surgery, radboudumc, nijmegen, the netherlands aims: compared to conventional laparoscopy, robot assisted surgery is expected to have most potential in difficult areas and demanding technical skills as minimally invasive suturing. this study was performed to identify the differences in the learning curves of laparoscopic versus robot assisted advanced suturing method: novice participants, with the knowledge of basic surgical procedures, were recruited and performed three suturing tasks on the eosim laparoscopic augmented reality simulator or the robotix robot assisted virtual reality simulator. each participant performed an intracorporeal suturing, tilted plane needle transfer and anastomosis needle transfer task. to complete the learning curve, all tasks were repeated for maximal twenty repetitions or until a plateau was reached three consecutive times. clinical relevant and comparable parameters regarding time (seconds), movements and safety were recorded. intracorporeal suturing was used to visualize and compare the learning curves between the groups. results: forty-six participants completed the learning curve, of which laparoscopically and robot assisted. when comparing the suture time, the plateau was reached much faster in the robot assisted group ( - repetitions) than the laparoscopic group ( ) ( ) ( ) repetitions) as shown in figure . there was a significant difference in 'time per suture', during the whole learning curve with median values of versus (first knot), versus (fifth) and and (eighteenth), all with a p \ . . however, the parameter 'adequate surgical knot' was reached earlier in the laparoscopic group than in the robot assisted group. first: % versus %, fifth: % versus %, and eighteenth: % versus %. when assessing the 'needle out of view' parameter, the robot assisted group scored a median of . and . s during the first, respectively eighteenth knot, and the laparoscopic participants had their instruments out of view for and s during the first respectively eighteenth knot. conclusion: the learning curve of minimally invasive suturing can be reduced with the use of robot assisted surgery, with a specific reduction in operation time. the rate of adequate knots seemed to remain lower in robot assisted surgery, although this could be due to the virtual reality aspect of the simulator. introduction: endoscopic sleeve gastroplasty (esg) is a novel promising bariatric endoscopy treatment. gastric volume reduction and delayed gastric emptying are the mechanisms driving weight loss. however, little is known about the factors influencing the effectiveness of weight loss overtime. the present study aims at evaluating the correlation between endoscopic suture appearance and excess weight loss (ewl%) at and months follow up. patients and methods: all patients who underwent follow-up endoscopy at and months after esg were included. esgs were classified in groups according to endoscopic appearance of the gastric sutures: optimal (group ) when all stitches were in place and tights; suboptimal (group ) when one or more stiches were displaced; loose (group ) when all the sutures were completely disrupted. bmi at enrollment and ewl% at and months were recorded and compared to the endoscopic appearance. results: a total of patients were included in the analysis. at months, ( . %) patients had an optimal esg, ( . %) had a suboptimal sleeve and ( . %) had complete sutures failure. bmi at enrollment and ewl% were respectively . ± . and . ± . % for group , . ± . and . ± . % for group and . ± . and . % ± . % for group . twenty five patients had months egds: ( %) presented an intact esg and were classified in group , ( %) in group and ( %) in group . twelve months ewl% was respectively . ± . %, . ± . and ± . %. initial bmi significantly correlated with suture status at both (rho - . ; p \ . ) and months (rho - . ; p = . ) follow-up. furthermore, the sutures' appearance itself correlated with ewl% at both time points (rho ? . ; p = . and rho . ; p = . respectively). conclusion: our preliminary results show that the aspect of the endoscopic suture has a significantly impact on ewl% at and months after esg. furthermore, bmi at enrollment seems to predict endoscopic suture duration overtime. larger studies and longer follow-up are needed to further validate our preliminary findings. background and aim: endoscopic sleeve gastroplasty(esg) is a relatively novel endoscopic procedure that reduces the gastric lumen with proven less complications and less months weight loss compared to laparoscopic sleeve gastroplasty (lsg) . at present there are no studies investigating the role of multidisciplinary approach in esg. the aims of the present study were to evaluate the role of multidisciplinary assessment(ma) prior esg, weight loss outcomes, quality of live improvements and adverse events. material and methods: from may to may all patients that underwent esg were retrospectively evaluated from a prospective database. until september before esg only psychiatric evaluation was requested, while after this date we adopted the guidelines of the italian society for obesity surgery and all patients were evaluated on a multidisciplinary fashion prior esg. the multidisciplinary team was composed by:gastroenterologist, surgeon, psychiatrist, endocrinologist and dietitian. patients were divided in two groups:group were patients with esg before ma and group were patients with esg after ma. we compared this two groups in terms of weight loss outcomes, quality of live improvements and adverse events. quality of live was measured with the bariatric analysis and reporting outcome system(baros).all procedures were done with the apollo overstitch suturing system(apollo endosurgery) and a double channel gastroscope olympus tgif- (olympus japan).all procedures were done in general anesthesia and with insufflation of co . all patients had ambulatory visit t , and months after esg and weight loss outcomes were measured in terms of excess weight loss (%ewl),the total body weight loss (%tbwl) and baros scale were assessed. statistical analysis was done with chi-square test and \ . value was considered significant. results: patients were identified ( female; mean age . , range - ) . mean bmi at inclusion was . (range . - . ). mean %ewl and %tbwl at months was . and . respectively (table ) .non procedure related complications were observed. comparing the two groups there was significant(p \ . ) difference in terms of %ewl and %tbwl (table ) ,with better results in group . there was also a significant improvement in the baros scale in the patients in group . conclusions: ma before esg has a fundamental role in terms of better procedure outcomes for both weight loss and quality of live in obese patients. gastroenterology, hadassah medical center, jerusalem, israel, israel aims: the over-the-scope clip (ovesco) is a novel endoscopic tool that enables non-surgical management of gastrointestinal defects. the aim of this study was to report our experience with ovesco for patients with staple line leaks following laparoscopic sleeve gastrectomy (lsg). methods: a prospectively maintained irb-approved institutional database was queried for all patients treated with ovesco for staple line leaks following lsg from to . primary outcome was complete resolution of leak following ovesco as defined by return to complete oral nutrition and no evidence of leak on imaging. secondary outcome was the number of additional endoscopic or surgical procedures needed following ovesco. results: twenty-five patients ( males, females) were treated with ovesco for staple line leaks following lsg. the median age was years (range - ), and mean body mass index was kg/m . nine patients ( %) were referred from an outside hospital. the median time from index operation to leak diagnosis and from leak diagnosis to ovesco was days (range - ), and days (range - ), respectively. all patients had upper staple-line leaks near the gastroesophageal junction. initial treatment included antibiotics- patients; computed tomography guided drainage and antibiotics- patients; and laparoscopic drainage- patients. ovesco led to final resolution of leak in patients ( %) within days of clip deployment (range - ). leaks which persisted following ovesco were eventually resolved with a combination of ovesco and stent- patients ( %), total gastrectomy and esophago-jejunostomy- patients ( %), and endoscopic suturing- patient ( %). one mortality was noted in a patient who suffered multiorgan failure. the number of additional endoscopic sessions ranged from to (median ). no procedure related complications were noted. all patients were treated with total parenteral nutrition and the total length of stay was days (range - ). conclusions: despite its low success rate, ovesco should be part of the bariatric surgeon's non-surgical armamentarium in treating staple line leaks following lsg. r. bademci , r. vilallonga , p. alberti , r. renato , c. yuhamy , s.s. cordero , l. posadas general surgery, istanbul medipol üniversitesi, istanbul, turkey; bariatric surgery, vall d'hebron, barcelona, spain background: in cases of morbid obesity, treatment is generally applied as either a surgical or endoscopic approach. the number of primary obesity surgery endolumenal (pose) procedures is increasing but the reliability and effectiveness is unclear as yet. the aim of this study was to present a series of cases that required revision surgery due to pose failure and to reveal possible alternative surgeries. materials and methods: a retrospective comparison was made of the data of obese patients with pose failure and conversion to surgical procedures between and in respect of operation, medical illness and bmi results. results: the patients comprised % females, % males with a mean age of . ± . years and mean follow-up period of . ± . months. on average, patients lost . ± . kg, with an average excess weight loss of . %. conclusion: no firm conclusions can be drawn from such a small group. although sg seems to be a safe procedure and should be considered as the first technique to be applied following pose failure, it is possible to perform gastric bypass on patients with this endoscopic precursor. introduction: the population of post bariatric surgery patients is rapidly increasing worldwide. due to the altered anatomy post roux-en-y gastric bypass (rygb), conventional endoscopic management for choledocholithiasis is challenging. these patients are now commonly managed by means of a laparoscopic assisted ercp. although effective, this requires significant resource utilization and potential morbidity related to the need for surgical intervention. we present our preliminary experience with a purely percutaneous management of choledocholithiasis in bariatric patients post-rygb. methods: a retrospective single center review identified five patients with choledocholithiasis after bariatric rygb who underwent percutaneous cbd access and treatment by interventional radiology. four patients underwent percutaneous transhepatic cbd access while one patient underwent percutaneous trans-cholecystic cbd access. in three of the five patients conscious sedation alone was sufficient to perform the procedure. results: all patients had radiologically confirmed choledocholithiasis and were clinically symptomatic prior to intervention. the biliary tree was successfully accessed percutaneously and cleared in all five patients. in the four patients where a percutaneous transhepatic access was utilized, three patients required only fluoroscopic balloon sphincterplasty and sweep of the cbd to clear the ductal stones, while the fourth required percutaneous cholangioscopy assisted lithotripsy for clearance. in the fifth patient with non-dilated intrahepatic bile ducts a trans-cholecystistic approach into the cbd was utilized with percutaneous cholangioscopic assistance to clear the ductal stones. all procedures were completed successfully with no post procedure complications. conclusion: percutaneous clearance of cbd stones in bariatric patients presents a minimally invasive alternative to current surgical practice. the use of conscious sedation and the purely percutaneous approach may potentially reduce morbidity and resource utilization for this increasingly common clinical scenario. laparoscopic narbona-arnau procedure to control the gerd after lsg- years results of a prospective study i.c. hutopila, c. copaescu background: after the laparoscopic sleeve gastrectomy (lsg) alone or associated with calibration of the esophageal hiatus, for some patients the reflux symptoms worsen postoperatively due to development of a hiatal hernia (hh) or due to the recurrence of the hh previously repaired. for these situations, when the conservative treatment fails, are proposed some surgical solutions, one of them cardiopexy with teres ligament-narbona arnau. objective: is to establish a standardized laparoscopic technique for cardiopexy using the teres ligament (narbona arnau technique) and to analyze the procedure's outcomes. methods: the study was performed in a bariatric and metabolic center of excellence-ponderas academic hospital. all the patients undergoing narbona arnau procedure to control gerd after lsg since were included and prospectively analyzed. the selection criteria included lsg patients, presenting hh and symptomatic gerd. preoperative investigations were upper gastrointestinal endoscopy, radiological contrast study, ph-metry, computed tomography with oral contrast. results: patients were included into the study. gerd and hh were preoperatively documented in all the cases. one patient was excluded after years of follow up after being converted to a laparoscopic roux-en-y gastric bypass, for intense relux symptoms. no incidents during surgery. for cases laparoscopic narbona arnau technique was performed concurrent with re-sleeve gastrectomy and gastric curvature plication. without postoperative complications. postoperative follow-up at months, , and years, the percentage of patients without gerd symptoms and free of treatment with ppis was , %, , %, , %, respectively . %. at years postoperatively the upper gi endoscopy showed remission/ improvement of the degree of esophagitis for patients. for the same period of follow-up, the ph-metry highlighted a normal value of demeester score for . % o patients (all the patients had preoperatively high de meester scores). no objective signs of hiatal hernia recurrence at imagistic investigations and upper gastrointestinal endoscopy were encountered. conclusions: complete preoperative evaluation is mandatory for choosing the optimal intervention. laparoscopic narbona arnau technique after lsg is proved to be a good option for the treatment of symptomic gerd, but further studies with high-volume patients are necessary. introduction: the aim of this study was to investigate the influence of baseline glycated hemoglobin level (hba c) level in bariatric patients on postoperative outcomes. we found scarce of clinical data regarding influence of baseline hba c on bariatric surgeries postoperative morbidity and readmission what was inspiration to conduct this multicenter retrospective study. methods and procedures: retrospective cohort study analyzed patients who underwent laparoscopic: sleeve gastrectomy (sg), roux-en-y gastric bypass (rygb) or mini-gastric bypass (mgb) for morbid obesity in seven referral bariatric centers. patients were divided into groups depending on preoperative hba c : hba c \ . %; . - . % and c . %. primary endpoints: influence of hba c level on perioperative ( -days) and postoperative ( -months) morbidity rates, operation time, length of hospital stay (los) and readmission rate. results: study group included , % females and % males. median age was ( - ) years. median hba c was . ( . - . ). hba c \ . % was present in % patients, hba c . - . % in %, and hba c c . % in %. percentage of male patients increased in groups from % in hba c \ . % to % in hba c c . % significantly. same tendency through groups we observed in case of bmi and age. uncontrolled diabetes (hba c c . %) was present in . % patients, while . % patients were not on antidiabetic medications despite having hba c c . %. median operative time in patients was significantly longer than in hba c \ . % and hba c . - . %. -days morbidity rate was . % and did not differ groups significantly, as -months morbidity rate (excl. -days) of . % . los did not differ groups significantly. patients having hba c in range of . - . % and with hba c c . % did not have significantly increased odds for perioperative morbidity, -months postoperative morbidity as compared with those with hba c \ . %. patients with hba c c . % had increased or for prolonged los as compared to those with hba c \ . % (or . ; % ci . - . ). hba c did not influence or for readmissions. patients with baseline hba c c % had significantly increased chances for hospital readmission (or . , % ci . - . ). conclusion: baseline level of hba c did not influence chance for perioperative morbidity, -months postoperative morbidity and prolonged los. patients with hba c c % have increased chance for hospital readmissions. surg endosc ( ) :s -s introduction: surgical resection is crucial for curative treatment of rectal cancer. through improvements in treatment and minimally invasive techniques, -year survival improved to over % of patients. the most recently introduced surgical technique is robotic-assisted surgery (ras). ras and conventional laparoscopy (cl) seem equally effective in terms oncological control. however, ras possibly provides further advantages e.g. d vision or the endowrist function, which have the potential to maximize the precision of surgery and thus has benefits for functional outcomes such as sexual function as well continence. therefore, the aim of this systematic review and meta-analysis was to compare functional outcomes of cl and ras for rectal cancer. materials and methods: this review was done according to the prisma and amstar guidelines andregistered with prosper-o(crd ). the search was planned with the pico criteria and conducted on medline (via pubmed), web of science and central. two independent reviewers first screened titles and abstracts and then eligible full-texts. inclusion criteria were original studies, comparative studies for cl vs. ras for rectal cancer as well as reporting of functional outcomes. quality assessment was done with the newcastle-ottawa-scale for non-randomized studies and the cochrane tool to assess risk of bias for randomized trials. results: the search retrieved hits, of which studies with patients met inclusion criteria. preliminary results yielded a lower rate of urinary retention for ras (odds ratio (or)[ %-confidence interval (ci)] . [ . , . ] ) while there were no differences for ileus (or[ci]: . [ . , . ] ). erectile function (iief) showed no differences after (mean difference (md)[ci] . [- . , . ] , (md[ci] . [- . , . ] ) and months (md[ci] . [- . , . ] ). in terms of urinary problems (ipss) there were no differences postoperative (md[ci] - . [- . , . ]) and month postoperative md[ci] - . [- . , . ] ), but advantages for the cl group after months md[ci] - . [- . , - . ] ). discussion: ras and cl seem to provide similar functional outcomes after rectal cancer surgery. however, the results need to be interpreted carefully as none of the studies had any functional outcome defined as primary endpoint. future studies should evaluate both surgical approaches in terms of functional outcomes and should be appropriately powered. methods: from april to november , laparoscopic right colectomy with intracorporeal anastomosis were performed in our surgical department. all patients in both groups were perioperatively managed using an eras pathway. seventy-two patients had the enterotomy closed with a single layer running suture of filbloc tm (assut europe). these patients were matched with patients who underwent intracorporeal right colectomy with enterotomy closed with a 'hybrid' double layer technique (first layer interrupted stitches in maxon tm - (covidien), second layer using a running suture in pds tm .intraoperative variables, anastomotic leak rate, morbidity and mortality rates were analyzed. results: the two groups were homogeneous with respect to demographics, body mass index (bmi), american surgical association score (asa) as well as for tumor stage. in the barbed group, median operating time was . min vs . min in the hybrid group (p = . ). anastomotic leak occurred in ( . %) patients in the hybrid vs ( . %) patients in the barbed group (p = . ) all patients required a reoperation. intraoperative findings at shows in ( . %) cases in the hybrid group a leak at the enterotomy closure, while an intact staler access was observed in both patients in the barbed group. no difference was observed with respect to non-infectious complications between the two groups (p = . ). patients in the hybrid group experienced a longer hospital stay when compared to the barbed group (p = . ). a re-admission occurred in the hybrid due an intraabdominal collection, while no re-admission was observed in the barbed group. no patient died in the postoperative period. conclusion: our results shows that the use of knotless barbed suture for enterotomy closure after laparoscopic intracorporeal right colectomy is safe, reproducible and associated with shorter operative time. aims: the accurate measurement and staging of rectal cancer, in particular the distal margin of low rectal tumours, is of paramount importance to optimise oncological surgical resection whilst preserving function. it is well recognised that the lower the tumour, the greater the technical challenges, operative time and the possibility of a temporary or permanent stoma. accurate localisation of the tumour is also essential to assist the multi-disciplinary team when considering neo-adjuvant chemoradiotherapy (crtx). the objective was to compare tumour height as reported on magnetic resonance imaging (mri) with endoscopic measurement. methods: a retrospective analysis of rectal tumour heights on pre-operative endoscopy and mri in patients undergoing radical colorectal surgery with curative intent over years from january . rectal tumours were identified as within cm of the anal verge (av). all mri measurements were reported by one of two specialist gastrointestinal radiologists. measurements were taken from the lowermost point of the tumour to the av. endoscopic measurements were as recorded by endoscopists including rectal surgeons, general surgeons, gastroenterologists and a clinical nurse specialist endoscopist. results: records of eighty one patients with histologically confirmed rectal adenocarcinoma were reviewed. median age was years ( to ). twenty three patients had or more endoscopies. on mri the median tumour height from the av was . cm ( . - cm) . on endoscopy the median tumour height was cm ( - cm) . on comparing endoscopy with mri, the median difference was cm ( - cm) . for over a third of patients ( %) tumours were lower on mri than endoscopy, median difference . cm ( . - cm) . only rectal surgeons documented tumour height in relation to the rectal folds. the majority of the repeat endoscopies were performed by surgeons to locate tumours more accurately pre-surgery. on no occasion was it documented whether the tumour had been measured during insertion or withdrawal of the endoscope. conclusions: precise localisation of rectal tumours is imperative to plan complex surgery and give informed counsel to patients. this study demonstrates the urgent need for a standardised protocol for all endoscopists to use while recording the distal extent of rectal tumours. objectives: the aim of the present rct was to compare the incidence of genitourinary (gu) dysfunction after elective laparoscopic low anterior rectal resection and total mesorectal excision (lar ? tme) with high or low ligation (ll) of the inferior mesenteric artery (ima). secondary aims included the incidence of anastomotic leakage and oncological outcomes. background: the criterion standard surgical approach for rectal cancer is lar ? tme. the level of artery ligation remains an issue related to functional outcome, anastomotic leak rate, and oncological adequacy. retrospective studies failed to provide strong evidence in favor of one particular vascular approach and the specific impact on gu function is poorly understood. methods: between june and december , patients who underwent elective laparoscopic lar ? tme in italian nonacademic hospitals were randomized to high ligation (hl) or ll of ima after meeting the inclusion criteria. gu function was evaluated using a standardized survey and uroflowmetric examination. the trial was registered under the clinicaltrials.gov identifier nct . results: a total of patients were randomized to hl (n ) or ll (n ). gu function was impaired in both groups after surgery. ll group reported better continence and less obstructive urinary symptoms and improved quality of life at months postoperative. sexual function was better in the ll group compared to hl group at months. urinated volume, maximum urinary flow, and flow time were significantly (p \ . ) in favour of the ll group at and months from surgery. ultrasound measured post void residual volume and average urinary flow were significantly (p \ . ) better in the ll group at months postoperatively. time of flow worsened in both groups at months compared to baseline. there was no difference in anastomotic leak rate ( . % hl vs . % ll). there were no differences in terms of blood loss, surgica l times, postoperative complications, and initial oncological outcomes between groups. conclusions: ll of the ima in lar ? tme results in better gu function preservation without affecting initial oncological outcomes. hl does not seem to increase the anastomotic leak rate. introduction: robotic single-site cholecystectomy (rssc) has been known to have some advantages such as reducing stress of the surgeon compared to single incision laparoscopic cholecystectomy (silc). however, there are few studies comparing the perioperative outcomes of these two operative methods. patient and methods: between march and february , rssc and silc were performed for benign gallbladder disease in our center. propensity score matching was performed to control variables including sex, age, body mass indes (bmi), diagnosis, american society of anesthesiologist (asa) score and cohorts were selected among the silc group through : matching. the perioperative data of these patients were analyzed retrospectively. the diagnosis was classified into acute cholecystitis, chronic cholecystitis, and gallbladder polyp. results: patient demographics between the two groups were evenly matched. total operation time including docking time was slightly longer in rssc group ( . min vs. . min, p \ . ), but real working time except the docking or set-up was shorter in rssc group ( . min vs. . min, p \ . ). conversion to additional robotic arm or additional port was frequent in silc group ( vs. cases, p = . ). intraoperative bile spillage rate ( . % vs. . %, p = . ) and postoperative hospital stay ( . days vs. . days, p = . ) were comparable in both group. conclusion: both surgical procedures performed safely. but the rssc demonstrated the better performance of the operation with shorter working time and the advantage of overcoming unexpected difficulties during the surgery with low conversion rate compared to silc. even though laparoscopic cholecystectomy(lc) is the gold standard procedure for cholelithiasis, patients are still suffering from various causes of pain. one of main causes is high pressure by pneumoperitoneum which makes peritoneal stretching and diaphragmatic irritation. however, there are few well-designed studies for evaluating pneumoperitoneum. therefore, we conducted a study to compare the postoperative pain after lc at serial different pressure methods. a prospective randomised double blind study was done in patients with benign gallbladder disease. they were divided into groups. each patients underwent lc with different pneumoperitoneum method; group a: far-low ( - mmhg), goup b: low ( - mmhg) and group c: standard pressure ( - mmhg). three groups were compared for pain intensity, duration, analgesic requirement and complications. post-operative pain score was significantly least in far-low pressure group as compared to low or standard pressure group during late periods ( , h). but, there were no pain score difference between far-low and low groups during early period ( , , , h) even though scores of standard group were significant higher than those of low group. number of patients requiring rescue analgesic doses and intraoperative complications were not significantly different among groups. this study demonstrates reducing the pressure of pneumoperitoneum results in reduction in intensity of post-operative pain. this study also shows that low pressure technique is safe with comparable rate of intraoperative complications. however, in immediate postoperative period, there is limitaton of pain relief after low pressure surgery. therefore, there may need new alternatives for pain. background and aim: anatomical hepatectomy with the glissonian approach is widely accepted as an important technique to ensure surgical safety and curability of the carcinoma. however, the histomorphological structure of the hepatic connective tissue is not sufficiently understood by surgeons. this study aimed to clarify the hepatic connective tissue structure using modern tissue imaging and analytical techniques. materials and methods: in total stained thin slices were loaded onto the computer and were reconstructed as dimages and analyzed. results: when the liver capsule enters the liver at the hepatic hilum, it becomes a sheath which envelops the portal pedicle. the hepatocytes in a row that constitute the periportal limiting plate at the edge of the hepatic lobule are firmly supported by the framework of the reticular fiber. the hepatic lobule and the portal area are in contact via the periportal space of mall. the framework of the limiting plate plays a role of a capsule of hepatic lobule (proper hepatic capsule) on the side in contact with the portal area. the binding site between the hepatic capsule and proper hepatic capsule (ppbs) is loose binding and is a layer that is easy to apply to surgical procedures. in order to enter between the liver capsule which became the sheath of the portal pedicle and the proper hepatic capsule at the hepatic hilum, the liver capsule must be dissected to reach the surface of the proper hepatic capsule. then, on the one hand, the portal pedicle is firmly gripped and pulled, on the other hand, the hepatic parenchyma covered by the proper hepatic capsule is pushed to expand between the portal pedicle and the liver parenchyma. at this time, the portal area (glisson's sheath) branched from the sheath of the portal pedicle into the gap of the hepatic lobule breaks like a string. with this dissecting plane, dissecting layer can reach to the next branch of the portal pedicle without entering into the portal pedicle or liver parenchyma. conclusion: understanding the connective tissue constituting the liver and conducting surgery turns the laparoscopic systematic hepatectomy into a standardized procedure. background: postoperative pancreatic fistula (popf) is the primary contributor to morbidity after distal pancreatectomy (dp). to date, no techniques used for the transection and closure of the pancreatic stump showed a clear superiority over the others. this study aimed to compare the rate of popf after pancreatic transection conducted with the reinforced stapler (rs) and ultrasonic dissector (ud) following dp. method: consecutive patients underwent dp from to were retrospectively reviewed. we included dps where pancreatic transection was performed by rs or ud and excluded dps extended to the pancreas head. to overcome the absence of randomization, we conducted a propensity matching analysis according to risk factors for popf. results: overall, patients met the inclusion criteria. the rs was employed in patients and ud in cases. after the one-to-one propensity matching, patients were selected from each group. the matched rs and ud cohort have no differences in baselines characteristics except for the mini-invasive approach, that was more common in the ud group ( % vs. %, p = . ). overall, patients ( %) developed a popf, a grade b ( %) and ( %) a grade c. in the rs group the rate of popf was % (n = ) and the ud group % (n = ) with a p \ . . conclusion: the results of this study suggest that the use of rs for pancreatic transection, reduces the risk of postoperative pancreatic fistula. a randomized trial is needed to confirm these preliminary data. aim: this study compares clinical and cost outcomes of robot-assisted single port and open longitudinal pancreaticojejunostomy (rlpj and olpj) for chronic pancreatitis. single incision mis needs more manual skills than conventional multiport operation. the advantage of better operation course is d vision and dedicate instrument. this paper aims to evaluate the feasibility and safety of the robot-assisted single incision with single port platform for chronic pancreatitis. materials and methods: clinical and cost data were retrospectively compared between open and ralpj. we collected patients since july, to september, . the patient was supinely placed in reverse trendelenburg position. the assistant surgeon was located between patient's legs. under general anesthesia a trans-umbilical . cm skin incision was made. a single incision advanced access platform with lagis port, glove portÒ (nelis, s. korea) and gelpoint combined with the da vinci si and xi surgical system (intuitive surgical, sunnyvale, ca, usa) pure or plus one was performed. the three arms, no. , no. , and da vinci scope, were in dwelled through the glove portÒ. pneumoperitoneum of mmhg was established through the port. a rigid -degree up scope was used during operation. results: twenty-one patients underwent lpj: open and ralpj. no robot-assisted cases converted to open were noted. patients undergoing ralpj had less intraoperative blood loss, a shorter surgical length of stay, less postoperative pain and lower medication costs. operation supply cost was higher in the ralpj group. no obvious difference in hospitalization cost was found. conclusions: versus the open approach, ralpj performed for chronic pancreatitis shortens hospitalization, less postoperative pain and reduces medication costs; hospitalization costs are equivalent. a higher operative cost for ralpj is mitigated by a shorter hospitalization and less pain control. robotassisted puestow procedure using single port platform is feasible and safe method. the total procedures by da vinci robotic system are safe and easily performed in highly selected patients. general surgery, hospital universitario infanta sofia, madrid, spain; general surgery, hospìtal quirón la luz, madrid, spain aims: the concomitant presence of abdominal wall midline hernias and diastasis recti is frequent. diastasis recti might be a risk factor not only for having but for recurrence of midline hernias. most open surgical procedures not consider the treatment of both pathologies, nor laparoscopic most spread out approaches. the author presents a novel endoscopic, extraperitoneal and retromuscular hernioplasty technique and its preliminary results. methods: a serie of patients is presented. a ct abdominal wall study is performed preoperatively. they all presented abdominal wall midline hernias in presence of a [ . cm concomitant diastasis recti. there were females and males. a totally endoscopic, extraperitoneal and retromuscular repair was performed, that included a midline anatomic restoration, tension-free hernia gap closure, omphaloplasty and skin treatment, if needed in every case. the tension-free massive-meshed hernioplasty included a bilateral totally endoscopic posterior components separation when needed. no drainages were used. all procedures included a bladder catheterization. results: all patient were dispatched within a period under h. no reoperations were needed in postoperative period. postoperative pain was measured by an eva scale. % of the patients have no pain medication after - h dispatching from hospital. % of the patients have a skin suffusion or hematoma. a male patient presented a temporary abdominal asymmetry due to a unilateral posterior component added to his technique. the mean following-up is to months ( - months) . no recurrence was observed. conclusions: preliminary results demonstrate this new approach to be a safe, feasible and a reproductible procedure. the 'terra' novel technique could provide of a new minimally invasive approach to abdominal wall midline hernias repair in the presence of a diastasis recti. only time and new results can predict the spreading out of this 'third way'. results: this study comprised males and females. mean age was years (range - years) and mean body mass index was . gh and mh were found intraoperatively in and cases respectively. mean operative time for all hernias (gh/mh) was min (range - min); min for gh (range - min); and min for mh (range - min). in . % of cases, hernia operative measurement was larger than preoperative size, especially in cases of incisional hernias ( . %). in . % of cases, laparoscopy found additional abdominal wall defects previously undetected by physical examination and by us-and/or ct-scan. a composite mesh and a non-composite mesh (up to cm in size) were used in . % and . % of cases respectively. the ethicon securestrap?? absorbable fixation device straps for sm fixation were employed in . % of cases. mean length of hospital stay was . days. mean follow-up time was months (range - months). in our study, there was one early (\ days) postoperative seroma ( . %), plus one late, small ( cm) symptomless recurrence, but neither needed reoperation. conclusion: the sutureless sm technique facilitates intra-abdominal introduction, as well as the handling and fixation of large/very large meshes. this new approach is safe and fast, even in cases of gh/mh repair. aims: any ventral hernia (vh) combined with rectus muscle separation (rms) must be repaired along with repairing the rms, otherwise there is a high risk for hernia recurrence. open rms repair is vast and traumatic surgery and laparoscopy is not effective. at a new era of repairing abdominal wall hernia by assisted endoscopy started with wolfgang reinhold's milos procedure. these procedures are somewhat complexed and real reconstruction of the linea alba (la) was limited, which done better by ferdinand koeckerling's elar technique. we perfected the elar technique to be fully endoscopic with wide mesh fusing to the muscles immediately by fibrin glue: extended endoscopic hernia & linea alba reconstruction glue (eehlarglue), achieving a low traumatic mis for vh and rms with excellent surgical and cosmetic results. methods: our eehlarglue is a totally endoscopic based technique used since . penetrating with optiview trocar and co pressure to the anterior rectus sheet (ars) level is followed by an extensive endoscopic dissection of the sub-cutaneous fat tissue from the ars. three trocars are inserted at the supra-pubic line enabling the dissection up to the xiphoid and costal margins laterally. any hernia sac is dissected, and the content reduced back to the abdominal cavity. relaxing incisions of the ars are performed longitudinally in the lateral aspect. the la is reconstructed by running two layers of non-absorbable sutures from xiphoid to pubis. a light mesh x cm is applied over the repair and the mesh is fused immediately to the muscles by fibrin glue. results: patients underwent the eehlarglue with follow up of months. all had significant rms of - - cm combined with primary or recurrent vh. recovery was smooth with - days of simple analgesics and return to regular activity within - days. no one had recurrent vh, but two males had limited rms and two early cases seroma formation. conclusions: our eehlarglue enables endoscopic vh repair and la reconstruction with extrastrength received by immediate mesh fusion to muscles with fibrin glue. thus, achieving low traumatic mis, easy recovering and very effective results-a perfect solution for patients with vh combined with rms. results: twelve blinded prospective rcts were used. when compared to tep repair, tapp repair has comparable seroma formation rates (chi = . ; (p = . ); ci - . , . ; i = %) and post-op pain at h (chi = . ; (p = . ); ci - . , . ; i = %). however, tep repair is associated with a significantly shorter operative time (chi = . ; (p = . );ci . , . ; i = %), post-op pain at hour (chi = . ; (p = . ); . , . ; i = %) and shorter hospital stay (chi = . ; (p = . ); ci . , . ; i = %). conclusion: tep is significantly better than tapp repair with regards to operative time, post-op pain at h and hospital stay. there is no significant difference with regards to post-op pain at h and seroma formation. background: primary hyperhidrosis (ph) is a neurological condition characterized by excessive sweating most often of the face, palms or axillae . palmar hyperhidrosis is treated through sympathetic chain clipping or transection .we aiming to compare the efficacy and results obtained with both techniques. patients and methods: sixty four patients underwent of sympathetic procedures from march to february . the patients were categorized into two groups: right sided transection sympathectomy and left sided clipping . patients were evaluated to compare the rates of success, satisfaction, compensatory sweating and recurrence either with transection or clipping of the t andt ganglion .mean follow up was ? _ months. results: sixty four patients males and females undergoing electro-coagulation sympathectomy on the right side and clipping on the left side. with mean age was years (range to years). all patients had balanced demographic data . no statistical difference between the two groups according rate of success. compensatory sweating was observed in patients ( . %) overall with cases of severe unsatisfied compensatory sweating. recurrence was reported in one case with transection and cases in clipping. satisfaction was occurred in cases in transection group and cases in clipping group .pnumothorax was occurred in cases in transection group compared to one case in clipping. no gustatory sweating and over dryness were reported in both groups. conclusion: both thoracoscopic sympathetic transection and clipping of t t ganglion are safe and effective procedure in palmar hyperhidosis treatment. with no differences regarding recurrence rate,satisfaction and incidence compensatory sweating. keywords: thoracoscopic sympathectomy,palmar hyperhidrosis, clipping, compensatory hyperhidrosis. introduction: primary ventral hernias and ventral incisional hernias pose a challenge for surgeons throughout the ages. even though minimally invasive surgery and hernia repair have evolved rapidly, there is no standardized method that adequately decreases postoperative complications. hybrid hernia repair is a surgical repair, which has not been adopted widely. it combines both a laparoscopic and open component allowing sac excision, primary defect repair as well as laparoscopic mesh insertion. aims: to evaluate the short-term and long-term outcomes of hernia recurrence for patients undergoing hybrid ventral repair (hvr) for the treatment of primary and incisional ventral hernias. methods: between october- and june- , hybrid vhr was performed in -patients at st mary's hospital, imperial college london. the medical records of these patients were reviewed retrospectively for demographics, comorbidities, prior surgeries, body mass index (bmi), hernial defects, hybrid technique used; mesh selection, operative time, complications and recurrences over a -year follow-up. results: twenty-four patients who underwent hybrid vhr were included with surgery performed by two surgeons. the mean age is -years with a mean bmi of . kg/m . % had incisional hernias and % had primary hernias. the number of hernia defects ranged from to , with the average mesh size used was x cm. extensive adhesionolysis was performed in % of patients. -day postoperative complications; patients developed post-operative seroma, paralytic ileus in , pain control in and urinary retention in patient. there were no conversions to open procedures. the mean length of hospital stay was -days. none of the patients developed chronic pain and only one recurrence over the -year follow-up period. conclusions: the hybrid technique for vhr is safe and feasible, and has important benefits over an open or purely laparoscopic approach, including a low rate of seroma formation, chronic pain and fiveyear hernia recurrence. future investigation may include randomized controlled trials, to fully evaluate the benefits of hybrid vhr, with careful assessment of patient-centred end-points including quality of life and postoperative pain. surgery, medical faculty-university of tetove, tetove, macedonia; general medicine, medical faculty-university of tetove, tetove, macedonia; anestesiology, medical faculty-university of tetove, tetove, macedonia; surgery, clinical hospital-tetove, tetove, macedonia laparoscopic cholecystectomy is widely used operative technique and it's characterized with less postoperative hospitalization and side effects. duration of the hospitalization after laparoscopic surgery depends on several factors of which pain and physical weakness are the most important. dexamethasone is well known; not only for its anti inflammatory effects but at the same time for analgesic and antiemetic effects, although the mechanism of this effects are not clarified yet. objectives: the aim of our study is the evaluation of analgesic effect of dexamethasone on reducing postoperative pain after laparoscopic surgery. patients and methods: in this study, patients aged - years old undergoing laparoscopic surgery, were classified into two groups, patients in each group. the first group were treated with a intravenous injection of mg dexamethasone preoperatively and another dose the next day after operation. the second group received a intravenous injection of normal saline. we evaluated the dose of consumed analgesics and antiemetic's drug during the first h in both groups. results: according to our experience results the total dose of tramadol in a postoperative period in dexamethasone receiving group was smaller than in normal saline group. measure of postoperative pain was assessed using the paper-based vas scale. our result shows that the intensity of post operative pain in a period during first h, after surgery in a group of patients treated with dexamethasone was lower compared with the group of patients treated with normal saline. nausea and vomiting during the first h was significantly lower in the dexamethasone group than in the normal saline group. surgery, hospital quiron sagrado corazon, sevilla, spain; surgery, hospital virgen macarena, sevilla, spain; surgery, hospital virgen del rocio sevilla, sevilla, spain aims: closing the defect (cd) during laparoscopic ventral hernia repair (lvhr) could be related to a reduction of seroma formation or bulging (hernia mesh) compared to conventional lvhr. but tension of the midline may contribute for some authors to a higher incidence of pain, recurrence in medium size defects and suggest to perform a component separation (cs) for restoring the midline in medium-large defects.we have developed a new technique for restoring the midline in medium ventral hernias (lira technique) and weanalyzed our results in terms of pain and recurrence compared to our conventional cd series (ccd). methods: we conducted a prospective controlled study of lvhr with ccd from january to december and a prospective controlled study performing lira technique from january to january . we analyzed and compared both techniques in medium size defects ( - cms) in terms of postoperative pain ( , days, , months and year) using a visual analogue scale (vas), bulging (return to prior distance among rectus muscles with the mesh in the sac in ct that didn't need surgical treatment)and recurrence (by physical examination and tomography). results: ccd was performed in patients (mean age was . ± . years old and mean bmi was . ± . kg/m ) and lira technique in patients (mean age was . ± . years old and mean bmi was . ± . kg/m ). the mean average follow-up in both series was year. mean average vas in ccd was . ± . ( day), . ± . ( days) . ± . ( month) . ± . ( months ) and at year. in lira series vas was . ± ( h) . ± . ( days), . ± . ( month), ( months) and ( year) . there are cases of bulging in ccd series and recurrence. bulging and recurrence were absent in lira series. conclusions: lira technique might be a safe procedure in medium size defects for restoring the midline in lvhr, and could be related to a lower pain rate compared to ccd with no recurrence or bulging. surg endosc ( ) :s -s background: the desire of pediatric surgeon to reduce incision related morbidity and pain while achieving good cosmetic results has recently led to the introduction of single incision pediatric endo-surgery [sipes] and needlescopic surgery. intracorporeal suturing and knot tying during sipes remains challenging. the aim of this study is to introduce a novel and simple technique for intracorporeal suturing of the pediatric inguinal hernia after needlescopic disconnection of hernia sac using just needles rather than laparoscopic instruments. it is an imitation of the principles of sewing machine. methods: the first author discussed the idea of the technique with the co-authors and a demonstration was done on a silicon pad before application of the technique on children with congenital inguinal hernia [cih] for peritoneum closure after needlescopic disconnection of the hernia sac. the main outcome measurements were; feasibility of the technique, knot quality, suture placement accuracy, performance and suturing time and recurrence rate. results: the sutures were snugly applied to the ridges of silicon pad with good approximation and the knot was firmly tightened in all experiments. after applying and mastering the technique on a silicon pad, we shifted to use it on children with hernia defect. all operations were completed by the needlescopic technique without the need for insertion of any laparoscopic instruments. the time required for suturing of the peritoneum around internal inguinal ring [iir] and knot tying, decreased considerably from min s in the first operation to less than min after the fifth operation and stabilized at approximately minute s. no major intraoperative complication and no recurrence. the primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups. results: a total of patients were enrolled ( of them underwent tapp and olr). drop out occurred in cases ( of tapp and of olr group). patient characteristics were statistically similar between the groups. tapp procedure had less early post-operative pain (p = . ), a shorter length of stay (p = . ) and less postoperative complications (p = . ) when compared with the olr approach. a slightly higher recurrence rate in the tapp group was found. additionally, there is a trend towards a higher postoperative quality of life and less chronic pain in the tapp group. conclusions: tapp procedure for bilateral inguinal hernia effectively reduces early postoperative pain, hospital stay and postoperative complications. cannizzaro hospital, catania, italy aim: the purpose of this study was to evaluate the long-term results in terms of safety and efficacy of a new technique to repair incisional ventral hernias with a self-gripping mesh, after a mean follow-up period of months. methods: a retrospective, single-centre study was performed from june to june . all patients undergoing elective incisional ventral hernia repair were included. hernias were diagnosed based on clinical examination at the outpatient clinic. in case of doubtful diagnosis, ct-scan was used to confirm the diagnosis. the component separation technique and, when needed, tar were performed. the self-gripping mesh was placed in sublay position (overlap cm) with the self-gripping surface face down. in all cases drainage tubes were placed in retromuscular and supraaponeurotic position. the following characteristics were collected: age, sex, body mass index (bmi), smoking, comorbidities, number of previous surgical operations, defect size (ehs classification), mesh size, postoperative complications, duration of follow-up. all patients were interviewed by telephone every six months. when patients complained recurrence or other symptoms, visits were organized and when there was the doubt of recurrence a ct-scan was performed. results: a total of patients were included in this study, males, mean age was years. % of patients had bmi [ , smokers and diabetics were respectively % and %. the mean defect size was cm . component separation technique was associated with tar in patients. in cases the size of mesh was cm, while in patients the size of mesh was cm and in cases this was cm. in the other patients the mesh sizes were tailored to defect dimensions. subcutaneous seromas occurred in patients, they were treated conservatively in cases and with percutaneous punction in cases. long-term follow-up demonstrated recurrences in one case, while in another one ct-scan revealed a bulging. no cases of mesh infection, pain or sensation of mesh. conclusions: this study with a mean follow-up period of months demonstrated that the use of self-gripping mesh in sublay position is safe and effective to treat incisional ventral hernias. aim: morgagni hernias present technical challenges. the laparoscopic approach was described at first in , however, as they are uncommon in adult life and, little data exist on the optimal method of surgical management. this study purpose was to analyse a method for laparoscopic repair of morgagni giant hernias using laparoscopic primary closure. methods: this case series describes a method of laparoscopic morgagni hernia repair using primary closure. in all patients a laparoscopic transabdominal approach was used. the content of the hernia was reduced into the abdomen and the diaphragmatic defect was closed with a running laparoscopic suture using a self-fixating suture. clips were placed at the edges of the suture to secure the pledged sutures to both the anterior and posterior fascia. demographic data as age, gender and bmi were collected. operative data (operative time, rate of conversion, blood loss) and post-operative data (short and long term complications, length of hospital stay, need of readmission and reoperation) were recorded. results: retrospectively collected data about patients were analysed. there were ( . %) male and ( . %) females. the median bmi was . ± . kg/m . median operative time was ± min. there were no intraoperative complications nor conversion to open surgery. patients began a fluid diet on the first post-operative day and were discharged after a median hospital stay of ± . days. in a median follow up of months we did not observe any recurrences. conclusions: transabdominal laparoscopic approach with primary closure of the diaphragmatic defect is a viable approach for repair of morgagni hernia. in our experience, the use of laparoscopic transabdominal suture fixed to the fascia allowed the closure of the defect laparoscopically with minimal tension on the repairs. can we predict the success of the laparoscopic approach in the adhesive small bowel obstruction? c. tellez marques, e. sebastian valverde, e. membrilla fernandez, l. grande posa, i. poves prim general surgery, parc de salut mar-hospital del mar, barcelona, spain aims: the laparoscopic approach in the acute adhesive small bowel obstruction and internal hernias (asbo) has shown superior to laparotomy in terms of morbidity and hospital stay. especially, in patients who present simple adhesions or internal hernias. according to this, the aim of the study is to determine those preoperative factors associated with simple adhesions and internal hernias, and consequently, improve the success of the laparoscopic approach in asbo methods: a retrospective study of patients who underwent urgent surgery for asbo was conducted from january to may . we compare preoperative variables between single adhesions and internal hernias vs complex adhesions. a p value \ . was considered statistically significant. results: we analysed patients who underwent surgery for asbo, ( %) by laparoscopy and ( %) by laparotomy. conversion rate in laparoscopy was . %. . % of patients presented a single adhesion or internal hernia; and . % were considered complex adhesions. sex and age did not correlate with the type of adhesions. previous surgery (p \ . ), number of previous surgeries (p \ . ), asa (p \ . ) and previous abdominal wall mesh (p = . ) were significantly associated with complex adhesions. laparoscopy as the only surgical history was significantly associated with simple adhesions (p = . ). only appendectomy (p = . ) or supramesocolic (p = . ) previous surgeries tended to present single adhesions but it did not reach statistical significance. the need for intestinal resection was not related to the type of adhesions (p = . ). there was a significant correlation between the findings in the ct (computed tomography) and the type of adhesion found (p = . ). signs of ischaemia on ct were related to the need for intestinal resection (p \ . ). in the multivariate analysis, the number of previous surgeries, asa and ct scan findings were identified as independent factors related to the type of adhesion. conclusions: according to our study, a lower number of previous surgeries, asa i-ii and internal hernia in the ct scan are associated with single adhesions and internal hernias. patient selection is a key factor for the success of laparoscopic approach in asbo. aims: there aims of this study were: (i) to compare england with the united states in the utilisation of minimal access surgery (mas) and in-hospital mortality from four common abdominal surgical emergencies (appendicitis, incarcerated or strangulated abdominal hernia, small or large bowel perforation and peptic ulcer perforation). (ii) within england to evaluate the influence of mas upon in-hospital and long-term mortality. methods: between and , the rate of mas and in-hospital mortality for four abdominal surgical emergencies were compared between the united states and england. univariate and multivariate analyses were performed to adjust for underlying differences in baseline patient demographics. results: , admissions in england for four abdominal surgical emergencies were compared to an estimated , , admissions in the united states. after adjustment for patient demographics, mas was used less commonly england for three conditions; appendicitis (odds ratio (or) . , % ci . - . ), abdominal hernia (or . , ) and small or large bowel perforation (or . , ). in-hospital mortality in multivariate analysis, was increased in england compared to the united states for three conditions; abdominal hernia (or . , % ci . - . ), small or large bowel perforation (or . , ) and peptic ulcer perforation (or . , % ci . - . ). in england, after adjustment for patient demographics, open surgery was associated with increased in-hospital mortality for three conditions; abdominal hernia (or . , % ci . - . ), small or large bowel perforation (or . , % ci . - . ) and peptic ulcer perforation (or . , . similarly open surgery was associated with increased long-term mortality for three conditions; abdominal hernia (hr . , % ci . - . ) , small or large bowel perforation (hr . , % ci . - . ) and peptic ulcer perforation (hr . , % ci . - . ). conclusions: minimal access surgery was used less commonly and inhospital mortality was increased in england compared to the united states for common abdominal surgical conditions. given the benefits of mas shown in this large study, strategies to enhance adoption of mas in emergency conditions in england need to be optimised and include appropriate patient selection and improved surgeon mas training and experience. surg endosc ( ) :s -s background: in the treatment of inguinal hernias, there is little hard evidence concerning the economic reimbursement in the diagnosis-related-group (drg) era. factors that affect whether a hospital may earn or lose financially depending on open or laparoscopic approach is still underexplored. the aim of this study is to provide a reliable analysis of in-hospital costs and reimbursements in inguinal hernia surgery. methods: this retrospective study analysed the -year experience in inguinal hernia repair in patients undergoing open lichtenstein (ol), laparoscopic totally extraperitoneal unilateral (utep) or bilateral (btep) hernia repair. demographics, results, costs and drg-based reimbursements were recorded and analysed. results: during the study period, patients underwent ol, patients utep and patients btep. the average total cost amounted to eur in ol, eur in utep and eur in btep groups (p \ . *). the hospital reimbursement amounted to eur, eur and eur in the ol, utep and btep groups respectively (p \ . *). finally, the mean hospital earnings were eur, eur and - eur for each patient in ol, utep and btep respectively (p \ . *). conclusions: in-hospital costs were higher in utep and btep as compared to ol. the drg-based reimbursement provided adequate compensation for patients with unilateral inguinal hernia, whereas hospital earnings were profitable in ol group only, and led an overall financial loss in the btep group. surgeons should be conscious that clinical advantages of the laparoscopic approach are not adequately compensated for, from an economic point of view. aims: umbilical hernias are common anatomical defects in swine which become a suitable model for surgical training and research in the field of surgical meshes. the aim of this study was to develop a surgical protocol for a successful laparoscopic implantation of stem cell-coated surgical meshes. methods: large white pigs, weighing - kg and with congenital abdominal hernia were anesthetized for the surgical procedures. non absorbable polypropylene surgical meshes were coated with fibrin glue (fg) (control group) or with fg admixed with porcine bone marrowderived mesenchymal stem cells (fg/bm-mscs). approximation of hernia's borders was performed by intracorporeal suture. the meshes were carefully rolled inside the trocar for laparoscopic implantation. the surgical implantation was performed by laparoscopy using helicoidal staples. laparoscopic inspections and biopsies of the tissue surrounding the mesh were performed at , and days post-implantation. at day , the animals were euthanized and macroscopically evaluated. ultrasonography was used at day , , and to evaluate the size of the hernia. the biopsies were then processed for the histological analysis. results: ultrasonography demonstrated that the mean size of umbilical hernias before mesh implantation was . ± . cm. a decrease in hernia mean size was observed at day and . the laparoscopic procedures allowed a successful mesh implantation in all animals. in most of cases, the implantation site did not show excessive inflammation or tissue adhesions. but one animal showed hernia maintenance. one animal had peritoneal and implant-site infection. foreign body reaction was noted in the histological analysis, although no significant difference was found between the control, and bm-msc group. conclusions: the anatomical similarities between humans and pigs in umbilical hernias make this animal model useful to: i) improve minimally invasive surgical procedures for hernia treatment; ii) evaluate new surgical meshes, and iii) introducing stem cell therapy to hernia surgical repair. the laparoscopic approach is efficient and safe for the implantation of stem cellcoated meshes. gene and protein expression analysis are required to evaluate the molecular changes between the conventional and the stem cell surgical approach. aims: fluorescence angiography with indocyanine green (icg) is used as a marker in the assessment of tissue perfusion, being more frequently used in colorectal procedures. this technology has shown to be a good technique to reduce complications related to vascular supply to the anastomosis. in esophagogastric procedures blood supply to the gastric pouch, jejunum and esophagus could be evaluated by icg fluorescence imaging. it could be also used in bariatric surgery to evaluated the anastomoses, during gastric bypass, and blood supply to the gastroesophageal junction and the angle of his during sleeve gastrectomy. methods: we have collected data during gastric resection due to adenocarcinoma and bariatric procedures that were performed by the same surgeon, using icg fluorescence to evaluate blood supply. the icg was infused before performing the anastomosis in order to evaluate the need to change the transaction line (tl). we analyzed those cases in which the tl was changed and the number of leaks in those cases that we changed this line. results: all the cases were performed by laparoscopic approach: subtotal gastrectomy (sg), total gastrectomy (tg), gastric sleeve (gs) and gastric bypass. there were no changes regarding the tl before performing the anastomosis in any of the four types of procedures (sg, tg, gs, gb). in the analyzed data there is anastomotic leak in one sg procedure ( . %). conclusions: icg fluorescence angiography could be helpful in assessing blood supply during gastrointestinal anastomosis, although we have not find an influence in the results during bariatric and gastric procedures. however, we do not have the sufficient evidence to determine the value of this technology in this entities, being needed more volume and data to improve the significance of the results. aims: hyperspectral imaging (hsi) combines a spectrometer with a camera to analyze the tissues' optical properties in a broad wavelength range, without the need for a contrast agent. it provides extensive real-time information about tissue physiology, including oxygen saturation (sto ). fluorescence-based enhanced reality (fler) is a software solution providing a dynamic, quantitative analysis of the signal evolution of a systemically administered fluorophore, during fluorescence angiography (fa) . the aim of this study was to compare the performance of hsi and fler to assess bowel perfusion, in a porcine, non-survival model of bowel ischemia. methods: in pigs, an ischemic small bowel segment was created and imaged after hour of ischemia. the imaging modalities were applied sequentially to the same area.hsi was performed first, to acquire the sto spectra, by means of the tivita tm system (diaspective vision, pepelow, germany), which provides a spectral range of - nm and a nm resolution. subsequently, fa was performed using a nir-capable laparoscopic camera (d-light p, karl storz, germany), after intravenous injection of . mg/kg of indocyanine green (icg; infracyanine, serb, paris, france). the fluorescence flow was recorded during s, then the slope of the fluorescence flow was analyzed using a proprietary software to obtain a virtual perfusion cartography. the virtual cartography was overlaid onto real-time images to obtain the enhanced reality effect. ten adjacent regions of interest (rois) were selected from hsi datasets and were superimposed to fler-generated cartographies using a custom plug-in software function, allowing for a quantitative comparison of both imaging modalities. hsi was repeated after icg injection. results: the r correlation coefficient between hsi-sto and the fler slope was . . at control hsi after icg injection, the correlation coefficient dropped significantly (r . ). the interference of icg on hsi imaging was clearly identified in the spectral curves. conclusion: sto given by hsi provided results comparable to those obtained with fler in our bowel ischemia model, without the need to inject a contrast agent. icg interferes with hsi datasets, disrupting sto values. surgical treatment is one of the most effective options for treatment of giant hiatal hernia. laparoscopic approach became is a 'gold standard' over the time demonstrating all advantages of minimally invasive techniques over the open procedures. however the utility of robotic operations still remains controversial. aim of the study: evaluate the initial experience of robotic fundoplication in compare to laparoscopic procedures. materials and methods: since the january till the december of thirty operations were operated on. mean age was . ( - ), among them ( %) were female and ( %) were males. mean bmi was . ( . - . ) . laparoscopic procedures were performed in patients ( st group), robotic procedures with davinci system were performed in patients of the second group. nissen fundoplication modified was performed in patients, toupet fundoplication was used for patients. results: the median operative time in laparoscopic group was min, in robotic group- , min. there were no statistical differences between two groups (p = . ). blood loss was minimal in both groups. mean postoperative hospital stay was . days ( - days) in the st group and , days ( - days) in the second. there were no statistical differences between two groups (p = . ). postoperative course was uneventful in all patients of both groups. surgical stress response is associated with systemic inflammatory syndrome, sepsis, multiorgan dysfunction syndrome. robotic assisted surgery has been introduced to overcome the limitations of conventional laparoscopy. this technique has potential advantages over laparoscopy, such as increased dexterity, three-dimensional view, and a magnified view of the operative field. these advantages could result in limited intra-abdominal trauma and hence in attenuated surgical stress response over conventional laparoscopy. aims: this study aimed to synthesize data on the effect of robot assisted surgery on surgical stress response. methods: electronic databases were searched with the search terms 'surgical stress', 'stress response', 'oxidative stress', 'robotic assisted surgery', 'c-reactive protein', 'interleukin ', 'interleukin ','cortisol',;'oxidative stress markers', 'antioxidants', 'antioxidant status', 'mda', 'glutathione', 'cortisol', 'acute phase response' up to and including march . results: one hundred forty studies were identified and their title and abstract were reviewed. one randomized controlled trial, six non randomized comparative studies, one experimental study and one case report met inclusion criteria. data were discordant. one prospective trial concluded that cortisol and il- were lower in laparoscopic assisted distal gastrectomy compared with robot assisted distal gastrectomy in another study comparing robotic assisted laparoscopic radical prostatectomy with open radical prostatectomy based on plasma measurements of il- , il- a and c-reactive protein, it was demonstrated that robotic assisted laparoscopic radical prostatectomy induces lower tissue trauma than open radical prostatectomy. in another study, it was reported reduced expression of genes associated with surgical stress response in patients treated with robotically assisted radical prostatectomy compared with patients treated with open prostatectomy. the case report concerned a case of polymyalgia rheumatic after robotic assisted laparoscopic prostatectomy. the experimental trial demonstrated that cortisol and substance p were significantly higher with open thoracic approach versus robot assisted thoracoscopic oesophageal surgery. conclusion: further research is needed to elucidate the effect of robotic surgery on surgical stress, based on a well standardized protocol for the measurement of surgical stress response. purpose: tissue compression is essential to prepare the tissue for proper staple formation. this study evaluates the risk factors of compression injury on the circular stapling line in vitro. methods: to reproduce the artificial bowel wall, a collagen plate was prepared by mixing collagen extracted from porcine with glycerin. artificial collagen plates with mm and mm in the thickness were made for dry and healthy condition and immersed plates in the tap water for min to make wet and edematous condition. circular stapler (cdh a, ethicon, usa) was applied in the collagen plates (dry and wet condition) and optimal compressions. compression line was evaluated for compression injury score. risk factors for excessive compressions and unacceptable injury were analyzed. results: in the dry condition, optimal compression didn't cause unacceptable injury. in the wet condition, excessive compressions were occurred in . % with optimal approximation. unacceptable injury was significantly different in proper and excessive compression cases as . % and . %, respectively. on the univariate analysis, thickness ( mm), wet condition, proximal side, maximal compression, and excessive compression were associated with unacceptable injury. on the multivariate analysis using logistic regression model, excessive compression was significant independent factor to cause tissue injury (p \ . ) and this significance was also proved in the optimal compression group (p = . ). background: minimal invasive appendectomy gained much popularity due to its better cosmoses, early recovery and less wound site infections. single incision laparoscopic appendectomy (sila) has many disadvantages such as, long operative time, bad ergonomics, surgical site infections, high conversion rate and port site hernia. needlescopic appendectomy (na) using mediflexÒ facial closure needle expected to be more superior over sila. here in we compare our results of needlescopic appendectomy with single-incision one. material and methods: one hundred and twenty patients with acute non complicated appendicitis were randomly assigned to na and sila children for each group during the period between january to october . the main outcome measurements included, demographics, operative time, intraoperative complication, conversion rate, post-operative hospital stay, surgical site infection, port site hernia and cosmetic results. results: a total of children underwent appendectomy. there were children who underwent na and children who underwent sila. there were no difference in age ( . vs . years, p = . ), weight ( . vs . kg, p = . ) and hospital stay ( . vs . days, p = . ) between the two groups. there were no intraoperative complication during the two surgical approaches. operative time for na group is significantly shorter than single incision group ( . vs . min, p = . ). no single case of conversion in na group and cases needed conversion in sila group. seven cases of sila showed surgical site infection. cases of sila group presented with port site hernia. the na group was superior as regard ergonomics. the two groups showed equal excellent cosmetic results. conclusion: needles scopic appendectomy and sila are comparable as regard cosmetic results and hospital stay. na proved to be safe, applicable, repetitive and superior over sila as regard better ergonomics, less operative time, absence of surgical site infection and port site hernia. aims: to objectively analyze the surgical performance and surgeon's ergonomics in the use of a novel flexible laparoscopic instrument during intracorporeal suture, and compare it with the use of a conventional laparoscopic needle holder. methods: three experienced laparoscopic surgeons performed five laparoscopic sutures on an organic tissue using the novel flexible instrument (flexdexÒ) and five sutures using a conventional needle holder with axial handle. the new device is based on a mechanical design with no electrical components, which transfers the surgeon's hand, wrist, and arm movements to the instrument tip in an intuitive manner. the use of the instruments was organized in a random fashion. prior to the study, participants conducted a -minute training session with the new flexible instrument. execution time and quality of the suture were assessed for each repetition. besides, flexion and radioulnar deviation of the wrist were recorded using an electrogoniometer (biopac systems, inc.) attached to the surgeon's hand and forearm. the intensity of the forearm's muscle activation was also analyzed by means of a myo armband (thalmic labs). results: surgeons required more time to perform the intracorporeal suture using the novel laparoscopic instrument ( . ± . s vs. . ± . s; p \ . ), but the quality of the suture was similar with both instruments. the wrist flexion ( . ± . °vs . ± . °; p \ . ) and wrist ulnar deviation ( . ± . °vs . ± . °; p \ . ) were significantly lower when using the flexible instrument. during the suturing tasks, the use of flexdexÒ instrument led to a higher muscular activation of the flexor ( . ± . vs . ± . rms; p \ . ) and extensor ( . ± . vs . ± . rms; p \ . ) muscle groups of the forearm. conclusions: the presented novel instrument allows surgeons to perform robotic-like laparoscopic suturing. we believe that with a longer training period surgeons could potentially reduce surgical times with this device. the preliminary results of this study suggest that the use of this new instrument provides a quality of the suture similar to that obtained with a conventional laparoscopic needle holder and an ergonomically more adequate wrist posture. aims: the intraoperative real-time evaluation of tissue perfusion is one key element for successful visceral surgery. traditionally, tissue evaluation is performed visually by surgeons. newer devices for objective quantification have in majority been based on the application of the fluorescent dye indocyanin green (icg). a novel method derived from geographic research is hyperspectral imaging (hsi). the aim of this study was the evaluation of hsi as a promising method for the evaluation of tissue perfusion and its implementation in the evaluation of the gastric conduit during esophagectomy in a porcine model. methods: the hsi camera records a dimensional data cube from a dimensional surgical situs obtaining wavelengths between and nm. the absorption at different wavelengths is tissue-specific and influenced by the amount of oxygenated haemoglobin and other pigments. a software calculates different indices in real-time including oxygen saturation. a porcine model (n = ) is used for esophagectomy with gastric conduit formation. ischemia is induced artificially by magnets simulating staplers. different shapes of the gastric conduit and anastomosis formation are evaluated for perfusion metrics in order to obtain recommendations for the optimal formation of esophagogastrostomy. conclusion: hsi is a promising method for intraoperative evaluation of tissue perfusion that does not require application or injection of any agents. the preliminary results in this study showed that the gastric conduit receives its main blood supply from the gastroepiploic arteries and not via the mucosa. further results from the current evaluations enable formation of an optimized gastric tube and esophagogastrostomy in esophagectomy. surg endosc ( ) pediatric surgery, al azhar university, giza, egypt; pediatric surgery, beni suef university, beni suef, egypt background: varicocele is one of the most common causes of infertility. many surgical interventions are used for varicocele ligation including open and conventional laparoscopic multiport or single incision techniques. the aim of the study is to present a new needlescopic lymphatic sparing varicocele ligation using mediflexÒ facial closure needle and gauge vascular access cannula. material and methods: twenty-two male children with bilateral varicocele of grade ii-iii. all children were counseled by clinical examination, doppler ultrasonography, abdominal ultrasonography, and routine laboratory investigations. testicular lymphatics were delineated by subcutaneous injection of / cm methylene blue in anterior wall of the scrotum min prior to surgery. the testicular vessels (both vein and artery) were ligated one cm above the deep inguinal ring using two mediflex needles with preservation of lympatics. the main outcome measurements included; operative time, hospitalization, testicular atrophy, hydrocele formation, recurrence of varicocele and intra or postoperative complication. results: a total of twenty-two male children with grade ii-iii varicocele subjected to needlescopic lymphatic sparing technique. twenty one were bilateral. background and aims: even if the clinical outcomes of robotic rectal resections are under investigation, the related robotic costs have not yet been well addressed, and the differences between the robotic rectal resection costs and the laparoscopic approach are still not well known. we have therefore performed a prospective comparative study of robotic rectal resections (rrr) and laparoscopic rectal resections (lrr) performed at our centre with the aim to evaluate the cost-effective outcomes of robotic versus laparoscopic surgery. study design: this is an observational, comparative prospective non-randomized study which includes patients that underwent laparoscopic and robotic rectal resection reaching a minimum of months of follow up from february to march , at the sanchinarro university hospital, madrid. an independent company performed the financial analysis and fixed costs were excluded. outcome parameters included surgical and post-operative costs, quality adjusted life years (qaly), and incremental cost per qaly gained or the incremental cost effectiveness ratio (icer). the primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups. results: a total of rrr and lrr were included. the mean operative time was significantly lower in the lrr approach ( versus min; p = . ). the main pre-operative data, overall morbidity, hospital stay and oncological outcomes were similar in both groups, except for the readmission rate (rrr: . %, lrr: . %;p = . ).the mean operative costs were higher for rrr ( . versus . €; p = . ); however, the mean overall costs were similar ( . € for rrr and . € for the llr; p = . ). mean qalys at year for rrr group ( . ) was higher than that associated with lrr ( . ) (p = . ). at a willingness-to-pay threshold of , € and , €, there was a . % and . % probability that rrr group was cost-effective relative to lrr approach. conclusion: this study provides data of cost-effectiveness differences between rrr and lrr approach showing a benefit for the rrr aim: the efforts were aimed to the introduction of novel surgical technologies to overcome the intrinsic anatomical and technical constraints of rectal surgery. this was the case of the introduction into the clinical practice of laparoscopy and later on of robotic surgery for rectal surgery. however, whether robotic surgery is actually superior to laparoscopy is still debated. the aim of this study was to compare d laparoscopy and robotic surgery for rectal cancer on technical and oncological outcomes. methods: this was a single-center, prospective, randomized controlled trial. all patients more than years of age undergoing elective surgery for rectal cancer situated from to cm from the anal verge were included. patients undergoing abdominal perineal amputation and/or with t and/or m tumours were excluded. patients were randomized before surgery into two arms: arms a ( d laparoscopy) and arm b (robotic), and gave their consensus to the study. demographic data, data regarding the tumour, operative and post-operative data were collected. patients with a follow up shorter than months were excluded as well. results: twenty patients were enrolled in arm a and in arm b in the period time of one year. patients' population of the arms was homogeneous as concerns demographic characteristics and stage of the disease. robot-assisted rectal resection results in comparable operative time ( . vs min; p = . ). the conversion rate was significantly lower for arm b ( vs p = . ). postoperative morbidity was comparable between groups. hospital stay was comparable but time required to resolve post-operative ileus was shorter in arm b ( . vs . days, p = . ). overall survival and disease-free survival were comparable between arms ( . % vs . %, p = . , and . % vs . %, p = . , respectively) conclusions: d laparoscopy and robotic surgery are two viable options for rectal surgery. robotic surgery can add some in terms of post-operative outcomes and ergonomics. aim: currently, robotic surgery for rectal cancer is a surgical operation that is being performed worldwide. we also introduced robotic surgery in . however, after robotic surgery, we observed a rise in creatinine kinase (ck), which is unlikely to happen in other surgeries. we studied the postoperative complications of rectal cancer patients who underwent either robotic surgery or laparoscopy during the same period of time. methods: from january to november , patients underwent surgery using robotassisted rectal resection (da vinci si cases and xi cases) and patients underwent laparoscopic rectal resection. in this study, abdominoperineal resection, intersphincteric resection, and lateral lymph node dissection were excluded. result: the operation time for the robotic surgery group was significantly longer than that for the laparoscopic group ( min vs. min; p \ . ). the ck value of the robotic surgery group on pod was significantly higher than that of the laparoscopic group ( iu/l vs. iu/l; p \ . ). in addition, one case of compartment syndrome was observed in the laparoscopic group. there were no significant differences in age, body mass index, intraoperative bleeding, tumor invasion depth, urination disorder, or postoperative hospital stay. in robotic surgery, it is considered that the increase in ck value is caused by the extended operation time, contact of the patient's cart with the left thigh of the patient, and the extra force applied to the abdominal wall caused by the displacement of the remote center. conclusion: in robotic surgery, it is suggested that the measurement of postoperative ck value is important. therefore, an attempt to shorten the operation time and paying attention to the surgical field are necessary to improve the outcomes. aims: anastomotic leak remains as one of the most important and life threatening post-operative complications in colorectal surgery. this complication has important consequences, both acute and long term, longer hospital stay, re-intervention, and increased morbidity and mortality. among all different circumstances that have been related to this entity, blood supply is an important factor that might have influence. fluorescence with indocyanine-green (icg) is used as a marker in the assessment of tissue perfusion in colorectal surgery which might reduce the numbers of leaks. methods: a multicenter analysis of the experience of centers in spain is collected in order to assess the value of icg in colorectal anastomosis. colorectal procedures were performed using icg to evaluate vascular supply in the anastomosis. icg was infused before performing the anastomosis analyzing the number of cases in which the transection line (tl) was changed. we also analyzed the number of leaks in those cases that we changed this line. results: out of the cases performed, cases were performed by open surgery, by laparoscopy, by single-port and with transanal total mesorectal excision(tatme). the following procedures were performed: right colonic resection(rc), splenic flexure partial resection(sf), left colonic resection(lc), subtotal colectomy(sc), total colectomy(tc), hartman reversal surgery(hr), low anterior resection with partial mesorectal-escision(lar) and ultra low anterior resection with total mesorectal-escision(ular). leak rate(lr) was . % ( . %rc, . %lc, . %sc, . %lar, . %ular). overall lr was . % in colonic surgery and . % in rectal surgery. the tl was changed due to icg in . % of the cases ( . %rc, . %sf, . %lc, % tc, . % lar, . % ular), being . % in colonic resection and . % in rectal resection. the relation between leaks and the cases in which the tl was changed, were % ( . %rc, %lc, . %ular). conclusion: icg fluorescence may play a role in anastomotic tissue perfusion assessment. the lr after colorectal surgery might decrease using icg to detect the proper tl before to perform the anastomosis. however, we do not have the sufficient evidence to determine that the changing transaction line can lead to avoid leaks. surg endosc ( ) aims: to analyse the value of postoperative day crp as an early predictor of safe discharge in robotic rectal cancer surgery. methods: a retrospective analysis was performed, including patients who had undergone robotic total mesorectal excision (tme) in a single centre over a -year period (may -september . patients who had a permanent stoma (abdominperineal resections or hartmann's procedure) were exluded from the study, leaving patients for further analysis. as the los is currently used as a performance tool in assessing outcomes in colorectal surgery (with a cut-off established at days), we compared the crp values in these groups. results: fourty one percent of patients were discharged home within days. they had an earlier peak of crp on postoperative day (pod) (median . , ) . the group of patients that were discharge home after days ( %) had a crp peak on pod (median , ). on pod , the group of patients that went home within days had a lower crp ( - -vs. - -) compared to the group of patients that were discharge after days, p = . ). conclusions: a crp peak on pod in robotic tme can predict an early and safe discharge (los within days). background: purposelateral pelvic lymph node dissection (lpnd) is suggested to treat suspected lymph node metastasis in pelvic side-wall in patients with rectal cancer who underwent preoperative chemoradiotherapy (crt). however, technical difficulties make it possible that lateral pelvic lymph nodes (lpns) are not dissected completely and, thus, remained in the narrow pelvis. near-infrared fluorescence imaging (fi)-guided surgery is expected to help visualization and complete excision of nonvisible lymph nodes during cancer surgery. this study aimed to evaluate the efficacy of fi using indocyamine green (icg) to identify lpns during robotic lpnd. methods: rectal cancer patients who were suspected lpn metastasis and had received preoperative crt were prospectively enrolled. icg in a dose of . mg was injected around tumor preoperatively. all procedures were performed with a totally robotic approach. after completing lpnd, fi was checked again for identifying remained lpns and resecting them completely. results: the lpns were successfully detected in ( . %) of the patients. however, after accounting for eight cases, having finished adjusting icg injection, the lpns were successfully detected in ( . %) of patients. the fi-guided lpnd group (n = ) showed similar mean operative time for unilateral pelvic dissection and complication rate, compared to patients who underwent conventional robotic lpnd (n = ). however, the mean number of unilateral harvested lpns was . in the fi-guided lpnd group, which was greater than the mean of . in the conventional group. lpn metastasis was identified in % of the fi-guided lpnd group, which was higher than that of the conventional group, . %. conclusion: fi-guided lpnd identifies lymph nodes in pelvic side-wall with great reliability. this contributes to increased number of lpns yield compared to conventional robotic lpnd. this technique should be considered to dissect them completely by preventing subsequent missing of nonvisible lpns. aims: to compare the medium-term oncological outcomes of laparoscopic total mesorectal excision (l-tme) vs. robotic total mesorectal excision (r-tme) for rectal cancer. methods: a retrospective analysis was performed including patients who underwent l-tme or r-tme resection between - . patients with disease stage iv at diagnosis or r resection were excluded. patients were initially included, and cases of r-tme were matched based on age, gender, stage and time of follow-up with an equal number of patientswho underwent l-tme. we compared -year disease free survival (dfs) and overall survival (os). in adittion, a multivariate analysis was performed in order to idenfity independent prognostic factors for -year dfs and os. results: pathological outcomes were similar between groups. however, major complications were lower in the robotic group ( . % vs. . %, p = . ), highlighting the anastomotic leakage rate, which was . % in the r-tme vs. . % in the l-tme group (p = . ). overall, the -year dfs rate was % in the laparoscopic group and % in the robotic group (p = . ). the -year os rate was % in the l-tme groups and % in the r-tme group (p = . ). for disease stage iii, -year dfs was significantly higher in the r-tme group. os was also significantly superior in the robotic group for every stage, reaching % in the stage iii. in the multivariate analysis, r-tme was a significant positive prognostic factor for distant metastasis (or . %ci . , . , p = . ) and os (or . %ci . , . , p = . ). conclusions: r-tme for rectal cancer can achieve better oncological outcomes compared to l-tme, especially in stage iii rectal cancers. the robotic approach has demonstrated to be a significant positive prognostic factor for local recurrence and overall survival, due to the better postoperative outcomes. however, a longer follow-up period is needed to confirm the oncologic findings. university hospital for visceral surgery, university of oldenburg, oldenburg, germany; bremen spatial cognition center, university of bremen, bremen, germany aims: in clinical settings, realistic assessment of one's own abilities can enhance performance and promote patient safety, especially in surgical residents, who inevitably have to acquire skills during real surgery. this study thus implemented the global assessment of laparoscopic skills (goals) questionnaire with the aim to explore divergences between resident self-evaluation and specialist's evaluation on laparoscopic performance, as a first step to implement the goals questionnaire as a tool for constructive and objective feedback. methods: between july and october , seven residents from the university hospital for visceral surgery at the pius-hospital oldenburg participated in this study. at the end of every laparoscopic operation where the resident acted as the primary surgeon, the resident and the supervising surgeon independently evaluated the resident's operative performance using the goals questionnaire. the five dimensions evaluated were depth perception, bimanual dexterity, efficiency, tissue handling and autonomy. a cumulative goals-score (with being the highest possible score) was calculated for n = laparoscopic operations. resident's year of training, the level of case difficulty and the type of laparoscopic procedure performed was also analysed. results: residents overestimated their laparoscopic abilities in . % of the operations (goals-scores: residents: median = , mean = . ; specialists: median = , mean = . ; p \ . ). residents in the first three years of surgical training were more likely to overestimate their performance (residents: median = . , mean = . ; specialists: median = , mean = . ; p \ . ) than those with more than three years of surgical experience (residents: median = , mean = . ; specialists: median = , mean = . ; p = . ). goals score differences did not depend on case difficulty and laparoscopic procedure. conclusions: surgical residents tend to overestimate their intraoperative laparoscopic performance when compared to specialist evaluation. overestimation was found to depend on one's own laparoscopic experience and seem to disappear with gained expertise. these results signify the importance of individually adapted training and the greater need for objective feedback for surgical residents. this approach could in return increase the skill acquisition rate of the resident and in return contribute towards enhancing patient safety. introduction: the delivery of safe surgical care is dependent of various, complex and interrelated factors. substantial data exist regarding the impact of training in human factor skills on surgical outcomes. however, except for the standardized time-out process, the best way to go about improving these skills remains unclear. the aim of this study was to gain more insights in the theatre staff's perception of human factors and their importance on surgical outcome in the operating theatre. methods: the surgical team assessment record (star) questionnaire was used to study the role of human factors, such as communication, situational awareness and organization, contributing to surgical team performance. the self-assessment questionnaire was filled out by the theatre staff, directly after the surgical procedure. conditional logistic regression was used to identify the impact of the role in the operating theatre on the yes versus no answers. results: some questionnaires were completed. the theatre staff rated their team's performance with a median of (iqr . , -point likert scale). the surgical fellows (n = ) rated their personal factors significantly lower compared to the rest of the operating team (median versus , p-value \ . ). the staff surgeon (n = ) indicated significantly more often that there were many distractions ( . %, yes n = ) and noticed aberrations ( . %, yes n = ) during the surgical procedure (pvalue \ . ) when compared to the rest of the operating team. most aberrations reported by the surgeons were related to technical performance. conclusions: human factors play an important role in the surgical environment. situational awareness may be less developed in members of operating teams, compared to the surgeon of that team. further work is needed to elucidate the impact of human factor skills on team performance. a team-based approach to safety interventions is recommended. future studies should determine what type of aberrations and distractions are most relevant and valuable to embark on with team training. dept. of digestive surgery, school of medicine, tokushima university, tokushima, japan; dept. of digestive surgery, tokushima university, tokushima, japan background: the qualitative evaluation for laparoscopic training of medical students was performed using rubric evaluation, and weak points in conjunction with the lack of anatomical knowledge were derived. to conquer these weak points, virtual reality (vr) ? augmented reality (ar) training for understanding of regional anatomy was investigated. materials and methods: one hundred and six students in th grade of tokushima univ. participated basic laparoscopic task training (gummy band ligation, beads transfer, delivery of beads, gauze excision) with training box and sham laparoscopic cholecystectomy with virtual simulator. rubric evaluation, as qualitative evaluation, which includes the evaluation standards for each maneuver were performed before and after basic task training and sham operation. the group which self-evaluation was higher in a rubric evaluation was investigated. the d image of vessels and bile duct obtained from mdct of real patient was projected in reality space with microsoft hololens. training of ar image using hololens was performed for understanding of regional anatomy. after training of regional anatomy with hololens, sham laparoscopic cholecystectomy was performed again, and quality of procedure was evaluated by rubric. anatomical questions were. results: rubric evaluation in basic task training showed no difference between self-evaluation and evaluation by tutor before and after practice. in sham laparoscopic cholecystectomy, several students showed higher score than tutor, especially in part of extension of operation field by elevation of the gall bladder, exposure of triangle of calot, and exposure of cystic duct. after ar training, all students showed high score in questions related regional anatomy during operation. especially, rubric evaluation of students who showed high self-evaluation in sham operation showed same score with tutor. conclusions: as rubric evaluation showed weak points of detailed parts of maneuver, and vr ? ar was useful for understanding details of regional anatomy for laparoscopic training. background: the eaes has recently published an intraoperative adverse event classification to aid reporting of minimally access surgery events. this includes capture of non-consequential errors. we aimed to investigate the clinical impact of these apparent 'near miss' events. methods: case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision randomised controlled trial was utilised (isrctn ). the eaes classification was applied by two blinded assessors to all enacted adverse events identified on video analysis using the observational clinical human reliability analysis technique. the total number of grade (non-consequential) errors were compared with the number and nature of day morbidity events (graded with the clavien-dindo system) and length of stay. results: cases ( h of surgery) contained error events of which ( . %) were classified as eaes grade (median per case, interquartile range - , range - ). there were significantly more inconsequential errors recorded in patients that developed any early morbidity event than those who had an uneventful post-operative recovery (median . (iqr - ) vs. ( - ), p = . ). a stepwise increase in the sum of eaes grade errors is seen for each additional day morbidity event reported ( . vs. vs. vs. , p = . ) and the highest clavien-dindo grade experienced ( vs. vs. vs. . p = . ). positive correlation is observed between the sum of eaes grade a errors and length of post-operative stay (r s = . , p = . ). conclusion: in the context of major laparoscopic surgery, near misses are commonplace and correlate with surgical outcomes. this may represent a novel surrogate assessment method for intraoperative performance. aims: diagnostic laparoscopy (dl) is an under-utilised procedure that can replace non-therapeutic exploratory laparotomies in many contexts. to date, no validated education programme for dl exists. this study seeks to evaluate the feasibility, acceptability and face, content, construct validity of the laplat curriculum (laparoscopic learning for abdominal trauma; a simulationbased curriculum for trauma dl). this is in addition to the development of a novel d-printed bench-top model for abdominal inspection. methods: this prospective and observational pilot study involved novice medical students and junior doctors. surgeons from the uk and international (n = ) were involved in a two stage delphi-process to determine the components of the training course which were used to formulate a final curriculum. in the absence of an adequate model for abdominal inspection, a novel dprinted abdominal inspection model was designed and produced. after an introductory familiarisation session as well as pre-course cognitive lectures, the novices performed tasks on a virtual reality and bench-top simulator with repetitions of each in a half-day session. outcome measures for construct validity were total time to complete task, accuracy, percentage of horizon maintained and economy of movement. face and content validity as well as acceptability was evaluated by a qualitative and quantitative survey. results: face, content and construct validity as well as acceptability was established. face validity was demonstrated in all components of the course (including pre-course cognitive content and technical tasks) in addition to content validity. all also met an acceptability threshold of / on a -point likert scale. one-way anova tests demonstrated construct validity in all tasks (p \ . ) with learning curves in reducing time observed. using a performance improvement metric, one-way anova tests showed similar rates of improvement per participant between most tasks (p [ . ). the course was rated overall mean . / (± . ). conclusion: this pilot study has demonstrated the feasibility, acceptability and face, content and construct validity of the laplat curriculum as well of the novel d-printed abdominal inspection model. randomised controlled trials are needed to establish higher-quality evidence, as part of a wider curriculum with transfer needed to the clinical environment. surgery, regional institute of gastroenterology and hepatology, cluj-napoca, romania; anesthesiology-surgical propedeutics, university of agricultural sciences and veterinary medicine, cluj-napoca, romania; radiology, regional institute of gastroenterology and hepatology, cluj-napoca, romania; urology, training and research center, prof. dr. sergiu duca, cluj-napoca, romania; general surgery, training and research center, prof. dr. sergiu duca, cluj-napoca, romania aims: to evaluate the benefits of systematical use of ex vivoliver model and ct imaging in the planning process for swine laparoscopic liver resections done by residents during training programs. methods: twenty four general surgery residents were equally divided into two groups: first one which performed laparoscopic liver resections without planning stage and the second one which systematically used anatomical data from a swine liver model and interactive ct scans d reconstructions. the planning stage included an interactive tutorial for establishing the strategy for the next resection followed by performing open liver dissection and the same resection on an ex vivoswine model. a total of twelve models were used during this step. afterwards, laparoscopic procedures were performed on sixteen anesthetized domestic pigs, two swine for every team, composed of three residents. both groups were part of a dedicated and continuous training program and used the same 'step by step' protocol for resections. results: the average time for imagistic planning was . min and for open dissection and resection was . min. all teams successfully completed the interventions and followed the standardized protocol without trainers' interventions and with no conversions. the second group obtained better results regarding the time needed for completion and blood loss. also, when the planning stage was applied the resection was more accurate and less functional parenchyma was removed. the 'warming up' by adding the imagistic and anatomical data to the core protocol offer more clarity before laparoscopic liver resections. this also makes an upgrade for our 'step by step' protocol and provides sufficient data to admit this planning stage as mandatory for laparoscopic liver resection on swine during a training program. introduction: submucosal tunnel endoscopic resections (ster) had been increasingly performed for treatment of gastric subepithelial tumors. one of the limitations for ster is the risk of incomplete tumor resection due to close dissection and bridging of tumor capsule. endoscopic full thickness resection (eftr) allowed complete resection of the tumor with margins to prevent recurrence. this study aimed to review the techniques and outcomes of eftr for treatment of gastric subepithelial tumors. method: patients who received endoscopic resection for gastric subepithelial tumors were recruited. the gastric subepithelial tumors were considered eligible for endoscopic resection with size \ mm. all patients received preoperative assessments including eus and ct scan to define the extend of tumors and the proportion of extra and intralumenal components. all the procedures were performed under general anesthesia with co insufflation. eftr started after injection with mucosal incision up to % of tumor circumference, followed by submucosal dissection to identify tumor margin. further dissection was performed using esd devices. after adequate exposure of lateral margins, incision into muscularis propria was performed to achieve full thickness resection. luminal defects were closed by either clips, clip-loop crown method or overstitch suturing. results: from to , patients received eftr for gastric subepithelial tumors. the mean age was . years, and were male. the gist were located at greater curvature ( ), cardia ( ) , lesser curve ( ) and antrum ( ) . the mean size was . mm ( - mm) . most of the eftr were performed in operation theatre while two were done at endoscopy. the mean hospital stay was . days, and mean operative time was min ( - mins). there was no conversion to laparoscopy. closure of luminal defect were performed mostly with clips ( ), followed by overstitch ( ) and clip and loop crown closure ( ) . most patients resumed full diet on day , and all the pathologies confirmed gist tumors with clear resection margins. conclusion: endoscopic full thickness resection is technically feasible and safe procedure for treatment of gastric gist. future research should focus on refining the techniques of eftr and closure of the defect. next generation endoscopic intervention (project engine), osaka university, suita, japan; gastroenterological surgery, osaka university, suita, japan; research & development, -d matrix, ltd., chiyoda-ku, tokyo, japan; research & development, fuso pharmaceutical industries, ltd., cyuou-ku, osaka, japan background: hemostatic peptides have received increased attention. self-assembling peptides (tdms) comprise synthetic amphipathic peptides that immediately react to changes in ph and/or inorganic salts to transform into a gelatinous state. since tdms do not carry a risk of infection, their clinical application as new hemostatic agent is expected to increase. the first generation of these peptides (tdm- ) is currently used as a hemostatic agent in europe. however, tdm- exhibits slow gel-formation and low retention capabilities on tissue surfaces. the second generation (tdm- ) was therefore developed to encourage faster gel-formation and better tissuesealing capabilities, and we subsequently verified its usefulness and increased performance relative to tdm- in preclinical open surgery. aim: the aim of this study was to verify the efficacy of tdm- in terms of its hemostatic effect in endoscopic surgery. materials and methods: evaluation of the hemostatic effect in endoscopic surgery (animal study) was performed using eight female ( kg) pigs in spine position. following systemic heparinization, we established a bleeding model by utilizing flexible endoscopic grasping forceps on the anterior wall of the stomach and duodenum. in the hemostasis method, an endoscope with a distal hood was brought into contact with the bleeding point, and ml tdm- was applied to the wound. after tdm- gelation, the endoscope was removed, and the acute hemostatic effect (after min) was confirmed. histologic evaluation was subsequently performed on resected specimens. results: in the endoscopic bleeding model, of the cases ( . %) showed complete hemostatic effects on the anterior wall of the stomach, whereas on the anterior wall of the duodenum, of cases ( %) showed complete hemostatic effects. moreover, none of the gels were displaced from the anterior walls of the stomach and duodenum, and histologic evaluation confirmed no infiltration of inflammatory cells. the new self-assembling peptide (tdm- ) displayed improved hemostatic effects relative to the previous generation (tdm- ) in endoscopic surgery. tdm- had potential usefulness for upper gastrointestinal bleeding. our future work will assess its usefulness for laparoscopic surgery. objective: indocyanine green (icg) is a dye used in medicine since the mid- s for different applications in ophthalmology, cardiology and hepatobiliary surgery; thanks to its selective hepatic uptake and biliary excretion, it can be used to evaluate hepatic function in patients scheduled for hepatic resection surgery. the aim of this study is to evaluate the efficacy and the feasibility of icg guided surgery in the intra-operative localization of liver tumors, comparing the pre-operative radiological aspect, the intra-operative visualization and the post-operative histopathological features of the tumors. materials and methods: icg was intravenously injected for a routine liver function test (limonÒ) in patients who underwent hepatic resection surgery for primitive and secondary liver tumors in the period between november and september . for each patient was performed an intraoperative visualization of the stain both in vivo and ex vivo, using a nearinfrared imaging system. all the images were recorded. results: a correct differentiation between liver parenchyma and tumor area was obtained in . % of cases. five patients were not evaluable due to widespread uptake or complete absence of uptake; it was probably the first cases enrolled in the study for which we were not able to set doses and timing of administration of icg. in patients in which the method had been feasible, we observed a prevalence of nodular pattern in patients with hepatocellular carcinoma ( %) and a predominance of rim pattern in both cholangiocarcinoma ( %) and metastasis ( %). furthermore, in patients with hccs well-intermediate differentiated (g -g ) was found predominantly a nodular pattern ( . %), whereas in poorly differentiated ones was prevalent a rim appearance ( %). regarding radiological correlations, the only one patient who presented an atypical radiological feature in pre-operative evaluation, showed a lesion with no icg captation in intra-operative visualization. conclusions: icg fluorescence imaging is a safe, minimally invasive and quite inexpensive method, that can be easily administered for routine evaluation of pre-operative liver function. it can be a useful support tool in the intra-operative detection of liver tumors, especially in laparoscopic surgery where it is not possible to directly touch the tissue. surgery, bundang cha medical center, seongnam-si, korea; surgery, severance hospital, seoul, korea; surgery, nhimc ilsan hospital, ilsan, korea; surgery, seoul national university bundang hospital, seongnam, korea; surgery, asan medical center, seoul, korea backgrounds & aims: robotic surgical system had been widely accepted in various surgical field with the expectations of overcoming the limitation of laparoscopic surgery. however, robotic liver resection had not generalized, so far. thus, this study aimed to evaluate the feasibility and safety of robotic major liver resection by prospective multicenter study. methods: from july to december , five surgeons who were novice in robotic liver resection but experienced a lot in open and laparoscopic liver resection in five tertiary hospitals performed cases of robotic major anatomical liver resection. perioperative patient's clinical data and surgical data were prospectively collected. results: cases of left hemihepatectomy, case of extended left hemihepatectomy, cases of right hemihepatectomy, cases of right anterior sectionectomy, cases of right posterior sectionectomy, and one cases of central bisectionectomy were performed. the most common indications were hepatocellular carcinoma for cases following intrahepatic cholangiocellular carcinomas for cases, liver metastases for cases, sarcoma for case, intraductal papillary neoplasms for cases, mucinous cystic neoplasm for case, hemangioma for case, and intrahepatic duct stones for cases. surgical resection margins for all tumor cases were negative. total average operation time was . ± . min and estimated intraoperative blood loss was . ± . ml (minimal to ml). in terms of severe surgical complication, there were cases of postoperative fluid collection treated with drainage and one case of bile leakage treated with percutaneous trans-hepatic biliary drainage. only one case out of cases was converted to the conventional open left hemihepatectomy because of bleeding. conclusions: in this study, robotic anatomic major liver resection might be safely performed even by robotic beginners but advanced open and laparoscopic liver surgeons. surgical technique: with the patient at °on right lateral decubitus, access is gained through the path of the percutaneous drainage catheter after opening of the aponeuroses of the oblique and transverse muscles of the abdomen. a mm laparoscopic trocar is inserted and a cavity is created with pneumoretroperitoneum at mmhg. it is accessed with an optic of °and mm, and the work space is extended with aspiration and hydrodissection. with mm grippers, the necrotic material is removed, washed and drained. a two light silicone probe is left, one light for drainage and another one for washing. results: the mean age was . background: minimally invasive surgery has achieved worldwide acceptance in various fields, however, pancreatic surgery remains one of the most challenging abdominal procedures. in fact, the indication for robotic surgery in pancreatic disease has been controversial. the present study aimed to assess the safety and feasibility of robotic pancreatic resection. methods: we retrospectively reviewed our experience of robotic pancreatic resection done in sanchinarro university hospital. clinicopathologic characteristics, and perioperative and postoperative outcomes were recorded and analyzed. aim: this work aims to study the contact pressure between the moving capsule and a synthetic small intestine in order to provide design guidance for prototyping the self-propelled capsule robot for small-bowel endoscopy. method: since small-bowel peristalsis consists of peristaltic contraction and wave distension, the contacts between the capsule and the small intestine are multimodal. we consider three contact cases for the capsule robot. case : the capsule moves on a flat small intestinal surface; case : the capsule moves in a collapsed intestine with a flat surface support; and case : the capsule moves in a surrounded small intestine. by considering these three contact cases, experimental testing and finite element analysis (fea) were conducted by measuring the contact pressure between the small intestine and the capsule. introduction: traditional laparoscopic instruments have limited degrees of freedom and are not ergonomic. this results in severe limitations in performing complex, and even simple tasks in surgery, limiting many surgeons from performing a variety of minimally invasive procedures. handx tm is a hand-held, electromechanical smart instrument with robot-like features. the instrument is composed of a sophisticated user interface that enables unrestricted hand movement, and a novel, motor driven articulating tool that is controlled by the interface. the instrument is . mm in diameter, lightweight, and can be easily moved between laparoscopic trocars and perform complex motions in the surgical field. after the regulatory process was completed we have tested the device clinically through a structured, approved, clinical trial. materials and methods: after irb approval patients were recruited to the trial. we have included a variety of procedures that require suturing and complex tissue manipulation. two experiences surgeons performed all procedures. after completing each procedure the surgeons completed a detailed standard usability (sus) questionnaire. results: procedures were completed successfully without complications or device malfunction. there were female and male patients with an average bmi of . procedures performed were right hemicolectomis with intra-corporeal anastomosis, paraesophageal hernia repairs and fundoplication, diagnostic laparoscopies, tapp procedures, ventral hernias with fascial suturing, and laparoscopic cholecystectomies. the average performance score was . / . the results suggest that the handx device is safe and easy to use and may offer a simple solution for enhancing minimal invasive surgery capabilities and possibly reduce conversion rates while maintaining current standard surgery flow.the handx could potentially extend the surgeon's abilities to access hard to reach anatomy and perform complex maneuvers and present a cost-effective alternative to large console-based robotic systems. objective: endoscopic submucosal dissection (esd) has become widely accepted treatment for rectum neuroendocrine neoplasm. the aim of this study is to evaluate the safety and efficacy of esd with dental floss-assisted suspension traction for rectal neuroendocrine neoplasm. methods: we retrospectively reviewed the medical records of the patients, who underwent esd for rectum neuroendocrine neoplasm at endoscopy center of zhongshan hospital, fudan university. the data of operation time, r resection and adverse events were collected analyzed.in dfs-esd group: after the mucosa was partly incised along the marker dots, the next step was to construct traction device, similar to others in esd, with dental floss and hemoclip. the dental floss was tied to any arm of the metallic clip. the hemoclip was attached onto the incised mucosa, another hemoclip was attached onto normal mucosa opposite to the lesion in the same way. the submucosa was clearly exposed with the traction of dental floss and the resection could proceed. results: patients were enrolled in the study. there were patients treated by esd with dental floss-assisted suspension traction and patients treated by conventional esd. the average tumor size was ( . ± . )cm in both group. the operation time was . ± . min in conventional esd group and ( . ± . ) min in dfs-esd group (t = . , p = . ). according to pathological grading about rectal neuroendocrine neoplasm, there were grade (g ) and grade (g ) in conventional esd group while grade (g ) and grade (g ) in dfs-esd group (? = . , p = . ). among cases in this study, all the basal resection margins were negative, the en blot resection rate was % and the curative resection rate was %. however, pathological results showed tumor tissue close to the burning margin in cases of conventional esd group and in cases of dfs-esd group (? = . , p = . ). conclusions: esd with dental floss-assisted suspension traction for rectum neuroendocrine neoplasm can assist exposing tumor borders, provide good vision during the procedure and offer clearer anatomic structure, so as to simplify operation, reduce operation time and ensure the negative basal margin. it is especially suitable to be promoted in primary hospitals. surg endosc ( ) aims: force feedback and assessment provides detailed insight into tissue manipulation skills. the aim of this study is to evaluate learning curves for basic laparoscopic skills based of force and motion learning curve patterns. morevover, we aimed to detect the favourable time span for this curriculum for each individual trainee. methods: in this prospective cohort study, first year surgical residents participated in a three week at home training course. a mobile box training was equipped with forcesense system for objective force, motion and time based assessment. the system provides seventeen unique metrics. the training goal was set by the mean score of proficient laparoscopic surgeons. each repetition was captured and made available for analyses. continuous force feedback was provided during training. curve fitting was used to estimate the learning curve plateau and the number of repetitions needed to approach the plateau phase and to reach proficiency level. finally, a comparisson between novices and experts was executed. results: a total of attempts, executed by residents were captured and analyzed. significant improvement of motion analysis parameters (e.g. path length and time) was observed for all training tasks, except for the fifth tasks. tissue manipulation skills (i.e. maximum and mean applied force) significantly improved by training tasks , and . learning curve analysis revealed various shapes and lengths of the individual learning curves. a large range in learning curve plateaus was found between trainees and between tasks. each trainee managed to accomplish the preset goals within three weeks. conclusion: force-and motion based assessment provides insight into both tissue manipulation and instrument handling skills. when combined in learning curve analysis, these parameters effectively show progression towards proficiency for each individual trainee over time. we emphasize the variation in learning curves between trainees. therefore, we recommend individually tailored courses provided with objective force-and motion-based learning curve tracking. aims: the posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation.the aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and perfusion assessment in the posterior retroperitoneoscopic approach. methods: six pigs underwent synchronous (n = ) or sequential (n = ) bilateral posterior retroperitoneoscopic adrenalectomy (pra, n = ). fluorescence imaging was obtained via intravenous administration of ml of indocyanine green (icg) using two near-infrared camera systems. fluorescence-based visualization of adrenal glands before vascular division (n = ), after main vascular pedicle ligation (negative control, n = ) or after adrenal division (n = ) was followed by completion adrenalectomy. one of the animals had undergone icg injection h previously, during another study. the dynamic evolution of fluorescence signal intensity over time was recorded and analyzed using a proprietary software. the computed color-coded perfusion cartography was superimposed onto real-time images obtained by corresponding left (l) and right (r) camera systems. the slope of fluorescence signal intensity evolution over time in the regions of interest (roi) served to assess adrenal perfusion by means of quantitative fluorescence signal analysis. results: in the retroperitoneum, the adrenal glands were promptly highlighted after primary intravenous icg administration or showed an increase in fluorescence signal intensity upon reinjection (both glands in a recovery pig and one gland in the sequential approach). after left adrenal main vascular pedicle ligation, the gland displayed low perfusion (blue; rois a -a in figure ), while a weak fluorescence signal after completion adrenalectomy suggests perfusion via collateral vessels. with intact vascular supply, the caudal segment of the right adrenal (a ) gland showed a significantly higher perfusion rate (red) than the ischemic cranial segment (a ). quantitative analysis of logarithmic fluorescence intensity showed a statistically significant difference between perfused and ischemic zones (p = . ) allowing to assess gland vascularity. kidneys (k) and adrenal glands showed distinct perfusion curves ( figure ). conclusions: prior to dissection, fluorescence imaging allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. during adrenal gland surgery, icg injection complemented by a computer-assisted quantitative analysis helps to distinguish between wellperfused and low-perfused segments. giant adrenal tumors:technical considerations and surgical outcome a. giordano, g. alemanno, c. bergamini, p. prosperi, v. iacopini, a. dibella, a. valeri sod chirurgia d'urgenza, aou careggi, firenze, italy objectives: giant adrenal tumors are tumors with size more than cm. these are rare cancer associated with malignancy in % of cases. the size of these tumors is an important topic in literature because of their higher probability of malignancy and possible technical limitations of laparoscopic approach. we report our center's experience on laparoscopic adrenalectomy. materials and methods: in the last ten years we performed about adrenalectomies for benign and malignant adrenal tumors. of these were giant tumors. the medium size was . cm ( - cm). tumors were on the left adrenal gland and on the right. there were women and men, the average age was ( - years). of these cancers were laparoscopically removed and with open approach. cases of open conversion. results: betweenn the tumors laparoscopically removed we recorded cases of carcinoma, endothelial cysts, adenomas ( with aldosterone and with cortisol hypersecretion), myelolipomas, pheochromocytomas and metastases from lung carcinoma. the surgical outcomes in these patients were optimal in terms of good pain control and hospital stay (median days). the average time of the intervention was min with very low blood less ( ml). no postoperative complications were recorded. the removal of the adrenal gland necessitated or trocars. in the dissection and resection phases we always used radiofrequency scalpel. the follow up after and months didn't show local recurrences. conclusions: laparoscopic adrenalectomy offers significant advantages over the open approach. the size of these tumors is still at the center of debate for the choice of the technique. the tumor size is only a predictive parameter of possible malignancy. the laparoscopic approach is a safe and feasible method in terms of surgical and oncological outcomes also for the giant adrenal tumors, only if performed by expert surgeons and in high-volume centers. vascular or adjacent organs infiltration is a contraindication to the laparoscopic approach. aims: adrenal gland size greater than cm is considered a contraindication to laparoscopic adrenalectomy (la). aim of the present case-control study is to compare the surgical outcomes in patients undergoing la for adrenal gland measuring = cm versus = . cm in diameter. methods: from january to august , las were performed in the two authors' centers which follow an identical treatment protocol. eighty-one patients with an adrenal gland size = cm (intervention group) were included in the study. based on body mass index (bmi) class [ kg/m ) , lesion side (right or left), surgical technique (anterior transperitoneal for right and left-sided lesions, anterior transperitoneal submesocolic for left-sided lesions) and lesion type (conn-cushing, pheocromocytoma, primary adrenal cancer or metastases, other type of lesion), patients with an adrenal gland lesion measuring = . cm in diameter were included (control group) and paired to the intervention group. results: comparing the intervention and control groups, statistically significant differences were observed in mean lesion size ( conclusions: the only significant difference between the two groups was the operative time which was longer in the intervention group. conversion and complication rates were also higher in the intervention group but the difference was not statistically significant. based on the present data, adrenal gland size measuring more than cm in diameter is not a contraindication to a laparoscopic approach. ; and orthopaedics and urologists for the remaining . %.the costs from these claims, differed from to % of the total damage burden per year. the review of medical charts of claims related to laparoscopic gynaecologic surgery showed that % of claims were filed for visceral and/or vascular injuries ( % bowel injuries, % ureter). % of the injuries were entry-related. a delay in diagnosing injuries was the primary reason for financial compensation. conclusion: evaluating and learning from complications and claims will improve medical health care. in contrast to overall trends and developments considering medical claims, claims concerning laparoscopic surgery decreased, possible due to a rising learning curve. considering laparoscopic surgery, extra caution is required at moment of entry and the early recognising complications and at pre-operative counselling from patients. the aim of the study was to determine indications and contraindications for laparoscopic splenectomy in abdominal trauma patients and to analyze results of the operations. patients and methods: the study involved patients with spleen injury grade iii who were admitted in our institute in the years of - . the patients were divided on two groups. laparoscopic splenectomy was performed in patients (group i) and 'traditional' splenectomy was carried out in patients (group ii). there was no difference in the demographic data and trauma severity between the two groups.non-invasive investigations, such as laboratory investigations, serial abdominal ultrasound examinations (us), x-ray in multiple views and computed tomography (ct) had been performed before the decision about necessity of an operation was made. results: patients after laparoscopic operations had better recovering conditions compare to patients with the same injury after 'traditional' splenectomy. neither surgery related complications no mortalities were registered in both groups. laparoscopic splenectomy was more timeconsuming operation than 'traditional' splenectomy. we suggest that as experience of laparoscopic splenectomy is gained the operation time will be reduced. conclusion: laparoscopic splenectomy is a safe feasible operation in patients with spleen injury. the operation is indicated in patients with spleen laceration more than cm of parenchymal depth with moderate continuing bleeding or expanding hematoma and contraindicated in patients with hemodynamic instability and high bleeding rate (more than ml/h on serial us examinations). the isolated hydatid disease of the spleen is a quite rare condition, liver and lungs being the most common locations. the treatment requires usually splenectomy, open or laparoscopic. there are few reports in the literature describing a spleen-preserving type of surgery. we present a case of a female patient, y.o., with a large cystic lesion of the spleen, cm in diameter. lab tests and ct scan confirmed that is a hydatid cyst. after albendazole treatment and vaccination the patient was referred to us for surgical treatment. the procedure was performed under general anesthesia and laparoscopic approach was performed with the intention to preserve the spleen. after the cyst was identified and adhesiolysis was done, the area was isolated from the rest of the abdominal cavity with sponges with a betadine solution in order to prevent contamination. a needle aspiration of the cyst allowed the evacuation of ml of purulent content, an indicator of a dead cyst. betadine solution was injected into the lesion. laparoscopic excision of the cyst was performed using advanced electrocoagulation devices and the spleen removal was not deemed necessary. two drainage tubes were placed in the remnant cavity. an abdominal ultrasound was performed in the third postoperative day and no collections were identified. the postoperative outcome was uneventful; the patient was discharged in the th postoperative day. the conclusion is that in selected cases, with the cyst located in the anterior part of the spleen, with proper equipment and experienced laparoscopic teams, the cyst can be successfully treated without splenectomy. deep neuromuscular block was induced with rocuronium . mg/kg. in group , forty patients were enrolled for reversal of profound neuromuscular block during thyroid surgery (sugammadex mg/kg, after identification of vagus nerve). in group , thirty-five patients were enrolled profound neuromuscular block during thyroid surgery(without reversal of nmbd). tof-watch acceleromyograph was recorded in response to adductor pollicis muscle for ulnar nerve stimulation in patients with both groups; recovery was defined as a train-of-four (tof) ratio = . .to prevent laryngeal nerve injury during the surgical procedures, all patients were neurophysiologically detected using ionm. results: the total duration of surgery was higher in group than group ( . ± . , . ± . ;p \ . ). the mean time to recovery of the tof ratio to . was higher in group than group ( . ± . , . ± . ; p \ . ). the mean duration of vagus reverse (v : , milisecond) was higher in group than in group ( . ± . , . ± . ; p \ . ). no significant difference was found between left and right v -v and r -r values in group following nerve monitoring, whereas in group , a significant difference was found between left v -v , left r -r and right v -v values ( introduction: oeosphagogastric oncology trials have often lacked robust methods of monitoring and surgical quality assurance (sqa), leading to difficulty in interpretation of trial results. this study aims to assess expert opinion regarding challenges to sqa in oncology trials and potential mitigating strategies. method: a purposive international cohort of expert stakeholders with experience in oncology trials were recruited including: surgeons; oncologists; trial methodologists, and; trial managers. semi-structured interviews were thematically analysed using grounded theory. spss was utilised to assess differences between trial stakeholders' opinions. results: emergent themes were identified and consensus themes emerged on qualitative analysis of stakeholder responses. key consensus challenges to implementation of sqa in oncology trials included: insufficient resources; limitations of surgical volume in centre selection; differing oncological beliefs and resistance to change adoption; overly prescriptive protocols and standardisation contributing to difficulty in surgeon recruitment; and cultural factors leading to difficulties in providing and receiving feedback. seminal consensus mitigating strategies to overcome challenges to sqa in oncology trials included: trial centre selection according to case volume (n = , %); requirement for specific centre attributes for inclusion in trials including specialist centre designation and participation in national audit (n = , %); consideration for surgeons learning curve in surgeon selection (n = , %); flexible standardisation of trial operating (n = , %); operation manual utilisation to aid standardisation of surgical interventions (n = , %); case monitoring using video (n = , %) or photographs (n = , %); direct intraoperative observation by an expert (n = , %), and; histopathological assessment of resected specimens (n = , %). other methods of monitoring surgical quality advocated included: recording post-operative outcomes; lymph node yield; case report forms; and real time data monitoring (n = , %). oncologists were significantly more likely to state the importance of standardisation of surgery in oncology trials (p \ . ), and trial methodologists significantly more likely to advocate consideration of surgeons' learning curve in surgeon selection (p \ . ). conclusion: surveying international expert stakeholder opinion revealed a wide variety of perceived challenges across all domains of surgical quality assurance. proposed mitigating solutions require consensus opinion to formulate a framework to aid design of sqa measures within future oncology trials. research group did not register a single case of ega leakage while patients in control group (? \ , ). had the leakage which was stopped by means of 'endovac' system. there were cases of esophagus postoperative strictures which developed months after the surgery in the research group which was less than in the control group which saw cases of strictures of ega (? \ , ). months after surgery, the number of post-operative strictures increased in both groups, but was lower in the research group and amounted to cases in the research group and cases in the control group (? \ , ). there were cases of esophagus postoperative strictures which developed months after the surgery in the research group which was less than in the control group which saw cases of strictures of ega (? \ , ). neither of the groups had any cases of post-operative mortality. purpose: to investigate the prognostic effects and risk factors of the omission and delay of postoperative chemotherapy of ii/iii gastric cancer (gc), with the goal of providing a reference for interventions of related departments. methods: the clinicopathological data of patients undergoing radical gastrectomy for ii/iii gc were collected and retrospectively analyzed. we defined the chemotherapy delayed until more than days after radical gastrectomy and the complete omission of chemotherapy as unacceptable chemotherapy initiation (uac group), while the chemotherapy conducted within days of radical gastrectomy was defined as acceptable chemotherapy initiation (ac group). the survival between the two groups was compared, and the trends and risk factors of uac were analyzed. results: the total number of patients who underwent totally laparoscopic distal gastrectomy with uncut roux-en-y and delta shaped billroth-i anastomosis was and , respectively. the mean reconstruction time was longer in uncut roux-en-y than in delta shaped billroth-i, ( . ± . vs. . ± . min, p \ . ). the uncut roux-en-y was used more cartridge than delta shaped billroth-i anastomosis ( . ± . vs. . ± . , p \ . ). however there was no significant differences in operation time, estimate blood loss, number of retrieved lymph node and postoperative course between reconstruction methods. postoperative complications more than clavien-dindo grade iiia occurred in cases ( . %) of postoperative early complications and cases ( . %) of late complications. the endoscopic findings showed excellent short and long-term outcomes in terms of very low incidence of bile reflux and reflux-induced remnant gastritis in uncut roux-en-y compared with delta shaped billroth-i anastomosis. conclusions: uncut roux-en-y gastrojejunostomy was a useful reconstruction method with totally laparoscopic distal gastrectomy for cancer, especially for diverting enteral contents from the remnant stomach and preventing remnant gastritis. therefore, it is recommended for young patients with early stage disease who have a long time to live after distal gastrectomy for cancer. operative technique: the seromuscular layer above the tumor is dissected, while the mucosa is kept unbroken. when seromuscular layer is dissected all around the tumor, the full layer is lifted, and the mucosa is stretched. the mucosa is then transected with a stapling device to execute fullthickness resection of the specimen. finally, the seromuscular defect is repaired by hand-sewn suture. results: since december , clean-net has been performed in patients with gastric smts. all tumors were resected en-blocwithout rupture. the average operation time ranged from to min with an average of . min. the postoperative course was uneventful. microscopically the surgical margin was tumor-negative (r resection) in all cases. the margin width was small with an average of . mm ± . . conclusions: clean-net is a useful option in the laparoscopic surgical treatment of gastric smt, when excessive sacrifice of the healthy gastric wall surrounding the endophytic tumor should be avoided. background: the type of fundoplication-complete or partial is still controversial for the surgical treatment of gerd. laparoscopic toupet ( wrap) fundoplication has less post op dysphagia and gas bloating compared to nissen fundoplication ( wrap) and is advised to be the procedure of choice when esophageal manometry findings are abnormal, however it is considered by some less effective and more difficult to perform. the aim of this research was to determine in the functionality and efficacy of the different types of fundoplication. methods: explanted pigs stomachs weighing - kg were studied. two different studies of the les were performed: distensibility and failure point (occurrence of reflux according to volume added to the stomach). for both studies we first disrupted the lower esophageal sphincter using a rigiflex tm dilating balloon. we then performed three different fundoplications-nissen, toupet, dor and measured the distensibility of the egj after each fundoplication. the failure point was determined following each fundoplication type. results: we used pig stomachs for the distensibility study and pig stomachs for the failure point study. there was no statistically significant difference between the nissen and toupet fundoplications when distensibility was measured, however the egj was more distensible following dor fundoplication (p = . for nissen, . for toupet). when the failure point was measured, nissen fundoplication was significantly more effective than toupet, and toupet was significantly more effective than dor (p = . ,p = . respectively) conclusions: we studied the differences between the mechanical effects on the egj following three different fundoplications, encompassing , , and of the esophagus. we demonstrated that there is a significant difference between dor fundoplication and nissen/toupet when distensibility was measured. there was no difference in the distensibility of the egj following a or wrap. there was, however a significant difference of effectiveness between all three fundoplications. these findings suggest that the and fundoplications have similar functionality while the wrap mechanically prevents possible reflux and support proponents of toupet fundoplication rather than nissen due to the similar functional results while decreasing the post op dysphagia and gas bloating complications. surg endosc ( ) aim: to describe patients undergoing surgical treatment of incident gastro-oesophageal reflux disease and the use of anti-reflux treatment in a danish population-based cohort. methods: all adult danes - undergoing upper endoscopy and receiving a diagnosis of gerd within days were identified. patients with previously diagnosed gerd, peptic ulcer-disease, barrett's oesophagus or cancer of the gastrointestinal tract were excluded. in this study, only patients undergoing anti-reflux surgery within two years of gerd-diagnosis were subsequently included. age, sex, charlson comorbidity index (cci), anti-reflux surgery (primary and re-operative) and endoscopic dilatation were identified using the danish national patient registry. mortality was identified using the national civil registry. pharmacological treatment of gerd (proton pump inhibitors, h \ su \/su-blockers and other prescription anti-reflux drugs) as well as use of nonsteroid anti-inflammatory drugs (nsaid) and anti-thrombotic treatment were identified using thethe danish national prescription registry. all data was linked on an individual level using the unique identification number that all danish citizen are assigned to at birth or first immigration. results: a total of first-time fundoplications were performed, hereof . % performed laparoscopically (n = ) and . % performed using open technique (n = ). at one-year followup, . % (n = ) had undergone endoscopic dilatation and . % (n = ) had undergone reoperation. the -day mortality was \ . %. patients had a median age of years ( - years) and were predominately male ( . %-n = ). a total of . % had cci (n = ). diagnoses were gerd with esophagitis ( . %-n = ), gerd without esophagitis ( . %, n = ) and gerd without specification ( . %, n = ). before initial endoscopy, , % (n = ) used at least one type of anti-reflux drug, dropping to . % (n = ) in the year after anti-reflux surgery. however, even when censoring patients with barrett's esophagus or peptic ulcer disease after initial endoscopy and patients undergoing concomitant treatment with nsaids or antithrombotic drugs, . % still used at least one type of anti-reflux drug after surgery. conclusion: in this population-based study, anti-reflux surgery was safe and lowered the use of pharmacological treatment. however, even when adjusting for competing reasons for use of antireflux drugs, . % used at least one type of anti-reflux drug one year after surgery. the new approach to perform nissen fundiplication m. paranyak, v. grubnyk surgery, odessa national medical university, odessa, ukraine nearly % of patients who undergo laparoscopic anti-reflux surgery at long-term follow-up need for surgical reintervention mostly because of hiatal hernia (hh) recurrence, wrap migration or disruption. purpose: the aim of our prospective study was to evaluate and compare several technics of wrap fixation and determine whether modified nissen fundoplication(mnf) reduce failure rate in the long term follow up. materials and methods: this was a prospective, randomized, controlled trial. from november to october one hundred and thirty-eight gerd patients who underwent anti-reflux surgery were divided into two groups. excluded criteria for our study ware diagnosed hiatal hernia (hh) type iii. in the i group which include patients we performed the following manipulations: nf was supplemented with suturing wrap to the diaphragmatic crura ( patients) on each side using two non-absorbable stitches. such technique permit us to create more symmetrical wrap. in case of weak conditions of crura or short esophagus ( patients) fundoplication wrap was sutured to the body of stomach using two non-absorbable stitches on each side. control group ( patients) underwent classic nissen fundoplication (nf) without wrap fixation. all patients were assessed before and after surgery using validated symptoms and quality of life (gerd-hrql) questionnaires, -h impedance-ph monitoring and barium-swallow. results: baseline characteristics were similar between groups. there were no conversion to open procedure or mortality. mean hospitalization was . days ± . days. at , months (range -- ) of followup, the overall rate of complications after mnf was , % ( hh reccurence) and nf , % ( hh reccurence, slipped wrap). patient in mnf group show significant improvement in gerd-hrql score, from . ± . (preoperatively) to . ± . (postoperatively) (p? \ ? . ). complete ppi independence was achieved in %. in the ii group of patients mean gerd-hrql score decline from . ± . (preoperatively) to . ± . (postoperatively), postoperative ppi treatment was necessary in %. conclusions: according to our study mnf minimized risk of slipped wrap and intrathoracic migration of the wrap and can make positive impact on reducing the failure rate of laparoscopic anti-reflux surgery. aims: comparative evidence across laparoscopic antireflux procedures does not exist. aim of this project was to identify direct comparative evidence between laparoscopic antireflux procedures and synthesize evidence using network meta-analytical methods. methods: the databases of medline, amed, central, opengrey were interrogated. pairwise meta-analyses for each pair of interventions using a random-effects model and network metaanalysis in stata was performed using the mvmetacommand and self-programmed stata routines. differences between direct and indirect evidence were explored by comparing direct and indirect estimates though computing the inconsistency factor within each closed loop of evidence. the ranking probabilities for all treatments of being at each possible rank for each intervention were computed using the mvmetacommand in stata. a hierarchy of the competing interventions was obtained using rankograms. quality of evidence was assessed using grade-nma and the cinema application. results: forty-three publications reporting on randomized trials and some patients were identified. the network of treatments formed a closed loop between °, °and anterior °; and star network between °and other treatments; and between anterior °and other treatments. laparoscopic °, °, anterior °and anterior °were equally effective in the control of heartburn and this was supported by low quality of evidence according to grade-nma. the odds for dysphagia were lower for anterior °(high quality evidence), anterior °( moderate quality evidence), °(moderate quality evidence) and proton-pump inhibitors (moderate quality evidence) compared to °. the odds for gas-bloat were lower for °and anterior °compared to °(low quality evidence). the odds for regurgitation, morbidity and reoperation were similar across treatments, albeit these were associated with very low quality evidence. anterior °had a % probability of being the best treatment in terms of dysphagia. conclusion: under consideration of treatment effect estimates, evidence quality as assessed with grade-nma and other parameters, anterior °, anterior °and °should be preferred over °. further research needs to focus on the comparison between °and °/ °. aims: we have recently demonstrated that the tension of crural closure can be reliably measured intraoperatively (alsgbi conference december ). the aims of this study were to further characterise tension at the diaphragmatic hiatus from our prospective pilot study of patients. methods: a prospective analysis was performed of patients undergoing laparoscopic hiatal hernia repair between april and december . patients underwent crural tension measurement intra-operatively. patients had a pre-operative ct scan of the abdomen within one-year of surgery. hiatal surface area (hsa) was measured intraoperatively and a sauter-fh universal digital force gauge was used to measure the tension of crural closure during cruroplasty. outcome measures included the mean tension of the crural closure and the presence of muscle splitting during the cruroplasty. results: for all patients, the mean crural tension measurement was . n and the mean hsa was mm . pre-operative ct was positively correlated with post-dissection intra-operative hsa (r = . , p = . ), however, strength of association was weak (r = . ) and ct consistently overestimated the size of hiatal defect intra-operatively (mean of differences mm , p = . ). crural tension was positively correlated with age (r = . , p = . ), hiatal height (r = . , p \ . ), hiatal width (r = . , p \ . ) and hsa (r = . , p \ . ). crural tension was correlated to the hiatal width to height ratio to assess the shape of defect and there was positive correlation (r = . , p = . ). tension was calculated for the posterior and anterior halves of the suture cruroplasty. anterior tension was significantly higher when compared to posterior tension ( . n vs . n, p \ . ) . patients had evidence of muscle splitting during the cruroplasty. the group with muscle splitting were significantly older ( vs , p = . ), had larger hsa ( mm vs mm , p \ . ) and higher crural tension ( . n vs . n, p \ . ). the lowest observed mean crural closure tension causing muscle splitting was . n. conclusion: there is now a possibility to optimise this operation with objective measures years after it was first described. initial findings suggest that crural closure up to * n could be the permissible tension threshold for suture cruroplasty and higher tension may benefit from the use of mesh reinforcement. background: endoscopic submucosal dissection (esd) and endoscopic full thickness resection (eftr) are advanced endoscopic techniques which can be time consuming using traditional endoscopic instruments. a new endosurgery platform, designed by fortimedix surgical, was developed featuring flexible articulating instruments to use in combination with a standard flexible endoscope. the platform is intended to perform endoscopic cutting, dissecting, and hemostasis. aim: evaluate feasibility of the platform in the upper gi-tract. project description: the platform was tested in a dry esophageal model as well as a second series with a porcine esophagus and stomach. the system has an external docking station affixed to the operative table to stabilize both flexible instruments for the right and left hand of the surgeon. at the tip of the endoscope, a cap containing instrument lumens is attached to allow advancing and removing the flexible instruments. the endoscope with the cap and instrument lumens attached is advanced via an overtube with outer diameter . mm. in the first series, flexibility and range of motion of the endeffectors was assessed. additionally, the ability to advance the instruments to the intraluminal target area from the docking station and along the scope was evaluated. in the second series, the functional capabilities of the system and instruments were evaluated in a porcine model. preliminary results: : in the dry model, the platform was adequately deployed to the target then range of motion was tested as well as cutting and grasping gastric wall with instrumetn triangulation achieved. the grasping forceps provided enough force to pull the mucosal wall and expose the dissection plane. in the pig model, the distal esophagus and stomach could successfully be accessed and platform deployed. esd was performed using newly designed flexible articulating scissors, dissection-hook, and graspers with good triangulation and sufficient grasping force with traction/counter-traction. the new fortimedix surgical endo-surgery platform applied to a standard flexible endoscope is feasible to perform esd. future studies are planned to determine learning curve and compare it to traditional endoscopic instruments. background: in laparoscopic surgery, we usually observe the organs in the same direction to avoid a mirror-image situation. therefore, we are unable to recognize how far the dissection has proceeded on the other side of the target organs or lesions, especially when the plane of dissection is under the mesentery or organs. this becomes a problem not to understand how far the dissection has progressed and how much more dissection is needed. aim: to solve this problem, we developed a laparoscopic device with tip illumination. project description: the device is configured by the long and narrow part made of polycarbonate resin and a battery-powered light-emitting diode to illuminate the tip by shining light through the polycarbonate resin. during the surgery, the tip of the device is inserted into the deepest part of the dissection area, and the transmitted light indicates how far the dissection has progressed. the tip of the device has a prism structure and light is emitted in a direction perpendicular to its axis. tip position can thus be more clearly identified even with insertion in the same direction as the laparoscopic view. to verify the utility of this instrument, laparoscopic surgeries were performed in a porcine model and cadavers. preliminary results: we performed some laparoscopic surgery such as the medial-to-lateral approach to the white line of the left side of the descending colon for sigmoidectomy, dissection of the posterior surface of the pancreas to the upper edge of the pancreatic body or splenic artery for distal pancreatectomy, and the separation of the anterior surface of the inferior vena cava from the liver to the area between the right and middle hepatic vein for right hepatectomy. we quickly and easily identified the deepest part of the dissection area even if identification had been difficult using other techniques such as placing gauze in the deepest position, inserting forceps into the dissection area or simply depending on the experience of the operator. background: recent advancements within surgery have seen artificial intelligence transform traditional approaches. robotic assistive devices have demonstrated particular success, as safe and cost effective, and are widely supported via industry and local government as a step closer to the future standard of practice. an example of seamless and touchless robotic assistive technology is based on touchless and interactive eye tracker glasses worn by the surgical team thereby enabling the team to perform wider surgical tasks, more efficiently and reduced human error. we introduce a perceptually-enabled, smart operating room (smart-or) based on a novel real-time framework for theatre-wide d gaze localisation in a mobile fashion. this framework enables dynamic gaze based user interaction with a robotic scrub nurse to facilitate meaningful practical integration of human and technology intra-opertively. aims: we tested participant acceptability of a novel robotic scrub nurse during simulated surgery. project description: surgeons performed segmental resection of pig colon and handsewn end-to-end anastomosis while wearing eye-tracking glasses to select surgical instruments on a screen. the robotic scrub nurse(rn) picked up and transferred the instrument to the surgeon. the study compared human nurse(hn) vs rn. gaze-screen interaction was based on a d gaze framework we developed with synergy of conventional wearable eye-tracking, motion capture system and fixed in space rgb-d cameras for real-time d reconstruction of the environment. nasa-tlx and van der laan's technology acceptance questionnaires were collected and analysed using anova. preliminary results: overall, teams of surgeons(st) and scrub nurses(sn) participated. nasa tlx feedback for st and sn revealed no significant difference between in mental, physical or temporal demand. importantly, st and sn reported no significant difference in task overall performance. st reported more significant frustration with rn vs hn. van der laan's scores showed positive usefulness and satisfaction scores in using the rn platform. overall, all outcomes were more positive by sn vs rn. conclusions: this is the first platform of its kind. overall, quantitative and qualitative feedback was positive. the source of frustration has been understood and we believe it can be improved by appropriately modifying robot behaviour. importantly,there was no difference on perception of performance. background: endoscopic tumor resections in the gi tract may be facilitated by more advanced instruments for dissecting and suturing. we have focused on developing an endoscopic suturing technique using a standard flexible pediatric endoscope with new, flexible instruments allowing for complex end-effector movements. aim: perform flexible endoscopic suturing using a standard flexible scope in the gi tract project description: a standard flexible pediatric endoscope and a standard gastroscope were used for testing the new technique. via an overtube, the endoscope and newly designed fortimedix surgical flexible instruments (needle holder; grasper) with a diameter of mm were inserted into the esophagus. suture training was performed in an experimental setting in a box in the dry lab and porcine model . the flexible needle holder was advanced into the esophagus next to the scope, and a suture of the esophageal wall was performed, followed by extracorporeal knot-tying with knots. the test series consisted of training with both resident trainees and surgeons to evaluate the learning curve. each participant performed sutures on the box model and in the pig-esophagus. feasibility, duration of the different steps, and handling problems were documented. preliminary results: test series (box training on esophago-gastric explant) with prototype showed good feasibility. suturing was possible in out of attempts. median duration for single bite: min ( - ); knot-tying: min ( ) ( ) ( ) ( ) ( ) ( ) ( ) . test series (training in pig-model) with prototype showed improved feasibility with better flexibility of instrument shaft: median duration of double bite: min ( - ); knottying: min ( ) ( ) ( ) ( ) ( ) , overall duration intraluminal esophageal double bite suture and closing with knots: median duration: min ( - ). the new flexible endosuture instruments seem feasible to use and perform dependable intraluminal sutures. the training period and learning curve is short and the objective is to apply this system clinically for closure of perforations and fistulas. school of mechanical and aerospace engineering, nanyang technological university, singapore, singapore; general surgery, national university hospital, singapore, singapore; gastroenterology, national university hospital, singapore, singapore; surgery, chinese university of hong kong, hong kong, hong kong background: ideally, endoscopic suturing should mimic surgical closure as the latter is stronger than most endoscopic closure devices. however, endoscopic suturing is challenging due to the confined endoluminal space and lack of dexterity of current endoscopic instruments. we have developed a novel robotic suturing device to overcome these problems. aim: this animal study aims to demonstrate the feasibility of this device in closing perforations. method: the trial was conducted on an anaesthetized live pig. a double-channel colonoscope was first inserted into the rectum. following saline lift, a mm submucosal incision was created in the rectum to simulate a perforation. the robotic suturing device and grasper were inserted into the two colonoscope channels, allowing the endoscope to remain in position for tool exchanges or needle reloading. both the effectors were intuitively tele-operated by the user via a robotic master console. this robotic suturing device manipulated a curved, double-point needle (with a cm - vicryl suture) to penetrate tissues at desired orientations. the needle could be switched between both jaws of the device through a locking mechanism. this facilitated passing the needle through tissues to form stitches or through suture loops to form surgical knots. the articulated joints and five degrees of freedom allowed dexterous steering to reach targets and triangulation with other tools in a confined space. the robotic grasper facilitated handling of tissue and suture. result: a total of four running stitches were performed and secured with a surgical knot by passing the needle through suture loops. the suture was cut and the needle was removed by the robotic grasper through the channel. min and min were required to stitch and tie the knot respectively. there was no complication. conclusion: our novel endoscopic robotic device can suture perforations resulting from complex endoscopic procedures. as our suturing method is similar to laparoscopic and robotic suturing, closure using our device is expected to be as strong as a surgical through-and-through closure. when developed further, this device can be used to close full-thickness resection sites and orifices in transluminal endoscopic surgery. modelling a collaborative robot with the ieee sdc standard for combined focused ultrasound and radiation therapy j. berger, m. unger, l. landgraf, a. melzer medical faculty, university hospital leipzig, innovation center computer assisted surgery, leipzig, germany background: surgical robotics require a smooth integration into the operating room (or) . for this propose the ieee sdc(service-oriented device connectivity) standard has been developed in the or.net project. in preparation for a combined focused ultrasound and radiation therapy (fus-rt) we have shown concepts and evaluations to position ultrasound and interventional devices with collaborative kuka arms. however, the safe and intraoperative cooperation with multiple different or-devices (e.g. an irradiation unit) requires a more sophisticated exchange of the robot's information and functionality. aim: to realize a safe clinical integration, the aim of this work is to implement and evaluate a dynamic connection between the kuka robots and other devices using the vendor-independent sdc communication standard. project description: a kuka lbr iiwa r robot (kuka ag, germany) was modeled inside the sdc standard for medical device communication. the interconnection with other devices was implemented and evaluated on a mobile platform to position a clarius l wireless ultrasound transducer (clarius mobile health corp, canada). all necessary information of the robot was represented in the medical device description of the sdc standard to be shared via network. for each joint of the robot arm the position, torque, stiffness, damping, velocity and functional-states were represented, resulting in a total of parameters. the software was implemented in c ?? on a standard pc accessing the kuka controller cabinet with ros (robot operating system) via ethernet. the accessibility of each parameter, as well as activation commands for planning and movement were tested with an sdc-consumer application. preliminary results: the sdc-provider functionality of the robot was successfully implemented, allowing for dynamic changes of the robot state during interventions. all appliances (sdc standard compatible) in the robots network can react to state changes and send movement and planning commands to the robot via activations. after testing, % of the defined parameters are safely accessible. implementing the medical device communication for the kuka robot enables its integration into any networked operation room that supports the sdc standard. it is, therefore, ready to be set up and evaluated for the application of fus-rt in a clinical environment. background: assessment of perfusion of the left colon with fluorescence during anterior resections for cancer changes surgical decisions in up to % of cases. use of fluorescence has been shown to be associated with lower leak rates, and improved short-and long-term outcomes with reduced costs. given the high incidence of colorectal cancer, fluorescence-guided perfusion assessment could be of great importance in contemporary surgical practice. however, there is currently no standardisation of this technique which represents a significant limitation to widespread adoption. aim: to standardise fluorescence-guided perfusion assessment in rectal anterior resection through a computer vision algorithm. project description: videos were collected by a single surgeon in a referral centre for colorectal cancer treatment. perfusion assessment was used before proximal colon division to identify the best location for transection. a bolus of indocyanine green was injected intravenously and a near-infrared camera used to assess perfusion through fluorescence. photographs of fluorescent imaging of the colon were analysed using a non-supervised learning algorithm called 'k-means clustering'. the first step was to digitally subtract all background pixels, leaving only the area of interest of the colon. this area was then subsegmented into 'clusters' corresponding to perfused and nonperfused areas. a mathematical model was applied based on the sub-clusters centres to select the area for transection with optimal perfusion of the proximal colon. preliminary results: representative images of proximal colon under perfusion assessment were presented to expert surgeons. the optimal point for transection was selected based on their clinical judgement on previously delimited areas indicated by random letters. this was compared with the results from the automated segmentation using the algorithm ( fig. ). the area identified for section by the algorithm included the area selected by the expert surgeons in . - % of test cases. these results need to be further validated due to high risk of overfitting. next steps include the collection of multicentre data with a standardised fluorescence perfusion assessment. after robust training, the algorithm will be validated on real-time clinical data to ensure improved outcomes for patients, which is our ultimate goal. background: endoscopic submucosal dissection (esd) is a flexible endoscopic technique that allows for an en bloc removal of lesions of the gastrointestinal (gi) tract. these procedures are typically time consuming due to the difficult control of the tools, and they often require around min for removing lesions, that can reach - cm in diameter. the probability of intestinal perforation exceeds % and the hemorrhage risk ranges from . % to . %. a flexible robotic endoscope may offer a solution to overcome these limitations, by improving the degrees of freedom (dof) and operational efficiency. aim: within this clinical panorama, the aim of this project is presenting the development of a novel miniaturized robotic device to be coupled to the tip of a traditional endoscope for the surgical dissection of gi neoplasms. project description: the robotic platform consists of the miniaturized robot, the actuator housing (hereafter called external platform), the control unit and the master console (i.e.,two geomagic touch phantom) to allow the user driving and control (figure a ). during the operation, one surgeon stands close to the patient to maneuver the endoscope for exploring the gi tract and reaching the target area. another surgeon operates the miniaturized robot through the master console, carrying out the surgical procedure. the robot has been designed to be coupled to the tip of traditional flexible endoscopes of . mm in diameter. it exploits the flexibility of the endoscope for navigation through the intestine and integrates two-active robotic arms (i.e.,cautery and gripper) extending the dofs, and thus enhancing the efficiency during complex tasks such as manipulation and surgical tissue dissection. furthermore, the endoscope provides the optical system for visual feedback and one working channels for conventional instruments. preliminary results: firstly, a mock-up that faithfully reproduces the miniaturized robot has been realized using a d printer machine (projet mjp , d system, inc.) to verify the feasibility of the design solution. after verifying the potentiality of the d printed prototype, a final device, with the same features (i.e.,dof and geometry) of the d printed prototype, has been designed, fabricated and assembled ( figure b ). background: virtual and augmented reality has been widely used in many fields mainly for entertainment purposes. we think that it could be beneficial to use augmented reality in medical practice. aim: the aim of this study was to evaluate usefulness of d holographic images of patients anatomy displayed using augmented reality goggles during endovascular aortic repair (evar). project description: one of the major challenges during endovascular procedures is working on two dimentional x-ray images of three dimentional vascular anatomy. using d holograms of patients anatomy could be beneficial during the evar procedure and could make the orientation in vascular anatomy easier for surgeon. we performed two endovascular aortic repairs with the assists of microsoft hololens -smart glasses using augmented reality. we used carna life application created by polish company medapp. it was one of the first use of holograms during vascular procedures in the world (second and third stent-graft implantation using holographic imaging in the world). results: two patients with abdominal aortic aneurysms, -years old male and -years old female, were operated on. holograms of patient's anatomy made from preoperative angio ct scans by polish company medapp were displayed during the procedures using microsoft hololens. holograms could be displayed in any place and configuration using augmented reality, which means that the images did not interfere with the surgeon's field of vision. microsoft hololens use voice commends which permits the surgeon staying sterile. stent-graft implantations were successful. both patients were discharged three days after the procedure and the hospitalization was uneventful. seeing precise patient's vascular anatomy reconstructions in three dimention certainly helped us to navigate in a vascular tree. we believe that in the future this technology would enable to reduce the operation time and need for radiation. background: interaction with electronically controlled operating room (or) systems embedded in modern surgical environments is everyday practice for surgeons performing minimally invasive surgery (mis). while there is a non-sterile operating nurse available in the or, capable of interacting with these systems upon request by the surgeon, this indirect control is mostly slow, prone for error and disrupting surgical workflow. facing an unanticipated and unwanted outcome may cause distress emotions. distress emotions are undesirable when performing surgery, since they may impact available cognitive workload. furthermore, they may result in negative communication, hampering or-team empowerment and effective leadership. both factors are known to negatively influence quality and safety in the or. aim: the aim of the tedtrial is to investigate what setup best enables surgeons to interact with the endoscopic operating room setup during surgical procedures. as a result, disruptions of workflow, delays and errors may be reduced. outcome parameters will be objectified using medical data recorder (mdr) derived output and biometric analysis using hexoskinÓ. subjective evaluation of outcome parameters is done using questionnaires. project description: the tedcubeÓ system is a plug-and-play device enabling wearable sensors to act as a wireless alternative for a regular computer mouse, therefore enabling direct hands-free and sterile control of the or. the study is an observational trial with three different arms: intervention group ) direct interaction by surgeon with or environment using tedcubeÓ and myo tm armband, intervention group ) direct interaction of surgeon with or environment using tedcubeÓ and plantronicsÓ wireless microphone headset. the third arm is the control group using indirect interaction of surgeon with or environment using third-person computer interaction. main endpoint of study is the number of workflow disruptions due to the operation of laparoscopic or equipment. secondary endpoints are error rate, delay, team communication, subjectively reported frustration and satisfaction with the system and objectively measured stress as symptom of frustration and anger as distress emotions. preliminary results: primary and secondary endpoints of study are compared among groups. it is anticipated that reduction of miscommunication, error and delay may result in a reduction of distress emotions. trial start is expected q . anticipating the automated intraoperative tissue recognition: intraoperative tissue classification using hyperspectral imaging and machine background: iatrogenic injuries may occur despite a sound expertise in surgical anatomy. hyperspectral imaging (hsi) is an emerging optical method, combining the use of a camera system with a spectrometer. hsi analyzes optical properties of tissues and acquires d data sets with two spatial dimensions (x, y) and one spectral dimension (?). the data sets contain information about tissue physiology, composition, and perfusion. those spectral features coupled with machine learning algorithms might allow for automatic tissue recognition. aim: assessing the ability of an hsi-based machine learning to discriminate the hyperspectral features of different tissues during neck and abdominal surgical procedures. methods and procedures: fourteen pigs underwent laparotomy (n = ) or neck dissection (n = ). twenty data sets were acquired in vivo from abdominal organs and from neck structures by means of a customized hyperspectral camera (diaspective vision, germany). different anatomical structures were manually outlined by a surgeon using an image manipulation software (gimp). each pixel contained a hyperspectral curve and each curve was composed of bands (from to nm with a nm resolution). the curves were normalized using the standard normal variate method. a logistic regression machine learning (ml) algorithm was used to train the model to discriminate tissues, based on the hsi spectral features. the efficacy of the prediction model was tested using the k-fold (k = ) cross-validation. results: a large number of tissue-related hyperspectral curves could be extracted ( thyroid, vagal nerve, fatty tissue, cartilage, carotid artery, muscle, carotid vein, portal vein, biliary tract, gallbladder, hepatic artery, pancreas, duodenum, abdominal adipose tissue). the algorithm used min to 'learn' all data sets, and prediction was provided as an immediate output. overall, prediction accuracy was and % for neck and abdominal structures respectively. in particular, biliary ducts could be identified with a % accuracy and the vagal nerve with an % accuracy (see figure for details). background: a gaze-controlled robotic endoscope is innovative technology with myriad potential applications in the rapidly advancing field of flexible endoscopy. improvements to the current flexible device to allow examination of the gastrointestinal tract whilst minimising procedural discomfort and complications are desirable. aim: to use a gaze contingent framework to manipulate a flexible endoscope through a simulated upper gastrointestinal tract (ugit) model. description: a flexible gastroscope (karl storz pks) was attached to a ur axis robotic arm (universal robots), mounted onto a rail and placed on top of a surgical table. two cogwheel shaped dials were d printed and placed onto the up/down and left/right wheels on the head of the gastroscope ( figure ). robotization of these controls was achieved by using two motors (dynamixel rx- f) to steer the distal tip. this system allows users to operate a robotised flexible endoscope using gaze control. gaze interaction with the screen was based on a d gaze framework we developed with the synergy of conventional wearable eye-tracking, motion capture system and fixed in space rgb-d cameras for d reconstruction of the environment. users are able to control endoscope movements without handling the device. the distal tip of the gastroscope was controlled using eye gaze technology. the ur robot was used to enable shaft rotation (initiated by fixed head movements) and linear movements were triggered using a joystick handle (up for forward movement, down for endoscope withdrawal). pause and retroflexion of the endoscope are achieved by moving the joystick left and right respectively. users were asked to navigate an endoscope through an ugit model (chamberlain group) simulating a diagnostic gastroscopy using gaze control and targeting ten points scattered through the stomach. results: four expert endoscopists and one novice used gaze control to successfully navigate a gastroscope through a simulated ugit. all were able to intubate the oesophagus and accurately locate ten targets placed in the fundus, body, antrum and pylorus of the stomach. conclusion: gaze control endoscopy is a feasible concept. it allows ergonomic, user-friendly and intuitive control whilst maintaining the benefits of a flexible endoscope. background: image-guided needle biopsies and histopathological evaluation are the gold standard for the diagnosis of liver neoplasms. most often, however, these are reserved for suspicious, but not diagnostic, situations. radiomic may help to characterize tumor biology by correlating imaging features with relevant tumor-biology information. features derived from radiomic analysis may provide complementary information to support clinical decisions, especially in situations where tissue analysis cannot be performed or is inconclusive. aim: the goal of our technology is to exploit computational capabilities for image analysis in order to identify radiomic features useful for characterizing liver lesions and to identify relevant information related to patient prognosis. project description: patients derived from an internal database and patients randomly extracted from the cancer archive liver dataset were included in this study. lesions were extracted from those volumes using expert annotations ( secondary vs primary; well differentiated vs non-well differentiated). lesions were then split into training and testing sets. first order statistical features were computed and a lasso regression step was performed to reduce the number of features. both logistic regression and random forest models were built using cross-validation to predict the target classes on the test set. preliminary results: only features namely the energy and the volume of the lesion were sufficient, when combined in either model, to predict the differentiation grade on the test set with an f -score of . (± . ). we are currently working on the addition of higher order statistical features to the analysis in order to differentiate primary from metastatic tumors and identify complementary features that may assist clinical decisions in patients with inconclusive hepatic lesions. objective of the technology or deviceideally, the use of medical simulators could provide trainees with initial background information about indications for procedures, endoscopic technique, and early hands-on training experience that could shorten the initial critical learning curve. rationale for using ex vivo models is that in the beginning of the learning curve, the most important issue is having an initial exposure to the basic movements and maneuvers. our objective of is to create a stomach model from renewable polymer, which would closely simulate normal human stomach with gastric pathology for endoscopic diagnostic or interventional skill acquisition/evaluation. description of the technology and method of its use or application stomach model is based in several steps; the first one is in the in-silicodesign of the overall shape, after that we d print the positive two halves of it. the interior detail is obtained shaping the d printer parts with ceramic putty. once concluded, this elaborated part will serve as a template in order to build injection bleeding moulds. in the injection bleeding moulding a mesh is placed between layers in order to provide structural attachment points as stiches or several pathological models that will be incorporated after the casting process. we have developed for these instance polyp moulds, fistulae structures in order to attach endoscopic clamps. the two halves are closed once the pathological models are placed inside via a thermic-fusing and stitching creating a leak proof stomach model. preliminary results if available: our models were evaluated by international experts in ircar/ihu france in interventional endoscopy course and were favorable accepting for next trails in these prestigious institutions. conclusions: future directionsa new endoscopic training model of stomach was made and will be evaluated and validated for feasibility in mastering diagnostic and interventional endoscopic skills. clinical trials will be necessary to compare the ability of the simulator to perform training compared with traditional methods of training in endoscopic procedures. background: endoscopes are the eye of surgeons in minimally invasive surgery (mis). conventional endoscopes are mostly chopstick-like and are steered by the assistant. this limits the field of view and results in issues such as endoscope-instrument fencing, surgeon-assistant coordination. existing robotic endoscope holder enables solo-surgery, however endoscope remains blocking the instrument movement and impairs the operational safety. flexible endoscope such as the endoeye provides angulation at the tip and could enlarge the field of view. however, its steering the view is much more complex compared to the rigid endoscope. aim: to provide an intuitive robotic flexible endoscope with enhanced safety. project description: in this work, we present a robotic flexible endoscope for mis with enhanced safety. in the proof-of-concept system, it contains a flexible endoscope module and a robot manipulator. the endoscope contains a proximal rigid shaft and a distal flexible bending section. it is installed onto the patient side manipulator (psm) of the da vinci research kit (dvrk). visual servoing is adopted to achieve autonomous instruments tracking. during the tracking process, movements of the manipulator as well as the endoscope are minimized to save space for the operation and avoid instrument-endoscope fencing. the endoscope could also be controlled by the surgeon. a foot pedal is used to switch between the tracking-mode and control-mode. preliminary results: a prototype was developed and tested experimentally. in tracking a volume of * * mm , the spaces required by the flexible endoscope are . % (inside the trocar) and . % (outside the trocar) of that occupied by the rigid endoscope. evaluation with the fls tasks involved subjects. all of the participants completed the tasks under the tracking-mode without failure. in the ex-vivo test with porcine stomach, the endoscope successfully guided the detection, dissection and knotting autonomously. background: fluorescence imaging allows to visualize deep-seated anatomical structures, using a deeper tissue penetration of near-infrared (nir) compared to visible light. the most commonly used fluorescent substance, indocyanine green (icg), is not naturally excreted by the urinary system and requires retrograde stent placement and injection. lighted catheters have been proposed to help visualise the ureter. fluorescent dye-coated ureteral catheters could well represent a more effective and less expensive solution. icg is unsuitable for coating materials. aim: to develop a stable fluorescent coating for catheters to be used intraoperatively, working in the same nir window as icg, to facilitate its use with clinically available systems. project description: the coating was developed based on poly(methyl methacrylate) (pmma), a biocompatible polymer, and on specifically designed fluorescent dyes exhibiting icg-like optical properties. three nir dyes (substances a, b, and c) were tested in order to find the optimal one, in terms of fluorescence signal intensity, and were compared to icg in a polymer form and to an icg-based reference card (green balance tm ). the fluorescent coating was applied onto common ureteral stent materials: hydrophilic-coated ultrathaneÒ, silicone-coated latex, and pvc. the coating process involved cycles of immersion into the respective dyes blended in pmma polymer (icg, substances a, b, and c), followed by a drying phase. the various tubes were partly inserted into a porcine ureter, next to the icg-based reference card. images were taken in white light and nir modes using the d-light p camera system (karl storz), at a fixed camera-to-target distance. the fluorescence signal intensity was measured for the different regions of interest (each material/coating combination inside and outside of the ureter, reference card) using proprietary software and normalised against the reference card. preliminary results: the signal intensity was significantly higher for all new substances as compared to icg. substance a showed the strongest fluorescence signal intensity among the tested coatings in all tested conditions and materials and was identified as the ideal candidate to undergo further evaluation and in vivo testing. background: endoscopic resection(er) of early gastric cancers provides tremendous patient advantages. however, post-resection findings of deeper sub-mucosal(sm) and/or lympho-vascular invasion can necessitate a second, surgical intervention. we propose that pre-resection evaluation of the submucosal architecture under the tumour can provide critical information for staging and operative planning. we evaluate three techniques to assess the submucosal architecture underlying the gastric mucosa in a pig model. aim: to evaluate three needle-based methods of evaluating the sm before er. project description: acute pigs were used. a simulation of sub-mucosal tumours (endoscopically and eus visible bleb) by injecting the sm with cc of undyed nac. a linear eus was use for all procedures. the tumours were marked and labelled according to geography. methodology: after creating the tumours, anterior lesions were evaluated using the following g needle-based modalities: confocal microscopy(cm) using the through-the-needle cellvizio (mauna-kea) system; mini-biopsy(mb) using the micro-biopsy forceps moray (us endoscopy) and fine-needle biopsy(fnb). results: cm examinations were video recorded in all a positions. submucosal vascular visualisation was possible in all cases, excellent in / . mb was performed in lesions with a total of biopsies obtained from each lesion (total = ). fnb was performed once in the anterior lesions and twice in the posterior lesions with different needle brands. therefore, there was a total of biopsies collected. passes were performed in each biopsy (total = ). each pass constituted - insertion/withdrawal movements combined with fanning, slow pull technique, no suction and suction ( - cc air negative pressure) to collect the material. all material were sent to an animal anatomo-pathologist blinded to the acquisition method. mean time of confocal examination was min sec ( ' ' '- ' '') . mbtook a mean time of min and fnb was a mean of min for each biopsy. cm identified different patterns of vessels in relation to the probe position (superficial/reticular, middle cross-roads or deep/longitudinal). conclusion: eus-fnb, cm and mb are three potential methods to assess the sub-mucosal space underlying the gastric mucosa. cm offered the most architectural information but required more time to perform. these method's may have a role in better staging patients for appropriate er. background: the overall and disease-free survival of patients with rectal cancer is dependant on its staging, and adequate selection of the treatment strategy. mri has a proven efficacy in rectal cancer local staging and recognition of the adverse prognostic features. however, it can be difficult to utilise it as a navigation tool for surgeons, as it represents a complex three-dimensional pelvic space with a series of individual two-dimensional images. d image reconstruction has been successfully adopted in other surgical fields to overcome these limitations. aim: our primary aim is to develop a bespoke automated generation of patient-specific d pelvic models, which will improve surgical planning and navigation, patient interaction and surgical education. true-size, rotatable d models will offer a more realistic three-dimensional representation of the surgical space and its complex relationships, allowing for a more confident surgical rehearsal and potentially better utilisation of minimally invasive techniques in rectal cancer management. our secondary aim is to develop a large multipurpose database of the d models of male and female pelvis in health and in the disease. project description: our multidisciplinary team consists of colorectal surgeons, radiologists specialising in pelvic mri imaging and computer scientists. virtual d pelvic models are generated based on standard d dicom mri images routinely used for rectal cancer staging, which guarantees the high fidelity of cancer delineation. segmentation of the pelvic anatomy is performed with the use of itk-snap, an open-access, multi-platform software. machine learning technology is then employed to automate the d model generation, making it time-efficient, allowing for its clinical application. preliminary results: in the initial stage, using the manual segmentation, we have created ten models of normal male and female pelvic anatomy. a good inter-rater agreement level was found, which proves reproducibility of the approach applied. various machine learning algorithms are being explored to fully automate the process of d model generation, which will allow for their use in clinical practice and in development of the d colorectal database. the technology will be further implemented in creation of dynamic models of functional pelvic floor disorders. surgery, toho university omori medical center, tokyo, japan; surgery, neuchâtel hospital, neuch tel, switzerland background: laparoscopic gastrojejunostomies are time-consuming and require a specific training. alternatively, sutureless anastomosis can be achieved by means of endoscopically delivered magnetic rings. objective of the study: assessing the feasibility and reproducibility of an endo-laparoscopic gastrojejunostomy technique, using magnets coated with a fluorescent biocompatible polymer. methods and procedures: four pigs ( acute, survival models) and one cadaver were included in this study. the anastomotic device was composed of two magnetic rings ( x x mm; attraction force newton), each one attached to a cm long thread. the distal ring was inserted endoscopically into the first duodenum, and the extremity of the thread was clipped to the gastric mucosa. twenty-four hours later, a two-port laparoscopy ( mm, mm) was performed, using a near-infrared (nir) laparoscope (d-light-p; karl storz). the magnet's position in the jejunum was detected thanks to the transluminal fluorescence of the dye. magnetic interaction with the metallic tip of the laparoscopic grasper allowed to catch the ring and bring the bowel loop to the future anastomotic site on the gastric wall. simultaneously, the proximal magnet was delivered to the gastroesophageal junction using a flexible endoscope. the magnet was carefully advanced into the stomach allowing precise connection with the distal ring. in one cadaver the procedure was repeated. the sole variation was that, in order to reach the second jejunal loop, the distal magnet was placed using a gastroscope inserted through a transgastric port. in two acute animals, the distal magnetic ring was introduced into the jejunum via an enterotomy. the anastomotic procedure (from the distal magnet detection via fluorescence to the magnetic connection using a hybrid approach) was reiterated times. survival animals were followedup for days and underwent control endoscopies and ct-scans. results: the procedure was easy to standardize and reproducible, with a mean anastomotic procedure time of . ± . min. there were no technical problems and magnetic connection could be precisely directed in all cases, at both the anterior and posterior gastric wall. no complications occurred during the survival period and the anastomoses were patent by day . transluminal fluorescence allowed for a rapid detection of the magnet. colorectal cancer is the fourth most common cancer in high-income countries counting [ . deaths worldwide. survival rate reaches % in case of early diagnosis, falling down to % in case of advanced stage. conventional colonoscopy screening is limited by invasiveness, pain and often need of sedation. wireless capsule endoscopy enables inspection without discomfort, but passive locomotion often leads to incomplete and/or false negative results. the european endoo project (grant agreement ) aims to develop a novel system that overcomes most of the drawbacks of conventional colonoscopy, maintaining accurate and reliable diagnosis and therapy. the system is composed of an active robotic platform that magnetically drives a soft-tethered capsule; magnetic guidance is achieved through the magnetic localization of the capsule in combination with a closed-loop control that maintains an optimal and safe link between the capsule and the magnetic end-effector. a stereoscopic camera is integrated in the capsule for enhanced diagnosis though d reconstruction and automated detection of lesions/pathologies. the different modules of the endoo medical platform are illustrated in the figures. the robotic guidance systemconsists of an anthropomorphic manipulator that controls the capsule through an external permanent magnet. the robot, positioned on a dedicated trolley, is equipped with sensors for performing safe human-robot collaboration. the medical workstationincorporates: screens, buttons and pedals for visualization and command initiation, a joystick for system teleoperation and a back-end for fluidic control and data communication. the soft-tethered capsuleembeds an internal permanent magnet, magnetic sensors, an accelerometer, white and infrared illumination and an hd stereoscopic vision system with two wide-angle customized optics. a controller serves as the main control unitfor performing real-time communication and closed-loop control of the robot, localization system, capsule and physician commands. the synergistic cooperation of academic, industrial and clinical partners within the project allowed to develop and validate the system in in-vitro \/i [ , exvivoand preliminary cadaver sessions, performing comparisons with state-ofthe-art commercial colonoscopes. in conclusion, the endoo medical platform provides: reduced procedural pressures, user-friendly procedures, similar functionalities and performances of commercial devices, comparable procedural times and considerably lower costs with a new painless approach. background: this study is aimed at the comparison of the process of manual and robotic-assisted positioning of the electrode performing radiofrequency ablation with the usage of multifunctional robot-assisted surgical platform. under the control of the surgical navigation system. the main hypothesis of this experiment was that the use of a collaborative manipulator will allow to position the active part of the electrode relative to the center of the tumor more accurately and from the first attempt. we also check the stability of the electrode's velocity during insertion and consider some advantages in ergonomics using the robotic manipulator. methods: sphere-shaped tumor phantoms measuring mm in diameter were filled with contrast and inserted in cow livers. livers were used for the robotic experiment and an equal quantity for manual. the livers were encased in silicone phantoms. analysis of ct data gave the opportunity to find the entry and the target point for each tumor phantom. this data was loaded into the surgical navigation system that was used to track and record the position of the rf-electrode during the operation for further analysis. results: standard deviation of points from the programmed linear trajectory totaled in the average . mm for the robotic experiment and . mm for the manual operation with a maximum deviation of . mm and . mm respectively. standard deviation from the target point was . mm for the collaborative method and . mm for manual method. the average velocity was . mm/s for the manipulator and . mm/s for the manual method, but the standard deviation of the velocity relative to the value of the average velocity was . mm/s and . mm/s respectively.thus, in two criteria out of three, the manipulator is superior to the surgeon, and equality is established in one. surgeons also noticed advantages in ergonomics performing the procedure using the manipulator. conclusions: this experiment was produced as part of the work on the developing of the robotic multifunctional surgical complex. we can confirm the potential advantages of using robotic manipulators for minimally invasive surgery in case of collaborative practice for cancer treatment. surg endosc ( ) background and aims: laparoscopy has reduced tactile feedback compared to open surgery. in neuropsychological literature there is increasing evidence that visual and haptic information converge to form a mental representation of an object. through the combination of these inputs, this representation is believed to be more refined and robust. we investigated whether tactile exploration of a lifelike anatomical object before executing a laparoscopic action on this object in a laparoscopic box trainer improves performance of this action. description: a randomized prospective cohort study with two groups (a ? b) of ten laparoscopically naïve medical students was conducted. we compared the groups for baseline characteristics and performance, using a basic laparoscopic task (post and sleeve). to investigate the effect of haptic exploration, students performed ten repetitions of a laparoscopic needle action on a lifelike silicone caecum model (applied medical, rancho santa margerita, usa). group a did a pre-test visual exploration of the model. in group b manual exploration of the anatomical model was added to the visual exploration before executing the task. the box trainer was equipped with the forcesense tm (medishield, delft, the netherlands) system for skill assessment using objective force, motion and time parameters. results: baseline characteristics and-laparoscopic performance were comparable (p [ , ) . performances of trials on the anatomical model were captured and parameter outcomes were compared between groups. significantly less force (maximal force, maximal impulse, mean force and force volume) was exerted by the 'touch' group (p \ . ) (fig. ). this group also completed the task with less distance travelled by the instruments (p \ , ). there was no significant difference in time needed to complete the task (p = , ). conclusion: this study showed that, when performing a laparoscopic task on an anatomical model, pre-task haptic exploration of the model results in the use of significantly less force and less movement. adding haptic exploration to a laparoscopic training curriculum could therefore result in more efficient and more refined learning of laparoscopic actions. this, in turn, could lead to better, quicker and safer performance of laparoscopic operations. . esophagogastroscopy was performed before gabe and -week post-procedure assessing gastric abnormalities. weight and fasting plasma ghrelin were obtained at baseline, -, -, -and -months post-index procedure. after months, the sham group was unblinded and received gabe. both gabe and sham crossover to gabe groups were followed for months and received lifestyle therapy (behavioral-diet education). preliminary results: gabe was successful in all patients with no serious complications. significant, progressive weight loss was observed at and maintained at months. ghrelin in gabe group decreased by % ( . pg/ml) compared to baseline and months levels. weight-loss was approximately . % greater in the gabe group versus sham at months ( table ) . itt = intent-to-treat, pp = per-protocol analysis preformed using independent-sample t-test and à paired-sample t-test conclusions: gabe using eles is safe, accompanied by significant and so far maintainable weight loss. gabe using the eles demonstrated a reduction in ghrelin levels. aims: transanal total mesorectal excision (tatme) is the latest colorectal approach that continues to be in the spotlight. this study aims to describe the technique in depth by identifying and understanding technical advantages, errors and adverse events. methods: detailed video analysis using observational clinical human reliability analysis (ochra) was completed on clinical tatme cases performed by international surgeons. error frequency and error pathways leading to adverse events were described. tatme expert surgeons were interviewed and engaged in a workshop to elicit error-reducing mechanisms. results: overall technical errors and adverse events per procedure on average occurred ± . (range -- ) and ± . (range - ) times respectively. inadequate insufflation and poor camera optics were the most frequent set-up problems. instrument handling errors consisted most commonly of excessive grasper movement during the pursestring phase ( times total), inappropriate force applied ( times) with the energy device during the rectotomy, inappropriate force with the grasper ( times) and excessive movement with the energy device ( times) during tme dissection. incorrect dissection planes were created during tme dissection mostly due to insufficient retraction ( times) which didn't allow adequate exposure of the tissue planes. the most frequently occurring consequence was bleeding (mean: times per procedure). rectal perforation ( cases), vaginal wall injury ( cases), and prostatic injury ( cases) were also recorded. adverse events regularly occurred as a result of poor set-up/exposure, inappropriate retraction and/or instrument movement and incorrect plane surgery. error-reducing mechanisms and 'technical tips' describe specific steps and actions, both set-up/equipmentrelated and technique-related, that aim to prevent errors from occurring and avoid adverse consequences. ochra and individual feedback with error-reducing mechanisms developed by this study have been implemented into the national training programme for tatme. conclusion: tatme is an advanced complex procedure during which technical errors and their consequences are not infrequent. tatme requires knowledge of anatomy 'bottom-up', familiarity with its specialised equipment and technical skill working in a narrow space. appropriate structured training and mentorship are therefore recommended. surg endosc ( ) objective: insufficient vascular supply is one of the main causes of anastomotic leak in colorectal surgery. icg has been shown to provide information on tissue perfusion, identifying a well-perfused location for colonic and rectal transections and thus possibly reducing the leak rate. objective of this study is to evaluate the usefulness of intraoperative assessment of anastomotic perfusion using intraoperative indocyanine-green dye (icg) angiography in patients undergoing left-sided colon or rectal resection with colorectal anastomosis. methods: this randomized trial involved patients undergoing laparoscopic left-sided colon and rectal resection randomized : to intraoperative icg or to subjective visual evaluation of the bowel perfusion without icg (clinicaltrials.gov nct ). the primary aim was to assess whether icg angiography could lead to a reduction in anastomotic leak rate. secondary outcomes were possible changes in the surgical strategy and postoperative morbidity. results: after randomization, patients were excluded. accordingly, patients were included in the analysis; in the study group, and in the control group. icg angiography showed insufficient perfusion of the colic stump, which led to extended bowel resection, in cases ( %). an anastomotic leak developed in patients ( %) in the control group and in patients ( %) in the study group (p = n.s.). conclusion: intraoperative icg fluorescent angiography can effectively assess vascularization of the colic stump and anastomosis in patients undergoing colorectal resection. this method led to further proximal bowel resection in cases, however its role in reducing anastomotic leak rate should be studied in further research. endoscopic sleeve gastroplasty (esg) is a promising endoscopic bariatric procedure carried out with the application of transmural sutures resulting in a gastric reduction and gastric shortening. sutures are placed in u shape fashion, from the incisura to the fundus, which is preserved, using an over the endoscope suturing platform (overstitch, apollo endosurgery, austin, texas, usa). the choice of right lankmarks for suturing the gastric wall is extremely important for the efficacy and safety of the procedure. flexible endoscopy suffers from little anatomical reference points. correct spatial relation to precisely target the insertion of the helix device used for retraction and correct orientation of the full thickhness tissue bite require a good undrestanding of the anatomy of the stomach and sourrounding organs including vascular structures that could be inadvertently injured (left lobe of the liver, gallbladder, spleen, short gastric vessels, pancreas, transverse colon). surgeons by training can 'see' the anatomy beyond the gastric wall and undrestand whether they work in a safe layer or whether an underlying structure should be spared. this video illustrates all the potential risks realted with a wrong chioce of endoscopic landmarks when performing esg with respect to gastric and abdominal anatomy. introduction: central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are technically demanding procedures in minimally invasive approach because of difficult expoure and extensive parenchymal transection planes. with limited robotic instruments including absence of cusa, these procedures have been rarely perfomed by robotic approach. method: consecutive robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy were performed. patients were all males and were , , and -years-old, respectively. pathologic diagnoses were all hepatocellular carcinomas of each . , . , and . cm diameter. operative settings were identical for the three kinds of procedure. the patients were placed in supine with a reverse trendelenburg and right side elevation. umbilical -mm camera port, three -mm ports and additional -mm assistant port were used. glissonian approach and icg fluorescence image clearly demarcated the resection planes. parenchymal transection was performed using the maryland bipolar dissector and harmonic scalpel. the rubber band self-retraction method and third arm of robot system helped for stable and excellent exposure of surgical planes result: there were no conversions to laparoscopic or open surgery. the operative time was , , and min and estimated intraoperative blood loss was , , and ml. the pathologic surgical margin was . , . , and . cm. the length of stay after surgery was , , and days and there were no postoperative complications. conclusion: robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are still demanding procedures with long operative time. however, these procedures could be performed safely in regard to short-term perioperative outcomes. robot surgical system provided several benefits for anatomical hepatectomies including a stable and excellent operative field and clear surgical planes. suprapubic hernias (less than cm above the pubic arch in the midline) require important anatomical knowledge because of complexity of their repair and low incidence, by approximately % of all hernias. the problem to repair this type of hernias is that inferior margin of the defect is very close to pubic symphysis, consequently, mesh overlap is often inadequate. treatment of suprapubic hernias is controversial because of limited evidence in the literatura. this video shows the case of a -year-old female patient with suprapubic hernia with a defect of x cm. we performed a laparoscopic repair with a bilateral peritoneal flap of the groin region (as it is perfromed during tapp) for proper view of the pubic symphysis, cooper's ligaments, epigastric and major vessels, nerves and meticulous dissection the space of retzius. the defect was repaired by reconstructing the middle line with a running sutures. subsequently, titanium helical tacks were used to fix the mesh to the pubis and cooper and following the double-crown technique having special attention when fixing the mesh near to inguinal chanal, due to the possibility of causing chronic pain. the peritoneal flap was fixed over the mesh with abdsorbable fixation devices and seal with fibrin glue. laparoscopic repair of suprapubic hernias can be considered as the first option in treatment, because it endeavors to join the advantages of a minimally invasive approach and it is associated to low recurrence. the main advantages are that allows a proper visualization the anatomy and a proper fixation of the mesh. background and aim: thoracoscopic esophagectomy has been performed for two decades and becomes widely spread. we evaluate our cases who undergone the thoracoscopic esophagectomy and consider the future prospective of this operation.transient recurrent laryngeal nerve palsy after lymphadenectomy in this surgery is not rare and induces not only hoarseness but also aspiration or pneumoniae. new method to avoid this complication is desired. patients and methods: patients who received thoracoscopic esophagectomy in our institute from march to october were enrolled and studied retrospectively. operative indication is an all of the clinically resectable cases including with a neoadjuvant treatment or definitive chemoradiotherapy before surgery. overall survival rate of the patients with thoracoscopic approach and with thoracotomy until was analyzed. long term outcome of the patients with thoracoscopic esophagectomy was compared to the result from comprehensive registry of esophageal cancer in japan. short term results of the perioperative parameters were analyzed between left lateral decubitus position and prone position.we had introduced intraoperative nerve monitoring system for prone esophagectomy from . results: there was no significant differences of the survival rate between thoracoscopic group and thoracotomy group based on pathological stage. year survival without neoadjuvant treatment was . % (pstagei), . %(pstageiia), . %(pstageiib), . %(pstageiii), respectively. year survival rate of cstageii and iii with neoadjuvant chemotherapy was . % and year survival rate of the salvage esophagectomy after failure of definitive chemoradiotherapy was . %. every outcomes are as good as any reported results in esophagectomy. in the comparison of the lateral position with the prone position, total blood loss was significantly lower in prone position. inflammatory response after surgery was improved more rapidly in prone group, therefore, prone position is recommended as a minimally invasive procedure for thoracoscopic esophagectomy. transient recurrent laryngeal nerve palsy was observed % of patients. conclusion: thoracoscopic esophagectomy will develop further as a standard operation for esophageal cancer. nerve monitoring is useful for detecting recurrent nerve and avoiding nerve injury. background: laparoscopic total mesorectal excision (tme), in a wide female pelvis is usually technically easier than in a narrow male pelvis. however, this is not always the case, as the uterus and adnexae may obscure the views and hinder safe dissection, especially in obese patients. techniques such as graspers through additional ports or suspension with sutures through the broad ligament may potentially cause injury or need additional ports/assistants. aim: we present a novel technique using a self-retaining gynaecological uterine manipulator to improve access during deep pelvic laparoscopic surgery in female patients. technical tip: the operation is commenced in the standard manner for a laparoscopic rectal excision. once pelvic dissection is commenced, whenever it is felt that uterine retraction would be advantageous (depending on the level of the rectal tumour, size of the uterus and ovaries, obesity etc.) a self-retaining uterine manipulator (as shown in the video) is used. the tip of this disposable device is introduced into the uterus after dilatation of the uterine cervix. once the balloon at the tip has been inflated, the instrument is secure and hence there is no need for active manipulation by an assistant. the shaft can be rotated to allow anteversion/retroversion of the uterus to varying degrees as required to aid dissection. as the video depicts clearly, it acts as a self-retaining retractor for the uterus and is removed at the end of the operation. though the procedure is being demonstrated by a gynaecologist in the video, the instrument is quite easy to insert and some of our colorectal team have been trained as well. conclusion: the self-retaining uterine manipulator is an efficient tool for uterine retraction in laparoscopic rectal surgery and we have been using it routinely in tme in females for the past years, with no complications. this was previously published as a technical tip in the journal of minimal access surgerybut has never been submitted for peer review as a video. the authors present a video of two clinical cases treated by trans-axillary endoscopic approach. methods: a years-old male and a -year-old male presented with intermittent dysphagia and frequent reflux (class ii of lahey). one had a history of recurrent respiratory infections. the disease was characterized by oesophagogastroscopy (egd) and oesophagogram. trans-axillary approach with areolar port. step-by-step as follows: (i) dissection anteriorly to the pectoralis major muscle (ii) isolation of the anterior border of sternocleidomastoid muscle (iii) omohyoid muscle's isolation (iv) identification of the thyroid's upper pole (v) zd isolation (vi) myotomy of the cricopharyngeal muscle (vii) zd's resection with stapler and its withdrawn with sac. results: both cases progressed without complications. complete local recovery was verified in both cases one month after the procedure. conclusion: this technique seems feasible and reproducible, allowing zd diverticulectomy with a better cosmetic result and perhaps lower surgical site infections (ssi). in the authors' knowledge, this approach to dz has never been published. background: gastric leak occurs in - % of patients who undergo roux-en y gastric bypass (rygb) for morbid obesity. the pathophysiology may be related to gastric ischemia, fistula, or ulcer.gastric leak is a severe complication of gastric bypass (gbp) that is associated with significant morbidity and mortality. fistula may have several clinical impacts, depending on patientrelated factors, fistula characteristics, onset time, and therapy proposal. abdominal drainage, gastrostomy, and revisional surgery constitute the traditional approaches to dehiscence and fistula closure, with variable results. methods: we present a video of a clinical case of -year-old lady with body mass index of kg/m who underwent roux-en-y gastric bypass and h later presentedtaquicardia and right cuadrantum pain. the ctscan inform a apical leak at the gastric pouch level. the video shows the relevant aspects of a revisional surgery and the key points to drain the fistula and close de defect laparoscopically. results: after monts, the patient achieved succesful results, defined as a stabel clinical situation with image evidence of gastric fistula remision. conclusions: gastric bypass (gbp) is one of the most efficient bariatric interventions in morbidly obese patients. the most severe risk of this procedure seems to be the staple line leak, and the management of this complication can be very arduous. without any guidelines it is very difficult to determine the right procedure addressing the staple line leak after gbp. laparoscopic sleeve gastrectomy (lsg) has become the most commonly performed operation worldwide as a primary bariatric/metabolic procedure. however, conversion to other surgical procedures such as roux-en-y gastric bypass (rygb) or one anastomosis gastric bypass (oagb) have been described as treatment options for inadequate weight loss after lsg and unresolved co-morbidities or complications such as leak, stricture, and severe gastroesophageal reflux disease (gerd). we present two clinical cases of weight regain and severe gerd and dysphagia, which account for the main indications to reversal of lsg to either oagb or rygb. aims: we show in the video the surgical technique that we perform by laparoscopic aproach, in order to construct a roux-en-y polipropilene banded gastric bypass lrygb-b. methods: we are performing this procedures within a prospective randomized trial that is design to compare the long term results of lrygb-b versus the standard laparoscopic roux-en-y gastric bypass.the video shows our technique in a case of a years old female with a bmi of kg/m . first we create a vertical gastric pouch of about - ml, and a polypropylene mesh ( x mm) is placed - mm proximal to the anastomosis around the gastric pouch, with the help of a laparoscopic band retractor. after that a cm roux-en-y limb is constructed in an antegastric antecolic fashion, been the lenght of the biliary limb cm. a mm gastroyeyunal anastomosis is performed with a linear stapler, and the enterotomy and gastrostomy are closed with a / barbed running sutures. jejunojejunostomy anastomosis is constructed in similar fashion, but with a lenght of - mm. the petersen space and the mesenteric defect are closed with polipropilene / sutures. results: patients has been operated following this technique, and there has been no complications related to the polipropilene band. (the ramdomized prospective trial is still ongoing). conclusions:the video shows a reproductible easy way to perform a lrygb-b using a polipropilene mesh. introduction: a -year old female patient presented at our clinic two years after initial rouxen-y gastric bypass. she had had a preoperative bmi of , and had a significant weight loss which resulted in a bmi of , at two years postoperatively. she currently suffered from severe dumping with glycaemia levels dropping to mg/dl. pharmacological treatment with metformine, sandostatine and acarbose did not yield any results. on top of these problems she felt less restriction, could eat large portions and had gained kg in the last three months. objective: the usual approach for severe dumping-related hypoglycemia would be to undo the gastric bypass. this patient however was extremely anxious to regain weight, so we sought other options. we assumed that by adding more restriction and slowing down the emptying of the gastric pouch we could alleviate some-if not all-of the dumping related symptoms and prevent further weight regain. methods: in this video we present the banding of a gastric pouch for severe dumping after rouxen-y gastric bypass. results: although unconventional, the banding of the pouch yielded excellent results. the slower pouch emptying and reduced portions resulted in a near complete remission of all symptoms. as an additional benefit we found a slight weight loss of four kilograms six weeks postoperatively. conclusion: the usual treatment of severe dumping-related hypoglycemia would be an undo of the gastric bypass. in this case however the patient was extremely anxious to regain weight, being very pleased with the results her gastric bypass had yielded. in agreement with both the patient and treating endocrinologist we attempted a different approach. the slower pouch emptying and increased restriction offered another way to alleviate the dumping and deep hypoglycemia while concomitantly resulting in weight maintenance. aim: the aim of this video is to present a novel surgical technique to avoid stent migration after endoscopic placement in patients with leakage subsequent to laparoscopic sleeve gastrectomy (lsg) . methods: this video shows the case of a patient (bmi , kg/m ) who developed an upper gastric leakage days after lsg. a ct scan showed a small leakage at the eg junction complicated by intra-abdominal abscess. a ct guided percutaneous drainage of the abscess was performed. a stent placement was attempted endoscopically three times and failed for migration. we decided to place laparoscopically a non adjustable gastric ring (nagr) around the stomach, in order to avoid stent migration.first of all the stent is replaced endoscopically in order to cover the fistula tract. the patient is placed in a half sitting position and the pneumoperitoneum was obtained using a veress needle in left subcostal space. a port technique is used as in standard laparoscopic sleeve gastrectomy.the procedure starts with the mobilization of adhesions, the fistula is identified in the upper part of the tubule.the gastric tubule is isolated and the lesser omentum is opened. the blunt needle at the tip of the ring is passed retrogastrically, a tourniquet can be useful is the positioning turn out to be difficult. the nagr is then closed over the gastric tubule containing the stent. a drain is finally placed. results: the stent was removed after weeks. a gastrointestinal ct scan with oral contrast showed a complete resolution of leakage. after months the patient was in a good condition with bmi , kg/m . the stent was endoscopically removed after weeks. a gastrointestinal ct scan with oral contrast showed a complete resolution of the leakage. after months the patient was in a good condition with bmi , kg/m . conclusions: this new technique is feasible and effective, as shown in this video; however the nagr can lead to complications, so a strict follow up is needed and if any complication appears, should be considered to remove laparoscopically the ring. introduction: in this case, we will discuss the case of a year old male patient who underwent a laparoscopic cruraplasty and gastric plication resulting in a weight loss of kg. other medical history reported insulin-dependent diabetes, reflux esophagitis and sleeping apnea with cpap. two years after gastric plication the patient presented with passage problems, gastro-esophageal reflux and epigastric pain. to this end a swallow test was performed revealing a large fundus with a restricted passage of contrast. due to the persistent complaints and the abnormal findings on barium swallow a surgical re-intervention was needed. objectives: despite the current bmi of and the age of the patient, conversion from a gastric plication to a roux-en-y gastric bypass was performed. several other surgical options were considered, including an undo of the gastric plication or a dilatation with a resizing of the fundus. methods: in the video we describe the laparoscopic approach for a conversion of a gastric plication to a roux-en-y gastric bypass. results: at months follow-up the patient showed a weight loss of kg and the resolution of his earlier symptoms. the patient had a normal oral intake without any gastro-esophageal reflux or epigastric pain. conclusion: after a gastric plication, partial loosening of the sutures and stenosis are both wellknown complications. as presented in the video, it is apparent that a laparoscopic undoing of gastric plication is not as straightforward as it seems. firm adhesions between folds can compromise the procedure and inhibit a complete separation of the tissues. we believe that in these cases the best surgical approach is to convert to a roux-en-y gastric bypass. laparoscopic sleeve gastrectomy (lsg) is a relatively new surgical approach in the weight loss surgeon's armamentarium. in literature there is a consensus about the importance of mobilizing completely the gastric fundus before transection. the resg (revised sleeve gastrectomyresleeve) may be a valid option for failure of primary lsg. we focused the attention on the consequences that can have an incomplete resection of gastric fundus during an operation of sleeve gastrectomy and how they can be solved by the repetition of this procedure. a sleeve gastrectomy was performed in an obese -year-old woman (bmi = ). three days after the operation, an upper gi x-ray with gastrografin did not show any abnormalities. three months after the surgical procedure, the woman referred frequent episodes of vomiting and a significant weight loss ( kilos). an upper gi x-ray with gastrografin demonstrated the presence of multiple communicating cavities of the gastric fundus. the esophagogastroduodenoscopy (egd) showed that the gastric tube close to the esophagogastric junction was separated from a recess ( - cm in diameter) by an incomplete septum. a severe hypokalemia and consequent ecg abnormalities were treated with intravenous infusion of potassium. then, we performed a laparoscopic operation. the gastric tube was completely released along the suture line of the previous operation and, especially, the posterior surface of the upper part until the left crus of diaphragm became evident. under the guide of the bougie, the recess was removed. results: the clinical course was regular, and the patient was discharged on third post-operative day after an upper gi x-ray with gastrografin which demonstrated the absence of leakage and a normal gastric tube. after year, the patient was very satisfied with the operation. conclusions: the complete mobilization of the gastric fundus allows to see clearly which part should be resected to obtain an adequate gastric tube and facilitate a correct placement of the stapler. in our experience, in patients with a residual fundus, an upper gi x-ray with gastrografin and an egd are needed to exclude the presence of stenosis. then, a resleeve gastrectomy is an efficient and safe procedure to treat this post-lsg complication. weight regain is one of the main problems in bariatric surgery. we have many surgical option but when we evaluate patients with long follow up and bmi of superobese patient before the first surgery, the weight recidivism can arrive up to - % at years.in most cases the first surgery is a restrictive procedure, and in many cases sleeve gastrectomy.here we present a case of weight regain after laparotomic super-magenstrasse (that we consider like a sleeve gastrectomy except for remnant removal) with a big incisional hernia. after a complete multidisciplinary re-evaluation we decided to perform an oagb (one anastomosis gastric bypass) but in this case we decided to create a functional exclusion to the duodenal transit by positioning a minimizer ring. this solution is effective in food diversion and guarantee gastric and duodenal endoscopic exploration in case of need. we think that this technique can represent an option to take in account for selected cases. at the end of bariatric procedure we perform a laparoscopic repair of incisional hernia with mesh in the hope to avoid future surgery and post operative small intestine herniation. patient rejected additional bariatric procedures and in fact she has gained kg two years later (bmi . ). conclusions: lagb gastric erosion is uncommon ( . - %) . intraoperative (such as perigastric approach) and patient related factors (smoking, alcohol…) have been described as risk factors. the most frequent clinical presentation is weight loss failure; band and port issues (such as infection) are also frequent. erosion is infrequent to present as an acute event (\ %: peritonitis, abscess…) or asymptomatically (\ %). diagnosis is mostly performed under upper endoscopy. the most common therapeutic technique is removal of the band (by endoscopy or surgery), repair of the stomach, if needed, and band replacement (at least three months later). some authors have performed immediate replacement but the incidence of recurrent erosion seems to be higher. other options are lagb removal alone or conversion to different bariatric procedure. for endoscopic removal, it has been advised to wait until the band buckle is in the stomach and is sometimes very difficult. replacement of the band is not associated with weight regain. she reports years of evolution presenting moderate intensity heartburn that was exacerbated during the night as well as submit occasional rejurgutation. the intensity of the symptoms is attenuated by maintaining a diet without irritants and improving feeding times. denies hematochezia, unintentional reduction of weight, dysphagia or early satiety. the patient has suffered from obesity since childhood, after pregnancy she had progressive weight gain and difficulty in controlling blood sugar, so she is scheduled a gastric bypass roux-en-y . preoperative endoscopy was performed, evidencing submucosal tumor in the gastroesophageal junction at of the dentary arch, approximately cm in diameter. an endoscopic ultrasound was performed, demonstrating subepithelial lesion of the gastroesophageal junction, hypoechoic, with well-defined borders, pseudobilobulated, . cm x . cm, and dependent on the external muscular layer. a fine needle aspiration is performed in which spindle cells are identified, leiomyoma is likely diagnosed. it is programmed for laparoscopic resection of submucosal gastric tumor, gastric bypass and laparoscopic cholecystectomy. a tumor at the level of the gastro esophageal junction of approximately . cm is identified in the surgery, which can be resected by laparoscopy without complications. the patient is discharged after days of postoperative stay. the final histopathological result: leiomyoma of . cm with free edges. cd (-) gog (-) caldesmon (?)s (?). background: fifty percent of patients who have undergone gastric bypass, posterior reversal and sleeve gastrectomy and finally complete hiatoplasty presents symptomatic gastroesophageal reflux disease. surgical reinforcement of the lower esophageal sphincter is necessary to prevent acid reflux. here, we describe ligamentum teres cardiopexy, a surgical technique that reinforces the lower esophageal sphincter and restores its competence with a new valve, in patients with previous conversion of sleeve gastrectomy to gastric bypass and hiatal hernia repair. methods: we present the surgical techhnique performed to a patient with initial gastric bypass who underwent sleeve gasterctomy for hipoglycemias and hiatoplastia for severe gerd. persistent gerd requested to undergo ligamentum teres cardiopexy. in this procedure, the ligamentum teres is released from its umbilical connection and the hernia reduced by manual traction, freeing the last - cm of esophagus in the abdomen. the distal ligamentum teres is fixed with one stitch to the apex of the angle of his, one at the gastroesophageal junction, and one joining the gastric fundus to the esophagus. the remainder of the ligamentum teres is fixed over itself with four to six stitches, forming a necktie cardiopexy. the procedure concludes with diaphragmatic crus closure. results: after months, the patient achieved successful results, defined as resolution of gerd, no protonpump inhibitor (ppi) use, and manometry measurement over mmhg after surgery. conclusions: ligamentum teres cardiopexy combined with closure of the gastric crus is a late alternative treatment for gastroesophageal reflux disease in patients with previous sleeve gastrectomy and hiatal hernia. general surgery, ponderas academic hospital, bucharest, romania introduction: as metabolic surgery techniques evolve during the years, we have to face more and more patients with complications ands uboptimal results after the older/initial procedures. vertical banded gastroplasty(vbg) is one of those procedures that gain momentum during the initial experience in bariatric surgery, but has proven to have dissapointing results and a lot of complications, nowadays surgeons having to deal with difficult revisional operations. aim in this video: we want to present from our experience the difficulties encountered during the revisional surgery, rouxen y gastric bypass (rygbp)aftervbg, and the tips and tricks that will make this a safer and easier procedure. objective: after thorough preoperative assessment and a review of the literature multiple treatment options were considered. the procedure of choice ended up being a laparoscopic adjustable gastric banding, with the objective to achieve optimal weight loss with the lowest risk for complications. methods: in this video we present the placement of an adjustable gastric banding in a patient with a cirrhotic liver and portal hypertension and the possible pitfalls. results: postoperatively there were no complications and patient had a satisfying weight loss both months and year postoperatively. in a short review of the literature we've found that bariatric surgery is feasible in patients with portal hypertension as long as the patient is not decompensated or has bleeding varices. conclusion: cirrhosis and portal hypertension are no absolute contraindication for banding, sleeve or rny gastric bypass as long as the patient is not decompensated or has bleeding varices. the type of surgery is dependent on patient and surgeon-related factors. the aim should be to achieve optimal weight loss with the lowest possible surgical risk in this type of patients. surg endosc ( ) :s -s introduction: in this case, we will discuss on a year old female patient who had undergone a laparoscopic nissen fundoplication years ago due to gerd grade b. because of morbid obesity a n-sleeve gastrectomy was performed year ago resulting in a weight loss of kg. at presentation she had regained all the lost weight, resulting in a bmi of , . the patient history also reported insulin-dependent diabetes and obstructive sleep apnea with cpap. gastroscopy was performed showing a large residual fundus but no esophagitis. on the subsequent upper gi series a relatively wide sleeve with an intact nissen-collar was detected. objectives: a laparoscopic conversion to a roux-en-y gastric bypass was performed. other potential surgical treatment options are a sadi procedure or a sleeve gastrectomy with transit bipartition (santoro procedure). methods: in the video we describe the laparoscopic approach for a conversion of a n-sleeve to a roux-en-y gastric bypass. results: at month follow-up the patient presented with a weight loss of kg. the patient had good restriction on oral intake and did not have any reflux-related symptoms or complaints. conclusion: conversion from a n-sleeve to a roux-en-y gastric bypass is a challenging procedure. the largest pitfall during the creation of the gastric pouch is to staple a double fold of the nissen fundoplication. we believe that in these rare cases of weight regain after n-sleeve, the best surgical approach is to convert to a roux-en-y gastric bypass. four years later, in , a laparoscopic conversion to roux-en-y gastric bypass was performed because of weight regain. she now presents with satisfactory and stable weight loss over the last few years. she was recently diagnosed with a brca- mutation for which she underwent a bilateral ovarectomy and mastectomy. the patient's brother was also diagnosed with this mutation and died of pancreatic cancer at the age of . genetic counseling advised a twoyearly follow-up because of an increased risk up to % of developing pancreatic cancer. control gastroscopy showed a normal esophagus and gastric pouch. control ct scan revealed hypertrophic stomach creases in the excluded stomach. these results prompted a laparoscopy-assisted gastroscopy of the excluded stomach which uncovered hypertrophic stomach glands and intestinal metaplasia on biopsy. methods: in this video we demonstrate the laparoscopic approach for complex revisional bariatric surgery. conversion from rny gastric bypass to a sleeve gastrectomy in a patient who already underwent a vbg. the focus of the video is on a manual gastro-gastrostomy with partial gastrectomy of the fundus and part of the stomach where the old vbg-band was placed. results: after , months follow-up the patient had no complaints and a stable weight. upper gi series shows a normal passage of contrast through the sleeve gastrectomy. conclusion: endoscopic surveillance of the remnant stomach and echo-endoscopy of the pancreas is no longer possible after rny gastric bypass. in cases where the need for such a surveillance arises after a rny bypass a patient-tailored approach is necessary. in our patient a laparoscopic conversion from a rny gastric bypass to a sleeve gastrectomy was performed. this approach keeps the patient's wish for weight loss intact while enabling further surveillance through natural-orifice endoscopy. a -year-old morbidly obese japanese woman with a body mass index of kg/m suddenly complained of swallowing difficulty months after laparoscopic roux en y gastric bypass surgery with retro-colic roux limb route. an internal hernia of the defect of the transverse mesocolon was suspected by computed tomography, and emergency intervention was performed. the surgery revealed no internal hernia. however, strong inflammation and adhesion were observed between the transverse mesocolon and the retrocolicroux limb. in addition, the roux limb on the oral side of the adhesion site was dilated and bent.the adhesion between the transverse mesocolon and the flexed roux limb was dissected, linearized and re-fixedby suturing to the transverse mesocolon. however, since the difficulty of oral intake persisted re-do surgery was performed again. after resecting the roux limb involved in the severe inflammation, a 'new' roux limb was lifted to the cephalad via the ante-colic route. finally, the gastric pouch and roux limb were re-anastomosed with - absorbable sutures in an interrupted full thickness single layer manner. in the present case, we experienced difficulty with both adhesiolysis and determining the accurate target line to resect at the 'old' gastrojejunostomy. however, blocking the blood flow of the 'old' roux limb facilitated the accurate recognition of the target line. esofagogástrica, cirugía general y ap digestivo, hospital regional universitario de málaga, malaga, spain; hepatobiliopancreática, hospital regional universitario de málaga, malaga, spain introduction: marginal ulcer is one a serious complications after a bariatric gastric bypass. tobacco, non-steroidal anti-inflammatory drugs (nsaids) and helicobacter pylori (hp) infection are known risk factors. methods: we present a -year-old women operated years before of bariatric surgery with a gastrojejunal (gy) bypass technique due to intraoperative dehiscence of the staple line after attempting a vertical gastrectomy (sleeve). she has persistent vomiting and epigastralgia from months after the intervention, affecting his quality of life. upper gastrointestinal endoscopy (uge) was performed, describing an ulcer in the gy anastomosis. she started hp eradication treatment, treatment with proton pump inhibitors (ppis), tobacco and nsaids were discontinued, but she had slight improvement. after months the uge was made again, which show peptic esophagitis and marginal ulcers. the plasma gastrin level was normal. due to the persistence of symptoms despite conservative treatment, we decided reoperation by laparoscopy. we found herniated bowel in petersen space, which were reduced and the space was closed. we proceeded to truncal vagotomy. the gy anastomosis was resected ( fig. ) and performed again. finally, we perform antrectomy. the pathological anatomy showed ulceration. she was diacharged home on the th postoperative day without any complications. results: a marginal ulcer after bariatric surgery appears in the jejunal mucosa of the g-y anastomosis. the symptoms are epigastric pain, nausea and vomiting. acid, tobacco, nsaids and hp infection has an important role in their development \ sup [ . \/sup [ the first treatment is medical, discarding out the risk factors, but if it is not effective, it will be surgical, resecting the previous anastomosis. the usefulness of vagotomy is debatable, but the percentage of success increases. in our case, we perform antrectomy to avoid retained antrum syndrome. the hernia through petersen space is a cause of intestinal obstruction and abdominal pain as the case presents. although we believe that the symptoms were mainly caused by the marginal ulcer, the internal hernia was probably a symptomatic cause. conclusion: the treatment of a marginal ulcer is medical, eliminating the risk factors, but if it is not effective, the surgery is indicated. results: bowel's measurements and confection of the gastric pouch are identical in both cases. in the first case, intestinal anastomosis is performed in the inframesocolic compartment once small bowel has been divided. in the second case, such union is made next to the gastrojejunal anastomosis with the bowel uncut, making the section once no leakage has been found conclusions: laparoscopic roux-en-y gastric bypass is currently considered one of the technique of choice in the surgical treatment of morbid obesity. there are variations and alternatives for its realization. to know them can allow to individualize the technique to each type of patient. we present a clinical case of a year old female. she had a vertical banded gastroplasty procedure (in another clinic) years ago with an initial weight loss of kg in a period of months. she was seen at our clinic because she was suffering from dysphagia to solids and general diffuse abdominal pain for the last month. at physical exam we found a bmi of and nothing else called our attention. we did an upper gi endoscopy and egd transit; we concluded that a gastric bypass would offer her the best results. therefore, we converted her vertical banded gastroplasty into a gastric bypass laparoscopically. she had an uneventful postoperative period and was discharged home without complications. aims: sadis emerged as a modification of biliopancreatic diversion with duodeno-ileal switch (bpdds) in which after sleeve gastrectomy (sg), the duodenum is anastomosed to an ileal loop in a billroth-ii fashion. sadis has promising outcomes for weight loss and comorbidity resolution in morbidly obese patients avoiding the high morbidity of biliopancreatic diversion with duodenal switch. clinical case: -year-old patient, subjected to bariatric surgery two years ago, including a sleeve gastrectomy (sg). despite this operation and dietary and hygienic modifications, the patient gained weight in recent months, reaching a bmi of kg/m and an overweight of kg. an endoscopy was carried out on her, which provided evidence of a gastric remnant of moderate size with flexible tissue, normal peristalsis, and fast disposal speed. the case was discussed in a joint session, leading to the decision to apply revision surgery. the decision was taken to apply sadis, a novel technique that had never been used before in andalucia. the rate of weight re-gain after the use of classical techniques such as sleeve gastrectomy (sg) or the roux-en-y gastric bypass (rybg) is considerable high. revision surgery due to weight re-gain is necessary in many of these cases. sadis emerged as a simplified alternative to the use of bpdds as revision surgery following a gv due to weight re-gain with good short-term results, in terms of both weight control and comorbidity control. since only one anastomosis needs to be applied, chirurgical time diminishes, as well as the rate of surgery-related complications. moreover, it could be used, through laparoscopy, for patients who have undergone previous, complex abdominal surgery. conclusion: sadis showed a promising short-term weight loss outcome and comorbidity resolution rate but long-term data are missing and there is currently a high level of technical variability. on the other hand, further studies are required to measure its cost-effectiveness compared to the currently popular bariatric procedures, sg and rygb. aims: the lps sleeve gastrectomy is the most common bariatric surgery technique because it has a low surgical complexity and acceptable weight loss results. however, - % of patients present with an insufficient weight loss, weight regnances, reflux or dysphagia. in these cases, it is recommended to perform a second bariatric surgery to combine a component of malabsorption such as gastric bypass or duodenal switch. the video describes the technique of a laparoscopic biliopancreatic diversion with duodenal switch with a previous laparoscopic sleeve. the objective is to describe the safety of the technique and the subsequent success of it. methods: a -year-old female patient presented morbid obesity with a bmi of after performing a laparoscopic sleeve gastrectomy in . initially, she presented a percentage of excess weight loss of %, reaching a bmi of after two years of follow-up. after this, she suffered a reganancia of all the weight lost despite diet and exercise, presenting a bmi . a study was made with tegd where no complications of the previous surgery or symptoms of gastroesophagical reflux or dysphagia were observed. the lps duodenal switch is proposed in the obesity unit committee in , without immediate postsurgical complications. the patient presented a favorable postoperative period and was discharged three days postoperatively. results: at the present time, the patient has achieved a % excess weight loss and has a bmi of . . presents good oral tolerance with stools a day without urgency. it doesn't present protein deficioncies. vitamin deficiencies are orally supplemented. the lps duodenal switch is a technique that can be performed after a sleeve gastrectomy safely in cases of insufficient weight loss or weight reganancia. the patients presented a greater weight loss after the duodenal switch than after the gastric bypass, observing a lost of excess weight of % compared to %. the differences being statistically significant. weight regain after gastric bypass is a challenging problem. a number of revisional surgical options have been reported. this is a case of a year-old woman years after lrygb. her initial bmi was , lowest after surgery- , at presentation- . the video shows a robotassisted laparoscopic conversion of rygb to loop duodenal switch. the roux limb is transected and dissected to the gastrojejunostomy. the gastrojejunostomy is resected and the gastric pouch is recreated over a bougie. the gastric blood suply is confirmed with icg. a gastro-gastrostomy is created to restore gastric continuity and a sleeve gastrectomy is performed. the duodenum is devided and a duodeno-ileostomy is created cm from the ileocecal valve. the remaining roux limb is resected. the patient recovered uneventfully. conversion of rygb to loop duodenal switch requires creation of as little as two anastomoses, in comparison to standard ds, which requires four. it is a safe option for patients with weight regain after lrygb. methods: irb approval and informed consent have been obtained. a dissection is conducted to separate the descending mesocolon of the gerota's plan from the medial aspect to the peritoneal lining to the left parietal gutter. the peritoneal layer is incised parallel to the vessel and close to the colonic wall. the dissection is continued anteriorly up to reach the resected parietal gutter. a passage into the mesentery of the upper rectum is created for the allocation of the stapler and the dissection of the rectum. these maneuvers permit to straighten the mesentery simplifying the identification and cutting of the sigmoid arteries. a caudal-to-cranial dissection of the mesentery is performed from the sectioned rectum to the proximal descending colon by a sealed envelope device. it can be very useful to mobilize the colon in any direction: laterally, medially, or upward. the dissection is performed along the course of the vessel up to the proximal colon, with progressive sectioning of the sigmoid arterial branches. the specimen is extracted by a pfannenstiel incision. the anastomosis is performed transanally with a circular stapler according to knight-griffin technique. results: we performed a laparoscopic segmental colectomy using this approach for patients with benign sigmoid lesions: diverticulitis, flat polypoid lesions (no lift-up sign), and bowel endometriosis. the mean operative time and blood loss were . ± . min and ± ml, respectively. there were not a single conversion to open surgery and no any leakage or stricture. only cases of intraluminal bleeding and case of wound infection (treated conservatively) were observed. conclusion: we consider this approach to be safe and useful for segmental colectomy to be performed sectioning the sigmoid artery close to the colonic wall. aims: to show a clinical case with a video of a patient was operated for colon cancer in hepatic angle by a single suprapubic incision (ssilrh). methods: a -year-old male assessed for abdominal pain and weight loss. on physical examination: a painful mass was detected in the upper right quadrant. the colonoscopy revealed an ulcerated lesion in the hepatic angle and the biopsy revealed a moderately differentiated adenocarcinoma. in the abdominal ct a mass of x cm was observed (figure). the patient was operated with ssilrh technique, as shown in the attached video. results: the patient was placed in the supine position and with the legs separated. the surgeon is placed between the patient's legs. a transverse incision of the skin was made in the middle line of . cm to cm above the pubis. the underlying fascia was divided transversely, the rectus abdominal muscle was exposed, a purse-string suture placed in the fascia. an mm reusable trocar was inserted for the chamber, a mm reusable flexible trocar was placed at the o'clock position and another trocar was placed at the o'clock position. the ileocecal valve was released from the peritoneal parietal foil, as well as the mesocolon right by a lateral to medial approach to the second portion of the duodenum. the hepatic angle was also dissected from lateral to medial. for the anastomosis, the mm trocar was replaced with a mm trocar and a stapler was placed. a mm °chamber was inserted through the mm flexible trocar. the small intestine was divided as well as the proximal transverse colon with endogia. an intracorporeal ileocolic anastomosis was performed. the piece was removed through the suprapubic incision. he was discharged after days without complications. the histological studies confirmed a differentiated adenocarcinoma of x x cm. the surgical margins were free, without infiltrated lymph nodes ( / ) with stage pt n . the ssilrh technique allows a complete resection of the mesocolon and complies with the oncological principles. they can present with abdominal pain, nausea, acute abdomen, symptoms of intestinal obstruction or asymptomatic with incidental diagnosis. their diagnosis can be difficult. the objective is to demonstrate the safety and efficacy of the laparoscopic approach in this infrequent pathology. material and methods: we present a video of the surgical intervention of a -year-old patient, with functional dyspepsia, with a casual diagnosis of a pseudocystic mass of the right colon after performing a ct scan: giant diverticulum of the hepatic colon angle with fecaloid content inside it under tension the patient goes to the emergency room for acute abdominal pain, pending colonoscopy, antibiotic treatment is established, and a laparoscopic approach is decided upon after the patient's evolution. results: intervention: complete laparoscopic approach, trocars. large size tumor in the right colon, diverticular in appearance, with stony content inside, with locoregional adenopathies, oncological radical right hemicolectomy, manual intracorporeal anastomosis, correct postoperative, hospital discharge. on the th day. definitive pathological anatomy: giant diverticula on areas of intense mucosal ulceration, free edges. conclusion: the laparoscopic approach of the symptomatic diverticula of the right colon is safe and effective. introduction: minimally invasive transanal surgery (tamis) is a surgical technique whose established indications are the complete exeresis of rectal polyps that are not resectable endoscopically or early rectal neoplasms with good prognosis criteria. transanal devices with gel platform facilitate dissection in this field. however, one of the drawbacks of this approach is the oscillation of the right nerve, which hinders dissection and prolongs the surgical time. material and methods: we present the case of a patient with a central depression neoformation, located cm from the anal margin in the posterior aspect of the rectum in a male patient. the lesion occupies % of the circumference and was considered unresectable endoscopically. the endoscopic biopsies showed a tubulovillous adenoma with moderate dysplasia. results: an exeresis of full thickness of the rectal wall is performed, with subsequent suture of the defect. we show in the video the use of a glove interposed in the pneumoperitoneum gum to maintain the stability of the neumorectum and the technique of dissection and suture, as well as the stability of the neumorectum with this technique throughout the procedure. the use of a glove as a reservoir to stabilize the nemorectum is an economical and easy-to-use method that can safely replace extra devices. aims: endometriosis is a gynecologic disorder defined by the presence of endometrial glands and stroma outside the uterine cavity. deep infiltrating endometriosis (die) invades mm to the retroperitoneum of the pelvic sidewalls, the rectovaginal septum, or the muscularis of the bowel, bladder or ureters. the rectum is being the most common bowel site of involvement. for symptomatic die, medical therapy should always be the first-line treatment. therefore, a minimally invasive approach using laparoscopy is considered the gold standard option and challenging aiming at complete disease excision. also, there are several advantages of natural orifice specimen extraction when compared with abdominal incision that may directly impact the postoperative results of these young patients. methods: we report a case of a -year-old female with a -month history of chronic pelvic pain, dyschezia and rectal bleeding. these symptoms were refractory to hormonal, antispasmodic and opioid therapy. magnetic resonance imaging reported a nodule x cm invading the rectal wall cm to the dentate lane. we performed a laparoscopy and we found the nodule at the uterine posterior wall invading the rectal anterior wall. the nodule was invading into the rectum in a large area so we proceeded with segmental resection and added hysterectomy and salpinguectomy because it was the preference of the patient. the anastomosis was created intracorporeally and the specimen was removed through the vagina performing in this way a totally laparoscopic procedure with natural orifice specimen extraction. results: the total operative time was h, the postoperative stay was uneventful and the patient was discharged on day four. the pathological report showed an endometrioma cm length predominantly involving colonic muscularis propria. conclusion: laparoscopic surgery is a safe and feasible approach for the surgical management of deep infiltrating endometriosis of the rectum and the gold standard for female young patients that often need multiple surgeries. in addition natural orifice specimen extraction avoids potential complications of abdominal incisions. week-day surgery, university, sapienza, ospedale sant'andrea, rome, italy; urology, clinica mater dei, rome, italy aims: we describe a case of a patient affected by a mass in the left kidney and a diverticular stenosis of the sigma. methods: a years old woman complained abdominal pain in the left flank of the abdomen and in the left iliac fossa radiated to the hypogastrium, with fever and no passing flatus. contrast enhanced computer tomography scan (ct-scan) showed a cm mass of the superior pole in the left kidney and a colonic diverticulitis with thickness of the wall and a microperforation of the sigma. she underwent to medical therapy with resolution of the diverticulitis. after weeks a laparoscopic nefrectomy and sigmoidectomy was planned. patient was positioned on the right flank. this position was kept for both the procedures. we performed four trocar accesses along the left subcostal region and a periombelical incision for the specimen extraction. results: post-operative course was uneventful. patient was discharged in post-operative day. istopathological exam showed a renal cell carcinoma confined to kidney with no positive lymph nodes and a diverticular stenosis of the sigma. laparoscopy allowed to perform two fine procedures in a critical situation using few trocar incisions and obtaining good results. background: hartmann procedure consists in a sigmoidectomy followed by a terminal colostomy. stoma is associated with complications and suboptimal quality of life, so the restoration of colonic continuity should be at least considered in any case. open restoration has been associated with significant morbidity and mortality. many authors have described the advantages of laparoscopic hartmann reversal. we want to go a step further showing our experience using a combined laparoscopic and transanal approach in an attempt to improve the surgical technique in a patient with previous abdominal surgeries and a rectovaginal fistulae. methods: the transanal and laparoscopic team work simultaneously. by the abdominal approach a pericolostomic incision is made, the distal affected colon is resected and a purse string suture is performed around the anvil of the eea mm single-use stapler with . mm staples (autosuture, covidien). a mm umbilical trocar is located for a °camera and a gelport laparoscopic system (applied medical) with two mm trocars is introduced through the colostomy wound. hard pelvic adhesiolysis was performed and splenic flexure was also mobilized.the gelpoint path transanal access platform (applied medical) is introduced through the anal canal with three trocars in a triangle position. the proximal rectum and mesorectum are dissected until the peritoneal reflexion. the previous stapler line with the resected tissue is then exteriorized throught the anus. the distal rectum is prepared with a circumferential purse string suture. the vaginal defect was sutured transanally. the proximal colon and the anvil are extracted through the rectal stump and connected to the circular stapler, performing an end-to-end anastomosis. results: the total operative time was h. the postoperative stay was uneventful and the patient was discharged on day . conclusions: as in patients with rectal cancer, dissection of the stump in hartmann reversal procedure may be better and associated with shorter operative time. as with any new surgical procedure, it is probably too early to draw conclusions but nowadays transanal combined with laparoscopic approach seems to be a safe and feasible technique to perform a hartmann reversal, especially in challenging cases. intravenous and endoluminal contrast enhanced ct revealed the presence of a large retroperitoneal fluid and gas collection, due to diverticular perforation, extended from pelvis to iliac bifurcation, involving the left urether. no hydrosoluble contrast media leakage or massive pnuemoperitoneum were present. after an initial conservative treatment without significant improvement an emergency laparoscopic left colectomy with primary anastomosis and laparoscopic retroperitoneal collection drainage was performed. the laparoscopic approach was very challenging due to the obesity of the patient and the presence of the abscess. the patient was discharged on pod after requiring re-intervention for dehiscence of the left iliac mini-laparotomy on pod . conclusion: diverticular perforation in obese patients adds a further challenge to its laparoscopic treatment and deserves an aggressive surgical approach since its outbreak. although intracorporeal anastomosis has been demonstrated to be safe and effective after right colectomy, limited data are available about its efficacy after left colectomy for colon cancer located in splenic flexure. there are few studies comparing patients who underwent laparoscopic left colectomy with intracorporeal anastomosis or with extracorporeal anastomosis. anyway literature shows that there is no significant difference between intracorporeal anastomosis and extracorporeal anastomosis about oncological result. as for right hemicolectomy, intracorporeal anastomosis seems to show a trend towards a faster recovery after surgery due to the shorter time to flatus and lower post-operative pain expressed in the mean vas scale. laparoscopic left colectomy with intracorporeal anastomosis is associated with a lower rate of post-operative complications as for right colectomy. literature results could suggest that a complete laparoscopic approach could be considered a safe method to perform laparoscopic left colectomy with the advantage of a guaranteed faster recovery after surgery. as usual further randomized clinical trials are needed to obtain a more definitive conclusion. we show a video of a years old patient with a pure splenic flexure colon cancer who underwent to a laparoscopic left hemicolectomy with intracorporeal anastomosis. case presentation: here we describe a case of a year old asthmatic and hypertensive lady with an asa score of iii who presented to emergency after a right knee replacement with a four day history of lower abdominal pain. she was septic upon arrival to the resuscitation roomimmediately prompting the hospital's local septic management protocol. a ct scan of her abdomen showed a rectosigmoid perforation with free intra-abdominal air and fluid. the patient underwent laparoscopic hartmann's procedure within h of admission. after an uneventful postoperative recovery the patient was discharged home after a total of days of hospitalisation. she was followed up at surgical outpatients with no adverse events over the course of the subsequent months. conclusion: this case exhibits the feasibility of laparoscopic hartmann's procedure as a surgical modality for hinchey stage iv diverticulitis. the positive outcome supports the claim that for experienced surgeons laparoscopic hartmann's procedure remains a safe and viable option for elderly comorbid patients in the emergency setting. introduction: mesenteric cysts are a very infrequent pathology, they usually present an anodyne clinic, and their diagnosis is reached casually. objectives: to demonstrate the safety and efficacy of the laparoscopic approach, in cases with intra-abdominal cysts of benign etiology, using material with mini-instruments, reducing surgical aggression, maintaining its safety and efficacy.material and method: clinical case: a -year-old man with no personal history of interest. in the last two months he presented episodes of pain in the right hypochondrium, exploration without findings, us-ct scan: a cystic tumor of cm. in hepatic colon angle compatible with uncomplicated benign mesenteric cyst, tumor markers and normal colonoscopy. evidence of interest is exposed. given the evolution it is decided tto. elective surgical. result: intervention: laparoscopic approach, trocars, two of . mm, optics of mm °, benign cystic tumor, with colloid content of more than cm. of diameter in antimesenteric border of colon, which is not possible to separate, mobilization and resection is carried out by endo-gia, including a portion of the colonic wall, appendectomy, extraction in a pocket. good postoperative course, alt to nd day. definitive ap: mesenteric cyst, absence of malignancy. the laparoscopic approach is a valid and effective alternative in cases of benign intra-abdominal cystic pathology, the use of mini instruments reduces surgical aggression, favoring the recovery of the patient. male, yr, wuth doblue post-operative coloanal stenosi and women, with ultralow rectal neoplatis stenosis ( cm from anla verge). both patients were discharge ater days from prosthesis positionins without pain and complications. the first patient, with protection ileostomy, showed fecal incontinence before the operation and was performed prosthesis positioning because rectal losses of infected material and fever. fecal incontinence was showed also after procedure but he had not fever. second patient, yr, with ultralow rectal tumor, after prosthesis positioning was submitted to radiotherapy and she decided for not to be operated and she survives after months in ful well-being. conclusion: endoscopic prosthesis positioning is a consolidated procedure for treatment of bowel obstruction. this study demonstrated that this procedure is safe and this kind of prosthesis is suitable for correct positioning. results: we present a case of a years old man with faecal occult blood test positivity that was diagnosed by colonoscopy of a villous lesion at cm of anal verge. biopsies were taken showing a tubulovillous adenoma with high grade dysplasia. a rectal mri was done showing the lesion fixed to the postero-lateral left side of the lumen at cm of anal verge. no pathological lymph nodes were reported. extension study was negative. the case was presented in multidisciplinary committee agreeing in local excision. in october the procedure was done without incidents. the patient was placed in lithotomic position finding a lesion occupying of the lumen. resection was done without incidents and posterior suture with continuous barbed sutures. he presented an uneventful recovery being the patient discharged in rd postoperative day. definitive pathological findings showed a ptis with negative margins. after three months of followup the patient remains with good functional results and waiting for the first endoscopic revision. conclusions: tamis is a safe and feasible technique with low morbidity that gives us an alternative for early rectal cancer or big rectal lesions much less invasive than techniques used until now. complete mesocolon excision and d lymphadenectomy are two fundamental points in the oncological surgery of right colon cancer. most of the adenopathic recurrences of colon neoplasia in tumors located in the hepatic angle and the ascending colon are located near the head of the pancreas and the vascular axis of the superior mesenteric vein due to an alleged incomplete dissection. we present a case of right colon neoplasia where we performed a laparoscopic right hemicolectomy associated with a d lymphadenectomy. we use medial to lateral dissection of the mesocolon focused on the dissection of the superior mesenteric vein with the identification of ileocolic vascularization, right colic vessels and henle's trunk. this approach is safe and facilitates a correct resection of the mesocolon, which is approached following the embryological plans and a vascular ligature near the bifurcation. the performance of an extended lymphadenectomy allows a wider resection of the mesocolon and the excision of a greater number of lymph nodes, all of which can contribute to a greater survival. the efficacy of pc treatment is related with a properly preoperative imaging diagnosis of the disease, but the poor sensitivity for identifying small peritoneal metastasis are the major obstacle to achieve a complete resection and that leads to peritoneal recurrence. imageguided surgery using icg, could represent an advance in the detection of small peritoneal nodules. there are only a few clinical studies that have analyzed the role of icg for the staging of pc, specially from ccr, and nearly in all of them the selected approach were exploratory laparotomy. this study presents a laparoscopy case, as a non-invasive way of cs in selected patients with limited pc. a new category, tis, was created for low-grade appendiceal mucinous neoplasms (lamns) that invade or push into the muscularis propia by ajcc cancer staging th ed. management of these tumors depends on stage and histology. traditionally, laparotomy was the most recommended approach, however, if laparoscopy is safe, it could be used. the laparoscopic appendectomy should be done with 'not touch' technique and a radical approach has been recently proposed for its treatment. the laparoscopic radical appendectomy should start by exploring complete abdominal cavity. grasping of appendix should not be done. complete resection of mesoappendix is obligated. cequectomy with stapled endogia is necessary. the specimen must be extracted in an endobag. methods: we report a case of a year-old female patient with a personal history of three caesarean sections. this patient was studied due to chronic abdominal pain. a computerized axial tomography was performed, showing an appendix increased in size and a thick wall. the colonoscopy evidence a lesion that protrudes from appendiceal base which is biopsied. results: a laparoscopic way was used and large and width appendiceal was viewed ( x cm). furthermore, a rounded right anexial tumor was also found. a radical not touch laparoscopic appendectomy with stapled cequectomy was done. the intraoperative study was mucinous appendiceal tumor without serose affection. the final result was ptisnx (lamn) without resection margins affected. after h of admission, the patient is discharged without incidents. conclusion(s): minimally invasive surgery in lamns is possible if it is performed with enough experience, following specific rules and tips to manage this tumors. a correct follow-up should be carried out using tumor markers and computer tomography (ct). introduction: resection of both benign and malignant colovesical fistulae can be particularly challenging and carry with it specific surgical considerations. often there is a large inflammatory mass sat within a narrow pelvis, limiting specimen mobility and consequently access to dissection plains. additionally, with the underlying inflammatory process, the ureters may be displaced anatomically and be at risk of injury. aim: to demonstrate a streamlined and reproducible approach to the laparoscopic management of both benign and malignant colovesical fistula, with specific emphasis on the different modalities for bladder repair. method: the following method portrays an overall technique which is adapted dependant on the clinical scenario and specific intra-operative findings: approach to abdominal cavity in standard fashion.identification of right ureter.poster-medial mobilisation of the mass to facilitate delivery out of the pelvis followed by visualisation of the left ureter on the medial and lateral sides before division of the fistula.division of the fistula in benign disease or resection of the bladder dome in malignant disease.transverse laparoscopically sympathetic suprapubic skin incision.vertical incision through linea alba to deliver bulky specimen.intra/extracorporeal repair of bladder dome. results: all of the considered cases were successfully completed with a laparoscopic approach, irrespective of the malignant status of the disease in question. conclusion: both benign and malignant colovesical fistula disease can make the laparoscopic approach to resection challenging, especially when encountering a bulky mass in a narrow male pelvis. the stepwise and streamlined approach considered here can help facilitate successful and safe laparoscopic completion without the necessity to convert to open. background: primary neoplasms of the retrorectal space are very rare. they are located in anatomically difficult area to be addressed, hence a complete evaluation of the lesion is required to determine the extent of resection and the appropriate surgical approach, which include posterior, abdominal and combined abdominoperineal, depending on the characteristics of the lesion. objective: to show a combined laparoscopic abdominoperineal approach of retrorectal tumor. method: we present a video of a combined laparoscopic abdominoperineal resection of a lowlying retrorectal tumor in a -year-old female without prior abdominal surgery. conclusion: retrorectal tumors are infrequent. their anatomical location can make difficult the surgical approach. preoperative imaging can provide useful information for surgical planning. in the recent years, minimally invasive surgical approach has been proposed. laparoscopic approach is feasible and safe, but it is important to select adequately the patients. background: adult intussusception is a rare clinical event representing only - % of all bowel obstruction cases and % of all intussusceptions and the occurrence of adult intussusception due to colonic cancer is even more rare. aim: we present this case of malignant colo-colic intussusception and literature review to increase the awareness of the incidence of colocolic intussusception due to colonic cancer. case report and literature review: our patient is a years old female was admitted to our hospital due to central abdominal pain, cea level of , she was further investigated with ct scan of the abdomen and pelvis which raised the suspicion of mid transverse colon intussusception due to large polypoid lesion. she was further assessed with urgent colonoscopy which confirmed mid transverse colon tumour with biopsies confirmed adenocarcinoma. laparoscopic extended right hemicolectomy with lymph node dissection was performed. upon laparoscopic exploration it was found that the colocolic intussusception was evident as described on the ct scan and as clearly shown on the video. histologically, the transverse colon carcinoma was a moderately differentiated adenocarcinoma, with no lymph node involvement ' out lymph nodes', tnm staging of pt pn pm and r resection. intussusceptions of the colon in adult are frequently found in the ileocecal portion or sigmoidal colon but rarely in the transverse colon. only two cases of adult intussusception of the transverse colon caused by colonic cancer have been reported. overall cases on literature review reported showing colo-colic intussusception due to colonic malignancy. conclusion: colo-colic intussusception due to colorectal cancer is a rare clinical event, however it should be included in the differential diagnosis of colonic obstruction. laparoscopic surgery is safe in malignant colocolic intussusception. aims: single-incision laparoscopic colectomy (silc) aims to achieve better cosmetic outcomes, less pain, and faster recovery compared to multi-port laparoscopic colectomy, but it also has several limitations, especially the technical difficulties. we report our experience with singleincision robotic right hemicolectomy via video presentation. methods: we arranged robotic-assisted single-incision right hemicolectomy for a -year-old female patient with ascending colon tumor. the operation was performed with gloveport singleport device and a three-arm da vinci robotic surgical system through a small midline umbilical incision. colectomy was proceeded by a medial-to-lateral approach along with one or two accessory instruments for maintaining sufficient bowel traction or surgical field exposure. after vessel ligation, complete colon mobilization and right side omentum division, the robotic arms were undocked to perform anastomosis extracorporeally. results: the operation was performed successfully without drainage tube placement. the total operative time was min. the bowel movement returned on post-operative day ,and the patient tolerated normal soft diet on post-operative day . she was hospitalized for days after operation. the pathology report revealed colon adenocarcinoma (t n m , tumor size . cm), and lymph nodes were harvested. conclusions: single-incision robotic colectomy (sirc) approach seems feasible and safe in treatment of ascending colon cancer. this surgical option provides less pain and wound scar for the patient. moreover, it also achieves further benefits for the surgical procedures compared to silc. reasons being, first, it has better instruments flexibility and precision with endo-wrist, as well as less instruments clashing. second, the improved camera stability achieved through the use of the robotic arm is unattainable through manual hand-controlled methods. third, roboticassisted approach gives us an ergonomic environment, which enables the operator to control the arms while sitting by the console, and also to reassign them whenever they cross each other or block the surgical view. in spite of the advantages above, we still need to sincerely consider each patient's situation for proper management. recently, indocyanine green (icg) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information.the aim of our study is the application of icg imaging during laparoscopic colorectal resections: to identify sentinel lymph node, for studying its prognostic value on nodal status, to facilitate vascular dissection when vascular anatomy of the tumor site is unclear and to assess anastomotic perfusion to reduce the risk of anastomotic leak. after tumor identification ml of icg solution ( . mg/kg) is subserosal peritumoral injected. a full hd image s camera, switching to nir mode, in about min displays fluorescence: the sln is identified and the sln biopsy (slnb) is performed.when tumor is in difficult site, as hepatic or splenic flexure, ml of icg solution ( , mg/kg) is intravenous injected. in about - s a real-time angiography of tumor area is obtained; on this guide, vascular dissection and pedicle ligation is performed.after anastomosis, another ml of icg solution is injected to confirm anastomotic perfusion. if there is an ischemic area, a new anastomosis is performed. from november , patients were enrolled: left colectomy, right colectomy, transverse resections, and resections of splenic flexure. in ten cases, intraoperative angiography led to the identification of vascular anatomy. in two cases the anastomotic perfusion wasn't good and the surgical strategy was changed. four postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. from november , patients were enrolled to perform the slnb: right colectomy, left colectomy, transverse resection and splenic flexure resections. the sln was identified in cases. cases were found to be n to the conventional examination and were subjected to ultrastaging. icg-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. it's recommended to reduce the incidence of anastomotic leak, to facilitate the assessment of vascularization in order to perform oncological resections, and to perform the slnb to study its clinical role on nodal status and for the sln ultrastaging in order to identify the micrometastases. background: surgical emptying of lateral pelvic lymph nodes (llnd) is a strategy used differently when compared the approaches to rectal cancer in the west and eastern countries. there is evidence that = mm lymph nodes in lateral compartment should be removed, even in the setting of neoadjuvant chemoradiation. minimally invasive surgery with nerve-sparing technique and sharp dissection with minimal bleeding may help overcome the significant complexity of the procedure that may have been a technical obstacle to implementation in the past. the standardization of the technique may help implementation with shorter learning curves and excellent surgical outcomes. methods: a -year-old male with distal rectal cancer underwent neoadjuvant crt for a mrt cn m mremvi ? mrcrm ? disease. there was one left obturator node of mm prior to crt. following weeks of crt completion, the patient underwent tatme for the primary disease followed by left lateral node dissection by laparoscopy. results: the present video illustrates the most relevant surgical steps to perform lateral node dissection. the procedure has been didactically divided into steps. the left ureter is identified and retracted using a vessel loop (step ). identification of the common iliac vein and dissection with subsequent identification of psoas and internal obturator muscles (step ). identification and dissection of accessory vessels. ( step ) identification of obturator nerve and obturator vessels (step ). blunt dissection of obturator nerve (step ). identification and ligation of obturatory vessels. (step ) umbilical artery is skeletonized to allow identification and clearance of fatty tissue along superior vesical arteries, internal iiliac artery/vein, inferior vesical artery and internal pudendal artery (step ). postoperative course was uneventful. conclusion: standardization of lateral-node dissection for rectal cancer has paramount importance. laparoscopic lateral-node dissection for rectal cancer provides optimal anatomical view and allows safe dissection of the nodes of interest. aims: the aim of this video is to describe our technique using fluorescence to assess the lymph flow to ensure a complete mesocolic excision and central vascular ligation in order to provide expertise to contribute to the standardization of this new tool. methods: laparoscopic right colectomy with total excision of the mesocolon was proposed in all cases. for the detection of lymph flow, we injected indocyanine green dye ( milliliter of milligrams dye dilution in milliliter of distilled water) into the subserosal to submucosal layer around the tumor at point with a -gauge injection laparoscopically after trocar insertion, and observed the lymph flow using a near-infrared system (visera elite ii, olympus) after injection. we also performed a total mesocolic excision with central vascular ligation in the region where the lymph flow was fluorescently observed. results: ( %) patients were included. no intraoperative or postoperative complications presented. no adverse effects were reported due to the infusion of indocyanine green. the lymph flow was visualized intraoperatively in a satisfactory way helping the surgeon in decision making to determine an appropriate separation line of the mesentery. the section line of the mesocolon was modified in ( %) case based on the findings obtained by fluorescence. the mean operative time was ( ) min. the morphometric laboratory data of the specimens to audit the correct complete mesocolic excision were satisfactory according to the oncological standards. conclusion: fluorescence lymphography during colorectal surgery was feasible and reproducible with a minimum of added complexity. fluorescence-guided surgery may be a helpful technique for determining an appropriate total mesocolic excision in colon neoplasms. aims: this video shows our technique for complete mesocolic excision (cme) during right colectomy for cancer. methods: in this video, a years old patient underwent a laparoscopic right colectomy with cme for a cancer of the ascending colon diagnosed with a colonoscopy performed after positivity to fecal occult blood test (fobt). after ct scan staging we obtained d printed models to clarify patient's vascular anatomy. patient was placed in supine position, trocars were inserted in left quadrants as for standard right colectomy. cme is performed by sharp dissection between the visceral fascia that covers the posterior lay of the mesocolon and the parietal fascia that covers the retroperitoneum (toldt's fascia). the ileo-colic vessels are used as landmark to identify the right anterior surface of the superior mesenteric vessels. with a caudo-cranial approach, the mesocolon is sharply dissected and the root of tributaries venous is ligated, up to the inferior margin of the pancreas. the gastro-colic trunk is dissected out with ligation of the right colic vein, while the gastroepiploic vein is preserved (harvesting the sixth group lymph node). the pancreas-duodenum fascial plane is entered and all the lymphoid tissue around the vessel surface is harvested. procedure is completed with ileo-transverse intracorporeal stapled anastomosis. results: in our experience, between april and december , laparoscopic right hemicolectomies with cme were performed. we had no major intraoperative vascular lesions. no patients needed intraoperative blood transfusion. compared to our series of standard right colectomies we did not notice any significant difference in post-operative complications. the follow-up is too short to demonstrate if the cme approach has a better oncological outcome compared to standard right colectomy. conclusions: laparoscopic cme is feasible, although it requires a higher expertise level of surgical know-how. the quality of evidence is limited and does not consistently support the superiority of cme as compared to standard right colectomy. better data are needed before cme can be recommended as the standard of care for colon cancer resections. h. bando gastroenterological surgery, ishikawa prefectural central hospital, kanazawa, japan aim: in case of right-sided transverse colon cancers, it is necessary to dissect the lymph nodes around the root o f the middle colic vessels. but in this area there are dangerous organs, for example : pancreatic head, duodenum, and gastrocolic trunk. it is the point of our technique that we resect the accessory right colic vein and middle colic vein, and then dissect pancreas head and duodenum at early step of the operation. method: we perform the operation by five trocars. the first step is to transect the great omentum, and confirm the lower edge of pancreas.there are much adhesion between mesocolon of transverse colon and stomach, great omentum. it is very important to dissect the adhesion accurately. secondly, the mesocolon is incised at lower edge of pancreas. it is possible to detect the lower edge of pancreas in obese people. the anterior surface of superior mesenteric vein is exposed. the accessory right colic and middle colic vein are resected. and then front face of surgical trunk, pancreas, and duodenum is dissected caudally as possible. the superior mesentery artery is resected below the mesocolon after flip up of transverse colon. this approach is safe and feasible, because the dangerous organs are handled by direct vision. by that, extraction of intestine is easy from small incision. afer flip up of transverse colon, the mesenteric of ileum is incised. the root of ileocecal vessels is exposed and these are resected. the peritoneum of the front of superior mesenteric artery is incised, and the lymph nodes around the surgical trunk are dissected. this dissected area is easily connected with the one done beforehand. uniquely we resect the mesocolon and major omentum from the root of dissected vessels to resected side of transverse colon. and then right-side colon is dissected medial approach. conclusion: we dissect the dangerous organs in advance. that prevent major injury of them. background: good visualisation of the operative field is a fundamental requirement for safe laparoscopic colorectal surgery. over the past years of the senior author's experience, camera systems have evolved from single to three chip, high definition (hd) and most recently, the k system. in parallel, the rest of the infrastructure such as cables, processors, monitors etc. have also undergone improvements, resulting in improved image quality. aim/methods: we present a video of a case of laparoscopic total mesorectal excision (tme), performed with strict adherence to our previously published 'stepwise approach to laparoscopic colorectal surgery' which places particular emphasis on safety aspects. tme was performed in a year old male patient with history of previous abdominal as well as robotic prostatic surgery. the procedure was filmed with all components including the camera head, cables, processing unit, screens as well as the recording/mixing decks being k. multiple external k cameras were also used. live transmission to a remote audience as part of our masterclass was achieved using appropriate bandwidth and projection on to k screens. results: feedback from the operating team as well as from the live audience was that the image quality was far superior to hd systems. the k system accorded a degree of clarity well beyond usual expectations. the depth of field also appeared to be different initially, but within a few minutes of starting the procedure and acclimatisation, the effects were appreciable. the clarity of the image which showed the fine details of the dissection planes and anatomical landmarks as well as the vibrancy of the vasculature gave a distinct three-dimensional effect to the picture. this excellent visualisation added one more layer of safety and complemented our stepwise approach for a successful procedure. conclusion: the laparoscopic k system, in our practice, proved to bea beneficial visualisation tool to enhance the accuracy of dissection. vital structures appeared to be more vivid and clearer with dissection planes being more easily apparent. in our opinion the laparoscopic k system when combined with a systematic approach enhances safety, especially in complex laparoscopic colorectal surgery. accumulating evidence suggests that laparoscopic surgery for colon cancer has feasibility and efficacy equal to or over conventional laparotomy. for cases with pasthistory of laparotomy, especially history of colon resection, however, there is almost no evidence for laparoscopic recolectomy for metachronous colon cancer. since , we have been used submucosal local injection of indocyanine green (icg) around primary colorectal cancer by using intraoperative endoscopy, and complete mescolic excision (cme) have been convincingly carried out, which was clarified by completely resected icg positive area. although evidence on the oncological efficacy of icg guided surgery has not yet been clarified, since it can be easily judged whether cme is performed clearly, it is considered that icg guided surgery for primary colon cancer is useful for education. recently, we are applying this to ensure convincing cme for patients with colorectal cancer who had a history of colic resection. the representative case is as follows. a -year-old female was diagnosed as advanced sigmoid colon cancer, and laparoscopic sigmoidectomy with high tie of the inferior mesenteric artery was performed years ago. then she was diagnosed as the metachronous descending colon cancer. the feeding artery of the new tumor should be the left colic artery, however, the left colic artery was already resected and genuine feeding artery was not identified by preoperative examination. by injecting icg into submucosa endoscopically during operation, it was clearly observed that the lymphatic flow from the tumor was directed to the inlet portion of the inferior mesenteric vein (imv). re-cme was performed by ligating the inlet of imv. intraoperative icg was also useful for clarifying the borderline for adhesion detachment of pastoperation between the mesentery and retroperitoneum (figure) . interestingly, icg flow in the mesentery direct to of the anus side was disrupted clearly at the past anastomotic site. we believe that laparoscopic surgery under icg guidance is potential useful tool that can confirm evidence to date more intuitively in real time. further studies, ideally randomized controlled trials, are required for define the oncological usefulness of icg guided surgery for re-do colectomy. the operation movie will be presented at the meeting. background: laparoscopic lateral pelvic node dissection (llpnd) is a minimally invasive alternative to open surgical therapy for advanced low rectal cancer patients. in this video, we demonstrate the technique of llpnd for rectal cancer patients with suspicion of lln metastases after neoadjuvant chemo-radiation. methods: the principle of this approach is en bloc resection with bilateral peritoneum. the peritoneum is incised lateral to the ureter following the line between external and internal iliac vessels. in the next step, llpnd dissection of the regional lymph node and high ligation of inferior mesenteric vessels were performed. a contralateral llpnd was performed in the same manner as a mirrored technique. after extracting the specimen, an end-to-end double-stapled circular anastomosis was performed. results: the procedure was done safely without any complications.the surgical duration was mins, and the blood loss was ml. the number of harvested lateral pelvic lymph nodes was . the tnm stage was ypt an m . conclusion: this approach enables extended resection during lymph node dissection, allowing autonomic nerve preservation. it is maybe a helpful approach in the treatment of locally advanced rectal cancer with a lateral lymph node metastasis. aims: the aim is to present an inspection method where the anastomosis vascularity is testing simultaneously using the indocyanine green fluorescent angiography intraluminal and intraperitoneal. methods: sixty-five year old female patient underwent standard laparoscopic-assisted low anterior rectal resection for rectal carcinoma. the proximal end of the bowel and the stump of the distal rectum were checked using near-infrared fluorescence imaging with d-light camera. after making sure of adequate perfusion of the bowel, the end-to-end stapled anastomosis was performed under the laparoscopic visualisation. the d-port proctoscope was inserted into the anus. the second icg injection was administered. the perfusion of the anastomosis in transabdominal way and viability of the mucosa in transanal way was evaluated with two d-light cameras simultaneously. the anastomosis was determined cm from the anal verge. an air-water leak and tension of the bowel tests were performed. after evaluation of anastomosis viability with fluorescence imaging, after negative air-water leak and tensions testing, the decision was made by surgeon not to perform preventive ileostomy. results: the patient had no complains for the first three days postoperatively. nevertheless, crp level was growing and was . mg/l on the second postoperative day, and . mg/l on the th postoperative day. the patient complained of the pain in the right iliac area and below symphysis on the th postoperative day. the abdominal and pelvis computed tomography scan with oral contrast was performed which denied our thoughts about the anastomotic leakage. intravenous cefuroxime and metronidazole antibiotics were prescribed. the crp level was . mg/l on the th postoperative day. the patient was discharged on the th postoperative day without preventive ileostomy. conclusion: using the original, standardized colorectal anastomosis inspection method we can determine which patient doesn't need the preventive ileostomy after low colorectal anastomosis. the important causes of anastomotic leak are local ischemia and staple line defect. the purpose of this study was to investigate the combination of methods aimed to reduce the risk of anastomotic leak after anterior resections for rectal cancer. methods: we retrospectively analyzed perioperative outcomes of the first patients, who underwent modified laparoscopic anterior resection with partial mesorectal excision for rectal cancer without preventive stomy. operative technique was modified and included routine preservation of the left colic artery (fig )(aimed to improve anastomotic blood supply), manual suture invagination of the 'dog ears' (fig ) (aimed to reduce the risk of staple line defects), transperineal pelvic drainage and pelvic peritoneum reconstruction (aimed to reduce the risk of reoperation in case of leakage). anastomotic leak rate, reoperation rate, left colic artery preservation rate, additional operative time (time required for left colic artery preservation, 'dog ears' invagination and pelvic peritoneum reconstruction), blood loss, morbidity and mortality were analyzed. results: ( . %) patient developed an asymptomatic leakage, which was managed conservatively. there was no postoperative mortality and no reoperations. median additional operative time was min for the first procedures and min for the last procedures. left colic artery preservation was successful in ( . %) patients. median blood loss was ml. conclusions: additional techniques used in our modification of laparoscopic anterior resection are safe and may lead to improved perioperative outcomes. however, they are associated with increased operative time, which may be reduced with a better learning curve. introduction: parastomal hernias are a significant cause of post abdominal ostomy morbidity with an overall life-time incidence exceeding %. the complications can range from a bulge resulting in stoma bag leakage, to life threatening bowel obstruction. the prevent-trial sought to determine if prophylactic utilisation of polypropylene mesh would decrease the incidence of parastomal hernias, with initial results demonstrating that it was safe to use in permanent end stomas. aim: to demonstrate a reproducible and streamlined technique for laparoscopic parastomal hernia repair with intraperitoneal funnel mesh, and assess the outcomes with the clavien-dindo (cd) classification tool. method: parastomal hernia repairs ( colostomy, ileostomy) were considered, with the following approach adopted for each: swab sutured in stoma orifice to prevent wound contamination.sharp dissection of the stoma using parachute technique.stoma end refreshed followed by change of gloves and instruments.lateral stay sutures placed to tighten sheath later on.pneumoperitoneum temporarily created to assess/divide adhesions.funnel mesh placed in-situ, orientated in the optimal intraabdominal position, and sutured to the peri-colic fat to prevent slip.medial suture placed to narrow the sheath further.pneumoperitoneum re-created and mesh fixed in place with double crown laparoscopic tacks.redundant portion of end stoma excised and stoma formed. results: at median follow up of months: no recurrence.no reported symptoms of pain or decreased stoma functionality.one superficial wound infection treated with drainage at bedside (cd = grade ) conclusion: laparoscopic parastomal hernia repair with intraperitoneal funnel mesh for permanent end stomas yielded good outcomes in our patient cohort. a streamlined and reproducible approach ensures that the technique can be adopted for both prophylactic, primary and recurrent repair. parastomal hernias are common and can be associated with significant morbidity. when taking this into account, in conjunction with the recommendations of the initial results of the prevent-trial, one may consider prophylactic utilisation of a mesh in patients receiving a permanent end stoma. general surgery, rambam medical center, haifa, israel year old, female patient referred to our institution with common bile duct stricture, caused by iatrogenic injury during laparoscopic cholecystectomy. during last year, patient suffered from recurrent episodes of ascending cholangitis. recently, she underwent ercp and severe stricture of middle cbd was diagnosed. plastic stent was inserted through the cbd. mrcp also showed severe stricture of cbd with dilatation of biliary tree, proximal to the stricture. due to severe and resistant (did not resolved by recurrent dilatation) structure of middle cbd, she was referred to operation. patient underwent da vinci robot-assisted excision of the cbd stricture, hepaticojejunostomy and extracorporeal jejunojejunostomy of roux-an-y limb. total operating time was min. day three after operation patient started regular diet and was discharged home on day four. final pathology has shoved part of cbd with severe inflammation. aims: extrahepatic biliary duct resection for the treatment of bismuth i and ii stage klatskin tumor is the standard surgical technique [ ] . methods: a years old patient present at emergency room (er) with right upper abdominal pain with an elevation of the inflammatory markers at the blood exams and fever. the patient was submitted to a computer tomography (ct) that shows a tumor involving the lower tract of the principal bile duct. an endoscopic retrograde cholangio pancreatography (ercp) with biopsy (intraductal papillary neoplasm of the bile duct,ipnb with high-grade dysplasia) and stent placement was performed. considering the good general conditions of the patient and an absence of vascular and nodal invasion at the preoperative imaging, a minimally invasive surgical resection of the biliary tract with cholecystectomy was performed. results: a four port laparoscopic biliary tract resection with cholecystectomy was performed with lymphadenectomy of the hepatic hilum. no vascular or liver infiltration was found. the hepatic hilum was completely skeletonized. the resection of the biliary duct was performed with adequate free margin. a biliary reconstruction with roux-en-y technique was performed and a fully laparoscopic hepatico-jejunal anastomosis was done. and abdominal retro anastomotic drain was placed. the operative time was min. the postoperative course was complicated by a low rate biliary leakage that was treated conservatively. the patient was discharged at post operative day in good general conditions. the histological examination revealed a moderately differentiated in situ cholangiocarcinoma of the principal bile duct with the involving of the cystic duct with free resection margin (pt bn r ). conclusions: laparoscopic resection of the biliary tract is a challenging procedure that allows, in expert hands, to achieve in selected cases negative pathological margin, complete linfonode retrieval and entero-biliary bypass. injury to the extrahepatic bile duct during bile duct or hepatic surgery can be reduced by better real-time visualization. recently, indocyanine green (icg) fluorescence imaging has been used in laparoscopic hepatobiliary surgery. we applied icg fluorescence imaging in patient with huge hepatic cyst which severely deviated extrahepatic bile duct. the patient had received laparoscopic cholecystectomy and huge hepatic cyst stuck firmly with peri-hepatic structures including bile duct. icg fluorescence imaging correctly identified the common hepatic duct and remnant cystic duct and allowed for more meticulous and easier dissection. therefore, icg fluorescence imaging may guide a safe and accurate dissection and excision in hepatobiliary surgery. results: total patients who underwent ercp were , and . percent ( cases) had a first failed ercp and of then were unsuccesfull in the second intent of ercp. intrahospitalary stay was more than days in the percent, in the . percent was to days, with and average of days. conclusions: before, during or after lcbde, ercp remains the gold standard for manegement of choledocolitiasis confirmed by clinics, laboratory and imagenology. lcbde is a very good option that requires experience and specific skills, and especialized equipment. in years the rate of sucess in our hospital was . % and there were no posoperatory complications such as: biliar peritonitis, pancreatitis or liver abscess. aims: easier intraoperative recognition of the biliary anatomy may be accomplished by using near-infrared (nir) fluorescence imaging after an injection of indocyanine green (icg). neither radiological support nor additional intervention such as opening the cystic or common bile duct is required, making it an easy and real-time technique to use during surgery. the aim of this video is to describe our experience in fluorescence-guided cholangiography in different clinical situations. methods: intravenous injection of icg is used to illuminate extrahepatic biliary anatomy. however, the simultaneous enhacement of liver parenchyma can disturb the visualization of clinical details. the key is in the used dose of icg, the route of administration and the time since its infusion. in the first case, a scheduled cholecystectomy is shown in which a dose ( ml of mg dye dilution in ml of distilled water) administered intravenously h before the intervention was used. the second case shows an urgent cholecystectomy in which the dose ( ml of mg dye dilution in ml of distilled water) was administered intragallbladder during surgery. all patients underwent laparoscopic cholecystectomy with traditional four-port technique. all procedures were performed using a -degree mm laparoscope with nir imaging capability (visera elite ii, olympus). results: there were no intraoperative or postoperative complications. there was no increase in operative time due to the use of icg. in the first case, a clear identification of the cystic duct and the main bile duct was obtained thanks to the biliary excretion of the icg and the intravenous clearance. in the second case, the identification of the cystic duct, the main bile duct and the cystic artery occurred due to the intravesicular absorption of icg. conclusion: fluorescence-guided cholecystectomy clarifies the dissection plane. it can be considered to increase the safety of laparoscopic cholecystectomy. being aware of the doses, times and possible routes of administration is basic to universalize the technique and give it utility in different scenarios. introduction: mirizzi syndrome type is an uncommon cause of obstructive jaundice caused by an inflammatory response to an impacted gallstone in hartmann's pouch or the cystic duct with a resultant cholecystocholedochal fistula. the obstructive biochemical changes can be caused by direct extrinsic compression from the impacted gall stone or from the fibrosis caused by advanced chronic cholecystitis, or for the established fistula. objective: we present a case of a mirizzi type syndrome with choledocholithiasis which was solved by laparoscopy approach. material and methods: a -year-old female patient with no past medical history. the history of present illness begans with the presence of icteric dye since the last days; she received symptomatic treatment with poor improvement. a liver and biliary tract ultrasound was performed with report of a mm coledochus, mm wall gallbladder. then an endoscopic retrograde clolangiopancreatography was performed with successful endoscopic sphincterotomy and removal of gallstones. but the patient jaundice persisted after the procedure. the patient underwent cholecystectomy and laparoscopic common bile duct exploration, where the findings were a mirizzi type according to the csendez classification, chronic cholecistitis and choledocholithiasis. results: in this laparoscopic approach we performed a partial cholecystectomy, bile duct exploration with removal of residual gallstones. the closure of the choledocotomy was performed with simple knots using vycril . . a subhepatic drainage was left. the patient showed adequate clinical evolution. after days the patient was discharged. conclusions: it is important to properly identify the anatomy at the time of surgery to avoid injury of the common bile duct. operative treatment of mirizzi syndrome type includes either laparoscopic or open subtotal cholecystectomy or placement of a t-tube or choledocoplasty. near-infrared fluorescent cholangiography (nirf-c) is an innovative intra-operative imaging technique that allows a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence. thanks to the development of laparoscopes/endoscopes with light sources emitting infrared frequencies, it is possible to visualize anatomical structures (vessels, ureters, bile ducts, etc.) through the luminous intensity of substances (fluorescein, blue of methylene, indocyanine green) which are injected into the patient. this technology may be considered as an important teaching tool for laparoscopic surgery, especially for young surgeons in their surgical learning curve and it could lead to reduce the risk of iatrogenic bile duct injuries during laparoscopic cholecystectomy. the following video is characterized by a series of intra-operative images of biliary anatomy by fluorescence, having an important educational interest, while also detecting anatomical variations of the cystic duct. a. umezawa, minimally invasive surgery center, yotsuya medical cube, tokyo, japan aims: laparoscopic cholecystectomy(lap-c) for cholecystolithiasis has become standard. however, serious bile duct injury has been reported as a complication. repeated colic and chronic inflammation in cholecystolithiasis lead to the so-called difficult gallbladder conditions, such as dense fibrosis and scarring of the tissue. dissection of calot's triangle includes the risk of bile duct injury. critical view of safety (cvs) is the most well-known land mark for safe cholecystectomy. in the revised tokyo guidelines (tg ), important land marks and bailout procedures had been proposed. those are for the difficult gallbladder which are not able to achieve cvs. methods land marks: baseline of segment of the liver and sulcus rouvier should be confirmed. the gallbladder wall itself is also useful landmark. bailout procedure: when the dissection of calot's triangle is considered impossible, bailout procedures should be considered. subtotal cholecystectomy which leave the neck is one of option. the fundus first technique is another approach. however, because fundus first technique has a possibility of leading to serious bile duct injury, it should stop by the neck. in this video, first case shows the importance of landmarks from near miss cases of misidentified injuries. second case shows bailout procedure, subtotal cholecystectomy with fundus first technique. result: in the atrophic gallbladder (case , near miss), it is liable to misidentify the junction of common bile duct as the gallbladder neck. the neck and common hepatic duct were lifted together easily. with confirming the landmark, misidentification was corrected and bile duct injury was avoided.in the case , since the calot's triangle was obscured due to repeated cholecystitis, dissection of gallbladder was performed from the bottom to the neck, and was excised with the cervical portion remained. the remaining neck was reconstituted.in each case, intraoperative cholangiography was performed, and it was confirmed that there was no bile duct injury. without postoperative complications, those patients were discharged pod as usual lap-c. conclusion: during lap-c for difficult gallbladder, the most annoying part is bile duct injury. confirming landmarks and switching bailout procedures can be contributory to avoid bile duct injury and to achieve safe lap-c. aims: choledocholithiasis is an important cause of morbidity and is present in about % of patients submitted a cholecystectomy. his treatment should be done in the same operative time, avoiding the morbidity and hospitalization time and costs of multiple procedures.the transcystic approach is preferable to prevent morbidity associated to choledochotomy.large stones can preclude this procedure. the use of laser lithotripsy to stone fragmentation is an option to provide transcystic extraction. methods: we present a video of laparoscopic transcystic common bile duct (cbd) exploration for choledocholithiasis. results: female patient, years old with a previous hospitalization for acute cholangitis with choledocholitiasis.submitted to laparoscopic cholecystectomy with intraoperative cholangiography that showed the presence of stone in distal cbd with cm size. the use of holmium laser lithotripsy made the stone fragmentation and provided his extraction by transcystic route using a basket.the patient was discharged at th postoperative day, with no complications. conclusion: the use of laser lithotripsy for large cbd stones is safe and effective, making possible the transcystic approach and preventing the choledochotomy morbidity. surg endosc ( ) :s -s gallbladder adenocarcinoma is rare and extremely aggressive. its' incidence is higher in elder females and its progression is rapid and silent with a dismal prognosis if diagnosed at advanced stages. we present the case of a years-old female with dyspeptic complaints. the abdominal ultrasound revealed a cm solid lesion of the gallbladder suspect for malignancy. the ct confirmed the presence of a vegetant mass on the free border of the gallbladder fundus with x mm. we performed a radical cholecystectomy with lymphadenectomy and liver bed excision. the post-operative period was complicated with a urinary tract infection, with full recovery after antimicrobial treatment. the histological sample revealed an adenocarcinoma of the gallbladder (t bn m ) and the patient remains asymptomatic and tumour free months after the surgery. gallbladder cancer treatment depends of the stage and clinical presentation of the disease. complete surgical excision is the only curative treatment and should include a limited hepatectomy and portal pedicle lymphadenectomy. laparoscopic surgery might be an option in early stages, although it is challenging and requires both expertise in hepato-biliary and laparoscopic surgery. seen at the emergency room for a two month history of abdominal pain associated with jaundice. she is evaluated by the surgical team and diagnosed with acute cholecystitis and moderate risk for choledocholithiasis. the initial surgical plan was cholecystectomy with intraoperative cholangiogram. during surgery, firm adhesions are found from the gallbladder to omentum. friable tissue with edema and easy bleeding. difficulty is encountered during the dissection of calots'triangle. an intraoperative cholangiogram is done through hartmans'pouch without identifying correctly the biliary tract. therefore, an endoscopic retrograde cholangiopancreatography (ercp) is done to visualize the correct anatomy. during the ercp, a stenotic common hepatic duct is found and no stones are visualized. a biliary endoprosthesis is placed. she is discharged asymptomatic. a month later, the patient is back in the emergency room with abdominal pain. after an abdominal ct scan, we found that the endoprosthesis had migrated to the th portion of the duodenum. a second ercp is done and this time we found a big stone ( . - cm) aims: when training in the residency you watch your teacher perform laparoscopic cholecystectomy with ease, and even yourself perform several steps. but as a young surgeon, when confronted with a patient with acute cholecystitis, you're filled with emotions, and you do not know where to start the gallbladder dissection. the aim of this presentation is to show to young surgeons that you can, and must achieve, critical view of safety when performing laparoscopic cholecystectomy for acute cholecystitis. methods: we present the case of a years old female patient, bmi of . , who presented with a grade ii (moderate) acute cholecystitis. following tokyo guidelines, we initiated antibiotics and general supportive care, but without clinical improvement. the patient was proposed for laparoscopic cholecystectomy. results: at initial exploration we identified a cm long gallbladder, with a thick wall, difficult to manipulate. we opted for an anterograde cholecystectomy, in our opinion the best option in acute cholecystitis. the dissection was started with hook electrocautery and then continued with a combination of blunt dissection with the aspirator and with the hook. when reaching the pedicle, blunt dissection was used in order to appreciate the anatomy of the cystic duct and cystic artery. after correct identification of these structures they ware clipped and cut. a drainage tub was then placed, and the abdomen deflated. conclusion(s): as a young surgeon, when dealing with acute you must maintain your calm, and try to achieve critical view of safety before transecting the cystic duct and cystic artery. this can be achieved with a combination of blunt and sharp dissection, keeping your camera clean and with a good collaboration with the assisting surgeon. conclusions: here, an easy and reproducible method is described for future macroscopic analysis by the surgeon following a cholecystectomy. in addition, we depict several frequent macroscopic abnormalities in order to provide surgical colleagues with some cases of abnormal macroscopic gallbladders. the left hepatectomy is a demanding and difficult procedure, still limited to reference centers. the caudal approach and exposure of the middle hepatic vein is a reliable way to achieve a safely and reproductible left hepatectomy. with this technique, exposing the middle hepatic vein, we believe that we can perform a safe and feasible laparoscopic left hepatectomy increasing the quality of this hepatectomy. we present a -year-old woman with an intrahepatic and common bile ductlithiasiswhich was previously submitted to an ercp. with an unsolved intrahepatic lithiasis the patient was proposed to alaparoscopic left hepatectomy. the minimally invasive approach for alpps in a patient with a large hepatocellular carcinoma in a liver with severe steatosis is shown. during the first stage a partial alpps is performed. pve is performed in postoperative day one. after days from the first stage both liver volume and function (by hida scan) are re-assessed. right hepatectomy (second stage of alpps) is then conducted by laparoscopic aproach. hepato-bilio-pancreatic, centro hospitalar são joão, porto, portugal a year old woman with a previous history of anxiety and catheter ablation to treat heart arrhythmias, was studied for for multiple pancreatic cysts incidentally discovered on a routine ultrasound. an mri was performed showing multiple cystic tumors throughout the pancreas, the largest of which was mm. this led to a suspicion of multi-focal, side-branch intraductal papillary mucinous neoplasm (ipmn), with minimal dilatation of the main pancreatic duct. an echo endoscopy was subsequently performed indicating probable multifocal ipmn. a fna was carried out during this procedure, with aspiration of cystic content which was sent for cea analysis and cytology. cytology was compatible with mucinous neoplasm with mild atypia and cea u/ml. a splenic preserving total laparoscopic pancreatoduodenectomy was proposed. the procedure was uneventful and the patient was discharged on the th post-operative day. pathology revealeded a mm ipmn, with severe dysplasia and foci of microinvasive ductal adenocarcinoma of mm-pt n r . indocyanine green immunofluorescence guided laparoscopic partial hepatectomy y. tai obtaining negative tumor margin during laparoscopic hepatectomy has always been a very challenging topic for surgeons in that the surgeons are not able to palpate the tumor during laparoscopic surgery. although intraabdominal echo is available, but it demands great experiences and skills. with the guidance of icg immunofluorescence, surgeons can avoid failure of not obtaining enough negative margins nor resect too much healthy liver. icg is often used to estimate the liver function prior to hepatectomy traditionally. it binds to plasma protein and has a peak absorbance at nm and emits fluorescence with a wavelength of approximately nm. icg is preferentially retained in or around biliary malignancies due to impaired biliary excretion of hepatocytes in the affected area. we performed icg immunofluorescence guided laparoscopic partial hepatectomy on a years old male who suffers from hcc located at segment and . icg was injected days prior to the operation day. while evaluation of liver is performed, it also allowed us to use a high-end laparoscopic camera system equipped with integrated filters for detection of near-infrared fluorescence. during the surgery, we were able to clearly locate the borders of malignancies through the use of integrated filters combine with icg injection. the pathology study also confirmed that the adequate tumor free margin ([ . cm) were obtained in both tumors and the patient's condition was stable as well. icg immunofluorescence guidance enables surgeons to obtain optimum result in tumor resection through laparoscopic surgery. it also has the ability to detect bile leakage. with the use of icg immuofluorescence, surgeons will have higher chances to achieve adequate negative margins. background: parenchymal sparing hepatic resection has the advantage of preserving valuable tissue in chemotherapy-treated livers, assuring an adequate future remnant volume without compromising long-term survival. moreover, the laparoscopic approach offers the decreased postoperative morbidity of minimally invasive surgery. whenever technically feasible, this kind of procedure should be considered a suitable alternative to the classic major hepatectomy for the treatment of multiple colorectal liver metastases. methods: -year old male with a previous history of laparoscopic sigmoidectomy in november for a pt n m sigmoid adenocarcinoma. a control scanner three years later showed liver metastases in segments v, viii, ii and caudate lobe. after chemotherapy (xelox), control mri and pet scans showed a good response. he was proposed for a laparoscopic parenchymal-sparing liver resection. results: total operative time was h and min with no intraoperative complications. patient presented a right atelectasis as the only postoperative complication and was resolved with respiratory therapy. he was discharged in days. pathology report showed that lesions on segment v and viii had no viable tumor ( % fibrosis) and lesions on segment ii and caudate lobe had moderately differentiated adenocarcinoma. margins were free in all the lesions. after a month follow up, the patient has no recurrence and normal liver function tests. conclusion: minimally invasive liver resection is possible in patients with multiple bilobar liver metastases and allows to perform parenchymalsparing surgery safely. difficult localization of lesions such as the caudate lobe are not a contraindication for this type of surgery. laparoscopic approach for perihilar cholangiocarcinoma is still poorly reported in the literature due to technical challenges secondary to the combination of major hepatectomy, lymphadenectomy and biliary confluence resection. despite this, in selected cases it can be a good option to provide a short term benefit to patients. the video reports the case of a perihilar cholangiocarcinoma with involvement of left bile duct and therefore requiring left hepatectomy. komagome hospital, bunkyo-ku,tokyo, japan aims: segmentectomy is an anatomic liver resection, in which the tertiary branches of the glissonean pedicles are selectively transected. however, the branching pattern of the tertiary branches varies depending on the case, particularly in segment (s ) and segment (s ). the extrahepatic approach to the glissonean pedicle from the hepatic hilum is very difficult depending on the branching pattern. furthermore, the distance of exposing the secondary branches that are to be preserved becomes longer, and there is an increased risk of biliary leakage and delayed biliary stricture due to excessive traction in laparoscopic surgery. therefore, laparoscopic s and s segmentectomy are considered technically difficult. we standardized the intrahepatic glissonean pedicle approach for laparoscopic s and s segmentectomy. methods: we standardized the intrahepatic glissonean pedicle approach for laparoscopic s and s segmentectomy. we identify the targeted glissonean pedicle intrahepatically after the parenchymal transection along the major hepatic vein or its branch running on the intersegmental plane, referring to the preoperative simulation by d imaging. (a)s segmentectomy; after the mobilization of the right lobe, the glissonean pedicles of s (g ) can be approached from the dorsal side by transecting the parenchyma between the ivc and the right hepatic vein. after the division of the g , the parenchyma is transected along the demarcation line and the rhv from the root side to the peripheral side. (b)s segmentectomy; first, the parenchyma is transected along the middle hepatic vein (mhv) from the root side to the peripheral. g is typically detected on the right dorsal side of the mhv. after the division of the g , the liver parenchyma is transected along the demarcation line and the rhv from the root side to the peripheral side. results: we have experienced cases of laparoscopic s segmentectomy and cases of laparoscopic s segmentectomy. conclusion: our approach to the g and the g is safe and very useful. laparoscopic anatomical segmentectomy of right anterior section is technically demanding because it is difficult to dissect the deep tertiary branches of right anterior portal pedicle (rapp). we present three cases of laparoscopic anatomical segmentectomy using the extrafascial and transfissural approach: ) anatomical resection of segment , ) anatomical resection of the ventral area ) anatomical resection of segment dorsal area. the extrafascial and transfissural approach means that the liver parenchyma along the fissure lines is opened, then the surgeon can confirm the glissonean pedicles and territory directly. the extrafascial and transfissural approach in laparoscopic anatomical segmentectomy of right anterior section is feasible and effective because this technique can easily be approached to the deep tertiary branches of rapp. repeated liver resection has significant role in patients with recurrent hepatocellular carcinoma (hcc) in several situations. laparoscopic redo surgery is becoming safer along with advance in surgical technique. we have performed laparoscopic re-resection for limited intrahepatic hcc recurrence. the aim of the present study was to investigate its significance comparing with first laparoscopic liver resections. subjects: patients with limited intrahepatic hcc recurrence after open hepatectomy underwent laparoscopic liver re-resection (n = ). methods: adhesion between abdominal wall and visceral organs was carefully divided, after the first laparoscopic port was safely inserted. adhesion between diaphragm and liver surface or between previous liver cut surface and colon or duodenum was also minimally dissected. approach to the glisson's pedicles at the hepatic hilum was often difficult due to previous surgical procedure, thus pringle's maneuver was generally applied. dissection of hepatic parenchyma approaching to the target glisson's branch was often preceded under the ultrasound-guidance. liver resection was performed using lcs, biclamp, and cusa using intermittent block of the hepatic inflow. operation time, intraoperative bleeding, morbidity, mortality, and postoperative hospital stay were compared with those in patients who underwent first laparoscopic liver resection during the same period (n = ). results: operation time was significantly longer in the re-resection group, possibly due to the adhesiolysis. meanwhile, no significant difference was detected in intraoperative bleeding, morbidity, mortality and postoperative hospital stay between the first and the redo surgeries. methods: the donor was a -year-old gentleman who decided to donate part of his liver to his wife suffering from viral liver cirrhosis and hepatocellular carcinoma. his bmi was . kg/m and the preoperatively estimated donor's right liver volume was ml, representing . % of his entire liver. with the recipient's weight of kg, the graft to recipient weight ratio (grwr) was . %. the liver had classic hilar anatomy except that the right posterior intrahepatic duct seperately joined to the left main hepatic duct. after isolation and clamping of right hepatic artery and portal vein, indocyanine green of . mg was injected intravenously. results: the total operation time was min and the estimated blood loss was ml without transfusion. indocyanine green fluorescence image clearly demonstrated the anatomical demarcation between the lobes and visualized the running of the biliary tree. his postoperative course was uneventful and discharged postoperative day . conclusion: real-time indocyanine green fluorescence image may be particularly helpful to delineate anatomical surgical plane and to determine the appropriate division point of hepatic duct during laparoscopic living donor hepatectomy. surg endosc ( ) the correct management of intraoperative volemic status is essential in laparoscopic liver resection in order to control bleeding and to perform even complex procedures with a good profile of safety. central venous pressure is not really reliable in laparoscopy, due to presence of the pneumoperitoneum and patient position. monitoring of haemodynamic parameters via vigileo system is a minimally invasive method to control stroke volume variation, cardiac output, cardiac index and oxygen delivery in order to optimize the anaesthesiological management by controlling venous bleeding and avoiding tissutal ischemia. introduction: non-hydatid liver cysts represent a heterogeneous group of disorders that differ in their etiology, prevalence and clinical manifestations.within them, the simple hepatic cyst is the most frequent.the majority of simple cysts are an incidental finding during the performance of an imaging test for another unrelated cause and few of them are symptomatic or are associated with complications, and surgery is not necessary in most of them. described various therapeutic approaches so far there is no consensus about the optimal treatment of simple symptomatic, complicated or growth-showing liver cysts during its follow-up. currently the laparoscopic approach is widely used for the management of cysts hepatic, with results similar to open surgery but with the advantages of laparoscopy. objectives: to demonstrate the safety and efficacy of the laparoscopic approach in the approximation of complicated simple hepatic cysts.material and method: clinical case: a -year-old female patient with a history of: giant hiatus hernia intervention with laparoscopic nissen, fibromyalgia, previous ischemic colitis. hospital admission due to pneumonia and right pleural effusion with us: simple cyst x x mm in segment v hepatic, with dilatation of biliary radicals adjacent to the cyst, distended gallbladder with irregular walls in the hepatic side. ct: cystic lesion in segment iv-v of the liver, which has increased in size, with small microabcesses adjacencies to the lesion, thickening of the gallbladder wall, to assess cholecystitis. antibiotic treatment is established with good evolution, deciding surgery. results: intervention: complete laparoscopic approach, trocars, edematous cholecystitis, large retroyuxta vesicular cyst,with thickened walls with serous content. cholecystectomy maintaining the cyst wall, puncturing and taking samples for cytology and biochemistry of the contents, resection of the cyst wall, partial flare of its internal surface, negative intraoperative biopsy, epipoplasty, with drainage placement.correct postoperative course.pathological anatomy: simple biliary cyst with negative cytology, ck ?, ck -, calretina-. conclusion: the treatment of choice of complicated simple hepatic cysts is laparoscopic.we recommend performing an intraoperative biopsy of all resected liver cysts to confirm its nature,we propose cyst enucleation as the best surgical treatment. objective: the objective of the following case is to present a patient with symptomatic polycystic liver disease, which was solved by laparoscopy approach and the management of its complications. material and methods: the case reported is about a years old female patient with abdominal pain in upper right quadrant associated to asthenia, adynamia and hyporexia. ct scan reported heterogeneous liver with multiple ovoid images with regular edges defined which the biggest one measure x x mm with volume of cc on segment and , which comprises stomach, and the other one in segment with a volume of cc and others small sized located in segment , and b. results: in this laparoscopic approach, we performed a cyst unroofing of the two biggest cysts as well as cholecystectomy because of firm and lax adhesions. the patient evolved with fever in the th day postsurgical day and biliary leaking in a volume of cc in hrs. an ercp (endoscopic retrograde cholangiopancreatography) was asked for that was carried out by finding leak at the intrahepatic biliary duct therefore; esphinterotomy with placement of plastic endoprotesis was performed. the patient evolved without complication and was discharged at the th day. conclusions: only symptomatic polycystic liver disease needs to be treated. the choice of treatment is not yet standardized, for voluminous cysts the unroofing ideally by laparoscopy is the gold standard and the ercp is the elected treatment when the biliary leak appears as a complication. introduction: laparoscopic liver resection (llr) for tumors located in the posterosuperior segments of the liver (segments (s) or ) is a challenging procedure. especially, llr for s is difficult because the access of instruments is limited, bleeding control is not feasible, major llr is sometimes required, and obtaining sufficient resection margin is not easy. to overcome this obstacles, we performed llr in s with a lateral approach using intercostal trocars. to obtain competent resection margin, llr through right hepatic vein (rhv) first approach was performed for . cm mass located near the rhv in a year old female. case: after full mobilization of right liver including all short hepatic veins and caudate lobe, rotate the whole liver completely to the left side to approach to the root of rhv. one intercostal trocar was inserted to access the lesion. parenchymal transection started from the confluence of hepatic vein and then, followed along rhv with ligating several small branches from rhv. resection margin was demarcated after localization using laparoscopic ultrasonography. after completion of parenchymal dissection using cusa and ultrasonic shears, hemostatic agents were applied and drain was inserted. operation time and estimated blood loss were mins and ml. the patient was discharged without any complication on postoperative day . final pathological assessment confirmed clear resection margin (safety margin : . cm). conclusion: laparoscopic s segmentectomy with hepatic vein first approach technique is safe and recommended to obtain better resection margin. aims: simple liver cysts are the most common cystic lesions of the liver. most are diagnosed casually in image tests such as ultrasound or computerized tomography, most of which are asymptomatic and do not require treatment. in symptomatic patients (abdominal distension with palpable mass, abdominal pain, dyspnea, jaundice, etc.) the clinical manifestations are usually due to the growth of the cysts or the compression of neighboring structures. liver function tests are usually not altered. intracystic complications occur in less than % of cases and malignancy is exceptional. in this video, we present the case of a symptomatic patient with polycystic liver disease including a large size hepatic cyst. material and methods: -year-old woman with a personal history of arterial hypertension, saos, partial hysterectomy due to endometrial cancer, who was referred to our department complaining of supraumbilical pain and abdominal distension with palpable mases. abdominal ultrasound showed cholelithiasis and multiple simple hepatic cysts. in ct scan, multiple hepatic cysts were found, the largest one of about cm of larger diameter. echinococcus granulosus serology test was negative. there was also no evidence of cancer disease in pet scan. results: a laparoscopic approach was performed with four trocars, three of mm and a hasson trocar inserted thought a umbilical small incisional hernia. aspiration and wide unroofing of the large size cyst and smaller accessible ones was done. the patient also underwent cholecystectomy with intraoperative cholangiography and umbilical eventroplasty. the patient recovered uneventfully and is asymptomatic one year after surgery. conclusion: simple liver cysts rarely require treatment. in some cases, especially in large, complicated and symptomatic simple liver cysts, surgery is indicated. laparoscopic fenestration treatment is the best choice. aims: liver resection is the preferable initial treatment option for solitary or limited multifocal hepatocellular carcinomas. surgical indications for laparoscopic liver resection (llr) are the most important consideration, like liver function, tumor size (diameter less than cm) and location (easy technical access like in the left lateral section or on the surface of the inferior region). partial liver resection or left lateral sectionectomy are the typical procedures for such tumors and are considered the best way to begin llr. with accumulating experience and technical advancement, llr has been performed for tumors larger than cm and for others locations. some requirements to perform llr are to have experience in liver surgery and laparoscopic also, adequate technology and intraoperative ultrasound. methods: a -year-old male smoker, ex-parenteral drug users with chronic hcv liver disease child-a stage. he is diagnosed with a single lesion of cm in segment iii of the liver, biopsied twice without conclusive diagnosis and with a three-phase ct suggestive of hepatocarcinoma li-rads with data of portal hypertension (pht) and mild ascites. after the study is commented on tumor committee deciding surgical intervention. results: a laparoscopic resection of segment iii was performed with trocars. liver is explored by intraoperative laparoscopic ultrasound. vascular control was performed using the pringle technique. liver transection was done with sonostar until identification of intraparenchymal segment iii vascularization, which is sectioned with endogia ( mm) with seamguard. after the resection, we perform hemostasis control with electrocoagulation and hemostatic material. intraoperative bleeding of ml. favorable postoperative evolution, high on the th postoperative day. ap: cm trabecular hepatocarcinoma moderately differentiated pt b, r resection. conclusions: llr allows major liver resections with low morbidity and mortality and the advantages of laparoscopic surgery. an efficient learning curve can be achieved by a parallel evolution of procedures and indications (according to modified bclc staging system and treatment strategy). studies suggest that llr results in less blood loss, shorter postoperative hospital stays, lower abdominal wall trauma and lower incidences of ascites accumulation and postoperative liver failure. with respect to oncological considerations, tumor margins are adequately maintained during llr. v. drakopoulos, s. voulgaris, i. iliadis, k. botsakis, p. trakosari, v. vougas st department of surgery and transplantation unit, district general hospital of athens « evangelismos » , athens, greece introduction: laparoscopic surgery is gaining acceptance in the treatment of liver metastasis. laparoscopic treatment of liver metastasis often presents technical difficulties and requires an extensive learning curve. material-method: we present the case of a year old woman presented with a liver metastasis in section of the liver. the patient had been submitted to a laparoscopic low posterior resection in february . patient underwent laparoscopic left lateral hepatectomy, with the use of three trocars (umbilical mm, and two in the midclavicular line bilaterally.) left lateral hepatectomy was conducted with the use of a linear stapler. the postoperative period was uncomplicated and the patient remains in good condition three months after surgery. conclusion: laparoscopic approach seems to be safe for treatment of liver metastasis, offering better surgical field view and less postoperative complications. year survival rate after laparoscopic hepatectomy is compared to the open approach. general surgery, chang gung memorial hospital kaohsiung division, kaohsiung, taiwan purpose: laparoscopic hepatectomy is a quickly growing method for liver tumor because of modern technology. but for the ihd thrombosis, it is still technique dependent. the video was tried to share our experience for special case. material and method: one y/o female patient suffered from fever episode and image show s cm hcc with right anterior ihd obstruction r/o tumor thrombosis, hilum ln enlargement, double right portal vein, hilum adhesion with duodenum, no ascites . lab data : no-b, no-c child a, afp , icg clearance rate . %, plt . heart, lung function exam normal. the laparoscopic right total hepatectomy and hilum ln dissection was conducted. results: laparoscopic approached was performed. the hilum ln dissection was done with vessel and bile duct isolation. hilum ln frozen show negative malignancy. hemi-vessel control was done with resecting the vessel. right hepatectomy was done with preserving middle hepatic vein. the right anterior and posterior ihd was opened and tumor thrombosis was removed from right anterior ihd carefully. the stump of ihd was closed by suture separately. the total op time was min with cc blood loss. post op minimsl bile leakage was found in the drain at day . the patient discharged at day with drain. conclusions: laparoscopic hepatectomy may be a feasible method for hcc even with ihd tumor thrombosis. surg endosc ( ) introduction: the progressive laparoscopic learning in gastric surgery and the great development of instruments and laparoscopic material that facilitates the realization of advanced procedures, has led to an increase in the use of laparoscopy in the treatment of gastric cancer. material and methods: we present the case of a -year-old man without amc with a history of ischemic heart disease who enters our surgery department for cholangitis secondary to choledocholithiasis. ercp is requested during his admission that describes a gastric lesion from which a biopsy is taken, making it impossible to access vater papilla to perform sphincterotomy and lithiasis extraction due to the existence of duodenal diverticula. the result of pathological anatomy of the gastric lesion was compatible with adenocarcinoma. negative extension study. the clinical case is presented in a committee of multidisciplinary tumors and it is decided to perform surgical intervention of both pathologies. a subtotal gastrectomy was performed with a roux-en-y reconstruction. surgical time of min. choledochotomy was performed with lithiasis extraction, as well as intraoperative exploration of the bile duct and main conduits by means of a choledochoscope. results: income of days, with a clavien ii. the definitive pathological anatomy was an ai stage with a total of isolated nodes without evidence of neoplasia in any of them, therefore it does not require adjuvant treatment. the patient is asymptomatic, with nutritional supplementation with follow-up in ccee of surgery. conclusions: in our case, there were no serious postoperative complications when performing gastric resection and bile duct exploration with drainage of the same. from the oncological point of view, the number of lymph nodes extracted and the surgical margins are similar to those obtained in patients in whom we perform open surgery; therefore, although it is a single clinical case, laparoscopy in expert surgeons is a safe and effective technique. the puestow procedure was initially proposed to alleviate the pain in patients with chronic pancreatitis and dilated wirsung duct. its objective is to provide an efficient drainage of the pancreatic fluids and, in the meantime, to preserve the pancreatic tissue and minimize the risk of endocrine and exocrine pancreatic insufficiency. aims: to describe the particular technical aspects and the efficacy of totally laparoscopic puestow procedure in patients with cystic duodenal dystrophy. methods: a years old patient presenting diffuse epigastric pain, vomiting and weight loss was diagnosed at endoscopic ultrasound and biopsy with cystic duodenal dystrophy. a conservative treatment was decided with octreotide and opioids. however, due to the persistence of symptoms surgery was performed. results: due to the association of a dilated wirsung duct, the patient was submitted to a puestow procedure. the surgical procedure was completed in a minimally invasive manner; after dissecting the anterior surface of the pancreas an intraoperative ultrasound was performed in order to identify the wirsung duct. therefore, the pancreatic parenchyma was transected along the wirsung duct, a totally laparoscopic pancreato-jejunostomy on roux en y limb being performed. the early postoperative outcome was uneventful, the patient being discharged in the sixth postoperative day. at one month and six months follow up the need for opioid treatment significantly diminished. a kinking of the enteral anastomosis required a laparoscopic intervention one year after with a very good evolution after. conclusions: totally laparoscopic puestow procedure seems to be a safe and efficient method in order to treat symptomatic patients with cystic duodenal dystrophy in whom a dilated wirsung duct is present. aims: the approach to the intraductal papillary mucinous neoplasm (ipmn) is various, from a radiological follow-up with magnetic resonance (rm) to the surgical treatment with a pancreatic resection [ ] . the surgical approach is various and depends on the localization of the lesion and on the surgical skills [ ] . methods: a years old patient was admitted at the chi possy-saint germain-en-laye with an acute pancreatitis. at the ecoendoscopy was found a pancreatic cystic at the junction of the pancreatic body and tail with a wirusng diameter of mm. a second episode of acute pancreatitis occurred a few months later. after that episode the patient was submitted to a computer tomography (ct) that found a cystic lesion of cm with an increasing dilatation of the wirsung duct. the serum ca - was ui/ml. a laparoscopic sils distal pancreatectomy with spleen conservation was performed. results: a trans-umbilical incision was performed with the positioning of the gelpoint sils platform with the placement of trocars. a distal pancreatectomy with a spleen preservation and without a standard linfadenectomy was performed. the pancreatic stump was closed with an endo-gia mm with seamguard device. any drain was placed. the post-operative course was uneventfull. a ct scan was performed in …. post-operative day which didn't show collections. the patient was discharged in -…… post'operative day. the histological examination shows an ipmn with low grade dysplasia. no invasive carcinomatoses cells were found. the distal pancreatic sils resection with spleen conservation is a feasible and safe technique that combine all the advantages of the minimally invasive laparoscopic approach with the esthetic advantages of the sils approach. pancreato-duodenectomy is a complex surgery, requiring several anastomoses to reconstruct the digestive tract. due to its technical complexity, the laparoscopic approach is not yet the goldstandard and there remains some controversy about its oncological safety. worldwide experience is limited, and its safety and effectiveness are yet under evaluation.we present the clinical case of a years-old woman with a prior history of epilepsy. she was studied due to painless obstructive jaundice and a cm pancreatic head tumour was diagnosed on imaging, causing cbd and wirsung channels' dilatation. the tumour was considered locally resectable and she was proposed for a radical pancreato-duodenectomy.we present the main steps of the surgery including the oncological resection with lymphatic basin clearance and totally laparoscopic reconstruction.the post-operative was uneventful, and the histologic sample revealed a ductal adenocarcinoma (t ) with an r resection and / lymph nodes invaded. although technically demanding, laparoscopic pancreato-duodenectomy is safe and effective requiring teams with experience both in pancreato-biliary and laparoscopic surgery. chronic pancreatitis is characterized by a progressive pancreatic fibrosis with loss of endocrine and exocrine function. one of its main symptoms is debilitating pain. surgical drainage of a dilated pancreatic duct is an option to consider in cases of refractory pain. longitudinal pancreato-jejunostomy allows an effective decompression of the pancreatic channel and a significant improvement in the quality of life. we present the clinical case of a years-old lady with a prior history of gallstones. she was treated for an acute pancreatitis in may , followed by recurrent relapses of pain and enzymatic elevation. she required opioid use for partial pain control and a significant kg decrease on body weight due to 'fear of eating'. the endo-ultrasonography and the mri revealed a chronic pancreatitis with an mm wirsung duct with ductal stones and an atrophic body and tail. we proposed a laparoscopic longitudinal pancreato-jejunostomy. the surgery was performed with trocars, with the surgeon on the right side of the patient. we performed a trans-mesocolic cm pancreato-jejunostomy. the post-operative was uneventful, and the patient was discharged on the th post-operative day, asymptomatic. laparoscopic longitudinal pancreato-jejunostomy, although effective is a technically demanding surgery but brings the benefits of a minimally invasive approach. background: preservation of spleen in distal pancreatectomy is also useful from the maintenance of platelets and the prevention of overwhelming post splenectomy infection. we have performed laparoscopic spleen preservation distal pancreatectomy: lspdp to benign and low-grade tumors of the pancreatic body tail. the aim of this study was to report our surgical experience with the method of svp: splenic vessel preservation and wt: warshaw technique of lspdp, describe our techniques with videos. method: there are three points of our surgical technique. , precede pancreatic dissection, improve the mobility of the pancreas. , confirming the courses of splenic artery and classified them into two major types. , preserving the left gastro-epiploic vessels and short gastric vessels.the postoperative cases of lspdp which performed from april to september was retrospectively studied. result: of consecutive patients were performed lspdp at our institute, were svp and were wt. ages, gender and bmi were similar for two groups. there were no significant differences in operative time, blood loss and length of stay after surgery. comparing pathological finings, wt was associated with a slightly large tumor lesion (median mm vs. . , p = . ). among the median observation period of months, splenic infarction was observed in case in svp and cases in wt. however, they were focal splenic infarctions, they did not need surgery or drainage. there were no cases in which late onset of splenic artery occlusion or esophageal / gastric varices. conculusion: after performing lspd, the function of the spleen was good in all cases. both svp and wt were safe and feasible procedures. this is the case of a -years-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last years. msct revealed pancreatic calcifications from mm to - mm and dilatation of the main pancreatic duct in the body of the pancreas up to mm. the patient underwent laparoscopic local resection of the head of the pancreas combined with longitudinal roux-en-y pancreaticojejunostomy-a technique known as frey's procedure. it is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.after performing the posterior wall of the pancreaticojejunal anastomosis we've faced an intraoperative complication such as volvulus of the roux limb causing serious ischemia of the limb. we were forced to remove all previous sutures in order to untwist the roux limb, thereafter the pancreaticojejunostomy was started anew.the purpose of this video is to demonstrate that frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. we demonstrate that even such serious intraoperative complication as volvulus of the roux limb can be managed without conversion. our center has an experience of over laparoscopic frey's procedures, however this is the first case where we encountered with such complication and we believe this is an experience worth sharing.yet we would like to underline that this approach should be used by highly skilled minimally invasive surgeons experienced in intracorporeal suturing which is the most challenging stage in frey's procedure. v. tomulescu, i. hutopila, c. copaescu spleen preserving distal pancreatectomy (spdp) is commonly applied in patients with benign or low-grade malignant tumors in the body and tail of the pancreas. two surgical techniques for spdp have been described. the first technique was described by kimura (spleen preserving distal pancreatectomy with splenic vessel preservation-spdp-svp) and preserves the main splenic artery and vein and excises the tail of the pancreas and those small, short vascular connections to the body;the second technique was described by warshaw and involves resection of the splenic vein and artery before distal pancreatectomy, and conservation of theshort spleno-colic and gastric vessels to keep normal blood flow for the spleen (spleen-preserving distal pancreatectomy with splenic vessel resection-spdp-svr). we present the case of a years old female with / mm tumor of the pancreatic tail on ultrasonography. ct scan confirmed the tumor and endoscopic ultrasonography with fna have shown a solid pseudopapillary tumor. due to the low grade malignancy we have decided to perform a laparoscopic spleen preserving distal pancreatectomy with splenic vessels preservation (lspdp-svp). for lspdp-svp the difficulty is related with the splenic vessels dissection and manipulation. primary dissection and control of main trunk of splenic artery and vein will help to quickly control bleeding during vascular rupture in small vessels dissection. optimal stapling of any tissue requires an adequate tissue compression time to allow elongation of the tissue being compressed, smooth firing of the instrument, consistent staple line formation balanced against the risk of increased tissue tearing and excessive tensile strength. this is why, for pancreatic division, we prefer choosing a cartridge loaded with higher staplers. the pancreatic stump transection line is evaluated for bleeding and when it is needed, hemostatic clips are applied. histology report confirmed a solid pseudopapillary tumor t nomxl v r at this moment with month good follow up. in conclusion lspdp-svp is safe, reproductible and demonstrated very good outcomes when certain indications are respected. surg endosc ( ) aim: advances in minimally invasive surgery has permitted to perform complex techniques by this approach, being the laparoscopic duodenopancreatectomy (lpd) one of these. the aim of this communication is to present a surgical technique video for a complete laparoscopic pd, showing the most important steps of the resective and reconstructive phase, with the anastomosis realized completely by laparoscopy. methods: a surgical technique video is presented showing the main steps for the lpd and a complete laparoscopic reconstruction with an hepaticojejunostomy, duct-to-mucosa pancreatic-jejunostomy and a gastrojejunostomy. results: an years old woman with past medial history of arteria hypertension, dyslipidemia, type ii diabetes mellitus and a breast cancer treated in with lumpectomy and axillary lymphadenectomy plus radiotherapy, recently diagnosed of and adenocarcinoma of the head of the pancreas. the ct scan showed a neoplasia localized in the head of the pancreas without extension to other organs. a laparoscopic pd was indicated after a multidisciplinary committee evaluation. a supraumibical hasson trocar was used for the pneumoperitoneum, three mm trocars and two mm trocars were used. lpd was performed. the resective phase was done following the conventional steps of the open whipple procedure and for the reconstructive phase, a child limb was used for a termino-lateral hepatico-jejunostomy with an absorbable / monofilament; a duct-to-mucosa pancreatic-jejunostomy with an absorbable / monofilament and finally a latero-lateral mechanical gastro-jejunostomy was performed. surgical time was min. postoperative course without complications and the patient was discharged on the th postoperative day. definitive anatomopathological exam: intraductal tubulopapilar neoplasia, x x mm, with wide high grade epithelial dysplasia. free margins. ptisn ( / ). conclusion: laparoscopic pd is a feasible procedure with a high technical requirement which should be performed in specialized centres with high experience in hepatobiliary surgery and in advanced laparoscopic procedures, because of its high morbidity and mortality. conclusions: robotic assistance in whipple may overcome limitations of laparoscopy and offer a minimaly invasive approach to this procedure potentially resulting in lower blood loss and less morbidity. we need further prospective randomized trials in order to determine the exact role of robotics in pancreatic surgery. aims: distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. the most obvious benefits of a laparoscopic approach to distal pancreatectomy include earlier recovery and shorter hospital stay. spleen-preserving distal pancreatectomy should be attempted in case of benign disease. laparoscopic spleen-preserving distal pancreatectomy (lspdp) is expected to be less invasive than laparoscopic distal pancreatectomy with splenectomy. however, there are few reports regarding the details of the procedure for lspdp, and its safety remains unclear. this study aimed to evaluate the feasibility and safety of lspdp. methods: retrospective analysis of surgery treatment of patients was made. lspdp was conducted in the period from to in the department of laparoscopy surgery of state institution o.shalimov national institute of surgery and transplantology. the average age was : . years, the body mass index (bmi) was . ± . results: laparoscopic distal pancreatectomys was performed in % of cases, were attempted in female and male patients. postoperative pathological examinations revealed cases of serous cystadenoma in the body and tail of the pancreas, case of serous oligocystic adenoma, case of mucinous cystadenoma, case of neuroendocrine tumor (insulinoma), and case of solidpseudopapillary neoplasm. complications related to the surgery were like acute pancreatitis with -fold increase normal plasma amylase confirmed by ct- cases, fluid collection- cases, pancreatic fistula (grade a)- cases. the operation time was . min, (range - min) blood loss of . g (range - g), mean hospital stay was . days (range - days). conversion to laparotomy was in case. mortality was . conclusion: laparoscopic spleen-preserving distal pancreatectomy is minimally invasive, safe, and feasible for the management of benign pancreatic tail tumors, with the advantages of earlier recovery and less morbidity from complications. aims: a pancreatic pseudocyst is an encapsulated, mature fluid collection occurring withing the pancreas that have a well-defined wall minimal or no necrosis secondary to pancreatic injury and mediated by the enzimatic and inflammatory disruption of pancreatic tissue. it is a common complication of acute and chronic pancreatitis. we present the case of a pancreatic pseudocyst located within the body of the pancreas due to recurrent necrotic pancreatitis. the objective of this video is to show the minimally invasive surgical approach of this entity. methods: a -year-old man without medical history was admitted to hospital in the digestive service on times for acute necrotizing pancreatitis. after study in which is evidenced cholelithiasis and pseudocyst in pancreatic body of cm maximum diameter and formation of two peripancreatic collections without signs of superinfection, cholecystectomy is indicated. magnetic control cholangiography was performed after surgery and it showed an increase in the size of the pancreatic pseudocyst, suspecting wirsung's duct disruption. therefore, endoscopic retrograde cholangiopancreatography (ercp) was performed by placing a plastic pancreatic prosthesis and performing a sphincterotomy. after hospital discharge, the patient is re-admitted due to recurrent abdominal pain without analytical alteration. tc abdominal observed an increase in the pseudocyst from to cm. this case was discussed in a multidisciplinary committee and surgical intervention was decided. results: laparoscopic approach is decided and four trocars were placed. initially, a gastrostomy was performed with liquid outlet. an aspiration of the liquid and quistogastrostomy with mm endogia was made. the patient progresses favorably, being high on the tenth postoperative day, without complications. conclusions: almost every pancreatic pseudocyst improves spontaneously and needs no specific treatment. draining is indicated when secondary symptoms to compression, complications or rapidly enlarging are found. depending on the complexity of the pseudocyst, its communication with wirsung's duct and the existence of ductal injury, it may perform a percutaneous, endoscopic or surgical drainage. the goal of pancreatic debridement is to excise all dead and devitalized pancreatic and peripancreatic tissue while preserving viable functioning pancreas, controlling resultant pancreatic fistulas, and limiting extraneous organ damage. only the surgical procedure is definitive. case: a y old male presents with intermittent low retrosternal pain and progressive dyspnea with exercise since a couple of months. cardiac investigation was negative and gastroscopy showed a grade b esophagitis. he was treated medically but with only partial response. on a thoraco-abdominal cat-scan the diagnosis of a left sided bochdaleks' hernia was made. the hernia includes the left kidney (with blood vessels and ureter), transverse colon and small intestine which are positioned in the left lower thoracic cavity with the left lung considerably compressed. method: given the clear correlation between the patients' complaints and these anatomical findings, he was referred to our service of abdominal surgery. we performed a laparoscopy with the patient in lithotomy position and the surgeon between the legs. the patient was tilted to his right side. mobilization of the spleen was necessary to gain maximal access to the hernia. we were able to reduce all the herniated content, freed the margins of the defect, reduced the hernia sac and repositioned the kidney intra-abdominally. the defect was manually closed with non-resolvable stitches and covered with a mesh which was secured with tackers. result: postoperatively the patient recovered well with adequate pain relief and pulmonary support. he could leave the hospital after days. control cat-scan on day postoperatively shows an intact lining of the diaphragm with normal positioning of the intra-abdominal organs. on follow-up weeks after surgery the patient had regained normal activities and was symptom free. conclusion: a symptomatic left sided bochdaleks' hernia in adults with an ectopic intrathoracic kidney is extremely rare. we hereby state that, during a laparoscopic repair, the kidney can also be safely reduced, which has almost never been described in literature yet, enhancing pulmonary recovery, improving access for mesh placement and thus diminishing recurrence rate. aims: large incisional hernias repair involves an actual problem for surgeons to face. anterior component separation has been an important method allowing to close the fascia defects without tension while also having underlay mesh reinforcement.therefore, we present a case of incisional hernia reparation performing endoscopic anterior component separation with advantages compared with open approach. method: we present the case of a -year-old woman, bmi kg/m , with previous laparoscopic gastric sleeve and posterior reintervention using open approach. the patient presented a cm size incisional hernia m w . a ct scan was performed, confirming a midline incisional hernia containing colon, with an herniary defect of cm. full minimal invasive abdominal wall repair was proposed. a cm size incision was made in left iliac region to reach the aponeurosis of external oblique muscle. we placed a balloon trocar and subcutaneous pneumo-dissection with mmhg pressure was performed; then, we placed a mm trocar in left lumbar space. the aponeurosis of external oblique muscle was incised and anterior component separation from inguinal to subcostal area was achieved. an extensive intermuscular dissection was performed to achieve complete midline closure. we performed the same procedure on the right side. then, with laparoscopic approach using v-loc n° suture, we completely closed the midline. eventually, we placed a x cm ptfe-c mesh fixed with a double crown of tackers and fibrin glue. results: postoperatory course was uneventful and the patient was discharged h after surgery without any remarkable event during his postoperative stay. the patient has been followed up for months without any complication or recurrence in ct scan, confirming the correct minimally invasive reconstruction of the abdominal wall. conclusions: trends in abdominal wall reconstruction and complex-hernia repairs have advanced rapidly in recent years. the goal is to perform a complete abdominal wall repair with no tension in midline incisional hernias. endoscopic anterior component separation and laparoscopic eventroplasty with closure of the defect, leads to a complete wall reconstruction without tension and avoids drawbacks due to primary close defect in those patients with herniary defects wider than cm. aims: endoscopic technique is a valid and safe approach for the treatment of abdominal wall defects. to combine the advantages of complete endoscopic extraperitoneal surgery with those of sublay mesh repair we propose totally endoscopic sublay anterior repair (tesar), a safe and feasible approach for the treatment of ventral and incisional midline hernias. methods: from may to september patients were referred to our unit for clinical and radiological diagnosis of midline ventral or incisional hernia and selected for tesar. exclusion criteria were: complicated ventral or incisional hernia (i.e. incarcerated hernia), maximum defect width [ cm, contraindications to general anesthesia. the procedure consisted of suprapubic access with trocars, complete endoscopic pre-aponeurotic dissection, isolation and reduction of the hernial sac, bilateral incision of the medial rims of recti aponeurosis and dissection of retromuscular plane to create the retromuscular space, sublay non-absorbable mesh positioning and anterior aponeurosis reconstruction. one drain was always placed in the retromuscular space and one drain in the subcutaneous space. results: all procedures were completed with endoscopic approach, with no conversion to laparoscopy or open surgery. no intraoperative complications were registered. total mean operative time was ± . min. no post-operative major complications were registered. only one subcutaneous seroma was registered ( . %), and treated conservatively. the mean postoperative stay was . ± . days. at post-discharge clinical checkups drains were checked and removed when indicated. no wound complications nor recurrence were registered to date. cosmetic and functional results were successful in all patients. conclusions: tesar is a safe and feasible technique for the extra-peritoneal sublay repair of ventral hernias with totally endoscopic approach. it provides accurate hernia repair with good outcomes in terms of resolution of symptoms and post-operative complications. r. mizuno, m. kondo backgrounds: abdominal incisional hernia is found in more than % after abdominal surgery, and risk factors such as wound infection, obesity, elderly, high abdominal pressure are pointed out. laparoscopic hernia repair using intraperitoneal onlay mesh (standard ipom) is becoming widespread in japan since the insurance release in , and our hospital is actively working on it. recently, ipom plus procedure which also carries out fascia suture in addition to laparoscopic mesh placement has been introduced. aims: we report the clinical results of laparoscopic abdominal incisional hernia repair in our hospital. methods: we performed hernia repairs using a mesh for cases from january to september . of these, cases were standard ipom and cases were ipom plus. there was no significant difference in the patient background such as gender, age, bmi, etc, and in the intraoperative findings such as hernia orifice diameters and adhesions. surgical time, postoperative hospital stay, and the rate of complications such as seroma, mesh bulging, postoperative pain, hernia recurrence were compared and examined between the two groups. results: as a result, in ipom plus group, the operation time was longer and the incidence rate of postoperative pain was higher, but the incidence of mesh bulging was significantly lower. also, in some cases since , the ' u reverse stitch method ' is used as an ingenuity of fascia suture in ipom plus. conclusions: laparoscopic abdominal incisional hernia repair has the advantage of being able to reliably confirm the hernia orifice from the intraperitoneal side?it is excellent in the identification of the fragile part of the abdominal wall and in the visibility of the restoration range. with regard to the ipom plus procedure which has been introduced in the last few years, although the operation time is extended, it has usefulness such as reduction of mesh bulging. from the viewpoint of cosmetic surgery, usage of ipom plus will increase in the future. introduction: incisional hernia is one of the most common complications after abdominal surgery. several methods have been introduced, and yet, there is no consensus on the best method of repair. we present a novel method for hernia repair which uses the retromuscular sublay mesh repair through a single incision at the pubic area to improve cosmesis. methods: medical records of patients who underwent single-port retrorectal incisional hernia repair from may to december were reviewed. patients were placed in supine position and a cm incision was made in the pubic area below the panty line. a flap is made upwards until the defect is found and bilateral rectus sheathes are dissected. a mesh is then placed between the posterior rectus sheath and the muscle. results: a total of patients with midline incisional hernia underwent single-port retro-rectal incisional hernia repair. mean age was . ± . years with an average bmi of . ± . . all the patients had midline hernia defect with an average of . ± . cm. mean operation time was . ± . min and estimate blood loss was . ± . ml. there was no postoperative complication, and ( %) patients were discharged on the day of surgery. conclusion: the single-port retrorectal incisional hernia repair is safe and effective while providing good cosmesis to selected patients with incisional hernia. aims: closing hernia defect during laparoscopic hernia repair is a vast extended technique nowadays. however, this technique is associated with mesh placemnt intraabdominally in contact by the abdominal content. nowadays there is a trend to recontruct the midline and to avoid a mesh intraabdominally in those cases suitable for it, as a new step forward of minimally invasive abdominal wall reconstruction. laparoscopic sublay approach with retromuscular placement of a mesh without mechanical fixation after reconstruction the linea alba migth be considered an option in primary hernias of the midline. methods: we present a case of a year old male with an umbilcal hernia of centimeter in diameter associated with rectus diastasis. a laparoscopic approach was performed, using one and two millimeter trocars placed on the left flank. the first step was to open the lateral side of the posterior fascia of the left rectus muscles, dissecting the retromuscular plane until we reach the linea alba getting into the preperitoneal space where the sac was diseected preserving the integrity of the peritoneum. the contralateral posterior fascia was also dissected all the way to the semilunaris line. the midline was closed, including th hernia defect, using a running double loop suture (maxon-loopÒ). a self gripping mesh (progripÒ) is placed in the retromuscular space in a sublay position ( cm long, cm wide). last, we close the fascia of the left rectus muscle using a barbed suture (v-locÒ). results: surgical time was min, being discharged of the hospital on postoperative day . pain was controlled with conventional analgesia and no postoperative complications, nor seroma was detected. conclusions: sublay approach for ventral hernia can provide a midline reconstruction, reestablishing abdominal function and avoiding the use of intraabdominal meshes and traumatic fixation, decreasing postoperative complications and pain. aims: lumbar hernia is one of the rare cases that most surgeons are not exposed to. hence the diagnosis can be easily missed. this is often related to previous surgery as lumbotomies or primary in the superior lumbar triangle. this leads to delay in the treatment causing increased morbidity. we report a case of adquired lumbar hernia in a middle-aged woman repaired by laparoscopic approach. methods: a years old woman with surgical history of a myelomeningocele surgery by posterior approach over years ago, a laparoscopic left nephrectomy years ago with a left colostomy due to a left colon injury during this procedure. a hartmann reversal by laparoscopic approach months later. patient showed a large lumbar mass over cms in the left lumbar region and a large scar near to spinal cord. it was soft in consistency, reducible and expansible on coughing and straining with defined borders. computerized tomography showed a large defect in the superior lumbar fascia over cms in the grynfeltt-lesshaft triangle with the left colon inside. results: patient was placed in a full lateral decubitus position. in order to optimize exposure, a lumbar roll was placed under the lumbar region. a capnoperitoneum ( - mmhg) was built up. one mm and two mm trocars were used and positioned in the left mid axillary line. a optic was used. adhesions were removed and toldt fascia was opened in order to expose the hernia defect bounded by quadrates lumborum, erector spinae muscles, rib and serratus. hernia content was carefully extracted from the sac using a ligasure maryland (covidien medtronic-usa). hernia defect was measured and an intraperitoneal mesh (dinamesh-ipom feg textiltechnik mbh, aachen, germany) was positioned and sutured by tackers to the margins included the bone. patient was discharged in h with a low pain rate and without complications. there is not recurrence in months follow-up. conclusion: laparoscopy might be a safe and feasible approach for repairing lumbar hernias, either primary or adquired, with a low rate of pain and complications s surg endosc ( ) after pneumoperitoneum is done, three mm trocars are placed on the left flank. the defect is delimited by drawing it over the skin of the patient with aid of an intramuscular needle and intraabdominal vision. posterior fascia is opened longitudinally at its medial edge and the retromuscular space is dissected. the arcuate line of douglas and the epigastric vessels are identified. from this point, transversus abdominis fascia is sectioned cranially cm medial to the semilunar line, preserving the neuro-vascular pedicles that reach the rectus abdominis laterally. at supraumbilical level, transversus abdominis fibers advance behind rectus abdominis, so they need to be sectioned to access to the space below the ribs. lateral dissection of this space enables a tensionfree closure at midline. once the procedure is repeated on the contralateral side using two mm and one mm trocars on the right flank, a continuous suture of the posterior fascia is performed with a barbed suture. the anterior fascia is closed with a slowly-absorbable monofilament loop-type suture. finally, a double-layer polypropylene mesh is placed at retromuscular level without any suture and fibrin glue is applied. results: the patient was discharged hous after surgery. no recurrence has been presented to the moment. conclusions: the section of the aponeurotic plane from the arcuate line of douglas enables a more accurate dissection of the retrotransversus plane without sectioning its fibers except for its cranial end, preserving the innervation and vascularization of the abdominal wall. this technical modification aims to simplify a complex laparoscopic procedure allowing its estandarization. aims: the authors present a video with their standardized laparoscopic ventral hernia intraperitoneal mesh (ipom) hernioplasty procedure but introducing a novel laparoscopic technique for tension releasing while hernia gap closure and midline anatomical restoration. methods: a years old male patient with a bmi presents a symptomatic ventral hernia recurrence after a sigma colic cancer open surgery. a ct scan study showed a cm transverse diameter midline ventral hernia. a laparoscopic ipom hernia repair procedure is performed using mm instruments and a mm camera. when checking tension while midline restoration suturing, we decide to add a tension-releasing maneuver: a totally laparoscopic transverse abdomini muscle release (taltar). this maneuver allow right rectus posterior sheath to advance some distance to the midline, in order to provide a tension-free midline closure. a double-faced ready-to visceral contact mesh is now placed and fixed. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with a rate in a eva acute pain visual scale. in a year follow-up, there has no been an anatomical or clinical recurrence. no chronic pain, anatomical recurrence, lateral asymmetry, umbilical or abdominal wall complications have been reported with this technique. conclusions: depending on the patient characteristics, anatomical hernia factors and surgeon mini invasive experience, a taltar maneuver could be a safe and feasible option for releasing tension when midline anatomical laparoscopic closure. more studies are needed in order to standardized this approach. aims: when primary ventral hernia and simultaneous diastasis recti are diagnosed, there is no consensus among the international surgical community on the surgical treatment regarding indications or surgical technique. however, if diastasis recti is symptomatic of or is associated with midline hernias, the corrective surgery of both pathologies at the same time could be the most recommended option. when we only correct the herniary defect, we risk performing a reparation on an anatomically weak tissue, so the rate of hernia recurrence may increase. we propose a minimally invasive access using totally endoscopic retromuscular hernioplasty. by developing this technique, several advantages are provided, such as no peritoneal opening without intraabdominal access, no mesh fixation needed and simultaneous solving of both pathologies. method: we present the case of a -year-old man, with bmi kg/m and no previous medical history complaining of ventral hernia with associated recti diastasis. a cm size umbilical hernia was diagnosed with a cm size supraumbilical diastasis recti associated. full endoscopy retromuscular hernioplasty was proposed. a cm size incision was made in left hypocondrium, openned the anterior rectus sheath and retracted the rectus muscle. we placed a balloon trocar and open the homolateral retromuscular space after placing two mm trocars in left lumbar space and epigastric position. we crossed-over the linea alba and achieve contralateral retromuscular space. after this step, the hernia sac was reduced and we extended the dissection cm caudal to the hernia ring. both medial posterior rectus sheaths were sutured with running barbed suture n° and a x cm size light-weight, big pore, polipropilene mesh was placed in retromuscular space and unrolled properly with enough overlap. a drain was placed and the anterior rectus sheath incision was closed. results: the patient was discharged h after surgery without remarkable events during his postoperative stay. he has been followed up for months remaining asymptomatic. conclusions: totally endoscopic retromuscular ventral hernia repair in men with umbilical hernia and diastasis recti associated, is feasible and reproducible procedure with several advantages compared to traditional laparoscopic ipom in terms of pain and mesh position. aims: parastomal hernia (ph) is one of the most frequent long-term complications of stoma formation, occurring in %- % of patients. surgical treatment for parastomal hernia is the only cure but a fairly difficult field with a recurrence rate ranging from % to % of cases. due to its advantages, the number of laparoscopic mesh repairs for parastomal hernia has gradually increased over the past decade. according to this common complication, we report a case of laparoscopic reparation of ph using the sugarbaker technique. method: we present the case of a -year-old patient with surgical antecedent of laparoscopic low anterior resection due to rectal cancer, presenting in postoperative period an anastomosis leakage with severe peritonitis was identified and a laparotomy with end colostomy was performed. the postoperative course was uneventful. during the follow-up the patient showed a centimetres size paraestomal hernia, being a m w incisional hernia confirmed with ct scan.the patient underwent full laparoscopic hernia repair, performing a sugarbaker technique, exposing parastomal hernia completely to measure the hernia ring size ( centimetres) and the midline associated defect ( centimetres). a x cm size ptfe-c was selected to allow a -cm overlap over two defects. results: using this approach, the bowel loop was pushed into the abdominal wall and appropriate place between the mesh edge and the abdominal wall is left to allow the bowel loop to pass through. postoperatory course was uneventful and the patient was discharged h after surgery without any remarkable event during his postoperative stay. he has been followed up for months without realizing any clinical signs or alterations in ct scan. compared with traditional open surgical repairs, laparoscopic repair has certain advantages including its safe operation, postoperative rapid recovery, fewer complications, and lower recurrence rate. however, it still faces challenges regarding parastomal hernia treatment, and there is a need to improve existing surgical techniques. aims: nowadays, the principal disadvantages of laparoscopic approach in hernia repair are the use of intraabdominal meshes and traumatic fixation. first, intraabdominal meshes involve the contact of the prosthesis with the intestinal loops with the consequent risk of adhesion and fistula. also, using helicoidal sutures in prosthetic fixation produces adhesions to the tackers and a non-negligible incidence of chronic pain. when it comes to lead to better results, placing the mesh in retromuscular space avoids the drawback of contact with the loops, and using self-fixation meshes may decrease the rate of acute and chronic pain. accordind to this facts, we present a case of laparoscopic ventral hernia repair with transabdominal retromuscular mesh placement without traumatic fixation. methods: we present a -year-old patient with a cm diameter hernia showed in preoperative ct scan, m w , with diastasis recti associated. the patient underwent laparoscopic surgery using transabdominal retromuscular route. one mm and two mm trocar were placed in left flank. the posterior rectus sheath on the left side is opened starting cms far from the left egde of the defect. once the retromuscular space is dissected, the hernia ring is dissected and the hernia sac reduced, we continue with the dissection in retromuscular space on the side. craniocaudal dissection is achieved cm distal to the defect margins. the hernia defect with the anterior rectus sheath and the diastasis recti were closed using v-loc running suture. self-adhesive mesh was subsequently placed. the mesh should be overlap cm from the margins of the defect, covering the defect widely, with grips facing upwards. finally, we closed the posterior rectus sheath with peritoneum on the left side with v-loc running suture. results: the postoperative course was uneventful and the patient was discharged h after the surgery. after months of follow-up no clinical or radiological recurrence was showed. conclusions: the combination of laparoscopic approach, retromuscular mesh placement and the use of self-fixation meshes, seems to be an actual useful solution, combining the advantages of each item and avoiding the use of intraabdominal meshes and helicoidal sutures. aims: laparoscopic ventral hernia repair has clear advantages over open repair, including less post-operative pain and earlier return to normal activity. however, a prolonged surgeon learning curve is necessary to perform this technique effectively. robot assistance may improve outcomes of minimally invasive ventral hernia repair with improved three-dimensional visualization and enhanced dexterity with articulating instrumentation. we report a case of robotic rives-stoppa epigastric hernia repair in order to demonstrate the feasibility of the robotic approach. methods & results: a -year-old man came to our attention for the presence of a palpable mass in the epigastric region. the abdominal ct scan showed the presence of an epigastric hernia with herniation of omental content, and the presence of diastasis recti. the patient was then submitted to a rives-stoppa robotic hernia repair under general anesthesia. the da vinci-si surgical system (intuitive surgical inc., sunnyvale, ca, usa) was brought into position over the head of the patient and docked after placement of the ports. three trocars were placed in the hypogastric region along the transtubercular line. a fourth trocar was placed in the left iliac fossa and used by the assistant. the operation started with an extended adhesiolysis and hernia reduction. then, the retromuscolar dissection began by incising the posterior sheath starting from cm above the pubic symphysis. an extended dissection of the rives space was performed to create a correct housing for the mesh. the hernia defect and the diastasis recti were closed using a - absorbable barbed suture. a phasix st tm mesh (bard inc./davol inc., warwick, ri) was positioned in the retromuscular plane, and was anchored with absorbable sutures and glue. the midline incision was closed using a - absorbable barbed suture. the operative time was minute. the postoperative period was uneventful, and the patient was discharged home on the second post-operative day. conclusions: robotic rives-stoppa ventral hernia repair is feasible, safe, and effective when a standardized approach is performed. whether robotics may improve the outcomes of minimally invasive ventral hernia repairs, including lower recurrence rates, decreased post-operative pain, or shorter surgeons' learning curve, will require careful prospective investigation. aims: the authors present a video with a left chronic bochdaleck hernia classical hernioplasty repair but performing a mini invasive thoracoscopic approach and mm instruments. methods: a years old female patient come to hospital due to chronic left dorsolumbar pain. a ct scan study showed a chronic left diaphragmatic bochdaleck hernia. a lateral right decubitus thoracoscopic repair is performed using mm instruments and a mm camera. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with no pain and a clean chest x-ray. in a year time follow-up, not an anatomical or clinical recurrence has been reported. neither chronic pain or respiratory complications happened, with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, left bochdaleck hernia mini invasive thoracoscopic hernioplasty repair using mm instruments could be a safe and feasible option. more studies are needed in order to standardized this approach. surg endosc ( ) abdominal wall surgery has expanded exponentially in the last decade. many techniques have been developed, mainly in minimally invasive surgery. laparoscopic ventral and incisional hernia repair (lvihr) has become a common procedure because of its feasibility and safety but unfortunately, it is not free of complications. chronic postoperative pain and bleeding are frequent complications, prolonging hospital stay and altering quality of life of the patients. absorbable or non-absorbable tacks are the usual method of mesh fixation and sometimes combined with transfascial sutures to secure the mesh. these mechanical fixations pierce the abdominal wall causing nerve or vessel injuries. some studies showed no differences between absorbable tacks, non-absorbable tacks or transfascial sutures concerning postoperative remarkably high pain. some authors consider that a non-penetrating fixation of the mesh getting an effective mesh-abdominal wall interface will reduce significantly the postoperative pain after a laparoscopic ventral hernia repair. tissue glues are used in different medical treatments and also have been used successfully for extra peritoneal mesh fixation in laparoscopic inguinal hernia repair, open ventral hernia repair but not so in laparoscopic ventral hernia repair in spite of good results published in the literature. cyanoacrylate and its derivatives are 'synthetic glues' and classified as medical devices with stronger adherent properties than fibrin glues. experimental studies have reported good results compared with suture fixationand also tissue toxicity doesn't lead to an increased foreign body reaction. some authors have studied the use of cyanoacrylate in laparoscopic inguinal hernia repair but unfortunately, clinical trial reports in ventral and incisional hernia repair were not found in the literature because the lacking of experimental studies that guarantee the safety of intra-abdominal mesh fixation and the interaction of the glue with the intra-abdominal tissue. our group developed an experimental study demonstrating the feasibility, safety and effectiveness of the cyanoacrylate using for intraperitoneal mesh fixation and after this conclusion, started a clinical study. this video shows the methodology for laparoscopic mesh fixation with only glue in our first cases. aims: small epigastric hernias, associated or not with the rectus abdominis diastasis, and small umbilical hernias are common in middle-aged women, particularly with past history of pregnancy. the aim of this video is to illustrate a new extraperitoneal approach to these clinical situations. methods: patients between the ages of and years old, with epigastric hernia orifice up to cm, with or without associated umbilical hernia (up to cm), were chosen for this procedure. the surgery begins with a vertical umbilical incision for the umbilical hernia's correction, and dissection of the pre-aponeurotic plane. two mm trocars (mini-laparoscopy instruments) are introduced at both flanks to enlarge the pre-aponeurotic plane towards the xiphoid appendix. in this way epigastric hernial defects are isolated. the surgery proceeds with defect suturing with braded suture, midline invagination and mesh placement if necessary. results: all patients had an eventful post-operative period and were discharged home at postoperative day . the aesthetic and functional results are optimal conclusion: for selected cases with high aesthetic motivation this technique seems to be feasible and with optimal cosmetic results. this technique allows the mesh placement both in-lay and onlay, protecting it from surgical site infections often present at the classical approac bochdalek hernia is a rare entity in adults. fewer than have been reported in medical literature, the majority of which were incidentally diagnosed. as such, the optimal repair of a symptomatic hernia is unknown. we present a case of adult bochdalek hernia repair. methods: a -year-old obese male patient with a years of chronic dry cough and left lung opacity in chest x-ray. a large posterior and lateral bochdalek hernia with herniation of intestinal loops and fat to the left hemithorax was seen in chest and upper abdominal ct scan. the hernia extended to mid-thorax, caused significant atelectasis of left lung. eighteen months later, due to appearance of chest and abdominal pain following a recent motor vehicle accident, a repeat chest ct was done and a slight enlargement of the hernia was shown. results: the patient was operated laparoscopically, positioned in a semi-right lateral decubitus with double lung intubation. a large left posterior and lateral diaphragmatic hernia which contained transverse and descending colon with omental fat was seen. they were pulled in to the intraperitoneal space carefully. the defect was measured to be * cm. it was reduced to * cm by suturing with a non-absorbable v-loc suture . advancing the camera to the thoracic cavity showed the left lung to be severely atelectatic. after selective recruitment lung was well expanded. a symbotex composite cm mesh was fixed to the defect area by suturs and laparoscopic tacker. the operation and post-operative course were uneventful. chest x-ray demonstrated the bowel below the diaphragm. the patient was discharged on pod . at -month follow-up, chest x-ray was normal. objective: to demonstrate the safety and efficacy of the standardized laparoscopic approach in the treatment of large parastomal hernia. currently, this approach is recognized as the one of choice in parastomal hernia pathology, being controversial which is the best technique of choice: keyhole vs sugarbaker. material and method: clinical case: a -year-old woman with a history of laparoscopic abdominoperineal amputation due to rectal neoplasia (pt n ), a year ago, with symptomatic parastomal hernia with incarceration episodes and inflamation changes in the stomal orifice.tac: large hernia parastomal with intestinal content inside. surgical treatment is decided. result intervention: complete laparoscopic approach, right lateral partial decubitus, trocars, dissection of the hernia defect and reduction of the content, partial mobilization of the pre-stomal colon, with bleeding at the level of the vascular origin, requiring careful hemostasis to avoid ischemia of the colostomy, herniorrhaphy with stitches with extracorporeal knotting, placement of polypropylene/pvdf mesh,fixed with irreabsorbable tackers with administration of biological glue at the edges of the mesh. correct postoperative, discharge at the rd day. asymptomatic and without hernia recurrence at one year of follow-up. conclusions: the technique of sugarbaker using a laparoscopic approach is a safe and effective alternative in the treatment of parstomal hernias. objetives: laparoscopic ventral hernia repair provides advantages in term of low infection rates and postoperatory stay when is compared with open repair. trends in laparoscopic abdominal wall surgery is to complete defect closure without tension in midline. closing the defect in ventral hernias wider than - cms creates high tension in midline and postoperatory pain. it's proposed different techniques to solve this drawback. laparoscopic posterior component separation makes the defects closure easier with no tension and placing the mesh extraperitoneally. methods: years old woman with previous total hysterectomy, a m m w midline incisional hernia was clinically diagnosed and confirmed with ct scan. full laparoscopic abdominal wall repair with defect closure was proposed. trocars in left side were placed and posterior rectus sheath right side in the defect margin is freed. once the lateral edge of the rectus sheath is reached, the posterior rectus sheath is incised, dividing the posterior aponeurotic sheath of the internal oblique muscle. this allows access to the plane between the internal oblique and the transversus abdominis muscles. it's is made the same steps in the left side with trocar on the right flank. the posterior rectus sheath both side is reapproximated in the midline and cms polipropilene mesh is placed and unfolded properly. it's fixed using cyanocrilate glue. one drain is left in retromuscular position and mm trocar wounds are sutured. results: postoperatory course was uneventful. hospital stay h. the drain was removed in day after surgery. after months follow-up no complication or recurrence were identified. methods: this video will show the evidence of gangrenous jejunal segment due to superior mesenteric vein thrombosis in a patient with history of breast ca on hormonal treatment.in this video, the gangrenous segment was resected and primary anastomosis was done using endogia mm. results: a second look after h revealed to be negative for any further ischemic bowel. conclusion: therefore, laparoscopy in acute abdomen is diagnostic and for treatment. introduction: gastric pseudo-volvulation is a rare entity of paraesophageal hernia that is characterized by migration of the stomach into the posterior mediastinum. this clinical-radiological picture has severe complications so in certain cases should be operated urgently. another small group of patients are asymptomatic, although the current literature recommends their regulated surgical intervention. we present a gastric pseudo-volvulation in the mediastinum, with a laparoscopic approach, showing that by systematizing the surgery, it is possible to perform this type of intervention with relative ease and safety material and methods: we present a video of an urgent laparoscopic approach in a female patient of years with a personal history of hypertension, smoking and dyslipidemia. with a hiatus hernia diagnosed more than ten years ago. he went to the emergency department due to significant symptoms of heartburn and reflux, as well as incoerctable vomiting and difficulty feeding one week of evolution. a simple abdomen and postero-anterior chest radiograph was performed, showing a paraesophageal hiatus hernia with almost the entire stomach included in the mediastinum. a thoraco-abdominal axial tomography corroborated giant hiatus hernia with pseudovolvulation and incarceration data. urgent intervention was decided by laparoscopic approach in which hiatus hernia reduction and esophageal abdominalization were performed. closure of pillars and reinforcement with bioabsorbable mesh. gastric and gastropexy toupet of anterior face to anterior peritoneum of abdominal wall. results: the patient had a post-operative h without incident, discharged with a crushed diet. the follow-up and evolution has been acceptable without notable complications. conclusion: the laparoscopic approach, in extreme cases of paraesophageal hiatus hernia with incarceration of the stomach and pseudovolvulation of it, is a correct, safe and effective alternative in experienced groups. surg endosc ( ) case report of incarcerated hiatal hernia. years old female was admited to the hospital due to severe chest pain and vomiting for about six h. physical examination and lab test showed no abberations. chest xray revaled incarcerated stomach above the diaphragm. she was rushed to the or. laporoscopic approach was used, the stomach was removed from the chest and nissen fundoplication was performed. day after surgery patient was asymptomatic, got full oral diet. she was discharged on postoperative day two, without a need of any analgetics. gastroduodenoscopy was performed weeks after surgery and showed proper image of oesophagus, stomach and duodenum, neither signs of hiatal hernia nor inflamation were present. laparoscopic approach is good way to treat incarcerated hiatal hernias and is related with shorter lenght of stay, lesser postoperative pain and better patient comfort. and it should be procedure of choice in this kind of cases. she was operated open technique using a cm long incision in right iliac fossa and the appendix was phlegmonous. the patient began feeling bad from the second day postoperative having temperature over °c, pain and increasing crp. the general condition worsened the next day when the temperature went up till . °c, extreme generalized pain and crp: . the ct abdomen control indicates signs for generalized peritonitis and rises the suspicion for a forgotten large gauze. the patient is operated using laparoscopy technique: identifying and taking out the foreign body, doing adhesiolises, extensive lavage and in the end inserting one drain in douglas. the video is presenting what king of special graspers can be used but also tips and tricks when speaking about identifying the anatomy but also dissection in acute and inflamed environment. postoperatively the patient began to feel better and in the th day was released home. conclusion: this case illustrates that even after open surgery, laparoscopy is a viable solution with the condition that there is available experience in minimally invasive surgery. introduction: foreign bodies can enter inside the human body by different mechanisms such as ingestion, aspiration, trauma or in some cases due to medical procedures. they are potentially life-threatening events, the diagnosis could be challenging and its management depends on their location. case report: a -year-old male was referred to our hospital due to chronic abdominal pain. he had cholelithiasis, medical history of acute pericarditis and past surgical history of left adrenalectomy, left nephrectomy, distal pancreatectomy and colon resection due to an adrenal adenocarcinoma (stage t n m ).abdominal radiograph showed a foreign body in the left lower quadrant of the abdomen, as an incidental finding. this was not detected in ct scans during ten years of oncology follow-up. ct scan revealed an extraintestinal metallic curved object in the right lower quadrant. this finding was not related to any surgical intervention or trauma. diagnostic laparoscopy was performed: the foreign body seemed to be a guidewire, it was included into the omentum and almost stuck to the abdominal wall. the guidewire was reached and carefully extracted through a mm trocar without any evidence of intra-abdominal organ injury. then an elective cholecystectomy was also performed due to his medical history of symptomatic cholelithiasis.the procedure lasted min. the hospital discharge was on the third postoperative day and no complication was registered. conclusion: is extremely rare to discover a guidewire that had migrated into the peritoneal space without abdominal injuries.this case report demonstrates the technical feasibility, safety and minimal postoperative morbidity associated with minimal invasive laparoscopic removal. aims: the authors present a video with their standardized laparoscopic groin hernia transabdominal preperitoneal hernioplasty (tap) procedure but using mm instruments and mm camera approach. methods: a years old male patient with a bmi presents a symptomatic bilateral groin hernia for months. us study showed an indirect bilateral inguinal hernia. a laparoscopic tap hernia repair procedure is performed using mm instruments and a mm camera. a selfgripping mesh preperitoneal hernioplasty and peritoneal flap barbed-sutured hermetic closure was performed. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with a rate in a eva acute pain visual scale. in a year follow-up, there has no been an anatomical or clinical recurrence. no chronic pain, anatomical recurrence, umbilical or abdominal wall complications have been reported with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, a laparoscopic bilateral hernia repair using mm instruments, could be a safe and feasible option. more studies are needed in order to standardized this approach. results: during tapp approach a direct hernia relapse was identified, the previous mesh was included on preperitoneal space and some non-absorbable sutures to inguinal ligament were identified. stitches and nearly total mesh removal (only the part surrounding cord elements was left in place) were performed. x heavyweight polypropylene mesh was employed fixed with gubran Ò and the flap was closed with running sutures. patient was discharged uneventfully the same day. seven months later he did not need analgesics and had no physical impairment. conclusions: post inguinal hernia repair chronic pain can be severe and disabling, and is becoming more prevalent. the origin is complex and meshes and sutures could play a role. the management is multimodal and demanding. for refractory patients, surgery may be an option. laparoscopic, open and mixed approaches have been employed. they usually combine mesh removal and substitution (often in different planes) and groin nerve therapies. nowadays, triple neurectomy seems to be the most effective treatment (more than % pain relief). generally, removal of mesh alone does not lead to lasting pain relief or has worse outcomes compared with associated neurectomy. introduction: mesh repair of inguinal hernia is sometimes followed by adverse effects such as mesh migration, chronic groin pain or recurrence. removal of the mesh is necessary in selected cases. we affront this cases by tapp intervention. methods: we present a video with two intreventions of inguinal recurrent hernia by laparoscopy (tapp). we remar the points to decide explant the mesh or not to explant. the conditions to decide the explant were the proximity to the main vessels in inguinal area (espigastric and femoral vessels) and the plication of the mesh. results: and conclusion as we show in the video, the explant of the mesh is only conditioned by the plicature of the mesh for its migration and recurrence, accompanied usually with pain. we don't remove any time the mesh or the plug if it is in the triangle of doom with firm adhesions to the main vessels. we cover the previous mesh with a new ligthweigth d mesh and closing at the end the preitoneum over the new reparation. introduction: tep technique isn't a controversial area in surgical practice for inguinal hernias anymore, but a fully accepted method. the use of general anesthesia has been the mainstay of laparoscopic hernia repair, but epidural anesthesia is not a contradiction to properly selected patients. material-method: the approach of the extraperitoneal area achieved without use of a dilation balloon, but via the indroduction of the camera and the dissection of the regional structures. trocars ports were used: a mm trocar through the umbilicus for the camera, exactly as in sils (single incision laparoscopic surgery), another one mm is placed in the midline between the umbilicus and pubis, the last mm trocar is placed in the midclavicular line ipsilateral with the hernia. the key for every operation was the tension free technique with placement and fixation of a mesh x cm. in / cases the mesh was placed with tacks on the inside of the inferior epigastric artery-vein complex. all patients were dismissed from the hospital in h, no drain was placed and no major postoperative complications took place. conclusion: tep is a demanding technique with serious learning curve. the use of a dilation balloon for insertion in the extraperitoneal area is not prerequisite. tep is an appropriate method both for first appearing and recurrent inguinal hernias. epiduralanesthesia instead of general anesthesia is no a contradiction for properly selected patients. aims: the aim of this study was to investigate the effects of preperitoneal carbon-dioxide (co ) insufflation during tapp (transabdominal preperitoneal) repair. materials and methods: male patients with inguinal hernia were include in our study. we obtain laparoscopic access at the umbilicus and introduce mm port. two mm working ports are placed lateral. diagnostic laparoscopy of the entire abdomen is necessary to rule out other pathology or contraindications for surgery. using aspiration needle we insuflate carbon-dioxide ( mmhg) preperitoneal at the level of anterior superior iliac spine while decrease abdominal gas pressure to mmhg. same procedure is made lateral to the umbilical artery. results: we found that preperitoneal carbon-dioxide (co ) insufflation during tapp facilitate the future parietalisation and even can reduce operating time in future improvements of the technique. there were no intraoperative complications related to this procedure. we did not found any potential risk of the technique when is use by trained surgeons. aims: laparoscopic inguinal hernia repairs (lihr) are performed more and more frequently because they offer some advantages; however, we cannot forget their specific complications. lihr are associated sometimes with peritoneal tears that can lead to bowel obstruction. we present two cases of bowel obstruction related to peritoneal defects post tapp procedure and review peritoneal closure, bowel obstruction and options to repair defects. a year-old male was scheduled for tapp due to bilateral relapse. two x tio mesh tm fixed with securestrapÒ, employed also for peritoneal flap closure, were employed. three days later he was readmitted with bowel obstruction with ct suggesting 'adhesions'. a year-old male had bilateral tapp in another centre. seven days later he presented with bowel obstruction. ct showed metallic tackers and suggested 'adhesions' results: first case: after four days of conservative treatment failure, a revisional laparoscopy showed ileum herniation through a peritoneal defect and firm adhesions to the mesh. bowel was labouriously separated and the peritoneal defect closed with two running sutures. he was discharged on the \ sup [ th \/sup [ postoperative day and three years later he is asymptomatic. second: after two days of conservative treatment failure, on laparoscopy, ileum was filmy adhered to polipropilene mesh through a big defect on flap closure. defect was closed with interrupted sutures. as tears persisted, an omental flap was created to cover the area. patient was discharged on the th day and continues asymptomatic three years later. conclusions: lihr bowel obstructions can be divided in adhesive disease and herniation. herniation can be early (through peritoneal defects) or late (trocar site). international guidelines recommends a thorough closure of peritoneal incision or bigger tears (grade b). the closure can be achieved with staples, tacks, running suture, or glue. these last two methods are more time-consuming but less painful. running suture seems to be the best, due to its low costs, tightness and low pain but sometimes can be technically difficult. low intra-abdominal pressures (= mmhg) facilitate suturing. when a herniation appears, careful bowel management is needed and running sutures are recommended. if tears persist, an omental flap can be useful. aims: application of a single port robotic platform to perform an entirely transanal tatme/ tata. methods: the following video demonstrates how a totally transanal proctosigmoidectomy is performed using a novel, single port (sp) robotic platform was used to carry out a totally transanal proctosigmoidectomy, single port robotic tatme/tata. a -year-old female patient with a clinical t n b rectal cancer at the cm level, status post neoadjuvant chemoradiotherapy ( cgy, xeloda) is presented. shown here is the open transanal dissection followed by docking of the sp robot, implementation of the single port instruments (fenestrated bipolar forceps, cadier, scissors, camera, clip applier) through a gelpoint path to complete a totally transanal proctosigmoidectomy including transanal tatme, ima/imv transection, splenic flexure release, and left colonic mobilization, loop ileostomy, and handsewn coloanal anastomosis. results: blood loss was cc. pathology demonstrated a moderately differentiated, rectal adenocarcinoma. the total mesorectal excision was complete (grade ), margins were negative, and all lymph nodes were negative for metastatic carcinoma. the patient was discharged on postoperative day after an uncomplicated hospital course. there was no postoperative morbidity or mortality. conclusions: application of the single port robot to transanal tatme/tata (sprtatme) is presented here. while much work remains to be done to validate the sp robot's safety, this first demonstration of a totally transanal tatme/tata establishes its feasibility and utility. this single port platform stands to greatly expand the application of natural orifice transluminal endoscopic surgery (notes). as shown, the sp robot offers more than sufficient visualization, technical control, and adequate reach to perform such an operation. we present an exciting new avenue by which to complete operations in an entirely transanal fashion, which are classically performed via a combined transanal and transabdominal approach. methods: this video shows the utilization of a new robotic platform to perform transanal endoluminal microsurgery, rtem. presented here is a year old woman with a recurrent rectal adenoma at the cm level, status post a previous tem resection in october . demonstrated is the utilization of the sp robot through a gelpoint path in order to perform a partial fullthickness and full-thickness resection. the robot is introduced through a mm in diameter cannula via a four-channel face-plate. the instruments' two-jointed mobility at the elbows and wrists as well as the novel navigation system are well demonstrated. the docking of the sp robot, utilization of the dissecting devices, and closure of the defect is shown. results: sprtem was performed with a blood loss of cc, and the patient was discharged on postoperative day . there was no postoperative morbidity, mortality, or moderate/severe pain. pathology showed tubular adenoma with low-grade dysplasia in a non-fragmented specimen with negative margins circumferentially. conclusion: initial experience using the sp robot for rtem is demonstrated here. the robot provides wonderful visualization and operative control to the surgeon. articulation of the robot's wrists and arms have the potential to facilitate technical aspects of the procedure. rtem stands as an exciting development in the field of transanal endoluminal surgery. introduction: the application of robotic approach in the esophageal surgical field is in its first phase. the microsuturing and microdissection capabilites of the robotic system can potentially overcome the traditional limitation of the laparoscopic surgery thus enhancing the indications of minimally invasive surgery. methods: we have performed a retrospective analysis of our prospectively maintained database that included patients who underwent robotic-assisted esophagectomy for malignant disease between and . results: ten out of sixteen patients had squamous cell carcinoma meanwhile six had adenocarcinoma. ten mckeown's and six ivor lewis were performed. the mean operative time was min ( - ) and the median blood loss was ml ( - ). no patients required conversion nor intraoperative transfusion. the morbidity rate was / ( . %) : a transitory laryngeal nerve paresis, a pneumotorax and pneumonia. the mean hospital stay was (range - ) days. an r resection rate of . % was achieved with a mean lymph node yield of ( - ). the -year disease free survival was . %, wheres the the -year overall survival was . %. conclusions: robotic assisted minimally invasive esophagectomy (ramie) is safe and feasible, it offers promising results while preserving a good oncology adequacy. this video shows our technique for the treatment of an esophageal diverticolum using a robotic left sided transthoracic approach, followed by a heller myotomy and dor fundoplication using a transabdominal approach. our case is a year old male, who suffered from severe dysphagia, halitosis and gastric reflux who on endoscopic and radiological investigations was found to have low grade and a cm wide esophageal diverticulum, cm from the lower esophageal sphincter. initially conservative management was attempted, however following poor compliance and the persistance of symptoms after year of therapy, surgical intervention was indicated. the operation was performed using the minimally invasive robotic system of the davinci siÒ, starting with the thorax time. the patient is positioned in left side decubitus. the camera-trocar is insert in the thorax via the fifth intercostal space the, two mm and one mm robotic trocars are added. the lung is liberated from pleural adhesions and the esophagus is then prepared exposing the diverticulum which is successfully removed with an endo-giaÒ. the esophageal muscle fibers, near the suture line is reinforced with separated vicryl stitches and the resected piece is extracted via endo-bag. a fr thoracic drainage tube is then placed and the trocar accesses repaired. the patient is the put in supine position with a °anti-trendelemburg angle. three robotic trocars (two mm and one mm) are placed and the robot docking is made from the patient left shoulder. the lesser omentum is divided to visualize and prepare the gastric-esophageal junction (gej) sparing the vagus nerve. the heller myotomy is then performed for cm over the gej and cm under it. the mucosal integrity is assured via laparoscopic and contemporary gastroscopic view. the gastric fundus is attached to the distal esophagus completing the dor fundoplication. post-operative care comprehends the removal of the thoracic drainage during the first post-operative day, the pain management and the progressive realimentation. the hospitalized period lasts day and the patient was dismissed without complications occurred. the uniportal video assisted lung lobectomies gained popularity all over the world during the last years. the technique is safely applied for peripheral pulmonary lesions, under cm, but more and more complex cases are being approached while the indications continue to evolve. our aim is to present the particular aspects of this technique in an -year-old female patient with a giant bullous lesion located in the lower lobe of the right lung. the preoperative work-up for this case is presented and commented. a multidisciplinary surgical team consisting of thoracic and pediatric surgeons was involved. a single . cm length incision in the fourth intercostal space was used for the access. due to the fact that the lesion involved almost the entire lobe and the margins were very close to the hilum, we have decided and performed a right lower lobectomy. dissection and stapling were quite difficult. all the anatomical structures had small dimensions, forcing us to perform an 'artery first approach' in a very narrow space. no complications during or after surgery were encountered. the patient was discharged after four days and she went to school on the sixth day. histopathological examination showed that the lesion was a type ccam (congenital cystic adenomatoid malformation). conclussion: the uniportal video assisted lung lobectomy was safety applied for a giant bullous lesion of the right lung. aim: dunbar syndrome, celiac trunk (ct) compression syndrome, caused by median arcuateligament is a rarely diagnosed disease because of its nonspecific symptoms, which cause adelay in the correct diagnosis. the aim of the study was to demonstrate the usefulness andadvantages of laparoscopic approach in the treatment of dunbar syndrome. methods: we performed laparoscopic release of ct in the department of general, minimallyinvasive and elderly surgery in olsztyn in . all of three patients suffered from severepain of abdominal cavity before the surgery. results: in two cases, there were a complete remission of the symptoms. in one case, there was animprovement. all patients reported relief of symptoms in the first days after the operation.there were no postoperative complications. conclusions: the laparoscopic treatment of dunbar seems to be safe and feasible procedure. thelaparoscopic surgery alone can often eliminate discomfort, while angioplasty and stentimplantation are no longer necessary. introduction: the advances in robotic surgery have permitted the application of such technology to various surgical fields, one of the last of these being hernia surgery. we present a case video of the treatment of a dual-hernia using a robotic retromuscular ventral hernia repair(rrvhr) using the davinci siÒ robotic system. the case report demonstrates the evolution of the trans-abdominal robotic umbilical prosthetic (tarup) in that it utilises a 'double docking' technique to allow the positioning of a large retromuscular mesh. methodology: our patient is a -year-old male who presented with chronic epigastric pain. the abdominal ct confirmed two abdominal wall hernias; an epigastric and supra-umbilical hernia with visceral contents and wall defect diameter of cm and . cm, respectively. using the minimally invasive robotic system of the davinci siÒ we adapted the well known retromuscular mesh technique. the operation was initially intraperitoneal with access to the retromuscular preperitoneale space using a right sided longitudinal incision.(as per standard tarup technique). we proceed with the dissection of the retro-muscular space until the left lateral edges of the rectus sheath, creating a preperitoneal space for the placement of a specifically modified ultrapro polypro-leneÒ x cm mesh. following this we repositioned the davinci siÒ in a symmetrical manner, with ports placed in the retromuscular space. the mesh is positioned and the peritneum subsequently closed with a v-lock sutureÒ. finally we opted for a negative pressure jackson-pratt drain, inserted preperitoneally. results: the patient was discharged on the nd post-operative day without complication follow up continued until months post operatively during which the patient remained asymptomatic, without signs for hernia recurrance . conclusion: the technique highlighted in our video demonstrates the utility of the robotic system in hernia repair. specifically the approach proved a success as it facilites the placement of the mesh totally extra-peritoneally with closure of the posteriore sheath without tension. the added advantages are that the port-sites are distant from the mesh thus reducing infective risk. additionally this technique allows the treatment of large peritoneal defects. surg endosc ( ) aim: to analyse the performance of a robotic fellow during a robotic total mesorectal excision (tme) at the end of the fellowship, and subsequently compare it with their mentor. methods: the fellow is exposed to robotic colorectal lists per week. during the fellowship, assessment of performance is recorded in a structured proforma covering aspects of autonomy, tissue handling and dissection. at the end of the fellowship, areview of cases performed by the fellow and the mentor was carried out in a blindly manner (video footage). results: robotic tme training was divided into modules in order of complexity and the trainee had to achieve sequential proficiency in each module, before progression. docking of davinci robotic system. inferior mesenteric artery exposure and ligation, development of medial to lateral plane and inferior mesenteric vein division. left colonic and splenic flexure mobilization. pancreas identification. rectal dissection (tme). qualitative assessments were recorded by the mentor; the fellow was 'able to perform with verbal help' most of the steps from early on. by the end of the fellowship, all steps were performed in a similar manner in terms of quality and oncological integrity when compared with the mentor. conclusions: at completion ofan advanced robotic colorectal fellowship, high quality trainees can perform every step of the tme dissection in a similar manner with the trainer, when assessed blindly, without compromising oncological integrity. aims: to find safe and simple method in robotic rectal low anterior resection with low tie arterial ligation and lymph node dissection around the root of inferior mesenteric artery. methods: we performed robotic rectal low anterior resection (rlar) by davinci si system in eight patients with rectal cancer. we applied low tie arterial ligation, just caudally to the origin of the left colic artery in all cases. during the procedure, we used tilepro function of davinci si system which enabled to display two other visual informations through external inputs under the normal -dimensional surgeon console view. preoperative d-ct vessel branching simulation video and intra-operative real time ultra sound navigation view were displayed simultaneously under normal operative camera view in the surgeon console. results: left colic artery preservation was completely done in all cases. the mean time to find and expose the left colic artery from the first incision in sigmoid mesentery was min, which was drastically shorter than conventional method. this method needed lesser mobilization of inferior mesenteric artery (ima), and may be less invasive to autonomic nerve around the root of ima which is very important for ejaculation function. conclusion: robotic rectal low anterior resection with low tie arterial ligation was performed safely and in short time, using tilepro intra-operative navigation method. preoperative d-ct vessel branching simulation video and intra-operative real time ultra sound navigation view were very useful in the procedure. we present the method in video. nerve sparing tme and pelvic neuroanatomy for colorectal surgeons p. tejedor, f. sagias, j.s. khan aim: to describe the critical points in which the pelvic nerves can be damaged during a total mesorectal excision (tme) for rectal cancer and the benefits of robotic surgery for identifying these points. methods: there are critical points regarding pelvic neuroanatomy: superior hypogastric plexus (shp): located in front of l -s . the ganglionic sympathetic fibres form the right and left sympathetic trunk, travel along the anterior surface of the aorta and coalesce in the shp at the level of the inferior mesenteric artery (ima). superior hypogastric nerves: they take an anterolateral course into the pelvis. there is an avascular 'holy plane' around the rectum between these two nerves. inferior hypogastric plexus (ihp): lies over the posterolateral pelvis, almost parallel to the internal iliac arteries. this can be identified at the lower end of the rectum. neurovascular bundles(of walsh): in front of the denonvillier's fascia, at and o'clock position. they are responsible for erectile function. results: lack of knowledge or identification of key structures at these points can lead to increased risk of nerve damage and translate into poor functional outcomes. the ima is dissected up to the origin from aorta and here the shp can be seen. care is taken to avoid any damage to these structures. the tme plane is found at the back of ima as the inner most dissectible layer between mesorectum pelvic fascia. right and left superior hypogastric nerves are identified. dissection is carried out posteriorly, laterally and anteriorly. ihp is identified at the lower third of the rectum, when the dissection is about to reach the pelvic floor. care should be taken in not to go too far lateral and damage this plexus. in the anterior dissection, plane is carried in front of the denonvilliers' fascia. the neurovascular bundles can be seen at and o'clock position and the surgeon has to be careful to stay inside that plane in order to avoid damage. conclusions: the precise dissection in robotic surgery results in minimal tissue damage and better visualization and preservation of the pelvic nerves. aims: to describe and evaluate new contributions and eventual advantages of icg fluorescence to perform an icg guided bilateral pelvic lymph node dissection in a patient who underwent low-anterior-resection for rectal carcinoma. we also present the basic steps to avoid ileostomy during rectal surgery in which icg and ghost ileostomy play an important role. methods: a -year-old male patient was referred to our hospital due to abdominal pain and significant changes in usual bowel habits.colonoscopy showed a no obstructing cm middle rectal mass, which was reported as an adenocarcinoma.ct scan and mri revealed a mm polyp in the anterior rectal wall which was located cm from the anal verge. it was involving mucosa and sub-mucosa with muscularis propia invasion. no pathological lymphadenopathies or hepatic metastatic disease were found (stage t n ).a laparoscopic ultra-low-anterior resection plus icg lateral lymphadenectomy with total mesorectal excision was performed. a complete splenic flexure mobilization was performed to achieve a safe tension-free anastomosis. transection line of the proximal rectum was checked after icg intravenous injection. icg was injected around the tumor by inserting an anoscope, just before the surgery. after the dissection of the rectum, lateral lymphadenectomy was performed assisted by icg. an end-to-side anastomosis was made. and a vascular loop was passed around the terminal ileum to create a ghost ileostomy.the procedure lasted min. reactive protein c was monitored to identify an initial leak. the patient was discharge in postoperative day and no complication was detected. results: pathological exam reported a rectal adenocarcinoma. pelvic lymphadenectomy results were: negative nodes, negative nodes and negative nodes from right lymph node dissection, left lymph node dissection and rectosigmoid resection specimen respectively. no metastatic disease was found (stage t n m ). conclusions: in our experience, icg fluorescence imaging system offers important contributions to rectal surgery furthermore than evaluating vascular supply to the anastomosis. lymphatic mapping of the lateral lymph nodes and avoiding ileostomy could be a potential important use in the future. larger studies and more specific evaluations are needed to confirm its role in colorectal surgery and to find its limitations. background: robotic surgery for colorectal cancer is an emerging technique. potential benefits as compared to conventional laparoscopic surgery have been demonstrated. innovative robotic technologies have helped surgeons overcome many technical difficulties of conventional laparoscopic surgery such as hand-eye coordination, a two-dimensional view, and a restricted range of motion. robotic-assisted surgery was established as a new approach to minimally invasive surgery, overcoming these limitations. the following video shows a total robotic sigmoidectomy step by step on the basis of ourexperience. intervention: a -year-old male patient with no previous medical historyand a colon adenocarcinoma, cm from the anal verge, no distant metastases. it was decided to perform a robotic sigmoidectomy. target anatomywas located andwe proceededto the exposure of the mesenteric vessels from medial to lateral. a cautery wasused to open the peritoneum,up to the origin of the inferior mesenteric artery, and caudally past the sacral promontory.the vessels weretransected by ligasuretm. we performedthe complete release of the colon taking care to avoid injury to retroperitoneal structures. we usedligasuretm to section the mesocolon in order to prepare the transection of the proximal colon. indocyanine green was used to check the correct vascularization. an endogia tristapletm was used to divide the colon. subsequently, we sectioned the rectumand extracted the specimen through itwith no need to make any auxiliary incisions. we introduced the anvil of the suture device to perform the anastomosis. we sectionedand close the rectum with an endogia tristapletm. finally we opened the proximal colon to introduce the anvil,making a pursestring to fix it and create a side to end anastomosis. outcome: the surgery took min. the patient started oral intake h after surgery and left the hospital on the rd postoperative day. pathological examination ruled out a colon adenocarcinoma pt n . conclusion: total robotic sigmoidectomy is safe and feasible and can be a procedure of choice to achieve a good surgical qualityand avoid assistance incisions in patients with colon cancer. surg endosc ( ) with more and more data now advocating wait and watch policy for these patients which require close radiological and endoscopic follow-up but unfortunately around % of them have regrowth of tumour which will require surgical intervention. the use of robot for cancer resections is becoming more frequent especially in narrow spaces like in an obese male pelvis. the reason being better -dimensional views, more angulation of the instruments and exclusion of tremors, which in turn leads to better dissection and preservation of hypogastric nerves. in this video, we present a robotic low anterior resection for rectal re-growth in an obese -years old male patient. he was offered neoadjuvant chemoradiotherapy after discussion in mdt. he had an complete response with chemoradiotherapy and was decided to offer him watch and wait regime. unfortunately, he developed rectal re-growth in the first year of his follow up. imaging showed t lesion with no distant metastasis and was later confirmed on histology as well. after mdt discussion he was offered robotic low anterior resection. the video starts by showing the clinicopathological features of patient including his radiological and endoscopic images. robotic port sites are shown. the edited video starts with rectal dissection after ligation of inferior mesenteric artery and vein with emphasis on narrow pelvis and preservation of hypogastric nerves, seminal vesicles and intact presacral fascia. postoperative histology was ypt no and patient was discharged home after days with no postoperative complications. background: minimally invasive surgery for colon resection has improved patient outcome, however a minilaparotomy still is necessary to extract the specimen. this report describes a new approach that combine laparoscopic parellel overlap stapling left colectomy with natural orifice specimen extraction surgery, with the aim to minimize abdominal wall trauma. method: laparoscopic left colectomy for malignant diesease was performed using a standard five-port technique. after releasing the left colon via laparoscopy, divide the proximal and distal of specimen with -echelon, and put distal sigmoid colon and proximal transverse colon together. open sigmoid colon cm apart from distal margin, and incise transverse colon at proximal margin. take transverse colon and sigmoid colon side-to-side anastomosis via -echelon. incise posterior vaginal fornix to get into the abdominal cavity and extract specimen through vaginal. outcome parameters such as complications, conversions, operative time, postoperative recovery, and postoperative pain were prospectively recorded in a database. results: surgery was performed for patients with left-colonic carcinoma. no perioperative complications or conversions occurred. the median operating time was min. the median visual analogue scale score of postoperative pain was , and of patients needed analgesia on postoperative day . the median postoperative hospital stay was days. for malignancies, tissue margins were oncologically adequate, the averge number of harvested lymph nodes were . . the -week follow-up period was uneventful. conclusion: the described technique, a combination of laparoscopic parellel overlap stapling and natural orifice surgery, has the potential to avoid incision-related morbidity of the minilaparotomy in laparoscopic left colon resections. background: open surgical skills training has been well established over centuries, however, there are some significant differences in laparoscopic surgical skills training. it is an obvious advantage that the trainee and the trainer have the same view; however, some of the hurdles include the differences in tactile feedback, hand eye co-ordination, spatial awareness, depth perception and maximizing assistance. aim: we present a video highlighting some of the key challenges faced in laparoscopic colorectal surgical training, show-casing our systematic, structured approach. our approach: we have developed a structured approach starting with junior surgical trainees and progressing through to consultant level as per the levels below: level : attend courses/ workshops level : master camera work level : contra-lateral assisting level : intermediate level trainee-start operating with trainer scrubbed. the trainer is an additional member of the scrub team and stands on the same side as the trainee (does not replace any assistant) level : advanced level trainee-gradual progression from level . trainer un-scrubbed but standing next to the monitor throughout the procedure. level : trainer in theatre but out of sight of the trainee, with little interference level : progression to trainer-once proficiency is achieved at level / , the trainee is trained to become a trainer, for the junior and intermediate level trainees. within each level the complexity of the procedure increases as the trainee progresses through the level. junior trainees (years - of surgical training) are taken through levels - , intermediate (middle years of training) level or and advanced (last - years) up to levels . this way of training allows multiple members of the team to be trained simultaneously in every case. each operating list is preceded by team briefings where the role of every member of the team is clearly identified and followed by individual and collective feedback. conclusion: this training ladder proved very successful through the years. the feedback from trainees at all stages has been consistently positive. several trainees who have progressed to independent consultant practice, in the uk and abroad, are adopting this approach in their practice. introduction: despite the potential microsuturing capabilities of the robotic surgery, most of the esofago-jejunostomy after robotic total gastrectomy are still performed extracorporeal or through mechanical staplers. this can increase the cost of the procedure, the risk related to a improper functioning of the stapler. methods: we reviewed our prospectively maintained database analyzing patients from april to september , who underwent robotic total gastrectomy with hand-sewn esophagojejunostomy for gastric cancer. results: a total of patients were included in the study. the mean estimated blood loss was ml ( - ). the overall operative time was min ( - ). length of hospital stay was days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . no conversion was necessary nor anastomotic leakage occurred. the morbidity rate was / ( . %) and included a subhepatic abscess and wound infection trough pfannenstiel incision. a r resection rate was achieved in all cases. the mean of lymph node yield was ( - ). the -year disease free survival was %, the -year overall survival . %. the robotic-assisted hand-sewn esophago-jejunostomy is a safe and no time-consuming technique. it avoids the complication related to the stapler firing and it offers cosmetic benefit to the patient in terms of extraction site. introduction: colorectal endoscopic submucosal dissection (esd) is increasingly practiced for treatment of early colorectal neoplasia. however, colorectal esd is difficult to perform due to lack of retraction as well as instability especially over hepatic flexure. dilumen eip is an external flexible sheath introduced during colonoscopy to stabilize environment for esd. this video demonstrated the use of dilumen eip for performance of colonic esd at the ascending colon method and results: this is a years old lady who received screening colonoscopy and found a mm lateral spreading tumor (lst) type iia lesion at ascending colon distal to ileocecal valve. under general anesthesia, patient received colonic esd using dilumen eip. due to significant looping, the dilumen device was introduced with the techniques of double balloon enteroscopy. after identification of the lst, the balloon in the front would be deployed to the proximal to the lesion while both balloons would be insufflated and created a stable environment. the esd procedure started after submucosal injection with normal saline in mix with indigocarmine, epinephrine and hyaluronate. mucosal incision was performed over the anal side of the lesion, and after adequate submucosal dissection, clips were applied to attach the mucosal flap to the sleeve of proximal balloon and achieved retraction. the submucosa was adequately exposed for dissection using dual knife jet. this enhanced submucosal dissection especially at one area with significant fibrosis. after the procedure, complete closure of the mucosal defect was performed by clips and assisted by the front balloon. the pathology confirmed intramucosal adenocarcinoma with clear resection margins. discussion: the dilumen eip device stabilized the environment within the colon with the double balloon and provide adequate retraction for performance of colorectal esd. surgery, kobe city medical center general hospital, kobe, japan background: robotic surgery has been widely spread all over the world, but robotic gastrectomy is not common and difficult because of complex anatomy and wide-ranging operation fields. in addition, it had been performed only under a few high-volume centers for reasons of the limitation of national health insurance in japan, which means medical expenses not covered by insurance. the situation was changed from this april, so we started robotic gastrectomy to reduce complications more rather than laparoscopic gastrectomy. we report results and aim to present the methods in detail using da vinci si surgical system. methods: we place five trocars, one is umbilical endoscopy port, and other four ports are placed at the reverse trapezoid, almost fan-shaped. using the arm number , the organ can be lifted up so that sharp lymphadenectomy is able to be done by almost a scissor as the arm number while applying the countertraction by the arm number . in order to achieve a clear and bloodless lymphnode dissection while maintaining the oncological safety, we think not only the ultrasonic coagulating scissor but also the electrocautery of the scissor is very essential in robotic surgery. less postoperative complication such as pancreatic fistula or pancreatitis might be derived from robotic surgery because we can avoid pressing the pancreas during the suprapancreatic dissection of lymph nodes. the billroth i reconstruction can be performed using da vinci endowrist stapler under stable and inflexible surgical fields without needing help of surgical assistant. results: from october to december , patients with gastric cancer were operated robotic gastrectomy, included total gastrectomy. there was no conversion to open surgery and no conversion to other procedures derived from intraoperative complications, and the overall operation time is gradually decreasing from the th case. we are now on the way of learning curve shortening operation time, but robotic gastrectomy is no less safer and adequate than laparoscopic surgery. we will show our robotic procedures including lymphadenectomy around subpyloric and suprapancreatic area, and reconstruction with several important points in our video purpose: this report describes the benefits and drawbacks in the use of a novel articulating device (artisential), which has a multi-degree wrist freedom like the davinci endowrist, in performing complete single-port d lymph node dissection (lnd) in single-incision distal gastrectomy (sidg). methods: the artisential was used in performing sidg with d lnd for patients with advanced gastric cancer. all operations were performed by a single surgeon using a threedimensional camera and a passive scope holder in place of a scopist. the artisential was used mainly in the sb and suprapancreatic lnd, an area that is relatively far from the single port. in certain cases when the pancreas needed to be pushed down, such as obese male patients, the intraabdominal organ retractor was used to lift the tissue and the artisential to push the pancreas. operative results and short-term outcome were analyzed. results: twelve patients underwent the procedure without any intraoperative events, conversion to conventional laparoscopy, or surgery-related complications including postoperative pancreatic fistula. all patients underwent single port d lnd by complete exposure of the portal and splenic vein. mean operation time was . ± . mins. and mean number of retrieved lymph nodes was . ± . . the artisential was found to be useful in grasping the tissues behind the pancreas and the major arteries throughout most of the lnd. the articulating motion also allowed the narrow single-port field of view to be clearly seen without the instrument body obstructing the camera. conclusion: the use of artisential in sidg appears feasible and reproducible, and is mandatory in performing a complete d lnd in sidg. the video shows a case of laterally spreading tumour of the rectum with preoperative benign histology, paris classification -is g (granular type), ut n eus stage, kudo type iv, nice type . the neoplasm measured x cm, and extended from to cm from the anal verge, mainly located on the posterior wall. according to our local policy the indication was a transanal full-thickness excision. this was performed with the medrobotics flexÒ robotic system, used here for the first time outside the united states.the system technology utilizes an articulated multi-linked scope that can be steered along non-linear, circuitous paths in a way that is not possible with traditional, straight scopes. the maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. this enables surgeons to perform minimally-invasive procedures in places that were previously difficult, or impossible, to reach. with the flexÒ robotic system, surgeons can operate through a single access site and direct the scope to the surgical target. once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass flexible surgical instruments. the system includes on-board d hd visualization. the flexÒ robotic system contains two working channels to accept a number of different surgical and interventional instruments including monopolar and bipolar electrodes, scissors and graspers for tissue manipulation.the video shows the introduction of the dedicated rectoscope, the connection of the flexible robot, and the way to operate the device performing a full-thickness excision, including suturing of the rectal defect by means of two running sutures by a v-lock / thread. while illustrating the technique the authors will comment pros and cons of the use of the device. background: hepatobiliary procedures using a minimally invasive approachare demanding, especially in major hepatectomies. the use of da vinci surgical system allows to overcome some of the kinematics limitations of the direct manual laparoscopy maintaining the potential advantages of a minimally invasive approach . we herein present a case of left hepatectomy and local lymphadenectomy for hepatocellular carcinoma, carried out with the use of the da vinci xi. methodology: a -years old man with a long-lasting hbv chronic infection and ct scan and mri finding of a -cm solid neoplasia of the left hepatic lobe and gallbladder stones, was operated with the da vinci xi platform. the patient was placed in a supine position, with °anti-trendelenburg inclination. the trocars were positioned according with the intuitive indication for the upper quadrants surgery. results: the procedure was successfully completed in min.at first, an intraoperative us scan with the use of tile-pro technology was done to determinate the tumor extension. the hepatic parenchyma transaction and the local lymphadenectomy were performed with monopolar scissors and bipolar grasps. the left hepatic vein section was performed with an endoscopic vascular stapler. there were no surgical complications or need for conversion to laparoscopy or laparotomy. the post-operative course was uneventful and the patient was discharged days after surgery. conclusion: the da vinci xi can facilitate some technically demanding procedures and ultimately widen the range of application of minimally invasive surgery such as hepatic surgery. besides the well-known advantages provided by robotic surgery on d imaging, increased range of motion and augmented surgical dexterity, one of the most interesting and innovative features of robotic technology is the digitalization of the operative view; furthermore the tile-pro multiinput display allows the surgeon a d view of the operative field along with the ultrasound exam for a precise understanding of anatomy and vascularity and of tumor location. during the last few years, robotic surgery as well, as the latest innovation of minimally invasive procedures, takes its position in this particular field with the benefits of overcoming the limitations of conventional laparoscopy. our aim is to demonstrate the advantages of robotic surgery in procedures of hepatectomies, on occasion of a robotic hepatectomy performed by our team. methods: we present video fragments of a robotic left lateral hepatectomy procedure in an elderly female patient with a symptomatic gigantic haemangioma of the left hepatic lobe. we emphasize on the technical aspects and the advantages that the surgeon gains applying the robotic techniques in such procedures. results: the procedure was completed with minimal blood loss and the patient presented an uncomplicated post-operative course, with discharge on the third postoperative day, minimal need of analgesics and full recovery. conclusions: the excellent three-dimensional and high quality visualization that the robotic system offers, combined with the flexibility and the accuracy of the robotic instruments (especially on suturing), provide to the surgeon an important aid, in order to avoid serious complications, such as intraoperative bleeding and post-operative bile leaks. the restriction of the limitations of conventional laparoscopy is far more beneficial and promising for the evolution and the future of minimal invasive liver surgery. aims: the new da vinci xi surgical cart allows multi-quadrant and complex surgical interventions in a minimally invasive fashion. we present a case of robotic appleby left pancreatectomy using this platform and its specific operating bed. methods: a -years old woman with ct scan finding of a -mm hypo-vascular neoplasm of the pancreas body underwent surgery with the use of the new da vinci xi with four arms upper quadrants trocar' disposition. results: the procedure was successfully completed in min. the pancreatic body was mobilized in order to expose the portal-mesenteric axis. the gland was transected using a robotic endo-stapler as well as the splenic vein. after evaluating the patency of collateral circles with intra-operative ultrasound, the common hepatic artery and the celiac artery were transected. then we increased the right tilted position and the neoplasia was detached from the gastric body by a tangential gastric resection using the robotic endo-stapler. finally, the operation was accomplished with the transection of the posterior attachment of the spleen and the pancreatic tail. no conversion or intra-operative complications were recorded. the post-operative course was uneventful and the patient was discharged days after surgery. the da vinci xi with its specific tools helps in performing challenging procedures such as appleby operation for locally advanced pancreatic cancer. in our experience, the robotic endo-stapler permits the operating surgeon to directly control the transaction phase whereas the specific operating bed allows to perform minimally invasive multi-quadrant surgery and to obtain a better exposition of the operating field. results: the whipple procedure was successfully completed in min. thanks to the dvtm the patient's position changed during the intervention to improve the exposure, with the instruments left inside the abdomen and without undocking the robot. the dissection of the pancreatic head from the portal vein and the section of the retroportal lamina were performed with the use of the endowrist vessel sealer device. a personal modified end-to-side pancreatojejunostomy was carried out, with / prolene and gore-tex double layer suture. no intra-operative complications occurred and no conversions to laparoscopy or laparotomy were required. the postoperative course was uneventful. conclusions: the use of the new fully wristed vessel sealer extend makes easier difficult maneuvers such as the fine dissection of the pancreatic head from the portal vein and the section of the retroportal lamina, enabling an optimized approach for vessels sealing and cutting and tissue bundles. moreover, the dvtm allows patient's movements without undocking the system or removing instruments from the abdomen, enhancing the surgical workflow. background: necrotizing pancreatitis is a devastating illness which can develop in up to % of patients who suffer from pancreatitis. it carries great morbidity with an associated mortality rate between to %. many of these patients require drainage of fluid collections to treat sequela related to pain, per-os tolerance, and source control of sepsis if infected. the step-up approach to treatment of this disease has trended towards minimally invasive techniques, considering the morbidity of open debridement. as such, many centers have implemented the use of transgastric debridement via endoscopic cystogastrostomy. this technique, while effective in draining fluid and particulate necrotic tissue, has difficulty in resection of large necrotic tissue, due to instrument and anatomic limitations. current endoscopic accessories designed for polypectomy or foreign body extraction, for example, are not optimal for performing necrosectomy. to overcome this obstacle, additional access sites can be utilized to assist debridement. we describe the first laparoscopic assisted transgastric endoscopic necrosectomy through a percutaneous gastrostomy in a year old male with infected pancreatic necrosis secondary to biliary pancreatitis. aim: to investigate the feasibility of utilizing gastrostomy access to assist in debridement during endoscopic necrosectomy. methods: the patient previously underwent an open necrosectomy and gastrostomy tube placement for acute emphysematous pancreatitis. post-operatively, there was a persistent and enlarging cm infected walled-off necrosis (won). therefore, endoscopic cystogastrostomy was performed using a lumen-apposing metal stent. results: frank pus was evacuated. initial endoscopic necrosectomy was technically challenging due to the large volume of solid necrotic tissue. repeat endoscopic debridement utilized a surgical laparoscopic grasper via the gastrostomy site to aide solid debris extraction (video). this allowed for complete necrosectomy and resolution of the won. the patient did well and was discharged subsequently. conclusion: this is another emerging minimally invasive technique in the step-up approach for debridement and drainage of won. the use of the gastrostomy as a utility port for accessory instruments not only enhanced the technical aspects of the procedure but increased its efficacy as well. further experience is needed to validate the utility and reproducibility of this technique. objective: the presentation of the minimally invasive surgical approach for pancreatic necrosectomy guided by videoretroperitoneoscopy or var (video assisted retroperitoneoscopic), established in our center, as one of the option of the step-up approach treatment for acute necrotizing pancreatitis (anp) methods: the placement of the patient on the operating table should be in decubitus, with right lateral inclination, at - °on the horizontal surface. the pancreatic cell is approached using the drainage catheter previously placed by radiological control (ultrasound or ct) as a guide, which will allow access to the cavity with safety. an incision of - cm is made around the previously placed catheter, crossing the subcutaneous cellular tissue and muscular fascias, dissolving the musculature. it continues in a blunt dissection, until a loss of resistance is appreciated which generally coincides with the outflow of necrotic or purulent material. once the retroperitoneal cell is accessed, a mm trocar is placed and a pneumoretroperitoneum is performed. the -mm trocar allows the joint use of a mm and °optic and the surgical material that allows debridement and cleaning. the aspiration and hydrodissection of the necrotic material, and the extraction of the solid component of the necrosis are proceeded. once the collection is drained and the necrotic material removed, a wash and drain system is placed, like a -way foley type probe. conclusions: in conclusion, the var is an alternative surgical technique, valid and reproducible in the treatment of anp, which offers comparable results and even superior, in some series, to those of open surgery, with satisfactory results in terms of morbidity and postoperative mortality. aim: lung subsegmentectomy is suitable for small and deep, non-palpable lung nodules. since it is difficult to intraoperatively detect the arteries, veins and bronchi of the subsegment, as well as the intersubsegmental borders, complete video-assisted thoracic surgery (vats) for lung subsegmentectomy is challenging. we use preoperative three dimensional ct to detect the arteries, veins and bronchi of the subsegment before conducting complete vats subsegmentectomy, and perform intraoperative bronchoscopy to detect the bronchi and intersubsegmental borders. i would like to describe our experience of complete vats combined subsegmentectomy for a non-palpable lung nodule. methods and results: the patient was a -year-old woman. during health screening, a small groundglass opacity was observed in her right lung on chest ct. the nodule was mm in diameter and was located in s b (horizontal subsegment of the posterior segment) near s (the anterior segment). we preoperatively diagnosed the lesion as well-differentiated adenocarcinoma, and planned combined subsegmentectomy for s b and s a (lateral subsegment of the anterior segment) of the right upper pulmonary lobe. before the operation, the locations of vessels were confirmed by three-dimensional ct angiography. video-assisted thoracoscopic surgery was performed using four ports: two cm ports in the th intercostal space in the post-axillary line and in the angulus inferior scapulae line for the operator, a cm port in the th intercostal space in the mid-axillary line for the assistant, and a cm port for the camera in the th intercostal space in the mid-axillary line. the cm port was also used for removal of the resected specimen. intraoperative bronchoscopy was used for detecting the subsegmental bronchi. she was diagnosed with primary lung cancer (adenocarcinoma in situ, nonmucinous) postoperatively. the tumor was pathologically graded as tisn m . no tumor recurrence has been noted in follow-up of twenty two months. conclusions: the combination of preoperative three-dimensional ct angiography, intraoperative bronchoscopy and complete video-assisted thoracoscopic surgery can be used for performing lung combined subsegmentectomy. aims: minimally invasive surgery is increasingly widespread for the diagnosis and treatment of abdominal pathology. laparoscopy is a diagnostic resource for those cases in which mass biopsy is not approachable through image-guided puncture, and is often therapeutic in the same act. it avoids the morbidity and mortality associated with laparotomy, favoring the early treatment of malignant processes. methods: we present a case of a year old male who was incidentally diagnosed with an oval-shaped pelvic mass in the right lateral wall of the pelvis, adjacent to the vascular bundle of the right external iliac at its origin( centimeter), without sign of infiltration of surrounding structures. no other pathological findings on the abdominal computerized tomography and magnetic resonance imaging were found. due to its localization, it was not accessible to percutaneous biopsy. the first diagnostic impression was a benign tumor of the nerve sheath (schwannoma), without being able to rule out other diagnostic possibilities. to provide a definitive diagnosis the patient was subjected to an elective laparoscopic resection of the tumor. surgical procedure was performed using a millimiter and two millimeter, umbilicus for the optical system and operative on hypogastrium and left iliac fossa respectively. acleavage plan between the tumorand rightiliac vesselswas found. the exeresis of the masswas achieved, and it was extracted using an endo-bagÒ through the umbilical port site. a drain was put in the surgical bed. results: the patient had a short, uneventful post-operative course, being discharged on postoperative day . pathological examination revealed a lymphatic node with metastasis of poorly differentiated carcinoma, with suspected urothelial lineage. cystoscopy was performed with the finding of a centimeter lesion on the right ureteral orifice with calcifications on the surface. biopsies were taken, confirming the bladder origin of the tumor. conclusions: both diagnostic and therapeutic laparoscopy is useful on pelvic masses because of the direct vision into this narrow anatomical space, especially in obese patients, providinga detailed view that makes easier to isolate and spear the anatomical structures surrounding the tumor, minimizing the risk of tumor rupture and bleeding. surg endosc ( ) aim: indocyanine green (icg)-enhanced fluorescence has been introduced initially in laparoscopic surgery to provide detailed anatomical information during laparoscopic cholecystectomy and to evaluate vascular supply to garantee correct anastomotic perfussion in order to reduce the risk of anastomotic leak. the uses of icg are increasing, specially in hepatic and oncological surgery in order to identify centinel lymph node and lymphatic mapping.we propose the use of icg imaging during complex laparoscopic colorectal resection in cases presenting ureter obstruction, to prevent iatrogenic ureteral injury. methods: we present a case of a year old female previously diagnosed of pelvic endometriosis with severe pain and symptoms related with episodes of pseudo-occlusion .a colonoscopy was performed finding sigmoid cancer in an area of endometriosis in a narrow colon with difficulties to perform a complete colonoscopy that could be related to the process of pseudo-occlusion. the biopsy was informed as an adenocarcinoma.the ct-scan showed a dilatated left ureter in an area next to the sigmoid colon.we propose a preoperative strategy with a bilateral double j stent insertion, finding a ureter obstruction caused by the endometriosis.icg was injected through the ureteral catheter, guiding us during the surgery to avoid a iatrogenic ureteral injury. results: a laparoscopic left colectomy was performed. the icg allows us to follow the ureter during the surgery, disecting the colon properly from the area attached to the ureter. the prestenotic area of the ureter was marked dilatated up to two centimeters allowing the icg to identify it from the anatomic structures of the areas and guarateeing that there was not spill of icg out of the ureter avoiding a postoperative leak of urine. conclussions: when tumors, or another entities like endometriosis, produce a ureteral occlusion, icg could be injected through a j stent, allowing us to identify and to avoid an injury.icg fluorescence imaging is a safe, cheap, and effective tool to increase visualization during surgery, offering additional information of the anatomy in colorectal surgery. in this video we are going to show three cases of the robotic treatment of splenic artery aneurism and the evolution of the technology that we relied on for the preoperative planning and intraoperative navigation. our preoperative evaluation evolved from a tridimensional virtual reconstruction with augmented reality to patient specific anatomical d printed models, initially made of rigid materials and afterwards made of malleable materials, in order to reproduce hollow anatomical structures such as vessels, feasible to simulate the planned surgical plan. the choice of a robotic approach, in selected cases, allowed to restore the continuity of the splenic artery after the exclusion or excision of the aneurism, in order to preserve the spleen. aims: tumor-induced osteomalacia (tio) is a rare paraneoplastic syndrome in which patients presents bone pain, fractures and muscle weakness caused by the fibroblast growth factor (fgf- ), a phosphate and vitamin d-regulating hormone. in tio, fgf- is secreted by mesenchymal tumors that are usually benign but small and difficult to locate. when medical treatment is unsuccessful, surgical treatment is indicated and conclusive.this video shows our technique for tio surgical treatment guided by indocyanine green (icg) fluorescent angiography. methods: the patient is an -years-old woman with tio confirmed by blood sampling of fgf- , gallium- pet/ct scan and abdominal ct scan which identified a highly vascularized mm nodule in the mesentery along the ileo-colic vascular axis.the patient was scheduled for a diagnostic laparoscopy with tio removal.the patient was placed in supine position. three trocars were introduced in the left quadrants. identified the last ileal loop, following ileo-colic vessels, a small mesenteric bulge was found. the icg fluorescent angiography confirmed the localization of the ipervascularised nodule and helped to define its edges. the nodule was removed through monopolar energy and the hemostasis was optimized through bipolar energy. the specimen was extracted through an endobag using one of the trocar access. results: the postoperative course was uneventful and the patient was discharged on postoperative day . histopathological examination showed an extrasurrenalic paraganglioma. conclusion: tio are often difficult to locate for surgical removal. icg fluorescent angiography allows to facilitate tio localization and removal. the minimally invasive technique decreases perioperative morbidity and mortality. laparoscopic removal guided by icg angiography should be considered when tio needs to be removed and is difficult to locate. aim: this video shows our technique to perform laparoscopic resection of a voluminous left paraaortic paraganglioma. methods: the patient is a -years-old man with a recent medical history offever, lumbar pain and haematuria.abdomen ct scan, performed during admission at emergency department, revealed a x cm left paraaortic retroperitoneal mass with pseudo-aneurysm. after procedure of angiographic embolization (with spermatic artery sparing), the patient was scheduled for a laparoscopic resection of paraaortic tumor. the patient was placed in the right flank position. three trocars ( mm) in the abdominal midline and one trocar in left hypocondrium were placed. at initial examination of the abdominal cavity, voluminous left paraaortic mass arising in the contest of left mesocolon was found, dislocating posteriorly kidney vessels. the parietal peritoneum was divided and the paraaortic lesion was dissected on the aortic plane from medial to lateral and from down to up, preserving the inferior mesenteric vessels; the mobilization was carried on to splenic vein. the vessels, supplying the mass and arising directly from aorta, was isolated and taped with vascular clips. on the inferior margin of the lesion a large vessel, probably connected with previously embolized pseudoaneurysm, was dissected with vascular linear stapler. the mobilization was completed through difficult dissection from aortic plane and mesocolic posterior surface. the colonic perfusion was verified with fluorescence angiography. specimen was extracted through an endobag.a drain was left in pelvis. postoperative day .histopathological examination showed a morphological and immunoistochemical pattern for benign paraganglioma. conclusion: laparoscopic resection of paraaortic paragangliomas is feasible by skilled surgeon. the minimally invasive technique decreases perioperative morbidity and mortality. careful preoperative planning and surgeon's experience with vascular dissection and visceral mobilization are mandatory for a good outcome. aims: posterior retroperitoneal endoscopic approach has been considered for many years as a very complex and unsafe surgical technique. often attributed to a difficult location and visualization of retroperitoneal structures. in addition, surgeons were forced to work in a small and easily altered space due to discontinuous flow with constant changes of the retroperitoneal vision. lately this approach is emerging thanks to technological advances, mainly better visualization laparoscopic cameras and high definition screens, as well as continuous flow insufflators of co , maintaining stable and smoke-free cavity uninterruptedly. methods: it shows a management of a potentially serious complication and the reproducibility of the technique through the retroperitoneal approach. results: to operate with high pressure of neumoretroperitoneum allows to contain the hemorrhage and to value with relative serenity and security, the best surgical option to repair said injury being laborious due to the reduced workspace. conclusions: the posterior or retroperitoneal approach is feasible, safe and fast. although the possibility of injuring the vena cava in right adrenalectomy remains one of the most serious and feared complications. as shown in the video, posterior retroperitoneal endoscopic approach allows repair of vascular injury correctly and safely. methods: four patients undergoing adrenalectomy, two of them with right adrenal pathology and two left. minimally invasive access, endoscopic approach, is exposed in all of them. results: in the first two surgeries, right gland is shown. initially, transabdominal approach, which requires mobilization and separation of the liver to access the retroperitoneal space and subsequent proceed to adrenal extirpation. later, right retroperitoneal approach is observed, with a meticulous sealing of the adrenal vein prior to complete the dissection of the gland, despite the small cavity created by co . in the second part, both left adrenal approaches are exposed. transabdominal pathway is necessary to mobilize left colon and spleen to access a narrow space above the upper edge of the pancreas to locate adrenal gland. this is very different in posterior adrenal approach. conclusions: posterior or retroperitoneal approach is feasible and safe, allowing access to adrenal glands, located in retroperitoneal space, without across peritoneal cavity and its disadvantages. colon and small intestine mobilization is not necessary, with a lower rate of intestinal lesions and postoperative ileus. in the same way, liver or spleen mobilization is avoided. aims: when performing a laparoscopic adrenalectomy, especially in the setting of pheochromocytoma, one of the most important steps is to gain control of the adrenal vein early on in the procedure before great manipulation of the adrenal gland. we present the case of a year old female with episodic headaches and tachycardia and severe uncontrolled hypertension, found to have elevated plasma and urine metanephrines with ct scan localizing a . cm right sided adrenal nodule. the patient was prepared preoperatively with phenoxybenzamine until mildly orthostatic with dry mucous membranes and was taken for laparoscopic right adrenalectomy. methods: after positioning our patient in left lateral decubitus, ports were placed inferior to the costal margin. the right lobe of the liver was mobilized and retracted cephalad and the ivc was exposed. careful and meticulous dissection was carried up the ivc, however no main adrenal vein was encountered. the adrenal gland was then dissected circumferentially and was removed in an endoscopic retrieval bag. there was no difficulty in hemostasis and the patient was deemed to be hemostatic prior to withdrawal of the ports and extubation. results: our patient had no issues with hemodynamic stability and her blood pressure was within normal ranges during and following the case. her hemoglobin was stable postoperatively with . immediately post op and . on discharge. her pre-op hemoglobin was . . conclusions: our video demonstrates a right adrenal gland that was congenitally missing a main adrenal vein. it is very possible that small venous branches were taken with dissection however we believe this report to be important to note in the literature for surgeons performing adrenalectomy. surg endosc ( ) aims: adrenal cysts are the most frequently identified adrenal cysts, although they are a rare entity. typically they are presented by abdominal pain or palpable mass, but nowadays, cystic lesions of the adrenal gland are more often discovered incidentally by radiologic studies. adrenal cysts have an extensive differential diagnoses, which makes a difficult definitive diagnosis and a difficulty in later management. the management of an adrenal cyst can be summarized in three fundamental pillars: discard the functional status of the cyst, evaluation of eventual malignancy by images, and avoid possible complications (hemorrhage, infection), especially in large cysts . methods: clinical case: a -year-old male patient, with no history, studied for nonspecific pain in the right hypochondrium, without other accompanying symptoms. an abdominal ultrasound was performed, a cystic lesion in hcd without being able to identify the origin was seen. complementary explorations of interest are shown (ct), the biochemical study discards functionality of the lesion, negative serology for hydatidosis. the minimally invasive approach is the gold standard in the surgical treatment of adrenal pathology, so a laparoscopic approach is proposed for this patient. aims: endometriosis is a high incidence disease (approximately % of women) with a large impact on women's quality of life and fertility. endometriosis nodules surgical treatment is necessary every time there is evidence of active disease. the aim of this video is to present a minimally invasive technique for the resection of an endometriosis nodule from the abdominal wall. methods: a -years-old woman, with past history of endometriosis and a c-section, presents at the office with a palpable nodule at the rectus abdominis left lateral border, close to the umbilical scar. she had complaints of exuberant catamenial pain and magnetic resonance imaging (mri) showed a mm nodule compatible with endometriosis depot. this technique uses trocars ( ? mm) placed at the pfannenstiel scar. stepby-step as follows: (i) dissection of the pre-aponeurotic plane and isolation of the lesion (ii) lesion excision and its removal with sac (iii) closure of the aponeurotic defect braded suture. results: the post-operative period was uneventful and the patient was discharged home at post-operative day one. the aesthetic result was excellent and the patient was asymptomatic one month after the procedure. conclusion: endometriosis of the abdominal wall is related to previous c-section, is a rare event (incidence . - . %) and usually located in the subcutaneous fat underlying the scar. the presence of nodules in the depth of the muscle is much uncommon and particularly in this clinical case, the nodule was located cm cephalad from the previous pfannenstiel scar. this technique seems easy and reproducible in the authors' opinio. aims: general surgeons often face gynecological pathological findings, either along with other abdominal pathology, or as primitive cases that need laparoscopic expertise. with this particular presentation, our goal is to demonstrate the essential laparoscopic skills and the basic operative strategy that a general surgeon should be familiar with, in order to manage such cases. the presentation is made on occasion of a woman with multiple uterine fibromatosis of the pelvis, who was treated by our team. methods: we present video fragments of the laparoscopic excisional procedure for multiple uterine fibromyomatosis of the pelvis, highlighting the proper strategy in order to conclude the operation effectively and uneventfully, in a minimally invasive fashion. results: patients with multiple, large or other complex forms of uterine or pelvic fibromas can effectively be treated with a minimally invasive approach, with minimal blood loss, very fast recovery and minimal postoperative pain and complications. % of pregnancies require emergency surgery for a non obstetric indication, including acute appendicitis, cholecystitis, adnexal torsion, choledoco-lytiasis, hernias, intestinal obstructions, oncologic pathology or other less frequent indications. laparoscopic approach is the preffered surgical option for the patologies presented above. aims: to present the technical particularities and to analyze the outcomes of the emergency operations in pregnant women operated in hospital. method: a retrospective study including all the pregnant women operated in our hospital between - was performed. the preoperative workup and the surgical indication was discussed by a multidisciplinary medical team. the anesthesic and the obstetrical risk and their management was evaluated and specifically planned for each patient. the intraoperative and post-operative outcomes were recorded. results: patients with gestational age between weeks and weeks who underwent emergency laparoscopic procedures were included in the study. out of the cases we have performed appedectomies, cholecystectomies, adnexal torsions. with a min mean operating time, we had no major intraoperative complications; the technical challenges are presented and discussed. the hospital stay was , days ( - days). no major complications were associated with the laparoscopic approach in these cohort. one pre-term labour in a weeks gestational patient was post-operatively encountered. conclusion: laparoscopic surgery can be the first option for pregnant woman with non obstetrical surgical emergencies; challenges in diagnostic, management and surgical techniques of the multidisciplinary team are expected. the objective of this presentation is to demonstrate step by step the technique to the oncologic surgeon and gynaecologist in training, including some tips and pitfalls. this is a laparoscopic transperitoneal approach in a woman with advanced cervical cancer (figo ib ) that will be treated with exclusive radio-chemotherapy. the purpose of the laparoscopic lumbo-aortic lymph node staging is to define the irradiation field. in this indication false negative in pet ct ranges from to % (depending of the existence of pelvic fixation or not). the limits of this lymphadenectomy are: both ureters as the lateral limit of the dissection, iliac bifurcation as the caudal limit and renal veins as the cranial one. since the tumour is cervical and not ovarian, both ovarian veins are not resected. in the pathologic report, lymph nodes were examined free of cancer spread. the patient have had a radio-chemotherapy with restriction of the irradiation field on the pelvis. lymphocele is a frequent complication that only sometimes needs treatment ranging from dietary changing to percutaneous drainage. if conversion to laparotomy for bleeding this technique loose its benefice but this is a rare complication. this technique is feasible and safe but requires advanced laparoscopic skills. objectives: although extremely rare, isolated splenic metastases are being increasingly diagnosed due to the improvement of imaging, survival times, and surveillance of oncologic patients. this video alerts to the growing diagnostic dilemma with primary lesions of the spleen, particularly in patients with history of cancer, and reviews the laparoscopic splenectomy 'step-by-step'. case-report: -year-old male patient diagnosed with rectal cancer (g adenocarcinoma at cm of the anal verge) after a colonoscopy for rectal bleeding. thoracic and abdominal ctscan and pelvicmri, showed a ct n lesion, without distant metastases, except for a mm suspicious splenic lesion. cea- . ng/ml. after neoadjuvant therapy, a complete response was verified at the th week post-crt with a stable splenic lesion, and a 'watch-and-wait' program was initiated with no evidence of disease at the rd month. pet-ctscan did not show active metabolic features, despite an increase in the splenic lesion. in mdt, elective laparoscopic splenectomy was proposed and afterwards performed uneventfully. with the patient in semi-right lateral tilt, we approached the spleen inferiorly by dividing the splenocolic ligament. then we continued upwards, dividing the gastrosplenic ligament and exposing the splenic hilum, which was then carefully dissected, clipped and divided. finally the splenorenal ligament was divided and the spleen was extracted within an endobag, through a small pfannenstiel incision. pathologic report revealed a splenic lymphangioma. the patient is currently under a 'watch and wait' protocol surveillance with no signs of regrowth or relapse disease after year and months of follow-up. conclusion: one out of five colorectal carcinomas are metastatic at their presentation. isolated metastases to sites other than liver, lung or axial skeleton, are extremely rare, but can be found in the spleen. although the rare splenic secondary involvement is usually associated with breast, lung, melanoma, and gynecologic malignancies, if we consider solitary splenic metastases, colorectal and ovarian carcinomas are important sources. also, imaging including percutaneous biopsy, is frequently insufficient to clarify the nature of splenic lesions. for all these reasons, the decision-making process about this issue can be a true challenge, and will probably end up with laparoscopic splenectomy. therefore, surgeons must be familiarized with a standardized technique. sarcoidosis is a multisystem disease of unknown etiology characterized by the formation of noncaseating granulomas. sarcoidosis should be considered in the differential diagnosis of lymphoid disease. indications for diagnostic splenectomy includes a suspicion of a neoplasic process. the less invasive laparoscopic approach is the gold standard. case report: a -year-old female was referred to a general surgery department to complete a study to rule out lymphoid neoplasia. followed by hematology for cytopenias. biopsy of bone marrow and adenopathies were negative for lymphoid process. patient presented ct with multiple solid ( - mm) lesions in spleen, in thorax showed no pathological changes. laparoscopic splenectomy was performed. access with optical trocar, in mammary line. triangle -mm trocars after pneumo under vision. section with ligasure of gastroesplenic ligament with short vessels and phrenic-splenic ligament. identification and preservation of pancreatic tail. section of splenic vessels at hilar level (branches) with ligasure. lower pole release. release of posterior part with gerota and diaphragm. incision by aid helps in bag without fragmenting. review of hemostasis, extraction of trocars under direct vision. intraoperative findings: spleen with normal external appearance, not megalic. postoperative evolution: satisfactory. first hours without incidents and with analytical control without anemization. tolerance and mobilization starts without incidents. the histopathology report shows granulomas formed by epithelioid histiocytes with the presence of multinucleated giant cells of the foreign body type, in some perisinusoidal granulomas the giant cells with the presence of asteroid bodies in their interior. the material has been revised with the extension of special studies. conclusion epithelioid granulomatosis, non-necrotizing, which suggests sarcoidosis. the procedure lasted min. the hospital discharge was on the next postoperative day and no complication was registered. conclusion: splenectomy can be performed in a classic way, but at present the less invasive laparoscopic approach is the gold standard. indications for splenectomy include splenic tumours of unknown origin, suspicion of a neoplastic process, and splenomegaly. sarcoidosis should be considered in the differential diagnosis for lymphoid disease. postoperative pathological examination confirms the diagnosis. week-day surgery, university, sapienza, ospedale sant'andrea, rome, italy aims: we describe an interesting case of a female patient affected by a suspected echinococcus granulosus large cyst of the spleen. methods: a years old woman complained abdominal pain and a sense of gravity in the upper left abdominal quadrant. computed tomography scan(ct-scan) showed a centimetre (cm) cyst of the spleen with thickness of the wall and contrast enhancement uptake referred to an echinococcus granulosus cyst. the sierological blood test assessment, antigens and antybody markes, for echinococcus granulosus infection was negative. a laparoscopic procedure was planned. the patient was positioned on the right flank, four trocars were inserted along the left subcostal region of the abdomen: one millimetre (mm) trocar for camera, one mm for the assistant, and two of mm for instruments. a periombelical minilaparotomy was performed for the specimen extraction. results: post-operative course was uneventful. patient was discharged in third post-operative day. istopathological exam showed a simple epithelial cyst of the spleen. conclusions: laparoscopy is safe and feaseable in case of large cyst of spleen in condition of unclear nature of the cyst. laparoscopy permits to explore the abdominal cavity and to assess the cyst characteristics in a lack overlap between the radiological exam and blood test examination. surg endosc ( ) we describe laparoscopic splenectomy for recurrent splenic cyst after laparoscopic marsupialization and partial resection of splenic cyst. the patient was a -year-old woman with abdominal discomfort and with a -cm palpable mass in the left upper and inferior quadrant. she undergone years ago in another country a laparoscopic operation for splenic cyst. abdominal computer tomography revealed a cystic lesion of the spleen with concomitant huge splenomegaly. serology and oncological marker were negative. we performed laparoscopic splenectomy for the recurrent splenic cyst. the operation took min. histologic examination of the resected spleen revealed a chronic hematoma. the patient had no abdominal symptoms during months of follow-up. postoperative long term follow-up and examination by ultrasound or computed tomography is required after surgical treatment for splenic cyst to exclude the possibility of recurrence after spleen-preserving surgery. hand-assisted surgery is a recognized technique that combines the advantages of laparoscopic approach with the tactile feedback of the laparotomic one. it proved beneficial especially for the treatment of megaspleens due to lymphoma localization, thanks to safer handling of splenic vessels, major bleeding control and more effective detachment of superior splenic pole from the diaphragmatic dome. here we show an hand-assisted splenectomy for megaspleen reaching the omolateral anterosuperior iliac spine due to lymphoproliferative disease, in which the hand, inserted through a right subcostal minilaparotomy, was very useful during the dissecting manoeuvres, the splenic artery recognition and ligation and the isolation of the superior pole of the spleen from the gastric fundus and diaphragm. in any case of huge spleens, the specimen bagging is very difficult to perform in a pure laparoscopic way, not to mention the inexistence of capable endobag; besides, a minilaparotomy would be necessary for the spleen extraction. hand-assisted approach allow to overcome this not underestimable technical difficulty, reducing operative time with similar aesthetic and functional results to that of laparoscopic approach. aim: the evolution of technology and its application to the minimally invasive surgery of the thyroid gland offers new surgical techniques, like the transaxillary approach. this new procedure is still being implemented in our environment and has recently begun to be incorporated into our surgical practice. the objective of this case is to explain step by step how to carry out a right transaxillary endoscopic thyroidectomy and emphasize in the most relevant tips to take into account. also, current indications and limitations of this technique will be addressed. methods: a -year-old woman is referred for evaluation of a right thyroid nodule without any associated symptomatology. the blood test shows normal thyroid profile. cervical ultrasound is performed identifying a . cm single right nodule with well-defined edges and presence of peripheral vascularization. no other nodules are identified. fine needle aspiracion (fna) of the nodule describes a bethesda iii. after evaluation, a right transaxillary endoscopic thyroidectomy was performed. results: dissection begins in the subcutaneous plane above the pectoralis major muscle until identification of the sternocleidomastoid muscle. dissection continues towards the prethyroid muscles in order to perform a lateral approach of the thyroid gland. section of the upper pole allows better exposure of the recurrent laryngeal nerve (rln) which is being monitored intermittenly. identification and preservation of the parathyroid glands is the next step. surgery is completed with the section of the inferior pole of the thyroid along with the istmus. the postoperative period was uneventful and patient was discharged at h after surgery. final pathology revealed a cm nodule without malignancy. conclusion: surgical treatment of the thyroid gland by transaxillary approach may be indicated in previously selected patients with benign pathology, offering the advantages from minimally invasive techniques (shorter recovery time, shorter incision length, etc.). further research is required to make a better assessment of the minimally invasive approaches in thyroid surgery. we present the video of a thoracoscopic esophageal leiomyomaenucleation. it has been widely demonstratedthe advantages of theminimally invasive approach in surgery. esophageal thoracoscopic surgery has been suggested as an alternative to open procedures, presenting less surgical trauma, lower risk of bleeding, less postoperative pain, lower wound infection and lower pulmonary morbidity, showing similar oncologic outcomes. although leiomyomas are the most commonof benign tumors of the esophagus, they are relatively rare, presenting an incidence of - per . autopsy series. in our case, the patient was diagnosed of leiomyoma located at the medium third of the esophagus. he referred a history of months of dysphagia for solid and liquids and retrosternal pain. the complementary studies were esophagoscopy, esophagography, ct and endoscopic ultrasonography. the patient was operated by a thoracoscopy approach using ports. it was completed the enucleation of the tumor following the closure of the muscular layer. methylene blue test confirmed no leaks. the patient was discharged on third day postoperative developing no incidences. pathology report: leiomyoma cm size, actin and desmin positive; s- , cd and cd negative. we want to demonstrate the advantages of a minimally invasive approach in this kind of pathology. aims: this video shows our technique to perform thoracoscopic enucleation of large esophageal leiomyoma. methods: the patient is a -years-old woman with a six months history of progressively worsening dysphagia. chest ct scan revealed a cm lesion of middle esophagus with extrinsic compression of mucosa and no increased fdg uptake on fdg-pet scan. barium swallow study showed a lateral deviation of thoracic esophagus due to extrinsic compression. endoscopic ultrasound confirmed the suspicion of esophageal leiomyoma. patient was scheduled for a thoracoscopic enucleation of esophageal tumor. she was placed in prone position and one-lung ventilation was employed. three trocars were placed in intercostals spaces on right hemithorax. azygos vein was identified and transected between vascular clips. esophagus was circumpherentially isolated from mediastinal structures. after myotomy, the lesion was dissected from submucosal-mucosal layer. since air leak test excluded injury of internal layer, muscular layer was closed with a continuous suture. the specimen was extracted through an endobag. a drain was left in place. results: the postoperative course was uneventful and the patient was discharged on postoperative day . final pathological examination confirmed esophageal leiomyoma. conclusion: thoracoscopic surgery in prone position allows removal of large esophageal tumor with several advantages. the minimally invasive technique decreases perioperative morbidity and mortality. introduction: spontaneous esophageal perforation is life threatening disease and requires emergent surgical treatment. recently, the efficacy of minimally-invasive surgery such as laparoscopic and thoracoscopic surgery for esophageal perforation has been reported. we report a novel technique of minimallyinvasive abdominal and left thoracic approach (malta) for spontaneous esophageal perforation. case presentation: -year-old male, who had been under hemodialysis due to iga nephropathy, complained of chest pain after vomiting several times. since the ct scan showed left hydropneumothorax and pneumomediastinum, and the gastrografin study demonstrated extravasation from left side of esophagus, we diagnosed him with the spontaneous esophageal perforation and planed emergent surgery. the patient was placed in the reverse trendelenburg position, and the legs were split, with the left side of the upper body lifted in order to perform thoracoscopy and laparoscopy simultaneously. first, we explored the thoracic cavity through a mm port in the left th intercostal space and added other ports. we identified the rupture site mm in size on the left wall of the lower esophagus and sutured the mucosa and the muscle layer with a running suture respectively. we covered the perforation section with pericardium fat and irrigated the cavity with physiological saline. then transferred to the abdominal cavity, no contamination was found in the abdominal cavity. a feeding tube was inserted into stomach through the round ligament of the liver and the operation was completed. the total operative time was min and the amount of intraoperative bleeding was ml including pleural effusion. postoperatively, the patient experienced left empyema pleurae but no other severe complications and was discharged on postoperative day . conclusion: we experienced a rare case of spontaneous esophageal perforation of a patient under hemodialysis. malta is an effective procedure for emergent esophageal operation because of great visual field of the chest and abdominal cavity without expanding contamination. introduction: digestive caustic injury is associated with high morbidity and mortality with stenosis in the long term. surgical treatment involves resection of the esophagus and reconstruction with the stomach, colon or jejunum. coloplasty provides several advantages but its vascularization is complex and involves anastomosis. classically, vascular assessment was achieved by palpation through laparotomy and color evaluation. indocyanine green (icg) allows a minimally invasive intraoperative angiography in real time. methods: a -year-old female with medical history of caustic ingestion and subsequent esophagogastric stenosis, carrier of feeding jejunostomy. . thoracoscopy (prone position): dissection of the esophagus from the hiatus to the upper thoracic inlet. . laparoscopy: patient in the supine position, placement of five trocars. total non-oncological gastrectomy, post-pyloric section of the duodenum and omentectomy were completed. mobilization of the righ, transverse and descending colon. measurement of the transverse colon with a tape (distance from the neck and the esophageal hiatus). individualization of the righ, middle (with its branches) and left colic arteries and placement of clamps at the right colic, right branch of the middle colic and left colic arteries. cc of icg were injected allowing for an assessment of the colon vascularization. section of the right branch of the middle colic artery. proximal section of the ascending and distal colon near the splenic angle, preserving the marginal arch. silk point to join the staple line of the descending colon and the pylorys. side-to-side mechanical antiperistaltic anastomosis between the distal endo of the coloplasty and the jejunum. finally an anastomosis between the ascending and descending side-to-side mechanical anastomosis using an assistance incision in the left flank was performed. . cervical dissection: extraction of the surgical especimen under laparoscopic control. vascular assessment with icg is performed before and after the side-to-side anastomosis is performed. results: there were no intraoperative complications. the patient was discharged on postoperative day . discussion: we describe the first case of total minimally invasive colonic interposition with icg assessment of the vascularization. this technique, although technically demanding, avoids the drawbacks of the open surgery and allows for a precise assessment of the vascularization of the graft. surg endosc ( ) introduction: large pedunculated fibrovascular polyps are uncommon, mostly benign, intraluminal massess, usually located in the upper esophageal tract. most frequent reported clinical manifestation is dysphagia, followed by regurgitation, chest pain and intestinal bleeding. ct scan, and mri are the key in the diagnostic work-up revealing a sausage-shaped intraluminal mass. endoscopy with ultrasonography and biopsy add important information for the diagnosis and pedicle location. surgical excision is deemed due to potentially life-threating complication related to airway obstruction. the most frequent polyp resection is performed through cervical esophagotomy or by direct esophagectomy. however, this approach is related to a high morbidity and mortality rate. in the last years, few excisions have been reported by a endoscopical approach with a lower post operative complication. material and methods: this video shows the surgical steps of a trans-oral endoscopic surgical resection of a giant ( cm) pedunculated polyp in a year old man. the procedure was performed under general anesthesia. a flexible endoscope probe was used and the distal end of the polyp was extracted through the oral cavity with a loop. the endo-gia stapler was used to cut the base of polyp and finally removed. the anatomo-pathological study confirmed the diagnostic of a fibrovascular polyp with no evidence of malignancy. results and conclusions: the patient had an uneventful recovery with no recurrency at years of follow up. this minimally invasive approach is a safe and feasible procedure to treat large esophageal fibrovascular polyps avoiding the complications related to more aggresive procedure. introduction: leiomyomas are the most common mesenchymal tumors affecting the esophagus and they usually grow in the mid to distal third of it. they tend to be asymptomatic, but sometimes they can grow to enormous size and produce dysphagia. case report: -year-old male asymptomatic patient was referred to our hospital due to an incidental finding. ct scan revealed a x mm rounded submucosal tumor on the dorsal side of the lower third of the esophagus. upper gastrointestinal endoscopy revealed a cystic lesion in the lower esophagus cm from the incisor teeth, with normal overlying mucosa. an endoscopic-ultrasound-guided fine-needle-aspiration of the mass was performed, which was reported as a likely leiomyoma.conservative treatment was performed, no growth was detected during eleven years of follow-up. but it became symptomatic, the patient complained of progressive dysphagia caused by compression so surgical resection was decided.laparoscopic enucleation of esophageal leiomyoma was performed. the tumor was reached by transhiatal dissection. a careful dissection of the mass was performed, preserving the vagal branches. an intraoperative endoscopy was performed to verify the integrity of esophageal mucosa and that the tumor was completely resected. the muscular layer was sutured after enucleation using absorbable suture material and the hiatus was closed with non-absorbable suture material. a dor fundoplication was also performed. a swallow test with a water-soluble contrast was obtained on postoperative day one. no pathological findings were found so the patient was asked to drink.histopathological exam revealed a tumor measuring mm mm mm consistent with leiomyoma.the procedure lasted min. the hospital discharge was on the third postoperative day and no complication was registered. conclusion: surgical excision is the mainstay of treatment and is recommended for symptomatic leiomyomas and those greater than cm. this case report demonstrates the technical feasibility, safety and minimal postoperative morbidity associated with minimal invasive esophageal surgery. introduction: total esophagectomy by means of minimally invasive surgery has proven to be a valid and effective alternative for performing this procedure. however, this procedure is not implemented in most centers. objective: demonstrate the technique of a total esophagectomy by endoscopic surgery for a benign esophageal stenosis. material and methods: clinical case: a -year-old female patient diagnosed with double esophageal peptic stenosis, treated on several occasions with endoscopic dilation by digestive, showing in the last endoscopy: severe esophagitis with stenosis impassable to cms. additional tests of interest are exposed. resolved: intervention: right thoracoscopy in prone position, dissection and complete mobilization of the thoracic esophagus, section of the azygos vein, pleural drainage. laparoscopic time, trocars, gastrolysis respecting the right gastroepiploic vessels, broad kocher until the cava is identified, vascular section of the vessels left gastric, full mobilization of the stomach, subxiphoid minilaparotomy, beginning of the cervical time with dissection of the cervical esophagus, section and fixation of this to a tube, externalization of the piece by abdominal route, creation of the gastric tubular with successive loads of gia, ascending posterior mediastinal plasty with manual esophago-tubular anastomosis, with placement of drainages and feeding jejunostomy. right operative with radiological control with gastrografin on the th day, discharge from hospital on the th day. asymptomatic one year after surgery, with radiological control without alterations. conclusions: the approach of esophageal peptic stenosis with minimally invasive surgery is safe and effective, adding the advantages inherent to this type of technique. (figs. , ) , showing a cystic lesion in the gastric submucosa with a well defined, medial and superior to the lesser curvature of the stomach with exophytic growth. it causes extrinsic compression of the cardia in the gastric body. within the differential diagnosis are gastric duplication cysts or gastrointestinal stromal tumor. a biopsy was taken, discarding the presence of neoplastic cells. finally, a study of digestive transit showed extrinsic compression at the cardial level, which causes difficulty in passing contrast. a laparoscopic approach was performed beginning with the dissection of the abdominal esophagus. the presence of a cystic lesion on the anterior face of the abdominal esophagus was identified (figs. , ) . we proceeded to the complete resection of cyst. the surgery was completed with °f undoplication anterior dor. the patient went home on the rd day without incident. results: duplication cysts are congenital malformations of the gastrointestinal tract contiguous with the esophagus, which can communicate with the esophageal lumen. most are diagnosed in childhood, but when it is diagnosed in adults, they used to be symptomatics. it is more frequent in men. although the pathogenic mechanism is unknown, it is caused by an anomaly during embryonic development. they are located in the thoracic esophagus, at the level of the lower and posterior mediastinum and, less frequently, in the abdominal esophagus, as in our case. they can give digestive symptoms(epigastralgia, vomiting) or respiratory symptoms. the diagnosis is made with eda, ct, and ecoendoscopy of choice, although it may be incidental. the treatment of choice in symptomatic patients is complete resection or cystic enucleation. in asymptomatic surgical is not defined, because it can cause complications, and, malignization due to degeneration is very infrequent. conclusion: the most of duplication cysts are diagnosed in childhood, although it's more frequent in adults to be symptomatic. surgical treatment can cure this disease. however, the choice between these becomes difficult in young patients, where the low incidence does not allow get series of long patients and decisions must be based on results achieved in adults. objetivos: to demonstrate the safety and efficacy of the laparoscopic approach in this infrequent pathology, pointing out the importance of having standardized the procedure to achieve better results. material and methods: case report: a -year-old man with progressive dysphagia until almost complete afagia, with clinical, endoscopic, radiological and manometric diagnosis,compatible with typical primary achalasia. chagas negative serology,we show the complementary studies of interest.dilatation is not performed, preoperative symptomatic treatment with calcium channel inhibitors. intervention: laparoscopic approach, trocars, aberrant left hepatic artery with signs of severe esophagitis,opening of the gastroesplenic-hepatic ligament, no retroesophageal window, dissection of the hiatus and inferior mediastinal, preservation and mobilization of the left hepatic artery and the anterior vagus,meticulous disection of the cardia,standardized myotomy: first proximal cms. with adequate simultaneous traction of both edges of the myotomy, then distal myotomy including - cm, including selectively the distal oblique fibers of les, tutorization with fouché and methylene blue to confirm good step and absence of leakage, dor-type funduplication, pts on each side, fixed to both pillars, hiatalmediastinal drainage. egd on the st day of normal po, dischargeat rd day, asymptomatic and with normal radiological control at year of age. conclusions: laparoscopic mh should be the first therapeutic option, in patients with primary achalasia, even in young patients. the length of myotomy, especially distal to ueg is one of the most important aspects of surgery, most authors (pellegrini) recommend that the myotomy extend - cm in the stomach, even up to cm below the ueg to achieve an effective disruption of the eei.the standardization of the procedure is fundamental to increase safety and effectiveness in these more complex cases. aims: the surgical treatment of giant hiatal hernias is a complex and demanding procedure, not only in terms of performing the operation in a minimally invasive abdominal fashion by avoiding thoracic approaches, but also concerning the management of large hiatal defects which contribute to high recurrence rates. our aim is to present our surgical technique for the reconstruction of such hiatal hernias, exploiting the benefits of the robotic approach and also to highlight the technical aspects of non-absorbable mesh placement in order to bridge effectively the hiatal defects. methods: we present video fragments from a procedures selected from a series of cases of robotic reconstruction of giant hiatal hernias performed by our team, in which a non-absorbable meshes were utilized to restore the hiatal gap. we emphasize on the clear benefits of robotic surgery in these cases and on the strategy of how to avoid high recurrence rates. results: all of our patients, who underwent reconstruction of giant hiatal hernias with this particular technique, experienced very good early post-operative results, very short hospital stay and no recurrence in a -month follow-up. conclusions: the robotic approach for the treatment of large hiatal hernias offers great advantages to both surgeons and patients, by eliminating the restrictions of conventional laparoscopic surgery, minimizing intra-operative incidents and post-operative complications. large hiatal defects are very effectively closed with the use of advanced suturing techniques and non-absorbable meshes in a tension-free bridging fashion. aims: mckeown esophagectomy is commonly used for invasive esophageal carcinoma. as the morbidity and mortality rates for esophagectomy are persistently high, minimally invasive esophagectomy in prone position is expected to reduce respiratory postoperative complications. there is still limited experience for the use of minimally invasive approaches in patients undergoing surgery after neoadjuvant chemoradiation and many concerns about the feasibility, safety, and oncological outcomes of these procedures are still present. methods: we present the case of a -year-old female with a middle third esophageal squamous cell carcinoma, who received neoadjuvant chemoradiation. she underwent laparoscopic and thoracoscopic (prone position) mckeown esophagectomy with hand-sewn esophagogastric anastomosis through a left lateral cervical incision. results: the operation was completed successfully, with no conversion to open surgery. the operative time was h with minimal blood loss and the patient was fed on day and discharged on day post-op. r resection was achieved and the number of total harvested lymph nodes was ( positive nodes, n ). conclusions: minimally invasive mckeown esophagectomy in patients with esophageal cancer and prior chemoradiation is feasible and safe procedure with acceptable oncological outcomes. results: preliminary results demonstrated that minimally invasive ivor-lewis esophagectomy procedure, provided of a better postoperative pain control and less respiratory complications. in order to standarise our procedure, the video shows how three different types of esophagogastric anastomosis are performed, depending on the patient characteristics, anatomical factors and safety and comfort for the surgeon: manual termino-terminal, mechanical termino-terminal and mechanical latero-lateral. conclusions: in our way to standardization, we are still looking for the best type of anastomosis, even though, we find out that, manually performed anastomosis are easier to performed, when the section in esophagus is lower, involving medium and inferior third. in the other hand, mechanical termino-terminal anastomosis seemed to be an ideal option for upper sections. more studies are needed in order to standardized one anastomosis, for all cases. because esophagectomy with radical lymphadenectomy is highly invasive, thoracoscopic esophagectomy (te) is attracting attention as a less invasive procedure. we first performed te with the left decubitus position in . in we developed a hybrid of the prone and left lateral decubitus positions for te, and a total of patients underwent te with a hybrid position . we introduced te with a hybrid position for the following three reasons: ( ) mobilization and lymphadenectomy around the middle and lower esophagus are easier in the prone position. thanks to artificial pneumothorax and the gravity, the middle and lower mediastinum are opened, and which give us good surgical field. ( ) lymphadenectomy along the left recurrent laryngeal nerve (rln) is more reliable and precise when performed in the left lateral decubitus position. we can dissect lymph node around the rln higher position in the upper mediastinum. ( ) unexpected events requiring conversion to thoracotomy (e.g., massive bleeding, injury of other organs, dense intrathoracic adhesion, resection of adjacent organs) are easier to deal with in the left lateral decubitus position. the patient is fixed on the operating table with the semi-prone position and we can easily change patient positions from the left lateral decubitus position to the prone position and vice versa using rotation system of the operation table. the upper mediastinal procedure including lymphadenectomy along the right and left rln is performed with the patient in the left lateral decubitus position, while the middle and lower mediastinal procedures are performed with the patient in the prone position with artificial pneumothorax ( mmhg). theabdominal procedures wereperformed by hand-assisted laparoscopic surgery (hals) and gastric tube reconstruction through aposterior mediastinal route was performed as a standard surgical procedure in our institution. the magnifying effect of thoracoscope enables us to perform more precise surgery and preserve nerve and vessels, and a hybrid position is thought to be feasible and effective methods. ivor lewis esophago-gastrectomy is a standard procedure for the treatment of distal esophageal cancer. among the years, the surgical community standardized the mininvasive abdominal phase. the thoracic phase is much more complex because usually all surgeons get in trouble in the phase of esophago-gastric anastomosis. in fact, is still very difficult and tricky to perform a mechanical circular anastomosis due to problems with the correct handling of the circular stapler through the minitoracotomy and is also difficult to place the anvyl in the proximal esophagus. the linear anastomosis (side-to-side) is a little bit easier but not so effective as the circular anastomosis in terms of leak rate. we think that robotic approach with its endowrist can allow us to overcome these limits and that a tailored double layer hand sewn esophago-gastric anastomosis could be the right choice. we treated patients with this approach and they were all uneventful in the post operative period except for a case of chylothorax we treated successfully with lipiodol injection in inguinal lymphnodes. we need more cases to analyze the technique in terms of leak rate and major complications but we think this is a promising and cost-effective procedure for robotic approach. aim: anastomotic leakage is one of the most dreaded complication after esophagectomy. indocyanine-green near-infrared angiography (nir-icga) intraoperative use has been recently introduced for visceral perfusion evaluation. in this video we present our technique for gastric conduit fashioning according to the nir-icga blood supply evaluation in a total minimallyinvasive ivor-lewis esophagectomy. methods: a years-old man affected by a siewert adenocarcinoma (ct , n , m ) underwent a preoperative neoadjuvant treatment according to cross protocol. at restaging ct-scan no more pathologic nodes were evident (ct , n , m ). the patient was submitted to a total minimally-invasive ivor-lewis esophagectomy. surgical procedure: after pneumoperitoneum induction and trocars insertion, the lesser omentum was opened and a lymphadenectomy at stations a, , , and performed. the esophagus was dissected at diaphragmatic hiatus with lymphadenectomy at station , and . the larger omentum was opened along the right gastroepiploic arcade, that was preserved, the short gastric vessels divided and gastric fundus mobilized. by evaluating the presence of an intense fluorescence at nir-icga, a tailored partial tubulization of the stomach was performed with multiple linear stapler firing. a right thoracoscopy was performed through trocars. the azygos vein ligated and divided. the mediastinal pleura was opened and the esophagus was dissected entirely with an en-bloc excision of nodes at stations , and . nodes at stations , , and were removed separately. the esophagus was sectioned above the azygos vein level and a purse-string fashioned. the cardia and the gastric tube were pulled up and a minithoracotomy performed. a new nir-icga was repeated to verify the good blood supply and tailor the site of anastomosis on a well perfused area. the stomach was opened and a circular stapler inserted. after the end-to-side esophago-gastric anastomosis fashioning, the tubulization was completed by linear stapler firing and the specimen removed. results: the post-operative course was uneventful and the pathologic examination revealed a cardial adenocarcinoma (ypt ,n , r ). conclusions: nir-icga is an interesting and easy-to use tool for surgeons. nevertheless in literature is still not clear which is the best parameter to measure the blood supply. large studied are needed. aim: uses and application of indocyanine green (icg) fluorescence in the field of surgery are growing exponentially. the safety and feasibility of its usage has been proven in several areas and various pathologies of surgery and surgeons are starting to incorporate it into their common practice. however, there are still several aspects to define regarding this technology. we present different uses of icg in the specific area of esophageal cancer. methods: we used icg fluorescence at different moments of a two-field minimally invasive esophagectomy. first of all, peritumoral injection of icg may offer a lymphatic mapping, both in the abdominal phase of the surgery and the thoracic one, improving lymph node dissection by allowing a more targeted and less morbid approach that includes all relevant nodal stations. at the moment of the gastric section, intravenous injection provides assessment of gastric conduit perfusion, therefore optimizing the construction of the graft to avoid the inclusion of poorly perfused areas that may increase the risk of leak of the anastomosis. besides that, the esophagogastric anastomosis can be tested in the thoracic phase of the operation in order to check an adequate perfusion and prevent further complications. results: we consider that icg fluorescence is a promising technology that could be easily introduced in the surgical routine of the esophageal surgeon as an instrument to assess the anastomosis perfusion. icg is also feasible in detecting lymph node drainage from the esophagus, although its technique of application needs to be defined. conclusions: icg fluorescence has opened a new world of possibilities in all the different surgical specialties. its use in the esophagectomy is safe, simple and feasible. in a near future, its application to esophageal cancer surgery could improve survival by predicting and preventing anastomotic leak and guiding in a tailored lymphadenectomy. further research is needed to demonstrate these promising applications. introduction: the oesophagectomy is currently still mandatory in the curative treatment of the malignant oesphagic pathology. this procedure is defined by important morbidity and mortality. the minimally invasive approach aims to reduce the complications without repercussion on the oncological outcomes, however it's not exempt from them being a demanding surgical technique like it is. aim: we present the video of three complications after a three-stage oesophagectomy (mckeown-like) with the thoracic stage via thoracoscopy and the minimally invasive surgical solution for both of them. methods: all three cases represent a three-stage oesophagectomy for malignant esophageal pathology. the first one was a -year-old male who suffered an intraoperative left main bronchus injury. the second case was a -year-old male with no intraoperative complications whatsoever. nonetheless, on the second postoperative day, milky drainage started to appear through the thoracic tube. the third and final case represents an intraoperative hemorrhage, which is the most common complication of this kind of surgery. results: the first case was diagnosed and treated intraoperatively with the use of an adhesive matrix. during the postoperative period the patient showed no further complications. the second case was a chylothorax, diagnosed on the second postoperative day. it was treated initially with conservative measures. due to bad evolution, he underwent surgery on the tenth postoperative day. we can see how we ligated the stump of the thoracic duct in the original surgery and then how we repaired the unexpected leak. after the second surgery, the patient was discharged on the sixth day. the last patient was also diagnosed and treated intraoperatively successfully, with no repercussion whatsoever in the postoperative time. conclusions: the minimally invasive surgery has many advantages in the upper gastrointestinal field. it is a demanding technique, so it is important to be able to treat the complications that may arise with this approach. surg endosc ( ) aims: the use of icg fluorescence is incrising in surgery, mainly as a test of vascular supply in colonic anastomoses. during the last years, other potential uses have been described, such as the identification of the sentinel lymph node and lymphatic mapping in oncological surgery. these advances could allow a better staging in order to decide the most appropriate treatment to each patient. gastric cancer is one of the fields where this could play a key role in the near future. we present a case of a patient who underwent a laparoscopic total gastrectomy with icg-guided d lymphadenectomy, where a personalized lymphatic mapping was performed. methods: a -year-old male patient underwent gastroscopy for gastric discomfort, and a gastric carcinoma was detected at the greater curvature of gastric body. endoscopic biopsy was informed as diffuse type gastric adenocarcinoma. the preoperative staging was completed with echoendoscopy and ct-scan (t bn m ). we decided to perform a laparoscopic total gastrectomy with icg-guided lymphadenectomy. the preoperative day, a gastroscopy was performed to inject . mg of icg in four submucosal areas around the tumor. results: intraoperatively, the lymphatic mapping marked by icg was checked, allowing the identification of the territory of drainage of the tumor to lymph nodes at the lesser curvature, the greater curvature and the splenic artery. a d lymphadenectomy and a total laparoscopic gastrectomy with roux-en-y reconstruction was performed. during the lymphadenectomy, we were able to observe marked lymph nodes in territory , and also observed that the paraaortic lymph node behind the celiac trunk did not become green and the lymphadenectomy at this area was not continued. the patient presented no postoperative complications, and was discharged on the seventh postoperative day. the histological results showed a diffuse type gastric adenocarcinoma pt n and isolated lymph nodes, being one of them possitive (corresponding to the adenopathy marked at the greater curvature). conclusions: lymphatic icg-mapping in gastric cancer is a potential revolutionary advance that could ensure a correct lymphadenectomy, avoiding lymph node understaging. it is necessary to continue carrying out studies that will allow developing protocols to define appropriate lymphadenectomy based on icg-mapping. introduction: petersen's hernia is one of severe postoperative complication after gastrectomy, which may result in massive resection of small intestine. it is considered an essential proscedure to close the petersen's defect for all cases after such reconstruction after gastrectomy as roux-en y method. we report a case of petersen's hernia after radical gastrectomy, which was repaired laparoscopically. patient: the patient was -year-old male, who underwent laparoscopic distal gastrectomy for gastric cancer (d lymph node dissection followed by roux-en-y reconstruction) two years ago. the closure of petersen's defect was not performed in the initial operation. he was aware of abdominal pain and visited emergency unit in our hospital. abdominal ct scan showed internal hernia of petersen's hernia. surgical procedure: in laparoscopic examination, dilation of small intestinal and mastoid ascites was observed. massive small intestine including y-limb entered into petersen's defect from left to right side. we carefully pulled through the small intestine and confirmed absence of ischemic change in the whole small intestine. then the petersen's defect was closed by continuous suturing with - non-absorbable barbed suture. results: the operation time was min and the estimated blood loss was ml. oral intake was started from the next day of the operation. there was no postoperative complication. the patient was discharged on the th postoperative day. conclusion: we could safely perform laparoscopic repair for petersen's hernia. regarding technical points in the procedure, it is important to judge the direction of the small intestine into the petersen's defect, to manage the dilated small intestine gently, and to close the petersen's defect by laparoscopic suturing. introduction: in this case we present a -year old male with a history of morbid obesity, sleep apnea and psychiatric affliction including alcohol and nicotine abuse. in he underwent a laparoscopic roux-en-y gastric bypass. the results were satisfactory, with no complications post-surgery, and a steady weight loss over time (pre: kg, post: kg). in november , he presented with complaints of dysphagia and weight loss ( kg in months). laryngoscopic examination by the otorhinolaryngologist was negative. he was referred to gastro-enterology for gastroscopy. biopsies showed a mildly differentiated adenocarcinoma of the gastro-esophageal junction with submucosal invasion. objective: after negative staging assessment, multiple treatment options were considered. the route of choice ended up being a laparoscopic radical gastrectomy with esophago-jejunostomy, with the objective to achieve optimal oncological results. methods: the procedure is demonstrated in this video. the gastric pouch as well as the remnant stomach, greater and lesser omentum were resected laparoscopically. due to the invasion of the carcinoma into the distal esophagus, a segment of the esophagus was resected as well. following anatomopathological examination on frozen section, the resection margins were reported malignancy free. results: postoperatively, there were no complications. ct scan with contrast showed no signs of leakage. anatomopathological examination confirmed the tumor to be a mildly invasive and poorly differentiated adenocarcinoma with local signet-ring cell differentiation (pt bn ). there was no need for adjuvant therapy. oral intake was sound. conclusion: adenocarcinomas of the gastric pouch are rarely seen following gastric bypass. this patient presented with complaints of dysphagia, and an adenocarcinoma was diagnosed. consequently, the patient had a total gastrectomy at our hospital. the surgery was performed laparoscopically, and was executed with success. to conclude, it is feasible to treat adenocarcinomas after gastric bypass laparoscopically via total gastrectomy and omentectomy. year old, female patient presented with upper abdominal discomfort and microcitic anemia. an ulcerative lesion was found on gastroscopy examination in body of the stomach (near the grate curvature). biopsy was done and pathology result showed poorly differentiated adenocarcinoma. chest computed tomography (ct) was without any significant findings. abdominal ct showed the lesion in stomach without enlargement of regional lymph nodes. her blood laboratory examinations were within normal limits, including serum cea. patient underwent laparoscopic total gastrectomy with modified d lymphadenectomy and roux-en-y esophagojejunostomy. total operating time (ort) was min. three days after operation, patient has developed none st elevated mi and respiratory failure. she was intubated. on day after operation she was extubated, on day patient started regular diet and was discharged home on day . final pathology result confirmed poorly differentiated adenocarcinoma of the stomach. this video shows our favourite technique for laparoscopic d subtotal gastrectomy. we usually perform the procedure with or trocars; after the coloepiploic detachment we perform the gastric transection first! this manoeuvre provides a perfect view for the lymphadenectomy. at the end of our dissection we transect the duodenum with seamguard reinforcement. before going on with the reconstructive phase, we prepare the roux en 'y' with double loop technique, usually without dividing the mesentery. then we remove the specimen through a periumbilical - cm minilaparotomy; we think it's important anyway to check margins and distance from the tumor before going on with the reconstructive phase. from the same minilaparotomy we retrieve the prepared limb for roux en y and we perform a side to side mechanical linear anastomosis outside.then we proceed with performing the anastomosis between the gastric pouch and the alimentary limb by laparoscopy. we like very much this technique for the increased exposition of tissues during lymphadenectomy. laparoscopic roux en 'y' d surg endosc ( ) a body-tc was performed in which axillary, mediastinal adenopathies and images suggestive of hepatic metastases were identified. the biopsy confirms a gastrointestinal stromal tumor. the case discussed in a multidisciplinary committee and the pet-ct study was completed, subcardial gist t n m was diagnosed. neoadyuvance was decided with imatinib for one month and surgery was performed using a laparoscopic approach. the approach was performed with trocars ( mm supraumbilical, two mm subcostal left and right, mm subxifoid and mm left flank). gastrectomy was performed with d lymphadenectomy following the oncological principles of subcardial tumors. the piece was removed in a bag by extending the mm port to mini-laparotomy. esophagogastric anastomosis was performed by hand assisted circular mechanical suture. methylene blue test was carried out. no nasogastric tube left, but drainage tutoring the esophagogastric anastomosis was left. results: the postoperative evolution was favorable. oral tolerance without incidents at fourth postoperative day. the patient was discharged without incidences on the seventh postoperative day. the pathological study of the piece was reported as subcardial gastrointestinal stromal tumor cm with respected surgical margins and lymph nodes free of malignancy, postoperative diagnosis of t n m . one month after surgery, the patient has adequate oral tolerance. she does not report gastroesophageal reflux and at months remains asymptomatic and with good evolution. conclusions: laparoscopic proximal gastrectomy is a technique that is not currently used but can be performed through a laparoscopic approach. it is a safe technique with good clinical and oncological results, especially in the early gastric cancer and gastrointestinal stromal tumors. however, long-term studies are necessary. laparoscopic gastrectomy is a perfectly safe option nowadays for the treatment of gastric cancer. every year the percentage of the laparoscopic approach is rising not only in the east but also in the west. we present a case of a year old female patient with a gastric tumor of the antrum-g adenocarcinoma with a ct n m staging. we perform a subtotal laparoscopic gastrectomy with a d lymphadenectomy and roux-en-y anastomosis. the patient begin clear liquids on the first post operative day and was discharged on the th. the final anatomopathological result of the specimen was a adenocarcinoma (g )-pt n . there were nodes resected all negative. the case was discussed in multidisciplinary team and was decided for clinical follow up with no further treatments. the patient was evaluated one month after surgery with no complaints and will continue the follow up. upper gi surgery, university of verona, verona, italy laparoscopic endoscopic cooperative surgery is an option in medium size submucosal cancers invading the muscular layer, mainly in border area were wedge resections are nor feasible.in this video we report a case of prepiloric gist treated with news technique (nonexposed endoscopic wall-inversion surgery).we think that this technique is feasible and safe and should be considered a valid option with a view to preserving the organ. aim: laparoscopic wedge resection or partial resection is a safe and feasible stomach preserving approach to gastric submucosal tumors (smt) such as gastrointestinal tumors (gist), and it has been widely performed recently. however, it should not be applied to the tumors at cardia in order to avoid stenosis or disruption of anti-reflux mechanism. we have introduced percutaneous endoscopic intragastric surgery (peigs) for smt at cardia since to preserve function of cardia. we will report the tips, techniques, and clinical result of our peigs. methods: from september to august , seven patients with smt at cardia underwent peigs in our hospital. we insert the mm port at umbilicus and investigate the abdominal cavity at first. then the incision is extended to . cm and lap-protector tm is equipped with the site to perform mini-laparotomy. using peroralendoscopy, a stomach was insufflatedand incision is made at an anterior wall of gastric body under direct vision. additional lap-protector tm is placed into the stomach so that the stomach is fixed on the abdominal wall. it enables us to keep direct access to gastric lumen and stable operative field. ez access tm is attatched on lap-protector tm , and intragastric operation is started. subsequently, two trocars are inserted using funada's gastropexy instrument. tumor is dissected by using energy devices, avoiding injury of capsule of the tumor. the defect of the gastric wall is closed by intragastric suturing. we should take particular care not to damage egj during the suturing, inserting peroral endoscopy in and out. results: the mean operation time was ( - ) min and the amount of intraoperative bleeding was . ( . - . ) ml. the maximum diameter of tumors was ( - ) mm. one case was low risk gist and otherwise were leiomyoma. the postoperative course was uneventful in all cases, without leakage or stenosis. total hospital stay was ( . - ) days. no patient had symptoms of esophagitis. conclusions: peigs for smt at gastric cardia is a feasible and safe approach, preserving function of cardia. our procedure achieves great stability and excellent visualization during the operation, which may have led to the fine surgical results. laparoscopic lymphadenectomyin gastric cancer is considered a feasible and safe procedure. data on the compliance of lymphadenectomy in the various lymph node stations is not yet well understood; moreover it is not clear if there are particular conditions relate to the patients impairing the oncological results. this video reports the use of the icg for the lymph node dissection of station number in a case of obese patient and a case of a cirrhotic patient. fist patient, m.a., was a year old man with distal cancer ct n and a bmi. second patient, t.d., was a year old man with distal cancer ct n and a alcoholic cirrhosis child b . in both cases, intraoperative endoscopy was performed to min before the onset of lymph node dissection. . mg of icg was injected into the submucosal layer in quadrants of the primary tumor. a laparoscopic subtotal gastrectomy was conduced with d lymphadenectomy. lymph note navigation were analyzed by novadaqÒ detector. using navigation system we removed the n basin. in both cases dissection were effective and pancreatic surface were easily detectable. number of lymph nodes retrieved was in the case of obese patient and in the case of cirrhotic patient. pathological tnm were pt n ( / n ?) in the first case and pt n ( / n ?) in the second. no n ? metastases were detected in n station for both cases. no pancreatic fistula was recorded. icg lymph node navigation system should be considered a valid support for the surgeon for completion of a correct lymphadenectomy in surgical challenging cases. aims: morgagni hernia is the rarest of congenital diaphragmatic hernias ( - %). its presentation is rare in adults and its finding is usually incidental. it was first described by giovanni b. morgagni in . it is located in the anterior region of the diaphragm. it is caused by a congenital defect in the fusion of the transverse septum of the diaphragm and the costal arches. the need for surgery depends on the presentation, it is recommended early repair before the development of complications. classically, the surgical approach was thoracotomy or laparotomy. currently, the tendency is to use a minimally invasive approach, which has shown good results, lower morbidity and faster recovery. the need to repair the defect with a mesh is controversial, recommended when it is not possible to close the defect without tension. the objective of this video is to demonstrate the safety and efficacy of the laparoscopic approach for the repair of this type of hernia, as well as the different types of mesh that can be used. aims: the treatment of the non-metastatic gastro intestinal stromal tumour (gist) is the surgical resection [ ] . the duodenal gastro-intestinal stromal tumour (gist) is a relatively rare clinical entity. from all the resected gist, only % are duodenal [ ] . the clinical presentation could vary from the most common acute gastro intestinal (gi) bleeding, chronic anaemia, but also acute abdomen caused by tumour rupture and intestinal obstruction. methods: a years old patient present at the emergency department of the chi poissy-st germain-en-laye (paris, france) with acute gastrointestinal bleeding. at the laboratory exams the haemoglobin was . g/ dl. the patient perform a computer tomography (ct) which shows two hyper vascularised lesion at the th duodenum; this lesions has an intra and extraluminare growing. the ct scan didn't show any other abdominal lesions. the patient were submitted to a minimally invasive surgical operation with the multiport laparoscopic technique. results: the resection of the th and th duodenum and of the first centimetre of jejunum was performed with a four trocar laparoscopic technique. a latero-lateral duodeno-jejunal mechanical anastomosis was performed. the operative time was min. the patient start with oral alimentation on the third post-operative day after a ct scan with oral contrast that was negative for anastomotic dehiscence and collections. the post-operative course was globally uneventful and the patient was discharged at fifth post-operative day without complications. the histological examination shows a low risk gist, cd positive and with a ki- inferior of % (classification tnm th edition pt aims: gastric volvulus are a rare condition that sometimes represent a diagnostic challenge for surgeons. here we present the video of a recent case of a gastric volvulus in our area that was treated with a minimal invasive approach. methods: we report the case of a -year-old woman who was admitted in the emergency room (er) with epigastric transfixing pain and impossibility to vomit that had started h prior to the admission. the physical exam showed good vital signs, and her abdomen was soft, with a tendency to tenderness with palpation in the epigastrium without guarding or rigidity. her lab tests were normal and the conventional radiology showed a double gastric bubble. we run an urgent computed tomography scan (ct scan) and a upper gastrointestinal (gi) endoscopy that showed a big type ii hiatal hernia that was complicated with a gastric volvulus. results: first, a nasogastric (ng) tube was placed for decompression of the stomach at the time when the endoscopy was made. the patient experienced a great improvement of the pain with that initial measure and remained stable. after almost a day of appropriate resuscitation, she underwent urgent surgery: we performed a hernia reduction, resection of the hernia sac, hiatal closure and a gastropexy and nissen fundoplication. the patient suffered no complications in the immediate postoperative time and was discharged after six days. conclusion: gastric volvulus are an uncommon emergency that we need to keep in mind. a simple abdomen x-ray can be very helpful, given that the double gastric bubble sign is a typical sign of this condition. it's always mandatory to perform an upper gi endoscopy in order to get to the diagnose and place a ng tube promptly. the surgery can be safely delayed in stable patients with no signs of ischemia, and a laparoscopic approach is associated with a shorter hospital stay and good long-term outcomes in this kind of patients. aims: during laparoscopic treatment of hiatal hernias the dissection can be complicated, but even more so the closure of the pillars, especially in giant hiatus hernias with a large defect. the use of prosthesis is controversial due to the lack of long-term studies and the possibility of secondary complications. the aim of this video is to demonstrate the safety of mesh hiatoplasty in hiatus hernia surgery. methods: we present the case of a -year-old woman with hypertension, hypothyroidism and right hemicolectomy for neoplasia years ago. the patient presented with malnutrition, with a weight loss of kg in the last months. a gastroscopy was performed in which a large hiatus hernia, that caused gastric volvulation, was shown. the upper gastrointestinal oral contrast study revealed esophageal tertiary waves and good passage to the gastric chamber, with an organoaxial volvulation of the stomach that was completely included in the thoracic cavity. results: through a five trocar laparoscopic approach, a large paraesophageal type iv hiatal hernia ( cm hiatal orifice) with complete herniation of the stomach and greater omentum to the mediastinum was observed. after reduction of the hernia content, complete dissection with partial resection of the sac was performed. an extended mediastinal dissection of the esophagus, with descent of the esophagogastric junction until achieving an abdominal esophagus of - cm, was carried out. after posterior and anterior phrenorrhaphy with nonabsorbable sutures, dislacement of the right pillar without diagragmatic opening was evidenced. it was decided to reinforce the hiatorraphy using a c shape composite mesh fixed with nonabsorbable sutures. the procedure was completed with a nissen-type fundoplication. postoperative course was uneventful and the patient remains without hernia recurrence months after the intervention. conclusion: prosthetic reinforcement in hiatal hernia repair can be a very useful resource in large hiatal defects in which a stress-free hiatus closure cannot be achieved. however, its use must be individualized according to the characteristics of the patient, the quality of the tissues involved and the result of simple hiatorraphy. aims: heller myotomy is an advanced laparoscopic surgical technique for the treatment of achalasia, a rare disease in which long time is needed to achieve the learning curve. surgical simulation, using animal models with an anatomy similar to humans, could help improving surgeon performance in a shorter time. the aim of our video is to show an ex-vivo and in-vivo animal model for heller myotomy training. methods: a cadaveric porcine model was developed using a tissue block including the esophagus and the stomach, without the diaphragm, mounted in a physical laparoscopic simulator. training procedures were also performed in an in vivo porcine model. experiments were carried out in the ' jesús usón' minimally invasive surgery centre in cáceres. results: the surgical technique is described step by step, first in the esophagus-stomach ex-vivo model and later in the live animal model. conclusion: surgical simulation using cadaveric an live animals offers a realistic representation, allows training in a safe environment, and can be very useful for advanced laparoscopic training in low incidence pathologies. introduction: esophagic perforation is one of the least frequent complications after laparoscopic nissen fundoplication, but it remains one of the most dreaded because of its morbidity and mortality rates and its technically difficult reparation. aims: to present how the authors dealt with an iatrogenic esophagus perforation post laparoscopic nissen fundoplication. methods: the authors report the clinical case of a -year-old woman who underwent a laparoscopic nissen fundoplication because of a symptomatic large hiatus hernia in a different hospital. the second postoperative day and after resuming oral intake, she presented respiratory and hemodynamic instability. she needed a chest tube that drained purulent content. the patient was referred to our hospital for clinical management. an urgent ct scan with oral contrast was performed without showing any leakage. results: in spite of the results, as the patient was unstable, she underwent an emergent diagnostic laparoscopy. it was found a small anterior esophagus perforation with right mediastinic collection. a running suture of the perforation was carried out and the nissen fundoplication was converted to a dör fundoplication. the operative time was min. she went to the intensive care unit for ten days. five days after the surgery, she was given methylene blue with no exteriorization through the drainages. as postoperative morbidity, she suffered from a right pneumonia and a thoracic collection that was treated by thoracic surgeons. the patient was finally discharged on the th postoperative day. she did well at home. she attended follow-ups without clinical reflux or any other particular condition. conclusions: esophagic perforation is a life-threatening complication that can be managed laparoscopically if it is detected soon after surgery and an expertise is available. surgical treatment of achalasia fails in - % of patients. the most frequent responsible cause is a previous incomplete myotomy, followed by fibrosis and aspects related with antireflux procedure. revisional surgery can represent a greater difficulty and a challenge. in this video we show revisional surgeries after heller's myotomy with dor fundoplication for achalasia. all cases presented a recurrence of the symptomatology and a revisional surgery was proposed. surgeries were characterized by the presence of a herniation of the previous fundoplication, fibrosis around the prior myotomy and/or the formation of a pseudodiverticulum. we show the steps followed and the aspects to consider during the dissection. these cases demonstrate that laparoscopic reoperation for achalasia is feasible, even after open surgery. aims: upside-down stomach (uds) is a rare type of large paraoesophageal hernia, characterized by migration of the entire or large parts of the stomach into the posterior mediastinum. uds is associated with severe complications like strangulation or volvulus development, possibly leading to acute gastric outlet obstruction and incarceration. surgical repair is the only curative treatment option and therefore recommended for these patients. standard procedure includes a hiatoplasty followed by an anti-reflux procedure. in a variety of studies, the use of mesh proved to be superior with respect to reduction of anatomical recurrences. methods: a -year old woman presented to us with reflux symptoms, dysphagia, dyspnea and tachyarrhythmias. she reported a weight loss of kg in the last months. ct scan and esophagogastroscopy showed a large paraoesophageal hernia, measuring approximately cm, with intrathoracic uds. results: we performed a laparoscopic hernia repair with dissection of the hernia sac from the posterior mediastinum, tension-free intrabdominal reposition of stomach and distal esophagus and hiatoplasty with biologic mesh (tutomesh tm ) augmentation. finally, a toupet fundoplication was performed to recreate the antireflux valve. in consequence of pronounced adhesions, a lesion of the muscularis of the distal esophagus occurred during surgery. the esophageal mucosa was unaffected. we treated the lesion laparoscopically with a simple interrupted suture (vicryl tm - ). an intraoperative patent blue v leak test did not identify any leaks. the recovery was uneventful. the patient was discharged on day after surgery and was free of symptoms in her follow-ups. conclusions: patients with large hiatal hernias and uds can be treated successfully and effectively with laparoscopic mesh repair. intraoperative complications can be handled laparoscopically in a safe manner. iatoplasty followed by nissen fundoplication represent the gold standard treatment of hiatal hernia; however it has been reported high hernia recurrence rate, especially in case of giant hiatal defects. in order to reduce recurrence rate, various techniques of hiatoplasty reinforcement have been implemented, such as prosthetic materials apposition. however, in literature have been reported various mesh complications such as esophageal and proximal stomach erosion and late esophageal perforation after ischemia, especially in case of synthetic non absorbable materials.in this video we are going to show the repair of a huge hiatal hernia by hiatoplasty and positioning of an absorbable biosynthetic 'bio a' mesh which is replaced by connective soft tissue over six months, therefore decresing complications and recurrence rate.as usual, we start with the mobilization of gastric fundus and isolation of diaphragmatic pillars by sectioning the aderences between them and herniated viscera. we proceed then with intrabdominal esophagus mobilization and higher mediastinal dissection in order to obtain an adequate esophageal lenght. after the exposition of the hiatus, we approximate the pillars with some non absorbable stitches and we reinforce the hiatus positioning a 'u' shaped bio a mesh over the esophagus, simply fixed to crura with single stitches. then we go on performing nissen fundoplication.the use of this prosthetic material appears to be cost-effective; first series in literature show very low complication rate and less recurrences of hiatal hernia than hiatoplasty without reinforcement. this video demonstrates the technique of laparoscopic identification and complete dissection of the sac of a totally intrathoracic stomach. identification of the sac is performed centrally by scoring the peritoneum overlying the arch of the diaphragmatic hiatus. the inferior edge is retracted and series of blunt dissection is undertaken. once the areolar tissue of the avascular plan is visualized; a raytec sponge is placed and advanced cephalad to expose the extra-saccular space. this raytec is kept in place to allow carbon dioxide to infiltrate and further delineate the anatomy. we then proceed with dissection at the left crus and right crus. complete reduction of the stomach can be achieved without grasping it. this can be performed by applying caudal retraction on the sac. this maneuver exposes the plane outside the sac. this space is divided into two compartments (right and left) separated by a septum which indicates the proximal extent of the sac. this plane is avascular and blunt dissection can easily free the hernia sac from the mediastinal structures and the pleura. this was followed by excision of the sac and hiatal repair which is reinforced with bioabsorbable mesh. the proximal short gastric vessels were then divided and a standard toupet fundoplication was performed. v -upper gi-reflux-achalasia introduction-objectives: the mixed giant hiatus hernias with paraesophageal component are hernias of difficult surgical correction, the laparoscopic approach of these implies a greater experience of the surgical team, given the complexity involved in its management, being the recurrence a complication that neither the use of meshes in this surgery has been able to avoid. in very high-risk patients, the gastric anterior pexy (boerema) may be an alternative to treat or alleviate the symptoms of these large hiatal hernias, although the frequency of recurrence with this technique is very high. material and methods. objective: the objective of the following case is to present a patient with type- hiatal hernia, barrett's esophagus without dysplasia and situs inversus. method: a laparoscopic partial fundoplication was performed on a -year-old male patient with a history of situs inversus totalis, who was seen in our general surgery service presenting a clinical history of retrosternal pain, heartburn and regurgitation. an endoscopy was performed, which reported hiatal hernia type and incompetence of lower esophageal sphincter, with squamocolumnar junction biopsies with report of barrett's esophagus without dysplasia. results: surgical time was programmed, for toupet type fundoplication; there were lax adhesions from omentum to wall, the lax hiatus and already known situs inversus. partial funcuplication was performed, with the usual technique adapted for structural anatomical abnormality, postoperative course without complications, oral initiation at the next day, drainage penrose type was set draining just a little serohematic liquid, diet was progressed and patient was discharged on the third postoperative day without complications. conclusion: situs inversus is the mirror image of situs solitus, which presents subdivision in situs inversus totalis, which is the most usual form, characterized by the mirror location of the intraabdominal and thoracic organs including the heart; in the case presented, the patient was referred with situs inversus and barrett's esophagus, performing laparoscopic fundoplication. the gold standard of surgical management is laparoscopic in benign esophageal pathology. gastroesophageal reflux disease (gerd) is a condition that reduces the quality of life and can causedisorders associated with acid reflux, such as bronchial asthma, barrett's esophagus and esophagealadenocarcinoma. gerd is often caused by existing of hiatal hernia. in rare instances gerd is associatedwith type iv hiatal hernias in which the part of stomach and other organs migrate into mediastinum.nowadays this condition can cause problems for some surgeons.patient was a -year-old man. he was diagnosed with hiatal hernia in . the condition had beenhaving asymptomatic course until . patient takes omeprazole mg for years. he startedexperiencing chest pains when inhaled and dyspnoea in june . co-morbidities were: arterialhypertension, chronic obstructive pulmonary disease (copd) and obesity (body mass index was . kg/m ). the posterior mediastinum contained the part of stomach, large bowel and small bowelaccording to chest roentgenography. sizes of esophageal hiatus were mm. in our clinical centerwas performed laparoscopic removal of hernia, cruroraphy, mesh repair of the esophageal hiatus andnissen fundoplication in july. during the surgery stomach, the part of small intestine, greatomentum and transverse colon were relocated into abdominal cavity. after cruroraphy, repair of theesophageal hiatus with prolene mesh was performed. the patient was in intensive care during h.total enteral feeding was initiated on second day. patients had been discharged within days aftersurgery. patient was re-examined by a surgeon in september , there were no signs of a reccurence.this case report shows an efficiency and feasibility of the laparoscopic approach to the treatment gerdassotiated with a large defect in the phrenoesophageal membrane, allowing other organs, such as colon,great omentum and small intestine to enter the hernia sac. aims: the authors present a video with their standardized laparoscopic hiatal hernia repair and anti-reflux nissen procedure but using mm instruments and mm camera approach. methods: a years old female patient with a bmi presents a symptomatic gastro esophageal reflux disease (gerd) for years. manometry and ph-metry showed a lack of esophageal motor disorders and a severe acid pattern with a . demeester score. panendoscopy study showed a cm hiatal hernia and a los angeles-grade esophagitis. she decided not to go with ppi treatment anymore. a laparoscopic hiatal hernia repair and standardized nissen procedure is performed using mm instruments and a mm camera. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with a rate in a eva acute pain visual scale. in a year follow-up, there has no been an anatomical or clinical recurrence. no chronic dysphagia, anatomical recurrence or abdominal wall complications have been reported with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, hiatal hernia and anti-reflux mini invasive standardized repair using mm instruments, could be a safe and feasible option. more studies are needed in order to standardized this approach. background and aims: parastomal herniation a very frequent complication in stoma patients. in isolated parastomal hernias (type i or iii)* a laparoscopic sugarbaker repair with intraperitoneal mesh is our preferred technique. if a concomitant incisional hernia is present (type ii or iii)* we currently opt for a retromuscular mesh repair as described by pauli. we adopted a minimal invasive approach using the robotic platform. methods: we performed a robot-assisted laparoscopic pauli repair for a wide incisional henria needing component separation and a small parastomal hernia (type ii)*. a non-slit retromuscular mesh was placed after a bilateral tar (transversus abdominus release) and lateralization of the colon. results: the operation was performed robot-assisted laparoscopically with x trocars without the need to convert to an open procedure. the procedure lasted min. the patient was discharged from the hospital on post-operative day three. one month after the repair our patient presented with a parastomal skin infection for which she received surgical cleaning and wound dressing. ct scan three months postoperative shows good positioning of the mesh with a reinforced abdominal wall. conclusions: the modified sugarbaker repair in parastomal herniation is feasible following a pauli approach (retromuscular mesh positioning) completely laparoscopic, albeit robotically assisted. short-term follow up is promising. long-term postoperative follow-up in these patients is needed. methods: case presentation results: a -year-old caucasian female patient was admitted on emergency due to a progressive alteration of her physical condition and weigh loss, caused by intermitent and intense epigastric pain and vomisments. symptomes occurred several years prior to admittance, but used to be mild and rare. during the last months, the described episodes became more intense, lasted longer and occurred more frequently. percutaneous ultrasound raised the suspicion, while thoraco-abdominal ct revealed an enormous intrathoracic morgagni hernia and gastric volvulus inside the hernial sack. after a careful preoperative preparation (restoring of the nutritional and hydric inballances, amelioration of respiratory parameters), laproscopy confirmed the diagnosis; we gently reintegrated the herniated organs from the thoracic hernia into the abdominal cavity (small bowel, large omentum, transverse-doloco-colon, and thisted stomach); a laparoscopic exploration of the hernial cavity was followed by a thorough hemostasis. do to patient's frailty, we decided to leave the hernial sack in situ. surgical direct repair of the defect technique was done by using extracorporeally tied separate sutures through separate skin incisions. the postoperative outcome was completelly uneventful; patient was discharged on postoperative day . barium contrast at mounths followup showed a slight esophageal diskynesia, but normal gastroduodenal passage; due to aerocolia, the normal position of the transverse colon could be confirmed aswell; no signs of reccurrence where detected. conclusions: although very rare, a morgagni hernia should be suspected and included in the differential diagnosis of patinets with dispeptic syndrome and epigastric/thoracic symptomes. thoraco-abdominal ctscanning is the imagistic technique of choice. laparoscopic approach became the gold standard, being far mora addvantageous as compared to laparotomy or thoracoscopy. direct suture with extracorporeally separate sutures through separate skin incisions was chosen for being less time consuming; for the same resons, the hernial sack was left in situ, with no consequences so far. aims: the giant fibrovascular polyp is one of the rarest benign lesions of the oesophagus. the most common locations of origin are the upper oesophagus or crico-pharyngeal region. the lesion is more common in elderly population, particularly men. symptoms include dysphagia, odynophagia. management options include surgical resection or endoscopic removal with endoloop. we aim to demonstrate the optimal management of these rare lesions using an endoscopic approach. method: we demonstrated the management of -year old patient with a giant oesophageal polyp, excised by minimally invasive endoscopic resection. the patient was placed in supine position and tracheal intubation was performed under general anaesthetic before an endoscopic approach was taken. the oesophago-duodenoscopy visualised a cresenteric shaped lumen due to an intraluminal mass occupying two thirds of the oesophageal diameter. the procedure was a multidisciplinary approach with the upper gi surgical and gastroenterology consultants. the polyp stalk was located in the oesophagus at the level of t and an endoloop was manipulated to surround the polyp. the polyp was then separated from the stalk by cauterisation and resected from the patient. the stalk was then injected with adrenaline to prevent haemorrhage. results: the excised specimen was a cm polyp with stalk originating from the t -t level. histology confirmed diagnostic suspicions of a benign pedunculated fibrovascular polyp. the polyp was covered by non-keratinising squamous epithelium with a discoloured tip demonstrating ulceration. there was no evidence of dysplasia or neoplastic process. the video shows a case of laterally spreading tumour of the rectum with preoperative benign histology, paris classification -is g (granular type), ut n eus stage, kudo type iv, nice type . the neoplasm measured x cm, and extended from to cm from the anal verge, mainly located on the posterior wall. according to our local policy the indication was a transanal full-thickness excision. this was performed with the medrobotics flexÒ robotic system, used here for the first time outside the united states. the system technology utilizes an articulated multi-linked scope that can be steered along nonlinear, circuitous paths in a way that is not possible with traditional, straight scopes. the maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. this enables surgeons to perform minimally-invasive procedures in places that were previously difficult, or impossible, to reach. with the flexÒ robotic system, surgeons can operate through a single access site and direct the scope to the surgical target. once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass flexible surgical instruments. the system includes on-board d hd visualization. the flexÒ robotic system contains two working channels to accept a number of different surgical and interventional instruments including monopolar and bipolar electrodes, scissors and graspers for tissue manipulation. the video shows the introduction of the dedicated rectoscope, the connection of the flexible robot, and the way to operate the device performing a full-thickness excision, including suturing of the rectal defect by means of two running sutures by a v-lock / thread. while illustrating the technique the authors will comment pros and cons of the use of the device. surg endosc ( ) the video shows the use of a barbed suture of novel concept. this first prototype thread developed together with assut europe (roma, italy) is characterised by a bidirectional / barbed suture, of cm length overall, with two needles mm in diameter, and circumference. in order to fix the thread to the tissue, on the exact midline of the thread a small ( mm) ball of the same material of the thread is fused with heat. this button as the entire thread is made of polydioxanone, a monofilament material for long-term absorption, self-retaining. this small advancement offera a consistent advancement in endorectal surgery helping in making transverse wound closures as easy as never before. the first stitch is placed on the transverse midline of the rectal wall defect, this way approximating proximal and distal edges. the button keeps the thread under tension allowing the completion of a running suture towards one of the two lateral ends of the would. when the first end is reached the needle is cut and the other needle is grabbed in order to perform the other half of the running suture keeping the right tension on the thread, with no risk of lumen stenosis. the two lateral ends of the suture are self-blocked passing them through the last stitch. no need for clips, knotting or buttonholes to pass through. while illustrating the technique the authors will comment pros and cons of the use of the device. background: the usefulness of robotic surgery has been largely reported; however, there are not enough reports on gist's treatment. the aim of this study is to report a single center experience on gastric gist's robotic resection. gastrointestinal stromal tumor (gists) are the most common mesenchymal tumors (overall incidence - % of all gastrointestinal malignant tumor). they are most frequently located into the stomach. complete surgical resection still remains crucial for patients with gists. in cases of difficult localization of tumor (e.g. posterior wall, his angle) and bigger tumor (more than cm in diameter), there still exist apparent difficulty and limitation to conduct laparoscopic resection. robotic assistance provides wide movements of its arms and was recognized particularly useful in case of difficult tumor localization, especially for those positioned at the posterior side of the stomach wall or around the lesser curvature. methods: six consecutive patients were analyzed focusing on safety (conversion/complications rate; hospital stay), oncological (margin resection, recurrence rate) and feasibility (operative time, technical tip and tricks) profile of robotic approach. results: the mean operative time was ± min, the mean hospital stay ± days. conversion rate was nihil. no intra and post-operative (mean follow-up months) complications were registered. in all cases, the resections were classified as r . conclusions: our experience supports the usefulness of robotic system in case of gist located at anatomically difficult gastric portion, such as lesser curvature or fundus close to gej, confirming the excellent oncological outcomes ( % r ) and the encouraging safety profile ( %). regarding the operative time our data are similar or better as compared to those reported by the previous literatures and didn't differ by the most recent published data for laparoscopic gastric resection. the anatomical hand-sewn reconstruction performed by precise hand-sewn suture instead of the usage of mechanical staplers represents a real great advantages of robotic resection. in our series, no patients suffered from stenosis or leakage after operation. background: we describe the use of a different suture from those historically used in the elaboration of a widely spread surgical technique such as the nissen fundoplication, for the treatment of pathological gastroesophageal reflux or symptomatic hiatal hernias. in our unit we have implemented the use of / irreabsorbable barbed suture to close the diaphragmatic pillars and the °fundoplication with the same continues suture. aim: the objetive of the use of the irreabsorbable barbed suture in the nissen fundoplication is to shorten the surgical times, which would achieve benefits for the patient and the institution, increasing the number of ambulant patients and the number of patients to be operated the same surgical session. objective: the goal of the present study was to demonstrate that intraoperative icg fluorescent imaging is a safe technique that can be used in laparoscopy establishing the exact location of the lymphocele and reducing intraoperative risks. method: fifty milligrams of icg dissolved in ml of saline solution was injected via percutaneous drainage placed into the lymphocele to decompress transplanted kidneys weeks before a laparoscopic lymphocele marsupialization procedure. results: during the first exploratory laparoscopy, in the flank and right iliac fossa, near the renal grafts, fluorescence was identified in raised areas that were the internal side of the lymphocele lobes. the lymphocele wall was dissected and ml of serous fluid was aspirated after puncturing. a cm breach was then made in the cyst wall using the ultracision harmonic scalpel (ethicon us). afterwards, a pedicle of the omentum in the lymphocele core was interfered with and fixed by stitches. conclusions: laparoscopic surgery seems to be the preferred surgical option for the treatment of primary symptomatic lymphocele after kidney transplantation. intraoperative icg fluorescent imaging is a safe technique to establish the exact location of the lymphocele and reduces the risk of damaging urinary structures during surgery. conclusions: this method proved safe and risk-free, easily reproducible and without the need for a different toolkit than the one of a modern operating theatre. the preliminary analysis shows a strong correlation between the perfusional data so far obtained and the early outcome of the graft. thus opening the way to further analysis aimed to a future better management of post-operative immunosuppressant and support therapy. these results are quite encouraging, even if our study is at an initial stage. conclusions: results show a persistent dread across specialities regarding ai. rather than be seen as threat, ai should be embraced by clinicians as it will ease the ever-increasing daily workload faced. this will enable clinicians to focus their skills on patient centred activities, interventional procedures and development. despite current regulatory hurdles, ai implementation in medicine is unavoidable. this coming revolution presents a unique opportunity for endoscopist and radiologist to refocus their expertise in novel areas. project description: from february to july a three-armed proof of concept study was conducted at three hospitals, in three groups of patients; recurrent ventral hernia, aortic aneurysm, and healthy controls. patients were measured once at the outpatient clinic using an electronic nose based on three metal oxide sensors. measurement data were compressed to low-dimensional vectors using a tucker like algorithm, and used to train an artificial neural network (ann) to provide a classification between patients (? ) and healthy controls (- ). preliminary resultsa total of patients (hernia n = , aneurysm n = ) and controls were included in the study. based on receiver operating curve (roc) analysis, the ann could differentiate between recurrent hernia patients and controls with the following details: area under the curve (auc) . , sensitivity . , specificity . . aortic aneurysm patients and healthy controls could be differentiated with an auc of . , sensitivity of . , and specificity of . . the aeonoseÒ enose can reliably distinguish patients with weak collagen (recurrent hernia and aortic aneurysm patients) from healthy controls. validation of these results in a prospective cohort study is required before clinical application of the device. background: laparoscopic and endoscopic cooperative surgery (lecs) has been performed gastric submucosal tumor (smt) or duodenal tumor. although minimally invasive surgery using thoracoscopy has been the usual approach for esophageal smt, the treatment method combined thoracoscopy and endoscopy has not been established. in addition, submucosal endoscopic tumor resection (set) for esophageal smt was reported using the technique of submucosal tunnel. aim and project description: we planned to resect large esophageal smt located in the upper or middle thoracic esophagus by a combined endoscopic and thoracoscopic approach. because set is only recommended for tumors up to mm in size owing to the limited submucosal space available and the left thoracic approach is restricted by the aortic arch and the trachea. preliminary results (case presentation): a -year-old woman was diagnosed with a benign schwannoma of length mm originated from either the submucosal or the muscular layer of the middle thoracic esophagus by endoscopic ultrasonography, enhanced computed tomography, and ultrasound-guided fine-needle aspiration biopsy. since the tumor had increased in the years and she had a symptom of dysphagia, we planned to resect it by a combined endoscopic and thoracoscopic approach. on endoscopy in the supine position, a submucosal tunnel was created mm proximal to the cranial edge of the tumor, and its only oral end was dissected from the mucosal and muscular layers. this was followed by the resection of the entire tumor by left-sided thoracoscopic procedure in the prone position. endoscopic mucosal closure was achieved by using clips. no postoperative complications were observed. large benign esophageal tumors can be safely excised with minimally invasive surgery by using a combination of endoscopy and thoracoscopy. background: haemorrhage remains a major cause of morbidity and death in all surgical specialties. in laparoscopic surgery. relatively small amounts of blood can obscure the view of the operative field and increase the risk of injury to surrounding structures. excessive bleeding often leads to longer hospital stays, increased healthcare service utilisation, and higher healthcare costs, among other negative consequences. aim: the aim of this study was to analyse the feasibility of purastatÒ, a new synthetic haemostatic device, made of self-assembling peptides in laparoscopic colorectal surgery. project description: this was a prospective observational non-randomised study. consecutive patients undergoing laparoscopic colorectal surgery were enrolled. informed consent was obtained from all patients inclusion criteria was the need employ a secondary method of haemostasis when traditional methods such as conventional pressure or utilization of energy devices to control the bleeding were either insufficient or not recommended/ appropriate due to proximity to ureter, pelvic/sacral veins and other important structure. preliminary results: twenty patients were enrolled ( males ( %) and ( %) females). mean age was years (± , years). all patients were undergoing elective laparoscopic colorectal cancer surgery ( right hemicolectomy, sigmoid colectomy, anterior resection). we utilised mls of purastatÒ in all patients. the mean area of application was , cm (± . cm ) with the amount of purastatÒ needed per centimetre being . mls. the mean time to apply the product was secs (± s), whereas the mean time to achieve haemostasis was , secs (± . s). there were no post operative complications in this cohort of patients. mean operative time overall was min (± . min). none of the patients experienced delayed post-operative bleeding and the mean hospital stay was days (± . ). in conclusion, according to the purpose of this preliminary study, we have demonstrated that purastatÒ can be easily used in laparoscopic surgery and it is a safe, effective haemostatic agent. this is a feasibility study and additional controlled studies would be useful in the future. during last three years the laparoscopic method of surgery in the presence of common bile duct stones was carried out. after performance of intraoperative cholangiography and visualization of stones in the common bile duct laparoscopic, choledochotomy and bile duct stones extraction was undertaken in patients, using flexible choledochoscopy control. in all patients with gallbladder stones was then performed laparoscopic cholecystectomy. results: laparoendoscopic intervention on common bile duct was successfully performed in patients ( . %) and the operation was completed by common bile duct drainage by kehr. in patients due to technical difficulties conversion to open surgery was carried out. postoperative morbidity in the form of bile leakage were diagnosed in patients ( . %). in three cases they stopped spontaneously in - days after the operation. patients were operated on repeatedly and additional suturing on choledocholithiasis was carried out. postoperative mortality was . %. the death of the patient of years was caused by acute cardiovascular failure. institute for image guided surgery, ihu-strasbourg, strasbourg, france; hepato-digestif, nouvel hôpital civil, strasbourg, france; image guided surgery, nouvel hôpital civil, strasbourg, france; gastroenterology, chu-besancon, besancon, france; gastroenterology, chu-lyon, lyon, france; gastroenterology, clinic de trocadero, paris, france background: eus is difficult to learn and has a steep learning curve. therapeutic eus (teus) is even more so. simulators, ex-vivo models and phantoms are the most common current teaching modalities but are felt by many to be unsatisfactory for high-level training. aim: we designed a training curriculum for teus that uses high-fidelity animal models and present a validation study performed by teus experts. project description: different simulated pathologies were created in each of acute pigs. teus experts performed therapeutic procedures in two or more animals over two days. each intervention was evaluated simultaneously using a structured survey by an non-expert observer. data included demographics and procedure details as well as likert-scale evaluation of the quality, realism and education utility of the simulations. global evaluation of the experience was captured from the experts as written comments. all data was consurrently registered and subsequently analysed by two blinded surgical educators. methodology: three types of models were created using surgical access: -tumors (injection of types of hydrogel), -retro-gastric collections ( - cm long intestinal loops filled with oatmeal, oil-water and gel), -obstructions (bile duct and ureteral ligations days prior to experience). gastric, pancreatic and liver tumor models were used for fna and fnb practice. retrogastric fluid collections and choledochal/ureteral obstructions were used for cyst gastrostomy, hepaticogastrostomy, gallbladder drainage and kidney drainage. results: experts age: - , median intervention time min , total of interventions evaluated, overall quality of experience: ( %) ranked - (excellent), ( %) from - (good), ( %) from - (poor), / procedures were successfully completed. models were rated good to excellent quality ( - ) in ( %), poor quality in ( %). for % ( ) of the interventions the model was considered not good enough to be repeated (solid retrogastric tumor and peripheral hepatic lesion). conclusion: high-fidelity live animal models with simulated pathologies are considered to be excellent training tools by experts and may provide a better learning experience for teus. surg endosc ( ) in our short videos, we present scenarios in which this technology helped: to distinguish a significantly dilated cystic duct from the cbd, to identify an anterior cystic artery in the contest of acute inflammation, to identify a luksha duct, to exclude a leak after endoloops positioning on cystic duct. intra-operative augmented visualisation of biliary anatomy with indocyanine green cholangiography is an essential technology tool with the potential to extend the hour window of safety for emergency cholecystectomies, with significant logistics benefits. introduction: endoscopic resection of subcardial polyps has its limitations; especially when it is necessary to dry out the entire gastric wall. uniportal intragastric surgery is a good alternative for the exeresis of subcardial premalignant lesions with gastric preservation. patient and method: we present a video with two cases. technique: we perform a laparoscopy to explore the entire abdominal cavity, then we open a . cm hole in the great curvature; a cm incision is made in left hypochondrium and the uniportal device is placed inside de stomach. we inject serum in the submucosa with a endoscopic needle. when submucosa is completely separated from muscular lay; a submucosal exeresis can be made; but when there is not a complete separation after injection, then we perform a entire wall resection with a cm circular margin. if a complete wall resection is made, then we close the defect with a barbed suture. results: case : years old male with a , cm subcardial polyp, preoperative biopsy was informed as severe dysplasia. in the laparoscopy we saw an unknown lesion in the great curvature that looked like a gist. we placed the uniportal device intragastric and proceed to the submucosal serum injection. as the submucosal lay was completely separated from muscular, then we performed a submucosal exeresis. we close the gastrotomy and made the resection of the great curvature lesion with endostapler. the pathological analysis confirmed the severe dysplasia in subcardial lesion and gist in the great curvature lesion. patient was discharged with no complications after days. case : years old male with a cm subcardial polyp. preoperative ecoendoscopy suggested a muscular layer infiltration but only severe dysplasia was found in the previous biospsy. laparoscopy did not found more lesions, and uniportal intragastric device was placed. a complete wall resection was made, and the defect was closed with manual barbed suture. pathologyst confirmed severe dysplasia and unaffected margin. patient was discharged with no complications after days. conclusion: uniportal intragastric surgery is feasible and safe and may be useful for subcardial premalignant lesions when endoscopic resection is very difficult or not feasible. introduction: the role of icg in bariatric surgery is still unclear. knowing the lack of perfusion in the gastric pouch could be of great interest in revisional surgeries; but the question remains: is the current icg technology reliable enough to make intraoperative decisions in bariatric surgery? methods: we have carried out a check of tissue perfusion with icg fluorescence in several cases of primary and revisional bariatric surgery. a solution of , mg/kg was injected intravenously and icg fluorescence was performed. we looked for the correct staining of the entire gastric pouch and the intestinal loop trying to rule out areas of tissue ischemia. results: the cases in which the test was performed showed a minimal delay of - s between the intestinal loop stain and the pouch. a correct staining was observed in all but one case shown in the video. is the case of a years-old male patient who was operated years earlier in another center; at that time he underwent a sleeve gastrectomy. we evaluated the patient for persistent gastroesofhageal reflux of years of evolution with esophagitis. we offered revisional surgery to perform gastric bypass and hiatal closure. fundus was dilated so a funduplasty was performed instead of using endostappler in the vertical side of the pouch. manual anastomosis gastric bypass was performed. when the icg test was performed, a corner of the pouch does not stain green (an area of , cm) . so the decision was to resect that part and redo the anastomosis or wait and see. it was decided not to resect and the patient was discharged two days later with no complications and good outcome with a months follow up. conclusion: icg fluorescence may be useful in bariatric surgery in the future but more evidence is needed of its usefulness in making intraoperative decisions. background: lymph node status is one of the key prognostic factors in patients with colorectal cancer, and remains the most important selection criteria for adjuvant chemotherapy. it is believed that at least % of node negative patients will suffer disease recurrence within the first years after surgery. this may be due to understaging of lymph node status. sentinel lymph node mapping is widely used for staging of breast cancer and melanoma, with injection of colloid tc and isosulfan blue (ib). however, indocyanine green (icg) fluorescence guidance is a new technical approach to this issue, with promising results for detection of aberrant lymphatic drainage outside of the planned resection. the icg lymphography has the advantage of offering a good visualization of the lymphatic channels but there are problems in order to identify the lymphatic nodes. aim: the objective of the experimental study is to investigate the possibility to detect the sentinel lymph nodes after the injection of different solutions with indocyanine green in the subserosal colonic layer in the pig. project description: twelve female large white pigs were operated with laparosocpic approach and spies optic filter (karl storz, germany). indocyanine green was injected in the subserosa of the colonic wall ( ml at points). lymphatic flow was observed at - - - - and min, searching for the migration of the icg by the lymphatic channels and its introduction in the sentinel nodes. preliminary results. the identification of the sentinel nodes is very difficult with the solution of icg-sterile water. with this technique we can see the lympjatic channels but not the lymphatic nodes. the adition of % human albumin as a transporter of the icg is very helpful for the correct identifiaction of the lymphatic channels at - - min and the correct visualization of the lymphatic nodes at min after the bowel injection. addition of other transporters like dextran solutions may be helpful too but the time to the correct visualization is longer. there was significant difference among the three groups as regards postoperative les and postoperative ph metery.the incidence of persistent dysphagia was significantly higher in the group i. postoperative gerd symptoms were significantly higher in group iii ( . %. p \ . ). recurrent achalasia was significantly higher in group i ( patients . %, patients in group ii ( . %) and nil in group iii (p \ . ). in conclusion: longer myotomy on the gastric side ([ . cm) ensures complete division of the les with better outcomes in term of resolution of dysphagia but may be associated with higher postoperative gerd. therefore, a myotomy length of . to . cm on the gastric side provides a balance between relieve of dysphagia and development of postoperative gerd. c/t scan of his abdomen revealed a large groin hernia with signs of small bowel obstruction and collapsed distal bowel. emergency theatre was organised for this patient with anaesthetic assessment prior to his surgery. initial plan of local exploration with possibility of small resection was changed once he was under full anaesthetic with muscle relaxation. his abdominal girth provided an opportunity to utilise laparoscopic intervention as an initial approach. laparoscopy with degree lens revealed moderately distended loops of small bowel and a large omental mass along with a loop of small bowel incarcerated in right direct inguinal hernia site. background: robotically assisted surgery is a rapidly developing modality of minimally invasive surgery with proven advantages in the management of cancer. despite its increasing prevalence, there is still an ongoing debate regarding its future role in colorectal surgery. while the prospective randomised multi-centre studies provide research evidence for its potential efficacy, an assessment of its effectiveness and realistic outcomes in everyday clinical practice can add an important perspective to this discussion. the international robotic colorectal registry will allow to compile and pool the international robotic colorectal experience. aims: the aim of the international robotic colorectal registry is to monitor the safety and outcomes, as well as the quality of specimen of robotically assisted colorectal surgery for malignant and benign diseases of the colon and rectum. the primary endpoint is a composite oncological failure. the secondary endpoints include anastomotic leak, resection margin involvement, conversion rate, operative time, post-operative -day morbidity and mortality, long term oncological outcomes, quality of life, functional outcomes and cost-effectiveness. project description: the international robotic colorectal registry is a multicentre web-based, online secure database. the registry has been awarded an ethical approval by a relevant national committee. all surgeons performing robotic or robotically-assisted surgery are invited to participate. the data collected includes patient demographics, cancer characteristics, operative details, histology of the specimen, wound healing, post-operative therapy, readmission, quality of life and functional (bowel, urinary and sexual) outcomes. all the sensitive patient information is encrypted before its introduction into the database. preliminary results: so far, twenty robotic colorectal centres have joined the international robotic colorectal registry. the preliminary results will be published once patients have been enrolled. univariate and multivariate analyses will be performed to identify possible risk factors for poor outcome.the possibility to record open, laparoscopic or other minimally invasive colorectal procedures will facilitate comparison of the outcomes of the robotically assisted surgery and other modalities. the registry will also allow each surgeon enrolled to monitor their skill progression and outcomes over the time. results will be published in surgical literature and presented internationally. background: gastric outlet obstruction (goo) due to benign strictures is an uncommon surgical entity today. this paucity relates to the decrease in its aetiological factors in the modern era as well as to advances in both prevention and medical as well as endoscopic treatments of such condition. the most common of causes relating to peptic ulcer disease, has been subdued for decades with quality acid control medications. on the other hand advances in gastroscopic dilatations skimmed even more the frequency of these cases from arriving to surgical intervention. aim: this presentation gives an update on the standing of this pathology and its surgical management today. it will also shed a light on our early experience in this condition at the royal hospital of muscat in oman. project description: a case series of all patients with goo, who were surgically managed between and results: there were a total of patients, males and females. the cause of obstruction was peptic ulcer disease in , corrosive injury in , iatrogenic perforation in and idiopathic hypertrophic stenosis in . emergency presentation was seen in . management included jaboulay pylorpolasty in , resection in (distal gastrectomy in , total gastrectomy in ) or a bypass (gastrojejunostomy) in . in of the above, the procedure was done by laparoscopy. post operatively, temporary gastric paresis delayed recovery in , however all symptoms resolved in . there were no recurrences at minimum of years of follow up. in spite of advances in medications and gastroscopy interventions, we still seem to identify this condition within our population. although infrequent, they demand awareness from surgeons since they could be managed successfully, especially laparoscopically, with minimal morbidities and early recovery. the introduction of advanced laparoscopy to the unit's setup in recent years, made such option feasible with satisfactory and durable outcomes. background: gists of the upper gi are found mainly in the stomach ( - % of cases) and small intestine ( %). duodenal gists however, comprise a smaller subset with a frequency of to %. the optimal surgical procedure for duodenal gist is still evolving. since wide margins and extensive lymphadenectomy are not required, restrain from more radical resections in this area would be a valid option. aim: this is a video case report of a patient with a gist involving the third part of the duodenum treated by laparoscopic lateral duodenectomy and end-side roux-en-y duodenojejunostomy case report: years lady presented with recurrent mid abdominal postprandial pain with anorexia, nausea and occasional vomiting an ultrasound showed well defined hypoechoic mass of . . cm at the right para-aortic region . ct scan defined the mass as retroperitoneal, intimately related to the pancreas uncinate process and the third part of duodenum with no clear cleavage line between them. an mri endorsed the diagnosis of gist of the duodenum. she was operated upon through a laparoscopic lateral duodenectomy including the gist at the third part of the duodenum. a frozen section confirmed the clear margins . reconstruction was done by a roux-en-y duodenojejunostomy with the alimentary limb taken cm from the dj flexure. she had an uneventful post operative recovery and was discharged well. the histology confirmed a low grade gist tumour hence no further treatment was needed. at follow up six months later, she was doing well and gaining weight. conclusion: complex anatomy of the pancreatico-duodenal area makes conserving the duodenum for tumours rather than a major resection a challenging option. in our case however, with the disease in the third part being of a moderate size, a lateral duodenal wall resection including the mass was possible rather than a segmental resection. this procedure could be an ideal choice for benign, moderate sized tumours in the third and fourth part of the duodenum. background: during laparoscopic colectomy, laparoscopic lymph node dissection and extracorporeal intestinal anastomosis is commonly performed. an umbilical incision of - cm and wide-range mobilization of the intestinal tract is required for extracorporeal anastomosis. previously, we introduced intracorporeal overlap anastomosis in june as a minimally invasive treatment. here, we report its short-term outcomes. aim: we retrospectively compared the surgical outcomes of cases of extracorporeal anastomosis and cases of intracorporeal anastomosis, all of which were performed between june to may . procedures: after lymph node dissection and sufficient mobilization of the intestinal tract, the proximal and distal intestines were resected perpendicularly to the intestinal tract with a -mm linear stapler. the anastomosis was performed after the specimen was extracted from an umbilical incision. the opposite sides of the mesenteric margin cm from the staple line of the one intestinal tract, and cm from the staple line of the other intestinal tract, were marked, and then the respective intestinal tract was positioned to join the opposite mesenteric sides together. an insertion hole was made in the intestinal tract at the marked site. side-to-side anastomosis with a linear stapler was performed, and then the insertion hole was closed with a linear stapler after several temporary sutures. preliminary results: in the extracorporeal anastomosis group, the mean operation time, blood loss, and post-operative days were min, ml, and . days, respectively. furthermore, there were three intraoperative cases of bleeding ( . %), and two postoperative cases of lymphorrhea ( . %) that occurred. however, in the intracorporeal overlap anastomosis group, the mean operation time, blood loss, and post-operative days were min, ml, and . days, respectively. additionally, there were no cases of intraoperative complications, and only one postoperative case of lymphorrhea ( . %). conclusion: intracorporeal overlap anastomosis in laparoscopic colectomy is safe and feasible, and can be used as a minimally invasive treatment. nowadays d-printing it's not a new technology any more but with an exponential developing. there are beliefs that in % of everything that will be produced will be d-printed. in medical field this technology knows the same exponential developing. first used in orthopedics and maxilo-facial surgery now d-printind is used in many other fields for different reasons, like preoperative training models, surgical special instruments, in medical education, etc.. liver surgery is in continuous developing and this is the reason why we need experimental liver model for training and testing. a best liver experimental model should heave liver consistency, to be flexible, to heave the same ultrasound feedback, to be cheap and easy to be reproduced. this is why we developed a liver experimental model made of gelatin by a simple recipe, using a dprinted mold, created after a human liver ct-scan. first was made the segmentation of the liver. after segmentation we create the d virtual liver model and the negative image of the liver, which was used for creation of the pieces of the liver mold, with connections between them and a hole on the top to pour the gelatin solution. ( ) ethical concerns on learning and training with real patients and substitutives such as animals, and ( ) reconciling time devoted to learning with clinical practice, considering the european work time directives. simulation in medical education is and has been the preferred route to address both pedagogical needs. virtual simulation has proven to be a valid tool for training; however, current systems restrict usage to tasks and modules offered, without possibility of personalization. we present the minimally invasive surgery simulator scenario editor (mis-sim) an environment where users can create, edit and run virtual reality tasks designed for medical training. the environment features an editor allowing users to develop learning tasks, defining its learning objectives and task goals in an easy way. a first proof of concept has been implemented for surgical training and training activities (demostrators and short courses) have been carried out in three european sites: spain, the netherlands and hungary. during training activities, different exercises have been created and uploaded to the contents' database. trained technical skills include handeye and bimanual coordination, instrument handling and pulling. preliminary results with users have shown mis-sim training potential, although some functionalities should be made easier. personalization has been highlighted as the key added value of mis-sim with respect to the current competitions in the market: the ability for target users to use virtual reality based learning tools while remaining in complete control of the learning process. mis-sim aspires to break the barrier between vr and medical education by empowering users to create their own tasks. with mis-sim teachers/course creators and learners (healthcare professionals & future healthcare professionals) will benefit from an innovative tool to ( ) create personalised medical learning contents tailored to preferred learning styles, allowing the creation of individualize learning paths; ( ) improve the efficiency of training by focusing on the training needs of the learners and ( ) share and sell vr-based didactic contents. c. tiu , p. sánchez-gonzález , m. chmarra , d. gutiérrez , c. guzmán-garcía , l. sánchez-peralta , g. wéber , f. sánchez-margallo , b. pagador , j. dankelman aims: currently surgical training is largely based on the improvement of technology enhanced learning solutions. the progress of engineering and the diversification of training facilities outside the operating theater results in an even greater contribution of technology in the future. the main reasons to encourage these changes are increased efficiency of simulators and directly increased patient's safety. the goal assumed by the easier project is to develop multi-skill, online platforms for minimally invasive surgical (mis) procedures-based on common pedagogical principles with reference value in a multinational space. the platform will allow the connection of external assets (such as simulators) to centralize all training data from residents. this work presents the milestones of the project during its first year of life. methods: the consortium's activity started with a knowledge elicitation process organizing brainstorms and workshops including experts in mis and interventional techniques, from spain, romania and hungary. this experience led to the formulation of a questionnaire that was implemented online and sent via email to surgeons and residents from the participating countries. results: accumulated experience was used to define the pedagogical needs of the platform. the pedagogical needs form the starting point for defining the technical requirements and specifications. based on them, the design of the platform has been achieved, including its architecture and communication protocol between external assets design, facilitated by the use of state of art educational standards. discussions and conclusions: next steps include the implementation of the easier platform, as well as the definition of cases studies selected by the clinical partners in spain, romania and hungary to solve applications of the platform dedicated to cholecystectomy, lumbar puncture and arthroscopy. a pedagogical model, built by the experience of the consortium, is being used to guide instructional design of the course. finally, results will be validated in a multi-center validation study.the easier project will create a training platform with reference value for european surgery. the structure of the consortium, based on the confluence between collectives with clinical, technological and pedagogical experience, will generate a complex learning tool in surgery embodying technology-based training systems with clinical experience. background: the treatment of groin hernia is an important part of our daily surgical activity. aim: we proposed to evaluate outcomes of the laparoscopic trans abdominal pre peritoneal treatment (tapp) of the groin hernia. project description : one hundred and fifty patients who underwent a tapp for a groin hernia were included in a retrospective study between january and november . results: the gender ratio was . the average age was , years. twenty percent of patients had a history of abdominal surgery. the operative indication was a unilateral hernia in % of cases, associated with an umbilical hernia in % of cases, a recurrent groin hernia in % of cases and a bilateral inguinal hernia in % of cases. the conversion rate was . %. the hernias were classified according to the ehs classification in l type in % of cases, l in % of cases, l in % of cases, m %, l r in % of cases and f r in % of cases. a contralateral inguinal hernia was discovered in % of patients. a polypropylene mesh x cm was fixed by a stapling in % of cases and by a suture in % of the cases. the average operation time was min. the hospital stay average was , day. an antalgic treatment was prescribed in % of patients. the average time to return to normal physical activity was days. a postoperative seroma was noted in % of patients. no cases of mesh suppuration were noted. chronic pain was noted in two patients. no recurrence was noted with an average follow-up of months. conclusion: laparoscopic treatment of the groin hernia by tapp had good results concerning the postoperative pain, early recovery of physical activity and aesthetic damage. a larger setback is needed in our study to evaluate the recidivism rate. background: surgeon's training in ultrasound is viewed and understood differently in different parts of the world. if in united states the need for surgeons' training was accepted and taken over by the american college of surgeons, in europe the practice is completely different from one country to another, from one city to another, from one department to another within the same premises hospital. in some european countries, surgeons currently use ultrasound for diagnosis-especially in urgency, for follow-up, intraoperative, or as guidance for many surgical gestures. during this time, access to ultrasound of other surgical specialties-gynecology, urology, ophthalmology-is considered natural. material and method: once the decision to initiate an ultrasound course for surgeons was taken, a team of experts with technical or clinical expertise in ultrasound was organized. at the initiative of the technology commission, the courses were to be organized at the eaes congresses or others communication events endorsed by eaes. starting from the importance of each ultrasound application in surgery, it was decided to develop different modules to solve different training needs. at this time, the course offered at seville covers the capitols like abdominal ultrasound, guided punctures and trauma. a module dedicated to intraoperative ultrasound is under construction and will be available in november . the course has a skill abilities dominant character, two thirds of it being thought of as a hands-on application on stationary, classical ultrasounds with large screens and also on small size wireless actual devices. results: after his debut in frankfurt in , the course was resumed in london and in bucharest, twice. in this process, new modules and better teamwork skills have been developed. the participants' satisfaction quizzes, coming from all continents, were really encouraging. for the intraoperative ultrasound module the team approach is unique. students will have the opportunity to practice on live animals both laparoscopic and open abdominal procedures conclusions: the ultrasound for surgeons course initiated by eaeas was received with interest. the team will seek to inspect the real needs of training surgeons in this field and will complement and diversify the current platform surg endosc ( ) preliminary results: a total of procedures ( - , ± . ) were carried out in patients. the indications included acute ( leaks following esophageal resection, rupture of the strictured anastomosis following pneumatic dilatation) and chronic conditions (esophagopleurobronchial and gastropleurobronchial fistulas following the resection of esophageal diverticulum and sleeve gastrectomy). the initiation of the therapy was in , and day in case of acute conditions, and after years of the duration of the unsuccessful therapy in chronic cases. the successful closure was observed in patients, patient passed from mods and ards. in case, the initiation of evac was provided as a combined surgical and endoscopic intervention (ct proven distant intraabdominal abscesses). in chronic cases, was discontinued due to the haemophagocytic syndrome of unknown etiology, in the second one, success in reduction of the lesion and symptomatology with long term duration was observed following just applications of evac, despite minimal remanent leakage. the success is to our experience linked to early initiation of the therapy and presumes complex intensive care. the future investigation should specify the timing including preemptive use of evac and the combination of evac with other endoscopic, interventional and surgical therapeutic modalities. the aim of this feasible study is to investigate complete robotic esophagectomy with total mediastinal lymph node dissection (retm) only by the robotic arms. methods: the patient is placed hemi-prone position with one lung ventilation by blocking balloon tube under general anesthesia. the robotic trocar for st arm of da vinci xi surgical system is placed in the th intercostal space (ics) on the scapular line, the trocar of nd arm is placed in the th ics on the posterior axillary line, rd arm trocar is placed in the th ics on the middle axillary line, th robotic arm trocar is placed rd ics on the middle axillary line, and assistant trocar only for taking in and out of gauze is placed in the th ics on the middle axillary line. on the upper mediastinal lymph node dissection, robotic camera exchanges from nd to rd robotic arm to close and identify anatomical structures. esophagectomy with lymph node dissection starts from middle and lower mediastinum to upper mediastinum including along bilateral recurrent laryngeal nerves. all procedure perform under close-up view along the robotic enhanced anatomy to preserve organ functions. background: complete stenosis of the duodenal lumen secondary to a surgical suture in the treatment of a duodenal ulcer is a rare complication. the usual surgical resolution corresponds to a gastrojejunostomy associated or not, to an antrectomy with vagotomy, as a treatment for the peptic disease. the endoscopic resolution of this complication requires the use of complex maneuvers and specific therapeutic instruments. aim: to describe the endoscopic resolution of iatrogenic occlusion after raffia of perforated duodenal ulcer. description: a -year-old man was admitted to the emergency service for four days of pain and abdominal distension associated with abundant retention vomiting. performed ten days ago of a perforated duodenal ulcer, in which manual raffia was performed in two planes and drainage. abdomen and pelvis ct showed great distension and diffuse thickening of the gastric wall. the endoscopy showed abundant gastric retention content, pylorus, and bulb edema, and complete closure of the duodenal lumen, secondary to suture material; it was possible to count three suture threads. with a tipped papillotome and electrocautery, all the suture threads were sectioned, identifying a filiform opening through which a hydrophilic guide is inserted under fluoroscopy until it is sure to overcome the stenosis; we dilated the trajectory with a dilator of mm in diameter and cm in length. with a contrast medium, we observed an adequate trajectory and installed a partially covered duodenal metal stent (hanaro stent) of cm in length by mm in diameter in order to sustain the dilation. he was sent to home with inhibitors of the proton pump. after two weeks, the stent was removed, without complications. he was controlled two weeks after withdrawal, and, with pharmacotherapy, the patient was asymptomatic, making a normal life. conclusion: in this case, the result was positive. satisfactory results can prevent major surgery, which reduces the risk and possible complications. a new range of non-invasive medical tools with a remarkable improvement on the existing market. a manual laparoscopy, with the important novelty of having a bending head with a high degree of movement. this head can get multiple spatial positions to work in surgery and is very easy to use, with the same scissors thimble who controls it, so its performance and learning is very simple and intuitive. the tools can be easily reusable and they can be cleaned and sterilized by ordinary methods, very ergonomic and lightweight . the generic type models we initially have developed are focused in general surgery, but gradually we will develop new applications and different heads for specific medical conditions such as arthroscopy, laryngoscopy, otolaryngology, ophthalmology, orthopedics . its operation is simple and functional, simply moving the scissors thimbles, where they have a dual role, combining the head tilt and the action of opening and closing of this is achieved.the design of this tool allows us to work with some degrees of unparalleled freedom from the existing tools. our instruments replicate the movements of the robot with a simple handheld mechanical instrument, our philosophy is to position our instruments in between a long empty field between the surgeon and the robot. the tip of our instruments are providing the surgeons with angulations impossible to reach with the traditional instruments unless applying huge movements from the hands of the surgeon. we consider that this devices will have a very fast acceptance from the market as this robotic type movements can be managed by the surgeon through the traditional mm trocars, without the need to change to a new surgical technique, just with the traditional method and a very brief training. background: diverticula of the middle thoracic esophagus are infrequent, its etiology may be secondary to traction or pulsion mechanisms. when the etiology is a mechanism of pulsion, they are associated with esophageal motor disorders and its prevalence is estimated between . % and . % of the population . they are rarely symptomatic and the diagnostic is usually incidental. the most common symptoms are episodes of food impaction, chest pain or bronchoaspiration.diverticulectomy and esophageal myomectomy by minimally invasive approach is the treatment of choice in those with large size or associated symptoms. aim: to describe a clinical case of esophageal diverticulum solved by minimally invasive surgery approach. clinical case description: a -year-old patient with a history of epilepsy and hypothyroidism consulted for atypical chest pain and dysphagia to liquids and solids. a study with esophagogastroduodenoscopy was performed: cm from the dental arch, a large wide-mouth diverticulum was identified. we complete the study with an esophagram with barium: voluminous diverticulum in the right lateral face of the middle esophageal and a thoracic ct scan showing esophageal diverticulum located in the carina, from . x . cm to cm from the esophagogastric junction. due to the suspicion of associated motor disorder, high resolution manometry was performed showing a significant motor disorder with alteration of peristalsis and exit obstruction with incomplete relaxation of the inferior sphincter and superior hypertonic sphincter. preliminary results: the patient underwent surgery: diverticulectomy and complete esophageal myotomy by thoracoscopy minimall invasive approach. the patient evolved favorably and was discharged after days with a previus control esophagram without pathological findings. currently, it remains asymptomatic months after surgery. , rectus muscles are re-approximated from xiphoid to pubis using laparoscopic running self-locking, pds sutures to restore anatomy and physiologic function of the abdominal wall. unlike the standard access to the abdominal cavity executed with lateral access, the lap-t technique is performed through sopra-pubic aesthetic approaches, using one mm and one mm bariatric ( cm) instruments laterally, and one mm camera in the middle.the entire procedure is performed in gas-less laparoscopy, with laryngeal mask and intra-peritoneal liquid anesthesia. the repair is consolidated placing an intra-peritoneal semi-absorbable mesh. preliminary results: in all cases abdominal functioning was successfully restored; no higher pain related to the continuous laparoscopic suturing has been reported compared to bridge ipom laparoscopic repair, while allowing for a more physiologic outcome and a stronger repair. the use of miniaturized instruments allowed for minimal tissue trauma and accurate surgical gestures; the tiny trocar sites did not require skin suturing and might reduce the risk of trocar hernias. no intra operative bleeding, no seroma formation, chronic pain, nor mesh infection have been recorded. % follow up at months, % at months with no recurrences observed. the lap-t technique allowed for a sound and anatomic reconstruction, reduced trauma, faster recovery and more satisfactory aesthetic results. surg endosc ( ) background: anastomotic leakage is a serious complication, associated with significant morbidity and mortality. one possible cause of anastomotic leakage is insufficient vascular supply. markers of sufficient perfusion include pink color of the bowel wall, visible peristalsis, palpable pulsations and bleeding from the marginal arteries. these signs are subjective and may be misinterpreted even by experienced surgeons. aim: the assessment of bowel perfusion with the use of indocyanine-green fluorescence angiography might be helpful in decreasing the number of anastomotic leaks. project description: we report a case report of a middle-aged patient without significant medical history who was treated by transanal total mesorectal excision (tatme) for rectal carcinoma. the patient underwent neoadjuvant treatment with radiochemotherapy. during the surgical procedure, indocyanine-green fluorescence angiography showed adequate perfusion of the bowel. the postoperative phase was uneventful and the patient was discharged home on the th postoperative day. preliminary results: indocyanine-green fluorescence angiography is a safe, cost-effective and feasible tool for assessment of tissue perfusion during colorectal resections. background: to properly learn how to perform a laparoscopic suture, along with safe tissue handling, applying an appropriate magnitude of the force on the tissue is essential. for this reason, it is fundamental to investigate and validate if training with real-time visual force feedback improves the suturing performance of laparoscopic novice surgeons. capturing all of the forces applied in laparoscopic in surgery in an unobtrusive way has been difficult in the past. sensor has supplied a novel force-sensing film (forcefilm) that can detect all of the forces applied with laparoscopic instruments without changing the surgical workflow or operation of the instruments. aim: to evaluate the effect of visual force feedback on surgical performance, applied force and surgeon's ergonomics during training of laparoscopic suturing using the sensor technology (sensor medical laboratories ltd.). methods: twenty novice laparoscopic surgeons participate in this study. they perform a laparoscopic suture on an ex vivo stomach tissue from a pig. participants are assigned, in a random fashion, to either group that receives visual force feedback (a) or the control group (b) without visual force feedback. five training trials (t -t ) are carried out in order to assess the learning curve. in addition, an evaluation pretest (t ) and posttest (t ), without visual force feedback but recording the force applied, will be performed after the training trials. the applied force on the tissue and visual force feedback of each instrument are provided by means of the sensor technology. it accurately measures the forces exerted on the tissue from the instrument tip and wirelessly communicates the force information to the surgeon via visual force-feedback. during each trial, several parameters are evaluated such as execution time, applied force, surgical performance, and mental and physical workload. preliminary results: laparoscopic training using visual force feedback leads to an improvement of suturing skills with a reduction of the applied force and therefore providing a potentially positive effect on patient outcomes and surgeon's ergonomics. background: hiatal hernia is a frequent disorder, characterized by a protrusion of any abdominal structure other than the esophagus into the thoracic cavity through a widening of the diaphragmatic hiatus. current anatomic classification is mainly based on the location of the gastroesophageal junction and the presence of a true hernial sac, differentiating sliding from paraesophageal hernias. there is no solid evidence to support an association between gastric carcinogenesis and peh. however, chronic reflux is considered as one of the strongest risk factors of developing adenocarcinoma of the esophagus and proximal stomach. aim: herein, we report a case of an -year-old caucasian female with dysphagia, regurgitation and heartburn accompanied by an iron deficiency anemia, a remarkable total body weight loss and recurrent lower respiratory tract infections due to microaspirations. subsequent work-up with ct, upper endoscopy and barium esophagram confirmed the presence of synchronous distal gastric adenocarcinoma and a giant paraesophageal hernia with complete intrathoracic stomach. after mdt discussion and keeping in mind the patient's age and comorbidity, a d laparoscopic distal gastrectomy with a synchronous hernia reduction with posterior cruropexy was scheduled. project description: the patient was placed in a supine position, five thoracoscopic ports were introduced, and a diagnostic laparoscopy of the abdominal cavity was performed. the stomach was identified through the dilated hiatus into the left thorax. the hernia sac was dissected away from mediastinal structures, then excised to untwist the stomach. after reduction of the stomach to abdominal cavity, a total d ? gastrectomy with a roux-en-y reconstruction was performed. maintenance of optimal vision during minimally invasive surgery is crucial to maintaining operative awareness, efficiency and safety. hampered vision is commonly caused by laparoscopic lens fogging (llf) and lens condensation which has prompted the development of various antifogging fluids and warming devices. numerous tricks have been proposed to overcome this issue, such as heating the scope into a sterile thermos flask filled with hot water, or using one of the commercially available antifogging solutions. however, whether one method is superior to another remains elusive. as most surgeons know, none of these tips are totally efficient, as they don't treat the cause: the temperature difference. taking into account this need, we have developed ehs (endoscopy heater system), a thermoadjustable system by microcontroller, which is implemented in the manufacturing process of the rigid endoscope focused on laparoscopy. the technology enables the self-modulation of the temperature of the endoscope within the different conditions during the surgery, avoiding the % of laparoscopic fogging. with the adoption of ehs surgeons get a clear field of vision avoiding continues repetitions of extraction and insertion of the endoscope in the body during the intervention. in this way the risks of the patients are reduced with a more efficient and shorter duration procedure. ehs also represents an alternative that meets sustainability criteria by reducing energy costs and eliminating much of the waste currently generated by this procedure. therefore, this innovation will disrupt the laparoscopic device market by enhancing safety and effectiveness without introducing new components that could complicate surgical procedures. case report: we presented the case of a year old women with chronic coloenteric fistula. conservative treatment was unsuccessful. the orifice was then closed with two subsequent clips, and the patient recovered well. to our knowledge, this is the first successful case of coloenteric fistula treatment with ovesco discussion: ovesco system is a technique that enables the closure of gastrointestinal defects (perforation sites, leaks, fistulas) . after the system application, the patient can be treated at home as was the case with our patient. a successful closure of the leak or fistula is possible when no extraluminal abscess is present. in our case, we had a cavity (previous sinus or abscess) that drained into the small bowel, thereby forming the coloenteric fistula. this allowed us to succeed with a fistula closure, as the cavity could drain into the small bowel conclusions: looking through the reports, one notes that the success rate of the otsc system procedure for insufficiency of anastomosis or colorectal fistula was - %, but only nine successful reports of chronic colorectal fistula were found). a % success rate is reported if the clip is placed within a week of occurrence of the leak . on considering the financial side, clips could reduce costs and time of hospitalization and avoid patients having to undergo a surgical repair . the major advantage of ovesco clips seems to be their ability to grasp more tissue compared to the standard clips and their strong grip on the wound margins because of their sharpened teeth. the drawback of the clips in fistula sealing is their incomplete grasp when the tissue is fibrotic. most authors agree that ovesco is not very appropriate for fistulas larger than - mm. inguinal hernia repair is one of the most performed interventions in minimally invasive surgery. in this opportunity we report a new technique through the use of innovative devices such as the robotic clamp and magnetic deviceswith this technique and thanks to the magnetized devices and the robotic clamp we have demonstrated to reduce the surgical time between - min as well as to optimize the ergonomics of the surgeon.we explain the technique with a demostrative video and exposition of the devices that are necessary for make it.with this new technique we get a greater capacity of mabiobra for dissection of the peritoneum and later a greater facility for the suture of the same in the repair of the inguinal hernia. a motorized and computerized laparoscopic tool that can be customized to the specific surgeon and procedure a. szold aim: surgeons have different levels of skill and use instruments for different tasks, but laparoscopic instrument are commonly simple mechanical instruments that allow limited degrees of motion, and the same instruments are used regardless of the surgeon or the task. robotized articulating instruments so far have added degrees of freedom, but perform in a standard way for all users and procedures. technology: human xtensions has developed a \ u[hand-held \/u [ motorized smart laparoscopic instrument, that was recently introduced in human procedures. the device has several features that enable to customize it to the user and procedure. the degrees of freedom can be reduced from to , the scale of rotation motion has options that can control both speed and range of rotation, a feature especially useful for the variable types of suturing tasks. results: the variable features were tested in different procedures requiring suturing and grasping. the combination of all optional settings made the instrument customizable to the different skill levels of the surgeons. as such, it enabled to control the complexity of the device and take the surgeon through the learning curve until full control of all features was achieved. in addition, the combination of different controls was used for performing specific tasks requiring different levels of maneuverability. in september , the results of a bomss survey regarding the routine use of pre-operative bariatric surgery were published. they found that % of units surveyed considered routine preoperative ogd completely unnecessary. as part of newly launching bariatric services in a single isolated centre we protocoled that all bariatric patients had to undergo pre-operative ogd, including a clo test, and reviewed if the ogd findings had influenced our surgical choice of operation and any necessary treatment before surgery. all patients embarking on the bariatric programme since its launch in jan to sept were included and had an ogd. the results of these ogds and all the clo tests were reviewed. these ogds were all performed by a single consultant to minimise any potential subjective differences. of the patients, ( %) tested clo positive of which had normal findings on ogd. patients had a hiatus hernia, gastritis, oesophagitis, gastritis and oesophagitis, had other findings e.g. ulcers, polyps' or nodules. the positive clo patients underwent eradication of h pylori. studies have shown that this is a treatable and preventable cause of gastritis/ gastric cancers and potential surgical complications causing prolonged hospital stay in % of patients. knowing about the presence of a hiatus hernia prior to surgery also contributed to the surgical planning, including allowing time for the concurrent correction of the hiatus hernia in the operation. all patients with demonstrable oesophagitis ( %) had their operative choice changed to roux en y gastric bypass thus aiming to prevent post-operative reflux which would have been exacerbated had they undergone a sleeve gastrectomy instead. carrying out a pre-operative ogd had a significant impact in operative choice and additional treatment before surgery and therefore should be advised in all patients. general surgery department, ahievran university, kirsehir, turkey the majority of fatalities worldwide in people under the age of years are caused by trauma . blunt mechanisms account for . to . %of injuries [ ] [ ] [ ] [ ] ,with the abdomen being affected in . to . % of all traumatic injuries. this case contribute to the literature: a patient with sleeve gastrectomy has distorted anatomy at duodenogastric junction, if has bat,her/his small bowel perforation(sbp) will occur on more distal segment. this a unique case before unpublished. years old female who had sleeve gastrectomy years ago presented to emergency department sustained blunt abdominal trauma (bat). when she arrived pyschical exam (pe) revealed an abdominal guarding, tenderness, normal vital signs but those increased h later. wbc values also increased h later. hb was normal.fast showed in cm thickness fluid early in douglas pauch (dp), mm in supravesical, mm diameter in dp h later. abdominal ct: mm diameter fluid in interloop, dp free air at th h from the accident. a diagnostic laparoscopy(dl) was done with diagnossed acute abdomen.there were a sbr-located cm from treitz, intraperioneal fibrin deposits and fluid-repaired with a primary suture.the patient discharged on days without any event. repeat ct scans are recommended for patients with initial suspected bowel injury. we could not do this; cause ct exam could taken in rush hours only but we did repeatly pe that peritoneal iritation signs increased,resulted a dl,surgical therapy. according to the literature; dl may be a good treatment option in these patients, to reduce morbidity or mortality, time to surgery has been emphasized. long interval between presentation and surgery was found to be associated with complications. very few reports of isolated jejunal transection following blunt abdominal trauma have been published in literature. the literature mentioned; the patients with sbp are hemodinamically stable on arrival to the hospital like our case are, a rupture of the jejunum was seen just distal to the duodenal-jejunal flexure but there were a perforation cm below treitz ligament and caused me to think the patient had sleeve gastrectomy and some brid around gastric and duodenal proximal jejunal part of intestines and also caused a new descended treitz ligament. normally external forces across to spine produce a blast effect on small bowel between treitz and ileocolic ligament. introduction: sasi bypass is a novel metabolic/bariatric surgery operation based on minigastric bypass and santoro's operation.it can be offered for patients with weight regain after sleeve gastrectomy. sleeve gastrectomy (sg)is a commonly performed bariatric procedure.weight regain following sg is a significant issue.yet,the understanding of this phenomenon is still unclear.rates of regain ranged from . % at years to . % at years.sasi bypass was an option for some candidates having sg done years back and failed to achieve the required weight loss or having weight regain.in sasi bypass, resleeve gastrectomy of the dilated gastric pouch is done followed by a side to side gastro-ileal anastomosis. the aim of this study is to report the clinical results and the outcomes of sasi bypass as a therapeutic option for patients with weight regain after sg methods: we conducted a retrospective study for morbidly obese patients having history of sg done more than years back and failed to achieve and/or to maintain the required bmi. exclusion criteria:patients with recent history of laparotomy(less than months). procedure was done at sidra hospital in kuwait from november to november . using ports, resleeve gastrectomy was performed over fr bougie tube starting cm above the pylorus then gastro-ileal anastomosis (side to side)was performed cm above the pyloric ring to an ileal loop counted cm from the ileocaecal valve. data was collected from the patients including:weight loss progress,laboratory full results. discussion and results: during the study period: morbidly obese patients with a mean bmi of ± kg/m were evaluated. -%ewl(excess weight loss)reached % at one year. -diabetes was cured in the known diabetic patients (type )within months,and the one known type diabetic patient had better control and less insulin daily doses(results were guided by glycated haemoglobin results every months). follow up laboratory results were normal in % of patients (all were kept on regular vitamins and proteins supplementation)-one patient had postoperative leak(day )from the anastomotic line that was treated conservatively. conclusion: sasi bypass is a promising operation that offers a good weight loss for morbidly obese patients having weight regain after sg conclusions: our study demonstrates a good agreement between the degree of liver steatosis and monocytes fat accumulation as well as between plin levels in liver and circulating monocytes. this suggests that ectopic fat deposition is a generalized feature of insulin resistance in obesity. sg reverses monocyte fat accumulation and restores insulin signalling, which correlates well with insulin sensitivity. moreover, circulating mmp levels significantly dropped after sg suggesting that the state of generalized inflammation characterizing obesity normalizes. her stomach stapled,a foreign tube like body was seen on cut surface of the stomach.the foreign body seen in dissected stomach wall is the tube is in placed a gastric banding insuflation tube.a laparatomy was made and the tube is extracted her stomach sutured primarily,nasogastric decompression,peritoneal drainage was made.her peritoneum was drained.she has a septic condition, leave in icu for a long period.her general status being well and discharged from hospital in days.we learn after the operation not before;she had a gastric adjustable banding and extraction the gastric band, but the tube of gastric band is not removed. alkhaffaf et al present a case of fistulation of the lagb tubing into the jejunum a review of the published data to identify the salient learning points with this and similar rare complications fistulation from lagb tubing is a rare complication that tends to follow removal of an infected port. the clinical presentation is nonspecific, rendering the preoperative diagnosis difficult. the tube and band can be removed laparoscopically, with closure of the small bowel fistula site. securing the tubing to the abdominal wall fascia after intentional detachment from the port might reduce the incidence of this complication.katherine j et al report a late and rare complication of a small bowel obstruction in a -year-old woman from an lagb placed for years. although not a common complication, one that could easily see the safety record of lagb patients tarnished if this small subgroup of patients is not acted upon promptly by emergency departments' unfamiliar lagb surgery. in our case we already made esophagogastroduodenoscopy before operation, ofcourse take past medical history from the patient.the patient hide past operation (gastric banding and removing band and port but leaving insuflation tube). ). there was no difference in the two groups regarding follow-up rate. basic demographics were the same, and other long-term results were similar between the groups. regression models for both post-op complications and failure as defined by baros score did not show that gender is a risk factor. discussion and conclusions: in our study, revisional sleeve surgery were similar. we did not see any significant difference in post-op complications, success of the operation as defined by baros, or subjective feeling of the patients. we do believe that gender-specific outcomes should be taken into consideration in optimizing patient selection and preoperative patient counseling, and that in the case of a sleeve post a band gender is not a risk factor for complication or failure of the procedure. objective: the internal hernia is a rare but a potentially fatal complication of laparoscopic roux-en-y gastric bypass (lrygb). the aims of this study are: ( ) to determine the impact of mesenteric defects closure on the incidence of internal hernia after lrygb; ( ) to determine the symptoms, characteristics and management of internal hernias after lrygb. the median interval between lrygb and reoperation was months in group a and months in group b. the median percentage of excess weight loss (%ewl) was % vs %, respectively (p = . ). the median percentage of total weight loss (%twl) was % vs %, respectively (p = ns). patients, % ( in group a), were admitted to the emergency room with acute abdomen pain. a ct scan was performed in patients, %, and showed signs of occlusion in all cases. the most common symptoms were abdominal pain and vomiting. the surgery was performed using laparoscopy in patients, %, and using laparotomy or conversion in patients, %. conclusions: the closure of mesenteric defects during lrygb is recommended because it is associated with a significant reduction in the incidence of internal hernia. our study intends to analyze the long term results of sleeve gastrectomies performed by d laparoscopic approach. materials and methods: a prospective cohort study was conducted to perform gastric sleeve for morbid abesity. all surgeries were performed by the same surgeon over a period of two years. the operating surgeon is a senior most laparoscopic surgeon with vast experience in laparoscopic surgery. during two years period, cases were operated using d laparoscopy system. scientific calculation was done using spss release . windows software. results: patients, female ( %) and male ( %), with median age of . ± . ( - ) the excess weight lost (ewl) was % in the first year, % in the second, % in the third, % in the fourth, % for the fith year, % for the sixth and % for the seventh. postoperative complications were stenosis of the sleeve always located in the incisura and treated with endoscopic dilatation except one that required conversion to oagb. three leakages, all of them reoperated with drainage and introducing prosthesis by endoscopy in the same act. we have never had a postoperative bleeding of the sleeve. conclusions: d gastric sleeve laparoscopy is a safe and feasible technique for morbid obesity and related pathologies. the ewl is correct in long time. complications are rare but is necessary to have a good level of suspicious in order to a rapid solution. the worst complication is the leak of the sleeve. the oversewn of the gastric section is a good technique to avoid this complication. surg endosc ( ) aims: leak is one of the common complications of laparoscopic sleeve gastrectomy that result prolongation of hospital stay, morbidity and even mortality. methods: i report new approach for the treatment of leaks presented to me post laparoscopic sleeve gastrectomy with laparoscopic roux en y bypass to the leak site at the level of gastroesophageal area. this new approach is possible and feasible, and avoids stenting due to high failure rate, prolonged hospitalization and saves life of patients. results: all leaks healed days from surgery due to well vascularized small intestinal patch, except for leaks that healed after weeks of conservative treatment. aims: analyse the effect of one anastomosis (mini) gastric bypass (mgb/oagb) in the treatment of gastro-esophageal reflux in patients previously submitted to laparoscopic sleeve gastrectomy (sg). methods: a retrospective analysis was performed on the data of patients who underwent mgb/ oagb after a previous sg at policlinico san marco, italy, from january to june . a total of patients, female and males ( % f/ % m) underwent mgb/oagb after sg, due to the development of significant gastro-esophageal reflux disease (gerd), refractory to proton pump inhibitors (ppi), detected with the gerd questionnaire (gerd-q) and esophagogastroduodenoscopy (egds). in three patients ( %) a weight regain was also observed (mean bmi . kg/m , range . kg/m - . kg/m ). mean patients age was . ( - years old). before sg none of the patients had declared symptoms of gerd or was subjected to a therapy with ppi, preoperative egds did not show signs of esophagitis. mean bmi of the patients who developed gerd without weight regain was . kg/m ( kg/m - . kg/m ) at the time of surgery, with a medium ewl% of % ( . - . %). patients were treated unsuccessfully with ppi for at least six months before programming revisional surgery. mean gerd-q score was . results: after mgb/oagb, with a mean follow up of months ( - months), mean bmi was . kg/m and gerd-q score was . however, five patients out of ( %) developed an anastomotic ulcer or a grade c esophagitis. we did not observe any post-operative immediate complication nor any death. conclusion: mgb/oagb is a simple, effective and safe surgical procedure for patients who underwent a previous sg and who developed gerd, with satisfactory results in the short and medium post-operative time, even if there is still concern regarding the complications linked to biliary reflux. v.s. kyosev aims: laparoscopic adjustable gastric band (lagb) was one of the common techniques in bariatric surgery worldwide. the advantages included the possibility of regulation, ease of placement, acceptable weight loss and low rate of perioperative complications. a late complication of lagb is penetration of the gatric band through the gastric wall and migration into the lumen of the stomach. hereby, we present three cases of gastric band migration following lagb. methods: from to we observed cases of gastric band migration in between and years after lagb placement. the patients were hospitalized in surgical department complaining of sudden sharp epigastric pain, nausea and vomiting, with symptoms onset in the last few days. all patients underwent abdominal ultrasound examination, x-ray investigation of the abdomen with oral contrast administration, fibrogastroscopy. in cases the imaging studies revealed gastric band migration into the stomach's lumen and in case-obstruction of the jejunum by the gastric band. all patients underwent laparoscopic surgery. results: two of the patients underwent gastrotomy, extraction of the gastric band and roux-and y-gatric bypass. the patient with jejunal obstruction underwent laparoscopic enterotomy, extraction of the gastric band and cholecystectomy due to concomitant cholecystitis. two of the patients had no additional perioperative complications and were discharged at the th postoperative day. one patient developed fever, left pleural effusion and partial insufficiency of the gastrointestinal anastomosis in the early postoperative period without the need of surgical treatment. the patient was discharged on th postoperative day. all patients were prescribed a diet and monthly blood test of ion balance. conclusions: lagb was one of the most common treatment methods due to the epidemic spread of morbid obesity in western countries. detailed knowledge on possible lagb complications is essential for the treatment of these patients. the diagnosis of lagb complications is often delayed due to its relative rarity and nonspecific clinical manifestations, but in most of the cases it requires emergency surgery for management of life-threatening conditions. results: there was conversion in patients (short mesentery of the small intestine). such postoperative complication like anastomotic leak in patient ( . %) and staple line bleeding in patient ( . %), which was managed laparoscopically. compensation for type diabetes was achieved in ( %) patients, improvement was recorded in ( . %), dyslipidemia in ( . %) and ( . %) patients, arterial hypertension in ( . %) and ( %) patients respectively, what led to metabolic syndrome resolution in ( %) patients. the liquid is allowed to take after day. average postoperative hospitalization- . ± . days. %ewl for months %. conclusions: laparoscopic mini gastric bypass is an effective method of surgical correction of body weight and metabolic disorders in patients with morbid obesity and allows to receive an adequate and stable correction of arterial hypertension, lipid and carbohydrate metabolism, which are components of a metabolic syndrome. introduction: over time laparoscopic sleeve gastrectomy lsg has become the most popular bariatric operation worldwide. a critical step during lsg is ensuring sleeve-size consistency. gastrisail device (gastric positioning system) is a three in one surgical device replacing the standard bougie used in lsg for the application of suction, decompression and to serve as a sizing guide for gastric sleeve creation. the aim of this study is to evaluate the possible merits of gastrisail device in lsg over the standard laparoscopic sleeve gastrectomy. methods: a prospective study of patients randomly divided into two groups: group a composed of twenty patients who undergo lsg with the use of gastrisail and group b composed of twenty patients who undergo lsg with the standard bougie without the use of gastrisail comparing both according to operative time, consistent sleeve formation, delineation and visualization, intraoperative and post-operative complication rates, the lenght of hospital stay,gastric pouch design and percentage of excess weight loss (%ewl). results: regarding intraoperative time, the mean time was . ± . and . ± . for group a and b respectively,while no patients in group b had consistent sleeve formation, patients ( %) had consistent sleeve formation. delineation and visualization were accomplished in % of group a patients, was not accomplished at all in group b patients. the alignment of the stomach was reached in patients in group a but no patients at all in group b, the mean of hospital stay was . ± . and . ± . for group a and b respectively, the smaller tube design illustrated by gastrograffin x-ray at rd post-operative day was accomplished in patients ( %) and patients ( %) in group a and b respectively. there was no significant difference in %ewl in both groups. conclusion: the use of gastrisail device is superior to the standard lsg in consistent sleeve formation, visualization, delineation and good alignment and accomplishment of a small tube design while no significant difference in %ewl. bariatric surgery has spread all over the world. since japan has few patients with morbid obesity compared with western countries, it has been implemented only in limited facilities. however, bariatric surgery in japan is rapidly spreading recently, and many facilities are about to install bariatric surgery. effects of bariatric surgery are known to last for a long time, but some cases require reoperation which is called revision surgery due to late complications or rebound. because of thick subcutaneous and visceral fat, open surgeries are not even always a good solution to make surgery easier in morbid obese patients and all procedures must be completed laparoscopically. therefore, especially in revision surgery, the incidence of complications tends to be increased. as the number of bariatric cases to be increased in japan, cases requiring revision surgery is likely to increase. in revision surgery, it is necessary to select the procedure according to patient condition, and it is necessary to familiar well with those procedures. we will present cases that underwent revision surgery in our department and show the clinical outcome. we have done four revision surgeries after sleeve gastrectomy so far. operative indications are mid-gastric stenosis and rebounding disease. for stenosis cases, we performed roux-en y gastric bypass with distal stomach resection, and for rebounding cases, we performed re-sleeve gastrectomy with duodenal-jejunal bypass. average interval from initial operation to revision surgery is months in rebounding cases, and months in stenosis cases. duration of operation was min in average, and mean estimated blood loss was ml. no postoperative mortality was observed. in rebounding cases, excess bmi loss at year after surgery was . % in average, and both cases achieve diabetes remission at year. one cases of mid-gastric stenosis required a nutritional support with formula diet temporally. in particular after sleeve gastrectomy, revising to roux-en y gastric bypass, re-sleeve gastrectomy, and adding the duodenal-jejunal bypass will be the main techniques. along with an increase of bariatric surgery in japan, it is necessary to acquire sufficient knowledge and skills to carry out revision surgery. methods: we present the case of a year old woman who underwent lsg after lagb removal and lgcp. the patient underwent preoperative endoscopy and barium swallow, with no sign of stomach perforation or erosion. we emphasize that the patient, had undergone three operations of gastric band placement, gastric band removal and gastric plication before sleeve gastrectomy. however, a successful lsg was achieved. results: no severe postoperative complications were mentioned. conclusion: weight loss in the first year was % of the excess weight.sleeve gastrectomy after gastric band removal and gastric plication, for morbid obesity seems to be safe and efficient, especially in casesof absence of gastric erosion. surg endosc ( ) department of surgery, patients were observed with serious septic complications many years after gastric banding operation. we detected a female dominance ( female, male) in patients with a mean age of . years. the leading symptoms were: dysphagia, upper abdominal tenderness and pain, spontaneous fistula formation, fever, masked septic signs, bowel and urinary obstruction. patients underwent video-endoscopy, chest and abdominal ct (computed tomography), fistulography and cystoscopy. results: in still morbid obese patients, laparoscopic procedures were performed with a conversion rate of %: atypic gastric and cardia resection in cases, gastric suture in cases, small bowel resection and suture in - cases. in one case, fistulectomy, abscess evacuation and combined urinary bladder suture and drainage were carried out. the duration of the surgeries were over h with minimal blood loss (\ ml). the foreign bodies were completely removed in every case. intraoperative complication was not occurred. early physiotherapy were promoted, oral feeding were gradually built up from the th postoperativ day depending on the type of the operation. early postoperative complications included recurrent fistula formation (n = ) and wound infection (n = ). all the fistulas were closed after conservative treatment. average hospital stay was days, regular check-ups were held on the rd, th and th months of follow up. conclusion: gastric banding is the most common, routine and safe technique for the treatment of morbid obesity. the development of late, severe septic complications draws attention to the crucial importance of follow up. the surgical management of these patients is recommended in specialized centers in regard to difficult operative conditions and atypic treatment options. aims: single anastomosis duodeno-ileal bypass with sleeve gastrectomy (sadi-s) has been proposed as an alternative to biliopancreatic diversion with duodenal switch (bpd-ds) in order to maintain the outcome of the original procedure simplifying the technical complexity and to avoid potential complications. moreover, it potentially represents the more natural second step bariatric procedure after sleeve gastrectomy (sg). we aimed to report the initial experience with sadi-s of our high volume bariatric center. methods: retrospective analysis of patients who underwent bariatric procedure between july and november was conducted. the primary aim was the evaluation of the safety of sadi-s, defined as the rate of postoperative complications. the secondary endpoint was the bariatric efficacy of the procedure, defined as percentage excess weight loss (%ewl). results: among patients who underwent bariatric procedures at our institution ( . %) patients were scheduled for sadi-s. all patients had multiple comorbidities. initial indication for sadi-s was failed sg in patients (median pre-sg bmi . kg/m \ sup [ \/sup [ ; median months after initial operation respectively) and primary procedure in patients (median pre-operative bmi . kg/m ). the surgical procedure was accomplished with robotic-assisted approach in cases (median operative time min) and with laparoscopic trocars standard approach in the remaining cases (median operative time min). the duodeno-ileal anastomosis was fashioned using a double layer hand-sewn running sutures. no patients showed early post-operative complications, the median postoperative stay was days. at a mean follow up of months the median %ewl was . . to date no patients experienced surgical. one patient develop wernicke encephalopathy months after surgery, but he was non-compliant to multivitamin supplementation. conclusions: at least in a high volume bariatric center sadi-s, both as second step after sg and as primary surgical option, seems to be a safe and effective bariatric metabolic procedure based on solid physiopathologic principles. on the other hand, longer follow-up is necessary to support the use of this procedure as a better alternative to bpd-ds. m.r. elkeleny , a. abo khozima git and bariatric surgery, faculty of medicine, alexandria university, alexandria, egypt; git surgery department, faculty of medicine,alexandria university, alexandria, egypt four bariatric cases . female patient with intragastric balloon, minor leak from the balloon leading to ballon migration to the jejunum;hance, small bowel obstruction occured. emergency diagnostic laparoscopy was done, enterotomy and extraction of the balloon, direct repair of enterotomy and balloon extraction through mm port site. . male patient presented after days of lsg with small bowel obstruction due to entrapment of small bowel loop through one of the port sites;therefor, emergency laparoscopy was done with reduction of the herniated segment and closure of the port site. . female patient presented with stricture of the ogj after re-sleeve gastrectomy managed by balloon dilatation which recur after weeks .she was managed by expandable metallic stent for weeks with good response and the stent was removed. . -year-old male patient presented with sever peripheral neuropathy following months after sleeve gastrectomy, and the patient was getting worse; thus, he used wheel chair. he has been making good progress on vitamin b complex injections. the aim of our study was to compare histopathological findings of gastric specimens to preoperative clinical symptoms and to conclude about the need for ugi endoscopy as a routine prior to surgery. methods: the last two years, morbid obese patients were selected to undergo laparoscopic sleeve gastrectomy (lsg) in our institution. for the needs of our study, all of them had ugi endoscopy and were reviewed for upper gi symptoms. histopathological reports obtained according to our protocol, after surgery. results: gastric histology from specimens revealed: no findings in / patients ( . %), gastritis in / patients ( . %) and focuses of incomplete intestinal metaplasia without dysplasia in / patients( . %). finally, two minor leiomyomas with low cellular proliferation rate were fully excised in a patient's specimen. there was no inconsistency between preoperative symptoms and gastric histology, while leiomyomas found were no reported to ugi endoscopy due to size. conclusions: some of the patients with clinical features of food intolerance, gastroesophageal reflux disease, and peptic ulcer disease had finally findings in histopathology of their stomachs. history of helicobacter pylori infection implements a raised incidence of mucosa pathology as well. because only one case revealed carrying significant pathology (leiomyomas), we consider that is safe to proceed with surgery in an otherwise asymptomatic patient based on his previous medical records and blood tests. aims: splenic abscess following laparoscopic sleeve gastrectomy (lsg) is a rarely seen complication. the aim of our study was to present a case of splenic abscess in a morbid obese patient who underwent lsg. as the main concern in these cases is leakage from the staple line, we present our diagnostic and treatment approach. methods: a -year-old, female morbid obese patient (bmi . kg/m ), without any predisposing risk factors, underwent elective lsg in our department. following an uneventful course, she was discharged at the nd postoperative day. however, at the th postoperative day, she readmitted to our unit with high temperature of . o c, left upper quadrant tenderness and leukocytosis. contrast computed tomography (ct) revealed an abscess at the upper pole of the spleen , cm in maximum diameter, without leakage from the staple line. results: the patient was treated with broad-spectrum antibiotics and radiological percutaneous drainage of the abscess. although there was a partial clinical improvement, a week later, a new ct scan revealed the continuous presence of the abscess. despite the stable general condition of the patient a laparoscopic splenectomy was performed and a gradual recovery was followed. the presence of splenic abscess without splenic trauma or leakage from the gastric staple line, is an extremely rare complication and only a few cases have been previously reported. the cause has not yet clarified, but the proposed mechanism involves infarction of the spleen, due to vascular compromise and subsequent infection. most of the reported splenic abscesses were diagnosed during the late postoperative period. in our report we present a case of early onset, hence highlighting the need of clinical awareness for early diagnosis and treatment. introduction: obese surgical patients with obstructive sleep apnea (osa) have a higher risk of peri-and postoperative desaturations and subsequent morbidity and mortality. currently, the best perioperative management of patients without known osa remains unclear. although routine osa screening has been advocated, sleep studies are costly and time consuming. we hypothesized that bariatric patients can be safely monitored on a surgical ward by continuous postoperative pulse oximetry without preoperative screening for osa. objectives: to evaluate outcomes of continuous postoperative pulse oximetry without preoperative osa-screening, and to compare the results to outcomes of patients with osa and continuous positive airway pressure (cpap) treatment. methods: all patients who underwent bariatric surgery between and were included in this single-center retrospective cohort study. all patients were postoperatively monitored with continuous pulse oximetry on the surgical ward. patients with less than two documented saturation measurements were excluded. patient files were reviewed for osa diagnosis, cpap usage and perioperative details. primary outcomes were -day complication rates, intensive care unit admissions due to cardiopulmonary causes and postoperative desaturations of spo \ %. secondary outcomes were icu admissions following all causes, length of stay and rates of reoperation and readmission. results: in total, patients were included. patients ( %) were preoperatively diagnosed with osa, ( . %) were cpap users. complications occurred in . % of patients without osa and in . % with osa(p = . ). desaturations were documented in . % and % (p \ . ), respectively. in both groups, patient was admitted postoperatively to the icu for cardiopulmonary causes that could be related to osa (p = . ). both recovered without further complications. icu admissions, regardless of cause, occurred in . % of patients without osa and in . % with osa(p \ . ). no significant difference between groups was observed in complications based on clavien dindo classification, length of stay, reoperation-and readmissions-rates. conclusions: these findings suggest that continuous postoperative pulse oximetry without preoperative osa-screening is a safe perioperative management strategy for bariatric surgical patients. future studies are needed to assess cost-effectiveness of pulse oximetry vs. routine preoperative osa-screening in a prospective clinical setting. background: the pathology of colon is one of the most pressing and socially significant problems of modern health care, because it leads to reduction of the working population employed in manufacturing, in some cases to disability and reduced quality of life. mini invasive surgery of the colon has a great advantage: speed recovery, shorter hospital stay and better cosmetic results, the quickest return of patients to work. as a result, mini invasive endovideosurgery is firmly established in clinical practice of coloproctology. objective: the choice of optimal surgical method for treatment of colostasis, achievement of favorable outcomes of treatment. introduction: laparoscopic roux-en-y gastric bypass (rygb) is one of the most important bariatric surgical procedures performed worldwide and it can produce an important loss of weight with reversal of metabolic disorders like diabetes and dyslipidemia. even though it has good results, some complications occur after gastric bypass. a rare but serious complication of rygb is the so-called postprandial hyperinsulinemic hypoglycemia. its prevalence has been estimated less than % of cases and its pathophysiology remains unclear. methods: the aim is to present a case series of reversal surgery in patients with severe hiperinsulinemic hypoglycemia after rygbp in the hospital general universitari de la vall d'hebron. unit of endocrine-metabolic and bariatric surgery (eac-bs center of excellence for bariatric and metabolic surgery by ifso). it is a retrospective analysis of a prospective database same surgical team. we present in this study, the main features of those patients. results: between and , patients underwent a laparoscopic reversal procedure to normal anatomy and age mean was year ( years to years). mean preoperative body mass index (bmi) was . kg/m (range - . kg/m ) and were women. all patients presented hypoglycemia symptoms years after and the longest was years after the procedure. the first step of the standard approach was a laparoscopic reversal to normal anatomy with resection of the alimentary rygb limb in cases. a concomitant sleeve-like gastrectomy (sg) was added. four patients presented postoperative complications: gastrogastric anastomosis leak ( ) introduction: laparoscopic sleeve gastrectomy is the most performed bariatric procedure, but complications might interfere with patient's long-term evolution based on its compliance and tolerance, surgical attitude and unpredictable evolution. materials: we present the case of a female obese patient, with type ii diabetes mellitus and blood hypertension, with multiple, sequential bariatric minimally-invasive interventions: sleeve gastrectomy in complicated by postoperative acute gastric dilation and mediogastric stenosis, reoperated for viscerolysis and cholecystectomy, with endoscopic gastric dilations, initially converted to functional one anastomosis gastric bypass ( cm limb), with a non-adjustable gastric ring positioned instead of stapled division. the last operation was complicated months after by persistent biliary gastro-esophageal reflux, chronic abdominal pain, and gas bloat syndrome. in the patient underwent conversion to laparoscopic r-en-y gastric bypass, with gastro-enteral anastomosis resection, band removal and viscerolysis. results: conversion to r-en-y was complicated by biliary leakage post-viscerolysis, treated with laparoscopic approach in the \ sup [ th \/sup [ po day. after multiple surgical and endoscopic interventions, the patient presents short-term favorable outcomes, with no reflux or abdominal pain, with further weight loss and diabetes improvement. conclusion: bariatric surgery has unpredictable evolution in same cases, and conversion to r-en-y seems to be the best solution. lgcp is widely used in developing countries due to its lower cost and good results. material and methods: we performed in our department lgcp for morbid obesity. excess weight loss (%ewl) was % at month after surgery and % at one year. in cases revision surgery was needed for different complications and in cases for inadequate weight loss or weight regain after month follow up. in cases we performed sleeve gastrectomy (in cases after taking down the plication) and in cases we performed a re-plication in one row. results: the rate of revision surgery was % overall and % for inadequate weight loss (excess weight loss \ %) or weight regain. major complications occurred only in one patient (leak with abscess) but it was solved by laparoscopy. minor complications as vomiting and nausea appeared in patients ( %) and were solved with medication. after one year follow up %ewl in these cases was %. conclusions: revision surgery after lgcp is possible. a new plication or sg was the option in our series with good results. further studies are needed to evaluate the use of lgcp in the armamentarium of bariatric surgery. background: roux-en-y gastric bypass (rygb) is one of the most commonly performed bariatric procedures around the world.however, rygb it sometimes carries the risk of rarebut serious long-term complications such as malnutrition and liver failure. we report a case of laparoscopic reversal of rygb. methods: in march , a laparoscopic rygb was performed for a -year-old female without comorbidities and with a bmi of kg/m . all laboratory test results at the preoperative evaluation were within the normal range. abdominal ultrasound revealed moderate hepatic steatosis and oral endoscopy a hiatal hernia with grade b esophagitis. one year later, patient experienced an important weight loss of kg (from to kg) with a bmi of kg/m . however, patient presented general weakness, abdominal pain, ascitis lower extremitiy edema, anemia, progressive caloric and protein malnutrition, vitamin (a, d), mineral (copper) and folic acid deficiencies, nonalcoholic steatohepatitis (nash) and liver function was progressive worsening. results: a laparoscopic reversal of gastric bypass was performed. the operation was successfully performed via laparoscopy. operating time was min. postoperative was uneventful and patient discharge home at day . hepatic biopsy revealed nash with steatohepatitis of % (fibrosis f - / ). eight months after reversal of gastric bypass, patient has improved her clinical situation (no asthenia), maintains of weight ( kg) and has improved her nutritional status and liver function parameters. conclusion: laparoscopic reversal of rygb is technically feasible and might be performed safely after thorough preoperative evaluation in carefully selected patients with malnutrition and liver failure. conclusion: laparoscopic sleeve gastrectomy it's a safety obesity procedure before major abdominal hernia repair. it's a minimally invasively technique with an absence of anastomoses. these factors prevent fewer complications, without using the small bowel, and skin problems and allow resolution of obesity-associated co-morbidities. body weight loss after surgery may be an opportunity to repair the severe loss of domain incisional hernia. bibliography borbély, y., zerkowski, j., altmeier, j., eschenburg, a., kröll, d. and nett, p. general surgery, benhazi medical center, benghazi, libia, general surgery, royal bahrain hospital, manama, bahrain obesity is a worldwide epidemic with an increasing incidence trends and as a consequence obesity related health problems become priority to healthcare authorities in all the countries. laparoscopic gastric plication is an emergent restrictive procedure which claimed to be low cost because they do not need staplers and carries less complications as compared to laparoscopic sleeve gastrectomy. we present here a years female who was operated for morbid obesity four months back where she underwent laparoscopic gastric plication with no immediate post operative complication and her wight loss was adequate. two days before presentation to our emergency department she started to complains of sever attacks or upper abdominal pain and vomiting.clinical examination was unremarkable apart of abdominal tenderness in left upper abdomen. all blood routine were normal and all inflammatory markers were within normal range.ct abdomen showed large cystic lesion around the greater gastric curvature containing fluid and raised possibility of collection. patient was admitted to hospital, in despite of medical treatment her pain persists and necessitate immediate laparoscopic exploration. gastro-gastric hernia at the greater curvature through loosen ethibond suture that was used to plicate the stomach in the previous surgery. we released the suture to liberate the strangulated stomach which is not gangrenous. re-plication was not possible because of the extensive gastric wall edema and as preoperative discussion with the patient she refused conversion to sleeve gastrectomy no intervention was done. post surgery patient was free of symptoms and tolerating oral diet and discharged home on third post operative day with no complications. gastro-gastric herniation could progress to gastric wall gangrene which will result in high morbidity and even mortality. high index of suspicion is required to diagnose the condition . preoperative patient counseling is important to explore the surgical options if deemed necessary to convert to another bariatric procedure. k. chouillard, a. d'alessandro, l. chahine background: bariatric surgery is the best available, long-term treatment for morbid obesity. currently, laparoscopic sleeve gastrectomy (sg) is the most commonly performed bariatric procedure in france. despite its safety and efficacy, long-term complications of sg are not rare including gastro-esophageal reflux disease (gerfd), twisting, stenosis, insufficient weight loss, and weight regain. the goal of this study was to analyze the pattern and short-term results of surgical revision in patients with sg. methods: revisional bariatric surgery, regardless of its motivation, was always a multidisciplinary decision after clinical, biological, endoscopic, and radiological assessment. patients who had revisional surgery after sg were retrospectively identified and subsequently divided in subgroups according to preoperative body mass index ( we aim to present the management and the particular aspects of the surgical technique in a gastrobronchial fistula after gastric sleeve . the mean time between intervention and diagnosis is . - . months. methods: between and , laparoscopic gastric sleeve resections were performed in our bariatric center. we had one case of gastrobronchial fistula associated with an inferior lobe abscess of the left lung, diagnosed months after the gastric sleeve. the patient was subject for medical treatment for h, than a laparoscopic intervention was performed in order to drain the lung abscess and the gastric fistula and to place a feeding jejunostomy. . months after this intervention ( . months after gastric sleeve) a laparoscopic roux-en-y fistulojejunostomy was performed. the evolution was monitorized with blood tests, upper gi contrast series and ct scans. results: the surgical drainage of the lung abscess, along with the antibiotherapy, controlled the infection and allowed the lung cavity to reduce in size, and thus the drainage tubes introduced in the thorax through the diaphragmatic orifice were retracted progressively. also, the feeding jejunostomy allowed a proper nutrition for the patient with a good recovery. however, . months after the drainage intervention, the gastric fistula was not healed, and a decision to interrupt the communication with the lung cavity was made, by creating a laparoscopic fistulojejunostomy. after this, the evolution was favorable, with the healing of the lung cavity, oral feeding was permitted and the jejunostomy was suppressed. conclusions: the treatment of the gastrobronchial fistula is complex (medical, endoscopic or surgical), phased and long lasting until healing. surgery was our initial choice for treatment due to the existence of the lung abscess, which needed to be drained. key words: gastrobronchial fistula, lung abscess, laparoscopy, fistulojejunostomy s.i. filip, i. hutopila, c. copaescu introduction: leakage remains one of the most dreadful complications in metabolic surgery. the main cause of leakage is poor tissue oxygenation due to inadequate vascular perfusion. the study of intraoperative tissue perfusion in real time due to icg enhanced fluorescence could provide valuable information for the surgeon in order to prevent postoperative fistula. aim: to present our experience in using icg enhanced fluorescence in laparoscopic bariatric surgery material and method: in cases of gastric sleeve, cases of gastric bypass and in cases of revisional surgery or redo cases we used intraoperative icg mediated fluorescence to assure the optimal vascularization of the involved tissues. in our video we present intraoperative aspects before and after using icg in different cases. results: in all cases of primary gastric sleeve and gastric bypass with intraoperative use of icg we did not encounter inadequate perfusion. in one case of redo gastric bypass after failed vertical banded gastroplasty for morbid obesity despite intraoperative laparoscopic normal aspect of the gastro-jejunal anastomosis, icg mediated fluorescence allowed to identify an unexpected ischemic anastomosis and we could prevent consecutive postoperative leakage. discussion: presented cases are discussed and result with referral to literature is made. conclusion: intraoperative use of icg is a valuable tool in assessing the perfusion of the tissues and provide essential information for the surgeon in order to avoid postoperative leakage. , including patients, hemostasis with clips has been performed in all cases. however, among these cases nine patients required reoperation for early postoperative bleeding. in five cases a bleeding source from the stapled line was identified while in cases no identifiable source was found. during the second period ( to present) patients were submitted to bariatric surgery and hemostasis was performed by over sewing with a running suture. among these cases reoperation for postoperative bleeding was needed in cases ( . %), but no bleeding from the staple line being encountered ( %). the difference has statistical significance. no significant complications related to the use of this type of reinforcement were encountered. conclusions: over sewing the gastric stapled line in bariatric surgery is superior to hemostatic clip application in preventing the postoperative bleeding from the stapled line postoperative bleeding. a protocol of active search of the bleeders during the bariatric procedure should be implemented and respected in all the cases. gastroenterological surgery, saitama medical university international medical center, hidaka-shi, saitama, japan intestinal endometriosis is a rare disease which is associated with about to % of patients with endometriosis, and it is favorable to the rectum and sigmoid colon. here we report cases (shown in the table) underwent laparoscopic resection for intestinal endometriosis. there were no postoperative complications in all cases, and all patient was discharged on - \ sup [ th \/sup [ postoperative day. before the operation, of patients were diagnosing intestinal endometriosis, and it was difficult to preoperatively diagnose. among them, the symptoms at the time of menstruation were clear was one case. in case of submucosal tumor, preoperative diagnosis seems difficult. additional image examination at menstruation may be useful for diagnosis. d dissection was performed for case , , because malignant disease could not be denied as a preoperative diagnosis. of them were strongly doubted endometriosis in surgical findings. in intestinal endometriosis surgery, pelvic adhesions and fibrosis are often advanced. in the sigmoidectomy, the average operation time was min and the blood loss was ml. in the rectal resection, the average operation time was min and the blood loss was ml. in case and , pelvic adhesion was severe, residual rectum could not be straightened, and side to side anastomosis was performed. in intestinal endometriosis surgery, intestinal anastomosis method should be considered flexibly. conclusion: laparoscopic surgery for intestinal endometriosis was safe, but technically difficult because of fibrosis and adhesion. it is important to accurately diagnose from clinical symptoms and image also intraoperative findings. anastomotic method should be decided according to the case. aim: the aim of the study was to identify and highlight some of the complications one can encounter in bariatric surgery-specific-sleeve gastrectomy and discuss the therapeutic options one has at his disposal. methods: the study was retrospective. we identified a number of patients which had a sleeve gastrectomy done in our clinic for a year period. of these had important surgical complications encountered during the surgery or in postoperative care. results: the group included patients, with an average bmi of [ kg / m . average hospital stay was days, with an average of . days which increased to days when fistulas were encountered. the most frequent surgical complications were bleeding from the gastric suture ( ) and gastric fistula ( cases). other complications encountered were wound hematoma. surgery was required in of the cases of bleeding and of the fistula cases required reintervention. one case was resolved with endoscopic stenting. conclusions: laparoscopic gastrectomy is considered a safe procedure with good results for the patient. although complications are rare they pose a series of technical difficulties for the surgeon due to the weight of the patient and frequent comorbidities which come with obesity. a thorough understanding of the symptoms and good follow-up ensures the best results. aims: to achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (lagb) can be converted to a laparoscopic roux-en-y gastric bypass (rygb). there is limited data on the feasibility and safety of routinely performing a single-step conversion. we assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution. to the best of our knowledge this series represents the largest single-center study on conversion from lagb to rygb methods: between october and december , a total of patients who underwent lagb removal with rygb were identified from a prospectively collected database. in all cases, a single-stage conversion procedure was planned. the feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed. results: a single-step approach was successfully achieved in ( . %) of the patients. during the study period, there was a significant increase in performing the conversion from lagb to rygb single-staged. no mortality or anastomotic leakage was observed in both groups. only patients ( . %) had a -d complication: most commonly hemorrhage (n? = ? / ), with no significant difference between the groups. conclusion: converting a lagb to rygb can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. with increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. only a migrated band remains a formal contraindication for a one-step approach. surg endosc ( ) . six months after surgery the mean hrql score, was ( - ) in patients underwent to lsg and . ( - ) in patients underwent lgb. twelve months after surgery the mean postoperative questionnaire score was ( - ) in patients who underwent lsg. at ph-manometry the mean percentage time of acid reflux in orthostatism was . (range - . ) and in clinostatism . (range . - . ). the mean demeester score at the distal electrode was . ( . - . ). conclusions: in asymptomatic patients, complete gerd evaluation before bariatric surgery allows better selection of surgical procedure, to reduce the postoperative occurrence of severe or de novo gerd. postoperative gerd evaluation provides useful data regarding the impact of lsg on gastroesophageal reflux. a larger patient sample size is required. aims: vertical calibrated gastrectomy (usually know as gastric sleeve) as unique technique gives better results than the roux y bypass in terms of improvement of anthropometric measures, reduces comorbidities and has a lower rate of postsurgical complications, with an improvement of quality of life. material and methods: an observational, longitudinal, retrospective and comparative study with patients, aged - years,during a period of years. everyone must comply with the protocol of the unit. demographics of the population and the anthropometric data will be measured in the presurgical consultation, the month and the year after the surgery: weight, height, bmi, weight loss percentage,bmi percentage and percentage of excess weight lost. we took data on the cardiovascular risk by the framingham score. the quality of life is measured by baros scale. mayor comorbidities are hypertension, diabetes, dyslipidemia. complications will be measured in absolute frequencies. for de statistical study, we apply type t student or chi square being statistically significant p equal to or less than . . results: there was not statistically significant difference between the techniques of surgery month (p = , ), but they were evident to the year of the same (p . ). not gender or age differences were apparent. mayor complications did not appear in gastrectomy (no leaks), highlighting the number of bleeds with this surgical technique. the bypass there were two leaks. there was no statistically significant difference in cardiovascular risk (p = , ) between the two techniques. there was a more significant decrease in number of comorbidities in gastrectomy against the bypass, with a total disappearance of patients with dyslipidemia. there were no statistically significant differences in baros score, although it was higher in gastrectomy. conclusions:-the vertical gastrectomy as unique technique can be considered superior in the short term, as well as safe, according to the aec quality parameter. we think it will be necessary to continue their studies into the medium-long term. aims: analyze the impact of different bariatric surgeries technics in carbohydrate metabolism and pancreatic beta cell population of none obese adult wistar rats. methods: we used twenty healthy not obese adult wistar rats divided in five groups randomly assigned. each with n = . the control groups were divided into fasting control (f) and sham (surgical control). the surgical groups were separated into vertical gastrectomy (gs), % resection of the middle small bowel (ri ) and gastric bypass (gb). in each group was assessment: beta cell mass modifications, pancreatic islets histomorphometry, proliferation, apoptosis and neogenesis in beta-cell pancreatic population; intraperitoneal glucose test tolerance, body weight and food intake. statistical analysis as evaluated using mann whitney test. results: the malabsorptive and restrictive group have a significantly smaller increase weight than the control groups. the intraperitoneal tolerance glucose test reports incremental glucose area under curve (auc) was significantly higher in the malabsorptive group and lower in the restrictive group compare to the control groups during the second (p \ . ) and third (p \ . ) month of the study. the beta-cell mass was significantly higher in the ri group compared with control groups respectively. there was a significantly increased number of beta-cell per pancreatic insulin positive area in gs and gb. proliferation was significantly increased in ri and gb group, and significantly decreased in sg compared. there was no significantly difference during apoptosis assessment among surgical and control groups. in neogenesis differences between groups were assessed qualitatively by the presence pdx - expression, being higher in rygb. the endocrine pancreas in our model is altered by the anatomical and functional conditions arising from surgical techniques. carbohydrate metabolism conditions are affected by temporary adaptive processes due to surgical alternatives. there is a hyperplasia and hypertrophy of the beta cells in surgeries with a malabsorptive component, as well as greater neogenesis. these results could explain part of the existing relationship between the enteropancreatic axis and the existing incretins. m. buza, c. copaescu introduction: nowadays, we have high volumes of obese patients for whom surgery is the answer, but unfortunately the psychological evaluation has no standard recomandation in preoperative evaluation of bariatric patients. it is argued that surgery success, in addition to the operation itself, relies on behavioral changes and that one of the goals of the preoperative assessment is to prepare the patient for the postoperative period, aiming to optimize surgical results. aim: although no formal standard exists in the literature, there is growing recognition of the important elements to be addressed and the appropriate means for collecting the necessary data to determine psychological readiness for these procedures. methods: information regarding the components of the clinical interview and the specific measures used for psychological testing are discussed. given the limited data on predicting success after surgery, determining psychological contraindications for surgery is addressed. additionally, the multiple functions served by the psychologist during this assessment procedure are highlighted along with the value of this procedure in the patients' preparation for surgery as well as the postoperative follow-up. in our center of excelence for bariatric and metabolic surgery (coe) we introduced since a mandatory pre-and postoperative psychological evaluation for all patients addressing the metabolic program. results: psychological evaluation of patients before bariatric surgery is a critical step, not only to identify contraindications for surgery, but also-and more so-to better understand their motivation, readiness, behavioral challenges, and emotional factors that may impact their coping and adjustment through surgery and the associated lifestyle changes. postoperative follow-up is necessary. the psychological evaluation of the patient undergoing bariatric surgery is an invaluable piece of the larger pre-and post-surgical assessment, aiming better results in the short and long term after bariatric surgery. introduction: a mesenteric cyst is defined as a benign abdominal tumors that is located in the mesentery of the gastrointestinal tract, identified in * of , hospital admissions. mesenteric chylous cysts are rare pathologic entities that often present with unspecific symptoms. the preoperative diagnosis requires all the common abdominal imaging techniques. usually the correct diagnosis may be made only at the operation stage or during the histological examination. all mesenteric cyst should be resected in order to avoid their complications, complete surgical resection is recommended and curative in the majority of cases with a low risk of local recurrence. the laparoscopic approach is the gold standard in the treatment of intraabdominal mesenteric chylous cyst. laparoscopic resection provides less pain, shorter hospital stay, and early recovery for the patient. case report: we report a case of -year-old saudi woman who presented to our clinic complaining of upper abdominal pain and mass in the epigastrium for one week, no history of nausea, vomiting, or recent changes in bowel habits. her medical and family histories were clear and she had never had any abdominal interventions. abdominal palpation revealed a smooth-surfaced mass palpable in the left upper quadrant, ultrasonography and with computed tomography of the abdomen revealed an approximately mm unilocular cyst closely related to the mesentery in the left side of upper abdomen not related to the pancreas .the cyst was excised by laparoscopy complete surgical excision to avoid recurrence within healthy borders, it is contained milky white fluid. the histopathological findings were chronic inflamed mesenteric cyst. a review of the literature considering this rare entity was also performed to evaluate our treatment strategy. conclusion: mesenteric chylous cysts represent a diagnostic challenge and they should be considered when a physician encounters an intraabdominal mass. usually the correct diagnosis may be made only at the operation stage or during the histological examination. the treatment of choice is the complete surgical excision that can be safely performed by laparoscopy. surg endosc ( ) background: diverticulum of appendix is relatively rare, and appendiceal diverticulitis was reported to have a higher risk of perforation than appendicitis. in the us and europe, because of the high risk of perforation, preventive appendectomy is recommended to appendiceal diverticulosis, even if the patient has no abdominal pain. methods: we retrospectively reviewed the records of post-operative patients, who were diagnosed appendicitis or appendiceal diverticulitis on the pathological findings in our institution from january to october . all patients were performed computed tomography (ct) before operation. patients underwent laparoscopic surgery, including appendectomy, cecal resection, ileocecal resection and right hemicolectomy, while patients underwent open surgery. total of cases of appendiceal diverticulitis were analyzed in our study. result: patients had abdominal pain before surgery. patients were diagnosed appendiceal diverticulitis by preoperative ct. all patients underwent laparoscopic surgery ( appendectomy, cecal resection, and ileocecal resection). on the pathological findings, perforation of appendix was found in patients and the pseudo type of diverticula with no muscle layer was found in all patients. patients with appendicitis were treated surgically during the same period. among them, a perforation of appendix was found in cases. the perforation rate was . %. on the other hand, the perforation rate of appendiceal diverticulitis was . % in our study. conclusion: the perforation rate of appendiceal diverticulitis was higher than of appendicitis in our study. for the examination of the treatment strategy, including preventive appendectomy, the accumulation of more cases will be expected. case presentation: a -year-old man was referred to our hospital with right lower quadrant abdominal pain for days. his fever was . °c. his white blood cell count was , / ll, and c-reactive protein level was . mg/dl. ct revealed multiple diverticula of cecum and appendix. micro-abscess and free air were found around appendix. we diagnosed this case as appendiceal diverticulitis and laparoscopic appendectomy was performed. a perforation was found in resected appendix. microscopic study revealed a pseudo-diverticulum. the inflammation of appendix was stronger in serous membrane side than in mucosa side. this finding accorded with appendiceal diverticulitis. introduction: in order to reduce the abdominal trauma and the length of scar incisions (also during laparoscopic surgery) many approaches during the last decade has been proposed, such as single access laparoscopic surgery (sals). the aim of our paper was to update the data of our previous paper with a greater cohort of patients and a longer follow-up, also showing the single access laparoscopic left colectomy (salc) technique in particular with inferior mesenteric artery preservation imap (valdoni's technique). materials and methods: we made a retrospective analysis from october and october of all patients who underwent a sals approach for colorectal disease in the department of general and mininvasive surgery of san camillo hospital of trento. statistical analysis was performed using ibm spss statistics . continuous data were expressed as mean ± standard deviation (sd). categorical data were expressed as absolute number and percentage. the results are presented as -tailed values with statistical significance if p values \ . results: from october until october , salc for colorectal surgery were performed in our unit. of this , were for left colectomy. in cases we performed an imap. the salc with imap were performed only in case of benign disease. the mean operative time was . ± . . only one intraoperative complication were recorded, that was a splenic capsule tear, resolved with apposition of fibrillar haemostats. according to clavien dindo classification there were in particular grade ii complications, a bleeding solved with blood transfusion and one pancreatitis solved with medical therapy; grade iiia complications that was anastomotic bleeding solved endoscopically (the two complications raised in patients with imap) and iiib complications due to anastomotic leakage which needed reoperation. the mean length of incision was . ± . cm. logistic regression did not show any correlation between imap and any complications. conclusion: in conclusion, salc is a safe but very challenging technique which need a longer learning curve than the conventional laparoscopic one. in laparoscopic colectomy, also, imap seems to be safe and effective without correlation with post-operative complications also if performed in single access laparoscopic approach. aims: to describe an infrequent anatomical variation that can give rise to diagnostic and therapeutic difficulties. methods: patient with ivermark syndrome (situs ambiguus and polysplenia) with acute appendicitis and bibliographic review results: a -year-old male who consulted for flank and right hypochondrium pain of h of evolution, associated with nausea without vomiting, no fever noir other symptoms. to the physical examination good general condition. painful to palpation selectively on the flank and right hypochondrium, with involuntary defense and positive decompression at this level. the signs of rovsing and psoas were negatives. in the analytical performed leukocytes of , with neutrophils in % and rpc (reactive protein c) in mg/l. abdominal ct (computed tomograph): cecum and the ilio-cecal valve were visualized at the subhepatic level with tubular structure on the side and seemed to correspond to the cecal appendix which is increased in size ( mm), with findings suggestive of acute appendicitis. sigma and descending colon located in right hemiabdomen. second per duodenal portion located anterior to the superior mesenteric artery. superior mesenteric vein located to the left of the superior mesenteric artery, rotating around it, (radiological signs compatible with intestinal malrotation). no free fluid collections nor pneumoperitoneum. laparoscopic appendectomy on phlegmonous acute appendicitis without incidents. correct post-operative course, being discharged at h; the pathological anatomy was reported as acute appendicitis in phlegmonous. conclusions: ivermark syndrome is a genetic alteration with a multifactorial inheritance pattern, characterized by an alteration in the situation of the mesenteric vessels, which leads to abnormal rotation of the intestine during the embryonic period and alteration of the situation of different intra-abdominal organs, without a specific pattern that is pathognomonic, is associated with congenital heart anomalies between and %. reaching adulthood only between and % of them. a case of acute appendicitis is presented in a patient with this anomaly, which can lead to diagnostic and therapeutic difficulties due to the anatomical variations involved. abdominal tomography is the image method that provides the best performance for the diagnosis of acute pathologies in this type of patients. background: the clinical manifestations which occur in relation to decompression during scuba diving are variable. mild symptoms have often been reported in gastrointestinal tract. this is one of the severe cases with gastrointestinal barotrauma. ischemic colitis caused by air embolism very rare, therefore it is to be reported and discussed. case presentation: a -year-old man visited our emergency room with diffuse abdominal pain and bloody diarrhea days ago. the patient was a skilled diver who took seafood through diving for years. two days before presenting, the patient had severe abdominal pain just after diving for h at a depth of meters. he was immediately transferred to a local hospital for hyperbaric oxygen therapy, but there was no improvement with the symptom. abdomen ct angiography showed terminal ileal, ascending, sigmoid colonic and rectal decreased enhancement with wall thickening. sigmoidoscopy showed diffuse huge ulcerative lesions and ischemic changes on mid rectum and sigmoid colon. emergent subtotal colectomy and temporary loop ileostomy were done, and pathologic findings revealed diffuse mural infarct with serosal abscess formation in whole colon and transmural infarct in terminal ileum. conclusion: surgical approach could be one of the treatment options, though it depends on severity of the symptoms and the patients' conditions. colonic lipomas are extremely uncommon benign tumours, with an incidence ranging between . % and . %. although they are most frequently asymptomatic, when colonic lipomas are [ ?cm, they may present symptoms such as constipation, abdominal pain or rectal bleeding. most colonic lipomas typically occur in middle aged women and are located in the ascending colon and the caecum, while occurrence in other parts of the colon and rectum is rare. in this case report, we describe a lipoma that caused descendent bowel intussusception. a -year-old male presented with longstanding history of constipation. personal history of interest included active smoker, hypertension, hypercholesterolemia, psoriasis with joint affectation and reiter syndrome. he had had no previous surgery. he attended the emergency services on th july with a two-day bowel obstruction, without fever or nausea, being attended by our surgical emergency unit. he had been assessed during the previous months by gastroenterology, with a colonoscopy that showed a cm submucosal lesion that partially occluded descendent bowel, with inconclusive biopsy. an abdominal contrast-enhanced computed tomography (ct) was performed, confirming a welldefined mass located in splenic flexure of descendent bowel, conditioning a large bowel intussusception, nevertheless with no obstructive acute signs. the surgery was scheduled a few weeks later, performing a laparoscopic segmental resection with primary anastomosis including oncologic margins. the patient evolved satisfactorily in the postoperative period and was discharged six days after the surgery without any complications. likewise, he was monitored on a regular basis at our outpatient department and was free of symptoms at the -month follow-up visit. the histological analysis revealed a cm ulcerated lipoma affecting % of bowel circumference. the molecular study, using fluorescent in situ hybridation (fish) showed no mdm gene amplification. laparoscopic segmental resection of the large bowel is a safe and feasible technique for the treatment of large bowel intussusception caused by a colonic lipoma. the complete removal of the lipoma will condition the prognosis. furthermore, in the future, endoscopic surgery using colonoscopy could be employed when having a certain preoperative diagnosis of lipoma. surg endosc ( ) introduction: acute appendicitis is one of the most common abdominal surgical emergency, the diagnosis of which mostly relies on conventional methods such as physical examination and blood tests. the use of ultrasonography and ct abdomen aids in more precise diagnosis especially in patients with atypical presentation or in elderly. aim: this study aims to evaluate the ability of the neutrophil/lymphocyte ratio (nlr), platelet/lymphocyte ratio (plr) and mean platelet volume (mpv) in predicting the diagnosis of acute appendicitis. methods: retrospective analysis of prospectivly maintained data of all patients ( ) admitted with acute appendicitis to the emergency department at a tertiary hospital in the middle east between january till september . medical records and database of patients,who had appendicectomy for clinically and radiologically proven appendicitis, were reviewed. the retrieved data included patient's demographic and laboratory values of white blood cells (wbc), neutrophil (n), lymphocyte (l), and platelet (p) along with their ratios for comparison. results: spss version was used for tabulating the data. the recommended cutoff value of the nlr, plr and mpv in predicting the diagnosis of acute appendicitis was decided by using receiver operating characteristic (roc) curve analyses. at least for nlr, the confidence interval (ci) was . which is percentage of the positive values, since the confidence limit was between to %. our results showed that the laboratory parameters were fairly significant since the confidence interval was . in predicting the diagnosis in our population. conclusion: although appendicitis is a clinical diagnosis but laboratory parameters specially nlr, plr and mpv can be used as an adjunct in the diagnosis of acute appendicitis. literature is scarce concerning the validity of such parameters in our part of the world and prospective randomized controlled trials are needed to prove the efficacy of such rationale. objective: tumors of the cecal appendix represent a subset of colonic neoplasms whose early diagnosis is a real clinical challenge. correspond to . % of all gastrointestinal tumors and their prognosis depends on the type of injury, being the most frequent variety the carcinoid type. appendix involvement in endometriosis is rare, accounting for % of all endometriosis cases, and sometimes mimicking cecal tumors. methods: a -year-old woman with a history of hypothyroidism due to autoimmune thyroiditis and atrophic gastritis with gastric neuroendocrine tumors resected by endoscopy that in the digestive unit reviews, tac with double contrast was requested, showing a lobulated lesion in the cecum adjacent to the ileocecal valve, with contrast enhancement of approximately mm, suggestive of tumor. the colonoscopy evidenced a protruding appendicular osteum with inflammatory aspect that was biopsied. the pathological anatomy of the biopsy reports chronic congestive colitis with edema of the own blade and minimal acute activity, with moderate local eosinophilia.the case was presented in the multidisciplinary oncology committee and it is decided, due to the patient's background, to perform surgery on the lesion. laparoscopic right hemicolectomy was performed, with extracorporeal latero-lateral mechanical anastomosis with endogia signiaÒ mm. results: the patient evolves favorably, with good oral tolerance and depositional habit. she is sent home at the sixth postoperative day. the pathological anatomy reports tumor injury in the appendicular ostium compatible with endometriosis at the base of the cecal appendix implantation, ruling out malignant tumor pathology. conclusions: gastrointestinal tract endometriosis represents - % of cases, being most frequently located in the rectal-sigmoid region. appendix involvement in endometriosis is rare, accounting - % of all endometriosis cases and presents a preoperative diagnostic challenge, because sometimes mimicking a carcinoid cecal tumor. in our case, due to the patient's history, we assumed that the cecal lesion was a carcinoid tumor, so we performed a laparoscopic right colectomy, but if we had known that it was an endometriosis, we could have performed an appendectomy, although in both cases the laparoscopic approach gives us some benefits compared to the open approach aims: the natural history and predictive factors associated with chronic anastomotic complications have not been clearly studied. the aim of this study was to evaluated the predictive factors related to chronic anastomotic complications methods: from january to december , a total of patients who underwent anastomotic leakage were enrolled in this study. all patients underwent anterior resection with or without defunctioning stoma due to colorectal cancer. the patients received follow-up by clinical examination and abdominopelvic computed tomography (ct). they underwent a follow-up ct every months for the first year and then every months for the next years after that. complicated group (cg) underwent chronic anastomotic complications. normal group (ng) didn't underwent chronic anastomotic complications like stricture, fistula, chronic sinus, etc. results: there were no significant differences in gender, age, preoperative chemoradiotherapy and operation type between two groups. low rectum lesion and defunctioning stoma at the time of primary surgery were more frequent in cg (p = . , . ). there were no significant differences in type of anastomotic leakage, international leakage grade and ct findings at the time of diagnosis of anastomotic leakage. however, abnormal ct findings at the time of month were more frequent in cg group (p \ . ). in multivariate analysis, abnormal ct finding at the th months was only significant factor related to chronic anastomotic complications. conclusions: abnormal ct findings at the th month associated with prediction of chronic anastomotic complications. aims: acute appendicitis is the most common cause of acute abdomen requiring surgical intervention in the world. nowadays, standard treatment of acute appendicitis involves a surgical approach, eitherlaparoscopic or open.the purpose of the present study is to evaluate the safety of a discharge within less than h after performing appendectomy as a result of an uncomplicated acute appendicitis. conclusions: patients who undergo appendectomy (open or laparoscopic) for acute uncomplicated appendicitis, without surgical incidents and an adequate social/family network, can be discharged in less than h without a higher risk of post-operative complications or readmissions than patients with longer postoperative stays. it will be necessary to conduct more prospective studies with higher level of evidence that could corroborate our results. aims: median arcuate ligament syndrome (mals), also known as the celiac axis compression syndrome, is a rare condition caused by to the compression of the celiac trunk and the nerves located in this area (celiac plexus) by the median arcuate ligament. it is believed that mals is caused by the median arcuate ligament compression of the celiac plexus nerves over the celiac trunk, but another probably cause may be the lack of blood flow to the organs supplied by the celiac artery, however, this theory is controversial. the first clinical sign of mals is the apparition of postprandial abdominal pain in the upper abdomen. this typical pain forces patients to avoid eating, which can lead to loss weight (often more than pounds). other associated symptoms may include nausea, diarrhea, vomiting and delayed gastric emptying (a delay in food moving from the stomach into the small intestine). in relation to this uncommon condition, we present a clinical case of laparoscopic management of mals. methods: we present a -year-old patient with complaints of recurrent epigastric pain, postprandial vomiting and loss weight. blood tests and gastroscopy were performed to help ruling out more common causes of his symptoms, such as gastroesophageal reflux disease (gerd), gastritis or gastroparesis. as a part of the differential diagnosis, mals was suspected and a mesenteric doppler ultrasound was ordered to check blood flow through the celiac trunk and evaluate a possible compression of the celiac plexus. also, an angio-ct scan was also performed to confirm the diagnosis. once the mals was diagnosed, we decided to perform a laparoscopic approach as definitive surgical procedure. results: the patient was discharged h after surgery with no remarkable events during his postoperative stay. he has been followed up during months, remaining asymptomatic. conclusions: laparoscopic approach in mals offers a superior visualization during the surgery and involves lower morbidity in compare to open approach, which makes it an optimal treatment for this condition. aim: pilonidal sinus is a common disease with annoying and often painful symptoms. traditional surgical techniques for its treatment are characterized by either intense postoperative pain and prolonged wound-healing periods (wide resection, marsupialization) or unsatisfying aesthetic results (advancement or rhomboid flaps). 'endoscopic pilonidal sinus treatment' (epsit) is a new minimally invasive technique which utilises the meinero scope, primarily designed for the endoscopic treatment of complex perianal fistulas in a technique known as vaaft. we present our experience and outcomes in three treatment centers in northern greece. methods: between july and november we treated patients with pilonidal sinus using the epsit technique. the mean age of patients was , and % of them were male. patients were treated in the acute phase with the presence of pilonidal abscess. all operations were performed by two laparoendoscopic surgeons specifically trained in the technique. most patients were treated on a day-case basis. postoperative wound care included daily tract irrigation with ml of saline for a total of days. results: there were no immediate postoperative complications. medium postoperative pain was . on a vas scale. % of patients were discharged on the same day, patients remained in hospital for one day mainly due to social reasons. return to daily activities was immediate. in a maximum follow-up of months we observed recurrences. conclusions: epsit is a promising minimally invasive technique for the treatment of pilonidal sinus. what makes it mostly attractive is the minimal amount of postoperative pain, the excellent cosmetic result and the fast recovery with return to daily activities. introduction: isolated acute chylous peritonitis is a rare event. when presented as an acute abdomen warranting surgical intervention, it is often difficult to determine the cause pre-operatively. here, we report a case of acute chylous peritonitis due to meckel's diverticulitis presented with the clinical features suggestive of acute appendicitis. presentation of the case: a -year-old female presented with abdominal pain and clinical features consistent with acute appendicitis underwent diagnostic laparoscopy. she was found to have four-quadrant chylous peritonitis and ileus caused by an inflamed meckel's diverticulum adhered underneath a loop of small bowel and mesentery leaking chyle. after uneventful postoperative recovery, she was discharged at post-operative day two with oral antibiotics and was advised to take a low-fat diet. aims: perforated diverticulitis with purulent peritonitis (hinchey iii) has traditionally been treated with surgery including colon resection and stoma (hartmann procedure) with considerable postoperative morbidity and mortality. laparoscopic lavage has been suggested as a less invasive surgical treatment. methods: a -year-old woman with a -day history of abdominal discomfort exacerbed during the last h. ct scan showed neumoperitoneum accompanied by free fluid and a cm collection adjacent to descending colon showing diverticula suggestive of covert perforation. after h of non-response to medical treatment, associated with the impossibility of percutaneous drainage through interposition of intestinal loops, colon and lumbar vessels, urgent surgical intervention is decided. results: laparoscopic lavage of all quadrants was performed with saline, l or more, of body temperature, until clear fluid was returned. two non-suction j-pratt drains were placed. intravenous antibiotics were continued for a minimum of h, then oral antibiotics were continued for week. oral fluids were commenced on the first postoperative day and solids were subsequently introduced, depending on clinical progress. conclusion: laparoscopic management is reasonable alternative to the traditional open resection for hinchey grade ii-iii perforated diverticulitis with generalized peritonitis. this approach has a low mortality rate despite patient co-morbidity and disease severity. benefits include stoma avoidance and minimal wound infection. subsequent elective resection is probably unnecessary and readmission in the medium term is uncommon. background: constipation and fecal incontinence are common annoying complications after pull through procedures for hirschsprung disease (hsd). many causes could be the etiology of these problems. perineal descent syndrome could be the major hidden cause of these complications. the aim of this study is to evaluate the role of perineal descent syndrome in the development of post pull through constipation and fecal incontinence in addition to evaluate the role of laparoscopic rectopexy for treatment of these problems. \ b[patient and methods: \/b [ patients treated with pull through for hsd over the period of five years. out of the patients presented with constipation and fecal incontinence. patients with constipation and patients with fecal incontinence. rectal exam, anorectal manomety, defecography, contrast enema, rectal biopsy, emg, proctoscopy and endorectal ultrasound were performed to all patients. patients with stricture, missed aganglionic segment, injured internal anal sphincter, and loss of the sensory mucosa above the dentate line were excluded from the study. anterior wall rectopexy was performed for anterior wall rectocele. posterior wall rectocele was treated by retro rectal mesh rectopexy. emg is repeated weeks and months after surgery. outcome measurements included constipation, fecal incontinence and pudendal nerve latency. results: cases of post pull through constipation and fecal incontinence. patients with constipation and patients with fecal incontinence. patients with stricture, patients with missed aganglionic segment, patients with loss of anal sensory sensation and patients with injured anal sphincter were excluded from the study. defecography showed patients with anterior rectocele ( males and females) and patients with posterior rectocele ( males and females). the patients mean age . ± . years . emg showed prolonged pudendal nerve conduction in all cases. anterior wall and retro rectal rectopexy were performed laparoscopically without complications. constipation was resolved in all patients after surgery. all patients showed fully control in defecation. pudendal nerve latency decreased in all patients. conclusion: perineal descent syndrome proved to be a major hidden cause of post pull-through constipation and fecal incontinence. laparoscopic rectopexy showed a good solution of these complications. cystic lymphangioma is a rare entity. the surgical indication is determined by the size and symptomatology, and consists of the complete exeresis of the tumor. the laparoscopic approach is feasible in these cases, allowing a broad visualization of the anatomy, accessibility to the retroperitoneum in the context of a minimally invasive approach and a better recovery of the patient, without providing an increase in morbidity compared to the conventional. in this way we defend as a technique of choice laparoscopic surgery against these rare tumors for the general surgeon in the abdominal cavity, betting on a minimally invasive surgery. aims: laparoscopicposterior sutured rectopexy is one of the accepted treatment options for fullthickness rectal prolapse. recently, reduced port surgery(rps) has beenan emerging concept that, compared with conventional multiple port surgery (mps), yields reduced postoperative pain and improved cosmesis. the aim of the study is to evaluate the feasibility and safety of rps for fullthickness rectal prolapse. methods: rps was performed by single-incision plus one puncture, using internal organ retractor(ior) to secure operative field. straining one ior by - strings in - directions makes it possible to retract the internal organs three-dimensionally. this multi-directional flexible retraction could secure good operative field. from to , patients (rps: cases, mrs: cases) underwent laparoscopicposterior suture rectopexyfor total rectal prolapse. shortterm outcomes were compared between the two procedures. results: there was no significant difference between rps and mps in median operative time ( vs . min, respectively, p [ . ). the median blood loss volume was not significantly different between rps and mps groups ( . vs . ml, p \ . ). the duration of median hospital stay after surgery was not significantly different between two groups ( . vs days, respectively, p [ . ). the frequency of complications after surgery were not different between them. conclusions: reduced port lap-rectopexy can be a good therapeutic option for total rectal prolapse. a prospective, randomized, controlled trial should be conducted to confirm the superiority of this procedure over mps. the piccolo project proposes a new compact, hybrid and multimodal photonics endoscope based on optical coherence tomography (oct) and multi-photon tomography (mpt) combined with novel red-flag fluorescence technology for in vivo diagnosis and clinical decision support. for its development it includes different phases of validation. within this framework, the present study has as main objective: to characterize a model of rat colonic hyperplasia, which will be used for the development and validation of the previously mentioned endoscopic technology. secondary objectives: procure the reproducibility of the model chosen and determine the optimal time, after induction of the model. material and methods: animals (rattus norvegicus), wistar, males and females \ -yearold, randomly distributed. group (n = ): by laparotomy, a non-resorbable suture (silk / ), not stenosing, is placed through the wall of the colon. group (n = ): by endoscopy, a . mm long segment of a polymeric catheter is inserted, which is fixed to the wall of the colon by means of a suture. group (n = ): by means of endoscopy, a self-expanding and uncoated metallic stent are placed in the colon. group (n = ): a superficial laser resection of the colonic mucosa is performed by endoscopy. group (n = ): as an extension of the most optimal model. weekly, the animals were anesthetized again to perform a colonoscopy, which determined the degree of mucosal growth in descending colon and colonic biopsies were extracted weekly ( weeks). results: group . growth around the sutures after the second follow-up, diagnosed as hyperplastic polyps after a histopathological analysis. aim: the role of laparoscopy in the management of generalized appendicular peritonitis is controversial. this is due mainly to the lack of scientific data. through this study and a laborious bibliography research, we proposed to report our experience in terms of postoperative results, in the laparoscopic treatment of generalized appendicular peritonitis and to try to identify the risk factors associated with the occurrence of global morbidity and conclude on the feasibility of this technique in its treatment. methods: we conducted a retrospective study including all cases of generalized appendicular peritonitis managed laparoscopically, in the general surgery department of charles nicolle hospital between january and december . results: we identified patients. the mean age was . years. one fifth of the cases required a midline conversion ( . %). the mean operative time was . ± , min. the overall morbidity rate was % including surgical complications. there were no deaths. in uni-variate analysis, comorbidity, crp [ mg /l, operative time exceeding min and midline conversion were significantly associated with postoperative morbidity. co-morbidity, diabetes, asa score [ , delay of consultation [ days, intra-abdominal abscess and operative time exceeding min were significantly associated with medical complications. the univariate analysis also revealed that crp [ mg /l and midline conversion were predictive of surgical complications.the multivariate analysis identified the midline conversion as the only independent factor significantly associated with post operative morbidity (odds ratio = . , % confidence interval [ . - . ] ). conclusion: based on our results, it appears reasonable to continue the laparoscopic management of diffuse appendicular peritonitis. however, enhance this technique is basic in order to reduce midline conversion rate and to shorten operative time, which can lead to post operative complications. aims: currently, acute appendicitis is the most common surgical emergency. laparoscopic appendectomy is the usual procedure to treat acute appendicitis. the aim of this study is to evaluate the safety of electrocoagulation in the treatment of mesoappendix in laparoscopic appendectomy. methods: we have retrospectively studied a prospective database of operated patients of appendecectomy in emergency surgery unit. we have reviewed laparoscopic appendectomies from june st, to december st, . the mesoappendix was electrocoagulated in every laparoscopic appendectomy. the statistical analyses has been done with spss . version. results: our group consists of patients of which . % were male and . % were female. the average age was . years with a standard deviation of . % and p was . years. the most common total stay was day ( patients). the usual post-operative stay was one day ( ). we classified the diagnosis in complicated apendicitis ( patients) and no complicated apendicitis ( patients). the conversion rate was . % ( ). the main surgical complications were: surgical wound infection ( . %); intraabdominal abscess ( . %); and bleeding ( %). only one of the patients that suffered bleeding had complicated appendicitis. the medical complications were catheter sepsis ( . %); respiratory infection ( . %); cardiologicals ( , %); and paralytic ileus ( . %). the treatment of mesoappendix with electrocoagulation is safe and effective since the complications rate is very low. even so, it would be necessary to conduct more prospectives randomized studies in order to get enough evidence about the treatment of mesoappendix with monopolar electrocoagulation. introduction: the difficulty of resection of the rectum is determined by its anatomical relationships, intimately in contact with the bladder, seminal vesicles, prostate and urethra in the case of the male, vagina in the woman and nerve structures that will give defecatory, genital and urinary functionality. this structure creates a big impediment due to problems of visualization and difficult dissection, in such a way that conventional surgical techniques instigates a series of complications derived from this difficulty. we propose a new approach in rectal surgery in patients with inflammatory bowel disease. material and methods: a -year-old man with a history of ulcerative colitis developed a severe acute outbreak refractory to treatment. a total laparoscopic colectomy with a terminal ileostomy was performed in . in he was notified for reconstruction. we evidenced a rectal stump of about cm with signs of inflammatory disease at the mucosal level. a transanal proctectomy was performed with confection of 'j-pouch' and ileoanal anastomosis about cm from the anal margin by laparoscopy. the postoperative courses favorably, being discharged on the sixth day. currently in follow-up in digestive and general surgery, he is asymptomatic and he has an optimum level of quality of life valued by the sf- weeks after the intervention. conclusions: our service introduces the transanal approach to the performance of proctectomy in cases of inflammatory disease, a technique that provides clear advantages by improving visualization and the identification of anatomical structures. in this way, a safe dissection of the pelvis is achieved, adjusted to the serosa of the rectum, with preservation of the mesorectum and the hypogastric plexus, and with the consequent improvement of the genital and urinary function. the result is an equally safe surgery, which implies little increase in operative time and with better and shorter postoperative recovery.the conservation of the pelvic innervation avoids disorders of ejaculation, vaginal lubrication and bladder and rectal motility. the transanal approach for the performance of proctectomy provides benefits in terms of the preservation of the hypogastric plexus, minimizing the anatomical difficulties involved in rectal surgery and maintaining urinary and sexual function. aims: to evaluate the feasibility and outcomes of laparoscopic appendicectomies in both simple and complicated appendicitis, given the increasing trend towards a laparoscopic approach in the last four decades for the treatment of acute appendicitis. we present data from a district general hospital over a -year period. methods: we retrospectively analysed a single consultant's continually updated database of laparoscopic appendicectomies between / / and / / ( months). patient demographics, investigations, intraoperative findings and postoperative outcomes were recorded and analysed. complicated appendicitis was defined as the formation of appendiceal mass or abscess with or without perforation and peritonitis. results: cases of laparoscopic appendicectomies were identified during the specified period. the median patient age was (range - years). true positive rates for uss and ct were % and %, respectively. the rate of negative appendicectomies was %. transanal minimally invasive surgery (tamis) has been used for the treatment of rectal neoplasms such us benign polyps and early rectal cancer. when the tumour is located in the upper rectum or close to the rectosigmoid junction, this approach may be technically dificcult.we present a video of a tamis resection of a large polyp located cm from the anal verge. after properative examination and ct and mri were performed, the patient was prepared for surgery, and a trasnanal minimally invasive surgery was proposed.resection of the polyp was performed with the aim of an endogia and conventional laparoscopic materials. total resection of the polyp with free margin was possible. the postoperative pathology report confirmed a high grade displasia villo-tubular adenoma with a lesion free margin. tamis resection of tumours located above the rectosigmoid junction may be a safe and feasible technique in selected patients. aims: pelvic organ prolapse (pop) is a very relevant problem for women's quality of life and has a prevalence of about % defined by symptoms and up to % when established by physical examination. nowadays, sacrorectopexy for posterior pop and sacrocolpopexy for apical pop are considered the gold standard techniques. recently, we have seen that laparoscopic lateral suspension is a feasible procedure for apical pop, obtaining a success rate higher than % at one year. these results are similar to what we can achieve with sacrocolpopexy. methods: we herein present the case of a -year-old woman with apical and posterior pop, this was provoking an important impact on her quality of life, with obstructive defecation (needing digitations) and urinary incontinence. we proposed sacrorectopexy for her posterior pop and laparoscopic lateral suspension for her apical pop. in the video we can see how we perform a ventral mesh sacrorectopexy, following d'hoore technique; and a laparoscopic lateral suspension with preperitoneal dissection, following the technique described by the team headed by dubuisson and veit-rubin. we used laparoscopic ports ( , , . and . mm). results: patient was discharged home on the second postoperative day and has not had any sign of recurrence or extrusion after more than two years of follow-up. in addition, she has not suffered lower urinary tract symptoms, constipation or pain. conclusions: we present a case in which we have carried out a laparoscopic lateral suspension instead of a sacrocolpopexy for an apical pop, obtaining good short-term and long-term results. we consider it is very soon to assess this technique's efficacy and it has to be validated in studies with larger source of patients. nevertheless, we think this procedure might become an excellent alternative to sacrocolpopexy for apical pop. aims: laparoscopy is a minimally invasive approach with low morbidity. the aim is to show the usefulness of the laparoscopic approach for massive intra-abdominal abscesses, which it is controversial. we report three patients who underwent emergency laparoscopy for peritonitis or massive intra-abdominal abscesses not amenable to percutaneous approach that were suspected to be caused by acute diverticulitis. methods: all patients had diagnosis of acute diverticulitis (hinchey ii-iii grade) with pelvic abscesses situated between sigma and bladder or diffuse peritonitis. the patients with hinchey ii grade had failed conservative management with antibiotics. they underwent emergency laparoscopy under general anaesthesia, with three abdominal ports. intra-abdominal abscess cavities were exposed and the purulent exudate was sampled and aspirated. copious irrigation was performed under direct vision and thorough examination without other findings. the procedure was completed laparoscopically in all cases. results: all patients had favourable evolution. one of them had a properly drained faecal fistula which changed to a purulent fistula on the twentieth postoperative day. this patient underwent laparoscopic left colectomy three months later because he had have a new episode of acute diverticulitis. other two cases showed very good clinical evolution, without evidence of fistula in postoperative period and they were complete asymptomatic one month later. conclusion: in our experience laparoscopic drainage is a feasible, safe, and effective for the treatment of pelvic abscesses and diffuse peritonitis secondary to acute diverticulitis. n. pinheiro, a. ziegler introduction: solitary rectal ulcer syndrome (susr) is characterized as a rare disease whose pathophysiology remains uncertain. it was first described in by cruveilhier and his clinicopathological feature was reported in by mandigan and morson, where he is associated with defective disorders, internal rectal prolapse, and psychological changes. according to works about % of the patients are asymptomatic. when symptomatic the diagnosis can be made through physical examination, clinical history and, often, confirmed by endoscopy with biopsies. treatment depends on the severity of the symptoms and the existence of associated rectal prolapse. according to the literature, conventional surgical options include local excision, rectal mucosectomy, retopexy, and segmental colonic resection. rolato: a -year-old male complaining of anal bleeding at bowel movements years ago. he performed, several times, conservative treatment, but without improvement. he sought proctological care and underwent colonoscopy, in which he showed an ulcerated lesion on the anterior wall of the distal rectum. new investigation with videodefecogram revealed colorectal intussusception with associated mucosal prolapse, being considered the factor causing the ulcer. elected by the sacropromontofixação. evoluiu with improvement of anal bleeding, mucorrhea and anal discomfort. after a proctological examination, which was normal, a control colonoscopy performed after months of surgery revealed rectal mucosa, with residual scarring and disappearance of the submucosal nodule present in the initial examination. reassessed after months, the patient is asymptomatic. conclusion: rectal solitary ulcer whose causal factor was a colorectal prolapse (intussusception) with mucosal exteriorization through the anal canal, which was individually treated with sacropromontofixation. j.p. mali, p.j. mentula, a.k. leppäniemi, v.j. sallinen approximately - % of patients diagnosed with colonic diverticulitis have an intra-abdominal abscess as a complication. abscess diameter of - cm is generally accepted as a cut-off determining the choice of treatment between antibiotics alone and percutaneous drainage. the aim of this study was to analyze the treatment choices and outcomes of patients with diverticular abscesses. this was a retrospective cohort study which was conducted in helsinki university hospital, an academic teaching hospital functioning as secondary and tertiary referral center. patients with computer tomography-verified acute left-side colonic diverticulitis with intra-abdominal abscess were collected from a database containing all patients treated for colonic diverticulitis in our institution during - . altogether, suitable patients were included in analyses. those treated primarily with percutaneous drainage or antibiotics alone ( and patients, respectively) were further compared in regards to treatment results. the main measured outcomes were need of emergency surgery and -day mortality. abscesses under mm were mostly treated with antibiotics alone with high success rate ( out of , %). in abscesses over mm, the use of emergency surgery increased and use of antibiotics alone decreased with increasing abscess size, but the proportion of successful drainage remained at - % regardless of abscess size (figure ). there were no differences in failure rate, -day mortality, need of emergency surgery, permanent stoma, recurrence, or length of stay in patients treated with percutaneous drainage versus antibiotics alone, even when groups were adjusted for potential confounders. white blood cell count = . * /l, abscess diameter = mm, and corticosteroid medication were independent risk factors for failure of treatment with antibiotics alone. patients without these risk factor had % and patients with one risk factor had % success with antibiotics alone. percutaneous drainage as treatment for large abscess does not seem to be superior to treatment with only antibiotics. majority of patients with abscesses over mm in diameter undergo surgery as primary intervention. introduction: even today, 'chronic appendicitis' is a clinical term that is not widely accepted nor well documented amongst the medical community. its etiology is the presence of a mass (e.g. fecal mass, hyperplasia of lymphatic tissue, etc.) that continuously and partially obstructs appendix lumen. it is presented as a low intensity, intermittent, with exacerbations and remissions, abdominal pain that is located at the right iliac region. the pain lasts up to several months and it is usually underestimated by the patient. its diagnosis is based on imaging examination. appendectomy is the treatment of choice for chronic appendicitis. the operation is challenging for the surgeon who has to cope with an intensively inflamed area around the appendix without the ease of access to that area. purpose: to present our laparoscopic approach to a chronic appendicitis case and to review the literature. case report: a -year-old woman is hospitalized due to chronic appendicitis. the patient was treated conservatively with the use of intravenous antibiotics in two separate hospital admissions dated and months back respectively. eight weeks after the last exacerbation, she underwent a laparoscopic appendectomy. results: even though the procedure was planned six months after the first episode, the laparoscopy revealed a severe inflammation of the appendix, which was extended to the caecum and the surrounding preperitoneal tissues. although the difficultness of the operation it was completed successfully laparoscopically. the histological examination confirmed without any doubt the existence of 'chronic appendicitis'. the patient was discharged uneventfully the third postoperative day. conclusions: chronic appendicitis is an existing clinical entity that the surgeon may come through during his career. in the hands of experienced laparoscopic surgeon, the laparoscopic approach is feasible and safe. introduction: ventriculo-peritoneal shunting (vps) used in the treatment for hydrocephalus is associated with several complications.the exact cause of such extrusion is not known. visceral perforation is an unusual but serious complication with consequeces such as peritonitis, meningitis or encephalitis. management involves prompt removal of shunt, intravenous antibiotics, an adequate recovery gap so that cerebrospinal fluid culture is sterile and then followed by shunt replacement on opposite side. aim: multidisciplinary approach of extrusion of vps through anus by laparoscopic and external ventricular drainage. case exposure: a -year-old woman had a vps inserted year ago after excision of gangliocytoma due to lhermitte-duclos disease. she was admitted in the emergency department without symptos after trans-anal protrusion of vps catheter. the neurological and abdominal evaluation was normal. laboratory tests did not reveal disorders and abdominal ct-scan suggested perforation, itshowed the insertion of the end of the catheter in sigma, without pneumoperitoneum or intraabdominal free fluid. cranial ct-scan did no describe sings of hydrocephalus. the patient underwent an emergencysurgical intervention. first of all, antibiotic therapy was initiated and neurosurgery's team was performed an external ventricular drain and they disconnected the proximal catheter side. after that, an exploratory laparoscopy was performed. it revealed a microperforation and collection beside to an appendix' base due to the proximity with the catheter. additionally, the catheter was freed from adhesions at the point of entry into the colon and after careful dissectionwe release the vps from colon with a . cm transmural trajectory at the sigmoid level. no free fluid was seen and rest of the bowel appeared normal. the distal end was removed through the anus and the proximal end through a laparoscopic port. we performed a laparoscopic segmental cecum resection and an extracorporeal colo-colonic anastomosis was performed for a mini-pfannestiel laparotomy of assistance. there were no complications in the postoperative period, being discharge on the th day. conclusion: the multidisciplinary approach and the laparoscopic support in the diagnosis and treatment of patients with colon perforation caused bay vps catheter is a feasible and safe option in third level centers. background: acute appendicitis continues to be the most common source of complicated intraabdominal infection worldwide. the high incidence of postoperative complications and dissatisfaction with the results of treatment in cases of complicated appendicitis and peritonitis gave the reason for conducting this study. aim: to evaluate the effect of different laparoscopic trocars position in case of laparoscopic appendectomy for diffuse appendicular peritonitis for the incidence of postoperative complications methods: the results of laparoscopic treatment of patients with acute appendicitis complicated by diffuse peritonitis were analyzed. the first group consisted of ( %) patients operated by triangulation access (type trocar placement according sages guidelines for laparoscopic appendectomy (sages qla). the second group consisted of ( %) patients operated by sectorisation access (type sages qla). postoperative complications were classified by clavien-dindo classification. results: the duration of the operation for the analyzed groups was . ± . vs . ± . min. there were no deaths among this group of patients. the incidence of postoperative complications for both group was . %. postoperative complications in the triangulation and sectorisation group were % and . % respectively (p . ). clavien-dindo iiib complications were noted in . % (n- ) patients and presented with intra-abdominal abscesses (iaa). all patients with iaa were operated in sectorisation group. conclusion: sectorisation trocar placement increases the incidence of intra-abdominal complications for laparoscopic appendectomy for diffuse appendicular peritonitis. introduction: the diverticular disease of the colon is a chronic entity with a variety of abdominal symptoms that can present with recurrent episodes of acute diverticulitis (ad). the prevalence of diverticulosis is not influenced by gender and increases with age, which, according to the increase in life expectancy, explains the accumulation of cases in western countries. the classic diagnostic-therapeutic algorithm of the disease is it has been based on the hinchey classification, the use of antibiotics and the intervention of hartmann (ih) at the acute time and elective colectomy in the multirecurrent cases. the use of laparoscopy with washing and drainage is actualymore extended in cases with peritonitis. objectives: to demonstrate the safety and efficacy of the laparoscopic approach, in cases with diverticular disease complicated by severe inflammatory plastron with 'covered' perforation, with several recurrent episodes. material and method: case report: a -year-old man with ap-diverticulitis years ago with complete resolution and normal control colonoscopy. he presents in the last two months three compatible episodes of acute diverticulitis, exploration with plastron-mass in hypogastrium without defense, tac-marked thickening of a segment of cms. of medium sigma, collection not drainable in mesosigma, of cm, which loses the plane of cleavage with loops of thin neighbors with a linear tract that suggests fistulization. evidence of interest is exposed. given the evolution, it is decided surgical elective treatment. result intervention: preoperative ureteral double catheterization, laparoscopic approach, is exposed by video, rectosigmoid resection by diverticular plastron, with negative io biopsy, mechanical colorectal anastomosis. good postoperative course, discaharge at th day. defini-tive ap: perforated diverticulitis, absence of malignancy. the laparoscopic approach is a valid and effective alternative in cases of complex and severe diverticular disease. aim: tamis resection has been described for the treatment of rectal neoplasms, wether benign or early malignant tumours. since tamis appearance, many different indications have been reported.we aim to show an special indication as seen in this video of a tamis resolution of a rectal stenosis non treatable by endoscopy. method: we present a video of a female patient, previously treated for a large rectal adenoma treated by trasnanal apporach, with a postoperative sepsis which required lateral colostomy and trasanal drainage. after surgery, the patient suffered from a rectal stenosis which couldn' t be solved by endoscopy, so the patient was sent back for a surgical treatment.we decided to performed a trasnanal apporach by tamis and a long and circunferiential stenosis around cm from the anal verge was seen.we performed a rectotomy by electrocautery in the posterior rectal wall until the perirectal fat was seen and the stenosis was passed. a dilatation with a foley catether was also performed. results: postoperative course was uneventful and after months she was prepared for colostomy closure with no complications and remains asymptomatic nowadays. conclusion: tamis approach of rectal stenosis may be a safe and feasible technique in selected cases if conservative treatments fail. iatrogenic endoscopic colon perforation it is a severe, but rare complication of colonoscopy. the incidence of this complication is estimated to be . - . % for diagnostic colonoscopies and . - % for therapeutic colonoscopies. the management of these complications depends on the size of the lesion,the time elapsed between the lesions were produced and diagnostic of the lesions and associated pathology. the treatment can be consevative,endoscopic or surgical(clasic/ laparoscopic) in our sevice in last years we treated cases with iatrogenic colon perforation after diagnostic colonoscopies. all lesions were at sigma level. one case was admission in our service at days after a diagnostic colonoscopy.the pacient was operated clasic,in emergency,we found a fecaloid peritonitis,a perforation at sigma level.we made a colostomy, lavage, drainage but the pacient died after days. in cases we made the operation at maximum h after the lesion was diagnosticated by the endoscopist(directly visualisation).we didn't made radiologic investigation.the pacients were operated laparoscopic,we made suture,lavage,drainage. evolutions of the pacients were good. conclusion: iatrogenic colonic perfortion are rare,but severe complication. laparoscopic surgery can be a choice in treatment of this complication introduction: complicated diverticulitis with fistula is responsible for about % of surgical procedures in diverticular disease and is commonly found in patients with diverticulitis of the sigmoid colon. colovesical fistulas are the most frequent ( %), with highest incidence in males. only a third of these patients have a history of diverticulitis. in most cases, treatment is surgical, and colectomy is performed, whether or not in association with vesical recession. case report: year old male with pneumaturia and fecaluria for the preceding months. the colonoscopy identified a diverticulitis of the sigmoid colon and the subsequent pelvic mri suggested a colovesical fistula. the cystoscopy was not able to identify any fistulous opening, but a double j catheter was placed in the left ureter, as surgical treatment had been proposed. a subsequently abdominal pain motivated a preoperative ctscan which revealed a pneumoretroperitoneum and a fluid collection near the left ureteral tract. the multidisciplinary team on the case decided to perform a percutaneous nephrostomy, followed by an exploratory laparoscopy. the fistula tract was identified and a laparoscopic sigmoidectomy with partial cystectomy was performed, as well as a ureterorenoscopy (with double j replacement). there were no intra or postoperative complications, and the patologic repport had no signs of malignancy. video of the surgical procedure is presented. conclusion: a laparoscopic approach to complicated diverticulitis with colovesical fistula is safe and effective when performed by experienced colorectal surgeons. introduction: diverticular disease is characterized by its high prevalence, being one of the most frequent causes for hospital admission when it comes to gastrointestinal pathology. even though it is more frequent in older patients, there has been an increase in incidence amongst lower age groups. the approach to the disease has also suffered changes in the last few years, showcasing a tendency for less invasive options, deferring elective surgery to later in the course of the disease. this study examines the therapeutic approach to diverticular disease in our hospital. methods: retrospective analysis of demographic data, therapeutic options and surgical outcomes in patients admitted for diverticular disease between january and june . results: patients(n = )were included in the study: ( %)were male and ( %) were female, with an average age of years. patients( %) underwent medical treatment, with surgery reserved for the remaining patients, of which were emergencies, with the other being elective( %).about % of patients were only admitted once, %were admitted twice and % had or more episodes. for the single-admission group, the most common treatment was medical( %of cases), as was the case for the group with or more episodes(in which %of cases were subjected to medical treatment). in the patient group with episodes, %were submitted for surgery, most of which elective.as far as the surgically operated group is concerned, no statistically significant differences were found with regards to patient sex. age, however, was significantly greater for the group that underwent emergency surgery vs that submitted to elective ( . years vs . years,p \ . ).the most common procedure overall was colic recession, with hartmann's operation standing out as the most frequent for the emergency surgery group. length of hospital stay was again higher for the emergency group (vs elective; vs ,p \ . ),as well as the morbidity rate. no statistically significant differences were found with regards to mortality rate. conclusion: knowledge of the natural history of diverticular disease led to changes in the approach to treatment, with a tendency to adopt a less aggressive therapeutic. despite controversy around aspects such as selection of patients for elective surgery, among others, it is key to the approach to diverticular disease that existing recommendations are taken into account, treatment is individualized and outcomes are closely monitored. surg endosc ( ) aims: the objective of this analysis is to establish if there is differences after the procedure of laparoscopy appendicectomy comparing the use of endoloop (el) vs. endostapler (es) in complicated and non-complicated acute appendicitis. methods: we performed a retrospective analysis of a prospective database of patients from february to june . we divided the patients in two groups: depending on that the procedure of the appendicectomy was with endoloop or endostapler. the groups were created selecting patients in order to be homogeneous as to perforation appendix rate, thus a propensity score was performed for sex, age and perforation rate. an univariant analysis was carried out in regard to the differences in the use of el vs es in the apparition of abdominal complication, as well as hemorrhage, ileo, surgical wound infection, collection, reintervention or hospital readmission.qualitative variables were expressed in terms of absolute frequencies and percentages and mean values and standard deviation were used to express quantitative variables. introduction: intramural haematomas can develop anywhere within any the gastrointestinal tract . these are most frequently associated with blunt trauma above the level of the sigmoid colon and very rarely occur in the rectum . spontaneous, non-traumatic haematomas are a rare clinical condition usually secondary to haematological blood disorders or anticoagulant therapy . case summary: a -year old gentleman presented to the emergency department with a day history of worsening lower abdominal pain and bloody stool. he presented twice within the previous week with worsening, generalised abdominal pain. the patient had been taking regular aspirin and clopidogrel following insertion of coronary artery stents. on clinical examination, he was guarding with a distended, generally tender lower abdomen but all observations were stable, afebrile. an initial computer tomography of the abdomen reported pneumoperitoneum with haemorrhagic ascites; a differential diagnosis being perforated sigmoid colon with a large localised haematoma. the patient underwent an emergency laparotomy and hartmann's procedure (appendicectomy, sigmoid colostomy and rectal stump). he recovered well with no significant post-operative complications. histology reported the rectal perforation macroscopically associated with an opened haematoma and no evidence of malignancy. the appendix shows reactive appendicitis with serousal inflammation background: ulcerative colitis (uc) is one of the risk factor of developing sporadic colorectal cancer. approximately % of uc patients develop an acute attack of severe colitis, and % of these patients require colectomy. one third of the patients will not respond to steroid therapy. thus, a long-term follow-up has been recommended. case report: we reported a single case of completed years follow of colorectal cancer related ulcerative colitis on years old female patient undergoing emergency operation ( staged total colectomy and j-pouch ileo-rectal anastomosis) after year no responsed of medical treatment before, presenting with bloody diarrhea and anemia. there was no post operative complication reported. pathologic finding was early adeno carcinoma, closed follow up was done each year and for another five years later, no progression of the disease was found in this period and the patients has good quality of life after this procedures. is becoming a standard and feasible surgical method worldwide. % of patients with crohn's disease (cd) and % patients with ulcerative colitis (uc) will require an operation during their life. over the last decade, there have been many studies documenting the safety and feasibility of the laparoscopic approach for ibd in well-selected patients. methods: patients with a cd with the tight stenosis in the distal ileum and/or ileo-colon or various colon and rectum stenosis, patients with uc with ineffective medical therapy, steroid dependence or dysplasia underwent the lcs. from to , ileocolic resections, hemicolectomies, subtotal colectomies and restorative proctocolectomies with ileopouchanal anastomosis were performed either totally laparoscopically or laparoscopically assisted (n = ).the average time of the procedure was min ( - min), average blood loss ml ( - ml) and the conversion to laparotomy was in . %. average return time of the bowel function was . days ( - days) and the average hospital stay was . days ( - days). complications occurred in patients ( . %). cases of the early ileus due to adhesions, cases of the anastomotic bleeding threated conservatively, case of the instrumental perforation of the small bowel, cases of the incisional hernia in minilaparotomy and wound infections occurred. conclusion: in well-selected patients with ibd, thanks to superior short-and long-term outcomes, the laparoscopic approach should be considered a safe and effective method when performed by experienced surgeons. supported by mo . aim: over % of patients with crohn's disease (cd) will require a surgical resection within years of their diagnosis and one quarter will have another resection for disease recurrence. laparoscopy should by preferred approach in surgery in cd due to reduced morbidity, faster recovery time, shorter hospital stay and reduction in adhesions and hernial formation. methods: patients with cd with the tight stenosis in the distal ileum and/or ileo-colon or various colon stenosis were indicated for the laparoscopy. from january to november we performed ileocolic resections, hemicolectomies and subtotal colectomies either totally laparoscopically or laparoscopically assisted. the average time of the procedure was min ( - min). the average return time of the bowel function was . days ( - days) and the hospital stay was from to days. complications occurred in patients ( . %) . in cases early ileus developed due to adhesions, in case was anastomotic bleeding threated conservatively, the incisional hernia in minilaparotomy occurred in cases and wound infections occurred. conclusion: minimally invasive surgery is becoming a gold standard in cd. it is safe and feasible in well-selected patients thanks to short-and long-term outcomes. laparoscopic approach for recurrent disease is still in debate. supported by mo . aim: the aim of the study was to observe when laparoscopy is avoided when treating surgical complications of crohn disease. methods: we did a retrospective study which included all of the patients diagnosed and operated in our clinic for complications of crohn disease during a period of years. results: we identified a number of patients operated for complications of crohn disease. of these were operated by minimally invasive procedures. we observed that laparoscopy was avoided in the case of intestinal fistulas (p = , ). also when sepsis associated the surgical complication-laparoscopy was avoided (p = , ). age under years represented another factor to avoid laparoscopy (p = , ). conclusions: although laparoscopy offers numerous advantages careful selection of the patients is of utmost importance so the safety of the procedure can be ensured. retroperitoneal sarcoma represents approximately - % of all sarcomas and less than . % of all neoplasia. radiotherapy and chemotherapy still do not represent valid therapeutic alternatives; therefore radical surgery remains the only valid option. complete surgical resection is the only potential curative treatment modality for retroperitoneal sarcomas. the ability of complete resection of a retroperitoneal sarcoma with tumor grading remains the most important predictor of local recurrence and disease-specific survival. hypoglycemia is a rare but potentially lifethreatening presentation of soft tissue tumors the etiology of hypoglycemia may be difficult to diagnose, assays for insulin-like activity (ila) were found to be high in the extract of tumor tissue, while insulin was not detected in significant concentration neither in the same extract nor in his serum. the most likely mechanism of hypoglycemia appears to be production of insulin like substance and increased utilization of glucose by the tumor. laparoscopic surgery represents an alternative technique for radical resection of such tumors rather than traditional surgery. only few cases of retroperitoneal tumors resected laparoscopically were reported in the literature. we report a rare case of years old male presented to ed unconscious due to hypoglycemia.he was resuscitated and admitted for further investigations. hypoglycemic attack recurred again during the same evening of admission. initial investigations were within normal except for serum glucose mg/dl ( . mmol/l). his tsh, glucagon & cortisol levels were within normal, insulin and c-peptide levels were undetectable. only hypokalemia ( . meq/l). he tested negative for the anti-insulin antibodies. his abdominal ultrasound as well as his ct scans showed the presence of a large retroperitoneal tumor ( cm cm cm) with a heterogeneous contrast effect. a glucose supplement was required to maintain the plasma glucose level within normal limits during which complete resection of the tumor which was performed laparoscopically. diagnosis of such hypoglycemia inducing retroperitoneal fibrosarcoma represents great challenge especially when patients presents only with hypoglycemia and no other abdominal symptoms, management using minimal invasive technique to resect and remove such tumors from the retroperitoneal region shows superiority in recovery and limitation of complications when done by experienced surgeons. solitary fibrous tumor (sft) is a rare fibroblastic mesenchymal neoplasm, tipically arising from the pleura, less frequently from other anatomic sites. sft is an indolent neoplasm, but it have been described cases of greater aggressiveness in terms of local recurrences and more rarelly of distant metastases. among the various extrapleural sites, intrabdominal, retroperitoneal localization is the most common site, followed by the pelvis soft tissues and parenchymatous organs. the most common clinical finding of intraabdominal localization is a palpable mass, and the pain is the most frequently associated symptom. the diagnosis is performed by imaging, but the histological as well as immunohistochemistry characterization of the lesion is the latest goal. furthermore, histological features are used to attempt to identify the patient with a hight risk of malignant evolution of the tumor. the gold standard treatment is surgical approach, meanwhile there are no evidences about the efficacy of any adjuvant treatment. we present the case of a -year-old man affected by symptomatic tfs arising from mesosigma treated by surgical radical excision. finally, we propose a review of the literature of last decade. background: laparoscopic right hemicolectomy involves making an additional incision to remove the specimen and perform the anastomosis. recently, natural orifice specimen extraction surgery (noses) has been reported as an alternative approach without any additional incisions or extensions, may lead to better outcomes compared to conventional laparoscopic right hemicolectomy. in this video, we aimed to evaluate the safety and feasibility of noses for laparoscopic right hemicolectomy. methods: we describe the technique with transvaginal specimen extraction and d lymph node dissection in laparoscopic right hemicolectomy by this video. we performed intracorporeal anastomosis combined with a transvaginal route of specimen extraction after medial-to-lateral mobilization. transverse transvaginal posterior colpotomy was performed under aid with visualization. the specimen was pulled into the sterilized plastic bag, passed transvaginally. the vaginal incision was then closed with a running suture. results: the operation time was min and the hospital stay was days. an excellent postoperative recovery was demonstrated and has shown future potential for less incision. the pathologic tnm stage is t n m . conclusions: this video has shown that laparoscopic right hemicolectomy with the noses technique is feasible and safe for selected cases. the long-term benefits of this procedure need to be more evaluated. recently, indocyanine green (icg) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information.the aim of our study is the application of icg imaging during laparoscopic colorectal resections: to identify the sentinel lymph node (sln) to search micrometastases that can be missed with the conventional pathological exam, and to assess anastomotic perfusion to reduce the risk of anastomotic leak. after tumor identification ml of icg solution ( . mg/kg) is subserosal peritumoral injected. a full hd image s camera, switching to nir mode, in about min displays fluorescence: the sln is identified and the sln biopsy (slnb) is performed.after the transection ml of icg solution is injected to confirm the stumps perfusion. if there is an ischemic area, a new resection is performed.after the anastomosis is performed, another bolus of icg is intravenous injected to confirm the anastomotic perfusion.when the sentinel node is negative for cancer metastases by conventional histological examination, ultrastaging is performed by serial sections. when no micrometastases are identified on these sections, immunohistochemical techniques are applied. from november , patients were enrolled: left colectomy, right colectomy, transverse resections, and splenic flexure resections. in two cases, one left colectomy and one right colectomy, the anastomotic perfusion wasn't good and the surgical strategy was changed. four postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. from november , patients were enrolled to perform the slnb: right colectomy, left colectomy, transverse resection and splenic flexure resections. the sln was identified in cases. cases were found to be n to the conventional examination and were subjected to ultrastaging. the serial sections showed micrometastases in two cases. in the other cases the immunohistochemistry was performed but the exam is still in progress. icg-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. it's recommended to assess the anastomotic perfusion in order to reduce the incidence of anastomotic leak, and to perform the slnb for the sln ultrastaging in order to identify micrometastases. methods: for the last years, tem was performed on patients' with early rectal cancer. there were women and nine men, age to . localization of tumors was - cm from anus. mean size of tumors was . cm. full thickness excision was performed in all patient with suturing of mucosa. during follow-up in three patients' metastasis in lymph nodes of mesorectum were detected. all of these patients were re-operated: laparoscopic colectomy with total mesorectal excision (tme) was done. for the last year in patients with early stage rectal cancer we used indocyanine green (icg) with fluorescent imaging for mapping sentinel lymph node. icg was injected in four quadrants to submucosa around the tumor. during the laparoscopy, sln was detected and removed with morphological examination. results: among nine patients in patients, sln was negative. tem was performed in these patients with good results. after - months no recurrence or metastasis were detected in these patients. in two patients with positive sn laparoscopic tme was performed with low colorectal anastomosis. anastomotic complication was occurred in one patient. conclusion: tem procedure is highly effective in selected group of patients with early rectal cancer. mapping and examination of sln can clarify indication for the tem in the patients with early rectal cancer. purpose: laparoscopic surgery for colorectal cancer provides better short-term benefits and similar long-term outcomes compared with conventional open surgery. unlike minimally invasive surgery, natural orifice specimen extraction (nose) can provide additional advantages by reducing morbidity and postoperative pain related to the surgical extraction site. this study aimed to evaluate the efficacy and safety of a nose procedure using needlescopic instruments for colon cancer surgery. methods: between november and february , patients underwent laparoscopic nose using needlescopic instruments. the first port for the camera was placed at the umbilicus. a -mm or -mm port was inserted in the right lower quadrant. a -mm or -mm port was inserted in the right upper quadrant. individual needlescopic forceps for the assistant were inserted into left upper and lower quadrant ports. thus, a total of ports were placed. the superior rectal artery and inferior mesenteric vein were ligated with clips, and colonic mobilization was performed using a medial to lateral approach. after rectal stump irrigation, the distal rectum was transected using an endoscopic linear stapler. the proximal colon and associated mesentery were transected. after the rectal stump was opened, a wound retractor was pulled through the anus and inserted in the rectal lumen. the resected specimen was transanally extracted through this route. an anvil was intracorporeally attached to the proximal colon, and the open rectal stump was reclosed using an endoscopic linear stapler; colorectal anastomosis was then performed using a double-stapling technique. results: of the patients, were male and were female, with a median age of years ( - years). median body mass index was . . the tumor site was in the sigmoid colon in patients and rectosigmoid colon in patients. median operative time was min and blood loss was ml. there was no conversion to open surgery. no postoperative complication was observed. median postoperative hospital stay was days ( - days). conclusions: nose surgery using needlescopic forceps is an easily performed type of reducedport surgery with a conventional port arrangement. this procedure is feasible for the selected patients. introduction: splenic flexure colon cancer accompanying obstruction is usually managed stent insertion as a bridge to surgery and left hemicolectomy, or subtotal colectomy. however, stent insertion can fail more often than in sigmoid colon because it requires longer colonoscopic approach in the circumstance of impossible bowel preperation. although subtotal colectomy has advantage in the aspect that it is -stage treatment, it needs open surgery in most cases, right colon has to be sacrificed without oncologic neccesity, and preoperative staging and evaluation can be insufficient. despite colostomy is reluctant procedure when considering quality of life, in splenic flexure colon cancer obstruction, we can obtain prompt stabilization of patient state, suffient time to preoperative staging and evaluation, and also we can achieve minimally invasive surgery by using colostomy site as mini-laparotomy and close colostomy before discharge. colostomy site, tumor location, and minilaparotomy site for next radical surgery have to be considered comprehensively before making colostomy incision. colostomy site has to be appropriate as mini-laparitomy site for feasibility of laparoscopic left hemicolectomy and the colostomy has to be included in the specimen with caution to prevent unneccessary lengthening of the specimen. we experienced cases which were treated succefully in this strategy and report them. result: temperary loop transverse colostomy and laparoscopic left hemicolectomy via colostomy site in splenic flexure colon cancer obstruction has advantage of quick stabilization of patient's status, suffient preoperative staging and evaluation, achieving minimally invasive surgery, and also rapid colostomy closure before discharge. our tatme procedure for locally advanced low rectal cancer following chemoradiotherapy y. nakamoto , r. okamoto , f. kimura , h. yanagi , t. nakajima , h. yoshie , n. yamanaka surgery, meiwa hospital, nishinomiya, japan, surgery, yoshie clinic, itami, japan background: short-course chemoradiotherapy using hyper-fractionation method (scrt; gy/ fraction/ days ? s- or xeloda) is performed to secure circumferential resection margin (crm) due to tumor shrinkage, reduction of cancer cells with viability, reduction of radiation hazard for resectable locally advanced lower rectal cancer (more t or n ). the patient underwent radical surgery after one month of scrt. for more locally advanced lower rectal cancer (t or n ), induction chemotherapy is performed before scrt. for patients with poor efficacy of chemotherapy, we also do normal fraction gy radiotherapy. methods: we introduced tatme from last august, and cases were performed so far. in all cases temporary stoma has been constructed, and intersphincter resection (isr) is based on partial isr avoiding total isr considering postoperative anal function. if possible, colonic j-pouch is added, and pelvic floor repair may be added for esr cases and older people. at first one team preceded with the anal operation and shifted to the abdominal procedure, now it is done with two teams with the advantage of getting good visual field from both sides when there is difficulty identifying the right dissecting layer. tatme is very useful in cases such as large tumor, obesity, and narrow pelvis. furthermore, when it is difficult to identify the dissecting layer by scarring after crt, it is more possible to control the crm/drm of cancer. results: cases of isr, case of apr, case of tpe were performed, and in of these cases lateral lymph node dissection was also performed (one side , both sides ). postoperative complications were anastomotic leakage, pelvic floor infection, perineum infection, and bowel obstruction. conclusions: tatme for locally advanced lower rectal cancer is useful even after chemotherapy and scrt. background: although many studies have demonstrated similar perioperative outcomes for single-incision laparoscopic surgery (sils) and conventional laparoscopic surgery (cls) for colon cancer, few have directly compared the costs of them. we aimed to compare costs between sils and cls for colon cancer. methods: we analyzed the clinical outcomes and overall hospital costs of patients who underwent laparoscopic surgery for colon cancer from july to september at severance hospital; were used for analysis after propensity score matching. the total hospital charge, including fees for the operation, anesthesia, preoperative diagnosis, and postoperative management was analyzed. results: the total hospital charges were similar in both groups ($ . vs. $ . , p = . ). however, the patients' total hospital bill was higher in the sils group than in the cls group ($ . vs. $ . , p \ . ) mainly due to the difference of the cost of access devices. there was no difference in the additional costs associated with readmission due to late complications between the two groups ($ . vs. $ . , p = . ). conclusions: sils for colon cancer yielded similar costs as well as perioperative and long-term outcomes compared with cls. therefore, sils can be considered a reasonable treatment option for colon cancer for selective patients. aims: technology improvements in medicine allow the development of new minimally invasive approaches. despite every single advantage of these new devices they also can cause technical problems and difficulties for the surgical team. well known from last few years-laparoscopic assisted transanal total mesorectal excision for distal rectal cancer is perfect example for a quite new procedure, based on the combination of forgotten old surgical principles and technology advances. the aim of the study is to analyze the rate of technical problems during the procedure and to measure the impact of them on the operative time. methods: we conducted prospective observational study related to technical problems during the procedure. for the period between september and november in the department of endoscopic endocrine surgery and coloproctolgy at military medical academy-sofia have been performed laparoscopic assisted transanal total mesorectal excisions. we used standard local preoperative work up and postoperative care protocols. we defined technical problem as intraoperative event different from complication leading to delay in operative time. every technical problem during the procedure was recorded and time for resolving the problem was measured in seconds. results: overall technical problems occurred in of the cases. most of them were related to the insufficient smoke evacuation during the cases. the second most common technical problem were the excessive rectal stump spasms during the procedure-this complication occurred in of the patients. mean delay of the procedure related to technical problems is min. in our series we experienced only one intraoperative complication which was specimen perforation during the dissection. three complications occurred in postoperative period-two urinary retentions and one perianastomotic abscess, without need of reoperation. conclusion: technical problems during the procedure can be source of delay in operative time. correct use of devices in operating room is the key to reduce technical issues. technical problems can increase the rate of intraoperative near miss events and complications during the transanal total mesorectal excision. surg endosc ( ) aims: anastomotic leak after rectal cancer surgery constitutes a severe complication associated with poorer oncologic outcome and quality of life. preoperative assessment of the risk for anastomotic leak is a key component of surgical planning, including the opportunity of creating a defunctioning stoma. methods: studies on rectal cancer surgery published between and were systematically reviewed according to the preferred reporting items for systematic reviews and meta-analyses of individual participant data (prisma-ipd) guidelines. with the aim to generate a score for anastomotic leak, all available per-operative covariates were used as independent factors in a logistic regression model with anastomotic leak as dependent variable. a receiver operating characteristic curve (roc) analysis was generated. we selected as threshold the value that allowed a missing rate of anastomotic leak \ %. the predictive power of the previously selected cut-off was validated in an independent set of patients. results: twenty-six centers provided individual data on patients. with a threshold value of the roc corresponding to . in the training set, the area under the roc curve (auc) was . (p \ . ). sensitivity and specificity of the model's probability [ . to identify anastomotic leak were . % and . %, respectively. accuracy of the threshold value was confirmed in the validation set with . % of sensitivity and . % specificity. conclusions: we trust that, with further refinement using prospective data, this nomogram based on preoperative risk factors may assist surgeons in decision making. the score is now available online (http://www.real-score.org). in ( . %) cases laparoscopic interventions were performed in patients with diverticular colon disease. in the group of patients with colorectal cancer localization of the tumor in the right parts was observed in ( %) patients, in the left-in ( %), in the rectum- ( %). results: in the adenocarcinoma of the sigmoid colon, performed a left laparoscopic hemicolectomy ( cases) and resection of the sigmoid colon ( ). was executed high clipping and intersection of the lower mesenteric vessels, aorto-iliac lymphatic dissection. in the standard scope, lymph node dissection was performed with removal and testing of not less than epi-, para-and mesocolical lymph nodes (max ). the average length of the laparoscopic stage is ± min. laparoscopic right hemicolectomy ( cases) was performed in accordance with the principles of cvl (central vascular ligation) and cme (complete mesocolic excision). intracorporal ileotransversoanastomosis was formed by a semimanual method with endogia universal and v-lock suture material. the average length of the laparoscopic stage was ± min, the open phase was ± . in the tumor of the lower and middle ampullary parts of the rectum ( cases) after neoadjuvant chemoradiotherapy, was executed a laparoscopic total mesorectumectomy. conclusions: the use of minimally invasive technologies in colorectal surgery provides a complete revising of the abdominal organs, adequate scope of resection and lymph nodes dissection in surgical interventions. background: it is thought that complete mesocolic excision (cme) improves the oncologic outcomes for colon cancer. but, precise mesenteric mobilization from retroperitoneum and safe ligations at the origins of central vessels are considered to be technically difficult in single port surgery(sps). to resolve this problem, we utilize retro-mesenteric medial approach for right side colon cancer. herein, we introduce this technique and assess its outcomes. operative procedure: the multi-trocar platform is placed in the umbilical site. d laparosopy is inserted from one of this channels. the surgeon manipulates instruments via the other channels. st step: right colonic mesentery is mobilized medial to lateral from the head of the pancreas and retroperitoneum along the embryonic plane. nd step: the origins of ileocolic and right colic vessels are divided and central lymph node dissection is achieved. rd step: hepatic flexure is taken down from cranial. and right lateral attachment is dissected away and cme is achieved. th step: specimen is extracted and anastomosis is performed using a functional end to end anastomosis extracorporealy. results: from april to december , consecutive patients underwent sps-cme with right side colon cancer. there were in stage i, in stage ii, in stage iii and in stage iv. the mean operative time was min. the mean estimated blood loss was ml. there was no conversion to open surgery. additional port was placed in patients ( . %). intraoperative bleeding was occurred in patient. anastomotic leakage was observed in patient ( . %), intestinal obstruction ( . %) and wound infection in ( . %). conclusion: these results suggest that retro-mesenteric medial approach in single port surgery with right side colon cancer is useful and safe technique. aims: this multicenter, randomized controlled trial (simple trial) aimed to investigate the quality of life (qol) and patient satisfaction of single port laparoscopic surgery (spls) for colon cancer, compared with multiport laparoscopic surgery (mpls). methods: patients with histologically diagnosed adenocarcinoma in cecum, ascending and sigmoid colon were eligible for this trial. eligible patients were randomly assigned to the spls or mpls group at a ratio of : . qol was measured with the eortc qlq-c third edition (korean version) preoperatively and postoperatively at month , , and . in addition, patient satisfaction was surveyed with a five-point questionnaire at postoperative month. to exclude the impact of adjuvant chemotherapy on qol, subgroup analysis for patients with or without adjuvant chemotherapy were carried out. (clincaltrials.gov identifier: nct ) results: total patients were randomly allocated into the spls group (n = ) and mpls group (n = ). in total patients, global health status and five functional scale steadily increased and nine symptom scales also gradually improved over time. but, nausea/ vomiting and appetite loss temporally deteriorated at postoperative month. pain score was significantly worse in the mpls group ( . in the spls group vs. . in the mpls, p = . ) at postoperative month and appetite loss score was significantly worse in the spls group ( . vs . , p = . ) at postoperative month. except for that domains, all the other items of qol between groups were not different until postoperative months. patient satisfaction was significantly higher regarding the operation (p = . ) and the abdominal wound (p = . ) in the spls group. in patients without adjuvant chemotherapy, some items of qol (global health status, physical functioning, role functioning, emotional functioning, fatigue and pain) were significantly better in the spls group at postoperative month. since postoperative month, all of qol domains (except pain score) were similar between groups. conclusion: although postoperative pain was temporarily better in the spls, most of qol domain were similar between the spls and the mpls group until postoperative month. in patients without adjuvant chemotherapy, spls showed better outcomes in some of functional scales and symptom scores at postoperative month. coloproctological surgery, juntendo university, tokyo, japan; gastroenterological surgery, juntendo university, tokyo, japan introduction: laparoscopic surgery causes less postoperative pain compared with pain after laparotomic surgery, and its low invasiveness should be considered for pain control. we have previously controlled postoperative pain by epidural anesthesia. in this study we compared postoperative multimodal analgesia centering on acetaminophen in patients who underwent laparoscopic colorectal cancer surgery with the conventional method. subjects: the subjects were patients who underwent laparoscopic colorectal cancer surgery between january and june . surgery was performed under epidural anesthesia in patients and multimodal analgesia in : periodic acetaminophen administration ? transverse abdominis plane (tap) block in , periodic acetaminophen administration ? local anesthesia of the wound in , and periodic acetaminophen administration ? intravenous patient-controlled analgesia (ivpca) in . the operating roomoccupying time, postoperative pain (nrs), frequency of taking analgesics as needed, and postoperative nausea were investigated for days after surgery and the duration of urethral catheter placement and postoperative intestinal movement were investigated in the epidural anesthesia and multimodal analgesia groups. results: while the time from entering the operating room to initiation of surgery was significantly shorter, the time from completion of surgery to leaving the room was significantly longer in the multimodal analgesia group. there was no difference in the operating room-occupying time. the frequency of postoperative pain was significantly lower in the multimodal analgesia group on postoperative day (pod) . the frequency of taking analgesics as needed was significantly lower in the multimodal analgesia group on pod , , and . no significant difference was noted in the duration (number of days) of urethral catheter placement or postoperative nausea between the groups. regarding postoperative intestinal movement, discharge of gas occurred significantly earlier in the epidural anesthesia group. the total number of incidents of complications in the epidural anesthesia group was . discussion: in laparoscopic colorectal cancer surgery, the effect of multimodal analgesia centering on periodic administration of acetaminophen without epidural anesthesia for postoperative analgesia was sufficient compared with the effectiveness of epidural anesthesia. this approach to analgesia may be useful because none of the potential complications of epidural anesthesia occur. surg endosc ( ) in the last years the application of new technologies like d vision or virtual reality have provided to surgeons the possibility of establish a preoperative surgical plan of each surgery and of each patient. these advances are specially useful in minimally invasive colorectal surgery due to the variability in location, anatomical relationship with other organs and vascular variants of these type of surgeries. the aim of our work is to built a digital -dimensional virtual model of the colorectal ct scan imagen of patients with colorectal cancer. the virtual models are obtained from the preoperative ct scan. the ct scans that we use to this work are general electric healthcare revolution gsiÒ and siemens somatom perspective Ò and the size of each image is mm. a medical software let us build a reconstruction of colorectal digital images where a radiologist has marked the exact image of the tumor so we obtain a d reconstruction which can provide an enhanced understanding of crucial anatomical details like the exact location of the tumor and the relationship with other organs and structures of the patient which can be selectively displayed or hidden. this information has an important applicability into clinical practice since it lets surgeons estimate the colorectal anatomy, tumor size and relationships, providing key landmarks to choose the most appropiate surgery, the best trocar location and a safer dissection specially in some cases whose location can change the kind of surgery radically. we present some cases where virtual models were crucial for the preoperative and intraoperative surgical plan, showing the potential interest of these d reconstructions in colorectal surgery. in conclusion the ct scan colorrectal image reconstruction can provide an enhanced understanding of crucial anatomical details of the colon and tumor location and relations which could contribute to choose the best surgical option and to improve safety in colorectal surgery. background: anastomotic leakage (al) after colorectal procedures are a common surgical experience and represents a significant burden both for patients and surgeons. the incidence of al has been reported to vary between . % to up to %, with rates for the colon and rectum of - % and - %, respectively. they, not only add to potential postoperative patient morbidities and to overall costs of postoperative patient care, but also are considered a quality indicator in colorectal surgery. aim: we aimed to evaluate the clinical burden associated with anastomotic leaks following colorectal surgery. methods: we conducted a retrospective analysis of colorectal patients who underwent conventional or laparoscopic colorectal surgery for colorectal cancer (crc), from january st, to december st, in a single colorectal centre (centro hospitalar de leiria). patient demographics, intraoperative and postoperative aspects were collected and analysed. all statistical analysis will be conducted using stata software (statacorp lp). results: in our cohort of pts, developed a clinical al ( . %), mostly males ( %), with an average age of ± . . male gender and conversion were independent risk factors. the group with al had a higher lohs ( . days vs, . -p \ . ). out of al have been detected after the discharge. the mean diagnostic day was the eighth, and mode estimated at day . when compared with a control group, wcc, eosinophils and crp were statistically significant different in al group, at day and . conclusion: in the present study, no statistically significant risk factors for al in crc surgery were detected, except for male gender and conversion. clinical methods and biomarkers were useful for early diagnosis. technology combined with experience and common sense may be the embodiment of the clinical method. conclusions: our regional screening program has significantly improved early diagnosis and quickened surgical treatment of crc. thanks to this, we obtained an earlier stage at diagnosis, a less invasive surgical approach, and a lower rate of complications and emergency surgery need were obtained also with an improvement in both os and dfs. introduction: surgeons are increasingly being faced with the problem of treating elderly colon cancer patients. we evaluated the outcome of silc in patients of over years with colon cancer with a propensity score matched comparison to assess its perioperative and long-term oncological outcomes. methods: this retrospective cohort study analyzed our experience with silc for colon cancer over years. eighty-seven patients of over years with colon cancer who electively underwent silc were included in this study (elderly group). eighty-seven patients were then chosen out of a collective of patients less than years old in a propensity score matched design (younger group). short-term clinical outcomes in both groups were compared and verified its long-term oncological outcome. results: american society of anesthesiologists score and post-operative complication rate were significantly higher in elderly group. however, the other short-term clinical outcomes including post-operative hospital stay were equivalent in two groups. the rates of -year cancer specific survival were . % in elderly group and . % in younger group, respectively, and the -year overall survival rates were . % and . %, respectively. no significant differences were seen between two groups. conclusions: our initial experiences suggested the oncological and clinical safety of silc in patients of over years with colon cancer. however, further studies are needed to demonstrate the advantages of this procedure compared to conventional laparoscopic colectomy. aim: some clinical trials have reported the safety and efficacy of laparoscopic colectomy for colon cancer. on the other hand, transverse colon cancer was excluded in these trials because of the difficulty of laparoscopic colectomy for transverse colon cancer. in this presentation, we report the tips for laparoscopic colectomy for transverse colon cancer. tips: in our department, transverse colon cancers has been resected by laparoscopically so far. to complete cvl and cme, lymph nodes around middle colic artery should be resected, however many important structure, duodenum, pancreas, superior mesenteric vein (smv) and so on, may be obstacles. this is most difficult point for this surgery. our surgery is as follows. mobilization of ileum and ascending mesocolon from caudal sideconfirm duodenum and pancreasexpose smv and ligation root of ileocecal artery and veindissect lymph nodes around smv and ligation of middle colic artery and accessary right colic veinconfirm pancreas from caudate side of transverse mesocolon and incise the peritoneum along the caudal side of the pancreasdissect lymph nodes sufficiently by dissection from both side of transverse mesocolonmost important point. to dissect lymph nodes safely, confirmation from both side of transverse mesocolon is necessary and dissection should be performed along important structure, smv, pancreas and so on. introduction: we have developed and previously reported single-incision plus one port laparoscopic anterior resection of the rectum (sils ? -ar) as a reduced port surgery in which we can utilize the incision for drainage as an additional access route for laparoscopic procedures including the transection the lower rectum. a consecutive experience from its introduction of sils ? -ar for rectal cancer is reviewed, and its -year oncological outcomes are evaluated retrospectively. methods: one hundred and forty-one patients ( female) with a mean age of . years adopted the sils ? procedure for rectal cancer. a lap protector (lp) was inserted through a . cm transumbilical incision; an ez-access was mounted to the lp and three -mm ports were placed. a -mm port was inserted in the right lower quadrant. results: one hundred and thirty-six patients ( . %) completed with sila ? -ar. the tumor locations in the rectosigmoid, rectum above the peritoneal reflection (ra), and rectum below (rb) were , and , respectively. the median follow-up interval was months. aims: colovesical fistulae came from inflammatory disease or cancer and do have a significant morbidity. the most common location is the sigmoid colon and the most common aetiology is diverticulitis. the treatment of choice is a surgical procedure. the aim was studying compare laparoscopic approach in patients diagnosed by benign (diverticulitis) and malignant (colon adenocarcinoma) colovesical fistulae. methods: from january to march all characteristics of surgical patients with diverticular and colon adenocarcinoma colovesical fistulae were reviewed. patient details (sex, age, symptoms, diagnosis, medical history and anaesthetic risk), surgical approach, hospital stay and complications were recorded. both groups were compared with significance level set at p \ . . results: nine laparoscopic ( %) and open approaches ( %) in diverticular colovesical fistulae were performed, with a conversion rate of %. the procedure done was sigmoidectomy. there were also performed laparoscopic ( %) and open approaches ( %) in colon adenocarcinoma colovesical fistulae. the procedures done were sigmoidectomy, pelvic exenteration, left colectomy, low anterior resection and loop colostomy. comparison between the two groups didn't show significant differences in characteristics but did show significant differences regarding the approach, with more cases performed by open approach in colon adenocarcinoma colovesical fistulae (p = . ). conversion rate didn't show significant differences. patients diagnosed for malignant colovesical fistulae had more complications, cases ( %), ( %) i-ii and ( %) iii-iv-v according to clavien dindo classification, manifesting significant differences (p = . ). laparoscopic approach didn't show significant differences regarding complications. conclusions: generally, surgical approach with colonic resection and partial or total cystectomy is the treatment of choice in colovesical fistulae, although vesical resection can be avoided if it is suspected benign aetiology. whenever laparoscopic approach is performed by experienced surgeons, is feasible in colovesical fistulae and the morbidity and mortality numbers are acceptable. laparoscopic approach allows the advantages of a minimally invasive treatment but implies clinical trials to stablish stronger evidence. aims: laparoscopic right hemicolectomy became the standard of care for treating cecum, ascending and proximal transverse colon cancer in many center. most centers use multiport laparoscopic colectomy with extracorporeal resection and anastomosis (mce). single-incision laparoscopic colectomy with intracorporeal resection and extracorporeal (sci) remains controversial. the aim of the present study is to compare these two techniques using propensity matching analysis. methods: this study analyzed patients who underwent laparoscopic right hemicolectomy including mce surgeries and sci surgeries from december to december . short-term outcomes were recorded. postoperative pain was evaluated using a visual analogue scale (vas) and postoperative analgesic use as outcome measure. results: the length of skin incision in the sci group was significantly shorter than in the mce group: median (range) ( - ) cm verses ( - ) cm (p \ . ). the vas score after surgery was significantly less in srhi than in mrhe. significantly fewer patients required analgesia after srhi after surgery. there were no significant differences in operative time, intraoperative blood loss, the number of lymph nodes removed and postoperative courses between the groups. the cost effectiveness was significantly cheaper in srhi than in mrhe. conclusions: sci for right colon cancer is safe and technically feasible. sci reduces the length of skin incision and postoperative pain compared with conventional mce. aim: this study was designed to clarify the utility of laparoscopic surgery for advanced lower rectal cancer after neoadjuvant chemoradiotherapy (ncrt). patients and methods: we investigated -year disease-free survival rate, operative outcomes and recurrence risk factor in patients with lower rectal cancer (ct - , n - ) who underwent laparoscopic surgery after ncrt from to december in kitasato university hospital. results: of patients, patients underwent low anterior resection (lar), patients underwent intersphincteric resection (isr) and abdominoperineal resection (apr). there were anastomotic leakage, and urinary disorder and sexual dysfunction. ypcr rate was . %, but patients ( . %) had recurrence ( liver, lung and lymph node and local recurrence; there is some overlapping). ypt and lymph node metastasis were detected as a recurrent risk factor. the -year relapse-free survival rate (rfs) was . % and the -year overall survival rate (os) was %. conclusion: in this examination, ypt and lymph node metastasis were risk factor for recurrence. the operative outcomes, -year rfs and the -year os are relatively good results. we will conduct further follow-up, and it is necessary to investigate a long term prognosis. laparoscopic surgery is warranted for rectal cancer after ncrt. surg endosc ( ) introduction: synchronous colorectal neoplasia presents an incidence ranges from % and %. classically its surgical treatment consisted in the realisation of a subtotal colectomy (stc), however, several authors have proposed that in certain occasions the realisation of two segmental resections with two anastomoses was not accompanied by an increased risk of anastomotic failure. the objective of this study was to compare the feasibility and safety of the laparoscopic approach of synchronous colorectal neoplasia using two different techniques: stc versus two segmental resections with two anastomoses. methods: we retrospectively reviewed the clinical data of patients over years of age who underwent colorectal surgery between and at a single center. we included patients with a synchronous colorectal neoplasia who underwent laparoscopic surgery, either stc or double resection (dr). results: a total of patients met the inclusion criteria. mainly males ( %) with an average age of years, with a scale of the american association of anesthesiologists superior to ii in % and with an average body mass index of kg / m . the mean operative time was min in the dr and min in the stc, the stc resulted in a higher conversion rate ( % vs %) and intraoperative bleeding ( % vs %), in addition to a postoperative period with more complications, only % of the patients undergoing stc didn't present any complication while % of the patients with a dr didn't present any complication. % of the stc presented anastomotic failure and only % of the dr. the mean hospital stay was days in the dr and . in the stc. in the dr, an average of cm of colon was resected with an average of . lymph nodes, while in the stc, cm of colon was resected with an average of . resected nodes. conclusions: the double resection with two anastomosis is a less aggressive surgery, with fewer complications and a shorter hospital stay, providing similar oncological results. there were no differences in morbidity, re-operations or hospital stay. regarding tumor stage there were no differences between the three groups. as for the resected nodes, we found a mean of in stc, in lc and sr with no statistical difference. there were no differences in the affected nodes among groups. in our patients we didn't find differences in the recurrences rate or in the distant metastases rate.the average follow-up was months (range: - ), with no differences in overall survival. conclusion: segmental resection of splenic flexure neoplasias is safe and feasible, with no differences in morbidity or in the oncological outcomes compared with more aggressive surgeries. introduction: the evaluation of perfusion in colorectal anastomosis is still a field of study and progress for the development of new modalities that allow reducing the ratio of dehiscence or anastomotic leakage (al) in said surgery. our objective with this work is to highlight the utility of indocyanine green (icg) in the said evaluation after colo-rectal surgery. methods: we present a series of cases of colorectal surgery (benign and malignant disease) intervened in the period between and . the population sample has been homogenized according to age criteria, risk factors and comorbidity. a retrospective database has been developed with the spss v. software for the evaluation of the results obtained. the primary outcome measure was al rate with at least month of follow-up. results: a significant reduction in the incidence of al was observed in patients who underwent colo-rectal surgery (p = . ). low al rates were shown in rectal cancer surgery (p = . ). there was no significant decrease in the al rate when colorectal procedures for benign and malignant disease were combined. conclusions: the use of the image by fluorescence with indocyanine green is a safe, reproducible and relatively simple method with which to evaluate the perfusion of the colorectal anastomosis as well as reduce the rate of anastomotic leak in the postoperative period. large well-designed randomized control trials are needed to provide evidence for its routine use in colorectal surgery. introduction: currently colonoscopy is the gold standard investigation for colonic evaluation. although caecal intubation is one of its quality indicators, it is not attained in up to % of cases. this remains a significant concern. limited data are available on the follow-up of patients with incomplete colonoscopy. aims: to assess colonoscopy completion rate, the reasons for incomplete colonoscopy, and the methods used to complete colonic evaluations after incomplete colonoscopy. methods: we performed a retrospective study of incomplete colonoscopies in our unit over a one year period ( ) these results compare favorably with published data. few statistically significant differences between groups suggest varying modalities of treatment broadly result in similar qol. this data highlights a need for well-delivered support programmes for specific issues, for example stoma care and sexual dysfunction. future studies will need to include a baseline questionnaire to truly measure the impact of surgery and measure quality in an increasingly elderly and comorbid population. splenic flexure cancer (sfc), comprising the tumours raised in the distal transverse colon and proximal descendingcolon, accountfor to %of all surgically treated colorectal cancers.in cme forsfc, dissection of both the transverse and descending mesocolon must be considered. however, the use of laparoscopic surgery as a curative treatment for sfc, has never been investigated in adequate controlled trials, because of difficulty in deciding on the appropriate operative procedure, as well as technical difficulties with laparoscopic lymph node dissection. the aim of this multicenter study is to evaluate the oncologic effectiveness of laparoscopic segmental resection with cme with for cancer located at the splenic flexure. we performed a retrospective analysis of all cases of sfc treated with a laparoscopic segmental resection with cme in five different institution. intra and post operative were evaluated. patientes were evaluated, the mean operative time was . ± . min. a total of ( . %) conversions occurred, due to splenic artery lesion, one for difficult adesyolisis and three due to locally advanced tumour. recurrence was observed in ( . %) patients. there was a significant association between disease stage and recurrence (p \ . ) with a higher proportion of stage iv patients in the recurrence group ( . % vs . %). at days follow-up no mortalitywere recorded.during a median follow-up of months (range - ), deaths occurred (all of them for disease progression). keplan mayer curves showed a compareble suvival with other colo-rectal cancer. in conclusion, laparoscopic segmental resection with cme and cvl seems to be an oncologically safe and effective procedure for treatment of sfc. it may be regarded as the standard surgical method for elective management of this disease. in the future, more tailored patient-and tumor-specific segmental resection might be achieved with the use of routine lymph node road mapping. it is very important to establish a minimum number of lymph nodes to analyse for a correct staging. it has been established as . the treatment of colorectal cancer is essentially surgical. the review of the medical literature indicates that laparoscopic colorectal surgery is a safe procedure that has not found significant differences in the survival rate from open surgery. aim: the aim of our study is to compare the outcomes of laparoscopic and open resection for colorectal cancer surgery evaluating lymph node assessment. methods: the patients were collected in our hospital during the period from / / to / / and the number of lymph nodes obtained in lymphadenectomy has been studied comparing the laparoscopic and laparotomy approaches. results: interventions were performed. were laparotomic, were laparoscopic and converted laparoscopic (fig ) . the average number of nodes found in these interventions was , . nowadays, the recommendations to obtain a proper lymphadenectomy is to find more than lymph nodes. analysing our procedures, surgeries had obtained a good lymphadenectomy. according to the approach, , % of the interventions ( ) are laparotomy, , % ( ) are laparoscopic procedures and , % ( ) are by reconverted laparotomy (figure ). the average number of lymph nodes isolated was similar. laparotomy approach found , nodes while , nodes were found in laparoscopy. converted laparoscopy found , ( figure ). conclusion: the treatment of colorectal cancer is essentially surgical. today, there are a lot of studies that support that laparoscopic surgery has a survival rate similar to laparotomy surgery. according to our study, the data collected indicates that the number of isolated lymph nodes in both approaches is very similar. to sump up, laparoscopic colorectal surgery is safe and has demonstrated oncological adequacy comparable to open approach and better short-term outcomes due to a less invasive approach. background: laparoscopic low anterior resection highlights the advantages of laparoscopic surgery (better surgical field, less bloodloss, less postoperativepain, better cosmeticresult). defunctioning ileostomy prevents anastomotic leakage in low rectal cancers, butincreases morbidity, degrades thequality of life and requires a second surgery for its closure. method: in the last months we performed laparoscopic low anterior resections for rectal cancer, whithout performing any protectiveileostomy, afterchecking the anastomosis intraoperatively( men, women. average age: years). the typical placement of trocars included one supraumbilical mm trocar, two right sided mm trocars in the midclavicular line, one mm in the left midclavicular line and one mm trocar in the suprapubic midline which is also used for specimen removal, after a cm transverse extension of the incision. we present themain stages of the procedure (dissection andmesorectal excision, division of the rectum with linear stapler using the 'chinese hat-parnex' technique, creation of an end-to-end intracorporeal anastomosisusing circular stapler under direct laparoscopic vision). results: no major postoperative complication was observed. the mean operative time was min ( - ) and free surgical margins were achieved. in one case a conversion to open surgery occured. the average length of hospital stay was days ( - ). conclusions: the laparoscopic approach facilitates access to the middle and lower rectum, total mesorectal excision and avoidance of ileostomy if possible. it is a demanding operation with extended learning curve, and requires adequate experience in laparoscopic surgery and colorectal surgical oncology. background: in colorectal cancer, local excision is an attractive treatment option, but additional resection is considered when lymph node metastasis(lnm) is expected at high rate. in lower rectal cancer, advanced surgery techniques are required, so it is often difficult to make judgments. the aim of the current study is to assess the reliability of laparoscopic surgery for submucosally invasive rectal adenocarcinoma (pt ) analyzing short-term outcomes and long-term survival. method: this cohort study analyzed patients who underwent laparoscopic rectal resection for submucosally invasive rectal adenocarcinoma (pt ). conversion rate and functional and oncologic outcomes were analyzed. data on long-term results and survival were evaluated. result: surgical procedure was low anterior resection / intersphincteric resection / abdominoperineal resection: / / , and conversion to open surgery was needed for ( . %) patients. sphincter-preserving procedures were performed in ( . %) patients. there were no perioperative mortalities and positive resection margin. the mean length of hospital stay was . days. complications beyond clavien-dindo grade iii occurred in ( . %) patients,the anastomotic leakage rate was . % ( / ). the positive lymph node metastasis rate was . % ( / ). high tumor budding (p = . ), lymphatic invasion (p \ . ), and mucinous /poor histological differentiation (p = . ) were significantly associated with lymph node metastasis on univariate analysis. on multivariate analysis, only lymphatic invasion was associated with lymph node metastasis (p \ . ).the median follow-up time was months (range, - months), recurrence free survival rates was . % ( / ). conculusion: the outcomes of this study suggest that laparoscopic surgery can be used for safe and radical resection of submucosally invasive rectal adenocarcinoma (pt )?and the absence of lymphatic invasion, budding, and mucinous /poor histological differentiation are each associated with low risk of lnm. risk stratification models integrating these factors need to be investigated further. conclusions: this study highlights the complex nature of sarcopenia, as well as its common incidence. minimally invasive surgery had a higher incidence of sarcopenia than that of open surgery when both were performed within an enhanced recovery setting. despite colorectal patients being a typically well-nourished cohort at low risk of complications, there may well be benefit from interventional strategies such as perioperative immunonutrition or pre-habilitation to reduce the incidence of this poor prognostic indicator. backgrounds: urinary dysfunction is frequently observed after rectal resection and justifies urinary drainage. the concept of enhanced recovery after surgery (eras) has been widely spread from the early s. however, the optimal duration of postoperative urinary drainage is unknown. aims: the aim of this study was to comprehend short-term outcome of early removal of urinary catheter after robotic rectal surgery (rrs). patients and methods: (patients) the data of consecutive patients who underwent rrs at two hospitals between april and november were retrospectively reviewed. the main indication of rrs was the patients who need rectal mobilization with autonomic nerve preservation regardless of benign or malignant disease. perioperative management: none of the patients received epidural anesthesia for postoperative analgesia. our basic principle was to remove urinary catheter on postoperative day (pod) . after removal of urinary catheter, trans-urethral catheterization (tuc) was performed in the following situations: ) no autonomous urination over h after removal ) the decrease in urine volume (\ ml/ hr) ) the appearance of subjective symptoms like abdominal distension. when tuc was required even once, residual urine volume was measured with ultrasonic examination device since then. results: twenty seven male and female were included. the median age of patients and bmi were years old and . kg/m , respectively. the surgical procedures included anterior resection (n = ), intersphincteric resection (n = ), abdominoperineal resection (n = ), hartmann's procedure (n = ), and total coloproctectomy (n = ). only one patient received lateral pelvic lymph node dissection. urinary catheter was removed on pod in cases ( . %), on pod in cases ( . %). although tuc was needed in three cases ( . %) immediately after removal, tuc was no longer needed within three days in all three patients. late dysuria was observed in two cases ( . %), and bladder overdistension was suspected in these two cases. conclusions: our study showed that urinary catheter could be safely removed on pod after rrs. however, careful follow-up observation to avoid bladder overdistension is essential after removal. introduction: intersphincterian low rectal resection is a valid alternative to lower rectal cancers located at about - cm from the anus. methods: we present cases from our personal experience for tumors localized - cm from the anus. of them required preoperative radiochemotherapy. in cases, abdominal surgery was performed laparoscopic, having the surgical specimen extracted transanal. lone star device was used for the perineal procedure in all cases. cases required a manually, separate wires anastomosis; the others cases benefited from mechanical anastomosis performed endoanal with - mm circular stapler. we performed complete mesorectum excision in all cases, ligation at the origin of inferior mesenteric artery, complete mobilization of left splenic flexure and lateral protective ileostomy. all pacients underwent inspection rectoscopy before transit reintegration, and cases were reintegrated over a period of - weeks, except for cases which developed a colo-anal fistula, that closed under conservative treatment over a period of - months. results: there were no postoperative anal incontinence. in one case, a relative anal stenosis occured, which required endoscopic dilation. there was case of tumor recurrence and required abdominoperineal resection. conclusion: literature data sustain a - / ratio for very low rectal resection versus rectum amputation. the limit resection under the tumor is accepted as . cm. very good functional results by considering oncological principles, is a sustainable argument for choosing this kind of procedure as an alternative of rectum amputation. in the few studies conducted on crcs, the reported rate of sln micro-metastases is up to - %. the aim of this ongoing prospective study is to assess the predictability of the ex-vivo nirf sln mapping and of the research of micrometastases in nnd crc patients to propose adjuvant chemotherapy. materials and methods: fifty-eight patients undergoing standard oncological crc laparoscopic resection have been prospectively enrolled in two centre. as previously described by the authors, the intact surgical specimen was extracted and opened longitudinally and ml of indocyanine green (icg; mg/ml) was injected submucosally at four corners around the tumor in order to identify the lymphatic pathway and the slns. each sln presenting as negative at conventional histological analysis, was further investigated with ultrastaging techniques including serial sectioning and additional immunohistochemistry, in order to detect the presence of micrometastases. results: thirty patients were n ? , and were nnd. overall, a total of lymph nodes were retrieved. a total of sln were identified (mean . per case) and of those were nnd. after ultrastaging investigations, micrometastatic cases were found in nnd patients. the patients were so upstaged to n . sln located deeper in the mesenteric and mesorectal fat could easily be identified by nirf (even after nchrt). conclusions: in our preliminary series, the ex-vivo nirf sln mapping rightly predicts the status of loco-regional nodes, as confirmed by the histological investigations. the micrometastases' identification let selected patients to undergo the adjuvant treatment with the aim to reduce the risk of recurrence. ( / ) in lateral node positive group and . % ( / ) in lateral node negative group. four of local recurrence were lateral lymph node recurrence. two patients recurred the other lateral side of previous lpl, then they were laparoscopically resected and no recurrence ( , months). two patients recurred the same side after lpl were not curable because of liver metastasis and extensive invasion to the common iliac vessels. conclusion: selective lpl for rectal cancer was safe and good local control for lateral lymph node positive patients. also curable local recurrence resection was possible for non-treated lateral lymph node recurrence. intestinal malrotation is an embriologic anomaly generally discovered in the first months of life due to bowel obstruction. adult presentation is rare and its association with colon cancer is far more rare. we report a case of a years old man affected by asymptomatic intestinal malrotation incidentally found during an abdominal computed tomography (ct) performed for retroperitoneal colonic perforation in a patient with an endoscopically diagnosed aenocarcinoma of the caecum and a large polyp of the descending colon. preoperative vascular anatomic study allowed us to plan a laparoscopic approach safely also with adequate lymphoadenectomy. the abdominal cavity was entered throught a right flank mm optical trocar on the transverse umbilical line. three additional mm trocars were placed in right iliac fossa, right and left hypocondrium respectively. exploratory laparoscopy confirmed midgut malrotation and a fresh flogistic area at the descending colon perforation site. caecum and ascending colon were on midline and attached due to adhesions to sacral promontory. ileocolic artery (ica), middle colic artery (mca) and ima were selectively ligated but not at their origins due to aberrant anatomy. laparoscopic subtotal colectomy with intracorporeal stapled ileosigmoid anastomosis were carried out (endogia mm, double layer / polyglicolic acid suturing of the breech). the anisoperistaltic nature of the anastomosis is due to the disposition of the mesenterium which did not allow an isoperistalting orientation of the two resected stumps. the specimen was extracted throught a pfannestiel incision. the postoperative course was complicated by intestinal obstruction conservatively treated with slow bowel function's restoration. the patient was discharged from the hospital in th postoperative day. unexpectedly specimen histology revealed two villous adenomas with high grade dysplasia. lymphnodes were retrieved from the specimen (ptisn ). to date our case is the only fully laparoscopic colonic resection reported in literature in malrotation as well as the first intracorporeal stapled ileo-sigmoid anastomosis for such disease. the median hospital stay was days. in-hospital mortality was nil. the overall morbidity was %. the median length of follow-up was months. conclusions: our preliminary results suggest that robotic-assisted surgery for colorectal cancer can be carried out safely and according to oncological principles. robotic surgery is advantageous for both surgeons (in that it facilitates dissection in a narrow pelvis) and patients (in that it affords a very good quality of life via the preservation of sexual and urinary function in the vast majority of patients and it has low morbidity and good midterm oncological outcomes). in rectal cancer surgery, the robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field. aims: postoperative inflammation have been reported as one of the independent prognostic factors in several types of malignancies.the aim of this study is to clarify the impact of laparoscopic approach on postoperative inflammatory status after surgery for colorectal cancer, and to analyze the association between postoperative inflammation and prognosis in patients with colorectal cancer. methods: a total of patients with stage l-lll colorectal cancer (crc) who underwent curative surgery were retrospectively analyzed. the maximum crp value measured between the times of surgical resection and discharge was defined as 'max crp'. the optimal cut-off value of max crp that best predicts rfs was determined to be mg/dl by the minimum p-value approach. methods: trainees working in this firm were responsible for data collection. patients who underwent emergency surgery during the calendar year of had the following details collected-the presence or absence of a complication in the -day post-operative period, the type of complication and description of complication along with the grade of the complication (see fig. .) . patients who underwent intermediate to major surgery were followed up at outpatients and were specifically asked for the occurrence of complications from the point of discharge up until the outpatient appointment. with one centralised national hospital-the people who were discharged and subsequently experienced considerable or major complications invariably represented back to hospital via the a&e department. results: a total of emergency surgeries were performed by this surgical firm in , % of these being done laparoscopically. of these cases- patients experienced post-operative complications within the first days after their procedure. this equated to a complication rate of . %. the most common complications were abdominal pain, nausea & vomiting, and wound infection. there were complications for each of these categories. post-operative bleeding occurred in cases with fistulas or leak of an anastomosis occurring in cases. death of a patient occurred in instances once as a result of post-operative bleeding from the site of anastomosis after a whipple's procedure, the nd occurred subsequent to post-operative bleeding from a peptic ulcer and in the rd case occurred in an instance of faecal peritonitis as a result of anastomotic failure after a roux-en-y bypass for a patient with pancreatic malignancy. conclusion: the davien-clindo classification proved to be simple, efficient and useful in analysing post-operative outcomes. the results indicate that despite the emergency setting & elderly cohort of patients-minimally invasive surgery proved to be a safe and viable option. conclusions: in this prospective study, we observed greater rates of detection of adenomas among endoscopists. screening colonoscopy on symptomatic and/or high risk group for crc is valuable in early detection and the prevention of crc. large sample size and long period of screening colonoscopy was needed. limitation of our study was the small sample size and no use of high detention endoscopy. results: the mean intraoperative blood loss volume was significantly less in the lap group than in the open group ( vs. ml, respectively, p \ . ). the mean operative time was not significantly different between the lap group and the open group ( vs min, respectively, p = . ). the incidence of severe postoperative complication (grade or higher in the clavien-dindo classification) was lower in the lap group ( / ( %) vs / ( %), respectively). the mean postoperative hospital stay was significantly shorter in the lap group than that in the open group ( vs. days, respectively, p = . ). conclusions: lap-tpe can be a safe and feasible procedure. background: amyloid light chain (al) amyloidosis is a rare protein deposition disorder with an incidence ranging between - cases per million people. it can present insidiously with localized or multisystem symptoms and usually occurs later in life. prognosis is poor as al typically presents at an advanced stage. intestinal pseudo-obstruction is a rarely reported complication of al amyloidosis. here we report a case of al amyloidosis which was identified during surgery for intestinal pseudo-obstruction. case presentation: a year old male presented to the emergency department with a month history of abdominal pain and distension, as well as marked swelling of his lower limbs. this had worsened in the previous weeks and he had developed intermittent diarrhoea. ct showed ileitis with marked dilation of the proximal small bowel. laparatomy revealed small bowel that was grossly distended that rapidly developed multiple petechiae and subsequent haematomas upon handling. two days later a repeat laparotomy was performed and . m of ishaemic small bowel was resected. histology showed amyloid deposition with positive congo red staining. subsequent cardiac events led to an echo being performed that showed concentric left ventricular hypertrophy attributed to amyloid deposition within the myocardium. free serum light chain ratio was sent and confirmed the diagnosis of al amyloidosis. he has recently been started on a treatment regimen consisting of cyclophosphamide and dexamethasone. discussion: systemic al amyloidosis frequently involves the gastrointestinal tract, typically presenting with chronic diarrhoea and associated malabsorption. only case presenting with pseudo-obstruction has been reported in the literature. al amyloidosis presents insidiously with non-specific symptoms depending on which organs are affected. treatment aims to prevent further deposition of protein within the organs. prognosis is determined by the organs that are affected and the extent of protein deposition within them. cardiac involvement holds the worst prognosis ultimately causing sudden cardiac death. the mainstays of management are early identification and treatment implementation to prevent protein build up and subsequent organ failure. conclusion: a diagnosis of amyloidosis should be considered in patients with intestinal pseudo-obstruction to expedite the diagnosis of al amyloidosis and improve survival. aim: in the management of locally advanced rectal cancer (larc), the achievement of a complete total mesorectal excision (tme) with clear resection margins was demonstrated to be the main predictor of overall and disease-free survival. predicting surgical difficulty in larc patients may be of particular importance to choose the best surgical approach. this study proposes a mri-based score to identify preoperatively larc patients with a high risk of having a difficult surgery. methods: this is a retrospective study based on the european mri and rectal cancer surgery (eumarcs) database, including patients with mid-low larc who were treated with neoadjuvant chemoradiation therapy and laparoscopic tme with primary anastomosis. data on pre-treatment and restaging through magnetic resonance imaging were available for all patients. surgical difficulty was defined as high or low grade taking in to account operative (e.g. duration of surgery), and postoperative factors (e.g. hospital stay). score accuracy was evaluated by estimating sensitivity, specificity and area under the receiver operating characteristics curve (aroc). results: seventeen ( . %) of larc patients were graded as high surgical difficulty. the eumarcs score was developed using the following significant predictors of surgical difficulty: bmi [ , interspinous distance \ . mm, ymrtstage = t b, and male sex. the score ranged from to . the cut-off score to best differentiate patients with a high probability of difficult surgery was = points. this cut-off value showed the best balance in sensitivity and specificity. the eumarcs score demonstrated high accuracy (aroc: . ) conclusions: the eumarcs score was found to be sensitive and specific in predicting surgical difficulty in larc patients who were candidate for laparoscopic tme. the score has the advantage of considering patient and cancer related characteristics that can be all assessed preoperatively and it can be useful in the decision making process. this score has not yet been externally validated. background: recently published two non-inferiority randomised control trials has raised questions on laparoscopic surgery for rectal cancer, showing lower quality pathological specimens to those achieved using an open technique. locally advanced rectal cancers add to the level of difficulty for laparoscopy approach. our study was aimed to assess feasibility of laparoscopic rectal surgery, comparing short term outcomes, quality of surgical specimen, morbidity and mortality, between propensity score match groups of locally advanced and early rectal cancers. methods: prospectively acquired data from consecutive patients undergoing laparoscopic surgery for rectal cancer at the minimally invasive colorectal unit in united kingdom between and . locally advanced rectal tumours were identified as t b or t with pre-operative mri scans. all the patients were operated by the same team and the procedures were performed laparoscopically. : propensity score matching was performed to create a perfect match in terms of tumour height. results: total of laparoscopic rectal resections were performed during the study period, out of which patients had locally advanced (la) disease and were propensity-score matched for tumour height with non-locally advanced (nla) patients. median operative time was higher for the la surgery group ( min vs min p = . ). however, conversion to open surgery (p = . ), readmission (p = . ), re-operation (p = . ), clinical anastomotic leak (p = . ) and -day mortality rates (p = . ) were all equivalent between the two groups. r resection was achieved in % of la group as compare to % of nla group (p = . ). conclusion: this study demonstrate that standardised approach to laparoscopy is safe and feasible in locally advanced rectal cancers. comparable post-operative short-term clinical and pathological outcomes were seen between la and nla groups. aims: the application of colorectal cancer screening programs, has showed a decrease in recurrence and mortality. for this reason, these programs are being implemented at a national level in the different spanish regions, as has happened in our community.to present the initial short-term results on the morbidity of the immediate postoperative period to days of colon cancer, mortality and hospital stay after the implementation of a screening program in our center. methods: a retrospective study was performed. patients aged between and years were included in the study, diagnosed with colon cancer. they underwent minimally invasive surgery, in most cases, with any type of colonic resection, from january to december . all patients were diagnosed, conventionally or through a screening program, the latter according to the plan implemented in our community. the sample was divided into two groups of patients according to the way of being diagnosed (group si screening = patients, group no screening = patients) and they were compared according different variables: dependent factors of the patient, factor of type colon cancer, factors of colon cancer resection and follow-up. results: both groups were comparable in all study variables. regarding the variables included in the follow-up, no statistically significant differences were found in terms of postoperative mortality-clavien-dindo v. however we found differences statistically significant in postoperative morbidity (p = . ) and in its classification according to clavien dindo i-iv (p = . ). the complications analyzed independently, such as anastomotic dehiscence (p = . ) or postoperative ileus (p = . ), have also presented significant differences, unlike surgical wound infection (p = . ). conclusion: at our center, the application of the screening program has not influenced in the initial stage of colon cancer or its surgical approach. however, we have found a lower overall morbidity rate and minor complications, justified by a lower incidence of anastomotic dehiscence and postoperative ileus. background: colorectal carcinoma is one of the most common malignancies. surgery is the only definitive method to achieve cure for this illness and can be performed via an open or a laparoscopic approach. the pros and cons of each approach have been discussed extensively, with the oncologic efficiency of the laparoscopic approach being one of the leading topics. objective: the aim of this study was to establish oncological non-inferiority of the laparoscopic approach to colorectal cancer. primary outcome measure was defined as number of harvested lymph nodes. secondary outcome measures were medium-term disease free and overall survival as well as length of hospital stay, time to oral feeding and short-and long-term complication rate. methods: this was a single center retrospective chart review. all consecutive patients who underwent colon or rectal resection due to colorectal carcinoma at hadassah medical center between the years - were included. patients who were operated on for recurrent disease or who had metastatic disease at the time of surgery were excluded. patients were divided into three groups according to the surgical approach: laparoscopic, open or converted. medium-term oncological outcomes were the same for all groups. time to oral feeding, length of hospital stay, short-and long-term complication rate were all significantly improved in the laparoscopic group. conclusions: we were unable to prove non-inferiority of the laparoscopic approach regarding the number of harvested lymph nodes. however, all surgical approaches yielded a high number of harvested lymph nodes which is most probably oncologically sufficient, as reflected by the non-existent difference in medium-term oncological follow up. this study supports previous studies showing the superiority of the laparoscopic approach regarding short term recovery and overall complications rates. aims: two non-inferiority randomised control trials have questioned the utility of laparoscopic surgery for rectal cancer by failing to prove that pathological markers of high quality surgery are equivalent to those achieved by open technique. we intend to present short and long-term postoperative outcomes from the largest single surgeon series of consecutive patients undergoing laparoscopic tme for rectal cancer. we describe the standardised laparoscopic technique developed by the principal surgeon, and the short-term outcomes from three surgeons who were trained in and subsequently adopted the same approach. methods: prospectively acquired data from consecutive patients undergoing surgery for rectal cancer by the principal surgeon (ap) at the minimally invasive colorectal unit in portsmouth between and were analysed along with data acquired between and from surgeons (tq,nf,ah) at three further international centres. end-points were overall and diseasefree survival at years, and early post-operative clinical and pathological outcomes. results: consecutive patients underwent laparoscopic tme surgery by the principal surgeon (ap). at years overall survival was . % (dukes' a = . %; b = . %; c = . %); disease-free survival was . % (dukes' a = . %; b = . %; c = . %). post-operative length of stay, lymph node harvest, mean operating time, rate of conversion, incomplete resection, major morbidity and day mortality were not significantly different between the principal surgeon and those he had trained when subsequently in independent practices. conclusion: laparoscopic tme produces excellent long-term survival outcomes for patients with rectal cancer. a standardised approach has the potential to improve outcomes by setting bench-marks for surgical quality, and providing a step-by-step method for surgical training. results: analysis of association of tumor location (sigmoid, right or left colon), operation time, blood loss, extraction site, type of surgical sutures used for wound closure with postoperative complications or specimen quality either did not show significant correlation or could not be conducted due to data nature. unexpectedly, a significant difference was demonstrated between two surgical teams in terms of hernias. majority of cases- ( . %) were performed by surgeon (s ), surgeon (s ) operated on ( . %) patients, nevertheless minilaparotomy closure was usually performed by junior members of the team. conversion rate was . % for s and . % for s (p = . ). operation time and blood loss were smaller in s group compared to s ( . ± . min vs . ± . min, p = . and . ± . ml vs . ± . ml, p = . respectively). specimen quality and early postoperative complications did not differ. postoperative hernia rate was . % for s and . % for s (p = , ). both surgeons used the same specimen extraction sites and materials for wound closure. hernias were more frequent after vertical minilaparotomy- % ( of patients), and in converted patients , % ( of patients), compared to , % ( of ) in transverse minilaparotomy group. there was no association of hernias and wound infections. conclusions: our study demonstrates, that besides consultant dependent surgical surrogates, steps which are often performed by other members of surgical team (such as wound closure) may contribute to complication rate as well. more thorough supervision of wound closure may be needed. aims: laparoscopic complete mesocolic excision (cme) right hemicolectomy is considered a demanding procedure and it is actually adopted in few centers from the west. the aim of the present study is to analyze the safety of laparoscopic cme right hemicolectomy and to compare its short-term results with standard right hemicolectomy in a single western center. methods: prospectively collected data from patients who underwent laparoscopic cme right hemicolectomy between june and november were retrospectively analyzed (cme group) and compared with data from patients submitted to standard laparoscopic right hemicolectomy between april and november (s group). results: no differences were observed between the cme and the standard right hemicolectomy groups in terms of clinical characteristics. in the cme group, . % of patients were = years old, . % of patients were asa class , . % of patients had = comorbidities, . % of patients had bmi [ and . % of patients had = previous abdominal surgeries. no differences were observed in terms of duration of surgery ( ± min vs. ± min; p = . ) and intraoperative complications ( . % vs. . %; p = . ) between cme and s groups; mean blood loss was lower in the cme group ( . ± . ml vs . ± . ml, p = . ). the percentage of overall ( . % vs. . %; p = . ) and severe (clavien-dindo = ) complications ( . % vs. . %; p = . ), redo surgery ( . % vs. . %; p = . ) and readmission ( . % vs. . %; p = . ) was comparable between cme group and s group. a significant difference was observed in the length of specimen ( ± mm vs. ± mm; p \ . ) as well as in the length of proximal ( ± mm vs. ± mm; p = . ) and distal margins ( ± mm vs. ± mm; p = . ) in favor of the cme group. the number of lymph nodes harvested was slightly higher in the cme group ( . ± . vs. . ± . ; p = . ) as it was for the percentage of cases with less than retrieved lymph nodes ( . % vs. . %; p = . ), although these differences did not reach statistical significance. conclusions: this study represents one of the few western experiences demonstrating the safety of laparoscopic cme right hemicolectomy. cme technique showed good short-term results and better quality specimens when compared with the standard procedure. aim and background: peritoneal dissemination of colorectal cancer (pc) makes the complete resection of cancer lesions impossible. in such cases, multidisciplinary therapy is essential with mainly chemotherapy. preoperative diagnosis of pc is usually uncertain by ct or mri image. for diagnosis of pc needs surgical materials with laparotomy. but the laparotomy and resection of pc with general anesthesia tends to make impossible for immediate chemotherapy. less invasive diagnosis of pc is necessary and expected.endocytoscopy (ec) makes the histological diagnosis with precise images gained by high magnification (x ). as a preliminary examination, ec diagnosis for resected specimens of pc were evaluated. methods: two cases of pc diagnosed in operation were evaluated. under general anesthesia, laparotomy was conducted. peritoneal dissemination lesions obviously diagnosed as pc were resected. immediately the lesions were stained by methylene blue solution for to s. ec observation was done according ec classification ) and ecv classification ). results: in two cases, ec observation was successfully done. images of dilated surface microvessels of a nonhomogeneous caliber or arrangement were observed in nbi ec corresponding to ec-v . histopathological diagnosis of resected specimens was metastatic colorectal carcinoma in peritoneum in both cases. conclusions: histological diagnosis for pc is gained by ec with resected specimen. as the result of this investigation, ec examination via camera port in laparoscopic operation might be possible for diagnosis for pc of colorectal cancer in vivo. aims: the aim of this presentation is to demonstrate and analyze surgical complications, arising during laparoscopic colorectal resections for cancer and to analyze the reasons of adverse events. methods: we demonstrate videos from our surgeries, where different types of complications occurred and share our classification of types of mistakes, that may lead to intraoperative complications and ways to prevent them. results: we divide mistakes in laparoscopic colorectal resections into two large groups-'false strategy' and 'dangerous techniques'. the first includes poor diagnosis, too extensive or insufficient extent of surgery and improper enthusiasm in using platforms. prevention of first type mistakes is in thorough training and peer-review of each consultant practice. second type of mistakes includes two subtypes : 'faulty habits'-use of unsafe techniques (blind port insertion, poor vascular exposure prior to clipping, not obtaining 'critical views', unsafe use of energy and stapling devices etc.) and 'failure in a certain case'-when despite correct general approach a complication occurred (misinterpretation of fascial layers or vessels). prevention of 'faulty habits' lies in supervised training in high volume colorectal departments including dedicated surgical devices training. to avoid 'failure in a certain case' standardization of surgical procedure is essential, as the most efficient way to prevent this type of mistake is 'pattern recognition'ability of a surgeon to compare the picture he sees during a procedure with a 'standard' view, he used to have during previously performed standard surgeries-this is apparentely impossible when every procedure is done differently. regular reviews of own surgeries recording and other surgeons' procedures may also fascilitate pattern formation. in case a complication occurres we use the four step course of action: preservation of the view, temporary control, decision on conversion, permanent control. conclusion: as popularity of laparoscopic colorectal resections is growing rapidly the number of intraoperative compliactions is increasing as well. we demonstrate videos of complications and our approach to classification of possible mistakes. systematic aproach to reasons, underlying certain mistakes helps to produce a strategy to reduce intraoperative complication rate. introduction: the drains placement inside the abdominal cavity has traditionally been carried out to evacuate hematic remains or postoperative collections. there is no scientific evidence of the prophylactic use of drainage in elective colorectal cancer (ccr) surgery to avoid anastomotic complications or other complications. however, it is traditionally used. when the anastomotic leak is produced, it is generally agreed that drainage system should be used for therapeutic purposes. aims: the aim of this study is to evaluate the effectiveness of the use of prophylactic drainage in elective surgery of ccr. we would check if they avoided the appearance of complications, and if they are useful when the anastomotic leak appears. methods and results: we analyzed the data collected in our hospital from / / to / / . we studied the number and type of interventions in which prophylactic drainages were placed, the appearance of anastomotic complications and if these drains were effective. interventions were performed during this period of time. % of these procedures had used prophylactic drainage ( interventions). this percentage was up to % in patients who have performed a left colon surgery as a sigmoidectomy or rectal procedure. during this period, there were cases of anastomotic leakage. in all of them had been placed drainage but only of them were effective. conclusions: we have seen that prophylactic drainage is a common practice independently of the location of the anastomosis. the last multimodal rehabilitation guidelines recommended the nonuse of drains systematically above the peritoneal reflection with a high level of scientific evidence. they cause discomfort to the patient and delay early mobilization. however, it may be useful to use drains in the first h of a pelvic floor procedure. there is not enough evidence to show sistematic drainage after colorectal anastomosis prevents complications of the anastomosis or other complications. aims: colonic cancers of the splenic flexure is uncommon and associated with poor prognosis. several studies were published aimed to identify the optimal surgical option for the best oncological outcomes. however, whether an extended colectomy or a segmental resection is required is still controversial. the aim of this study is to analyse the outcome of the two different approaches through the experience of a single centre. materials and methods: retrospective data of consecutive patients with diagnosis of colonic cancer situated at the splenic flexure of our department between and were analysed. based on type of surgical procedure, patients were enrolled in arm a (segmental resection) and arm b (extended resection). arm a patients were treated with segmental resections with a wide mobilisation of the transverse and descending colon and ligation of the left colic artery, sparing the middle colic artery and the inferior mesenteric artery. functional lateral to lateral anastomosis was performed extracorporeally. arm b patients were treated with more extended colectomies, both associated with central vascular ligation. results: out of patients included, were allocated in arm a and in arm b. patients' population of the arms was homogeneous as concerns demographic characteristics and stage of the disease. operative time was comparable ( , min vs min, p = , ). the length of the specimen was significantly shorter in arms a ( , vs , , p = , ) . the number of harvested lymphnodes did not differ between the two groups ( , vs p = , )postoperative short term complications was comparable in both arms ( vs , p = , ). no postoperative mortality was observed. overall -year survival and disease free survival rates were similar in arm a and b ( . % vs . %, p = , and , % vs , %, p = , ). hospital stay was similar in the two groups (p = , ). conclusions: despite a shorter length of surgical specimen after limited resections, postoperative complications, lymph node harvest, and survival were comparable in both.in our opinion the extracorporeal anastomosis is functional to both the achievement of a cleaner operative field and a better control of the resection margins. incidence of neuroendocrine tumours in the rectal area has increased in recent years.before the onset of minimally invasive colorectal surgery, these lesion had to be treated by a more radical technique when not suitable for endoscopic resection.selection of the cases is mandatory in order to achieve good results not only surgical, but also oncological. we present our series of neuroendocrine tumoirs treated by tamis approach, including technical aspects, deffect closure techniques and data regarding pathological findings.all cases were low grade carcinoid tumours. resection with free margin was obtained in all cases. defect closure was performed in all cases. the tumours were settled , and cm form the anal verge. postoperative course was uneventful, ann no adyuvant therapy was needed.tamis apporach for rectal neuroendocrine tumours is a safe and feasible technique. proper selection of the cases is mandatory in order to achieve good results. surg endosc ( ) aim: to assess the safety and efficacy of single layer of barbed vs double layer 'hybrid' (interrupted and running) suture for the closure of anastomotic stapler access enterotomy after laparoscopic right colectomy with intracorporeal anastomosis. methods: from april to november , laparoscopic right colectomy with intracorporeal anastomosis were performed in our surgical department. all patients in both groups were perioperatively managed using an eras pathway. seventy-two patients had the enterotomy closed with a single layer running suture of filbloc tm (assut europe). these patients were matched with patients who underwent intracorporeal right colectomy with enterotomy closed with a 'hybrid' double layer technique (first layer interrupted stitches in maxon tm - (covidien), second layer using a running suture in pds tm - (ethicon). intraoperative variables, anastomotic leak rate, morbidity and mortality rates were analyzed. results: the two groups were homogeneous with respect to demographics, body mass index (bmi), american surgical association score (asa) as well as for tumor stage. in the barbed group, median operating time was . min vs . min in the hybrid group (p = . ). anastomotic leak occurred in ( . %) patients in the hybrid vs ( . %) patients in the barbed group (p = . ). all patients required a reoperation. intraoperative findings show in ( . %) cases in the hybrid group a leak at the enterotomy closure, while an intact staler access was observed in both patients in the barbed group. no difference was observed with respect to noninfectious complications between the two groups (p = . ). patients in the hybrid group experienced a longer hospital stay when compared to the barbed group (p = . ). a re-admission occurred in the hybrid due an intraabdominal collection, while no re-admission was observed in the barbed group. no patient died in the postoperative period. aims: lymph node status is one of the key prognostic factors in patients with colorectal cancer, and remains the most important selection criteria for adjuvant chemotherapy. it is believed that at least % of node negative patients will suffer disease recurrence within the first years after surgery. this may be due to understaging lymph node status. sentinel lymph node mapping is widely used for staging of breast cancer and melanoma, with injection of colloid tc and isosulfan blue (ib). however, indocyanine green (icg) fluorescence guidance is a new technical approach to this issue, with promising results as it is not influenced by body mass index or lymphatic invasion. intraoperative fluorescence icg navigation also aims for detection of aberrant lymphatic drainage outside the planned resection. the icg lymphography has the advantage of offering a good visualization of the lymphatic channels but there are problems to identify the lymphatic nodes. our objective with this study is to rate the use of the intraoperative lymphogram in cases of elective colorectal surgery to evaluate if there were changes in the surgical attitude regarding the performance of lymphadenectomy. methods: indocyanine green was injected into the submucosal layer around the tumor at points with?a -gauge localized injection before lymph node dissection and the lymph flow was observed at , and min after injection, using a near-infrared camera system. in addition, a complete mesocolic excision with central vascular ligation guided the region where the lymph flow was observed to be fluorescent. the following table summarizes the procedures carried out as well as the lymphadenectomy performed before and after the use of icg. in brief, after the application of intraoperative icg it was observed that in % of patients additional lymph nodes were obtained after the expansion of the surgical plan, moreover % affected lymph nodes were spotted after the expansion of the surgical plan. conclusions: intraoperative real-time visualization of the lymph flow using indocyanine green fluorescence imaging during laparoscopic colon cancer surgery is feasible and a helpful technique for lymph node mapping which may lead to intraoperative changes in lymphadenectomy. tamis resection of rectal tumours has proven to be a sefe and feasible technique, specially for lesion located in the mid and low rectum.when the tumour is located in the upper rectum, and specially near the colorectal junction, tamis resection may be more difficult, not only due to technical aspects, but also due to the risk of a free perforation, specially when a full thickness resection is performed.we present our results of tamis resections of lesions located around the colorectal junction. four resections where performed with the aim of an endostpaler in order to achieve full resection without the risk of a free colonic perforation.in cases, an abdominal combined laparoscopic exploration was made, in order to help and assure proper resection of the lesion as well as avoiding intraoperative complications.distance from the anal verge ranged from to cm.postoperative course was uneventful in all cases, and a complete specimen resection was obtained in all cases.tamis resection of tumours located in the rectosigmoid junction may be a safe and feasible technique in selected patients. methods: between january to april , patients with diagnosis of right colon adenocarcinomas underwent right hemicolectomies. the data was analysed for patients demographic, histology, type of surgical approach, intraoperative details (length of surgical procedure, blood loss, blood transfusion, conversion rate) and short-term post-operative outcomes including complications. introduction: postoperative ischemic colitis is a life-threatening vascular gastrointestinal condition, that mainly occurs after cardiovascular surgery. we present a surprising case following a laparoscopic rectum resection. case report: a -year-old diabetic patient with upper rectal adenocarcinoma undergoing laparoscopic anterior rectal resection (partial mesorectum excision) and mechanical anastomosis following chemotherapy / radiotherapy. after h postsurgery he presented abdominal pain, distension and fever. on adominal computed tomography (ct) scan (contrast enema) no anastomotic leakage (al) finfings were revealed. neither digital palpation nor proctosigmoidoscopy ( th day) showed al signs. the patient clinical situation improve with conservative treatment (antibiotics, digestive rest …), c-reactive protein levels decreased and the blood cultures were negative. on the th day he was discharged presenting semiliquid stools. eight days later he needed hospital readmission: air and feculent/purulent discharge from the previos abdominal drainage orifice. ct scan: no evidence of dehiscense found although rectum and sigmoid colon distention and an image of a 'large fecaloma' were observable. on the th day of hospitalization he expulsed a large malodorous segment of tissue with necrotic asppearance (image) through the anus with surprising histologic features: 'complete-thickness necrotic colonic wall'. further rectosigmoidoscopy: complete anastomosis, signs of ischemic colitis proximate to the anastomosis and a fistulous orifice. surprisingly, the patient progressed favorably, being discharged the th day for ambulatory control with a low debit enterocutaneous fistula. histopathological diagnosis: ypt n m . follow up: the fistula discharge quantity increased maintaining diarrheal stools through anus along with persistent anemia and malnutrition. a exploratory laparotomy was schedule. fistulous tract towards a small stenotic segment of colon inmediately proximal to the colorectal anastomosis was identify and resected. finally a terminal colostomy was performed. subsequent postoperative without incidents. currently the patient is asymptomatic. comments: it seems indisputable that a colon segment, proximal to the anastomosis, was necrosed and expelled through a colorectal anastomosis. the mechanism seems inexplicable to us. it is even more disconcerting that there was no disruption of the anastomosis. objectives: fluorescence-guided surgery has emerged as a new imaging modality to improve the detection of liver and lymph node metastasis in colorectal cancer. in right-sided colon cancer, the standard lymphadenectomy should reach the ileocolic vessels and the right branch of the middle colic vessels. the purpose of this study is to perform an objective estimation of lymphatic drainage and metastatic lymphonodes in right-sided colon carcinoma through indocyanine green (icg) lymphography. methods: patients with right-sided colon adenocarcinoma were included, excluding those in stage iv, t and those who underwent urgent surgery. cc of icg peritumoral were injected using a peripheral intravenous catheter at the beginning of the intervention. the lymphatic drainage mapping of the tumor was identified. lymphadenectomy of the ileocolic vessels and right branch of the middle colic vessels was performed extending it to the left branch and origin of middle colic vessels if it was shown in the mapping. results: patients were included. the average age was . in patients the tumor was located in the ascending colon and in patients in the hepatic angle. in patients, the mapping showed lymphatic drainage to ileocolic vessels and right branch of the middle colic vessels. in patients ( %) it showed drainage to the left branch and origin of the middle colic artery, therefore extended lymphadenectomy was performed at that level. in patients, the postoperative period was uneventful. patient presented infection of the surgical wound and another patient developed a cm perianastomotic collection treated with percutaneous drainage. the anatomopathological report showed nodal metastasis in of the patients ( %) in whom lymphatic drainage was observed in the territory of the middle colic vessels with icg. these patients presented the tumor in the hepatic angle. therefore, of the patients with right-sided colon carcinoma ( %) presented nodal metastasis in the territory of the middle colic vessels. conclusions: fluorescent lymphography may improve the results of lymphadenectomy in colon cancer. in patients with tumors of the hepatic angle, lymphadenectomy extended to the left branch and origin of middle colic vessels, could be an adequate alternative. introduction: over the last decade, the common principles of surgical treatment in colon surgery are central vascular ligation (cvl) and complete mesocolic excision (cme). however, the superior mesenteric vessels anatomy, while performing the right colectomy is characterized by wide variability, which can lead to complications, especially during minimally invasive surgical intervention. objective. the purpose of this study is describing vascular variations around the superior mesenteric artery and vein-middle colic, right colic and ileocolic vessels, henle trunk in the laparoscopic right colectomy. materials and methods: the study was held in the 'dobrobut' clinic and o. o. bohomolets national medical university, department of general surgery (kyiv, ukraine) during the - period. patients were included to the study, females ( . %), males ( . %) in the average age of , ± , years. all the patients underwent the laparoscopic right colectomy (cme ? cvl) with d lymph node dissection. recorded video materials from each laparoscopic right colectomy were analyzed during the study. results: ileocolic vessels were the most stable. there were typical anatomical position in all cases. . % of cases, ileocolic vein was identified anteriorly to the ileocolic artery, while . % being posteriorly. right colic vein was absent in . % of cases. right colic vein drainage was to henle trunk and inferior mesenteric vein in . % and . % respectively. the right colic artery was present in % of patients, it's origin was superior mesenteric artery in . % and . % the middle colic artery. the middle colic vein was present and drained to superior mesenteric vein in % of cases. same as the middle colic artery with the superior mesenteric artery origin. henle trunk was present in . %, gastro-pancreato-colic trunk in . % of cases gastro-pancreatic trunk in . %, gastro-colic in . %. conclusions: knowing the options of surgical vessels anatomy, while performing the right colectomy, altogether with surgeons preparation, using the ct-scan data can reduce the risk of iatrogenic damage and complications risks. introduction: the enhanced recovery after surgery (eras) protocol was designed to accelerate convalescence, reduce morbidity and shorten the length of hospital stay (los). one of its major interventions is balanced perioperative fluid therapy. the impact of this single intervention on short-term outcomes is widely discuss. aim: the aim of this study was to assess the impact of perioperative fluid therapy on short-term outcomes. material and methods: the analysis included consecutive prospectively registered patients operated laparoscopically for colorectal cancer between november and january . patients were divided into two groups: balanced (= ml) or unbalanced ([ ml) perioperative fluid therapy. all patients were treated according to eras protocol. study outcomes were: recovery parameters, morbidity rate, los, -day readmission rate. results: group consisted of and group of patients. there were no statistically significant differences between the groups in terms of demographic and operative parameters. morbidity was lower in group ( . % vs . %, p = . ). patients in group were discharged home earlier than in group ( vs days, p \ . ). moreover, we observed differences in recovery parameters between the groups: tolerance of an oral diet on the st postoperative day ( % vs. %, p = . ) and patient mobilization on the day of surgery ( % vs. %, p = . ). -day readmission rate was lower in group ( . % vs. %, p = . ). conclusion: a balanced perioperative fluid therapy on the day of surgery may be associated with faster convalescence, lower morbidity rate, shorter los and lower -day readmission rate. methods: a retrospective analysis was performed including patients who underwent lcs or ocs for cancer treated as emergency in a single centre between and . patients who underwent palliative surgery were excluded. lcs were : propensity score-matched based on pposum and stage of disease with ocs. short-term outcomes included oncological quality, length of hospital stay (los) and postoperative mortality. for long-term outcomes, -year overall and disease free survival (os and dfs) rates were analyzed. results: during the study period, a total of emergency colorectal resections were performed. of them, % (n = ) were coloniccancers. lcs were matched to an equal number of ocs.median age was ( ) years and % were females. median follow-up was ( ) months. the majority of resections were right hemicolectomies ( %), followed by sigmoid resections ( %) and subtotal colectomies ( %). operative time ( ( ) background: total mesorectal excision (tme) offers the best reported rates for local recurrence and survival in patients with rectal cancer. our series from a single high-volume center, assessed the feasibility, safety and long-term oncologic adequacy of laparoscopic total mesorectal excision methods: we reviewed the prospective database of consecutive unselected patients undergoing laparoscopic tme for rectal cancer between and at the department of general surgery, onze-lieve-vrouwziekenhuis hospital (olv), campus aalst, belgium. the objective of the present study was to evaluate the effectiveness of laparoscopic tme, with an emphasis on perioperative variables and long-term oncological outcomes. results: pts with mid and distal rectal cancer up to cm from the anal verge had laparoscopic tme resection. patients ( . %) underwent a sphincter-preserving surgery and the remaining patients ( . %) had an abdominoperineal resection. end-to-end anastomoses: pts ( %), j-colonic pouch: pts ( % introduction: the rica clinical pathway (intensified recovery in abdominal surgery), also called surgical multimodal rehabilitation, is the application of a series of perioperative measures and strategies in those patients who are going to undergo a surgical procedure with the objective of reducing secondary stress to the surgical intervention. in this way, we achieve a better recovery of the patient and significantly reduce complications and morbidity. objective: s to analyze, through our database of patients undergoing crc, the percentage of postoperative ileuses and the following quality indicators: the postsurgical hospital stay, the anastomotic leak, and the infection of the surgical site. to check if the implantation of the rica pathway has meant an improvement in our postoperative hospital stay and with that, a lower sanitary cost. methods and results: we analyzed the data collected from those patients who underwent ccr in our hospital between / / and / / , during which time we implemented the rica clinical pathway. the average hospital stay was days. of the patients, . % presented anastomotic leak, . % infection of the surgical wound and . % paralytic ileus. we have verified how the average hospital stay increases with the appearance of anastomotic leak ( . days), infection of the surgical wound ( . days) and paralytic ileus ( . days). when we divided this -month period into two halves to see the impact of the implantation of the clinical pathway, we obtained the following results: the post-surgical hospital stay in the period from / / to / / was . . the stay from / / to / / was . . the implantation of the rica clinical pathway is providing us with important advantages in our clinical practice, with greater postoperative comfort and an improvement in our quality indicators, such as the decrease in the average hospital stay of our patients. on the other hand, after starting its implementation we have encountered the resistance to change clinical habits and the one that requires a multidisciplinary participation, so adherence to this is being progressive, and requires periodic audits to reinforce and consolidate our achievements, and identify our points of improvement. however, tem has not yet achieved widespread use. recently, transanal minimally invasive surgery (tamis) using single-port surgery devices has been reported. initially facilitated by existing single-port surgery devices, two platforms for transanal access, the gelpoint Ò path (applied medical, rancho santa margarita, ca, usa) and the sils tm port. the gelpoint Ò path is the only platform to be specifically designed for tamis y tatme. objetive: in the present study, usesa gelpoint Ò path was performed in patients with lower rectal neplasms. results: complete full-thickness excision was performed in all cases of tamis and free margins over rectal cancer. on two cases no neoplasm was visualizad. the patient characteristics, operative techniques and operative outcomes were evaluated. the mean age of the patients was . years (range - ). the mean operating time were min (range - ). patients was selsted for tatme, for tamis and two patients for evaluation and biopsy if was necesary. additional transabdominal rectal resection was not performed, and adjuvant chemoradiotherapy was performed in all cases. tamis using a gelpoint Ò path was revealed to be easy and safe to perform. although only a small number of cases were treated, and the operation was demonstrated to be sufficiently feasible. conclusion: gelpoint path is a good tool for colorectal surgery in tatme, tamis and evalluation of anastomoses or de novo lesions introduction: several improvements in rectal cancer treatment, in the last decades, resulted in a markedly increased survival. nevertheless, surgery remains the prevalent treatment and to % of operated patients experience some kind of functional abnormalities. as nowadays we acknowledge the importance to focus not only on survival rates but also on quality of life, we craved for a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation. therefore, we performed a thorough translation with cultural adaptation of the patient reported outcome tool, low anterior resection syndrome (lars) score, to the portuguese language (lars-pt) and population. methods: according to the current international recommendations, we designed this study encompassing three main phases: (i) cultural and linguistic validation to european portuguese; (ii) feasibility and reliability tests of the version obtained in the previous phase; and (iii) validity tests to produce a final version. the questionnaire was completed by patients from six portuguese colorectal cancer units, and completed it twice. results: the portuguese version of lars score showed high construct validity. regarding the test-retest, the global intraclass correlation showed very strong test-retest reliability. looking at all five items, only items and presented a moderate correlation. lars score was able to discriminate symptoms showing worse quality of life in patients submitted to preoperative radio and chemotherapy. conclusion: lars questionnaire has been properly translated into european portuguese, demonstrating high construct validity and reliability. this is a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation. therefore, his sistematic use should be implemented. oesophagectomy is the mainstay of curative treatment for oesophageal cancer and post-oesophagectomy diaphragmatic hernia (podh) represents a potentially life-threatening surgical complication characterized by an underestimated occurrence rate and unknown related risk factors. this study analyses the experience of two tertiary designated centers in order to evaluate key elements concerning development and treatment of podh. a cohort of consecutive patients affected by a clinically resectable oesophageal cancer (any t, any n and m ) underwent ivor-lewis oesophagectomy between march and april according to three different approaches: totally open incision procedure (oilo), hybrid (hilo) and totally mininvasive to esophagectomy (milo). all population was retrospectively observed in the context of a postoperative calendarised follow-up in order to record the incidence and postrepair results of podh. patients underwent ivor-lewis oesophagectomy for cancer and ( . %) developed podh within a median follow-up period of months ( - ). surgical repair was generally applied by the mean of laparoscopic cruroplasty ( %) with a conversion rate of %. postoperative morbidity did not include early recurrences but exclusively cardio-pulmonary complications ( patients) with one case of respiratory failure leading to death. the discharge was reached after a median hospital stay of days ( - ) while recurrences ( %) occurred over a median followup period of . months. a wide univariate analysis identified statistically significant associations between podh occurrence and the administration of preoperative chemoradiotherapy, the complete pathological response (cpr) and a lymph node harvest (lnh) larger than stations (p-value of . , . and . respectively). the strong influence of an extended lnh was confirmed by the multivariable analyses ( . ) along with cpr which should however be considered as longer survival-related bias. the minimally invasive surgery and the neoadjuvant chemoradiotherapy represent a considerable part of multimodal treatment for oesophageal cancer presenting a not statistically significant association with podh development while a lnh including more than nodes resulted to be an independent risk factor mirroring the extent of surgical demolition in oesophagectomy. l. barbulescu aim: to asses the safety and effectiveness of robotic total meso-rectal excision vs laparoscopic total meso-rectal excision and to analyse the primary outcomes. methods: the operative, post-operative and oncological outcomes were evaluated to assess the effectiveness of both techniques of tme. in our center were performed robotic rectal resections and laparoscopic resections from january to present. results: the rtme was associated with longer operation time, early bowel movements, lower risk of conversion and shorter hospitalization. the statistical equivalence was seen between rtme and ltme for non-oncological variables like blood loss, morbidity and reintervention risk. the oncological variables such as number of harvested nodes and positive circumferential resection margin risk were also comparable in both groups. the length of distal resection margins was similar in both groups. conclusion: rtme in patients with rectal cancer was associated with a lower rate of conversion and less incidence of urinary retention. the operative time in rtme was significantly longer than in ltme. the initial oncological and function outcomes of rtme seem to be equivalent with ltme. c. athanasiou aims: two randomized controlled trials failed to show non-inferiority of the laparoscopic total mesorectal excision (ltme) compared to open. ltme becomes particularly challenging in low rectal cancers and in narrow pelves. many surgeons report that robotic tme (rtme) may be beneficial in that setting. our aim was to systematically review the literature and compare the pathologic outcomes of open, laparoscopic and robotic tme for rectal cancer methods: medline, embase, scopus, cochrane library and web of knowledge databases were searched for randomized controlled trials (rct) reporting patholologic outcomes of open, laparoscopic or robotic tme with no language restriction. our primary outcome was quality of tme on macroscopic assessment of the specimen. secondary outcomes included positive circumferential resection margin, distance to radial margin, number of lymph nodes and positive radial margin. the included studies were quality assessed and the jadad score was reported. the grade approach was used to rate the certainty of each network estimate. results: fourteen rcts were included in our study. seven rcts compared the otme to the ltme, six compared the ltme and rtme and one study the otme to the rtme. no statistical significant difference was found in quality of tme when the the ltme was compared to the otme or = . ( . , , ) or the rtme or = . ( . , . ) . no difference was found in pcrm for the laparoscopic or = . ( . , . ) or the robotic approach or = . ( . , . ) when compared to open. distance to radial margin and number or lymph nodes didn't differ between the groups. conclusions: no significant advantage on pathologic specimen quality has been found with the robotic approach. the ltme doesn't seem to compromise the quality of the specimen. h. samura , j. arakaki , k. sugata , y. hori , y. nagamine , f. kohagura , h. motonari , s. kameyama , t. ishimine division of digestive and general surgery, urasoe general hospital, okinawa, japan; department of surgery, urasoe general hospital, okinawa, japan colorectal cancer often invade adjacent organs and it is known that prognosis improves with resection of the involved organ. we report our experience of invaded adjacent organ resection, which include seminal vesicle, uterine and bilateral appendages, posterior wall of the vagina and bladder wall. method: although the range of resection is predicted by image study preoperatively, at the time of operation, it was decided by palpation with a forceps. each operation is evaluated by operation time, blood loss, blood transfusion volume, postoperative complication, postoperative hospital stay, and short term prognosis. result: resection cases of seminal vesicle, posterior vaginal wall, uterine and bilateral appendages and bladder wall were , , and , respectively. the results are shown in the order of seminal vesicle / vaginal posterior wall / uterine / bladder. median age was , , and years old. the median operation time was , , , min, the median blood loss was , , , ml, and only one case of uterine and bilateral appendages resection required the blood transfusion. the average postoperative hospital stay was , , , days. nine cases have postoperative complication, that include delayed wound healing, anastomotic leakage and rectovesical fistula, postoperative ileus, chyle ascites and neurogenic blodder. all of those were improved with conservative treatment. the mean hospital stay in complication cases was days ( - ) and ( - ) days without complications. the median observation period was days ( - ), and there was no local recurrence. all of the case of stage iv were dead. there was no local recurrence and all patient without stage iv are alive, it seems that the resection range was sufficient. conclusion: even with adjacent organ invasion colorectal cancer, it was possible to determine the resection line by palpation with laparoscopic forceps manipulation, and possible to resect margin free of cancer. laparoscopic low rectal resection with/without diverting ileostomy p. ihnát, m. tesar, p. ostruszka, p. gunková, p. vávra background: the construction of diverting ileostomy (di) is recommended to avoid septic complications of anastomotic leakage. the aim of our study was to assess the benefits and risks of di constructed during laparoscopic low anterior resection (lar). methods: retrospective clinical cohort study was conducted in university hospital ostrava, czech republic. all patients undergoing laparoscopic lar with tme because of rectal cancer within a -year study period were assessed for study eligibility. results: a total of patients ( patients without di, patients with di) after laparoscopic lar were enrolled into the study and underwent analysis. both study subgroups were comparable in terms of demographic and clinical features. postoperative -day morbidity was significantly lower in patients without di ( . % vs. . %, p = . ). anastomotic leakage frequency was higher in patients without di ( . % vs. . %, p = . ); surgical intervention was necessary in . % of patients without di. stoma-related complications were noted in . % of patients with di; some patients had more than one complication. surgical intervention because of stoma-related complications was needed in patients ( . %). distinctive complications of di laparoscopic construction (small bowel obstruction due to di semi-rotation around its longitudinal axis) was noted in patients ( . %). mean stoma period (interval between lar and di reversal) was more than months in our study; only . % of patients were reversed without delay (= months). postoperative morbidity after di reversal was . %; re-laparotomy was needed in . % of patients. conclusions: despite benefits of di in protecting low rectal anastomosis, ileostomy construction remains fraught with many stoma-related complications and long stoma periods associated with significantly decreased quality of life. aims: single port laparoscopic is a minimally invasive surgical technique that joint the cosmetic advantages with the well recognized benefits of the standard laparoscopic approach [ ] . we describe a laparoscopic single port hartmann reversal in a patient by the use of the umbilical colostomy site for surgical access [ ] . methods: a years old patient was submitted to a laparoscopic single port hartmann procedure with an trans-umbilical colostomy for a recurrent sigmoid volvulus that was treated at the beginning by endoscopic de-rotation. after three months the patient was reevaluated for a hartmann reversal with a laparoscopic single port technique. after routine skin preparation and laparoscopic setup, the colostomy is mobilized from its mucocutaneous border, and the anvil of a circular stapler is secured to the distal lumen. by the use of a gelpoint system with trocars, the intra-abdominal adhesiolisis in performed. the splenic flexure is mobilized to achieve a sufficient mobilization of the left colon that allows the fashion of a tension free anastomosis. the rectal stump is mobilized to the mid rectum, starting from the posterior mesorectal fascia around to the anterior rectal wall. a tension-free colorectal anastomosis is secured with a standard circular mm stapling device inserted transanally. the colostomy wound is closed. the operative time was min. results: the postoperative course was uneventful, the patient was discharged at forth postoperative day, oral intake started on postoperative day three. conclusions: single port laparoscopic hartmann reversal thought the umbilical stoma site is a minimally invasive surgical option that is safe in selected patients and offer the best cosmetic results. [ the progressive evolution of surgical techniques and oncologic protocols on rectal cancer disease facilitates surgeons to challenge the skills for anus preservation in low rectal cancer surgery. the laparoscopic surgery is already one of the best ways to reach the pelvic floor and to try procedures, which were previously difficult to apply through open surgery. the anastomotic leakage has particularly high occurrence if the anastomosis is performed in the anal or distal rectum area. it is evident that although the fecal diversion does not decrease post operatory mortality, it significantly reduce the risk of anastomotic leak and the risk of a second major surgery when the leak occur. diverting stomas are low-risk procedures from a technical point of view, but they potentially expose the patients to postoperative morbidity, impacting the patients' quality of life. it is not easy to decide whether the fecal diversion is needed or not. this decision must be made on a case to case basis, trying to apply the stomas only when they are really needed. we report our initial experience by living a transmesenterial cotton loop around the pre terminal ileum which extremities are turned out usually through the lateral trocar wound in laparoscopy or by applying a dedicated mini incision in open surgery. the purpose is to perform (in case of suspected fistula), a mini invasive diverting procedure, by widening the loop wound and by pulling up the ileum in a lateral loop ileostomy. we applied this procedure to consecutive patients with low colorectal anastomosis and in two of them we performed a lateral loop ileostomy with good results. we believe this can be an alternative that needs to be standardized. purpose: sarcoidosis is a chronic, multisystem inflammatory disorder with unknown aetiology characterised by noncaseating granulomas within involved organs. gallbladder involvement in sarcoidosis is extremely rare and literature review revealed only reported cases to date. in this paper, we present a case of gallbladder associated sarcoidosis. method: a -year-old lady was known to the clinic for regular surveillance of liver steatosis and incidental gallbladder polyps. the largest polyp was mm at presentation in and has grown to mm in . in view of worsening symptoms of biliary colic and growing polyps, a laparoscopic cholecystectomy was performed. results: laparoscopic cholecystectomy was unremarkable and specimens of the gallbladder and lymph nodes were sent for histology. histological examination revealed chronic cholecystitis with polypoid cholesterolosis of the gallbladder and noncaseating granulomata within a lymph node, which strongly suggest sarcoidosis. conclusion: in conclusion, we report a case of incidental finding of gallbladder sarcoidosis over the course of treatment of biliary colic and symptomatic gallbladder polyps. therefore, the definitive treatment for patients with symptomatic gallbladder sarcoidosis is a cholecystectomy. the surgical management of cholelithiasis can be associated with significant morbidities. despite the relatively low incidence of bile duct injuries during laparoscopic cholecystectomy, the total number is large due to the high frequency of the operation. the subtotal cholecystectomy with its variants is a well known bailout strategy to the surgical community. however, there is no agreement on when and how to perform these procedures. indeed, the majority of surgeons will adopt these solutions when there is a struggle to identify the critical view of safety. this struggle results increases the risk of injuries. we hypothesize that a primary intent gall bladder lithotomy and disconnection (glad) when the dissection of the gb pedicle is anticipated difficult dissection is a safe and feasible strategic option. methods: out patients elevtively admitted to aberdeen univesity hospital with gall stone disease between march and november , consecutive patients were operated with glad procedure based on intraoperative criteria. the primary outcome was the operative time. secondary outcomes were length of hospital stay, the criteria to do this procedure will be explained, the outcomes will be listed. indocyanine green is a molecule that becomes fluorescent when excited struck with light of a specific wavelength in the infrared spectrum (nir-infrared), allowing the visualization of anatomical structures in which it has accumulated. the aim of the study is the application of icg enhanced fluorescence in laparoscopic cholecystectomy in order to identify the anatomy of the biliary tract, to reduce the risk of iatrogenic lesions and the conversion rate. the study involves laparoscopic cholecystectomy for cholecystitis and gallstones of main biliary tract. the evening before the surgery, a vial of icg ( mg) diluted in ml of saline solution was intravenous injected. during the procedure, after opening the calot triangle, switching to the nir mode on the camera, the anatomy of the biliary tract and in particular of the main biliary tract is visualized. the cystic duct and cystic artery are isolated, their section between clips is cut and the cholecystectomy is performed. from january patients were enrolled: cases of acute cholecystitis, cases of gallstones of main biliary tract, undergoing preoperative ercp. in cases of cholecystitis, the angiography allowed the visualization of the main biliary tract. in one case, an abnormal course of the cystic duct was identified. in two cases of gallstones of common bile duct, it favoured the visualization of the biliary tract anatomy. all cases were completed with laparoscopic technique. there were no intra-and post-operative complications. icg-enhanced fluorescence is a safe, effective, cheap and rapid tool that can also be applied in small hospitals with no need for training. its use does not extend the time of surgery and allows the visualization of the anatomy of the biliary tract, especially in situations where it can be altered by reducing the conversion rate and potentially the risk of iatrogenic lesions of the main biliary tract. case presentation: patient is a year old female with no significant past medical or surgical history presented to the emergency department with a day history of worsening sharp right upper quadrant pain with associated nausea, vomiting, and po intolerance. the pain started a few months prior, however it was self-limited with diet modifications. an ultrasound demonstrated a contracted gallbladder with a mm gallbladder wall. white blood cell count was within normal limits and total bilirubin was slightly elevated to . mg/dl. no palpable mass was noted on physical exam. an mr cholangiopancreatography was performed which demonstrated a dilated gallbladder measuring . x . cm, a severely thickened gallbladder with a small intramural collection and multiple gallstones. the patient proceeded with a laparoscopic cholecystectomy. intraoperatively, the omentum was densely adhered to the gallbladder and needle decompression of the gallbladder was unsuccessful due to the wall thickness. the gallbladder was subsequently removed without any complications. patient's remaining hospital course was uncomplicated. surgical pathology returned demonstrating acute on chronic cholecystitis. discussion: cholecystomegaly or 'giant gallbladder' disease is a rare pathology encountered in the surgical world. there have been few reported cases, most of which occurred in the elderly ([ years). kuznetsov et al. defined an enlarged gallbladder to have a volume of - cc and a giant gallbladder as exceeding cc (the average weight of the liver). the etiology remains unknown, however certain factors exist to allow the gallbladder to reach this size without life-threatening sequela. preoperative imaging, such as mr cholangiopancreatography, is important to differentiate biliary pathology and delineate anatomy. removal of the gallbladder is recommended to prevent the development of complications like cholangitis or bowel obstruction. the cause of cholecystomegaly still remains uncertain and warrants further research. the management and treatment remains similar to acute cholecystitis. aims: mini-laparoscopic cholecysectomy (mlc) is considered to be the best variant of minimizing surgical trauma and improving cosmesis in laparoscopic cholecystectomy. the most challenging techniqual step of mlc is clipping the cystic duct. it may be impossible or unsafe when diameter of cystic duct exceeds mm, which is common in severe chronic colecystitis or acure cholecystits. there is very limited data in the literature about the use of mlc in acute cholecystits. the aim of study was to access the first results of new technique of mlc. methods: five women with the mean age of years ( - ) underwent mlc. the st -mm troacar was inserted in the umbilicus and used for the camera and removal of the gallbladder. the nd -mm troacar was inserted in subxyphoidal area and used for the main working instruments, including medium-large polymer clip-applier (hem-o-lok type). the rd and th -mm troacars were placed in right subcostal area and used for mini-graspers (karl storz). in initial procedures we used conventional -mm clip-applier with adopted medium-large titanium clips. to improve safety, we aplied -mm hem-o-lok type clip-applier for the last patient with acute cholecystitis. in this case the diameter of cystic duct was , mm. the clipping was performed successfully. the -mm drain was placed via subcostal troacar incision. also, in this case we applied original technique of removal of the bladder using wound retraction instrument (karl storz). results: in all the cases there were no intra-or postoperative complications. the mean duration of procedures was min ( - min). the postoperative stay was days in every patient. the patients estimated their pain on postop day as 'almost absent' and cosmethic results mo postop as 'exellent'. conclusions: . new technique of mlc alowed to perform the clipping of cystic duct safely, which is essential in acute calculous cholecystitis. was conducted in department of surgery lumhs jamshoro. all the patients having age = year of age, either gender presented with history of abdominal pain, nausea and vomiting and were diagnosed as cholelithiasis included in the study and were planned either for mini-laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy were explored for outcome while the patients with empyema gallbladder, gangrene, mucocele gallbladder and adhesions were excluded from the study. results: during one year study period, total five hundred patients were diagnosed as cholelithiasis with means age . ± . (sd). of five hundred, ( . %) were underwent for mini-laparoscopic cholecystectomy with ( . %) were males and ( . %) were females. the outcome were measured as postoperative pain (vas) . ± . , size of wound (umbilical mm, epigastrium mm and subcostal mm), excellent cosmetic results, mean ± sd for hospital stay (hrs) and operative time (minutes) was . ± . and . ± . , early return to work ( . %), minor oozing ( . %), port size hernia ( . %). remaining ( . %) were underwent for conventional laparoscopic cholecystectomy with ( . %) were males and ( . %) were females. the outcome were measured as postoperative pain (vas) . ± . , size of wound (umbilical mm, epigastrium mm and subcostal mm), mean ± sd for hospital stay (hrs) and operative time (minutes) was . ± . and . ± . , early return to work ( . %), port size hernia ( . %) along with zero ( %) mortality. conclusion: it has been concluded that mini-laparoscopic cholecystectomy is superior and feasible than conventional laparoscopic cholecystectomy and has decreased early postoperative incisional pain, avoided late incisional discomfort and safe procedure with nearly scarless wounds with superior cosmetic effect especially for young female patients. objective: to determine the outcome of immediate versus late laparoscopic cholecystectomy in acute cholecystitis at tertiary care hospital hyderabad / jamshoro sindh pakistan patients and methods: the descriptive case series study of one year ( - ) was conducted in department of surgery lumhs jamshoro. all the patients having age = year of age, either gender presented with history of abdominal pain, nausea and vomiting and were diagnosed as acute cholecystitis (cholillthiasis) included in the study and were planned for laparoscopic cholecystectomy and were explored for outcome as immediate (within h) and late components ([ weeks). the frequency and percentage was calculated for categorical variables and mean ± sd was calculated for numerical variables. as this was descriptive case series so there was no any statistical test of significance was applied. results: during one year study period, total one hundred patients were diagnosed as acute cholecystitis with means age . ± . (sd). of one hundred, % were females and % were males. the immediate outcome reported as tissue fragile %, pancreatitis %, slipage of ligature of cystic duct %, empyema gallbladder %, mucocele % and gangrenous gallbladder % while the late outcome reported as adhesions %, cholecystoduodenal fistula and mirizzi syndrome % and %, gallstone ileus %, perforated gallbladder % and cholidochiolithiasis % while the mean ± sd for hospital stay (days) in immediate as . ± . while in late outcome (days) during acute cholecystitis . ± . and after surgery ( weeks later) as . ± . respectively. conclusion: it has been concluded that early lc for acute cholecystitis with cholelithiasis is safe, low cost and feasible intervention and offering the additional benefit of shorter hospital stay and reduce the economical burden. surg endosc ( ) :s -s general surgery, chang gung memorial hospital kaohsiung division, kaohsiung, taiwan background: the treatment of common bile duct (cbd) stones is challenging while unclear hepatic hilum anatomy especial experience of previous laparotomy. a minimally-invasive approach choledocholithotomy is feasible, but can be difficult and converted for the unclear anatomy of the biliary tree. near-infrared (nir) cholangiography by systemic administration of indocyanine green (icg) can enhance the visualization of the biliary tree anatomy but is limited by the high intensity of background fluorescence signal coming from the liver. nir fluorescence cholecysto-cholangiography by direct biliary tree administration of the icg can enhance the biliary tree without background noise signal. we created the nir cholangiography via different route according to patient situation : systemic circulation or biliary tree injection to see the feasibility of those application. material and method: ten patients who suffered from obstructive jaundice due to cbd stone and patients received percutaneous biliary tree drainage as first treatment and patients received endoscopic biliary tree drainage. those patients received laparoscopic choledocholithotomy as definite treatment after acute infection phase. patients received biliary tree icg injection via drain tube and patients by systemic injection. visualization and fluorescence patterns around cbd was recorded. results: in our series, one patient received previous gastrectomy and patients had previous biliary tree surgery. background: laparoscopic cholecystectomy (lc) has become the gold standard for the treatment of gallstone disease. multiple studies have confirmed its safety, lc at index admission is still not widely practiced in ireland. we present our experience in performing index cholecystectomy at cuh after the start of acute care surgery program in may . aim: the aim of this study is to determine the safety of laparoscopic cholecystectomy at index admission, complications,re-admissions, and los. methods: electronic records, theatre records and imaging reports were searched to enroll all patients who underwent lc for gallstone disease at index admission from may to october . patient demographics, indication for surgery, postoperative complications, readmission and conversion rate were recorded.in addition timings of mrcp and ercp, imaging findings, and los were also noted. results: a total of patients underwent lc during the study period. median age was years ( - ). male to female ratio was : . . ( %) patients had acute cholecystitis, ( %)had acute biliary pancreatitis, ( . %)biliary colic and ( . %) had cholecystitis with signs of cbd obstruction. ( . %)patients had obstructive jaundice and one with adenomyomatosis. patients ( %) had preop mrcp while ( %) underwent pre-op ercp. all except patients undergoing ercp had preprocedure mrcp. patients had pre-op cholangiograms. in terms of complications, ( . %) patients had bile leak and one( . %) had re-operation. one patient had the post-op hematoma which was drained percutaneously, one patient had procedure abandoned because of bradycardia upon induction of anesthesia. there was no common bile duct injury, no conversion to open and no days mortality was reported. the average length of hospital stay has been days. ( to days). conclusions: laparoscopic cholecystectomy at index admission for cholecystitis, choledocholithiasis, and biliary pancreatitis, has been a safe and feasible treatment option in our hospital. a safe practice can be ensured by adherence to a care pathway and a multidisciplinary, consultant-led service. index cholecystectomy service can be provided safely across the country to prevent diseaserelated morbidity and multiple re-admissions in patients awaiting interval surgery. when to use the two-stage surgery to treat choledocholithiasis: the size aims: the treatment of choledocholithiasis has been provided by various of studies worldwide. the most common accepted minimal invasive treatment was two-stage treatment using endoscopic retrograde cholangiopancreatography before or after laparoscopic cholecystectomy(ercp ? lc), and one-stage treatment with laparoscopic exploration of the common bile duct(lcbde). in fact, despite several large studies have been published in recent years, the debate for the ideal treatment of choledocholithiasis is way from being concluded. we aim to find the proper treatment option for the patients with variable sizes of choledocholithiasis. methods: we retrospectively analyzed patients who underwent treatments for cholidocholithiasis in our institute between january , and july , . the patients who received either ercp and lc in the same admission, and the patient who received lcbde, irrespective of trans-cystic(ltcbde), or choledochotomy(lcd), were included. the data was analyzed with chi-square test and mann-whitney u test. results: the stone size of the ercp ? lc group is significantly smaller than the lcbde group. we further analyzed the ercp failure case, and the group of stone size [= . mm has a significantly higher rate of procedure failure. the failure rate is increasing with the stone size. conclusions: both the treatment of lcbde and ercp ? lc have similar safety and success rate, and the rate of residual stone was also similar in both group. however, the failure rate for ercp is significantly increased when stone size is larger than . mm in this study. aims: the xanthogranulomatous cholecystitis (xc) is a rare entity that can cause doubt in the choice of surgical treatment, because of differential diagnosis with gallbladder carcinoma (gc). methods: a -year-old patient presented acute abdominal pain in the right upper quadrant, nausea and low-grade fever with signs of peritonitis. he had elevated pcr, leukocytosis with neutrophilia. abdominal ultrasound showed an acute xanthogranulomatous cholecystitis. a laparoscopic cholecystectomy was decided but it was converted to open surgery due to the difficulty in the dissection, with fundus embedded in the hepatic bed and intraoperative finding of hilar adenopathic conglomerate .the postoperative period was torpid, with abdominal pain, jaundice, elevated bilirubin and enzymes of cholestasis. postoperative abdominal tomography showed injury in the iv segment of the liver suggestive of neoplasia. metastatic adenopathic conglomerate at the hepatic hilum caused extrinsic biliary obstruction with hepatic failure later so an internal-external drain was placed in the bile duct. the patient was died a week later. the pathological anatomy reported a stage four of gc. results: xc is a rare, non-neoplastic, inflammatory and destructive entity of the gallbladder wall, considered a variant of chronic lithiasic cholecystitis. it may be due to extravasation of bile or ulceration of the mucosa, causing an inflammatory reaction and fibrosis, with xanthomatous cells. the prevalence is to % in the resected gallbladders. it is more frequent in - years oldfemales. its clinical presentation does not have specific characteristics that differ from cholelithiasis, except for the weight loss. radiologically it is characterized by nodular thickening and increased attenuation of the vesicular wall with signs of cholecystitis, indistinguishable from a vc. the xanthogranulomatous inflammatory foci infiltrate the hepatic parenchyma, having an invasive behavior; hence, it mimics a neoplastic disease. the confusion in diagnostic and the risk of gc (up to %) makes treatment contentious. conclusions: the xc can simulate an advanced gc that sometimes makes us wonder if we should perform a radical surgical treatment; when presented in an emergency situation, our therapeutic decision can focus on solving the acute problem and be conditioned by the patient's general condition. single port transumbilical laparoscopic surgery (sptls) is a techinque that has been around for about years. although the enthusiasm for this type of surgery seems to have diminished in recent years it is expected to rise considering the recent development of sophisticated devices for its execution . we report retrospectively our year experience with procedures performed by sptls technique. in a private practice setting in mexico city. procedures include cholecystectomy ( ), appendectomy ( ), inguinal hernia tapp and tep ( ), hiatus and esophageal ( ) , sleeve gastrectomy ( ), colon ( ), gyn ( ) . different access platforms were employed. we explain our selection criteria for the application of the technique and describe the evolution of the instruments employed during the past years, from laparoscopic conventional to curved and bendable; regular scopes to extra long telescopes with different angles. or time, top bleeding, conversion rate, the need to employ an extra trocar, complications, pathology reports, scheduled or urgent kind of surgery and length of hospital stay were recorded from the beggining; patients variables such as bmi, asa status, tep risk, satisfaction with the procedure and other were recorded . we describe the evolution of our technique, and our learning curve with cholecystectomies. we compare our group of sptls transvaginal assisted laparoscopic hysterectomy (tvalh) patients vs tvalh multiport patients. we explain the feasibilty, and efficiency of the procedure in our hands compared to other series. background: in japan, the severity of acute cholecystitis(ac) is assessed by the severity classification of the tokyo guidelines (tg ). the value of c-reactive protein (crp) is not included in the severity classification criteria. the first line treatment, according to tg , for mild (grade i) to moderate (grade ) ac is laparoscopic cholecystectomy, but laparoscopic surgery may not be feasible in some cases due to adhesion or local inflammation of the gall bladder. aim: the aim of this study is to assess the effect of crp on the open conversion rate in laparoscopic cholecystectomy for acute cholecystitis.method: we conducted a retrospective study. patients who were diagnosed with ac and treated with emergent laparoscopic cholecystectomy between june and may in our institution are included. we set the cutoff value for crp at mg/dl and compared the open conversion rate. secondary endpoints are amount of bleeding, operation time, post-operative course (peak in body temperature and inflammatory markers) and the frequency of complications according to the clavien-dindo classification. results: out of patients had a crp value greater than or equal to mg/dl. the median crp values for the crp \ group and crp = group were . and . , respectively. the open conversion rate of the crp = group was significantly higher than that of the crp \ group ( / , / , p = . ). the most common reason for these conversions was local adhesion ( / ) . there were no differences in the amount of bleeding, operation time, post-operative course, and frequency of complications with clavien-dindo grade ii or higher. background: reports about clinical value of fluorescent cholangiography using indocyanine green (icg) during single-incision laparoscopic cholecystectomy (silc) were increasing. we report clinical value and pitfalls of fluorescent cholangiography during silc for the patients with the infraportal type of the right posterior bile duct. methods: our silc procedure utilized the sils-port with an additional -mm forceps through the umbilical incision. before silc, ml of icg ( . mg) was administrated by intravenous injection. for fluorescent cholangiography, icg fluorescent laparoscope system was used. results: we performed fluorescent cholangiography during silc in patients with the infraportal type of the right posterior bile duct. all procedures were completed successfully. the interval from the injection of icg to the first obtained fluorescent cholangiography before the dissection of calot's triangle ranged from to min. detectability of infraportal type of the right posterior bile duct before dissection in claot's triangle was . % (n = ) and that during dissection in calot's triangle was . % (n = ). the infraportal type of the right posterior bile duct could be identified under fluorescent cholangiography only when it joined into the common hepatic duct. conclusions: utilization of fluorescent cholangiography can lead silc to safe even for the patients with the infraportal type of the right posterior bile duct. its benefit is emphasized when the infraportal type of the right posterior bile duct joins into the common hepatic duct. aims: due to the development of laparoscopic surgery and the progress made in surgical treatment ofhydrocephalus, surgeons may come across patients with ventriculoperitoneal (vp) shunt, as candidates for laparoscopic procedures. according to this fact, we report a case of an unusual complication of laparoscopy surgery that can appear in this kind of patients. methods: we present a case of a -year-old man with medical history of normotensive hydrocephalus with vp shunt, that came to the emergency room complaining of abdominal pain and fever since two days. blood test showed an elevation of infection parameters and inflammatory markers, and the ultrasound study revealed an emphysematous cholecystitis. therefore, we decide to carry out an emergency laparoscopic cholecistectomy. the patient did not present any adverse event during the surgery or the immediate postoperative period, being discharged the third postoperative day and evaluated ambulatory one month after the surgery with no complications. two months after surgery, the patient returned to the emergency room presenting alteration in consciousness and fever. results: during the study of the pacient, an abdominal ct was performed, showing a complete section of the vp shunt in the subcutaneus space of the upper abdominal wall and intraperitoneal migration of the remaining catheter. the patient was transferred to neurosurgery to carry out an emergent replacement of the ventriculoperitoneal shunt. after surgery and intravenous antibiotic treatment, the patient evolved favourably and was discharged a few days later. conclusions: the rate of serious complications associated with a laparoscopic approach is overall low and up to % of them occur during the abdominal access for camera or port placement and may not be recognized until postoperative period. vp shunts should not be a contraindication for laparoscopic surgery. however, laparoscopy approach must be carry out with good anesthetic and monitoring facilities and taking several previous considerations, such as verifying the proper functioning of the vp shunt, identifying the path of the catheter within the abdominal wall to avoid inadvertent damage to the catheter during trocar placement and ensuring that the intraperitoneal portion of the catheter is not twisted or obstructed prior to decompression of the abdomen. surg endosc ( ) introduction: since advantages of robotic surgery is being more emphasized, robotic cholecystectomy (rc) cases are increasing. ajou group had introduced a method called which technique places the trocars transversally on the bikini line and it makes cosmesis and pain beneficial. however, rc with low incision port has several limitations. therefore, we changed port placement which may be a one of safe tehniques for rc. method: this study retrospectively reviewed data for patients who received rc with port changing method (rcpc, n = ) and rc with low incision port (rcli, n = ) from february -february and surgical variables were analyzed. results: patients in both groups had similar demographic features and indications for surgery. the rcpc group required no conversions to conventional robotic surgery and no additional operation, whereas the rcli group had one incisional hernia ( . %) and two bowel perforation ( . %) cases. length of stay ( . ± . vs. . ± . days, respectively; p = . ) did not significantly differ between the rcpc and scli groups. however, the rcpc group had shorter operative time ( . ± . vs. . ± . min; p = . ) than the rcli group, although the parameters mentioned above were not statistically significant. conclusion: robotic cholecystectomy with bikini line incision has some limitations even though it has cosmetic benefits. whereas robotic surgery with changing port method is one of safe and feasible procedures for performing robotic cholecystectomy. also nothing more to say that it gains cosmesis effect and escapes complications. mini surgery, odessa medical university, odessa, ukraine the aim of the study was to optimize the diagnostic and therapeutic tactics for yatrogenic injuries of the extrahepatic bile ducts. methods: patients were examined. typical manifestations were jaundice, cholangitis, biliary peritonitis, external biliary fistula, subhepatic abscess.cholecystectomy main cause of damage.a visual, manual and x-ray examination of the hepato-choledochus and cholangioscopy were performed. ultrasound, endoscopic retrograde cholangiopancreatography, fistuloholangiography or percutaneous transhepatic cholangiography play a leading role in diagnosing. the results: high damage to the bile duct was detected in . % of patients, low-in . %.percutaneous transhepatic drainage under ultrasound control was performed in . % of patients.emergency laparotomy, sanation of the abdominal cavity and external drainage of the bile ducts were performed with bile peritonitis. recovery operations produced . % of patients. reconstructive interventions were performed in . % of patients after - weeks after the first stage. the covery operations were successful in . % of patients. . % of the sick had complications in the form of biloma. a scar stricture formed in . % of patients after - months. patient underwent recanalization of the stricture zone with a dilatation balloon through interchangeable transhepatic drainage. balloon dilatation was performed retrogradely through the large duodenal papilla in patients. deaths in the postoperative period was not observed. conclusions: the surgical team should be strengthened by an experienced surgeon when intraoperative diagnosis of yatrogenic damage to the bile ducts.the operation should be completed by external drainage of the bile duct and the abdominal cavity in the absence of an experienced specialist.recovery operations are shown only with lateral injury of the ducts.the patient must be sent to a specialized institution for radical surgical treatment after stabilization of his general condition. aim of the study sub-hepatic bile collections, biloma and hematoma are rare complications and we present our experience in treatment this complications. material and methods: from laparoscopic cholecystectomy performed in our clinic, three patients (two women and one men) to whom it was performed laparoscopic cholecystectomy, came back two weeks later after they were released from the hospital because of epigastric discomfort, fever and nausea. results: clinical examination after rehospitalization showed tenderness in the epigastrium and right subcostal region. in all patients were measured high levels of leukocytosis and crp . an ultrasound examination of the abdomen revealed a large hypoechoic collection in the sub hepatic space, after the abdominal ct scan was performed, the density of the collection did not indicate the presence of blood in two patients. percutaneous drainage of the collection in both patients was realized under us guidance and - fr catheter was inserted in the sub hepatic region. in the first patient cc of bile-stained liquid, and in the second patient cc of biliary liquid was drained. in a third patient h after surgery signs of significant hypotension and limited tenderness at the right subcostal region occurred. a complete blood count (cbc) showed a decrease in the level of haemoglobin to . g%. ultrasound examination revealed a fluid collection in the sub hepatic space, which is also confirmed by computed tomography. laparotomy was performed and the large sub hepatic hematoma was evacuated. after that the fr abdominal drain was inserted into the sub hepatic space. the postoperative course of all three patients was not complicated. conclusion: sub hepatic biloma and hematoma are rare complications of laparoscopic cholecystectomy, while early diagnosis followed by percutaneous drainage or open laparotomy is the only way to resolve these complications. ( ), hemoperitoneum . % ( ) . the average number of days of hospitalization was . days. there was no mortality at days. conclusion: in the emergency setting the rendezvous technique has an adequate success rate of cannulation and clearence of the bile duct, an acceptable surgical time, few complications, these being more frequent in those patients with inflammation of the gallbladder and without associated mortality at days. there is a need for controlled randomized studies with a greater number of patients recruited and follow-up to determine the usefulness of this technique. intraoperative cholangiography could serve as a fundamental solution to avoid the bile duct injury during laparoscopic cholecystectomy. however, it is difficult to identify the cystic duct to which the contrast catheter should be inserted in cases with high degrees of adhesion around the calot's triangle. in these cases, it is not possible to conduct cholangiography from the cystic duct. for these types of cases, intraoperative cholecystography may serve as an option. however, since the bladder is a bag-like organ that expands when liquids are entered, directly inserting a contrast dye into the bladder would make the bladder itself expand, which makes it impossible for to maintain enough pressure in the contrast dye to flow into the cystic duct, extrahepatic bile duct, and intrahepatic bile duct. also, since it is difficult to control leakage of the contrast dye from the catheter insertion site, it is not possible to obtain enough images to sufficiently understand the anatomical characteristics of the bile duct in many cases. therefore, cholecystography is not generally recognized as a method to be used during surgery. in our facility, we insert the contrast catheter through the bladder after stretching the gallbladder neck as much as possible, hold the gallbladder neck with a removable intestinal clamp, and then apply the contrast dye to the bile duct. through this method, it is possible to insert enough contrast dye into the cystic duct, extrahepatic bile duct, and intrahepatic bile duct to understand the anatomical characteristics of the bile duct, allowing us to obtain appropriate images of the biliary tract. because this method uses equipment that is highly versatile, we believe that it is inexpensive and convenient. during this presentation, we will also conduct a case presentation of the methods of bladder contrasting that we utilize in our facility during laparoscopic cholecystectomy. introduction: retrieval of a thick walled gallbladder during a difficult laparoscopic cholecystectomy (lc) for an acute or chronic calculous cholecystitis can be exasperating. it increases operative time and often necessitates enlargement of mm port to deliver the specimen. the 'in-situ cholecystotomy', which we wish to call the 'delhi maneuver' is very helpful in improving the ergonomics of specimen retrieval, saves time and conserves cosmesis. patients & methods: one hundred and ten patients of acute or chronic calculous cholecystitis were placed randomly in groups. a disposable transparent plastic bag was used in all cases to retrieve the gallbladder specimen through the - mm port using a rampley's sponge holding forceps. retrieval was done using conventional technique in patients (group b). the delhi maneuver was used in the remaining patients (group a). it involved cutting the gall bladder inside the plastic bag in a certain fashion, delivering the gallstones in the bag, and removal of gallbladder preceding the stones. the retrieval time, number of insertions of sponge holder, any rupture of plastic bag as well as the number of cases needing port enlargement were noted. results: the average time taken by delhi maneuver (group a) was min as compared to was min by conventional method (group b). the number of insertions of sponge holder ranged from - in group a (mean ) and - in group b (mean ). four patients needed port enlargement in group a ( %) while patients needed enlargement in group b ( . %). there were incidences of bag rupture in group a ( %) and in group b ( %). the delhi maneuver improved the ease and speed of specimen extraction at laparoscopic cholecystectomy for thick walled gallbladders. it also decreased the need for port enlargement for specimen retrieval. the bile duct injuries are a very complex desease to confront, the inciian managment is to clasificate the injury and to identifie the mechamism of the injury. it's important for the optimal heal of the patient to have a multidisciplinary approach including internal medicine, surgery, endoscopy and interventional radiology specialists. the laparoscopic cholecystectomy responsible for %- % of them.this is a retrospective study on the incidence, classification and management of bile duct injuries in a private sector hospital in monterrey nl. mexico. in this study, bile duct injuries were identified in years of experience in a single center. were categorized using the strasberg classification. variables were evaluated such as type of injury, mechanism of injury, hospital stay, if the surgery was scheduled or of emergency, the moment in which the surgeon evidenced the injury, the way in which the surgeon became aware of the injury performed. the type of management that was given to this lesion was also studied and the days of intrahospital stay and the number of reinterventions or procedures performed were compared.the average age of the patients was years, patients belonged to the female sex, although there were lesions of all kinds in this work, there was a greater incidence in strasberg type a lesions, which represented % of the lesions. the most common diagnosis presented was cholecystolithiasis. in surgeries the evidence and repair of the bile duct was in the same intervention aims: bile leak is a rare but recognised complication after laparoscopic cholecystectomy. this usually occurs after a difficult procedure complicated by adhesions, unusual anatomy or if the surgeon is inexperienced or unfamiliar with the anatomy. this video aims to demonstrate the laparoscopic diagnosis and treatment of this complication particularly for surgical trainees. methods: we report a case of significant bile leak occurring soon after a straightforward laparoscopic cholecystectomy due to very short cystic duct (cd). the procedure was carried out uneventfully but the cd was clipped flush with the bile duct. the patient was discharged on the day of surgery feeling well but readmitted with abdominal pain h later. results: after readmission the patient underwent a ct demonstrating only a small amount of fluid suggestive of a small collection. she was treated conservatively but suddenly deteriorated and a repeat ct confirmed significant intraperitoneal fluid. a diagnostic laparoscopy was carried out urgently confirming a cd stump bile leak where the clips had sloughed off causing the leak. two litres of bile was aspirated with copious irrigation and a latex t-tube inserted into the cbd. patient made a full and rapid recovery. conclusions: this is a rare complication and learning opportunities for trainees are therefore infrequent. this video demonstrates a successful laparoscopic approach to management of postoperative bile leak showing t-tube insertion technique and highlighting the need for careful cd closure techniques during laparoscopic cholecystectomy when the duct is very short. about - % of bile duct stones could not be extracted using conventional endoscopic techniques (baloon, sphincterotomy). there is lower success rate in elderly patients; among the biggest challenges are intrahepatic stones, size of stone is large, etc. aims: to present the case of a recurrent intrahepatic lithiasis and its management using spyglass choledochoscopy.to expose, other cases and the main outcome and complications of other difficult cases of bile duct stones that solvedusing this choledochoscope vs. the traditional one and the beneffits. we present a case of years old male who presented with cholangitis caused by an intrahepatic stone that required multiple sessions of endoscopic retrograde cholangiopancreatography with spyglass for clearance. one year later, he presented again with cholangitis, that required another session of spyglass lithotripsy and cholecistectomy. conclusions: besides ercp, there are different approaches to treat difficult bile duct stones, as transhepatic percutaneous drainage, surgical techniques, or other endoscopic techniques (doubleballoon, enteroscopy). ercp and sphincterotomy are the first step of endoscopic treatment with more than % of success rate, and a low mortality and morbility rate; other steps include some lithotripsy techniques, or the use of biliary stent as a bridge before definite treatment. spyglass is a visualization & intervention system used when common ercp has been unsuccessful, and it is first line for better and direct image of biliary ducts, with °range of motion, with multiple advantages like the concomitant use of lithotripsy devices. aims: the number of elderly people has increased, because of the strong association between age and gallstone disease, both prevalence and incidence of this disease are increasing. this presentation aims to review our current management options of octogenerian patients with acute cholecystitis. methods: we retrospectively analyzed octogenerian patients who were admitted to the our hospital with the diagnosis of acute cholecystitis between january and october . the patients were initially allocated to four different treatment groups as follows: immediate surgery, delayed surgery, medical treatment and cholecystostomy. differences in the outcomes between the treatment groups were evaluated. results: there were males ( . %) and females ( . %) with a mean age of . years (range - years). the patients had different co-morbid diseases, especially hypertension ( , . %) cardiovascular disease ( , . %) and diabetes mellitus ( methods: a retrospective observational study where were analyzed patients older than years who underwent urgent surgery for ac who fulfilled an indication for surgery according to tokyo guidelines . the type of cholecystitis, stay and postoperative complications, the type of intervention, the conversion rate, the need for reoperation and re-admissions in patients older than years were analyzed and compared with those of patients operated on for cholecystitis younger than years. outcomes: a total of patients were registered, older than years ( %) and younger ( %). in cases, cholecystitis were complicated ( . %), cases older than years ( . %) and in cases younger than years ( . %). the approach was laparoscopic in % of the cases older than years, with a conversion rate of . %, not finding statistically significant differences with younger than years ( % laparoscopies with . % of conversions). % of patients older than years had some type of postoperative complication, not finding statistically significant differences in patient younger than years ( %); being the most frequent complication the intrabdomintal abscess ( . % of patients [ years, and . % of those \ years = '' span = '' [ being not statistically significant with % ci. any patient older than years required re-entry after discharge, compared to patients younger than years who were re-entered, not being statistically significant; and any patient older than years required reintervention, while it was necessary to reoperate patients younger than years ( %), being not statistically significant. mortality was very low, finding case in older than years ( . %) and case in younger ( . %), not obtaining statistically significant differences. the postoperative stay in patients younger than years of age has a median of days and in older than years a median of days, not finding statistically significant differences with % ci conclusions: laparoscopic cholecystectomy is safe and effective in the treatment of elderly patients with (ac), there being no differences with younger patients. introduction: significant bile leak is an uncommon but serious complication of laparoscopic cholecystectomy. our study aims to evaluate the efficacy of relaparoscopy in treating symptomatic bile leak and biloma formation. material and methods: patients presenting with postoperative bile leak after different operations on extrahepatic biliary tree from january to december were reviewed retrospectively (in total, , laparoscopic surgical interventions were performed for the period under study). the sites of bile leaks were the cystic duct stump in thirty seven patients, the bile ducts of luschka in fifty two, liver beds in cases after hepatectomy, in had small injury of cbd, and seven patients with tubular stenosis of the common bile duct. results: three main approaches of mini-invasive treatment of bile leakage was used: ( ) percutaneous puncture with or without drain under ct-scan or ultrasound guidance in patients; ( ) endoscopic management in patients (in patients ( . %) were managed with ercp alone and fifteen ( . %) were treated with a percutaneous intervention followed by ercp. endobiliary stent placement was performed after es in patients and without es in twenty seven patients ( ) relaparoscopy has been performed in patients, in cases of biliary peritonitis. conclusions: relaparoscopy was the ultimate method of treating postoperative complications of laparoscopic surgery in . % of patients. in general, this method, as well as laparoscopic intervention, is highly effective in the diagnosis and correction of postoperative complications, with minimal surgical trauma for the patient, with great therapeutic effect and subsequent rapid social rehabilitation of patients. introduction: laparoscopic operations have already become routine, even for pancreatoduodenectomy for periampular cancer. for unresectable cases, endoscopic bibliary stenting or hepaticojejunostomy are usually used. these methods are quite expensive and may be accompanied by complications. materials and methods: laparoscopic cholecystogastroanastomosis was performed in patients with unresectable periampullary cancer. there were females and men and average age was , . the indications for surgery in all patients was unresectable periampullary cancer and biliary hypertension with preserved patency of the cystic duct. the level of bilirubinemia ranged from to lmol/l (the average level was , lmol/l). we used -port technique. optical trocar was placed in the right iliac region, one mm above the navel and one mm in the right hypochondrium after punction gallblaber and aspiration of bile, we cut the apex of the gallbladder and gastric antrum up to . cm and performed cholecystogastroanastomosis with barbed-suture v-loc. results: we had not conversion to open surgery. the average operation time was min. postoperative stay was average days and on median follow-up of month. post-operatively, there were no major morbidity and nil mortality. we had cases of leakage of bile through drainage for up to - days, which spontaneously stopped. all patients showed a decrease in the level of bilirubinemia. patients were later radical operated (pancreatoduodenectomy), while they did not have such phenomena as cholangitis, pancreatitis, inflammation of the hepatoduodenal ligament elements, which we often observe after endoscopic biliary stenting. conclusions: laparoscopic cholecystogastroanastomosis is safe, effective and feasible for patients with periampular cancer and obstructive jaundice. aims: surgeons with the expertise and resources to perform laparoscopic common bile duct exploration often prefer the 'one stage approach' over endoscopic retrograde cholangio-pancreatography (ercp) for the management of common bile duct (cbd) stones. this case series aims to evaluate the effectiveness of lcbde in a single benign upper gastrointestinal (gi) unit. methods: all patients with suspected and confirmed pre-operatively cbd stones who underwent a lcbde between january and october were included. lcbde was performed on the basis of pre-operative suspicion of cbd stone confirmed by intra-operative imaging. results: patients with confirmed choledocolithiasis had lcbde during this time period. the indications for lcbde were deranged liver function tests, dilated cbd or confirmed stones on preoperative imaging. median age was (range - ), % of whom were female. % of patients had confirmed cbd stones pre-op. % of cases were performed as emergencies and conversion rate to open was . %. choledocotomy was performed in % of cases. in % of these t-tube was left in situ. transcystic approach was used in the remaining %. despite positive intraoperative imaging no stones were found on cbd exploration in cases ( %). in patients stones were unable to be cleared with lcbde. the overall morbidity was %. % of patients had gallstone related complications. overall mortality was % (due to bile leak). / patients required re-intervention with re-look laparoscopy (n = ) or ercp (n = ). patients re-presented within months with cbd stones. overall median length of stay was days. conclusions: our case series demonstrates that lcbde is an effective and safe treatment for choledocolithiasis in both the elective and emergency settings. complication rates are comparable with therapeutic ercp ( % specific complications) followed by laparascopic cholecystectomy ( % day morbidity). the variability in anatomic location of subvesical bile ducts puts them in danger during hepato-biliary operations. its prevalence varies between % and %. the origin and drainage of these ducts were limited mainly to the right lobe of the liver, but great variation could be seen. some authors think of them as small bile ducts that drain directly into the body of the gallbladder; others consider them to be networks of miniscule bile ducts between the liver capsule and the gallbladder. recent studies suggest that clinically relevant bile leaks complicate approximately . - . % of cholecystectomies. injury to a subvesical duct is one of the most common causes of cholecystectomy associated bile leak and occurs as often as major bile duct injuries and leaks from the cystic duct stump. indeed, recent studies suggest that about % of clinically relevant bile leaks are caused by inadvertent injury to a subvesical bile duct. there are four types of subvesical bile ducts, including ( ) superficial variations of segmental and sectorial bile ducts, ( ) superficial or intercommunicating accessory bile ducts, ( ) hepaticocholecystic ducts, and ( ) aberrant bile ducts.we present a case of year old patient who developed a coleperitoneum after a routine daycase colecystectomy due to the inadvertent injury of a hepatocholecystic duct. a superior comprehension of ductal anatomy is essential in preventing and managing operative injury to the subvesical ducts, although some times is unavoidable. nowadays, the diagnosis of liver cancer is primarily radiological, as recommended by the principal international societies. in doubtful cases or due to the clinician needs, diagnostic evaluations can eventually be completed with a liver biopsy. the goal is to perform the examination, or the examinations, that guarantee the most elevated sensibility and specificity levels being as little invasive as possible. nevertheless, even using the best radiological tools, the diagnosis is not certain, due both to device limitations and radiology experience. recently, various diagnostic algorithms have been proposed, relating with contrast enhancement characteristics, different radiological techniques, blood examinations and cross evaluations from different radiologists. one of the most recent algorithm purposed is liver imaging reporting and data system (li-rads), that evaluates ct and mri imaging to classify hepatic lesions in different diagnostic categories, in order to perform a better and more precise diagnosis of hcc or other liver benign or malignant lesion. through a retrospective study, we evaluated and compared preoperative imaging and post-operative histological reports. results reveal that li-rads routine use increases hcc diagnosis up to %. background: we previously developed a modified difficulty scoring system (dss-ihd) of laparoscopic liver resection (llr) for patients with intrahepatic duct (ihd) stone. we validated dss-ihd in patients who underwent llr for hepatolithiasis. methods: dss-ihd was based on the extent of liver resection ( to ), stone location ( to ),atrophy of liver parenchyma ( to ), ductal stricture \ cm from the bifurcation ( to ), and combined choledochoscopic examination for remnant ihd ( to ). results: the dss-ihd ranged from to and divided to -level groups of low group (score * ; n = ), intermediate group ( objective: improving the surgical treatment of patients with cholangiogenic abscesses of the liver through the application of minimally invasive technologies. material and method: in the presented study presented results of treatment of patients with biliary liver abscesses. surgical interventions for hepatic abscesses were performed simultaneously with the elimination of the primary pathological process of the biliary system, which caused the occurrence of cholangitis, or in the near future (up to days) after biliary drainage drainage. among patients with biliary liver abscesses, treated with minimally invasive methods, revealed abscesses of the right hepatic lobe, -abscesses of the left hepatic lobe, -abscesses and right and left hepatic lobes. single abscesses were detected in patients, and in -two or more abscesses. in terms of liver abscesses, more than cm were detected in patients, more than cm in patients. drainage of the biliary tract was carried out endoscopically transpapillary and (if the endoscopic approach was unsuccessful) with transcutaneous transhepatic approach. results: drainage under ultrasound guidance was performed on patients with solitary and patients with two or more cholangiogenic abscesses of the liver. laparoscopic interventions were performed on patients. among the patients operated on using minimally invasive technologies, occurred complications ( . %). patient died due to the development of biliary sepsis ( . %). conclusion: percutaneous drainage of liver abscesses under ultrasound control is appropriate not only for single abscesses, but also for their larger number, which has many advantages over other interventions. it was proved possibility of simultaneous drainage of liver abscess and bile duct. percutaneous drainage of the liver abscess, drainage of the biliary tract and laparoscopic surgical intervention are complementary aspects in the treatment of liver abscesses of biliary origin. after laparoscopy residual calculus can be removed endoscopically in more favorable conditions after stabilization of the patient's condition is achieved and the infection-associated disorders are eliminated. in case of localization of abscesses in the marginal segments of the liver, laparoscopic atypical resection of the liver with an abscess is most desirable. general surgery, rambam medical center, haifa, israel background: recently robotic surgery has emerged as one of the most promising surgical advances. despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary (hbp) surgery remains relatively unexplored. our study presents single institution's initial experience of robotic assisted surgery for treatment of benign hepatobiliary pathologies. methods: a retrospective analysis of a prospectively maintained database on clinical outcomes was performed for consecutive patients that underwent robotic assisted surgery for benign hbp disease at rambam medical center during - . results: there were robotic assisted surgical procedures performed for benign hbp pathologies during the study period. there were anatomical robotic liver resections for symptomatic hemangiomas, cases of giant liver cyst, robotic assisted surgery for type i choledochal cyst, case of benign (iatrogenic) common bile duct (cbd) stricture, cases of robotic (cbd) exploration due to large intra choledochal stones and cases of cholecystectomy for cholelithiasis. the median postoperative hospital stays for all procedures were . days (range - days). general morbidity (minor) was %. there was no mortality in our series. conclusion: robotic surgery is feasible and can be safely performed in patients with different benign hbp pathologies. further evaluation with clinical trials is required to validate it's real benefits. most liver cysts are asymptomatic and tend to have a benign clinical course. however, symptomatic or complicated liver cysts sometimes require surgical intervention. needle aspiration is safe and can be the lease invasive procedure, this procedure is however associated with a high failure rate and rapid recurrence. surgical approach is the crucial and provides definitive treatment for such cysts. thirteen cases were nominated from shonan kamakura general hospital between january and december . mean age and body mass index (bmi) were . and . , respectively. all patients have had any complaint such as upper abdominal pain, dyspnea, and fever. two cases were clinically diagnosed as the infectious cyst and serum crp was elevated before surgery. additional cholecystectomy was planned for one case of chronic cholecystitis with gallbladder stones. all cases were prompted the reduced port surgery (rps) and cases were performed rps with trans-vaginal approach (hybrid notes) and case was chosen in single port surgery. cyst unroofing was performed for all cases. mean operation time and blood loss of all cases were . min. and . ml, respectively. no surgical complication has been occurred in all cases, an infectious cyst case was however required additional drainage for infectious control after surgery. although statistic difference was not shown, fewer blood loss and shorter hospital stay was seen in non-infectious cases, compared to laparotomy cases. mean hospital stay after surgery of whole cases, non-infectious cases, infectious cases was . , . , . days, respectively . no recurrence of any symptom was shown in any cases in observation period ( - days) . laparoscopic unroofing is the definitive treatment for the complicated or symptomatic liver cyst. however, for the infectious cyst, infection control such as intensive drainage and/or administration of antibiotic before surgery may be needed to avoid additional treatment, leading to longer hospital stay. laparoscopic unroofing of liver cyst can be the first choice for symptomatic or complicated liver cyst. also, reduced port surgery can be nominated to achieve less invasiveness. introducction: laparoscopic liver resection (llr) has been increasing since it was first reported in . three international expert consensus conferences on llr surgery were held in louisville, ky, usa, in , morioka, japan in and southampton, uk, in . while most initial minimally invasive liver resections were typically done for benign lesions in anterior o left segments, llr is currently being applied for major anatomic resections, malignancy, cirrhosis and liver donor hepatectomy. clinical case report: this is a -year-old male patient with a history of hta and liver cirrhosis due to hepatitis b virus. hepatocarcinoma is diagnosed in liver segment vi with a size of cm . in the digestive study the patient presents a child a stage, meld \ , without signs of portal hypertension. complete analytical with normal afp and cea . markers. after presentation of the patient in a multidisciplinary committee and being a stadium according to the early bclc classification, laparoscopic surgery with segment vi resection was decided. discussion: laparoscopic liver resection is becoming widely accepted for the treatment of hepatocellular carcinoma. liver resection is a first-line option in very early and early-stage disease. many meta-analysis have shown that llr is better than open liver resection in terms of short-term outcomes for patients with child-pugh a cirrhosis, solitary tumors, and minor resections. in the long-term setting, the results demonstrate that a minimally invasive approach is comparable to an open approach in terms of overall. in conclusion, the current evidence conclude than llrs for hcc are safe and may be considered a standard practice in specific settings. results: there were women ( %) and men ( %). the age of patients ranged from to years. the patients underwent complex examination including abdominal ultrasound, esophagogastroduodenoscopy, and some of them underwent ct (computed tomography). all patients in the first stage were performed antegrade external drainage of biliary tracts with x-rays of the biliary tracts, and specifying the level and extent of the block.total miniinvasive interventions were hold. two patients in connection with the uncoupling of equity ducts were performed antegrade bilobar stenting with preliminary split external bile release.there were complications after carried out interventions in cases, which were associated with dislocation of holangiostomic drainage in patients ( . %); with acute cholecystitis in patient ( . %); with hydrothorax in patients ( . %); perihepatic biloma in case ( . %). patient ( . %) had a recurrence of obstructive jaundice due to germination of endobiliary stent in the late period after stenting. lethal outcome appeared in patient. conclusions: ultrasound examination allows us to determine the level of obstruction of the biliary tract, to substantiate the tactical position in the application of mini-invasive technologies. antegrade miniinvasive technologies in the treatment of tumor lesions of the proximal bile ducts allow timely and effectively stop biliary hypertension and to determine further treatment strategy. acknowledgements this study was supported by the russian science foundation under project ? - - . background: repeat hepatectomy is an effective treatment, with long-term surgical outcomes for recurrent hcc and colorectal liver metastasis(crlm). however, the efficacy of a minimally invasive surgical approach for recurrent liver tumor is not yet confirmed. the purpose of this study is to examine the efficacy of laparoscopic repeat hepatectomy(lrh) compared with open repeat hepatectomy(orh) for recurrent liver tumor. we retrospectively analyzed the clinicopathological features and short-term surgical outcomes between lrh and orh. methods: from to , patients with liver cancer underwent repeat hepatectomy. of those patients, patients underwent partial hepatectomy, patients were undergone laparoscopically, and patients underwent open hepatectomy. we compared the clinicopathological and surgical parameters in the lrh group with those in the orh group. results: there were no significant differences in patients' gender, age, viral infection status, child-pugh classification, tumor size, tumor number, and tumor location in the two groups. the operative times were similar, but blood loss was significantly lower in lrh group ( vs. ml, p \ . ). the postoperative hospital stay was significantly shorter in the lrh group ( . vs. . days, p = . ). postoperative complications(cd = a) were observed only in the orh group, with a complication rate of . %. conclusions: we demonstrate that lrh reduces blood loss and postoperative complications compared with orh. lrh might be a feasible and effective procedure for the selected patients. background: the liver is the most common site of metastatic disease with up - % of all cancers having the potentiality for sending liver metastasis during the disease. consequently, increasing value for surgical resection of hepatic deposits of different types of cancers, the need for accurate evaluation of the extent of hepatic metastasis was established for choosing the most suitable patients for surgery and in planning the extent of hepatic resection. the aim of this work is to evaluate the role of intra-operative ultrasound in the detection of hepatic deposits in intra-abdominal malignancies with special emphasis on its accuracy, sensitivity, specificity. patients and method: this study was carried out on thirty patients who were admitted to the gastrointestinal surgery unit, main alexandria university hospital with intra-abdominal malignancies for whom elective open surgical intervention was recommended in the period from st of september till the th of march . results: in the present study consisted of males ( . %) and females ( . %). their mean age at admission was . ± . years. six of the included patients ( %) were found to have hepatic lesions by using ious including the four cases ( . %) already detected by preoperative imaging. two cases ( . %) were newly discovered in the operative room by using ious. conclusion: the current study has proved that ious demonstrates superior lesion detection over the various non-invasive preoperative imaging modalities causing significant impact on change of the planned surgical strategy laparoscopic approach to the liver has become an integral part of surgery. two consecutive international consensus meeting recommends major hepatectomy has been on the expert hands. tumors located in the right posterior section are considered to be difficult for laparoscopic resection. patients and methods: since , until , cnuhh has been performing laparoscopic hepatectomies including major hepatectomies. among major ones, there are rh, lh, rps, ch, and as. we analyze data on patient demographics, tumor characteristics, operative date, and posterior outcome retrospectively. results: during - , laparoscopic rps were performed. the diagnosis were hcc in and crlm in patients. median operative time was min, and median blood loss was ml. no blood transfusion was occurred. median tumor size was mm, and median resection margin was . mm. six of the patients ( %) were cirrhotic on pathology. there was no conversion and was no postoperative mortality. median hospital stay was . days. conclusion: laparoscopic rps is known challenging procecedure. strict preoperative planning and operative procedure is mandatory. even though it should be performed by the experienced hands both on hepatic surgery and laparoscopic skill, it can be an good option for treatment of the tumor locating over right posterior section. purpose: previously we developed a new sponge (named endoractor) as an organ retraction device in laparoscopic surgery in and have reported that it is useful in various surgical procedures including rectal surgery we confirmed that it is also useful in laparoscopic radiofrequency ablation of the liver in terms of pulling and protecting organ, so we report it materials and methods: a case is an -year-old female with liver cirrhosis. she had primary hepatocellular carcinoma in s lesion with a diameter of . cm very close to the inferior vena cava and middle hepatic vein root and in s lesion with a diameter of . cm we thought she could not put up with hepatic resection because of her poor hepatic reserve capacity. and we could not expect treatment effect by embolization therapy since contrast effect was poor. so we decided to select ablation therapy in the puncture and ablation of the s tumor, since there was concern about the thermal damage of the middle hepatic vein and the cooling effect by the inferior vena cava, we would dissect the right coronary mesentery sufficiently and pull the liver apart from the inferior vena cava and the middle hepatic vein as much as possible using our endoractor also, in the puncture and ablation of the s tumor, it was feared that the stomach would be thermally damaged, so we would place endoclactor between the liver and the stomach to protect the stomach results: when ablating the s tumor, we could pull the liver securely without slipping, so we did not cause thermal damage to the middle hepatic vein. and there was no cooling effect by the inferior vena cava, so we could obtain sufficient cautery margin. in ablation of s tumor, we were able to puncture by stabilizing the lateral segment of the liver on our endoractor, and avoid thermal damage of the stomach conclusion: it seems possible to perform safe and reliable puncture and ablation by using our endoractor as well in laparoscopic radiofrequency ablation surg endosc ( ) surgical reinterventions in patients with complicated hepatic hydatid cysts usually occur as a result of diagnostic or technical failures during the initial procedure. according to recent studies, the most common complication after liver hydatid cyst surgery is local sepsis at the residual cavity and long-term biliary leak. we report the case of a -year-old male with a history of liver hydatid disease four years before the current episode, admitted in our surgical department for intense upper right quadrant pain. abdominal ultrasonography, ct and mri scans revealed three cysts in the gastrosplenic ligament, in liver segments vii-viii, and ii-iii respectively, sized between and cm. the intraoperative aspect during laparoscopy was strongly suggestive for liver hydatid disease. laparoscopic fenestration with tunneling for the hepatic cyst in segment viii, partial cystectomy in the left liver lobe and ideal cystectomy in the gastrosplenic ligament were performed. postoperatively, the patient displayed a constant biliary drainage output of - ml from the cavity remnant in the segment viii. conservative therapy for external biliary fistula and concomitant treatment with albendazole for months were initiated. evolution was slowly favorable with decreased biliary drainage to ml two months after surgery and complete symptom resolution five months after hospital discharge. aims: this study aimed to evaluate the effectiveness of fluorescence imaging with indocyanine green (icg) during laparoscopic deroofing of hepatic cysts. methods: this was a single-center, case-control study. we included patients who underwent laparoscopic deroofing between november and october . imaging with and without icg fluorescence was performed in (icg group) and (non-icg group) patients, respectively. icg was intravenously administered between min and . h before surgery. we performed a standard laparoscopic procedure. we detected a thin bile duct on the hepatic cyst on using intraoperative icg fluorescence imaging. we adjusted the resection line of the cyst wall and ligated the bile duct at the point at which it crossed the resection line. data on age, sex, cyst size, resected cyst size, operative time, estimated blood loss, post-operative hospital stay, complications, and recurrence were compared between the groups. results: the mean cyst size was ± . and ± . mm, the mean resected cyst size was ± . and ± . mm, and the mean operative time was . ± . and ± . min in the icg and non-icg groups, respectively. using icg fluorescence imaging, the bile duct was detected on the cyst wall in patients ( %). all surgeries were completed laparoscopically, and no post-operative complications occurred in either group. recurrence of the hepatic cyst occurred in one patient ( %) of the non-icg group. conclusions: fluorescence imaging with icg is used widely in hepatobiliary surgery for intraoperative identification of biliary and vascular anatomies. this method does not require complicated techniques or instruments. icg fluorescence imaging may facilitate the prevention of intra-or post-operative complications, such as biliary leakage, in laparoscopic surgery. in this study, icg fluorescence imaging was found to be effective in detecting the bile duct on the cyst wall intraoperatively, allowing for wider resection of the cyst and avoiding inadvertent injury. our study suggests that wider resection of the cyst wall might prevent recurrence of hepatic and that icg fluorescence imaging could ensure procedural safety. abdominal ct showed: large hepatic cyst ( x , x cm size), with no malignity signs, that occupies practically the whole right liver, causing subsegmentary atelectasis of the middle lobe, superior and inferior cava vein compression, and displacement of right kidney, pancreas and right atrial. due to breath involvement, a percutaneous drainage is performed achieving clinical improvement and reduction of the size of the injury. the patient was released but a cyst superinfection occurred; once this problem was solved, the drainage was removed. results: in light of the complication, surgical treatment was decided, which confirmed the large cyst located in right posterior hepatic segments with tight diaphragmatic adhesions. we carried out the cyst evacuation and a wide laparoscopic resection of the cyst walls, until the posterior area of the cava vein, combining supra and infrahepatic access. the patient was released on the sixth postoperative day and continues asymptomatic. conclusions: simple cysts can be approached in a no surgical way (punction-aspiration with/ without sclerosing products injections) or in a surgical way (cyst wall fenestrations, cystectomy or liver resections). a conservative treatment will obtain symptomatic relief but with a high risk of recurring. recurrence is the main drawback of unroofing. cystectomy is the better option but may be too complicated depending on the cyst's location. to our patient, we carried out a wide laparoscopic unroofing (even though its posterior localization) to minimize recurrence possibilities. in conclusion, laparoscopic resection of the cyst wall is a simple and effective approach in symptomatic or complicated cases. background: single-incision laparoscopic surgery or laparoendoscopic single-site surgery is emerging as an alternative to conventional multiple-incision laparoscopic surgery. it has a potential benefit of less postoperative pain and faster recovery compared with conventional multiple-incision laparoscopic surgery. single-incision laparoscopic hepatectomy (silh) has been reported in only a few small series and the majority were minor resections. case report: a y/o male patient is a case of chronic viral hepatitis b and early cirrhosis of liver. two atypical hepatocellular carcinomas (up to . cm in diameter) located at the junctions of segments & and segments & were impressed by liver magnetic resonance imaging (mri). we performed single-incision laparoscopic anatomical hepatic resection of the right posterior section via a -cm transverse incision on the right middle abdominal wall. inflow control was carried out with an extra-glissonian approach before parenchymal transection. the glissonean pedicles of segments and were divided by linear staplers respectively as well as a major branch of the right hepatic vein in segment . the operative time was min and the estimated blood loss was ml. the pathologic examination revealed two foci of hepatocyte dysplasia with a safe margin of cm. the patient was discharged eight days after the surgery uneventfully. conclusion: single-incision laparoscopic anatomical right posterior sectionectomy is feasible and safe by experienced laparoscopic surgeons. it provides a fast recovery but needs a long operative time. the mortality in the patient with liver cirrhosis is very high. the aim of this work was to decrease mortality and morbidity by using endoscopic local heamostasis and laparoscopic operations, in the patients with bleeding from cirrhosis by variceal bleeding. methods and material: we observed patients with cirrhosis complicated by variceal bleeding during years. there were patients with child phue a, ones with child phue b, ones with child phue c. all the patients were performed prolonged endoscopic heamostasis with conservative therapy. the main methods that we used were the ligation in cases, sealing in cases, sclerotherapy in cases. in cases we couldn't stop the bleeding with band ligation method and introduce the danis stents into esophagus and stopped the bleeding successfully. to prevent the re-bleeding we performed the laparoscopic dissection the abdominal part of esophagus with suturing the venous vessels, coagulations and dissection of short gastric vessels between stomach and spleen, clipping the left gastric artery and vein in the patients. in patients we performed laparoscopical suturing the variceal veins by introducing the laparoscopic trocars into the stomach. in cases with varices vien of stomach, with non-effective local endoscopic heamostasis we performed laparoscopic resection the fundal part of stomach. results: endoscopic local heamostasis were successful (in %) in cases. the relapse of bleeding were in patients. patients died. there was no mortality after laparoscopic operations. there were cases for trocar wounds infection, cases of subphrenic abscess. goals: the advance of laparoscopic surgery also includes the more complex procedures of abdominal surgery such as those affecting the liver and pancreas. there are multiple indications that laparoscopy has in hepatobiliopancreatic surgery, both in benign and malignant pathologies. material and methods: we present the video of a -year-old male patient with a history of right hemicolectomy due to disease-free intestinal lymphoma who, in the control analysis by his attending physician, detects the elevation of tumor markers. an extension study was started showing a hepatic lesion in the caudate lobe with a pathological anatomy suggestive of hepatocarcinoma and an adenopathy suspicious for malignancy adjacent to the right renal vein. the clinical case is presented in a multidisciplinary tumor committee and it is decided to perform surgery. a laparoscopic caudate lobe resection was performed, previously performing intraoperative ultrasound and a lymphadenectomy of the portal territory, vena cava and exeresis of adenopathy of the right renal vein. introduction: major vascular complications during laparoscopic surgery occur approximately in one in cases, but mortality rate can reach - %. most major vascular injuries lead to conversion to laparotomy but successful laparoscopic repair is also possible. simulation training improves laparoscopic performance and possibly reduces surgeons mental strain. materials & methods: during two editions of advanced laparoscopic training course participants had a task to control a major vessel damage (damage). before the task an educational video explaining the methods of obtaining haemostasis was shown. the algorithm of the 'damage' task was as follows: without previous preparation a cm injury of a major vessel was done with l-hook electrocautery. after the injury participants were free to control the damage the way they wanted. heart rate of the participants was measured with an ear electrode. measurements were carried out times-before the injury, immediately after, and afterwards obtaining vessel control. after participants were interviewed for their feelings after the 'damage' task. results: there were vessel injuries in animals. one animal died during the 'damage' task min after desuflation due to relapse of bleeding. there was no conversion to open procedure. temporary vessel control was obtained with different methods. all participants used vicryl . or pds ii . suture for final hemostatic purposes. heart rate of the participants before injury were - ± . bpm, immediately after the injury it rose to - ± . bpm, and after obtaining vessel control were in the range - ± . bpm. a statistically significant difference was found between the ratio of the first and second hr measurement (p = . , t = - . ), and second compared to the third (p = . , t = . ) measurement. participants judged their experience on a -point scale ( - was not helpful at all; -was extremely educative). the educational value of the task received points in cases and points in one case. conclusion: participants feel stress during major vessel bleeding even in animal model, and this stress can result in a serious intraoperative mental strain and significantly increase heart rate. participants found the 'damage' task very useful for their daily practice. the aim of study was to improve the results of treatment of patients with hepatic echinococcal cysts by using of argon plasma coagulation. methods: the analysis of treatment results of patients was put into the basis of this study. it was ( . %) men and ( . %) women in total. an average age of them was . ± . years. the main difference between groups was a way of liver parenchyma coagulation in order to make reliable hemostasis. in main group the final stage of surgical intervention on liver was argon plasma coagulation. it was performed to ( . %) patients. alternatively, monopolar coagulation was performed to ( . %) patients (comparison group). results: in main group in the . % cases pericystectomy was conducted. the resecting surgeries was performed to . % cases. in comparison group was conducted in . % cases. in early postoperative period in main group the complications were observed in . % of cases. the same parameter was . % in comparison group. it led to relaparomies. the forming of external biliary fistulas was observed in ( . %) patients in main group and in ( . %) patients in comparison group. however, all the fistulas have closed spontaneously on th- th day in both groups. hernias of abdominal wall and peritoneal adhesions that manifested by intestinal obstruction of different degree were considered as complications of late postoperative period. these values were % and . % in main group versus % and . % in comparison group, respectively. the resection of hepatic echinococcal cysts with further application of argon plasma coagulation on the cyst bed was accompanied by complications quantity decrease in patients that underwent surgery in early as well as in late postoperative period. in this case more positive dynamics of functional liver values improvements was observed. aims: indocyanine green (icg) fluorescence imaging has been reported as a reliable and safe navigation tool in laparoscopic hepatectomy. however, the factors affecting the sensitivity of tumor detection with icg fluorescence imaging is relatively unclear. the aim of the present study is to analyze the factors of successful icg fluorescence in laparoscopic hepatectomy. methods: this is a retrospective single-center study. this study population consisted of laparoscopic hepatectomies from january to november undertaken at kurashiki central hospital. we excluded patients whose tumors were located more than mm from the liver surface, those who did not receive icg fluorescence imaging, and those who were not injected with icg dye ( . mg/kg) intravenously within days of surgery. the pinpoint endoscopic fluorescence imaging system was used to detect the tumor location. we evaluated the relationship between successful fluorescence and the timing of injecting icg before operation, tumor size, icg r , liver damage and bmi. results: following exclusion, patients were eligible for analysis. among the tumors resected, icg fluorescence imaging detected tumors ( . %), including hepatocellular carcinomas and liver metastases. icg fluorescence imaging detected all tumors in the patients injected with icg to days before hepatectomies . icg fluorescence imaging detected all tumors which were more than mm in diameter. there was no relationship between indocyanine green fluorescence with icg r , liver damage and bmi. conclusions: the injection of icg to days before operation and a tumor size of more than mm can be factors in successful fluorescence in laparoscopic hepatectomy. introduction: cysts in the liver have a wide variety of aetiologies. it is important to characterize the cystic lesion before treating it. the simple cyst has a low prevalence and is more frequent in women. fenestration is a useful option for the treatment of simple cysts in selected patients. case presentation: a -year-old woman was referred to our hospital with a one-year history of intermittent, right upper quadrant pain, with no other associated symptoms. computed tomography and magnetic resonance imaging showed a large cyst ( , x , cm) in the right of the liver. the cyst presented lobulated morphology, smooth edges and well delimited. there were other smaller cysts in the left lobe. hepatic function in blood analysis was normal. biomarkers, tumor markers and hepatitis virus markers were negative. outpatient follow-up and symptomatic treatment of pain was decided. after six months of follow-up, the pain persisted, so surgical treatment was proposed. a laparoscopic fenestration was performed, widely resecting the free wall of the cyst. there was no evidence of a connection to the bile duct. there were no complications. on days she was discharged. discussion: some giant hepatics cysts become symptomatic due to mass effect. persistence of pain is an indication of surgical treatment. laparoscopic fenestration is an alternative for the management of simple hepatic cysts. aim: laparoscopic liver resection for malignant pathology such as colorectal cancer metastases has been a matter of discussion for several groups in the last years. it has been proposed as a safe and feasible treatment but subjects like short and long term outcomes and oncologic results have not been adequately assessed. methods: we performed an observacional retrospective study of patients undergoing laparoscopic liver resection for colorectal metastases in our center. from november to november a total of patients underwent laparoscopic liver resection. data for resection margin, hepatic and extrahepatic recurrence and both disease free survival and overal survival were collected. patients were discussed in a multidisciplinary group with oncologist, radioterapic oncologist and surgeons. the surgical procedures were perfomed by the same team in all the cases to minimize bias. results: a total of patients ( . %) were non resectable at the time of surgery.the mean overall survival was months with a maximum of months. we got a mean of disease free survival in our patients of . months. the hepatic recurrence was %, most of them in high risk patients, and from this group . % underwent a new liver resection. major complications took place in patients ( . %) two biliar leaks, one bowel perforation, two hepatic failure, one evisceration and three respiratory insufficiency needing urgent surgery in three of the cases. mean hospital stay was . days. a mean of days of this stay were in an intensive care unit. conclusions: laparoscopic liver resection for colorectal liver metastases could be a feasible technique when perfomed by trained surgeons. it improves the postoperatory recovery with a reduction of hospital stay and less postoperatory pain without increasing the development of major complications or mortality in the first days after surgery. we got good oncological results that have been improving with the experience acquisition of the surgical team. aged to underwent surgery for cirrhosis with massive refractory ascites child c ( - ), without obvious signs of hepatic encephalopathy. major etiological factors were: viral hepatitis c ( patients ( . %)), b ( patients ( . %)), b ? d ( patients ( . %)), toxicity ( patients ( , %) ). to prevent possible bleeding at the first stage, endoscopic filling of esophageal varices with fibrin glue was performed in patients ( . %). after testing the effectiveness of varices filling, in the following - days decompression surgery of thoracic lymphatic duct was performed under local anesthesia to improve lymphatic drainage from liver and abdominal organs. simultaneously, laparoscopic sanitation of abdominal cavity was performed, with complete evacuation of ascites fluid, rinsing and drainage. fractional post-surgery rinsing was repeated daily for - days towards removing peritoneum edema and improving its absorptive properties. results evaluation was performed , and months after surgery, based on criteria of liver reserves and ascites volume. results: post-surgery mortality from liver failure was . % ( patients) . other patients died of the same cause the following - months. annual survival rate was . %. complete ascites regression over - months after surgery was noted in patients ( . %), significant regression and stabilization in ( . %), moderate regression with need for periodic decompressive laparocentesis in cases. in all patients, functional liver reserves and life quality significantly improved. conclusions: the use of the given technique of refractory ascites correction, in patients with depleted liver cirrhosis, by laparoscopic sanitation with post-surgery fractional rinsing of abdominal cavity, with simultaneous decompression of thoracic lymphatic duct showed very high efficiency and deserves establishment as a clinical practice. t. urade, hepato-biliary-pancreatic surgery, kobe university, kobe, japan aim: anatomical liver resections guided by a demarcation line after portal staining or inflow clamping of the target territory were established as essential methods for the curative treatment of hepatocellular carcinoma (hcc) and then subsequently applied to other malignancies. however, laparoscopic anatomical liver resection (lalr) is much more difficult to reproduce these procedures and to confirm demarcation of the hepatic segment visually on the monitor. recently, laparoscopic fluorescence imaging system has been used as a tool for real-time intraoperative navigation in llr. the aim of this study is to demonstrate how to perform lalr using indocyanine green (icg) fluorescence imaging. methods: three patients underwent pure lalr using icg fluorescence imaging. the following operative procedures were performed: partial liver resection for hcc, segmentectomy for liver metastasis and right anterior sectionectomy for hcc. in all patients, preoperative d simulation images from dynamic ct were reconstructed using a d workstation to decide on cutting points of the glissonean branches. after mobilization of the liver, intraoperative ultrasonography was performed to identify the location of the tumor and glissonean pedicles corresponding to the tumor-bearing hepatic region. we dissected or transected the hepatic parenchyma to encircle the glissonean pedicles. after clamping or closure of them, . mg of icg was injected intravenously to identify the boundaries of the hepatic segments under near-infrared light. parenchymal transection was started according to the demarcation on the liver surface. the lateral aspect of the parenchymal transection was carried out based on the demarcation between non-fluorescing and fluorescing liver parenchyma as far as possible. results: in all the cases, demarcation lines on the liver surface could be visualized clearly after injection of icg. in addition, boundaries of cone units, segments and sections could be recognized to some extent because the tumor-bearing hepatic region became non-fluorescing parenchyma during parenchymal transection. these procedures were completed successfully, and the postoperative courses were almost uneventful. aim: sintrahepatic cholangiocarcinoma is the second most common primary liver cancer after hepatocellular carcinoma (hcc). although the laparoscopic approach of these tumours is not frequent due to its complexity, it is performed increasingly by hepatic surgeons.traditionally, the abdominal surgery in cirrhotic patients has been reserved to selected cases secondary to the high rate of complications. the advance on the treatment of the hcc on liver cirrhosis and the higher safety when performed by laparoscopic approach has encourage some surgeons to extend surgery to child b-c or portal hypertension patients. methods: we present a male of years old, diagnosed in of liver cirrhosis accompanied with portal hypertension. on mri in was found a solid lesion of mm located on segment ii hepatic. biopsy confirmed the diagnostic of intrahepatic cholangiocarcinoma. after a liver function evaluation (child c, meld ), an hepatic chemoembolization was performed. sequentially ct scans indicated a complete radiologic response. after years of follow up, mri showed a recurrence of mm between segment ii and iii of the liver.on multidisciplinary committee liver resection was decided due to suitable liver function and low aggressiveness of the tumour. a laparoscopic left lobe liver resection was performed. sonastarÒ and ligasure tm were used to perform the liver transection and endo gia tm for portal and hepatic veins sections. the surgery develop was complicated due to trend to bleeding that finally was achieve through cauterization. results: early after the surgery, the patient presented a haematic debt through the drain of cc accompanied of hypotension, therefore an emergent surgery was indicated. an exploratory laparoscopy was performed finding hemoperitoneum and diffuse bleeding of the liver surface that was controlled. the patient had a proper recovery and was discharged on the th day post-surgery. the analysis of the specimen showed a . cm cholangiocarcinoma with a . cm margin of resection. conclusion: there is an augmented risk of complications on liver resection of cirrhotic patients with portal hypertension. the laparoscopic approach allows to reduce potential complications, despite bleeding continuous to jeopardize this surgery, this option could be proposed on selected patients. introduction: accessory spleen itself is found in approximately % to % of the population. most ( %) are located near the splenic hilum but intrapancreatic accessory spleens (ipas) are the second most frequent location ( . %) of accessory spleens. in adults, ipas are clinically silent. they may become clinically important because of their radiographic similar appearence of cancer. intrapancreatic accessory spleen is a rare cause of pancreatic pseudotumors and is located in the pancreatic tail in approximately % to %. ipas can be difficult to differentiate radiologically from hypervascular pancreatic tumors such as pancreatic endocrine neoplasms because theycan share a similar enhancement pattern. as a result, most of the reported cases of ipas have been diagnosedonly after distal pancreatectomy was completed. material and methods: we present the case of a -year-old male patient with a history of large vessel vasculitis followed-up for rheumatology, which showed a pancreatic nodule in a control ct so he was referred to digestive for study. an echoendoscopy was performed. it showed, at the level of the tail, in the third distal, a lesion of x mm, hypoechoic, with rounded morphology and well-defined edges that can not be biopsied given the absence of adequate window for the realization of fine needle aspiration biopsy (fnab). based on these radiographic findings, the differential diagnosis included a pancreatic endocrine tumor. due to the high suspicion of malignancy and the absence of biopsy, he was referred to general surgery for scheduled surgery. a laparoscopic corporocaudal pancreatectomy was performed without incidents and the definitive histology showed an intrapancreatic accessory spleen in the pancreatic tail that excluded the presence of cancer. conclusion: intrapanceratic accesory spleen is a challenging diagnosis to make and it should be included in the differential diagnosis of pancreatic neoplasm. its early identification precludes surgical resection. however, the preoperative diagnosis of ipasmay be difficult, and distal pancreatectomy is a safe and relatively simple operation, most of the reported cases of ipas being diagnosed correctly only after surgery there are various options for treating pps. this paper describes our tailored and methodological approach to laparoscopic drainage of pancreatic pseudocysts based on an anatomical classification. methods: we adopted the laparoscopic approach in patients who had pps requiring surgical drainage. the laparoscopic method had been decided according to preoperative computed tomography (ct) and intraoperative findings. the results shown represent median (range). the aim of this work was to decrease mortality and morbidity in patients with combined trauma. methods and material: for years patients were brought to our clinic with combined trauma. everybody was performed ct and ultrasound examination. patients were performed open laparatomic operation due to massive liver rupture, spleen rupture and massive trauma of bowels, pancreas and kidney with massive bleeding. in circumstances we didn't found the trauma of the abdominal organs and the massive abdominal bleeding after ct observation. those patients were cured conservatively. in circumstances with combined trauma after ct examination we performed laparoscopic operation. in circumstances from the patients, who we started laparoscopic operation in, we conversed to laparotomy, due to massive liver rupture, and trauma spleen and hollow organs. in those circumstances we performed urgent laparotomies with suture ligation of bleeding points, suturing of liver and hollow organs and drainage of abdomen cavity. results: we performed laparoscopic operation in patients. in circumstances with trauma of liver we performed laparoscopic electro coagulation and argon-plasma coagulation. in circumstances with trauma of liver we performed electro coagulation with packing the omenture to its surface. in circumstances with trauma of spleen we performed argon plasma coagulation and used fibrin glue. after laparotomic operations mortality were in circumstances, morbidity were in patients. after laparoscopic operation mortality were in circumstances of severe combined trauma with multiple abdominal trauma and morbidity in patients. conclusion: laparoscopic operations in patients with combined trauma decrease mortality and morbility. aims: in laparoscopic distal pancreatectomy, getting away liver and stomach from the surface of the pancreas is sometimes difficult. when we separate the pancreatic body from the retroperitoneum, we must not injure the pancreas to prevent breaking a tumor. when we cut the dorsal side of the spleen from the retroperitoneum, we rarely cut into the spleen accidentally. based on our experiences, we gradually explored a set of procedural operation steps to resolve these problems. our three-step maneuver simplifies the procedure and improves the efficiency and safety of laparoscopic distal pancreatectomy. methods: as the first step, to get away the liver we sutured the round ligament of liver and crus of the diaphragm using - pds and the both ends were tugged form the outside of the body through both side of the xiphoid process. and the stomach was hung from the outside using two nylon thread like a bridge, so we could see the surface of the pancreas body with a good view. the second step was a rolling up maneuver of the pancreas. when we separate the pancreatic body and tail from the retroperitoneum, we rolled the pancreas with gauze for use in laparoscopic surgery and lifted the gauze up in only one assistant's forceps. then we could find the correct line for dissection clearly. the last step was a hanging maneuver of the spleen. when we cut the dorsal side of the spleen from the retroperitoneum, we hanged the hilum of spleen with cotton tape. with this technique we could find easily the correct line to dissect. results: the operation time was h and min and the estimated blood loss was a little. we did not injure the tumor or spleen in this operation. the patient recovered uneventfully after short hospitalization. conclusion: our three-step maneuver can be effective to perform laparoscopic distal pancreatectomy. about - % of patients with pancreatic collections will develop walled off necrosis, with an associated - % mortality. there are multiple options for intervention and drainage, usually the outcomes after endoscopic drainage are related with the nature of the collections. aims: to evaluate and present the rol of endoscopy in pseudocyst and walled off necrosis treatment, and favorable outcomes. methods and results: we present a case of a years old male, who presented biliary pancreatitis treated with cholecystectomy and transoperative cholangiogram weeks ago. he continued with persistent abdominal pain; his ct scan showed a big walled off necrosis; he was taken to surgery for an endoscopy-assisted laparoscopic cystogastrostomy with necrosectomy, he was discharged days po. conclusions: the step-up management of walled off necrosis has proven to be a better option than conventional surgical or endoscopical techniques alone; by reducing complications and mortality vs conventional necrosectomy. the use of endoscopic treatments reduce the pro-inflamatory response. drainage of walled off necrosis can be done by a transpapilar or transmural endoscopic apporach each one with its own advantages. some authors avoid the use of endoscopy in walled off necrosis because of a higher rate of complications, re-interventions and a greater lenght hospital stay. in our experience, we have achieved excellent results with this combined technique. nearest and long- patients underwent chemotherapy after electroporation procedure. day mortality was . % (n = ) in electroporation group. it was found that erreversible electroporation improved local recurrence-free survival ( and months, respectively, p = . ) and distant recurrence free survival ( and months, respectively, p = . ) . overall survival was and months, respectively (p = . ). conclusion: irreversible electroporation of locally advanced pancreatic cancer is safe. four month chemotherapy followed by surgical procedure is associated with good local response and better overall survival compared with chemotherapy alone. these data will be validated in further multicenter study. introduction: pancreatic pseudocysts are the most frequent complication of acute or chronic pancreatitis. usually asymptomatic, they can be managed conservative or, in case of complications, by several methods, endoscopic, percutaneous or by surgery. material and method: we present the case of a years old patient known with an episode of acute pancreatitis five years ago, who was hospitalised now for an upper gastrointestinal bleeding with hematemesis. the upper endoscopy showed a subcardial bulking with an erosion of the posterior gastric wall, with signs of recent bleeding, managed by clipping. patient work-up showed a cm pancreatic pseudocyst at endoscopic ultrasound. taking into consideration the history of the patient, the size and the complication of the cyst, the patient was proposed for a drainage intervention. results: a minimally invasive approach was decided. using ultrasonography guidance, a posterior gastrotomy was performed with the cystotome, establishing the comunication with the pancreatic pseudocyst. dilatation of the path with mm cre baloon, with partial evacuation of turbid liquid. the drainage consisted in pigtail fr plastic stents. the patient was discharged the following day in a good health condition.the endoscopic ultrasound control at weeks showed complete resolution of the pancreatic cyst and was followed by stent removal. the endoscopic drainage of the pancreatic pseudocyst represents the first treatment option as an alternative to the surgical intervention, being minimally invasive, with low risk and fast recovery. clinical case report: a -year-old man was admitted to the hospital with a diagnosis of severe acute pancreatitis and multi-organ failure. during the first month patient has in uci and non invasive procedures were attempted: enteral feeding by a nasoduodenal tube was started and antibiotics were administered to control sepsis. on day , percutaneous drainage was performed for large retroperitoneal abscess. on days, endoscopic transgastric necrosectomy was performed and the left collection was resolved. due to the multi-organ failure persistence and the evidence of size increase of the right retroperitoneal collection, a vard was decided.the right collection was accessed following the previously pigtail catheter. a mm trocar was placed to create retro-pneumoperitoneum with a pressure between - mmhg. a trocar of mmhg was placed, purulent content was aspirated and a debridement was performed. irrigation and aspirate was performed with normal saline and povidone-iodine solution. drainage was used to perform washes with physiological saline and urokinase.on days, the ct confirmed collection resolution. on days he was discharged. after months, the patient is in good clinical condition. discussion: drainage of the retroperitoneal abscesses via laparotomy is highly invasive and risky. vard enables radical necrosectomy and drainage less invasively. in this patient, the complete resolution of the right collection is obtained with retroperitoneal debridement without complications. we conclude that careful retroperitoneal necrosectomy is a valid alternative for the management of right collections. aims: in this study we analyze laparoscopic approach for hepatocellular carcinoma in order to clarify iwe can take advantage in some outcomes as complications, postoperative recovery or long-term survival outcomes. methods: a retrospective case consecutive study has been taken analyzing: age, sex, body max index, comorbidity, surgical extension and tumor size. the outcomes analyzed were: operation time, intraoperative blood loss, blood transfusion, postoperative morbidity and mortality, intensive care stay, hospital stay, tumor size, r resection, conversion rate, early reintervention, disease-free survival rate, overall survival rate results: in this study patients were analyzed males and females with ages between and years (mean age ) and diverse comorbidities: arterial high pressure ( / ; %), diabetes ( / ; , %) ; dislipemy ( / ; , %) , hepatophaty measured as liver cirrhosis ( / ; , %). all of them underwent laparoscopic liver surgery, in cases non-anatomical resection was performed while in the other a segmentectomy was performed. in cases the laparoscopic was strict, in and assistance incision was needed. operative time was - min (mean: min). blood loss mean was , g/dl and only intraoperative transfusion were needed. massive blood loss was reported in case. postoperative medical complications were observed: hepatic failure and renal insufficiency and in case we observed a postoperative hemorrhage that needed an urgent reintervention. the mean of intensive care stay was day and hospital stay was . days. about oncological outcomes r resection was achieve in / ( %), r in / ( %). at years / cases were free disease, dead by progression of disease and dead by other causes. aim: the purpose of this study is to analyze our initial experience with laparoscopic duodenopancreatic resection. introduction: laparoscopic procedures have advanced to represent the new gold standard in many surgical fields. laparoscopic pancreatoduodenectomy and laparoscopic distal pancreatectomy(ldp) are advocated to improved perioperative outcomes, including decreased blood loss, shorter length of stay, reduced postoperative pain and expedited time to functional recovery. however, the indication to minimally invasive approach for pancreatic surgery is often benign or low grade malignances. material and method. the steps of ldp procedures are similar to the open procedure. we perform destructive part of procedure totally laparoscopically and we prefer to do reconstructive part of procedure using hand-assisted techniques. for the period - , we have been perform pd, ( %) we have done with laparoscopic approach. ( %) of patients were operated totally laparoscopic and ( %) of patients were operated by handassisted techniques. results: a significantly higher conversion rate was encountered when lc was done - weeks after es, as compared to week after ercp. it is estimated that pancreatitis after ercp affects roughly three to percent of patients and many endoscopists quote a post-ercp pancreatitis rate of - %. however, - % is probably a more realistic answer for the majority of ercp endoscopists. wise endoscopists inform their patients that there is a spectrum of post ercp pancreatitis severity, from mild ([ % of cases) to severe ( - % of cases). in mild forms, pancreatitis after ercp may resolve itself. conclusion: endoscopic retrograde cholangiopancreatography is a procedure used to diagnose and treat disorders involving the pancreatic and bile ducts. acute pancreatitis is the most common and feared complication of endoscopic retrograde cholangiopancreatography. the assumption is that the duration of the laparoscopic method is longer, but on the other hand the patient have better wound healing and fewer possibility of developing postoperative hernia . the postoperative period is much more simple due to the significantly shorter hospitalization and the faster recovery, and according to patients the level of pain is much smaller as well. however the oncology results are the same. introduction: spiegel hernias are a rare, representing only between . % and % of all abdominal wall hernias. due to its location, below the spiegel line, its diagnosis requires a high index of suspicion. the physical examination only detects % of the spiegel hernias and, in many occasions, imaging tests are necessary for the diagnosis. goals: our objective is to describe the case of an urgent laparoscopic repair of a case of high grade bowel obstruction secondary to a spiegel hernia. material and methods: we present the case of a -year-old male patient with no medical history that comes to the emergency department of our center due to an eight hour evolution of abdominal discomfort associated with nausea without vomiting or other symptoms. the patient was afebrile and hemodynamically stable at all time. on physical examination, the abdomen is soft and depressible, painful on the left flank where a tumor compatible with spiegel's hernia is palpable. in the blood count there is no leukocytosis nor alteration of inflammatory parameters. an abdominal computed tomography (ct) scan was requested from the emergency department which demonstrated a high-grade small bowel obstruction caused by an entrapped loop of distal jejunum conditioned by a left-sided spiegel hernia. given the situation, an informed consent was obtained, and the patient was taken to the operating room for emergency laparoscopic repair. we performed a laparoscopic hernioplasty with ventralpatch mesh between oblique major and transverse and primary closure of defect in continuous suture. after this, the evolution of the patient is favorable, with good oral tolerance and re-establishment of intestinal transit, being able to be discharged h after surgery. the spiegel hernia is a rare entity that requires a high index of suspicion for its diagnosis. despite the limited evidence published in the literature on the laparoscopic repair of incarcerated spiegel hernias, the studies published so far suggest that the laparoscopic repair is a valid alternative to the classic approach when it is performed by a well-trained laparoscopic surgeon. introduction: repair of lateral abdominal wall hernias (both primary and incisional) can be challenging due to the complexity of anatomy, issues with fixation and the low incidence of such cases. a good understanding of abdominal wall and retroperitoneal anatomy, coupled with proficient laparoscopic technique is essential for successful repair via the minimally invasive approach. methods: a retrospective review of a prospectively maintained database was performed to identify patients with lateral abdominal wall hernias who underwent laparoscopic repair from january to july . results: patients with hernias were identified ( primary, incisional). mean patient age was (range - ) and mean bmi was . kg/m (range . - . ). according to ehs classification, the incisional hernia defects were located at subcostal (l , n = ), flank (l , n = ), iliac (l , n = ) and lumbar (l , n = ) regions. background: it is commonly admitted that laparoscopic surgery has the advantage of abdominal wall preservation. however, the increased use of laparoscopy has resulted in certain complications specifically associated with the laparoscopic approach, such as trocar-site incisional hernia. until today, it is not finally clarified 'patient-dependent' factors contributing to the occurrence of postoperative hernia after laparoscopic abdominal surgery. methods: between and , patients were operated due to trocar-site incisional hernia in one surgical centre. 'the patient-depending' factors which caused postoperative trocar site incisional hernia data was collected and retrospectivily analysed. results: port site incisional hernia occurred in % ( patients) after the use of trocars with mm or larger diameter. the presence of metabolic syndrome was the decisive factor in the development of postoperative incisional hernia in % ( patients). in % ( patients) the postoperative hernia occurred on the background of a long cough symptoms caused by chronic obstructive pulmonary diseases. the cause of postoperative hernia in % ( patients) of patients was the condition of lifting a one-time severity or heavy physical work. in % ( patients) of postoperative patients hernia developed due to prolonged constipation of chronic inflammatory colon diseases. conclusions: thus, when the aponeurosis of the trocars is adequately closed, the reason of the occurrence of postoperative hernias was caused by patient-dependent factors which increase intra-abdominal pressure. for this method, small midline incision cm in length - cm away from hernia orifice was carried out initially. dissection of intraperitoneal adhesion was carried out by sils with sils device. subsequently after closure of initial laparotomy unilateral anterior rectus sheath was incised from the same incision and dissection of retro-rectus space up to preperitoneal space was done under laparoscopic vision. dissecting the other side was carried out by same fashion. initial dissection of linea alba could be done by open surgery from initial incision. further dissection of linea alba, retro-rectus space, and hernia orifice was carried out by sils. defect closure of anterior and posterior rectus sheath using barbed suture was also done by sils and self-grip mesh was inserted. additional trocar to assist retro-rectus dissection, defect closure, and decompression of intraperitoneal cavity was inserted as required. aims: the laparo-endocsopic approach of inguinal hernia contiue to bring many clarifications concerning inter-parieto-peritoneal space of this region through in vivo exploration, obtained by magnification by means of specific optic intrumentation. our study aimed to revalue the in vivo fascias, to establish their embryological correspondences and to reunite the variable nomenclature existing in the classical anatomy of this region. these observations find their applicability in tapp and tep hernia procedures, as the old anatomical descriptions are no longer operative. methods: we have tried to identify the structures that delimit the anatomical regions of retzius and bogros in recording of tapp procedures performed on men, on the right side, for small indirect hernias on patintes with clear view of the structures. additional, a review of literature on this subject has been performed through a search in the detabases according to the following keywords: bogros space, retzius space, preperitoneal approach, urogenital fascia. results: retzius and bogros are the medial and lateral compartments of the inter-parietalperitoneal space, located between the transversal fascia and the parietal peritoneum. these narrow, virtual spaces are best highlighted today with the help of insufflation techniques during laparo-endoscopic procedures. a competent and careful dissection confirms a 'deep and superficial' stratification, highlighting embryonic relics derived from the uro-genital fascia: urinaryprevesical fascia and spermatic fascia. in addition, the real retzius space is located previously and the real bogros space is located behind this strcuture. the confluence area of the two spaces is a critical point of laparo-endoscopic dissection, its non-recognition may 'wander' the dissection. conclusions: literature data in this topic reflects a certain terminological confusion using general terms such as 'preperitoneal tissue' or 'arreolar tissue' to denote what we consider to be the urogenital fascia or its prologations. the data obtained were synthesized in several drawings and diagrams very useful in training surgeons to use tapp / tep techniques. aim: spigelian hernia containing epiploic appendage is really rare entity. in this paper, we present a very rare case of spigelian hernia involving epiploic appendage performed laparoscopic hernia repair. case report: a -year-old woman presented to the emergency department with sudden onset abdominal pain in the left lower quadrant. on physical examination, she had a small, palpable tender mass in the left lower abdominal quadrant. temperature and white blood cell count were normal. an inflamed epiploic appendage with an oval shape, a fatty core, and a central thin hyperdense line in the hernia sac was detected on abdominal computed tomography. its intraabdominal relationship with the normal wall of the sigmoid colon was well appreciated (figure a, b) . diagnostic laparoscopy was performed. (figure ) adhesions between the sac and epiploic appendage are released using sharp dissection. a peritoneal flap is then created (figure ). laparoscopic tapp repair was used without closing the defect (figure ) . the patient was discharged on th days uneventfully. aims: morgagni's hernia is an in infrequent, congenital, anterior or retrosternal diaphragmatic defect. the right side is the most frequently affected, up to % of cases. it represents between and % of congenital diaphragmatic hernias. in childhood, they usually attend asymptomatically or with respiratory symptoms. up to % are diagnosed in adulthood, incidentally or after gastrointestinal obstruction debut. the treatment is surgery, which can be by laparoscopic or open approach.we present a case of laparoscopic approach with intra-abdominal mesh placement of giant morgagni's hernia diagnosed in senile age. methods: -year-old woman with a history of advanced alzheimer's dementia, partially dependent in daily life activities and institutionalized who consulted for intermittent episodes of oral diet intolerance associated with vomits of one month of evolution. abdominal examination was anodine. chest radiograph revealed a right lower lung field mass with fluid collected. thoracoabdominal scan showed small bilateral pleural effusion and large, right anterolateral morgagni's hernia, which contains dilated segment of transverse colon and greater omentum . results: laparoscopic approach was performed. hernia was reduced and hernia sac was removed. the defect was repaired with a dual-component (absorbable and non absorbable) mesh anchored with intracorporeal suture. patient recovered and was discharged days after surgery. conclusion: laparoscopic approach for morgagni's hernia reapir is secure and offers the advantages of less post-opertive pain, faster recovery and short postopatory stay. introduction: recently, laparoscopic operations for ileus are increasing. we have undergone laparoscopic operation to adhesive ileus with umbilicar incision at the beginning. the umbilicar incision at the beginning makes it possible to secure the laparoscopic field by peeling the adhesion under direct view, and makes it easy to repair damage to the intestinal tract. surgical procedure: at first, the umbilicus - cm incision was made and peeled the adhesion as much as possible under direct vision. secondly, ez access was set and inserted one mm port, therefore laparoscopic operation was performed with or pieces of mm ports. when the repair or resection of small intestinal due to damage is necessary, it is pulled out through the ez access. objective: to investigate the possibility of problems of laparoscopic ileus operation to adhesion ileus by umbilicar incision at the beginning. introduction: small bowel obstruction (sbo) during pregnancy is a rare condition with an incidence of . - . % and in around % of cases it is most caused by adhesions from previous abdominal surgery. other diagnosis, such as, hernias, malignancy, volvulus or intussusception are extremely rare. when sbo occurs in pregnancy, it carries a significant risk to mother and fetus. its diagnosis of can be difficult to make as symptoms are often attributed mistakenly to the pregnancy. goals: a case report of congenital bowel obstruction during the second trimester of pregnancy handled by laparoscopy. material and methods: we report the case of a year old woman with a history of chronic lung disease, pregnant because in vitro fertilization ( ? weeks) who attended the emergency department with abdominal pain and bloating accompanied by nausea and vomiting for two days. on physical examination she showed a distended, soft, depressible and painful abdomen without peritonism. laboratory tests were normal. a nasogastric tube was placed with generous output fecaloid intestinal contents. abdominal ultrasound by expert radiologists in abdomen showed a moderate amount of free abdominal fluid with normal uterus moderate and sbo to the ileum because of intestinal adhesion. this results were confirmed with an magnetic resonance imaging (mri). results: the patient was operated by laparoscopic approach with three trocars. the main problem was discovered. we founded a congenital adhesion which conditionated the obstructive syndrome. postoperative recovery was uneventful and the patient was discharged h after surgery. conclusion: the non-obstetrical acute abdomen in pregnant patient is a reality that occurs in one of every pregnancies. its diagnosis in more difficult than in nonpregnant patients requiring or high index of suspicion. the laparoscopic approach of acute abdomen during pregnancy is a valid and safe option, even in the early hours after diagnosis of bowel obstruction when it is performed by a well-trained laparoscopic surgeon. aim: intestinal malrotation (im) without midgut volvulus in adults is a rare clinical entity, which is the result of an incomplete rotation of the small bowel during embryogenesis, due to the nonlysis of the ladd bands. these ligaments spread between the duodenum and caecum and do not allow the gastrointestinal tract to take its normal position into the peritoneal cavity. im appears in to - newborns and is usually asymptomatic. diagnosis is usually made in the first month, and presents with findings of an acute abdomen, small bowel ileus and volvulus. im in adults is a rare entity. most of the times it is asymptomatic, but it can cause chronic abdominal discomfort and constipation. we present the laparoscopic management of an adult patient with intestinal malrotation. methods: our patient, a year old female, presented to the emergency room with a -month history of abdominal pain and nausea. all blood tests were normal. an abdominal mri showed intestinal malrotation without volvulus. due to persisting symptoms, she underwent a diagnostic laparoscopy with complete lysis of the ladd bands. the only unusual finding was a slight oedema of the duodenum. results: her symptoms settled postoperatively and she was discharged on the nd postoperative day. since her discharge, she has not developed any similar abdominal pains or complaints. conclusions: symptomatic intestinal malrotation in adults is an unusual clinical entity, but it is definitely one of the differential diagnoses we need to consider in case of chronic abdominal symptoms. the management consists of the division of the ladd bands, and this procedure can be performed safely with laparoscopy. many small intestinal obstructions are due to adhesions after laparotomy, but small bowel obstructions without history of open surgery is relatively few. in diagnostic imaging such as preoperative ct examination, the cause is diagnosed to some extent, but details are sometimes unknown unless operative observation is actually made. in many institutions, laparoscopic surgery is also actively introduced into the operation to relieve bowel obstruction, and its effectiveness is beginning to be recognized. we examined the usefulness of laparoscopic surgery for patients with small bowel obstruction without history of laparotomy from experience in our hospital. aim: from december to october , we searched cases of laparoscopic surgery for a small bowel obstruction without previous laparotomy at our hospital, and clinical findings, surgical results, and postoperative course were examined. results: there were ten cases. eight men and two women. the median age was years ( - yrs.) . reasons for intestinal obstruction were adhesions cases, internal hernia cases, persimmon stones case, small intestine tumor case. four cases of adhesions were emergency surgery. there were cases of emergency surgery and waiting surgery. five laparoscopic operations were completed and five cases during laparotomy transition. the median surgical operation time was min ( - min), and the median bleeding amount was g ( - g). there was no fatal case after operation, only one complications of ileus. the median length of hospital stay was days ( - days) . conclusion: laparoscopic surgery for intestinal obstruction with no history of laparotomy was thought to be a safe and effective procedure. although the transition to laparotomy would be higher in case of emergency, but there was no case of large incisional laparotomy. conclusions: laparoscopic surgery for sbo reduces postoperative complications and contributes to shortening the postoperative hospital stay and to decreasing the rate of recurrences, although it is a retrospective study, which is a safe and a useful approach. furthermore, first episode of sbo without previous operation seems to be an appropriate indication for laparoscopic surgery. background: postoperative adhesion after abdominal surgery may cause intestinal obstruction, chronic pain, or female infertility, which constitutes the major problems after surgery. adhesion formation are reported to be reduced by laparoscopic surgery and the use of anti-adhesion barriers. seprafilm composed of sodium hyaluronate carboxymethylcellulose bioresorbable membrane has been widely used to date, especially in open surgery. the characteristics of seprafilm, which is easily stick when wet, conversely brittle when dry cause it difficult to deliver into the abdominal cavity via the small incision in laparoscopic surgery. therefore, seprafilm is not much used in laparoscopic surgery. although various methods of insertion of seprafilm have been reported, some need special devices, or some acquire skill. methods: we adopted the pre-moistening technique for the replacement of seprafilm in consecutive cases of laparoscopic gastrointestinal surgery. a sheet of seprafilm was cut into equal pieces. to soften the sheets, one of the pieces was placed on a folded wet gauze until it became naturally curled then it was reversed, and the same procedure was repeated. softened sheet is easily to deliver into the abdominal cavity via a small incision by pushing with digital finger. moistened sheet expands naturally in the abdominal cavity. one or two pieces were needed to cover the incision. this process took only a few minutes. results: in all cases, the sheets were successfully introduced into the abdomen and spread widely enough to cover the incision. there have been no adverse effects, no postoperative complications, or gastrointestinal obstruction due to adhesion in the observation period of median two years. conclusions: short term outcomes were good after applying this technique. however, to record the incidents of intestinal obstruction and chronic pain, over years observation is indispensable. long term follow-up studies are required to clarify the usefulness of the anti-adhesive barrier in gastrointestinal surgery. b. east, rd department of surgery, motol faculty hospital, prague, czech republic aim: since when the ipom acronym was used for the first time our views at intraperitoneal mesh positioning has changed several times. despite growing evidence on its possible long term consequences it is still preferred method at some centres for large number of patients. the aim of this study is to point out the pitfalls of this method but also show that ipom is a good technique but only for highly selected cohort of patients. methods: this is a review of the literature focusing on the indications and complications of ipom pointing out controversies among the published articles over last two decades. some mesh material characteristics are being discussed as they are basic for understanding this complex and highly sensitive issue. results: a wide range on indications of ipom from little umbilical to large incisional hernias is advocated by many. however, some opinion leaders promoting this technique as universal and ideal for everyone just few years ago are advising to avoid it if possible lately. a necessary overlap has also been questioned recently. despite improving anti-adhesion barriers and methods of fixation in may a surgical mesh has become classified as risk class iii by the eu parliament and council on medical devices hoping to prevent physiomesh like incidents in the future. the need for post market registries and long term follow up is obvious. conclusion: us as surgeons implant a mesh in our patients and therefore we should be aware of its possible long term effects. no mesh on the market has a long term safety evidence especially in the intraperitoneal space. ipom is a good technique but possess a significant risk of long life complications and therefore should be spared only for those unfit for other methods of repair, patients with too high mesh infection risk, obese or older patients. introduction: acute appendicitis in elderly patients is relatively uncommon and could represent an underlying neoplasm. hence patients over the age of are often referred for a follow-up colonoscopy after management of acute appendicitis. the current routine use of computed tomography (ct) scans in the evaluation of suspected acute appendicitis in elderly patients prior to surgery coupled with intra-operative findings at laparoscopy question the role of follow-up colonoscopy for these patients. aims: to determine the role and optimal timing of colonoscopy in early detection of colorectal neoplasia after treatment of acute appendicitis in elderly patients. methods: all patients aged years and above with confirmed appendicitis admitted to our hospital during the period / / to / / were included. follow-up colonoscopy, diagnosis of colorectal neoplasia and its location in this patient cohort was evaluated. results: number of people aged and above in olol who had appendectomies from the dates / / to / / = . out of them / ( %) had full colonoscopy within years of the appendectomy.of them of the colonoscopies done were maleand were females. / ( %) of these colonoscopies were completely normal. colonoscopy identified colorectal carcinoma in ascending colon ( . %). other pathologies identified included: benign polyp ( %), polyp with low grade dysplasia ( %) and others ( . %) (lymphocytic colitis, ulcerative colitis, medication related ulceration, diverticulosis, melanosis coli, haemorrhoids). conclusions: in elderly patients above years of age: there may be an increased risk of colorectal cancer after acute appendicitis. only % of this patient cohort underwent colonoscopy after appendectomy. the current recommendations suggest the need for follow-up colonoscopy in elderly patients post acute appendicitis. further studies are needed to decide whether routine colonoscopy is indicated after acute appendicitis patients over years. introduction: it is generally accepted that the main aetiology of appendicitis is obstruction due to appendicoliths in adults and lymphoid hyperplasia in children. in contrast, incidental appendicoliths have been reported to occur in up to % of the asymptomatic population. controversy still exists regarding the association of appendicolith and appendicitis. is the appendicolith a causative factor or merely an incidental finding? aims: to determine the association between the presence of appendicolith and acute appendicitis (perforated or non-perforated) vs healthy appendix. methods: we collected the data retrospectively from the electronic records of all appendicectomies performed between january and december in our institution. data collected included: age, sex, appendix histology and the presence of appendicolith. interval or incidental appendicectomies were excluded from this study. we analysed the data using spss software version . results: during the study period appendectomies were performed (males: , females: , age range: - years). cases were histologically confirmed cases of acute appendicitis and of these, were perforated. a normal appendix was identified in cases. the remaining cases were due to chronic appendicitis, sub-acute appendicitis, lymphoid hyperplasia, parasitic infestation, and neoplasm. appendicolith was found in cases, of which were found in a normal appendix and were found in an inflamed appendix. out of the cases of appendicolith with normal appendix: cases were aged between and years old, cases were aged between and years old and case was aged between and years old. out of cases of appendicolith with acute appendicitis, cases were aged between and years old, cases were aged between and years old and case was aged over . conclusions: appendicolith may merely be an incidental finding and is not the primary cause of appendicitis. no significant correlation between gangrenous/perforated appendicitis and the presence of appendicolith. contrary to popular belief appendicoliths are more common in paediatric appendicitis than in adult cases. further research is recommended. over the last years, patient satisfaction surveys have gained increased popularity. nowadays, respect for patients' needs is central to our health care system. hospitals use patient satisfaction surveys to assess quality of care. many hospitals routinely survey patient satisfaction but relatively little data has been published. our acute surgical assessment unit operates from am to pm monday to friday and in its first year saw surgical patients, of whom were discharged and were admitted to the hospital for further management. aims: to assess the levels of satisfaction of patients attending asau at our lady of lourdes hospital. methods: a random sample of patients seen in the asau was surveyed to determine their level of satisfaction and the experience they had whilst attending asau. a novel self-reported patient satisfaction questionnaire was developed and used to assess patients' opinion regarding the treatment they received, the doctor's explanation of their condition, the waiting time and the service in asau. also the questionnaire encouraged patients to suggest improvements to the service. aim: sintestinal obstruction is a very common cause of presentation to an emergency department. the most common cause in patients with prior abdominal surgery are adhesions, but the list of differential diagnosis is large. internal hernia is a very rare cause of obstruction, with a reported incidence of between . and . %. the herniation related with broad ligament defects is even more uncommon. methods: we report the case of a -years-old woman with antecedents of liver transplant, tubal ligation and appendectomy. the patient was admitted refering abdominal pain in the epigastrium of h duration, accompanied by nausea and vomiting. on physical examination, abdomen was depressible, tender in the right low quadrant, without evidence of peritoneal irritation. laboratory studies were normal except for an elevated leukocyte count with a left shift. computed tomography (ct) revealed dilated small bowel loops with a transition point in right lower quadrant. radiological diagnosis was intestinal obstruction, with fibrous adhesion as the most probably aetiology. management was conservative at the beginning, with intravenous hydration, nasogastric tube and administration of gastrografin (diatrizoate) without a good response. results: at h, an exploratory laparoscopy was perform, finding dilatation of small bowel loops and a cm defect in the right broad ligament in which a segment of ileum was herniated. ileal segment was liberated without evidence of ischemia. the hernial defect was closed by laparoscopy with simple silk stitches. the postoperative course was excellent, tolerating oral feeding next morning. the patient was discharged h after surgery. conclusions: internal hernias of the broad ligament are an extremely rare cause of intestinal obstruction, but must be added to the differential diagnosis for female patients due to the risk of intestinal strangulation and perforation. even if clinical and radiological diagnose is difficult, ct is the best tool to delineate the cause and location of the obstruction. laparoscopy allows reduction of the hernia and closure of the defect with minimal invasiveness. because of that, the laparoscopic approach of bowel obstruction should be considered as the first choice if there is the suspicion of an internal hernia, without signs of necrosis or perforation. the laparoscopic approach is a safe and effective tool in the management of postoperative complications. it is well tolerated in critically ill patients and avoids respiratory and wound related morbidity associated with laparotomy. it also reduces diagnostic delay and a considerable number of unnecessary laparotomies, with a high resolution rate and minimal morbidity. it thus represents a valid and necessary alternative in surgeon's armamentarium. in the management algorithm of our institution we always choose the laparoscopic technique as the fisrt tool in case a reoperation is necessary. , small bowel obstruction ( . % vs . %), and colorectal cancer obstruction ( . % vs . %) was found higher for acs unit group, and also progressively higher during the last years. conclusion: according to our study, laparoscopic approach in abdominal emergencies shows an upward trend, and surgeons from acs units seem to have higher rates of laparoscopy than general surgeons in emergency procedures. background: incarcerated and strangulated hernias present a major problem in emergency medicine. there is scarce data about the role of laparoscopy in the management of these patients. laparoscopic repair offers the benefits of the ability to survey the incarcerated organ and to evaluate its viability, apart from the obvious advantages of laparoscopic surgery. the use of mesh repair in these emergent operations is also a major concern, due to the un-sterile conditions in which they are performed. objective: to evaluate the safety and short-term efficacy of laparoscopic emergent repair of incarcerated hernias. methods: retrospective review of prospectively collected data of all the patients who underwent emergent laparoscopy due to an incarcerated hernia between november and october . results: during the study period, patients underwent emergent laparoscopy due to incarcerated hernias ( females, males). had incarcerated inguinal hernias, and had incarcerated umbilical hernias. mean age was . . all inguinal hernias were repaired in the tapp approach, and using an absorbable mesh. all umbilical hernias were repaired using the ipom approach. patients had bowel obstruction, had incarcerated omentum, and one patient had incarcerated urinary bladder. patients underwent resection of an ischemic organ ( bowel, urinary bladder, omentum). mean hospital los was . days. during the follow up period there were no mortalities, and no recurrences. one patient had a wound infection that resolved with antibiotics. conclusion: laparoscopic emergent repair of incarcerated hernias is a safe and feasible approach. further studies with longer follow up time need to be conducted, in order to evaluate the added benefit of the laparoscopic approach. gibraltar is a small overseas british territory with a residential population of approximately , inhabitants, that increases up to , daily due to incoming tourists and cross-frontier workers. as a geographically isolated center we have to provide a varied service including emergency surgery, and elective operating such as colectomies, gastrectomy's etc. one of the challenges faced is the limited stock of red blood cell (rbc) units within gibraltar and reliance on platelets (plt) from across the border from spain. given the immanent brexit we need to prepare for the challenges we will face in these times of political and distribution uncertainty. a prospective audit of all blood use within gibraltar was carried out over months. the number and type of units requested, the number of units given, the speciality, location and indication for requests was recorded. introduction: the use of laparoscopic surgery in abdominal emergencies, such as in trauma, has had a slow acceptance. the advantages with this approach include less postoperative pain, faster recovery, quicker return to everyday activities, and fewer complications. we have collected the cases and indications of laparoscopy in abdominal trauma in the main hospitals in the andalusian capitals and compared with the national registry material and methods: a total of patients who underwent laparoscopic surgery in the main hospitals of seville, cordoba, malaga, cadiz, huelva, jaen, granada and almeria were analyzed. they have been compared with the traumas archived nationally by the spanish association of surgeons taking into account age, sex, score of the american society of anesthesiologists, hemodynamic stability and mechanism of injury. the intra and postoperative variables were compared between groups. results: at the national level, the main cause of abdominal trauma were traffic accidents, therefore, it was the patients who had a greater number of laparoscopies ( . %), followed by stab wounds ( , %) and run over ( . %). in our series, the average age of the patients is years and % are male. only eco-fast was performed in % of the patients, being positive in . % of the cases. as they were stable patients, in % of the cases a tac was possible. in our data, % of the laparoscopies were performed for therapeutic purposes as well as being diagnostic, thus avoiding a posterior laparotomy. conclusion: slaparoscopic surgery for abdominal trauma, either blunt or penetrating, is safe and technically feasible in hemodynamically stable patients. we found that laparoscopic surgery was associated with shorter operative time, lower estimated blood loss and faster return to normal diet. based on our findings we establish the indications of laparoscopy in these patients aims: submucosal aneurysm of small intestine is extremely rare, but its rapture can be lifethreatening. due to the unstable hemodynamics and unknown site of bleeding, emergency laparotomy has been widely performed for the rupture. we will present case reports and show the strategy for minimally invasive treatment for ruptured aneurysm. methods: we experienced two cases of ruptured submucosal aneurysm resected by laparoscopic surgery. case is a -year-old male who was taken to our er with massive hematochezia. ct showed arterial bleeding in the small intestine and angiography revealed bleeding from the ilial artery. selective embolization using gelatin sponge and micro coil was performed and hemostasis was obtained. video capsule endoscopy found the hemispheric elevated lesion with protrusion at the top in the ileum. using balloon assisted enteroscopy, the site of aneurysm was marked with injecting india ink, which allows surgeons to accurately and easily identify the part of small intestine with aneurysm. subsequently, a single incisional laparoscopic assisted partial ileectomy was performed for the purpose of definitive diagnosis and preventing re-bleeding. the ileum with aneurysm was easily identified in laparoscopic exploration owing to the marking, and it was taken out from the incision to perform resection. case is a -year-old female who was transferred to our emergency department with sudden onset of massive melena. ct and angiography were perfomed, and bleeding from the rd jejunal artery were confirmed. subsequently, therapeutic embolization was performed in the same way as case . enteroscopy revealed submucosal elevation similar to case in the jejunum. we carried out endoscopic tattooing, followed by single incisional laparoscopic assisted partial jejunectomy. results: the operative time in case and case were min and min, respectively, and the amount of blood loss was both ml. the postoperative course was uneventful in both cases. case was discharged on the postoperative day , and case was on postoperative day . conclusions: our experience indicates that ruptured submucosal aneurysm of the small intestine can be effectively managed by a laparoscopic surgery with combination of therapeutic embolization and enteroscopic evaluation, which is safe and minimally invasive. background: laparoscopic bilateral inguinal hernia repair may be completed with one large selffixating mesh crossing the midline in front of the bladder. no studies have investigated in detail whether preperitoneal mesh placement induces temporary or more lasting urinary symptoms. methods: urinary and hernia related symptoms were evaluated preoperatively and postoperatively at , and months in patients using the iciq-mluts questionnaire and eurahs-qol score. results: voiding symptoms and bother scores were unchanged at or months, but there was significant improvement at months compared with preoperative findings (symptoms p \ . ; bother score p \ . ). incontinence symptoms improved at month (p \ . ) but not at or months, with a bother score significantly improved at month (p \ . ) and months (p \ . ). diurnal and nocturnal frequency did not change significantly postoperatively, but months nocturnal bother score was decreased (p \ . ). eurahs-qol scores showed significant improvement in all domains for all measurements compared to previous measurements. postoperative symptoms were improved at months, compared with preoperative pain scores (- . ), restriction of activity (- . ) and cosmetic scores (- . ) these findings were statistically significantly (p \ . ). at months, there were no patients with severe discomfort (score = ) for any of domains. no recurrences were diagnosed with % clinical follow-up at months. conclusion: placing a large preperitoneal self-fixating mesh for bilateral groin hernia repair did not cause new urinary symptoms and demonstrated significant improvement in voiding symptoms at months. incontinence and nocturnal bother score were significantly improved. introduction: tep/tapp hernia repair is an increasingly widely used surgical methods for minimally invasive treatment of inguinal hernia. tep advantages to tapp are noincision of the parietal peritoneal sheet, therefore no need for its recovery-sewing or sticking at the end of the procedure, and no need for attachment of the prosthetic mesh to the structures of the anterior abdominal wall, which results in a reduction in the financial cost of operation.various types of meshes with different characteristics are used, depending on the surgeon's preferences.the aim of this study is to highlight mesh-related postoperative complications, which can be serious and life-threatening. material and methods: a retrospective cohort study of cases of unilateral or bilateral tep and tapp hernia repair performed at the university hospital for the period - with a study of early and late postoperative complications potentially causally related to the implanted prosthetic mesh and methods of their treatment. results: for a -year period tapp ( bilateral) and tep ( bilateral) have been performed. three complications (clavien-dindo iva, ivb and v) were found, of which were early postoperative (up to pod)-one in tapp- pod small bowel adhesive ileus due to suture dehyscense of the peritoneal sheet and adhesion of a bowel loop to the surface of polypropylene mesh.one in tep- pod-a large preperitoneal hematoma with haemorrhagic shock at years old female in anticoagulant therapy-an open revision of the preperitoneal space and definitive haemostasis; followed in pod established bladder lesion from erosion from the edge of self-locking polypropylene mesh. suture and drainage performed, but the patient died of decompensation of concomitant diseases. a late complication- months after bilateral tep-erosion of soft polypropylene mesh of sigma (probable undetectable lesion of the peritoneum) with faecal peritonitis-hartmann procedure with laparostoma followed by restitution but persistent chroniosepsis with established abscess in retzii. months after-revision with abscess incision and extraction of infected meshes. discussion: use of biologic meshes is quite expensive, however synthetic non-resorbable meshes implanted in preperitoneal layout is a prerequisite for specific severe postoperative complications. inguinal hernia repair is one of the most performed procedure all over the world, with more than million procedures performed each year, it represents one of the top three most performed procedures. the lichtenstein procedure is one of the first procedures that a young trainee in general surgery learn, not only for its reproducibility and for the great numbers of procedures that could be done in each department, but also because during inguinal hernia repair the trainee learn a lot of skills which are the basis of major surgical interventions. the surgeon's performance for any procedure could be evaluated by way of established learning curves that can predict the minimum number of procedures required to reach the same intra and post-operative outcomes as an experienced surgeon performing the same technique. the aim of our multicentre study was to analyse how many cases are required to stabilize operating time (ot) and intra and post-operative complication rates over the course of the learning curve period for a lichtenstein procedure. from january to december all lichtenstein procedures from four different institutions were recorded in a prospective maintained computer database. the results of the first consecutive procedures performed by three different trainees (group a; group b; group c) were compared with the same numbers of procedures by two senior surgeons of the same institutions (group e, group f). cusum analysis was performed to evaluate the achieving of learning curve. no differences in terms of biometric and hernia type were recorded between the five groups. cusum analysis showed that the trainees achieve the learning curve between the - procedures. no intra or post-opertive complications were recorded during the training period.in conclusion after our analysis we found that at least procedures are needed for the trainees to achieve the learning curve for lichtenstein procedures. background: since its first description in the s, the total extraperitoneal (tep) technique has established itself as a popular endoscopic method for the repair of inguinal hernias. the tep repair is generally viewed as a technically-demanding procedure requiring adequate experience to minimize and handle complications. in this case report, we describe an uncommon complication of urethral injury, which was successfully repaired laparoscopically. case report: mr r is a year old gentleman with no significant past medical history who presents to the department of general surgery, tan tock seng hospital, with a two-month history of a reducible right inguinal hernia, associated with some tenderness. an ultrasonography confirmed the diagnosis of a fat-containing indirect right inguinal hernia. in view of persistent pain, mr r was counseled for a laparoscopic repair of his right inguinal hernia. as mr r was able to empty his bladder just prior to surgery, no urinary indwelling catheter (idc) was inserted. an infra-umbilical incision was made to access the posterior rectus sheath and a balloon was used to bluntly dissect the pre-peritoneal plane. on inspection of the operating field, persistent pooling of blood was noted in the retropubic space. careful inspection revealed a defect in a tubular structure just inferior to the bladder neck. an idc was inserted, which confirmed a . cm defect in the pre-prostatic urethra. decision was made for primary repair using absorbable sutures in two layers. the bladder was subsequently filled via the idc, which did not reveal any leak. we then completed the right inguinal hernia repair using a mesh. mr r made an uneventful recovery and was discharged on post-operative day with instructions to keep the idc in-situ for two weeks. the idc was removed after two weeks and a micturating cystourethrogram was performed, which showed no filling defects along the urethra and no contrast leaks. discussion: though uncommon, urethral injuries can be a complication of laparoscopic tep repair. the key to managing these complications is in the early identification of such injuries intra-operatively. with early recognition and careful assessment, such complications can be managed laparoscopically with minimal post-operative morbidity. aim: the purpose of this study is to report surgical technique and outcome of hybrid tapp procedure (a combination of tapp and ipom) for inguinal hernia patients complicated with preperitoneal space adhesion. methods: hybrid tapp procedure is applied if peritoneal dissection or closure of the peritoneum is difficult due to severe adhesion. the peritoneum should be dissected as much as possible. for the site where adequate dissection was achieved, the collagen mesh is placed outside the peritoneum. in the part where dissection was difficult it is placed inside the peritoneal cavity. in order to prevent mesh migration, the mesh should be directly fixed to the cooper's ligament with a tacker. for this purpose, the peritoneum around the cooper's ligament must be well-dissected, even if it is strongly adhered, so that the ligament can be exposed. the crucial points in the hybrid tapp procedure are fixation of the mesh and prevention of the bowel herniation into the preperitoneal space. at the site where peritoneal dissection is possible, the mesh is directly fixed on the fascia using a tacker. if it is difficult, the mesh is placed in the peritoneal cavity and fixed over the peritoneum. if there is a risk of migration along with peritoneum, transcutaneous full-thickness fixation can be performed using non-absorbable sutures. the preperitoneal space should be closed tightly as soon as possible in order to prevent the bowel herniation into the preperitoneal space. at closure of the preperitoneal space, the peritoneum is fixed on the collagen mesh using non-absorbable sutures. objective: show a tapp approach using a self-fixating mesh( x cm. progrip tm laparoscopic self-fixating mesh, medtronic) with bipolar peritoneal defect sealing, avoiding the use of tackers and performing an easy and sutureless peritoneal closure. material and methods: years old male, asa ii, medical history of beta-latacm allergy, high blood pressure, dyslipidemia and bilateral knee surgery. diagnosed of bilateral inguinal hernia at consultation due to inguinal disconfort. surgical site infection prophylaxis with iv vancomycin. balanced general anesthesia. supine decubitus position with shoulder supporting to allow a forced trendelemburg. degree optical device with trocars disposition: one mm umbilical trocar and mm trocar in both flanks, same distance and height to umbilical trocar. peritoneal opening and flap creation with monopolar energy, blunt maneuvers and pneumoperitoneum dissection. anatomical landmarks identification(cooper's ligament, epigastric and iliac vessels, hernia defect and spermatic cord elements). reduction of hernia sac content(pseudosac in this case, direct hernia) and complete peritoneal dissection to achive a correct mesh placing. mesh is folded in parts(one inferior part, two superior parts) in vertical axis outside the abdomen to facilitate the posterior intraabdominal maneuvers. introduction: into abdominal cavity with grasping forceps and correct unfolding mesh assesment: medially(pubic bone), caudal(cooper's ligament) cranial(more than cm of hernia defect/ deep inguinal ring) and lateral(anterior superior iliac spine). finally, we use a bipolar forceps to close de peritoneal defect. in order to facilitate this step, its necessary to decrease pneumoperitoneum pressure and to use the grasping forceps to bring together both peritoneal flap edges prior to bipolar energy sealing. results: min. surgical procedure. h hospital discharge, no complications. routine outpatient follow up(week, month, months and month later) with an epididymitis episode months after surgery(treated with oral ciprofloxacin). conclusions:-this procedure is an easy implementation technique once the intraabdominal mesh unfolding procedure control is reached.-the use of a self-fixating mesh avoid the use of tackers and its potential disadvantages(e.g. increasing postoperative pain).-bipolar peritoneal sealing offers a quick, easy, cheap and safe peritoneal closure, avoiding the contact of the mesh with the viscera in the same manner. results: we performed procedures within patients. the average age was years. twenty six percent of hernias were bilateral, , % were inguinoscrotal and % in the right side. the median asa score was . the conversion rate was , %. the average duration of the procedure was , min min. overall morbidity was %. there were seromas ( , %) . on -year follow-up, one recurrence ( , %) was found and chronic postoperative pain in one case . we had no mortality. in the univariate analysis, male sex, inguinoscrotal hernias, hernias classified as nyhus a were significantly associated with overall postoperative morbidity. a chronic obstructive pulmonary disease was the only variable significantly associated with the occurrence of medical complications. conclusion: given these results, the tapp technique is a good alternative in the treatment of groin hernias. however, enhancing this approach is essential to reduce the operating time and the postoperative outcomes. introduction: studies have emphasized the impact of a strong safety culture on patient outcomes. consequently, many interventions focus on improving the safety culture, of which teamwork and safety climate are important ingredients. it is known that differences in culture and safety attitudes may also impact teamwork. implementations of safety interventions, such as a ' black box', are dependent upon these differences. the aim of this study was to assess the safety culture at the operating theatre complex, along with the theatre staff's attitude towards a specific quality improvement intervention, a black box in the operating room as a tool for structured team debriefing. methods: the validated dutch version of the hospital survey on patient safety culture was administered to all healthcare professionals working in the operating room complex at one academic medical centre. this survey was supplemented with questions regarding the use of a 'black box', a medical data recorder in the operating room, to measure the staff's attitude towards this quality improvement tool and its potential contribution to patient safety. aims: the aim of the study was to compare two methods of treatment of dunbar syndrome: thelaparoscopic release of median arcuate ligament alone and the hybrid method consisting ofsurgery and percutaneous stent implantation to celiac trunk. methods: we performed laparoscopic release of ct in the department of general, mini-mallyinvasive and elderly surgery in olsztyn in - . all of patients suffered from severepain of abdominal cavity before the surgery. three patients underwent doppler percutaneousangioplasty of the ct with stent implantation one month after the laparoscopy. results: all patients reported relief of symptoms in the first days after the operation. in two cases fromboth groups, there were a complete remission of the symptoms. in one case respectively,there was an improvement. there were no postoperative complications. the results of both methods do not show the differences therefore the surgery alone seems tobe a safe and feasible procedure. it increases the comfort of the patient and brings theopportunity for normal functioning. the method of wedge resection of lungs in patients with limited forms of chemo-resistant pulmonary tuberculosis is developed. in order to evaluate the efficacy, patients underwent surgery (the main group). for comparison, the data on similar operations in patients, made according to the traditional method (with the help of a cardboard weaving machine yo- ) were selected. compared the duration of the stage of resection itself, the frequency of need for additional hemostasis of the parenchyma sutures, the degree of deformation of the pulmonary tissue in the seam area, the frequency of postoperative complications and reoperations, the duration of postoperative inpatient treatment. the developed method, in comparison with the traditional one, has the following advantages: simultaneously leak proofness and hemostasis with minimal electrothermal damage to tissues are provided and there is no need for additional hemostasis, there are no negative effects of manual stitching of parenchyma of lung with abandonment of foreign material, a significant reduction in the duration of wedge resection of the lung from . to . min, a decrease in the number of postoperative pulmonary-pleural complications is achieved by . % and caused by them reoperations-by . %, shortening the duration of postoperative inpatient period of treatment from . to . days. introduction/aims: laparoscopy is a diagnostic and therapeutic resource that is largely used in elective gastrointestinal surgery due to its well-known advantages over the classic open approach. nevertheless, there is still some discussion about its application in emergency surgery. our aim is to analize the use of the laparoscopic approach by the members of the surgical emergency unit from our medical center. methods: a descriptive research based on the data of patients who required emergency surgery, that was performed by the members of the surgical emergency unit of a spanish hospital between november and may , was conducted. these data were analyzed according the pathology that motivated the surgical procedure and the chosen form of surgical approach (open versus laparoscopic). results: out of the patients in whom emergency surgery was performed, suffered from a pathology that actually allowed the laparoscopic treatment. laparoscopy was used in . % of these patients. according to pathology, the most common were acute appendicitis and cholecystitis, in which the laparoscopic approach was used, respectively, in % and % of the cases. regarding other less frequent pathologies, such as gastroduodenal perforation, bowel obstruction, diverticulitis and pancreatitis, laparoscopy had a less significant role. according to the year, a general tendency to increase the use of the laparoscopic approach was found, most notably in the cases of acute appendicitis and cholecystitis (with rates above % in ). conclusions: despite our positive results in the terms of the implementation of the laparoscopic approach in emergency surgery, there is still room for improvement, especially in regards of the less common pathologies. furtheremore, additional studies are needed in order to identify the factors that have had an effect, in favour or detriment, in the development of emergency laparoscopy in our center. aims: laparoscopic surgery, which produces small scars, has become widespread. when performing surgery through small laparoscopic incisions, a surgeon manipulates tools inserted into the abdomen through ports. for minimally invasive accurate procedure, the port as the pivot point should be stabilized on the abdominal wall. however, these laparoscopic incisions are loaded while manipulation because it is difficult for the port to be fixed on. thus, it is necessary for the patient friendly manipulation to be fixed the port mechanically. we developed a new pivot restraint device (prd) attached to a trocar for guiding the tool. the purpose of this study is to evaluate both of reducing the operating time and the load of the port with the prd experimentally. methods: the prd uses gimbal mechanism for two rotating axes and a linear guide mechanism for the insertion axis though into the forceps. in the experiment, the left hand forceps with or without the prd and the right hand forceps without the prd were set on the training box. the box had a measuring system created with a pressure sensitive sensor for the continuous force (resolution . n, fps) applied to abdominal wall fulcrum. the experiment task was performed as following three steps. ( ) the surgeon lifted the g weight for s at the initial position using the right hand forceps. ( ) the weight was transferred from the right hand forceps to the left hand forceps, and held for s. ( ) the weight was moved to the predetermined position, held for s, and returned to the initial position. the surgeons were five endoscopic specialists and five non-specialists. the operating time and the time ratio exceeded n for the left hand forceps were measured. two grouped datasets with or without the prd were compared using two-sided t-test. results: the prd was associated with both of reducing the operating time ( . s vs. . s; p \ . ), and the load of the port ( . % vs. . %; p \ . ) at the statistical analysis. conclusion: the prd could be used for reducing the operating time and the load of the port in minimally invasive accurate procedure. background: pathophysiological changes during laparoscopic surgery and positive pressure pneumoperitoneum (pp) may include (beside cardiovascular changes) elevated intra-thoracic as well as intracranial pressures. however, the possibility of physiological and functional cerebral impairment under pp is still debated. aim: to study the effects of pp on brain activity during different modes of anesthesia and ventilation during laparoscopic cholecystectomy (lc). patients and methods: thirty patients undergoing elective lc were divided to those who were ventilated by intermittent positive pressure ventilation (ippv, pt.) and by high frequency jet ventilation (hfjv, pt.). in those under hfjv we used total intravenous anesthesia (tiva). in those under ippv we either used inhalational anesthesia or tiva. intra-ocular pressures were detected in both eyes, trans-cranial doppler was used to measure the changes in flow of the middle cerebral artery, and cerebral oxygenation (o saturation) was measured too. each parameter was detected during anesthesia before surgery, several times during surgery under pp and after co evacuation. a novel computerized signal analysis by a continuous recording through a single electrode was done to explore cerebral cognitive activity during surgery. results: all surgeries went uneventful and without complications, pp was set to mmhg, and each patient was positioned in a degree anti-trendelenburg posture. cerebral perfusion and oxygenation were not changed significantly during pp. intra-ocular pressures decreased during anesthesia and increased during pp, but to a lesser extent under tiva. however, pressures during pp did not exceed pre-surgical values. we did not observe changes in cognitive brain activity during pp, although enhanced cerebral activity was seen under hfjv. conclusions: increased intra-abdominal pressure during laparoscopic surgery was not accompanied by decreased cerebral functions, maybe due to cerebral circulatory auto-regulation. changes in cerebral cognitive functions under hfjv might be explained either by the different cerebral effects of tiva in comparison to inhalational anesthesia, or due to dissimilar hemodynamic changes during hfjv. aims: gallstone ileus (gi) is a rare complication of cholelithiasis and accounts for . - % of small bowel obstructions. intermittent and non-specific presentation often results in late diagnosis. the triad of rigler is pathognomonic (pneumobilia, small bowel obstruction and ectopic gallstones), so an image test is usually mandatory in order to assure the diagnose. our aim is to expose our experience regarding this topic to show that a minimally invasive approach is feasible in selected cases. methods: since january we treated cases of gi, of whom ( %) underwent laparoscopic surgery. in all cases a ct was made to reach diagnosis. enterolithotomy alone is our preferred procedure for the resolution of this pathology. here we present a descriptive analysis of our data in those cases where a laparoscopic treatment was attempted. epidemiological variables, surgical technique, postoperative complications, days until hospital discharge, recurrence, etc. has been collected. results: % of patients were female( ) and % male ( ). mean age was . size of gallstones varied from to mm and ct located them all in the ileum. two conversions to open surgery were made ( %), in one case because the gallstone could not be found and in the other case due to the need of an intestinal resection. in two cases ( %) la aparoscopic-assisted surgery was performed using a pfannestiel incision for the gallstone extraction and enterorrhaphy. only one case was total laparoscopic approach ( %). two cases needed an intestinal resection and anastomosis, one of them was complicated with a leak that needed reintervention. there were two cases of recurrence during the follow-up time. hospital stay varied from to days, mean of days. conclusion: the widespread use of ct facilitates early diagnosis with high sensitivity detecting rigler's triad. a totally laparoscopic procedure might be ideal for patients specially with solitary stones even though a laparoscopic-assisted approach is an easier technique for surgeons with less experience in laparoscopic surgery. although experience in minimally invasive surgical treatment of gi is still developing, it may be recommended in selected cases and experienced hands. introduction: most of surgical interventions in hospitals in the world, where laparoscope is used, it is common that the vision inside the human body is constantly interrupted by fogging in laparoscope tip. the laparoscope fogging is caused by the difference of temperatures between the optic tip and the abdominal cavity. material and method: we replaces the traditional laparoscope for the ehs (endoscope heater system) with resistance between the internal and external tube that maintains the temperature of laparoscope at ( - °celsius) without modifying the external architecture of traditional laparoscope. results: ehs does not generates any waste like other anti-fog systems, like liquids, plastics covers or electric heater. reduces intervention time, can keep same instruments or accessories for the intervention. all of the above means a saving of resources with have a positive environmental impact. conclusions: the discomfort transmitted by surgeons about the fogging in laparoscopy tip make success of the product and it will replace the current laparoscope which is fogged. aim: synchronous locally-advanced low rectal cancer and prostate adenocarcinoma represent a rare condition and a challenging situation for colorectal surgeons and urologists. the simultaneous resection of both adenocarcinomas after long-course chemoradiation therapy combines two major surgical procedures associated with a potentially increased postoperative morbidity. in the other hand, simultaneous resections minimize the risk of difficult dissections, which are expected if the two procedures are scheduled sequentially. in the past decade, robotic-assisted minimally-invasive surgical techniques have been increasingly used to treat both rectal and prostatic malignancies. especially in case of prostatic malignancy, the robotic approach is considered the treatment of choice because it is associated with significantly lower blood loss and transfusion rate, and much greater functional outcomes compared to laparoscopy. methods: we present the case of a -year-old male patient (bmi: . ) diagnosed with a histologically proven locally-advanced rectal adenocarcinoma (ct an ) located at cm from the anal verge and concurrent histologically proven prostatic adenocarcinoma [gleason score of ( ? )] located in the postero-basal right lobe. the preoperative total-body computed tomography (ct) scan showed no evidence of metastatic disease. after discussion in a multidisciplinary meeting, the patient received a long-course neoadjuvant chemoradiation therapy (ncrt). at the restaging positron emission tomography / magnetic resonance imaging (pet-mri), the rectal lesion was classified as ymrt n . preoperatively, the surgical difficulty was assessed as high, based on the calculation of the eumarcs score (equal to / ). moreover, due to the high-risk status of the prostate cancer (gleason ), it was decided not to preserve the neuro-vescular bundles during the radical prostatectomy. results: the patient was operated on after weeks from completion of ncrt by using the da vinci robot system si with a single docking approach, as previously described, in order to address both cancers. conclusions: this video shows the main surgical steps of the simultaneous robotic resection of the low rectal adenocarcinoma first, of the prostatic carcinoma then, and the mechanical colo-anal anastomosis followed by drain positioning and ileostomy. this video demonstrates the perioperative safety and feasibility of the minimally invasive robotic approach in case of extended and challenging oncologic resections. general surgery, rambam medical center, haifa, israel year old, male patient presented with melena, without abdominal pain, nausea or vomiting. patient underwent colonoscopy and tumor was found in ascending colon (near the hepatic flexure). biopsy from the tumor has showed moderately differentiated adenocarcinoma. his blood laboratory examinations were within normal limits except of hgb level- . . cea and cea - were normal. abdominal computed tomography was normal . patient underwent da vinci robot-assisted right hemicolectomy with extracorporeal anastomosis. total operating time was min. three days after operation patient started regular diet and was discharged home on day four. final pathology result confirmed diagnosis of moderately differentiated adenocarcinoma. introduction: one of the goals of colorectal surgery is to decrease the number of leaks once an anastomosis has been performed. this life-threating entity after elective surgery has been related to the clinical history of the patients, the location of the tumor and to technical reasons, specially due to tension in the anastomosis or to lack of vascularization. tension could be identified during surgery, while vascular supply is evaluated by the surgeons based on a subjective analysis of the color of the colon/ileum. fluorescence tries to make these subjective parameter more objective in order to avoid an anastomosis with lack of vascularization, decreasing the numbers of leaks related to this factor. patients and method: the study presents a quasi-experimental analysis made from january to october in two hundred and eighty-five patients who underwent elective colerectal surgery, performing either a colo-rectal, ileo-rectal or intracorporeal ileo-colic anastomosis. vascular supply was eveluated using indocianyne green (icg) in one hundred and forty-five patients, while one hundred and forty subjects were operated in a previous period without using this technology, being considered the control group. the number of time that the attitude changed and the number of leaks were collected. results: out of the cases performed, were right colectomies (rc), left colectomies (lc) and rectal excision (re). in % the transection line was changed ( , % in rc, , % in lc and , % in rr) . in comparison with the control group, the icg group had a significantly less indicence of anastomotic leak compared to the control group ( , % vs. , %, p = , ), lower rate of terminal stoma after reoperation ( , % vs. , %, p = , ), a shorter length of hospital stay ( days vs. days, p = , respectively), and a low morbidity and mortality. conclusions: the rate of leaks after colorectal surgery decrease using icg to detect the proper transsection line before to perform the anastomosis in comparison with control group. these findings might influence in the final results although it is necessary in the future to find a system that provides greater objectivity by quantifying icg. aims: anastomotic leaks continue being one of the most important complications when a colorectal surgery is performed. this complication is usually related to the level and type of resection, the patient clinical history and surgical technique, where tension and vascular supply are the most important. indocyanine green (icg) fluorescence angiography seems to be helpful in order to evaluate the vascularization at the resection margins. methods: we have collected data on colorectal procedures that were performed by the same surgeon using icg fluorescence angiography to evaluate vascular supply to the anastomosis. in order to asses in which of the different type of colorectal procedure has more value to be used, we analyzed the type of surgical procedure, the percentage change in the resection margin and the number of anastomotic leaks (al). results: all of the cases were performed by laparoscopic approach: left colonic resection (lc), right colonic resection (rc), splenic flexure partial resection (sf), low anterior resection with partial mesorectal escision (lar), ultra low anterior resection with total mesorectal escision (ular) and total colectomy (tc). there was a change of transection line (ctl) in lc ( , %), rc ( %), sf ( , %) and ( , %) in rectal anastomosis (lar, ular and tc). as far as al we found: lc ( , %), rc ( %) and , % in rectal procedures. lc, sf and rectal procedure showed more ctl and less al, while rc showed less ctl and more al. conclusion: icg fluorescence angiography as an additional tool to try to reduce the anastomtic leak rate seems to have more value in the procedures that involve the left colon and the rectum, since that is where we have observed the greatest number of ctl, this could be explained by the riolan's arcade and the variability of the vascular anatomy. however, it seems that this is a line of research should continue developing with longer and larger studies, so in that way we can have more significant results. retrorectal tumors ara rare and often found incidentally. the majority of retrorectal tumours are benign, but they have potential for malignant transformation and therefore should be resected when found. a case of a -year-old female patient with a retrorectal tumor is showed. the tumor was found incidentally on ct scan of the abdomen for evaluation of non specific right side abdominal pain. a mri was also performed and imaging was informed as a probably congenital retrorectal tumor (tailgut cyst) there was no evidence of involvement or invasion of other structures the tumor was palpable at rectal examination. a transanal minimally invasive surgery (tamis) approach was proposed. preoperative preparation was done with a full mechanical and oral antibiotic bowel preparation. preoperative parenteral antibiotics werw administred. under general anesthesia, lithotomy position. the contour of the tumor is not visible due to the small size. palpation of tumor and placement of clips to lolocate was done. placement of gel point path and rectal insufflation. a longitudinal incision was made to the posterior left side of rectal wall. the insufflation of the perirectal extraperitoneal space allowe for excellent exposure of the tumor. the tumor was disected with ligasure. then the tumor was extracted transanally.the proctotomy was closed in a single layer with reabsorbible monofilament continuous suture (pds). no complications after the procedure. the patient was discharged at days. discusion: traditionally, the retrorectal tumors have been resected using a posterior parasacrococcygeal approach, an abdominal approach or a combined abdominal and posterior approach. with the advent of minimally invasive surgery, laparoscopyc approach has been described too. however, tamis approach is feasible, with low pain, morbidity, fester recovery and excellent cosmetic (no scare) results. it can be accomplished using standard laparoscopic equipment, with transanal access. we think that perhaps it could be the gold standar approach for this tumors. aimes: robotic-assisted laparoscopic surgery (rals) is a promising advanced technology that can overcome the inherent limitations of conventional laparoscopic surgery (cls). its advantage includes free-moving multijoint forceps, a motion scaling function, high-quality three-dimensional imaging, and stable camera work by an operator. this study aimed to clarify the short-term outcomes of rals for rectal tumors. methods: this study group comprised patients who underwent rals for rectal tumors (cancer in patients and gastrointestinal stromal tumor in patient), excluding ones with distant metastasis from november through december . the clinicopathological findings and short-term outcomes in rectal tumors were analyzed. results: the median operative time was min ( - ). the median console time was min with a median blood loss was ml ( - ). conversion rate was . % ( / ). the median postoperative hospital stay was days ( - ). patients ( . %) had postoperative complications. patients ( . %) had lymph nodes metastases. the mean harvested lymph node was . . the r resection rate was % ( / ). conclusions: these results suggest that rals for rectal tumors is safe and feasible, and the perioperative outcomes are acceptable. introduction: anastomotic healing defects are a feared complication which might have a fatal impact on the patient. fundamental conditions for proper anastomotic healing include sufficient blood supply. fluorescent angiography using indocyanine green in the spectrum of near infrared light facilitates the monitoring of tissue perfusion during a surgery. aim: a presentation of the results of our non-randomized study in which we assessed prospectively obtained data from a perioperative assessment of anastomosis perfusion by fluorescent angiography using indocyanine green during robotic rectal cancer surgery. method: thirty patients with rectal cancer, who underwent a robotic resection with primary anastomosis, were consecutively included in the study between april , and june , . the study included patients facing a least invasive surgery with a guaranteed payment by a health insurance company. during the surgery, we monitored and assessed the quality of the perfusion of the resection line of the sigmoid colon and subsequent anastomosis by means of fluorescent angiography using indocyanine green in the spectrum of near infrared light. the data were obtained prospectively and subsequently analyzed. results: between april , and june , , we consecutively included rectal cancer patients in the project: men and women. monitoring of the perfusion of the resection line and anastomosis was successful in all cases and perfusion quality was satisfactory across the sample. perfusion insufficiency requiring a change in the resection line level or anastomosis adjustments was not detected with any patient. in two cases ( . %) of tme, we gave up the planned protective ileostomy owing to quality perfusion of the anastomosis. one patient ( . %) suffered from defective anastomosis healing without clinical symptomatology (type a). we found no technical complications related to fluorescent angiography or undesirable effects due to the application of indocyanine green. conclusion: even though we did not register insufficient perfusion in our sample and hence we did not have to change the resection line level or adjust the anastomosis, we may state that fluorescent angiography performed by an experienced colorectal surgeon may potentially reduce the frequency of complications linked to defective anastomosis healing.supported by mo aims: the aim of our study is to demonstrate whether robotic surgery has any influence on the reduction of complications in the aged population undergoing rectal cancer. methods: we performed a retrospective analysis of a prospective database of patients who underwent robotic surgery for rectal cancer. we divided our population in groups: under year old, between and year old and above year old. we recorded complications in each group intra and post procedure. qualitative variables were expressed in terms of absolute frequencies and percentages and mean values and standard deviation were used to express quantitative variables. the analysis of data was applying fisher's exact test or chi-squared test for qualitative variables and variance analysis or student'-t test for quantitative variables. statistically significant values of p \ . underwent multivariate logistic regression analysis. results: the present study included patients ( males).seventy seven patients were under year old, patients were between and year old and patients were above year old. the analysis showed conversion rates of . %, . %, . %, and complication rate of . %, . %, and . % in each group. univariate analysis showed no differences between the three groups. nevertheless, there were statistical differences from bmi, asa and neoadjuvant therapy. in multivariant analysis only neoadjuvant therapy was significant. conclusions: robotic approach do not decrease complications in elderly population. introduction: it has been described the advantages of total transanal mesorectal excision (tatme), with better visualization and access to the lower rectum. we use this access whith the gel point path device, to repair a rectovaginal fistula with stenosis of low rectal anastomosis in two patients, that would be difficult by conventional abdominal approach method: we show our surgical technique for repair a rectovaginal fistula with stenosis of low rectal anastomosis in two female patients operated due to rectal neoplasia. one of the patients underwent prior chemo-radiotheratpy. rectoscopy and image test was performed at the patients prior the intervention. no recurrence signs are recorded at mri.we describe the operation technique: a new anterior rectal resection was performed with a combined transanal (gel point path) and abdominal minimally invasive approach. redo anastomosis whith eea stappler was performed, vaginal repair and epiploplasty. the intervention was especially laborious due to the fibrous tissue. pathology: fistulous path without tumor infiltration in the two patients. at two months, a opaque enema show permeability and absence of leaks in the two patients. the ileostomy was closed at three months. discusion: we believe that transanal access through the gel point path can be a good option for rectovaginal fistula and stenosis of low rectal anastomosis, allowing a better visualization and acces, and making more easy a very difficult intervention. introduction: tamis or transanal minimally invasive surgery for polyp resection has increased fame for several situations in which adenomas with or without dysplasia cannot be removed with conventional colonoscopy. in this video we show the step by step technique performed with the da vinci xi system. material and methods: in this video we show the setting and the location of the patient-side cart and the arms to perform the resection of polyps in different patients and how to develope the procedure. results: after placing the patient-side cart the arms are connected to ports and the camera, double fenestrated grasper and scissors are connected to the arms through a transanal gel-port device. a line is described around the polyp with monopolar energy to determine the place of the dissection. the scissor is exchanged by a robotic harmonic wrist instrument and the complete dissection is performed. the wound is closed using a robotic needle holder and a suture. results: transanal robotic surgery could be safely performed after a standardized technique is stablished. aims: robotic rectal cancer surgery has demonstrated to obtain at least the same results than laparoscopic surgery. however, robotic surgery is associated with high rates of costs, specially when conversion to opened surgery occurs. the goal of this study is to create a predictor nomogram of conversions for robotic rectal cancer surgery. methods: we performed a retrospective analysis of a prospective database of patients who underwent robotic surgery for rectal cancer from october to november . we performed a bivariant analysis and detected the variables which were related with the conversion: body mass index (bmi) and the t. we divided the patients of the population in two groups depends on obesity (bmi of kg/m ) and on t (t - /t - ). we registered conversions in each group calculating the pretest risk. we performed likelihood index (lr ?/-) for under and above kg/m of bmi, adding in a second step the lr of t; obtaining the prediction index for four groups by using a standardize nomogram. results: the present study included patients ( males). were under bmi of kg/m and above. regarding t, were with a tumor of t - and with t - . the analysis showed a conversion rate of the statistical sample of %. univariant analysis showed significative differences in the bmi (p = . ) and t (p = . ). a nomogram was performed; as regards the bmi, the positive likelihood index in the group of bmi [ a prediction index of conversion of % (lr ? , ) and in bmi \ the prediction index of conversion is % (lr- , ). adding the t group data, for bmi [ and t - the conversion prediction rate is . % (lr- , ); for bmi [ and t - the conversion prediction is % (lr ? , ). bmi \ and t - the conversion prediction is % (lr- , ); imc \ and t - , the conversion prediction is %. conclusion: a standardize nomogram with the variable bmi and t facilitates the selection of patients for robotic surgery in rectal cancer avoiding conversion to open surgery. background: d-laparoscopy is proven to improve performance in dry laboratory settings, especially for novice surgeons due to better depth perception. however, the benefits for experienced laparoscopic surgeons are still discussed. aim: the aim of this study is to compare the results of right hemicolectomy (rc) using a conventional ( d hd) laparoscopic system with rc performed using a d laparoscopic system in terms of duration, complications and results. material and methods: from all laparoscopic right hemicolectomies performed in our clinic we selected all procedures performed by the same team of consultant surgeons using the same technique and divided them in groups. the study group comprised of all patients operated using our d einstein vision . system; all other patients which were operated using our standard wolf hd laparoscopy system comprised the control group. all patients were retrospectively analyzed in terms of patients characteristic, or time, duration of operation, intra-and postoperative complications, length of hospitalization, pain score, necessity of analgesics and number of lymph nodes retrived. risk factors for complications (bmi, smoker, diabetes, copd, bph) were also registered. results: there were patients included in the study group, while the control group comprised of patients. mean operation time in the study group was . min in the study group, while mean or time was . min. mean operation time in the control group was . min, while mean or time . min. one reintervention was noted in the control group and two in the the study group; no conversion to open surgery was noted. there were no significant differences regarding patient characteristics, pain score, wound complications, hernia rate, length of hospitalization or number of lymph nodes removed. conclusions: there were no significant differences regarding the outcome of rc using d laparoscopy; total or time was significantly higher in the study group due to the time needed to set up the d-laparoscopy unit. this is biased by the fact that the d system needs to be set up manually while the conventional hd system is integrated in the or. also, there was no significant difference in complication rate. background/purpose: robotic approach can be a treatment option for patients with pelvic recurrence after primary resection for rectal cancer. however, data regarding patient selection, complication rates, and oncologic outcomes are rarely reported. we aimed to present initial experience and to evaluate feasibility, safety, and oncologic outcomes of robotic salvage surgery for recurrent rectal cancer. methods: ten patients who underwent robotic salvage surgery for local recurrence at the anastomotic site, lateral pelvic side-wall, or lateral pelvic lymph nodes (lpns) were retrospectively evaluated from a prospectively maintained database. results: two patients underwent pelvic mass excision with en bloc resection of anastomosis and redo-anastomosis, and eight patients underwent lateral pelvic lymph node dissection (lpnd) for lpn metastasis; one of these eight patient underwent additional en bloc resection of anastomosis. all patients achieved r resection. the median operation time was min and the median estimated blood loss was ml. there were no conversions. as for intraoperative complications, one patient experienced ureter injury during lpnd because the metastatic lpn was closely abutting to the ureter. the median hospital stay was days. in six patients who underwent lpnd, the median number of harvested lymph nodes was (range - ) and the median number of metastatic lymph nodes was (range - ). with median follow-up months, one patient developed lung and pelvic recurrence at months after salvage operation and seven patients remained in disease-free state at the last follow-up. conclusion: initial experience of robotic salvage surgery for pelvic recurrence in rectal cancer indicated that it is safe and feasible. therefore, the robotic approach can be considered as a treatment option for the treatment of local recurrence in selected patients. introduction: there is uncertainty regarding the effects of simulated patient death. several reports showed increased cognitive load and poorer learning outcomes, and others increased performance without causing stress to learners. we have not found any report studying the impact of animal death in the simulation lab. methods: this was an observational cohort study to assess the emotional and cognitive load of surgeons who experienced animal death in the simulation lab. seventy-four faculty and residents from different surgical specialties training minimally invasive surgery participated in the study. one cohort consisted of surgeons whose animal died during surgery, and the other by those whose animal survived. emotions were assessed using the scale for mood assessment and cognitive load with nasa task load index. results: twenty percent of participants experienced mortality while training anti-reflux surgery ( cases) and other procedures ( cases). causes of death included intraoperative pneumothorax (n = ), hemorrhage (n = ), and cardiac dysrhythmias (n = ). participants exposed to animal death had higher levels of sadness and anxiety, and lower levels of happiness (p [ . ). cognitive load was slightly higher in the exposed cohort (p [ . ). conclusions: these findings suggest that mortality in the animal lab do not have a significant effect on cognitive workload and emotions of surgeons training complex laparoscopic procedures. introduction: the visuospatial profiles of expert laparoscopic surgeons remain unaccounted in the current literature for as the influence of visuospatial ability on laparoscopic learning has mainly been investigated in medical students or novice surgeons and using simulators as means of performance measurement. such knowledge is critical, as without understanding how clinical experience may impact visuospatial processes in surgeons, we hinder our efforts to utilize the available knowledge to support surgical education for the future. this study is aiming to explore the development and influence of visuospatial processes on intraoperative laparoscopic learning. method: the study reports the interim baseline results from the ongoing longitudinal study throughout a -year period of training on laparoscopic surgery. data from surgeons including residents undergoing training were captured and compared to specialists who are working in departments of general and visceral surgery at two large hospitals. the mean experience of the surgical residents was years. the mean laparoscopic experience among the senior surgeons is years, with each surgeon performing an average of laparoscopic procedures per week. visuospatial ability was tested using mental rotation test (mrt), guay visualization of views tests (gvvt), spatial perspective taking and spatial orientation test (ptost) and pictorial surface orientation (picsor). spearman correlation coefficient was used in this study with a p-value of significance at \ . . results: senior surgeons have an overall good visuospatial profile, in the sense that they performed close to optimum on all measurement scales. the spearman rho revealed a significant correlation between scores on gvvt and picsor (r = . , p = . ) and between ptost and picsor (r = -. , p = . ). a significant correlation between years of laparoscopic experience and ptost score was also observed (r = . , p = . ). when comparing residents and senior surgeons, no significant difference on the mrt was observed (m = . , sd = . ), nor between baseline scores of senior surgeons and resident surgeons on all tests. conclusion: the results of this study carry important clinical and theoretical implications, as the results hint towards the idea that intraoperative laparoscopic experience lends little to no influence over the development of visuospatial ability. learning models and laparoscopic technical skills, how to adapt each case to improve objectives: according to da. kolb learning is the result of how people perceive and then process what they have perceived. the aim of this study is to identify the personal characteristics of learning in of the participants in a course of laparoscopic technical skills according to the styles described by kolb. methods: between june and november , participants performed a h course distributed over five consecutive days performing laparoscopic manual intestinal anastomosis in endotrainer. they all filled in kolb's learning style test adapted to spanish. the anastomoses were performed in 'ex-vivo' swine intestines. in each anastomosis we evaluated the quality at the end and execution time. the test and quality variables were analyzed through statistical studies. results: in our study, % of the participants were women and % wew men. %were staff surgeons and % were resident. the median age among residents was years and among the staff years. the most frequent learning model in the sample studied was converging ( %). the predominant model among women was assimilating ( %), which, however, represented only % in men. in men, converging model was predominant ( %). among the staff, the most frequent model was diverging ( %). adaptation style prevailed among residents ( %), being rare among the staff ( %). the mean time of the anastomosis was min for both the adapter model and the assimilator, min, for the convergent and divergent models. the quality of the anastomosis performed by each participant was % for the adapter model, % for the assimilator model, % for the convergent model and % for the divergent model. the predominant style in our study was convergent. among women, the most frequent model was assimilator wheras in men it was the least frequent. in the residents, the most frequent model was adapter however, it was very rare in adjuncts. among residents we do not find divergent styles. the highest quality of the anastomosis was achieved by those who worked with an assimilating style. knowing previously the training style we can individualize the teaching methodology in order to improve competences. aims: assess whether laparoscopic appendicectomies (la) are a superior option to open appendicectomies (oa). specifically, comparing the time taken, complication rates and whether it is more appropriate to perform an la overnight, as opposed to oa. finally, to find out how a range of outcomes differs between different grades of surgeon. methods: an information request was sent to the clinical coding department to derive patient identification numbers for all appendicectomies over a ten-month period ( total surgeries). these numbers were then inputted into the hospital information system where the electronic operation note is present, and specific outcomes were derived and analysed. results: % of operations were oa and % were la. mean la times for consultants, sas and spr were . , and min respectively and oa , and min respectively. their respective conversion rates were %, % and %. oa had a complication rate of . %, la was . %. conclusion: oa are performed more than la. spr doctors had the slowest completion times for la but the lowest conversion rates. sas doctors had the fastest completion times for la and oa but higher conversion. la takes longer than oa but has lower complication rates; key factors when performing at night. key statement: laparoscopic appendicectomies require more surgeon-hours and have the potential to be converted to open, however the rates of complications and serious complications are significantly lower. background: paper based resources have been the standard sources for information for centuries. however, more and more people (patients and staff alike) are looking online for information. while the internet often provides excellent resources, there is often conflicting and confusing material of doubtful veracity. trainee staff and patients/carers should be able to access reliable resources whenever and wherever they are. the aim of this project was to create a high-quality resource fulfilling these needs. aim: we present a video demonstrating our integrated colorectal education website ( http://www.colorectaleducation.com/). our approach: high quality health care provision requires highly trained staff as well as wellinformed patients. information resources for these two groups are usually accessible from different repositories. our integrated website provides a common platform for all those involved in colorectal surgery, to use, learn and reflect on. users are directed to separate sections for patients and colorectal professionals. multiple disclaimers prevent patients accidentally stumbling across clinical/ operative information, whilst providing access to those who wish to do so. trainees struggle with balancing their educational needs with their service commitments. this website gives them the opportunity to view detailed operative training videos on the go. many of videos are chapter based allowing them to stop and re-start with ease. modules are also available for nurses providing them access to relevant educational material. the modular design of the website allows us to build upon it with more topics planned to be added over the next eighteen months. the resource also has detailed chapterised videos for patients due to undergo various colorectal procedures. all have been approved by a multi-professional panel including patients and are designed to provide information, offer support and to allay any anxiety. videos with the care pathway and previous patients' experiences are accessible on demand. conclusion: on demand information has now become the norm with the use of smart phones/ tablets. this website provides patients, surgical trainees and other healthcare professionals access to information and education in a clear and reliable format anywhere in the world. colorectal education, on demand and just a click away! objective: in the last decade the growing interest in robotic surgery is evident as shown by several published articles. the aim of the present study is to evaluate the main outcome of a single center experience and to describe the organizational system we have progressively established in our center in order to improve the development of robotic program in all surgical area. materials and methods: we report a case series of patients who underwent robot-assisted surgery at sanchinarro university hospital since the beginning of the program (october ) until november main patient demographic characteristics, type of surgery, peri and postoperative data and follow-up were evaluated. results: a total of robotic procedures were performed for a total of patients. the prevalence of malignant disease was %. a total of pancreatic surgery were performes; liver resections (mean operating time: min); gastrectomy (mean operating time min); esophagectomy (mean operating time: min); colorectal resections ( rectal resections, sigmoidectomy hemicolectomies right, left colectomy) (mean operating time: min); nissen procedures (mean operating time: min), esofagheous myomectomy for achalasia (operating time: min); adrenalectomy (mean operating time: min); three biliary surgery for benign desease, splenectomy. eight partial resection of the duodenum, one yeyunal resection, one mesenteric cyst resection and retroperitoneal tumor have been performed. conversion rate was %, total morbidity have been %. there has been no peri and postoperative mortality up to days after surgery. the average hospital stay and intensive care were respectively days (range - days) and . days (range - days). conclusions: the organizational model defined in our center is facilitating the constant and progressive development of the robotic program. a broad and flexible availability of the robotic system, a progressive increase of young surgeons joining this technology as well as the institutional and departmental economical effort are the points with which the robotic system may increase its development in a surgical department. aims: endoscopic surgery has been widespread in the field of general surgery. however, in japan, there is no standard program for endoscopic surgery training, and its competency has not been considered for the acquisition of board certified surgeon. the purpose of this survey was to investigate the current situation of endoscopic surgery training and autonomy of young surgeons for endoscopic surgery in japan. methods: the survey was planned to target general surgery members of the japan society for endoscopic surgery (jses) who was post graduate year or less. after approval by the ethics committee of jses, the request for the participating in survey was mailed to object members. questionnaire responses were available in print or online media. the contents of the questionnaire consisted of items, about the conditions of endoscopic surgical training, experienced case number, and the self-assessment of autonomy from to point by zwisch scale in specific procedures of endoscopic surgery. results: the total response rate was . % ( / ). sixty five answers were excluded due to inadequate response and answers were analyzed. of the questionnaire respondents, % were male and % were female. the ratio of board certified surgeon was %. although % of the teaching hospitals had simulators for basic training of endoscopic surgery and % of the respondents practiced basic skill of endoscopic surgery, only % teaching hospitals had specific training programs for endoscopic surgery. the surgeons who operated cases of laparoscopic appendectomy and inguinal hernia repair and cases of laparoscopic cholecystectomy, right hemicolectomy and sigmoidectomy, felt confident to perform each procedure independently. regarding with laparoscopic rectal resection and gastrectomy, even though the surgeons who had cases of experience, they didn't had confidence to perform those procedures independently. conclusions: this study is the first national survey to investigate the status of endoscopic surgery training in japan and the autonomy of young surgeons for endoscopic surgery. in order to develop a training system for not only basic skills but also advanced procedures of endoscopic surgery, cooperation of each teaching hospital, academic surgical society, medical specialty board is necessary. currently there is a debate about what is the most optimal work schedule for residents of general surgery, it is important to respect the free time of residents to avoid burnout, however it is also important have enough exposition to clinical cases that allow a satisfactory development in the clinical practice. this becomes even more important when we talk about the learning of surgical skills. this is where the laparoscopic simulation industry opens a large area of opportunity, for a reasonable price it is possible to practice basic laparoscopic skills without compromising patient safety. this is a pilot study that was carried out during the period from january to june , in a public hospital in monterrey, nl, mexico, the composition between the execution of the standardized exercises of the fls (fundamental laparoscopic surgery) in an endoscopic simulator was performed to residents of general surgery (from first to fifth year) hrs before being on call vs these same residents post call. a series of questions was asked to each resident in each measurement, so in this way they answered the same questions twice, then a comparison of the results of both questionnaires was made. the results of the exercises were assessed and rated by the same person using the criteria established in the fls for the scores of each exercise and for the final grade. an average age of years was obtained, measurements were taken of residents of which are male and female. on average, the residents before be on call performed the exercises with h of having slept while the post call performed the exercises with . h of having slept, the residents before be on call had on average . h without sleep while the post call had h without sleep. the average number of hours worked per week is h, measured by the time in and out of the hospital. in this study, conclusive results were obtained regarding the null relationship of sleep deprivation with the performance of laparoscopic skills in surgical residents. aim: 'precision cutting' is one of skills tasks of the fundamentals of laparoscopic surgery (fls) program, which is cutting a circle on a piece of gauze under laparoscope and assessed by completing time (maximum time limit: s). there is no definition of quality of the final product. the aim of this study is to develop an assessment tool of laparoscopic precision cutting and test its reliability. method: an assessment tool of laparoscopic precision cutting was developed with four items based on completion, degree of deformation, degree of being pulled, and overall appearance of the final product of laparoscopic precision cutting by experts' meetings. the scale of each item was points likert scale. a descriptive sheet with a legend and a text description for each scale (fig) was attached for assessors' reference. for our high school entry medical students, they gained hands-on experiences of laparoscopic skills first time by attending a -hour course at minimally invasive surgery training center, national taiwan university hospital (ntuh). we invited students to participate this study after this training. we collected participants' final products of ' precision cutting' station and assessed them by using this assessment tool. this study was proved by institutional review board, ntuh (irb no: rinb). results: students were enrolled between february to june . two non-medical assessors and a senior surgeon were invited to assess the products. the mean score and cronbach' s alpha value of each item were as followed: completion . ± . , . ; degree of deformation . ± . , . ; degree of being pulled . ± . , . ; and overall appearance . ± . , . . conclusions: in summary, we successfully developed an assessment tool for laparoscopic 'precision cutting' and showed its reliability. the tool could provide qualitative descriptions for objective feedbacks. validating this tool in a large scale is undergoing. purpose: to evaluate whether the participants who experienced this scenario could recall an interventional scenario for testing trainees' situational awareness and intra-operative decision making when they participated this training again. methods: we designed an iodm training course for junior surgical trainees and nurses by using live pigs since sep . in the first simulation, we created an interventional scenario and then provided an educational session. a researcher disconnected the ekg monitor on purpose for creating a scenario that the pig would lose vital signs when the team nearly finished a diagnostic laparoscopy. if the team did not aware the situation after . min, a researcher would remind the team (fig). we used a new developed assessment tool of iodm and an assessment tool for nontechnical skills for surgeons (notss) for self-evaluations and objective assessments. we also discussed with them about their reactions while encountering this interventional scenario. results: between sep to june , teams participated this training and experienced this interventional scenario. fourteen nd year surgical trainees have experienced it before. only one participant ( %) recalled it and made a quick decision while encountering this interventional scenario again. the results of iodm assessment and notss did not show statistical difference comparing their self-assessments in the first and second year. based on the analysis of the discussions, most of them remembered this this interventional scenario and reminded themselves to react it properly before the simulation. however, when they were the primary surgeon of diagnostic laparoscopy, they focused on performing this procedure and tutoring their junior trainee. they had no capacity in their brain to notice the change of vital signs. in addition, although they increased their situation awareness in clinical settings after the st time iodm training, they did not show this ability in the simulation. conclusions: recalling of an interventional scenario for testing situational awareness of surgical trainees was very poor ( / , %) among the nd year surgical trainees. qualitative analysis of discussions showed their brain capacities were occupied by performing new procedures and tutoring others. how to enhance trainees' situational awareness should be addressed. aims: a well-designed learning curve is essential to measure the progress of surgical abilities. learning curves are very important to test the skills of trainees. however, there are still no welldefined criteria for developing good learning curves. as a result, many authors use subjective evaluation criteria. the purpose of this review is to analyse this field of surgical education and to identify the key criteria for good learning curves. methods: learning curves were investigated in the field of laparoscopic and robotic minimally invasive surgery. surgery of appendectomy, cholecystectomy, cholectomy, inguinal hernia repair and gastrectomy were considered. the type of surgery, the year of publication, the design of the study, the surgeon's experience (resident, young or senior), the surgical technique, the number of patients involved in the study and the suggested learning curve by the different studies were taken into account. in the selection of articles, more importance was given to those based on the activity of young surgeons or residents. results: the literature analysis showed conflicting results. the different learning curves for the same surgery may be due to the different evaluation criteria considered. only a few studies investigate the learning curves of young surgeons and residents. conclusions: the data available in the literature on learning curves are contradictory. several factors need to be evaluated in order to create more accurate learning curves. we suggest the introduction of checklists with a score for each parameter to be examined, in order to develop more objective and standardized learning curves. aim: the uk training programme for transanal total mesorectal excision (tatme) has completed its first round of training. the study aim was to design a reporting platform that provided trainees with video-assisted feedback in a clear, concise and useful manner to support their training. methods: an established method of video analysis called observational clinical human reliability analysis (ochra) was used to assess the surgical performance of the trainees during their clinical tatme cases. a reporting form for the ochra results was designed identifying areas of difficulties in each procedure and providing error reduction mechanisms. this was piloted during the national training programme for tatme in the uk. results: the ochra reporting form underwent three modifications before the content and format was agreed upon. the final version is divided into three sections: a. case details, b. ochra findings, and c. suggested error-reducing mechanisms. for part b the tatme procedure was divided into four phases of the operation: . pursestring, . rectotomy, . tme dissection, and . connected phase when the abdominal and transanal teams work together synchronously. for each phase, ochra findings described the most frequently occurring technical inaccuracies/errors, number of consequential errors/adverse events and the most frequent and serious consequences encountered. suggested error-reducing mechanisms in part c were developed and established by an expert workshop and individual interviews with international surgeons experienced in tatme.trainee and mentor feedback stated that the reporting form had a clear format, easy to follow and understand. the error-reducing mechanisms were particularly useful and allowed the trainee to focus on improving specific technical aspects in their subsequent cases. conclusion: video analysis using ochra can provide a wealth of information on surgical performance, especially for trainees at the start of their learning curve. as an exploratory study, validation of the reporting platform is required; however, its potential to offer detailed, individualised feedback to enhance training is promising. laparoscopic pelvic surgery training program-using a new concept d-printed versatile pelvi-trainer r.c. elisei , f. graur , c. popa , e. mois , l. furcea , n. al hajjar general surgery, bistrita emergency county hospital, bistrita, romania; general surgery, regional institute of gastroenterology and hepathology ,,prof. o. fodor,,, cluj-napoca, romania pelvic laparoscopic surgery (rectal, urological, or gynecological laparoscopic surgery) is an advanced surgery which require advanced skills, not easy to acquire. there are a lot of training programs for advanced laparoscopic skills but many of them are not affordable for most of surgery residents in eastern europe, where the training programs are far behind from those in western europe. because of that those training programs need to be improved and optimized. in the european union we want equal and high skilled surgeons. this is why we designed a new concept of pelvi-trainer, a versatile one in order to offer the residents the possibility to achieve advanced laparoscopic skills like perfect coordination, precise movements, ability to cut and suture after a well defined route, all of them in the pelvis tight space. we d-printed this pelvitrainer which has multiple characteristics: cheap and easy to produce, easy to be used, versatile because offer the possibility to achieve the skills named above, and many others, but also to train on real ex vivo animal rectum (suine model). we also believe that with a proper training a medical student and a young surgery resident are able to achieve the same skills like experienced surgery residents or specialists. in order to demonstrate that we need a study to compare the time to perform or more exercises in this new concept pelvi-trainer by the medical students, young and experienced residents and surgery specialists. what we want to achieve with this training program project is to have more and more skilled surgeons in advanced laparoscopy and an equal laparoscopic surgery training all over the country, close to the level of training in the western europe. also we want this training program to make a standardization of the pelvic laparoscopic surgery training first in our country and then in other countries if possible. aims: the objective of this systematic review is to provide an evidence-based overview of the different components of laparoscopic training curricula, emphasizing the value of objective forcebased assessment and how this in implemented in modern laparoscopic training. methods: bibliographic databases of pubmed and embase were searched till april to identify studies reporting on evidence-based laparoscopic skills training. abstracts of retrieved studies were reviewed by two authors independently and those meeting the inclusion criteria were selected for full-text review. results: the search yielded a total of individual records. a total of articles were included. the articles were divided into nine different categories, which include 'metrics', 'benchmark criteria', 'measurement systems', 'timetable', 'training modalities', 'camera settings', 'training tasks', 'serious gaming', and 'competition'. a descriptive analysis of the data is provided. motion analysis parameters, such and path length and time are frequently validated and used for assessment. the results of validation studies on tissue manipulation parameters, such as maximum force and mean force show proved their discriminating power between different levels of proficiency. however, implementation of these metrics remain restrained. conclusions: numerous studies on laparoscopic skills training have been conducted over the years. nevertheless, no consensus is reached towards the use of objective assessment tools. although the value of validated metrics is described well, implementation of objective metrics is limited. we recommend to consider objective force-and motion metrics for feedback and assessment during laparoscopic skills training. surgery, regional institute of gastroenterology and hepatology, cluj-napoca, romania; anesthesiology, university of agricultural sciences and veterinary medicine, cluj-napoca, romania; radiology, regional institute of gastroenterology and hepatology, cluj-napoca, romania aims: the aim of the study was to create a new easy learning method of swine liver anatomy for residents in training. based on human liver surgical anatomy we put 'face to face' the similar structures and also the differences using ex vivo porcine models and ct reconstructions from live pigs. methods: having in mind the human liver anatomy, in the first stage we used data obtained from dissection of twelve porcine liver models to create an anatomical pattern, which summarized the most important surgical information. in the second stage, anatomical data obtained from ct scans of twelve living anesthetized pigs were analyzed. the ct reconstructions and volumetry data were added to the gross anatomy pattern to create a more complex learning module. results: the residents established the most frequent description of swine liver anatomy by putting together the information from ex vivo model dissection. the liver parenchyma is divided into four main anatomic lobes: left lateral, left medial, right medial and right lateral. all those lobes are connected only in the posterior part, which allows a very good separation between them by deep fissures. just as in humans, we found eight distinct segments with independent vascularization and biliary drainage. portal vein has a specific 's' shape; in most cases hepatic artery was found like a trifurcation and extrahepatic biliary tree has a very thin wall. in the right hemi-liver, the inferior vena cava passes through the liver parenchyma. most frequent, we found five hepatic veins which are running completely intraparenchymal. the imagistic data offered a very useful d reconstruction with anatomical positions of the vascular-biliary tree and liver segmentation and gave us the possibility to create practical scenarios for resections. perhaps the most important information was to discover and see the section plan and to calculate the volume of the remaining liver after resection. conclusions: the anatomical-imagistic pattern based on \ i[ex vivo \/i [ model disections combined with imagistic data offers a unique mindset before intervention. the concept 'human \ i[vs \/i [ swine' to create an easy method of learning for residents in training can be applied to swine liver anatomy. the learning of surgery is traditionally based on the behaviourist model . goals are set, standards of care fixed, with regular assessments of the level achieved. the teacher exercises control over the student, imposing rules and models, supported by 'reinforcing' actions (reward or punishment). the theory of skinner's program of education, from , is reflected in surgical learning. it foresees a gradual progression by level of difficulty, following a transmission-imitation model . these theories seem currently outdated to face the new challenges of medicine and surgery and to keep up with technological developments. bruner, one of the theorists of the constructivist model, proposed in a method of collaborative learning between those who teach and those who learn. the goal of the method was to improve strategic problem solving. the comparison between various perspectives (between teacher and student), allowed the learner to better absorb knowledge and improve critical thinking. in kapur published on the theory of 'productive failure'. this model makes the error of a single person useful for all his colleagues, privileges the practice of theoretical knowledge, contextualised learning as opposed to abstract learning, and 'guided' practice compared to a 'guided' theory. bruner and kapur's systems favour creativity, critical analysis of a problems origin, and the practical use of knowledge. they represent a hypothesis of learning, based on constructive discussion and a continuos 'give-take' feedback system. in order to put these new models into practice in the clinical context, one may hypothesise and propose the adoption of a formal discussion of clinical cases that are complicated or difficult. thereby making the theoretical lessons more collaborative, intuitive and inclusive. in the surgical field, one could adapt such a concept to surgery simulation, virtual reality and anatomical models. aim: large hiatal hernias have a surgical indication when the patients suffering disabling symptoms such as anaemia, dyspnea, chest pain, gastric reflux. several studies showed that in the case of large hernias the placement of a prosthesis was safe and could protect against recurrence. mini-invasive surgery is the preferred approach for hiatal hernia repair and anti-reflux procedure and the toupet fundoplication has been shown to be the best surgical technique for the hiatal hernias repair.the laparoscopic approach is currently the surgical gold standard but is burdened by technical difficulties especially in the case of large hiatal hernias. the robotic system is designed to overcome some technical difficulties of laparoscopy and the studies available in literature report the safety and effectiveness of the robotic approach in complex hiatal hernias repair. methods: we present the case of a grade iv hiatal hernia treated with a robotic approach in a years old woman (bmi: kg/m ). the medical history consisted of a road accident with a probable mechanism of deceleration, three years before. the patient had been suffering from dyspnea for three years. due to the recent discovery of an anaemia, the patient was subjected to an endoscopic examination with the identification of a voluminous grade iv hiatal hernia. a subsequent computed tomography (ct) scan showed also the partial herniation of the transverse colon. results: the patient underwent to surgery by using the da vinci robot system siÒ (intuitive surgical, sunnyvale, usa) with a single docking approach. the surgery consisted in the liberation of the hernial sac, the placement of a goretex prosthesis and the packaging of a toupet fundoplicatio. the surgery was performed without complication. conclusions: the robotic approach in the hiatal hernia surgery seems to be a valid alternative to laparoscopy, especially in complex cases. the surgical ability in robotic surgery is of paramount importance. general thoracic surgery, kawasaki municipal hospital, tokyo, japan aim: video-assisted thoracoscopic surgery (vats) with carbon dioxide (co ) for mediastinal surgery is known to improve the visualization of medaistinal space. we report our experiences with two cases that underwent vats thymectomy using co insufflation under the one-lung ventilation general anesthesia by double lumen tube. methods: the instruments that were used for vats thymectomy were only the -mm -degree rigid thoracoscope, maryland jaw energy device, cotton made-dissectors, and straight endoscopic grasping forceps. they were used through sealed ports designed for laparoscopic surgery. lowpressure co insufflation set at mmhg were used for compression of surround tissue of mediastinal tumor during the releasing procedure. results: the patients were an -year-old male and a -year-old female. thoracoscope with the mmhg co insufflation provides excellent visualization of the medaistinal space and operation could be done smoothly without any hemodynamic compromise. their pathological diagnoses were thymic cancer and thymoma, type b . the operative times were min and min. the postoperative courses were uneventful and the patients were discharged on day th and rd . conclusion: we have just begun to routinely use co insufflation for mediastinal tomorectomy and present our early experiences of successful vats thymectomy by utilizing co \ su \/su insufflation. aims: this retrospective study aims to evaluate the feasibility of single-incision thoracoscopic surgery (sits) for primary spontaneous pneumothorax (psp), using a novel multichannel port (x gateÒ). methods: between october and november , ten patients who underwent sits using x gateÒ. nine patients were male and was female, with mean age of . ± . years old. a . cm incision is placed in the middle axillary line on the th or th intercostal space, depending on the lesions. postoperative outcomes of these patients were compared with those of patients with psp who underwent conventional three-port video-assisted thoracic surgery (vats). results: there were no conversions from sits to vats. mean operative time of sits group was significantly shorter than that of three-port vats group ( . ± . min vs . ± . min, p = . ). mean number of staplers used in surgery was . ( ) ( ) ( ) ( ) in sits group and ( ) ( ) ( ) ( ) ( ) in vats group (p = . ). mean duration of postoperative drainage was also shorter in sits group ( . ± days vs . ± . days, p = . ). no recurrence and wound infection were observed in sits group. conclusion: sits using x gateÒ is feasible when performed for selected patients with psp. x gateÒ provides good visualization of intrapleural space and esthetic outcomes, as well as a superb maneuverability by decreasing mutual interference of surgical instruments. although conventional three-port vats for psp is well established, sits using x gateÒ can be a permissible alternative. further examinations are required to evaluate efficacy of sits using x gateÒ. aims: haemorrhage remains a leading cause of potentially preventable death in trauma. in particular non-compressible torso haemorrhage is approximated to cause - % of mortality in civilian trauma patients with otherwise survivable injuries and % in war setting. we performed a literature review to assess the potential for using endovascular stenting in traumatic venous injuries and explore the evidence of their efficacy and safety with different venous injury patterns. methods: systematic online search of pubmed performed using key words'endovascular stent', 'venous injury', trauma, penetrating, blunt, abdominal and pelvic. inclusion criteria included all studies that explored the use of endovascular stents following traumatic abdominopelvic venous injuries. english language studies were used. results were presented according to prisma guidelines. results: of the studies generated by the search,there were only four case reports in the literature documenting the use of endovascular stents in traumatic venous injuries dating back to and most recently . the four cases included three retrohepatic ivc injuries, two secondary to blunt trauma and one penetrating; whilst the final case a blunt injury at the ilio-caval bifurcation. all four cases reported successful deployment of stents via the femoral or internal jugular veins, with subsequent resolution of haemorrhage. length of time taken for stent insertion ranged from to min. three of four patients made full recoveries and discharged from hospital, with one patient subsequently dying of a brain injury independent of the successful venous stent insertion. no complications were reported at up to months follow up in remaining cases including stent leak, stenosis or migration. conclusion: endovascular venous stents have been used successfully in managing complex abdominopelvic traumatic venous injuries. in particular retrohepatic venous injuries refractory to hepatic packing and vessel embolization, which are not amenable to direct surgical repair due to anatomical location. however before endovascular stenting can be added to the arsenal of interventional radiologists for abdomino-pelvic trauma, further development of stents custom made for venous injuries as well as prospective studies examining their long term safety and outcomes is needed. tracheal papilloma is a rare neoplasm growing from the tracheal or bronchial epithelium and has no specific clinical presentations. this is a -year-old female who complained of progressive dyspnea for about months. physical examination was unremarkable and the there was no abnormal finding by the chest plain film. chest computed tomography was arranged and revealed a mass lesion located at the tracheal lumen with more than % luminal obstruction. we used fiberoptic bronchoscopy to evaluate the airway and found a mass lesion with pedicle originated from the posterior tracheal wall. cryotherapy was considered for the tumor mass removing to establish a patent airway. the pathologic report revealed tracheal papillomatosis without any malignant component. dyspnea was immediately improved and the patient chose closely observation after the bronchoscopic cryotherapy. aims: recent advances in laparoscopic surgery, both in techniques and instrumentation material, have led to the emergence of innovative technological fields, among which robotic surgery stands out.one of the handicaps of this surgery is its high cost as well as the long learning curve. in this stage a new tool arises, the flexdex semi robotic arm, which combines the precision and the range of movements of robotic surgery with the greater availability, simplicity of use and learning of conventional laparoscopic surgery.the objective of this study is to evaluate the efficacy and safety of the flexdex device in different laparoscopic procedures. methods: flexdex's is a three-axis gimbal technological device integrated in a conventional laparoscopic instrument that translates the surgeon's hand, wrist, and arm movements from outside the patient into corresponding movements of an end-effector inside the patient's body.the greater accessibility provided by the flexdex allows the surgeon to perform sutures in areas of difficult access where mobility with conventional laparoscopic instruments is not optimal. the comfort of the surgeon remains fundamental in any type of surgery, even more when we are in anatomical locations with complex access, especially for the realization of sutures. here is where surgical innovation instruments such as flexdex provides ergonomic comfort for the surgeon and improves the patient's safety, especially in high-risk situations, such as when performing anastomosis. results: we present a prospective series of laparoscopic procedures carried out by the same surgical team being the initial experience in our environment in the use of the flexdex semi robotic arm for the realization of complex anatomical sutures.this is a case series of patients to whom different surgical techniques requiring manual suture have been performed. these being tapp procedures, nissen-type fundoplicature and reinforcements of colorectal anastomosis. it is important to note that in none of the cases complications were recorded conclusions: flexdex can provide an excellent alternative to the robotic systems in complex surgical procedures, offering surgeons the precision and control they desire while maintaining the balance of cost, outcome and patient benefit. background: a new single-port device (fsis-flexible-single-incision-surgery) is presented. this new platform has three working channels, two for rigid instruments and one for the flexible endoscope. the channel for flexible instruments offers a pneumatic sealing to avoid the air's leak of the cavity (abdomen, rectum, vagina) . in this study the preclinical data are shown testing the feasibility and safety for laparo-endoscopic instruments. methods: experimental evaluation of feasibility and safety in two stages. in the first stage a working channel with pneumatic sealing was tested in simulators to use a flexible endoscope. in the second stage (animal model) the single incision device that makes possible to use laparoscopic instruments and flexible endoscopes was tested. the measured variables were: time of the procedure, co employed, adverse intraoperative events, grip's losing, losing of pneumatic sealing, feasibility and safety of the procedure for the surgeon. results: the hysterectomy and double adnexectomy was done with a median time of . min. the median of the co consumption was . litres. only in one case ( . %) the surgeon had problems with the abdominal navigation of the endoscope that was easily solved. the grip's lose wasn't a major problem. the median size of the skin incision was . cm. the median surgeon' score for the feasibility was and for the safety was . . conclusions: the surgeons considered that the use of the device was very feasible and safe. the fsis-device is a universal platform for single-incision-surgery for surgeons and gastroenterologists and for abdominal, rectal and vaginal access. aim: despite the near-infrared fluorescence (nirf) via the intravenous administration of indocyanine green (icg) improves the visualisation of the cystic duct (cd) and the extrahepatic biliary tract (ebt), the back fluorescence of the liver reduces the signal-to-noise ratio.we have modified the technique of nirf cholecystocholangiography with intragallbladder icg injection by using the arrow-karlan tm balloon cholangiography catheter instead of the purse string at the gallbladder's fundus. this procedure allows a high rate of visualisation of the ebt, with few cases of icg leakage.aim: of this study is to confirm the feasibility of this different technique and to analyse the icg spillage from the gallbladder and to identify the ebt. methods: we enrolled nine patients undergoing laparoscopic cholecystectomy for cholelithiasis. the gallbladder was perforated with the cholangiogram catheter, the balloon inflated with . ml of saline and tightened. the bile was drained and the icg bolus injected. a titanium clip was the placed on the catheter strict closely to the gallbladder in order to prevent the catheter dislocation. results: the cd and the ebt were visible before dissection in / and / patients respectively. after dissection the cd was visible in all the patients and the ebt again in / patients. there was only one icg spillage due to a tardive positioning of the clip. in a case of inflamed gallbladder this technique helped in the identification of the dissection plane. conclusions: our preliminary results of this ongoing study confirm the feasibility of this different approach as a possible alternative to the purse string and a good visualisation of ebt. introduction: robotic-assisted surgery is a promising technique for overcoming the limitations of laparoscopic surgery, especially with regards to complex and advanced surgical procedures. here, we describe the establishment and implementation of our robotic upper gastrointestinal (gi) and hepato-pancreato-biliary (hpb) surgery program within our center of excellence for minimally invasive surgery as well as the first-year results. method: robotic-assisted surgery was performed using the davinci xi surgical system tm and performed by two surgeons specialized in minimally invasive surgery (db and tk). our robotic surgery program of upper gi and hpb surgery was established in three steps: ( ) first, surgical procedures with easier degree of difficulty were performed robotically, including cholecystectomy, minor gastric resections and fundoplications. ( ) then, pancreatic distal resections, enucleations, adrenalectomies and atypical liver resections were robotically performed, as procedures with moderate degree of difficulty. ( ) finally, advanced and highly complex procedures were performed, including right hemihepatectomy, complex pancreatic head resections (including portal vein resections), total gastrectomy and esophagectomy. data collected from july till july were retrospectively analyzed with regard to conversion rate, morbidity (clavien dindo grade £ ) and mortality. results: within the first year, a total of robotic assisted upper gi and hpb resections were performed. the first step of establishing our robotic surgical program included eight procedures. here, conversion rate, morbidity and mortality were %. within the second step of establishment procedures were performed. conversion rate, morbidity and mortality were %, % and %. the last step included of advanced and highly complex procedures. these procedures resulted in a conversion rate of %, % morbidity and % mortality. conclusion: our stepwise approach enables a safe implementation of a robotic surgical program for upper gi and hpb surgery with low morbidity and no mortality even for highly complex procedures. however, highly complex procedures required a high conversion rate, which might be caused by the early stage of experience. the standard surgical procedure of choledochal cyst is a complete excision of the cyst with rouxen-y hepaticojejunostomy and laparoscopic surgery had been increasingly used. this is still a challenging way to perform anastomosis due to the small diameter of bile duct and the possibility of bile leak or stricture. robotic system can overcome the shortcomings of laparoscopy with providing three-dimensional view, magnification, and articulated instruments. from jan to dec , patients underwent robotic cyst excision and hepaticojejunostomy by single surgeon. we reviewed the clinical data and compared with laparoscopic outcomes of early (from to ) and late (from to ) group, retrospectively. patients of robotic series were all female with mean age . years and bmi . . the mean size of cyst was . . cm, and todani type ia , ic and iva , respectively. total trocars were used with robotic working arm and assist and camera. the mean operative time . ± . min, and it was similar with late laparoscopic group ( ± . min) and significantly shorter than early group ( ± . min).there were no open conversion in robotic and late laparoscopic group, however, the early laparoscopic group involved % of conversion rates. the hospital length was ± . days in robotic group, and it was similar with late group ( ± . ) and more shorter than early group ( . ± . ). in robotic series, postoperative complications occurred patients. one case included cholangitis which was resolved after conservative treatment. bile leakage was developed in patient, and treated with drain that inserted intraoperatively. last cases showed incisional hernia at postoperative months, and was corrected by laparoscopic herniorrahphy. complications (n = ) in late laparoscopic group included hepaticojejunostomy stricture and stone, bleeding of jejunal branch, portal vein thromobosis, acute pancreatitis, and adhesive ileus. there were no mortaility case in any groups.robotic surgery of choledochal cyst is a safe and feasible option with short-term results that are comparable to laparoscopic approach. general surgery, sanchinarro university hospital, madrid, spain background: the incidental detection of benign to low-grade malignant small pancreatic neoplasms increased in the last decades. the surgical management of these patients is still under debate. the aim of this paper is to evaluate the safety and feasibility of robotic enucleations. methods: we retrospectively reviewed our prospectively databases from november . demographics, pathological characteristics, perioperative outcome, and medium-term follow-up of patients who underwent robotic pancreatic enucleations were collected. results: patients were included. the mean age of the patients was years ( - ). the median body mass index was ( - ). ten lesions were located in the pancreatic head, in the pancreatic body, in the pancreatic tail. operative time was min (range - ), no intraoperative transfusion were needed and in one patient conversion to open approach was needed. in three patients grade b pancreatic fistula occurred. the mean postoperative stay was , days. conclusions: robotic enucleation is a feasible and safe approach, with low incidence of morbidity. the results of surgical treatment of patients with pulmonary tuberculosis were evaluated depending on the prevalence of the tuberculosis process and the type of surgical intervention used. according to the results of the questionnaire, people operated on pulmonary tuberculosis in the period from to years ago, the frequency of cases of tuberculosis reactivation, the complicated course of the remote postoperative period, as well as the mortality and causes of lethal outcomes were assessed. it was found that after sublobular resection and lobectomy, treatment failure was noted at . %, relapse of tuberculosis- . %, pleural empyema- . %, bronchial fistula- . %, cardiovascular insufficiency-in . % operated. the mortality rate was . % with a total clinical efficacy of . %. after combined resection and bylobectomy, treatment failure was noted at . %, relapse of tuberculosis- . %, pleural empyema- . %, bronchial fistulae- . %, cardiovascular failure- . % operated. the mortality rate was . % with a total clinical efficacy of . %. after pneumonectomy, treatment failure was noted at . %, relapse of tuberculosis- . %, pleural empyema- . %, bronchial fistulae- . %, cardiovascular failure- . % operated. the mortality rate was . % with a total clinical efficacy of . %. robotic reduced-port splenectomy using single-site platform j.h. lee background: in the era of minimal invasive surgery, single incision laparoscopic splenectomy can offer some advantages compared to conventional laparoscopic splenectomy. but it requires expertise in minimally invasive techniques due to technical difficulties. the da vinci robotic reduced-port splenectomy using single-site platform permits greater freedom of movement and higher levels of accuracy than previous laparoscopic surgery through two small incisions. methods: we performed a retrospective review of all patients who underwent robotic reduced-port splenectomy using single-site platform at our institution between january, and november, . one cm periumbilical incision was made for glove port insertion and the other incision was made at left side of abdomen for additional mm port insertion.the surgical technique is much same as open procedure. short gastric artery was ligated, firstly. splenic artery and vein were ligated individually. during the surgery, any stapling device was not used. vessel sealer was used for hemostasis and mobilization of spleen. a specimen was removed through umbilical port site within lap-bag. result: eight patients ( female and male) with median age of . years underwent robotic reducedport splenectomy using single-site platform (one case with combined robotic cholecystectomy for gall bladder stones without additional trocar). the indications were; hematological disease (n = ), splenic mass (benign n = , malignant n = ). preoperatively measured spleen size was ranged . cm to cm (mean cm). there were no intraoperative complications and open conversion. mean operative time was min. (range - min) including docking (mean min) and console time (mean min) mean blood loss was under ml. mean hospital stay was . days after surgery. one patient underwent oral anticoagulation therapy only for portal vein thromobisis without any symptoms, and thromobisis was resolved at month follow-up ct scan. there were no clavien-dindo class iii or above postoperative complication. conclusions: robotic reduced-port splenectomy using single-site platform seems to be feasible and effective. it seems to overcome certain limits of previous robotic or conventional single-site laparoscopic splenectomy and single-site only robotic splenectomy. we think mm additional port allows to use endo-wrist da vinci instruments such as vessel sealer which enhances dissection efficiency andsafety of procedures. aims: inguinal lymph node dissection carries an important risk of post-operative complications, mainly related with wound complications and long term lymphedema. the minimally invasive approach aims to reduce the morbidity of this procedure, avoiding the traditional groin incision but still allowing a full access to the lymph node basin. the authors aimed to describe their videoassisted inguinal lymph node dissection (vilnd) cases, comparing the surgical outcomes with a sample of open inguinal lymph node dissection (oilnd) cases. methods: we performed a retrospective descriptive study that compared the data from patients submitted to vilnd since (the year in which this technique was first performed in our institution) with the patients submitted to oilnd in and . gynaecologic and urologic malignancies were excluded. the statistical analysis was performed using spssv Ó, with a p value \ . indicating statistical significance. results: a total of cases of inguinal lymph node dissection were analysed, . % of which vilnd (none of them requiring conversion to the open approach). melanoma was the primary tumour in % of patients. the vilnd and oilnd groups had no statistically significant difference between them regarding age, body mass index, smoking status or the reason for lymph node dissection-clinically detected lymph node vs. positive sentinel node biopsy. the mean of isolated lymph nodes in the vilnd ( . ) and oilnd ( . ) groups was also not statistically different (p = . ). there was no difference in the rate of post-operative seroma, wound dehiscence or lymphedema. the rate of surgical site infections was higher in the oilnd group- % vs. . % during post-operative hospital admission (p = . ); . % vs. . % after discharge (p = . ). conclusions: in our population of patients we conclude that the main advantage of the videoassisted approach regarding surgical morbidity lies in the reduction of the infection rate, as the published literature also confirms. the equivalent number of lymph nodes retrieved in both groups points toward the oncological safety of the minimally invasive procedure, that we hope to study further in the future after a longer follow up period. objectives: to evaluate the clinical feasibility of tumor localization technique with radio-frequency identification (rfid) clip marker methods: we developed the proto-type rfid integrated endoscopic clip (rfid-clip) and probe to detect it on serosa surface during the laparoscopic surgery. a pig weighing kg was used as the specimen for the in-vivo test. endoscopist performed the application of the rfid-clip on porcine gastric mucosa. after then, the surgeon tried to find the location of rfid-clip using the detection probe and marked with the electrocautery. after the gastrectomy with cm margin (each to proximal and distal), we confirmed the prediction of rfid-clip location and accuracy of resection. results: rfid-clip location was detected and recorded on the exact site of clip application. detection range was very short and we confirmed there are almost no differences between actual clip location and our prediction. this result might arise from using the low-frequency rfid tag to increase the accuracy through reduction of the range. however, some rfid-clip were not detected because of the issue of clipping trouble, not rfid tag. conclusions: this is a basic study to evaluate the clinical usefulness and feasibility of the new localizing technique. we confirmed the possibilities of this system and it could be the helpful option to provide the information of exact location for the minimally invasive surgery or early gastrointestinal tumors. background: the advantages of laparoscopic posterior retroperitoneal adrenalectomy (lpra) have been described in the literature. the aim of this study was to compare the clinical outcomes of lpra and robotic posterior retroperitoneal adrenalectomy (rpra) and determine the differences that could affect the outcomes. methods: we retrospectively analyzed adrenalectomy cases at asan medical center from to . there were lpra and rpra cases, and their clinicopathological features and surgical outcomes were compared. results: in lpra, there was a positive relationship between operation time and male gender, early period of experience, adrenal tumor size, and pheochromocytoma. in rpra, adrenal tumor size and pheochromocytoma were the only factors affecting the operation time. when the adrenal tumor size was = . cm, the operation time of lpra was shorter than that of rpra (p = . ). when the tumor size was [ . cm, there was no significant difference in the operation time of lpra and rpra (p = . ). conclusions: rpra is a feasible and technically safe approach for benign adrenal diseases. the use of rpra could benefit patients with large tumors and provide comfort by overcoming the factors contributing to a longer operation time in the laparoscopic technique. methods: twenty years experience at the american university of beirut medical center for laparoscopic adrenalectomy. a total of cases were done laparoscopically with no conversion and minimal complication. the average operative time is mins.the video will show the various steps used for lap redo (lt) adrenalectomy for a cm pheochromocytoma using the lateral position and through trocars. attempt to remove the pheochromocytoma in iraque was complicated by cardiac arrest treated successfully and patient referred to the american university of beirut medical center. results: patient had smooth postoperative course following laparoscopic adrenalectomy and patient discharged days later with no complications. conclusions: even large adrenal masses can be completed laparoscopically in advanced experienced centers in laparoscopy. surg endosc ( ) aims: the adrenocortical of uncertain malignancy neoplasm is a spectrum of classification for adrenal tumors whose histopathological diagnosis is uncertain. clinical case: we present a year old patient with constitutional syndrome and severe hypercortisolism and hypokalemia reason why she was admitted to icu for episodes of ventricular fibrillation. no other medical history of interest except refractory hypertension to treatment. the tc showed a left adrenal mass of . . cm with microcalcifications, areas of necrosis and hemorrhage, no infiltrating, without disease to distance. the surgery was a laparoscopic left adrenalectomy with no evidence of infiltration and no lymph nodes. the histopathology lesion presented a dense proliferation cellular of cortical type, with incomplete fibrous, without vascular or capsular invasion, with a % ki ; positivity vimentin and cd . all epithelial markers, were negative. all this leads to the diagnosis of a neoplasm of uncertain malignancy potential adrenocortical. during the postoperative period, the patient presents a crisis of adrenal insufficiency that was treated with intravenous replenishment corticoidea and later orally with good clinical response. discussion: the adrenal carcinoma has a low incidence ( . %), incidence peak around the years, the most frequent is the mixed secretory. they are - % of the adrenal incidentalomas. it is usually presented to the diagnosis as a locally advanced tumor with metastases (to liver, lung, retroperitoneal ganglia and bone). may present clinically due to hormonal hyperproduction; or be non-functioning tumors. the adrenal carcinoma poses a great difficulty at the time of the diagnosis pathological, and includes as differential diagnosis to other abdominal tumors. the distinction between corticoadrenal adenoma and adrenal carcinoma is sometimes difficult, so it has been defined a spectrum of intermediate category called adrenocortical neoplasm of intermediate or uncertain malignancy. it is obtained with the weiss criteria, being necessary at least of them for confirm the diagnosis of adrenal carcinoma. this category has a low risk of local recurrence or metastasis, but it needs a narrow follow-up. conclusion: adrenal carcinoma of uncertain malignancy implies a new category in those tumors of difficult classification. aims: multiple endocrine neoplasia type (men ) is an autosomal dominant disorder with an estimated prevalence of per , in the general population. among patients suspected to have a pheochromocytoma, the diagnosis is rarely confirmed and only % is presented bilaterally. we present bilateral laparoscopic adrenalectomy in patients with men . method: a -year-old woman with a family history of medullary thyroid cancer and breast cancer. personal history: hypertension, medullary thyroid cancer, breast cancer, laparoscopic cholecystectomy. appendectomy. after a study by endocrinology and suspicion of bilateral pheochromocytoma, discussing the case in a multidisciplinary committee, bilateral adrenalectomy was decided by laparoscopic approach. selective alpha- -adrenergic blocking agent (doxazosin) were utilized before surgery. under general anesthesia left adrenalectomy was performed first in right lateral decubitus position. mmhg pneumoperitoneum was started with the verres needle and trocars ( mm umbilical, mm subxifoid and mm left subcostal).once dissection was completed the gland was placed in a plastic bag and extracted through one of the trocars incisions, then the position of the patient was changed to left lateral decubitus for the right adrenal approach. another right subcostal mm trocar was used. adhesiolysis of previous cholecystectomy was performed to right adrenal approach. adrenal veins were divided between metallic clips.no drainage was employed. results: the procedures were successfully performed without conversion. surgical time was min and hospital stay was days. had a clinical reversion with control of blood pressure monitored by endocrinology conclusions: currently, the laparoscopic approach is the technique of choice for the management of adrenal pathology.lateral decubitus transperitoneal approach is the procedure of choice in most cases. bilateral laparoscopic synchronous adrenalectomy is feasible and safe with good results as in our patient. traditionally the treatment of hyperparathyroidism for patients with familial hyperparathyroidism was subtotal parathyroidectomy or total parathyroidectomy and auto transplantation. in the era of minimally invasive parathyroidectomy, the removal of only abnormal glands guided by preoperative localizing studies has been suggested. aims: this systematic review aimed to investigate the role of focused minimally invasive parathyroidectomy in the treatment of patients with familial hyperparathyroidism. methods: electronic databases were searched with the search terms 'men i', 'familial hyperparathyroidism', 'men a','hyperparathyroidism-jaw tumor syndrome', 'parathyroidectomy', 'minimally invasive ', for the time period up to and including december . full publications, including clinical trials randomized or not, retrospective studies, case series, case reports that provided relevant data met inclusion criteria. results: thirty five possibly relevant studies were identified. abstracts were reviewed and fifteen articles were excluded. twenty studies, that met inclusion criteria were retrieved in full text and included in the systematic review, including three retrospective cohort studies i.e. two presenting data on meni associated hyperparathyroidism and the third study on familial hyperparathyroidism and seventeen small case series or case reports. the two retrospective studies on meni hyperparathyroidism included patients treated either with focused minimally invasive parathyroidectomy or with the conventional approach. these studies presented conflicting data with one supporting and the other negating the focused minimally invasive parathyroidectomy due to the failure of localization studies to identify enlarged parathyroid glands in a great number of patients. conclusion: undoubtedly, the idea of minimally invasive parathyroidectomy in patients with hereditary and familial hyperparathyroidism is interesting. this idea is especially challenging in the case of meni. existing data suggest that focused mimimally invasive parathyroidectomy is feasible under the condition of exact preoperative localization studies. the main advantage of this approach is the minimization of the risk of postoperative hypoparathyroidism. however, data are limited and further research is needed before valid conclusions can be drawn on the suitability of this approach. objective: resection of pheochromocytomas is a challenging procedure due to hemodynamic lability, tumor vascularity and malignant potential.given the technical challenges for resection of large pheochromocytomas, there were hesitations about using the laparoscopic approach for these tumors during the first decade of laparoscopic surgery. however, improvement in imaging modalities,better pharmacological preparation,advances in anaesthesia and laparoscopic surgery rendered laparoscopic surgery for pheochromocytomas safe and efficient. our aim was to evaluate surgical outcomes in patients with pheochromocytoma and to validate the role of laparoscopic surgery in the treatment of these tumors. design: a total of procedures for pheochromocytoma were performed between january -september . the preoperative diagnosis, operative details, complications, length of hospital stay, morbidity and follow up were retrieved from the hospital records of patients who underwent adrenalectomies for benign and malignant adrenal tumors in the same period. preoperative localization was established in all patients with computerized tomography (ct) or magnetic resonance imaging (mri), while iodine - -metaiodobenzyguanidine(mibg) scan was reserved for ambiguous cases where paraganglioma or metastatic disease was suspected. endocrinological evaluation and complete adrenal dynamic testing were performed to determine whether the tumor was functional or not. results: eighty-seven tumors were removed from patients. one patient with meniia underwent bilateral resection of pheochromocytomas in two stages. tumor size in laparoscopic procedures ranged from . cm to . cm (mean . cm). forty-three patients had benign disease, potentially malignant (based on pass), malignant with metastasis. eight were in the context of a familial syndrome. sixty -eight patients underwent laparoscopic adrenalectomy, patients had open approach from the start for recurrent pheochromocytoma or large benign tumor, patient had open approach due to inoperable malignant pheochromocytoma and patients had conversions from laparoscopic to open procedure. nine patients received sodium nitroprusside intraoperatively to treat hypertension. one patient developed pulmonary embolism, and succumbed month later. there were no recurrences for the benign tumors during the follow-up period. conclusions: laparoscopic resection of pheochromocytomas despite its increased level of difficulty compared to that of other adrenal tumors, is a safe and effective procedure. aim: the concept 'large' in transperitoneal lateral laparosopic adrenalectomy (tlla) has been evolving along time, ranging from to - cm depending on different authors. on the other hand, some authors discourage laparoscopic surgery in larger tumors due to the increased risk of malignancy in those larger than - cm, referring to malignancy in out of or cases. paragangliomas are rare tumors originated in extra-adrenal chromaffin cells, with an incidence of - cases per million inhabitants. they can appear in any location between neck and pelvis. sympathetic paragangliomas are usually functional and catecholamines producers. we present a movie of surgical intervention of a -year-old patient who, in study for refractory hypertension, presented paraganglioma producing norepinephrine, whose approach was performed laparoscopically. -year-old woman studied by nephrology for refractory hypertension. on physical examination, only obesity standed out. in blood exams, levels of normetanephrine were observed in plasma of pg/ml and aldosterone pg/ml. abdominal scintigraphy was performed in which there was no evidence of increased activity at adrenal level. abdominal ct shows retroperitoneal extra-adrenal tumor of inter-aortocava location immediately below renal vessels with dimensions of . . cm. after preparation, she was operated. laparoscopic access was performed under exhaustive monitoring. an heterogeneous, polylobulated tumor of cm, located interaortocava, intimately adhered to left renal vascular pedicle, was observed. a cattell-braash and kocher maneuver was performed, with exposure of inferior cava and aorta to iliac bifurcation. complete tumor excision was performed after clipping arterial and venous tributary branches. after the operation, the pacient presented favorable evolution being discharge on the second postoperative day with good control of blood pressure levels. laparoscopic approach of retroperitoneal paragangliomas is a safe technique, which allows minimally invasive access, with consequent improvement in postoperative results. the exact location of lesions and their relationships with surrounding structures, as well as their functional behavior, are very important when considering the best therapeutic strategy for these patients. we present the case of a -year-old obese male patient referred for adrenalectomy after being diagnosed with left adrenal incidentaloma. abdominal mri showed a . / . / . left adrenal mass with normal hormonal levels. after preoperative workup, the patient underwent standard laparoscopic adrenalectomy. the lateral to medial dissection and mobilization of the spleen and pancreatic tail was difficult due to the abundance of peritoneal and pararenal fat. the anatomy was peculiar: the bulky pancreatic tail was located well inferior to the splenic hilum and was visible throughout the intervention and the spleen was quite elongated-long axis = cm. the exposure of the adrenal gland was therefore cumbersome. the operating time was min and blood loss ml. the abdominal drainage was maintained for h. before discharge the patient underwent a control abdominal us examination that only showed a thin line of left pleural fluid. the patient was readmitted days after discharge for chest pain, fever ( . °c) and malaise with no abdominal signs. the emergency ct scan diagnosed left basal pneumonia with minimal pleural effusion and a / cm fluid collection between the spleen and diaphragm while the blood test showed leukocytosis. the patient was treated for pneumonia with an apparent clinical benefit for three days and lowered white cell count but his condition worsened during the forth day. repeat abdominal us demonstrated that the abdominal collection increased in size therefore the patient underwent emergency surgery. during laparoscopic exploration, the collection was unveiled as being pancreatic juice (more than times the normal serum levels of lipase and amylase). after thorough lavage, two drainage tubes were positioned in the left subphrenic space. the postoperative course was uneventful under antibiotic treatment for pneumonia and pancreatic antisecretory medication. the patient was discharged after days with minimal pancreatic drainage and the drainage tube was extracted after more days. the aim of the study was to develop the algorithm and the choice of the method of endoscopic treatment of a combined pathology of uterine leiomyoma and adenomyosis depending on the reproductive plans. methods: the study involved patients with a combined pathology of uterine leiomyoma and adenomyosis. indications for conservative myomectomy were: the size of the uterus is more than weeks. pregnancy; multiple leuomatous nodes and adenomyotic foci up to cm in size; hemorrhagic and pain syndromes, anemia, compression of the adjacent organs; suspected node malfunction; submucous leiomyoma deforming the uterine cavity with foci of adenomyosis; subserous, cervical isthus nodes and foci of adenomyosis; the presence of endometrial hyperplasia, tumors of uterine appendages; growth rate of uterine leiomyoma more than weeks pregnancy for the year; the growth of uterine leiomyoma on the background of drug treatment; infertility associated with leiomyoma and uterine adenomyosis.the laparoscopic myomectomy of the subserous node on the 'leg' with a size of more than cm and nodes of more than cm of intramural location is shown with an interest in preserving the organ.the hysterectomy is indicated for women after years of age who insist on hysterectomy, with a combination of uterine leiomyoma with atypical endometrial hyperplasia. results: the conservative myomectomy and removal of adenomyotic foci were performed in ( . %) patients: from hysteroscopic access- , vaginal access- , laparoscopic access- , abdominal access- in the presence of reproductive plans.the hysteroscopic myomectomy was performed in ( . %) patients, hysterectomy in ( . %) patients: from laparoscopic access- , from vaginal access- , from abdominal access- in the absence of reproductive plans. conclusions: the choice of surgical treatment of uterine leiomyoma and adenomyosis depends on the reproductive plans of the woman and the severity of the lesion.the laparoscopic method of treating a combined pathology of uterine leiomyoma and adenomyosis in the presence and absence of reproductive plans is a priority for women. surgery, policlinico ,,paolo giaccone,,, palermo, italy background: breast cancer in females represents the most frequent neoplasm in all age groups. the risk of getting breast cancer (mc) increases with age. the brca and the brca genes (tumor-suppressor genes, autosomal dominant transmission at high penetrance) alone justify from % to % of cases of hereditary breast cancer. methods: from january to june we have analyzed patients with brca mutation. all patients had in common a genetic mutation of brca or brca tumor suppressor genes. results: the frequency of germline mutation on brca ( patients: %) was identical to brca gene ( patients: %). of the analyzed patients were women ( . % of patients) brca and brca , and men ( . %) all with brca mutation. conclusions: prophylactic surgery must be seen as a way to put the patient in the condition to implement the most appropriate treatment. further studies will be necessary to support the validity of prophylactic surgery in patients with mutations in brca and brca genes. introduction: laparoscopic hysterectomy is a safe surgical technique for removing the uterus with or without including the ovaries and fallopian tubes. laparoscopic surgery of endometrial cancer is a safe method, with the mean time of recovery being two days only. material-method: the case of a yr old woman with metrorrhagia and anaemia (ht , %) due to adenocarcinoma of the endometrius is presented. the patient underwent a laparoscopic hysterectomy and oophorectomy. trocar ports were used during the procedure (a mm transumbilical port, similar to the port used in single incision laparoscopic operations, two mm ports at the level of the anterior superior iliac spines, and a mm port in the middle of the imaginary line between the pubic symphisis and the umbilicus). the uterine vessels and the uterine ligaments were ligated and dissected by using a thermal energy source. the patient's postoperavite course was uneventful. the patient continues to be in good condition, months post-surgery. conclusion: laparoscopic hysterectomy seems to be a safe method for addressing endometrial cancer, as it offers the surgeon a better surgical field, is tissue friendly and causes fewer postoperative complications. it is considered to be a less traumatic operative method, as due to zooming in the picture there is greater accuracy in handling the tissue, and blood loss is minimal. m. shahin background: hysterectomy is one of the most frequently performed surgical procedure. though there are three approaches in hysterectomy (open, vaginal and laparoscopic), still there are controversies regarding the optimal route for performing it. methods: this prospective comparative study included obese patients subjected for panhysterectomy as a treatment. the forty-two patients were allocated into two groups: group (a) subjected to laparoscopic pan-hysterectomy, group (b) subjected to open pan-hysterectomy. results: there was significant difference between the two groups regarding mean operative time, blood loss, analgesic requirements and hospital stay, while no significant difference regarding intra-operative complications. conclusions: laparoscopic hysterectomy in obese patients has emerged as a viable, safe and better alternative to open hysterectomy amongst appropriately trained surgeons. general: endometriosis in the inguinal region is rare. the usual presentation is that of a woman in the reproductive age group. it accounts for . - . % of patients affected by endometriosis. the groin swelling is usually slow growing, painful with exacerbations during menses. the incidence of inguinal endometriosis on the right side is - % as compared to the left. aim: to present our laparoscopic approach for the treatment of the diagnostic dilemma. case presentation: a -year-old woman presented with a palpable mass in the right groin. the swelling was associated with a dull aching pain. the patient was suffering from increasing pain over the swelling during menstruation. she had undergone cesarean section some years ago and the scar had healed by primary intention. mri scan revealed a nodular hypoechoic lesion at the level of the internal inguinal ring with the absence of vascular flow around the lesion. results: since inguinal endometriosis was in the differential diagnosis and it may be associated with pelvic or intraperitoneal endometriosis, a laparoscopic approach was decided. the procedure was successfully completed laparoscopically following the transabdominal preperitoneal approach. the endometriosis was found, after dissecting the internal inguinal ring, firmly adhered to the round ligament. it was excised en bloc with the round ligament. a preperitoneal polypropylene mesh was inserted to protect for future inguinal hernias due to extensive dissection at the level of the internal inguinal ring. no intraperitoneal endometriosis was appreciated. histopathology revealed endometriosis of the round ligament. the patient was uneventfully discharged the next day. on follow up the patient was asymptomatic. conclusions: round ligament endometriosis is a rare entity. it is a disease of specific interest to the physician. it can be confused with an inguinal hernia and thereby pose a diagnostic dilemma. we recommend considering endometriosis in the differential diagnosis of groin swellings in women. the transabdominal preperitoneal approach is feasible and safe in the hands of an advanced laparoscopic surgeon. introduction: sentinel node biopsy is the newest accepted method for surgical staging of early stage endometrial and cervical cancer. aim: to evaluate the role of the technique of indocyanine green (icg) identification of the sentinel lymph nodes in cases of early endometrial cancer. material and method: five patients with early endometrial and cervical cancer were introduced in a prospective study. icg was locally injected during the laparoscopic exploration. novadac pinpoint near to red technology was used. guided biopsies were performed into the marked sentinel nodes and histological results were evaluated. results: sentinel lymph nodes were easily identified by using icg and near-infrared technology. technical details are described. no associated complication was encountered. conclusion: sln mapping using icg in uterine cancers is demonstrated as an effective and safe procedure. laparascopic extraction of an intraperitoneal gossypiboma following c/s and a retroperitoneal gossypiboma following pyeloplasty n. ozlem general surgery department, ahievran university, kirsehir, turkey gossypibomas are forgatten foreign bodies,iatrogenic.their symptoms are different where they are. they extracted with laparotomy in the past but now we can some article mentioned their extraction was made with laparoscopy. case : y o female has abdominal pain after c/s for . years. a gossypiboma was extracted with laparoscopy above umblicus.a superficial surgical site infection existed,drained,subsided. case : yo m had a pyleoplasty operation years ago.a gossypiboma was extracted with retroperitonescopy,no postoperative event. basibuyuk et al reported retroperionescopic extraction of a gossypiboma from single port in first time.althoug every effort taken the incidence of foreign body detected in the body is about . - . %.they are most frequently localized in the intraabdominal cavity followed by tracheobronchial area,pleural cavity,pararenal area,vagina,spinal chord, neck, femur,breast,bladder,pancreas,and they may cause local irritation,and infection.tactile sense is absent in laparoscopy. all radiologic examinations(usg ct pet mri etc) be used to detect.we used usg ct.in the end laparoscopy make the diagnosis and remove gossypibomas in our cases with less postoperative pain and cosmosis. justo et al the computerized tomography (ct) scan is the most useful method for diagnosis; however, sometimes the preoperative diagnosis remains uncertain even after the imaging exam. in that case, laparoscopy arises as a valuable diagnostic tool, as well as a prompt treatment option. concerning gossypiboma, prevention is preferred rather than treatment. notwithstanding, there is no highly reliable prevention system. counting sponges is a method based on staff communication during the surgery with only % sensibility. routine surgical postoperative x-ray (spox) constitutes an early detection system, but the need to incorporate a radiopaque marker and to expose the whole surgical field to maximize its efficacy limits its use. more recently, electronic dispositives based on barcode detection and other technological adjuncts for counting sponges are being developed. none of these prevention systems are reliable when used alone. our education and research clinic was a state hospital before. no surgeon followed above instruction.but now we use all. multiple procedures and surgical teams, long operations and non-elective operations are the evidenced risk factors.c/s operation was learned full opened of ostium of cervix of the patient. urology, japan, nagoya, japan aims: some scoring systems have been suggested to standardize the renal tumor characteristics. among them, renal score is widely used in partial nephrectomy. whereas diameter-axis-polar (dap) score was developed to be more significantly related with postoperative renal function. our study compared dap score with renal score in robotic partial nephrectomy (rpn) outcomes. methods: records of patients who underwent rpn at nagoya daini red cross hospital between april to october were analyzed retrospectively. those include three oncocytomas. accordingly, we calculated the estimated glomerular filtration rate (egfr) just before rpn and month postoperatively in patients. we compared two nephrometry scores with warm ischemic time and change in egfr. results: in our institution, four surgeons performed rpn. according to dap score, patients were high, were middle and were low. according to renal score, were high, were middle and were low. the median warm ischemic time was min ( - ). the median egfr decreased from . ( . - . ) to . ( . - . ) ml/min/ . m . there were no significant differences in warm ischemic time and percentage change in egfr between renal score groups (p = . and . ) but significant differences between dap score groups (p \ . and p \ . ). univariate and multivariate analyses were used to identify factors influencing postoperative renal function. that confirmed that dap score was independent poor predictors of change in egfr after rpn. conclusions: dap score is simpler estimate system than renal score. our study suggested that dap score is a useful scoring system for preoperative evaluation of renal tumor for rpn. further investigation is needed to better understand preoperative dap score. aims: retroperitoneal primary tumors comprise a great variety of neoplasm with different histological typologies, with insidious clinical symptoms and little specificity in most cases. its diagnosis is established through imaging tests and anatomopathological study is needed so complete surgical resection is the treatment of choice. the aim of the video is to demonstrate the safety and efficacy of the minimally invasive approach in patients with retroperitoneal lesions. methods: a -year-old female patient who, in the course of an abdominal pain at the right iliac fossa suspected of possible acute appendicitis, is diagnosed with a right retroperitoneal tumor, compatible with primary neurogenic tumor on a ct. radiographic imaging is a key component of the evaluation of a patient with a retroperitoneal mass, a ct scan is necessary to evaluate the primary site as well as to rule out metastatic disease. after complete biochemical study, nonfunctioning tumor is determined. the study is completed with mri where the lesion is located below the right kidney, in front of the right psoas muscle and lateral to the inferior vena cava, and without contact with these structures. ??it is in intimate contact with the ovarian vein. the complementary tests and iconography of interest of the case are exposed. surgical intervention is proposed with a laparoscopic approach. results: full minimally invasive approach in left lateral decubitus position: trocars-lateral laparoscopic transabdominal approach. laparoscopic liberation of the right colon, kocher maneuver until the inferior vena cava is visualized, identification of a tumor of approximately cm in the right infrarenal region, lateral to the right ureter, which includes the gonadal vessels. resection of the tumor in block with margins previous dissection and clipping of the proximal and distal gonadal vessels with ligasureÒ. the patient presented a successful postoperative recovery, being discharged h after the intervention. definitive result of the specimen: leiomyosarcoma, grade of the fnclcc with negative margin. the laparoscopic approach is a safe and effective technique in the approximation of retroperitoneal tumors, a radical oncological criterion is always needed with correct margins of resection especially in those of uncertain etiology. we started endoscopic thyroidectomy using the lifting method in and have developed single incision endoscopic thyroidectomy (siet) via chest (c-) or axillary incision (a-) by our original retractor since . we created a new approach in . recently, we have applied this method to parathyroid surgery. in this study, we present our method and results in parathyroid surgery with regard to surgical outcome and patients' complaints. method: endoscopic parathyroidectomy of c-siet was performed in patients with hyperparathyroidism (primary , secondary ) in new approach (mean age , male female ). single parathyroid adenoma was diagnosed using ultrasonic device, preoperatively. the patient is placed in a supine position with the neck extended. mm vertical incision is made in anterior chest. flexible endoscope (olympus co. japan) is used through mm trocar detached the retractor. in new approach, the parathyroid and thyroid are exposed through the avascular space between sternal head and clavicular head of sternocleidomastoid muscle. both of the skin and sternal head are lifted up by our original retractor (takasago medical co. japan). parathyroid adenoma behind the thyroid is resected using an ultrasonic scalpel. i would like to present our c-siet procedure. results: no scars in the neck were left in all cases. benign and hemi lateral parathyroid adenoma sized from mm to mm (mean: . mm) were operated. mean operation time is min. in new approach. there was no complication. parathyroid hormone levels decreased in all patients immediately after operation. conclusion: it is a little possible to make recurrent nerve palsy in this approach. new approach is useful to operate and make the working space wider without stress to find out of parathyroid adenoma. our original retractor can be introduced easily in most hospital, because it is not so expensive. most of women satisfied cosmetic results because of hidden scars. objectives: radiofrequency ablation (rfa) is a novel and developing technique for the treatment of parathyroid hyperplasia/adenoma in the context of secondary hyperparathyroidism (hpt) to chronic kidney disease (ckd) and there is little literature on the subject. the purpose of this study is to determine its usefulness by contributing a case carried out in our hospital. methods: we selected a case of secondary htp in a patient of years old with ckd who presented a parathyroid adenoma detected clearly by ultrasound scanning. the patient was dismissed for surgery due to high surgical risk due to his comorbidities. rfa of a right inferior parathiroid adenoma was performed. intact parathyroid hormone (ipth) was measured before arf and min after de procedure, calcium and phosphorus were measured the day after. the treatment was considered effective if ipth levels decreased at least % min after rfa and calcium levels decreased the day after. results: ipth level before rfa was pg/ml. ipth level after min of rfa was pg/ ml, this meant a % reduction (normal values - pg/ml). calcium levels were from . at the baseline to . the day after (normal values . - . mg/dl) and phosphorus from . to . mg/dl (normal values . - . mg/dl). the patient presented dysphonia as a complication that improved with corticosteroid therapy. we are currently waiting for the next analytical controls at , and months after the proceidure. conclusions: rfa of parathiroid adenomas for treating secondary hpt in patients with ckd is feasible in selected patients. this treatment may reduce the morbidity that surgery supposes, it is developed in an outpatient regime avoiding hospital admission and this contributes to a reduction of health costs. however, a longer follow-up is necessary to verify the good results in our case. splenectomy is one of the treatment strategy for advanced portal hypertension due to liver cirrhosis. after splenectomy, thrombocytopenia is dramatically ameliorated, and liver function parameters have also been improved in several clinical settings. however, the mechanism underlying such a phenomenon remains unclear. the aims of the present study was to analyze histological changes of the liver after splenectomy in human, and to speculate the underlying mechanism. subjects and methods: cirrhotic patients with hepatocellular carcinoma (hcc) who had undergone laparoscopic splenectomy prior ( weeks- months) to hepatic resection were analyzed (n = ). non-tumorous liver specimens obtained at hepatectomy were histologically investigated. liver tissues from cirrhotic hcc patients who underwent only hepatectomy were used as controls (n = ). results: after splenectomy, significant leukocytosis, especially increase in monocytes, was observed in addition to thrombocytosis. in the non-cancerous liver tissues, many round-shaped cd -positive macrophages accumulated after splenectomy, while this phenomenon was merely observed in patients without splenectomy. the macrophages were cd ? (m marker) and cd -cd ? , suggesting their anti-fibrotic population. the accumulated macrophages existed around fibrous scar as well as ck ? epcam ? cells spreading out from the ductular reactions (dr). as a result, the number of ki -positive hepatocytes significantly increased after splenectomy. the amount of platelets detected in the liver did not change even after splenectomy. finally, remarked attenuation of the established liver fibrosis was detected after relatively long duration. the accumulated macrophages expressed metalloproteinase (mmp)- and fibroblast growth factor (fgf)- , suggesting these molecules may possibly participate in resolution of established fibrosis and hepatocyte proliferation. conclusion: splenectomy in cirrhotic patients with portal hypertension ameliorate liver fibrosis, and stimulate liver regeneration. the mechanism possibly include hepatic accumulation of anti-fibrotic cd -positive macrophages and stimulation of dr-derived ck ? epcam ? progenitor-like cells. in patients with advanced splenic fibrosis, splenectomy could be a feasible therapeutic modality. the paper tries to establish the role and the opportunity of using laparoscopy in regard with abdominal contusions, as well as its indications or contraindications, combined in a therapeutic algorithm. we analyzed two groups of patients with abdominal contusions divided over two -year periods, - ( patients) and - ( patients) respectively. we have separated the two periods because starting from we have established a strategy for dealing with cases of abdominal contusions where we included diagnostic and / or therapeutic laparoscopy and nonoperative management. the investigation was done by fast echography, ct scan, simple abdominal radiography, peritoneal lavage puncture, and sometimes arteriography. in the second period we determined the diagnostic and therapeutic laparoscopy indications: suspicion of hollow or parenchymal organ injury, or mesentery injury, the presence of hemoperitoneum or fluid in the peritoneal cavity in a stable patient without major hemorrhage, apparent with unique injuries, without immediate vital risk and without other associated severe trauma. we have associated in this last period the nonoperative management for patients with grade and lesions of parenchymal organs that do not have fluid in the peritoneum, or only a very discreet quantity. in the first period, all patients were treated by classic surgery, resulting in unnecessary laparotomies where no visceral lesions were revealed. in the second period, we applied non-operative management to patients out of , patients with grade and splenic injuries, and patients with grade and hepatic lesions. diagnostic laparoscopy was performed in cases, in of them without evidence of lesions, and in other cases of grade lesions no therapeutic action was required. therapeutic laparoscopy was required for one case of splenectomy and one of hepatorrhaphy. diagnostic laparoscopy is useful in abdominal contusions, if certain indications are followed and in selected patients. in our study, with the introduction of modern therapeutic strategies, unnecessary laparotomies were completely avoided, some lesions being even treated by laparoscopy. the new algorithm introduced allowed % of patients to avoid laparotomy. aims: about cases of splenic hamartoma have been described in the literature since it was first described by rokitansky in , it is a rare benign tumor. it is usually a casual finding in laparotomies or autopsies. they are usually asymptomatic, but there are few symptomatic splenic hamartomas and they can be associated with haematological alterations, being in some cases associated with spontaneous splenic rupture and acute abdomen, two thirds of them have multiple tumors. there are no specific data that allow the preoperative diagnosis of this entity, which is performed after the anatomopathological study of the surgical specimen, which must be extracted entirely, this together with the size of the spleen makes the laparoscopic approach difficult. the aim of this video is to demonstrate the surgical technique of a complete laparoscopic approach for this type of lesions, without the need for assistance laparotomies (handport). methods: clinical case: a -year-old man admitted to internal medicine due to fever and left lumbar pain. additional explorations of interest are discussed, including: thrombopenia of probable peripheral origin secondary hypersplenism (fna of bone marrow), ct: splenomegaly with splenic masses, which deform the splenic contour, compatible with atypical hemangiomas, without being able to discard other vascular splenic tumors. results: complete semi-laparoscopic approach, trocars, multilobulated splenomegaly ( x cm.), mechanical vascular section, complete bag extraction after minilaparotomy on the left flank. the patient presented a successful postoperative recovery, being discharged on the th po day. abdominal ultrasound at st week with portal vein thrombosis, which resolves after treatment with heparin. definitive result of the specimen: multiple splenic hamartoma. asymptomatic one year after surgery. the laparoscopic approach is a valid and effective alternative to splenic benign tumor lesions. the size does not contraindicate this type of approach, although the complete extraction of the spleen is recommended for its pathologic study. we recommend eco-doppler control per week, given the risk of portal thrombosis with an existing laparoscopic post-splenectomy. objectives: splenic cysts are a rare entity, currently described between - cases in literature. a female patient's case is hereby presented, giant splenic cyst treated by conservative laparoscopic surgery obtaining good results. method: years old female, without any relevant medical history, examined after abdominal pain on the left hypochondriac region, nausea, postprandial swelling and mass sensation. after exploration the presence of such mass was ratified, the rest of exploration found no relevant findings, no record of previous traumatism nor any other relevant incidence. diagnosis was made through ultrasound and computerized tomography, the existence of a big splenic cyst is confirmed, cm by cm, on the superior section of the spleen, negative results after parasitism test, normal haemogram, coagulation and biochemistry levels. patient was intervened using laparoscopic surgery, performing the deroofing technique on the cyst (two liters of orangey amber serous liquid that was sent for analysis) as well as extirpation of superior wall of the cyst, which was sent to pathological anatomy, a saline solution was used to cleanse the cavity, omentum and drainage were then set in place. results: patient evolved satisfactorily, hospital discharge and drainage withdrawal after h. regular check-ups, after and months, patient presents no symptoms nor recurrence. pathological anatomy confirmed primary splenic cyst and the extracted liquid as cystic. conclusion: splenic cysts are primary ( %) or secondary ( %). diagnosis is performed through imagery tests, cat scan the being standard test used. regarding her treatment there is no clear consensus, due to the fact that up to a few years ago, complete splenectomy was the recommended treatment, techniques with preservation of the spleen are currently being widely recommended through laparoscopy in literature. among the conservative techniques percutaneous aspiration, with or without the injection of a sclerosing agent, partial splenectomy, marsupialisation, cystectomy, decapsulation, unroofing or fenestration can be found. the main issue is recurrence rates. few cases of primary giant splenic cysts treated by laparoscopic decapsulation can be found in literature, this treatment being simple and quick to perform, resenting a recurrence rate lower than other techniques such as aspiration and marsupialization. introduction: technology's progress and its application in the minimally invasive surgery of the thyroid gland offers us new surgical approache's like the transaxillary approach. this new technic still unusual in our environment and has recently begun to be incorporated into our surgical practice. the objective of this case is to explain step by step how to carry out a right transaxillary thyroidectomy and emphasize in the most relevant tips to take into account. also we going to review the main limitations we observed so far. statement of the case: we present the case of a -year-old woman referred for evaluation of a left thyroid nodule without associated symptomatology. the blood test shows normal thyroid profile. cervical ultrasound is performed identifying a . cm single right nodule with welldefined edges and presence of peripheral vascularization . no other nodules are identified. fna of the nodule describes a bethesda iii. after evaluation we decide to perform a left transaxillary thyroidectomy. discussion: surgical treatment of the thyroid gland by transaxillary approach may be indicated in previously selected patients, offering the advantages from minimally invasive techniques (shorter recovery time, shorter incision length, etc.). surely, more evidence and experiencie is required to make a better assessment of minimally invasive approaches in thyroid surgery. surgery, taipi city hospital, yan-ming branch., taipei, taiwan; surgery, taipei city hospital, taipei, taiwan the first endoscopic thyroidectomy was performed in using a cervical approach. since then, various remote-access method, have been developed for thyroid surgery to avoid scarring of the neck. trans axillary approach(taa),bilateral axillo-breast approach(baba),and retroauricular approach(raa) are common in use. the main benefit of these procedure is that there are no visible scar that is one of the drawbacks of conventional kocher's incision. however,these methods require more dissection and longer operation time than conventional thyroidectomy transoral thyroidectomy(tovet) is a new approach and has become popular in recent years, however,most surgeons peformed a single procedure because of the limited patients and the learning periods sine ,more than cases were performed,patients received endoscopic thyroidectomy(et) procedure at our hospital. we compare the surgical procedure of bilateral axillo-breast approach(baba) with transoral vestiblar approach(tovet) in our hospital both performed by one single surgeon .the surgen has expended eaqual amounts of time with these two procedures. the patient seletion process,operation time, operation procedure and approach,learnig experience, consmetic effect,onaologic consideration and surgical outcome were discussed yhroughly. presenting a case of a thyroid metastasis from an ovarian carcinoma, we conducted a review of the literature without finding similar reported cases. case: a -year-old woman consults for progressive asthenia, weight loss and ascites. abdominal ct finds a conglomerate in the pelvis involving the ovaries and peritoneal implants, the largest up to cm. an omental epigastric lesion biopsy and paracentesis is performed resulting in adenocarcinoma and omental metastasis from ovarian neoplasm, associated with ca of . patient starts neoadjuvant therapy with carboplatin-paclitaxel. in image controls there is a favorable response. three months later, intervention was carried out; laparotomy hysterectomy ? double anexectomy ? omentectomy ? appendectomy ? pelvic and paraaortic lymphadenectomy.the anatomopathological study shows a low-differentiated endometrioid carcinoma, omentum infiltration and absence of metastatic lymphatic involvement. while getting the maintenance treatment with bevacizumab the patient presented symptoms of arthritis and hypercalcemia was detected ( . ) with pth . a gammagraphy was performed and an increased uptake area was detected in the lower pole of rtl, suggestive of a parathyroid adenoma. we initially proposed the possibility of performing radiofrequency ablation but in a previous thyroid ultrasound we visualize nodular lesions in rtl compatible with adenoma and a mass in the superior mediastinum that seems to correspond the area of greatest uptake in the gammagraphy so finally the procedure is dismissed and surgery is proposed. during the intervention we found a hard consistency nodule in the inferior pole rtl and lymphadenopathies of hard consistency in right vi area that are sent for intraoperative anatomopathological study with the result of adenocarcinoma metastasis without identifying origin. a total thyroidectomy, parathyroidectomy and central ganglion drainage is performed with the result of a parathyroid adenoma, lymphatic invasion of ovarian-grade latent carcinoma and extensive vascular permeation by carcinoma of the thyroid. the patient maintains oncological treatment with carboplatin-caelix. in the last follow-up, the pth and calcemia remains normal. conclussion: although some cases of neoplasic thyroid involvement associated with struma ovarii have been published, no cases similar to the one described are found, neither in our experience, which is why it is an exceptional case. the aim of the study was to evaluate the effectiveness of the use of embolization of the splenic artery in order to prevent portal bleeding. methods: the study included patients, who had esophageal varices bleeding, which developed as a result of decompensated cirrhosis of the liver of various etiologies of classes b and c according to child-pugh. patients were divided into groups. the main group included ( . %) patients who underwent endoscopic ligating of bleeding varix and in order to prevent recurrence of bleedingembolization of the splenic artery with gianturco coils. the comparison group consisted of ( . %) patients who received only drug therapy. to assess the effectiveness of the treatment, the patient's condition was monitored for months. results: the average age of patients in the comparison group was . ± . years. using only drug therapy, we stopped bleeding in ( . %) patients. in all cases, at the end of treatment, we received an improvement in clinical and laboratory parameters. ( . %) patients died. the duration of treatment was . ± . days. the average age of patients in main group was . ± . years. performing endoscopic ligation of bleeding varices, we stopped bleeding in ( . %) patients. in all cases, at the end of treatment, we received an improvement in clinical and laboratory parameters. ( . %) patients died. the duration of treatment was . ± . days. a statistical analysis of mortality and duration of treatment revealed a significant difference (p \ . ) between the groups in both indicators. after splenic artery embolization in all cases managed to achieve a reduction in blood flow of - %. after months among patients in the comparison group, bleeding relapse occurred in ( . %) cases. in the main group, this indicator was . % ( patients). the indicator in the main group was significantly (p \ . ) different from the same indicator in the comparison group. conclusion: performing embolization of the splenic artery in patients after endoscopic hemostasis of variceal bleeding allows to reduce the pressure in the portal system, which in turn leads to a decrease in the frequency of bleeding recurrences. thoracoscopic esophagectomy for aortoesophageal fistula y. ebihara, t. shichinohe, y. kurashima, s. murakami, surgery ii, hokkaido university, sapporo, japan background: aortoesophageal fistula (aef) is an uncommon but one of highly fatal conditions. there are surgical, endoscopic and interventional radiological treatment options, however, definitive treatment is the surgical intervention. video-assisted thoracoscopic surgery (vats) has been gradually accepted as a substitution for thoracotomy to reduce the invasiveness of the surgery as radical surgery for esophageal cancer. we aimed to evaluate a feasibility of vatsesophagectomy (vats-e) for aef in this study. introduction: achalasia is the most common motility disorder of the esophagus. heller's cardiomyotomy associated with a antireflux technique is the treatment of choice in patients with this disease; however, a small group of patients could present a recurrence of the symptoms being necesary a new surgery, what is an important challenge for most of the surgeons. we report the case of recurrence after a laparoscopic miotomy and dor fundoplication as a paradigm for the appropiate management in this kind of patients. methods: a years old female, who underwent a previous miotomy and a dor fundoplication in due to an achalasia.six years after surgery, the patient showed epigastric pain and dysphagia. the study of the patient was performed with: barium swalow, phmetry, manometry, ct-scan and mri showing a recurrence of her disease.the patient was transfered to our center where she underwent a new surgery.the key points of the new surgery includes the next steps: dissection of the previous adhesions, dissection of the dor's partial fundoplication, avoid dissection of the anterior esophageal wall at the leve lof the hiatus (the area of previous myotomy) in order to avoid perforation of the esophagus, lateral and posterior dissection of the distal esophagus, lateral myotomy at the rigth wall of the esophagus and a toupet's funduplicatury. all of thisis procedures are done under intraoperative endoscopy in order to confirm a good passage to the estmach and to identify a perforationic supervision. results: following theseis steps several patients have been operated in our center with excellent results. in all of these cases, including the patiente presented previously, the symptoms have dissapeared. conclusions: achalasia is a rare motility disorder of the esophagus, being recurrences an important challenge for surgeons. a great proper therapeutic strategy using the different diagnostic exams and the supervison by a group of experts in this kind of entity are the basis in order to obtain good results in these situations. aims: re-do fundoplication is usually performed for recurrent reflux symptoms due to wrap failure or recurrent hiatus hernia. conversely, persistent dysphagia may occur early due to tight wrap/crural repair which should be avoided by good surgical technique. a small group of patients however may suffer progressive dysphagia due to weakening motility (especially in older patients), fibrosis of the wrap or a combination of the two. this video demonstrates the successful treatment of this problem with a laparoscopic conversion from nissen to posterior toupet fundoplication. a year old man underwent an uncomplicated laparoscopic nissen fundoplication in with complete resolution of reflux symptoms. he re-presented years later, still free of reflux but suffering progressive dysphagia and troublesome regurgitation. investigations demonstrated intact wrap and no mechanical obstruction, but confirmed low-amplitude peristalsis. a trial endoscopic dilatation improved symptoms for days before recurrence, suggesting likely wrap fibrosis (which would reduce elasticity and impede passage of food bolus), justifying consideration for a conversion from nissen to toupet. results: this video demonstrates the expected adhesions between fundoplication and inferior surface of left lobe liver, mobilisation and division of the nissen fundoplication, and reconstitution of a posterior toupet fundoplication. the patient made a good recovery and was discharged the following day. three-and six-month follow-up confirmed complete resolution of symptoms with no recurrence of reflux. conclusion: laparoscopic re-do surgery for late-onset progressive dysphagia is a safe and viable option. patients must be thoroughly investigated and carefully selected for an appropriately tailored procedure. they should also be advised of the increased risks associated with re-do surgery. the anatomy can be unpredictably distorted by variable adhesions and this operation should therefore only be performed by laparoscopic surgeons experienced in both primary and re-do fundoplication. methods: i report unusual iatrogenic injury of cervical esophagus that resulted with complete resection post total thyroidectomy for papillary ca of thyroid patient presented days post surgery to our center. the video will show the steps used to treat this unusual complication by neck exploration, laparoscopic trans hiatal esophagectomy with creation of gastric tube with preservation of the right gastroepiploic artery and the neck anastomosis between the cervical esophagus and stomach. were open and minimally invasive esophagectomies. of the patients, were for squamous cell carcinoma, were adenocarcinoma and were of other histological diagnosis such as gastrointestinal stromal tumor and schwannoma. the median length of stay for patients who underwent minimally invasive esophagectomies was days ( to days) while the median length of stay for patients who underwent open esophagectomies was days ( to days). the minimally invasive group had a shorter icu stay of day. for day morbidity, the minimally invasive esophagectomy group had patients who encountered anastomotic leaks, with post operative pneumonia while the open esophagectomy group had patient with anastomotic leak, patient with post operative stricture and patient with delayed gastric emptying. there were mortalities in the minimally invasive group while there were no mortalities in the open group. conclusion: our data show that patients who underwent minimally invasive esophagectomies had a shorter duration of hospitalization with similar perioperative morbidity rates. minimally invasive esophagectomy is a viable surgical option for a select group of patients. aims: there has been an increasing tendency towards minimally invasive surgery for esophageal cancer. our aim was to evaluate the results of the thoracoscopic approach (ta) and compare them with the ones of open approach (oa) at our institution. methods: retrospective review of all patients who underwent esophagectomy due to esophageal cancer (adenocarcinoma or squamous cell) between and were included. patients with siewert iii tumors and those who didn't need a thoracic approach were excluded. results: during the study period were performed esophagectomies, through ta. in . % of these, the abdominal stage was done by laparoscopy. when comparing ta versus oa, there were no statistically significant differences in the baseline characteristics of the two groups (mean age, median body mass index, ecog performance status, asa score, smoking status, diabetes mellitus, pulmonary disease, histologic type, clinical staging and neoadjuvant chemo and radiotherapy). regarding outcomes, there were no significant differences in need of intraoperative transfusion, median intraoperative blood loss, operative time and length of stay. although not significant, in ta group there was a tendency for higher overall morbidity ( . % versus . %, p = . ); major morbidity-ctcae - ( . % versus . %, p = . ); anastomotic leak ( . % versus . %, p = . ) and re-intervention rate ( . % versus %, p = . ). on the other hand, in ta group there was a tendency (although not significant) towards lower rate of respiratory complications ( . % versus . %, p = . ), lower rate of r margins ( . % versus . %, p = . ) and higher median of lymph nodes removed ( versus , p = . ). conclusions: in our series, outcomes of ta were similar to oa, with a tendency towards lower respiratory complications, lower rate of r margins and higher number of lymph nodes removed in ta group. the impact of these findings in survival remains to be seen. the tendency towards higher morbidity may be related to the learning curve, since this were the first cases performed at our center. background: esophagectomy is a surgical procedureburdened by a high morbidity rate. the effect of minimally invasive (mi) approach on elderly patients is still not clear. aim: of this study was to analyze the impact of mi approach on post-operative course according to the patient age. methods: a consecutive series of patients underwent to elective oncological esophagectomy between and . all data were entered into a prospective database. patients submitted to -flield or trans-hiatal esophagectomywere excluded andonly ivor-lewisopen, hybrid or totally minimally invasive esophagectomywere. patients were stratified according to age in groups:group a(= years) patients, group b ([ and \ years) and group c (were = years) .clinical and pathological factors influencing surgical outcome were evaluated. complications were classified according to clavien-dindo (cd). results: as expected outcomes worsened with patients age(cd = b: . % group a, % group b and % group c. p = . ), mortality ( % group a, % group b and . % group c. p = . ) and length of stay ( days group a, days group b and days group c. p = . ).a statistically significant higher incidence of anastomosticleaks was observed among patients submitted to totally mi esophagectomy in group c vs a and b that were respectively , %, % and %. major respiratory complications were not statistically different among these three sub-group. conclusions: old age has a significant impact on outcomes afteresophagectomy. in this subset of patients a mi approachcould also increasepostoperative morbidity. elderly patients should be carefully selected before to be submitted to mi esophagectomy. introduction: esophagectomy is a major surgical procedure with morbidity and mortality related to the patient's condition, stage of the disease, complementary treatments, and surgical experience. minimally invasive esophagectomy (mie) may lead to a reduction in perioperative morbidity and mortality with very good quality of life. material and method: we present the experience of the center of excellence in esophageal surgery regarding totally mie through thoracolaparoscopic modified mckeown three-stage approach followed by esophageal reconstruction by gastric intrathoracic pull-up and cervical esophagogastric anastomosis used for the treatment of thoracic esophageal cancer. results: in the last years, mie was performed initial, in our clinic with extracorporeal preparation of the gastric conduit with reduced lung complications and hospital stay. we introduced the totally minimally invasive esophagectomy with laparoscopic-assisted feeding jejunostomy using a d high definition camera. operative times were: thoracic- min, abdominal- min and cervical- min with a total of min. the augmented d high definition image provided an excellent visual field, that allowed an accurate identification of dissection plans and extensive periesophageal and perigastric lymphadenectomy. the short-term outcomes of the totally minimally invasive esophagectomy procedure were very encouraging with early feeding on jejunostomy and the control of cervical anastomosis was usually performed in the th day postoperative and the patients were discharged in the th day postoperative without any symptomatology. at the first and third-month follow-up was not reported any major complications. the long-term oncological results are being evaluated. conclusions: the totally minimally invasive approach using advanced technology of endoscopic surgery allowed for these patients a simple postoperative evolution, no major complications, and a good recovery after an extensive surgery. the solid experience in open esophageal surgery of the upper gastrointestinal surgeons provides a fast learning curve of complex minimally invasive surgical procedures with reduced perioperative morbidity. long-term follow-up should confirm the results from the literature regarding the survival, which is expected to be for these patients at least equivalent with outcomes after open esophagectomy. introduction: esophageal fistulas, benign or malignant, represent a real challenge for the surgeons and gastroenterologists, regarding the treatment and the outcome. in these cases, endoscopic treatment is the first line approach, being less invasive and sometimes avoiding the need for surgery. this includes clips, stents, glue and even suture. material and method: we have analyzed esophageal fistulas in patients with benign or malignant pathology, diagnosed and treated in the first months of . the management of this complication included a self-expandable esophageal metallic stent. we have evaluated the diagnosis, the surgical intervention, the timing until the development of the leak, the localization and management of the fistula. results: were postoperative leaks and spontaneous esophageal fistulas. the localization was cervical in one case, thoracic in cases and abdominal in cases. for the postoperative fistulas, in patients the treatment included at least one surgical reintervention with lavage and drainage, beside the insertion of an esophageal metallic stent. in the other cases, endoscopic treatment and antibiotic therapy was enough. in cases, the stent migrated needing repositioning. days mortality was %, both patients from postoperative group. conclusions: esophageal fistulas represent a severe complication, usually in patients already immunocompromised. endoscopic management, including self expandable esophageal metallic stent, can be the main approach, by stopping the contamination and by permitting the early per oral feeding. disadvantages include the possibility of migration and the need of removal after - weeks. methods: five hundreds and one patients with esophageal cancer who underwent mie from to at our department were eligible. we considered the risk factors of complications of pneumonia, anastomotic leakage, and hoarseness after surgery, and the risk factors of difficulty of surgery. results: the risk factors of postoperative complications in univariate analysis were more than years old (odds ratio: . , p = . ), more than ii in asa-ps (odds: . , p \ . ), more than g of bleeding (odds: . , p = . ), more than min. of operation time (odds: . , p \ . ), and colon reconstruction (odds: . , p = . ). the one in multivatiate analysis was more than ii in asa-ps (odds: . , p = . ). the risk factors of much bleeding were colon reconstruction (odds: . , p \ . ), and more than of lymph node dissection (odds: . , p = . ). the risk factors of long operation time without cervical lymph node dissection were neo-adjuvant therapy (odds: . , p \ . ), more than of lymph node dissection (odds: . , p = . ), and colon reconstruction (odds: . , p \ . ). the ones with cervical lymph node dissection were more than pstage iii (odds: . , p \ . ) and more than of lymph node dissection (odds: . , p = . ). conclusions: considering those risk factors, we should perform perioperative management more carefully. method: sa -year-old man with a tobacco and alcoholic habit was suspended for years, under treatment for arterial hypertension, who consults for a logical dysphagia of months of evolution. he is diagnosed of stenosing esophageal distal third epidermoid carcinoma txn m . it is decided to place a prosthesis that is effective and subsequent neoadjuvant qt-rt, after weeks of its completion the surgery is performed. results: the surgery is performed in times, initially by laparoscopy. the esophageal hiatus and the greater curvature are dissected preserving the right gastroepiploic, and lymphadenectomy of the celiac trunk with pedicle section of the left gastric. gastric plasty is performed with a section of lesser curvature towards fundus. it is continued by thoracoscopy. a section of the azygos vein is performed, dissection of the esophageal middle and lower third and lymphadenectomy. gastric plasty is promoted, proximal esophagus section and latero-lateral intrathoracic gastro-oesophageal anastomosis. the anatomopathological study reports ypt and pn with / adenopathies, and disease-free surgical margins. he was discharged without complications on the th day and did not require re-entry. conclusions: ivor-lewis endoscopic surgery is safe and meets oncological criteria in selected patients with distal esophageal neoplasia and performed by an experienced esophagogastric unit. background: the rates of thoracoscopic esophagectomy performed in the prone and left lateral decubitus positions are similar in japan. we retrospectively reviewed short term outcomes of thoracoscopic esophagectomy for esophageal cancer performed in the left lateral decubitus position under artificial pneumothorax by co insufflation in a single institution. this study aimed to evaluate the feasibility of applying this procedure. methods: between july and december , patients with esophageal cancer underwent thoracoscopic esophagectomy in the left lateral decubitus position under artificial pneumothorax by co insufflation. the thoracic procedure is performed as follows:the lymph nodes around the right recurrent laryngeal nerve are dissected. on the cranial side, the lymph node dissection is advanced to the level of the inferior thyroid artery. then, the assistant rotates the trachea toward the ventral side, and the lymph nodes around the left recurrent laryngeal nerve are dissected. the middle and inferior mediastinal lymph nodes are dissected including supradiaphragmatic lymph nodes and the dorsal lymph nodes around the thoracic descending aorta. then, the esophagus is transected using an automatic suture device. finally, the tracheal bifurcation area lymph nodes are dissected. we retrospectively analyzed these patients. results: the completion rate of thoracoscopic esophagectomy was . %, and the procedure was converted to thoracotomy in five patients, due to hemorrhage,severe adhesion. the mean intrathoracic operative time, intrathoracic blood loss, and number of dissected mediastinal lymph nodes were . min, . ml, and . , respectively. postoperative complications included pneumonia ( . %), anastomotic leakage ( . %), and recurrent nerve paralysis ( . %). postoperative ( d) mortality was / ( . %) due to ards and nomi, respectively. conclusions: standardization of the procedure for thoracoscopic esophagectomy in the left lateral decubitus position under artificial pneumothorax by co insufflation, with a standardized clinical pathway for perioperative care led to favorable surgical outcomes. introduction: recently thoracoscopic surgery has become widespread even in chest procedure in thoracic esophageal cancer surgery. as an advantage of minimally invasive esophagectomy, it is possible to perform sophisticated procedures due to its magnified visual effects. on the other hand, short-term perioperative safety and oncological safety are still unclear. in cases where abnormal anatomy or comorbidity in the thoracic cavity is observed, it is thought that it is necessary to carry out thoracic surgery which ensures safety while keeping in mind the transition to transthoracic surgery. here, we report on esophageal resection of the thoracic esophageal cancer accompanied by a mm saccular aneurysm inside the aortic arch. patient: a -year-old man visited a nearby doctor with a chief complaint of discomfort during swallowing. upper gastrointestinal endoscopy examined middle cervical esophageal cancer and received referral to our hospital. ct revealed a mm saccular aneurysm inside the descending aorta in contact with the thoracic esophagus. preoperative diagnosis was middle thoracic esophageal cancer; -iic ct bn m stageia (uicc th). we performed thoracoscopic esophagectomy and lymph node dissection as curative surgery. the anterior surface of the aorta was exposed from the lower mediastinum and descended ascendingly, reaching the lower end of the saccular anus at the head level of the lower pulmonary vein. peeling off the esophagus dorsal side along the margin of the saccular sac and performing esophageal resection. conclusion: we reported thoracoscopic esophageal resection for thoracic esophageal cancer with chest descending aortic saccular aneurysm. thoracoscopic surgery, which can fully exploit close magnification effect, seemed to be useful for anatomically disqualified cases. introduction: anastomotic leakage from oesophagojejunal (oj) anastomosis after total gastrectomy is associated with a high morbidity and mortality rate. leakage rates reported vary between ?% and ?% but lack of consensus in management. in the past, it often required surgical intervention or radiologically abscess drainage that will keep patients fasted with external drain for a long duration. recently, variable endoscopic options-oesophageal stents, clips, fibrin glue and endoluminal vacuum therapy had been introduced with variable outcomes. here, we presented a case of oj anastomotic leak management with combination innovative endoluminal and radiologically technique to insert double pig-tailed catheter. aim: to introduce the feasibility of double pig-tailed catheter for drainage and management of oj anastomosis leak. a year old man presented with two months history of dysphagia. upper endoscopy (ogd) showed suspicious cardio-oesophageal lesion. histology biopsy confirmed with adenocarcinoma. ct-scan of thorax, abdomen and pelvic showed irregular thickening at cardiooesophageal junction with regional lymphadenopathy. no distant metastases. he underwent uneventful d total gastrectomy. on th post-operative day, patient had spike fever and newly developed atrial fibrillation. urgent ct-thorax, abdomen and pelvis with oral omnipaque. it showed lower mediastinal gas-containing fluid adjacent to oj anastomosis within the left retrocrural space suspicious for leak. ogd evaluation showed pin-hole oj leak. guidewire inserted via endoscopy into left retrocural space under radiologically guidance. double pig-tail fr cm subsequently inserted via seldinger approach over guide wire. the proximal end of pig-tail pushed into left retrocural space and distal end positioned into efferent jejunal limb with crocodile jaw through endoscope. diluted contrast injected and passed down to efferent limb with minimal leak. outcome: after double pig-tail insertion, patient started on clear feed on st day post-insertion. one week later, he was started on full feed. repeat upper endoscopy and stent removal done two weeks later. contrast injection showed small blind ended sinus tract from anastomosis toward left pleural space without obvious leak. conclusion: radio-endoscopic is a novel minimally invasive technique that allows insertion of double pig-tailed internal drainage to control oj anastomosis leak. it allows early enteral nutritional feeding and avoid external drainage. background: the number of gastric cancer (gc) survivors, especially long-term survivors, is increasing. how best to evaluate the diseasespecific survival (dss) of gc survivors over time is unclear. we aimed to assess changes in the conditional survival of patients with gc after curative intend gastrectomy and the evolution of the impact of well-known risk factors. methods: clinicopathological data from , patients who underwent curative intend resection for gc at four specialized centres (three in china and one in italy) and from the surveillance, epidemiology, and end results (seer) database were retrospectively analysed. changes in the patients' -year conditional disease-specific survival (cs ) were analysed. we used time-dependent cox regression to analyse which variables had long-term effects on dss and devised an accurate, dynamic dss predictive model based on the length of survival. results: the median follow-up time was months, and disease-specific death occurred in , cases ( . %). the dss of the patients after surgery was dynamic, and most of the disease-specific deaths occurred within the first years after surgery. based on -, -, -, -and -year survivorships, the cs of the population increased gradually from % to . %, . %, . %, . %, and . %, respectively. subgroup analysis showed that the cs of patients who had poor prognostic factors initially demonstrated the greatest increase in postoperative survival time (e.g., n b: . %- . %, ? . % vs. n : . %- . %, ? . %). time-dependent cox regression analysis showed the following predictor variables constantly affecting dss: age, the number of examined lymph nodes, t stage, n stage and site (p all \ . , years after gastrectomy). the influence of prognostic factors on dss and cs changed dramatically over time. based on data from several large global centres, we developed an effective model for predicting the dss of gc patients based on the length of survival time. this model can provide personalized long-term follow-up strategies for patients. methods: we retrospectively analyzed clinicopathological data for rgc patients who underwent radical gastrectomy from centers. the prognosis prediction performances of the ajcc th and ajcc th tnm staging systems and the trm staging system for rgc patients were evaluated. web-based prediction models based on independent prognostic factors were developed to predict the survival of the rgc patients. external validation was performed using a cohort of chinese patients. result: the mean number of retrieved lymph nodes was . , and in . % of patients, the number was = . the predictive abilities of the ajcc th and trm staging systems were no better than those of the ajcc th staging system (c-index: ajcc th vs. ajcc th vs. trm, . vs. . vs. . ; p [ . ). within each staging system, the survival of the two adjacent stages was not well discriminated (p [ . ). multivariate analysis showed that age, tumor size, t stage and n stage were independent prognostic factors for overall survival (os), disease-specific survival (dss) and disease-specific survival (dfs). based on the above variables, we developed web-based prediction models, the huang os model, the huang dss model and the huang dfs model, which were superior to the ajcc th staging system in their discriminatory ability (cindex), predictive homogeneity (likelihood ratio chi-square), predictive accuracy (aic, bic), and model stability (time-dependent roc curves). the stratified analysis showed that regardless of whether more or fewer than lymph nodes were retrieved, the predictive performances of the web-based prediction models were still better than those of the other three staging systems. a decision curve analysis showed that the huang model provided better net benefits than the other three staging systems. external validation showed predictable accuracies of . , . and . , respectively, in predicting os, dss and dfs. conclusion: the ajcc tnm staging system and the trm staging system did not enable good distinction among the rgc patients. we have developed and validated visual web-based prediction models that are superior to these staging systems. objective: to perform competing risk analysis and evaluate cancer-and noncancer-specific mortality in patients with gastric cancer after radical surgery. methods: a total of patients from our department (as training set) and a total of patients from the surveillance, epidemiology, and end results (seer) database (as validation set) were enrolled in the study. the cumulative incidence of cancer and noncancer-specific mortality was determined by univariate and multivariate competing risk analysis. results: the five-year cancer-and noncancer-specific cumulative incidence of death (cid) in the training set were . % and . %, respectively, which were significantly lower than that in the validation set ( . % and . %, respectively). multivariable analysis showed that age, tumor site, tumor size and ptnm stage were independent predictors of gastric cancer-specific mortality and overall survival, whereas age was an independent predictor of gastric noncancer-specific mortality. noncancer-specific cid surpassed cancer-specific cid for ptnm stage i patients after approximately years of surgery, but never for stage ii and iii patients. moreover, for stage i patients, the time point when noncancer-specific cid surpassed cancer-specific cid become earlier as age increasing, with only . years after surgery for patients more than years of age. conclusions: age is an independent predictor of gastric cancer-and noncancer specific mortality and overall survival for patients after radical surgery. for patients with stage i gastric cancer, noncancer-specific mortality is a significant competing event, with an increasing impact as age increases. aim: of the study was to analyse the possibility of function preserving gastrectomy based on the sentinel lymph node (sln) concept. methods: during last years in two clinics odessa national medical university we used mapping procedures in the patients with early gastric cancer. there were men and women, age to years, mean age . ± . years. blue dye was injected into quadrants of the submucosal layer surrounding the primary lesion using an endoscopic puncture needle in patients. blue lymphatic vessels and blue-stained lymph nodes can be identified by laparoscopy within min. of the blue dye injection. we used . % indocyanine green in patients, which we injected by intraoperative endoscopy. new technology indocyanine green (icg) fluorescent imaging was used for sln mapping in this patients. results: amany patients, in which we used blue dye for mapping sln, positive sln was in patients, negative-in patients. in all patients distal gastrectomy (dg) was performed with d lymphdissection. from patients with negative sln in patients metastasis in other lymph nodes were detected.among patients in whom we used icg fluorescent mapping positive sln were detected in patients. laparoscopic-assisted distal gastrectomy with d lymph node dissection was performed in these patients. in patients with negative sln partial wedge resection was performed in patients, segmental pylorus preserving gastrectomy was performed in patients. during follow-up period from to months no recurrences or metastasis were detected in these group of patients. qol in this group of patients was much better, than in patients with conventional distal gastrectomy. conclusions: icg fluorescent method is highly effective for detection of sln. in the patients with early gastric cancer function preserving gastrectomy based on sln navigation may be promising strategy to achieve better results. laparoscopic procedure taking advantage of robotic gastrectomy for gastric cancer to prevent pancreatic fistula gastrointestinal surgery and surgical oncology, ehime university, toon-city, japan backgrounds and aims: analysis of japanese national clinical database (ncd) showed that laparoscopic gastrectomy(lg) had rather increased pancreatic fistula (pf) compared with open gastrectomy. on the other hand, last year, multicenter collaborative research result of robotic gastric cancer surgery(rg)was shown that the complications including pf were significantly decreased as compared with lg. in this study, we have employed a new easy to use device in lg to minimize pf during suprapancreatic lymph nodes dissection requiring pancreatic retraction and compared with conventional lg and rg. materials and methods: internal organ retractor (aesculapÒ) to grasp the gastropancreatic fold and the suprapancreatic peritoneum to imitate davinci's forceps was guided with a thread outside the body. patients(jan. * nov. ) were divided into three groups as follows, group lg- (n = ), lg using the standard devices, group lg- (n = ), lg using organ retractor, group rg (n = ). amylase value in drain(d-amylase) and the volume in drainage, intraoperative bleeding, postoperative hospital stay, incidence of cd (] grade iii) were compared among three groups. results: data are indicated as lg- /lg- /rg(mean ± sd), respectively. on the day and third day after surgery, d-amylase were ± / ± / ± and ± / ± , ± (iu/l). d-amylase was significantly lower in lg- and rg group than in lg- the day after surgery. the operation time was significantly longer in rg, ± / ± / ± (min). bleeding volume and hospital stay did not differ among groups. pancreatic fistula (cd ] grade iii)was observed only in lg- group at (%) . discussion: pf(grade]cdiii), which may lead to mortality, occurred in lg- group. a significant elevation of d-amylase on the st postoperative day was prevented in lg- just like rg, which seemed to lead to prevent pf afterwards. the multijoint forceps is known to be an advantage of rg but it cannot be reproduced by lg using a linear forceps. however, another advantage such as vertical grasping and lifting of the gastropancreatic fold at rest could be mimicked by lg using this device, which seemed to enable a safe lymph node dissection and lead to reduce the pancreatic damage. conclusion: this inexpensive and easy to use method taking the advantage of rg seems to reduce surgeon's fatigue and tissue damage(pf). the study presents comparison of perioperative outcome between different surgical approaches for gastric adenocarcinoma (ac). methods: retrospective cohort of patients that underwent gastrectomy for (ac) at rambam hospital during - . patients data was collected based on demographic characteristics, bmi, operating room time (ort), number of lymph nodes (ln), length of hospitalization (loh), and perioperative complications. results: study population included patients after total gastrectomies, of them robotic and partial gastrectomies, of them robotic. age, gender and bmi were similar between patients who underwent any type of procedures. median length of hospitalization (loh) for robotic total gastrectomy was . days and it was significantly shorter than both laparoscopic total gastrectomy (ltg) . days (p = . ) and open total gastrectomy (otg) . days (p \ . ). similar significant differences in (loh) between the groups were observed among patients who underwent partial gastrectomy, but the comparison between robotic and laparoscopic procedures was limited due to small numbers of (lpg). median(ort) was significantly longer among robotic gastrectomies compared to open, the difference was min in total gastrectomy group and min in partial gastrectomy group (p \ . for both differences), but the difference in(ort) between laparoscopic and robotic procedures were smaller and non-significant. the number of dissected (ln) was similar between the procedures in total gasrectomies. in partial gastrectomies, the number of dissected (ln) was even higher among both laparoscopic and robotic gastrectomies compared to open (p \ . ).) conclusions: robotic total and partial gastrectomies for gastric (ac) are associated with oncologically adequate lymphadenectomy and faster patient recovery, but longer ort. objectives: during esophagojejunostomy using a circular stapler after latg, placement of the anvil head via the transabdominal approach proved difficult. the authors report on a method modified for laparoscopy-assisted, esophagojejunostomy performed by placing the pretilted anvil head(orvil) via the transoral approach. methods: between january and november , esophagojejunostomy was performed using orvil in patients after latg. the anesthesiologist introduced the anvil while observing its passage through the pharynx. during the anastomosis, we kept the jejunum fixed in position with a silicone band lig-a-loops, thereby preventing the intestine from slipping off the shaft of the stapler. results: esophagojejunostomy using the orvil was achieved successfully in all patients. no other complications, such as hypopharyngeal perforation and/or esophageal mucosal injury, occurred during passage. the postoperative complications of anastomosis were leakage in two patients and stenosis in patients, in whom mild relief was achieved using a bougie. conclusions: esophagojejunostomy using the orvil is a simple and safe technique. gastrointestinal tract surgery, fukushima medical university, fukushima-shi, japan; surgery, ohara general hospital, fukushima-shi, japan background: juvenile polyposis of the stomach is a very rare disease, and its malignant potential has been reported previously and total gastrectomy has been recommended as a standard treatment. recently, the usefulness of laparoscopic surgery for this case has been reported, however this type of surgery is thought that maintaining the surgical space is difficult because of distended and thickening stomach. case presentation: eight years ago, a -year-old woman who had no family history of gastrointestinal polyposis had been diagnosed with gastric polyposis and polyp-related anemia and received twice endoscopic submucosal dissection to early gastric cancer in another hospital. she had received an annual upper gastrointestinal endoscopy and she had taken iron supplements for anemia caused from the occasional bleeding from the polyps. however, the number of the polyps had increased over time. because she had a loss of appetite, she admitted to our hospital. enhanced computed tomography showed gastric wall thickening and multiple gastric polyps without lymphadenopathy or distant metastasis. colonoscopy showed no specific findings. she was diagnosed as the juvenile polyposis of the stomach, and she received laparoscopic total gastrectomy with roux-en y esophagojejunostomy. in operative findings, although there were the excessive distention and congestion of the stomach, standard laparoscopic surgery could be performed. the resected specimen revealed multiple variously sized polyps throughout the stomach except for lesser curvature and fundus and the histopathological examination revealed that all polyps were hyperplastic polyps without containing cancer. she was discharged on postoperative day . we successfully performed laparoscopic surgery to treat a rare case of juvenile gastric polyposis. introduction: we report a novel technique for combined use of laparo and thoracoscopy for faradvanced adenocarcinoma of esophagogastric junction (aeg). case presentation: a 's years old man presented with far-advanced aeg. an esophagogastroduodenoscopy revealed a type lesion with the entire circumference around esophagogastric junction (egj). contrast radiography revealed a severe stenosis in the egj and wall irregularity from egj to cardia. computed tomography revealed a stenosis of egj, suspected invasion into the left side diaphragm and some lymph nodes metastases at the abdomen. we diagnosed siewert type ii aeg (ct an m , cstage iiia : japanese classification of gastric carcinoma ver. ). surgical technique :the patient was placed in the reverse-trendelenburg position with the left upper body lifted and legs spread, under general anesthesia. the tumor was huge, exposed from the serous membrane and invaded the left crus. first we performed from laparoscopic proximal gastrectomy using five ports. then, three ports were added in the th, th, and th intercostal spaces with the patient in the same body position, and performed thoracoscopic lower esophagectomy under artificial pneumothorax with intrathoracic pressure of - mmhg, which allows the ventilation of both lungs. the lower esophagus was resected under the thoracoscopic view to ensure an adequate margin. following this resection, intrathoracic esophagojejunostomy was performed by using the laparo-and thoracoscopic techniques. the operative time was min, and the blood loss was g. he was discharged on the th day after the operation without any postoperative morbidity. the histopathological diagnosis was pt bn am , p , pstage iv. after adjuvant chemotherapy with capecitabine and oxaliplatin, ramcilumab monotherapy is undertaken now. ct revealed solitary lung metastasis in months after the operation. conclusion: malta for locally advanced aeg invading the surroundings could be performed safely. introduction: despite being the pioneer in laparoscopic surgery, europe did not have similar surgical experience compared to east asia due to decreased exposure to gastric cancer. several studies on minimally invasive gastrectomy for gastric cancer have been conducted in europe. however, some of them did not analyse total gastrectomy as a distinct entity combining both distal and total gastrectomies; moreover, most of them do not provide data on full five-year follow up for each patient. baltic countries stand in between east and west in terms of gastric cancer incidence: incidence rate per , is . in united kingdom, . in lithuania and . in japan. this exposure to gastric cancer provides unique opportunity to investigate the role of laparoscopic gastrectomy. therefore, a case-control study was designed to evaluate laparoscopic (ltg) versus open total gastrectomy (otg), comparing short-term surgical and long-term oncologic outcomes. surgery, jeju national university, school of medicine, jeju, korea; surgery, chosun university, school of medicine, gwangju, korea objective: although mcv (mean corpuscular volume) levels are known to be associated with the prognosis of various diseases, few study investigated mcv as prognostic factor after gastric cancer surgery. the aim of this study is to address the prognostic value of mcv in gastric cancer who underwent curative gastric cancer surgery. methods: patients (june -december ) with stage i, ii, and iii cancer were consecutively included in this study. all patients underwent curative gastric cancer surgery including subtotal gastrectomy or total gastrectomy. overall survival (os), disease-free survival (dfs) and postoperative complications rate were compared between mcv [ group and = group. results: of all patients, the mean mcv was fl (normal range, to fl). the dfs was significantly higher in the high-mcv ([ ) than low-mcv group(= ) (p \ . ) group. there was no significant difference in postoperative complications when compared with clavien-dindo scale. the survival rate of the high mcv group was higher but there was no significant difference. conclusions: mcv may be a predictive factor after gastric cancer surgery. unlike previous studies, patients with low mcv group showed lower dfs. more research is needed on the significance of mcv in variety of disease. methods: and materials. for years we observed cases with gist of stomach and duodenum. seven patients were brought to clinic with the bleeding and two patients were brought to clinic with vomiting and compensate stenosis. in all circumstances we done the ct, mrt and endoscopic examinations of stomach and duodenum with biopsy . in two circumstances we performed endoscopic operation. in one circumstance we successfully take off the gist from the duodenum endoscopically. during the operation we use the endoscopic instruments. in another circumstances,after endoscopic excision the tumor appear the bleeding which was stopped by endoscopic local heamostasis, by putting clipps on the vessels. in circumstances the tumors were in stomach. in circumstances we performed laparoscopic wedge resection the tumors by staplers. in circumstances when the tumor was very big and situated in the fundus of stomach, we performed laparoscopic resection of the fundal part of stomach by using laparoscopic staplers and 'liga sure' sealing. in circumstance we took off the tumor by putting laparoscopic trocars inside the stomach for instruments and for visualization tumor. after excision the tumor and took it of the stomach we sutured the holes in the stomach. we have no mortality after laparoscopic operation. there were no malignisation in all circumstances. we have cases morbidity. in circumstance the bleeding from the stomach that was stopped endoscopically. in circumstance there was wound infection. the aim of the study to decrease the morbidity in the patients with perforated ulcers of the stomach and duodenum. we observed patients with perforated ulcers of stomach and duodenum. women were , men were . average age about years. patients had perforation ulcer of stomach and duodenum. patients had perforations with bleeding. all patients were divided in two groups. the first groups patient operated laporocopically, in the second group patients operated traditionally. results: there were no mortality in the group that operated laparoscopically. in the group that were operated traditionally one patient died after rebleeding. the average stay in hospital in the group that were operated laporoscopically about days. in the groups with traditional operations, were about days. the morbidity in the first group were in cases. pneumonia in cases, suppuration of the troacar points were in cases. in the second group pneumonia were in cases, suppuration of the operation wound were in cases, subdiaphragmatic abscess was in cases. conclusion: laporoscopic operation in during treatment decrease the mortality, morbidity and hospital staying in the patients the perforated ulcer of stomach and duodenum . of the patients of the third group ( . %) were operated about ulcer rebleeding in the hospital, and ( . %)-about the profuse bleeding ulcer. noonr patient had recurrent bleeding. the average treatment time for patients in group was . ± . days. conclusions: the development of hemorrhagic shock in patients with peptic ulcer bleeding significantly increases the risk of rebleeding and mortality. the application of endoscopic hemostasis allows to reduce the risk of rebleeding and mortality compared with conservative antiulcer therapy. surgical treatment can achieve reliable hemostasis, but accompanied by higher mortality and longer duration of hospital treatment. tan tock seng hospital is second largest hospital in singapore. it is affiliated to two medical schools in singapore and it is a training hospital for both undergraduates and postgraduates. minimally invasive surgery for both benign and malignant diseases of upper gastrointestinal tract becomes more and more popular nowadays. in our department, all the residents have to view the step by step instructional videos of mininally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant surgeons. the viewing of the instructional videos help them with better understanding of the procedures. the viewing of videos help them with the importance of steps, standardization of steps. with the help of instructional video, they can not only assist better in the surgery but also reduce the learning curve when they start doing the procedure themselves after the graduation from the residency programme. this is the step by step instructional video of laparoscopic repair of perforated duodena ulcer for surgeons-in-training rotated to our department. in general duplication cysts are rare developmental congenital disorders of the gi tract. three morphological criteria should be met in order to confirm the pathological diagnosis: . they should be attached to the stomach's wall and should be the continuation of it, . at least one of the muscle layers of the stomach's wall should be included and .it should have normal gastric mucosa. the treatment is either enucleation or partial gastrectomy. aim: present our minimally invasive approach to a rare prepyloric submucosal cystic lesion causing gastric outlet obstruction. case report: a -year-old female with vomiting, weight loss and in bad general condition was diagnosed after a full work-up (blood tests, endoscopies, eus, ct and mri) with a submucosal cystic tumor. this cyst first was thought to be a duplication cyst. since the patient was young, our intention was to offer the least invasive surgical technique in order to spare gastrectomy and billroth anastomosis. results: the procedure was completed laparoscopically with enucleation of the cyst through a gastrotomy on the anterior wall of the stomach. after the enucleation of the cyst the gastric mucosa was sutured back and then the gastrotomy was closed with continuous sutures. the result of the pathological report confirmed a rare case of a heterotopic pancreatic cystic lesion. the postoperative course of the patient was uneventful and was discharged with instruction for her diet the th postoperative day. the patient months post-operative has no symptoms. conclusion: in such benign conditions and especially in young patients, gastrectomies could be avoided if possible and give their place to less invasive approaches in order to reduce lifelong risks and morbidity. trangastric enucleation of the cyst although a demanding approach is safe and could be considered as a 'gentler' technique with reduced morbidity. background: pancreatoduodenectomy is considered to be very invasive for early superficial duodenal tumors (sdts), which have a lower risk of lymph node metastasis. partial duodenal resection with endoscopic submucosal dissection for sdts is an attractive technique but it is associated with a high risk of complications. the full-thickness resection of the duodenum wall including laparoscopic and endoscopic cooperative surgery has risk of spreading tumor cells and digestive juices into the abdominal cavity. we have developed novel technique for sdts to decrease the risk of exposure to abdominal cavity of tumor cells and digestive juices, called nonexposed duodenum laparoscopic and endoscopic cooperative surgery (neo-dlecs). aim: the aim of this study is to evaluate the feasibility and safety of neo-dlecs for sdts. surgical procedure: the attachment of the transverse mesocolon was freed from the head of the pancreas and retroperitoneal tissues under laparoscopy. the duodenum and the head of the pancreas were mobilized from the retroperitoneum using the kocher maneuver. a standard esd was performed for the sdt using endoscope. the serosa of the esd ulcer bed was reinforced using the laparoscopic hand-sewn suturing technique in the seromuscular layer around the resected area. after completing the procedure, the endoscope was inserted and passed over the resected area to confirm that there was no stenosis or leakage. methods: ten consecutive patients with sdt underwent neo-dlecs in our institute between march and march . the clinicopathological features of the patients and surgical outcomes were prospectively collected and retrospectively analyzed. results: pathological diagnosis was adenocarcinoma for six patients, adenoma for three patients, and neuroendocrine tumor grade for one patient. the median tumor size was ( - ) mm. the median operative time was . ( - ) min. the median blood loss was ( - ) g. there were no conversions to open surgery in this series. intraoperative perforation was found in two cases during the esd procedure. however, all perforations were closed and reinforced using hand-sewn sutures. no postoperative complications were above grade in the clavien-dindo classification system. conclusions: neo-dlecs is safe and feasible and can be an option for surgical sdt resection. aims: wilkie's syndrome is caused by the entrapment of the rd part of the duodenum between the aorta and the superior mesenteric artery (sma). surgery is indicated for chronic cases and failure of conservative management, being reported a laparoscopic duodenojejunostomy as a minimally invasive option. methods: all cases treated by laparoscopic duodenojejunostomy in our centre because of chronic wilkie's syndrome were recorded. results: females and male underwent a laparoscopic duodenojejunostomy, with a mean age of years (range - ). all patients presented abdominal pain, and weight loss was identified in most of them. a reduced aortomesenteric angle measured by ct scan was the key for the diagnosis (mean angle . degrees, range - ). conventional laparoscopic approach was performed in two patients, the other two patients underwent a sils port approach. mean time of surgery was . min (range - ) and length of stay was days (range - ). after a mean follow-up of . months (range - ), patients improved their symptoms. conclusions: surgery is the mainstay in complicated or refractory cases of sma. laparoscopic duodenojejunostomy has the advantages of the laparoscopic approach (including rapid recovery time, reduced post-operative pain and shorter hospital stay) and it is feasible, safe and effective. in mexico in , gastric cancer represented the rd cause of death; it may manifest in a variety of histologic, anatomic, and genetic patterns, which influences the surgical approach. until now gastrectomy with curative intent is the only treatment that offers potential cure in gastric cancer. in recent years, laparoscopy has emerged as an important modality in the surgical management. in multiple trials no significant difference in recurrence, long-term survival and disease-free survival was observed when compared to the standard open gastrectomy. we present the case of a year old man. with a smoking history of pack years, suspended years earlier. he presented unspecific upper gastrointestinal symptoms; an upper endoscopy was made observing a suspicious depressed lesion of cm located in the greater curvature between the body and the antrum, the biopsy resulted in a poorly diferentiated signet-ring cell carcinoma of the stomach. an endoscopic ultrasound and a thoracoabdominal ct scan showed no evidence of enlarged adenopaties or metastatic disease. initially a diagnostic laparoscopy was made, there was no evidence of carcinomatosis, nor free intraperitoneal fluid; so the greater omentum was dissected towards the splenic and hepatic flexure; a d lymph node dissection was performed, and a subtotal gastrectomy with reconstruction of roux en y was done; intraoperative endoscopy was done to identify the lesion, so adequate margins could be obtained. the patient had a good post operative evolution and was discharged home at th day tolerating oral intake. minimally invasive techniques have proved equivalency of oncologic results when compared to the conventional approach; these techniques are becoming the preferred approach in the treatment of well-selected patients with gastric cancer and have a role in definitive staging, curative resection, and lymphadenectomy. appropriate selection of patients and optimal technical approach are paramount for good outcomes. most data of laparoscopic gastrectomy come from eastern countries, where the prevalence is higher; however western experience is growing along with evolution and development in surgical instruments and new technology. wilkie syndrome is a rare cause of high intestinal obstruction, resulting from the compression of the duodenum between the abdominal aorta and the superior mesenteric artery. the main symptoms are nausea and vomiting, weight loss, early satiety, abdominal distension and epigastric pain. historically, the barium study and arteriography were the diagnostic tests used; more recently the angiotac has shown greater sensitivity. the diagnostic criteria are: dilated duodenum, duodenal compression by the superior mesenteric artery and aortomesenteric angle less than degrees. patients with an acute condition usually respond to conservative treatment (decompression, correction of hydroelectrolyte alterations, nutritional support…). however, those with chronic symptoms usually require surgery preferably with laparoscopic approaches of duodenojejunostomy or the strong's procedure. the strong procedure mobilizes the duodenum by dividing the ligament of treitz. once the duodenal-jejunal junction is mobilized, the duodenum is positioned to the right of the superior mesenteric artery and it is preferred because it provides less morbidity due of the maintaining of the integrity of the gastrointestinal tract, but it has a failure rate of %. gastrojejunostomy allows gastric decompression, but does not relieve duodenal compression, so digestive symptoms may persist, leading to the appearance of a blind loop syndrome or recurrent peptic ulcers. on the other hand, the duodenojejunostomy, which according to some series may be the procedure of choice, may obtain a success rate higher than %. we advocate to initiate the surgical approach with the strong procedure and if it fails to perform to a duodenojejunostomy. during this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. if the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. if the reflux was observed intensely up to cervical esophagus, the position was returned to head high position for the safety and the case was assigned to severe category. the anti-reflux surgery was considered in the moderate and severe categories. results: we have performed laparoscopic nissen procedure in cases. the outcome was assessed by reflux test performed on - postoperative day, and the results showed the reflux was disappeared in every cases. median follow-up period of this study was months ( - months) . in cases ( . %) ppi was restarted before months after the anti-reflux surgery. in cases ( . %) ppi was restarted after the anti-reflux surgery during the whole follow-up period of this study. the bmi of the patients had no relationship to the needed restart of ppi. to evaluate the degree of esophagitis objectively before and after the anti-reflux surgery we designed 'the esophagitis score'. in this scoring method, a number from - was assigned according to the degree of esophagitis along with the la classification. the results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the ppi restarted group (p \ . ). discussion: to extract the gerd patients who really need anti-reflux surgery is important. reflux test is feasible because of its convenience and visual effects for the patients. the results of the laparoscopic nissen fundoplication were good. background: laparoscopic paraesophageal hernia repair with fundoplication has become more and more popular nowadays due to less morbdity and mortality with shorter length of hospital stay. discussion: tan tock seng hospital is the second largest hospital in singapore. it is affiliated to two medical schools in singapore and it is a training hospital for both undergraduates and postgraduates. in our department, all the residents have to view the step by step instructional videos of mininally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant surgeons. the viewing of the instructional videos help them understand the procedures better. the videos can also help them recognize the important steps and standardized safe approach. with the help of instructional video, they can not only assist better in the surgery but also reduce the learning curve when they start performing the procedure themselves during their training period. this is the step by step instructional video of laparoscopic paraesophageal hernia repair with fundoplication for surgeons-in-training who are posted to our department. conclusion: the step by step instructional video on laparoscopic paraesophageal hernia repair with fundoplication can help the surgeons in training reduce their learning curve and improve their surgical skills so that they can perform the procedure safely. the human immunodeficiency virus (hiv) is a neurotropic virus. there have been reports of patients with hiv who have esophageal motility problems, sometimes associated with opportunistic infections. the absence of contractility is defined as a major motility disorder according to the chicago v . classification, which is characterized by normal esophagogastric union relaxation and % peristalsis failure. we present the case of a -year-old male patient with a history of acquired immunodeficiency on treatment with efavirenz, emtricitabine and tenofovir. he presented progressive dysphagia, gastroesophageal reflux and pyrosis of months of evolution. physical examination showed no alterations. upper endoscopy is done reporting a normal esophagus and diffuse chronic gastritis. the esophagogram reported inadequate esophageal motility with contrast stasis and a delayed emptying. the esophageal manometry reported an upper esophageal sphincter with high resting pressure. the middle and distal esophagus showed absence of peristalsis with a pan-esophageal pressurization pattern. the lower esophageal sphincter presented normal resting pressure and borderline relaxation ( %). the integrated relaxation pressure was less than mmhg. the diagnostic impression was absence of contractility (chicago classification v . ).medical management was initiated with inhibitors of the proton pump, isosorbide dinitrate and injections of botulinum toxin without success. it was decided to program the patient for a heller myotomy with toupet fundoplication. a trans-surgical endoscopy revealed a complete myotomy with no leakage or obstruction. the patient went home on the second postoperative day tolerating a solid diet.heller myotomy by laparoscopy with partial fundoplication is safe in the treatment of patients with hiv and esophageal motility disorders, reporting a mortality of . %. the effect of endoscopic treatments prior to surgery is controversy aims: epiphrenic diverticulum represents an infrequent entity and it is usually associated with esophageal motility disorders, such as achalasia, distal esophageal spasm, nutcracker esophagus or hypertensive lower esophageal sphincter. nowadays, epiphrenic diverticulectomy, esophageal myotomy and partial fundoplication is the gold standard technique; although it supposes a challenging procedure and it may provoke lots of complications. approach for diverticulectomy usually depends on the distance from the upper border of the diverticulum's neck to gastroesophageal junction, considering that thoracoscopy should be carried out when this distance is more than cm. methods: we presentthecase of a -year-old male patient, with a bodymass index of anda medical history of diabetes, smoking and alcoholism. his symptoms were mainly regurgitation and dysphagia. upper endoscopy showed esophageal dilatation and the presence of a diverticulum with its neck cm over the gastroesophageal junction. ct scan confirmed these findings and manometry showed achalasia. in the video we can see how we perform a laparoscopic diverticulectomy with esophageal myotomy and dor fundoplication. results: patient was discharged home on the second postoperative day with no complication. after more than two years of follow-up, he has not suffered regurgitation, heartburn, dysphagia or chest pain. conclusions: we present a case with an epiphrenic diverticulum secondary to achalasia in which we performed a laparoscopic diverticulectomy, esophageal myotomy and dor fundoplication. some authors suggest that the correction of the underlying motility disorder is the key in the management of these patients and they do not recommend concomitant diverticulectomy for all cases. however, we consider that the complete procedure, adding diverticulectomy, supposes the gold standard and it is feasible to perform for teams which are skilled in esophageal and gastric laparoscopic surgery, despite its high morbidity rates. purpose: a laparoscopic wedge resection for a gastric submucosal tumor closed to gastroesophageal junction or involved to gastroesophageal junction is technically challenging and more aggressive compared with tumors in other sites of the stomach. a gastroesophageal reflux disease would be more prevalent after laparoscopic wedge resection of a gastric submucosal tumor in gastroesophageal junction because of the destruction to low esophageal sphincter. we hypothesized that a prophylactic anti-reflux surgery after this surgery would be less prevalent the gastroesophageal reflux disease (gerd) and more improve the quality of life of the patients. the aim of this study is to analyze our experience with prophylactic anti-reflux surgery after laparoscopic wedge resection for a gastric submucosal tumor of gastroesophageal junction materials and methods: we retrospectively collected data from patients who diagnosed with submucosal tumor of near the gastroesophageal junction underwent laparoscopic wedge resection between january and december . the patients were divided into groups according to operation with prophylactic anti-reflux surgery (group a) and without one (group b). results: there were no difference in the frequency of the preoperative gerd symptoms between the groups, whereas postoperative gerd symptoms and postoperative use of acid suppressive medications were more frequent in the group b (p = . , p = . ). however, there were no differences in the follow-up endoscopic findings in terms of reflux esophagitis and hill's grade between the groups. in group a, postoperative mean low esophageal sphincter (les) pressure was . ± . . the les pressure was dropped until mmhg in the only one patient. however, there was no reflux symptom in this patient. conclusions: the prophylactic anti-reflux surgery after laparoscopic gastric wedge resection of gastroesophageal junction is an effective method of prevent gastroesophageal reflux symptoms. background: the most critical obstacle is a pancreatic leakage(pl). the most cause of pl might be an activation of pancreatic juice by the mixing of pancreatic juice and intestinal fluid because of the anastomosis technique, the difference of anastomosis between pancreatic duct and caliber of jejunum, and the topple of jejunal mucosa. aim: in this study, we devised the new anastomotic method of pancreato-jejunostomy, so called ' pancreatic stent sliding guide' (pssg) method using a pancreatic duct stent. we would like to demonstrate its method and results. (operative procedure) the cases of hybrid laparoscopic pancreatico-duodenectomies (pd) were done by shuriken-shaped umbilicoplasty with pssg. the pancreatic duct stent, which is fit for a diameter of pancreatic duct, is used for the direct puncture without any incineration. the aims of direct puncture are both the avoidance of the enlargement of anastomotic opening and disturbance of blood flow. the contralateral of anastomotic opening is also punctured and the stent is pulled out of the jejunum. the - pds with the needles at both ends is used for anastomotic thread. firstly, the eversion anastomosis of posterior wall is done by sliding the needle on the stent. and then the anastomosis of anterior wall is done by the same way. the stent of contralateral side is cut and the hole is closed. materials and methods: the cased of pancreato-jejunostomy by pssg method were done by february . the average of patient's age was y.o. the disease of patients were pancreatic cancer (n = ), bile duct cancer (n = ), and papilla vater cancer(n = ). the pancreatic leakage by the isgpf were grade : ,a: ,b: ,c: respectively. in the same periods, we underwent the more ten cases of open pd by pssg method. the pl were only one case of grade a and there were none of clinical pl. conclusion: our new device of pancreato-jejunostomy by pssg might be very effective for the decrease of pl from the view point of machanisms of pl even for laparoscopic pd. year old, male patient presented with upper abdominal discomfort and pain, without nausea, vomiting or weight loss. an sub mucosal lesion was found on endoscopy examination in first part of the duodenum. endoscopic ultrasound has showed . cm sub mucosal lesion in first part of duodenum (anterior wall and close to pylorus). cytology examination from the lesion has showed neuroendocrine tumor. computed tomography of abdomen and chest were normal. his blood laboratory examinations were within normal limits. patient underwent da vinci robotic partial gastrectomy with intra corporeal billroth ii gastrojejunostomy. total operating time (ort) was min. three day after operation patient started regular diet and was discharged home on day fife. final pathology report confirmed diagnosis of carcinoid tumor with ki less than %. surg endosc ( ) :s -s p -robotics & new techniques-education integrated education for colorectal disease-a digital solution for a digital age united kingdom aims: surgical plume has problem in poor visibility of the operative field, inclusion of harmful chemical substances, and biological risk. it is desirable that plume should be removed appropriately to minimize these risks. we assessed whether these problems can be solved by using commercialized evacuator semi-quantification of residual chemicals in the abdominal cavity: was performed using industrial smoke tester by aspirating the intra-abdominal plume onto filter papers and digitizing the stains. ( ) detection of dna in the exhausted gas from the evacuator: the hepa filter, which was interposed at the inlet or outlet of the evacuator, was analyzed using pcr method to detect any dna derived from porcine tissues. results: ( ) laparoscopic visualization: judgement score were . vs. . for ec and . vs. . for us (evacuator: on vs. off, both p \ . ), indicating the visualization was significantly better in the use of the evacuator on both devices general surgery, royo villanova hospital general surgery minimally invasive surgery centre, jesús usón minimally invasive surgery centre methods: i report my experience at the american university of beirut medical center for laparoscopic adrenalectomy cases, left adrenalectomy and cases for right adrenalectomy. three out of the series are large adrenal of cm, and all of these were completed laparoscopically.the video will show the steps of this procedure.a large rt. adrenal mass measuring cm, wt. gm was removed laparoscopically using trocar techniques. the lateral position facilitated the exposure and ease of dissection. the mass was removed by extending one of the trocar site with muscle splitting using endocatch mm. results: patient was discharged home days after surgery. the operative time was hour. pathology revealed carcinoma with no involvement of the capsule or vascular invasion patients (male: n = ; female: n = ) underwent minimally invasive adrenalectomy (tp: n = ; rp: n = ) at our institute. mean patient age was . years ( - years). besides comparing operative (intraoperative blood loss, previous abdominal surgeries, conversion rate, operative time, tumor size) and perioperative factors (time of hospitalization, time to oral intake, histology, postoperative complications) in each group, perioperative outcomes of a learning curve (lc)-the first procedures in both groups-was also analyzed in terms of tumor size, significantly larger lesions were removed with tp (tp: . ± . mm vs rp: . ± . mm; p = . ). the number of asa (american society of anesthesiologists) ii patients were significantly higher in the tp group while there were significantly more asa iii patients in the rp group conversions ) showed no significant difference. the analysis of lc showed a significant difference in previous abdominal surgeries min vs rp: . ± . min; p = . ] all favoring the tp approach. conclusion: both methods proved to be feasible and safe in terms of minimally invasive adrenalectomy. based on our own experience the tp approach resulted in improved operative time and conversion rates to demonstrate the safety and efficacy of the laparoscopic approach in the treatment of large splenomegaly. currently, this approach is recognized as the one of choice in benign splenic pathology, being controversial in the face of a massive splenomegaly or neoplastic pathology. material and method: clinical case: a -year-old man followed in the dept. of internal medicine for a hepatosplenomegaly of probable lymphoproliferative origin. additional explorations of interest are provided. result: intervention: complete laparoscopic approach, right lateral partial decubitus, massive splenomegaly, ? cm, splenuncle of - cm that is resected, section of short vessels, dissection of the splenic hilum, vascular section with endogias, splenectomy with full extraction in a pocket through reduced laparotomy in the left flank for anatomopathological study the aim of this video is to demonstrate the safety and efficacy of the laparoscopic approach in the treatment of large splenomegaly. currently, this approach is recognized as the one of choice in benign splenic pathology, being controversial in the case of a massive splenomegaly or neoplastic pathology it can transform into adenocarcinoma. patients and methods: between and we performed laparoscopic nissen fundoplication (lars) in cases of gerd. in cases of gerd patients be was proved by endoscopy and histological examination. the demeester score was higher ( . versus . , p \ . ), and bile re?ux was measured more frequently among the be patients on the other hand during the . years long endoscopic follow up early barrett carcinoma developed in patients, . months after the lars. both patients underwent a limited surgical resection of the distal esophagus and esophagogastric junction, regional lymphadenectomy, and reconstruction by interposition of an isoperistaltic jejunal segment. there were no complication. histological examination was shown pt n stage disease in both cases. oncological follow up was months long ( . y) and both patients are still disease free. conclusions: although lars can affect regression in a part of be patients, progression to adenenocarcinoma can also occur. endoscopic surveillance is important in the case of be to recognize early cancer, to perform limited surgical resection with low morbidity and long overall-and disease free survival gastric cancer development a nomogram for predicting the conditional probability of survival after d lymphadenectomy for gastric cancer this study aimed to devise a nomogram to predict the conditional probability of cancer-specific survival (cpcs) in gastric cancer (gc) patients after gastrectomy with d lymphadenectomy. methods: clinicopathological data for , gc patients who underwent d lymphadenectomy in a large-volume eastern institution (the training cohort) were analysed. cancer-specific survival (css) was predicted using cox regression models. a conditional survival nomogram was constructed to predict cpcs at and years post-gastrectomy. two external validations were performed using a cohort of , chinese patients and a cohort of italian patients. results: in the training cohort, the -year cpcs was . % immediately post-gastrectomy and increased to . %, . %, . % and . % at , , and years post-gastrectomy, respectively. multivariate cox regression analyses showed that age; tumour site, size and invasion depth; numbers of examined and metastatic lymph nodes; and surgical margins were independent prognostic factors of cancer-specific survival (all p \ . ) and formed the nomogram predictor variables. internal validation showed that the conditional nomogram exhibited good discrimination ability at and years post-gastrectomy (concordance index, . and . , respectively) gastric cancer does non-compliance in lymph node dissection affect oncological efficacy in gastric cancer patients undergoing radical gastrectomy? univariate and multivariate analyses revealed that non-compliance was an independent risk factor for os. logistic regression analysis demonstrated that the extent of gastrectomy, primary tumour site, history of intraperitoneal surgery, bmi and open gastrectomy were independent preoperative predictive factors for non-compliance. cox analysis demonstrated that age, pt, pn, and the extent of gastrectomy independently affected os in patients with noncomplaint lymphadenectomy. however, os was significantly better in the compliant group than in the non-compliant group regardless of the recommendation for chemotherapy. stratified analysis demonstrated that os was significantly better in chemotherapy patients than in patients without chemotherapy and stage ii patients (pt n /n m and pt n m ) in whom chemotherapy was not recommended. conclusion: non-compliance is an independent risk factor after radical gastrectomy for gc we prospectively collected and retrospectively analysed the medical records of patients with proximal gc who underwent lspsd. the data were split / , with one group used for model development and the other for validation testing. results: of the patients enrolled in this study, ( . %) required laparoscopic haemostasis treatment. a multivariate analysis determined the following preoperative adverse risk factors for the model group: gender, preoperative n stage, and terminal branches of the splenic artery (spa), and we developed a scoring system based on these findings. each of these factors contributed point to the risk score. the intraoperative laparoscopy hemostasis rates were . , . , . , and . % for the low-, intermediate-, high-, and extremely high-risk categories, respectively. there were statistically significant differences among groups (p \ . ). with the increase in risk, both blood loss volume (blv) and operative time (min) of lspsd increased significantly (p \ . ).the area under the receiver operating characteristic curve for the score of intraoperative laparoscopic haemostasis was . . the observed and predicted incidence rates for intraoperative laparoscopic haemostasis were parallel in the validation set. conclusions: this simple we compared the survival of src patients with that of tubular adenocarcinoma patients according to bmi. results: the -year survival of src was significantly worse than that of wmd (p \ . ) but superior to that of pd (p \ . ). bmi-stratified analysis showed that in the high-bmi group, the prognosis of src was similar to that of wmd (p [ . ) and better than that of pd (p \ . ). in normal-bmi patients, src had a worse prognosis than wmd (p \ . ) but a more favorable prognosis than pd (p \ . ). src among low-bmi patients displayed much poorer survival than did both wmd (p \ . ) and pd (p = . ). multivariate analysis indicated that the risk of death was lowest for src patients with a high bmi and highest for src patients with a low bmi baseline characteristics were compared in a -patient rspshl cohort and a -patient lspshl cohort. one-to-four propensity score matching was performed to determine between-group differences. result: in total, patients were matched, including patients who underwent rspshl and who underwent lspshl. no significant differences in baseline characteristics were observed between these groups after matching. significant differences in total operative time, estimated blood loss (ebl), splenic hilar blood loss (shbl), splenic hilar dissection time (shdt), and splenic trunk dissection time were detected between these groups (all p \ . ). furthermore, no significant differences were evident between rspshl and lspshl in the overall noncompliance rate of lymph node (ln) dissection ( the highest body temperature within week after operation was used to establish diagnostic thresholds for high body temperature and low body temperature, which was obtained by x-tile software. the study used cox regression to analyze the influence of high body temperature on -year dfs. results: a total of patients were included in the analysis. the diagnostic threshold for high body temperature was defined as °c; patients with a high postoperative body temperature were allocated to the high temperature group (htg), while another patients were allocated to the low temperature group (ltg) cao department of gastric surgery, fujian medical university union hospital, fuzhou, china background: laparoscopic surgery for remnant gastric cancer third step: baring of the right side of the esophagus. fourth step: exposure of left gastroepiploic vessels and lns dissection in the splenic hilar area. fifth step: baring of the left side of the esophagus. the above procedure was performed for rgc patients with stage ct - an /? disease. results: there was no conversion to open surgery. mean operation time was . ± . min, mean blood loss was . ± . ml, and mean times to first flatus p -upper gi-gastric cancer a novel prognosis prediction model after gastrectomy for remnant gastric cancer: development and validation using international multicenter databases fuzhou, china; department of gastrointestinal surgery the model calibration was accurate in predicting -year survival. dca showed that the model has a greater benefit. the results were also confirmed by bootstrap internal validation. in external validation, c-statistics and dca showed good prognostic performance in patient datasets from participating institutions. moreover, we verified reliability of the model in an analysis of patients with different eln counts p -upper gi-gastric cancer a novel abdominal negative pressure lavage-drainage system for anastomotic leakage after r resection for gastric cancer while risk of gastric cancer for ppi users was higher than non-ppi users when duration between - year, = year, = year and = year. the risk of gastric cancer when duration = year(rr = . )and duration = year(rr = . )are higher than risk of gastric cancer when duration between - year (rr = . ). according to location subgroups meta-analysis,risk of non-cardiac gastric cancer for ppi users higher than non-ppi users conclusion: based on a systematic review with meta-analysis, we found the correlation between long-term use of ppi and the risk of gastric cancer and long-term use of ppi may increase the risk of non-cardiac gastric cancer when duration = year p -upper gi-gastric cancer age-adjusted charlson comorbidity index (acci) is a significant factor for predicting survival results: there were patients included in the analysis. the high-acci and low-acci groups had significant differences in preoperative abdominal surgery history, asa grade, tumor size, tumor stage, histologic type, age and comorbidity (all p \ . ). the incidence of postoperative complications was . % in the high-acci group and was significantly higher than that in the low-acci group (p = . ). the overall survival rate (os) and cancer-specific survival (css) rate in the low-acci group were both higher than those in the high-acci group (p \ . ). univariate and multivariate analyses showed that the acci was an independent risk factor for os and css (p \ . ). furthermore, a combination of the tnm staging system and acci showed a trend toward higher prognostic value and higher auc for os and css than the tnm staging system alone (p \ . ). conclusions: the acci was an we aimed to investigate the clinicopathological features and prognosis of patients with mgc and the impact of postoperative adjuvant chemotherapy on long-term survival. methods: the clinical and pathological data of patients diagnosed with gastric adenocarcinoma and undergoing radical gastrectomy from stratified analysis showed that, in advanced gastric cancer (agc), the -year os rates of mgc without adjuvant chemotherapy and sgc without adjuvant chemotherapy were . % and . %, respectively, with a statistically significant difference (p = . ). the -year os rates of advanced mgc after adjuvant chemotherapy and of advanced sgc after adjuvant chemotherapy were . % and . %, respectively, and the difference was not statistically significant (p = . ). the -year os rate of advanced mgc after adjuvant chemotherapy was significantly higher than that of patients without adjuvant chemotherapy ( . % vs. . %, p = . ). conclusions: mgc is a poor prognostic factor after radical gastrectomy for gastric cancer background: whether the tumor-node-metastasis (tnm) staging system is suitable for patients with node-negative gc is still controversial. the modified staging system established by rpa showed good prognostic performance in a variety of cancers. the application of rpa has not been reported in the prognostic prediction of gc. methods: node-negative gc patients who underwent radical resection at fujian medical university union hospital (n = ) and sun yat-sen university cancer center (n = ) with an at least -year follow-up information were selected as the training set. rpa was used to develop a modified staging system. patients from the surveillance, epidemiology, and end results databases (n = ) were selected as the external validation set. results: the -year overall survival (os) rates of patients with th ajcc-tnm stage ia-iiia in the training set were ia %, ib %, iia %, iib % and iiia %. multivariate analysis (mva) showed that larger tumor size, older age, and deeper depth of invasion were independent risk factors for os in patients with node-negative gc (all p \ . ). patients were reclassified into rpa i, rpa ii, rpa iii, and rpa iv stage based on rpa, the -year os rates were %, %, %, and %, respectively, with significantly difference (p \ . ). two-step mva showed that the rpa staging system was an independent predictor for os (p \ . ) were retrospectively collected. patients were classified into two groups according to bmi of \ kg/m ( patients; high bmi group) and = kg/ m ( patients; low bmi group). for these patients, clinicopathological variables were analyzed using propensity score matching to mitigate the selection bias: sex, age, asa physical states, clinical stage, laparoscopy-assisted total gastrectomy (latg) or totally laparoscopic total gastrectomy (tltg), d lymph node dissection, combined resection of other organs, method of anastomosis, jejunal pouch reconstruction. the surgical results and postoperative outcomes were compared and examined between the two groups. results: a total of patients were matched for the analysis. contrary to our expectations, there were no differences in the surgical results about operative time and estimated blood loss (low bmi . ± . min, high bmi . ± . min; p = . , low bmi . ± . g, high bmi . ± . g; p = . , respectively). furthermore, there was no significant difference in postoperative outcome of complication (clavian-dindo [ iiia) and the length of postoperative hospital stays (low bmi cases, high bmi cases baiocchi general surgery, university of brescia-spedali civili, brescia, italy background and aim: recently indocyanine green (icg) was introduced in clinical practice as a fluorescent tracer. the use of icg for sentinel lymph node (ln) mapping was investigated in lots of fields such as breast methods: we conduced a single center prospective trial. we included patients with gastric cancer candidate to surgery. icg was injected intraoperative or the day before surgery, via submucosal or subserosal. total or subtotal gastrectomy was performed open, laparoscopic or video-assisted access. during gastric cancer standard lymphadenectomy we studied lymphatic flow and ln bright in vivo and ex vivo japan introduction: in japan, the number of elderly patients with gastric cancer has been increasing in correlation with the increase in average age of the population. the aim of this study is to assess the safety and efficacy of laparoscopic gastrectomy for cancer in elderly patients compared with the short-term outcome in the nonelderly. method: we reviewed patients who underwent laparoscopic gastrectomy (dital gastrectomy,proximal gastrectomy,total gastrectomy)between ).the incidence of advanced cancer(stageiior more)was higher in elderly patients there were no significant differences in the operating time,blood loss and postoperative hospital stay. there were no significant differences in the incidence of postoperative morbidity. conclusion: in elderly patients, there was a tendency of reduction surgery being selected according to individual condition, but there was no significant difference in the short-term outcome.hence,we conclude that laparoscopic gastrectomy is indicated even in elderly patients. p -upper gi-gastric cancer improved technique of vacuum therapy and carried out ltg . a patient factor (the gender, the age and bmi), an operation factor (operation time, the bleeding amount, lymph node dissection and conjurer), a coincidence related complication (clavien dindo classification, sutural insufficiency of grade more than , anastomotic stricture, anastomotic region bleeding and reflux esophagitis) and the post-operatively length of stay were considered . result: cs crowd met cases ( . %) and ls cluster ( . %) cases. years old of age medians ( - ), men and women were examples ( . %), examples ( . %) and bmi median . ( . - . ) by a patient factor, and a significant difference didn't admit by two groups for days, the post-operatively average length of stay was days by ls group by cs group. conclusion: operation time was short for a coincidence by linear stapler more than a coincidence by circular stapler in comparison of an esophagoenterostomy way in ltg on the day before the operation, we endoscopically clipped several points located cm proximal to the tumor edge to cover about half of the tumor. after lymph node dissection, we incised the stomach with an endoscopic linear stapling device,including the previously placed clips. reconstruction was performed in all patients who underwent billroth i or roux-en-y procedures. result: no complications were observed during pre-operative endoscopic clipping or intraoperatively p -upper gi-gastric cancer small intestinal tumors after laparoscopic surgery in our hospital small intestinal tumors are rarely observed, accounting for about - % (malignant cases: - %) of all gastrointestinal tumors. therefore, occasionally, their diagnoses can be difficult. however, recently, capsule and balloon endoscopes have been widely employed were examined regarding patient backgrounds, diagnostic methods, pathological findings, postoperative courses, and prognoses. results: the subjects consisted of males and females, with a mean age of years. their chief complaints were black stools the median distance from the treitz ligament or bauhin valve was cm ( - ) postoperative complications were abdominal abscess ( cases; . %) and surgical site infection (ssi), hemorrhage, and paralytic ileus ( case each; . %). pathological diagnoses were lymphoma metastatic small intestinal tumor ( cases; . %), and granuloma, lipoma, peutz-jeghers polyp, clear cell sarcoma, malignant mesothelioma, and ectopic pancreas most patients were diagnosed in bleeding, complicated by anemia and black stools. however, as most tumors were relatively close to the treitz ligament and bauhin valve, almost a half could be diagnosed with a small intestine endoscope before surgery patients were classified as popf and no-popf according to their grade b or c popf status. popf was diagnosed according to international study group of pancreatic fistula (isgpf) criteria or clinical findings. patient characteristics, intraoperative parameters, electrosurgical device type, pathological findings, and early postoperative outcomes were compared. electrosurgical devices were classified asthunderbeat (tb) or laparosonic coagulating shears (lcs) based on energy sources. results: eighteen patients developed grade b or c popf. among them, ( . %) and ( . %) were diagnosed with popf according to isgpf criteria and clinical findings ), operation time (p = . ) and electrosurgical device type (p = . ) were significant risk factors for popf following lag ) and tb device (or, . ; % ci ) were independent risk factors for popf following lag. conclusions: operation time and tb use significantly affect the risk of popf and should be considered in future clinical studies. p -upper gi-gastric cancer feasibility and nutritional benefits of double flap with no-knife stapler reconstruction after laparoscopic proximal gastrectomy for gastric cancer were analyzed. receiver operating characteristic curves were generated, and by calculating the areas under the curve(auc) and the c-index, the discriminative ability of crps during different periods were compared, including pre-crp, postoperative days , , and postoperative maximum crp (post-crp max ). a decision curve analysis was performed to evaluate the clinical utility. result: ultimately, patients were included this study and the median follow-up time was ( - ) months. for postoperative recurrence, the auc and c-index of pre-crp were . and . , respectively, significantly higher than the other crps, all p \ . . among = ''''''the = '''' post-crps = '''' post-crp = '''' sub = similar findings were observed for overall survival. conclusion: both pre-crp and post-crp max , cheap and easily obtained, are independent predictors of recurrence for gc. act significantly prolonged the rfs for stage ii/iii gc patients with high-prep p -upper gi-gastric cancer robot-assisted gastroduodenal surgery: a single center experience robot-assisted gastroduodenal surgery (ras) was introduced to overcome the technical limitations of conventional laparoscopy. it provides a d-amplified view to the surgeons and an increased ability to control the operative field by manipulating optics, as well as enhanced mobility and precision of instruments. the aim of the present study is to evaluate the main outcome of a single center experience in gastroduodenal robotic surgery. materials and methods: we report a case series of patients who underwent robot-assisted gastroduodenal surgery at sanchinarro university hospital between conclusions: robot-assisted gastroduodenal surgery is a safe and feasible technique in experienced centers with advanced robotic skills. in the literature, there are only few reports of robotic assisted gastroduodenal resection. further studies are necessary to better confirme our results. p -upper gi-gastric cancer atypical methods: retrospective review of ogd reports before and after the introduction of the new guidelines. inclusion criteria: all elective ogds. exclusion criteria: emergency ogds and elective therapeutic ogds. data recorded: patient demographics, endoscopist, indication, number of photos, anatomical site photographed, pathology identified and whether pathology photographed or not. results: ogds reviewed, before the guidelines (group ) and afterwards (group ). the most common indication was reflux ( %) in group and anaemia ( %) in group clinical utility of systematic pre treatment staging laparoscopic exploration methods: all locally advanced gastric adenocarcinoma managed in surgical oncological unit between st january and th november were prospectively enrolled in the study. in the absence of emergency surgery or preoperative contraindications, all patients with curative intent underwent either preoperative chemotherapy followed by surgical exploration in the intent of curative gastrectomy (g)or systematic pretreatment laparoscopic exploration (l) benkabbou surgical department the patient background (age, gender, bmi) and c-stage of the preoperative factor were matched using propensity score matching method, and the surgical results were compared and examined. results: thirty rg groups matched rag cases. the operation time (rag / lg) was significantly longer in the rag group as . ± . min / . ± . min (p \ . ). amount of blood loss was not significantly different each other; ml / ml (p = . ). pathologically t a case was involved in cases in rag and cases in lg. the extent of lymph node dissection (d ? / d ) was / cases in both groups conclusions: rag in our clinical experiences can be safely introduced and short-term results are comparable to those of lg. verification of superiority of robotic surgery including long-term results seems to influence the future of robotic surgery conclusions: totally laparoscopic gastrectomy is feasible method in terms of surgical outcomes. furthermore, totally laparoscopic total gastrectomy is not technically difficult in advanced gastric cancer such as early gastric cancer and safety method. key words: gastrectomy, reconstruction, laparoscopic surgery, stomach neoplasm aims: meckel's diverticulum (md) is one of the most common congenital anomalies of the small intestine caused by an obliteration defect of omphalomesenteric duct. the objective of this study was to review surgical treatment and clinical outcomes of md, and evaluate the safety and feasibility of minimal invasive surgery (mis) in md. methods: we performed a retrospective analysis of medical record for patients who underwent meckel's diverticulectomy at six hallym-university-affiliated hospitals between d), as well as the average of drainage stay. patients who underwent laparoscopic repair required significantly less parenteral analgesics than the open group.the mean postoperative stay was significantly shorter for laparoscopic group (mean, . d) than the open one.morbidity of medical and surgical complication was higher in open groups ( vs ). the most common complication in both groups was medical complication.more case of pneumonia was occurred in open groups compared to laparoscopic groups methods: a retrospective study using our prospective database was designed to analyse all the resected md in our centre. epidemiological data, clinical setting, diagnostic test and histological results were reported. results: md was resected in patients, males and females, with a mean age of . years ( . - . ). in cases, a laparoscopic approach was chosen. eighty-seven percent of the patients had a presurgical imaging test (ultrasounds, ct-scan or meckel's scan) background: perforated peptic ulcer (ppu) is a substantial health problem with significant postoperative morbidity up to % and mortality up to % worldwide. aims: this study aimed to estimate the sensitivity scoring systems for prognosis morbidity of patients operated for ppu with diffuse peritonitis. methods: a total of patients were underwent emergency repair for ppu with diffuse peritonitis in pirogov russian national research medical university's surgical clinics during - years. different scoring systems used to predict outcome in ppu patients were identified: boey score, peptic ulcer perforation (pulp) score, asa, mannheim peritonitis index (mpi), world society of emergency surgery sepsis severity score (wses score). to quantify the strength of the concatenation of prognostic score and morbidity we use odds ratio (or) with % ci ), respectively. pulp score and asa score have good prognostic value in relation to morbidity, but less than boey, mpi and wses sss. patients with pulp [ had or with % ci of p -upper gi-gastroduodenal diseases gastrostomy tube placed by laparoscopy as a new therapeutic option for continuous intestinal infusion treatment with levodopa/ carbidopa we present year outcomes of our initial consecutive patient cohort. methods: patients were identified in a prospectively maintained irb-approved database ( - ). post-operative eckardt scores and a -point validated system questionnaires were obtained via telephone interviews one patient required reoperation for failed myotomy. the mean eckardt score at years was . (± . ), with all fourteen patients having an eckardt score \ . all patients reported significant improvement in their quality of life. classic gerd symptoms (heartburn and regurgitation) were present in ( . %) patients. proton-pump inhibitors are being used by % of with patients with excellent symptom control. seven patients returned for a repeat egd (median . yrs) with patients having normal anatomy and having la grade a esophagitis ( patient on ppi). barrett's esophagus was not detected. conclusion: long-term results from our early experience with lhm are excellent and durable with only one patient requiring re-intervention in years until recently the esophagectomy was the only choice in treatment of patients with end-stage achalasia. developing of minimally invasive techniques such as a laparoscopic heller miotomy and peroral endoscopic myotomy (poem) allowed to use them as a treatment options. aim: to present an experience of treatment of patents with end-stage cardiac achalasia. materials and methods: since . till the laparoscopic heller myotomy was performed in , and esophagectomies were performed in patients with failed previously myotomy made in other clinics. gastric tube was used to replace the esophagus in patients underwent esophagectomy after skeletization of crura posteriorly to esophagus, two separated rectangular patches of parietene progrip mesh (covidien) measuring x . - cm were attached to the posterior surfaces of the crura. the patches were fixated themselves due to special hooks. than continious twodirections suture was placed through both crura along with the patches using self-gripping v-loc - suture (covidien). the same suture was used for construction of nissen fundoplication wrap . cm long. aditional anchoring stich through the wrap and esophageal wall was placed using ti-cron - suture (covidien). d laparoscopy was used while suturing using richard wolf epic system. results: all the procedures were performed successfully. there were no cases of bleeding from the suturing points either from the crura and the fundus wall. there were no crural dehiscence while suturing, even if the distance between crura was more than cm. the mean duration of suturing facilitated by d laparoscopy was min (range, - min) for crural repair, and min (range, - min) for fundoplication. there were no excessive postoperative pain in all the patients. there were no disphagia month postop in every patient. conclusions: . the new technique of posterior buttress of crural repair using small patches of parietene progrip mesh and v-loc suture showed feasibility and safety. . the use of d in such case most commonly manifested symptoms are cough, sore throat, hoarseness, dysphonia, globus and only % patients with lpr have typical gerd symptoms. also ppi therapy are less effective in patients with lpr in comparison with patients which have typical features of gerd. purpose: to compare the outcomes between surgical treatment and conservative therapy in patients with laryngopharyngeal reflux. materials and methods: for the period chesarev faculty surgery # , federal state autonomous educational institution of higher education i.m. sechen, moscow, russia p -upper gi-reflux-achalasia a case of a primary parahiatal hernia associated with a type i hiatal hernia emergency county hospital parahiatal hernia is a rare disease that occurs when an abdominal organ protrudes through an opening adjacent to an anatomically intact esophageal hiatus. the herniated organ is usually the stomach, although cases of omental and colonic herniation exist we report the case of a -year-old woman which accused epigastric pain, starting years prior, pseudo-angina, heartburn and bloating. based on imagistic findings the patient was diagnosed with a parahiatal hernia and an associated type i hiatal hernia. patient underwent surgery and a cm diameter defect in the diaphragm lateral to the left crus was discovered, through which - % of the stomach had herniated. the hiatal orifice was slightly enlarged but anatomically intact, with an associated small sliding hiatal hernia. we performed closure of the defect, hiatoplasty and a floppy-nissen fundoplication pneumatic dilation with mm balloon was performed under general anesthesia. radiological contrast control and endoscopy reevaluation revealed a perforation just above the squamo-columnar junction. a minimally invasive approach was decided. an fully covered esophageal stent was inserted. radiological control after days reveals left pleurisy and migration of the stent. the same day was performed an endoscopic repositioning of the stent with clip fixation. left pleural puncture was performed and clear fluid was extracted. the condition of the patient got worse and she was transferred on icu ( . ). we performed left pleurostomy and initial exploratory laparoscopy-no intraperitoneal lesions. due to difficult transhiatal access to the inferior mediastinum the surgery was converted to open-perisophageal mediastinal abscess was found, evacuated and drainage and jejunostomy were performed. after a week, the patient presented progressive altered condition, febrile syndrome. thoraco-abdominal ct-scan showed left pleural effusions. left pleurostomy was performed, with extraction of fetid fluid. continuous lavage was instituted. on st of august, the pleurostomy tube drained gastric content, and the clinical examination revealed signs of generalized peritonitis. laparotomy was performed with lavage, drainage and posterior decompression gastrostomy. results: postoperative evolution was favorable, with the suppression of pleural drainage in . and discharge in . with alimentation exclusive on jejunostomy. one month later, she had normal clinical and radiological examination evaluation of efficacy was performed with reflux symptom index (rsi) specific for extraesophageal symptoms, subjective satisfaction and occurrence of dysphagia and gas-bloat syndrome. a rsi score [ was considered as pathological. results: rsi significantly decreased after surgery ( and msa as compared with total fundoplication; , % of patients were satisfied with surgery: a comparison between techniques showed superiority of msa objective: to demonstrate the efficacy of hiatorraphy without the use of meshes in thegiant paraesophageal hiatus hernia, as well as the standardization of our technique, with thetechnical steps that we make successively. material and method: clinical cases: -year-old man,with symptomatic hiatal hernia with progressive intolerance and dysnea. egd: the stomach rotated in a giant hiatal hernia.gastroscopy not completed due to endoscope loop formation within giant hiatal hernia with gastric volvulation. ct: large hiatal hernia,combined volvulation (axial axial mesenteric organ), the stomach in a right subpulmonary situation. results: intervention: laparoscopic approach.hh of large paraesophageal size,double organoaxial-and-mesenteric volvular component,gastric walls very thickened and adhered to the mediastinum.reduction of all content and the sac,is adhered to the pleura, extended med-iastinal esophageal disection, up to vein pulmonary and get enough abdominal esophagus and rule out the presence of an short esophagus,posterior-anterior and left tutorized modified hiatorraphy with stitches in ''u'' with non-absorbable suture on teflon reinforcement patches.nissen fixed to both pillars, intramediastinal drainage.egd at the st day with esophageal stenosis due to inflamation of the nissen, resolved with medical treatment. dischage at th day.asymptomatic and without radiological recurrence after months of follow-up. conclusions: in giant and paraesophageal hiatus hernias, modified primary hiatorraphy together with mediastinal esophageal dissection extended can be an effective and safe alternative, and can be advised as a technical gesture prior to a collis nissen and-or placement of a hiatal-hiatoplasty mesh united states of america aim/background: prescribed opioids for pain control have been implicated as major contributors to addiction through their illicit use. efforts to reduce opioid prescriptions and measure their impact on outcomes are novel. we analyzed how patient outcomes are affected with reduced opioid prescriptions following laparoscopic foregut surgery narcr: %), length of hospital stay (narcs: . days vs. narcr: . days), -day readmission rates (narcs: % vs. narcr: %) and perioperative complication rates. additionally, no significant qol outcome differences between the groups were reported at one month postoperatively. conclusion: our study supports reducing opioid prescriptions as a strategy to counter illicit drug use and addiction patients who underwent paraesophageal hernia repair at a tertiary referral center were analyzed retrospectively. demographic data, asa classification, characteristics of peh, onset of symptom, dysphagia severity score, characteristics of fundoplication (partial vs. total; laparotomy vs. laparoscopy; emergency vs. elective) and surgical outcome (length of stay, complication and -day mortality) were recorded and reviewed. results: patients were included; % were female (mean age of . years old and mean body mass index of . ). mean onset of symptom was . weeks after peh repair, dysphagia severity scores were changed . from . . conclusion: in our series, the dysphagia severity scores reduced after surgery upper gi surgery, the catholic university of korea mary's hospital, incheon city, korea p -upper gi-gastric cancer general surgery biopsy from the mass has showed poorly differentiated signet ring cell adenocarcinoma. chest computed tomography revealed mm thoracic aortic aneurism. abdominal computed tomography showed mm infra renal aortic aneurism and no evidence of metastatic disease general surgery year old, female patient presented with upper abdominal pain, weight loss ( kg during last three month), without nausea or vomiting biopsy was done and pathology result showed intestinal type, her -negative adenocarcinoma of the stomach. chest and abdominal computed tomography (ct) were normal. endoscopic ultrasound (eus) revealed cm lesion with invasion to the muscularis propria (mp) she was treated by neo adjuvant chemotherapy ( cycles carboplatine ? fu). patient underwent laparoscopic partial gastrectomy with modified d lymphadenectomy and billroth ii gastrojejunostomy. total operating time (ort) was min. three day after operation patient started regular diet and was discharged home on day fife. final pathology result confirmed intestinal type, modified differentiated adenocarcinoma of the stomach economou st surgical department general, visceral and transplant surgery, section minimally invasive surgery, heidelberg university hospital, heidelberg, germany; department of surgery, iuliu hatieganu university, cluj-napoca, romania; general and visceral surgery, klinikum mittelbaden, baden-baden, germany surgery, toyonaka municipal hospital, toyonaka city, osaka, japan; gastroenterological surgery, osaka university, osaka, japan; next generation endoscopic intervention, osaka university, osaka, japan aims: uncomplicated healing of anastomoses in colorectal surgery is the basis for early adjuvant oncology therapy. the basis for proper healing is good blood flow. we use by robotic surgery foor control the firefly by intuitive. since january , icg has used for blood flow in laparoscopic bowel surgery for the d-light system of storz. method: use of icg wants to accurately determine the resection line for free colon operations based on good blood circulation. we use icg pulse in two batches and color detection using d light from storz to verify blood flow. the first dose is given after the skeletalisation of the intestines intraabdominally and the second after the colic anastomosis to verify its vitality. results: in the period under review we performed laparoscopic operations on the free colon, % of the operations were elective. we had . % leakage across the set, however, in the subset of elective operations, we had only a leak of . %. conclusion: in an unselected set of colorectal operations, leakage was . %, but only . for elective operations. in our group there was a clear effect of using icg in elective laparoscopic resections with an intracorporal anastomosis, the effect was not shown in others, probably due to leakage were factors other than blood flow. objective: right hemicoloctomy (rhce) is the first choice in treating the right colon cancer. complete mesocolic excision with extended lymph node dissection at the roots of superior mesenteric artery (sma) branches enables removal of all lymphatic tissue and prevents local recurrence. previously variability of sma branches was demonstrated. the aim of presented study was to compare the distribution of sma branches in two ethnically different cohorts methods: preoperativect scans with vascular d reconstruction were assessed in patients ( - years) from russia and patients ( - years) from turkey with right colon cancer operated in - . the distribution of ileocolic artery (ica), right colic artery (rca) and middle colic artery (mca) was investigated. results: ica and mca could be found on ct scans in all patients, whereas rca had significantly different distribution between patient cohorts: it was visible in ( %) of turkish patients and only in ( %) of russian patients (p = . ). conclusion: these results suggest that there might be ethnical differences in sma branches distribution. in turkish patients all named sma branches ate visible on ct scans in %, whereas in russian patients only in %. the majority of patients from russia don't have rca. ica and mca could be found in all patients regardless ethnicity. knowing the variant of sma branching before the operation can help plan extended lymph node dissection. the national training programme in laparoscopic colorectal surgery (s-micras-lapserb) in serbia was set up to introduce standardized and structured training in laparoscopic colorectal surgery. method: an assessment based structured training programme (lapserb) started in . series of hands on supervised workshops were conducted for four different hospitals using the structured training by single trainer. this study aims at retrospective analysis of prospectively collected data for patients undergoing colorectal resections. we look at short-term clinical and pathological outcome of patients within laparoscopic colorectal resections performed in national training program. results: during the period november until november , laparoscopic colorectal resection was performed in ( male and female) patients. mean age of patients was . ( - ). the most common indication was colorectal cancer ( patients, . %), ( . %) patients were operated due to the colorectal polyps not suitable for endoscopic resection and ( . %) was operated due to ibd. there were ( . %) right colonic, ( . %) left colonic /tme and ( . %) other resections. average number of lymph node harvested in patients with colorectal carcinoma was . . there were / ( . %) r resections mean duration of hospital stay was . days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . postoperative complications were encountered in / patients ( . %). overall, mortality rate was . % ( / ). conclusions: this study demonstrates successful and safe adoption of laparoscopic technique for colorectal resections. short term clinical and pathological outcomes are compared to published data and shows wider adoption at the national level. standardization of operative technique and structured training remains the key in success. introduction: femal adnexal tumor of probable wolffian origin (fatwo) was first described in . it is a tumor of mesonephiris wolffian duct origin. fatwo is rare tumor which is usualle benign. in the literature has been reported cases and only cases of recurrent disease. next rare tumor in pelvic localisation is sex cord-gonadal stromal tumor of sertoli cells. methods: we present case report of women who presented metastatic fatwo with duplicity of sertoli tumor. results: -year old women underwent years ago exstirpation of tumor in the left broad ligament. histologically there was rare benign fatwo. this year was indicated adnexectomy at gynecology department. during the operation was done bilateral adnexectomy and discovered tumor of anterior wall on upper rectum. microscopic examination showed sertoli tumor on the left ovary. afterward we completed next examinations. colonoscopy without any abnormality. on ct scan was tumor cm without contact to rectum wall, without distant metastasis. the same was described on rectal ultrasonography-normal wall of rectum, tumor probably from uterus. at diagnostic laparoscopy was tumor mass cm, with necrosis arising from anterior wall of the rectum. next small metastasis on pelvic peritoneum. we performed debulking of this big tumor and metastasectomy, there was no infiltration to muscularis propria of the rectum. patient did not have any postoperativ complications. microscopic examination of the rectal tumor and small peritoneal metastasis showed metastatic fatwo. after weeks she underwent laparoscopic second look operation. there were small metastasis on pelvis peritoneum. we removed two biggest metastasis and the rest was destroyed wit j plazma. microscopic examination showed in this metastasis sertoli tumor. conclusion: our patient has metastatic fatwo and sertoli tumor. fatwo is so rare, that in the literaure is not enough information for observation or adjuvant therapy. in one case was described imatinib mesylae (gleevec) therapy with good results. surgeons must be ready to meet new diagnosis. bochdalek hernia is a type of congenital diaphragmatic hernia. in most cases, it is diagnosed during the neonatal period. we present a case of laparoscopically treated congenital bochdalek hernia that led to jejunal strangulation in an adult . case: an fifty eight year old obese(bmi = . ) female admitted for gradually worsening right flank pain, vomiting and respiratory distress for one day. there was no trauma history to chest or abdomen. the past medical history were old cva, well controlled hypertension and dm. she was hemodynamically stable. her right flank was very tender. there was no abdominal distension. initial cbc tests showed leukocytosis ( , /ul) , but electrolytes were normal. chest pa revealed right side diaphragmatic hernia. there was poorly enhanced, herniated small bowel in the right hemithorax on chest ct scan. the patient was taken for emergency operation. on laparoscopy, the normal liver was displaced leftward because of herniated bowel. there was incarcerated jejunum and omentum which could not be reduced. so we widened a cm sized posterolateral diaphragmatic defect first, and then we could reduce the strangulated jejunum( cm in length) and omentum. there was no hernial sac. the defect was closed with -o prolene. finally, the strangulated jejunum was resected and anastomosed extracorporeally. the hospital progress of the patient was not eventful. on post-operative day , the patient was allowed soft diet. the patient was discharged on post-operative day without any complication. conclusion: congenital diaphragmatic hernia is an uncommon condition in adults, but you should keep in mind the diaphragmatic hernia as a cause of intestinal obstruction and respiratory distress in an adult. prompt surgical intervention is required to a favorable outcome. laparoscopic repair of bochdalek hernia is a good management option. aims: intestinal obstruction is one of the most frequent abdominal conditions in the emergency department (ed). up to % of patients having undergone a laparotomy will have an episode throughout their lives, of which % up to % will respond to conservative management. the laparoscopic approach is widely accepted and supported by the studies published up todate. it is recommended in patients with suspected single band, who have less than one previous laparotomy and less than h of clinical evolution. our objective is to validate in our experience that these premises are the appropriate ones in the election of candidates for a minimally invasive approach. methods: we present a series of cases admitted with symptoms compatible with adhesive intestinal obstruction in the ed of a third level hospital during months. all patients underwent abdominal ct to rule out the possible causes of obstruction. emergency surgery was indicated because of failure of a conservative medical treatment or for the findings of the complementary tests. results: a initial laparoscopic approach was performed in the patients, with a conversion rate of % of the cases (resection and anastomosis was required in patients, due to loop suffering or intestinal tumor not seen in the ct). among the patients who required laparotomy, % had more han h of clinical evolution before de surgery and % had free fluid in the tc. as surgical complications: intestinal perforations were produced secondary to the manipulation. there was recurrences of obstruction in the following months. conclusion: the laparoscopic approach is feasible in selected cases and experienced hands. acording to our results it is recommended to perform it in only in patients with less than h evolution and with a single band image in the ct without free fluid. the intestine should be explored avoiding the manipulation of the most extensive loops to prevent complications and keep in mind the possible conversion to laparotomy in case of complications. aim: the aim of the study was to evaluate whether physiologic and operative severity score for the enumeration of mortality and morbidity (possum) is useful to predict the risk of complications in patients older than years. methods: we performed a retrospective study of patients older than years old diagnosed with acute abdomen who were admitted to the department of general, minimally invasive and elderly surgery in olsztyn between may and october . results: the most common disagnosis was ileus. the mortality rate in surgery department was %.after relocation to the intensive care unit, the overall mortality rate was . %. the patients who died a short time after surgery had mortality rates greater than % and morbidity rates greater than % according to possum. conclusions: this study shows that possum seems to be a valuable scale to predict the risk of death after surgery in older patients. patients with higher mortality and morbidity scores should be very carefully selected for surgery. aims: diaphragmatic hernia in adulthood is rare. the most common causes are blunt and penetrating trauma. we present an intraoperative video of the laparoscopic repair of an adult onset, non-traumatic, diaphragmatic hernia in a patient with splenomegaly. method: a year old woman was referred to upper gastrointestinal surgery with epigastric burning and pain in the left side of her chest, radiating to the left shoulder, for one year. there was no recent or distant history of trauma. she has a past medical history of treated hepatitis c, cirrhotic liver disease, splenomegaly, thrombocytopenia and iron deficiency anaemia. gastroscopy was interpreted as a fundal diverticulum. ct abdomen/pelvis with intravenous (iv) contrast showed this to be a left diaphragmatic defect with herniated stomach causing a volvulus, which lay immediately above an enlarged spleen. a ct three years prior to this showed no diaphragmatic hernia. the patient had some symptomatic relief with a proton pump inhibitor and oral antacids, however due to her persistent symptoms surgery was undertaken. the patient had laparoscopic repair of the diaphragmatic hernia. ports were as follows: mm umbilical, mm left upper quadrant, mm right upper quadrant, mm left iliac fossa. a left posterior diaphragmatic defect was found, just above the enlarged spleen, containing the incarcerated fundus of the stomach. the hernia was reduced by gradual dissection of the sac. a cm nonabsorbable polypropylene mesh (proceed) was used to cover the defect a cm margin. this was tacked in place with protack. a single french robinson drain was left in situ. results: the procedure was uncomplicated. oral diet was introduced on post-operative day and the drain was removed and patient discharged on day . there were no post-operative complications. conclusions: the video shows an effective dissection of a left sided diaphragmatic hernia and mesh repair, overcoming multiple technical challenges secondary to splenomegaly and portal hypertension. aims: creating laparoscopic anastomosis is a challenging surgical skill with high clinical relevance. to assure efficient training and enhanced learning curves, constructive and objective feedback is essential. currently there is no appropriate instrument to assess the surgical performance while creating laparoscopic anastomosis. the aim of this study is to develop and validate the anastomosis-objective structured assessment of technical skill (a-osats) score. methods: to obtain an international expert consensus for a procedure specific checklist (psc) for laparoscopic anastomosis, a modified delphi survey with an integrated analytic hierarchy process is currently being performed. each a-osats sub step is assigned a specific weight to determine its importance to the final outcome of the anastomosis. to validate the a-osats score, a laparoscopic side-to-side small bowl anastomosis with a linear stapler and hand-sewn closure of the enterotomy was chosen and is performed by surgeons with varying degrees of laparoscopic experience on a live porcine model. all performances are recorded and rated twice using the a-osats by two blinded experts. results: the final a-osats score includes a weighted psc developed by the modified delphi survey and the already validated global rating scale of previously published osats scores. four key steps (bowel placement, creation of enterotomies, stapling, closure of enterotomy) and sub steps, as well as their definitions, were established during the delphi survey. to validate the a-osats, surgeons ( experts, intermediates, novices) have participated in the study so far. preliminary results showed significant differences between all three levels of laparoscopic experience (novices: . ± . ; intermediates: . ± . , experts: . ± . ; p \ . ) for the overall a-osats score as well as the psc itself (novices: . ± . , intermediates: . ± . , experts: . ± . ; p = . ). conclusions: the a-osats is a weighted score that objectively assesses surgical skill during the creation of laparoscopic anastomosis. preliminary results confirm construct validity of the proposed score. furthermore, by offering the possibility to differentiate single aspects during the procedure, the a-osats allows focused feedback to enhance one's performance. minor changes in weights are expected after the last round of the delphi survey. interand intrarater reliability will be assessed after final inclusion of all participants.aims: to apply augmented reality technology from three-dimensional colon models as preoperative planning method in colorectal surgery. method: from three-dimensional anatomical models of the colon we have developed holograms of augmented reality. the models were obtained from ct images (siemens somatom perspective Ò) with abdominal image cuts with mm thick. the recovery of the images was in dicom format and the processing to achieve the three-dimensional reconstruction was performed with the programs osirixÒ and horosÒ, which made a complete segmentation of the colon surface, and a modification of the image density. in this way models d were obtained of the isolated colon, and in relationship with the bone structure. the application colon d ar was designed (increased hyper experience-visualizer with slam technology) creating a hologram of augmented reality to scale : from each three dimensional model to make a projection of it on the abdomen of the patient by modifying the position in height of the reconstruction, using the bone pelvis as anatomic reference point to calibrate the placement of the hologram. results: in the preliminary phase (from october to december ) holograms of augmented reality were developed in patients with colorectal cancer (right colon, left colon, transverse colon and rectum) to complement the radiological reconstruction with the virtual model. in the application phase (from january ) the holograms developed are going to be applied as a method to improve preoperative study. conclusions: three dimensional reconstruction of the tumor in the preoperative plan of colorrectal surgery combined with hyperreality technology allows to develop models of augmented reality in order to improve colon anatomy knowledge and to plan the surgical technique.aims: laparoscopic adrenalectomy has become the standard of care for most adrenal masses. we report a case of laparoscopic adrenalectomy for left adrenal adenoma. methods: we present the case of a -year-old caucasian female patient with an asymptomatic, left-sided adenoma, that was incidentally detected during abdominal ultrasound. no headaches, palpitations, tachycardia, tremor, dizziness or vomiting were reported. pre-operative blood tests confirmed that the tumor was a non-secreting one and a ct-scan revealed a . . cm left adrenal mass. laparoscopic surgical excision was proposed. the patient was placed in semilateral right-sided decubitus position. four trocars ( epigastric- mm & subcostals- mm & mm) were used, without the use of a liver retractor. the adrenal vessels were clipped not only with the standard laparoscopic clips, but also with the hem-o-lok ligation system. results: the operation lasted for h with minimal blood loss. the patient's post-operative course was uneventful and she was finally discharged four days post-operatively. histology report ensured that it was adenoma of the adrenal cortex. aims: since the first laparoscopic adrenalectomy in (gagner), the laparoscopic lateral transabdominal approach has proved to be the one of choice. it provides an easy anatomical orientation, overall the technique is similar to other traditional laparoscopic procedures. on the other hand, the posterior retroperitoneoscopic adrenalectomy (pra), described in (waltz), has proven to be a safe technique and effective for the surgical management of several adrenal pathologies. the advantages include direct access to the adrenal gland, without the need for visceral mobilization or lysis of adhesions from previous abdominal operations and the ability to perform a bilateral adrenalectomy without repositioning the patient. currently there is controversy about which is the approach of choice, having to take into account the learning curve necessary for the retroperitoneal approach and the reduced number of patients with adrenal pathology subsidiary of surgical management. the objetive is to demonstrate the safety and efficacy of the standardized laparoscopic approach of the left adrenal gland with trocars for selected cases. methods: clinical case: -year-old man, resistant hypertension despite concurrent use of three antihypertensive agents, with biochemical and radiological diagnosis of left adrenal adenoma with primary hyperaldosteronism. demonstrative video of the technical steps in a standardized way that we propose for laparoscopic left adrenalectomy only using trocars. results: full laparoscopic surgical approach in right lateral decubitus position: trocars-lateral transabdominal approach. steps: . laparoscopic liberation of the splenic flexure of the colon for the colo-spleen-pancreato-gastric en block mobilization until identification of the left pillar, . dissection of the medial border of the gland, identification of left renal and diaphragmatic vein, as well as the adrenal vein which is dissected and clipped, . dissection of the lateral edge of the adrenal gland, . lower pole dissection of the gland completing the resection with ligasureÒ. the patient presented a successful postoperative recovery, being discharged h after the intervention. asymptomatic, the patient does not need antihypertensive drugs at year follow-up. conclusion(s): the standardization of the procedure allows reducing the number of trocars, maintaining the safety and effectiveness of the minimally invasive approach. aims: cortical-sparing adrenalectomy is a suitable treatment for hereditary and sporadic bilateral pheochromocytoma, in cases of low risk of malignancy, to reduce the possibility of adrenal insufficiency assuming the chance of local recurrence. the aim of the study is to analyze the functional results of partial adrenalectomy by retroperitoneal endoscopic approach in singleadrenal patients or patients requiring bilateral adrenalectomy. methods: prospective study between january and october including pheochromocytoma patients diagnosed with low risk of malignant mutations. all patients agreed to be included in the study. experienced endocrine surgeons who have been trained in minimally invasive endocrine surgery performed the procedure using the same surgical technique. demographic variables and clinical characteristics were collected, subsequently carrying out the descriptive analysis of the data. results: a total of eight patients were registered, five associated with men type syndrome and three in the context of vhl syndrome. retroperitoneoscopic resection was performed without laparoscopic or open conversion and no postoperative complications; the average hospital stay was . days. preservation of the functional cortex without corticosteroids was achieved in ( . %) of out cases with a follow-up of . ± months. today, these seven patients have a preserved adrenal function without hormone replacement. conclusions: cortical-sparing adrenalectomy by the retroperitoneal endoscopic approach, in expert hands, is safe and feasible for the treatment of hereditary and sporadic pheochromocytoma in a context of low malignancy, making it possible to avoid the need for corticoid replacement in most cases. biomedical sciences, university of west attica, athens, greece partial adrenalectomy has been suggested for patients benign adrenal tumors especially in the case of hereditary syndromes, like multiple endocrine neoplasia type , von hippel-lindau disease and neurofibromatosis type i. aims: this systematic review aimed to investigate the role of partial adrenalectomy in the treatment of hereditary pheochromocytoma. methods: electronic databases were searched with the search terms 'men ii', 'von hippel lindau', 'neurofibromatosis', 'laparoscopic partial adrenalectomy', 'robotic assisted partial adrenalectomy' for the time period up to and including december . full publications, including clinical trials randomized or not, retrospective studies, case series, case reports that provided relevant data met inclusion criteria results: thirty five possibly relevant studies were identified. abstracts were reviewed and fourteen articles were excluded as they were review articles or articles presenting data on open partial adrenalectomy. twenty one studies, that met inclusion criteria were retrieved in full text and included in the systematic review. eight studies presented data on partial adrenalectomy in patients with von hippel lindau including two case series with median follow up ranging from to . years and six case reports. thirteen studies presented data on partial adrenalectomy in patients with men ii, including two case series and eleven case reports. recurrence rate was estimated at about % for pheochromocytoma. overall steroid dependence rate was estimated at %. conclusion: minimally invasive partial adrenalectomy is a therapeutic option especially in patients with heritable pheochromocytoma, given that tumors are often bilateral, tumors are commonly benign and severe morbidity and mortality may be associated with life-long steroid replacement therapy such as the possibly lethal addisonian crisis . however, data are limited, follow up is not standardized and not appropriately reported and rcts are difficult to be done due to the rarity of the disease. a multinational registry on the short term and long term outcomes of partial adrenalectomy in hereditary pheochromocytoma would be a significant source of knowledge. results: patients were operated on after an average of months with complaints. in both groups, the leading symptoms were severe dysphagia and severe regurgitation. no intraoperative complication was detected. in the transoral group, one patient had to be reoperated on for bleeding, another patient developed pneumonia in the transcervical group. the average duration of the surgeries ( . vs. min, p \ , ), the time to oral feeding ( . vs. . days, p \ , ) and the mean hospital stay ( . vs. . days, p \ , ) were significantly shorter in the transoral group than the transcervical group. patients were completely symptomless postoperatively. after transcervical treatment, complaints were developed in cases (moderate dysphagia and hoarseness). after transoral surgery, recurrent symptoms were observed in patients, had to be reoperated transcervically due to severe regurgitation. conclusion: transoral stapler diverticulostomy is a fast procedure and offers short hospital stay especially in comorbid, aged patients and intermedium diverticulum size. in the long term, some of the patients may require reintervention due to persistent regurgitation. the transcervical approach has higher perioperative morbidity, which can be performed in patients with less than cm or large diverticulum size. aims: complex hiatal hernias, either implicating large hiatal defects or concerning cases of recurrence, often need apart from the primary closure of the hiatal gap, the re-enforcement of the crura with the use of meshes. our aim is to demonstrate the surgical technique for the on-lay placement of the absorbable mesh (phasix tm st mesh /bard) in challenging cases, presenting both the laparoscopic and the robotic approach. methods: we present video fragments from procedures of laparoscopic and robotic reconstruction of complex hiatal hernias, performed by our team, in which an absorbable mesh was utilized in an on-lay fashion. results: patients having undergone a minimally invasive surgical approach (laparoscopic or robotic) for the treatment of complex hiatal hernias with the use of an absorbable mesh, had an uneventful post-operative course and very short hospital stay and recovery time. the -month follow up revealed no recurrences or late complications. conclusions: treating complex cases of hiatal hernias with a minimally invasive approach can be proven quite challenging, with high recurrences and possible complications rate. a proper surgical technique, either laparoscopic or better (based in our primary experience) robotic, by experienced surgical teams and the use of meshes with the right strategy, minimizes the complications, offers all the benefits of minimally invasive surgery and reduces the recurrence rates. aims: several flexible endoscopic techniques for symptomatic zenker's diverticulum have been developed during the last decade. thulium laser has limited tissue penetration and may decrease the risk of perforation. this study reports the first use of thulium laser through flexible endoscopy for cricopharyngeal (cp) myotomy. aims were safety and efficacy of flexible endoscopic thulium laser myotomy and quality of life (qol) changes after treatment. methods: a retrospective review of a prospectively collected database of patients who underwent thulium laser septum division for symptomatic zenker's diverticulum was done. demographic data, presenting symptoms, diverticulum characteristics, and intraoperative data were analyzed. functional outcome swallowing scale (foss) and m.d. anderson dysphagia inventory (mdadi) questionnaires were administered to determine severity of dysphagia and its effect on qol, both preoperatively and during follow-up visits. all the operations were carried out under general anesthesia. a continuous laser configuration and an emissionpower of w was used in non-contact mode. once the mucosa was opened, the fibers of the cricopharyngeal muscle were divided until the buccopharyngeal fascia was visibile. results: between march and september , patients ( males) underwent flexible endoscopic cp myotomy with thulium laser. mean age was ± . , mostly males ( . %). seven patients ( . %) presented with recurrent diverticulum after previous transoral or open treatment. mean diverticulum size was . ± . cm. preoperative main symptoms were dysphagia ( . %), regurgitation ( . %), and cough ( . %). foss score was = in patients ( . %). mean mdadi global and composite score were . ± . and . ± . . complete division of the septum was achieved in all patients. mean hospital stay was . ± . days. there was only one perforation treated conservatively. no -days mortality was observed. at median follow-up of months, foss was = in ( . %) patient and mdadi global and composite score were . ± . and . ± . . all main symptoms were significantly reduced and qol significantly increased. conclusions: flexible endoscopic approach with thulium laser is a safe and effective treatment option for zenker's diverticulum either as a primary treatment or as a rescue therapy. objective: this study sought to explore prognostic factors for patients with borrmann type iv gastric cancer and to establish a predictive model for survival benefit of postoperative adjuvant chemotherapy in such patients. method: this study reviewed the clinical data of patients who underwent curative surgery at fujian medical university union hospital from to for borrmann type iv gastric cancer using a prospective database. cox regression analyses were performed to identify prognostic factors that formed the basis for a nomogram and risk groups. establishment of risk groups to identify patients with borrmann type iv gastric cancer who would benefit from adjuvant chemotherapy. results: patients who underwent r resection were included in this study.multivariate analysis showed that bmi, tumour differentiation, pt stage, pn stage, and asa score were independent prognostic factors. patients in the act-group had longer os than patients in the sagroup, although the p-value for this difference was marginally above the threshold for statistical significance ( . % vs. . %, p = . ). stratified analysis showed that there was no significant difference in os between the act-group and the sa-group for each ajcc stage (stage ii: . % vs. . %, p = . ; stage iii: . % vs. . %, p = . ).a nomogram was established based on these independent risk factors, and nomogram scores were used to divide all patients into a high-risk group (score [ ), an intermediate-risk group ( \ score = ) and a low-risk group (score = ).further stratified analysis based on ajcc stage showed that the -year survival rate was higher in the adjuvant chemotherapy group than in the surgery alone group for low-and intermediate-risk patients in each ajcc stage, while high-risk patients in stage iii did not significantly differ. objective: this study sought to explore the prognostic factors for smoking patients with gastric cancer and to establish a predictive model for the survival benefit of postoperative adjuvant chemotherapy in such patients. methods: we studied patients who were diagnosed from september to september at union hospital of fujian medical university. cox regression analyses were performed to identify prognostic factors. the kaplan-meier method was used to assess the effect of smoking history on the benefit of adjuvant chemotherapy after gastric cancer surgery. a decision tree algorithm was used to identify smoking patients who benefited from postoperative adjuvant chemotherapy. results: the median follow-up time for the whole group was . months, and the average age of all the included patients was . years.multivariate analysis showed that age (p \ . ), bmi (p \ . ), degree of tumor cell differentiation (p \ . ), and ajcc stage (p \ . ) were independent risk factors for the prognosis of smoking patients. based on these independent risk factors, a decision tree model for the benefit of adjuvant chemotherapy for smokers with gastric cancer was established, and the smoking patients were divided into the low-risk patients . %), medium-risk patients ( - year os, . %) and high-risk patients ( - year os, . %) (p \ . ). conclusion: cigarette smoking may reduce the efficacy of adjuvant chemotherapy after gastric cancer surgery. our decision tree model is simple and effective for identifying smokers who would benefit from adjuvant chemotherapy. objective: our study investigated the effect of lymph node (ln) noncompliance on the longterm prognosis of patients after laparoscopic total gastrectomy (ltg) and explored the risk factors of ln noncompliance. methods: the clinicopathological data of gastric cancer (gc) patients who underwent ltg with d lymphadenectomy from june to december were prospectively collected and retrospectively analyzed. the effects of ln noncompliance on the long-term prognosis of patients with gc after ltg were explored. results: the overall ln noncompliance rate was . %. ln noncompliance was significantly correlated with age, bmi, asa score, tumor size, macroscopic tumor type and tnm staging (p values \ . ). the survival rate of patients after ltg with ln compliance was significantly superior to that of patients with ln noncompliance (p = . ). the stratified analysis of tnm stage indicated that there was no difference between the os of stage i patients with ln compliance and those with ln noncompliance; os of stage ii/iii patients with ln compliance was significantly better than that of those with ln noncompliance. cox regression analyses showed that ln noncompliance was an independent risk factor for os. logistic regression analysis showed that high bmi ([ kg/m ) was an independent risk factor for preoperative prediction of ln noncompliance in cstage ii/iii patients. compared with patients with a low bmi (bmi \ kg/m ), those with a high bmi were more likely to show ln noncompliance during surgery, especially during the dissections of # , # a and # a ln stations. conclusion: ln noncompliance was an independent risk factor for poor prognosis in patients with advanced gastric cancer (agc) after ltg. patients with high bmi were more likely to have ln noncompliance, especially during the dissections of # , # a and # a ln stations. ln tracing was recommended for these patients to reduce the rate of ln noncompliance. aim: to study the differences in pathology, survival, and recurrence between special remnant gastric cancer (srgc) and nonspecial rgc (nrgc). method: a total of rgc patients were analyzed in hospitals in china from january to july .we compared the -year overall survival (os) disease-free survival (dfs) rates and used two-step regression explore the influence of the rgc categories on patient outcomes. results: all of the patients divided into srgc group (group s) (n = ) and nrgc group (group n) (n = ). the r resection rate and lymph node (ln) dissection number of group s were significantly higher than group n (p \ . ). the difference in -year os was not significant (p = . ), but the -year dfs of group s was worse than group n (p = . ). twostep multivariate analyses showed nrgc was an independent risk factor for poor dfs. of the patients who had undergone r resection, patients ( . %),suffered recurrence, and the recurrence rate of group s was significantly higher than group n (p = . ), moreover, the ln recurrence rate of group s was significantly higher than group n (p = . ). cox regression analysis showed that age, ca level, n stage and category of rgc were independent risk factors for rgc recurrence. conclusion: srgc has a higher r resection rate and ln dissection number than nrgc, but among patients who had undergone radical gastrectomy, srgc patients had worse dfs and a higher tendency for ln recurrence; thus, they should be treated differently in the clinic. objective: the aim of this study was to report our institution's experience with a novel abdominal negative pressure lavage-drainage system (anplds) for anastomotic leakage (al) after radical gastrectomy (rg) for gastric cancer (gc). background: al is a severe complication associated with high morbidity and mortality after rg for gc. the optimal creation of drainage in al patients after rg remains controversial. methods: the study enrolled patients who underwent r resection for gc at our institution between and . anplds was routinely used for patients with al after january . al rates and postoperative outcome were compared before and after the anplds therapy. we used multivariate analyses to evaluate clinicopathological and perioperative factors for associations with al and failure-to-rescue (ftr) after al. results: al occurred in patients ( / , %), leading to deaths. the al rate was similar before ( - , period ) and after ( - , period ) the implementation of anplds ( . % vs . %, p = . ). age and malnourished were independently associated with al. the ftr rate and abdominal bleeding rate after al occurred were respectively . % and . % for the entire period, but compared with period , it significantly decreased at period ( . % vs . %, p = . ; . % vs . %, p = . , respectively). what's more, only anplds therapy was an independent protective factor for ftr after al. conclusion: our experience demonstrates that anplds is feasible and cost-effective for the management of al after rg for gc. objective: to apply the principles of the 'metro-ticket' paradigm to develop a novel tnm staging system (ntnm) for gastric cancer (gc). background: the 'metro-ticket' prognostic tool for hepatocellular carcinoma has been proven to predict outcome, but a similar concept has not been investigated for gc. methods: the ntnm considered the distance from the origin on a cartesian plane incorporating the pn (x-axis) and pt (y-axis) stages. gc patients undergoing radical resection at fujian medical university union hospital (fmuuh) (n = ) were included. the ntnm was validated using external cohorts from the sun yat-sen university cancer center (sysucc) (n = ) and surveillance, epidemiology, and end results (seer) (n = ) databases. results: ntnm classes with the same distance from the origin have same stage; the stage increases with this distance. among all patients, . % (n = ) were restaged in the ntnm compared with the th edition of the ajcc-tnm classification; . % (n = ) were downstaged in the ntnm compared with the th edition. the ntnm provides significant survival differences between stages (all p \ . ). the survival difference between stages ib and iia was especially large for the ntnm (p \ . ) compared to the th and th editions (p = . ). the concordance index and hazard ratio increased successively with the ntnm stage. similar findings were observed in both external cohorts. conclusion: compared with the ajcc-tnm classification, the 'metro-ticket' ntnm for gc is easier to remember and provides some improvements; therefore, the ntnm may be considered for adoption in future editions of the ajcc-tnm classification. objective: to investigate the prognostic value of complete blood count (cbc)-based biomarkers for patients with resectable gastric cancer (gc). methods: patients with gc who underwent curative resection between december to december were included. estimated area under the curve (auc) and multivariate cox regression models were used to identify the best cbc-based biomarker. time-dependent receiver operating characteristics (t-roc) analysis was used to compare the prognostic impact. results: based on multivariate analysis, the lymphocyte-monocyte ratio (lmr) and hemoglobin (hb) level were the independent prognostic factors (both p \ . ). based on the lmr and hb level, we established the cbc-based inflammatory score (cbcs). higher cbcs was associated with older age, female sex, higher american society of anesthesiologists (asa) score, proximal tumor location, larger tumor size, later stage and vascular involvement (all p \ . ). univariate analyses showed that higher cbcs was also associated with poorer overall survival (os), which was consistent in each stage (all p \ . ). multivariate analysis revealed that the cbcs was a significant independent biomarker (p \ . ). furthermore, t-roc curve of the cbcs was superior to that of the prognostic nutritional index (pni), systemic immune-inflammation index (sii), modified glasgow prognostic score (mgps) and c-reactive protein/albumin ratio (crp/ alb) throughout the observation period. conclusion: preoperative lmr and hb were optimal cbc-based biomarkers for predicting os in gc patients after curative resection. based on the lmr and hb, we developed a novel and easily obtainable prognostic score called the cbcs, which may improve the prediction of clinical outcomes. purpose: the aim of this study was to evaluate the prognostic value of the eighth ajcc tnm staging classification for patients with gastric cancer who had already survived for years. patients and methods: patients who underwent radical gastrectomy at a large eastern center were considered. the prognostic value of staging systems were assessed and compared. additional external validation was performed using a dataset from the surveillance, epidemiology, and end result (seer) database. results: the -year overall survival (os) rate for patients in the training set was . %. with the prolongation of the survival time after surgery, the -year os improved significantly (p \ . ). however, there were no significant differences in survival curves among patients who have survived years after surgery. the auc and c of the eighth ajcc classification for predicting of -year os decreased gradually after surgery and appeared stable after years. for patients who survived years after surgery, we constructed a new tnm staging system (ntnm) according to the survival curves of t stage and n stage. a -step multivariate analysis showed that ntnm, age and sex were independent prognostic factors. the ntnm demonstrated superior prognostic stratification, with higher c-statistic and likelihood ratio chi-square scores and lower aic values than those of the ajcc classification. similar results were observed in the external validation set. conclusion: the ntnm predicted an additional survival more accurately than did the ajcc classification for patients who have survived years after surgery; this may guide decisions regarding surveillance. objective: to investigate the relationship between preoperative sarcopenia and systemic inflammation and evaluate the prognostic impact of these factors on patients with resectable gastric cancer (gc). methods: patients with gc who underwent radical gastrectomy between december and december were included. a multivariate cox regression analysis was performed to identify the prognostic factors. a novel prognostic score (slmr) was developed based on preoperative sarcopenia and the lymphocyte-monocyte ratio (lmr), and its prognostic value was evaluated. results: in total, patients with resectable gc were included in the study. on multivariate analysis, preoperative sarcopenia and the lmr were shown to be independent prognostic factors (both p \ . ). a low lmr was an independent predictor from sarcopenia (p \ . ). based on preoperative sarcopenia and the lmr, we established the slmr. an elevated slmr was associated with older age, higher asa scores, larger tumor size, advanced stages and vascular invasion (all p \ . ). multivariate analysis revealed that the slmr was a significant independent predictor (p \ . ). we incorporated the slmr into a prognostic model that included tumor size and tnm stage and generated a nomogram, which accurately predicted -and -year survival for gc patients. objective: to explore whether adjuvant chemotherapy is still needed in patients aged less than years with pt n - and pt / n gastric cancer. methods: multi-center cohort data of patients with gastric cancer who underwent radical gastrectomy were analyzed. kaplan-meier curves and cox regression were used to analyze the relationships between chemotherapy and prognosis. additionally, nomograms to predict the benefit of chemotherapy were established. results: in total, , patients with pt n - and pt / n gastric cancer were included. patients ( . %) were aged \ years. the -year overall survival (os) was not significantly different between the \ years of age group and = years of age group ( . % vs. . %, respectively; p = . ). lymph node (ln) metastases (hr . ; p = . ) and ln dissection number \ (hr . ; p \ . ) were independent risk factors for the os of patients aged \ years. adjuvant chemotherapy did not improve the -year os for patients aged \ years with pt n - and pt / n gastric cancer (p = . ). however, chemotherapy showed a significant benefit (p = . ) when there were ln metastases and/or ln dissection number was \ . two nomograms were constructed, and the calculated difference was the potential benefit of adjuvant chemotherapy for the patients aged \ years. conclusions: ln metastases and ln dissection number \ were independent prognostic risk factors of patients aged \ years with pt n - and pt / n gastric cancer. patients with these risk factors may benefit from the addition of adjuvant chemotherapy. objective: the choice of reconstruction after distal gastrectomy remains controversial. we have performed roux-en-y (r-y) method after laparoscopic distal gastrectomy(ldg) as a standard since , but we have performed billroth ii (b-ii) method in an increasing number of cases, depending on the patient. we retrospectively investigated the outcomes of patients with b-ii method after laparoscopic distal gastrectomy in our hospital. methods: patients who underwent b-ii and r-y reconstruction after ldg from january to december were included. the patient characteristics, surgical outcomes, and postoperative outcomes between the procedures were retrospectively analyzed. we also compared extend of gastritis on endoscopy and loss of body weight after surgery at year. results: b-ii / r-y : / . b-ii was selected in the elderly patients with poor asa-ps (p \ . ). in surgical outcomes, operative time was shorter for b-ii than r-y (p \ . ), and blood loss was also smaller (p = . ). in postoperative outcomes, there were significant differences in complications (?grade ) (b-ii vs. r-y: . vs. . %, p = . ) and length of stay (b-ii vs. r-y: median . vs. -day, p \ . ). there was significant difference in presence of gastritis between b-ii ( . %) and r-y ( . %) (p \ . ), but no significant difference in loss of body weight (p = . ). conclusion: b-ii reconstruction may be an adequate procedure for high-risk cases because of its shorter operative time and the absence of severe complications. background: numerous studies have shown that the short-term efficacy of three-dimensional ( d) laparoscopic radical gastrectomy (lg) is comparable to that of two-dimensional ( d)-lg. whether d-lg affects the recurrence pattern after surgery has not been investigated. using data from a prospective clinical trial, the present study compares the recurrence patterns between d-lg and d-lg. methods: from january to april , a total of patients were recruited for the clinical trial (nct ). the recurrence types, the first recurrence time and recurrence-free survival (rfs) were compared between the two groups. multivariate analyses of factors associated with rfs were performed to identify whether d-lg affects the recurrence patterns. results: ultimately, patients were analyzed ( in the d-lg group and in the d-lg group), and there were no differences in the clinicopathological data between the two groups. distant metastasis was the most common type of recurrence. there were no significant differences between the two groups in the recurrence types, the first recurrence time or rfs (all p [ . ). according to the th american joint committee on cancer tumor-node-metastasis (tnm) staging system, both groups were stratified into pathological (p) i, ii, and iii stages. the stratified analysis showed that there were no statistically significant differences in rfs between the d group and the d group among patients in each subgroup (all p [ . ). the multivariate analysis of rfs showed that pathological tnm (ptnm) stage and lymphovascular invasion were independent risk factors (all p \ . ). the multivariate analysis of post-recurrence survival (prs) showed that adjuvant chemotherapy was an independent protective factor (p = . ). conclusions: distant metastasis was the most common type of recurrence after lg. the postoperative recurrence patterns, rfs and prs after d-lg were similar to those after d-lg. purpose: the aim of this study is to evaluate the efficacy of delta-shaped anastomosis compared to circular stapler anastomosis in laparoscopic distal gastrectomy with billroth i reconstruction (ladg-bi). method: this is a single-center randomized controlled study. eligibility criteria included histologically proven gastric adenocarcinoma in the lower third of the stomach, clinical stage i tumor. patients were preoperatively randomized to circular stapler anastomosis or delta-shaped anastomosis. the primary endpoint is the number of analgesics use during days after surgery. we compared the surgical outcomes of the two groups. postoperative qol was evaluated using the postgastrectomy syndrome assessment scale- . this trial was registered at the umin clinical trials registry as umin . results: between december and september , patients (delta-shaped anastomosis , circular stapler anastomosis ) were enrolled. there was no difference in the number of analgesics use during day after surgery (median : delta-shaped anastomosis vs. : circular stapler anastomosis, p = . ). there was no difference in the overall proportion with in-hospital grade ii-iiib surgical complications ( %: delta-shaped anastomosis, %: circular stapler anastomosis). there was no operation-related death in either arm. regarding postoperative qol evaluated month after surgery, diarrhea subscale was significantly worse in delta-shaped anastomosis than in circular stapler anastomosis. conclusion: we did not demonstrate the advantage of delta-shaped anastomosis in terms of postoperative pain. since delta-shaped anastomosis tended to cause postoperative abdominal symptoms related to diarrhea, we should carefully apply the delta-shaped anastomosis to ladg. introduction: the use of a three-dimensional( d) camera for laparoscopic surgery has been reported in literature. however, there are only few comparative studies demonstrating its benefits, and no reports on the application of d vision to single-incision laparoscopic surgery. this study aims to compare d vision to the previous two-dimensional( d) system in solo single-incision laparoscopic distal gastrectomy(sidg). methods: medical charts of gastric cancer patients who underwent solo sidg from february to december were retrospectively reviewed. patients were grouped into either d group or d group depending on the type of camera used. all the operations were performed by a single surgeon using a flexible camera(olympus, japan), fixed onto a passive scope holder without the use of a scopist or an assistant. operative data, postoperative outcome, and early complication were analyzed. results: ninety had their operations under d vision and used the d scope. in both groups, there was no difference in age, body mass index, staging, and other demographic or histopathologic criteria. operative time was significantly faster in the d group( . ± . vs. . ± . mins., p = . ) and ebl was also less( . ± . vs. . ± . ml, p = . ). patients in the d group started small fluid diet faster( . ± . vs. . ± . postoperative days, p = . ), and were discharged faster( . ± . vs. . ± . postoperative days, p = . ). early complication was also less in the d group( . % vs. . %) but there was no statistical significance(p = . ). conclusion: the use of the d camera improves operative outcome and hospital stay in patients undergoing solo sidg. the frequency of anastomotic leakage after gastrectomyreaches - %. at the same time, mortality in this group of patients reaches %, and the use of aggressive methods of surgical treatment for the treatment of anastomotic leakage increases the mortality rate from to %. since , vacuum-assisted closure has been used to treat anastomotic leakage of various localizations. the essence of this method is based on the creating a local negative pressure, which is transmitted to the drip cavity through a special porous spongy system. the negative pressure created in the closed cavity, allows you to remove exudate, helps to reduce tissue swelling, improvesmicrocirculation, which in turn contributes to the development of granulations and wound healing with separation of the fistulous course. failures in using the method of vacuum therapy in anastomotic leakage are associated with the great difficulty of delivering a polyurethane sponge with a drainage tube to the leakage zone. in this regard, we have developed an improved method of endoscopic local vacuum therapy, in which the delivery of a polyurethane sponge was carried out with the help of a thread through a pharyngeal ring, a leakage zone and brought out through a drainage tube. this technique has been successfully used in the treatment of four patients with anastomotic leakage after operations on the upper part of the digestive tract. for complete healing of the cavity of the leakage and defect of the organ wall, it took , , and sessions of replacing the vac system, respectively (average . ± . ). there were no complications during the endoscopic local vacuum therapy. when the control endoscopic studies after months after the completion of the treatment at the site of defects of the seams of the anastomoses formed tender scar tissue without signs of narrowing of the organ. aims: enhanced recovery after surgery pathways are safe and effective for patients undergoing gastrectomy. this study aimed to identify perioperative factors influencing the adherence to the protocol, the postoperative course, and the consequent length of stay. methods: between and , patients were referred to our institution for gastric cancer. among these, patients underwent atypical gastric resection and were excluded from this analysis. were assigned to either total or distal gastrectomy and represent the study population. all patients were managed with a standardised perioperative pathway according to eras principles. according to data from the literature and based on our clinical experience, patients with optimal adherence to eras protocol may fit the criteria for discharge within ninth postoperative day, that was considered our ideal threshold for hospital discharge. data were retrospectively collected and analysed from a prospectively maintained database. statistical analyses were performed using spss version for macintosh. the v test, with a significance level of . , was used to investigate the association between the outcome and perioperative categorical variables. when parametric assumptions were met, student's two-tailed t-test was used to compare the means of continuous variables; otherwise, the mann-whitney test was performed. a significance level of . was chosen. logistic binary regression with a backward selection procedure and selection criteria of p-value \ . were exploited to determine significant predictors. results: preoperative, intraoperative and early postoperative variables were considered. among all, multivariate regression analysis revealed that incomplete preoperative immunonutrition, failure to extubate the patient at the end of surgery, intraoperative crystalloids infusions [ ml and blood transfusion [ ml, surgery duration [ min, and failure to mobilise patients within h from surgery were associated with delayed discharge. the logistic regression model was statistically significant (p \ . ) and correctly classified . % of cases. sensitivity and specificity were . % and . %, respectively. conclusions: results seem to be clinically rational and focus the attention on the importance of some perioperative clinical issues for the management of postoperative course. these variables could be considered as clinical goals to be reached in order to get an early discharge. objectives: the purpose of this study is to confirm the safety of laparoscopic gastrectomy with intraperitoneal cisplatin administration as a treatment for advanced gastric cancer with potential for peritoneal seeding. methods: from july to august , patients with advanced gastric cancer who underwent ip chemotherapy after diagnostic laparoscopy were retrospectively studied. all patients underwent laparoscopic gastrectomy with ip chemotherapy or ip chemotherapy alone after a diagnostic laparoscopy. gastrectomy was performed for palliative purposes even with seeding. results: the average age of the patients was years. eight patients ( . %) had preop chemotherapy. curative resection (r ) was performed in patients ( . %). in diagnostic laparoscopy, cytology was performed in patients ( . %) and cy was ( . %). peritoneal metastasis was detected in patients ( . %). of the total cohort, the year os rate was . % and the median survival time was months. in the case of stage iiib and below, the -year os rate was %, but it was % in stage iiic-iv group. when the r resection group and the r - resection group were compared, the -year os rates were . % and . %, respectively. hematological toxicity such as neutropenia was not seen in all patients. the mean hospital stay was . days and adjuvant chemotherapy was performed in patients ( . %). background: radical proximal gastrectomy (pg) and lymph nodes dissection are indicated for selected gastric cancers at the upper third of the stomach. with the advent of laparoscopic surgeries, more and more pg were performed by laparoscopic apporaches. in the past years, our team has accomplished and reported the oncological outcome of laparoscopic distal gastrectomies in cases of clinical stage i gastric cancer in taiwan. through the evolution of surgical trechniques and team work, we have cruised the learning curve of laparoscopic gastrectomy and reconstruction. materials and methods: in this report,we would like to present our surgical experience of laparoscopic proximal gastrectomy for gastric cancer patients. from to , pateints with gastric cancer underwent laparoscopic gastrectomies by the same surgical team at the national taiwan university. among them,six consecutive pateints (male:female = : ) with gastric adenocarcinoma of the upper stomach underwent laparoscopic pg in . the demographics, dissection, reconstruction methods and peri-operative outcome are presented. all six patients tolerated the procedure well, onepatient had mild anastomotic stenosis and improved with one session of endoscopic dilatation. one patient needed temporary proton pump inhibitor for controlloing acid reflux. four of the patients were pathological stage i, and the rest two pateint were stage iia and iiia disease. there was no tumor recurrence until now. summary: laparoscopic proximal gastrectomy is technically safe for treating upper third gastric cancers. the long term oncological outcome deserve further observation. introduction: open gastrectomy (og) has long been the preferred surgical approach worldwide for treatment of gastric cancer (gc). nowadays, several randomized, prospective trials have confirmed improvements in postoperative outcomes for laparoscopic gastrectomy (lg) compared to open procedures, with similar oncologic outcomes. however, most part of these studies comes from the eastern countries. material and methods: a prospective non randomized study was conducted with all patients operated of gc at ramón y cajal university hospital from january to december . over patients enrolled, patients underwent lg and og. textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. results: a textbook outcome was achieved in . % of patients operated of gc. the outcome parameter 'no severe postoperative complication' had the greatest negative impact on the textbook outcome. a statistically higher number of patients with early cancer ( % vs. . %) and subtotal gastrectomy ( . % vs. . %) were found in the laparoscopic group. no statistically differences were found between open and laparoscopic approach regarding operating time, rate of microscopic margin positivity, hospital stay, number of retrieved lymph nodes, complications, reinterventions, mortality and readmissions. no statistical differences in textbook outcome were found between both groups ( . % vs. %; p = . ). conclusions: laparoscopic gastrectomy for treatment of gastric cancer seems to be safe and feasible with similar textbook outcomes compared to open gastrectomy. introduction: laparoscopic surgery has been increasing for treatment of gastric cancer. however, standardization of this minimally invasive approach has not been reached yet because of its technical difficulties and the concern about oncological safety. the aim of the study was to analyze the outcomes of our learning curve in this complex surgical technique. material and methods: the first consecutive cases of laparoscopic gastrectomy (lg) performed at our hospital from november to february were enrolled. patients were divided into two groups based on the period they were operated. training phase (tp) was considered between and ( cases) and more-developed phase (mdp) between and ( cases). conversion, lymphadenectomy and retrieved lymph nodes (ln), hospital length of stay, mean operative time, complications, reintervention and mortality rates were compared between the two phases of learning curve. results: the number of retrieved ln was higher in the mdp ( ± , vs. , ± , ; p = , ). furthermore, we have also found less complications ( , % vs. , %; p = , ), a decreased reintervention rate ( , % vs. , %; p = , ) and overall mortality ( , % vs. %; p = , ) in the mdp. there were no significant differences in conversion rate, mean operative time, and hospital length of stay between phases. conclusion: although we consider that our learning curve is not completed yet because the average of monitored parameters have not reached a steady state, the improvement on surgical parameters and postoperative course in the last two years have showed our results are near to the best results published in the literature. aims: lymph node (ln) dissection proves to be essential for oncological gastrectomy, given that the presence of ln metastases is very high, even for early gastric cancer ( . % for t a and . % for t b). this way, d dissection for advanced gastric cancer and d ? for early gastric cancer are the gold standard procedures. some teams are using indocyanine green (icg) lymphography to improve their ln dissections, claiming that this technique facilitates the harvesting of small fluorescent ln that, otherwise, would be difficult to identify by conventional laparoscopic methods. methods: we herein present the case of a -year-old man with a t b distal gastric cancer. endoscopic ultrasound discarded the presence of metastatic ln and ct scan showed no distant metastases. icg was administrated endoscopically the day before the surgery, an amount of mg was injected along the submucosal layer around the tumour. in the video we can see how we perform a laparoscopic distal gastrectomy with d ? ln dissection and roux-en-y reconstruction. icg lymphography helped us to complete our expected ln harvesting, especially for groups (infrapyloric) and (left gastric artery). thanks to this technique, we could resect ln that we might have obviate during a usual laparoscopic procedure. results: patient was discharged home on the sixth postoperative day without complications and with adequate oral tolerance. conclusions: we present a case in which we have performed a laparoscopic distal gastrectomy with d ? dissection and roux-en-y reconstruction. we used icg lymphography to help us to improve our ln harvesting. although it is soon to assess if this technique may increase the number of retrieved ln and in which stations might be more useful, we consider this is a harmless method that may help gastric teams to complete their expected ln dissections. introduction: gastrointestinal stromal tumor (gist) represents around . % to % of gastrointestinal neoplasms, with the mesenchymal tumor being more frequent than the digestive one.the gist can be produced from the esophagus to the anus, at any point, being the stomach of ( to %) and the small intestine ( to %) more frequent sites.it is characterized by the expression of the tyrosine kinase growth factor receptor,cd ,differentiating it from other mesenchymal tumors,which do not express it.it is accepted that its origin corresponds to the interstitial cells of ramón y cajal,which act as a pacemaker for intestinal motility.they are very heterogeneous tumors, which vary in size,morphology and biological behavior,being neoplasms with uncertain malignant potential.the incidence is between the fourth and sixth decades,being the distribution by gender similar. clinical case: female patient of years,who goes to the general surgery service,as interconsultation,after a veda,by dyspepsia.it is reported stomach:ceiling mucosa without alterations,at the level of the greater curvature is seen a tumor of cm,hard to the touch with the biopsy forceps,slightly irregular covered with mucosa of normal appearance. computed tomography: stomach body:rounded image of nodular aspect which does not present heterogeneous enhancement after administration intravenous iodine contrast extending to peritoneal region, measures x x mm liver:hypodense image without heterogeneous enhancement adjacent to this,a mm rounded image that is suggested to be studied with nmr. gadolinium nmr liver hypodense image with well-defined limits without heterogeneous enhancement of cystic aspect. gastric roof,heterogeneous formation,which enhances with gadolinium mmx m-mx mm,having to discard a gist. surgical technique laparoscopic partial gastrectomy. pathological anatomy and immunohistochemistry . cm injury with net edges.uncertain malignant fusocellular nodule, cd ??? actin-dog ??? s -no mitosis or invasion of the mucosa is observed. conclusion: a case of stomach gist is presented,which,the main symptom was dyspepsia,being the clinical presentation very variable,in relation to the place in which it is located. there is fletcher criteria for the risk of malignancy,this being less than . cm,very low risk,less than cm, the patient evolved favorably,without surgical complications.aims: to present the surgical procedure of resection of the lesser gastric curvature and its pedicle with laparoscopic surgery, fulfilling oncological criteria, carried out in the general surgery service of the hospital of torrecárdenas. methods: an -year-old man with prostate cancer treated with complete hormonal block and epoc, who consults for rectal bleeding of week of evolution. it is diagnosed of gist in gastric lesser curvature, x x cm, very vascularized and infiltrates the wall producing marked imprint on the fundus. it is tributary of left gastric artery. precise blood transfusion and presents hemodynamic stability, is decided surgical resection scheduled. results: the surgery is performed by laparoscopy, with a tumor of approximately cm, which is dependent on the lesser curvature. the esophageal hiatus and the lesser curvature are dissected with section of the left gastric pedicle. atypical gastrectomy of the lesser curvature including gist, making a gastric sleeve dependent on the greater curvature. the anatomopathological study reports pt pn with lymph nodes without adenopathies, and disease-free surgical margins. he was discharged without complications on the th day and did not require re-entry. conclusions: the laparoscopy surgery for atypical gastrectomy of lesser curvature is safe and meets oncological criteria in selected patients and performed by an experienced esophagogastric unit. aims: to present the surgical procedure of total gastrectomy with d lymphadenectomy with laparoscopic surgery, fulfilling oncological criteria, carried out in the general surgery service of the hospital of torrecárdenas. methods: a -year-old male with a tobacco habit who consults due to epigastric pain and constitutional syndrome of months of evolution. it is diagnosed of gastric adenocarcinoma t n m . neoadjuvant qt is decided, after weeks of its completion, scheduled surgery is performed. results: the surgery is performed by laparoscopy, showing a stenosing tumor in at gastric antrum of approximately cm. dissection of the greater curvature with section of the right gastroepiploic at its birth and duodenal section is performed. dissection of the lesser curvature with d lymphadenectomy, section of the pedicle of the left gastric and the distal esophagus. the transit is restored with latero-lateral esophageal-jejunal anastomosis and jejunojejunostomy. the anatomopathological study reports ypt a and pn with / adenopathies, and disease-free surgical margins. he was discharged without complications on the th day and did not require reentry. conclusions: the laparoscopy surgery for total gastrectomy with complete d lymphadenectomy is safe and meets oncological criteria in selected patients and performed by an experienced esophagogastric unit. background: in gastric cancer surgery, to secure surgical margin, it is necessary to accurately judge the position of the tumor. however, with conventional marking clips, it is difficult to identify the exact location of the tumor during laparoscopic surgery. purpose: we investigate whether icg (indocyanine green) fluorescence navigation method is effective and safe for determination of cutting line in laparoscopic gastrectomy. patients and methods: subjects underwent laparoscopic gastrectomy (including robot-assisted surgery) based on the icg method for gastric cancer in the period from april to december . the day before surgery, icg diluted times ( . ml of reagent ? . ml of distilled water) was injected at cm from the tumor edge and . ml at the four submucosal layers around. then clip to the same part. gastrectomy based on standard surgery is performed, and the position of the tumor and spread of icg are confirmed by icg fluorescence navigation during operation, and a cutting line is determined. the extent of icg from the tumor is again measured with the excised specimen and compared with the pathological margin. results: among the patients who underwent intraoperative pathological examination, they were negative in all cases except one. the spread of icg was . cm on average, and considering the marking position ( cm) from the tumor edge, securing of . cm or more was possible. the operation time was . ± . min and the estimated bleeding loss was . ± . ml. conclusion: laparoscopic gastrectomy with icg method can evaluate tumor position and spread easily and in real time during operation and it was effective for determining the cutting line in laparoscopic gastrectomy. epstein-barr virus (ebv) has been known as one of causal virus of gastric cancer. ebv-related gastric cancer considered to be about % of the entire gastric cancer, and it is rare that ebvrelated gastric cancer has multiple lesions. the patient was years old female. she was diagnosed with upper gastrointestinal endoscopy with lesion in the lower major stomach body, lower anterior wall of the stomach body, rear wall in the middle part of the stomach, rear wall in the middle part of the stomach, and lesser curvature of the stomach angle, as a result of biopsy, adenocarcinoma was observed from the former four. the patient underwent a robot-assisted total gastrectomy. adding a newly found lesion, the histopathological diagnosis was pt b in the lower major stomach body, pt b in the lower anterior wall of the stomach body, pt b on rear wall in the middle part of the stomach, pt b on rear wall in the middle part of the stomach, and pt a in lesser stomach body, pn , pstageia. pathological examination results showed that the four lesions were positive for tumor cells in eber in situ hybridization and were considered to be ebv-related gastric cancers. she was discharged on the th day after the operation without any postoperative morbidities.there has been no sign of recurrence without postoperative therapy for months. results: a -year-old female with no medical history of interest or allergies to medications, who consulted for palpable mass at mesogastric level to the left of the midline associated with abdominal pain of - months of evolution, without concomitants or relationship with the intake, valsalva or physical efforts, without change in the depositional habit or toxic syndrome. the abdominal ct (computed tomography) revealed a cystic mass in jejunum mesentery, defined edges, about cm in diameter and that does not capture contrast; likewise, there is no ascites, retroperitoneal adenopathies or other intra-abdominal or pelvic masses, radiology recommends completing the study with abdominal mri (magnetic resonance imaging) that informs of possible lymphangioma at the level of the jejune mesentery. surgical exeresis was decided, which was carried out by laparoscopic approach, with emptying of the lesion and enucleation of the lesion without incidents, the postoperative evolution was favorable being discharged at h. the pathological anatomy reported fibro-adipose tissue with presence of lymphatic dilatations associated with a cystic lesion without epithelial lining, with serous fluid and abundant macrophagic reaction compatible with mesenteric lymphangioma. conclusions: the mesenteric cyst is a rare pathology with an incidence ranging from / , to / , , predominating in the fourth decade of life. it is defined as any cystic lesion in the mesentery, and is subdivided according to its origin into lymphatic, mesothelial, urogenital, dermoid, and enteric and pseudocysts. most of the time they are asymptomatic although they can (as in our case) present with abdominal pain and even produce complications such as intestinal obstruction, volvulus, intracystic hemorrhage, infection, rupture, and even malignant transformation. for the diagnosis, the palpation can be of great help, showing mass of well-defined limits and partially mobile. the imaging test of choice is abdominal ultrasound / abdominal ct, supplemented by magnetic resonance imaging. the recommended treatment is surgical exeresis, considering laparoscopy as the first option; if it is complete, it can be considered as a curative treatment. purpose: gastrostomy(og) is an alternative method for nutrition support, especial for the patients with oral-esophagus route obstruction or dysfunction. the most operation were conducted by young surgeon or residents. laparoscopic gastrostomy(lg) was a new coming procedure and the skillful suture techniques were needed. the most the residents can't be qualified for this operation. we designed the method for laparoscopic gastrostomy to provide the traning opportunity of suture skill training and guarantee the patient's safety. material and method: laparoscopic gastrostomy procedure was done with two mm trocar. the lower body of stomach was chose. four point around gastrostomy wound were chose for subcutaneous fixation. the straight needle with - prolene was inserted into peritoneal cavity from upper point, then punctured the sero-muscular layer of stomach. the needle was retrieved out from the same point by guidance of gauge needle. the same way was used for other three points. one purse string around gastrostomy was created by one hand suture method and fastened by köckerling knot tier after insertion of fr foley tube. finally, the peritonization was finished by hand tie externally and knot were keep in subcutaneous layer material-method: we present the case of a year old woman who presented with melena, hematemesis, anemia (ht . %) and being haemodynamically unstable. after the stabilization of the patient, a gastroscopic examination followed, where it revealed a tumor of the fundus (adenocarcinoma). the patient was submitted to laparoscopic total gastrectomy and oesophagojejunal anastomosis, omega type (o), and intestinal anastomosis braun, with the usage of trocars (umbilical mm as inserted in laparoscopic surgery of a single incision, and two mm in the midclavicular line bilaterally). the oesophagojejunal anastomosis was conducted with the use of a linear stapler for the posterior wall and the convergence of the anterior wall with laparoscopic sutures in two layers. patient remains in well condition, months after the operation. conclusion: laparoscopic approach seems to be safe for treatment of gastric cancer of the fundus and of the gastroesophangeal junction, as it offers better surgical field view and less postoperative complications. the restoration of the continuity of the gastrointestinal tube with anastomosis of w type is considered safe alternative to the classic roux-en-y anastomosis. git and bariatric surgery, faculty of medicine, alexandria university, alexandria, egypt; git surgery, faculty of medicine, alexandria, egypt background: superior mesenteric artery syndrome is best described as compression of the third part of duodenum by the superior mesenteric artery, resulting in obstruction. the study of this rare medical condition was carried out since decades yet remain obscure. this study aimed to analyze different clinical presentations, diagnostic modalities, treatment approaches and outcomes, as well as to emphasize the importance of long term follow up. methods: thirty-five superior mesenteric artery syndrome cases were collected retrospectively from a facebook group called 'superior mesenteric artery syndrome awareness & support'. a questionnaire was designed using google form to obtain the demographics, presenting symptoms, risk factors and co-morbidities, investigations, means of treatment and the outcomes. data was entered into microsoft office excel for statistical analysis. results: the median age at diagnosis was years. the median body mass index was . kg/ m ;. the median time interval from symptom onset to initial diagnosis was months. the major presenting symptoms were abdominal pain ( . %), nausea ( . %), and vomiting ( . %). abdominal computed tomography scan with contrast ( . %) was commonly used for confirmation of diagnosis. thirteen cases ( . %) were congenital. thirty patients ( . %) had received treatment. the overall management success was only . %. surgical management ( . %) was the most used regimen. conclusion: diagnosis of superior mesenteric artery syndrome is established after a thorough assessment of the clinical presentations and confirmation with suitable imaging modalities. the choice of treatment should be dependent on the causes and severity as different patients respond differently to therapy. recurrence is possible in all patients thus a long-term follow up is required. aims: in the last hundred years much has been written on peptic ulcer disease and the treatment options for one of its most common complications: perforation. laparoscopic repair of perforated peptic ulcer has been gaining popularity in recent years. treatment for perforated ulcer can be performed laparoscopically in % of cases, making it possible to avoid a median laparotomy which can lead to wound infection and late eventration. methods: a -year-old male presented to emergency room with a three-hour history of progressively worsening epigastric pain and nausea. physical examination revealed rebound tenderness compatible with an acute abdomen. a ct scan showed: important pneumoperitoneum unable to define the drilling point; distended stomach with plenty of fluid inside and dense content fundus / body suggestive of active arterial bleeding . results: the patient was emergently taken to the operating room for diagnostic laparoscopy . perforation shown in greater gastric curvature associated blood remnants. gastrotomy for clot removal is done without observing active bleeding. the gastrotomy was repaired using standard stitches. all exudate was aspirated and the peritoneal cavity was irrigated with warm saline solution the patient had an uncomplicated post-operative course. jp drain was removed and he was discharged one week after surgery. conclusion: the role of laparoscopic surgery in emergencies is well documented. laparoscopic approach is indicated in any case of suspected gastroduodenal perforation and seems to offer the same advantages as for the vast majority of laparoscopic procedures. laparoscopic surgery may therefore have a real place in the treatment of perforated peptic ulcer. the aim: of our study was to evaluate of effectiveness of local injection of platelet-rich plasma for treatment of peptic ulcer bleeding with hemorrhagic shock in experiment. methods: the study was performed on wistar rats according to local and international rules for working with experimental animals. the average weight of animals was ± grams. in all animals our modification of type acetic acid ulcer (susumu okabe, ) was modeled. we randomly divide all animals in groups. rats with only modeled ulcer were included in group . rats with modeled ulcer and hemorrhagic shock after - . ml blood sampling were included in group . in group we included rats with modeled ulcer and hemorrhagic shock and performed local injection of platelet-rich plasma (local periulcelar injection of . ml of autologous platelet-rich plasma). on st, th and th day measurement of the ulcers square and morphological study were performed. results: the data we have received demonstrate a tendency of decrease of ulcers' square in all groups with time flow. we also compared sizes of ulcerative defects in all groups at every point of the study. on the st day of investigation there were no differences (p [ . ) between ulcers' square in all groups. on the th day we found out more rapid decrease of size in group (p [ . ). however, this tendency had no statistical significance. on the th day difference was larger and it was statistically significant this time (p \ . ). also the better ability to stimulate the activity of fibroblasts and revascularization in the young connective tissue with improving oxygenation in the ulcers and enhancing of cell proliferation, differentiation and accelerating of maturation of connective tissue and healing of ulcers was demonstrated in group . conclusion: platelet rich plasma reduces inflammatory response and stimulates proliferation of gastric epithelial cells on th day with the restoration of secretory activity and epithelialization of ulcers in . % of experimental animals on th day, the activation of the fibroblastic reaction during the all experiment and decreasing of ulcers' square. h. fujii, depat. of surgery, japanese red cross fukui hospital, fukui, japan introduction: in conjunction with charmant, a local eyeglass frame manufacturer, we developed novel devices called the fj (free jaw) clip to grasp organs in the abdominal cavity and the f (free) loop plus to pull thread extracorporeally from within the abdominal cavity. product summary: the fj clip is used to grasp organs in the abdominal cavity, a stainless steel, removable forceps for use in laparoscopic surgery. it provides a strong grip but rarely crushes organ tissue. the clip comes in two sizes, one for use in a -mm port and the other for use in a -mm port, and in two lengths, . mm and . mm, respectively. to pull out thread tied to the fj clip, we developed the f loop plus, which is a g by -mm-long special stainless needle with f . -mm niti alloy thread which is used pull suture threads from inside the abdominal cavity to outside the body. case: we performed cases of reduced port laparoscopic and endoscopic cooperative surgery (lecs). we performed reduced port surgery (rps) by making a . -cm incision at the umbilicus, inserting trocars ( mm and mm), and inserting another trocar ( mm) at the left side of the abdomen. we expanded the left hepatic lobe with a -mm fj clip for penrose drain placement, grasped the front wall of the gastric body with a -mm fj clip, applying traction toward the legs to pull up the tissues around the tumor, and resected all layers of the tumor via oral endoscopic submucosal dissection technique. the resected area was closed with a suturing device or interrupted sutures in the abdominal cavity. a year-old female was admitted to the emergency department with complaints of abdominal cramping pain, back pain and diarrhea for one day. she also had fever, ever up to °. in these two weeks, she felt occasionally epigastric pain. her past medical history included hypertension. on physical examination, she was conscious and alert. abdominal examination revealed diffuse tenderness and knocking pain over right flank. laboratory tests indicated an degraded white cell count of /cumm with % band forms, c-reactive protein of mg/dl and abdominal liver function tests (alanine aminotransferase: u/l, alkaline phosphatase: u/l, gammaglutamyl transferase: u/l) without hyperbilirubinemia. abdominal x-ray showed paralytic ileus. our presumptive diagnosis was acute peritonitis, based on the patient's symptoms. empirical antibiotics were administered immediately, and a computed tomography (ct) imaging study was performed. the ct scan showed a stick like foreign body noted between ventral side of pylorus and smv lumen, about . cm in length and associated with perifocal infiltration and segmental smv thrombus formation. (fig. ) however, there is no obvious pneumoperitoneum and no evident ascites is associated. an emergency exploratory laparotomy was performed, revealing stomach perforation at posterior wall with a cm fish bone thourgh pancreas into smv. localized inflammation and fibrosis were identified without obvious fluid accumulation( fig. - ) . removal of fish bone and simple closure of stomach perforation were performed. blood cultures revealed bacteroides thetaiotaomicron. three weeks later, she received a follow-up ct scan which showed smv obliteration with chronic pylephlebitis. aim: here we present a case report about the endoscopic treatment for iatrogenic gastric perforation secondary to a chest tube insertion. methods: a case report of a -year-old male with history of a road traffic accident. described injuries were severe brain injury with gcs \ at pre-hospital care arrival, thoracic injury with several rib fractures on the left hemithorax and hypoventilation on the left side. prior to hospital transfer a chest drain was inserted on the left side, and the patient was intubated. results: at hospital admission, the patient was hemodynamically stable and connected to a mechanical ventilator. thoracic exam showed persistent hypoventilation on the left chest. no other abdominal or pelvic injuries were found in the physical exam. a frontal chest x-ray revealed pneumothorax and the chest tube was not viewable. a further ct scan showed the chest drain placed in the abdominal cavity, into the stomach, besides a subdural hematoma, comminuted pelvic fracture of the pubic rami and a left sacroiliac fracture. during the first h in the icu, neurological worsening was observed, and a new cranial ct revealed enlargement of the subdural hematoma, for what the patient underwent decompressive craniectomy, with improvement thereafter. following a five-day period of stabilization after surgery, the patient was evolving satisfactorily, and the removal of the intragastric chest drain was considered. endoscopy was performed to confirm the placement of the drain, and it was removed under direct vision. approximately twenty five centimeters of the catheter were visualized in the gastric lumen, and then successfully removed. the patient recovered well and was discharged from icu to medical hospital ward after fourteen days, and a week later he was discharged home. conclusion: endoscopic management for gastric perforation after a chest drain insertion may result effective and can prevent open surgery morbidity. aims: intestinal infusion treatment with levodopa/carbidopa (duodopa) is a therapeutic option concerning the advanced parkinson disease cases with no response to the conventional treatment. the drug requires carrying out a gastrostomy either by percutaneous endoscopy way, or by laparoscopy -if the first one is not possible-. later, a duodenum-yeyunum tube is placed in order to infuse the duodopa gel continuously by a portable bomb. in this report, we explain the laparoscopic gastrostomy technique. method: sin this report, we include two patients with advanced parkinson disease: the first one is a year-old female patient suffering from an important gait disorder; and the second one is a year-old male patient with uncontrolled motor fluctuations. in both cases, a percutaneous endoscopic gastrostomy was proposed, but neither was feasible because of the non-traslumination between the gastric and the abdominal wall. under general anesthesia, neumoperitoneum by veress needle was performed. three main trocars and one accessory were placed. at the level of the gastric antrum, a cm incision was conducted to insert a gastrostomy tube, to be the guide for the drug infusion catheter. next, the gastrostomy is fixed to the abdominal wall by the stamm technique, externalizing the catheter through the accessory trocar in the medial line. results: on the first post-operative day, a duodenum-yeyunum tube is placed by endoscopic control through the gastric device. both patients got well satisfactorily, and no complications were described; and they develop a total normal life within the limitations of their underlying disease. conclusions: the duodopa intestinal infusion shows a significative improvement for the advanced parkinson disease symptoms, compared with oral medication; appreciating positive results referring to life quality. when the catheter placement by endoscopy way does not seem posible, gastrostomy by laparoscopy constitutes a valuable surgical option for the treatment of this kind of patients. peptic perforated ulcus (ppu) is a common surgical emergency and laparoscopic repair has been introduced as an alternative to open repair. it has shown good results and allows closure and peritoneal lavage, just like the open repair does but with the advantages of a minimally invasive surgery. the objective is to report the outcome of laparoscopic ppu in our hospital. methods: from january to october , patients with a clinical diagnosis of ppu were assigned to undergo laparoscopic repair. this retrospective study included all husm patients who underwent laparoscopic ppu repair by emergency surgeons. minimum follow-up of months is carried out. results: of the patients in this series, % were men and % were women, between and years of age at the time of surgery, average of years. the time between the manifestation of symptoms and surgery was [ to h in % of patients. in patients there was a history of previous ulcer or non-steroidal anti-inflammatories intake and up to % were smokers. a ct scan was performed in all cases to reach the diagnosis primary closure with simple suture plus omental patch was the elected technic ( %). the approach was performed with trocars in %, trocars in % and in case. cases ( %) were gastric ulcer, duodenal cases ( %) and in one case no perforation was found. the conversion rate was %, in two cases due to technical difficulty and in the other case because the level of the perforation was not found. the median postoperative stay was days although there were cases with intrabdominal complications. there was an exitus due to a metastasic pulmonary neoplasia diagnosed in the immediate postoperative period. there were no cases of recurrence in the follow-up time. conclusion: in most centers, including ours, the rate of laparoscopic management has gradually increased along with the improvement of technical skills. improvements in the outcome of laparoscopic ppu repair are to be expected with more experience surgeon and a good selection of the cases. general surgery, jzu hospital ,,sveti vracevi,, bijeljina, bosnia-herzegovina introduction: diverticulum is an outpouching of a hollow organ. gastric diverticulum is rare form od this disease. incidence of detection varies depending on investigation method. it has been reported in . % cases of autopsies, . % cases of gastroduodenal roentgenographies with contrast, and . - . % cases of upper endoscopies.small diverticula are usually asimptomatic, but bigger diverticula can cause variable symptoms such as abdominal pain, feeling of epigastric fullness right after meal, feeling of discomfort in upper parts of abdomen, and severe 'foetor ex ore' .diagnosis is usually established in procedures such as gastroduodenal roentgenographies with contrast, upper endoscopies and abdominal ct scan. case report: a -year-old woman came to our hospital because of feeling of discomfort and mild pain in upper abdomen that lasted for last year. diagnosis is established after ct scan of abdomen and upper endoscopy procedure. initially she has been prescribed conservative therapy (proton pump inhibitors). since the symptoms persisted, laparoscopic resection of the gastric divertuculum was performed using endogia stapler. considering the feeling of discomfort and abdominal pain dissapeared, the patient was discharged from hospital on the fourth postoperative day. conclusion: asymptomatic gastric diverticula doesn't require treatment. since gastric diverticulum can have complications such as bleeding, perforation and neoplasia, patient without symptoms should be monitored. initial therapy for symptomatic diverticula is conservative therapy (proton pump inhibitors). if conserative therapy doesn't procude expected results, laparoscopic resection of the diverticulum should be considered. introduction: the acute perforation of a gastric ulcer is a serious entity that requires urgent surgical treatment in most of the occasions, it is increasingly accepted that the approach of choice is laparoscopic, depending, above all, on the time of evolution of the process. objectives: to demonstrate the safety and efficacy of the laparoscopic approach in the perforation of a pyloric peptic ulcer, even in cases of severe peritonitis, by means of a standardized procedure, insisting on the sequential thorough washing of the cavity.material and methods: we present a video of the surgical intervention of a patient with acute abdomen, with a history of nsaid ingestion, exploration and ct-analysis compatible with perforation of hollow viscus, probably of gastric origin. results: intervention: complete laparoscopic approach, trocars. severe biliopurunitic peritonitis, by pyloric perforation 'acute', liquid culture, suture of the perforation, epipoplasty, sequential thorough washing of the cavity with physiological saline and placement of drainages.correct postoperative period, discharge from the hospital on the th day after completing antibiotic treatment. endoscopy and helycobacter test are performed on an outpatient basis with normal results. conclusion: the laparoscopic approach is safe and effective in acute and complicated gastric ulcer disease, even in cases of severe peritonitis. surgical procedure: the clean-net procedure involves the selective dissection of both the serosa and muscle layer using a laparoscopic monopolar endoscopic scissor. the preserved mucosal layer provides a mechanical barrier between the gastric lumen and peritoneal cavity that aids in the prevention of peritoneal cavity contamination with gastric contents. tumors are observed with an upper gastrointestinal endoscope with the injection of indocyanine green (icg) into peri-tumoral submucosal layers at points. selective seromuscular dissection is performed using a laparoscopic electrocautery monopolar scissor. the mucosa surrounding the gist is then resected using a endoscopic mechanical stapler to prevent exposure of the gastric lumen to the peritoneal cavity and peritoneal tumor cell seeding. results: there were males and female, and the average age was years. the operation time was min, the average bleeding volume was . ml, the postoperative hospital stay was . days. the mean tumor diameter was . mm, the final histopathological diagnosis was gist, schwannoma. there were no postoperative complications of clavien-dindo classification or more. conclusion: clean-net was found to be safe and useful for the treatment of gastric smt with ulceration. year outcomes: laparoscopic heller myotomy stands the test of time aims: laparoscopic cardiomyotomy leads to excellent relief of dysphagia in % of patients and avoids thoracotomy or laparotomy. methods: we present a video illustration of the procedure that was modified at the american university of beirut medical center. so far, patients underwent laparoscopic cardiomyotomy, age range of to years, with males and females. most of them have had previous balloon dilatation. results: all cases were successfully completed laparoscopically without complications. followup of months to years revealed excellent results with complete resolution of symptoms and no need for further medications. this will result in minimal post-operative pain and very short recovery period and is associated with low complication rate. conclusion: cardiomyotomy for achalasia is ideal for laparoscopic approach. magnification allows for precise division of muscle fibers. the new technique of hydro dissection and enseal for division of esophageal muscle allows for completion of the procedure without injury of the mucosa. therefore, adequate release of the obstructing segment followed by anti reflux procedure toupet will lead to excellent results with minimal morbidity and no mortality. aims: laparoscopic repair of huge hiatus hernia methods: twenty two cases of huge hiatus hernia presented to the american university of beirut medical center. patients underwent through trocars in the upper abdomen reduction of the hernial sac from the chest. special care was taken in the dissection of the mediastinum to keep the thoracic fascia and pleura intact. the defect was sutured primarily by -ethibond sutures reinforced by onlay prolene mesh u-shaped was fixed at the rt. and lt. crus and a floppy nissen fundoplication performed . results: the video presentation includes the technical aspects and the method of reducing and repair of huge hiatus hernia.aim: nowadays, there is little experience in the world of applying robotic surgical system (rss) in treatment of patients with hiatal hernia (hh) and reflux-esophagitis (re). the aim of study was to determine the possibility and feasibility of using rss in treatment of patients with hh. materials and methods: a total of patients underwent robot-assisted hh repair without mesh, followed by fundoplication with our original method ( °full symmetric wrap). the clinical and technical analysis did not reveal any advantages over similar laparoscopic procedures, so we abandoned the use of rss for hh type i, and these patients were excluded. there were ( %) patients with hh type iii and ( %) type iv. the surgeries were performed by experienced robotic upper gastrointestinal surgeon and conducted with the davinci si surgical system (intuitive surgical, sunnyvale, ca). results: average operation time was ± ( - ) min. the respondents' mean age was . ± . years (range - ) and bmi was . ± . (range . - . ) cm/kg . average blood loss was ± ( - ) ml. average hospital stay was ± . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) days. the average follow-up time was ± . ( - ) months. postoperative x-ray imaging and upper gi endoscopy was conducted in all ( %) patients. there was no hh recurrence diagnosed. we did not observe a relapse of hh or clinical manifestations of re in the early (less than days) and long-term (more than months) postoperative periods. conclusion: we can conclude that robot-assisted surgery is safe, appropriate and justified in patients with hh type iii and iv. all procedures performed to the patients with giant hh revealed clear technical advantages of rss over similar laparoscopic operations: an enlarged d hd image, bendable instruments with endowrist technology allowed for precise dissection of tissues (hernial sac, cicatricial adhesions) in a narrow anatomical space-posterior mediastinum without damage to pleura, pericardium and vagus nerves. we believe that use of rss in treatment of patients with reflux esophagitis and/or hh type i is unjustified, due to the lack of proven advantages over laparoscopy. introduction: the presence of major anatomical obstacles -such as massive caudate lobe-in the confined operative field of laparoscopic hiatal hernia repair (lhhr) poses significant challenge to the foregut surgeon. aim: to provide a safe alternative for lhhr using a laparoendoscopic approach. method: this patient is a year old female, with bmi of . . her past medical history includes diabetes, hypertension and hyperlipidemia. she had gerd for years. her egd showed x cm hiatal hernia and class b esophagitis. manometry showed ineffective esophageal motility. we used the classic five ports approach for lhhr. we found a massive caudate lobe which was comparable to the size of an already enlarged left lobe of the liver. the operative strategies: terminating the procedure proceeding with the standard approach and taking the risk of bleeding from the caudate lobe itself or the inferior vena cava (ivc) with possible catastrophic outcome. using the laparoendoscopic approach. the following three steps facilitated the performance of safe and effective surgery. additional liver retractor this improved exposure and minimized manipulation of the caudate lobe. extracorporeal sliding arthroscopic knots (esak) esak are similar to the knots used in endoloop. they are tied extracorporeally and require a single insertion of the knot pusher as they do not unravel. transoral incisionless fundoplication (tif) we performed tif to avoid a limited operative field and to prevent excessive tissue manipulations associated with laparoscopic fundoplication. tif also preserves the angle of his and produces partial fundoplication which has less side effects of dysphagia and gas bloat syndrome. results: the operative time was min (lhhr min and tif min). there were no complications. patient discontinued omeprazole which she used daily for years. at months follow up, her gerd related quality of life (hrql) and gerd symptom (gerss) scores were ( vs ) and ( vs ). conclusion: the laparoendoscopic repair of hiatal hernia in the presence of anatomical obstacles is safe and effective. longer follow up is needed to assess the durability of this repair. gastroesophageal reflux disease (gerd) is a condition that reduces the quality of life and can causedisorders associated with acid reflux, such as bronchial asthma, barrett's esophagus and esophagealadenocarcinoma. gerd is often caused by existing of hiatal hernia. nowadays, some surgeons haddifficulties with the laparoscopic approach to treatment of recurrent hiatal hernias.patient was a -year-old man. he requested medical assistance with dysphagia, nausea after eatingand heartburn getting worse in a horizontal position. conservative treatment was not effective.transthoracic nissen fundoplication was performed in . the main complaints of the patientpersisted during the postoperative period. the upper half of stomach and s-like curved esophagus werelocated in the mediastinum according to multislice computed tomography of the thorax in august.in our clinical center was performed laparoscopic cruroraphy, cardiomyotomy and nissen fundoplicationin november. during the surgery the normal anatomical position of stomach has been restored, s-like curve of esophagus has been removed; a gastric cuff (collis-nissen) has been created and anteriorand posterior cruroraphy has been performed. the patient was in intensive care during h. anasogastric tube feeding was continued during the first h. passage of the contrast through theesophagogastric junction was free within h after surgery. patients had been discharged within days after surgery.this case report shows that at the current stage of surgery laparoscopic approach can be useful not onlyfor treatment of primary hiatal hernias-but also for treatment of recurrent ones. aims: laparoscopic heller myotomy procedure, completed with an anti-reflux procedure is technically demanding. we report a case of laparoscopic heller myotomy followed by a dor anterior fundoplication. methods: this is the case of a -year-old caucasian woman with gradual dysphagia for solids and liquids, accompanied by severe regurgitation and chest pain. an initial diagnosis of achalasia was made in , with the use of manometry and barium swallow. endoscopic dilatations were attempted pre-operatively with no clinical improvement. decision was made to perform a laparoscopic heller myotomy, combined with a standard dor anterior fundoplication. a -ports operation took place (one intra-umbilical mm trocar-single incision laparoscopic surgery (sils) technique, two -mm subcostal trocars, and one another mm subcostal trocar for the use of liver retractor). the operation lasted h and min. results: no post-operative complications were noted. the post-operative swallow test showed improvement of the esophageal patency. the patient started a liquid diet three days later and was discharged six days post-operatively. two months later the patient presented no complications. conclusions: heller's myotomy has demonstrated good long-term results in the treatment of esophageal achalasia and the laparoscopic approach has been well established in the last two decades. it is a very demanding operation to perform and the disease is relatively rare, making the learning curve difficult to achieve. aims: achalasia is a type of motor disorder of the esophagus due to degeneration of ganglion cells in the myenteric plexus, leading to failure of relaxation of the lower esophageal sphincter, accompanied by a loss of peristalsis in the distal esophagus. the association of a long-term achalasia and a large size hiatus hernia is an infrequent entity. among the therapeutic options is medical treatment, endoscopic treatment and surgical treatment associated with an antireflux procedure. the laparoscopic approach being the more indicated due to its better results in terms of morbidity, mortality and recurrences. the aim of the video is to show the effectiveness and safety of the laparoscopic approach in this infrequent pathology, pointing out the importance of performing a standardized procedure. methods: -year-old male patient, with personal history of chronic ischemic heart disease and obesity, diagnosed with long-term achalasia with moderate dilatation of the esophagus associated with giant hiatus hernia. the complementary explorations and iconography of interest are exposed. results: intervention: complete endoscopic approach, trocars. reduction of hernial content into the abdominal cavity, dissection of the hernial sac and esophageal lipoma. extended mediastinal esophageal dissection. complete resection of both the sac and lipoma, respecting the posterior vagus. heller's myotomy of cm, including cm distal to the ueg, perforation of mm of the mucosa at the ueg level, suture and blue methylene verification of the sealing. hiatorraphy and dor-type anterior fundoplication as antireflux technique. correct postoperative, with egd control on the rd po day and discharge on the th. asymptomatic at months after surgery. conclusion(s): for achalasia laparoscopic heller myotomy with a partial fundoplication should be the treatment of choice in patients who are at low surgical risk. the length of the myotomy, especially distal to ueg is one of the most important aspects of the surgery, to achieve an effective disruption of the les. the presence of a giant hiatus hernia makes the procedure difficult, increasing the risk of complications, such as perforation. standardization is essential to increase safety and efficacy in these complex cases. purpose: there is evidence that the application of mesh-reinforced hiatal repair has resulted in a significant reduction in recurrence rates in comparison with primary suture repair, at least in short-term follow-up. however, and instead of this, the standard of care for repairing large paraesophageal hiatal hernias (lphh) remains controversial because no clear guidelines are given regarding indications, mesh type, shape and position. the aim of this study is to evaluate our short-term outcomes in management of lphh with a biosynthetic monofilament polypropylene mesh surrounded by a high-purity and adherent titanium dioxide surface coating to enhance the biocompatibility (tio mesh tm ). methods: a retrospective study was conducted on our institution between december and october . data were collected on patients with lphh greater than cm in which a laparoscopic repair was carried on by primary suture and additional reinforcement with a tio mesh tm . clinical and radiological recurrences, dysphagia and mesh-related complications were investigated. results: there were females and males with a mean age of years (range, - years). all operations were completed laparoscopically. median postoperative stay was days. after a mean follow-up of months, patients developed clinical recurrence of reflux symptoms ( . %) and radiological recurrences ( . %). there were no mesh-related complications. conclusions: the use of tio mesh tm for laparoscopic repair of lphh is suited and with a reasonably low recurrence rate in this short-term study. additional long-term studies with enormous numbers carried out for years will be necessary to affirm whether this mesh is convenient in the prevention of recurrences and mesh related complications. background: surgery for refractory gastroesophageal reflux disease (gerd) has a satisfactory outcome, however sometimes fundoplication fails and redo surgery is required. several publications have investigated the feasibility of performing reoperative fundoplications using laparoscopic techniques. the aim of this study was to describe our experience in laparoscopic redo fundoplications in the last years. material and methods: we retrospectively reviewed consecutive patients who required laparoscopic redo fundoplication from january to august .the indications were recurrent symptoms of gastroesophageal reflux disease (gerd) ( . %), recurrent symptomatic paraesophageal hernia ( . %), dysphagia ( . %) and acute volvulus ( . %). results: all redo fundoplications (basically toupet . % and nissen . %) were completed laparoscopically. the mean operative time was min (range, - . min). a mesh was placed in % of cases. intraoperative and postoperative complication rates were . % and . % respectively. the mean hospital stay was days (range, - days). one patient ( . %) from the laparoscopic group required a third operation-one for acute recurrent paraesophageal herniation of the redo wrap one month after surgery, which was repair laparoscopically again. symptomatic outcome was successful in . % without any kind of proton bomb inhibitors therapy. conclusion: laparoscopic redo fundoplication is technically feasible and clinically effective with a reasonable low rate of postoperative complications p -upper gi-reflux-achalasia objectives: in recent years, balloon dilatation (bd) for diseases requiring correction of the impaired patency of the sphincter zones of the esophagogastroduodenal region has become widespread. purpose: to assess the effectiveness of the use of the balloon dilatation in patients with impaired sphincter zones of the esophagogastroduodenal region. materials and methods: in the institute department of surgery for the period from to , bd was performed in patients. of them diagnosed with achalasia of cardia (ac): - stage, - stage, - stage, - stage. patients diagnosed with pylorospasm, patients had compensated stenosis and patients had subcompensated ulcerative pyloroduodenal stenosis. there were males, females, average age ( . ± . ). bd was performed under endoscopic and / or x-ray control by 'boston scientific' balloons with a diameter of - mm, mm and mm, a course of - sessions with an interval of - days and a cylinder exposure of - min. evaluation of bd was performed using esophagogastroscopy, balloon manometry and x-ray passage of barium. results: in the course of the study, the existing indications were refined and new indications were developed for performing an endoscopic bd in pyloroduodenal stenosis and in ac. in patients with stage - ac, a positive result was noted in . % of cases already after the first session of bd. recurrences of ac after bd for up to years were established in ( . %) patients: at stage -in . %, at stage -in . %, at stage -in . % and at stage -in . %. repeated bd courses in case of ac recurrence in ( . %) cases turned out to be ineffective. recurrence of pyloroduodenal subcompensated stenosis was diagnosed in . % of cases in the period of months after performing bd. conclusions: bd is an effective method for correcting the permeability of the sphincter zones caused by the pathology of the esophagogastroduodenal region. keywords: balloon dilatation, achalasia of cardia, pylorospasm, ulcerative pyloroduodenal stenosis, recurrences. introduction: the reoperation in antireflux surgery significantly increases morbidity and mortality up to - %, reaching rates of % in patients undergoing or more surgeries. the advantages of laparoscopic surgery used in this surgical technique have amplified its acceptance and use, resembling its results in terms of feasibility, safety and efficacy of laparoscopic surgery to open surgery.objective: :evaluate the currently literature about antireflux surgery reintervention, focusing on the main indications of re-intervention, type of approach and morbidity and mortality of laparoscopic antireflux surgery. material and methods: a literature search was conducted in two electronic databases, med-line and embase. the search was limited to the period to . terms were used in relation to the procedure or intervention and the underlying disease. we chose observational studies (cohort, cases and controls and series of cases), where the main indication for antireflux surgery would have been gastroesophageal reflux disease. results: a total of studies were selected, most of them were case series ( . %), cohort studies ( %) and case-control studies ( . %). a total of patients. the main indications were anatomical faults, of these failures, recurrent hiatus hernia and sliding occupy the highest percentage, while physiological failures, failure in esophageal and gastric motility occur more frequently. the main type of approach was laparoscopic in %, the conversion rate was . % and the open approach was reserved for complex cases with more than one re-intervention . %, for abdomen . % and chest . %, this last for cases with high esophageal lesions that can not be repaired via trans-abdominal.the main complications were injuries to hollow viscera, such as: esophagus and stomach among others. these complications are related to the complexity of the procedure. mortality has remained low up to . %, however, the cause of death was due to medical complications and not related to the procedure. conclusions: this systematic review on reoperation in reflux surgery has confirmed that morbidity after reoperation surgery is higher than after primary surgery and reoperation indications increase with the use of new technologies (manometry) and the laparoscopic approach continues on the rise, with great adaptation to its use and improvement in results. aims: eras protocol is not commonly used in acute emergency procedures. elective lc is commonly performed as one day surgery, while in an emergency setting of acute cholecystitis, the in hospital stay averages , days. the aim of this trial is the application of eras protocol in patients with acute cholecystitis, undergoing laparoscopic cholecystectomy. methods: a randomized prospective trial was conducted in first surgical department of sismanogleion g.h.a. the study included patients, who were admitted with acute cholecystitis and underwent lc into h from their admission. preoperatively, they all received crystalloid isotonic solutions and antibiotics. . % were submitted to ercp, preoperatively, due to choledocholithiasis. the postoperative care included early mobilization into h after surgery, early fluid intake (into h) and early liquid food intake (into h). they all received systematically antibiotics, analgesics and antiemetic on demand. asa score was not an exclusion criterion. results: conversion to open procedure was necessary in . % of patients, whom were excluded from the study. all the rest were discharged into h from the surgery with the guidance to receive oral antibiotics for more days. readmission was necessary for patients, one week after the operation. the first one presented with bile leak and submitted to ercp with stent placement and percutaneous drainage of the intrabdominal collection. the second one presented with choledocholithiasis and underwent ercp with balloon catheterization. conclusion: it is commonly accepted that eras protocol in elective procedure enhances the postoperative recovery while reduces the in hospital stay and cost. in emergency condition eras cannot be applicated preoperatively. however, a modified post surgery application seems to have advantages equal to those observed in elective procedures. aim: laparoscopic cholecystectomy is the gold standard for the treatment of symptomatic cholelithiasis. administration of one single dose of chemoprophylaxis before an elective laparoscopic cholecystectomy is a broadly accepted practice. however, its value is currently questioned, especially in low risk patients. method: this study was conducted in a high volume surgical department. one hundred and twelve patients submitted to elective laparoscopic cholecystectomy were included in this research. a written consent was acquired after thorough patient briefing. half the patients that underwent surgical operation received one dose of antibiotics min prior to the incision and the other half did not receive any chemoprophylaxis. results: the age ranges from to years old. commonest concomitant diseases were arterial hypertension, type ll diabetes, hypothyroidism and respiratory deficiency. approximately % of patients were smokers and % were obese (bmi [ ). the duration of the operations was between and min. intra-operative gallbladder rupture was observed in patients (rate %). all the patients were discharged the first post-operative day and their monitoring continued for more days. in the chemoprophylaxis group, no surgical site infection or other major complication was observed. from the group that did not receive any antibiotics, one patient developed surgical site infection and specifically infection of the surgical port in the epigastrium, which was treated with drainage of the abscess and oral antibiotics administration. no other complications were recorded. conclusion: our study concluded no statistically significant difference between the two patient groups, which depicts that chemoprophylaxis may not be necessary in elective cholecystectomy operations. on the contrary, antibiotics increase the cost of hospital stay and are often accompanied by multiple mild or severe side effects. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -ftkoxzz authors: grossman, valerie aarne title: catastrophe in radiology: considerations beyond common emergencies date: - - journal: j radiol nurs doi: . /j.jradnu. . . sha: doc_id: cord_uid: ftkoxzz abstract disasters often occur without warning and have the potential to affect large numbers of people. those in the radiology environment experience unique effects on them, their equipment, and their ability to provide quality patient care. lessons can be learned by reviewing events and their impact on imaging departments around the world. radiology departments need to be actively involved in the disaster planning and the management of disasters when they occur. common themes emerge regardless of the type of disaster and these themes should be included in all planning. organizations around the world, increasingly prepare for the "what ifs" of our environments. regulating and certifying agencies mandate organizational plans for threat management to include risk factor identification, threat mitigation, prevention (when possible), response to, and recovery from the event. the world health organization (who) estimates that natural disasters kill approximately , people annually and affect an additional million people worldwide (who, ; who, ) . the disaster recovery reform act of developed improvements to the federal emergency management agency (fema) by establishing a clearer framework for disaster management in both the preparation for and response to each event; pre-staging now occurs with incident command centers, resource mobilization, and search/recovery teams on standby, ready to act (fema, ; reynolds & knox, ) . the joint commission continually updates their expectations for organizations, uses information obtained through their post disaster organizational debriefing, and supports organizations by providing informational resources (joint commission, ) . the occupational safety and health administration (osha) provides a number of resources to assist organizations in the creation of their individual disaster management plans (osha, ) . in , a policy directive was developed to deal with all natural and manmade disasters, which evolved into the hartford consensus that addresses the loss of life and has a chief principle that no one should die from uncontrolled bleeding (jacobs, burns, pons, & gestring, ) . while disasters of every kind have occurred throughout history, the number and severity continue to increase. society demands to be kept safer … demands that are at times, difficult to achieve. even with an ever-increasing amount of information available and regulations to comply with, radiology departments are still often excluded from a hospital's disaster management plan and drills. it often isn't until an organization experiences a catastrophic event that the catastrophes in radiology identification of a plan for radiology's role during a disaster, comes to mind. regardless of the event type, radiology will be affected in some manner. while no amount of preplanning can fully prepare any organization for the unpredictability of a catastrophic event, having a plan in place will provide for better response and care during any mass casualty incident (mci), regardless of the type of catastrophe. many radiology departments are now creating their own disaster management plan within their department: while the hospital may have an organizational plan, individual departments should be aware of the role they will need to play when a catastrophe occurs (dargan, ; haygood, ) . anecdotal reports from events around the world are valuable to consider when creating an organization's disaster response plan. firsthand lessons learned by others should be considered when organizations create their own disaster management plan, inclusive of considerations for the imaging departments. whether external or internal in origin, many similar considerations apply to nearly all mci events. while catastrophic events may vary in type, length, recovery time, number of victims/relief workers, and a host of other important details, radiology departments should consider all types and create disaster plans accordingly. redundancy and back up plans are essential to also have in place, as established disaster plans do at times, fail (dargan, ) the following chart lists types of disasters which could be catastrophic to any healthcare facility, its imaging department including some historical examples. (insert table (schoeberl, ; snair, ; berger, ; sen, ; cdc, b; flammarion, : richmond enquirer, torok, ; goodwin veenema, ; trevisanato, ; grojec, ; opcw, n.d.; sutherland, ; haygood, ; aarne grossman, ) hospitals are seen as part of the solution to any catastrophic event in the community, however, hospitals can also be the problematic during mass casualty incidents (mci) as people often flock to a local hospital to seek safety and to look for loved ones, which creates additional issues for the healthcare team. the who describes an mci as any event that results in a greater number of people seeking assistance and support than what a local system can provide (who ) . mcis are usually a sudden and dramatic event that cause a surge in patients or a change in normal business. whether an act of violence or a natural disaster, the healthcare community must have an action plan that can be immediately implemented to provide safety and recovery to all people affected. healthcare personnel by nature, are dedicated to responding to any event they are faced with: it is this dedication that drives them to figure out a back-up plan when the original disaster plan doesn't or can't work. the who outlines guiding principles which all disaster management plans should incorporate. clear lines of responsibility should define roles, responsibilities and assigned activities to all dealing with the event. the plan should have scalability and be flexible to meet the needs of any mci which could occur. it should address whole health and be prepared to deal with: injuries and death, environmental issues (water, sanitation, housing, food, transportation), disease management (communicable and non-communicable), health care delivery, and mental health services. the evidence based plans should include case reviews of historical events and consider lessons learned from past events worldwide when developing their own plan. all plans must be multisectoral in order to be successful, with the inclusion of different organizations which will need to work together in a professional manner. these will often include but not be limited to: communication providers, transportation, law enforcement, security forces, military, water/sanitation departments, social services, health care providers, emergency service personnel, local industry/businesses, and emergency response teams (red cross, governmental agencies, etc.) (who, ) . it is essential for organizations and communities to drill repeatedly, looking for potential flaws in any disaster management response plan (haygood, ) these acts can be difficult to predict or understand. the goals of these individuals who intentionally inflict harm and fear towards others are usually intended to impact the greatest number of victims possible. sometimes, the goal is more about maximum disruption (hysteria) than maximum damage (injury, death, environmental destruction). the aggressor(s) may be a single individual, a small group of people, "homegrown" violent extremists, international terrorist groups, or transnational criminals. (breslin, ; williams, ) . the purpose of their destructive actions may be based on perceptions and beliefs and can be quite difficult for others to understand and explain. these could include beliefs or goals such as: unfairness in social, racial, economic or political arenas; spiritual or religious ideology; personal revenge towards another person or group; a statement in support of or against a person, group, nation, ideological; some may have a mental illness however, there is no clear proof that all people who commit aggressive acts towards others, are mentally ill. (gotzsche-astrup & lindekilde, ). when a violent act occurs, initial response focuses on neutralizing the threat and minimizing any additional damage. this is most successful when responding services have preplanned and carried out robust, ongoing training and practice drills. partnerships must be formed and maintained between all agencies that may be involved. ongoing monitoring of activity that may appear suspicious can pre-empt some attacks. it is difficult to smuggle bombs into a country or to transport them, so some terror groups are sending their bomb making recipes to home grown terrorists in locations where an attack is scheduled to occur, and the bomb can be crafted close to where the attack will occur. to help combat this, the new york city metropolitan transportation authority's security awareness campaign introduced "if you see something, say something" in , as a method to be able to report suspicious behavior or packages. in , the department of homeland security expanded this to be a nationwide campaign. (dhs, n.d.) in , a terrorist drove a truck into a crowd of people in nice, france. people died, were injured, and people received care at local hospitals. challenges included being able to properly identify patients as many were unconscious or did not speak french. one hospital that normally performed ct scans during an average night, performed ct scans on patients in hours. (dargan, ; amoretti, ) mass shootings: these events can occur anywhere, at any time. mass shooting events externally to a hospital can result in a surge of injured patients coming to a hospital. shooting events which happen inside of a hospital pose their own risks for a number of reasons. a person can plan their assault within a hospital by conducting surveillance ahead of the event, planning entrance and exits, identifying departments or offices to target, and studying the habits of security and other staff. hospitals are open to the public, and the aggressor optimizes the sudden chaos and fear to their own advantage. staff may be confused between saving themselves, or someone near them. some key facts about shooting events and hospitals include: ♦ active shooting events often begin spontaneously and end quickly (average is less than minutes) ♦ since over healthcare facility related shootings in the us with % occurring inside of hospitals and % occurring outside of buildings on hospital property ♦ hospitals are high stress environments where individuals may have weakened coping skills, experience fear, aggression, anger and seek retaliation ♦ there are large concentrations of potential victims ♦ % of healthcare facility-based shootings occur before police arrive ♦ smaller hospitals may be more vulnerable due to easier maneuverability, less security, (blair, ; schwerin, ; bjelopera, ; borchers, ) to be best prepared in the event of a mass shooting, disaster plans must include threat assessment and frequent training and drills. each department, including radiology, should have their own threat assessment conducted including a map of the department, location of staff, patients, and visitors. staff should be inserviced on policies, procedures, methods of communication, and behaviors that can preserve lives during such an emergency. staff may be trained in the following for use during an active shooter event: ♦ run (escape route, leave belongings behind, save self not others) ♦ hide (out of shooter's view, block/lock the door, silence electronics, turn off lights) • while waiting for help to arrive, administer first aid to those who are hurt (jacobs, ) in las vegas, nevada experienced a mass shooting that killed people, injured people ( of them sustaining gunshot wounds). the shooter was positioned on the nd floor of a nearby building, fired , + rounds in less than minutes into a crowd of , concert attendees. many victims self-transported to area hospitals, "carloads" of gunshot wound victims appeared at unsuspecting hospitals. ♦ most victims were cared for at three of the over hospitals in the area ♦ a national shortage of intravenous (iv) fluids complicated the care of the patients: it is estimated that + intravenous lines were started that night and supplies of iv fluids ran short ♦ it is estimated that ~ units of blood components were transfused in the first hours post incident. (lozada, ) in at the fairfield air force base hospital in spokane, washington a mass shooting event killed people and wounded . one of those wounded was months pregnant and miscarried a day after the shooting. ♦ the shooter was a former airman who was diagnosed with schizophrenia and recommended for military discharge by two psychiatrists. these two physicians were among those murdered by the shooter. after killing two psychiatrists, the gunman walked through the facility, firing randomly until he exited the building. theft of radiopharmaceuticals may occur for use in making "dirty bombs" (radiological dispersion device = rdd). these would typically result in "weapons of mass disruption" instead of "weapons of mass destruction". victims of a dirty bomb may have radioactive shrapnel embedded in their bodies, respiratory injury from inhaled radioactive dust, or wounds with radioactive contamination but not likely have injury or illness directly related to the exposure to radiation. these attacks could occur inside of a hospital or in a community with the contaminated injured patients transferred to the hospital. blast related injuries are meant to cause massive injury to a large number of people with the most common injuries including blunt, penetrating, burn, amputation, and emotional trauma. the most common injury locations include: brain, ear, eye, lung, cardiac, abdominal, limbs in , the boston marathon bombing occurred when pressure cookers, packed with shrapnel (nails, metal pellets, etc.), exploded, killing and injuring + people. of the patients were treated at hospitals (patients were cared for by a total of hospitals). hospital emergency response teams were immediately alerted, outpatient schedules were cleared, and additional radiology teams were called in to work. ct scans and x-rays were able to quickly identify the scope of injuries caused by the shrapnel contained in the explosive devices (ready.gov, ; goodwin, ; singh, goralnick, velmahos, biddinger, gates & sodickson, ) cyber attacks: cyber-attacks can happen to individuals, businesses, governments, and hospitals. fraudulent access enters a computer system with goals to steal, dismantle, alter, extort, or take part in other criminal activity. these actions can be conducted by one individual or from an international criminal enterprise in , a ransomware attack occurred at the erie county medical center (ecmc) in buffalo, ny. it locked down , computers by encrypting files, and severely affected the bed hospital and bed nursing home. ecmc did not pay the $ , + ransom, however, it did spend $ million to recover from the attack. the hospital was forced to revert to paper charting for weeks while they recovered from this event. earthquakes can occur suddenly and without warning. those who live in earthquake prone zones, know that damage occurs quickly to infrastructure, buildings, and equipment. to minimize personal injury, it is important for people to get low to the ground, cover the head and neck, and avoid windows, doorways, falling furniture/equipment. imaging departments in elevators were inoperable. during the first hours post initial earthquake, only portable x-rays and ultrasound imaging were available to the ed patients. without generator power available, radiologists relied on flashlights and headlamps for light. nuclear medicine department received no damage, computed tomography was up after the initial hours. while this hospital was built with seismic upgrades, geotechnical failures did occur and lead to widespread damage to the hospital (walls/ceilings/floors cracked, tunnels flooded, damage to the roof/boiler stack/medical equipment, etc.). (gregan, ; mitrani-reiser, kirsch, jacques, giovinazzi, mcintosh, & wilson, ; haygood, ) hurricanes/tornadoes/flooding: powerful and at times, unpredictable storm systems which can include strong winds, heavy rainfall, storm surges, rip currents, flooding, and landslides. most areas have emergency communications and alerts which should be listened to carefully and directions followed. emergency crews will be mobilized, emergency supplies will be on standby (ready to infiltrate the disaster area), and individuals as well as businesses will make necessary arrangements and preparations (reynolds, ) . hospitals can be best prepared by: ♦ frequent training drills that are comprehensive ♦ ensuring a - day supply of emergency power, water, medication, food, linen, and other essential supplies ♦ the more emergency power a hospital has available, the more successful they can be during a catastrophic event ♦ hospitals located near known threats, should be built to expect the worst (flooding, earthquake, tornadoes, etc.). this includes: special windows that protect against flying debris (withstand up to mph); underground wiring to guard against power outages with different wiring pathways; a reinforced roof, safe interior rooms to protect against wind, rain, and flooding; watertight barrier storm doors; and equipment with extra battery backup (ventilators, bassinets, specialty equipment, etc.) (lallanilla, a) (hayes, ) when a severe storm system attacks a hospital, care consideration and planning must occur that includes care of those within the structure (food, safe shelter, medical care) as well evacuation. care of the equipment should be considered as loss of electrical power, flooding, or wind damage can severely damage equipment and hinder the ability to care for patients. tornado prone areas may have sirens that alert the community of an approaching tornado. other indications of an approaching tornado include: a dark or green colored sky; large, dark, low-lying cloud; large hail; or loud roar that sounds like a freight train. not all tornadoes will present with the characteristic funnel cloud. danger exists from extremely high winds, flying debris, falling objects, etc. people should seek protection during a tornado, including: underground shelter, interior part of a basement or the lowest floor of a building away from windows and doorways. it is never safe to stay in a mobile home, car, bus, long-span building (i.e. mall). regardless of the type of weather event, flooding is a potential danger. fast flowing water or standing water, pose a dangerous risk. flood waters commonly test positive for waterborne and/or sewage contamination including: (haygood, ; lallanilla, b; schubert & busciolano, ; grossman, ) mudslide/landslide/avalanche: these disasters can occur without warning and create a sudden loosening of earth from a mountain side, that travels quickly down the slopes. there is great danger to structures in the path of this disaster as the moving landslide carries with it any structure in its path, which increases the danger to those below. roads can be disrupted which increase danger to motorists, emergency vehicles, and may hinder evacuation routes (cdc, ). victims suffer from crush injuries from rock, soil, mud, snow, ice and debris (trees, cars, etc.). drowning can occur from swift moving flood waters. many victims also sustain ocular injuries due to infiltration of mud into the eyes, and must be treated emergently to limit traumatic blindness. in a sudden, heavy downpour resulted in a mudslide in leh, india sending mud, rocks, and boulders cascading down the barren mountains to the communities below. the closest hospital became inoperable due to overwhelming sludge and flooding. this disaster occurs as a result of a series of enormous waves (known as seismic sea waves) caused by displaced water following underwater earthquakes, volcanic eruptions, landslides, or meteorite. tsunamis are not preventable nor entirely predictable other than a few warning signs that may include: ♦ the ocean may appear to be "boiling" as large quantities of gas bubble up from far below the ocean surface ♦ the ocean water may smell of rotten eggs, be hot, and/or sting the skin ♦ a loud thunder boom may be heard, followed by a roar or whistle ♦ the ocean shoreline may recede a large distance from the coastline ♦ the horizon may appear red in color ♦ animals often are seen running to higher ground in advance of the receding water line tsunami damage is often catastrophic in nature as powerful waves destroy structures in its path, injure or kill living beings, destroy basic infrastructure (transportation, communication, public water/sewage, etc.), cause widespread chemical contamination and debris to be washed over land. resulting health risks occur from contaminated water, destruction of safe housing, food supply, healthcare services, etc. there is a usually a high death toll from drowning, resulting in fewer victims seeking emergency health care. in , the great east japan earthquake (magnitude . ) and resulting tsunami caused the evacuation of , people claimed the lives of over , people ( % of those deaths were from drowning), , + people missing, damaged over , structures, and cost over $ billion in damages. (mccurry, ; ehara, ; fuse, ; goodwin veenema, ; nohara, ; oskin, ) volcanoes: volcanoes are an opening in the earth that allows molten rock, gases, and debris to erupt and flow across land at up to mph. volcanic ash can travel hundreds of miles and cause respiratory difficulties, skin/eye/nose/throat irritation for all living beings. volcanic activity can be monitored, and be somewhat predictable however, they are also quite unpredictable. areas that would be affected by a volcanic eruption have emergency alert systems that announce instructions for those in danger. volcanic eruptions can additionally cause flooding, mudslides, and loss of infrastructure (roads, power, communication, clean water, etc.) . common injuries and diseases include multiple trauma, burns, infectious disease, respiratory compromise/suffocation, ocular injuries, etc. in , the nevado del ruiz volcano erupted in south america. the enormous lahar of molten lava and mudslides buried the small town of armero, killing , people (the deadliest lahar in history). the entire town was submerged in lava and mud. all buildings and infrastructure were completely destroyed, and the town was eventually declared a 'national cemetery' ♦ for those few who were able to be rescued, they suffered abrasive burns and other injuries from the caustic substances mixed in with the mud ♦ the loss from this disaster included schools, hospitals (including all equipment), roads, railroad tracks, bridges, water/sewer systems, pipelines, , acres of farmland and livestock. (nrc, ; cdc, ) wildfires: wildfires are often fast moving and unpredictable. a raging fire can travel . mph through a forest, mph in open fields, and these speeds can be higher if there is an upward slope involved (siegel, ) . those areas in the danger zone, should heed evacuation orders, ♦ due to the high cost of repairs, the hospital was closed and + employees laid off. (sutherland, ; gabbert, ) preparing for the "what ifs" and the "worst case scenarios" in our world can be very difficult. disasters are difficult to anticipate and properly plan for perfectly. by listening to the experts in the field of disaster management and learning from those who have lived through catastrophes, we can better evaluate our own environment and strengthen the disaster management plan that we create. community services, emergency response organizations, industries, businesses, and governmental agencies must work together when responding to a crisis in a community. intelligence and law enforcement agencies must work together with effective communication and role delineation. during the initial event and response, competition should be set to the side and the focus placed on the safety of all members of the community. from a review of case studies looking at disasters that have occurred, there is a repeated recommendation to have a "back up plan" in case the original disaster management plan fails. (reynolds, ) each healthcare organization must have an individualized plan that is fitting of the facility, the size, the patient populations, layout, security (onsite and also municipal). in addition to the organization's plan, each imaging department should have their own disaster management plan that works in concert with the organization's overall plan. investing large amounts of capital into resilient infrastructure can be difficult to justify when there are competing projects that need to be completed in the immediate future. until an organization has endured great hardship and loss as the result of a catastrophe, investing money into a project that may never be needed, is often pushed to the side. (grain, ; lau, ) the events listed earlier, are examples of what can happen during a disastrous event. hospitals in earthquake zones, should invest in appropriate foundations and watertight rooms to protect their expensive equipment. radiology reading rooms should always be on a back-up generator and remote reading capability should always be in place. regional businesses should be included in the responsibility for disaster plans and their back up: the financial district of new york city, the oil/gas industry in texas, or the shipping industry in southern california are essential to the well-being of not just their local communities but also the nation as a whole. including key players in the preparation for catastrophic events for the entire area, should be a priority for all involved. (lau, ) . communities and organizations that have experienced catastrophic events, can offer valuable first-hand accounts of the lessons learned and offer suggestions for others to consider when creating their own disaster management plan. precise needs for each individual catastrophe may differ, however, there are many common considerations that should be included in all plans. electrical considerations: ♦ guard against flooding of the generators, have ample fuel available to run generators ♦ if there is a loss of power to industry, water treatment stations, etc. may negatively impact the hospital ♦ the more emergency power a hospital has available, the more successful they can be during a catastrophic event ♦ incident command centers must be deployable and not fixed ♦ organizations must keep up-to-date phone lists (employees, local business, vendors, fuel companies, utility companies, medical equipment companies, etc.) ♦ portable wi-fi units can be used if it down or power outages occur ♦ satellite telephones, wireless radios, amateur radios, and other forms of communication may be used if cellular telephones and/or landlines fail ♦ organizational leadership must be visible around the building, calm, optimistic, and ready to respond to issues (bluth, ) ◊ communication must be honest, transparent, and frequent in order to counter the spread of inaccurate rumors and contain mounting fear among staff, patients, visitors (jones, ) ♦ when calling for emergency assistance (" ") or reporting suspicious activity, essential facts should include: gray, ; doh, ) patient transport to/from radiology (berger, ) ♦ if the disaster is an approaching storm, all studies should be dictated, rooms stocked with supplies, phone numbers updated, disaster management plan reviewed with team ◊ extra staff should be called in ◊ consider moving some portable equipment to essential upper floors (in case elevators fail during the storm event). (bluth, ) ♦ the role of imaging in a mci is to increase triage accuracy, identify injuries, and more precisely assign resources ◊ whole body ct scans using an mci protocol can increase the number of ct scans per hour and also detect indirect injuries that could otherwise be missed. a disadvantage is the large number of images generated that the technologists then need to reconstruct, and the radiologists need to read (korner, ) ♦ if technology is intact, remote radiologists may be able to assist in reading exams ♦ all steps of imaging may be affected by a catastrophic event: orders from referring physicians, patient transport, images (acquisition, coding, worklist, storage, retrieval, viewing, reporting, etc.) . ◊ communication may need to be flexible (face to face, paper notes, etc.) if telephones, computers, etc. are inoperable ♦ some hospitals have found that having a radiologist go to the ed with the technologists to perform bedside x-rays and ultrasounds, allows for immediate reading of images ... which allows for immediate identification of injuries, streamlines communication between radiologist and emergency physician, reduces the risk of errors from high volume and miscommunication or lost information, incorrect patient id, etc. elevate any equipment that could be water damaged if flooding occurs such as coils, control consoles, and mri quench duct • mri suites should close until threat of quench passes. (gregan, ) o risk of quench if the quench pipe is damaged, loss of temperature regulation of the liquid helium, movement of the helium inside cryostat vessel, o mri rooms should be designed to be watertight, with an additional stabilizing foundation construction. (hayes, ) ♦ staff: ◊ staff shortages (staff can't come to work, those who can't leave will face exhaustion) ◊ plan for % of normal staffing levels with enough food and water ◊ care of the staff must include risk protection and: • physical needs must be met • protection from chemical, biological, infectious, and radiologic exposure • psychological and behavioral health should be provided for ◊ staff coming into work should bring own supplies (water, food, medicines, etc.) and waterproof clothing for both hot/cold temperatures ◊ staff must stay, until replacements have arrived. consider staffing up, in case future replacements can't get into the hospital and those on duty, must work elongated shifts ◊ maintain employees on payroll … need to have adequate staff for disaster recovery periods ◊ staff should be encouraged to create a family emergency plan in advance, that covers all possible disasters. plans should cover a minimum of days (best if week supply on hand) and should include: • phone numbers (family, legal, medical, community, etc) • bottled water ( gallon/day for each person and each pet) there is no perfect plan, when preparing for a catastrophic event. the best preparation includes an evidence based plan, consideration of past events (case reviews, lessons learned, etc), ongoing education, frequent drills, and stock piling of essential supplies. considerations need to be designed for the individual (person, patient, staff, etc), the departments that could be affected, the organizations that could be involved, and the community as a whole. fast facts for the radiology nurse massive influx of patients to a radiology department emergency imaging after a mass casualty incident: role of the radiology department during training for and activation of a disaster management plan public mass shootings in the united states a study of active shooter incidents managing in a catastrophe: radiology during hurricane katrina accessed / / the squishy definition of 'mass shooting' complicates media coverage core principles of threat management units natural disasters and severe weather preparedness and safety messaging for hurricanes, flooding, and similar disasters past pandemics center for disease control and prevention: rabies natural disasters and severe weather: infectious disease after a disaster including radiology in emergency plans is critical nationwide suspicious activity reporting (sar) initiative (nsi) if you see something, say something campaign in a radiology department during an earthquake, tsunami, and nuclear power plant accident raw sewage released by hurricane harvey disaster recovery reform act the necrology of aeronautics". wonderful balloon ascents; or, the conquest of the skies lessons learned from the japan earthquake and tsunami feather river hospital evacuated patients and staff as camp fire approaches. wildfire today the initial response to the boston marathon bombing: lessons learned to prepare for the next disaster disaster nursing and emergency preparedness either or? reconciling findings on mental health and extremism using a dimensional rather than categorical paradigm after katrina: hospitals in hurricane katrina challenges facing custodial institutions in a disaster. the urban institute critical infrastructure security and resilience national research and development plan. national infrastructure advisory council radiology in the christchurch earthquake of february : challenges, interim processes and clinical priorities chemical weapons: a deadly history. radio free europe disaster management hurricanes test radiology's disaster preparedness including radiology in discussion paper: health and medical response to active shooter and bombing events active-shooter events in the workplace: findings and policy implications initial steps in training the public about catastrophes in radiology bleeding control: surgeon participation and evaluation emergency management resources -general references 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health systems in iwate prefecture worker safety in hospitals: caring for our caregivers what's your plan? radiology today organisation for the prohibition of chemical weapons japan earthquake & tsunami of : facts and information. live science radiological dispersion device. department of homeland security preparing for and responding to disaster: a the joplin tornado: the hospital story and lessons learned developing a hospital disaster preparedness plan for mass casualty incidents: lessons learned from the downtown beirut bombing. disaster medicine and public health preparedness cbrne weapons & islamic state -a bad combination analysis of storm-tide impacts from hurricane sandy active shooter response usns comfort arrives in puerto rico to aid maria relief efforts sewage, fecal bacteria in hurricane harvey floodwaters coping in a calamity the terrifying physics of how wildfires spread so fast radiologic features of injuries from the boston marathon bombing at three hospitals cloud burst in leh: pattern of casualties; challenges faced and recommendations based on the management of such natural disaster at multi-specialty hospital improving local health department cybersecurity minutes. national fire protection association journal. february catastrophes in radiology a large community outbreak of salmonellosis caused by intentional contamination of restaurant salad bars the 'hittite plague', an epidemic of tularemia and the first record of biological warfare fecal bacteria contaminated surface water after hurricane harvey: hurricane harvey delivered five consistent days of flooding and storms to texas last august the hillsborough tragedy biologic, chemical, and radiation terrorism review mass casualty management systems: strategies and guidelines for building health sector capacity who: disasters and emergencies world health organization ( ) flooding and communicable disease facts sheet environmental health in emergencies planning for catastrophes affecting imaging departments ♦ disaster management plans rarely include radiology ♦ million people worldwide are affected by a disaster each year ♦ lessons can be learned from those who lived through one key: cord- -shew sfw authors: susilarini, ni ketut; sitorus, martahan; praptaningsih, catharina yekti; sampurno, ondri dwi; bratasena, arie; mulyadi, ester; rusli, roselinda; fandil, ahmad; mangiri, amalya; apsari, hana; hariyanto, edy; samaan, gina title: application of who’s guideline for the selection of sentinel sites for hospital-based influenza surveillance in indonesia date: - - journal: bmc health serv res doi: . / - - - sha: doc_id: cord_uid: shew sfw background: a sentinel hospital-based severe acute respiratory infection (sari) surveillance system was established in indonesia in . deciding on the number, geographic location and hospitals to be selected as sentinel sites was a challenge. based on the recently published who guideline for influenza surveillance ( ), this study presents the process for hospital sentinel site selection. methods: from the , hospitals in indonesia, the first step was to shortlist to hospitals that had previously participated in respiratory disease surveillance systems and had acceptable surveillance performance history. the second step involved categorizing the shortlist according to five regions in indonesia to maximize geographic representativeness. a checklist was developed based on the who recommended attributes for sentinel site selection including stability, feasibility, representativeness and the availability of data to enable disease burden estimation. eight hospitals, a maximum of two per geographic region, were visited for checklist administration. checklist findings from the eight hospitals were analyzed and sentinel sites selected in the third step. results: six hospitals could be selected based on resources available to ensure system stability over a three-year period. for feasibility, all eight hospitals visited had mechanisms for specimen shipment and the capacity to report surveillance data, but two had limited motivation for system participation. for representativeness, the eight hospitals were geographically dispersed around indonesia, and all could capture cases in all age and socio-economic groups. all eight hospitals had prerequisite population data to enable disease burden estimation. the two hospitals with low motivation were excluded and the remaining six were selected as sentinel sites. conclusions: the multi-step process enabled sentinel site selection based on the who recommended attributes that emphasize right-sizing the surveillance system to ensure its stability and maximizing its geographic representativeness. this experience may guide other countries interested in adopting who’s influenza surveillance standards for sentinel site selection. influenza surveillance has been instrumental in advancing global understanding of the disease, monitoring changes in antigenicity of different subtypes and guiding influenza vaccine strain selection [ , ] . with the emergence and circulation of the avian influenza a/h n virus in several countries, including in indonesia, influenza surveillance became a global public health priority to prepare for an ensuing influenza pandemic. during the influenza a/h n pdm pandemic in , influenza surveillance systems enabled monitoring of pandemic disease trends, severity and mortality [ ] [ ] [ ] . in july , the world health organization (who) released updated standards for influenza surveillance [ ] . this guideline built on the lessons learnt from the influenza pandemic and outlined both the epidemiological and virological surveillance objectives, as well as revised case definitions and minimum data set requirements. the primary objective of sentinel influenza surveillance systems as stated in the guideline is to monitor influenza activity rather than to detect outbreaks. sentinel influenza surveillance systems can provide valuable information about epidemiological trends including seasonality, age groups affected and groups at risk of severe disease. sentinel systems can also provide information about virological trends, and to identify the emergence of viruses with unique characteristics or with antigenic drifts or shifts [ ] . as of september , indonesia had seven surveillance systems administered by ministry of health (moh) that provided information about acute respiratory illness (ari), pneumonia and influenza ( table ) . three of these systems had hospital-based surveillance sites. evaluations of two hospital-based sentinel surveillance systems, the sentinel pneumonia surveillance system operated by the ari subdirectorate since and the laboratory-based severe acute respiratory infection (sari) surveillance system operated by the national institute of health research and development (nihrd) since , found that both had limited utility. both systems had sites with very low surveillance activity and the sentinel pneumonia surveillance system lacked laboratory data while the sari surveillance system lacked epidemiological focus. this led the ari subdirectorate and nihrd teams to terminate these systems in december and combine efforts to establish a sari surveillance system in that addressed their collective needs. the new sari system called 'surveilans ispa berat indonesia' (sibi) enabled the ari subdirectorate to focus on the epidemiology and influenza disease control program aspects whilst nihrd focused on the laboratory diagnostics. the objectives of sibi were to monitor epidemiological and virological trends of influenza in different parts of indonesia. even though the system may detect cases of novel or emerging influenza viruses, this was not deemed the primary objective of the system as other systems such as the nationally comprehensive early warning alert and response system (ewars) provide such function. one aspect that had to be considered carefully in establishing sibi was the selection of the geographic locations and hospitals to become sentinel sites. the who guideline highlights system stability, feasibility and representativeness as the most important factors to consider when choosing a sentinel site [ ] . the guideline also suggests considering the suitability of sites to assess the disease burden of influenza whereby information about the population served by the hospital can be determined to enable disease incidence rate calculation. when multiple sentinel sites are being considered, who recommends selecting sites that represent different population centers or climate zones since this will provide information about transmission patterns among sub-populations with unique demographic or socio-economic characteristics. critically, the guideline states that there is no ideal number of sentinel sites in a country but that countries should start with one or a few sentinel sites and only expand if these function well. as indonesia is a large archipelago nation, national decision-makers are cognizant of the regional differences in culture, religion, economic prosperity and development [ ] . this results in a push for public health initiatives to have representation according to administrative divisions such as a surveillance site in each province or to apply statistical approaches for calculation of the number of sentinel sites. these approaches may not be suited or feasible for sentinel surveillance systems where the objective is to obtain high-quality patient level data to monitor regional clinical, epidemiological and microbiological disease trends. for example, having sentinel sites in contiguous provinces with similar population demographics would yield more cases enrolled into the system but would not yield additional novel information about regional variation in disease activity. similarly, having representativeness according to population density would yield large numbers of sentinel sites due to the size of the country but would also not necessarily capture unique regional characteristics. lastly, since influenza surveillance involves costly laboratory diagnostic testing, the larger the number of sentinel sites the more expensive the shipment and testing of specimens. considering the guidance from who and the national prerogatives, deciding on the number, location and hospitals to be selected as sentinel sibi sites was a challenge. previous studies have reported on lessons learnt from establishing influenza surveillance systems [ , ] , but none have reported comprehensively on the process of sentinel site selection. this study describes the process and rationale by which the six hospitals were selected as sentinel sibi sites in indonesia. the experience may guide other countries interested in adopting the who guideline and provide an approach for sentinel site selection or future surveillance system expansion. step one: creation of a hospital shortlist indonesia has , public and private hospitals [ ] . before applying the who guideline for sentinel site selection, we shortlisted from , hospitals to a manageable number to enable detailed assessment and final selection. to achieve this, we limited selection to public hospitals that had previously participated in the sentinel pneumonia or sari surveillance systems. we ranked these hospitals in terms of two performance indicators, timeliness and completeness of data reporting to national level. ranking of hospitals according to their surveillance performance history enabled prioritization of good sites in subsequent steps of the selection process. timeliness indicated the proportion of on-time reports received by moh from the sentinel site, where % indicated full compliance with data reporting requirements (by the th of each month). completeness indicated the number of reports made to moh per year, where % indicated full compliance ( reports received from the sentinel site per year). timeliness and completeness data for the hospitals were extracted from the moh surveillance system databases. hospitals with less than % timeliness and completeness were excluded based on poor surveillance performance history. this resulted in hospitals in the shortlist from step one ( figure ). step two: application of who guideline the second step was to operationalize the who recommended attributes for sentinel site selection; stability, representativeness and feasibility. since influenza disease burden has not been established in indonesia, we incorporated this into the selection process. for stability, the who guideline recommended calculating the funds needed to cover general costs of surveillance operations for the long term. we operationalized this by calculating the yearly costs of one sentinel site and determining the number of sites that could be established using funds available from moh and donors for the next three years. cost calculations were based on previous surveillance system experience and included one training for five hospital staff ( doctors, nurse, laboratory worker and medical records staff ), four monitoring visits to the site, six-monthly national meetings and costs for stationery and staff incentives. based on previous sari surveillance experience, each sentinel site was expected to generate specimens per year. costs for specimen collection, shipment to nihrd and testing using real-time polymerase chain reaction (rt-pcr) and virus isolation (for % of specimens) were also calculated. for representativeness, we first considered geographic representation of the hospitals. we ranked the hospitals from step one according to their geographic location to represent west (sumatera island, n = ), north (sulawesi island, n = ), central (java and kalimantan islands, n = ), south (east and west nusa tenggara islands, n = ) and east (maluku and papua islands, n = ). for hospitals in the same geographic regions, only the two top-performing hospitals were kept in the list and the others excluded. this resulted in a shortlist of eight hospitalsa number more aligned with the resources available for the surveillance system (figure ). we developed a sentinel site selection checklist to address the other attributes and criteria. this included five questions to assess representativeness, such as the type of hospital (general versus specialty), accessibility of wards for influenza surveillance and the demographics of the population served by the hospital (table ) . for feasibility, we included questions to assess the motivation of the hospital to participate in the system, the infrastructure and human resource capacity available for surveillance activities ( table ) . as stated by the who guideline, adequate patient volumes and ability to ascertain the hospital's catchment population are needed to calculate influenza disease burden. we added three questions to the checklist to explore these issues. for patient volumes, we requested data on total patient admissions not respiratory patient admissions since hospitals may vary in their disease coding and recording systems. four teams comprising ari subdirectorate, nihrd and centers for disease control and prevention (us-cdc) staff were trained in the sentinel site selection checklist objective and administration. each team visited two hospitals where the teams met with the hospital director (or management representative), the medical and nursing staff and the laboratory team. these hospital personnel were targeted as they could answer the various administrative and procedural questions in the checklist. after introducing the concept of sibi and answering any general questions, one team member administered the questionnaire and the others documented the answers. the teams then toured the hospital facilities including the medical records unit, emergency/patient admission, the laboratory and some patient wards. this enabled visual confirmation of the hospital capacity and likely flow of sari patient enrolment into sibi. the teams also reviewed medical records data on the number of monthly hospital admissions. each sentinel site selection visit took - hours and all hospitals were visited in a three-week period. funding for the sentinel site selection visits was made available by who. step three: analysis and selection of sentinel sites checklist data from the eight hospitals were entered into a spreadsheet and analyzed descriptively ( table ). the four teams met to determine which hospitals would be enrolled as sibi sentinel sites based on the visit findings. hospital management motivation to participate as a surveillance site was deemed a key criterion for selection as solutions to other issues could be addressed as long as the hospital was willing to collaborate. thus, if hospital management did not welcome the surveillance activity, it no longer qualified for selection. the cost of establishing one sentinel site was usd , per year. costs included training for five hospital staff (usd , ), specimen management and testing (usd , ), quarterly national monitoring missions by ari subdirectorate and nihrd staff (usd , ), six-monthly national review meetings (usd , ) and administrative costs such as printing forms, hospital staff incentive payments, stationery and part-salary of a national level data manager apportioned to one-third of the person's time (usd , ). from the moh government and donor funds available and projected for the next three years, six sibi sentinel sites could be established. based on the geographic location of the eight hospitals visited, there was representation of east (maluku), west (north sumatra), north (north sulawesi), central (yogyakarta, kalimantan) and south indonesia (west nusa tenggara). all hospitals were general hospitals and reported coverage of all age-groups and socio-economic population groups, although the hospitals in west nusa tenggara and yogyakarta reported that more than % of their hospital admissions were for low socioeconomic population ( table ). all hospitals confirmed that surveillance could be conducted in all wards where sari patients may be admitted. all eight hospitals visited had five staff available for the day-to-day operation of sibi surveillance as well as basic infrastructure requirements such as a refrigerator, back-up power supply, computers and internet service for data reporting ( table ). even though four sites reported unreliable internet service at the hospital, back-up measures such as a wifi modem could be utilized. for specimen shipment to nihrd in jakarta, three sites were uncertain of couriers available in the hospital vicinity. however, based on the locations of these hospitals and the nihrd team's experience, courier services were likely to be available. two hospitals did not express willingness to participate in the surveillance system due to difficulties to internally coordinate surveillance activities ( table ) . all hospitals collected patient home addresses which would enable estimation of the hospital catchment population ( table ) . six hospitals had > admissions per month and two reported lower admission rates ( and admissions per month for west nusa tenggara and north sulawesi respectively). none of the hospitals had a standard protocol mandating chest x-rays for respiratory patients, but all hospitals estimated that % of patients would have x-rays requested by the treating physician. for surveillance purposes, the number of patients with x-rays generated through this approach would be large enough to enable analysis trends relating to pneumonia. thus, for future calculation of disease burden of influenza in indonesia, all eight hospitals were considered suitable. six hospitals were selected and enrolled as sibi sentinel sites based on the multi-step sentinel site selection process ( figure ). these were the hospitals in maluku (east), north sulawesi (north), east kalimantan (central), north sumatra (west), yogyakarta (central) and west nusa tenggara (south, figure ). the lack of hospital management motivation to participate as a sentinel site was the key reason for not selecting the hospitals in south and west kalimantan. the who guideline was useful as it identified the key attributes to consider in sentinel site selection and it helped address public health decision maker concerns regarding the geographic representation of the surveillance system. however, since the who guideline does not provide an algorithm or scoring system for site selection, we had to operationalize the attributes into quantitative and qualitative criteria, and to prioritize these according to our context. we also had to develop our own approach for shortlisting from all the hospitals in indonesia to a number that could be assessed using the detailed who approach. despite using a multi-step approach to sentinel site selection, there were some limitations to our process. these included reliance on self-report for checklist items such as the hospital's motivation to participate in the surveillance system and availability of hospital staff to conduct surveillance activities. respondents may have sought to appease the assessment team by positively biasing their answers. to address this limitation, hospitals ultimately selected as sentinel sites were asked to write a formal letter to confirm their commitment to become a surveillance site, and to list surveillance staff and their specific role in the surveillance system. for other checklist items, such as the proportion of respiratory disease patients receiving chest x-ray or the socioeconomic level of the population served by the hospital, it was not feasible to verify the answers provided by the hospital team during the assessment visit. however, these issues will be revisited in more detail once the surveillance system stabilizes and disease burden can be enumerated. another limitation is that the sentinel site selection process does not guarantee good surveillance performance. we endeavor to maximize performance through the routine monitoring visits and twice-yearly review meetings. as the primary objective of sari surveillance is to monitor the epidemiological and virological characteristics of influenza, surveillance does not have to be comprehensive at all hospitals or in all provinces. a few sentinel sites may appropriately represent the situation in-country and to inform public health officials on groups that need to be targeted for preventive and treatment measures. to date, there have been no studies to investigate whether influenza patterns vary across regions in indonesia, but since difference regions have different climatic patterns and this is known to impact influenza circulation [ , ] , it is possible that influenza patterns are different. future studies will be required to determine whether the six sibi sites adequately represent influenza activity in indonesia and the extent to which the clinical, epidemiological and virological findings from the six sentinel sites are generalizable. this approach may address decision-maker concerns about surveillance representativeness in a cost-efficient manner. as sibi stabilizes over time and long term resources are assured, there is potential to enhance the system to also monitor other important diseases such as dengue, meningitis and severe diarrheal illness [ ] . this allows for further efficiencies in utilization of sentinel surveillance systems for specific public health objectives and to minimize the burden of establishing additional standalone systems. the surveillance system can also be used to evaluate the benefits of public health interventions and to monitor disease severity and impact during a future influenza pandemic [ ] . sibi can also be used for emerging zoonotic diseases and allow for laboratorybased collaborations with the ministry of agriculture on diseases such as nipah and hendra virus or emerging coronavirus infections. overall, we hope that this report clarifies the rationale for the geographic distribution, the number of sites and the methods for selection. on the epidemiology of influenza influenza: epidemiology, clinical features, therapy, and prevention. semin respir crit care med mmwr morb mortal wkly rep: pandemic influenza a (h n ) virus infections flucan : initial results from sentinel surveillance for adult influenza and pneumonia in eight australian hospitals real-time epidemic monitoring and forecasting of h n - using influenza-like illness from general practice and family doctor clinics in singapore who interim global epidemiological surveillance standards for influenza who recommended surveillance standards establishing a national influenza sentinel surveillance system in a limited resource setting, experience of sierra leone mounts aw: improving influenza surveillance in sub-saharan africa seasonal influenza activity in hong kong and its association with meteorological variations comparison of the incidence of influenza in relation to climate factors during - in five countries world health organization: assessing the severity of an influenza pandemic submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution we acknowledge ministry of health decision makers at the national institute of health research and development and the directorate-general for disease control and environmental health for their leadership and the commitment of the various hospitals participating as sentinel sites. the authors declare that they have no competing interests. key: cord- -ocgfgx r authors: boyce, john m; cookson, barry; christiansen, keryn; hori, satoshi; vuopio-varkila, jaana; kocagöz, sesin; Öztop, a yasemin; vandenbroucke-grauls, christina mje; harbarth, stephan; pittet, didier title: meticillin-resistant staphylococcus aureus date: - - journal: the lancet infectious diseases doi: . /s - ( ) - sha: doc_id: cord_uid: ocgfgx r nan the epidemiology and the clinical management of mrsa infections have continued to evolve in recent years in the usa. the prevalence of mrsa has increased progressively since the early s, and by mrsa accounted for nearly % of nosocomial s aureus infections acquired in intensive-care units. mrsa strains have been reported to account for - % of nosocomial s aureus bloodstream infections and - % of s aureus surgical-site infections. [ ] [ ] [ ] [ ] [ ] [ ] in some facilities, the proportion of health-care-associated s aureus infections caused by mrsa is even higher. vancomycin-intermediate s aureus (visa) strains, which have vancomycin minimum inhibitory concentrations (mics) of - mg/ml, have continued to cause occasional health-care-associated infections, although transmission within health-care facilities of such strains has seldom been documented. at least three well-documented isolates of vancomycin-resistant s aureus (vrsa) that have vancomycin mics of mg/ml or greater have been recovered from patients in the usa. although it is possible that the relatively high frequency of co-colonisation by vancomycinresistant enterococci (vre) and mrsa among patients in the usa may create more opportunities for in-vivo transfer of the vana gene complex from vre into mrsa strains, it is not known if this has affected the frequency of vrsa in the usa. by contrast with the uncommon occurrence of visa and vrsa, mrsa strains that are still classified as susceptible to vancomycin (ie, mics of - mg/ml) have caused an increasing number of health-careassociated infections that respond poorly to vancomycin therapy. , , the poor response to vancomycin therapy in such cases appears to be associated with several strain characteristics. patients infected with mrsa strains with vancomycin mics of - mg/ml have responded to vancomycin therapy less frequently than patients with infections caused by strains with mics of less than · mg/ml. in some cases, poor clinical responses may have been due to strains with hetergenous resistance to vancomycin-so-called hetero-visa. fowler and colleagues found that mrsa bloodstream infections that persisted for more than days despite appropriate vancomycin therapy were significantly more likely than short-duration mrsa infections to have been caused by strains that exhibited ( ) higher rates of survival in vitro after exposure to thrombin-induced platelet microbicidal protein (p= · ), ( ) defective delta-lysin production (suggestive of loss of accessory gene regulator [agr] function; p= · ) and ( ) agr type ii (p= · ). in two prospective randomised trials of treatment of ventilator-associated pneumonia (vap), vancomycin therapy was significantly less effective than treatment with linezolid (p= · ) among a subset of patients with vap caused by mrsa. unfortunately, the microbiological characteristics of mrsa from these pneumonia studies were not described in detail. the above trends suggest that although vancomycin remains the drug of choice for most serious health-careassociated mrsa infections, clinicians in the usa may need to consider the use of other agents-eg, linezolid, daptomycin, or tigecycline-in some clinical situations based on the characteristics of the infecting strain and the body site affected. another major change in the epidemiology of staphylococcal infections in the usa is the rapid emergence of community-acquired mrsa strains since the late s. [ ] [ ] [ ] [ ] although such infections have been more common among population groups such as young children, native american and pacific islander communities, prisoners, military personnel, men who have sex with men, intravenous drug users, and individuals involved in amateur or professional competitive sports, spread within the general community is likely occurring. , [ ] [ ] [ ] a relatively small number of unique uk mrsa was first described in england in the early s, just months after meticillin had been introduced into clinical practice. mrsa has waxed, waned, and waxed again over the following decades. the international union of microbiology and who's staphylococcal centre is based in the laboratory of healthcare associated infection of the health protection agency (hpa), and was the first to identify and number epidemic mrsa strains (emrsa - ), plot their spread, and identify the existence of other epidemic mrsa strains in europe as part of the harmony network project. community mrsa are evident in england but have not yet emerged to be the problem encountered in some other countries. in the early s, about % of s aureus bacteraemias were due to mrsa; the mean figure is now about %, although there is a large range, with some hospitals encountering the organism infrequently. current english data show that the occurrence of meticillinsensitive strains has also increased, so merely focusing on the percentage of total s aureus bacteraemias can be misleading. ever since the organism was first described, hospitals have continued to vary in mrsa occurrence within and between different cities and in different wards within the same hospital. the reasons are complex and may include aspects of the reporting system; a comparison of reporting methods is underway. we know that the current prevalent uk epidemic mrsa (emrsa strains and ) differ genetically from their predecessors and also contain more or different toxins. however, we still do not understand why certain mrsa strains have this epidemic potential. when such strains spread to other countries they seem to exploit the more stressed or less "infection control compliant" hospitals or wards. mrsa are opportunistic pathogens colonising more patients than they infect. the patient case mix has also changed. mrsa has always preferably colonised and infected elderly people. improved nutrition and medical advances has meant that elderly patients are now admitted to "high-risk" units-eg, cardiovascular and orthopaedic wards with periods of care on intensive care units. such units can then "carousel" forum strains appear to be responsible for many of the community-acquired mrsa infections occurring in the usa. most of such strains contain the mobile genetic element staphylococcal cassette chromosome mec (sccmec) type iv, which is relatively uncommon among health-care-associated mrsa strains in the usa. emergence of community-acquired mrsa has also required that clinicians alter their approach to empiric treatment of community-acquired skin and soft tissue infections. physicians have been encouraged to routinely culture skin lesions to determine if community-acquired mrsa is the cause, and in geographic areas where community-acquired mrsa are relatively common, empirical therapy of such infections with clindamycin, trimethoprim-sulfamethoxazole (co-trimoxazole), doxycycline or minocycline, or linezolid is becoming common. if empiric clindamycin is administered, testing community-acquired mrsa isolates for inducible clindamycin resistance by using the "d-test" is recommended. by contrast with the netherlands and some other parts of northern europe, no standard set of measures has been adopted in all health-care facilities in the usa for controlling transmission of mrsa. measures recommended by the society for healthcare epidemiology of america for controlling health-care-associated mrsa include the use of screening cultures to detect colonised patients, placing patients in private rooms or cohorting patients, wearing gloves for room entry, gowns for substantial contact with patients or their environment, and hand hygiene before and after patient contact. however, there is considerable debate among experts in the usa about whether or not the use of screening cultures to detect patients at high risk of mrsa is necessary or practical in all health-care settings. given the considerable body of evidence that screening cultures, when combined with contact precautions, are beneficial and cost-effective, [ ] [ ] [ ] it is disconcerting that a recent survey of infectious disease consultants found that only % of respondents favoured the use of screening cultures to detect multidrug-resistant pathogens, and only % worked in facilities where screening cultures were routinely done. the costs of surveillance cultures, potential logistic problems that may result from an increased number of patients requiring isolation, and lack of controlled trials demonstrating the efficacy of screening cultures are often cited as concerns by those who do not use screening cultures. further studies are necessary to establish the relative efficacy of control measures such as screening cultures, cohort nursing, increased staffing levels, and improved hand hygiene adherence rates in controlling transmission of mrsa in health-care facilities. at present, there is no consensus regarding which measures are most appropriate for reducing transmission of community-acquired mrsa in community settings and for preventing the spread of these strains in health-care facilities. in the past year i have served as a consultant to dial corporation and woodward laboratories, who produce hand hygiene products, including alcohol-based hand rubs and soaps. i am currently a consultant to gojo industries. infectious diseases section, hospital of saint raphael, new haven, ct, usa forum mrsa-affected patients to other parts of the hospital, spreading the organisms elsewhere. there is also mrsa spread between orthopaedic wards and residential or nursing homes, which now care for more severely ill patients. another change has been the increasing involvement of paediatric populations; this is being studied specifically. it is interesting that obstetrics and paediatrics had encountered mrsa infrequently in previous decades in the uk. perhaps the development of mixed specialty wards has facilitated its introduction into this population? implementation of effective measures is being deleteriously affected by other changing environmental factors. reduced hospital bed numbers have resulted in increased interward transfers of patients, which have been shown to increase the risk of mrsa acquisition. decreased lengths of stay have resulted in patients being discharged before they present with mrsa infections. we have thus reduced the effectiveness of our alert organism laboratory surveillance systems. our data also show that inter-city transfers of patients has encouraged national mrsa spread. bed occupancy in many hospitals is over % and in some parts over %. some uk infectioncontrol teams have problems closing mrsa-affected wards because of the pressures on waiting lists. however, the relation between bed occupancy and mrsa rates is not clear-cut. insufficient numbers of skilled staff further compounds the problem. studies have shown that compliance with infection-control practices decreases as workloads increase, resulting in more mrsa crossinfection. these practices include mrsa screening, effective hand hygiene, wound and intravascular/urinary device care, and appropriate isolation measures. when we did an intra-uk comparison of hospitals in , those that were better able to control mrsa outbreaks had fewer delays in identifying mrsa patients ( · % vs %), fewer inter-hospital transferred patients ( · % vs · %), and no problems with mupirocin resistance ( % vs · %) compared with those less able to control the problem. a recent english mrsa systematic review concluded that there were many problems with the quality of the reviewed papers. absence of evidence should not be taken to mean that there is an absence of effect. the authors emphasised that the current guidelines for mrsa control should be followed until evidence emerges that other approaches are effective. prescribing of certain antibiotics probably contributes to the acquisition of mrsa, although the evidence for this is not clear-cut. the authors indicated the ways in which better studies could be designed to inform the most cost-effective means to produce sustained improvements in compliance. mrsa control guidelines were first written in and were similar to the "search and destroy" approach used in non-endemic countries. in we revised them in the light of the endemic problems encountered in many english hospitals. there has been much debate as to how to best control endemic mrsa and other writers in this forum have outlined many of these issues. our analyses of the current situation will further inform the most effective mrsa control measures. new guidelines have been written and a consultation on them is underway. several interventions will be required. the department of health and the hpa in consultation with many other bodies and health-care workers are introducing a suite of initiatives with various performance indicators and outcome measures that should enable improvements in infection control. however, these initiatives will require substantial funding. multidisciplinary involvement will be crucial, as well as ownership of infection control by all healthcare workers and sharing of good practice. there are clearly many issues that need to be discussed with policy makers; bed managers also need to work closely with infection-control teams. in some parts of england mrsa-free wards are being created, elsewhere mrsafree or fast-track orthopaedic hospitals are being assessed. i believe that effective control and real reductions in mrsa will be possible. screening strategies are critical-eg, planned screening and eradication of mrsa before admissions, monitoring of acquisitions on high-risk units and among patients who have been in hospital for prolonged periods (ie, more than a week), and rotating screening programmes on wards to provide feedback data to inform interventions such as hand hygiene improvement campaigns. a good example of this is the cleanyourhands campaign, which uses a multifaceted approach including the use of alcohol handrubs and patient empowerment. rapid mrsa detection systems are being examined for costeffectiveness. many systems have been used to isolate patients-eg, an open ward, side rooms, four-bedded cohorting, or an isolation ward. whatever strategy is used should be validated by screening strategies. modelling studies have further informed isolation strategies. the hpa and others have done much to ensure that the news media are well informed about mrsa and have provided leaflets to educate the public. however, we will also need to do more to look at infection-control standards in nursing homes and to plan the eradication of mrsa from patients better after discharge. epidemic mrsa has a long history in australia. the bacterium was first isolated in in sydney and spread rapidly through teaching hospitals over the next years, such that by the end of the s the prevalence was - % in hospitals in the cities on the eastern side of australia. annual surveillance studies by the australian group on antimicrobial resistance have allowed us to track the evolution of both epidemic and community mrsa for the past years. the current prevalence ( ) for multidrug-resistant epidemic mrsa varies for the state capital cities, and is approximately % in sydney, % in melbourne, % in brisbane, % in adelaide, and % in perth. recent epidemiological typing studies have enabled the identification of these epidemic strains as predominantly st -mrsa-iii (uk emrsa , , , vienna, portuguese/brazilian clones) with two variants, one in melbourne and adelaide and the other in sydney, canberra, and brisbane. active screening and infection-control policies initiated in the early s following a single hospital outbreak have prevented the establishment of epidemic mrsa in any western australian hospital. since , increasing numbers of st -mrsa-iv (uk emrsa ) have been detected clinically, on screening, and in the annual surveillance studies. this non-multidrug-resistant clone is the major epidemic strain in western australia, where it comprises % of all mrsa isolates and % of all epidemic strains. a similar trend is occurring on the eastern side of australia, with sydney having the highest prevalence of this strain ( % of all mrsa). nurses coming from the uk are an important source of these isolates, which are often detected on pre-employment screening. this clone has also become established in many long-term care facilities. in addition to nosocomial epidemic mrsa we have been documenting the evolution of true community-acquired mrsa strains in australia over the past years, such that now we have at least clones that have evolved independently around the country. it is somewhat ironic that western australia, the state with the lowest rate of noscomial epidemic mrsa, should now have the highest rate of communityacquired mrsa ( % of all mrsa isolates). these strains, although frequent in admitted patients, rarely seem to be transmitted to others in the hospital. when identified, patients colonised or infected with community-acquired mrsa are managed with enhanced precautions (single room if possible, attention to hand hygiene, contact precautions, and extra cleaning during admission and on discharge). to date, we have not had any major hospital outbreak with community-acquired mrsa, despite an increasing prevalence in the community. my experience with mrsa has been as a western australian, where we have successfully used a "search and destroy" policy for at least years. it is state policy that any patient who has been hospitalised outside the state in the preceding year be isolated and screened for mrsa before joining the general hospital population. in addition, staff who have worked clinically outside western australia are also screened pre-employment. this screening has led to my colleagues in sydney, melbourne, and brisbane calling us "fortress wa". we have had a number of outbreaks over the years, particularly in my own hospital, which has a lack of single rooms, but swift screening of contact patients and staff, isolation of colonised patients, attention to hand hygiene, and enhanced ward cleaning has terminated the outbreaks rapidly. we also routinely screen all patients in high-risk areas (intensive care, burns, vascular, and spinal units) on admission, discharge, and after prolonged stay. decolonisation is initiated for persistently colonised staff and patients likely to have frequent readmissions. in general, topical hexachlorophene or triclosan together with mupirocin nasal ointment is used. however, if oral carriage is detected or the topical regimen fails, systemic therapy with two agents is given. i cannot speak for my colleagues on the other side of australia who have lived with endemic nosocomial mrsa for many years, but i believe that there are a variety of practices mostly aimed at containment rather than eradication. in brisbane, where the prevalence has been very high, rates have dropped substantially with the move to new hospital accommodation and intensification of infection-control procedures. it is perhaps easiest for those of us who do not have endemic nosocomial mrsa. we have a very defined end point-no endemic mrsa-that we wish to achieve. for those with endemic mrsa, realistic end points for any containment programme must be established and measures instigated to ensure the attainment of those outcomes. containment or eradication is important-we are all aware of the emergence of vrsa carrying the vana gene complex. the coexistence of mrsa and vre provides the environment for gene transfer. policies for the control of both these organisms are therefore of paramount importance. community-acquired mrsa presents a new challenge. fortunately in western australia, most of the community strains are panton-valentine leucocidin (pvl) negative. the infections seen are therefore of similar severity to those caused by susceptible s aureus. however, there are disturbing data indicating that our most frequent community-acquired mrsa clone can, and has, acquired pvl on several occasions. we are currently contemplating what community strategies should be implemented, in particular whether we should follow the example of denmark where a search and destroy policy has been used within the community. it would not be feasible for us to do this with all our community-acquired mrsa isolates but it may be possible for those with pvl. this toxin is carried on a prophage and is therefore potentially mobile. if we can prevent wide dissemination of the pvl genes we could perhaps limit the associated disease severity. the australian public is very aware of "the golden staph" tag by which the press has labelled mrsa. there is episodic press coverage, both print and television, of personal stories and individual hospital problems. however, understanding of antimicrobial resistance of any kind is minimal within the community. providing and disseminating relevant, understandable information that will change community and prescriber attitudes is a challenge that should be met by our profession, regulatory authorities, and politicians. i declare that i have no conflicts of interest. head of the department of microbiology and infectious diseases and associate professor of the school of biomedical sciences, curtin university, perth, australia japan japan has one of the highest prevalences of mrsa in the world. among s aureus bloodstream isolates in , nearly % were meticillin resistant. to control mrsa in hospitals, it is essential to identify potential mrsa patients immediately after admission. since microbiological testing usually takes - days, the identification of those who are at high risk for mrsa carriage is required to decide whether proper precautions should be taken for each new patient. no mechanism to identify patients within hospitals currently exists in japan-there is no general database that includes previous medical and laboratory results of patients that can be shared by clinicians between different hospitals. in addition, people can attend any hospital they choose-from a large teaching hospital to a general hospital-without an appointment. without mrsa screening on admission, this situation makes it difficult to know whether the patient has already been colonised or infected with mrsa in the past. ignorance about mrsa is a huge problem among the public and media in japan. although there is some interest in the subject, the risks and safety issues surrounding mrsa are generally not that well known. mrsa carriage is seen as a "stigma" for patients and because colonisation with mrsa is not usually differentiated from an infection, the media are quick to generate a scandal and attach blame to hospitals and doctors when mrsa is reported. hence, most hospitals tend to refuse mrsa-positive patients to avoid potentially damaging repurcussions for the hospital. moreover, this situation can lead to clinicians hesitating to identify mrsa carriage of patients who are being transferred to another hospital. in many countries it is strongly recommended that clinicians at the transferring hospital should notify mrsa carriage status of the patient to the infection control team at the receiving hospital before transfer. however, this procedure has not been followed stringently in japan. an mrsa flagging system to highlight previously identified patients within the same hospital or upon readmission is expected to become available soon to most clinicians. this flagging system needs to be computerised and added on to the individual database in each hospital. however, it is still difficult to share microbiological results through a single medical computer network system. each hospital needs to develop mrsa flagging software for this purpose. although japanese hospitals are extensively computerised, the main purpose of the hospital computer system is for ordering and accounting for medical procedures. the data sorting function from previous laboratory results is usually optional. we have recently developed a small computer programme on our hospital network to indicate an "alert spot" on the individual patient record window. if a patient has a previous history of being mrsa positive, a redcoloured alert spot automatically appears on the computer display. this alert system helps us to recognise whether the patient is a potential or current mrsa carrier without checking any previous microbiological results, which is usually a tedious and time-consuming procedure for busy clinicians and hospital officers. this function will be introduced to a new hospital computer system in the future. ideally, these data will become indispensable information for inter-hospital transfers via a shared database that should be set up in the future. an alternate route of importing mrsa into hospitals is from the community. only a few studies of mrsa prevalence in the community have been published from japan. one study reported that out of ( · %) healthy children aged - years old carried mrsa in their anterior nares. this prevalence of community mrsa among children is high, and deserves further prevention efforts. mrsa surveillance is currently mandatory in large general and university hospitals but not in middle to small-sized hospitals that are the most common types of hospital in japan. for example, geriatric hospitals with less than beds are usually one of the most important reservoirs of mrsa. mrsa-positive patients are sent to us from these types of institutions without information of mrsa carriage. therefore, it is important that mrsa surveillance should be made mandatory by legislation. another less common strain of mrsa is visa, which was first reported in japan. although the hetero-visa strain (a possible precursor of visa) was identified in · % of mrsa isolates in seven university hospitals, a new visa strain has not been identified in japan so far, because therapeutic drug monitoring has become widely available from both "in-house" and commercial laboratories since . controlling the use of vancomycin means there is less chance for the emergence of vancomycin-resistant strains. educational awareness of mrsa should be provided to all health-care workers as well as the general public, and should be supported by the government or relevant associations and academic societies. mrsa carriage should be notified properly when the patient is transferred from one hospital to the next. senior lecturer, department of infection control science, juntendo university, graduate school of medicine, tokyo, japan finland is a country with low mrsa incidence. the incidence figures are based on mandatory reporting by clinical microbiological laboratories of each new mrsa isolation since and analysis of mrsa strains at the national reference laboratory at the national public health institute. in recent years, however, we have seen a worrying increase in the number of mrsa cases. the number of reported cases has increased from in to in (from · to · cases per ) in a population of · million. for many years mrsa remained below % among invasive cases, but during we saw the first signs that the figures were worsening substantially. at the same time, the coverage and efficacy of mrsa reporting has remained stable, thus we assume that we are facing a true change. strict mrsa prevention measures are taken following each newly identified mrsa case, regardless of whether it is symptomless carriage or infection. in response to three large mrsa epidemics in southern finland, national mrsa prevention consensus guidelines were adopted in . the updated version of these guidelines was published in . the new guidelines cover both acute care hospitals and long-term health-care facilities, including homes for elderly people. the main principles are promotion of hand disinfection, identification of mrsa risk patients (carriers and contacts of known mrsa cases), rapid microbiological identification of mrsa, contact isolation of mrsa cases, and treatment of mrsa infections. emphasis is placed on trying to target preventive measures at the very first steps of possible mrsa transmission. according to the guidelines, every patient who has been treated in a hospital outside of finland during the previous year and is transferred to a finnish hospital is screened for mrsa colonisation at the time of hospital admission. patient records of each mrsa case are labelled accordingly, and an "mrsa alert" is also added to electronic patient records in many institutions. these actions have proven to be effective in controlling several rather large hospital mrsa outbreaks in the s. some of the international mrsa clones have also repeatedly entered our country via patients or health-care workers who have come from abroad, but they have caused few secondary cases or outbreaks. during the past couple of years, the mrsa situation has changed in finland. in - , one-fifth of our cases showed no contact with the health-care system, and were thus considered community-acquired mrsa. usually, these mrsa strains possess only beta-lactam resistance, carry the sccmec type iv genes, and cause problems in younger age groups. however, the proportion of elderly people with mrsa has increased steadily. in , over % of cases were found in individuals aged years or older. in , over half of finnish mrsa cases were reported in long-term care facilities, and outbreaks are forum occurring in these facilities. these two settingscommunity acquisition and long-term care facilitiescreate new and demanding challenges to our mrsa prevention policy. the finnish health-care system is currently struggling with increasing output demands and decreasing funding. the nursing staff is often overwhelmed with work, and patient wards are crowded and often lack single-bed isolation rooms, creating problems for infection control. in long-term care facilities, we are witnessing the lack of trained personnel and problems in finding functional placement options for mrsa carriers. there has been a considerable amount of debate about the ethical right to isolate mrsa carriers in the nursing home setting. it is difficult to find a solid answer that would hold for every case. in our decisions about mrsa-positive people we try to respect two basic principles: the patient's right for proper medical treatment and the individual's right to live a normal life. the actions taken now and over the next few years are crucial in determining how the trend of mrsa in finland progresses. at present, we still have the chance to prevent the situation from becoming much worse. in , the finnish government launched a fund for the health districts to update their resources on emerging hospital infection issues, including mrsa prevention. sweden, denmark, norway, iceland, and finland have also started a joint initiative, provoked by the scandinavian society for antimicrobial chemotherapy, to try to find ways to keep mrsa levels below % among s aureus isolates in each country. at the very least, this cooperative effort will mean that information on the mrsa situation is exchanged, attempts are made to improve mrsa laboratory diagnostics, common reasons for why mrsa is emerging sought, and attempts made to increase awareness among the public and health-care workers. in countries where mrsa case levels have remained low, the only right and ethical decision is to try to fight hard to keep the situation from becoming worse. this battle requires new investments now, but it will save money and resources in the future. chief physician, hospital bacteria laboratory, department of bacterial and inflammatory diseases, national public health institute, helsinki, finland turkey mrsa emerged in turkey in the s as a major clinical problem in hospitals, and to date has continued to be one of the most problematic nosocomial pathogens. the extent of resistance varies nationally, regionally, and even institutionally. in addition to meticillin, these strains are also resistant to routinely used antimicrobials, and thus infections caused by such isolates cause serious treatment difficulties. unfortunately for turkey, accurate and recent population-based national surveillance for communityacquired and hospital-acquired drug-resistant microorganisms does not exist. however, data from sporadic reports of the number of cases suggest an urgent need for surveillance. available reports provide a fragmented and incomplete picture to guide our understanding of the problem. the most recent and only national resistance screening programme data supported by the turkish scientific and technological research council is from . in this study, clinical isolates both from outpatient and inpatient clinics (including surveillance isolates) from different hospitals were collected and screened. overall, mrsa resistance varied from % to % at different centres. this range of resistance may have been due to variations in patient population, hospital care practices, and infection control activities. other factors-eg, size, locality, and type of hospital-were also contributing factors to the wide disparity in resistance. among the identified isolates, nosocomial strains were randomly selected for evaluation of the mechanisms of meticillin resistance, and the presence of meca was found to be the most frequent type ( %). when various other studies from different centres were evaluated up to , it was noted that up to % of strains in some places were mrsa. in a further evaluation extending to , this figure rose to %. more recently, data from the past years from individual centres across turkey state the percentage of mrsa strains is · %. [ ] [ ] [ ] [ ] when tested, all strains were reported to be vancomycin and teicoplanin susceptible but potential emergence of resistance to these drugs should be kept in mind, since this has prompted the overuse of glycopeptides in empirical and even prophylactic therapy. , evaluation of reports showed no correlation between mrsa rates and sex, profession, hospital department, or carriage. it was difficult to evaluate the age distribution and age group at risk. ideally at each hospital multidrugresistant strains should be regularly identified. clonal typing methods should be used to identify the relations between these strains, and to see which strains predominate in the country. we evaluated our hospital's main nosocomial mrsa clone and tried to track the sources of the clonal types in different clinics by pulsed field gel electrophoresis. one major type was identified among their strains. this single clone was compared with another turkish university hospital's clone and several main international clones including the iberian and brazilian clone, and it was found to be different from them. predominance of this clone or any other clone is not known. this type of evaluation needs to be done by most hospitals. with enough funding a national netherlands yes, they do not like to see us coming: physicians, nurses, and hospital administrators may shrink away when the banner of mrsa is raised by the hospital infection-control practitioner-it always means expensive and timeconsuming isolation, may mean temporary removal of staff, or the partial or complete locking of wards that have to stop admissions. yet the incidence of mrsa in the netherlands remains one of the lowest of europe. in , mrsa was isolated from people, one-fifth of whom were health-care workers, which means that approximately patients newly acquired mrsa in the course of a year. to put this number into perspective, the netherlands has million inhabitants, hospitals, and approximately million patient-days of stay in hospital. a timely implementation of a national policy of stringent control measures, and a long-standing tradition in parsimonious antibiotic use surely contributed to keeping mrsa at bay. as in many other countries, after a short appearance in the late s, mrsa entered the netherlands in the early to mid- s. three large hospitals in rotterdam, amsterdam, and utrecht experienced outbreaks that were eventually controlled by strict infection-control measures that included isolation of patients, screening of patients and hospital staff members, and closure of wards. both in amsterdam and in utrecht, mrsa was introduced by a patient who had been transferred from a hospital abroad. these early experiences prompted the dutch working party on infection prevention (wip) to formulate national mrsa guidelines. this working group is funded by the ministry of health, and its task is to develop guidelines for infection prevention in hospitals, nursing homes and institutions for the mentally handicapped, and dental care and homecare. the guidelines issued by the wip are considered professional standards and are used as such by the dutch public health inspector; this undoubtedly contributes to the adherence to the guidelines by nearly all health institutions. the mrsa guidelines are based on three main principles. first, patients with mrsa are always isolated in single rooms, whether they have an active mrsa infection or not-carriers are also considered potential sources of transmission. isolation for being a carrier raises anxiety in the patient and their relatives. however, % of adults are staphylococcal carriers, and they develop an infection only occasionally, so, in itself, carriage of a staphylococcus that has additional resistance is not a source of worry for the individual patient. second, patients suspected of potential carriage are always placed in isolation; potential carriage is considered in all patients transferred from hospitals abroad to dutch hospitals, in patients from dutch hospitals, or from nursing homes with an actual problem of mrsa, and in patients who have been nursed in the same room as a patient in whom mrsa is detected unexpectedly. this isolation may come forum epidemiological surveillance group should be established. data emerging from various centres indicate that in turkey-like many other countries-both infections and the rate of mrsa is gradually increasing. the main factors that contribute to this organism's resistance are misuse and overuse of antimicrobials, which include constant pressure on the physician to prescribe antimicrobials when they are not indicated, the patient's failure to finish a prescribed antibiotic regimen, and also the availability of antimicrobials without a prescription. we believe that control of such factors, alongside implementing good infection-control procedures in turkey, will result in decreasing rates of mrsa. studies from other countries have shown that surveillance activities-eg, setting up a national/regional system to collect and evaluate data from all centres and updating data on antibiotic resistance patterns that will form the basis for prevention guidelines of nosocomial infections-decrease infection rates by as much as %. the negative impact of nosocomial infections on our health-care system is not well documented. data obtained from limited number of studies are not suitable for comparison with each other and neither are data from other countries. thus, a national nosocomial infection control project (nosoline), supported by the turkish hospital infections society, has recently started at the hacettepe university hospital, ankara. the project's aim is to develop a regular, standardised surveillance system, allowing electronic data transfer and online announcement of the results to the member centres. to achieve its goals, the problems of gaining financial support and recruiting qualified personnel for data evaluation and processing need to be solved, and additionally all major hospitals will need access to the system. despite the absence of extensive data, reports of recent percentages of up to % of nosocomial mrsa infections confirm the urgent need for an effective antimicrobial usage policy for our country. to prevent resistant isolates spreading within and between hospitals, proper infection control procedures should be enforced, which currently most hospitals lack. in time we hope to prevent the uncontrolled availability of antimicrobials, increase awareness of such problems to physicians and the community, and have more available funds to support programmes in hospitals. we declare that we have no conflicts of interest. as a shock to people who become ill abroad, are repatriated, and arrive with a sigh of relief in a hospital in the netherlands, only to be faced with strict isolation measures, where even the family members have to wear gowns and masks upon entering the patient's room. an often-heard reaction is "am i a leper?", and it may be taxing to the attending physician to explain the reasoning behind the precautionary measure. third, contacts of patients with mrsa-both other patients and hospital staff-are screened for mrsa carriage and treated with mupirocin nasal ointment if found positive. this screening can prove trying for staff, because they are not allowed to return to work unless negative. fortunately, mrsa is usually quickly lost in normal community life or upon treatment with mupirocin nasal ointment. on occasion, a staff member proves to be a "stubborn" carrier, and several courses of mupirocin and the use of disinfectant soap are needed to clear the carriage. this upsets personal life and the working schedules of staff colleagues, who have to fill in for their colleague during the period he or she is not allowed to work. fortunately, untreatable carriage is very unusual, but may lead to the necessity to change job. the wip guidelines for mrsa are also published in english and can be found at http:// www.wip.nl. this very active searching policy implies that many of the mrsa strains that are identified in dutch hospitals are not actually causing infections, but are merely colonisers at the moment that they are detected. indeed, of the strains isolated in the past year, one-fifth were from health-care workers, who very seldom have an active infection when they are screened; the remainder were from patients who may have had an active infection or may just have been colonised. in the netherlands, mrsa occurs mainly in isolated cases or in smaller outbreaks, and it is not yet endemic in any hospital. because of this, it is possible to institute strict control measures whenever needed, although every time they cause great upheaval in the implicated ward, which has to isolate patients and screen patients and staff. the decreased therapeutic options, the nightmare of impending vancomycin resistance, and the higher numbers of therapeutic failures that accompany infections with mrsa provide a firm ground for the dutch policy. it is therefore strongly supported by the inspectorate of health care and by all microbiologists, infectious disease specialists, and infection-control officers involved. there is the odd dissenting voice of a surgeon or intensive-care physician who points to his colleagues in the uk or the usa where mrsa is rampant-"medical life is possible over there isn't it?" part of the unease of physicians is the result of misunderstandings and some "urban myths"-more appropriately "hospital myths"about mrsa. for instance, surgeons may think that they cannot operate on a patient who carries mrsa. nothing could be further from the truth. yes, elective surgery might be postponed, but all necessary surgery should go on as planned, with extra precautions. again, it is too often forgotten that % of all adults are staphylococcus carriers, and that the carriage in itself does no harm. up to now there have been neither legal nor ethical qualms about the dutch "search, isolate, and destroy" strategy, as in the end, all sections of medical life in the netherlands-physicians, nurses, and administratorssee the value of prevention. after careful explanation, even if some measures may tax the ingenuity of administrators and staff, the experience is almost invariably one of excellent cooperation, and most people involved enjoy the process of working for the greater good. although the exact burden of disease caused by mrsa remains largely unknown, most experts would agree that mrsa infections represent an important clinical and public-health problem. we hardly need to call readers' attention to the thousands of articles published over the past three decades about epidemiological and microbiological aspects of mrsa. yet uncertainty remains about the best approach to prevent and control this worldwide plague. in this issue of the lancet infectious diseases, several authors offer insight into mrsa control approaches used in different areas of the world. countries like finland, denmark, and the netherlands have managed to keep mrsa at a low level using surveillance cultures of patients and personnel, strictly enforced contact precautions, and judicious use of broad-spectrum antibiotics. unfortu-nately, these countries are facing now the paradoxical situation that transmission of community-acquired mrsa may jeopardise their well-established strategies to control nosocomial mrsa. denmark, for instance, has seen a substantial increase in mrsa since , due to the epidemic spread of genetically distinct communityacquired mrsa strains. conversely, many middleincome countries (eg, turkey, argentina) and some highincome countries (eg, italy, greece, uk, usa) that were not able to install stringent counter-measures now have hyper-endemic mrsa and are obliged to concentrate available resources to prevent mrsa infections in highrisk populations-eg, dialysis, transplant, or critically ill patients. a few countries with endemic mrsa (eg, australia, france, belgium) have managed to stabilise or even decrease mrsa prevalence in confined geographic areas. on the other hand, several asian countries (eg, china, south korea, japan) have more or less ignored this public-health problem for a long time, resulting in some of the highest mrsa incidence rates worldwide. in these countries, financial incentives for physicians' antibiotic prescribing linked to the pharmaceutical reimbursement system have strongly influenced antibiotic overuse and increased antibiotic selection pressure on mrsa; an issue that has only recently been adequately addressed at the policy level. why do mrsa rates vary so much across countries? differences are caused largely by uneven control and isolation measures, hand hygiene practices, antibiotic prescribing behaviours, and allocation of resources. cultural and economic factors pervade all aspects of mrsa control, which can only be fully successful if strict measures and policies are installed at an early stage of mrsa dissemination, sufficiently supported by financial and staff resources. especially at the early phase of a nationwide mrsa epidemic, the full clinical impact of mrsa may not be visible, leading to misconceptions among clinicians and policy makers that mrsa may not be a threat to patient safety. do we have any hope for the future? as mrsa surveillance systems and control strategies improve in quality and become more coherent among different countries, international pressure may start to be applied to induce change in countries where infection-control policies are lax or non-existent. the situation with mrsa might become comparable to that observed for other infectious problems such as severe acute respiratory syndrome and mad cow disease-economic and political pressure may contribute to compliance and uniformity in control measures and to allocation of resources to improve patient safety. yet stringent mrsa control worldwide will remain difficult to implement and will require intensive surveillance efforts and substantial resources. to achieve this goal may be possible, as shown by several examples where successful action against mrsa has been endorsed by strong policy support. adequate hand hygiene decreases the transmission of mrsa, although the practice is difficult to enforce, because of psychological, practical, and organisational barriers. promoting hand hygiene to improve patient safety and decrease health-care-associated infections worldwide constitutes a core component of the first global patient safety challenge ("clean care is safer care") of the who world alliance for patient safety launched in . if successful, clean care is safer care will certainly have a positive impact on mrsa transmission and other antibiotic-resistant infections. low mrsa prevalence in a country is good news in that preventive measures are more likely to succeed than if endemic mrsa levels are already present. unfortunately, for key questions regarding the most cost-effective control of endemic mrsa, we have only weak or contradicting evidence. several well-conducted studies from france, germany, the uk, and the usa have recently illustrated this dilemma. [ ] [ ] [ ] [ ] [ ] whatever the final outcome of this ongoing debate, health authorities and policy makers are well-advised to put effort and money into their mrsa control efforts. mrsa is everybody's business, not only that of hospital epidemiologists and a few opinion leaders. national nosocomial infections surveillance (nnis) system report, data summary from predicting methicillin resistance and the effect of inadequate empiric therapy on survival in patients with staphylococcus aureus bacteremia occurrence and antimicrobial resistance pattern comparisons among bloodstream infection isolates from the sentry antimicrobial surveillance program outcomes analysis of delayed antibiotic treatment for hospital-acquired staphylococcus aureus bacteremia the impact of methicillin resistance in staphylococcus aureus bacteremia on patient outcomes: mortality, length of stay, and hospital charges adverse clinical and economic outcomes attributable to methicillin resistance among patients with 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infections successful long-term program for controlling methicillin-resistant staphylococcus aureus in intensive care units we declare that we have no conflicts of interest. infection control program, department of internal medicine, university of geneva hospitals, switzerland key: cord- -ukqux authors: curtis, l.t. title: prevention of hospital-acquired infections: review of non-pharmacological interventions date: - - journal: j hosp infect doi: . /j.jhin. . . sha: doc_id: cord_uid: ukqux hospital-acquired (nosocomial) infections (hais) increase morbidity, mortality and medical costs. in the usa alone, nosocomial infections cause about . million infections and deaths per year. hais are spread by numerous routes including surfaces (especially hands), air, water, intravenous routes, oral routes and through surgery. interventions such as proper hand and surface cleaning, better nutrition, sufficient numbers of nurses, better ventilator management, use of coated urinary and central venous catheters and use of high-efficiency particulate air (hepa) filters have all been associated with significantly lower nosocomial infection rates. multiple infection control techniques and strategies simultaneously (‘bundling’) may offer the best opportunity to reduce the morbidity and mortality toll of hais. most of these infection control strategies will more than pay for themselves by saving the medical costs associated with nosocomial infections. many non-pharmacological interventions to prevent many hais will also reduce the need for long or multiple-drug antibiotic courses for patients. lower antibiotic drug usage will reduce risk of antibiotic-resistant organisms and should improve efficacy of antibiotics given to patients who do acquire infections. much of the recent research on nosocomial infections has dealt with the need for new antibiotics, better antibiotic management and better diagnostic techniques to detect infections earlier. better drug treatment and earlier infection diagnosis can certainly play a major role in reducing morbidity and mortality from hospital-acquired infections (hais). however, there are many nonpharmacological interventions that can significantly reduce the incidence of hais, but these are often overlooked in practice. this review is not exhaustive and will not attempt mathematical data analysis but will examine recent research that examines non-pharmacological interventions for reducing hais. it will also include a brief description of the morbidity, mortality and medical costs associated with nosocomial infections, along with a brief discussion of the routes by which hais spread. a bibliographic search between january and january was conducted in databases including pubmed, medline and google scholar. additional research articles were collected from conference proceedings, books and pre- journal articles as appropriate. many terms were used in the literature searches including nosocomial, hospital acquired, mrsa (meticillin-resistant staphylococcus aureus), staphyloccoccus, streptococcus, vre (vancomycinresistant enterococcus), clostridium difficile, legionella, klebsiella, tuberculosis, airborne infection, waterborne infection, hand washing, hospital cleaning, urinary catheters, central catheters, haemodialysis, ultraviolet light, hepa (high-efficiency particulate air) filtration and many others. a total of articles was included in this review. care was taken to see that a balanced representation of articles was presented. hais cause a huge amount of morbidity and mortality. klevens et al. used data from the national nosocomial infections surveillance (nnis) system, and data from the national hospital discharge survey and the american hospital association survey to estimate nosocomial morbidity and mortality. this study estimated that there were nosocomial infections in the usa in , of which were due to urinary tract infections, to surgical site infections, to pneumonia, to bloodstream infections and to other causes. it is difficult to obtain a precise estimate of deaths from nosocomial infections since patients often die from several causes and infection is often not mentioned on death certificates of patients who die of a combination of a chronic illness (such as cancer) and acute infection(s). estimated annual deaths in the usa due to hais in was . in , an estimated died in the usa of mrsa infections, of which most were nosocomial. a study of consecutive deaths in a spanish -bed tertiary care hospital reported that . % of the deaths of patients which occurred more than h after admission were due to nosocomial infections. while it has been long known that hais are very expensive to treat, cost estimates of nosocomial infections vary. a us study of admissions in us hospitals from to estimated that each nosocomial infection increased medical costs by $ , . a french study reported that hospital-acquired sepsis increased medical costs by a mean of v , . various studies have estimated that the average cost of ventilator associated nosocomial pneumonia from us$ , to $ , per case. , hospital-acquired bacteraemia has been estimated to increase medical costs in a belgian study by an average of v , and in a michigan study by $ , . , a british study reported that the average increased medical cost for each central venous catheter infection was £ , . traditionally, it has been believed that most nosocomial infections, with a few exceptions such as tuberculosis and aspergillus and viruses like respiratory syncytial virus (rsv), influenza, rhinoviruses and coronaviruses, are not spread through the air. while a large percentage of hais are spread through surface contact (such as hands) or by catheters, intravenous (iv) lines or surgical incisions, many nosocomial infections can also spread through the air. it was previously believed that most pathogenic bacteria could not survive as bioaerosols and spread significant distances to infect patients. however, many airborne pathogenic bacteria are viable but not culturable, and some experts have estimated that as little as % of viable bacteria are culturable by standard microbiological techniques. , for example, heidelberg et al. reported that viable counts of serratia marcescens, klebsiella planticola and cytophaga allerginae in -hour-old bioaerosols were, respectively, , and % of the original counts even though none of the bacteria was culturable on tryptic soy agar plates. many pathogens present on sneezes evaporate in less than a second into small droplet nuclei of about mm diameter. , such small droplet nuclei can remain suspended for hours and travel long distances before settling. a number of studies have reported airborne transmission of many pathogenic bacteria to humans including mrsa, coagulase-negative staphylococci, corynbacterium diphtheriae, neisseria meningitidis, bordetella pertussis, acinetobacter and pseudomonas. e a mouse study reported two strains of klebsiella pneumoniae which could infect and multiply in mouse lungs after airborne exposure. therefore it may be concluded that while many nosocomial bacterial infections are spread by contact or by iv routes, the airborne route is also an important source of many hais. pathogens from hospital water are another underappreciated and underdiagnosed source of hospital infection. , over published studies employing both epidemiology and molecular biology techniques [such as polymerase chain reaction (pcr) and dna probes] have confirmed that contaminated hospital water sources can cause nosocomial outbreaks from many pathogens including legionella, mycobacteria, pseudomonas, stenotrophomonas, serratia, acinetobacter, aeronomas and moulds such as fusarium, aspergillus and exophialia. , hospital water can also be contaminated with amoebae and viruses. it is estimated that waterborne nosocomial pseudomonas infections kill annually in the usa. legionella is found in many hospital water systems and can persist for years. viable legionella were found in the water systems of of ( %) us hospitals and of ( %) spanish hospitals. , environmental pulsed-field gel electrophoresis studies have confirmed that specific legionella strains can persist for as long as years in hospital water supplies. viable pathogens can grow in many sources of hospital water including drinking water, hand-washing water, ice, dialysis water, shower water, water in storage tanks and distribution systems, water from decorative pools/fountains, and carpets, furniture, ventilation ducts and building materials that have become wet. contaminated environmental surfaces (such as bedside rails) are also an under-recognised source of hospital infections. many surfaces in hospitals contain viable pathogens such as mrsa and vre. in rooms of patients with diarrhoea, viable mrsa has been collected from % of the room surfaces and viable vre has been collected from % of room surfaces. , many strains of mrsa and vre can remain viable for several weeks to several months on dry surfaces. , infections can also be spread to hospitalised patients via drugs, intravenous solutions, cleaning solutions or by foodstuffs. a review of hais obtained via contaminated substances reported that the most commonly involved items were disinfection materials (n ¼ patients), heparin solutions (n ¼ ), red blood cells, clotting factors and other blood products (n ¼ ), albuterol inhalers (n ¼ ), total parenteral nutrition (n ¼ ), propofol (n ¼ ), rantidine (n ¼ ) and ultrasound gel (n ¼ ). the remaining part of the results section will concentrate on research on interventions to reduce hais. table i gives a summary of nonpharmacological interventions that have either been proven to reduce nosocomial infections or some level of evidence suggests may be effective. hand washing, gloving, gowning and personal items frequent and adequate hand washing is the best way to prevent spread of most nosocomial infections. the extreme importance of hand washing has been known since at least , when dr ignaz semmelweis discovered that washing hands before performing obstetric exams on pregnant women reduced childbirth-related infectious mortality from more than % to less than %. however, rates of hand washing among healthcare providers usually range from only about to % per hospital patient encounter, although some studies have reported hand-washing rates as high as %. e viable pathogens are often found on hands of healthcare providers. various studies have reported the following pathogens on the respective percentage of healthcare providers' hands: acinetobacter spp. e %, clostridium difficile e %, klebsiella spp. %, mrsa up to . %, pseudomonas spp. . e %, rotavirus . e . %, vre to % and yeasts (including candida) e %. most studies have reported that increases in hand-washing rates significantly reduce rates of hais including mrsa although a few studies have reported negative results. , e alcohol-based hand-washing solutions are generally considered to be more effective than soap and water. compared with plain soap and water, some studies have reported significantly lower rates of nosocomial infections when alcohol-based solutions or chlorhexidine-or triclosan-based hand-washing agents are used. , , , an australian hospital study noted a hand hygiene programme that switched from soap to a chlorhexidine/isopropyl alcohol solution reduced mrsa bacteraemia by % (p ¼ . ) and reduced clinical isolates of lactamase-resistant e. coli and klebsiella by % (p < . ). some studies have also reported that the economic savings that alcohol or chlorhexidine hand-washing solutions provide by reducing nosocomial infections will far more than pay for the cost of the hand-washing solutions. , it is estimated that hand washing with plain soap for s removes most soil and dirt, eliminates about % of transient hand flora but a low percentage of resident hand flora. hand washing for s with a soap containing chlorhexidine or triclosan removes most soil and dirt and about . % of transient flora and about % of resident flora. hand rubbing for s with an alcohol-based gel does not remove soil or dirt, but kills about . % of transient flora and about % of resident flora. many healthcare providers prefer using alcoholbased solutions instead of soap and water, and compliance rates are generally higher when alcohol-based hand-washing solutions are used. use of alcohol-based cleaners saves time and these generally abrade and irritate the skin less than antiseptic soaps. however, some people complain that alcohol-based cleaners dry out and crack their skin. hospitals and healthcare providers may want to experiment with several alcohol or chlorhexidine-based hand cleaners. soap and water may still have to be used in cases when hands are visibly soiled. in that case, staff and visitors should wash hands carefully for at least s with soap and water. table ii lists six abridged 'golden rules' to improve hand hygiene compliance proposed by dr gunter kampf. in , the us centers for disease control and prevention (cdc) published new guidelines for hand hygiene. major changes of these guidelines over the guidelines included use of waterless alcohol-based cleaners (unless hands are visibly soiled), prohibition of artificial fingernails and an institutional mandate to provide staff education and develop a multidisciplinary programme to monitor compliance. to measure effectiveness of these new cdc guidelines, an anonymous survey of staff in hospitals was made after the new guidelines had been in force for a year. this survey found that mean hand-washing rates were only . %, and % of the hospitals had no multidisciplinary programme to improve compliance. it is not certain what type of glove provides the best protection for infection control. some studies have suggested that latex gloves are somewhat better in preventing penetration of water and virus than vinyl gloves. however, about e % of healthcare workers are sensitive to latex and sometimes experience severe respiratory reactions to it. if latex gloves are used in the healthcare setting, only the powder-free gloves should be used since these release much lower levels of latex allergens than the powdered latex gloves. nitrile gloves also have good barrier penetration but are more expensive and heavier than either latex or vinyl gloves. gowns are often used in rooms of patients with infectious disease. data on gown use and nosocomial prevention are sparse. one study reported that use of disposable gowns in an intensive care unit (icu) was associated with a % reduction in vre (p < . ). gown use in this study also produced an annual net benefit of $ , in the icu by averting an estimated vre cases. another study reported that use of gowns was associated with a modest and insignificant drop in mrsa cases. rates of gown usage by healthcare providers and staff are generally mediocre, with one study reporting mean gown usage in rooms of patients with contact precautions was only % for healthcare providers and % for visitors. shoe and head covers are often recommended for use in areas containing immunocompromised or surgical patients. although bacterial pathogens have been collected from shoes, research on the use of shoe covers and/or separate hospital shoes and spread of pathogens has been meagre. one study reported that wearing gowns and shoe covers in bone marrow surgery did not significantly reduce patient infection risk (as measured by antibiotic therapy). an experimental laboratory study involving sham surgery reported significantly lower levels of airborne bacteria when headgear was worn versus no headgear. various studies have reported that nosocomial pathogens are present on many items of healthcare providers such as laboratory coats, stethoscopes, blood pressure cuffs, ekg electrodes, pens, finger rings, neck ties, artificial nails and ambulances. e to prevent spread of nosocomial infections, these items should be disinfected or cleaned regularly. disposable one-use electrodes even a small number of nosocomial infections prevented will outweigh the cost of effective hand hygiene products. . encourage senior staff to set a good example to motivate junior staff. . have adequate staff:patient ratios. are now available. sometimes, pieces of equipment such as stethoscopes or blood pressure cuffs are dedicated to one patient only in order to limit spread of pathogens. proper cleaning techniques and proper cleaning chemicals can also significantly reduce hospital pathogen levels and risk of nosocomial infections. one study utilised a fluorescent marker solution to determine cleaning efficacy of surfaces found in patient care rooms of us hospitals. terminal room cleaning after patient discharge was able to adequately clean only a mean of % of the standardised surfaces, including less than % for toilet hand holds, bedpan cleaners, room door knobs and bathroom light switches. carling et al. recommended that hospitals monitor performance of cleaning personnel and provide feedback and training as needed to optimise cleaning effectiveness. several studies have reported that hospital cleaning personnel often receive little initial training and, after receiving instruction, often do a much better job of eliminating pathogens by their cleaning. , an illinois prospective study reported that following a cleaning educational programme, average rates of cleaning icu surfaces rose from to %. rates of vre infection were reduced by % [ % confidence interval (ci): . e . ]. a british retrospective icu study reported that significantly higher rates of mrsa infection were associated with inadequate surface cleaning and nurse understaffing. research on chemicals used to clean non-porous surfaces (such as floors, walls, tables etc.) in hospitals and their effects on reducing nosocomial infection has been sparse. in a literature review, no randomised controlled trials and only four cohort studies could be identified. three studies detected no significant differences between nosocomial infection rates when comparing surface cleaning with aldehydes, quaternary ammonium compounds, active oxygen cleaners or ortho-benzyl para-chlorophenol compared with plain detergent solutions. the fourth study reported that use of : hypochlorite (bleach) solution was associated with a significantly lower rate of c. difficile infection in bone marrow patients compared with cleaning with quaternary ammonium compounds. another study of rooms which housed vre-positive patients found that ( %) of the rooms' surfaces contained viable vre before cleaning, but ( %) had viable vre after thorough cleaning with a % bleach solution (p < . ). hydrogen peroxide vapour may be used to decontaminate rooms containing pathogens. a british study compared manual cleaning of rooms (via a protocol compliant with uk standards) with a h protocol using min of ppm hydrogen peroxide vapour to decontaminate rooms. in surgical ward rooms, % of swab samples were positive for viable mrsa before manual cleaning, and % of matched swabs were still positive for viable mrsa after cleaning. by comparison, in six other surgical rooms, viable mrsa was found on % of swabs before hydrogen peroxide treatment, but on only % of matched swabs following hydrogen peroxide treatment. during the hydrogen peroxide disinfection, hydrogen peroxide levels in adjacent rooms were no greater than ppm at head height. more study is needed on the safety and efficacy of this hydrogen peroxide vapour technology. research is currently underway to use copperoxide-impregnated textiles and paints in order to prevent spread of infections. better nutrition can also play a critical role in reducing nosocomial infections. malnutrition is very common in hospitalised patients. a review of published studies in acute care patients reported that malnutrition ranged from to % of all hospitalised patients and e % of hospitalised elderly. malnutrition was measured by such parameters as weight, weight loss, body mass index, grip strength, respiratory function, nutritional intake and blood levels of albumin, and prealbumin. many nutrients play a key role in maintaining immunity including protein, omega- fatty acids, vitamins a, b , b , c, d, and e; selenium, zinc, copper and iron. most of these nutrients become depleted following acute illness. malnutrition is a major risk factor for infection. a study of hospitalised patients reported that the odds ratio risk of hais was . times as great ( % ci: . e . ) in severely malnourished patients compared with adequately nourished patients. other studies have reported that malnourished elderly are significantly more likely to acquire nosocomial infections and are significantly more likely to acquire pneumonia compared with well-nourished elderly. , better nutrition may play a major role in reducing nosocomial infection in acutely ill hospital patients who cannot eat by the regular oral route. in recent years, 'immunonutrition' enteral formulas containing larger quantities of antioxidant vitamins, zinc and other trace metals, omega- fatty acids and amino acids like glutamine have become more commonly used. meta-analysis has calculated that enteral immunonutrition in hospitalised patients is associated with a % lower risk of nosocomial pneumonia ( studies, p ¼ . ), a % lower risk of bacteraemia (nine studies, p ¼ . ), a % lower risk of abdominal abscesses (six studies, p ¼ . ), and a % lower risk of urinary tract infections ( studies, p ¼ . ) compared with patients receiving standard enteral formula. many hospitalised patients develop serious c. difficile infections after several antibiotic courses. probiotic bacteria and yeasts can be helpful in preventing or clearing infections by c. difficile and other bacteria. meta-analysis of studies reported that supplemental saccharomyces boulardii, lactobacillus spp. or bifidobacterium spp. were associated with significantly lower levels of antibiotic-associated diarrhoea. meta-analysis of six studies indicated that s. boulardii was effective in reducing the incidence of c. difficile diarrhoea. yoghurt containing active lactobacillus spp. has been found to be effective in preventing or clearing infections caused by c. difficile and vre in hospitalised patients. , housing patients in separate rooms, pathogen surveillance and 'search and destroy' strategies for nosocomial infections housing patients in separate rooms may reduce risk of hais. a quebec observational study of a bed icu measured rates of nosocomial infections during a . -year period. the incidence of nosocomial mrsa, pseudomonas and candida infections per patient-days were respectively . , . , . for patients housed in multiple patient icu rooms and . , . , . for patients housed in single rooms (p < . for all three comparisons). however, another study conducted in two british icus reported that isolating patients had little effect on mrsa acquisition rates. screening patients at hospital admission for common pathogens like s. aureus may be an effective way to prevent the pathogens from becoming established infections. a recent study estimated the health and economic impacts of preadmission s. aureus screening and subsequent decolonisation therapy for the . million us patients who undergo elective surgery annually. an s. aureus screening and decolonisation protocol for all elective surgical patients was projected to save inpatient lives and save $ million in net medical costs annually. for some nosocomial infections such as mrsa, 'search and destroy' control strategies have been developed. such search and destroy protocols involve a number of interventions including: (i) active surveillance which includes a nasal swab for mrsa cultures upon patient admission and every third day throughout hospitalisation. (ii) contact precautions including proper gloving, gowning and mask use. (iii) treatment of carriers with antibiotics and surface disinfectants. (iv) microbiological controls: starting h after the end of treatment three control samples were taken at colonised sites. if mrsa was isolated, treatment was resumed. (v) isolation or cohorting: mrsa positive patients were placed in separate rooms or cohorted with other patients with mrsa infection. (vi) educational programme on infection controls for healthcare workers. such a search and destroy mrsa programme was found to reduce mrsa infection in a spanish icu from . to . cases per patient-days (p ¼ . ). the netherlands has been addressing the mrsa problem since the s with a programme of patient isolation, search and destroy protocols and restrictive antibiotic usage. , by , mrsa comprised less than % of clinical s. aureus specimens collected in netherlands hospitals, while mrsa comprised %, %, % and % of clinical s. aureus cultures respectively in belgium, france, germany and the usa. molecular biology techniques such as pcr and gel electrophoresis techniques have been very useful in hospital surveillance and tracking of nosocomial infections. such techniques can be used to test samples from patients, staff and environmental substrates. implementation of an enhanced infection control programme which included molecular typing to assess microbial clonality was associated with an % reduction of nosocomial infections in a large hospital (p ¼ . ). this infection control programme was calculated to annually prevent nosocomial infections and save us$ . million in net healthcare costs. inadequate nurse staffing may increase risk for nosocomial infections. a us study of patients in icu units served by nurses measured rates of nosocomial infections and nurse staffing levels. icu units with higher nurse staffing had significantly lower rates of centralline-associated infections, ventilator-associated pneumonia, ducibitus ulcers and day mortality (p < . for all comparsions). a -month study from a -bed taiwanese hospital reported that higher nursing staff levels were associated with significantly lower levels of urinary tract infections (p < . ), respiratory infections (p ¼ . ) and pressure ulcers (p ¼ . ). public reporting of hais may provide a good incentive for hospitals to reduce nosocomial infection rates. in the usa, since , a number of states have passed laws mandating reporting of hai rates. there is some concern that such reporting of infections may undercount the true nosocomial infection rates. there is also concern about the need for proper adjustment of infection rates for factors such as age, chronic health problems and preadmission health of the patients received by specific hospitals. many administrative problems have beset these mandating laws. for example, the state of illinois passed the 'hospital report card act' (sb ) in mandating public reporting of several types of nosocomial infections. however, by january none of the reporting systems had been implemented. about e % of hospital-acquired urinary tract infections originate from urinary catheters. urinary catheters should be used only if necessary and should be removed as soon as practicable. , some studies have indicated that early removal of urinary catheters can reduce urinary tract infection rates by up to %. about % of urinary hais have been linked to improper handwashing and poor aseptic techniques in cleaning the urinary meatus area and inserting and maintaining the urinary catheters. however, studies have shown that vigorous twice-daily meatal cleaning does not seem to reduce urinary infection rates. many studies and meta-analyses have reported that silver alloy/silver hydrogel-tipped urinary catheters significantly reduce urinary tract infections. a meta-analysis of eight published studies reported that use of silver-tipped urinary catheters was associated with a mean % reduction of urinary tract infections ( % ci: . e . ). a more recent study reported that using silver-tipped catheters (both short-and long-term users) was associated with a % reduction in urinary tract infections. none of the bacteria and yeasts isolated from these silver-tipped catheters developed any resistance to silver. these studies have also indicated that while silver-tipped urinary catheters cost more than standard catheters, the saving in nosocomial urinary infections far more than pays for the extra cost of the silver-tipped catheters. , however, according to meta-analysis of urinary catheters inserted for less than days, post- studies have reported that silver-tipped catheters reduce urinary tract infections by a smaller margin than in pre- studies. the reason for this possible reduced effectiveness of silver-tipped catheters after is not known. the use of nitrofurazone-coated catheters was associated with a e % reduction in urinary tract infections in three recent published studies. a number of interventions can significantly reduce the morbidity and mortality of central venous catheter (cvc)-related infections. cvcs should be used only when necessary and should be removed as soon as practical, since longer catheterisation periods significantly increase risk for bloodstream infection. three studies reported that the use of extensive barrier precautions (long-sleeved gown, sterile gloves, mask, cap and large sterile sheet drape) when inserting a central line was associated with a significantly lower rate of bloodstream infections compared with when only gloves and a small drape were used. these studies also found that extensive barrier precautions were very cost-effective in terms of saving costs of nosocomial infections. other studies have reported that subclavian central venous insertion is associated with significantly lower bloodstream infection rates compared with femoral insertion. meta-analysis of eight studies reported that use of antiseptic chlorhexidine-containing solutions to prepare the catheter site was associated with a % lower risk of catheterrelated bloodstream infections compared with when iodine based solutions were used ( % ci: . e . ). the institution of multiple interventions at the same time ('bundling') may be the best strategy to reduce cvc-related infections. a huge study of catheter-related bloodstream infections was conducted in icus and analysed patientcatheter-days. an education programme was conducted in icus that included hand washing, using extensive barrier precautions when inserting a cvc, cleaning skin with chlorhexidine, and avoiding the femoral site and the use of unnecessary catheters. catheter-related bloodstream infections were . / catheter-days at baseline to . / at e months follow-up ( % reduction, p < . ). another study reported that a multidimensional educational programme for central catheter insertion and maintenance reduced bloodstream infections from . to . / catheter-days ( % reduction, p < . ) and produced a net saving of from $ . to . million in months secondary to reduced bloodstream infection rates. the use of coated cvcs can also significantly reduce the risk of nosocomial infections. a twoyear study at a large michigan hospital reported that using chlorhexidine/silver sulfadiazene-coated catheters reduced bloodstream infections in hospitalised patients by % (p < . ). metaanalyses and many studies have reported that the use of cvcs coated with chlorhexidine/silver sulfadiazene significantly reduces rates of catheterrelated infections and significantly lowers hospital costs. cost savings were estimated to be $ for each chlorhexidine/silver sulfadiazene-coated catheter used. use of new agents such as lysostaphin in catheters and catheter lock solutions may also reduce infection. lysostaphin is an enzyme which effectively breaks up and kills staphylococci in biofilms on catheters. haemodialysis patients are at high risk of many nosocomial infections including s. aureus, coagulasenegative staphylococci, many types of gramnegative bacteria and candida. temporary catheters have the greatest risk of infection and should not be used any longer than necessary. a review of eight studies calculated that mean rates of bacterial infections in haemodialysis patients were about . / days when temporary catheters were used, . / days with cuffed temporary catheters, . / days with polytetrafluoroethylene grafts, and . / days when arteriovenous fistulas are used. renal patients are at significant risk for hepatitis c (hcv) transmission from haemodialysis procedures. risk of hcv transmission can be significantly reduced by using separate haemodialysis machines and equipment for hcv þ and hcv À patients, proper gloving and other barrier precautions by healthcare workers, proper cleaning of machines and sending all tubing and dialysis units for either disposal or disinfection and reprocessing after each use. a spanish study reported that hcv þ prevalence fell from . % ( patients) in to . % ( patients) (p < . ) in following the institution of universal precautions and increased cleaning along with the separation of hcv þ and hcv À patients. no serconversions were noted during this time in hcv À haemodialysis patients following separation of hcv þ and hcv À haemodialysis. preventing ventilator-associated pneumonia although prompt use of proper antibiotics is the cornerstone for treating ventilator-associated pneumonia (vap), there are many non-pharmacological interventions which can significantly reduce risk of vap incidence. longstanding methods of reducing risk of vap include: (i) avoiding tracheal intubation whenever possible and using noninvasive positive pressure ventilation instead; (ii) placing the patient in semi-erect position of e above horizontal reduces risk of aspiration-related vap; and (iii) using enteral feeding rather than parenteral feeding whenever possible. recent meta-analysis has also indicated that the following interventions are associated with significantly lower levels of vap: (i) kinetic bed therapy ( studies; rr: . ; % ci: . e . ); (ii) subglottic secretion drainage (five studies; rr: . ; % ci: . e . ); (iii) heat and moisture exchangers vs heated humidifiers (eight studies; rr: . ; % ci: . e . ); (iv) oral decontamination with chlorhexidine (seven studies; rr: . ; % ci: . e . ). five studies employing multiple interventions were able to significantly reduce rates of vap by e %. one of these studies involved four hospitals and employed an intensive educational programme for icu nurses and respiratory therapists coupled with posters and fact sheets posted in the icu. following these broad based interventions, vap rates fell from . to . / ventilator-days ( % reduction, p < . ). about e % of all surgical patients develop a significant infection at the wound site. while antibiotics play a major role in preventing and treating surgical infections, many other factors are important in preventing surgical infections. higher rates of surgical infections are associated with operations of two or more hours, a contaminated or dirty procedure, or inadequate scrubbing procedures. traditionally patients have been shaved at surgical sites, but it is now believed that clipping hair is better since shaving leaves small cuts in the skin. a review of three trials involving surgical patients reported that there were significantly more surgical site infections when patients were shaved versus clipped (rr: . ; % ci: . e . ). cleaning surgical sites with antiseptics such as iodine compounds or chlorhexidine has long been recommended to reduce risk of surgical infection. however, meta-analysis of six studies found that bathing or swabbing sites with % chlorhexidine solutions was associated with only a marginal decline in surgical site infection rates compared with bathing with plain soap or placebo solutions (rr: %; % ci: . e . ). warming the patient before or during surgery has also been shown to significantly reduce rates of surgical infection. warming may reduce surgical infection rates by improving blood circulation and immune function in the surgical areas. an ultraclean air-filtered operating room coupled with use of whole-body ventilated exhaust suits by operating personnel was associated with a % drop in deep sepsis rates compared with standard operating room procedures (p < . ). multiple interventions simultaneously may prove to be the most effective way to reduce surgical infections. institution of a comprehensive surgical infection control programme was associated with a % drop in surgical-related infections for coronary artery bypass graft patients (or: . ; % ci: . e . ). this infection control programme included prospective surveillance and reporting, chlorhexidine showers, discontinuation of shaving, elimination of ice baths for cardioplegia solution, limitation of operating room traffic, reducing use of flash sterilisation and elimination of postoperative tap-water wound washing for four days. laparoscopic surgery should be done instead of open surgery whenever possible, since laparoscopic surgeries generally have significantly lower rates of infection, adhesions and other complications. many studies and meta-analyses have reported much lower infection rates when laparoscopic surgery is performed instead of open surgery for many types of abdominal procedures including perforated peptic ulcer surgery, cholecystectomy, splenectomy, lysis of small intestine adhesions causing obstruction, appendectomy, rectal cancer surgery and ventral hernia repair. e relatively few studies have been conducted involving sterilisation of surgical instruments and medical devices such as endoscopes. cleaning must also precede sterilisation or high-level disinfection. surgical and medical instruments may be sterilised or disinfected by a number of methods including autoclaving, ethylene oxide chambers, or solutions containing phenolics, aldehydes, quaternary ammonium compounds, hydrogen peroxide, peracetic acid or chlorine compounds. all of these techniques have advantages and disadvantages. autoclaving provides excellent sterilisation but not all equipment can withstand the heat. ethylene oxide chambers provide excellent disinfection but they must be monitored for potential ethylene oxide gas leaks. disinfectant aldehydes such as glutaraldehye and ortho-phthaladehyde can cause respiratory, skin and eye irritation. peracetic acid systems provide good sterilisation but are relatively expensive and can only be used for immersible instruments. preventing waterborne hospital infections a number of interventions have been proven effective in reducing rates of hospital waterborne infections. numerous studies have found that replacing tap water with sterile water for drinking, bathing and procedures can significantly reduce rates of many hospital infections including crytosporidium, legionella, aeromonas and stenotrophomonas. sterile sponges can be used for bathing. boiling and water filtration in hospital water systems can also sterilise water, but these systems need to be monitored closely because many problems can develop which cause these systems to fail. daily cleaning of patient shower areas with a detergent and phenolic compound has been shown to significantly decrease airborne levels of moulds including aspergillus. heating water to more than c has been shown to significantly reduce levels of legionella spp. in storage tanks and hospital water systems; however, water heating alone will not usually eliminate all legionella in a contaminated hospital water system. some studies have found that the uv-light water treatment can greatly reduce levels of legionella in hospital water systems. copperesilver-based ionisation systems can also significantly reduce waterborne concentrations of legionella, moulds and gram-negative bacteria such as p. aeruginosa and actinetobacter baumannii. e a spanish hospital saw legionella infection rates fall from . to . cases per discharges following installation of a copperesilver ionisation system (p < . ). routine surveillance of hospital water supplies for legionella is highly recommended in cases of confirmed legionella infections; however, it is controversial as to whether such routine testing is needed in hospitals with no legionella infection history. , all water leaks and water damage should be repaired and remediated within h to prevent growth of pathogenic bacteria and moulds. hospitals should avoid using indoor decorative fountains since they encourage legionella and the splashing water facilitates ready aerosolisation of the organism. hepa filtration is relatively inexpensive and probably should be used for all hospital rooms. various studies have found that the hepa filtration in hospitals can significantly reduce airborne levels and/or infection rates for several aerosolised pathogens. many studies have reported that the hepa filters in patient rooms can significantly reduce both airborne aspergillus concentrations and rates of human aspergillus infections. e meta-analysis of six non-randomised controlled trials reported that hepa filtration for neutropenic patients was associated with a significant drop in mortality due to mould infections (rr: . ; % ci: . e . ). meta-analysis of six randomised controlled studies reported that hepa filtration for neutropenic patients was associated with only a marginal drop in overall mortality (rr: . ; % ci: . e . ). use of portable hepa filters has been found to significantly reduce airborne levels of mrsa and p. aeruginosa in hospitals. , a porcine study reported that hepa filtration was associated with significantly lower rates of porcine respiratory syndrome virus (prsv). hepa air filtration has been shown to reduce airborne concentrations of droplet nuclei (which transport tuberculosis) by %. recently, a new hospital air filtration system has been developed by airinspace technologies (montigny le bretonneux, france). this portable immunairä system forms a protective hood around the patient, filters air at air changes per hour and uses a 'cold plasma' system to destroy microbes. early tests have indicated that such a system has a more than % single-pass efficiency in destroying bacteria, viruses and moulds such as aspergillus. more study of this and other air filtration systems is needed. provision of adequate outdoor air ventilation rates is also essential to dilute out and control hospital pathogens. a study with army recruits reported significantly higher rates of acute respiratory disease when housed in poorly ventilated barracks compared with well-ventilated barracks. the american society for heating, refrigerating and air conditioning engineers (ashrae) has proposed standards of at least four outdoor air changes per hour (ach) for hospital rooms, outdoor ach for operating rooms and six outdoor ach for icus. , hospitals undergoing construction or renovation have increased dangers for airborne and dustborne pathogens and may require additional outdoor ach as well as barrier protections. , uv light machines in rooms or in ventilation systems can effectively kill mycobacteria, legionella and many viruses, but uv light is not effective in killing many species of bacteria and moulds. special interventions for control of tuberculosis tuberculosis (tb) remains a serious health problem in both the developed and developing world. recent cdc guidelines have recommended a number of administrative, engineering and personal protection measures to control tb spread in healthcare settings. recommended administrative controls include tb testing for all patients at risk of tb, implementing a written tb control plan in the hospital and housing infected patients in separate rooms. all rooms housing tb patients should have at least outdoor ach, have a negative pressure of at least . inch water, and the rooms of patients with actual or suspected tb should be checked visually with tests such as smoke tests. hepa air filters in patient rooms and uv irradiation in the ventilation systems or upper part of rooms is also strongly recommended to reduce airborne tb levels. hepa masks or other respiratory protection need to be worn by healthcare workers and visitors to rooms of infectious tb patients. proper cleaning and disinfecting of instruments used by tb patients are also essential. controlled studies for individual interventions of tb control programmes are lacking. however, risk of tb transmission can be greatly reduced when many infection control measures are applied simultaneously. a -bed hospital in atlanta, georgia, used a variety of controls for tb including administrative (patient isolation, staff tb education programme, tb tests to staff every six months and hiring a nurse epidemiologist), negative-pressure tb rooms, and hepa masks by all healthcare workers in respiratory protection areas. over a -month period, the number of tb exposure incidents fell from . to . per month (p < . ). the rate of tuberculin skin test conversions among healthcare workers also fell from . % to . % in this period (p < . ). many non-pharmacological interventions have been shown to significantly reduce rates of hais, but are often overlooked in clinical practice. widely varied interventions such as proper hand washing, better nutrition, housing patients in separate rooms, sufficient numbers of nursing staff, coated urinary and cvcs, hepa air filters, copperesilver water ionisation and numerous interventions for ventilated and surgical patients have all been documented to significantly reduce risk of nosocomial morbidity and/or mortality. many of these studies have also indicated that these infection control interventions will more than pay for themselves in terms of reduced total medical costs. the hospital environment is a complicated ecosystem and many interventions are needed for optimal infection control. while many hospitals are using a number of these infection control strategies, relatively few hospitals are employing most of the broad range of infection control methods available today. multiple interventions ('bundling') often give better results than single interventions. most bundling studies have used only two to five infection control interventions at the same time. larger interventional studies should be undertaken which employ large numbers of infection control methods simultaneously. such multifaceted infection control protocols will probably result in larger declines in nosocomial infection rates than strategies employing only one to five interventions. however, it is difficult to sort out the efficacy of individual interventions when many interventions are simultaneously used. aboelela et al. have suggested that in studies with many interventions, groups of several interventions or bundles can be studied as one intervention. current levels of multidrug-resistant bacteria will increase in the future as antibiotics are heavily used in both human and veterinary medicine and relatively few new antibiotics are being developed. multifactorial non-pharmacological infection control strategies will not only substantially reduce the numbers of nosocomial infections, but should also significantly reduce hospital antibiotic usage. lower overall antibiotic use will reduce risk of antibiotic-resistant organisms and should improve efficacy of antibiotics given to patients who do acquire nosocomial infections. multiple-intervention infection control strategies should significantly reduce mortality, morbidity and overall medical costs. there needs to be more support for improved hospital infection control on the part of patient advocacy groups, nursing, medical and public health associations, hospital administrators, health insurance companies, business and labour groups, the media and public officials. research and implementation of multifaceted hospital infection control strategies should clearly be one of the highest priority items facing healthcare in the early st century. estimating health-care associated infections and deaths in u.s. hospitals invasive methicillin resistant staphyloccocus aureus infections in the united states proportion of hospital deaths potentially attributable to nosocomial infections the costs of nosocomial infections epidemiology and economic evaluation of severe sepsis in france: age, severity, infection site, and 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particles in the size range of myobacterium tuberculosis evaluation of a new mobile system for protecting immune-suppressed patients against airborne contamination building-associated risk of febrile acute respiratory diseases in army trainees control and management of hospital water quality ventilation for acceptable indoor air quality control and prevention of healthcareassociated tuberculosis: the role of respiratory isolation and personal respiratory protection guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings preventing the nosocomial transmission of tuberculosis effectiveness of bundled behavioural interventions to control healthcareassociated infections: a systemic review of the literature acknowledgements i thank all of the infection control researchers who have published useful papers. none declared. none. key: cord- - r qmc authors: liao, yunfei; feng, yong; wang, bo; wang, hanyu; huang, jinsha; wu, yaxin; wu, ziling; chen, xiao; yang, chao; fu, xinqiao; sun, hui title: clinical characteristics and risk factors for developed covid- patients transferring to designated hospital from jianghan fangcang shelter hospital: a retrospective, observational study date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: r qmc background the outbreak of coronavirus disease (covid- ) has become a world-wide emergency. fangcang shelter hospitals have been applied in covid- to ease ongoing shortage of medical resources in wuhan since february . methods this study enrolled all cases (no= ) with mild or moderate type of covid- in fangcang shelter hospital of jianghan in wuhan from feb th to mar th, . diagnosis of covid- was based on the national health commission of china. epidemiological history, comorbidity, vital signs, symptoms and signs were recorded in detail. laboratory tests included biochemical indicators and nucleic acid tests by throat swabs have been performed as well. findings a total of patients reached the criteria of isolation release. meanwhile, patients have been transferred to the designated hospitals for further treatment, including severe type, fever more than days, and severe comorbidity. the case-severity rate (rate of mild or moderate type transforming to severe type) was . % in the shelter hospital. the patients from mild or moderate type to severe type showed the following clinical characteristics: the median incubation (onset to shelter) period was days; they were all symptomatic at admission; fever, cough, and fatigue were the most common symptoms; hypertension, diabetes and coronary heart diseases were common co-morbidities; most of the patients had elevated levels of crp at ill onset with . % over mg per l; bilateral distribution and ground-glass opacity were the most common manifestations in chest ct. interpretation the potential risk factors of fever, fatigue, high level of c-reactive protein were the risk factors to identify the progression of covid- patients with mild or moderate type. fangcang shelter hospitals have substantially reduced the time from the onset of severe symptoms transfer to a designated hospital. early application of the fangcang shelter hospital may contribute to decrease the ratio of mild transforming to severe patients. funding no specific grant from any funding was applied to this research. the coronavirus disease (covid - ) has been shown the ability of human-to-human transmission and become a world-wide emergency. the world health organization (who) has recently declared covid- outbreak in several countries. since january , thousands of new patients have been diagnosed every day, which requires enormous medical resources. the surge of infections placed huge pressure on the national medical system. the fangcang shelter hospitals in wuhan were large-scale, temporary hospitals, rapidly built by converting existing public venues, such as exhibition centers and stadiums, into health-care facilities. they were served to isolate patients with mild or moderate covid- from their families and communities, while providing basic medical care, disease monitoring, food, shelter, and social activities. fangcang shelter hospitals presented five essential functions: isolation, triage, basic medical care, frequent monitoring and rapid transfer, and essential living and social engagement. patients with mild or moderate covid- who met additional admission criteria were isolated and treated in the fangcang shelter hospitals, whereas patients with severe or critical covid- received medical care in traditional hospitals. [ ] [ ] [ ] [ ] fangcang shelter hospitals provide basic medical care and monitored the progression of disease. as some patients remain experienced progression of covid- or development of severe chronic diseases, they were transferred in a timely manner to the designated higher-level hospitals. the clinical characteristics of patients transferred to the designated hospital were important for the revision of admission criteria of covid patients in fangcang shelter hospitals. the case-severity (from mild or moderate to severe case) rate was an important benefit index for therapeutic efficacy assessment in shelter hospital. dynamic observation the risk factors of mild to severe patients is contribute to great value for early prognosis and treatment. therefore, a retrospective review of overall medical record was performed in fangcang shelter hospital of jianghan, which received the largest number of patients among fangcang shelter hospitals in wuhan. a total of all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint cases with mild or moderate covid- were included and cases transferred to the designated hospital were analyzed. the risk factors of patients from mild or moderate to severe case were detected as well. the jianghan fangcang shelter hospital opened on the th feb and closed on the th mar . a total of cases with covid- were enrolled in jianghan fangcang shelter hospital of wuhan from feb th to mar th, . the admission criteria of fangcang shelter hospital were covid- patients with mild or moderate type. diagnosis of covid- was based on the national health commission (nhc) of the people's republic of china. the clinical classifications are as follows: ( ) before admission into fangcang shelter hospital, all suspected patients of covid- were taken upper respiratory throat swab samples. chest ct scan was performed as well. clinical and laboratory findings were recorded and carefully checked. laboratory tests included biochemical indicators, blood routine, and c-reactive protein (crp, normal range - mg per l). epidemiological history, comorbidity, vital signs, symptoms and signs were recorded in detail. patients meeting the diagnosis of mild or moderate type were admitted to the mobile cabin hospital. two reviewers (hw, jh) independently checked all collected data. in case of disagreement among two reviewers, consensus was conducted by a third reviewer (yw). during the following days in fangcang shelter hospital, the patients were re-examined for laboratory and imaging examination, and recorded symptoms, signs, treatments and outcome events. the throat swab specimens of rt-pcr test and chest ct scan were performed according to the symptoms and signs. the clinical outcomes of patients in the mobile cabin hospital were divided into three ways. they were the patients transferred to the designated hospitals for further treatments, the patients reaching the criteria of isolation release, and the patients kept treatment in the mobile cabin. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint throat swab samples were stored in virus transport medium and transported to wuhan union hospital for laboratory diagnosis. throat swab specimens of all patients were subject to real time pcr tests by amplifying orf ab gene and n gene of sars-cov- (biogerm, shanghai, china). the ct examinations were carried out with a -row multidetector ct scanner (μct , shanghai lianying medical technology co., ltd) using the following parameters: detector collimation widths × . mm, × . mm, × . mm, and × . mm; and tube voltage kv. continuous variables were represented by mean (standard deviations, sds) or median (interquartile range, iqr) as appropriate, categorical variables were described as number (%). significant differences between the groups (mild patients and mild to severe patients) were compared by student t test, mann-whitney u test, chi-square or fischer exact test where appropriate. in addition, we also used univariable and multivariable logistic regression models to explore potential risk factors related to mild developing to severe. considering the total included severe patients (n= ) in this study and in order to avoid over-fitting in our multivariable logistic regression models, we chose five variables for this model based on significant results (p< . ) from the univariate regression. the results were present as odds ratio (or) [ % confidence interval]. because all tests were two-sided, p value less than . was considered statistically significant. analyses were performed using spss . statistical package. according to the spatial structure, jianghan fangcang shelter hospital was is divided into districts. each district contains about rooms and each room had - beds. about - patients were kept in each district per day. at least one nurse was assigned to each room and the distance between the neighboring beds was . - . meters in the room. there were about doctors and nurses on duty by turns in each distract, ensuring that doctors and nurses were available hours a day. doctors and nurses carried out the daily round separately. the digital ratio of patients to doctors and nurses was about . ( / ). after admission, all patients were given antiviral therapy (e.g., abidor hydrochloride) and other individualized treatments (such as antibiotics, antihypertensive and hypoglycemic therapy) according to the doctor's advice and nhc's interim guidelines. among enrolled patients, the age range was from to years, and . % were men. from feb th to mar th, patients were transferred to designated hospitals for further treatment. meanwhile, the other patients reached the criteria of isolation release or discharge, (figure ). among patients transferring to the designated hospitals, . % patients with severe type from mild or moderate type ( cases), . % ( cases) patients with body temperature more than . °c for days or more after treatment, . % ( cases) patients with cancer or severe liver/kidney/heart disease, . % ( cases) patients with the persistent positive nucleic acid testing after weeks treatment, and . % ( cases) patients with other reasons (including new onset severe symptoms or mental illness or tremendous mental pressure or pregnant woman). the basic clinical characteristics of patients transferring to the designated hospitals were in table . the case-severity rate was identified as the proportion of mild or moderate type progressing to severe type in this study. a total of patients have progressed from mild or moderate type to the all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . the risk factors from univariable analysis with statistic difference were included in multiple regression analysis. compared with mild or moderate patients, odds of mild-to-severe were higher in patients with cough and fatigue in univariable analysis. patients of fever on cabin admission, and high level of crp (≥ mg per l) were also associated with mild-to-severe type (table ) . furthermore, the shelter period of patients less than days was related with high odds transforming severe type. we then included those patients with complete data for top five most statistically significant variables in the multivariable logistic regression model. the results showed that patients with fever on admission of fangcang shelter hospital, less shelter period ( days), fatigue and high level of crp (≥ mg per l) were associated with increased odds of mild-to-severe type (table ) . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . the novel coronavirus covid- rapidly spread globally, affecting now nearly every continent. the number of patients with severe type determines the final mortality rate of covid- . in this study, the case-severity rate was observed with a relatively large prospective cohort, which might be a valuable complement to the characteristics of covid- . in the fangcang shelter hospital of jianghan, about . % of the patients transformed to severe, which was significantly lower than the % cases classified as severe or critical in the spectrum of covid- disease. , furthermore, the median incubation (onset to shelter ) period was days and over half of the patients were less than days. meanwhile, the median time of staying in mobile cabin was days, ( . %) less than days, . % between - days, . % more than days. this suggests that the difference in incubation time at the onset of the disease is more indicative for the mild or ordinary patients transforming to severe type. the important function of fangcang shelter hospital is frequent monitoring and rapid referral. the jianghan fangcang shelter hospitals were integrated into the overall health systems of wuhan via simple pathways of transfer. overall, fangcang shelter hospitals had substantially reduced the time from the onset of severe symptoms to admission to a designated hospital, compared to the alternative of home isolation. , previously, older age (over years) was associated with higher odds of progression to severity of covid- , which also has been reported as an important independent predictor of mortality in sars and mers. [ ] [ ] [ ] in order to better display the clinical characteristics of mild or moderate to severe patients below years old, age-and sex-matched mild or moderate patients stayed in the fangcang shelter hospital at the same time. in this study, several factors in adults who were hospitalized in fangcang shelter hospital were associated with mild progressed to severe covid- . in particular, all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint patients aged - years constituted the highest proportion within the severe group in this study. it have reported that % of covid- death cases previously suffered - underlying diseases, a majority of which were diabetes and cardiovascular diseases. in line with above evidence, our study also found that . % of the mild to severe patients had - basic diseases, such as cardiovascular diseases, cerebrovascular diseases and endocrine system diseases. the most common symptom on admission was fever and . % ( / cases) mild to severe patients got fever on cabin admission. however, some patients with covid- did not have fever abnormalities on initial presentation, which has complicated the diagnosis. in this study, . % patients were with peek temperature more than . °c, while . % of patients were once with fever over . °c. high fever was associated with the development of severity and critical death. [ ] [ ] [ ] therefore, keep vigilance of those mild patients whose peak temperature over . °c. they were quickly transferred to designated higher-level hospitals once the blood oxygen saturation of those patients was less than % in fangcang shelter hospital of jianghan. for more specialized monitoring, chest imaging and laboratory services were applied in the fangcang shelter hospitals. ground-glass opacity ( / , . %) was the most common morphological depiction in ct scan on admission. however, only . % of patients showed multiple lesions, . % patients presented bilateral lesions. compared with mild patients, most severe patients took ct scan in this study within seven days. the lesions that were present in asymptomatic individuals progressed to bilateral diffuse disease with consolidation around day after the symptom onset. [ ] [ ] [ ] the predominant ct pattern was unilateral and multifocal ground-glass opacities in early stage, then lesions quickly evolved to bilateral, diffuse ground-glass opacity in later stage. however, those characteristics were not consistent with what we had expected in this study. therefore, the value of lung ct in determining the prognosis of mild covid- patients still needs further research. meanwhile, most of the patients had elevated levels of crp at ill onset with . % over mg/l. similarly, compared to mild or moderate cases, severe cases more frequently had higher levels of crp. , - therefore, imaging and laboratory results could contribute to make the quick decision of transferring to the designated hospitals. notably, several clinical manifestations were identified as risk factors for progression from mild to severe in the univariate logistic regression analysis. we found that fatigue on admission was associated with increased odds of mild to severe (table ) . furthermore, . % patients had the manifestation fatigue. report had showed that % severe survivors still had cough on discharge and % severe non-survivors still had cough at the time of death. , in this study, we found cough is associated with case-severity outcome of covid- in univariable analysis. less common symptoms include a sore throat myalgia or arthralgia, poor appetite. however, respiratory system affection remained as the primary symptom. , - overall, onset of fever and fatigue symptoms should be closely monitored among cabin hospital, more attention should also be paid to patients on those isolation patients at home. moreover, the shelter period of patients less than days was related with high odds transforming severe type. there were some limitations in this study. firstly, due to limited medical resources in fangcang shelter hospital, not all laboratory tests have been performed, such as lactate dehydrogenase, il- , and serum ferritin. secondly, the study was limited to the patients with mild or moderate infection in a single center study. however, we focused on the therapeutic and preventive value of mobile cabin hospital in the covid- patients with mild or moderate type. the study population is representative of cases mild developed to severe in wuhan. to the best of our knowledge, this is the largest all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint retrospective cohort study to disclose the clinical characteristics and risk factors for developed covid- patients transferring to the designated hospital in fangcang shelter hospital. overall, fangcang shelter hospitals have substantially reduced the time from the onset of severe symptoms to admission to a designated hospital. early application of the fangcang shelter hospital may contribute to alleviate the shortage of medical resources and decrease the ratio of severe patients. we believe that the information in the article will provide valuable data for other countries facing the covid- pandemic, when they are establishing the national public health emergency management for covid- . hs designed the study and had full access to all of the data in the study and was responsibility for the integrity of the data and the accuracy of the data analysis. hw, jh, yw, zw, xc, cy and xf collected data. bw, yl and yf analyzed data. yl and yf wrote the article. all authors critically revised the manuscript for important content and gave final approval for the version to be published. we declare no competing interests. covid- : too little, too late? national health commission of the people's republic of china. updates on the epidemic (in chinese) fangcang shelter hospitals: a novel concept for responding to public health emergencies novel coronavirus pneumonia emergency response key places protection and disinfection technology team ccfdcap. health protection guideline of mobile cabin hospitals during novel coronavirus pneumonia (npc) outbreak the national health commission of the people's republic of china. manual for working in fangcang shelter hospitals practice and thinking of the informationized for disease control and 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course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study. the lancet respiratory medicine time course of lung changes on chest ct during recovery from novel coronavirus (covid- ) pneumonia radiological findings from patients with covid- pneumonia in wuhan, china: a descriptive study covid- pneumonia: what has ct taught us? the lancet no specific grant from any funding was applied to this research. the jianghan fangcang shelter hospital was managed daily by union hospital, tongji medical college, huazhong university of science and technology and twenty-one medical teams from other provinces associated with six local hospitals participated in the work. we thank staff in the jianghan fangcang shelter hospital, including doctors, nurses, medical technician, hospital infection-control staff and administrative logistical staff. key: cord- -ukz hnmy authors: nan title: poster date: - - journal: j frailty aging doi: . /jfa. . sha: doc_id: cord_uid: ukz hnmy nan background: frail older adults are at increased risk of postoperative morbidity compared with robust counterparts. simple methods testing frailty such as grip strength have shown promising results for predicting post-operative outcome, but there is a debate regarding the most appropriate and precise frailty assessment method. objectives: we compared the predictive value of multidimensional frailty score (mfs) with grip strength or conventional risk stratification tool for predicting postoperative complications in older hip fracture patients. methods: from january to december , older hip fracture patients (age >= years) who underwent surgery and comprehensive geriatric assessment (cga) were retrospectively included for analysis. hip-mfs was calculated based on the cga with component of sex, charlson comorbidity index, serum albumin, koval grade, cognitive function, risk of falling, mini-nutritional assessment and mid-arm circumference. grip strength was also measured before surgery. the primary outcome was a composite of postoperative complications (e.g. pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission). results: among patients (mean age . ± . years, . accordingly, grip strength could be used for screening tool to identify high-risk patients who need for further comprehensive geriatric assessment among older hip fracture patients. information and data suspected of post-operative infections. the diagnostic criteria of infection dealt with grade ii or more of clavien-dindo classification. diagnosis of infectious disease was made with reference to vital sign, blood test, imaging and bacterial test results. surgical site infection (ssi) was evaluated based on the infectious control team surveillance. results: elderly patients were registered with necessary data. the average age was . years, males and females were included. in the sarcopenia evaluation, there were cases without sarcopenia and cases with it. cases developed some infectious complications postoperatively. the types of infectious complications (including duplication) were cases of some surgical site infections including suture failures, of pneumonia, of urinary tract infection, of pneumonia and cases of sepsis in patients. infectious complications occurred in cases in the non-sarcopenia group and in the sarcopenia group (p = . ). the average postoperative hospitalization was . days overall, . in the group with postoperative infectious complications, and . in the group without sarcopenia. conclusion: in this study, there was no relation in the incidence of postoperative infections and preoperative sarcopenia. however, the postoperative hospitalization in the group with postoperative infectious complications was almost tripled. background: hypertension is one of the major risk factors for cardiovascular disease. lowering blood pressure is effective for preventing stroke, heart failure (hf), myocardial infarction and possibly dementia. in france, the prevalence of elderly people treated for hypertension rising leading to a possible increase of potentially inappropriate antihypertensive prescribing (piap) that may cause adverse drug events. objectives: to identify associated factors with potentially inappropriate antihypertensive prescribing (piap) in elderly people. methods: we conduct a retrospective observational study based on a cohort from geriatric day hospital for assessment of frailty and prevention of disability in toulouse, between january and april . piap was defined with several explicit criteria: the european list of potentially inappropriate medications, alert and control of iatrogenesis (aci) criteria by the french health authority, the french society of hypertension guidelines, screening tool of older people's potentially inappropriate prescriptions (stopp) version two and summary of product characteristics. the piap has been considered as a binary variable (logistic regression) then as a counting variable by number of nonconformities on antihypertensive drugs (negative binomial regression). results: among the patients, % had piap. frailty, polypharmacy, history of angina and hf are associated with a higher risk of piap. similarly: frailty, polypharmacy and history of angina are associated with an increase in the number of non-conformities antihypertensive drugs. analysis of subgroup of patient hf -piap indicated that % had aci criteria whose % the aci criteria " antihypertensive drugs or more" and % the aci criteria " diuretics or more". analysis of subgroup of patient history of angina -piap indicated that % had stopp criteria, focused on loop diuretics. conclusion: our work suggests that some elderly people characteristics are associated with an increase likelihood of piap. targeting these patients would be beneficial in preventing medicine-related illness. background: social frailty was reported to be associated with age, sex, income, education, marital status, and household status. however, mood status including depression and emotion was relatively less investigated. objectives: the aim of this study is to clarify the association between depression and apathy status and social frailty in community-dwelling japanese elderly. methods: a health promotion project (teng tv project) is designed to distribute health promotion programs including enhancement of nutrition and physical activity via cable tv channel for community-dwelling elders. we ran a cross-sectional analysis using baseline characteristics of all participants (n= ). demographic data, socio-economic status, comorbidities, and nutrition evaluated by mininutritional assessment-short from (mna-sf) were recorded. functional capacity was assessed by the japan science and technology agency index of competence (jst-ic). mood status including depression, and emotion was measured by geriatric depression scale (gds- ) and apathy evaluation scale (aes). social frailty was defined by household status (living alone or not), financial difficulty, social activity, and fulfilment of social needs. we defined total deficit scores of or more as social frailty, as social pre-frailty, and as robustness. we used a linear regression model to analyze the association between mood status and social frailty after adjusting for age, sex, education, marital status, comorbidities, bmi, mna-sf, jst-ic. results: at baseline, mean age of all participants ( . % men) was ± . years. a total of . % and % of all participants were categorized as social prefrailty and social frailty, respectively. the mean scores of gds- and aes were . ± . , . ± . , respectively. in linear regression model after full adjustment, participants with social pre-frailty and social frailty were associated with increased gds- scores (social pre-frailty vs. social robustness: b= . , %ci . - . ; social frailty vs. social robustness: b= . , %ci . - . ) and aes scores (social pre-frailty vs. social robustness: b= . , %ci - . - . ; social frailty vs. social robustness: b= . , %ci . - . ). in addition, jst-ic was also associated with gds- and aes scores. conclusion: social pre-frailty and social frailty were associated with greater level of depression and apathy. future studies are warranted to determine the causal relationship among mood status and social participation. inthira roopsawang , , hilaire thompson , oleg zaslavsky , basia belza (( ) ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bkk, thailand; ( ) biobehavioral nursing and health informatics, school of nursing, university of washington, seatlle, usa) background: frailty is a common geriatric condition with an impact on surgical outcomes. no research has been published on frailty assessment in hospitalized orthopedic patients in thailand. having a valid frailty measure has the potential to improve screening and could enhance quality of care. objectives: to test the ability of the reported edmonton frailty scale-thai version (refs-thai) in predicting hospital outcomes compared with preoperative assessment measures, the american society of anesthesiologists physical status classification (asa) and the elixhauser comorbidity measure (emc) in older thai orthopedic patients. methods: a prospective study was conducted at a university hospital. the hospitalized patients aged years or older scheduled for elective orthopedic surgery were recruited in this study. multiple firth logistic regression modeled the effect of frailty on postoperative complications, postoperative delirium (pod), and discharge disposition, while length of stay (los) was examined by poisson regression. the area under the receiver operating characteristic curve (auc) and mean squared errors (mse) were used to compare predictive ability of the instruments. results: two hundred participants with mean age of (range - years) were mostly female , % were frail, and % underwent knee surgery; of which . % had postoperative complications, . % developed pod, and % were unable to be discharged home. average los was days. adjusting for other variables, frailty was significantly associated with postoperative complications (or = . , p = . ), pod (or = . , p = . ), and prolonged los (relative risk [rr] = . , p = . ). applying the refs-thai alone shows good performance in predicting postoperative complications (auc = . , % ci = . - . ) and pod (auc = . , % ci = . - . ). the combination of refs-thai with asa and emc demonstrates improvement in predicting postoperative complications (auc = . , % ci = . - . and . % ci = . - . , respectively) and pod (auc = . , % ci = . - . and . % ci = . - . , respectively). conclusion: frailty assessment using the refs-thai was useful in predicting adverse outcomes in older adults undergoing orthopedic surgery. integrating the refs-thai for preoperative assessment may be useful for enhancing orthopedic care quality. anthony frioux , matthieu faure , margot de battista , benoit roig (( ) université de nîmes, france; ( ) université de france) background: the attention of the scientific community to frailty has been drawn over the past several years. frailty is defined as a state of increased vulnerability that may lead to functional disability. if this state is managed soon enough it may be reversible. in parallel, the possibilities of monitoring health status through connected objects such as smartphones are increasing. similarly, it is possible to measure the activity of the inhabitants of a house collecting usage data (water and electricity consumption). our project is in the field of smart home and aging monitoring. objectives: therefore, the objective of our work is to develop an integrative model of frailty based on the contributions of existing scientific tools (fried et al., ; mitnitski, mogilner, & rockwood, ) and current sensors to measure a person's activity. eventually, we are aiming for the detection of the frailty trajectory early on. for example, real-time activity monitoring is used to detect a fall and alert rescue. in our case, these sensors will allow us to identify as soon as possible a dimension that would be abnormal in order to intervene and propose an appropriate intervention. methods: our tool will be able to measure the five fried's frailty criteria which are currently used in clinical practice. we compare the data from the sensors with the results of the evaluation of fried's frailty phenotype. results: we expect to obtain a correlation between our data and phenotype results. conclusion: the main contribution of our tool resides in the possibility to observe deviations from an individual's normal aging trajectory. thus, the evaluation we propose would be more ecological as it will enable us to consider the individual's habits and to have a more detailed assessment of his activity evolution. in conclusion, the holistic aspect of our work will allow the practitioners to base their intervention on a wide range of health data. l. van wagenberg, r.m. wösten-van asperen (department of paediatrics, paediatric intensive care unit. wilhelmina children's hospital, utrecht, the netherlands) background: a frail phenotype is recognized in the elderly population. frailty is associated with a higher mortality for adult intensive care (icu) patients. research in oncology suggests biological age is not the key contributor to frailty, since frailty is also found in the younger population. in paediatrics frailty is an unknown concept and as a consequence, the prevalence and meaning of being frail at young age are unknown. objectives: to assess whether a possible frail phenotype can be found in a critically ill paediatric oncological population. methods: a retrospective cohort study in a paediatric oncological icu population between january and september . demographic data and need for icu resources (mechanical ventilation, inotropic support and s continuous renal replacement therapy (crrt)) were collected. since specific paediatric frailty scores are not available, we addressed patients as having a frail phenotype by textmining their electronic health records on the words "fatigue", "cachexia" and "diminished physical activities" before, during, and after paediatric icu admission. risk factors for a possible frail phenotype (cachexia, use of corticosteroids and lowest serum albumin levels) were collected. primary endpoint was mortality during icu treatment or course of illness. results: admissions were included, of which admissions had a possible frail phenotype. these admissions included unique patients. % of patients was male and the median age was years (iqr - ). patients were predominantly treated for a haemato-oncological malignancy ( %). mortality during icu-admission was %, and % died subsequently during the course of disease after picu discharge. patients were severely ill, with a mean icu length of stay of . days (± ), % on ventilator support, % receiving vasopressor or inotropic support, and % on crrt. loss of muscle function or fatigue was present in % before icu admission and in % acquired atrophy or cachexia was documented during icu treatment. % were treated with corticosteroids during picu stay. in % a serum albumin ≤ gram/dl was measured. conclusion: a possible frail phenotype is present in the oncological patient population of a paediatric icu. more research on the contributing factor of frailty on outcome of these patients is needed in the near future. john muscedere , , amanda lorbergs , jayna holroyd-leduc , anik giguere , leah gramlich , heather keller , ada tang , danielle bouchard , donna fitzpatrick-lewis , , diana sherifali , (( ) canadian frailty network, kingston, on, canada; ( ) queen's university, kingston, on, canada; ( ) university of calgary, calgary, ab, canada; ( ) laval university, quebec city, qc, canada; ( ) background: despite research evidence related to nutritional and physical activity interventions, there is a gap in provision of evidence-based care focused on preventing and managing frailty among older adults. objectives: to systematically generate evidence-based nutrition and physical activity (pa) clinical practice guidelines to improve health and functioning in older adults with or at risk of frailty. methods: we are using the agree ii guideline development protocol to generate guidelines to improve health and functioning in older adults. for each guideline, systematic review of meta-analyses was conducted by searching three databases for english language citations published since that included adults aged y and older with frailty and/or pre-frailty. nutrition or pa interventions with a comparison group were considered eligible. acceptable study designs included rcts, quasi-experimental trials, and observational cohorts with a comparison group. in a face-to-face meeting with multidisciplinary content experts, healthcare professionals, and end-users we will further appraise the quality and strength of the evidence using the grade approach. this group will use this evidence to form recommendations related to nutrition and pa in this population. results: the nutrition and pa searches resulted in and citations, with and eligible for full-text review, respectively. the results will inform guideline recommendations. knowledge translation strategies will be developed to support guideline dissemination and implementation. conclusion: the guidelines will inform health professionals by providing evidence-based nutrition and pa interventions for adults with frailty. ( background: physical and psychosocial factors play important roles in the severity and progression of frailty. frailty screening tools include measures of the more common risk factors, including advanced age, comorbidities, poor diet, weight loss, lower socioeconomic status, and physical inactivity. however, there has been limited standardization in the us on specific frailty screening measures to include in national health surveys or frailty tools/protocols for community health settings. this makes it difficult to monitor frailty incidence/prevalence in the older adult population and to best identify and treat individuals at risk. results: we reviewed the most recent versions of us national health surveys that include older adults, to identify whether frailty screening measures were included in. no national surveys had a battery of measures that would allow for frailty risk screening. most commonly, questions on weight, disability, mental health, physical functioning were included. however, physical functioning measurements such as grip strength or gait speed, measured height and weight, unintentional weight loss, dietary intake or appetite changes were not. further, we used the world health organization criteria for effective community screening programs to review published evidence of the validity, reliability, and feasibility of data-driven screening tools for frailty risk among community-dwelling older adults. of the frailty screening tools reviewed, the frail scale was identified as the most promising, based on test characteristics and cost/ease of use. more community-level s research is recommended, particularly on predictive validity of favorable outcomes following physical activity/nutritional interventions. finally, because nutrition plays a significant role in frailty risk, we surveyed registered dietitian nutritionists who work with older adult populations (n= ) to identify their awareness/use of frailty screening protocols/tools and dietitians' potential role in frailty screening. dietitians practicing in the community recognized a potential role, but few dietitians were aware of (< %) or using (< %) specific frailty screening tools. conclusion: future opportunities to better support healthy aging include: addition of frailty screening measures to national health surveys to help prioritize high-risk populations, conduct additional research to validate/recommend a common community-level screening tool, and promote engagement by dietitians and other health professionals who can establish protocols for community-based frailty screening. ming-yueh chou , , ying-hsin hsu , yu-chun wang , chih-kuang liang , , li-ning peng , , liang-kung chen , , yu-te lin (( ) center for geriatrics and gerontology, kaohsiung veterans general hospital, kaohsiung, taiwan; ( ) aging and health research center, national yang ming university, taipei, taiwan; ( ) department of geriatric medicine, national yang ming university school of medicine, taipei, taiwan; ( ) center for geriatrics and gerontology, taipei veterans general hospital, taipei, taiwan) background: older people with frailty are at risk of adverse outcomes, such as falls, functional decline and mortality, and multi-domain intervention program may prevent those. objectives: the purpose of this study is to evaluate the effectiveness of multi-domain intervention program among those community-dwelling frail older people in southern taiwan. methods: a week multi-domain intervention program were provided for all participants, including physical activity, high protein diet education, medical knowledge education and cognitive simulation activity for hours per week. comprehensive geriatric assessments were performed before and after the intervention program, including basic demographic data, risk for malnutrition (by mna-sf), mood condition (by gds- ), cognitive condition (by mmse) and frailty status according to the definition by the cardiovascular health study (chs) . results: during jan and may , totally participants were invited for study ( . % female, mean age . ± . years). among them, ( . %) were clarified as frailty status and ( . %) as prefrailty status. after the multi-domain intervention program, their mood condition ( . ± . to . ± . , p< . ) and cognitive condition ( . ± . to . ± . , p< . ) improved significantly. in addition, the walking speed ( . ± . to . ± . m/s, p< . ) and physical activity ( . ± . to . ± . mets/week, p< . ) improved, but not handgrip strength (p= . ). for the frailty status, those clarified as frailty status decreased from . % to . % and prefrailty status from . % to . % (p< . ). conclusion: our results showed that through the week multi-domain intervention program, those frail older people could improve their mood condition, cognitive condition, usual gait speed and frailty status. sarah b. lieber , stephen a. paget , , jessica r. berman , , medha barbhaiya , , lisa sammaritano , , kyriakos a. kirou , , john a. carrino , dina sheira , mangala rajan , yingtong lyu , lisa a. mandl , (( ) division of rheumatology, hospital for special surgery, new york, ny, usa; ( ) department of medicine, weill cornell medicine, new york, ny, usa; ( ) department of radiology and imaging, hospital for special surgery, new york, ny, usa) background: frailty is a clinical phenotype that increases with age, but can occur in younger patients with chronic disease. based on few studies, frailty has been found in up to . % of patients with systemic lupus erythematosus (sle) and is associated with increased mortality. whether frailty is prevalent in other sle cohorts and associated with objective and subjective factors is unknown. objectives: we aimed to determine the prevalence of frailty in a prospective cohort of women with sle and whether inflammatory biomarkers, body composition, and patient-centered domains differed between frail and non-frail women. methods: adult women < years old who fulfilled american college of rheumatology sle criteria were recruited from one center. exclusions included pregnancy, dialysis, active malignancy, overlap autoimmune syndromes, and severe sle disease activity. frailty was measured according to fried criteria. patient-reported outcomes (pros) were measured using pro measurement information system (promis) computerized adaptive tests; lupusqol; and disability based on valued life activities. physicianreported sle disease activity and damage indices were collected. inflammatory biomarkers and sarcopenia according to dual-energy x-ray absorptiometry were assessed. differences between frail and non-frail women were evaluated using chisquare tests and kruskal-wallis tests; the association between frailty and disability was determined using logistic regression. results: women enrolled from / - / . despite age under years old, % were frail. frail women had greater disease damage (p= . ) and were more often smokers (p= . ). high-sensitivity c-reactive protein (p= . ) and interleukin- (p= . ) were higher and sarcopenia trended toward greater prevalence (p= . ) in frail women. significant differences in promis mobility, physical function, pain interference and behavior, and fatigue and lupusqol physical health and pain (all p< . ) were observed between frail and non-frail women, with frail women reporting consistently worse scores. frail women were . x more likely to be disabled than non-frail women, including after adjustment for age, comorbid conditions, and disease activity/damage. conclusion: the prevalence of frailty was high in this cohort of mid-aged women with sle. frail women had poorer health-related s quality of life than non-frail women, including substantially higher disability. if frailty is associated with worse health outcomes, it could be a potential therapeutic target. chariya sumcharoen, supreeda monkong, nuchanad sutti (ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bangkok, thailand) background: bed bound older adults need caring of physical activities, mental, mood, and social from family caregivers. family caregivers usually gets the role strain from caregiving. there are many factors associate with the caregiver role strain but have been rarely reported in bed bound older adults at home. objectives: the study examined age, adequacy of incomes, mutuality, health status, preparedness, and social support influencing caregiver role strain from caregiving activities for bed bound older adults at home. methods: caregiver role strain concept by archbold and colleagues with literature review were used to guide this study. the sample was recruited by purposive sampling consisted of caregivers aged years or older, who have cared for bed bound older adults at home in thailand. data were collected by structured interview using the questionnaires including demographic data, preparedness, health perception, mutuality, social support, and caregiver role strain from the care activities. data was analyzed using descriptive statistics, pearson's product moment coefficients, and multiple regression analysis. results: the most of participants were women ( . %), age ranging from to years (m= . , sd= . ) . the result showed that age, adequacy of incomes, mutuality, health status, preparedness, and social support jointly significantly explained . % of the variation in caregiver role strain from caregiving activities. the regression effects were strongest for health status (beta=-. , p=. ), followed by preparedness (beta=-. , p=. ), age (beta=. , p=. ), and adequacy of incomes (beta=-. , p=. ) respectively. conclusion: this finding suggests that healthcare providers should find strategies for promoting health status and preparedness of family caregivers for decrease caregiver role strain from caregiving activities. of life, and hospital admissions. objectives: we estimated the prevalence and describe the characteristics of the population with recurrent falls and fear of falling and their association with frailty, physical performance and cognitive fragility. methods: data came from the "salud, bienestar y envejecimiento" (sabe) colombia study, a cross-sectional study conducted in at the urban and rural research sites ( municipalities) in colombia. sociodemographic, health, cognitive and anthropometric measures were collected from community-dwelling adults aged years and older, representative form the total population. frailty was defined using the frailty phenotype proposed by fried. cognitive frailty was defined using the inaa/iagg consensus definition. low performance was evaluated with sppb (short physical performance battery). logistic regression analyses were used to identify factors associated with recurrent falls and fear of falls. results: our study identified elderly who had recurrent falls and fear of falling ( . % and . % respectively). young elders (≤ years) had more falls and greater probability for fear of falling compared to older ages. sex had no significant differences. the factor associated with an increased risk of recurrent falls and fear of falling in the elderly were low physical performance, fragility and polypharmacy. chronic illness such as osteoarticular disease, mental disease, diabetes and chronic pulmonary disease were significantly associated with recurrent falls and fear of falling. finally, when adjusted for age, sex, sociodemographic factors and comorbidities in a logistic regression model, frailty was associated with fear of falling and recurrent falls, while cognitive frailty and low physical performance only were associated with fear of falling. conclusion: recurrent falls have a significantly association with frailty. there are cognitive, physical performance and clinical factors associated with fear of falling that could be preventable and treatable. rubbieri gaia , ceccofiglio alice , mazzeo nicla , pupo simone , cartei alessandro , rostagno carlo , mossello enrico (( ) department of perioperative medicine, careggi hospital and university of florence, italy; ( ) department of geriatric medicine, careggi hospital and university of florence, italy) background: the prevalence of frailty in patients with hip fracture is high, but little is known about the choice of the best frailty tool in terms of prediction of functional recovery. objectives: the aim of this preliminary study was to determine the most predictive validated frailty tool in older people with hip fracture and to determine whether frailty can predict functional recovery during the hospital acute phase. methods: this study was observational prospective cohort study. participants aged + admitted to hip fracture units in florence, were assessed pre surgery (t ), and post surgery. each participants underwent a comprensive geriatric assessment and frailty was defined using: clinical frailty scale (csf), frail scale (fs), reported edmonton frail scale (refs), postal frailty screening (pfs). the outcome was functional recovery, evaluated by a score of postoperative performance on the cumuleted ambulation score (cas). data recorded included pre-recovery barthel index (bi), charlson comorbidity index (caci), handgrip strenght test (hg), asa score, mini nutritional assessment short-form (mna-sf), delirium. results: sample included patients (mean age ± years, female . %). cfs was the most predictive frailty tool, with a % sensitivity and a % specificity (auc = . , cut off > ). dividing the sample according to premorbid bi, while bi itself had the highest predictive value when premorbid level was < %, cfs was the best predictor of functional outcome in the %+ subsample (auc= . ). conclusion: frailty defined by cfs can predict short-term functional recovery during acute phase following hip fracture. this appears particularly relevant for subjects with a higher pre-morbid functional independence. s % were women. individuals had data for all five frailty measures. nine percent of participants were non-frail by all instruments, % were frail by all measures and thus % had discordant frailty measurements. % were frail by at least one measure method. the prevalence of frailty ranged from % to % for the different measures. those classified as frail by cfs and non-frail by bp were more likely to be men, be co-living, have lower cognitive function and a higher dependency in iadl compared to those classified as frail by bp and non-frail by cfs. conclusion: frailty measures cannot be used interchangeably. specifically the cfs might not identify physical frail women, with high cognitive ability who lives alone. factors contributing to the heterogeneity of groups classified as frail by different measures need to be further explored. background: polypharmacy is increasingly common amongst older, multimorbid adults. in these individuals, studies have shown a high prevalence of frailty. identification of frailty can be performed using comprehensive assessments registering accumulation of deficits like in the frailty index, or using single-trait markers of frailty like gait speed and handgrip strength. polypharmacy is recognized as an independent risk factor for the development of frailty, and the subgroup of psychotropic drugs may be particularly important in the development of this syndrome. objectives: our objectives were to study the relationship between the total burden of polypharmacy on frailty status using three different measurements of frailty, and specifically the influence of psychotropic drug use on frailty status. our overall aim was to explore whether either of these could be used as independent predictors of frailty. methods: we used data from a -year follow-up study of older people living in the community and receiving home care nursing, i.e. the cascade-study. data collection was completed in june . all participants were aged > years (mean years). a item frailty index was calculated based on results from a comprehensive geriatric assessment performed in the patients' own home. a fourmeter gait speed test was performed, as well as measurement of handgrip strength. information on regular medications was collected from the patients if they administered own medications, or from the home care nursing service if they were responsible for administering the patients' medications. psychotropic drugs were selected based on beers criteria. results: we found a significant association between the use of psychotropic drugs and frailty index, and frailty index increased by . for each psychotropic drug added (p< . ). one additional psychotropic drug decreased gait speed by , m/s (p< , ). there was no statistically significant association between psychotropic drug use and handgrip strength. conclusion: our study showed that psychotropic drug use was a significant predictor of increased frailty index and reduced gait speed. this was not the case for handgrip strength in our material. laetitia beernaert , frédéric schuind , sandra de breucker (( )department of geriatrics, hôpital erasme -université libre de bruxelles, belgium; ( ) department of orthopedics, hôpital erasme -université libre de bruxelles, belgium) background: anemia is a condition whose prevalence might reach % in the geriatric population. anemia and frailty are two prognostic factors for patients admitted for a hip fracture. objectives: we analyzed retrospectively if preoperative frailty and anemia were independently predictive of postoperative complications and mortality in old patients admitted for hip fracture. methods: ninety-seven patients above years old have been admitted for urgent surgery for a hip fracture during and . we excluded patients with a pathological fracture or fractures due to high energy trauma. preoperative anemia was defined as an hemoglobin level under g/dl for women and g/dl for men. frailty was assessed with the isar (identification of seniors at risk) score. results: seventy-five percents of patients were considered as frail (isar score> ). the prevalence of preoperative anemia was %. we found no statistically significant correlation between anemia and frailty (r = - . -p = . ). in multiple regression logistic analysis, the only independent parameter associated with anemia was the presence of comorbidities (or . ( . - . )-p = . ), and the only parameter associated with frailty was the presence of malnutrition (or . ( . - . )-p = . ). neither anemia nor frailty was associated with postoperative complications and mortality. conclusion: preoperative anemia and frailty are not interrelated in patients admitted for hip fracture. anemia is associated with comorbidities, but not postoperative mortality. frailty is associated with preoperative malnutrition. the isar score may not be ideal to screen for frailty in old patients admitted for hip fracture, an item being attributed to the current loss of autonomy. settings. m martinez , maria montoya , , davide angioni , lizeth canchucaja , natalia ronquillo , maria luz gallego , claudia bejar , emmanuel gonzalez , olga vazquez , anna renom (( ) institute de viellisement toulouse, france; ( ) hospital del mar, barcelona, spain; ( ) hospital de terrasa, barcelona, spain; ( ) parc tauli, barcelona, spain) background: frailty is a common critical geriatric syndrome which has been associated with poor health outcomes.a wide variety of frailty indices (fis) have been developed. frail-vig («vig» is the spanish/catalan abbreviation for comprehensive geriatric assessment).it contains simple questions that assess different deficits. it has been inspired by the rapid geriatric assessment. objectives: the aim is to compare the prediction capacity of clinical rockwood index frailty (rif) and frail-vig index (vif) for poor health outcomes (pho) defined as: emergency department visits and/or hospital admission and/or mortalityamong elderly patients. methods: a retrospectiveobservational study was conducted with a followup up to months or pho occurred. patients were admitted in acute geriatric unit care and geriatric day hospital at hospital del mar; barcelona; spain during august and march . the inclusion criteria were the admission ones. frailty was measured at admission. survival analysis was conducted; cox proportional hazards regression was used to build a pho predictive model based on both indexes. best model according to contrast of hypothesis log-rank ,aic; bic and c harrel was selected.diagnoses of the chosen model was done. results: a total of patients were included, mean age was and . % female. the mean of follow-up was . , % patients presented a pho. . % died, % were admitted at emergency department, . % were hospitalized and % presented more than one event.survival curves for frail and non-frail according to pho showed statistically significance for vif (x = . p= . )but not for rif (x = . p= . ). cox proportional hazards regression showed vif hazard ratio . (p= . ) and rif hazard ratio . (p= . ). predictive capability resulted in a model for vif containing cognition and sex, with harrel c of . . as for rif the most parsimonious model rif would be absent and harrel c . . the diagnoses of the model showed time covariate variable test with p= . , p= . , p= . for each predictive variable; squared linear predictor with p= . of and outliners. conclusion: the vig frailty index performed better; compared to rockwood clinical index; in predicting a composite outcome composed by mortality, hospitalization and visits to emergency departments in patients admitted in acute and outpatient settings. after hospital discharge. methods: this study was conducted in the departments of internal medicine and neurology of the university hospital of araba (basque country, spain). participants were >= years, scoring >= on the mmse test and able to stand and walk independently for at least -meter. participants performed twice-weekly moderate intensity group sessions of multicomponent exercise at the hospital during -week, followed by a home-based intervention ( week) . both were focused on balance, aerobic capacity and strength. taking together both interventions, participants completed -week of physical exercise. at the beginning and the end of the program, frailty was measured though fried´s index and sarcopenia with different criteria : muscle strength ( -chair stand), muscle quality (dxa) and physical performance (sppb). we compared the results before and after the intervention by mcnemar test. results: patients ( females, %) were enrolled, were lost to follow-up at the -week time point and people finished the intervention. the intervention decreased significantly the percentage of frail individuals (p< . ) according to fried´s index, and the percentage of people who met sarcopenia criteria for sitto-stand (p= . ) and sppb (p= . ). however, there were no differences in the percentage of people with low appendicular muscle mass. conclusion: our study showed that a multicomponent exercise program is effective for posthospitalization patients because after -week intervention there were significant reductions in frailty and improving results in muscle strength and physical performance. we did not find changes related to muscle mass. references: . background: alcohol addiction can impact every part of the body, including bones. research shows that chronic heavy alcohol use, especially during adolescence and young adult years, can dramatically affect bone health and increase the risk of osteoporosis and bone fracture later in life. objectives: the purpose of this study is to compare data from international scientific literature with data from the study of patients admitted for alcohol dependence, to assess whether there are significant connections between alcohol dependence and unrecognized fractures. methods: we analyzed meta-analysis's studies from the pubmed search engine to evaluate the association between bone fractures with alcohol use disorders. only humans studies from the last years have been analyzed. subsequently, data related to patients admitted for an alcohol rehabilitation cycle were analyzed. results: scientific literature show that there is a close correlation between alcohol abuse and greater frequency of bone fractures. this is partly due to association between alcohol consumption and both osteoporotic fracture and bone density, and partly to the fact that there is an increased risk of falls in alcohol intoxicated patients compared to the general population. patients were considered: % male and . % female. the average age was years. of these , . %, patients, had unrecognized fractures. conclusion: intoxicated patients admitted in alcoholic rehabilitation with recurrent falls anamnesis often did not perform any diagnostic assessment. this is due to the lack of pain perception in the patients or due to family members or emergency physicians who placed the state of drunkenness before any consequences caused by repeated falls. there is an increased risk of unacknowledged fracture in the patients admitted in alcohol rehabilitation this is partly due to the fact that alcohol intoxicated patients often do not perceive the pain and therefore do not investigate any falls that occurred in a state of drunkenness, in part it is due to the damages that alcohol causes on the bone. our data show that alcohol dependence and unrecognized fractures can often be associated. studies in the literature confirms that there is an increased risk of non-cone fractures in patients with alcohol dependence. zamudio-rodríguez, hélène amieva, luc letenneur, karine pérès (centre de recherche inserm u université de bordeaux -isped, bordeaux, france) background: although conceptually distinct, frailty and disability are very common among older adults. both are multifactorial conditions and share some risk factors and pathophysiological mechanisms, such as inflammation or sympathetic-parasympathetic balance alteration. furthermore, each individual component of the frailty phenotype defined by the cardiovascular health study (chs) has been associated with disability in basic and instrumental activities of daily living. objectives: the present study aimed to determine whether pre-frail and frailty are part of the natural history of the disability process. methods: a sample of people aged of the three cities ( c) study in bordeaux were followed for four years. pre-frailty and frailty were defined according to the original phenotype proposed in the chs. disability was defined using the basic (adl) and instrumental (iadl) activity of daily living scales. seven mutually exclusive hierarchical groups were distinguished at inclusion: ) robustness (no frailty or disability); ) pre-frail (without disability); ) frailty (without disability); ) iadl (without pre or frailty or adl) ) pre-frail with iadl (no adl); ) frailty with iadl (no adl); ) frailty with iadl and adl. results: deaths ( . %) occurred during the four years follow-up. compared to the robust group, all other hierarchical subgroups had an increased risk of death, with an increasing gradient: pre-frailty (hr= . ; ic %= . - . ); frailty (hr= . ; ic %= , ) , iadl disability (hr = . ; ic %= . - , ); pre-frailty with iadl disability (no adl) (hr= , ; ic %= , - . ); frailty with iadl disability (no adl) (hr= , ; ic %= . - . ); frailty with iadl and adl disability (hr= , ; ic %= . - . ) were significant after adjustment by age and sex. conclusion: there is a gradual risk of mortality across the different groups ( i.e., ) robust; ) pre-frail; ) frail; ) iadl disability without pre or frailty; ) pre-frail with iadl disability; ) frail with iadl disability; ) frail with iadl and adl disability) thus suggesting a hierarchical relationship. this study could have important clinical implications since pre-frailty and frailty are assumed more effectively reversible conditions in order to interrupt the continuum at the early phase of the disability processes. background: joint replacement provides significant improvement in pain, physical function, and quality of life in patients with osteoarthritis. with a growing body of evidence indicating that frailty can be treated, it is important to determine whether targeting frailty in joint replacement patients is feasible and improves post-operative outcomes. objectives: to examine the feasibility of a preoperative multi-modal frailty intervention (mmfi) compared to usual care in pre-frail/ frail older adults undergoing elective unilateral hip or knee replacements. methods: in this pilot randomized controlled trial (rct), participants who are )>= years old; ) pre-frail (score of - ; (fried frailty phenotype (ffp)) or frail (score of - ; ffp); ) having elective unilateral hip or knee replacement with surgery wait times between - months were recruited from the regional orthopaedic clinic mcmaster university, ontario canada. the mmfi included tailored exercise, protein ( - gm/day), vitamin d ( iu/day) supplementation, and medication review with recommendations sent to family physicians. frailty and mobility were assessed at baseline and -weeks post-operative using ffp, short performance physical battery (sppb) and oxford hip/knee score (ohs/ oks) respectively. results: we recruited and randomized participants between september and may . of those, . % were referred for total hip replacement and . % for knee replacement. the included participants' mean age (standard deviation (sd)) was . ( . ) years; . % were women; . % lived alone, body mass index was . kg/ m ( . ) and . % were former smokers. at the baseline assessment, on the ffp, % were prefrail, % were frail and the sppb was . ( . ). for participants with hip osteoarthritis, ohs mean (sd) was . ( . ) and for participants with knee osteoarthritis, oks mean (sd) was . ( . ). the study recruitment rate was . %, and the retention rate was %. eighty three percent of participants of the intervention group completed the intervention. self-reported adherence to the intervention components was as follow: ) exercise sessions: . %, ) protein supplement: . %, ) vitamin d supplement: . % and ) medication review completion: %. conclusion: this is the first study to examine the feasibility of a multi-modal frailty intervention in pre-frail/frail older adults undergoing joint replacement. this study showed that frailty screening, assessment and management is feasible for older adults undergoing joint replacement in orthopaedic surgery clinics. results have informed the current multi-centre rct to determine effectiveness. christine tocchi , sathya amarasekara , michael cary (( ) school of nursing, duke university durham, nc usa; ( ) school of nursing, duke university durham, nc usa; ( ) school of nursing, duke university durham, nc usa) background: inpatient rehabilitation facilities (irfs) provide intensive rehabilitation therapy to patients to reduce functional impairment, enhance independence and return patients to the community. determination of eligibility for irf is currently based on preadmission screening. subpopulations of older adults may require special consideration in determination of irf admission due to greater risk for poor functional recovery such as those with pre-existing functional limitations and those who are frail. frailty, a pervasive characteristic in older adults with hip fractures has not been examined as a clinical factor influencing discharge destination outcomes in irfs. objectives: ) determine the prevalence of frailty among older adult with hip fracture receiving inpatient rehabilitation; and ) determine the association between frailty and discharge destination among hip fracture patients receiving inpatient rehabilitation. methods: a retrospective cohort study design using cms inpatient rehabilitation facility-patient assessment instrument file. multivariate regression models were performed to examine the association between frailty and discharge destination. frailty status was measured using a frailty index of items with the following cut-off points: - . robust/non-frail; . - . pre-frail; and . or greater as frail. the final sample included , hip fracture patients. results: frailty, pre-frailty, and nonfrail were present in . % (n= ), . % (n= ), and % (n= ) of hip fracture patients, respectively. the majority ( %) of the frail hip fracture patients were discharged home. there were significantly greater proportion of females than males discharged home and those of white race, to years of age, and with higher functional status. regression analysis showed significantly lower functional status at discharge (p < . ) for patients with these characteristics: males, non-white race, and older age. additional factors that influenced discharge destination included: marital status, living in the community prior hospitalization, and length of stay. conclusion: frailty was the most common frailty status on admission to irf. home is the most common discharge destination for all frailty status groups. frailty status could be used to identify hip fracture patients at high risk for adverse outcomes. future studies should be used to explore the potential of frailty to provide valueadded utility to clinical settings such as irfs. background: front-line care providers are seeking direction on how frailty measures may be integrated into existing or future care pathways to enhance the experience of individuals who live with it. multidimensional frailty measures such as the edmonton frail scale offer the potential for case-finding, estimation of severity, and definition of frailty components. objectives: test the feasibility of the implementation of a multidimensional frailty order set into acute care. methods: in , we conducted a literature search to identify existing frailty guidelines and systematic reviews related to frailty in acute care. an expert panel graded the quality the evidence, then generated recommendations, graded by strength to inform the generation of a clinical knowledge and content management (ckcm) topic for dissemination throughout alberta health services (ahs). ahs is the largest province-wide, fullyintegrated health system in canada. this ckcm would include graded statements and recommendations, clinical decision support, electronic alerts, and a frailty order set. results: four guidelines, systematic reviews, and one scoping review informed the development of the frailty ckcm. from this, we developed eight recommendations, covering topics such as prevention, case-finding, estimation of severity, definition of components, triggers for expert assessment, and linkage to care processes. the recommendations also addressed safeguards to avoid labelling and other unintended consequences. an order set employs the clinical frailty scale, electronic frailty index, and edmonton frail scale to support a clinician to develop a personalized care plan. the order set empowers front-line clinicians to administer these frailty measures, based on cut points that prompt personalized recommendations on diet, activity, fall prevention, bladder management, and infusions. depending on the frailty component of concern, clinicians are also prompted with specific options to address cognitive impairment, functional dependence, falls and immobility, social isolation, nutritional risk, polypharmacy, urinary incontinence, chronic pain, and constipation. in preparation for the conversion to a province-wide electronic medical record (emr) in november , the ckcm was released in may and the frailty order set was built into the emr by september . conclusion: development and implementation of a multidimensional frailty order set in the setting of acute care is feasible. masayo kojima , toshihisa kojima , yuko nagaya , yasumoto matsui (( ) national center for geriatrics and gerontology, obu, aichi, japan; ( ) nagoya university, nagoya, aichi, japan; ( ) nagoya city university, nagoya, aichi, japan) background: prevention programs for frailty at community usually target healthy older people. to further prolong healthy life expectancy, we need to approach those who already have got chronic diseases such as rheumatoid arthritis (ra). objectives: the aim of this study is to assess the prevalence and factors associated with frailty in japanese ra patients. methods: ra patients aged - -yearold who visited two university hospitals between march and july were consecutively invited to join the study. those who agreed to participate the study provided written consent forms. frailty was assessed by the total score of the kihon checklist >= . self-report questionnaires were used to evaluate patients' demographic characteristics, perceived degree of pain, depression (the beck depression inventory-ii) and physical function (the health assessment questionnaire, haq). rheumatologists' global assessment of disease severity, swelling and/or tender joint counts, years of ra duration, frequency of arthritis surgery and crp level were also measured. results: total of ra patients were included in the study ( women, average age: . ± . years, average disease duration: . ± . years), and the prevalence of frailty was . %. the higher the age and the longer the duration of the disease, the higher percentage of ra patients with frailty was observed. . % among ra patients of working age ( - years), were frail, whereas . % and . % were frail among those aged - years and >= years, respectively. stepwise logistic regression analysis revealed that age, haq, depression severity and trust in neighbors were independently associated with frailty in ra. no significant gender difference was observed. conclusion: frailty is common even among working age in ra patients. physical function, depression and social capital were suggested to be independently associated with frailty. on-going followup study will disclose the influence of frailty on fracture, dependency, and mortality among ra patients. background: frailty is an important modulator of ageing and might impact on clinical presentation and progression of parkinson's disease. objectives: to evaluate the prevalence of frailty and correlation with motor and non motor symptoms as well as mri atrophy and white matter hyperintensities in parkinson's disease. methods: consecutive parkinson's disease patients underwent a comprehensive motor and non motor evaluation and geriatric assessment using multidimensional prognostic index (mpi). a subset of patients underwent mri with assessment of atrophy and white matter hyoperintensities by visual rating. results: pd outpatients (mean age . y, mean disease duration . years) entered the study. pre-frailty assessed by mpi was presented by % of patients and correlated with age and disease duration. when adjusting for these ariables, mpi correlated with updrs-iii, non motor symptoms assessed by umsar, prevalence of prevalence of orthostatic hypotension, rbd and depression. the mri assessment showed a correlation between global atrophy and frailty indipendently from mmse and educational levels. no association between frailty and wm hyperintensities was found. conclusion: frailty is a possible important modulator of pathology and brain vulnerability in parkinson's disease and could explain different severity in motor and non motor symptoms. longitudinal studies are warrented to evaluate the impact of frailty in disease progression. background: accidental falls in older adults have been associated with worse health-related outcomes especially in the frailest individuals, such as nursing home (nh) residents. in this special population of older adults, falls have been related to greater morbidity and mortality, but their impact on nutritional status is still unclear. moreover, so far there are no data on the potential role of unmodifiable (e.g. cognitive impairment [ci] ) and modifiable factors (e.g. assistance from informal caregivers) in influencing the impact of falls on nutritional status in older residents. objectives: we aimed to evaluate the changes in body weight during the six months after the occurrence of a fall in nh residents, and the possible influence of severe cognitive impairment, depressive symptoms and of the assistance from informal caregivers on such variations over time. methods: the sample included older residents who experienced at least one fall since nh admission. for each participant, we collected data on sociodemographic information, mean frequency of visits from informal caregivers, medical history, and cognitive and functional status at nh admission. severe ci was defined as the presence of a physician-based diagnosis of ci or a mini-mental state examination < points. the frequency of the visits from informal caregivers was categorized as none or (low) vs > (high) per week. falls' date and characteristics were obtained from structured forms completed by physicians. monthly body weight in the six months before and after the fall were derived from the nh medical records based on nurses' assessments. linear mixed models were used to evaluate the body weight changes after a fall, as a function of the presence of severe ci and low visits' frequency from informal caregivers, alone or in combination. results: the mean age of our sample was . ± . years and % were women. more than half ( . %) of residents involved had severe ci and . % had low visits' frequency from informal caregivers. after adjusting for potential confounders, the presence of severe ci (b=- . , se= . , p< . ) and the report of low visits' frequency from informal caregivers (b=- . , se= . , p= . ) were associated with steeper decline in body weight during the six months after the fall. when combining these variables, we found an additive effect of severe ci and low visits' frequency from informal caregivers in influencing weight loss (b=- . , se= . for residents with severe ci and high visits' frequency, and b=- . , se= . for those with severe ci and low visits' frequency; p< . for all). conclusion: our results suggest that cognitive impairment may worsen the impact of falls on nutritional status in nh residents, and that this effect may be exacerbated by scarce assistance from informal caregivers. ( ) tokyo women medical university, tokyo, japan, japan; ( ) department of geriatic medicine, kyorin university medical hospital, tokyo, japan; ( ) tokyo metropolitan institute of gerontology, tokyo, japan) background: in consideration of the future rapid aging of the society, to achieve healthy and active aging is indispensable. because especially the major issue is to prevent "multi-faceted frailty", it is necessary to reconsider regarding nutrition, physical activity and sociality/sociability in the elderly. sarcopenia is associated with adverse health outcomes, such as frailty, limited physical function, falls, disability and loss of independence. objectives: our aim to notice evidencebased new information, leading to frailty prevention, and let the community-based activity by elderly citizen only promote as a voluntary motion in each community. methods: we have already established many new evidences from our on-going japanese large-scale longitudinal study 'kashiwa study'. these evidences include the impact of overlapping of slight oral dysfunction, namely "oral frailty", as well as unbalanced diet and inadequate physical activity in early-stage sarcopenia. furthermore, we found the negative impact of several social disengagements including eating alone, so-called "social frailty", leading to subsequent sarcopenia. we developed a simple screening tool, ''frailty check-up activity'', which elderly citizen supporters only can operate in each small gathering place (e.g. community salon) via support by its local government. results: based on the concept of all-including three pillars, ) nutrition (i.e. dietary food intake including diversity and adequate protein intake, and treatment/maintenance against oral frailty), ) physical activity (not only exercises but also social daily activity) and ) social participation, the newly citizen activity ''frailty check-up'' has developed. after elderly citizen supporters received training fully, they could implement this activity completely and repeatedly in each local municipality. elderly participants could learn how to improve/conquer by themselves with raising their self-awareness for the importance of early frailty/sarcopenia prevention and could change their behavior modification. in addition, using big data combined with preexisting database of new-onset regarding care needs and/or all-cause mortality, we found the new cut-off point in our frailty check-up activity. conclusion: we could confirm that our interdisciplinary "action-research" can raise the citizen's early awareness and affect their behavior modification via elderly citizen supporter system for frailty prevention, consequently leading to extend healthy life expectancy. saguez, carlos márquez, bárbara angel, mario moya, lydia lera (inta, universidad de chile, santiago, chile) background: physical phenotype of frailty has been associated with quality of life deterioration and some studies have calculated cost-effectiveness of interventions on frailty in quality-adjusted life years (qalys), however studies on the direct burden of frailty expressed in qualys lost in community dwelling older adults are scarce. objectives: to forecast qalys lost caused by frailty in older chileans and describe health profiles as determined by euroqol (eq- d) in community-dwelling older chileans with and without frailty. methods: cross sectional study in ( , % women, mean age y± . ) community dwelling people >= years participants in alexandros cohorts. the frailty phenotype was defined as having >= from the following criteria: weak handgrip dynamometry, unintentional weight loss, fatigue/ exhaustion, five chair-stands/slow walking speed and low physical activity. qol was evaluated trough euroqol (eq- d) five dimensions: mobility, self-care, usual activities, pain/ discomfort and anxiety/depression and self-rated health trough eq -visual analogue scale (eq- d-vas). qualys were calculated by the eq -d time trade-off (tto) method. to estimate life expectancies (le), multistate methods based on the follow-up of alexandros cohorts, were employed. results: frailty was identified in , % of the sample. selfrated health according to eq- d-vas was lower in frail than non-frail people ( . ± . vs . ± . , p< , ). after adjusted multinomial logistic regression, the eq- d dimensions of anxiety/depression (very depressed rrr= . ; %ci: . moderate rrr= . ; %ci: , ) and pain (much pain rrr= . ; moderate pain rrr= . ; had the highest association with frailty. the valorisation of years in qualys was lower in frail than in non-frail people ( . ± . vs. . ± . qalys per year, p< , ) and among those frail, much lower in people >= y than in the group - y ( . ± . vs. . ± . , p< , ). the qualys remaining years were lower in frail people than in non-frail:total le at - y was , y corresponding to , qalys in frail and , qalys in the non-frail; in the group >= y tle was , y corresponding to , qalys in frail people and , in the non-frail. conclusion: the high burden of frailty on qalys, mostly related to pain and anxiety/depression makes compulsory its early detection and treatment. its knowledge allows calculating cost-effectiveness of interventions. background: + agil barcelona is a real-life a multicomponent intervention against frailty implemented in a primary care center, which promotes a comprehensive and coordinated approach between primary care, geriatrics teams and community resources, to detect and reverse frailty in the older adults. objectives: we aimed to assess the -months impact on physical function of +agil barcelona in community-dwelling frail older adults with cognitive impairment. methods: the study population was driven from the +agil barcelona program population. we included participants with cognitive impairment or dementia past history and those who performed a minicog test < points. after frailty screening by the primary care team, a geriatric team performed the comprehensive geriatric assessment. according to cga results, a tailored and specific multidisciplinary intervention for each person was designed. the intervention could include a) multi-modal physical activity (pa) sessions, b) promotion of adherence to a mediterranean diet c) health education and d) medication review. the physical performance was assessed at baseline and at -omths follow-up by the short physical performance battery (sppb) and gait speed. the pre/post intervention analysis was done by a paired sample t-test for repeated samples for continuous variables and chi-square for categorical variables. results: we included participants (mean age= . ± . , . % woman and . % lived alone). despite being independent in daily life, . % had fallen the past year, . % were vulnerable or frail according to the csf. physical performance was impaired: sppb= . ± . and gait sped= . ± . m/sec and . % had balance impairments. after months, . % of participants completed >= . physical activity sessions. the mean improvements were + . ± . points (p< . ) for sppb, + . ± . m/ sec (p< . ) for gait speed, - . ± . sec (p< . ) for chair stand test, and . % (p . ) improved their balance. additionally, psychoactive treatment was withdrawn in . %. conclusion: according to our results, a multidisciplinary and comprehensive geriatric intervention for frail elderly people with cognitive impairment of the community improves physical function and could reverse fragility at months. clarence mwelwa patrick chikusu, amritha narayanan, joel james (ashford and st peter's nhs foundation trust, chertsey, uk) background: frailty and muscle strength are a critical component of walking ability and presence of these can result in high prevalence of falls. it also results in increased morbidity and mortality among the elderly. despite sarcopenia being very common and a reversible condition in its early stage it is a frequently overlooked and undertreated geriatric syndrome a greater understanding of sarcopenia and frailty among healthcare professionals could have a dramatic impact on outcome and quality of life of the elderly. objectives: this study aimed to assess the current knowledge about the concept of sarcopenia and frailty among the healthcare professionals working in an nhs district general hospital in surrey. methods: this longitudinal study included nhs healthcare professionals (n = ) who were asked to complete a questionnaire regarding awareness of concept, risk, diagnostic strategy and management of frailty and sarcopenia. results: . % of healthcare professionals stated to know the concept of sarcopenia, % indicated to know how to diagnose sarcopenia and % had seen patients with suspected sarcopenia in the last one month. only % knew the risk associated with sarcopenia. . % used sarc f questionnaire as diagnostic method for sarcopenia. percent of the cohort experienced bottle necks during the implementation of diagnostic strategy. lack of awareness and time ( . %) was the main reason for this . . percent heard the term frailty and . % knew that sarcopenia and frailty is not the same . . percent was aware of the scoring methods for the frailty and . % used clinical frailty score as the method. . % was aware of the frailty pathway but only . % knew whom to contact regarding managing frailty. . % heard the term comprehensive geriatric assessment. only . % was aware of key recommendations of managing frailty in the acute settings. conclusion: although concept of sarcopenia and frailty is familiar to most nhs healthcare professionals, the practical and clinical application is limited due to a lack of awareness regarding the diagnostic methodology, risks as well as time constrains. as such the benefits and potential treatment options may be overlooked and we aim to improve awareness so that these measures can improve outcomes for patients. mahtab alizadeh-khoei , fatemeh sadat mirzadeh , reyhaneh aminalroaya , fati nourhashemi (( ) gerontology & geriatric department, medical school, tehran university of medical sciences, ziaeian hospital, tehran, iran; ( ) department of internal medicine and clinical gerontology, toulouse, france) background: frailty is a potentially reversible geriatric syndrome associated with geriatric risk factors. detecting risk factors is a useful purpose to predict frailty levels incidence to plan for institutional or home care services. objectives: the aims were finding frail and prefrailty frequency in iranian geriatric outpatients' and determining demographics related factors and geriatric syndrome predictors on frailty levels, based on frailty fried index. methods: in this cross-sectional study elderly >= years old, selected by convenience sampling from geriatric day clinics in the area of tehran university of medical sciences. the effect of risk factors (adl and iadl dependency, obesity, and polypharmacy) and geriatric syndromes (falling, chronic pain, sleep problems, vertigo, vision and hearing impairments, incontinence, dementia, and depression) were evaluated on frailty fried index. predictor factors by logistic regression model were analyzed, according to demographic risk factors and geriatric syndromes. results: the mean age was / ± / years old, majority were male ( %). prefrailty was . % in men and . % in women based on fi. the significant risk factors in elderly prefrail women were depression ( . %), polypharmacy ( . %), visual impairment ( . %), and chronic pain ( . %); although, in prefrail men were vertigo ( . %), falling ( %), sleep disorder ( . %), and incontinence ( . %). in prefrail older adults>= years, only sleep disorder was significant. in logistic regression model, six significant predicted factors were included depression, iadl dependency, falling, chronic pain, vertigo, and age. depression increased the risk of prefrailty by . times, dependency in iadl increased . times; moreover, chronic pain and vertigo increased prefrailty risk about times. dependency on iadl increased the risk of frailty . times, and chronic pain and falling increased the risk of frailty about . times. by logistic regression model, % of prefrail outpatients elderly could be diagnosed. conclusion: geriatric syndromes in outpatients' elderly could predict prefrail more than frail elderly. in the iranian community dwellers prevalence of prefrailty was high, so the on-time screening and outpatients' interventions can help to prevent frailty. background: frailty is a key condition to be screened among elderly oncological patients. nevertheless, the use of the frailty index (fi) in onco-geriatrics is still limited. objectives: aim of our work is to measure the functional and prognostic value for -year mortality of the frailty index (fi) in a cohort of older women with gynecological cancer. methods: the prognostic value of fi was tested in older women with gynecological cancer (mean age = . years). fi was retrospectively calculated following the rockwood model[ ]. spearman's rho test was used for correlations with other oncological scales: eastern cooperative oncology group performance status (ecog); karnofsky performance status (kps); vulnerable elders scale- (ves- ). cox proportional hazard models and roc curve were performed to estimate prognostic role of -year mortality. sensitivity and specificity were also calculated. results: fi is normally distributed and descriptive statistics define our population as frail (mean = . ± . , range . - . ). . is confirmed as an upper limit compatible with life. fi doesn't significantly correlates with age, ecog and kps while it positively correlates with ves- (r= . , p < . ). fi is the strongest predictor for -year mortality confirmed after all adjustments for confounders (or . ; % ci . - . , p < . ) and by roc curve analyses ( . , % ci . - . , p=. ). conclusion: frailty index is a useful tool to detect vulnerability in onco-geriatrics and it predicts -year mortality. it predicts negative health-related outcomes (mortality) better than other traditional scales. its adoption may support a more efficient identification of patients in the need of adapted and personalized care. further studies are needed to confirm and extend these findings. background: frailty has been studied in the old population due to its association with negative outcomes but more information is needed about frailty in very old samples. the fried frailty phenotype (ffp) has been widely used and includes a set of objective indicators: weakness, slowness, unintentional weight loss, exhaustion and low physical activity. objectives: to determine which sociodemographic, functional and health-related variables predict ffp in a sample of community-dwelling individuals aged +yrs. methods: data from individuals living in the metropolitan area of porto were considered: sociodemographic information (age, sex, education level, living status), ffp ( - ), functionality (basic and instrumental activities of daily living), health information (nr. medicines, nr diseases, nr. falls, cognitive impairment, and self-perception of health). descriptive and correlational analysis were conducted and followed by a linear regression analysis (stepwise method) of variables significantly associated with ffp. results: participants' mean age was . years (sd= . ), they were mainly women ( . %), with - years of education ( . %) and living with a relative ( . %). high disability levels were found both for basic and instrumental activities of daily living. the mean of medicines intake was . (sd= . ) and of diseases . (sd= . ); . % of the participants rated their health as poor. the median number of falls in the last year was (iqr= ). participants scored on average . points (sd= . ) in mmse. gender or age were not associated with ffp. basic and instrumental activities of daily living, selfperception of health and cognitive performance significantly predicted ffp. in the adjusted model (r = . ), the stronger predictor was the higher dependency for basic activities of daily living, followed by worst self-perception of health and lower scores of cognitive performance. the dependency for instrumental activities of daily living lost its significance in the adjusted model. conclusion: our results identify three main predictors of ffp (basic activities of daily living, selfperception of health, and cognitive performance) in participants with advanced age. these results provide relevant information for further understanding of frailty and the ffp among the oldest old. background: unplanned hospital readmissions are associated with poorer prognosis and increased risk of functional decline and dependence in older people. identifying major risk factors and assessing clinical risk scores can help to distinguish patients at risk of worse outcomes and rehospitalization, allowing the proposal of preventive measures. the aim of this study was to compare the accuracy of different instruments and risk factors in predicting readmission, functional decline and death in hospitalized older patients in a brazilian geriatric unit. methods: in a cohort study performed at a geriatric unit, patients, years old or over were included. demographic data, functional status, prisma scale, geriatric depression scale, mini mental state examination, timed get up and go test, gait speed, mini nutritional assessment, palmar prehension strength, charlson comorbities index, frailty score of the cardiovascular health study and the senior index risk for rehospitalization were assessed at study admission. all patients received a follow-up telephone call at days after discharge to assess potential readmissions, deaths and functional status. results: mean age was . years (sd +- . ) and the mean barthel adl score was . (sd +- . ). altered barthel ( . ; ci % . - . ; p< . ), chs score ( . ; ci % . - . ; p< . ), isar-hp ( . ; ci % . - . ; p= . ), tgug ( . ; ci % . - . ; p< . ), palmar prehension ( . ; ci % . - . ; p= . ) and gait speed ( . ; ci % . - . ; p= . ) were associated with higher mortality days after discharge. the risk of functional decline at -month follow up evaluation was higher in patients with altered barthel ( . ; ci % . - . ; p< . ), lawton ( . ; ic % . - . ; p= . ), chs score ( . ; ci % . - . ; p< . ), isar-hp ( . ; ci % . - . ; p< . ), prisma ( . ; ci % . - . ; p= . ), tgug ( . ; ci % . - . ; p< . ), palmar prehension ( . ; ci % . - . ; p< . ) and gait speed ( . ; ci % . . ; p= . ). conclusion: altered iadl, frailty chs score, isar, tgug, palmar prehension strength and gait speed are predictive of functional decline and mortality days after hospital discharge. these tools can be useful to pinpoint frailty in older patients, allowing the implementation of preventive interventions to avoid functional decline. more research is needed to evaluate the role of these tools in predicting rehospitalization. to limit the strain on available resources and prevent an unnecessary increase in patient burden. objectives: this study aimed to improve patient selection for multi-disciplinary care by identifying risk factors for disability after cardiac surgery in elderly patients. methods: two-centre prospective cohort study in patients aged >= years undergoing elective cardiac surgery. before surgery frailty characteristics were investigated. outcome was disability at three months defined as world health organisation disability assessment schedule . >= %. multivariable modelling using logistic regression, concordance statistic (c-statistic), and net reclassification index were used to identify factors contributing patient selection. results: disability occurred in ( %) patients. ten out of frailty characteristics were associated with disability. a multivariable model including euroscore ii and preoperative haemoglobin yielded a c-statistic of . ( % ci . - . ). after adding prespecified frailty characteristics (polypharmacy, gait speed, physical disability, preoperative health related quality of life, and living alone) to this model the c-statistic improved to . ( % ci . - . ). net reclassification index was . (p< . ) showing improved discrimination for patients at risk for disability at three months. conclusion: using preoperative frailty characteristics improves discrimination between elderly patients with and without disability at three months after cardiac surgery and can be used to guide patient selection for preoperative multi-disciplinary team care. fabiola valero , , henry tapia , , enrique valencia , , tania tello , , (( ) facultad de medicina, universidad peruana cayetano heredia, lima, peru; ( ) instituto de gerontología, universidad peruana cayetano heredia, lima, peru; ( ) hospital cayetano heredia, lima, peru) background: frailty is increasingly recognized as a risk assessment to detect vulnerability and complexity. currently, there are limited tools to predict adverse perioperative outcomes for the geriatric population with hip fracture. objectives: to determine frailty and functional dependence as predictors of intrahospital adverse events in hospitalized older adults with hip fractures in the orthogeriatric unit of a general hospital in lima, peru. methods: we conducted a prospective cohort involving patients aged years or older who were admitted to the orthogeriatric unit with hip fracture from june to june . data were obtained at the time of admission to our unit: frailty was assessed with the frail scale, function ability with the barthel scale, cognition with the short portable mental state questionnaire (spmsq) scale of pfeiffer, comorbidities, socio-family assessment and geriatric syndromes. patients were followed up to discharge, and adverse events were evaluated during this period. univariate models were performed, and logistic regression was done subsequently. results: patients with hip fractures were evaluated, the mean age was . ( . ) years, . % ( ) were women and . % ( ) came from nursing homes. hypertension was the most frequent comorbidity in . % ( ). % ( ) had a history of functional dependence on basic activities of daily living (abvd), % ( ) had some degree of cognitive impairment, . % ( ) had social problems, polypharmacy in . % ( ) and . % ( ) history of falls in the last year. according to frail scale, . % (n = ) were robust, . % (n = ) were pre-frail and . % were frail (n = ). . % ( ) had an adverse event while hospitalized (pneumonia, uti, delirium, acute renal injury, pet), of whom % ( ) were robust, . % ( ) pre-frail and % ( ) frail (p = . ). . % of patients with functional dependence on abvd presented adverse events. in the multivariate analysis, the factors associated with in-hospital adverse events were functional dependence in abvd, or: . , (ci: . - . ); frailty with an or: . ic ( . - . ) and social problem, or: . ic ( . - . ). conclusion: older adult patients hospitalized for hip fracture who had frailty, functional dependence, and social problems had significant adverse events at a general hospital in lima, peru. aiko inoue , chi hsien huang , , chiharu uno , kosuke fujita , , tomoharu kitada , , joji onishi , hiroyuki umegaki , masafumi kuzuya , (( ) institutes of innovation for future society, nagoya university, japan; ( ) department of community health and geriatrics, nagoya university graduate school of medicine, nagoya, japan; ( ) department of business administration, seijoh university, aichi, japan) background: social frailty was associated with age, sex, income, education, marital status, and household status. however, the risk factors of social frailty relatively less investigated. objectives: the aim of this study is to clarify the risk factors of social frailty in community-dwelling japanese elderly. methods: a health promotion project (nagoya-teng project) is designed to distribute health promotion programs including enhancement of nutrition and physical activity via cable tv channel for community-dwelling elders. of all participants (n= ), participants with complete baseline information (mean age . ± . years, men ( . %)) were included in our cross-sectional analysis. at baseline, demographic data, socio-economic status, geriatric depression scale (gds- ), japanese version of european health literacy survey questionnaire (j-hls-eu-q ) were obtained. social frailty was defined by household status (living alone or not), financial difficulty, social activity, and fulfilment of social needs. total deficit scores of or more were defined as social frailty, as social pre-frailty, and as robustness. results: a total of ( . %), ( . %), and ( . %) of all participants were categorized as social non-frailty, pre-frailty and social frailty, respectively. in multivariable logistic regression model after adjusting for age, sex, bmi, and education level, living without a spouse is a significant risk factor (p< . ) for social pre-frailty (or . , % ci . - . ) and social frailty (or . , ). low gds- scores were associated with high risk of social prefrailty (or . , % ci . - . ) and social frailty (or . , % ci . - . ). in addition, health literacy was inversely associated with social frailty (or . , % ci . - . ). age, sex, and education level were not associated with social frailty. conclusion: regardless of age and sex, living with a spouse and depression which is associated with activity of daily living and quality of life are associated with social frailty. low health literacy is also a risk factor of social frailty. in literature, loneliness and social frailty were associated with functional decline and mortality in the elderly. future approaches incorporating health literacy interventions are warranted to prevent social frailty in the aged society with increasing number of physical frail older adults. background: frailty increases the risk for morbidity and mortality after cardiac surgery. the influence of frailty on postsurgical functional outcomes is largely unknown. objectives: the aim of this research was to study the association of preoperative frailty characteristics on adverse functional outcomes and to investigate the trajectory of functional recovery among frail and non-frail elderly patients up to one year after elective cardiac surgery. methods: a prospective two-centre observational cohort study in elective cardiac surgery patients aged >= years. preanaesthesia assessment was supplemented with frailty tests covering the physical, mental, and social domain. functional outcomes were assessed at one year and included change in health related quality of life (hrql) measured by the short form and disability measured by the world health organisation disability assessment schedule . . adverse functional outcome was considered when worse physical or mental hrql or disability was present after surgery. results: frailty characteristics were present in ( %) patients of whom ( %), ( %) and ( %) showed frailty in the physical, mental or social domain respectively. adverse functional outcome at one year after surgery occurred in ( %) patients. patients with an adverse functional outcome were more often frail ( ( %)) than patients without an adverse functional outcome ( ( %) p< . ). worse physical or mental hrql occurred in ( %) and ( %) patients respectively. the most important frailty characteristic associated with worse physical hrql was high preoperative physical hrql (β - . per point ( % ci - . to - . ). preoperative mental hrql showed the strongest associations for worse mental hrql (β - . per point ( % ci - . to - . )). disability was reported by ( %) patients and associated with preoperative polypharmacy, gait speed, health related quality of life, living alone or dependent living. gait speed had the strongest association (β . per second ( % ci . to . )). conclusion: preoperative frailty characteristics were common and predictive for adverse functional outcome one year after cardiac surgery. frailty screening can be used to improve risk stratification and decision making in older cardiac surgery patients. background: frailty frailty has many elements and these can be characterised as physical, nutritive (including body composition), cognitive and sensory (including hearing and seeing). the relative prevalence and importance of these elements are not known. objectives: to estimate the prevalence of frailty and relative contribution of physical/ balance, nutritive, cognitive and sensory frailty to important adverse health states (falls, physical activity levels, outdoor mobility, problems in self-care or usual activities, and lack of energy or accomplishment) in an english cohort. methods: analysis of community-dwelling older people. the sample was drawn from a random selection of all people aged or more registered with general practices across england. data were collected by postal questionnaire. frailty was measured with the strawbridge questionnaire. we used cross sectional, multivariate logistic regression to estimate the association between frailty domains and adverse health outcomes. some models were stratified by sex and age. results: mean age of participants was years (sd . ), range to and . % ( / ) were men. the prevalence of overall frailty was . % ( / ) and there was no difference in prevalence by sex (odds ratio . ; % confidence interval . to . ). sensory frailty was the most common and this was reported by more men ( / ) than women ( / ; odds ratio for sensory frailty . , % confidence interval . to . ). men were less likely than women to have physical or nutritive frailty. physical frailty had the strongest independent associations with adverse health states. however, sensory frailty was independently associated with falls, less frequent walking, problems in selfcare and usual activities, lack of energy and accomplishment. conclusion: physical frailty was more strongly associated with adverse health states, but sensory frailty was much more common. the health gain from intervention for sensory frailty in england is likely to be substantial, particularly for older men. sensory frailty should be explored further as an important target of intervention to improve health outcomes for older people both at clinical and population level. background: it live independently. our goal is to encourage independent living, wellbeing and to relieve health and care services budget pressure. longevity is one of the biggest achievements of modern societies. by , a quarter of europeans will be over years of age. combined with low birth rates, this will bring about significant changes to the structure of european society, which will impact on our economy, social security and health care systems. the most problematic expression of population ageing is the clinical condition of frailty. frailty develops because of age-related decline in multiple physiological systems. it is estimated that a quarter to a half of people over years are frail , and this is set to reach epidemic proportions over the next few decades. while frailty increases, the average amount of health spending increases as well with the frailty level in a range from , to , €/person year, depending upon the frailty status and the setting of care. frailty usually comes along associated with another risk facto; loneliness. then, ageing, frailty and loneliness constitute overlapping conditions submitted to multiple health and care interventions. ecare project aims to deliver disruptive digital solutions for the prevention and comprehensive management of frailty to encourage independent living, wellbeing and to relieve health and care services budget pressure, throughout the implementation of a pre-commercial procurement scheme. pre-commercial procurement is an ideal framework for the delivery of innovative solutions. the ecare network of procurers and the service providers are often on the frontline as new needs emerge. this pcp will allow the procurers to voice out their unmet needs, create a new demand to access sustainable products of higher quality, and develop new applications with lower life cycle costs. the demand and the supply side will work together to co-create and co-design the solutions and validate their functionalities against the specific challenges outlined in the pcp call for tender. this will clearly maximize the engagement of innovation in health and care services. solutions should improve outcomes for frailty in old adults entailing the physical and the psychosocial factors. the target group are the pre-frail/frail old adults with emphasis on those that feel lonely and/or isolated. the project will procure the development, testing and implementation of digital tools/services and communication concepts to facilitate the transition to integrated care models across health and social services and country-specific cross-institutional set-ups, including decentralised procurement environments and collaboration across institutions. objectives: the project objectives are: • newly development easy-to-use and reliable solutions that facilitate early detection of frailty based on the most efficient standards and methods. • improve the understanding of the factors affecting frailty and the feelings of loneliness and isolation, and how they do correlate (e.g.: gender dimension, social context, etc.). • deliver personalised intervention plans taking into account the end-user societal context. • innovative and meaningful means to tackle the feelings of loneliness and isolation. • new approaches to engage patients as active self-managers of their own health. • new technology developments designed and oriented to the target end-user. • and among all, investigate to deliver cost-efficient solutions, affordable to the payers involved. methods: ecare procurers will proactively organize the requirements of the demand for care solutions in a coherent way. the procurers (buyers' group) will assess the solution adequacy to the targets. the preferred partners will contribute with solid knowledge of innovative procurement paths to the innovation procurement tender. the project partners will do this by: • providing a solid and informed base for dialogue between stakeholders by determining a coherent picture of the market state of the art of the sector based on practical experience of customers and suppliers. • enabling a genuine and credible dialogue between the supply-chain and customers to determine the practical policy and procurement actions required to deliver the ecare solutions. • defining the common unmet needs, communicating these to stakeholders and initiating a mobilization plan for a pcp addressing ecare needs. the pcp may be summarized in a series of actions: • convey the relevance of innovation procurement to public procurers: encouraging suppliers to offer novel solutions to address ecare challenges rather than the lowest price solutions. • analyze the state of the art of the market with all potential suppliers, as well as the main problematic and barriers faced in the sector and that need to be overcome a set of actions involving both the supply and demand sides will be carried out: a coordinated first analysis of the state of the art conducted by all project members followed by a coordinated market sounding through all dissemination channels managed by the consortium will be undertaken to spread project results aiming to receive feedback from all key market players. for this, the role of procurers is vital to replicate and stretch the impact of the project. • providing public procurers with procurement know-how to improve public sector procurement efficiency and increase public sector market power by giving support to apply the methodologies of innovation procurement. market sounding will provide an opportunity for engagement and two-way dialogue with innovative companies that can offer solutions and guidance on how to overcome the procurement barriers. • launching an agreed, realistic and validated joint pcp tender. results: the ecare consortium is immerse in a deep process of unmet needs detection. our goal is to be extraordinarily concrete when defining what the end users and the healthcare professionals are willing for. those unmet needs will be critical for the definition of the requirements and uses cases that the it suppliers will have to follow to design the ict solutions. then… what a better way to know their needs that asking them personally? the vision of providing tailored fit solutions and tools to the end users led to the consensus in creating and facilitating focus group sessions across the procurers regions -campania (italy), barcelona (spain), santander (spain) and wroclaw (poland)-. these sessions will be involving end users, health and social care professionals, and it internal departments of the procurers' organisations. -the focus group script for the end users sessions integrates as main topics the specific condition and related symptoms; experiences of services and care provided; experiences of managing condition when progressing rapidly ; needs for symptom management and how these can be met ; integration of it supportive tools in the management of frailty and loneliness. -the professionals are invited to reflect and discuss the topics of common symptoms and actual care model; experiences of monitoring elderly when condition is progressing rapidly; views about the supportive care needs of elderly and caregivers; early integration of the new care in the management of frailty and loneliness; integration of it supportive tools in the management of frailty and loneliness. -the identified and proposed topics for the it staff would be the state of the art of the relation in between it and social/healthcare; state of the art of interventions on frailty and loneliness. all the four procurers were challenged to organize, at least, focus sessions, one with each specific target group. so far, all the procurers already organized and scheduled the sessions that will occur until the end of january. in terms of impact, participants are expected to be involved ( end users, healthcare professionals and it people). all the representative of the procurers reported so far that the participants have been considering the sessions so interesting and useful. in fact, new topics have been put in the table for discussion in all the different sessions, adding more important information for the definition of the unmet needs. the journey of the project so far has been providing very powerful insights and evidences that people and professionals appreciate to be involved and e(motionally) cared. conclusion: ecare will progress beyond the state of the art by approaching older people not just in terms of their diseases but also in terms of physical, cognitive and psychosocial care and support to prevent functional decline, frailty and disability. the project key components to address frailty are those that define also integrated care, with the addition of targeting high risk frail individuals, an enablement attitude and a focus on outcomes most relevant to frail individuals and their caregivers. for these, a multimodal comprehensive system able to provide the most effective care will need to be provided. background: maintaining autonomy as life progresses has become a challenge for the health systems. this objective can only be achieved by moving the axis of health policies and health care practice from the disease to the preservation of functional capacity. objectives: the aim of this study is to design and pilot a model for the assessment and support of functionality for community dwelling older people. methods: a space in which nurse and social worker jointly assess the functional capacity of older people and identify and provide responses to the detected deficits was proposed. this study was performed in osi donostialdea (gipuzkoa, spain). three main tasks were carried out: . definition of the joint assessment procedure of functionality. . identification of the existing resources and community assets to give answer to the identified needs. . piloting the model in a sample of older people. the identified needs and the availability of resources to respond to them were obtained from the pilot phase. results: in the initial version of this integral assessment were included, functional capacity, physical activity, cognitive capacity, sense organs, nutritional status, social assessment and housing and environmental conditions. a total of individuals ( % women; mean age years, sd= . ; barthel index, mean . , sd= . ; % living alone; % without cognitive impairment) were recruited during the pilot. the following needs were identified: personalized workout routines, fine motor skill exercises, visual and efficient diets adjusted to each patient, make sure resources reach the community, promote the use and design of gadgets to assist the needs of basic and instrumental activities of daily living, improve strategies to prevent cognitive function impairment, ease loneliness and avoid or minimize physical and environmental barriers to access home, to walk the streets and, particularly, to use public transport. there were no resources available for all the identified needs. conclusion: this study will allow the development of a model for the integral assessment of functionality for the aged population, based in a multidisciplinary team, a space and a new way of working in primary care. mónica machón - , maider mateo-abad , , mercedes clerencia-sierra , , , carolina güell , , beatriz poblador-pou , , kalliopi vrotsou - , antonio gimeno-miguel , , alexandra prados-torres , , itziar vergara - ( ( ) background: multimorbidity and frailty are often present in older people and are found to be associated to increased risk of adverse health events. it is necessary to improve the knowledge of the characteristics of such populations to design adequate clinical guidelines seeking to avoid or delay the onset of dependence. objectives: the aim of this study was to identify clusters of chronic diseases in robust and frail individuals and compare sociodemographic and health characteristics between these clusters. methods: this was a cross-sectional study based on data from two longitudinal studies. the sample was composed of functionally independent community-dwelling older people with multimorbidity living in gipuzkoa (basque country, spain). information from electronic health records (diagnose diseases and medication) and a baseline assessment (sociodemographic characteristics, functional status, self-perceived health, cognitive status, sight and hearing impairments, history of falls and nutritional status) was used in the analysis. the timed up and go test of physical performance was included as a measure of frailty. multiple correspondence and cluster analyses were performed to identify groups. results: the study population consisted of individuals ( . % women; mean age . years, sd= . ). frail individuals (n= ) were older, had a lower educational level and a poorer health status than robust individuals (n= ). three clusters were obtained in robust (rc , n= ; rc , n= and rc , n= ) and four among the frail individuals (fc , n= ; fc , n= ; fc , n= and fc , n= ). in rc and fc , none of the chronic diseases had a higher prevalence than in rc -rc and fc -fc -fc , respectively. individuals pertaining to rc and fc presented more frequently diseases related to mobility limitation or limb pain compare to the other clusters. higher rates of cardiovascular diseases and risk factors were seen in rc and fc . in frail individuals a new cluster emerged, fc , containing individuals with higher rates of cognitive and eye problems and a clearly poorer health status. conclusion: the findings obtained in this exploratory study may provide insight for the designing of more specific health interventions for older patients with multimorbidity, even though the chronic diseases cluster identified were similar in robust and frail individuals. background: older african americans (oaa) are at high risk for becoming frail in later life. interventions can reverse or delay frailty, yet oaa have largely been excluded from frailty intervention research. many interventions are also time and resource intensive, making them inaccessible to socially disadvantaged oaa. objectives: we present results of a feasibility trial of a low dose frailty prevention intervention among community-dwelling, pre-frail oaa aged + recruited from a primary care clinic between june st and october st . methods: using a -arm rct, participants were assigned to the intervention, which was delivered by an occupational therapist (ot) and comprised of four sessions over four months (an ot evaluation, and sessions on healthy dietary practices, increasing physical activity, and maintaining a healthy lifestyle), or enhanced usual care (publicly available information about healthy lifestyle, home safety, and local elder services). feasibility criteria were set a priori at % for participant retention (including attrition due to death/ hospitalization), % for session engagement, participants/ week for mean participant accrual, and % for program satisfaction. results: participants were % female with an average age of . years, . % of which lived alone and . % lived off of less than k per year. feasibility metrics were met. the study recruited . participants per week and retained % of participants who attended % of scheduled sessions. mean satisfaction scores were %. the treatment also resulted in positive trends in the expected direction in the treatment group for the following outcomes (d = effect size): global health (d = . ), mental health (d = . ), qol (d = . ), social functioning (d = . ), depression (d = . ), and pain reduction (d = . ). descriptively, treatment group participants were also less likely to experience a progression (deterioration) in three frailty status indicators at -months compared to controls: weight lost, walking speed slowness, and grip strength weakness. conclusion: the intervention was feasible to deliver. qualitative findings from exit interviews suggested changes to the program dose, structure, and content that could improve it for future use. background: it is well known that frail patients are potentially most at risk of functional decline following a hospital admission. objectives: to measure the effects of an augmented prescribed exercise programme versus usual care, on physical performance, quality of life and healthcare utilisation for frail older medical patients in the acute setting. methods: this was a parallel single-blinded randomised controlled trial. within two days of admission, older medical inpatients with an anticipated length of stay >= days, needing assistance/aid to walk, were blindly randomly allocated to the intervention or control group. until discharge, both groups received twice daily, monday-to-friday half-hour assisted exercises, assisted by a staff physiotherapist. the intervention group completed tailored strengthening and balance exercises; the control group performed stretching and relaxation exercises. length of stay was the primary outcome measure. blindly assessed secondary measures included readmissions within three months, and physical performance (short physical performance battery) and quality of life (euroqol- d- l) at discharge and at three months. time-to-event analysis was used to measure differences in length of stay, and regression models were used to measure differences in physical performance, quality of life, adverse events (falls, deaths) and negative events (prolonged hospitalisation, institutionalisation). results: of the patients allocated, patients' (aged ± . years) data were analysed. groups were comparable at baseline. in intention-to-treat analysis, length of stay did not differ between groups (hr . ( % ci, . - . ) p= . ). physical performance was better in the intervention group at discharge (difference . ( % ci, . - . ) p= . ), but lost at follow-up (difference . ( % ci, - . - . ) p= . ). an improvement in quality of life was detected at follow-up in the intervention group (difference . ( % ci, . - . ) p= . ). overall, fewer negative events occurred in the intervention group (or . ( % ci . - . ) p= . ). conclusion: improvements in physical performance, quality of life and fewer negative events suggest that this intervention is of value to frail medical inpatients. its effect on length of stay remains unclear. background: to propose a simple frailty screening tool able to highlight frailty profiles, already since the initial screening phase. methods: a -item questionnaire (lorraine frailty profiling screening scale, lofpross), constructed by an experts' working group, was administered by health professionals to participants > years old (n= ) and living at home, in different clinical settings: a primary care outpatient clinic (rural population, n= ), a geriatric day clinic (day-clinic population, n= ) and healthy volunteers (urban population, n= ). a multiple correspondence analysis (mca) followed by a hierarchical clustering of the results of the mca performed in each population was conducted to identify participant profiles based on their answers to lofpross. a response pattern algorithm was resultantly identified in the rural (main) population and subsequently applied to the urban and day-clinic populations and, in these populations, the two classification methods were compared. finally, clinically-relevant profiles were generated and compared for their ability to similarly classify subjects. results: the response pattern differed between the subpopulations for all items, revealing significant intergroup differences ( . ± . positive responses for urban vs. . ± . for rural vs. . ± . for day-clinic, all p< . ). five clusters were highlighted in the main rural population: "non-frail", "hospitalizations", "physical problems", "social isolation" and "behavioral", with similar clusters highlighted in the remaining two populations. identification of the response pattern algorithm in the rural population yielded a second classification approach, with % of tested participants classified in the same cluster using the different approaches. three clinically-relevant profiles ("non-frail" profile, "physical frailty and diseases" profile and "cognitive-psychological frailty" profile) were subsequently generated from the clusters. a similar double classification approach as above was applied to these profiles revealing a very high percentage ( . %) of similar profile classifications using both methods. conclusion: the present results demonstrate the ability of lofpross to highlight frailty-related profiles, in a consistent manner, among different older populations living at home. such scale could represent an added value as a simple frailty screening tool for accelerated and better-targeted investigations and interventions. ( ) homburg/saar/germany, saarland university medical center, neurology, homburg/germany) background: frailty is the most important short and long term predictor of disability in the elderly. no study to date evaluate the impact of frailty on short and long term independently from neurological outcome measures. objectives: the aim of the study was to evaluate whether diagnosis frailty predicts short and long-term mortality and neurological recovery in old patients who underwent reperfusion acute treatment in stroke unit. methods: consecutive patients were older than years who underwent thrombectomy or thrombolysis in a single stroke unit from to . predictors of stroke outcomes were assessed including demographics, baseline nihss, time to needle, treatment and medical complications. premorbid frailty was assessed with a comprehensive geriatric assessment (cga) including functional, nutritional, cognitive, social and comorbidities status. at and months, all-cause of death and clinical recovery (using mrs) were evaluated. results: patients, of whom underwent mechanical thrombectomy and venous thrombolysis (mean age . , - years) entered the study. frailty was diagnosed in out of patients and associated with older age (p= . ) but no differences in baseline nihss score or treatment strategies. at follow-up, frail patients showed higher incidence of death at ( % vs %, p= . ) and ( % vs %, p= . ) months. frailty was associated with worse neurological recovery at month (mrs . + . vs . + . , p= . ) and one year followup (mrs . + . vs . + . ) for free survival patients. conclusion: frailty is an important predictor of efficacy of acute treatment of stroke beyond classical predictors of stroke outcomes. larger prospective studies are warranted in order to confirm our findings. background: frailty becomes increasingly common as adults age and has known associations with activity limitations and injurious falls among older adults. while it is believed that frailer older adults are less socially connected than their more functional counterparts, less is known about the relationship between frailty and social isolation among community-dwelling older adults. objectives: the purpose of this study was to examine associations of frailty indicators on self-reported social isolation risk among community-dwelling adults age years and older. methods: the upstream social isolation risk screener (u-sirs) was developed to assess social isolation risk among older adults within clinical and community settings. comprised of items (cronbach's alpha= . ), the u-sirs assesses physical, emotional, and social support aspects of social isolation. using an internet-delivered survey, data were collected from a national sample of , adults age years and older. participants completed the u-sirs and additional items on sociodemographics and other health risks. theta scores for the u-sirs serve as the dependent variable, which were generated using item response theory. an ordinary least squares regression model was fitted to identify frailty indicators associated with social isolation risk. results: participants' average age was . (± . ) years. the majority of participants was female ( . %) and lived with a partner/spouse ( . %). twenty eight percent of participants reported difficulty walking or climbing stairs, . % reported difficulty dressing or bathing, and . % reported a fall in the past year. higher u-sirs theta scores were reported among males (b= . , p< . ) and those with more chronic conditions (b= . , p< . ). participants who reported difficulty walking or climbing stairs (b= . , p< . ), difficulty dressing or bathing (b= . , p= . ), or a fall in the past year (b= . , p< . ) also reported higher u-sirs theta scores. further, higher u-sirs theta scores were reported among participants who had not left their home in the past three days (b= . , p< . ). conclusion: findings suggest frailer older adults and those with functional limitations may have greater risk for social isolation. this highlights the critical demand for easy-to-administer and practical assessments for frail older adults that identify their social isolation risk and link them to needed resources and services. background: peak expiratory flow (pef) has been linked to several negative health-related outcomes in older people, but its association with frailty is still unclear. objectives: this study investigates the association between pef and prevalent and incident frailty in older adults. methods: data come from community-dwelling participants of the swedish national study on aging and care in kundgsholmen (snac-k), aged >= years. baseline pef was expressed as standardized residual (sr) percentiles. frailty was assessed at baseline and over six years, according to the fried criteria. associations between pef and frailty were estimated crosssectionally through logistic regressions, and longitudinally by multinomial logistic regression, considering death as alternative outcome. obstructive respiratory diseases and smoking habits were treated as potential effect modifiers. results: our crosssectional results showed that the th- th and < th pef sr-percentile categories were associated with three-and fivefold higher likelihood of being frail, than the th- th one. similar estimates were confirmed longitudinally, i.e. adjusted or= . ( %ci: . - . ) for pef sr-percentiles< th, compared with th- th. associations were enounced in participants without physical deficits, and tended to be stronger among those with baseline obstructive respiratory diseases, and, longitudinally, also among former/current smokers. conclusion: these findings suggest that pef is a marker of general robustness in older adults and its reduction, exceeding that expected by age, is associated with frailty development. background: as consistently reported in the literature, muscle strength (ms) decreases at a higher rate than muscle mass (mm) during aging resulting in a decreased muscle quality (mq). loss of mq has been associated with loss of mobility, falls, frailty and an increased risk of mortality. however, the degree of muscle declines is varying throughout the population leading to states: successful, normal or pathological. it has been proposed that healthy life habits such as be physically active, having a healthy diet etc. could reduce the muscle aging decline. thus, identifying if life habits could counteract or maintain muscle quality during successful aging is important to better characterize aging and to intervene more specifically. objectives: the aim of the present study was to identify whether a physically active lifestyle could attenuate the effects of aging on mq. methods: active young were compared to active older men. to be considered active, young and older men need to practice voluntary physical activity at least min/week since yrs. body composition (dxa; mri) and maximum knee extension strength were measured. mq was calculated as the ratio of ms to mm. aerobic capacity (vo max; moxus©) and muscle contractility (emg) were also measured. muscle biopsies were performed to determine fiber typing, size, intermuscular adipose tissue (imat) and intramyocellular lipid content (imcl). results: absolute mm (p< . ) and ms (p= . ) was greater in young participants compared to their older counterparts while mq was similar between them. even if total (p= . ) and type iia (p= . ) fiber size were greater in ya than in oa, muscle fiber proportion, muscle contractility and lower limb fat mass (imat, imcl) were similar between both groups (p> . ). conclusion: mq was similar between younger and older physically active men suggesting that being physical activity may have mitigated the loss of mq with aging and delayed some physiological age-related changes (muscle composition, contractility). i r a t x e e g a ñ a , itxaso mugica , , nagore arizaga , maider ugartemendia , nagore zinkunegi , janire virgala , maider kortajarena ( ( ) and sppb test (p< , ). similar results have been found in other researches. the parameters that have higher influence in cognition are handgrip test (p< , ) and frailty (p< , ). in other investigations, they got the same results; better cognition is related to better physical capacity and less fragility. in regards with functionality, the values of tug test (p< , ) and gait speed (p< , ) are the ones that show stronger relation. in other investigations, they observed that physical state and functionality were related. conclusion: the quality of life, the functionality and moca test are interconnected and the parameters that have the strongest statistical relationship are fragility and physical state. the greater the physical capacity of the older person is, the greater the functional capacity is too and the fragility decreases. in conclusion, the quality of life is better. kazuki kaji , jun kitagawa , takahiro tachiki , naonobu takahira , masayuki iki , junko tamaki , etsuko kajita , yuho sato , jpos study group (( ) national center for geriatrics and gerontology, obu, aichi, japan; ( ) nagoya university, nagoya, aichi, japan; ( ) nagoya city university, nagoya, aichi, japan) background: the skeletal muscle mass index (smi), which is the appendicular skeletal muscle mass (asm) adjusted for height squared (kg/m ), is used to assess skeletal muscle mass. we reported at this conference last year that smi was overestimated by height loss due to aging in elderly women. furthermore, age-related changes in smi were inconsistent with changes in physical function such as grip strength and walking speed. objectives: the purpose of this cross-sectional study was to investigate the effects of height loss on agerelated changes in smi and physical function in japanese women aged or older. methods: this study was part of the / -year follow up survey of the japanese population-based osteoporosis (jpos) cohort study conducted in / . the jpos study was started in . the subjects of the / year follow-up were women (mean . ± . years). we divided the subjects into quartiles based on years of height loss (q : the lowest, q , q and q : the highest). asm was measured by dual x-ray absorptiometry (qdr a, hologic, usa). grip strength, maximum walking speed, and timed up and go (tug) were also measured. results: the mean change in height during the / -year follow-up was - . ± . cm. mean changes in height in q (n= ), q (n= ), q (n= ) and q (n= ) were - . ± . cm, - . ± . cm, - . ± . cm and - . ± . cm, respectively. the trend test demonstrated significant increases in the mean age and smi from q to q . on the other hand, there was a significant decrease in asm from q to q . the mean grip strength and maximum walking speed significantly decreased from q to q . tug results were similar, suggesting that greater height loss led to longer times. conclusion: in japanese elderly women with height loss, asm and physical function decreased with age, but the smi adjusted for height increased. it may be necessary to establish a muscle mass parameter other than smi to investigate the relationship between muscle mass and physical function. kota tsutsumimoto , takehiko doi , sho nakakubo , satoshi kurita , hideaki ishii , hiroyuki shimada (( ) section for health promotion, department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan; ( ) center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan) background: sarcopenia was defined as decline in skeletal muscle mass and muscle function, leading to serious health problems including disability. the modifiable risk factors of sarcopenia should be elucidated to contribute to develop intervention from sarcopenia. objectives: to examine the association between anorexia of aging and sarcopenia among community-dwelling elderly japanese individuals. methods: population-based, cross-sectional cohort study in japanese older adults was conducted and participants were identified from the database of the national center for geriatrics and gerontology-study of geriatric syndromes. anorexia of aging was assessed via a simplified nutritional appetite questionnaire. handgrip strength and walking speed were tested, and skeletal muscle mass was assessed using a bio-impedance analysis device. subjects with sarcopenia were defined as those who met the criteria of the asian working group for sarcopenia. the association between anorexia of aging and sarcopenia was then analyzed via multiple regression analysis. results: in total, , elderly japanese individuals were evaluated. the prevalence of sarcopenia and anorexia of aging was . % and . %, respectively. in multivariable logistic regression model adjusted for the covariates except for nutritional status such as albumin, anorexia of aging was independently associated with sarcopenia (or: . , % ci: . to . ; p = . ). this significant association remained even after adjusting for all covariates including nutritional status (or: . , % ci: . to . , p = . ). conclusion: anorexia of aging is associated with sarcopenia among japanese older adults. further studies are needed to determine whether a causal association exists between anorexia and sarcopenia. background: low grip strength is consistently associated with higher rates of mortality, disability and other age-related health outcomes, and is a key characteristic of sarcopenia. grip strength has thus been proposed as a general biomarker of ageing. life expectancy in russia is substantially lower than in norway but whether this is reflected in differences in grip strength across adulthood, as observed in previous comparisons of older adults from russia, denmark and england, needs to be established and explained. objectives: we aimed to compare grip strength in norwegian and russian populations by age and gender, and investigate whether any observed differences were explained by contrasts in height, weight, smoking or education. methods: we used harmonised cross-sectional data on grip strength for , men and women aged - years. this comprised participants from the russian know your heart study (n= , ) conducted in the cities arkhangelsk and novosibirsk in - , and from wave of the norwegian tromsø study (n= , ) conducted in - . grip strength was assessed using the jamar+ digital dynamometer in both studies, and the maximum of six measurements (three in each hand) was used. the association between grip strength and covariates was assessed using linear regression. results: norwegian males had stronger grip than russian males at all ages, for example they were an average of . kg ( % confidence interval (ci) . , . ) stronger at age years and . kg ( % ci . , . ) stronger at age years. among women, corresponding numbers were . kg ( % ci . , . ) at age and . kg ( % ci . , . ) at age . adjustment for weight, education and smoking did not affect the results, but height attenuated the between country differences, especially at older ages. among women aged +, differences in height between countries fully explained the differences observed in grip strength. conclusion: norwegian -year-olds had the grip strength of -year-old russians suggesting that russians are ageing more rapidly in terms of muscular strength than their norwegian counterparts. the important role of height in explaining these differences, especially at older ages, suggest contrasts in early life circumstances may be of key importance. eleanor lunt , , paul greenhaff , , adam l gordon , , , john rf gladman , ( ( ) background: frailty is a state of vulnerability to stressors resulting in adverse clinical outcomes including falls and fragility fractures. identifying biomarkers associated with these outcomes may help target interventions. objectives: to compare parameters of body composition, muscle thickness and muscle strength between patients and healthy older and young volunteers. methods: six young ( - years) and older (>= years) healthy female volunteers were recruited by advert from community groups. female patients (>= years) with an acute fragility fracture were recruited from hospital wards and measured during first week of admission (median th day (iqr - )). frailty was determined by the -item frail scale. height, weight, handgrip (jamar dynamometer) and knee extension (lafayette manual muscle tester) were assessed. body composition was estimated using whole body bioelectrical impedance (bodystat quadscan ®). midpoint vastus lateralis (vl) muscle thickness and mid-thigh subcutaneous fat thickness were assessed using ultrasound (mylab gold, esaote biomedica, italy) with a hz linear-array probe. oneway anova and post hoc tukey's test were used to compare end-point measures between groups. results: frailty was significantly more prevalent in the patient group ( % frail, % pre-frail, % robust) than the healthy older group ( % robust, p< . ). the patient group was older ( ± years vs ± years, p< . ) and had more co-morbidities (p< . ). there were no significant differences between the patient and healthy older group in weight, height, bmi, percentage body fat or subcutaneous fat thickness of lateral thigh. vl muscle thickness was lower in the patient group compared to healthy older and young volunteers ( . ± . cm, . ± . cm and . ± . cm respectively, p< . ). the patient group also had lower handgrip strength ( . ± . kg, . ± . kg, . ± . kg respectively, p< . ) and lower knee extension strength ( . ± . kg, . ± . kg, . ± . kg respectively, p< . ). vl muscle thickness associated with muscle strength (knee extension r= . , p< . and handgrip r= . , p< . ) and was significantly lower in the frail compared to pre-frail or robust participants ( . ± . cm, . ± . cm, . ± . cm respectively p< . ). conclusion: female patients presenting to hospital with a fall and fragility fracture have lower muscle thickness in the thigh compared to non-frail older women, despite no difference in other body composition variables. register, health technology assessment, nhs economic evaluation database) were searched from inception to april , . cross-sectional and cohort studies that reported adjusted risk ratios with % confidence intervals (ci) for frailty with serum level of total testosterone, free testosterone, sex hormone-binding globulin (shbg) were selected. a metaanalysis was carried out by using fixed effects and random effects models to calculate the or of relationship between low level of testosterone and risk of frailty. results: the crosssectional study concluded articles, there was statistically significant association between lower level of total testosterone and risk of frailty (or= . ; %ci, . - . , i = %), as well as free testosterone (or= . ; %ci, . - . ,i = % ), the highest level of shbg was no significant associated with the risk of frailty(or= . ; %ci, . , . ; i = %). the prospective cohort studies obtain articles, no significant were found between frailty and low total testosterone and frailty (pool or= . ; %ci, . - . , i = %). conclusion: the meta-analysis indicates that low level of serum testosterone is significantly associated with the risk of frailty in the crosssection studies. however, we found no significant relationship between low total testosterone and frailty in the cohort studies. more research is needed to address the underlying mechanisms to explain this relationship and to determine whether testosterone supplementation is effective for preventing frailty syndrome. background: although frailty and abdominal obesity are known risk factors for disability in older persons, few studies have investigated the interaction between both factors on the association with disability. objectives: to investigate the association of frailty and abdominal obesity with disability in older persons. methods: we used data from , participants ( % men) in the prospective, population-based singapore chinese health study cohort, who were interviewed and examined for frailty, abdominal obesity and disability at mean age of (range to ) years from - . we defined frailty as having three or more features of weak handgrip strength, slow timed-up-and-go test, low energy level, multiple comorbidities, and difficulty carrying out usual activities. we defined abdominal obesity by waist circumference using sexspecific cut-offs, and assessed disability using the lawton instrumental activities of daily living (iadl) scale. we used multivariable logistic regression models to compute the odds ratio (or) and % confidence interval (ci) for the association between frailty/abdominal obesity and disability. results: about . % of participants were frail and . % had abdominal obesity. frailty was associated with increased or ( % ci) of . ( . - . ) for disability. conversely, the or ( % ci) for the association between abdominal obesity and frailty was only . ( . - . ). compared to participants who were neither frail nor abdominally obese, the or ( % ci) for disability was . ( . - . ) in those who only had frailty, and . ( . - . ) in those who only had abdominal obesity. however, participants who were both frail and abdominally obese had markedly increased or ( % ci) of . ( . - . ) for disability; p-value for interaction between frailty and abdominal obesity was . . furthermore, while men who were both frail and abdominally obese had increased or ( % ci) of . ( . - . ) for disability compared to their counterparts who were neither frail nor obese, the corresponding or ( % ci) was much higher at . ( . - . ) in women; p value for heterogeneity by sex < . . conclusion: frailty and abdominal obesity interacted synergistically to increase the risk of disability in older persons, and the combined effect of both factors on disability was much stronger in women than in men. background: as the world's population ages, the prevalence of cognitive impairment associated with age increases exponentially. objectives: objective of this study was to investigate the longitudinal association of physical activity and cognitive function in two deferentl populations; older adults from mexico representing latin america and south korea representing asia. based on two large population-based longitudinal studies. methods: this is a secondary analysis of two surveys, mhas and klosa, designed to study the aging process of adults living in mexico and south korea. participants> were selected from rural and urban areas. here we investigate the longitudinal association of exercise and cognition using the two waves of each study. cross cultural cognitive examination and mini-mental state examinarion were used to analyze the association between physical activity and cognition in mexican and korean older adults. multivariate logistic regression models were used to evaluate the said association. results: in mexico, the prevalence of physical activity was . %, physical active older adults obtained a higher score in ccce ( . ± . ) p-value < . . they also had more years of education ( . ± . vs. . ± . ) p-value < . , had depression ( . % vs. . %) . and consumed less alcohol ( . vs. . ) p-value < . . in korea, the prevalence of physical activity was . %. the physical active group performed better in mmse (- . ± . vs. . ± . ) p-value < . . the no physical active group had a higher proportion of women, less alcohol consumption ( . vs. . %) p-value < . , fewer years of education p-value < . and a higher prevalence of depression ( . % vs . %) p-value . . in the multivariate analysis an independent association was found in the korean population between physical activity and mmse score even after adjusting for confounders ( . ( . ; . ) p value . ). conclusion: physical activity could have a protective effect on the cognitive decline associated with ageing. background: aging is related to the increase of several chronic diseases, such as, osteoarthritis, osteoporosis, diabetes, hypertension and sarcopenia. sarcopenia (progressive loss of muscle mass and physical performance) is related to difficulties in treating other comorbidities, whether pharmacologically or non-pharmacologically. it's important to understand the relations between muscular strength (w), muscular mass and the phase angle (pa) of bioimpedance, in sarcopenic subjects to prescribe more accurate treatments. objectives: to study the relations of skeletal muscle index (smi) with w, pa and the presents of comorbidities (nc) in elderly subjects. methods: a prospective, observational secondary analysis of data from the "the sarcopenia screening and health related issues in the region of algarve", was performed. community independent living elderly subjects were recruited. body composition was measured by bioimpedance (seca analytics ), knee flexion and extension isokinetic strength ( º/sec) (humac norm). a screening questionnaire was used to determine the presence of comorbidities. smi levels were assessed using european working group on sarcopenia in older people cut-off points. results: a total of female and males, were included, mean age , (± , sd). subject were divided into groups according to smi: normal (n= ), moderated impairment (n= ) and severe impairment (n= ). pearson correlation were calculated within each group for w; pa and comorbidities. normal smi level, were correlated to knee extensors w in both legs (right: r= , , p< , and left r= , , p< , ) . no significant correlations were found with pa. moderate smi level: were correlated to knee extensors w in both legs (right: r= , , p< , and left r= , , p≤ , ), and also with knee flexors w (right: r= , , p< , ; left: r= , , p< , ). a moderate correlation was also found in this group with pa (r= , , p< , ). severe smi level: no correlations were found, in this group, with w. a moderate correlation was found with pa (r= , , p< , ). comorbidities did not have any correlations with smi levels. conclusion: our results seem to indicate that isokinetic strength (work) may have in the future a role in understanding sarcopenia, once it is related to smi. also, pa may indicate moderate and severe smi impairment. background: body characteristics as low muscle mass and high fat mass (fm) affect the physical function of older people. physical function is a fundamental component for the performance of daily activities and for the maintenance of the independence of older adults. however, the relationship between body composition and physical performance varies in different studies and still demands further research. objectives: this study aimed to investigate the association of fat mass index (fmi) determined by dual-energy x-ray absorptiometry (dxa) with physical performance in brazilian communitydwelling older adults. methods: a cross-sectional study with a sample of participants aged years and older, living in ribeirão preto, brazil, including both men and women, was conducted. fm was measured by dxa and fmi was calculated as fat mass/height (kg/m²). the physical performance was assessed by the -minute walk test, and walking distance was recorded as the main parameter, considering the distance predicted by sex. the kolmogorov-smirnov test was used to verify the normality of data distribution. the association of physical performance and fmi was analyzed using the pearson's correlation test and statistical significance was set at p ≤ . (two-sided). results: the participants were aged . ± . years, fmi was . ± . kg/m and distance walked was . ± . m. there was a significant negative association (r = - , p = . ) between fmi and distance walked, showing that higher fat mass index is associated with worse performance in the -minute walk test. conclusion: high fat mass index is associated with worse physical performance in brazilian older adults. background: sarcopenia and physical frailty have been shown to be risk factors for mortality and major morbidity in older adults suffering from various forms of cardiovascular disease. ultrasound measurement of quadriceps muscle thickness (qmt) is an emerging biomarker for sarcopenia, which we hypothesized could be conveniently acquired during the routine echocardiographic exam. objectives: to demonstrate the feasibility of measuring qmt at the time of echocardiography, and determine the association between qmt and clinical indictors of frailty. methods: adult inpatients and outpatients undergoing a clinically-indicated echocardiogram for known or suspected cardiovascular disease were recruited for this cross-sectional study at the jewish general hospital. prior to the echocardiogram, trained research assistants measured height, weight, and three clinical indicators of frailty: rockwood's clinical frailty scale, handgrip strength (jamar dynamometer), and bioimpedance phase angle (inbody ). at the conclusion of the echocardiogram, cardiac sonographers blinded to the preceding assessments acquired a biplane image of the anterior thigh midway between the anterior superior iliac spine and knee, and measured qmt as the combined thickness of the rectus femoris and vastus intermedius muscles. a cardiac ultrasound machine and probe were used (ge vivid e /e , . - . mhz probe). results: the cohort consisted of patients, of which had an available measure of qmt. the acquisition and measurement of qmt added - minutes to the echocardiographic exam. the mean age was +/- years with % females. the mean qmt was +/- mm, similar in men and women, with the lowest quintile being < . mm. higher age and lower body mass index were associated with lower qmt. after adjustment for age, sex, and body mass index, qmt was found to be associated with the multivariate composite of frailty indicators (p< . ), particularly with the clinical frailty scale (beta - . per mm; ci - . , - . ) and bioimpedance phase angle (beta . per mm; ci . , . ). additional adjustment for heart failure and inpatient status did not alter results. conclusion: qmt can be efficiently measured during a routine echocardiographic exam and can add incremental insights about frailty in a diverse group of patients with cardiovascular disease. background: frailty is a clinical syndrome whose signs and symptoms are predictors of health complications, making this a major public health problem. objectives: this study aims to evaluate the prevalence of frailty, in communitydwelling older adults enrolled in a physical exercise program in the north region of portugal, based on fried's phenotype, its association with other variables. methods: in this crosssectional analysis, we used data from individuals who were enrolled in physical exercise programs. gender and age standardized prevalence and the association between frailty and sociodemographic (age, gender, marital status, education, shortage of money) physical (self-perceived health, polypharmacy, physical fitness, vision, hearing), cognitive (memory), social (emptiness, loneliness and abandonment) and psychological (depression and anxiety) variables were evaluated. results: of the participants, the mean age was . ± . years old, and . % were female. prevalence of pre-frailty and frailty were of . % and . %, respectively. from the fried's phenotype criteria, exhaustion is the most common reported by . % of the pre-frail and . % of the frail participants. age, marital status, self-perception of health, physical fitness, memory and depression were found to be independently associated with pre-frailty, while age, education, self-perception of health, physical fitness and anxiety were independently associated with frailty. conclusion: we reported lower prevalence of pre-frailty and frailty compared with other studies, showing that physical exercise may delay the progression of frailty. interventions aimed to prevent frailty must address the diversity of the associated variables. background: frailty is related with ethnicity and impaired physical capacity which is also affected by diabetes. however, little is known about how physical health indicators of frailty are associated with each other in older hispanics with diabetes. objectives: the goal of this study was to investigate the relationship between physical health indicators of frailty in older hispanics with diabetes. methods: thirty-eight older hispanics with diabetes ( women, men, age = ± years) participated in the study. the variables included age, weight, body mass index, body composition (% of muscle mass and body fat -bio-impedance), fear of falls (falls efficacy scale international -fes-i), chair stands in sec, grip strength (jamar® dynamometer), balance with eyes open and closed (force plate), preferred walking speed, gait velocity during regular and reduce time street crossing simulations (gaitrite®). results: characteristics: body mass = ± kg, % of muscle mass = ± %, % of body fat = ± %, fes-i score = ± points, chair stands = ± repetitions, grip strength = ± kg, center of pressure area with eyes open = ± cm and with eyes closed = ± cm , preferred walking speed = ± cm/s, gait velocity during regular = ± cm/s and during reduced time street crossing = ± cm/s. there were significant correlations (*p< . , **p< . ) between age and gait velocity during regular street crossing (r = - . *); grip strength and % of body fat (r = - . **) and % of muscle mass (r = . **); chair stands and preferred walking speed (r = . **), gait speed during regular (r = . **) and during reduced time street crossing (r = . **) and center of pressure area with eyes closed (r = - . *), and between fear of falls and center of pressure area with eyes closed (r = . **). conclusion: gait speed during street crossing simulations decreased with age. greater grip strength was associated with lower % of body fat and higher % of muscle mass. people who completed less chair stands in s also walked slower and had worse balance, and those with poor balance had increased fear of falls. britta c arends, lisa verwijmeren, peter g noordzij, douwe h biesma, leon timmerman, eric pa van dongen, heleen j blussévan oud-alblas (st. antonius hospital -nieuwegein, netherlands) background: chronic pain after cardiac surgery is common and has a negative impact on quality of life. frailty is an important risk factor for adverse surgical outcomes. the influence of frailty on chronic pain after cardiac surgery is unknown. objectives: this study aimed to address whether frailty characteristics were associated with chronic pain after cardiac surgery in an older population. methods: this study was based on the anesthesia geriatric evaluation (age) and quality of life after cardiac surgery study, which included patients >= years undergoing elective cardiac surgery. preoperatively, frailty was tested in physical, mental and social domains. pain was evaluated with the short form questionnaire (sf- ) preoperatively and one year after surgery. multivariate logistic regression was used to investigate the association between frailty and chronic pain. change in health related quality of life (hrql) was analyzed to evaluate the impact of chronic pain. results: ( %) patients were included in the analysis. / patients ( %) reported new or increased pain one year after surgery. in patients ( %) at least one frailty characteristic was present and patients ( %) were frail in two or more domains. after adjustment for possible confounders in multivariate analysis, patients with single status and polypharmacy were at increased risk for new or increased chronic pain (aors . ( % ci . - . ) and . ( % ci . - . ). new or increased chronic pain was associated with a worse hrql (aor . ; % ci of . - . ). conclusion: frail patients are at risk for chronic pain and worse hrql after cardiac surgery. future research should focus on perioperative interventions to reduce chronic pain in elderly patients. background: frailty is a vulnerability state that is associated with negative outcomes such us falls, in-hospital admissions and mortality. many factors can contribute to the pathogenesis of frailty and nutritional status is playing and important role. that´s why undernutrition and frailty must be overview in older adults before surgical procedures in order to treat them earlier. objectives: identify the relationship between physical frailty and undernutrition in older adults undergoing elective abdominopelvic surgery in a general hospital in lima-perú. methods: this is a secondary database study from the original "physical frailty and adverse events in older adults undergoing elective pelvic abdominal surgery in a general hospital, lima-perú", it was realized between august and march , using validated face to face questionnaires. physical frailty was determined with fried criteria, undernutrition by mini nutritional assesment (mna). in adition, they also evaluated functional status and cognition. univariate models were performed, and logistic regression was done subsequently. results: older adult met inclusion´s criteria, the mean age was . (+ . ) years old, , % ( ) were female, , % ( ) had hypertension, , % ( ) were diabetic, the mean number of comorbidities were . (+ . ), , % ( ) had functional impairment, , %( ) had cognitive impairment. the mean bmi was . ± . . , % ( ) were underweight, . %( ) normal , . %( ) overweigth and . % ( ) obese. by mna % ( ) had risk or undernutrition, . % ( ) of them had functional impairment in contrast with , %( ) who weren´t at risk or undernutrition; p= . . also, . %( ) who had risk or undernutrition had cognitive impairment in contrast with . %( ) who weren´t at risk or undernutrition; p= . . by fried criteria, % ( ) were frailty, % ( ) prefrailty and , % ( ) robust. the frailty patients % ( ) had risk or undernutrition vs , %( ) in prefrailty and . %( ) in robusts; p= . . conclusion: there is an increased risk of undernutrition in frail older adults undergoing abdominopelvic surgery at a general hospital in lima, peru. background: cognitive frailty increases the risk of dementia, dependency and mortality in older people. moderatevigorous physical activity (mvpa) improves frailty syndrome and cognitive functions in older people, but being physically inactive is still prevalent. walking is the most common and inexpensive form of physical activity in older people and brisk walking is a form of mvpa. m-health has been successful in changing health behaviours in many populations. however, its effect in treating cognitive frailty through promoting mvpa in older people is not known. objectives: the aims of this study were to examine the effects and feasibility of an m-health intervention. methods: a pilot randomized controlled trial was employed. eligibility criteria include ) age > years, ) living in community, ) having cognitive frailty, and ) mobility at "outdoor walker" level. the study was conducted in community settings. subjects were recruited in the elderly community centres. subjects were randomized into either intervention or control at a : ratio. in the intervention groups, the subject received a smartphone pre-installed with physical activity tracking and social media applications. they received a course of brisk-walking in daily living training, health education, and a -week behavioural change intervention on the smartphone platform. in the control group, participants received a course of brisk-walking in daily living training, health education, and telephone follow-up. the outcomes were frailty (ffi), cognitive function (moca) and mvpa (actigraph). we targeted at recruiting totally subjects. nonparametric tests were used to compare the effects within and between groups. missing values were replaced by last observed values. results: this study recruited subjects (intervention: n= , control: n= ). significant improvements in frailty (p< . ), cognitive function (p< . ), and mvpa (p< . ) were observed in the intervention group after the completion of the intervention. only cognitive function was also observed to be improved in the control group (p< . ). the compliance of wearing devices (i.e., smartphones and actigraphs) and the usage of the smartphone applications were highly satisfactory. three subjects withdrew from the study (intervention: n= , control: n= ). conclusion: m-health intervention is feasible to treat cognitive frailty in older people. it is more effective to ameliorate frailty and increase mvpa in older people with cognitive frailty when compared to conventional training. background: the prevalence of dementia and associated healthcare cost increases with aging population. population health management and proactive screening with increased emphasis on primary risk reduction may reduce the overall prevalence of dementia. motoric cognitive risk syndrome (mcr) has been increasingly studied as a pre-dementia stage to identify older adults at risk of transiting to dementia while few studies explored the association between mcr and functional capabilities. objectives: the aims are to investigate the prevalence of mcr and its associated factors among community-dwelling older adult and also to examine possible impact of mcr on functional capabilities. methods: data for older adults aged above years old staying in northwest region of singapore was used. mcr was defined as slow gait speed over m ( sd below population mean) with subjective memory complaints in the absence of dementia. functional capability was determined by administering the lawton instrumental activities of daily living (iadls). differences in demographics, socioeconomic and lifestyle factors between mcr positive and mcr negative groups were found using independent t-test and chi-square test. risk factors of mcr and impact of mcr on functional capability were examined using logistic regression. results: the prevalence of mcr in the studied population was . %. after adjusting for demographics and socio-economic factors, indians (adjusted or = . , % ci = . - . , p = . ), increasing age (adjusted or = . , % ci = . - . , p < . ), higher bmi (adjusted or = . , % ci = . - . , p < . ) increased likelihood of mcr while increased years of education decreased likelihood (adjusted or = . , % ci = . - . , p = . ). the odds of having at least one impairment in iadl after adjusting for demographics, socio-economic and health factors amongst those with mcr were . (adjusted or = . , % ci = . - . , p = . ). conclusion: our study found in to have mcr, the pre-dementia stage. indian ethnicity, those with increased age and higher bmi are at greater risk of having mcr. as mcr is also associated with functional impairment, it can serve as a useful screening tool to identify those at risk of progressing to dementia. background: sleep disturbance has been found in older persons with dementia, which impact on the quality of life of older persons and on the caregiving burden of the family. little is known about the sleep patterns and sleep problems of older persons with dementia. exploring these data would provide basic information to develop interventions for this population. objectives: to explore sleep patterns and sleep problems in community-dwelling older persons with dementia. methods: the sample recruited by purposive sampling consisted of community-dwelling older persons with any stage of dementia who used healthcare services at outpatient departments of a university hospital, thailand. data were collected using a demographic data questionnaire, a sleep diary recorded by caregivers, and an electronic wrist activity tracker to assess sleep data for consecutive nights. the data had been collected for three months and were analyzed using descriptive statistics. results: the sample had an age range from to years (m= . , sd = . ). the total sleep data of the older persons with dementia consisted of episodes. almost all of the sleep data showed the polyphasic sleep pattern (sleeps for several periods of time a day), but a few had monophasic and biphasic sleep patterns. the total sleep time per night ranged from to hours with a mean of hours. the mean sleep latency was minutes, by which two-thirds of them had sleep latency less than minutes. three-quarters of the data woke up at night. the mean duration of waking up at night was minutes. two-thirds of the data had sleep problems, including insomnia, waking after sleep onset, and excessive daytime sleeping. also, most of them had snoring ( %), followed by sleep talking ( %). conclusion: the polyphasic sleep pattern was found mostly in older persons with dementia. also, they had sleep problems of insomnia at night and excessive sleeping during the daytime. healthcare providers may use the results from this study to understand the sleep patterns and then find strategies to promote the sleep quality of older persons with dementia. yumi umeda-kameyama , masashi kameyama , taro kojima , masaki ishii , shinya ishii , mitsutaka yakabe , kiwami kidana , tomohiko urano , , sumito ogawa , masahiro akishita (( ) department of geriatric medicine, the university of tokyo school of medicine, tokyo, japan; ( ) department of diagnostic radiology, tokyo metropolitan geriatric hospital and institute of gerontology, tokyo, japan; ( ) department of geriatric medicine, international university of health and welfare, narita, chiba, japan) background: «perceived age» of facial appearance in elderlies was shown to be a robust biomarker of aging that predicts survival, telomere length, and dna methylation. it is also reported to correlate with carotid atherosclerosis and bone status. objectives: this study aims to determine whether perceived age is a better biomarker than chronological age for a variety of aspects in dementia assessment, which includes general cognition, vitality, depressive state, and selfsupportability. methods: one hundred twenty-six patients admitted to the department of geriatric medicine, the university of tokyo hospital with suspect of cognitive decline were enrolled. mmse, vitality index, gds , iadl, and barthel index were performed. ten geriatricians and clinical psychologists determined the perceived age of subjects based on their photographs. results: the average values of rates showed excellent reliability (icc( , )= . ). perceived age showed significantly better correlation with mmse (female), vitality index (total, female), and iadl (total) than chronological age by steiger's test, but not with gds and barthel index. conclusion: perceived age was demonstrated to be a better biomarker for cognitive assessment than chronological age. l a u r a t a y , h u d a m u k h l i s , jolene ho , aisyah latib , eeling tay , shimin mah , candy chan , yeesien ng (( ) department of general medicine, sengkang general hospital, singapore; ( ) office of regional health system, singhealth, singapore; ( ) department of physiotherapy, sengkang general hospital, singapore; ( ) dietetics, sengkang general hospital, singapore) background: cognitive frailty is characterized by co-existence of physical frailty and cognitive impairment. earlier studies reported aggravated health outcomes attributable to cognitive frailty over physical frailty alone. objectives: we examine risk factors for cognitive frailty, and its impact on physical performance and health outcomes, compared with isolated occurrence of cognitive impairment or physical frailty. methods: cross-sectional analysis of communitydwelling older adults who completed multi-domain geriatric screen assessing for social vulnerability, mood, cognition, functional performance, nutrition, physical frailty (frail) and sarcopenia (sarc-f). cognitive impairment was defined using locally validated education-adjusted cut-offs on modified-chinese mini-mental state examination. participants underwent physical fitness tests comprising grip strength, gait speed, lower limb strength and power, flexibility, balance, and endurance. health outcomes included hospitalization, emergency department visits, falls and self-rating of health. each participant was categorized as robust-cognitive intact (pf--/ ci-), pre-frail/ frail only (pf+/ ci-), cognitive impaired only (pf-/ ci+), and cognitive frailty (pf+/ ci+). results: mean age of study cohort was . ( . )years. ( . %) were pf-/ci-, ( . %) pf+/ci-, ( . %) pf-/ci+, and ( . %) pf+/ ci+. in multi-nomial logistic regression referenced to pf-/ci-, older age significantly increased risk for pf-/ci+ and pf+/ci+. cognitive frailty contributes to worse physical performance and poorer health outcomes compared to physical frailty and cognitive impairment in isolation. while social vulnerability and depression were differentially associated with isolated frailty status, malnutrition and sarcopenia should be targets for preventing frailty and cognitive impairment. osamu katayama, sangyoon lee, seongryu bae, keitaro makino, ippei chiba, kenji harada, yohei shinkai, hiroyuki shimada (department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, japan) background: cognitive frailty is a condition recently defined by operationalized criteria describing coexisting physical frailty and mild cognitive impairment (mci). however, there is no consensus on the definition of cognitive frailty for use in clinical and community settings. objectives: this study aimed to use latent class analysis (lca) to discover potential subtypes of cognitive frail older people. in addition, we explored the relationship between the identified cognitive frailty subtypes, and their demographical, neuropsychological, body composition, and lifestyle activity characteristics. methods: a total of community-dwelling older adults aged >= years participated in the study. we characterized physical frailty as >= of the following criteria: slow walking speed, muscle weakness, exhaustion, low physical activity, and weight loss. we used tests of word list memory, attention, and executive function, and processing speed to screen for cognitive impairment. the presence of >= cognitive impairments were defined as mci. we defined the condition where physical frailty and mci coexist as cognitive frailty. lca was applied to characterize classes or subgroups with different cognitive frailty phenotypes. subsequently, we performed multinomial logistic regression analysis with cluster membership as dependent variable and dichotomized demographics and lifestyle activity characteristics as independent variables. results: lca identified eight distinct subgroups included three different cognitive frailty phenotypes: cognitive frailty composed of physical frailty and amnestic mci (acf), cognitive frailty composed of physical frailty and non-amnestic mci (nacf) and, cognitive frailty in which physical frailty and global cognitive impairment (gcf). cognitive frailty subtypes were associated with distinct demographical, neuropsychological, and lifestyle activity characteristics. in particular, the acf cluster was associated with younger age and also related to the inactivity of productive and cognitive activities (p< . ). the nacf cluster was related to the inactivity of social and cognitive activities (p< . ). finally, the gcf cluster was associated with older age (p< . ). conclusion: using lca, we identified eight distinct subgroups included three different cognitive frailty phenotypes in a large sample of community-dwelling older adults. cognitive frailty subtypes were associated with distinct demographical, neuropsychological, and lifestyle activity characteristics. sara g aguilar navarro, alberto j mimenza alvarado, itzel aparicio gonzález, clarita cabrera juárez, alejandra samudio cruz, monsal alexa, ja avila funes, teresa juarez-cedillo (instituto nacional de ciencias médicas y nutrición salvador zubiran, ciudad de méxico, mexico) background: the prevalence of mild cognitive impairment (mci) ranges between - % and is times more frequent than dementia. the dcl has been associated with cardiovascular risk factors, mainly changes at the executive level. the apoe genotype, on the other hand, is a gene that confers susceptibility to alzheimer's disease in addition to participating in lipid metabolism, giving greater risk of atherosclerosis and cardiovascular risk. however, given the genetic heterogeneity of the mexican population, this association is not clear. objectives: to establish the strength of association between the different types of dcl (amnesic and non-amnesic) in mexican mestizo older adults according to their carrier status of the apoe allele and cardiovascular risk factors. methods: patients in a memory clinic were evaluated from to , older than years, without sensory deficit, psychiatric diseases or uncontrolled metabolic pathology, separating them into mutually exclusive groups: healthy controls, group with amnesic mci, group with nonamnesic mci, performing geriatric and neuropsychological evaluation. parametric and nonparametric statistics (x , anova, multivariate linear regression analyzes) were used to find statistical differences between groups. results: multivariate linear regression analyzes were performed to examine the relationship between vascular risk factors, the presence of the apoe ε allele, and cognitive change. apoe genotype significantly modified the associations between both hypertension and cardiovascular disease and a decline in language abilities as well as diabetes and decline in verbal memory, attention, and visuospatial abilities in non-amnestic mci. associations between increased vascular risk burden and greater cognitive decline were observed among apoe ε carriers but not non-carriers with mci. conclusion: the present study revealed an increase in the association between non-amnestic mci (apoe ε carriers with vascular risk factors) and suggests that the treatment of vascular risk factors could contribute to reducing the risk of progression of cognitive impairment, particularly among patients with apoe ε mexicans. background: a number of cross-sectional and longitudinal studies have demonstrated an association between physical frailty and cognitive impairment ( ). many mechanisms have been suggested to explain the presence of cognitive impairment in frail subjects, such as cardiovascular risk, hormonal disturbances, chronic inflammation or nutrition ( , ). another hypothesis is that cognitive impairment in frail patient may be due to alzheimer's disease (ad) ( , , ). however, the link between frailty and amyloid deposition has to date never been studied in vivo. objectives: ( ) to examine the prevalence of cerebral amyloid pathology as measured with amyloid positron emission tomography (pet) or amyloid-β- - level in cerebrospinal fluid, among frail and pre-frail individuals presenting an objective cognitive impairment ( ) to characterize the cognitive and clinical progression of frail cognitively impaired patients according to the amyloid status. methods: cogfrail is a monocentric observational prospective study of cognitive frail and prefrail older participants (according to fried criteria), aged >= years, with an objective cognitive decline (defined by a clinical dementia rating (cdr) scale scoreat . or ). the participants will be followed up every months, during years. in addition to cerebral amyloid pathology (measured by amyloid positron emission tomography (pet) or amyloid-β- - level in cerebrospinal fluid), measurements include cognitive performance, physical function, nutritional status, depressive symptoms biology, nutrition, magnetic resonance imaging (mri), and body composition to better understand the mechanisms and progression of cognitive frailty. results: the study is currently being recruited. to date, patients were included. mri pet scan and lumbar puncture have been performed. subjects completed the study. conclusion: this study will allow us to determine, for the first time, the prevalence of amyloid pathology, a marker of ad, among frail and pre-frail patients presenting objective memory impairment. the results will help characterize the cognitive decline in frail and pre-frail patients, with important implications for the detection, management and ultimately prevention of neurocognitive disorders among frail old individuals references: ) kojima g, taniguchi background: cognitive impairment is a well-known risk factor for falls in older adults. the risk of falls is increased in those with diminished executive function and reduced processing speed. while participants with cognitive deficits are more prone to falling, it is unknown whether risk of falling on cognitively intact individuals placing them at higher risk for future cognitive decline. objectives: to ascertain the incident development of cognitive decline in those at higher risk for falls using the center for disease control's fall risk assessment tool, steadi (stop elderly accidents, deaths, and injuries) in community dwelling individuals > years of age. methods: we identified individuals >= years old using the longitudinal national health and aging trends study (nhats) that consists of eight years of follow-up. these individuals did not have cognitive impairment at baseline. fall risk was defined using the algorithm from the center for disease control's steadi initiative. participants were classified at baseline in three categories of fall risk (low, moderate, severe). impaired global cognition was defined as nhats-defined impairment in either the alzheimer's disease- score, immediate/delayed recall, orientation, clock-drawing test, or date/person recall. the primary outcome was the risk of incident cognitive impairment over time. cox-proportional hazard models and linear mixed-effects modeling ascertained the incidence of cognitive impairment, adjusting for age, sex, smoking status, education, co-morbidities and an ability to walk. our referent variable was individuals at low steadi fall risk. results: of the , participants ( . % female), median age category was - years. prevalence of baseline fall risk using the steadi measure in participants was low ( . %), medium ( . %) and high ( . %). the rate of cognitive impairment in our sample was . %. in our fully adjusted model, the risk of developing cognitive impairment was hr . [ %ci: . - . ] in the intermediate risk group, and hr . [ %ci: . - . ] in the high risk group. using linear mixed-effects modeling yielded similar results. conclusion: steadi fall risk at baseline was predictive of higher rates of cognitive decline in those with normal cognition. elevated fall risk by steadi may suggest need for more thorough cognitive assessment. background: the concept of cognitive reserve (cr) has been developed as a potential factor able to describe individual differences in vulnerability to cognitive, functional, or clinical decline along aging. the progressive reduction of cognitive and functional performances represents an outcome commonly associated with aging. objectives: the aim of this crosssectional study is to investigate the association of cr with cognitive and functional outcomes in a sample of elderly outpatients. methods: subjects aged >= were consecutively recruited. patients who were unable to undergo the execution of required tasks due to severe cognitive, functional or sensory impairment were excluded. mini mental examination (mmse), brief intelligence test (tib) and cognitive reserve index questionnaire (criq) were administered. handgrip strenght, gait speed and daily life autonomy were measured; a frailty index (fi) was eventually calculated. results: data from patients were analyzed. criq was significantly correlated with mmse (r = . , p < . ), handgrip (r = . , p < . ) and gait speed (r = . , p= , ). furthermore, criq was correlated with badl (r = , , p= , ), iadl (r= , , p= , ) and inversely with fi (r= - . , p < . ). significant correlations were found between tib and mmse (r = . , p < . ), between tib and criq (r = . , p < . ), and between tib and iadl (r = , , p= , ). conclusion: this preliminary report highlighted that patients with higher cr showed not only better overall cognitive functioning, but also better functional status and a lower degree of frailty. in the light of a multidimensional geriatric assessment, the integrative evaluation of cr in elderly might offer the opportunity to track possible trajectories of aging, since it appeared related either to cognitive status, either to functional oucomes and to frailty. background: the clinical syndrome of "physical" frailty has been conceived without regard for cognitive decline. nevertheless, it has been suggested that frail elders exhibit frailty-specific cognitive impairments, and that the cognitive correlates of frailty may be dementing in their own right. meanwhile, we have used confirmatory factor analysis (cfa) in a structural equation model (sem) framework to construct a latent dementia phenotype, "δ". our approach is modular and can be redirected to other clinical targets. objectives: in this analysis, we create a δ ortholog representing the "cognitive correlates of frailty" (df). methods: first, we constructed a frailty index (if) from wave- data collected as part of the hispanic established population for epidemiological studies in the elderly (h-epese). a δ ortholog targeting if was then constructed from a cognitive battery that included the mini-mental status exam (mmse) and clox: an executive clockdrawing task (clox). results: the model fit the data well and df exhibited factor determinance. dfrailty was strongly indicated (r = . , p< . ) by if and explained % of the index's variance. it was also significantly indicated by mmse and clox scores. df was strongly correlated (r = . , p< . ) with instrumental activities of daily living (iadl), independently of age, gender and education. the remaining % of if's variance had no significant association with iadl. the orthogonal latent variable "g'", df's residual in spearman's general intelligence factor "g", was strongly indicated by all three cognitive performance measures. nevertheless, it was weakly associated with iadl. measure specific cognitive performance, residual to both df and g', had no independent: association with iadl. conclusion: these results suggest that the frailty syndrome does indeed have specific cognitive correlates. these are strongly associated with iadl and therefore potentially "dementing". like δ, the cognitive correlates of frailty are extractable from spearman's g, which may constrain the biology and psychometric properties of frailty-specific cognitive changes. independently of df, cognition has little association with iadl. this suggests that frailty may be a major determinant of iadl performance in elderly ma, and possibly a major etiology of "all cause" dementia in that population. background: cognitive-frailty has been proposed as a distinctive entity which preludes dementia. objectives: we aimed to examine the relationship between physical frailty, cognitive status, and gait performance as predictors of cognitive decline and incident dementia. methods: cohort study of community older adults free of dementia at baseline with a year follow-up. inclusion criteria: > years, english speaking, able to ambulate one city block. exclusion criteria: hip/knee joint arthroplasty in past months, parkinsonism, major depression, and diagnosis of dementia (dsm-iv criteria). cognition was assessed using the moca, the mmse, and the clinical dementia rating (cdr) scale was performed. physical frailty was defined using the phenotypic criteria described by fried and walston. cognitive-frailty was defined as the simultaneous presence of physical frailty with objective cognitive impairment, and absence of concurrent dementia. the main outcome measure was all-cause dementia (dsm-iv criteria). cox proportional hazards models were used to estimate the risk of cognitive decline and incident dementia. results: over a -year follow-up, participants experienced cognitive decline and participants progressed to dementia (global incidence rate (ir): per -person/y). participants with frailty had a higher prevalence of cognitive impairment ( %) compared to those without ( %, p= . ) but the risk of progression to dementia was not significant. adding cognitive impairment to the frailty phenotype (cognitive-frailty) predicted further cognitive impairment and progression to dementia. dementia ir for frailty was per person/y and for cognitive-frailty, per person/y. however, when slow gait was combined with baseline cognitive impairment, it showed the highest risk of progression to dementia (hr: . , %ci: . - . ; p = . ) with an ir of per person/y. conclusion: frailty and cognitive impairment are common and often coexist in the same individuals. however, slowing gait seems to be the frailty component driving the association with future dementia. background: assisted bathing requires the most hours of home care. for the frail elderly and their caretakers, the bathroom presents the most risk factors for falls and injury. bathroom adaptation is the primary reason for consultation in community occupational therapy and available resources cannot meet the increasing demand. the hygiene . (h . ) website (https://algo.grismoir.com/) addresses this need by offering a structured questioning to identify bathing assistive technology for the frail elderly living at home. objectives: our actionresearch protocol aims to establish a partnership between actors in the home care social economy enterprises (eÉsad), the home care programs offered through the healthcare system and the private sector (e.g., assistive technology providers). this implies: ) adapting h . to the home care service workers' needs; ) designing an implementation model for h . in order to formalize a partnership in the community; ) conducting pilot testing in two eÉsad. methods: ) user-centered design and a multiple case study where a case represents a home care worker (n= ) from a eÉsad (québec, canada) offering bathing assistance for the elderly. during testing, the home care worker will explore the h . prototype with an elderly in his or her home, sharing their thoughts out loud. the unit of analysis is the usability of h . , allowing improving to the prototype after every three participants. ) all collaborators will participate in the iterative modification of a preliminary logic model for the implementation of h . . modifications suggested will be integrated to the model throughout three meetings, or until a consensus is reached. ) the adapted version of h . (obj. ) will be tested according to the implementation model developed (obj. ). a pilot project using mixed methods in collaboration with two eÉsad will be conducted with older adults having difficulty bathing. results: anticipated results: responsive h . website adapted to the users' needs, an implementation model and pilot data allowing scaling-up technology meeting needs of frail elderly and their caretakers issues during bathing. li-ning peng , , , fei-yuan hsiao , , , wei-ju lee , , , shih-tsung huang , liang-kung chen , , ( ( ) background: the theory of cumulative deficits using big data to develop the multimorbidity frailty index (mfi) has become a widely accepted approach in public health and healthcare services. however, constructing the mfi using the most critical determinants and stratifying different risk groups with dose-response relationships remain major challenges in clinical practice. objectives: this study aimed to develop the mfi by using machine-learning methods that select variables based on the optimal fitness of the model and to further establish four entities of risk using a machine-learning approach as well as to ensure the dose-response relationship and the best distinction between groups. methods: in this study, we used taiwan's national health insurance research database to develop a machine-learning multimorbidity frailty index (ml-mfi) using the theory of cumulative diseases/deficits of an individual older person. compared to the conventional mfi, in which the selection of diseases/deficits is based on expert opinion, we adopted the random forest method to select the most influential diseases/deficits that predict adverse outcomes for older people. to ensure that the survival curves showed a dose-response relationship with overlap during the follow-up, we developed the distance index and coverage index at any time point to classify the ml-mfi of all subjects into the categories of fit, mild frailty, moderate frailty and severe frailty. survival analysis was conducted to evaluate the ability of the ml-mfi to predict adverse outcomes, such as unplanned hospitalizations, intensive care unit (icu) admissions and mortality. results: the final ml-mfi model contained diseases/deficits in this study. compared with conventional mfi, both indices had similar distribution patterns by age and sex; however, among people aged - , the mean mfi and ml-mfi were . (standard deviation (sd) . ) and . (sd . ), respectively. the difference may result from discrepancies in the diseases/deficits selected in the mfi and the ml-mfi. a total of , subjects aged to years were included in this study and were categorized into groups according to the level of the ml-mfi. both the kaplan-meier survival curves and cox models showed that the ml-mfi significantly predicted all outcomes of interest, including all-cause mortality, unplanned hospitalizations and all-cause icu admissions, at , and years of follow-up (p< . ). in particular, a doseresponse relationship was revealed between the four ml-mfi groups and adverse outcomes. conclusion: the ml-mfi consists of diseases/deficits that can successfully stratify risk groups associated with all-cause mortality, unplanned hospitalizations and all-cause icu admissions in older people, which indicates that precise, patient-centered medical care can be a reality in an aging society. to return home. understanding the home environment prior to discharge is crucial. occupational therapists (ots) often depend on client's verbal descriptions, pictures and sketches when planning rehabilitation exercises and suggesting adaptations. the information obtained is therefore partial. mapit is a new mobile application which scans a room producing a d representation with virtual measurements of environmental elements. this could provide a more complete representation of the home needed by inpatient rehabilitation ots. objectives: to target mapit's clinical applications for inpatient rehabilitation of the frail elderly. methods: multiple case study where mapit was introduced in three inpatient geriatric rehabilitation units over days. five ots maintained a logbook and participated in four individual semi-structured interviews. a deductive thematic analysis of the logbooks and interview transcripts was corroborated by two additional ots. results: mapit is useful for ots in rehabilitation settings by allowing them to ) see it: see the home environment, ) measure it: take measurements of desired environmental elements, ) document it: have a copy of the environment on hand, ) communicate it : facilitate exchanges with the client and with colleagues. with mapit, ots gain a better understanding of the environment, which informs the rehabilitation intervention. better communication could also improve the client's implementation of the therapeutic strategies. conclusion: mapit is a useful resource to optimise intensive rehabilitation for the frail elderly. sonia jiménez-mola , javier idoate-gil , david idoate , maría plaza carmona (( ) geriatric department, complejo asistencial universitario, león, spain; ( ) university of salamanca, salamanca, spain; ( ) urgency department, complejo asistencial universitario, león, spain) background: as the age of the population increases, the incidence of osteoporosis and its direct consequence, fragility fractures, are also increasing. hip fractures are associated with the greatest number of complications, functional deterioration, and mortality of up to % one year after the fracture. objectives: the aim of this study is to determine the prevalence of previous diagnosis of osteoporosis in elderly patients who suffer hip fracture and its relationship with age distribution ( - , - and > years old), gender, type of fracture and funtionality. methods: we enrolled patients with hip fracture, aged years or older in an orthogeriatric unit between december and november . underwent comprehensive geriatric assessment that evaluates comorbidities, medication use, ability to perform basic activities of daily living, place of residence, anesthesia risk as measured by the asa score, type of fracture, type of surgery and anesthesia and in-hospital mortality. spss®, v. . . results: the mean age was . ± . years ( - years). . % female. % pertrochanteric fractures. ( %) underwent surgery. only . % received general anesthesia. % walked independently, % had barthel > , ( %) had a previous diagnosis of dementia, and % live in nursing home prior to fracture. we found a previous diagnosis of osteoporosis in patients ( . %). in these patients, statistically significant differences were shown for sex p< . ( . % female vs . % male), age distribution p< . ( . %( - ) vs . % ( - ) vs . % (> ) and the presence of anti-osteoporotic treatments p< . . all other measurements (barthel index, cognitive degree, type of fracture, asa score and type of surgery, did not show statistically significant differences (p>. ). conclusion: patients in very advanced age showed neither significantly higher percentage of diagnosed osteoporosis, not significantly higher amount of preexisting osteoporosis-related medication. although the prevalence of osteoporosis increases with age, the diagnosis and treatment prevalence decreased in higher age groups. background: aging is associated with a decrease in bone density, muscle mass and a gain in fat mass which increase physical disabilities and falls. nevertheless, the impact of obesity on bone density and architecture is still controversial. furthermore, protein intake appears to be associated with maintenance of muscle and physical function, but also with bone density and architecture. however, the role of initial protein intake in osteopenic-obese older adults is still unclear. objectives: to examine the influence of initial protein intake on muscle and bone function in osteopenic-obese older adults. methods: cross-sectional a-posteriori matched study design. fourteen obese (total fat (%): men > ; women: > ) osteopenic (bmd t-score <- . ) older adults (age > years old) were divided in groups according to their initial protein intake (prot-(n= ): < g/kgbw/d or prot+ (n= ): > . g/ kgbw/d) and were matched for age (± years) and gender. body composition (fat, fat-free and bone masses, dxa), muscle composition and bone architecture (qpct), muscle function (grip strength, knee extension strength, muscle power), physical performance (walking speed ( m), tug ( m), unipodal balance, stair and chair tests), cardiorespiratory function ( min walking test) and lifestyle habits (physical activity level: -axial accelerometer and nutritional status: food record) were assessed. results: our groups (prot-vs. prot+) were similar (p> . ) in terms of age ( . ± . vs. . ± . years), bmi ( . ± . vs. . ± . kg/m ), body fat (total(%): . ± . vs. . ± . ), muscle quantity (fat-free mass or limb muscle area) and quality (intra & submuscular adipose tissues), bone density (total hip or spine) and architecture (marrow, cortical or total area, and compressive or torsion strength), physical performance (walking speed(m/s): . ± . vs. . ± . ), cardiorespiratory function, lifestyle habits (steps: ± vs. ± ), except (by design) for the initial amount of protein intake ( . ± . vs. . ± . g/kgbw/d) respectively. conclusion: the initial protein intake does not seem to influence bone architecture, muscle function, or physical performance in elderly osteopenicobese. obesity but also the level of protein intake above the official recommendation (> . g/kgbw/d) could explain these conclusions. thus, future studies are needed to confirm our preliminary results. background: the glim definition of malnutrition is the first intended to be used globally. glim uses five criteria (two phenotypic and three etiologic) for the diagnosis of malnutrition, which is made when at least one etiologic and one phenotypic criterion are present. mna-sf is a validated widespread screening tool used in geriatric settings. glim and mna have not been compared in acute geriatric care. objectives: to measure the prevalence of malnutrition in older patients admitted to an acute geriatric unit using glim criteria and to assess the accuracy of the mna-sf in predicting glim defined malnutrition. methods: a prospective study was conducted among all patients older than years old admitted to an acute geriatric unit. end-of-life situations and wearers of pacemakers were excluded. glim criteria and mna-sf were assessed on admission. muscle mass (one of the glim criteria) was estimated by bioimpedance (thresholds for low muscle mass: < . kg in men; < . kg in women). results: patients were included (mean age . ± . years, % women). on admission, . % were malnourished according to the glim criteria ( . % met at least one etiologic criterion, . % met at least one phenotypic criterion). . % were malnourished using mna-sf. however, there was no correlation between glim and mna-sf (correlation coefficient r=- . , p= . ). mna-sf had low sensitivity ( . %) and low specificity ( . %) to detect malnutrition diagnosed with the glim criteria (roc curve auc= . ). conclusion: more than half of the very old patients admitted to an acute geriatric unit were malnourished according to the glim diagnostic criteria. a very similar proportion of patients had a mna-sf suggesting malnutrition. however, mna-sf had a low reliability to detect patients with glim defined malnutrition. corina naughton , rachel simon , tj white , darren daly ( ( ) background: hospitalised older adults are at risk of hospital associated decline (had). optimising nutrition intake is an important modifiable factor in protecting against had and promoting recovery, but food intake and the quality of mealtimes are frequently overlooked nursing activities. objectives: the study aim was to undertake an in-depth analysis of mealtime practices and to identify patient and mealtime factors associated with low food intake (<eating % of meal provided). methods: we carried out structured observation of mealtimes using a validated tool examining patient positioning, mealtime set up and assistance. the primary outcome was food consumption categorised as , %, % % or % based on visual inspection of food trays. data were also collected on patient characteristics. data analysis used descriptive statistics and univariate logistic regression to examine the association between low food intake and mealtime and patient factors. results: we included mealtime observations on patients aged years and older. at % (n= ) of meals, patients ate half or less of the food provided. meal time factors with a weak association with low intake were: allocated red tray (an indicator of nutrition risk), modified diet, and needing assistance. breakfast time was the most important meal for food intake. nearly half of the patients ( / ) ate % or less of the food provided on two or more occasions over a -hour period. patient frailty and a moderate to high nutrition risk score were independently associated with low food intake. conclusion: patient factors are the strongest predictors of low food intake. increasing the quality of the mealtime experience and more tailored nutrition plans could improve nutrition intake in frail older adults. were hospitalized at least once, ( . %) fell at least once, and ( . %) had at least one fracture during the -year follow-up. no association was found between malnutrition and -year risk of institutionalization, hospitalization, falls, or fractures (p> . ). conclusion: malnutrition according to glim criteria was associated with a . -fold higher mortality risk; double that of the espen criteria, during a -year followup. no association was found between malnutrition according to these two criteria and incidence of other adverse health consequences. glim criteria anticipate outcome and might guide interventions, with important implications for clinical practice and research. background: older adults are at high risk of developing cardiovascular disease. pre-clinical studies indicate that resveratrol (rsv), a polyphenol present mostly in grapes and red wine, may prevent development of cardiovascular disease. objectives: our hypothesis was that rsv will reduce biomarkers of cardiovascular disease risk in obese, rather healthy older adults in a dose-dependent manner. methods: older participants ( years and older) were randomized to a day rsv treatment with mg (n= ), mg (n= ) or placebo (n= ). we measured levels of atherosclerosis development risk biomarkers i.e. oxidized low-density lipoprotein (oxldl), soluble e-selectin- (se-selectin), soluble intercellular adhesion molecule- (sicam- ), soluble vascular cell adhesion molecule- (svcam- ), total plasminogen activator inhibitor (tpai- ). statistical significance was set at p< . . results: changes in svcam- mg vs. mg vs. placebo: (- . ± . ng/ml vs. . ± . ng/ ml vs. . ± . ng/ml) and tpai- mg vs. mg vs. placebo (- . ± . ng/ml vs. . ± . ng/ml vs. . ± . ng/ ml) indicate significantly higher levels in a mg group compared to a mg and a placebo groups. other biomarkers ( mg vs. mg vs. placebo: oxldl, seselectin- and sicam- ) followed the same trend toward higher levels in the mg group compared to the mg and placebo groups, without reaching statistical significance. conclusion: this pilot project suggests that a higher dose of rsv may increase the levels of cardiovascular disease risk biomarkers in overweight older adults. given no change in the cardiovascular disease risk biomarkers in response to a lower dose, future studies should test the effects of different doses of rsv on reduction of cardiovascular disease biomarkers in overweight, rather healthy older adults. background: actual nutrition is a factor that continually effects physiological capacity and workability, the functional aging rate of an elderly persons. objectives: the purpose of this study was to determine the relationship between nutrition and physiological abilities, the work performance, functional aging rate, residual working capacity and frailty of the elderly. methods: it has been studied anthropometric and functional parameters of respiration, physical performance, mental capability, sensory skills, as well as the rate of functional aging in different aging groups: - years - persons, - years - persons, - years - persons. we have also analyzed the professional history, social status, and factual nutrition (according to the questionnaire proposed by the who and adapted for ukraine) of the elderly. results: the nutrition or diet factors influence on the problems dealing with working capability, reduction of the hand grip strength and endurance, independence and frailty (for elderly) in overall . % for all mentioned factors. right and left hand grip strength associate with protein consumption (r = . ; r = . ; p < . accordance) with variety of cereals (r =- . ; r =- . p < . accordance) also with variety of vegetables (r = . ; r = . ; p < . accordance)variety of fruits (r = . ; p < . ; r = . ; p < . accordance). it was studied features of an actual food at centenarians of ukraine which not only have lived to this old age, but also have the relatives who have lived to age of centenarians. it was established, that meals of ukrainian centenarians include high percentage of vegetables, fruits and dairy products. meanwhile menu has been deprived practically all basic alimentary pathology risk factors which accelerates biological age, creates certain preconditions to preservation of health and longevity. conclusion: as a result of a comprehensive study and mathematical modeling was developed a quantitative method for assessing the residual working capacity for elderly persons. background: age-related decline in olfactory function has implications for health and nutrition due to reduced appetite and decreased sensory perception of food. several studies have investigated olfactory performance in the elderly, but studied mostly single odour components often less related to food and meals. food odours are composed of multiple odorants and compensation for specific perceptual losses among elderly may occur. therefore, it is relevant to study olfactory perception of complex food odours to improve understanding of odour perception in the context of foods and meals. objectives: to develop a test method to screen young and elderly ( +) subjects on their olfactory capacity for everyday food odours. the method included a series of sniffing sticks with relevant and familiar complex food odours from primarily essential oils. methods: the olfactory sniffing sticks test kit was developed in four steps: ) selection and validation of relevant, familiar and diverse food odours, evaluated on perceived familiarity. ) standardization of an iso intensity reference level for the food odours in relation to n-butanol. ) assessment of shelf-life stability for the sniffing sticks within an weeks period. ) evaluation of test-retest reliability for intensity and identification of the odours within a weeks period. results: food odours were selected due to their diverse sensory characteristics. they were provided from a french manufacturer which may have compromised the familiarity in a danish context as only out obtained satisfactory familiarity score. however out showed reliable results in a test-retest procedure. n-butanol, in two concentrations provided a satisfactory reference frame for the iso intensity scaling. furthermore the food odours were overall shelf-life stable within an weeks period. conclusion: a new odour test kit for everyday food odours was developed and validated for screening olfactory capacity (intensity perception, familiarity and identification) in elderly subjects. based on the evaluations, odours were included in the final test kit. this olfactory test reflects the complex stimulation of the olfactory system, when stimulated by eating a food, compared to odour test kits with single or few components which makes it relevant when customizing of meals for elderly to improve nutrition and wellbeing. background: nordic nutrition recommendations (nnr) ( ) suggest protein intake >= . g/kg body weight (bw) to preserve physical function in nordic older adults. however, no published study has used this cut-off to evaluate the association between protein intake and frailty. objectives: this study examined associations between protein intake, and sources of protein intake, with frailty status at the -year follow-up. methods: participants were women aged - years enrolled in the kuopio osteoporosis risk factor and prevention -fracture prevention study. protein intake g/kg bw and g/d was calculated using a -day food record at baseline . at the -year follow-up ( ), frailty phenotype was defined as the presence of three or more, and prefrailty as the presence of one or two, of the fried criteria: low grip strength adjusted for body mass index, low walking speed, low physical activity, exhaustion was defined using a low life satisfaction score, and weight loss > % of bw. the association between protein intake, animal protein and plant protein, and frailty status was examined by multinomial regression analysis adjusting for demographics, chronic conditions, and total energy intake. results: at the -year follow-up women were frail and women were prefrail. higher protein intake >= . g/kg bw was associated with a lower likelihood of prefrailty (or= . and % confidence interval (ci) = . - . ) and frailty (or= . and ci= . - . ) when compared to protein intake < . g/kg bw at the -year follow-up. women in the higher. conclusion: protein intake >= . g/kg bw and higher intake of animal protein may be beneficial to prevent the onset of frailty in older women. background: sarcopenia is a geriatric syndrome with increasing importance due to the aging of the population. progressive resistance training and protein supplementation are currently recommended for the prevention and treatment of sarcopenia. however, elderly are less responsive to these anabolic stimuli compared to healthy adults. inflammation is considered an important contributor to this age-related anabolic insensitivity. therefore, anti-inflammatory strategies, such as omega- , are a promising strategy to combat sarcopenia. furthermore, omega- were also shown to improve muscle anabolism though activation of the mtor signalling pathway and reduction of insulin resistance. objectives: firstly, we performed a narrative review of literature that gives an overview of the current knowledge about omega- intake and sarcopenia defining parameters (grip strength, gait speed, muscle strength or physical performance). secondly, we provided an overview of data on omega- supplementation and sarcopenia defining parameters. methods: a literature search was conducted in november , using electronic bibliographic databases (pubmed and embase). the reference lists of all full texts retrieved during the search process or as identified in already published (systematic) reviews were scanned. results were published in a narrative review (dupont j. et al. aging clin exp res.) results: seven observational studies described the associations between omega- intake and sarcopenia defining parameters. four interventional studies looked at the effect of omega- supplementation alone and suggested an improved muscle protein synthesis, improved gait speed and increased muscle strength and physical performance. three studies combining exercise with omega- supplementation suggested an enhancing effect of the supplement on the exercise-induced gains in muscle mass and strength. we found one study combining omega- and protein supplementation with exercise, but omega- dosage was too low for conclusive results. conclusion: observational data on omega- intake and sarcopenia remain conflicting. from current interventional data we conclude that there is growing evidence for a beneficial effect of omega- supplementation in sarcopenic elderly, which may add to the effect of exercise and/or protein supplementation. however, the exact dosage, frequency and use (alone or combined with exercise and/or protein supplementation) in the treatment and prevention of sarcopenia still need further exploration. background: with the growing incidence of cancer in older persons, malnutrition rates have increased. tumor-related malnutrition is a risk factor of treatment side effects. it reduces the quality of life and increases morbidity and mortality. therefore, malnutrition screening and diagnosis are mandatory to implement proper nutritional support. objectives: this study aimed to evaluate and compare the short form of mini nutritional assessment (mna-sf) nutritional screening tool with the new global leadership initiative on malnutrition (glim) diagnostic criteria for malnutrition among elderly patients with cancer. methods: patients >= years old, with a g screening tool ≤ , were referred to an oncogeriatrics consultation between february and september . the data recorded comprehended, demographic variables (age, sex), type of tumor, functional (barthel, lawton index, fac) and mental (mmse, yesavage) status, nutritional (mna-sf, glim criteria) and social assessment and number of drugs. if-vig, cirs-g, rockwood-ms, cci-sf, sppb and handgrip strength were used to estimate frailty. the roc curve was used to evaluate the ability to accurately distinguish malnourished patients. to determine diagnostic concordance between the assessment and the new glim diagnostic criteria of malnutrition, retrospectively analyzed, cohen's К statistic was calculated. results: patients were included, mean age . ± . , . % were women. gastrointestinal ( . %) and gynecological ( . %) neoplasms were most prevalent. . % were independent or had mild dependence on badl, . % on iadl. . % had no cognitive impairment and . % had no depressive symptoms. frailty scales showed a pre-frail patient profile, with good social support and a . ± drugs on admission. according to the new glim diagnostic criteria for malnutrition, % of the patients were malnourished. with the use of mna-sf, . % of the patients were found to be at risk of malnutrition. the roc curve of mna-sf had an area under the curve (auc) of . . no concordance was found between the mna-sf and the malnutrition diagnostic results (К= , p< . ). conclusion: in this small sample, most cancer patients were male, > years old, with low frailty index, good functional and mental status and at risk of malnutrition. the mna-sf scale detected more risk cases so preconditioning and nutritional recommendations before specific oncological therapies could be made. concentration is associated with muscle mass and strength in healthy elderly. however, there are several confounders, including body composition, nutrient intake, physical activity level and blood parameters which may also influence muscle mass. previous studies have not thoroughly examined the relationship between serum (oh)d concentration and muscle indices by comprehensively considering the potential confounders in healthy elderly. objectives: the purpose of this study was to investigate the relationship of serum (oh) d concentration with muscle mass and strength in healthy japanese elderly. methods: this cross-sectional study included healthy elderly in shiga prefecture in japan (age: . ± . years, m = , w = ). total fat-free mass (tffm) and appendicular (affm) were measured using dual-energy x-ray absorptiometry. in addition, handgrip strength and leg extension power were measured. a blood sample was collected in an overnight fasted state, and serum (oh)d concentration was assessed. habitual dietary intake and physical activity were assessed. protein intake, carbohydrate, and vitamin d intakes were adjusted for energy by the residual method. association of serum (oh)d concentration with tffm, affm, handgrip strength, and leg extension power was assessed by hierarchical multiple regression analysis with adjustment for age, gender, weight, energy, energy-adjusted protein, carbohydrate, vitamin d intakes, serum albumin concentration, and physical activity. results: the mean serum (oh)d concentration of participants was . ± . nmol/l. low serum (oh)d status (< nmol/l) was observed in . % ( / ) of participants. the mean affm was . ± . kg, and handgrip strength was . ± . kg. serum (oh)d concentration was significantly associated with affm (β = . , p = . ), but not with tffm (β = . , p = . ), handgrip strength (β = . , p = . ) and leg extension power (β = - . , p = . ). conclusion: serum (oh)d concentration is related to affm japanese healthy elderly people, even if confounders are comprehensively considered. background: muscle quality, often defined as force produced per area or mass of muscle, declines as people age. objectives: we hypothesized that dietary protein quality will better predict muscle quality than energy, carbohydrate, protein, fat, or leucine intakes when controlling for age, bmi, composition, and moderate to vigorous physical activity (mvpa). methods: strength was measured using isokinetic dynamometry at degrees per second, leg composition (lc) was examined via dual-x-ray-absorptiometry, and mvpa was measured with accelerometry. dietary intake was estimated using three-day food logs and esha software. muscle quality was defined as right knee extensor peak torque relative to right leg lean mass. protein quality was the ratio of total leucine over total protein intake. multiple linear regression and stepwise linear regression models were used. results: ninety-four women (mean ± sd; age . ± . years; bmi . ± . kg/m ; lc . ± . % fat; mvpa . ± . min/day; energy , ± kcal/day; carbohydrate . ± . g/ day; protein . ± . g/day; fat . ± . g/day; leucine . ± . g/day) completed the assessments. only protein quality (mean ± sem; beta = . ± . ; t = . ; p = . ) was significant to the full regression model containing all covariates (r = . ; adjusted r = . ; f ( , ) = . ; p = . ). to verify the importance of protein quality, a stepwise regression analysis using the same variables was performed and resulted in a model (r = . ; adjusted r = . ; f ( , ) = . ; p < . ) that included protein quality (mean ± sem; beta = . ± . ; t = . ; p = . ) and energy intake (mean ± sem; beta = . ± . ; t = . ; p = . ). conclusion: dietary protein quality is positively associated with muscle quality when controlling for bmi, lc, mvpa, and energy, protein, fat, carbohydrate, and leucine intakes. the most parsimonious model included protein quality and energy intake, suggesting that they are most related to muscle quality. background: it has been suggested that disruption of the apoptotic process may have an effect on the incidence of sarcopenia. on the other hand, one of the dietary recommendations for seniors is to increase their daily protein intake. however, the effect of protein intake on apoptosis is not well understood. objectives: the purpose of this study was to investigate the effect of eight weeks of protein whey supplementation on the expression of genes involved in the internal and external pathways of apoptosis of long extensor muscle of thumb of aged wistar rats. methods: this is an experimental studies. statistical sample of this study consisted of male wistar rats (age: months, weight: ± gr). they were randomly divided into supplement (n= ) and control (n= ) group. supplement group received . gr per body weigh protein whey daily for eight weeks. the left thumb extensor muscle of all subjects was carefully separated and after freezing in liquid nitrogen transferred to - ° c. quantitative real time-pcr was performed to measure bax, bcl- , caspase , and gene expression levels. independent t-test and mann-whitney u test were used to compare the means and rankings. the hypotheses were tested at the significant level p< . . results: results showed that bax, caspase , caspase , and caspase genes expression increased in all samples in training group compared to the control group but this increase was only significant for bax, caspase and gens (p < . ) and also bcl- gene expression significantly deceresed (p < . ) in comparison with control group. conclusion: it seems that protein supplementation lead to activation of the internal pathway of apoptosis by increasing mitochondria permeability. background: the presence of obesity alongside with impaired aging in general, and with impaired muscular performance in particular, may result in a unique and growing phenotype of obese frail/sarcopenic, which may be hardly diagnosed by simple observation. characterizing the nutritional intake of this phenotype is of a substantial relevance. objectives: to characterize the nutritional intake among frail prone (fp) and obese subjects in a sample of community dwelling older adults in israel. methods: in this cross sectional study we evaluate the nutritional intake of frail, frail prone and robust subjects (with and without the presence of obesity), as well as their adherence to the dietary reference intakes (dri). data were retrieved a series of national studies on the status of health and nutrition in different age groups in israel (mabat zahav) for [ ] [ ] . the frailty likelihood presented here is based on a previous study from our group suggesting a non-direct validated model estimating frailty based on components. results: compared to the robust, fp subjects were more likely to have lower intake of several nutrients. among them are: iron (mg) (mean . vs. . , p < . ), vitamin c (mg) (mean . vs. . , p < . ), folate (μg) (mean . vs. . , p < . ), vitamin a (iu) (mean . vs. . , p = . ). the average overall adherence score according to the dri (based on a sum of nutritional components) was . among fp subjects, compared to . among robust subjects (p = . ). obesity either defined by bmi or by wc had a lower «effect» on the nutritional intake differences as compared to frailty status. this observation was seen when obese subject were compared to non-obese subjects and as fp subjects were more likely to show a poor nutritional status regardless of the presence of obesity. conclusion: our results show a clear association between frailty and poor nutritional intake, regardless of the presence of obesity. moreover, the functional status may better reflect nutritional gaps than obesity -challenging the concept of the frail -obese phenotype regarding to nutritional status. background: the loss of bone density during aging induces risks of falls, fractures and mobility decline. moreover, bone structure seems to be a better predictor of fractures than bone density. these phenomena are exacerbated in the presence of sarcopenia. however, dynapenia alone or in combination with obesity is more involved in falls and loss of mobility than sarcopenia. nevertheless, the impact of obesity on bone density and bone structure is still controversial. furthermore, protein intake appears to be associated with maintenance of muscle, bone density and bone structure. to our knowledges, the impact of protein intake on bone density and bone structure among dynapenic-obese older adults is not known even if this condition reached around % of elderly. objectives: to assess the influence of protein intake on bone density and bone structure among dynapenic-obese older adults. methods: twenty-six older adults (>= years), obese (%fat: men > ; women: > ) and dynapenic (relative to body weight grip strength: men < . ; women < . ) were divided into groups according to their initial protein intake : prot-: < g/kg/d (n= ; . % of women; . ± . years) and prot+: > . g/ kg/d (n= ; . % of women; . ± , years). the following measurements were performed: relative to body weight grip strength using lafayette dynamometer, body composition using dxa, femoral bone structure using ct-scan, nutritional intake using the -day food record method. results: excepted, by design, for initial protein intake, both groups were comparable at baseline. the prot-group had a higher (p< . ) marrow area ( ± ) than the prot + group ( ± ). in addition, the compressive loading strength was greater (p< . ) in the prot-group ( ± ) than in the prot + group ( ± ). finally, the total bone area was larger (p< . ) in the prot-group ( ± ) compared to the prot + group ( ± ). conclusion: surprisingly, a lower protein intake but higher than rda seems to protect bone structure but not bone density among dynapenic-obese older people. these results should be confirmed in larger studies designed to address this question. background: unintentional weight loss occurs in % to % of older adults and has been associated with morbidity, functional incapacity, risk of hip fracture, and overall mortality. while the impact of this condition is well established in frailty, studies involving sarcopenia are still insipient. objectives: to investigate the association between unintentional weight loss and sarcopenia in community-dwelling older adults. methods: a cross-sectional study was conducted among older adults (>= years) assisted in primary care. the unintentional weight loss was assessed by questions contained in three frailty assessment tools and one nutrition screening and assessment tool, described below: ( ) "have you recently lost weight such that your clothing has become more loose?" [edmonton frail scale (efs)]; ( ) "have you lost a lot of weight recently without wishing to do so? ('a lot' is: kg or more during the last six months, or kg or more during the last month)" [tilburg frailty indicator (tfi)]; ( ) "in the last year, have you lost weight unintentionally (i.e., not due to dieting or exercise)? (unintentional weight loss is: more than . kg or of at least % of previous year's body weight)" [phenotype for frailty (pf)]; ( ) «weight loss greater than kg during the last months" [mini nutritional assessment (mna®)]. sarcopenia was identified by european working group on sarcopenia in older people (ewgsop ) criteria. the data were analyzed with use of pearson chi-square test (p< . ). results: a total of older adults were evaluated ( . % female). the mean age was . ± . years ( - y). sarcopenia was identified in . % of the sample (n= ). the frequency of unintentional weight loss in sarcopenics was % in tfi (n= ; p= . ), % in efs (n= ; p= . ), . % in pf (n= ; p= . ) and . % in mna® (n= ; p= . ). conclusion: we observed that the unintentional weight loss evaluated by tfi and efs (frailty assessment tools) was associated with sarcopenia. so, different ways to evaluate weight loss (amount and time) seems to influence this association. funding: this study was financed by fapergs (process number - / - ) and capes (finance code ). background: half of older adults admitted to hospital are malnourished. malnutrition often leads to weight-loss and may lead to a loss of muscle mass, muscle strength and physical performance. nutritional interventions should individualise nutritional requirements, particularly energy and protein. objectives: to assess if energy requirements, determined by indirect calorimetry compared to usual care (predictive equations), can lead to a reduction in weight loss (primary outcome) and improvements in muscle mass, muscle strength and physical performance (secondary outcomes) in geriatric rehabilitation patients at risk of malnutrition. methods: geriatric rehabilitation inpatients were derived from the resort cohort (royal melbourne hospital, australia) and allocated by wards to either the indirect calorimetry or usual care group for the need study. energy requirements were measured using indirect calorimetry; the results were utilised by dietitians in the indirect calorimetry group and concealed for the usual care group. weights were obtained weekly. food intake assessment, muscle mass (bioelectrical impedance analyser), handgrip strength (hgs) and physical performance (short physical performance battery (sppb)) were measured at admission and discharge. within-group and betweengroup differences were calculated for the changes in outcome measures during hospitalisation. results: twenty-one patients (indirect calorimetry n= ; usual care n= ) were included (mean age . ± years; males, females). preliminary results showed that in the indirect calorimetry group, five patients gained weight, four patients maintained weight and one patient lost weight during hospitalisation; the usual care group had four patients with weight gain and five patients maintaining weight. there were no significant within-group differences or between-group differences for changes in weight ( background: many older people have difficulties in performing daily living activities such as preparing meals and food shopping, which could be partly due to cognitive and physical decline [ ]. these factors may influence food choice and represent a potential barrier to achieving good nutrition [ ] . nevertheless, the association between mealrelated difficulties and nutritional risk, as well as dietary intake, has been understudied. objectives: ( ) to examine the prevalence of autonomy in food-related activities, as measured with instrumental activities of daily living scale (iadl), among frail and pre-frail older subjects with an objective cognitive impairment ( ) to characterize the association of food autonomy with an insufficient dietary intake and nutritional risk of cognitive frail older people. methods: this is a secondary cross-sectional analysis using baseline data from the cogfrail study, which is a monocentric observational study of cognitive frail and prefrail older participants, aged >= years, with an objective cognitive decline. dietary intake is evaluated with a dietitian, using a diet history method. autonomy in food-related activities is assessed using iadl scale. nutritional status was categorized according to the mini nutritional assessment (mna). results: ongoing analyses. preliminary results show a mean energy intake of less than kcal and g of protein per day, we considered all nutritional needs cannot be covered under this threshold. conclusion: frail older people, with cognitive impairment, are particularly at nutritional risk and insufficient dietary intake. food autonomy has to be evaluated systematically to prevent nutritional risk in this population. elderly aged years or over, and this number will continue to increase. in order to extend the healthy life expectancy, disease prevention and health management of the elderly are important. preventive intervention of sarcopenia is considered to be an important issue in promoting care prevention for the elderly. objectives: the purpose of this study was to clarify the relationship of muscle weakness and physical characteristics with nutritional intakes. methods: subjects were men and women ( to years old) in the nagoya longitudinal study for healthy elderly (nls-he) in , excluding those who had missing values of the examinations. nutritional intakes were assessed by the food frequency questionnaire (ffq). low grip strength (gs) was diagnosed by asian working group for sarcopenia (awgs) criteria. the cut-off value of gs was kg for men and kg for women. results: the number of the subjects diagnosed with low gs was , ( men and women). comparison was made between the low gs group and the normal group. there were no significant differences between the two groups in age, sex, number of teeth, chewing ability and occlusal force, whereas mini nutritional assessment (mna) score, walking speed at the normal and maximum speed, exercise habits, and percent of body fat were significantly lower in the low gs group than the normal group. also, the rate of polypharmacy was significantly higher. in nutritional intakes, vitamin d and b were significantly lower in the low gs group. in the intakes by food groups, fish and meat intakes were significantly lower, but the intakes of snack were significantly higher. furthermore, the protein ratio and the amount of animal protein intakes were significantly lower in the low grip strength group. conclusion: in this study, muscle weakness was related to lower intake of specific nutrients such as vitamin d, b , and animal protein, independent of number of teeth, chewing ability, and occlusal force. background: the status of calcium intake, the main mineral of the bone has no suitable biomarker to assess it. its evaluation is relevant in clinical practice as in research. postmenopausal women should be evaluated for risk factors for osteoporosis, including poor calcium intake. objectives: to develop and validate a food frequency questionnaire (ffq) to assess the calcium intake of mexican postmenopausal women. methods: after obtaining approval from the institutional ethics committee, a pilot study was performed including mexican women whose calcium intake was assessed trough a day food diary ( dfd). the ffq was designed including the foods reported by the participants of the pilot study that provided more than . % of the calcium requirement and that were reported by at least participants. the ffq was tested through a validation study that included postmenopausal whom also completed the dfd. the validity of the ffq was assessed with the interclass correlation coefficient (icc) alongside a bland-altman analysis. results: postmenopausal women were assessed from june , to january , . participant's characteristics are shown in the table . the ffq underestimated mean calcium intake compared to day food diary (- mg ± . , p< . ). the two methods were strongly correlated by the icc (icc= . , ci . - . ). the ffq could identify individuals who consumed >= mg/ day with a high sensitivity, and a reasonable specificity (table ). figure shows the agreement between the dfd and the ffq were plotted against the average of the two measurements (figure ), the mean (solid line) and the % ci (broken lines) of the difference are shown. conclusion: conclusions: the ffq´s good sensitivity in identifying low calcium intake in postmenopausal women makes it useful also as an educational tool in diet counselling and for identifying subjects in need of supplementation. the difference between methods limits its utility as an epidemiological tool. helen yl chan , winnie kw so , regina cheung , kc choi , brenda ho , francis li , ty lee , janet wh sit , martin mh wong , sy chair ( ( ) background: nutritional status has been recognized as a predictor of the level of frailty. however, little is known about how the eating habits and dietary preferences associated with frailty, especially in the chinese elderly population. objectives: this study aims to identify dietary factors in predicting frailty among community-dwelling older adults. methods: a multicentre cross-sectional correlational study was conducted in hong kong in . frailty was defined by using fried's phenotype model. the frail scale was used to classify level of frailty and the mini-nutritional assessment (mna) was used to evaluate the nutritional status, in addition to anthropometric parameters. association between nutritional status (at risk or malnourished vs normal) and frailty status was examined using ordinal regression in a hierarchical fashion for adjusting participant socio-demographics, health status, lifestyle characteristics, eating behaviours and dietary habits. all the statistical analyses were performed using ibm spss . . all statistical tests were two-sided with level of significance set at . . results: a total of chinese older adults participated in the study. the prevalence of robust, pre-frail and frail were . %, . % and . % respectively. one third of the participants were malnourished or at risk of malnutrition. malnutrition and at-risk of malnutrition significantly increased the likelihood of frailty (or . , % ci . - . ). however, the level of frailty was not associated with age, gender, anthropometric measurements, eating behaviours, and use of dietary supplements. other nutritional factors significantly increased the likelihood of frailty were chewing difficulties (or . , % ci . - . ) and inadequate consumption of vegetables (or . , % ci . - . ). however, good appetite significantly reduced the likelihood of frailty (or . , % ci . - . ). conclusion: the findings showed that chewing difficulties and inadequate consumption of vegetables were associated with frailty, whereas good appetite was a protective factor. hence, interventions for addressing chewing problem and promoting appetite and consumption of vegetables are imperative to counter frailty in the older population. lack of energy was associated with nutritional status in nursing-home (nh) residents. methods: we performed a cross-sectional analysis of the incur study cohort. lack of energy was measured at baseline as part of the -items geriatric depression scale. nutritional status was evaluated according to mini nutritional assessment short-form (mna-sf). a -items frailty index (fi) was computed. logistic regression models were performed to test the association of lack of energy with nutritional status. results: a total of nh residents were available for analysis. the median age (iqr) was ( - ) years, with ( . %) females. at baseline, median mna-sf (iqr) was ( - ) with ( . %) patients that were malnourished. among the patients included . % ( patients) reported lack of energy. at univariate logistic regression analysis mna was inversely associated with lack of energy. at multivariate logistic regression analysis, adjusted for age, sex nursing home years and fi, we found that mna was independently inversely associated with lack of energy (or . , % ci . - . ). being malnourished is independently associated with lack of energy (or . , % ci . - . ). among mna components we found that item a (decrease in food intake), item c (reduced motricity) and item d (psychophysical stress) were inversely associated with lack of energy (or . , % ci . - . ; or . , % ci . - . ; or . % ci . - . ; for each point respectively), independently each one and from the other confounders. conclusion: in a cohort of very old nh residents, we found that an impaired nutritional status is associated with lack of energy. in particular, being malnourished bring a -fold risk of reporting lack of energy. more precisely, decrease in food intake, reduced motricity and psychophysical stress, each one were independently associated with lack of energy. a g e . m a r g u e r i t a s a a d e h , , f e d e r i c a p r i n e l l i , , anna-karin welmer , , weili xu , davide l vetrano , , serhiy dekhtyar , laura fratiglioni , , amaia calderón-larrañaga ( ( ) background: while declines in physical function are a common feature of ageing, the rate of the loss varies substantially between individuals, and has been attributed to intrinsic but also extrinsic (modifiable) factors such as diet, physical activity, and psychosocial well-being. objectives: ( ) to assess the role of food and nutrient intake in the speed of functional decline over years of follow-up. ( ) to explore whether such an association differs between levels of physical activity and psychosocial well-being. methods: we analysed data from individuals aged + from the population-based swedish national study on aging and care in kungsholmen (snac-k). the mediterranean diet score, mds (trichopoulou et al.) and the healthy diet indicator, hdi (who recommendations for saturated fatty acids, monodisaccharides, cholesterol, pufas, protein and fibre) were calculated for each participant, based on baseline data from a validated food frequency questionnaire and the corresponding transformation into nutrient intake. physical activity levels were assessed with questions about type, frequency, and intensity, and categorised as inadequate vs health/fitness-enhancing. we created a psychosocial well-being index by integrating variables linked to life satisfaction, positive/negative affect, social network and social participation. a global score of physical function was obtained by combining data on walking speed, balance, and chair stand tests. linear mixed models were used and adjusted for age, sex, education, smoking, baseline number of chronic diseases and impaired activities of daily living, total energy intake and time to death/drop-out. results: one standard deviation (sd) increase in the mds was associated with a lower functional decline both crosssectionally (β= . ; p= . ) and over the -year follow-up (β*time= . ; p= . ). higher scores of the hdi were also significantly associated with a lower functional decline, but only cross-sectionally (β= . ; p= . for one sd increase). when stratifying the analyses by levels of physical activity and psychosocial well-being, the protective effect of high mds was limited to subjects with health/fitness-enhancing physical activity (β*time= . , p= . ) and high levels of psychosocial well-being (β*time= . , p= . ), respectively. conclusion: a high adherence to a mediterranean dietary pattern, especially in combination with higher physical activity and psychosocial well-being, may slow down the age-relate decline in physical function. background: this cross-sectional study describes the application and follow-up of the self-care actions applied in a white male, years old, . m tall, a former athlete, currently sedentary, who in january presented % of glycated hemoglobin in medical consultation -between . and . %: pre-diabetes; fasting glycemia (mg / dl); (mg /dl) and the postprandial dose between and mg / dl. blood pressure between - mmhg; characterizing hypertension in stage. objectives: the objective was applying and follow-up a food re-education program associated with a resistance training program to reduce non-communicable diseases. methods: during , a program of dietary reeducation was carried out, with a few complex carbohydrates, an increase in proteins of high biological value, associated with a program of resistance exercises, which was adapted and individualized, obeying the individual's particularities. a short physical performance battery (sppb) was also applied to assess walking speed, strength and muscle balance. this program was performed three times a week, under the supervision of a physical education professional. capillary blood glucose was collected and analyzed times and blood pressure times, respectively. it was carried out a basic training for weeks aiming to rescue the muscular memory of the elderly, after beginning the adaptive phase of the physical valence training (cardiovascular endurance, localized muscular resistance); for weeks and the specified. the loads corresponded to % of rm for - repetitions with three series and to minutes intervals at each stage of the training. we used the ibm spss statistics program to perform descriptive statistics. results: the mean glycemia was (mg / dl), the glycated hemoglobin analyzes showed . ; low risk of diabetes. systolic blood pressure and diastolic blood pressure presented a mean of . ± . mmhg, and . ± . mmhg, respectively. we observed a gradual gain every months of resistance training. the sppb score changed from to points; performance between intermediate to high. conclusion: dietary re-education associated with a well-designed strength training program can result in the reduction of diabetes and hypertension, as well as strengthening the muscular system of the elderly. background: diet can be an important non-pharmacological aspect in order to prevent and/or attenuate brain and frailty outcomes in older adfults. objectives: to investigate, by a systematic review, studies associating the dietary inflammatory index (dii) with brain and frailty outcomes in older adults. methods: we searched the publications in pubmed and lilacs databases up to june . inclusion and exclusion criteria were formulated based on pi(e)cos strategy (population= older adults, >= years; intervention/ exposition= dietary inflammatory index; comparison= not applied; outcomes= brain and muscle outcomes; study type= randomized clinical trials, cohorts, cross-sectional, casecontrol studies). results: searches resulted in publications, and after exclusion due to duplicity (n= ) and not compliance with exclusion and inclusion criteria (n= ), eight studies were selected. these studies were published from to , all of them were cross-sectional, with participants above years old, and the outcomes investigated were frailty and frailty risk, survival free of disabilities (by fried's frailty criteria, sppb test, lawton and broady scales); memory, cognitive decline and risk of dementia (by meem, cerad, gds, prime-md, dsst and animal fluency test). conclusion: the data extracted from the articles showed significant association between dii and the outcomes investigated, namely, the more inflammatory diet was associated with higher odds to be frail and pre-frail, and to have any type of cognitive impairment. therefore, the dii showed to be associated to brain and frailty outcomes in older adults, however, to understand causality, longitudinal studies are still necessary. background: it is well established that reactive oxygen species (ros) are increased in skeletal muscle with age. we have recently shown that increased ros with age is associated with increased expression of the senescence-associated microrna mir- a- p (mir- a) in skeletal muscle as well as in muscle-derived extracellular vesicles. these vesicles enriched in mir- a are elevated in aged mouse serum, and can induce senescence in bone stem cells. the histone deacetylase sirt is a validated target of mir- a, and sirt plays important roles in cell survival as well as in muscle hypertrophy with functional overload. importantly, we previously found that mir- a expression was much higher in muscle from aged female mice compared to male mice, a phenomenon others have observed in mouse cardiac muscle. objectives: here we tested the hypothesis that pharmacological ablation of senescent cells could modulate mir- a and sirt bioavailability in skeletal muscle of aged mice. we utilized the senescent drug abt- (navitoclax) since previous studies have shown that oral administration of abt- removed senescent satellite (stem) cells in mouse skeletal muscle. methods: ten male and ten female c bl mice, months of age, received either abt- ( mg/kg bw, ul) or vehicle by oral gavage for ten days. tibialis anterior muscles were removed at the end of the study for examination of mir- and sirt levels using rt-pcr and elisa, respectively. results: abt- reduced mir- a expression in both male and female mice, although the effect was more pronounced in male mice compared to females. abt- significantly increased sirt levels in male skeletal muscle but not in females. the changes in sirt and mir- a levels were not associated with significant differences in muscle fiber size over the treatment period. conclusion: these findings suggest that certain senolytic compounds can modulate levels of senescence-associated mirnas and their targets in aging skeletal muscle. these data also underscore the importance of considering sex differences in the molecular mechanisms underlying age-related muscle atrophy. background: the growth of the elderly population is a worldwide phenomenon and is associated with profound changes in body composition. the purpose of this study was to describe the magnitude of the problem, to evaluate the associated factors and the relation with functional capacity in the study population. objectives: to estimate the association between demographic factors, comorbidities and muscle mass index over time until functional disability or death appears in non-obese elderly individuals. methods: longitudinal study of elderly individuals aged years or over, non-obese and absence of functional disability at the beginning of the cohort on the epidoso project database. the variables gender, age, ethnicity, medical history, functional capacity and death were investigated. the low or normal muscle mass index (mmi) was obtained through anthropometric data and a predictive equation. the functional capacity was measured using a structured and validated multidimensional questionnaire. the deaths occurred in the period were investigated with relatives through household surveys, in registries and registries of the state system of data analysis foundation. estimates of eventfree survival (functional disability or death) were calculated using kaplan-meier curves using the log-rank test in the gross comparisons. a multiple cox proportional hazards model was used to identify the independent effect of time predictors until onset of functional disability or death. results: the mean time found for the onset of functional disability or death was . years ( %ci=[ . ; . ]). in the crude analysis, there were statistically significant differences in the time to occurrence of functional disability or death, by age group (p< . ), arterial hypertension (p= . ), diabetes mellitus (p= . ) and marginal statistical difference muscle mass level (p= . background: a consequence of the ageing population is the increasing number of older adults with physical limitations. these limitations are mainly caused by decreased muscle mass and strength (sarcopenia). treatment or rather prevention of sarcopenia is necessary, as it may lead to lowered quality of life, hospitalization, loss of independence and even mortality. since older ethnic minorities are more likely to have an unfavourable health status compared to the majority population, variations in the prevalence of sarcopenia for ethnic minority groups are expected. further investigation seems imperative to be able to target preventive interventions to those at high risk of sarcopenia within the population. objectives: to examine the sarcopenia prevalence and its association with protein intake in an older multi-ethnic population in the netherlands. methods: we used cross-sectional data from the helius (healthy life in an urban setting) study, comprising the largest ethnic populations living in amsterdam, the netherlands. in total individuals from dutch, south-asian surinamese, african surinamese, turkish and moroccan origin aged years and over were included. sarcopenia was defined according to the ewgsop . in a subsample (n= ), protein intake was measured using ethnic-specific food frequency questionnaires. descriptive analyses were performed to study sarcopenia prevalence across ethnic groups in men and women, and logistic regression analysis were used to study associations between protein intake and sarcopenia. results: sarcopenia prevalence was found to be sex-and ethnic specific, varying from . % in turkish to . % in south-asian surinamese men and ranging from . % in turkish up to . % in south-asian surinamese women. higher protein intake was associated with a % lower odds of sarcopenia in the total population (or= . , % ci . - . ) and across ethnic groups. conclusion: ethnic differences in the prevalence of sarcopenia and its association with protein intake suggest the need to target specific ethnic groups for prevention or treatment of sarcopenia. background: few studies have evaluated the relationship between frailty and acute respiratory illness (ari), despite of increasing heavy burden of ari in older people. objectives: we conducted a prospective cohort study in communitydwelling older people in hong kong, to evaluate the impact of frailty on the risk of acute respiratory infections in the community setting and the potential modifying role of outdoor activities. methods: we recruited and followed up participants who were chinese and aged from to years, from december to may . frailty was measured by fried frailty index (ffi) twice during the study period. daily hours of outdoor activities were collected by a monthly activity journal (n= ) during the whole period, and by wearable gps device from some participants for one week in summer (n= ) and winter (n= ), respectively. the ari incidence was collected by monthly phone calls to the participants. we used a logistic regression model to estimate the odds ratio (or) of ari associated with frailty status (robust as reference group). results: the participants were classified into three groups according to the ffi criteria: ( . %) as robust, ( . %) as pre-frail and ( . %) as frail groups. of them, reported ari during the study period. according to the activity journals, daily hours of staying outdoors in the ari participants were slightly less than those in without ari ( . vs . in whole study period, . vs . in summer, . vs . in winter). while, the gps data showed that the participants with ari had longer daily hours of outdoors activities in summer ( . vs . ) but shorter in winter ( . vs . ), although none were statistically significant (p > . ). after adjustment for age, age, living alone or with family and daily hours of outdoor activities, we found that the frailty and pre-frailty groups had a higher risk of ari incidence compared with the robust group, with or . (p = . ) and . (p = . ), respectively. conclusion: frailty might be associated with a higher risk of ari among older people, but the role of outdoor activities remains inconclusive. background: previous studies have investigated the association between impaired muscle health and mortality. however, muscle health is a dynamic entity which change with time. objectives: to assess the effect of a short-term decline of muscle health (i.e., over year) and its association with long-term mortality (i.e., over years). methods: the sarcophage cohort follows up older belgian adults to assess consequences of sarcopenia. an assessment of muscle mass (dxa), muscle strength (handheld dynamometer) and physical performance (by means of sppb, including gait speed) are performed annually. all-causes deaths are collected annually. the association between short term (i.e. after one year) decline in muscle parameters and -year occurrence of deaths was tested using cox model. roc analyses were performed to assess performance of prediction of the different muscle components and to find optimal cut-points. missing data were handled using multiple imputations. results: from the subjects recruited ( . ± . years, . % women), were discarded from our sample because they died during the first year. therefore, the muscle decline was available on a sample of subjects. deaths occurred within the first years of follow-up. a -point decrease in performance at sppb test resulted in % higher risk of dealth (hradjusted = . [ %ci . - . ]). for each decrease of . m/s of gait speed, we observed an % higher risk of death (hradjusted = . [ . - . ]). a -kg decrease of muscle strength resulted in % higher risk of death in men and % higher risk of death in women (hradjusted = . [ . - . ] and hradjusted = . [ . - . ], respectively). we did not found any association between short-term loss of muscle mass and the occurrence of death (p= . ). then, we tried to find cutoffs optimizing the sensitivity-specificity ratio and we found following results : over year, a decline of sppb superior or equal to , of gait speed superior or equal to . m/s and of muscle strength superior or equal to . kg in men and . kg in women. conclusion: a short-term decline in muscle function is predictive of premature deaths. background: sarcopenia, the age-related progressive loss of muscle mass and function, is associated with an increased likelihood of adverse outcomes like falls, fractures, physical disability, and mortality. international consensus groups continue providing new definitions and clinical cut-off points despite over a decade of work in this area. objectives: we examined the prevalence of sarcopenia using two of the most current operational definitions (foundation of nih sarcopenia project (fnih) and the european working group on sarcopenia in older persons (ewgsop )) in a cohort of older adults (n= , >= yrs) hospitalized for an acute disease at utmb hospital in galveston (jan -may ). methods: testing included measures of: demographics (age, gender, race, education), body composition (dexa), physical function tests (sppb, tug, grip), psychological wellbeing and independence questionnaires, and chart review (comorbidity, length of stay). results: we found % had low physical performance, % had low muscle strength, and % low lean mass. we compared multiple tests and cutoffs for each of the three groupings under the fnih and ewgsop and found there to be differences depending on the test usedespecially for low performance which varied from %- %. in our cohort, the prevalence of sarcopenia was . % by ewgsop and . % by fnih. the subgroupings were found to be near identical across almost all measures despite the definitions' discrepancies in cutoff points between fnih and ewgsop . conclusion: in conclusion, recent updates to the new ewgsop make it almost indistinguishable to the older fnih standard, but the new ewgsop algorithm does provide a grading system to identify different levels of severity of sarcopenia. background: the population is experiencing a fast growth in the number of older adults, therefore determine the prevalence of frailty could help to inform future strategies to reduce its social and health burden. objectives: determine the prevalence of frailty in chilean older adults. methods: participants, aged > years, from the chilean national health survey - were included in this study. frailty was assessed by fried criteria modified, therefore people classified as frail should meet at least out of the criteria (low strength, low physical activity, low body mass index, slow walking pace and tiredness). results: the prevalence of frailty was . % ( . % for men and . % for women). the prevalence of prefrailty was . % whereas . % was classified as normal. the prevalence of frailty increased with markedly with age, . % and . % of men and women, respectively, were frail at the age of . this prevalence increased to . % and . % for men and women at the age of . the prevalence of pre-frailty increased from . % to . % for men and from . % and . % for women from the age of to years, respectively. conclusion: the prevalence of frailty increased markedly with age. with the chilean population expected to increase their life expectancy and number of older adults, it is important to implement prevention strategies that allow for early identification of high-risk individuals. a year follow-up. jair licio ferreira santos , yeda aparecida de oliveira duarte , tiago da silva alexandre background: sarcopenia has been increasingly recognized as leading to poor prognosis in health outcomes. likewise, falls -although important at older ages -have not been studied frequently and may lead to an increased risk of death. we evaluated survival of elderly people living in são paulo -brasil in a -year follow-up, considering the presence of sarcopenia at baseline and the occurrence of falls before the interview. objectives: to investigate whether sarcopenia and/or falls increase mortality among brazilian older adults. methods: data came from the second ( ) and fourth ( ) rounds of the health, welfare and aging study (sabe), which begun in , with a sample of the population over years old in the city of são paulo, brazil. after the first round, follow-up was performed every five years. sarcopenia was defined according to the consensus of the european working group on sarcopenia in the elderly (ewgsop), and the occurrence of falls was assessed by direct questions answered by the elder or his caregiver. a multivariate analysis with robust estimation and control for exposure time was done using the poisson regression model. results: mortality rates (per thousand person years) were: . (non sarcopenic, no falls) ; . (non sarcopenic with falls); . (sarcopenic no falls) ); and . (sarcopenic with falls. the poisson regression resulted in incidence rate ratios (when compared to sarcopenic, no falls) of . for non sarcopenic with falls; . for sarcopenic elders with no falls and . for sarcopenic with falls. conclusion: sarcopenia and the occurrence of falls are important risk factors for mortality. this finding highlights the importance of considering sarcopenia in health risk assessment and developing educational programs to prevent falls. ecosse l. lamoureux, , , alfred t.l. gan , ryan e.k. man , , eva k. fenwick , , bao lin pauline soh , angelique chan , david ng , chong foong-fong mary , preeti gupta (( ) singapore eye research institute and singapore national eye centre, singapore; ( ) duke-nus medical school, singapore; ( ) singapore institute of technology, health and social sciences, singapore; ( ) saw swee hock school of public health, national university of singapore, singapore) background: individually, sarcopenia and frailty are known risk factors for cognitive impairment (ci) in older adults, but information on their conjoint presence on the increased risk of ci is unavailable in this same population. objectives: we examined the association of the combined presence of sarcopenia and frailty with ci in elderly singaporeans. health profile in elderly singaporeans study (pioneer), a nationally-representative, population-based study of singaporean chinese, malays, and indians aged >= years. participants underwent body composition (dual energy x-ray absorptiometry -dxa); grip strength (hand dynamometer) and habitual m-walking speed assessments. sarcopenia was defined using the asian consensus as low appendicular lean mass (lalm; men < kg/m , women < . kg/m ) and low muscle strength (lms; men < kg, women < kg) or slow walking speed (sws; < . m/s); and frailty was defined as meeting three or more of the following components: ) unintentional weight-loss >= . kg in the past - months and/or bmi < . kg/m , ) lms, ) self-reported exhaustion in the past one month, ) sws, and ) low physical activity level. ci was determined using the montreal cognitive assessment (moca) basic scale. logistic regressionb models were used to determine the cross-sectional sarcopenia-frailty and ci relationship. results: of the included participants (mean age [sd]: . [ . ] years; . % females), ( %); ( %); and ( %) had neither sarcopenia nor frailty, either sarcopenia or frailty, and both sarcopenia and frailty, respectively. ci was present in ( . %) individuals without sarcopenia and frailty; ( . %) with either sarcopenia or frailty; and ( . %) individuals with both sarcopenia and frailty. in multivariable-adjusted analyses, presence of either sarcopenia or frailty was not significantly associated with higher odds of ci (odds ratio (or) [ % confidence interval]: . [ . - . ]), while having both sarcopenia and frailty significantly increased the odds of ci by nearly . times ( . [ . - . ]). conclusion: the co-presence of sarcopenia and frailty is independently associated with a higher risk of ci, compared to one condition alone, although longitudinal studies are needed to confirm this finding. strategies to prevent the concomitant onset of sarcopenia and frailty may be warranted to potentially reduce the risk of ci in older adults. background: car accidents related to older adults increased with aging, particularly in japan. safety driving required robust of physical function. however, the association between frailty and car accidents was still unclear. objectives: the aim of this study was to examine the association between frail status and car accidents. methods: participants were , older adults ( . % women, mean age: . years) enrolled current drivers in the national center for geriatrics and gerontology -study of geriatric syndromes. the criterion of frailty used in this study was j-chs index modified according to fried's criteria (chs index). the components of frailty in j-chs index were based on the original chs index: shrinking (weight loss), weakness, poor endurance (exhaustion), low activity level, and slowness. based on the presence numbers of these five components, our study defined "frailty" as and over, i.e., including pre frail and frail. the data of car accidents were collected from self-reported history of car accidents during years. results: among , participants, , participants ( . %) had a history of car accident. higher proportion of car accidents group was observed in shrinking ( . % vs . %, p = . ), exhaustion ( . % vs . %, p = . ), physical inactivity ( . % vs . %, p = . ) and slowness ( . % vs . %, p = . ), but not weakness ( . vs . , p = . ). in a logistic regression analysis, frailty was independently associated with car accidents in an adjusted model (or . [ %ci . - . ], p < . ). conclusion: this population study reveals frailty associated with car accidents. the findings have contribution of enhancing utility of risk assessments among older drivers. further studies were required to clarify risk of car accidents.model. background: frailty, a state of vulnerability to stressors resulting from a loss of physiological reserve across multiple systems. frailty is associated with higher morbidity, mortality and healthcare utilization. the national prevalence of frailty among us older veterans was found to be as high a %. however, little is known about the incidence of frailty in older, community-dwelling veterans. objectives: determine the incidence over years of frailty among robust or prefrail community-dwelling older veterans. methods: this is a retrospective cohort study of community-dwelling veterans years and older who had determinations of frailty from july -june and were followed until their last clinician visit before september , . a -item va frailty index (va-fi) was generated at baseline and during each subsequent primary care encounter as a proportion of all potential variables (morbidity, function, sensory loss, cognition and mood and other) with data from electronic health records. the va-fi categorized veterans into robust (fi<. ), prefrail (fi=>. , <. ) and frail (fi>=. ). using baseline and median duration of follow-up data based on event rates, incidence rates of frailty per person/years were calculated for robust, prefrail, combined (robust and prefrail) and gender groups. results: patients were . % white, . % non-hispanic, . % male, mean age . (sd= . ) years. the proportion of robust, pre-frail and frail patients at baseline was . % (n= ), . % (n= ) and . % (n= ) respectively. among robust veterans surviving a median follow-up of . (iqr . ) years, . % ( / ) became frail with an incidence rate of . cases/per person-years. among prefrail veterans . % ( / ) became frail and the incidence rate was . cases/per person-years. among the combined group, % became frail, with an incidence rate of . per person-years. the proportion of veterans becoming frail and the incidence rates were higher in women than men ( . % vs. . % and . vs . cases per person-years respectively). conclusion: this study shows a high incidence of frailty in community-dwelling older us veterans. identification of older veterans at high risk for frailty may assist in the development of interventions aimed at preventing frailty and its associated complications. background: anticholinergic drugs are prescribed to treat a variety of medical conditions through pharmacological actions opposing the actions of acetylcholine. anticholinergics and may contribute to frailty by causing cognitive, functional and physical impairment. frailty represents a state of vulnerability to stressors resulting from a loss of physiological reserve across multiple systems. frailty may potentially make patients more susceptible to the deleterious effects of anticholinergic medications on cognition. objectives: determine the crosssectional association of anticholinergics with cognitive impairment according to frailty status among communitydwelling older veterans. methods: this is a cross-sectional study of , community-dwelling veterans years and older whose frailty status was assessed october -october . the use of medications (active/inactive) with high anticholinergic burden scale (acb ) and cognitive impairment diagnoses (icd codes for mild cognitive impairment/dementia) were obtained from electronic health records. a -item va frailty index (va-fi) was generated as a proportion of all potential variables at the time of the assessment. we compared robust (fi≤. ), prefrail (fi=>. , <. ) and frail (fi>=. ) patients. after adjusting for age, gender, race, marital status, median household income, and bmi, odds ratios (ors) and % confidence intervals (cis) were calculated using binomial logistic regression with cognitive impairment as the outcome variable and anticholinergics (acb ) as independent variables. we repeated the analysis according to frailty status. results: patients were % white, . % male, mean age . (sd= . ) years, . % ( ) had cognitive impairment, . % (n= ) were taking acb medications, . % ( ) took them in the past and . % ( ) never used them. the proportion of robust, pre-frail and frail patients was . % (n= ), . % (n= ) and . % (n= ) respectively. in binomial logistic regression, active and inactive acb medications were associated with higher risk for cognitive impairment, adjusted or= . background: frailty, a state of vulnerability to stressors resulting from a loss of physiological reserve across multiple systems. the national prevalence of frailty among us older veterans was found to be as high a %. multiple studies have shown a higher prevalence of frailty and mortality in african americans. however, little is known about racial-differences in all-cause mortality in older veterans who had just transitioned to frailty. objectives: determine racial differences in allcause mortality over years among community-dwelling older us veterans who transitioned to frailty. methods: this is a retrospective cohort study of , community-dwelling veterans years and older who transitioned to frailty from july -september and were followed until death or september . a -item va frailty index (va-fi) was generated at baseline and during each subsequent primary care encounter as a proportion of all potential variables with data from electronic health records. the va-fi categorized veterans into robust (fi≤. ), prefrail (fi=>. ,<. ) and frail (fi>=. ). at the end of follow-up, we aggregated data on mortality only on those veterans who transitioned to frailty (robust/prefrail at baseline) and compared whites and african americans. after adjusting for age, gender, ethnicity, marital status and median household income, the association of race with mortality was determined using a multivariate cox regression model. results: patients were . % white, . % african-american, . % non-hispanic, . % male, mean age at frailty transition was . (sd= . ) years. over a median follow-up period of days (iqr= ) from the time they transitioned to frailty, deaths occurred (n= , in whites vs. n= in african americans). african american veterans had a lower risk for all-cause mortality than white veterans, unadjusted hazard ratio (hr) =. ( %ci: . -. ), p<. . however, these mortality differences disappeared after adjustment for covariates, adjusted hr =. ( %ci: . - . ), p=. . conclusion: our study suggests that in community dwelling older us veterans who had transitioned to frailty, race is not significantly related to overall survival when adjusting for other covariates. background: previous studies show that sarcopenic obesity (so) is associated with higher risk of mortality. however, a consensus definition of so is lacking, and more information is needed on the validity of simple measures applicable at a regular health care visit, such as anthropometric measurements and hand-grip strength or chair stand test. objectives: to examine the association between so and mortality, defining so based on body mass index, waist circumference, hand-grip strength and chair stand test, in a representative sample of finnish population. methods: this study was based on , participants aged years or over with data on anthropometrics, hand-grip strength and chair stand test from the nationally representative health survey. baseline sarcopenic obesity was defined as having bmi >= kg/m or waist circumference >= cm (men)/ cm (women), and hand-grip strength < kg in men, < kg in women, or chair stand > s for five rises. register-based follow-up data of the statistic finland containing , deaths during the years of follow-up were individually linked with the baseline data. survival analyses were based on cox proportional hazards models using age as the time scale. results: mean age was . years (sd . ) and . % were females. overall prevalence of sarcopenic obesity was . % at baseline. sarcopenic obesity was associated with higher risk of mortality (hr . , %ci . - . ) in an age and sex adjusted model. further adjustments for education, smoking, alcohol use, and physical activity did not notably change the results (hr . , %ci . - . ). conclusion: sarcopenic obesity, as defined based on anthropometric measurements as well as hand-grip strength or chair stand test, predicted higher mortality over years of follow-up. background: malnutrition and sarcopenia have a negative impact on mobility, risk of falls, fractures, physical disability and mortality. currently, limited information is available on nutritional status and nutritional interventions in geriatric rehabilitation (gr) patients. objectives: to characterize nutritional status and evidence of nutritional interventions with and without physical exercise in gr patients. methods: eight electronic databases were screened for nutritional status and interventions in patients >= years, admitted to gr, one search string was used for both topics. pooled estimates were calculated for mean bmi and prevalence of (risk of) malnutrition (mna). meta-analyses were performed to quantify intervention effects on albumin, muscle mass, barthel index (bi), and hand grip strength (hgs). results: observational and intervention studies were included out of references. pooled estimates ( % confidence interval (ci)) for prevalence of malnutrition and risk of malnutrition were ( - )% and ( - )%. pooled estimate ( %ci) for bmi was . ( . - . ) kg/m². low protein and energy intake and vitamin d deficiency were prevalent. intervention studies were heterogeneous in interventions and outcomes. meta-analyses showed no significant effects on albumin (standardized mean difference (smd) . , % ci - . : . ), muscle mass (mean difference (md) . kg, % ci - . : . ), bi (md . points, % ci - . : . ) and hgs (smd - . , % ci - . - . ), based on - studies. eight interventions tested oral nutritional supplements (ons) with protein, with or without exercise, reported protein intake and showed an increase, / studies showed increased albumin levels and / reported improved functional outcomes. conclusion: a high percentage of gr patients was affected by reduced nutritional status. intervention studies were limited and heterogeneous, but studies with ons improved nutritional outcomes, and functional outcomes in the majority of reporting studies. the results emphasize the need for malnutrition and sarcopenia screening and show benefits of protein supplementation in this population. future well-designed, well-powered trials are needed to clarify existing controversial aspects. therefore, feasibility of an intervention with a high-whey protein, leucine and vitamin d enriched ons (fortifit®), combined with resistance-type exercise in gr hip fracture patients will be investigated in a new intervention study (empower-gr). background: sarcopenia is a progressive and generalized skeletal muscle disorder associated with an increased likelihood of adverse outcomes such as falls, fractures, physical disability and mortality. the geographical region of residence (urban and rural area) may affect the prevalence of sarcopenia due to physical and environmental conditions. in , the european working group on sarcopenia in older people (ewgsop) updated the definition of sarcopenia (ewgsop ). objectives: to describe the prevalence of sarcopenia related to ewgsop and ewgsop criteria and to analyze the association between sarcopenia and geographical regions of residence. methods: this is a cross-sectional study involving elderly women ( years old or more) that were undergoing dxa in a radiology facility located in palmeira das missões (southern brazil). sociodemographic data were collected through a questionnaire. for the diagnosis of sarcopenia, we used the criteria recommended by the ewgsop (low muscle mass plus low grip strength and/or low gait speed), and ewgsop (low grip strength plus low muscle mass and/or low gait speed). the study was approved by the university ethics committee. results: out of the participants, . % was married, . % had education between and years of schooling, . % was caucasian, and . % was retired. the mean age was . ± . years old ( - ). the frequency of sarcopenia in the total sample assessed by the ewgsop and ewgsop was . % and . %, respectively. the prevalence of sarcopenia by the ewgsop was % in the urban area and . % in the rural area (p= . ) and by the ewgsop was . % in the urban area and . % in the rural area (p= . ). conclusion: in a sample of elderly women from the southern brazil, the prevalence of sarcopenia was low through both consensus (ewgsop and ewgsop ), and was higher among urban area. funding: this study was financed in part by the coordenação de aperfeiçoamento de pessoal de nível superior -brazil (capes) -finance code . background: patients with disuse syndrome have gradually increased with aging of inpatients in saitama medical university hospital. because these patients have been inactive in the acute phase, sarcopenia is likely to occur. sarcopenia was graded by three criteria in ewgsop ; muscle strength, muscle quantity and physical performance. muscle volume can be measured only in limited medical centers. many of patients with disuse syndrome can not walk even after the acute phase. for these reasons, muscle strength is the only quantitative factor reflecting sarcopenia, especially in old patients with disuse syndrome after the acute phase. objectives: to show ) muscle strength in old patients with disuse syndrome after the acute phase, ) effect of muscle strength on activities of daily living (adl). methods: subjects were old patients with disuse syndrome admitted in the department of rehabilitation medicine (rm) in saitama medical university hospital from january to december . inclusion criterion were as follows; ) patient age was or older ) patients could not walk independently at admission in the department of rm exclusion criterion were as follows; ) patients with motor paresis, contracture of fingers ) patients in inactivity before the onset of the disease causing disuse syndrome. grip strength (gs) was measured by handheld dynamometer. cut-off point of gs set by awgs in was adopted; kg for men and kg for women, adl was evaluated using functional independence measure motor scale (mfim) one week after admission in the department of rehabilitation medicine . percentage of gs below cut-off point was shown in men and women respectively. effect of gs on mfim was investigated using regression analysis. results: ninety nine out of patients were subjects in this study. median age was . years in men (n= ), . years in women (n= ). only two in men and one in women were below gs cut-off point. correlation coefficient between gs and mfim was . (p= . ) in men, . (p= . ) in women respectively. conclusion: gs was below cut-off point in most of the subjects. gp may affect adl after the acute phase in old patients with disuse syndrome. death, whereas measures of functional ability, physical strength and morbidity were stronger associated with time to death than with chronological age. from the age of and forwards participants have a high life-satisfaction in general, however, a decline is seen as persons get older and with proximity to death. measures of functional ability (e.g. going shopping) and morbidity (e.g. self-related health) had a significantly increasing effect on life-satisfaction with increasing age. whereas social function (e.g. living alone, meeting friends) did not significantly modify the decrease in life satisfaction with increasing age. conclusion: physical strength, functional ability and morbidity were measures mostly linked to biological aging, while social functioning was strongly correlated with chronological age. functional ability and self-related health are important factors to prevent age-related decrease in life satisfaction. background: previous studies mostly conducted in western countries support that physical frailty predicts future cognitive decline in general older populations. however, longitudinal evidence on this association is limited, especially among older japanese women. objectives: this study has investigated the prospective associations of frailty status with cognitive decline over two years among community-dwelling older japanese women, including which individual frailty components (i.e., slowness, weakness, exhaustion, low activity, and unintentional weight loss) could predict cognitive decline. methods: this study was a two-year population-based cohort study conducted in a metropolitan area of tokyo, japan. data were collected in october (baseline) and september (follow-up) and analyzed between december and january . participants were community-dwelling older japanese women, aged to years at the baseline, without any neurological diseases or cognitive impairment as measured by a mini-mental state examination (mmse) score of >= points. cognitive decline was defined as a drop of two points or more in the mmse score over two years. the physical frailty phenotype was classified by the japanese version of cardiovascular health study criteria. multiple poisson regression analyses with a robust error variance were applied to assess risk ratios (rrs) of two-year cognitive decline across the baseline frailty statuses (robust [reference category], prefrail, or frail). results: of the women analyzed, ( . %) were prefrail ( or components), and ( . %) were frail (≥ components) at the baseline. at the follow-up, ( . %) robust, ( . %) prefrail, and ( . %) frail women experienced cognitive decline. after being adjusted for various confounding factors including age, educational attainment, and baseline mmse score, the rrs of cognitive decline were . ( % confidence interval [ci]: . , . ) in the prefrail and . ( %ci: . , . ) in the frail women. among the five frailty components, slowness (rr: . , %ci: . , . ), weakness (rr: . , %ci: . , . ), and unintentional weight loss (rr: . , %ci: . , . ) were significantly associated with cognitive decline. conclusion: over the two-year period, approximately % of women experienced cognitive decline. baseline physical frailty status, particularly slowness, weakness, and unintentional weight loss, predicted this decline. intervention strategies targeting physical frailty may help delay cognitive decline in older japanese women. background: menopause leads to estradiol (e ) deficiency that is associated with decreases in muscle mass and strength. yet the mechanistic role of e in the loss of muscle mass has not been established. programmed cell death termed apoptosis has been proposed a key signaling route in skeletal muscle homeostasis, including muscle aging and sarcopenia. to date several micrornas (mirs) have been found to regulate key steps in apoptotic pathways. objectives: here we studied the effect of e deficiency on mir-signaling in skeletal muscle apoptosis. our aim was to reveal whether e -responsive mirs have mechanistic role in inducing skeletal muscle apoptosis. methods: we utilized c bl mice with three study groups; sham (normal estrous cycle, n= ), ovx (e deficiency, n= ) and ovx+e (high e supplemented by pellet, n= ). in our setup, ovx and ovx+e groups represent the extremes of e level. six weeks following the sham or ovx surgery, mice were sacrificed, gastrocnemius muscles were harvested and rna isolated. mir-profile was studied with ngs and candidate mirs verified using qpcr. the target proteins of the mirs were found using in silico analysis (target scan) and target proteins measured at mrna (qpcr) and protein levels (western blot). results: of the apoptosis-linked mirs found, four ( - p, a- p, - p and - p) indicated differential expression patterns between ovx and ovx+e groups. in qpcr verification, ovx had lower expression in all of the studied mirs compared with ovx+e (p= . ). accordingly, ovx had higher expression of cytochrome c and caspases , and compared with ovx+e at the mrna level (p< . ). at protein level, ovx had greater cytochrome c and active caspase compared with ovx+e (p< . ). conclusion: in muscle from e deficient mice (ovx vs. ovx+e group), several apoptosis-linked mirs were down regulated concomitant with higher mrna expression of the target proteins. furthermore, e deficiency was associated with higher cytochrome c and active caspase protein levels. to conclude, e deficiency down regulated several mirs related to apoptotic pathways that may lead to increased apoptosis and reduced skeletal muscle mass. background: although sarcopenia's pathogenesis is multifactorial, with its major phenotypes, muscle mass and muscle strength, being highly heritable, its genetic underpinning is not well studied. objectives: summarize evidence for use of zebrafish as a model system to decode the sarcopenia's gwas findings. methods: several genome-wide association studies (gwas) of muscle-related traits were published recently, providing dozens of candidate genes, many of them with unknown function. therefore, animal models are required not only to identify causal mechanisms, but also to clarify the underlying biology and to translate this knowledge into new interventions. over the past several decades, small teleost fishes had emerged as a powerful system for modeling the genetics of human diseases. due to their amenability to rapid genetic intervention and the large number of conserved genetic and physiological features, small teleosts, such as zebrafish (d. rerio), are indispensable for skeletal muscle genomic studies. results: we summarize the evidence supporting the utility of small fish model for accelerating our understanding of human skeletal muscle in norm and disease. the following stable mutants (mostly knockouts) exist for the «monogenic muscle» diseases (human gene, fish mutant, disease): for duchenne and becker muscular dystrophy (md), sapje/dmd (homology of human dmd gene); for limb-girdle md, popdc s f (bves); for bethlem myopathy and ullrich congenital md, col a ama (col a ); for nemaline myopathy, froto c (myo b), and tmod trg (tmod ); for merosin deficient congenital md, lama cl /cl ; candyfloss/lama (lama ); for limb-girdle md, bvesicl /icl (popdc ), heltg (ttn), and «foie gras» (trappc ); for native american myopathy, stac mi (stac ), as well as fish homologues of the acvr , cacnb , cavin , cms, dag , fhl , flnc, vcp and other human genes. these models provide evidence of muscle-related gene's conservancy and similarity of skeletal muscle morphology and physiological phenotypes. we will outline challenges in interpreting zebrafish mutant phenotypes and translating them to human disease. conclusion: we conclude with recommendations of future directions to leverage. centenarians exhibit extreme longevity and a compression of morbidity. we showed previously that centenarians display a unique genetic signature, in terms of mrna and mirna profile, which is similar to that found in young people and different from that found in octogenarians. centenarian offspring seem to inherit centenarians' compression of morbidity, as measured by lower rates of age-related pathologies such as hypertension, diabetes, strokes, and heart attacks. we therefore hypothesized that they will also display a lower incidence of frailty. in this study, we aimed to ascertain whether centenarian offspring are endowed which such "genetic footprint" and a lower incidence of frailty, when compared to their contemporaries. for this purpose, we collected plasma and peripheral blood mononuclear cells from septuagenarians, , age-matched centenarian offspring (but not sons or daughters of the centenarians included in this study) and centenarians. mirna expression and mrna profiles were performed by the genechip mirna . array (affimetrix) and genechip clariom s human array (affimetrix), respectively. frailty phenotype was determined by meeting three or more of the following criteria: unintentional weight loss, low grip strength, exhaustion, slow gait speed, and low physical activity. we found that mirna and mrna expression patterns in centenarians are similar to centenarian offspring and different to non-centenarian offspring (p< . ). importantly, we found a lower incidence of frailty among centenarians' offspring (p< . ), when compared to their contemporaries. taken together, our results indicate that centenarian offspring resemble centenarian characteristics and that they enjoy significantly less frailty than their less fortunate contemporaries that are not sons or daughters of centenarians. this lower incidence of frailty may be a key feature to achieve extraordinary ageing. background: hypoglycemic episodes increase in older patients and their consequences are more significant. objectives: the aim of this prospective observational study is to explore unknown hypoglycemic episodes diagnosed by continuous glucose monitoring in older type diabetic patients and to describe the link between the occurrence of hypoglycemia and glycosylated hemoglobin (hba c) level. methods: we included patients with type diabetes aged years or over hospitalized during consecutive months in a geriatric acute care unit in tours university hospital in france. demographic characteristics, type of diabetic treatment, mini mental state examination, hba c levels, albumin and creatinin level were recorded. continuous glucose monitoring (cgm) was used to detect hypoglycemia for a maximum of days, and capillary blood glucose measurements (cbgm) were also performed to times a day. patients with at least one blood glucose measure lower than mg/dl were compared with others for demographic, clinical and biological parameters. results: seventeen patients experienced hypoglycemia. these groups did not differ in demographic characteristics and in diabetic drug class. among these patients, had an episode of severe hypoglycemia (< mg/dl) and patients had nocturnal episodes, more often between and am. twelve patients had unrecognized hypoglycemia by cbgm. the average duration of hypoglycemic episodes was . hours. there was no difference in the hba c levels between the two groups (mean . %, p= . ). conclusion: the prevalence of hypoglycemia is underestimated in the oldest diabetic population receiving hypoglycemic drugs. measurements of cbgm and hba c level in the target may overlook nocturnal and prolonged hypoglycemic episodes. our study showed the benefit of cgm in older diabetic patients in order to detect unknown hypoglycemia. more prospective studies are needed to explore factors that predict hypoglycemia. catenacci, sophie le-gonidec, alizée dortignac, ophélie pereira, romain madeleine, jean-philippe pradère, philippe valet, cedric dray (umr inserm,universitéfédéral de toulouse -universitépaul sabatier toulouse iii, france) background: healthy lifespan does not increase proportionally compared to global lifespan leading to an increased number of disabled aged persons. to increase healthy lifespan, locomotion could be considered in the future as the main targetable outcome to fight against the frailty to dependency transition. the so-called sarcopenia, characterized as the loss of muscle mass and function, affects to % of the populations over . mechanistically, sarcopenia is associated with an imbalance between protein synthesis and degradation, an increase of muscle inflammatory processes, a reduction of mitochondria-driven metabolism and an exacerbated fibrosis. several therapeutic strategies have been proposed such as hormonal replacement but, regarding the adverse effects, these strategies have been abandoned. in this context, we hypothesize that, through a modified secretory profile, adipose tissue could play a crucial role in the muscle loss of function. we previously promoted an unbiased proteomic study and identified haptoglobin as an up-regulated cytokine overproduced by the adipose tissue during aging. objectives: in this context, our project proposes to better understand the role of adipocyte haptoglobin in age-related muscle weakness. methods: to do so, we used complementary in vitro and in vivo models of haptoglobin supplementation and strategies of adipocyte haptoglobin over-expression/deletion. impacts of such interventions have been monitored by measuring myogenesic processes as well as muscle aging. moreover, a human cohort in progress will help to constitute a new biobank by collecting blood, adipose and muscle from sarcopenic individuals in order to evaluate the role of hapatoglobin on sarcopenia (inspire cohort). results: the results obtained in vivo and in vitro suggest that haptoglobin treatments induced an age-dependent decrease in muscle mass. moreover, these protocols indicated a muscle-specific role of haptoglobin when we measured the fiber diameter. in addition, a direct effect of haptoglobin on differentiation alteration was also observed in in vitro human muscle cells. conclusion: these results suggest that haptoglobin induces effects according to the age, the muscle type and the dose on muscle physiology. thus, a better knowledge of adipocyte haptoglobin production could help to better apprehend the age-related muscular complications. background: sarcopenia contributes to loss of independence and is increases risk of mortality. mitochondrial dysfunction and loss of proteostasis are two interrelated hallmarks of aging with well-established roles in skeletal muscle function. mitochondrial dysfunction increases cellular oxidative stress and impairs atp-generating capacity. consequentially, oxidatively-damaged proteins accumulate; however, a dysfunctional mitochondrial reticulum cannot sufficiently provide energetic resources to repair the proteome. in skeletal muscle, this impaired proteostasis and mitochondrial dysfunction promote sarcopenia. thus, improving mitochondrial function by increasing endogenous antioxidants could attenuate age-related loss of muscle function. objectives: using a phytochemical nrf activator (nrf a), we sought to determine if upregulation of cytoprotective genes would improve mitochondrial function and gait, an integrative metric of musculoskeletal function. methods: we utilized dunkin-hartley (dh) guinea pigs that develop primary osteoarthritis and experiences age-related skeletal muscle dysfunction by months of age (~ % of their maximal predicted lifespan). we treated young ( mo) and older ( mo) dh guinea pigs for and months, respectively, daily with a nrf a. we assessed metrics of gait monthly to measure the effect of nrf a on agerelated musculoskeletal dysfunction. we evaluated the effect of nrf a on skeletal muscle protein turnover using the stableisotope deuterium oxide. we also assessed soleus mitochondrial function using high resolution respirometry. results: while nrf a did not affect gait in young guinea pigs, months of nrf a treatment maintained stride length (p= . ) in older male and stance width (p< . ) in older female guinea pigs compared to untreated controls. nrf a improved (p= . ) adp vmax in young females and old males compared to their respective controls. nrf a also increased uncoupled electron transport system capacity in both male and female guinea pigs of both ages (p< . ). nrf a augmented contractile protein synthesis in the soleus of old male and female guinea pigs (p= . ), but did not prevent the age-related declines in the gastrocnemius. conclusion: in summary, long-term nrf a treatment improved skeletal muscle mitochondrial function, increased contractile protein synthesis, and maintained aspects of gait. together, our findings provide evidence that targeting the transcription factor nrf mitigates the decline in musculoskeletal function in a model of osteoarthritis and sarcopenia, with concomitant improvements in mitochondrial function and protein turnover. . j a n n e k e v a n w i j n g a a r d e n , francina j dijk , miriam van dijk , lisette cpgm d e g r o o t , y v e s b o i r i e , , y v e t t e c l u i k i n g background: sarcopenia is a muscle disease rooted in adverse muscle changes that accumulate across the lifespan. multiple factors cause or worsen sarcopenia, with aging as the primary factor and malnutrition, inactivity and diseases as secondary factors. objectives: to design a nutritional strategy to manage sarcopenia. methods: our research program investigated ) specific nutrient deficiencies in sarcopenic older adults, ) muscle protein synthesis (mps) response in cells and rodent models, and ) effect of a specific nutrient combination (whey protein, leucine and vitamin d -actisyn(tm), present in the medical nutrition supplement fortifit(r), on mps in older adults. results: cross-sectional studies indicated a significantly lower intake of protein (- %) and vitamin d (- %) in sarcopenic versus healthy older adults (p< . ) [verlaan, clin nutr ], and higher prevalence of sarcopenia among those with lower blood levels of leucine, total essential amino acids ( the specific combination of whey protein, leucine and vitamin d (actisyn(tm)) provides the right environment for muscle building in sarcopenia, where these nutrients are often deficient. this combination acts through a proven anabolic mode of action with optimal nutrient bioavailability for the muscle to stimulate mps. fortifit and actisyn are trademarks of n.v. nutricia. background: age-related sarcopenia is a major responsible for premature death, poor quality of life and several adverse outcomes, which lead to higher health care costs. despite its recent incorporation as a muscle disease (icd- -cm m . ), early identification of this disease remains challenging. mostly, due to classification and diagnostic criteria, which are predominantly based on technically advanced assessment tools, which may not be available in all clinic settings. recently, a non-invasive technique to analyze variations in biological tissues considering the effect of physiological and biological properties on microwave signals is being studied for its potential to determine muscle mass, with possible applications in the early diagnosis of this disease. objectives: therefore, the principal objective of this study is to preliminarily test the potential of this technique as a new tool for early diagnosis of age-related sarcopenia in a clinical setting. methods: muscle surface area are going to be assessed by abdominal computational tomography (ct) on the third lumbar spine vertebra (l ) and bioimpedance measurements among men and women, aged >= years in the maastricht university medical center, the netherlands. participants will also be subjected to measurements done with the device under test (dut) (the proposed technique) in the same location. the data collected from the three different measurements are analyzed looking for correlation. laboratory experiments made from synthetic materials emulating human tissues and from ex-vivo porcine tissues are used for optimization and interpretation of the clinical measurements. results: up-tonow, the campaign has just started and there is no enough data to give a preliminary result. initial laboratory experiments prove that the thickness of the fat and muscle tissues is correlated to the system response. conclusion: this prospective device will estimate the muscle mass locally using microwave electromagnetic principles. the results of this study can contribute to reveal the potential of this approach as a tissueanalysis tool for early diagnosis and management of age-related sarcopenia. the results might also provide useful evidence to consider in a future planned prospective cohort study, which aims to examine the impact of dietary biomarkers and genetic factors on the incidence of age-related sarcopenia in older adults. background: sarcopenia has become a serious problem in this aging society. at present diagnosis of sarcopenia consist of physical performance and muscle quantity. dexa has been widely applied to examine muscle quantity in clinical but it's radioactive, inconvenient and unaffordable in remote area. as a result, there are more studies in ultrasound in replace of dexa. objectives: based on others researches csa might be a suitable parameter to evaluate the muscle quantity. we develop a cheaper ultrasonic imaging system to evaluate the cross-sectional area (csa) of rectus femoris (rf)muscle. methods: we use a cmos image sensor combing with digital signal processor to detect the displacement of single element ultrasonic transducer. therefore, we combine us a-mode signal with displacement into b-mode image. by circling region of interest (roi), we can obtain the csa of rf muscle. then, we use siemens s evaluating the csa in the same region to testify the reliability. results: we recruited young college students undergoing the experiment. the result shows that the correlation coefficient is up to . . conclusion: in conclusion, our device can successfully evaluate the csa of rf muscle. moreover, our system using single element ultrasonic transducer is much cheaper than linear transducer in practice .it can be affordable in remote village or somewhere lacking in medical resource. a case-control study. camille nicolay , sandra higuet , sandra de breucker (( ) geriatric department, hôpital erasme, brussels, belgium; ( ) geriatric department, hôpital isppc-charleroi, charleroi, belgium) background: ten percents of belgian population are considered to be informal caregivers. little is known about their frailty status and their physical health. objectives: we compared the frailty status, the clinical and psychosocial status of old caregivers with controls (> ). we analyzed the association of frailty status according to fried's criteria and rockwood frailty index (fi) with the characteristics of caregivers and controls in multiple regression analysis. methods: eighty six caregivers and gender and agematched controls were included. frailty was assessed by the frailty phenotype (fried) and the -deficit frailty index (fi). social data, sf- health survey, basic and instrumental adl, geriatric depression scale, mini nutritional assessment, mini-cog, cumulative illness rating scale-geriatric, usual gait speed, handgrip strength, and burden scale (zarit) were collected. results: the prevalence of frailty was similar in caregivers and controls with the fi (p= . ) but higher with the fried's criteria (p= . ). compared with the control group, caregiving was associated with a lower mental quality of life (p< . ), a higher risk of depression (p< . ), a higher consumption of antidepressant (p= . ), a lower nutritional status (p= . ), a more frequent help from health care providers (p= . ), and more problems to maintain physical contacts with a social network (p= . ). in multiple regression, the fried's criteria adjusted for age, gender, marital status and incomes were associated with the age, the grip strength, the physical quality of life, the gait speed and the nutritional status (r = . -p< . ), while fi was associated with the risk of depression, the use of antidepressants, the physical quality of life, the cognitive status and basal & instrumental adl (r = . -p < . ) in caregivers. conclusion: the prevalence of frailty is similar in caregivers and controls when using fi, but higher in caregivers with fried's criteria. compared with controls, caregiving is associated with poorer health and psychological issues. while fried's criteria focus on physical frailty, the fi is more related with geriatric syndromes like depression, cognitive disorders, loss of autonomy, and quality of life. this study could help researchers to choose between frailty scales before starting a study about older caregivers. background: nursing home (nh) residents are often undernourished and physically inactive contributing to sarcopenia and frailty. mobility is identified by older nh residents as being key to their quality of life and well-being. the combination of protein supplementation and physical exercise has been shown to be most effective to maintain and increase muscle mass. objectives: the older persons exercise and nutrition (open) study aimed to investigate the effects of sit-to-stand exercises (sts) integrated into daily care combined with a protein-rich oral nutritional supplement (ons), on physical function, nutritional status, body composition, healthrelated quality of life and resource use. methods: residents in eight nh were randomized by nh units into an intervention group (ig) or a control group (cg) (n= /group). the ig was offered a combination of sts (four times/day) and ons ( bottles/day providing kcal and g protein) for weeks. the participants resided in nh units (dementia and somatic care), were >= years and able to rise from a seated position. the seconds chair stand test ( scst) was the primary outcome. secondary outcomes were balance, walking speed, dependence in adl, nutritional status and body composition, health-related quality of life and resource use. data was analyzed using descriptive and inferential statistics including regression models. results: altogether residents ( ± years, % females) completed the study. no improvement in the physical function assessments was observed in the ig, whereas body weight increased significantly ( . ± . kg, p= . ) vs the cg. twenty-one (of ) participants with high adherence to the intervention, i.e. at least % compliance to the combined intervention, increased their fat free mass ( . kg ( . , . iqr), p= . vs cg. logistic regression analyses indicated that the odds ratio for maintained/improved scst was . (ci . , . , p= . ) among the participants with high adherence compared to the cg. waly dioh , cendrine tourette , carole margalef , amy chen , rené lafont , , pierre dilda , stanislas veillet , samuel agus (( ) biophytis, sorbonne université -bc , paris, france; ( background: sarcopenia is a geriatric condition characterized by loss of muscle mass and functions and can contribute to risks of falls, fractures and hospitalization. sara-obs is a multicenter, observational trial designed to better characterize age-related sarcopenia in a community dwelling population at risk of mobility disability. this is part of a clinical program that strives to provide more understanding of the target population in order to further develop a potential sarcopenia medical intervention. sara-obs study rationale, design and main baseline characteristics are presented. objectives: the objective is to characterize sarcopenia and sarcopenic obesity in older adults through evaluation of their physical performance and body composition. changes in baseline characteristics after a -month period will be assessed and used for development of a phase interventional study on the efficacy and safety of an investigational drug, bio . methods: participant recruitment was based on age (>= years), sppb score =< and body mass based on the fnih criteria. physical functions were assessed by two walking tests ( m walk test and the -minute walk test), the sppb, the handgrip strength test and the stair climb power test. patient reported outcomes were also assessed with the sf- and the sarqol questionnaires. results: subjects were included in this study and the main screen failures were sppb scores and body mass criteria. baseline characteristics indicated that the average bmi was high, ~ % of the participants were women and that the alm/bmi in men was lower than the fnih threshold ( . vs . ) but was similar in women ( . vs . ). m gait speed was . m/s, the mean total sppb score was . with the gait speed component of < . m/s and the chair stand sub-score of . . conclusion: this population has a similar m gait speed as the populations in life and sprint-t studies at baseline. however, the sppb total score and the chair stand sub-score correspond more closely with the sprint-t study. addressing the loss of physical function and preventing mobility disability is still an unmet need of older adults. sara-obs included a population representative of a suitable target for subsequent interventional studies aimed to fulfill this need. yen-lung chen, hui-hua chiang (department of biomedical engineering, national yang-ming university, taipei, taiwan) background: in whole world, the elderly formally entered the aging society , and the patients with sarcopenia were highrisk groups in the fall. more than % of the elderly suffered moderate injuries due to falls. the sarcopenia as defined by the eu's sarcopenia working group was refers to progressive reduction in muscle mass and decreased muscle function. objectives: it is expected to provide diagnostic tools and techniques for the rapid determination of sarcopenia and muscle strength. at the same time, it will also be developed toward portable devices to facilitate the diagnosis of the aging of muscle function in the elderly at home to take care of the health and well-being of the elderly. methods: at present, the clinical measurement part is assisted by the radiation department of the veterans general hospital to collect and measure the subjects. clinical testing methods are mainly for older people over years of age. the walking speed test is firstly performed on the method. if it is normal, then the grip strength test is performed. if the grip strength is too small, the femoral rectus femoris muscle volume test should be performed. generally, dual energy is used. dual-energy x-ray absorptiometry (dxa) is used for testing. if the walking speed is too slow, the dxa test should be performed directly. the test value is less than . (kg/m ) in woman and less than . (kg/m )in man. that is, it is determined as a sarcopenia patient. since dxa has a small amount of free radiation, high cost, and a large space occupation, we expect to obtain a wide range of data through ultrasonic scans. back-end development algorithms are calculated to determine if there is sarcopenia and how severe it is. results: at present, the rectus femoris muscle volume obtained by using ultrasound has a highly linear relationship with the appendicular muscle mass measured by dxa (r = . ,p< . ), and has the ability to distinguish whether it is sarcopenia. conclusion: the use of muscle volume of rectus femoris can improve the accuracy of sarcopenia prediction. in the near future, this plan will be used to develop automated ultrasonic scanners. background: although sarcopenia has multifactorial causes, the decline in physical activity has been considered a very important aspect for its development. since the promotion of higher levels of physical activity can attenuate the progression of sarcopenia, it is possible that the participation in a programmed training increases the spontaneous physical activity of the participants. objectives: to investigate if the participation of sarcopenic older women in a resistance training program and supplementation with fish oil leads to changes in the level of spontaneous physical activity (sedentary time and number of steps). methods: randomized, double-blind, placebo-controlled clinical trial. thirty-two older women, aged >= years, participated in the study. all participants were classified as sarcopenic based on the criteria of the european consensus on sarcopenia (ewgsop). the participants were divided into two experimental groups: ( ) exercise group + placebo (ep) and ( ) exercise group + fish oil (efo). both groups underwent a resistance exercise program over weeks, consisting of three weekly supervised sessions. all volunteers were instructed to take two capsules of food supplement at each main meal, lunch and dinner ( g/day). the ep group used capsules composed of sunflower oil as placebo, and the efo group fish oil capsules, (epa mg and dha mg). measurements of the level of spontaneous physical activity were made before and after the intervention by using the actipal® physical activity monitor (glasgow, uk), for a period of seven consecutive days, during which the volunteers were instructed to maintain their normal routine. the volume of the quadriceps muscle in the pre and post intervention periods was calculated from the images obtained by magnetic resonance imaging. for statistical analysis, a linear regression model with mixed effects was used to compare longitudinal data on mean intra-group differences between groups and moments. for all analyzes, a significance level of . was adopted. results: both groups showed an increase in muscle volume after the intervention ( . cm ( . %) and . cm ( . %), respectively). regarding the level of spontaneous physical activity, both groups had a similar sedentary time and number of steps, at both times (average . h and , steps in the pre-intervention period and . h and , steps in the postintervention period for the ep group, and . hrs and , steps in the pre-period and . h and , steps in the postintervention period in the eop group). conclusion: although sarcopenic older women supplemented with fish oil showed a higher increase in muscle volume, the level of spontaneous physical activity remained unchanged both in the pre and post intervention periods and between groups, indicating that the increase in muscle volume was not associated with significant changes in the level of spontaneous physical activity. background: regardless of improvements in surgical and anesthetic practices, older surgical patients often experience postoperative complications. the purpose of this study was to investigate the association between physical frailty and cognitive function using a validated upper-extremity function (uef) test with in-hospital outcomes in aging adults undergoing abdominal surgery. objectives: to recognize frailty and cognitive function as a risk factor for in-hospital adverse outcomes. methods: we administered pre-operative uef tests, within -hours after admission, among patients aged years and older undergoing emergent/urgent abdominal surgery. the uef involved two tests; -and -sec of respectively fast and consistent elbow flexion, while angular velocity was measured via two wearable motion sensors applied to the wrist and upper-arm of the dominant arm. uef physical score was calculated, based on slowness, weakness, flexibility, and exhaustion (range: resilient= -frail= ). uef cognitive score was assessed based on motor function variability within a dual-task performance that involved uef motor task and a cognitive task of counting backwards by threes (range: cognitive normal= -cognitive impairment= ). adverse outcomes included: length of stay, complications, and death during their hospital stay. a logistic regression model was used to assess the association between uef physical and cognitive scores (independent variables) and in-hospital outcomes (dependent variable). results: a total of participants (mean age . ± . years) completed the preoperative uef assessment. thirty-six participants with an average age of . ± . years experienced at least one adverse outcome while in the hospital. while age independently predicted in-hospital outcomes with receiver operating characteristic area under the curve (roc-auc) of %, this prediction improved by adding either the uef physical or the cognitive score. the physical score predicted in-hospital outcomes with a roc-auc of %, and the cognitive scores predicted in-hospital outcomes with a roc-auc of %. conclusion: the proportion of emergency surgical procedures increases with age, and population trends indicate that this demand will increase significantly. results from the current study showed that sensor-based measures of physical and cognitive function can provide an objective tool for predicting adverse outcomes, with potential applications for other surgical procedures. risk stratification can help to establish targeted management strategies to improve the healthcare system and patient-centered outcomes. background: while sensor-based daily physical activity (dpa) gait performance has been demonstrated to be an effective measure of physical frailty, it is not clear how repeatable the dpa gait parameters are between different days of measurement, especially across frailty groups. objectives: to evaluate the test-retest reliability (repeatability) of dpa gait performance parameters (stride time, variability, and irregularity) and quantitative measures (number of steps and walking duration) between two separate days of assessment among older adults. methods: dpa was acquired for -hours from older adults (age>= years) using a tri-axial accelerometer motion-sensor attached to the trunk. purposeful continuous walking bouts (>= s) without long pauses (> . s) were identified from acceleration data and used to extract gait performance parameters, including stride time, power spectral density (psd) slope (representing the variability of walking cycles), dominant frequency of walking, and gait irregularity (sample entropy, representing predictability of walking cycles). to assess repeatability, intraclass correlation coefficient (icc) was calculated using two-way mixed effects f-test models for day- vs. day- as the independent random effect. repeatability tests were performed once for all participants and once within each frailty group (non-frail and pre-frail/frail). results: data from older adults, non-frail (age: . ± . years) and pre-frail/frail (age: . ± . years) were analyzed. within all participants with purposeful walking bouts on both the days, gait performance parameters of stride-time and gait variability parameters (slope and dominant frequency of walking) showed excellent test-retest reliability values (icc>= %) while quantitative parameters, including number of steps and walking duration showed poor test-retest reliability results (icc< %). among gait performance parameters (stride time, dominant walking frequency and sample entropy), we observed higher repeatability among the pre-frail/frail group with icc> % compared to icc< % for non-frail individuals. conclusion: from our study, it is evident that gait performance parameters including average step-and stride-time and frequency-domain gait variability parameters provided higher test-retest reliability compared to quantitative measures. further, gait performance parameters showed higher repeatability among pre-frail/frail volunteers between the two days compared to non-frail volunteers, which may be attributed to a lack of functional capacity among frail individuals for performing more intense and more variable physical tasks. background: while evaluation methods for skeletal muscle characteristics which are necessary to know the pathogenesis of sarcopenia are being considered, ultrasonography is attracting attention as a method simultaneously evaluate quantitative and qualitative evaluation of skeletal muscle. although we have found many, the statements that examined the relation between muscle thickness, echo intensity, physical function, and sarcopenia by quadriceps muscle ultrasonography in the previous report, there are few reports for the lower leg muscles. objectives: we conducted a study to examine whether the lower leg muscle ultrasonography is useful for evaluating sarcopenia index and muscle quality (muscle strength per unit muscle mass) evaluation in comparison with the quadriceps ultrasonography. methods: the participants were patients over years old ( males, females). the muscle thickness of the quadriceps muscle, tibialis anterior muscle, gastrocnemius muscle, soleus, and echo intensity were measured by ultrasonography, and the relationship between lower extremity muscle mass, muscle strength, physical function, and muscle quality was examined. results: the muscle thickness of quadriceps muscle, tibialis anterior muscle, soleus muscle was related to lower extremity muscle mass, grip strength, leg muscle strength, and only quadriceps muscle was related to gait speed. the echo intensity of the quadriceps, tibialis anterior, gastrocnemius was related to, grip strength, leg muscle strength, and only the tibialis anterior muscle was related to gait speed. the muscle thickness and the echo intensity of tibialis anterior muscle and soleus muscle are highly correlated with the quadriceps. the echo intensity of the tibialis anterior muscle, as well as that of the quadriceps muscle, showed a high correlation with the muscle quality of lower extremity. conclusion: concerning the assessment of sarcopenia using ultrasonography, muscle thickness and echo intensity evaluation by tibialis anterior muscle showed the same utility as them by the quadriceps muscle, and echo intensity of the tibialis anterior muscle can be a marker of muscle quality. lucena germano , cristiano dos santos gomes , juliana fernandes de sousa barbosa , , raysa freitas , , alvaro campos c. maciel , ricardo oliveira guerra ( ( background: phase angle (pha) is emerging as a measure of great clinical relevance provided through bioimpedance assessment and its related to health adverse outcomes such as osteoporosis and sarcopenia. on the other hand, poor physical performance as gait speed and grip strength in elderly is associated with poor health conditions. we hypothesized it is plausible that those two measures might be related and can be used as a tool in clinical practice. objectives: to investigate the relationship between pha and physical performance measures in community-dwelling older adults from brazil. methods: this cross-sectional study enrolled older adults of both sexes who had a comprehensive health evaluation including physical performance tests (gait speed and handgrip strength) and electrical bioimpedance screening. linear regression models were used to estimate the associations between pha and physical performance measures. results: the mean age of . ± . and . ± . for men and women respectively. hand grip strength (n: , ; p-value < , ) and gait speed (n: , ; p-value < , ) were independently correlated with pha. conclusion: pha could help to easily identify elderly on the onset of present heath adverse outcome and guide specific interventions by clinicians. shosuke satake , , kaori kinoshita , yasumoto matsui , background: in japan, we have a simple yes/no questionnaire to assess multiple functions in daily living for older adults; the kihon checklist (kcl). in the questionnaire, questions to assess mobile functions are included. objectives: we examined whether the -item questions in the physical domain of the kcl (kcl-phys) could be a surrogate of validated measurements of physical functions. methods: subjects were independent and ambulatory seniors aged years or older who had been consulted in our frailty clinic. all of them received grip strength test, dual energy x-ray absorptiometry, physical performance tests, cognitive examination, and the kcl questionnaire. among them, we excluded subjects with missing data, and with moderate cognitive impairments. we examined the relationships between scores of the kcl-phys and usual gait speed, short physical performance battery (sppb), and timed up and go (tug) with the spearman's rank correlation. the score of the kclphys were counted when the subject meets any criteria with each question as previously reported. also, we evaluated the cutoff point of the kcl-phys equivalent to slow gait speed (< . m/s), low sppb score (sppb < ), and slow tug (tug >= sec) with the receiver operating characteristic (roc) curve analysis. results: the mean values of age, body mass index, and prevalence of sarcopenia were . years old (women . %), . (kg/m ), and . (%), which were no differences between sexes. on the other hand, physical functions of gait speed, sppb, and tug were all worse in women than in men. relationships between the scores of the kcl-phys and usual gait speed, sppb, and tug were moderate with the coefficients of - . , - . , and . , respectively (p< . for all). the area under the roc curve of the kcl-phys score equivalent to slow gait speed, low sppb score, and slow tug were . , . , and . , respectively. the cutoffs were thought to be the best at points of the kcl-phys to identify low physical functions based on the youden index. conclusion: physical domain of the kcl could be a surrogate of assessments of physical functions in older people. yuji hirano , izumi kondo , tetuya nemoto , naoki itoh , hidenori arai (( ) national center for geriatrics and gerontology, japan; ( ) nihon fukushi university, japan) background: we have developed a new type of grip strength measurement that addresses the time axis in evaluating physical function. it can measure the dynamic force, response in gripping performance, and maximum grip strength. the "kihon checklist" (kcl) is used to screening the frail elderly, based on the japanese long-term care insurance system. however, the relationship between the gripping performance and kcl has not been well investigated. objectives: the purpose of this study was to introduce a novel automatic reading method for dynamic force parameters in gripping performance and to evaluate their relationship with the kcl. methods: the subjects comprised patients ( men, women, average age . ± . years) who visited the integrated healthy aging clinic (locomo-frail outpatient clinic in japanese) of our hospital. the four indices of grip force response measured were: reaction start time (rst), time constant (tc), maximum value of force (mvf), and force rising slope (frs). we examined the relationship between these four indices and seven categories of the kcl; activities of daily living (adl), physical functions and fall, nutrition state, oral functions, outdoor activities, cognitive functions and mood, using spearman's correlation coefficient. results: in the female right hand, the mvf was only significantly correlated with adl and overall scores; whereas, in the female left hand, the mvf and the frs were significantly correlated with many items (adl, physical functions and fall, nutrition state, outdoor activities, and cognitive functions). the time-dependent items (rst and tc) were significantly correlated with outdoor activities in the female left hand and significantly correlated with adl and oral functions in the male left hand. however, in the right hand, the time-dependent items were not correlated with any of items in kcl in both sexes. conclusion: our newly developed grip strength measurement system could automatically calculate not only the maximum grip strength but also the time response of the grip force. moreover, their relationship with kcl was clearly indicated. the relationship between detailed grip strength response indicators and kcl items differed between men and women, and the left hand was correlated with more items than the right hand. ranyah almardawi, rao gullapalli, michael terrin (university of maryland school of maryland, baltimore, usa) background: rotator cuff (rc) tear and shoulder pain are both highly prevalent in older populations. routine medical screening for shoulder dysfunction is uncommon for community-dwelling older adults. the disabilities of the arm, shoulder and hand (dash) survey estimates self-reported dysfunction of both upper limbs in a composite score. dash offers a quick method to identify older adults with potential dysfunction in either shoulder, which otherwise may go unrecognized during routine medical visits. objectives: . to determine if dash, american shoulder and elbow surgeons (ases) and simple shoulder test (sst) surveys are related to one another in older adults. . to assess dash, ases and sst score relationships to the sf- physical functioning (pf) subcomponent score, shoulder forward flexion range of motion (ff-rom) and shoulder abduction range of motion (abd-rom) in older adults. methods: cross-sectional study: twenty-three community-dwelling-older-adult volunteers [mean age, . ± . years; range, to years; female, %] with no history of rc surgery and no history of shoulder injury or shoulder physical therapy in the prior months completed shoulder magnetic resonance imaging (mri) and dash, sf- , charlson co-morbidity index (cci), katz activities of daily living (adls) and lawton instrumental adls (iadls) surveys. for the shoulder ipsilateral to mri, participants completed ases, sst, visual analog scale for pain (vas) surveys; and shoulder ff-rom and abd-rom. descriptive statistics and spearman rank order correlation (rho) were performed. results: frequencies: rc tear (supraspinatus tendon) on mri: . %; shoulder pain >= on vas: . %; no limitation (score= ) on katz adls: . %; no limitation (score= ) on lawton iadls: . %. means: cci, . ± . ; dash, . ± . ; ases, . ± . ; sst . ± . ; . ± . ; . ± . ; . ± . . range of correlation among dash-ases-sst surveys: (|rho|= . - . , p< . ). range of correlation for dash-ases-sst with sf- pf(|rho|= . - . , p< . ), p< . ), abd-rom (|rho|= . - . , p< . ). conclusion: dash, ases and sst correlate well, and all three surveys show a consistent relationship with sf- physical functioning, ff-rom and abd-rom. next steps would be to evaluate the feasibility of dash to identify older adults with shoulder dysfunction during routine medical visits. background: physical performance is closely associated with chronic diseases and dysfunction of numerous organ systems. old persons with chronic renal failure have shown the apparent decline in physical performance, especially in the end-stage. however, it is unclear whether the subclinical kidney dysfunction is associated with skeletal muscle function deficit in the elderly population. objectives: the aim of this study is to determine the association between renal function and skeletal muscle function deficit in old persons without nephropathy. methods: eight hundred fifty-four korean elderlies (female, . %) aged to years were included in the cross-sectional analysis. of the participants, elderlies (female . %) were available for the -year follow-up test session. all participants were interviewed face-to-face and received measures of anthropometry, body composition and serum biomarkers of metabolic diseases. estimated glomerular filtration rate (egfr) was calculated using the chronic kidney disease epidemiology collaboration (ckd-epi) equation based on serum creatinine concentration. skeletal muscle function deficit was defined as a combination of weakness and slowness based on the handgrip strength to body mass index ratio (hs/bmi, men < . , women < . ) and converted timed up-and-go to walking speed (tugspeed < . m/s). results: the subjects with <= egfr < ml/min/ . m showed significantly lower physical performance for muscular strength and functional mobility than those with <= egfr < and egfr > ml/min/ . m , respectively (all for p < . ). logistic regression analysis indicated the significant association between egfr and skeletal muscle function status even after adjustment for potential confounders (p for trend < . ). moreover, the prospective observational analysis by ancova showed the significant effects of enhancement in hs/bmi [f( , ) = . , p = . ] and tugspeed [f( , ) = . , p < . ] on the improvement in egfr during -year followup. conclusion: taken together, skeletal muscle function status is associated with even moderately reduced egfr in an older population. these results suggest that maintenance of physical and functional fitness may be a contributory factor for preserving renal function in elderly persons. rn, brazil) background: sarc-f is a brief and useful test to identify older people at risk of sarcopenia-associated adverse outcomes. previous studies with older populations have suggested that it may be useful to screen those with severe sarcopenia. its ability to screen sarcopenia among low-income brazilian older adults is still unknown and its association with sarcopenia diagnostic criteria may be useful to understand its utility among this population. objectives: this study aims to evaluate the validity of sarc-f in screening low muscle strength and low physical performance among a low-income sample of older adults. methods: in a cross-sectional study, community-dwelling older-adults (>= years old; men and women) from santa cruz (northeast brazil) answered the sarc-f questionnaire and were classified as sarcopenic (>= ) and non-sarcopenic (< ) according to sarc-f scores. they were also evaluated in relation to the sarcopenia criteria of muscle strength (handgrip strength) and physical performance (sppb). the cutoff of < kg for women and < kg for men were used to classify those with low muscle strength. a sppb score of <= was used to classify low physical performance. a chi-square test was used to assess the association between the sarc-f and the objective parameters of sarcopenia. sensitivity and specificity of the sarc-f according to the objective functional parameters were also assessed. results: the sample was composed by % of women, with mean age of . (± . ) years old. according to sarc-f, . % of the sample was sarcopenic. low muscle mass and low physical performance were identified in . % and . % of the sample respectively. sarcopenia was significantly associated to low muscle mass (p< . ) and low physical performance (p< . ). the sensitivity of sarc-f in identifying those with low muscle mass was of % and specificity of %. for low physical performance, sensitivity and specificity were of % and % respectively. conclusion: sarc-f has a moderate ability to identify the sarcopenia criteria of low muscle mass and low physical function among older adults from a low-income setting. since it is a simple measure, it can be advantageous for low-income and rural communities. background: menopause marks a critical transition towards older adulthood for women and studies suggest that it is associated to several sarcopenia parameters, such as muscle mass and physical functioning. understanding how the menopausal transition associates to sarcopenia diagnostic criteria may help to direct screening tests for middle-aged populations and to identify earlier those at higher risk of sarcopenia. objectives: to evaluate the association between menopausal status and sarcopenia diagnostic criteria (muscle strength, muscle quantity and physical performance). methods: in a cross-sectional study, communitydwelling women from northeast brazil ( - yearsold) were evaluated in relation to menopausal status using the stages of reproductive aging workshop classification (premenopausal, perimenopausal or postmenopausal) , and in relation to sarcopenia diagnostic criteria according to european working group on sarcopenia in older people (ewgsop ): muscle strength (grip strength -handheld dynamometer), muscle quantity (appendicular muscle mass adjusted for height through bioelectrical impedance) and physical performance (gait speed). association between menopausal status and sarcopenia criteria was evaluated with multiple linear regression models adjusted for covariates (current age, education, family income, walking, bmi, reproductive history). results: among the participants, . % were classified as premenopausal, . % as perimenopausal, and . % as postmenopausal. menopausal status was significantly associated to grip strength, since premenopausal women were significantly stronger than perimenopausal or postmenopausal women, even in the fully adjusted analyses (b= . ; % ci= . : . ). muscle quantity and gait speed were not significant according to menopausal status. conclusion: perimenopausal and postmenopausal status are associated with less muscle strength among middle-aged women. muscle weakness may be the first sarcopenia parameter that is affected by women's aging and should be tracked among middle-aged to women for early identification of sarcopenia risk.. background: we speculate maintaining good postural stability is the key to good adl in elderly patients. this is a preliminary study to evaluate which factor relates to good postural stability. objectives: we evaluated patients ( males and females) over years old. the average age was . years old ranging to . methods: we measured index of postural stability(ips) using gravicoder gw- manufactured by anima. the ips was adovocated by mochizuki in . it was defined following this equation; ips=log[(area of stability limit + area of postural sway)/area of postural sway). larger ips means better postural stability. the average ips in each age was already known. ips was calculated automatically through gravicoda. we devided these patients into two groups by the results of ips. group a with the patients whose ips was larger, group b with the patients whose ips was smaller than the average in their age. we compared the following items between the two groups. nutrition(albumin, calcium, magnesium, ferritin, vitamin b ,b , , -d , zinc in blood test) , bone status(bone density, % of yam), spinopelvic parameters (pelvic incidence(pi), lumbar lordosis(ll), pelvic tilt(pt) using whole spine x-ray photograph. results: ten patients were classified into group a and patients were into group b. the average age was . ± . years old in group a and . ± . in group b. in group a , ll and pt were respectively . , . . in group b, . , . . ll and pt were significantly different between the two groups. pi minus ll is an important indicator to determine the spino-pelvic balance. it is known that pi-ll< means good spino-pelvic balance. in group a, pi minus ll was . ± . . in group b, it was . ± . . according to nutrition and bone status, albumin was significantly higher in group b. conclusion: our results showed spino-pelvic alignment related to the postural stability. this suggests good spino-pelvic alignment is likely the key to good postural stability. background: physical performance is of main relevance for quality of life and independence in the community. identification of deterioration of physical performance helps to start early interventions to stay independently in old age. objectives: to determine physical performance of communitydwelling older adults above years by using a comprehensive geriatric assessment to find most sensitive tests for functional decline. methods: older community-dwelling adults aged +. analysis of baseline and (t ) and months (t ) of followup data of hand grip strength (hgs), stair climb power test (scpt), timed up and go test (tug), short physical performance battery (sppb), m gait speed ( mgs), -time chair rise test ( tcr), minute walking test ( mwt) and frailty categories according to fried. results are shown in mean (± sd) in total numbers and percentage. results: participants ( , y.± , ) were included, ( %) female. overall physical performance was on high level, above geriatric cut-offs for physical disabilities at baseline: (hgs female: , (± , ) (- , (± , )%) followed by scpt (- , (± , )%). all tests showed a decline except tcr (+ , (± , )%). conclusion: physically active, communitydwelling older people show a high level of functional performance, far from geriatric cut-offs indicating physical disabilities. nevertheless, after two years a clinically relevant reduction of strength in upper (handgrip) and lower extremities (stair climb) was detected. these data may be relevant for the identification of older individuals who may benefit from early intervention exercise programs to keep them physically independent as long as possible. tcr showed divergent results and could be of special interest for continuous measurements to identify gradual decreases in functional performance. background: sarcopenia is characterized by loss of skeletal muscle mass and strength and it is a frequent finding in oncology, being associated with reduced quality of life, impairment in the response to antineoplastic therapy and increased toxicity, especially in older patients. objectives: the aim of the present study was to evaluate the association between low muscle mass (lmm) assessed by computed tomography (ct) analysis and sarcopenia considering the revised european consensus published by the european working group on sarcopenia in older people (ewgsop ) with the variables of the comprehensive geriatric assessment (cga) in older oncological patients. methods: for this purpose, patients ( . % female; mean age of . ± . years) followed at the oncogeriatric outpatient clinic of a university hospital were enrolled. clinical data were obtained from electronic medical records and the skeletal muscle mass evaluation was performed using ct (in the height of the third lumbar vertebra). for lmm and sarcopenia classification, specific cutoff points were adopted. cga variables were compared between lmm and normal skeletal muscle mass (nsmm) and between sarcopenic and non-sarcopenic individuals. groups were compared by the independent t test (r core team®, p< . ). results: the most frequent tumors were breast, intestine, stomach and lung, at different stages of the disease. the prevalence of lmm was . % and the prevalence of sarcopenia was %. of all cga variables evaluated, hand grip strength ( , ± , ) and katz scale ( , ± , ) were associated with lmm and sarcopenia. conclusion: the results highlight the importance of early geriatric clinical assessment of older cancer patients, considering the association of cga variables with low muscle mass and most important, to sarcopenia, for the possible reversal of functional and nutritional impairments and for the indication or appropriate planning of cancer therapy. lygia paccini lustosa , patricia parreira batista , jéssica rodrigues de almeida , andré gustavo pereira de andrade , aimée de araújo cabral pelizari , stephanie aguiar , leani de souza máximo pereira (( ) physical therapy department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil; ( ) sports department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil) background: functional tests in the older person reflect the integrity of the interrelationship between muscle mass and function, vascular, endocrine and neurological aspects of central and peripheral command. the reduction in functionality, muscle mass and strength associated with advancing age is related to the increase of circulating proinflammatory cytokines in plasma, which in turn predisposes the individual to negative repercussions, such as the development of chronic diseases, falls and disability. they can identify changes in the intrinsic capacity of the older people. objectives: to compare older women who reported being active or sedentary regarding functional capacity and plasma indices of inflammatory mediators. methods: participated community older women ( years or older), recruited for convenience. those unable to walk were excluded; acute musculoskeletal diseases; lower limb fractures in the last year; neurological diseases and sequelae; history of cancer in the last five years and cognitive impairment (mental state mini-exam). all responded to clinical and demographic information, performed the short physical performance battery (sppb), timed up and go (tug) and plasma tests of stnfr and il- (elisa method). correlation analysis by spearman test. % significance level. approval by the research ethics committee/ ufmg (caae: . . . ). results: older women participated, with a mean age of . ± . y; number of comorbidities . ± . and medications in use of . ± . . mean of body mass index were . ± . kg/m . there was a significant negative relationship between the sppb test and stnfr (rho= . ; p= . ) and a significant positive relationship between tug and stnfr (rho= . ; p= . ). other relationships were not significant (p> . ). conclusion: older women with better functional capacity presented lower plasma dosage of stnfr . the results suggest influence between these variables -functional capacity, mobility and inflammatory process -and no causal factor can be attributed. in these case, longitudinal studies are needed to verify functional performance vulnerability factors and their causal relationship with circulating inflammatory mediators in plasma. however, these results point to the importance of evaluating these variables in daily clinical practice. patricia parreira batista , stephanie aguiar , andré gustavo pereira de andrade , jéssica rodrigues de almeida , leani de souza máximo pereira , lygia paccini lustosa (( ) physical therapy department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil; ( ) sports department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil) background: perceptions of health and well-being in the older people are identified as subjective aspects by the international classification of functioning (icf), with direct and indirect interference with overall performance, activities of daily living, social relationships and independence. subjective well-being is associated with the form of coping adopted with a health condition, adaptability and resilience. positive and negative physiological repercussions on functionality and interaction with the family and social network may be consequences of inadequate adaptation and perception of subjective well-being. objectives: to explore the relationship between subjective well-being, functionality and plasma indices of inflammatory mediators in community older wowen. methods: participated community older women ( years or older), recruited for convenience. those unable to walk were excluded; acute musculoskeletal diseases; lower limb fractures in the last year; neurological diseases and sequelae; history of cancer in the last five years and cognitive changes (mini-mental state examination). all answered about clinical and demographic data and information about subjective well-being. they performed tests of functional capacity (short physical performance battery -sppb) and mobility (timed up and go -tug). plasma dosages of stnfr and il- were by elisa method. correlation analysis by spearman test. significance level of %. approval by the research ethics committee/ ufmg (caae: . . . ). results: elderly women participated, with a mean age of . ± . years; number of comorbidities . ± . , final sppb score . ± . , tug of . ± . seconds; body mass index of . ± . kg/m . there was a significant positive relationship between subjective well-being and sppb (rho= . ; p= . ) and tug (rho= . ; p= . ). other associations were not significant (p> . ). conclusion: the results showed a significant association of subjective well-being with functional capacity in the older women. however, this condition was not associated with inflammatory markers, suggesting the need for further studies. on the other hand, it can be thought that the identification of personal strategies and perception of health and well-being act as barriers and/ or facilitators in a functional rehabilitation process, indicating the need for a multidisciplinary approach. background: the united states census bureau projects a rise in the population aged and over from . million in to . million by . the projected rise in the elderly population represents an accompanying increase in geriatric syndromes. frailty is a common geriatric syndrome defined as a clinically recognizable state of increased vulnerability to adverse outcomes related to a decline in physiologic reserve. this decline in reserve places the individual at increased risk for poor health outcomes including falls, disability, hospitalization, institutionalization and mortality. various effective interventions for frailty are established in the literature. the body of knowledge on the role of technology in reducing frailty is less abundant. objectives: to summarize available evidence on frailty and technology use for community dwelling older adults. methods: a comprehensive search of computerized databases was conducted in the following databases published between - : cinahl, pubmed, and academic search complete. the prisma search strategy was utilized for this review. articles were included if they met the following criteria: ) focused on community dwelling adults aged and over; ) peer-reviewed; ) published in the english language; ) featured randomized controlled trials (rcts), cohort studies or qualitative research; and ) included an operationalized definition for frailty. results: the database searches yielded a total of articles. duplicates were removed. results were excluded based on title and abstract. relevant articles were retrieved for full text examination. articles were excluded based on inclusion/exclusion criteria. references of included articles were hand searched for relevant works. four additional relevant articles were identified. the final analysis included articles. conclusion: current research focuses on assessment and diagnosis as opposed to intervention studies. methodological weaknesses limit generalizability and validity of findings. few studies utilize frailty as an outcome measure thus, limiting available research directly related to frailty. emerging technologies represent potentially effective, flexible and integrative solutions for frailty assessment, monitoring and intervention in the home environment. more research is needed on the potential for technological tools as interventions for frailty in community dwelling elderly specifically, for the purpose of detection and prevention of pre-frailty. a study protocol. inae c. gadotti , raquel aparicio ugarriza , , fernanda civitella , jorge g. ruiz , , edgar ramos vieira ( ( ) background: there are several studies on the association of balance and gait impairments with frailty and falls in older adults. however, little is known about the associations between postural alterations, frailty and falls in older adults in general and among older veterans. also, inter-relations among postural alterations, balance, strength, gait impairments, falls and frailty in older adults are not well known. objectives: the objective of this study is to evaluate if postural alterations, gait and balance impairments are associated with falls and frailty in older veterans. methods: sixty veterans, years old or older, will participate on a voluntary basis. one-hour long assessments will be completed at baseline, , and months. participants will fill out a questionnaire including information on demographics (age, sex, height, and weight), health conditions, falls (history, characteristics, and fear of falls), mobility impairments, physical activity level, medication history, medication changes and adherence, and health care utilization. frailty status will be assessed based on fried's frailty phenotype. the following physical health variables will be assessed: sagittal head and neck posture using photogrammetry, spinal curvatures using flexicurve, deep neck flexors activation by performing the craniocervical flexion test with a pressure biofeedback, grip strength using a dynamometer, usual and fast gait analysis using a gaitrite, balance using a force plate, and lower limb functional strength based on chair stands in s. differences among the variables by frailty status and falls history will be assessed using manovas. results: the results will be presented at conferences and published in scientific journals. conclusion: the results of this study may inform interventions to reduce frailty and falls in older veterans and possible among non-veterans as well. background: the number of deaths caused by pneumonia is increasing. the guidelines for pneumonia recommend optimal application of antibiotics based on a pathogenoriented strategy. despite wide distribution of these guidelines, pneumonia demonstrates high mortality in aged people. thus, for developing the next strategy for pneumonia management in aged people, new targets are required. with aging, the loss of skeletal muscle mass and strength occurs, which is named sarcopenia. the sarcopenia phenotype is associated with malnutrition. little is known about relationship between muscles and pneumonia, however, we reported that aspiration pneumonia induced respiratory muscle atrophy. impaired swallowing and/or cough functions often induce pneumonia in aged people. the swallowing muscle weakness is associated with impaired swallowing function. the strong respiratory muscles generate effective cough, which clears the airways and prevents pneumonia. objectives: to investigate presently unknown relationships between onset or recurrence of pneumonia in aged people and; respiratory muscle strength; swallowing muscle strength; and malnutrition. methods: a cross-sectional cohort study consisted of patients aged -year-old and older admitted to the hospital by pneumonia, and controls. the respiratory muscle strength was measured by a hand-held multi-functional spirometer with a pressure sensing transducer. the swallowing muscle strength was evaluated by measuring tongue pressure. a bioelectrical impedance analysis evaluated muscle and body fat masses. malnutrition was evaluated by serum albumin level and body fat mass. results: the respiratory (both the inspiratory and the expiratory) and the tongue muscle strengths, body trunk muscle mass, serum albumin level, and body fat mass divided by height were lower in aged pneumonia patients than in controls. body trunk muscles include the respiratory and swallowing muscles. the multivariate logistic regression model showed the low inspiratory and expiratory respiratory muscle strengths, the low body trunk muscle mass divided by height , and the low serum albumin level as risk factors for onset of pneumonia. for recurrence of pneumonia within months after the onset of pneumonia, low body fat mass divided by height was a risk factor. conclusion: above findings suggest that the respiratory muscles and malnutrition as new targets of the new management strategy for pneumonia in aged people. background: more than % of the people with hiv are older than fifty years. data about this population are still scarce and mainly focused on comorbidity instead of on physical function and frailty. hiv-funcfrail cohort is one of the four european cohorts of older hiv adults launched in . objectives: our main objective in this work was to know the factors associated to physical impairment. methods: longitudinal prospective cohort study. patients from the "hiv-funcfrail: multicenter spanish cohort to study frailty and physical function in years or older hiv-infected patients" were included. eleven centers participated. we recorded sociodemographic data, comorbidities and variables related to hiv infection. physical function was measured by gait speed and sppb and frailty according to frailty phenotype. other components of the comprehensive geriatric assessment such as depression and cognitive impairment were evaluated too. results: were included. median age was . ( . - . ). . % were women. at baseline median cd count was . ( . - . ). viral load was undetectable in . %. % of the patients had > comorbidities and . % had polypharmacy. . % of the patients were able to walk independently and % were completely independent for the activities of daily living. more than half were prefrail, . % prefrail and . % were robust according to frailty phenotype. . % of the patients had a sppb score < and . % had a gait speed < . m/sg. in the univariate analysis we found association between physical impairment defined as sppb score < with: diabetes, copd, osteoarthritis, comorbidities number, moca test < , gds-sf > and age. but in the multivariate analyses the factors associated were just: polypharmacy ) p= . ], gds-sf > [ . ( . - . ) p= . ]. conclusion: functional impairment was prevalent among older adults with hiv in their middleage. polypharmacy doubles the risk of functional impairment and depression increases the risk three-fold. therefore, polypharmacy, depression and physical function should be assessed in all the older adults with hiv in order to implement early prevention intervention to avoid physical impairment. sophie bastijns, anne-marie de cock, maurits vandewoude, stany perkisas (university of antwerp, antwerp, belgium) background: acute sarcopenia is defined as a decline in muscle mass and muscle function within days after hospitalization or acute illnesses, sufficiently to meet the sarcopenia criteria. muscle ultrasound is an objective and non-invasive technique that can measure muscle quantity and quality. muscle elastography can furthermore measure muscle stiffness, which is regarded as an important qualitative parameter. objectives: the primary aim of the study is to assess the effect of acute hospitalization on muscle stiffness. the secondary aim is to evaluate other influencing parameters. methods: this study is a prospective, observational study. patients admitted for at least days to one of the geriatrics departments of the zna antwerp hospitals are included. rectus femoris (rf) and vastus lateralis (vl) muscle stiffness are measured through elastography on day of admission, and then every days until discharge. results: preliminary results show significant differences between rf and vl values in men, but not in women. in rf, a non-significant downwards trend is seen for elastography between day and day . in vl, a non-significant downwards trend is seen in women, but also a non-significant upwards trend is seen in men between day and day . in rf, a non-significant trend of decreasing stiffness is seen with increasing age in men, but an increase is seen in women. a significant negative correlation is seen between elastography of rf and vl on day and hand grip strength on day . conclusion: this study seeks to gain insight in parameters affecting muscle stiffness and of the evolution of muscle stiffness after acute illness or hospitalization. a trend of decreasing muscle stiffness is seen after seven days of hospitalization and illness. this study showed no direct relation between age and muscle stiffness. a decrease in muscle stiffness results in higher hand grip strength and therefore better muscle performance. more data and longer follow-up periods are needed and are expected by march . ainhoa indurain , , jennifer linge , mikael petersson , thobias romu , fredrik uhlin , , anders fernström , mårten segelmark , , olof dahlqvist leinhard (( ) departments of nephrology and medical and health sciences, linköping university, linköping, sweden; ( ) departments of acute internal medicine and geriatrics and medical and health sciences, linköping university, linköping, sweden; ( ) background: sarcopenia is a prevalent condition in hemodialysis patients and it´s associated with poor quality of life, hospitalization and mortality. recent research using magnetic resonance imaging (mri) has demonstrated the importance of proper body size-adjustment in the assessment of muscle mass, and that the addition of muscle fat infiltration reflecting muscle quality, improves functional correlations and prediction of hospitalization in sarcopenia. it is not yet demonstrated if this new mri method, combining body sizeadjusted muscle volume and muscle fat infiltration, improves the evaluation of sarcopenia in hemodialysis patients. objectives: to investigate if adverse muscle composition, defined using mri, predicts survival and comorbidity in hemodialysis patients. methods: in , patients on hemodialysis were scanned using rapid whole body fat and water separated mri. following years, survival and comorbidity index (nci) were recorded using electronic health care records. thigh muscle fat infiltration (mfi) and fatfree muscle volume (ffmv) normalized with height was assessed using amra research (amra medical, linköping sweden). a z-score describing the deviation from expected ffmv/height was calculated using sex and bmi-matched virtual controls (ffmvvcg) and mfi adjusted (mfiadj) was calculated using the sex-specific population mean. for these calculations, normative data from subjects in uk biobank was used. to estimate a combined muscle score (musclecomb), mfiadj and ffmvvcg were projected on the linear regression line describing the normal population relationship between mfiadj and ffmvvcg in the uk biobank dataset. spearman rank correlation was estimated comparing mfiadj, ffmvvcg and musclecomb to nci. wilcoxon signed-rank test was used to estimate the association to survival. roc values and confidence interval were also calculated. results: musclecomb (combined muscle score) was significantly correlated to comorbidity (p< . ) and predicted survival (p< . ) while mfiadj (adjusted muscle fat infiltration) and ffmvvcg (deviation from an individual´s expected muscle volume) did not reach significant level on either test. the roc values for predicting survival were . ( . - . ) for ffmvvcg, . ( . - . ) for mfiadj, and . ( . - . ) for musclecomb. background: frailty is a risk factor for cardiovascular disease (cvd). as declines in bone metabolism and impaired inflammatory response are often associated with frailty, bone analytes and inflammation markers involved in these signaling pathways may act as biomarkers of frailty-related disease progression. objectives: this study sought to examine differences in systemic bone analyte and inflammation marker concentrations based on cvd risk profile and frailty status. methods: females with no prior cvd were stratified into low or high cvd risk groups based on their framingham risk scores. frailty was assessed using the fried phenotype of frailty. greedy matching with pre-frailty as the exposure variable was used to identify a set of closely matched pairs in both the low and high cvd risk groups for a total of females in a case-control design. factorial anova was used to compare differences in log transformed concentrations of bone and inflammation analytes based on frailty status, cvd risk, and their potential interaction. results: differences for il- ( . ± . vs. . ± . pg/ml, p= . ), leptin ( . ± . vs . ± . pg/ml, p= . ) and tnfα ( . ± . vs . ± . pg/ml, p= . ) systemic concentrations were found with high cvd risk status compared to low. no differences in bone or inflammation analyte concentration were found based on frailty status, nor were any interaction effects. conclusion: there was a difference in inflammatory marker concentrations based on cvd risk status indicating that higher cvd risk is associated with impaired inflammatory response in females. there was no difference in bone or inflammation analytes in the pre-frail group compared to their robust peers as these females may be too early in the progression of frailty to have these signs of impaired bone health and inflammation. ( ) pancreato-biliary cancer center, gangnam severance hospital, yonsei university college of medicine, seoul, korea) background: biliary tract cancer (btc) is a highly lethal disease, and improved prognostication methods should be sought. sarcopenia (low muscle mass), poor muscle quality (low muscle attenuation) and excess adiposity (subcutaneous and visceral) can be surrogate markers of sarcopenia and related frailty. however this hypothesis has not been demonstrated conclusively in btc patients. objectives: to evaluate associations of all four body composition measures, derived from clinically acquired ct at the time of initial diagnosis, with overall survival in advanced btc patients. methods: we measured skeletal muscle index (smi), mean muscle attenuation (ma), visceral adipose tissue index, and subcutaneous adipose tissue index via computed tomography at the level of the l vertebra. clinical data were extracted from patients' charts. results: a total of patients ( % males, median age [range - ]) were included in this study, % were metastatic and % were recurrent disease. during the follow-up duration (median of . months; range . month to months), patients ( %) died. sarcopenia, defined as low l smi (lower than cm /m for women and lower than cm /m for men) was noted in patients ( %), and patients ( %) had low muscle radiodensity. for adiposity, % and % of patients had low subcutaneous and visceral fat, respectively. when we combined this four factors and grouped the patients, no risk group (n = ) had the best overall survival (median . months, % ci, . - . ), while the patients who suffered all the risk factors (n= ) showed the poorest survival (median . months, % ci, - . ) which was statistically significant (log-rank test < . ). this classification was independent factor for survival in multi-variate analysis along with other clinical factors, carcinoembryonic antigen (cea), neutrophil-to-lymphocyte ratio, white blood count, platelet, and cholesterol (hr . , % ci . - . ). conclusion: sarcopenia, ma, and adiposity independently predict mortality in patients with btc and can be utilized as surrogate markers for prognosis. background: frailty is a clinical syndrome of reduced systemic physiological reserve that phenotypically overlaps with heart failure. nt-probnp is a cardiac-specific marker that increases with ventricular stress, whereas growth differentiation factor (gdf- ) is a non-tissue specific systemic marker that increases with inflammation, tissue injury and possibly inflammageing. objectives: this study aims to determine if combination of nt-probnp and gdf- organised in a x matrix can classify cardiac dysfunction with and without frailty, non-cardiac frailty, and non-frailty. methods: this is a cross-sectional analysis of a prospective cohort study (phase ), undiagnosed heart failure in older adults (ufo), that recruited community-living older adults aged >/= years in a ratio of : : for robust, pre-frail and frail status classified by the frail scale. participants without a history of heart failure and meeting the eligibility criteria were entered into the study. nt-probnp and gdf- levels were measured using the roche cobas elecsys platform. echocardiography and -minute walk distance ( mwd) were documented. informed consent was obtained from all participants. the study was approved by the local institutional review board. ) was ascertained by correlation with abnormal echocardiographic diastology represented most prominently by increased left atrial volume index (r= . , p= . x e- ). conclusion: a x dual biomarker approach utilising nt-probnp and gdf- may assist in subclassification of cardiac (diastolic) dysfunction and frailty. background: frailty was occurred frequently in elderly and known as higher risk of mild cognitive impairment (mci) and dementia than healthy elderly. hippocampus, parahippocampus and entorhinal cortex as memory system is considered one of the key regions of dementia especially alzheimer's disease. in addition, atrophy of these regions presumably related to higher risk of alzheimer's disease. on the other hand, it is poor understood about neural substrates of relationships frailty and higher incident rates of mci and dementia. objectives: the purpose of this study, therefore, to clarify differences of atrophy level of hippocampus, parahippocampus and entorhinal cortex and total gray matter between healthy, pre-frail and frail in elderly. methods: a total , elderly were measured brain structure with t-mri, and , were fulfilled inclusion criteria in this study. structural brain images were preprocessed and total hippocampal volume was estimated using freesurfer v . . and ubuntu . lts. we classified participants into three groups as healthy, pre-frail and frail characterized by , or and or more of the following domains respectively: low activity, slowness, weight loss, exhaustion and weakness. we compared total gray matter or hippocampal volume between healthy, pre-frail and frail in elderly with one way analysis of covariance (ancova) adjusted for sex, age, educational years, drinking and smoking habit, geriatric depression scale points and estimated total intracranial volume (etiv) and multiple comparison using bonferroni correction. results: the prevalence of pre-frail and frail was . % and . % respectively. hippocampus, parahippocampus and entorhinal cortex volume were significantly decreased in elderly with frail compared healthy and pre-frail (hippocampus: p= . and p= . ; parahippocampus: p= . and p< . ; entorhinal cortex: p= . and p= . respectively). in contrast, total gray matter volume was not significantly difference between three groups. conclusion: hippocampus, parahippocampus and entorhinal cortex were atrophied in elderly with frailty compared healthy or pre-frail elderly. it might be neural substrates of higher risk of dementia in elderly with frailty. rasekh kashkosh , irina gringauz , jonathan weissmann , gad segal , , michael swartzon , abraham adunsky , , dan justo , (( ) geriatrics division, sheba medical center, israel; ( ) biomedical engineering department, israel; ( background: low alanine aminotransferase (alt) blood levels prior to rehabilitation are associated with poor rehabilitation outcomes in terms of low mobility and function in older adults following hip fracture. objectives: we have hypothesized that low alt blood levels prior to rehabilitation are also associated with -year mortality in this population. methods: included were older adults (age >= years, median age years, . % women) admitted for rehabilitation following hip fracture. alt blood levels were documented between one and six months prior to rehabilitation. excluded were patients with alt blood levels over iu/l possibly consistent with liver injury. the study group included patients with low ( iu/l or lower) alt blood levels, and the control group included patients with high-normal ( - iu/l) alt blood levels. the main outcome was all-cause mortality one year following rehabilitation admission. results: the study group included ( . %) patients with low alt blood levels, and the control group included ( . %) patients with high-normal alt blood levels. overall, ( . %) patients died within one year following rehabilitation admission. compared with the control group, patients with low alt blood levels had significantly higher -year mortality rates ( . % vs. . %, or . , %ci . - . ). cox regression analysis showed that low alt blood levels prior to rehabilitation were associated with -year mortality (hr . , %ci . - . ) together with peripheral vascular disease (hr . , %ci . - . ) -independent of age, gender, albumin serum levels, length of rehabilitation, and rehabilitation outcomes. conclusion: low alt blood levels prior to rehabilitation are associated with -year mortality in older adults following hip fracture. fawaz azizieh , dia shehab , khaled al jarallah , renu gupta , raj raghupathy (( ) gulf university for science & technology, mubarak al-abdullah area, kuwait; ( ) faculty of medicine, kuwait university, jabriya, kuwait) background: in addition to some well-characterized bone turnover markers, cytokines and adipokines have also been suggested to be linked to osteoporosis seen in menopause. however, there is much controversy on the possible association between these markers and bone mineral density (bmd). objectives: this study was aimed at measuring circulatory levels of selected cytokines and adipokines in postmenopausal women with normal and low bmd. methods: the study population included post-menopausal women, of whom had normal bmd, had osteopenia and had osteoporosis. circulatory levels of selected pro-resorptive (tnf-a, il- b, il- , il- , il- , il- ), anti-resorptive (ifng, il- , il- , il- , tgf-b) and five adipokine markers (adiponectin, adipsin, lipocalin- /ngal, pai- and resistin) were measured using the multiplex system and read on the magpix elisa platform. further, two bone turnover markers (p np, ctx) as well as estradiol levels were assayed from the same samples. results: while circulatory levels of cytokines were comparable between groups, women with low bmd had statistically significantly higher median circulatory levels of adipokines as compared to those with normal bmd. further, while levels of ctx were not different between the two groups; p np, p np/ctx ratio and estradiol levels were significantly lower in women with low bmd. levels of adiponectin, p np, p np/ctx ratio and estradiol correlated significantly with bmd of the hip and spine. conclusion: while the associations between the studied markers and bmd may be complex and multivariate, our data provide insights into the possible use of circulatory levels of cytokines, adipokines and bone turnover markers on the pathogenesis of postmenopausal osteoporosis. background: with the application of diffusion tensor imaging (dti), a few studies have found that some white matter (wm) structures were closely related to impaired gait speed. however, the evidence is still sparse and the wm structural association with overall lower-body physical function, which can be evaluated by short-physical performance battery (sppb), has never been investigated among older adults. objectives: the aim of this study is to explore the associations between wm structures (evaluated by dti parameters) and sppb scores among older adults. methods: data of participants ( ± years old), who were recruited in the multidomain alzheimer's preventive trial (mapt) study and with no dementia at baseline level, were analysed in this study. based on the functional magnetic resonance imaging data, dti parameters of fractional anisotropy (fa), mean (md), axial (ad) and radial diffusivity (rd) were calculated in wm structures that were annotated by the john hopkins university white matter parcellation atlas. linear regression was used to analyse the association between sppb score and each dti parameter while controlling for age, gender, body mass index, physical activity level, total intracranial volume, cardiovascular risk and time interval between the dti and sppb measurement. results: three dti parameters (the md and rd of left corticospinal tract, and the md of right cerebral peduncle) were associated with the sppb score at a p-value < . . conclusion: the findings indicate that wm structures of corticospinal tract and cerebral peduncle might be related to overall lower-body physical function of older adults. further studies on the changes of these wm structures with physical function alterations during ageing will be more informative. background: ct-derived skeletal muscle index and skeletal muscle density (smd) have been independently associated with mortality in older adults. although smd is a commonly used measure of myosteatosis on ct images, more novel muscle texture (i.e., radiomic) features may provide an alternative measure of muscle quality, independent of smd. there have been no prior studies on the association of ct-derived muscle texture features and mortality. objectives: to examine the association of skeletal muscle texture features with all-cause mortality in older adults from the national lung screening trial (nlst). methods: the relationship between ct-derived skeletal muscle texture and all-cause mortality over years was determined in , participants ( % women, age range - years, mean age . ) in the nlst. using ct images at the level of t vertebra, paraspinous muscle was automatically segmented using machine learning algorithm, and muscle texture features determined using pyradiomics. second order (and higher) texture features were grouped into categories: gray level dependence matrix (gldm), gray level co-occurence matrix (glcm), gray level run length matrix (glrlm), gray level size zone matrix (glszm), and neighbouring gray tone difference matrix (ngtdm). muscle texture features often indicate greater or lower heterogeneity/complexity of an image. associations between standardized muscle texture variables and all-cause mortality were determined using cox proportional hazards models, adjusted for age, sex, race, body mass index, pack years of smoking, presence of type diabetes, chronic lung disease, cardiovascular disease, cancer at enrollment, and smd. multiple comparisons were accounted for using false discovery rate testing. results: after a mean . ± . years of follow-up, ( . %) participants died. in fully adjusted models, the following muscle texture features were associated with mortality: gldm-dependenceentropy (hazzard ratio (hr) per standard deviation (sd)= . , p< . ), gldm-dependencenonuniformity (hr per sd= . , p= . ), gldmsmalldependencelowgraylevelemphasis (hr per sd= . , p< . ), glrlm-graylevelnonuniformity (hr per sd= . , p< . ), glszm-small area low gray level emphasis (hr per sd= . , p= . ), ngtdm-coarseness (hr per sd= . , p= . ), ngtdm-strength (hr per sd= . , p= . ). each of these associations were in the direction that suggested greater heterogeneity of the image was associated with increased mortality. conclusion: in a large multicenter cohort of community-dwelling older adults, ct-derived muscle texture features indicating greater heterogeneity were associated with mortality, independent of common covariates including skeletal muscle density. background: growth differentiation factor (gdf ) has been related with disease progression, mitochondrial dysfunction, and mortality. elevated gdf- level was recently reported to be associated with poorer physical performance in very healthy community-dwelling adults. however, until now, the relationship of serum gdf- level with sarcopenia in community-dwelling older adults has not been well characterized. objectives: this study aimed to investigate the association between serum gdf- levels and sarcopenia in community-dwelling older adults. methods: we analyzed participants (mean age, . ± . years; . % men) who underwent measurement of serum gdf- level and sarcopenia parameters, using their baseline data from the korean frailty and aging cohort study. participants with reduced kidney function, specifically an estimated glomerular filtration rate (egfr) from creatinine of < ml/min/ . m , were excluded. serum gdf- level was quantified with an enzyme-linked immunosorbent assay kit. appendicular skeletal muscle mass was measured using dual-energy x-ray absorptiometry. sarcopenia status was determined in accordance with the asian working group for sarcopenia (awgs) guidelines. results: according to the awgs algorithm, ( . %) of the participants in the whole study population were classified as having sarcopenia. gdf- concentration had significant negative correlations with appendicular lean mass (men, r = - . , p < . and women, r = - . , p = . ), grip strength (men, r = - . , p = . and women, r =- . , p = . ), and gait speed (men, r = - . , p = . and women, r = - . , p = . ). in the multivariate analysis adjusted for potential confounders, the highest gdf- quartile (>= pg/ml) was associated with a greater risk of sarcopenia (odds ratio [or] = . ; % confidence interval [ci], . - . ) than the lowest quartile (< pg/ml). these associations remained unchanged (or = . ; % ci, . - . ) after further adjustment for potential biomarkers (e.g., myostatin, dehydroepiandrosterone, and insulin-like growth factor- ). the or per unit increase in log-transformed gdf- level was . ( % ci, . - . ). conclusion: higher circulating gdf- levels were independently associated with a greater risk of sarcopenia in community-dwelling older adults. gdf- may be considerate a promising biomarker of sarcopenia. background: frailty has been recognized as an emerging public health problem in rapidly aging populations worldwide. use of biomarkers to identify frailty has been suggested for early frailty screening. among multiple risk factors of frailty, inadequate nutrition such as inadequate intake of protein and vitamin d has been shown to be associated with increased risk of frailty. therefore, nutritional biomarkers could be useful for early screening of frailty. objectives: to review the evidence of potential biomarkers, especially nutritional biomarkers for early screening of frailty in community-dwelling older adults. methods: a literature search was conducted using pubmed and scopus databases. studies evaluating blood biomarkers and frailty in community-dwelling older adults from to were included. information on the definition of frailty, study design, characteristics of the study populations, and the associations between biomarkers and frailty was summarized. results: in total, studies were identified in which observational studies were published since . majority of studies used physical frailty. other definitions such as multidimensional, social and frailty were also used. biomarkers were identified. cross-sectional and longitudinal studies consistently showed that low level of vitamin d was associated with frailty. emerging scientific evidence suggested that abnormal level of albumin, low levels of high-density lipoprotein (hdl), beta-hydroxy beta-methylbutyrate (hmb), vitamin b (measured by pyridoxal- -phosphate), carotenoids, or a-tocopherol (vitamin e), and high level of dp-ucmgp (marker of vitamin k) could have the potential for frailty screening. besides nutritional biomarkers, the evidence showed that inflammatory markers such as c-reactive protein (crp), interleukin- (il- ), and fibrinogen, and endocrine-related markers such as hemoglobin, dehydroepiandrosterone sulfate (dheas), and hemoglobin a c could be useful for screening frailty. additionally, there is evidence suggesting that some oxidative or immune-related markers were associated with frailty. conclusion: vitamin d could be a useful nutritional biomarker for early frailty screening in the community setting. other nutritional biomarkers, inflammatory markers and endocrine-related markers could be associated with frailty. further research is needed to validate and refine other potential biomarkers. jonathan quinlan , , , amritpal dhaliwal , , felicity williams , , matthew armstrong , , leigh breen , , , ahmed elsharkawy , , carolyn greig , , , janet lord , , ( ( ) background: end stage liver disease (esld) is associated with reduced muscle mass with a reported incidence of sarcopenia of - % (bhanji, ). loss of muscle mass in esld patients has a negative impact on clinical outcomes including mortality and recovery rates from liver transplantation (montano-loza, ) . previous research has investigated loss of muscle mass in esld via appendicular skeletal muscle mass and psoas muscle cross sectional area (csa) using dxa and magnetic resonance imaging (mri) respectively. however, the quadriceps muscle group has high functional significance and thus should be investigated in esld patients in whom function may be limited. ultrasound (us) offers a non-invasive, bedside imaging assessment of quadriceps muscle mass. however, esld may be associated with increased subcutaneous fat which can present an operational challenge for us and thus its application in esld patients requires validation. objectives: the aim of this research is to validate the accuracy of ultrasonographic measures of quadriceps muscle mass by comparison with the gold standard of mri. methods: parallel mri and us were collected from patients with an esld diagnosis and awaiting liver transplant ( patients, age ± yrs, bmi . ± . ). participants underwent us scanning of both left and right quadriceps followed directly by an mri. specifically, measures of vastus lateralis (vl) muscle thickness (mt) and quadriceps csa were obtained at % femur length during longitudinal and extended field of view us respectively. to enable direct comparison with quadriceps csa obtained during mri, an oil capsule was placed upon the leg to mark the exact location of us image collection. all procedures received research ethics committee approval and written informed consent from the participants. results: a significant (p< . , n= ) positive correlation was found between vl mt and quadriceps csa obtained via mri (r = . ). similarly, there was a significant positive correlation (p< . , n= ) between csa obtained via extended field of view us and mri (r = . ). bland-altman plots demonstrated a bias of - . ± . cm , with % limits of agreement of - . cm and . cm . conclusion: our data demonstrate that the assessment of quadriceps csa and vl mt via us may offer a suitable bedside alternative to mri in patients with esld. background: sarcopenia is defined as the gradual ageassociated loss of both muscle quantity and strength in older adults, and severe sarcopenia affects subject performance (such as reduced gait speed). it is a devastating condition, predicting an increase in mortality, falls, fractures and hospitalizations. current clinical criteria diagnose sarcopenia through dual x-ray absorptiometry (dxa) measures of muscle mass, a test that cannot be performed at the bedside and is rarely used to find this condition. point-of care ultrasound (pocus) is rapidly becoming a standard part of the physical exam, and has the potential to become a quick, noninvasive marker for both muscle mass and function. objectives: we examined the relationship between ultrasound measures of muscle mass (vastus medialis thickness, mt) and other measures of muscle quantity (appendicular skeletal mass, asm; mid-arm biceps circumference, mabc). we also examined the association between mt and measures of muscle strength (grip strength) and muscle performance (gait speed) in an older adult population. methods: older adults (age >= ; mean age . ± . years, women, men) were recruited sequentially from geriatric medicine clinics. each subject had appendicular skeletal muscle mass (asm, by bioimpedance assay), grip strength, mid-arm biceps circumference (mabc), gait speed, and an ultrasonic measure of muscle quantity (mt, vastus medialis muscle thickness) measured. our initial models contained age, sex, bmi, and mt as predictor variables, and our outcome variables were asm, grip strength, mabc and gait speed. results: in our final parsimonious models, mt showed a strong significant correlation with all measures of muscle mass, including asm(standardized ß= . ± . , r = . , p< . ) and mabc(standardized ß = . ± . , r = . , p= . ). with respect to measures of muscle quality, there was a strong significant correlation with grip strength (standardized ß = . ± . , r = . , p= . ) but not with subject performance (gait speed). conclusion: mt showed strong correlations with both measures of muscle mass (asm and mabc) and with muscle strength (grip strength). riki kosugi , yung-li hung , toshiharu natsume , shuichi machida (( ) faculty of health and sports science, juntendo university, inzai, chiba, japan; ( ) institute of health and sports & medicine, juntendo university, inzai, chiba, japan; ( ) coi project center, juntendo university, bunkyo-ku, tokyo, japan; ( ) graduate school of health and sports science, juntendo university, inzai, chiba, japan) background: loquat (eriobotrya japonica) leaves are commonly used in teas and folk medicines. recently, loquat leaf extract (lle) has been reported to promote muscle protein synthesis in vitro. additionally, resistance exercise has been shown to promote muscle protein synthesis in vivo. it is considered that lle and resistance exercise might have a synergistic effect on activating muscle protein synthesis. however, this has never been investigated. objectives: the purpose of the present study was to investigate whether lle enhances the muscle contraction-induced activation of muscle protein synthesis signaling in rats. methods: male wistar rats ( weeks old, n= - /group) were categorized into a control (con) group, an lle-administered (lle) group, an electrical muscle stimulation (ems) group , and an ems with lle (ems+lle) group. rats were administered lle ( . g/kg/ day) or distilled water once in a day by oral gavage for days. on the seventh day, h post-lle administration, the gastrocnemius muscle of the right legs of ems group and ems+lle group rats were stimulated by ems ( hz, v) through sets of isometric contractions ( s contraction, s rest) with min inter-set intervals. rats were then sacrificed and their gastrocnemius muscles were rapidly excised h post-ems. expression levels of muscle synthesis-related proteins [protein kinase b (akt), mammalian target of rapamycin (mtor), and ribosomal protein s kinase beta- (p s k)] were determined by western blotting. results: no significant differences were observed in body weight, water intake, and diet intake among the groups. akt phosphorylation at ser was found to be significantly increased in the ems+lle group compared to that in con group; mtor phosphorylation at ser did not show a significant difference. p s k phosphorylation at thr was found to be significantly increased in the ems group compared to that in con group, while the ems+lle group was observed to have significantly higher p s k phosphorylation at thr than the ems group. conclusion: our study suggests that lle enhances the muscle contraction-induced activation of p s k phosphorylation. background: metabolic aging has emerged as a new sedentarity related syndrome combining metabolic diseases and sarcopenia, a degenerative loss of skeletal muscle mass, quality, and strength associated with aging. it has been recently shown that kynurenic acid (ka), a key metabolite of tryptophan/ kynurenine pathway, improved glycemic control and lipid profile in rodents. objectives: to show that ka has a key role in metabolic aging, we have evaluated its effect on muscle function and mass in vitro and in vivo in muscle cell line and in a model of hindlimb immobilization in mouse. methods: in vitro in c c muscle cells we measured the ability of ka to inhibit myostatin gene expression (endogenous inhibitor of muscle growth), stimulate protein synthesis and enlarge muscle cell size. differentiated cells were exposed to ka for h for protein analysis, h for gene study and the days of differentiation for cell enlargement examination. in vivo, muscle mass (tibialis and soleus) was measured after a week-hindlimb immobilization in mice treated or not with ka ( mg/kg.day per os). results: in vitro, ka significantly and dose-dependently inhibited myostatin gene expression, stimulated protein synthesis and enlarged c c muscle cells. in mice, ka treatment significantly reduced tibialis and soleus muscle wasting induced by immobilization. conclusion: we demonstrated for the first time the positive impact of ka on muscle function and mass preservation offering a promising therapy for patients affected by metabolic aging, who do not currently benefit from relevant therapeutic solutions. Â n g e l a m a r i a p e r e i r a , , , a n a f r e i t a s , a n a p a c i f i c o , c a t a r i n a c o s t a , m a r g a r i d a a l m e i d a (( ) physiotherapy departement, escola superior de saúde egas moniz, portugal; ( ) centro de investigação interdisciplinar egas moniz, monte da caparica, portugal; ( )hospital garcia de orta, almada; portugal) background: as people age they are more likely to fall. although most fall-related injuries are minor, they can cause significant pain and discomfort, affect a person's confidence and lead to loss of independence. some falls can cause serious long-term health problems. one strategy to promote greater adherence and motivation to intervention in physical therapy is the use of virtual environment (ve) programs associated with a balance exercise programs as an effective method of preventing falls. objectives: the purpose of this study was to analyze the benefit of a virtual environment exercise program in non-institutionalized elderly at the end of six weeks. methods: in this randomized controlled trial non-institutionalized elderly were included. subjects, age . ± . yrs constituted the experimental group (eg); and , age, . ± . yrs constituted the control group (cg). the eg was submitted to weeks of a ve exercise program performed on a nintendo wii, and to a set of recreational activities. the cg only performed the activities. the instruments used in the present study to evaluate performance were tinetti's index, which evaluates the static balance and the gait to quantify the risk of fall, and the fullerton's functional fitness tests to assess physical parameters such as strength, aerobic endurance, flexibility and agility/ balance. results: at the end of the weeks of intervention in a virtual environment, significant improvements in upper limb strength, agility and static balance were observed. in the intragroup comparison, it was possible to verify improvements in all physical fitness battery tests. the values of functional fitness tests were significantly different (p<. ) between eg and cg groups for the following variables: -second chair stand . ± . vs. . ± . times; arm curl . ± . vs. . ± . times; -foot up-and-go . ± . vs. . ± . sec; two min. step . ± . vs. . ± . steps, respectively; as well as for the tinetti index. conclusion: this study, suggests that exercise in ve context applied to non-institutionalized elderly, promotes improvements in mobility, in lower limbs muscular strength, and may help to reduce the risk of falls by improving the static and dynamic balance. background: the small non-coding micrornas (mirs) are endogenous regulators of gene expression. they bind to complementary sequence on target messenger rna transcripts resulting in translational repression or target degradation. they are involved in the skeletal muscle response to training in animals and humans (kirby, ) . objectives: the aim of our study was to measure the effects of high intensity interval training (hiit) associated or not with l-citrulline on the expression of serum and muscle mirs in a group of men. methods: we selected men (mean age: . ± . years, men in the placebo group and in the l-citrulline group, gr/day) from a cohort of men and women submitted for weeks to hiit (buckinx, ) . we evaluated the expression of serum and muscle mirs before and after training. the quantification of mir expression was performed using the next generation sequencing (ngs) technique (exiqon). for statistical analysis, the measurements were normalized with the tmm method (trimmed mean of m-values). results: we identified mirs from serum and mirs from muscle above the detection limit (>= tpm, tags per million). after benjamini-hochberg correction, serum mirs from the l-citrulline group had a significantly different level of expression before and after training: - p, b - p, , a- p and - a- p (p < . , % fdr). no mir of the placebo group had a significantly altered expression. in muscle, our approach revealed mirs with a significantly different level of expression before and after training in the placebo group and in the l-citrulline group, of which were common to both groups. these mirs were different from those highlighted at the serum level. the most-expressed muscle mirs with the greatest difference in expression before and after training were - p, - p, - p, - p and b- p (p < . , % fdr). conclusion: with the ngs approach, we identified mirs differentially expressed before and after hiit. expression of circulating mirs appears to be influenced by l-citrulline. the next validation step will be to measure these specific mirs in the entire cohort to determine the clinical utility of these markers. background: recent interventional studies on frailty used multicomponent programs (physical exercise, cognitive stimulation, and nutritional supplementation) with some promising results. however, these emerging programs developed to counter the multidimensional concept of frailty still need methodological improvements to be completely effective. objectives: the objective of this innovative project is to develop personalized multicomponent interventions that could be easily used by frail older adults in order to reverse physical, cognitive and psychosocial symptoms associated with frailty. three original and specific action levers will be used to insure a better effectiveness: /to target a key population (hospitalized frail older adults who will be discharged to home), /to use a real multicomponent program (physical exercises simultaneously associated with cognitive and social components that mimic daily gestures), and /to encourage adherence through medical prescription. methods: one hundred and twenty frail older adults (>= ) will be recruited from the geriatrics unit of the university hospital of tours (france), and randomly assigned to one of the two study arms: the intervention group (ig), who will receive a medical prescription of an adapted multicomponent intervention, vs the control group (cg; no intervention). twelve-week programs will be adapted according to observed intrinsic capacities of the frail older adults. including exercises will be based on effective international physical programs, with original cognitive and social components added to the physical exercises. all participants will perform pre-and post-tests to compare their physical health (gait speed, balance, and strength), cognitive health (global cognition and executive functions), and psychosocial health (self-efficacy and quality of life) before and after the three-month program. results: a pilot study to this rct has already started in tours. the international conference on frailty and sarcopenia research would be the perfect opportunity to share preliminary results. the intervention will be considered as feasible if ig participants adhere to > % of the prescribed exercise and as effective if we observe significant improvements in all clinical outcomes for ig participants, compared to the cg. conclusion: final objective will be to disseminate to a large number of individuals the idea that several concrete ways exist to age well. amanika kumar, clarissa polen-de, gladys asiedu carrie langstraat, aminah jatoi (mayo clinic, rochester, minnesota, usa) background: frailty in patients with advanced stage ovarian cancer (oc) is common and associated with increased oncologic and surgical morbidity and mortality. prehabilitation is one option to reverse frailty in this subset of patients. objectives: our aim was to investigate potential barriers and facilitators of prehabilitation during neoadjuvant chemotherapy (nact) in oc patients. methods: we identified patients who underwent nact from - at a large volume single institution. patients underwent a semi-structured one-on-one phone interview. transcripts from interviews were read by independent reviewers to identify emerging themes related to patients' experience, functioning and exercise during chemotherapy. results: five primary themes emerged following analysis of the participants transcripts. participants were overall willing to participate in exercise during chemotherapy, with / patients stating they would walk or did walk at least minutes daily during treatment; this was linked to a strong motivation to improve surgical and survival outcomes. only / patients stated they were not interested in exercise during treatment. most notable, patients' motivations were tied closely to physician recommendation. patients prominently identified a shift in health as a priority following their ovarian cancer diagnosis, which subsequently lead to an increase in daily activities and exercise. surgery and improvement in mental well-being were strong motivators for patients to start or continue an exercise program. participants also identified barriers to exercise during treatment including a variety of treatment related and nontreatment related concerns, including neuropathy, nausea, pain, program availability, time and most significantly fatigue. despite this, most retrospectively thought they would have been willing to exercise with modifications. almost all participants voiced the importance of a supportive treatment community, including their medical care team, family, friends and the local community. conclusion: patients with advanced ovarian cancer demonstrated high motivation and willingness to exercise during chemotherapy when there was a perceived benefit to overall survival. prehabilitation may be a helpful to improve outcomes, but a prehabilitation strategy should be designed specifically for the patients with the most need and designed with barriers and motivators in mind. randomized control trial. kosuke fujita , , hiroki umegaki , aiko inoue , huang chi hsien , , hiroyuki shimada , masahumi kuzuya , (( ) institute of innovation for future society, nagoya university nagoya, japan; ( ) department of community healthcare and geriatrics, nagoya university graduate school of medicine nagoya, japan; ( ) department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology obu, japan) background: gait disorder in older adults could lead fatal consequence following falling or reducing physical activity, especially in individual with pre-clinical / clinical cognitive decline. effectiveness of exercise intervention for the gait characteristics has been examined in previous studies, however, evidence about differences between exercise modality such as aerobic training (at) and resistance training (rt) for the acute and long phase is unclear. objectives: the aim of the present study was to compare the effect of different exercise modality on the gait characteristics of older adults with preclinical cognitive decline. methods: individuals (mean age, . years) with self-reported cognitive decline were enrolled in randomized controlled trial. subjects assigned to at group (n = ), rt group (n = ) and at+rt group (n = ) underwent exercise intervention days a week for weeks. subjects assigned to control group (n = ) were provided information about healthy aging. gait characteristics were examined before, just after the intervention and after the weeks of follow-up period using an electronical walkway system. results: in the analyses about the change between pre and just after the intervention period, all of three exercise groups significantly improved gait velocity (at, p < . ; rt, p < . ; at+rt, p < . ), stride time (at, p < . ; rt, p = . ; at+rt, p < . ), cadence (at, p < . ; rt, p = . ; at+rt, p < . ), stride length (at, p < . ; rt, p = . ; at+rt, p < . ) and double support time (at, p < . ; rt, p < . ; at+rt, p < . ), and at+rt group improved significantly with cv of step width (p < . ). in the analyses about the change between pre and follow-up period, rt group only had improvements with gait velocity (p < . ), stride length (p = . ) and double support time (p = . ). conclusion: all exercise interventions could improve gait characteristics of older adults with pre-clinical cognitive decline. for the purpose of maintain improved gait characteristics for a long phase, rt is likely to be recommended. activity and a broader array of physical and psychological outcomes among nursing home residents. however, some limitation of this game should be acknowledged (e.g. too long, too bulky, exercises too simple). taking into account these weaknesses, we decided to develop and validate a new version of a giant exercising board game: the gamotion. objectives: to evaluate the impact of gamotion on physical capacity, motivation and quality of life among nursing home residents. methods: a one-month randomized controlled trial was performed in two comparable nursing homes. eleven participants ( . ± . years; men) meeting the inclusion criteria took part in the intervention in one nursing home, whereas participants ( ± . years; men) were assigned to the control group in the other institution. the gamotion required participants to perform strength, flexibility, balance and endurance activities. the assistance provided by an exercising specialist decreased gradually during the intervention in an autonomy-oriented approach based on the selfdetermination theory (ryan & deci, ) . physical capacity (i.e. quantitative evaluation of walking using locometrix; grip strength using jamar dynamometer; knee extensor isometric strength using microfet ; fall risk using tinetti test; dynamic balance using timed up and go test (tug) and physical abilities using sppb test), motivation (i.e. using behavioral regulation in exercise questionnaire- ) and quality of life (i.e. using eq- d questionnaire) were assessed at baseline and at the end of the intervention. a two-way repeatedmeasure analysis of covariance (ancova) was used to assess time*group (intervention vs. control group) effects. results: globally, during the intervention period, the experimental group displayed a greater improvement in symmetry of steps (p= . ), tinetti score (p< . ), tug (p= . ), sppb (p< . ), knee extensor isometric strength (p= . ), grip strength (p= . ), domains of the eq- d (i.e. mobility, self-care, usual activities : p< . ) and intrinsic motivation (p= . ) compared to the control group. conclusion: the effects of gamotion on physical capacity, motivation and quality of life of nursing home residents confirm the results obtained with the previous version of the giant exercising board game. in-hospital stay, even in short stays, is associated with functional impairment in older patients. objectives: the agecar plus study aims to evaluate the effectiveness of a program of physical exercise and health education to prevent the functional deterioration during the in-hospital stay. methods: randomized clinical trial. patients older than years admitted to the ace of the general university hospital gregorio marañón were included and randomized at admission in control group (cg) or intervention group (ig). exclusion criteria were baseline barthel ( days before admission) less than points, severe cognitive impairment or unable to walk. both groups received usual care, and patients in intervention group also performed simple supervised exercises (strengthening of lower limbs, walking, and inspiratory muscle training). in the preliminary analysis, we analyzed the effect of the intervention on changes in short physical performance battery (sppb) and alusti test, at admission and discharge, by t-test of repeated measures in the study periods. results: from may to february , patients were included: gc and ig. the cg and ig were homogeneous in sex (women . %), age ( . ± . vs. . ± . ), comorbidities (charlson: . ± . vs. . ± . ), cognitive impairment (pfeiffer: . ± . vs. . ± . ), fragility (fried >= : % p= . ), and functional-physical capacity (sppb: . ± vs . ± . ; alusti, . ± . vs . ± . ). p < . for all variables. a significant effect of the intervention was found, with a higher mean score in the alusti test in the ig (cg: . ± . vs . ± . ; f( , )= . ; p= . ), not finding such differences with the sppb ( . ± . vs . ± . ; f( , ) = . ; p= . ). conclusion: the preliminary analysis shows that the alusti test could be used as an evaluation test for functional capacity in hospitalized elderly patients. a physical exercise program during hospitalization in an acute unit improves the functional capacity assessed by the alusti test at discharge significantly. funding: instituto de la salud carlos iii (pi / ), ciberfes, fondo europeo de desarrollo regional (feder). the authors declare no conflicts of interest. a. sampaio , i. marques-aleixo , , j. carvalho (( ) ciafel -research center in physical activity, health and leisure, faculty of sport, university of porto, portugal; ( ) faculty of psychology, education and sports, lusófona university of porto, portugal) background: cognitive impairment is a highly prevalent, poorly managed, and disabling consequence of dementia. exercise training that improves physical fitness can represent a promising approach for managing cognitive impairment in persons with dementia. objectives: the aim of this crosssectional study investigated the association of physical fitness and balance with cognitive function. methods: sixty-four institutionalized older adults, aged . ± . years, with dementia, predominately female ( %) and with dementia due to alzheimer's disease ( . %). regression analyses were used to examine associations between physical fitness components (senior fitness test), balance (tinetti index) and cognitive function (mini-mental state examination). results: univariate regression indicates a significant association between the strength of the upper body (p= , ) and aerobic endurance (p= , ) with the cognitive function in older people with dementia. conclusion: these results suggest an association between the specific dimensions of physical fitness and cognitive function. consequently, multicomponent exercisebased therapeutic strategies aiming to improve physical fitness could be an important nonpharmacological strategy for dementia management. satoshi kurita, takehiko doi, kota tsutsumimoto, sho nakakubo, hideaki ishii, hiroyuki shimada (section for health promotion, department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan) background: women had higher risk of cognitive impairment or dementia compared to men. although studies reported physical activity (pa) and/or cognitive activity (ca) had protective association with cognitive impairment among older adults, it is unknown whether the association is depended on sex or not. objectives: the purpose of the present study was to examine the sex differences in the association of pa and/or ca with cognitive impairment in community-dwelling older adults. methods: a community-based cohort survey was conducted in a total of participants (mean age . ± . years; . % female) who met the study criteria. time of moderate-to-vigorous intensity pa was measured using an accelerometer. ca was assessed by the frequency of engaging in activities using a ca scale including reading, doing crossword puzzles, and playing board games or cards. participants were categorized into four groups based on quartile (low) and to (high) values of pa and ca. cognitive impairment was defined by at least out of neuropsychological tests having a result at least . standard deviation below the reference threshold. results: in both sex, the prevalence of cognitive impairments showed significant differences among groups; that of low pa/low ca group, low pa/high ca group, high pa/low ca group, and high pa/high ca group were respectively . %, . %, . %, and . % for male (p < . ) and . %, . %, . %, and . % for female (p < . ). in binomial logistic regression models for male, all groups showed a low odds ratios of cognitive impairment compared to the low pa/low ca group (odds ratio = . to . , all p < . ), while for female, only high pa/high ca group had significant association with cognitive impairment (odds ratio = . , % confidence interval = . to . , p = . ). conclusion: in male, pa and ca are associated with cognitive impairment even in the case of low engagement in either pa or ca. in female, higher engaging in both activities are associated with cognitive impairment. female older adults may need to engage in more activities than male to acquire benefit on preventing cognitive impairment. ( interventions) were included in the systematic review and in the meta-analyses ( interventions). there was considerable heterogeneity in the number for interventions that detected significant increases in muscle mass ( / , %) and muscle strength ( / , %). of those muscle strength interventions / ( %), / ( %), / ( %) and / ( %) interventions reported a significant increase in handgrip strength, lower body muscle strength, upper body muscle strength and whole body muscle strength respectively. ret factors associated with the greatest gains in muscle mass and muscle strength were: use of combination of equipment, seven to eight exercises per session with three lower body exercises, a volume of three to four sets and to repetitions per exercise, a frequency of two-three days per week, intervention length of greater than six weeks, progressive intensity, intervention duration of - minutes, and in a supervised individually training structure. these results align with current guidelines provided by american, australian, japanese, british, canadian and japanese societies. conclusion: not all ret interventions are effective for improving muscle mass and strength, but our meta-analysis suggests that adhering to the current ret guidelines for older adults are likely to be most effective. duarte barros, andreia pizarro, arnaldina sampaio, joana carvalho (research center in physical activity, health and leisure, faculty of sports, university of porto, portugal) background: sedentary time (sed) and low physical activity (i.e. low levels of moderate-to-vigorous physical activity [mvpa] ) are different behaviours associated with negative health outcomes, but how synergetic combinations of these behaviours impact the risk of frailty are still unexplored. objectives: to examine the relationship between different combinations of sedentary time and mvpa in the risk of being frail. methods: a cross-sectional study including community dwelling elders ( . ± . years; . % female) accessed frailty through the phenotype of frailty. daily sed and mvpa were objectively measured using accelerometry. sed and mvpa were ranked by the median and then participants were categorized into one of four groups: lowsed+lowmvpa, l o w s e d + h i g h m v p a , h i g h s e d + l o w m v p a a n d highsed+highmvpa. results: overall, . % of the participants were frail. mvpa was associated with reduced odds of being frail (or . ic: . - . , p < . ). moreover, compared to the highsed+lowmvpa, the groups lowsed+highmvpa (or . ic: . - . , p = . ) and highsed+highmvpa (or . ic: . - , p < . ) were associated with reduced odds of being frail. conclusion: mvpa seems associated with reduced odds of being frail, irrespective of sedentary time. background: sarcopenia is central to frailty and the strongest evidence for reversal lies in the combination of resistance exercise and protein supplementation. unfortunately, uptake amongst older adults remains low, partly due to a lack of suitable exercise programs. delivery by health professionals alone will not achieve widespread participation. objectives: defrail aims to develop a novel exercise program (focused on resistance training), feasible for delivery to frail older adults in a group setting without the input of health professionals, and to examine its effect when combined with commercially-available protein-supplemented milk. methods: a multi-component exercise program was designed by expert consensus using a modified delphi process. participants were recruited from geriatric medicine clinics and primary care, with assessments at baseline, after eight weeks of regular activity and then after the eight-week intervention. the primary outcome measure was the change in the fried frailty criteria (ffc) during the intervention compared with the period of regular activity. secondary outcome measures included the timed up & go (tug) and -second sit-to-stand ( sts) tests. results: the first participants to complete the program ( females, males, mean age , range - ) had a median ffc score of (interquartile range (iqr) , ), i.e. frail, both at baseline and after the period of regular activity period, but had improved to (iqr , ), i.e. pre-frail, following the intervention. similarly, the median tug was . (iqr . , ) at baseline, increasing to . (iqr , . ) after the period of regular activity, improving to . (iqr . , . ) following the intervention. the median sts was (iqr , ) at baseline, (iqr , ) after the period of regular activity, improving to (iqr , ) following the intervention. conclusion: median frailty improved from frail to pre-frail for the first defrail participants. this program could allow increased community-based participation in resistance exercise for frail older adults. further work now includes completion of the intervention and analysis of data on a range of secondary outcome measures (assessments of cognition, mood, pain, body mass composition and biochemical markers of frailty). background: exercise interventions have been shown to improve functional status and quality of life of frail older people, and in some cases to reverse frailty status. it is important that such interventions are targeted to those people who would benefit the most. objectives: the objective of this pilot study was to assess the effectiveness of a physical activity intervention given to mildly frail older people, who were identified using electronic health records (ehr). methods: the electronic frailty index (efi) was used to identify mildly frail older people and offer them a physical activity intervention of their choice. the pilot study was offered in one area of luton (uk), with invitation letters sent by the participants gp. participants were tested before and after a -week programme of strength, balance and mobility, delivered in a weekly session lasting one hour. participants were assessed at baseline for motivation using the patient activation measure (pam), physical function using the short physical performance battery (sppb), and fear of falling using the falls efficacy scale international (fes-i). each test was carried out in a follow-up test after the programme had concluded. bootstrapped paired t-tests were used to assess the effect of the intervention. results: twenty-seven people aged . ± . years took part in the intervention. the pam scores improved from . % to . % ( . , % ci: . , . ), which is twice the minimal clinically important difference (mcid) of . for sppb, there was an improvement from . to . ( . , % ci: . , . ). the average increase was greater than the mcid for a substantial improvement of . . when fes-i was assessed, only three people ( %) had high concern about falling. there was no significant improvement in fes-i after the intervention (- . , % ci: - . , - . ). after the intervention, % of participants choose to pay for the continuation of the programme. conclusion: the findings of this study suggest that a targeted exercise programme including strength and balance training can significantly improve motivation and functional status among mildly frail older people identified using the efi, with the majority choosing to continue exercising. background: despite frailty has traditionally been examined from a physical standpoint, recent studies advocate for the existence of cognitive frailty ( ), and suggest that both physical and cognitive frailty are interrelated. thus, interventions should aim to prevent or attenuate the effects of frailty from a multidimensional perspective. objectives: to evaluate the effects of three different exercise programs on frailty among older adults living in long-term nursing homes (ltnh). methods: participants ( . % female) met the following criteria: aged years, scored on the barthel index, scored on mec test (an adapted version of mmse in spanish) and capacity to stand up and walk m independently. participants were randomly assigned to a progressive multicomponent group (mcg; n= ), a multicomponent dual-task group (dtg; n= ), or to a walking group (wg; n= ). the mcg underwent a -month moderate intensity strength and balance exercise program twice a week. the dtg performed simultaneous cognitive training (attention, inhibitory control, calculations and semantic memory) to the mc program. the wg walked up to minutes per day for days a week. frailty was measured though the following tests: fried frailty index (ffi), the tilburg frailty index (tfi) and the study of osteoporotic fractures (sof). results: the ffi revealed reductions in frailty in all groups, although only the mcg and the wg reached statistical significance (p< . ). as for the tfi and sof tests, no statically significant differences were found in any of the groups. however, there was a positive trend in tfi in the dtg (p= . ). no group-by-time interactions were found in any of the frailty tests used (p> . ). conclusion: our study showed no differences between interventions regarding frailty. however, the mcg and the wg showed significant reductions in phenotypic frailty, whereas the dtg showed a positive trend in the tfi, which takes into account physical, psychological and social domains. therefore, further studies should explore the effects of different exercise modalities on frailty from a broad perspective in older adults living in ltnhs. references: kelaiditi et al . j nutr health aging. ( ) : - . noirez , , iraj hashemi , deborah kopoin , pierrette g a u d r e a u , m a r c b é l a n g e r , g i l l e s g o u s p i l l o u , josé a morais , aubertin-leheudre ( ( ) background: aging leads to a loss of muscle strength and functional capacity. these phenomena can be slow down by daily exercise practice or resistance training intervention. objectives: the aim of this study was to investigate in elderly men muscle fiber size and type after resistance training. methods: among sedentary older men who completed a -week mixed power training program, were biopsied in the vastus lateralis before and after the program. cross sections were performed on these muscles, followed by triple immunohistochemical staining with antibodies directed against laminin, myosin heavy chain (myhc)- and myhc- a coupled with staining with secondary fluorescent antibodies. immunostaining analysis of laminin allowed us to determine fiber size and these of myhcs to determine fiber type. results: the size of the muscle fibers remained the same between before and after the mixed power training (p= . ).there was no significant difference in the percentage of expression of myhc- , a, x (p= . , p = . , p = . ) between before and after intervention. in addition, there was no difference in the size of fiber expressing myhc- between before and after the training (p = . ). however, significant increase in the sizes of fiber expressing myhc- a and myhc- x (respectively p = e- , p <. ) after the mixed power training was observed. conclusion: in elderly men, an increase of the size in fibers both expressing myhc- a and myhc- x in vastus lateralis muscle could explained the improvement on muscle mass observed previously (carvalho et al. acer ) . to confirm the mechanism explanation of this promising exercise modality, mitochondrial parameters should be also analyzed. background: muscle (in)activation related with sedentary behavior (sb) and physical (in)activity (pa) is a risk for sarcopenia in older adults. although age is not yet a risk factor for sarcopenia in adulthood, other factors such as lifestyle may significantly contribute to its progression. objectives: considering the primary and secondary prevention of sarcopenia, the aim of this study was to analyze associations of sb and pa with markers of muscle strength (lower limb muscle power) and muscle mass (fat mass (fm) to fat free mass ratio (ffm) in adult women and men with and without deficits in these markers. methods: participants were apparently healthy adults ( women) with a mean age . ± . yrs, employed in activities requiring office work. fm and ffm were evaluated by bioelectrical impedance analysis (bia, khz bia rjl, akern bioresearch, florence, italy akern). muscle power relative to body mass (pmax/mass) was assessed during a single two-legged jump on a force platform (leonardo mechanograph, novotec medical, pforzheim, germany) . sb and pa were assessed by accelerometry (actigraph, gt x model, fort walton beach, fl, usa) during four consecutive days ( -week+ -weekend days). the variables analyzed were time spent per day in sb, in light-, moderate-, vigorous-, moderate to vigorous-intensity pa, total pa and breaks per day of sb. multiple linear regressions were performed by stepwise to examine associations of sb and pa with muscle power and fm/ffm, separately for men and women with and without muscular deficits. for the identification of deficits (<- . sd), muscle power and fm/ffm were standardized separately for men and women having as reference their respective mean. results: linear regressions by stepwise evidenced an association of sb with muscle power in women with muscular deficit (β = - . , p = . , adjr = , %%) and an association of vigorous pa with fm/ffm in men without muscular deficit (β = . , p < . , adjr = , %). no associations were observed between sb or pa with muscle power or fm/ffm in other groups. conclusion: sb was negatively evidenced in women with muscle power deficit while vigorous pa revealed to be associated with fm/ffm in men without ffm deficit. funded by portuguese science and technology foundation; project c mup-eri/hc i/ / patricia parreira batista , andré gustavo pereira de andrade , jéssica rodrigues de almeida , aimée de araújo cabral pelizari , leani de souza máximo pereira , lygia paccini lustosa (( ) physical therapy department, ufmg -eeffto, belo horizonte, brazil; ( ) sports department ufmg -eeffto, belo horizonte, brazil) background: the practice of regular physical activity in the older people leads to the decreased of the loss of muscle mass and function with advancing age, and enhances the functionality in activities of daily living and social interaction. in addition, exercise promotes gains in the quantity and quality of muscle fibers and improves muscle strength and power, acting as a protective factor for negative health-related outcomes such as falls, frailty, and hospitalizations. regular practice of physical activity is known to modify the chronic proinflammatory condition common in the older people. probably, exercise reduces the drive of catabolic stimuli from this proinflammatory cascade, modifies the metabolism and production of cytones in tissues and organs, promoting protective and anti-inflammatory effect in the body. objectives: to compare older women who reported being active or sedentary regarding functional capacity and plasma indices of inflammatory mediators. methods: participated women ( years or older), recruited for convenience. those unable to walk were excluded; acute musculoskeletal diseases; lower limb fractures in the last year; neurological diseases and sequelae; history of cancer in the last five years and cognitive impairment (mental state mini-exam). all informed clinical and demographic data and performed the tests short physical performance battery (sppb) and timed up and go (tug). plasma dosages of stnfr and il- were by elisa method. comparison was by independent student t test. approval by the research ethics committee / ufmg (caae: . . . ). results: fiftytwo sedentary older women participated ( . ± . ys.); number of comorbidities of . ± . ; body mass index of . ± . kg/m . from the active group were elderly women ( . ± . ys.); comorbidity number of . ± . ; body mass index of . ± . kg/m . there was significant difference between groups in sppb (p = . ), tug (p = . ) and stnfr (p = . ). conclusion: the results showed that the active older women had better functional and mobility performance and worse plasma stnfr levels. in this case, one can think about the possible influence of body mass index in these older women, which should be explored in future studies. background: our research group designed a comprehensive geriatric intervention program (cgip) consisting of resistance exercise, physical activity increments, oral functional care, and a nutritional guide. we conducted a -week intervention and investigated the effects. after the short-term intervention, we followed up the all participants. we hypothesized that the follow-up could mitigate the loss of short-term intervention effects. objectives: the aim of this study was to compare physical functions before and after the -week intervention, and the end of the follow-up. methods: a total of were willing to participate in the -week cgip. we encouraged them to increase their daily steps and to carry out the program by using daily self-monitoring logs. the participants were randomly assigned to two groups [class-styled session (cs) group ; home-based (hb) group ] based on their residential districts. while cs group attended -minute weekly sessions and independently executed the program on other days, hb group did not attend the weekly sessions but received instructions on program execution. after the shortterm intervention, all participants were instructed to carry out the gcip habitually. also, three optional sessions for all participants were held in order to recommend implementation of the program. physical functions, such as knee extension strength (kes), maximum walking speed (mws), and anterior thigh muscle thickness (mt) were measured before and after the short-term intervention, and the end of the follow-up. results: of the participants identified, (cs ; hb ) took part in the measurements after the follow-up. thus, we analyzed their data. a significant interaction were observed in mws (p= . ). the -week cs intervention significantly improved mws (p< . ). but, mws in cs group significantly decreased after the follow-up (p= . ). there was no significant difference between before the intervention and after the follow-up in mws in cs group. on the other hand, no significant change was observed in hb group. significant time effects were observed in kes and mt (p< . ). both -wk interventions significantly improved kes and mt. while kes was maintained even after the follow-up, mt was significantly decreased. conclusion: the results suggested that appropriate follow-up helps to preserve short-term intervention effects. background: with the increasing prevalence of alzheimer disease and the current absence of drugs therapeutic, nonpharmacological strategies are definitively necessary. physical intervention is often proposed to aid in preventing or slowing cognitive decline. recent studies suggest that combining physical exercise with cognitive stimulation may have more global effect. objectives: we aimed at assessing effect of aerobic exercise alone or combined to intellectual exercises on major cognitive functions: attention (stroop), problem solving (hanoi tower) and working memory (digit span). subjects were trained twice a week for eight weeks. cognitive functions were assessed before training (base line), at the fourth and at the eighth weeks. to evaluate persistency of the effect, subjects were assessed one month after the end of training. methods: two groups were randomly constituted mild cognitive impairment subjects (mci) and alzheimer disease moderate patients (adm). each group was subdivided into three sub groups according to the task to be performed. aerobic exercise (pedaling) alone or combined to cognitive games presented on screen. control groups performed a reading task. results: an effect of training on cognitive functions was observed in adm as well as in mci subjects. however, only adm patient's performances were further improved by adding cognitive games. after four weeks, the observed effects were still maintained in both groups. mci results were obviously better than those of adm. there was no significant change in performances for control groups. conclusion: aerobic exercise induce cognitive improvement in adm and mci patients. combined physical exercise and cognitive games potentiated this effect mainly in adm group. this procedure has long lasting beneficial effect. this supports the necessity of regular aerobic exercise to prevent cognitive deficits in aging cognitive deficits. background: increasing physical activity represent a key therapeutic intervention to prevent the loss of mobility disability for enhancing health related quality of life. hence, we have set up a primary and secondary prevention care path through exercise training and nutrition to improve mobility and physical performances. objectives: our primary goal is to integrate a prevention care path into daily life of elders who may present a mobility disability risk. we aim to improve quality of life and mobility. methods: our program includes years or more who present a risk of developing a mobility disability. initially, we identify and screen a risk of mobility disability in wide elders communities. we diagnose mobility disability risk factors, sarcopenia and frailty, in day hospital (dietician, geriatrician and a kinesiologist). we use the ewgsop algorithm to diagnose sarcopenia. the patient then attend a -months training program, including sessions per week. sessions combine resistance exercises and balance training during minutes. we support the patient for his own project of long-term maintenance quality of life between physical activity and nutrition. results: patients have been seen after sessions. physical performance was significantly improved after months of intervention (sppb p< , , gait speed p< , and time-up-and-go p< , ) likewise grip strength (p< , ). the "sarqol" score was also significantly higher (p< . ). sub-group sppb ≤ with severe sarcopenia improve significantly more its score (+ . ± . p< , ) comparing to the overall population (+ . ± . ). moreover, there was a significant difference (p< , ) for sppb at baseline between responders ( . ± . ) and nonresponders ( . ± . ). conclusion: our intervention enhances mobility through physical performance benefits. we can make the assumption that adverse events will be occurring less and physical dependence will be delayed, regarding gait speed improvement. patients with lower physical performance are responding better than the overall population meaning that our intervention is more specially indicated for patients with severe sarcopenia. furthermore, our program sustains motivation for physical activity and exercise after months. we were able to show that it was possible to set up a comprehensive and effective care path for frail and sarcopenic elderly people. background: middle-aged adults who are pre-sarcopenic are at the highest risk of developing sarcopenia due to the progressive nature of the syndrome. objectives: to determine whether high intensity interval training (hiit) results in greater improvements in body composition, compared to a control group, in middle-aged adults with pre-sarcopenia. methods: eighty-two sedentary adults ( - yrs) with a low appendicular skeletal muscle mass index (asmi) were randomized into control (n= ) or intervention group (n= ) using stratified randomization based on age, sex and bmi. low asmi (asm/ht ) was determined by dxa (lunar prodigy, ge healthcare) using age-and sex-specific cut-scores as proposed by prado. the control group received one education session on general physical activity recommendations. the intervention was supervised, group-based, high-intensity aerobic and resistance interval training (hitt), times weekly for -weeks. an intention-to-treat mixed model linear regression, with a random effect, was used to analyse group differences for body composition. results: . % of the sample were female, the mean age was . yrs ( . ) and the mean bmi at baseline was . kg/m ( . ). people ( %) completed the intervention, people in the hitt group and in the control group. no adverse events were reported. significant group differences were observed for total muscle mass ( . kg, %ci: . - . ), leg muscle mass ( . kg, %ci . - . ), asmi ( . kg/m , %ci . - . ) and visceral fat mass our study indicated that group-based hiit is an effective, tolerable and safe exercise modality to increase total body and appendicular muscle mass, and to decrease visceral fat, in middle-aged adults with pre-sarcopenia. background: aging is related to body composition modifications and functional capacities declines. it is recognized than being active can prevent these changes and improve quality of life. however, it is unclear if gender or age influence this relationship and if a sub-type of voluntary physical activity is more efficient to maintain these physical parameters. objectives: to assess the association between current physical activity level or type and functional capacities and body composition among elderly people and to examine if age (< or >= yrs old) or sex modulate the relationship. methods: functional capacities using different validated tests (i.e. grip strength, timed up and go, sit-to-stand, muscle power, alternate step test, leg extension, vo max), body composition (fat & fat-free masses) using dxa were assessed. current global (total) and specific (aerobic, resistance or body and mind) physical activity levels (duration) were obtained through a questionnaire. multiple regressions, adjusted on age, sex and bmi, were performed to assess the relationship between current physical activity level and functional capacities or body composition. sub-group analysis, according to the sex and age (< y vs. >= y) were also performed by means of pearson correlations. results: a total of subjects ( . ± . years; women: . %; bmi= . ± . kg/ m²) were enrolled. after adjustment on confounding factors, total current physical activity level has positive impact on total fat mass (%; β=- . , p= ) and balance (β= . ; p= . ). moreover, current body & mind activities influence total fat-free mass (kg; β=- . , p= . ) and balance (β= . ; p= . ) whereas resistance activities influence fat-free mass (kg; β= . ; p= . ), fat mass (%; β=- . ; p= . ) and sitto-stand test (β=- . ; p= . ). sub-analysis shows that total physical activity level was significantly associated with fat mass, sit-to-stand test, balance and vo max in women but not in men. moreover, among people under y, the time spent on cardio activities does not affect functional capacities and body composition. nonetheless, among people aged y and over, the time spent on resistance activities is associated with functional capacities and body composition. conclusion: being active is associated with body composition and functional capacities, especially among women aged years and over. itxaso mugica-errazquin , nagore arizaga , janire virgala , julen gomez , garbiñe lozano , yune aranburu , udane elordi , maider kortajarena , ana rodriguez-larrad , jon irazusta ( ( ) background: low physical fitness, frailty and dependency are highly prevalent in people living in long term nursing homes (ltnh). multicomponent physical exercise, including strength, balance and endurance, has demonstrated to be effective for improving physical fitness and reducing frailty in ltnh. however, there is no evidence that this type of programs are capable to improve or even maintain the levels of autonomy in activities of daily living (adl) of this population. objectives: the major aim is to ascertain whether a new approach of months, individualized and progressive multicomponent program focused on functioning maintains autonomy in older adults living in ltnhs; the secondary aim is to assess the effects on frailty and physical fitness. methods: people living in ltnh, between and years, participated in this single group interventional study. inclusion criteria were: >= years, >= barthel index, >= mec- and be able to stand up from a chair and walk meters with or without one person/technical assistance. the intervention consisted of months of a progressive multicomponent physical exercise program (ep) aiming to improve the physical condition, followed by months of physical exercises focused on functional adl with the objective of maintaining/improving autonomy of the participants. barthel index was used to assess autonomy level in adl, frailty was measured by fried frailty index and short physical performance battery (sppb) was used to assess physical fitness. the study is registered in u.s clinical trial (nct ) and approved by the committee on ethics in research of the university of the basque country (m / / ). results: during the first months of ep participants lowered the score in the barthel index (p< , ). however, participants showed significant improvements in frailty (fried frailty index p< , ) and in physical fitness (sppb p< , ) . from the rd to th months, while physical fitness of participants did not change, they improved autonomy in adl, and decreased frailty non-significantly. when comparing the effects of the entire intervention, barthel index did not change significantly and physical fitness and frailty improved (sppb p< , ; fried p< , ). conclusion: this new approach of months of individualized and progressive multicomponent program focused on daily functioning maintains autonomy in activities of daily living, improves physical fitness and reduces frailty in older adults living in ltnhs. shuji sawada , hayao ozaki , , toshiharu natsume , daiki nakano , pengyu deng , toshinori yoshihara , takuya osawa , shuichi machida , hisashi naito (( ) juntendo university, chiba, japan; ( ) tokai gakuen university, aichi, japan; ( ) japan women 's college of physical education, tokyo, japan) background: in previous study, we found that low-load resistance training using own body weight and elastic band even only biweekly could induce muscle hypertrophy in older adults after weeks of training. however, it is unclear whether levels of different blood parameters before training associated with the effects of training. objectives: this study aimed to clarify whether levels of different blood parameters before training influenced the effect of low-load resistance training on lower limb muscle thickness (mt). methods: sixty-nine communitydwelling japanese subjects aged . ± . years ( women and men) volunteered for this study and participated in a lowload resistance training program using their own body weight and elastic band. the training was performed biweekly for weeks. each participant's mt at the anterior aspects of the thigh (at) was measured using a b-mode ultrasound device. further, the levels of the following blood parameters were assessed before and after the training program: serum albumin (alb), hemoglobin (hb), total cholesterol (tc), and hemoglobin a c (hba c). we checked the first quartile value of each blood parameter to establish the cutoff criteria for reduced levelsserum alb = . g/dl, hb = . g/dl, tc = mg/dl, and hba c = . %. participants were divided into low or normal groups in each blood parameter, and their data were analyzed using two-way analysis of variance. results: when using the abovementioned criteria, biweekly low-load resistance training increased mt at the at in every group after training. the interaction between time and groups was only detected with low (< . g/dl) versus normal (>= . g/dl) serum alb levels. in this case, there was no difference in mt at the at before training, but participants in the normal serum alb level group had greater mt after training than those in the low serum alb level group. conclusion: the effect of low-load resistance training on lower limb mt appears to be limited in participants with low pre-training serum alb level. objectives: it was to estimate the affect of complex -week treatment with kinesiotherapy methods on body weight loss and muscle function in patients with obesity. methods: men and women aged - years old with alimentary obesity were enrolled in the study (mean age . ± years, weight . ± . kg, bmi . ± . kg/m , waist circumstance wc . ± cm, hip circumstance hc . ± cm). the complex kinesiotherapy administered daily for week and included interactive sensorimotor trainings on double unstable platform, kinesiohydrotherapy in a pool, special complex of physical exercises in a gym and ergocycle trainings. weight, wc, hc, fall number for last weeks were measured at baseline and after the treatment was completed. muscle strength and walking speed functional tests results assessment ( -meters-walk test, up-and-go test, special tests for back and abdomen muscle endurance to static and dynamic loading) were performed at baseline and in weeks. results: there was a significant reduction in body weight ( . ± . kg at baseline vs . ± . kg in weeks; p= , ), in bmi ( . ± . vs . ± . kg/m ; p= . ), in wc ( . ± . vs . ± . cm; p= . ) and in hc ( . ± . vs . ± . cm; p= . ) in treated obese patients. -meters-walk speed increased from . ± . m/sec at baseline to . ± . m/ sec in weeks (p= . ). up-and-go test results improved from . ± . to . ± . sec (p= . ). we registered statistically significant elevation of the endurance to static loading in abdomen muscles from . ± . to . ± . sec (p= . ) and in back muscles from . ± . sec to . ± . sec (p= . ). the endurance to dynamic loading increased in abdomen muscles from . ± . to . ± . times (p= . ) and also in back muscles from . ± . to . ± . times (p= . ). fall namber markably decreased from . ± . at baseline to . ( %ci: . ; . ) after completion of treatment. conclusion: investigated complex treatment with kinesiotherapy methods promotes body weight loss, wc and hc reduction in obesity. -week special training of obese patients is associated with increasing in gate speed and lower extremities muscle strength, and it also causes improvement in static and dynamic loading endurance of back and abdomen muscles. those changes may probably improve balance function and decrease risk of falling in obese patients. thaiana pacheco, candice medeiros, rummenigge dantas, inae c. gadotti, edgar r vieira, fabrícia costa cavalcanti (department of physical therapy, florida international university, miami, usa) background: integrating technological advances into clinical practice can be challenging. physical therapists have been developing serious games/exergames for a variety of rehabilitation purposes, but uptake has been slow. games with virtual scenarios are an engaging and affordable way to encourage and increase physical activity levels. serious games have been developed to adapt virtual gaming environments to patients' needs and evolving capabilities. games can improve adherence and therapy effectiveness. the sensory and motor stimulation while playing serious games can help geriatric rehabilitation to improve mobility and balance. objectives: this study analyzed the effects of a new serious game on the balance of older adults. methods: this was a pilot quasiexperimental design study in which older adults completed six sessions of dynamic balance training using the virtualter serious game that uses the kinect sensor for motion capture. this game was developed by researchers from the federal university of rio grande do norte in brazil. the game consists of static and dynamic tasks for training balance. it involves stationary walk, lateral reaching and climbing steps up and down. it has phases with increasing the level of difficulty. the participants were evaluated before and after the program using the berg balance scale (bbs) and the short physical performance battery (sppb). t-test for dependent samples was used to analyze the pre vs. post data. results: twenty three participants participated in the study (age = ± ; sex = % women). the results indicate improvement in bbs scores (pre: ± ; post: . ± ; p = . ) and sppb scores (pre: ± ; post: ± ; p = . ). conclusion: playing the virtualter serious game improved balance in older adults. helen chan , duncan wong , cindy fan (( ) the nethersole school of nursing, the chinese university of hong kong, hk; ( ) silver yoga lab, hk) background: evidence showed that both frail and prefrail significantly increase the risk of developing or worsening disability in activities of daily living, poor quality of life and institutionalisation. yoga has been consistently reported as effective intervention in improving physical functioning in terms of balance, lower limb strength, mobility and body flexibility. objectives: to assess the feasibility of silver yoga in older adults and to examine the preliminary effects of silver yoga on their physical health. methods: this was a one group pre-test post-test study conducted in a community centre. people who aged and above, were mentally competent, home-living, and classified as prefrail based on physical phenotypes using fried criteria, were eligible to the study. the silver yoga class included eight . -hour weekly sessions delivered by two experienced yoga instructors with specialized training in silver yoga. senior fitness test (sft) was conducted to assess changes in physical health. paired t-test was used to compare the within-subject differences across -month time. results: a total of older adults were recruited. there were significant improvement in six dimensions of the sft, including upper extremity muscle strength, lower extremity muscle strength, upper body flexibility, lower body flexibility, agility and dynamic balance, and aerobic endurance (ps < . ). all participants except one completed the yoga programme, with high level of satisfaction. in addition to the effects of physical conditions, the participants also appreciated it as mind-soothing and relaxing. conclusion: the findings showed that silver yoga is well-received by older adults generally, with significant effects in improving their physical fitness. more rigorous study is needed to examine its effects in a longer term and also in a more holistic manner. ku leuven, leuven, belgium; ( ) physical activity, sports and health research group, department of movement sciences, ku leuven, leuven, belgium) background: with aging skeletal muscle tissue becomes less responsive to anabolic stimuli, eventually contributing to muscle wasting. inflammation is considered an important player in this age-related anabolic insensitivity. recent reports provide a promising role for omega- polyunsaturated fatty acids (ω- ) in (muscle) health, as they possess systemic anti-inflammatory properties and stimulate muscle anabolic signaling. objectives: we investigated whether ω- supplementation improves the systemic inflammation and muscular adaptations (i.e. strength, mass, molecular signaling) to resistance exercise in an elderly population. methods: twenty-three elderly ( - y; ♀) were randomized to receive either ω- (~ g/d) or an isocaloric amount of corn oil (plac) during weeks. after two weeks of supplementation, participants engaged in resistance exercise (re; x/week) for weeks. prior to and after completion of the intervention, muscle and blood tissue, parameters of body composition, muscle strength and functionality were assessed. results: upon re, -rm significantly improved in plac (+ . %) and in ω- (+ . %), irrespective of condition. isometric strength significantly improved in ω- (+ . %), but not in plac (- . %). muscle volume did not change following re. plasma crp levels decreased, though not non-significantly, in ω- (- . %), whereas only a small increase was observed in plac (+ . %). ω- supplementation nor re affected the muscle anabolic sensitivity (akt phosphorylation) in response to a protein bolus. conclusion: this study confirms that ω- pufas improve the gains in isometric but not in dynamic muscle strength upon re in elderly. however, this was not associated with changes in anabolic sensitivity or systemic inflammation. further analyses will investigate whether the ω- induced gains in strength can be related to systemic hormones or muscle molecular signaling (mtor signaling, inflammation). meera suresh, clarence chikusu, caroline goodger (nutrition and dietetics, st. peter's hospital, chertsey, uk) background: deconditioning is a common phenomenon in patients over years old in acute settings. it is well known that poor nutritional status has a major impact on adverse outcomes in frailty and can exacerbate sarcopenia ( ). currently, there is limited research exploring the impact of dietitians on optimising nutritional status in acute settings in older populations for frailty and sarcopenia. objectives: compare the impact of dietetic intervention on the change in frailty scores between a patient group (n= ; mean age . years) who received dietetic intervention (di) and a patient group (n= ; mean age . years) who did not receive dietetic intervention (ndi). methods: a -month retrospective study (august-december ) was undertaken at the older persons short stay unit at a district hospital in england. frailty scores were calculated based on the rockwood model of clinical frailty. dietary intake was recorded and analysed using a standardised nutritional profile of hospital meals. the di group was given standardised dietetic care including oral nutrition support and build up dietary advice. descriptive statistics were used to determine frequencies. results: the di had higher frailty scores (mean of . ; range: - ) and a higher mortality rate ( %).the ndi had a mean score of . (range: - ) and mortality rate of %. the average oral intake for energy and protein for patients in the di group prior to dietetic intervention was % lower than the espen recommendations. despite the higher frailty scores and mortality rates in the di group, progression in their frailty score was slower compared to the ndi group ( % vs %). conclusion: the results highlight the importance of a timely referral for early dietetic intervention which is crucial for optimisation of better clinical outcomes in these patients. a dietitian is a key member of the mdt and can prevent further deterioration in muscle mass and the impact on patients' frailty and independence and also slow down the progression of sarcopenia and frailty. this has long term impact on health and social services by reducing length of stay, hospital re-admissions and the increasing burden on social care. uz leuven, leuven, belgium) background: while the protein recommended dietary allowance (rda) for healthy adults is . g protein/kg bodyweight (bw)/day (d), expert groups recommend a protein intake up to . g protein/kg bw/d for older people with chronic diseases. in addition, at least - g protein (whereof at least . g of leucine) is recommended per meal. objectives: we aim to assess in (pre)sarcopenic older people the daily energy and protein quantity and quality intake, and their change due to supplementation. methods: dietary protein quantity, and quality (plant/animal source, amount of amino acids, amount of leucine and leucine distribution over a day) and dietary energy intake were calculated from four day estimated dietary records of (pre)sarcopenic participants of the enhance study (clinicaltrials.gov nct ) before and after a -week supplementation period. participants received an individualized protein supplement (resource® instant protein, nestlé) , to achieve a total (dietary + supplemental) intake of . g protein/kg bw/d. results: (pre)sarcopenic adults ( . ± . years, % female) had an average dietary protein intake of . ± . g/kg bw/d, which is higher than the rda, but below the . g/kg bw/d recommended by experts. (pre)sarcopenic adults were supplemented with protein powder, which improved the total protein intake to . ± . g/kg bw/d without affecting dietary protein or energy intake. moreover, supplementation increased the protein intake to at least g protein/meal without affecting dietary intake. more than % of dietary protein intake was of animal origin. leucine intake at baseline was insufficient at all meals, but increased to at least . g at lunch and dinner by supplementation without affecting dietary leucine intake. conclusion: community-dwelling (pre)sarcopenic older people do not reach the recommended protein intake proposed by expert groups. individualized protein supplementation results in adequate intake of protein without substantial change in dietary intake. nutrition and dietetics, internal medicine, amsterdam university medical centers, amsterdam, the netherlands) background: weight loss is a main treatment goal in obese older adults with dm . combined lifestyle interventions (cli) may be more effective in preserving muscle mass during weight loss. whether severe obese benefit similar to less obese is unknown. objectives: our probe-study showed an increase in muscle mass during cli in obese older adults ( +) with dm . do severe obese (bmi > kg/m ) benefit similarly to less obese. methods: in a post-hoc analysis, out of enrolled older adults had both body weight and protein intake data before and after a -month cli consisting of dietary advice (- kcal/day) and resistance exercise. a selection of assessments were appendicular skeletal muscle mass (asmm, by dxa), physical performance (wmax; by cycle ergometer steep ramp test), quality of life (rand- physical component summary score (pcs), visceral adipose tissue (vat, by dxa), crp, insulin sensitivity and resistance (matsuda, homa-ir; by ogtt), blood pressure (sbp, dbp). linear regression analysis was used with protein intake (g/kg, except for asmm being included in kg) as independent and assessments after -months as dependent (with assessment before intervention as confounder) for both groups bmi> (severe obese n= ) and bmi<= (n= ). results: mean age was , mean bmi was . , sex m/ f and protein intake during intervention was + gram/day. mean weight loss was - . + . kg and fat loss - . + . kg. per g protein intake increase + g muscle was preserved (p= . ). however, this appeared + (p= . ) vs + g (p= . ) for severe obese vs not severe obese. severe obese showed higher response for wmax (+ . + . (p= . ) vs - . + . ) and pcs (+ . + . (p= . ) vs - . + . ), for vat (- . + . (p= . ) vs + . + . ) and crp (- . + . (p= . ) vs + . + . ), for insulin sensitivity (matsuda + . + . (p= . ) vs + . + . ) and insulin resistance (homa-ir - . + . (p= . ) vs + . + . ), sbp (- . + . (p= . ) vs - . + . ) and dbp (- . + . (p= . ) vs + . + . ). while whole group and not severe obese group showed no significant effect. conclusion: these results suggest that severe obese might benefit even more from combined lifestyle intervention compared to less obese older adults with dm . further investigation is needed to confirm these findings and identify potential mechanisms. background: nutritional interventions have been shown to stimulate muscle protein synthesis. to optimize muscle mass preservation and gains, several factors, including type, dosage, frequency, timing, duration and compliance have to be considered. objectives: this systematic review and meta-analysis aimed to summarize these factors influencing the efficacy of nutritional interventions on muscle mass in older adults. methods: data sources: a systematic search was performed using the electronic databases medline, embase, cinahl, cochrane central register of controlled trials and sportdiscus, from inception date to nd november , in accordance with the prisma guidelines. inclusion criteria included randomized controlled trials, mean/median age >= years and reporting muscle mass at baseline and post-intervention; exclusion criteria included genetically inherited diseases, anabolic drugs/hormone therapies, neuromuscular electrical stimulation, chronic kidney disease, kidney failure, neuromuscular disorders and cancer. data extraction: extracted data included study characteristics (population, sample size, age, sex), muscle mass measurements (method, measure, unit) , effect of the intervention versus the control group, and nutritional intervention factors i.e. type, composition, dose, duration, frequency, timing and compliance. data analysis: standardized mean differences and % confidence intervals were calculated from baseline to post-intervention for the intervention and control group. a meta-analysis was performed using a random-effects model and grouped by the type of intervention. results: twentyeight articles were included encompassing participants (mean age . years, sd . ). amino acids, creatine, betahydroxy-beta-methylbutyrate, and protein with amino acids supplementation significantly improved muscle mass. no effect was found for protein supplementation alone, protein and other components, and poly-unsaturated fatty acids. high inter-study variability was observed regarding the dose, duration and frequency, coupled with inconsistency in reporting timing and compliance. conclusion: overall, nutrition alone is an effective intervention to improve muscle mass in older adults. due to the substantial variability of the intervention factors among studies, the optimum profile is yet to be established. background: physical and functional capacities decline with age. one new potential intervention is oral citrulline supplementation (cit) since cit seems to increase muscle protein synthesis, mass, size and strength, improve mobility but also decrease adipose tissue mass, particularly visceral depot in old rats. furthermore, exercise is known to be another efficient intervention. however, studies assessing cit supplementation combined or not with exercise on muscle function and mobility in older human adults are emerging and literature conclusions are needed to help health professionals. objectives: establish the potential effectiveness of citrulline supplementation combined or not with exercise on muscle function and physical performance via a systematic review of randomized controlled trials (rcts) in human aged years and older. methods: the preferred reporting items for systematic reviews and meta-analysis (prisma) statement has been followed. medline, cochrane central register for rcts and scopus databases have been searched. studies selection and data extraction have been performed by two researchers independently. methodological quality of each included studies was assessed using the quality assessment of diagnostic accuracy studies- (quadas- ) tool. results: based on prisma guideline, references have been identified. among this number, only rcts ( participants) matched the inclusion criteria (e.g rcts, age> yrs, human, cit supplementation, muscle or physical parameters) and were included in the systematic review. among these studies, / reported beneficial effects of cit on muscle mass. effects on muscle strength is reported on / studies but when cit is combined to exercise better improvements in upper muscle strength are observed. finally, / studies reported beneficial effect of cit on physical performance but suggested that cit with exercise displayed greater improvements in walking speed than exercise or cit alone. the overall quality of studies was rather high. conclusion: cit supplementation seems able to improve muscular and physical factors in specific elderly people (malnourished, women, hypertensive, obese, dynapenic-obese) compared to placebo. more importantly, cit with exercise is more efficient than exercise or cit alone. however, due to the small number ( ) and heterogeneity (dose, duration, population) of the studies, further investigations are needed to confirm its promising intervention for health professionals. background: the medical nutrition supplement fortifit (r), containing the specific nutrient combination actisyn™, is designed to support muscle building in sarcopenia (muscle loss). actisyn (whey protein, leucine and vitamin d) provides high bioavailability of leucine and essential amino acids for the muscle; the nutrients in actisyn act together to optimize the muscle protein synthesis response in a state of sarcopenia where these nutrients are often deficient. preclinical and acute human studies confirmed this mode of action. objectives: to demonstrate the longer-term effects of fortifit supplementation on muscle building in healthy and sarcopenic older adults and on muscle preservation in obese (diabetic) older adults during a weight-loss lifestyle intervention. methods: our clinical research program investigated the effects on muscle mass, strength and function in healthy and sarcopenic older adults and in obese and type diabetic patients. muscle mass was measured by dexa; strength and function by handgrip strength, -times chairstand test and short physical performance battery (sppb). all studies were randomized-controlled trials with an intervention duration of to weeks. results: a significant increase in appendicular lean mass and leg lean mass was observed in healthy older adults after weeks supplementation (p< . vs non-caloric control) [chanet, jnutr ]. in sarcopenic older adults, -week intervention increased appendicular lean mass ( . kg, %ci . - . kg; p= . vs iso-caloric control) [bauer, jamda ] . moreover, during a -week lifestyle intervention of energy restriction and resistance exercise training in obese older adults with or without type diabetes, fortifit preserved appendicular lean mass (p< . vs iso-caloric control) [verreijen, ajcn ; memelink, clin nutr ] . a significant improvement was observed in chairstand time after -week intervention in sarcopenic older adults (- . s, %ci - . to - . s; p= . vs isocaloric control), but improvements in handgrip strength and sppb (primary outcomes) were only significant versus baseline (p< . ) and not versus control [bauer, jamda ] . conclusion: the medical nutrition supplement fortifit effectively supports muscle building in healthy, sarcopenic and obese older adults. moreover, the improvement in chair-stand time observed in sarcopenic older adults is clinically relevant. background: chronic kidney disease (ckd) is commonly found in older persons and it affects the quality of life and economic burden. knowledge and health literacy have been reported as fundamental factors for persons with chronic illness to perform health behavior. however, from a literature review, relationships among knowledge, health literacy, and health behavior in older persons with non-dialysis ckd have rarely been reported. objectives: to examine relationships among knowledge, health literacy, and health behavior in older persons with chronic kidney disease. methods: nutbeam's conceptual framework of health literacy was used to guide the study. the sample recruited by purposive sampling consisted of older persons with non-dialysis stage to ckd, who sought healthcare services at a ckd clinic in a university hospital, thailand. data were collected by interviews using the questionnaires about the demographic data, knowledge about care of ckd, health literacy, and health behavior of older persons with ckd and then were analyzed using descriptive statistics and spearman's rho correlation coefficients. results: the sample consisted of men and women with their age ranging from to years (m = . , sd = . ). the analysis revealed that the sample had the mean scores of total knowledge about care of ckd, health literacy, and health behavior at a high level. health literacy was positively associated with health behavior (r = . , p = . ), but knowledge about care of ckd was not significantly associated with health literacy (r = . , p = . ), nor health behavior (r = . , p = . ). conclusion: only health literacy was significantly positively related to health behavior. although knowledge is fundamental of health literacy, it was not significantly related to health literacy nor health behavior in this study. it is explained that health literacy is the ability and skills that might link knowledge of individuals to perform behaviors. thus, healthcare providers should find strategies for enhancing health literacy of older persons with ckd to promote appropriate health behavior, thereby delaying complications. background: handgrip strength (gs) is linked to the vitality domain of the intrinsic capacity (ic) construct and is a marker of sarcopenia and frailty. low gs is a predictor of adverse health outcomes like disability onset and mortality. small increases in gs have been reported after exercise interventions, suggesting that life-course determinants rather than short-term determinants influence gs. objectives: to assess social inequality in the distribution of gs and the association of gs levels with a proxy of social determinants of health (sdh) among adults and older adults. methods: secondary analysis from wave ( - ) of the world health organization (who) study on global ageing and adult health (sage), which is nationally-representative of six countries, including , participants aged >= years and , < y. gs was computed in kg. wealth quintiles were assigned according to ownership of household assets. the last level of education of the participant and his/her mother was self-reported (the latter was used as a marker of early life sdh). social inequality was estimated using pairwise comparisons among the average of gs of the extreme social groups; and gradient inequality by the slope index of inequality (multivariate linear regression to adjust for age, sex, body mass index). estimations were weighted to consider the complex design of the sample. results: average gs was . kg for participants >= y and . kg for < y. participants >= y who reported a postgraduate level of education or higher showed % ( . kg) higher gs than their illiterate counterparts ( %, . kg, for participants < y). gs was on average % higher in participants >= y in the most top wealth quintile compared to those in the lowest quintile ( % in < y). in the multivariate models, gs was . kg higher in urban than rural participants and . kg higher among participants whose mothers had completed >= years of education compared to those whose mothers were illiterate. slope coefficients were significant after controlling for confounders. conclusion: grip strength displayed an unequal distribution among social groups and also among groups of early life exposures, which suggests that vitality as a domain of ic is shaped by the sdh and built through the life course. background: intrinsic capacity (ic) is the composite of the physical and mental abilities of an individual. the distribution and correlates of ic in older adults (oa) have not been reported using an integrative score with routinely-collected clinical data. it is not clear how ic is associated with multi-systemic biochemical age-related processes captured by alterations in standard clinical laboratory tests. objectives: to describe the distribution and correlates of ic in a population of older adults from the frailty day hospital of toulouse and to test its cross-sectional association with low or high haemoglobin or high crp, accounting for frailty status. methods: using routinely collected cross-sectional data of , first visits of oa aged + to the frailty day clinic of toulouse ( - ), we calculated an index of ic (biomarkers and validated scales for five who domains). low/high haemoglobin levels or high crp levels served as indicators of acute and middleterm multisystem disruption. we used descriptive statistics to learn the distribution of ic across sex, age, education and fried frailty categories. multivariate linear models were used to test the hypothesis that higher ic holds a negative association with the multi-system deficits depicted by altered laboratory tests. results: % of the population was female, and % was frail. our ic score has theoretical limits ( - ). overall, the ic was: mean= . ,sd= . ,min= . , max= . . on average ic men scored . (ic % . , . ) and women . (ic % . , . ). the relationship found between ic and age was not linear. frail older adults displayed % less ic than their robust counterparts and % less ic than their pre-frail counterparts. if frail oa would return to robust in this population, the average ic would potentially* rise %. disruption in haemoglobin or crp was inversely and significantly associated with the ic score after adjusting for age , sex, level of education and fried frailty status. conclusion: the population attending the toulouse frailty clinic displayed highly-heterogeneous ic levels, with frail oa showing significantly lower levels than robust oa. the association between ic and age is not linear. sex, age, education, frailty status and disruption in haemoglobin or crp levels were all significantly associated with ic in a multivariate model. background: older persons tend to be hospitalized increasingly because of the complex interaction among acute problems, age-related changed, and chronic diseases. qualified nursing care needs knowledge, understanding, and a positive attitude towards the care of older persons. however, little is known factors predict the caring behavior of nurses to care for hospitalized older persons. objectives: to examine the predictability of selected factors to explain intention to care and caring behavior for older persons of professional nurses. methods: the theory of reasoned action was used to guide the study. the proportionate stratified random sampling was used to recruit a sample of professional nurses from clinical wards providing care for older patients in a university hospital. data were collected using questionnaires and then, analyzed with descriptive statistics, pearson's product-moment correlation, and multiple regression analysis with the enter method. results: almost all of the sample were female, with their age ranged from to years (m = . ). factors related to professional nurses' intention to care were perceived caring climate in organization and attitude toward caring for older persons. also, factors related to caring behavior for older persons were perceived caring climate in an organization, intention to care, and attitude toward caring for older persons. through multiple regression analysis, perceived caring climate in an organization, attitude toward caring older persons, and basic knowledge about older persons jointly predicted . % of the variance in intention to care. together, perceived caring climate in an organization, intention to care, attitude toward caring for older persons, and basic knowledge about older persons accounted for . % of the variance in caring behavior for older persons of professional nurses. the perceived caring climate in an organization was the strongest predictor of caring behavior, whereas basic knowledge about older persons was not a significant predictor. conclusion: the findings support the notion of the theory of reasoned action. it is suggested that strategies to promote perceived caring climate in an organization, attitude toward caring for older persons, and intention to care should be established and maintained to promote caring behavior for older persons of professional nurses. background: environmental and social conditions play a major influence in the development and progression of negative health-related outcomes. they represent crucial elements when taking clinical decisions and planning the care plans of frail patients. nevertheless, they still often remain overlooked because priority is given to the clinical manifestations. objectives: the aim of this study is to explore the importance of social support in the definition of major health-related outcomes among hospitalized patients compared to other critical factors of older persons (i.e., frailty, age). methods: data were retrospectively collected from the medical records of patients aged years and older admitted to the geriatric unit of the fondazione irccs ca' granda ospedale maggiore policlinico (milan, italy). a -items frailty index (fi) was computed from clinical variables recorded during the first days of hospitalization (i.e., medical history, cognitive, functional and social assessment, physical examination, laboratory tests). mortality, length of hospital stay above the median, and risk of institutionalization were the outcomes of interest. results: we included patients (mean age . , sd . years, women . %). six patients died during the hospital stay ( . %). the median duration of hospital stay was (iqr - ) days. twenty-seven patients were discharged to other institutions ( %). the mean fi was . (sd . ). the fi showed a statistically borderline association with mortality (or . , % c.i. . - . , p= . ), and was predictive of longer length of stay (or . , % c.i. . - . , p= . ), even after adjustment for confounders. the presence of a caregiver was the only factor significantly associated with the discharge at home of patients (or . , % c.i. . - . , p= . ) at the multivariate analysis. age had no significant association with the three studied outcomes. conclusion: health systems should be organized according to an integrated model of care in order to adequately address the complex health needs of older people. social and environmental context plays a critical role in determining the person's health trajectory. social factors (as the presence of a caregiver) may play a stronger role in clinical decisions than biological or clinical aspects. background: the acute therapy team was formulated after the integration of an older persons assessment and liaison team (opal) with medical ward therapists. the team was spread across all acute areas. this team worked closely with the acute geriatric and frailty clinical team and it was recognised that length of stay, and improved patient experience and overall outcomes would be improved with earlier assessment and cga planning at the front door allowing closer collaborative working between the clinicians and therapists. objectives: to enhance service improvement and prevent the impact of sarcopenia and frailty syndromes leading to greater hospital stay and disability as a consequence of a delay to assessment by clinicians and therapists in the acute setting. through the screening of frailty syndrome risk and sarcopenia risk patients by the ed geriatrician and junior doctor, there would be a speedier response to therapy led interventions thereby reducing the conversion rate from ed and also therefore improving overall outcomes in length of stay and reduced disability through prolonged hospital stay. methods: consultant geriatrician and junior doctor (opssu team) to go to the emergency department in the mornings and see up to patients in cdu/a&e beds; the use of a the rockwood frailty score template identified those patients at risk of frailty syndrome and likely to benefit from early therapy intervention. these patients would have been highlighted as having the potential to be discharged within hours. a month data collection period from was chosen with data collected monday to friday only. data examined was categorised as follows: new patients, follow-ups; how many patients were seen on day of ed attendance vs after day of attendance?; number of patients seen by therapists same day of ed attendance number of patients not seen by therapists day of attendance; which team was looking after the patient from a clinically; how much time spent with patients; therapy led plan after initial assessment; an integrated assessment too was instrumental in the cga component of the therapy and clinical assessments. results: % of patients seen by therapists in ed are new patients referred. % of patients referred are seen on the actual date of ed attendance. the rest are seen later admission episode. % of therapy time is spent doing non-face to face tasks such as documentation. but up to % of patients have a discharge plan put in place after being seen by therapists in the ed. conclusion: a great deal of time is spent by therapists on documentation during assessment. this has a negative impact on the amount of time dedicated to clinical assessments and physiological and functional assessments required in the cga. there is a large number of patients referred by the clinical team to the therapists for review but a majority of patients are seen elsewhere during an admission episode and not in the ed. streamlined assessments and screening tools are recommended & planned for the future model of care. yi-chun cheng , li-ning peng , (( ) center for geriatrics and gerontology, taipei veterans general hospital, taipei, taiwan; ( ) aging and health research center, national yang ming university, taipei, taiwan) background: older people with frailty are at risk of adverse outcomes, such as falls, disability, hospital admission, long term care placement, poorer quality of life, and mortality, which denotes the importance of sarcopenia in the health care for older people, and integrated intervention program may prevent those. objectives: to evaluate the effectiveness of an integrated intervention program among those communitydwelling frail older people in north taiwan. methods: a total of participants over years old mild to moderate disability and mild cognitive impairment persons were recruited from a community-dwelling frail older people in north taiwan during august and july , frail older people were invited for the study. a weeks integrated intervention program was provided for all participants. they attended the hours program once per two weeks and physical activity, high protein diet education, and cognitive stimulation activity were included in the integrated intervention program. comprehensive geriatric assessments were performed before and after the intervention program, including basic demographic data, risk for malnutrition (by mna-sf), mood condition (by gds- ), cognitive condition (by mmse), weakness (by handgrip strength), exhaustion (by self-report in chs) slowness (by gait speed) and time-up-go test. pretest on the st week before intervention and post-test on the th week to compare the difference between twice evaluate consequence. results: overall, participants were identified as having pre-frailty ( . %) and frailty ( background: low appendicular skeletal muscle mass (asm), an integral component of current sarcopenia definitions, is commonly measured using bioimpedance analysis (bia). bia equations for estimation of asm are not generalizable across population groups and instrument types, potentially giving rise to inaccurate results when applied inappropriately. there is a lack of bia prediction equations for asian populations, none of which have been developed or validated for singaporean older adults. objectives: to develop a bia prediction equation for estimation of asm in communitydwelling older singaporean adults. methods: we studied healthy community-dwelling subjects (mean age . years) from the gerilabs- cohort. bia was performed using a single-frequency instrument. the reference method used for asm measurement was dual-energy x-ray absorptiometry (dxa). we first identified independent asm predictors by assessing the correlation of demographic, anthropometric and bia variables with dxa-measured asm. the best-fitting prediction equation was derived from these variables using stepwise (backward elimination and forward selection) linear regression with bootstrap validation. using asian working group for sarcopenia (awgs) cutoffs, we then compared anthropometric, strength and physical performance parameters between normal and low bia-derived asm groups. results: the derived bia equation incorporated predictorsimpedance index, weight, gender and body mass index (bmi), i.e. asm(kg) = . + ( . x impedance index) + ( . x weight) + (- . x gender) + (- . x bmi), where males = , females = and impedance index = height(cm )/resistance. the r and standard error of the estimate of this regression model were . and . kg respectively, with impedance index accounting for . % of its variability. individuals with low bia-derived asm have significantly smaller mid-arm and calf circumference and weaker grip strength, compared to individuals with normal bia-derived asm (p< . ). physical performance was similar in both groups. conclusion: we have developed a valid single-frequency bia prediction equation which can provide good estimates of asm in communitydwelling older singaporean adults. validation of this prediction equation in an independent sample of population is required to establish its accuracy and precision. ( ) faculty of sport sciences, waseda university, tokorozawa, japan) background: it has been well known that appendicular lean mass (alm) and skeletal muscle mass index (smi), which is the ratio of alm to height (m), is positively proportional to regional bone mineral density (bmd) in elderly men. however, there is limited information about these relationships in middleaged men. objectives: the purposes of this study were to investigate the difference in bmds (arms, lumbar spine, pelvis, legs, and subtotal: total body without head area) in middleaged men with low and normal smi (alm/height ≤ . kg/ m from asian working group for sarcopenia: awgs), and to determine the associations between alm, smi, and bmds. methods: three hundred and two middle-aged japanese men between and years of age participated in this study. alm and bmd measurements were taken using dual-energy x-ray absorptiometry (dxa, delphi a-qdr, hologic). results: based on the definition from awgs, the prevalence of low smi was approximately % in middle-aged men. the subjects with low smi (low smi group, n = , . kg/m ) had significantly lower body weight ( . vs. . kg), bmi ( . vs. . kg/m ), and fat mass ( . vs. . kg) compared to the normal group (n = , . kg/m ), although there were no differences in age ( vs. years), standing height ( . vs. . cm), and body fat percentage ( . vs. . %) between the two groups. bmds were significantly lower in low smi group than normal group for regional body parts (arms . vs. . g/cm ; lumbar spine . vs. . g/cm ; pelvis . vs. . g/cm ; legs . vs. . g/cm ) and subtotal ( . vs. . g/cm ). moreover, body weight, fat mass, alm, and smi were positively correlated with bmds using partial regression analysis controlling for age in all subjects, except for fat mass vs. lumbar spine bmd. in a stepwise multivariable model, alm was more closely related to bmds, except in the case of pelvis. conclusion: these results suggest that in order to maintain the regional bmd in middle-aged men, a key factor is to maintain or increase both alm and smi. background: the societies on sarcopenia have recently accepted the use of bioelectrical impedance analysis (bia) in the assessment of appendicular skeletal muscle mass (asm). several bia equations and devices have been introduced, which analyze the whole body composition, including the trunk and excluding the left arm and left leg at khz. it is necessary to measure the appendicular body segments of impedance parameters with a specific frequency (hz) that optimally analyze the muscle for valid assessment of asm. prior our study, literature-based bia equations and the two devices estimated asm at > % of r (coefficient of determination) with the significant constant-errors rated as «poor». objectives: thus, the aims of this study were ( ) externally cross-validate the equations and devices of bia on the appendicular skeletal muscle mass and ( ) develop valid equations based on appendicular bioimpedance parameters at the specific frequency (khz) that reflects the muscle for estimating asm; methods: community dwelling koreans over -year-old ( + . yrs, females and males) participated. asm was predicted using bia-based equations available in literature and bia devices and compared to dxa outcomes which is the gold standard. we conduct internal cross-validation and stepwise multiple linear regression to develop asmformulas with segmental multi-frequency bias. results: our new prediction formulas were developed by the appendicular impedance(z) index = height / (z of right arm + z of left arm + z of right leg + z of left leg)) at higher than khz and the appendicular reactance(xc) = xc of right arm + xc of left arm + xc of right leg + xc of left leg at khz. r s were over %, see wes under . kg of asm with the subject rating as «excellent» for men and «good» for women. conclusion: we found that our new protocol resulted in higher agreement with dxa and improved bia accuracy for this specific age group. clinicians can use this lower cost protocol and equations to better diagnose sarcopenia in larger cohorts with comparable to measurement of dxa. background: greater protein intake throughout the lifespan may be related to better body composition through the preservation of lean body mass during aging. objectives: we sought to determine whether an association between dietary protein intake (pi) and body fat percentage (bf) exists among women when controlling for dietary and lifestyle factors. methods: body composition and lean body mass were examined via dual-energy x-ray absorptiometry, grip strength (gs) was assessed using a hand grip dynamometer, and moderate-to-vigorous physical activity (mvpa) was measured by accelerometry. dietary intakes were estimated via threeday food logs and esha software. multiple linear regression and stepwise linear regression models were used. results: a total of women (mean ± sd; age . ± . years) finished all assessments. a full regression model (i.e., containing all covariates; r = . ; adjusted r = . ; f( , ) = . ; p < . ) was created using fat, carbohydrate, protein and leucine intake (g/day), protein quality (g/day of leucine over g/day of protein), energy intake (kcal/day), age (years), lean body mass (kg), bmi (kg/m ), gs (kg), and mvpa (min/day). only bmi (mean ± sem; beta = . ± . ; p < . ), gs (mean ± sem; beta = - . ± . ; p < . ), and pi (mean ± sem; beta = - . ± . ; p = . ) were significant to the full regression model. to verify their importance, a stepwise regression using the same variables was performed and resulted in a model (f( , ) = . ; p < . ; r = . ; adjusted r = . ) that included bmi (mean ± sem; beta = . ± . ; p < . ), gs (mean ± sem; beta = - . ± . ; p < . ), and pi (mean ± sem; beta = - . ± . ; p = . ). conclusion: greater protein intakes are associated with lower bf in women when controlling for various covariates. we theorize that greater protein intakes preserve lean body mass which results in improved body composition. more specifically, a one gram per day increase in dietary protein is predicted to decrease bf by . % when controlling for all other variables. background: muscle aging and the increased prevalence of obesity in the geriatric population create a new area of research: sarcopenic obesity. in prospective cohorts of nonhospitalized subjects, it is associated with an increased risk of developing physical limitation. hospitalization is an event with high risk of loss of independence. the impact of sarcopenic obesity during this episode isn't known yet. objectives: analyze the evolution of functional independence during a hospitalization in an acute geriatric ward, looking for a link between the presence of sarcopenic obesity and a decline of independence. early readmission, length of stay and changes in body composition during hospitalization were also examined. methods: prospective descriptive monocentric cohort study carried out in an acute geriatric ward of the pau hospital. sarcopenia was diagnosed using the european working group on sarcopenia in older people algorithm by an impedancemeter. a bmi over was used to report obesity. functional independence was rated on the adl katz scale. results: patients were included. sarcopenic obesity was diagnosed in . % of cases, sarcopenia and obesity in % and % of patients, respectively. the greatest variation in functional independence during hospitalization was observed in sarcopenic obese patients (mean variation of out of points, p= . ). a total of early readmission at month were counted, with the highest rate for sarcopenic obese ( %, but % at the sample level) (p= . ). the average length of stay was . days. conclusion: sarcopenia is common in patients hospitalized in geriatrics, and when associated with obesity, there is greater variation in functional independence and more readmissions. background: known that is sarcopenic obesity, excessive accumulation of adipose tissue is detected, with a decrease in muscle mass and strength, which is already over the age of years. modern diagnostic methods have their drawbacks for the diagnosis of sarcopenic obesity. bodpod quality and timeliness of diagnosis of signs of sarcopenia in obese patients is improved, which ultimately will contribute to an earlier targeted treatment of sarcopenia and an improvement in its prognosis. bodpod methodology can be recommended for use in complexes for the diagnosis of sarcopenic obesity. objectives: to compare the effectiveness of three methods of body composition assessment such as bioimpedans analysis (bia), air-replacement bodyplatismography (bodpod) and dual x-ray absorptiometry total body program (dxa total body) in the verification of reducing of skeletal muscle mass as sign of sarcopenic obesity in obese patients. methods: the study group included patients aged - y.o. (average age , ± , years) with bmi>= . kg/m . the control group included patients aged - y.o (average age , ± , years) of the same age without obesity with bmi . - . kg/m . body composition was tested using bia, bodpod and dxa with calculating fat, lean and skeletal muscles mass (kg) and % in all the patients. (bodpod) is the most sensitive in the verification of skeletal muscle mass reduction in obese patients. this method shows that patients with obesity have a significantly reduced muscle mass compared with normal weight or overweight subjects. background: in overweight and obesity excess energy and changes in body composition may favor the onset of metabolic derangements. combined with excess adiposity, the age-related decline in lean body mass can accelerate the development of insulin resistance and the consequences in terms of cardiovascular risk. objectives: the aim of our study was to investigate the association between the phenotype of sarcopenic obesity and cardio-metabolic risk in postmenopausal women. methods: postmenopausal women were recruited among subjects admitted to the high specialization centre for the care of obesity (casco), at the sapienza university, rome, italy. fat mass (fm) and fat-free mass (ffm) were assessed by dxa. obesity was defined as body fat >= %. appendicular skeletal muscle mass (asmm) was calculated. sarcopenia was defined as asmm/weight < sd than the sex-specific mean of a young population. the cut-point was asmm/weight< . . the lipid accumulation product was calculated: lap = (waist circumference cm - ) × triglycerides mmol/l]. the estimated glucose disposal rate (egdr) was calculated. high-sensitivity c-reactive protein (hs-crp) was measured. results: women were included (age: . ± . years, bmi: . ± . kg/m ). sarcopenia was diagnosed in . % of study participants. sarcopenic obese women were older than nonsarcopenic women ( . ± . vs. . ± . years, p= . ). lap was higher in sarcopenic obese women compared to their nonsarcopenic counterparts ( . ± . vs. . ± . , p= . ) after adjustment for age, body fat, and hs-crp levels. estimated gdr was significantly lower in sarcopenic obese women ( . ± . vs. . ± . , p= . ) after adjustment for age and body fat. an inverse association emerged between the index of sarcopenia, asm/weight, and lap (beta: - . * - , se: . * - , p= . ), independent of age, body fat, and hs-crp levels. a positive association was observed between asm/weight and egdr (beta: . * - , se: . * - , p= . ) adjusting for age, body fat, and hs-crp levels. conclusion: postmenopausal sarcopenic obese women exibithed a high lap and a low egdr, indicating increased cardiometabolic risk and decreased insulin sensitivity, respectively. l e a t h a a . c l a r k , , , todd m. manini , nathan p. wages , , janet e. s i m o n , , d a v i d w . r u s s , , b r i a n c . c l a r k , , , ( ( ) background: muscle weakness strongly contributes to mobility limitations and physical disability. the role of neural mechanisms contributing to age-related weakness have not been fully delineated to sufficiently target interventions that enhance strength and physical function in older adults. objectives: we sought to compare differences in voluntary inactivation and measures of motor corticospinal excitability in older adults with clinically meaningful muscle weakness compared to young adults and stronger adults without muscle weakness. methods: maximal voluntary isokinetic and isometric leg extensor strength, electrical stimulation of the leg extensors, and transcranial magnetic stimulation (tms) of the motor cortex were performed in older adults and young adults. outcome measures of leg extensor strength relative to body weight, voluntary inactivation (via), motor evoked potential (mep) amplitude and silent period (sp) duration during isometric leg extension contractions at %, %, and % of maximum voluntary contraction (mvc) were obtained. older adults were classified into three weakness groups based on previously established isokinetic leg strength/ body weight cut points (severely weak, moderately weak, or not weak). group differences were examined after controlling for sex. results: the older adults had % lower isokinetic strength/body weight when compared to the young adults. the severely weak older adults were % and % weaker than the moderately weak and older adults who were not weak, respectively. severely weak older adults exhibited higher levels of leg extensor via than older adults who were not weak ( . + . % vs. . + . %). severely weak older adults exhibited % longer sp's compared to the older adults who were not weak, but this difference was not statistically significant (p= . ). the severely weak older adults' mep's were approximately half the amplitude of the older adults who were not weak. regression analyses demonstrated that mep amplitude and sp duration -indices of hypoexcitability-were associated with relative strength. conclusion: weak older adults have significant deficits in their nervous systems' ability to fully activate their leg extensor muscles. additionally, motor corticospinal hypoexcitability is associated with age-related weakness, suggesting that interventions targeting the nervous system could be used to enhance muscle strength and prevent future health risks in older adults with muscle weakness. model. results: we evidenced oxidative stress in a mouse model of the pathology at different ages ( , and months) and aimed to identify the consequences of opa inactivation on redox homeostasis. increased ros levels were observed in cortices of the murine model opa +/-as well as in opa down-regulated cortical neurons. this increase is associated to a decline in mitochondrial respiration and an increase of antioxidant enzyme levels. upon exogenous oxidative stress opa -depleted neurons did not further up-regulated antioxidant defenses. finally, low levels of antioxidant enzymes were observed in fibroblasts from patients supporting their role as modifier factors. moreover, the simulations obtained with our mathematical model of complex i are able to reproduce biological experiments of quantification of ros production by complex i. conclusion: our study shows: (i) the prooxidative state induced by opa loss can be considered as a pathological mechanism (ii) differences in antioxidant defenses can contribute to the variability in expressivity and (iii) antioxidant defenses can be used as prognostic tools to gauge the severity and the evolution of the disease. (iv) furthermore, our mathematical model model of ros porduction by complex i will help to understand the dysfunctions of oxidative metabolism in opa gene related disorders. we will present the last results of our algorithm and wet laboratories experiments. amanika kumar, deepa m narasimhulu, michaela e. mcgree, amy l.weaver, aminah jatoi, nathan k lebrasseur (mayo clinic, rochester, mn, usa) background: patients with advanced ovarian cancer (eoc) are often frail and require multi-agent chemotherapy. objective: to evaluate the relationship between frailty and adjuvant chemotherapy tolerance and toxicity among women with advanced epithelial ovarian cancer. methods: women who underwent primary debulking surgery for stage iiic or iv eoc and received adjuvant chemotherapy at the same institution were identified. a frailty deficit index (fi) was derived from items representing comorbidities and activities of daily living. frailty was defined as a fi ≥ . . if data were unavailable for frailty index calculation, patients were excluded. relative dose intensity (rdi) for carboplatin and paclitaxel was calculated as the percentage of the standard dose that was actually administered and compared between frail and non-frail using the wilcoxon rank sum test. results: of the women who met inclusion criteria, . % ( / ) were frail. frail women were older ( . vs . years, p= . ), had a higher bmi ( . vs . kg/m , p= . ), and were more likely to have american society of anesthesiologists (asa) score ≥ ( . vs . %, p= . ) compared to nonfrail women. frail patients were less likely to complete cycles of adjuvant chemotherapy, ( % versus %, p< . ). despite the decrease in total cycles of chemotherapy, we did not observe significant differences in dose delays ( . vs. . %), dose reductions ( . vs . %), and severe neutropenia ( . vs. . %) between frail and non-frail women. we analyzed a subset of patients ( frail and non-frail) women received both intravenous carboplatin and paclitaxel. we observed that frail women were less likely to have a carboplatin rdi of % or higher ( . % vs. . %, p< . ) and less likely to have a paclitaxel rdi of % or higher ( . % vs. . %, p= . ). conclusion: frail women with advanced eoc undergoing adjuvant chemotherapy receive reduced rdi and are less likely to complete cycles of chemotherapy despite no increase in dose reduction, delays, and neutropenia. physician bias and patient choice may influence chemotherapy intensity decisions. further studies are needed to explore the association between frailty, chemotherapy, and survival. background: gait speed is a core component of physical frailty (pf) and, as a single measure, is correlated with important health outcomes, including mortality. immune dysregulation has been previously associated with pf -including increased il- production in peripheral blood mononuclear cell (pbmc) lipopolysaccharide (lps) stimulation assays. it is not known whether gait speed is associated with lps-stimulated cytokine production. objectives: this pilot study evaluated whether gait speed is correlated with dysregulated immune response in two populations of older adults undergoing procedures -knee osteoarthritis (oa) scheduled for knee replacement, and chronic kidney disease (ckd) approaching hemodialysis initiation. methods: older adults with ckd and older adults with knee oa underwent preoperative evaluation including gait speed (usual pace, -meter walk, best of two trials) and immune stimulation testing (in vitro, thawed pbmcs stimulated with lps at doses , . , and ug/ml, with il- quantified by elisa at , , , and hours; reported as area under the curve (auc)). correlation coefficient and p-value were calculated. results: for ckd, the il- auc of lps stimulated pbmcs was negatively associated with gait speed (lps . ug/ml r = - . , p= . ; lps ug/ml r= - . , p= . ). for oa, the correlation between il auc and gait speed was positively correlated for lps dose . ug/ml (lps . ug/ml r = . , p= . ; lps ug/ml r= . , p= . ). none of these associations were statistically significant. similar results were obtained when age was included as a covariate. conclusion: in people with ckd, increased cytokine production was correlated with decreased gait speed. in people with knee oa, results do not support this hypothesis. further studies with larger sample size are warranted. for participants with knee oa, future studies should account for severity of knee pain at time of gait speed assessment. background: skeletal muscle drives fuel utilization, and carbohydrate (cho) is a major fuel source. metabolic flexibility describes the ability to balance cho and fat oxidation efficiently in response to changes in metabolic demands or conditions. despite its role in long-term metabolic health, little is known about cho oxidation or metabolic flexibility in sarcopenic older adults. objectives: to examine resting metabolism and metabolic flexibility from a fasted to fed state after a cho-rich meal in sarcopenic versus nonsarcopenic older adults. methods: twenty-two men and women (age ± sd= ± y) were enrolled into this pilot study with either normal (non-sarcopenic, n= ) or low (sarcopenic, n= ) handgrip strength, gait speed and relative skeletal muscle index. resting metabolism was assessed in a fasted state at baseline, and metabolic flexibility was assessed after ( min, post-prandial) consuming a meal containing g of fat, g of protein, and g of a rapidly-digestible cho. respiratory quotient (rq), cho, and fat oxidation were measured with open-circuit spirometry, indirect calorimetry. fat and fat-free mass were measured with dual x-ray absorptiometry. blood glucose was assessed from venous samples using glucose oxidase methodology. results: rq was - % higher (p= . - . ) in sarcopenic participants throughout the experiment. after adjusting for fat-free mass, fat oxidation was % lower (p= . ), while cho oxidation was % higher (p= . ) at baseline for sarcopenic men and women. sarcopenic participants also exhibited delayed and limited (p< . ) postprandial increases in cho oxidation, despite greater (p< . ) increases in blood glucose. conclusion: sarcopenic individuals are more reliant on cho and less reliant on fat oxidation than non-sarcopenic adults, which is generally consistent with poorer metabolic health. when compared to non-sarcopenic adults, sarcopenia delayed and truncated cho utilization after a meal, indicating impaired metabolic flexibility in this population. impaired metabolic flexibility could be a mechanism underlying the losses of strength and physical function accompanying sarcopenia. anton de spiegeleer , , , hasan kahya , , nele van den noortgate , evelien wynendaele , tine decruy , srinath govindarajan , dirk elewaut (( ) unit for molecular immunology and inflammation, vib-center for inflammation research, ghent, belgium; ( ) department of geriatrics, faculty of medicine and health sciences, ghent university hospital, ghent, belgium; ( ) drug quality and registration (druquar) group, faculty of pharmaceutical sciences, ghent university, ghent, belgium) background: acute and chronic muscle wasting represent an important unmet clinical health problem. most pathophysiological studies suggest an effect of the immune system, primarily through catabolic cytokine productions such as il- . also endoplasmic reticulum (er) stress is considered to be an important pathway favouring muscle wasting. er stress in turn plays an important role in innate-like t cells, particularly invariant natural killer t cells (inkt cells), by controlling their cytokine production [govindarajan et al., nat. commun. ]. as such we reasoned that inkt cells may play a pivotal role in muscle homeostasis through their excessive cytokine production. previous studies have already highlighted the importance of these cells in a wide range of diseases such as cancer and metabolic disorders such as obesity. objectives: the aim of this study was to investigate the in vivo role of inkt cells in muscle homeostasis. methods: we compared wild-type (wt) versus inkt cell depleted mice (jα ko) for clinical, histological and gene expression differences in lower limb skeletal muscle. results: interestingly, we found that inkt cell depleted mice (jα ko) had a lower relative muscle weight, i.e. a muscle wasting phenotype, compared to wt mice. this clinical muscle wasting was associated with a decrease in oxidative enzymatic activity (succinate dehydrogenase histology). moreover jα ko mice showed a decreased transcription of genes involved in skeletal muscle growth and differentiation (follistatin and myogenin), sarcomere assembly (myosin- ) and neuromuscular junction function (neuronal acetylcholine receptor subunit alpha- ). conclusion: taken together, our results suggest a role for inkt cells in muscle wasting diseases and put innate-like t cells at the centre stage of immune cells controlling skeletal muscle biology. a r m a n d a t e i x e i r a -g o m e s , , s o l a n g e costa , , bruna lage , , dietmar fuchs , vanessa valdiglesias , , blanca laffon , joão paulo teixeira , ( ( ) background: frailty is a multidimensional geriatric syndrome characterised by increased vulnerability and functional decline that may be reversed if addressed early. it has been identified to be the most common condition leading to disability, institutionalisation and death in older adults. despite its known biological basis, no particular biological trait has been consistently associated with frailty syndrome so far. objectives: on this basis, the main objective of the present work was to evaluate the possible association between immunological: biomarkers and the frailty status in a group of community dwellers. methods: a group of older adults (>= years old) was engaged in this study. frailty status was assessed via fried's frailty model. the levels of several immune activation molecules -neopterin, tryptophan, kynurenine -were analysed. results: the classification of the study population was . % robust, . % pre-frail and . % frail. no significant differences were found between robust and pre-frail groups regarding serum concentrations of neopterin. although, the kynurenine/tryptophan ratio was significantly higher in pre-frail individuals as compared with robust subjects. conclusion: the preliminary data obtained suggest the activation of immunobiochemical pathways and are in agreement with previous studies that report alterations of the immune response in frail older adults. nevertheless, further investigation is encouraged and required to consistently demonstrate these findings. in future studies physical activity, nutritional, psychological, sociological and clinical features should also be considered when evaluating changes in immune biomarkers and frailty. the work developed by armanda teixeira-gomes and solange costa is supported by fct under the grants sfrh/bd/ / and sfrh/ bpd/ / , respectively. vanessa valdiglesias was supported by beatriz galindo research fellowship beagal / . background: frailty and hemoglobin count, above what would be considered clinical anemia, are two common findings in older patients and lead to an increased risk of negative health outcomes. objectives: evaluate whether hemoglobin concentration is an independent predictor of frailty and investigate possibe causal pathways in particuliar the relationship between inflammation and nutrition with hemoglobin concentration. methods: communitydwelling participants aged years or older who visited the toulouse frailty clinic between and were included in this analysis. patients underwent a comprehensive geriatric assessment and had a blood sample. a series of multivariate logistic regression models were perfomed after minimizing potential influence from age, gender, kidney function, inflammation, cognition, nutritionnal status and certain socioeconomic factors. results: hemoglobin count and frailty are significantly associated after minimizing potential influence from other covariates (p< . ). an increase in one point of hemoglobin concentration is associated with a % risk decrease of being frail (or= . , %ic= . - . ). there were no evidences of significant impact of inflammation and nutritional status in the relationship between hemoglobin concentration and frailty status (p> . ). conclusion: hemoglobin concentration is strongly associated with frailty in older adults. these results can have potentially important implications for prevention policies targeting frailty, by identifying potential patients with high risk of adverse outcomes and functional outcomes. juliette tavenier , line jee hartmann rasmussen , jan nehlin , morten baltzer houlind , aino leegaard andersen , ove andersen , janne petersen , , anne langkilde ( ( ) background: chronic inflammation is thought to be involved in the development of frailty. we hypothesized that increased monocyte inflammatory activity plays a role in chronic inflammation and thereby in frailty. objectives: to study the potential role of chronic monocyte inflammatory activity in frailty. methods: two groups of elderly adults (>= years) were included: patients with a recent admission to the emergency department (ed) and age-and sex-matched controls, without recent ed admission. data was collected at baseline and after year. participants were considered frail if they had or more of the following: hand grip strength ≤ kg for men or ≤ kg for women, gait speed ≤ . m/s, unintentional weight loss of > kg within the last months. frailty was also assessed using the frailty index (fi)-outref. we measured cognitive function (mini mental state examination -mmse) and chronic inflammation (soluble urokinase plasminogen activator receptor -supar). monocyte inflammatory activity was assessed by nf-κb phosphorylation (pnf-κb) using flow cytometry. results: participants had a mean age of . years (range: . - . ) and % were women. preliminary results show that at baseline, the patient group had a greater proportion of frail individuals compared to the control group ( vs. , p< . ). fi-outref was on average . points higher (p< . ) and supar levels % higher (p< . ) in the patient group, however, there was no difference in mmse score between the groups (p= . ). at year, although the proportion of frail individuals decreased in the patient group, it was still greater than in the control group ( vs. , p= . ). fi-outref remained elevated in the patient group (p= . ), but there was no difference in supar levels (p= . ). pnf-κb was positively associated with age in the control group (p= . ), but not in the patient group (p= . ). pnf-κb was % higher in the patient group compared to the control group (p< . ), and this was unchanged when adjusting for frailty, supar, and mmse. conclusion: the patient group was more frail and had elevated monocyte inflammatory activity compared to the control group. however, none of the frailty measures were confounders for the difference in monocyte inflammatory activity between groups. background: aging is most often accompanied by a loss of body weight: a decrease of fat deposits and muscle body weight. body mass index (bmi) in adults is considered normal if it is in the range of . to . kg / m (according to the who classification). bmi is widely used in the diagnosis of obesity. the association of bmi and cardiovascular and cerebrovascular diseases is known. objectives: the purpose of research is to identify the relationship of bmi with physical abilities and cognitive functions in long-livers. methods: long-living subjects aged . ± . years were examined. in long-livers, height, body weight were measured, calculated bmi. the level and direction of cognitive disturbances was determined by the mmse test (mini mental state examination). physical abilities were determined by the questionnaire and physical tests (tests the muscular strength in forearms and of the hands, chair stand test). results: bmi in long-livers had a normal distribution. the median bmi was . kg / m , the minimum value was . kg / m , and the maximum value was . kg / m . . % of long-livers had a bmi ranging from . to . kg / m . . % of long-livers have lost weight during the past year, including . % by kg or more. . % of long-livers could stand up of the chair. however, only . % of long-livers were able to complete the test correctly. amongst them, . % had a normal bmi. indicators of muscular strength in forearms and of the hand in long-livers who completed the chair stand test were significantly higher compared to long-livers who did not completed the chair stand test (r = . , p < . ). bmi had a positive correlation with the ability of a long-lived to wash without anyone's help (r = . , p < . ), go up and down the stairs (r = . , p < . ), do light housework (r = . , p < . ). mmse indicators also positively correlated with bmi (r = . , p < . ). the average mmse . ± . was observed with average bmi . ± . . conclusion: against the background of a decrease in the bmi indicator in long-livers, a decrease in physical abilities and cognitive functions is observed. however, there is a problem in determining the boundaries of the ratio of height and body weight for elderly people. in all likelihood, there are not linear, but more complex dependencies between bmi and functional abilities of long-livers. suparb aree-ue , inthira roopsawang , jansudaphan boontham , surinrat baurangtheinthong , yuwadee phiboonleetrakun (( ) ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bkk, thailand; ( ) faculty of graduate studies, mahidol university, bkk, thailand) background: depressive symptom results in increasing poor outcomes and care dependency in older adults. the prevalence of depressive symptoms is common with its associated multiple factors. however, this conundrum problem is underestimated, particularly in older people living in rural areas. to promote healthy aging, understanding of the conundrum problem is essential in strengthening care quality and enhancing the quality of life in this population. objectives: to determine the relationships of the number of medication use, pain, frailty, and locomotive syndrome and their effects on depressive symptoms among community-dwelling thai older adults. methods: a cross-sectional study was employed. the sample consisted of community-dwelling thai older adults who met the inclusion criteria. data were assessed by using demographics questionnaire, thai version -question geriatric locomotive function scale: glfs- ; numeric rating scale; the reported edmonton frailty scale: refs-thai version; and the -item geriatric depression scale, tgds- . a path analysis was employed to determine the pathways linking the number of medication use, pain, locomotive syndrome, frailty to influence depressive symptoms. results: there were significant positive direct paths from pain (beta = . , p <. ) to locomotive syndrome and from locomotive syndrome to the number of medication use (beta = -. , p <. ). an inversely, the locomotive syndrome was a negative significant direct to depressive symptoms (beta = -. , p <. ). pain had an indirect effect on depressive symptoms (beta = -. , p <. ). additionally, the model explained . % of the variability in depressive symptoms. conclusion: the locomotive syndrome is a major factor influencing depressive symptoms. the complex relationship among pain, number of medication use, locomotive syndrome, and depressive symptoms should be taken into account for designing an appropriate intervention to reduce depressive symptoms among community-dwelling thai older adults. background: total knee arthroplasty (tka) is a clinical curative treatment for severe knee osteoarthritis. however, the outcomes are differences in each patient's perception. preoperative patients' expectations to functional abilities are one of important factors influencing on postoperative outcomes and satisfaction. objectives: to investigate the association among preoperative patients' expectations, postoperative functional abilities, and satisfaction to functional abilities among older adults undergoing tka at -week after surgery. methods: participants were older adults who were diagnosed with knee osteoarthritis and required to receive tka at a university hospital in bangkok, thailand. the sample was purposely selected based on the following criteria: were aged years or over, received tka for the first time, and had no cognitive impairment. the data were collected at preoperative and postoperative tka by using the demographic data questionnaire, the hospital for special surgery knee replacement expectations survey, and the knee and osteoarthritis outcome score in the part of function in daily living (koos adl) thai version. the data analysis was performed by using descriptive statistics, paired t-test, and pearson product moment correlation coefficient. results: before surgery, patients' expectations to postoperative functional abilities had a high level with the total mean score of . (sd = . ), and the item of improving ability to walk in a short distance was rated as the highest expectation. at -week after surgery, the overall functional ability had a significant improvement (t = - . , p = . ). satisfaction to functional ability also had a high level (mean ± sd = . ± . ), and the improving ability to walk in a short distance item had the highest. patients' expectations to functional abilities had a significantly low positive correlation to postoperative functional ability and satisfaction (r = . , p < . ; r = . , p < . , respectively). moreover, there was a significant moderate positive correlation between functional abilities and satisfaction to functional abilities (r = . , p < . ). conclusion: a better understanding of expectations may be beneficial in gaining knowledge, paving expectations on possible outcomes, and developing trust resulting in enhancing quality of care for thai older adults undergoing tka. background: identifying low muscle strength is a key step in many operational definitions of sarcopenia including the one recently proposed by the european working group on sarcopenia in older people- (ewgsop ). grip strength is widely used to identify people with low muscle strength. however, it is unclear what impact variation in the type of hand-held dynamometer used to measure grip strength has on the prevalence of low muscle strength. objectives: we aimed to assess the impact of estimated differences of between and kg in the measurement of grip strength when using different types of hand-held dynamometer on the case-finding of low muscle strength. methods: study participants were men and women aged - from a randomised, repeated measurements cross-over trial. maximum grip strength was assessed using four hand-held dynamometers (jamar hydraulic; jamar plus+ digital; nottingham electronic; smedley) in a randomly allocated order. ewgsop recommended cutpoints (< kg men; < kg women) were applied to estimate prevalence of low muscle strength for each device. agreement between devices was assessed using kappa statistics. results: prevalence of low muscle strength varied by dynamometer type ranging between % and % for men and, % and % for women. of the men identified as having low muscle strength by at least one of the four dynamometers, only % were identified by all four and % by just one. of the women classified as having low muscle strength by at least one of the four dynamometers, only % were identified by all four and % by only one. when comparing pairs of devices, kappa statistics ranged from . to . suggesting poor to moderate agreement. conclusion: case-finding of low muscle strength is influenced by the type of hand-held dynamometer used. it is important to identify the sources of variation in the measurement of grip strength and consider the implications of these for sarcopenia. further research is required to understand how best to standardise the assessment of each of the different components of commonly used operational definitions of sarcopenia and take account of sources of variation in these measures where standardisation cannot be achieved. background: sarcopenia is characterized by a progressive loss of skeletal muscle mass and strength associated with mortality and severe adverse events on health. for a healthy aging, the quality of life (qol) is essential and it is associated to autonomy of persons, social relations, and socioeconomic factors. objectives: to compare the qol of chilean older people with sarcopenia living in santiago de chile, according to an adapted version of the european working group on sarcopenia. methods: community-dwelling older people (mean ± sd: . ± . years; . % females) were interviewed, registering self-reported chronic diseases and the questions of short-form- health survey (sf- ). anthropometry, dynamometry and physical performance were measured. qol was measured using sf- , validated in chilean older adults. norm-based score of subscales and two summaries components -mental and physical (mcs and pcs; respectively)-were calculated using the chilean-specificscoring for older people. low score was defined as having a score ≤ th percentile of mcs and pcs. logistic regressions were estimated. results: sarcopenia was identified in . % of the sample ( . % women; . % men; p= . ). the average score of the subscales were significantly higher in non-sarcopenic adults than sarcopenic. the average of mcs and pcs were also significantly higher in non-sarcopenic adults than sarcopenic (mcs: . vs . ; p= . ; respectively; pcs: . vs . ; p< . ; respectively), and were significantly higher in men than women non-sarcopenic (mcs: . vs . ; p= . ; respectively; pcs: . vs . , p= . ; respectively). there were non-significant differences in sarcopenic adults by sex. logistic regressions demonstrated an association between sarcopenia and low mcs and pcs (or = . ; %ci: . - . ; or = . ; %ci: . - . ; respectively), adjusted by age, sex, multimorbidity, body mass index and lean/fat mass ratio. conclusion: sarcopenia was associated with a worse quality of life, which shows the impact of this pathology and the importance of developing programs for its prevention, delay or reversal. funded by fondef i p -munich sarcopenia registry (idsar): first results. uta ferrari , , marina schraml , ralf schmidmaier , , navina röcker , , sigrid adler-reichel , , christian lottspeich , , martin bidlingmaier , , benedikt schoser , , sabine krause , , martin reincke , , michael drey , (( ) department of medicine iv, university hospital, lmu munich, germany; ( ) friedrich baur institute at the department of neurology, university hospital, lmu munich, germany; ( ) preventive geriatrics study group, germany) background: since sarcopenia can be coded as disease in germany (icd-gm . ). in the same year we established the first sarcopenia registry linked with a biobank to identify modifiable, crucial risk factors for sarcopenia and its adverse outcomes. objectives: objectives of the registry are (i) how to optimize and standardize the diagnosis over in-and outpatient settings for musculoskeletal health, (ii) identification of clinical and molecular modifiable risk factors (iii) improvement of interdisciplinary treatment and prevention of sarcopenia as a new icd-code-based geriatric syndrome here we present the design as a practical approach for diagnosis in out-and inpatient care and a first descriptive analysis of influencing factors and comparison between in-and outpatients data. methods: patients older than years of age from outpatient clinic and acute geriatric ward at munich university hospital were consecutively screened by the sarc-f questionnaire. patients with high risk (sarc-f score >= ) were further assessed for sarcopenia in line with the european consensus definition (ewgsop ). among further factors assessed in the registry, we retrieved presence of further comorbidities, daily medication, nutritional status, sppb, frailty, and quality of life. results: at time of analysis, patients have been screened and within the first patients with high risk ( % women) % had sarcopenia. patients screened positive for sarcopenia have lower quality of life, even in a subclinical condition (mean euroqol (eq d-vas) = . ± . ). lower bmi ( . ± . , p= . ) and sex (p= . ) were statistically significant different for sarcopenia status, but not age (mean . ± . years, p= . ) or number of medication (p= . ) and comorbidities (p= . ). but the latter two were the most significant factors for inpatient status (both p< . ). the results underline the need for an early screening for sarcopenia in all patients older than years of age, suggested by hand grip strength in inpatients and sarc-f for outpatients. sex differences and further laboratory factors are necessary to add in sarcopenia diagnosis for precision medicine approaches. hospitalised older adults. we consider acute sarcopenia to be the last remaining acute organ insufficiency, with potentially devastating impact on function. characterising this condition will enable development of targeted interventions to ameliorate these changes. mobility disability, and incident mobility disability over . + . years. factor was associated with incident and prevalent mobility disability only, and factor was associated with only prevalent mobility disability. conclusion: muscle mass by d cr co-segregated with strength and physical performance measures, and together was associated with mobility and disability outcomes in older men. body composition measures (including dxa alm) did not co-segregate with strength and physical performance measures and together was associated with only mobility disability. background: currently, there are no registered drug treatments for the loss of skeletal muscle mass, strength and function that occurs during sarcopenia and cachexia. moreover, they are only limited relevant pharmacological screening options available. objectives: to improve in vitro pharmacological screening options, we developed a model of muscle wasting using donor primary muscle cells and our myoscreen™ platform that generates standardized myotubes for high-throughput phenotypic screening (young et al., slas discov. ( ) : - ). methods: myoblasts from four donors aged , , and years were compared in terms of proliferation, differentiation, size of formed myotubes and achr cluster formation using imaging and high content analysis. we then established an assay for muscle wasting: in each of the four donors various molecular pathways implicated in the pathogenesis of sarcopenia were activated using tnfa, tgfb or dexamethasone. results: myotubes formed from elderly patient's myoblasts displayed a reduced capacity to proliferate and differentiate, thinner myotubes and fewer acetylcholine receptor clusters. therefore, myotubes cultured using the myoscreen system continue to reflect age-related properties of donor muscle. interestingly, we also found that myotube sensitivity to atrophy stimulation increased with increasing age. myotubes were then co-incubated with growth/ repair factor igf- or hdac inhibitor, trichostatin a (tsa). both agents attenuated tnfa-induced myotube atrophy and differentiation inhibition in a dose-dependent manner. the extent of fusion index and myotube size increase was highest in myotubes from elderly subjects while myotubes from young subjects were more resistant to the protective effects of igf- and tsa. conclusion: myoscreen can be exploited to quantify age-dependent modifications in skeletal muscle fibers in vitro and identify candidate compounds that counteract the muscle wasting phenotype. andreas friedberger , alexandra grimm , wolfgang kemmler , klaus engelke , (( ) institute of medical physics, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany; ( ) department of internal medicine; ( ) friedrich-alexander-universität erlangen-nürnberg and university hospital erlangen, erlangen, germany) background: sarcopenia is characterized by a progressive loss of skeletal muscle mass, which is infiltrated by adipose tissue. dual energy x-ray absorptiometry can only differentiate overall lean and fat mass. a local muscle analysis requires d imaging like magnetic resonance imaging (mri). usually, t weighted images are used for a visual grading of the amount of intermuscular adipose tissue (imat). however, a quantitative analysis requires segmentation of the fascia lata (fl, deep fascia of the thigh). objectives: our aim was to develop a highly reproducible d segmentation method in oder to quantify imat and the fat fraction of the thigh muscles using a combination of t weighted turbo spin echo (t wtse) and corresponding pt turbo spin echo (tse) dixon fat fraction (ff) images. methods: mri scans were acquired on a t scanner (magnetom skyrafit siemens) at the midthigh (length cm, slices, voxel size t w . x . x . mm³, dixon . x . x . mm³). since the fl is difficult to detect in the ff images, the t wtse images were used for segmentation. this process involved several steps, starting with a fuzzy c-mean clustering followed by several filtering steps to enhance d surface like structures representing the fl. finally, a level set algorithm was applied to obtain a closed d surface. if necessary, results were corrected manually. segmented masks were transferred from the t w to the ff images by rigid registration. imat was then segmented using a threshold determined from the histogram of the ff values within the intra-fascia region. sarcopenic ( ± y) and healthy ( ± y) male subjects were analyzed by three operators once (interoperator reproducibility) and three times by one operator (intraoperator reproducibility). results: inter-and intra-operator variability results of imat are shown in the table as mean / root mean square of the standard deviation (rms-sd) in units of the measured variable / coefficient of variation (rms-cv) in %. overall precision was excellent with errors below . %. conclusion: a semi-automatic d segmentation for the fascia of the thigh was developed. the operator impact on imat was almost negligible. background: sarcopenia a muscle disease that causes muscle mass loss and weakness. the calf circumference is a good screening test for sarcopenia in older adults in primary care. the most commonly used cutoff point is cm, but it is derived from north american studies and it may not be adequate for screening different populations that have lower height, weight and bmi. objectives: the objective of this study was to determine the ideal cutoff point for calf circumference for sarcopenia in community-dwelling older people in northeastern brazil. methods: this was a cross-sectional study of community-dwelling older people with a mean age of ± years ( % women). data on sociodemographics, anthropometrics, grip strength, gait speed, and skeletal muscle mass (bioimpedance) were collected. sarcopenia was assessed based on the diagnostic criteria suggested by european working group on sarcopenia in older people (ewgsop ). the area under the roc curve (auc) was calculated for different calf circumferences to identify the best cutoff point to determine sarcopenia among the participants. results: the prevalence of sarcopenia was %. the most appropriate calf circumference cutoff point was cm, with an auc of . , % sensitivity and % specificity. conclusion: it was found that the most appropriate calf circumference cutoff point to diagnose sarcopenia in older northeastern brazilians was cm. this is a more accurate cutoff point and will reduce the number of false positives and optimize health services in brazil. background: osteosarcopenia is a new geriatric syndrome defined as the presence of both sarcopenia and osteopenia or osteoporosis. this musculoskeletal disorder is related to higher prevalence of disabilities, falls and fractures and higher risk of mortality among community-dwelling older adults. therefore, the early diagnosis of this condition must be considered in order to reduce costs and negative impact on function. objectives: to explore the use of the infrared spectroscopy as a potential screening tool for osteosarcopenic older women (>= years old). methods: sarcopenia was identified by observing the presence of both reduction of muscle strength (grip strength) and mass (appendicular skeletal muscle mass) as suggested by the revised algorithm of the european working group on sarcopenia in older people ( ). reduction on bone mineral density was identified through bone densitometry and a t-score of <- , was adopted to classify the older women as osteopenic/osteoporotic. infrared spectroscopy through attenuated total reflection-fourier transform infrared spectroscopy (atr-ftir) was used to collect the sample information and to perform a multivariate analysis model. vibrational spectrum was obtained from serum. six samples of each group (osteosarcopenic and non-osteosarcopenic) were used to test the model and thirteen ostesarcopenic samples and fifteen non-osteosarcopenic samples were used for training. results: the most suitable model was the ga-svm with an accuracy of . %, % of sensibility and . % of specificity to differ osteopenic to non-osteopenic women. the more important selected variables found in the model were at the spectral regions: ~ cm- for carbs, ~ to cm- for nuclei acids and ~ to cm- for proteins. conclusion: infrared spectroscopy may be a promisor future method to early and easily diagnosis osteosarocopenia and prevent the harms this health condition may cause to the elderly population and minimizing costs to treat them. background: the modified european working group on sarcopenia in older people (ewgsop- ) algorithm to identify older people with sarcopenia contains three steps after initial clinical suspicion. the chair stand test, also known as the fivetimes sit-to-stand test ( sts), is one of two tests that can be used to assess muscle strength. the sts is also a component of the short physical performance battery (sppb), which is used as a measure of severity in the ewgsop- algorithm. objectives: the objective of this study was to determine whether the sts could be used to assess both muscle strength and physical performance in the ewgsop- algorithm to detect sarcopenia. methods: one hundred and ten older people aged . ± . years participated in the study. all participants were evaluated using the sppb score, as well as the timed-upand-go (tug). the ewgsop- algorithm specifies cut-off points of ≤ points on the sppb, ≤ . m/s for gait speed, and ≥ s for the tug. each participant was classified for tug and gait speed using the ewgsop- cut-offs, with stepwise discriminant function analysis used to predict the classification of participants. the remaining participants were used for cross-validation. prediction of sppb classification used the sts score in combination with predicted balance and sppb gait scores from stepwise linear regression. the total sppb score obtained using this method was used to predict sppb classification for the ewgsop- cut-off for sppb. results: the sts scores were able to predict tug and gait speed classification with % and % accuracy, respectively for the learning set of participants. the predicted sppb score had a classification accuracy of %, with % sensitivity and % specificity. when the remaining participants were evaluated, the sppb classification was correctly predicted for participants ( %), with % sensitivity and % specificity. conclusion: the sts can be used to accurately predict sppb classification in the ewgsop- algorithm to detect sarcopenia, meaning that the sts test could be used as a standalone test in an initial screening for sarcopenia. barrientos-calvo (nutritional support department and geriatric department, geriatric national hospital , san josé, costa rica) background: obesity is a disease characterized by increased adiposity with negative impact on patient health. aging process is associated with a progressive loss in muscle function, that may lead to functional decline and frailty. there are only few studies that have compared the prevalence of sarcopenia and dynapenia in obesity. objectives: the aims of this study were to determine the prevalence of sarcopenic and dynapenic obesity in elderly using the european working group on sarcopenia in older people criteria. methods: we conducted a cross-sectional study that included elderly patients with obesity from the obesity clinic since january to june . sarcopenia was defined according to the european working group on sarcopenia in older people (ewgsop ) criteria, and obesity with body mass index (bmi) > kg/m . handgrip strength was assess using a hydraulic dynamometer (jamar). bioimpedance analysis (bia) was performed. results: we evaluated persons, but only had bia data ( %). a total of older ( . ± years), % were women. mean body mass index, waist circumference, weight and calf circumference were . ± . kg/m , . ± . cm, . ± . kg and . ± . cm respectively. all patients had elevated body fat (mean %) and % had abdominal obesity. patients showed higher frequency of hypertension ( %), diabetes ( %), dyslipidemia ( %). sedentary was present in % and falls in %. mean handgrip strength and muscle mass for men and women were . ± . kg; . ± . kg and . ± . kg; . ± . kg respectively. there were ( . %) individuals fulfilling criteria for sarcopenic obesity, all women. but, dynapenic obesity was present in . % men and % women. conclusion: although the loss of muscle mass is associated with the decline in strength during aging, the decline in strength is more prevalent than the loss in muscle mass in our obeses. a large difference in prevalence of the two conditions was observed, sarcopenia obesity . % and dynapenic obesity %, respectively. barrientos-calvo (nutritional support department and geriatric department, geriatric national hospital, san josé, costa rica) background: sarcopenia is a geriatric syndrome characterized by progressive and generalized loss of skeletal muscle mass, strength, and function. several operative definitions for sarcopenia have been proposed over the past two decades. objectives: the aim of this study was to determine the prevalence of sarcopenia in costa rican longevity and health aging study (creles) using the ewgsop and ewgsop criteria. methods: to carry out the analysis, all the available cases of the creles study database in which belong to the cohort that follows in the period - were used. we analyzed community-dwelling older adults. low muscle mass was assessed using calf circumference < cm and low strength if < kg in men or < kg in women (ewgsop) vs < kg in men or < kg in women (ewgsop ). results: according to the ewgsop . % of the participants had sarcopenia, while according to the ewgsop sarcopenia was present in , % of participants. there was an increasing trend of sarcopenia by age group, it was more prevalent in women. mean handgrip strength was , kg in men and , kg in women with sarcopenia. mean calf circumference was , cm. sarcopenia was positively associated with age (or= . ; ci: . - . ), incomplete primary education (or , ; ic , ) , perceived as unhealthy (or , ; ic , - , ), antecedent of ischemic vascular event (or , ; ic , - , ), arthritis (or , ; ic , - , ), and falls ( r , ; ic , - , ). conclusion: the overall prevalence sarcopenia were significantly lower in ewgsop . prevalence of sarcopenia varies widely depending on the grip strength cut-off points applied. based on a -hour dietary recall, and poorer nutritional status as determined using must compared to their non-sarcopenia counterparts (all p<= . ). conclusion: the high prevalence of sarcopenia in community-dwelling older people who are at risk of malnutrition highlights the importance to devise targeted exercise and nutrition interventions to improve muscle health, physical performance and nutritional status. these interventions are essential to reduce the risk of progression to frailty and disability in this population group. v i n c e n z o m a l a f a r i n a , l e t i z i a s u e s c u n p u e r t a , a r a n t z a z u b i a i n u g a r t e , i ñ a k i a r t a z a a r t a b e , virtudes niño martín ( ( ) s o p h i e g u y o n n e t , c a t h e r i n e t a k e d a , philipe de souto barreto , yves rolland , sandrine andrieu , bruno vellas and the inspire study group ( ( ) background: the new geroscience field should not only be focusing on preventing age-related diseases, but should investigate the optimal maintenance of intrinsic capacity (ic): mobility, cognition, psychological, vitality and sensorial (hearing and vision) capacities as defined by the w.h.o. a better understanding about how to measure biological aging is an indispensable step that may lead to the definition of the best putative markers of aging capable of predicting healthspan. objectives: the main objective of inspire bioresource research platform for healthy aging is to build a comprehensive research platform gathering biological, clinical (including imaging) and digital resources that will be explored to identify robust (set of) markers of aging, age-related diseases and ic evolution. methods: the inspire platform will gather clinical data and biospecimens from subjects in the occitania region of different ages (from years or over -no upper limit for age) and functional capacity levels (from robust to frail to disabled) over years (inspire human translational research cohort). data are collected annually. between two annual visits, ic domains are monitored (with or without the help of a caregiver) each -month. once ic declines are confirmed, participants have a thorough clinical assessment and blood sampling to investigate the response of markers of aging at the time declines are detected. biospecimens includes blood, urine, saliva, and dental plaque that are collected from all subjects at baseline and then, annually. nasopharyngeal swabs and cutaneous surface samples are collected from all subjects at time-points (baseline visit and follow-up visits at m , m , m , m and m ). feces, hair bulb and skin biopsy are collected optionally at the baseline visit. results: recruitment started in october for a two years period. the identification of markers of aging will take advantage of three complimentary approaches to look for the best markers of aging: without a priori approach (transcriptomics, proteomics, lipidomics); semi a priori approach (metabolism, inflammation, cell cycle, mitochondrial network…); and targeted approach (pre-identified targets). the inspire platform will also aim to develop an integrative approach to promote novel new technologies for the assessment and monitoring of functional capacities. *acknowledgments: the inspire plateform is supported by grants from the occitania region and the european regional development fund (erdf), and co-funding by the apoc, the ctad, and the edenis, korian, pfizer, and pierre fabre groups. the promotion of this study is supported by the university hospital center of toulouse. background: energy balance is usually regulated by silent information regulator related enzyme (sirt ) and adenosine monophosphate-activated protein kinase (ampk). caloric restriction (cr) can postpone the pathological process of aging-related diseases and has a neuroprotective effect on nervous system degenerative diseases, but the mechanism is complex and not yet fully elucidated, although some of the cr effects may be mediated by sirt and ampk. objectives: to evaluate the beneficial effects of a cr diet on learning and memory ability. methods: six-week-old male c /bl mice were fed ad libitum for week before the experiment began. animals were weight-matched and randomly divided into three different groups: normal control group (nc group, n = ), high-energy group (he group, n = ), and cr group (n = ). the energy of nc diet, he diet and cr diet caloric ratio was : . : . . the total experimental duration was months. results: cr improved spatial learning and memory ability and decreased body weight and serum glucose. nissle staining showed the cell density was significantly decreased in the he group and increased in the cr group. cr decreased the expression of insulin signal pathway-related proteins such as igf- , ir, irs- , pi k, akt/pkb, and p-creb. more sirt -immunoreactive cells and fewer mtor-and s k immunoreactive cells were observed in the hippocampal in the cr group than in the nc group. cr decreased hippocampal mtor and s k protein activation and mrna expression. the expression of beclin , lc and cat b was increased and p was decreased in the cr group. the number of gfap-positive and iba- -positive cells in the cr group was significantly reduced compared to the nc group. conclusion: cr may prevent age-related learning and memory impairment via suppression of pi k/akt pathway and activation sirt / ampk/ mtor pathway in brain. background: head-down ( °) bed rest (hdbr) is a wellaccepted model to understand the pathophysiology of disuseinduced sarcopenia. human centrifugation as a measure to counteract muscle wasting during spaceflight is discussed. previous studies have observed decreases in maximal voluntary contraction force of the knee and hip-extensors of up to % following weeks of hdbr. muscle force is regulated by the recruitment of motor units (mus) and the modulation of mu firing rate. objectives: the aim of this study was to assess whether long-duration hdbr alters motor unit properties as one cause for disuse induced sarcopenia and whether human centrifugation can attenuate this decrement. methods: twelve healthy participants ( . ± . yr; ± cm & . ± . kg) were confined to -days ° hdbr in the frame of the first campaign of the agbresa bedrest study. eight received mins of artificial gravity (ag) daily via human centrifugation whereas four belonged to a control group. estimations of mu number (munix) and size (musix) in the abductor digiti minimi (adm) and tibialis anterior (ta) muscles were made using the motor unit number index method from on day preceding bed rest (bdc ) and on days (hdt ) and (hdt ). mean compound muscle action potential (cmap), munix and musix as a percent change from bdc were compared using repeated-measures anova, where muscle and time were ascribed as within-group factors and intervention a between-group factor. significance was denoted by p< . . results: both cmap and munix were unaltered over time in both muscles, irrespective of the intervention. although musix was also indifferent over time for both muscles, a significant muscle*time interaction was observed, indicating that the changes over time differed between the two muscles. conclusion: the preliminary data from the ongoing study indicate that neurodegeneration due to bedrest might affect muscles differently. there does not seem to be an effect of ag on mu number. analyses have to be repeated when the study is completed with a larger number of participants. additional histological and biochemical data will give further insight in the pathophysiology. living. soumaya msaad , geoffroy cormier , guy carrault (( ) univ rennes, inserm, ltsi -umr , f- rennes, france; ( ) neotec vision , rennes , france) background: several models have been proposed for elderly frailty detection. there is a consensus on two of them: the fried model, and the rockwood model. however, daily monitoring of the elderly is impossible with these models, whereas it is very important to detect any change as soon as possible to prevent dependency, since frailty is reversible only if early detected. objectives: the objective of this study is to propose a non-intrusive and low-cost method that anticipates frailty using depth images. crucial hypotheses are that regularity of daily activities is important for the elderly and that any prolonged change is considered as an indicator of frailty. methods: the proposed method consists in three steps: ) extraction of parameters from depth images: lying and sitting time percentage during the day, walking speed, and number of falls, visits, and exits. ) classification of the daily state using logistic regression and the extracted parameters. the daily state is considered as normal if the daily routine is maintained and abnormal if it is broken. ) computation of the weekly percentage of maintaining routine based on the classification of the nature of the day. results: tracking frailty is a difficult task that requires recording data over several months. as real data has not been collected yet, the feasibility of our approach was assessed on simulated data. in the latter, we reproduced variations of the parameters we would have extracted from real images of a patient after investigating his or her daily life. the classification of the days (normal/abnormal) led to an accuracy of % (training dataset: days, test dataset: days). a patient is considered frail when the weekly percentage of maintaining routine decreases steadily. conclusion: the preliminary results prove that in addition to being non-intrusive, a depth-imaging based approach can be a promising tool for frailty detection. anna franke , ellen freiberger , robert kob simon moskowitz , david w. russ , , leatha a clark , , , nathan p. wages , , dustin r. grooms , , brian c. clark , , ( ( ) background: one putative mechanism explaining mobility limitations (mls) in older adults (oas) is a reduction in the central nervous system's (cns) ability to rapidly drive muscle force/torque production. rapid movements can be mathematically expressed as the time derivative of force/ torque, also termed 'yank' (y). muscles are ultimately responsible for generating y, but cns input (ni) to the muscles clearly influences y. the time derivative of the voluntary electromyogram during maximal efforts is associated with gait speed (gs) and chair rise time (crt). however, since the electromyogram is influenced by non-physiological factors (e.g., subcutaneous adipose tissue acting as a low pass filter), it is difficult to fully ascribe this finding to cns deficits. theoretically, normalizing y to the time derivative of electrically evoked force/torque controls for musculoskeletal factors contributing to y (ymsk), which yields a value representing the cns's ability to rapidly produce force/torque (yni=y/ymsk). objectives: to better understand the role of the cns in mls in oas we ) compared leg extensor yni between young and oas, and ) examined the association between leg extensor yni and measures of mobility. methods: twenty-one young and fifty-nine oas ( . +/- . and . +/- . yrs) were instructed to "kick out as fast and hard as possible" against a fixed lever arm attached to a torque motor, and we quantified y between onset and -msec. next, we quantified ymsk from a supramaximal electrically evoked torque-time recording (potentiated -hz doublet) and calculated yni as described. on a separate visit six-minute walk ( mw) gs, stair climb power (scp), and x crt were measured. results: oas had higher yni vs. young adults reflecting a % reduction in central neural activation during rapid torque development ( . +/- . vs. . +/- . ; p< . ). significant associations were observed between yni and mwgs (r= . ), scp (r= . ), and x crt (r=- . ). conclusion: oas have a slower rate of volitional neural activation during rapid leg extensor torque production relative to young adults. in addition, yni explained ~ - % of the variability in measures of mobility, thereby supporting the notion that age-related reductions in the ability of the cns to rapidly activate muscles contribute to mls. background: opa mutations cause dominant optic atrophy (doa), an incurable retinopathy with variable severity and which mechanisms are still unknown. more than % of patients will endure a doa plus syndrome with ataxia, deafness or parkinsonism. the hypothesis of an oxidative stress has been proposed to explain the variability of these symptoms. objectives: that's why our goal is to improve understanding of the physiopathological mechanisms involved in this disease by developing mathematical models of the production of reactive oxygen species (ros) by the mitochondrial respiratory chain. methods: we monitored the levels of mitochondrial respiration, reactive oxygen species (ros), anti-oxidant defenses and cell death by biochemical and in situ approaches using in vitro and in vivo models of opa related disorders and model the complex i functioning with a detailed stochastic background: the sarc-f is a -question screening tool for sarcopenia. we present results for reliability and validity of the german version of the sarc-f. objectives: translation, adaptation and validation of the german version of the sarc-f for community-dwelling older adults in germany. methods: design: cross-sectional. setting and participants: community-dwelling outpatients with a mean age of . ± . years were included in the study, ( . %) of them were female. ( . %) had a positive sarc-f score of >= points. according to the definition for sarcopenia from the european working group on sarcopenia in older people (ewgsop ), eight patients ( . %) were identified as sarcopenic and ( . %) as probable sarcopenic. methods: translation and cultural adaption was composed of seven different steps that were in general based on the guidelines put forward by the world health organization. validation include test-retest and the inter-rater reliability (intra-class correlation coefficient) as well as internal consistency (cronbach's alpha). further, sensitivity, specificity, positive predictive value, and negative predictive value of the sarc-f were calculated. receiver operating characteristics (roc) analysis was performed to calculate the area under the curve. results: the translated and culturally adopted version of the sarc-f for the german language has shown excellent interrater reliability and good test-retest reliability. the internal consistency is acceptable. sensitivity ( %) and specificity ( %) for sarcopenia is low. for detecting patients with probable sarcopenia, the sarc-f in the german version has shown % sensitivity and % specificity. conclusion: due to a low sensitivity for detecting sarcopenia but an acceptable sensitivity for identifying probable sarcopenia, the german version of the sarc-f is a suitable tool for case finding of probable sarcopenia. background: skeletal muscle is a vital component of the locomotor system necessary for physical function. however, there is increasing evidence that skeletal muscle acts as a secretory organ in itself, communicating with other organ systems. acute sarcopenia is an emerging condition affecting adults following hospitalisation, which should be considered akin to organ insufficiency elsewhere. however, acute sarcopenia remains poorly characterised to date. objectives: • to characterise changes in muscle quantity, strength, physical performance, and patient-reported physical function in hospitalised older adults at one week and three months. • to determine what biological and clinical factors are predictive of changes to enable further research towards targeted interventions. methods: planned recruitment will include hospitalised patients aged years and older; elective colorectal surgery patients, emergency surgery patients, and general medical patients with acute bacterial infections. patients will be recruited to the elective cohort in pre-operative assessment clinic with repeat measures within hours of surgery, at one week, and at three months. emergency surgery patients will be recruited pre-or post-operatively with repeat measures at one week, and at three months. medical patients will be recruited within hours of admission, with repeat measures at one week, and at three months. muscle quantity will be measured by bilateral anterior thigh thickness using ultrasound and bioelectrical impedance. muscle function will be measured by handgrip strength and short physical performance battery. serum and plasma samples will be obtained prior to admission in the elective cohort, within hours of surgery in both surgical cohorts, and within hours of admission in the medical cohort. background: sarcopenia is common in old age and is associated with various diseases. as human life expectancy is projected to increase, this will pose a challenge for the global healthcare industry. since sarcopenia is highly heritable, study of its genetic underpinning can help its etiology. in the past decade genome wide association studies (gwas) have allowed the identification of new genetic markers for various conditions. identification of new genetic markers through gwas requires functional validation using cellular models in order to both prioritize and validate the potential loci/genes. objectives: demonstrate that a locus identified in gwas may affect muscle health, which is approximated by lean mass and hand grip strength. methods: gwas results are screened using a two-step scoring system which utilizes publicly available databases such as genecards, ensembl and coxpresdb to assess the relevance of a certain locus. relevant genes are then knocked out using crispr-cas in c c mouse myotube cells which are induced to differentiate. after cell harvest rt-qpcr and western blot are performed to assess mrna and protein expression, respectively. knocked out cells are also examined against wild type cells for morphological phenotype. results: slc a is a promising candidate based on: (a) muscle gwas results, (b) the expression of the gene in smooth and striated muscle tissue, (c) the lack of co-expression with other genes that have an effect on muscle; (d) mouse phenotypes associated with a mutation in the mouse ortholog slc a , (e) cell epigenetic data and (f) the topologically associated domain (tad) at chr. : , , - , , . rt-qpcr of wild type c c cells showed a fast increase in the expression of slc a 's mrna which remains constant during the entire differentiation process. conclusion: preliminary results indicate that slc a might be a promising candidate to investigate for involvement in muscle health. there is a fast and stable increase of the gene's expression during myotube formation. positive results may suggest that slc a is of importance to muscle health. to farther assess slc a role, wild type cells will be compared to knocked-out cells. this might lead to a new genetic marker for muscle health, thus extending personalized medicine in the field of sarcopenia and muscle health. jesse zanker , terri blackwell , sheena patel , kate d u c h o w n y , , s h a r o n b r e n n a n -o l s e n , s t e v e n r . cummings , , william j. evans , , eric s. orwoll , david scott , , sara vogrin , gustavo duque , peggy m. cawthon , ( ( ) background: muscle mass, strength and physical performance are independent risk factors for disability and mobility disability in older adults. it is not known how measures of body composition (muscle, lean and fat mass), strength and physical performance are interrelated or how empirical groupings of these measures relate to disability and mobility disability. objectives: to determine the relationship between measures of body composition, strength and physical performance in older men and to examine how empirical groupings of these measures relate to adverse mobility and disability outcomes. methods: muscle mass was assessed by d -creatine dilution (d cr muscle mass) in men ( . + . years) enrolled in the osteoporotic fractures in men (mros) study. participants completed anthropomorphic measures, walk speed ( m), grip strength (kg), chair stands (s), and dual x-ray absorptiometry (dxa) appendicular lean mass (alm) (adjusted for weight, body mass index or height ) and body fat percentage. factor analysis was conducted to reduce variables into smaller components. men self-reported limitations in mobility (walking - blocks, climbing steps, or carrying pounds); activities of daily living (adls); and instrumental adls at initial and follow-up visits. negative binomial models adjusted for participant characteristics were used to determine the relative risk of factors with mobility and disability outcomes. results: factor analysis reduced variables into four factors: factor , body composition, with strong loading by alm, body fat percentage, weight and muscle mass; factor , body size and lean mass, with strong loading by height, weight and alm; factor , muscle mass, strength and performance, with strong loading by walk speed, chair stands, grip strength, and muscle mass; and factor , lean mass and weight, with strong loading by alm and weight. only factor was associated with prevalent disability and background: urinary incontinence(ui) is a prevalent and costly condition that affects ~ % of older communitydwelling women.one of the contributors of ui is decreased pelvic muscle strength. objectives: to determine the effect of additional oral glutamine supplementation to kegel-exercise on pelvic floor strength and clinical parameters of ui in females. methods: it is a randomized, double-blind study. females with ui were included. digital test and a vaginal manometer were used for measuring the strength of the pelvic floor muscles. hours pad weight test was examined. participants were randomized into groups as oral glutamine gr/day and placebo. it was asked to use the supplementation and kegel-exercises to all participants for months. basic and th month measurements were compared by paired sample t -test and wilcoxon tests in each group. the progression between measurements at basic and th months was compared between the groups by using mann-whitney-u test. (clinical trials protocol id: / background: it is important to identify if middle-aged people are at risk for sarcopenia. a screening-tool identifying predictors of pre-sarcopenia early in the lifespan may inform prevention focused interventions. objectives: develop and validate a practical screening-tool to identify middle-aged adults at risk for pre-sarcopenia using data from the dunedin multidisciplinary health and development study (dmhds). methods: the dmhds is an ongoing longitudinal birth cohort study from the greater dunedin (nz) metropolitan area. the primary outcome of the screening-tool was low appendicular lean muscle index (almi) in middle-aged adults, at age . low almi was classified using prado's age-specific median cut-scores. the models were developed in % (n= ) of the cohort and cross-validated in the remaining % (n= ). possible predictors at age , were examined for associations with low almi, using univariate logistic regression. significant predictors were selected in a multivariate logistic regression to derive sex-specific prediction models. each individual in the cohort was allocated a risk-score and classified as low, medium and high risk, based on the quartile risk score. overall performance of the final models was estimated with nagelkerke r score, discrimination of the models with the area under the roc curve and calibration of the final models with hosmer-lemeshow tests. results: % of the development set and % of the validation set were female. the final models for both sexes included body mass index (b=- . , p= . ; b=- . , p= . ), vo max (b=- . , p= . , b=- . , p= . ) and grip strength (b=- . , p= . , b=- . , p= . ). the final model for females also included creatinine (b=- . , p= . ). nagelkerke's r showed that . % and . %, of the variance in low almi, is explained by the variables in the screening-tool for males and females, respectively. the area under the roc curve demonstrated good discrimination ( . ). sensitivity in the lowest quartile was . %, specificity in the highest quartile was . %. the hosmer-lemeshow p-values were respectively . and . , showing goodness of fit. conclusion: this screening-tool was able to predict the sex-specific risk of pre-sarcopenia in a large birth cohort of early middle-aged adults. clinical utility and application of this screening-tool require further investigation. background: aging-associated changes in body composition include a decrease in skeletal muscle mass, which may predispose women to physical limitations and disabilities. in women, these changes may already be accelerated during menopause, when ovarian estradiol (e ) production ceases. e , the main female sex hormone, is known to have beneficial effects on female skeletal muscle mass. objectives: the aim of this study was to investigate the effects of menopausal transition on lean body mass, lower limb muscle mass, muscle area and muscle fiber cross-sectional area in middle-aged women. methods: middle-aged women (n= ) were followed from perimenopause to postmenopause. menopausal state was defined based on repeated follicle-stimulating hormone (fsh) measurements and menstrual bleeding diaries. serum hormone levels (e and fsh; immulite ), lean body mass (lbm), right leg lean mass (dxa, n= ), and thigh muscle cross-sectional area (computed tomography (ct), n= ) were measured in peri-and postmenopause. muscle biopsies for immunohistochemistry were obtained from participants at peri-and postmenopausal phases, and muscle fiber crosssectional areas were measured. the level of physical activity (pa) from the previous months was assessed with a questionnaire (met-hours/day, n= ). statistical differences were analyzed with paired t-test and wilcoxon signed rank test. gee-modeling was used to analyze the effects of covariates during follow-up. results: the average followup time was . years (range . - . years) and there was a significant difference in e and fsh levels during the transition (p< . for both). lbm decreased . % (p= . ) and leg lean mass . % (p= . ) during the menopausal transition. no changes were found in the cross-sectional area of thigh muscles or muscle fibers. the level of pa declined during the transition (p= . ). when individual menopausal transition time and pa were controlled, only systemic e levels were positively associated with lbm (b= . , p= . ). conclusion: despite the relatively short follow-up time, significant declines were observed in lbm and leg lean mass during the menopausal transition. the decrease in lbm was associated with lower systemic e level. therefore, it seems that although pa might slow the decrease in muscle mass, estradiol loss is one key factor in whole body muscle loss during menopausal transition. hiroyuki shimada , takehiko doi , sangyoon lee , kota tsutsumimoto , seongryu bae , sho nakakubo , keitaro makino , hidenori arai (( ) department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan;( ) national center for geriatrics and gerontology, aichi, japan)background: in , the european working group on sarcopenia in older people met again (ewgsop ) to update the original definition of sarcopenia. ewgsop uses detection of low muscle quantity and quality to confirm the sarcopenia diagnosis, and identifies poor physical performance as indicative of severe sarcopenia. however, it is not clear that the relationships between the revised definition of the sarcopenia and disability incidence in japanese older adults. objectives: to examine the associations between sarcopenia for ewgsop criteria and disability incidence among community-dwelling older japanese individuals. methods: a total of older adults participated in the study ( women; average age, . ± . years) form a japanese national cohort study called the ncgg-sgs. skeletal muscle mass was assessed using a bioimpedance analysis device and handgrip strength and walking speed were measured as physical performance. we used the cut-points of the asian working group for sarcopenia to determine the low muscle mass and low physical performances. the participants were divided into non-sarcopenia, sarcopenia, and severe sarcopenia groups. the incidence of disability was determined using data collected by the japanese longterm care insurance system over months. results: the prevalence rates of sarcopenia and severe sarcopenia were . % and . %, respectively. the participants with sarcopenia, included sarcopenia and sever sarcopenia, showed higher risk of disability incidence than those with non-sarcopenia (hazard ratio [hr]: . , % confidence interval [ % ci]: . - . ). in analysis between non-sarcopenia and sarcopenia or severe sarcopenia, although the association between disability incidence and severe sarcopenia remained significant (hr: . , % ci: . - . ), there was no significant association in sarcopenia (hr: . , % ci: . - . ). conclusion: severe sarcopenia combined low muscle mass and low physical performance could have a higher risk of disability than healthy older adults or older adults with low muscle mass alone. further studies are needed to determine whether sarcopenia without poor physical performance is associated with disability incidence.background: sarcopenia is one of the biological hallmarks of frailty that has been associated with adverse events in older adults undergoing cardiac surgery. dual x-ray absorptiometry (dxa) is a recommended modality to measure muscle mass, however, dxa may be less accurate in acute cardiac patients due to the confounding effects of peripheral edema and fluid shifts. objectives: the study aims to determine if sarcopenia as measured by a combination of dxa and timed chair rises is associated with mortality in older adults referred for cardiac surgery. methods: a convenience sample of hospitalized older adults being evaluated for cardiac surgery was prospectively enrolled at the jewish general hospital. after a questionnaire and physical performance battery, patients underwent a dxa scan (ge lunar) to measure their appendicular muscle mass (amm). patients were categorized as sarcopenic based on the european working group guidelines if they had low amm defined as < kg/m in men or < kg/m in women and low muscle strength defined as chair rises > seconds. multivariable logistic regression was used to test the ageand sex-adjusted association between sarcopenia and allcause mortality. results: the cohort consisted of patients with a mean age of . ± . years and % females. the interventions were isolated coronary bypass in %, valve surgery in %, and decision not to proceed with surgery in %. the mean amm was . ± . kg in men and . ± . kg in women. the prevalence of sarcopenia was % (n= ), similar in men and women. sarcopenia was not associated with -year mortality (or . , % ci . - . ) and, in a separate model, neither was low amm (or . , % ci . - . ). slow chair rise time was associated with higher -year mortality (or . , % ci . - . ). when patients with heart failure and reduced ejection fraction were excluded, sarcopenia appeared to be more prognostic (or . , % ci . - . ) although it did not reach statistical significance. conclusion: lower-extremity muscle strength, but not dxa-based measures of muscle mass or sarcopenia, is predictive of survival in hospitalized older adults referred for cardiac surgery. background: the "blue zone" are limited areas with a high prevalence of centenarians, with rather homogeneous characteristics, life styles and environment." this blue zone, located in the nicoya peninsula, is in the province of guanacaste. even though costa rica has this blue zone, there are no studies that characterize the prevalence sarcopenia in the centenarians of the region. objectives: the aim of this study was to determine the prevalence of sarcopenia on centenarians from nicoya, costa rica, using the ewgsop criteria. methods: this is a cross-sectional study using a population base of community-dwelling centenarians from guanacaste. antropometric measures, weight, height and strength were assessed. to assess the nutritional state, the mini nutritional assessment (mna) was used and activities of daily living (adl) scores. low muscle mass was assessed by calf circumference < cm and low strength if < kg in men or < kg in women. results: the mean age of the patients were . ± . years. from this group, ( . %) were men and ( . %) were women. patients showed comorbilities: hypertension ( . %), diabetes ( . %), copd ( . %), cancer ( %), osteoarthritis ( %) and depression ( %). mean body mass index, weight, brachial and calf circumference were . ± . kg/m , . ± . kg, . ± . cm and . ± . cm. mean handgrip strength was . ± . kg. the mean score for the mna test was . ± . and adl score . ± . . with respect to sarcopenia prevalence, a total number of ( . %) subjects were detected, ( . %) men and ( . %) women fulfilled the criteria. according to the nutritional status, patients with sarcopenia had malnourishment, were on nutritional risk and had a good nutritional state. from the sarcopenic centenarians, at least % of the subjects had dependency with adl. conclusion: we had high prevalence sarcopenia in centenarians from the "blue zone". there are few studies in centenarians, but using the ewgsop criteria, it is the first in latin america. background: sarcopenia is a geriatric syndrome characterized by low muscle mass and low muscle function and/or reduced physical performance. malnutrition is a major risk factor for sarcopenia. there is limited data on the prevalence of sarcopenia in community-dwelling older people who are at risk of malnutrition in singapore. objectives: the objectives were (i) to determine the prevalence of sarcopenia and its components i.e. low handgrip strength, low appendicular skeletal muscle mass index (asmi) and low gait speed based on the asian working group for sarcopenia consensus (chen et al., ) , (ii) to describe the characteristics and dietary intake of older adults with sarcopenia to those without sarcopenia. methods: a total of community-dwelling older adults (>= years) who were at risk of malnutrition (malnutrition universal screening tool; must score >= ) took part in this study. sarcopenia was diagnosed by low muscle mass (asmi using bioelectrical impedance analysis) plus low muscle strength (handgrip strength) and/or low physical performance ( -meter usual gait speed). anthropometric measurements, dietary intake, and short physical performance battery (sppb) were also collected. results: over % of participants had a charlson comorbidity score of . the overall prevalence of sarcopenia was %; . % had low asmi, . % had low handgrip strength and . % had low gait speed. participants with sarcopenia were significantly older, shorter, and with lower body weight and bmi, mid-upper arm circumference, calf circumference and bone mass compared to those without sarcopenia (all p< . ). they also had lower physical functions as measured using handgrip strength and endurance, leg strength, and sppb score than those without sarcopenia (all p<= . ). additionally, older adults with sarcopenia had lower total energy intake and energy-adjusted protein intake background: the prevalence of sarcopenia varies according to the diagnostic criteria used, however it is an important geriatric syndrome related to a worse functional state in the elderly. very older adults are often excluded from clinical trials. objectives: the aim of this observational prospective study is to describe the prevalence of sarcopenia in community very older adults with high comorbidity. methods: we included patients who enter the geriatric day hospital of the hospital of navarra, spain, aged more than y, underwent bioelectrical impendance analisys (bia), measurement of hand grip strength (hgs), gait speed (gs), short physical performance battery (sppb), mini-nutritional assessment (mna-sf), barthel index and cumulative illness rating scale-geriatric (cirs-g). sarcopenia were defined according to ewgsop ( ). the study begining in and it is actually ongoing. we registered variables at baseline, and at the time , and months. all-cause mortality were registered. results: we present the preliminary results of baseline value. we icluded patients ( . % men, . ± . y). sarcopenia were present in participts, vithout sex differences. sarcopenic vs no-sarcopenic patiets were older ( . ± . vs . ± . y) (p< . ) and they presented worse nutritional status (bmi . ± . vs . ± . kg/m ) (p< . ), mna-sf ( %ci - ) vs ( - ) (p< . ). sarcopenic patients presented lower barthel index ( , %ci - vs , - ) (p= . ), but we have no observed differnces nor in the sppb , %ci - in sacropenic, vs , - in no-sarcopenic participats (p= . ), neither in comorbididy index (cirs-g , - vs , - respectivelly) (p= . ). sarcopenia is significantly associated with higher mortality (hr . , %ci . - . ) (p= . ). at the present time the mean follow-up is . ± . months. at months in patients ( %) the sarcopenia reverted, and we have observed new sarcopenic cases ( %) (incident sarcopenia). conclusion: sarcopenia is highly prevalent in very older adults with high comorbidity. sarcopenia is associated with malnutrition and with higher mortality. background: disability is a multifactorial trait that contributes substantially to decline of health/wellbeing and increases steeply with age after midlife. progress in genomewide sequencing has created the potential for discovering genes influencing various health-related traits. the vast majority of such studies focus on the genetic bases of different traits assuming that they have independent mechanisms. as conceptualized by geroscience age/aging are major risk factors of geriatric traits of distinct etiologies. accordingly, the same mechanisms can predispose not to just one, but to a large fraction of geriatric conditions. objectives: identify the common genetic architecture of various traits by discovering the genetic architecture of complex multifactorial trait such as disability. methods: genome-wide association study of disability in a sample of , subjects from five studies with , disabled individuals from the women's health initiative (whi) genomics and randomized trials network, whi memory study, cardiovascular health study, framingham heart study, and health and retirement study. disability was defined as having at least one of four basic activities of daily living impairments (bathing, dressing, getting out of bed, and walking). results: we identified promising disability-associated single nucleotide polymorphisms (snps) in loci at p< - . four of them attained suggestive level of significance, p< - . in contrast, polygenic risk scores (prs) aggregating effects of minor alleles of independent snps that were adversely or beneficially associated with disability showed highly significant associations in meta-analysis, p= . × - and p= . × - , respectively, and were replicated in each study. the analysis of genetic pathways, related diseases, and biological functions supported the connections of genes for the identified snps with disabling and age-related conditions primarily through oxidative/nitrosative stress, inflammatory response, and ciliary signaling. we identified musculoskeletal system development, maintenance, and regeneration as important components of gene functions. conclusion: the discovery of adverse and beneficial prs for a multifactorial trait of distinct etiologies such as late life disability supports the concept of geroscience. the beneficial and adverse gene sets may be differently implicated in the development of musculoskeletal-related disability with the beneficial set characterized, e.g., by regulation of chondrocyte proliferation and bone formation, and the adverse set by inflammation and bone loss. key: cord- -dh oh z authors: advani, sonali d.; baker, esther; cromer, andrea; wood, brittain; crawford, kathryn l.; crane, linda; adcock, linda; roach, linda; padgette, polly; anderson, deverick j.; sexton, daniel j. title: assessing severe acute respiratory coronavirus virus (sars-cov- ) preparedness in us community hospitals: a forgotten entity date: - - journal: infection control and hospital epidemiology doi: . /ice. . sha: doc_id: cord_uid: dh oh z we performed a cross-sectional survey of infection preventionists in us community hospitals between april and may , . several differences in hospital preparedness for sars-cov- emerged with respect to personal protective equipment conservation strategies, protocols related to testing, universal masking, and restarting elective procedures. novel coronavirus (sars-cov- ) has been associated with the largest recorded coronavirus outbreak to date. in the united states, there have been > . million cases with > , deaths (as of june , ). this pandemic has placed a tremendous strain on the us healthcare system leading to personal protective equipment (ppe) and resource shortages. most hospitals have implemented contingency and crisis capacity strategies to optimize the use of resources. although public health agencies like the centers for disease control and prevention (cdc) have provided interim guidance on infection prevention and control in us hospitals, the current state of community hospital preparedness is unknown. assessing preparedness of community hospitals is crucial to risk assessments and outbreak control activities in these settings. hence, we conducted a cross-sectional survey of sars-cov- preparedness among community hospitals in southeastern united states. we performed a cross-sectional survey of community hospitals within the duke infection control outreach network (dicon). dicon provides infection control services to community hospitals and surgery centers in states (north carolina, south carolina, virginia, florida, georgia, and west virginia). these hospitals range in size from to beds, with a median size of beds. also, % of these hospitals have maternity and pediatric wards. this study was deemed exempt from institutional review board review by the duke university health system (no. pro ). the survey (provided in the supplementary data online) was conducted between april and may , , using qualtrics (qualtrics, provo, ut); it was distributed electronically to infection preventionists at community hospitals. participation was voluntary, anonymous, and without compensation. the survey included questions related to ppe availability, crisis capacity strategies to extend and reuse ppe, policies related to restarting surgeries, testing prior to elective surgery and prior to transfer to extended care facilities, universal masking, and daily screening of hospital staff. extended use was defined as using the same single-use ppe for encounters with multiple patients without removing it between encounters. reuse was defined as using the same ppe for multiple encounters but doffing it after each encounter and donning it prior to the next encounter. survey responses were analyzed using descriptive statistics. of hospitals, ( %) responded to our survey. these hospitals reported varying degrees of ppe shortages (fig. ) . overall, hospitals ( %) reported "no supply" or "few days supply" of powered air-purifying respirators (paprs), environmental disinfectant, and gowns. almost % of facilities reported an insufficient supply of face masks and n respirators, and % reported an insufficient supply of face shields. more than % of community hospitals were implementing strategies to reuse n respirators, face shields, and goggles. only hospitals ( %) were reusing gowns at the time of this survey. similarly, at least % of hospitals were extending the use of n respirators, face shields, and surgical masks (table ) . furthermore, community hospitals ( %) reported reprocessing n respirators, mostly using hydrogen peroxide plasma ( . %), ultraviolet radiation ( %), and/or hydrogen peroxide vapor ( %). most community hospitals had implemented universal masking policies: ( %) required masking of patients, visitors and healthcare personnel (hcps), ( %) required masking of hcps and visitors; and ( %) required universal masking of hcps only. also, % of hospitals were performing daily employee screening at point of entry. additionally, ( %) hospitals had restarted tier elective surgical procedures at the time of this survey; ( %) restarted tier nonurgent surgical procedures; and ( %) were performing only tier emergent surgical procedures. only facilities ( %) reported performing preoperative testing for sars-cov- . moreover, facilities ( %) performed sars-cov- pcr test before discharging an asymptomatic patient to skilled nursing facilities, and facilities ( %) performed tests prior to discharge to these facilities. the community hospitals in our network reported a wide variety of laboratories used for sars-cov- testing, with most using in-house testing (n = , %), followed by testing by labcorp (n = , %), quest diagnostics (n = , %), department of health (n = , %), and others. only % of hospitals performed antibody testing for sars-cov- at the time of this survey. the results of this survey reveal gaps and differences in sars-cov- preparedness among community hospitals in the southeastern united states. a recent survey of hospitals in the society for healthcare epidemiology of america research network highlighted similar shortages in academic hospitals and large medical centers, but our survey is the first report, to our knowledge, focusing on the state of smaller community hospitals during the covid- pandemic. almost half of the community hospitals reported shortages in their supplies of paprs, environmental disinfectants, and gowns. in addition, % of hospitals reported an adequate supply of n respirators, face shields, and googles, likely due to use of crisis capacity strategies to extend, reuse, and reprocess these ppe. our report is different from a recently reported survey of hospitals in idaho that reported shortages of face shields. our survey highlights that face shields are less prone to shortages due to their simpler design, reuse potential, and durability. more than half of the community hospitals in our network had employed strategies to extend the use of face masks, n respirators, gowns, face shields, and googles. currently, to our knowledge, no data are available on the safety of extended use ppe or time limits for safely extending the use. similarly, most hospitals were employing strategies to reuse n respirators, paprs, face shields, goggles, and masks. although some data exist on the safety of reprocessed n respirators, safety data on reuse of other single use ppe are scarce. shortages of disinfectants and sanitizers may lead to the introduction of new agents with a potential decrease in cleaning efficiency, variation in equipment compatibility, an increase in staff dissatisfaction, and occupational safety hazards. our survey also demonstrates that most of our community hospitals had implemented policies related to employee screening at the point of hospital entry. although most hospitals had developed policies related to universal masking, the content of these policies varied widely. there was significant variation in policies related to testing for active infection with sars-cov- infection, with respect to the laboratory used, testing before surgical procedures, and testing prior to discharge to skilled nursing facilities. our study has several limitations. it was a cross-sectional study and relied on self-reported data from infection preventionists. we did not include other healthcare facilities such as nursing homes. however, this survey provided valuable information on differences in outbreak readiness among community hospitals that may help identify factors influencing preparedness. we found several differences in community hospital preparedness for sars-cov- with respect to type of conservation strategies used to preserve ppe, protocols related to testing, masking, and restarting elective procedures. we believe that this lack of standardization in approaches was due to differences in state guidelines, the decentralized federal approach to sars-cov- preparedness, and a lack of confidence in public health guidelines. these differences also highlight the challenges with implementing guidelines related to sars-cov- in community hospitals because of ppe and personnel shortages, financial constraints, and uncertainty regarding how and when to implement policies such as universal masking, preoperative testing, and predischarge testing. this study also offers a starting point for future assessments of pandemic preparedness among community hospitals in the united states. ? cdc_aa_refval=https% a% f% fwww.cdc.gov% fcoronavirus% f -ncov% fcases-in-us.html. published conserving supply of personal protective equipment-a call for ideas challenges and solutions for addressing critical shortage of supply chain for personal and protective equipment (ppe) arising from coronavirus disease (covid ) pandemic-case study from the republic of ireland interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease (covid- ) in healthcare settings duke infection control outreach network website policies and practices of shea research network hospitals during the covid- pandemic a survey of covid- preparedness among hospitals in idaho universal masking in hospitals in the covid- era: is it time to consider shielding? hand sanitisers amid covid- : a critical review of alcohol-based products on the market and formulation approaches to respond to increasing demand acknowledgments. we thank the community hospitals in our network for participating in this survey.financial support. this work was funded by the centers for disease control and prevention (grant no. u ck ).conflicts of interest. dr advani reports grants from the cdc. dr anderson reports grants from the ahrq, the cdc, and the niaid, as well as personal fees from uptodate, outside the submitted work. all other authors report no conflicts of interest or disclosures relevant to this article. key: cord- - m xkbok authors: testa, alexander; santos, mateus rennó; weiss, douglas b. title: incarceration rates and hospital beds per capita: a cross-national study of countries, - date: - - journal: soc sci med doi: . /j.socscimed. . sha: doc_id: cord_uid: m xkbok rationale. incarceration carries several negative ramifications for population health, while diverting scarce resources from other public goods. at a time when health care systems around the world are strained, the current study investigates the long-term relationship between incarceration and health care infrastructure. objective. we investigated the longitudinal association between incarceration rates and hospital beds per capita for countries between - . method. fixed effects regression analyses were employed to examine the effect of within-country changes in incarceration rates on hospital beds per capita. results. findings demonstrated that increases in national incarceration rates over time were associated with declines in hospital beds per capita, net of controls for socio-demographic and economic factors. conclusions. increased incarceration negatively impacts hospital bed availability at the cross-national level. a growing body of research documents that incarceration carries negative ramifications for population health (blankenship et al., ; jahn et al., ; stuckler et al., ; testa et al., ; weidner & schultz, ; wildeman, ; wildeman & wang, ) and shows increased incarceration has spillover effects that negatively impact other institutions including labor markets (western & beckett, ) and political institutions (uggen & manza, ) . while the influence of incarceration on population health and other social institutions has received considerable attention, less research has focused on how incarceration effects the wider functioning of health care systems (schnittker et al., ) . even so, previous research has drawn attention to this issue, noting, "consideration of the [impact on the] health care system is essential to evaluating the total social costs of incarceration" (schnittker et al., : p. ). this consideration is particularly relevant in light of the covid- pandemic, which has increased awareness of the spread of infectious diseases within correctional institutions (rubin, ) , and the capacity of hospital and health care infrastructure worldwide (cavalo et al., ) . thus far, existing research has focused on the relationship between incarceration and a single measure of health care infrastructure: psychiatric hospitalization (kim, ) . this line of research stems from penrose's ( ) hypothesis and subsequent observation of an inverse relationship between prison populations and psychiatric bed capacity in european countries. this hypothesis received increased attention during the latter half of the th century as many countries began undergoing a period of psychiatric deinstitutionalization (mundt, ) . while this relationship has been observed in other parts of the world including south america (mundt et al., ) and the united states (harcourt, ) , there are a variety of issues surrounding data and methodology that prevent any firm conclusions from being made in regard to the penrose hypothesis (kalapos, ; kim, ; mundt, ) . the focus on psychiatric hospitalization leaves open the question of whether the inverse relationship between incarceration and health care infrastructure extends beyond that of mental health care capacity alone. the exclusive focus on the tradeoff in the relationship between incarceration and psychiatric hospitalization neglects the possibility that investment in social control via incarceration may be offset by broader reductions in health care infrastructure across public, private, general, and specialized hospitals (schnittker et al., ) . indeed, one plausible hypothesis is that the inverse relationship between incarceration and psychiatric hospitalization is that it is just one reflection of the broader extent to which a society emphasizes social support relative to social control (cullen, ) . that is, increased emphasis on social control through incarceration will be associated with broader reductions in social support that extend beyond just psychiatric hospitalization and negatively impact other forms of social support including general health care infrastructure. according to prior research, countries that emphasize greater social support expenditures are likely to be characterized by a stronger emphasis on investing in public health (papanicolas et al., ) and less investment in institutions of social control such as incarceration (sutton, ) . at the same time, greater investment in social control via incarceration may be offset by reduced investment in the broader health care infrastructure. as one example, schnittker and colleagues ( ) found that u.s. states with a higher percentage of former prisoners have a weaker health care infrastructure characterized by a higher percentage of uninsured residents and higher rates of emergency room visitations. however, extant research has only begun to consider the general relationship between incarceration and health care infrastructure. existing research that has examined this relationship has largely been conducted at sub-national levels within the united states. wildeman ( : p. ) notes that "virtually all existing research on the macro-level consequences of incarceration has to date focused solely on the united states … which is problematic because there are several reasons to expect changes in the incarceration rate in the united states and in other developed democracies to yield qualitatively different results." indeed, incarceration rates vary substantially across countries, with the united states being particularly unique in this regard having an especially steep rise incarceration rate between the s and s relative to other countries (travis et al., ) . in this study, we use longitudinal data for a sample of countries from - to assess the longitudinal relationship between incarceration and health care infrastructure. specifically, we address the following research question: data for this study were compiled from a variety of international organizations including the world health organization (who), united nations (un), and world bank. the study was restricted to countries with available data beginning during the s and s -a key phase in the buildup of incarceration in many countries (walmsley, ) . because several variables used in the analysis were not collected every year, we used a five-year average of variables which is a common practice in cross-national incarceration research (weiss et al., ) . the final analytic sample is comprised of nine (t) -year waves ( - , - , - , - , - , - , - , - , - ) for (n) countries resulting in a sample size of country-waves (n x t). appendix a details the sample selection process and appendix b provides the countries and years included in the sample. hospital bed rate measures the number of inpatient beds available in public, private, general, and specialized hospitals and rehabilitation centers, including both acute and chronic care per , population. hospital bed data are compiled by the who and are supplemented by the world bank. hospital beds are a key measure of health care infrastructure as they indicate the availability of inpatient services in each country. the hospital bed rate is transformed using the natural logarithm to account for the positive skew. incarceration rate measures the average number of incarcerated persons in prison and jail per , population. incarceration rates are collected from the world prison brief, which is hosted by the institute for crime & justice policy research (walmsley, ) . incarceration rates are based on national government statistics, as well as other official sources. the incarceration rate is log transformed to adjust for positive skew. several control variables are included to account for relevant socio-demographic characteristics of a country. percent male represents the percentage of a country's population that is male and is obtained from the from the un world population prospects. the gini index is used to control for economic inequality and ranges from a hypothetical value of (completely equal) to (completely unequal) and is obtained from the standardized world income inequality database (swiid) (solt, ) . for analyses, we rescaled the gini index to - . to account for cross-national differences in crime, we include the homicide rate per , obtained from who mortality database. homicide rate is log transformed to account for the positive skew. to adjust for differences in the age structure of a population, we include an ordinal variable for the percentage of the population in each of five age groupings ( - [reference], - , - , - , and and older). data on age-structure were obtained from the un world population prospects. we measure the system of governance in a country using data from the polity database, which produces a -point scale (- to + ) (marshall & jaggers, ) . following prior research, we collapse the scale into three categories: full democracy ( points on the polity scale), transitional democracy ( - points), and autocracy (− to points) (lafree & tseloni, ) . finally, to adjust for socio-economic development, we generate a development index using four highly correlated items from the world bank: gross domestic product per capita, infant mortality rate, life expectancy, and percentage of a country's population that lives in urban areas. the development index is created using principal components analysis and is set to a standardized scale ranging from - , where higher scores equate to more socio-economic development (cronbach's α = . ; eigenvalue = . ). the longitudinal association between incarceration and hospital bed rates is assessed using fixed-effects linear regression. fixed-effects modeling assesses within-country changes in incarceration and hospital beds, while controlling for the influence of any unobserved timeinvariant measures that may confound this association. also, the observed controls account for the influence of several time-varying variables. the coefficients from fixed-effects models provide an estimate of how contemporaneous changes in incarceration rates over time correspond with changes in hospital beds per capita over time (kropko & kubinec, ) . a hausman test revealed that the fixed-effects model is a preferred estimation method compared to random-effects (χ = . , p < . ). standard errors are clustered by country to account for dependence of observations within countries (wooldridge, ) . a statistical power analysis performed using g*power . (faul, erdfelder, buchner, & lang, ) indicates adequate sample size to detect a small effect size and a . significance level for a multivariable fixedeffects regression (two-tailed test). table provides the summary statistics for the analytic sample. the mean incarceration rate is per , population and ranges from a low of . (greece; - ) to a high of . (united states; - . the average hospital bed rate is . per , population, and ranges from a low of . (venezuela; - to a high of . (finland; - . [ table here] [ figure here] table presents the results of the fixed effects regression of hospital beds per capita regressed on incarceration rates. model demonstrates that incarceration rates yield a strong negative bivariate association with hospital beds per capita (β = -. , % ci = -. , -. ). after adding the controls in model , we find that the inverse association between incarceration and hospital bed rates remains similar (β = -. , % ci = -. , -. ). substantively, the results indicate that each % increase in the incarceration rate is associated with a . % decline in hospital beds per capita. appendix c displays this inverse association: thus, a country with an incarceration rate of persons per , is predicted to have . hospital beds per , persons. however, this predicted rate falls to . hospital beds per capita for countries with an incarceration rate of per , . a robustness analysis that removed the united states from the analytic sample produced substantively similar findings (results available as an online appendix). [ table here] the global spread of covid- has drawn attention to the importance of population health, the vulnerability of prison systems across the world to the spread of infectious disease, and how under-resourced health care systems are in many countries. drawing from a growing body of research that suggests incarceration is a key social institution that impacts population health (wildeman & wang, ) , as well as a smaller body of research suggesting that incarceration may have spillover effects on healthcare (schnittker et al., ) , the current study investigated whether increases in incarceration rates within countries over time are associated with changes in the number of hospital beds per capita. results suggest that there is an inverse association between incarceration and hospital beds per capita at the country level. while this is the first study to examine the relationship between incarceration and hospital bed availability, this result is consistent with the penrose ( ) hypothesis which is specific to psychiatric hospitalization, as well as prior research on incarceration and health care infrastructure at the sub-national level in the united states (schnittker et al., ) . these findings also expand upon efforts to understand how incarceration is related to population health by suggesting that incarceration may increase the strain placed on national health care systems by contributing to adverse health outcomes while simultaneously reducing the capacity of the systems that treat these health problems. in this sense, the findings highlight broader societal consequences that result from increased incarceration. sampson ( ) previously proposed that research should evaluate the full ramifications of the benefits of incarceration (i.e. crime reduction) against any unintended and hidden costs. on this point, recent work has suggested the one fruitful avenue is "to more fully assess the incarceration ledger and the potential offsetting consequences of the prison boom for health inequalities." (light & marshall, : p. ). our study highlights the degree to which prison booms may contribute to a weakening of health care infrastructure, which in turn may generate greater vulnerabilities for population health. several limitations in the current study may be expanded upon in future research. first, the study was limited to mostly developed countries due to limitations in the availability of longitudinal data. as more longitudinal data emerge, future research can investigate the relationship between incarceration and health care infrastructure in a broader sample of both developed and developing countries. second, the current study used five-year averages and could not assess annual changes in incarceration and hospital beds per capita because data on key variables are not collected annually. third, this study focused on the impact of incarceration on hospital beds per capita only. future research can investigate the link between incarceration and other metrics of health care infrastructure such as the number of doctors per capita, the percentage of uninsured citizens, and the frequency of emergency room visitations. fourth, because detailed measures on crime rates are not available cross-nationally, we used national homicide rates to control for differences in crime. while homicide rates are considered the most reliable and available indicator of crime in a cross-national context, incarceration rates may be influenced by rates of property and violent crime beyond that of homicide. fifth, the measure of hospital beds per capita combines a variety of inpatient beds including public, private, general, and specialized hospitals. thus, we cannot disentangle the specific hospital bed types in each country. sixth, while the focus of this study was on incarceration, future research could explore other measures of punitiveness, such as the number of police, the use of alternative punishments aside from incarceration, and the prevalence of capital punishment. finally, the current study offers insufficient evidence of a trade-off between investment in incarceration and health care infrastructure as countries have numerous budgetary considerations in any given year, which were not fully accounted for, including national infrastructure investment, social welfare programs, and national security. the covid- pandemic highlights challenges in the tradeoff between investment in public goods including public health and public safety. as the effects of the virus strain the existing resources of national health care systems by requiring high levels of hospitalization, large populations in jails and prisons can contribute to the further spread of contagions while placing an even greater strain on existing resources. countries should take a holistic approach to public welfare by considering the potential negative ramifications of prioritizing one public good at the expense of others. year group hospital bed rate mass incarceration, race inequality, and 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infant mortality and homicide in the incarceration ledger polity iv project: political regime characteristics and transitions asylums and deinstitutionalization: the penrose hypothesis in the twentyfirst century psychiatric hospital beds and prison populations in south america since : does the penrose hypothesis apply the relationship between health spending and social spending in high-income countries: how does the us compare mental disease and crime: outline of a comparative study of european statistics the challenge of preventing covid- spread in correctional facilities the incarceration ledger: toward a new era in assessing societal consequences the institutional effects of incarceration: spillovers from criminal justice to health care the standardized world income inequality database mass incarceration can explain population increases in tb and multidrug-resistant tb in european and central asian countries imprisonment and social classification in five common-law democracies incarceration as a unique social stressor during pregnancy: implications for maternal and newborn health the growth of incarceration in the united states: exploring causes and consequences global incarceration and prison trends world prison population list. london, uk: international centre for prison studies institutional anomie and cross-national differences in incarceration examining the relationship between us incarceration rates and population health at the county level. ssm-population health incarceration and population health in wealthy democracies mass incarceration, public health, and widening inequality in the usa econometric analysis of cross section and panel data key: cord- -m lfk a authors: nuñez, jorge h.; porcel, juan antonio; pijoan, joan; batalla, lledó; teixidor, jordi; guerra-farfan, ernesto; minguell, joan title: rethinking trauma hospital services in one of spain's largest university hospitals during the covid- pandemic. how can we organize and help? our experience. date: - - journal: injury doi: . /j.injury. . . sha: doc_id: cord_uid: m lfk a introduction: the severe disruptions caused by the sars-cov- coronavirus have necessitated a redistribution of resources to meet hospitals’ current service needs during this pandemic. the aim is to share our experiences and outcomes during the first month of the covid- pandemic, based on the strategies recommended and strategies we have implemented. methods: our experience comes from our work at a referral hospital within the spanish national health system. changes to clinical practice have largely been guided by the current evidence and four main principles: ( ) patient and health-care worker protection, ( ) uninterrupted necessary care, ( ) conservation of health-care resources, ( ) uninterrupted formation for residents. based on these principles, changes in the service organization, elective clinical visits, emergency visits, surgical procedures, and inpatient and outpatient care were made. results: using the guidance of experts, we were able to help the hospital address the demands of the covid- outbreak. we reduced to a third of our orthopaedics and trauma hospital beds, provided coverage for general emergency services, and five icus, all continuing to provide care for our patients, in the form of trauma surgeries, phone interviews and emergency clinic visits. also in the third week, we were able to restart morning meetings via telematics, and teaching sessions for our residents. on the other hand, eight of the healthcare personnel on our service ( . %) became infected with covid- . conclusions: as priorities and resources increasingly shift towards the covid- pandemic, it is possible to maintain the high standard and quality of care necessary for trauma and orthopaedics patients while the pandemic persists. we must be prepared to organize our healthcare workers in such a way that the needs of both inpatients and outpatients are met. it is still possible to operate on those patients who need it. unfortunately, some healthcare workers will become infected. it is essential that we protect those most susceptible to severer consequences of covid- . also crucial are optimized protective measures. on march th , , the world health organization (who) declared coronavirus disease- (covid- ) a pandemic. currently, more than , , people across all the world have been infected by this virus, and more than , people have died [ ] . the rapid increase in this contagion have forced all area hospitals to transform rapidly from general or specialized care facilities to dedicated -covid structures‖. all elective procedures have been postponed and only emergency care has continued. emergency rooms are filled with patients coming in for respiratory distress and fever, and the number of contagions increases daily [ ] . on march th , , a state of emergency (implementation of stringent lockdown measures for the population) was declared in spain, and this has persisted to this date [ ] . regular hospital wards are now called covid , covid , and so on. every single medical professional is involved. there were and are no longer any subdivisions in our work [ ] . hospitals' work regimes have been re-prioritized. however, even though coronavirus infection must be a priority, this pandemic does not cause other health emergencies, including orthopaedic and other trauma, to disappear [ ] . orthopaedic surgery and trauma staff is the largest surgical department in most hospitals around the world. although most traumatologists are not fighting on the front line against covid- , we must guarantee treatment for orthopaedic and trauma patients and, in the meantime, protect healthcare workers and patients from covid- infection [ ] . many different strategies have been proposed and implemented worldwide in an attempt to contain this pandemic, some more successful than others [ ] . each decision requires an individualized risk/benefit assessment, with the aims of protecting healthcare personal and patients, helping hospitals deal with covid- lines, and not compromising the assessment and outcomes of our patients. we cannot provide specific guidance, because resources and coronavirus infection curves are different between countries, cities, and hospitals. nonetheless, we can share our experiences and outcomes during the first month of the covid- pandemic, based on the strategies recommended and the strategies we have implemented. we think this is important because, despite guidance via expert opinions [ ] [ ] [ ] [ ] [ ] , no published outcome experiences are based on the strategies applied. furthermore, that guides do not explain how orthopaedic and trauma staff can help and be part of the solution of this outbreak. our experience comes from our work at a referral hospital within the spanish national health system. specific records have been kept since march th , , when a state of emergency (implementation of stringent lockdown measures for the population) was declared in spain. our hospital is one of the orthopaedic and trauma referral centers in spain. we perform all kinds of elective and emergency surgery in trauma and orthopaedics, surgeries per year. since the emergence of the covid- outbreak, local orthopaedics and trauma practices have been markedly affected. changes to clinical practice have largely been guided by the current evidence and four main principles: ( ) patient and health-care worker protection, ( ) uninterrupted necessary care, ( ) conservation of health-care resources, ( ) uninterrupted formation for residents. based on these principles, changes in the service organization, elective clinical visits, emergency visits, surgical procedures, and inpatient and outpatient care have been tailored, as will be described later. daily information on the status of covid- positive patients at our institution was presented via telematics. on april nd , covid- patients were admitted, among whom were considered critical and requiring intensive care unit (icu). a policy of avoiding all wearing of street clothes and street shoes in the hospital was implemented, as was the mandatory use of surgical masks and gloves throughout the hospital. in the emergency room and in surgery rooms, wearing a n mask, ffp mask, or ffp mask was mandated. separate teams (a&b) work in separate weeks. only people essential to the delivery of healthcare services are encouraged to go to the hospital. in our service, there are units, which include a hip unit, knee unit, ankle and foot unit, shoulder and elbow unit, hand and microsurgery unit, spine unit, tumor unit, septic pathology and bone reconstruction unit, trauma unit, and orthopaedics and childhood trauma unit. the teams were constructed so that one person from each unit is always present or on call. likewise, an attempt was made to exclude elderly healthcare providers (over years old) from the service, as well as those with newly-born children, so that such individuals may avoid going to the hospital unless absolutely essential. daily telematics reunions between the chief of the service and chiefs of the individual units occur. personnel have been organized to support the covid- units, to cover trauma care (emergency clinical visits and emergent surgeries), operating rooms (delayed fracture emergencies) and clinical consultations (general and specialized consultations via telemedicine). on the third week, we were able to restart the services' morning meetings, via telematics. morning meetings have included information on the number of patients admitted the previous day for emergency care and a morning teaching session for the residents. in our hospitals, we have beds for trauma and orthopaedics patients, divided between three floors. two floors are currently being used for covid patients, while one floor is used for non-covid patients. during the pandemic, inpatient visits are performed by different teams that include two faculty and two residents each day. also, a new icu was constructed on one floor of the orthopaedics building, consisting of intensive care unit beds, and this unit is partially covered by orthopaedics and trauma faculty and residents. the adoption of telemedicine was improved. we started to conduct phone interviews with outpatients to determine if their health issues might be resolved without a hospital visit or their visit postponed. at our intuition, we have weekly clinics, each with between and patients. fifty of these clinics are for orthopaedics and trauma specialties and for general trauma and orthopaedic consultations. each doctor was responsible for their own patients' telephone visits. general clinic schedules were distributed among the older specialists and those with newborn children. only one daily consultation clinic remains, with a maximum of patients, with an attending physician available to see patients whose visit could not be postponed. also, two weekly general clinics for fracture patients who require follow-up were left open (maximum of patients). for the implementation of stringent lockdown measures for the population, emergency clinical visits were reduced. consequently, the trauma emergency team was reduced to a minimum, consisting only of two traumatologists and orthopaedic surgeons and three traumatologists and orthopaedic residents. in the beginning, a real-time reverse transcription-polymerase chain reaction (rt-pcr) for covid- was only requested if the patients had symptoms or had pathological chest x-ray evaluated by a radiologist, our biggest mistake. due to the increase of the pandemic outbreak and for the protection of health workers, we improved the protocol. currently, all patients that need visit wear gloves and mask, also all patients who need hospital admission undergo a rt-pcr test for covid- and have a chest x-ray ( figure ). elective surgical cases have been postponed to permit hospitals to free up beds for the treatment of patients with either confirmed or suspected covid- . for emergent and urgent surgical cases, two different surgical areas have been created, each on a different floor: one a covid-positive surgical area and the other a covid-negative surgical area. rt-pcr tests for covid- and chest x-rays are performed the night before or the same day that patients undergo surgery. the description of personal protective equipment (ppe) in surgery rooms was performed in table , and is shown on figure . the results, the mortality and the nosocomial infection of covid- were recorded, to know if it was pertinent to operate patients during this pandemic outbreak. covid- nosocomial infection was defined as the covid- infection that was acquired in the hospital. even though we adopted a split team policy and encouraged complete team segregation, out of orthopaedics and trauma faculty and orthopaedics and trauma residents, five faculty and three residents ultimately were discovered to have been infected with covid- . of these eight, seven have already recovered, while the other remains in isolation at home. on march th , orthopaedic and trauma patients were admitted to the hospital. by the end of the first week, the number of patients admitted had been reduced to a third ( patients). from that day forward, the mean number of hospital admissions for this cohort of patients has been (range, - ), all admitted to trauma emergency services. it was essential, the help of the faculty surgeons to make a faster discharge of the patients. eight faculty and eight residents help the covid teams every day. this helps to cover the general emergency department and five icus. a description of the duties that were performed in the icus is in table . phone interviews were conducted with , outpatients. more than . % of patients had their issue five hundred twenty emergency clinical visits occurred. mean patient visits per day were (range - ). a decrease of more than %, relative to the normal number of visits performed, was observed during this first month after stringent lock-down measures were implemented across the country. there also was a decrease in the number of poly-trauma patients, traffic accidents and work-related accidents. a comparison with the previous month, before lockdown measurements were done in table . we performed trauma surgeries. because of the implementation of stringent lock-down measures for the general population, polytrauma surgeries decreased, such that only three such surgeries were performed. the remaining . % of surgeries were deferred emergencies. brief descriptions and percentages for the surgeries performed are provided in table . forty-six surgeries ( . %) were for osteoporotic hip fractures, the most common indication for admission for surgery during this period. among the patients admitted for surgery, covid- positive patients were identified at admission. we also identified nosocomial covid- infections, cases in elderly patients who underwent surgery for an osteoporotic hip fracture. the nosocomial covid- infection rate was . %. among the covid- free patients, % were discharged home, while six patients remain in the hospital with good outcomes and no intrahospital mortality. among the covid- patients, only three died after surgery, while are still in-hospital and were discharged to home or some other residence. the intrahospital mortality rate among operated-upon patients over this time was . %. among the eight healthcare personal who became infected with covid- , no infection was related to surgeries, since none of these physicians performed any surgery at our hospital prior to their infection. for the surgeries, a maximum of three surgeons was allowed ( faculty and one resident), although most of the surgeries were performed by only two surgeons ( faculty or faculty and resident). using the guidance of experts, we were able to help the hospital address the demands of the covid- outbreak. we reduced to a third our orthopaedics and trauma hospital beds, provided coverage for general emergency services and five icus, all the while continuing to provide care for our patients, in the form of trauma surgeries, phone interviews and emergency clinic visits. also in the third week, we were able to restart morning meetings via telematics, and teaching sessions for our residents. on the other hand, eight of the healthcare personnel on our service ( . %) became infected with covid- . our biggest mistake was not performing a rt-pcr in all the patients that need hospital admission since the first day. that we had . % of our attending and resident physicians become infected with covid- is a problem. in fact, this is one of the most important problems that has arisen facing the coronavirus outbreak. it is known, for example, that covid- has forced thousands of healthcare workers out of action in europe [ ] . on april th , , more than , healthcare workers were infected in spain [ ] . of our own healthcare workers' infections, six were in the first week, and the other two in the second week. we think that the reduced infection rate among healthcare workers was because we had implemented more stringent hospital policies. at the beginning of the first week, healthcare personnel only used surgical masks in the hospital, and we only tested emergency room patients who reported symptoms. presently, all healthcare workers wear gloves and a surgical maskeither a n or ffp maskthroughout their time in the hospital. all patients who come to the hospital also must wear at least a surgical mask and gloves. we perform chest x-rays and rt-pcr testing for covid- on all patients who need hospital admission. furthermore, among patients admitted through the emergency room or a clinic and those who undergo surgery and test positive for covid- , appropriate ppe has been implemented. supporting covid- teams is important at this time. the first thing we can do is minimize patients' exposure to covid- by postponing all elective surgical procedures and hastening the discharge of patients who are admitted. we postponed all elective surgeries and were able to reduce our hospital bed use to a third of its baseline. the purpose of this recommendation is also to limit the use of hospital beds, increasing the hospital beds available for covid- patients [ ] . discharging patients as early as possible also is important because it reduces the likelihood of nosocomial covid- infection via spread back and forth between patients and healthcare workers. another vital point during this pandemic is the assistance of all healthcare workers [ , ] . even though many of us are relatively unprepared to handle the use of mechanical ventilators, and many of us have not worked in an er or icu in years, we can help. we must recognize that, just like we understand that most physicians cannot apply an external fixator device, they also know that we cannot intubate patients and operate mechanical ventilators. depending on the will, knowledge and skills of each member, our teams were divided in such a way that all necessary aspects of care could be addressed, including handling patients' medications, making calls to patients' relatives, providing emergency care prior to the initial triage of covid- and non-covid- patients, and helping to transport patients. in our institution, none have regretted having helped. also, apart from helping, we must not forget our service, our patients and the formation of our residents. over trauma surgeries were performed. to our knowledge, no healthcare personnel has become infected with covid- during any of these surgical procedures. we cannot say the same about inpatient visits. first, we recommend only operating when it is essential, and remember that we put both ourselves and our team, which includes anesthesiologists and nurses, at risk too. even most trauma surgery could be performed with regional anesthesia, as we must remember that intubation is considered one of the highest-risk procedures when dealing with covid- patients [ ] . surgical indications also depend on the severity of the epidemic and the availability of resources. in locations with widespread infections and limited resources, the risk of surgical procedures, both for the patient and community, may outweigh the benefit [ ] . in the current literature, lei et al, in their retrospective review, analyzed surgical patients who underwent elective surgeries during the incubation of covid- in wuhan, and found that all patients developed covid- , % required admission to an icu, and seven died after icu admission [ ] . even though the intrahospital mortality rate was low ( . %), nosocomial covid- infections developed in . %. this percentage correlates with that of our healthcare workers, so that we believe that these new covid- infections occurred during inpatient visits. one potential explanation is that hospital inpatient floors are more fluid sites, where doctors, nurses, security, and housekeeping personnel change every or hours. for this reason, minimizing the number of healthcare workers and increasing protective measures (e.g., ppe, cleaning supplies, etc.) is vital on hospital floors. another important factor has been pre-operative mortality. during the first week, two patients admitted to the hospital for an osteoporotic hip fracture were discovered to be covid- positive, so we decided to delay their surgery; both ultimately died. based on this, if resources and equipment are available, we recommend trying to operate on such patients promptly. among our elderly patients, were discharged home covid- free, while patients developed a covid- infection. among these , are still in the hospital, three have died, and two have been discharged. surgical contraindication would be a patient with active pneumonia, dyspnea or fever. but for the mere fact of being covid, the surgery of any patient should not be postponed. every doctor can help to keep as many patients as possible at home [ ] . as in the usa, trauma and orthopaedic consultations comprise almost % of all clinical consultations [ ] . for that reason, we organized and made phone interviews with outpatients to try to resolve their health issues, so they could avoid going to an emergency room. because losing a friend or a coworker can be fatal for a service, despite their willingness to help, elderly physicians and those with newborn children were asked to contribute from home, especially providing clinical consultations by phone. as such, infection of our center's healthcare personnel generally affected our younger physicians, ranging in age from - . finally, another important objective is the training of residents. it is obvious that their time in surgery has decreased, but their development should not [ ] . during the second week of the pandemic, we were able to resume morning rounds and a morning teaching session for the residents. the use of videoconferencing is strongly recommended to facilitate continued learning and counteract the stress of social isolation. with respect to assisting in surgical procedures, all residents took turns so they continued to develop their skills, stressing the importance of there currently being as few people in the operating room as possible. as priorities and resources increasingly shift towards the covid- pandemic, will it be possible to maintain the high standard and quality of care necessary for trauma and orthopaedics patients while the pandemic persists? in our opinion, it is possible. we must be prepared to organize our healthcare workers in such a way that the needs of both inpatients and outpatients are met. daily telematics-obtained information on the status of covid- positive patients is vital. this information is crucial because it helps healthcare personnel to appreciate exactly what are they facing. it is still possible to operate on those patients who need it, being careful both in the operating room and, even more importantly, on hospital floors. unfortunately, some healthcare workers will become infected. it is essential that we protect those most susceptible to severer consequences of covid- , like those who are elderly and those with young children. also crucial are optimized protective measures. . glasses. because of the power tools, aerosols are produced during procedures, so that complete ocular screen coverage is essential. . full face coverage screen. this does not protect from aerosols, but is necessary when there is a risk of splashing (blood, vomiting or other biological fluids). . cap. it is a good idea for all staff with long hair to have it fully tied up in a low bun and properly restrained. . exclusive footwear for the area of activity, without perforations. we recommend long boots for arthroscopy. once the ppe is in place, surgical scrubbing with an alcohol gel will be performed on the surgical gloves, and sterile equipment necessary for the surgical intervention (gown and sterile gloves) will be placed on the ppe. %: percentage, ppe: personal protective equipment table . description of the duties that were performed in the intensive critic units (icus). verification of medical treatment (computerized system) of admitted patients: -review allergies of the patients. if they have allergies, activate the computer alert -review standard basic treatment: -check that all patients have an ekg in the computer system. -check that medical orders are printed and signed on top of the patient's folder. novel coronavirus ( -ncov) situation reports cov- : an emerging coronavirus that causes a global threat real decreto / , de de marzo, por el que se declara el estado de alarma para la gestión de la situación de crisis sanitaria ocasionada por el covid- being a doctor will never be the same after the covid- pandemic planning and provision of ecmo services for severe ards during the covid- pandemic and other outbreaks of emerging infectious diseases specialty guides for patient management best practice for surgeons evidence-based scoping review. a unifying report of global recommendations a review of state guidelines for elective orthopaedic procedures during the covid- outbreak guidelines for ambulatory surgery centers for the care of surgically necessary/time-sensitive orthopaedic cases during the covid- pandemic surgical management of patients with covid- infection. recommendations of the spanish association of surgeons virus knocks thousands of health workers out of action in europe. the new york times unos . sanitarios se han infectado del coronavirus en españa what's important: redeployment of the orthopaedic surgeon during the covid- pandemic: perspectives from the trenches pandemic: effects on low and middle-income countries clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid- infection managing resident workforce and education during the covid- pandemic evolving strategies and lessons learned * in case of institutionalized patient: coverage for pseudomonas tocilizumab (under discussion) will be evaluated individually in those patients with refractory progressive impairment ekg: electrocardiogram, nt-probnp: pro b-type natriuretic peptide, il- : interleukin , ldh: lactate dehydrogenase key: cord- -uniz tuc authors: wang, shi-yi; hsu, sylvia h; chen, li-kuei title: the impact on neonatal mortality of shifting childbirth services among levels of hospitals: taiwan's experience date: - - journal: bmc health serv res doi: . / - - - sha: doc_id: cord_uid: uniz tuc background: there is considerable discussion surrounding whether advanced hospitals provide better childbirth care than local community hospitals. this study examines the effect of shifting childbirth services from advanced hospitals (i.e., medical centers and regional hospitals) to local community hospitals (i.e., clinics and district hospitals). the sample population was tracked over a seven-year period, which includes the four months of the severe acute respiratory syndrome (sars) epidemic in taiwan. during the sars epidemic, pregnant women avoided using maternity services in advanced hospitals. concerns have been raised about maintaining the quality of maternity care with increased demands on childbirth services in local community hospitals. in this study, we analyzed the impact of shifting maternity services among hospitals of different levels on neonatal mortality and maternal deaths. methods: a population-based study was conducted using data from taiwan's national health insurance annual statistics of monthly county neonatal morality rates. based on a pre-sars sample from january to december , we estimated a linear regression model which included "trend," a continuous variable representing the effect of yearly changes, and two binary variables, "month" and "county," controlling for seasonal and county-specific effects. with the estimated coefficients, we obtained predicted neonatal mortality rates for each county-month. we compared the differences between observed mortality rates of the sars period and predicted rates to examine whether the shifting in maternity services during the sars epidemic significantly affected neonatal mortality rates. results: with an analysis of a total of , observations between and , an insignificantly negative mean of standardized predicted errors during the sars period was found. the result of a sub-sample containing areas with advanced hospitals showed a significant negative mean of standardized predicted errors during the sars period. these findings indicate that despite increased use of local community hospitals, neonatal mortality during the sars epidemic did not increase, and even decreased in areas with advanced hospitals. conclusion: an increased use of maternity services in local community hospitals occurred during the sars epidemic in taiwan. however, we observed no increase in neonatal and maternity mortality associated with these increased demands on local community hospitals. regionalization of perinatal care, which links a tiered structure of facilities and refers women with high-risk pregnancies to a central facility with advanced technology and increased staff, has been established to improve perinatal health care and decrease neonatal mortality [ ] [ ] [ ] . studies have demonstrated that the relative risk for low birthweight infants in local community hospitals is significantly higher than that in advanced hospitals, ranging from . to . [ ] [ ] [ ] . although the benefits of perinatal care for low birthweight infants in advanced hospitals are well established, the data on the outcome of infants of normal birthweight are still inconclusive [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the public considers advanced hospitals, with their sophisticated technology and equipment, safe places for both high-and low-risk deliveries because undetectable prenatal conditions can cause unexpected complications during childbirth. even though several studies on low-risk pregnancy show no statistically significant difference in neonatal mortality rates between low technology facilities and advanced technology hospitals [ ] [ ] [ ] [ ] , there is still evidence of increased risks for low-risk deliveries in local community hospitals [ ] [ ] [ ] [ ] [ ] . for example, heller et al. reported a more than three-fold risk of neonatal death in small hospitals compared to large hospitals [ ] . these inconsistent results have raised concerns about the impact of regionalization on the outcome of low-risk deliveries. in taiwan, the accreditation system classifies medical institutions into four categories: medical centers, regional hospitals, district hospitals and clinics. medical centers and regional hospitals provide neonatal intensive care for high-risk pregnancies, while district hospitals provide premature observation care for mild-risk pregnancies. obgyn clinics are run by obstetrics-gynecology specialists and provide medical care for women, including low-risk child deliveries. in taiwan, low-risk pregnant women are allowed to seek services from medical centers without restrictions. during the sars epidemic in taiwan, the general population avoided seeking health care due to a combination of factors, including the vulnerability of health-care workers, and the rapid transmission of and limited knowledge about the disease [ ] . in particular, people avoided seeking care from advanced hospitals (i.e., regional hospitals and medical centers) because sars patients were being treated there. therefore, expectant mothers began seeking maternity services at local community hospitals instead of at advanced hospitals to avoid becoming exposed to sars [ ] . this change in expectant mothers' preference of healthcare providers led to an increase of . % and . % of the market share of total childbirth deliveries in clinics and in district hospitals, respectively [ ] . due to inconclusive evidence surrounding birth outcomes in local community hospitals, this large shift in childbirth services to local community hospitals has led to serious concerns about quality of care [ ] . therefore, this study undertook a population-based examination of neonatal and maternal mortality between and to investigate the impact of an increase in deliveries in district hospitals and clinics during the sars epidemic. the analysis was based on data from taiwan's national health insurance annual statistics, which included detailed monthly and county maternal and neonatal mortality numbers. we retrieved the data from to to compare the impact of the shift in childbirth services during the sars epidemic, which took place from may to august [ ] . examining the data from the period after the sars epidemic (i.e., post september ) allowed us to rule out the effect of technological progress on the outcome of maternity services, which might mitigate the potential negative impact of the shift in treatment from may to august . we applied an interrupted time-series design to analyze the effect of shifting childbirth services from one hospital level to another. both neonatal and maternal mortalities were analyzed to examine the impact of shifting hospital services on childbirth outcomes. for each county, monthly neonatal and maternal mortality rates were calculated; neonatal rates were determined by dividing the number of neonatal deaths by the number of childbirths, and maternal mortality rates were determined by dividing the number of maternity deaths by the number of childbirths. because the small number of maternal mortality cases precludes a meaningful analysis, descriptive statistics are presented. linear regressions were estimated using data from the years to to examine the changes in neonatal mortality rates for the pre-sars period. a total of counties were included in the analysis. we excluded the data from three isolated islands with no advanced medical institutions and small populations because the expense of transportation in these locations may have prevented expectant mothers from voluntarily selecting advanced hospitals and little shifting would have occurred. furthermore, the sars patients were found only on taiwan's main island. the dependent variables were monthly county neonatal mortality rates; the independent variables included "trend," a continuous variable that measured for the effect of yearly changes, and two binary variables, "month" and "county," which controlled for seasonal and county-specific effects. with the estimation results, we calculated the predicted mortality rate for each month and county from to . the differences between observed mortality rates and predicted mortality rates were standardized with the standard error of individual predicted values. the data were managed with sas software, version . . . all analyses were tested for a significance level by using á value of . . because only secondary data are analyzed, no institutional review board (irb) approval is necessary. figure is adapted from lee et al. and shows the changes in childbirth services in hospitals of different levels [ ] . to compare the mortality rates for the sars period of may to august with the same months of other sample years, we aggregated the monthly mortality rates into a four-month period. after the exclusion of the data from the three isolated islands, the number of childbirths from to was , , and the number of neonatal mortality cases was , . table shows a decrease in neonatal mortality rates over time, which did not increase during the sars epidemic. using the analysis of a linear regression model based on pre-sars observations, table summarizes the univariate statistics of predicted errors of monthly county mortality rates. we applied the standard error of an individual predicted value to obtain standardized predicted errors. the mean of standardized predicted errors of counties during the sars epidemic period (i.e., may-august ) is - . ( % confidence interval: - . - . ), which indicates that the predicted values are insignificantly different from the observed values during the sars period. this result demonstrates that, despite an increased use of local community hospitals, neonatal mortality during the sars epidemic was lower, even though the difference was insignificant. we formed a sub-sample containing counties where there were hospitals with more than , beds. the impact of shifting services would be greater in these areas because switching from one hospital level to another tends to occur more often there. the sub-sample presents a significantly negative mean of standardized predicted errors, (- . , ci (- . -- . )) during the sars period. this evidence indicates that the neonatal mortality rate in areas with large hospitals was significantly lower than predicted, despite the shift of childbirth services to local community hospitals during the sars epidemic. with the aggregation of the county data from year to year , we recalculated total neonatal mortality rates of the pooled data and estimated a linear regression model with "month" and "trend" variables. table presents the observed monthly mortality rates and predicted mortality rates of year , which provides the comparison of the predicted errors of four months before the sas, of the sars period and of four months after the sars period. similar to the results of monthly county mortality rates, the analysis of the aggregated data shows negative predicated errors during the sars period of may -august . the aggregated data of counties with large hospitals demonstrates a significant predicted error in july , which indicates that in counties with advanced hospitals of more than , beds, neonatal mortality was significantly reduced in july , despite an increased use of childbirth services in local community hospitals. normal birthweight or low-risk deliveries account for the majority of childbirth experiences. although regionalized perinatal care is well-established for high-risk deliveries, it is crucial to examine the outcomes of normal birthweight deliveries in local community hospitals. the issue of whether high-technology hospitals provide better quality of care for normal birthweight deliveries than small maternity units has been examined extensively; however, the literature shows conflicting results regarding the outcome of normal birthweight infants in local community hospitals [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . due to these inconsistent results, the concern about quality of care as a result of the shifting of maternity services from advanced hospitals to local community hospitals associated with the sars epidemic is understandable [ ] . this study has shown that neonatal mortality during the sars period did not increase. hence, this evidence resolves the questions that lee et al. raised about the impact of sars on the shifting of childbirth services between hospitals of different levels [ ] . we assumed that the majority of the shifts in childbirth services during the sars event involved low-risk deliveries. at present, the national health insurance (nhi) program of taiwan provides ten free antenatal clinics, which help obstetricians in local community hospitals assess high-risk pregnancies that they are then required to refer to regional hospitals and medical centers. furthermore, obstetricians in local community hospitals have also been referring these high-risk patients to medical centers more often, due to the legal concerns associated with the complications inherent in high-risk deliveries and the increased malpractice lawsuits in taiwan. in addition, lee et al.'s study of the impact of the sars epidemic on childbirth shows a . % increase in the cesarean section rate in medical centers, but no increase in the cesarean section rate in local community hospitals during the sars period, which implies that the increased services provided by local community hospitals involved low-risk deliveries [ ] . therefore, our assumption that the majority of childbirth cases that shifted from high-to lower-level hospitals involved low-risk deliveries is reasonable. our results echo the results of similar studies that tracked the outcome of low-risk births [ ] [ ] [ ] [ ] , but contradict pre- dictions of a worse outcome for low-risk deliveries in local community or small hospitals [ ] [ ] [ ] [ ] [ ] . a possible explanation for our findings of the similar outcome in both advanced and local community hospitals is that the analysis is based on the data of the most recent sample period, which is characterized by improved monitoring at local community hospitals. frequent monitoring and quick detection thanks to more advanced technologies, such as bedside monitoring machines, have been allowing obstetricians to take appropriate precautions and avoid compli-cations. however, the results of studies concluding lower neonatal mortality rates in advanced or large hospitals than in local community hospitals sampled the birth data before [ ] [ ] [ ] [ ] [ ] . for example, using german data from to , heller et al. found that birthweightspecific mortality rates were lowest in large delivery units and highest in smaller delivery units [ ] . similar findings were documented in the study with the norwegian data from to [ ] and data from the united states in [ ] . research on birth settings for women with low-risk pregnancies often involves methodological challenges, such as small samples, non-random samples, differences between women who choose local community versus technologyadvanced hospitals, confounding factors associated with inconsistencies in physician behavior, and data limitations [ ] . this study applied a population-based approach to research the change in neonatal mortality during the increased use of local community hospitals associated with the sars epidemic. the exogenous nature of the sars event mitigates the problem of confounding factors as they relate to characteristics of expectant mothers and physician behavior among levels of hospitals. issues surrounding non-random sampling are also moot because we used data on neonatal mortality for the entire newborn population in taiwan between and . furthermore, this study's large sample size of , observations allows us to demonstrate clearly that the shifting of childbirth services among hospitals associated with the sars epidemic did not increase the risk of neonatal deaths. in contrast, we found that the neonatal mortality rate decreased in areas that contained large hospitals which were more likely to incur the shifting of childbirth services. we acknowledge a limitation of this study that we did not directly measure neonatal mortality among hospitals because of data availability. considering the small effect size associated with the impact of a . % service shifting among hospitals, we recognize potential weak statistical power of our sample in concluding the outcomes of different hospitals. however, our result of the subsample with a larger shifting effect is robust against the concern of the impaired childbirth outcome associated with the shifting of childbirth services. this study has important implications for public health policy; in addition to the improved outcome of perinatal care, regionalization of high-and low-risk deliveries leads to better allocation of health-care resources and cost savings for the health-care system. in response to the escalation of health expenditures, health planners can not only maintain quality of care, but also better allocate resources and minimize costs by encouraging the use of less expensive healthcare facilities for low-risk deliveries whenever possible. regionalized perinatal care ensures that highrisk deliveries that require more sophisticated equipment and care are referred to technologically advanced hospitals. the concentration of high-risk deliveries in a smaller number of advanced hospitals increases patient volume in neonatal intensive care units (nicus), and leads to better outcomes for high-risk infants [ ] . hence, regionalized perinatal care has efficiently allocated expensive resources of advanced hospitals to high-risk infants who are most in need of help and has provided better quality of care for these babies. in acknowledging governmental budget constraints and the need for efficient allocation of health-care resources to enhance the quality of childbirth care, we emphasize the importance of routine antenatal screening services and a well-established referral system for high-risk pregnancies. this study shows that it is possible to successfully shift low-risk deliveries from advanced hospitals to local community hospitals without impairing childbirth outcomes. the shift allows for a more efficient use of resources because low-risk deliveries seldom need high-technological medical facilities, such as nicus. in addition, the shifting of childbirth services to local community hospitals would likely reduce patient travel and wait times and, thereby, increase the accessibility of care. however, public perception that technologically advanced hospitals provide a safer environment in which to deliver can discourage low-risk expectant mothers from using local community hospitals. policy makers should therefore encourage pregnant women to seek childbirth services in local community hospitals in combination with providing antenatal screening services and appropriate referrals. although it has not been documented conclusively whether or not advanced hospitals provide better care for normal birthweight deliveries than small maternity units [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , this study has demonstrated that childbirth outcomes were not influenced by the shift in maternity services to local community hospitals during the sars epidemic in taiwan. there was no significant change in neonatal and maternity mortality associated with the increased services in clinics and community hospitals, implying that local community hospitals provide similar quality of maternity care for low-risk births as advanced hospitals. therefore, this study offers a potentially costefficient strategy for public health planners by providing evidence that can be used to encourage low-risk expectant mothers to seek childbirth services in local community hospitals. the provision of antenatal screening services and the implementation of an effective referral system for high-risk deliveries must also be in place. shh contributed to the design and the analysis of the data, commented on the interpretation of the results, and completed the writing of the article. lkc collected the data and contributed to the interpretation of the results and writing of the article. all authors reviewed and approved the final draft of the manuscript. identifying the sources of the recent decline in perinatal mortality rates in california a review of perinatal mortality in colorado, to , and its relationship to the regionalization of perinatal services the regionalization of perinatal services: summary of the evaluation of a national demonstration project newborn intensive care and neonatal mortality in low-birthweight infants. a population study association between level of delivery hospital and neonatal outcomes among south carolina medicaid recipients changing patterns in regionalization of perinatal care and the impact on neonatal mortality is obstetrics safe in small hospitals? evidence from new zealand's regionalised perinatal system perinatal mortality distributed by type of hospital in the central district of helsinki, finland the choice of place of delivery: effect of hospital level on mortality in all singleton births in new york city the relationship between neonatal mortality and hospital level perinatal mortality rates in isolated general practitioner maternity units neonatal mortality in normal birth weight babies: does the level of hospital care make a difference? hospital setting and fetal death during labor among women at low risk relation between size of delivery unit and neonatal death in low risk deliveries: population based study are we regionalized enough? early-neonatal deaths in low-risk births by the size of delivery units in hesse the impact of the sars epidemic on the utilization of medical services: sars and the fear of sars the immediate effects of the severe acute respiratory syndrome (sars) epidemic on childbirth in taiwan birth setting for low risk pregnancies the effects of patient volume and level of care at the hospital of birth on neonatal mortality the authors thank robert kane for his valuable comments and tim hanson for his helpful statistical comments. the authors also thank the associate editor and the reviewers for their helpful comments and suggestions. sars: severe acute respiratory syndrome; irb: institutional review board; ci: confidence interval; nicu: neonatal intensive care unit; nhi: the national health insurance the authors declare that they have no competing interests. syw planned and designed the study, collected and analyzed the data, interpreted the results, and led the writing. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /prepub key: cord- -ef xg q authors: kelen, gabor d; kraus, chadd k; mccarthy, melissa l; bass, eric; hsu, edbert b; li, guohua; scheulen, james j; shahan, judy b; brill, justin d; green, gary b title: inpatient disposition classification for the creation of hospital surge capacity: a multiphase study date: - - journal: lancet doi: . /s - ( ) - sha: doc_id: cord_uid: ef xg q background: the ability to provide medical care during sudden increases in patient volume during a disaster or other high-consequence event is a serious concern for health-care systems. identification of inpatients for safe early discharge (ie, reverse triage) could create additional hospital surge capacity. we sought to develop a disposition classification system that categorises inpatients according to suitability for immediate discharge on the basis of risk tolerance for a subsequent consequential medical event. methods: we did a warfare analysis laboratory exercise using evidence-based techniques, combined with a consensus process of expert panellists. these panellists were asked to define the categories of a disposition classification system, assign risk tolerance of a consequential medical event to each category, identify critical interventions, and rank each (using a scale of – ) according to the likelihood of a resultant consequential medical event if a critical intervention is withdrawn or withheld because of discharge. findings: the panellists unanimously agreed on a five-category disposition classification system. the upper limit of risk tolerance for a consequential medical event in the lowest risk group if discharged early was less than %. the next categories had upper limits of risk tolerance of about % (iqr – %), % ( – %), % ( – %) and % ( – %), respectively. the expert panellists identified critical interventions with a likelihood of association with a consequential medical event if withdrawn, ranging from to on the -point scale. interpretation: the disposition classification system allows conceptual classification of patients for suitable disposition, including those deemed safe for early discharge home during surges in demand. clinical criteria allowing real-time categorisation of patients are awaited. the ability to provide medical care during sudden increases in patient volume during a disaster or other highconsequence event is a substantial concern for health-care systems. history has shown that during disasters and epidemiological outbreaks, hospitals take the burden of caring for the sick and injured. [ ] [ ] [ ] [ ] [ ] [ ] in most major city hospitals, inpatient capacity is constrained on a daily basis. [ ] [ ] [ ] thus, hospitals are concerned about maintenance of inpatient capacity during normal operating conditions, and they are developing methods to improve resource capabilities during surges. , several measures have been suggested for the creation of hospital surge capacity. [ ] [ ] [ ] [ ] [ ] these include: cancellation of elective admissions and operations; redesign of current inpatient space to accommodate more beds when needed; opening of unlicensed or unstaff ed beds; rapidly outfi tting temporary nearby space, such as cafeterias or outpatient facilities; or deployment of temporary portable inpatient units. all these possibilities present unique operational challenges, such as imposition of unpractised routines in the context of rapid incremental demand for inpatient census. furthermore, most options need hospital staffi ng to be increased at a time when the case-mix index can also be expected to increase. however, during some publichealth emergencies, especially those of a com municable nature, hospitals are likely to have substantial reductions in available staff , as happened during the severe acute respiratory syndrome outbreak. [ ] [ ] [ ] thus, for acute-care hospitals, a means to achieve maximum availability of capacity resources to allow for the care of victims of a disaster is a priority. one novel approach to capacity management during disasters is reverse triage, which includes the safe discharge of current inpatients and refocus of hospital resources to those in even greater need. patients might be discharged home, to facilities set up to care for less acute inpatients (eg, public-health contingency stations specifi cally designed for this purpose), nursing homes, or other acute-care facilities. thus, a need exists to develop an easy method to categorise hospital patients for safe discharge to suitable venues (including early discharge home), taking into account the existence and competence (or lack thereof) of available external resources. we report the fi rst phase in the development of inpatient disposition criteria for the creation of hospital surge capacity during catastrophic or high-consequence events. the aim of this phase was to develop a disposition classifi cation system (reverse triage) based on risk tolerance of a consequential medical event as a result of discharge; assuming that critical interventions were withdrawn or withheld. we focus on the main components of the fi rst phase: ( ) conceptualisation of the disposition classifi cation system; ( ) development of operational defi nitions of consequential medical events and critical interventions; and ( ) derivation of risk estimates related to early discharge from a multidisciplinary panel of experts. subsequent phases of this project will use clinical data obtained from nearly hospital patients to examine the validity of the classifi cation system to correctly identify those who can be discharged early. we used evidence-based materials combined with an expert panel consensus that was approved by the institutional review board on human subjects research. we hosted a warfare analysis laboratory exercise, which was developed by the johns hopkins applied physics laboratory in . the exercise uses networked computers that allow anonymous participation through streaming comments entered into individual laptops by panellists. expert panellists ( clinicians or practitioners, nonclinicians, or non-practising clinicians) took part in the -h exercise. conference organisers determined the composition and the variety of desirable backgrounds of the panel members, who were then identifi ed and specifi cally invited. all panellists were involved in health care, but represented diverse perspectives, including those of nonclinicians. the composition of the expert panel is shown in panel . of the participants were from various components of the johns hopkins medical institutions, and eight were from outside agencies and institutions. almost all the local panellists had experience in other health systems in the usa, and four had experience in other countries. those from the home institution represented three distinctly diff erent establish ments: a major academic health centre, an affi liate teaching centre, and a community hospital. four of the authors participated in the panel discussions. individual panellists received a detailed manual of background information on the day's proceedings, goals, objectives, and expectations from the expert panel. need for written informed consent for participation was waived by the institutional review board on human subjects research because all written comments and risk estimates made by the panellists were anonymous and could not be linked back to an individual. the warfare analysis laboratory is a specialised facility equipped with a network of laptop computers, an integrated audio and visual infrastructure with six large-screen, high-resolution, interactive three-dimensional computer graphics display monitors, a designated data-analysis station, and a -seat observation gallery. plans, defi nitions, and assumptions can be displayed on large-screen monitors at the front of the room. one or more of the screens can be dedicated to continuous display of anonymous comments from panellists on each networked computer in real time. items that need opinions or need to be voted on can also be processed and displayed in real-time. computer comments are numbered consecutively to help with responses to specifi c statements. the exercise is a formally defi ned process and is further described elsewhere. the warfare analysis laboratory has a professional team that oversees the process. a trained facilitator guides the process, allowing for discussion of key issues, and maintaining the focus on the day's objectives. before the exercise was started, eight consensus panel organisers held two separate full-day rehearsals for the conference, to ensure that presentations, discussion, and voting would go smoothly. on the day of the exercise, panellists were shown how to use the facility and computer data-gathering techniques with presimulations unrelated or indirectly related to the planned session. panellists were then exposed to short formal presentations on disaster management, surge-capacity concepts (fi gure), notions of risk and risk tolerance in health care, an overview of the project, and rationale and specifi c objectives. evidencebased information was presented about decision-making devices (eg, patient outcomes research team [port] and acute physiology and chronic health evaluation [apache] iii), peer-reviewed publications, and data for adverse events, readmission rate of discharged patients, and iatrogenic events related to being in hospital. the tasks of the expert panel during the exercise were to: ( ) develop an evidence-based disposition classifi cation system for discharge or transfer based on tolerance for the occurrence of a consequential medical event or the need for a critical intervention during the ensuing h after discharge or transfer; ( ) develop consensus defi nitions of consequential medical event and critical intervention; ( ) assign, for each category of the system, the panel's tolerance for a subsequent consequential medical event, or need for an in-hospital critical intervention; and ( ) compile a list of ( ), psychiatry ( ), infectious diseases ( ), obstetrics/gynaecology ( ), oncology ( ), paediatrics ( ), paediatric emergency medicine ( ), general surgery, paediatric surgery ( ), critical care/anaesthesiology ( ), cardiology ( ), nephrology ( ), trauma surgery ( ), ear nose and throat ( ), military surgery ( ), military emergency medicine ( ), military psychiatry ( ) obstetrics and gynaecology ( ), psychiatry ( ), internal medicine ( ), emergency medicine ( ), surgery ( ), paediatrics ( ), military ( ), oncology ( ) disaster management ( ), disaster and military triage ( ), hospital epidemiology ( ), research methodology ( ), risk management ( ), hospital administration ( ), home health services ( ), social work ( ), medical law ( ), medical ethics ( ), patient safety ( ), data analysis ( ), military public health ( ), city and state public health ( ), public health ( ), public health preparedness and response ( ), homeland security ( ), prehospital care ( ), international health care ( ) numbers in each category are shown in parentheses. some physicians and experts are included in more than one specialist area. critical interventions that would imply the need for continued stay in an acute-care hospital. discussions were held of assumptions to be used for defi nition of the disposition classifi cation system. panellists were presented with proposed assumptions developed by the project leaders and were invited to criticise and include additional assumptions. final assumptions under which the conference proceeded are shown in panel . panellists were shown examples of classifi cation systems used for clinical decision making. [ ] [ ] [ ] [ ] the notion and number of categories were discussed by panellists both via open comment and anonymous computer input. discussion focused on dispositions that defi ne severity of illness and likelihood of treatable complications. the process also included a discussion on the language used to defi ne the categories to help with assignment of tolerance of risk for a consequential medical event. consensus was reached about the number of categories based on tolerance for a consequential medical event. to determine into which category of the disposition classifi cation system a patient falls requires the assessment of risk for a consequential medical event. assessment of risk took into account the possibility of medical deterioration, a new medical event, or the untoward eff ect of the withdrawal of a continuing treatment (ie, withdrawal of a critical intervention). the consensus defi nition of consequential medical event developed by the panellists was: unexpected death, irreversible impairment, or reduction in function within h of hospital discharge for which an in-hospital critical intervention would be initiated to stabilise or ameliorate the medical disorder or disorders. panellists reasoned that medical events were consequential only if acute in-hospital treatment or intervention was needed. thus, when the probability of a consequential medical event was determined, the panellists agreed that likelihood should be judged on the basis of need for a new or continuing in-hospital treatment, termed critical intervention. thus, failure to initiate or continue a critical intervention risked a consequential medical event. to orientate panellists with respect to tolerance of risks taken in daily medical care, panellists were presented data for: -day and -day readmission rates taken from adult discharges during year ( ) for various medical services from one of our hospitals (unpublished data), as well as data of baseline inpatient hospital errors from the institute of medicine. risk, consequential medical event, and the defi nition of critical intervention were then discussed in detail. after the defi nitions had been decided on, the panellists voted to defi ne the upper limit of acceptable risk for the occurrence of a consequential medical event (ie, need for critical intervention), for each of the categories of the disposition classifi cation system. voting was on a scale of - %, with votes given to one decimal point. results of the fi rst vote were revealed and further discussion ensued. a second (and fi nal) consensus vote was then taken. after discussion, a consensus defi nition of critical interventions was formed and became embedded in the defi nition of consequential medical event, as noted above. panellists were then presented with a list of critical interventions to consider, and asked to validate or criticise each in view of the consensus defi nition. a list of possible candidate critical interventions was initially developed by the conference organisers. all panellists were allowed to suggest and add interventions to the list. panellists with clinical experience or responsibilities were then asked to rank on a likert scale of to (whole numbers only), how likely, in their opinion, the withholding or withdrawal of • panellists should think globally and not specifi cally about their facilities • the hospital will remain functional (ie, not a target of terrorist threat or disaster) • government and other disaster response will occur • disaster plans will exist • health-care system will recover or be aided within - h • assume ability to smoothly discharge or transfer patients (specifi c logistical issues will be considered separately). • a model to compare risk profi les of competing new patients requiring hospital resources exists • hospital liability protection exists or is not an issue • inpatient beds could be redistributed across various services • quality of care will not be compromised • only basic (non-professional or family) care will be available to patients discharged into the community (relatives, shelters, or home) • hospital patients with dismal prognosis will be considered separately • other eff orts to improve surge capacity will be continuing each of the listed critical interventions would lead to a consequential medical event. a score of ten was deemed to be synonymous with certainty of a consequential medical event, whereas a score of one implied virtually no associated risk with withholding or withdrawing the specifi c critical intervention. panellists without clinical experience or responsibilities participated in discussions, but did not vote. separate votes were taken for withholding and withdrawing the critical intervention. data generated by these votes were presented. after further discussion, a fi nal vote was taken. data were recorded and stored in a database and were then tabulated. only the fi nal votes were used for analysis. data only from clinicians were used for those questions requiring clinical expertise (clinicians could be identifi ed because they logged on as "clinician" rather than "nonclinician"). because the warfare analysis laboratory exercise requires anonymity in recording participant responses, subgroup analyses by medical specialty were not possible. the study sponsor had no role in the study design, data collection, data analysis, data interpretation, or the writing of the report. the corresponding author had full access to all data in the study and had fi nal responsibility for the decision to submit the paper for publication. the panellists agreed that a fi ve category disposition classifi cation system was optimum, for the intended task (table ) . consensus was reached on the understanding and wording of the categories. the upper limit of risk tolerance for a consequential medical event for the fi rst category was less than %. this category represented patients who the panellists judged to be at low risk of a consequential medical event if discharged early; on the assumption that no skilled medical care was available outside the hospital setting. an example would be a patient admitted for intravenous antibiotics for uncomplicated cellulitis, who could readily be discharged and switched to oral medication. the next categories had upper limits of risk tolerance of about %, %, %, and % respectively. the panellists agreed that category represented those patients who, although at some risk of a consequential medical event, might nonetheless warrant discharge if surge capacity was needed for victims of a disaster; especially if incoming victims are at higher risk of consequential medical event than those patients considered for discharge. panellists also agreed that this category of patients could warrant discharge in certain biothreat or other contagion situations in which spread of disease in hospitals would present a substantial added risk. an example would be a patient with acute coronary syndrome with no evidence of high risk for adverse events. category represented patients who were potentially suitable for transfer to another medical facility. as a group, the risk was judged too high for simple discharge home. an example would be a stable elderly patient who is progressing well days after hip-fracture surgery. category patients were those at substantial risk and judged likely to need continued acute-hospital resources. examples of such patients include those in need of emergency surgery, those in need of pressors, and those in active labour. finally, category patients were those who might be too unstable or critically ill even for transfer to another appropriate facility. most of these patients would require specialised medical care. most patients in intensive-care units would be in this category. table shows the consensus list of critical interventions that if withdrawn would result in a consequential medical event. less than half the critical interventions were assessed as or higher (on a scale of - ). only two-thirds were ranked higher than . for every situation, panellists' scoring for critical interventions that were withdrawn compared with those that were not available or withheld was much the same as that for critical interventions that were withheld. we have proposed the notion of in-hospital disposition classifi cation scheme (reverse triage) of inpatients to deal with increased hospital demand during high consequence disasters. a system of patient categorisation based on risk tolerance developed by an expert panel provides a context for further work to determine which patients can be safely discharged early at the time of overwhelming need for hospital-based resources. mean upper limit of tolerance for consequential medical events (iqr) high consequent events are disasters that overwhelm local or regional infrastructure including the health system. the need to plan for and increase hospital capacity during high consequence disasters is now a standard recommendation. , many techniques have been suggested, such as cancellation of elective admissions and surgeries, opening of licensed but unstaff ed beds, use of other spaces that can be readily converted for clinical use, and triage and treat off site as many victims as possible. most of these techniques need increased staffi ng at a time when either staff are not available, staffi ng is degraded because of the disaster itself, or staff are co-opted by the public-health system for other needs. volunteer staff who are unfamiliar with hospital routine, remain an untested resource, and have yet to be shown as valuable for augmenting hospital capacity in any disaster. thus, other ideas for increasing or preserving capacity become important. much has been written about the appropriate triage of disaster victims. the focus is to concentrate resources on the most severely injured or ill who are likely to survive with defi nitive medical care. [ ] [ ] [ ] one way to create hospital surge capacity-through reverse triage-has received scant attention. in military terms, reverse triage refers to treating those who are not seriously injured fi rst to allow them to return to the battlefi eld sooner. here, we expand the notion to the civilian medical model and include consideration of early discharge of the least sick. with present constraints on hospital capacity, making the most of available resources, rather than hoping that plans to augment them can be implemented, becomes an important consideration. patients are generally not discharged from hospitals if a consequential medical event is potentially foreseeable. however, a zero risk policy, although desirable, is not feasible. forster and colleagues report that up to % of discharged patients have an adverse event in the immediate ( week) post-discharge period. despite a strong patientsafety movement today, zero risk for an out of hospital consequential medical event as a condition of discharge is not attainable, and must be balanced against risk tolerance for various medical adverse events, including iatrogenic ones. , [ ] [ ] [ ] [ ] [ ] despite the accepted risks discussed, our experienced panellists were reluctant to ascribe a substantially higher risk to the category patients. even the risk tolerance assigned for category patients can be regarded as conservative in view of the complex issues faced in major disasters. if a % risk of a consequential medical event is accepted, as was the consensus for category , the rate is still much less than the adverse event rate reported by forster. the iqr for votes on categories , , and were fairly narrow, indicating a cohesive consensus. however, the iqr for categories and were quite wide. categories and would be unlikely to be discharged. this report represents the fi rst part of a multiphase study. once the categories are established, the next step will be to derive a system that allows classifi cation of individual hospital patients in real time. to accomplish this, measurable outcomes and prognostic variables are required. the panel initially defi ned critical interventions as a means to understand the notions of risk. however, the consensus critical interventions will also serve as the outcome measures in subsequent studies. what constitutes a consequential medical event is subjective. thus, the critical interventions that are the outcome proxy measures were weighted for likely importance. future analysis will consider the accuracy of such weighting. the ultimate goal is to produce a disposition classifi cation system that guides clinical decision making during a disaster in a manner similar to the use of the apache score , or port score in everyday clinical practice. in view of the increasing trend toward electronic medical data, prognostic variables of potential interest-eg, vital signs, key laboratory values, diagnostic considerations, co-morbid conditions-could be captured and continuously updated in real-time. thus, in the event of a disaster, patients would be predesignated for the lowest risk disposition options, through the use of a system such as the one proposed here. if such a system were in place, each patient would have a continuously, updated reliable risk score to assist in disposition making. starting with those with the lowest risk, discharges would take place in an ascending order of risk. furthermore, in the future when prognostic scoring of risk for pre-hospital or emergency-department based disaster triage are developed and reliable, the entire demand for inpatient resources from all sources can be simultaneously ascertained and decisions made accordingly. the value of such a device is not only to augment surge capacity, but also to help with rapid decisions when complete or part hospital evacuations are required, such as happened during hurricanes katrina and rita, and the severe acute respiratory syndrome epidemic in toronto. a further and potentially important value of the development of a risk-based disposition classifi cation system is that it is also designed for everyday hospital use. emergency departments in many parts of the world are often overcrowded, mainly as a result of severely restricted in-patient capacity. thus, on a small, but real scale, disaster-like settings arise every day. the device being developed here could have a substantial eff ect on the safe management of hospital capacity on a routine daily basis. in fact, preliminary data from the next phase of the study, available at this time, show that such a device might prove useful for such dual purpose. simulating a disaster, we randomly sampled non-intensive-care unit adult patients from medical units in our three-hospital system during weeks. of the patients sampled, ( %) were discharged routinely on the day of the disaster. of the remaining patients, ( %) either had no critical interventions or were discharged in any event during the next h. although full analysis remains to be completed, these data are consistent with those reported by davis and colleagues. physicians and nurses in this study opined that about % of patients were dischargeable during h. when controlling for patients in intensivecare, the proportion of capacity is similar to ours. finally, a study from a tertiary-care teaching hospital in the uk, also using opinion survey of nurses showed that more than a third of inpatient beds (including those in intensive-care units) could be made available within - h of a disaster if increased care were available in the community. the fundamental problem with estimation of capacity on the basis of opinion surveys is absence of evidence that the estimates would result in safe practice. furthermore, as in the case of the uk study, which called for aug mentation of community resources, it is unclear whether these resources could reasonably be increased during catastrophic events. our approach is to establish the scientifi c basis for a practice that can be modifi able for use both daily and during catastrophic events. comments are needed on concerns that might be raised about the work presented here. the expert panellists were from a wide array of professions. although many of the panellists have varied geographic and institutional experience, we did not attempt to ensure that every hospital structure and size was represented by all disciplines. thus, inherent geographic or regional bias in the established ranges of risk tolerance could have occurred. however, as noted, about % of the panel were not from our system, and most of the panellists had other national and international experience. even so, the model described is suffi ciently robust that risk tolerance notions can be scaled to an individual hospital and even an individual service. if adopted for daily routine use, risk tolerances for categories and might change or be subject to local customs. we did not consider patient or lay perspectives, but again, the variables of the proposed device can be modifi ed in those settings that wish to consider such views. also, simulations used here might not represent reality, but most disaster planning is based on simulated exercises due to an absence of empirical data. furthermore, other systems have been developed on the basis of clinical judgment, in the absence of empirical data. one example is the abbreviated injury scale, , which was originally based on clinical-judgment ratings, and has subsequently been shown to be both valid and reliable in measuring injury severity. more recently, hick and o'laughlin, using a less structured consensus format, developed an ethical framework for the distribution of scarce intensive-care-unit resources during disasters. the - h period of concern is not arbitrary. generally local resources are highly stressed for this duration in the aftermath of a severe and sudden disaster. , in fact, the us joint commission on accreditation of healthcare organizations position on hospital preparedness states that hospitals should "ensure a - hour stand-alone capability through the appropriate stockpiling of necessary medications and supplies." other systems for augmenting surge capacity resources, including those defi ned by the national incident management system, are activated within our period of concern. thus, external validation of our approach by the general community is needed, and this report serves as an appropriate foundation for such discussions. the next step is to derive a real-time decision rule or scoring system based on clinical variables that allows accurate categorisation of individual patients, followed by prospective validation. the experience of st vincent's hospital, manhattan two new york city hospitals' surgical response to the emergency department impact of the oklahoma city terrorist bombing severe acute respiratory syndrome and critical medicine: the toronto experience tornado: assessment of the trauma system 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hospital in the madrid report of the events and the prehospital emergency response can external signs of trauma guide management? lessons from suicide bombing attacks in israel the incidence and severity of adverse event aff ecting patients after discharge form the hospital incidence of adverse events and negligence in hospitalized patients: results of the harvard medical practice study i the nature of adverse events in hospitalized patients: results of the harvard medical practice study ii institute of medicine medical error fi gures are not exaggerated deaths due to medical errors are exaggerated in the institute of medicine report creation of health system surge capacity by the immediate discharge of inpatients hospital bed surge capacity in the event of a mass-casualty incident accelerated discharge of patients in the event of a major incident: observational study of a teaching hospital rating the severity of tissue damage: i. the abbreviated scale rating the severity of tissue damage: ii. the comprehensive scale concept of operations for triage of mechanical ventilation in an epidemic state and regional responses to disasters: solving the -hour problem learning from disaster: the role of federalism and the importance of grassroots response national incident management system this study was sponsored by funding from the agency for healthcare research and quality (u hs - ). data in this manuscript were presented, in part, at the th world congress of disaster and emergency medicine, may , , edinburgh, scotland. key: cord- - ixylnny authors: gupta, shaili; federman, daniel g. title: hospital preparedness for covid- pandemic: experience from department of medicine at veterans affairs connecticut healthcare system date: - - journal: postgrad med doi: . / . . sha: doc_id: cord_uid: ixylnny the – pandemic coronavirus disease (covid- ) has inundated hospital systems globally, as they prepare to accommodate surge of patients requiring advanced levels of care. pandemic preparedness has not been this urgently and widely needed in the last several decades. according to epidemiologic predictions, the peak of this pandemic has still not been reached, and hospitals everywhere need to ensure readiness to care for more patients than they usually do, and safety for healthcare workers who strive to save lives. we share our hospital-wide rapid preparedness and response to covid- to help provide information to other healthcare systems globally. coronavirus disease (covid- ) caused by severe acute respiratory syndrome coronavirus (sars-cov ) originated in wuhan, china, quickly became a global pandemic, and has impacted the u.s.a. at an extraordinary pace. within three months from the first diagnosed case of covid- in the u.s. a. in late january , the number of sars-cov -infected individuals in the u.s.a. is close to a million, and the number of casualties have surpassed , [ ] . globally, sars-cov has infected millions, with an overall case fatality rate of > . % [ ] . as rapid testing becomes more readily available in the next few weeks, it is expected that many more cases will be diagnosed, and many of them would need hospitalization for care. the severity of disease in those with the infection has overwhelmed healthcare systems and frontline healthcare providers, and has exhausted resources, revealing how illequipped the world was to handle this pandemic. the peak of this pandemic is expected in the next few weeks, when a surge of hospital admissions for covid- will emerge globally [ , ] . in the u.s.a., while currently covid- seems to preferentially be affecting densely populated urban areas, this pandemic will likely impact other urban as well as rural areas soon. healthcare centers everywhere should prepare to implement measures for an efficient hospital-wide approach to manage the imminent surge in hospitalized patients with covid- . connecticut is one of the states impacted heavily and early by covid- [ ] . we present an outline of how connecticut veterans affairs healthcare system prepared for this pandemic in order to share our experience, and hopefully help inform other facilities across the country and globally. response to pandemic is a multi-disciplinary team effort with efficient leadership that meets several times daily to work at a quick pace in order to make effective implementation of preparatory measures before the actual arrival of the first infected patients, followed by a continuity of the same diligence to ensure modifications in plans as needed and addressing new demands as they arise. one of the first steps taken at our institution was the organization of an incident command center (icc) that comprised of leaders from all pertinent institutional departments in order to have an effective team leading the preparation for our pandemic response. . icc was also accessible around the clock via a unique e-mail address, which any hospital employee with either potentially helpful suggestions or questions could write to and obtain answers expeditiously. this centripetal, accessible, and highly motivated approach of management, we find, has been an important reason why our preparedness was both rapid and effective. . the covid response coordinator (author dr. gupta) streamlined both the influx of preparation needs for the icc to potentially act on, and the administrative coordination of hospital-wide preparedness based on icc policy decisions. additionally she created protocols for well-informed care of patients, enhanced the education and protective measures for hcws including residency trainees, developed a clinical algorithm to guide judicious testing, and participated in covid- treatment group meetings at other institutions to help create or modify local treatment algorithms. . the participative leadership style of hospital administration was complimented by an affiliative leadership style at department level where developing needs were analyzed in real-time, interactive and intimate feedback from all levels of staff was encouraged, attempts were made to foresee problems that the frontrunners would confront, solutions were provided to problems as they emerged, and policies were implemented as envisioned by the administration. . several committees and subcommittees conducted specialized work. delegates from several committees would report back on committee decisions, so that a cohesive overall structure of all plans could be maintained. these committees included research and ethics committee, treatment committee, code and emergency response committee, discharge and post-discharge planning committee, scarce resource allocation committee, and a committee that included members of our ethics team and palliative care service to guide policy on the triaging of patients in case of bed shortages. critical care staff underwent training and refreshment courses for proning, extracorporeal membrane oxygenation (ecmo), minimization of bedside personnel while still providing stateof-the-art care during high-aerosol generating procedures, etc. . gatekeeping: screenings at entrances, off-site testing, emergency room safeguards va connecticut was the first healthcare system in the state to enact several measures within a week of the first case reported on the east coast and days after the first case reported in the state. these measures were fully implemented sequentially within weeks from initiation. . all elective and non-emergent procedures were canceled or postponed. outpatient clinics underwent a rapid succession of conversion to video-medicine clinics. va has been a national leader in clinical video medicine to reach patients living far away from the va hospitals and clinics, and the conversion from inperson clinic visits to video visits was effortless and immediate. when video visits were not feasible, telephone clinics were established. . letters were mailed to patients advising them to call their primary care providers before arriving at hospital if they had fever or respiratory symptoms. physicians staffing the call centers provided stay-at-home and social distancing counseling, as well as individualized education on symptoms that should prompt a hospital visit. . off-site testing centers were erected to conduct outpatient drive-up testing for patients who were thought to have suggestive symptoms. . visitation to inpatients underwent a rapid sequential limitation to eventual complete barring of all visitors to the hospital without an approval from our central command. . our major healthcare facility, the west haven va, has multiple entrances for patients and employees. as part of the covid response, entrance to our hospital was limited to the emergency room (er) and two manned entrances where primary screenings were conducted on everyone entering the facility, including questions about exposure to covid , personal symptoms and signs, and temperature checks. those who failed primary screening received a secondary screen by a physician who examined and collected samples for testing as indicated. . the er underwent an expeditious transformation so patients could be evaluated in private rooms. every patient arriving into er was given a mask to wear, until evaluation and triage by er physicians. engineering and facilities management were able to convert some non-negative pressure rooms to negative pressure rooms. . all hcws as well as ancillary staff were provided surgical masks in an attempt to prevent nosocomial transmission of sars-cov . this was implemented after a patient initially admitted to the psychiatry locked unit for non-covid-related reasons tested positive days later after the development of new cough and fever, which raised concern for pre-symptomatic phase of covid- among patients, and for potential transmission of virus by asymptomatic hcws. . droplet precautions, personal protective equipment (ppe), social distancing . cdc guidelines for respiratory isolation with airborne precautions were followed as implemented by heip. negative pressure rooms were used for all patients being admitted with suspicion of covid- until it was ruled out by testing. distinct covid units were created in the hospital. private rooms were also prepared for a surge of patients if needed. strict protocols were instituted for any aerosol-producing procedures including nasopharyngeal sample collection, nebulizer administration, and intubation. full ppe [gown, gloves and either n- respirator with face shield, or powered air-purifying respirator (papr)] was ensured to prevent infection among hcws. . regular trainings, fit testing, and educational sessions on donning/doffing were conducted to ensure hcws were fully conversant in ppe. . 'buddy system' was encouraged as a culture so that hcw would be helped and watched by another hcw while donning and doffing the ppe to ensure correct steps, and to avoid accidental contamination of self or environment. hcws providing care to covid- positive or person under investigation (covid-pui), while still ensuring state-of-the-art care and management. this helps protect hcws from unnecessary exposure and save ppes, which are still in short supply. this was achieved by indepth education to hcws on novel way of providing healthcare. patient rooms were equipped for video surveillance and in-room phones so that providers could gather the bulk of history by speaking to the patient via phone while watching them on the video. i-pads were also issued to patients so that they could interact with providers and 'virtual visitors'. a protocol for cleaning of i-pads was disseminated. providers were trained to conduct team huddles to review all data they would need, examination findings they would look for, and information they would provide to the patient at bedside before one of the team members entered the covid-pui room. bedside physician visit for uncomplicated patients was limited to one physician per visit per day when medically feasible. consults were encouraged to be electronic/virtual too, if possible. . nursing care was similarly streamlined with strictly enforced ppe measures and provision of care with bundled approach: carefully planned bedside nursing visit that would provide meal, medications, vital sign checks, and all other required care in the same visit if possible. meal trays were replaced by paper service meals so that leftovers and paper plates/cups could be disposed of into trash, and nursing would not need to enter rooms multiple times to collect the used trays and have others return them for cleaning and re-use. . decontamination of certain equipment with strong disinfectant wipes can reduce the shelf life of such equipment. therefore, while also trying to conserve ppe, modifications were made to some usual practices. instead of taking the computer-on-wheels to the bedside to obtain an electronically signed informed consent, consent for procedures could be obtained via phone from the patient, provided the patient could provide consent, and this conversation was witnessed by another provider. echocardiograms for covid-puis and covid+ patients were limited to critical need only; all routine echocardiograms for these patients as well as all pre-scheduled echocardiograms on stable outpatients were deferred until infected patients were covid- test negative or when the pandemic eased. as medications used for management of covid- can cause qtc prolongation (hydroxychloroquine, azithromycin, etc.), this interval was closely monitored for inpatients via telemetry and calculation of qtc from rhythm strip if possible. this reduced unnecessary exposure by hcw in order to obtain a -lead ecg to calculate the qtc. . simulation was conducted several times for all hcws to be fully conversant on conducting resuscitation and emergency procedures on covid-puis or known covid+ patients, as these involve high-risk aerosolgenerating maneuvers. new policy was instituted that outlined how the code would be announced overhead so that responders would come prepared knowing it was a code for a covid-pui or covid+ patient. rapid and ensured ppe provisions were delineated carefully, measures were placed by anesthesiology for reduction of aerosol generation during code, and number of inroom personnel was streamlined significantly, with predesignated roles in the conduction of resuscitation. a weekly virtual meeting was led by two infectious disease-trained physicians to answer questions by employees and hopefully allay their concerns. . all educational and clinical conferences were immediately converted to virtual meetings to ensure social distancing. workstations were individually assigned to minimize use of shared space/keyboards. a distance of feet between providers was underscored. containers of disinfectant wipes were placed in all workstations. . in order to prepare for inpatients with covid- , negative pressure rooms were needed on regular wards, as well as icu. our facility had a total of negative pressure rooms before the emergence of covid- . within a week, negative pressure was created on an entire floor of the hospital. portable forced air system was used to create such rooms in an icu section too that was devoted to covid- patient care. . icu and on-ward policy of care was devised and revised in real-time to continue state-of-the-art management of covid- patients, with a multidisciplinary team approach, involving general medicine, cardiology, infectious diseases, infection prevention, pulmonary and critical care medicine, and pharmacy. . patients who had been undergoing 'blind rehabilitation' were discharged to open up a floor unit and new admissions to our community living center were stopped. this was done to protect the veterans from acquiring this infection while residing in the hospital, and also to create more rooms for sick patients with covid- . . hcw teams were restructured to provide longer resting periods between service times to allow for de-stressing and for high intensity care during service hours. we made sure to not exclude house-staff from patient care. this was done to allay fears, to enhance preparedness, to strengthen workforce and continue the dedication toward education. medical students were excused from inpatient care, based on acgme policy. . protocols were created with back-up workforce and back-up hospital space to be deployed for anticipated covid- surge in waves. . to facilitate discharge of covid- patients who were not requiring inpatient services anymore, we were able to give each patient a thermometer and home pulseoximeter. we established a hospitalist-led virtual video clinic to allow daily visits with these patients and have them transmit their home data. in addition, covid- also has the notable predicament of a long incubation period that ranges from to days, and often causes a rapid respiratory/cardiac decompensation at any time during the illness [ , ] . therefore, asymptomatic patients who are hospitalized for reasons other than covid- , and who are not tested for covid- upon admission, may develop symptoms during hospitalization and may also become a source of nosocomial infection. until the capacity to test widely and repeatedly becomes available widely, a clinical algorithm that can be used for outpatients as well as inpatients would be helpful. we developed a clinical algorithm to help direct providers toward testing for covid- (table ) . this algorithm is based on review of clinical data from china, italy, and within the u.s.a. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . it can be used by providers to help determine whether covid- is a likely diagnosis for patients in outpatient setting, those being seen in er, and those hospitalized for another reason and later developing suggestive symptoms. clinical judgment must supersede any algorithms. however, this algorithm has been found to be helpful in our institution, and may be found to be useful at facilities when and where ample rapid testing is not available. in order to ensure that the proper ppe were utilized and other specific critical care instructions for covid-puis were carried out, we created a covid-order set for use by ed providers when they admitted a patient as covid-pui, and for use by inpatient providers when they decided to test a hospitalized patient for covid- (table ) . these orders then ensured all necessary instructions were implemented, including covid- precautions/isolation, nursing orders, nutrition specifications, covid-relevant laboratory orders, and telemetry. the toll on frontline workers of a pandemic caused by a virus that is highly transmissible and virulent, especially when combined with lack of appropriate supplies of ppes, can be profound. early intervention, teamwork, self-care and enhancement of existing resilience are all critical for the healthcare providers who are involved in the fight against this pandemic. we therefore sought help from employee assistance program (eap), health psychology, and department of psychiatry to create a robust support system. this system was designed to provide critical and valuable mental health support, acute psychiatric first aid, coping strategies and tools, an app for stress-o-meter to self assess the daily stress burden, and various mindfulness and cheerfulness endeavors and workshops. some of these materials and resources are shared here. pandemic response has never been this quickly needed globally, nor this better informed. the covid- pandemic has occurred in the age of unprecedented global a. new abnormalities in liver tests (ast/alt > iu, bilirubin > mg/dl) b. new elevation of: ferritin (> but < ) or fibrinogen (> but < ) c. leukopenia with tlc < . k d. ldh > or troponin elevation . fever (≥ . ) . new onset unexplained anosmia or ageusia please note: other less common clinical features of covid- include nausea, vomiting, diarrhea, abdominal pain, only rarely seen without other criteria above. connectivity, and has affected countries worldwide, turning necessity of information sharing into a blessing. journals, networks, virtual meetings and conferences, governmental response dissemination systems, and the overall willingness to propagate information and experience have been a remarkable contribution to the preparedness for this pandemic. our experience with hospital preparedness at our facility has been multidisciplinary and effective, largely because of the central incident command body that ensured quick and thoughtful application of measures and helped us organize our covid- response. while some of the measures used at our facility may not be applicable at resource-limited healthcare systems, most of our preparedness steps can be implemented globally, and we share them here to help other institutions learn from our experience, if and as needed. while these are unprecedented and frightening times, a coordinated, facile, and effective response can help minimize the impact of covid- . ward options should only include covid units for floor and icu . for diagnosis: covid-pui forecasting covid- impact on hospital bed-days, icu-days, ventilator-days and deaths by us state in the next months. medrxiv. institute for health metrics and evaluation estimating the number of infections and the impact of nonpharmaceutical interventions on covid- in european countries covid- cases in the us the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china clinical characteristics of coronavirus disease in china. nejm clinical features of patients infected with novel coronavirus in wuhan, china. lancet epidemiological and clinical characteristics of cases of novel coronoavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of hospitalized patients with sars-cov- infection: a single arm meta-analysis chest ct features of covid- in covid- in critically ill patients in the seattle region -case series cdc guideline: evaluating and testing persons for coronavirus diseases the authors would like to thank dr richard sutton (infectious diseases) who helped create the clinical algorithm, christine bihday (eap) who provided the employee mental health support resources, and all the key members of icc at their hospital who brought about this hospital-wide response to covid- , including: al the authors have no conflicts to disclose. this work was not supported by any grant/funding. the contents of the paper and the opinions expressed within are those of the authors, and it was the decision of the authors to submit the manuscript for publication.peer reviewers on this manuscript have no relevant financial or other relationships to disclose. http://orcid.org/ - - - activity: cannot leave room without md order call md: vital parameters for md alert as in original order-set diet: same as standard order set. all meals are to be paper service prefer to have these care times at meal times ± bedtime . use video visit or in-room phone for checking in on patient and to screen for symptoms or changes whenever possible prior to entering room and proceed with bedside assessment only if concerns identified. if patient is unable to effectively communicate by phone/video, perform routine assessment at bedside at preferred care times as above . facilitate video visit or in-room phone for visits by family . md order needed for visitors to enter patient room, even after they obtain permission from the hospital director . nursing to perform phlebotomy for any laboratory tests ordered . nursing to deliver meals at bedside . please ensure patient can reach bedside in-room phone at all times and knows what extension to call to reach nursing laboratory orders:the following orders are automatic, with option for md to override . cbc with differential . key: cord- -kjeqs zh authors: shen, bingzheng; chen, li; zhang, lu; zhang, mengke; li, jing; wu, jie; chen, kunlin; xiong, yuanguo; song, wei; zhou, benhong title: wuchang fangcang shelter hospital: practices, experiences, and lessons learned in controlling covid- date: - - journal: sn compr clin med doi: . /s - - - sha: doc_id: cord_uid: kjeqs zh in early january , the outbreak of the new corona virus pneumonia (corona virus disease , covid- ) occurred. wuhan, the capital city of hubei province, became the epicenter of the disease in china. the rapid growth of patients had exceeded the maximum affordability of local medical resources. a large comprehensive gymnasium was converted into wuchang fangcang shelter hospital in order to provide adequate medical beds and appropriate care for the confirmed patients with mild to moderate symptoms. for these hospitalized patients with covid- , medication became the mainstay of therapy. from th february to th march, a team of pharmacists successfully completed drug supplies and pharmaceutical services for patients and approximately medical staff, and, while doing so, received zero complaint, and experienced zero disputes and zero pharmacist infection. this paper summarizes the development and construction of the pharmacy, human resource allocation of pharmacists, pharmacy administration, and pharmaceutical services. it aims to review a -day period of pharmaceutical practice and serve as a reference for other health professionals working on covid- prevention and treatment in other regions. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. on th december , a confirmed case of the new coronavirus infection of pneumonia, termed corona virus disease (covid- ), was detected in wuhan city [ ] . in a short period of time, the virus spread quickly throughout the country, and the number of infected patients increased rapidly. at the beginning of february , available hospital beds soon reached full occupancy in those hospitals designated for antivirus treatment. to complicate matters further, some medical workers were infected due to occupational exposure, which forced the medical team into quarantine for medical observation. based on clinical manifestations, confirmed patients are divided into mild, moderate, severe, and critical types [ , ] . since more than % of covid- patients were mild or moderate types [ ] [ ] [ ] , a novel public health measure, fangcang shelter hospitals, was conceived [ ] . in case of emergency, these temporary hospitals have been able to provide extra beds capacity at short notice and provide classified treatments. all confirmed patients with mild and moderate symptoms could be admitted to the fangcang shelter hospital for free medical treatment. during the worst epidemic period in wuhan, a total of fangcang shelter hospital were established. wuchang fangcang shelter hospital was developed from the hongshan gymnasium and was one of the first three hospitals accepting patients and was the last one to be closed. it covered an area of , m and housed a total of beds, which were separated across three independent regions in order to optimize management and treatment efficiency. during this major public health emergency, pharmacists, as a member of the medical team, have been responsible for providing professional and superior pharmaceutical services. this paper looks back at the pharmacy construction, occupational protection, pharmacy administration, and pharmaceutical services at wuchang fangcang shelter hospital. these practices and lessons at the forefront of containing the virus may help others in their efforts around the world. the pharmacy of wuchang fangcang shelter hospital was a conversion from two referee meeting rooms in hongshan gymnasium ( fig. a and b) . the two rooms were adjacent and connected by a shuttle door. one room was used as pharmacy, the other served as a level warehouse (fig. c and d) . due to space constraints, there was no room for a level warehouse for medications requiring refrigeration. all central air conditioners were turned off to prevent the virus spreading through the ventilation systems. several household heaters, humidifiers, air purifiers, and refrigerators were used to maintain the appropriate temperature, humidity, and clean air for the storage of medicines. ten pharmacists from renmin hospital attached to wuhan university provided strong support and formed a professional pharmaceutical team ( table ). the pharmacy was open / (pharmacists working -h shifts), enabling the constant availability of pharmaceutical services at all times. considering the long hours, high-intensity, and complexity, most pharmacists working in wucang fangcang shelter hospital were young to middle-aged, well-educated with a master's degree or higher, and with at least years of pharmacy experience. the team of pharmacists was monitored regularly. body temperature was measured twice a day, and nucleic acid and specific antibodies of covid- were tested twice per month. attention was also paid to the staff's mental and emotional health. if necessary, psychological evaluations were carried out, and psychological counseling was provided. the correct use of personal protective equipment (ppe) and regular and thorough hand hygiene were key measures in the prevention and control against infection through contact transmission, droplet transmission, and airborne virus particles. according to the risk of exposure in different working areas, pharmacists took different precautions ( table ) [ ] . various protective measures were taken to ensure that pharmacists provided professional services in a responsible manner. all medications used in wucang fangcang shelter hospital were obtained from three sources: . renmin hospital of wuhan university, which acted as the national general coordinating agency for all medical teams, provided medicines for chronic diseases and firstaid. . some medicines recommended in the diagnosis and treatment guidelines were obtained from wuhan epidemic prevention and control headquarters [ ] . . medicines donated by pharmaceutical companies or charitable organization. the diverse sources of medications added to the need for efficient and accurate pharmacy work, caused many difficulties for the pharmacy administration. the corresponding work processes, including the receipt of medicines, selection, inspection, prescription-checking dispensing, and distribution were established under the unified leadership of wuchang fangcang shelter hospital (fig. ) . according to their characteristics and according to the diagnosis and treatment guidelines, other regulatory documents [ , ] , combined with expert clinical opinions, a list of medicines was determined for infected patients with mild and moderate symptoms. this involved symptomatic treatment, prevention of complications, treatment of underlying diseases, emergency rescue medications, and so on. based on the actual clinical situation, the variety and quantity of medication were regularly adjusted and supplemented. a catalog containing medications was finally revised in mar and showed in table s . the category of medicines in the pharmacy was compatible with the function of the fangcang shelter hospital, and covered antiviral, antibacterial, antipyretic, antitussive, antianxietic, expectorant, and chronic disease medications. it conformed the treatment protocols for covid- , and met the needs of some patients with underlying disease, as well as including first-aid medicines to be able to deal with any sudden incidents. to integrate traditional chinese and western medicine to treat infected patients, kinds of traditional chinese medication, including preventive and therapeutic decoctions for medical staffs and patients (fig. s ) , respectively, were also available. in addition to maintaining a constant and regular supply of drugs, the provision of pharmaceutical services was another important and indispensable duty during the pandemic [ ] [ ] [ ] . relying on the g network and medical information systems, the team of pharmacists accomplished pharmaceutical services smoothly, helping to reduce the risk of occupational exposure in the shelter hospital. pharmaceutical services focused on the following six aspects: . checking medical orders related to the drug therapy . paying attention to the prescriptions for patients with underlying diseases . the suitability of the usage and dosage of the medication . monitoring adverse drug reactions and drug-drug interactions . summarizing and sharing the latest drug information . providing medication-related consultation and education. in some cases, several patients with chronic diseases took repeated medications or overdose. they were admitted to the hospital with their own chronic disease medicines. not clearly understanding the situation, doctors prescribed the same medication or other drugs possessing the same pharmacological effect. to overcome this problem, patients taking chronic disease medicines (such as antihypertensive drugs and hypoglycemic agents) were screened out by the pharmacy information system. as a result, pharmacists could intervene in time on medical orders and prescriptions. the pharmacists also while our understanding of the virus deepens and with the constant improvement of diagnosis and treatment and strategies for prevention and control, pharmacists should continue to actively collect and improve their services based on the latest information. for instance, it has recently been discussed whether or not angiotensin-converting enzyme inhibitor (ace-i) and angiotensin receptor blockers (arbs) increased the susceptibility of covid- . in the pharmaceutical services provided at wuchang fangcang shelter hospital, ace-i and arbs were not recommended, but now, the latest joint viewpoint from three u.s. heart groups states that patients with covid- should take ace inhibitors and arbs [ ] . not to be neglected, the mental health of the pharmacist also requires close attention. having worked in this shelter hospital for days, one pharmacist felt anxious and uncomfortable. tests of viral-specific nucleic acid and antibody were negative and computed tomography reported normal results. after psychological counseling and a brief period of rest, the physical and mental states were greatly improved, and the pharmacist gradually recovered. psychology-related research shows that during the peak of the covid- epidemic in china, more than one-third of medical staffs suffer from insomnia, which may progress to depression, anxiety, and stress trauma [ ] . on march , , wucang fangcang shelter hospital was closed, thus indicating that all of these large-scale temporary hospitals had completed their missions in wuhan. the team of pharmacists has done their utmost efforts to perform their professional duties, ensuring the supply of medicines and providing high-level pharmaceutical services. currently, the covid- outbreak is spreading worldwide, and the situation awaits a vaccine. pharmacists should unite globally to contribute their expertise and strength to help prevent the spread of the virus. acknowledgments in this concerted effort against the covid- virus, thousands of medical staffs in china (doctors, pharmacists, nurses, inspection, and image technicians) put their hearts and souls into curing infected patients, subjecting themselves to huge risk of infection. we thank all pharmacists for their valuable suggestions and great contributions in fighting this epidemic disease. thanks also to all logistics support workers in delivering invaluable protection equipment and living supplies to medical staffs and patients. authors' contributions bs and bz initiated the topic. bs, bz, lc, lz, mz, jl, jw, kc, yx, and ws participated in discussions. bs wrote the first draft of the manuscript. all authors read and approved the final manuscript. conflict of interest the authors declared that they have no conflict of interest. ethics statements not applicable. this is a descriptive and retrospective study that and does not undermine the principles according to the ethical standards of the institutional and/or national research committee and/or the helsinki declaration and its later amendments or comparable ethical standards. clinical characteristics of coronavirus disease in china a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster office of state administration of traditional chinese medicine. diagnosis and treatment protocol for covid- coronavirus disease (covid- ): a perspective from china coronavirus disease (covid- ): current status and future perspectives clinical characteristics and imaging manifestations of the novel coronavirus disease (covid- ): a multi-center study in wenzhou city fangcang shelter hospitals: a novel concept for responding to public health emergencies coronavirus sars-cov- infection: expert consensus of guidance, prevention and control strategy for hospital pharmacy work (the second edition) china national health commission. diagnosis and treatment guidelines for the new coronavirus infected pneumonia international pharmaceutical federation. coronavirus -ncov outbreak: information and interim guidelines for pharmacists and the pharmacy workforce providing pharmacy services during the coronavirus pandemic providing pharmacy services at cabin hospitals at the coronavirus epicenter in china fighting against covid- : innovative strategies for clinical pharmacists covid- and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: what is sn compr survey of insomnia and related social psychological factors among medical staff involved in the novel coronavirus disease outbreak publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations electronic supplementary material the online version of this article (https://doi.org/ . /s - - - ) contains supplementary material, which is available to authorized users. key: cord- -dnuakd h authors: chan, hui yun title: hospitals’ liabilities in times of pandemic: recalibrating the legal obligation to provide personal protective equipment to healthcare workers date: - - journal: liverp law rev doi: . /s - - -z sha: doc_id: cord_uid: dnuakd h the covid- pandemic has precipitated the global race for essential personal protective equipment in delivering critical patient care. this has created a dearth of personal protective equipment availability in some countries, which posed particular harm to frontline healthcare workers’ health and safety, with undesirable consequences to public health. substantial discussions have been devoted to the imperative of providing adequate personal protective equipment to frontline healthcare workers. the specific legal obligations of hospitals towards healthcare workers in the pandemic context have so far escaped important scrutiny. this paper endeavours to examine this overlooked aspect in the light of legal actions brought by frontline healthcare workers against their employers arising from a shortage of personal protective equipment. by analysing the potential legal liabilities of hospitals, the paper sheds light on the interlinked attributes and factors in understanding hospitals’ obligations towards healthcare workers and how such duty can be justifiably recalibrated in times of pandemic. the onslaught of covid- has led to a worldwide race for personal protective equipment ("ppe") ranging from protective goggles, gloves, full face shields, fluid repellent gowns, aprons, surgical masks, and medical equipment such as ventilators and respiratory machines. the british medical association has repeatedly issued urgent pleas to the uk government for the timely supply of ppe for frontline healthcare staff in delivering patient care. frontline healthcare workers without ppe continue to face severe infection risks posed by ppe shortage constitutes a pressure point for healthcare systems, with strong correlations between its scarcity and high covid- infections and death among healthcare workers. covid- has claimed more than healthcare workers' lives, and infected more than , in the usa, while ppe shortage and substandard ppe in spain have resulted in more than , healthcare workers becoming infected. reports of heightened stress experienced by frontline staff are not new; either from the fear of being infected or in transmitting the infections to their families. the shortage has prompted drastic reactions from some governments in downgrading ppe protection standard inconsistent with who advice, inevitably raising questions about harm to healthcare workers. this measure in turn produced several adverse effects on care provision. it has created an exodus of critical healthcare staff due to their inability to continue working. clinical decisions were made to either delay care or minimise the risks of harm (while still working in high risk environments), underscoring rationing in action, and making difficult situations more taxing. although they are not compelled to continue treating patients, the inability to do so generated moral guilt as they see their colleagues on the frontline operating in hazardous conditions. recent developments have witnessed strong responses from the public and healthcare workers, ranging from pursuing legal actions against the government or their employers (hospitals) for breaching their obligations of care towards employees to calling for a full public inquiry into pandemic management, including the status of the ppe stockpile. specific claims by healthcare workers include the legality of guidance on reusing ppe and permitting patients to be treated without ppe in contravention of their right to protection of health and safety at work. this development is not only confined to the uk, as doctors in spain have launched legal actions against the health authorities for breach of duty in ppe procurement failure. considerable coverage continued to be given to issues concerning allocation of scarce resources, the clinical and moral dilemma to treat, and the urgent need to have protective gears for frontline staff. the pressing legal considerations regarding employer's failures in procuring sufficient resources for pandemic purposes remain under-explored. this paper examines how the pandemic affects the obligations of hospitals as employers towards their frontline healthcare staff in fulfilling their responsibilities during pandemic, and the impetus on re-evaluating existing and future legal obligations. it considers the extent to which hospitals have breached their obligations in failing to take appropriate measures to safeguard the health and safety of their employees and to prevent them from being exposed to avoidable risks. while convincing justifications are available regarding the difficult roles of hospitals during pandemic, significantly persuasive arguments can be made for hospitals' liability in breaching their duty to ensure the safety of healthcare workers. these claims will be considered in determining the extent to which such liability can be recalibrated in times of pandemic. while the analyses are drawn from the uk context, the substantive importance is equally relevant as the battle for critical medical supplies is felt across the world. an employer's duty is personal and non-delegable. the employer's duty is one of reasonable care and skill, to provide a safe place and system of work, with adequate plant and equipment, including competent employees and resources, according to the industry and environment in which they operate. such obligations extend to maintaining the equipment and ensuring that they are of sufficient quantity, necessitating regular inspections and monitoring. providing a safe system of work signals a gamut of considerations; ranging from ensuring proper working systems, arrangements and instructions, identifying the purpose of the work, specific tasks and scope to assess risks and install precautionary measures for the employees' health and safety. a system of work thus encompasses an assessment of the adequacy for the "whole course of the job or it may have to be modified or improved to meet circumstances which arise." the consequence of this duty is that the system ought to be reasonably safe, and not perfectly safe, through assessing the inevitable dangers associated with the work, guided by industry norms. these norms often evolve through time and employers must be aware of such developments in updating their emanuel et al. ( ) , ranney et al. ( ) . wilsons & clyde coal company v english [ ] ac , lunney et al. ( , p safety standards to reflect current knowledge based on best scientific evidence. consequently, though it can be suggested that the science of covid- is still developing, the lack of knowledge regarding its effect may not automatically preclude employers from being liable. doctors, surgeons and nurses employed in the service of hospitals are treated as employees under the law and hence they are owed a duty of care. the common law duty of care identified above thus obliges hospitals to provide competent staff, adequate material and a safe, proper system and effective supervision. the extent to which employers ought to provide for ppe invites considerations such as the risk, likelihood, magnitude and consequences of the injury, and the availability and costs of providing such protective equipment. in hospitals, the provision of adequate plant and equipment signifies ppe such as gloves, masks, full length gowns, shields and goggles. hospital working zones have become "contagion hubs" with streams of patients (symptomatic and asymptomatic) receiving care and treatment from healthcare workers. it is reasonably anticipated that healthcare workers are continuously exposed to significant infection risks from treating these patients. the provision of ppe is directly relevant to the work for which healthcare workers are employed to do, and which are normally and reasonably expected to be provided with, consistent with who guidelines for treatment of infectious diseases. the omission to provide ppe to frontline staff unavoidably attracts questions of hospitals' negligence. in determining whether the employers are negligent in failing to remedy the lack of ppe, reference is made to a number of important factors under the common law and statutory instruments. factors that illuminate the liability of the parties, such as the nature of the work, its inherent risks, the (im)possibility of establishing precautionary measures in preventing or reducing the likelihood of risks materialising, the extent to which such measures commensurate with the means and ends, are examined. risk assessments, particularly whether the risks are amplified by the failure to provide in an otherwise acceptable risk in employment, common practices, and resources similarly influence the determination of duty. statutory duties under the health and safety act, regulations on ppe , the relevant guidance issued by the department of health and social care and public health england to healthcare workers are relevant considerations. risk assessment is an important feature in determining the likelihood of injury and whether a breach has occurred in a system of work. it sets the level of reasonableness of precautionary measures against the health and safety risks employees may encounter in the course of their employment. the firemen assuming risks associated with not having a jack fitted in the truck, thus precluding their employers from liability. it has been questioned whether this approach has unjustly discriminated claimants from emergency services that continue to assume risks for the greater good but is otherwise uncompensated for the injuries sustained. there is considerable force in this reasoning that applies to frontline healthcare workers. they face prolonged risks on a daily basis, which includes periods of emergency and hours with clinical rotations between high and low infection risks zones in hospitals. their purpose is to save lives, but without ppe they are putting the lives of patients at risk. the likelihood of injury is real and the gravity of the consequences is magnified. while there are risks inherent in patient treatment, infectious diseases attract extra hazardous elements into the work. the seriousness of harm caused to healthcare workers is not considered small. infected healthcare workers would be off sick, unable to treat, and face the possibility of death. the risks of infection are higher without ppe compared to those with basic ppe. standard public health practices require healthcare workers to don appropriate ppe. this in turn invites questions on cost and practicability in addressing the risks that persist in daily clinical encounters. although frontline healthcare work is not intrinsically dangerous compared to crane workers in the building industry, the cumulative risks arising from covid- , and other preventable factors could potentially render such employment dangerous. healthcare workers combating infectious diseases accept the associated risks that are intrinsic to the work; that does not mean that they have voluntarily assumed all those risks which could be prevented or reduced with the exercise of reasonable care by the hospitals. the example of healthcare staff at weston hospital in england who tested positive after contact with infected patients only goes to demonstrate the severity of the situation. if we accept that covid- is hazardous, then it justifies the protection from the risks of infection through ppe provision. ppe constitutes the first line of protection against infections, as they need to be in close proximity to patients. ppe thus can reduce the chances of infection and in some cases prevent further infections among healthcare workers. such risks clearly outweighed the cost of providing ppe, and the omission to provide is obvious. while the likelihood of the majority of the healthcare workers to succumb to the virus is small owing to the age and health demography, the consequences of such infection materialising are grave if they were infected. courts usually take into account established practices in assessing whether the defendants have breached their standard of care given the circumstances prevailing at the time. it can be reasonably said that ppe is a common practice; logical and of common sense in treatment of infectious diseases. hospitals should act in accordance with such approved, common practice of ensuring adequate ppe supply. the most practical preventive measure, which is providing ppe is not onerous, compared to the risks of injury to healthcare workers. while cases have shown that employers have not breached their duty in failing to provide protective screens or suitable emergency vehicles for the employees at wartime, ultimately, balancing these risks against the measures to remove the risk requires a consideration of the end to be achieved. the end to be achieved in the pandemic context is the dual outcomes of protecting public health and maintaining the health and safety of healthcare workers in the course of their employment. statutory instruments have given the duty of care a stronger emphasis. the personal protective equipment at work regulations ("ppe regulations") under the health and safety at work act clearly set out the types of legal responsibilities that employers should follow. ppe under the regulations means "all equip-ment…intended to be worn or held by a person at work and which protects the person against one or more risks to that person's health or safety, and any addition or accessory designed to meet that objective." consequently, ppe in the hospital context is broad enough to include all equipment that protect healthcare workers from infectious particles arising from aerosol generating procedures, ventilators, respirators or testing facilities with high concentrations of droplets or airborne diseases. regulation ( ) provides the litmus test for the suitability of such ppe. ppe are considered "suitable" relative to the risks involved for the purpose of carrying out the work, the conditions and duration of exposure, the state of health of the wearer, the workstation's characteristics, and practicable in controlling the risks. ppe has to be hygienic and for the sole use of the wearer, thus the guidance to reuse them may raise questions, unless they are addressed by having adequate measures that ensure the hygiene is not compromised where reuse is needed. such ppe should also be maintained and replaced. the exposure to covid- infections is directly workrelated, and employers have the means to protect and implement control measures to reduce the chances of risks materialising. these circumstances directly oblige hospitals to ensure that ppe stockpiles are sufficient so that they are readily at hand when they are needed by the healthcare workers. the difficulty arises when there is a disparity between the actual supply and provision of ppe, and meeting compliance with the legal requirements. recent public health england (phe) guidance has emerged in response to the pandemic in advising hospitals on establishing a safe system of work through yorkshire traction company limited v walter searby [ ] ewca civ ; in daborn v bath tramways ltd [ ] all e.r. , at , the driver of ambulance with left-hand drive was found not negligent when, in wartime, she turned to the right without giving a signal. watt v hertfordshire [ ] all e.r. . regulation ( )(a). for example the phe guidance noted that some ppe may be reused, subject to effective cleaning system. regulations and . phe is tasked with national oversight and leadership on public health issues, and in this capacity support nhs, manage national public health service and support the public health workforce development, see also herring ( , p ). organisational means, ranging from suitable work processes, engineering controls, environment, and provision and use of both work equipment and ppe (single sessional use of particular ppe, reusable ppe) and decontamination procedures. the guidance recognised the employers' legal obligation to protect workers from health and safety risks in controlling and limiting infection transmissions, including assessing risks associated with patient influx, and reduced staff numbers due to illness. this aspect corresponds with regulation in assessing the risks of injury and the purpose and adequacy of such gears where available. however, developing phe guidance, in addressing ppe shortage highlighted "the compromise needed to optimise the supply of ppe in times of extreme shortage… protect stock levels from unnecessary use and support staff to use the right equipment." such modifications mean that ppe are used throughout the session unchanged between patients, "as long as it is safe to do so", which differ from the who guidance. other modifications, such as lower grade face masks reflect a standard which is lower than the who recommendation. while reusing gloves should be avoided, some ppe such as face masks, gowns and eye protection are only liable to be changed when they are visibly contaminated or damaged. the implication is that such ppe would have lost the protective function, putting the healthcare workers at risk under the guise of protection. the direct correlation between staff engagement and patient experience demonstrates the close association between the quality of care patients received and the provision of treatment by healthcare workers. the nhs, a government-funded healthcare service under which hospitals in the uk operate sets the standards for service provision and professionalism. in essence, it commits to provide high quality, safe and effective care, and recognises that a valued and supported workforce will translate to quality patient care. the nhs constitution, which outlines the basic principles and values of the nhs governing the relationships between healthcare workers, patients and the public generally, illuminates particular rights under employment laws, and nhs pledges to their staff, with the overarching priority of delivering patient centred care. patients have the right to be treated professionally by qualified healthcare workers as part of a safe system of work in a clean and secure public health england, department of health and social care and nhs england ( ). guidance: handbook to the nhs constitution for england ( ). nhs, the nhs constitution for england ( ). several guidance were published advising hospitals of rapid changes to ppe use and disposal: guidance: introduction and organisational preparedness may https ://www.gov.uk/gover nment /publi catio ns/wuhan -novel -coron aviru s-infec tion-preve ntion -and-contr ol/intro ducti on-and-organ isati onal-prepa redne ss; guidance: covid- personal protective equipment (ppe) may https ://www.gov.uk/ gover nment /publi catio ns/wuhan -novel -coron aviru s-infec tion-preve ntion -and-contr ol/covid - -perso nalprote ctive -equip ment-ppe produced jointly by department of health and social care (dhsc), public health wales (phw), public health agency (pha) northern ireland, health protection scotland (hps), public health england and nhs england. environment, signalling the necessity of an appropriately equipped and maintained environment. the cyclical nature of patient care and duty to staff is clearly reflected, with explicit recognition that staff should be provided with the resources and support to deliver quality patient care and for healthcare workers to identify and eliminate risks to patients. the failure to provide ppe for healthcare workers has significant relevance and broader implications to patient care. healthcare workers with substandard or without ppe are exposed to infection risks, rendering them susceptible to absence from work for at least days, resulting in workforce depletion. this is especially critical for healthcare workers functioning in high risk zones. healthcare workers operating in other units would be asked to support the continuity of care for covid- patients, thus creating a void in patient care in less critical areas. frontline healthcare workers face immense pressure treating patients under crisis. while there is an expected level of stress that corresponds with the nature of the work in providing care, transferring workers from other specialty units to assist their frontline colleagues may prove exacting, given that their training and competency for the job can vary. the rerouted human resources meant that patients in other units are inadvertently neglected due to reduced staff. another serious, adverse outcome is the risks of transmitting the infection to patients where healthcare workers are unaware that they have been infected; particularly in asymptomatic situations. ppe greatly reduce the risks of infection in the first place, for both the health and safety of the healthcare workers and patients. the strong correlation between the augmented risks of infection and ppe shortage creates a system where patients are harmed. the commitment to deliver quality patient care and a good working environment has, unfortunately, become questionable in this environment. while the nhs constitution provides for avenues of complaints to line managers, the bureaucracy meant that staff will continue to face infection risks unless they refuse to treat patients. prior insights from previous pandemic and the lack of remedial measures to address the weaknesses identified in the healthcare system during national pandemic simulation exercises may raise valid concerns regarding errors of judgement that resulted in the inability to provide ppe in a timely manner. public authorities hold and exercise discretionary powers within the constraints of complex decisions, social utility and organisational objectives. however, are we setting a standard too high for the nhs managers in procuring ppe, given the prevailing circumstances? are there any exceptions to this duty in times of pandemic, where it can be reasonably anticipated that healthcare systems may become inundated, resulting in the necessity of working within a less than optimal environment? the following sections consider arguments see walker v northumberland cc [ ] all er . bowcott ( ) . and counterarguments limiting hospitals' legal obligations towards healthcare workers. the characteristics of covid- are essential in understanding the severity of the pandemic, its impact on the healthcare systems, and why particular focus on the legal obligations of hospitals towards healthcare staff becomes significant now and in the future. the morphology of covid- has garnered international attention, with scientists investigating its biochemical components for preventive, containment and vaccine trials purposes. it was first reported in wuhan, hubei province of china on december , with origins traced to the s as common viruses that infect humans, particularly in respiratory functions. the transmission methods and survival on various surfaces have been the subject of intense scrutiny with findings that the virus can be detected on surgical masks for up to seven days. hospital working areas such as intensive care units, self-isolation wards, doorknobs and keyboards are found to carry high concentration of viruses. viruses were present in the body for more than a week prior to visible symptoms with the highest virus load found in the early stages of infection, suggesting that asymptomatic individuals could be more infectious than symptomatic ones as sources of population transmissions. these findings are crucially linked to the recommendations for use, reuse and disposal of ppe and its effect on healthcare workers who were infected. around % of infections in england recorded between april and june were found in health and social care workers resulting from their direct interactions with patients in hospitals. spain, italy, china and the usa have reported between % and % of infection cases from healthcare workers while treating infectious patients. this underscored the detrimental effects of ppe shortage on healthcare workers. the lack of ppe has cast the spotlight on augmented risks to healthcare workers. such risks of harm are widely acknowledged. healthcare workers experienced psychological and moral distress, frustrations and anxiety in carrying out treatment decisions, fear of risking their health, and infecting their families and patients. they are similarly exposed to emotional harms from being prevented to voice their concerns on health and safety, or compelled to provide care under unsafe circumstances. the british medical association has repeatedly supported the position that healthcare workers should not continue working with substandard ppe or without basic ppe that could prevent them from avoidable harm. however, this has not allayed the harmful consequences to healthcare workers. ibid. wilson et al. ( ) . who ( ). british medical association ( ), carrington ( ), smyth ( ) . british medical association (n , p ). european centre for disease prevention and control ( ). the force of the covid- exigency poses an arguably persuasive factor in limiting employers' liability. while covid- is frequently hailed as unprecedented, the nature of influenza pandemic is not completely unknown. history has revealed examples of pandemic that occurred across centuries with various degrees of severity. once the who declared covid- as a pandemic, ppe became global focal points. countries rushed to secure additional ppe, with demands far exceeding supply within an asymmetrical circulation of medical resources. although the challenge of scarce resources is a common predicament affecting hospitals, simulation exercises (e.g.: public health england ) undertaken in some developed countries provide ample opportunities for advance preparatory measures. the experiences of frontline healthcare workers from other countries several months before the pandemic reached the uk would have constituted sufficient notice of the gravity of the situation. hospitals have grown in complexity through centuries. the extent to which institutional structures, devolved administrations and resourcing constraints provide justifications for their omission needs to be determined within their role as public authorities. the nhs structure is represented by a complex matrix of quasi-government, private entity with specific powers and responsibilities, thus affecting their liability to healthcare workers as employees, moving beyond the simplicity of hospitaldoctor employment relationship. it has been said that "to describe the structure of the nhs is not an easy task…partly because it is a labyrinthine and partly because the nhs has been and still is undergoing enormous structural changes with bodies being created, merged and destroyed at an astonishing rate." the nhs is funded from taxes, with allocations approved by parliament, and expenditures controlled by clinical commissioning groups. nhs managers work in a complex environment, from purely administrative to larger roles of system management and leadership with accountability to frontline healthcare workers, the department of health, private providers, and subject to public scrutiny. nhs managers are expected to balance several competing rights, among others the public health, healthcare workers' rights and organisational constraints. the creation of internal market supported by the health and social care act has been critiqued as one of the structural problems permeating nhs which produced a considerably weakened responsive capability during pandemics. continuous public sector changes, marketisation strategies walsh ( ) . and funding cuts have led to the government's reliance on private firms to provide services during public health emergencies. suggestions that phe decisions were politically influenced have led to allegations that ppe guidelines were not necessarily led by public health science, as seen in the case of lowering ppe standards due to shortage, contrary to who recommendations. hospitals performed their functions within the wider framework of organisational complexities, decision-making hierarchies and limitations, and political willpower. they often have statutory responsibilities involving difficult and sensitive judgements to make. they also inadvertently suffer from particular authority or financial barriers, which puts them in unenviable positions when faced with claims of negligence in equipping employees with ppe. the discretionary powers available for public authorities, other remedial options and consequences for public service delivery influence how standards are determined. a finding of liability may result in obstructions with the exercise of discretionary powers guided by particular reasoning within the system for purposes of efficient and necessary governmental machinery. the structural determinants illuminate the systemic failures that plagued these entities. as christian witting accurately observed : "in some cases, decisions made at a high political level inevitably entail difficulty in meeting service targets or in under-servicing, and must be expected to result in failures in care. the failures in care that result are systemic in nature. their acceptability is politically pre-determined and courts might have little authority to redress them." resource availability within public authorities remains a pressure point among competing sets of considerations. it indicates the dilemma of meeting social needs for the effective functioning of society within a finite environment of resources. public authorities traverse the boundaries of public and private law in judicial applications of the law of negligence, human rights and statutory powers. this is reflected in the nhs context, which represents one of the most politically charged and publicly contentious issues of all times. daborn demonstrated that in cases of national emergency, the lack of available transportation resources, the inherent limitations of the ambulance and the need for continuity in emergency services precluded the defendant from further duties. while not a complete defence, public service liability is closely connected to resource constraints, weighing against the finding of liability. cases have shown that although public body should not be treated any differently from commercial employers, financial constraints and rigidity in decision-making are relevant factors. this signifies the balance between resource availability and cost and practicability of preventing workplace injury. the issue of how far the duty should go when it comes to omissions to provide ppe in a pandemic context is unresolved. given the public health crisis precipitated by the pandemic, it is likely that hospitals would be 'forgiven' for their failure in fulfilling their legal obligations on the basis of emergency and their constraints as public authorities. however, hospitals are the linchpin in delivering frontline healthcare services and maintaining public health in an infectious disease setting. it is argued that hospitals should depart from an approach that expose healthcare workers to infection risks, harm public health and is inconsistent with the core nhs patient centred care principle. the provision of ppe is fundamental to healthcare workers in carrying out their work. ppe protect healthcare workers, and in turn enable them to deliver crucial care especially in times of pandemic. it is not an infallible method, but without these ppe they are most likely to suffer from injury and harm from the risks of infection. the failure to provide ppe to healthcare workers is a failure to deliver care to patients at critical points. the size, capacity and resources available to hospitals are influential considerations; nevertheless, they are not determinative to the extent of justifying the omission to provide ppe. a comparison can be drawn to ppe provision during normal times and in times of emergency. in normal times, the impact, while it may be felt, may not be acute for patient delivery care because the limit has not been breached. however, in emergency times, the impact of the failure to provide ppe to healthcare workers is severe. the daborn and watt v hertfordshire cases had established the importance of the end to be achieved in saving lives, consequently such emphasis can be inferred as recalibrating the obligations of essential services and balancing the rigidity and prescribed exclusion of liability. when the objectives are to save lives and ensure the continuity of vital healthcare delivery, it would appear contradictory to omit the provision of ppe that directly enable the treatment and care of patients. the lives of frontline healthcare workers and patients justified the provision of ppe. these arguments deviate from the standard argument of resource constraints, but they offer a strong reasoning why they should not be precluded. imposing the duty to provide ppe is therefore central in ensuring healthcare workers are protected from the risks of infection and to realise the aim of delivering patient-centred care to the public. thus, this duty should be adjusted to the extent of meeting the requirement of basic provision of ppe and ensure the continuity of such ppe supply in spite of the pandemic. this argument may seem contentious because there are persuasive cases that will preclude the finding of liability in a situation where resources are scarce and that individuals are expected to endure the crisis. however, hospitals need to demonstrate that they have proper mechanisms in place to address shortages in prolonged crisis instead of relying on arguments of budgetary limitations and hierarchy in decision-making. these points need to be identified at each step along the way to determine if the standard of care has been reasonably met. while cases involving public authorities often lend weight to the exclusion of liabilities; they can be distinguished from the current situation in several ways. first, the shortage in question is remedied by the availability of vehicles for the continuity of services, despite not the usual vehicle (e.g.: left-hand drive in daborn). the covid- situation represents a context where healthcare workers have exhausted these basic supplies and faced the consequences of no ppe for the remaining clinical encounters. second, covid- is not a singular incident but an event that is urgent in nature and continues on a daily basis. the severity of the harm meant that without any protection they face a high likelihood of being infected. the lowered standards of ppe use and recommendation for reusing ppe are attempts at remedying the complete shortage. the argument is that some protection is better than no protection. although hospitals are attempting to meet their obligations; ppe which are visibly damaged would cause harm under the guise of protection. the persistent lack of funding to hospitals has contributed to an environment where ppe shortage is tolerated and accepted as standard (though not reasonable) practice. ppe guidelines that decrease the health and safety standard exemplifies resource consideration. it is difficult to comprehend, even at the basic level, for employers not to provide essential ppe for protection against known risks within standard public health measures. covid- is an infectious disease, and the reasonable response is to provide ppe that eliminate or reduce the risks from exposure to such infections. while the purpose of the work is such that infections are incidental to the nature of the employment, ppe is an indispensable and cost-effective measure in minimising such risks. in spite of the difficulty in functioning within a resourcelimited environment, ppe is not purely best practice, but fundamental medical practice. an implication flowing from these considerations is recalibrating the mutual obligations between hospitals and their employees, underpinned by effective healthcare delivery consistent with the nhs constitution. a blanket approach to the finding of liability may be unsuitable, as not all hospitals are similarly equipped, though it remains incumbent on hospitals to fulfil their basic obligations without jeopardising the safety of healthcare workers. parallels can be drawn to the established standards and practices relating to ppe for employees working with hazardous materials. ppe can be modified but only to the extent where they are capable of providing full protection to healthcare workers, and not lower than the recommended standards. ppe availability inculcates a sense of assurance that frontline healthcare workers are valued and appreciated, both by the public and their employers, and for the workers, the confidence in carrying out their roles in treating and caring for infectious patients. system deficiency may be influential in determinations of liability, but it does not always prevail over what is reasonably expected from hospitals. hospitals have the moral duty to take care where their actions will affect those who might be affected by the failure to provide adequate and safe ppe: staff and patients. such duty falls within the remit of nhs managers. as covid- progresses, hospitals ought to have foreseen the impact of ppe on healthcare workers and patients; given the length of the pandemic, rather than a singular emergency. not all finding of liability will automatically result in floodgates, trivial claims or become burdensome for public authorities. rather, it reflects the social and public expectations of what is fair and reasonable. the legal claims filed by healthcare workers for ppe shortage reflect societal expectations of what ought to be done in ensuring healthcare workers are provided with sufficient ppe. departing from this standard would have stretched the limits of acceptable assumption of risks. the public, while accepting that covid- is an unprecedented health threat to the population, will not be kind in their assessment of the measures to contain the pandemic, particularly in response to the dearth of vital medical resources in times of crisis. it becomes imperative to recognise their vulnerabilities and to keep healthcare workers safe. systemic failures may well be compelling, but it is unsatisfactory to then say, there is nothing hospitals could do. reports have continuously demonstrated the correlation between the lack of ppe and higher risks of infection for healthcare workers compared to the public. this naturally translates to poor patient care as they become sick. there is clear neglect in ensuring stockpiles of ppe in meeting the basic requirement of ensuring workers' health and safety. the lack of clear direction and protocols in management and leadership has contributed to the failure of establishing a safe system of work. what would a reasonable healthcare provider do? it is to provide adequate ppe when it is needed and to have processes in place to supplement the stockpile. the saving of lives is a continuous emergency, reflected by the number and severity of patients healthcare workers treat daily. the discretionary power should be exercised towards ensuring resources are allocated towards meeting the obligations of hospitals during pandemic, in preparing sufficient ppe for healthcare workers. for example, the procurement team of the nhs trust is responsible for purchasing supplies and equipment for the hospital, where specific purchasing rules and budgetary limits apply. this translates to broader governmental responsibilities within the decision-making authority which subsequently influenced the overall level of pandemic preparedness. the long-term deficiency in preparedness for a potential infectious diseases outbreak, and the failure to remedy ppe availability through systematic and appropriate procurement arrangements for continuous supply have contributed towards hospitals' inability to replenish severely dwindled ppe stocks in a timely manner. these cumulative factors have resulted in the breaching of ppe limits to the detriment of healthcare workers. the hesitance towards advance preparedness is remarkable, given the window period available to the uk with precedents from china and neighbouring european countries. hospitals, especially the well-resourced ones, with the hindsight of previous experiences in treating patients under the deluge of pandemic could have phelps v london borough of hillingdon [ ] a.c. . parshley ( ) . hunter ( ), mahase ( a, b, c, d). foreseen the need to install precautionary measures to safeguard the continuity of essential supplies and safe functioning of workplace for healthcare workers. adopting such preparatory measures would have enabled a safer response strategy for critical patient care in anticipation of increased burden on the frontline staff, adjusted according to the size and scope of the hospitals' operations and resources. the next section offers practical recommendations in pre-empting ppe shortage. the failure of hospitals in providing healthcare workers with ppe has resulted in concerted and self-help measures in procuring ppe. the most common preparation is stockpiling essential ppe. this comes as a benefit of hindsight; nonetheless valuable in preparation for second or third waves of infections, and as crucial planning for future pandemics. for example, prior to the onset of infected cases in new york, some hospitals have acquired millions worth of ppe as early as february on the basis that "you can never have enough." this foresight paid off, enabling healthcare workers to continue working while protected. an appreciation for improved procurement procedures in place, such as the role of supply chains in ppe procurement is integral in successful pandemic preparation. the public-private procurement chain has ensured that new zealand has sufficient ppe for the healthcare workers and the population, with additional weekly supplies from local manufacturers. the shortage in the uk remains acute. reports have emerged that care home workers were requested to continue caring for infectious patients without ppe in the event of extreme shortage. local councils are responsible for delivering healthcare services (e.g.: care homes and community mental health services) which falls outside the nhs supply chain scope. this means that they are most likely to lack ppe in times of national emergency. jurisdictional divisions have, unfortunately hampered the effective cooperation for public health to the detriment of frontline healthcare workers and the public. the systemic impediments in the nhs organisational structures might be difficult to overcome immediately, but the awareness of how ppe delivery is hampered by these institutional barriers can pave the way for alternative routes to remedy the situation. supply chain management and logistical issues are beyond the remit of employees personally, and those in charge of organisational operations should be responsible in fulfilling the obligations in ensuring that ppe are in stock and at hand when they are needed. this means having additional supplies for emergency purposes ornstein ( ) . covid coronavirus: tonnes of ppe now in auckland warehouse apr, https ://www.nzher ald. co.nz/nz/news/artic le.cfm?c_id= &objec tid= . taylor ( ) . see further laurie and hunter ( ). while procurement for additional ppe is in progress to ensure continuity in supply for healthcare workers. consequently, measures include revisiting internal procedures in assessing the individual levels of preparedness in hospitals, and preparing alternative plans in redirecting patients to hospitals with more capability to deal with infectious patients if the scale and capacity of the local hospitals do not permit the proper treatment and availability of care to the patients without risking staff safety. it is equally valuable to treat the pandemic as akin to disaster response with mass casualties as it enables the operation of protocols and processes for such emergencies occurring for a substantial period of time. nhs managers must be aware of such developments, encompassing clinical and administrative appreciations of the effect global supply chain has on essential ppe procurement in planning and reducing the gap between stock depletion and arrivals. this entails building good, working relationships with relevant suppliers and producers. as resources are finite, having operational plans in advance at the institutional level would alleviate the burden of dealing with these issues during emergency when there are absolutely no ppe available. infrastructural planning, reorganisation and improvisation are essential to remedy the weaknesses that prevented hospitals from fulfilling their obligation in providing a safe system of work and adequate plant and equipment for the purpose of caring for patients. it is not advocated that there should be a perfect system but a functioning system at a fundamental level that ensures that employees' health and safety are not compromised in times of pandemic, and that risks are controlled within reasonable limits. longer term measures include instituting improved communication among hospitals within proximate areas in breaking the disease transmission chains locally and regionally. this approach will facilitate local capabilities in minimising the disease spread, especially in under-resourced and rural areas healthcare services. such regional networking approach has resulted in successful pandemic response among hospitals in lombardy, italy in coping with patient surge. the current decentralised decision-making approach in the nhs and the lack of effective communication policies in disaster management have led to critical resourcing issues. processes and procedures that allow a centralised, consistent response mechanism in national emergency are essential in ameliorating some of the difficulties in pandemic response and management. for example, an emergency "clearinghouse" that acts as a centre is helpful to identify areas with high needs for ppe so that immediate actions can be taken to distribute ppe to these critical areas. increasing local production capacity and supply in times of crisis are central in ensuring uninterrupted supply from local sources and less reliance on external producers during ppe scarcity. spain, for example has aimed to produce millions of masks and other essential ppe on a monthly basis to meet the needs of healthcare workers. when the shortage was first reported, the local and national level cavallo et al. ( ) . hunter (n ). livingston et al. ( ) . sappal ( ). communities in the uk were very supportive towards the healthcare workers in creating homemade ppe and supplying them to healthcare workers. although this is admirable, these supplies may not meet the adequate level of protection to ensure that infection risks are minimised. one way of overcoming the obstacle is to create a streamlined effort between local governments, charitable organisations and local volunteer groups to ensure they meet the safety requirements. this approach would help local and independent manufacturers to achieve local production capacity for the benefit of the communities within a shorter amount of time, and less dependent on outsourced procurement agencies or importation. it is also a stop-gap measure while awaiting incoming ppe supplies from centralised distribution centres. this move is advantageous to the local communities, as local hospitals can continue to treat patients without being forced to turn them away due to ppe shortage. reusing ppe is an option to ease the pressures of ppe shortage. however, the direction to reuse ppe can only be safely implemented where there are protocols for cleaning, disinfecting and storing reusable ppe and limited to ppe that are capable of being reused safely. such essential protocols must include appropriate laundry capacity, whether in hospitals or outsourced to commercial entities. other options include repurposing suitable equipment into ppe that are safe to use for eye and face shields, such as gas masks or sports eye protectors. employees should not be put in an already vulnerable position without the minimum support and infrastructure to carry out their work. the pressing problem of insufficient ppe represents the tip of the iceberg. it reveals a fragile structure in the healthcare system, with the implications of covid- felt long after it has come and gone. the level of provision of care for the population in times of pandemic is closely connected to the health workers' risks and safety. the analyses bring to light the importance of implementing sustainable measures for population health. more innovative ideas are needed for producing and replenishing important resources to pre-empt the domino effect arising from a lack of resources in times of pandemic. hospitals are obliged to be more forthcoming in providing clarity with regards to the supply of resources, and to accommodate the possible reluctance of healthcare workers in working in unsafe circumstances. frontline workers who are being prevented from airing their concerns on the severe lack of adequate ppe is detrimental to their functions in providing care. it could not be said to have met the aims of patient safety when staff are not equipped, valued, empowered or supported in carrying out their work. this paper has highlighted how the pandemic has affected the legal obligations of hospitals to healthcare workers in the provision of ppe. hospitals as employers have obligations towards healthcare workers, which include providing a safe livingston, desai, and berkwits (n ). ibid; cavallo, donoho and forman (n ). working environment and adequate equipment. the nature and extent of their duty are affected by their role as public authorities and in times of emergency. hospitals usually do not incur liability on the basis that they have service provisions that are influenced by resource constraints, limits in decision-making authority and bureaucracy. daborn and watt v hertfordshire exemplify the types of constraints public authorities face in providing social services, which weighed against the finding of liability. there are persuasive arguments from both perspectives in determining the extent of liability hospitals may incur in their failure to provide ppe in a timely manner. yet legal actions against governments and hospitals have opened up the possibility to reconsider the scope of liability, and the fulfilment of the expected standard under pandemic circumstances. the analyses show nhs managers would be in breach of duty for provision of ppe on the basis that the purpose of their activity is relevant in determining if an employer has breached a duty of care to an employee. while the negligence may be arguably excused during crises, the failure to meet the basic resourcing needs of frontline healthcare workers has breached the minimum standard and ethical imperatives in protecting them from life-threatening harm while they continue to treat an increased influx of patients. additionally, it has highlighted broader issues that plagued ppe procurement readiness preceding the pandemic. the analyses have indicated the extent to which the meeting of legal obligations in a pandemic can be undermined by external, underlying pressures arising from austerity policies introduced throughout the years, and an increasingly privatisation-oriented procurement practice, consequently weakening the public sector capacity in competently meeting public health threats. it is hard to dismiss the consistent pleas from frontline healthcare workers. such pleas strengthened the recognition of obligations to provide ppe. maintaining public health and safety in times of pandemic is of utmost importance; however the public can only be properly cared for where healthcare workers are able to continue working in a relatively safe environment in the midst of a pandemic. the fundamental need for ppe and the health and safety of healthcare workers must be prioritised. while this paper has gestured towards the obligations in providing ppe, the analyses have shed light on the inextricable implications of sound governance in meeting health priorities during a pandemic. it has canvassed a broader profile of underlying issues and proposed recommendations, emphasising the need for cohesive measures to address ppe shortage and alleviate the risks to frontline healthcare workers. the state may not be able to salvage the deaths and distress caused to frontline healthcare workers, but it can act more substantively to protect them and to restore public trust that the healthcare system would not collapse in times of pandemic. it has been argued here that hospitals ought to maintain their obligations to provide ppe to healthcare workers, because a failure to adequately protect them is also a failure to protect public health. supporting the health care workforce during the covid- global epidemic lacking beds, masks and doctors, europe's health services struggle to cope with the coronavirus apr bma. . covid- : ppe for doctors doctor couple challenge uk government on ppe risks to bame staff covid- -ethical issues. a guidance note uk strategy to address pandemic threat 'not properly implemented. the guardian hospital capacity and operations in the coronavirus disease (covid- ) pandemic-planning for the nth patient bereaved relatives call for immediate inquiry into covid- crisis doctors step up plea for adequate protection against coronavirus covid coronavirus. . tonnes of ppe now in auckland warehouse cecilia faulty batch of face masks prompts the isolation of more than a thousand spanish healthcare staff doctors to file legal challenge to ppe guidance fair allocation of scarce medical resources in the time of covid- european centre for disease prevention and control: an agency of the european union guidance: considerations for acute personal protective equipment (ppe) shortages s-infec tion-preve ntion -and-contr ol/covid - -perso nalprote ctive -equip ment-ppe. department of health and social care (dhsc) guidance: handbook to the nhs constitution for england bma demands urgent ppe solution after italian doctors die from covid- oxford: oup. high proportion of healthcare workers with covid- in italy is a stark warning to the world: protecting nurses and their colleagues must be the number one priority covid- and the stiff upper lip-the pandemic response in the united kingdom covid- : doctors still at "considerable risk" from lack of ppe, bma warns mapping, assessing and improving legal preparedness for pandemic flu in the united kingdom how a decade of privatisation and cuts exposed england to coronavirus sourcing personal protective equipment during the covid- pandemic text and materials, th ed global stocks of protective gear are depleted, with demand at " times" normal level, who warns covid- : % of cases will hit nhs over nine week period, chief medical officer warns covid- : hoarding and misuse of protective gear is jeopardising the response, who warns novel coronavirus: australian gps raise concerns about shortage of face masks protecting health care workers against covid- -and being prepared for future pandemics covid- : doctors' leaders warn that staff could quit and may die over lack of protective equipment nhs. . the nhs constitution for england how america's hospitals survived the first wave of the coronavirus remember the n mask shortage? it's still a problem exercise cygnus report tier one command post exercise pandemic influenza press release: new personal protective equipment (ppe) guidance for nhs teams up to % of staff tested at hospital after covid- patient contact had virus critical supply shortages the need for ventilators and personal protective equipment during the covid- pandemic spanish government faces legal action over lack of ppe for medics spain gears up to manufacture million masks a month as well as other vital covid- equipment stone, will, carrie feibel. . covid- has killed close to u.s. health care workers, new data from cdc shows care home staff could be asked to work without ppe under council plan the changing role of managers in the nhs king's fund department of health with powers derived from national health service act national health service and community care act implementing the code of conduct for nhs managers here's how some of the countries worst hit by coronavirus are dealing with shortages of protective equipment for healthcare workers covid- : the history of pandemics shortage of personal protective equipment endangering health workers worldwide who and countries are engaged in massive preparedness activities covid- news: uk could eliminate coronavirus entirely, say scientists national health service rationing: implications for the standard of care in negligence street on torts key: cord- - c ut authors: nan title: cis annual meeting: immune deficiency & dysregulation north american conference date: - - journal: j clin immunol doi: . /s - - -z sha: doc_id: cord_uid: c ut nan abstract/case report text oral lichen planus (olp) is a t-cell mediated chronic inflammatory tissue reaction in which presentation can range from asymptomatic plaques to painful, erosive, bullous, or ulcerative lesions. here, we present a year-old female with a novel ctla- variant, multiple autoimmune conditions, and unusual tongue lesions. our patient was healthy until years of age when she developed hashimoto's thyroiditis. at , she developed psoriasis. at , she was diagnosed with alopecia totalis and epstein-barr virus (ebv) with resultant and persistent anemia, thrombocytopenia, lymphopenia and neutropenia. she had chronic abdominal pain and diarrhea since age . esophagogastroduodenoscopy revealed lymphocytic esophagitis and active duodenal inflammation with increased intraepithelial lymphocytes. colonoscopy revealed mildly active chronic colitis with eosinophils. whole exome sequencing revealed a heterozygous c. dela (p.q rfs* ) pathogenic mutation in exon of ctla- . family history is remarkable: father (splenomegaly and psoriasis) and brother (autoimmune hemolytic anemia) have ctla haploinsufficiency with the same mutation. abatacept was initiated with re-growth of hair, improvement in cytopenias, improvement in psoriasis, and some reduction of gastrointestinal symptoms. since her abdominal pain persisted repeat endoscopies after six months of abatacept revealed persistent active lymphocytic esophagitis with some improvement in inflammatory injury in her duodenum and colon. physical exam revealed glossitis with a gel-like coating and ulceration on her tongue, xerosis along her face and scalp without other abnormalities ( figure) . she denied recent dental procedures, appliances, or tongue biting. her wbc ranged from - x ^ cells/l and hemoglobin . - . g/dl. absolute lymphocyte count ranged from . - . x ^ cells/l. immunologic evaluation revealed low iga and pan-low lymphocyte subsets (table) . ebv pcr ranged from - , copies/ml. tongue scraping revealed candida dubliniensis and she responded to days of fluconazole. two months later, she developed painful white patches along her tongue and subsequent kilogram weight loss recalcitrant to viscous lidocaine, antacids, and days of fluconazole. incisional tongue biopsy revealed ulceration with underlying granulation tissue with lymphocyte and plasma cell infiltration consistent with olp ( figure) . periodic acid-schiff diastase stain and grocott stain were negative. aerobic culture was normal. no fungus was isolated within days. epstein-barr encoding region in situ hybridization was negative. two weeks of topical dexamethasone lead to temporary improvement. her tongue lesions waxed and waned over the following months. due to persistent psoriasis, methotrexate was initiated without worsening in her tongue lesion. to our knowledge, this is the first case of olp reported in a patient with ctla- haploinsufficiency. ctla- haploinsufficiency may present with variable clinical phenotypes including increased risk of ebv viremia and malignancies. therefore, after ebv and malignancy are ruled out, olp may be a prudent diagnosis to consider in a ctla insufficient patient with unusual oral lesions. mutations of bcl b appear to be associated with lymphoproliferation and autoimmunity as well as susceptibility to herpes virus infections. additional research focusing on characterization of dna binding sites of bcl b as well as the downstream expression of associated target genes is needed. these data combined with longitudinal analysis of additional patients with confirmed bcl b mutations, will help clarify determinants of bcl b pathogenesis and highlight potential therapeutic strategies. consanguineous marriages in tribal cultures, such as that in the united arab emirates significantly increase the prevalence of autosomal recessive disorders. premarital genetic screening and counseling, thus, are expected to reduce the frequency of these diseases. in this pilot study, diagnostic exome sequencing was used in the premarital screening program to identify recessive pathologic variants preventable by premarital counseling. a total of pathologic or likely pathologic variants were identified in studied emiratis ( couples), averaging . variants per person. four percent of the persons had negative diagnostic exome sequencing; the remaining had one to eight variants per person. of the distinct variants, ( %) were novel. twenty ( %) couples had pathologic or likely pathologic variants of inborn errors of immunity (iei). two couples ( %) had iei pathologic or likely pathologic heterozygous variants in both partners imposing risk for autosomal recessive disease in the offspring. other eighteen couples ( %) had pathologic/ likely pathologic heterozygous variants present in only one person of the couple. total of sixteen ( . %) iei variant identified and eight ( %) were novel. fourteen known phenotypic iei diseases were recognized (table. ). these preliminary results support a need for nationwide premarital genetic screening, and primary immunodeficiency registry to identify common and novel pathogenic variants with high heritability rate. these results will aid adopting a preand post-connectional reproductive carrier counseling to reduce autosomal recessive diseases. also, it will assist the diagnosis of these complex diseases in our community. table pathologic or likely pathologic variants of primary immunodeficiency (pid). abstract/case report text background: chronic granulomatous disease (cgd) is a primary immunodeficiency disorder caused by defects in the phagocytic nadph oxidase complex, leading to increased susceptibility to infection and inflammatory or autoimmune disease. up to % of patients have gastrointestinal (gi) involvement and meet diagnostic criteria for inflammatory bowel disease (cgd-ibd). objectives: we analyzed cgd patients from the united states immunodeficiency network (usidnet) registry to determine whether ibd may change the presentation, treatment, and outcomes of cgd patients, as compared to those without ibd. methods: a retrospective evaluation of cgd cases from the usidnet registry was completed. cgd-ibd was defined as the presence of any major physician-reported inflammatory, non-infectious gi tract disease manifestation, including crohn disease, ulcerative colitis, ibd endoscopy findings, gi fistulas, gi strictures, gi obstruction, and proctitis. demographic information, genotypes, symptoms and conditions, infections, antimicrobial therapies, immunomodulator use, and allogeneic hematopoietic stem cell transplantation (hsct) data were analyzed. results: patients with a diagnosis of cgd were identified. met criteria for ibd; were categorized in the non-ibd group. crohn disease and colitis were the most common gi disease manifestations in the cgd-ibd group (n= ), followed by gi fistulas (n= ). cgd-ibd patients had an increased average frequency of infections ( . events/patient) compared to the cgdnon-ibd group ( . events/patient). in both groups, lower respiratory tract infections were the most common infection type and aspergillus was the most common organism. enteric organism infections were more common in ibd patients. temporal data regarding the timing of infections were not available. immunomodulators, including biologics and interferon-gamma, were used at a significantly higher rate in ibd patients compared to non-abstract/case report text down syndrome (ds) is characterized by the occurrence of three copies of human chromosome (hsa ). these patients often develop chronic mucocutaneous candidiasis (cmc) and autoimmune thyroiditis, mimicking patients with heterozygous gain-of-function (gof) stat mutations, which enhance cellular responses to the three types of interferon (ifn). hsa contains a cluster of four interferon receptor (ifn-r) genes: ifnar , ifnar , ifngr and il rb. a gene dosage effect at these four loci may contribute to the infectious and autoimmune manifestations observed in individuals with ds. we report high levels of ifn-αr , ifn-αr and ifn-γr expression on the surface of monocytes and ebv-transformed-b (ebv-b) cells from ds patients. levels of ifn-ɣr , encoded by a gene on chromosome , were similar in the immune cells of ds patients and healthy controls. total and phosphorylated stat (stat and pstat ) levels were constitutively high in unstimulated and ifn-α-and ifn-γ-stimulated monocytes from ds patients, although less so than those in patients with gof stat mutations. following stimulation with ifn-α or -ɣ, but not with il- or il- , pstat and ifn-ɣ activation factor (gaf) dna binding activities were significantly higher in the ebv-b cells of ds patients than in controls, this response resembling the dysregulated responses observed in patients with stat gof mutations. plasma type i ifns concentrations were high in about % of the ds patients tested. a genome-wide transcriptomic analysis involving principle component analysis and a comparison of interferon modules was performed on circulating monocytes. it showed that ifn-stimulated genes (isgs) were expressed more strongly in ds than in controls. ds monocytes have intermediate levels of ifn-α-and ifn-γ-induced isgs relative to monocytes from healthy controls and from patients with gof stat mutations. by contrast to patients with gof stat mutations, circulating th counts were normal and the proportion of terminally differentiated cd + t cells was high in ds patients. the constitutive upregulation of type i and type ii ifn-r, at least in monocytes of ds patients, may therefore contribute to the autoimmune diseases observed in these individuals. scid screens (positive screen defined as trec values less than units/ul per statewide criteria). results forty nine neonates were identified with low trec values. ( %) of these infants had repeat trec screening, ( %) of which were found to have a positive second trec screen. lymphocyte subsets were evaluated in of these infants and of which were noted to have lymphopenia (defined as absolute lymphocyte count less than ). infants were noted to have low cd levels (defined as < cells/ul) and were noted to have low cd levels (defined as less than cells/ul). of note, % of the infants with cd and cd lymphopenia had normal repeat trec levels. of the infants were noted to have low b cell levels (defined as < cells/ul). infants had quantitative immunoglobulin levels and of these two were noted to have igg levels less than . of note one infant was diagnosed with partial digeorge syndrome via microarray. in our study population, no infants were diagnosed with scid. discussion our study shows that testing for trec levels on newborn screen may be beneficial in identifying not only scid, but also other immunologic conditions. infants in our study had evidence for both cell mediated and humoral immunodeficiency which necessitated further workup and follow up from allergy and immunology specialists. it may be beneficial to develop further programs to track infants identified with abnormal trec levels on newborn screens to determine if they develop signs of immunodeficiency syndromes later in life. abstract/case report text the patient was transferred to our adult clinical immunology transition clinic for low igg and iga, elevated igm and b cell lymphopenia, treated with subcutaneous gamma globulin. his medical history was relevant for recurrent respiratory infections since two years-old, failure to thrive and developmental delay. he also developed chronic auto-immune hemolytic anemia (aiha) at ten years old, accompanied by prominent lymphoid hyperplasia. our initial evaluation at the age of twenty years old showed massive polyadenopathy and splenomegaly. work-up confirmed flair-up of aiha. at that point, the diagnosis of apds was raised. he also had mild intellectual impairment and dysmorphic features such as a mild degree of ocular depression, deep-set eyes, vaguely triangular face, small chin, but had normal stature. a customized panel for usual genes involved in classic hyperigm syndromes, apds, noonan and kabuki syndromes came back negative. at years old, an urgent coloscopy was performed because of acute abdominal pain and showed diffuse ileal lymphoid hyperplasia. biopsies confirmed reactional lymphoid hyperplasia without infection nor malignancy. a second genes ngs panel associated with pid identified a heterozygote mutation in tap ; expression of hla class was normal on flow cytometry. the patient was then started on sirolimus for an "apds-like syndrome" despite the lack of genetic confirmation. six months after introduction of mtor inhibitor, his abdominal pain had completely disappeared. tep scan showed complete resolution of axillar, retroperitoneal and inguinal lymph nodes and significant regression of splenomegaly. a third large non-biased + genes ngs panel revealed a pb de novo deletion that included the splice site of pik r exon typically involved in apds : c. _ + del p.(asp glufs* ) , which was missed by the first two panels. indeed, oligonucleotide-selective sequencing technology used for the previous panels was associated to mapping errors of short reads and difficult detection of large deletions. interestingly, the patient also presented some but not all dysmorphic features of short syndrome which is related to pik r haploinsufficiency. in this new era of genetic testing, this case is a reminder that we need to be aware of the pitfalls of genetic tests and that clinical judgment is still our best diagnostic tool. abstract/case report text intro: patients with chronic granulomatous disease (cgd) are theorized to have a lower risk of malignancy related to their lack of free radical formation. there are relatively few reports of malignancy described in patients with cgd. we report three cases of malignancies in the large cohort cgd population at the national institutes of health followed between - to add to the seven cases described in the literature. case : a -year-old man with x-linked chronic granulomatous disease with a history of severe inflammatory bowel disease, who presented with progressive left-sided chest pain in , decreased appetite and weight loss. transthoracic lung biopsy showed atypical cells and a pet/ct showed abnormally dense mesentery and widespread hypermetabolic abnormalities. a mesenteric biopsy showed metastatic pancreatic adenocarcinoma. palliative care was initiated. patient expired four months after diagnosis. case : a -year-old man with x-linked chronic granulomatous disease and severe inflammatory bowel disease requiring total proctocolectomy and who had been remotely treated with infliximab, presented in with right upper quadrant pain. abdominal ultrasound and mri of the liver showed multiple liver lesions. biopsy of these lesions revealed hepatocellular carcinoma. patient underwent two courses of radiolabeled itrium spherules. however, his disease progressed and he expired approximately five months after diagnosis. c a s e : a n -y e a r-o l d m a n w i t h x -l i n k e d c h r o n i c granulomatous disease and inflammatory bowel disease who presented in with fevers, abdominal pain and pancytopenia. during the course of his hospitalization, he developed sepsis which led to his demise. on autopsy, an incidental finding of papillary thyroid carcinoma was made. discussion: these three patients all had poorly controlled inflammatory bowel disease. additionally, patients with cgd are typically exposed to higher doses of radiation, leading one to expect higher rates of radiation induced malignancies. however, there are still relatively few case reports of cancer in the cgd population. tissue biopsy is necessary for diagnosis. due to end organ damage secondary to the underlying disease in the first two cases, treatment options were limited. managing infections during chemotherapy can be complex due to drug interactions with chemotherapeutic agents. abstract/case report text myeloperoxidase (mpo) deficiency is the most common inherited defect of phagocytes that impairs microbial killing since the toxicity of the respiratory burst is dampened without myeloperoxidase release from the azurophilic granules. a significant portion of these patients remain asymptomatic, however there is a clinically variable phenotype that can present if they do become symptomatic. fungal infections with candida strains appear to be the most frequently reported. we present an adulthood case of recurrent invasive candidal disease due autosomal recessive myeloperoxidase deficiency from a pathogenic missense variant in the mpo gene (c. c>t (p.arg trp)). a -year-old caucasian male was in his normal state of health without any major illnesses until years of age when he was diagnosed with candida osteomyelitis of the heel, followed by cryptococcal meningitis the following year which ultimately required a ventriculoperitoneal shunt. in , he had a prolonged hospitalization after presenting with lethargy, headache and vomiting that culminated in seizure activity and prompted an emergency room visit. imaging at the time showed ventriculomegaly, and fluid from the shunt revealed yeast, but no bacteria. he was started on broad spectrum antifungal therapy and admitted for further management. cerebral spinal fluid and blood cultures confirmed invasive candida albicans meningitis. during this hospitalization, he also developed sepsis secondary to serratia marcescens. because of the pathogens that were being isolated, our service was consulted. of note, our patient does not have diabetes mellitus. a neutrophil oxidative burst assay showed an absent respiratory burst compared to control. a primary immunodeficiency panel to identify genetic variants was also sent to invitae. variants in cyba, cybb, ncf , and ncf were not identified, making chronic granulomatous disease less likely. peroxidase staining was negative on neutrophils and normal on eosinophils, suggesting a diagnosis of mpo deficiency. this led to mpo gene sequencing for deletion and duplication analysis. a homozygous pathogenic variant consistent with a molecular diagnosis of a mpo related condition was identified. immunoblotting of patient-derived immune cells demonstrated an absence of mature enzyme. although not typically indicated, given the severity of his presentation, our patient remains on fluconazole for long term prophylaxis. his younger brother also had a history of invasive disease with candidaosteomyelitis and meningitis. a neutrophils oxidative burst assay showed similar results in his brother and similar results with peroxidase staining, also suggesting a diagnosis of mpo deficiency. confirmatory genetic testing has not been performed yet. their father, who reported severe skin infections with candida, had peroxidase stains performed on neutrophils and eosinophils which were both normal. we have presented a patient without a significant history of diabetes mellitus who developed invasive disease from candida and serratia and was ultimately diagnosed with myeloperoxidase deficiency. abstract/case report text introduction: juvenile xanthogranuloma (jxg) is an often benign, histiocytic proliferative disorder of the mononuclear phagocytic system. patients typically present with localized cutaneous lesions. systemic disease, especially central nervous system involvement, rarely occurs but has significant morbidity and mortality risk. no standard evaluation nor therapy regimen exists for systemic jxg and little is known about the genomic alterations underlying its pathology. case report: a full-term male infant presented at months of age with post-prandial abdominal pain, fevers, altered mental status and weight loss. abdominal ultrasound and ct identified renal masses. a chest ct was obtained showing a paraspinal mass with possible neural foramina extension. mri brain and total spine was consistent with diffuse leptomeningeal disease involving the left frontal convexity, brainstem, cerebellum, and multiple cranial nerves. abnormal enhancement was also present along the entire surface of the spinal cord extending into the cauda equina with additional enlargement of the cervical/upper thoracic cord with intramedullary enhancing masses and a right paraspinal mass. renal biopsy yielded a pathologic diagnosis of disseminated jxg. integrative clinical sequencing of the mass identified a somatic driving alk rearrangement (kif b-alk in-frame fusion). tumor and matched germline dna sequencing did not detect any alterations in the ras/mapk pathway. bone marrow biopsy was negative for disease with cerebrospinal fluid analysis showing numerous monocytes and macrophages consistent with jxg. the patient was started on therapy consisting of systemic dexamethasone, intrathecal methotrexate/hydrocortisone and systemic intravenous cytarabine. his first cycle was complicated by pseudomonas aeruginosa bacteremia and gangrenous cellulitis of the perianal region, treated with systemic/topical antibiotics and topical gm-csf. following completion of the initial cycle of therapy, the patient was noted to have declining neurologic status, including seizure-like activity. repeat mr imaging revealed worsening cns disease with new subdural fluid collection and progression of leptomeningeal enhancement and intramedullary cervical lesion. in light of disease progression, the decision was made to continue dexamethasone treatment, but add adjunct intrathecal cytarabine, and transition to targeted alk inhibition via daily oral ceritinib, given its predicted cns penetrance followed by ceritinib in combination with systemic intravenous clofarabine. significant clinical and radiographic improvement was noted with the new targeted treatment regimen. ceritinib therapy was tolerated well overall after a % dosing reduction made for initial grade gastrointestinal toxicity and grade hypertriglyceridemia (non-life threatening but level > mg/dl). following continued treatment with daily ceritinib and completion of cycles of clofarabine therapy, our patient experienced complete disease remission. he continues to do well on daily ceritinib monotherapy with plan to complete an additional year of therapy. conclusion: our report highlights the potential benefit of real-time integrative clinical sequencing in the management of systemic histiocytic lesions, specifically non-langerhans cell conditions. it has the potential to identify novel somatic genetic alterations, other than the typical lchassociated braf mutations of the mapk pathway, that may be therapeutically targetable. treatment with nd generation alk-inhibition in our pediatric disseminated jxg patient was a novel, biologicallyrationale management approach with minimal toxicity and potentially contributed to his complete remission. abstract/case report text background: c glomerulonephropathy (c gn) is a progressive kidney disease with the predominant pathological feature of c deposits around the glomerular capillaries. c gn patients suffer from dysregulated activation of the alternative pathway as the result of autoantibodies or congenital genetic defects that stabilize cleavage of c . despite therapy involving immunosuppression and complement-pathway inhibition, the prognosis for c gn is poor. we report a patient with autoantibody-mediated, refractory c gn who demonstrated no improvement on rituximab but achieved sustained remission on bortezomib. follow up studies after one year demonstrated clearance of the culprit autoantibody, normalization of c levels, and improved pathologic appearance of the kidneys. this case supports the idea that c gn is frequently driven by pathogenic autoantibodies that may not clear with rituximab alone. plasma cell directed therapy has the potential to clear these autoantibodies and halt the progression of disease. case presentation: we report the case of a hispanic male with chronic renal dysfunction initially diagnosed with membranoproliferative glomerulonephritis on renal biopsy at years of age. despite cellcept and prednisone, over the next years, he had worsening proteinuria and an increase in protein-to-creatinine ratio. renal biopsy suggested c gn, and lab studies revealed a factor-h autoantibody and c level below the assay limit of detection. after initiating eculizumab, the proteinuria temporarily improved; however, the proteinuria eventually worsened, and he was referred to immunology. we hypothesized that the factor h-binding autoantibody was the cause of dysregulated c cleavage and disease progression, and blocking the terminal complement pathway with eculizumab would not halt upstream c -mediated kidney injury. at the age of , rituximab and plasmapheresis were administered to clear the factor-h autoantibody. three months after rituximab administration, the factor-h autoantibody level decreased to the normal range, but he continued to have significant proteinuria with low serum albumin and undetectable c level. we concluded that the relevant autoantibody was not solely produced by differentiating memory b cells, so we decided to target the plasma cell compartment. bortezomib was started at the age of , and eculizumab was continued given his initial response to treatment. after adding bortezomib, factor h autoantibody levels dropped below prior levels and serum c level normalized. renal biopsy at the age of showed evidence of imp r o v i n g c d e p o s i t i o n a n d l e s s p r o m i n e n t g l o m e r u l a r hypercellularity, with stable mesangial hypercellularity, interstitial fibrosis, tubular atrophy, and sclerotic glomeruli. although his proteinuria did not worsen, it remained persistent, suggesting that earlier introduction of bortezomib could have prevented disease advancement. there has been no further progression of kidney failure. conclusions: the majority of c gn patients harbor autoantibodies to components of the alternative pathway of complement. this case provides evidence that at least some of these autoantibodies are indeed the cause of complement dysregulation, and thus are prime targets for therapy. b cell targeting therapies may be inadequate to decrease autoantibody levels for some patients. early initiation of bortezomib, or other plasmacell directed therapy, may effectively induce complement normalization and disease remission in these cases. inhaled corticosteroid and a long-acting bronchodilator. he has no family history of immunodeficiencies or congenital disorders. computed tomography(ct) chest showed bronchiectasis. his complement studies and isohemagglutinin titers were also normal. his serum immunoglobulin(ig) and lymphocytes on presentation are shown in table . he had a poor response to polysaccharide pneumococcal vaccination. he was diagnosed with combined igg /igg subclass/iga deficiency and was started on immunoglobulin replacement therapy and prophylactic rotating antibiotic therapy. thereafter, his clinical course markedly improved with a reduction in the frequency of rti's as well as the number of bronchiectasis exacerbations. there was high suspicion for an underlying genetic disorder based on his constellation of neurodevelopment disorders and immunodeficiency. cytogenetic evaluation with array comparative genomic hybridization(cgh) analysis showed duplication of xq and xq consistent with mds. discussion: mds is caused by duplications involving the mecp gene locus of the x chromosome at xq . it has a % penetration rate in males whereas females act as carriers and are usually unaffected. rarely, cases of de novo mutations causing mds have been reported. chromosome microarray analysis is currently the best initial clinical test when mecp duplication syndrome is suspected. management needs a multidisciplinary approach involving geneticists, neurologists, ophthalmologists, physical medicine and rehabilitation specialists, psychologists, gastroenterologists, and allergy and immunology specialists. prophylactic treatment with ivig and antibiotics has been the standard of care for immunodeficiency in these patients. prognosis is guarded and most male patients die in the mid to late 's because of severe rti's secondary to immunodeficiency. conclusions: this case confirms the association of mds with combined iga and igg subclass deficiencies. clinicians should consider pursuing genetic evaluation for mds in patients with neurodevelopmental disorders and immunodeficiency because the diagnosis of the syndrome can change the overall approach to management and expectations in prognosis. abstract/case report text introduction: c nephritic factor is an autoantibody that binds to the alternative pathway c convertase (c bbb). this results in unchecked overactivation of the alternative complement pathway, which can lead to renal disease, partial lipodystrophy, retina disease, and frequent infections. in this case, we present a patient with partial lipodystrophy and low c , subsequently found to have c nephritic factor. case description: a year old female presented with a month history of low c levels. she was diagnosed months ago with poststreptococcal glomerulonephritis (psgn) after presenting with hematuria and elevated aso titers. she had c levels drawn - months after time of diagnosis and c level was low at (normal range - ), which was consistent with psgn. it was rechecked months after time of diagnosis and was still low. she was referred to rheumatology at this time and was found to have a positive ana titer : . tests for lupus and anti-phospholipid syndrome were negative. c normalized to the low-normal range at months after time of diagnosis to . her pediatrician checked to make sure it remained normal around months after initial diagnosis and c was low again at . c was normal at . she was referred to immunology for further evaluation. during this time she was asymptomatic with no fevers, infections, hematuria, rashes, joint pain, or joint swelling. she has no history of hospitalizations other than the first for psgn. mother denied family history of autoimmune disorders. physical exam: physical exam was notable for abnormal subcutaneous facial fat with normal fat distribution in the rest of her body. the rest of the exam was unremarkable with normal cardiac, pulmonary, abdominal, and skin exam. testing: c level was rechecked and low at . c nephritic factor was elevated at . (normal range . - . ). alternate pathway complement (ah ) was confirmed twice and was undetectable, < (normal level greater or equal to ). total hemolytic complement (ch ) was low at (normal level - ). other complement levels were checked and c q, c , c , c , c , c , c , and c complement were within normal range. discussion: the overactivation of the alternative complement pathway by c nephritic factor can result in various clinical manifestations, such as c glomerulopathy and acquired partial lipodystrophy in predominantly the face and the upper torso. the exact mechanism of how c nephritic factor is related to facial and upper body lipodystrophy is not known. one proposed mechanism is that adipocytes in the face and upper body produce more factor d, which is a complement protein utilized by c nephritic factor. overactivation of the alternative complement pathway on the adipocyte then leads to formation of the membrane attack complex, resulting in adipocyte lysis. eye disease, such as retinitis pigmentosa and macular degeneration can develop. c nephritic factor can also lead to more frequent infections and renal disease. patients need to be closely monitored. if patients develop c glomerulopathy, they may need to be considered for immunomodulatory therapy, such as steroids and other immunosuppressants. project manager/ucsf benioff children's hospital senior clinical research associate/ucsf benioff children's hospital associate professor/department of clinical pharmacy, ucsf staff research assistant iv/ucsf benioff children's hospital senior supervisor/ucsf benioff children's hospital laboratory specialist/ucsf benioff children's hospital research specialist/ucsf benioff children's hospital assistant professor/ucsf benioff children's hospital clinical professor/ucsf benioff children's hospital assistant professor/ucsd rady children's hospital staff pediatrician/tuba city indian health service staff pediatrician/phoenix children's hospital associate professor/seattle children's hospital chief, genetic immunotherapy section/niaid, nih professor/university of minnesota professor/ucsf benioff children's hospital abstract/case report text background: artemis-deficient scid (art-scid) represents % of all scid, but occurs in / births in navajo and apache native americans. artemis protein, encoded by dclre c, is essential for repairing dna double-stranded breaks, including those generated during v(d)j recombination of antigen receptor genes as t and b cells develop. artemisdeficiency causes not only t-b-nk+ scid, but also increased sensitivity to alkylating drugs and radiation. art-scid is the most difficult scid to treat with allogeneic hematopoietic cell transplantation (hct) due to high rates of rejection and gvhd, incomplete immune reconstitution, and toxicity following intensive conditioning regimens. as an alternative, we developed a self-inactivating lentiviral vector containing the human artemis promoter and dclre c cdna (aproart). we are evaluating its toxicity and efficacy in a phase i/ii gene transfer trial in art-scid patients. methods: newly diagnosed infants with art-scid and older patients with insufficient immunity despite prior allogeneic hct were eligible if organ function was acceptable. infants needed to have no matched sibling donor and be at least months old at conditioning. cd + cells were isolated from bone marrow or cytokine-mobilized peripheral blood, cultured with cytokines, transduced x with aproart, and cryopreserved. patients received daily doses of busulfan, targeted for a cumulative exposure (cauc) of mg*hr/l, with infusion of thawed cells on the following day. results: we treated newly diagnosed infants (art - & - ) with median age . m (range . - . ) and previously-treated patients (art - ) ( . y, . y and . y), with a median follow-up of . m (range . - . ). the mean (sd) bu cauc was . ± . mg*hr/l. patients received a median of . x aproart-transduced cd + cells/kg (range . - . ). the average vector copy number (vcn) and transduction efficiency in the marrow grafts exceeded those in the pbsc grafts: . ± . copies/cell vs . ± . (p= . ) and ± % vs ± . % (p= . ), respectively. there were no serious busulfan side effects. all patients had transduced peripheral blood leukocytes by w and of developed gene marking in t, b, nk and myeloid cells by w (fig. ) . gene-corrected cd , cd , cd / ra/ccr , cd and cd cells appeared in of patients (fig. ) , with art having t, nk and myeloid marking without b cells at m post infusion. normalization of lymphocyte proliferation to pha occurred in the evaluable (> w) infants (fig. ) , all now outpatients off isolation. two infants and previously treated child developed autoimmune hemolytic anemia (aiha), with requiring immunosuppressive therapy. infections included rhinovirus at presentation in art that resolved with t cell reconstitution. after discharge art acquired and recovered from norovirus and art acquired and recovered from cmv and rotavirus. analyses of insertion sites and t cell receptor diversity are pending. conclusion: infusion of aproart-transduced autologous cd cells into art-scid patients pretreated with very low exposure busulfan resulted in multilineage engraftment of transduced cells with evidence for t and b cell immune development. aiha, the only complication to date, occurred early and appears to resolve following restoration of t cell immunity. these encouraging results suggest potential effectiveness of ex vivo gene therapy for art-scid. ( ) submission id# mailan nguyen, md , susan canny, md, phd , andrea ramirez, md , ivan chinn, md abstract/case report text background: systemic lupus erythematosus is a heterogeneous disorder of the immune system. systematic genetic evaluation of patients with childhood-onset sle (csle) has begun to identify phenotypic clusters of csle patients with classic sle-causing genetic variants, as well as revealed unexpected genetic mimics of lupus. we report patients diagnosed with csle with similar typical and atypical lupus features, who were subsequently found to carry pathogenic nras variants that are the cause of ras-associated autoimmune leukoproliferative disorder (rald). cases: all patients ( females, male) presented at < years of age (average age . months, range - months) with antinuclear antibodies, anti-double-stranded dna antibodies, autoimm u n e h e m o l y t i c a n e m i a , s e v e r e t h r o m b o c y t o p e n i a , antiphospholipid antibodies, hypocomplementemia and nephritis. additionally, the patients all displayed fevers, organomegaly, lymphadenopathy and hypergammaglobulinemia. two out of patients had a malar rash, leukopenia, lymphopenia, anti-smith antibodies, serositis or arthritis. no patient had oral or nasal ulcers or photosensitivity. despite the fevers, lymphoproliferation and systemic autoimmunity, the patients did not display overwhelming immune dysregulation (peak ferritin - ng/ml). interestingly, the patients were found to have monocytosis ( - %), as has previously been reported in rald. double negative t cells were within normal range in the patients in which this was tested. all patients required aggressive immune modulation for control of their disease manifestations. two of the developed severe infections, specifically pneumococcal sepsis, during therapy. current follow-up covers an average of . years (range . to years). the patients responded to corticosteroids and were given sequential trials of various steroid-sparing therapies. in general, they appeared to benefit from both b cell depletion and t cell-directed modalities (cyclosporine, rapamycin), which are not first line therapy in csle. unfortunately, patient developed a fatal pulmonary infection while on treatment; her underlying disease was felt to be quiescent. due to the early-onset of disease, each patient was selected for genetic evaluation ( by exome sequencing, by gene panel). this lead to the discovery of pathogenic nras variants (c. g>a, p.g d) in all patients, assumed to be somatic, although this was confirmed in only case. conclusion: ras-associated autoimmune leukoproliferative disorder can present indistinguishable from csle with positive autoantibodies, immune cytopenias, arthritis, nephritis and hypocomplementemia. clinicians should consider evaluating for rald in csle patients who present at an early age ( < years) with predominant features of lymphoproliferation and hematologic abnormalities, particularly monocytosis. t cell-directed therapy with cyclosporine or rapamycin should be considered for rald. ( ) human ctla loss-offunction causes dysregulation of foxp + regulatory t (treg) cells, hyperactivation of effector t cells, and lymphocytic infiltration of target organs. patients also exhibit progressive loss of circulating b cells, associated with an increase of predominantly autoreactive cd (lo) b cells and accumulation of b cells in non-lymphoid organs. inherited human ctla loss-of-function demonstrates a critical quantitative role for ctla in governing t and b lymphocyte homeostasis. ( ) this case highlights the importance of next generation sequencing (ngs) in diagnosing and managing complex presentations with multi-system involvement. case presentation: patient was diagnosed with diffuse large b cell lymphoma at age and treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (r-chop) in / . he underwent autologous stem cell transplant with preparative carmustine, etoposide, cytarabine, and melphalan (beam) in / . he subsequently developed recurrent giant condyloma acuminata following transplantation requiring surgical resections, refractory immune thrombocytopenic purpura (itp) requiring aggressive systemic steroids and high dose ivig at least yearly, experiencing hypogammaglobulinemia, recurrent sinopulmonary infections, disseminated herpes zoster, and kaposi sarcoma. in / , he underwent ct/pet, revealing extensive hypermetabolic lymphadenopathy and splenomegaly. bone marrow biopsies were negative for lymphoma, although showed a slightly hypocellular marrow ( - % cellularity), % blasts, and eosinophilia without peripheral eosinophilia. repeated evaluations for hiv, syphilis, histoplasma, cmv, hhv , hhv , bartonella, coxciella, brucella, htlv, toxoplasma were negative. htlv and antibodies had been negative prior to transplantation. tonsillectomy / due to progressive enlargement showed reactive follicular hyperplasia with focal acute tonsillitis without granulomas or viral inclusions. repeated lymphocyte enumeration and proliferation studies were normal. a repeat pet scan / revealed persistent diffuse lymphadenopathy involving the neck, chest, abdomen, and pelvis. left lung biopsy revealed non-caseating granulomas without lymphoma. stains for ebv were negative. repeat pet scan / indicated disease progression prompting a left axillary excisional lymph node biopsy, revealing ebv lymphadenitis with large, reactive follicles with interspersed inflammation and loosely formed granulomas and cd positive b cells within the follicles. ebv blood pcr was negative. afb and fungal stains were negative on all biopsies. in / , his igg was ( - ), iga ( - ), and igm ( - ) with only out of protective serotypes to pneumococcus post-vaccination at . or greater. in / , igg was ( - ). custom ngs panel showed a heterozygous missense variant in ctla c. c>g (p.s r) located in the transmembrane domain. this variant of uncertain significance is suspicious and strongly suggests the diagnosis of ctla -related autoimmune lymphoproliferative syndrome . patient was referred to the national institute of health, where he received a bone marrow transplant. conclusion: primary immunodeficiency diseases comprise a group of highly heterogeneous immune system diseases and around forms of pid have been described. ngs has recently become an increasingly used approach for gene identification and molecular diagnosis of human diseases guiding treatment to patients who may otherwise have poor outcomes. ( ) ( ) submission id# erik newman, md , cullen dutmer, md allergy and immunology fellow/university of colorado and children's hospital colorado assistant professor of pediatrics/section of allergy & immunology, children's hospital colorado, university of colorado school of medicine, aurora, co, usa abstract/case report text introduction: inherited defects of the complement system are rare disorders that can result in unique susceptibility to infections with select bacteria. patients with a deficiency of a complement protein early in the complement pathway (affecting c qrs, c , c , factor h, or factor i) have increased susceptibility to infection with encapsulated bacteria, most notably streptococcus pneumoniae and neisseria species. in contrast, patients with a deficiency of a complement protein at the terminal end of the complement pathway (affecting c , c , c , c alpha/beta/gamma, or c ) almost universally present with severe, recurrent, or disseminated neisseria species infections. most genes encoding complement proteins are found on autosomes, in which specific complement deficiencies result from biallelic mutations. although particular complement deficiencies occur at higher frequencies in certain populations, the prevalence of specific complement deficiencies is unknown in many parts of the world, especially in underdeveloped regions, including sub-saharan africa. herein, we describe a young congolese boy with an atypical presentation of c alpha deficiency. case description: a -month-old congolese boy with consanguineous parents (first cousins) presented with recurrent infections. prior to an evaluation of his immune system, he was hospitalized five times. his infections included episodes of acute otitis media, bacterial pneumonia, and viral pneumonitis. a bronchoscopy revealed diffusely edematous airways and growth of candida albicans, moraxella catarrhalis, and streptococcus pneumoniae in bronchoalveolar lavage cultures. concurrently, his respiratory pcr panel was positive for adenovirus. his initial immune evaluation included assessments of his serum immunoglobulin levels, vaccine titers (tetanus, diphtheria, haemophilus influenzae, and streptococcus pneumoniae), neutrophil oxidative burst, lymphocyte subsets, and ch , in which only his ch was abnormal ( u/ml). his ch remained low on repeat assessment ( u/ml), at which time an ah was pursued and also returned with a low result ( % of normal). a complement system genetic panel identified a homozygous intronic variant in c a (c. - g>a). functional confirmation of the variant revealed that the patient had a significantly decreased c level ( mcg/ml) and absent c function. discussion: we present a case of a young congolese boy with c alpha deficiency and a clinical presentation atypical for defects in terminal complement proteins. our patient presented primarily with recurrent respiratory infections, including streptococcus pneumoniae pneumonia, but without a preceding history of meningococcal disease. while it is well established that patients presenting with terminal complement pathway defects have an increased susceptibility to meningococcal disease, it is less clear if they have increased susceptibility to pneumococcal infections. occurring between exons and , the homozygous intronic variant in c a identified in our patient is predicted to result in abnormal splicing. while the allele frequency of this mutation is relatively high in the african population ( . ), functional confirmation of the variant demonstrated a decreased c level and absent c function that support the pathogenesis of the mutation. the discrepancy between the allele frequency and reported disease cases could be explained in part by varying clinical manifestations seen in c deficiency or underrecognized disease in sub-saharan africa. abstract/case report text rationale: scid is a syndrome characterized by profound t, b, and (in some cases) nk cell defects that is universally fatal unless immune reconstitution is achieved. a total of scid infants have been given allogeneic bone marrow transplantation at duke university medical center without pre-transplantation chemotherapy or post-transplantation graft-versus-host disease (gvhd); % received t cell-depleted haploidentical parental marrow and ( %) are known to be deceased. post-transplantation follow-up ranged from months to years. the aim of this cross-sectional study is to characterize the clinical status of a large cohort of survivors treated at a single medical center. methods: clinical status was assessed by detailed questionnaires delivered by mail or electronically. adult (≥ years old) and pediatric questionnaires were based on patients' age. patients were also contacted by telephone and evaluated at clinic visits. molecular type of scid, demographics, type, date and age at transplant were obtained from a clinical database. results: fifty questionnaires were completed to date from survivors ranging in age from to years. twenty-nine/ were adults ≥ years at the time of the questionnaire. genetic defects were known for all patients-xlinked scid was the cause in about half ( figure ). twenty-three of patients were on immunoglobulin replacement. thirty of reported having received immunizations, and about half of those received live vaccines. fifteen of reported they were taking no regular medications; reported taking prophylactic antibiotics. >we found substantial scholastic achievement, with / adult patients reporting college attendance. two had post graduate education including doctorate level degrees. occupations included physician, nurse, factory worker, musician, teacher, and engineer. one patient had children. twenty-seven / adult patients shared their height and weight and % ( / ) had a healthy bmi (bmi . - . ), while % ( / ) were overweight, and % ( / ) were underweight (< . ) . in pediatric patients, the average age and sex-adjusted bmi was at the th percentile and only had a bmi that was < th percentile. thirty-four/ patients reported seeing an immunologist regularly. in the adult group, % reported no longer seeing an immunologist. the health conditions reported were similar to those common in the general population, and included rashes, warts and mouth ulcers. most reported these were transient, self-resolving issues. thirteen of ( %) reported having adhd, higher than nih reported rates which estimate adhd in . % of adults and % of children). ten of ( %) reported having anxiety, similar to the nih reported prevalence of . % in the general population. / (~ %) reported having no active concerns about their health. conclusions: overall, our findings are consistent with those in the last update done by railey et al, j. peds. : [ ] [ ] [ ] [ ] [ ] [ ] [ ] in this population. patients are doing well with most problems similar to those common in the general population. most have a healthy bmi. adhd had a higher prevalence than in the general population. more than / of scid patients are not seeing an immunologist regularly, and a majority do not have any active concerns. . genetic causes of scid in the patients whose questionnaire data are presented. x-linked scid was the most common, followed by ada and il- r deficient scid clinical fellow/national institute of allergy and infectious diseases (niaid/nih) research nurse/nih-nhgri professor of pediatrics and allergy and immunology/ann & robert h. lurie children's hospital of chicago chief, laboratory of clinical immunology and microbiology/national institute of allergy and infectious diseases, niaid/national institutes of health, nih abstract/case report text rationale: myopathy has been occasionally documented in patients with primary immunodeficiency (pid). however, data on frequency and patient characteristics associated with myopathy are lacking. we performed a descriptive analysis of patients with primary immunodeficiency (pid) in the usidnet having myopathy as a feature of their primary disease. methods: the usidnet registry was queried for the spectrum of myopathic disorders in pid patients that had been entered into the registry as of november , . results: a total of pid patients with myopathy were identified, of which ( . %) were female. median age at onset of symptoms related to pid was years (range . - years, iqr . - years). median age of diagnosis of pid was . years (range . - years, iqr - . years). age at onset of myopathic disorders was not known. twenty-eight ( . %) patients had a diagnosis of common variable immunodeficiency (cvid), ( . %) had agammaglobulinemia, patients each ( . %) were diagnosed with severe combined immunodeficiency, hypogammaglobulinemia, or 'hlh and pigmentary disorders', while patients ( . %)were reported in each category of combined immunodeficiency (cid), autoimmune lymphoproliferative syndrome (alps), and autoinflammatory disease. thirty-five patients ( . %) had a causative gene variant identified attributable to pid. the most common variant identified was btk ( patients) followed by aire, lyst, cybb ( patients each) and pi kcd ( patients). eighteen individual patients had other variants identified ( figure ). patients had cellulitis or skin/ subcutaneous tissue infection, patients had a 'skin or subcutaneous tissue abscess', had pyoderma gangrenosum, and patient with eczema herpeticum. within this cohort of patients, the most common myopathy listed was myositis ( ) followed by 'muscle weakness' ( ), dermatomyositis ( ) , myalgia/s ( ) , myalgia/myositis ( ), myopathy ( ), polymyositis ( ) , steroid-induced myopathy ( ) . no patient had an infectious myositis or muscle abscess listed. eighteen patients ( . %) had a myopathic disorder at the time of diagnosis of their pid. thirtyone patients ( . %) received prednisone, ( . %) received hydrocortisone and ( . %) received dexamethasone. two patients had a diagnosis of adrenal insufficiency. nine patients ( . %) underwent hematopoietic stem cell transplantation. nine patients ( . %) died; median age of death years (range . - . years, iqr . - . years). ). one patient with chronic granulomatous disease had myopathy due to duchenne muscular dystrophy, which was listed as a cause of death. no other myopathic disorders were listed as a cause of death for the other patients. conclusion: myopathy and inflammatory myopathic disorders occur at relatively high frequency in pid, and may be present even at the onset of clinical symptoms. the underlying etiology can be speculated to be multifactorial. further subgroup analysis is warranted to elucidate possible variant-specific or treatment-associated characteristics of myopathy in pid. laboratory studies at years revealed normal igg/iga/igm but markedly elevated serum ige ( , ku/l), anemia (hb . g/dl), thrombocytopenia ( x /l) and lymphopenia ( cells/l), with low t and b cell counts, very low proportion of naïve t cells, skewed repertoire of cd + t cells, undetectable trec levels, and impaired t cell proliferation to mitogens and antigens. there was an elevated percentage of circulating plasmablasts ( . %) and of dysreactive cd low cd low b cells ( . %). at the age of , hsct with reduced intensity conditioning was performed from her phenotypically hla-matched father, with improvement of t and b cell count and function. whole exome sequencing (wes) identified a homozygous missense variant in the mannosidase alpha class b member (man b ) gene (p.asp asn), that segregates with disease in the pedigree. the man b asp residue is evolutionary conserved. the p.asp asn allele has a minor allele frequency of . in gnomad, with no homozygotes. the cadd score for this variant is . , significantly higher than the mutation significance cutoff score ( . ). man b is involved in the lysosomal degradation of glycoproteins and demannosylation of free n-glycans. in particular, man b cleaves man glcnac to generate man glcnac . serum n-glycan profiling revealed elevated man /man and man / man in the patient. n-linked and free glycan profiling by mass spectrometry (ms) showed accumulation of man glcnac , man glcnac and man glcnac glycans in patient fibroblasts as compared to control cells, consistent with defective lysosomal glycoprotein degradation. lentiviral transduction of wild-type man b into patient fibroblasts led to normalization of the n-linked glycan profile, with reduction of man glcnac from . to . times control levels, and of man glcnac from . to . control levels, indicating rescue of the impaired deglycosylation ( figure a ). western-blotting demonstrated defective n-glycosylation of lamp and icam proteins in patient fibroblasts ( figure b) , which were corrected upon lentiviral transduction of wild-type man b ( figure c ). overall, our results indicate that loss of man b enzymatic activity leads to dysregulation of deglycosylation and abnormal mannosylation of glycans. in conclusion, we have demonstrated that man b deficiency accounts for a novel autosomal recessive cdg with prominent features of immune deficiency and immune dysregulation. abstract/case report text heme oxygenase- (hmox ) is a rate-limiting enzyme that catalyzes the degradation of heme to carbon monoxide, ferrous iron, and biliverdin, which becomes bilirubin. these byproducts are implicated in inflammation, cell homeostasis, and antioxidant defense( ). hmox -deficiency is an extremely rare autosomal recessive disorder with a complex presentation of a wide spectrum of symptoms, including hemolytic anemia and hyperinflammation, requiring genetic testing for confirmed diagnosis ( ) . we report the fifth known case of hmox -deficiency ( ) ( ) ( ) , a boy who presented at years of age with aspects of the characteristic phenotype, but also had early onset asplenia, interstitial lung disease, and previously undocumented immune deficiency. patient's presentation was notable for hyperinflammatory exacerbations triggered by viral and bacterial infections as well as vaccinations. episodic flares occurred every few months lasting weeks to months with fevers of - f, hypoxia, leukocytosis above , /mm , hemolytic anemia with negative coombs, thrombocytosis exceeding million/ mm , transaminitis, hemoglobinuria, hyperferritinemia to , ng/ml, and elevated ldh to , iu/l. immune evaluation revealed normal immunoglobulin levels and adequate vaccine titers to both protein and carbohydrate antigens. although class switched populations were normal, b-cell phenotyping showed absent immature and transitional b-cells, low mature memory, and reduced cd + memory b-cells at % (normal > %). mitogen stimulation with phytohemagglutinin and anti-cd were decreased ( . % of control and . % of control, respectively). t-cell phenotyping demonstrated cd population heavily skewed to immaturity with % of cells with naïve phenotype cd ra+cd +ccr +. there were few effector-memory t cells and the cd population was skewed towards immaturity with > % of the cells naïve. liver biopsy was performed secondary to hepatomegaly yielding mild to moderate sinusoidal fibrosis. bone marrow biopsy revealed a normocellular marrow with % blasts, increased megakaryocytes, and extensive hemophagocytosis. natural killer cell function was very low, while soluble il- ra level was normal. further workup for hemoglobinopathies, metabolic defects, congenital disorders of glycosylation, lysosomal storage disorders, wilson's disease, autoimmune hepatitis, inherited and autoimmune hypercoagulability disorders, connective tissue disorders, myositis, and myopathies were all unremarkable. imaging demonstrated asplenia and howell-jolly bodies were present. hemophagocytic lymphohistiocytosis (hlh) genetic testing showed no variants. he was suspected to have systemic juvenile idiopathic arthritis (sojia) with episodes of macrophage activation syndrome. the frequency of his autoinflammatory flares increased such that he was corticosteroid dependent by age , having failed methotrexate, azathioprine, and anakinra. he was started on tocilizumab with laboratory improvements, but his lung disease progressed and became oxygen dependent. lung biopsy confirmed nonspecific interstitial pneumonitis (nsip) with cholesterol granulomas also seen in sojia. ultimately, chronic lung disease led to his death at age . whole exome sequencing yielded a paternal frame shift hmox and maternal splice donor hmox resulting in absence of protein. bone marrow transplantation (bmt) in hmox deficient mice have rectified phagocytotic defects and thereby their autoinflammatory phenotype, but no human reports for bmt treatment of hmox -deficiency has been described. here we describe a phenotype expansion for hmox deficiency to include not only asplenia and hepatomegaly, but also interstitial lung disease with cholesterol granulomas and inflammatory flares. abstract/case report text introduction: mutations in the gene encoding signal transducer and activator of transcription (stat ) cause autosomal dominant hyperimmunoglobulin e syndrome (ad-hies) characterized by recurrent skin and sinopulmonary infections, atopic dermatitis, and elevated serum immunoglobulin e (ige) levels. treatment is largely aimed at controlling symptoms and preventing infections with no standard of care. there is a paucity of literature describing the utilization of biologic therapies in the ad-hies patient population. we present patients from one family with ad-hies successfully treated with monoclonal antibody therapies targeted at il- , il- and il- . case descriptions: patient : -year-old female with stat lof c. c>t (p.arg trp) with a history of atopic dermatitis and asthma requiring - steroid courses per year with frequent school absences. she developed a severe pruritic rash covering her upper body months ago that failed to respond to antihistamines and topical antibiotics prescribed by her primary care provider. given her poorly controlled asthma and our concern for a follicular type morphologic variant of atopic dermatitis, dupilumab was initiated. her scoring atopic dermatitis (scorad) prior to initiation of biologic therapy was . and improved to . following doses ( weeks) of dupilumab with clear dramatic improvement in her skin and quality of life ( figure ). she also reports decreased asthma severity with no steroid courses, reduced albuterol usage, and significant decline in school absences since initiation of dupilumab. patient : -year-old female with stat lof c. c>t (p.arg trp) who is the sister of patient . she has a history of severe asthma requiring frequent emergency department visits, hospitalizations, and - steroid courses per year despite therapy with high-dose fluticasone-salmeterol. spirometry prior to april demonstrated an obstructive pattern with an fev ranging from - %. she was initiated on mepolizumab in april . subsequent spirometry demonstrates an fev average of % with a range of - %. she had one hospitalization in early but otherwise no hospitalizations for asthma since initiation of biologic therapy. patient : -year-old female with stat lof c. c>t (p.arg trp) who is the paternal first cousin of patients & . she has a history of severe atopic dermatitis with associated pruritus and picking behaviors, poorly controlled despite daily triamcinolone application. she previously failed ultraviolet therapy and crisaborole. she also has a history of severe asthma requiring - steroid courses per year despite high-dose fluticasone-salmeterol. dupilumab was started in may . scorad prior to initiation monoclonal antibody therapy was . and declined to . following weeks ( doses) of dupilumab therapy with marked improvement in skin appearance and pruritus ( figure ). discussion: we present three cases of ad-hies caused by stat loss-of-function mutations treated successfully with monoclonal antibody therapies targeted at il- or il- and il- . to the best of our knowledge, there is no published data describing the use of these biologic agents in the treatment of ad-hies. future studies are needed to clarify the role of these cytokines in the pathogenesis of ad-hies and to elucidate clinical indications for biologic therapy in this patient population. informed consent was obtained from all individual participants included in the study. abstract/case report text ctla- is a potent inhibitor of t cell proliferation that competes with costimulatory receptor cd for its ligands cd and cd expressed on antigen presenting cells. heterozygous loss-offunction mutations in ctla- have been identified in patients with lymphocytic infiltration of multiple nonlymphoid organs (lo et al). the patient is a -year-old jordanian male born at term to nonconsanguineous parents, hospitalized at mo for lll pneumonia, and at mo and at mo he was evaluated in the ed and diagnosed with non rsv-bronchiolitis with lll infiltrate thought to be secondary to atelectasis. at yo he developed lll pneumonia and respiratory failure requiring picu admission. he was treated with ceftriaxone. after discharge, he had weeks of intermittent fever, progressive fatigue, productive cough, and ftt. he received courses of cefdinir, clindamycin, and tmp-smx without improvement. chest ct revealed left lung consolidation, lll bronchiectasis, lul tree in bud opacities, and hilar lymphadenopathy. bronchoscopy with bal revealed no bacterial growth and no acid-fast bacilli. srrna ngs was positive for h. influenzae. lung biopsy demonstrated acute and chronic bronchiolitis with bronchiolitis obliterans and intraluminal polyps, with lymphocytic infiltration involving the bronchi and bronchioles. the lung parenchyma showed airspace filling with foamy macrophages and chronic interstitial inflammation. acid fast and fungal stains were negative. he was treated with systemic steroids for bronchiolitis obliterans with noted improvement. the severity of lung disease at such an early age prompted an immune evaluation. sweat test, anca, anti-pr and hiv were negative. total immunoglobulins were normal for age, and titers to s. pneumoniae, diphtheria and tetanus were protective. lymphocyte enumeration revealed elevated t and nk cell numbers for age. lymphocyte proliferation to pha, pwm, candida and tetanus were normal. dihydrorhodamine assay was normal. b cell phenotyping was normal. there was normal expression of cd , hla-dr and cd on activated t cells; of note the patient was on systemic steroids when tested. invitae gene pidd panel revealed a variant in ctla : c. g>a (p.gly glu) that has been shown to be pathogenic in one patient (schawb et al). flow cytometry showed normal frequency of t follicular helper cells and t regulatory cells compared with controls, however ctla- expression by t regulatory cells was lower than control. due to the severe and progressive nature of the patient's lung disease, therapy with x weekly azithromycin and abatacept mg sq weekly was initiated. we report a case of ctla- haploinsufficiency presenting with recurrent pneumonia and bronchiolitis obliterans in a -year-old child. based on patient registry data, our patient appears to be the youngest child diagnosed with ctla- haploinsufficiency reported in the literature to date (schawb et al). notably, our patient l a c k s o t h e r f e a t u r e s c o m m o n l y d e s c r i b e d i n c t l a - haploinsufficiency, including autoimmune cytopenias, gastrointestinal disease, lymphoproliferation, and hypogammaglobulinemia. this case illustrates the importance of consideration of this diagnosis in young children with severe lung disease without other evidence of immune dysregulation. our hope is that prompt recognition and early treatment administration will prevent disease progression and further decrease in pulmonary function. splenectomy, he had an episode of pneumococcal meningitis at age , and sepsis of unknown origin at age . over the past several years he has developed chronic tinea corporis, onychomycosis, and otitis externa infections despite numerous antimicrobial regimens. at age , the patient developed urinary retention, walking, and balance difficulties. he was found to have diffuse white matter changes on mri, elevated wbc, and positive oligoclonal bands. initially, he was diagnosed as progressive ms treated with steroids with partial improvement. csf microbiology studies including afb stains, bacterial, fungal, mycobacterial cultures, cryptococcal antigen, vdrl, t. pallidum particle agglutination (tppa), as well as, pcr for cmv, ebv, vzv, enterovirus, hsv - , jc virus and t. pallidum were all negative. peripheral blood studies included mycobacterial blood culture, pcr for cmv, ebv, hhv- , in addition to serology for cryptococcal antigen, and coccidioides species, all of which were negative. additional neurological complications include granulomatous uveitis and oscillopsia, which he developed around age . immune evaluation performed at age revealed low igg and igm, and the patient was started on grams of monthly ivig. cbc with differential was notable for normal monocyte count and thrombocytopenia, mild neutropenia (table ). immunophenotyping revealed absent b cells and nk cells, while the cd t cells were elevated. cd t cells were normal (table ) . at age , whole-exome sequencing identified a heterozygous missense mutation in gata c. c>t, p.(arg trp). after the diagnosis of gata haploinsufficiency, he was found to have myelodysplastic syndrome with multilineage dysplasia (mds-mld) on bone marrow biopsy. he is currently awaiting bone marrow transplant discussion: we present a -year-old male with cytopenias, splenomegaly, leukoencephalomyelopathy, granulomatous uveitis, and recurrent fungal infections found to have a pathogenic heterozygous missense mutation in gata . leukoencephalomyelopathy in gata haploinsufficiency has been associated with jc virus and ebv infection. our patient did not have any evidence of a chronic csf infection. to our knowledge, myelopathies have not been reported with gata c. c>t, p.(arg trp). this case highlights the variable nature of presentation in gata haploinsufficiency, and the need for clinical awareness of this entity in order to facilitate early diagnosis and appropriate therapy. immunoglobulins* white blood cells . x * /l (n: - ) magnetic resonance imaging (mri) of the brain and spine showed numerous enhancing parenchymal nodules (figure one). brain or spinal biopsy was requested, but not recommended by our neurosurgery service. lumbar puncture evaluation was performed. cerebral spinal fluid showed no bacterial or fungal elements. both quantiferon gold for tuberculosis and three consecutive sputum cultures for acid fast bacilli were negative. he continued his sirolimus and the intravenous immunoglobulin replacement was increased to two grams/kg. the patient was cleared from respiratory isolation and discharged after two weeks in our facility with mild improvement in his neurologic status. within five days he was sent to a nationally renowned hospital. at this facility, extensive evaluation for his neurologic deficits were performed including culture and pcr for bacteria, virus, mycobacteria from csf bone marrow, lymph node, blood, and induced sputum. these were noncontributory. he was given high dose corticosteroids for two days. one of our facility's sputum cultures was reported with acid fast bacilli. but sputum mycobacterium tuberculosis pcr was negative. repeat mri scans of the brain and spine showed improvement (figure ), so no brain biopsy was performed. he was sent back to our facility with the recommendation to start a targeted pi kinase inhibitor on compassionate grounds as he was not eligible for the clinical trial because his weight was less than kg. but pretreatment abdominal ct revealed multiple low-density lesions scattered throughout the liver (figure ) not previously seen on prior noncontrast ct four months prior. discussion: although this gain in function mutation of the pi kδ signaling pathway disorder has been well characterized, this is a rare report of a patient with pasli immunodeficiency with central nervous system and later liver lesions pet imaging showed subcarinal, mediastinal, retroperitoneal lymphadenopathy, splenic enlargement to cm and bilateral lung nodules ( figure ). excisional biopsies of left axillary and left lower lobe of lung were performed and showed low-grade b-cell lymphoma (mucosal) and underlying lymphoproliferative disease. invitae alps and cvid panels ( genes) revealed a heterozygous variant of unknown significance in exon of fas (c. a>g(p.asp gly) unlike most fas mutations causing alps, this mutation is in the extracellular region rather than the death domain . the c. a>g variant has been reported in a single patient with alps phenotype, affecting fas protein function by inhibiting binding to fas ligand (fas-l), reducing fas-l induced apoptosis . this fas c. a>g mutation was found in alps affected brother and was absent in the unaffected father. the patient's mother passed away prior to testing. since diagnosis, the patient's malt lymphoma has been treated with rituximab weekly for the first month and then monthly. he continues to receive monthly ivig for hypogammaglobulinemia. after two years, ct demonstrates a significant decrease in pulmonary nodules and splenomegaly ( figure ). the patient's forced vital capacity (fvc) improved from . l ( % predicted) to . l ( % predicted). conclusion: we report the first case of malt lymphoma seen in a patient with alps. it is unknown whether the unique fas c. a>g mutation in the non-death domain contributes to malt lymphoma progression. we propose malt lymphoma is a malignant transformation of chronic inflammation that has the potential to occur in patients with alps. in the future, improved knowledge of mechanistic pathways of inflammation in lymphoma development and progression is important in the optimal management of alps. abstract/case report text background wiskott-aldrich syndrome (was) is a rare x-linked disorder characterized by combined immunodeficiency, eczema, microthrombocytopenia, infections, autoimmunity and increased risk of hematological malignancies. gene therapy (gt) using autologous cd + cells is an emerging alternative treatment with possible advantages over standard allogeneic hematopoietic stem cell transplant. we report the outcomes of a phase i/ii clinical trial in which was patients underwent gt using a self-inactivating lentiviral (sin-lv) vector expressing the human was cdna under the control of a . kb fragment of the human was promoter. subjects and methods: five patients with severe was (clinical score - ) were enrolled (table ) . cd + cells were transduced ex-vivo and reinfused after conditioning with busulfan and fludarabine. two subjects (p , p ) had autoimmunity pre-gt, manifested as skin vasculitis and autoimmune cytopenias. results: all subjects were alive at median follow-up of . (range . - . ) years. multi-lineage vector gene marking was sustained over time. all had clinical improvement of eczema, infections and bleeding diathesis. was protein (wasp) expression was increased over baseline but remained below normal levels. proliferation of t cells in response to anti-cd improved post-gt. humoral immune deficiency improved, with normalization of igm, and independence from ig replacement and vaccine responses in those tested. platelet levels increased to > x cells/ul in only the two subjects with a vcn ≥ in transduced stem cells. podosome formation in monocyte-derived dendritic cells was near absent pre-gt and improved in all subjects post-gt, but only reached healthy control levels in the subjects with highest vcn. in contrast to other trials using this sin-lv, two patients (p and p ) had flares of autoimmunity post-gt, offering the opportunity to study the poorly understood mechanistic features of immune dysregulation in this disease. selfreactive vh - -expressing b cells and cd lo b cells remained elevated in most patients. however, despite wasp expression in foxp + tregs, those with autoimmunity had poor numerical recovery of t cells and tregs at the time of clinical symptoms ( fig a) . in addition, il- producing regulatory b cells (bregs) were highly deficient pre-gt, recovered in subjects who did not experience autoimmunity, but failed to recover in p and p ( fig b) . moreover, transitional b cells, which are enriched in bregs and are potent inducers of treg populations, also recovered poorly in those two subjects ( fig c) . there have been neither severe gt-related adverse events nor abnormal clonal expansion in transgene-marked cells to date. conclusion in summary, our data confirm and extend the safety and efficacy of gt in correcting disease manifestations associated with was, with the longest overall follow-up reported so far in studies using sin-lv. in addition, our findings suggest that higher vcn is needed in order to correct myeloid compartments such as platelets and monocytes. finally, we report the novel finding of the restoration of bregs and suggest that recovery of this compartment, along with tregs, is protective against development of autoimmunity post-gt. overall, these data suggest a mechanism for breakdown of immune tolerance in was with important therapeutic implications and prognostic value. this is an -year-old hispanic female who initially presented with failure to thrive, recurrent fevers and intermittent cough with episodes of perioral cyanosis. symptoms started at age months and were attributed to recurrent viral and bacterial infections. at months old, she was hospitalized with fever and hypoxemia (o saturations %). cxr showed prominent interstitial lung markings and she was diagnosed with pneumonia. ct scan confirmed cxr findings and ruled out anatomical anomaly. she was lost to follow up for years, and re-presented with worsening respiratory status. a repeat ct scan demonstrated worsening interstitial thickening. immune workup, including quantitative immunoglobulins, ch , lymphocyte subsets and vaccine response titers (pneumococcal and tetanus), was unremarkable, except for elevated igg levels. genetic testing for surfactant dysfunction mutations was negative. thoracoscopic lung biopsy revealed interstitial fibrosis, pas-positive granular alveolar proteinosis, type ii cell hyperplasia, and lymphoid follicles. at age , she was admitted for a pericardial effusion. rheumatology was consulted for evaluation frequent fevers and persistently elevated inflammatory markers, with concern that the pericarditis was autoinflammatory. she had an elevated ana (> : homogeneous pattern), il- ( . pg/ml), and igg ( mg/dl) at that time. she had an atypical anca pattern with positive myeloperoxidase antibodies. anti dsdna, smith and scl were negative. she was treated with steroids and hydroxychloroquine with some improvement in her oxygen requirement. one year later she had an additional episode of pericarditis, treated with colchicine. a few months later, she was admitted with newonset gross hematuria and elevated serum creatinine (to mg/ dl). kidney biopsy showed anca vasculitis with glomerulonephritis ( % crescents, no scarring or fibrosis). she provisionally received a diagnosis of microscopic polyangiitis, with lung and kidney involvement. she did not have peripheral vasculopathy. she was started on cyclophosphamide, rituximab, and iv steroid pulses. cyclophosphamide was discontinued due to recurrent episodes of posterior reversible encephalopathy syndrome (pres) after infusion. her igg level decreased as she developed nephrotic range proteinuria. a primary immunodeficiency genetic panel was sent to evaluate for monogenic immune dysregulation syndromes and revealed a tmem gene mutation (c. g>a) which has previously been reported in other subjects with savi (stingassociated vasculopathy of infancy syndrome). sting is a cytosolic dna sensor that leads to type i interferon production upon stimulation. this gain-of-function mutation was confirmed by measuring interferon signature gene expression at the nih (fig ) , and her diagnosis was revised accordingly. the patient was started on a jak-inhibitor (tofacitinib) to block interferon signaling. unfortunately, the patient is now deceased, due to overwhelming infection and multi-organ system failure. conclusion: genetic testing can be crucial in aiding the diagnosis of complex patients with immune dysregulation and can provide an opportunity for targeted therapy, which should be employed as soon as able to stop disease progression. abstract/case report text background: activated phosphoinositide -kinase δ syndrome (apds- ) was first described in as a monogenetic immune dysregulation syndrome with a variable phenotype. increased sinopulmonary and herpesvirus infections are well described, but fungal infections such as candidiasis have been rare. to date, disseminated histoplasmosis has not been described. history: a yo caucasian male who was previously diagnosed with common variable immunodeficiency (cvid) in late childhood due to recurrent sinopulmonary infections presented with recurrent fever, pancytopenia, severe splenomegaly, and lymphadenopathy. urine histoplasmosis antigen and beta-d-glucan were elevated. a bone marrow biopsy demonstrated granulomatous inflammation. transbronchial biopsy of a subcarinal lymph node was consistent with granulomatous disease. this led to a diagnosis of disseminated histoplasmosis. he was treated with amphotericin b and then months of itraconazole, with improvement of his symptoms. he was admitted to the hospital about years later when he presented with fatigue, fever, chills, dark urine, and scleral icterus. he was found to have an acute worsening of chronic anemia with a hemoglobin of . g/dl. due to elevated ldh, presence of schistocytes on peripheral smear, and undetectable haptoglobin, he was diagnosed with autoimmune hemolytic anemia, despite a negative direct coombs. a bone marrow biopsy specimen was hypercellular with marked erythroid predominance, with normal flow cytometry and no blasts identified. infectious workup was negative. ct chest during the workup revealed new right hilar and mediastinal lymphadenopathy, in addition to calcified right hilar and subcarinal lymph nodes, bronchiectasis, and stable hepatosplenomegaly. transbronchial biopsy of lymph nodes showed benign lymph nodes with calcified necrotizing granulomata and presence of non-viable fungal species, presumably "old" histoplasmosis. family history: family history was significant for mom dying at years-old from undefined cns infection. immune labs: · panlymphocytopenia: absolute lymphocyte count of /ul, cd + t cells /ul, cd + /ul, cd + /ul, cd + /ul, cd +cd + /ul. cd +/cd + ratio . · decreased class-switched memory b cells and plasmablasts · elevated t central memory cells and activated (hla-dr+) cd + and cd + t cells · hemoglobin . g/dl, platelets , /ul, anc ranging from /ul to /ul · iga mg/dl, igm mg/dl; reportedly had low igg prior to initiating ivig in childhood · ebv pcr and cmv pcr negative genetics: · pik cd (c. g>a), consistent with diagnosis of autosomal dominant apds- . discussion: gain-of-function variants leading to increased pi kδ activity have been shown to cause both b and t cell dysfunction, leading to impaired immunologic responses to bacterial and viral infections. recurrent sinopulmonary infections and herpesvirus infections are commonly seen and while mucocutaneous candidiasis has been reported in cohorts of patients with pik cd, other fungal infections are not common. severe disseminated histoplasmosis infections have been described in primary immunodeficiencies characterized by signaling defects in the il- /ifn-γ pathway, stat deficiency, cd l deficiency, gata deficiency and in stat gain-of-function mutations. to our knowledge, disseminated histoplasmosis has not been previously reported in patients with pik cd immunodeficiency. abstract/case report text the reported case represents the first case of nbas disease detected by newborn screening program for primary immunodeficiency, based on krec assay. the patient came to our attention due to the complete absence of krecs and normal trecs on dbs (dried blood spot) while hospitalized for low weight at birth ( , g), intolerance for enteral feeding, hepatosplenomegaly, slightly elevated liver transaminase, head and face eczematous dermatitis. during the st month, he also presented klebsiella pneumoniae urinary tract infection and methicillin-resistant staphylococcus aureus sepsis. peculiar phenotypic features including triangular face, proptosis, flat philtrum, mild retrognatia, hirsutism, loose and slightly wrinkled skin, and apparent reduction of subcutaneous fat were noticed at birth. complete blood count showed lymphocytopenia, marked hypereosinophilia. serum immunoglobulin g (igg) were markedly decreased, iga and igm were undetectable. extended immune-phenotyping showed complete absence of cd + cells, low count of cd + lymphocytes, and reduced natural killer (nk) levels. at month of age a colonoscopy was carried out for persistent diarrhea and reduced tolerance to enteral feeding. the histological examination of mucosal intestinal biopsies showed signs compatible with autoimmune enteropathy. for this reason immunosuppressive therapy with rapamycin was started without consistent clinical amelioration. many cvc-sepsis occurred in the last months, associated with persistent gastrointestinal symptoms and severe growth restriction. despite the absence of experience data in literature for nbas syndrome, we retain that hsct represents the only resolutive therapy for him. abstract/case report text case: a -year-old female with asthma and allergies presented to immunology clinic with a history of chronic fatigue and sinusitis. fatigue occurred daily every - weeks and was described as not feeling rested even after hours of sleep. chronic sinusitis required - prolonged antibiotic courses per year. nasal cultures grew methicillin-sensitive and -resistant staphylococcus aureus and haemophilus influenzae type b (hib). three separate sinus surgeries over the prior few years reduced her sinus symptoms. other infectious history was significant for recurrent urinary tract infections with e. coli and klebsiella, recurrent otitis media as a child, and a diagnosis of transient hypogammaglobulinemia of infancy that resolved at years of age. review of systems revealed axillary lymphadenopathy for - days twice per year not related to infection. she had longstanding eczema that responded to topical tacrolimus, multiple environmental allergies, and recently diagnosed asthma that improved with inhaled budesonide/formoterol. as a teenager she received allergy immunotherapy for a few years but stopped due to frequent adverse reactions. family history revealed that father died from cancer. physical exam was unremarkable. laboratory evaluation demonstrated normal igg mg/dl, igm mg/dl, iga mg/dl, elevated ige mg/dl, normal t and nk cell enumeration, mildly low total b cells ( cells/mcl, . %), and normal b cell subsets (cd +igm+cd - %, cd +igm+cd + %, cd +igm-cd + %). tetanus antibody titer was protective, but hib antibody titer was undetectable at < . mcg/ml with marginal response after vaccination ( . mcg/ml). pneumococcal serotype specific igg levels (mayo) were mostly undetectable with of serotypes protective at baseline and only protective post vaccination with pneumovax . cd / cd blastogenesis was poor. due to poor antibody response and continued sinus infections she was started on igg replacement. her fatigue and sinus symptoms improved moderately but she continued to require antibiotics and sinus ct scans continued to demonstrate significant disease. a focused exome sequencing panel was pursued and a novel heterozygous card variant was found (c. g>t, p.r l). discussion: the card /bcl /malt (cbm) complex is a critical signaling adapter that facilitates several downstream immune responses predominately through nf-kb. mutations in several different domains of card result in a clinical entity collectively referred to as card -associated atopy with dominant interference of nf-kb signaling (cadins). cadins is associated with a broad range of clinical manifestations but most have marked atopy with infections, poor t cell proliferation, and varying levels of poor antibody response. both our variant (p.r l) and a previously reported pathogenic variant in the same amino acid (p.r g) involve a change from a charged arginine to a non-polar amino acid in the critical bcl / card binding interface. iκbα degradation was not present in b cells from our patient ( figure ) confirming the functional defect in nf-kb signaling. thus, we present a novel variant that fits cadins both clinically and genetically. clinicians should be aware of cadins when patients present with recurrent infections in the setting of significant allergic disease. i b degradation assay. stimulation: μl of whole blood was stimulated in a ml facs tube with ng/ml phorbol -myristate -acetate (pma; sigma, cat# p ) at °c for , , or min, at which point ml of pre-warmed x lyse/fix buffer (bd, cat# ) was added. cells were fixed for min at °c, centrifuged and washed twice with facs buffer (pbs supplemented with % fbs and mm edta). staining and permeabilization: fc receptors were blocked for min at rt (human trustain fcx; biolegend), followed by a min stain on ice with anti-cd af (clone rpa-t ; biolegend), and anti-cd bv (clone hib ; biolegend). cells were washed with facs buffer and permeabilized for min on ice with ml phosflow perm buffer ii (bd biosciences, cat# ) that had been precooled to - °c. after permeabilization, two ml facs buffer was added and the samples were centrifuged. after three additional washes, the cells were stained with anti-iкbα pe (clone /ikba/mad- ; bd biosciences) for min at rt. samples were washed three times and data were collected on a cytek dxp flow cytometer. data were analyzed with flowjo software. abstract/case report text introduction: wiskott-aldrich syndrome (was) is a rare, but well-defined x-linked disorder. loss-of-function mutations in the was gene result in classic was and x-linked thrombocytopenia (xlt), while gainof-function mutations lead to x-linked neutropenia (xln). classic was phenotypic features include recurrent infections, microthrombocytopenia and eczema along with increased susceptibility to autoimmune disorders and malignancy. most males with classic was are diagnosed in early childhood and early death can result from its various clinical manifestations. case: we present a -year-old male who was referred to immunology for hypogammaglobulinemia. as an infant he had moderate eczema, and at the age of two was diagnosed with immune thrombocytopenia (itp) with baseline platelets of - x ^ /l. infectious history was notable for one episode of pneumosepsis and recurrent otitis media, influenza, and herpes labialis infections. around the age of , he was diagnosed with common variable immunodeficiency (cvid) based on the finding of low immunoglobulins. he developed diffuse large b cell lymphoma at age , and was treated with cyclophosphamide, doxorubicin, vincristine, prednisone and rituximab (chop-r). at age he developed abdominal pain with bloody stools. investigations confirmed an endoscopic and pathologic diagnosis of ulcerative colitis. due to the severity of his disease, he has required maintenance therapy with vedolizumab. he was again noted to have hypogammaglobulinemia at which point he was referred to immunology at our centre. there was no significant family history of immunodeficiency, malignancy or autoimmunity. blood work was notable for normal white blood cell and lymphocyte counts, platelets of x ^ g/l, low igg at . g/l ( . - . g/l) with normal iga, igm and ige. lymphocyte subsets including t, b and nk cells were within the normal range. genetic testing was performed and he was found to have a known pathogenic mutation in the was gene (c. g>a, p.asp asn) which has been previously reported in association with was and xlt. he has since been placed on immunoglobulin replacement and has been referred for consideration of hematopoietic stem cell transplantation. discussion: was is a rare syndrome that can have a similar phenotype to other immunodeficiency disorders including cvid, omenn syndrome and ipex (immune dysregulation, polyendocrinopathy, x-linked). individuals with cvid present with hypogammaglobulinemia and recurrent infections, and these individuals also have an increased susceptibility to autoimmune disorders, gastrointestinal disease and malignancies, especially lymphoma. although eczema is a common disorder, its presence in addition to features of early onset thrombocytopenia, immunodeficiency, autoimmunity and/or malignancy in male patients should heighten the suspicion for was. it is important to make the diagnosis of was as hematopoietic cell transplantation and gene therapy are potentially curative treatment options. abstract/case report text secondary immune deficiencies (sid) are caused by varied mechanisms and are common in patients with hematological malignancies such as chronic lymphocytic leukemia (cll) and multiple myeloma (mm). in this setting, both the disease and its treatment (such as b cell ablation therapy) contribute to the development of secondary antibody deficiency. infections remain a major cause of morbidity and mortality in cll and mm patients. this underscores the need for early recognition and stratification of risks in order to guide appropriate treatment, including immunoglobulin replacement therapy (igrt). new guidelines for the use of human normal immune globulins in sid patients were implemented by the european medicines agency (ema) in . despite these new guidelines, significant variations remain across european countries in the assessment and approaches aiming to achieve reduction in infection burden, including different strategies for initiation, dosing and discontinuation of igrt. the same is true for north america where igrt is widely used off-label to prevent infections in patients with sid due to hematological disease or other reasons. in order to address this variability, a task force comprising both immunologists and hemato-oncologists drafted statements aiming to test for consensus. statements were related to six major areas: definition of infections, measuring igg levels, initiating igrt, igrt dosing, scig usage and discontinuing igrt. this was followed by an international delphi consensus exercise in three rounds which aimed to develop recommendations on how to diagnose, treat and follow-up patients with antibody deficiency associated with hematological malignancies. the first delphi round consisted in testing the statements with a panel of sid specialists and subsequently their comments were used by the task force to refine the statements. in the second delphi round, the refined statements were presented via phone interviews to the same panel to assess their level of agreement with each statement (ranging from "i totally disagree" to "i totally agree"). consensus was considered to be reached per statement if % of the experts agreed with each statement overall. the cut-off for overall agreement was "i somewhat agree". if the expert chose level or less the reasons underpinning his/her choice were discussed. consensus was achieved for all statements on level ("i somewhat agree"). only statements did not achieve consensus on level "i mostly agree". in delphi round , panelists who had not "mostly agreed" with these five statements were given the opportunity to reconsider their assessment based on the feedback from other panelists, which was shared with them. the panelists then chose to maintain or refine their assessment. analysis of the full results on the six key areas identified by the task force will be presented at the conference to offer recommendations and help guide the management of sid in patients with hematological malignancies. abstract/case report text introduction: mast cells (mcs) are hematopoietic-derived immune cells, whose precursors migrate within tissues reaching maturation and differentiation. masitinib, a selective tyrosine kinase inhibitor, is efficient in controlling the survival, differentiation, and degranulation of mcs. aim: to optimize mast cell-differentiation from human bone marrow (bm) hematopoietic stem cells, and to find best cell culture conditions for proliferation, differentiation, and maintenance of mcs, which is important when studying particularly mcs' response to cytotoxic compounds. material-methods: to produce mcs in vitro, the first method (m ) we used was a modified semi-solid culture method ( ). briefly; human bm mononuclear cells (mncs) were obtained with ficoll gradient from bm sample of a patient with idiopathic thrombocytopenic purpura. colonyforming unit (cfu)-mast was developed from mncs in methylcellulose medium supplemented with scf ( ng/ml) + il- ( ng/ml), and il- ( ng/ml; only first week). - weeks later mast cell colonies were transferred into suspension cultures, in which mcs matured and multiplied up to - weeks and were used in experiments till th week of culture. on the other hand, in our second method (m ); mncs were separated by ficoll, seeded in well-plates with imdm containing fbs %, pen/ strep, and a little amount of methylcellulose, and incubated at o c, %co . cultures were then supplemented with imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml) on day ; and imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml) + il- ( ng/ml) on day . beginning on day till the end, imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml) were added to cultures. for both methods, morphological assessment of colonies/cells were evaluated under an inverted microscope (figure and ). verification of mcs was performed by immunoflorescence staining for anti-tryptase andchymase antibodies, and by toluidine blue staining. macrophages were verified by anti-cd- immunoflorescence staining. mcs were exposed to masitinib or dmso for the evaluation of dose-related effects of masitinib, and cytotoxicity was evaluated by mtt assay. results: in m , culture conditions were easier to handle compared to m . in m , high amounts of mcs in immature and pre-mature forms were appeared as early as - days, and peak levels of proliferation rate was around - weeks of culture, which was about weeks earlier than m . culture could be maintained till weeks in both methods. although mcs are non-adherent cells, in liquid method adherent bm cells such as fibroblasts, endothelial cells and mesenchymal stem cells have adhered to the plate and grown up, providing an attachment site for mcs and serving as a natural bm nest, mimicking in-vivo environment, for mcs to grow and proliferate ( figure ). attachment of mcs has provided medium exchange available without changing culture dishes. when mcs were exposed to masitinib ( . , , and μm/μl), approximate survival rates were %, %, %, respectively. discussion: in our liquid medium method, the adherent bm cells not only provided a natural nest supporting mc development and differentiation, they also served as an attachment site for mcs. as the cells slightly adhered, when trypsinized shortly, they easily detached and used for experiments. and we also report for the first time that adding a little amount of methylcellulose to the liquid medium provides ease of aggregation of cfus, and easy development of mcs. we suggest that our liquid culture may be superior to semi-solid method, that it is faster and easier to handle. in studies subjects crossed over to subcutaneous (sc) igiv-c %, and in the third study crossover was to immune globulin sc (human), % caprylate/chromatography purified (igsc %). a total of pi patients from these studies were included in the poppk analysis and serum igg concentrations were included in the final pk analysis. the pk of igg following iv and sc administration was adequately described by a two-compartment model with first-order elimination from the central compartment. administration of igiv was modeled as an infusion directly into the central compartment. absorption of exogenous igg from the depot site of sc infusions into the central compartment was modeled as a first-order process with an absorption rate constant (ka). the full model was constructed by incorporation (forward selection process) of covariates of interest into the model. after completion of the covariate model development, the final model showed that igg pk was not influenced by (a) the igsc formulation used in the different studies ( % vs. %), (b) gender, and (c) age (pediatric vs. adult). body weight was identified as a significant covariate having an effect on clearance and volume of distribution. based on the final pk results, serum clearance of igg for the reference population was estimated to be . l/day. the volume of distribution of the central and peripheral compartments accounted for . l and . l, respectively. the intercompartmental clearance was . l/day, and the absorption constant from the depot (ka) was . day- . the absolute bioavailability of igg after sc administration was calculated as . %. the developed method was used to evaluate alternative dosing intervals following sc administration. the equivalent of a weekly igsc maintenance dose administered , , , , or times per w e e k , o r b i w e e k l y p r o d u c e d o v e r l a p p i n g s t e a d y -s t a t e concentration-time profiles and similar area under the concentration versus time curve (auc), maximum concentration (cmax), and minimum concentration (cmin) values. the results of the evaluation and simulations for igg exposure following a switch from igiv-c % dosing (every -or -weeks) to sc dosing further suggest that a range of dose-adjustment factors (daf), from : to : . would be sufficient to provide clinically effective trough igg concentrations throughout the course of treatment at various treatment frequencies. current us product labeling for igsc % specifies a daf of : . for transitioning immune globulin dosing from iv to sc, and specifies igsc % dosing frequencies of weekly or more frequently ( - times per week). in this poppk analysis all sc dosing regimens evaluated theoretically would provide viable alternative administration options for maintaining adequate immunoprotection in pi patients with dosing flexibility over a range of regimens. however, in % or more, no causative gene can be found going down to undefined inflammatory syndromes (uis). anti-il drugs (ail d) revolutionized some il- mediated diseases, such as traps, caps, hyper-igd/mkd and fmf. nevertheless, treatment response among disorders are not the same as well as no specific study was designed for uis. papa et al, , recently suggested the use of anakinra for the treatment of uis, especially those refractory/intolerant to colchicine with severe or very symptomatic phenotype. this paper aims to retrospectively report for the first time the experience with canakinumab in monogenic and multifactorial disorders in a single, private center in brazil. patient and methods: patients's records that received canakinumab from january to december at clinica croce, ima-brazil, were revised. demographic and clinical data were extracted and descriptively described. all statistical analysis are presented as: average (minimal; maximum; standard deviation). results: a total of patients with autoinflammatory diseases were enrolled and % (n= ) are female. of them, % (n= ) patients had a monogenic disease: % (n= ) caps, % (n= fmf), % (n= ) mkd, % (n= ) homozygous nlcr and % (n= ) pami syndrome. multifactorial disorders were % (n= ) patients : % (n= ) recurrent idiopatic pericarditis, % (n= ) schnitizler syndrome and % (n= ) uis. the average age of the first symptoms was , years ( ; ; , ) and the average age of diagnosis was , years ( ; ; , ) while the aveage of diagnosis delay was , years ( ; ; , ). all patients had used, prior to anti-il , corticosteroids with % prevalence of cushing syndrome and % (n= ) tried at least one steroid sparing agent without clinical success due to: intolerance or non-effective disease control or side effects. in the fmf group (n= ) % tried colchicine prior to canakinumab and this drug was not effective to % because of amyloidosis status and in % colchicine-induced hepatitis was observed. canakinumab was effective for disease control in % (n= ) considering: control of clinical manifestations, amyloidosis reversion and normalization of acute reactants markers. the only side effect observed during the follow up were acute flu-like symptoms and psicomotor agitation ( , % , n = ). the average time of follow up is of , months ( ; ; , ). canakinumab could be discontinued in just one patient with uis. conclusions: this is the first report of canakinumab use for autoinflammatory disorders in brazil. canakinumab is an effective and safe drug for monogenic and multifactorial disorders control. no serious adverse effect could be observed in the years maximum follow up of this drug. neither, no specific infectious disease more prevalent in south america, such as yellow fever, dengue, zika or chikungunya was observed. abstract/case report text a -year-old caucasian male with autosomal recessive hyper igm syndrome type (higm ) due to aicda mutation, diagnosed at age , presented with a newly developed mediastinal mass. he receives routine ivig, pulmonary function tests (pft's) and chest x-rays. at age , patient was noted to have cervical and inguinal lymphadenopathy. ct scan indicated left mediastinal, hilar and pleural lymphadenopathy with soft tissue infiltration around the descending thoracic aorta and esophagus. biopsy indicated no evidence of a lymphoma or infection. years after initial workup, routine pft's showed a declining diffusion capacity by %. patient complained of intermittent chest pain but displayed no clinical symptoms of cough, dyspnea, dysphagia or reflux. ct scan which revealed an extensive illdefined soft tissue mass extending from the thoracic outlet to the level of the esophageal hiatus that encased vascular structures resulting in narrowing and occlusion of left upper lobe pulmonary artery and left lower lobe pulmonary arteries respectively. imaging demonstrated homogenous ventilation to bilateral lungs and decreased perfusion in the left lung compared to the right lung. infectious workup was negative for atypical infections. biopsy revealed miced cellular infiltrate with no predominenant cell type or evidence of malignancy, consistent with previous lymph node biopsy years prior. cd and cd stains revealed aggregates and scattered b-cells and t-cells, respectively. removal of mass was proposed but due to the ambiguous borders and location, surgical excision was not possible. patient was given doses of rituximab ( g), doses mg/kg pulse steroids hours apart, and daily sirolimus (level was adjusted based on sirolimus level). follow-up ct scan indicated significant interval improvement with - % reduction of the soft tissue mass. blood flow in the left lower lobe pulmonary artery has still not returned. this may be due to collaterals and may be a separate problem from compression due to the mass. cytotoxic t-lymphocyte antigen (ctla- ) is an inhibitory immune regulator critical for governing t and b cell homeostasis. heterozygous ctla mutations can cause a syndrome of immune dysregulation with a variable clinical phenotype including hypogammaglobulinemia , autoimmune cytopenia and endocrinopathies, lymphoproliferation, predisposition to malignancy, tissue specific lymphocytic infiltration of brain, lung and gi tract as well as colitis. methods: we retrospectively reviewed medical records of all patients with ctla haploinsufficiency evaluated at the nih between - . a pathologic variant in ctla was confirmed in all patients. we analyzed frequency of campylobacter species detected in the stool samples by pcr based biofilm rapid array as well as reflex bacterial stool and blood cultures when available. results: forty-six patients aged - years were evaluated at the nih between and . six of patients ( %) had at least one episode of campylobacter species associated acute or worsening diarrhea, with one patient also having campylobacter bacteremia. all patients with positive campylobacter species in stool samples had clinical histories and/or endoscopic biopsy findings consistent with enteropathy or colitis predating the incidence of campylobacter infection. two of the six patients ( %) had recurrent or chronic campylobacter infection, while four of the six patients ( %) had multiple gastrointestinal pathogens detected by stool pathogen screening at various times. conclusions: campylobacter species infection of the gastrointestinal tract seem to occur at an increased incidence in our ctla haploinsufficient cohort. to the best of our knowledge, this is the initial report for the association between ctla haploinsufficiency and campylobacter species infection of the gastrointestinal tract. although ctla- is a critical immune checkpoint involved in mucosal immune homeostasis and gut microbiota-immune system cross talk, the underlying mechanism predisposing to campylobacter infection in ctla- deficient patients remains to be explored. our study suggests screening of stool for campylobacter species in patients with ctla haploinsufficiency associated enteropathy. ( ) submission id# abstract/case report text ikaros transcription factor and ikaros family members are critical for development of lymphocytes and other blood cell lineages. full length ikaros (isoform ) contains six c h zinc fingers (zf), four nterminal dna binding zf and two c-terminal dimerization zf. somatic ikaros mutations and deletions have been associated with increased predisposition to b-acute lymphoblastic leukemia (all) as well with poor disease prognosis. recently, germline ikaros mutations affecting the n-terminal dna binding domain and acting in a haploinsufficiency or dominant negative manner were reported to be associated with common variable immunodeficiency (cvid) and combined immunodeficiency (cid), respectively. herein we describe a novel set of germline heterozygous ikaros allelic variants affecting the c-terminal dimerization domains in four unrelated families. clinical manifestations include hematopoietic cytopenias presenting as evans syndrome, and hematologic malignancies including t-cell all and burkitt lymphoma; other manifestations observed were b-cell lymphopenia and hypogammaglobinemia, but recurrent or severe infections were not prevalent or characteristic. we demonstrate that mutants affecting dimerization abolish ikaros homodimerization as well as heterodimerization with ikaros family members aiolos and helios. these variants also affect dna binding at dimerization sites and pericentromeric targeting. opposed to previous allelic variants reported, dimerization changes alter post-translational sumoylation and gene transcription regulation. our data show that mutations affecting ikaros dimerization are mainly associated with cytopenias and/or malignancies, have a different mechanism of action than previously reported variants, present with incomplete clinical penetrance, and contribute to the growing spectrum of genotype-phenotype ikaros associated diseases. introduction: there has been much discussion regarding the return of secondary findings in genetic sequencing research. opinions differ on whether researchers should return secondary findings to participants at all and if so, what the best method is to do so. we have opted to systematically identify and return pertinent secondary findings to participants in our cohort of patients with immune-mediated diseases that undergo exome sequencing. additionally, exome sequencing may determine multiple or other genetic diagnoses in addition to the primary diagnosis, which we call "incidental findings." here, we discuss the secondary and incidental findings discovered in our cohort thus far. methods: individuals in our protocol underwent consent for exome sequencing, including a discussion of the possibility of secondary findings. exome sequencing data was analyzed, and variant pathogenicity was scored using the acmg criteria (richards et al); variants determined to be likely pathogenic, pathogenic, or otherwise clinically important were confirmed via clia-certified sanger sequencing. confirmed variants were returned to participants. we then queried internal databases for cases involving secondary and incidental findings. results: as of november , exome sequencing, interpretation and reporting had been completed for participants. we detected a total of secondary findings in ( . %) participants, including variants in apob, brca ( ), brca ( ), dsp, fbn , kcnh , ldlr, mybpc ( ), ryr , pkp ( ), and vhl. additionally, we detected possible dual/multiple genetic diagnoses in ( . %) participants, some of which explained an unusual clinical presentation or symptom. these included individuals with variants in multiple immune-related genes, including one individual with variants in gata and tnfrsf a, and those with variants in genes related to multiple organ systems, including an individual with variants in ifngr and sco . discussion: exome sequencing in this cohort detects not only important secondary findings, but also discovers a significant portion of individuals with multiple genetic diagnoses. notably, exome sequencing may provide further context or explanation for unusual phenotypic presentation and help determine specific symptom etiology even when a primary genetic etiology is already known. additionally, these secondary and incidental finds may be important to consider when delineating risks and symptoms of novel or recently-discovered conditions. abstract/case report text background: immune dysregulation and lymphoproliferative disorders including alps like disease, hlh ebv driven lymphoproliferative disease leading to rare lymphomas require a multidisciplinary approach utilizing expertise in immunology and hematology/oncology to care for these patients as we learn the molecular etiology of their underlying disorders. at texas children's hospital, the immunology lymphoproliferative evaluation and diagnostic (ilead) clinic was created to provide a comprehensive clinical and research approach to caring for patients with these rare disorders. in an effort to streamline care and access, we recently on-boarded an advanced practice provider (app) . methods: a chart review was conducted months before and after onboarding the app for ilead patient visits. we reviewed the following patient care and access parameters to determine increase in efficient and effective patient care as well as improved access to the clinic. these parameters included: referral process, time of referral placement to appointment, number of patient visits, wait time in clinic, lab interpretation and reporting time for disseminating results to families, and collaboration process with other specialties. results: within months of the app starting our average wait from placing the referral to first appointment fell by an average of %. in addition, we created an algorithm to prioritize patients with immediate need to be seen. by streamlining the referral process and patient priority, we developed a "pre-clinic" conference process by which all patients are reviewed and preliminary plans are made prior to the patient's arrival. this has translated into our ability to increase the number of patients seen in clinic from to and decreased the wait time in clinic by approximately minutes. since the app started, no patient has been in clinic for more than minutes. this has also led to an increase in rvu generation. in terms of efficiency in patient care, all labs are now ordered while in the room with the patient by the app and physician providers. in turn, all labs are resulted directly to the app who reviews labs, collaborates with physicians for care and reports to families in a timely fashion within - weeks of labs being resulted compared to greater than month previously. to improve collaborator communication and post visit plans, a post-visit clinic summary was created. this has been effective in reducing the time to other specialty referrals, follow up visits and effective care for ongoing clinical needs. conclusions: the addition of an app in our ilead multidisciplinary clinic which provides specialized care for patients with immune dysregulation and lymphoproliferative disorders effectively increases work productivity of providers and enhances patient care by increasing access to care, decreasing wait time in clinic and time of reporting of results and future plans. the app with knowledge and expertise in immunology and immune dysregulation is a cost effective way to enhance provider and patient support. with the overwhelmingly positive results, future plans include expanding our multidisciplinary clinic to other services that care for patients with suspected immune deficiency. abstract/case report text introduction: pediatric lymphoproliferative disorders represent a clinically and genetically heterogeneous group of conditions. misdiagnosis and delayed diagnosis can contribute to substantial morbidity and mortality. identification of molecular etiologies and underlying disease mechanisms may facilitate timely interventions and guide targeted or curative therapies. methods: the study was performed through retrospective chart reviews in accordance with all local ethics and irb committees. the study was designed to investigate a cohort of pediatric patients who met criteria for non-malignant lymphoproliferative disorders from texas children's hospital and collaborating centers for underlying genetic etiologies. results: a total of affected individuals from families met criteria. distribution between male and females was nearly equivalent: males (n = ) and females (n = ). approximately half of the cohort was hispanic (n = ). overall kaplan meier survival was % (n = ). whole exome sequencing was performed in all subjects and available family members. likely disease-causing genetic defects were identified in of families ( %). within these families, ( %) carried variants in genes in international union of immunological societies established primary immunodeficiency diseases. potential novel genetic causes of immune deficiency or immune dysregulation were also discovered. mechanistically, all of the implicated genes had roles in modulating lymphocyte activity; initial activation, cytoskeletal organization, or apoptosis of lymphocytes; or regulation of inflammation. all subjects less than one year of age had an identified gene in one of the three mechanistic categories with the dominant mechanistic genetic category being defective control of lymphocyte signaling ( %). in addition, % of patients between and years of age were found to have a potential genetic diagnosis underlying the lpd, with a more equal distribution of mechanistic categories compared to patients greater than years of age where only % have a genetic cause. other important disease manifestations identified were ebv-associated disease in subjects ( %) and subjects ( %) met hlh- criteria. conclusion: primary immunodeficiency diseases and other genetic abnormalities of the immune system underlie a significant percentage of pediatric lymphoproliferative disorder cases. greater than % of patients less than years of age have a genetic etiology underlying the lymphoproliferative disorder. many of these gene defects can be treated with targeted therapies or hematopoietic stem cell transplantation. genetic testing therefore plays an essential role in the diagnosis and management of children with these conditions. abstract/case report text a -year-old gentleman with a history of immune dysregulation polyendocrinopathy enteropathy x-linked (ipex) syndrome with known pathogenic variant in foxp presented to our emergency department with two witnessed episodes of tonic-clonic seizures earlier that day. he has had a longstanding history of recurrent infections and autoimmune conditions since birth, and was being treated with monthly ivig infusions and sirolimus while awaiting bone marrow transplantation. his symptoms on admission included foaming at the mouth, generalized shaking, bladder incontinence, and tongue biting that lasted about five minutes. family reported recent sores inside his mouth and lips, but denied any recent fevers, neck pain, headaches, chest pain, abdominal pain, nausea, vomiting, and sick contacts. he lives on a farm with livestock and reportedly had recent tick exposure. his last ivig infusion was two weeks prior to admission, at which time he also received inactivated flu vaccine. in the ed, a third seizure was witnessed by multiple medical providers. he subsequently received lorazepam and lacosamide with interval improvement. he underwent diagnostic lumbar puncture, as well as extensive evaluation for infections. he was started on empiric antibacterial and antiviral meningitis coverage. analysis of the csf showed a lymphocytic pleocytosis; bacterial cultures and hsv / pcr were negative, as was a -pathogen meningitis/ encephalitis panel performed by pcr. eeg was negative for seizure-like activity, and brain mri showed mild atrophy without sclerosis in the left hippocampus. subsequently, anti-infectious therapy was stopped, and patient was discharged with outpatient followup scheduled for suspected non-infectious aseptic meningitis that was potentially triggered by flu vaccination versus ivig. on day four post-discharge, however, pcr for ehrlichia chaffeensis in the serum returned positive, and he was started on oral doxycycline. ehrlichiosis is a rare tick-borne illness that may cause various nonspecific symptoms including fever, headaches, myalgias, and generalized malaise. most prevalent in the mid-atlantic regions of the united states, tick-borne ehrlichia spreads through the mononuclear phagocytic system and can infiltrate many organs including the kidney, liver, lungs, and heart. csf penetration can cause sometimes fatal meningoencephalitis. aseptic meningitis due to ehrlichiosis has been described in recent literature. cases in hiv patients and transplant patients on chronic immunosuppressive therapy have been severe, resulting in organ dysfunction in many instances and death in a few. however, this case marks the first documented ehrlichia infection in a patient with primary immunodeficiency. this patient's presentation of aseptic meningitis and clear exposure history fits the clinical picture. his relatively benign course could be due to preserved t effector function not seen in persons with hiv or transplant patients with significant immunosuppression. patients with ipex usually present with autoimmunity and allergies, but are also prone to significant infections. it is important to perform a comprehensive workup, including testing for atypical infections, in patients with immune dysregulation syndromes who present with symptoms of unclear etiology. special attention should be paid to patients who live in areas with known endemic exposure risks. empiric antibiotic therapy may need to be considered early to prevent delays in treatment. abstract/case report text introduction autosomal recessive hypomorphic mutations in pgm have been described to result most commonly in either hyper-ige or severe combined immunodeficiency (scid) clinical phenotypes in humans, with one report of an individual with combined immunodeficiency without atopy. herein, we describe a series of individuals newly diagnosed with pgm deficiency functionally confirmed using lectin-based flow cytometric analysis of peripheral blood mononuclear cells, that broadens the associated clinical phenotypes to confirm cid without atopy and childhood evans syndrome. in addition, we present new disease-causing pgm variants, and functionally confirm the pathogenicity of a fourth (p.i t). classical hies phenotype cases . and . identify sisters of spanish descent with a classical hyper-ige phenotype. the younger sibling demonstrated severe atopic dermatitis, mild-moderate asthma, multiple food allergies, one episode of itp, and adhd. the older sibling demonstrated atopic dermatitis, skin infections, and c. albicans otomastoiditis. the siblings were found to have the damaging compound heterozygous variants p.t i and p.q x in pgm . case is a year-old guatemalan boy with prominent atopy including asthma, allergic rhinitis, food allergy, elevated ige, atopic dermatitis, as well as oral hsv who was found to be homozygous for the damaging pgm variant p.i t. cid phenotype with a paucity of atopy case is a -year-old turkish girl who is the daughter of a consanguineous union. she presented with infantile nephrotic syndrome at months of age, and subsequently developed leukopenia, neutropenia, and low igg. complications include bronchiectasis, sinusitis, pseudomonas urinary tract infection, and inflammatory skin lesions without atopy. she was found to be homozygous for the damaging pgm variant p.r h evans syndrome case is a -year-old girl from guatemala. she developed multilineage autoimmune cytopenias including immune thrombocytopenic purpura (itp), autoimmune hemolytic anemia (aiha) and autoimmune neutropenia (ain) at the age of years, refractory to multiple treatments and finally responding to mycophenylate mofetil. she has a history of mild eczema but is without other atopy and suffered from multiple invasive bacterial infections. an additional patient, case , was diagnosed with coombs positive aiha and itp at age years refractory to multiple treatments and finally responsive to cyclosporine. cytopenias recurred year later, resulting in hypoxic brain injury. he died of infectious complications at the age of years. both patients were found to be homozygous for the damaging pgm variant p.i t. discussion this is the first report of pgm deficient individuals presenting with evans syndrome as a primary presentation without additional pathology. while disease-associated mutations appear to cluster around the key conserved domains of the protein, no clear genotype-phenotype correlation is readily observed. in addition to autoimmune cytopenias, pgm deficient individuals have also been reported with splenomegaly, lymphoma, and ebv viremia. thus, in particular for children with lymphoproliferative disease, pgm deficiency should also be considered in the differential diagnosis. abstract/case report text introduction: meningitis is a life-threatening manifestation of cryptococcus neoformans (c. neoformans). it occurs in increased frequency in those with impaired cell-mediated immunity, especially those with hiv/aids. infection with c. neoformans has been seen in previously healthy individuals diagnosed with idiopathic cd lymphopenia (icl). icl is defined by an absolute cd + count of less than cells/m on multiple occasions, usually to months apart, without other apparent cause such as hiv infection, immunodeficiency, or immunosuppressive medications. case description: our patient is a previously healthy -yearold female with cryptococcus meningitis and fungemia. her course was complicated by elevated intracranial pressure requiring extraventricular drain. she was treated with amphotericin and flucytosine for month. notably, the patient was also found to have moraxella catarrhalis (m. catarrhalis) bacteremia without identifiable source. she denied history of environmental risk factors, was not up to date on cancer screening, and recently returned from a trip to italy. initial evaluation revealed lymphopenia ( cells/ul), low cd + ( cells/ul), cd + cells ( cells/ul), and cd / + ( cells/ul), but normal cd + ( cells/ul) and cd + cells ( cells/ul). hiv, ana, leukemia/ lymphoma flow cytometry panel was negative. she also had a normal lymphocyte proliferative responses to pha ( . %), normal cd ra:ro, and protective tetanus titers ( . iu/ml), but only / protective pneumococcal serotypes. initial immunoglobulins demonstrated slightly low igg ( mg/dl). laboratory studies months after presentation demonstrated improved lymphopenia ( cells/ul) continued low cd + cells ( cells/ul), but normalized igg levels ( mg/dl). followup labs also demonstrated decreased cd + b cells ( cells/ ul) and insufficient response to polysaccharide vaccine ( / pneumococcal serotypes). three months after discharge, she is continued on daily fluconazole without recurrence of infections although she still has diplopia and headache. discussion: in a review of cryptococcosis in patients with icl, of them had cryptococcal infection in both the cns and blood. of these patients, was cured, improved, relapsed and then improved, and died. three of these patients were treated with amphotericin and flucytosine. five of these patients had underlying disease and had notable infections with vzv, tb, or hpv, however other infections such as m. catarrhalis were not mentioned. m. catarrhalis bacteremia has been described in children with underlying immune dysfunction and respiratory infection as well as secondary to pneumonia with m. catarrhalis. in cases of m. catarrhalis bacteremia in adults, most had underlying malignancy and/or neutropenia, predisposing respiratory factors, or source for infection. conclusion: this report of c. neoformans meningitis and m. catarrhalis bacteremia in the setting of icl is unusual in that to our knowledge, m. catarrhalis bacteremia has not been reported in icl. cases like this also raise the question as to whether some laboratory abnormalities are secondary to infection, treatment, or underlying disease. it is important to report these cases with icl in order to group disease phenotypes, as continued monitoring and data collection of these cases may lead to discovery of new disease processes. abstract/case report text cytokines play critical roles in regulating the development, survival, differentiation and effector function of immune cells. cytokines exert their function by binding specific receptors on the surface of immune cells and typically activating intracellular jak/stat signaling pathways, resulting in induction of specific transcription factors and regulated expression of target genes. in order to differentiate into an appropriate effector fate, lymphocytes need to integrate multiple signals often provided concomitantly by numerous cytokines that activate shared transcription factors. how these signals are balanced and regulated to yield the optimal class of immune response remains to be completely determined. inborn errors of immunity, or primary immunodeficiencies (pids), result from germline mutations in defined genes, leading to loss-of expression, loss-of function, or gain-of function of the encoded protein. pids are characterised by defects in immune cell development, or their differentiation into effector cells during immune responses, thereby rendering patients not only highly susceptible to infectious diseases, but also autoimmunity, autoinflammation, allergy and cancer. pids are thus an unprecedented model to link defined monogenic defects to immune dysregulation in clinical settings. indeed, pids have unequivocally revealed non-redundant roles of single genes, molecules, signaling pathways and lymphocyte subsets in host defense and immune regulation, and formed the basis of better therapies for immunopathologies. our indepth analysis of inborn errors of immunity of cytokine signalling pathways have identified fundamental requirements for generating long-lived humoral immune responses in humans. here, i will present data relating to our recent studies of how inactivating mutations in il r, il r, znf , stat , stat , and stat , disrupt or dysregulate the generation and function of human memory b cells and tfh cells, thereby precipitating humoral immunity, as well as allergic disease and autoimmunity. abstract/case report text introduction: flow cytometry is a powerful diagnostic tool for detecting hematologic malignancies in a variety of patient specimens including body fluids and lymph node aspirates. cytopathologists are frequently confronted with lymphocyterich effusions, and the definite decision of whether the lymphocytosis is of a purely reactive nature or a presentation of an indolent lymphoma may be an extremely difficult based on microscopy alone. moreover, small proportions of malignant cells that may be missed out by routine morphology can be detected by flow cytometry. objective: the purpose of this study was to evaluate the usefulness of multiparametric flow cytometry immunophenotyping (fci) to confirm the presence of leukemia or lymphoma cells in body fluids and fna specimens. methods: body fluids and fna specimens simultaneously obtained for fci, cytologic analysis and real time pcr from patients were submitted to our flow cytometry laboratory from january to september . the samples studied were body fluids ( pleural fluids and ascitic fluids) and fna samples ( enlarged lymph nodes and lung mass).four color fci method was performed and the following fluorescent monoclonal antibodies were used: cd , cd , cd , cd , cd , cd , cd b, fmc , kappa and lambda light chains, cd , cd , cd , cd c, cd , cd a, cd , cd , cd , cd , cd , tdt, cd , cd , cd , cd , cd , cd , bcl , cd . fci analysis was performed on a beckman coulter cytomics fc flow cytometer using software cxp to analyze data. the cases were diagnosed as leukemia or lymphoma as per tuberculosis ( case). ascitic fluid (n= ) samples showed positivity for angioimmunoblastic t-cell lymphoma ( cases) and dlbcl ( case). fna of lymph nodes (n= ) were positive fort-lymphoblastic lymphoma ( cases), angioimmunoblastic tcell lymphoma ( cases), dlbcl ( cases), hodgkin lymphoma ( case), nodular lymphocyte predominant hodgkin lymphoma ( case), peripheral t-cell lymphoma (nos) ( case), splenic b-cell marginal zone lymphoma( case), tuberculosis ( cases). one fna of lung mass were tumor of neural cell origin. both immunophenotype and cytomorphology positive for malignancy were in / ( . %) cases.cytomorphology was negative/ suspicious in / ( . %) cases, of which both cytomorphology a n d i m m u n o p h e n o t y p e n e g a t i v e w e r e ( % ) a n d cytomorphology negative but immunophenotype positive cases were ( . %). mtb dna was detected in pleural fluid in case and fna sample in cases. conclusion: multiparametric flow cytometry by using comprehensive panel of monoclonal antibodies is a useful diagnostic test to evaluate body fluids or fna as it can demonstrate small malignant populations that may be missed out by routine cytomorphology. clinical laboratory geneticist/department of genetics, university of groningen, groningen, the netherlands abstract/case report text the phenotypes of primary antibody deficient (pad) patients range from milder (e.g. specific antibody deficiency) to severe (e.g. x-linked agammaglobulinemia) deficiency of the immune system. pad patients form a clinically, immunologically as well as genetically heterogeneous group. often, the genetic background has not been elucidated; it probably is not monogenetic in a large subgroup of patients. pad patients suffer most frequently from recurrent bacterial infections of the respiratory or gastrointestinal tract due to immune deficiency, but may also have varying degrees of autoimmune and lymphoproliferative comorbidities due to immune dysregulation. unfortunately, a standardized description of pad phenotypes is lacking rendering robust definitions of pad-subtype diagnoses, including cvid, difficult. this impairs the formation of homogeneous cohorts that can form the starting point for future clinical and genetic research. the pad subgroup of the human phenotype ontology (hpo) immune mediated disorders consortium supported by ern rita and esid is addressing the gaps in standardized phenotypic description of pads. using the hpo dataset, literature mining, and esid, iuis and omim classifications, we aimed to reevaluate and complete the pad-related hpo terms to allow efficient data exchange and matching of phenotypically similar pad patients. as a principle, it was decided to avoid the ongoing variance in pad-subtype definitions and to build the pad-related hpo tree based as much as possible on unambiguously interpretable items. 'hypogammaglobulinemia' was deleted as hpo term, and replaced by separate hpo terms such as 'decreased total igg in blood', subdivided in 'transient' vs. 'chronic', and '(near) absent' vs. 'partially decreased' (the same for igg , igg , igg , igg , iga and igm). 'decreased specific antibody level in blood' was specified further into 'decreased natural antibody level to blood group antigens in blood', subdivided in '(near) complete' vs. 'partial' absence (the same for protein, polysaccharide and protein-conjugated polysaccharide vaccination). relevant hpo terms related to infection and to specific organ manifestations like bronchiectasis, autoimmunity and lymphoproliferation were re-evaluated and completed, and will be linked to pad diseases in the hpo online system by the pad subgroup experts. once finalized, existing pad cohorts will be classified according to the new hpo pad-related terms, and studied by clustering technologies (example of two patients shown in figure ; white = absent, color = present). acceptance and widespread use of this pad-related hpo tree for standardized phenotyping will be essential to empower future multicenter clinical research and related genetic discoveries as well as support clinicians in diagnosing pad through the linkage of hpo terms to pad disease entities. senior investigator oral immunity & infection section/nih/nidcr abstract/case report text leukocyte adhesion deficiency type (lad ) is an autosomal recessive disorder characterized by the inability of granulocytes to emigrate from the bloodstream to sites of inflammation. lad is caused by mutations in the itgb gene ( q . ), encoding the beta- -integrin, cd , which is essential for firm adhesion of leukocytes to the endothelium. in lad survival is compromised, morbidity from inflammatory lesions is high, and treatment is poor. the moderate form of lad is often managed with antibiotics for prophylaxis and during acute infections. after infancy severe gingivitis and chronic periodontitis are universal. periodontal findings affect primary and permanent teeth, causing intense oral mucosal (gingival) inflammation and destruction of tooth supporting bone, which are hallmarks of the disease periodontitis. blocking the il- /il cytokines, which are up regulated in lad gingiva, can reduce bacterial load and resolve inflammatory gingivitis. ustekinumab binds to the shared p subunit of human il- and il- , cytokines that modulate lymphocyte function, including t helper (th) cells and th subsets, thereby blocking them. objective: explore the effect of ustekinumab on lad inflammatory disease. method: prospective study using ustekinumab for oral inflammation. patients receive five doses over year, -or mg depending of weight. results: (two patients have enrolled, p is > year post treatment, p is still on study) patient characteristics · patient : age at diagnosis, yrs.(itgb mutation c. delt (null)); cd (%pmn control): . %; cd a(%pmn); . %. at the initiation of the protocol ( yrs old) wcc: . k/ul; crp: . · patient : age at diagnosis, yrs.(itgb mutation c. a>g,p.g s c. c>t,p.a v) cd (%pmn control): %; cd a(%pmn): . %. at the initiation of the protocol ( yrs old) wcc: . k/ul; crp: . response: patient : oral ulcers before treatment: episodes every two months. during ustekinumab therapy: · oral ulcers: episode in a year · reduction in bleeding on probing: . % · gingival index reduction: % patient : oral ulcers before treatment : monthly. during ustekinumab therapy: · oral ulcers: none in first months · reduction in bleeding on probing : . % · gingival index reduction: . % safety: no significant adverse events were documented during the therapy p had a previous skin lesion that flared leading to iv antibiotics. p had a previous sebaceous cyst drain spontaneously. discussion: two patients showed improvement in chronic periodontitis and a substantial decrease in oral ulcers while on ustekinumab. no clear safety signals were seen. durability of these findings is still unknown. ustekinumab in lad deficiency appears to be safe and potentially effective. post doctoral fellow/servicio de inmunología, inst. multidisciplinario de investigación en patologías pediátricas (imipp), hospital de niños ricardo gutiérrez. chief resident/servicio de inmunología-hospital de niños "dr. r.gutierrez" immunologist/centro de inmunología clínica "dra. liliana bezrodnik y equipo"-servicio de inmunología htal. de niños "dr. r.gutierrez" immunologist/centro de inmunología clínica "dra. liliana bezrodnik y equipo" immunologist/servicio de inmunología-hospital de niños "dr. r.gutierrez" abstract/case report text introduction: primary immunodeficiencies with dysregulation associate defects in the immune homeostasis leading to inappropriate immune response (lack or excess) that causes autoimmunity, allergy and/or inflammation. impairment of different subsets of t and b compartments may be associated with these pids. aim: ) describe t and b memory compartment of pid patients (pts) with dysregulation: cd deficiency, stat gof, stat b deficiency, ctla variant, pi kcd variant and cvid-like (with no molecular defect) and compare them with a group of healthy donors (hd). ) associate ctfh profile with b cell compartment impairment. results: ) pts showed a significant decrease of naïve cd + t cells (cd ra+cd +) ( , % vs , %) (p < . ) with expanded central memory t cells (cd ra-cd +) ( . % vs . %) (p < . ); cd + t cells had higher levels of activation markers (cd +hla-dr+) ( , %vs , %) (p < , ). pts showed a significant increase of circulating follicular t cells (ctfh) (cd ra-cxcr +) compared with hd (mean , % vs , %) (p < , ) with pd- overexpression (p < . ). stat gof, ctla , pi kcd and cvid-like pts showed a skew towards ctfh (cxcr +). regulatory t cells (cd +cd ++ foxp +) were absent in cd and stat b deficiency and decreased in the other pts. within cd + cells, although effector memory (cd ra-cd -) (p < . ), temra (cd ra+ cd -) (p < . ) and hla-dr+ cd + (p < . ) subsets showed a significant increase compared with hd, the behaviour was variable between different mutations. regarding b cell compartment, pts with stat gof, pi kcd and cvid-like showed a severe impairment of switched-memory b cells (sw-mbl) (cd +igd-igm-); the stat b deficient patient had increased frequencies of this subset, while ctla pts had a variable b defect. ) lower sw-mbl values were significantly associated with lower values of ctfh cells (p < . ) (r= . ). cd low b cells were exclusively high in cvid-like pts, and transitional b cells were increase in pi kcd and almost all cvid-like pts. discussion: in summary, patients with dysregulatory syndromes associate a defect of t and b homeostasis (survival, activation and differentiation). specific mutations can differentially affect the quantity and/or the quality of ctfh. there is a strict association between the differentiations of tfh with th profile with the generation of sw-mbl. these alterations may play a role in the pathophysiology of primary immunodeficiencies with b lymphocyte functional impairment. immune monitoring of lymphocyte subsets of patient with dysregulation may approach to the diagnosis of specific monogenic mutations. objective: the purpose of this study is to increase awareness and improve diagnosis of primary immune deficiency (pid) in the heterogenous group of patients with autoimmune cytopenia (aic) by identifying clinical characteristics and laboratory biomarkers that distinguish those with underlying pid, disease activity and guide mechanism-based targeted therapy. methods: patients with aic (autoimmune hemolytic anemia (aiha), immune thrombocytopenia (itp), or autoimmune neutropenia (ain)) were referred to our immune dysregulation team and prospectively enrolled during - . detailed immune phenotyping (igg, iga, igm, lymphocyte subsets, vaccine titers, lymphocyte proliferation to mitogens/ antigens), serum lipopolysaccharide (selps) and autoantibodies were measured and/or collected by chart review and genetic testing for pid was pursued. results: from to , patients were enrolled; two subjects were removed due to parental request or lack of aic diagnosis. of the remaining patients, ( %) were classified as "aic-pid" based on genetic testing and/or immune phenotyping; ( %) were classified as aic-only, and ( %) were asymptomatic family controls. the patients were predominantly children (ages - years, average age . years); % ( / ) were male. among patients who have had genetic testing to date (n= )( %), pathogenic genetic mutations were confirmed in / ( %) of patients. mutations include fas/fasl (n= , including family members without aic), ctla (n= ), q (n= ), and one patient each with nfkb , was, pole- , pi k, casp , card , and cgd; the remainder of aic-pid patients were classified as combined immune deficiency or common variable immune deficiency based on immune phenotyping. lymphocyte subsets (cd +t, cd +t, cd +b, cd + nk) and immune globulins (igg, iga, igm) tended to be lower in aic-pid patients vs aic-only (p < . ). evans syndrome was more common in aic-pid patients ( / , %) compared to aic-only ( / , %). lps was elevated in the serum of aic patients compared to healthy controls (mean vs pg/ml, p < . ). excluding partial digeorge syndrome patients (average lps pg/ml), selps levels were significantly higher in genetically-defined untreated pid patients (average pg/ml) vs. other pid (average pg/ml)(p= . ) or patients with aic alone (average pg/ml)(p= . ). studies are ongoing on specific subsets that are linked to immune dysregulation (switched memory b cells, t-regulatory cells, double negative t cells, t follicular helper cells) and the use of soluble il- as a biomarker of disease activity. conclusions: a high fraction of aic patient were identified with underlying pid in our study. basic immune evaluation with immunoglobulin levels and lymphocyte subsets expedited diagnosis of pid. genetic evaluation distinguished a group of patients with aic-pid and highly elevated lps level, reflecting high bacterial load, which may distinguish them from the rest the aic cohort. the source of bacterial lps can be multifactorial and is yet to be determined. our studies continue focusing on biomarkers that can be applied to the heterogenous group of patients with aic. this will allow early detection and timely initiation of targeted therapies. investigator/dermatology branch, niams, nih head, dermatology consult service/dermatology branch, niams, nih chief, fungal pathogenesis section/laboratory of clinical immunology and microbiology, nih abstract/case report text introduction/background: autoimmune-polyendocrinopathy-candidiasis-ectodermal dystrophy (apeced) is a monogenic autoimmune disease resulting from biallelic mutations in the aire gene. although typically characterized by the classic triad of chronic mucocutaneous candidiasis, hypoparathyroidism and adrenal insufficiency, we recently reported that the clinical spectrum of the syndrome is far broader and that incorporation of an adjunct triad of apeced rash, intestinal dysfunction, and enamel hypoplasia in the classic triad could lead to earlier diagnosis (ferre et al., jci insight, ). among the adjunct triad manifestations, apeced rash occurs in % of american apeced patients by age , most often developing in the first year of life. objectives: to report and describe the clinical features of apeced rash as the first manifestation in a -month old patient with apeced. methods: following enrollment in a niaid irb-approved protocol ( -i- ) the patient was evaluated with history and physical examination, aire sequencing, measurement of interferon-autoantibodies, and skin biopsy with immunohistochemical analyses. results: a -month-old girl with a family history of genetically confirmed apeced in her -year old sister developed discrete circular, maculopapular erythematous lesions on her torso that spread to the face, arms, and legs while sparing the palms and soles. the rash was partially blanching, non-painful and non-pruritic and was preceded by low-grade fever ( □c) without other accompanying symptoms. she had not received medications or vaccinations prior to the rash onset. the lesions increased in size with associated central clearing and resolved . months after onset. the rash recurred with similar appearance times over months with each recurrence lasting between days and . months. as with the first rash episode, recurrences were often preceded by fever ( - □c) without accompanying symptoms or inciting factors. neither topical nor oral antihistamines improved the rash. aire sequencing identified the same compound heterozygous mutations (c. _ del and c. c>t) that the sister has. high titers of interferon-□ autoantibodies were measured in serum. skin biopsy revealed superficial perivascular chronic inflammation and intraepidermal lymphocytes composed predominantly of mixed cd and cd t lymphocytes with few perivascular b lymphocytes. no eosinophils or vasculitis was observed. myeloperoxidase immunostaining revealed extensive karyorrhexis. laboratory studies revealed normal white count and esr, negative anti-ige receptor antibody, and positive anti-ige antibody. at months, she developed oral candidiasis as second manifestation of apeced, thus reaching a diagnostic dyad when applying our proposed expanded diagnostic criteria. she has not developed hypoparathyroidism or adrenal insufficiency; thus, she has not yet reached a classic diagnostic dyad. systematic screening for these endocrinopathies will be needed to avoid lifethreatening complications of acute endocrine failure. conclusions: we report the clinical and histologic features of apeced rash manifesting as the first disease component of apeced in a month old girl. apeced should be considered in the differential diagnosis of recurrent erythematous maculopapular urticaria-like eruptions characterized by mixed lymphocytic and neutrophilic infiltration unresponsive to antihistamines. our case illustrates the clinical utility of incorporating the expanded diagnostic criteria of apeced rash, enamel hypoplasia and intestinal dysfunction into the classic diagnostic triad, which can lead to earlier apeced diagnosis. who presented with prolonged severe neutropenia despite g-csf and seven hospitalizations for febrile neutropenia in the span of ten months. prior to his neutropenia, patient was on monthly ivig, with igg trough - in the past year. he was evaluated for bmt in but declined. patient was first found to be neutropenic in aug when he was admitted with pseudomonas thigh abscess, hsv stomatitis and rhinovirus infection. he was treated with broad-spectrum antibiotics with improvement in neutropenia. the following month, he was hospitalized again with neutropenic fever, left axilla pseudomonas abscess and rhinovirus infection. he underwent bone marrow biopsy revealing left shifted myeloids with decreased maturing forms and t cell predominant lymphoid aggregates, suggestive of autoimmune neutropenia vs. hyper igm syndrome associated with neutropenia. anti-neutrophils antibodies were negative. he was then admitted the following month ( / ) with febrile neutropenia with cxr concerning for viral pneumonitis vs. atypical pneumonia. he was started on g-csf therapy with significant initial response in anc. however, this response was short-lived as he was again admitted in / with febrile neutropenia and upper respiratory rhinovirus infection. he was continued on daily g-csf. due to persistently normal anc for approximately three weeks, he was weaned off g-csf in / . in / and / , he had two more hospitalizations for febrile neutropenia. g-csf was restarted with dose uptitrated to mcg/kg during his hospitalization in april. he was found to be thrombocytopenic with splenomegaly on abdominal ultrasound. anti-platelet antibodies and repeat anti neutrophil antibodies were not detected. he was discharged with close follow up with immunology and hematology. due to his age, he was transitioned to penn allergy/immunology in / . there was close communication between chop allergy/immunology, chop hematology and penn allergy/immunology during this transition period. patient was admitted to hup in / with febrile neutropenia (despite higher dose of g-csf), rhinovirus infection, pseudomonas sinusitis and ct chest findings suggestive of possible fungal pneumonia. due to persistent neutropenia refractory to g-csf treatment, hematology was consulted and repeat bone marrow biopsy showed hypercellular bone marrow with markedly left shifted granulocytic hyperplasia, compatible with g-csf therapy. flow cytometry showed no evidence of plasma cell neoplasm. dose of ivig was adjusted and increased based on his weight. per hematology, he also received an additional high dose ivig g/kg x days for presumed immune mediated neutropenia with immediate increase in anc. despite anc of for days,anadditional g/kgofivigimprovedhisancto> within hours of his first dose. thrombocytopenia also improved to normal range. since then, patient has been on monthly - mg/kg ivig with no recurrence in neutropenia. this patient's prolonged persistent neutropenia with immediate response to high dose ivig is suggestive of autoimmune neutropenia, which should be taken into consideration in hyper igm patients with persistent neutropenia. abstract/case report text background: children with digeorge anomaly (dga) represent a heterogenous group, often classified as either partial dga (pdga) or complete dga (cdga) based upon the degree of thymic hypoplasia. this paucity of t-cell parameters and function has serious implications for infection risk, autoimmunity, and malignancy. however, there are limited studies stratifying children with dga by these subgroups, especially in regard to immune function and subsequent infection risk. study design: single-center, retrospective cohort analysis evaluating the relationship between pdga and cdga to infection risk with particular focus on infection-related hospitalization, pathogenic organism identification, and antimicrobial resistance profiles. the source population includes all pediatric patients < years of age diagnosed with either pdga or cdga while receiving care at duke university from january , to june , . the final analysis sample included patients. methods: to evaluate the differences in immune function between dga subgroups, we will report the proportion of low ( < th percentile for age) t cell immune biomarkers for both subgroups and compare populations using a chi-squared test. to compare per year incidence of infectionrelated hospitalization for dga subgroups, a poisson model with number of hospitalizations per patient as the outcome, an offset equal to the time at risk for hospitalization, and either pdga or cdga diagnosis as the exposure will be used. models will be bivariate. we will report an incidence rate ratio (irr) and % confidence interval ( % ci). to evaluate the impact of cellular and humoral immune function on infection-related hospitalization, we will use poisson models where the outcome is the number of hospitalizations per patient, an offset equal to the time at risk for hospitalization, and low immune biomarker as the exposure. all models will be bivariate. we will report an irr and % ci. infection type and resistance profiles will be completely descriptive. results: as expected, children with cdga had a significantly higher probability of a low ( < th percentile for age) values for total t cells (cd +), helper t cells (cd +cd +), cytotoxic t cells (cd +cd +), and naïve helper t-cells (cd +cd ra+cd l+) as well as a significantly lower probability of low pan memory t-cells (cd +cd ro+) compared to children with pdga. no differences were detected in the percentage of low natural killer (nk) cells (cd +cd +) or b cells (cd +) between subgroups. cdga patients had a significantly higher incidence of hospitalization per year ( . ( . , . )) compared to pdga patients ( . ( . , . )). the irr is . ( . , . ). across both subgroups, the incidence of hospitalization was higher in dga patients who had low helper and naïve t-cells. there is ongoing analysis into hospital-related infection and resistance profiles. notable frequencies include bacteremia ( > %), invasive viral disease ( > %), and opportunistic infections ( > %). conclusions: children who had cdga were % more likely to have an infection requiring hospitalization than children who had pdga, emphasizing the need for thymus transplant for cdga. further analysis of infection type and patient outcomes is critical to enhancing management of this unique patient population. abstract/case report text antibody cross-reactivity among flavivirus has been documented. in recent times zika virus has been emerging in pockets of the mosquito-infested regions, while southwestern saudi arabia is known for arthropod-borne viral diseases and we do not know the incidence or even presence of zika virus in this region. it is restricted to predict the igm and igg antibody detection ranges owing to limited data and colossal cross-reactivity among the zika and other flaviviruses. we tested sera from pregnant women irrespective of their clinical presentation for zika and dengue igm, igg respectively. the zika positive samples were further confirmed by plaque reduction neutralization tests (prnt). from our results, . % ( ) cases were positive for zika igm against . % ( ) positivity to igg. when these samples were assessed for dengue igm and igg, we observed . % ( ) seropositivity for igm and igg respectively. there was no single sample positive for both igm and igg of zika or dengue. however, we observed one sample positive for both zika and dengue igm. upon mapping the overlapping serotiters, there was no significant correlation observed between the dengue igm and igg. whereas zika igg positive sample showed high serotiter for dengue igg indicating the contribution of cross-reactivity for observed zika positivity. screening for the incidence of zika, therefore, becomes particularly hard in a population that has the presence of pre-exposure of dengue and this cross-reactivity makes it hard to determine the zika incubation and antibody prevalence confounded with other flaviviruses. abstract/case report text introduction humoral pid diagnostic protocol includes the analysis of the immune response to different protein and polysaccharide antigens (ags) ( ) . although the analysis of the immune response against the polysaccharides vaccine from pneumococca has been the standard method, the use of s. typhim vi vaccine has appeared as a good alternative ( ) . in this report we show the results obtained with the use of s.typhim vi in adults patients attending the pid outpatient clinic. material and methods patients with humoral-suspected pids were challenged with typhoid polysaccharide vaccine (typhim vi®; sanofi-pasteur). serum was obtained on basal and after weeks of vaccination. specific igg levels against s.typhim were measured using "vacczyme tm human anti-salmonella typhi vi igg enzyme immunoassay kit" (binding-site). results a total of adult patients attended the pid clinics during nov -nov . from those, patients were fully evaluated using a humoral-suspected pid algorithm that includes the s.typhi vaccination. in total male and female patients completed the protocol and were analyzed. twenty patients were considered as responders (ratio pre/ post > x) whereas patients were non-responders. discussion the main advantage of assessing polysaccharide immune response using s.tyhpim is the usual lack of specific igg at the moment of the initial evaluation. in this serie, just one patient has a high basal level (# -vaccinated in the past). thirteen patients had basal levels below the detection limit of the test ( , u/ml) and patients between , and , u/ml, that has been described as a cut otf level for nonimmunised individuals (personal experience, , ). regarding the polysaccharide immune response as a tool to distinguish pid vs non-pid patients, the results showed a good correlation between those non-responders with more clinical relevant pid diagnostics. seven non-responders patients were subsequently diagnosed with a primary (* on table i ) and/or secondary id (** on table i ). despite this, there were patients that we could have classified as strong responders (ratio > x, absolute specific igg postvaccination level > u/ml) and patients considered as weak responders (ratio post/pre > x, absolute specific igg postvaccination level < u/ml). strong responders were considered non-pid after including other clinical investigations and laboratory tests (cell subpopulation study, pcp response) whereas weak responders group consisted in some "minor" forms of pid, like isolated igm or ig subclasses deficits. more patients are needed to confirm this functional classification of pid patients regarding their s.typhi immune response. abstract/case report text activated pi kδ syndrome (apds) is a primary immunodeficiency characterized by recurrent respiratory infections, as well as increased risk of chronic viremia with herpes family viruses, benign lymphadenopathy and b cell lymphoma. it is caused by heterogeneous germline gain-of-function mutations which ultimately lead to the hyperactivation of the phosphoinositide- -kinase δ (pik δ). pik δ exists as a heterodimer composed of a catalytic and a regulatory subunit. it interacts with b cell receptors, t cell receptors, costimulatory and cytokine receptors, and is a key player in a signaling pathway involved in cell growth, proliferation and survival. apds is caused by mutations in the pik cd gene, affecting its protein product p δ (catalytic subunit). apds is caused by mutations in the pik r affecting p a (regulatory subunit). short syndrome is a rare multisystem disorder characterized by short stature, hypertextensible joints, ocular depression, reiger anomaly and tooth eruption delay. the primary causes of short syndrome are heterozygous loss-of-function mutations in the pik r gene. the combination of apds and short syndrome is very rare, with only few cases described in the literature. in this report we present a teenager with a pathogenic variant in the pik r gene, and phenotypic characteristics of both apds and short syndrome. our patient is a -year-old female with a history of growth delay and short stature, delay tooth eruption, recurrent sinopulmonary infections and hypogammaglobulinemia. evaluation performed at a prior institution for recurrent infections revealed low igg levels. she did not initiate therapy at that time and was lost to follow up for several years. at the time of our initial evaluation she reported continued recurrent episodes of upper respiratory infections and sinus infections requiring antibiotic treatment that often did not clear the infections. her physical exam was relevant for short stature ( %ile, z=- . ), low weight for age ( < %ile, z=- . ) and hyperextensibility. her facial features were significant for prominent forehead and triangular face. given concern for immune deficiency, a complete immune evaluation was obtained. her workup revealed low igg levels, with igm and iga within normal limits. she did not have protective titers to s. pneumoniae, h. influenza or diphtheria and tetanus. after administration of vaccine boosters, she was able to generate a response to all vaccines except for tetanus. she had remarkably low absolute b cells ( cells/ul) and percentage ( %), and low cd :cd ratio ( . ). she was started on amoxicillin prophylaxis and monthly ivig replacement therapy. invitae immunodeficiency panel genetic testing was sent and revealed a pathogenic loss of function variant in an intronic splice site in the gene pik r (c. + g>c). after initiating treatment with ivig, her sinus infections significantly improved and she has not had any further episodes. igg levels have remained within normal limits with monthly ivig therapy. this pathogenic variant had been previously associated with apds ; however, it had not been associated with short syndrome. the mechanisms that link both conditions is yet to be identified. this case report emphasizes the importance of screening for comorbidities associated with short syndrome in apds patients, and vice versa. finding the genetic diagnosis for patients with suspicion of primary immunodeficiency (pid) is becoming increasingly important in the management of primary immunodeficiency and estimating the risk for family members. we constantly increase the diagnostic yield for pids by improving the sequencing technology, updating the panels with new genes discovered related to pid, and finding diagnoses from difficult to sequence regions and regions with high homology. here we report our experiences with nearly patients suspected with pid. moreover, we provide a case example, how we increase the diagnostic yield by developing unique techniques for specific genes which cannot be reliably analyzed by ngs alone. diagnostic yield including all immunology related panels was . % ( / ). the majority of the tested individuals were males ( / , . %) and the most common age of testing was between to years ( / , . %). the highest diagnostic yield . % ( / ) is in children from ages to years, whereas in patients over years of age the diagnosis was found for only . % ( / ) of the patients. in two patient cases, our cnv detection algorithm indicated a homozygous deletion in the index patient samples potentially covering the whole ncf gene. additional bioinformatic analysis targeting specifically two coding positions that differ between the ncf gene and the two pseudogenes showed that all reads in those positions originated from the pseudogenes. homozygous deletion in the ncf gene was further confirmed by sanger sequencing two regions in ncf with primers that specifically bind to either ncf or the pseudogenes. while clean ncf sequences from both regions were obtained for a control sample, no ncf -specific amplification product was obtained for the index patient samples. pseudogenes were amplified and sequenced successfully in both index patient samples and positive control samples. loss-of-function of ncf is a well-established mechanism leading to cgd and by overcoming the difficulties regarding ncf deletion detection by ngs, we can improve diagnostic rate in individuals affected with cgd. gata deficiency can lead to a broad spectrum of clinical and hematological phenotypes; in some cases, nk cell deficiency is the primary manifestation, resulting in a greatly increased susceptibility to viral infections and malignancy. gata -deficient patients, particularly those who suffer from severe viral infections, have reduced frequencies of peripheral blood nk cells and loss of function in the existing nk cells. specific loss of the less mature (cd ^bright) nk cell subset is a hallmark of the immune phenotype in gata deficiency, suggesting that generation or survival of nk cell precursors is impaired. given the remarkable spectrum of clinical phenotypes in gata -deficient patients and the poorly understood biology underlying their nk cell defect, we sought to characterize circulating nk cells on a single-cell level. we performed single-cell (sc)rnaseq of lineage-depleted innate lymphocytes from a patient with gata deficiency. as expected from flow cytometric phenotyping of peripheral blood cells from this and other patients, scrnaseq revealed decreased representation of canonical cd ^bright cells. within the cd ^dim population, we identified two nk cell populations that were seemingly unique to the gata deficient patient relative to a healthy donor. pathway analysis defined the first of these populations (population ) by the expression of genes associated with cellular response to stress, extracellular stimulus and inflammation, as well as programmed cell death and regulation of proliferation and apoptosis. the second population (population ) was defined by genes associated with nk cell chemotaxis, cytokine responses and interferon signaling. to extend our findings, we performed scrnaseq of additional healthy donors and analyzed an additional gata -deficient individual who was clinically asymptomatic (yang et al. ). of note, we detected population in seemingly healthy cmvnegative individuals, suggesting it was not uniquely a result of gata deficiency but associated with an inflammatory response and not related to adaptive nk cells generated in response to cmv infection. population , on the other hand, only appeared in our symptomatic gata -deficient patient. we additionally performed bulk gene expression analyses from an unrelated gata -deficient patient that confirmed the altered expression of genes associated with both novel cell populations. current efforts are focused on better defining the functional response of nk cells in these patients and confirming the identification of our novel populations by mass cytometry (cytof). together, our data define the heterogeneity and complexity of nk cells in gata deficient and healthy individuals. perforations have been reported with tocilizumab, a monoclonal antibody of the interleukin (il- ) receptor, suggesting that il- signaling plays a role in intestinal wall integrity. as il- signals through stat , we sought to investigate the potential association between lof stat and intestinal perforations, as well as the incidence and outcome in our patient cohort. methods: we performed a retrospective chart review of patients with lof stat (n= ) followed at our institution, looking for those with non-malignancy associated spontaneous gastrointestinal perforations. the demographic information, stat mutation, comorbidities at the time of perforation, clinical presentation, management, and clinical outcomes were compiled results: ten lof stat patients were identified as having documented intestinal perforations, an approximate rate of %. one perforation was the initial presentation of diffuse large b cell lymphoma (dlbcl) of the duodenum and liver, and was excluded from the rest of the analysis. the other nine perforations occurred between to years old (mean: ), and % were female. stat mutations were localized to the dna binding domain (n= ) and the sh domain (n= ). two of the perforations occurred while inpatient for lung infection. another occurred while recovering from pneumonia at home. two perforations were associated with the initial diagnosis of diverticulitis (at age and ). one perforation occurred in the terminal ileum, one in the cecum, one in the transverse colon, and six in the sigmoid. five patients underwent primary closure of the bowel. four patients required a temporary ostomy, with subsequent successful ostomy reversal. only one patient has since died of pulmonary hemorrhage, the other patients are alive with a mean of years post perforation follow-up, with no recurrence of perforation. one patient with prior sigmoid resection required ileal resection post perforation due to as massive intestinal bleed. conclusion: spontaneous gastrointestinal perforations occurred in our lof stat cohort at a rate of approximately %. one case was associated with malignant infiltration of the gastrointestinal tract and two cases were associated with diverticulitis both known risk factors for perforation. although the pathogenesis of the perforations in lof stat remains unclear, the connective tissue phenotype likely contributes as well as the association with diminished il- signaling, as has been demonstrated with the perforations and tocilizumab. abstract/case report text background granulomatous and lymphocytic interstitial lung disease (glild) is a life-threatening complication that occurs in patients with common variable immunodeficiency (cvid) and monogenic cvid-like disorders, but the optimal treatment is unknown. objective to determine if the use rituximab and azathioprine (rtx-aza) or rituximab and mycophenolate mofetil (rtx-mmf) would improve the radiographic abnormalities as determined by high-resolution computed tomography (hrct) of the chest and/or pulmonary function tests (pfts) in patients with cvid and glild. methods this is a retrospective study of patients seen from july to december with cvid and glild who completed immunosuppressive therapy (rtx ( mg/m ) for weeks, repeated at -month intervals for or total courses, and aza ( . - . mg/kg/day) or mmf ( mg- mg-bid) for months). complete pfts and hrct scans were performed prior to therapy, at the conclusion of therapy, and periodically thereafter. hrct scans were blinded, randomized, and scored independently (in pairs) by two radiologists. all patients underwent whole exome sequencing (wes). number (percentage) and median (interquartile range) were reported for categorical and continuous variables, respectively. differences between pre-and post-treatment and between relapse and post-relapse hrct scores and pft parameters were analyzed with wilcoxon signed ranks test. kaplan-meier survival curves were also done. unadjusted one-sided p-values < . were considered statistically significant. results the glild cohort (n= ) had a : female predominance, and age at glild diagnosis was ( - ) years (table ) . autoimmunity was present in the majority of patients, with thrombocytopenia ( ( %)) the most common manifestation. enteropathy ( ( %)), inflammatory bowel disease ( ( %)), and nodular regenerative hyperplasia of the liver ( ( %)) were also present. splenomegaly ( ( %)) was present in the majority, but polyarthritis ( ( %)) was notably absent. twenty ( %) patients had been previously treated with systemic steroids. hrct scores substantially improved between pre-and posttreatment for rtx-mmf (p= . ) and rtx-aza (p < . , figure ). fev (p= . ), fvc (p= . ), and tlc (p= . ) also improved, but dlco (p= . ) was unchanged (figures and ). excluding two ( %) patients who died . and years after therapy of respiratory failure ( ( %)) and septicemia ( ( %)) respectively, / ( %) patients relapsed . ( . - . ) years following therapy with an estimated % relapse rate after years ( figure ). as of december , of patients that relapsed showed improvement in hrct scores (p= . ), and the remaining patients are still undergoing retreatment ( figure ). four ( %) pneumonias occurred during immunosuppressive therapy, all with severe restrictive lung disease . eight ( %) patients had a damaging mutation in a gene known to predispose (tnfrsf b, n= ( %)) or cause a cvid-like primary immunodeficiency (ctla : ( %); kmtd : ( %); birc : ( %)). immunosuppressive treatment improved the hrct scores regardless of the absence (p < . ) or presence of a damaging mutation (p= . ) ( figure ). conclusion combination chemotherapy appeared to be effective in improving the radiographic abnormalities and pulmonary function of patients with cvid and glild. a majority of patients had sustained remissions, regardless of the presence or absence of a monogenic disorder. iqr=interquartile range, cvid=common variable immunodeficiency, glild=granulomatous and lymphocytic interstitial lung disease, vats=video-assisted thoracoscopic surgery, tbx=transbronchial biopsy, ms=mediastinoscopy excluding b cell malignancy, pft=pulmonary function test, h/o=history of, dz=disease, nrh=nodular regenerative hyperplasia, ibd=inflammatory bowel disease table . baseline patient characteristics since its first description the number of cases has increased progressively [ ] . although described as a predominant antibody deficiency [ ] , various complex phenotypes have been associated with mutations in this gene [ ] . case description. female patient with no remarkable history until years old, when she suffers from a persistent fever associated with purulent abscesses in venipuncture areas and hyperleukocytosis with neutrophilia, so she was treated for about months in hospitals in the city of barranquilla before she was referred to our institution. the patient's clinical picture consisted of persistent fever unresponsive to broad-spectrum antibiotic treatments, skin abscesses, left subphrenic abscess and toes osteomyelitis. the microbiological studies documented a bacteremia by acinetobacter baumannii and isolation in bone marrow of candida parapsilosis. during her care stay in barranquilla, she was approached as a chronic granulomatous disease versus job's syndrome, she received two doses of immunoglobulin with partial control of symptoms. due to the recurrence o f fever, abs ces ses and hyperleukocytosis, they decided to refer to our institution for further studies. upon admission to our institution, the patient presented nutritional compromise, with spontaneous resolution of fever but persistence of high acute phase reactants, with significant improvement of leukocytosis. all the cutaneous lesions she presented were debrided at the site of remission. immunoglobulin levels, lymphocyte populations and dyhidrorhodamine test were normal. she remained with no weight gain, constipation, abdominal distension and hepatic involvement with elevated liver enzymes and prolonged coagulation times. new bone compromise was documented. inflammatory bowel disease, neoplastic or chronic infectious disease involvement was ruled out. during the stay in our institution no microbiological isolation was documented. skin, colon and bone tissue biopsies were performed and extra-institutionally performed liver biopsy were examined, showing as a single common finding leukocytoclastic vasculitis in all tissues. given the heterogeneous nature of the condition, the diagnostic possibility of an immune dysregulation disorder was considered and a therapeutic trial with nsaids and prednisolone at mg/kg/day was started, as well as genetic studies by exome sequencing. the exome results documented a novel mutation in the pik cd gene [c. t> a (p.phe tyr)] as probably pathogenic. the patient has presented a clinical improvement and a significant decrease in inflammation markers. at the moment, we are waiting for the performance of functional tests to define the definitive therapy for this patient. conclusions. this case description highlights the diagnostic difficulties that face in developing countries, where the nonavailability of functional testing has implications on the diagnosis opportunity and establishment of optimal therapeutic for patients with complex diseases such as primary immune regulatory disorders abstract/case report text background: autoinflammatory syndromes, a wide family of diseases, defined as attacks of inflammation that are unprovoked (or triggered by a minor event) and are primarily related to dysregulation of the innate immune system. periodic/recurrent fever syndromes were the former name of these diseases. however, only in two conditions: cyclic neutropenia (cn) and periodic fever, aphthous stomatitis, pharyngitis, and adenitis (pfapa) are febrile episodes truly periodic. for pfapa, although diagnostic criteria differ and there is no consensus research definition, patients are usually not difficult to recognize based on clinical course and presentation . high index of suspicion and understanding the parental experiences and descriptions of febrile episodes is imperative in facilitating early recognition and timely diagnosis. aims: to standardize and summarized the clinical presentation of pfapa, based on parental descriptions and providers observation of febrile episodes. methods: utilizing a query for the icd- diagnosis code m . ( + ) we identified a cohort of children diagnosed and managed for periodic fever, excluding those with monogenetic mutation (e.g. blau, majeed) and those with chronic illness. we reviewed the charts for documented parental report and provider observation of febrile episodes. standardized signs and symptoms were recorded for each patient [ table ]. results: a cohort of children, boys ( %) and girls ( %) with documented, cyclic episodes of fever > , was identified. the average age at diagnosis was . +/- . years. classic symptoms were reported or observed in % of patients ( ). more than half ( %, patients) had documentations of other symptoms, usually reported by parents to occur sporadically during some fever episodes. decreased oral intake and general "ill appearance" was reported by parents in % of patients. when reporting the time intervals, parents usually reported similar length for each episode, typically between - days, and regular interludes, typically between - weeks. the findings are summarized in table . discussion: the findings presented here are in concordance with previously published data describing pfapa as a syndrome affecting young, generally healthy children with identical episodes of fever lasting for a few days, recur with regularity. our data support the approach that parental observation is fundamental in identifying the unique pattern of illnesses. engaging the parents with directed interview is crucial to establish this clinical diagnosis in a timely fashion, prevent misdiagnoses of future febrile episodes as presumptive infections, and avert unnecessary antibiotics courses. this cohort adds the observation that up to % of patients who display this identifiable pattern of illnesses, do not present with aphthous stomatitis, pharyngitis, or adenitis. these classic symptoms although common, are not the rule. the cyclic chronicity of febrile episodes associated with general ill appearance (but not lethargy), and decreased po, in an otherwise healthy child is the clinical gold-standard of this condition. abstract/case report text heterozygous mutations in nfkb are frequently identified among immunodeficient patients with highly variable clinical symptoms. in a world-wide collaborative effort, we characterized the clinical and cellular phenotype and the management of of these patients harboring distinct nfkb variants. nfkb encodes the transcription factor precursor p which is processed to p (canonical pathway). known pathogenic variants cause p haploinsufficiency (due to protein decay) or p -skipping (with expression of p -like forms). most variants however are single amino acid changes with yet unknown effects. all sequence changes were assessed in silico for their probability of pathogenicity including variants which were additionally tested in vitro. these analyses include the sub-cellular protein localization (microscopy), protein expression, stability and processing (western blotting), transcription factor activity (reporter assay) and dna-binding ( figure ); the associated unadjusted odds ratio (or) was not significant, suggesting igrt had restored cases to a similar baseline infection risk as the controls. in a multivariate conditional logistic regression model adjusting for the significantly higher occurrence of risk factors in cases compared with controls in the preindex period, cases were associated with a % lower adjusted odds of major/severe infections in the post-index period versus controls (or= . ; p= . ). conclusions: patients who required treatment with igrt (privigen®/ hizentra®) had previously experienced more major/severe bacterial infections than those not needing treatment with igrt. however, igrt was associated with a reduction in the risk-adjusted odds of major/severe bacterial infections compared with non-igrt treated sid patients with haematological malignancies. abstract/case report text introduction: real-world data are lacking as far as identifying patients with secondary immunodeficiency (sid)/hypogammaglobulinemia who may benefit most from interventions to protect them from potentially fatal infections. this study aimed to identify risk factors for major/severe infections in patients with sid with underlying haematological malignancies. methods: a retrospective database analysis was conducted using the iqvia real-world data adjudicated claims -us database (study period: january -september ). inclusion criteria were adults newly diagnosed with sid (first diagnosis termed the index date), with ≥ months continuous health plan enrolment pre-index (baseline period) and a minimum of months' data post-index (mean: days), with chronic lymphocytic leukaemia, multiple myeloma and/or non-hodgkin's lymphoma and without claims for any ig therapy in the -month baseline period. patient characteristics in the -month baseline period were assessed. over the post-index period, antibiotic/antiviral use and frequency of infections were assessed. the frequency of major/severe infections was determined using diagnosis codes for bacterial, viral, fungal, parasitic, other or unspecified causal pathogen infections. major/severe infections were defined as those requiring inpatient hospitalisation with an infection diagnosis code and/or use of intravenous (iv) antibiotics or iv antivirals in an outpatient setting. a multivariate cox proportional hazards (ph) model evaluated baseline patient characteristics associated with risk of major/severe infections post-index. results: a total of , patients met the inclusion criteria. the mean age of patients was years and . % were male. in the -month baseline period: . % of patients received cancer treatments and . % of patients received antibiotics ( . % iv antibiotics). a total of . % of patients experienced any infection, . % experienced ≥ infections and . % experienced major/ severe infections. the mean number of infections over the baseline months was . for any infection (at the unique diagnosis code level) and . for major/severe infections (unique hospitalisations with any infection diagnosis code and/or unique days with an outpatient iv antibiotic or iv antiviral). in the post-sid diagnosis period, . % of patients had major/severe infections; of the major/ severe infections, . % were identified as bacterial, . % were viral, . % were fungal, while . % did not have a causal pathogen specified. a total of . % of patients experienced one severe/ major infection and . % experienced ≥ severe/major infections ( figure ). the mean annualised number of major/severe infections post-index was . . receiver operating characteristic (roc) curve analysis to optimise sensitivity versus false positives in identifying those at risk of major/severe infections post-index identified a cutoff point of three bacterial infections in the baseline pre-index period as a potential optimal trigger to consider treatment to avoid major/severe infections post-index ( figure ). the multivariate cox ph analysis suggested that hospitalisations, infections (≥ ), or antibiotic use in the -months pre-index (prior to sid diagnosis) were predictive of major/severe infections post-index (post-sid diagnosis) (all p < . ). conclusion: infections are common in patients with haematological malignancies and sid. key baseline predictors for major/severe infections in patients with an sid diagnosis were a history of infections, hospitalisations or antibiotic use. unfortunately, ms/ms detection is limited by the extremely low (e.g., pmol/l) protein concentrations in blood cells. peptide immunoaffinity enrichment coupled to selected reaction monitoring (immuno-srm) is a robust method for quantification of low abundance proteins in complex matrices, including dried blood spots (dbs). in a study of patients, immuno-srm reliably identified wiskott-aldrich syndrome (was) and x-linked agammaglobulinemia (xla) patients using direct quantification of proteins responsible for disease (front. immunol., ). we further expanded our approach for x-linked chronic granulomatous disease (x-cgd), ada and dock deficiency. marker proteins representing platelets, nk cells, and t-cells have also been analyzed to provide additional information about disease processes. these results demonstrate the utilization of immuno-srm as a sensitive platform for multiplexed signature peptide quantification and its potential for pidd newborn screening and clinical diagnosis from dbs. methods: candidate peptides were selected based on ms/ms sensitivity and uniqueness in the proteome. anti-peptide monoclonal antibodies (mabs) were then generated for peptide enrichment from dbs. blood from normal controls, xla, was, xl-cgd, dock and ada deficiency patients was collected after consent on filter paper, dried, and stored at - °c. proteins were extracted from dbs, digested with trypsin, and enriched using mabs bound to magnetic beads. the enriched peptides were then eluted and analyzed with a waters xevo tq-xs. results: a multiplexed immuno-srm panel has been generated for screening eight signature peptides representing five pidd-specific and three cell-type specific proteins from dbs. limits of detection and quantification were femtomoles of peptide, the assay showed a broad linear range, and intra-assay and inter-assay coefficients of variation were < %. in samples from xla, was, xl-cgd, dock and ada deficiency patients, signature peptides are significantly reduced relative to normal controls and patient identification had excellent agreement with clinical and molecular diagnosis. also included in the multiplex panel are cell specific markers for platelets (cd ), t-cells (cd ɛ), and nk cells (cd ). diagnostic cutoffs for each peptide concentration have been established. in was patients, cd levels were significantly reduced consistent with characteristic thrombocytopenia. immuno-srm also has the ability demonstrate the effects of pidd treatment. a was patient analyzed before and after bone marrow transplant showed normalized was protein and cd after treatment. two ada deficiency patients showed normal levels of ada enzyme after rbc transfusion. finally, a high-throughput (ht) immuno-srm method screens pidd-specific peptides in a . -minute runtime meeting high volume nbs workflow requirements. this ht method returned identical results to the standard immuno-srm pidd panel. conclusions: the data herein demonstrate the feasibility of using immuno-srm as a broad clinical diagnostic for identifying and studying pidd patients from easily collected and shipped dbs. significantly, ht immuno-srm workflows represent a promising potential option for nbs of pidds and other congenital disorders. chief, laboratory of clinical immunology and microbiology/national institute of allergy and infectious diseases, niaid/national institutes of health, nih abstract/case report text we have previously used the artificial thymic organoid (ato) system, based on the d aggregation and culture of a delta-like canonical notch ligand -expressing stromal cell line (ms -dll ) with cd + cells, to study t cell differentiation from cd + cells obtained from patients carrying defects that are intrinsic to hematopoietic cells (rag - , ak , il rg) or that affect thymus development (digeorge syndrome). we now report results of in vitro t cell differentiation of cd + cells obtained from patients with either haploinsufficiency or dominant negative (dn) mutations of the ikzf gene. ikzf is an essential transcription factor expressed throughout hematopoiesis and involved in both lymphocyte and myeloid differentiation. heterozygous germline mutations in ikzf give rise to distinct clinical phenotypes, depending on the nature of the mutation. in particular patients with ikzf haploinsufficiency present with common variable immunodeficiency (cvid) associated with b cell immune deficiency, b-all susceptibility, and autoimmune manifestations. no clinical t cell defects are evident among these patients, except for elevated naive and central memory cd +cd + t cells. in contrast, patients carrying dn ikzf mutations present with combined immunodeficiency (cid) characterized by the presence of an increased proportion of naïve t cells, associated with defective generation of memory t cells, impaired t cell activation, signaling and proliferation, reduced t-helper (th) polarization, and susceptibility to pneumocystis pneumonia. different mouse models of ikzf mutations have been developed, however their phenotype does not fully match what reported in patients, and in some models indicates a more severe defect in t cell development. to address these controversies and to gain novel insights into the effects of distinct ikzf mutations on human t cell development, we used the ato system to analyze progression of t cell development from cd + cells obtained from one patient with ikzf haploinsufficiency and one patient with dn ikzf mutation. both patients showed a similar early block in t-cell differentiation a t p re -t c el l s ta g e. ho w ev e r, th e p a ti e nt wi t h i kz f haploinsufficiency showed a more pronounced leakiness, with a residual production of cd +tcrab+ cells, which could account for the milder t-cell phenotype presented in this type of patients. interestingly, the dn patient presented an increased accumulation of cd -cd b-cd aa+ cells. these results show an unexpected role for ikzf in humans in early stages of t-cell differentiation and indicate ikzf as a necessary factor for the induction of cd b expression in t cells. abstract/case report text background: pediatric acute liver failure without an identifiable cause (indeterminate palf/ipalf) is associated with increased rates of liver transplant and mortality. aplastic anemia (aa) may develop weeks after the diagnosis. the immunologic mechanisms that contribute to disease pathogenesis have not been clearly elucidated. we report detailed immunophenotyping of a patient with ipalf/aa. case: a previously-healthy -year-old male was admitted for acute hepatitis presenting with jaundice and hepatosplenomegaly. evaluation for infectious, toxic, metabolic, autoimmune, and rheumatologic disorders was negative. he was pan-lymphopenic (cd +alc cells/μl) with an inverted cd :cd ratio of . on admission. liver biopsy showed severe portal, interface, and lobular inflammation characterized by activated sinusoidal macrophages and perforinexpressing cd +t-cells. compared to a healthy control, the percentage and number of peripheral blood cd +t-cells expressing perforin ( %v. %, v. cells/μl) and granzyme-a/b ( %v. %, v. cells/μl) was also increased, while percentages of perforin+ ( %) and granzyme-a/b+( %) nk cells were normal. bone marrow (bm) showed % cellularity with rare hemophagocytosis. serum cytokine analysis demonstrated il- pg/ml, il- -binding-protein pg/ml, cxcl pg/ml, and sil- rα u/ml, consistent with smoldering hemophagocytic lymphohistiocytosis (hlh), but he did not meet hlh diagnostic criteria. genetic sequencing did not identify pathogenic variants in genes associated with primary immunodeficiencies. he was diagnosed with ipalf and treated with three doses of anakinra and two weeks of ruxolitinib, followed by prednisone - mg/kg/day and intravenous immunoglobulin g/kg/month. immunophenotyping performed after two months of therapy showed persistent inversion of the cd :cd ratio with small expansions of cd +cd -cd -cells and tcr··+t-cells. in the cd +t-cell subset, there was a substantial paucity of naïve cells, with effector memory t cells (tem) being more abundant than central memory t cells (tcm). in the cd +t-cell subset, the majority of cd ro+cells were tem with no detectable tcm, and % of all cd +t-cells were cd +temra. in both cd + and cd +t-cell subsets, activated (hla-dr+) and senescent (cd +) subpopulations were increased, and the majority of cells expressed the exhaustion marker pd- . the hepatic inflammatory infiltrate similarly reflected repetitive antigenic stimulation, with expansion of cd +cd +t-cells. quantitative immunoglobulins and total memory b-cells and plasmablasts (cd +cd +) were normal for age. however, there were no circulating iga-memory b-cells and a reduced number of iggswitched memory b-cells (table ) . given the severity of his phenotype and bm hypocellularity ( %), allogeneic hct was performed using a matched-related-donor ( / ) with conditioning of flu+cy+alemtuzumab. at d+ , he shows improved liver function but persistent pancytopenia, with transfusion-dependence for platelets. discussion: to our knowledge, this is the first description of detailed immunophenotyping in blood from a patient with ipalf/ aa. other studies have identified distinguishing hepatic infiltrates and cytokine/chemokine profiles that suggest excessive activation of cytotoxic t-lymphocytes and macrophages contribute to disease pathogenesis (alonso et al, ). our preliminary data supports this hypothesis and expands the spectrum of immune dysregulation in the t and b cell compartments, proposing a primary immune etiology. immune dysregulation may be concordant with hyperinflammation and cytokine storm, the latter offering potential therapeutic targets. early diagnosis and treatment of immune dysregulation may prevent development of aa. background: x-linked agammaglobulinemia (xla) is one of the first inborn errors of immunity identified, with thousands of patients described to date. infections originally dominated the clinical phenotype, but early diagnosis and immunoglobulin replacement allowed for long term survival as well as recognition of late-onset complications. nodular regenerative hyperplasia (nrh) of the liver is a silent cause of non-cirrhotic portal hypertension. nrh underlying pathophysiology remains blurry and the disease has no specific treatment. nrh has been increasingly reported in primary immunodeficiency but data in xla are very limited. objectives: to assess and characterize nrh in patients with xla. methods: we retrospectively reviewed the medical records of all xla patients referred to the nih between and . hepatology evaluation and liver biopsies were performed when clinically indicated. patients were stratified into nrh+ or nrhgroups, according to their nrh biopsy status (patients with no liver biopsies were classified as unknown). laboratory values are presented as medians. fisher's exact test and mann-whitney test were used to compare categorical and continuous variables, respectively. results: twenty-one xla patient records were reviewed, with a median age at start of follow-up (f/u) of y and a median duration of f/u of years. eight patients underwent at least one liver biopsy of whom ( % of nih xla cohort) were nrh+. the median age at nrh diagnosis was y ( - ). among patients who had liver biopsies, alanine aminotransferase (alt) levels were mildly elevated in all, while alkaline phosphatase (alp) levels were only increased in nrh+ patients (p= . ). both nrh+ and nrhgroups had similar aspartate aminotransferase (ast) levels at baseline but higher values were observed at the end of f/u in the nrh+ group ( vs. u/l, p= . ). persistently low platelet count ( < k/μl for more than months), mildly to highly elevated hepatic venous pressure gradient (hvpg) and either hepatomegaly and/ or splenomegaly were present in all nrh+ patients. in opposition, neither persistently low platelet counts, nor hepato-or splenomegaly were present in the two nrh-patients evaluated. hvpg was normal in the only nrh-patient tested. all-cause mortality was higher among nrh+ patients ( / , %) than in the rest of the cohort ( / , % among nrh-and unknown patients, p= . ). conclusions: based on our retrospective analysis, nrh appears as an underreported, frequent and severe late-onset complication in xla, which is highly associated with increased mortality. persistent thrombocytopenia, elevated alp, elevated hvpg, hepato-and/or splenomegaly were common in liver biopsyproven xla/nrh+ patients and distinguish them from xla/ nrh-patients. based on nrh prevalence, severity, lack of specific treatment and poor outcome in xla, immune-reconstitution (rather than igg replacement and infectious prophylaxis) should be considered early in this population in order to prevent fatal long term complications. abstract/case report text introduction: barth syndrome (bths) is an x-linked recessive disorder caused by a mutation in the tafazzin (taz) gene resulting in an inborn error of cardiolipin phospholipid metabolism (an important mitochondrial inner membrane lipid). it is commonly characterized by intermittent neutropenia and cardiac and skeletal myopathies. we present a case of bths with associated lymphopenia and hypogammaglobulinemia, which has not been previously described in the literature. case report: a two-month old male, born full term with normal newborn screening, was first admitted for rsv bronchiolitis. at this time, patient underwent an echocardiogram given his older brother with hydrops had died hours after birth and on autopsy was found to have dilated cardiomyopathy (dcm). patient was similarly noted to have dcm and thus had whole exome sequencing done that showed a hemizygous mutation in the taz gene (c. g>a). this novel variant resulted in early termination of the protein (p.trp ter) with concern for loss of function. in regard to patient's first year of life, he had frequent uri symptoms, episodes of acute otitis media requiring tympanostomy tubes, but no documented pneumonias or other serious bacterial infections. patient also had gross developmental delay, particularly motor, and feeding difficulties with persistent failure to thrive requiring g tube placement. his absolute neutrophil count ranged from - cells/mm in the first year. at age months, patient was found to be in acute decompensated heart failure with concern for myocarditis (ck , u/l, troponin i . ng/ml) as well as acute hypoxic respiratory failure with respiratory cultures growing pseudomonas. he was incidentally found to have an igg level of mg/dl (normal for age - ) and treated empirically with ivig. when seen by immunology, further workup showed persistent b cell lymphopenia (absolute cd of - /mm ). he also had a low initial nk cell count ( - /mm , later normal) with normal cd and cd t cell counts. tetanus and hib titers could not be assessed as he had recently received ivig. his igg trended up to mg/dl a few days after initial ivig and then subsequently dropped to mg/ dl, with a level of mg/dl two weeks following initial dose. workup for gastrointestinal or renal losses of immunoglobulin were negative. he also shortly after developed enterobacter bacteremia. his igg levels at this time continue to remain around mg/dl. he subsequently required a heart transplant at age months for his dcm. after transplant, he continued to improve from a cardiac standpoint, but his lymphopenia persisted and each time he was weaned off ivig, his hypogammaglobulinemia persisted at - mg/dl thus requiring additional ivig replacement over the course of the next months. the remainder of immunoglobulins were normal initially, but the igm slowly dropped over time to - . mg/dl. patient was started on weekly subcutaneous immunoglobulin replacement at months, doing well clinically at age -month follow up. conclusion: here we present a patient with bths, with a novel variant, who had b-cell lymphopenia as part of his presentation with persistent hypogammaglobulinemia requiring ivig replacement. year fellow/ucla associate professor/division of allergy, immunology, and rheumatology, university of california los angeles chief of pediatric allergy and immunology/harbor-ucla chief, laboratory of clinical immunology and microbiology/national institute of allergy and infectious diseases, niaid/national institutes of health, nih biologist/laboratory of clinical immunology and microbiology, division of intramural research, national institute of allergy and infectious diseases, national institutes of health project scientist/ucla abstract/case report text a -year-old female presented for combined immunodeficiency. at years of age she was diagnosed with rag hypomorphism and started on ivig. as a child, she was hospitalized for pneumonias and cryptococcal meningitis. she suffered sinusitis, hepatitis, tooth abscess, cmv and herpes stomatitis. later, she experienced recurrent cutaneous abscesses, utis, vaginal yeast infections, and hidradenitis. she twice hospitalized recently for pneumonias and diagnosed with mycobacterium abscessus on bronchoscopy. she suffers onychomycosis, osteomyelitis and oral and esophageal candidiasis with odynophagia. on exam, she had white plaques on tongue and buccal mucosa. she had hyperpigmented plaques on forehead and cheeks and thickened nails. immune evaluation was significant for lymphopenia with alc and thrombocytopenia with platelets k. b cells were nearly absent ( absolute count) and nk cells were low at absolute count. ige was absent, igm mg/dl, iga mg/dl and igg mg/dl (on replacement). her total cd + count was , cd + t cells were low at %, but cd + cells normal at %. the cd + t cells were mostly memory phenotype, which probably reflects lymphopenia-induced proliferation of a small number of clones. her cd + t cells also had an elevated amount of memory cells for age, but still had presence of naive cd + t cells. as expected with perpetual lymphopeniainduced proliferation, there was evidence of terminal memory (temra) in the cd + lineage. proliferative responses of t cells were modest. cd + t cells did respond to pokeweed, but less to pha and cona. there were no antigen specific responses. trecs were normal. esr was mildly elevated at . of note, her liver enzymes were elevated with alkaline phosphatase and ast , presumably secondary to prolonged fluconazole use. w es r e v e a l e d a k n o w n p a t h o g e n i c v ar i a n t i n s tat (nm_ . : c. c>g (p.n k)) as well as a heterozygous variant in rag p.m t. the stat mutation is de novo and was previously published as a gain of function mutation. however, when we performed validation studies to evaluate cd + cells with stimulation to ifna, the patient had decreased pstat as compared with control. va . analysis was performed to evaluate rag defect and showed % of t cells with va . expression confirming that the rag defect is not clinically significant. she developed severe thrombocytopenia refractory to platelet transfusions and ivig. she was started on ruxolitinib which improved platelet counts. however, she presented with shortness of breath, persistent tachycardia and was found to have cmv carditis and hepatitis significant for echocardiogram with ef %. cmv pcr is improving with last check iu/ml after month of therapy with ganciclovir. we now are looking for evidence of socs to explain the decreased stat phosphorylation. genetic testing is critical when evaluating a patient with immunodeficiency. our patient demonstrates that genetic mutations cannot be taken at face value and should be evaluated and validated fully to optimize patient care. fellow/university at buffalo / oishei children's hospital abstract/case report text opportunistic infections (oi) are commonly seen in patients undergoing hematopoietic cell transplantation (hct). different strategies for antimicrobial prophylaxis are often employed in the transplant setting to reduce the likelihood of encountering infection. the predisposing risks for infections include the expected neutropenia and lymphopenia following conditioning, prolonged defects in cell-mediated and humoral immunity during the engraftment period, and iatrogenic immunosuppression by medications for graft versus host disease (gvhd). we report the case of a -year-old male with acute lymphoblastic leukemia, which relapsed to chronic myelogenous leukemic blast crisis, and failed a subsequent allogeneic hct with central nervous system relapse. he was subjected to a second allogeneic hct. his immediate post-second transplant course was complicated with skin and gut gvhd, and infection and/or reactivation of coronavirus, respiratory adenovirus, epstein-barr virus, and human herpesvirus . while the herpesviral infections were controlled with antivirals and rituximab, adenovirus c infection proceeded to involve the gastrointestinal tract, and proved persistent over several months despite use of cidofovir. the patient's gvhd and transplant-associated thrombotic microangiopathy necessitated use of further immunosuppressants, including the complement protein c -binding eculizumab (an inhibitor of formation of the terminal c b- complex), ruxolitinib (a janus kinase [jak] / inhibitor) and low-dose interleukin- . h i s c l i n i c a l c o u r s e w a s f u r t h e r c o m p l i c a t e d b y stenotrophomonas maltophilia gut colonization and subsequent bacteremia, as well as multiple gram-positive bacteremia courses. at around day + , there was a life-threatening pericarditis with pericardial effusion and respiratory distress, associated with pneumocystis and stenotrophomonas being isolated from bronchoalveolar lavage. this occurred despite the patient being on pentamidine prophylaxis. the patient eventually recovered on trimethoprim/sulfamethoxazole therapy. we discuss the various risk factors potentially contributing to each oi in this illustrative case. in particular, complement and jak inhibitor therapy are fairly new drugs approved for other indications, whose off-label use in transplant patients is increasing. both have recently been associated with certain oi in the literature, as they are in this patient. abstract/case report text background: autoimmune lymphoproliferative syndrome (alps) is characterized by chronic nonmalignant lymphadenopathy, splenomegaly, hepatomegaly, cytopenias, and other autoimmune manifestations. typically, the biomarker profile of patients with alps includes elevated tcr αβ+ dnt cells, serum igg, serum b , serum il and soluble fas ligand (sfasl). hdl cholesterol can also be significantly low. alps is caused by lymphocyte accumulation due to defects in the fas-mediated apoptosis signaling pathway. these defects cause resistance to physiological apoptosis in lymphocyte populations that results in chronic lymphoproliferation. the molecular defect underlying most alps etiologies is attributed to heterozygous germline or somatic (limited to dnt cell subpopulation) pathogenic single nucleotide variants (snv) in fas. we describe copy number variants (cnvs) at the fas locus underlying alps in unrelated families. methods: through the centralized sequencing initiative at at the national institute of allergy and infectious diseases (niaid), patients undergo genomic workup to identify molecular defects contributing to clinical phenotypes of immune system disorders. all patients receive exome sequencing and a subset of patients also receive array-cgh analysis. patients and results: we performed exome sequencing on patients with a clinical diagnosis of alps. for patients with no molecular defect through exome, we performed cnv analysis. in this cohort, we identified three patients with a copy number variant involving the fas locus. all patients presented with splenomegaly and lymphadenopathy in childhood with ages of onset ranging from months to years old. all patients experienced anemia, autoimmune neutropenia, and thrombocytopenia. they had biomarker evidence showing elevated serum b levels, sfasl levels, and elevated αβ+dnt cell populations. they were found to have very low hdl cholesterol in early childhood ranging from - mg/dl ( - mg/dl). all patients had negative family histories for lymphoproliferative disorders and immunodeficiency. these patients had clinical presentations and biomarker profiles similar to alps patients with germline and somatic fas variants. patient : we detected a~ . mb copy number loss encompassing all of fas. parental studies were not performed. patient : we detected a~ . mb copy number loss encompassing all of fas. parental studies showed this to be maternally inherited. in addition, prior karyotype testing of the bone marrow showed the same deletion. patient : we detected a~ . mb copy number loss encompassing exons - of fas. parental studies were not performed. these results are consistent with the pathogenic nature of copy number variant losses involving fas. the mechanism of disease in these patients is consistent with haploinsufficiency. in family , the mother harboring the fas deletion is unaffected. this is consistent with prior observation of reduced penetrance within a family in alps. conclusion: these three cases harbored causative deletions in fas in the presence of biomarkers indicative of alps and negative results for germline and somatic genetic variant testing. these patients demonstrate that copy number variant analysis should be pursued if there is robust clinical and biomarker evidence of alps as it can lead to a molecular diagnosis and appropriate treatment when exome or next generation panel based fas sequencing is inconclusive. abstract/case report text rationale: the thymus is essential for the development of tcells. patients with thymoma have decreased aire expression and have an abnormal thymic microenvironment where the negative selection of t-cells is compromised, resulting in a broad spectrum of autoimmune-mediated diseases. besides myasthenia gravis, which is found in to % of patients with thymoma, other autoimmune diseases have been reported including erythroblastopenia, systemic lupus erythematosus, inflammatory myopathies, thyroid disorders and good's syndrome. recent studies have described additional autoimmune conditions such as pneumonitis in thymoma patients. we identified a patient who developed chronic cough post-thymectomy and was found to have lymphocytic pneumonitis with associated autoantibodies against lung antigen kcnrg and lung immunopathology consistent with apeced pneumonitis, which implies a common pathogenic mechanism between these conditions. methods: we describe a patient with thymoma who developed autoimmune pneumonitis associated with kcnrg autoantibodies and a characteristic pattern of immunopathology recently described in patients with monogenic disorder caused by primary aire deficiency (apeced) and secondary aire deficiencies (thymoma, rag deficiency). results: patient is a -year-old male with no significant past medical history who was in good state of health until age when he was diagnosed with and received treatment for guttate psoriasis (resolved with uv therapy) and alopecia areata. at age , he developed severe abdominal pain and weight loss. he had an abdominal ct performed that showed chronic pancreatitis and thymoma. one month later, the patient underwent thymectomy and subsequently, underwent ercp and pancreas biopsy, revealing atrophic pancreatitis with negative staining for lgg and lgg . at that time, he was started on pancreatic enzymes with improvement of abdominal symptoms. following thymectomy, he developed persistent dry cough and recurrent symptoms of sinusitis which did not respond to several courses of oral antibiotics to treat his positive culture for pseudomonas. he had a negative work up for vocal cord dysfunction and cystic fibrosis, and negative autoantibodies against ifn-gamma, il- a, and gm-csf. for work up of chronic cough, the patient underwent ct imaging of the chest which revealed diffuse peri-bronchial thickening, mucus plugging, and tree-in-bud nodularity through most of his lungs. he underwent bronchoscopy with bal which revealed n o r m a l b r o n c h i a l m u c o s a a n d a i r w a y n e u t r o p h i l i a . endobronchial biopsies showed basement membrane thickening and dramatic lymphocyte infiltration in intraepithelial and submucosal areas. his bal cultures revealed mycobacterium intracellulare/chimaera. patient was also tested for autoantibodies against lung-specific bactericidal/permeabilityincreasing fold-containing b (bpifb ) and the potassium channel regulator kcnrg that have been associated with the development of pneumonitis in patient with apeced, thymoma and rag deficiency, and was found to have kcnrg-targeted autoantibodies. conclusions: thymoma is a disease associated with secondary aire deficiency. this case illustrates common clinical, radiographic, histological, and autoantibody features in thymomaassociated and apeced-associated pneumonitis, indicating that disorders with primary and secondary aire deficiencies may have common pathogenetic mechanisms. bpifb and kcnrg should be included in the autoantibody profile testing of patients with thymoma and lung disease. immune suppression and antimycobacterial antibiotic treatment are planned. abstract/case report text introduction/background: activated phosphoinositide -kinase δ (pi kδ) syndrome (apds) is a primary immunodeficiency caused by a gain-of-function mutation in the pik cd gene that encodes the p δ catalytic subunit of pi kδ. it is characterized by recurrent respiratory tract infections, lymphoproliferation, nodular mucosal lymphoid hyperplasia, enteropathy, ebv and/or cmv infection, reduced t cell function and high levels of igm. there is not evidence of this disease in peruvian patients. methods: a case series of two pediatric patients with apds. results: the first patient is a girl of non-consanguineous parents. family history shows four maternal uncles died at pediatric ages with unknown diagnosis. at the age of , she presented lymphadenopathy and fever being treated as cat scratch disease without improvement of symptoms. months later, she was hospitalized due to anemia, mild hepatosplenomegaly, ascites and chronic diarrhea and diagnosed with gastrointestinal tuberculosis (tb). a hepatic biopsy only showed reactive hepatitis. however, the patient did not improve her symptoms despite anti tb treatment. years later, she was hospitalized for lymphadenopathy, pancytopenia, chronic diarrhea, ascites and severe hepatosplenomegaly. cmv igg was positive and lymph node biopsy revealed paracortical and follicular lymphoid hyperplasia due to ebv infection without neoplastic proliferation. low cd + t and cd + b cells and high igg levels were found (table ) . at this time, it was suggested the diagnosis of apds which was confirmed by next generation sequencing (ngs) identifying a heterozygous mutation in the pik cd gene (c. g>a, p.glu lys). she was treated with sirolimus and ivig for years. the symptoms persisted despite treatment and died at the age of . the second patient is a -year-old girl also of non-consanguineous parents. family history includes eczema (father) and colorectal cancer (mother). she has had recurrent respiratory infections, chronic diarrhea and poor weight gain since months old receiving symptomatic treatment only. at the age of , she was hospitalized for persistent pneumonia ( p s e u d o m o n a s p o s i t i v e ) , l y m p h a d e n o p a t h y a n d m i l d hepatosplenomegaly. a ct scan showed bilateral bronchiectasis and the sweat chloride test was negative. based on this, a diagnosis of cystic fibrosis was made and treatment was started. however, a genetic study only showed heterozygous mutations in the cftr gene (g d and g x). year later, she presented a neck-located skin abscess. at the age of , she was hospitalized for complicated pneumonia, diarrhea, lymphadenopathy, ascites and severe hepatosplenomegaly. multiple polyps in the duodenum and colon with lymphoid hyperplasia were detected, ebv igm and igg were positive and a lymph node biopsy showed paracortical hyperplasia without neoplastic proliferation. cd + t cells and igm levels were increased (table ) . a diagnosis of apds was suspected and ivig was started. ngs showed the same mutation as the first patient (c. g>a, p.glu lys). conclusion: apds should be considered in patients with recurrent respiratory tract infections, lymphoproliferation, enteropathy and abnormal immunologic function without another explanation. ngs is a useful tool to identify these cases in low-income countries. acknowledgments: we thank drs. raif geha and janet chou, division of immunology, boston children's hospital, harvard medical school for the genetic diagnosis. background: granulomatous-lymphocytic interstitial lung disease (glild) is an increasingly recognized pulmonary complication associated with common variable immunodeficiency (cvid) but the natural history and long term prognosis remains poorly defined. imaging findings with computed tomography (ct) are heterogeneous and visual features do not consistently predict a patient's progression to fibrotic lung disease. computer-aided lung informatics for pathology evaluation and rating (caliper) provides an objective analysis of lung parenchymal texture and quantifies the extent of normal lung, along with abnormal features such as honeycombing, reticular/consolidative and groundglass opacity. this may be useful in cvid patients to monitor changes in character or extent of disease and may facilitate early intervention before the disease becomes more aggressive or advanced. case description: our patient is a -year-old non-smoking female with cvid who has been followed for her cvid and associated interstitial lung disease. for more than twenty years, she has had varying abnormalities found on chest ct and these appear consistent with glild. specifically, she has had variable regions of mixed consolidation, ill-defined nodularity and septal thickening. the changing morphology and distribution made assessment of overall severity and extent of fibrosis versus parenchymal infiltration inconsistent. for clinical decision support we used caliper to analyze the current ct ( ) and compared caliper results for previous ct data. caliper provided a comprehensive analysis of the extent and characteristics of parenchymal features, and objectively determined normal and abnormal regions, some of which were not visually apparent. the caliper color overlay was able to highlight subtle regions of ground-glass opacity in areas that visually were regarded as uninvolved lung and quantify the extent of the reticular densities/ consolidation over time. caliper does not differentiate reticulation from consolidation, does not detect nodularity or septal thickening, and ct imaging cannot distinguish inflammation from fibrosis. however, caliper has the power to quantitatively assess overall disease extent and demonstrate subtle abnormalities that would otherwise have been dismissed as normal, given relative sparing compared to other regions. caliper may also provide evidence for disease progression or therapeutic response that is not otherwise radiographically apparent. conclusion: caliper assessment may be a useful tool as an adjunct for a patient with glild to help quantify the extent and character of lung parenchymal involvement. this information may serve as an important guide for clinicians in the assessment of successful management and early intervention to prevent irreversible fibrosis. patients had a trial of fingolimod without any beneficial changes in immune status. both patients receive pneumocystis jirovecii pneumonia prophylaxis with sulfamethoxazole-trimethoprim. conclusions: these results indicate that s pl deficiency due to sgpl mutations is a syndromic primary immunodeficiency leading to profound lymphopenia and hypogammaglobulinemia. our data emphasize the importance of sphingolipid metabolism for an efficient immune response and the need for more studies to delineate the exact mechanisms on how this happens in humans. after d at °c there was a median - % (range - % to + %; p= . ) change in activity. after d - % (range - % to + ; p= . ), d - % (range - % to + %; p < . ), d - % (- % to + %; p < . ) and after d - % (- % to + % p < . ). a °c stability of d was determined from the median percentage reduction; total allowable error adjusted stability data indicated a °c stability of d. samples stored at - °c following repeat freeze thawing saw a freeze/thaw cycle dependent decrease in ch activity. after freeze/thaw cycle there was a median - % (range - % to + %; p= . ) change, cycles - % (range - % to + %; p= . ), cycles - % (range - % to + %; p < . ), cycles - % (range - % to - %; p < . ) and after cycles - % (range - % to - %; p < . ). allowable error adjusted stability data indicated a maximum of freeze/thaw cycles. conclusion: sample storage and handling can have a significant impact on functional complement assessments. room temperature storage should be avoided unless samples will be analysed on the day of collection, °c storage is tolerable providing that assessment is within d; freezing samples at - °c with limited freeze/thaw analysis would be optimal. however, further investigations into longer-term storage at - °c and - °c would be beneficial. conclusions: gi disease is common in cvid affecting % of patients in our cohort. gi+ cvid patients have a higher frequency of autoimmune manifestations than those without gi complaints. the odds of itp, hypothyroidism, and evans syndrome all showed significantly increased odds in the gi+ group. the results of our study may have implications for both gastroenterologist and immunologist. recurrent infections especially those of the sinopulmonary tract are often the trigger for cvid evaluation. autoimmune and gi symptoms however may be the initial presentations of cvid and overlooked until other more recognizable manifestations evolve. the combination of gi issues and autoimmunity especially thrombocytopenia, evans syndrome, and hypothyroidism should include cvid in the gi differential. for the immunologist, a cbc is standard in the work-up of cvid and may reveal autoimmune cytopenia. evaluation for autoimmune disease and in particular hypothyroidism is not. given our findings an initial immune work up specifically for thyroid disease may be indicated. is the transcriptional factor for many cytokines such as il- , responsible for t cell and neutrophil defense again fungal infection. stat mutation leads to defect of neutrophil proliferation and chemotaxis to inflammatory site as well as production of antimicrobial peptides by respiratory epithelial cells. the poor tissue repair in the cavitary lesions and bacterial superinfection in patient's lung created a culture dish for fungal growth and dissemination. traveling to the endemic area and patient's noncompliance to antifungal prophylactic treatment further increased the risk of histoplasmosis infection. pediatric immunologist/john hunter children's hospital abstract/case report text we present the case of a month old boy, the first child to his nonconsanguineous parents of european descent. he first presented at months of age with a cellulitis of his right fourth finger culture positive for staphylococcus aureus which responded to a prolonged course of flucloxacillin. at months he presented with norovirus positive gastroenteritis leading to a brief admission and slow resolution. the first of two severe episodes of oral stomatitis and respiratory distress occurred at months of age. hsv was isolated from the oral lesions and blood culture during that admission was positive for kingella kingae. no cardiac or bone involvement was identified. a more severe episode of oral stomatitis occurred two months later (age months) swab positive for an enterovirus (not typed). due to airway compromise and rapid deterioration he was admitted to the pediatric intensive care unit. again, kingella kingae was cultured from blood cultures with no obvious focal systemic source. the only notable clinical finding was rapid deterioration and, in retrospect, the absence of any significant recorded fever ( < oc). crp elevation was observed (max. mg/l) and neutropenia was found with each of the more severe infectious presentations but recovered in the interval. baseline immunological investigations were normal (lymphocyte subsets, naïve t cell populations, lymphocyte proliferation, serum immunoglobulins and vaccine responses). serial measurement of circulating neutrophils did not identify a cyclical pattern and they were morphologically normal. a panel of genes relevant to primary immunodeficiency (invitae©) revealed a homozygous mutation in irak ((c. c>t (p.gln *)) which leads to a premature stop codon. this is a known pathogenic mutation leading to disease and is most prevalent in the european population (allele frequency (gnomad) = . ). prophylaxis with sulfamethoxazole / trimethoprim and amoxicillin was commenced along with monthly ivig. he has been well since diagnosis with no further severe infectious presentations. functional testing is underway to assess in vitro host viral defence in our patient and potential novel mechanisms relevant to this rare innate immunodeficiency. case studies will be presented on the five cases of fmp that were diagnosed and treated in . potential exposures were identified in four out of five cases: gardening exposure in one case and vaping exposure in three cases. all five were male, age range - . four were gp deficient, and one was p -phox deficient. historically, the vast majority of cases of fmp could be traced to a significant gardening exposure such as lawn mowing or spreading mulch. this was the first year that we saw patients with no identifiable gardening exposure in the setting of significant vaping exposure. with vaping at epidemic levels, especially among teenagers and young adults, it is important to consider that a vaping history is potentially a risk factor for fmp and counseling regarding the potential risks of vaping should be included in infection risk modification for all patients with cgd. abstract/case report text background: granulocyte-macrophage colony-stimulating factor (gm-csf) plays a critical role in macrophage and dendritic cell maturation and host defense against fungus. autoantibodies to gm-csf are associated with susceptibility to cryptococcus and nocardia infections as well as pulmonary alveolar proteinosis (pap) in otherwise healthy individuals. we report a case of a -year-old previously healthy female who presented with cryptococcal meningitis and was found to have autoantibodies against gm-csf. case presentation: weeks prior to admission, our previously healthy -yearold taiwanese female developed a headache associated with tinnitus and visual changes. the headache worsened over the next few weeks and she developed photophobia, phonophobia, and severe nausea/vomiting. at presentation, her exam was notable for papilledema, bilateral cn vi palsy and right foot & left hand paresthesia. mri brain showed ring-enhancing lesions in the anterior frontal lobe, caudate head, and the inferior globus pallidus. she underwent a diagnostic and therapeutic lp. opening pressure was elevated at and csf studies were notable for low glucose, elevated protein, pleiocytosis ( % lymphocytes) and positive cryptococcal antigen. csf culture grew cryptococcus gattii. ct chest revealed a right upper lobe and a left lower lobe nodule. workup: cbc with diff was unremarkable. hiv was negative. lymphocyte subsets were unremarkable with only mildly decreased nk cells, normal immunoglobulin panel including ige, protective titers to tetanus, diphtheria, and ppsv . targeted genetic sequencing did not identify any known mutations in primary immunodeficiency. notably, anti-gmcsf autoantibodies were detected by elisa and were able to neutralize gm-csf phosphorylation of stat detected by flow cytometry. autoantibodies to ifn-γ were not detected. management: patient was initiated on a -week course of liposomal amphotericin b and flucytosine. her csf cultures were cleared of cryptococcus after days of treatment, but her hospital course was complicated by persistently symptomatic intracranial hypertension, worsening pleiocytosis, and elevated cytokine levels in the csf, all of which were consistent with post-infectious inflammatory syndrome (piirs). she received therapeutic lps - x/week until subsequent ventriculoperitoneal shunt placement. concurrently, methylprednisolone was administered for days with a gradual prednisone taper. these interventions led to improvements in her symptoms, including diplopia, and reduction in opening pressures and inflammatory markers in the csf. lifelong fluconazole prophylaxis was recommended. from a pulmonary standpoint, she remained asymptomatic without signs of pap and has had normal pulmonary function tests (normal dlco) and stable chest imaging. conclusion: in otherwise healthy hiv-negative patients presenting with extrapulmonary cryptococcus or nocardia infections, autoantibodies to gm-csf should be suspected and testing for functional autoantibodies to gm-csf (and ifn-γ) should be sent, as genetic testing will not pick up this disease entity. genetic testing should be considered to rule out gata deficiency and x-linked cd l deficiency. idiopathic cd lymphopenia can be ruled out with lymphocyte enumeration. immediate treatment of cryptococcosis is not necessarily different from patients without gm-csf autoantibodies. long-term prophylaxis (fluconazole if presenting with cryptococcus; trimethoprim-sulfamethoxazole if with nocardia) is likely warranted in addition to monitoring for the development of pap. recognizing piirs in patients with cryptococcal meningitis and management with corticosteroids are critical steps. abstract/case report text background: non-infectious complications cause most morbidity and mortality in common variable immunodeficiency (cvid). cvid with complications (cvidc) is defined by elevated t helper (th ) responses attributed to increased circulating microbial products resulting from mucosal iga deficiency. however, complications do not uniformly occur in those with iga deficiency. objective: we tested whether cvidc occurs preferentially in those with hyper-responsiveness to microbial stimuli, manifested by elevated nf-κb-driven cytokines and resultant th responses in cvid patients with increased circulating microbial products. methods: we applied unbiased high-throughput seromics and mass cytometry, cellular and molecular biology approaches, and clinical record review in a subject cvid cohort. results: cvidc was defined by increased nf-κb-driven cytokines that promote th immunity in blood in association with elevated soluble cd , a marker of circulating microbial products, and elevated tnf production by peripheral blood mononuclear cells stimulated with lipopolysaccharide. this cytokine upsurge was associated with mutation of full-length nfkb p gene product ( delt) but not mutations that also involved the nfkb p product involved in transactivation. cytokine elevation corresponded with increased cd +cd -monocytes expressing higher cd and hla-dr and more central and effector memory cd + t cells, t cell chemoattractants, and t cellpredominant tissue pathology. those with granulomatous or neutrophilpredominant, rather than t cell, pathology had the highest tnf. tnf antagonism improved neutrophilic gastritis in cvid with nfkb delt after t cell targeted therapy failed. conclusion: nf-κb dysfunction underlies th immunopathology and tnf-associated innate inflammation in cvidc. both forms of nf-κb immune dysregulation may divergently shape cvid immunopathology. staff clinician/laboratory of clinical immunology and microbiology, immunopathogenesis section, national institute of allergy and immunology, national institutes of health, abstract/case report text introduction: patients with autoantibodies to ifn-γ develop severe and progressive infections with intracellular pathogens, despite aggressive antimicrobial treatment. we describe the use of daratumumab (anti-cd , targeting plasma cells) in a patient with autoantibodies to ifn-γ and progressive disseminated mycobacterium avium infection. she had progressive disease despite treatment with multi-drug antimycobacterials rituximab, and bortezomib. methods: clinical symptoms, total cd /cd , anti-ifn-γ autoantibody titers, and specific imaging were obtained before and after treatment with daratumumab. anti-ifn-γ autoantibody titers were determined by serial -fold dilutions of plasma and measuring anti-ifn-γ autoantibody levels by a particle-based technique as previously described. results: a -year-old filipino woman had progressive disseminated m. avium with extensive bone and soft tissue involvement (calvarium, ribs, bilateral arm soft tissue, paraspinal muscles, bilateral glutei, left inferior pubic ramus, bilateral iliac bones, sacrum, and bilateral humeri) and a tracheo-esophageal fistula. she received bedaquiline, azithromycin, ethambutol, tedizolid, moxifloxacin, clofazimine and meropenem as well as rituximab g once monthly for months. despite these she had progression of clinical and radiographic disease. bortezomib . mg/m twice weekly for weeks was added, but discontinued for ast and alt elevations. rituximab was continued to maintain cd numbers undetectable but clinical and radiographic disease progressed. while on rituximab, total igg level and anti-ifn-γ autoantibody levels decreased from mg/dl to mg/dl and to , respectively. while on bortezomib, total igg levels remained stable ( mg/dl to mg/dl) and anti-ifn-γ autoantibody levels fell slightly ( to ). after starting daratumumab, there was clinical and radiographic improvement, with reduced pain and disappearance of multiple soft tissue lesions. igg levels decreased from mg/dl to mg/dl and anti-ifn-γ autoantibody levels decreased from to . adverse effects of daratumumab were urticaria, pruritus and shortness of breath after the first infusion and aseptic meningitis after the th infusion. conclusions: daratumumab resulted in clinical and radiographic improvement of disseminated m. avium in a patient with rituximab and bortezimib-refractory autoantibodies to ifn-γ. daratumumab is another potentially effective therapeutic agent for anti-ifn-γ autoantibodies. abstract/case report text next-generation sequencing (ngs) is now routinely used as a clinical diagnostic tool. however, regions of high sequence homology continue to be a major challenge for short-read technologies. regions within ikbkg, ncf , sbds, c a, c b, coro a, fcgr a, fcgr b, pms , slfn , slfn , stat b, unc b , and ups are not available by standard ngs. we discuss strategies for analysis of these special regions. we have developed a strategy for supplementing our disease targeted panels which are performed using capture chemistry and a standard reference file. the supplemental method uses gene specific long range amplicon and a special gene specific reference file for alignment. the genes of interest are separated from their homologous counterparts using specific long range amplification primers. multiple amplicons may be pooled together and prepared for sequencing on an illumina miseq instrument using truseq nano dna library prep. bioinformatic analysis proceeds with a custom reference file in which non-specific regions of homology have been removed. this allows reads to be uniquely mapped despite significant homology; a requirement for variant calling. we prepared specific amplicon for several homologous gene targets including the ikbkg gene and the ikbkg pseudogene (ikbkgp ). both amplicons were sequenced in separate reactions and were compared with the standard capture method. variants which are not called in the standard-capture method due to poor mapping scores (non-uniquely mapped reads) are called in the amplicon method. in the capture method, the variants are visualized in the bam as a mixture of gene and pseudogene, while gene and pseudogene variants are clearly separated and identified in the amplicon method. due to high variability in alignment, many homologous regions do not provide reliable copy number variant (cnv) results and must be removed from cnv analysis. however in some situations, we are able to creatively leverage cnv analysis to identify alleles that mis-align to the pseudogene. the pathogenic ncf gt deletion in exon appears to resemble a copy number deletion event when present as reads from one allele mis-align to the ncf b and ncf c pseudogenes. complement genes, c a and c b, share alignment due to their high homology with each other. cnv analysis in normal samples represents four alleles rather than two alleles. cnv events may have a weak signal with no indication of which gene is affected. variant frequencies from the capture and supplemental pcr analysis can be used in tandem with cnv analysis to detect events and may indicate which gene is affected. we plan to include these strategies in our new inborn errors of immunodeficiency gene panel (ieigp) which will enable us to provide a more comprehensive analysis than is currently available. the im diagnosed were inflammatory bowel disease-like (n = , with perianal fistula in / ), mouth ulcers (n = ), discoid lupus (n = ), autoimmune dermatitis (n = ) and eczema (n = ), chronic lung disease (n = ) and granulomas (pulmonary n = ; ocular n = ; bladder n = ; oropharynx n = ). three patients presented more than one site of inflammatory disease. all patients were treated with systemic or topical immunosuppressive or immunomodulatory therapy, most of them corticosteroids. five patients underwent hematopoietic stem cell transplantation (hsct), median age at hsct was years ( - ), and two died month after hsct. conclusions: although infections are more frequent and have a major impact on patient morbidity and mortality, im are increasingly prevalent in patients with cgd. awareness regarding this possible comorbidity is of major importance, since earlier diagnosis and adequate treatment may be crucial for patients survival and quality of life. there is a gap in clinical knowledge regarding associations between specific pid and different rheumatological diseases. in this study, we are reporting the incidence of various rheumatological conditions reported in a large pid population using the usidnet (united states immunodeficiency network) registry. methods: we used the retrospective usidnet registry to conduct the analysis. we included all primary immunodeficiency patients with physician diagnosed rheumatological diseases. results: the total number of pid patients in our query was . ( . %) patients had a diagnosis of rheumatological disease. this cohort included ( . %) female and ( . %) male patients. rheumatologic complications were highest in the interferonopathies ( . %), complement deficiencies ( . %) and autoimmune lymphoproliferative syndrome (alps) ( . %). additionally, disease patterns were noted to be different in each pid. dermatomyositis was found to be the most common rheumatologic condition in patients with x-linked agammaglobulinemia (xla) with a rate of . %, which was remarkably higher than the reported prevalence in the united states ( . %). alps patients had a higher ( . %) numbers of sjogren syndrome diagnoses as compared to the general population ( . - . %). systemic lupus erythematosus was increased in patients with mucocutaneous candidiasis ( . %) as compared to the general population ( . %) and other pids. rheumatoid arthritis (ra) was reported in patients with specific antibody deficiency ( . %), common variable immunodeficiency (cvid) ( . %) and alps ( . %). wiskott-aldrich syndrome patients had the highest numbers of cases diagnosed with vasculitis ( . %). . % of patients with severe combined immunodeficiency (scid) had reported rheumatologic disease. juvenile rheumatoid arthritis (jia) and systemic sclerosis were reported in . % of patients with digeorge syndrome. conclusions: this study reports that higher numbers of rheumatologic diseases are diagnosed in pids compared to the general population. the incidence of different rheumatological disease was variable based on the pid diagnosis. early diagnosis of these diseases is crucial, given the high risk of irreversible complications. limitations of our study include possible selection bias as majority of cases were enrolled from tertiary care centers. abstract/case report text background disorders of immune dysregulation are associated with autoimmune features. this feature could potentially have an impact on the outcome post hematopoietic stem cell transplantation (hsct). hsct, although curative, can be challenging with the underlying immune dysregulation resulting in significant morbidity and mortality. we present the journey through hsct for these children and the factors affecting the outcome. we analysed the data on children up to the age of years diagnosed to have a disorder of immune dysregulation through gene mutation analysis and who underwent hsct at our centre from to . results . xiap mutation a -year-old boy underwent a haploidentical hsct from his father using fludarabine, treosulfan, and gray radiotherapy with post-transplant cyclophosphamide. after initial complete chimerism and cytomegalovirus reactivation responsive to valganciclovir, he developed progressive diarrhoea almost months post-hsct. a rectal biopsy confirmed cmv reactivation and features of inflammation. he has since been treated for the same and is on follow up for inflammatory bowel disease. his chimerism had dropped to % and has remained stable. the second child is a -year-old girl who underwent tcr alpha/beta depleted haplo sct and is months post-hsct, with no features of gvhd or infections, and is doing well with complete chimerism. . il r deficiency three boys aged eight months, one year, and two years of age, diagnosed to have il r deficiency underwent hsct. all three children needed nasogastric tube feeding, parenteral nutrition, and vigilant monitoring for electrolyte disturbances. in the first two children, we had performed tcr alpha/beta depleted pbsc transplants from their haplo matched fathers. the -year-old engrafted by d+ and is doing well two years post hsct with complete chimerism, no gvhd, and infections. his autoimmunity, including recurrent skin scarring, has resolved entirely. the -month-old, however, had primary graft failure and succumbed to his illness. the -year-old boy underwent matched unrelated donor hsct and engrafted by d+ with completed chimerism documented on three occasions. he, however, had secondary graft failure around d+ , and he succumbed to the illness. . lrba deficiency an -month-old girl with lrba deficiency had presented at four months of age with excessive sweating, hepatosplenomegaly, and recurrent chest infections. she was started on monthly intravenous immunoglobulin replacement and abatacept. she received myeloablative conditioning with thiotepa, treosulfan and fludarabine and underwent a matched sibling donor hsct. she engrafted by d+ and has been well ten months post hsct with complete chimerism, no gvhd, and infections. conclusion disorders of immune dysregulation are a heterogeneous group with a varied spectrum of immune dysfunction. myeloablative conditioning is essential, and there is a high risk of cytokine release syndrome and the need for supportive care. the autoimmune features need to be followed for progression in organs other than the hematopoietic system and may require interventions. as long-term data evolves, more precise definitions for patient and donor selection will enable improving outcomes. we performed a retrospective observational analysis of case records of children up to years of age, diagnosed to have variants of scid, and underwent hsct at our centre from to . results . zap deficiency a -month-old girl presented with oral thrush and submandibular cellulitis from one week of life with failure to thrive. she underwent a tcr alpha/beta depleted haploidentical hsct. conditioning included treosulfan/thiotepa/fludarabine/anti-thymocyte globulin. she engrafted by d+ ; now three years post-hsct with complete donor chimerism without gvhd or infections. . orai- mutation a -month-old girl presented with failure to thrive, generalized hypotonia, oral thrush, and recurrent respiratory infections. she underwent haplo-sct with post-transplant cyclophosphamide with pbsc from her haplo-matched father. conditioning included fludarabine/treosulfan. she had cytokine release syndrome grade , which responded to tocilizumab. she had hypertension throughout the peri-engraftment period and had an episode of pres with seizures. her symptoms abated with neutrophil engraftment by d+ . the post-transplant period was complicated by grade skin gvhd and cytomegalovirus reactivation. she has remained disease-free with complete chimerism three years post-hsct. her hypotonia is steadily improving with physiotherapy. . cernunnos-xlf deficiency a -year-old male presented with recurrent infections from years of age, aplastic anemia diagnosed at years of age, subsequent transformation to acute myeloid leukemia at years of age. he had developed multiple fusarium abscesses during the neutropenic period post-chemotherapy for aml. he was referred for a matched sibling sister hsct when in remission. conditioning included fludarabine/treosulfan. he engrafted by d+ with complete chimerism. he developed progressively worsening skin, gut, and liver toxicity secondary to chemotherapy and succumbed to the illness two months post-hsct. . ikzf mutation an -month-old girl presented with failure to thrive, massive splenomegaly, persistent pneumonia, anemia, and thrombocytopenia. she underwent a matched sibling donor pbsc transplant after myeloablative conditioning with thiotepa/treosulfan/fludarabine. she engrafted by d+ , following which all her symptoms abated. she had secondary graft failure two months post-hsct and succumbed to her illness. . mhc class ii deficiency (bare lymphocyte syndrome) three children, aged months, two years, and four years underwent matched sibling donor hsct. myeloablative conditioning with thiotepa/treosulfan/fludarabine resulted in engraftment. the first child died of invasive intestinal aspergillosis days post-hsct. the other two children are well months post-hsct with complete chimerism without gvhd or infections. the two-year-old girl received one cycle of pre-transplant immunosuppression with fludarabine/dexamethasone to prevent graft rejection pre-hsct as she was referred for a second transplant. conclusion children with scid have traditionally been transplanted using reduced intensity (ric) conditioning with immunomodulation. scid variants require myeloablative conditioning with a vigilant follow up for the detection of graft rejection. radiation sensitive scid associated with dna breakage repair defects require ric and close monitoring for gvhd. advances in hsct, including supportive care and haplo-sct, have provided a ray of hope for these hitherto rare conditions. j clin immunol abstract/case report text immune dysregulation, polyendocrinopathy, enteropathy, x-linked (ipex) (omim # ) is a monogenic autoimmune disorder that occurs due to loss of function variation in foxp causing dysfunctional t regulatory cells. although immunosuppression is a mainstay of treatment for autoimmunity, ipex treatment is frequently limited by insufficient response to therapy or side effects of immune suppression. we present a year old male with ipex whose prior immunosuppressive treatment was complicated by inefficacy and medication side effects, requiring a new approach to treat his colitis and erosive dermatitis. he initially presented with infantile diabetes and subsequently developed dermatitis, squamous cell carcinomas, alopecia totalis, and colitis. his clinical diagnosis of ipex was confirmed by foxp sequencing, demonstrating known pathogenic variant c. g>a (p.ala thr). this variant has been described in ipex affected individuals in multiple publications (ref ). his variant affects at the frkhead domain of foxp and has been associated with others with severe psoriasiform dermatisis and alopecia universalis (ref ). his prior immunosuppressive therapies included at different times combinations of corticosteroids, tacrolimus, sirolimus, azathioprine, infliximab, adalimumab, rituximab, dupilumab, and oral mesalamine. the relative efficacy of these agents based on experiences in a cohort of ipex patients was reviewed in (ref ), with the exception of duplimab, which was not listed in that review. for our patient, management of his widespread autoimmunity has been limited by toxicity or lack of efficacy of medications. notably, his dermatitis had no improvement with duplimab, consistent his low total ige and lack of allergic manifestations. at age , after initiation of treatment with sirolimus, he had spontaneous colonic perforation requiring descending colectomy. after stabilization of his colonic perforation, his multi-disciplinary team of allergy-immunology, gastroenterology, and dermatology initiated tofacitinib. tofacitinib is small molecule inhibitor of janus kinase (jak) signaling pathways that mediate cytokine driven autoimmune activation. it is fda approved to treat rheumatoid arthritis, psoriatic arthritis and ulcerative colitis. the decision to use this jak inhibitor was due to its fda approved use for ulcerative colitis, to target our patient's colitis and his other autoimmune manifestations, specifically his dermatitis. its off label for primary immune dyregulatory disorders including candle, stat -gain of function and stat -gain of function disorders has been published (ref ), but thus far its use to treat autoimmunity due to ipex has not been published. he experienced leukopenia while on mg of tofacitinib, which resolved after lowering his dose. currently, he has had improvement in his colitis and dermatitis, and partial improvement in alopecia. he has been on tofacitinib mg daily for months, with only prednisone mg daily as additional immune suppression. as the number and types of selective immune modulators increases, there is continued need to share the experiences of treating physicians of which therapies have been successfully able to decrease disease manifestations with tolerable side effect profiles. we present a year old male with ipex syndrome with severe dermatitis and colitis complicated by colonic perforation despite standard immunosuppressive therapy, who is safely and effectively being treated with tofacitinib. is not frequently associated with autoimmunity, likely due to impaired il- and il- pathways. however, in our relatively large cohort of lof stat patients, we have noted an increased incidence of systemic lupus erythematosus (sle) diagnoses and sle-like symptoms. herein, we characterized the clinical and laboratory features of the patients in our cohort with sle and sle-like disease, with the aim to better understand the pathogenesis by evaluating ifn stimulated genes and neutrophil net formation. methods a retrospective chart review was performed of patients with lof stat to identify those with sle and sle-like presentations, and included clinical features, laboratories including inflammatory markers, auto-antibodies, and complement levels. rt-pcr was performed for interferon stimulated genes (isgs) from neutrophils and pbmcs of lof stat patients with and without sle, and healthy controls. neutrophil net formation was assessed for lof stat patients with and without sle, and healthy controls. results out of a cohort of patients, five patients (ages - ) were identified who carried the diagnosis of sle, and with slelike disease (ages - ). for those with sle, age of presentation was - years, of were female. clinical features included nephritis ( ), alopecia ( ), autoimmune cytopenias ( ), arthritis ( ), discoid rash ( ), and raynaud ( ). all had positive auto-antibodies, and of had low c and/or c . for those with sle-like disease, age of presentation was - , and of were female. clinical features included alopecia ( ), autoimmune cytopenias ( ), raynaud( ), and nephritis ( ). all had positive autoantibodies, and of had low complements. lof stat patients with and without clinical features of sle had increased expression of isgs from both pbmcs and neutrophils. increased spontaneous net formation was observed for lof stat patients both with and without sle symptoms. discussion although autoimmunity is not a common finding in lof stat , we have identified sle or sle-like disease in about % of our cohort, with a high incidence of kidney disease, including one patient who required kidney transplant. the interferon signature and net formation were unexpectedly high in both the patients with and without the sle features. ongoing studies include whole exome sequencing for possible second mutations or modifiers, the role of ige in the kidney disease, and further autoantibody detection. the increased ifn signature raises the question about jak-stat modulation for therapy. chief, genetic immunotherapy section/niaid, nih abstract/case report text chronic granulomatous disease (cgd), a rare immunodeficiency with decreased reactive oxygen species (ros) production, increased susceptibility to infection, and increased mortality is caused by mutations in any one of distinct phagocyte oxidase (phox) components of the nadph oxidase, nox . in the past, identification of the specific protein defect was primarily determined by immunoblotting using specific antibodies to the phox proteins. recently, however, we have shown using fluorescenceactivated cell sorting (facs) analysis of neutrophils in whole blood permeabilized and stained with specific anti-p phox antibody that p phox protein expression was absent in p phox cgd patients and significantly reduced in p phox cgd carriers [kuhns et al. . blood adv. ( ): - ]. these findings demonstrated that determination of phox protein expression by facs analysis provide an alternative to immunoblotting and can aid in the identification of p phox cgd patients and carriers. we now have extended these studies to patients and carriers with p phox cgd. facs analysis of p phox expression in permeabilized neutrophils demonstrated that p phox expression was absent in four patients with different mutations in ncf [two patients homozygous for c. e (+ ) g>a, one patient homozygous for c. _ del aag, p.glu del; and one patient compound heterozygous for the mutations, e (+ ) g>a and c. _ del aagaaggac]. moreover, the expression of p phox in nine p phox cgd carriers was significantly reduced > % compared to expression in neutrophils from healthy volunteers. another cytosolic phox protein, p phox, has been shown to associate with p phox in a : molar ratio [tsunawaki et al. . biochem biophys res comm. ( ): - ]. the expression of p phox was reduced in both carriers and patients with mutations in ncf . despite reduced expression of p phox and p phox, neutrophils isolated from carriers of p phox cgd exhibited normal dihydrorhodamine (dhr) oxidation after stimulation with phorbol ester and fell within the normal range for ros production (measured by luminol-enhanced chemiluminescence) after stimulation with either fmlf, opsonized zymosan, or phorbol ester with one notable exception. included in this cohort of p phox carriers was a p phox cgd patient (homozygous for a gt deletion at the start of exon in ncf ) who also carried a heterozygous damaging mutation in ncf [c. a>t; p. asn ile]. normal ros production in the presence of reduced p phox and p phox expression suggest that these proteins are not rate-limiting components for maximum nox activity in neutrophils. finally, determination of the expression of specific phox components by facs analysis of permeabilized neutrophils from whole blood provides a rapid and alternative approach to immunoblotting to determine the specific protein defect in cgd, and, importantly, one that could be easily established in most clinical labs. funded by nci contract no. n d . the original clinical observation that defined patients with hyper-ige syndrome (hies) was the presentation of cold abscesses ("job's syndrome"), which indicated a deficient inflammatory response. mutations in the stat gene have now been identified in most classic autosomal dominant hies patients, but we do not fully understand how these mutations cause the clinical presentation. since the discovery of stat mutations, research on hies focused largely on the adaptive arm of the immune system and suggested that the innate immune defects could be secondary. for example, the discovery that there is a th cell and il- cytokine deficiency in hies provided a possible explanation to the neutrophil chemotaxis defects in hies, as il- is one of the chemokines critical for neutrophil recruitment in vivo. the goal of this study was to investigate myeloid cells from hies patients. first we used c a, fmlp, il- , cxcl , and cxcl to study neutrophil chemotaxis in vitro. responses to c a, fmlp, and il- were equally robust in hies compared to healthy controls, demonstrating that neutrophils from patients are capable of efficient directed migration in vitro. neutrophils from all hies patients responded to cxcl and cxcl significantly below that of the healthy controls. cxcl and cxcl are cxcr -specific chemokines. these results indicated a neutrophil intrinsic cxcr -specific defect. we also found that patient-derived cells express comparable levels of cxcr on the cell surface, suggesting a cxcr chemokine receptor signaling defect. after identifying a neutrophil defect in hies, we wanted to get a broader view of myeloid cells in hies in addition to identifying the cxcr specific defect. stat is a transcriptional regulator, therefore we performed transcriptional profiling of hies and healthy control-derived neutrophils and monocytes. as it was shown before, the expression of stat was not different between patients and controls, since hies is usually caused by the decrease in stat activity not by decrease in expression. we found, however, an increase in stat and stat expression as well as significant changes in the expression of genes regulated by interferons. increased expressions of stat / in both neutrophils and monocytes likely provide and explanation for the increase in interferon regulated genes. multiple genes were identified as potential regulators of cxcr signaling. the balance between the stat and stat signaling has long known to be a regulator of immune cell activation, especially in t cells, but less studied in myeloid cells. stat and stat / signaling pathways crossregulate each other in healthy cells. we propose that in hies the decreased stat signaling leads to not only changes in expression of effector (e.g. inflammatory) genes, but also decreases expression of genes in the regulatory (negative) feed-back loop, which are required for decreasing stat / activity. therefore, the immune cell defects caused by decreased stat activity are compounded by the increase in stat / activity. increase in stat / signaling can cause pathologies in the absence of stat defects, as well as further decrease stat signaling, thus contributing to hies. interfering with stat / signaling in hies may represent a therapeutic opportunity. abstract/case report text rationale: t-cell receptor excision circles (trecs) testing on newborn screening (nbs) has been vital for identifying patients with severe combined immunodeficiency (scid). we aimed to determine whether one or more abnormal trecs result on a nbs might predict higher mortality rates despite the absence of an identifiable underlying etiology. methods: newborns with a positive trecs nbs result without the diagnosis of scid or q . deletion syndrome born from october to december were included (n= ). newborns were divided into three groups: group infants had a subsequent normal repeat screen (n= ); group infants did not undergo repeat screening as the majority expired before a repeat screen could be conducted (n= ); group infants had a normal initial screen but subsequent abnormal screen (n= ). cases were matched : to controls on gestational age, birth weight, nicu status, race, birth quarter, and birth year. nbs records were linked to birth and death certificate records. demographic characteristics were compared and mortality rates were calculated between the groups. results: the mortality rate of group was . %, group was . % and group was . %. when compared with matched controls, there was no difference in the mortality rate of group when compared to the control group. there was a significant difference in the mortality rate between cases and controls in both group (p < . , % ci . , . ) and group (p < . , % ci . , . ). the apgar scores in group infants were comparable to their matched controls. infants in group (p = . ) and group (p = . ) had significantly lower apgar scores than the controls. the majority of the infants in all three groups were less than weeks gestation, however, group had a higher percentage of infants born very premature (less than weeks). there was no significant difference in maternal age, maternal education, prenatal care status, cigarette use, or maternal steroid use between the cases and controls in all three groups. conclusions: infants with an initial abnormal screen who had a subsequent normal repeat screen did not have an increased rate of mortality compared to their matched controls (group ). however, group infants (with unresolved repeat screen) and group infants (with a first abnormal value on a repeat screen) did have increased mortality rates when compared to their controls. overall, an abnormal trecs level on nbs without a confirmed negative repeat screen, was associated with higher mortality in our study population. further studies will be needed to determine if the trecs assay can serve as a predictor for mortality in newborns with an abnormal screen. abstract/case report text introduction: primary immunodeficiency refers to a heterogeneous group of diseases characterized by altered function or composition of the immune system, and are grouped into adaptive or innate system defect. immunoglobulin g subclass immunodeficiencies (iggscs) are classified as a b-cell-related adaptive system disorder and are therefore associated with recurrent sinopulmonary infections with encapsulated bacteria, presenting with pneumonia, recurrent bronchitis, rhinosinusitis, and herpes zoster. its primary mechanisms are still unclear, although the cause for this deficiency might be related to gene deletions, transcription errors, or be an effect of allotype. igg immunodeficiency reaffirms its association with the patient's clinical condition and is often associated with igg deficiency. objective: to evaluate the prevalence of igg immunodeficiency in ferraroni's clinic, classify it by gender, age, igg dosage and other subclasses, correlate it with igg immunodeficiency and the clinical presentations presented by the patients under analysis. method records of patients with igg immunodeficiency whose clinical pictures were followed throughout years were evaluated, patients aged from to years. all tests were done at the same laboratory and all patients have consented to be part of this study, which has been approved by the ethics committee. results twenty-four patients with igg deficiency, , % (n= ) were women and , % (n= ) were male, with average of and years, respectively. the average of igg was . mg/dl, and that of igg was mg/dl. of the patients evaluated, . % had upper airway infections (sinusitis, rhinitis, otitis and tonsillitis), % herpes simplex, . % asthma. less prevalent cases were reported as . % of patients had bronchiectasis, . % candidiasis and . % herpes zoster. . % presented the association of igg and igg deficiency. discussion: the role of specific igg deficiency in the infectious setting is still unknown, but it usually occurs in association with other isotypic deficiencies and sinopulmonary infections. furthermore, the igg subclass is relevant on the study of environmental antigens -suggesting its involvement with allergic disordersand has been described in association with other diseases, such as chronic mucocutaneous candidiasis, ataxia-telangiectasia and allergic colitis. igg deficiency is related to increased susceptibility to bacterial infections. studies show a correlation between igg and igg immunodeficiency that generally imply clinical features characterized by recurrent infections by encapsulated bacteria. the data obtained through the analysis of patients' charts corroborated this information, since it was evident that most of the patients had really similar clinical conditions. conclusion: igg deficiency has a direct correlation with higher prevalence of upper airway infections, such as rhinitis, sinusitis and pneumonia, and with an increased incidence of allergic disorders, here presented by our cohort. additionally, research suggests that hies may cause impaired cd + t cell function. we hypothesized that a low percentage of both th and th cells would be predictive of hies and would differentiate hies from atopic disorders. to evaluate this hypothesis, we examined the percentage of th , th , and ifng+cd + t cells, laboratory parameters, and genetic diagnoses from a large cohort of patients to determine which parameters distinguish patients with stat loss-of-function variants. methods: we conducted a retrospective, multi-institutional chart review of over patients who received a th assay at the medical college of wisconsin clinical immunology research laboratory. the th assay is performed by activating pbmcs with pma/ionomycin/brefeldin a and staining for cd , cd , ifng and il- a. the following parameters were included in the chart review: the percentage of th , th , and cd +ifng+ cells, immunoglobulin levels, atopy scores, infectious history, and genetic diagnoses. results: using logistic regression, we demonstrated that the percentage of th , cd +ifng+, and th cells were positively correlated with age, and percentage of cd +ifng+ cells was higher in females than males. we found that the percentage of th and th cells were decreased in both atopic disease and hies, with hies having the lowest values. interestingly, one subject with a stat gain-of-function (gof) variant had an elevated percentage of th and th . in addition, we determined that ige levels were inversely correlated with the percentage of th , cd +ifng+, and th cells, while iga and igm were positively correlated with the percentage of th cells. several different monogenic defects characterized by increased fungal infections exhibited a low percentage of th including tatton-brown-rahman syndrome and cornelia de lang syndrome. conclusions: we confirmed that the percentage of th cells is low in both hies and atopy in a large cohort of subjects, and that the percentage of th cells may be helpful in distinguishing hies from atopic disease. however, since the percentage of th , cd +ifng+, and th cells correlate with age, caution should be used when testing young children. the inverse correlation between ige levels with th and th responses suggests that similar pathway(s) may drive both hies and atopy. additionally, the decreased th responses in stat lof and increased th responses in stat gof hies raise questions about the role of stat in regulating ifng levels. we also identified patients with different genetic disorders with fungal infections in which the th percentages were low, suggesting that the th test may be useful in evaluating individuals with unusual fungal infections. abstract/case report text background:primary and secondary autoimmuune neutropenia (pan/san) are well described entities. several autoimmune neutropenias do not fit the criteria of either pan or san showing peculiar characteristics mainly for older age at onset and/or for duration of the disease; moreover they are not associated , at least at the beginning, with autoimmune markers/diseases aim of the study: to describe a cohort of subjects affected with autoimmune neutropenia, defined as "atypical" (aan), registered in the italian neutropenia registry (inr) and to compare these data with those from subjects diagnosed with pan still in the inr. patient and methods: subjects with neutropenia and positivity of indirect antibodies against neutrophils (registered in the inr from to ) lasting for more than years, or diagnosed after years of age ( up to y), without any associated autoimmune, signs/markers were considered eligible for the present study. results: data from patients were collected: / subjects ( %) were defined as aan and / ( %) as pan. among aan affected patients %, were "long lasting" aan, while % were defined as "late onset" aan .the degree of neutropenia in aan group was mild in %, moderate % and severe in % of the subjects . leukopenia at onset was a common hall mark seen in % of aan patients (median values /mm³ ; range - /mm³ ) especially in the "late onset" aan if compared with pan and " long lasting" one ( p= . ). as for clinical features, almost half of the aan cohort suffered from recurrent or "significative infections", while severe episodes (namely sepsis, meningitis , osteomyelitis , pneumonia, deep abscess or flemmon) were shown in % being more frequent, but non significantly higher than those reported in the pan group ( % )( p=ns) interestingly, recurrent apthae were significantly more seen in the "late onset" aan group if compared with the "long lasting" aan (p= . ). during follow up, markers and/or symptoms of autoimmunity appeared in % of the aan cohort, being another element of peculiarity in respect to pan (p < . ). as for immunological pattern in aan, immunoglobulin values were lower than the references for age in %,while were above them in % of the cohort . lymphocytes subsets evaluation showed decreased value of cd +cd + cells in % of cases, followed by depletion of cd -cd +cd + subtype in %, cd +cd + in % of cases and cd + cd + in % . preliminary study on b memory and t-reg cells values, showed a quantitative deficiency respectively of in % and % of the studied subjects. mutation analysis performed by ngs in % of the subjects identified pathogenic variants of : taci ( ), tinf ( ) and lrba ( ) .comparison between pan and aan is detailed in table . conclusions atypical neutropenia in childhood is a disorder which show many difference with pan; indeed appears an epiphenomenon of a complex immunological disturbances rather than a disease itself. occasionally mutations of genes of immunodeficiency/disimmunity can be demonstrated abstract/case report text background: medications treating ra typically include systemic corticosteroids used to treat inflammation flares, and disease modifying therapies (dmards). traditional dmards include methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine. recently, biologic/immuneresponse modifiers have come to the forefront for overall therapeutic benefit, however, an unfortunate side-effect may be the risk of increased immunosuppression. this study seeks to determine the occurrence rates of immune deficiencies among patients initiating ra therapies. methods: using the pharmetrics plus commercial claims database from - , ra patients (icd- and - codes: m , m ) over the age of were indexed on their first use of a new biologic therapy. all patients were required to have enrollment six-month pre and one-year post index. cohorts of patients were grouped by medication: methotrexate, adalimumab, etanercept, and rituximab. ra patients receiving adalimumab, etanercept, and rituximab were allowed concomitant use of methotrexate, but could not use any other biologic medications in the post period. a minimal adherence of % was required of all biologic treated ra patients. an additional cohort of ra patients untreated with biologic therapies was indexed on their first ra diagnosis within the time window and used as a control. ra patients with comorbid conditions who would also require biologic treatment were excluded including crohn's disease and ulcerative colitis. between group comparisons were made with the no treatment group as the referent. to account for differences in age, gender, and elixhauser comorbidity conditions patients in each cohort were matched : to the rituximab group. results: , ra patients met inclusion criteria: , in the methotrexate group, , receiving etanercept, , receiving adalimumab, and receiving rituximab. a total of , in the treated groups and , in the no biologic treatment group. demographic information including age and gender were significantly different but numerically similar between the groups, with rituximab group having the highest proportion of female patients but limited dispersion with the lowest proportion being in the etanercept group. healthcare utilization metrics highlighted a significantly higher average number of office visits ( . , sd: . vs no treatment . , sd: . , p < . ) and a higher proportion of rituximab patients being hospitalized ( . % vs no treatment . %, p < . ). the diagnosis of immune deficiency was highest among the rituximab group with . % followed by methotrexate . %, adalimumab . %, etanercept . %, and no treatment . %. after matching, similar rates were seen for healthcare utilization to the pre-match results. the post-match odds of being diagnosed with immune deficiency were significantly greater for the rituximab group (or . , ci: . - . ) than the no treatment group. conclusions: the purpose of dmards is to modulate the immune system and decrease autoimmunity in ra. however, this treatment may lead to significant immunosuppression. this study suggests that treatment with certain biologic/immune-response modifier therapies may be associated with higher rates of healthcare utilization. in particular, the increased post-treatment diagnostic coding of immune deficiency demonstrates the heightened awareness among healthcare providers of the chronic immunosuppressive potential of rituximab. evaluation of potential secondary immunodeficiency pre-and post-dmard use should be incorporated into routine practice. abstract/case report text introduction: autoimmune lymphoproliferative syndrome (alps) is a rare inherited disorder of lymphocyte homeostasis due to a fasmediated apoptosis and characterized by non-infectious and nonmalignant lymphoproliferation, autoimmunity, and secondary malignancies (national institute of health criteria). in spite of recent progress, one third of alps patients still remain gene orphan and they have been previously categorized as alps-u. in some cases, patients fitting alps diagnostic criteria have been shown to carry mutation on genes involved in other immune-dysregulation syndromes. aims: the aim of this study is to compare the clinical and immunological features, and the outcome of a cohort of alps patients with mutations on the typical causing genes (fas, fasl, fadd and casp )-here defined as alps-g -vs the ones without a molecular diagnosis or carrying mutations on other genes (both defined as alps-u). patients and methods the demographic, clinical, biochemical, genetic informations and details about treatment are derived from the alps italian network. search of mutations was performed with sanger pcr and/or next generation sequencing techniques (extended to immunodeficiency genes panel). results: alps patients were registered in our data base; the genetic analysis was performed in subjects ( %): / pts ( %) were alps-g and the remaining ( %) alps-u. six-teen out of ( %) alps-u patients resulted to carry mutations on other genes (lrba, stat +cecr, ctla , baffr, taci, nmlrc , ikbkg, gaucher), and the remaining ( %) were negative. the alps-u subjects showed a more complex phenotype compared to the alps-g group, which was characterized by multi-organ involvement (p= . ) and positivity of autoimmune markers (p= . ). (table ). cytopenia affecting one or more haematopoietic lineages was present in both groups ( % and %) with no significant difference, apart from lymphocytopenia that was more frequent in alps-u group (p= . ) ( table ) . as for lymphocyte subets and immunoglobulin dosage no differences were shown within the two groups. vitamin b and il- were more frequently raised in alps-g group (p= . , p= . ) (table ). four out of ( %) patients did not require any treatment. first-line treatment (steroid or intravenous immunoglobulins) controlled the disease only in / ( %) cases. the response rate to second line therapy -micofenolate mofetile (mmf) or rapamycin-was % and % in alps-g and alsp-u group, respectively. moreover, target therapies or drug combinations were more commonly applied in alps-u subjects (p= . ) ( table ) . conclusions: our study showed that alps-u subjects, despite the alps phenotype, represent distinct clinical entities and that genes associated with other immune-dysregulation syndromes are frequently represented in this group ( / , %). the identification of such disorders is crucial for the management of second-line treatment and/or the administration of target therapies abstract/case report text background: we have shown previously that allergic reactivity to ovalbumin (ova) could be regulated in mice following perturbation of immune networks using combinations of an immune ig along with antiidiotypic ig. we have explored features of this regulation including: its persistence after cessation of administration of combined igs; the ability of heterologous igs to produce immunoregulation; a role for treg induction in regulation; and the ability to attenuate responses in mice presensitized to an allergic stimulus. methods: balb/c mice were sensitized to ova. mice also received weekly injections of immune ig or anti-idiotype ig (at separate sites) from either homologous (mouse) or heterologous (human) sources. in the latter case pooled ivig (given im, hence hereafter imig) was used as a source of anti-idiotype ig, and human anti-tet as immune ig. injections of the ig were given from the time of ova sensitization (to attenuate development of immunity), or after pre-sensitization of mice (to attenuate existing allergic responses). all mice were assayed for development of ova-specific serum ige and igg, as well as the production of ova-induced il- , il- , il- , il- and il- in splenocytes cultured for hrs. in studies examining possible mechanism(s) responsible for inhibition of immunity mice received, in addition to the ig treatments described, infusion of depleting anti-cd , and/or anti-cd antibodies, or a mab to tnfsfr , known to expand tregs implicated in regulation of allo immunity. results: combinations of both heterologous and homologous immune igs and anti-idiotype igs attenuated ova allergic responses in both naïve and pre-sensitized mice. this attenuation persisted in mice greater than weeks after cessation of treatment with the igs used. finally, depletion of either cd or cd cells ameliorated the suppressive effect seen, while the combination of anti-cd and anti-cd essentially abolished suppression. suppression was further enhanced by anti-tnfsfr mab. conclusions: we conclude that the combine ig treatment protocols used produced a long-lasting suppression of allergic immunity, even in pre-sensitized animals. the effects seem to depend upon induction and expansion of tregs and represents a novel approach to treatment of allergic disease in humans and other animals. abstract/case report text background wiskott-aldrich syndrome protein (wasp) is found in the cytoplasm of hematopoietic cells but can transit to t lymphocyte nuclei at distinct developmental timepoints. wasp deficiency is a rare, x-linked combined immunodeficiency disease. affected patients display qualitative but not quantitative t cell defects. we report two immune deficient subjects with nearly identical exon frameshift mutations in was, the gene encoding wasp. one subject lacked circulating t cells, the other possessed several distinct cd t cell populations each expressing quantitatively different amounts of wasp. objective to determine how similar was mutations can cause scid in one person and generate b and t cells with heterogenous wasp expression in another. methods to identify somatic was mutations, we deeply sequenced was exons, introns, promoters and ' untranslated regions at , read depth in genomic dna from various b and t cell populations of each subject and their unaffected relatives. we confirmed genomic variants were transcribed and translated by sequencing was transcripts and analyzing wasp in primary cell lysates, both fractionated and not. to model our subjects' diseases we transfected primary cells and cell lines with mutant was transcripts and then measured viability and nuclear localization via confocal microscopy. results deep sequencing of genomic dna revealed all of subject one's cells carried the same germline exon frameshift was mutation. the mutation was incorporated into subject one's was transcripts and translated into a truncated form of wasp, which was relegated primarily to the cell nucleus. subject two possessed three distinct cd t cell subsets that each carried either the germline exon frameshift was mutation or a variety of somatic mutations that circumvented frameshift wasp expression. evasion strategies included exon skipping, adoption of a cryptic exon splice site and reversion to wild type amino acid sequence. subject two incorporated somatic mutations into was transcripts which encoded either stable near full-length proteins or unstable non full-length ones. subject one's sister and subject two's mother, who both carried the germline exon frameshift mutation, produced only wild type transcripts and proteins. conclusion we report two patients with was mutations encoding truncated wasp. if expressed, truncated wasp localized to the cell nucleus, and this was associated with t cell developmental arrest and severe combined immune deficiency. if, through a variety of epigenetic and somatic strategies, t cells could avoid expression of truncated wasp, they would survive but display phenotypical abnormalities and functional defects. patients with pidds show a higher susceptibility to hematopoietic malignancies, in particular to non-hodgkin lymphomas (nhl) that, generally, account for approximately - % of paediatric cancers and their incidence increases with age. recently new gene defects responsible for pidds with lymphoproliferation as a key clinical sign have been identified. our goal is to investigate possible immune-mediated mechanisms underlying malignant lymphoproliferation in children who did not show other typical symptoms of pidds. we retrospectively selected and reviewed the clinical history of nine patients with nhl ( burkitt lymphoma, large b cell lymphoma and lymphoblastic tcell lymphoma). immunophenotyping and exome analysis of known pidds genes were performed after lymphoma remission. six out of nine patients showed a mild hypogammaglobulinemia at time of presentation, not noticed before. moreover, one patient had history of recurrent respiratory infections, one of hematologic autoimmunity and two of nine were ebv-positive at diagnosis. preliminary results show an aberrant b cell phenotype in four patients; exome analysis reveals a novel heterozygous genetic variation in ikzf gene in one patient with burkitt lymphoma and autoimmune cytopenia was identified. concerning the remaining patients, further studies are ongoing. a detailed review of clinical history of paediatric patients affected from nhl as well as an impaired immunophenotyping can be important indicators of immune-mediated disorder underlying lymphoproliferation and helpful signs of possible pidds that should promptly be investigated by genetic analysis. this will allow an appropriate diagnosis and disease management. abstract/case report text introduction: caspase activation and recruitment domain (card ) encodes a scaffold protein that links antigen receptor activation to intracellular signaling. dominant heterozygous loss of function (lof) mutations in card cause a syndrome of severe atopic dermatitis, elevated ige, and allergic disease. atopic dermatitis can be difficult to control leading to substantial morbidity. dupilumab is a humanized monoclonal antibody that blocks il- and il- signaling approved for treatment of refractory atopic dermatitis. we present a case of a -year-old female with card deficiency successfully treated with dupilumab. case: a -year-old puerto rican female with history of recurrent sinopulmonary infections with episodes of pneumonia, moderate persistent asthma, food allergies, recurrent skin boils, and severe atopic dermatitis was referred for further management and evaluation for autosomal dominant hyper-ige syndrome (ad-hies). her atopic dermatitis was refractory to conventional therapy with topical corticosteroids, twicedaily emollient use, and bleach baths; it was also refractory to immunosuppression with mycophenolate mofetil and cyclosporine. on exam the patient exhibited coarse facial features and a high palate. she had eczematous lesions on the face, trunk, and extremities (scorad ). laboratory evaluation showed: eosinophilia ( cells/ul), elevated ige (> ku/l), low igm ( mg/dl), and elevated iga ( mg/dl). lymphocyte subsets and mitogen response were normal but antigeninduced proliferation was abnormal. autosomal dominant hyper ige score was indicating a high likelihood of ad-hies. no mutations in stat were identified and th cell expression was elevated. dedicator of cytokinesis (dock ) deficiency was also considered but dock protein expression was normal. further genetic testing revealed an base pair deletion in card (c. _ del) predicted to be pathogenic. the combination of the patient's phenotype and large deletion was consistent with card deficiency. despite continued immunosuppression with cyclosporine and aggressive skin care, the patient's atopic dermatitis was still severe and poorly controlled. off label (patient < years) treatment with subcutaneous dupilumab mg every weeks was initiated. at last follow-up, months after dupilumab start, the patient had substantial improvement in dermatitis with clear skin on the face, trunk, and extremities (scorad ). cyclosporine was discontinued and topical medications were applied less frequently. discussion: hypomorphic heterozygous dominant negative loss of function mutations in card have recently been associated with severe atopic dermatitis and allergic disease. treatment of atopic dermatitis in card deficiency remains challenging, but dupilumab appears to be an effective alternative to refractory disease. longer follow-up and a larger cohort of card -lof patients treated with dupilumab are necessary to understand the long-term efficacy and safety for use of dupilumab in these patients. abstract/case report text purpose: the micromilieu within premalignant respiratory papillomas supports persistent hpv / infection and disease recurrence in recurrent respiratory papillomatosis (rrp). these patients show polarized (th -/treg) adaptive immunity in papillomas and blood, enriched immature langerhans cell (ilc) numbers, and overexpressed cox /pge in the upper airway. to better understand the adaptive and innate dysregulation in rrp, we studied blood-derived monocytes, ilcs, and tissue-derived ilcs from rrp patients and controls. experimental design: monocyte subpopulations were isolated, differentiated into ilcs, activated, and then assessed by flow cytometry. monocytes were induced to differentiate into ilcs with/ without added pge , and then activated by il- γ, pge , pge +il γ, or lps. ilc cd expression was identified by flow cytometry. monocyte-derived ilcs, papilloma, foreskin, and abdomen skin ilcs, were also analyzed by qpcr for select chemokine/cytokine mrna expression after isolation, hrs later in culture, and again after poly(i:c) or tnfα stimulation. results: the three monocyte sub-populations differed between patients and controls, and patients' monocytes generated fewer ilcs. classical monocytes generated most, but not all ilcs. pge levels were higher in rrp plasma, and added pge reduced control, but not patients' monocyte-ilc differentiation. pge had no effect on ilc maturation identified by cd expression. papilloma-derived ilcs expressed low ccl- , and high ccl- mrna and were unresponsive to poly(i:c) or tnfα. tissuespecific cytokine/chemokine responses between ilcs from papillomas, foreskin and abdominal skin differed. only papilloma ilcs expressed il- γ after isolation, and they up-regulated ccl mrna hrs later without further stimulation. conclusions: monocyte/ilc innate immunity is impaired in rrp, in part due to increased pge exposure. the immunosuppressive papilloma micromilieu likely alters ilc responses that skew, hpv / -specific th /treg adaptive immunity in rrp. abstract/case report text introduction: familial mediterranean fever is a hereditary auto inflammatory disorder that typically manifests with recurrent fevers, abdominal pain and in some patients there is an associated with amyloidosis leading to eventual renal failure. while there are several common mutations in the mefv gene that when homozygous give these classic symptoms, patients with atypical mutations or heterozygous mutations often have a different clinical course. we present identical twin siblings with compound heterozygous mefv mutations but differing clinical phenotypes. case description: the index patient is a year old girl, conceived via ivf, who began having fevers at age . . her fevers occurred every weeks for months before she was referred to immunology for evaluation. her parents describe her as happy and otherwise not ill appearing during these episodes. genetic testing for familial mediterranean fever revealed compound heterozygous e q and p s mutations in the mefv genes. initiation of colchicine therapy in the affected sibling has resulted in a complete resolution of her symptoms. a trial off colchicine resulted in return of cyclic fevers. her identical twin sister was also tested, and carries the same mutation, but is still asymptomatic. this created great concern amongst their parents who had genetic testing prior to undergoing ivf that revealed no parental mutations in mefv. in consultation with genetics the mother was tested again through the same laboratory that had performed testing on the children. this revealed an identical mutation in mom who is also asymptomatic. conclusions: although classic homozygous mefv mutations have resulted in well described fever syndromes, there is considerably less data on heterozygous and compound heterozygous mefv mutations. in these two identical siblings only one patient has a classic manifestation of familial mediterranean fever. while it is possible that the other twin will develop similar symptoms later on in life, it is also possible that another factor is necessary to trigger symptoms in this unusual genetic presentation of fmf. in addition this case highlights the importance of understanding the testing method used by the laboratory performing the genetic testing. while the mother was initially reported as negative the laboratory that performed her testing only tested for the most common mefv mutations. more complete testing, that included the entire gene sequence, revealed that she did contain an mefv mutation in e q, which although more rare is thought to be pathologic when combined when combined with a second mutation. abstract/case report text there are several lines of evidence that link the pi k/akt/mtor signaling pathway to primary immunodeficiencies. hyperactivation of the pi k/akt/mtor/s k signaling pathway in immune cells can be the consequence of dominant gain-of-function mutations in the genes encoding for pi kδ that cause the activated pi kδ syndrome (apds). patients with these mutations may develop immunodeficiency and immune dysregulation as well as neurodevelopmental delay and growth retardation. in addition, mutations of genes within the pi k-akt-mtor pathway were also known to cause megalencephaly and segmental cortical dysplasia. mutations in akt , a member of the akt family of proteins and a downstream effector of pi k-mediated signaling, was shown to be associated with autosomal dominant megalencephalyassociated syndromes. here we describe a year old girl, born to consanguineous healthy parents, who presented with megalencephaly, developmental delay, hypotonia, cervical lymphadenopathy and hepatosplenomegaly. the patient had recurrent hospital and icu admissions for idiopathic thrombocytopenia (treated with ivig), recurrent laryngitis, recurrent peritonsillar abscess, preorbital cellulitis, conjunctivitis with purulent discharge, otitis media, pneumonia with pleural effusion (required drainage), metapneumovirus pneumonia with respiratory failure, recurrent skin cellulitis, and abscesses that grew mrsa (required drainage). in addition, the patient is known to have asthma and allergic rhinitis. mri of the brain showed megalencephaly, ventriculomegally, thin and dysplastic corpus callosum, a normal cerebellum, and myelination appropriate for age. immunoglobulin levels, lymphocyte subsets and the oxidative burst test were all within normal limits. cmvand ebv were not detected. bacterial cultures grew mrsa (skin), strept. pneumoniae, h. influenzae, and e. coli (urine). extensive metabolic workup was done, which was inconclusive (metabolic/mitochondrial diseases). whole exome sequencing identified an akt variant c. g>a; p.(asp asn) in exon . the variant was identified in the patient but not in the parents and it was confirmed by sanger sequencing. further molecular testing concluded that the variant is caused by a de novo mutation during early development. although pathogenic variants in akt gene were shown to be associated with megaloencephaly-associated syndromes, no associations with immune deficiency have be reported. functional studies will be pursued to confirm the link between the clinical phenotype and the identified variant in the akt gene. complex is a critical signalling adaptor that regulates lymphocyte activation, proliferation, survival, and metabolism. primary immunodeficiencies affecting each component (termed 'cbm-opathies') result in broad clinical manifestations ranging from combined immunodeficiency (cid) to atopic disease or lymphoproliferation. we present the laboratory and clinical findings of two canadian first nations patients found to be homozygous for the same novel card mutation (c. c>t; p.r *) causing complete card deficiency. results: we recently identified an -month-old boy who presented with a severe case of entero/rhinovirus bronchiolitis with interstitial lung disease and a -year-old boy with a history of severe pulmonary infections with bronchiectasis (including pjp), chronic sinusitis, candidiasis, invasive bacteremia, and severe ileo-colitis and oral ulceration requiring total colectomy. testing of both patients demonstrated absent tregs, elevated naïve b cells with absent memory b cells, and panhypogammaglobulinemia. next generation sequencing revealed that both patients were homozygous for the same novel variant of card (c. c>t; p.r *), which rendered card protein undetectable by immunoblot. card deficiency was confirmed by stimulating patient b cells with phorbol -myristate acetate (pma) and ionomycin and immunoblotting for signalling proteins in both the nf-κb (ikkα/β, iκbα, p ) and mapk (mek / , mkk , jnk / , erk / ) pathways as well as cleavage substrates of the malt paracaspase (relb, cyld, bcl , hoil ). nf-κb and jnk activation were completely absent and m a lt p a r a c a p a s e a c t i v i t y w a s l o s t . f u r t h e r m o r e , c oimmunoprecipitation experiments revealed that card was required for optimal malt association with bcl in response to stimulation. to define the impact of card deficiency on the b cell transcriptome, rna-seq experiments were performed. this revealed an inability to upregulate critical genes involved in immunity and tolerance (e.g. cd lg, ctla , il , il ), decreased enrichment in cytokine pathways (e.g. ifn-α, il- , tgf-β), and decreased enrichment in malt -dependent genes. furthermore, rna-seq confirmed the developmental block observed in patient b cells and suggested that b cells were halted at the centroblast to centrocyte transition. both patients ultimately underwent hematopoietic stem cell transplantation (hsct), which restored lymphocyte signalling and activation as measured by nf-κb, jnk, and malt paracaspase substrate cleavage. conclusions: we have presented the most comprehensive clinical and molecular characterization of human card deficiency to date. these two cases highlight the crucial role of card in regulating b cell development, function, and humoral responses, as confirmed by signalling and transcriptomic analyses. furthermore, hsct is potentially helpful for these patients as assays performed on post-transplant cells demonstrated restored signalling and activation. abstract/case report text introduction: primary immune deficiencies (pid) can have a significant impact on the quality of life of patients and their families. as more patients with pid are surviving to adulthood, the need to monitor them closely and ensure they are transitioned appropriately is even more crucial. we compared the perspectives of pediatric and adult immunologists toward the transition of patients with pid at our institution. methods: pediatric allergy/immunology providers at lurie children's hospital and adult allergy/immunology physicians at northwestern university both in chicago, il completed respective surveys anonymously (www.surveymonkey.com). questions were derived from the validated 'attitude' and 'quartt' instruments for transition. respondents were asked to rate their level of agreement on a -point likert scale, ranging from strongly disagree to strongly agree. results: overall, pediatric and adult providers participated (response rate . %). of total respondents, % thought the transition process should be initiated at age - . about % of the adult immunologists selected and older, whereas pediatric providers would begin earlier; . % of pediatric providers note they would initiate transition at age - . both pediatric and adult immunologists agreed that patients should be transferred when the provider felt they were ready ( %) and when they were in stable condition ( %). both adult and pediatric immunologists selected transfer of complete medical file as a preferred communication method for transition. other strategies preferred by adult providers were a referral letter with brief summary of medical history ( . %) and staff meeting with pediatric and adult immunologists ( . %), whereas pediatric providers would prefer a joint outpatient dedicated transition clinic ( . %). pediatric and adult immunologists, patient, parent, and transition liaison were considered the most important active participants in the transition process. the most prominent barriers to a formal transition were unavailability of a transition coordinator or nurse specialists ( %) or of all disciplines of the interdisciplinary team ( %), and limited time ( %). on the other hand, limited demand (too few patients) was strongly rejected as a barrier. all participants agreed during transition patients should be educated about medications and their side effects, their condition and related potential future complications, and symptoms that require seeking health care. over % of participants also agreed that education about how to set up ivig and further insurance needs were important. all participants agreed that the transition process should include assistance on how to promote the patients' independence and self-management skills, medication management/adherence, and understanding of immunoglobulin replacement and side effects. other important transition components included knowing how frequently lab draws are required for monitoring ( %) and having a written individualized transition plan ( %). pediatric providers also thought having an email or telephone help line would be beneficial. conclusion: this study adds to the growing body of literature examining attitudes of immunologists toward transition, and it highlights important transition components and barriers. further work is ongoing to determine the transition needs identified by patients and parents and define markers for successful transfer in order to build a transition policy at our institution specific to immunodeficiency patients. abstract/case report text introduction: bronchiectasis (bq) is an abnormal and irreversible dilatation of bronchi secondary to repeated cycles of airway infection and inflammation. predominantly antibody deficiency is the main group of primary immunodeficiencies (pid) in adults and had been reported up % of subjects with non-cystic fibrosis bronchiectasis (ncfb). hypergammaglobulinemia (igg level higher than , mg/dl) had been observed in . % of ncfb cases (retrospective data). diagnostic delay and inappropriate management of patients with predominantly antibody deficiency can lead to irreversible lung damage or even death from serious infections. the effect of hypergammaglobulinemia on ncfb is unknown. here we present the frequency of immunoglobulin abnormalities (pad and hyperigg) in adults with ncfb in cali, colombia. methods: we present preliminary data of a descriptive prospective study that will include patients with ncfb. women and men > and < years old will be included. all volunteers will be evaluated by a clinical immunologist, complete blood count and serum igg, iga, igm and ige levels will be determined. according with clinical suspicious, igg subclasses, anti-pneumococcal igg response and b cell subpopulations will be performed. the project will be executed in months. written informed consent has been obtained for all subjects included. this project count with irb approvals at universidad del valle and hospital universitario del valle. results: a total of ncfb cases have been included in the study. the mean age was . years ( - years) with a female:male ratio : . moderate-severe dyspnea was observed in / cases (medical research council -mrcdyspnea scale to ). recurrent pneumonia was found in / cases ( %). the main etiologies of bronchiectasis were: post-infection / ( %); idiopathic / ( %); autoimmunity / ( %); primary immunodeficiency / ( %) asthma / ( %); copd / ( . %); primary ciliary diskinesia / ( %); reflux / ( %) and others. primary immunodeficiencies, . % of ncfb cases, were classified as: predominantly antibody deficiency ( cases) including cvid cases, igm deficiency cases, igg subclasses deficiency case, selective iga deficiency case and hypogamaglobulinemia case. combined immunodeficiency (dock deficiency) case. interestingly igg hypergammaglobulinemia was observed in / cases ( . %) suggesting humoral immune response deregulation. conclusion to the best of our knowledge this is the first prospective study evaluating the etiology of non-cystic fibrosis bronchiectasis (ncfb) in colombia. hypergammaglobulinemia and predominantly antibody deficiencies affect % of adults with ncfb in colombia. our study reinforced the necessity to evaluate humoral immune response in patients with bronchiectasis. conflict of interest: authors disclosure any potential financial conflict of interest related to this abstract. acknowledgements: this investigator-initiated research was supported with a grant from baxalta us inc, a member of the takeda group of companies bt - /iir-col-bxlt- . abstract/case report text background: early-onset inflammatory bowel disease (eoibd) is defined as ibd diagnosis in children less than years of age. the occurrence of autoimmune disease in children (where it is relatively rare, compared to adults) may be caused by a highrisk predisposition gene (monogenic disorders). mayo clinic children's center has a unique care model, where a patient who is referred for eoibd meets with a team of physicians, including gastroenterology, immunology, genetics, and nutrition. we describe our experience of our eoibd clinic from an immunologic perspective. methods: we conducted a retrospective cohort study through emr chart review of pediatric patients who were referred to our eoibd program ( - ). first diagnosis of ibd under the age of was the inclusion criteria. we assessed the presentation, clinical correlates, and immunologic evaluation. approval was obtained from mayo's institutional review board. data abstraction and analysis was done using the software jmp. results: pediatric patients met the inclusion criteria, with ( %) males and ( %) females. the median age of ibd diagnosis was years ( - years range). median values and the distribution of variables used in the nutritional and immune evaluation were assessed (fig ) . nutritional assessment was remarkable for low to low normal hemoglobin and ferritin levels. vitamin d and albumin levels were overall within the normal range. growth parameters indicated that the median bmi percentile was ( - ). with immune and genetic screening, one patient was found to have x linked chronic granulomatous disease (cgd). immune evaluation of other patients was overall within normal limits. fecal calprotectin served a reliable non-invasive biomarker for inflammation with the median being . ( . - . ). of these patients underwent gi pathogen panel testing of which ( %) tested negative, four ( %) tested positive for c. diff, and two ( %) others to shiga toxin-producing e. coli. it was also noted during the chart review that most patients had poor disease control despite undergoing treatment with various anti-inflammatory and immunosuppressive drugs. the patient diagnosed with cgd underwent bone marrow transplantation. a higher proportion of patients referred to our program in recent years underwent a more comprehensive multispecialty evaluation. conclusion: awareness of monogenic causes of inflammatory disorders in children has increased in recent years. it is also important to rule out intestinal infections that can act as ibd mimic. identifying monogenic disorders and other ibd mimics helps with targeted therapy and symptom improvement in these patients who have a difficult-to-treat disease. the group of children with eoibd, regardless of whether there is an inborn error of immunity, suffers from very high morbidity and a high burden of disease. comprehensive immune-nutrition assessment of eoibd patients paves way for further in-depth immunogenic assessments and allows for global management. abstract/case report text background: chronic granulomatous disease (cgd) is a primary immunodeficiency (pid) affecting the nadph oxidase system in phagocytes resulting in increased susceptibility to catalase-positive organisms. holland presented the first report of dual impact of cgd and hiv in a patient with disseminated nocardiosis. because their cgd patient admitted to history of iv drug use, he was frequently screened for hiv. case: a -year-old african american male with known cgd tested positive for hiv by western blot in the ed in when he presented with complaints of intermittent fever and cervical lymphadenopathy. his cgd was diagnosed by nbt blood testing at years of age. he had frequent skin infections and fever prior to diagnosis. clinically, he did so well that his cgd diagnosis was questioned by his immunologists. however, cgd was confirmed by additional abnormal nbt tests and, ultimately, dhr flow cytometry testing. during his second infectious disease consultation for hiv, at age , he disclosed that he was bisexual. previously, the patient was screened for hiv and hiv antibodies in due to anal fissure. he was screened again in for marked cervical and supraclavicular lymphadenopathy. his cd + t cell absolute count was noted to be low ( /mm ) in at age . until , his prior hiv screenings were negative. during his cgd treatment course as an adult, he was known to be variably adherent with administration of interferon gamma due to adverse effects, particularly pain at the site of injection and malaise. at the time of his positive hiv western blot in , his cd + t cell count was / mm . after starting hiv antiretroviral treatment, his viral load became undetectable. at age , he had burkholderia cepacia pyelonephritis resulting in left nephrectomy. sepsis from b. cepacia was fatal (positive blood cultures without known primary source) in at age . his recent viral load was still undetectable and cd + count was /mm . summary: our case reveals the complexities of treating a patient with both primary and acquired immune deficiencies. it illustrates the importance of taking a thorough social and sexual history starting in adolescence, including those patients with pid. patients with pid should be followed closely by a primary care physician, in addition to an allergist-immunologist and infectious diseases specialist, to ensure age appropriate medical and developmental screening. the recognition of pids is improving due to better screening, awareness, and treatment. currently, the rate of hiv infection is highest among young homosexual african american males. it remains important to understand the epidemiology of primary and acquired immunodeficiencies to best identify those at highest risk. ( ) submission id# phosphatase and tensin homolog (pten) hamartoma tumor syndrome identified by newborn tcell receptor excision circle screening for severe combined immunodeficiency δ) subunits that are critical for cellular signaling. heterozygous gain-offunction (gof) mutations in pik cd (encoding p δ) result in activated pi k δ syndrome (apds ), while heterozygous loss-of-function (lof) mutations in pik r (encoding p α) result in activated pi k δ syndrome (apds ). given its role as a negative regulator of the pi k signaling pathway, heterozygous lof mutations in pten (encoding phosphatase and tensin homolog, pten) result in a clinical phenotype that approximates that of apds /apds and is therefore referred to as activated pi k δ syndrome-like (apds-l). however, sequelae of heterozygous pten lof mutations extend beyond the immune system and include a group of disorders collectively known as pten hamartoma tumor syndrome (phts). although severe t cell lymphopenia at birth would be unexpected in apds , apds , or apds-l, below normal t cell receptor excision circle (trec) counts have been reported in apds , but only in individuals outside of the neonatal period. herein, we describe an infant girl with a low trec count at birth who was found to have phts. case description: a -day-old girl, born at a gestational age of weeks, was found to have a low trec count of /microliter (normal => ). a second trec count obtained at weeks of age resulted as /microliter. arguing against a diagnosis of severe combined immunodeficiency (scid), flow cytometric analyses performed at weeks of age revealed only a modestly diminished cd + t cell count ( /microliter; cd + and cd +) with a normal percentage of naïve and memory cd + t cells ( % and %, respectively). by months of age, her cd + t cell count dropped to /microliter, which was accompanied by a significantly decreased percentage of naïve cd + t cells ( %). sequencing and deletion/duplication analysis was pursued via a commercially available -gene panel aimed at genetically defined primary immunodeficiency (pid), in which no clearly pathogenic mutations were identified. over the following months, the patient was noted to have macrocephaly, tall stature ( th percentile), axial hypotonia, and gross motor delays. sequencing and deletion/duplication analysis was then pursued via a commercially available -gene panel aimed at genetically defined macrocephaly and overgrowth syndromes, in which a hemizygous pathogenic mutation in pten (c. a>g, p.gln arg) was identified. subsequent flow cytometric analyses demonstrated findings characteristic of apds-l, including expanded transitional and cd lo b cells, decreased isotype switched memory b cells, increased effector memory t cells, a lowered threshold for intracellular calcium mobilization upon b cell receptor engagement, and increased basal akt (protein kinase b) and s (ribosomal protein s ) signaling. discussion: we report the first case of phts identified by newborn trec screening for scid. as pten is not included in most commercially available, scid-or pid-tailored gene panels, phts would be missed by conventional genetic testing. therefore, analysis for variants in pten should be considered in neonates with low trec counts, macrocephaly, developmental delay, and other suggestive sequelae. abstract/case report text primary (or familial) hemophagocytic lymphohistiocytosis (hlh) is a rare, life-threatening hyper-inflammatory syndrome affecting mainly young children. it is caused by mutations in genes involved in the granule-dependent cytotoxic pathway, inducing extreme inflammation and massive tissue infiltration by activated t cells and macrophages. standard chemotherapy-based treatment regimens are toxic and induce remission in only % of patients. to this day, hsct is the only available curative treatment, but the inability to efficiently control the inflammation in many patients prior to transplantation often leads to graft failure, with transplant-related mortality around %. thus, the development of new, more potent and less toxic anti-inflammatory regimens would be a major advancement in the treatment of hlh. here, we hypothesize that combination therapies targeting several jak-dependent cytokines will be more effective than monotherapy to reduce the life-threatening symptoms induced by this pathology. using a perforin-deficient (pko) mouse model, we first tested the effects of blocking antibodies against ifnγ, the dominant cytokine secreted during hlh, in combination with antibodies targeting other highly elevated cytokines, such as il- and il- , on the manifestations of the disease. we found that anti-il- r and anti-il- antibodies, when used in combination with anti-ifnγ antibodies, did not significantly improve the symptoms of hlh compare to anti-ifnγ antibodies alone. further, we found that targeting the jak-stat signaling pathway with ruxolitinib, a specific inhibitor of jak and jak , molecules downstream of ifnγ and il- , but not il- signaling, was as beneficial as anti-ifnγ monotherapy. next, we tested the efficacy of ruxolitinib in combination with anti-il- antibody, as this later cytokine is not jak-dependent and was shown to drive macrophage activation syndrome in other contexts. unfortunately, this combination did not result in better symptom resolution than the use of ruxolitinib only. in contrast, combination therapy using ruxolitinib and anti-ifnγ antibodies showed a striking synergistic effect on the resolution of most disease manifestations, to such an extent that our pko mice presented a clinical phenotype indistinguishable than that of a c bl control mice. our findings demonstrate that jak-dependent cytokines are the main cytokines driving the progression of hlh in pko mice. collectively, our results suggest that anti-ifnγ antibodies and ruxolitinib, although effective independently, should be used in combination to more efficiently suppress hlh progression. these results are particularly relevant since the emapalumab, an anti-ifnγ monoclonal antibody was recently approved by the fda for the treatment of hlh while ruxolitinib will soon be in clinical trials for this indication. this project was supported by funds from the fondation de cancérologie charles bruneau and the canadian institutes of health research (mop- ). abstract/case report text introduction: transcription factor (tcf ), also known as transcription factor e -alpha (e a), is a helix-loop-helix transcription factor which plays a critical role in lymphopoiesis. tcf is required for b and t lymphocyte development. defects in tcf have been associated with agammaglobulinemia , autosomal dominant, characterized by low levels of immunoglobulin and early onset recurrent bacterial infections. deletion or diminished activity of tcf may also play a role in lymphoid malignancies. runs of homozygosity (roh) are contiguous stretches of homozygous genotypes at consecutive polymorphic dna marker positions. roh are important reservoirs of homozygous deleterious variation. the homozygosity heterogeneous hmm (h m ) algorithm was specifically developed for analyzing whole exome sequencing (wes) data. the branch point sequence (bps) is an essential splicing signal located - bases upstream of splice acceptor sites. while bps variants are rare, they may result in aberrant pre-mrna splicing and genetic disorders. these variants may be overlooked by standard wes analysis methods because they are intronic and the mammalian bps is a degenerate motif. objective: describe the method used to identify a bps variant in consanguineous brothers with immunodeficiency, including early onset recurrent infections and b-all, hypogammaglobulinemia, t and nk lymphocytosis, low b cells, and low naïve t cells. methods: wes was performed for all family members. data were analyzed using standard read mapping, variant calling and annotation methods. roh were analyzed using the h m algorithm (magi et al. ). roh from the siblings was intersected (bedtools) and the output was submitted to the genomic oligoarray and snp array evaluation tool (v . ). variants were confirmed by sanger sequencing. results: no candidate disease variants were detected in the coding regions, ' or ' splice sites, or utrs for both brothers; however, analysis of intersected roh revealed a homozygous tcf intronic variant within a putative bps (tcf c. - a>t). sanger sequencing of the mutant cdna revealed activation of a cryptic splice site. heritability for routine childhood vaccines has been shown to range from - %. the genetic component of vaccine response suggests we should be able to predict vaccine response in infants with biomarkers. methods: multi-center study of infants born vaginally at full term and followed through months of life. cord blood was collected at birth & peripheral blood was collected at and months of life. six-month collection was weeks post administration of routine vaccinations, while -month collection was immediately prior to receiving the -month booster vaccines. b cell subsets were analyzed with flow cytometry. vaccine titers and cytokines were measured via multi-plex elisa. study was irb approved. results: our data confirmed the immaturity of the newborn humoral immune system with a lower overall b-cell abundance, a predominance of naïve b cells, an inability to class-switch and produce igg or iga, and a th bias. maturation was observed over the first year with increasing overall b-cell abundance, frequency of memory b-cells producing iga, igg, and igm, and frequency of plasmablasts. scd levels also increased throughout the first year due to microbial translocation reflecting establishment of the microbiome. conversely, cord blood contained high levels of baff, april, scd l, il- , and il- , with levels decreasing thereafter. all infants displayed evidence of humoral immune system activation after getting -month vaccines. total plasmablast levels peaked weeks after receipt of month immunizations. a decrease in total plasmablasts was evident between and months, although levels remained above those at birth, corresponding with the need for -month booster vaccinations to maintain long-lasting immunity. il- and ifn-gamma had a significant positive correlation with memory b cells and plasmablasts at subsequent time points suggesting that these cytokines play a role in b cell differentiation and vaccine response. baff and april cytokines were elevated at birth, consistent with germinal center formation and underwent a compensatory decrease thereafter. april & scd levels in cord blood significantly correlated with higher tetanus titers at months suggesting that vaccine response may be predicted by cytokine biomarkers at birth. response to vaccines was also dynamic with il- levels being significantly correlated with tetanus titers at weeks after receipt of month immunizations. conversely, scd l levels did not correspond to b cell development consistent with a known b cell hyporesponsiveness to cd l in infants. conclusion: humoral immune development is both predictable and dynamic. biomarkers in the cord blood, produced by the infant, are predictors of b cell development and vaccine response in infancy. background: adult-onset immunodeficiency with anti-ifnɣ autoantibodies is a newly described immunodeficiency syndrome characterized by disseminated nontuberculous mycobacterial and other opportunistic infections in previously healthy middle-aged individuals typically from southeast asia. it is caused by the presence of autoantibodies directed against the cytokine ifnɣ, which is required for intracellular pathogen killing by macrophages as well as phosphorylation of the transcription factor stat , which is involved in cell survival gene expression. successful treatment of the immunodeficiency has been described in prior case reports with immunomodulatory therapies, including rituximab. however, there are no standard recommendations for dosing or timing of these agents, or recommendations for longterm monitoring of disease activity. case presentation: a -year-old laotian woman with a history of type diabetes and possible prior hepatitis c infection presented to the immunology clinic for evaluation of immunodeficiency. in the two years prior to presentation, the patient was diagnosed with mycobacterium avium infection involving the parotid gland and lymph nodes of the neck, mycobacterium avium complex bacteremia, histoplasma capsulatum involving the lymph nodes of the neck, and leukocytoclastic vasculitis of the lower extremities. as a child and young adult, she had no severe or recurrent illnesses and did not suffer from any chronic disease. preliminary immunologic testing demonstrated normal t, b, and nk cell subsets, elevated immunoglobulin g, a, and m levels, and protective titers to tetanus, diphtheria, and / pneumococcal serotypes. measurement of anti-ifnɣ autoantibodies was positive, which led to the diagnosis of adult-onset immunodeficiency with anti-ifnɣ autoantibodies. the patient was treated with four doses of monthly rituximab with resolution of the anti-ifnɣ autoantibodies, restoration of normal stat phosphorylation, and depletion of cd -positive b cells. after a -year period of being lost to follow-up, during which she continued to receive rituximab every months at the direction of a local provider, the patient re-presented to the immunology clinic to re-establish care. at that time, the patient had no evidence of anti-ifnɣ autoantibodies based on titers and normal stat phosphorylation. cd -positive b cells remained depleted. the patient also confirmed subjective clinical improvement and denied any interim infectious complications. conclusion: this case provides an example of successful treatment of a patient with adult-onset immunodeficiency with anti-ifnɣ autoantibodies with rituximab. it also highlights the utility of ifnɣ functional testing with stat phosphorylation, which may be used to monitor disease activity and to make decisions about ongoing immunomodulatory treatment. it is necessary to monitor additional immunological markers to refine the diagnosis of a secondary post-lt immunodeficiency to take preventive measures before infections occur. we sequentially measured t lymphocytes and antibodymediated immunity in a -year-old male receiving a lung transplant for idiopathic pulmonary fibrosis to determine which immune indicators could improve the identification of a secondary immunodeficiency. methods: t and b cell numbers, igm, igg, iga, ige and igg subclasses and specific antibodies to s. pneumonia capsular polysaccharides were assessed over a months-long post lt period. the clinical progress, infections and pulmonary function were monitored prior to transplantation and at regular intervals thereafter. results: the patient had progressive idiopathic pulmonary fibrosis starting with an episode of pulmonary hypersensitivity years earlier. he developed increasing respiratory failure progressing to complete dependency requiring a lt in june . he was treated with prednisone, mg/ day continuously for months, then decreased to mg/day. other immunosupressants included mycophenolic acid and tacrolimus and on/ off antibiotics that eventually led to severe tendinitis at - months post lt. at ½-month post lt he developed an early onset bronchiolitis obliterans syndrome (bos) that was controlled by increasing the prednisone dose. sequential immunologic evaluation showed his igg dropping from , mg/dl to after two weeks and then remaining stable at that level for the rest of the observation period. igm and iga had minor variations and ige remained very low. igg fell from - mg/ml pre-lt to - in weeks and remained stable at that level thereafter. antibodies against s. pneumoniae polysaccharides started high, between - ·g/ml for all serotypes and fell rapidly in the first weeks post lt, then continued a steady decline with > % serotypes falling < . ·g/ml at months. twelve of pneumococcal serotype antibodies increased above . ·g/ ml after igg replacement at months. cd t lymphocytes decreased from ± , cells/ul to - at month, remaining at that number after that. cd /th cells increased from - cells/ul to at months when prednisone was tapered down and then decreased to after increasing the prednisone dose again. this decrease coincided with a reduction in bos manifestations. conclusions: immune monitoring revealed an independent decrease of immunoglobulins with a stronger decrease in igg and specific pneumococcal antibodies. the role of th cell increase in developing bos needs further investigation. stat is a frequent target of cancer therapies due to its role in certain malignancies for cell proliferation and metastasis. with lof stat , decreased incidence of some cancers may be expected, however increased rates of lymphoma are described. we sought to describe the incidence and spectrum of malignancy in our relatively large lof stat cohort. methods: we performed a retrospective analysis of lof stat patients evaluated at the nih clinical center to determine the type of malignancies diagnosed, treatments received, and outcomes following therapy. results: a total of patients with malignancies were identified (cancer incidence %). six patients ( %) were diagnosed with non-hodgkin lymphoma (nhl); with diffuse large b-cell lymphoma (dlbcl) and with burkitt lymphoma (bl) with age at diagnosis ranging from years to years with median age of years. pathology staining for ebv was available in four patients; all of whom were negative by eber. all dlbcl patients received da-epoch-r for - cycles, and all achieved complete remission. five of patients with lymphoma are alive and disease-free. one patient died of heart failure years post chemotherapy without disease relapse. two patients were diagnosed with papillary thyroid carcinoma at ages and , one of whom was subsequently diagnosed with nhl. two other patients were diagnosed with basal cell carcinoma of the skin at ages and ; both of whom had prior voriconazole exposure. conclusion: malignancy, most commonly nhl, occurs in patients with lof stat mutations. nhl should be considered in patients with progressive lymphadenopathy, and thyroid carcinoma should be considered in patients with thyroid nodules. patients treated with voriconazole are at an increased risk of skin cancer and require careful skin monitoring. as survival increases, it will be important to monitor the incidence of malignancies diagnosed, as it is possible that decreased stat signaling may prove to be protective of some cancers, such as colon and breast carcinoma, in which increased stat signaling is implicated in pathogenesis. abstract/case report text introduction: recurrent pneumonia is defined as or more episodes of pneumonia in one year or more than pneumonias throughout life (with radiological resolution between episodes). in retrospective studies, up to % of adult subjects with recurrent pneumonia coursed with primary immunodeficiencies (pid). prospective studies evaluating the etiology of recurrent pneumonia are scarce. diagnostic delay and inappropriate management of patients with pid (predominantly antibody deficiency for example) could lead to irreversible lung damage or even death from serious infections. here we present the frequency of primary immunodeficiencies in adults with recurrent pneumonia in cali, colombia. methods: we present preliminary data of a descriptive prospective study that will include patients with recurrent pneumonia. women and men > and < years old will be included. all volunteers will be evaluated by a clinical immunologist, complete blood count and serum igg, iga, igm and ige levels will be determined. according with clinical suspicious, igg subclasses, anti-pneumococcal igg response and b cell subpopulations will be performed. the project will be executed in months. written informed consent has been obtained for all subjects included. this project count with irb approvals at universidad del valle and hospital universitario del valle. results: a total of recurrent pneumonia cases have been included in the study. the mean age was . years ( - years) with a female:male ratio : . moderate-severe dyspnea was observed in / cases (medical research council -mrcdyspnea scale to ). non cystic fibrosis bronchiectasis was found in / cases ( %). the main etiologies of recurrent pneumonia were: primary immunodeficiency / ( %); asthma / ( . %); autoimmunity / ( . %); primary ciliary diskinesia / ( . %) and others. hypergammaglobulinemia represented / ( %) of cases. primary immunodeficiencies, % of recurrent pneumonia cases, were classified as: predominantly antibody deficiency ( cases) including cvid cases, igm deficiency cases, selective iga deficiency cases, igg subclasses deficiency case, hypogamaglobulinemia case and agammaglobulinemia case. combined immunodeficiency: dock deficiency case and ataxia telangiectasia case. conclusion: to the best of our knowledge this is the first prospective study evaluating the etiology of recurrent pneumonia in colombia. predominantly antibody deficiencies and igg hypergammaglobulinemia affect % of adults with recurrent pneumonia in colombia. this study allows us diagnosed more than new cases of adult onset pid. immunological evaluation is critical in the assessment of patients with recurrent pneumonia. conflict of interest: authors disclosure any potential financial conflict of interest related to this abstract. acknowledgements: this investigator-initiated research was supported with a grant from baxalta us inc, a member of the takeda group of companies bt - /iir-col-bxlt- . abstract/case report text introduction: lysinuric protein intolerance (lpi) is an autosomal recessive metabolic disorder due to pathogenic mutations in slc a . it is distinguished by decreased plasma concentrations and increased urinary excretion of lysine, arginine and ornithine and can present with multiorgan involvement and a spectrum of immune deficiency. we present a five-year-old female with lpi, early-onset juvenile systemic lupus erythematous (sle), hemophagocytic lymphohistiocytosis (hlh), and granulomatous skin lesions that were positive for vaccine-strain rubella. methods: retrospective chart review was conducted. laboratory investigations included lymphocyte immunophenotyping by flow cytometry, lymphocyte proliferation to mitogen, quantitative serum immunoglobulins, vaccine titers, autoantibodies, metabolic studies, and genetic evaluation by next generation and whole exome sequencing. results: a five-years-old female of mixed native american and african american race presented at years of age with severe failure to thrive, history of recurrent fevers, joint swelling, recurrent skin lesions, severe anemia and neutropenia, and hypergammaglobulinemia. upon further evaluation, she demonstrated hyperferritinemia and ana, rnp, smith, and ss-a autoantibodies and was diagnosed with early-onset juvenile sle. laboratory immune evaluation revealed age-appropriate lymphocyte subpopulations and lymphocyte proliferative responses to mitogens and antigens, markedly elevated igg, iga, igm with no associated monoclonality, and protective tetanus and pneumococcal titers. given her severe clinical manifestations at an early age, concern for immunodeficiency prompted further genetic evaluation with next generation dclre c sequencing, which was negative, and whole exome sequencing, which revealed two heterozygous mutations in slc a , consistent with lpi. laboratory metabolic evaluation was also consistent with a diagnosis of lpi. she continued to experience recurrent cutaneous lesions on her upper and lower extremities. biopsy findings were consistent with a granulomatous lesion and subsequently identified by the cdc to have vaccine-strain rubella infection. due to recurrent pneumonia and concern for pulmonary alveolar proteinosis (pap), pulmonology was consulted and eventually confirmed pap, and she has required home oxygen supplementation. given her history of recurrent infections and vaccine-strain rubella infection, supplemental ivig was initiated. her sle has been fairly refractory to medical management, including systemic corticosteroids, mycophenolate, rituximab, and cyclosporine. she recently developed hlh at years of age and is currently maintained on canakinumab, mycophenolate, and systemic corticosteroids, yet continues to have sle and pap that has been difficult to control. conclusion: the range of clinical and immunologic findings in lysinuric protein intolerance has varied widely in the literature. our patient presented with early-onset juvenile sle and did not develop hlh and pap until years after initial presentation. despite relatively normal cellular immunity by laboratory evaluation, our patient was identified to have chronic infection with vaccine-strain rubella virus, indicating severe t cell dysfunction, and poses challenges for future immunomodulatory treatment. introduction: x-linked immunodeficiency with magnesium defect, ebv infection, and neoplasia (xmen) disease is caused by lossof-function (lof) mutations in the magnesium transporter (magt ) gene. it is a rare x-linked combined immunodeficiency and selective congenital disorder of glycosylation. clinical manifestations include chronic ebv viremia, recurrent bacterial and viral infections, lymphadenopathy, splenomegaly, autoimmunity, liver and central nervous system (cns) abnormalities. magt deficiency was first noted to result in chronic ebv infection and an increased susceptibility to ebv+ lymphomas. we recently recognized merkel cell carcinoma at a very young age in two xmen patients, leading to our review of the malignancies in this cohort. methods: we reviewed the records of male patients ( seen at the nih) with confirmed hemizygous lof mutations in magt for diagnosis of malignancy, therapy, and outcome. results: we identified malignancy in patients of with magt deficiency ( %). four patients had hodgkin's lymphoma (hl) (ages - years), three had non-hodgkins lymphoma (nhl) (ages - years), one had kaposi sarcoma ( years) , one patient developed eber-negative liposarcoma (age years) after receiving chemo and radiotherapy for severe lymphoproliferative disease (lpd) at age years and two had merkel cell carcinoma at exceedingly young ages ( and years). all patients had chronic ebv viremia. they all received treatment according to established protocols. currently, all except for three patients are alive and in remission, including one post-hsct. overall malignancy survival of %. it is important to note that three patients who did not have malignancy had ebv lpd so severe that it warranted treatment with a malignancy protocol, with one mistaken as having lymphoma. conclusion: xmen immune deficiency, an x-linked glycosylation disorder, is a multisystem disease associated with increased susceptibility to malignancies. initially, ebv driven lymphoproliferation and lymphoma was described with xmen; however, with increasing diagnoses, more malignancies are being recognized. all the recognized malignancies are associated, at least in part, with dnaviruses, including ebv, hhv- , and merkel cell virus. understanding the clinical phenotype and pathogenesis of this disease will improve monitoring and early diagnosis of malignancies for patients with magt deficiency. abstract/case report text background: primary immune deficiencies (pid) constitute a heterogeneous group of over individually rare congenital diseases that involve genes coding for proteins of the immune system, and which result in increased susceptibility to infection, inflammation, autoimmunity, allergy and cancer. the complexity of the diagnostic task, and the intrinsic biases and limitations of the human mind, can be aided by computational tools. among the available machine learning approaches, decision tree algorithms select the best node to split based on entropy and information gain; random forests build dozens or thousands of decision trees randomly to improve accuracy and reduce overfitting. aim: to implement a machine learning-assisted clinical decision support system for the diagnosis of pid. methods: with a local database of patients with suspected iei, we built a decision tree using c . dtc, and a random forest on python . (jupyter notebook, scikit, mathplotlib, pandas, numpy). the database was obtained by conducting an electronic search on medsys of patients with the term "immunodeficiency" in their electronic medical records, and then hand-picking cases in which a pid had been confirmed or ruled out. it consisted of patients, of which had been diagnosed with iei. we first split the dataset randomly into training ( %) and testing ( %) sets. the decision tree was tasked with classifying correctly pid or not. after running the algorithm in the training set, we evaluated in the testing set through cross-validation. results: accuracy was greater than % for the dataset (pid/not). . for the dtc with levels. the attribute with the lowest gini coefficient was low iga ( . ). accuracy for the random forest classifier was . with trees. feature importance was highest for lung infection ( . ), high igg ( . ), low iga ( . ), skin infection ( . ), no isolate ( . ), and allergy ( . ); it was lowest for consanguinity, high igm, central nervous system infection, parasites and no infections. during the random generation of trees, accuracy reached up to %. discussion: we built two classification models. decision trees lend themselves more easily to learning and deriving rules of thumb from their sequences. random forests are more robust and better suited for categoric (as opposed to binary) classification. we next want to develop a chatbot, currently under construction, that will ask relevant questions in optimal sequence, and extract undiagnosed patients with suspected iei, based on statistical "red flags". we also have preliminary results of this process applied to a usidnet database with over , patients, and are also working on multinomial logistic regression and naïve bayesian classifiers for this and other databases. abstract/case report text objectives: acute viral respiratory infections (avri) are associated with significant healthcare resource use and cost. the use of intravenous immunoglobulin (ivig) may be an effective treatment for immunosuppressed patients and reduce overall healthcare resource utilization. the goal of this study was to assess hospital resource utilization associated with ivig use among patients hospitalized for avri. methods: using data from the - premier hospital database, we identified patients hospitalized with a diagnosis of avri [respiratory syncytial virus (rsv), parainfluenza virus, rhinovirus, or metapneumovirus], and who had an immune deficiency (chemotherapy treatment, transplant, primary immunodeficiency disorder (pidd), specific antibody deficiency, other immunodeficiency, or disorders of the immune or lymphatic systems). patients receiving ivig within the first hours were compared to patients who did not receive ivig at all. due to the nature of the need to better understand the treatment effect associated with ivig, we used an inverse probability weight-based regression model. since there were substantially more controls than cases, we randomly drew , controls. a logistic regression model was developed to adjust for factors associated with the probability of ivig use within hours of admission. this propensity score was then used to weigh subsequent models to assess length of stay (total and icu) using negative binomial models and logistic regression for inpatient death. results: a sample of , immunocompromised inpatients were identified, receiving ivig within the first hours of admission and , who did not receive ivig. the ivig group was older (mean age vs , p < . ), had more antiviral use ( % vs %, p < . ), and had less cancer ( % vs %, p < . ). after adjustment for immunity type (transplant, cancer), rsv, pidd, age, prednisone, antiviral use, ribavirin use, urban hospital setting, teaching status, intubation and lung disease, patients with ivig use had . less days of hospitalization (p= . ) and . less days in the icu (p= . ) than non ivig users. conclusions: this data analysis suggests that hospital length of stay and icu length of stay were significantly shorter for immunocompromised patients hospitalized for acute viral respiratory infections who were administered ivig within the first hours of admission, as compared to patients who did not receive ivig. it is possible that ivig use may have an impact on hospital resource utilization and costs. future prospective studies would help further assess the role of ivig in patients hospitalized with acute viral respiratory infections. associate professor/yale university abstract/case report text background: cd ligand deficiency is an x-linked combined immunodeficiency associated with opportunistic infections and increased risk of malignancies. expansion of memory cd + t-cells with senescent features is known to be associated with chronic immune stimulation including aging, chronic infection and malignancy. cd + t-cell characteristics of cd l deficient (cd ld) patients in relation to their clinical history have not been described. objective: we studied correlation between cd + t-cell senescence with clinical histories of cd ld patients. methods: we analyzed the frequency and phenotypic characteristics of peripheral cd + t-cell subsets in four cd ld patients ( , , and years old (yo)) and healthy controls (hcs). t cell excision circle (trec) counts and telomere lengths of the patients and hcs were measured using quantitative pcr. in-depth analysis of cd + t-cells of the yo patient and hcs was done using high-dimensional cytometer time of flight analysis (cytof). results: three patients ( , and yo) with histories of recurrent infections and poor compliance with immunoglobulin therapy (ivig) showed an increased frequency of effector memory cd + t-cells with the senescent phenotype compared to age matched hcs. whereas yo patient with excellent ivig compliance starting at infancy did not show any senescence phenotypes of the cd + t-cells. the telomere length and trec count of each patient correlated with the degree of cd + t-cell senescence and their current ages, respectively. in-depth analysis showed similar expression patterns of molecules related to senescence and cytotoxicity in cd + t-cells including cd , t-bet, eomes, granzyme b and perforin in the yo patient and mid-elderly hcs. conclusion: our findings suggest that prompt diagnosis and compliance with ivig starting at the infancy may prevent early onset cd + t-cell senescence in cd l deficiency. abstract/case report text introduction: immunoglobulin g -related disease (igg -rd) is an immune-mediated fibroinflammatory condition that affects multiple organs. when igg -rd is found in the ocular adnexa, the term "igg related ophthalmic disease (igg -rod)" is used. objective: our case describes a patient with igg -rod without systemic involvement. case: mr. x is a -year-old male with a pmh of cml (on imatinib) and allergic rhinitis who presented to clinic with orbital swelling for twenty years. his swelling had always been responsive to steroids, but would return once steroids were tapered. patient was diagnosed with biopsy proven cml in and is currently taking imatinib. because his peri-orbital edema persisted, a right lacrimal gland biopsy was done which showed "marked lymphocytic infiltrate of soft tissue with lymphoid follicles, many plasma cells, and eosinophils. no atypical histiocytes." flow cytometry was negative for malignancy. results: crp . mg/l. esr mm/hr. igg elevated at mg/dl. ct chest from and ct chest, abdomen, pelvis from were without fibrotic changes. assessment: when diagnosing igg -rd, we categorize diagnosis into three levels (possible, probable, or definite) by three criteria (clinical manifestation, elevated serum igg , and histopathology). this is detailed as follows: clinical exam showing organ specific swelling or masses, elevated serum igg (> mg/dl), and histopathology with either lymphocyte and plasmacyte infiltration and fibrosis or infiltration of igg + plasma cells (ratio of igg +/igg+ cells ≧ % and ≧ igg + plasma cells per high power field). not all these components are required for diagnosis, but meeting histopathologic criteria makes diagnosis more probable. our patient's disease was localized to his eye, and patients with igg -rod have unique diagnostic criteria. these criteria are similar to the criteria for igg -rd, but emphasize enlargement of the ocular adnexa, less frequent fibrosis, and ≧ igg + plasma cells per high power field. our patient's histopathology revealed a lymphoplasmacytic infiltrate, but lacked storiform fibrosis or obliterative phlebitis. his serum igg level was mg/dl, and his biopsy was positive for an igg +/igg+ ratio of % and more than igg + plasma cells per high power field. based on this, he meets criteria for igg -rod. conclusion: igg -rod is a rare condition that is usually associated with systemic organ involvement. our case is unique, as no systemic disease has been detected. we also suspect our patient has been living with igg -rod for several years, as his orbital swelling began in high school. it is important to note that he has been on imatinib, a tyrosine kinase inhibitor, for treatment of his cml. imatinib inhibits c-abl and platelet-derived growth factor receptor, tyrosine kinases involved in profibrotic pathways. patient's lack of fibrosis could also be due to his longstanding use of this drug. it is also possible that he has a rare form of igg -rod without systemic involvement. a limited number of such cases have been reported, but no consensus has been made on why disease course was localized. our patient was started on rituximab, and his serum igg decreased to mg/dl after the first cycle. we hope his disease achieves remission. informed consent: informed consent was obtained from all individual participants included in the study. abstract/case report text platelet abnormalities with eosinophilia and immune-mediated inflammatory disease (plteid) is a recently discovered combined immunodeficiency with inflammatory and allergic manifestations with few cases reported. we describe a female patient with compound heterozygous mutation in arpc b gene with suggestive clinical findings of plteid. a -year-old girl presented with chronic diarrhea since neonatal period, with bloody stools and failure to thrive. she also presented atopic dermatitis, recurrent cutaneous and mucosal ulcers, recurrent respiratory infections ( episodes of otitis media, pneumonias) and many episodes of mucocutaneous candidiasis. family history revealed a sibling deceased in the second month of life, who presented a similar clinical picture and a paternal uncle and second degree cousin that died in the first year of life. there is no history of consanguinity. laboratory evaluation revealed peripheral eosinophilia ( /mm ), normal platelet numbers with low platelet volume ( , fl -reference value , - , fl), normal igm levels with elevated igg ( mg/dl-rv - mg/dl), iga ( mg/dl -rv - mg/dl) and ige ( iu/ml -rv a) associated with plteid. t h e i n f a n t r e c e i v e s a n t i m i c r o b i a l p r o p h y l a x i s w i t h sulfamethoxazole-trimethoprim and fluconazole, intravenous immunoglobulin replacement and was referred to hematopoietic stem cell transplantation (hsct). this case was the first one described in brazil and highlights the importance of seeking for a genetic diagnosis in patients with complex clinical phenotypes. precise diagnosis can impact on treatment approach. live vaccines are generally contraindicated in patients with combined immunodeficiency (cid). however, in less severe cid, such as partial dgs, those vaccines can be considered depending on the immunologic status of the patient. there are recommendations regarding to measles, mumps, rubella (mmr) and varicella vaccines, but yellow fever vaccine (yfv) is generally contraindicated in this population. considering the severity of the yellow fever disease and the absence of specific treatment, the use of this vaccine is an important topic for debate in cases of patients from endemic areas. objective: this study aimed to describe the use of yfv and other live attenuated vaccines in patients with dgs, associating it with their immunological profiles and the presence of adverse effects. methods: retrospective study of medical records of patients with dgs confirmed by mlpa or fish, followed in a pediatric reference center for primary immunodeficiencies between and . collected data included: demographic characteristics, medical history, history of immunization with live vaccines, postvaccination adverse reactions and immunological profile, including immunoglobulins levels, serologic vaccination responses, lymphocyte immunophenotyping, lymphocyte proliferation responses to mitogens and prophylactic treatments (antibiotic or immunoglobulins). results: thirty-five patients with confirmed dgs and median age of years ( - y) were included ( m: f). thirty-three children ( %) received mmr vaccine: nine presented t lymphopenia. two of the patients had cd < , one of them with normal mitogenic proliferation response and the other was not tested. three of the patients had low immunoglobulins levels ( / low igg, / low igm and / low iga), and one of them received intravenous immunoglobulin (ivig). twentynine of had normal serologic vaccination responses. adverse effect was only reported by one patient, who had one episode of fever after the administration of all vaccines. yellow fever vaccine was administrated to children ( %): had t cell l y m p h o p e n i a ( b u t c d > ) , a n d a n o t h e r p a t i e n t h a d hypogammaglobulinemia and received ivig and prophylactic antibiotics. twelve of showed adequate serologic responses to mmr and hepatitis b. only patient reported mild reaction (tremors) two days after the yfv administration. the same patient had normal t cells, immunoglobulins and vaccine responses. twenty patients ( %) received bacillus calmette-guerin vaccine (bcg), ( %) received oral polio, ( %) rotavirus and ( %) received varicella vaccine. no severe adverse events were documented in any patient that received live vaccines, and no patient developed measles, mumps, rubella or yellow fever diseases as a consequence of administration of the vaccine. conclusions: in this cohort of pediatric patients with dgs, yfvand other live vaccines were well tolerated, and no severe adverse events were reported, suggesting that widespread contraindication of yfv may endanger unvaccinated patients with less severe phenotype living in endemic areas. immunological evaluation and individualized decisions are always recommended, and further studies are needed to assess the safety of the yfv in this pediatric population. abstract/case report text introduction: lad-i is a rare inherited disorder of leukocyte (primarily neutrophil) adhesion to endothelial cell surfaces, migration, and chemotaxis resulting from itgb gene mutations encoding for the β -integrin component, cd . severe lad-i (i.e., cd expression on < % of neutrophils) is characterized by recurrent serious infections, impaired wound healing, and childhood mortality. although allogeneic hematopoietic stem cell transplant (allohsct) is potentially curative, its utilization and efficacy are limited by hla-matched donor availability and risk of graftversus-host disease (gvhd). rp-l - (clinical trials.gov # nct ) is a phase / open-label clinical trial evaluating the safety and efficacy of autologous cd + cells transduced with a lentiviral vector (lv) carrying the itgb gene encoding for cd (chim-cd -wpre) in severe lad-i. methods: pediatric patients ≥ months old with severe lad-i (demonstrated by cd expression on < % neutrophils and at least one prior significant bacterial or fungal infection) are eligible. peripheral blood (pb) hematopoietic stem cells are collected via apheresis after mobilization with granulocyte-colony stimulating factor (g-csf) and plerixafor. cd + hspcs are selected, transduced with chim-cd -wpre lv, and cryopreserved. myeloablative conditioning with busulfan (therapeutic drug monitoring (tdm) dosing with adjustments to enable target area under the curve (auc)) is administered over days, followed by infusion of the thawed investigational drug product (rp-l ). patients are followed for safety assessments including replication competent lentivirus (rcl) and insertion site analysis (isa), and for efficacysurvival to age ( months) and at least -year post-infusion without allohsct, increase in neutrophil cd expression, pb vector copy number (vcn), decrease in infections and/or hospitalizations, and resolution of skin or periodontal abnormalities. results: an initial lad-i patient (age years) with recurrent severe infections and documented itgb mutations has been treated as of november . baseline cd , cd a, and cd b expression were < %. mobilization and apheresis procedures were performed successfully and busulfan conditioning was administered at the target auc. investigational product was comprised of . x e cd + cells/kg with vcn of . copies/cell (liquid culture), and was infused without complications. no serious treatment-emergent adverse events were reported. neutrophil engraftment ( consecutive days of anc ≥ ) was observed days post-infusion. pb pmn cd expression months posttreatment was . % with comparable cd a and cd b expression levels; pb cd (myeloid) vcn at . months was . . safety and efficacy data months post-treatment will be available at the time of presentation, in addition to preliminary data regarding a potential additional patient. conclusion: preliminary evidence demonstrates that rp-l enables itgb genetic correction with robust cd /cd neutrophil expression in this frequently fatal primary immunodeficiency. abstract/case report text introduction: the complement system plays an integral role in the innate immune system and links innate and adaptive immunity. complement deficiencies, hereditary or acquired, are rare. acquired deficiencies are more prevalent, occurring in nephrotic syndrome, reduced hepatic synthesis or transiently in sepsis/viremia. they are also seen in the presence of autoantibodies known to cause depletion of complement factors, such as c nephritic factor (c nef). c deficiency is associated with infection susceptibility, particularly to encapsulated bacteria, and immune complex disease. case description: a year old male was evaluated for recurrent infection. in childhood, he had recurrent sinusitis, otitis media requiring tympanostomy tube placement and persistent pharyngitis despite tonsillectomy. as a teenager, he developed glomerulonephritis, progressing to end stage renal disease and requiring transplant at age . the kidney allograft failed years later, with biopsy demonstrating recurrent glomerulonephritis. the patient was transitioned to peritoneal dialysis and later hemodialysis, due to recurrent pd-related infections. his adult course was complicated by recurrent methicillin sensitive staphylococcal aureus (mssa) catheter and soft tissue infections (cellulitis and abscess), sinusitis, sepsis (streptococcal, mssa and tularemia), multifocal pneumonia and a left below knee amputation for osteomyelitis that required revision surgery. patient reported other autoimmune phenomena including a presumptive diagnosis of vasculitis and possible lupus-like syndrome. the constellation of recurrent infections and autoimmune features was most concerning for an early complement deficiency. prior work up was notable for low c , ch and ah with normal c , factor h and factor i. extensive laboratory work up revealed normal c q, c level and function, serum immunoglobulins, vaccine titers, factor b and factor d levels. atypical hus (ahus) panel revealed a heterozygous silent variant in exon of cfh and a heterozygous polymorphism within an intron in mcp/cd , seen with increased prevalence in the patient population with ahus. wes was notable for a variant of uncertain significance in the vcl gene only. c level and function were markedly decreased, alongside low ch and ah . both sc b- level and c nephritic factor were elevated. a diagnosis of acquired c deficiency due to c nef was made and patient was started on bactrim prophylaxis. he has remained free of serious infection since starting antibiotic prophylaxis. discussion: c nef stabilizes the alternative pathway c convertase, c bbb, increasing its half-life and blocking dissociation. this leads to unregulated consumption of c with subsequent deficiency. c nef has been associated with c glomerulopathy, infection and partial lipodystrophy. however, there is marked heterogeneity in clinical phenotypes with reported asymptomatic individuals. our patient's glomerulonephritis likely represents c glomerulopathy. case reports and series of successful treatment of c glomerulopathy with rituximab and eculizumab have not commented on immune outcomes beyond the kidney. other potential therapeutic strategies include plasma cell depletion with either bortezomib or daratumumab. further study is needed to evaluate these therapies influence on both reversal of c depletion and overall impact on immune function in the setting of c nef. abstract/case report text introduction: patients with heterozygous signal transducer and activator of transcription (stat ) gain of function (gof) pathogenic variants exhibit an array of phenotypes including susceptibility to viral, bacterial, fungal and mycobacterial infections, autoimmunity, and cancer predisposition. progressive disseminated histoplasmosis (pdh) is well-described to affect infants. however, no reports have evaluated underlying monogenic immune dysregulation in previously healthy infants presenting with pdh. we report an infant who presented with pdh and associated hemophagocytic lymphohistiocytosis (hlh) leading to the diagnosis of a heterozygous stat gof mutation. case report: a previously healthy -month old male presented with persistent fever, pancytopenia, transaminitis, elevated ferritin, hepatosplenomegaly and coagulopathy. his clinical and laboratory evaluations were concerning for hlh syndrome. he had no prior history of immune hyperactivation or atypical infections. secondary causes of hlh were investigated, and patient was diagnosed with pdh based on marked histoplasma antigenemia. targeted genetic testing did not reveal a genetic etiology of familial hlh. he was successfully treated with a pulse and taper of dexamethasone as well as liposomal amphotericin b with transition to itraconazole. immunologic evaluation at the time of initial presentation demonstrated increased mean channel fluorescence for both perforin and granzyme noted in his nk cells. his nk function was decreased; however, he had a normal cd a degranulation assay. his b-cell panel demonstrated low non-switched memory b-cells, low switched memory b-cells and low total memory b-cells. given his extreme immune activation with histoplasmosis, abnormal immunologic testing, and persistent lymphopenia despite resolution of his infection, a primary immunodeficiency next generation sequencing panel was sent. the results demonstrated a pathogenic variant in stat (c. c>t; p.ala val). this single nucleotide variant has been previously shown to be pathogenic (clinvar). abstract/case report text introduction: cytotoxic t lymphocyte antigen- (ctla- ) is known to have an important role as a negative regulator of immune responses, participating in the control of regulatory t cells and effector t cells. in mice its absence is associated with fatal autoimmunity and several ctla- mutations, leading to low or absent ctla- expression, have been shown in humans to be associated with a phenotype that includes hypogammaglobulinemia (with recurrent respiratory infections) and several manifestations of autoimmunity (enteropathy, granulomatous lymphocytic interstitial lung disease, organ infiltration, splenomegaly, autoimmune cytopenias, lymphadenopathy, amongst others), in an autosomal dominant mode of transmission. one of the published mutations, c.c t, that results in an alanine to valine substitution (p.a v), with a highly conserved alanine at that position, had a cadd score of and was associated with the phenotype above, and was shown to be associated with a low expression of ctla- on regulatory t cells and with low ctla- function (reduction of ctla- -mediated transendocytosis). methods: after irb approval, we searched for ctla- mutations present in the biome biobank· biorepository, containing whole exome sequencing data on patients, with data obtained using illumina· v hiseq sequencing platform. sifting through all the ctla mutations in the data, we identified four patients with the c.c t mutation described above. extensive chart review of the four patients was performed. results: four patients were found with the ctla- c.c t mutation. none of them had any of the described phenotypical characteristics of ctla- deficiency. patient is a -year-old male with history of coronary artery disease, atrial fibrillation, stroke, hypertension, brain aneurysm, chronic kidney disease, gout and depression. patient is a -year-old female with history of morbid obesity. patient is a -year-old female with history of hypertension, obesity, pre-diabetes, dyslipidemia and iron deficiency anemia. patient is a -year-old female with history of peripheral artery disease, hypertension, dyslipidemia, chronic kidney disease and lung cancer. conclusion: prior literature has attempted to characterize the clinical penetrance of ctla- mutations, suggesting it to be around %, with that number applying to different mutations in ctla- mutation carriers. we screened a large biorepository of more than thousand patients for ctla- patients and identified four patients that carry one of the best described ctla- mutations, previously validated from a functional standpoint and associated with a severe phenotype. none of the four patients demonstrated any of the previously described phenotypical characteristics, and all four have ages above the median age of onset of years. with the increasing use and broad population application of genetic studies, it is crucial to define the value of identifying presumed pathogenic variants in the absence of the adequate phenotype, with all the prognostic, therapeutic and ethical considerations it may imply. prior case reports of pil patients with b-cell malignancies have discussed treatment regimens with chemotherapy, radiation, and/or surgery, but neither the use nor the outcomes of allogeneic hematopoietic stem cell transplantation (hsct) in the management of recurring b-cell malignancies have been readily reported. case description: a -year-old man with pil and an accompanying history of lymphopenia, hypoproteinemia, hypoalbuminemia, and hypogammaglobulinemia was diagnosed with diffuse large b-cell lymphoma (dlbcl) of the liver following a preceding history of burkitt lymphoma of the ileum at years of age and dlbcl of the liver at years of age, in which each malignancy was genetically distinct. in addition, the patient had a history of benign nodular adenomatoid hyperplasia of the thyroid at years of age that required a hemi-thyroidectomy. treatment considerations for the patient included chimeric antigen receptor t-cell therapy, autologous hsct, and allogeneic hsct, in which allogeneic hsct was ultimately pursued. prior to hsct, the patient was lymphopenic ( cells/microliter) with significant t-cell lymphopenia ( cells/microliter) and an increased proportion of memory t-cells ( % of his cd + t cells were cd ro+), as well as hypogammaglobulinemic (igg mg/dl; iga mg/dl; igm mg/dl). immediately following treatment of his dlbcl with rituximab, ifosfamide, carboplatin, and etoposide, the patient underwent a matched-related sibling donor hsct with a preparative regimen of busulfan, thiotepa, and fludarabine. now months status-post hsct, the patient has maintained full-donor chimerism and has no evidence of graft-versus-host disease or malignancy. as expected, hsct has not corrected abnormalities in certain parameters associated with his pil, as he continues to display significant hypoproteinemia, hypoalbuminemia, and hypogammaglobulinemia, but he has an improved lymphocyte count ( , cells/microliter). discussion: there is no definitive or curative treatment for pil; furthermore, the genetic etiology of pil remains unknown. supportive regimens to help mitigate or offset manifestations of pil exist, such as adherence to a low-fat diet with medium-chain triglyceride supplementation, but there are no therapies available to prevent or reduce the risk of developing bcell malignancies in this patient population. although previous case reports have detailed successful treatment of b-cell malignancies in pil patients with chemotherapy, radiation, and/or surgery, there are no published consensus guidelines regarding management of b-cell malignancies in the setting of pil, especially if recurrent in nature. for non-pil patients with chemotherapy-refractory disease, or recurrent disease following autologous hsct, allogeneic hsct is a potentially curative option. herein, we describe a pil patient with a history of multiple b-cell malignancies who underwent a successful allogeneic hsct, indicating that allogeneic hsct may be an effective treatment option for similarly affected patients. abstract/case report text introduction diarrhea in young infants is common and generally self-limited. in persistent cases, the differential diagnosis is broad and includes infections, food protein-induced allergic proctocolitis, congenital diarrheas and enteropathies. in addition to monogenic inflammatory bowel diseases, many cellular, humoral, and combined immunodeficiencies should be considered, including but not limited to cvid, ipex and ipex-like phenotypes, lad, dyskeratosis congenita, intestinal lymphangiectasia, omenn syndrome, cartilage hair hypoplasia, cgd, il- axis defects, aid deficiency and wiskott-aldrich syndrome. case presentation a full term infant born after an uncomplicated pregnancy to nonconsanguineous honduran parents presented with non-bloody, non-bilious vomiting and dehydration at days of life. the infant later developed frequent loose stools, some of which were bloody, and failure to thrive. his family and prior medical history, including newborn screen, were normal. an extensive workup was initiated which showed: -persistent and severe anemia with a hemoglobin nadir of . mg/dl -hypoalbuminemia requiring multiple infusions -elevated alpha- -antitrypsin and calprotectin level in stool -profound hypogammaglobulinemia with normal iga, igm and ige for age -normal gross and histologic findings on esophagogastroduodenoscopies and colonoscopies besides a gastric ulcer thought not be the cause of his anemia -normal abdominal imaging including ultrasound, ct angiography and mri -no source of bleeding on meckel scan or exploratory laparotomy -normal dhr assay, g pd level and positive myeloperoxidase stain -immunophenotyping showing t cell lymphocytosis affecting cd + more than cd + compartment, with normal lymphocyte proliferation to mitogens -normal sweat chloride level genetic testing was initiated with a targeted immunodeficiency panel which showed variants of unknown significance in adar, dock , lyst, ptprc and tbx genes, none of which adequately explained his presentation. whole exome sequencing showed that he was a compound heterozygote in the dgat gene. a pathogenic variant c. + t>c (ivs + t>c) was inherited from the father and a likely pathogenic variant c. g>c (p.r p) was inherited from the mother. patient was diagnosed with dgat deficiency, an inborn error of lipid metabolism resulting in protein-losing enteropathy (ple). under gastroenterology's guidance, a low fat diet was initiated, resulting in rapid improvement in stool consistency, weight gain, albumin level and stool alpha- -antitrypsin level. he remains on subcutaneous immunoglobulin replacement therapy for ongoing hypogammaglobulinemia. conclusion: protein-losing enteropathies commonly present with intractable diarrhea and significant laboratory derangements due to malabsorption including hypogammaglobulinemia. as a result of these findings and since many of the etiologies are immunologic in origin, immunologists are an integral part of the evaluation of such cases. in cases where immune system interrogation reveal normal results, genetic testing is crucial in guiding the diagnosis. in our case, whole exome sequencing not only provided the diagnosis but also characterized a variant that was previously of unknown significance as likely pathogenic. dietary management provided rapid improvement in growth and nutritional status. ongoing monitoring will reveal if this management also assists in igg level maintenance and hematologic abnormalities or if even more stringent control of dietary fat will be required abstract/case report text background: foxp gene mutations are associated with immune dysregulation polyendocrinopathy x-linked (ipex) syndrome, a rare xlinked monogenic disease of immune dysregulation and autoimmunity. the classic presentation consists of severe enteropathy, dermatitis, and endocrinopathies (commonly early onset insulin dependent diabetes mellitus). clinical presentation and severity can be variable even in family members with the identical variant. we present a patient with ipex symptomatology and a hemizygous variant in the polyadenylation (polya) signal of foxp that is classified as a variant of uncertain significance (vus). this specific variant was reported in a single case study in which the patient improved after hematopoietic stem cell transplantation (hsct). case presentation: a month-old ex -week gestation boy was admitted with lethargy, hypovolemia, electrolyte disturbances, and acute kidney injury. he developed persistent diarrhea and vomiting after receiving rotavirus vaccine. his family history is significant for early deaths of three maternal unclesone stillborn, one death at months and another at years from unknown gastrointestinal problems. he demonstrated peripheral eosinophilia (to . k/ul), elevated ige, and anemia requiring multiple transfusions. he developed severe enteropathy with hypoproteinemia requiring total parenteral nutrition, continual albumin infusions and maintenance of npo. he had generalized edema, respiratory distress requiring high flow nasal cannula, and repeatedly spiked fevers with negative infectious evaluation. acute kidney injury improved but renal ultrasound showed persistent nephrocalcinosis. endoscopy yielded biopsies demonstrating duodenitis with severe villous atrophy, scanty isolated intraepithelial eosinophils and neutrophils, a few crypts with mucin, reactive epithelial changes and increased lamina propria eosinophils. colon biopsies showed mucosa with focally increased lamina propria eosinophils with scanty neutrophils and surface epithelium without cryptitis. esophagitis with reactive epithelial changes, spongiosis, and many intraepithelial eosinophils was also present. the patient's lymphocytes showed unremarkable proliferation to pha and pwm. cd + cd + t cells demonstrated intracellular foxp expression by flow cytometry. a commercially-available immunodeficiency targeted panel revealed that he was hemizygous for a vus in foxp (exon , c.* a>g non coding). this variant is also referred to as an aauaaa>aauaag or aataaa>aataag change in the polya site. he was also heterozygous for vus at these additional loci: cd a c. c>t abstract/case report text introduction: implantation of allogeneic cultured thymus, partially depleted ex vivo of t cells, can result in naïve t cell development in patients with complete digeorge syndrome (dgs). in a few patients, early and transient skin rash, often characterized as "atypical dgs" or late autoimmune manifestations have been reported following implantation. here we describe a patient with complete dgs who developed immune reconstitution inflammatory syndrome (iris) or atypical dgs following thymus implantation. case description: a female patient was diagnosed at birth with complete dgs due to absent t cell receptor excision circles (trec), hypoplastic thymus, profound hypocalcemia with hypoparathyroidism and cardiac defects. the patient also had microretrognathia, oral motor dysfunction, sialorrhea, recurrent aspirations and reflux requiring a gastro-jejunum feeding tube, low-set ears with right ear microotia, semicircular canals atresia, alopecia and mal-rotated kidneys. prior to thymus implantation, the patient was thriving, had no skin rash, no eosinophilia and no t cells. detailed genetic analyses, did not reveal a cause for her syndrome. at months of age pulmonary aspergillosis was diagnosed presumptively. at months of age the patient received an allogeneic t-cell depleted thymus implant from a male donor, without prior conditioning or post-implantation immune suppressive medications. the procedure was uneventful and the patient returned home after days. results: four months after implantation, a pruritic maculopapular rash appeared on the head and trunk that spread to the extremities including the palms and soles. there was no lymphadenopathy or splenomegaly. an infectious etiology could not be found. eosinophilia and an increase in liver enzymes were noted. there was an increase of cd + and cd + t cells with predominantly memory phenotype, which had been undetectable month earlier. analysis of t cell diversity showed a restricted repertoire with expansion of two v-beta families. there was no evidence of donor cells to suggest graft versus host disease. skin biopsy showed minimal superficial perivascular inflammatory infiltrate composed mainly of cd + histiocytes and rare cd + t cells. the patient was treated with prednisone and cyclosporine. a liver biopsy was performed weeks after initiation of treatment that showed moderate and diffuse peri-portal ductular reaction but no duct associated lymphocytic infiltrate or significant duct epithelial injury or ductopenia. the skin rash rapidly resolved with desquamation, while the liver enzyme abnormalities persisted for two more months. cyclosporine and prednisone were weaned over months. t cell numbers, their response to stimulation and diversity have since normalized, as well as trec and naïve t cell production. the patient is producing appropriate antibodies to protein and polysaccharide vaccines. sixteen months after implantation the patient developed grave's disease with markedly elevated free-t , undetectable tsh and elevated antibodies to the thyroid receptor, which rapidly normalized with ongoing methimazole treatment. the patient is currently months after the implantation and is free of infections, thriving and developing appropriately. conclusions: this patient developed atypical dgs or iris, often associated with autologous and allogeneic hematopoietic stem cell transplants, organ transplants or effective treatment of hiv, after successful thymus implantation for complete dgs. abstract/case report text congenital disorders of glycosylation are a rare group of genetic disorders due to defects in protein glycosylation. phosphoglucomutase (pgm ) is an enzyme necessary for the synthesis of uridine diphosphate n-acetylglucosamine, an important precursor for protein glycosylation. patients with autosomal recessive pgm deficiency have a multisystemic disorder characterized by a neurologic impairment and clinical features classically observed in autosomal dominant hyper-ige syndrome due to stat mutations; including recurrent pneumonias, skin abscesses, elevated levels of ige, and abnormalities in connective tissues and bones. we hypothesized that gp , a highly glycosylated protein and coreceptor of the cytokine il- , would be weakly expressed on pgm deficient cells, due to impaired glycosylation. we studied pgm -deficient patients from kindreds and showed that il- -driven stat phosphorylation was impaired in their pbmcs and ebv-transformed b cells. accordingly, the induction of socs target gene was significantly decreased. in contrast, the patients had normal stat phosphorylation and socs induction downstream of il- , a cytokine whose signaling is independent of gp . flow cytometry and immunoblotting showed significantly lower gp expression in peripheral t-cells and ebv-transformed b cells from pgm -deficient patients compared to healthy donors. we did also show that in vitro inhibition of n-glycosylation, using tunicamycin in ebv-transformed b cell line from healthy donor, alters gp -mediated signaling. collectively, our findings demonstrate that defective glycosylation in pgm -deficient patients results in reduced expression of gp and consequently, impaired gp dependent stat phosphorylation and defective il- signaling. this may account for the overlapping clinical features shared by pgm and stat deficient patients. abstract/case report text introduction: there are no known effective therapeutic modalities for patients hospitalized with moderate to severe acute viral respiratory infections, and treatment is primarily supportive. intravenous immunoglobulin (ivig) has been reported in limited cases to be used in this setting, especially in immunocompromised patients. the primary objective of this retrospective study is to compare clinical and economic outcomes among immunocompromised patients hospitalized with viral respiratory infections who received ivig to those who did not receive ivig at a large academic center hospital. methods: we performed a double-center, retrospective cohort study of all immunocompromised patients who were hospitalized for acute documented respiratory viral infections between and . we divided patients into two groups: those who received ivig therapy for respiratory infections, and those who did not receive ivig therapy. data on age, gender, immune status, viral type, immunosuppression type, respiratory support, microbiological data, length of hospital stay (los), icu los, as well as death and readmission rates were extracted from medical records. in order to adjust for severity bias typically present in observational data such as these, we employed inverse probability weighting (ipw) using all collected baseline covariates. outcomes (death, length of stay in hospital and icu, readmission) were examined using a series of logistic and poisson regression models adjusting for baseline covariates and employing ipw. results: a total of individual hospital admissions were analyzed; patients received ivig and did not receive ivig. there were no significant differences between the two groups in terms of mean age, gender . average age was . , % were female, . % were transplant patients of which . % had lung transplant, . % had liver transplant, . % had bone marrow transplants (bmt), . % had kidney transplant, . % had heart transplant and . % had both solid organ and bmt. . % of patients had a hematologic malignancy, and . % had a primary immunodeficiency. the most common isolated respiratory virus w a s r h i n o v i r u s ( . % ) , f o l l o w e d b y r s v ( . % ) , parainfluenza ( . %) and metapneumovirus ( . %). overall, the use of ivig as associated with a significantly shorter icu length-of-stay, with an (or=- . , p= . ), and a higher hospital readmission rate. in the sub-analysis of patients who received ivig within the first hours of hospitalization (n= ), ivig use was associated with a significantly shorter icu los (or=- . , p= . ), significantly shorter overall hospital los (or=- . , p= . ), and no significant change in readmission rate. conclusions: to our knowledge, this is the first retrospective cohort analysis evaluating the effect of ivig in immunocompromised patients hospitalized with respiratory viral infections. the results suggest that immunocompromised patients receiving ivig may have a shorter hospital and icu los, especially if ivig is provided within the first hours of admission. this may result in reduced healthcare costs. this study is limited by its retrospective nature, and the potential bias that patients treated with ivig are sicker to start with. future prospective studies are suggested to further evaluate these findings. ( , ) . the most common precipitant in children is medication, followed by infection ( , ) . although a clear association between mycoplasma pneumoniae and sjs has been established, there is a scarcity of literature exploring the role of this infection in recurrent sjs in children ( ) ( ) ( ) . case presentation: a -year-old female with prior history of sjs was admitted for mucosal and skin lesions in the setting of community acquired pneumonia. her past medical history included sjs with eye involvement, secondary to mycoplasma pneumoniae (ig m positive), occurring five years prior to this admission. she also had frequent episodes of acute otitis media and sinusitis in early childhood. family history was negative for immunodeficiency. her clinical presentation included respiratory symptoms and fever for days treated with ceftriaxone, followed by cefdinir and levofloxacin. her fever improved the day prior to admission, but she developed conjunctival injection, ocular pain, and ulcerative lesions in her mouth and nares. on physical examination, she had low grade fever with mucosal lesions including conjunctival erythema with serous discharge, painful blisters and denudated skin in lips, perioral area, nares, tongue and oropharynx. initial testing included negative blood hsv pcr, blood culture, rapid antigen testing for group a streptococcus and influenza a/b, and elevated crp in . mg/dl and esr mm/hr. right lower lobe p n e u m o n i a w a s c o n f i r m e d w i t h a c h e s t r a d i o g r a p h . nasopharyngeal pcr and serum igm were positive for mycoplasma pneumoniae. she had a mildly elevated anticardiolipin igm ( mpl), a mildly decreased c ( mg/dl) and a negative ana. she was diagnosed with recurrent sjs secondary to mycoplasma pneumonia infection. she completed treatment with levofloxacin for mycoplasma pneumonia, and received cyclosporine and high-dose methylprednisolone. she had bilateral amniotic membrane transplantation to prevent corneal ulceration . she was discharged after clinical improvement, and recurrent oral lesions were noted at followup. immunological work up as an outpatient revealed normal serum immunoglobulins, normal lymphocyte subsets and low pneumococcal titers with adequate response post-vaccination. sjs secondary to mycoplasma pneumonia infection has predominance of mucosal involvement over rash, which was observed in our patient ( , ) . some case series reported a recurrence of sjs up to % within a -year follow up. almost half of patients with recurrent sjs developed multiple sequelae ( , ) . early diagnosis of sjs, especially in those with prior history of sjs, helps to provide appropriate supportive care, monitoring of complications and treatment of possible superinfections ( , ) . conclusions: there is limited information in the literature regarding the role of mycoplasma pneumoniae associated recurrent sjs in children. it is possible that these episodes are triggered by and/or immune predisposition. there is ongoing discussion regarding whether these clinical presentation should be labeled sjs secondary to mycoplasma pneumonia infection or, depending of the skin involvement, m. pneumonia-associated mucositis (mpam) and m. pneumonia-induced rash and mucositis (mirm) ( , , ). mycoplasma should be treated appropriately in patients with recurrent sjs. abstract/case report text background: growing access to genetic testing has facilitated the genetic evaluation of primary immunodeficiencies but has also greatly increased the number of variants of uncertain significance (vus) encountered in clinical practice. interpreting the significance of vus requires multiple lines of evidence. w e d e s c r i b e a n e u t r o p e n i c i n d e x p a t i e n t w i t h hypogammaglobulinemia, unusual hpv susceptibility, and dual heterozygous pathogenic loss-of-function nfkb and heterozygous missense cxcr vus. family analysis showed the nfkb variant was inherited from his mother, while the novel cxcr variant was present in his father and sister. all four patients presented with recurrent infections, warts, and hypogammaglobulinemia. (figure ) the nf-κb gene encodes p /p transcription factor of the canonical nf-κb pathway, the most common autosomal dominant monogenic cause of common variable immunodeficiency (cvid). cxcr is a g-protein-coupled chemokine receptor with cxcl as cognate ligand. autosomal dominant pathogenic gain-offunction cxcr variants lead to impaired receptor downregulation and retention of neutrophils and other leukocytes in the bone marrow defining whim (warts, hypogammaglobinemia, infections, and myelokathexis) syndrome. all cxcr pathogenic variants truncate the carboxyl-tail of the cxcr receptor, a region responsible for receptor internalization, with the exception of one missense non-truncating variant p.e k. case series: the proband (p ) is a -year-old male with history of recurrent bacterial respiratory tract infections, warts, moderate neutropenia, thrombocytopenia and hypogammaglobulinemia requiring immunoglobulin replacement therapy (igrt). bone marrow biopsy didn't show myelokathexis. next-generation panel sequencing identified a novel heterozygous missense cxcr (c. c>a, p.s y) vus. the serine residue is highly conserved up to zebrafish. this variant was present in heterozygous form in two cases in gnomad database ( , alleles). additional whole-exome sequencing revealed a heterozygous pathogenic nfkb variant (c. dup, pa sfs* ) located in the nterminal rel homology domain, consistent with nfkb loss-offunction. both, the patient's sister (p ) and their father (p ), carry the heterozygous cxcr vus but not the pathogenic nfkb variant, and have history of warts, hypogammaglobinemia, and recurrent infections. the hpv susceptibility is particularly striking in p manifesting by genital warts and hpv-positive oropharyngeal cancer. bone marrow evaluation didn't identify myelokathexis in p (p is pending). the mother of the index case (p ) has cvid requiring igrt and immunomodulation. she shares the nfkb variant with p but is negative for the cxcr vus. extensive t and b cell phenotyping revealed low class-switched memory b cell count ( - counts/ul) in all subjects, and loss of transitional and mature naïve b cells in p and p with nfkb variant. proband b cells showed the highest tendency for apoptosis ( - %) within the family. we describe members of a family with similar presentation (infections, hypogammaglobinemia, warts), however variable combination of nfkb and cxcr variants, where either genetic defect or their combination could explain the clinical phenotype. biochemical consequence of our novel cxcr variant is pending. as the proband showed the most severe immune phenotype and neutropenia, we hypothesize that cxcr has a synergistic effect on nkfb loss-of-function. the contribution of cxcr vus of the clinical phenotype of the two other family members is yet to be determined. background: the yield of diagnosis by exome sequencing for some primary immunodeficiencies (pid) has been less than the typical diagnostic rate for clinical exome analysis (~ - %). the relatively low diagnostic rates for certain subtypes of the pids may be attributed to variable expressivity and/or an incomplete understanding of the genetic basis, among others. additionally the extent of multiple diagnoses and phenotypyic expansion in pid is not well explored. cohorts with highresolution clinical and genetic data are instrumental for exploring these questions. we evaluated the use of human phenotype ontology (hpo)annotated datasets to systematically address the prevalence of these issues using a cohort of individuals with pid who participated in research exome sequencing at the niaid. results: we generated a phenotype dataset of individuals with pids by annotating the clinical features of these subjects obtained from electronic health records (ehr) with hpo terms. exome sequencing of these individuals identified probands with a pathogenic or likely pathogenic (p/lp) variant in a gene associated with the respective clinical presentation. we identified probands where the same gene harbored a p/lp variant in at least three unrelated individuals. we used the clinical and genetic data of individuals in the following areas: ) we identified p/lp variants in aire, pik cd, nlrp , fas, ctla , gata , cybb, stat and tnfrsf b in at least ten patients that explained their clinical presentations. this dataset allowed us to characterize variable expressivity of diseases associated with these genes by capturing the variability in the observed hpo terms among probands with p/lp variants in the same gene. dimensional reduction of clinical features of probands allowed us to cluster patients sharing similar phenotypic profiles. we found clinical presentation of individuals with monoallelic p/ lp variants in aire were relatively less variable and clustered more compactly compared to that of individuals with gata variants. ) the extent of multiple diagnoses in pid is not well explored. the benchmark cohort we developed allowed us to identify candidates for multiple diagnosis or phenotype expansion by comparing the phenotype profile of each patient expressed in hpo terms to the hpo terms typically observed for a given pid. for example, we identified gain-of-function pathogenic variant in pik cd in a patient that explained the clinical features of the pid observed in this patient. however, the patient also displayed developmental delay, congenital hemiplegia, cerebral palsy and absent speech. these features are not known to be associated with pik cd variants, making this individual a candidate for > genetic diagnoses. conclusions: we developed a benchmark dataset where clinical features of patients were described using hpo terms. this dataset allowed us to quantify variable expressivity for certain pid subtypes and to systematically identify potential candidates for multiple diagnosis or phenotypic expansion. abstract/case report text warts, hypogammaglobulinemia, recurrent infections and myelokathexis syndrome is a rare combined immunodeficiency due to autosomal dominant gain-of-function mutations of cxcr chemokine receptor. the late diagnosis of whim syndrome in two ukrainian adolescents highlights the diagnostic challenges in this disease. patient , year-old girl, had recurrent pneumonia since the first year of age; overall she had episodes of pneumonia. she has suffered from chronic bronchitis for last several years. she had recurrent otitis media and chronic pyelonephritis. neutropenia was revealed when she was year old. during episodes of bacterial infections she occasionally had normal value of neutrophils. the girl does not receive any treatment. patient , year-old boy, had three episodes of pneumonia when he was , and year old. others symptoms include recurrent herpetic infection, warts on the hands. since years of age he has haven persistent low neutrophil counts. the child was followed by hematologist and since years of age he has received g-csf ( mg/kg) twice a month. both children have leukopenia - cells/mm , neutropenia - - cells/mm , lymphopenia - cells/mm , low number of bcells - - cells/mm . hypogammaglobulinemia was not prominent in both children, they have slightly decreased level of igg ( , g/l), normal level of igm ( , - , g/l), patient has low level of iga , g/l. patient does not have protective level of antibodies to diphtheria and tetanus anatoxin, and anti-hbs antibodies were absent despite complete immunization. bone marrow aspirate revealed hypercellular marrow with granulocytic hyperplasia which was characterized by hypersegmented nuclei and cytoplasmic vacuolization of neutrophils. on molecular analysis of cxcr , heterozygous mutation c. c>t (p.arg *), known as r x mutation, was detected in both patients, confirming the diagnosis of whim syndrome. replacement therapy with intravenous immunoglobulin was started in both children together with antibacterial prophylaxis and g-scf. vaccination with -valent vaccine against hpv infection was recommended for both patients. whim syndrome is very rare immunodeficiency but may be underdiagnosed. the awareness about rare forms primary immunodeficiency is very important in clinical practice for early diagnosis and treatment. methods: clinical providers recruited from nicer institutions electively completed web-based survey questions related to provider characteristics as well as initial diagnostic evaluation of itp, aiha, ain and es via securequestionpro® software. likert scales ranging from ("rarely" < %), ("sometimes" to %), ("half the time" % to %), ("frequently" to %), and ("almost always" to %) were used to ascertain frequency of evaluation for each diagnostic study. statistical analysis and plotting was done using rv . . . plots were created using packages ggplot , v . . and ggiraphextra v . . . mean likert scale scores were calculated for each study for each suspected disease and plotted on radar charts. results: the survey was completed by providers, including hematology/oncology ( . %), rheumatology ( . %), allergy/ immunology ( . %) and other sub-specialties ( . %). a slight majority of physicians ( %) were fellows or within years of graduation; physician extenders and clinical pharmacists were also respondents. the majority ( . %) of respondents indicated that ≤ new immune-mediated cytopenia patients were seen at their institution annually. the vast majority of respondents ( . %) reported evaluating ≤ new es patients per year at their institution with % evaluating ≤ cases annually. collated data from all respondents showed that in all disease states, the primary evaluation was focused on peripheral destruction mechanisms; the majority of patients are only "sometimes" or "rarely" evaluated for bone marrow failure syndromes, connective tissue disease, immunodeficiency and non-malignant lymphoproliferative disorders, but when done were more likely in es ( figure ). evaluations were biased by sub-specialty with higher degrees of connective tissue focus by rheumatology and immunodeficiencies by allergy/immunology (table ) . genetic sequencing was "frequently" or "almost always" sent in . % of itp, . % of aiha, . % of ain and . % of es p a t i e n t s . p e r s o n a l o r f a m i l y h i s t o r y o f a u t o i m m u n e / hyperinflammatory disease, malignancy or cytopenias most strongly influenced the decision to send genetic testing. lack of insurance coverage/negative financial impact on the patient and concerns about the inability to resolve variants of uncertain significance were the biggest barriers for obtaining genetic testing. conclusions: current practices in the evaluation of immunecytopenias are heterogeneous by sub-specialty and globally limited in scope with few patients being evaluated for underlying etiologies. in particular, despite a known high frequency of pathogenic variants in es, less than a third of patients are undergoing sequencing, highlighting a need to reduce barriers to genetic testing. development of a consensus guideline with multi-disciplinary engagement to harmonize an optimal evaluation for patients with immune-mediated cytopenias is needed. interferon regulatory factor- (irf ) binding protein- (irf bp ) was originally identified as a transcriptional co-repressor of irf ( ). mutated irf bp was identified in a -member family with recurrent sinopulmonary infections, progressive hypogammaglobulinemia, and poor response to protein vaccines ( ) . we have now identified additional families ( subjects) with irf bp mutations. clinical histories show an expanded phenotype with / having chronic gastrointestinal disease; with gastrointestinal manifestations as the initial clinical complaint. five had granulomata in liver(x ), spleen, lung(x ) and gastrointestinal tract. five out of six tested had poor pneumococcal vaccine responses and four patients reported viral infections including varicella zoster(x ), influenza a and sapovirus. irf bp is a amino acid protein containing a highly conserved cterminal protein-protein interaction ring domain (rd). constraint metrics from gnomad indicate mild tolerance to missense changes and intolerance to loss-of-function alleles. we identified categories of mutations: rd mutation or deletion (n= patients), null alleles (n= ) and non-rd missense changes (n= ). functional studies assessing the ability to affect nfatdriven luciferase expression were performed. rd mutations ( / ) had more profound loss-of-repression than wild-type, while missense changes had lesser, but still measurable effects. further, mutation categories and functional studies correlated with clinical phenotypes. of patients with rd mutations, / had infections as presenting symptoms, / tested had hypogammaglobulinemia and / were diagnosed with cvid. one patient with a missense rd mutation had only an infectious phenotype (pulmonary mycobacterium avium) with slight decrease in immunoglobulins; in functional studies this mutation had the least effect of the rd mutations. haploinsufficient patients reported respiratory infections ( / ), recurrent urinary tract infections ( / ), gastrointestinal disease ( / ) and hypogammaglobulinemia ( / ). in contrast, / patients with non-rd missense changes presented with gastrointestinal complaints while only patients had infections (recurrent bronchitis, shingles). gi disease prevalence is consistent with high levels of irf bp expression in the colonic crypt cells (human protein atlas). to confirm this, immunohistochemical staining of colon biopsies from two patients was performed, identifying epithelial and glandular cells of the colon. irf bp is involved in multiple processes, including the negative regulation of nfat signaling( ), tcr signaling( ), inflammatory macrophages ( ) , and pd-l transcription ( ) . interaction with the glucocorticoid receptor affecting anti-inflammatory and metabolic transcription ( ) has also been reported. these observations highlight the irf bp response to type-i interferons (irf ) and tcr stimulation (nfat), regulation of inflammatory macrophages and co-regulation of glucocorticoid receptor mediated signaling. the expanding role of irf bp in multiple biologic systems correlates with the broad clinical presentation we observed in our patients. further studies utilizing irf bp mutation knock-in mice will help characterize the gastrointestinal, lung and immune pathology seen in our cohort. abstract/case report text common variable immunodeficiency (cvid) is a disorder of antibody deficiency arising from over genetic lesions. the clinical presentation of patients with cvid varies from recurrent, severe infections to autoimmunity. the immune dysregulation in cvid is especially difficult to treat and the lifespans of patients suffering from autoimmunity are much shorter than those without such complications. unfortunately, we have no way to identify which patients fall into which categories, or even know how many sub-categories of cvid there are. therefore, the field requires a method to classify patients into categories to precisely recognize and aggressively treat the more severe phenotypes. we address this goal by integrating analyses of patient exomes with analyses of cellular signaling. by analyzing stimulation assays with phospho-protein mass cytometry and high-dimensional data analytics, we aimed to elucidate signaling and phenotyping deficiencies in patients with cvid. importantly, our panel identifies all circulating immune cell subsets in whole blood. in eosinophils, we found amplified responses of pp , pstat , and cleaved caspase- in response to tlr / stimulation. we found additional amplified responses of pstat and pstat in cd lo monocytes. this finding suggests a previously unidentified role for eosinophils and cd lo monocytes to contribute to the pathophysiology of cvid. we found abormal numbers of memory b cell counts, total switched b cell counts, and igm+, cd + b cell (plasmablasts) counts between cvid patients and healthy controls. cd expression on b cells was significantly reduced in cvid patients as well. these b cell results mirror findings from prior, seminal studies on cvid. notably, we have found higher pd- expression in the effector cd t cells of patients. integrating phenotype data, genetic analysis, and mass cytometry data will provide a deeper understanding of each patient's phenotype and how the are clustered. we also expect that a better understanding of alterations in the exomes and functions of the circulating immune cells of cvid patients will lead to new therapeutic approaches. abstract/case report text objectives: primary atopic disorders are monogenic disorders leading to profoundly dysregulated allergic responses. studying patients with these disorders has been instrumental in expanding our understanding of the pathogenesis of allergic inflammation with therapeutic implications for common polygenic versions of allergic disease. clinical findings: we have identified a now -year old boy who presented with severe eczema, extremely high blood eosinophil counts ( . x cells/l, normal range: - . x cells/l) after birth and very high serum ige levels ( υg/l, normal range: - ug/l) since birth. known allergic disorders and parasitic infections are ruled out. given the extreme phenotype, whole exome sequencing was performed on the trio of patient and parents, and the patient was found to have a homozygous mutation in the evolutionarily conserved fibronectin iii domain of the osmr gene (c. t>a, p.v d) (figure ). osmr encodes oncostatin m receptor-beta, a component of both the osm type ii receptor and the il receptor, and is important for keratinocyte cell proliferation, differentiation, apoptosis and inflammation. mutations in osmr have been reported in association with familial primary localized cutaneous amyloidosis, however this condition was ruled out in this patient through skin biopsy which showed no amyloid deposits. methods and results: we modelled the c. t>a osmr mutation in hek cells and observed a loss of expression of the osmr receptor on the cell surface (with normal intracellular protein levels). this observation was mirrored in primary fibroblasts obtained from the patient. signal transduction through phosphorylation of stat and stat and gene expression (il and ccl measured via qpcr) was absent after stimulation with osm in patient fibroblasts. these signaling defects were rescued using a lenti-viral transduction approach to introduce the wild-type (wt) osmr gene. whole transcriptome analysis using rna sequencing confirmed that osm mediated jak-stat signalling pathways were deficient in the patient fibroblasts and were rescued after lenti-viral transduction of wt osmr. rna sequencing analysis also suggested significantly enhanced expression of genes in the nf-κb signalling pathway (e.g.: il and cxcl ) and decreased expression of genes in the tgf-β signalling pathway (e.g.: smad and smad ) in patient fibroblasts at baseline. this was also rescued upon lentiviral transduction. conclusion and future directions: our findings shed light into the disease mechanism of a novel primary atopic disorder, caused by a homozygous missense mutation in osmr. abstract/case report text -year-old caucasian female presented to immunology clinic with hypereosinophilia, eosinophilic esophagitis, peptic ulcer disease, severe gi bleeds, and chronic hepatitis. healthy throughout childhood, with minimal infectious history. in adolescence developed chronic severe myalgias and nsaid overuse, to which the peptic ulcer disease and bleeding were attributed. parents healthy and non-consanguineous. son with severe bleeding episodes and small stature. on exam she weighed lb, bmi . sclerae anicteric. tongue deeply furrowed. cervical nodes palpable. heart and lung exam normal. no hepatosplenomegaly. no clubbing of the digits or edema. skin was clear. wbc , /ul, eosinophils /ul, hemoglobin g/dl, normal platelet count. however, platelet aggregation testing abnormal. bone marrow normocellular, and flow cytometric and molecular analysis did not show hematolymphoid malignancy, primary hypereosinophilic syndrome, or systemic mastocytosis. lymph node biopsies did not show lymphoma or aberrant t cell populations. noted to have chronically elevated creatine phosphokinase, ranging from - u/l over two years at our institution. deltoid muscle biopsy showed non-specific myelopathic changes. an adult dystrophy immunostaining panel was normal. ultrastructure examination showed no abnormal storage material. a genetic panel for metabolic myopathies failed to reveal a cause. total igg, iga and igm normal. ige elevated at ku/l, and igg subclasses showed igg elevated at mg/dl. flow cytometry showed normal t, b and natural killer cell numbers. normal proportions of naïve, mature and activated t cells. vaccine response assessment was normal. evaluation for autoimmune/rheumatologic diseases was negative. liver biopsy demonstrated findings consistent with primary or secondary sclerosing cholangitis (without increased igg staining). given her inflammatory phenotype, additional genetic analysis was sent, assessing for primary immunologic disorders. this identified heterozygous variants of uncertain significance in ctla (c. t>a; ps t), zap (c. c>g; p.d e), and stim (c. t>c; p.l s). analysis of the ctla variant in vitro revealed that it was expressed normally. foxp expressing regulatory t cells were present in normal proportions in vivo and appeared phenotypically normal. this variant was found in her unaffected father. the zap variant is present in population databases (rs , exac . %), and was felt unlikely to be clinically relevant. the stim l s variant, although not shown previously in human patients, has been previously shown in vitro to be a gain of function mutation [ ] [ ] [ ] . furthermore, familial analysis revealed that this was a de novo mutation arising in the patient, and present in her son. humans with other gain of function mutations in stim and the orai channel it activates have overlapping syndromes including storkmorken syndrome, tubular aggregate myopathy and york platelet syndrome, characterized by chronic myopathy and platelet aggregation defects [ ] . the stim l s mutation is predicted to cause constitutive stim activation and calcium influx and likely provides an explanation for the patient's chronic myopathy and abnormal platelet aggregation. neither eosinophilic disease, nor cholangitis, have been described previously in stim gain of function-related diseases. it is unclear whether these issues are related to this novel stim mutation, or to other genetic or environmental influences. treatment of diseases caused by overactive crac channels is challenging as no pharmacologic inhibitors are yet clinically available. nomid/cinca syndrome is one of the periodic syndromes associated with cryopyridines. it is a defect in the innate immune system causing excessive activation of the inflammasome, with consequent il- secretion and neutrophil recruitment. clinically, damage occurs to organs such as the skin (neutrophilic urticaria), central nervous system (meningitis and deafness) and joint (arthritis). levy et al. ( ) evaluated a large series of patients and median onset age was . years, while the median age at diagnosis was years, although the symptoms initiate in the first days of life. treatment includes corticosteroids, which act by nonspecifically blocking all inflammatory cytokines, or by blocking il- specifically. if early diagnosis and treatment of the disease is not made, natural evolution leads to motor and adaptive disability and death in % of cases already in adolescence due to infection, neurological complications or secondary amyloidosis. we report a -month-old male child from nonconsanguineous parents who presented shortly after birth, multiple scaling and erythematous lesions throughout the body, evolving with following symptoms: abdominal abscess, hepatitis, meningitis and pioarthritis. laboratory tests showed elevation of inflammatory tests (esr, crp, amyloid protein a) and leukocytosis. the diagnosis was suspected at the nursery where the patient remained hospitalized for days. a personalized multigene panel was requested. it was identified the variant p.gly val, heterozygous for nlrp gene, not described in the literature, confirming the diagnosis of cinca/nomid syndrome. after discharge, it was introduced prednisolone ( , mg/kg/day) and antiinterleukin- (il- ). after the second dose, skin lesions and joint edema regressed, weight gain, and neuropsychomotor development improved. this case reports a very early diagnosis of nomid/cinca syndrome. it warns neonatologists and pediatricians about the need of precocious recognition of the syndrome, probably improving the prognosis of the patient. professor/university center health abc abstract/case report text background: leprosy affects more than , people worldwide. brazil represents the rd. country in the world in leprosy frequency and maranhão state is an hyperendemic region. the city of imperatriz (ma) stands out as a reference center in the care of these patients. according to few reports, lectin pathway of complement system may play a role in susceptibility to leprosy. mannose binding lectin (mbl) and ficolins (fcns) recognize patterns of sugars and acetylated residues (pamp), respectively, in a wide variety of pathogens, including m. leprae. high levels of ficolins and mbl may act unfavorably promoting the spread of m. leprae. the present study evaluated the role of ficolin and mbl in m.leprae patients and contacts. methods: a cross-sectional case-control analytical study was carried out, evaluating clinical and epidemiological data and serum levels of mbl and fcn (elisa) from july to april . the study was approved by ethics committee and informed consent forms were signed before sample collection. data analysis was performed using the spss . for windows statistics program. results: we evaluated serum samples ( patients and healthy family contacts), . % were female, % under years old, % african-brazilian, % of the families had more than contacts at home. clinical data showed multibacillary forms in . %; dimorphic ( %) and virchowian clinical forms ( . %), up to affected nerves in ( . %) and more than lesions in ( . %). it was observed that ( . %) had a reaction, being type ( %) more predominant. disability grade was found in patients ( . %). in children under years, . % were multibacillary, . % dimorphic and % undetermined; ( . %) also had reactions, % type reaction and degree of disability in . % of children with the disease. the evaluation of serum fcn and mbl levels for the patients (n = ) and contacts (n = ) were . ng/ml and . ng/ml, (p = . ), and . ng/ml (p) and . ng/ml (c) (p = . ), respectively. there were lower values of fcn in patients with type reaction (sudden and intense inflammatory processes) versus no reaction ( . ng/ml vs . ng/ml) (p = . ) and in patients with disability grade (severe sequelae) versus disability grade ( . ng/ml vs . ng/ml) (p = . ). higher fcn values was observed in patients with no disability ( . ng/ml) (p = ). mbl concentrations were higher for patients above years in comparison with patients below that age ( . ng/ml vs . ng/ml)(p = . )) and correlated with the occurrence of a multibacillary clinical form. conclusions: mbl and fcn levels were not different in the patients and contacts of m. leprae, nevertheless the presence of severe forms with sequelae (reaction type and disability grade ) were associated with lower levels of fcn . in addition, it is possible that lower mbl levels could influence the higher frequency of multibacillary disease below years old. abstract/case report text introduction: hyper ige syndrome (hies) is a primary immunodeficiency characterized by elevated ige levels. symptoms can range from severe eczema, recurrent skin infections or pneumonias, and typical dysmorphic facies. there have been wide non-immunologic presentations in patients with hies, including retained primary teeth, scoliosis, craniosynostosis, arterial aneurysms and joint hyperextensibility. an association between hies and autoimmune hemolytic anemia (aiha) has further been described in the literature. however, there have been no reported cases of hies in association with iron deficiency anemia and concurrent pica. we present a unique case of a patient with a history of eczema, recurrent skin infections and pica found to have hies and iron deficiency anemia. case presentation: a -year-old boy with a history of allergic rhinitis presented to the allergy & immunology clinic for evaluation of chronic eczema and recurrent skin infections. the patient had a history of multiple hospitalizations requiring intravenous antibiotics for cellulitis and superinfected eczema since he was an infant. symptoms were refractory to the use of multiple skin barrier ointments and oral antihistamines. his mother further noted that for the past two months prior to initial evaluation, he developed a fixation with eating crayons, baby powder and chewing on drywall. physical exam was notable for a dysmorphic face, broad based nose, pale nasal mucosa with ample clear discharge, high-arched palate and lower incisor supernumerary teeth. his skin was characterized by generalized dryness, lichenification and scaly desquamation with boils on extensor surfaces of knees and elbows. initial screening for hies via t-helper functional assay was consistent with decreased expression of il- . genetic testing revealed stat s g missense pathogenic variant consistent with hies. cbc was also notable for decreased hemoglobin at . g/l and mcv of fl. patient was diagnosed with concurrent hies and pica in the setting of iron deficiency anemia. iron supplementation was started and patient's pica improved. discussion and conclusion: our patient with hies had a peculiar initial presentation with the classic signs and symptoms of hies and pica. the diagnosis of hies can often be delayed due to the wide range of clinical presentations. to our knowledge, the association of hies with iron deficiency anemia and pica has been underreported in literature. screening for anemia should be considered when evaluating patients with hies in order to rule out comorbid iron deficiency anemia which can be easily treated with iron supplementation. abstract/case report text introduction: common variable immunodeficiency is a primary immunodeficiency with variable and diverse phenotypic presentations. the two main phenotypes include a group which primarily exhibits recurrent infections and a group with or without infections and primarily inflammatory and autoimmune complications. the latter, may lead to a delay in diagnosis and is associated with poorer outcomes and higher morbidity and mortality. ( ) another group of patients present with t-cell defects, lung disease, autoimmunity, and infections and may be diagnosed as having cvid but instead can have mutations in lrba or pi kinase. this subset of patients has been referred to as "cvid-like" in the literature. ( ) case presentation: patient is an year old female who initially presented to an outside facility due to days of fatigue, fever, and abdominal pain. upon presentation, she was found to have massive splenomegaly, hepatomegaly, and an abnormal chest x-ray showing mediastinal lymphadenopathy and pleural effusion. laboratory results demonstrated pancytopenia, hypogammaglobulinemia, and low b cells, t cells, and nk cells via flow cytometry. she was transferred to our institution for further work up. she did not have any prior history of recurrent infections, asthma/lung disease, or autoimmune conditions. initial ct of the chest was consistent with granulomatous lymphocytic interstitial lung disease. patient was diagnosed with common variable immunodeficiency with granulomatous lymphocytic interstitial lung disease and was treated initially with high dose ivig, corticosteroid taper, rituximab, and imuran. she had interval worsening of pft and lung disease as shown by ct scan. genetic panel for cvid and related conditions revealed variants of unknown significance. one heterozygous mutation in blnk gene (c. g>a) and one heterozygous mutation in lrba gene (c. g>a). she was started on infliximab with plans to repeat ct scan in months. discussion: mutations in both blnk and lrba have been associated with primary immunodeficiency. mutations in blnk, which is located on chromosome , have been associated with autosomal recessive agammaglobulinemia. homozygous or compound heterozygous mutations in lrba on chromosome , can lead to lrba deficiency which encompasses a wide range of clinical presentations including hypogammaglobulinemia, autoimmune disease, inflammatory bowel disease, antibody deficiency, organomegaly, and recurrent infections. ( ) without genetic testing, the clinical presentation can be difficult to distinguish from common variable immunodeficiency. the patient presented has clinical features that can be seen with mutations in both blnk and lrba, however she is heterozygous for both mutations. further analysis, including measurement of lrba protein expression, is needed to further define her underlying immunodeficiency so appropriate treatment can be administered. abstract/case report text a month-old, previously healthy, unvaccinated male presented with one week of diarrhea and cough and was admitted for dehydration and hypoxemia. his mother and sister both had a history of incontinenti pigmenti (ip). on physical exam, he was alert, afebrile, with tachypnea and subcostal retractions. enterovirus/rhinovirus and parainfluenza were detected, but he became progressively hypoxemic and eventually required intubation and high-frequency oscillatory ventilation. chest x-ray showed multifocal bilateral airspace opacities. empiric treatment for pjp with trimethoprim/ sulfamethoxazole and glucocorticoids was started. tracheal aspirate pcr confirmed p. jiroveci. hiv rna pcr was negative. ivig was started due to suspicion for primary immunodeficiency. although his respiratory status gradually improved, he subsequently developed multiple skin lesions. skin biopsy grew mycobacterium szulgai. m. szulgai osteomyelitis of the right fibula and the left nasal bone was also detected, indicating hematogenous spread of the infection. he was started on four-drug anti-mycobacterial therapy and interferon-gamma (actimmune) at doses ranging from μg/m^ three times weekly to μg/m^ qod. immune work-up revealed t-cell lymphopenia [cd +/cd + /μl ( - , /μl) and cd +/cd + /μl ( - , /μl)] with an abnormally increased proportion of memory cd t-cells compared to naïve cells for age. b-cell numbers were normal, and nk cells were decreased [cd +cd +/cd - /μl ( - /μl)]. nk cell lytic function by k lysis was normal, whereas cd a degranulation was decreased. the serum igm level was normal [ mg/dl ( - mg/dl) whereas iga [ mg/dl ( - mg/dl)] and igg [ mg/dl ( - mg/dl)] were elevated. mononuclear cell cytokine response to ligands for tlr -tlr , tlr -tlr , tlr , tlr , and tlr -tlr was normal. dna sequencing revealed a novel nonsense mutation in exon of the ikbkg (p.gln ter (q x) (cag>tag): c. c>t, confirming the diagnosis of nemo deficiency, which was suspected based on the infectious disease presentation and the maternal history of ip. the diagnosis was further supported by signs of ectodermal dysplasia of teeth that appeared starting at months of age. he underwent hsct using bone marrow from a / matched unrelated donor after conditioning with atg, busulfan, fludarabine and rituximab. actimmune therapy was continued until days prior to transplant. for gvhd prophylaxis, he received tacrolimus and low-dose methotrexate. he achieved full donor chimerism post-transplant and has had no significant gvhd. interesting features of this case include the prominence of ip in mother and sister, which is usually due to female heterozygosity for an ikbkg null allele. such null alleles when inherited by the male fetus are embryonic lethal. our patient's nonsense mutation would be expected to result in severely impaired ikbkg protein expression and function. however, the fact that he had was born at term and initially was healthy coupled with his preservation of normal tlr function suggests that his ikbkg allele is likely to be a hypomorphic mutation. studies are in progress using ebv-transformed b-cell lines from the patient to evaluate ikbkg expression and function. also of interest, our patient was able to tolerate relatively high doses of interferon-gamma therapy without inflammatory side effects or an adverse impact on engraftment or gvhd. abstract/case report text background: primary atopic disorders are caused by genetic mutations that skew the immune system towards severe allergic disease. germline gain-of-function (gof) mutations in jak are a newly described monogenic cause of severe atopy, with affected patients demonstrating profound eosinophilia and allergic inflammation. our initial report of this novel condition identified a dramatic clinical response to the combined jak / inhibitor ruxolitinib. we aimed to determine the long-term clinical response to ruxolitinib in patients carrying a germline jak gof mutation, and to characterize the effect of enhanced jak signaling on t lymphocyte effector functions and hematopoiesis. methods: clinical outcomes were evaluated in two pediatric patients carrying the c. c>a (p.a d) gof mutation in jak after . years of ruxolitinib treatment. t cell phenotyping was performed using extracellular surface marker and intracellular cytokine staining by flow cytometry, and by gene expression signature profiling of rna sequencing data. to evaluate the effect of enhanced jak activity on myelopoeisis, we reprogrammed jak gof patient-derived peripheral blood mononuclear cells into induced pluripotent stem cells (ipsc) and performed directed myeloid differentiation. rna sequencing was performed on rna collected during ipsc myeloid differentiation and from whole blood of affected patients before and after ruxolitinib treatment. results: long-term use of ruxolitinib was associated with improved growth, reduced eosinophilia, and control of allergic inflammation without significant infectious complications, however, anemia represented a dose-limiting adverse effect. t cell immunophenotypic analysis revealed severe t helper (th) cell skewing towards a th phenotype preruxolitinib treatment, in keeping with the allergic clinical manifestations. analysis of myeloid differentiation revealed an increased myeloid to erythroid ratio in colonies derived from jak gof ipscs compared to controls. rna sequencing analysis of jak gof human whole blood and ipscs compared to controls revealed upregulation of cytokine and cytokine receptor genes implicated in allergic inflammation and early eosinophil precursor commitment, including csf- and the interleukin- receptor. reactome pathway analysis of genes upregulated in both jak gof ipsc and whole blood compared to controls showed enrichment of several pathways including interferon alpha/beta, interleukin- /- and interleukin- signaling. conclusions: this work demonstrates a critical role for jak in atopic immune dysregulation, specifically driving a th phenotype and eosinophilia. combined jak / inhibition can reverse much of the allergic inflammation, with dramatic clinical effects. this has important implications for our understanding of the pathogenesis and potential therapeutic targets for early life allergic immune dysregulation. had severe combined immunodeficiency (scid) and/or severe disease in association with their combined immunodeficiency (cid) necessitating haematopoietic stem cell transplantation (hsct). we present clinical and laboratory features of new zealand patients from the same family with a novel heterozygous missense variant in rac [c. t>g, p.ile ser (i s)]. the index patient (p -age y, m) has a history of infectious gastroenteritis, staphylococcal aureus conjunctivitis, recurrent otitis media and recurrent herpes simplex virus (hsv)- cutaneous infections. his siblings (p age y, m; p -age y, f) and his mother (p age y, f) all have a history of recurrent viral (hsv- ) and bacterial (staphylococcal aureus, streptococcal pyogenes) cutaneous infections and/or recurrent sinopulmonary infections that respond to empiric antimicrobial therapy. their neutrophils all had enhanced superoxide production in response to stimulation by fmlp and pma as compared to healthy controls'. these findings suggest that rac i s is an activating mutation causing notable abnormalities in neutrophil morphology and nadph oxidase activation similar to other recently reported mutations. this novel mutation expands the phenotypic spectrum of rac activating mutations. clinical management of affected patients needs to be tailored to their phenotype and disease severity. background and aims: heterozygous mutations in cytotoxic tlymphocyte antigen- (ctla ) are associated with recurrent infections, lymphoproliferation, autoimmunity and lymphocytic infiltration of target organs. disease penetrance can be highly variable even among related family members carrying the same ctla mutation. our evaluation of a subset of the ctla patient cohort followed at the national institutes of health (nih) revealed that % of ctla mutation carriers have gastrointestinal (gi) manifestations which include diarrhea and diffuse lymphocytic enteropathy. our aim was to determine whether the intestinal microbiome, metagenome and metabolome could distinguish patients with ctla haploinsufficiency (ctla -h) based on disease severity, and the presence or absence of gi manifestations. methods: clinical metadata and fecal samples were collected from healthy individuals (n= ) and patients with ctla -h (n= ). patients with ctla -h were classified as having minimal (n= , only endocrine and/or dermatological manifestations) or systemic disease (n= , hematological and multi-organ involvement). they were further classified based on whether they had a history of enteropathy (n= ) or active gi disease ( < bowel movements per day and/or blood or mucus in stool) at time of sampling (n= ). metabolomic profiling (using a panel of metabolites) and s rrna gene sequencing (v region) was performed on fecal samples (total samples: ; number of reads/sample: , to , ; median: , ). a subset of samples were subjected to shotgun metagenomic sequencing based on findings from the s rrna gene sequencing analysis. results: all patients with ctla -h and a history of enteropathy or active gi disease also had systemic disease. fecal samples from patients with a history of enteropathy had a distinct microbial community structure (fig. ) which was significantly less diverse (fig. ) compared to healthy individuals and patients with minimal vs. systemic ctla -h. patients with a history of enteropathy had significantly higher relative abundance of bacterial taxa including shigella-escherichia (fig. ) . shotgun metagenomic sequencing confirmed that samples from patients with a history of enteropathy were dominated by subsets of identified escherichia coli strains, all of which share genes coding for specific types of virulence factors such as curli fibers (facilitate uptake into host cells), flagellar proteins (increase motility) and enterobactins (increase bacterial iron transport). meanwhile, samples from patients without active gi disease at the time of collection were enriched for several taxa including bacteroides nordii and akkermansia muciniphila compared to patients with ctla -h and active gi disease (fig. ) . metabolomic analyses showed that asparagine, -hydroxybutyrate, cytosine and cystine were enriched in samples with abundant e. coli, whereas samples without e. coli were enriched in metabolites involved in pyrimidine (holm p= . ), purine (holm p= . ), and alanine/aspartate/glutamate metabolism (holm p= . ) (fig. ) . conclusions: fecal samples from ctla -h patients with a history of enteropathy were heavily colonized with e. coli strains that are associated with a specific metabolomic profile and that share virulence factor genes that may facilitate host invasion. these data suggest that the microbiome and metabolome can distinguish patients with ctla -h and gi disease, and support the potential use of antibiotics or even antimetabolites to treat ctla -hrelated enteropathy. the dna polymerase delta (pol δ) complex is essential for leading and lagging dna strand synthesis. its catalytic subunit (pold ), carries both polymerase and exonuclease activities and plays a crucial role in dna replication and repair. heterozygous pold mutations have been associated with inherited colorectal cancer and mandibular hypoplasia, deafness, progeroid features and lipodystrophy (mdpl) syndrome. more recently a biallelic loss of function mutation in pold (p.r c) that impairs the stability of the pol δ complex, has been reported in related subjects with recurrent infections, deafness and combined immunodeficiency (cid) with t-cell lymphopenia, cd + t cell oligoclonality but preserved b cell proliferation. we report here a second family in which a novel biallelic missense mutation in pold gene was associated with cid. the proband is a -year-old boy born to consanguineous pakistani parents. since infancy he suffered from failure to thrive and recurrent infections, including episodes of pneumonias, multiple otitis media, sinusitis, recurrent cellulitis at the g tube site, bk viruria and shingles. live and dead vaccines were well tolerated. at years of age sensorineural hearing loss together with profound leukopenia (anc cell/μl, alc cells/μl) and hypogammaglobulinemia ( mg/ dl) were identified. intermittent ivig replacement and antimicrobial prophylaxis were initiated. immunophenotyping at years of age showed severe t cell lymphopenia ( cd + cells/μl, cd + cells/μl, cd + cells/μl, figure . volcano plot of metabolites present in fecal samples enriched with e. coli vs. samples without e. coli. c e l l s / μ l , c d + c d h i f o x p + c e l l s / μ l ) , a n d hypogammaglobulinemia (igm mg/dl, igg mg/dl, iga < ). physical exam was remarkable for multiple acquired nevi in the groin area, teeth abnormalities and global developmental delay. whole exome sequencing analysis revealed a homozygous pold missense variant (nm_ c. c>g, p.q e) absent in public databases (cadd score of ). parents were heterozygous. tcr-vβ family expression was normal in both cd + and cd + t cells, but the proportion of t cells expressing vα . (encoded by the distal trav - gene) was markedly reduced (less than %), consistent with impaired vdj recombination at the tra locus and/or with defective thymocyte survival. constitutive expression of γh ax was observed in t and nk cells after h and h of culture in unirradiated conditions. at h post-irradiation ( gy), reduced levels of p-atm were detected in t and nk cells, and lack of atm, smc and h ax phosphorylation was observed in a subset of b cells, suggesting inability of these cells to mount an effective dna repair response. bone marrow examination showed normal trilineage hematopoiesis but decreased proportion of cd -cd + mature b cells and increased proportion of pre-b cells. conclusion: we report the second mutation associated with autosomal recessive pold deficiency. our findings broaden the understanding of the mechanisms underlying the immune defect in this disease to include b cell maturation arrest in the bone marrow and a dna repair defect that may support the generation of a restricted tcr repertoire in the thymus and increased malignancy risk. abstract/case report text following allogeneic hematopoietic cell transplantation (hct) for scid, the development of a diverse t cell repertoire is essential for optimal immune recovery. high-throughput sequencing (hts) of the trb repertoire is the best tool for the evaluation of clonotype dynamics during immune reconstitution as compared to cdr spectratyping and staining of vβ families. we investigated whether longitudinal hts analysis of trb would accurately assess development of tcr repertoire diversity over time and reflect the quality of t cell reconstitution following hct for scid. we wanted to study the effect of conditioning regimen, scid genotype, donor type on tcr diversity post hct. we hypothesized that repertoire diversity may represent an early biomarker to predict long-term immune reconstitution vs. need for a second intervention. we assessed if the trb repertoire post-hct carried a molecular signature of selfreactivity. methods: the composition and diversity of trb repertoire of scid infants, pre-hct and at d, and mo and yearly posttreatment(s) was studied by hts. median time of follow-up was mo. subjects were part of a prospective study of scid by the primary immunodeficiency treatment consortium. equal amounts of total rna extracted from peripheral blood was used as template to semi-quantitatively amplify trb rearrangements. the vdj statistics file (past program) was used to calculate a shannon entropy (h) index of repertoire diversity and simpson ( -d) index of repertoire clonality. results: trb sequence analysis of scid patients showed poor diversity at baseline, followed by improvement to normal complexity (h index > . ) after hct. similar kinetics of development of trb diversity were seen in patients with il rg, jak , and il r defects (n= ) as in those with rag and artemis defects (n= ). in the latter group, however, hct with no conditioning or immune suppression only was associated with persistently lower diversity than hct with conditioning (p < . ), a difference not found in the il rg/jak /il r group (fig. ) . hct from a matched donor ( / conditioned) correlated with higher diversity than hct from a mismatched donor ( / conditioned) (p= . ). having > cd + t cells/ul at mo post-hct correlated with higher trb diversity at and mo post-hct (p < . ). the trb repertoire d post-hct was enriched for the presence of central cysteines at the apex of the cdr (p < . ), a biomarker of self-reactivity ( fig. ). an h-index of . or lower at d after hct predicted need for second intervention (hct or gt) (fig. ) . conclusions: analysis of trb diversity allows for detailed assessment of development of a diverse t cell repertoire following cellular therapies for scid and confirms the need for patienttailored treatment strategies based on scid genotype. t-cell repertoire d post-hct is characterized by a molecular signature that may contribute to the increased rate of autoimmunity early post-transplant. furthermore analysis of trb diversity at d post-hct may identify patients at risk for failure of sustained immune reconstitution, thus prompting a second intervention without delay. abstract/case report text background atopic dermatitis is a chronic, multifactorial, relapsing inflammatory skin condition which is one of the main known health problem worldwide. atopic dermatitis lesions are frequently colonized by staphylococcus aureus and staphylococcus epidermidis. their susceptibility to form biofilms, ability to form adhesive skin colonies which lead to extremely resistant to antibiotics and immune responses. formation of skin biofilm resulted in complex bacterial communities that have unique effects on human keratinocytes, mouse fibroblasts and host immunity. aims: the aims of this study to confirm the specificity of s. aureus or its secreted factors in induction of pro-inflammatory cytokines il- , tslp and toxicity on human keratinocytes and mouse fibroblast. the second aim to study the inhibitory effect of co-culture of s. epidermidis with s. aureus in term of production of pro-inflammatory cytokines and toxicity. method and materials: human epidermal keratinocytes and mouse embryonic fibroblasts cell lines from t were used as a control strain to examine production of inflammatory response (il- and tslp) and cell death induced by s. aureus in the presence and absence of s. epidermidis. tslp and il- were detected by elisa and the apoptosis of s. aureus and s. epidermidis on these cells was evaluated by flow cytometry. result: recent findings propose the important role of skin biofilms in the pathogenesis of atopic dermatitis. s. aureus have been found to induce secretion of pro-inflammatory cytokines and cause apoptosis of human keratinocytes and mouse fibroblasts. presence of s. epidermidis as skin biofilm found to protects the human keratinocytes and mouse fibroblasts from induction of proinflammatory cytokines and cytotoxicity. conclusions and future work: s. aureus are essential in production of inflammatory response and cell death of mouse fibroblasts and human keratinocytes. future work will be carried out to identify the soluble factors that responsible in induction of pro-inflammatory cytokines. in addition, more studies are needed to be able to understand the mechanism by how s. epidermidis reduce the induction and cytotoxicity caused by s. aureus. j clin immunol in adult patients, in whom arbitrarily defined diagnostic criteria for antibody deficiency syndromes are not fulfilled, is subject to interpretation and decision differences reported by immunologists world-wide. in this study, we explored whether training in one particular program would decrease the variability in diagnostic and treatment approaches seen in the responses to two nationwide questionnaires in the uk and the usa. methods: a -minute online survey originally administered to a cross-sectional sample of us allergists/immunologists (usa/i) in january, , was also answered by a/i subspecialists who had trained in the last years at the louisiana state university health science center allergy immunology training program in new orleans (laa/i). respondents were asked questions on patient assessment, antibiotic use, initial igrt, and immune response assessment in decisionmaking to prescribe igrt. usa/i participants were recruited from the dynata physician professional panel. laa/i participants were recruited by the louisiana primary immunodeficiency network (lapin). results: overall, laa/i had consensus responses to the various practice questions close to % of the time, but outliers were always present, as was also observed in the usa/i. there was a higher frequency in the reported care of patients as described in the questionnaire by laa/i. over % of laa/i assessed vaccine responses prior to commencing igg replacement vs only % of usa/i p < . . all la a/i used the pneumococcal vaccine for assessment purposes while few used tetanus and hemophilus influenza, and none used meningitis or salmonella vaccines. these vaccines were still used by some of usa/i. a high level of concordance was observed among all respondents in that only few regarded pneumococcal antibody testing as the definitive test to commence igrt. high resolution chest ct scan was used more often by laa/i before starting igrt. assessment of effectiveness of igrt was decided after only months by more usa/i, vs laa/i, who tended to wait months to decide to continue or discontinue igrt. conclusions: all a/i responders saw a significant number of patients who do not conform to strict diagnostic criteria for antibody deficiency syndromes. there is diversity in the approach of usa allergists/ immunologists in determining the indication for igrt for non-classical antibody deficient patients. laa/i responses made it obvious that post graduate influences always play a role in shaping the way a/i practice evolves after graduation. drawing on clinician experiences through questionnaires offers a valid contribution to developing consent approaches to improve patients' clinical conditions. diagnostic criteria and treatment guidelines would benefit from practice-based realistic recommendations based on a/i experience. abstract/case report text background: autoimmune lymphoproliferative syndrome (alps) is a rare genetic disorder secondary to a defective fas-mediated apoptotic pathway of mature lymphocytes. it is characterized by chronic nonmalignant lymphoproliferation in the form of lymphadenopathy and/or splenomegaly, autoimmune manifestations such as cytopenias, increased risk of lymphoma, and expansion of tcrαβ+ cd -/cd -(dnt)t-cells. germline or somatic pathogenic variants in fas, fasl, and casp are well described genetic defects associated with alps. the definitive diagnosis for alps, based on the revised nih diagnostic criteria, include both required criteria (chronic non-malignant, non-infectious lymphadenopathy, splenomegaly, or both and elevated tcrαβ+ dnt t-cells) and one of the primary accessory criteria (defective lymphocyte apoptosis or mutation in the genes mentioned above). patients who do not meet the current diagnostic criteria are considered for alps-related disorders. case presentation: we report a -year-old male who presented with recurrent infections, splenomegaly and chronic lymphadenopathy since month of age. due to its chronicity he was evaluated by multiple specialists for malignant and infectious causes. hematological workup including bone marrow biopsy was unremarkable except for an elevated ldh level. infectious workup identified a past cmv infection. clinical course is pertinent for chronic splenomegaly which was identified incidentally at . years of age during an evaluation for intussusception. family history is pertinent for a father with recurrent infections, paternal grandmother with thrombocytopenia of unknown cause requiring platelet transfusions, and paternal cousin with neutropenia. there is no family history of lymphomas. history of chronic lymphoproliferation and recurrent infections prompted an evaluation for lymphoproliferative disorder. full immune workup was notable for elevated plasma il- and il- , normal immunoglobulin levels, lymphocytes subsets, vitamin b level, soluble fasl, and relative frequency (%) but borderline increased absolute count of tcrαβ+ (dn) t-cells. in addition, he was noted to have presence of anti-platelet antibodies, poor lymphocyte proliferation to antigens, and low pneumococcal antibody titers. genetic testing with a pid gene panel identified a likely pathogenic heterozygous variant in prf c. del (p.his thrfs* ), a heterozygous variants of uncertain significance in casp c. c>t (p.pro leu) and stim c. a>g (p.thr ala). the casp variant is present in alleles in gnomad ( k total allele count) and reported deleterious by sift. discussion: unlike the typical alps presentation, characterized by dominantly lymphoproliferation and autoimmunity, our patient's clinical phenotype is striking for recurrent infections, abnormal t-cell function, and poor antibody response. our patient does not the meet diagnostic criteria for alps due to normal relative frequency of dn t-cells. however, presence of elevated of il- , il- , platelet autoantibodies raise concern for alps-related disorder. in addition, family history of recurrent infections and cytopenias raises concern for familial autoimmunity and alpslike phenotype. although casp is associated with autosomal dominant and autosomal recessive alps, the role of this vus is yet to be determined. conclusion: we continue to investigate the pathogenicity of our novel casp vus. further studies include pedigree analysis, fas apoptosis assay and apoptosis pathway testing to assess for the etiology of this alps-related disorder. (word count , max ) abstract/case report text rationale: ocrelizumab is a recombinant anti-cd monoclonal antibody, which binds to a different, but overlapping cd epitope than rituximab. there have been increasing reports evaluating hypogammaglobulinemia and morbidity and mortality in patients receiving rituximab, but there is a paucity of data on hypogammaglobulinemia in patients treated with ocrelizumab. methods: we performed a retrospective review of patients who received ocrelizumab in our healthcare system. we evaluated the demographics, indication for ocrelizumab, frequency of immunologic evaluation, and h y p o g a m m a g l o b u l i n e m i a p r e -a n d p o s t -o c r e l i z u m a b . hypogammaglobulinemia was stratified as mild (igg < mg/ dl or less than lab reference range), moderate (igg < mg/ dl) or severe (igg < mg/dl). results: we identified patients who received ocrelizumab for multiple sclerosis (average number of ocrelizumab cycles = ; range - cycles). there were ( %) female patients, with a mean age of years old (range - ; standard deviation ± t-cells. tnfα, ifnγ, and il- were not statistically different between cgd patients and healthy controls. tnfα, ifny, il- , and il- a expression in patients with cgd who had active colitis or history of colitis were increased as compared to cgd patients without a history of colitis but did not reach statistical significance. in two patients, il- a expression that was elevated pre-hct normalized post-hct. discussion: the mechanism for increased susceptibility to inflammatory disorders in patients with cgd has not been well elucidated. our results agree with previous studies demonstrating increased il- and il- a production from cd + t-cells in patients with cgd indicating a proinflammatory state in these patients at baseline. also, there appears to be an increase in tnfα, ifny, il- , and il- a expression from cd + t-cells that correlates with presence of inflammatory disease vs. those without inflammatory disease indicating that these cytokine perturbations may be able to serve as biomarkers of disease activity. a larger sample size with prospective collection will be analyzed in the future. abstract/case report text background: glucose- -phosphatase catalytic subunit (g pc ) deficiency, is characterized by severe congenital neutropenia, recurrent bacterial infections, mild intermittent thrombocytopenia and a high incidence of congenital cardiac and uro-genital defects. we report the case of a -yo male with chronic neutropenia and thrombocytopenia, who was found to have homozygous pathogenic variants in g pc (c. del, p.phe serfs* ). unique to this case is the patient's long history of misdiagnosis of evans syndrome (chronic autoimmune neutropenia with thrombocytopenia). case presentation: a -yo male with reported diagnosis of chronic autoimmune neutropenia and thrombocytopenia since age was referred to our a b clinic with concern for an underlying immune dysregulation syndrome. he had a history of oral ulcers, gingivitis, recurrent bacterial infections (otitis media, pneumonia, skin abscess) concomitant with severe neutropenia ( < cells/ul), for which he had received treatment with systemic steroids and g-csf since he was years old. he also had history of asthma and short stature, thought to be secondary to his chronic systemic steroid use. we present the first chilean patient with stat gof immunedysregulation . moreover, to our knowledge this is the first stat gof patient presenting with lymphomatoid granulomatosis. this is a severe pulmonary disease in which primary immunodeficiencies including stat gof should be considered in the differential. in this case rituximab successfully resolved pulmonary nodules and respiratory symptoms. there was persistence of mild hepatosplenomegaly but otherwise clinical stability and monitored expectantly until the age of . at that time he presented with fever, left knee and ankle arthritis. he underwent arthrocentesis of the left knee and left ankle, both aspirates were sterile, with notable leukocytosis with heavy neutrophilic predominance. an extensive rheumatologic and infectious workup was non-diagnostic. both sil- r and il- were elevated, , units/ml ( < ) and pg/ml ( < ), respectively. he was treated with systemic corticosteroids, ultimately arthritis resolved after months. at age he presented for the first time with periorbital pain and conjunctival injection of the left eye that persisted after minor trauma. he was found to have nongranulomatous uveitis, which responded ultimately to systemic corticosteroid. he then presented at age with fever and right knee and great toe arthritis. again he underwent arthrocentesis which revealed aseptic arthritis, and at that time was started on anakinra (anti il- β) and prednisone. there was clinical improvement over several weeks followed by return of right knee arthritis, coupled with onset of symptomatic uveitis of the left eye. despite systemic corticosteroids and anakinra and il- blockade, the patient was again admitted shortly thereafter to the hospital with arthritis, fevers, rash and abdominal pain. there was concern for evolving hlh and the patient was ultimately transferred to cincinnati children's for further evaluation and treatment. pertinent inflammatory biomarkers at that time included sil- r of , units/ml and il- level of , pg/ml. in addition to anakinra and systemic corticosteroids, the patient was started on tadekinig alfa (recombinant human il- binding protein) as part of a prospective study. hlh flare ultimately resolved without use of antineoplastic agents, and the patient was discharged home. soluble il- r levels since normalized, and il- levels decreased to less than pg/ml. the patient has been doing well on anakinra and tadekinig alfa, though continues to experience mild to moderate right knee effusion. this case suggests il- inhibition may be an effective therapeutic approach for patients with xiap deficiency. in the absence of neurological involvement and infectious trigger, ruxolitinib was initiated at a dose of mg/m /day, in combination with dexamethasone ( mg/m /day). this treatment led to rapid normalization of the neutropenia ( hours), complete resolution of the splenomegaly ( days) and disappearance of hlh biological markers (triglycerides levels in week, activated hla-dr+ cd t cells in weeks, fibrinogen levels in month), without the need for etoposide or serotherapy. dexamethasone was weaned every two-weeks and stopped after weeks. ruxolitinib was well-tolerated with no side effects. while in complete remission of her hlh, the patient then received alemtuzumab ( . mg/kg total dose) and a fludarabine-based myeloablative conditioning regimen. ruxolitinib was weaned over one week, and a / unrelated transplant was performed with success. the immediate posttransplant period was complicated by a veno-occlusive disease that responded rapidly to defibrotide and a corticosteroidresistant skin and ocular graft-vs-host disease (gvhd) despite a prophylaxis with ciclosporine and mycophenolate mofetil. gvhd was controlled by the reintroduction of ruxolitinib. at months post-hsct, her chimerism is % donor. to our knowledge, this case is the first description of a patient with primary hlh successfully treated in first intent by a combination of dexamethasone and ruxolitinib prior to hsct. our observation suggests that this targeted and less-toxic treatment regimen, that does not include etoposide nor high-dose alemtuzumab, is effective, well-tolerated and could be used in first intent to treat primary hlh. abstract/case report text presentation a -year-old girl, presented in ambulatory consultation, with a -year history of recurrent fever, influenza-like symptoms (sore throat, malaise), associated with self-limited painful genital ulcers (just within the period of fever). the first episode was characterized for an fournier's infection, requiring in-hospital treatment, multiple surgical procedures, antibiotics and hyperbaric oxygen therapy. after that catastrophic debut, she was diagnosed approximately episodes per year pharyngitis (with fever, malaise and sore throat) treated with corticoids, antibiotics and topic medication. the last year, noticed that every episode of fever (total of ) were associated with one or several genital lesions. the patient had no relevant medical history, she didn't receive long-term medication, she received all immunizations, she was sexually inactive, and hadn't apply any topic medication or product on the vulva, there was no trauma history, psychological medical history or sexual abuse. episodic gynecologic examination showed her labia minor several lesions, fibrinous, soft ulcerations on their inner aspect, these lesions had a symmetrical appearance, known as kissing lesions; no vulvar swelling, vaginal discharge or lymphangitis were noticed. there were no other skin or mucous membrane lesions (figure ). investigations viral (hiv, hbv, hcv, ebv, cmv) and treponemal (tpha-vdrl) serologies were negatives. erythrocyte sedimentation rate (esr) and pcr analysis within ulcers episodes were positive. specific antibodies (cardiolipin, anti ro/ss-a, anti la/ss-b, anti ccp, anti ena, anti gliadin, anti tpo anti tpo) serologies were negative. otherwise, important elevation immunoglobulin d was observed ( , mg/dl, twice the normal value): mild elevations of immunoglobulin m and immunoglobulin a were observed. serum subtypes of immunoglobulin g and immunoglobulin e were normal. leukocytosis with monocytes elevation and an increase of lymphocytes b were present. (table ). discussion lipschütz ulcers are uncommon and an often unknown entity for physicians, but it is important to recognize and include it in the differential diagnosis of vulvar ulcerations. this condition is characterised by self-limited painful ulcerations of the vulva or lower vagina in adolescent or young women, non-sexually transmitted, and usually preceded by influenza or mononucleosis-like symptoms. hyperimmunoglobulin d syndrome (hids) is characterized for unremitting fever lasting four to seven days and the presence of palpable tender lymphadenopathy, splenomegaly, arthralgia/arthritis, abdominal pain, and mucocutaneous manifestations. laboratory findings suggestive of hids include elevated age-specific serum immunoglobulin d (igd) and/or immunoglobulin a (iga) levels, elevation of acute phase reactants, and urinary excretion of mevalonic acid during, but not between, attacks. the diagnosis is established if an elevated age-specific level of igd is detected. iga levels are typically measured at the same time but are not required for diagnosis. elevated serum igd is not specific for hids and can occur in patients with certain neoplastic, infectious, heritable, and idiopathic disorders. in the present case report, the patient was treated with colchicine, with favorable evolution and free from new events. levels of ig d, platelets and monocytes remain high. we describe a young female patient presenting recurrent lipschütz ulcers, fever and elevation of serum immunoglobulin d, suggesting that hids could be associated with genitalia ulcers. ( ), and transmission in vivo in extremely low birth weight infants was considered ( ) . based on these considerations, the risk/benefit was considered favorable for restarting pasteurized donor breastmilk feeds. given his small size and young age, we had significant concerns about using ganciclovir prophylaxis and opted to hold this and monitor weekly cmv pcr. the child has been titrated up on these feeds, is gaining weight appropriately, and has had weekly cmv pcrs which are negative x since restarting donor breastmilk. t cells, last checked at weeks of age ( weeks gestational age) remain essentially absent. given the lower risk of nec in premature infants with breastmilk-based enteral feeds, a broader, multi-institutional study is warranted to best examine the safety of pasteurized donor breastmilk in infants with scid and complete digeorge syndrome. transfected with a reporter plasmid (for luciferase), wt or mutant-stat plasmids. nk cell cytotoxicity was measured by cr release assay. we used multiparametric immune profiling to dissect the effect of stat -gof mutations on nk cell developmental phenotype. results: similar to our previous studies, we observed higher levels of stat phosphorylation after two hours of stimulation from the dbd mutation compared to the ccd mutations. the stat activity assay confirmed gain of function observed by flow cytometry, but this activity was higher in k q mutant and d e mutant (ccd-closer to dbd) than v i mutant. all patients demonstrated low nk cell lytic unit compared to healthy donors. interestingly, we observed a correlation between low lytic unit and lower numbers of cd dim perforin + cd + nk cells; much lower in patient with k q mutation. stat -gof patients showed a significant decrease in total nk cell numbers and impaired nk cell maturation was characterized by low expression of cd , and higher levels of immature nk cell markers (cd , nkg a, cd b). conclusions: these data suggest that impairment of nk cell function is affected by the location of the stat mutation and continues to be the case in novel mutations identified. the identification the genotype/ phenotype correlation in the spectrum of the nk cell defect in stat gain-of-function mutants may help to better understand the molecular basis for stat activation and/or function to predict clinical manifestations of disease and ultimately treatment regimens. mutation specific analysis after an amniocentesis showed that one twin was a carrier (l m) and the other was a compound heterozygote (r c and l m). after birth, twin a had a mildly low erythrocyte ada level ( . nmol/h/mg; normal range + ) with normal metabolites and a normal immunophenotype, similar to both parents. twin b showed a normal absolute lymphocyte count and mitogen proliferation, normal t lymphocyte subsets, mildly low b and nk cells with % naïve t cells and a normal trec assay. erythrocyte ada levels were absent in peripheral blood, with mildly elevated metabolites [daxp= . μmol/ml rbc (normal < . ) and %axp= . (normal < . )]. weekly recombinant ada enzyme replacement therapy (ert) was started at week of life with subsequent normalization of the metabolites by week . absolute lymphocyte, t cell subsets were normal at birth but continued to rise slightly above normal range after starting ert. b and nk cell counts were mildly low at birth but normalized by week . genetic testing confirmed the prenatal genotypes in the twin girls. the patient is now months old and doing well with no history of infections. her twin was not an hla match and family is currently awaiting gene therapy approval. discussion: ada deficient patients show substantial clinical and metabolic heterogeneity that tends to correlate with the genotype but phenotypic discordance occurs even within the same genotype. we describe an infant with prenatally diagnosed compound heterozygous mutations in the ada gene (grade-i: r c and grade-ii: l m). ada alleles are graded from -iv with increasing ada expression and decreasing severity respectively. there are reports of children with grade i/iii allele combinations with delayed, late and partial phenotypes. two siblings have been reported with l m allele (grade iii) in combination with a different grade i allele (r q), presenting with combined immunodeficiency at and months. the specific allele combination from our patient has not been previously reported, however, we expected that the grade-i allele likely would be more deleterious than the grade-iii allele. in our case, predicting a future phenotype remains a challenge, creating a dilemma regarding management strategies. however, with only mild metabolite elevations in our patient after birth, we may speculate whether the prenatal diagnosis with early ert precluded the development of a full immunophenotype and it remains to be seen whether nonimmune sequeli may be prevented. conclusion: children with compound heterozygous mutations in the ada gene can pose diagnostic and therapeutic challenges, especially due to the associated metabolic and clinical phenotypic variability. early recognition and treatment may potentially alter long-term morbidity and mortality. (ipex)-like phenotype. immunodeficiency is often combined with impairment of the humoral and cellular compartments. hematopoietic cell transplant (hct) can resolve disease-related manifestations in stat -gof, but overall survival is poor and there is a high rate of secondary graft loss in transplanted patients. jakinibs are a class of medications that block cytokine-induced jak/stat activation. ruxolitinib preferentially inhibits jak and jak and has been used as precision-directed therapy for treatment of stat -gof related manifestations with success in stabilizing and in some cases reversing organ-specific manifestations. the utility and safety of jakinibs for long term treatment of stat -gof and in the prevention of disease-related manifestations is not known. as such, hct is often pursued for patients once disease-related manifestations are controlled with jakinibs. we present a patient with stat -gof mutation with gradual secondary graft loss following hct years ago, that has had continued disease progression despite chronic ruxolitinib treatment. case presentation this is a years-old male diagnosed with a de novo heterozygous stat mutation (c. a>g/a) at age , years following hct for ipex-like disease. he has been treated with ruxolitinib for the last three years. this patient initially presented at months of age with wasting enteropathy, failure to thrive, early-onset type diabetes and hypothyroidism. he had frequent upper respiratory infections during childhood including mycobacterium fortuitum mediastinal lymphadenitis. at years he underwent / matched, unrelated bone marrow transplant following reduced-intensity conditioning. mixed donor chimerism was present in the first days following hct, and he continued to have a slow progressive decline of donor chimerism with full graft loss ( % whole blood donor chimerism) by age . at age , enteropathy returned leading to cachexia and tpn dependence. concurrently, he had recurrent upper respiratory tract infections, lymphopenia, and hypogammaglobulinemia. imaging showed bronchiectasis and lung function was consistent with obstructive lung disease (fev : . l fvc: . l dlco: . ml/min/mmhg). initiation of ruxolitinib at age resolved his enteropathy with discontinuation of tpn and > -pound weight gain. enteropathy has not returned. pulmonary clearance measures have also been employed. dlco initially improved (dlco: . ml/min/mmhg) but obstructive lung pattern continued (fev : . l fvc: . l). after initial improvement, dlco began to decline. over the last years and despite treatment with ruxolitinib, lung function has deteriorated with worsened fev ( . l), fvc ( . l), and dlco ( . ml/min/mmhg). with this progressive decline, the family is now pursuing second hct. discussion jakinibs apply precision-directed therapy for immune dysregulatory features of stat -gof. their use leads to substantial disease control and clinical improvement but does not prevent disease progression. jakinibs should be used as a bridge to definitive therapy with hct in patients with stat -gof mutation. a recent large registry study showed a higher risk of infections (hr . , % c.i . - . ) in children with thymectomy as compared to surgery controls, in addition to demonstrating differences in the risk of cancers, autoimmunity and atopy. limited small studies have described some risk factors for altered immune consequences; however, specific predictors of infections among children with congenital heart disease (chd) undergoing thymectomies have not been systematically assessed. among children with chd and thymectomy, we sought to characterize children with and without reported infections within years postthymectomy and identify predictors of bacterial and viral infections. methods: using a retrospective chart review (institutional irb approved) from / / and / / , we identified children with chd that underwent thymectomy and excluded any known conditions associated with immunodeficiency and those with less than -month follow-up post-thymectomy. first absolute lymphocyte count (alc) after thymectomy was stratified using a cutoff at % of the lower limit of age-adjusted normal values (alc value < % vs alc value > % of the lower limit of age-adjusted normal levels). we sought to assess predictors of reported bacterial (positive blood, cerebrospinal fluid, respiratory cultures and chest-x-ray confirmed pneumonia) and viral infections (positive viral pcr tests) within years postthymectomy. results: we identified children with chd who had thymectomies, of which, % ( / ) were male. the median age at thymectomy was months (interquartile range months- . years); % ( / ) underwent a complete thymectomy; and % ( / ) developed a chylothorax within week post-thymectomy. a substantial proportion of children had an alc below % of the lower limit of age-adjusted normal levels after thymectomy ( % [ / ] pre-thymectomy vs % [ / ] postthymectomy). among children with chd post-thymectomy, % ( / ) and % ( / ) reported bacterial and viral infections within years, respectively. children with post-thymectomy alc values below % of the lower limit of age-adjusted normal levels had higher odds of reported bacterial (or . , % c.i . - . , p= . ) and viral (or . , % c.i . - . , p= . ) infections post-thymectomy as compared to those with an alc greater than % of the lower limit of ageadjusted normal levels (multivariate logistic regression). there was no association with the type of thymectomy (partial vs complete), age at thymectomy, weight at thymectomy, sex or prematurity. conclusions: among children with congenital heart disease with no known immunodeficiency undergoing thymectomy, alc below % of age-adjusted normal levels post-thymectomy may be associated with higher odds of bacterial and viral infections. a retrospective study design with a small sample size poses several limitations; however, this study suggests that post-thymectomy absolute lymphocyte values may be a potentially useful marker to identify higher risk patients in this population. radiological assessments esp. in the ct chest is commonly performed, but has associated radiation exposure and pulmonary function testing, at times, maybe insensitive to small changes in lung pathophysiology. many pids may have overlapping features with short telomere syndromes (sts) a, which are accelerated aging syndromes affecting hematopoietic, pulmonary, hepatobiliary and/or immunological systems, unified by a high cell turnover in these organs. clinical assessment of ageappropriate telomere length (tl) is performed using flow cytometry & fluorescence in-situ hybridization (flowfish). methods: we retrospectively analyzed telomere lengths in lymphocytes and granulocytes using the flow cytometry and fish method .flowfish testing was done at reference laboratories in johns hopkins university (jhu, usa).approval was obtained from mayo's institutional review board. data abstraction and analysis was done using the software jmp. results: patients were included in our analysis with females ( %) and males ( %).the median lymphocyte count of our cohort was . ( . - . ).the telomere length was strongly associated with the presence of lung disease (p= . *) and the presence of interstitial lung disease closely paralleled the changes in telomere length (delta-as compared to age adjusted normal percentiles lengths). shorter lymphocytic telomere length was associated with more severe reduction on total lung capacity (tlc; p= . *). conclusion: shorter lymphocytic telomere length served as a reliable biomarker for interstitial lung disease in pid patients. this may open up newer avenues for assessment of aging pathways in pid and may offer the option of using senolytic therapies in pids. mutations in the il- receptor common gamma chain gene (il rg) result in x-linked severe combined immunodeficiency (scid). the common gamma chain is shared by il- , il- , il- , il- , il- and il- receptors. x-linked scid typically presents with low or absent t and nk cells and normal or elevated numbers of b cells. we report a case of x-linked scid with elevated b and nk cell numbers (t-b+nk+). the male patient had an abnormal newborn screen for scid in north carolina. lymphocyte enumeration performed at days of life showed cd + cells/mm , b cells/mm , and nk cells/mm . he had no naïve t cells. repeat lymphocyte enumeration two weeks later showed that the cd + count had increased to /mm . only . % ( cells/mm ) were cd ra+ naïve t cells. he continued to have elevated b cell and nk cell numbers. chimerism studies revealed the presence of % female cells in mitogen-stimulated pbmc by fluorescence in situ hybridization, indicating the presence of transplacentally transferred maternal cells. lymphocyte proliferation responses to pha and cona mitogen stimulation were very low (less than % of normal). immunoglobulin levels were igg mg/dl, igm mg/dl, and undetectable iga and ige. genetic studies revealed a missense mutation in il rg, c. c>t, resulting in an amino acid substitution (p.ala val) in the extracellular domain. family testing showed that the patient's mother was a carrier for this variant. the father and the two healthy older brothers did not have this variant. of note, the family history was significant for lateral maternal male early deaths. at weeks of age, the patient received an unfractionated bone marrow transplant from his hla-identical brother without conditioning or gvhd prophylaxis. at the time of this report's submission, he is weeks post-transplantation and has had successful engraftment (whole blood-cd + fraction was composed of > % donor cells). he also now has normal t cell proliferation in response to mitogens and normal levels of all immunoglobulins. genetic defects that cause primary immunodeficiency can have variable phenotypic presentations. the patient's phenotype was atypical in that he had elevated nk cell numbers. to further evaluate these cells, we checked for stat phosphorylation following il- stimulation of abstract/case report text background: stat gain-of-function (gof) mutations cause a multisystem disease of early onset autoimmunity and lymphoproliferation, severe post-natal growth restriction, and recurrent and/or invasive infections. treatment of the autoimmune and auto-inflammatory features of stat gof patients relies heavily on immunosuppression and is often challenging. the full scope of phenotypes, treatments and outcomes may be broader when analyzing a substantially larger cohort than those already reported. methods: we gathered and analyzed data on patients from centers world-wide with confirmed gof mutations in stat . retrospective chart reviews were performed in accordance with all local ethics and irb committees to determine clinical manifestations, immunophenotype, treatment regimens, success of treatment methods, and overall survival. funcitonal transcriptional activity was assessed by luciferase reporter assay on each individual mutation. results: fifty-nine individual mutations were identified and all conferred gof by a validated luciferase assay. there were mutations in the nterminal domain, in the coiled-coil domain, in the dna binding domain, in the sh domain, and in the transactivation domain with the overwhelming majority being missense mutations. median age at presentation was approximately years; % of subjects are male and % are female. immunodysregulatory features presented in all patients. autoimmune cytopenias were the most common occurring in % of subjects (n= ), followed by lymphoproliferation in % (n= ) with increased frequencies of double negative (cd -cd -)t cells being found in % of of patients tested, enteropathy in % (n= ), endocrinopathy in % (n= ), interstitial lung disease in % (n= ), dermatitis in % (n= ), and inflammatory brain disease in . % (n= ). growth failure was present in % (n= ) with half of those patients having concurrent enteropathy. infections were reported in % of the cohort to include recurrent and/or invasive viral, bacterial, opportunistic, fungal, and mycobacterial infections. prominent abnormalities of immunophenotyping included t cell ( %) and b cell ( %) lymphopenia with reduced t cell proliferation in response to mitogens or antigens in % of those evaluated patients. fifty-nine percent of the patients hypogammaglobulinemia while % exhibited poor specific antibody responses to recall antigens. overall survival was % at data collection.treatment of stat gof patients often included multiple agents: ivig , chronic and pulse steroids, mtor inhibitors, calcineurin inhibitors, rituximab, mycophenolate mofetil, alemtuzumab, tocilizumab, and jakinibs. those started on jak inhibition showed improvement in clinical symptoms and, to date, there are stat gof patients on targeted jak inhibition. thus far, patients have undergone bone marrow transplant with a % survival rate. discussion: stat gof mutations were first reported in to cause a heterogeneous syndrome of autoimmunity and lymphoproliferation with immunodeficiency and infection susceptibility. earlier treatment with targeted therapy such as jak inhibitors has led to reduced disease morbidity. we report the largest cohort of stat gof patients collected through a multi-national collaboration of the longitudinal data and natural history of stat gof disease. understanding the heterogeneity of presentation and key features that will lead to proper diagnosis and early treatment in an effort to prevent long term disease associated sequelae. we present the case of month old male with a novel heterozygous mutation in tcf and two previously unreported phenotypes: ) absent circulating cd + b cells yet preserved immunoglobulin synthesis and vaccine responses and ) significant thrombocytopenia that improved with immunosuppression. there is also a striking family history of two half-sisters who died during early infancy with similar clinical and lab findings and the same genetic change. the infant boy was born at term with respiratory failure and generalized rash. at birth he had thrombocytopenia ( k/ul) and lymphopenia ( / ul). initial absolute cd + t cell count was low ( /ul), yet he had normal thymic output and proliferative responses to mitogens ruling out scid. cd + b cells were < /ul and bone marrow biopsy revealed decreased hematagones, yet he had a normal igm level ( . mg/dl) elevated iga ( mg/dl), and elevated ige ( iu/ml). igg levels were initially obscured by maternal igg and ivig; in turn he made positive titers to diphtheria and tetanus vaccination. the infant has maintained his own igg production. rapid genome sequencing revealed a heterozygous predicted deleterious vous in tcf , in the second transactivation domain (c. c>t, p.pro ser). the same change in tcf was identified in the deceased half-sisters as well as the father: all infants had different mothers, suggesting autosomal dominant inheritance. the sisters had similarly severe thrombocytopenia and absent circulating b cells; their causes of death were not completely understood. the year-old father has normal platelet levels, very low cd + b cells ( /ul), elevated igg ( , mg/dl) and ige ( , iu/ml), and normal levels of iga and igm. the father also has an elevated number of cd + t cells ( , /ul) with an increased percentage of t cells expressing hla-dr ( %). in the months after birth, the infant boy continued to require frequent platelet transfusions. despite the persistent t lymphopenia, there was evidence of increased t cell activation with elevated levels of soluble il- r ( pg/ml) and increased percentage of cells expressing hla-dr ( %) cd ( %), cd ( %), cd ( %), and cd ( %). a -day trial of prednisone was associated with an increase in his platelet count to > k/ul. he was switched to rapamycin as a steroid-sparing agent, and his platelet count has remained > k/ul for several weeks without transfusions. interestingly, his b cell counts also improved after the steroid trial ( /ul) and his absolute lymphocyte count is normalizing on rapamycin. a potential mechanism could be rapamycin decreasing t cellmediated destruction of platelets or b cells. reassessments of t cell activation markers and b cell phenotyping while on rapamycin will be done in the future. in contrast to multiple published cases of tcf mutations associated with complete agammaglobulinemia and absent b cells, we present a case of an infant with absent b cells yet preserved humoral function as well as severe thrombocytopenia responsive to rapamycin. in collaboration with colleagues at nih, studies are underway to understand whether/how the unique change in tcf is related to either phenotype described above. abstract/case report text background: childhood-onset, chronic, multi-system inflammatory diseases are increasingly being characterized as monogenic inborn errors of immunity. arpc b deficiency is a recently described, rare combined immunodeficiency characterized by recurrent/severe infections, a variety of autoimmune manifestations and platelet defects. we describe a case of arpc b deficiency identified in an adult patient with recurrent ulcers/ bechet-like disease, non-malignant lymphoproliferation and intermittent microthrombocytopenia. patient case: at year of age, our female patient was diagnosed with behcet disease based on a history of bloody stools at months, oral ulcers at months and vulvar lesions at year. she underwent rheumatology evaluations for inflammatory arthritis, episcleritis, eczema, vasculitic ulcerating nodules of the trunk, perineum and extremities, and verrucae forming flat plaques similar to epidermodysplasia verruciformis without a unifying diagnosis. other infections include otitis media, sinusitis, pseudomonas ecthyma gangrenosum, cervical lymphadenitis, and pneumonia. at years old, the patient was referred to our immuno-hematology comprehensive program clinic with a concern for malignancy versus a primary immune regulatory disorder (pird). she had a -month history of drenching night sweats, urticarial plaques, edema in her extremities and diffuse cervical, axillary and inguinal lymphadenopathy. past complete blood counts showed intermittent mild microthrombocytopenia. lymph node biopsies were negative for a neoplastic process but identified plasmacytosis, including focally increased iga-kappa+ plasma cells. expert review of the lymph node biopsy, and further evaluation excluded multicentric castleman disease. consideration was also given to autoimmunune lymphoproliferative syndrome (alps)-like disorders; however, her alps flow cytometry panel was nondiagnostic. her basic immune evaluation showed severe t cell lymphopenia (cd + cells/ cm, cd + cells/cm, cd + cells/cm) with adequate b and nk cells, normal lymphocyte proliferation to pha and pwm, and dysgammaglobulinemia with igg g/dl, iga g/dl, igm g/ dl and ige g/dl. due to concern of an underlying pird, a primary immunodeficiency panel was sent for gene analysis with negative results. however, trio clinical exome sequencing identified biallelic variants in the gene arpc b. one allele has a truncating, nonsense pathogenic variant in exon denoted as c. g>t, p.glu ter. the other allele has a likely pathogenic variant in intron denoted as c. - a>g, resulting in disruption of the canonical splice acceptor for exon . this is predicted to cause exon skipping, with an in-frame deletion of amino acids coded by exon . conclusion: this case highlights the value for evaluation for pirds in patients presenting with behcet-like disease, particularly in the context of other autoimmune manifestations and/or microthrombocytopenia. it also underscores that patients with arpc b deficiency may present with chronic non-malignant lymphoproliferation. moreover, this patient emphasizes the value of exhaustive genetic testing for complex immunologic phenotypes. abstract/case report text lipoyltransferase gene defect is associated with severe mitochondrial dysfunction disrupting lipoic acid biogenesis. clinical manifestations associated with early seizures, hypotonia, cardiomyopathy and pulmonary hypertension and encephalopathy. early neonatal death due to sepsis and cardiovascular collapse is commonly seen. the patient is a week preemie male with congenital heart disease who developed severe intractable lactic acidosis on day of life with increased excretion on organic acids of -methyl- , dihydroxybutyric acid. a mitochondrial disorder , echs or hibch deficiency was suspected. at mo of age the patient was admitted for apneic spells and respiratory compromise. he was found to have elevated crp associated with rhinovirus infection and gram-negative bacteremia. due to the history of failure to thrive and sepsis, immunology was consulted. immunologic work up indicated normal b, t and nk cells with normal dhr, but showed agammaglobulinemia. the patient was started on ivig and whole exome sequencing was done. molecular analysis showed compound heterozygote mutations in the lipt gene: c. g>a (p.arg gln) and c. t>g (pval gly). subsequent biochemical analysis also showed biochemical abnormalities consistent with lipt defect. lipoyltransferase is an enzyme involved in activation of a number of enzymes requiring lipoic acid. it is involved in lipoic acid synthesis. lipoic acid is required for the activity of pyruvate dehydrogenase, alpha-ketoglutarate dehydrogenase, and branched-chain alpha-ketoacid dehydrogenase. the literature indicates that most patients with lipt defect have a severe, often fatal course. the patient is now almost years old and has stable clinical course without any major infections. he certainly has significant hypotonia and developmental delay. in conclusion, we are presenting the first case of lipt gene mutations associated with agammaglobulinemia who responded well to ig supplementation therapy. our immunologic findings in this case highlights the importance of immunodeficiency work up in challenging cases. as we see more cases lipt gene mutations, we will better understand the clinical spectrum. abstract/case report text a now -year-old male was initially evaluated for concerns regarding food allergy, eczema, food protein-induced enterocolitis syndrome, and failure to thrive. he had reactions of varying severity to multiple foods. these usually involved immediate urticaria or prolonged vomiting, diarrhea, and abdominal pain. ige and skin prick testing was performed to suspected foods and was positive to milk, egg, pork, wheat, peanut, pecan, coconut and corn. these foods had historically caused reproducible immediate symptoms. testing was negative to other suspected foods. he developed an oral aversion and extremely restricted diet. symptoms of abdominal pain, hematochezia, rashes, arthralgias, headaches, fatigue, dyspnea, and palpitations increased. urticaria and severe abdominal pain with vomiting and diarrhea continued intermittently without identifiable triggers on a restricted diet. laboratory markers demonstrated elevated inflammatory markers, anemia, iron deficiency, vitamin b deficiency, and vitamin c deficiency (scurvy). gastroenterology work up did not identify any pathology. gastrointestinal symptoms did not respond to treatment with multiple gerd medications or oral steroids. baseline tryptase was elevated. low histamine diet was initiated and repeat tryptase remained elevated. fractionated tryptase revealed normal mature (beta) tryptase with elevated total tryptase, negative genetics for c-kit mutation, normal urine prostaglandins. family members had tryptase levels drawn. one parent and sibling had elevated tryptase levels, while the other parent's tryptase was normal. hereditary alpha tryptasemia syndrome is defined by elevated blood tryptase levels and symptoms involving multiple organ symptoms. patients with elevated tryptase levels without symptoms are defined as having hereditary alpha tryptase trait. there is significant variability regarding which patients are symptomatic. organ symptoms that may be involved include skin, gastrointestinal, neurologic, connective tissue, cardiac, neuropsychiatric. severe allergic reactions such as anaphylaxis can occur. increased blood levels of the protein tryptase are caused by extra copies of the alpha tryptase gene (tpsab ). treatment is usually directed at specific symptoms, antihistamines, and mast cell stabilizers. research continues into additional treatment options. this patient was started on cromolyn and long-acting antihistamine. his gastrointestinal symptoms and rash/urticaria improved, and he began tolerating a small, but increased, variety of foods. the majority of his constitutional symptoms of fatigue, arthralgias, weakness resolved as he began gaining weight, and hemoglobin, vitamin c and b normalized. his sibling was evaluated and noted to have food allergy, asthma, abdominal pain, gerd, and eczema. she was also started on cromolyn and antihistamines which improved her gastrointestinal symptoms. parent with elevated tryptase was recommended to be evaluated further with allergist. this is an example of a patient with elevated tryptase and multiple organ system involvement. some of his signs and symptoms responded to mast cell stabilizing and antihistamine medications. patients with history of recurrent episodes of allergic reactions to foods and multiple constitutional symptoms would benefit from baseline tryptase levels. family members should also be tested if the patient has elevated tryptase. multiple studies have been published looking at the rates of scid in the united states. the estimated rate of scid prior to screening was per live births. post screening implementation, on average rates of scid were found to be closer to in live births. results : development of a t cell receptor excision circles (trec) scid screen in alberta involved the screening of anonymous term neonates using quantitative pcr for trecs. the cycle threshold for the control gene, rnasep, was set at . as % of our population had a cycle threshold < . ( % ci [ . , . ]). from those bloods spots with adequate dna, a final trec cut off of was chosen, as it would give an accuracy of . %, and fairly low false positive rate of . % ( % ci [ . , . ]). since starting a population based screen for scid in june of , we have identified cases of scid and cases of low trec not caused by scid. to date we have detected one case of reticular dysgenesis, cases of ada scid and one case of x-linked scid. other causes of lymphopenia in the neonatal period detected with abnormal trecs include one syndrome associated with variably affected cellular immunity (charge) and cases of secondary lymphopenia including four cases of prematurity, three cases of diaphragmatic hernia or gastroschisis, four patients with underlying cardiac disease, and one patient with severe hydrops. discussion : canada has multiple unique populations with increased risk of scid. the estimated rate of scid in canada prior to implementation of a population based screen was . per live births. the rate within canada's first nations, métis and inuit populations is . per live births. prior to scid screening, alberta had cases of scid identified between - with an estimated rate of per live births. to date, our screen in alberta has identified cases of scid with a rate of per live births which is significantly higher than previously estimated. given that early diagnosis and definitive management through bone marrow transplant or gene therapy has been shown to reduce mortality this screen will help reduce morbidity and mortality in this vulnerable population. abstract/case report text introduction: human herpesvirus (hhv- ) has the ability to integrate its genome into host telomeres. if this integration occurs in gametes, then the virus can be genetically transmitted and offspring will carry a copy of chromosomally integrated hhv- (cihhv- ) in each somatic cell. this can lead to false attribution of infectious and non-infectious presentations of hhv- , and make the diagnosis of active hhv- infection difficult. we present the case of a patient with meningoencephalitis attributed to hhv- and persistently elevated blood levels of hhv- by pcr concerning for primary immunodeficiency who was discovered to have cihhv- . case description: a -year-old female who carried a past diagnosis of hhv- meningoencephalitis was seen in immunology clinic for follow up of persistently elevated levels of hhv- dna in her blood by pcr. she was born at weeks and as an infant had failure to thrive (ftt), anemia and a varicella like rash after varicella immunization. at the age of , she received flumist vaccine and developed a fever the following day. over the next few days, she developed lethargy, altered mental status, headache, photophobia, seizure, papular rash and oral ulcers. she was admitted to the hospital and csf studies were consistent with viral meningoencephalitis ( wbc, l, m, rbc) although hsv, cmv, ebv and enterovirus were negative. she was treated for presumed hsv encephalitis with days of iv acyclovir and days of high dose steroids. one week after discharge, she again developed papular rash on feet, headache, oral ulcers and lethargy. she was admitted and csf studies this time showed only wbc but positive hhv- . blood and skin swab were also positive for hhv- . immunology was consulted while admitted and work up for primary immunodeficiency was initiated. her work up was normal including responses to vaccine titers, complement studies, moderate in t cells, monocytes, neutrophils, lung and muscle, and low in skin, liver, heart and kidney tissues. analysis of each individual gene expression level by nanostring in comparison with healthy controls demonstrated significantly higher levels of the following irgs: ddx , epsti , gbp , ifi , isg , ly e, oas , oas , oas , rsad , rtp and socs . whole blood rna-seq was performed in patients and pathway analysis with the differentially upregulated genes demonstrated an enrichment of intraluminal vesicle formation and negative regulation of apoptotic signaling pathways. stimulation of pbmcs with the tlr ligands poly i:c, odn, and lps induced a fold increase in ifi and a -fold increase in ifna and ifnb transcription compared to baseline. one patient had constitutive upregulation of stat and stat in monocytes and of stat and stat in t cells. conclusion: we describe a novel immunedysregulatory disease caused by de novo truncating variants in samd l that presents similar to candle with neutrophilic pannicultis and points to an important role of samd l on regulation of adaptive and innate immune responses. acknowledgements: this work was supported by the nih irp of niaid abstract/case report text introduction: ataxia telangiectasia (at) is caused by a defect in the atm gene which is responsible for repair of damaged dna. it is a rare, devastating neurodegenerative disease that results in ataxia and telangiectasias, particularly of the sclera and skin. those with at are at increased risk for immunodeficiency and cancer. the immunodeficiency is variable and may result in deficiency in humoral and cellular immunity in some patients. here we present a patient with ataxia telangiectasia and hypogammaglobulinemia on immunoglobulin therapy who developed recurrent urinary tract infections (uti) and sepsis. case presentation: the patient is a -year-old female with ataxia telangiectasia and hypogammaglobulinemia who presented with three episodes of uti, one of which resulted in prolonged hospitalization due to sepsis and acute kidney injury (aki). she presented with days of flank and back pain and was hospitalized for days for e coli uti. she improved on iv antibiotics and was discharged home to complete treatment with oral ciprofloxacin. due to persistent emesis, she was readmitted weeks later with urosepsis and aki with a creatinine of . mg/dl, over times her baseline creatinine. after additional antibiotics and iv fluids, she improved clinically, renal function normalized and she was discharged home. renal ultrasound was unremarkable with no anatomical abnormalities. she was relatively healthy prior to this with only one episode of bacterial pneumonia in . she receives weekly subcutaneous immunoglobulin therapy dosed at mg/kg with normal igg levels ( , , mg/ dl). at baseline, she had high igm ( mg/dl) and low iga ( < mg/ dl) levels, as well as decreased t cells but normal nk and b cells ( cells/ul cd +, cells/ul cd +, cells/ul cd +, cells/ul cd +cd +, and cells/ul cd +). she has hyperglycemia (on metformin), hypertriglyceridemia (on atorvastatin) and hypertension (on losartan). she is thin and wheelchair bound with bilateral telangiectasias to the sclera, neck, and chest. she has occasional eye bleeding and epistaxis, presumably from her telangiectasias. she has good hygiene and good adherence to medications. she voids voluntarily, has no indwelling urinary catheter and is not sexually active. discussion: patients with ataxia telangiectasia may have frequent viral and bacterial infections, most frequently upper and lower respiratory tract infections, as well as wart and skin infections. based on our review, this is the first reported case of ataxia telangiectasia with hypogammaglobulinemia on immunoglobulin therapy with recurrent utis complicated by urosepsis and aki. despite adequate igg levels on immunoglobulin therapy, our patient continued with recurrent utis. it is uncertain whether her non-ambulatory status, hyperglycemia or related immunodeficiency are the causes for her increased susceptibility to utis. the literature reports patients with at and bladder wall telangiectasias can result in significant hematuria, and perhaps this may be a source of entry for bacteria and consequent development of uti. this suggests that patients with ataxia telangiectasia and recurrent utis may benefit from renal ultrasound and possible cystoscopy to better visualize telangiectasias. we recommend consideration of workup for recurrent utis in patients with ataxia telangiectasia. abstract/case report text objectives: patients with partial rag deficiency frequently present with humoral autoimmunity suggesting breach in tolerance mechanisms and subsequent expansion of autoreactive b cell clones. here we aim to trace polyreactive b cells and their descendants at b cell developmental stages through our in-house bioinformatic pipeline, immchaintracer (ict). methods: the b cell receptor (bcr) was expressed as monoclonal antibodies from single sorted mature naive b cells (n= - per donor) from patients with hypomorphic rag deficiency and healthy donors. xthe recombinant monoclonal antibodies were screened for polyreactivity (dsdna, insulin, lps and ifnα) by elisa. in parallel, igh repertoires were deep sequenced from sorted mature naïve, activated naïve and memory b-cell compartments. our in-house assembled bioinformatic pipeline called immchaintracer (ict) was applied to track down the descendants of cloned autoreactive igh sequences in repertoires of subsets above. results: igh sequences (n= including polyreactive, nonpolyreactive clones) from mature naive b cell from six patients with partial rag deficiency and healthy donors (n= including polyreactive, non-polyreactive) were analyzed with our novel inhouse bioinformatic approach to track lineage fate in repertoire at specific developmental stages. interestingly, . % of the patients' sequences and their descendants were identified in their mature naive, activated naive or memory b cell repertoires, while none of the analyzed healthy donor clones were found at later subsets. furthermore, genealogical analyses of related clones revealed lineage expansion and progressive positive antigen selection of the autoreactive clones in the patients. conclusions our findings demonstrate that peripheral tolerance checkpoint is broken in hypomorphic rag patients. our novel method enables tracing the fate of autoreactive naive b cells in the effector repertoires. we have shown that impaired b cell tolerance allows the expansion and combination of sirolimus and rituximab therapy controlled his autoantibody production which was an important goal for his autoimmune condition. we present a new treatment approach for anti-nmda receptor encephalitis. rituximab was tried on these cases before but the combination of sirolimus and rituximab therapy was never given before. we now recommended that on refractory cases of anti-nmda receptor encephalitis, combination of rituximab and sirolimus therapy can be tried. ( ) submission id# mosaic variants in immune function genes identified through exome sequencing stable with no interim infections and is doing well on thyroid hormone replacement. the current plan is for the patient to undergo a stem cell transplant for the arpc b deficiency as he is at high risk for recurrent infections and severe disease. although this gene mutation is rare, review of the current literature describes patients with this condition that have undergone stem cell transplant and have done well. at this time, this seems to be the best option for management, and it may potentially be curative. abstract/case report text introduction: common variable immunodeficiency (cvid) is a disorder characterized by impaired immunoglobulin production and frequent or recurrent infections, but also associated with an increased risk for developing malignancies such as lymphomas. although intravenous and subcutaneous immunoglobin g replacement has been successful in reducing the number of bacterial infections and prolonging survival, it fails to address other complications that arise from this disorder. we report a case of a patient with cvid who developed mycosis fungoides (mf). mf is a rare form of cutaneous t-cell lymphoma, occurring in about in , to , individuals, lack of treatment could potentially be fatal. case presentation: a -year-old caucasian woman with a history of ulcerative colitis, allergic rhino-conjunctivitis and tonsillectomy was referred to the immunology clinic for evaluation of low serum immunoglobulins. there was no family history of infections or immune deficiencies, but paternal grandfather had colon cancer and maternal grandmother had lung cancer. the patient reported frequent episodes of bronchitis, and sinus infections. immunizations were up to date for her age. medications included azathioprine, cetirizine, fluticasone nasal spray, hyoscyamine, montelukast, lactobacillus, omeprazole, and olopatadine ophthalmic solution. no history of frequent use of systemic steroids. initial serum immunoglobulins revealed normal ige and igm but low iga ( mg/dl, normal range - mg/dl) and low igg ( mg/dl, normal range - mg/dl). cbc with differential, lymphocyte subsets, c and c levels were normal. while she had adequate protective titers against haemophilus influenza type b, diphtheria and tetanus, titers against pneumococcus were < % protective and she failed to mount an adequate response to pneumococcal polysaccharide vaccine. given her diagnosis of cvid, she started scig ( mg/kg every weeks). a year later, she developed a bilateral nonpruritic rash in the abdomen and upper trunk. initial skin biopsy suggested a drug reaction. a subsequent biopsy revealed a superficial perivascular lymphoid infiltrate with focal epidermotropism and positive t cell receptor gamma gene rearrangement, consistent with mf. testing for cell t receptor beta gene rearrangement was negative. while mf treatment consisted of triamcinolone . % ointment, treatment for ulcerative colitis transitioned from azathioprine to vedolizumab. conclusions: cutaneous t cell lymphomas, although uncommon, can be seen in cvid. there are several reasons for the increased risk of lymphoma in cvid. the role of chronic infections and the development of lymphoma as of yet, is not clear. skin reactions to scig products in the areas of infusion are relatively common and resolve promptly. high index of suspicion is crucial in obtaining tissue sample to confirm or rule out malignancy therefore avoiding delaying proper treatment. abstract/case report text patients with lipopolysaccharide responsive beige-like anchor protein (lrba) deficiency present with a plethora of immune related defects including a defective humoral response characterized by low numbers of switched memory b cells and plasma cells, as well as an impaired production of antibodies, leading to recurrent infections. however, the molecular mechanisms behind the defective b cell response remain unknown. to gain better insights into the possible roles of lrba in b cell physiology, we screened for lrba-interacting proteins using computational predictions. twenty-seven proteins involved in vesicle trafficking and autophagy were identified as potential lrba-interacting partners. to validate those potential lrba interactions, we performed coimmunoprecipitations and proximity ligation assays (pla), finding that endogenous lrba interacts with the phosphoinositide kinase regulatory subunit (pik r ) in b cells. pik r (aka vps ) is the regulatory subunit of vps , the catalytic subunit of the pi k-iii complex, which acts as a positive regulator of autophagy by producing phosphatidyl inositol- phosphate (pi( )p). autophagy is a catabolic mechanism essential for cell survival and plasma cell differentiation. in fact, we observed that reduced lrba impaired the production of pi( )p upon autophagy induction. in addition, we observed in both lrba-deficient hela and b cells reduced mobility, abnormal accumulation and increased size of autophaghosomes, accompanied by an atypical lysosomal positioning. these abnormalities are due to a blockade of the autophagosome-lysosome fusion, as detected by reduced lc -ii lipidation upon autophagy induction in the presence of lysosome inhibitors. interestingly, lrba-deficient hela and b cells exhibited enhanced activity of mammalian target of rapamycin complex (mtorc ) signaling, a key suppressor of autophagy whose activation possibly contributes to defective autophagy. taken together, b lymphocytes lacking lrba can form autophagosomes but they fail to fuse with lysosomes. thus, we propose a role of lrba at late stages of autophagy through the binding to pik r . abstract/case report text apds caused by gain-of-function mutations (gof) in the genes (pik cd and pik r ), encoding for the p δ and p subunits of phosphoinositide -kinase δ (pi kδ), results in hyperactivation of the pi k/akt/mtor/s k pathway and lead to immune dysregulation, lymphoproliferation and immunodeficiency. apds manifests with respiratory tract infections, bronchiectasis, susceptibility to herpes group viruses, autoimmunity, cytopenia, lymphoproliferation and lymphoma. gastrointestinal system manifestations include enteropathy, colitis, and liver disease. eosinophilic esophagitis (eoe) or eosinophilic gastrointestinal disease (egd) have been under diagnosed in reported apds cohorts. objectives: to review the incidence, demographics and relevant clinical data for eosinophilic gastrointestinal disease in a single center apds cohort. methods: review of clinical and laboratory findings from apds patients followed at the nih clinical center, from to . results: patients were either historically diagnosed or actively studied at our center for egd. incidence of all egd is % in our cohort and all patients had mutations in pik cd, none in pik r . most patients also had multiple gi manifestations. conclusion: immunopathology and genetic predisposition leading to eoe is complex. eosinophilic gi disease including eoe appears to represent significant gi pathology in apds. this implies that activation of pi k pathway may be directly involved in the etiology of eoe. abstract/case report text introduction: dominant negative mutations in stat (lof stat ; job's syndrome) cause a primary immune deficiency characterized by eczema, recurrent skin and lung infections, and connective tissues and skeletal abnormalities. over the last several years, vascular abnormalities causing tortuous and aneurysmal middle-sized arteries have increasingly been recognized. our institution has been imaging prospectively the coronary and cerebral arteries since - for brain imaging and from - for heart imaging. the purpose of this review is to provide an update on the extent of clinical manifestations noted in hies (continued) pain improved but rapidly worsened with tapering of steroids. the pet/ ct at that time, showed extensive hypermetabolic areas in lymph nodes, femurs, left acetabulum, left pubic ramus, right ischium, sacrum, both iliac bones, eight rib, t and t , both clavicles, both humeral, manubrium, and extension into musculature. initial biopsies were culture negative, s was positive for mac. she was referred to the national institutes of health where she was diagnosed with autoantibodies to interferon-γ . prior to referral, she initially was treated with azithromycin, ethambutol (need to discontinue due adverse effects), amikacin, rifampicin, linezolid, with not no evidence of clinical response. she underwent debridement of epidural anterior abscess to t . surgery involved t - laminectomy, and curettage on several bones. she presented unable to walk secondary to pain and neuropathies. initial laboratory: crp: mg/l; wc . ; hgb: . g/dl; ana : . (strongly positive) cd : ul her first course of rituximab consisted of doses of gm at d , , and monthly thereafter for a total of doses with clinical and radiographic improvement. she was maintained on optimal antibiotics therapymeropenem, rifampin, azithromycin, moxifloxacin, and clofazimine. two years after she completed rituximab, she presented to her home hospital with increased left hip pain and biopsy grew mac. retreatment with rituximab failed to show clinical improvement. her medical regimen was augmented with tedizolid and bedaquiline, however no iv antibiotics were added. rituximab was reinitiated, after the progression of symptoms despite treatment with rituximab; bortezomib, was trialed using the schedule based on the multiple myeloma literature. she completed full cycles (two at the nih, three at home). she subsequently has had clinical improvement and is working again and has not had progressive neurologic decline. the titers of antibodies to interferon-· did not follow the clinical improvement. however, we plan to keep her cd + cells zero and continue the bortezomib given her clinical and radiologic improvement. abstract/case report text for patients with primary immunodeficiencies (pid), finding a genetically defined diagnosis can be critical for prognosis, treatment, and counseling. however, for many patients, determining a genetic etiology remains elusive despite routine gene panel and exome sequencing because of an inability to resolve variants of uncertain significance (vus). crispr-based genome editing could be used to address this need by introducing patient-derived vus into primary human immune cells for further study; however, existing techniques are limited by poor efficiency. we recently developed novel non-viral techniques for large gene editing in primary human t cells and hematopoietic stem cells (hscs). we achieve up to fold greater efficiency than existing tools using crispr cas ribonucleoprotein nanoparticles that are non-covalently linked to homology directed repair (hdr) template dna. whereas mutation analysis has previously been limited to expensive and time-consuming animal models and transformed cell lines, we now have the ability to rapidly recreate any mutation in the native gene locus in otherwise healthy primary human cells. we demonstrate this ability by using our technique to knock-in well characterized loss-of-function mutations in jak and il rg and gain-of-function mutations in jak that are known to cause severe combined immunodeficiency and tumor growth, respectively. we show that these recreated mutations have the expected effects on t cell proliferation and intracellular signal transduction in the setting of il- stimulation. we then use our technique to investigate a prototype case of an adult patient with the unusual combination of common variable immunodeficiency, inflammatory arthritis and uveitis, and neutrophilic urticaria. genetic testing in this patient had previously revealed heterozygous coding vus's in four genes previously associated with a pid disease, including jak , but none of the specific variants have been previously reported. it is thus not clear which mutation (if not more than one) causes this patient's dysregulated cell activation, which limits targeted treatment options with kinase inhibitors or future gene or cell therapy. by knocking our patient's jak variant into primary human t cells and comparing these cells to those carrying wild-type, known loss-of-function, and known gain-of-function mutations, we are able to rapidly characterize the functional impact of our patient's variant and isolate its effect on his complex phenotype. this in vitro genetic engineering approach thus allows patient-specific vus to be modeled directly in primary human immune cells with a rapid turnaround time that is relevant for clinical applications, including molecular diagnosis and screening of pharmacologic or gene therapies. further, similar strategies could be leveraged as a potential basis for future gene correction therapy. abstract/case report text definition : "at variants" comprise a heterogeneous group characterized by the later onset of clinical symptoms, a slower progression, a prolonged lifespan compared to most patients with at and decreased levels of chromosomal instability and cellular radiosensitivity. in these patients, telangiectasia and / or immunodeficiency may be absent, while neurological features are present.( ). material and methods :a years old girl, born out of a non-consanguineous parents with clinical picture consisting in progressive alteration of the march ( months), associated to exotropia, no weight gain or height, alteration of balance while she is sitting, she walks by herself. she has acute bronchiolitis. results and discussion: brain magnetic resonance without alterations. abdominal ultrasonography and cpk normal. ophthalmologist assessment found exotropia, he did not find telangiectasia. motor and sensitive neuro-conduction were reported normal. alpha fetoprotein ng / ml increased. karyotype xx, non-structural alterations. normal auditory-visual evoked potentials. whole exome sequencing (wes): identified the small homozygous pathogenically deletion ¬c. + _ + del taag; p.? have a spelling effect in the splicing. it is not present in the population database or not as a known variant in function mutation of smad has been shown to increase smad phosphorylation in the nucleus in fibroblasts. further research is needed to examine the role of this mutation in t and b lymphocytes, given the interesting immunological phenotype of this patient. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. outbreak of mycoplasma pneumoniae-associated stevens-johnson syndrome characterization of children. with recurrent episodes of stevens johnson syndrome recurrent stevens-johnson syndrome secondary to mycoplasma pneumoniae infection recurrence and outcomes of stevens-johnson syndrome and toxic epidermal necrolysis in children syndrome after mycoplasma pneumoniae infection a review of causes of steven-johnson syndrome and toxic epidermal necrolysis in children submission id# expanded phenotype and genotype-phenotype correlations bsc(hons) msc bmbs mrcp dominant activating rac mutation with lymphopenia, immunodeficiency, and cytoskeletal defects an autosomal dominant scid form due to a gain of function mutation in the rac gene national institute of allergy and infectious diseases (niaid) professor biochemistry/molecular pharmacolog/nyu langone health canada head of the ircm bioinformatics core facility/montreal clinical research institute (ircm) associate investigator/national human genome research institute (nhgri) division of intramural research (dir), national institute of allergy and infectious diseases (niaid) translational and functional genomics branch/chief and senior investigator of the translational and functionanational human genome research institute (nhgri) division of intramural research (dir), national institute of allergy and infectious diseases (niaid) formula versus donor breast milk for feeding preterm or low birth weight infants cytomegalovirus (cmv) inacƟvaƟon in breast milk: reassessment of pasteurizaƟon and freeze-thawing prevenƟon of cytomegalovirus transmission via breast milk in extremely low birth weight infants submission id# the costa rican registry for primary immunodeficiencies department chief/department of pediatric immunology and rheumatology, national children´s hospital "dr. carlos sáenz herrera national children´s hospital "dr. carlos sáenz herrera" cid % (n= ), cid with syndromic features % (n= , at ), antibody deficiencies % (n= , xla ) ada deficiency, cd l-, flh- (syntaxin deficiency), ipex and osteopetrosis. nineteen patients developed malignancies, mainly non-hodgkin lymphomas among at patients conclusions: during the study period, pid were registered, mainly at and osteopetrosis cases. scid represented % and xla % of patients allergy and immunology/ department of pediatric immuunology and texas children's hospital director immunogenetics program/department of immunology, allergy and rheumatology at baylor college of medicine associate professor, director food allergy program/department of pediatric immuunology shearer center for human immunobiology associate professor/department of pediatric immuunology, allergy, and retrovirology granuloma faciale: successful treatment of nine cases with a combination of cryotherapy and intralesional corticosteroid injection intralesional steroid injection: a novel method to treat the symptoms of idiopathic granulomatous mastitis long-term effectiveness of intralesional triamcinolone acetonide therapy in orofacial granulomatosis: an observational cohort study sarcoidosis in the periocular scar as the first finding of systemic sarcoidosis: clinical-radiological characteristics a case of scar sarcoidosis of the eyelid submission id# null mutations: a gene dosage effect shubham goel, phd , hye sun kuehn clinical centre, nih, staff scientist/immunology service certified molecular geneticist/national institute of allergy and infectious diseases, national institutes of health genetic counselor/national institute of allergy and infectious diseases, national institutes of health division of intramural research; chief, immunopathogenesis section/laboratory of consultant/university hospital freiburg center for pediatrics and adolescent medicine cci -center for chronic immunodeficiency medical director professor/division of blood and marrow transplantation and cellular therapies new south wales, australia. professor of medicine and pediatrics/icahn school of medicine at mount sinai senior investigator/laboratory of clinical immunology and microbiology, national institute of allergy and infectious diseases, national institutes of health functional nk assay, t/b/nk panel, tlr assay phd staff scientist/translational autoinflammatory disease section, lcim, niaid, nih, bethesda, md research fellow/translational autoinflammatory disease section post-baccalaureate fellow/translational autoinflammatory disease section pediatric rheumatologist/department of pediatric infectious diseases and immunology shupyk national medical academy for postgraduate education alder hey children's nhs foundation trust hospital, liverpool, uk pediatric rheumatologist/department of pediatrics dra. liliana bezrodnik y equipo dra. liliana bezrodnik y equipo"-servicio de inmunología htal. de niños hospital de niños ricardo gutiérrez pathology department/children's hospital of philadelphia, philadelphia, pa post-doctoral fellow/translational autoinflammatory disease section results: we identified patients with de novo frameshift variants in samd l (c. dela, p.i lfs* reduced toxicity allogeneic hct with a busulfan, fludarabine regimen: a promising approach for non-cgd primary immune deficiencies requiring myeloablation? phd , blachy davila saldana college of medicine assistant professor/division of bone marrow transplant, immunedysregulation and immuno-hematology program, aflac cancer and blood disorders center instructor of pediatrics/division of bone marrow transplantation and immune deficiency, cincinnati children's division of bone marrow transplantation and immune deficiency, cincinnati children's national institutes of health certified molecular geneticist/national institute of allergy and infectious diseases genetic counselor/national institute of allergy and infectious diseases, national institutes of health operations manager and genetic counselor/national institute of allergy and infectious diseases collaborative bioinformatics resource/national institute of allergy and infectious diseases genome in a bottle analysis team/genome in a bottle consortium division of intramural research (dir), national institute of allergy and infectious diseases (niaid) medical genomics and metabolic genetics branch/national human genome research institute, national institutes of health table clinical and demographic characteristics, severity measures, and previous treatments for the pid cohort geographic region, n (%) north central , ( . ) ( . ) , ( . ) northeast , ( . ) ( . ) , ( . ) south ) ( . ) , ( . ) high-potency oral antibiotics , ( . ) ( . ) , ( . ) systemic high-dose corticosteroids copd, chronic obstructive pulmonary disease cd / cd : . , lymphocytes b , natural killer cell/mm . conclusions: although the atm activity corresponding to this new splicing mutation is unknown, it is presumed that it has some residual function, since splicing mutations is associated with better neurological prognosis have been reported (pidd) . at the immunodeficiencies research unit we discuss and pursue the molecular and genetic diagnoses for patients with suspected pid from all around the country. starting this year, we are processing and analyzing our own patients' wes results at the unit. evaluating the diagnostic yield of wes, as a measure of effectiveness or quality control, may result in process optimization and perhaps allow for better patient selection and resource allocation. objective: to describe and characterize our patients with suspected pidd whose dna samples were sent out for whole-exome sequencing; to analyze and compare our wes diagnostic yield after the first batches of patients; to identify patient attributes that may predict a positive diagnostic wes result. methods: genomic dna was obtained from whole-blood samples of patients with suspected pidd from hospitals in mexico city, monterrey and puebla. wes was performed using a ng sequencer (illumina hiseq) in new jersey (admera health, llc), with % coverage and a x depth of the idt xgen library, human genome version (december ). two fastq files for each patient sample were transferred back to our unit, where the bioinformatic workflow was completed. we used galaxy in the cloud for quality control, mapping & alignment, and detection of variants; variant effect predictor to process, map, annotate and filter variants; and igv (broad institute) and genome browser (ucsc) for visualization. we defined diagnostic yield as the proportion of patients with a genetic diagnosis after analysis of their wes results. we performed multivariate logistic regression, tree partitioning algorithm and linear abstract/case report text a -year-old male with x-linked chronic granulomatous disease (cgd) complicated by severe perianal disease and proctocolitis presented with two weeks of open draining lesions on the thighs, bilateral inguinal regions, and gluteal cleft. the wounds became excruciating and prevented normal ambulation. the patient was admitted for iv antimicrobial therapy, local wound care and systemic steroids. wound cultures, throughout his course, yielded growth of klebsiella pneumonia, candida parapsilosis, malassezia globose, escherichia coli, enterococcus faecalis and staphylococcus epidermidis allowing for directed antibiotic and antifungal therapies. despite improvement, the wounds persisted after several weeks of treatment. faced with recalcitrant cutaneous lesions despite aggressive systemic and topical therapies, we looked to alternative options. noting that other granulomatous diseases show response with intralesional corticosteroid therapy, we considered this for our patient ( , ) . for example, patients with idiopathic granulomatous cheilitis had a complete response after three monthly injections of intralesional corticosteroids ( ) . sarcoidosis patients also improve with intra-granuloma corticosteroid injection ( , ) . our patient received mg triamcinolone acetonide injections two separate occasions, administered in multiple open lesions at eight-week intervals. the cutaneous lesion improvement was gradual and complete resolution of the first open wound was noted fifty-two days from initial steroid injection. to our knowledge, intralesional glucocorticoid therapy has not previously been used to treat cutaneous disease in cgd patients. we are reporting the first cgd patient with successful lesion resolution following steroid injection as part of therapy. as such, we believe this case is significant and suggests that direct lesion injection with glucocorticoids can add to treatment options for cgd patients with recalcitrant cutaneous disease. serum igg, alone or in combination with iga and/or igm, were reduced in all patients. t-follicular helper cells were reduced only in patients carrying biallelic mutations (a.ii. , a.ii. and a.ii. ) but not in any patients with monoallelic tcf null mutation. t cell enumeration and function by means of proliferation was normal in all mutation+ individuals. no mutated (truncated) protein expression was detected from patients with either biallelic or monoallelic tcf null mutations. however, wildtype tcf protein was detectable in about half amount in heterozygous patients. cdna data showed either / or / wt/mutated transcripts ratios in homozygous or heterozygous individuals, respectively, suggesting mutated proteins instability; and all together, protein haploinsufficiency for the heterozygous cases. ex-vivo, cd l and il -induced plasmablast differentiation was found to be reduced in / patients tested ( biallelic patient a.ii. and monoallelic patients a.i. , b.i. and c.i. ). moreover, decreased igg, iga and igm production in vitro correlated with reduced plasmablast cell differentiation.in conclusion, all individuals carrying either mono-or biallelic null mutations have immunological penetrance of the b cell defect. however, while clinical penetrance was complete in patients with biallelic mutation, it was partial for those with monoallelic tcf null mutation suggesting a gene dosage effect for clinical penetrance. in addition, our study emphasizes that tcf is relevant to the plasmablast differentiation process as well as for ig production. further studies are being conducted to evaluate the individual roles of e and e on the immune and clinical features. background: heterozygous gain-of-function (gof) mutations in the stat gene result in a hyperphosphorylated state where patients develop recurrent or persistent chronic mucocutaneous candidiasis (cmc), other cutaneous mycosis, bacterial infections, disseminated dimorphic fungal infections and autoimmune disease. furthermore, the nk defect we characterized illustrated an immature cd dim nk cell subset with decreased expression of cd , perforin, cd , and impaired cytotoxic capacity associated with increased susceptibility to viral infections observed in these patients. methods: in this study, we evaluated patients with novel stat mutations (d e mutation, located in coiled-coil domain and k q mutation, located in dna-binding domain). a third patient with the previously reported v i mutation (ccd) was also recruited for this study. in vitro, pbmcs from these patients were stimulated with ifn-α for , , and minutes and levels of phospho-stat on cd dim nk cell subset were measured by flow cytometry. the stat activity (firefly and renilla luciferase activities) was evaluated in u a-stat deficient cells abstract/case report text background: t cell lymphopenia associated with genetic syndromes can be identified with low t cell receptor excision circle (trecs) up on the newborn screen for severe combined immune deficiency (scid). jacobsen syndrome (js), q terminal deletion, is a rare genetic disorder seen in / , births characterized by facial dysmorphisms, platelet abnormalities, neurologic complications, immune system abnormalities including t and b cell defects. we report an infant with js found to have low trecs on nbs and review the immune phenotypes of our cohort of patients with js. methods: a retrospective chart review of all patients with js seen by the allergy immunology service at a large tertiary referral center from / / - / / was performed in accordance with irb standards. result: the index patient had two newborn screens hours after birth and two weeks later in accordance with texas state law. the first nbs resulted normal trecs while the second nbs had low trecs. a third nbs was done per protocol and again showed low trecs. subsequently, lymphocyte subsets at months of age showed severe t-cell lymphopenia: cd cells/ dl ( %), cd cells/dl ( %), cd cells/dl, and low recent thymic emigrants (cd +cd ra+ccr +cd +) cells/dl ( %) with normal lymphocyte mitogen proliferation. a chromosomal microarray (cma) revealed a q deletion known to cause js.over the five year study period we evaluated seven patients with js referred to our center. the majority of patients ( %) presented to clinic with history of recurrent infections including recurrent pneumonia, sinusitis, otitis media, skin abscesses and warts. t-cell lymphopenia was found in of ( %), / ( %) had abnormal lymphocyte proliferation (mitogens and antigens) and met criteria for pjp prophylaxis. in addition, / ( %) had antibody deficiency requiring igg replacement therapy. of the cases reviewed, only patients were born during the period of time that texas was performing the nbs. conclusion: jacobsen syndrome can present with a spectrum of immune defects most notably t cell lymphopenia and antibody deficiency. these patients can present at birth with low trecs. this cohort analysis highlights the importance of considering chromosomal genetic syndromes with features of primary immunodeficiency in evaluating patients with low trecs. further evaluation of larger cohorts gathered from neurology or genetics clinics at multiple centers would be helpful for future study in identifying those who need close immunology care. abstract/case report text introduction: recognized as sentinels of the immune system, mast cells (mcs) and dendritic cells (dcs) are both derived from hematopoietic/ progenitor stem cells in bone marrow (bm). the crosstalk and direct contact between these cells have been well documented and play an important role in modulating immune response. we showed that presence/absence of il- directs cell fate; whether progenitor cells will be differentiated into mcs or dcs. we also report an easy method in which in vitro generation of dcs is possible without external induction of gm-csf or il- . material-methods: to produce mcs and dcs in vitro, briefly bm samples were collected from patients with idiopathic thrombocytopenic purpura., bm mononuclear cells (mncs) were seperated by ficoll gradient, and seeded in plates with imdm medium containing fbs %, pen/ strep, and a little amount of methocult, and incubated in oc, % co (day ). the treatments on the following days were as follows: day , imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml); day , imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml) + il- ( ng/ml). on day , groups were formed: group i: imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml) + il- ( ng/ml), group ii: imdm (fbs %) + scf ( ng/ml) + il- ( ng/ml), group iii: dmem + fbs %. the cultures were evaluated every days under an inverted microscope. verification of mcs was performed by toluidin blue and tryptaseimmunoflorescence staining. macrophages were verified by cd- immunoflorescence staining. dendritic cells of different stages of abstract/case report text introduction a reduced toxicity busulfan, fludarabine regimen with alemtuzumab or anti-thymocyte globulin (gungor et al.) was efficacious in patients undergoing allogeneic hct for cgd. we report our experience with a similar approach for patients with non-cgd primary immune deficiencies needing a reduced toxicity myeloablative approach. methods we retrospectively reviewed records of consecutive patients who underwent allogeneic hct for primary immune deficiencies with a preparative regimen containing busulfan, fludarabine and alemtuzumab or anti-thymocyte globulin(atg), at three transplant centers between - . busulfan was given either every hours over days with target auc of to μmol/min (based on q hr. dosing) or twice daily over days with target auc of to μmol/min (based on q hr. dosing) or once daily over days with a target auc of - μmol/min (based on q hr. dosing). fludarabine mg/m to mg/ m was given divided over - days. serotherapy included alemtuzumab . - . mg/kg or atg . mg/kg given divided over days. gvhd prophylaxis consisted of cyclosporine and mycophenolate mofetil. results forty patients (was= , hlh= , cd l deficiency= , ipex/veoibd= , scn= , ifngr def./cid/x-scid/msn / lad= ) received busulfan, fludarabine and alemtuzumab or atg for allogeneic hct (first hct in patients and second hct in the patients with hlh). median age was . years (range, . years - . years). patients received a graft from an hla-matched related (n= ), unrelated (n= ), or single allele mismatched related or unrelated donor (n= ). all except one patient engrafted at a median of days (range, - days). one patient developed veno-occlusive disease and two patients developed diffuse alveolar hemorrhage. notably, it was the second transplant for all patients. eight patients ( %) developed grade - acute gvhd and patients ( %) developed chronic gvhd. one patient developed primary graft failure and two patients secondary graft failure. nineteen patients ( %) maintained full donor (> %) chimerism following allogeneic hct. twenty patients ( %) developed mixed chimerism, predominantly in the t-cell lineage, but t-cell donor chimerism progressively increased post-hct. at -year post-transplant, of patients ( %) with mixed chimerism had donor myeloid chimerism > % and t-cell chimerism > %. two patients underwent a second transplant for graft failure. there were deaths in the cohort. overall survival was %( of ) and event free survival was %( of ) at year. conclusion our experience suggests that a reduced toxicity busulfan, fludarabine regimen with alemtuzumab or atg as serotherapy offers a promising approach with low toxicity, durable myeloid engraftment, low incidence of grade - gvhd and excellent survival and can be considered for a variety of primary immune deficiencies where myeloablative hct is desired. abstract/case report text this is an -year-old patient who has the diagnoses of anti-nmda receptor encephalitis with associated catatonia. the patient has history of a pineal gland germinoma diagnosed in august after months of double vision. however, after several months, the patient developed difficulty in sleeping, anxiety and nightmares. the patient presented to emergency department in february with personality changes. he was diagnosed with nmda encephalitis based on the clinical findings as well as presence of elevated serum and csf anti-nmda antibodies. the patient was initially treated with high dose systemic steroids with poor response. due to the worsening of his clinical condition, he was started on plasmapheresis, but had poor response to this therapy as well. these treatments are known standard treatment options for this condition. during his hospital stay, different therapies were discussed. cyclophosphamide was one of the treatment options, but because of the side effect profile and severe toxicity, we recommended different treatment modality. we started the patient on rituximab as well as sirolimus therapy to suppress both t and b-cell responses. after receiving two doses of rituximab in addition to daily sirolimus, the patient showed improvement of his symptoms. and declining nmda receptor antibody titers. this treatment plan was chosen for autoantibody mediated encephalomyelitis due to the fact that rituximab has inhibitory effect on naive b cells, but not on the proliferation of memory b cells and sirolimus has profoundly inhibiting role on memory b cells as well as a t-cell responses. a mosaic gene variant is one which is present in some, but not all, cells within an individual. they are increasingly associated with a number of diseases, including a number of primary immunodeficiency disease (pid). here we systematically analyzed mosaic variants in known or putative immunodeficiency genes from exome sequencing data from individuals. lofreq was used to identify mosaic variants with a variant allele fraction (vaf) of . - . ( . is the vaf for a non-mosaic, heterozygous variant). we removed variants from extreme read-depth (> standard deviations), unmappable, repeat-rich, and duplicated genomic regions. the average number of detected variants per mb was . and the total number of genomic locations with variants was , . mosaic variants were underrepresented in exonic regions, suggesting that coding variants may be deleterious. more mosaic variants were detected in saliva exomes compared to peripheral blood exomes (p-value < x - ), suggesting tissue-specific mosaic variants in buccal epithelial cells and white blood cells of saliva. to understand the clinical relevance of these findings, the variants were further filtered to include only nonsynonymous variants found in fewer than % of samples, leaving a total of , variant locations. of the remaining variant locations, had a pathogenic assertion in the human gene mutation database, and were in international union of immunological societies pid genes. further variant interpretations and clinical correlations are underway. these data suggest that mosaic variants in pid genes are common, vary by location of collection, and may have clinical diagnostic relevance. abstract/case report text introduction/background: the arpc b (actin related protein / complex subunit b) gene is a protein coding gene prominently expressed in blood cells and is necessary for the assembly and maintenance of the human actin-related protein / complex (arp / ). actin polymerization plays a central role in many immune functions including proliferation and differentiation of immune cells, migration, intercellular and intracellular signaling and activation of both innate and adaptive immune responses. defects in the actin cytoskeleton affect hematopoietic cells in the bone marrow and the immune response giving rise to a distinct primary immune deficiency, which is phenotypically similar to wiskott-aldrich syndrome (was). arpc b deficiency clinically presents as a severe multisystem disease which includes platelet abnormalities, recurrent infections, failure to thrive, inflammatory changes in the intestine, eczema, cutaneous vasculitis, eosinophilia, and elevated inflammatory markers. arpc b deficiency is rare and has only recently been described in the literature. here we present a clinical case of a patient found to have a pathogenic arpc b mutation via whole exome sequencing. case report: here we describe a month old somalian boy who presented to the immunology team at months of age with hematemesis, hematochezia, melena, failure to thrive, atopic dermatitis, hypothyroidism, autoimmune thrombocytopenia and recurrent infections concerning for a primary immune deficiency. family history was notable for parental consanguinity and an older sibling with a similar presentation of hemorrhagic gastroenteritis who died in kenya around months of age due to complications of his symptoms. the initial primary immunodeficiency evaluation revealed normal inflammatory makers, normal igg and protective vaccine (prevnar and tetanus) response. iga and ige were elevated at mg/dl and . ku/l respectively. flow cytometry was remarkable for t cell lymphopenia (cd , cd , and cd ) with reduced naïve cd and cd t cells. b and nk cell count were normal. alps panel and was protein expression was unremarkable. whole exome sequencing was performed and revealed homozygotic mutation of arpc b c. t>c, ivs + t>c which was predicted to be a pathological variant. subsequently, dhr flow cytometry with fmlp showed significant increase of dhp fluorescent (mfi . when compared to control mfi . ) consistent with findings from other arpc b deficiency patients. at the time of the most recent clinic visit, the patient has remained abstract/case report text introduction: activation of the nod-like receptor family cardcontaining protein (nlrc ) leads to the formation of an inflammasome. the inflammasome, a large cytosolic multiprotein complex of innate immunity, promotes proteolytic cleavage, maturation, and secretion of pro-inflammatory cytokines, including il- and il- . a gain-of-function mutation (gof) in the gene encoding nlrc or nlrc -inflammasomopathy is characterized by hyperinflammation with persistent elevated il- , infantile enterocolitis, and early-onset macrophage activation syndrome (mas). objectives: to describe phenotypic variation among three siblings with a novel nlrc gof variant and to expand our current understanding of the clinical manifestations of the disease methods: clinical and laboratory features were studied in three siblings of a hispanic family with a novel nlrc gof variant. results: a novel variant, c. g>a (p.arg gln) on the nlrc gene, was identified in a -year-old male with recurrent febrile episodes since one year of age. his laboratory findings showed highly elevated esr, crp, il- , and fecal calprotectin. his endoscopic finding was unremarkable. the recurrent fever partially responded to canakinumab. a -year-old sister with ileocolonic crohn's disease for two years was found with the same nlrc variant and highly elevated il- . crohn's disease was well controlled after adding infliximab infusion to methotrexate therapy. a -year-old sister, who has been asymptomatic and healthy, was tested with the same positive nlrc variant and highly elevated il- . the nlrc variant is inherited from their father, who currently has a diagnosis of psoriasis vulgaris. the il- levels of the three siblings show in the figure patients with flh- develop the classic hlh phenotype early in life, with periods of remission. the pathogenesis is associated with a defect of perforin-dependent cytotoxicity. t-ctl and nk cells fail to remove abnormal cells, consequently, an uncontrolled proliferation and activation of cd + t cells and macrophages develops and generates an inflammatory cytokine storm and a solid organs infiltration. mortality of fhl- is very high without treatment; allogeneic hsct is the only curative therapy. we report the outcome of a child with fhl- , four years after his treatment with an allogeneic hsct using an hla haploidentical donor. case report: a boy born in december , previously healthy, the only child of parents without consanguinity. he has a normal family and perinatal history. when he is years old, he begins suffering from with fever, arthralgia, hepatosplenomegaly and pancytopenia. he meets the diagnostic criteria for hemophagocytic lymphohistiocytosis (hlh) and received treatment with iv methylprednisolone and entered in remission of its hlh. six months later, he restarts his clinical picture of hlh and j clin immunol receives treatment with the hlh- protocol, which leads to remission. ayear later he presents a new episode of hlh that responds to ivig, cyclosporin a and dexamethasone. the possibility of primary hlh is then suggested. when he is years old, the molecular diagnosis is made with the identification of a mutation in the stx gene, the case was classified as fhl- due to syntaxin deficiency. in october , a hsct was performed. at the age of , his clinical status is evaluated and laboratory studies show that his immunodeficiency due to syntaxin deficiency was cured. his -year-old mother, hla haploidentical was used as a donor and a protocol developed for the treatment of osteopetrosis was applied. the hsct protocol did not use a tcell depleted graft. hstc conditioning was done with melphalan days - and - , fludarabine days - to - , anti-thymocyte globulin days - and - , and cyclophosphamide day - . (figure) . clinical and demographic characteristics, including the use of a novel claims-based weighted algorithm (risk vital sign; rvs) and those initiating ivig and scig, were described. stratified analysis based on pid diagnosis codes was performed. probability of receiving available ig treatments based on baseline characteristics was evaluated by logistic regression and propensity score methods. results: selected clinical and demographic characteristics, severity measures, and previous treatments between the overall pid population (n= , ), pid patients initiating scig (n= , ), and pid patients initiating ivig (n= , ) are presented in the table. patient characteristics and previous treatments tended to be stable, although hypertension, obesity, and corticosteroid use increased during the study period. new ig users tended to be older and female, with increased depression, dyslipidemia, and hypertension than all pid patients. new scig users had more diagnoses of respiratory (e.g., asthma, copd) and inflammatory (e.g., arthritis, fibromyalgia, inflammatory bowel disease) comorbidities and less cancer than all pid patients. new scig users compared with new ivig users had increased asthma and copd, fibromyalgia, and inflammatory bowel disease and decreased cancer and peripheral vascular disease. previous corticosteroid use was higher in ig users than all pid patients. among scig users, prior pid treatments of iv antibiotics, and oral high potency antibiotics were similar to all pid patients. ivig users had higher iv antibiotic and antifungal use. rvs was initially developed to identify patients likely to have undiagnosed pid. this analysis applied rvs to patients diagnosed with pid to assess severity. rvs based on -year history in the overall pid cohort was predominantly low, with only . % of patients scoring in the medium and high ranges. rvs was increased in incident ig users, with ( . % medium/high for scig; . % medium/high for ivig). in other markers of severity, scig users had more sinusitis and ivig had more pneumonia than all pid. ig users had fewer abscesses, cellulitis, and otitis media than the full pid cohort. conclusions: this exploratory analysis showed a trend toward increased hypertension, inflammatory and respiratory comorbidity, higher rvs, and previous corticosteroid treatment in patients initiating on ig compared with all pid patients. results could be confounded based on pid diagnosis codes used and warrants further research. author disclosures: mp, cas, and zh are employees and stockholders of the takeda group of companies. jo is a consultant to takeda. jbl is an employee of rti health solutions, an organization funded by takeda to conduct this research. mer was an employee of rti health solutions at the time this research was conducted.presenting author: colin anderson-smits submission topic: immunoglobulin replacement therapy patients in a larger cohort group and to determine if there are patterns of disease not previously reported. methods: we performed a retrospective chart review of patients with lof stat (n= ) followed at the national institutes of health. we specifically looked at tortuosity, aneurysms, and dilation of both coronary and cerebral arteries. epidemiologic information, stat mutation, co-morbidities, and laboratory information were reviewed along with imaging studies, specifically brain mri, brain mra, heart mri, and coronary ct. results: most recently, patients with hies are found to have vascular abnormalities including tortuosity, dilatation, narrowing, and aneurysms of middle sized, cerebral, and coronary arteries. in an effort to determine the extent of vascular involvement in addition to miscellaneous organ involvement, we are reviewing a cohort of patients with hies who were evaluated at the nih. of these patients, are women and are men. of these patients, two have passed away due to vascular events leading to their deaths. there are four patients under the age of , patients between the ages of and , patients between the ages of and , and three patients above the age of (age range - , mean age . ).of the patients, five of these patients were found to have abnormal brain mri/mra at an approximate rate of . %. two of these patients were found to have at least one cranial aneurysm, two of these patients were found to have a level of narrowing or stenosis, and one patient was found to have dilatation.in terms of coronary abnormalities, of the ( . %) patients were noted to have at least one coronary abnormality including dilatation, aneurysm, or tortuosity on heart mri or coronary ct. eight patients ( . %) were found to have dilatation of which four patients were female and patients were male. of the patients, ten patients ( . %) were found to have at least one aneurysm. there were patients ( %) that were found to have at least mild tortuosity. conclusion: vascular abnormalities in our lof stat patients occurred at an exceedingly high rate-cerebral and coronary artery, . % and . % respectively. due to this, patient's with lof stat should be considered for screening with brain and heart imaging. currently, there are no guidelines which outline the appropriate timeline for screening in these patients however following these patients over time will allow us to determine the most appropriate interval for imaging follow up. abstract/case report text year old woman with personal history of severe and recurrent upper and lower respiratory infections, chronic pulmonary disease with bilateral bronchiectasis and several micro nodules, chronic diarrhea without diagnosis (colonoscopy with mild colitis, without cmv. no bacterias no parasits were found in stools), mild osteopenia, focal lesion in right hepatic lobe, atopic dermatitis and anemia. she was followed up in other center and in she was diagnosed with common variable immunodeficiency (cvid) and started treatment with intravenous immunoglobulin (ivig), but with low adherence to it. she did not have referred history of lymphoproliferation nor significant viral infections. she had a daughter with spherocytosis who required esplenectomy and also had bronchiectasis and cvid diagnosis, she deceased at years old due to pulmonary infection. one years old son has anemia. her other daughter and son are healthy. objective: to describe unique management of recurrent viral respiratory infections in a qds patient. case: -year-old male with a history of qds complicated by truncus arteriosus, vsd, hypoparathyroidism, asthma, and autism was followed for a history of "frequent pneumonias." he had daily rhinitis and a history of frequent otitis media which resolved after tympanostomy tube placement at age y. however, over the next two years, he had admissions with various respiratory viral infections resulting in respiratory distress and prolonged oxygen need. viruses detected during these separate admissions varied and included parainfluenza , metapneumovirus, rsv, b and coronavirus nl , coronavirus hku , and rhino/enterovirus ( times total). he was previously on a prophylactic course of antibiotics which made no difference in his symptoms. laboratory evaluation showed protective adaptive immunity with normal immunoglobulin numbers for age (igg mg/dl), along with normal b and t cell numbers. he had protective pneumococcal titers and mounted a normal mitogen response. while his nk cell numbers were normal, his nk t cells were low. his tlr functioning also appeared normal. in order to decrease his overall illness burden and to keep him out of the hospital, ivig infusions (~ mg/kg) were initiated monthly. shortly after initiation of treatment, his nasal purulence and drainage resolved and his family noted that he became more active and playful. treatment was continued for months, during which time he had only one episode of influenza infection needing inpatient management. he has been off of ivig for months without recurrence of his viral infections. conclusion: in this patient, severe recurrent viral respiratory infections despite apparently normal adaptive and cellular immunity presents a unique management dilemma. this was not an issue of recurrent bacterial infections as prophylaxis did not make a difference in the frequency of his infections. his nk t cells were low, which could have contributed to his frequent viral infections as nkt cells are known to play a role in viral immunity. the successful use of ivig treatment in his case points to a different use for ivig, namely for the anti-respiratory virus antibodies which are presumably contained within the formulation.given this finding, it may be prudent to consider ivig in management of qds patients, even with normal immune evaluation, in order to decrease risks of complications associated with severe and recurrent viral respiratory infections. abstract/case report text introduction: smad is a critical downstream signaling molecule for transforming growth factor-β (tgf-β) and bone morphogenic protein (nmp ). initially, smad , also known as dpc deleted in pancreatic cancer locus , was described as a tumor suppressor gene, and somatic deletion of the smad is seen in % of pancreatic carcinomas. subsequently, a germline point mutation in the smad gene (p. i v) was reported to cause myhre syndrome (mim# ). myhre syndrome is an autosomal dominant disease characterized by cognitive impairment, hearing loss, and musculoskeletal anomalies. the immunological phenotype of these patients has not been previously described, despite the critical role of tgf-β in regulating t cell response and the prevention of excessive inflammation. case report: a -year-old boy with myhre syndrome was referred to immunology clinic for evaluation of recurrent ear infections. he developed acute otitis media infections as an infant and had tympanostomy tubes placed at one year of life. he also had a recurrent sinus infections. at two years of age, he was diagnosed with autism and sensory neuronal hearing loss. brain mri showed a mildly hypoplastic pituitary gland, and a thickened corpus callosum with decreased myelination. given these findings, whole-genome sequencing was performed, which revealed a heterozygous de novo mutation in smad (p.i v / c. a>g) consistent with the diagnosis of myhre syndrome. through age , he was in the th percentile for height until he was started on growth hormone, which he responded to robustly. he is now he is in the th percentile for height. he had adenoidectomy due to sleep-disordered breathing at the age of years. he is maintained on montelukast and inhaled corticosteroids for treatment of rhinitis and mild persistent asthma. he is on atenolol for the treatment of primary hypertension. on physical exam, he has facial dysmorphisms, thickened skin, and contraction of the fingers consistent with myhre syndrome. immunologic elevation showed significant hypogammaglobulinemia (igg mg/dl), low iga ( mg/dl) and normal igm mg/dl. igg subclasses showed low igg and igg at mg/dl and mg/dl respectively. although he was fully vaccinated, his tetanus antibody was low at . iu/ml. however, this improved after repeat vaccination to . iu/ml. total t and b lymphocyte counts were normal; however, his memory cd and cd t cells were low for age at . % and . %, respectively. additionally, his switched memory b cell count was low at . %. conclusion: smad gain of function (myhre syndrome) can lead to impaired memory t and b cell formation with significant hypogammaglobulinemia and low iga. although the patient was able to respond to protein vaccination (tetanus), it is not clear if he will be able to maintain a long-term response. in a previous study, a similar gain of key: cord- - q py j authors: guan, wei-jie; liang, wen-hua; zhao, yi; liang, heng-rui; chen, zi-sheng; li, yi-min; liu, xiao-qing; chen, ru-chong; tang, chun-li; wang, tao; ou, chun-quan; li, li; chen, ping-yan; sang, ling; wang, wei; li, jian-fu; li, cai-chen; ou, li-min; cheng, bo; xiong, shan; ni, zheng-yi; xiang, jie; hu, yu; liu, lei; shan, hong; lei, chun-liang; peng, yi-xiang; wei, li; liu, yong; hu, ya-hua; peng, peng; wang, jian-ming; liu, ji-yang; chen, zhong; li, gang; zheng, zhi-jian; qiu, shao-qin; luo, jie; ye, chang-jiang; zhu, shao-yong; cheng, lin-ling; ye, feng; li, shi-yue; zheng, jin-ping; zhang, nuo-fu; zhong, nan-shan; he, jian-xing title: comorbidity and its impact on patients with covid- in china: a nationwide analysis date: - - journal: eur respir j doi: . / . - sha: doc_id: cord_uid: q py j background: the coronavirus disease (covid- ) outbreak is evolving rapidly worldwide. objective: to evaluate the risk of serious adverse outcomes in patients with coronavirus disease (covid- ) by stratifying the comorbidity status. methods: we analysed the data from laboratory-confirmed hospitalised patients hospitals in province/autonomous regions/provincial municipalities across mainland china between december (th), and january (st), . we analyse the composite endpoints, which consisted of admission to intensive care unit, or invasive ventilation, or death. the risk of reaching to the composite endpoints was compared according to the presence and number of comorbidities. results: the mean age was . years. patients ( . %) were females. severe cases accounted for . % of the study population. ( . %) patients reached to the composite endpoints. ( . %) reported having at least one comorbidity. the most prevalent comorbidity was hypertension ( . %), followed by diabetes ( . %). ( . %) patients reported having two or more comorbidities. after adjusting for age and smoking status, copd [hazards ratio (hr) . , % confidence interval ( %ci) . – . ], diabetes (hr . , %ci . – . ), hypertension (hr . , %ci . – . ) and malignancy (hr . , %ci . – . ) were risk factors of reaching to the composite endpoints. the hr was . ( %ci . – . ) among patients with at least one comorbidity and . ( %ci . – . ) among patients with two or more comorbidities. conclusion: among laboratory-confirmed cases of covid- , patients with any comorbidity yielded poorer clinical outcomes than those without. a greater number of comorbidities also correlated with poorer clinical outcomes. since november , the rapid outbreak of coronavirus disease (covid- ) , which arose from severe acute respiratory syndrome coronavirus (sars-cov- ) infection, has recently become a public health emergency of international concern [ ] . covid- has contributed to an enormous adverse impact globally. hitherto, there have been , laboratory-confirmed cases and , deaths globally as of march th , [ ] . the clinical manifestations of covid- are, according to the latest reports [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , heterogeneous. on admission, - % of patients reported as having at least one comorbidity, with diabetes ( - %), hypertension ( - %) and other cardiovascular and cerebrovascular diseases ( - %) being most common [ , , ] . previous studies have demonstrated that the presence of any comorbidity has been associated with a . -fold increased risk of developing acute respiratory distress syndrome in patients with h n infection [ ] . similar with influenza [ ] [ ] [ ] [ ] [ ] , severe acute respiratory syndrome coronavirus (sars-cov) [ ] and middle east respiratory syndrome coronavirus (mers-cov) [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , covid- more readily predisposed to respiratory failure and death in susceptible patients [ , ] . nonetheless, previous studies have been certain limitations in study design including the relatively small sample sizes and single center observations. studies that address these limitations is needed to explore for the factors underlying the adverse impact of our objective was to evaluate the risk of serious adverse outcomes in patients with covid- by stratification according to the number and type of comorbidities, thus unraveling the sub-populations with poorer prognosis. this was a retrospective case study that collected data from patients with covid- throughout china, under the coordination of the national health commission which mandated the reporting of clinical information from individual designated hospitals which admitted patients with covid- . after careful medical chart review, we compiled the clinical data of laboratory-confirmed hospitalized cases from hospitals (representing . % of the certified hospitals for admitting patients with between december th , and january st , . the diagnosis of covid- was made based on the world health organization interim guidance [ ] . because of the urgency of data extraction, complete random sampling could not be applied in our settings. all clinical profiles outside hubei province were centrally provided by the national health commission. three respiratory experts from guangzhou were dispatched to wuhan for raw data extraction from wuhan jinyintan hospital where most cases in wuhan were located. our cohort included patients from wuhan jinyintan hospital, and one each from hospitals. our cohort represented the overall situation as of jan st , taking into account the proportion of hospitals (~ one fourth) and patient number ( . %, , / , cases) as well as the broad coverage (covering all major provinces/cities/autonomous regions). confirmed cases denoted the patients whose high-throughput sequencing or real-time reverse-transcription polymerase chain reaction (rt-pcr) assay findings for nasal and pharyngeal swab specimens were positive [ ] . see online supplement for further details. the interval between the potential earliest date of transmission source (wildlife, suspected or confirmed cases) contacts and the potential earliest date of symptom onset (i.e., cough, fever, fatigue, myalgia) was adopted to calculate the incubation period. in light that the latest date was recorded in some patients who had continuous exposure to contamination sources, the incubation periods of less than . day would not be included in our analysis. the incubation periods were summarized based on the patients who had delineated the specific date of exposure. the clinical data (including recent exposure history, clinical symptoms and signs, comorbidities, and laboratory findings upon admission) were reviewed and extracted by experienced respiratory clinicians, who subsequently entered the data into a computerized database for further double-check of all cases. manifestations on chest x-ray or computed tomography (ct) was summarized by integrating the documentation or description in medical charts and, if available, a further review by our medical staff. major disagreement of the radiologic manifestations between the two reviewers was resolved by consultation with another independent reviewer. because the disease severity reportedly predicted poorer clinical outcomes of avian influenza [ ] , patients were classified as having severe or non-severe covid- based on the american thoracic society / infectious disease society of america guidelines [ ], taking into account its global acceptance for severity stratification of community-acquired pneumonia although no validation was conducted in patients with viral pneumonia. the predictive ability of the need for icu admission and mortality has been validated previously [ , ] . briefly, severe cases denoted at least one major criterion (septic shock requiring vasoactive medications, or respiratory failure requiring mechanical ventilation), or at least three minor criteria (respiratory rate being times per minute or greater, oxygen index being or lower, multiple lobe infiltration, delirium or loss of consciousness, blood urea nitrogen level being mg/dl or greater, blood leukocyte count being , per deciliter or lower, blood platelet count being , per deciliter or lower, body temperature being lower than degrees, hypotension necessitating vasoactive drugs for maintaining blood pressure). comorbidities were determined based on patient's self-report on admission. comorbidities were initially treated as a categorical variable (yes vs. no), and subsequently classified based on the number (single vs. multiple). furthermore, comorbidities were sorted according to the organ systems (i.e. respiratory, cardiovascular, endocrine). comorbidities that were classified into the same organ system (i.e. coronary heart disease, hypertension) would be merged into a single category. the primary endpoint of our study was a composite measure which consisted of the admission to intensive care unit (icu), or invasive ventilation, or death. this composite measure was adopted because all individual components were serious outcomes of h n infections [ ] . the secondary endpoint was the mortality rate. statistical analyses were conducted with spss software version . (chicago, il, usa). no formal sample size estimation was made because there has not been any published nationwide data on covid- . nonetheless, our sample size was deemed sufficient to power the statistical analysis given its representativeness of the national patient population. continuous variables were presented as means and standard deviations or medians and interquartile ranges (iqr) as appropriate, and the categorical variables were presented as counts and percentages. in light that no random sampling was conducted, all statistical analyses were descriptive and no p values would be presented for the statistical comparisons except for the cox proportional hazards regression model. cox proportional hazards regression models were applied to determine the potential risk factors associated with the composite endpoints, with the hazards ratio (hr) and % confidence interval ( %ci) being reported. our findings indicated that the statistical assumption of proportional hazards analysis was not violated. moreover, cox regression model was considered more appropriate than logistic regression model because it has taken into account the potential impact of the various duration of follow-up from individual patients. the age and smoking status were adjusted for in the proportional hazards regression model because they have been recognized as the risk factors of comorbidities even in the general population. the smoking status was stratified as current smokers, ex-smokers and never smokers in the regression models. the national health commission has issued , patients with laboratory-confirmed covid- in china as of january st , . at this time point for data cut-off, our database has included , cases from hospitals in province/autonomous regions/provincial municipalities (see online supplement for details). of these , cases, the mean age was . years. patients ( . %) were females. ( . %) patients were managed inside hubei province, and , ( . %) patients had a contact history of wuhan city. the most common symptom was fever on or after hospitalization ( . %), followed by dry cough ( . %). fatigue ( . %) and productive cough ( . %) were less common. at least one abnormal chest ct manifestation (including ground-glass opacities, pulmonary infiltrates and interstitial disorders) was identified in more than % of patients. severe cases accounted for . % of the study population. ( . %) patients reached to the composite endpoints during the study ( table ) . overall, the median follow-up duration was days (interquartile range: , ) . of the , cases, ( . %) reported having at least one comorbidity. the prevalence of specific we have further identified ( . %) patients who reported having two or more comorbidities. two or more comorbidities were more commonly seen in severe cases than in non-severe cases ( . % vs. . %). patients with two or more comorbidities were older (mean: . vs. . years), were more likely to have shortness of breath ( . % vs. . %), nausea or vomiting ( . % vs. . %), unconsciousness ( . % vs. . %) and less abnormal chest x-ray ( . % vs. . %) compared with patients who had single comorbidity ( table ) . non-severe cases. furthermore, comorbidities were more common patients treated in hubei province as compared with those managed outside hubei province as well as patients with an exposure history of wuhan as compared with those without ( table ) . overall, patients ( . %) reached to the composite endpoints during the study. patients ( . %) died, patients ( . %) were admitted to the icu and patients ( . %) received invasive ventilation. the composite endpoint was documented in ( . %) of patients who had at least one comorbidity as opposed to ( . %) patients without comorbidities. this figure was cases ( . %) in patients who had two or more comorbidities. significantly more patients with hypertension ( . % vs. . %), cardiovascular diseases ( . % vs. . %), cerebrovascular diseases ( . % vs. . %), diabetes ( . % vs. . %), copd ( . % vs. . %), chronic kidney diseases ( . % vs. . %) and malignancy ( . % vs. . %) reached to the composite endpoints compared with those without ( table ) . patients with two or more comorbidities had significantly escalated risks of reaching to the composite endpoint compared with those who had a single comorbidity, and even more so as compared with those without (all p< . , figure ). after adjusting for age and smoking status, patients with copd (hr . , %ci . - . ), diabetes (hr . , %ci . - . ), hypertension (hr . , %ci . - . ) and malignancy (hr . , %ci . - . ) were more likely to reach to the composite endpoints than those without (figure ) . results of unadjusted analysis was presented in table e - . overall, findings of unadjusted and adjusted analysis were not materially altered. as compared with patients without comorbidity, the hr ( %ci) was . ( %ci . - . ) among patients with at least one comorbidity and . ( %ci . - . ) among patients with two or more comorbidities (figure ). subgroup analysis by stratifying patients according to their age (< years vs. ≥ years) did not reveal substantial difference in the strength of associations between the number of comorbidities and mortality of covid- (table e ). our study is the first nationwide investigation that systematically evaluates the impact of comorbidities on the clinical characteristics and prognosis in patients with covid- in china. circulatory and endocrine comorbidities were common among patients with covid- . patients with at least one comorbidity, or more even so, were associated with poor clinical outcomes. these findings have provided further objective evidence, with a large sample size and extensive coverage of the geographic regions across china, to take into account baseline comorbid diseases in the comprehensive risk assessment of prognosis among patients with covid- on hospital admission. overall, our findings have echoed the recently published studies in terms of the commonness of comorbidities in patients with covid- [ ] [ ] [ ] [ ] [ ] . despite considerable variations in the proportion in individual studies due to the limited sample size and the region where patients were managed, circulatory diseases (including hypertension and coronary heart diseases) remained the most common category of comorbidity [ ] [ ] [ ] [ ] [ ] . apart from circulatory diseases, endocrine diseases such as diabetes were also common in patients with covid- . notwithstanding the commonness of circulatory and endocrine comorbidities, patients with covid- rarely reported as having comorbid respiratory diseases (particularly copd). the reasons underlying this observation have been scant, but could have arisen from the lack of awareness and the lack of spirometric testing in community settings that collectively contributed to the under-diagnosis of respiratory diseases [ ] . it should be stressed that the observed frequency of comorbidity may also reflect the transmission dynamics within particular age groups, case detection or testing practices or hospital admission policies during the early phases of the epidemic. consistent with recent reports [ ] [ ] [ ] [ ] [ ] , the percentage of patients with comorbid renal disease and malignancy was relatively low. our findings have therefore added to the existing literature the spectrum of comorbidities in patients with covid- based on the larger sample sizes and representativeness of the whole patient population in china. a number of existing literature reports have documented the escalated risks of poorer clinical outcomes in patients with avian influenza [ ] [ ] [ ] [ ] [ ] , sars-cov [ ] and mers-cov infections [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the most common comorbidities associated with poorer prognosis included diabetes [ , ] , hypertension [ ], respiratory diseases [ , ] , cardiac diseases [ , ] , pregnancy [ ] , renal diseases [ ] and malignancy [ ] . our findings suggested that, similar with other severe acute respiratory outbreaks, comorbidities such as copd, diabetes, hypertension and malignancy predisposed to adverse clinical outcomes in patients with covid- . the strength of association between different comorbidities and the prognosis, however, was less consistent when compared with the literature reports [ , , , ] . for instance, the risk between cardiac diseases and poor clinical outcomes of influenza, sars-cov or mers-cov infections was inconclusive [ , , , ] . except for diabetes, no other comorbidities were identified to be the predictors of poor clinical outcomes in patients with mers-cov infections [ ] . few studies, however, have explored the it has been well accepted that some comorbidities frequently co-exist. for instance, diabetes [ ] and copd [ ] frequently co-exist with hypertension or coronary heart diseases. therefore, patients with co-existing comorbidities are more likely to have poorer baseline well-being. importantly, we have verified the significantly escalated risk of poor prognosis in patients with two or more comorbidities as compared with those who had no or only a single comorbidity. our findings implied that both the category and number of comorbidities should be taken into account when predicting the prognosis in patients with covid- . our findings suggested that patients with comorbidities had greater disease severity compared with those without. furthermore, a greater number of comorbidities correlated with greater disease severity of covid- . the proper triage of patients should be implemented by carefully inquiring the medical history because this will help identify patients who would be more likely to develop serious adverse outcomes of covid- . moreover, better protection should be given to the patients with coivd- who had comorbidities upon confirmation of the diagnosis. a main limitation was the self-report of comorbidities on admission. under-reporting of comorbidities, which could have stemmed from the lack of awareness and/or the lack of diagnostic testing, might contribute to the underestimation of the true strength of association with the clinical prognosis. under-reporting of comorbidities could also lead to over-estimation of strength of association with adverse outcome. however, significant under-reporting was unlikely because the spectrum of our report was largely consistent with existing literature [ ] [ ] [ ] [ ] [ ] and all patients were subject to a thorough history taking after hospital admission. the relatively low age might help explain the low prevalence of copd in our cohort. moreover, the duration of follow-up was relatively short and some patients remained in the hospital as of the time of writing. more studies that explore the associations in a sufficiently long time frame are warranted. caution should be exercised when extrapolating our findings to other countries where there are outbreaks of covid- since the prevalence of comorbidities may differ among different countries. therefore, future studies that include an external validation of the results would be desirable. although the temperature and systolic blood pressure differed between some subgroups, they were unlikely to be clinically relevant. finally, because of the rapid evolving outbreak globally, ongoing studies with the inclusion of more patients would be needed to increase the statistical power and lend support to subgroup analyses stratified by the specific comorbidities (i.e. copd) and their association with the risk of death. data are mean ± standard deviation, n/n (%), where n is the total number of patients with available data. copd=chronic obstructive pulmonary disease. icu = intensive care unit. data are mean ± standard deviation, n/n (%), where n is the total number of patients with available data. copd=chronic obstructive pulmonary disease. icu = intensive care unit data are mean ± standard deviation, n/n (%), where n is the total number of patients with available data. copd=chronic obstructive pulmonary disease. icu = intensive care unit cox proportional hazard regression models were applied to determine the potential risk factors associated with the composite endpoints, with the hazards ratio (hr) and % confidence interval ( %ci) being reported. shown in the figure are the hazards ratio (hr) and the % confidence interval ( %ci) for the risk factors associated with the composite endpoints (admission to intensive care unit, invasive ventilation, or death). the comorbidities were classified according to the organ systems as well as the number. the scale bar indicates the hr. cox proportional hazard regression models were applied to determine the potential risk factors associated with the composite endpoints, with the hazards ratio (hr) and % confidence interval ( %ci) being reported. the model has been adjusted with age and smoking status a b comorbidity and its impact on , patients with covid- in china: a 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first people's hospital, lu'an people's hospital, affiliated hospital of qingdao university, qingyuan people's hospital, quanzhou county people's hospital, rizhao people's hospital, shaodong people's hospital, shiyan xiyuan hospital, tongling people's hospital, wenzhou people's hospital, wenzhou central hospital, the second affiliated hospital of wenzhou medical university, wuxi fifth people's hospital zhijiang people's hospital, people's hospital of dianjiang county, chongqing, chongqing jiulongpo first people's hospital, chongqing shizhu tujia autonomous county people's hospital, the first people's hospital of wanzhou district, chongqing, yongchuan hospital affiliated to chongqing medical university, anguo hospital, the third hospital of peking university, peking university shenzhen hospital , boluo people's hospital, changde lixian people's hospital, changde second people's hospital, chenzhou central hospital, chengjiang people's hospital, dalian central hospital, danzhou people's hospital, dengzhou central hospital hangzhou first people's hospital, hangzhou lin'an district people's hospital, nanpi county hospital of traditional chinese medicine of hebei province, henan people's hospital, hefeng county central hospital, hohhot first hospital, huludao central hospital, the first affiliated hospital of hunan medical college, shenzhen union hospital of huazhong university of science and technology, huaibei people's hospital, huangshi second hospital, huangchuan people's hospital jiangyou infectious diseases hospital, jieyang people's hospital, jinhua central hospital, jinzhong pingyao people's hospital, jingjiang people's hospital, the second affiliated hospital of kunming medical university, laifeng county central hospital, yueqing people's hospital, lijiang people's hospital, lixin people's hospital, the fourth people's hospital of lianyungang, linqu county people's hospital xuanwu hospital of capital medical university, sichuan mianyang hospital, sixian hospital of traditional chinese medicine, suihua first hospital, suiping county people's hospital, tianjin fourth central hospital, tianjin haihe hospital, tiantai county people's hospital, tongchuan mining bureau central hospital, tongren people's hospital, weihai central hospital, the first affiliated hospital of wenzhou medical university, wuzhou third people's hospital, armed police hubei provincial general team hospital, xixian people's hospital, longshan county people's the first affiliated hospital of xinjiang medical university, xinmi hospital of traditional chinese medicine, xinxiang county people's hospital, xinye people's changsha eighth hospital, changsha first people's hospital, st hospital of the joint service support force of the chinese people's liberation army, central theater general hospital of the chinese people's liberation army, the first affiliated hospital of china medical university, the third affiliated hospital of zhongshan university, zhongshan second people's hospital, chongqing chengkou people's hospital, chongqing hechuan district people's hospital, chongqing red cross hospital, zhoushan women's and children's hospital, zhoukou infectious diseases hospital, zhuzhou first people's hospital, zhumadian central hospital, anlong people's hospital, anxi county hospital, anyang fifth people's hospital, anyang people's hospital, anyuan people's hospital, badong county ethnic hospital, wuyuan county people's hospital of bayannur city, baise people's hospital, the first affiliated hospital of bengbu medical college, baoding first central hospital, changping district hospital of beijing municipality, changping district hospital of traditional chinese and western medicine of beijing chizhou people's hospital, chongxin county people's hospital, chongyi people's hospital, affiliated hospital of north sichuan medical college, dazhou central hospital, dali first people's hospital, the second affiliated hospital of dalian medical university, the first affiliated hospital of dalian medical university, danyang people's hospital, daocheng people's hospital, deqing people's hospital, dezhou second people's hospital, dezhou people's hospital, dezhou qingyun people's hospital fuzhou fifth people's hospital, fuzhou dongxiang district people's hospital, fuyang district first people's hospital, ganzhou longnan county people's hospital, gaolan county people's hospital, gongcheng yao autonomous county people's hospital, gushi people's hospital, guang'an people's hospital, guangdong hospital of traditional chinese medicine, guangzhou eighth people's hospital, guangzhou th people's hospital, shenzhen hospital of guangzhou university of traditional chinese medicine, people's hospital of guiding county, hanjiang hospital of sinopharm, harbin acheng district people's hospital, nangang district people's hospital of harbin, the first affiliated hospital of harbin medical university, haikou people's hospital, hainan west central hospital, handan sixth hospital, handan central hospital, hanshan people's hospital, hangzhou dingqiao hospital, the third people's hospital of yuhang district, hangzhou, the first people's hospital of yuhang district, hangzhou, minzhou people's hospital, hefei sixth people's hospital (hefei infectious diseases hospital), he xian memorial hospital, hebei chest hospital, hechi people's hospital, hejin people's hospital, the first affiliated hospital of henan university of science and technology, zhangye people's hospital affiliated to hexi university, heyuan people's hospital, heze municipal hospital, heilongjiang provincial hospital , south yunnan central hospital of honghe prefecture, hulunbuir manzhouli hospital, hunan youxian people's hospital, the first affiliated hospital of hunan university of traditional chinese medicine, china resources wisco general hospital, huaihua chenxi county people's hospital, huai'an fourth people's hospital, huainan mashan infectious disease hospital, huangshan people's hospital, huangshi fifth hospital, huichang people's hospital, huining county people's hospital, huizhou first people's hospital, jixi people's hospital, qianan county people's hospital of jilin province, jinan fourth people's hospital, jining second people's hospital, affiliated hospital of jining medical college laixi people's hospital, the second hospital of lanzhou university, lancang second people's hospital, leping people's hospital, leshan people's hospital, lengshuijiang people's lianjiang county hospital, the first people's hospital of lianyungang, liaoning chaoyang disease control center hospital, liaocheng people's hospital, linshui people's hospital key: cord- -ptkw csu authors: gilbert, gwendolyn l.; kerridge, ian title: the politics and ethics of hospital infection prevention and control: a qualitative case study of senior clinicians’ perceptions of professional and cultural factors that influence doctors’ attitudes and practices in a large australian hospital date: - - journal: bmc health serv res doi: . /s - - -y sha: doc_id: cord_uid: ptkw csu background: hospital infection prevention and control (ipc) programs are designed to minimise rates of preventable healthcare-associated infection (hai) and acquisition of multidrug resistant organisms, which are among the commonest adverse effects of hospitalisation. failures of hospital ipc in recent years have led to nosocomial and community outbreaks of emerging infections, causing preventable deaths and social disruption. therefore, effective ipc programs are essential, but can be difficult to sustain in busy clinical environments. healthcare workers’ adherence to routine ipc practices is often suboptimal, but there is evidence that doctors, as a group, are consistently less compliant than nurses. this is significant because doctors’ behaviours disproportionately influence those of other staff and their peripatetic practice provides more opportunities for pathogen transmission. a better understanding of what drives doctors’ ipc practices will contribute to development of new strategies to improve ipc, overall. methods: this qualitative case study involved in-depth interviews with senior clinicians and clinician-managers/directors ( doctors and nurses) from a broad range of specialties, in a large australian tertiary hospital, to explore their perceptions of professional and cultural factors that influence doctors’ ipc practices, using thematic analysis of data. results: professional/clinical autonomy; leadership and role modelling; uncertainty about the importance of hais and doctors’ responsibilities for preventing them; and lack of clarity about senior consultants’ obligations emerged as major themes. participants described marked variation in practices between individual doctors, influenced by, inter alia, doctors’ own assessment of patients’ infection risk and their beliefs about the efficacy of ipc policies. participants believed that most doctors recognise the significance of hais and choose to [mostly] observe organisational ipc policies, but a minority show apparent contempt for accepted rules, disrespect for colleagues who adhere to, or are expected to enforce, them and indifference to patients whose care is compromised. conclusions: failure of healthcare and professional organisations to address doctors’ poor ipc practices and unprofessional behaviour, more generally, threatens patient safety and staff morale and undermines efforts to minimise the risks of dangerous nosocomial infection. in high income countries, an estimated - % of hospital inpatients develop healthcare-associated infections (hais) [ ] and nosocomial transmission of multidrug resistant organisms (mrdo) is a major contributor to antimicrobial resistance (amr) and its associated healthcare costs [ , ] . it is estimated that - %, or more, of hais are preventable [ , ] , although rates are highly variable, depending on how effectively ipc measures are implemented [ , ] . failures of routine hospital infection prevention and control (ipc) practices, in high income countries during this century, have resulted in devastating nosocomial outbreaks of exotic or emerging infections, such as severe acute respiratory syndrome (sars) in toronto, in [ ] and middle east respiratory syndrome (mers) in seoul in [ ] , causing preventable deaths and massive social and economic disruption. hand hygiene is the most obvious, easily audited and, arguably, the most effective ipc practice [ , ] , its efficacy has been recognised since at least the mid-nineteenth century, with numerous studies showing that significant reductions in pathogen transmission and hai rates are temporally associated with improved hand hygiene compliance [ ] . nevertheless, the use of hand hygiene as a surrogate for ipc quality and the moral status of noncompliance have been questioned, largely as a consequence of ongoing controversy about auditing methods and plausible compliance targets [ ] [ ] [ ] . ethical considerations have particular salience in light of numerous studies reporting lower than average compliance with ipc policies among doctors, compared with other health professionals, albeit with wide variation [ ] [ ] [ ] . doctors' attitudes and behaviours are important, because they disproportionately influence those of other hospital staff and doctors often overestimate their own knowledge and compliance [ , ] . yet their peripatetic clinical practice provides numerous opportunities to transmit pathogens [ ] and to be pathogen "super-spreaders" [ , ] . doctors retain considerable professional autonomy and power, despite repeated challenges from increased regulation, other health professions, evidence-based medicine and consumerism [ ] [ ] [ ] . despite recent attempts to redefine "medical professionalism", a universally agreed definition remains elusive; but all versions include common commitments to e.g. patient welfare; maintenance of knowledge and skills; and securing public trust through professional self-regulation and avoidance of conflicts of interest [ ] [ ] [ ] . how doctors interpret these commitments depends on how they perceive their professional identity [ ] . in practice, their attitudes and practices are complex and sometimes perplexing. assuming that patient welfare is doctors' highest priority [ ] , one may reasonably ask why some would expose their patients to preventable infection risks by failing to observe well-established ipc rules [ , ] ? previous qualitative and mixed methods studies of factors that affect adherence to ipc practices have generally involved mixed groups of healthcare workers and/or focused on particular institutional settings, such as intensive care units. while these studies have identified factors that contribute to ipc practices including: self-protection, role modelling, belief (or not) in the effectiveness of ipc, knowledge, communication and workload [ , , , ] they have not, for the most part, explained why these factors are so influential. the aim of this study was to explore what factors affect doctors' ipc practices and, more specifically, why they are so influential. it took the form of in-depth conversations between researchers and participants, all of whom were senior clinical leaders and or clinician-director/managers with many years' experience. our expectation was that the perspectives of both "insiders" [senior doctors] and more objective "outsiders" [senior nurses] would provide new insights to inform strategies to raise the priority of ipc within the medical community and limit harm from hais and amr more effectively. our research question was: what professional and cultural factors influence doctors' attitudes to and practice of infection prevention and control? both researchers are senior physicians, one female, one male. our special interest in hospital ipc stems from longstanding experience in caring for patients who are at high risk, have suffered and, in some cases, died, from preventable hais and/or have experienced the uncertainty and fear associated with being colonised by a mdro. both of us were employed, for many years before or during this study, at the hospital where it was conducted. most of the participants were known to at least one of us, as colleagues, but with few exceptions, we had not worked closely with them. our aim was to build a rich portrait of doctors' attitudes to and practice of ipc, in one large australian tertiary hospital, by means of in-depth interviews with experienced senior doctors and nurses. together with them, we hoped to formulate new theories to better explain the reasons behind doctors' ipc practices, in order to develop more effective and generalisable strategies to improve them. we used a thematic analysis approach to data analysis [ ] . participants were senior doctors (i.e. medical practitioners) and nurses with varied clinical and/or management responsibilities, who were purposively selected as being likely to have a broad perspective on the attitudes, beliefs and practices of the hospital's medical staff across age-groups and specialties. invitations were sent by email, explaining the purpose of the study. thirty-two potential participants - doctors and nurses -were contacted sequentially. all of the nurses and doctors agreed to participate; two doctors were unavailable, one refused and three did not respond. sixteen participants were facility/divisional directors or unit managers, were specialist consultants; they had had - years' professional experience and most had been employed in the hospital for more than years. doctors were either full-time staff specialists [ss] or visiting medical officers (vmos) contracted on a sessional basis. nurses were all full-time employees. participant characteristics are summarised in table . the setting was a~ -bed university teaching hospital, serving a population of about . million in sydney and providing a broad range of tertiary specialist services to more than , inpatients, annually. the study was conducted at a single site to enable a rich and detailed understanding of the influences on doctors ipc practices and to avoid potential confounding effects of different policies, patient populations or physical environments. semi-structured interviews, lasting - min, were conducted by one researcher. they took the form of frank conversations between colleagues. most were conducted in the participant's -or occasionally the interviewer's -office with no-one else present. interviews were recorded and digitally transcribed by a professional transcription service, with participants' informed consent. examples of questions used to prompt discussion are shown in table . interview transcripts were checked for accuracy by one researcher. both authors reviewed the transcripts, coded them manually and analysed them thematically [ ] , to identify themes and subthemes relevant to the research question. after initial analysis, transcripts and emergent themes/subthemes were reviewed, iteratively, and modified after further discussion. recruitment ceased when data saturation had been reached. participants gave written informed consent to interviews being recorded and transcribed. they were assured that their comments would be confidential and quoted, if at all, only after removal of identifying information. in describing our findings, we identified participants' professions and roles, broadly, to preserve anonymity, as nursing director (nd), manager (nm) or consultant (nc); or medical director (md) or consultant (mc). the relevant local health district human research ethics committee approved the study. four major themes emerged from the data and, within theme , four subthemes were identified. these themes and subthemes are outlined in table . theme is the subject of this paper. other themes/subthemes will be discussed, in detail, elsewhere. you can't tell doctors what to do (medical director [md] ). doctors' highly valued clinical autonomy was seen as one of the most important determinants of ipc practices. participants described doctors, generally, as self-motivated and averse to being told what to do, particularly as they become more senior. this was attributed to: the types of people who become doctors; doctors' perception that others expect them to be confident and decisive; and their tendency to rely on clinical judgment and experience, rather than "rules". however, participants described differences in how doctors enact clinical autonomy in their ipc practices. those of some individual doctors and unitsrepresenting such varied specialties as transplantation surgery, haematology, general surgery and neurosurgerywere described, by participants, as exemplary. a unit director (md ) recounted his own unit's practice, of having a junior doctor audit the team's hand hygiene compliance and present the results at weekly meetings, and his pride in the resulting improvement. at the other extreme, several participantsindependently -cited examples of units in which ipc standards were notoriously poor and hai rates (reputedly) excessive; they also described individual consultants who had to be reminded, repeatedly, about basic ipc precautions and who vehemently demurred, refused or tried to avoid situations where they may be asked, to comply: from a political point of view, we (intensive care unit [icu] clinicians) are in a bind. we encourage outside (surgical) teams to see their high-risk patients daily, (but) they're saying "i don't want to go to icu, they always give me a hard time about washing my hands or taking my jacket off". so, we're trying to make sure that they have easy access to the patients, but in such a way that the whole process is smooth. for some clinicians, hand hygiene presents an objectionable obstacle. (emphasis added) (md ) several (doctor) participants thought their colleagues' objections, to ipc "rules" that they perceived to be inflexible, inappropriately applied or imposed by outsiders, were legitimate. for example, patients being placed in contact isolation, when the risk of cross-infection was minimal, caused increased pressure on already over-burdened junior doctors and potentially endangered other patients, because of misplaced priorities. the infection control nursing staff don't understand the pressures that medical staff, particularly junior medical staff, are under. some of the attitudes to infection control appear to be given in isolation without really an understanding of how they might be integrated into all the various things that have to be done by residents and senior doctors and nurses. a bit of an irritant is if i'm asked to take precautions that i don't think are appropriate (when) nursing staff have instituted a policy (and) gone a bit too far. (for example) a patient who has minor neutropenia and a (mild) fever that you're keeping in just in case.... they're given priority, put in a single room and everybody's in gloves and gowns; and they've got other people out in the ward coughing and hacking, perhaps harbouring something much more significant. (md ) several medical directors attributed doctors' poor ipc practices to ignorance, although on-line ipc training and attendance at education sessions was supposedly mandatory. there's a poor understanding of what's required, even though you're meant to do mandatory training. but apparent adherence to ipc principles sometimes reflected tradition or habituated behaviour, rather than knowledge of organisational policies. a surgeon contrasted his colleagues' almost ritualistic "surgical scrubbing" and donning of theatre attire in the operating theatre, with cursory adherence to standard ipc precautions in the wards: participants emphasised the importance of leadership in moulding the ipc practices of junior doctors, who are likely to emulate those of senior consultants. they characterised good ipc leaders as consistently adhering to good practices, themselves, and being willing to discuss ipc principles and review practices and outcomes with their teams (see md 's anecdote about registrar hand hygiene audits, above, and unit x director's response to his patients' hais below). of course, clinical leadership is about much more than ipc practices: i often talk about (a particular surgical unit) because they are a high performing team and their leadership is very strong across the board in all sorts of areas; they're very solid as a team and the interns know the rules and abide by them even when (the consultants) are not there. (nd ) on the other hand, bad or absent leadership is often also associated with poor ipc practice. if the "boss" ignores or disparages ipc practices, junior doctors would follow suit. it's about leadership and followership. senior staff 's lack of role modelling -automatically the followers see that "it's not a big deal for sir, so it's not a big deal for me". (md ) one participant wondered whether leadership and role modelling might be less critical, now that junior doctors were increasingly aware of the importance of ipc and could influence consultants' ipc behaviours, by reminding them of the policies. the more prevalent view was that the (still) powerful medical hierarchy was a strong deterrent against any attempt to correct the "boss", even implicitly, for fear of retribution. where a junior person speaks to a more senior person (about) a protocol that hasn't been performed correctly, the senior person feels threatened. the normal thing is to stamp your authority and say "well hang on, who are you?". (mc ) most participants felt that any good habits learnt in medical school were likely to be superseded by hidden curricula assimilated during postgraduate training. doctor participants admitted that they would not personally feel comfortable speaking to senior colleagues about poor ipc practices; on the other hand, some nurse participants said they would willingly speak up to a consultant or team with whom they had a good working relationship. participants acknowledged the devastating effects, on patients, of serious hais, but pointed out that most doctors personally manage such complications infrequently and hear about only the worst cases at morbidity and mortality (m&m) meetings. many doctors have little appreciation of the incidence, or impact on patients, of more minor infections. moreover, hais are often regarded as unavoidable; they are rarely attributable to specific actions, omissions or even patterns of behaviour, because of the inevitable delay and multiple factors and people involved. nevertheless, participants described doctors' contrasting reactions to their own patients' hais: one saw it as a disaster, for which he felt personally responsible, another as a driver for change. a nurse manager described starkly contrasting attitudes between two unit directors: (unit x's director says) "what did we do wrong: what are we going to do to make sure this doesn't happen (again)?" he doesn't want to see bad things happen to patients. (unit y's director at the departmental m&m meeting) … . it's: "what's the patient done wrong this time? it's the patient's fault. it's not our fault. the patient's dirty (or) too fat; they should have looked after themselves better". there's no accountability, no insight. (nm ) several participants noted that hais are often overlooked because of inadequate patient follow-up; they were highly critical of some senior consultants' infrequent ward rounds, expectation that trainees would manage and follow-up patients, often with minimal supervision, and apparent lack of interest in patient outcomes. somebody who swans in, looks at something, swans out again and never understands that what he actually did was screwed up the patient's life -that's the problem. interviewer: what can you do about it? participant: throw their noses in the data. (md ) unfortunately, for most departments, very limited data are available. collection of unit-specific hai data was seen as the organisation's, not individual unit's, responsibility. while participants noted that monthly hand hygiene audit data were posted on ward notice boards, they believed that medical teams rarely reviewed them or, if they did, were skeptical about their accuracy and unaware of how they compared with those of other wards. one medical director (md ) acknowledged that ward compliance data showed large discrepancies between wards and the lowest compliance rates amongst doctors, which were masked by the hospitals' satisfactory results, overall. another director (md ) suggested that audit results overestimate actual compliance because auditors were not strict enough, but he rationalised doctors' relatively low rates as being due to the fact that the auditors were nurses. in answer to an open question about general issues of concern, all medical divisional directors mentioned their frustration at some senior consultants' apparent lack of commitment to their public hospital responsibilities, because of the demands or attractions of private practice. [they] ... come in, do an operation, bugger off. they probably won't ever see that [public] patient again; they don't know what the outcome is. they don't have to front these patients in their office. [md ] participants attributed this to better remuneration, working conditions, infrastructure and capital equipment in the private sector. while noting that vmos value the prestige and challenging case-mix of a public hospital appointment, one director (md ) pointed out that their contracts do not stipulate specific obligations (that many would take for granted), such as teaching and supervision of junior staff or accountability for patient outcomes. he suggested that, rather than relying on vmos' "altruism", the public system should provide more attractive conditions. if you want the talent you've got pay for it -an adequate salary, medical indemnity, secretary, reasonable office, parking space. it's a very big package, but that's what you need to do. if you offered them that they would be prepared to take a or per cent cut in income to concentrate their activities in one place and give up all the angst of being an employer. (md ) while this solution seemed unlikely in the current public health system, a senior manager mentioned the hospital executive's plan to revise vmo contracts to define the "rules of engagement", to which applicants must agree, including regular attendance at ward rounds and teaching sessions, trainee supervision and formal delegation of decision-making at weekends. in common with many australian public hospitals, the case hospital's recent devolution of accountability for key performance indicators (kpis), to divisional directors, had made them more aware and less tolerant of consultants, whom they perceived to be failing their implicit obligations, with impunity. in the context of this study, they linked this behaviour to ignorance of ipc policies and poor practice. however, they all agreed that instigating disciplinary action against senior doctors, in these circumstances, would be professionally and legally difficult, divisive and bitterly opposed, on principle, by medical organisations and most doctors, including those whose own behavior was above reproach. none of the divisional directors could offer solutions, other than more explicit employment contracts and/or more pay, but they conceded that it would still be difficult to monitor or enforce compliance. despite their frustration, some directors described recent success, in delegating responsibility for clinical and administrative improvements, including in ipc, to unit directors, and assimilation of autonomous senior consultants into unit teams. while doctors' relatively poor ipc practices, overall, have been well-documented, this qualitative study is one of few which have deeply interrogated why this is so. participants regarded senior doctors' perceived entitlement to professional independence as a major contributor to how they choose to practice ipc and just one expression of how they fulfil implicit obligations to provide evidence-based patient care and clinical leadership. there was consensus that, although doctors are aware of the importance of ipc, for many it is not their highest priority. nevertheless, most observe ipc policiessometimes with modification -and/or do not object to being reminded. uncertainty about the efficacy of some ipc measures and a lack of data about hais are barriers to doctors' becoming more involved in ipc policy development and implementation. however, for most participants, the greatest concern was some senior consultants' hostile disregard for ipc policies and its adverse effects on patients and other staff and their apparent immunity from censure. participants regarded doctors as generally resistant to external rules, which they see as a challenge to their clinical autonomy and self-perception as independent thinkers [ ] . in relation to ipc they may exercise autonomy, either by taking it very seriously (exemplary practice) or by choosing to remain ignorant or dismissive of basic ipc precautions, which participants interpreted as evidence of a perceived entitlement to decide, for themselves, what is important. it has been shown, previously, that compliance with hand hygiene is inversely related to educational level and seniority [ ] . in making sense of this observation, we noted that many senior consultants completed their training and developed habituated behaviours at a time there was little focus on ipc, because of a prevalent belief that infectious diseases had largely disappeared [ ] . while this belief is now known to have been misguided, the fact that it persists could be interpreted as a failure of continuing professional education (cpe). although cpe is a condition of annual medical registration, in australia, it is largely confined to specialty topics. specialist colleges endorse, and expect members to comply with, ipc guidelines and online ipc training is mandatory for all hospital staff, but many senior doctors choose to ignore both, with impunity. college expectations and hospital requirements are futile if professional autonomy is interpreted as meaning that compliance is discretionary [ ] . previous studies have also suggested that doctors' poor compliance with guidelines, in general, reflects ignorance or skepticism about their effectiveness and/or an exaggerated confidence in their own judgment [ , ] . as charani et al suggest: senior doctors consider themselves exempt from following policy and practice, within a culture of perceived autonomous decision-making that relies more on personal knowledge and experience than formal policy [ ] . senior consultants for whom ipc is a high priority may, nevertheless, seek to selectively 'modify' hospital ipc policies. this observation is supported by a recent study [ ] that found that violations of transmission-based precautions were often not due to ignorance, but a clinicians' judgment that the risks did not justify the extra staff time and cost or adverse effects on patients [ ] . participants gave examples of such modifications, which they regarded as sometimes appropriate. however, they are likely to be interpreted as arbitrary and a source of confusion and conflict; they might be avoided if doctors were more willing to be involved in the development and local implementation of ipc policies, as leaders or champions [ , ] . doctors' apparent independence may be partly illusionary, if their clinical practice is guided by habituated behaviours, learnt during their early postgraduate training, by emulating teachers and supervisors, whom they admire or fear [ ] . participants identified leadership, as others have done [ ] , as an important determinant of (good or bad) ipc practice. within a hierarchical hospital system, leadership is usually based on seniority, status and power [ ] . most senior consultants exercise their leadership roles appropriately and model acceptable or exemplary ipc practices but the attitudes of the minority, who repeatedly ignore or dispute basic ipc precautions, will also be transferred to junior doctors. medical students are now taught about the importance of ipc and the risks of hai and amr but, as postgraduate trainees, they absorb the hidden curricula [ ] of the specialties and units in which they train, which may be at odds with what they have been taught. once entrenched, senior doctors' habituated behaviours are difficult to change, since even their peers are deterred, by professional etiquette and their own uncertainties, from challenging colleagues' unsafe practices [ ] . even doctors who are knowledgeable about and aware of the importance of ipc may struggle to understand how hais occur, because the effects of practice breaches are delayed, hidden and uncertain. some regard hais as unavoidable or someone else's fault -"the problem of many hands" [ ] -and many have little concept of patients' fears or the significant personal cost of even minor hais [ ] . these problems are compounded by lack of data. results of mandatory reporting to health authorities or internal incident reports of serious, but rare hai-related events, such as bloodstream infections or unplanned readmissions, have little resonance and there are virtually no data about less serious hais. so it is impossible to monitor trends or reflect on individual consultant's or unit's performances vis-à-vis their peers, despite evidence that surveillance and feedback of results can motivate ipc improvement and reduce hai rates [ , ] . the lack of consistent national hai surveillance, in australia, is a recognised barrier to sustained ipc behavior change, particularly among doctors, and state-or hospitalbased surveillance is highly variable [ ] . the perceived failure of a small proportion of consultants to meet their obligations to the public hospital system was the issue that our participants spoke about most vehemently. our participants felt strongly that senior doctors' infrequent presence in the hospital and poor trainee supervision, (public) patient follow-up and ipc practices were not valid expressions of professional autonomy and agency, but manifestations of disrespect both for patients, who are exposed to unnecessary risk and colleagues who conform with, or are responsible for maintaining, ipc standards. moreover, the hostile reactions of some doctors, to being reminded about basic ipc precautions, were interpreted as a manifestation of the bullying, which is endemic in healthcare settings in many countries, including australia [ , ] , and as 'yet another' failure of professional self-regulation [ ] . in this regard, recent media scrutiny of withdrawal of postgraduate training accreditation from two major sydney public hospitals, largely as a consequence of bullying and harassment by senior medical staff [ , ] , raises the question of whether hospital administrators and specialist colleges will act to address cultural problems in medicine, including bullying, more effectively. where to from here? the vanderbilt university medical centre's system of co-worker observation and reporting is one promising approach to doctors' (and others') unprofessional behaviours. it involves, as a first step, a suitably trained colleague initiating an informal, respectful conversation with a doctor whose behaviour has been the subject of complaint from a patient or co-worker. in most cases this is apparently sufficient but, if a pattern of behaviour emerges, it is followed by staged escalation [ ] . it has proven to be feasible and effective in reducing bullying [ ] , patient complaints [ ] and poor ipc practices [ ] and limits the need for more direct disciplinary action. it has been introduced or considered by several australian hospitals [ ] and the royal australasian college of surgeons [ ] . such an holistic approach to organisationwide culture change, would complement better surveillance and feed-back of hai-related data and innovative strategies, such as the use of video-reflexive methods that have been used successfully to raise clinician awareness and improve ipc practices [ ] . a major strength of this study was the seniority, varied clinical and management experience and broad vision of our participants, who were among the hospital's most senior clinicians and clinician-managers/directors. many of them were responsible for service quality and efficiency across multiple departments and acutely aware of the issues discussed. in addition, we believe that, because the interviewer was an "insider", with comparable seniority and professional background, participants shared their insights and frustrations more candidly than they may have done with an external researcher. as researchers, we were inevitably influenced by our own perspectives and biases, which we sought to mitigate by discussion and self-reflection and by consulting as broad as possible a range of participants. as typical of qualitative research, they were but a small sample of the larger cohort of senior hospital clinicians, but represented a wide range of specialties, seniority, management responsibilities and attitudes to ipc. the fact that participants and researchers were staff of a single hospital is appropriate for a case study but could also be seen as a limitation. however, our observations, experience and published literature suggest that the issues identified are common to most large, tertiary hospitals in australia and countries with similar mixed public/private health systems. moreover, limiting the study to a single site meant that all participants were familiar with the organisation's idiosyncrasies and illustrative examples of doctors' attitudes or practices were corroborated, and given added cogency, by multiple participants. while participants expressed their opinions, frankly, about the attitudes and behaviours of colleagues, they generally did not identify them except by specialty. we did not seek to corroborate opinions about ipc practices with objective evidence of compliance, which was not the focus of this study, and none of the few units mentioned by participants, as having poor ipc practices, was represented amongst participants. this was unintended but may be seen as a limitation. clearly many factors contribute to doctors' ipc practices, other than (and sometimes contrary to) the norms, values and precepts of the medical profession. one of the most salient is how they interpret professional autonomy, which is a strongly defended principle of medical professionalism, but surely not intended to imply that doctors are entitled to ignore the policies of their employer organisations. although participants sometimes defended doctors' objections to, or ignorance of ipc "rules", they clearly regarded doctors who reacted to reminders or requests to comply aggressively or unprofessionally, as an "out-group". in common with other preventive programs, ipc is sometimes a victim of its own (partial) success; there is a widespread but unsubstantiated impression that ipc practices are "good enough" and further improvements not cost-effective. however, the continuing prevalence of preventable hais and nosocomial transmission of mdros and the threat of emerging infections mean that sustained improvement is needed. we argue that this will not be achieved without the full support and participation of all healthcare professions, includingperhaps especiallydoctors. however, our findings suggest that improving doctors' ipc practices will require greater commitment from professional organisations and healthcare administrators to a) more appropriately measure, and inform clinicians about, the adverse effects for patients of non-adherence and b) effectively enforce appropriate policies and practices that prevent these harms. the poor ipc practices of some doctors are just one aspect of the broader issue of unprofessional behaviour and immunity from criticism that must be addressed, if the medical profession, in general, is to be seen to conform with its espoused professional values and those of the community that supports it. report on the burden of endemic health care-associated infection worldwide. geneva: world health organisation nosocomial transmission of antibiotic-resistant microorganisms the relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs the preventable proportion of healthcare-associated infections - : systematic review and meta-analysis an integrative review of infection prevention and control programs for multidrug-resistant organisms in acute care hospitals: a socio-ecological perspective effectiveness of national and subnational infection prevention and control interventions in high-income and upper-middle-income countries: a systematic review investigation of a nosocomial outbreak of severe acute respiratory syndrome mers-cov outbreak following a single patient exposure in an emergency room in south korea: an epidemiological outbreak study my five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene a qualitative exploration of reasons for poor hand hygiene among hospital workers: lack of positive role models and of convincing evidence that hand hygiene prevents cross-infection role of hand hygiene in healthcare-associated infection prevention hand hygiene compliance: are we kidding ourselves? hand hygiene compliance rates: fact or fiction? infection control, ethics and accountability compliance with methicillin-resistant staphylococcus aureus precautions in a teaching hospital attitudes toward practice guidelines among intensive care unit personnel: a cross-sectional anonymous survey hand hygiene compliance by physicians: marked heterogeneity due to local culture? focus group study of hand hygiene practice among healthcare workers in a teaching hospital in toronto influence of role models and hospital design on hand hygiene of healthcare workers relative risk of physicians and nurses to transmit pathogens in a medical intensive care unit peripatetic health-care workers as potential superspreaders using sensor networks to study the effect of peripatetic healthcare workers on the spread of hospital-associated infections bureaucratization and medical professionals' values: a crossnational analysis professional dynamics and the changing nature of medical work doctors on status and respect: a qualitative study american college of physicians-american society of internal medicine; european federation of internal medicine. medical professionalism in the new millennium: a physician charter doctors in society: medical professionalism in a changing world rules, safety and the narrativisation of identity: a hospital operating theatre case study definitions of professionalism: a search for meaning and identity system failure versus personal accountability--the case for clean hands systematic review of studies on compliance with hand hygiene guidelines in hospital care behavioural considerations for hand hygiene practices: the basic building blocks using thematic analysis in pychology use of an innovative personality-mindset profiling tool to guide culture-change strategies among different healthcare worker groups inverse correlation between level of professional education and rate of handwashing compliance in a teaching hospital on the exoneration of dr. william h. stewart: debunking an urban legend the short history and tenuous future of medical professionalism: the erosion of medicine's social contract physicians and hand hygiene practice: a focus group study why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia?: a survey based on the opinions of an international panel of intensivists understanding the determinants of antimicrobial prescribing within hospitals: the role of "prescribing etiquette identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study contact precautions for endemic mrsa and vre: time to retire legal mandates the role of the champion in infection prevention: results from a multisite qualitative study. qual saf health care the importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study beyond curriculum reform: confronting medicine's hidden curriculum new' and distributed leadership in quality and safety in health care, or 'old' and hierarchical? an interview study with strategic stakeholders infections and interaction rituals in the organisation: clinician accounts of speaking up or remaining silent in the face of threats to patient safety patient safety and the problem of many hands involving patients in understanding hospital infection control using visual methods effectiveness of a nationwide nosocomial infection surveillance system for reducing nosocomial infections healthcare-associated infections in australia: tackling the 'known unknowns use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications endemic unprofessional behaviour in health care: the mandate for a change in approach why is u.k. medicine no longer a selfregulating profession? the role of scandals involving "bad apple" doctors sydney hospital's cardiothoraacic surgery unit trainee ban over bullying: the sydney morning herald westmead hospital icu stripped of training accreditation over alleged bullying: the sydney morning herald a complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors using coworker observations to promote accountability for disrespectful and unsafe behaviors by physicians and advanced practice professionals an intervention model that promotes accountability: peer messengers and patient/family complaints sustained improvement in hand hygiene adherence: utilizing shared accountability and financial incentives royal melbourne hospital targets bullying with new cognitive institute program: the age building respect and improving patient safety an innovative approach to strengthening health professionals' infection control and limiting hospital-acquired infection: video-reflexive ethnography the authors wish to sincerely thank the senior clinicians who gave so generously of their time to participate in this study and emeritus professor miles little, dr. suyin hor and dr. julie mooney-somers for helpful comments on early versions of this paper. this research received no funding. the datasets generated and/or analysed during the current study are not publicly available because participants did not give consent for interview transcripts to be published but (selected portions) are available from the corresponding author on reasonable request. authors' contributions glg developed the project concept, conducted interviews, reviewed, coded and analysed interview transcripts and wrote the first and subsequent drafts of the manuscript. ik contributed to conception and development of study design, reviewed and coded interview transcripts and contributed to editing of manuscripts drafts. both authors have approved the final version of the article.ethics approval and consent to participate this study was approved by the western sydney local health district human ethics research committee. all participants provided written informed consent to interviews being recorded and transcribed and quotes to be used in publications after removal of identifying information. the information sheet/consent form was approved by the ethics committee. participants were not asked and did not consent for transcripts to be published or for any personal identifying information to be made available other than their professional status (medical/nursing; director/manager/ consultant). quotes were selected to ensure that the source would not be identifiable. the authors declare that they have no competing interests. key: cord- -sizuef v authors: nan title: ectes abstracts date: - - journal: eur j trauma emerg surg doi: . /s - - -y sha: doc_id: cord_uid: sizuef v nan the gertality-score: a feasible and adequate tool to predict mortality in geriatric trauma patients introduction: a large number of prediction models and subsequent outcome scores for trauma mortality have been developed over the last decades. however, feasible scoring systems for the severely injured geriatric patient are lacking. the aim of this study was to develop a new mortality prediction model for severily injured geriatric patients. materials and methods: the german trauma registry was utilized and all geriatric individuals (c years) admitted between and with an iss [ ] c were included. patient and trauma characteristics, diagnostics, therapy and outcome data were gathered. the specific odds of all variables for mortality were calculated. relevant variables were added to the novel gertality-scoring system. subsequently, this score as a sole predictor for mortality was compared with the geriatric trauma outcome score , iss, patient's age and max ais. results: a total of . trauma patients with a mean age of years were included. based on the univariable analysis, the following five variables were included in the gertality-score: age c years, pbrc-transfusion requirements from admission to ward, asa-score c , gcs b , ais c . the values of a given parameter are added to reach the total gertality-score (range - points). the auc found in the novel gertality-score was . , whereas the geriatric trauma outcome score had an auc of . . conclusions: the novel gertality-score is a simple and feasible scoring system that enables an adequate prediction of the probability of mortality in severely injured geriatric patients by using only five specific parameters. references: . champion hr, et al. the major trauma outcome study: establishing national norms for trauma care. j trauma. ; : - . . zhao fz, et al. estimating geriatric mortality after injury using age, injury severity, and performance of a transfusion: the geriatric trauma outcome score. j palliat med. ; ( ) : - . the longer the better! 'extending thawed plasma shelf life to days' introduction: major bleeding is one of the most common causes of death after severe polytrauma. one of the most recent interventions that aims for bleeding control is resuscitative balloon occlusion of the aorta (reboa). this study aims to compare macro-and microcirculatory changes of intraabdominal organs and the lower extremity during the use of reboa. materials and methods: six pigs were anesthesized and received a median laparotomy. the reboa catheter (reliant balloon, medtronic) was inserted via the inguinal artery and occluded in zones , and . the occlusion of the reboa was vizualized with fluoroscopy. the balloon was inflated for min per zone. during this time the local microcirculation was measured with oxygen to see (o c, lea). between each zone the balloon was deflated for min. blood pressure was measured at the carotis artery and the femoral artery. results: baseline values of microcirculation differ significantly among organs. the flow rate is significantly higher in intraabdominal organs (colon . a.u., stomach . a.u.) compared to the extremity ( . a.u., p \ . ). blood pressure measured at the carotic artery increased significantly after inflation of the balloon (p \ . ). this increase depends on the zone of inflation (increase of ? mmhg in zone compared to baseline). the increase of blood pressure after inflation in zone is comparable to the baseline value. the colon is most sensitive to changes of microcirculation whereas the stomach and the extremity are most robust. conclusions: reboa is a new device to control for massive bleeding. different organ systems react differently to the same occlusion of the aorta. the systemic blood pressure does not mirror the local microcirculation of the abdominal organs. during emergency resuscitation with reboa these changes should be kept in mind. none of the authors have any conflicts of interests to declare. investigation of coagulopathies and its relevance with mortality and transfusion rates using thromboelastography in trauma patients introduction: fibrinolysis shutdown after injury is a common and lethal coagulopathic phenotype. patients with polytrauma, especially those with brain hemorrhage, require delayed initiation of prophylactic or therapeutic anticoagulation despite a measurable hypercoagulable state. to understand and modulate the post-trauma coagulation milieu, we assess patients with daily thromboelastography(teg). we hypothesized that persistently high clot strength and low dissolution is associated with thrombotic adverse outcomes in severely injured patients. materials and methods: adult patients with blunt or penetrating injuries admitted to the icu of a level i urban trauma center from jan-jul were included. adverse outcomes were defined as death, ventilator-free-days (vfd) = , acute lung injury (ali), acute kidney injury (aki), and venous thromboembolic events (vte). we assessed trends of clot dissolution (fibrinolysis, ly %) and strength (maximum amplitude, ma) in the first icu days using linear mixed models to account for repeated measures and missing observations. ly % was box-cox power-transformed to approximate normality. significance for pairwise comparisons at each time was adjusted by false-discovery-rate. results: patients: median age -years, % female, iss (iqr - ), % blunt mechanism, median icu days . overall, % developed one or more of the following; %vfd = , %ali, %aki, %vte, %death. ly was persistently lower in patients with adverse outcomes compared to those without (interaction time*adverse_outcomes p = . ), with fdr-adjusted significant differences at icu days and (fig ) . conversely, ma did not differ significantly by adverse outcome status(interaction time*complications p = . , fig ) . conclusions: low clot dissolution, not clot strength, is associated with adverse outcomes in severely injured trauma patients. additional work is underway for earlier identification of sd phenotypes and strategies to mitigate impaired fibrinolysis. introduction: angioembolization (ae) is can be both diagnostic and therapeutic in management of a hemodynamically unstable trauma patient. however, patients who would benefit from ae typically require emergent surgery for their injuries. the critical decision of transferring a patient to the operating room versus the interventional radiology suite can be bypassed with the advent of intra-operative angioembolization (ioae) . while the ability to perform such an intervention was previously limited by the availability of costly rooms termed raptor (resuscitation with angiography, percutaneous techniques and open repair) suites, it has been suggested that using c-arm digital subtraction angiography (dsa) is a comparable alternative. this case series aims to establish the feasibility and safety of ioae. materials and methods: we conducted a retrospective anlaysis of all trauma patients at our level trauma centre who underwent ioae with a concomitant surgical intervention from january to april . results: a total of patients ( . % male, . ± . years, . % blunt) underwent ioae using the c-arm dsa. all but one patient underwent exploratory laparotomy, . % of which underwent an additional surgical procedure (ex. exploratory thoracotomy, orthopaedic). either gelfoam ( . %), coils ( . %), or a combination of both ( . %) were used for embolization. internal iliac embolization was performed in . % of cases ( . % bilateral) and five patients ( . %) required hepatic embolization. ae was successful in all but one case, inferior vena cava filters were placed in . % of cases, and . % of patients required a second ae. the -day mortality was . %. conclusions: our results suggest ioae is a feasible and safe management option in severe trauma patients with the advantage of concurrent operative intervention and ongoing active resuscitation with good success in hemorrhage control. introduction: partial resuscitative endovascular balloon occlusion of the aorta (reboa) is a new concept of aortic occlusion to reduce the ischemic injuries below the occlusion level. it is, however, difficult to determine when the occlusion is partial in a clinical setting. end-tidal carbon dioxide (etco ) is a product of aerobic metabolism and its production is reduced during ischemia and anaerobic metabolism. the aim of this study was to investigate if etco is a good predictor of the degree of aortic occlusion during normovolemia and hemorrhagic shock in a porcine model. methods: nine pigs, - kg, were anesthetized and surgically prepared. then, gradual zone aortic occlusion by %, % and % was induced, during first normovolemia and then controlled hemorrhagic grade iv shock. hemodynamic/respiratory variables, blood gases, aortic/mesenteric blood flow, blood pressure of common femoral artery and etco were measured continuously. oxygen consumption and carbon dioxide production were calculated for each timepoint for correlation measurement to different methods for partial occlusion determination. background: acute appendicitis is one of the most common surgical emergencies worldwide. the aim of this meta-analysis of randomized controlled trials was to compare the safety and efficacy of antibiotic treatment versus appendicectomy as the primary treatment for patients diagnosed to have acute appendicitis. methods: a systematic online search was conducted using the following databases: pubmed, scopus, cochrane database, the virtual health library, clinical trials.gov and science direct. only randomized controlled trials (rcts) that compared antibiotics treatment (a) versus surgical treatment (s) as primary treatment of appendicitis were included. results: eight rcts with . patients were included: in the antibiotics group and in appendicectomy group. higher rate of treatment success was noted in appendicectomy group . % versus only . % in the antibiotics group (p \ . ) (fig. ). follow up period for recurrence was one year in all studies and the recurrence at year was reported in . % ( / ) of patients treated with antibiotics and . % ( / ) of them underwent appendicectomy. moreover, rate of overall were . % in a group and . % in s group (odd ratio . [ . - . ], ci %, p-value: . ) (fig. ) . a longer length of hospital stay was reported among antibiotics group ( . ± . in a group versus . ± . in s group, p . ). conclusions: appendicectomy has significantly higher efficacy rate but higher complications rate when compared to antibiotics treatment. most of the studies included in this meta-analysis conveyed a high risk of bias, hence more well-designed rcts are recommended. introduction: post-operative adhesions are associated with increased risk of morbidity and mortality. up to date no effective measures has been introduced to decrease intra-abdominal adhesions following laparotomy. oxiplex-ap gel has been used in extra-abdominal surgical procedures to prevent adhesions. in the current study oxiplex-ap was tested in a mural animal model to investigate its efficacy in reducing post-surgical intra-abdominal adhesions. materials and methods: forty rats subjected to laparotomy were randomly divided into groups of . a serosa injury was made on the small intestine and three different treatments were applied: simple suture, simple suture ? oxiplexap, and oxiplex-ap only; the last group received no treatment of the injury before closure of the abdomen. all animals were kept alive for days, and a second laparotomy was done to measure the intra-abdominal adhesion by the nair classification. results: at second look laparotomy a significant difference in adhesion was noticed between the simple sutures and simple suture ? oxiplex-ap were the latter had developed less adhesions. there was also a trend towards less adhesion development between the simple sutures and oxiplex-ap only group, with less adhesions in the latter. conclusions: the use of oxiplex-ap was associated with decrease adhesion formation in the current animal model particularly without suturing. further investigations into these findings are needed. introduction: emergency abdominal surgery is known to result in high morbidity and mortality. furthermore, evidence suggests that unplanned admissions to the intensive care unit (icu) are associated with higher in-hospital mortality than those patients with planned icu admissions . the aim of the study was to describe the patient population who required an unplanned admission to icu following emergency laparotomy at the royal melbourne hospital. materials and methods: a single-centre retrospective observational study was performed using prospectively collected data between and . patients who underwent an emergency laparotomy and experienced an unplanned icu admission were included. patients who underwent a trauma laparotomy were excluded from the study. results: emergency laparotomies were performed. of these, ( . %) required an unplanned admission to icu. fourty-two patients ( %) were female, and patients ( %) were aged years and above. sixty-three ( %) were admitted due to single organ dysfunction (clavien-dindo iva). the median time to icu admission was days in patients classified to have experienced clavien-dindo iva, while it was days in patients who experience multi-organ dysfunction (clavien-dindo ivb). thirty-seven patients ( %) were admitted to icu due to complications classified as cardiopulmonary. conclusions: recognising that emergency laparotomy is a high risk procedure, with the elderly patients accounting for the majority of unplanned icu admissions, it is imperative to utilise risk stratification methods to guide optimal peri-operative management. this should result in improved utilisation of critical care resources and overall patient outcomes. introduction: the way of reconstruction following intestinal resection in the emergency settings is still controversial. the question which is better between hand-sewn and stapled anastomosis in trauma and emergency surgery occasionally arises; however, there have been few reports comparing these methods. materials and methods: a record-based retrospective study was performed to compare hand-sewn with functional end-to-end anastomoses in trauma and emergency operations from october to october in one of the largest trauma and emergency centers in japan. the patients who had intestinal resection with functional endto-end or hand-sewn anastomosis in an emergency surgery were included. the patients who had covering ileostomy or colostomy, or who underwent surgery as an elective operation were excluded. the primary outcome is the rate of complication associated with anastomosis. the statistical analyses were performed using a chi introduction: injuries are the fourth leading cause of death in europe. laparotomy is the standard treatment for penetrating abdominal wounds. because of the morbidity and the high rate of negative laparotomies, the nonoperative treatment is effectively developing. the aim of this study is to analyze the complications and the quality of life of the patients after laparotomy for this kind of wounds. materials and methods: a retrospective cohort of patients was studied between and at the laveran military teaching hospital in marseille. one hundred and eighty-six trunk gunshot or stab wound were recorded, including abdominal wounds. thirtyfour patients were managed by laparotomy and included in this study. the patients and their referring general practitioners were contacted to complete missing data and the sf- quality of life score. results: among the patients included, the average age was years and most of them were men. the indication for laparotomy was mainly based on the hemodynamic instability, then according to the results of the computed tomography in case of suspicion of specific lesions: bowel injuries, major vascular injury, mesenteric or mesocolic vascular injury, diaphragmatic injury and intraperitoneal bladder rupture. only laparotomies were negatives. eleven complications after laparotomy were found ( , %), including early (within the days) and late. no complication was found after negative or non-therapeutic laparotomies. the quality of life of the patients after one year is similar to those of the general population. conclusions: the most common indication for laparotomy for abdominal penetrating trauma is hemodynamic instability. the rate of laparotomy complications for penetrating abdominal trauma is similar to those of scheduled surgeries. the quality of life after this care remains unchanged. these results may insist on the fact that the ''gold standard'' treatment for penetrating abdominal injury remains the laparotomy objectives: splenic artery embolization (sae), a routinely used adjunct in the non-operative management (nom) of splenic injuries(si), was widely adopted in trauma about two decades ago. we examined complications that occurred with this modality at a level trauma center over a recent -year period and compared this to the prior years. methods: patients who had sae for si between - were identified. sae complications were noted. splenic abscess, splenic infarction and contrast-induced renal insufficiency were considered major complications. coil migration, fever and pleural effusions were regarded ''minor'' complications. the results were compared with data from a prior study examining similar indices at the same trauma center between and . fishers exact test was used for comparison. results: there were patients admitted with si in the recent period, of which ( %) underwent immediate splenectomy. sae was performed in ( . %) of the patients who underwent nom. of these sae patients, % had a contrast blush and . % were either aast grade or . five sae patients ( . %) had splenectomy for continued bleeding. the overall complication rate was . %. major complications occurred in patients ( . %) and minor in patients ( . %). embolization location in the splenic artery was proximal in . %, distal in . % and in both in . %. there was no association between complications and coil location by logistic regression. differences between the two periods shown in table . conclusion: sae continues to be a useful adjunct in nom of si and has seen increased utilization. complications continue to occur,although fewer minor complications were noted in the second period. no association between embolization location and complications was noted in the recent period. judicious utilization of sae is imperative given the complications that continue to be noted from this procedure. the effect of the time spent in the emergency department on the mortality rates and cause of death in patients who underwent emergent laparotomy introduction: the purpose of this study was to a) examine the effect of the time spent in the emergency department (ed) on hypotensive patients in need of emergent laparotomy and b) to determine the mortality rates and cause of death in these patients. materials and methods: between - , patients were included ( men and women, mean age . years) who underwent laparotomy less or equal to min from ed admission. of the patients, (group ) had a systolic blood pressure (sbp) greater than mmhg and had a sbp less or equal to mmhg. all patients had abdominal injuries with an injury scale score (iss) between and . the in-hospital mortality represented the primary outcome, while secondary outcomes included cause of death and time to death. results: in this study both groups spent a median of min in the ed, but the time from the ed to the operating theatre was shorter in the group ( min versus min). in total, the mortality rate was %, but in the group the mortality was %. the sbp on arrival in the ed was strongly associated with the risk of death. furthermore, we observed significant positive correlation between the probability of death and the time spent in the ed, with an increase of probability of death equal to . % per minute spent in the ed. in both groups the hemorrhage was the commonest cause of death ( %). the results of this study indicate that, in patients with abdominal injuries requiring emergent laparotomy, the probability of death is proportional to both extent of hypotension and the length of time spent in the ed. especially, in patients who were presented with a sbp inferior of equal of mmhg, this probability increased as much as % for each min. despite many advances in trauma surgery, half of hypotensive patients are going to die in the first h. introduction: injury to the pancreas may lead to significant morbidity and mortality. we studied the prevalence of pancreatic endocrine and exocrine functions and evaluated the morphological regenerations in pancreas following partial pancreatectomy. materials and methods: patients with pancreatic trauma were recruited ambispectively from january to december . endocrine functions were assessed at the time of admission and at months follow up with g oral glucose tolerance test (ogtt), serum insulin and c-peptide levels, hba c estimation and exocrine functions were assessed with faecal elastase test. pancreatic volumetry was done with imaging studies at -and -months post discharge. results: twenty patients were studied with a median age of years at the time of injury. all the patients were normoglycemic on admission; only one patient who underwent pancreatic resection developed diabetes mellitus requiring insulin on follow up. patients ( %) were found to have prediabetes by american diabetes association (ada) criteria. patients ( %) had pancreatic exocrine insufficiency. pancreatic volume increment, from mean pancreatic volume of . cm to . cm , was noted in partial pancreatectomy patients. conclusions: overt endocrine and exocrine insufficiency is rare in pancreatic trauma patients. but subsets of patients are biochemically predicted to have higher risks of endocrine dysfunction and exocrine insufficiency. hence, while dealing with pancreatic trauma patients, one should remember the possible metabolic disorders associated and the need for specific investigations. pancreatic volume increment is a new finding which opens up more opportunities for further research. hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal, hospital de santo espírito da ilha terceira, orthopedics and traumatology, angra do heroísmo, portugal introduction: rope bullfights are traditional events in the azores islands, where a bull is set on the streets, arrested by a rope on its neck. around events happen every year and it is already part of the island's touristic attractions. inevitably, every year, people get injured either from direct trauma with the bull or from falls when trying to escape from the animal. the aim of this study was to characterize the type of injuries that occur in these bullfighting events, as to their incidence, mechanism of injury, anatomical affected area and severity. materials and methods: we prospectively registered all cases of injured people who suffered any type of trauma during rope bullfights and received emergency therapy in the local hospital, between and . results: patients recured to the emergency department, . % female, with mean age of . years. regarding the mechanism of injury, . % occured due to direct trauma to the animal while in the remaining . % resulted from falls during escape or handling of the rope. the most commonly affected anatomical areas were the limbs ( . %) followed by the head and neck ( . %) and thorax ( . %). in , % of the cases, patients suffered from multiple traumas. in . % of the cases the treatments performed were wound care, wound closure and/or symptomatic therapy. in total, patiens were hospitalized, patients required interventions in the operating room ( closed fracture reductions and exploratory laparotomy with splenectomy) and patients were hemodynamically unstable upon admission (hypovolemic shock due to splenic fracture and cet). conclusions: the rare articles published describe the mechanisms of injury associated with bullfights in spanish centers and injuries resulting from wild cow accidents in indian cities. this is the first local descriptive study on the prevalence of traumatic injuries associated to this specific type of rope bullfights. introduction: the two-stage splenic rupture is seldom, its risk is unpredictable and a precise diagnosis of a ct and/or mri imaging unexpectable or unexcludable. generally, and due to our experience and current literature a two-stage rupture occurs within one week after trauma. though dramatic courses after two or three weeks are known. therefore, it is suggested to perform a prophylactic angioembolization in (still) hemodynamically stable patients. materials and methods: a retrospective study in a level-one trauma centre of switzerland did analyse all patients that underwent a prophylactic angioembolisation after an explicit diagnose by ct and/or mri of a splenic parenchymal lesion after trauma between and . further inclusion criteria were hemodynamical stability (sys rr [ mmhg) and missing indication for immediate laparotomy. results: patients ( f, m) with an average age of ± years underwent preemptive angioembolisation after traumatic lesions of the spleen. the ais abdomen was in and in patients. besides a splenic injury patients did also have a kidney injury. the overall iss was ± points. patients suffered additional thoracic or head trauma. in patients the angioembolisation was performed on admission, in on the st, in at the nd and respectively in the rd and th day of. in case an uncomplicated selective embolization of a main duct of the splenic artery was performed. in patients the trouble-free proximal embolization of the splenic artery was done. the average stay was ± . days. no deaths or complications seen due to angioembolisation or splenic rupture. there were no complications or operative introduction: traumatic abdominal wall hernias (tawhs) are uncommon, and the optimal management is debated. tawhs most often result from blunt trauma and are associated with severe intraabdominal injuries. our institutional protocol mandates primary repair only if the patient undergoes laparotomy for other reasons and is without mesh. since , primary repair of lumbar hernias included bone anchors when indicated. we wanted to describe the tawh patients treated operatively during initial hospitalization focusing on injury mechanism, diagnosis, associated injuries, operative techniques, early complications and outcomes. materials and methods: we performed a retrospective, descriptive cohort-analysis of data from the institutional trauma registry from - . all operatively managed tawhs were identified based on ais codes, ncsp codes and relevant key words. results: of the identified patients, ( %) were women. median age was years (range - ). median iss was and patients had iss [ . injury mechanism was blunt except for one explosion. patients ( %) had been in a mvc, and of these ( %) had seat belt injuries. of these patients had a disruption of the muscle from the iliac crest, and one had a hernia through a fractured iliac wing. bicycle falls and fall from height had hernias in the anterior abdominal wall. two meshes were placed, with no known complications. bone anchors (twinfix Ò , mm) were used in patients. no recurring hernias were identified in the patients with routine follow-up ( - months) . conclusions: surgery for tawh is uncommon in our institution. tawh is often associated with severe torso injuries and primary repair is only done when laparotomy for other reasons is indicated. primary suture of the muscle, including use of bone anchors seems to be adequate treatment, as we have identified no recurrences. a longterm follow-up study is warranted for operated and non-operated patients with tawh. a comparison of sub-specialty operative adolescent patient outcomes in adult and pediatric trauma centers introduction: adolescent trauma victims may be treated at either an adult (atc) or pediatric trauma center (ptc). these centers have different resources, surgeon training and overnight in-house coverage. it is not known how outcomes compare with regards to the very small subset of patients that actually undergo a surgical trauma intervention. we hypothesized that presentation to a ptc would yield increased mortality when subspecialty intervention was required and that this would be most pronounced at night when in-house attending coverage is absent at all state ptcs. materials and methods: a review of the pennsylvania trauma outcome study (ptos) database was performed to capture patients aged - who underwent any non-orthopedic trauma surgery. cohorts were created for cranial, thoracic, abdominal or vascular surgery from - . trauma centers were divided as adult level (atc ), adult level (atc ) or pediatric (ptc). groups were created based on time of arrival with am- pm being dayshift and : pm- am being night shift. age, race, mechanism of injury, vital signs, gcs, iss, los and mortality were evaluated. ancova was utilized to control for iss variation. spss was used for all analyses. results: patients met initial criteria. atc s saw more minority patients and more males than other center types. atc s saw an overall older cohort ( . years vs . years in atc and . years in ptc, p \ . ). despite this age difference, presenting systolic blood pressure was lowest at the atc s ( . mmhg vs . mmhg at atc and . mmhg at ptc, p \ . ). iss and triss and overall mortality were not different and this included when grouped by day or night shift. of note, trauma thoracotomy was more likely to be performed at night in adult centers. hospital length of stay was significantly lower for atc ( . days vs . in atc vs and . in ptc). conclusions: adult and pediatric trauma centers see different patients. operative trauma cases are surprisingly low at our state's ptcs and trauma thoracotomy was more likely to be performed at night in atcs than ptcs. broader study is needed to uncover differences in operative care and outcomes. treatment of dislocation of the patella as a result of sports injuries in children. forecast and consequences in adulthood k. furmanova , o. loskutov , a. naumenko medinua clinic and lab, ortopedics, dnepr, ukraine introduction: dislocations of the patella with a rupture of the medial patellofemoral ligament (mpfl) account for - % of acute injuries of the knee joint [ , ] . inadequate therapeutic tactics of these injuries in childhood and youth, as a result of sports injuries, are fraught with complications in the form of the instability of the knee joint, residual deformities and contractures in patients in adulthood [ , ] . materials and methods: in the period from to cases of rupture of mpfl among children aged - years who were involved in sports were observed. the examination included conducting a clinical examination, axial radiography with flexion of the joint at angles of °and °, mri of the knee joint. results: in . % ( cases) the integrity of the mpfl(with a reduced number of sutures) was restored using a yamamoto suture, and in cases ( . %), the autoplasty of the mpfl was performed. excellent medium-term ( years) clinical and functional results according to the ikdc scale were noted in . % of cases, good in . %, satisfactory in . %. in patients ( . %) there was a relapse of dislocation after performing an mpfl suture during the first year after surgery mainly due to noncompliance with the recommendations. conclusions: injury to the knee joint with the patella dislocation in childhood and adolescence, associated with a sports injury is an indication for surgical treatment in order to adequately restore the integrity of the mpfl and prevent disabling complications. our yamamoto suture technique is more optimal for treating young patients with instability of the patella and is recommended for widespread use in pediatric orthopedists due to its undeniable clinical advantages. osteotomy with a defect cm placed cm below tibial plateau. types of fixation have been simulated: plate fixation of only a medial pillar, plate fixation of only a lateral pillar, plate fixation of both pillars, and locking intramedullary nailing. results: in case of plate fixation of only a medial pillar, the injury to an interosseal membrane causes an expressed valgus deformation at axial loading, leading to a reasonable ( . mpa) overload of the fixator in the osteotomy area. the use of a lateral plate leads to excessive loading on an external pillar, while the medial pillar remains unsupported. this causes overloads of the fixator in the osteotomy area ( . mpa). the double plate fixation is typical of the lowest extent of bone fragments displacements ( . mm) . this is a super-rigid type of osteosynthesis, able to cause a stress-shielding syndrome in the adjacent bone. it has been estimated that the method of im nailing is an optimal fixation method, with minimum loading of the fixator ( . mpa) and the best distribution of changed elastic strains in the bone-implant system. conclusions: the mathematical simulation demonstrates that fixation by a medial plate is possible only if support functions of the ligament system and interosseal membrane remained intact. if an injury is a high-energy one, nailing is preferable. introduction: treatment of large bone defects is one of the great challenges in contemporary orthopedic and traumatic surgery. grafts are necessary to support bone healing. a well-established allograft is demineralized bone matrix (dbm) prepared from donated human bone. a recent development is a new fibrous demineralized bone matrix (f-dbm) with a high surface-to-volume ratio. in this study we examine toxicity of an innovative dbm fibers preparation. materials and methods: f-dbm was transplanted to a mm, platestabilized, femoral critical-size-bone-defect of mm in sprague-dawley (sd)-rats (n = ). healthy animals were used as control. after months histology, hematological analyses as well as serum biochemistry was performed. were measured as indicators of free radical exposure. there were no significant differences between the control group and animals receiving f-dbm. hematology as well as biochemistry did not differ between operated animals and control. histologically no evidence of damage to liver and kidney and a good bone healing could be observed in most cases. conclusions: taken together, these results provide evidence for no systemic toxicity of the bone allograft. i have received no significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services or financial support related to this abstract. • i hereby confirm that my abstract is based on previously unpublished data and that i own the rights to the written summaries of research or observations presented in the abstract, or that i have obtained permission for the acknowledged sources for other excerpts taken from copyrighted works. • in submitting an abstract i hereby agree that the copyright of my abstract is transferred to the european society of trauma and emergency surgery. • i hereby confirm that i will present my abstract at the congress in case it is accepted. sponsor: german institute for cell and tissue replacement (dizg, gemeinnützige gmbh), berlin, germany. intramedullary nailing through suprapatellar approach in distal tibia fractures: a retrospective study evaluating clinical and radiographic results d. bustamante recuenco , a. gómez , j. m. pardo garcía , e. garcía , p. castillón , p. caba doussoux hospital de octubre, madrid, spain, madrid, spain, hospital mutua terrasa, orthopaedics, barcelona, spain introduction: distal tibia fractures (dtf) can be operated either by intramedullary nailing (imn) or by orif with plates. the current literature shows a higher rate of malalignment and consolidation delay with imn when compared to plates. in these studies, an infrapatellar approach for the imn is performed. recent studies show a better alignment in dtf treated with imn by suprapatellar approach, though functional and biological outcomes have not been analyzed yet. our goal is to assess the clinical and radiographic results of the treatment of dtf with imn using a suprapatellar approach. materials and methods: a two-center retrospective study was performed, collecting the cases with dtf treated with suprapatellar imn from / to / . results: a total of patients were obtained, with a mean age of . years. the average follow-up was months. % of the fractures were ao type a, presenting the remaining % intra-articular involvement. patients presented complications, corresponding in of them to superficial infections. as for clinical results, complete mobility in the knee and ankle was obtained in almost all cases. at the radiographic level, a total of % ( ) of distal malalignment cases were detected, defined as more than °deviation from normal axis in the coronal and sagittal planes. most of the fractures consolidated in a period of - months. there were cases of delayed consolidation, from which developed pseudoarthrosis. conclusions: intramedullary nailing through a suprapatellar approach for dtf offers good clinical and radiographic results, with low rates of malalignment and lack of consolidation. more studies are required to compare the results obtained with other fixation methods for these fractures. reference: avilucea fr, triantafillou k, whiting ps, perez ea, mir hr. suprapatellar intramedullary nail technique lowers rate of malalignment of distal tibia fractures. j orthop trauma. ; ( ) : - . the clinical consequences of follow-up radiographs in ankle fractures are unclear and indications for these radiographs are seldom well-defined. routine radiographic imaging in the follow up of patients with an ankle fracture adds to treatment costs, although retrospective studies dispute its usefulness. the aim of this study was to assess if a protocol with a reduced number of routine radiographs would lead to cost savings, without compromising clinical outcomes. materials and methods: a multicentre randomized controlled trial was conducted. patients were randomly assigned in a : ratio to usual-care (consisting of routine radiography at one, two, six and twelve weeks) or reduced-imaging (radiographs only obtained for a clinical indication at six and twelve weeks). functional outcome was assessed using the omas and aaos ankle questionnaires, quality of life was measured with eq- d- l and sf- questionnaires. other outcome measures included complications, pain, the number of radiographs, health perception and self-perceived recovery. costs were measured with self-reported questionnaires results: the study group consisted of participants, of which ( %) received operative treatment. patients in the reduced-imaging group received median radiographs, whilst patients in the usual care group received median radiographs (p \ . ). omas, aaos scores, quality of life, pain, health perception and self-perceived recovery did not differ between groups. we observed complications in the reduced imaging group. this did not differ significantly from the usual care group ( complications p = . ). a significant reduction in radiographic imaging costs was observed (-€ per patient, % ci - to - ). overall costs per patient were comparable ( [ % ci - to ]). conclusions: implementation of a reduced imaging protocol in the follow up of ankle fractures leads to cost savings and more importantly does not lead to worse functional outcomes. results after percutaneous and arthroscopically assisted osteosynthesis of calcaneal fractures w. grün , m. molund , f. nilsen , a. stødle oslo university hospital, orthopaedic department, ullevål, oslo, norway, Østfold hospital, orthopaedic department, grålum, norway introduction: operative treatment of calcaneal fractures using the extensile lateral approach is associated with high rates of soft tissue complications. during the last years there has been a trend towards less invasive fixation methods. percutaneous and arthroscopically assisted calcaneal osteosynthesis (paco) combines the advantages of good visualization of the posterior facet of the subtalar joint with a minimally invasive approach. materials and methods: we conducted a clinical and radiographic follow-up of patients with calcaneal fractures treated by paco with a minimum follow-up of year. there were sanders ii and sanders iii fractures. the mean follow-up period was . months (sd . ). our primary outcome was the american orthopaedic foot and ankle society (aofas) ankle-hindfoot score. secondary outcomes were the calcaneus fracture scoring system (cfss), the manchester-oxford foot questionaire (moxfq), the visual analog scale (vas) for pain and the incidence of complications. radiographs were obtained to evaluate the reduction of the fractures as well as the presence of subtalar osteoarthritis. results: the median aofas score was (range, - ), the cfss score ( - ), the moxfq score . ( - . ). the vas pain score was ( - . ) at rest and . ( - . ) during activity. the böhler angle improved from mean . degrees (sd . ) preoperatively to . degrees ( . ) postoperatively. however, the follow-up radiographs showed subsidence of the fractures and a böhler angle of . degrees ( . ). % of the operated feet showed signs of posttraumatic subtalar osteoarthritis. there were no wound healing complications. two patients were reoperated with screw removal due to prominent screws. conclusions: our results suggest that paco gives good clinical results and a reduced risk of complications in selected calcaneal fractures. prospective longterm studies will be necessary to better evaluate the potential advantages and limitations of paco. with the nascent state of microsurgical services in the region the application of negative pressure wound therapy (npwt) has proven to be very helpful. an improvised npwt has made it locally available to patients. this report aims to show how this has improved the management of open fractures of the lower limb in a resource restricted setting. materials and methods: a -month review of cases of lower limb open fractures managed at a regional trauma centre in nigeria was done. the type of wounds were classified based on region and need for soft tissue coverage. results: a total of cases were reviewed approximately % of these case were gustilo and anderson type iii. of these had npwt as part of their management. some of the benefits of observed were; reduced frequency of wound dressings, and shorter time to optimize wound for closure. conclusions: the locally improvised npwt has proven to be an affordable and cost-effective tool in the management of open lower limb fractures. it remains an invaluable alternative of care in the absence of microsurgical skills and patented device with are far from reach owing to financial constraints. references: . hussain a, singh k, singh m. cost effectiveness of vacuum assisted closure and its modifications: a review. isrn plast surg. ; : - . . isiguzo c, ogbonnaya i, uduezue a. modification of negative pressure wound therapy in the economically constrained region: a preliminary report. vol. , nigerian j plast surg. joytal printing press; . p. - . . mba u, nevo a. challenges of limb salvage in a resource limited environment: case report and review of literature. niger j plast surg. ; ( ): . . novak a, wasim sk, palmer j. the evidence-based principles of negative pressure wound therapy in trauma and orthopedics. open orthop j. ; : - . introduction: lower extremity vascular trauma may result in limb loss or mortality. this study examined outcomes of lower extremity vascular trauma (levt) and potential associations to amputation/mortality. materials and methods: a retrospective cohort study of patients (n = ; limbs) with levt between and in a single trauma center. only patients requiring a vascular procedure were included. data were extracted from the swedish vascular registry (swedvasc) and the swedish trauma registry (swetrau). results: mean age ± years; men % ( / ); trauma mechanism % ( / ) blunt and % ( / ) penetrating. % of patients underwent preoperative cta; % of patients ( / ) were transferred to hybrid operating room. arterial injury was present in / limbs ( %) and venous injury in / limbs ( %). the most frequently injured artery was popliteal artery ( / ; %) followed by superficial femoral artery ( / ; %). most common vascular operative procedure was arterial bypass/interposition graft ( / ; %). a vascular shunt was used in % of cases ( / ). fasciotomy was performed in % ( / ) of limbs. four patients were lost to follow-up after less than five days. there were eleven limbs ( / ; %) amputated within -day postoperative follow-up. all amputations were caused by blunt trauma. % ( / ) of arterial injuries below-the-knee led to amputation. thirty-day mortality rate was . % ( / ) . univariate analysis showed that fractures (p \ . ), soft tissue injury (p \ . ), multiple injuries (p = . ), and blunt mechanism (p \ . ) were associated with amputation and mortality after levt. conclusions: this study showed that amputations after levt are caused by blunt trauma. also levt combined with fractures, soft tissue injury, or multiple injuries increased the risk of amputation and mortality. multi-center study enabling multivariate analysis to adjust for potential confounding factors is imperative to confirm these findings. incidence, treatment and financial burden of tibial plateau fractures in belgium between and describe the incidence, evolution in management and financial burden of tpf in belgium between and . we compare national data with data from uz leuven (uzl), the largest university hospital in belgium. materials and methods: this study includes all tpf treated in belgium between and . we identified . tpf, of which fractures were treated in uzl. despcriptive statistics were used to analyze the data. results: the annual incidence increased from . to . / , /y. an increase in number was true for both operatively treated patients (otp) and non-operatively treated patients (notp), but was more pronounced in the latter ( % vs. % increase). the rate of surgery (ros) decreased from . % to . %. the mean ros for uzl was . %. the total financial burden in belgium increased with %, mainly driven by increasing costs in otp. hospitalisation rates for notp decreased from % to %, as day hospital admission occured more commonly. the mean hospitalisation cost was € , for otp and € , for notp. costs for uzl inpatients were € , and € , . nursing days accounted for % of the cost in otp and % in notp. the mean los was . days for otp and . days for notp. uzl patients had a mean los of . and . days. conclusions: tpf are associated with increasing hospital related healthcare costs. as nursing days determine the majority of the financial burden, measures should be taken to avoid prolonged los. introduction: rotational malalignment (rm) is a common postoperative complication after intramedullary (im) nailing of tibial shaft fractures. computed tomography (ct) is commonly used for detection of malrotation, however reliability is frequently questioned. the purpose of this study is to evaluate the intra-and inter-observer reliability of low-dose protocolled bilateral postoperative ct-assessment of rotational malalignment after im nailing of tibial shaft fractures. materials and methods: a total of patients were prospectively included with tibial shaft fractures that were treated with imn in a level-i trauma center. all patients underwent postoperative bilateral low-dose ct-assessment (effective dose of . - . mgy) as per hospital protocol. four observers performed the validated reproducible measurements of tibial torsion in degrees, based on standardized techniques. the intra-class coefficient (icc) was calculated to evaluate intra-and inter-observer reliability. the intra-and inter-observer reliability was categorized according to landis and koch. results: intra-observer reliability for quantification of rotational malalignment on postoperative ct after imn of tibial shaft fractures was excellent with . ( % ci = . - . ). the overall inter-observer reliability was . ( % ci = . - . ), also excellent according landis and koch. discussion and conclusion: first, bilateral postoperative low-dosesimilar radiation exposure as plain chest radiographs-ct assessment of tibial rotational alignment is a reliable diagnostic imaging modality to assess rotational malalignment in patients following imn of tibial shaft fractures and it allows for early revision surgery. second, it may contribute to our understanding of the incidence, predictors, and clinical relevance of postoperative tibial rotational malalignment in patients treated with imn for a tibial shaft fracture, and facilitates future studies on this topic. the trauma emergency laparotomy audit (tela) t. collaborators , m. marsden , p. vulliamy , r. carden , o. najiuba , n. tai , r. davenport tela collaboration, natric, n/a, united kingdom, queen mary university of london, centre for trauma science, london, united kingdom introduction: mortality for shocked trauma patients undergoing emergency laparotomy remains unchanged for years. the tela study aimed to describe the contemporary peri-operative management and patient outcome following abdominal injury. materials and methods: a prospective multicentre observational study of all patients undergoing emergency abdominal surgery within h of injury was performed in the uk and ireland for six months from the st january . shock was defined as the receipt of blood transfusion, with clinical or biochemical evidence of hypoperfusion. results: the study included patients from hospitals, of whom ( %) were shocked and received a median of units red blood cells. shocked patients were more likely to have a blunt mechanism of injury ( % vs %, p \ . ) and had a % mortality ( / ). half of these deaths occurred in the operating room (or). patients that died were more severely injured (injury severity score (iqr - ) vs (iqr - ), p = . ) and had a greater degree of shock at hospital arrival (base deficit . (iqr . - . ) vs . ( . - . ) , p \ . ). processes of care were equivalent or better among non-survivors, with a higher proportion of patients that died undergoing laparotomy within min of arrival in the emergency department ( % vs %, p = . ) and a lower proportion receiving crystalloid in the or ( % vs %, p \ . ). however, delays to achieving definitive haemorrhage control and delivering balanced blood transfusion ratios were observed among both survivors and non-survivors. conclusions: damage control resuscitation principles are followed most closely in patients that die. despite better processes of care, in shocked patients died in this study justifying the continued search for novel therapeutic approaches. pre-operative temporary haemorrhage control and pharmacological mitigation of the effects of shock may be productive avenues of research to improve patient outcomes. introduction: tranexamic acid (txa) has been shown to reduce mortality in bleeding trauma patients, with greater effect if administered early. normally administered intravenously, txa can also be administered intramuscularly, which could be advantageous in low resource and military settings. intramuscular use has only been tested in healthy patients, and it is likely that shock will reduce intramuscular uptake. materials and methods: in a prospective experimental study norwegian landrace pigs ( - kg) utilised in a surgical course in haemostatic emergency surgery were subjected to various abdominal and thoracic trauma. after h of surgery the pigs were injected with mg/kg txa either intravenously or intramuscularly. blood samples were drawn at , , , , , , and min. the samples were centrifuged and analysed with liquid chromatography-mass spectrometry (lc-ms/ms). results: preliminary results from animals in the intramuscular and animals in the intravenous group. mean plasma concentration with sd of txa as a function of time is shown in figure . plasma concentration in the intramuscular group was near ug/ml min after administration, and rose above ug/ml after min. conclusions: plasma concentrations reported to inhibit fibrinolysis in vitro is - . ug/ml ( , ) . if this extrapolates to the clinical situation intramuscular administration would yield plasma levels within the lower end of therapeutic range after min. in ongoing haemorrhagic shock plasma concentrations of txa after intramuscular administration were considerably lower than after intravenous administration, but within therapeutic range . introduction: fallowing laparoscopic cholecystectomy(lc), patients suffer from postoperative pain, especially in the abdomen. intraperitoneal local anesthesia (ipla) reduces pain after laparoscopic cholecystectomy(lc). acute cholecystitis(ac)-associated inflammation, increased gallbladder wall thickness, dissection difficulties, and a longer operative time are several reasons for assuming a benefit in pain scores in urgent lc with ipla application. the aim was to determine the postoperative analgesic efficacy of high-volume lowdose intraperitoneal bupivacaine in urgent lc. materials and methods: fifty-seven patients, american society of anesthesiologists(asa) physical status i or ii were randomly assigned to receive either normal saline(group a) or intraperitoneal bupivacaine(group b) at the beginning or at the end of the surgery in urgent lc. the primary outcome was the scores of postoperative pain by visual analogue scale score (vas) after surgery. results: postoperative vas scores at st and th hours were significantly lower in group b than group a (p \ . ). postoperative vrs scores at st, th and th hours were significantly lower in group b than group a (p \ . , p: . , p: . ). anelgesic use was significantly higher in group a at st postoperative hour than group b (p \ . ). shoulder pain was significantly lower in group b than in group a (p \ . ). patient satisfaction was significantly higher in group b than in group a (p \ . ). conclusions: high-volume low-concentration intraperitoneal bupivacaine instillation resulted in better postoperative pain control along with reduced incidence of shoulder pain and analgesic consumption in comparison to control group in urgent lc. introduction: in-hospital resuscitative thoracotomy is an established procedure for patients with penetrating cardiac injuries. the survival rate is dismal in patients with cardiac arrest prior to admission. prehospital resuscitative thoracotomy (prt) was introduced by the london hems with the highest published survival rate of %. we aimed to identify the number of patients who could potentially benefit from prt in our major trauma center catchment area. materials and methods: data from to were collected from the institutional trauma registry and electronic records. we included patients [ years, with penetrating cardiac injury, or penetrating chest trauma and cardiac arrest, or penetrating chest trauma and sbp \ mmhg. commonly used criteria for prt are tamponade with cardiac arrest lasting \ min at the time of ambulance arrival and with [ min remaining transportation time to hospital. results: cardiac injury was found in of included patients. of these , arrived at the hospital with signs of life and survived. of the patients who died had tamponade. criteria for prt were not met in of patients with tamponade. two patients could have been eligible for prt. one patient was found in oslo with cardiac arrest lasting min. the patient had multiple stab wounds to the chest and had several perforations of the right atrium, not technically manageable in a prehospital setting. the second patient was injured outside our primary catchment area and arrested with prehospital personnel present. prt was performed and the tamponade relieved, but compression of the aorta was necessary. the patient was declared dead shortly after hospital admission. conclusions: in years in a population of . million, two patients met london hems criteria for prt. prt was performed in one patient who was declared dead shortly after hospital admission while one patient suffered from injuries which are unmanageable in a prehospital setting. isolated tissue injury leads to fibrinolytic shutdown, tpa resistance and alterations in clot structure in a porcine model introduction: trauma-induced coagulopathy includes a spectrum of hypo-to hypercoagulable phenotypes with differing levels of fibrinolysis and tpa sensitivity. fibrinolysis shutdown is associated with increased late mortality and shown in small animal studies to be driven by tissue injury. utilizing a novel method of clot structure analysis, we hypothesize that isolated tissue injury provokes fibrinolysis shutdown, tpa resistance and is associated with altered clot structure resulting in enhanced clot stability. materials and methods: all male pigs (n = ) underwent anesthesia, intubation, femoral artery cannulation and mini-laparotomy. tissue injury (n = ), was inflicted with bilateral chest wall muscular cutdowns and bilateral femoral fractures using a captive bolt pistol. mean arterial pressure was maintained at [ mmhg. timed blood samples analyzed using tpa challenged and citrated native teg to evaluate tpa resistance and fibrinolytic shutdown respectively. after mm punch biopsy induced splenic injury, clot was collected, washed, and chemically fractioned by strong cation exchange chromatography. tandem mass spectrometry and bioinformatic analysis were used to evaluate clot structure and factor xiiia cross-linking patterns and covalently associated proteins. results: tissue injury pigs showed increased tpa resistance (change tpa-teg ly : - . % vs - . % p = . ) and a trend of fibrinolytic shutdown evidenced by teg compared to control (fig. ) . splenic clot structure analysis demonstrated altered clot structure (fig. ) and identified elevated levels of protease inhibitors such as alpha macroglobulin and alpha antiplasmin at h post tissue injury compared to baseline. conclusions: in a porcine model, isolated tissue injury provokes fibrinolysis shutdown and tpa resistance resulting in altered clot structure with an increased incorporation of anti-protease proteins resulting in enhanced clot stability. there is a high incidence of rotational malalignment after intramedullary nailing of tibial shaft fractures: a prospective cohort series of patients n. j. bleeker amsterdam medical centre, flinders university, department of orthopedics and trauma surgery, amserdam, netherlands introduction: intramedullary nailing (imn) is the treatment of choice for most tibial shaft fractures due to its minimalistic surgical approach, superior fracture healing, and rapid recovery. however, an iatrogenic pitfall is rotational malalignment (rm). the aim of this prospective cohort study was to determine the incidence of rm and to evaluate the efficacy of protocolled bilateral postoperative computed tomography (ct) assessment of rotational tibial alignment. materials and methods: between and we prospectively included patients ( male ( %)), with a mean age of years, with a unilateral tibial shaft fracture. as per hospital protocol, patients underwent a routine low-dose bilateral postoperative ct to assess rm. forty-two patients ( %) suffered open injuries; ( %) were involved in a multi-trauma sustaining more than one injury. according to the ao/ota classification, there were simple ( %), wedge ( %), and complex fractures ( %). fracture location within the tibial shaft varied with six patients ( %) being within the proximal third, ( %) middle third, and ( %) distal third. there were segmental ( %) fractures that involved more than one third of the tibia. results: fifty-five patients ( %) had post-reduction rm including patients ( %) between °- °, seven patients ( %) with a rm between °- °, and two patients ( %) with a rm greater than °w hen compared to the uninjured side. of the patients with rm, the tibia was externally malrotated in patients ( %). three patients ( % of cohort or % of those with rm) underwent revision surgery to correct the rm as detected on ct scan. conclusions: this study reveals a high incidence of rm following tibial nails ( %) with a surprisingly low revision rate ( % of those with rm). a subsequent study should aim to assess clinical relevance of rm in terms of functional outcome and gait analysis. for now ctrotational-profiling provides a platform for early recognition and correction of rm secondary to tibial imn. level of evidence: therapeutic level ii -prospective cohort study. materials and methods: the tarn database was analysed retrospectively to quantify the number of trauma team activations, patients with major trauma (mt), causes of injury, and subspecialty-specific trauma procedures. crude and risk-adjusted mortality rates, observed to expected (o/e) mortality ratio, and risk-adjusted rates of survival from mt were also calculated. results: the number of trauma team activations has risen by a factor of . the predominant injury mechanism that resulted in mt was a fall from less than m. there has been a fivefold increase in the overall number of trauma surgical procedures. orthopaedic surgeons have performed % of trauma procedures, followed by neurosurgeons, oral and maxillofacial surgeons, and visceral trauma surgeons. the rate of trauma laparotomies per consultant fluctuated between . and . per month. a fall from less than m, road traffic accident and a fall from more than m were the three leading causes of death from mt. the overall o/e mortality ratio was . . conclusions: aintree trauma profile has significantly changed since . this change highlights the potential need for a review of how mt services are offered at aintree to reduce the o/e mortality ratio. this may be achieved through more co-ordinated provision of trauma care, prevention, audit and research programmes. the role of visceral trauma surgery should be reconsidered within the context of the surgical patients' needs and demands, and fundamental requirements of the profession. inter-hospital variation in surgical intensity for trauma admissions: a multicenter cohort study l. moore , m. p. patton , i. farhat , p. a. tardif , c. gonthier , a. belcaid , f. lauzier , a. turgeon , j. clément université laval, social and preventive medicine, québec, canada, chu de québec-université-laval, québec, canada, introduction: guidelines for trauma patients are increasingly moving away from surgical management towards less invasive procedures but there is a knowledge gap on how these recommendations are influencing practice. we aimed to assess inter-hospital variation in surgical intensity for trauma patients and identify determinants of surgical intensity. materials and methods: we conducted a retrospective multicenter cohort study based on the trauma centers of an inclusive canadian provincial trauma system. we included adults admitted for major trauma between and . analyses were stratified for orthopedic (n = , ), neurological (n = , ) and thoracoabdominal surgery (n = ). surgical intensity was quantified with the number of surgical procedures during the first h. inter-hospital variation was assessed with the intra-class correlation coefficient (icc) from multilevel poisson regression models. relative risks (rr) were generated to identify determinants. results: moderate inter-hospital variation was observed for orthopedic surgery (icc = . %, % confidence interval [ci]: . - . ) whereas variation was low for thoracoabdominal surgery (icc = . %, % ci: . - . ) and neurosurgery (icc = . %, % ci: . - . ). level iv centers had similar surgical intensity for thoracoabdominal injuries (rr: . , % ci: . - . ) but lower intensity for orthopedic injuries (rr = . , % ci: . - . ) than level i/ii centers. during the study period, we observed a decrease in intensity for neurosurgery (rr for (rr for - versus . , % ci: . - . ) and thoracoabdominal surgery (rr = . , % ci: . - . ). conclusions: the observed inter-hospital variation in risk-adjusted surgical intensity suggests that there may be opportunities for quality improvement in surgical care for injury admissions. a better understanding of how surgical intensity influences clinical outcomes is needed to inform quality improvement activities. pre-hospital injury diagnosis a. easthope , m. marsden , g. grier barts and the london medical school, london, united kingdom, royal london hospital, centre for trauma science, london, united kingdom introduction: accurate pre-hospital diagnosis of a patient's injuries may improve care by facilitating effective intervention at the scene and reducing time to definitive treatment in hospital . we sought to assess the diagnostic accuracy of injuries by london's air ambulance (laa) clinicians and identify conditions in which clinical accuracy may deteriorate. materials and methods: a retrospective review was undertaken of all patients conveyed to the royal london hospital by laa from october for six-months. pre-hospital injury scores, coded using the abbreviated injury score (ais) were compared to hospital discharge ais. patient outcomes were evaluated in the case of underscored injuries. results: during the study period patients were seen and met eligibility. mean clinical sensitivity and specificity was % and % respectively. chest injury identification was most sensitive ( %) and pelvic injury least sensitive ( %). the relative risk (rr) of underscored injuries to the chest, abdomen and pelvis increased with decreasing glasgow coma scale (gcs) peaking at . (iqr . - . ). the average accuracy of injury identification was % with a negative predictive value of %. no overt patient morbidity resulted from a missed, or under-scored injury. all missed injuries were subsequently identified in the emergency department. conclusions: the pre-hospital diagnosis of injuries has reasonable sensitivity and excellent specificity. accurate pelvic injury diagnosis is more challenging than chest or abdomen. with decreasing gcs, the risk of missing injuries increases. clinicians should be aware of the potential for error when treating trauma patients with impaired conscious levels. comorbidities, injury severity and complications predict mortality in severe thoracic trauma: a retrospective analysis from the norwegian national trauma registry of epidemiology, clinical factors and risk factors for mortality of patients with thoracic injuries. materials and methods: adult patients treated for severe thoracic trauma (injury severity ais c ), between and at haukeland university hospital were included. data were extracted from ( ) the haukeland university hospital local trauma registry, and ( ) the norwegian trauma registry. additional data on comorbidities and complications was collected from patient records. the factors age, gender, comorbidities [charlson comorbidity index (cci)], anticoagulant use, injury severity [revised trauma score (rts)], [injury severity score (iss)] and complications [clavien-dindo scale (cds)] were analyzed for being predictive of in-hospital mortality. multivariate logistic regression analyses with backward selection methods were used. results: data of patients were analyzed, of which ( %) patients died. median iss was in the non-survivors (iqr , ) and (iqr , ) in survivors (p = . ). data of patients were used in the risk factor for mortality analysis. two or more comorbidities measured by cci (or: . , p = . ), injury severity measured with the rts (or: . , p = \ . ), and grade c complications on the cds (or: . , p = . ) were significant predictors for mortality. conclusions: severe comorbidities significantly decreased the chances of survival after thoracic trauma. injury severity was also found to be a significant predictor of mortality. physiological injury severity, measured by rts, appeared to be a stronger predictor of mortality than iss after thoracic trauma. finally, severe complications led to considerably higher risk of mortality following thoracic trauma. the psychosocial impact of e-bike accidents and changing values of older patients in the netherlands, a qualitative study s. berben , l. vloet , e. c. t. tan , m. edwards , , a. brants , , , g. olthuis , , , , a. oerlemans , , , , f. haverkamp , , introduction: the mechanical impact of e-bike accidents, increasingly used by older persons, has shown to be higher compared to regular bike accidents. however, the psychological impact of e-bike accidents in older trauma patients, their experiences in emergency and follow-up care, and the possible change in values and beliefs in response to the accident is still unknown. materials and methods: we used a qualitative design and included older patients ( ? years) with a variety of (severe) injuries, who were admitted to the emergency department after an e-bike accident (n = ) and their relatives (n = ). they were interviewed within one month (t ) and after three months (t ) of the date of accident. interviews were transcribed verbatim and analyzed via a thematic analysis approach using an ethical perspective. results: many patients required (in)formal care after hospital discharge. in general patients were satisfied with the provided emergency surgical care, although some patients reported limited and insufficient information on rehabilitation and homecare support. the analysis yielded impaired physical condition, anxiety, increased vulnerability and dependency of care givers as psychosocial impact. freedom impairment, shifting relational autonomy, and confrontation with vulnerability and mortality were reported changes in values. central values as mobility and freedom, vitality and health, social participation and recreation were put under pressure and needed to be negotiated again after the accident in order to decide whether to use the e-bike again. conclusions: follow-up information of surgeons and emergency physicians after initial hospital care for older trauma patients with an e-bike accident shows room for improvement, with more specific consideration for the psychological impact of trauma and changes in values after e-bike accidents. eur j trauma emerg surg. . https://doi.org/ . /s - - - . traumatic subaxial cervical fractures: functional prognostic factors and survival analysis introduction: the main goal of this study is to identify the risk factors for poor functional outcomes and to analyze the overall survival (os) and complications rate in patients with traumatic cervical spinal cord injury (sci) and subaxial cervical fracture (sacf) treated with open surgical fixation. materials and methods: the authors retrospectively reviewed sixtyfive consecutive patients from one single center with traumatic unstable sacf and associated sci treated surgically between and . we exclude cervical fractures with concomitant severe head injury, brachial plexus injury, lumbar plexus injury, superior or inferior limb fractures and patients who were lost during the followup period. statistical analysis using a chi square test, student's t-test and logist regression were used to identify factors associated with poor functional outcomes after surgical treatment. os analyses were performed using kaplan-meier curves. results: the -year survival rate was . %. four patients died in the first days after surgery and , % need a reoperation. the median time from injury to surgery was . days. the complication rate was %, being respiratory failure the most common one. preoperatively, % had an asia \ c. about % of the patients with asia between a-d had improve one or more asia grades. logistic regression analysis show that older age, sacf above c , asia \ c pre-surgery and long time from injury to surgery were related with poor prognosis. the os rate was higher in patients with neurological improvement, without signs of neurogenic shock at presentation and in sacf bellow c . conclusions: our results suggest that sacf should be treated as soon as possible in order to improve the os rates and functional outcomes. older patients, lower asia at presentation and sacf above c are related with worst functional outcomes. introduction: compression fractures of multilevel vertebral bodies are common in children. due to segmental plasticity, several adjacent vertebral bodies are compressed to a lesser degree at each body. plain ap and lateral x-ray is the first diagnostic examination in the emergency department (ed), but a proper diagnosis is often delayed or missed. materials and methods: this is a retrospective, monocentric study in children falling on their back who showed up at the orthopedic ed, between december and september . nine children ( f, m) with an average age of . years were included. trauma occurred playing games and doing sports in all cases. all children were subjected to x-ray, followed by mri scans for doubtful findings on the plain x-ray or persistent mild pain (t , t , t -stir sequences). results: cuneiform vertebral fracture or vertebral body height reduction was diagnosed with x-ray in five vertebrae while mri showed fractures in vertebrae including compression and edema of adjacent vertebrae in the t -stir sequence. therefore only . % vertebral fractures have been detected by plain x-ray. the injured vertebral bodies were so distributed: t n = , t n = , t n = , t n = , t n = , t n = , t n = , t n = , t n = , t n = , l n = , l n = , s n = , s n = . the most involved spine section was between t and t with fractures. conclusions: vertebral fractures are not always related to hyperflexion or forward hinging mechanism. mri showed vertebral compression fractures and the t -stir sequence showed edema as post-traumatic evidence that had not been detected by x-ray. in absence of a radiologically visible lesion, the persistence of pain should be investigated by performing mri scans. the middle thoracic spine level appeared to be the most involved one in pediatric vertebral fractures. introduction: occipitocervical fixation (ocf) is an effective surgical method to treat various craniovertebral junction (cvj) pathologies. a rigid fixation achieved from ocf displaces other techniques of cvj stabilization unfortunately during procedure deep and wide wound is performed. aim of this study is to share our experience in ocf and lately performed percutaneous ocfs with intraoperative ct guided navigation system. materials and methods: of patients who underwent ocf were performed percutaneously. o-arm ct scans were used to illustrate and measure radiologic parameters. screws were implanted in c lateral masses ( ) , isthmus of c ( ) and c pedicles ( ) and assessed according gertzbein robbins (gr) in modification of bredow classification from a to e. results: a total screws were implanted, of them was performed in open surgery and percutaneously. outcome in gr classification for screws implanted in open surgery was: a ( , %), b ( , %), c ( , %), d ( , %) and e ( , %) while in percutaneous: a ( , %) and b ( , %) . in open surgery one screw was revised. conclusions: percutaneous occipitocervical fusion seems to be a good option to achieve desirable effect in cervical pedicle screws implantation. during procedure whole nuchal muscles are preserved. ct guided surgery and microscope view are necessary to perform percutaneous ocf. introduction: studies have found higher risk of traumatic deaths in rural areas in norway combined with a paradoxically decreased prevalence of severe, non-fatal injuries ( ) . this study investigates the risk of fatal and non-fatal injuries among all adults in norway in the period - . materials and methods: all traumatic injuries and deaths among persons with residential address in norway from - were included. data was collected from the norwegian patient registry and the norwegian national cause of death registry. all cases were stratified according to six groups of centrality based on statistics norway's classification of centrality . mortality-and injury rates was calculated per , inhabitants per year. results: the mortality rate differed significantly according to the levels of centrality (p \ . ). the mortality rate in the most urban group ( ) was . and in the most rural group ( ) . . the lowest mortality rate was found in centrality group ( . ). there was an increased risk of death between centrality group and group with a relative risk of . (ci: . - . , p \ . ). the most common cause of death was transport injuries, self harm, fall injury and other external causes. the highest urban-rural gradient was seen in transport injuries with a relative risk of . (ci . - . , p \ . ) comparing group to group . group had the lowest risk of nonfatal injuries ( ) and group the highest ( ). the risk of nonfatal injuries increased with higher grade of rurality, comparing group and revealed a relative risk . (ki . - . , p \ . ). conclusions: the more rural the higher risk of traumatic deaths and non-fatal injuries. transport injuries had the highest urban-rural gradient. references: . bakke hk, hansen is, bendixen ab, morild i, lilleng pk, wisborg t. fatal injury as a function of rurality-a tale of introduction: virtual fracture clinics (vfcs) are an alternative to conventional fracture clinics for management of musculoskeletal injuries. they have been shown to be a safe and effective model for upper and lower limb injuries. there is limited data to support their use for specialist thoracolumbar fracture follow-up. materials and methods: lean methodology including process mapping was applied to identify a safe virtual alternative for the pathway. first cycle analysis of consecutive referrals to a traditional specialist thoracolumbar fracture clinic. second cycle analysis of consecutive referrals six months after introduction of a vfc. results: mean time to first outpatient review in first cycle was days. referrals led to booked outpatient appointments and were missed ( % non-attendance). % of referrals had or more scheduled appointments. / were ao type a - and all of these received non-operative treatment. / were ao type a or b and of these received non-operative treatment. patient received operative stabilisation (ao type b). process mapping identified two pathways-virtual review with advice letter and physiotherapy referral (outcome a-ao type a - ) or face to face review (outcome b-ao type a or b). mean time to outpatient review in second cycle was days. / received outcome a. / ( %) made a telephone call for advice and only / ( %) asked for a face to face appointment. / received outcome b and all were discharged after one visit. patients in cycle required operative stabilisation. statistically significant reduction in number of scheduled face-to-face reviews ( versus ; p \ . ) and mean time to first review ( days versus days; p \ . ). conclusion: virtual thoracolumbar fracture clinics are a safe and clinically effective alternative to traditional fracture clinic models. lean methodology can be uses to extend virtual clinic pathways to specialist trauma clinics. treatment prognosis of cases of fragility fracture of pelvis m. yoshida fujita health universityhospital, emergency, aichi, japan introduction: the number of cases of fragility fracture of pelvis in the elderly has been increasing in recent years, but there are still not enough reports of surgical treatment as a treatment method, but there is still no certainty how to treat. so we investigated prognosis of cases of fragility fracture of pelvis. materials and methods: subjects were fragility fracture of pelvis treated at a single center from april to april , males, females, average age ± . years. only cases that had ct scan were included. we examined rommens classification, the presence of injury, presence of hip implants, functional prognosis, and -year mortality. results: the breakdown of rommens classification is type ia cases, ib cases, iia cases, iib cases, iic cases there were cases of iiia, cases of iiic, case of iva, cases of ivb, and cases of ivc. surgical treatment was indicated in cases ( . %) (iic case, iiia cases, ivb cases, ivc cases) there were cases ( . %) with no injury mechanism and cases ( %) with hip implants. cases ( %) were able to follow up for more than year including telephone surveys, and . % of them did not recover to functional level before injury. the one-year mortality rate was . %. conclusions: in the cases studied here, cases ( . %) were indicated for surgery. the prognosis and mortality rate are almost the same as those reported overseas, and as with proximal femoral fractures, there is a possibility that it may be greatly involved in adl decline in the elderly. we think that further study is needed in the future. conclusions: patients with a femoral neck fracture who received a hip hemiarthroplasty and used anticoagulation had no significant longer delay to surgery and had a higher mean loss of hemoglobin points. as a clinical consequence of this, more packed cells were supplemented. also more postoperative hematomas were found in the population with anticoagulation. no differences were found in mortality rates at -days and one year. results: on all eight patients the easy-approach was applied without adverse events. in four cases the plate osteosynthesis was done completely endoscopically with excellent results for the patients regarding pain relief and scar development. in the remaining four cases the endoscopic stabilization was not performed for the following reasons: in the first overall case primarily only the endoscopic approach was planned. in the fourth overall case, ventilation showed high end-expiratory co -levels after endoscopic situs preparation, so we converted to the open plating. in the fifth overall case, the easyapproach was applied to evacuate a retrosymphyseal hematoma in a patient with a stable pubic rami fracture. in the eighth overall case, the anterior pelvic ring injury was a bilateral multifragmentary pubic rami fracture in combination with a disruption of the symphysis. after endoscopic situs preparation with clipping of the corona mortis vessel, reduction of the displaced symphysis could not be done endoscopically. conclusions: we demonstrated that the endoscopic plate osteosynthesis of the anterior pelvic ring is feasible with existing standard laparoscopic instruments. the evaluation of the easy-approach in the clinical setting is going on, while the development of suitable reduction tools is one major goal of future studies. introduction: retrograde intramedullary pubic ramus screw fixation is less invasive method and biomechanically stable compared to the plate fixation. the purpose of this study is to examine the feasibility of screw insertion using computed tomography (ct). materials and methods: we analyzed sixty ct data ( cases in male and female each). by using ct analyzing software, the virtual column with . mm diameter was inserted so that we analyzed the feasibility of the screw insertion. and the intramedullary diameter of the pubic ramus at the parasymphyseal area, base, and acetabulum were measured. results: the virtual . mm diameter screws could be inserted in % ( / ) in male and . % ( / ) in female. the cause that screws insertion was impossible was penetration to the hip joint in all cases. the screw inserting point was . mm and . mm from the medial border of the pubic symphysis and . mm and . mm from the upper border of the pubic symphysis in male and female respectively (p [ . ). the intramedullary diameter of pubic ramus was . mm, . mm and . mm at parasymphyseal area, . mm, . mm and . mm at the base of pubis, and . mm. . mm and . mm at the acetabulum in male, female who had the screw corridor and female who didn't have the screw corridor respectively. the diameter of the pubic ramus of the female who didn't have the screw corridor was significantly small compared to male and pubic ramus in three measuring points (p \ . ). , % of the screws were revised. there were no neurovascular or urologic complications. radiographic nonunion was observed in % with a minimum follow-up of months, this correlated with a peri-implant infection (p . ), operation [ months after trauma (p . ) and non-significantly with implant loosening (p . ). there was no correlation of nonunion with patient's age, the fracture mechanism or a non-excellent reduction. in total, . % of the patients were re-operated, in . % a re-osteosynthesis was conducted. conclusions: retrograde trans-pubic screws show good clinical results with lower or similar complication rates compared to alternative methods as plate fixation or external fixator. fracture union did not depend on fracture mechanism or age. hence, this minimal-invasive method is especially attractive in elderly patients with an ffp. because it is an internal fixation of the superior pubic ramus with relative stability, an anatomic open reduction is not necessary to achieve fracture union. the need for extraperitonal pelvic packing -finally confirmed to be vanishing? introduction: the presence of cerebral venous thrombosis (cvt) is increasingly recognized in traumatic brain injury (tbi), but its complication rate and effect on outcome remains undetermined. in this study, we characterize the complications and outcome-effect of cvt in tbi patients. materials and methods: in a retrospective, case-control study of patients included in the oslo university hospital trauma registry and radiology registry from - , we identified patients with cvt (cases) and without cvt (controls). groups were matched regarding abbreviated injury severity (ais) head region score - . cases were identified by ais or icd-code for cvt and a ct/mr venography confirmed to be positive for cvt, whereas controls had no ais or icd-code for cvt and a ct/mr venography confirmed to be negative for cvt. risk of mortality was assessed using multivariate logistic regression adjusting for initial gcs, iss and rotterdam score. results are also reported for subgroups according to cvt location ( fig. introduction: the aims of this prospective cohort study were (i) to identify trajectories of recovery in patients with mild traumatic brain injury (mtbi) during the first two years after trauma and (ii) assess patients and injury characteristics for these trajectories. materials and methods: all adult trauma patients with mtbi (aisseverity or and an injury severity score \ ) who were admitted to a hospital in a region of the netherlands from august to november were asked to complete questionnaires. the questionnaires could be completed at week, and , , , and months and included the euroqol- -d for health status, including a cognition dimension, the hospital anxiety depression scale (hads-d and hads-a for symptoms of depression and anxiety respectively) and the impact of event scale (ies) (for post-traumatic stress symptoms). latent class trajectory analysis was used to determine trajectories of recovery in latentgold . , patient and injury characteristics of the classes were assessed in ibm spss . . results: a total of patients ( % of total) completed at least one follow-up questionnaire. the number of classes (trajectories) ranged from for cognition to for depression. poor recovery classes of cognition and health status consisted of mostly females, patients with low education, higher age, longer length of stay at the hospital and frail patients. the class with full recovery consisted of young patients, with most recovery occurring during the first six months after injury. patients who reported poor health status before injury scored significantly lower health status after injury and showed no recovery over time. conclusions: different recovery patterns were present in patients with mild traumatic brain injury. especially frail elderly patients who reported poor health status before injury have poor outcome up to months after injury. post-concussive symptoms in children and adolescents with traumatic brain injury: a center-tbi study introduction: acute respiratory is associated with high morbidity and mortality. in addition, its etiologies are heterogeneous and the outcome depends on the underlying cause. the aim of the present study is to analyze, whether the mortality of posttraumatic ards is affected ( ) over time, ( ) attributable to geographic distribution, ( ) related to the used definition and ( ) introduction: many factors of trauma care have changed in the last decades. this review investigated the effect of these changes on overall and cause-specific mortality in polytrauma patients admitted to the intensive care unit (icu). moreover, changes in trauma mechanism over time and differences between continents were analyzed. materials and methods: a systematic review of literature on overall mortality in polytrauma patients admitted to the icu was conducted. overall and cause-specific mortality rates were extracted as well as the trauma mechanism of each patient. linear regression on changes in overall and cause-specific mortality rates was performed. results: thirty studies, which reported mortality rates for , observed patients, were included and showed a decrease of . % in overall mortality per year ( fig. ). brain-related death has become more common over the years, whereas multiple organ dysfunction syndrome (mods), acute respiratory distress syndrome and sepsis became less prevalent (fig. ) . mods was the most common cause of death in north america and brain-related death was the most common in asia, south america and europe (fig. a) . penetrating trauma was most often reported in north and south america and asia (fig. b) . conclusions: overall mortality in polytrauma patients admitted to the icu has been decreasing as a result of the improvements in trauma care. a shift from mods to brain-related death could be observed. more research on preventative measures for the latter is required to ensure a further decline in mortality. moreover, we have shown geographical differences in cause-specific mortality, which may provide learning possibilities between similar trauma centers resulting in improvement of trauma care introduction: aim of the current study was to assess an association between trauma patient volume of the intensive care unit and inhospital mortality. materials and methods: from data of the japan trauma databank, this retrospective cohort study selected adult (c y) trauma patients hospitalized in the intensive care unit with the injury severity score of c . after applying a multiple imputation on all the study variables, a logistic regression generalized estimating equation after adjustment for age, sex, mechanism of trauma, and the injury severity score as covariates and hospitals as a cluster assessed an association between quartile of patient volume in intensive care unit and hospital mortality. introduction: quality and content of early fracture hematoma (fh) dictate the healing process in long bone fractures. different reaming protocols for intramedullary nailing (imn) are available. however, the impact of reaming strategies on immune cell characteristics of early fracture hematoma is unclear. we hypothesized that the application of reaming irrigation and aspiration (ria) techniques optimizes cellular content of fracture hematoma. materials and methods: twenty-four pigs underwent standardized femur fracturing. then, animals were exposed to different protocols of imn. group a underwent no reaming prior to imn. group b was treated with conventional reaming plus imn and group c composed of animals treated with ria and subsequent nailing. fracture hematoma was collected h after reaming. fh-immune cells were isolated and studied by flowcytometry. cell viability was tested by annexin-v-labelling. neutrophil activation was determined by mac- /cd bcell surface expression levels, whereas fcyriii/cd -receptor expression was utilized to investigate neutrophil maturation. results: all animals survived the observation period. propertions of white blood cell subtypes in fh did not differ between conditions. however, the percentage of viable fracture hematoma immune cells was significantly higher in the ria-group, compared with conventional reaming (respectively mean . % vs. . %, p = . ). additionally, both neutrophil cd -expression (- %) and cd bexpression (- %) were significantly lower in those animals treated with ria compared with the conventional reaming condition. conclusions: this experimental study reveals that reamed irrigationaspiration (ria) prior to imn is associated with increased immune cell viability and less neutrophil senescence/activation in early fracture hematoma. this underlines the important role of imn in optimizing local cellular immune homeostasis during the formationphase of early fracture hematoma. introduction: the study and determination of the traumatic pattern in bicyclists-delivery employees. the recording of personal protective equipment and evaluation of the selection criteria of their self protection. materials and methods: a total of patients ( men and woman) with mean age of . years ( - years) were included over a study period from january to march . twenty-one patients admitted to the hospital with a total of injuries treated operatively, whereas injuries were treated conservatively. we recorded and evaluated the use of adequate personal protective equipment of these delivery employees. results: the mean hospitalization time was . days ( - days) . a total of thoracic injuries, traumatic brain injuries, spine injuries, lower extremity injuries and upper extremity injuries were recorded. surgical treatment concerned patients with upper extremities and patients with lower extremities injuries and the anatomic regions involved were the distal radius ( ), pelvic ring injury ( ), femoral fractures ( ), tibial plateau fractures ( ), patella fractures ( ), diaphyseal tibial fractures ( ), and ankle fractures ( ) . conclusions: the lack of an adequate personal protective equipment due to their low financial status in combination with the absence of driving professional education among workers in this category of delivery employees results in lower extremity injuries with the majority requiring hospitalization and surgery. further investigation is needed, as well as constant training and setting right criteria for the pursuit of such employment. results: a total of nine rct's ( patients) and the sixteen observational studies ( patients) were included. the pooled nonunion rate did not differ significantly between both treatment groups (risk difference: %; or . , % ci . - . ). more patients treated with nailing required re-intervention (risk difference: %; or . , % ci . - . ) with shoulder impingement being the most predominant indication. more patients treated with pate fixation developed radial nerve palsy compared to nailing (or . , % ci . - . ). notably the absolute risk difference is small ( %) and during follow-up the palsy resolved spontaneously in the majority of patients. nailing lead to a faster time to union (mean difference: . week, % ci . - . ), lower infection rate (risk difference: %, or . , % ci . - . ) and shorter operation duration (mean difference: min, % ci . - . ). functional scores were comparable in both groups (standardised mean difference: - . , % ci - . to . ). there was no difference between effect estimates form observational studies and rct's. conclusion: there appears to be no difference between plate fixation and nailing for humeral shaft fractures with regard to non-union rate and functional outcome. patients treated with plate fixation have a higher risk for infection and radial nerve palsy, but lower risk for reintervention. the absolute differences, however, are small. nailing does differ significantly from plate fixation in terms of shorter operation duration and time to union. the pooled estimates from randomised clinical trials did not differ significantly from estimates obtained from observational studies. post-traumatic complications are more often after medial clavicle injuries compared to lateral clavicle injuries introduction: medial clavicle injuries (mci) are widely unexplored, especially in contrast to lateral clavicle injuries (lci). current research concerning mci assumes a higher severity of mci, e.g. concerning concomitant injuries. our aim is to evaluate by big data analysis if these rare injuries would also lead to a higher number of post-traumatic complications. materials and methods: we focused on the mci subgroup consisting of medial clavicle fracture and sternoclavicular joint dislocation. the lateral clavicle fracture and the acromioclavicular joint dislocation were summarized to the subgroup of lci. the midshaft clavicle fracture was analyzed for comparison. the data are based on icd- codes of all german hospitals as provided by the german federal statistical office. anonymized patient data from to were evaluated. the retrospective analysis addresses the fracture healing in dislocation, delayed union and non-union. results: the proportion of all patients suffering from complications was . %, which were attributed to one of the three post-traumatic complications. each complication rate for the single injury and the single complication was rather low with a maximum of %. mci were more likely to be affected by post-traumatic complications than lci with a ratio of . to . times (p \ . ). the midshaft clavicle fracture was similarly frequently affected by complications with . % of all complications as the mci ( . %). the lci accounted for the smallest proportion at . %. conclusions: we proved that mci are more often associated with post-traumatic complications than injuries of the other parts of the clavicle. this is another hint that mci appear to be more complex than lci. this could be due to a missing standard procedure and the higher number of concomitant injuries in mci. further representative clinical studies are required since miscoding is a frequent issue in research concerning clavicle injuries, especially in a big data analysis. quantification of trauma center accessibility using gis-based technology introduction: there is no generally accepted methodology to asses trauma system access and optimal geographical trauma center distribution. the goal of this study is to determine the influence of trauma center(tc) distribution during high and low traffic density using geographical-information-system(gis)-technology. methods: using arcgis-pro, we calculated differences in transport time (tt) and population coverage in seven scenarios with , , or tcs during rush [r]-and low traffic [l] hours in a densely-populated region with tcs in the netherlands (fig. ) . results: in the seven scenarios, the population that could reach the nearest tc within (\) min, varied between - % ( fig. ) in the three-tc-scenario, roughly % of the population could reach the nearest tc \ min in [r] and [l] . the hypothetical scenarios with two geographically well-spread tcs showed similar results as the current three-tc-scenario. in the one-tc-scenarios, the population reaching the nearest tc \ min decreased by - % in both [r] and [l] compared to the three-tc-scenario. in the three-tcscenario the average tt increased with about . min to almost min in [r] , in comparison to min during [l] (fig. ) . similar results were seen in the scenarios with two geographically well-spread tcs. in the one-tc-scenarios and the geographically close two-tcscenario the average tt increased by - min [l] and - min [r] in comparison to the three-tc-scenario. conclusion: this study shows that a gis-model for trauma center access offers a quantifiable and objective method to evaluate trauma system configuration in areas with different geography and demography. applying this technology to one of the most densely populated areas in the netherlands shows that the transport time from accident to trauma center would remain acceptable if the current situation with three trauma centers would be changed to a scenario with two geographically well-spread centers. classifying posttraumatic stress disorder courses in physical trauma patients: an observational prospective cohort study introduction: the aim was to identify different courses of posttraumatic stress disorder (ptsd) in physical trauma patients. then, to examine whether these classes could be characterized by sociodemographic, clinical, psychological, and personality outcomes. methods: patients completed the impact of event scale-revised (ies-r), m.i.n.i.-plus after inclusion, , , , and months after injury to examine different courses. the hospital anxiety and depression scale, neo-five factor inventory, state-trait anxiety inventory-trait, and the whoqol-bref were completed after inclusion only. latent class analysis, chi square tests, and anova were performed to analyze the aims. results: in total, patients were included. the mean age was . (sd = . ) and % were male patients. the ies-r (see figure ) and the m.i.n.i-plus had five classes ( : moderately, : little bit, : worse, : none, : quite a bit of ptsd symptoms). patients in class are diagnosed with ptsd (cut-off score c ). on both questionnaires, patients (proportion & %) in class or , scored higher on anxiety, depressive symptoms, neuroticism, and trait anxiety compared to the other classes over months after trauma. lower scores on all domains, except for social domain on the ies-r, were found compared to the other classes (ies-r; physical domain: class vs. (mean ± sd): . ± . vs. . ± . , p-value = \ . ). psychological and personality outcomes were significantly different on all courses. also, patients in class or were younger compared to the other classes (ies-r; class vs. : . ± . vs. . ± . , p-value = \ . ). no medical outcomes for ptsd were found. conclusions: about % suffer from ptsd symptoms months after trauma. different courses were defined by sociodemographic, psychological, and personality characteristics. professionals can, short after trauma, recognize patients at risk for ptsd when they focus on these characteristics. then, an intervention can be offered. six meter, the criterion for severe adult trauma to falls from heights in cdc field triage needs to be lowered introduction: trauma is one of major public health care issue which is costly to society. differences vary from region to region, but blunt trauma accounts for a large part of the total trauma, and the rates of the falls from heights among the blunt trauma is getting higher. it is serious that falls from heights is often accompanied by severe multiple trauma. therefore, authors studied the relationship between the height of the fall/other related factors and outcomes including hospital stay/mortality. materials and methods: retrospective cohort study of the adult falls-from-heights patients visited a regional trauma center for years (from . . to . . ). results: of total patients, the number of d.o.a patients were . the height from falls of the deceased patients was statistically significantly higher than that of the survived patients. ( . ± . m vs. . ± . , p \ . ) the auc of the roc curve of the height from fall to mortality was . . (figure) the sensitivity of . m was . % and . m was . %, respectively. the traumatic brain injury, pelvis fracture, visceral organ injury, age, and the height from fall were statistically significant risk factors in multivariate analysis for mortality (p = \ . , . , , , . , and . respectively). conclusions: the height from the fall is closely related with mortality. we think the current height for the severe fall injury in cdc field triage for trauma is high and needs to be lower to . introduction: operative management of severe trauma is a team effort, requiring excellent communication skills. surgeons, anesthesiologists and nurses need to coordinate effectively in order to ensure an excellent clinical outcome. the definitive surgical trauma care (dstc), definitive anesthesia trauma care (datc) and definitive perioperative nurses trauma care (dpntc) courses provide an excellent opportunity to train efficient teamwork. we aimed to study the impact of the joint dstc-datc-dpntc courses in candidates' perceptions and skills in perioperative communication. materials and methods: study population of candidates ( surgeons, anesthesiologists and nurses) participating in a joint dstc-datc-dpntc course in coimbra, portugal. median age of years (range - ). female gender in ( %) of cases. all participants attended joint lectures, case discussions and surgical skills session, emphasizing intraoperative communication. postcourse survey on several aspects of peri-operative communication, with responses on a likert scale. participants were also asked which aspects of intraoperative communication they valued the most. statistical analysis with spps, . (wilcoxon signed rank test, significance with p-value \ . ). results: all participants responded to the survey. results displayed an increase in the self-assessed importance of team briefing and intraoperative communication, particularly routine periodic communication, rather than only at critical moments (p \ . ). postoperative team debriefing was also valued as highly relevant. closed-loop and direct, by-name communication were highly rated (p \ . ). self-reported communication skills improved significantly during the course (p \ . ). conclusions: joint training in the dstc-datc-dpntc courses provides a unique opportunity to improve candidates' self-awareness and skills in intraoperative communication. a public health approach to knife related trauma in liverpool: a geospatial study r. shellien , n. misra , , j. germain , m. whitfield aintree university hospital, emergency general surgery and trauma unit, liverpool, united kingdom, liverpool john moores university, public health institute, liverpool, united kingdom introduction: liverpool is a city that has undergone recent rapic socioeconomic change. despite reductions in overall deprivation, incidents of stabbings have increased by % in the last years. this study will describe the trend in knife crime, drawing on governmental data and policies to conclude the reasons behind the trend. materials and methods: a retrospective cohort study of patients presenting to north-west ambulance service (nwas) with a penetrating injury in liverpool between and . data collected included patient demographics, geography and timing of incidents and correlation to datasets of multiple indices of deprivation and knife crime prevention outreach education programmes. results: incidents of stabbings have increased by % between and . victims were more likely to be males ( %) between the ages of and ( %). the peak rate was between : - : ( . %) and trough between : - : ( . %). there is a spike in incidents of stabbings of - year olds from : to : , correlating with school closure. there appears to be statistically poor correlation between deprivation of lower super output areas and stabbings (r = . , . and . for , and respectively). however, when the data is split into larger areas, middle super output areas (msoas), deprivation appears to be a further risk factor. this study has identified certain geographical areas as high risk. conclusions: this study allows for targeted public health interventions at populations most at risk of knife trauma, including geographical mapping of high-risk areas, so that interventions can be distributed appropriately. references: ministry of housing, communities and local government ( government ( , government ( , introduction: trauma teams treat complex patients with injuries posing significant resuscitative and management challenges. effective teamwork is essential to optimise patient outcomes and improve survival, with failure contributing to adverse events [ ] . the role of multidisciplinary (mdt) trauma training has been demonstrated by the military operational surgical training course (most) [ ] . it is imperative that civilian trauma training adopts similar methodology to optimise team work. materials and methods: the three-day multidisciplinary trauma course comprised cadaveric-based skills teaching supplemented by lectures and real-life scenario discussion. delegates were senior surgical and anaesthetic registrars and consultants, alongside trauma team leaders (ttl), scrub staff and operating department practitioners (odp). pre-and post-course questionnaires assessed perceptions of multidisciplinary trauma simulation and confidence in specialty specific skills. results: all delegates reported mdt simulation clarified each role, including their own, in the trauma team. post-course, scrub staff and odps felt confident gaining intraosseous access (p \ . ), surgical delegates had improved confidence performing all skills (p \ . ), with anaesthetists and ttls more confident in haemorrhage control and performing resuscitative thoracotomy (p \ . ). conclusions: mdt trauma training improves team understanding of role and effectively teaches skills. mdt courses with experienced faculty are one way of improving mdt trauma team function. further careful evaluation is required to assess performance of trauma teams in real scenarios. introduction: despite a dramatic rise in youth knife crime, the factors associated with it remain underexplored, especially in the critical pre-college years, which hinders effective counter-knife carrying interventions. the current research is the first to addresses this deficit. materials and methods: british male school students (mean age = . , sd = . ) coming from four different schools completed a short -min survey. they indicated their standing on a number of dimensions (school-adapted and shortened-scale-based predictors) derived from theories of violence, developmental psychology and related research (i.e. violence acceptance, need for respect, belief in self-defence, belief in a just world, narcissism, psychopathy, impulsivity, sensation seeking, and need for closure). results: for perceived knife harmfulness (i.e., the knife's assumed value in inflicting injury and death)-the total variance explained by the model was . %, r = . ; f( , ) = . . the only statistically significant predictors were: right-wing authoritariamism (b = . , p = . ) and need for respect (b = . , p = . ). the other factors were not statistically significant. for the perceived value of knife defence (i.e., its assumed defensive worth in violent confrontations) -the total variance explained by the model was . %, r = . ; f( , ) = . , pviolence acceptance (b = . , p = . ), followed by need for closure (b = . , p = . ), narcissism (b = . , p = . ) and psychopathy (b = . , p = . ). conclusions: this study provides evidence for future knife-carrying prevention interventions, such as talks in schools or social media videos, to focus more on how to increase self-esteem, stimulate empathy for and better understanding of other people, and approach problems from multiple (rather than just two) perspectives, emphasizing the ultimate superiority of the human intellect over brute force. introduction: the physician's response unit (pru) is a novel service that operates from the royal gwent hospital's emergency department (ed), in newport, south wales. it involves an emergency medicine consultant and a paramedic responding to calls in a rapid response vehicle. their aim is to treat and, hopefully, discharge patients at the scene, reducing ed admissions. the pru can also refer patients on to other departments, e.g. the medical assessment unit, allowing patients to bypass the ed. methods: the author spent six weeks out in the pru and in the ed to observe and speak to patients. to assess whether ed admissions were reduced, the dispositions of patients seen by the pru were recorded on a daily log sheet. the service users' satisfaction with the pru was evaluated using simple questionnaires. this included both patients and paramedics, who can request the pru for support with a patient. results: the pru saw patients during the project's timeframe. % (n = ) of these patients were discharged at scene, while % (n = ) were sent to the ed. % (n = ) of patients asked described the care they received from the pru as equal to or better than care they have received previously. % (n = ) of patients rated their overall satisfaction with the pru as / . conclusions: the pru is very well received by both patients and paramedics and has been shown to reduce the number of patients attending the ed. this system excellently implements the principles of prudent healthcare introduction: in germany reducing alcohol related harms in youth is still a priority, because adolescents and young adults still have the highest accident risk in road traffic. therefore, the p.a.r.t.y.-project aim to increase awareness of alcohol and risk-related issues. the purpose of this study was to analyse the risk behaviour of adolescents before and after a prevention project in two different hospitals in germany. materials and methods: during a one-day prevention project, young people within the age of to years got an overview of the route an accident victim go through from the ambulance until the rehabilitation. before and after the prevention day, a structured written survey was completed by the adolescents. results: students participated in the p.a.r.t.y. program between and . the gender distribution of the participating students were balanced. the average age of the adolescent was years. according to the program, the risk assessment and risk behaviour improved through the project significantly (\ . ). the evaluation of the students' satisfaction was rated as good. the majority of students prefer to repeat the project day after years. conclusions: the prevention program shows that the program increase for short-term the awareness for risk related trauma in youth. nevertheless, long-term studies are necessary to receive data regarding the long-lasting effect. references: the present study is funded by the ministry for energy, infrastructure and digitization of the country mecklenburg-vorpommern, germany. development of a claims-based risk adjustment model for trauma introduction: duodenal injury is rare. the diagnosis requires a high index of suspicion which might result in delayed treatment. there is limited data on the delayed diagnosis group, especially high grade duodenal injuries. the purpose of this study is to determine the characteristics and outcomes of delayed high grade duodenal injuries. materials and methods: charts of all patients from - who had history of small bowel injuries are reviewed. the inclusion criteria were age between - years old, diagnosis with duodenal injuries at least grade with delayed operation at least h after injuries. baseline characteristics and postoperative outcomes were recorded. results: of the small bowel injuries, ( %) were duodenal injuries. the overall mortality was %. delayed diagnosis more than h with at least grade of duodenal injuries were cases. the overall in-hospital mortality rate of the delayed group was . % ( / ) who had concomittent hemorrhagic shock and low initial systolic blood pressure. cases ( . %) were diagnosed within h and had better outcomes without leakage. they could step diet within days and had shorter length of hospital stay (mean = days). patients ( . %) presented with delayed diagnosis more than h (the maximum was h after injuries). all these patients had anastomosis leakage and need reoperation. they had initial low level of serum albumin (mean . mg/dl), high white blood cell count, low serum bicarbonate and presented with preoperative acute kidney injury. conclusions: delayed diagnosis and surgical treatment of high grade duodenal injuries lead to poor outcome. low initial blood pressure associated with mortality and delayed treatment more than h had higher morbidity. references: gary sa, frederick am, charles sc, et al. delayed diagnosis of blunt duodenal injury: an avoidable complication. acs meeting. ; ( ) : - . routine follow-up imaging has no advantage in the non-operative management of blunt splenic injury in adult patients modality. the aim of this study was to investigate the incidence and time to failure of nom as well as to evaluate the relevance of follow-up imaging. materials and methods: all adult patients with bsi admitted to our level i trauma center, including two associated hospitals, between / / and / / were retrospectively analyzed. demographic data, injury severity score, splenic injury grade, modality, results and consequences of follow-up imaging were retrospectively analyzed. results: a total of patients with a mean age of . ± . years ( - years) met inclusion criteria. patients ( . %) underwent immediate intervention. patients ( . %) were treated by nom. failure of nom occurred in patients ( . %). failure was significantly associated with active bleeding (or . , % ci . , . , p = . ) , and liver cirrhosis (or , % ci . , . , p = . ) . patients ( . %) in the nom-group received followup imaging by ultrasound (us, n = ) or computed tomography (ct, n = ). in cases, routine imaging examinations were conducted ( us and ct scans) without prior clinical deterioration. ( . %) of these imaging results revealed no new significant findings. every failure of nom was detected following clinical deterioration. conclusions: to our knowledge this study includes the largest monocentric patient cohort undergoing ultrasound as first-line followup imaging modality in the nom setting of bsi in adult patients. the results indicate that a routine follow-up imaging, regardless of the modality, has no therapeutic advantage. indication for radiological follow-up should be based on clinical findings. if indicated, a ct scan should be used as preferred imaging modality. the association between bmi and mortality of renal injuries in adult trauma patients introduction: the role of body mass index (bmi) on solid organ injuries remains debatable. while some studies have shown no association between bmi and hepatic or splenic injuries, others have reported that severe hepatic injuries were more common in pediatric patients with bmi [ . the aim of this study is to examine the association of bmi and mortality, as well as any significant differences between operative vs. non-operative management. materials and methods: this was a retrospective study using the american college of surgeons-trauma quality improvement program database to identify all adult patients (ages to \ ) with traumatic renal injuries. the primary analysis showed a different pattern of mortality between patients with bmi \ and those with bmi c kg/m . then, the study population was divided into patients with bmi \ and those with bmi c kg/m . multivariable logistic regression was conducted to assess any association of mortality with age, gender, bmi, and injury severity score (iss). results: adult trauma patients were identified. a greater proportion of males ( . %) and females ( . %) had bmi \ kg/m (p = . ). the average age of patients with bmi \ kg/m was . (sd = . ) years which was significantly younger than that in patients with bmi c kg/m , . (sd = . ) years (p = . ). patients with bmi \ kg/m were found to have a significantly higher mortality rate of . % vs. . % in patients with bmi c kg/m (p = . ). however, there was no significant difference in type of operative or nonoperative management between patients with bmi \ vs. bmi c kg/m . after multivariable logistic regression, mortality was associated with age, bmi and iss. no effect modification of sex was observed in the relationship of mortality and bmi. conclusions: adult patients with renal injuries and bmi \ kg/m have significantly higher rates of mortality compared with adult patients with renal injuries and bmi c kg/m . introduction: trauma is an ever-evolving surgical discipline. trauma remains a major source of global mortality. the operative and non-operative options for trauma patients has steadily increased. the development of trauma protocols, advancement in transport to trauma centres and radiological techniques has seen a shift in trauma surgery caseload. observing and understanding this shift from operative management to an increasing non-operative management of trauma cases will better prepare the acute medical team in this setting. materials and methods: prospective trauma registry data was collected and analysed retrospectively. patients presenting to a tertiary referral hospital between jan to dec with an injury severity score of [ were reviewed. patients who were transferred to another facility for management were excluded. the demographic data and surgical outcome data were collected and analysed. trend analysis of the operative cases performed for each specialty. results: major trauma patients presented to the john hunter hospital between january to dec . there was a non-statistically significant increase in the number of presentations ( pt in vs in , p = . ). there was a decreasing rate of operations performed for trauma patients ( % in vs % in , p \ . ). there was an increasing rate of orthopaedic surgery cases and operative time compared to other specialties ( in vs in , p \ . ). general surgical major trauma operating cases noted a significant decline over the study time ( in vs in , p \ . ). conclusions: there is a sizeable shift in the caseload of different surgical specialties in regard to major trauma patients over the course of years from to . orthopaedics has seen a significant increase in operative caseload and surgical time required to adequately manage major trauma presentations. the workload and experience of general surgical teams will likely be affected by these changes. the distribution of resources needs to be reflected in the changing work demands of each surgical subspecialty. traumatic internal hernia with delayed small bowel strangulation after pelvic ring injury hospitalization, follow up abdomen ct checked. there was no other specific change than increased thigh hematoma. eight days after hospitalization, ct was re-examined due to abdominal pain with abdominal distraction. an ct showed peritonitis with pneumoperitoneum and small amount of ascites. small bowel herniation through right pubic bone fracture site with ischemic change also noted. diagnosis: diagnosis was traumatic pelvic hernia with delayed small bowel strangulation. therapy and progressions: an emergency operation was performed. ileal loop was hernitated and perforation was found. emphysematouns change and fluid collection was exsited at perineal area and left high. after small bowel loop segmental resection, wound vac was applied at thigh area. comments: traumatic pelvic hernia is rare. diagnosis is challenging in the acute setting and often delayed due to lack of awareness. when diagnosed, efforts should be made to look for other serious injuries as traumatic pelvic hernia usually associated with concomitant intraabdominal injuries. the optimal management of traumatic hernia should be individualised based on the mechanism and severity of injury, presence of concomitant injuries, size of defect, and presence of incarceration. delayed treatment may read to fatal outcomes. careful inspection of the patient is important. references: vincent k, cheah sd. traumatic abdominal wall hernia-a case of handlebar hernia. med j malaysia. ; ( ): - . angio-embolization in pediatric trauma patients with blunt splenic injury: a systematicreview t. nijdam , r. spijkerman , l. hesselink , t. hardcastle , l. leenen , f. hietbrink umc utrecht, traumasurgery, utrecht, netherlands, inkosi albert luthuli central hospital, trauma, durban, south africa introduction: non-operative management (nom) for children with blunt splenic injury (bsi) is nowadays a commonly used treatment in pediatric trauma departments. in adult trauma departments the addition of splenic angio-embolization (sae) is suggested to decrease the failure rate of nom in high grade splenic injuries. however, the use of sae in pediatric trauma departments is very uncommon and it is unknown if sae is of additional value in pediatric trauma patients. therefore, the aim was to analyze the available literature on sae in pediatric trauma patients with bsi. materials and methods: a literature search was performed to find eligible studies that analyzed sae in pediatric patients with bsi. the primary outcome was failure of treatment in these patients. secondary outcomes were the success rate of sae, length of stay and mortality. the relative risk (rr) was calculated to compare primary outcome between study groups. results: in total studies were identified through the search, a total of studies matched our inclusion criteria and were selected for this review. studies included a total of . pediatric patients, of whom underwent sae. patient age ranged from &lt; year to years, mean age was . years. both injury severity score and spleen injury grade were higher in the sae group compared to the nom group. failure rate of sae was %. no spleen related morality was observed in the sae group. conclusions: the literature suggests that sae might be of added value in a very selective group of pediatric trauma patients with high grade splenic injures. however, since limited evidence is available concerning the use of sae in pediatric trauma patients with bsi, no firm conclusions can be drawn about safety and effectiveness. introduction: the management algorithms for trauma have changed with the development of specialised trauma centres. the aim of this study was to review the management and outcomes of patients with traumatic small bowel (sb) and colonic injuries. material and methods: patients treated for sb and colonic injuries between - at aintree university hospital (liverpool) were identified using the prospective trauma audit and research network database. the management and outcomes of the patients included were analysed. results: patients sustained sb and colonic injuries. there were ( . %) sb injuries and ( . %) colonic injuries ( patients had a sb and colonic injury). patients ( . %) of injuries were due to knife stabbing wounds, ( . %) patients were due to gunshot wounds, and ( . %) patients were due to road traffic accidents/ blunt blows. damage control surgery was performed in ( . %) patients. colonic injuries included ( . %) haematomas and ( . %) perforations. a resection and stoma (rs) procedure was performed in patients ( . %), primary repair (pr) in patients ( . %) and resection with anastomosis (ra) in patients ( . %). sb injuries included ( . %) haematomas and ( . %) perforations. pr was performed in ( . %) cases and ra in ( . %) cases. the overall complication rate after sb and colonic injury was % ( patients) with a significant complication rate ( patients, p value = . ) for patients undergoing rs in colonic trauma. the -day mortality rate was . % ( patient). conclusions: pr in sb and colonic injuries appears safe. in our dataset, rs appeared to have a higher complication rate. our study highlights that such injuries are uncommon with a high complication rate. surgeons need to provide individualised treatment. introduction: nowadays, patients with high grade bsi are preferably treated using spleen preserving treatments (spt). it is assumed that patients with low grade bsi treated with spt have a good splenic function after recovery. however, there is no consensus on splenic function after high grade bsi. in several institutions, asplenic/hyposplenic infection prevention protocol will be executed in all patients who had spt after high grade bsi, where other institutions evaluate splenic function first. scintigraphy is believed to be the best flow/activity test to approximate splenic functionality. the aim of the study was to analyze whether spleen injury grade is associated with diminished splenic function. secondarily, we aimed to evaluate whether splenic function testing is necessary in pediatric patients after bsi. material and methods: a retrospective study was performed from january to january . in our institution patients with bsi grade iv of v are assumed hyposplenic and will receive a splenic function test. we included all patients with a minimum follow-up test period of days. all tests were analyzed by the radiology specialist. for each patient we furthermore collected clinical data, including the date of trauma, gender, age, mechanism of injury, ais of splenic injury and iss. results: patients consisted of male and female, with a median (iqr) age of . ( . - . ) . median iss was . ( - . ) and the median spleen ais was ( ) ( ) . nom was used in patients, sae in five patients and two patients were treated with surgical mesh technique. the median follow-up time of all performed tests was ( - ) days. a total of patients ( %) had a grade iv or v splenic injury. scintigraphy was utilized to test most patients. a total of out of patients had an adequate splenic function, including all sae patients. conclusions: even high grade splenic injuries show adequate splenic function in the follow-up of pediatric trauma patients after bsi. therefore routine diagnostic follow-up by scintigraphy is not necessary in this specific patient group. evaluation of abdominal injuries treated at stavanger university hospital: occurrence, severity and mortality j. w. larsen , k. søreide , , j. a. søreide , , k. tjosevik , k. material and methods: retrospective evaluation of data recorded prospectively in the hospital's trauma registry between january and december . patients with abbreviated injury scale (ais) code for abdominal injury were included. descriptive analyzes are presented for demographic data, injury type, mechanism, and severity, as well as -days mortality. results: a total of patients with abdominal injuries were included ( . % of all trauma patients). % where men. median age was . the injury mechanism was blunt in %. transport accidents were the most frequent cause of injury ( %). median iss was , and median niss . overall -days mortality was . %, with a median trauma injury severity score (triss) of , . multiple abdominal injuries were recorded in % of the patients. % had associated injuries in other body regions, most frequently in the thoracic region ( . %). solid organ injury occurred in % of the patients, with liver injury ( %), splenic injury ( %), and kidney injury ( %) encountered most frequently. an ais score c was found in % of liver injuries, % of splenic injuries, and in % of patients with kidney injuries. hollow viscus injuries were found in % of the patients. injuries to the small intestine ( %) and colon ( %) were most frequent. abdominal vessel injuries were encountered in %, and % of these had an ais score c . conclusions: abdominal injuries are dominated by solid organ injuries following blunt injury mechanism and are often associated with concomitant thoracic injury. patients who dies within days from admission are characterized by a low probability of survival shown by triss. pancreatic trauma management in a third level centre a. gonzález-costa , r. gracia-roman , s. montmany-vioque , a. campos-serra , r. lobato-gil , c. zerpa-martin , f. j. garcía-borobia , p. rebasa-cladera , s. navarro-soto management. the aim of the study is to review the management and describe the most frequent complications of pancreatic trauma in our centre. material and methods: observational study with prospective collection of data, from march to march . inclusion criteria: trauma patients older than admitted to the emergency department who were admitted to icu or died before admission. demographic data has been collected, also vital signs, iss, mechanism of action, mortality, complications, and lesions. results: between and , polytraumatic patients were registered. only had pancreatic trauma ( . %). the male: female ratio was : ; with an average age of . years (sd . ) . mean iss of . (sd . ), mean ais of . (sd . ) and mortality of . % ( patients). the most frequent pancreatic lesion was at the head of the pancreas ( patients; . %), followed by body-tail ( patients; . %) and two patients with full section ( . %). . % of patients were treated with non-operative management. five patients required urgent surgery ( %), requiring corporocaudal pancreatectomy in cases and drainage in patients. an embolization of a gastroduodenal artery aneurysm was performed in patient. respiratory complications were the most frequent. patients developed a pancreatic fistula ( . %), although in surgical patients this complication was much higher ( % in our series). one of them required puestow pancreaticojejunostomy and patient developed necrotizing pancreatitis ( . %). conclusions: pancreatic trauma is very uncommon. its management can be difficult, depending on the degree of injury (aast), with a high rate of complications. therefore, combined management and monitoring by the surgery and intensive care team will be very important. introduction: the aim of this retrospective study was to evaluate and compare the clinical outcomes of conservative versus surgical treatment in a series of patients with liver injury. material and methods: between - , there were included patients. according the treatment chosen, the patients were subdivided in two groups. non-operative management was considered in hemodynamically stable patients. the failure of conservative treatment was defined as need to resort to operative management after a period of strict monitoring when the reason was related to the liver or associated injuries or need for late angioembolization. all hemodynamically unstable patients were subjected surgical treatment. results: conservative treatment was selected for patients and only in of them was failed due to associated delayed bleeding and small bowel injury. patients underwent emergent surgery which included packing, lobectomy and splenectomy. operative findings revealed grade iii liver injuries in % and grade iv in %. pneumonia, sepsis and ards were the most frequently associated complications. the overall mortality rate was . %. in patients of conservative group, non-surgical treatment failed with surgery being required. the mortality in the group of patients who underwent emergent laparotomy on admission was of patients. conclusions: conservative treatment of blunt traumatic hepatic injuries is applicable in patients presenting hemodynamic stability with mild hepatic injuries and it could be successful even in high graded injuries with low morbidity and mortality. surgical treatment is indicated in grade v injuries. nevertheless, failure of conservative treatment does not necessarily lead to an increase in the incidence of complications or mortality. with the trend towards more conservative management strategies, surgeons' exposure to laparotomies for blunt injuries in rtas has decreased. the aim of this study was to examine surgeons' exposure to laparotomies following blunt trauma which remains important to maintain low patient morbidity and mortality rates. material and methods: data was collected for adult patients admitted to mater dei hospital (malta) following rtas with ctproven intrabdominal injuries between january and january . results: patients ( ( . %) males vs. ( . %) female (p value \ . ), mean age = . years) were included in the study. patients ( . %) were car occupants whilst patients ( . %) were pedestrians. ( . %) patients had single intraabdominal organ injury, whilst ( . %) had multiple intraabdominal organ injuries. the -day mortality rate was . % ( patients). liver injuries occurred in ( . %) patients, splenic injuries occurred in ( . %) patients, kidney injuries in ( . %) patients and other organs were injured in ( . %) patients. conservative management was followed in ( . %) patients, angioembolisation was utilised in ( . %) patients and operative management was performed in ( . %) patients during the -year period. this resulted in trauma laparotomies following rtas per year. conclusions: only a minority of patients require operative management after rtas. surgeons in small countries have limited exposure to complex rta's. in view of the low exposure to emergency laparotomies following rtas, changes to our local training programme was done. trauma courses, lectures and fellowships in eu have been implemented to maintain surgical skills to an optimal level. references: european commission, annual accident report. european commission, directorate general for transport june . case history: a year old female presented to the accident and emergency department h post colonoscopy with complaints of left sided abdominal pain. this colonoscopy was requested under a -week wait for a history of chronic diarrhoea. this was a complete and uneventful examination ath the time, with random colonic and ileal biopsies taken. she attended a ? e with left sided abdominal pain increasing in severity. clinical findings: she was found to have an exquisitely tender abdomen, experienced more in the left upper quadrant. she was clinically shocked with a marked hypotension and tachycardia. investigation/results: a ct of her abdomen and pelvis showed free fluid within the abdomen and pelvis, with active bleeding and large haematoma adjacent to the spleen. the grade of splenic injury however was not commented upon by the reporting radiologist. interventional radiological embolism was considered but unfeasible as patient not stable haemodynamically. diagnosis: she was diagnosed with a splenic injury post-colonoscopy, with internal bleeding and haemodynamic instability. therapy and progressions: she underwent an emergency splenectomy overnight and was transferred to the intensive care unit for postoperative care. she recovered well, was stepped down to ward level care and was discharged with post splenectomy protocols, including all necessary vaccinations. comments: splenic rupture post-colonoscopy is a very rare event, with less than cases reported worldwide since . however, it still should be considered as a cause of a ? e presentation in patients with upper abdominal pain and haemodynamic instability after recent colonoscopy. we wanted to present this rare case to the international audience of estes congress to raise awareness of this rare complication. clinical findings: hemorrhagic shock and consciousness disorder were observed. her abdomen was distended, and she was intubated in the emergency room. investigation/results: ct revealed massive intra-abdominal bleeding. diagnosis: massive intra-abdominal bleeding due to hepatic laceration. therapy and progression: damage control surgery (dcs) and transcatheter arterial embolization (tae) were performed. she was transported to a hybrid operating room. she experienced cardiac arrest before operation. cardiopulmonary resuscitation was immediately initiated, resulting in the return of spontaneous circulation. laparotomy with perihepatic packing (php) was performed, but she experienced two more episodes of cardiac arrest during operation. then, tae was performed for right hepatic artery extravasation. after physiological function restoration, including rewarming, coagulopathy correction and hemodynamic stabilization in the intensive care unit. she gradually became hemodynamically stable. however, incomplete hemostasis was obtained at second-look laparotomy h later. because of bleeding, we repeated php. we performed cholecystectomy and abdominal closure after confirming complete hemostasis ( h post-accident). she was discharged ambulatory without neurological deficit (day ). comments: prognosis of traumatic cardiac arrest is generally poor, and survival without considerable neurological deficit is very rare. we reported a surviving patient with severe hepatic laceration. sharing of strategies and tactics, such as blood transfusion, tae, trauma team approach to surgery, early decision of dcs improves outcome of patients with severe abdominal trauma. references: resuscitation. ; : - . introduction: the spleen is the most commonly injured organ after blunt trauma. non operative treatment (nom) of splenic injuries has gained wide acceptance. transcatheter embolization of the splenic artery is considered a useful adjunct in aast lesions c without active bleeding. we report a retrospective review of all patients admitted to a level trauma center with blunt splenic injury from to and compare their treatment and outcome with a previous series from to , when angioembolization was performed only in case of contrast blush at ct scan. patients and results: from to june , patients with blunt splenic injuries were admitted to the ed of a level university hospital in milan, italy. men to female ratio was : ,the mean age . ± years (range - ), and the iss ± . (range - ). eight patients ( . %) underwent emergent splenectomy due to hemodynamic instability. of the stable patients treated with nom, those with aast lesions c (n = ) were submitted also to angiography and to embolization of the spleen ( %), either proximally ( ) or distally ( ). two nom failed, and the patients were submitted to splenectomy or distal embolization. the median hospital stay was . ± . days. the total spleen salvage rate was %. no associated abdominal injuries were missed in the nom group. in the previous series of patients (mean age . ± . years, range - , #:$ = : , iss ± , range - ), underwent emergency splenectomy ( %), and ( %) were treated conservatively, with only embolization ( , %) in case of aast c at ct scan. failure of nom were , and the spleen salvage rate . %. liver injury following multiple cardiopulmonary resuscitations case history: this is a case of a year old woman who presented to the emergency department (ed) due to worsening dyspnea complicated by two lengthy cardiac arrests. after the first resuscitation and return to spontaneous circulation (rosc), echocardiography was done and showed severely dilated right ventricle with strain, suggestive of massive pulmonary embolism, for which rtpa was given. arrest occurred again, and post rosc, heparin was started and the patient was transferred to the icu. extracorporeal membrane oxygenation (ecmo) was initiated but complicated by severe hemodynamic instability and a third cardiac arrest, so cardiopulmonary resuscitation (cpr) was performed till rosc and massive transfusion protocol was started for suspected intraperitoneal bleeding. clinical findings: after ecmo cannulation, abdominal distention was noted with a severe drop in hemoglobin and an increased intraabdominal pressure ( mmhg). abdominal bedside ultrasound showed significant amount of dense free fluid. the decision for an urgent exploratory laparotomy was made and the patient was taken to the operating room. therapy and progressions: deep liver laceration over the right hepatic dome with rupture of the capsule and an estimated hemoperitoneum of l were found intra-op. controlling the bleeding was difficult due to the laceration site and the patients coagulopathic status, so packing was done and the patient was transferred to icu for correction of the coagulopathy and re-evaluation in h. the liver was unpacked after h, bleeding sites were cauterized and sutured and the liver was wrapped with a mesh with an attempt for a tamponade effect. the patient's stay in icu was complicated with kidney injury requiring chronic dialysis but otherwise recovered well. comments: liver injury is a rare but serious complication after cpr that should be considered in case of persistent hemodynamic instability along with bedside findings. this case is intriguing due to the right sided liver injury with no overlying rib fractures. blunt renal trauma after electrical injury: a series of curious events. a. nixon , e. falidas , d. davris , a. botou , g. sofos chalkida general hospital, department of surgery, chalkida, greece case history: a yr old patient was referred to the emergency department (ed) of our hospital from a primary health center after sustaining an electrical injury ( v ac). the patient experienced loss of consciousness (loc) and promptly fell to the ground in a supine position. the patient arrived approximately h after the incident. clinical findings: vital signs: bp: / mmhg, hr: bpm. the patient's major complaint was left flank and abdominal pain. no obvious thermal injuries were observed or any other signs of external trauma. a left abdominal mass developed which was evident on physical examination. in addition, examination of urine revealed gross hematuria. investigation/results: ekg monitoring documented sinus tachycardia without evidence of cardiac arrhythmias. fast indicated the presence of a massive retroperitoneal hematoma. the fast exam indicated the left kidney as the probable source of hemorrhage. the initial hematocrit (hct) from the primary health facility was % while results from the ed recorded a hct of %. diagnosis: grade v renal trauma. therapy and progressions: a massive transfusion protocol was initiated. the patient underwent an emergency laparotomy and a left nephrectomy was performed. subsequent imaging did not reveal other injures. comments: the history of electrical injury could have misdirected investigation efforts towards cardiogenic shock. this case suggests that even in the absence of a high energy impact, sustained hemodynamic instability should always be attributed to hemorrhagic shock until disproven. in addition, the management of grade v renal trauma in blunt injury remains a controversial topic, however we believe that in cases of class iv shock, surgical management is imperative. case history: y.o. female with a history of chagas' disease of years duration and esophageal involvement in the last few months. she's admitted for a first endoscopic balloon dilatation due to dysphagia, which is performed according to protocol, and a tear of the mucosa layer is observed during it. clinical findings: she's stable for the first h but with continuous thoracic pain of moderate intensity according to the gi specialist. on the second day there's a general worsening of the patient's condition, with dyspnea, fever, desaturation and tachycardia. results and diagnosis: she develops leukopenia and elevations of acute phase reactants, and a ct scan reports a distal esophageal perforation with free extravasation of contrast in the mediastinum and bilateral pleural effusions. therapy and progressions: emergency surgery is performed through a midline supraumbilical laparotomy which shows peritonitis around the epigastric area. after opening the hiatus, a very long transmural esophageal tear with devitalized tissues and severe contamination are observed. a trans-hiatal esophagectomy was decided and, given the hemodynamic stability, a gastroplasty is performed and brought up to the neck without anastomosis, along with a terminal cervical esophagostomy and feeding jejunostomy. the patient did well in the postop period. we were able to do the esophagogastric anastomosis in the neck days later, during the same admission. comments: the surgical technique in esophageal perforation depends mainly on the time elapsed since the perforation, and on the condition of the patient. esophagectomy is sometimes unavoidable, and a gastroplasty can be brought up to the neck at the same time in selected cases, with reconstruction of the upper gi tract during the same admission. introduction: the spleen is one of the most frequently injured abdominal organ. the anatomy of the lesion defines the degree according to aast, ranging from grade i to v in increasing complexity. the diagnosis of splenic trauma may be difficult, as % of patients may show no signs or symptoms at primary survey. the approach involves two main strategies: conservative or surgical. the strategy should take into account four aspects: hemodynamic status, anatomy of the lesion, associated injuries and organizational structures of the evaluation site. this study aims to evaluate the type of approach performed on different degrees of splenic trauma during years in a portuguese trauma center. material and methods: we conducted a retrospective study including all patients diagnosed with splenic trauma during a period of seven years. by consulting the patient's clinical files we evaluated and compared: demographic data, trauma kinetics, degree of splenic injury and the approach taken as well as morbidity and mortality. results: of the patients studied, most were male with blunt trauma. in patients the inicial approach was surgery and in the option was conservative treatment. in grade iii or iv lesions conservative treatment failed in % of patients. patients in whom the surgical approach was first chosen had predominantly grade iv lesions, with total splenectomy being the preferred approach. in grade iii lesions, the option was mainly conservative surgery of the spleen. conclusions: the initial approach of splenic trauma results essentially of the experience of emergency teams and support structures for surveillance and intervention (intervention radiology and -h operating room availability). the attempt to try conservative strategy is increasing over time. introduction: for decades, helicopter emergency medical services (hems) contribute greatly to prehospital trauma patient's care by performing advanced medical interventions on scene. unnecessary dispatches, resulting in cancellations, cause these vital resources to be temporarily unavailable. these cancellations contribute to overtriage and provide additional costs to society. an earlier study showed a cancellation rate of % in our trauma region. however, little empirical knowledge exists about reasons for cancellations for different mechanisms of injury (moi) and type of dispatch. this study aims to examine the current cancellation rate in our trauma region over a -year period. additionally, insights in cancellation reasons for different moi and type of dispatch are evaluated. methods: a retrospective study was performed, using data derived from the hems database of trauma region north west netherlands, between april st and april st . information regarding patient's characteristics, date and time of day, moi, type of dispatch, and cancellation reason were compared. results: in total, , patients were included. hems was cancelled in . % of dispatches. the majority of dispatches ( . %) were cancelled because the patient was physiologic-and neurologically stable. dispatches simultaneously activated with ems were cancelled . % of times, compared to . % when hems assistance was additionally requested by ems on scene. no differences were found between dayand night-time dispatches. trauma related dispatches were cancelled more frequently compared to non-trauma related dispatches. conclusions: this study found a considerable-and increased cancellation rate compared to previous research. an explanation for this finding could be better adherence to dispatch protocols. furthermore, a great variety in cancellation rates was found among different moi's. therefore, continuous critical evaluation of hems triage is important and dispatch criteria should be adjusted if necessary. case history: two separate cases of high speed road traffic collision. the first is years old female without significant past medical history. the second is years old male who had short extremitis due to history of spastic quadriplegic cerebral palsy alongside congenital kyphosis and postural scoliosis. clinical findings: on examination the first patient was hemodynamically stable with soft abdomen and bruising over the left pelvic area. the second patient had left side neck and right side chest bruises; furthermore, he was tachycardic with normal blood pressure, but he was generally pale, getting clammy and significantly sweaty. investigation/results: fast scan for both patients showed free fluid in the abdomen and ct scan was uncertain of the source in the first patient. in the second, a large mesenteric haematoma was evident on ct with contrast extravasation with corresponding significant drop in hemoglobin and raised lactate levels. diagnosis: case : hemodynamically stable blunt abdominal trauma. case : hemodynamically unstable blunt abdominal trauma. therapy and progressions: the first patient was managed conservatively initially but worsened overnight with a drop in haemoglobin and increase in lactate mandating emergency laparotomy. hemoperitoneum and cm of ischaemic bowel with tear in the mesentery was found. she had an uneventful recovery after resection and primary anastomosis. the second patient underwent immediate emergency laparotomy. there was evidence of hemoperitoneum ( l) and similar mesenteric tear with ischemia involving cm of the terminal ileum. resection with end to end anastomosis was done. patient was then transferred to itu; however, he developed chest infection which prolonged hospital stay. comments: hemodynamic instability is a major factor in mandating urgent exploratory laparotomy in bat and bucket-handle injury is not uncommon following road traffic accidents. introduction: incisional hernias are one of the most common complications post-abdominal surgery, affecting between - % of patients undergoing a laparotomy. a number of risk factors are associated with their development such as age, bmi, type of surgery and co-morbidities. these risk factors also affect their levels of recurrence which is why the technique undertaken to repair these is of such interest. the primary purpose of this meta-analysis was to examine which repair technique is associated with the lowest level of recurrence whilst a secondary aim was to examine whether the frequency of common complications was dependent on the type of repair utilised. material and methods: this systematic review and meta-analysis was conducted by both co-authors. the following information sources were utilised; cochrane/embase/google scholar/pubmed/scopus. in relation to the eligibility criteria-papers that were published from onwards and in the english language were included with any length of follow-up. study selection was as per the inclusion/exclusion criteria below and only cohort studies/rcts/systematic reviews/ meta-analyses and case control studies were included. inclusion criteria: abdominal incisional hernias, all types of repairmesh/open/laparoscopic/sutured repair/primary repair etc. in terms of the exclusion criteria-any hernia repair that was not incisional was excluded. results and conclusions: in terms of the primary question posed by this repair, meta-analysis shows that there is a significant difference between open vs laparoscopic technique and recurrence rates in relation to the primary question posed by this paper whilst the use of mesh impacts negatively on post-operative wound infection rates. this invites an interesting debate on the merits of each technique whilst demonstrating the need for a multicentre randomised controlled trial. laparoscopic approach in penetrating abdominal trauma: case study and review of the literature b. vieira , v. taranu , a. silva , d. galvão , a. soares hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal introduction: laparoscopy(ls) has greatly improved surgical outcomes in many elective abdominal procedures. the use of ls in acute care is becoming widely accepted. however, a number of safety issues have limited its application in abdominal trauma. notwithstanding with the reports and studies of the past decade proving its safety and accuracy, ls is slowly replacing the need for exploratory laparotomies. case report: a yo male sustained with penetrating stab wound on the left flank. he was hemodynamically stable. ct confirmed intraperitoneal positioning of the knife, without free fluid or air nor any evidence of organ injury. an exploratory ls was performed and confirmed the intraperitoneal positioning of the knife. abdominal exploration revealed a jejunal transfixating lesion about m from treiz's angle that was manually closed. the patient maintained a favorable po evolution and was discharged on the thpo day. discussion/conclusion: a number of concerns have limited the use of ls in abdominal penetrating trauma. initially, it resulted in high rates of missed injury, mainly of the small bowel, generating considerable criticism. the development of systematic abdominal explorations in ls, as described by choi and kawahara, resulted in a rate of missed injuries close to zero. moreover, direct visualization using ls has shown superior specificity and sensitivity in identifying peritoneal penetration, hollow viscus injuries and diaphragmatic lesions when compared to ct. in the case reported here, ct didn't show any image suspected of perfuration such as free air or fluid, and yet ls showed a small bowell injury. besides its advantages as a diagnostic tool avoiding negative laparotomies in more than % of the cases, thanks to evolving techniques and improved practice, it may also be therapeutic and allow safe definitive treatment for many types of injuries as described here. method: this is a monocentric retrospective study from a database entered prospectively. all patients admitted to the university hospital in nice with splenic trauma between / / and / / were included. the primary endpoint was performing splenectomy as a failure of a nom. results: patients were included in our study. the majority of splenic lesions were severe grades, that is to say greater than . in total, splenectomies were performed urgently, i.e. % of patients; angio-embolizations were performed, i.e. % of patients with a success rate greater than %; . % of patients who had not anterior angio-embolization required secondary splenectomy; . % of the patients who had anterior angio-embolization required secondary splenectomy. in the patient group with successful angio-embolization, the mean age was years vs . years in the nom failure group (p = . ). a decrease in hemoglobin between admission and h after admission was found in the nom failure group compared with the successful embolization group (p = . ). conclusion: hemoglobin monitoring in the hours following admission of a patient with splenic trauma may be an important factor in the surveillance of hemodynamically stable patients. prospective studies could confirm these results. missed ureteric injuries in gunshot injuries of the abdomen: how to avoid? introduction: traumatic ureteral injuries are uncommon. penetrating rather than blunt trauma is the most common cause of ureteral injuries. the aim of this study is to make a strategy to avoid missing ureteric injuries in gunshot injuries of the abdomen. material and methods: patients were operated in our hospital in years period. all patients were managed according to atls guidelines. for stable patients, full radiological work up was done, while hemodynamically unstable patients were shifted to or immediately for laparotomy and exploration. all patients demographic and clinical data were recorded these include :patient age, sex, mechanism of injury, hemodynamic state on arrival to the rr, anatomical site of gunshot injury, associated injuries, ureteric injuries detected early or late, early repair, delayed presentation and morbidly associated with delayed discovery. results: ureteric injuries were found in patients out of patients who underwent laparotomy for gunshot injuries had ureteric injury in an incidence of . %. ureteric injuries were missed in the first laparotomy in patients. associated injuries of other abdominal viscera include; colon injuries affecting ascending and descending colon in all the patients. conclusions: ct and pyelogram are the modalities of choice in stable patient but in unstable patients the early recognition of ureteric injuries depends on high index of suspicion leading to surgical exploration of the ureter along its course. case history: we present a case of a year old man, who was injured by his agricultural machine in the abdomen. clinical findings: he was transferred in the emergency department and he was hemodynamically stable. he had several traumas in his abdominal wall. from the largest one, in the left iliac fossa, omentum, transverse colon and loops of the small intestine were protruded out of the abdominal wall. the small bowel was ischemic and ruptured. investigation/results: computed tomography investigation, revealed small amounts of liquid and air in the abdominal cavity. diagnosis: the patient was immediately operated. the destroyed loop of the small bowel was resected with the use of a stapler and the field was washout. then with a midline incision the abdomen was opened. there were no other injuries inside the abdomen cavity. there was an extensive injury with a creation of a large gap in the anterolateral abdominal wall. it was impossible to identify the left rectus abdominis muscle as also the lateral muscles (external and internal oblique and transversus abdominis). therapy and progressions: a side to side entero-enteric anastomosis was created and a meticulous observation and washout of the abdomen were performed. for the closure of the abdominal wall a double-sided mesh from polypropylene coated with silicone on one side ( cm) was placed and the operation was completed. all the other wounds of the abdominal wall were closed with loop nylon stitches no . a closed suction drain was placed above the mesh. the patient had a very good postoperative course. he was dismissed from the hospital after days in a very good condition. comments: the usage of mesh was very useful for the reconstruction of the abdominal wall. there is no conflict of interest. strategy shift from damage control surgery to primary radical surgery improve the outcome of blunt hepatic injury involving inferior vena cava introduction: the diagnosis of abdominal trauma is a real challenge even for surgeons experienced in trauma. clinical findings are usually unreliable, and abdominal examination is made up of various factors. diagnostic tools that help the attending physician make critical decisions, such as the need for laparotomy or conservative treatment, are mandatory if we propose a favorable outcome. material and methods: the study was performed in the clinic i surgery, the county clinical emergency hospital craiova, between - and analyzed a number of abdominal traumas hospitalized, investigated and treated in the clinic. the methods of paraclinical diagnosis are evaluated comparatively, the study analyzing the evolution and the tendencies during the studied period, from , to . results: the study allowed an evaluation of the diagnosis and treatment methods compared to the data in the literature. conclusions: thus ct scan remains the standard criterion for detecting solid organic lesions. in addition, a ct scan of the abdomen may reveal other associated lesions. fast ultrasound is an important and valuable alternative for diagnosing abdominal trauma, especially for patients who are hemodynamically unstable and cannot be mobilized. there is a tendency in the treatment of abdominal trauma, as evidenced by the literature data on the use of conservative versus surgical treatment for a larger number of cases introduction: antiplatelet agents and anticoagulant drugs are widely used in prevention of cardiovascular incidents, which poses a challenge in surgical emergencies. the drafting of a multidisciplinary protocol for the treatment of pharmacological induced coagulopathy in patients who require urgent surgery standardizes management and increases patients' perioperative safety. material and methods: aims of the study were to describe the results from the protocol implementation. a retrospective study was conducted by examining reports of every patient presenting pharmacological induced coagulopathy and undergoing emergent surgery, recorded in our center from to inclusive. different algorithms used were explained and data such as need of transfusion, reintervention rate and perioperative complications were analyzed. results: data from patients were analyzed, median age of , ( %) men. patients ( %) used anticoagulant drugs. fresh frozen plasma transfusion and/or prothrombin complex concentrates were used according to the guideline. ( %) patients used antiplatelet agents. % of them underwent a delayed h surgery directly. tirofiban therapy was established in patients on dual therapy due to medium-high risk of cardiovascular event. regarding surgical approach, ( %) were laparoscopic, ( %) open and conversion occurred in ( %) cases, but only of them due to intraoperative hemorrhagic complication. only cases of postoperative hemorrhagic complications led up to reintervention and only one isolated case of thrombotic complication was reported. finally, ( %) mortality cases were reported, but none was caused by hemorrhagic nor thrombotic complications. conclusions: establishment of a guideline on management of pharmacological induced coagulopathy in emergent surgery is crucial in all surgical emergency units and has proven to be effective and safe. introduction: digestive haemorrhage is a frequent pathology. most of the episodes are self-limited, but in some cases massive haemorrhage occurs, leading to a % mortality rate. severe problems occurs when endoscopic treatment is not effective, requiring emergent surgery with poor prognosis. the aim of this study is to evaluate the implementation of interventional radiology techniques on short-term results. methods: a retrospective descriptive study was performed reviewing patients who underwent radiological embolization after failure of endoscopic conventional treatment between - in our hospital. a total of patients were included. results: patients were male. cases were from lower gi track and were from the upper gi with a similar death rate between them, with a higher rebleeding rate in upper gi ( . % vs . %). % of the arteriographies did not show any bleeding site, of them developed a new bleeding episode. overall patients who undergo embolization, urgent surgery was avoided in of the patients diagnosed as upper gi haemorrhage and in of the patients diagnosed as lower gi haemorrhage. patients died, those death occurred later on the recovery of the acute bleeding episode and embolization, all of them related to patients comorbidities. conclusions: arterial embolization has become an important tool in order to treat massive haemorrhages of the gastrointestinal tract. it seems to decrease the mortality and morbidity rate, but some complications can be associated such as rebleeding or bowel ischaemia. massive transfusion protocol with early administration of platelet and fresh-frozen plasma along with packed red cells in the initial phase of resuscitation is associated with improved outcomes introduction: massive transfusion (mt) in a ratio of : : (prbc:platelet:ffp) is the standard of care in hemorrhaging trauma patients. the aim of our study was to compare the outcomes of patients who receive near balanced resuscitation (nbr) compared to unbalanced resuscitation (ubr) during the initial phase of resuscitation. material and methods: we performed a -year analysis of the acs-tqip. all adult patients (age [ ) who received mt (defined as transfusion of prbc c units in -h) were included. patients were stratified into two groups: nbr defined as prbc:platelets:ffp in : [ . : [ . and ubr ( : \ . : \ . ) in the first h of resuscitation. primary outcome measure was mortality. secondary outcome measures were complications, and hospital length of stay. propensity matching was performed to match the two groups. results: a total of , patients received mt. mean age was ± years, median iss was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . overall h mortality was . %. only % patients received nbr while % received ubr in the first -h. using propensity score matching, patients were matched for demographics, ed vitals, iss, ais and injury parameters. patients who received nbr in the early resuscitation phase had lower mortality ( % vs. %, p = . ), lower overall complications ( % vs. %, p = . ), with no difference in hospital length of stay ( days vs. days, p = . ) compared to the ubr group. conclusions: only one-third of patient receiving massive transfusion receive prbc, ffp and platelet in a ratio closer to : : in the initial -h and they have lower mortality and complications compared to patients with unbalanced resuscitation. material and methods: the goal is to assess mtp strategies in level- trauma centres in the netherlands and compare these with each other and (inter) national guidelines. a trauma surgeon or anaesthesiologist involved in compiling the mtp in each level- trauma centre in the netherlands and dutch ministry of defence was approached to share their mtp and comment on their protocol in a survey or oral follow-up interview. results: all eleven level- trauma centres responded. content of the packages and transfusion ratio (red blood cells/plasma/platelets) was : : , : : , : : , : : , : : , : : , : : and : : . tranexamic acid was used in all centres and an additional dose was administered in eight centres. fibrinogen was given directly (n = ), with persistent bleeding (n = ), based on clauss fibrinogen (n = ) or rotem Ò (n = ). standard coagulation monitoring are used in all centres, but most hospitals use also rotational thromboelastometry (rotem Ò ) (n = ), thromboelastography (teg Ò ) (n = ) or both (n = ). all centres used additional medication for patients using anticoagulants, but its use was ambiguous. conclusions: mtps in dutch level trauma centres differs from (inter) national guidelines in transfusion ratio and additional medication, which could be explained by misinterpretation of the : : ratio, changes in components and following an outdated dutch national guideline. whether these differences in mtps actually leads to different patient outcomes will follow from data that is currently being collected. this study is sponsored by the dutch ministry of defence. anastomotic bleeding after colorectal surgery: incidence, management and complications introduction: postoperative anastomotic bleeding (pab) is a frequent minor complication ( - %) that usually resolves by a conservative approach. hemodynamic instability and anemization may develop requiring urgent management. the aim of our study is to describe pab and its treatment. material and methods: observational retrospective cohort study of patients with pab collected between july and september . pab was defined as an episode of lower gi bleeding after colorectal surgery with at least one anastomosis. characteristics of patients, surgery, length of hospital stay, morbidity and mortality, and management of pab were reviewed. results: a total of ( . %) patients with pab was collected. median age was of years (iqr - ), with a median estimated asa grade of . the most common procedure was a right hemicolectomy ( %), followed by sigmoidectomy ( %). % of surgeries were laparoscopic. only cases were converted to an open approach. % of patients had the first episode of pab during the first h after surgery, while % after the third postoperative day. pab was treated conservatively in % of the cases. the remaining % required urgent endoscopic management identifying the bleeding through the anastomosis line, using clips in patients and hemospray in patient to control it. no complications were recorded after endoscopic treatment. just case required surgical reintervention. a total of ( %) patients required blood transfusion with a median of (iqr - . ) units. length of hospital stay was . days. no mortality related to pab was registered. conclusions: pab is a mild complication after colorectal surgery. most of the patients respond to conservative management. urgent endoscopic treatment seems to be effective and safe to control pab even during the first postoperative day. introduction: hemorrhagic shock and associated reperfusion injuries are davastating situations during the treatment of polytrauma patients. the aim of this study was to analyze and compare alterations of the local circulatory changes of various body regions during hemorrhagic shock and after fluid resuscitation. material and methods: this study was conducted on male pigs. they suffered a standardized polytrauma including femoral fracture, blunt thoracic trauma and liver laceration. further, the suffered a hemorrhagic shock for h (aimed map mmhg). fluid resuscitation with three times drawn blood volume after hemorrhagic shock. retrograde nailing for femoral fracture and chest tube in case of pneumothorax liver packing. measuring circulation at liver, colon, stomach, and extremity. results: inclusion of animals. local circulation at the extremity decreased significantly compared to baseline values during hemorrhagic shock ( . a.u. versus . a.u., p \ . ). after resuscitation the flow rate at the extremity was comparable to baseline values. the stomach was least sensitive to hemorrhagic shock, whereas the oxygen delivery rate at the colon decreased during shock phase and remained decreased during fluid resuscitation (p \ . ). conclusions: different body regions react differently to hemorrhagic shock. the colon appears to be most vulnerable to changes based on hemorrhage. the delayed improvement of circulation in liver, colon, and extremities may represent a trigger for systemic hyperinflammation and subsequent sirs and sepsis. none of the authors have any conflicts of interest to declare. massive transfusion in penetrating trauma: the search for a specific prediction system introduction: prediction systems of massive transfusion (mt) were developed from cohorts with a small proportion of penetrating trauma. some of them required laboratory tests. we aimed to evaluate abc score and to identify independent predictors of mt in a cohort of torso penetrating trauma (tpt) material and methods: adults with tpt, managed in a level-i trauma center, who received one or more packed red blood cells (prbc), were included. variables obtained during the evaluation in the trauma bay were registered prospectively. the ability to predict mt was evaluated with simple, multiple logistic regressions and roc curves. results: we included patients; . % were male, and . % received fire-arm wounds. twenty-one ( %) received mt. mt patients were intubated more frequently in the pre-hospital, had lower sbp, higher hr, lower gcs, and received more frequently vasopressors (p \ . ) when compared with the no-mt patients. trauma mechanism, number or localization of the wounds, and positive fast could not discriminate mt (p [ . ). hypotension, tachycardia, and alteration of the glasgow coma scale or its motor response behaved as independent predictors of mt. models created with these variables showed better discriminative ability than abc score, with adequate goodness to fit. conclusions: prediction models of mt, based on heart rate, systolic blood pressure, and neurologic alteration outperformed abc score in a tpt cohort. introduction: rectus sheath hematoma presents with abdominal pain and anterior abdominal wall mass. it can be followed conservatively and rarely causes mortality ( ) . in this study we aimed to review rectus sheath hematoma cases consulted to our department and to present our management. material and methods: the data of patients admitted with rectus sheath hematoma between and was collected using hospital database. treatment modalities, demographic data and complications were reviewed retrospectively. results: all the cases presented with abdominal pain and/or with a palpable abdominal mass. . % of the patients (n = ) were receiving anticoagulant therapy at the time of admission. the mean inr value was . . patients were followed up with es&ffp transfusion and conservative treatment. patients not eligible for conservative care underwent inferior epigastric artery embolization and hematomas in patients were evacuated via a percutaneous drainage catheter. patient went through laparotomy for an infected hematoma and one patient underwent laparotomy plus packing. the patient who had laparotomy plus packing died due to intraabdominal hematoma and sepsis. conclusions: rectus sheath heamatoma is a rare cause of acute abdominal pain. the patients diagnosed early and have suitable indications can be treated conservatively ( ) . rectus sheath hematoma should be considered in the differential when a patient with a history of anticoagulant drug use presents with acute abdominal pain in order to prevent unnecessary surgery and complications. introduction: an early delivery of blood products when massive transfusion protocols (mtp) are triggered is mandatory to improve trauma patients survival. scores predicting massive transfusion (mt) have already been described ( ) . the aim of our study is to compare scores for predicting mt and identify the best trigger for mtp. material and methods: multicentric retrospective study from the trauma registry of the spanish surgeons' association. severe trauma patients (injury severity score [iss] c ), admitted to different level trauma centers, from january to september were included. demographic and clinical information was recorded, and predictive scores for mt were assessed. results: patients were included. medium age was . ± . years, ( . %) were male. median iss was (iqr ). in % of the patients a mt (defined as c units of packed rbc) was necessary, while a mtp was triggered in . %. surgery was performed in . %. the overall mortality was of . %. predictive scores for mt were compared: gap (glasgow coma scale, age, systolic blood pressure), shock index (si), assessment of blood consumption (abc) and mabc (modified abc). auroc for gap was . ± . , si . ± . , abc . ± . and mabc . ± . , showing differences between gap (the worst score) and the others, p \ . . no differences were found between si, ab and mabc. best cut-off points were calculated. si c . better predicts mt with a sensitivity %, specificity . %, positive and negative predictive values . % and %. conclusions: si, abc and mabc are all good scores for predicting mt in our population. appealing by its simplicity, we recommend si as the best trigger for mtp. protocols should be standardized to improve the accuracy of mtp activation for trauma patients. introduction: the prevalence of knife-related offences is rising in the uk. successful management of trauma patients requires the co-ordinated response of specialist services, including transfusion. we aimed to assess the impact of knife-crime on transfusion support within a uk adult major trauma centre (mtc). material and methods: retrospective review of patients admitted to a uk mtc following knife injuries resulting from interpersonal violence during a three-year period (may -april ). source material included electronic patient records, tarn database and massive transfusion protocol (mtp) logbook. patient characteristics, resource utilisation including transfusion, mtp activation and outcome were collated. results: patients were identified, ( %) were male. median age was years. ( %) were under the age of . patients ( %) presented with circulatory compromise (sbp \ ). patients ( %) had attended our hospital previously for violencerelated trauma. % arrived at hospital between h to h. ( %) required one or more surgical procedures. median length of stay was days. patients ( %) received blood transfusion. median units transfused were prbc, ffp, platelets (atd). mean component use was pbrc (range - ), . ffp ( - ), platelets . ( - ), cryoprecipitate . ( - ). annual mtp activations increased from to during the study period (total ). stabbings accounted for . % of these ( patients), of which ( %) were transfused. conclusions: knife crime presents a burden to blood transfusion, accounting for a quarter of mtp activations. patients typically present out of hours with implications for service planning and delivery. patient profile together with repeat healthcare attendance and surgery requiring transfusion has implications for red cell allo-immunisation. we recommend timely baseline blood grouping and triage to optimise the safe use of rhd positive cellular components. introduction: spontaneous intramural small bowel hematoma is a very rare complication of anticoagulant therapy. nowadays, the prevalence is increasing due to the widespread use of computerized tomography and the increasing number of patients receiving anticoagulant therapy. material and methods: patients admitted to our center between january and june and treated with the diagnosis of intramural hematoma were retrospectively evaluated. results: the median age of the patients was years ( - ) and ( %) were male. at the time of appeal, warfarin intoxication was present in cases ( %) and the median inr was . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . one patient had known factor deficiency. diagnosis was made by computerized tomography in all cases. one intramural hematoma was localized in the duodenum ( . %), nine in the jejunum ( %), and five in the ileum ( . %) six patients ( %) had ileus findings. all patients underwent fresh frozen plasma replacement due to high inr levels and bleeding. median tdp transfusion was units ( - ). only patients ( %) required erythrocyte suspension replacement. all cases were followed up conservatively and there was no need for intensive care. the median hospital stay was ( - ) days. conclusions: due to the limited number of studies in the literature with a large number of cases, retrospective evaluation of singlecenter cases may be helpful. spontaneous intramural small bowel hematoma should be considered in the elderly population under warfarin therapy who present with abdominal pain, especially if inr values are above therapeutic limits spontaneous regression is seen in the majority of cases. non operative management and correction of coagulopathy with fresh frozen plasma replacement is the preferred approach. references: abbas ma, et al. spontaneous intramural small-bowel hematoma: clinical presentation and long-term outcome. arch surg. ; ( ) : - . pre-hospital decision-making: identifying the challenges assessing and managing traumatic haemorrhage and coagulopathy m. marsden , r. bagga , k. gillies , r. lyon , s. kellett , r. davenport , n. tai expert pre-hospital clinicians in making decisions about the diagnosis and treatment of patients with major haemorrhage and suspected tic. methods: semi-structured interviews were conducted with senior pre-hospital consultants from london's air ambulance and air ambulance kent, surrey and sussex. interviews probed clinicians on how they make decisions relating to the pre-hospital assessment of major haemorrhage and tic and subsequent blood product transfusion. the interviews were analysed using descriptive thematic analysis. results: all clinicians agreed that identifying and treating major haemorrhage was vital. half of the clinicians reported making no conscious assessment for tic and six reported tic should be managed in a hospital setting. four broad themes were identified: collation of information, weighing utility of different approaches, influence of experience and evaluation of unknowns. collating information from multiple sources drove clinical decision-making. decisions on blood product transfusion were made after weighing potential benefits (e.g. improve microvascular perfusion) against harms. clinical experience was reported as key to nuance clinical assessment, detect subtle signs and identify patterns. uncertainty complicated clinical decision-making in two domains; incomplete knowledge of a patient's injury and uncertainty of best clinical practice. conclusion: the pre-hospital identification and treatment of major haemorrhage was recognised as challenging and fundamental. necessity of pre-hospital tic diagnosis and treatment divided opinion. identifying these four themes allows for a greater understanding of the factors involved in making these decisions and will guide the creation of more accurate decision support tools to aid pre-hospital clinicians. nothing to declare. introduction: massive transfusion (mt) is defined as the administration of c packed red blood cells (prbc) in h. alternative definitions have been proposed; however, there is little understanding about the discriminative ability of different mt definitions with regards to mortality and multiorgan failure (mof). we aim to assess and compare the discriminative ability of different definitions of mt concerning mortality and mof. material and methods: we included patients who arrived to the emergency department and required trauma team activation at a level i trauma center in the city of cali, colombia between - . demographics and trauma characteristics were evaluated. the following mt definitions were measured: units of blood products in h (t ), u prbc in (t - ), u prbc in h (t - ), prbc in h (t - ), the combination of t - and t (t-combi), prbc in h (t - ), prbc in h (t - ) and units of prbcs in min. the operative characteristics were calculated for each definition. mof was defined as a sofa score of c points. results: we included subjects, . % male. trauma mechanism was penetrating in . %. the median and interquartile range (iqr) of age was years iqr ( - ) and of iss ( - ). lesions were located in the torso in . % of patients, and . % had a positive abc score. a total of ( %) received at least unit of prbc. tables and presents the operative characteristics of definitions of mt with respect to mortality and mof, respectively. conclusions: although all definitions showed an association with higher odds with the outcomes of interest, none of them showed an accurate diagnostic capacity regarding mof and mortality. thus, we advise caution when relying on the classical definition of mt ([ rbc units in h) to guide the flow of care of severely injured patients. trauma and coagulation: trends in coagulation factors in the severely injured trauma patient introduction: trauma-induced coagulopathy (tic), affects about - % of the major trauma patients. in the past, tic was considered as a consequence of the coagulation factors' dilution after a highvolume colloid administration. today tic is seen as a phenomenon that can arise after trauma; the first event is the c-protein activation by the tissue damage and hypoperfusion, resulting in the subversion of the hemostatic process. material and methods: the patients of the pilot study ''trauma and coagulation'' run in irccs san raffaele scientific institute have been reviewed and analyzed using a suite of experimental coagulation factors including rotem parameters, activated protein c (apc), thrombomodulin, endothelial protein c receptor, thrombin-antithrombin complex (tat), plasminogen activator inhibitor (pai- ), seselectin, interleukin- (il- ), interleukin- (il- ), d-dimer (xdp), antithrombin iii (atiii), and prothrombin fragment f ? (f ? ). new patients have been enrolled to validate the results of the pilot study. results: there is a statistically significative correlation between clinical scores of severity of trauma and risk of massive transfusion (iss, abc and tash) and some of the experimental coagulation factors analyzed. case history: to evaluate the role of negative pressure wound-care systems applied to the pleural cavity in case of severe acute empyemas and frail patients not amenable to conventional surgery. clinical findings: we report the case of a yrs old male critically ill patient suffering from complications of cardiac surgeries who developed a severe right empyema with broncho-pleural fistula through the site of a previous pulmonary hernia. investigation/results: we review the actual indications of negative pressure therapy in thoracic surgical emergencies especially in septic patients unfit for surgery. in our case the repeated application of negative pressure with dedicated dressings through the initial thoracotomy was the chosen damage control approach because of the sepsis and poor conditions. diagnosis, therapy and progressions: air leaks were later found to originate from a subsegmentary branch of middle lobe bronchus. subsequent video-assisted debridement procedures followed by negative pressure therapy managed to ( ) control the infection, ( ) reduce the thoracotomy incision into a thoracoscopic access and ( ) heal the pleural cavity, restoring eventually better general conditions of the patient. the closure of the bronchial fistula required further procedures after the acute phase when sepsis was overcome. comments: negative pressure systems can be applied to the pleural cavity with many advantages in selected critically ill patients. they allow to contain, treat and resolve infections both of chest wall and pleural cavity in case of severe empyemas reducing also wound pain and eliminating the need of chest drains. air leaks may also be managed by negative pressure therapy with adequate indications and particular attention to its settings. references: sziklavari z. mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema. eur j cardiothorac surg. . flail chest: the renaissance of rib osteosynthesis c. leite , a. oliveira , a. lemos , b. barbosa , c. casimiro centro hospitalar tondela-viseu, general surgery, viseu, portugal case history: we present the clinical case of a male patient of years old. injury mechanism: fall from his own height over the right hemithorax. clinical findings: rib fractures with flail chest and significant displacement of bone edges. symptoms: intense thoracic pain. diagnosis: rib fractures with flail chest. therapy and progressions: multimodal analgesia. on the th day, he presented a tension pneumothorax. after adequate intercostal drainage, the pneumothorax relapsed. on the th day, he underwent a right posterolateral thoracotomy, open reduction and internal fixation of ribs with plates and screws and intercostal drainage. evolution: he received respiratory kinesiotherapy and was discharged on the th pos op day. follow-up at st and th months, without functional impairment and with preservation of quality of life. comments: rib fracture is the most common injury in the setting of thoracic trauma and is associated with a higher morbimortality. in the last years, positive pressure mechanical ventilation was the first line treatment of respiratory insufficiency caused by rib fractures. however, severe complications associated with prolonged mechanical ventilation, have elicited the rising implementation of open rib reduction and internal fixation techniques. the most consensual indications are: flail chest with fracture of at least ribs, significant displacement of bone edges or uncontrolled pain. rib osteosynthesis is a simple method but requires clinical experience in thoracic approaches and handling of specific instruments and material. its implementation in non-ventilated patients reduces the need for mechanical ventilation, pain, length of stay and allows preservation of quality of life. yokohama city university medical center, advanced critical care and emergency center, yokohama, japan, saiseikai yokohama-shi nanbu hospital, department of surgery, yokohama, japan, yokohama city university, department of general surgery, yokohama, japan, yokohama city university, department of emergency medicine, yokohama, japan introduction: although americans and europeans report emergency room thoracotomy (ert) is of value in penetrating trauma patients, most of ert is performed for blunt trauma in japan. after the establishment of the local government-directed major trauma center in the city of yokohama, the unexpected trauma survivor rate increased in the single center study. we report our experience in ert and surveyed the effect of the establishment. material and methods: patient characteristics (backgrounds, mechanism of injury, indication for ert, anatomic injuries, interventions and survival) of those who underwent emergency thoracotomy compliant with the guideline of western trauma association, between october and september were analyzed. results: fifty-eight patients ( males) underwent emergency thoracotomy. median age was . ( - ) years. fifty-seven were performed for blunt trauma ( %) and only for penetrating injuries. twenty-three patients presented with cardiac arrest on arrival, while thirty-five had deep and refractory hypotension. overall, survival rate improved from ( / ) to % ( / ) (p = . ) after the establishment of the trauma center. of patients presenting with cardiac arrest, only one survived. conclusions: the establishment of major trauma center seemed to affect the survival rate of the patient edt was performed. introduction: more than % of polytrauma events involve chest injuries. one third of these patients sustain thoracic instability due to serial rib fractures. thanks to numerous innovations in implant development several approaches currently exist for surgical rib stabilization (srs). however, no consensus exists regarding patient selection for srs to date. material and methods: retrospective single center cohort analysis in trauma patients. serial rib fracture was defined as three consecutive ribs confirmed by chest ct. cohort includes patients that were treated conservatively and patients that underwent srs by plate osteosynthesis. demographic patient data, trauma mechanism, injury pattern, injury severity score (iss), glasgow coma scale (gcs) and hospital course were analyzed. two matched pair analyses stratified for iss ( pairs) and gcs ( pairs) were performed to minimize selection bias. results: the majority of patients was male ( %) and aged ± years. serial rib fractures were located left/right/bilateral in %/ %/ % of cases. other thoracic bone injury included sternum ( %), scapula ( %) and clavicula ( %). visceral injury consisted of pneumothorax ( %), lung contusion ( %) and diaphragmatic rupture ( %). average iss was ± . . overall hospital stay was . and icu stay . days. in hospital mortality was %. srs did not improve hospital course or postoperative complications in the complete study cohort. however, patients undergoing srs had significantly reduced gcs ( . ± . vs . ± , ; p = . ). matched pair analysis stratified for gcs showed a reduced need for blood substitution and shorter icu stays ( vs days; p = . ) including shorter respirator time ( vs h; p = . ) and reduced in hospital mortality ( vs %). conclusions: patients with serial rib fractures and simultaneous severe cerebral injury benefit from surgical rib stabilization. tracheal and bilateral recurrent laryngeal nerve disruption injury secondary to accidental strangulation by dupatta case history: year old female brought to trauma emergency with a/h/o accidental strangulation injury with dhupatta at farm field while working with thresher machine after h of injury. patient had severe dyspnoea, dysphagia, paining neck clinical findings: primary survey revealed threatened airway with extensive surgical emphysema, rr- /min, spo - % on high flow oxygen mask, hemodynamically stable, and had no neurological deficits. patient was immediately intubated, however ventilation could not be maintained and surgical emphysema worsened hence immediate tracheostomy was established. investigation/results: computed tomography (ct) head and ct angiography of neck with venous phase study of neck and chest with ct esophagogram revealed complete disruption of cricotracheal junction with extensive cervical and upper thoracic surgical emphysema and no other injuries. diagnosis: disruption of trachea from cricoid cartilage with crushed trachea with loss of approximately cm, cricoid and thyroid cartilage fracture, complete avulsion of bilateral recurrent laryngeal nerves and serosal tear of esophagus. therapy and progressions: neck exploration with debridement of tracheal margins and anastomosis between trachea and cricoid cartilage with repair of cricoid, laryngeal cartilage and esophageal serosal repair was performed. comments: post-operatively patient underwent fibreoptic bronchoscopy and revealed paramedian location of vocal cords. at present patient is with tracheostomy tube in situ undergoing speech therapy and is able to generate comprehensible sounds. further laryngeal framework surgery is being planned. introduction: emergency resuscitative thoracotomy (ert) is a lifesaving procedure in selected patients and it is often considered a controversial ''last chance'' method of resuscitation. objectives of ert are to resolve pericardial tamponade, to repair heart injuries, to perform an open cardiac massage, to cross-clamp the aorta to redistribute blood flow to the myocardium and brain, to control intrathoracic bleeding and air embolism in the bronchial venous system. outcome mostly in blunt trauma is believed to be poor. material and methods: we retrospective reviewed patients c years who underwent ert at san camillo-forlanini hospital (rome, italy) between january and september with traumatic arrest for blunt or penetrating injuries. results: of ert, ( . %) were for blunt trauma, ( . %) were for penetrating trauma. . % of patients were male. the collectively reported overall survival was % (n = ). when including erts designated as done in the emergency department for blunt mechanism, only patient survived ( . %). survival after erts for penetrating trauma was % ( of ). conclusions: our experience suggests that ert is a technique that should be utilized for patients with critical penetrating injuries. the reported outcome after ert in european civilian trauma populations is favorable with an overall survival of %. multicenter, prospective, observational data are needed to validate the modern role of ert in blunt or penetrating trauma. references: narvestad jk, et al. emergency resuscitative thoracotomy performed in european civilian trauma patients with blunt or penetrating injuries: a systematic review. eur j trauma emerg surg. ; ( ) case history: an -year-old male driving a car collided with a wall at a speed of km/h and was brought to a hospital near the scene. he was diagnosed with right multiple rib fractures and hemopneumothorax, and transferred to our emergency center for definitive care. clinical findings: the patient's consciousness was clear and his heart rate, blood pressure, respiratory rate, and o saturation (room air) on arrival were /min, / mmhg, /min, and %, respectively. subcutaneous emphysema was identified on the right side of his chest and his right breathing sound decreased on auscultation. there was no tenderness and rebound on abdominal examination. investigation/results: an enhanced whole-body computed tomography scan revealed a small disruption on the right diaphragm behind the sternum and free air in the abdomen. diagnosis: the diagnosis was right traumatic diaphragmatic injury, sternum fracture, and right multiple rib fractures with pneumohemothorax. there was free air in the abdomen but without evidence of perforation of the digestive tract as there was no finding of peritonitis on physical examination. thus, pneumoperitoneum from the thorax was strongly suspected. therapy and progressions: laparoscopic observation revealed a . cm-length of disruption on the diaphragm in the right sternocostal triangle. this was covered with falciform ligament using extracorporeal knot tying method because there was little seam allowance in front of the disruption on the sternum side, and direct suture was not possible. prognosis was good following surgery, and the chest drain was removed on postoperative day and the patient was discharged on postoperative day . comments: laparoscopic repair of the diaphragm using extracorporeal knot tying method is often used for retrosternal (morgagni) hernias. however, the method was also useful in this case because the diaphragmatic injury occurred in the sternocostal triangle. rib fractures associated with pneumo-and/or hemothorax; does everyone need a chest tube? v. snartland , p. a. naess , c. gaarder , m. hestnes , p. majak , , faculty of medicine, university of oslo, oslo, norway, oslo university hospital, department of traumatology, oslo, norway, oslo university hospital, trauma registry, oslo, norway, oslo university hospital, department of cardiothoracic surgery, oslo, norway introduction: pneumo-and/or hemothorax are often seen in trauma patients with rib fractures (rfs). standard treatment for pneumothorax (ptx), hemothorax (htx) and hemopneumothorax (hptx) is tube thoracostomy (tt). however, a non-operative approach can be applied in selected patients. we wanted to assess our practice in patients with rib fractures and associated ptx, htx or hptx. material and methods: all adult patients (c years) with rf, admitted by a trauma team at oslo university hospital in were identified retrospectively and those with associated ptx, htx or hptx were then included in the study. patients who underwent tt prior to arrival and those who died were excluded. spss v was used for statistical analysis. results: of the patients with rfs, a total of patients had ptx, htx or hptx. fifty-one percent ( / ) of these patients were treated with tt and % ( / ) of the patients underwent tt within h after arrival. the presence of opacification (p \ . ), chest wall deformity (p \ . ) and pneumothorax size (p \ . ) were significantly higher on chest x-ray in the tt group compared to the nonoperative group. intubation at arrival was also significantly more common in patients treated with tt (p \ . ). there was no difference in the presence of subcutaneous emphysema between the groups. the tt group was sicker than the non-operative group (had a significantly lower systolic blood pressure, a lower gcs and a higher lactate on arrival). oxygen saturation, heart rate, respiratory rate, ph and hemoglobin did not differ significantly between the groups. conclusions: in trauma patients with rf concurrent ptx, htx or hptx should be suspected. in our study only half of these patients were treated with tt, and % of tubes were inserted within h after admission. size of the ptx, radiological presence of opacification and deformity of the chest wall should be addressed when choosing treatment strategy. introduction: emergency department thoracotomy (edt) is a potentially life-saving surgical procedure performed in the emergency department (ed) in patients presenting with cardiac arrest following penetrating thoracic trauma. however, it is not clear if all surgeons are prepared or motivated to perform this procedure. furthermore, not all institutions are equipped, either in terms of logistics or team training, to perform edt. our purpose was to perform a pilot study in a cohort of polish surgeons of various specializations, in order to ascertain who would and who would not (and why) perform edt in their departments. material and methods: study population of surgeons ( specialists, residents) from various hospitals in poland, mean age: - years, . % men, . % women. study respondents were asked to fill in a questionnaire on the indications and motivation to perform edt in their clinical practice. results: most respondents (n = , %) correctly recognized the indications to perform edt. however, only ( %) declared they would perform it. the reasons for not performing edt were: lack of team training ( . %); lack of equipment ( %); lack of motivation among ed personnel ( . %); the ed is not prepared ( . %); the respondent is not prepared ( %). only participants ( . %) declared that their institutions had the edt protocol. conclusions: this survey demonstrates that, although most surgeons agree on the indications for edt, the level of preparedness in its execution is lacking. the main reasons are the lack of team training, the lack of equipment and the lack of motivation among ed personnel. other relevant reasons were the lack of preparation of either a surgeon or a department. these results demonstrate that improvements in institutional logistics as well as in team and individual training can translate into improved care. we strongly advise the performance of a pan-european survey on edt to address other unrecognized issues. mediastinum widening: how to manage it? a. gonzález-costa , r. gracia-roman , s. montmany-vioque , m. s. santos-espi , r. lobato-gil , m. pascua-solé , a. campos-serra , a. luna-aufroy , p. rebasa-cladera , s. navarro-soto parc tauli hospital universitari, trauma and emergency general surgery department, sabadell, spain, parc tauli hospital universitari, esofagogastric general surgery department, sabadell, spain, parc tauli hospital universitari, angiology and vascular surgery, sabadell, spain case history: a -year old male was admitted to our emergency department as a polytrauma code, because of a gunshot wound in the neck. clinical findings: his airway was compromised with expansive cervical hematoma. intubation was difficult. he was hemodynamically unstable with cervical bleeding, in which manual compression was applied. results: chest x-ray showed mediastinal widening without pneumo or hemothorax. diagnosis: urgent sternotomy while maintaining manual compression on the cervical bleeding, followed by left antero-lateral cervicotomy. injuries: section of left jugular vein and left carotid artery, lesions of unnamed vein. free cervical chylous fluid. left pleura and pericardium were opened without identifying major injuries. therapy and progressions: jugular vein was repaired with continuous suture and carotid artery with patch sutured. unnamed vein was sectioned between ligatures. thoracic duct was ligated. after surgery, ct scan showed cervical and mediastinal hematomas without signs of active bleeding, and correct permeability of the vessels, with no cranial lesions. the patient was admitted to the intensive care unit. tracheostomy was performed. fibrobronchoscopy, fibrogastroscopy and esophagogastricoduodenal discarded airway and esophageal lesions. he presented the following complications: • small mediastinal collection • right diaphragmatic paralysis. • paralysis of vi left cranial nerve (mononeuritis of vascular origin). the patient was discharged on the th postoperative day. comments: in this kind of trauma is essential the airway management with intubation when necessary. it is important that mediastinal widening visualized in the chest x-ray in a traumatic patient, should be an indication of surgery. in our case, it was essential to start it with sternotomy while maintaining manual neck compression, and in a second time, perform the cervical approach since that prevented the patient from suffering a greater blood loss. background: clavicular fracture is very common in childhood. otherwise, the medial third of the clavicle is the less affected. the current report describes a new pattern of clavicular injury, in which a medial third clavicular fracture and posterior sternoclavicular joint (scj) dislocation occur together in a skeletally immature patient. clinical findings: an -year-old boy sustained a direct impact to his left shoulder resulting from the fall of a sofa. at admission, he complained of severe pain in the clavicular and shoulder associated with functional limb impotence. physical examination revealed deformity of the proximal third clavicle, with swelling and tenderness to palpation along the medial left clavicle. no signs of skin pression or neurovascular impairment were found. the anteroposterior radiograph of the left clavicle showed a fracture of the proximal third shaft and an asymmetry of the scj. computed tomography confirmed the association of a greenstick fracture of the proximal third clavicular shaft, accompanied by a mild posterior scj dislocation. therapy and progressions: the left limb was immobilized with a sling during weeks, after which physical therapy was initiated to improve range of motion using active and gentle active-assisted exercises. at the months medical consultation, he presented asymptomatic, with good bone healing, full range of motion of the shoulder and absence of relevant aesthetic deformity. comments: in the immature skeleton, scj dislocation and epiphyseal fracture of the proximal clavicle are very rare entities due to the multiple strong ligaments that stabilize the scj. trauma in the proximal third of the clavicle typically results in fractures in the region of the physis and only more rarely culminate in dislocations of the scj. these injuries warrant a high index of suspicion, and early ct scanning is recommended. although treatment may be conservative, in situations of major displacement, surgery should be considered. use of rib fracture scoring systems in a uk major trauma unit: a retrospective audit and lessons learnt introduction: rib fractures are detected in % of trauma patients [ ] . significant morbidity and admission to intensive care units (itu) is common [ ] . rib fracture scores do not have strong validity as a predictor, but are a useful screening tool to identify patients at higher risk, of morbidity. the aim of this study was to audit the use of rib fixation scores in a single major trauma centre. material and methods: a retrospective audit of trauma patients with rib fractures presenting to a single major trauma centre over a -year period subsequently admitted to itu was performed. demographics, length of itu stay, rib fracture score (rfs) and ribscore were recorded and comparisons made between patients who had surgical rib fixation and those who did not. results: patients with traumatic rib fractures were admitted to itu over -year, of whom had rib fixation. mean age of patients undergoing surgery was compared to in the non-surgical cohort. average rfs was higher in the surgical cohort ( vs ; p = \ . ), as was average ribscore ( vs ; p = \ . ). incidence of flail segment was higher in surgical cohort ( % vs %; p = \ . ), as was number of rib fractures ( vs ; p = \ . ) and incidence of st rib fracture ( % vs %, p = \ . ). rib fractures treated surgically had a longer itu stay ( . days vs . ; p = \ . ). conclusions: surgical rib fixation patients were older and had longer itu stay. higher rib fracture scores correlated with need for surgical intervention. this highlights the need for careful patient selection for rib fixation, as they appear to fall in a more vulnerable patient demographic. there is a need for a score combining ribscore and rfs, ensuring the nature of fractures and presence of flail segments are interpreted in the context of patient age, to ensure this vulnerable patient group undergoes surgical fixation only when necessary. jichi medical university, shimotsuke tochigi, japan case history: an -year-old female individual hurt her back while walking during a hospital rehabilitation program after experiencing a brain stroke. her hemoglobin level gradually decreased to . g/dl on the th day after injury. a non-enhanced abdominal ct scan revealed a burst fracture of the lumbar spine. the patient was brought to our emergency center for a thorough examination. clinical findings: her vital signs on arrival were gcs: e v m , hr: , bp: / , rr: , and bt: . . her back presented a severe kyphotic spine. the palpebral conjunctiva was anemic and there were no injuries on her surface. no abnormalities were detected upon auscultation of the thorax and no tenderness and rebound was detected upon physical examination of the patient's abdomen. investigation/results: hemoglobin level was . g/dl and lactate . mmol/l on arrival. an enhanced chest and abdominal ct scan revealed a burst fracture of the th lumbar spine, a large hematoma around it, and a pseudoaneurysm of the lumbar artery. diagnosis: a pseudoaneurysm of the lumbar artery and a burst fracture of the th lumbar spine was diagnosed. therapy and progressions: the angioembolization of the lumbar artery was abandoned because the distance between the abdominal aorta and the aneurysm was \ mm. endovascular aneurysm repair (evar) was finally performed. after the successful completion of the surgery, the patient was discharged on the th day after evar. comments: slight injury caused the fracture of the lumbar spine, possibly yielding pseudoaneurysm of the lumbar artery. such pseudoaneurysms are rare and employing evar for its treatment is equally rare. blunt lumbar artery injury may be a differential diagnosis for the elderly patients who present burst spine fractures with extreme anemia or shock, even if it results from a minimal injury. case history: a year old co-driver was hit by another car on her side. air rescue found the patient with gcs and right tension pneumothorax. oral intubation, decompression with chest tube and transportation to the nearest level one trauma center was undertaken. clinical findings/investigation/results: on presentation in the emergency room the patient was hemodynamically instable with free fluid in efast-sonography and a haemoglobin of . g/dl. she was immediately taken to the operation room where laparotomy was performed. liver rupture and right diaphragm rupture was found. diagnosis: right hilar bronchial disruption. therapy and progressions: despite packing of the liver the patient remained instable. due to continuous bleeding from diaphragm rupture side right anterolateral thoracotomy was performed. bronchial disruption close to the hilus was detected leading to total pneumonectomy. after surgery the patient recovered under intensive care. six weeks after initial trauma the patient presented with ileus. a gastric tube was placed without complications. chest x-ray was performed showing intrathoracal displacement of the gastric tube. in an emergency operation the insufficient bronchus trunk was covered with an intercostal muscle flap. comments: this case shows the rare necessity of total pneumonectomy after blunt chest trauma and its typical complication with insufficiency of the bronchial trunk. after total pneumonectomy surgery covering the bronchial trunk should be performed as soon as possible to prevent insufficiency. in these patients gastric tubes should only be placed under endoscopic vision. because of the high complication rate total pneumonectomy should only be performed as a last resort procedure in the context of damage-control surgery. introduction: multiple rib fractures continue to be a challenging problem as the associated pain leads to a compromise in respiration. proper analgesia is required for physiotherapy, and to prevent development of respiratory failure. ultrasound-guided serratus plane block (spb) has recently been described as a regional anesthetic technique to provide analgesia to a hemithorax by blocking the lateral branches of the intercostal nerves. material and methods: from sept we applied the serratus plane block for pain control in patients with multiple rib fractures. we administered . - . % bupivacaine solution with easypump for - days, the infusion rate was ml/h. after admission we measured pulmonary function of patients and recorded the forced vital capacity (fvc). we repeated the test after the catheter insertion on the - - days. in our control group ( patients introduction: rib fractures are the most frequent injury after blunt thoracic trauma. it is very important to choose the most appropriate interventions to minimize or prevent complications. but who will benefit most of those interventions remains a challenge. material and methods: a retrospective study with a prospective data collection from march to december . there have been included all traumatic patients older than years old, that were admitted to the icu or who were died before the admission and had a plain chest radiograph (cxr) and thoracic or thoraco-abdominal scan (ct scan) in the first h. demographic data has been collected, vital signs, iss, mechanism of action, need of ventilation or intubation, lesions, complications, cause of death. a total of cxr were reevaluated by one general surgeon (one of the authors) and one radiologist, who were blinded to the results of the subsequent chest ct scan, the written radiology report and the patient's outcome. rib fractures, pneumothorax, hemothorax, pulmonary contusion, laceration and atelectasis were described. results: attending to the number of fractures, the kappa between the radiologist, the surgeon and the ct report is very low: surgeon-ct k = . , radiologist-ct k = . , and radiologist-surgeon k = . . both radiologist and surgeon under-diagnosed rib fractures. we tried to predict respiratory failure and pneumonia using the number of fractures, and scores (chest trauma score, ribscore and rib fracture score). results are shown on the table. conclusions: plain radiography seems not to be a good diagnostic method for rib fractures. both radiologists and surgeons under-diagnosed rib fractures. scores based on radiography seem un-useful given that this under-diagnoses rib fractures; but with a precision of % by the surgeon evaluating cxr and using a score like rfs perhaps it is enough to decide which patients require a ct scan or more specific treatment in the icu. surgical experience of traumatic diaphragm injury in a single regional trauma center for years introduction: this study is a retrospective review of the experience with the management of traumatic diaphragm injury in our trauma center from to . material and methods: we identified a total of patients with the traumatic diaphragm injury coded from the institutional trauma registry. we reviewed the radiographic finding of radiologists and the electronic medical record (emr). results: the mean of injury severity score (iss) was . ± . . except for case, the plain chest x-ray was evaluated in the patients before surgery, only patients were revealed positive finding for diaphragm injury (n = / , %). the computed tomography (ct) was performed for patients, the positive finding was . % (n = / ). according to the clinician impression before surgery, the diagnosis for diaphragm injury was showed . % (n = / ). approaches were laparotomy in patients ( . %), thoracotomy in ( . %), thoracoscopy in ( . %), laparoscopy in ( . %), open conversion after thoracoscopic or laparoscopic exploration in ( . %), median sternotomy in ( . %). the occurrence of herniation was ( . %). the mean of the calculated rupture size in the operation field was . ± . cm. in our study, the herniated peritoneal organ was observed in more than cm size rupture of the diaphragm. patients were performed surgical management of diaphragm rupture after h. conclusions: without herniation of organs, the radiologic evaluation was difficult to detect diaphragm injury. and, detect of diaphragm injury with herniation of organ, the injury of the diaphragm was predicted a larger than cm. case history and clinical findings: a -year-old man presented to the emergency room with a single self-inflicted left chest gunshot wound at the level of nd rib. on arrival patient was conscious, with systolic blood pressure mmhg and heart rate bpm. extremities were pale, cold. jugular veins distended. investigation/results: fast scan was negative. chest radiograph revealed a metal foreign body with the size of mm at the projection of heart. a ct scan of chest and abdomen demonstrated bullet inside the dorsal wall of the left ventricle and blood in pericardium and left pleural cavity (figs. , ) . therapy and progression: patient was taken to the operation room for median sternotomy. due to severe deterioration of patient's condition, ml of blood was aspirated from the pericardium prior to sternotomy. during subsequent pericardiotomy ml of blood was evacuated. main pulmonary artery wall gunshot injury was detected above the pulmonary valve. the wound was sutured, after which the hemodynamics stabilized. cardiac surgeon was consulted about the air gun bullet inside the myocardium. it was decided that removal of the bullet is not indicated. the patient was observed in the icu for the next h, later transferred to the thoracic surgery ward. the postoperative course was uneventful. an echocardiogram demonstrated a perforation of the anterior leaflet of mitral valve with a mild to moderate regurgitation, otherwise no abnormalities. patient was discharged on day . patient has been followed up on an annual basis for the last years. patient's exercise tolerance and cardiac function according to repeated echocardiography remains unchanged with no evidence of dyskinesia or other abnormalities. bullet is retained in the same location (fig. ) . comments: this case illustrates a successful management of usually lethal injury of main pulmonary artery and reflects that retained myocardial foreign body does not necessarily cause any complications. profile of penetrating chest injuries in hostile environment: a three year study introduction: penetrating chest injuries are one of the leading causes of death and major morbidity in operations involving high energy weapon systems. this study aimed at assess the profile of penetrating chest injuries suffered during armed combat operations in a hostile environment over a three year period. material and methods: a retrospective and prospective, non-randomized study designed to assess the profile of chest injuries in armed combat operations over years. all patients with penetrating chest injuries were included in the study. results: there were trauma cases out of which patients suffered penetrating chest injuries. the age range of patients was - years and all were male. a total of casualties were brought dead ( . %). there were lung injuries and two diaphragmatic injuries. thoracotomy was required in patients ( . %) and intercostal chest drainage (icd) in patients ( . %). average blood loss was ml and duration of hospital stay ranged from to days. conclusions: ballistic injuries to the chest are frequently fatal due to injuries to the heart, major vessels and tracheobronchial tree. prompt and efficient pre hospital treatment, expedient evacuation to a surgical facility and swift management by critical care specialists and surgeons can be instrumental in reducing mortality and morbidity. the cornerstone of management is bedside intercostal chest drain insertion as a formal thoracotomy is seldom needed. penetrating chest injuries can be managed by general surgeons with training in thoracotomy and repair of intra-thoracic structures does the number of a-or low symptomatic but intervention requiring complications justify regularly chest x-ray controls after less than rib fractures? c. deininger , , f. wichlas , , s. deininger , v. hofmann , university hospital of salzburg, orthopedics and traumatology, salzburg, austria, universitätsklinikum salzburg, klinik für orthopädie und traumatologie, salzburg, austria, universitätsklinikum salzburg, universitätsklinik für urologie und andrologie, salzburg, austria introduction: fractures of less than ribs may still cause delayed complications ( ) . the aim of this retrospective study is to determine whether standardized control imaging in a-or low symptomatic patients reveals a significant number of intervention requiring complications and therefor should be recommended. material and methods: all patients with less than rib fractures presenting in our emergency department after any trauma mechanism in the study period of years ( - ) and available for follow up were included retrospectively in the study. results: we included patients in this study, ( . %) of which were male, female ( . %), with a median age of . ± . years. in patients ( . %) rib was affected, in patients ( . %) , the fractured ribs being true ribs ( - ) in cases ( . %), false ribs ( - ) in cases ( . %) and both in cases ( . %). the affected thorax half was the left side in cases ( . %), the right side in cases ( . %) and both thorax halves in cases ( . %). the trauma mechanisms were falls at home, traffic accidents, sporting accidents, work accidents, fighting related and minor trauma in ( . %), ( . %), ( . %), ( . %), ( . %) and ( . %) cases, respectively. the median follow up time was ± days. patients ( . %) required delayed intervention: case of hemopneumothorax and cases of pneumothorax all treated with chest tube. conclusions: planned chest x-ray controls seem not to be necessary. symptom triggered reappearance for patients after rib fractures in hospitals seems to be sufficient and more economical compared to regularly re-imaging ( ) is computed tomography a first line modality in stable blunt chest trauma elderly patients? a. becker , , y. berlin , , d. hershko , emek medical center, department of surgery a, afula, israel, technion-israel institute of technology, haifa, israel, emek medical center, surgery, afula, israel introduction: adult older, patients aged [ years, represent up to - % of all trauma patients admitted to the trauma centers. chest trauma in older patients have been recognized to strongly influence mortality. the estimated of % mortality and pneumonia rate for these patients was observed ( , ) . based on low diagnostic accuracy of cxr, interpretation difficulties due to aging chest wall deformities, we hypothesized that ct chest should be the first imaging modality in stable elderly blunt chest trauma patients. patients and methods a retrospective analysis of all blunt trauma admissions at emek medical center between - years was performed in order to identify patients with blunt chest trauma. only stable trauma patients with abbreviated injury score (ais). results: among patients that met inclusion criteria, there were ( %) patients aged - years old and ( %) patients aged c . in the first group of patients ( - ), had ct chest on arrival. in the second group of patients (aged c ), there were ( . %) patients with missed injuries. in this group, patients who had ct chest on arrival, of ( . %) patients had missed injuries. eleven of ( %) patients who had no ct chest on arrival, diagnosed with missed injuries (p- . ). readmission rate in the first group of patients ( - ) was of ( %) who had ct chest on arrival, and of ( %) who had cxr on arrival only (p- . ). in the second group (c ), readmission rate was of ( . %) patients with ct chest on arrival, and of who had cxr on arrival only ( %) (p- . ). conclusions: based on our study result we conclude that ct chest should be a first imaging tool in stable elderly patients with blunt chest trauma. no disclosures. efficacy and safety of small-bored tube thoracotomy for chest trauma: large-bored chest tubes will no longer be needed introduction: tube thoracostomy drainage is an important treatment for traumatic pneumothorax and hemothorax. traditionally, largebored chest tubes have been recommended for successful drainage and prevention for clogging by clots. however, there is little evidence that large-bored tubes are more effective than smaller ones. in consideration of invasiveness, in our emergency room (er), we use fr chest tube for all trauma patients when chest thoracotomy is indicated. the aim of our study is to investigate the efficacy and safety of small-bored tubes for chest trauma patients. material and methods: we conducted a retrospective observational study. we included the adult patients ([ years old) who had undergone tube thoracostomy with fr chest tubes for chest trauma during the years from october to september in our er. the patients with cardiopulmonary arrest on contact or on arrival were excluded. we evaluated tube-size related complications defined as obstruction and worsening of pneumothorax/hemothorax due to ineffective drainage. results: there were eligible patients, % were male, mean age was . and the average injury severity score was . (± . ). sixty-six tube thoracostomies were performed by emergency physicians and were performed by thoracic surgeons. the average duration of tube placement was . days (± . ). there were not any tube-size related complications nor any patients who required additional tube insertion. case history, clinical findings: different stable hemodynamic cases with thoracoabdominal penetrating trauma and negative fast evaluation were enrolled in study. subsequent hemo/pneumothorax was managed initially by tube thoracostomy. investigation/results: hence laparoscopic investigation is an effective method for evaluation of diaphragmatic injuries in thoracoabdominal penetrating trauma, patients underwent diagnostic laparoscopy. in case , classic approach was done by open technique mm port insertion in sub umbilical. two mm ports inserted in lower abdomen at the level of midclavicular line. then mm port was added in subxiphoid area and by introducing zero-degree camera through it a better exposure was obtained. in case , mm sub umbilical port, mm port in subxiphoid and another mm working port at the level of umbilicus and right midclavicular line were applied. a -degree camera used. exposure, working space and exploration maneuvers were much easier to perform in compare with case . in case , port placement was identical to case but zerodegree camera was used. due to poor exposure, subxiphoid port was replaced by a mm one and used for camera insertion, then an acceptable exposure was obtained. in case , port placement of case was used by using -degree camera which resulted in a great exposure. diagnosis, therapy, progressions: patients tolerated the operation well and underwent appropriate management according to their intra operation findings; post-op courses passed without any complications. comments: in patients with suspicious diaphragmatic injury and according to available facilities in our centers, in unilateral injuries we suggest that a mm port in subxiphoid area can be used instead of contralateral midclavicular mm port. in bilateral injuries, if enough exposure doesn't achieve, a mm port in subxiphoid can be added. in absence of degree cameras, mm port use in subxiphoid can give surgeons better exposure. hemodynamic instability in patients with extremity injuries: motor vehicle accidents and shot wounds vs. explosions a. mahamid , i. ashkenazi hillel yaffe medical center, hadera, israel introduction: we previously reported that hemorrhagic instability (hs) was a complication of extremity injuries in as many as of of patients treated in one medical center following explosions. the objective of this study was to evaluate whether the prevalence of hs in patients with other high energetic injuries such as motor vehicle accidents and shot wounds (mva/sw) is different or not. material and methods: victims following mva/sw with extremity injuries and hs treated in one medical center during were identified with the aid of the national trauma registry and the center's blood bank. hs was defined as tachycardia (pulse [ /min) and/or hypotension (systolic pressure \ mmhg) in need of blood transfusions to reverse instability. patients in whom hs could be attributed to injuries other than the extremity injury were excluded. these were compared to patients treated following bomb explosions ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) conclusions: the proportion of patients in need of blood transfusion is much higher in patients whose extremity injury was caused by an explosion. the relative risk for hs is almost times higher in these patients. new technologies in soft tissue wound management limit reconstruction complexity and enhance recovery introduction: large soft tissue losses are associated with infection, increased morbidity and mortality, increased costs and poor outcome functionality. the purpose of this study was to evaluate the efficacy of a combination treatment of combined topclosure Ò tension relief system (trs) and administration of regulated oxygen and antibiotic irrigation negative pressure-assisted wound therapy (roi-npt) in the treatment of patients suffering from significant soft tissue loss. patients with open abdomen, large infected wounds, and extensive soft tissue loss treated with trs and roi-npt. results: full wound closure was achieved in [ patients treated without skin grafts or flaps. primary failure was successfully followed with secondary closure with the same system. the trs system allowed early postoperative physiotherapy with good to excellent functional results. limitations and complications will be discussed. . trs is a novel device for stretching, and securing wound closure, applying stress relaxation and mechanical creep for primary closure of large skin defects that otherwise would have required closure by skin grafts, flaps or tissue expanders. . irrigation may accelerate the evacuation of infectious material from the wound and may provide a novel method for antibiotic administration. . supplemental oxygen to the wound reverses reduced o levels in the wound's atmosphere inherent to the conventional negative pressure-assisted wound therapy restricting vacuum use in anaerobic contamination. moris topaz is the inventor and patent holder of the topclosure Ò and vcarea Ò . attendees' perceptions about tourniquet safety use aboard, easiness of application, and preference among four devices tested assessed. material and methods: the descriptive study design assessed employing a post-seminar survey, participants' perceptions of tourniquet safety use, application easiness, and preference among the four devices tested (cat, sam-xt, swat-t, and rats). the first two variables measured on a one-to-ten scale (being ten the easiest or safest, and one the least easy or least safe), while preference was measured by frequency count, with only one device to select as the preferred. frequencies and percentages for categorical variables and averages calculated and compared using the anova test (p \ . ). results: a total of sailors, ( %) females, and ( %) males, aged between and , participated in the workshop and completed the survey. the mean for the perception of safety regarding onboard usage was . . as for application easiness, cat and sam-xt ranked equally high ( . ), followed by swat ( . ) and rats ( . ), and the only statistical difference found was for rats (p \ . ). cat was reported as preferred by participants ( %), followed by sam-xt ( %), swat-t ( %), and rats ( %). conclusions: jse crewmembers (non-medical personnel) considered safe the use of tourniquets on board. of the four devices assessed, cat and sam-xt were regarded as equally easy to use and rats the least of all. cat was reported as preferred by almost three out of every four respondents. introduction: surge capacity is the ability to manage the increased influx of critically ill or injured patients during suddenly onset crisis, like a mass-casualty incident (mci) or disaster. during such an event all ordinary resources are activated and used in a systematic, structured and planned way. there are, however, situations where conventional healthcare means are insufficient and additional resources must be summoned. this study investigates the possibility of using community resources such as primary health care centers, nonmedical professionals and non-standardized facilities together with educational initiatives to increase surge capacity in a flexible manner. purpose: to investigate the possibility of an increased and flexible surge capacity during a crisis, disaster or mass casualty incident (mci) by examining the main components of surge capacity (sc) (staff, stuff, structure, and system) in the västragötaland region of sweden. method: this thesis uses a mixed methods research approach with an explanatory sequential design. a literature search was performed by using standard search engines utilizing relevant keywords, questionnaires and semistructured interviews were used for data collection from primary health care centers, dental and veterinary clinics, schools, hotels and sports facilities to determine capabilities, barriers, limitations and interest to be included in a flexible surge capacity system. results: preliminary findings indicate that there is interest, capacity and capability in the investigated municipalities to partake in a fscplan: primary healthcare centers can be toned up with drills and exercises, civilians can be educated in advanced first aid procedures (immediate responders) and focused leadership (scene management), schools, hotels and sports facilities can be prepared with advanced first aids kits and be used as alternative care facilities. these alternatives together represent the concept of flexible surge capacity. conclusion: flexible surge capacity can be a possible approach to create extra resources in disaster situations, mci's, or whenever supporting infrastructure is not intact. new educational initiatives, drills and exercises, laymen empowerment and organizational and legal changes might be needed to realize a flexible surge capacity. introduction: a hospital may need partial or total evacuation because of internal or external incidents, such as in natural disasters and or armed conflicts. an evacuation aims either to transport a large number of patients to other medical facilities or to prepare enough space to receive a large number of victims. despite many publications and reports on successful and unsuccessful evacuations, and lessons learned, there is still no standardized guide for such an evacuation, and many hospitals lack the proper preparedness. we aimed to analyze the preparedness of hospitals for a total evacuation by looking into some key parameters necessary for a successful performance. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. eleven questions were sent to representatives from euand non-eu countries. results: our findings indicate that there is neither a full preparedness nor a standard guideline for evacuation within the eu or other non-eu countries included in this study. some countries did not respond to our questions due to the lack of relevant guidelines, instructions, or time. conclusions: hospitals are exposed to internal and external incidents and require an adequate evacuation plan. there is a need for a multinational collaboration, specifically within the eu, to establish a standardized evacuation plan. references: nero c, Ö rtenwall p, khorram-manesh a. hospital evacuation; planning, assessment, performance and evaluation. j acute dis. ; ( ): - . introduction: the importance of and the need for medical management during any armed conflict is a fact. many medical achievements have been accomplished due to wars and armed conflicts. the world is, however, divided into countries with and without related military healthcare services. there is a need for joint structure with the civilian in the former, while in the latter the civilian healthcare is responsible for offering services to the military. this study aims to identify the needs of military healthcare system and military medicine as an independent specialty. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. relevant professionals were asked about the pros and cons of having established military healthcare. the data was collected and analyzed. results: although our findings indicate a need for military medicine/ healthcare as a professional specialty, the organizational divisions between military and civilian healthcare systems seems to be changing. the current security issues worldwide, the pattern of injuries and resource scarcity indicates a need for improved collaboration and maybe a fusion between these entities. conclusions: new security threats, modern technology, the pattern of medical injuries, and the lack of adequate surge capacity may indicate a very close collaboration between military and civilian healthcare systems. such a close collaboration may develop to fusion and a total defense healthcare system that can act both in peace and during conflicts. references: ringel js. the elasticity of demand for health care. a review of the literature and its application to the military health system. https://apps.dtic.mil/docs/citations/ada khorram-manesh, a. facilitators and constrainers of civilian-military collaboration: the swedish perspectives. eur j trauma emerg surg. . https://doi.org/ . /s - - - . alternative methods of mandibular comminuted fracture fixation in severe maxillofacial injured patients introduction: severe maxillofacial injuries refer to significant facial trauma with communitive bony fractures and soft tissue loss. they result in violent trauma as firearm injuries (wartimes injuries, terrorist attack, suicide attempt) and high velocity motor vehicle accidents. the initial management consist of fighting hemorrhage, fighting asphyxia, wounds debridement and suture, and fractures stabilization, especially mandibular fracture stabilization. our study aims to share thoughts on the alternative methods of comminuted mandibular fracture fixation within the context: kind of injury, multitrauma patients, mass-casualty situation, precarious situation or hostile environment. material and methods: based on our experience (clinical cases), on senior surgeons questioning and on medical literature data, we sought to identify, to evaluate and to compare the different available methods to stabilize comminuted mandibular fractures in severe facial injured patients. results: open reduction and stable internal fixation (using macro plate), external pin fixation and closed reduction with maxillomandibular fixation are the methods of treatment which are the most classically used and described. however, some methods using kirschner wires are reported: in cross extrafocal pinning ( fig. ) , external fixation and handmade splints. all these methods differ in their complexity of use, in their availability, and in their possibilities to treat one kind of mandibular fracture or another. conclusions: the stabilization method of comminuted mandibular fracture will be choose depending on material availability, on surgeon's abilities, on the time available (mass-casualty situation) and on the patient's overall condition. even if stabilization methods using wires are less commonly used, they appear to us to be useful in the initial management of the severe maxillofacial injured patient with comminuted mandibular fracture, especially in austere conditions. causes of combat casualties' death at medical treatment facilities (mtf) in modern conflicts: russian experience i. samokhvalov , v. badalov , k. golovko , t. suprun , v. chupriaev material and methods: data including mechanism of injury, physiologic and laboratory variables, staged surgical treatment and cause of death were obtained from the combat trauma registry of the kirov military medical academy war surgery department. the combat trauma registry includes russian wounded in military conflicts over the past decades, of them ( . %) dead of wounds (dow) at the mtf. results: . % of the total dow number died at the role ii field medical units, . % died at the forward military role iii hospitals, and . % died at the role iv hospitals. the causes of dow patients delivered to the mtf were nonsurvivable traumatic brain wound ( . %), life-threatening consequences of injuries-mainly massive blood loss due to external and internal bleeding and acute respiratory failure ( . %), as well as the late septic complications ( . %). terms of death depended on the cause of dow. so for nonsurvivable traumatic brain injuries, they amounted to . ± . days, for lifethreatening consequences of wounds- . ± . days, and in the development of complications- . ± . days. conclusions: there is a high mortality rate among the combat casualties delivered to mtf in modern asymmetric warfare ( . %). moreover, half of these patients ( . %) die at role ii field medical units mostly from nonsurvivable injuries and from acute irreversible blood loss that occurred at the prehospital stage. the main cause of hospital combat mortality is severe septic complications of combat trauma. in consideration of the present counterterrorism practices, prevention and initial treatment for primary blast injury by shock waves constitute a particularly urgent subject because blast injuries and gunshot wounds account for the majority of terrorism deaths. in japan, due to strict ethical standards in animal experiments, there is no appropriate animal model of blast injury. we established an original small animal model of blast injury using a laser-induced shock wave at the national defense medical college (ndmc). however, since the experiments were conducted using only small animals, such as mice and rats, it was necessary to establish a medium-sized animal model aimed to test the applicability in human patients in the long term. correspondingly, we established a blast tube, which was authorized globally as a shock wave-generating device that causes blast injury based on air pressure differences, in the ndmc research institute using the budget of advanced research on military medicine of japan in . this allowed us to conduct scientific studies on blast injury using mediumsized animals. in this presentation, we will introduce the structure and function of the blast tube installed in the ndmc and present some of the results of our research thus far. this research is financially unfortunately, even if hospital and their staff are an essential key for successful response to mcis, the plan are seldom well-known and, above all, exercises are quite neglected at local and national levels. due to mci rarity, simulation exercises are the only way to achieve proficiency in mci response. therefore, we tested an original mci training system (macsim Ò ) adapted to the pemaf of a large university hospital in milan (italy). material and methods: the original mci training format called macsim-pemaf (emergency plan for massive influx of casualties)was developed for the italian society for trauma and emergency surgery (sicut) in . it uses macsim Ò , a simulation tool scientifically validated for training and assessment of healthcare professionals in mci management. between and the course was held for the emergency department staff of a single university hospital of milan (italy) (foundation cà granda-ospedale maggiore policlinico). macsim Ò was used to reproduce the hospital resources, with different mci scenarios. during the simulation the participants had the opportunity to test the local pemaf, in adjunct to their knowledge and skills. course effectiveness was evaluated by a pre-and post-course self-assessment questionnaire. results: macsim-pemaf was tested in seven courses, for a total of participants. pre-and post-test questionnaires showed a significant improvement in hospital staff self-perception of knowledge and skills in mci management. on a - scale, the improvement value was from . ± . to . ± . (p \ . ). conclusions: macsim-pemaf is a useful tool to test single hospital pemaf. it is versatile enough to adapt to specific realties, mimicking different traumatic scenarios. participants, acting in their usual professional roles, can increase their self-perception to be able to respond to a mci with in-hospital resources. introduction: emt are field health facilities, specifically structured to operate in case of disaster, where local healthcare resources are insufficient. there are types of emt. ''emt regione piemonte'' is the first italian emt to be certificated by who. it's a type , meaning that more than triage and stabilization of emergency cases it's provided with an icu, a / working operation room, a test lab, radiological and ultrasound devices. it can admit up to inpatients. cyclone idai made landfall on / / in the district of dondo in mozambique. it brought torrential rains and strong winds and had heavy impacts on the city of beira and surrounding areas resulting in loss of communication and access. in addition important damage and destruction to shelter, settlements, health and wash facilities occurred. on / italian government approved the aid mission, from march st to th three italian military aircraft transported the medical staff and the boxes containing the hospital to maputo and then in beira. on / , the hospital began working, treating an average of patients and performing - surgeries per day, involving mozambican staff who immediately well integrated with the italian colleagues. results: days of activities. surgeries ( orthopaedic, general surgery, gynaecology, plastic surgery). . % of the cases related to cyclone. mean tiss: ( - ). mean age ( - ) females, males. types of anaesthesia: % locoregional, % general, % analgosedation. conclusions: our first experience in a mass casualties' scenario showed how important is to refresh team skills through periodic drills. the leadership is of paramount importance to keep the team united and to support collaboration with other nations' teams and with the local population. adaptability and open-mindedness are fundamental. emts do not arrive in loco immediately so that longer periods of mission and integration with local medical staffs should be programmed. introduction: in utrecht, the netherlands, a worldwide unique major incident hospital is continuously standby to receive multiple victims during mass casualty events. each year, different types of mass casualty events are simulated with a varying number of victims, to train command and control under extreme circumstances. in utrecht, on march th , a terrorist opened gunshot fire in crowded public transport. the aim of the study is to compare our experiences in simulation versus reality. material and methods: an internal evaluation was performed by questionnaires completed by participants and an external evaluation was performed by interviews. results: all five victims were brought to the major incident hospital, of whom two were dead on arrival, one died seven days after due to multiple organ failure and two survived after multiple surgical procedures. all victims arrived within min after the major incident hospital was activated. a sufficient number of medical staff was alarmed for these five victims, however, since the event occurred during office hours, at least a double amount of staff showed up. among some medical staff on commanding key positions fear arose about their own safety and of relatives outside the hospital. this was exaggerated by incomplete and incorrect provided information from the scene. although medical care of the victims was not affected at all, occasionally the anxiety negatively influenced the command and control structure. conclusions: the combination of anxiety and a surplus of awaiting and benevolent curious medical staff resulted in occasional insufficient performance of the existing command and control structure, despite proper training. however, simulation of fear in a training is very difficult. nowadays, with the increasing threat of terror attacks, one should be aware of the influence of fear and anxiety on personnel, even with low numbers of victims. ethic and law issues during mass casualties management operations in foreign countries introduction: mass casualties incidents occur even more frequently during the last years globally. international help in order to manage them, when needed and asked, has to take into consideration special aspects of ethics and local law status in order to successfully fulfill its expectation. purpose: to demonstrate the ethic and law issues that arise during mass casualties management operations in foreign countries. material and method: literature review from recent management operations in syria, iran and sub saharan africa. results: during such operations a lot of ethical and law issues arise. the knowledge of ethics and laws in the country that these take place is essential and critical for the successful result of them. special care must be taken for the management of women, children and dead people. traditions and religion status of the local populations also must be taken into consideration and actions must take place in accordance to respect of the local authorities and social conditions. conclusions: mass casualties management operations in foreign countries is a challenging mission. ethic and law issues arise and must be taken into consideration for the success of the mission. western surgical experience is one thing, but surgical practice in countries in conflict zones is another. the pathologies are different, the thermal conditions are often difficult and the follow-up of the patients is fundamentally modified. humanitarian surgery is becoming more professional and most organizations are setting up a training program for new surgeons embarking on the humanitarian adventure. international committee of the red cross (icrc) has implemented an onboarding-surgeon experience, before to become a fully icrc surgeon. i hereby present my personal onboarding experience in south sudan: how to learn a new type of surgery, how to come with an helicopter to collect patients in the bush and then, how much you learn about yourself. conflict of interest: i only represent my own experience and i do not represent icrc. surgical clinical reasoning during the war in the period between and , i was the head of operating rooms and icu at the clinic for orthopedic surgery and traumatology, in sarajevo. working in the operating room whose walls are shaking because of the sniping and shelling was not remembered by any other generation of surgeons. there were around traumatized citizens of sarajevo. thousands of injured, dying patients were seeking for help from a small number of surgeons. the duty of a surgeon working in the war conditions, without water, electricity, medicines, or heat, is not easy at all, and there were a lot of difficult situations. for example, one day, operated children were again wounded by direct shelling on the walls of pediatric department of our clinic. after we re-operated the children, we also operated the injured nurses. th may, , th february, , and th august, were the most painful experiences in the surgical treatment of disaster in the center of sarajevo, with a large number of massively traumatized patients. while you were helping one casualty, others were pulling our arms or legs. while you were helping one patient, others were dying in the cramp of pain. during the war, a series of traumatic events happened. above many thousands of them, i admitted a -year-old girl, severely injured, with traumatic lower leg amputation of the leg, and severe injuries of the thigh, pelvis, and neck. we operated on her through the night. during the surgery, she received whole blood transfusions. following the surgery, she was stabilized on pediatric department of our clinic. one day, i saw her mother brought her a gift, immensely valuable in those days, a small canister of pure water. in the , one girl approached me, and asked me if i remembered her. i remembered the canister of pure water. she was happy to show me how she can walk now, and told me she lives in canada and works as a university assistant. i was more than happy to see her walk proudly, as she was leaving. she injury pattern of earthquake in athens, greece: the panic-effect introduction: earthquakes are devastating events. greece is known to be in the first place of seismicity in europe and sixth worldwide. lately, a . richter earthquake shook the greek capital, and fortunately no substantial construction damage was sustained. the aim of the study is to evaluate the classification and severity of all injuries, as well as the type of orthopedic surgical procedures performed, in addition to the role that panic plays on the occurrence of these kind of trauma material and methods: prospective case-series study, conducted in the emergency department of our hospital after the july th, earthquake. the study included patients treated by our department, who sustained injuries in their attempt to run away from the scene. age range was from to years old (mean . y.o), were female and were male. results: a total of injuries reviewed. upper extremities were involved in of all cases, lower extremities in and one patient suffered minor head trauma. four patients required hospitalization and all of them underwent surgical treatment. open reduction and internal fixation performed in patients ( calcaneus fracture and olecranon fracture), patient underwent intramedullary nail fixation (tibial shaft fracture) and external fixation was applied to another (distal tibia fracture). six patients were conclusions: panic is an independent contributing factor in natural disaster associated trauma. prior education, preparedness and combined team effort are clearly needed, in order to reduce the incidence of these injuries. regardless of age, panic may result in various types of fractures, even in cases there are no substantial construction damages after an earthquake. digital and analogue record system for mass casualty incidences at sea: results, reliability and validity introduction: mistriage may have serious consequences for patients in mass causality incidences (mci) at sea. therefore, an exercise was conducted to compare the reliability and validity of an analogue and tablet based recording system for triage of sample patients. material and methods: volunteers were asked to triage with the start-algorithm (black, red, yellow and green) patients in a given time using an analogue and tablet based system. triage score distribution and agreement between the two triage methods and a predefined standard were reported. the present study assessed the triage results as well as the reliability through cronbachs alpha and kappa. for testing of validity and internal consistency, the sensitivity, specificity and predictive value was measured. results: forty-eight participants completed a total of triages. while the number of triaged patients in the given time was significantly higher with the analogue system compared to the digital system (p-value . , t-test), the validity measured with the cronbachs alpha and unweighted cohens kappa was higher with the digital system. for each triage category, higher values were gained with the digital system. the sensitivity, specificity and predictive value for the digital system was higher than for the analogue system. conclusions: this study gives reliable and valid results comparing a digital versus an analogue triage system for a mci at sea. significant differences could be found for the number of triages and the number of under triage. the results of the study show that the used digital system has a slightly higher reliability and validity than the analogue triage system. references: the present work is part of the project improved emergency treatment and organization in the event of a mass casualty of casualties at sea (venomas), planned within the framework of the research network ''kompetenz und organisation für den massenanfall von patienten in der seeschifffahrt'' (kompass) and funded by the federal ministry of education and research (grant number: n ). predicting outcome for extremity wounds in pediatric casualties of war introduction: during the early s, the international committee of the red cross (icrc) implemented the red cross wound classification (rcwc) for penetrating wounds. wound grades of , and describe the amount of kinetic energy transferred to the tissue (low, high and massive, respectively). currently, this classification system mostly serves as a descriptive tool, but it is hypothesized it could also support clinical decision making. the aim of this study is to assess whether the wound grade of a pediatric patient's extremity wound correlates with patient outcomes. material and methods: this study included pediatric patients (age \ years), who have been treated by the icrc for conflictrelated extremity injuries between and . the correlation of the following variables with the wound grade were analyzed: number of surgeries required, length of stay, and in-hospital mortality. results: the study cohort consisted of pediatric patients. the higher the wound grade, the more surgeries were performed per patient (p \ . ), with a mean of surgeries per patient if they had a wound grading of . there were no significant differences in mortality rates between any of the wound grades, which were . % ( / ), . % ( / ) and . % ( / ) for wound grade , and respectively. pediatric patients with wound grade were hospitalized for the longest period (mean . days), followed by wound grade (mean . days) and wound grade (mean . days; all with p \ . ). conclusions: the wound grade of pediatric patients' extremity wounds appears to correlate with some patient outcomes, but not with mortality. grading of extremity wounds according to the rcws could support clinical decision making in pediatric patients. introduction: during the last few decades, french armed forces have regularly deployed in asymmetric conflicts. surgical support for casualties of these conflicts occurs in nato role and medical treatment facilities (mtf); definitive surgical care occurs in france following a strategic medical evacuation. the aim of this study was to describe the combat injury profile of these soldiers who presented with either non-exclusively orthopedic and/or non-exclusively brain injuries. material and methods: this descriptive study is a retrospective analysis of the surgical management of french casualties performed in role or mtf in afghanistan, mali, niger, djibouti and the central african republic between january and december . results: one hundred patients were included. forty had fragment wounds. the most severe lesions were of the head, neck or thorax. the average injury severity score (iss) was . (ic % . - ). damage control procedures were performed. thirty patients died with a mean iss of (ic % - ); deaths were considered as preventable deaths. the most frequent surgical procedures in the mtf were digestive (n = ) and thoracic surgery (n = ). thirty patients needed second-look surgery in france; eleven had severe complications. no patient died following medical evacuation to france. conclusions: results from this study indicate that the mortality following non-exclusively brain or orthopedic injuries remains high in modern asymmetric conflicts. introduction: telemedicine has been applied to disasters and extreme environments for more than years, however, despite the many lessons learned so far, telemedicine is still not a common part of the immediate disaster response. for this reason, a review of the literature was conducted to investigate whether telemedicine technology can be used to address medical and non-medical needs in extreme environments. material and methods: this systematic review included studies published in the period - , originating from literature search bases medline, scopus, cinahl and pubmed. the case of neemo project were studied so to evaluate the diagnostical and surgical care of the patients regarding the emergency response in a remote and constricted area, with limited human medical resources and using the telecommunications and telerobotic technologies. results: the majority of the included studies have highlighted the importance of telemedicine interventions in extreme environments, stressing that it is a viable solution to health care provision. in addition, it has been found that telemedicinal technology provides the possibility of virtual collaboration between healthcare professionals with various specializations. projects neemo , , engaged to eliminate the challenges of telesurgery. conclusions: future studies such as large multicentre randomized trials will have to be conducted that will lead to safe conclusions on the usefulness and efficiency of telemedicine applications in extreme environments. introduction: tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage. the optimal tourniquet type and effectiveness of non-commercial devices is unclear, and the aim of this study. material and methods: this prospective observational cadaverbased study was performed using a perfused cadaver model with a standardized superficial femoral artery injury bleeding at ml/ min. five devices were tested: cat (combat application tourniquet), rats (rapid application tourniquet system), swat-t (stretch, wrap, and tuck tourniquet), a triangle bandage and a stick and a leather belt. volunteer medical students with no prior clinical tourniquet experience participated. each student underwent a practical hands-on demonstration of each of the tourniquets, prior to the test. using a random number generator, they then placed all tourniquets in random order. outcomes measures included time to hemostasis, total time to secure devices, estimated blood loss (ebl) and difficulty rating. a one-way anova repeated measures was used to compare efficacy between the tourniquets in achieving the outcomes. results: participants' mean age was ± . years and ( %) were male. all participants were able to stop the bleeding with of the tourniquets. with the rats there was a % failure rate. among the five types of tourniquets, time to hemostasis and ebl were not statistically significantly different (p [ . ). the swat-t required the longest time to be secured ( . ± . ), while the belt was the fastest ( . ± . ; p \ . ). conclusions: all five tourniquets, including the non-commercial devices, were effective in achieving hemostasis. a standard leather belt was the fastest to place and able to stop the bleeding. however, it required continuous pressure to maintain hemostasis. nevertheless, in an emergency setting where commercial devices are not available, improvised tourniquets may be an affective lifesaving bridge to definitive care. hospital preparedness for mass gathering events and mass casualty incidents in matera, european capital of culture for introduction: mass casualty incidents (mci) may occur during mass gathering events (mge). lack of preparedness of health system increases mortality. education and training are crucial. hospital mci plans are mandatory in italy, but they are poorly known. on , matera was declared italian host of european capital of culture for : the local hospital decided to revise the hospital plan for massive influx of injured (pemaf) and to start a program to train the staff. material and methods: the pemaf was reviewed through simulations that involved all the staff. a partnership with mrmi-italia (italian chapter of the international association medical response to major incident and disaster-mrmi&d) leaded to the support of experts and to the organization of residential courses based on the macsim Ò (mass casualty simulation) simulation tool. educational capacity of the residential events was tested through a self-assessment tool. results: alert, coordination and command sequences were defined. all the available resources were recorded and the functional areas identified. the communication network was improved. documentation and registration system was prepared. standard operational procedures (action cards) were created for the key positions. residential educational events of macsim-pemaf were organized. the educational capacity was tested through self-evaluation: knowledge of participants resulted improved. conclusions: mge are a great opportunity for the hosting community but they also represent an increased risk of mci. preparedness is mandatory for health system. the format macsim-pemaf seems to be adequate to review the existing plans and transfer skills to attendants. introduction: the cruise industry is facing a constantly growth of infectious diseases. some of them are reaching the extent of mass casualty incidences (mci), which are overwhelming the capacity of the local rescue system. our aim was to improve the ability to act in a mci due to an infectious emergency regarding the situation at sea/in the port. hamburg, as one of the largest ports in europe, was chosen for analysis. material and methods: the collaborative project ''adaptive resilience management in the port'' (armihn) is funded by the german federal ministry of education and research. scenarios due to an infectiological emergency were developed together with the university central department of occupational medicine and maritime medicine and the hamburg port health center in hamburg, germany. these scenarios were specified with all key stakeholders in the port. the organizational structure of the current emergency management was analyzed and a new concept was developed. results: for the ship and the port, emergency strategies dealing with mass casualties of injured persons are available. nevertheless, current concepts regarding this special situation of an infectiological mci were missing. we developed a new concept, which based on the models concerning mass casualties of injured persons. for this purpose, emergency surgeons can be recommended as experts regarding coping with a major emergency and for developing adaptive training concepts. conclusions: new operational concepts coping with mci of infectious patients were developed. in a second step, an emergency plan and a training concept for relevant stakeholders in the port will be developed. these will be evaluated in a full exercise in the port of hamburg and tested for their suitability. the results will be transferred to comparable infrastructures to cope with a major case incident with infected people in the port area. emergency surgeons should be involved in these steps due to their expertise. the work was funded by the german federal ministry of education and research ( n ). no further significant relationships. war surgery training, the use of swine model in military simulation center introduction: due to the international instability, our forces are deployed in many place and our military surgeons have to deal with ballistics trauma and improvised explosive devices related trauma. in order to be well prepared and effective in these isolated situation, the val de grace school (our military health service academy) provide a years course to train the young surgeon. this year surgical courses ended with war trauma surgery simulation on a swine model. material and methods: this use of the swine alive model is incorporated in the cesimco (military surgical simulation center) and also use for the training of our fully registered surgical team. this laboratory responds to all civilian authorizations and ethical considerations as enacted by european rules (felasa). results: the aim of this presentation is to show the different procedures and the teaching provided in this structure to improve surgical skills in war condition. all procedures are approved by the ministry in charge of the animal experimentation and respond to the animal welfare regulation. the number of swine used in these teaching is reduced to the minimum. we think that this animal model and its use in military forward surgical facilities, is the end point of the years military surgical course provided by the val de grace school. conclusions: this model is actually the most reliable and ethically acceptable teaching procedure we've found. during these teaching the students have to deal with open trauma and hemorrhagic lesions in damage control situation. we try to follow the different type of war related lesions observed in french military in order to stick to the reality of the field. this teaching is now mandatory before being deployed as a military surgeon on field. case history: -year-old male, previously healthy, admitted to the er due to shotgun injury to the right hip. during transport, the bleeding open wound was covered, two iv catheters were introduced, and saline and painkillers were administered. on admission, the patient was conscious, eupneic and normotensive, with a gcs score of . clinical findings: after the primary survey and exclusion of cranial, thoracic and abdominal lesions, the limb injury was addressed, showing a cm oval-shaped wound. the right leg was shortened and externally rotated. pulses were present but the patient referred calf and foot hypoesthesia. investigation/results: x-rays showed a comminuted pertrochanteric fracture and the presence of metallic foreign bodies. diagnosis: open right pertrochanteric fracture. therapy and progressions: initially, the wound was covered, and iv antibiotics and supportive therapy were given. in the or, irrigation, surgical debridement, and foreign body removal were performed, followed by orif with one dall-miles cable and a cephalomedullary femoral long nail. after surgery, the patient maintained lower limb hypoesthesia and had plantar flexion and foot dorsiflexion grade motor deficit. during follow-up, soft tissues recovered uneventfully and bone healing successfully occurred. full weight-bearing was tolerated at weeks post-op but the neurological deficits persisted despite physiatric treatment. electromyography confirmed severe partial lesion of the sciatic nerve. comments: generally, clean wound, fracture stability, restoration of circulation and skin closure of neurovascular structures are a priority and should be a reason for delayed nerve repair. introduction: despite mass casualty incidents (mci) are becoming a common concern, particularly regarding the care of paediatric victims, pure paediatric trauma centres (ptc) are still rare in europe. the purpose of this study is to assess the capacity of the hospitals in the metropolitan area of milan in case of mci involving the paediatric population, with focus on the pre-impact planning phase. material and methods: relevant literature and existing guidelines were reviewed by the representatives of four referral centres for the management of either trauma or paediatric patients. minimum standard requirements of care of paediatric trauma and consequently the maximal surge capacities for each hospital were defined based on the severity of injuries and personnel/equipment availability. results: overall, the four hospitals are able to treat patients with the highest priority (t ), to patients with intermediate priority (t ), and patients with deferrable priority (t ). severely injured patients \ years old should be preferentially transported to the hospitals with paediatric expertise, whereas patients between to years of age can be managed in multi-speciality structures. conclusions: in case of mci it is not always possible to rely on the availability of a ptc. hospitals with paediatric trauma care expertise can work in synergy with ptcs, or offer an alternative if there is no ptc, and should therefore be included in disaster plans for mci involving paediatric victims. case history: we present a case of a -year-old male with a proximal radius and ulna gunshot fracture associated with a complete lesion of the brachial artery, which was urgently repaired by grafting in his native country. a partial proximal radius excision was also performed. three months later, after soft tissue recovery, the ulna fracture was fixed with a dcp plate plus iliac crest bone graft. at months follow up x-rays showed hardware loosening, so the plate was removed and an external fixator was implanted. in this situation the patient attended to our clinic months after the initial injury. clinical findings: findings included proximal pin purulence, an elbow varus deformity and a limited joint motion: flexion °, extension °, supination/pronation °. investigation/results: x-rays and ct scan showed proximal ulna pseudoarthrosis. diagnosis: proximal ulna pseudoarthrosis after a gunshot fracture. therapy and progressions: a two-stage procedure was performed. initially we performed a wide debridement and external fixator removal. an ulna nail combined with gentamicin and vancomycin pmma spacer was implanted. s. aureus was identified in intraoperative cultures. in a second stage, year after, the nail and spacer were removed and a vascularized fibula graft with saphenous loop was implanted and fixed with a va-lcp plate. the central band of the interosseous membrane was repaired with a prosthetic device. currently, the patient presents full flexion range, hyperextension of °, active pronation of °and supination of °. x-rays show graft consolidation. comments: gunshot fractures are complicated lesions with significant soft tissue damage and high risk of vascular and nervous injury. a thorough study and initial systematic approach is mandatory in order to avoid later complications. introduction: the purpose of our study was to independently analyze pediatric trauma data, especially that of preschool-aged children, including demographics, injury patterns, the associated mechanism of injury, and outcomes, at a single institution in korea to gain a better understanding of current trends in non-regional trauma centers. material and methods: we conducted a retrospective review of preschool-aged children with trauma, who presented to the emergency department a single center between march and december . results: overall, there were pediatric patients who experienced trauma admitted during this study period. the frequency of admissions was similarly high in all seasons except winter. falls were the most common mechanism of injury at all ages, except , , and years of age, according to comparative analysis by age and mechanism. the most common place of trauma at - years of age was at home, and outside the home at the age of years or older. the most common injury region was to an extremity ( . %). mean injury severity score was ± . , and the mean hospital stay was . ± . days. conclusions: although mortality from trauma is low in pediatric patients, we must continue to improve treatment outcomes for children. it is unlikely for a hospital to have a pediatric trauma specialist, such as a pediatric orthopedic surgeon or plastic surgeon, due to manpower constraints. in order to further improve the outcome of treatment with insufficient resources, it is necessary to recognize agespecific characteristics. question: the new safety situation in europe and the lessons learnt civilian events of damage show that hospitals have to be prepared for mass casualties. the shift of the operational mode to ''emergency medicine'' have to be planed and practiced. the reporting tool for this is the hospital action plan (hap) that every hospital should have. the efficiency of the existing plan is already proven in different largescale exercises. in germany the legislator obligates the hospitals to enable there staff to properly perform the different tasks of the hap. in addition, the have to develop and evaluate proper training and exercises. goal of this study was to establish along the hap of a level one trauma center an modular mass casualty training (manv ) that would help to analyze the tasks to face and to deepen the existing structures of communication. method: we set a scenario with casualties and evolved the different shifting phases of the trauma center (alarming-, mobilization-, constitution phase). setting the concept of training outside the regular service period we took in account that there will be a lack of resources and material. we did not exercise in a large-scale but trained in small groups modular. we also did a screen adaption of the hap of the trauma center to have a mind set for the staff and a starting point to the scenario. to teach our operative procedure we simulated our '' columns concept'' (medical, personal and infrastructure) to the staff. specific to the different task groups (medical doctors, technicians, nurses) we exercised and the different sectors (er, triage, or, command etc.) and the necessary shifts of the different hospital sectors when a mass casualty occurs. before and after we did a query of the staff to see how much impact the modular exercise would have on the hap-knowledge of our staff. results: we were able to simulate realistically an identical mass casualty scenario to different staff groups of our hospital. knowledge about the hap increased significant from to % after the trainings. % of the staff see a clear improvement of information about the hap. also, the specific shifting-phases and the enrolment of the plan to move in an ''emergency medicine mode'' understand % better. % of the staff fell now a much better preparedness than before. % think that through modular exercises and small group training the communication in between working groups improved. conclusion: we could manage to improve a significant increase of knowledge about the hap in our staff. all the small group modular training in the different sector can be easily but together in large-scale exercise and other teams like police, military or fire-department can easily be added. introduction: dstc course focusses on surgical skills for trauma care. it is designed to teach surgical techniques for the definitive treatment of severe trauma. currently, it has evolved into an international trauma team course. our objective was to assess faculty members' opinion regarding course content, educational methods, and incorporation of non-technical skills. material and methods: a descriptive study was designed using an anonymous online survey issued from may to august , . senior international faculties' opinion from countries assessed. the survey inquired views of courses content, duration, adequacy of hands-on practice, need for updates, and usefulness of incorporating non-technical skills to the course. results: from the surveys issued, were ( %) answered. the course content was valued as very satisfactory by %; % were very satisfied or satisfied with courses educational method. % considered the time devoted to lectures, case discussions, and skills lab very adequate or adequate. course duration ( days) was valued suitably by % of responders. the inclusion of non-technical skills was considered as very important by %, important %, of some importance %, of little importance by %, and unimportant by %. this result reflects the insufficient sense of significance, among some, of the importance of trauma team dynamics. course content updates were seen as convenient by % of the surveyed population, suggesting them at least every - years. conclusions: dstc international faculty response to the online survey tool was inadequate, receiving % of the targeted study population. of the assessed faculty, most were satisfied with course content, duration, and educational methods. the surveyed population lacked a uniform perception of the importance of incorporating nontechnical skills. introduction: dstc is an iatsic course emphasizing on teaching surgical skills for trauma care. in many countries, it is an essential course focused on the ''second hour'' beyond atls and teamwork. initially centered on the surgeon, it currently seems to be adopting a trauma team training (ttt) model, incorporating the anesthetist to the program (ds-datc). our objective was to review this changing trend in three countries: spain, portugal, and brazil. material and methods: a descriptive study was designed by faculty from the three countries examining course records and analyzing its evolution during the last five years. number and types of courses delivered in each country from to reported, and the proportion of dstc to ds-datc scrutinized. frequencies and percentages calculated for categorical variables and the proportion of course types also determined. results: during the -year studied period, dstc courses were issued: ( %) in spain, ( %) in brazil, and ( %) in portugal. a total of ( %) ds-datc courses in the three countries, and the percentage of total delivered in each country was as follows; spain ( %), portugal ( %) and brazil ( %). overall ds-datc to dstc ratio was : , detailed as follows: portugal : , spain : , and introduction: thailand is a disaster-prone country with a high dependency on tourism. it has been affected by both natural and manmade emergencies. the thai emergency healthcare system consists of emergency physicians working at hospitals and prehospital levels, emphasizing their essential role in emergency management of any incident. we aimed to investigate the thai emergency physicians' level of preparedness by using tabletop simulation exercises and three different scenarios. material and methods: using the lc (three level collaboration) method, two training sessions were arranged for over thai emergency physicians, who were divided into three groups of prehospital, hospital, and incident command staff. three scenarios of a terror attack and explosion, riot and shooting, and high building fire were discussed in the groups. results: our findings indicate that the initial shortcomings in command and control, communication, coordination, and the ability of situation assessment increased in all groups step by step and after each scenario. new perspectives and innovative measures were presented by participants, which improved the whole management on the final day. conclusions: tabletop simulation exercises increase the ability, knowledge, and attitude of thai emergency physicians in managing major incidents in strategic, tactical, and operative managerial levels, and should be included in their professional curriculum. introduction: non-operative management of traumatic injuries has led to decreased surgical exposure for trauma trainees [ ] . while simulation using cadavers may improve exposure to damage control techniques, tissue handling realism is variable depending on embalmment and perfusion techniques [ ] . objective: to evaluate the feasibility of perfused thiel cadaver use for trauma surgery simulation. material and methods: thiel cadavers were cannulated in the ascending aorta and right atrium to create a left-to-right perfusion system. a magnetic pump was used to achieve a pulsatile flow with a gelatin-based solution, aiming for a flow of l/min. peripheral circulation was improved with arteriovenous fistulas (carotid-jugular, femoro-femoral and brachio-brachial). a left common iliac vein injury was performed laparoscopically through the sigmoid mesentery. the surgical trainee was blinded to the initial injury and assisted by a staff surgeon. results: a trauma laparotomy was performed. the small bowel was eviscerated and all four quadrants were packed with gauze. a left, expanding zone iii hematoma was detected. the left sigmoid colon was mobilized to achieve proximal control of the left iliac vessels. the left common iliac vein was actively bleeding and ligated according to damage control principles. the left ureter was uninjured. the sigmoid mesentery was closed, without active bleeding. the remaining of the abdominal cavity was explored without other injuries. time from laparotomy to closure was min. tissue handling and circulation dynamics were highly realistic due to thiel embalmment and pulsatile perfusion. conclusions: pulse-perfused thiel cadavers represent a realistic simulation option for surgical trainees. widespread implementation may provide accurate simulation for lifesaving procedures rarely performed in an era of non-operative management of traumatic injury. a new concept of intra-operative performance monitoring and self-assessment in hepato-pancreato-biliary surgery and other surgical specialties s. kharchenko , , m. yanovsky colmar civil hospital, university of strasbourg, department of general surgery, colmar, france, hepato-biliary institute henri bismuth, paris, france, interceg, kharkiv, ukraine introduction: currently, the majority of learning curve studies for surgical interventions associated with simple chronometric estimation in a whole: from incision to closure. a selective approach for step-bystep time fixation of all hpb interventions (hepatectomy, others) or other surgical specialties can bring a new vision of correlation between intra-operative timing and the clinical outcome. material and methods: every operation can be divided into step items so standardized worldwide, for example, planned or urgent laparoscopic cholecystectomy e.g. incision to port placement, exposure, dissection to cholangiography, cholangiography, extraction, closure. results: the prototype named chronoi of infrastructure for automated monitoring (simulator of time tracking activities, web-service for request processing, database and knowledge base collection subsystems, learning curve representative and analytics software) is designed and to be implemented. individual self-assessment is available in a real-time fashion. the learning curve changes are shown per procedure. up to our knowledge, we can firstly in the world describe the surgeons, incl. in hpb, as speedy, standard or nonstandard depending on the surgeon's ''individual speed'' in operative performance. it's to be documented in their e-logbooks according to the current fellowship standards or practice re-certification. conclusion: the intra-operative monitoring and worldwide standardization give a new vision of the surgical practice in hpb surgery meaning an introduction of monitoring-based clinical outcomes (timing with morbi-mortality or other). only new trials will approve the role of the presented concept in hpb surgery as well as in general, emergency and trauma. introduction: the management of patients victims of war weapons and collective emergencies represents a major public health issue in france, but also abroad. terrorist events in recent years on the national territory have highlighted the need for training the population and caregivers in the management of these injuries. because of his experiment in the domain, the french military medical service (fmms) was requested to cooperate with the french prehospital teams in order to improve knowledge and teaching in this area. today, a continuing medical education, easily available and free access is needed in this area. material and methods: development of video podcasts (infographics) of a few minutes on the theme of management of patients victims of war weapons and collective emergencies. the working group ensures the production and quality of educational messages. production is provided by the communication establishment of defense. the broadcast is displayed on the channel you tube of the fmms. results: the title of the traum'cast podcast is the contraction of trauma and podcast. twelve episodes are scheduled on a -weeks rhythm. the podcast program is as follows: conclusion: fmms knowledge and experiment in managing patients victims of war weapons is unique. teaching can take various forms, theoretical, practical, academic, or through publications. traum'cast is a major innovation in the dissemination of this knowledge and each episode focuses on a specific skill. traum'cast will highlight the applicability of military medicine concepts in a civilian environment. traum'cast will be translated in an english version. project was supported by grants of french ministry of defense (innovation department). splenectomy in current surgical practice: a tricky and elusive procedure for the surgical resident? introduction: splenic rupture and oncologic resections are the most common indications for splenectomy, but technical expertise is progressively being taken over by non-operative and more conservative approaches. material and methods: retrospective review of all total splenectomies performed between february and january at an italian academic hospital, assessing demographics, diagnosis, operating surgeon, surgical approach, complication rate, postoperative critical care admission, and -day mortality. results: over years, consecutive splenectomies were performed by different surgeons, of whom surgical trainees, with unplanned (i.e. emergency/iatrogenic injury) and planned (i.e. benign/malignant disorders) procedures and an average of . and . procedures per year respectively. over the study period, only surgeons performed at least procedures and only performed at least procedures. laparoscopy was performed in . % of cases, predominantly during planned procedures, with an overall . % conversion rate mostly related to technical difficulties (i.e. spleen dimension, difficult vascular visualization). overall major postoperative complication rate (clavien-dindo c ) was . %, slightly higher in emergency procedures although not significantly different ( . % vs. . %, p = . ). reintervention rate was . %, due to hemorrhage in more than half of cases. overall -day mortality rate was . %, with elective -day mortality rate of . % (p = . ). conclusions: splenectomy may be required ever more rarely but potential risks are not irrelevant. competence for surgical trainees should be achieved elsewhere (e.g. simulated/cadaveric training case history: an year old femal patient underwent changing of the components of the tha because of aseptic loosening. due to circumstances the surgeon decided to implant a cemented femoral component. the procedure was without any significant abnormalities. the first postoperative radiograph was planned after recovery-as usual. the x-ray imaging showed a misplaced femoral component. therefore a ct-scan was performed additionally and the malposition of the cemented femoral component was confirmed. the patient had to undergo another surgery-removing of the cemented femoral component and implantation of a new well placed one. therapy and progressions: after prompt resuscitation, an emergency laparotomy was performed and an anastomotic leak was found, requiring re-do ileo-ileal anastomosis. postoperative course was complicated by intra-abdominal collection treated by antibiotics alone (clavien-dindo grade ). the patient was discharged on th pod. at pathological report, segmental absence of intestinal musculature (saim) was diagnosed. the revision of past specimens confirmed the same finding. comments: usually recognized in neonates/premature infants, saim is generally an incidental finding in adults [ ] , often undiagnosed and more frequently described in the colon [ ] . in such scenario, main differential diagnosis is ischemia. etiology is unclear and can be classified as either primary/congenital or secondary. the former is characterized by acute onset of symptoms, whereas in the latter a longer history of intestinal symptoms is usually present [ , ] . most authors agree upon a congenital pathogenesis. generally, saim is associated with hollow viscus perforation and treated with surgical resection. contrary to our experience, no recurrence of intestinal perforation has been reported [ ] virgen del rocío university hospital, general surgery, seville, spain, hospital regional de málaga, general surgery, málaga, spain, hospital de estella, general surgery, navarra, spain, hospital gregorio marañón, general surgery, madrid, spain, complejo hospitalario de jaen, general surgery, jaen, spain introduction: specific training in the management of trauma patients is essential for surgeons. training through courses in this area (atls, dstc, musec) directly impacts the care of these patients. the aim of this study is to know the specific training in trauma care of spanish surgeons. materials and methods: a national survey has been sent to all member surgeons of the spanish surgeons association. it has evaluated their degree of participation in emergency surgery acute care, and therefore the possibility of attending trauma patients, their participation in the initial care at their hospital, as well as their specific training in this area. results: the survey has been completed by surgeons from spanish regions, and most surgeons who responded were from catalonia and andalusia. ( . %) of those surveyed take calls for the ed. only ( . %) report having a hospital registry of trauma patients. . % of surgeons answer that in their hospital the general surgeon is not involved in the initial care of trauma patients. . % have taken the atls course, . % the dstc course, and . % the musec course (or another course on e-fast). despite this, . % consider the atls course should be mandatory during residency, and . % of those surveyed consider trauma care in their hospital as very bad or deficient. conclusions: according to this survey, specific training in trauma care is still deficient in spain and with many aspects that can be improved. only % of those surveyed have received specific training in definitive surgical management of severe trauma. despite this, a large percentage of surgeons take calls for the ed routinely, and face the challenge of managing these patients. exploring team leaders' decision-making challenges in civilian and military complex trauma introduction: in the nordic countries professionals may work in both civilian and military trauma care. timely and effective decisionmaking in complex trauma is essential in improving survival benefits. the mindset and management priorities differ among medical professionals, and correlate with different experience levels. trauma leaders are usually senior surgeons with extensive experience and well-developed decision-making skills. simulation training has been shown to be effective in practicing decision-making. the aim of this study is to explore the team leaders' decision-making challenges in complex trauma care and structure them with the activity theory framework (at). material and methods: video recordings at a trauma center in johannesburg and live observations of complex trauma training in gothenburg focusing on team leaders' decision-making challenges were analyzed and systemized using the at. results: the team leaders' activities were mapped onto the main elements of at ( fig. ) whereby the decision making challenges were classified into six categories (table ) . conclusions: the at framework may benefit and inform the design of educational interventions by structuring key issues of complex activities. introduction: trauma is one of the main causes of mortality worldwide and prevention stands out as one of the main ways to modify its incidence. a prime example of such initiatives is the prevent alcohol and risk-related trauma in youth program (p.a.r.t.y.). it aims to raise awareness of the population most at risk for trauma, young people from to years. the study objective was to evaluate the program impact on students' knowledge and behavior. material and methods: a quantitative, uncontrolled intervention cohort study was conducted through the responses of the p.a.r.t.y. in and . data collection occurred through the application of a questionnaire to participating and non-participating students of public schools in the city of campinas, after a few months of participation in the program. results: among answers, . % were male, . % between and years, and . % program participants. time between participation and answers was . (± . ) months. regarding the first conducts when facing traffic trauma, . % of those who participated chose the correct answer, against . % of those who did not. about the first care while the service does not arrive, . % of the first group answered correctly, compared to . % of the second. concerning about the service that should be called in the event of a trauma, . % of participants would call correctly against . % of non-participants. in questions related to traffic laws, . % of participants opted for the correct answer as to what should be done in the face of a running over, against . % of non-participants. conclusions: students who had participated in the program had a higher rate of correct answers, a few months after the event, compared with students who did not attend. thus, it is concluded that there is a impact over the time caused by it. introduction: currently, intraosseous (io) devices are necessary for the resuscitation of severe trauma patients. however, opportunities to learn io device insertion are limited for residents. the aim of this study was to conduct a simulation of io device insertion for residents and to evaluate its effectiveness. material and methods: in this simulation, residents inserted io needles into the sternum of pigs under general anesthesia with the instructor's guidance. comprehension tests and questionnaires about satisfaction level and self-efficacy were conducted before and after the simulation. the objective evaluation was the io access success rate, and the subjective evaluation was obtained from points on comprehension tests and questionnaires. results: thirty-six residents participated in this study. just one resident had successfully obtained io access clinically. success rate of establishing io access in the simulation was %. the rate of test completion was % and that of questionnaire with survey response was %. the comprehension test results improved from . ± . to . ± . (mean ± standard deviation, p = . ) out of points. the questionnaires concerning satisfaction level changed from . ± . to ± . (p \ . ) out of points. the questions specifically concerning self-efficacy dramatically increased from . ± . to . ± . (p \ . ) out of points after the simulation. conclusions: the simulation in this study improved the knowledge, satisfaction level, and self-efficacy of the residents for io access. the success rate of confirmation of io access in this study was %. this experience may positively affect their clinical performance in trauma care. case history: case . a -year-old white man presented to the ed complaining of intense abdominal pain and vomiting. he referred at least two previous episodes with associated fever which resolved spontaneously. case . a years old white man consulted at the ed for intense abdominal pain, nausea, anorexia and constipation for the last h. none history of abdominal surgery were registered. clinical findings: in both cases, the abdomen was distended without bowel sounds. investigation/results: case . abdomen xr: distended small bowel loops localized at the right side. ct scan: an encapsulated cluster of dilated small bowel loops into the ascending mesocolon. case . ct scan: an encapsulated nonrotated small bowel in the right side of transverse mesocolon and mesenteric vascular pedicle displaced. diagnosis: intestinal obstruction secondary right paraduodenal hernia therapy and progressions: emergency midline laparotomy that evidenced a rpdh which was reduced before closing the mesentery defect. the postoperative was uneventful. comments: paraduodenal hernias are a type of internal hernia and a rare cause of intestinal obstruction accounting for about . % of all hernias. right paraduodenal hernias are far less common than left ones. symptoms of paraduodenal hernias are nonspecific. preoperative diagnosis of pdh by imaging techniques is difficult. contrastenhanced ct scan is highly recommended as the most specific method of diagnosis for pdh. with the increased use and improved enhancement of ct scans, paraduodenal hernias currently can be diagnosed preoperatively. this advancement in diagnostics coupled with increasing experience and facility of general surgeons in using laparoscopic techniques has led to the initiation of laparoscopic repair of internal hernias. case history: a -year-old female patient who goes to the emergency department due to vomiting and abdominal pain. since the accident, the patient reported post-prandial discomfort and gastroesophageal reflux, as well as self-limited abdominal cramps. clinical findings: soft, depressible abdomen. bowel sounds on left hemithorax. investigation/results: cxr: right hemidiaphragm elevation. lab test: leukocytosis. thorax and abdomen ct: right anterior diaphragmatic hernia and passive atelectasis secondary to ascent of dilated small intestine and colon. diagnosis: intestinal obstruction secondary post trauma diaphragmatic hernia. therapy and progressions: emergency laparotomy due to symptoms compatible with intestinal obstruction secondary to incarcerated diaphragmatic hernia. it is right diaphragmatic chronic rupture chronic with omental incarceration, antrum, small bowel and ascending colon with reversible signs of suffering. chelotomy and content reduction, herniorrhaphy with loose spots with non-absorbable material are performed. endothoracic drainage is left removed at h. the postoperative course is uncomplicated. comments: trauma events should be considered in the diagnostic process to avoid delayed treatment. case history/clinical findings: we present a -year-old male patient with a history of large pelvic mass in the rectum-prostate space under study, since months. he were admitted into the emergency unit, days after the mass biopsy, with fever up to °c and rectorrhagia. the patient rapidly developed septic shock with hemodynamic instability and elevation of acute phase reactants. abdominal ct was performed: pelvic mass of . . cm, of heterogeneous content, with areas of blood density. we decided doing an emergency surgical exploration of this mass as the only suspected origin of infection. investigation/results: in the surgical exploration the mass was protruding on the anterior rectum wall. the mass was drainaged with an output of ml of purulent material mixed with clots and necrotic tissue. foley no. probe was placed inside the cavity. in the postoperative period, the patient showed significant hematochezia, so he was reoperated performing hemostasis and rectal tamponade. it was effective and a new foley catheter was replaced at h. when the purulent drain gave way, the catheter was removed and the patient evolved favorably. diagnosis: cytology analysis: mesenchymal type lesion, morphologically and immunophenotypically compatible with gist (gastrointestinal stromal tumor). ihq profile: cd , dog , c-kit positive. therapy and progressions/comments: the complications of gist are usually acute abdomen due to peritonitis secondary to perforation or hemorrhage. however, the formation of intratumoral abscesses is very inusual, although is described in the literature. emergency surgery is often necessary due to the significant affectation of the general condition of the patient and the difficulty of the diagnosis. fournier's gangrene (fg) is a surgical emergency defined by an obliterating endarteritis of the subcutaneous tissue arteries of infectious etiology, with progressive necrotizing fasciitis of the perineal, abdominal, thoracic or lower limbs, which can lead to multiorgan failure. a years old woman was admitted in our er presenting with a week worsening vulvar pain. clinical exam showed vulvar and mons venus erythema, without lesions, bp was / mmhg and she had a fever of . °c. blood work showed leukocytosis ( . /ll), neutrophilia ( . /ll) and crp of mg/ l. past medical history of obesity, right thp and total thyroidectomy. vulvar cellulitis was the initial diagnosis and empirical atb was implemented. on d , due to an evolution into septic shock and spread of an emphysematous inflammatory process to the right thigh and buttock, the diagnosis of fg was made. during emergent surgery we observed extensive fascial and tissue necrosis from the asis and suprapubic region to the proximal third of the right thigh and perineum. extensive necrosectomy, drainage of purulent exudate and transversostomy were performed. empirical second-line broad-spectrum atb was started. she underwent new necrosectomies and surgical debridements on po days and and needed icu stay for days. daily dressing changes were performed with povidone iodine and later with octenidine. microbiology sample showed polymicrobial infection with gram positive and negative organisms as well as anaerobes, thus confirming the diagnosis of fg type i of vulvar origin. after surgical and hd stabilization, the patient underwent plastic reconstructive surgery, with local flaps and partial skin graft. the postoperative period was uneventful and the outcome was great. introduction: appendicitis is not uncommon in the elderly but may often be mis-diagnosed [ ] . the aim of this study was to explore the specific traits and treatments of this group in a swedish context to better understand where to optimize the management. material and methods: all acute appendectomies registered in the southern general hospital registry between january and june constituted the cohort (n = ). patients were stratified into two groups; c and \ years of age. significances were computed with pearsons chi and anova. results: the older group made up % of the study population (n = ). the elderly population was female to a larger extent (or . , p \ . ), triaged higher in the emergency department (p \ . ) and had higher asa classifications (p \ . ). the elderly were also perceived as sicker at the time of decision for surgery, expressed as having higher priorities for surgery (p \ . ). no significant difference between the groups in time from arrival to decision for surgery was found, nor for the time from arrival to surgery. there was a higher rate of perforations in the elderly group ( . % vs . %, p \ . ), twice the length of hospital stay (p \ . ) but no significant differences in complication rates ( . vs . %, p = . ). twenty-eight day mortality rate was % in the younger group and . % in the older group (p \ . ). conclusions: this study shows that an elderly group of appendicitis patients are more frail and more acutely sick when presenting to the hospital. in spite of higher priority for surgery, the elderly experience longer hospitalization and higher mortality rate, but not more complications. the findings are consistent with antecedent research. introduction: existing evidence points towards the notion that patients undergoing emergency surgery receive a poorer consenting quality when compared to their elective counterparts. with , cholecystectomies in england a year, cholecystectomy is one of the most frequently performed procedures both in the emergency and elective settings. however, to date, no studies have explored the relationship between consenting quality and the setting of cholecystectomy. we aimed to measure the quality of informed consent (ic) for patients who underwent emergency vs elective cholecystectomy. material and methods: the final review included the analysis of ic forms completed between - . percentage proportions were calculated to demonstrate the degree of completeness of consenting against a total of components of information. binary regression was utilised for subgroup analysis. results: patients undergoing emergency surgery were more likely than elective patients to be warned of severe perioperative complications such as cardiac disorders ( . % vs . %, p = . ), fluid collection ( . % vs . %, p = . ), and infected bile spillage ( . % vs . %, p = . ). elective patients were more likely to be counselled about the risk of less serious side effects of cholecystectomy such as diarrhoea ( . % vs . %, p = . ). patients in asa - group were more likely to be counselled about the occurrence of pulmonary embolism. interestingly, patients were more likely to receive a patient information leaflet if they were females and under . conclusions: the results of this study demonstrate multiple inconsistencies in the level of disclosed information to patients undergoing cholecystectomy. the results suggest that the consenting physicians make assumptions regarding the information that the patient would like to receive based on patient demographics and clinical factors, highlighting the need for more consistent consenting procedures. acute calculous cholecystitis and the timing of cholecystectomy: advocating early surgery i. moutsos , r. lunevicius liverpool university hospitals nhs foundation trust, general surgery, liverpool, united kingdom introduction: cholecystectomy cures acute calculous cholecystitis (acc) in nearly all patients and, according to nice, augis, tokyo and wses guidelines, should be conducted at the earliest opportunity, within days of the diagnosis. the present audit aimed to measure whether the care of patients with acc meets the standards of best practice and to assess whether early cholecystectomy was a more beneficial and safer intervention as compared to delayed cholecystectomy. material and methods: a ''snapshot'' sample of patients operated on between / and / with an index admission diagnosis of acc was reviewed. the selected patients were divided into three subgroups according to the timing of their surgery: - (early), - , and[ days. the other measures used in this audit were the rates of conversion to open surgery, subtotal cholecystectomy (stc), perioperative complication-specific morbidity, secondary interventions, and admission to intensive therapy unit (itu). results: nine patients ( %) underwent early cholecystectomy-laparoscopic (n = ) or primary open (n = ); of the other patients-delayed laparoscopic cholecystectomy. the rates of stc were similar in both subgroups- . % ( / ) vs . % ( / ). delayed cholecystectomy was related to five side effects: higher rates of postoperative collections (three patients, . %), external bile leak (one patient, . %), ercp ( . %), emergency re-operations (two patients, . %), and admission to itu ( . %). they all occurred in the delayed [ weeks surgery subgroup of patients. conclusions: although no significant associations were found when comparing early to delayed cholecystectomy, this analysis shows that postoperative morbidity, the rates of secondary interventions and admissions to itu were higher when surgery was delayed. this audit advocates that early cholecystectomy should become a standard of practice as per national and international guidelines. esophagopericardial fistula following primary repair for chronic esophageal ulceration presenting with pericardial tamponade: a case report and outline of management and treatment case history: a -year-old man with chronic esophageal ulcerations presented with substernal pain, fever, and shortness of breath. a radiograph revealed a right pleural effusion and pneumomediastinum consistent with an esophageal perforation (fig. ). he underwent a right thoracotomy, primary esophageal repair with intercostal muscle flap buttress, and gastrojejunostomy feeding access. a post-procedural gastrograffin study demonstrated an anastomotic leak (fig. ) . a right thoracostomy drain was placed for diversion. the patient was discharged home and returned days later. clinical findings: he presented with substernal pain, hypotension, and fatigue. thoracic computed-tomography (ct) revealed a pneumopericardium and an esophagopericardial fistula (epf) manifesting as pericardial tamponade (fig. ) . diagnosis: epf. therapy and progressions: the patient underwent a subxiphoid pericardial window and mediastinal drain placement for decompression. an esophagogastroduodenoscopy revealed an exposed right atrium, thus precluding esophageal stenting. sepsis and antibioticassociated clostridium difficile colitis complicated his post-operative course. once resolved, the patient underwent a partial esophageal resection, epf ligation, and esophagogastrostomy. the postoperative gastrograffin study did not demonstrate an anastomotic stricture or leak. the patient tolerated a regular diet and was discharged home. comments: esophagopericardial fistula is a rare clinical entity most often caused by benign disease. prompt diagnosis and treatmentpericardial decompression and fistula ligation-is critical. due to wide use of proton pump inhibitors and development of interventional radiology (ir), causative reasons are changing. introduction: secondary peritonitis yields high morbidity and mortality rates. besides rapid source control, adequate antimicrobial therapy is essential to improve outcomes. thus initial empiric therapy has to take suspected germ spectrum as well as possible resistance rates into account. microbial selection and resistances may pose problems during prolonged administration of antibiotics. however, a possible negative effect of multi-resistant germs on mortality has not yet been clarified. the choice of a suitable antibiotic and the relevance of its efficacy on isolated germs as well as the relationship between germ spectrum and clinical condition of the patients need to be clarified. material and methods: intraabdominal swabs from consecutive patients from to requiring intensive care due to secondary peritonitis were evaluated retrospectively. patient characteristics and outcomes, germ spectrum and resistance rates were collected. changes over the course of therapy and development of resistance as well as influences on the clinical course were analyzed. introduction: complicated intra-abdominal infections (c-iai) represent challenging diseases with high mortality rates. depending on different selection criteria and therapy strategies the reported mortality rates vary between . and %. usually a distinction between community (cap) and hospital acquired peritonitis (hap) is made. hap can further be classified as postoperative peritonitis (pop) or non-postoperative peritonitis (hap-non-pop). we conducted a retrospective analysis of patients with c-iai requiring intensive care therapy. material and methods: all patients with c-iai requiring surgery and intensive care treated at the danube hospital in vienna from to were retrospectively analyzed. a total of patients where included into the study and grouped as cap, hap-non-pop or pop. for each group comorbidity and patient characteristics, source and cause of infection, hospital and icu stay, apache ii, saps ii and sofa-scores, mortality and outcome were calculated and compared to each other, using fisher exact test or mann-whitney-u-test. results: a total of c-iai were treated, consisting of . % cap, . % hap-non-pop and % pop. concerning the patient characteristics and comorbidities no significant differences were seen between the groups, except for malignant diseases which were significantly higher in pop. the postoperative (source control) apache ii and saps ii values did not differ between cap and pop (apache ii mean: cap . , pop . ) whereas both were significantly higher in hap-non-pop (apache ii mean: . ). mortality rates were not significantly different in cap and pop ( . % vs. . %): however, hap-non-pop was complicated by a nearly doubled death rate ( . %). conclusions: although patients with pop are described to have a higher mortality in the literature, this could not be shown in our study. postoperative survival was comparable between cap and pop patients. hap-non-pop demonstrated a significantly higher mortality. acute appendicitis and acute diverticulitis presenting concurrently treated surgically and conservatively clinical findings: on examination the abdomen was soft but there was tenderness and guarding in the right iliac fossa and suprapubic region. her observations were stable on admission and she was afebrile. investigation/results: laboratory tests demonstrated a wcc . ( /l) and crp of . (mg/l). urinalysis was normal. a ct of the abdomen and pelvis with intravenous contrast demonstrated acute appendicitis with non-perforated sigmoid diverticulitis (fig. , fig. ). diagnosis: concurrent acute appendicitis and non-perforated sigmoid diverticulitis. therapy and progressions: the patient underwent a laparoscopic appendicectomy. intraoperative findings included a retrocaecal inflamed appendix and diverticulitis in the pelvis which was not disturbed. there was no pus in the pelvis. she recovered well postoperatively and was discharged home to complete one week of oral antibiotics the following day. the histology demonstrated acute appendicitis. comments: there are very few reports in the literature of concurrent appendicitis and sigmoid diverticulitis despite these two pathologies being amongst the most common presentations of abdominal pain. this case demonstrates the value of cross sectional imaging, ct imaging is a helpful diagnostic tool and is highly sensitive and specific for both diverticulitis and appendicitis.the challenge in this case is balancing the two differing managements of these two conditions. most cases of diverticulitis are managed conservatively with dietary modification and antibiotics. operative management is only usually considered if there are associated complications such as intraabdominal perforation. this is in contrast to appendicitis where the standard treatment is to undergo surgery. references millions of people die from major trauma annually. - % of these deaths are due to exsanguination, with nearly half dying prior to hospital arrival. when properly managed, these deaths are preventable. this paper summarizes data relating to the extent of hemorrhage as a cause of mortality in the traumatic arena. an overview of the pathophysiological steps occurring during massive bleeding and their clinical implication is presented. a variety of treatment options, both historical and current, is then discussed, including vascular occlusion methods and hemostatic dressings, along with their limitations and complications. finally, woundclot, a new hemostatic gauze, is introduced, which not only requires no compression when it is applied, but allows the first responder to rapidly and effectively treat more than one casualty within seconds. additionally, it is adaptable to a wide array of clinical applications, both traumatic and surgical, including situations where vascular occlusion methods are not practical or are contraindicated. i am the clinical research administrator for core scientific creations treating acute colonic diverticulitis with extraluminal pericolic air; a multi-centre retrospective cohort study background: since the emergence of acute care surgery as an entity encompassing trauma and emergency general surgery there have been several studies evaluating patient outcomes noting a higher unexpected survivorship and expedited operative times, shorter hospital stays, and fewer complications for patients undergoing procedures such as appendectomy; however, these superior outcomes have not been demonstrated across the array of emergency surgical cases. the aim of this investigation is to determine whether patients operated on by acute care surgeons in a trauma center benefit from the trauma model of in-house availability, earlier availability of surgical care, and care dictated by evidence-based protocol. we examined our health care system's data to determine if trauma centers were to able to provide more timely care with improved outcomes, by focusing on truly emergent general surgery cases. this was examined by identifying and quantitatively comparing time to operative intervention, need for re-operation, hospital length of stay, duration of stay spent in intensive care unit, and patient disposition at time of discharge. methods: this is a retrospective cohort study. patients presenting with emergency general surgery conditions (incarcerated hernia, perforated viscus, sbo, necrotizing soft tissue infection) who underwent surgery within h of presentation were selected. outcomes were compared between patients presenting to our two trauma centers versus our two non-trauma centers. n = results: at this time we are nearing the finalization of our data interpretation. we are examining mean time to operation, los, icu los, need for re-operation, and disposition at discharge. discussion: although our data analysis is not complete we feel that the results of our data will shed valuable and needed light onto the care delivered to emergency general surgery patients by surgeons in this increasingly complex population. anastomosis leakage after hartmann removal, with conservative treatment at the beginning but after, bad evolution, a surgery was performed with colostomy and vac system. patient. after h, he develop a compartmental syndrome and a vac system was applied. investigation/results: patient. after the first change the distance between the two layers was cm and botulinum toxin was applied. pat. the distance between the two layers of abdomen was cm and botulinum toxin was applied. patient. the distance between the two layers was cms and toxin was applied. unfortunately, he suffered from a hepatorenal syndrome and died. diagnosis: open abdomen with distance between the two layers: cm, and cm. therapy and progressions: we have added botulism toxin with doses of units in each side of abdominal wall. patient. three changes after, the abdomen wall was closed. months later, the abdominal wall is ok. patient. a reduction of % was got. comments: the use of open abdomen in patients suffer from septic shock or after an abdominal compartment syndrome often poses a challenge in the abdomen closure. we have developed a protocol, dividing our patients according to the distance between the two layers in two group: more than cm or cm or less. in the first group ([ ), we present our first cases in our protocol. conclusions: botulinum toxin can make easier abdomen closure when the distance between the two layers is more than cms incidentally discovered splenic peliosis in a patient with no comorbidity clinical findings: a -year-old man with no comorbidities visited our emergency medical center based on a complaint of chest pain. the chest and abdomen radiographs, electrocardiogram, and cardiac markers showed no abnormalities; therefore, he was discharged from the hospital. two months later, he returned to our hospital with abdominal pain and distension. he was hemodynamically stable, and there were little tenderness and rebound tenderness on his abdomen, although he complained a slight abdomen discomfort investigation/results: no abnormalities were found on the laboratory examinations, including complete blood cell count, cardiac markers, and coagulation profile. an abdomen computed tomography revealed multiple hemorrhagic cysts on spleen with moderate amount of hemoperitoneum. diagnosis: ruptured splenic peliosis with hemoperitoneum. therapy and progressions: laparoscopic splenectomy was done because recurrent rupture of hemorrhagic cysts was strongly anticipated. on histologic examination, the blood-filled cysts were welldemarcated, distributed in red pulp congestion. no vascular-endothelial cells were observed, and normal lining cells were disappeared in the wall. comments: a peliosis is a rare disorder characterized by widespread, blood-filled cystic cavities within the parenchymatous organs. the liver is the most commonly involved organ, and an isolated splenic peliosis is extremely uncommon. patients are often asymptomatic; therefore, early recognition and withdrawal of offending agents is crucial. in cases with the rupture of surface lesions, which can occur spontaneously or by the minor trauma, prompt surgical management is necessarily required. splenectomy offers the advantage of a definite histological diagnosis with the complete elimination of the risk of recurrent hemorrhage. introduction: despite an evident success and advantages of endoscopic surgery, the discussion on reasonability of endoscopic surgeries in children with acute appendicitis is still going on. purpose: to assess the effectiveness of laparoscopic techniques for treating appendicular peritonitis in children. material and methods: children with appendicular peritonitis were operated in our hospital ( ) ( ) ( ) . they aged - years ( ± . ); . % of boys, . % of girls. appendicular peritonitis was registered in . % cases of acute appendicitis. three ports were used for the approach: appendectomy was performed by the ligature technique with roder loop. results: laparoscopic surgery is indicated in all forms of appendicular peritonitis, except appendicular abscess stage , and total abscessing peritonitis. in appendicular abscess stage , we perform a puncture and drainage under ultrasound control. - months later appendectomy is made. total abscessing peritonitis is an indication for laparotomy. laparoscopic surgery in patients with peritonitis has the following stages: diagnostic laparoscopy; sanation of the abdominal cavity by the aspiration of purulent exudate; ligature appendectomy; in diffuse and combined peritonitis a pelvic aspiration drainage is made. in appendicular abscess stage , we additionally put the aspiration drainage in the cavity of destructed abscess. conclusions: laparoscopic technique applied for surgeries in children with acute appendicitis has considerably improved outcomes introduction: nighttime emergency surgery is associated with increased postoperative morbidity and mortality [ ] , and delayed appendectomy due to acute appendicitis is not linked to a higher rate of postoperative complications (pc) [ ] . the aim of this study was to determine whether appendectomy on-call (oc) was associated with higher risk of pc. ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . two patients underwent major thigh amputation. negative pressure wound therapy and hyperbaric oxygen therapy were used in and patients, respectively. three patients died (mortality rate = %). conclusions: the mortality and major amputation rates ( % and %, respectively) were lower than those reported previously. in this study, even when patients had multiple organ failure or septic shock, major amputation was not always needed because of effective communication between the infection control team and intensive care specialists, resulting in radical debridement without amputation. material and methods: a systematic search in pubmed/medline, embase, cinahl and central was performed. the primary outcomes were mortality and amputation. these outcomes were related to the following time related variables ( ) time from onset symptoms to presentation; ( ) time from onset symptoms to surgery; ( ) time from presentation to surgery; ( ) duration of the initial surgical procedure. for the meta-analysis, effects were estimated using random-effects meta-analysis models. results: a total of studies ( patients) were included for qualitative analysis, of which patients died ( . %). a total of studies ( nsti patients) were included for the different quantitative analyses performed. mortality was significantly lower for patients with surgery within h after presentation compared to when treatment was delayed more than h (or . ; % ci . - . ). surgical treatment within h resulted in a % mortality rate compared to % when surgical treatment was delayed more than h. also, surgery within h reduced the mortality compared to surgery after h from presentation (or . ; % ci . - . ). patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. none of the time related variables assessed reduced the amputation rate. conclusions: average mortality rates reported remained constant (around %) over the past years (fig. ) . surgical debridement as soon as possible lowers the mortality rate for nsti with almost %. thus, a sense of urgency is essential in the treatment of nsti. altemeiers procedure in an emergency setting case history: three patients with irreducible incarcerated rectal prolapsed were referred to our department for treatment. all patients were female and their age was , and years old. all patients suffered from severe co-morbidities. clinical findings: all patients presented with incarcerated rectal prolapse. in one patient there was macroscopic evidence of mucosal necrosis, whereas the other two patients had evidence of ischemia. the former patient was febrile whereas the latter did not exhibit signs or symptoms indicative of sepsis. investigation/results: blood panels demonstrated leukocytosis and elevated levels of c-reactive protein (crp) in all patients. apart from routine imaging upon admission (e.g. chest radiography), no other imaging modalities were performed. diagnosis: irreducible incarcerated rectal prolapse. therapy and progressions: initially manual reduction of the prolapsed was attempted without success. all patients were evaluated as high risk surgical candidates. altemeier's procedure was selected as a safer alternative to an abdominal approach. all patients were successfully discharged after resumption of bowel function. comments: incarcerated rectal prolapse is a rare clinical condition. initial management involves manual reduction of the prolapse. when this is not feasible, urgent surgical management is mandatory. in patients with severe co-morbidities, altemeir's procedure is a safe and effective treatment when performed by an experienced practitioner. introduction: treatment options for sigmoid volvulus are decided by its severity. uncomplicated cases are usually treated by endoscopic detorsion followed by elective surgery and complicated cases or cases can't be detorsioned are treated with emergency surgery. in this study we aim to review a single center experience in long term management of sigmoid volvulus cases. material and methods: data of the sigmoid volvulus cases between - were collected using hospital database. files of patients were reviewed for treatment modalities, demographic info and complications. patients were dropped from the study due to inadequate long term follow-up. results: were men and were women. mean age was , . endoscopic detorsion was attempted in cases. success rate was % (n = ). of these patients were followed up with elective surgery. patients with complicated cases and unsuccessful detorsion patients were managed by emergency surgery. hartman procedures, anterior resections, left hemicolectomies, subtotal colectomy and transverse loop colostomies were done. a stoma was created in cases. patients had their stoma created in the primary surgery and an additional of stomas were created due to anastomosis leakage. mortality rate in the first days was % (n = ) in patients with a stoma (n = ). asa and charlson co-morbidity scores were exceptionally high in the mortality group. in the remaining patient group, stoma closure rate was . %. conclusions: endoscopic detorsion is a powerful and highly successful management option in uncomplicated cases when done by an experienced staff. emergency surgery shouldn't be delayed in complicated cases or after unsuccessful detorsion attempts. introduction: esophageal perforation has high mortality rates when not treated aggressively. treatment options are conservative approach, endoscopic intervention and surgery. purpose of this study is to review cases of esophageal perforation in a single center and to evaluate types of diagnosis and treatment options. material and methods: using hospital database we collected data of patients diagnosed with esophageal perforation between - . we reviewed treatment modalities, demographic data and complications. patient was removed from the study due to insufficient long term data. results: were female and were male. average age was . . average time between the onset of symptoms and admission was . days. the most common etiology was iatrogenic (n = ) followed by consumption of corrosive substances in patients, spontaneous perforation in patients, esophageal tumour in patients and foreign body ingestion in patients. patients were treated surgically, patients were treated with endoscopic stenting and patient was treated with surgery following stenting. patients were managed conservatively with antibiotherapy. average time in intensive care was . days and average hospital stay was . days. mortality was seen in patients treated with surgery and patients treated with stents. conclusions: esophageal perforations are mainly iatrogenic but also can be caused by multiple reasons. especially in cases developed after endoscopy, rapid intervention can be a significant factor that can decrease both mortality and morbidity rates. introduction: spontaneous rupture of liver tumors (rlt) is a rare but potentially life-threatening condition. damage control techniques, namely perihepatic packing (php), is a resource for the most physiologically compromised patients, with more stable patients undergoing transarterial embolization (tae) or immediate resection. decision algorithm depends on patient status, available resources and liver function. the authors present their center experience in managing rlt and propose a management algorithm. material and methods: eighteen consecutive patients who underwent surgery for rlt in our department (january -october ). inclusion criteria: spontaneous rupture and evidence of intraperitoneal bleeding. fourteen patients were male. mean age of . years ( - ). thirteen patients ( %) presented in hemorrhagic shock. mean tumor size was . cm ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . most frequent pathological diagnosis were: hepatocellular carcinoma in cases ( %); adenoma in three cases ( %); metastases in two cases ( %); liver sarcoma in one case ( . %). median of seven units transfused by patient ( - ). statistical analyses with spss tm version . results: six patients ( %) needed immediate surgery (php in three and resection in three). five ( %) underwent urgent ([ h and \ h) and seven ( %) delayed ([ h) resection. hepatectomy was performed on all (fifteen minor and two major) but one patient php only. eight patients ( %) underwent tae prior to resection, two of them ( %) between php and hepatectomy. median length of stay days . major morbidity in three patients ( %); mortality in three patients ( %). number of transfused units associated with increased risk of complications (p = . ). conclusions: rupture of liver tumors is a severe complication. although hepatic resection, with or without preoperative tae, should be considered gold standard, damage control techniques such as php are the only option for physiologically compromised patients (fig. ) . seasonal variability of cellulitis: a five year retrospective cohort study introduction: it is commonly purported that the incidence of cellulitis is highly seasonal but there is little empirical evidence supporting this assertion. this year retrospective cohort study set out to identify whether there is a statistically significant relationship between an increase in temperature and incidences of cellulitis. as a corollary to this proposition, length of hospital stay for cellulitis was examined in relation to the level of inflammatory markers upon admission and micro-organism identified on culture. material and methods: this is a year retrospective single centre cohort study of all patients admitted with cellulitis to tallaght university hospital from to inclusive. the patient cohort was identified via the use of a prospectively managed database of all surgical admissions and corroborated via examination of clinical chart records. dates of admission were correlated with the average temperature of dublin as provided by the meteorological office of ireland. site of infection, inflammatory markers and the prevalent micro-organism were also identified whilst the length of admission was extrapolated from hipe (hospital inpatient enquiry) records. results: there were admissions for cellulitis with cases of necrotising fasciitis. there was a statistically significant (p \ . ) relationship between temperature and cellulitis with admission peaking in late summer/autumn. age correlated significantly with readmission. furthermore, the level of crp had a statistically significant prognostic value as an independent predictor for the length of hospital stay with a high level resulting in a prolonged admission. conclusions: there is a statistically significant relationship between a rise in temperature and the incidence of cellulitis. furthermore age is an independent risk factor for re-admission with same whilst inflammatory markers at time of admission can be used as a prognostic marker for length of stay. case history | clinical findings: a -year-old female patient, with history of type ii diabetes, high blood pressure and major depressive syndrome, was admitted in the emergency room department complaining of abdominal pain. based on the patient's history and physical examination, a presumptive diagnosis of renal colic was initially made. however, after days, the patient showed signs of fever, aggravated abdominal pain and vomiting. investigation/results | diagnosis | therapy and progressions: a ct scan showed the presence of a radiopaque foreign body near the duodenum, the presence of air bubbles outside the intestinal lumen and an hepatic abscess. we agreed to perform a laparoscopy, drainage of hepatic abscess and fish bone removal after successfully identification. after days, the laboratory findings showed persistent leukocytosis and raised cpr, which led to a second ct scan with maintenance of the hepatic abscess. the decision was to perform a percutaneous drainage. after the second drainage, the patient had an uneventful recovery. comments: foreign body ingestion into the gastrointestinal (gi) tract is rare and typically accidental in adults. most ingested foreign bodies pass through the gastrointestinal tract without the need for any intervention. gi perforation is rare and can occur at any site. surgical intervention is required in less than % of the cases. fish bones are the most commonly ingested objects. preoperative diagnosis, when possible, is made with ct scan, identifying a linear high-density structure. high level of suspicion is of paramount importance. in cases of delayed diagnosis, perforation may lead to intraperitoneal abscess formation. reports of hepatic abscess secondary to fish bone perforation has been limited to isolated case reports in the literature. case history: description of two cases of appendicular goblet cell carcinoid tumors, which debuted as acute appendicitis. patient a was a -year-old woman with a -h evolution of classic symptoms of acute appendicitis. patient b was a -year-old female that consulted for chronic abdominal pain in rlq that recently increased pain intensity and fever. clinical findings: patient a had pain and defense in rlq without a fever. patient b had a chronic painful fluctuating mass in rlq, with fever over °c. investigation/results: patient's a lab test showed leukocytosis and us findings of acute appendicitis. the patient's b ctscan showed an intra-abdominal abscess fistulized to the abdominal wall, along with formation of a phlegmonous mass related to appendicular plastron. diagnosis: the anatomopathological reports for both patients were informed as appendicular goblet cell carcinoid tumor. therapy and progressions: both underwent laparoscopic exploration. after appendicectomy in patient a, when the diagnosis of gcct was made, the case was discussed at our mdt meeting and a right hemicolectomy was indicated and performed shortly after. in the patient b a right hemicolectomy was performed in the initial surgery due to the magnitude of tissue involvement. currently, both are receiving chemotherapy with xelox without signs of recurrence or tumor spread on follow up. comments: the gcc is a rare entity of appendicular tumors with a less favorable prognosis than the appendicular pure neuroendocrine tumors. it behaves like a low-grade adenocarcinoma and often presents as disseminated disease. therefore, sometimes surgical treatment with appendicectomy is not enough, needing the right hemicolectomy to avoid recurrence. this is recommended for tumors [ cm, pt or t and higher grade histology. introduction: among the post-pancreatoduodenectomy complications post pancreatoduodenectomy hemorrhage (pph) is the least common complication, but severe form may be life-threatening without an urgent treatment. late pph are more likely due to a complex physio-pathological pathway secondary to different etiologies. the understanding of the etiology and such a pathway could therefore be of great interest to guide the treatment of potential lifethreatening late severe pph. results: during the aforementioned period patients underwent pd, of whom ( . %) developed pph. early pph was reported in one patient ( . %) with severe bleeding from the gastric stapler line. late pph were reported in of these patients ( . %). the most common causes were bleeding from a vascular pseudoaneurysm reported in patients of which, one had mild and had severe hemorrhage and bleeding from gastro-enteric anastomosis marginal ulcer in patients, all with mild hemorrhage. no etiology was fond in patients with mild hemorrhage. a significant association was found between the severity of late hemorrhage and the vascular pseudoaneurysm as a cause of bleeding (p \ . ). all pseudoaneurysm bleeding occurred in cases complicated by a postoperative pancreatic fistula (popf) with a significant statistical association (p \ . ). conclusions: the most common cause of pph was bleeding from a vascular pseudoaneurysm, most of them were severe bleeding with late presentation and all were associated with a popf. in these cases, early detection by cta is mandatory, allowing an urgent treatment by angiography of such a bleeding vascular complication following pd. ventral hernia in hostile situation introduction: there is no consensus about the benefit or harm derived from adding a mesh hernioplasty at the same time as an urgent intraperitoneal surgery for another cause. the use of a prosthesis in contaminated fields is controversial, but suture repair has a high risk of recurrence. the main objective has been to analyze the impact of the simultaneous repair of uncomplicated midline hernias at the same time as emergency surgery for another cause, in relation to the presentation of complications, the surgical site infection rate (isq) and recurrences. material and methods: retrospective, observational study of all urgently operated patients (surgery open and laparoscopic) in the period between - who underwent a simultaneous midline primary ventral hernioplasty. the background, circumstances of the surgery and postoperative complications during the first month and long term through the basis of prospective data of emergency surgery and complications of our surgery department. results: a total of patients ( female) met the inclusion criteria with a mean age of . years (sd = . ), average bmi of . kg/ m (sd = . ). the most frequently performed interventions were: appendectomy ( . %); cholecystectomy ( . %); and lysis of adhesions ( . %). the . % of all interventions were performed by laparoscopic approach. they presented associated peritonitis in . % of the cases. the . % of patients presented some complication, in . % surgical site infection ( . % organ space). during the followup three recurrences were detected ( . %), no patient has presented chronic infection related to the use of prostheses. conclusions: in our series the simultaneous performance of hernia repair of the midline in the context of emergency surgery for another cause has been safe and not associated with long-term complications and low recurrence rate. the open abdomen: our experience introduction: ''open abdomen'' refers to a solution in which the abdominal content is left deliberately exposed under a temporary cover for a variable amount of time. since this method has been used more and more for the treatment of severe intra-abdominal infections. starting from the s the concept has been also applied in trauma surgery. material and methods: between / we have treated patients with this technique. in cases the etiology was traumatic, in the remaining cases the abdominal pathology was inflammatory. in the last years we also started to use it in some cases of treatment of surgical complications. the techniques we used were different and changed during the time. at the beginning of the experience we've completed drainages of the abdominal cavity according to mickulizt, laparostomies with mesh, bogota bags. these techniques have been abandoned since the negative pressure therapy came out. we started with the barker vacuum pack ( cases), followed by the vac (vacuum assisted closure) and ab thera kci Ò ( patients) systems and in the last three years we used the cnp suprasorb Ò of lohmann and raucher ( patients case history: year old lady presented at the a&e with few days history of constipation, faeculent vomiting, abdominal distension and pain in the lower abdomen. she had hysterectomy many years ago through a lower midline incision. her urgent ct scan of the abdomen and pelvis confirmed an incarcerated right obturator hernia containing a small bowel loop causing bowel obstruction. clinical findings: elderly, frail patient with mild tachycardia, distended abdomen and lower abdominal tenderness with guarding in the left iliac fossa. per rectal examination was unremarkable. investigation/results: inflammatory markers were raised, lactate, liver and kidney function was in normal limits with only mild hypokalaemia and hyponatraemia. ct abdomen and pelvis confirmed small bowel obstruction at the mid ileal level due to right obturator hernia. diagnosis: incarcerated right obturator hernia causing small bowel obstruction. therapy and progressions: patient was taken to the operating theatre for urgent laparotomy. dilated small bowel loops and incarcerated right obturator hernia was found with proximal ileal loop in it. after blunt stretching and dilatation of the obturator foramen, the involved ileal loop was reduced. it was deemed viable, therefore no bowel resection was required. the defect at the right obturator foramen was closed with suture. post-operatively the patient was transferred to the intensive care unit for further management. comments: obturator hernias are a rare type of pelvic hernias. their real incidence is unknown but it is thought to be less than % of all hernias worldwide and due to its non-specific symptoms and late diagnosis, they require bowel resectional surgery in nearly % of the cases. howship-romberg sign is helpful in diagnosing such a hernia, but the ultimate diagnostic choice is ct scanning which is the only way to find this condition early and avoid bowel ischaemia. case history: a -year-old woman without previous medical history presented to the emergency department with abdominal pain and dysphagia associated with nausea, vomiting and absolute constipation. during previous months, she reported having ingested hair. clinical findings: abdominal examination revealed a distended abdomen with rebound tenderness and tinkly bowel sounds. investigation/results: ct-scan showed a distended stomach with a mussel-shaped, heterogeneous and non-enhancing mass. an esophagogastroduodenoscopy revealed hair inside the lower esophagus and the stomach. diagnosis: high intestinal obstruction due to a gastric trichobezoar. therapy and progressions: the patient underwent laparotomy, gastrotomy and trichobezoar removal (fig. ) . the postoperative period was uneventful and she was discharged home on the th pod with a psychiatric evaluation scheduled. comments: bezoars are rare conditions consisting of compacted material that is unable to pass through the gastrointestinal tract. this condition usually involves the stomach; rarely, it can extend into the small bowel and even the colon, giving the so-called rapunzel syndrome. bezoars could be composed by vegetable material (phytobezoars), hair (trichobezoars), drugs (pharmacobezoars), or other materials. , a trichobezoar is the result of trichotillomania, trichophagia or other psychiatric disorders. always consider bezoars in differential diagnosis. introduction: the effectiveness of different step-up approaches is increasingly evaluated but results are controversial. we assessed the results of a standardized step-up approach protocol in the treatment of acute severe necrotizing pancreatitis, with a special focus on patient stratification to obtain an early identification of those deserving a more aggressive strategy. matherials and methods: this is a retrospective analysis of patients with acute severe pancreatitis over a period of years. the variables taken into account were: etiology and severity of the disease, sepsis, organ failure, hemodynamic stability, treatment, los, morbidity, mortality. since , patients with infected necrosis underwent a standardized step-up approach: percutaneous drainage only; percutaneous and endoscopic procedure; surgery. the results were compared with the standard care delivered from to . results: among patients, ( . %) were identified as affected by severe necrotizing disease. overall mortality was . %. the initial management was non operativein all patients. mortality in the step-up group was % ( / ) vs % ( / ) in the standard care group. conclusion: a standardized step-up approach protocol offers better results than standard care in the management of acute severe necrotizing pancreatitis. however, a better stratification of patients. introduction:the appendix stump closure in complicated appendicitis has been widely practiced in different ways such as metal clip, hem-o-lok clip, endoloop and endostapler. the treatment of complicated appendicitis with necrosis and perforation of the appendix base is controversial. we aimed evaluate the efficacy of laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and base perforation. material and methods:from january to october , we evaluated consecutive patients who underwent a laparoscopic partial caecum resection in complicated appendicitis with necrosis and perforation of the appendix base. partial caecum resection was performed with the endostapler to close the appendix base at ileocaecal junction. results:the laparoscopic partial caecum resection with endostapler was used in % . of the cases. the mean operative time was . ± . min. there were necrosis of appendix base in , perforation of appendix base and diffuse peritonitis in , perforation of the appendix base and localized peritonitis in of the patients. the wound and intra-abdominal infection rates were . % and . %, respectively. there were no operative complications and the conversion rate was . %. the average length of hospital stay was . ± . days. there was no leakage on the stapler line. conclusions:the laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and perforation of the appendix base, is a safe and effective technique. introduction: the term ''''volvulus'''' comes from the latin ''''volvere''''meaning twist. if left unattended, sigmoid volvulus can compromise the blood supply of the involved segment,leading to ischemia,gangrene,perforation and death. the mainstay of sigmoid volvulus management has been through proctoscopic or colonoscopic decompression when feasible, followed by surgery either during the same admission or electively. the aim of our study is to identify patients which can benefit of immediate surgical approach and prognostic factors associated with failure of conservative/endoscopic treatment. materials and methods: charts of patients admitted for sigmoid volvulus to our institute were retrospectively analysed. we revised ct scan images and laboratory tests of all the patients to identify risk factors for conservative treatment failure. results: patients underwent surgical procedures; in cases after a failure of an initial conservative approach; patients were managed with endoscopic approach only. elective surgery was performed in patients. case history: we report a -year-old male case presenting left hand middle finger pain after pressured paint gun shot in volar proximal phalanx clinical findings: on physical examination swelling and tenderness on the volar side of the hand was observed (fig. ) investigation/results: pain was remarkably more intense with passive finger extension. distal nerurovascular status was unscathed. there was no fracture reported on radiography. leukocytosis and acute phase reactants rise was observed on laboratory examination diagnosis: after physical, radiological and laboratory examination the diagnosis of acute flexor tenosynovitis was made. therapy and progressions: open debridement and irrigation following bruner incisions on middle finger was undertaken within h of injury. paint impregned in tissues could be observed in subcutaneous tissue, palmar fascia and flexor tendon sheath. paint affected tissues samples were analysed in microbiology laboratory (fig , ) after checking nerurovascular indemnity, g drainage was left in deep tissues and skin suture was performed with - monofilament non absorbable suture. the patient followed days intravenous antibiotical therapy followed by weeks oral treatment. he attended physiotherapy program postoperatively, reporting no functional disability or wound complications after weeks. comments: chemical flexor tenosynovitis is an important emergency which must be correctly diagnosed and treated due to quick progression and potential morbidity if not treated effectively ( ) in our experience, case was managed by open debridement and irrigation but different treatments can be followed depending of patientsclinical situation, such as iv antibiotics with serial examinations or percutaneous drainage. it should also be noted that australia does not have a specific subspecialty in emergency surgery. the acute surgical unit at the tch was set up in in order to provide a dedicated acute unit to service the ever increasing demand acute surgery. previous model was that the acute surgical service was integrated into the elective work. additional beds were provided to the unit including the positions of a dedicated director and chief nurse. the achievement of the unit has been the decreased time to theatre, less after-hours operating, standardised treatment approaches, and dedicated emergency surgery medical staff. the difficulties have included clinician engagement, competing resources with elective surgery, emergency surgical presentations increasing by - % each year, and the unit''s beds being used for non-acute patients as the hospital approaches regular %. the acute surgical unit has evolved into a specialised acute care that enables rapid assessment and treatment of patients with staff dedicated with skills in this area. treating pyogenic liver abscesses secondary to diverticulitis in a patient using immunosuppressants for crohns disease by performing a sigmoid colectomy introduction: pyogenic liver abscess (pla) formation due to microbial contamination of the liver parenchyma is often seen secondary to intra-abdominal infections. pla formation due to crohn''s disease (cd) is a rare complication and not well-documented in current literature. as symptoms often mimic a cd exacerbation, diagnosis is often delayed and severe disease may develop. optimal treatment for this group of patients remains debatable. case presentation: a -year-old man was admitted to the hospital with a -week history of overall malaise, fever and night sweats. patient''s history solely stated a -year treatment of cd that was stable over the past period with infliximab and azathioprine. investigations and treatment: biochemical analysis revealed a c-reactive protein of mg/l and a white blood cell count of . /l. an abdominal ct scan showed multiple abscesses in the right lobe of the liver and a thickening of the wall in the transition of the descendent colon to sigmoid. the patient''s immunosuppressants were paused, intravenous antibiotics were administered and a percutaneous drainage of the biggest pla was performed. however, the clinical condition of the patient did not improve. colonoscopy and pet-ct scan did not reveal any other sites of infections. as patient remained septic and previous imaging revealed mild diverticulitis rather than active cd, an emergency hartmann''s procedure was performed. hereafter, the patient recovered rapidly and the plas resolved completely. conclusion: diverticulitis of the sigmoid colon should be considered as causative pathology in patients presenting with multiple pyogenic liver abscesses and a history of crohn''s disease that is in full remission with immunosuppression. when the abscesses exceed cm in size and are multilocular, resection of the inflamed colon can be a treatment option of value. clinical findings: epigastric pain and recent episode of hematemesis. pain at deep palpation of the epigastrium, no signs of peritoneal irritation investigation/results: abdominal x-ray and ct showing a large right sided strangulated paraesophageal peh, with pneumatosis of the gastric wall diagnosis: right sided strangulated peh therapy and progressions: emergent laparotomy. peh reduced, ischemic portion of the stomach recovering viability. closure of diaphragmatic defect with non-absorbable suture, reinforcement of lower esophageal sphincter with round ligament (ligamentum teres hepatis) and anterior partial fundoplication (dor). postoperative course uneventful, patient discharged on th pod. comments: peh are mediastinal displacements of abdominal organs, most often the stomach, associated with laxity or a hole in the phrenoesophageal membrane, large enough to allow the gastric fundus to herniate. because the stomach is attached to the gastroesophageal junction, it tends to rotate around its axis leading to organoaxial volvulus. occurrence and size increases with age. peh account for - % of all diaphragmatic hernias. in patients without prohibitive operative risk, they should be surgically corrected, avoiding the risk of acute and potentially life-threatening complications when emergent surgical repair is required. the risk of developing these complications is less than %/yr and associated mortality rate is approximately %. case history: patient was a previously healthy -year-old female with an unremarkable past medical history, non-smoker with a high body mass index (bmi [ ). she first presented to a level medical facility with acute left upper leg pain and swelling. one week prior to this she had a progressive cough, swinging fever, and malaise. clinical findings: patient was transferred to our hospital haemodynamically unstable, acidotic, hypoxemic and delusional. tachypnea and oliguria were present. she continued to deteriorate clinically with pyrexia (t , oc), resistant shock, and toxaemia. on examination her left leg was found to be paresthetic below the femoral-inguinal fold. investigation/results: abg samples showed lactic acidosis with a ph of . and lactate of . mmol/l. hypoxia and hypocapnea were present.her biochemical profile showed acute kidney injury (aki) with raised creatinine kinase (cpk) and serum creatinine (cr) . . chest x-ray illustrated bilateral lung infiltrations (ards image). diagnosis: patient was urgently referred to a ct scan of the left femur with i.v. contrast for suspected necrotising fasciitis. ct findings highlighted a deep muscular femoral abscess with multiple regional fluid collections and necrotizing inflammation from the femur diaphysis to the patella. therapy and progressions: the patient was immediately transferred to or for emergency surgical exploration and debridement. almost the entire anterior compartment of the femur was necrotic and hence an extensive excision of the dead tissues and packing with npwt was performed. comments: severe snm can cause marked systemic toxic effects, namely, the streptococcal toxic shock syndrome (stss). stss secondary to snm is a life-threatening host response to gas superantigens with a mortality rate as high as %. clinical findings: patient had a diffusedlty tender abdomen and had not passed flatus proceeding his admission to the a ? e department and was vomiting. investigation/results: ct abdomen showed small bowel dilatation with abrupt cut-off point proximal to the icv diagnosis: a diagnosis of small bowel obstruction was made based on the clinical and ct findings. therapy and progressions: patient was taken to theatre for laparoscopy ? -proceed and a 'slipped' bowel lopp was noted within the peritoneal flap that had been created a week prior during the original hernia repair. the 'v lock'' suture line was found to be loose which is thought to have led to this complication. the bowel loop was reduced, deemed viable and an internal hernia repair was performed. post-operative period was unremarkable and the patient was discharged day posy-operatively. comments: during lap tapp hernia repair, there are currently at least options avaiable for peritoneal flap closure; (sutures, tackers and glue.) suregons prefernce prevails over the chosen approach. when sutures are chosen, most surgeons prefer the self-locking v-lock stitch. by adopting this technique, meticulous periotneal closure is impoartan, as loose suturing of the peritoneum can lead to post operative complications of internal herniation and small bowel obstruction, as described in this case. a multi-centre prospective study would be welcomed, to compare efficacy and safety of all types of peritoneal closure devices. introduction: peer review assessment of medical treatment has been shown to be a robust way of improving quality of care in trauma in our institution and globally. in we introduced regular morbidity and mortality meetings at the department of gastrointestinal surgery. severe complications (revised accordion classification [ ) after surgery were identified on a weekly basis, evaluated and data included in a local quality registry with the aim of revealing suboptimal surgical quality and continuously improving our results. material and methods: retrospective analysis of collected data from the described quality registry. all adult patients who had undergone gastrointestinal surgery in were assessed. results: of surgical procedures performed, % were emergency procedures. a total of % ( / ) experienced a severe complication after surgery and % ( / ) required reoperation. in the group of upper gastrointestinal surgery [n = ( %)] % were emergency procedures. anastomotic leak (al) was identified in % ( / ) undergoing thoraco-laparoscopic esophagectomy and in % ( / patients) after gastrectomy. of laparoscopic cholecystectomies, % were emergency procedures with % ( / ) reoperation. of hernia repairs, % required reoperation. in the group of lower gastrointestinal surgery [n = ( %)] % were emergency procedures. al was diagnosed in % of colonic resections and % of patients after rectal resection. in emergency colorectal resections(n = ) there were no al. of appendectomies, patients ( %) required reoperation. the most frequent cause of reoperation was revision of stoma ( ), followed by reoperation for al ( ), abscess ( ), and wound dehiscence ( ). patients died after surgery of which were emergency surgical patients. conclusions: systematic assessment of all severe complications helps reveal surgical procedures which can be improved but also to identify surgical procedures with low complications rates. plans are being developed to improve the quality of the identified procedures. all surgical departments should have regular and thorough assessment of their activity. acute surgical patients operated by emergency surgeons has less risk of post-operative complications and mortality d. gumaa east kent hospitals university nhs foundation trust, general surgery, ashford, united kingdom introduction: in england and wales, we perform over , emergency laparotomy every year. days mortality rate is around - %. in our study we are trying to demonstrate if have dedicated emergency surgery service will make a difference in the outcome of emergency laparotomy. material and methods: retrospective study on prospectively collected data from nela database done in a large district general hospital. all patients over years old who underwent emergency laparotomy for acute surgical condition between november and january were included in the study. mortality and post-operative complications were the primary outcomes. results: total of patients were included in the study, operations were performed by emergency surgeons (es). days mortality rate was %, while it was . % for the none emergency surgeons group (nes) post-operative complications were . % compared to % for patients operated by nes. there was shorter itu stay with average of . days, while the itu stay for the other group was . days, but the es group had higher chance of unplanned return to theatre. . % of the patients went back to theatre compared to % of the other group. reasons of unplanned return to theatre was mainly post-operative collection or wound dehiscence. conclusions: emergency surgeons has better outcomes when they perform emergency laparotomy, may be because they perform higher number of laparotomy compared to their peers. emergency surgery has been a growing subspeciality recently, and with no doubts having surgical emergency units has improved the patient's care around uk. the advantage of g over g of prophylactic cefazolin in surgical site infections in trauma surgery below the knee introduction: the rate of surgical site infections(ssi) after foot/ankle surgery remains high, despite the implementation of antibiotic prophylaxis ( ) . recently guidelines suggest a single dose of g instead of g of cefazolin for implant surgery, this decision is largely based on pharmacokinetic studies ( ) . however, the clinical effect of this higher dose has never been investigated in this region. this retrospective cohort study therefore investigated the effect of g compared to g of prophylactic cefazolin on the incidence of ssis in foot/ankle surgery. material and methods: all patients undergoing trauma-related surgery of the foot, ankle or lower leg between september and march were included. primary outcome was the incidence of a ssi. ssis were compared between patients receiving g and g of cefazolin as surgical prophylaxis. results: a total of patients received g and patients received g of cefazolin. the groups did not differ in gender, age, weight, co-morbidities or intoxications. the overall number of ssis was ( . %) in the g group and ( . %) in the g group. corrected for the confounders ''age'', ''smoking'' and ''blood loss'' this was not statistically significant (p = . ). conclusions: even though the decrease in ssi rate from . to . % was found not to be statistically significant, it might be clinically relevant considering the reduction in morbidity, mortality and healthcare costs. research linking pharmacokinetic and clinical results of prophylactic cefazolin is needed to establish whether or not the current recommendations and guidelines are sufficient for preventing ssis in foot/ankle surgery. introduction:right-sided colonic diverticulitis (rd) is much rarer than left-sided (ld) and subsequently, controversies concerning the most appropriate treatment remain unsolved. our experience let us believe that mild rd can benefit from an outpatient management. material and methods: we performed a single center retrospective comparative study in which we included all our diverticulitis patients that were treated as inpatient in our unit. we divided in two groups:rd and ld group. the ld group was created by randomization from a prospective ld patients database. results: we included rd and ld patients treated in our unit from july to july . median age was . in rd and . in ld, with a . % of females in rd vs . % in ld. asa classification was significantly lower in rd (asai: . % vs %, asaii: . % vs , , asaiii: vs . %, asaiv: vs . % p = . ). the presence of neumoperitoneum in ct scan was significantly higher in ld . % vs . % p = . ) surgery was performed in . % of the left-sided diverticulitis compared to of the rd group (p = . ). antibiotics of third line (imipenem and meropenem) were only required for ld ( vs . % p = . ). length of hospital stay was significantly shorter (p = . ) in rd ( . ± . ) than in ld group ( . ± , ) conclusions: in our series, patients with right diverticulitis had fewer perforations in the ct scan, they required lower spectrum antibiotics and did not required any surgical treatment with a shorter length of hospital stay. we consider that mild right diverticulitis could benefit from an outpatient treatment with oral antibiotic following similar recommendations to those followed for mild ld patients. when surgery should not be immediate, a night of hospitalization in a specialized environment is performed and surgery deferred overnight. in some selected patients, a return home is possible with a scheduled emergency surgery the next day. the pa.r.c.o.ur protocol is set up in the surgical emergencies of the university hospital of lille after a suitable medical treatment and enlightened information. this retrospective study assesses whether this deferred surgical management allows a return home on the day of the operation. methods: between / / and / / , records of patients operated for an abscess, appendicitis, cholecystitis or symptomatic inguinal hernia were reviewed. patients who did not have criteria for immediate surgical management (peritonitis, occlusion, sepsis, cellulitis, intravenous treatment need) agreed to return to their home for an os the next day. results: / % interventions were performed in os and allowed a return home at day , within a median time of h [iqr - ]. conclusions: the pa.r.c.o.ur protocol makes it possible to reserve the availability of the entire technical platform (operating rooms and beds) to the most serious pathologies with a failure rate of %. the medico-economic benefits, the efficiency in the management of the beds and the satisfaction of the patient and medical staff of this protocol must be evaluated prospectively. a years old woman was admitted in our er presenting with a h sharp epigastric and ruq pain, fever, nausea and vomiting, hd stable. the patient had a past medical history of tachyarrhythmia, open-angle glaucoma and lower limb venous insufficiency. her past surgical history included an hysterectomy and bilateral salpingooophorectomy, appendectomy and left inguinal hernioplasty. during clinical examination, signs of peritoneal irritation were present. ct scan revealed a small pneumoperitoneum in the luq and multiple small and large bowel diverticula, without free peritoneal fluid. blood work showed mild leukocytosis and neutrophilia. we performed an urgent exploratory laparoscopy in which dozens of small intestine diverticula were found, increasing proximally in number. one of them, cm distally from the treitzs angle, showed signs of perforation, with a small abscess and surrounding fibrin. the affected bowel was externalized through a cm laparotomy for segmental resection and a manual double-layer terminoterminal jejunojejunostomy was performed. in the perforated jejunal diverticulum, a mm cod fishbone was identified as the cause of the perforation. the histopathological examination of the extracted cm tissue sample, found several diverticular structures of the muscular wall, one of which with a mm perforation and a granulocytic infiltrate with serosa involvement. complicated cases of small bowel diverticulosis are best managed by segmental resection surgery. despite being quite rare, every surgeon should be aware of such acute abdomen presentation. asymptomatic cases benefit from a watch-and-wait approach. case history: a -year-old female consulted to the emergency department for a h epigastric pain. it was accompanied by nausea without vomiting. clinical findings: the patient was hemodynamically normal and the abdomen was soft with minimal distention. investigation/results: x-rays showed large gastric dilation. the abdominal ct scan showed mesenteric axial gastric volvulus with minimal free fluid. suddenly, the patient presented diffuse abdominal pain with diaphoresis, mucocutaneous pallor, hypotension and tachycardia. diagnosis: a gastric volvulus with gastric ischemia was suspected. broad-spectrum antibiotic therapy and resuscitation measures were started. emergency surgery was indicated. therapy and progressions: a decompressive gastrostomy, gastric reduction and devolvulation, transverse colon resection due to ischemia and splenectomy were performed. after h, she required total gastrectomy and right hemicolectomy due to ischemia secondary to severe septic shock associated with disseminated intravascular coagulation. comments: the gastric volvulus is an uncommon entity, being the mesenteric-axial type so rare. there are very few cases described whose manifestation is accompanied by hypovolemic shock secondary to splenic laceration, which occurred due to the great gastric distention. early diagnosis is the key to start treatment as quickly as possible, due to high mortality the main mechanism of death is usually vascular involvement, perforation and multiorgan failure. results: we analyzed , pediatric ogis, and . % of pediatric cases occurred in the - age group, . % in - , . % in - , and . % in - . the average age of the cohort was . years and . % of cases occurred in boys. racial distribution revealed . % of cases in caucasians, . % in african americans, and . % in hispanics. most ( . %) cases were documented in the southern united states. of our , cases, . % underwent vitrectomy, . % underwent enucleation, and . % developed endophthalmitis. the rate of endophthalmitis development after ogi was highest ( . %) in the asian/pacific islander group. the average length of stay for the entire cohort was . days, and the average cost per day was $ , . . table contains a breakdown of our statistics. conclusions: as documented in the nis, ogi occurs more commonly in boys than in girls at a ratio of approximately : . the rates of vitrectomy and enucleation are higher in boys. we noted a higher of rate of enucleation in asian/pacific islanders and african americans. the plurality of ogis occur in the - age group; this age group also has the highest relative rate of enucleation. with respect to location, ogis occurring in the western united states had the highest average cost per day of inpatient stay. autologous tissue from intramedullary channel parietes for femur nonunions management introduction: a reamer-irrigator-aspirator (ria) method is deeply reliable for getting high volumes of bone graft/mscs. high rates of successful outcomes have been reported after the use of ria bone fragments to cure non-unions. material and methods: being supported by histomorphological examination of the material acquired while drilling intramedullary channels of patients with femur nonunions ( -hypertrophic, oligotrophic), we have discovered that nevertheless, expressions of the dystrophy and necrosis in bone tissue and marrow in pseudoarthrosis areas depend on time since fracture occurrence, the microscopic study of the material cm above and below a fracture line has demonstrated ordinary structures of bone tissue and marrow in all cases. introduction: this study aimed to evaluate the outcomes of ankle fractures with posterior malleolus fragments (pmfs) involving \ % of the articular surface treated with or without screw fixation. material and methods: among patients with ankle fractures and pmfs who underwent surgery between march and february , with type pmfs involving \ % of the articular surface were included. of these patients, underwent screw fixation for pmfs and lateral and/or medial malleolar fracture fixation (group a) and underwent internal fixation for malleolar fractures without screw fixation for pmfs (group b). ankle joint alignment and fracture healing were measured using plain radiography and computed tomography (ct). clinical outcomes were determined using the american academy of orthopaedic surgeons foot and ankle questionnaire, short form- , and american orthopaedic foot & ankle society scale. results: nonunion was not noted in either group. however, we detected union with a step-off of mm or more in cases from group b. with regard to ankle joint alignment, case in group a and cases in group b showed mild asymmetry of the medial and lateral clear spaces on ct at months. clinical outcomes at and months after surgery were better in group a than in group b. conclusions: screw fixation of pmfs was effective for fracture healing and maintaining ankle alignment. additionally, it improved short-term clinical outcomes, which we believe was due to stabilization of ankle fractures with pmfs involving\ % of the articular surface. references: level ii, prospective comparative study. how accurate can gaps and step-offs be determined in acetabular fracture treatment? introduction: the assessment of gaps and steps in acetabular fractures is challenging. studies evaluating the value of various imaging techniques to enable accurate quantification of acetabular fracture displacement are limited. this study aimed to assess the inter-and intraobserver variability of gap and step-off measurements using pelvic radiographs, intraoperative fluoroscopy and computed tomography (ct). material and methods: sixty patients, surgically treated for acetabular fractures, were included. five observers measured the gap and step-off on all the pre-and postoperative pelvic radiographs and ct scans. intraoperative fluoroscopy images were reassessed to determine the presence of gaps and/or step-offs. the inter-and intraobserver variability were calculated for the measurements using pelvic radiographs or ct scans. kappa was calculated for the intraoperative fluoroscopy assessment. results: for the preoperative displacement, the intraclass correlation coefficient (icc) was . (gap and step-off) using pelvic radiographs, and . (gap) and . (step-off) using ct scans. for the postoperative displacement the icc was . (gap) and . (step-off) using pelvic radiographs and . (gap) and . (step-off) using ct scans. the average kappa for the intraoperative gap and/or step-off assessment using fluoroscopy was . (- . to ) both for the inter-and intraobserver assessment. conclusions: there is little agreement between the observers regarding the measurements of the preoperative displacement, the presence of gaps and step-offs intraoperatively and the measurements of the postoperative displacement. a possible explanation for this is that the acetabulum has a three-dimensional spherical shape with multiple fracture lines and fragments going in different directions. single radiographic or ct-based gap or step-off measurements do not seem to be representative for the fracture characteristics, therefore the use of d measurements should be considered. introduction: long-term intake of glucocorticoids leads to pathologic changes in bone and cartilage tissues. material and methods: to understand how to prevent the occurrence of the pathology, we studied the use of vitamin d, vitamin e and a combination thereof on the background of the intake of prednisolone, . mg/ g of body weight. the experiment involved male rats of wistar linear breed. the animals were months old and weighted . ± . g. the experiment included series of animals, rats in each, namely: the first group-intact animals; the rest of the animals received prednisolone, . mg/ g of body weight. the rats of the third series received additionally iu of vitamin d . the animals from the fourth group also received . iu ( . mg) of vitamin e. results: long-term administration of prednisolone to the experimental animals has caused significant structural and functional disorders in their bone and cartilage tissues. they can be construed as simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d and e has demonstrated its ability to promote restoration of histomorphologic features of bone and articular cartilage in proximal femur epiphysis and epiphyseal cartilage of proximal femur epimetaphysis in animals with simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d and e has demonstrated a better effect on the background of the glucocorticoid-induced osteochondropathy, compared to the vitamin d alone. conclusions: preventive administration of the vitamins d and e while treatment with prednisolone leads to avoidance of the majority of pathologic changes, resulting otherwise from glucocorticoid-induced osteochondropathy. konyang university hospital, orthopaedic, deajeon, south korea introduction: the purpose of this study was to evaluate clinical, radiological and functional outcomes of patients had osteochondral autograft harvested from the ipsilateral femoral head for a femoral head defect after posterior hip fracture dislocation material and methods: this study was approved by irb at our institution. a retrospective chart review of a prospectively performed operation was performed at two university hospital between march , , and june , . all fracture was classified by the ao/ota classification. we included the patients had minimum months of follow up periods. ten displaced head fractures were addressed through posterior surgical dislocation and two patients had no posterior dislocation was operated using smith-peterson approach. an osteochondral graft was harvested from inferior non-weight bearing articular surface and grafted to osteochondral defect. all patients were full weight bearing by months results: we had femoral head fracture dislocation. patients were excluded due to lost to follow up. twelve of with type i/ii pipkin fracture dislocation with the articular defect and reduced within h of injury was identified for review. the patients were followed up for a mean of . months. there was no osteonecrosis. decreased joint space was identified in two patients. all fractures achieved union. the mean harris hip score of last follow up was . ( - ) one patient who operated using the smith-peterson approach had femoral nerve palsy. conclusions: the clinical and radiological results after treatment of femoral head fracture dislocation with articular defect by osteochondral autograft harvested from its own non-weight bearing articular surface show good outcomes. hospital universitario fundacion jimenez diaz, madrid, spain, hospital universitario de octubre, madrid, spain, hospital universitario la paz, madrid, spain introduction: preoperative computerized tomography scan provides important information about ankle fractures associating posterior malleolus, helping us distinguishing fractures affecting distal tibiofibular joint. the aim of our paper is to describe our series of patients suffering an ankle fracture with posterior malleolus involvement. methods: fifty-two consecutive patients, with ankle fracture involving posterior malleolus were evaluated prospectively. all of them were assed with a preoperative ct scan, demographic data, fracture mechanism, surgical approaches, posterior malleolus size measured classification and treatments were analyzed. results: most frequent posterior malleolus pattern according to bartonicek classification was type ii, twenty-two patients ( . %). an alternative surgical approach was performed in thirty-three patients ( %) as a consequence of information provided by ct scan. no statistical differences were observed when measuring posterior malleolus in conventional x-rays or ct scan. analysis of variance showed a p value less than . when comparing pm size and haraguchi and bartonicek classifications. discussion and conclusion: ct scan is required to perform an adequate preoperative study of ankle fractures involving posterior malleolus, using this information to provide a better outcome to our patients. effect of atorvastatin and losartan on gene expression and cell count in a rat model of posttraumatic joint contracture of the knee-a blinded and randomized animal study introduction: myofibroblasts have been associated with increased posttraumatic joint contracture, which has a massive impact on articular function. atorvastatin and losartan have shown to reduce the proliferation of cardiac, hepatic and pulmonary myofibroblasts. the aim of this study was to evaluate the effect of atorvastatin and losartan on gene expression, cell count and collagen deposition in the posterior joint capsule , and weeks after trauma in a rat model of posttraumatic joint contracture of the knee. material and methods: posterior capsular injury and kirschner-wire immobilization of the knee were performed in sprague-dawley rats. atorvastatin, losartan, or placebo was administered daily orally. the rats were sacrificed at either (n = ), (n = ) or (n = ) weeks after initial surgery. rats euthanized at week had their k-wire removed at week , followed by a remobilization period of another weeks. the results were evaluated via qpcr and immunohistochemistry. results: losartan reduced the number of myofibroblasts in comparison to the control at week and , whereas atorvastatin lowered myofibroblasts only at week (p \ . ). atorvastatin reduced the collagen deposition at week , whereas losartan had no effect on collagen deposition. losartan decreased gene expression of connective tissue growth factor (ctgf) at week and of tgf-b at week . clinical findings: positive anterior drawer test, grade iii valgus instability, and a palpable gap below the patella were assessed. no neurovascular alterations were found and ankle-brachial index scored [ . . investigation/results: initial immobilization with a splint was performed. radiographs showed a high patella with no other lesions. mri revealed a complete rupture of the patellar tendon and a complex multiligamentous injury with complete anterior cruciate ligament (acl) tear, avulsion of distal medial colateral ligament (mcl), and a complex rupture of both meniscus. diagnosis: knee dislocation with patellar tendon rupture. therapy and progressions: definitive treatment was performed days after the initial lesion, with arthroscopic resection of the posterior horn of the external meniscus and reconstruction of the acl with posterior tibial tendon allograft, as well as open repair of the patellar tendon and the internal meniscus, with subsequent mcl distal reinsertion. immediate partial weight-bearing with an extension orthosis was allowed. the patient is currently progressing with rehabilitation. comments: knee dislocation is a rare injury, and most cases are due to highenergy trauma. concomitant rupture of the patellar tendon is very unusual, and most cases are described in the context of open injuries. surgery is mandatory in order to restore full stability of the knee, with either one intervention or a staged surgery, including repair of the collateral ligaments and the patellar tendon followed by arthroscopic reconstruction of the cruciate ligaments. postoperative management consists on early rom restoration and weight-bearing as tolerated. introduction: apophyseal anterior inferior iliac spine (aiis) fractures are rare injuries. they most commonly occur in athletes in adolescence period. because the ossification of pelvis is not completed, apophyses are the weakest part of musculo-tendinous unit during this period, thus avulsion fractures are more frequent than muscle ruptures. aiis avulsions are the result of sudden and forceful contraction of rectus femoris muscle concentrically or eccentrically. material and methods: we report a clinical case of a aiis avulsion fracture in a young male football player, after being misdiagnosed as muscle strain. results: our patient was treated with conservative treatment including bed rest, analgesia, using crutches and toe-touch weight bearing, progressing to full weight bearing as tolerated and nonsteroidal anti-inflammatory drugs. at follow-up, he showed relief from his pain and mechanical symptoms and regained full range of motion and returned to his previous levels of activity. conclusions: diagnosis requires careful attention to the physical examination and imaging. in this case, the fracture was managed successfully with a conservative approach. good results and return to previous levels of activity can be achieved with conservative treatment. when misdiagnosed as a simple strain, the late diagnosis may cause chronic pain with decreased sportive performance in the future. therefore, a carefully taken anamnesis and physical examination with comparative anterior-posterior pelvic x-rays are needed not to miss avulsions in adolescents; also in some instances, more advanced scanning methods must be considered. introduction: the problem of meniscus damage in children is due to unsatisfactory treatment results, which is associated with the frequent execution of meniscectomies. amount of unjustified meniscectomies and the incidence of osteoarthritis can be reduced if menisci are repaired. material and methods: during the period january -august children with injuries of the meniscus were treated in morozov children's clinical hospital. children underwent meniscus repair by suturing using three techniques: ''all inside'', ''inside out'' and ''outside to inside''. meniscus suture decision was made taking into account the assessment of the severity of the damage. the period from the moment of injury wasn't taken into account. the technique of meniscus suture was determined depending on the location and type of damage. we met children with damage to the discoid meniscus who underwent partial resection and meniscus suture. children underwent a meniscectomy due to severe traumatic and degenerative changes. children had mri of the knee after months and x-ray after months. results: children achieved a satisfactory functional result; operated children are at the rehabilitation stage. we faced a complication-limitation of flexion in the knee joint in child. in all children on the control mri, the absence of synovitis, the safety of the reconstructed meniscus contour and the decrease in the intensity of the hyperechoic signal in the gap zone in dynamics are determined. conclusions: the introduction of a technique for repair meniscus integrity in the daily practice of an arthroscopist makes it possible to reduce the number of meniscectomies, which will reduce the number of unsatisfactory treatment results for this pathology and prevent the development of early osteoarthritis of these, children revealed a fracture-dislocation of the patella. in children, a tangential fracture of the lateral condyle of the femur was noted. in children, the dislocation was repeated. we met children with bilateral damage. all children with complete damage to the medial patellofemoral ligament, fracture-dislocation of the patella and dysplastic dislocation were performed tendon plastic using the quadriceps femoris tendon. the technique includes: transplanting a graft quadriceps tendon graft without cutting off the patella. next, the transplant is subfascial carried out in the medial direction and is fixed with a bio-integrated screw in the femur. results: the rehabilitation period was months. % of children have a satisfactory result (there is a limitation of flexion in the knee joint to °). % have an excellent clinical result: the full range of motion in the knee joint, the absence of pain and a return to sports. none of the operated children had relapses of dislocation. conclusions: it is recommended to consider the technique of tendon plasty of the medial patellofemoral ligament using the quadriceps femoris tendon as a method of choosing the treatment for patellar dislocation in children. case history: a -year-old boy who was injured while playing baseball. he was playing as a catcher and was bumped into the runner, therefore his ankle got twisted. he was immediately taken to the hospital. clinical findings: x-ray the distal tibial epiphyseal growth plate was irregular. although the ankle joint was not dislocated. in the ct, the proximal fibular fragment was caught behind the posterior edge of epiphysis of the distal tibia and was trapped there. investigation/results: the patient must be operated in order to repair the ankle. but the reduction of the entrapped distal tibia epiphysis was not easy without open. diagnosis: we diagnosed with bosworth like fracture. therapy and progressions: reduction was not easy, however we performed it by the pulling the fibula towards to outside, pulling out the curled anterior tibiofibular ligament, and then pushing into the tibia. we performed screw fixation after reduction of distal tibial epiphysis. furthermore, we fixed the fibula with plate. we made him to do range of motion exercise and toe touch gait from next day, and full weight bearing from weeks. we removed the implant months after the surgery. he did well subsequently, and at years after injury, he had normal function of the ankle, and normal x-ray. and he has returned to sports without pain. introduction: judo is the most popular martial art in the world and the first martial art recognized since as an olympic sport. worldwide, the international judo federation has registered countries with about million judo practitioners. like martial arts, judo mainly involves grip and throwing techniques. the competition rules in judo have been subject to constant adjustment and optimization in recent years. injuries prevalence is an important factor in the contact martial arts. material and methods: a prospective cohort study of all registered international athletes ( ) at three different european judo contests in germany were accomplished with the aim to investigate the injury rate as well as the pattern of injury. the age of the athletes ranged between and years. injury incidence rates were calculated per athlete-exposures (iirae) and per min of exposure (iirme). independent variables were sex and weight division. subgroups were compared by calculating the injury incidence rate ratio. results: severe injuries by judo tournaments are rare. the most frequently injured regions were the hand and head. the fights of the main block are riskier than the finals. the incidence of injury in heavyweight division differed with lightweight competitors. the risk of injury for female and male competitors differed slightly. conclusions: further studies are needed to determine a judo specific injury patterns and factors especially in the pre-competitional phase. investigation of prevention-strategies like the adaptation of competition rules etc. makes sense. does garden''s classification of femoral neck fracture match between orthopedic specialist and clinical resident? t. inoue , s. inoue , t. muraoka prefectural miyazaki hospital, orthopedics, miyazaki, japan introduction: garden''s classification is the most popular classification of femoral neck fractures. femoral neck fracture should be operated^ h; however poor agreement make waiting time longer because it takes more time to prepare implants and biological clean room. we investigate the agreement of the garden''s classification (non-displacement type or displacement type) between clinical resident and orthopedic specialist. material and methods: the examiner are a clinical resident ( nd year) and an orthopedic specialist ( th year). the subjects were cases of femoral neck fractures treated at our hospital between january and december . first, the examiners classified them into a non-displacement type and a displacement type (test ). second, the examiners studied the literature about unclassifiable type. third, the examiners classified cases month later once more (test ). finally, we compared the first test with the second test using the agreement (the number of matched patients/total) and kappa coefficient. results: the test showed that the agreement and kappa coefficient were . % and . . the test showed agreement was . %, . . the intra-observer agreement of clinical resident was . % and kappa coefficient was . . the orthopedic specialist was . %, and kappa coefficient was . . at test , cases did not match. cases of those were unclassifiable type, which were valgus type with medial fracture line. with slight displacement, agreement will get lower; some doctors consider it displacement type. conclusions: unclassifiable type makes us confused. it makes agreement better to discuss about unclassifiable type. introduction: the aim of this retrospective study was to describe the profile of missed hand and foot fractures in multitrauma patients and to elucidate risk factors for the delayed diagnosis. material and methods: from to , there were included patients. missed fractures were defined as fractures, which were not diagnosed during primary and secondary survey. patients were assessed for age, sex, glasgow coma scale, injury severity score, and length of stay in hospital (los). timing of hand or foot diagnosis related to admission date (measured in days) was noted. results: overall, . % of patients had a delayed diagnosis of hand fracture, . % ha a delayed diagnosis of foot fracture. the mean gcs for patients with delayed diagnosis was , whereas patients with diagnosis the day of admission had and mean gcs of (p \ . ). patients with delayed diagnosis had a mean iss of . versus . for those diagnosed the day of admission (p \ . ). furthermore, patients with delayed diagnosis had a mean los of . days, whereas those diagnosed at the time of admission had a mean los of days (p \ . ). concerning delayed diagnosis hand fractures, metacarpal and phalangeal fractures were the most common injuries overall ( . % and . %, respectively). concerning delayed diagnosis foot fractures, metatarsal fractures ( cases) and calcaneus fractures were the most common injuries overall, followed by talus fractures and toe fractures. conclusions: this study revealed that with a decreased gcs and increase in iss, polytrauma patients are increasingly at risk for delayed diagnosis of hand and foot fractures with a concomitantly increased los. as a delayed diagnosis has significant impact on the final functional outcome, correct and careful primary, secondary and tertiary survey is essential. introduction: the aim of this study was a) to determine the methods of hemorrhage control currently being used in clinical practice and b) to analyze pelvic fracture mortality rates before and after initiation of a multidisciplinary pelvic fracture protocol. material and method: between and , we included trauma patients with pelvic fractures (group ). a similar retrospective examination was performed on a number of trauma patients without pelvic fractures (control group). there were collected injury severity score (iss), the highest abbreviated injury scale (ais) score in each anatomic region and methods of pelvic hemorrhage control. there were also recorded hospital lengths of stay (los) and in-hospital mortality. results: the average follow-up was -months. the average iss in group and group was respectively . and . . in both groups the commonest mechanism of injury was motor vehicle crash ( . %). in group , angioembolization and external fixator placement were the commonest used method of hemorrhage control. patients underwent diagnostic angiography with contrast extravasation noted in patients. patients with pelvic fracture had a mean hospital los of . days. the overall in-hospital mortality rate of patients with pelvic fractures was . %, while in group the overall in-hospital mortality was . %. age, shock, severe head injury and increasing iss, are all significantly associated with mortality in the pelvic fracture group. conclusions: the findings from this study demonstrate no clear relationship between the choice of hemorrhage control intervention used and the patient's clinical status. in healthier patients with unstable pelvic fractures, the mortality rate was similar to that of patients with stable fracture patterns. introduction: various percutaneous screw placement for pelvic and acetabulum fractures is often difficult because of complex anatomical morphology, however, it becomes very beneficial to set enough fixation stability if we can insert the long screws. d-ct navigation system for the screw placement is beneficial for precise screw insertion. we investigated the accuracy of screws with d-ct navigation. material and methods: our retrospective case series were assessed by the accuracy of screws with d-ct navigation for pelvic and acetabulum fractures. twenty-six patients who sustained pelvic fractures and thirteen patients who sustained acetabular fractures were included in this study and . mm cortical screws or . mm cannulated screws were inserted with d-ct navigation. we investigated the number of screws and screw positions which is measured by postoperative ct scan and classified by smith criteria. results: we inserted tits (transiliac-transsacral) screws and is (iliosacral) screws for pelvic fractures. of screws ( . %) were placed in correct position (grade or ). screw for s lesion was placed in incorrect position. meanwhile we inserted antegrade pubic screw, anterior column screws, posterior column screws and infra-acetabular screws. of screws ( . %) were placed in correct position (grade or ). screws were in incorrect position and they were all cortical screws. and there was no complication related to screw insertion. conclusions: our study highlights that d-ct navigation system reduced the malposition rate of screw insertion for pelvic and acetabular fractures. however, we sometimes had difficulty in inserting tits screw for s lesion and cortical screw for acetabular fractures. we assumed that this was caused by narrowness of s corridor and flexibility of drill or inserting cortical screws in wrong position manually. we should pay much more attention even using d-ct navigation. is operative therapy still warranted for dislocated acetabular fractures in elderly patients? introduction: the incidence of acetabular fractures in elderly patients is increasing. there is no consensus about the right treatment for the impaired elderly patient with an acetabular fracture. the aim of study was to investigate acetabular fractures in the elderly patient and the risk of a secondary tha. material and methods: a retrospective study was performed from till in the radboudumc nijmegen. all patients with an acetabular fracture were reviewed. they were divided into two groups, younger than and or older. ct scans were used for classification according to letournel and for the quality of the reduction according to matta. there was a follow-up of minimal years. results: in total, patients attended at the radboudumc with an acetabular fracture, of which were years or older. in the younger group, patients received surgery and elderly patients. according to matta, an anatomical reduction was achieved in % of the young patients and % of the elderly patients. imperfect reduction was achieved in % of the younger patients and % of the elderly patients. thirteen percent of younger group and % of the older group needed a tha based due to the posttraumatic arthritis, the younger group after months and the older group after months on average. one younger patient with anatomical reduction needed a tha, none of the elderly patients. twenty-three percent of the younger patients and % of the elderly patients, all with a poor reduction, needed a tha. age, the complexity of the fracture and the quality of the reduction were important factors leading to a secondary total hip arthroplasty. conclusions: elderly patients are two times more likely to need a secondary total hip arthroplasty. after an anatomical reduction, the risk is very low, even in the elderly. surgery for dislocated acetabular fractures is a good option when there is a possibility for a good reduction. references: letournel e. matta jm. introduction: in japan, as a definition of basicervical fractures of the proximal femur, a fracture line is placed into and out of the joint capsule of the hip joint. however, in fact there are various fracture types.we classified these fracture types based on treatment methods and reported on these results. material and methods: cases of proximal femoral fractures treated in our hospital from january to december . basicervical fractures occurred in cases ( . %). all cases diagnosed with x-ray and d-ct, and observed for months or more after surgery. results: there are two types of basicervical fractures: the fracture line exists around the just inside of the intertrochanteric part: normal type(n type); cases ( . %), and fracture line exists subcapital at ventral side, the coronal plane in the center of the neck and the trochanteric fossa at the dorsal part: coronal shear type(c type); cases ( . %).c type was further classified by treatment method depending on existence of posterolateral fragment and anterior wall fracture. c type without comminution ( part:c- type) was cases ( . %). with posterolateral fragment ( part:c- type) was cases ( . %), with posterolateral fragment and anterior wall fragment ( part:c- type) was cases ( . %).n type and c- type were treated by sliding hip screw (shs) with anti-rotation screw. c- type: shs with trochanteric stabilizing plate, c- type because of the bony contact area is very small: hemi-arthroplasty with calcar replacement was performed. cut out occurred in cases of c- type and case of c- type, but others obtained union.. one case of c- type occurred peri-prosthetic fracture intraoperatively. conclusions: we classified cases of basicervical fractures, and according to its classification, treatment method was decided and good clinical results were obtained. strategies aimed at preventing chronic opioid use after trauma: a scoping review c. cô té , m. berube université laval, faculty of nursing, québec city, canada, chu de quebec research center, université laval, trauma, emergency, critical care medicine, québec city, canada introduction: a high incidence of chronic opioid use (up to %) has been documented after trauma. solutions are urgently needed considering the importance of this public health issue. we aim to identify strategies to prevent chronic opioid use in the trauma population and to assess their level of evidence. material and methods: we initiated a scoping review of literature to identify research articles and guidelines on preventive strategies. several databases and websites of trauma were searched. strategies were classified according to their types and targeted trauma populations. the level of evidence was summarized according to an adaptation of oxford center for evidence-based medicine classifications and strategies effectiveness. results: close to items have been screened until now from which studies - and one guideline were found eligible. two studies - combined education with mandatory limit of opioid prescriptions (level iii) in the orthopaedic trauma population and the other study used tailored physical training after whiplash injury (level i). findings showed reduction of opioid use or complete weaning at and weeks after trauma, however the effect was not maintained beyond weeks. guidelines on orthopaedic trauma made the following recommendations: prescribe the lowest effective dose for the shortest period (strong, high-quality evidence), avoid long-acting opioids in the acute setting (strong, moderate-quality evidence), and prescribe precisely (avoiding ranges of dose and duration) (strong, low-quality evidence). conclusions: chronic opioid use is an important issue in trauma patients. findings highlighted the need for more research to reduce the burden associated with chronic opioid use in this population. references material and methods: we analyzed clinical cases: men- and women- , mean age years. trauma circumstances: habitual trauma- cases, traffic accident- , precipitation- , sport- , aggression- . for cohort analize schatzker classification was used: especially type i was meet in cases, ii- , iii- , iv- , v- , vi- ; close, open. for paraclinic examination were used x-ray and ct. surgical management consisted of: close reduction, internal fixation- cases ( -percutaneus canulated screws arthroscopic assisted, -external fixator), open reduction, internal fixation- cases. bone graft was done in cases. results: postoperative follow up was performed at , , , weeks. patients were evaluated according to the lysholm knee scoring scale, obtaining an average score of points. bone healing was achieved in a period of between to weeks. postoperative complication developed in cases. results were depending on the stability of osteosynthesis, precocity, rightness of functional reeducation and patient compliance. conclusions: favorable functional results and less complication were met in cases of individual approach of surgical management, a good choice of implants and minimally invasive surgical techniques. fractures of the shoulder processes-a case report case history, clinical findings and diagnosis: -year-old male, low-speed motorcycle crash with subsequent polytrauma. he presented with right shoulder pain, swelling and pain to the touch. articular ct revealed a type i fracture of the coracoid base, type iii acromion fracture and scapular body fracture without displacement. results, therapy and progressions: he was submitted to surgical treatment days later. a superior ''sabercut'' approach with open reduction and osteosynthesis of the coracoid process was performed with a cancellous screw and washer and fixation of the acromion with k-wires and tension band wire. fracture of the scapular body followed a conservative treatment. immediate postoperative period was uneventful and he presented with favourable evolution in the subsequent -week, -week and -month follow-up. at present time, at -month follow-up, maintained anatomical reduction in radiological control, complete arm abduction and no limitation with efforts. comments: conservative treatment is generally indicated for all shoulder body fractures without displacement. fractures of the coracoid or acromion with [ cm displacement are described as an indication for surgical treatment. fractures of the acromium without displacement may follow conservative treatment with sling immobilization. surgical fixation can be achieved with screws, plate and screws or tension band wire. although controversial, surgical treatment for coracoid fractures is preferred, especially in active young patients with open reduction and fixation with screws or, if necessary, with plate and screws. the treatment applied in the present case, all approaches described in the literature as being effective and with good results, is in agreement with the options described in the literature and constitutes a corroborative example of its efficient results. case history: a -year-old male, hand worker, attended to our emergency department after a traffic accident complaining about pain and swelling in his left wrist. initial radiographs revealed an isolated dorsal dislocation of the lunate that went unnoticed. two and a half months later he was referred to our clinic. clinical findings: findings included dorsal wrist deformity and pain. he presented a decreased passive wrist flexion and extension range of motion, with normal finger tendinous function. investigation/results: plain x-rays showed persistence of the lunate dorsal dislocation without any associated injuries. diagnosis: chronic isolated dorsal dislocation of the lunate therapy and progressions: open reduction was performed using a dorsal approach. the scapholunate, lunotriquetal and scaphocapitate spaces were stabilized with a compression screw and kirschner wires respectively. the patient persisted with pain and functional limitation after the surgery, showing an insufficient reduction of the scapholunate space on the x-ray. nine months after the initial surgery, he developed a purulent fistula on the ulnar edge of the carpus. after it was resolved, a total wrist arthrodesis was performed using the mannerfelt technique. at the months follow up, he was clinically stable, consolidation of the arthrodesis was documented and he had returned to his previous normal activities. comments: isolated dorsal dislocation of the lunate is a rare lesion. the delay in the diagnosis of carpal dislocations is frequent. this compromises the final outcome of reconstructive techniques and the risk of residual instability, hence increasing the risk of chronic pain associated with posttraumatic osteoarthritis. in the case of chronic lesions, treatment with palliative techniques such as proximal carpectomy or joint arthrodesis should be taken into consideration. references: siddiqui n., sarkar s. isolated dorsal dislocation of the lunate. open orthop j. ; : - is ultrasound-guided regional anesthesia safer than landmark technique? one-hospital experience introduction: according to the literature the application of ultrasound (us) in performing regional anesthesia had a significant impact on patient safety by increasing the success rate [ ] . in a donated ultrasound device became available in the institute of emergency medicine, chisinau, republic of moldova. due to lack of equipment both us guided and landmark techniques have been performed. the aim of this study was to analyze the two methods of performing regional anesthesia, in order to estimate the potentials benefits of of us guided techniques (succes rate and doses). results: the bivariate analysis showed that, out of anesthetics in lmg, a number of were reported as unsuccessful, compared with a number of in usg. the v test with corrections for continuity did not determine significance (test value . , df = , p = . , effect size = . ), rr being . ( % ci . - . ). linear regression for dose (lidocaine) modeling, in patients included in the research, showed a decrease of the dose by mg in lmg, the confidence interval being quite wide ( % ci -. , -. ). that is, the actual decrease is within the limits of and mg. conclusions: the tendency towards higher failure rate in successfully performing an us guided regional anesthesia and relative ''uncertain'' decreasing of dosage are in contradiction with the international statistical data. this in turn evidenced probable deficiencies in the training of the practitioners in field of ultrasound guided techniques in our country. the prospective research to confirme/infirme these results and estimate the complication rate follows. references: . barrington mj, uda y. did ultrasound fulfill the promise of safety in regional anesthesia? current opinion in anaesthesiology ; ( ) results: average age years old ( - ).all were active labour patient. the most frequent mechanism was high energy trauma (traffic accident), of who presented gustilo grade iiib open fractures operated in the country of origin. most frequent pattern of fracture was -c. ( cases) and -c. ( cases). initial conservative treatment was performed in of the cases. one persistent pseudoartrhosis with osteosynthesis material failure. in every case, preoperative ct and early surgical intervention were carried. in cases, an additional procedure was associated at the radioulnar distal joint. in all cases consolidation occurred. one patient required reintervention for persistent pseudoarthrosis. average consolidation time months ( ) ( ) ( ) ( ) ( ) ( ) ( ) .average follow-up of months ( - ). average active joint balance: flexion °( °- °), extension °( °- °), pronation °( °- °), supination °( °- °). average dash . ( - . ).force reduction greater than % compared to contralateral in of the cases. radiological parameters:radial height . mm ( - ),radial inclination °( - °),volar angulation . °( . °- °), ulnar variance . mm ( ) ( ) ( ) ( ) ( ) . conclusions: malunion of the distal radius is an uncommon and severe complication with increasing incidence that requires early and personalized surgical treatment to achieve the correction of the deformity, preserving mobility acquiring consolidation with acceptable functional results case history: isolated ulnar translocation of the carpus is unusual. when the translation occurs without injury of the radius, ulna or carpal bones are often misdiagnosed. early diagnosis is key, to avoid further complications such as redislocation of the carpus ( ). clinical findings: in our case a young male patient suffered a high energy motorcycle accident. he had no a b c d problem investigation/results: the ulnar translation of the left carpus was evident but comparison x-rays were taken on both wrist for further evaluation. the distance between the line, drawn through the axis of the radius and the center of the capitate bone was measured bilaterally. the results were . mm vs . mm. diagnosis: isolated, open ulnar translocation of the radiocarpal joint, dumontier type i, was diagnosed. treatment: the primary treatment was debridement, reposition and fixation with ex fix. after the wound healing on th days we made reconstruction. volar approach was used, we re-reponate the carpus and fixated the position with two mm smooth kirschner wires. the radioscaphocapitate and long radiolunate and radioscaphoid ligaments were reattached to the volar margins of radius using mitek mini anchors. we put the ex fix and left the bended wires percutaneously. after weeks the ex fix and the k wires were remove. wrist motion exercises were initiated under supervision of physiotherapist. comments: after weeks the wrist was in good alignment, the flexion-extension were - , the deviations were - °. the radiographic signs of this injury are unusual and often misdiagnosed. it can be useful to compare with contralateral x-rays. the radiolunate and radioscaphocapitate ligaments is considered crucial in prevention of ulnar translation. in our opinion the radiolunate arthrodesis can be reserved for failed ligament repairs. introduction: within the orthopaedic paediatric population, there is a distinct paucity of literature in regard to post-operative paediatric analgesic regimes. supracondylar humeral fractures account for % of all paediatric limb fractures and there has been a marked divergence in recent literature concerning the most appropriate choice of analgesia for this cohort with recent studies recommending the routine inclusion of an opioid agent post-operatively on prescription. opioids have deleterious side effects pertinent to paediatrics. in our institution, patients'' only receive a prescription for acetaminophen and nsaids upon discharge. our study assessed postoperative analgesic satisfaction rates in all paediatric patients who underwent crpp for supracondylar humeral fractures in our institution from january to december . material and methods: this is a retrospective multi-surgeon case series of all paediatric patients who underwent crpp from january to december . patient data was extrapolated from theatre records and clinical charts. for each patient, all analgesic agents given were identified, the dosage, route and frequency of administration in addition to the length of their hospital stay and time from injury to operation. following discharge, patients'' guardians were contacted retrospectively and a questionnaire was administered which ascertained the efficacy and duration of analgesia used by the patient postoperatively. results: fifty patients were identified for inclusion within the study who met the inclusion and exclusion criteria. there was a % satisfaction rating amongst the responders with the analgesic regime recommended-acetaminophen & nsaids. conclusions: in stark contrast to papers which we discuss throughout our paper, our study conclusively demonstrates that opioid prescriptions are not required upon discharge for supracondylar fractures within a paediatric population case history: a -year old man suffered an isolated injury of his right hand in a motorcycle accident. clinical findings: the patient presented with a swollen hand, a subtotal amputation of the middle finger at the level of the middle phalanx and lacerations to the other fingers (fig. ) . investigation/results: after excluding injuries to other body regions, radiographs and a ct of the hand were performed (fig. ) . diagnosis: closed fracture dislocation of cmc joints from ii. to v. finger, comminuted fracture of the middle phalanx of the middle finger, closed fracture of the proximal phalanx of the middle finger, other lacerations to the iv. and the v. finger. therapy and progressions: urgent open reduction and internal fixation (orif) with k wires of the cmc joints. exploration of the middle finger reviled heavy contamination and comminution of the phalanx, with injury to one neurovascular bundle. a phalangectomy with acute finger shortening was performed with creation of a new ip articulation (distal to proximal phalanx) (fig. , ) . progression after the surgery was uneventful. there was no sign of infection. the shortened finger was sufficiently perfused and the patient reported a sense of touch. k wires were removed after weeks and physical therapy was started. the patient has limited rom in his neo ip joint with minimal pain (vas - ) (fig. ) . comments: middle phalangectomy of the hand was described in the literature only in two papers which report treatment of chronical or congenital diseases. the authors propose this method as an alternative to amputation in selected trauma cases. results: patients ( m, f, mean age y) with fractures were included. kidney-tpl, lung-tpl, liver-tpl, heart-tpl, kidney/pancreas-tpl. all patients got treated with at least two immunosuppressive drugs. cause of accident: . % sports/leisure, % work/household, . % traffic accidents, % without trauma. the operation was performed under perioperative long-term antibiosis, often with a combination of two or three drugs. patients were hospitalized for an average duration of . days and were also examined by the particular organ specialists. osteosynthesis: in % primary operative fracture treatment, in % two-step procedure. plates distal radius and ulna [healing period (h) conclusions: the fracture healing was possible but significantly delayed. the wound healing took longer. the immunosuppressive therapy may be responsible for these problems. the rehabilitation of movement and weight bearing has to be adapted to the slowed fracture healing. introduction: the prevalence of fragility fractures of the pelvis (ffp) increases, including in up to % a lesion of the posterior pelvic ring. an operative therapy is indicated in cases of prolonged or immobilizing pain or in a displaced dorsal fracture. methods: patients suffering an ffp treated with a minimal-invasive trans-sacral bar through s from to were included. the patients or their relatives were contacted to ask about mortality, the present mobility and place of residence. % of all patients still alive could be included in follow-up. results: females and males with a mean age of . ± . years ( - ) were included. concomitant stabilization of the anterior pelvic ring was performed in %. . % underwent an operative revision ( % evacuation of hematoma, % peri-implant infection, % hardware removal-combinations possible). the trans-sacral bar was removed in one case due to malpositioning. the length of stay was ± days. at discharge, % were mobile on the ward, % in their room, % for transfer to sitting position and % were bedridden. % were discharged to their home, % in geriatric rehabilitation unit, the remaining to other rehabilitation or to a nursing home. during follow-up, mortality was %, one patient died during hospital stay. the patients died in average ± weeks after discharge. after a follow-up of ± weeks, % lived at their home, thereof one-third with assistance. % needed a walking aid, % were mobile without walking aid, % were bedridden or only mobile to sitting position. conclusion: the trans-sacral bar in s is a valuable minimal-invasive stabilization method to recover mobility in elderly with an ffp. a relatively long in-hospital stay could be explained by the initial trial of conservative treatment and due to intra-and inter-departmental cogeriatric services. the high mortality and need for assistance reflects this geriatric, multi-morbid patient collective. case history: a -years-old woman was admitted in the emergency room after being run over by a bus. clinical findings: at the emergency room, she was conscient and hemodynamic stable. head, thoracic or abdominal trauma were excluded. the patient presented with an open wound in left popliteal area with massive bleeding with exposure of gastrocnemius and soleus muscles and achilles tendon investigation: radiologic images didn't show any fracture. a limb angiography showed complete perfusion of the leg, without any lesion on major arteries. diagnosis: open aquilles tendon avulsion through the popliteal fossa therapy and progressions: the patient was taken to the operating room. we approach the popliteal area and found a small laceration of popliteal vein, which was sutured with prolene / . then, we reference the achilles tendon, and tunneled the posterior face of the leg, and passed the tendon through the tunnel. a distal approach, above the insertion of achilles tendon was done, and two suture anchors preloaded with sutures were inserted in the medial and lateral sides of the calcaneal tuberosity, then we did an krackow suture. we also did a fasciectomy on the lateral side of the leg, to prevent compartmental syndrome. the patient was put in a posterior cast with of flexion for weeks. the immediate post-operative time was in an intermedia unit care, to control possible multiorgan failure. in days, she was discharged to orthopedics nursery. due to the degloving of subcutaneous tissue, she evolved with some blisters which made her stay inpatient about weeks. after some time, she developed some areas of skin necrosis, which needed some intervention by plastic surgery with skin graft. now, she has skin completely healed, some loss of strength in the leg, with loss of plantarflexion, and is under prolonged rehabilitation program. therapy and progressions: she was rushed into the or and submitted to external fixation of the humerus and bones of the forearm, debridement, and primary closure of the forearm and hand. successive dressings and debridement was maintained and, at th postoperatory day(po) the external fixator of the left humerus was removed and a nailing was performed as well as an osteosynthesis of the clavicle fracture with anatomical plate. at thpo the external fixator of the forearm bones was removed and an open reduction and internal fixation of the radius with lcp plate and closed reduction and internal fixation of the ulna with an anterograde ten nail was performed. at thpo, she underwent an autologous skin graft of the forearm and hand wounds. good clinical evolution of the wounds and fractures, all of which evolved to consolidation, although m fracture malunion was verified as well as deficit of thumb abduction and extension of rd- th fingers. uefi of / . comments: the approach of polytrauma patients should be sequential, according to the atls protocol, preserving life, limb and function. treatment of these lesions is complex and, if poorly managed, can be associated with high morbidity, as most patients combine severe and contaminated lesions, extensive skin loss, open fractures, postoperative infection. a sequential approach is required, which involves injury assessment, infection prevention, soft tissue treatment and fracture stabilization. introduction: pelvic fractures, though rare ( - %), are often associated with high mortality ( - %). the factual outcomes in polytrauma patients with the additional burden of pelvic fractures are unknown. the purpose of this study is to provide an in-depth analysis of pelvic fractures in seriously injured patients. material and methods: this is a retrospective analysis of prospectively maintained trauma registry from to . we included all trauma patients with iss c . group i, which had an additional burden of pelvic fractures, was compared with group ii, consisted of patients without pelvic fractures. a double-adjustment propensity score match (psm) analysis was utilized to minimize confounding and unbiased estimation of the impact of pelvic fractures. . ± . , asmd = . ).patients in group i had higher number of genitourinary surgery (p = . ), exploratory laparotomy (p = . ). therequirement of angio-embolization was similar in between two groups (p = . ). while there were no difference in mortality (or . , % ci . - . , p = . ), group i had higher odds of severe sepsis (or . % ci . - . , p = . ) and ventilator-associated pneumonia (or . , % ci . - . , p = . ) conclusions: pelvic fractures in polytrauma patients did not translate into higher mortality. however, there was an increased risk of sepsis and vap. evidence-based management at tertiary care specialized centers can further enhance the outcomes. investigation/results: ap pelvis x-ray reveals a complex left proximal femur fracture with neck and trochanteric extension. a ct-scan was obtained and showed a complex fracture pattern with subcapital and trochanteric extension. blood analysis showed a hemoglobin of . g/dl. diagnosis: therapy and progressions: at admission, patient refused erythrocytes'' concentrate transfusion and was hospitalized for pain control and hemodynamic stabilization. despite alternative measures such as intravenous iron supplementation and erythropoietin, hemoglobin values remained lower than . g/dl, thus preventing any surgical procedure. at day , patient finally decided to accept packed red blood cells and was then transfused. at day and with a hemoglobin of . g/dl, the patient was finally submitted to a total hip arthroplasty with an uncemented revision femoral stem. at day , the patient initiated the rehabilitation protocol with hospital discharge at day with a hemoglobin of . g/dl. comments: proximal femur fractures arise as one of the major problems of present traumatology. comorbidities frequently prevent surgical treatment within the golden hour (first h) and thus limiting the postoperative results. in this particular case, a timely surgical approach would have made it possible to try a more conservative procedure with femoral osteosynthesis. the surgical delayed due to low hemoglobin values limited the surgical options and forced a more aggressive procedure. routine versus on demand removal of the syndesmotic screw; a multicenter randomized controlled trial on functional outcome introduction: syndesmotic injuries are common, being present in approximately - % of surgically treated ankle fractures . one of the most commonly used ways of fixation is the syndesmotic screw (ss). traditionally, this screw is removed after - weeks as it is thought to hamper ankle function and cause pain. however, a recent study showed that implant removal does not always result in improvement of functional outcome . with the relatively high complication rate of implant removal in mind, retaining sss could be beneficial. we therefore aimed to investigate the effect of retaining the ss on functional outcome. material and methods: in this multicenter rct, patients were randomized between routine and on demand removal (upon patients request). the primary outcome was functional outcome at months after ss placement, measured by the olerud-molander score (omas) with a non-inferiority limit of points ( % power, a = . ). secondary outcomes include quality of life, range of motion, complications and costs of ss removal. results: a total of patients were randomized, of which for routine removal and for on demand removal. the mean age was years old and % was male. follow up of all participants will be completed in march . results of the primary outcome analysis are therefore not yet available, but will be at the conference. conclusions: if on demand removal of the ss is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. this means that patients will not have to undergo a secondary procedure, resulting in fewer complications and subsequent lower costs. introduction: treatment options for pertrochanteric fractures of the hip are extra-or intramedullary fixation. the aim of this study is to identify risk factors for the development of complications: varus deformity, neck shortening, revision and cut-out. material and methods: retrospective cohort study in which radiographs of patients with pertrochanteric fractures, treated at the uz brussel between and , were reviewed. fracture type, type of the device, cut-out and revision where noted. measurements for the centrum-collum-diaphyseal angle (ccd) of the two hips, impaction, tip apex distance (tad), parker''s ratio were realized. statistical analyzes were made with logistic and multiple linear regression analyzes. results: patients were included. bmi (p = , ), type of osteosynthesis (p = , ), dhs ? plate (p = , ), short nail (p = , ) and the tad (p = , ) are independent risk factors for the development of varus deformity after consolidation. for impaction are bmi (p = , ), short nail (p = , ), long nail (p = , ) and fracture type a (p = , ) independent risk factors. we identified a marginal statistical significant risk factor for cut-out: tad (p = , ). conclusions: , % of the patients had varus deformity after consolidation. the risk of varus deformity rises with a higher bmi and a higher tad. the risk for this complication was higher when using a nail. neck impaction was shown more together with a high bmi and less in fracture type a and with the use of a short or long nail. in the prevention of cut-out, it is important to keep the tad low. case history: -year old female with previous distal femoral plating ( years ago) and ipsilateral proximal femoral nailing ( months ago) presented with a diaphyseal femur fracture. clinical findings: extremity was swollen, painful, neurocirculatory intact, no shortening or external rotation was seen. she was unable to lift her leg. scars showed no sign of infection. investigation: x-ray revealed a spiral fracture including distal pfna locking screw, unhealed proximal femur fracture without loss of reduction, protruding pfna blade and a healed distal femoral fracture. diagnosis: peri-implant fracture classification proposed by the singapore group presented a discrepancy between nail type subtype b and plate type subtype. by simplification, we disregarded the distal (healed) fracture to choose the first option. therapy: firstly, the distal femoral plate was removed as the preoperative simplification dictated. secondly, pfna distal locking screw was removed and the pfna blade shortened. after open reduction cerclage wires were applied. a long lcp plate was initially fixed through the plate and pfna locking hole, adjusted in line, fixed proximally with screws through a locking attachment plate and cerclage, distally locking screws were used. comments: distal femoral callus prevented the use of a long nail. as the proximal fracture was not yet healed, we avoided full implant removal. as the pfna was unstable, fixation through the plate and pfna distal locking hole enabled implant coupling to strengthen the construct. the plate covered the entire bone to bridge the possible loci minori left by the plate removal and minimize stress risers. background: we have been reported the usefulness of intra-medullary antibiotics perfusion (imap) and intra-soft tissue antibiotics perfusion (isap) for suppressing open fracture and bone infection. imap and isap was a method of antibiotics delivery with the continuous administration of high-dose aminoglycosides. however, the best dose was not obviously. the purpose of this study was to evaluate translation of aminoglycosides from imap or isap. as follows: males and females, average age was . years old, intramedullary nails and plates. one dialysis patient was including. we measured concentration of gentamicin from imap, isap and in blood, outflow. results: average administration concentration of all cases was . lg/ml. average blood concentration of all cases was lg/ml and outflow concentration were . lg/ml. average blood and outflow concentration of each dosage were shown as follows: lg/ ml: . lg/ml, lg/ml, lg/ml: . lg/ml, . lg/ml, lg/ml: . lg/ml, lg/ml, lg/ml: . lg/ml, . lg/ml. in dialysis patient case, lg/ml administration lead concentration of blood as . lg/ml, outflow as lg/ml. side effect were not observed. discussion: local antibiotic administration using imap and isap showed increasing blood concentration depend on administration dose. under lg/ml administration dose showed safe blood concentration(\ lg/ml). on the other hand, lg/ml administration dose achieve trough concentrations over - times of minimum inhibitory concentration. furthermore, we need to pay attention for administration dose in dialysis patient case. conclusion: lg/ml administration dose achieved safe and effective local concentration. introduction: distal radius fractures and supracondylar humerus fractures are two of the most common fractures seen in children. most can be treated with non-operative treatment but a small number require operative reduction and surgical stabilisation, often with percutaneous kirschner wires. this study aims to identify whether an early review is required before planned removal of the wires. materials and methods: retrospective review of paediatric patients undergoing surgical reduction and stabilisation with percutaneous kirschner wires for upper limb injuries. data collected over threemonth period (june-august ). number and type of outpatient reviews, imaging episodes and clinical interventions recorded. results: consecutive patients with mean age years (range - ). distal radius fractures and supracondylar humerus fractures. patients transferred to another unit. / patients received a week check and then a second review where the wires were removed. mean time to first outpatient review . days (sd . ). at initial appointment all patients had a change of cast and a satisfactory radiograph. mean time to second outpatient review was . days (sd . ). at the second appointment / patients had the wires and cast removed and subsequent satisfactory radiograph. / required a further period of casting. / had a third appointment. / required formal physiotherapy after cast removal. there was one transient anterior interosseous nerve palsy after supracondylar fracture stabilisation. clinical union of the fracture and good functional outcome was seen in all cases. conclusion: the initial outpatient review at - weeks allows a lighter weight cast to be applied but in this series the radiograph taken after the cast was changed did not alter management. our findings support a cast change alone at weeks and then clinician review with radiographs at the time of wire removal. introduction: the aim of this study was to describe surgical technique, report on patient-based functional outcomes and complications following open reduction and internal fixation in patients with scapular fractures. methods: the study comprised patients who were treated with open reduction and internal fixation (orif) of a scapular fractures between september and july . surgical indications were as follows: medial/lateral displacement greater than mm; shortening greater than mm; angular deformity greater than °; intraarticular step-off greater than mm and double shoulder suspensory injuries (including fracture of clavicle, coracoid or acromion with displacement greater than mm). all patients underwent x-ray examination (true ap, y scapular view) and computed tomography (ct) scans. fractures were classified according to the revised (ao/ota) classification system. functional outcome were measured using the constant-murley score. results: seven patients had glenoid fossa fracture, six patients had scapular body fracture and one patient had acromion process fracture. all glenoid fossa and scapular body fractures were exposed via the judet approach. eleven of patients were reviewed with constant-murley score at the final follow-up examination, three patients were lost for follow-up. the mean follow-up after injury was months ( - months). we found in four patients infraspinatus muscle hypotrophy. mean constant-murley score was . (± . ) for injured arm and . (± . ) for uninjured arm. mean score between injured and uninjured arm was . (± . ) which is excellent functional outcome according to grading the constant-murley score. conclusions: open reduction and internal fixation of displaced scapular fractures is a safe and effective treatment option that results in reliable union rate and good to excellent functional outcome. introduction: the aim of this study was to evaluate clinical and radiological results of intramedullary radius and ulna nails in treatment of adult forearm fractures. methods: the retrospective study included patients who were treated with intramedullary nailing of forearm fractures between january and september . the medical records and radiographic images of all patients, taken preoperatively and postoperatively, were reviewed. fractures were classified according to the ao/ota classification system by reviewing the radiographs. we analayzed time to union, union rate, clinical outcome and complications. results: primary intramedullary osteosynthesis were performed in patients with forearm diaphyseal fractures. the average time to union was months (range, - months) in primary osteosynthesis cohort. secondary intramedullary osteosynthesis were performed in four patients following removal of plates and screws due to pseudoarthrosis. the average time to union was months (range, - months) in secondary osteosynthesis cohort. overall union rate was , % in forearms with fractures or pseudoarthrosis of the radius, ulna, or both bones, which were treated with intramedullary nail with compression screw. overall complications were one nonunion, one postoperative rupture of the extensor pollicis longus tendon and one postoperative transitory radial nerve palsy. conclusions: intramedullary nailing of adult forearm fractures is a safe and effective treatment option that results in reliable union rate and good to excellent clinical outcome. key words: forearm fractures, intramedullary nailing, biological fixation, union rate results: transverse or short oblique fractures of the middle third of the humeral shaft were treated using a retrograde approach. spiral fractures of the middle third of the humeral shaft were treated through the antegrade approach. comminuted fractures of the proximal third of the humeral shaft were treated mostly through the antegrade approach. comminuted fractures of the distal third of the humeral shaft were usually treated using the retrograde approach. whenever possible, we prefer retrograde insertion because the approach through the shoulder joint is avoided. reduction with retrograde nailingnis easier because upper arm was placed on the radiolucent operating table extension. interlocking screw insertion by freehand techique is also easier to perform because there is no danger of radial nerve injury. nonunion was found in eight patients ( , %). there were five patients ( , %) with postoperative transitory radial nerve palsy that fully recovered within months. conclusions: the choice of approach to the medullary canal depends on the fracture type and the fracture site. therefore, antegrade nailing should be performed for proximal third humeral shaft fractures and complex middle third humeral shaft fractures, while retrograde nailing should be perforemd for distal third humeral shaft fractures and simple transvese or short oblique middle third humeral shaft fractures. keywords: humeral shaft fractures, intramedullary nailing, radial nerve palsy, nonunion the diaphyseal aseptic tibial nonunions after failed previous treatment options managed with the reamed intramedullary locking nail i. kostic , m. m. mitkovic clinical center nis, university hospital, orthopaedics and traumatology, nis, serbia, university of nis, serbia, orthopaedics and traumatology, nis, serbia introduction: in this article, we present our approach to the surgical treatment of noninfected tibial shaft nonunions. material and methods: between and , patients with aseptic diaphyseal tibial nonunion was treated by reamed intramedullary nailing and were retrospectively reviewed. all patients, preoperatively, were evaluated for the signs of the infection, by the same protocol. results: the time that elapsed from injury to intramedullary nailing ranged from to months (mean months).open intramedullary nailing was unavoidable in cases ( , %), while closed nailing was performed in patients ( , %). all patients were followed up in average period of years postoperative (range - years), and ( , %) patients achieved a solid union within the first months. conclusions: in conclusion, a reamed intramedullary nail provides optimal conditions for stable fixation, good rotational control, adequate alignment, early weight-bearing and a high union rate of tibial non-unions. percutaneous figure of suture as a novel technique for treating closed tendinous mallet injuries following failed splinting therapy. t. eltantawy , a. yousif , k. maheshwari , a. hartpinto bedford hospital, plastic surgery, bedford, united kingdom introduction: mallet injuries are common injuries affecting the hand. majority of them are managed using conservative method, however a small percentage of patients that do not do well on conservative treatment need an operative intervention. we wish to evaluate the efficacy of percutaneous figure of suture as a new technique for treating closed tendinous mallet injuries resistant to splinting therapy, as a minimally invasive treatment option. material and methods: we present a case series of patients who had persistence of more than degree extensor lag, despite splinting minimally for weeks. all of these were treated with a percutaneous figure of suture placed across the dorsum of dipj, which provided splinting for further weeks. this technique provides fixation for the dipj in hyperextension position by going through the periosteum on both sides and was done under local anaesthesia. results: the mean age of our patients was years, with a single digit involved in all patients. all the five cases had nearly fully straight dipj with less than °extensor lag following weeks of percutaneous stitch placement. there was no further recurrence with mobilisation or overlying skin necrosis. conclusions: percutaneous figure of suturing technique can be an effective, minimally invasive and safe technique to treat closed tendinous mallet injuries not responding well for conservative splinting. introduction: osteosynthesis of pertrochanteric fractures (pf) is a frequently performed procedure in orthopaedic trauma care. dynamization of the osteosynthesis during fracture healing can lead to dynamization of the lag screw. which can cause debilitating complaints. a spontaneous femoral neck fracture (sfnf) after implant removal was seen in patients over a month period. based on these cases we evaluate the different aspects of the pathophysiological and mechanical mechanisms of lag screw dynamization, complaints and complications in pf healing. material and methods: pubmed search on incidence of chronic pain, gait impairment associated with dynamization of osteosynthesis, risk factors for dynamization and complications after implant removal. based on research data preventive recommendations are suggested. results: literature describes complaints as reduced mobility, gait impairment and chronic pain in association with lag screw dynamization. an important risk factor is the ao-classification of pf, a type fractures are significantly associated with more dynamization and the onset of trochanteric pain and gait disturbances. partial implant removal can reduce complaints in the majority of symptomatic patients, and induce symptoms in % of asymptomatic patients. literature study shows a sfnf after lag screw removal with an incidence of %, affecting mostly vulnerable elderly patient resulting in a high mortality rate. risk factors associated with an increased risk of this complication are pre-existing systemic osteoporosis, stress-shielding, pre-loading of the implant. most importantly the removal itself, a sfnf with the implant in situ is very uncommon. conclusions: the clinical indications for implant removal in healed pf are not well established, and should be restricted to specific cases. after removal, partial weight bearing and good patient counselling is extremely important. replacement with shorter lag screw should be considered. metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with a spray on their surface of hydroxyapatite and % silver v. protsenko , a. abudayeh , v. chornyi , y. solonitsyn institute of traumatology and orthopedics of nams of ukraine, onco-orthopedics, kiev, ukraine, bogomolets national medical university, kiev, ukraine introduction: surgical intervention in the case of pathological bone fracture against the background of metastatic lesion involves performing osteosynthesis. for more effective integration of the metal plate with the bone, a material based on bioactive glass was sprayed on their surface. bioactive glass-based material is an osteoinductive and osteoconductive biomaterial that integrates quickly with bone, forms a bone-ceramic complex, and is transformed into bone over time. material and methods: metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with spraying on their surface of hydroxyapatite and % silver was performed in patients. the functional result of the operated limb was calculated on the msts scale. evaluation of pain was performed on the scale of r.g. watkins. the quality of life of patients was evaluated using the eortc qlq-c system. the evaluation of the integration of the plate with the bone was performed by radiological examination and by osteoscintigraphy. results: postoperative complications were found in ( , %) patient, recurrence of metastatic tumor was noted in ( , %) patients. the functional result of the operated limb after metal osteosynthesis was , %. the degree of pain decreased from , % to , %. the quality of life of patients after metal osteosynthesis improved from to points. x-ray examination revealed the formation of callus within a shorter timeframe, as evidenced by the more intense accumulation of radioisotope during osteoscintigraphy. introduction:the aim of this study was to evaluate the results in patients who had heal intertrochanteric fracture but did not receive adequate mobilization and rehabilitation support. material and methods:sixty patients over years old age were included in our study. the rehabilitation emphasized pain relief, muscle strength, range of motion, endurance, balance challenges, and proprioceptive enhancement for all patients. it started postoperative first day and was delivered twice a day by the physical therapist until discharge. patients were discharged on average . days ( - days) after surgery. the mobilization of patients was evaluated with the parker and palmer mobility scoring system, the clinical evaluation was performed with the haris hip scoring and daily living activities were evaluated with the barthel life index before and at the end of the fracture. results: female male patients were included in our study. the mean age was , ( - ) years and the mean follow-up period was , ( - ) months. patients had a type, patients had a type intertrochanteric femur fracture. in the last follow-up, all patients had fracture union. patients' mobility, daily life activity and clinical evaluations were found to be statistically significantly worse in the last control than before surgery. conclusions:the success of the surgical treatment and the union of the fracture after fixation are not sufficient for the successful mobility,daily life activity,and clinical results.the success in the functional results are significantly related with the ambulatory ability.although early mobilization and rehabilitation support are important in intertrochanteric femur fractures after surgery,the continuity of mabilization and rehabilitation support after hospital discharge is more important.the rehabilitation which administered by the patient''s ralations after hospital discharge is not sufficient.therefore,the importance of home-based rehabilitation is increased. the prognostic value of the hip screw position in trochanteric fractures i. gárgyán , î csonka , t. ecseri university of szeged, department of traumatology, szeged, hungary introduction: in our study, we analyzed one of the hungarian population's most frequent injuries, the hip fracture, focusing mainly on the lateral femoral neck and the pertrochanteric fractures. according to the classification of the swiss association for ostheosynthesis (ao), we focused on -a and -a fractures, the incidence of which increases by ageing. material and methods: between and , we analyzed the data of patients. all of the fractures were stabilized with intramedullary nails. patients received stryker gamma Ò , whereas patients' fractures were solved with synthesis pfna Ò nail. in all cases, closed reduction method was used with fluoroscopy on an extension table. the surgeries were done in general or epidural anesthesia and performed by traumatology residents or specialists using standard lateral exploration. data were collected using gepacs software and statistical analysis was done with ms excel. results: cut-out occurred in cases ( , %): out of that ( . %) were left sided and were ( , %) right sided. ( . %) patients were treated with gamma nail, and in ( , %) cases pfna nail was used. the average tad-index was mm. conclusions: according to recommendations of the tad-index value, when using dynamic hip screw, it should be mm or lower. the average index value was mm which was equal in the complicated and non-complicated groups. our study shows that the cutout is independent from the tad-index value, thus this recommendation cannot be applied for intramedullary nails. oita university hospital, acute trauma, emergency, and critical care center, yufu, japan, oita university, orthopaedic surgery, yufu-city, oita, japan introduction: dome impaction fragments (difs) in acetabular fractures are typically accompanied with anterior column fragments and recognized as the gull sign on plain radiographs. meanwhile there are some difs which do not fit into typical difs. the aims of this study were to define atypical dif and describe tips for diagnosis and intraoperative visualization. material and methods: this study was a retrospective case review. we defined atypical difs as the fragments which were independent of anterior column fragments and did not show the gull sign on plain radiographs. from jan to july , there were patients of acetabular fractures, and patients ( . %) had difs. among them, patients ( . %) were identified as the cases with atypical difs. all of them were male. the ages were from to . results: the atypical difs were not obvious on x-rays (fig. ) . all three atypical difs were located at posteromedial weight bearing zones of the acetabulum. case and were displaced in accordance with posterior column fragments, and were visualized clearly on the sagittal view of ct images (fig. ) . case was impacted posteriorly into a posterior part of the ilium as a free fragment, and well visualized on ct sagittal and coronal views. anterior intrapelvic approach was chosen in all patients to treat atypical difs. the iliac oblique view was useful to visualize the atypical difs intraoperatively in case and . in both cases, the reverse gull sign appeared after reduction of posterior column fragments (fig. ) . in case , the inlet view was useful to visualized the atypical dif intraoperatively.the fragments were reduced and fixed with supra-acetabular screws (fig. ) . results: we found prospective two to years after acetabular osteosynthesis , % complications. avn of the femoral head was present in , % of the hips reduced within h and , % of the hips reduced more than h after the injury [p = , ; = , ; or = ( % ci = , - , ) ]. post-traumatic oa of the hip we found in , % (fig. ) infections we found in , % ( deep, superficial), iatrogenic nerve palsy in ( , %), traumatic nerve palsy in , % ( ), dvt in , % ( ) , and ho in , % ( ) cases. in one case ( , %) revision surgery was done. conclusions: acetabular fractures are followed with complications. some complications depend on surgery, meanwhile others cannot be affected on (type of fracture, impaction of acetabulum, injury of the femoral head, dislocation of femoral head). good knowledge of acetabular anatomy, surgical technique, experienced surgical team, early surgery, anatomical reduction and stable orif, early mobilization, can significantly influence excellent/good functional outcomes and reduce possibility for complications. introduction: reduction is one of the important factors in surgical treatment of femoral trochanteric fractures. in this study, postoperative reduction status was examined and the relationship between this reduction status and unsatisfactory cases was investigated. material and methods: cases of femoral trochanteric fractures over years treated with pfna-ii were investigated. postoperative reduction status was evaluated in ap and lateral view of x-ray and ct. anatomical reduction means medial or anterior cortex is reduced anatomically (abbreviation am and aa). intramedullary reduction means medial or anterior cortex of proximal fragment is inside the shaft (im, ia). extramedullary reduction is medial or anterior cortex of proximal fragment is overlapped to cortex of shaft (em, ea). unsatisfactory cases were ununited cases until months and excessive sliding cases over mm. reduction status of these cases was evaluated. results: postoperative status was classified with combination of medial and anterior reduction status. so there are nine groups and number of each group are as follows; im-ia: case, im-aa: cases, im-ea: case, am-ia: cases, am-aa: case, am-ea: cases, em-ia: cases, em-aa: cases, em-ea: cases. non-united cases until months were cases. reduction status of non-united cases were; im-ia: cases, im-ea: cases, am-ia: cases, am-aa: cases, em-ia: cases, em-aa: cases. there was no case in extramedullary reduction of anterior cortex. excessive sliding of blade over mm was cases. there was also no case of extramedullary reduction of anterior cortex in these cases ( cases were cut out). conclusions: our results show there are no ununited cases and excessive sliding cases in extramedullary reduction of anterior cortex. this means extramedullary reduction of anterior cortex is important to reduce unsatisfactory results in surgical treatment of femoral trochanteric fractures. male injured open lateral condyle fracture of femur by to be bitten by a pig. after months from initial debridement, i confirmed the size of bone defect was cm( ) cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after months from bone transplantation, i confirmed bone union and two . mm diameter osteochondral grafts and . mm diameter osteochondral graft were transplanted for the chondral defect lesion. case ; seventy year old male injured open lateral condyle fracture of femur by traffic accident. after months from first debridement, i confirmed the bone defect (size cm( ) cm in depth) and the same size of bone was harvested from iliac crest and transplanted in the bone defect area. and simultaneously two mm diameter osteochondral grafts were transplanted for the chondral defect lesion. case ; year old male injured open lateral condyle fracture of femur by traffic accident. i confirmed the size of bone defect was cm( ) cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after month from bone transplantation, he had undergone autologous chondrocyte implantation. investigation/results: at last follow-up, average flexion angle of knee was degrees. in all cases, lysholm knee scoring scale was good. diagnosis: large traumatic osteochondral defect of the weightbearing articular surface of the knee comments: treatment of large traumatic osteochondral defect of the weight-bearing articular surface of the knee is a difficult condition to treat. combination of bone transplantation and osteochondral autograft transfer or autologous chondrocyte implantation is useful strategy for the injury. references: tegner y., lysholm j., clin orthop relat res., , - , pr treatment of double tension band wiring method with ai wiring system for transcondylar distal humeral fractures m. uchino hakujikai memorial general hospital, orthopaedic surgery, tokyo, japan introduction: as ai wiring system is united the pin with the cable due to compressed sleeve, the pin is never deviated. we review the treatment of transcondylar distal humeral fractures with ai wiring system in geriatric patients. patients and methods: were identified as receiving this surgery. all patients were female and their mean age was years. they were assessed union rate, range of motion for elbow joint, postoperative complication and functional outcome for japanese orthopedic score. results: union rate was %. the mean arch of motion was °at latest follow-up. the complications were detected cases which were temporary ulnar palsy for cases and hardware failure for case. the average of functional outcome was points ( / ). conclusion: tension band wiring of transcondylar distal humeral fractures with ai wiring system provides stable fixation for osteoporotic bone and tiny fragment. introduction: the purpose of this study was a comparative evaluation of the complications related to the treatment of trochanteric fractures using -screw proximal femoral nail (pfn) versus proximal femoral anti-rotational blade nail (pfna). material and methods: a retrospective review was conducted between march and march . the study included patients treated surgically for trochanteric fractures. the mean age was , ± , ( - ) years. patients were treated by pfn ( patients, , %) or by pfna ( patients, , %). implant related complications were the primary objectives. infection and revision surgery were also recorded. results: complications were observed in ( . %) patients in pfn group and ( , %) patients in pfna group (p = . ). screw backout (n = ) and cut-out (n = ) occurred in , % patients treated with pfn. in the pfna group, cut-out occurred in , % (n = ) of cases. infection (n = ) represented , % in pfna patients and , % (n = ) in pfn group. there were no statistically significant differences in both groups considering implant-related complications (p = , ) and infections (p = . ). revision surgery was performed in ( , %) patients. soft tissue problems are more likely in fractures due to high energy impact than low energy type fractures. high energy type present with horizontal fractures of tibia and fibula (i.e. on the same level), whereas in low energy type tibia fractures they present with spiral or oblique fracture patterns often associated with concomitant fractures of the posterior rim of the distal tibia (i.e. volkmann's triangle). posterior malleolus fractures occur regularly but are often missed and seen only on ct scans obtained either for preoperative planning or to verify postoperative rotation. in literature these mostly undisplaced fractures are treated with screw fixation mostly from anterior. but is this really necessary? material and methods: we retrospectively analysed consecutive tibia shaft fractures operatively treated over the past years at our regional hospital analysing the fracture pattern. results: out of patients with tibia shaft fractures patients presented with a posterior rim fracture of the tibia. no routine stabilisation of the volkmann fragment was performed, in all cases the posterior rim fragments healed uneventful. angles of °and above seem to present themselves with a concomitant fracture of the posterior malleolus. they are mostly undisplaced and the trauma mechanisms is low energy and torsion. none out of the patients had known osteoporosis. conclusions: low energy and torsion-type tibia fractures with an angle of [ °seem to have an accompanying undisplaced fracture of the posterior malleolus. these fractures are usually undisplaced and do not need to be addressed. as a consequence there seems to be no need to actively rule them out with ct scans prior to surgery. concomitant ankle fractures including posterior rim fractures should be addressed like isolated ankle fractures. the dangers of bouncing: a prospecive cohort study of injuries associated with trampolines and bouncy castles over a month period in a paediatric population. introduction: within the orthopaedic paediatric population, there is an increasing incidence of presentation of fractures associated with both trampolines & bouncy castles. whilst this phenomenon has been depicted frequently within the media in recent years given the dramatic upsurge in trampoline and bouncy castle usage, there have been few studies documenting either the incidence of fractures associated with either. materials and methods: this was a prospective cohort study conducted within our institution over a month period june to august inclusive . all paediatric patients who sustain a fracture and present to the national childrens'' hospital are referred to the orthopaedic department either whilst as an inpatient or as an outpatient depending on the assessment of the severity of injury. a standardised mixed questionnaire was given to all parents''/guardians which recorded the type of injury, type of trampoline/bouncy castle, inherent awareness of safety precautions governing the usage of either and application of same was recorded. the type of fracture was corroborated via examination of x-ray in addition to the recording of any complications via examination of clinical chart records. results: there were patients who sustained a fracture directly related to the usage of either a trampoline or bouncy castle for which the majority required operative intervention. there was wide variability in the nature of injuries recorded; supracondylar/radial fractures were the most common whilst more complex injuries such as an open fracture of the femur was rarer. conclusions: awareness and application of necessary safety precautions was low ( %) amongst parents'' supervising parents''/guardians highlighting the need for greater public awareness of same. furthermore, the incidence of severe injury relating to usage of trampolines/bouncy castles is not uncommon highlighting the high risk activity that trampolining is. introduction: conventional plate fixation (pf) of distal fibular fractures in elderly patients is associated with a high risk of wound and implant related complications. intramedullary fixation (imf) using a fibular nail is a minimally invasive alternative to pf that provides superior biomechanical strength and allows immediate full weight-bearing postoperatively. aim: to compare the postoperative complications of minimally invasive intramedullary nail fixation to conventional pf for lauge-hansen supination external rotation type fractures in patients aged years or older treated in a single geriatric trauma unit in the netherlands. methods: a retrospective cohort study was performed including unstable ankle fractures in patients aged years or older treated with either imf or pf between january to january . the primary outcome measure was the total number of wound related complications. results: a total number of patients were included with a mean age of . years (range to ). the imf-cohort (n = ) had a significantly higher mean age ( . versus . years, p = . ) and charlson co-morbidity index ( . versus . , p = . ) compared to the pf-cohort (n = ). the total number of postoperative complications was lower after imf ( %) compared to pf ( %), although this relative difference was not statistically significant (p = . ). all complications observed in the imf-cohort were wound related but demanded no debridement or implant removal. wound related complications did not differ significantly from pf ( % versus %, p = . ). no implant related complications, hospital-acquired complications or mortality were observed after imf. conclusion: despite the higher mean age and co-morbidity status of patients treated with a minimally invasive intramedullary nail, the total number of postoperative complications was lower after imf compared to pf. this technique might be a promising alternative in a selected group of patients. the authors declare that they have no commercial associations that might pose a conflict of interest. no funding or other compensation was received for the research, authorship or publication of this article. gustilo type ii and gustilo type iii fractures. the treatment protocol was external fixation at admission and definitive osteosynthesis with plate at ± days. a single approach to the tibia was performed in patients, and a combined anterior and posterior approach was used in . the incidence of complications was %: cases of poor soft tissue evolution, of which were infections. patients evolved to nonunion. osteoarthritis appeared in % of patients ( . % grade ), and only one patient needed arthrodesis. . % had a valgus ldta (\ °) and . % a varus deformity ([ °). we found a significant relationship between the history of open fracture and the development of complications (p \ . ). we found no relationship between the incidence of complications and the approach. conclusions: tibia ao c fractures have a high percentage of complications and evolve to well-tolerated osteoarthritis. open fracture seems to significantly influence the poor postoperative outcomes of these patients. clinical findings: a -year-old male, who suffers a closed chest trauma with pneumothorax, right pulmonary contusion and poor pneumoperitoneum. also a grade iiia open fracture of the right femur, with a cm bone defect. investigation/results: upon arrival at the hospital, he needs orotracheal intubation, as well as blood transfusion with red blood cell concentrates. external fixator is placed on the right femur. diagnosis: a iiia grade diaphyseal open fracture of the right femur with cm bone defect, bearing external fixator with one broken proximal pin and positive culture for s maltophila in the distal pin. therapy and progressions: antibiotic treatment and medical optimization are performed, cemented intramedullary nailing (t -stryker) with antibiotic (vancomycin-tobramycin), as well as cement spacer with antibiotic (masquelet's first stage) in the defect area. in second time, withdrawal of spacer and contribution of ria autograft of contralateral femur and allograft respecting membrane. the patient begins the protected weight bearing with two crutches immediately, without using them months after the surgery. bone consolidation without pain or limitation after year. comments: the induced membrane technique is a simple and effective technique for the reconstruction of segmental bone defects and can be used as a first time technique together with the initial stabilization, leaving the defect ready for graft delivery in the second time. introduction: carpal metacarpal dislocation is a rare entity that accounts for less than % of all carpal injuries. dorsal dislocations are the most common and occur most frequently after violent trauma in young individuals and are easily overlooked and may lead to longterm sequelae. material and methods: we present the case of a carpal metacarpal dislocation from d to d . male, years old, no relevant personal history. brought to the emergency service after a motorcycle accident with projection. he had a symphysis pubis diastasis, a distal radius fracture on the right wrist and a fracture of the left forearm bones. no other apparent injuries associated. at week , he presented edema and dorsal deformity of the left hand associated with limited finger movements. neurovascular assessment was normal. the radiological evaluation showed a carpal metacarpal dislocation from m to m . it was an unstable reduction so open reduction was performed, with debridement of fibrous material, until exposure of the articular surfaces, and reduction and fixation with k wires of the three metacarpals (from d to d ). similarly, m was stabilized with a k-wire due to clinical instability observed intraoperatively. results: it is necessary to reduce and stabilize these lesions to avoid vasculonervous compression and skin distress. open reduction is indicated in irreducible cases allowing debridement and excision or os of small osteochondral fragments and fixation of associated fractures. conclusions: combined dislocation of multiple metacarpals is a rare lesion that compromises the functional prognosis of the hand in the absence of adequate treatment. instability and post traumatic arthrosis are among the sequelae of this lesion. identify the lesion to allow the appropriate treatment usually leads to good results. case history: -year-old suffered direct trauma to his right hand after falling off his bicycle. clinical findings: on physical examination showed edema and bruising from the base of the thumb and thenar eminence, tenderness over the cmc joint and functional disability speacialy in pincer grasp. no neurovascular injuries investigation/results: the x-ray revealed a comminuted fracture of the base of the thumb metacarpal. diagnosis: we identifed a rolando fracture. therapy and progressions: on the day after the trauma, he was submited to open reduction and osteosinthesis with lateral-palmar plate and screws, through radiopalmar aproach of the thumb base. intra operatively no dorsal fragments werefound to be left undisplaced. two months after surgery, the patient went back to the hospital for sudden pain and inability to extend the thumb. clinically with rupture of the long extensor of the thumb. on the x-ray, the fracture was aligned. the latero-lateral tenorrhaphy with kessler suture was preformed and intraoperatively a bony spicule was identified in the proximal stump of the tendon, which was removed. months after the initial trauma, the patient has a consolidated neck and no limitation of the mobility of the thumb. comments: rollando fracture is relatively rare in adolescents. the aim of treatment should be exact reduction usually with open technics. the main complications are stifness and early arthrosis. there are also records of conflicts with the plates and even rupture of the extensor tendon, so the radiopalmar placement of the plate was chosen. nevertheless, the rupture occurred due to conflict with an unidentified bone fragment during surgery causing an unexpected complication in this case. the immobilization necessary after tenorrhaphy could have caused joint stiffness, but in this case the teenager fully recovered after physical therapy case history: periprosthetic and periimplant femoral fractures are an increasingly frequent pathology. in many cases they are a challenge with limited or too aggressive therapeutic options. it is important to investigate new approaches that increase the arsenal of the orthopedic surgeon. the recently described mipo (minimally invasive plate osteosynthesis) approach for the medial aspect of the femur may seem like a dangerous procedure because of the anatomical structures that run along the medial aspect of the thigh, but it is a viable and useful option in selected cases. clinical findings: we present the case of a -year-old patient with a total hip replacement who presented a first periprosthetic vancouver b fracture of the femur that was treated with a lateral blocked plate. subsequently the patient presented a second supracondylar femur fracture below the first plate (vancouver c). investigation/results: after thinking over the possible therapeutic options, we decided to treat our patient by means of the medial femoral mipo approach with a long medially placed blocked plate, managing to stabilize the fracture and superimpose the plate on the previous implants without the necessity of removing the previous lateral plate. diagnosis: periprosthetic and periimplant supracondylar left femoral fracture. therapy and progressions: we used the surgical technique of the medial femoral mipo approach as described by apivatthakakul . comments: we consider that the medial femoral mipo approach is a useful therapeutic tool to consider. it seems a safe and low-invasive option for the resolution of cases in which the lateral mipo approach is not a feasible option. references: c. jiamton y t. apivatthakakul, « the safety and feasibility of minimally invasive plate osteosynthesis (mipo) on the medial side of the femur: a cadaveric injection study » , injury, vol. , n.o , pp. » , injury, vol. , n.o , pp. - » , injury, vol. , n.o , pp. , nov. . posterior knee dislocation with neurovascular injury associated-a case report case history, investigation and diagnosis: a -year-old male was brought in after h following a heavy straw bale fall. he presented with a posterior knee dislocation that had already been reduced and an open wound in the popliteal fossa. the limb was flushed and pale on the extremity, with absence of the pedis and posterior tibial pulses. stability tests revealed unstable knee in all axes. an anterior shoulder dislocation was diagnosed and reduced. therapy and progressions: an emergent surgery was performed, involving a transarticular external knee fixation and a femoro-popliteal bypass above the knee (angiogram revealed a stop sign at the level of the interarticular popliteal artery). he developed circulatory shock and was admitted to the intensive care unit. on the stpostoperative day(po) was diagnosed a compartment syndrome that was treated with fasciotomies. these incisions showed a slow but progressive evolution, that required vacuum dressings and underwent autologous skin graft on the thpo day. the external fixator was removed on the stpo day and rehabilitation was started. on a -month follow-up, the patient had a good evolution of the wounds, but a knee with valgus and anteroposterior laxity and severe complete peroneal, tibial and sural neurological injury, confirmed with electromyography, and neuropathic pain. introduction: isolated iliac wing fractures represent only a small part of all pelvic fractures. these fractures are associated with severe injuries, but are considered benign. the literature lack information about the function and quality of life of these patients. our objective was to evaluate the long-term effects of isolated iliac wing fractures. material and methods: patients with pelvic fractures treated at oslo university hospital, ullevaal, in the time period - , were extracted from the local fracture registry. patients were registered in this period. a search was also made in the hospital''s administrative electronic database for patients registered with diagnose code s . in icd- in the same period. patients were identified. in total, patients had an isolated iliac wing fracture, and these were invited to a follow-up examination, including proms (eq- d- l and majeed score), clinical examination, and pelvic x-ray. results: nine patients agreed to participate in the study, median years after the fracture (range - ). all of them were injured from high energy trauma, with mean niss , (range - ) . four of the fractures were open, and seven of the patients had associated injuries. five were treated with internal fixation. the mean eq- d vas was (range - ). five patients reported pain, one of them related to the pelvic fracture. the mean majeed score was (range - ). seven patients had sensory deficit in the lateral thigh. one patient had difference in range of motion between the two hips. the x-rays showed healed fractures in all the patients. eight of them showed ectopic ossification. conclusions: our study confirms previous studies that isolated iliac wing fractures are results of high energy trauma with severe associated injuries. however, the majority of this group of patients seem to have a good general state of health, which is in accordance with the general assumption of the injury as a benign one. fenton's syndrome-a case report of a common underdiagnosed entity case history: a right handed -year-old male, construction worker, was admitted in our emergency department, after a meters fall. the authors report a case of fenton's syndrome in a politrauma scenarium. clinical findings: both right elbow and left wrist were painful, swollen and with a remarkable restriction of the range of motion (rom). patient also reported lower back pain. no neurovascular injuries were detected. investigation/results: x-ray and ct scan confirmed a fracture of a lumbar vertebra, fracture of the right olecranon and, on is left wrist, a carpal fracture-luxation mayfield of both scaphoid and capitate associated with rotation of the last one proximal pole-fenton''s syndrome. diagnosis: this syndrome is an atypical presentation of perilunate fracture dislocation and, therefore, difficult to diagnose. few reports were found in literature. after an open reduction of the fractures, a definitive fixation with headless herbert screws was achieved. percutaneous kw and immobilization of the wrist were performed to further stabilization of the lunotriquetral joint. weeks later consolidation was noted. a decrease of °in extension and flexion were detected when compared with the contralateral wrist. grip strength test was similar on both hands. osteosynthesis of the right olecranon was also realized. comments: a careful neurovascular assessment is important. although it is rare, injuries of median nerve were already reported associated to this complex fractures. open reduction and osteosynthesis are necessary due to the great instability and the risk of nonunion and osteonecrosis of the rotated proximal segment. introduction: intramedullary nailing has been popularly applied for the femoral shaft fractures. the current study aimed to analyze the femur geometry for development of implant design with dimensional skeletonization. material and methods: we acquired computed tomography (ct) images of both femur reviewed in a single center from to . the total participants were enrolled and they were divided into subgroups according to age (decades) and gender. each subgroup included persons, respectively. these images are used to produce d samplings. with the skeletonization, we obtained the geometry parameter; ( ) femur shaft length from the tip of the greater trochanter to the bicondylar line, ( ) the minimum diameter of the medullary canal and its location, ( ) anteroposterior (ap) diameter and lateral diameter of the entire femur, ( ) radius of curvature (roc) of the femur (bowing). we compared all parameters according to sex and age. results: the average age of the participants were . years (range - years) and the number of each gender was exactly same. the femur length was . ± . mm (range, . - . mm) and the femur shaft length was . ± . mm (range . - . mm), both of them were longer in male (p = . , \ . ). the minimum diameter of the medullary canal was . ± . mm (range . - . mm). the roc was . ± . mm (range . - . mm) . the rate of the minimum diameter less than mm and mm was . % and . %, respectively. the rate of roc with less than mm and mm was . % and . %, respectively. conclusions: this geometry analysis showed that there are mismatch problem between the current nail and the medullary canal in . % and the roc of the femur was smaller than that of the current nail systems ( - mm). the result indicates potential mismatch problem in clinical cases and the problem can be resolved with newly designed nail system. the study was funded by national reserach foundation of korea (nrf- r d a b ). safe zone of the infracacetabular screw: virtual mapping of three-dimensional hemipelvises for quantitative anatomic analysis introduction: an infra-acetabular screw can provide increased stability in fixating acetabular fracture. we conducted this study to define the incidence of the safe corridor for infra-acetabular screw and to determine the correlation between the safe corridor and other demographic factors such as age, sex and height. material & methods: pelvis computed tomography (ct) of participants was extracted with evenly age-and sex-allotted. virtual three-dimensional ( d) model was generated. a search was performed to find the maximum-with corridor connecting two points. the entry and exit point was displaced in the template. the maximum diameter of each corridor was measured in automatic procedure. a minimum mm corridor diameter, sate corridor, was defined as a cutoff for placing a . mm cortical screw in clinical setting. all data were presented as mean and range or mean and standard deviation. two-sample t test and regression analysis were used to compare difference between groups based on sex, age, and height. results: among hemipelvis, hemipelves ( . %) satisfied a minimum safe corridor diameter of mm. when divided into a subgroup by the patient's gender, the incidence of the safe corridor of a male group was statistically higher than a female group ( . % vs . %), with the mean corridor diameter of . mm ( % ci, . ) and . mm ( % ci, . ), respectively (p \ . ). in correlation analysis, only the height showed a positive correlation with the diameter of the safe corridor of a total population (r = . ; p \ . ). conclusions: the study provided the safe corridor was found in % of male and % of female, and the taller had the higher incidence of the safe corridor. the patient''s height was correlated with the corridor diameter of the infra-acetabular screw, whereas the patient''s age did not correlate with the corridor diameter. introduction: femoral neck fractures in middle-aged and older patients represent one of the most common orthopedic conditions. osteosynthesis, as a primary treatment option for femoral neck fractures has shown to have successful outcomes. however, this is not the case for old fractures. the purpose of this study was to evaluate the outcomes of treatment of femoral neck fractures in which cementless total hip arthroplasty was indicated. the aim of our study was to analyze the prosthetic failure, i.e., the reasons for unsuccessful outcome, in order to suggest the indications for primary osteosynthesis which could guide the femoral neck fracture management. material and methods: a total of patients were analyzed in this study, with femoral neck fracture treated with osteosynthesis. reviewing the radiological findings, as well as the course of the treatment, we set up the criteria, on the basis of which we could advice the immediate implantation of total hip prosthesis for the femoral neck fracture. results: old fractures, varus deformity of the femoral head and neck, dislocation, as well as the comminuted fractures, are all factors affecting the surgical outcomes of osteosynthesis. additionally, medical and technical equipment of medical institution, personnel competence, and minutious surgical technique affect the treatment outcomes. introduction:proximal ulnar fractures are usually osteosynthesized by means of angle stable plate osteosynthesis. despite good functional results of this procedure, complications such as high access morbidity and disruptive osteosynthesis material with a high rate of material removal are described. the aim of our study was the development of a new locking nail and test setup for comparison with a plate osteosynthesis on artificial bones. material and methods: in our biomechanical laboratory, a jupiter b fracture of the proximal ulna was standardized on sawbones and stabilized by means of the newly developed nail or anglestable posterior plate osteosynthesis. a servopneumatic testing machine, the specimens were flexed under a cyclic load ( - n) in the physiological range of movement of the elbow from °to °.the maximum elastic deformation of the specimens and the loosening of the implants were evaluated after test cycles. results: the primary stability of the constructs at the anterior cortical bone after nail osteosynthesis was significantly greater ( . ± . mm) than in the angle-stable plate osteosynthesis ( . ± . mm, p \ . ).after passing through the test cycles, both implants showed a low loosening rate. in the area of the anterior cortex, the locking nail showed a significantly lower rate of loosening (nail . ± . mm, plate . ± . mm, p \ . ). at the dorsal cortex, there were no differences between plate and nail in both series of measurements. conclusions: intramedullary implants provide biomechanical benefits in fracture stabilization. good biomechanical results have already been shown in the literature after nailing olecranon fractures . nevertheless, due to the complex anatomy and the resulting difficult implantation technique, ulnar nails could not prevail in practice. the presented nail allows a safe stability with simple surgical technique. introduction: adequate treatment of tibial plateau fractures is crucial to minimize patient disability, development of posttraumatic arthritis and subsequent need for a total knee arthroplasty (tka). however, due to the complexity of the fracture, adequate reduction cannot always be achieved which could result in the early conversion to a tka. in this study we introduce a quantitative d fracture assessment method and investigate whether it could help to identify patients that are at risk of conversion to a tka. material and methods: we retrospectively included patients, who were treated for a tibial plateau fracture between and . patients developed severe posttraumatic arthritis and underwent conversion to a tka. from all patients, d models were created using the pre-operative ct-scans. for each patient, the d gap area between the fracture lines, representing an innovative combined gap and step-off measurement in d, was determined in order to quantify the displacement (figure ). roc curve analysis was performed to determine a critical cut-off value for the d gap area. kaplan-meier survival curves were created to assess the association between d fracture anatomy and risk on a tka at follow up. results: a critical cut-off value of mm was found to give highest combined sensitivity and specificity for d gap area and the risk of tka at follow-up. kaplan-meier survival curves showed . % knee survival (no tka) at year follow up in the group with a gap area of \ mm , whereas in the group with a gap area of c mm a knee survival of . % was found. at year follow up knee survival was . % and . %, respectively, for the two groups (\ mm and c mm ). conclusions: we developed an innovative method to quantify the amount of displacement in d. pre-operative d fracture assessment could be used as an addition to the current fracture classification methods to help identify patients who have a high risk on conversion to tka at follow-up. introduction: soft tissue sarcomas (sts) in the anterior compartment of the thigh are frequent. the extent of quadriceps resection is controversial. the aim of the present study is to communicate our results in complete quadricectomies due to high-grade sts. material and methods: we present sts, in stage iiib of the ajcc, with a mean craniocaudal diameter of cm ( - ). there were women and men, with a mean age of years ( - ). six were undifferentiated pleomorphic sarcomas, myxofibrosarcoma and clear cell sarcoma. in every case, total quadricectomy was performed with wide margins. posterior reconstruction with local muscle transfers was performed, expect for the younger patient, who received a vascularized contralateral vastus lateralis transplant. in all cases, complementary radiotherapy was indicated, and in patients adjuvant chemotherapy. results: three patients required friedrich due to necrosis of the edges of the surgical wound. one patient died months after the intervention as a result of multiple metastasis, and two due to medical complications after week and months, respectively. the average follow-up time for the rest was months , with no local recurrence. as for functional outcomes, mean msts score was ( - ), with deficit of active knee extension in most of them. the functional result of the patient with the vascularized muscle transplantation was excellent. all of them were satisfied with the results of the treatment. conclusions: quadricectomy provides good functional and acceptable cancer results, although it is not exempt from complications in frail patients. vascularized muscle transplantation, though complex, can improve functional results, especially in younger patients. introduction: operative treatment is a valuable option in displaced proximal and/or middle one-third diaphyseal humeral fractures. although plate osteosynthesis is preferred to intramedullary nailing, surgery can be complicated by radial nerve palsy. a helical plate could avoid this high-impact complication. to date there is however a lack of published evidence in literature, although recent asian case reports show promising results. material and methods: we retrospectively reviewed patients who were treated with open reduction and internal fixation with a helical plate consecutively from october until august at az groeninge, kortrijk. a deltopectoral approach was used in combination with a distal anterolateral incision, whether or not in continuity. a self-molded long philos plate was used in the first patients, while in our last patients the a.l.p.s plate (zimmer Ò ) was used. standard radiographs were obtained pre-and postoperatively. we retrospectively searched for complications, e.g. radial nerve palsy, infection and/or loosening. in autumn , patients were reassessed. patient''s general health status was evaluated using the eq- d- l score. constant-murley scores and dash scores were used for evaluating shoulder function and disability measures consecutively. results: all humeral fractures consolidated at months. there were no radial nerve palsies due to surgery. one plate was removed after year due to a late infection. with a minimum follow up of year, the mean dash score was ( - ) and the mean constant-murley score was ( - ). the dash score was inversely proportional with the constant-murley score and patient''s general health status. conclusion: a helical plate avoids neurological complications with similar healing rates and good to excellent shoulder function at year follow up in the treatment for proximal and/or middle one-third diaphyseal humeral fractures. the use of antibiotic-impregnated cancellous bone grafts in onestage surgery for chronic orthopaedic infection: preliminary clinical results k. dendoncker , g. putzeys , az groeninge, tissue bank, kortrijk, belgium, az groeninge, orthopaedic center, kortrijk, belgium introduction: the use of cancellous bone allografts is an established technique in reconstructive orthopaedic surgery. unfortunately, its use is generally avoided in the presence of a local infection. antibiotic impregnated cancellous bone grafts has shown its effectiveness as an local antibiotic delivery system [ ] [ ] [ ] . in this clinical study, we report our first personal experience with the use of vancomycin-impregnated cancellous bone grafts in one-stage surgery for periprosthetic joint infections (pji) and fracture-related infections (fri). material and methods: between december and march nine patients were treated during a one-stage surgery with vancomycinimpregnated cancellous bone grafts, containing g vancomycin per cc bone. regular clinical, laboratory and radiographic follow-ups were performed for at least months after surgery. results: the procedures included revision of pjis (hip and humerus) and fris (tibia, femur and clavicula). one tibia required further revision because of recurrent infection and one hip has an uncertain infection state, however the remaining patients stayed free from infection during a follow-up of at least months. interestingly, in one patient the vancomycin concentration could be determined in the drainage fluid from the wound. radiographic examination revealed no signs of osteolysis or loosening, good incorporation of the bone graft and progressive consolidation. conclusions: within the limits of the study, the use of vancomycinimpregnated cancellous bone grafts in one-stage surgery to treat pji and fri yielded positive outcomes in terms of clinical, laboratory and radiographic follow-up. this technique might offer new treatment strategies in often devastating injuries. references: . putzeys g., et al. orthopaedic proceedings. ; -b:supp_ , - . with the modified arthroscopic approach (group b). the prospective follow-up included the lysholm score, the subjective questionnaire of the ikdc score and the specifically extended oak score for clinical evaluation. the rolimeter Ò was used to test the translational mobility of the knee joint. the statistical significance level was set at %. results: the follow-up was . ± . months and . ± . months postoperatively in group a and b, respectively. the subjective scores were tested. group a and b achieved a mean lysholm score of . ± . and . ± . points respectively. in the subjective ikdc assessment, group a achieved . ± . points and group b . ± . points. the clinical oak score was . ± . points in group a and . ± . points in group b. the following values could be recorded for the stability of the posterior cruciate ligament: the side difference in the rear drawer test was . ± , mm in group a and . ± . mm in group b. in the reversed lachman test, a difference of . ± . mm and . ± . mm was measured in group a and b, respectively. all values mentioned were comparable between the two evaluated groups. conclusions: the results of the two surgical techniques were comparable. therefore the arthroscopic approach is the preferred method in our institute. simple correction technique of femoral malrotation after pfn-a osteosynthesis of trochanteric fracture k. pavotbawan , p. stillhard , c. sommer kantonsspital graubünden, department of trauma surgery, chur, switzerland introduction: malrotation after intramedullary nailing in femoral shaft fractures are well known. but malrotation after nailing of trochanteric fractures is an underestimated problem. during surgery the axial alignment can easily be evaluated by fluoroscopy in both planes. but the torsional alignment is difficult to assess especially with the patient placed on the traction table. in literature a malrotation after pfna is described in up to % of the cases. a revision with replacement of the blade, especially in patients with poor bone quality, may result in a reduced stability. to our knowledge there is no publication till to date to give a treatment pathway for this problem. we developed a rather easy technique to derotate a malrotated femur after pfna fixation. material and methods: the basic idea is to leave the usually well placed blade insitu in the femoral head, just rotating the distal main fragment around the nail. therefore, a small u-shaped osteotomy with a chisel is performed in the femoral cortex just anterior of the entry site of the blade. the length (l) of this osteotomy can be calculated, following the formula: l = d x p x a/ (d = diameter of femur, a = angle of malrotation). then the distal locking bolt is removed, the leg derotated and finally locked again. the procedure is controlled by two schanz''screws separately inserted in both main fragments angulated to each other in the angle ''a''. results: since patients were detected with a clinically relevant femoral malrotation. all patients had an internal malrotation from to degrees confirmed and measured by ct scan. all of them were successfully revised in the above described technique - days after initial fixation. conclusions: first, we believe that malrotation after trochanteric fracture fixation is an underestimated problem. and second our method is a simple salvage procedure for malrotated trochanteric fractures after pfna, leaving the blade in situ in the femoral head. optimal intramedullary nailing for trochanteric fractures: the importance of distal locking screw and reduction position t. waki , t. yano , k. ito , s. matsushima akashi medical center, orthopaedic surgery, akashi, japan introduction: distal locking issue for trochanteric fractures is still controversial. therefore, the purpose of this study was to investigate the complications between distal unlocked group and distal locked group. further, the relationships were evaluated between these complications rates and their reduction positions after operation. material and methods: operations were performed for trochanteric fracture (ao a ?a ) from to . of these, patients with f/u periods [ month were . gamma im nailing system (stryker) was used for all patients. patients (unlocked group) from to operated without distal locking screw. patients (locked group) from to operated with distal locking screw. we retrospectively analyzed those patients who suffered complications such as delayed healing and postoperative periimplant fractures and cut-out of the lag screw. further, in lateral view of their radiographs, we evaluated the position of the proximal fragment compared with distal fragment. the reduction positions were divided into groups: anterior (subtype-a), neutral (subtype-n), and posterior (subtype-p). results: in unlocked group, complication was shown in patients (complication group). delayed healing was shown in / ( . %) in unlocked group and / ( . %) in locked group. peri-implant fracture was shown in / ( . %) in unlocked group and / ( %) in locked group. cut-out of the lag screw was shown in / ( . %) in unlocked group and / ( . %) in locked group. in complication group, subtype-p was more than non-complication group. conclusion: in the current study, higher number of complications was seen in the distal unlocked group. and, our study showed the reduction position might be associated with post-operative complications. we concluded that nailing without distal locking screw might be dangerous and subtype-p should be avoided. introduction: heterotopic ossification (ho) after acetabular fracture surgery has been one of the common complications and often limits function with the range of motion severely. surgical resection is challenging and only effective treatment for established ho. we herein report four cases who underwent surgical resection and mobilization for ho after acetabular fractures surgery. material and methods: four cases with severe ho after acetabular fracture surgery were included in this study. the mean age at operation was years old, and all patients were males. in judet-letournel classification, there were three cases classified as posterior wall fracture, and one case as transverse and posterior wall fracture. two of four cases were combined with posterior dislocation of the hip. in all cases, the first operation was performed using with the kocher-langenbeck (kl) approach. results: surgical resection of ho was performed using with the kl approach at . months (range - months) after the first operation. the median operating time and intraoperative bleeding were respectively . h and ml. intraoperative d navigation was used in one case. as postoperative complications, one case developed sciatic nerve palsy and another case sustained the iatrogenic femoral neck fracture. all cases have no recurrence with a follow-up of . years after the surgical resection. conclusions: surgical resection is the only treatment for symptomatic ho. but that requires preoperative planning and must be performed carefully because the extent of resection is still controversial and that may develop severe complications such as nerve palsy and iatrogenic fractures. by using navigation, we can determine the extent of resection easily and operated safely. case history: -year-old male, previously healthy, turned to the hospital after a motorbike crash, resulting in high energy direct trauma of the right wrist. clinical findings: upon admission, cranial, thoracic, abdominal and other traumatic injuries were excluded. the patient presented with pain, swelling and visible deformity of the right wrist and hand, hypoesthesia of the th finger, and no perfusion deficits. investigation/results: x-rays showed volar perilunate carpal dislocation with associated comminuted scaphoid fracture, radial styloid avulsion, and metacarpal phalangeal dislocation of the th digit. under sedation, closed reduction of the metacarpal phalangeal joint was accomplished, and reduction of the carpal dislocation was attempted unsuccessfully. the wrist was temporarily immobilized in a cast and taken to the or. diagnosis: transcaphoid-transradial-styloid-perilunate volar dislocation therapy and progressions: surgical treatment comprised loose bodies removal, reduction of the perilunate dislocation, orif of the scaphoid using a herbert screw, and stabilization of the carpal rows using two percutaneous kirschner wires. after surgery, a thumb spica cast was applied. post-operatively, neurovascular status was normal. at weeks, x-rays showed signs of bone healing, the cast and k wires were removed, and physical therapy was initiated. at months, scaphoid fracture consolidation was achieved. the patient remained with a mild deficit in wrist extension but reported no pain nor important limitation in daily living activities. comments: perilunate injuries with displacement or dislocation usually require surgery. persistent instability is a described complication, often progressing to secondary post-traumatic arthritis of the wrist and carpus, termed scapholunate advanced collapse. introduction: this study was conducted to study the patient characteristics, classification, treatment, complications and functional outcome of operatively treated displaced intra-articular calcaneal fractures (diacf) in a level trauma center in the netherlands material and methods: patients with an diacf, classified as sanders c and operatively treated with percutaneous screw fixation (psf) or open reduction and internal fixation (orif) between january and december were identified. pre-and postoperative radiological assessment was performed. functional outcome, range of motion and change in footwear were evaluated with the use of the american orthopaedic foot & ankle society (aofas) score and the maryland footscore. general health and patient satisfaction was assessed using the short form- (sf- ) and the visual analogue scale results: in total, patients with an operatively treated diacf were identified. patient with diacf completed the questionnaires. there were males and females, mean age at trauma was years. average follow up was years. were classified as sanders type , and as respectively type and . were joint depression and were tongue-type fractures. there were no differences in sanders classification between the group treated with orif and psf. for orif and psf there were ( - %), ( - %) and ( - %) for respectively sanders type , and fractures. mean aofas, mfs, sf- and vas was ( - ), ( - ), ( - ) and ( - ) for respectively orif and psf. mean pre-and post-bohler angle was ( - ) and ( - ) for respectively psf and orif. underwent an ankle arthrodesis. surgical site infection and deep infection occurred in ( , - %) and ( , - %) in respectively psf and orif conclusions: long-term comparison shows no significant differences between orif and psf in treatment of sanders fracture type, bohler angle reduction, on functional outcome or complication rates introduction: the prevalence of hand injury in the pediatric population is attributed to their curiosity, limited fear of pain and diminuted motor coordination. the seymour fracture, which was first reported by seymour in , represents a transverse extra-articular open fracture of the distal phalanges associated with nail bed injuries. the fracture includes salter-harris type i and ii fractures as well as juxta-epiphyseal injuries. material and methods: the aim of this report is to present a case of a seymour fracture in a young boy and describe the injury mechanism associated with misuse of the newly emerging vehicle, the hoverboard. results: our patient was treated promptly and provided with appropriate management following the standard of care in our hospital for such injuries: disimpaction and repair of the nail bed, reduction of the fracture, and k-wire fixation across the distal interphalangeal joint. the patient was discharged with a volar slab and was prescribed an oral antibiotic. the patient recovered well with no major deficits. conclusions: the timely recognition and management of seymour fractures is crucial. the surgical treatment has good results however, conservative management can be an option in some specific cases. antibiotics are always required. we report a case of a fracture pattern resulting from the improper use of an hoverboard. although improper use was a factor, design fault also plays a role in causing the injury. hoverboards are a new transport technology that has been introduced in recent years. because of the number of injuries that have resulted from hoverboards, they should be used in the most controlled way possible to prevent any unnecessary injuries. case history: we report the case of a years old male from bangladesh, with months of progressively increasing pain, limited range of motion and swelling on his left knee, with kg of weight loss and inguinal lymph nodes. clinical findings: knee radiography and mri of the knee demonstrated a voluminous soft tissue mass surrounding the distal femur with intraarticular and posterior extension. a toracic-abdominal-pelvic ct showed supra and infradiaphragmatic lymph nodes. c-reactive protein level was , mg/dl. investigation/results: the clinical picture suggested a lymphoproliferative syndrome. a biopsy was performed, revealing cm of purulent material. synovial fluid had leucocytes/ul, % of polymorphonuclear cells, % of mononuclear cells and undetectable glucose. acid-alcohol resistant bacilli test and pcr test for mycobacterium tuberculosis were positive. diagnosis: mycobacterium tuberculosis knee arthritis therapy and progressions: the patient was treated with polytherapy consisting on rifampin, isoniazid, pyrazinamide and ethambutol. months later, the patient reports no pain, and tumor size has decreased. comments: mycobacterium tuberculosis infection is not a common disease in developed countries. however, the incidence in europe is increasing due to immigration. even though the lung is the most affected organ, osteoarticular tuberculosis represents around % of extra-pulmonary cases. tuberculosis simulates several diseases. because of non-specific symptoms and radiological signs, it can be difficult to diagnose. in a patient with chronic knee pain and limited range of motion, tuberculosis infection should be kept in mind, among other differential diagnoses, such as fibromatosis, pigmented villonodular synovitis or soft tissue sarcomas. clinical findings: the patient presented with a valgus deformity of the knee, the medial femoral condyle protuding on the medial side of the knee. neurovascular status was intact. investigation/results: xray revealed lateral dislocation of the knee. mri revealed mcl, pcl and acl rupture. diagnosis: knee dislocation (kd) grade iii (schenck). therapy and progressions: the patient underwent emergent closed reduction. neurovascular status was intact after resuction. due to important oedema and blisters, the lower limb was immobilized with a brace to allow for skin surveillance. after weeks, the brace was replaced by a long leg cast for more weeks. after months, the patient maintained residual pain, rom - / and minor instability. comments: kd are unusual injuries, associated with high energy trauma, therefore they often result in disruption of at least major ligaments and associated injuries, from soft tissue to vascular structures. emergent reduction is mandatory, and definitive treatment can be conservative, or early/late surgical repair/reconstruction of the ruptured ligaments. there is a lack of large prospective clinical studies comparing the different types of treatment. even so, data tend to associate early surgical treatment with better functional outcomes, though there is no statistic evidence supporting its improvement of the range of motion or stability. long term complications most frequently include residual pain, instability or rigidity. rarely the knee returns to its pre-injured state, independently of the treatment used. references: dwyer, t., et al. ( ) . outcomes of treatment of multiple ligament knee injuries. the journal of knee surgery, ( ), - . advising a reduction after a fracture of the distal radius, reliability with and without use of expert based criteria introduction: distal radius fractures (drf) are common, however many aspects of its management remain subject of debate . this study assessed the interobserver reliability of surgeons concerning the recommendation for a reduction and the improvement of expert based criteria for reduction. material and methods: we sent out surveys to members of the science of variation group. the first survey divided participants in groups, each rated - radiographs of drf. resulting in rated fractures by participants. each observer indicated whether they would advise a reduction or not. the second survey randomized participants ( surgeons) to either receive or not receive criteria for reduction and participants indicated if they would recommend reduction. results: the reliability for advising a reduction was poor, kappa . ( % ci . - . ). multivariable linear regression analyses indicated that each additional degree of dorsal angulation increased the change of recommending a reduction by % (beta . , % ci . - . p \ . ). criteria for reduction did not increase interobserver reliability for recommending reduction (no criteria kappa . % ci . - . vs. criteria . % ci . - . ). the likelihood of recommending a reduction was higher in the group using the criteria ( . vs . , p = . ). conclusions: poor interobserver reliability is associated with greater practice variation. dorsal angulation is the main drive for recommending a reduction. the liberal use of the criteria in combination with a specific focus on dorsal angulation leads in our opinion to less variation in treatment recommendation for distal radius fractures. this is something future study could assess for distal radius fractures in actual practice introduction: the number of pertrochanteric hip fractures increases proportionally to the increase in life expectancy. currently, the most used treatment in these fractures is the antegrade nailing. suffering a second fracture in the same femur around an antegrade nail is an uncommon complication, but it has a great impact on the patient. the aim of this study is to describe the type of perinail femoral fractures observed in our center, the treatment performed and the medium-term results. material and methods: between and , patients presented a perinail femoral fracture. were women and one was male, with an average age of . initial fractures were classified according to the ao classification: were a , were a and were a . of them were synthesized by short pfn-a (synthes), with short pfn (synthes) and with gamma (stryker). the average time since osteosynthesis of the proximal femur fracture and the perinail fracture was . years ( month- years). results: of the peri-implant fractures occurred at the level of the nail tip or the distal locking screw. the remaining fractures occurred in the distal femur. these supracondylar fractures and of the fractures at the level of the nail tip were synthesized with a va condylar plate (synthes), overlapped with the nail. in the rest of the fractures around the tip of the nail, the short nail was removed and replaced by a long pfn-a nail. one of the patients died in the immediate postoperative period. two patients died during the first year. in the rest of the patients, a complete consolidation of the fracture was observed, and their previous baseline situation was recovered. conclusions: peri-implant femur fracture is a rare but very severe condition, which requires good surgical planning, and is not without complications. gamagori city hospital, department of orthopedics, gamagori, japan, nagoya daini redcross hospital, department of orthopedics, nagoya, japan introduction: hip fracture is a leading worldwide health problem for the elderly. a missed diagnosis of hip fracture on radiography leads to a dismal prognosis. the application of a computer-aided diagnosis (cad) system using artificial intelligence (ai) to detect hip fracture can potentially improve the accuracy and efficiency of hip fracture diagnosis. material and methods: cad system using ai was trained using cases, plain frontal pelvic radiographs (pxrs) between and from each institution. the accuracy, sensitivity, falsenegative rate, and area under the receiver operating characteristic curve (auc) were evaluated on independent pxrs. the authors mixed resnext as classification algorithm and ssd as object detection algorithm to train cad system. results: the algorithm achieved an accuracy of . %, a sensitivity of . %, a false-negative rate of %, and an auc of . for identifying hip fractures. the visualization algorithm showed an accuracy of . % for lesion identification. conclusions: our cad system using ai not only detected hip fractures on pxrs with a low false-negative rate but also had high accuracy for localizing fracture lesions. the cad system using ai might be an efficient and economical model to help clinicians make a diagnosis without interrupting the current clinical pathway. medical faculty university of nis, orthopaedic surgery, nis, serbia, clinical center nis, orthopaedic and traumatology clinic, nis, serbia, orthopaedic word of medical center, cuprija, serbia introduction: bone reconstruction and limb lengthening usually refers to application of ilizarov or other ring external fixation devi-ces . we present here series of posttraumatic reconstruction and limb lengthening, by the use of new concept of d unilateral external fixation device. material and methods: as a clinical material, we present series of patients with different posttraumatic deformities ( ) and limbs discrepancy ( ) as a result of severe traffic accidents and wars. all patients have been treated by specially designed unilateral d external fixation system. that system is not bulky and it is more comfortable in comparison to ring fixators. procedure is relatively simple, so patients handle the device by themselves. during biomechanical testing, it was found that stability of this device is similar to ring systems. the last version of the device includes computer program and two sensors. results: all deformity corrections have been achieved successfully. sliding graft procedure has successfully been performed in all patients with bone defect reconstruction from to cm. in one patient with complex deformity and shortening, correction couldn''t be achieved during one procedure, so additional operations, by the use of the same system have been performed and correction completed. superficial pin tract infection rate was . % and we didn''t have deep infection. there were no other complications including dvt, joint stiffness, neurovascular injuries. conclusion: unilateral external fixation device with balanced d stability provides the same success of bone reconstruction and limb lengthening as ring fixators, but it is more comfortable and more easy for handling. references: treatment principles in bone reconstruction and limb lengthening of the lower extremity. olesen uk, nygaard t, kold sv, hede a. ugeskr laeger. nov ; ( ) at this moment author has licence agreement with the producer of external fixation devices. all patients were classified into the isolated hip fracture and the concomitant fracture. we analyzed these patients'' characteristics such as age, gender, bone mineral density (bmd), body mass index (bmi), korean version of mini-mental state examination (mmse-k), injury mechanism, and length of hospital stay. results: the most common site of upper extremity fracture was distal radius fracture of patients ( . %), followed by proximal humeral fracture of ( . %). concomitant fractures occurred on the same side in patients ( . %). the mean age of patients with a concomitant fracture was younger than that of patients with an isolated hip fracture (p \ . ). mean preinjury mmse-k was . in isolated hip fracture and . in concomitant fracture patients (p \ . ). mean length of hospital stay was statistically significant different between two groups (p \ . ). according to fracture site of hip, there was no statistically different prevalence of upper extremity fracture in femoral intertrochanteric fracture compared to the neck fracture. conclusions: we found a . % prevalence of concomitant hip and upper extremity fractures. it was found that the younger the age with preserved cognitive ability in elderly patients with a hip fracture, the higher the prevalence of upper extremity fracture. in addition, it is important to keep in mind that patients with a concomitant fracture have a longer hospital stay and difficulty in rehabilitation. on the other hand, the amount of bleeding was ml in group e and ml in group l, and there was no significant difference between the two groups. poor cases on postoperative images were % in group e and % in group l, and the joa hip score was . (groupe) and . (group l). in clinical results is significantly improved in group l. conclusions: the treatment results improved significantly in group l. as the number of experienced cases increased from these results, the reduction accuracy and treatment results improved, so experience was considered important for improving the treatment results of acetabular fractures. the additional value of the weight-bearing and gravity stress radiograph in determining stability of isolated type b ankle fractures introduction: the goal of the current study is to investigate whether the weight-bearing and gravity stress radiographs have additional value in determining stability in isolated type b fibular fractures. this in order to make the important distinction between fractures that need surgical treatment and fractures that can be safely treated conservatively. material and methods: patients with an isolated type b ankle fracture, without medial or posterior fracture, and a medial clear space (mcs) \ mm on the regular mortise radiograph were included. in the emergency room, a gravity radiograph was performed (in accordance with out protocol). within week, an additional mri scan was made. at this moment, in patients a weight-bearing radiograph was performed too. the mcs measurements of these regular mortise, gravity and weight-bearing radiograph were compared with the mri findings. the mri scan was set as reference standard to detect injury of the deltoid ligament in order to determine (in)stability. results: mean mcs on mortise radiograph was . mm (range . - . ); in ( . %) patients the mcs was [ mm and in patients ( . %) the superior clear space (scs) was [ mcs ? mm. in ( . %) patients, the scs [ mcs ? mm. on the gravity stress radiograph, . % of the patients had a mcs [ mm. the weight-bearing radiograph showed a mcs [ mm in ( . %) patients. in ( . %) patients, the mri showed a complete rupture of the deltoid ligament. in ( . %) patients a partial rupture was seen. patients ( . %) received surgical treatment. in all conservatively treated patients, no secondary dislocation occurred and there was no need for postponed surgical treatment. conclusions: the gravity stress view has a tendency to overestimate the mcs. thus, potentially too many stable fractures are incorrectly diagnosed instable and receive unnecessarily surgical treatment (with additional costs and risks). the weight-bearing radiograph, on the contrary, does not overrate the medial injury and can safely be used in the decision making process of treating conservatively and weightbearing (for example by using a brace) introduction: the purpose of this study was to identify the effect of the intravenous iron supplementation on demand of perioperative blood transfusion and post-operative hemoglobin recovery in geriatric hip fractures. material and methods: a retrospective cohort study was performed on patients who underwent surgery with proximal femoral nail for hip fracture and age years old or older between jan and may in a single center. the participants were divided into groups according to preoperative intravenous iron supplementation (iron isomaltoside, monofer Ò , pharmacosmos, holbaek, denmark); group (n = ) with monofer mg before surgery and group (n = ) without monofer. transfusion was preformed when the hgb was less than mg/dl). primary endpoint was incidence of perioperative transfusion. secondary endpoints were various hemoglobin (hgb) levels. results: the average age of the participants were . years old, and average body mass index (bmi) was . . demographic data including age, sex, bmi, comorbidity (charlson comorbidity index) of each group showed no difference. the complications from intravenous iron administration were not occurred. the preoperative hgb was . mg/dl (group . ± . vs, group . ± . , p = . ). the hgb at the postoperative day was . mg/dl (group . ± . vs group . ± . , p = . ). the average hgb at the postoperative month was . mg/dl (group . ± . vs group . ± . , p = . ). transfusion rate was . % ( / ) and the rate showed no difference between groups ( . % vs . %, p = . . the recovery of hgb between postoperative month and preoperative state showed statistically difference (group . vs group -. , p = . ), and iron supplementation group had more recovery. conclusions: intravenous iron supplement before the hip fracture surgery in elderly helped to recover hgb at postoperative month. comminuted subtrochanteric femur fractures-our experiences introduction: subtrochanteric femoral fractures account for approximately % of all the hip fractures and their treatment represents a challenge because of the short proximal fragment and highenergy forces. material and methods: a total of patients with subtrochanteric, highly comminuted fractures, were included in this study, with age range from to years. the mechanism of injury in all patients was high-energy trauma. in each case we applied a long gamma nail (limma lto) without focus opening. results: in all patients, good clinical and radiologic results were accomplished, in addition to early weight-bearing, without shortening of the legs, or consequences on the state of the hip and morbidity in general. conclusions: although the comminuted subtrochanteric femur fractures represent a challenge for the orthopedic surgeons, osteosynthesis using long gamma nail without the focus opening provides outstanding results. introduction: this study analyzed the association between the postoperative reduced position obtained on using short femoral nails (sfns) and the amount of sliding after fixation in unstable trochanteric fractures. material and methods: this retrospective study included patients with unstable trochanteric fractures with posterolateral support deficiency who underwent osteosynthesis with sfns and were followedup for months or longer. the study included men and women with a mean age of . years at the time of fracture. closed or open reduction was performed to achieve anatomical to medial type position on frontal view and anatomical to extramedullary type position on lateral view, followed by fixation with sfns. immediately and extramedullary type in patients immediately after surgery. three months after surgery, the reduced position worsened from the anatomical to intramedullary type in patients. according to the reduced positions at months after surgery, the mean amount of sliding was . mm in patients with intramedullary type, . mm in those with anatomical type, and . mm in those with extramedullary type. the amount was larger in those with intramedullary type than in those with anatomical and extramedullary types. moreover, excessive sliding was observed in patient with intramedullary type. conclusions:to prevent excessive sliding by ensuring anteromedial bony support in unstable trochanteric fractures with posterolateral support deficiency, open reduction should be aggressively performed to overcorrect to the extramedullary type when reduction performed on a traction table results in either anatomical or intramedullary type positioning. in this paper, we report patient previously studied for osteomyelitis caused by high-energy missile trauma, in . that study involved a total of patients with osteomyelits, divided into two groups, according to the treatment protocol applied. the group included patients treated using classic surgical methods, including debridement, curretage, forage, perfusion drainage and sequestration. the group included patients treated using recommended surgical methods and used pmma antibiotic beads. years after, we tried to contact all of the patients, for the purpose of follow-up. however, only patient was available for analysis. among patients we followed-up, were treated using recommended surgical protocol, while the remaining patients were treated using classic surgical methods. we present the patients' general status, as well as the local surgical status and radiographic analysis, years after. we obtained long-term results of both treatment protocols applied. from the group , patients developed chronic recurrent osteomyelitis, while only one patient from the group developed such condition. introduction: the aim of this study was to evaluate the treatment results using anterior subcutaneous internal fixation(infix) for the pelvic fractures and to consider an improvement strategy for the complications. material and methods: from to , pelvic fractures were enrolled. there were two males and females. the average age was years. there were fragility fractures and five high energy fractures. our operative procedure was as below: the connection between screws and rod was just above the fascia of the sartorius muscle. the connection bar was pre-bended before the operation using the initial axial ct scan. we assessed bone union, additional fixation, the distance between the femoral artery and connection rod (dar), the distance of protruded bar lateral to the connection (dpb), and complications. results: bone union achieved in out of cases. there was one nonunion and three early deaths because of medical complications. seventeen out of cases required additional posterior fixations. the average dar was . ( . - . mm) , and the dpb was . ( - ) mm. thirteen out of cases ( . %) had complications. there were seven lateral femoral cutaneous nerve (lfcn) symptoms ( required implant removal (ir)), two infections ( required ir), one hematoma (ir), one irritation (ir), one heterotopic ossification, one loosening (re-operation). there were no femoral vessels and nerve-related symptoms. to release lfcn and surrounding soft tissues decreased the nerve symptoms. conclusions: to connect the screws, and the rod just above the sartorius fascia could avoid major vessels and nerve complications, and also irritations. although this study found a high complication rate of infix, to release the lfcn and around soft tissue could decrease the complications. introduction: several studies have reported that posterior or anterior tilt increases the risk of reoperation in undisplaced femoral neck fractures (garden i/ii) after internal fixation performed using nonangular stable devices such as pins and multiple screws. however, to the best of our knowledge, there is limited research involving angular stable devices. the present study aimed to investigate the clinical outcomes in undisplaced femoral neck fractures after internal fixation using angular stable devices. material and methods: this retrospective study included patients (mean age, . [range, - ] years) who underwent internal fixation using angular stable devices between january and january . undisplaced femoral neck fractures with garden alignment index (gai) b °(posterior tilt angle c °) or gai b °( anterior tilt angle c °) were included (posterior: , anterior: ) in this study. patients were followed up for at least months (mean, . months). we analyzed the preoperative and last-followed gai on lateral radiographs, non-union, and late segmental collapse (lsc). results: among the patients, non-union was identified in ( . %) and lsc was observed in ( . %). the mean preoperative gai was . °(range, °- °), and the mean last-followed gai was . °( °- °). the overall complication (non-union and lsc) rate was . % ( / patients). among patients with gai c °, lsc occurred in ( . %). conclusions: in undisplaced femoral neck fractures, preoperative posterior c °is a risk factor for postoperative complications even when internal fixation is performed using angular stable devices; thus, primary arthroplasty may be considered. case history: the patient is a -year-old female who had undergone lumpectomy at the age of when she was diagnosed with breast cancer. she had antiresorptive drug therapy for bone metastasis, since years after the lumpectomy. she fell down from standing height and was diagnosed as right femoral subtrochanteric fracture. her femur was fixed with short femoral nail. she complained left hip pain at age .she complained left hip pain from july . clinical findings: she could walk with crutch.rom of left hip was normal. investigation/results: breast surgeon took mri and there was metastasis in the proximal part of femur. he thought the cause of pain was this metastasis. however, there was fracture line at the height of lesser trochanter when she visited our department. diagnosis: atypical fracture was strongly suspected, however, fracture line was little higher as normal atypical fracture. therapy and progressions: osteosynthesis with long femoral nail was performed months after first visit to our department because of increasing pain. pathological findings were metastasis and fracture. after surgery, radiation to femur was performed. she can walk without pain by crutch and fracture line is almost disappeared on months after surgery. comments: atypical femoral fractures (affs) are recently observed as a complication of antiresorptive drugs for bone metastasis. however, there were metastasis and atypical fracture in this case. introduction: in the present study we aim to evaluate the articular surface reduction quality by means of postoperative computer tomography (ct), in complex tibial plateau fractures, treated with an illizarov frame. materials and methods: this retrospective case series covers the period from - to - . forty-four patients with a mean age of years (range - years), with a complex intrarticular proximal tibia fracture were included. fracture types iii to vi according to schatzker's classification were included. the majority were closed injuries, apart from cases (a gustilo anderson type a and a type ). all patients were placed on a fracture table. a mini-open reduction of the articular surface was followed by application of a knee spanning illizarov frame. post-operatively all patients were subject to ct of the injured knee. outcomes were measured using the american knee society score. results: mean outpatient follow up was of at least months (range of - months). mean time for fracture consolidation . weeks (ranging from to weeks). according to the degree of postoperative articular surface depression patients were grouped as follows: had under mm, had - mm and over mm of depression. those with less than . mm of collapse had % chances of an excellent result according to akss. on the contrary, those with more than . mm of articular surface collapse had % chances for low scores and functional results. the achievement of a mechanical axis within °of the contralateral limb was positively correlated with good functional results but did not have a correlation with the akss. conclusions: complex tibial plateau fractures may be treated successfully with mini open reduction and the application of an illizarov frame. post-operative ct denotes the exact degree of displacement of the articular surface, which is prognostic regarding outcome. postoperative x-rays may be misleading, since they can underestimate articular surface collapse. introduction: a new trauma center building was constructed in march , and the process from the trauma bay to the operation room is faster. we hypothesized that this process improved the survival rate of trauma patients in need of trauma laparotomy. material and methods: the new trauma center separates the trauma bay from the emergency room, and the trauma team exam patients initially. it also has a separate operation room that is always available for emergency surgery. therefore, the decision to perform laparotomy and time to operation has been shortened. from january to december , trauma patients who underwent emergency laparotomy were included. those younger than years, who had delayed operation, underwent surgical observation, delayed admission by patient, or underwent angiography first were excluded. patients were dichotomized to the before-trauma-center (bc) and after-traumacenter (ac) groups, and their characteristics and clinical outcomes were compared. results: of patients, were included in the bc group and were included in the ac group. the times from admission to operation introduction: acute care is a growing worldwide burden with increasing visits to the emergency department (ed). the acute care system in the netherlands is almost overloaded and costs are increasing. almost % of ed visits have surgical disease. there is no nationwide acute care surgery (acs) model implemented yet, and resources and infrastructure are organized differently in almost every hospital. this study provides an overview of the existing systems nationwide, and basis for a national uniform model. material and methods: an online survey was distributed through the dutch surgical society and sent to all dutch hospitals. after sending a reminder, the survey was closed and results were analyzed. results: thirty-two hospitals ( %) participated in the survey. in % a surgeon (trauma, vascular or gastro-intestinal) was assigned as consultant and responsible for ed admissions, emergencies in-house, and in some cases also emergency surgeries. % of hospitals have an ed observation unit (edou). a dedicated emergency surgery operating room (esor) is available in % ( / available in %), and used efficiently in % primarily due to the following challenges: elective surgery scheduled at esor ( %), necessary stop of esor when elective programs are delayed ( %). in hospitals without an esor, the emergency surgeries are scheduled in between elective surgeries resulting in extending programs into the evening. finally, % of respondents was familiar with acs, with % being positive about exploring options of implementing such a model in our country, and % of the respondents opts for more focus on acs in surgical residency. conclusions: in the netherlands the organization of acute care varies. the main common bottleneck is the logistics around the or. implementation of a dedicated esor and unconditional availability / of this or seem to be the most important factors for optimal efficiency. although there needs to be more focus on acs in general, implementing a uniform model nationwide seems challenging at this moment. trauma team activations (tta) at an european trauma center: cases analyzed s. saar , , e. lipping , h. vospert , r. volmer , h. k. laas , j. lepp , k. g. isand , p. talving , north estonia medical centre, division of acute care surgery, tallinn, estonia, university of tartu, tartu, estonia, north estonia medical centre, tallinn, estonia introduction: the north estonia medical centre (nemc) is the largest trauma center in estonia with evolving capabilities. however, studies scrutinizing trauma team activations (tta) are currently lacking. thus, we initiated an investigation to document tta profile and outcomes. material and methods: all tta patients admitted to the nemc between / and / were retrospectively identified. data collected included demographics, injury severity score (iss), management, hospital length of stay (hlos), and in-hospital outcomes. primary outcome was -day mortality. results: overall, patients were included. mean age was . ± . years and . % were male. penetrating and blunt trauma accounted for . % and . % of the cases, respectively. non-ground level falls were the predominant mechanism of injury constituting . % of the admissions. mean iss was . ± . and . % of the patients were severely injured (iss [ ). blood alcohol level (bal) was positive at . %. a total of . % of the patients had an emergent operation. mean hlos was . ± . days.overall -day mortality and mortality of severely injured patients was . % and . %, respectively. conclusions: the current investigation documents comparable outcomes with established european trauma facilities [ , ] . blunt injury patterns predominate, however, high penetrating trauma incidence for european settings was noted. high rate of positive bal in tta patients warrants national preventive measures. introduction: the acute care surgery (acs) model was initially developed as a dedicated service for the provision of high quality / non-trauma emergency surgical care. after implementation in the united states (us), the model has been adopted in several variations around the world.in this systemic review we investigated which components are essential for a potential uniform acs model, by giving an overview of the current available acs models worldwide and their state of implementation. material and methods: a literature search ( - ) was conducted using pubmed, medline, embase, cochrane library and web of science databases following the prisma guidelines. all relevant data of acs models were extracted from included articles. results: sixty-five articles describing acs models in different countries were included in this review. the majority consist of a dedicated surgical service, providing non-trauma emergency surgical coverage, with daytime on-site attending coverage by an attending surgeon who is cleared from elective duties, and / in-house resident coverage. emergency department coverage and access to an acute care operating room varied widely across countries. critical care is fully embedded in the original us model as part of the acute care chain (acc), while in most other countries it is still a separate unit. while in most european countries acs is not a recognised specialty yet, there is a tendency towards more structured acute care, with training and separation from elective practice. conclusions: acs is gradually implemented worldwide. however, large national and international heterogeneity exists in the structure and components of the model. critical care is still a separate unit and specialty in most systems while it is essential to be part of the acc in order to provide the best peri-operative care of the physiologically deranged patient. universal acceptance of one global acs model seems challenging, however a global consensus on essential components would benefit any healthcare system. introduction: the recent financial crisis in greece is coped mainly with reformations towards cost effectiveness and rationality in the management of public expenses. the goal of the study is to evaluate the cost and time effectiveness in the management of the surgical patients admitted in emergency department (ed). methods: for a period of h/day in consecutive days, surgical cases presented in the ed of a tertiary university hospital of athens were followed. inclusion criteria were need for laboratory tests or imaging examinations or an immediate resuscitative intervention. data recorded regarding demographics, vitals, critical time points, disease and management. physician related data and cost of examinations were also collected. case severity was calculated by early warning score [ ] . results: she average waiting time for each patient was min and the average total time until final decision was : h. blood tests costs reached an average of , € per case and imaging an average of , €. the striking finding was that only one out of patients was of medium clinical risk, while all the others were of low. thus, substantial symptoms and clinical findings were lacking and as the ''tertiary care'' character of the hospital was mandating conclusive diagnosis, exams were ordered. this approach absorbs time and funds putting at risk the very few severe cases which are the target population for the magnitude of the facility. the current study indicates that the use of a tertiary hospital as a primary health care center by the public, is disorganizing the system, and increase the cost in time, funds, and preventable morbidity and mortality. a pre-hospital triage and management of the low severity cases system is pending to be established in our environment and becomes top priority in an era of prolonged financial crash. for years, surgical emergencies in ecuador have been managed without significant standardization. scarce numbers of specialists, lack of a constant presence of full-time teaching faculty versed in emergency surgery and lack of continuity with surgical trainees led to variability in clinical and surgical decision-making. to address these issues, the regional hospital vicente corral moscoso (hvcm) adapted and implemented a model of ''trauma and acute care surgery'' (tacs) to the reality of cuenca, ecuador. a cohort study was carried out, comparing trauma and acute care surgery patients exposed to the ''traditional care model'' before the implementation of the tacs model. variables assessed included: surgical wait times, number of hospital visits, number of surgical interventions, number of surgeries performed per surgeon and inhospital mortality. higher mortality was found in the traditional care model (rr of . , p b . ) compared to the tacs model. we observed a statistically significant decrease in surgical wait time ( . - . h for emergency general surgery, . - . h for trauma, p b . ). lengthof-stay decreased in trauma patients ( - days p b . ). the total number of surgical interventions increased ( , . - , . , p b . ) ; by extension, the total number of surgeries performed per surgeon also increased ( . - . , p b . ) . the implementation of tacs model in a typical resource-restrained, tertiary care hospital in latin america had a positive impact by decreasing surgical waiting time in trauma and emergency surgery patients, and length-of-stay in trauma patients. we also noted a statistically significant decrease in mortality. while cost could not be objectively evaluated with the available data, savings to the overall system and patients can be inferred by decreased mortality, length-ofstay and surgical wait times. to our knowledge, this is the first implementation of an tacs model that has been described in latin america. introduction: traumatic injuries constitute one of our major public health challenges. the most effective means to reduce the impact trauma has on individuals and society is primary injury prevention, reducing the incidence of traumatic events, which relies on detailed knowledge of risk factors. the aim of this study is to facilitate targeted injury prevention through improved data collection and analysis on impairing substances as risk factors for traumatic injuries. material and methods: idart is a national prospective observational study including analyses of the toxicological profile of all patients c year of age admitted via trauma team activation to any norwegian trauma hospital (n ) during a month study period. residual blood from routinely drawn blood samples at trauma admission is analyzed for alcohol, illegal and psychoactive drugs. toxicological data will be linked to clinical data from the national trauma registry. results: the study period started march st, , and during the first months patients were included from trauma hospitals. more than % of the included patients tested positive for psychoactive substances according to preliminary data. data on the prevalence of different psychoactive substances disaggregated by mechanism of injury, demography and geography from the month study period will be presented. conclusions: the idart study will provide a detailed descriptive analysis on the prevalence of alcohol, illicit and medicinal drug use among all patients admitted to a norwegian hospital with suspected severe injury. subgroup analyses will include prevalence of alcohol and other substances in subgroups analyses on patient and injury characteristics and geographical variations. analyses will aim to identify high risk groups according age, gender, circumstances of the injury, geographical location and type of psychoactive substance. the dutch nationwide trauma registry: the value of capturing all acute trauma admissions m. driessen , l. sturms , l. leenen lnaz/umcu, trauma surgery, nijmegen, netherlands introduction: twenty years ago the dutch government decided to reform the trauma care system and designated level regional trauma centers (rtcs). these centers, in collaboration with ambulance services and regional hospitals, have managed to set up regionalized inclusive trauma systems. moreover, they set up the dutch national trauma registry (dntr) as a quality evaluation and epidemiology resource. in this resource all acute hospital admissions were included, in order to measure the hospital and prehospital processes and outcomes. in the current study we demonstrate its current status and compare it with national trauma registries from the uk and germany. material and methods: the dntr includes all injured patients treated at the ed of % of all hospitals in the netherlands within h after the trauma followed by direct admission, transfer to another hospital or death at the ed. a representative descriptive analysis of extracted data from is demonstrated. results: between and a total of , trauma cases have been registered in the dntr. hospital participation has increased from % up to %. in alone, a total of . patient were included, % concerned males, the median age was years. % of all admissions had an iss c , of which % was treated at a rtc. from this cohort, in comparison, only % and % of the dntr patients met tr-dgu or tarn inclusion criteria. particularly children, elderly and patients admitted at non rtcs are not captured in the tr-dgu or tarn. also, part of iss c and fatal cases do not meet tr-dgu or tarn inclusion criteria. conclusions: the dntr has evolved into a comprehensive wellstructured nationwide population-based trauma register, with an annual number of , cases being entered in the database the dtr has grown to be one of the largest trauma databases in europe. the registry enables studies on the injury burden and quality and efficiency of the entire trauma care system encompassing all traumareceiving hospitals. introduction: trauma mortality is not distributed evenly. rural areas have higher incidence rates of trauma mortality than urban areas. the rural northern part of the nordic countries have common challenges with sparsely populated areas, long distances, and an arctic climate. the aim of this study was to compare the cause and rate of fatal injuries in the northernmost area of the nordic countries over a fiveyear period. material and methods: in this retrospective cohort we used the cause of death registries and collated all deaths from to with an external cause of death (icd- , v -y , except y - and t - ). the study area was the three northernmost counties in norway, the four northernmost counties in finland and sweden and the whole of iceland. we used % confidence intervals (ci ) to test for differences between the countries. results: there were deaths in the study area during the -year period. low energy (le) trauma constituted % and high energy (he) trauma % of deaths. northern finland had the highest incidence for both high energy trauma and low energy trauma. iceland had the lowest incidence for high-, and low energy trauma. iceland had the lowest prehospital share of deaths at % and the lowest incidence of injuries occurring in a rural location. the incidence rates for he trauma death was , / . /year in northern finland, , / . /year in iceland, , / . /year in northern norway and , / . /year in northern sweden. conclusions: there were significant and unexpected differences in the epidemiology of trauma death between the countries. the differences suggest that a comparison of the trauma care systems and preventive strategies in the countries is required. the diurnal and seasonal relationships of pedestrian injuries secondary to motor vehicles in young people introduction: there remains a significant morbidity and mortality in young pedestrians that are hit by motor vehicles, even in the era of pedestrian crossings and speed limits. the aim of this study was to compare incidence and injury severity of motor vehicle-related pedestrian trauma according to time of day and season in a young population. we hypothesised that injuries in young people would be more prevalent during dusk and dawn and during autumn and winter. material and methods: data was reviewed from patients in the - year old age group in the trauma audit and research network (tarn) national database, who had been involved as a pedestrian in a motor vehicle accident between and . the incidence of injuries, their severity (using the injury severity score [iss]), hospital transfer time and mortality were analysed according to the hours of daylight, darkness and seasons. results: . % of injuries occurred during time of darkness post sunset, while . % occurred during daylight. the incidence of injuries in motor vehicle accidents, in absolute terms, was highest during - , with a second peak at - . the greatest injury rate (number of injuries/hour) occurred during - and - with respective rates of . and . injuries scoring an iss over occurred . % at - and a further . % until . mortality was greatest during - involving out of the total deaths. autumn was the predominant season and lead to . % of injuries, with a further . % in winter. this demonstrated a clear difference to . % and . % in spring and summer. conclusions: we have identified a relationship between reduced daylight and the frequency and severity of pedestrian trauma in young people suggesting that reduced visibility may play a significant role which could be addressed through a targeted public health approach to implement change. enhancing cost effectiveness in a system in crisis: a , patient study a. tsolakidis , c. christou , p. smyrnis , a. prionas , a. tooulias , g. tsoulfas , v. n. papadopoulos aristotle university of thessaloniki, st department of surgery, papageorgiou general hospital, thessaloniki, thessaloniki, greece introduction: to date, there is no national trauma database in greece. the goal of our study is to record and evaluate trauma management at our university hospital as well as to measure the associated healthcare cost, while laying out the foundations for a national database. material and methods: retrospective study of trauma patients (n = , ) between and . demographic information, injury patterns and severity, outcomes and cost were recorded. results: the proportion of patients that were transferred to the hospital by the national emergency medical services was , %, whereas ( %) of our trauma patients did not meet the us trauma field triage algorithm criteria. over-triage of trauma patients to our facility ranged from . to . %, depending on the criteria used. ( . %) of our patients received operative management and % ( ) of them had postoperative complications. an iss [ was seen in ( %) of our patients and their mortality was , %. the overall non-salary cost for trauma management was . . euros. the cost resulting from the observed over-triage ranged from . to . . euros. furthermore ( . %) of our patients underwent at least one ct scan that did not show any significant traumatic lesion. the cost of hospitalization of these patients was . euros. conclusions: the prehospital triage of trauma patients in the greek national health system is ineffective, with significant over triaging, leading to excessive costs. appropriate use of criteria for diagnostic procedures and algorithms may lead to a, much-needed, reduction of these costs. introduction: in japan, there are emergency and critical care centers nationwide (one center for approximately every , people), and a system is in place to accept local critically ill patients h a day, irrespective of whether their conditions are intrinsic or extrinsic. however, manpower and medical care systems differ depending on the emergency and critical care center, and the establishment of a system for consolidating severe trauma patients has been particularly problematic. material and methods: this study examined cases where the patient had some sign of life when encountered by ambulance teams of the cases of traffic accident deaths that occurred in chiba prefecture between and . thirteen emergency and critical care center representatives in chiba prefecture met to verify each case based on data from the police, fire department, and medical institutions. the cases were classified into ( ) preventable trauma death (ptd) cases, ( ) suspected ptd cases, and ( ) non-life-saving cases; the problems (causes of ptd) in each case were examined. result: there were cases ( %) of ptd and suspected ptd. sixty-eight of these cases were transported to emergency and critical care centers. the most common cause of death was bleeding, accounting for cases and the locations where the problems that caused ptd occurred were outside of the hospital (n = ) and in the hospital (n = ). the problems that occurred in the hospital (including duplications) include circulatory management (n = , %), the treatment plan (n = , %), delay of lifesaving surgery (n = , %), and delay of diagnosis (n = , %). most of these occurred in the initial emergency care room. conclusion: this study clarified that ptd still occurs in relation to bleeding control in the current trauma care system in chiba prefecture. it is vital to establish a national ''trauma center'' and to thoroughly consolidate trauma cases to eradicate ptd. analysis of the impact of the implementation of a trauma team in a trauma center from an upper-middle-income country introduction: trauma teams (tt) improve the care process and the outcomes. a multidisciplinary tt was conformed in september to achieve a rapid response by specialists in emergency medicine, trauma surgery, diagnostic imaging services, and blood bank in a level i trauma university hospital in southwestern colombia. objective: to evaluate the impact of a tt implementation in terms of times of attention and mortality. material and methods: retrospective study. all the patients with the highest level of tt activation treated in the months after the tt implementation were included. the subjects triaged to the trauma center in the months pre tt were taken as controls. four hundred sixty-four patients were included, before the implementation of the tt (btt) and after (att). demographic data, trauma characteristics, times to tomography, and trauma surgery and mortality were recorded. the analysis was made on stata , Ò . categorical variables were described as quantities and proportionscontinuous variables as mean and standard deviation or median and interquartile range (iqr). categorical variables were compared by chi or fisher's test. continuous variables with student's t or wilcoxon-mann-withney. a multiple logistic regression model was created to evaluate the impact on mortality if being treated att, adjusted by age, trauma severity, and physiologic response on admission. results: the time from admission to the ct scan was min (iqr - ) in the btt group and min (iqr - ) in the att group, p &lt; . . the time to trauma surgery was min (iqr - ) in the btt group and min iqr - ) in the att group, p &lt; . . mortality in the btt group was . % and . % in the att group. adjusted or was . ( . - . ) p = . conclusions: the implementation of a multidisciplinary trauma team associated with a reduction of the times to tomography and surgery and with a decrease in mortality risk. no prediction of an unfavourable outcome after surgical treatment of chronic subdural hematoma patients using machine-learning l. riemann , a. younsi , c. habel , j. fischer , a. unterberg , k. zweckberger university hospital heidelberg, neurosurgery, heidelberg, germany introduction: chronic subdural hematomas (csdh) are expected to become the most frequent neurosurgical disease by the year . although often perceived as a ''benign'' condition, considerable rates of mortality and poor outcome have been reported. we therefore evaluated factors associated with an unfavorable outcome after surgical treatment of csdh patients by developing a predictive model using machine-learning. material and methods: consecutive patients treated for csdh with surgical evacuation between and at a single institution were retrospectively analyzed. potential demographical, clinical, imaging and laboratory predictors were assessed and a decision-tree predicting unfavorable outcome (gos - ) was subsequently developed using the classification and regression tree (cart) algorithm. out-of-sample model performance was evaluated using repeated cross-validation (fivefold with repetitions). results: eligible patients were analyzed. median age was (iqr - ) years and % were males. mortality rate was . % and rate of unfavorable outcome was . %. the developed decision-tree to predict unfavorable outcome had splits and included the following clinical variables (in descending order of calculated importance): gcs, comorbidities, hb, and age. after cross-validation, the following model performance metrics were obtained: a model accuracy of . ( . - . ), sensitivity of . ( . - . ), and specificity of . ( . - . ). conclusions: gcs, comorbidities, hb, and age were identified as the most important clinical predictors for an unfavorable outcome in csdh patients after surgery. the developed model was simple and still displayed a high accuracy and very high specificity, the sensitivity was however rather low. our results might help clinicians to better assess the prognosis in patients with csdh. introduction: in most developing countries access to tertiary care neurosurgical setup is uncommon. majority trauma including neurotrauma & medical conditions requiring emergency neurosurgical interventions present to a general surgeon. this study is an attempt to highlight the importance of emergency neurosurgery as a skill amongst general surgeons & also focus on the challenges in managing such cases in austere environments material and methods: this study was a retrospective analysis of progressively collected data of trauma patients with a specific focus on head injuries & emergency neurosurgical interventions for both traumatic & non traumatic indications in a level trauma centre in a semi urban area over a period of years from august to september results: a total of patients of trauma were analysed out of which were head injuries. road traffic accidents accounted for nearly % of head injuries. atypical trauma especially in rural setup e.g. train collision, animal related causes were also seen. males accounted for majority (m:f = . : ). mean age was yrs. patients had imaging findings suggestive of severe head injury. acute sdh was the commonest post traumatic finding and mca territory infarct in non traumatic group. patients underwent emergency neurosurgical intervention with a survival of %. factors associated with poor outcome were delayed presentation (p \ . ), sdh with diffuse axonal injury. alcohol consumption was a significant factor. conclusions: emergency neurosurgery is an essential skill for general surgeons. performing such cases in a low resource environment in absence of modern day facilities for imaging, icp monitoring & powered equipment presents a significant challenge. general surgeons should be able to perform operative interventions with basic handheld instruments. operative management whenever indicated should be done & helps improve outcomes. head trauma in polytraumatized patient. analysis of risk factors and neurological prognosis b. castro , , , m. morote gonzález , , , l. cebolla , , , a. sada , , , l. seisdedos , , , , , j. gil , c. rey valcárcel , , f. j. turégano fuentes , , c. tristan , c. ruiz moreno hgugm, surgery, madrid, spain, hospital, madrid, spain, hospital, madrid, spain, hospitall, madrid, spain, hospital, madrid, spain, hospital, madrid, spain, hospital, madrid, sri lanka introduction: severe trauma is one of the most frequent causes of death and disability and traumatic brain injury (tbi) in polytrauma is the main cause of death and disability in survivors. the aim of this study is to analyze mortality associated to tbi in the last years, prognostic factors associated with it and neurological outcomes in survivors with tbi. methods: retrospective observational study that includes risk factors and functional neurologic evaluation in polytrauma patients attended in gregorio marañon hospital between - . inclusion criteria were severe trauma patients (iss c ) with a tbi and abnormal ct of the head. we analyzed mortality trend in two periods : - and - , and neurological evolution and outcome at discharge with functional scores (ramkin scale and gos) in the second one. results: from to , severe trauma patients were admitted, ( , %) with brain or central nervous system injuries visible on head ct. median age was ' ; . % were men. the global mortality of the cohort has been , %, . % of them for neurological causes. ischemic heart disease, anticoagulation, abnormal pupils or eye opening, the need for surgery, shock, gos, iss, niss, cranial ais are significant associated with higher mortality (p \ , ).the mortality rate due to neurological causes decreases in the second period from , to , %, this descent being statistically significant (p = , ). between and , % patients died from cnsi, and , % of tbi survivors had a vegetative status at discharge, , % had major disability, and , % had a good neurological recovery. conclusions: mortality due to tbi decreased in the last years, but this improvement after tbi was at the expense of a high rate of vegetative status and great disability, showing the need for continuous research in this area. introduction: severe traumatic brain injury (tbi) constitutes one of the most frequent causes of intensive care unit admissions and is a major cause of death and disability among young people. decompressive craniectomy (dc) is a life-saving measure used to relieve intracranial pressure (icp). this procedure is related with low mortality rates and poor functional outcomes. the aim of this study is to analyze the survival rates and prognostic factors related with functional outcomes after dc for severe tbi. material and methods: retrospective, single center study of patients with severe tbi in whom a dc was performed between the years and . demographic features, clinical parameters, radiological findings and clinical outcomes were included in the study. for the statistical analysis we used anova, chi-square, kaplan meyer, cox regression and logistic regression. a p value of less than . was considered to indicate statistical significance. results: the mean initial glasgow coma scale was , ± , and the mean initial motor response (imr) was , ± , . the mean icp after dc was , ± , . the -day survival after dc was %. twenty percent of the patients improve ate least point in the glasgow outcome scale (gos) between and months after surgery. twelve patients improve from unfavorable gos to favorable gos. at -month follow-up, % of the patients has gos [ . younger age, high irm a post-operative icp were the factors significantly associated with a higher chance of outcome improvement. conclusions: dc is useful for the management of refractory intracranial hypertension related to severe tbi, and in selected patients is associated with good functional outcomes. introduction: antiplatelets and anticoagulation, commonly referred to as antithrombotic therapy, are frequently used in patients c years. the use of antiplatelets and anticoagulation are associated with increased incidence of intracranial bleeding ( , ) . there are two research questions addressed in this study: ( ) does preinjury antithrombotic therapy affect survival in elderly patients with tbi? ( ) are direct oral anticoagulants (doacs) associated with better survival than vitamin k antagonists (vka) in tbi patients on anticoagulation? materials andmethods: retrospective cohort study based on data extracted from the oslo tbi registry. included in the study are tbi patients c years admitted to ouh with cerebral-ct showing signs of acute trauma (hemorrhage, fracture, vascular injury) in the time period - . the impact of age, comorbidity, antithrombotic medication and antithrombotic reversal protocol for survival will be explored. results: the patient inclusion is ongoing. preliminary data will be presented at the st ectes in april . the estimated number of tbi patients c years with cerebral-ct showing signs of acute trauma in the study period is * . in this patients group, the expected preinjury use of antiplatelet and anticoagulation medication is * % and * %, respectively. conclusions: the knowledge regarding impact of preinjury antithrombotic therapy on survival in elderly tbi patients is clinically relevant, and may improve patient management in the acute phase of injury. references: introduction: traumatic acute subdural hematoma (asdh), especially the large ones in need of surgical evacuation, is associated with high mortality. contemporary population-based series of surgically treated asdh are sparse. the two main aims of this single-center study from oslo university hospital (ous) were to estimate incidence of surgery for asdh in the population of helse sør-Øst, and estimate in-hospital and -month survival of these patients. treatment of tbi at ous adheres to the brain trauma foundation guidelines, with icp controlled therapy and evacuation of asdh when gcs \ and hematoma volume c cm or midline shift c mm or hematoma width [ mm. the goals of tbi treatment for adults have been to maintain icp \ mmhg and cerebral perfusion pressure (cpp) c mmhg. methods: from . . all patients with traumatic brain injury (tbi) with positive head ct, admitted to ous, living in helse sør-Øst ( . million inhabitants) and having a norwegian social security number, have been included in our approved tbi-quality register. included in the present study are all patients with asdh undergoing evacuation of the hematoma within days of trauma. the following data were extracted from the register; demographic variables, date of injury and trauma mechanism, severity of head injury according to hiss grade, rotterdam ct score, surgical procedures, multitrauma, glasgow outcome scale at discharge and date of death. results: asdh patients were operated in the -year period - , % males, mean age was years ( - ), the most frequent trauma mechanism was falls ( %), % were under influence of ethanol, % had severe tbi and % had multitrauma. the incidence of surgically treated asdh in helse sør-Øst was / . /year. in-hospital and -month mortality was . % and %, respectively. conclusion: the presented data for incidence and mortality will be compared with earlier reports. age-related difference in impacts of coagulopathy in patients with isolated traumatic brain injury: an observational cohort study w. takayama , a. endo , y. otomo tokyo medical and dental university hospital of medicine, trauma and acute critical care, tokyo, japan background: age and trauma-induced coagulopathy (tic) have been reported to be the predictors of poor outcome following traumatic brain injury (tbi). whether the impact of brain injury induced coagulopathy on outcomes have age related differently is unknown. objectives: we evaluated the age-related difference in the impact of tic on outcomes in patients with isolated tbi. methods: a retrospective observational study was conducted in two tertiary emergency critical care medical centers in japan from to . the patients with isolated tbi [head abbreviated injury scale (ais) c , and other ais \ ] were included. we evaluated the impact of coagulopathy (international normalized ratio c . , and/or platelet count \ /l, and/or fibrinogen b mg/dl) on the outcomes [glasgow outcome scale-extended (gos-e) scores, inhospital mortality and ventilation free days (vfd)] in both group using univariate and multivariate models. furthermore, we visualized the impact of coagulopathy on gos-e according to age, by using a generalized additive model. results: of the patients studied, they were divided based on their age: non-elderly group (n = , - years) and elderly group (n = , age c years). although, in the multivariate model, age and coagulopathy were significantly associated with lower gos-e, in-hospital mortality and shorter vfd in the non-elderly group, significant impact of coagulopathy was not observed for all the outcomes in the elderly group. the correlation between coagulopathy and lower gos-e decreased with age after round years old. conclusions: in patients with isolated tbi, impact of coagulopathy on functional and survival outcomes was lower in geriatric patients. no difference in mortality between isolated tbi and polytrauma with tbi: it is all about the brain introduction: despite improvements in trauma and critical care mortality caused by traumatic brain injury (tbi) remains high. [ ] as polytrauma is naturally associated with increased mortality, this study compared mortality rates in isolated tbi (itbi) patients and polytrauma patients with tbi admitted to icu. material and methods: a -year retrospective cohort study included both consecutive trauma patients with itbi with ais head c (ais of other body regions b ) and polytrauma patients with ais head c admitted to a level-i trauma center icu. patients \ years of age, injury caused by asphyxiation, drowning, burns and transfers from and to other hospitals were excluded. patient demographics, shock and resuscitation parameters, denver multiple organ failure scores and acute respiratory distress syndrome (ards) data were collected. [ ] data is shown as medians with interquartile ranges. p-values \ . were statistically significant. results: a total of patients were included. the median age was ( - ) years, ( %) patients were male, median iss was ( - ). seventy-nine ( %) of all patients died. polytrauma patients developed more often ards ( % vs % p = . ) but had similar mods rates ( % vs % p = . ). polytrauma patients stayed longer on the ventilator ( vs. days p b . ), longer in icu ( vs. days p b . ) and longer in hospital ( vs. days p b . ). there was no distinction in in-hospital mortality of itbi and polytrauma patients ( % vs. % p = . ). tbi contributed to all deaths in itbi patients and all but three deaths ( %) in polytrauma patients. conclusions: tbi was the main cause of death in both groups. there was no difference in mortality rates between polytrauma patients with tbi and itbi patients, even though polytrauma patients were more severely injured. references: [ ] dewan mc et al. estimating the global incidence of traumatic brain injury. j neurosurg. ; ( ): - . no significant relationships or conflict of interests. how modeling the brain ventricles could help brain trauma understanding ( ). in pathological cases as in hydrocephalus, or in brain trauma, it is likely that each patient's ventricle structure has an impact on the way they behave. for instance, a shock wave may turn out differently according to the ventricle's shape. this can explain why for a same shock, the clinical translation is not the same. the aim of the study is to implement a finite element model of the cranio-cerebral system and to analyse the impact of a trauma simulation. material and methods: this is amonocentricretrospective study from . the database contains ct scans of healthy patients. we used itk-snap software to segment the ventricles and matlab to implement the model. results: the mean volume of the total ventricles is ml (sd = ). the median is ml (table ) .to identify the correlation between the parameters acquired we performed a pearson test. we found multiple significant correlations and one of the most relevant one is between the ventricular volume and the width of the third ventricle ( table ). showing that the total ventricular volume is statistically correlated to the width of the third ventricle is clinically interesting. we could potentially simplify our analysis of the ventricular system in head trauma by measuring less coordinates and yet come up to an accurate prognosis. the ventricle volumes are used as neuroimaging marker of brain changes in health and brain trauma. to our knowledge, it is the first time they are studied in vivo on ct-scan. this study and the existing correlations are relevant for the configuration of the finite element model on going. it can surely help the comprehension of the interaction between the structural parts of the cranio-cerebral system during brain trauma. (excitatory-glutamate, and inhibitory-c-aminobutyric acid, gaba), is crucial for the normal cerebral functioning. gaba concentrations vary in different cerebral zones [ ] responsible for different cerebral tasks. in this study, [gaba] is measured in the posterior cingulate cortex (pcc) of children with acute mtbi. material and methods: acute mtbi patients (\ h since injury, . ± . y.o) and healthy controls ( . ± . y.o). mri scanner philips achieva t was used. standard mri protocol for tbi revealed no pathological lesions in brain of any subject. magnetic resonance spectroscopy (mega-press [ ] ) was applied to obtain gaba signal without macromolecules. spectroscopy voxel is demonstrated on fig. . intensities of gaba, glutamate ? glutamine, creatine and water signals were calculated in gannet program [ ] . absolute concentrations were calculated. mann-whitney was used to reveal the statistical significance of between-group differences. results: typical gaba spectrum processing in gannet is demonstrated on fig. . no changes in glx were found. the values of [gaba] in pcc are demonstrated on fig. : the increase in gaba is not statistically significant. conclusions: this is the first study of [gaba] in pcc of children with acute mtbi. the result of current work disagrees with our previous study, where gaba was increased (p \ . ) in the anterior cingulate cortex of children with mtbi [ ] . this indicates to a necessity of further data collecting in order to reveal any [gaba] alterations in various cerebral loci. this would help to identify the causes of an inhibition/excitation imbalance and to predict possible dysfunctions of cns following mtbi. results: tnaa and naag concentrations along with stable naa concentration were found to be reduced in patient group. reduced asp and elevated mi concentrations were also found. the main finding of the study is that tnaa signal reduction in wm after mild traumatic brain injury is associated with the drop of the naag concentration rather than of naa one, as it was thought previously. this highlights the importance of separation of these signals at least for wm studies to avoid misinterpretations of the results. naag plays an important role in its selective activation of the mglur receptors, thus providing neuroprotective and neuroreparative function immediately after mtbi. it might have potential for the development of new therapy strategy for patients with injuries of various severity. introduction: traumatic brain injury (tbi) is globally recognized as a major health and socioeconomic issue. however, reported numbers vary and often represent subgroups. the number of hospital-admitted tbi has an important impact on hospital resources. thus, the monitoring of hospitalized tbi patients is needed. in , oslo neurosurgical tbi registry was established and includes patients admitted to oslo university hospital (ouh) with traumatic intracranial injury identified by neuroimaging. the aim is to introduce the registry; describe the patient group and volume. material and methods: descriptive study from oslo neurosurgical tbi registry. results: patients from south-east region were included in - (population million). mean age was years (sd ), % were males. most frequent cause of injury was falls ( %), increasing with age. % was influenced by alcohol at time of injury. preinjury antithrombotic therapy was common ( %). most of the patients had multiple pathologies on ct caput, e.g. simultaneous cranial fracture, sdh, tsah and brain contusion (four most frequent). accompanying injuries were found in %. % was transported to ouh directly form accident scene. % was classified as severe tbi upon arrival ouh, % was intubated, and trauma team was activated in %. median annual and monthly numbers of cases were (range - ) and (range - ), respectively. no clear change in case load between years and months, except a slight decline in march. admission rate peaked during the weekend. patients were continuously admitted throughout day and night, [ % between : and : . conclusions: patients included in the registry were older than those included in previous tbi studies. the numbers of cases admitted were stable across the months and years. however, the majority of patients were admitted during weekends and nights; thus handled by duty staff. relationship between brain-body temperature difference and neurologic outcomes in patients with severe head trauma introduction: brain is one of the most vulnerable organ to temperature. the association between core body temperature(ct) and neurologic outcomes in patients with post-cardiac arrest, severe head trauma and stroke has been reported. there were few reports comparing brain temperature(bt) with ct and peripheral temperature(pt). we investigated the association of differences among bt, ct and pt with neurologic outcomes in patients with severe head trauma. material and methods: we retrospectively reviewed data for patients with severe head trauma who underwent monitoring intracranial cerebral pressure(icp), bt, ct and pt simultaneously between january and december . results: we evaluated patients with a median age of years (range - years). glasgow outcome scale(gos) at discharge were as follows: good recovery(gr) , severely disabled(sd) , vegetative state(vs) , death(d) . table showed the average values of icp, cerebral perfusion pressure(cpp), bt, ct, pt, differences between each temperature (bt-ct, ct-pt, bt-pt) and gos in each patients. there was remarkable difference between bt and ct in the dead patient, whereas less differences were found in the other alive patients. we found greater difference between bt/ct and pt in the vs patients than gr patients. conclusions: greater differences between bt/ct and pt can be related to poorer neurologic outcomes introduction: minor head traumas are difficult to assess even with guidelines, hence head cts are often requested. as head cts are increasingly accessible, the demand on the radiology department often exceeds its capacity. there has been an increase in head cts at the oslo emergency department (oed), norway. the scandinavian guidelines for initial management of head injuries in adults (sg) is standard practice in the oed when assessing patients with head trauma.the aim of this study is to assess the number of patients with traumatic brain injury, evaluate guideline compliance and false negative initial reports by junior radiologists. material and methods: a consecutive cohort of patients from jan-june who received a head ct at oed due to minor head trauma was assessed. data was gathered from the ct request form, radiology report and ct images. the data points analyzed were: type of trauma, gcs, anticoagulants, loss of consciousness, nausea and vomiting, positive traumatic ct findings, and number of head cts within a year period. results: intracranial bleeds were reported in ( %) patients, ( . %) required neurosurgical intervention. skull fractures were reported in ( . %) patients, however no intracranial bleeds were present. it was impossible to assess guideline compliance because % of the referrals lacked adequate clinical information. ten bleeds were missed, however no further action was needed. % received more than head cts in years conclusions: head injury guidelines can improve clinical practice and reduce unnecessary ct scans; thus minimizing radiation exposure. based on the low number of positive findings, we hypothesize that sg compliance can be improved at oed. compliance was not assessable for nearly half of the patients, due to vital clinical factors missing. implementation of a standardized ct referral form based on the sg and educating junior ed doctors may decrease the number of unnecessary head cts. introduction: to date, there is no ideal allograft that provides local antibiotic release. along with this, existing fillers are expensive material, which complicates their application in practice. all this leads to the need to look for new ways to solve this problem. material and methods: gentamicin was used as an antibacterial drug because of its wide spectrum of action and thermal stability. for the study, staphylococcus aureus attc was used as a microbial strain. the antibiotic release from the studied materials was determined by equilibrium dialysis over the entire observation period. gentamicin antibiotic concentration was determined by hplc. results: an allograft impregnated with an antibiotic, prepared according to the marburg system in the area of the subcortical part of the bone, suppresses the staphylococcus aureus attc strain twice as much as perossal. when comparing bone allografts impregnated in various ways, the longest release time showed a perforated allograft.a bone graft impregnated with an antibiotic by incubation showed a % longer release time compared to perossal granules (p \ . ).when in vitro incubation of the antibiotic gentamicin with the drug ''perossal'', the dissociation rate is more than % in the first two days. when the antibiotic gentamicin with a bone allograft is incubated in vitro on the second day, dissociation into the extracellular space makes up more than % of the drug from the previously bound (p \ . ), which also indicates a longer release time from the bone allograft. conclusions: in vitro, a bone allograft impregnated with an antibiotic is able to reversibly bind the antibiotic gentamicin and gradually release it over a period of days. the use of a bone allograft impregnated with an antibiotic suppresses the growth zones of staphylococcus aureus strains. references: rudenko a., impregnation of the bone allograft: comparison of heads coloring. european journal of trauma and emergency surgery (suppl) p. acute appendicitis and pregnancy: from incidence to modern management: literature review and proposal for consensus estes experts guidelines a. l. bubuianu , a. mihailescu , g. pokusevski tameside general hospital, general/emergency surgery, ashtonunder-lyne, united kingdom introduction: acute abdominal pathology during pregnancy has historically been a challenging decision for the emergency surgeon, that had to deal with patients at same time. acute appendicitis has probably the highest prevalence of all. early involvement of the gynaecological team was considered paramount and the ongoing debate laparoscopic versus open intervention, has been more recently challenged by case reports where antibiotics alone have been a successful strategy. material and methods: literature review has been conducted by the investigating team, using the following search algorithm: reviewers screened pubmed portal to conduct a thorough search of the most important medical databases, cochrane's library, medline and embase. case reports and low quality case series have been excluded from the literature review. results: there is currently no general consensus in regards to operative strategy in acute appendicitis during pregnancy, but most authors described safety of laparoscopic intervention in the first trimesters and favoured open approach in a mother closer to term. the antibiotic treatment alone can only be considered in presumed early appendicitis, where there are no features of pending perforation, presence of phlebolith or established peritonitis and should be done under the close monitoring of experienced general surgeons. conclusions: an expert consensus is required in first instance, (set of questions submitted to audience at end of presentation for their expert opinion) regarding optimal treatment strategy in acute appendicitis during pregnancy, followed by a multicenter prospective randomised control trial, which we are hopeful to engage with help of numerous european hospitals where estes members activate. introduction: deep tissue pressure injuries (dtpi) are complex and difficult to treat. the higher prevalence is observed in paraplegic and elderly populations. primary closure of large, stage- dtpis is rarely feasible and flap closure is customarily applied. presented is a technique using tension relief system (trs; topclosureÒ tension relief system) and regulated oxygen and irrigation negative pressure wound therapy (roi-npt; vcareaÒ) to facilitate simple primary wound closure of dtpis. methods: large, stage- dtpis were closed by a limited surgical procedure entailing conservative debridement, en-bloc primary wound closure based on the application of trs and roi-npt. results: details of the closure of consecutive large dtpis in patients is presented. immediate primary closure was achieved in cases, while three others were closed over - days. surgery time ranged between . and h and hospitalization between and days. following a median follow-up of months (range - months), all wounds healed with one late recurrence. post-operative wound infection observed in one patient was successfully treated with systemic antibiotics. minor skin damage inflicted by the tension sutures at the anchoring sites healed spontaneously. gradual return to partial loading of the operated area was enabled within - weeks and full weight-bearing was achieved within - weeks. introduction: chronic pain is a disabling condition affecting - % of trauma patients. considering the burden of chronic pain, interest in interventions to prevent this disorder after trauma has grown. a descriptive review of literature was undertaken to assess the evidence on these interventions. material and methods: medline, cinahl and cochrane library databases were searched to identify interventional studies published up to august . websites of injury, critical care and pain organizations were also consulted to retrieve relevant guidelines. the literature search used combinations of medical subject headings and keyword under the themes of pain, trauma, surgery and preventive interventions. results: many knowledge syntheses relevant to the population of trauma published between and were found. low to moderate level of evidence was reported for pharmacological interventions such as the administration of ketamine, neuropathic pain medication and multimodal analgesia. local or regional nerve block in the presence of factures was associated with a high level of evidence. very low to low evidence was described for nonpharmacological interventions including cryotherapy and early mobilization. finally, psychological interventions were associated with a low to moderate level of evidence and multimodal pain management interventions (pharmacological and non-pharmacological) with a high level of evidence. conclusions: research is still needed to define the role of interventions to prevent chronic pain in trauma patients. thus far, multimodal pain management interventions involving multidisciplinary team management appear to be the most promising. implementing such interventions could reduce the negative consequences associated with chronic pain. introduction: chronic use of opioids has been documented % of trauma patients. accordingly, the tapering opioids prescription program in trauma (topp-trauma) was developed. the aim of this study was to assess the feasibility of topp-trauma and explore the efficacy of topp-trauma in reducing opioid use. material and methods: a -arm pilot rct was conducted in patients presenting a high risk for chronic opioid use. we aimed to recruit participants to receive either topp-trauma or an educational pamphlet. topp-trauma comprised educational and counseling sessions. the feasibility assessment of topp-trauma was based on the ability to provide its components. the morphine equivalent dose (med) per day as well as pain intensity and pain interference with activities were measured at and weeks following discharge. results: preliminary findings based on data collected in participants showed that counseling sessions were most frequently needed to completely taper opioids. sessions attendance reached %. nearly % of eligible patients accepted to participate and an attrition rate of % was found. even though the experimental group consumed a higher med h prior to hospital discharge compared to the control group ( . vs . ), its med/day intake was lower at weeks ( . vs . ) and weeks ( vs . ). these self-reported data were validated by the total med delivered by participants'' pharmacy at both time points ( . vs . at weeks; . vs . at weeks). minimal mean score differences were observed in both groups with regard to pain intensity and interference with activities. conclusions: data collected until now provided evidence on the feasibility of topp-trauma and on the program potential efficacy. challenges that will require to be addressed in future rct include the acceptance to take part in the study and participants' drop out. introduction: head preserving surgical treatment for ao-type b fractures with little to no dislocation consists of three canullated screws or a dynamic hip screw (dhs). there is a new alternative: the femoral neck system (fns). the fns has some advantages over dhs. the anti-rotation screw provides extra rotational stability because of the diverging design. furthermore, the incision is smaller in fns and only one locking screw is necessary for plate fixation. we present the first results of this new surgical fixation of femoral neck fractures with fns. material and methods: during the period of november until october , all patients with femoral neck fractures treated with fns, were included in this prospective single center cohort study. patient characteristics, fracture classification (ao, garden, pauwel), perioperative parameters and postoperative complications were registered. patients were allowed to mobilize based on the principle of permissive weightbearing. follow up was planned after weeks and weeks. primary outcome measure was cut-out rate within months. results: twenty-four patients with a femoral neck fracture (ao-type b) were surgically treated with fns. median age was , (range - ). median operation time was mins (range - ). mean duration of in hospital stay was days (range - days). twentytwo ( , %) patients completed the regular follow up of weeks. one patient ( %) had a reoperation due to a cut-out. during follow up one patient developed a wound-infection ( %) which was treated with intravenous antibiotics conclusions: femoral neck system as surgical treatment for femoral neck fractures shows promising first results. low cut-out rate, limited operation time, low mortality and short duration of in-hospital stay make this device a possible alternative for dhs of canullated screws. definitive conclusions should be made after studying long term results in larger cohorts. references: none. new personalized approach to enteroatmospheric fistulas using d bioprinting device introduction: enteroatmospheric fistula is a challenge for surgeons. it presents a great clinical variability. this diversity means that, despite having tried multiple devices and techniques to achieve local control of the intestinal effluvium over the rest of the wound, there is currently no technique that can solve this problem in all patients. d printing is a novel therapy that allows the customization of the devices according to the needs of each patient. the aim of this study is to describe the technique of manufacturing a custom device designed by bioscanner imaging and manufactured using a d printer for use in the management of enteroatmospheric fistula. we describe our initial results. materials and methods: we present four patients with enteroatmospheric fistula. the intestinal segment involved, the dimensions of the wound, the intestinal debit and the size of the exposed intestinal surface are substantially. all require an average of - daily cures by the nurse. after obtaining images of each fistula with a bioscanner, a personalized device was designed and made by a d printer. the polycaprolactone device was placed including inside the fistulous orifices and surrounding it with npwt in order to accelerate the healing of the wound to ostomize the fistula or achieve its definitive closure. results: four devices with different designs have been manufactured. the wound remained isolated from the intestinal contents after placement, favouring the granulation of the surrounding tissue with npwt and thus avoiding contamination of the wound. the system remained without leaks for an average of h, reducing the need for daily cures, improving patient comfort and avoiding complications. conclusions: the use of a manufacturing model using d bioprosthesis printing in order to create a personalized device that fits the characteristics of the patient's wound is feasible and offers promising results in the management of enteroatmospheric fistulas. new approaches in bone tissue engineering: innovative scaffold design for principle unlimited size bone substitutes introduction: in bone tissue engineering (bte), autologous boneregenerative cells are combined with a scaffold for large bone defect treatment. microporous, polylactic acid scaffolds showed good healing results in bone defects in small animals. transfer to large animal models, however, is challenging and not easily achieved simply by upscaling the design. increasing diffusion distances has a negative impact on cell survival and nutrition supply. this can lead to cell death and ultimately implant failure.this approach focuses on scaffold architectures, that meet all the requirements for a modern bone substitute. biological-functional, porous subunits in a loadbearing, compression-resistant frame structure characterise the innovative design. an open, macro-and microporous internal architecture provides optimal conditions for oxygen and nutrient supply in the inner areas of the implant by diffusion. material and methods: during the design process, prototypes (temple (figure a) , grid (figure b) , onion (figure c)) were dprinted (fused filament fabrication) using polylactic acid (pla). -after incubation with saos- (sarcoma osteogenic) cells for days (measurements on days , , and ), cell morphology, distribution and survival (fluorescence microscopy, ldh-based cytotoxicity assay), metabolic activity (mtt test) and osteogenic gene expression were determined. results: all designs not only showed cell colonization, but cells also sustained their ability to differentiate (already after days) and to divide. the open, hierarchical-structured design, with its innovative porous structure, provides a good basis for cell settlement and proliferation. the modular design allows easy upscaling and offers potential solutions to previous limitations scaffold developement in bone tissue engineering. references: the value of d reconstructions in determining post-operative reduction in acetabular fractures: a pilot study introduction: in patients with acetabular fractures, the reconstructed three-dimensional ( d) model of the contralateral acetabulum could be used as a mirrored template for the anatomic configuration of the affected joint. this has not been validated. material and methods: computer tomography (ct)-scans of twenty patients with unaffected acetabula were used. the symmetry of the generated d models was evaluated through; ( ) mirroring of the acetabulum; ( ) initial rough matching; ( ) automatic optimisation of the matching via surface-based matching; ( ) calculation of distances between surfaces by evaluating the euclidean (straight-line) error distance between the closest points between left and right. the percentages of surface-points of the left and right acetabulum with a distance smaller than . , . , . and . mm were calculated and evaluated, in relation to matta's criteria, for acetabular fracture reductions. the analysis was performed using the mirrored left acetabulum matched onto the right original structure (left mirrored to right original; ''lm ro'') and the right mirrored to left original (rm lo). to determine the inter-observer agreement the procedure was repeated by a second assessor for the first ten patients. results: patients had a mean ± sd age of . ± . years, % was male. the mean distance deviation was less than . mm in all comparisons. the calculated distances in . % of the surface points of the left and right acetabulum were below the tolerance threshold of . mm, based on matta's anatomical reduction critera (table ). absolute differences between assessors were\ . mm per patient with an overall moderate agreement of %. conclusions: d reconstructed models of healthy left and right acetabula are highly similar and could potentially be used as mirrored duplicates. the next step will be to investigate these results in patients with reduced acetabular fractures. : matta, j. ( ).j bone joint sur am. : - pr minimally invasive plate osteosynthesis technique for distal humeral fracture: a cadaveric study v. hofmann , c. deininger , t. freude , f. wichlas university hospital salzburg, orthopedics and traumatology, salzburg, austria introduction: in our study we want to evaluate the feasibility of minimally invasive plate osteosynthesis (mipo) technique for distal humeral fracture using anatomically precontoured double plate osteosynthesis. material and methods: eight elbows from four thiel fixed cadavers were included. on unfractued cadavers we tested the minimally invasive approach with two separate incisions, one at the lateral and one at the medial epicondylus. the preformed plates were inserted directly into the bone on sides and fixed with percutaneous screws. then we created an ao type a and c fracture. the reduction was performed under x-ray control and stabilized with k-wires. then we also inserted the plates in mipo technique. in the case of an intraarticular fracture, an olecranon osteotomy was additional performed in a minimal invasive way to control the distal humeral joint surface. after finishing reduction and fixation the approach were extended to control the fracture alignement, position of the plates and to expose the ulnar nerve. results: the plate position was satisfactory and we could not detect any major soft tissue damage or ulnar nerve injury by using the minimally invasive plate osteosynthesis technique. in the extraarticular fractures, reduction was achieved with k-wires and was acceptable in all cases. the intra-articular fractures were controlled by an additional olecranon osteotomy using the mipo technique with a good view on the joint surface of the distal humerus. conclusions: the findings of the present study show that mipo technique in distal humerus fracture is feasible and save especially for ao type a fractures. in ao type c fractures the olecranon osteotomy provided enough visibility to evaluate the distal humeral joint surface. the surgical technique is demanding, and care must be taken not to injure the ulnar nerve. never the less it is an effective surgical treatment method and an alternative option to open techniques. correlation between pelvic incidence and acetabular orientation in anteversion and inclination-an analysis based on a d statistical model of the pelvic ring introduction: the pelvic ring is a complex bony structure with a central role for the human''s mobility building the connecting part between the upper body and the lower extremities. pelvic incidence and acetabular orientation are two important parameters used in the description of pelvic anatomy and are of central importance for understanding the biomechanical interaction of spine, pelvis and hip joints. the objective of the study was the analysis of a potential correlation between pelvic incidence and acetabular orientation. material and methods: a d statistical model of the pelvic ring consisting of individual ct scans of european adults without bony pathologies was used to analyse pelvic incidence and acetabular orientation in anteversion and inclination. an additional analysis on the correlation between those parameters was performed using the software spss. results: a slight positive correlation between pelvic incidence and acetabular anteversion could be shown (r = . ; p = . ) as well as a strong positive correlation between anteversion and inclination (r = . ; p \ . ). pelvic incidence and acetabular inclination showed none statistically significant correlation (r = . ; p = . ). conclusions: the results of the study might contribute to a better understanding of the biomechanical interaction between the axial skeleton and the lower extremities and deliver valuable information concerning preoperative planning in orthopaedic and trauma surgery of the lumbar spine, the pelvis and the hip joints like for example reconstructive surgery after trauma, operative treatment of congenital or acquired deformities or total joint arthroplasty. references: boulay et al., ''pelvic incidence: a predictive factor for three-dimensional acetabular orientation-a preliminarystudy. '' anat res int. ; : . doi: . / . epub . introduction: the majority of distal clavicle fractures (dcfs) are displaced fractures and are prone to delayed-or non-union. there are several options for surgical reconstruction, open reduction and fixation or hook plate, but in patients with a comminuted or small fracture they are known to have a high complication and failure rate, and secondary surgery for removal is often necessary. we hypothesize that resection of the distal fracture fragment and subsequent stabilization with the lockdown device, is an alternative for selected patients with dcfs. methods: eleven patients with a comminuted dcf were treated with a lockdown device. data on pain and range of motion were documented and the constant shoulder score (css), oxford shoulder score (oss) and nottingham clavicle score (ncs) were assessed at one year follow-up. results: eight patients underwent surgery within weeks, compared to patients where the surgery was delayed ([ weeks) due to persisting pain and delayed-union. none of the patients had postoperative complications. in months after treatment, patients were complaint-free. one patient had hardware removal due to pain at the site of the screw head. four patients were assessed after one year follow-up. the mean pain score was . . the mean flexion , °, abduction , °, exorotation °and extension °. the css had a mean of . , oss . and the ncs a mean of . conclusions: all patients had a good short-term clinical outcome and hardware complications did not occur. we are the first to describe the use of the lockdown device in dcfs. this device is not dependent on fracture healing and secondary surgery is not necessary, therefore it can be an alternative in the treatment of dcfs. a larger series and longer follow-up is necessary to confirm this conclusion. in this ongoing study, the remainder seven patients will be included and presented at the estes. moore type i tibial head fractures are one of the most challenging fractures to treat. material and methods: we performed the following approaches on eight thiel fixed cadavers: the anterolateral (with an osteotomy of the tuberculum gerdyi, a subcapital fibula-osteotomy and an osteotomy of the tuberositas tibia), the medial approach (with submeniscal arthrotomy and a dissection of the medial collateral ligament) and the posterior approach with a submeniscal athrotomy. the reachable borders of the articular joint surface have been marked by a k-wire. the visual joint surface has also been radiographically documented by inserting k-wires into the tibia head. finally the results have been photo documented on the exarticulated joints. results: the reachable areas of the articular surface have been defined and documented. the combination of the subcapital fibulaosteotomy and the submeniscal arthrotomy showed the most increase in accessibility to the articular surface in the dorsal part. an additional osteotomy of the tuberculum gerdyi increased the vision on the entire lateral and anterior articular surface. the submeniscal arthrotomy, at the medial approach, has not a good view on the surface. the posterior approach showed only a limited view on the lateral and medial articular surface at the dorsal part. none of the surgical approaches sufficiently visualizes the intercondylar region. conclusions: a fracture-specific approach strategy is critical for the preoperative planning of complex tibia-head fractures. subcapital fibula osteotomy is the most efficient surgical approach to reach the posterior and lateral articular surface. for the anterior articular surface, the best overview was achieved by an osteotomy of the tuberculum gerdyi. it was not possible to see and control the intercondylar region with any approach. introduction: osteosarcoma (os) is the most common bone carcinoma in humans. at the time of the first diagnosis are already in about % metastases present. the current treatment strategies include above all radical surgical resection and chemotherapy. in the search for alternative therapy methods. treatment with cold atmospheric plasma (cap) shows promising prospects. at the cellular level, this leads to various cellular mechanisms and finally to induction of anticancerogenic effects such as growth inhibition, apoptosis, and changes in the cell-cell interactions. the impact of cap on the integrity of the cell membrane of os cells, however, is unknown. material and methods: suspended cells from two human osteosarcoma cell lines (u -os, mnng) were treated for s, s, and s with cap. cell proliferation was determined after h, , , , and h using casy cell counter. dye loss assay was performed by using fluorescein diacetate (fda). this was followed by indirect treatment with cap for s. in the cell-free supernatant was determined by tecan multireader the dye emission. flow cytometry assay was used after cap treatments and incubation with fda. the mean fda fluorescence intensity of individual cells in the flow cytometer was measured. results: cell kinetics showed significant inhibition of cell proliferation in both cell lines after cap treatment. the assays for determination of the dye level showed a significantly increased membrane permeability of both cell lines after cap treatment. the significant effect on the membrane integrity correlated with treatment duration. conclusions: this confirms a modulating influence of cap on the functionality of the cell membrane and may support the anti-proliferative effect of the cap treatment. thus, cap is a promising therapy option, especially for chemotherapy-resistant entities introduction: osteosarcoma (os) is the most common bone cancer in humans. standard therapy includes radical surgical resection and chemotherapy, but due to strong toxic effects, new treatment options are urgently needed. currently, there is a discussion about expanding the oncological therapy spectrum and treat with cold atmospheric plasma (cap). it is a reactive ionized gas rich in radicals, photons, and electromagnetic rays. its biological effects are primarily mediated by reactive oxygen and nitrogen species (rons). due to its low temperature, cap is suited for medical applications. in vitro studies have shown the antitumoral effect of cap also for pancreatic cancer, melanoma, ovarian, breast, and colon cancer. material and methods: human os cell lines u -os and mnng/ hos were used. proliferation assay. the growth of cap-treated cells was examined using a casy cell counter. caspase / assay. following cap treatment, the activities of caspase- and caspase- were measured using a specific substrate peptide coupled with a fluorescent dye (cellevent tm ). single-cell gel electrophoresis comet assay. dna damage after cap treatment was identified using alkaline microgel electrophoresis. dna migration was measured using comet score software. the percentage of tail dna was used to indicate the relative fluorescence intensity of the head and tail. tunel assay. after cap treatment tunel analysis was performed. results: the results revealed that the cap treatment of os cell lines leads to significant inhibition of cell growth. subsequently, the activation of caspases and the induction of apoptotic dna fragmentation was demonstrated. the treatment of os cells with cap leads to an induction of apoptosis and a reduction of cell growth. introduction: extra peritoneal packing (epp) is a quick and highly effective method to control pelvic hemorrhage. we hypothesized that this procedure may be as safely and efficiently performed in the emergency room (er) as in the operating room (or). methods: retrospective study of patients who underwent epp in the er or or in two trauma centers in israel between - . material and methods: retrospective study of patients who underwent epp in the er or or in two trauma centers in israel between - . results: patients were included in our study, in the er-epp group and in the or-epp group. the mean injury severity score (iss) was . ± . . following epp, hemodynamic stability was successfully achieved in of patients ( . %). a raise in the mean arterial pressure (map) with a median of mmhg (mean . ± . , p = . ) was documented. all patients who did not achieve hemodynamic stability after epp had multiple sources of bleeding or fatal head injury and eventually succumbed. the overall mortality rate was . % ( / ) with no difference between the or and er-epp groups. patients who underwent epp in the er showed higher change in map (p = . ). no differences were found between er and or epp in the amount of transfused blood products, surgical site infections and length of stay in the hospital. however, patients who underwent er epp were more prone to develop deep vein thrombosis (dvt): % ( / ) vs % ( / ) in er and or-epp groups respectively (p = . ). conclusions: epp is equally effective when performed in the er or or with similar surgical site infection rates but higher incidence of dvt. level of evidence: retrospective cohort study, level iv. introduction: application of supraacetabular schanz screws is usually performed under image intensifier guidance. the aim of this study was to perform it without imaging, with the hypothesis that, respecting anatomical landmarks, pre-and intraoperative fluoroscopy can be avoided. material and methods: insertion of the supra-acetabular schanz screws was performed in human adult cadavers. with cadavers placed in supine position, the anterior superior iliac spine (asis) was palpated. starting from this landmark, cm were measured in a distal and cm in the medial direction. at this point, a cm long oblique skin incision was performed. through this approach, mm schanz screws were drilled bilaterally into the supra-acetabular corridor with an angulation of °to distal as well as °to medial. combined obturator oblique-outlet views (cooo) were taken bilaterally to prove the screw position. six of the specimens underwent a d-ctscan. images were evaluated concerning correct screw positioning. skin and subcutaneous tissues were removed in the ilioinguinal region and possible lesions to the lateral femoral cutaneous nerve (lfcn) or to the joint capsule were evaluated. results: during radiographic evaluation of the cooo-scans ( specimens) and the d-scans ( specimens), the schanz screws were placed inside the supra-acetabular corridor in all specimens ( / ). during dissections, no intracapsular screw placements or lfcn lesions were found. conclusions: using our technique, all schanz screws could be sufficiently inserted without intraprocedural x-ray imaging. references: . karaharju, e. and p. slätis, external fixation of double vertical pelvic fractures with a trapezoid compression frame. inhury, . : p. - . . mears, d. and f. fu, external fixation in pelvic fractures. orthop clin north am, . : p. - . . mears, d. and f. fu, modern concepts of external skeletal fixation of the pelvis. clin orthop, . : p. - . pr epidemiology of self-inflicted major trauma r. stoner , n. misra , l. mason aintree university hospital, liverpool, united kingdom introduction: in the united kingdom, severely injured patients are taken directly to a major trauma centre (mtc). whilst deliberate self harm (dsh) is a known mechanism for this, there is limited prior research. - % of major trauma is thought to be self inflicted , . our aim was to describe the epidemiology of presentation to our mtc resulting from dsh. material and methods: retrospective review of patient records in our mtc for adult trauma team activations between / / and / / . data was collected on patient demographics, location type, injury severity score (iss), mechanism of injury and mortality. results: episodes of dsh made up . % of all trauma cases, involving patients; . % re-attended. z-scores show no change in incidence over time, but significant variability month by month, with / months [ sd from mean. mean patient age years (range - ). . % were male. . % came from residential location and . % from prison. most common mechanism was penetrating trauma ( . %). in-hospital mortality was % ( . % in males vs . % in females, chi p = . ). conclusions: this is the largest review of self inflicted trauma cases in a uk mtc, with a similar incidence to prior studies. there was no observed correlation with season or trend over time. mortality was higher in male patients, in keeping with national statistics on suicide, whilst dsh in females was linked to less severe injury; severity is related to mechanism of injury. injury from self stabbing/cutting was most common in patients from residential locations, whilst hanging was more common in prisoners. this study identifies preventable risk factors for major self inflicted injury. introduction: the distribution of trauma deaths was classically described following a trimodal pattern. during the last decade improvements in trauma care as damage control resuscitation (dcr) have minimized resuscitation injury. we hypothesized that the implementation of dcr in severely injured trauma patients is associated with less mortality and modifies mortality pattern. material and methods: we performed a -year ( - ) retrospective cohort analysis of all severely injured trauma patients (niss c ) who underwent surgery at our level trauma center. since , dcr was implemented including damage control surgery, minimizing crystalloids and increasing the use of blood products. our patients were stratified into two phases: pre-dcr ( - ( ) and post-dcr ( . results: a total of patients were identified. there were patients ( . %) in the pre-dcr group and patients ( . %) in the post-dcr group. mean age ( . vs . , non significant (ns)), mechanism of injury (blunt trauma: . % vs . %, ns) and shock on admission ( . % vs . %, ns) were similar between groups. there is a significant reduction in the rate of overall mortality ( . % vs . %, p \ . ). while early deaths from traumatic brain injury ( . % vs . %, ns) and hemorrhage ( . % vs . %, ns) are alike, mortality secondary to multisystem organ failure (msof) is lessened ( . vs . %, p \ . ). conclusions: dcr has helped in reducing overall mortality and mortality due to msof in our severely injured trauma patients. introduction: the mangled extremity severity score (mess) was constructed as an objective quantification criterion for limb trauma. a mess of or greater than was proposed as a cut-off point for primary limb amputation. opinions concerning the predictive value of the mess vary broadly in the literature. the aim of this study was to evaluate the applicability of the mess in a contemporary civilian central european cohort. material and methods: all patients treated for extremity injuries with arterial reconstruction at two centres between january and december were assessed. the mangled extremity severity score (mess) and the amputation rate were determined. results: seventy-one patients met the inclusion criteria and could be evaluated for trauma mechanism and injury patterns. the mean mess was ). seventy-three percent of all patients ( / ) had a mess b and % ( / ) of c . eight patients ( %) underwent secondary amputation. patients with a mess c showed a higher, but statistically not significant secondary amputation rate ( . %; / ) than those with a mess b ( . %; / ; p = . ). the area under the roc curve was . (ci . ; . ). conclusions: based on these results, the mess seems to be an inappropriate predictor for amputation in civilian settings in central europe possibly due to therapeutic advances in the treatment of orthopaedic, vascular, neurologic and soft tissue traumas. introduction: in polytrauma victims the acute respiratory distress syndrome (ards) is a major cause of morbidity and mortality. it presents a complex pathophysiology that is characterized by pulmonary activated coagulation and reduced fibrinolysis. due to the fact that the pulmonary endothelium is considered a key modulator of ards and that tpa in plasma is predominantly synthesized and secreted by vascular endothelial cells, we hypothesized that the time courses of serum tissue-type plasminogen activator (tpa) and its main inhibitor, the plasminogen activator inhibitor type- (pai- ), might indicate a clinical approach to preventing ards in polytrauma victims. material and methods: twenty-eight consecutive polytraumatized patients with concomitant thoracic trauma, age c years, iss c , who were directly admitted to our level i trauma center, were evaluated. blood samples were taken initially and on day , , , , , , and during hospitalization. luminex multi-analyte-technology was used for analysis of tpa and pai- antigen levels. results: both levels were particularly high at admission. although they significantly declined within three and seven days, respectively, they remained elevated throughout three weeks. throughout this observation period mean tpa antigen levels were higher in polytrauma victims suffering ards than in those without ards, whereas mean pai- levels were higher in polytrauma victims sustaining pneumonia than in those without pneumonia. noteworthy, in each patient, who developed ards, the tpa antigen level raised up to the onset of the syndrome and declined afterwards. conclusions: the development of ards has to be expected in a polytrauma victims if the tpa antigen level continues to rise after admission. potentially, in patients with a low risk of excessive bleeding the onset of the syndrome might be prevented by the timely administration of recombinant profibrinolytic proteins. motocross is a dangerous business: small bowell perforation case report case history: a year-old male, previously healthy, was admitted to the ed after being involved in a motorcross accident. he suffered blunt abdominal trauma. clinical findings: at admission, patient presented pale but haemodinamically stable. physical examination was unremarkable except for an evident abdominal wall hematoma and abdominal guarding over the left quadrants. investigation/results: abdominal ultrasound showed an intestinal loop with decreased peristalsis with a small amount of liquid adjacent (fig ) . due to the patient's haemodynamic stability, ct scan was performed (fig . ) which showed liquid in the left flank and iliac fossa, but without an identifiable intrabdominal lesion. diagnosis: the patient was admitted to the operating theatre with acute abdomen. therapy and progressions: intraoperatively fecal peritonitis was evident from a cm-hole on the antimesenteric border of the jejunum, the enterotomy was closed and profuse lavage was done; the abdominal wall closed without drainage. the patient went through an empirical antibiotic cycle. liquids per os were started on the first postoperative day and the patient progressed without issues. he was discharged at the th postoperative day. the remaining follow-up was uneventful. comments: small bowel perforation after blunt abdominal trauma is rare. sbmi has a high morbidity and mortality that increase with delayed diagnosis; however, clinical and radiographic signs of perforation are often absent, like in the case presented. ct is considered the gold-standard. in our specific situation, the small bowel perforation did not produce any pneumoperitoneum in a young patient with very good physiologic status that kept him hemodynamically stable. the prognosis of pelvic injury is closely related to the severity of vascular injury rather than the complexity of bony fracture y. wu , c. hsieh , c. fu chang gung memorial hospital, trauma and emergency surgery department, taoyuan city, taiwan introduction: pelvic injuries are among the most dangerous and deadly trauma. although complex pelvic fractures are often associated with vascular injuries, it is still unclear regarding the impact of the severity of vascular injury to the outcome of patients. we hypothesized that, in addition to the complexity of bony fracture, the severity of pelvic vascular injury plays a more decisive role to the patients'' outcome. material and methods:medical records of patients with pelvic fracture in a single trauma center between jan and dec were retrospectively reviewed. those who had an abbreviated injury scale (ais) c other than pelvis were excluded. based on ct results, the type of pelvic fracture was classified according to young-burgess classification, and the severity of vascular injury were recorded as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling or extravasation). the patient demographics, clinical parameters, and outcome measures were compared between the groups. results: among the patients, severe vascular injury were noted in patients. patients with severe vascular injuries had significantly increased amount of red blood cell transfusion (rbct) ( . vs. . units, p = . ), longer icu stay (is) ( . vs. . days, p = . ) and total hospital stay (hs) ( . vs. . days, p = . ) compared to minor vascular injuries. on the other hand, those with complicated pelvic fracture (lc type ii/iii, apc type ii/iii, vs and combined type) had similar amount of rbct and is compared to that of simple pelvic fracture (lc type i, apc type i) except a longer hs ( . vs. . days, p = . ). conclusions: our results indicated that the severity of vascular injury is more closely correlated to the outcome of patients with pelvic fractures than the type of bony fracture does. in addition to the type of bony fracture, the grade of vascular injury should be considered as an important part of pelvic injury classification. associated abdominal injuries do not influence reduction quality in operatively treated pelvic fractures-a multicenter cohort study from the german pelvic registry results: . patients with pelvic injuries were treated during this period. . % had a concomitant abdominal trauma. the mean age was . ± . years. comparing the two groups, patients with a combination of pelvic and abdominal trauma were significantly younger ( . ± . vs. . ± . years; p \ . ). both, complication rates ( . % vs. . %; p \ . ) and mortality ( . % vs. . %;p \ . ) were significantly higher. in the subgroup of acetabular fractures, the time until definitive surgery of the pelvis was significantly longer in the group with the combined injury ( . ± . vs. . ± . days; p \ . ) . the grade of successful anatomic reduction did not differ between the two groups. conclusions: patients with a pelvic injury have a concomitant abdominal trauma in about % of the cases. the clinical course is significantly prolonged in patients with a combined injury, with increased rates of morbidity and mortality. however, the quality of the postoperative results is not influenced by a concomitant abdominal injury. a. martins rangel , r. pozzi , j. alfredo cavalcante padilha , s. sardinha , f. eduardo silva , d. teixeira rangel heat, trauma center, são gonçalo, brazil f.f.c., male, years old, was admitted to the trauma center about h after a stabbing wound in the neck. upon examination the patient was mechanically ventilated and hemodynamically stable, with an exposed sectioned trachea, which had a tracheostomy tube applied. the penetrating injury itself was mostly allocated in zone ii. he had a ct angiography and was referred to the or for surgical treatment. the cervicotomy found that both the external and internal right jugular veins had been injured alongside the sternocleidomastoid, sternohyoid and homohyoid muscles, the thyroid cartilage, just above the vocal cords, which had exposed the anterior larynx and the epiglottis the right anterior jugular vein and smaller tributaries of the right internal jugular vein, were ligated; a tracheostomy was performed and the thyroid cartilage and anterior laryngopharyngeal wall were reconstructed with the epiglottis implantation, sternoid, homohyoid and sternocleidomastoid muscle sutures, after which the platysma was closed but not the skin, left to secondary healing. patient was extubated within h, discharged from icu on the fifth postoperative day. thickened oral diet was introduced on the th day, and by the th day he was discharged without the tracheostomy tube, with a normal diet. comments: the cervical region is an area susceptible to serious injury due to the presence of vital structures, with massive hemorrhage, airway obstruction, cervical spine injuries and cerebral ischemia as the leading causes of death. initial management of penetrating injuries follows the principles of trauma care with airway control initially. references: bhatt nr-penetrating neck injury from a screwdriver: can the no zone approach be applied to zone i injuries? bmj yan wang-penetrating neck trauma caused by a rebar-a case report. medicine ( ) introduction: annually, approximately , people decease as a result of a fall in the netherlands, according to the statistics netherlands. the aim of this study is to evaluate the demographic parameters, fall characteristics and resulting injury patterns of this group in the region of amsterdam. methods: all patients deceased as a result of injury due to a fall in the period july st until july st in the region of amsterdam were included. data were collected from the database (formatus) of the department of forensic medicine (public health service amsterdam). results: during the study period , patients deceased after a fall. the mean age was years ( - years) and % was male. a psychiatric disease was diagnosed or suspected in % of the population of which cognitive impairment, including dementia, was encountered in most of the cases ( %). the majority of the falls happened at home ( %) or at nursing facilities. a minority ( . %) was work related. over % of the falls was from standing position, . % was not from standing position of which . % regarded falls from stairs, the majority was male. multitrauma patients accounted for . % of the population. from the remaining , patients, . % sustained one or more injuries to the pelvis or extremities. central nervous system (cns) injuries were described in . % of the patients. mortality was in . % of the cases due to primary cns injury, . % was due to complications of which clinical deterioration ( . %) and infection ( . %) were the most common. conclusions: in the region of amsterdam the majority of deaths due to a fall regards the geriatric population. fall from standing position and mortality due to complications, mainly clinical deterioration, accounted for the majority of deaths. intervention to prevent falls and thereby complications need more awareness to reduce mortality. results from a multidisciplinary blunt splenic injury protocol introduction: the majority of splenic injuries are currently managed non-operatively. failure of non-operative management includes grade iv or v splenic injury or vascular abnormalities that are suitable for embolization. the primary indication for operative management of blunt splenic injury is hemodynamic instability. in our center, the last twenty splenic injuries, admitted during two years, were not managed according to published guidelines. ten patients ( %) underwent splenectomy, being unstable only of them ( % of the whole sample). material and methods: staff from anesthesiology, interventional radiology and trauma surgery came up with a joint protocol. grade iii splenic injury non-operatively management, including fluid responsiveness (achieving shock index (ht/bp) below . after a bolus of colloids) and, focus placed only on hemodynamic stability instead of on vascular abnormalities are our principal modifications regarding already published protocols. results: seventeen patients with blunt spleen trauma were admitted after starting up our protocol. six ( grade iii, grade ii and grade i) splenic injuries were successfully managed non-operatively. prophylatic embolization was performed in five patients: were grade iv spleen trauma and were grade iii spleen trauma with vascular abnormalities. one grade iii splenic trauma was embolized due to a pseudoaneurysm detected in ct scan performed h post injury. five grade v spleen trauma required urgent surgery. of them presented with shock index [ . . conclusions: our multidisciplinary protocol has helped in improving outcomes in blunt splenic injuries. we have achieved an almost full compliance to our protocol. case history: -year old male experienced severe blunt trauma after a bus accident. clinical findings: he is found alert (gcs = ), hemodynamically stable and with a patent airway. he presented catastrophic lower left limb where tourniquet was applied. gram of tranexamic acid (txa) and ml of crystalloids were administered. he was intubated in the site of injury and transfered to our center, being always hemodynamically stable. on hospital admission he was normotensive (bp = / mmhg, sinus rithm ppm), shock index \ . . he suffered uneventfully amputation of the limb with no need for blood products transfusion. his past medical history was only pertinent for hypertension. investigation/results: following urgent damage control surgery, ct scan was performed where acute bilateral pulmonary embolism was diagnosed. diagnosis: asymptomatic acute bilateral pulmonary embolism therapy and progressions: during icu stay, the patient kept hemodynamically stable. endotracheal tube is removed one day later and he is successfully transfered to the ward three days later. comments: hypercoagulability can occur after severe tissue injury, that is likely related to tissue factor exposure and impaired endothelial release of tissue plasminogen activator (tpa). in contrast, when shock and hypoperfusion occur, activation of the protein c pathway and endothelial tpa release induce a shift from a procoagulant to a hypocoagulable and hyperfibrinolytic state with a high risk of bleeding. it can be inferred that a patient presenting with severe tissue injury without shock is at high risk of perioperative thrombosis and txa might not be administered. ( ) . it signifies high energy force, representative of severe overall trauma. study reported mortality of blunt pelvic trauma to reach . - % ( ) . injury severity score (iss), hypotension, head injury, posterior fracture & haemorrhage have been implicated ( ) . however, there is a paucity of data in developing countries. this study identifies the problem burden, management outcomes and factors predicting mortality. material and methods: patients had pelvic trauma, retrospectively from jan to dec and prospectively from may to april . patients was included after excluding less than years and coagulation disorder results: majority were males ( . %),with a mean age of . . mechanism was rti ( . %) followed by fall from height ( %), railway accidents ( . %). mean iss & rts was . and . respectively. associated injury were long bone fractures ( . %), chest injuries ( . %).head injury ( . %). lateral compression ( . %), was the most common followed by anteroposterior compression ( %) & combined ( . %).majority underwent operative intervention ( . %) for pelvis or associated injury. the mortality rate was . % secondary to haemorrhagic shock ( . %) and sepsis ( . %). the factors were male gender, age, iss, rts, head injury, unstable pelvis. however, no association with haemoglobin, long bone fracture, and massive transfusion protocol was found conclusions: our study showed a mortality of . % which is comparing with previous study introduction: the number of patients admitted to oslo university hospital (ouh) due to bicycle trauma is increasing. we aimed to identify possible predictors of serious and fatal bicycle injury. material and methods: the ouh trauma registry was searched for patients treated for bicycle trauma between and . data extraction included putative predictors of serious and fatal injuries, defined as iss c and death within days, respectively. univariate analyses were performed and reported as odds ratios (or). p \ . was regarded as statistically significant. results: bicyclists were admitted, % were males, median age was years (range - ). injury mechanisms were single bicycle crash in %, collision with a motorized vehicle in %, bicycle vs. bicycle in % and others in %. serious injuries were seen in % and . % died. predictors for serious and fatal bicycle trauma are presented in figure . conclusions: we identified age c , high comorbidity and loss of consciousness (gcs b ) as predictors for both serious and fatal injury after bicycle trauma. single bicycle crash was the most common cause of serious bicycle injury in our trauma center. diagnosis, investigation and results: all case reports represent polytrauma patients with clinical worsening and admission to the icu, with subsequent development of acute respiratory distress syndrome (ards) refractory to primary measures. therapy and progressions: different mechanisms led to the development of ards in the different cases. on a primary approach, standard measures such as curarization, recruitment maneuvers, prone positioning and peep increase were applied whenever possible. an absence of improvement led to an almost inevitable need of extracorporeal membrane oxygenation (ecmo) rescue therapy. all patients responded positively to this treatment without major complications and were eventually discharged from the icu. comments: ards is a major cause of respiratory failure in polytrauma patients. among the many therapeutic options, ecmo emerges as a powerful tool as rescue therapy in respiratory failure refractory to all other measures, being the present case reports corroborative examples of its efficiency. introduction: nowadays when cities are improving fast and significantly, including transportation system, even more we encounter with high energy trauma . still the most vulnerable on the roads are pedestrians. material and methods: the analysis of the data collected prospectively from january to october was performed including the mechanism and diagnosis of polytrauma, patient demographics and the main outcomes. results: in total, patients were assessed according to the polytrauma protocol. the median age of the cohort was years (iqr - ), male patients, . % vs. . % females, p = . . the most frequent mechanism was a pedestrian struck by a vehicle in . % cases, and falling from a height of over m in . %. of those patients who had musculoskeletal injuries, in . % the trauma mechanism was a fall from a height and in . % pedestrians were struck by a vehicle, . % of patients who fell from a height and . % of those struck by a vehicle suffered visceral injuries. the most common cause of neurotrauma was a fall from a height in . %, and pedestrians involved in car accidents in . %. from the whole cohort, patients were not saved, resulting in a . % mortality rate. most patients ( ) who died had iss [ . the mortality reached . % among pedestrians struck by a vehicle and . % among patients who fell from a height of over m. conclusions: the most common mechanism in the cohort was a pedestrian struck by a vehicle, followed by falling from a height, with a predominant involvement of male patients. similarly, the most frequent cause of musculoskeletal injuries and visceral injuries was falling from a height and pedestrians struck by a vehicle, demonstrating an important direction for polytrauma prevention. introduction: recent reviews of uk trauma data show altering demographics. patients are increasingly older and sustain lower energy injuries, with falls \ m being the most common ( ) . material and methods: data collected over years in a major trauma centre was used to calculate injury specific admission rates, case fatality rates and injury specific mortality attribution. data on patient age, footwear, lighting, alcohol intoxication and previous admissions were collected in falls \ m resulting in mortality. results: patients sustaining falls \ m represented % of admissions and % of mortalities. all falls represented % of admissions and % of mortalities. case fatality of falls of \ m and [ m was . % and . %. all fall case fatality was . %. this was significantly higher than the case fatality of stabbings ( . %) and rtas ( . %). in falls \ m causing fatality, mean patient age was . years. % of patients aged - were under the influence of alcohol when falling, with % aged - , but only % patients aged - . % aged - who died when falling were wearing slippers. this increased to % in those aged - , and % aged - . % of falls occurred under daylight/full light. % of patients aged - who died after falling had been admitted to hospital within the last year, although this increased to % in those aged - , and % aged - . conclusions: falls were the most common cause for hospital admission, had the highest case fatality of injury mechanisms and caused the most patient mortality. alcohol intoxication was associated with falls in younger patients who died after falling, but this was less common in older patients. wearing slippers was less common in the young but significantly associated with fatal falls in older patients. these results offer a range of therapeutic targets when developing fall prevention strategies. introduction: the treatment of splenic lesions is determined by the hemodynamic situation, the degree of injury and the presence of bleeding. arterial embolization has expanded the indications of the conservative treatment. retrospective observational study on splenic traumatism and its therapeutic options. material and methods: a total of patients with splenic injury have been treated at our centre between and . patients were hemodynamically stable: were embolized and received a conservative treatment. patients were hemodynamically unstable: had a good response to the resuscitation treatment so they were embolized, but there was one patient who deceased because of other causes. from these patients, patients received splenectomy. results: the main objective of this study is to review the management of the trauma patient with splenic injury. of the total of patients with splenic trauma, average iss of , underwent splenic embolization, underwent urgent splenectomy and were treated with conservative treatment. the embolized, were hemodynamic unstable at arrival but responded to the fluid therapy, had a splenic lesion grade iv, a grade iii, grade ii and another a grade i. the success rate of embolization was % in the embolized patients. patient died, only one of them in the embolization group and was not related to the splenic trauma nor embolization, were in the urgent splenectomy group due to severity of trauma, died before receiving any treatment and in the conservative treatment group due to other complications. conclusions: patients who respond to volume or are hemodinamically with high-grade lesions, arterial embolization would be less aggressive treatment options with excellent results. haukeland university hospital, surgical unit/ regional traumacenter, bergen, norway, norwegian university of science and technology, trondheim, norway, haukeland university hospital, physical and rehabilitation medicine, bergen, norway, university of bergen, bergen, norway, st olavs hospital, physical and rehabilitation medicine, trondheim, norway introduction: during the past decades acute trauma care has improved through the development of highly specialized trauma centres and teams. since patients are considerable young when being affected, trauma may lead to life-long physical, cognitive and emotional constraints interfering with an independent self-determined life ( , ) . in , a revised national plan for the treatment of trauma patients in norway was published ( ) . the plan emphasizes the importance of rehabilitation and the need for early interdisciplinary rehabilitation. this study will examine in which extent patients receive rehabilitation in early phase after trauma as recommended in the norwegian national plan. in addition we will examine what follow-up patients receive after trauma, quality of life, functional level and use of health care and next-of kin resources. material and methods: patients admitted to regional trauma center in mid-or western norway in with niss c are recruited to participate. data will be collected from national trauma register, the norwegian patient register, the municipal patient and user register, data from statistics norway, the electronic patient record (epj) and the patient/relatives questionnaire. discussion: the results will be useful in the preparation of patient courses that comply with strong recommendations in the national trauma plan, ensuring equal treatment and raising awarness about rehabilitation for trauma patients. introduction: diaphragmatic lesions involve wounds and rupture of the diaphragm, through penetrating wounds or thoraco-abdominal trauma. their incidence is - %. the diagnosis may be late, despite the technical advances made by medical imaging. the choice of surgical approach and technique is still controversial. mortality is usually related to the associated injuries. the present paper analyzes the incidence of diaphragmatic lesions that occur in thoraco-abdominal trauma, their epidemiology, diagnosis and treatment. material and methods: we performed a retrospective study over a -year period ( - ) , in the surgical units of the emergency county hospital of braila, including all patients diagnosed with diaphragmatic lesions. results: during the study period, patients had thoracic-abdominal trauma. there were cases of blunt trauma and thoracic-abdominal trauma. our study involved cases of diaphragmatic injuries ( . %), by road accident and by white weapon. the sex ratio was : . the average age was years. chest radiography was a contributory preoperative diagnosis in cases. the diaphragmatic wound was on the left side in cases, and its average size was cm. the surgical procedure involved the reduction in the abdomen of the herniated viscera and the monoplane suture of the diaphragm by nonabsorbable ''x'' points in all cases. chest aspiration was the rule. there was only one death in a complex polytrauma case. case history: we report the one case which performed tae, angioplasty, thoracotomy, laparotomy and preperitoneal pelvic packing (ppp) in the hybrid emergency room (h-er). the patient was male in the s, who was riding on his motorcycle and fell from a m height. clinical findings: he was in shock state. diagnosis: we scanned cect and diagnosed subdural hematoma, traumatic subarachnoid hematoma, lt hemopneumothorax, lung contusion, multiple costal bone fracture, intercostal artery injury, splenic injury (gradeiii), pelvic bone fracture. therapy: we inserted the drainage tube to the hemopneumothorax and did the tae for the pelvic bone fracture and splenic injury. after tae, he was in still shock state. the bleeding volume from the lt drainage tube increased, so trauma surgeons did the emergency thoracotomy and thoracic endovascular aortic repair (tevar) for intercostal artery injury. we suspected he also had abdominal compartment syndrome due to recanalization of tae, and they performed the emergency laparotomy and did ppp for the pelvic bone fracture. comments: we install an ivr-ct system in our trauma resuscitation room in october . we named it h-er, as it enables us to do all examinations (sonography, ct and fluoroscopy) and treatments (ir, operation) required for trauma in a single room. we have to perform prompt diagnosis and treatment, especially in cases of severe polytrauma cases. a retrospective study proved that the h-er had shortened the time of ct initiation and emergency procedure and that lead to improve mortality ). h-er is a novel trauma resuscitation room to do all treatments required in the only one room for severe traumatic patients introduction: according to the previous advanced trauma life support (atls) guidance, the early assessment of trauma patients with haemorrhage were classified upon the vital signs. recently, national trauma registry analyses suggested to extend the assessment criteria with the base deficit (bd), referring to the metabolic status. our objective was to investigate the relevance of bd and to explore new prognostic factors in the early assessment of the severely injured. material and methods: our study included patients registered between . . and . . on our emergency ward for whom the trauma team was activated. they were grouped into severity groups (i-iv) according to either the vital signs (classical) or the extended criteria with bd. the data were extracted from medical documentations of the early phase of treatment. as primary outcome, we compared the -h mortality rate of the patient groups. we studied the need for massive transfusion and intensive care unit care as secondary outcomes. results: according to the classical assessment, % of the patients were assigned to group i (lowest risk for haemorrhagic shock) and % to group ii. the remaining % were grouped into groups iii and iv (higher risk). with taking bd into consideration, % were reassigned to a higher risk group; however, this change affected only groups i and ii. the -h mortality changed only in group i ( . % vs . %; p = . ). bd did not affect the need for massive transfusion. in groups i and ii, . % of the patients, in groups iii-iv % needed intensive care unit treatment. conclusions: bd is an effective prognostic factor in the early assessment of trauma patients. however, compared to the vital signbased evaluation, it provides extra informaton only in less severe cases. according to our findings, it may help to assess the need for the administration of blood products. grants: nkfi k ; ginop- . . - - - ; efop- . . - - - . complejo hospitalario de jaén, servicio de cirugía general y del aparato digestivo, jaén, spain, complejo hospitalario de jaén, servicio de anestesiología y reanimación, jaén, spain case history: years old male, with history of hypertension and dyslipidemia, suffered a backhoe accident and was admitted in a regional hospital. on initial assesment he presented contusion and two laceration wounds in left chest and in lumbar region. body ct informed subcutaneous emphysema and left rib fractures from th to th, left hemidiaphragm edema, laminar left pneumothorax and contusive lung. posterior lumbar hematoma and no intra-abdominal free fluid. laceration wounds were partially sutured, with drainages through the wounds clinical findings: he was transferred to our emergency department, presenting dyspnea, tachycardia, sweating, painful luq and left hemithorax worsening with breathing investigation/results: reviewed by our radiologist, tc images showed herniation of abdominal organs into the chest diagnosis: traumatic hernia in left costophrenic recess. multiple rib fractures therapy and progressions: the hernia contents (left colonic flexure and omentum) were reduced and defect closed with primary repair in emergency surgery. rib fractures treated by osteosynthesis.on th pod left renal artery dissection and renal infarction were evidence in a new ct. comments: diaphragmatic injuries are caused by blunt or penetrating thoraco-abdominal trauma. potentially life-threatening due to the herniation of abdominal organs and severe associated lesions. clinical suspicion is important as prompt diagnosis and treatment are necessary for good outcomes. in our case, the initial clinical assessment was incorrect and the transfer put the patient in danger as an emergency surgery should have been performed before transfer. this enhances the importance of a correct initial management of polytrauma patients. introduction: the fractures of the calcaneus account for about - % of all fractures of the human skeleton. the majority of these fractures ( %) are intra-articular and surgical intervention is a widely accepted way of treatment material and methods: the aim of this study was to evaluate the results of open reduction and internal fixation for di-afc.in a period of years ( - ) patients ( patients with bilateral fractures) with age range from to years old, were treated surgically using the lateral extensile approach. follow-up was - years. the results were evaluated based on x-ray parameters (calcaneal morphology, bohler''s and gissane''s angles), active range of motion, footwear problems and time needed to return to work. the sf- health survey was used for outcome assessment. results: fracture mean healing time was , weeks. the outcome was excellent in cases, good in cases and poor in cases. the complications were malposition of fixation in patients, superficial wound slough in patients, reflex sympathetic dystrophy in patients, deep infection in patients who were treated with antibiotics and metalwork removal following union of the fracture. one patient resulted in metal breakage with consequent pseudarthrosis. finally one patient developed chronic osteomyelitis and is under treatment. the treatment with open reduction and internal fixation for di-afc is indicated, provided that the restoration of calcaneal shape, alignment and height is achieved. long term functional results with mild pain, few alterations in activities of daily living or work, and essentially no footwear problems, can be expected from a properly performed open reduction and internal fixation. extraperitoneal rectal injury in emodinamically unstable patient treated after dcs with external traction applied in an endorectal balloon r. somigli hospital, general and emergency surgery, pistoia, italy case history: a -year-old man was crushed between two vehicles while he was working. he arrived in er hemodynamically unstable, so he underwent to emergency surgery. clinical findings: at rectal examination there was evidence of almost complete antero-lateral anorectal laceration. at abdominal examination there was evidence of anorectal full-thickness laceration and urethra full laceration. investigation/results: no diagnostic was required in preop because of patient instabilty. diagnosis: pelvic fracture with hemodynamic instability, severe rectal injury and complete prostatic urethra transection. therapy and progressions: el, lateral colostomy, pelvic paking, cistostomy and hip external binder. damage control surgery was performed. on pod second look was carried out and an almost complete extraperitoneal rectal injury was found during pelvic depaking. properitoneum was drained and a baloon probe was introduced in the rectum to allow the proximal rectal flap to advance to the distal rectum. stomal washes were performed with no rectal leak and rectal baloon traction mantained for days. radiological and endoscopic check haven't shown any leak and a good mucosal reconstruction. mri no sphincteral anatonical defects. waiting for emg before stoma reversal. comments: the optimal managment for extraperitoneal rectal injuries remains controversial. an approach with lateral colostomy and conservative treatment of rectal lacerations with rectal trac-tion baloon, could represent a safe treatment alternative in those cases with sphincter preservation, with a lower risk of complication. exploring differences between iss and niss scores for -day mortality in adult and elderly trauma patients in a norwegian national trauma cohort m. introduction: injury severity score (iss) and new injury severity score (niss) with a threshold over is commonly used to define severe injury and to define the study population in trauma registrybased studies for both adult and elderly trauma patients ( ) . for elderly patients (c years) this might be unreasonably high and might lead to exclusion of significantly injured elderly with increased risk of mortality. the aim of this study was to assess whether there were significant differences in -days mortality between adults and elderly trauma patients for different frequently used iss and niss thresholds material and methods: the norwegian trauma registry was interrogated to identify all adult (c years) trauma patients included in the registry from january through december . data were dichotomized to age groups ''adult'' and ''elderly'' ( - and c respectively) with -days mortality as primary endpoint. mortality rates were assessed for iss and niss thresholds of [ , [ and [ . we applied descriptive statistics and chi-squared test for comparisons. results: patients with available information about age, -days mortality and iss and niss scores were included in the analysis, of which patients were - years old and patients were c years. adult and elderly patients died, giving overall mortality rates of . % and . % respectively. for iss and niss [ there was a significantly higher -days mortality in elderly trauma patients ( . % and . % respectively) than adult patients ( . and . % respectively) (p \ , ), as for all other iss and niss thresholds tested. conclusions: this study demonstrates that elderly trauma patients has a significantly higher mortality risk than adult trauma patients at all iss or niss-thresholds analysed. this group has a significant mortality even at iss and niss above . introduction: the trauma tertiary survey (tts) is a widely accepted tool in the prevention of missed injury. existing literature on its effectiveness focusses on multitrauma patients. this study investigates the yield of the tertiary survey in trauma who are admitted for tts, without having any significant injury. material and methods: a single center retrospective cohort study was performed in a level ii trauma center. trauma patients without any clinically significant injury at the primary and secondary survey were included. the primary outcome was missed injury found during tts (type ). secondary outcomes were missed injury found after tts but during admission (type ), mortality and hospital length of stay [ days. results: from included patients, patients ( . %) had a type missed injury. alcohol consumption was associated with an increased risk for type missed injuries (odds ratio = . , % ci: . - . ) . a type missed injury was only found once, it concerned the only case of trauma related mortility. out of nonoperated patients, ( . %) were admitted for more than two days. these patients were significantly older ( vs. years, p \ . ) and had a higher asa classification, - vs. - ( . % vs. . %, p \ . ). conclusions: tts showed missed injuries in only . % of trauma patients who had no clinical significant injury found during primary and secondary survey. high costs of admission, together with a low yield found for this study's population the cost benefit of hospitalizing these patients is for discussion. future research should therefore focus on the identification of predictors of a positive tertiary survey. references: . advanced trauma life supportÒ student course manual. . keijzers, et al., the effect of tertiary surveys on missed injuries in trauma: a systematic review. . enderson et al., the tertiary trauma survey: a prospective study of missed injury. the -h rule in the emergency department and its association with surgical mortality in one public hospital in israel: retrospective study i. ashkenazi hillel yaffe medical center, hadera, israel introduction: in order to improve patient treatment the -h rule in the emergency department (ed) was introduced in many countries as well as in israel. within four h, patients attending the ed must be seen, treated, and a decision must be reached whether these patients are to be admitted or discharged. though a popular performancebased measure, whether the -h rule in ed is associated with a decrease in mortality is controversial. the primary objective of this study was to evaluate the association between time in the ed and surgical mortality in one public hospital in israel. material and methods: included in this retrospective study were patients admitted to the ed of hymc during . patients dying on the first day were excluded. . results: included in this study were , patients. of these, , ( . %) patients were hospitalized and the rest were discharged. overall, patients died. general surgery accounted for , patients of which died ( . % of hospital deaths; . % of all surgical patients; . % of patients hospitalized in general surgery). internal medicine together with general surgery and orthopedic surgery accounted for . %, . % and . % of the mortalities observed in patients with decisions made within - h, in patients with decisions made beyond h and in all the patients respectively. forty-five patients with decisions made within h died compared to with decisions made beyond h. these represent . % and . % of all surgical patients in the ed (whether hospitalized or discharged) and . % and . % of those hospitalized. conclusions: general surgery is the second largest contributor to hospital morality. in both absolute terms and relative terms, mortality was not increased by delays in decisions made beyond h. the adoption of this performance-based measure should be questioned. introduction: trauma is an important cause of mortality [ , ] . researchers are looking for optimal death/survival predictive models in trauma population. one way is to validate traumatic scores for different medical systems [ ] . the aim of our study was to validate the new injury severy score (niss) in severe trauma ( introduction: the international classification of diseases-based injury severity score (iciss) has been proposed as a reliable tool to measure trauma system performance especially in countries where a trauma registry has not been yet established. the purpose of this study is to assess the predictive capability for in-hospital mortality of iciss with international and adjusted survival risk ratios (srrs) in greek trauma population. material and methods: this single center, retrospective cohort study was conducted in a greek tertiary care hospital between january to december . the trauma population was defined as hospitalized patients with a principal hospital discharge diagnosis in the range icd- s -t . duplicated injury icd codes, readmissions, transfer to another hospital and missing data were excluded. the primary outcome was in-hospital mortality. adjusted srrs was calculated from patients with multiple injuries and the following two iciss scores were evaluated: multiplicative-injury (iciss) and singleworst-injury (swi). the models were assessed in terms of their discrimination, measured by receiver operating curve (roc) analysis and calibration measured using calibration curves. results: a total of patients were included in the study. median age was ± years and mortality rate was , %. based on international srrs, the area under the curve was , ( % ci . - . ) for iciss-multiplicative and , ( % ci . - . ) for iciss-worst injury. both modes had statistically significant better performance with adjusted greek srrs (aur = , % ci . - . and aur = , % ci . - . , respectively). conclusions: this analysis has demonstrated the validity iciss model for in-hospital mortality prediction in greek trauma population. further research is warranted to confirm the performance of iciss using a sufficiently sized sample to define national srrs. introduction: the occurrence of intra-abdominal abscesses is the most serious post-operative infective complication after appendectomy. a significant amount of research has been conducted in an attempt to identify those patients at greatest risk. pct is initially described as an early, sensitive and specific marker for sepsis associated with bacterial infection. we hypothesize that pct could serve as a predictor of the development of intraabdominal abscess and postoperative infective complication material and methods: the present study is a prospective, single centre, observational cohort study involving patients undergoing emergency appendectomy. all patients admitted to the acute care surgery ward for appendicitis were screened for study eligibility. pct poc samples will be obtained preoperatively (t ) and post procedure (t ) at h (t ), h (t ), and days (t ) post procedure. the primary objective of this study was to assess the diagnostic accuracy of point-of-care testing for pct in identifying post appendectomy abscess. the secondary objective was to determine the diagnostic accuracy in identifying any infective complication conclusions: we expect the incidence of abscess and infective complication to be increased in the pct elevated group compared with the control group. previous investigations indicate the overall morbidity related to infective complication is approximately - % of patient undergoing laparoscopic appendectomy. our pilot study revealed that the incidence could be as high as % in patients with prolonged elevated pct levels. introduction: hand trauma is a common cause for attendance to the accident and emergency (a&e), accounting for nearly - % of all patients . it is essential that accurate treatment and management is done as the implications of mismanagement are long term, which may lead to disability, loss of work and income, livelihood, and even psychological issues . the presence of a specialised hand surgeon is essential for management of these injuries , but in the a&e setting it is not always possible to have such specialised care and there is a need for an efficient triage system. materials and methods: we did an audit in our department and found a delay in the referral of patients from a&e to our trauma clinic, which was quite expected due to a high patient inflow. we devised a trauma pathway for the a&e, known as the d-system which outlines for them till what day from trauma is a particular hand patient safe to be sent to the hand clinic or who needs an urgent referral to a higher trauma centre, based on urgency of need of intervention. the pathway is in the form of a simple flowchart, which is easy to understand even for junior members of the team. we intend to do another audit after implementation of the pathway to assess change in practice. conclusion: it is essential to have simplified pathways for non-specialist areas in order to streamline treatment and offer the best care, in the limited availability of resources, especially at smaller hospitals. our aim is to develop one such system and assess it's effective in delivering better care. introduction: a quantitative method for measuring trauma severity has many potential applications. the intent of this study was to evaluate the accuracy of the mgap score and its components in prediction of in-hospital mortality versus the accuracy of the revised trauma score rts at a trauma center. material and methods: this study included patients with trauma. data regarding age, mechanism of injury, systolic blood pressure, glasgow coma score and respiratory rate were collected at trauma center of alberto torres hospital. mgap and rts scores were calculated, and their accuracy to predict survival/death outcome. results the study included patients, ranging in age from to years, % male. from the total sample, patients who suffered from penetrating trauma and patients who suffered from blunt trauma were observed. in the comparison of the scores, rts and mgap, there was no significant superiority in any of them for predicting the outcome -which in our study was hospital discharge or death -even when compared by trauma mechanism. the gcs proved to be a very sensitive criterion in both scores, especially in patients with traumatic brain injury, totaling patients in our statistical analysis, of which , % had a negative outcome. rts was slightly superior than mgap in patients classified by the score as high chance of mortality, with % versus % of assertiveness. conclusions: up to the moment, there is no evidence to support the superiority of one of the analyzed scores as a predictor of mortality in the patients evaluated. although the rts score is more widely used in trauma centers, the application of the mgap score is more feasible in pre or in-hospital care of polytrauma patients, since it does not use respiratory rate in its parameters. validation of d-dimer for screening for venous thromboembolism in pelvic and lower extremity trauma patients t. uehara , , t. noda , t. yumoto , n. kobayashi , a. nakao , t. ozaki okayama university, emergency healthcare and disaster medicine, okayama, japan, okayama university, orthopaedic surgery, okayama, japan, okayama university, musculoskeletal traumatology, okayama, japan, okayama university, emergency and critical care medicine, okayama, japan, okayama saidaiji hospital, okayama, japan introduction: venous thromboembolism (vte) is a life-threatening complication after major trauma patients. we previously reported that the patients with higher injury severity score (iss) and lower extremity trauma had high risk for vte. additionally, high d-dimer levels (cut-off d-dimer value, . lg/ml) on day were useful for screening for vte in major trauma patients. we validated d-dimer levels for vte screening for patients with pelvic and lower extremity trauma. material and methods: a retrospective study was undertaken between april and august at the okayama university hospital. patients with pelvic or lower extremity trauma were included (median iss, ). we collected following data; age, sex, iss, the number of operation times, value of d-dimer in screening, incidence of vte and use of anticoagulants. results: eleven patients showed high d-dimer levels in screening, furthermore, six patients were diagnosed vte using contrast-enhanced computed tomography. symptomatic pulmonary embolism was not occurred. patients with vte had undergone orthopaedic surgeries two or more times. fourteen patients received therapeutically or prophylactic anticoagulation therapies. conclusions: measurements of d-dimer levels after pelvic or lower extremity trauma patients were useful for screening of incidence of vte. direct oral anticoagulants were convenient for treatment to vte. trauma patients often needed several times of surgeries, heparin was also useful in perioperative period. introduction: early assessment of the clinical status of severely injured patients is crucial for guiding surgical treatment. several scales are available to differentiate between risk categories. we compared four established scoring systems in regard to their predictive abilities for early versus late in-hospital complications. methods: database from a level i trauma center. the following four scales were tested: the clinical grading scale (cgs; covers acidosis, shock, coagulation, and soft tissue injuries), the modified clinical grading scale (mcgs), the polytrauma grading score (ptgs), and the early appropriate care protocol (eac; covers acid-base changes). admission values were selected from each scale and the following endpoints were compared: mortality, pneumonia, sepsis, death from hemorrhagic shock, and multiple organ failure. results: in total, severely injured patients were included (mean age, . ± years; mean iss, . ± . points; incidence of pneumonia, . %; incidence of sepsis, . %; death from hem. shock, . %; death from multiple organ failure (mof), . %; mortality rate, . %). istinct differences in the prediction of complications, including mortality, for these scores (or ranging from . to . ). the ptgs demonstrated the highest predictive value for any late complication (or = . ), sepsis (or = . , p = . ), or pneumonia (or = . , p = . ). the eac demonstrated good prediction for hemorrhage-induced early mortality (or = . , p \ . ), but did not predict late complications (sepsis, or = . and p = . ; pneumonia, or = . and p = . ) cgs and mcgs are not comparable and should not be used interchangeably (krippendorff a = . ). conclusion: our data show that prediction of complications is more precise after using values that covers different physiological systems (coagulation, hemorrhage, acid-base changes, and soft tissue damage) when compared with using values of only one physiological system (e.g., acidosis). none of the authors have any conflicts of interest to declare. mortality rate related to trauma mechanisms in trauma center at alberto torres hospital from january to july r. p. pereira , r. adriana martins , j. a. c. padilha , f. e. silva , , d. rangel alberto torres hospital, trauma center, são gonçalo, brazil, federal university of rio de janeiro, niterói, brazil introduction: to demonstrate the healthcare services of the trauma center of rio de janeiro based on epidemiological data and on the specificity of the type of initial care delivered to multiple trauma patients, comparing the mortality rate at the second peak of death with the worldwide literature. materials/methods: retrospective study extracted from ''ct heat'' database. polytraumatized patients of both sexes were included and the mortality rate was calculated taking into account the second peak of death from trauma, gender, age and primary mechanisms of injury. discussion: the data collected show % mortality in the second peak, with firearm projectiles ( %) followed by traffic accident and fall as the primary causes of death. conclusion: because of the structural and health care profile of this trauma center, it was possible to reach the desirable mortality rate according to the worldwide literature (less than %). introduction: trauma patients are sometimes in critical condition upon arrival and need aggressive treatments to survive. despite all efforts many end up dying. it seems necessary to try to identify those patients with a very high risk of death to avoid futile treatments. the aim of our study was to develop a simple clinical tool to predict mortality in trauma patients that can be easily calculated in the ed. material and methods: we analyzed data from all trauma patients arriving at a spanish trauma hospital from june to june . patient demographics, physiologic trauma scores, vital signs, and glasgow coma scale (gcs) were recorded. our primary outcome was mortality. logistic regression analysis (lra) was performed using three variables (age, shock index (si), and gcs) to determine the appropriate weights for predicting mortality. using them, we constructed a simple score to calculate mortality. results: patients were studied. the mortality rate was . %. our score was constructed using weights derived from lra for age [ y ( points), si [ ( points) , and gcs conclusions: our score is easy and quick to calculate and could be a useful tool to predict mortality using early available parameters upon arrival in the ed. acknowledging the ethics involved in this topic, this score could sort out patients with a very high risk of death and in whom aggressive therapeutic measures could be limited early or withdrawn in agreement with family members references: haider a, et al ( ) ( ) ( ) states the average cost for an a&e attendance and non-elective inpatient stay is £ and £ , respectively highlighting the importance for schemes to reduce hospital admissions. assess impact of ambulatory care, surgical emergency assessment unit (seau) and ''emergency surgeon of the week'' (esw) on hospital admissions for surgical referrals (gp/ a&e). material and methods: retrospective analysis of prospectively collected data of hospital admissions from the patient centre database before and after implementation of seau (in november ) and esw (in november ), including the units'' activities. emergency general surgeon followed : (monday-thursday, - ) rota based at seau. results: since ( months), seau has reviewed (new ; follow ups ) patients. surgical admissions (sa) pre and post implementation seau were * and */month respectively, a drop by %. esw helped a further drop by another % to */month. % of new referrals were admitted and overall % of all patients reviewed were admitted. juniors (st /st ) and seniors (st - /staff grades/consultants) admitted % and % of the referrals respectively. uss and ct were performed in dedicated seau slots. % attending seau were likely to recommend the unit to friends or relatives. conclusions: in the face of unprecedented demand for hospital beds (more so in the winter), ''emergency surgeon of the week'' based at seau could be the answer to relieving the capacity, financial pressures and providing high quality safe patient care for our already strained nhs. surgical emergencies, an educational and medico-economic challenge introduction: surgical emergencies are a frequent reason for consultation in the emergency department and are responsible for significant morbidity and mortality. our study aims to present the number of patients admitted for a surgical emergency in a french level trauma-center and the volume of patients operated in emergency depending on the different specialties. method: we conducted a retrospective, single-center study of the hospital emergency department (uas) of the university hospital center of nice between january and december . we studied the volume represented by surgical emergencies according to the different specialties. results: the emergency department welcomed , patients, of which , surgical emergencies patients accounted for % of the total activity; patients were operated on urgently, which represents % of all surgical procedures in our hospital. conclusion: surgical emergencies are an important part of the activity of our hospitals. an academic definition is difficult to achieve. a regional organization is needed for the management and optimal care of these patients. the creation of regional centers, as for the trauma centers, seems indispensable, especially for the most serious patients, allowing both a better medico-economic and educational management of surgical emergencies. introduction: every new admission to the icu prompts a handover from the referring department to the icu staff. this step in the patient pathway provides an opportunity for information to be lost and for patient care to be compromised. mortality rates in intensive care have fallen over the last years, however, % of patients admitted to an icu will die during their admission ( ) . communication errors contribute to approximately two-thirds of notable clinical incidents; over half of these are related to a handover ( ) . nice have concluded that structured handovers can result in reduced mortality, reduced length of hospital stay and improvements in senior clinical staff and nurse satisfaction ( ) . material and methods: a checklist was created to review to score the handover. this was created with doctors and nurses and is relevant for handovers between all staff members. information was gathered prospectively by directly observing handovers on the icu. results: there is a notable discrepancy in the quality of handovers of new patients. this is true of handovers between doctors, nurses and a combination of the two. % (n = ) of patients weren't handed over to a doctor. the most commonly missed pieces of information were details of the patient's weight ( %, n = ), their height ( %, n = ), whether the patient has previously been admitted to an icu ( %, n = ) and whether the patient has any allergies ( %, n = ). conclusions: the handover of new patients to the icu is often unstructured and important information is missed. this can be said for all staff members and grades, and for handovers from all hospital departments. introduction: bowel resection for acute mesenteric ischaemia (ami) in elderly is associated with significant morbidity and mortality, and increasing age and frailty are associated with increased risk. this study aims to assess the short-term outcomes for elderly patients undergoing surgery for ami, and to assess the accuracy of surgical risk calculators in this population, to determine their utility in preoperative discussions. introduction: intertrochanteric femoral fracture of the super-elderly is often difficult to treat because good surgery does not always lead to good functional prognosis. we investigated the factors affecting the functional prognosis in patients with intertrochanteric fracture over years old. material and methods: cases of intertrochanteric fracture over years old who had undergone surgical treatment at our hospital between december and september were examined. nine men and women, age at injury ranged from to years, with a median of years. the average postoperative follow-up period was . months. for these cases, the mobility was classified into independent walking, assisted walking (cane, walker), wheelchair, bedridden, and the transition of pre-and postoperative mobility was analyzed. the significance test was performed using the mann-whitney u test, and p \ . was considered significant. results: by fracture type, when jensen classifications i and ii were stable, iii, iv, and v were unstable, mobility of unstable type was significantly reduced (p = . ). when the waiting period for surgery is divided by the median of days, there was no difference in mobility reduction between groups of less than days and groups of more than days (p = . ). although there was no significant difference in the presence or absence of preoperative rehabilitation intervention (p = . ), there was a tendency for less decline in mobility when preoperative rehabilitation intervention was performed. conclusions: in the treatment of this fracture, early surgical treatment after injury is recommended, but in the case of very elderly people, waiting is often required due to existing diseases and poor general condition . this study suggests the importance of preoperative rehabilitation intervention during the waiting period for surgery to prevent disuse disorders. references: . kelly-pettersson et al. waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: a cohort study international journal of nursing studies ( ) - . older patients with traumatic shock exhibited lower pulse pressure compared with younger patients; an analysis of nationwide trauma data base in japan introduction: the study purpose was to assess the effect of age on the relationship between pulse pressure (pp) and systolic blood pressure (sbp) in patients with traumatic shock. material and methods: in this retrospective cohort study using nationwide trauma data base in japan from april to may , trauma patients years of age and older with sbp \ mmhg were selected. patients with severe traumatic brain injury (the abbreviated injury scale on head [ ) and cardiac arrest (hr = and sbp \ mmhg) were excluded. linear regression analysis assessed association between pp and sbp interacted by age group dichotomized as \ or c years old. results: during the study period, patients were included. the linear regression analysis indicated the significant association between pp and sbp in overall population (ec, estimated coefficient = . %ci [ . , . ], p \ . ). association between pp and sbp was significantly interacted by the age group (ec = . %ci [ . , . ] introduction: high rates of trauma in south africa (sa) predominantly affect the youth, yet the geriatric population is not exempt. in addition to inherent challenges of age, elderly trauma patients are further compromised by resource constraints. we aimed to assess injuries and outcomes in elderly patients admitted to a tertiary trauma unit in sa. material and methods: a retrospective record review was done of all patients years and older, admitted to the trauma unit over an -month period. injury severity score (iss), mechanism of injury (moi), in-hospital complications and length of hospital stay were documented. results: patients (mean age: years; % female) were included with mean iss of . the most frequent mois included nontraumatic falls ( %), falls from height ( %), motor-vehicle collisions ( %), pedestrian vehicle collisions ( %), and blunt injuries ( %, % intentionally inflicted). eighty patients ( %) experienced at least one in-hospital complication. the mortality rate was %. the mean length of hospital stay was days. conclusions: despite the known vulnerablities of the elderly, the mortality rate and isss of this cohort were relativley low. however, when compared to first world literature, intentionally inflicted injuries and certain preventable mois (e.g. fall from height and pedestrian vehicle collisions) were common, [ ] [ ] introduction: the majority of new colorectal cancer is diagnosed in people [ years, yet the elderly are less likely to undergo curative surgery. chronological age is poorly correlated with post-operative outcomes and is not an acceptable measure of risk. conversely, frailty is a strong predictor of poor outcomes following surgery and presents an opportunity for patient optimisation. the aim of this systematic review is to assess the available evidence between frailty and outcomes in patients of all ages undergoing surgical resections for colorectal cancer. material and methods: pubmed was searched for articles reporting outcomes for patients deemed frail undergoing elective or emergency colorectal cancer resection up until august . the primary outcome was mortality ( and day). secondary outcomes; length of stay, readmission, reoperation & post-operative complications. results: studies identified, studies were deemed eligible for inclusion. study types, frailty assessments & outcomes measured were variable. despite this heterogeneity, categorisation of ''frailty'' was associated with higher rates of post-operative mortality, complications, readmission, and length of stay. conclusions: based on current evidence, frailty is a strong predictor of poor clinical outcomes in patients undergoing surgery for colorectal cancer. standardisation of frailty assessment and measure of outcomes is needed for more robust analysis. accurate risk stratification of patients will allow us to make informed treatment decisions and identify patients who may benefit from prehabilitation and intensive tailored post-operative care. introduction: pneumatosis intestinalis (pi) and hepatic portal venous gas (hpvg) are two radiological findings associated with a broad range of medical conditions. pi can be primary ( % of cases),usually with a benign course, or secondary ( % of cases),which results from obstructive or ischemic gastrointestinal diseases. only a minority of pi is associated to free abdominal air. in literature there is no consensus on radiological and biochemical markers of favourable outcome nor on treatment options-medical or surgical. we tried to identify prognostic markers in a series admitted to a single university hospital. material and methods: the medical records of patients with pi and/or hpvg admitted to ospedale maggiore policlinico (milan, italy) in the period - were collected the ct scan were reviewed by a single radiologist. results: mean age was . ± years ( - ). pi was primary in , % of the patients (n = ), and secondary in , % (n = ). at ct, pi was associated to portal gas in patients ( %) ( dead, alive) and to free air in patients ( %) ( dead, alive). linear or rounded gas collections were equally distributed in primary and secondary pi. the colon was involved in patients ( %), followed by the small intestine in ( , %),and the stomach (n = ). in patients serum lactate was [ , and died. leucocytosis (wbc [ , /mm ) was present in patients ( alive).four patients had peritonitis and abdominal tenderness. laparotomy was performed in primary (alive) and secondary pi ( deaths).in two patients it was diagnostic; in and associated to right or left colectomy, in to ileal resection and in to other procedures.surgery was judged futile in patients; all died a few hours after emergency department access. conclusions: we could not found any relationship between clinical, biochemical and radiological findings and outcome of pi. mesenteric and portal gas is a ominous finding, but did not reach significant value. successful transcatheter arterial embolization for a giant pseudoaneurysm of gluteal muscle due to ground level fall in elderly woman with direct oral anticoagulants t. kadoya , r. nakama , k. arakawa , t. ogura , k. kase saiseikai utsunomiya hospital, department of emergency medicine and critical care medicine, utsunomiya, japan, saiseikai utsunomiya hospital, department of radiology, utsunomiya, japan case history: a 's year-old woman using apixaban fell on the ground and was transferred to previous hospital. magnetic resonance imaging was taken and she was diagnosed as gluteal hematoma. she was treated conservatively but hemoglobin (hb) level was gradually decreased. although she was administered red blood cell as needed, anemia progressed. contrast-enhanced ct showed expanding hematoma of gluteal muscle. she transferred our hospital for advanced treatment including surgery on th day on hospital. clinical findings: vital signs were stable on arrival at our hospital. extensive subcutaneous hematoma was found in the right thigh and gluteal lesion. investigation/results: laboratory test showed that hb . g/dl and normal coagulation status. contrast-enhanced ct showed a giant pseudoaneurysm inside the gluteal muscle. therapy and progressions: angiography showed a giant aneurysm of peripheral branch of internal iliac artery. we performed transcatheter arterial embolization (tae) for it by gelatin sponge. after tae, there was no complication and progressive anemia was stopped. she was transferred to another hospital for rehabilitation six days after tae. comments: increase use of direct oral anticoagulants in elderly people could induce severe hemorrhagic trauma by minimal mechanism. tae is minimal invasive and safety procedure for such trauma case. introduction: the number of elderly people will increase during the next few decades. more importantly, the number of people aged or above are projected to increase % in developed countries. in spain, people over age were . % of the population in , and this will increase to . % in . that has implications in the health services and in the management of trauma patients. material and methods: we did a retrospective cohort analysis of trauma patients c y.o. admitted to our level i trauma center during the time-period of - . demographic data, icu care, and mortality were assessed. results: trauma patients c y.o. were admitted during that period. this is a % increase compared with the number of patients admitted during the previous decade ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . mean age was . ± . years, and median new injury severity score (niss) was (interquartile range to ). % were male. the mechanism of injury was % falls, and % pedestrian runovers. patients were admitted to icu, with median niss of and mortality rate of %. among severely injured trauma patients (niss c ) the hospital mortality rate of those c years was %, much higher than in the age group of - years ( %), with a significant difference (p \ . ). no differences mortality rates between - years and youngers with the same niss. conclusions: the geriatric trauma patient population is on the rise worldwide. this should be taken into account in our trauma centres in order to be able to adapt and try to improve trauma care in these patients. introduction: frailty is a geriatric syndrome which has been considered as a risk factor in the elderly, increasing adverse events in terms of global health, as hospitalization, increase of falls, need of institutionalization, and mortality. the aim of this study is to evaluate relationship between frailty, and the presence of major complications in the postoperative course of patients older than years undergoing emergency surgery. material and methods: prospective, longitudinal, cohort study, using four different scales of frailty as a predictor of risk for short-term adverse events, for patients during the postoperative course of emergency surgery (may -september ). the sample is categorized according to four frailty scales (clinical frailty scale, frail score, trst and share-fi) . we analyze the variables regarding diagnoses, clinical examination at admission, surgical procedures, and postoperative outcomes during the first days. clavien-dindo classification was used in order to graduate the severity of complications. results: patients were included with a mean age of , years (sd , ) . , % of the simple are women. frailty prevalence ranges, according to the frailty scales, from , % to %. median hospital stay was days ( iqr , ) . all four frailty scales show statistical differences to predict major complication in our simple. trst and frail scales show the strongest measure of association (or , and , , respectively). the frail phenotype, is also related to an increased of mortality, and frail scale is the frailty scale with largest or (or = , ).only frail show association with longer hospital stay ([ days), and reoperation rate. conclusions: frailty represents a predictive marker of major complications and mortality, for patients older than years undergoing emergency surgery. frail score, shows the strongest relationship with mortality and complications. introduction: age has been identified as a predictor of trauma mortality [ ] and it is known that even low energy trauma may cause severe injuries in the elderly [ ] . the aim of this study was to explore how the elderly trauma patients, and the care thereof, differ from the younger ones in a swedish context. material and methods: the swedish trauma registry (swetrau) was used. consecutive recorded trauma cases that presented at one level ii trauma hospital during december -august were included (n = ). patients were stratified into groups; those c and those results: in the c years group, sex distribution was more even (female . vs . %, p \ . ), physical status according to pretrauma asa classification was higher (mean . vs . , p \ . ) and the trauma mechanism was predominantly low-energy (falls from no height) as opposed to the conclusions: the trauma among elderly swedish patients are more often of low energy compared to the younger population. in spite of this, the elderly are more severely injured, require more surgical interventions, and their short term mortality is increased -fold. measures aimed at prevention of low energy trauma of the elderly are therefore much needed. introduction: there are intramedullary or extramedullary methods in internal fixation od trochanteric fractures. seldynamisalbe internal fixator with two sliding screws (sif), as an extramedullary method, and gamma nail (gn), as an intramedullary method, are in routine trochanteric fractures treatment at our institution for last two decades. material and methods: health related quality of life and hip function were assesed at least two years after surgery, in the series of patients with a surgically treated ao a or a fracture type. there were two groups of patients: group treated by sif and group treated by gn. examination had been performed using sf- test, with its physical component score (pcs) and mental component score (mcs), and harris hip score (hhs) tests. results: in sif group, mean pcs was , , mean mcs was , and mean hhs was , . in gn group mean pcs was , , mean mcs was , and mean hhs was , . there was no significant difference regarding all these parameters between the groups of patients (p [ , ). there was correlation between all evaluated parameters, both in groups of patients particularly and in all patients (p \ , we identified undertriage in , % ( / ). falls from own height ( - m) was found in patients with iss [ , / ( %) of them was found to have been undertiaged (p . ). we found an association between gcs \ and undertriage (p = . ). % ( / ) falls between - m and % ( / ) of these without trauma team. falls between - m , % ( / ) without trauma team. all with fall [ m had trauma team. mortality was % ( / ), no association between height of fall and mortality (p . ). undertriage was not associated with increased mortality (p = , ). median age in mortality group was years versus years in surviving group (p \ . ). in univariate analysis there was association between prehospital bp \ (p . ), gcs \ (p \ , ), iss (p \ . ), prehospital rr [ , rts \ (p \ . ) asa score [ (p \ . ) and mortality. conclusions: we found significant undertriage in the geriatric trauma population with fall injuries. gcs \ and low energy falls was associated with undertriage but not with mortality. laparoscopic direct repair of an incarcerated spigelian hernia c. bergamini , v. iacopini , r. de vincenti , a. bottari , g. alemanno , p. prosperi aou-careggi, emergency surgery, firenze, italy spigelian hernia occurs through a defect in the anterior abdominal wall adjacent to the semilunar line. it is in itself very rare and more over it is difficult to diagnose clinically. it has been estimated that it constitutes . % of abdominal wall hernias. the majority of patients present with symptomatic incarceration of preperitoneal fat or intraabdominal viscera. radiographic studies are beneficial in confirming the diagnosis. the high rate of incarceration with or without strangulation mandates operative repair once the diagnosis is confirmed. the spigelian hernia has been repaired by both conventional and laparoscopic approach. laparoscopic management of spigelian hernia is well established. most of the authors have managed it by transperitoneal approach either by a direct repair or by placing the mesh in intraperitoneal position or raising the peritoneal flap and placing the mesh in extraperitoneal space. there have also been case reports of management of spigelian hernia by total extraperitoneal approach. we present the case of an obese eighty-four y.o patient. complaining for a sudden onset abdominal pain in the right low quadrant, mimicking an appendicitis. the ct scan demonstrated a typical picture of a spigelian hernia containing an intestinal loop. the loop showed classical signs of parietal wall ischemia. the video describes the surgical laparoscopic approach of this case which was able to confirm the diagnosis e to reduce the loop into the abdomen. the loop initially appeared diffusely ischemic, but after the intra-abdominal reduction some signs of vitality started to be noticed. however, they were incomplete; thus the loop was resected. the hernia defect was successively repaired in a direct way because of the small caliber (\ cm of diameter) and the possible contamination coming from the intestinal resection. post-operative course was particularly benign and the patient was discharged on the seventh post-operative day in good health. introduction: trauma audit & research network (tarn) data shows older persons falling from standing height and sustaining significant injury has become the commonest trauma presentation in england and wales . we aimed to assess whether frailty predicts poor outcomes in the elderly. material and methods: retrospective database review of tarn eligible patients [ years old admitted in a week period with documented rockwood clinical frailty score . age, injury severity score (iss), length of stay (los) and mortality were noted. the inhospital mortality group was sub-analysed. logistic regression was performed (stata v ), odds ratios and % ci reported. results: older age was associated with higher cfs in the patients studied. increasing cfs was associated with increased overall mortality (cfs - vs cfs - or . ; % ci . - . ), decreased likelihood of pre-hospital trauma alert and increased length of stay (cfs - stayed days more than cfs - ). all deaths had cfs [ and head or chest injury. adjusting for age and cfs those with chest injury were . times more likely to die (or . %ci . - . ). mortality in those with rib fracture was times higher in cfs - vs cfs - (or . %ci . - . ). conclusions: increasing age and cfs (especially - ) are associated with poor outcomes in elderly trauma, thus cfs is a useful prognostic tool in severely injured elderly patients. chest injuries are a major cause of mortality in this group, especially with increasing frailty. major trauma centres must develop practice management guidelines to appropriately manage these patients. introduction: major trauma causes activation of the complement system, which plays a key role in development of systemic inflammatory response syndrome and multiple organ failure. complement is known to be activated early after trauma , but the relationship between outcome and the extent of complement activation during the first critical hours after injury is unknown. we hypothesized that complement activation in the first hours after trauma displays a highly dynamic pattern which is associated with outcome. material and methods: complement activation was assessed by plasma terminal c b- complement complex (tcc) using elisa in a prospective cohort of trauma patients. samples were obtained at admission, after , , and h, and daily in the intensive care unit. the extent of complement activation was assessed as area under the concentration curves - h after injury (tcc-auc - ). the relative contribution of complement activation, base excess (be) and new injury severity score (niss) to outcome was analyzed by multivariable analyses. results: niss and be were associated with tcc-auc - in bivariate analyses (spearmans rho (p) was respectively , (p = . ) and - . (p = . )). in multivariable analyses, niss and initial tcc alone predicted % of the variability in ventilatorfree days (vfds), whereas initial tcc and tcc-auc - predicted %. tcc auc - alone contributed with % to the model. tcc-auc - was also significantly higher in patients deceased at day ( . ; . - . (median; quartiles) vs. . ; . - . , p = . introduction: massive transfusion protocols [mtp] have been widely adopted for the care of bleeding trauma patients but their actual effectiveness is unclear. this study aims to conduct an updated meta-analysis to evaluate the effect of implementing an mtp on the mortality of trauma patients. material and methods: medline, pubmed, google scholar and cochrane library databases were systematically searched for relevant articles published from january , to july , using a combination of key words and additional manual searching of reference lists. three reviewers independently screened the articles for potential inclusion. eligible articles were original articles in english, included trauma patients and compared mortality outcomes before and after institutional implementation of a mtp. primary outcomes were h and overall mortality. results: nineteen studies met inclusion criteria, analyzing outcomes from , trauma patients. there was a wide range of outcome and process indicators utilized by the different authors. mtps significantly reduced over-all mortality, pre-mtp- . % and post-mtp . % [or . ( . - . )] for trauma patients. -h mortality was not significantly reduced [or . ( . - . )]. conclusions: the institution of an mtp has a significant over-all mortality reduction for trauma patients. we encourage that researchers use standard nomenclature and indicators, provide more details regarding protocols and patient populations and incorporate advances in the management of bleeding trauma patients in all future mtp studies. introduction: when resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized with good outcomes for penetrating trauma patients. however, evidence that these concepts apply well to the management of blunt trauma is lacking. this study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock. material and methods: in this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival \ . . patient's characteristics, examinations, severity and administrated therapies were compared between survivors and non-survivors. data are described with median ( - % interquartile range) or number. results: thirty patients were included and median injury severity score in survivors vs non-survivors was ( - ) vs ( - ) (p = . ), with no significant difference in probability of survival. despite no significant difference in injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. total blood transfusion amount administered within h after admission was significantly higher in survivors ( [ conclusions: vasopressor administration and high-dose use for hemorrhagic shock following severe blunt trauma are significantly associated with increased mortality. although the transfused volume of blood products tends to be increased, early termination of vasopressor should be considered. all authors have no significant relationships with regard to this study. early amplitudes of citrated functional fibrinogen in thromboelastography to predict massive transfusion introduction: this study aims to evaluate the role of early amplitudes of the thromboelastography measure of citrated functional fibrinogen (cff) to predict massive transfusion (mtx) defined as transfusion of c of any blood products within an hour of arrival to a major trauma centre. material and methods: trauma patients c years requiring activation of the major haemorrhage protocol with teg performed on a tegÒ s hemostasis analyser were eligible for inclusion. exclusion criteria were arrival [ h after injury, pregnancy, bleeding disorder or anticoagulant use. patient demographics and transfusion requirements were obtained from medical notes. teg manager was accessed to extract amplitudes at min (a ), min (a ) introduction: hyperfibrinolysis, remains a significant characteristic of acute traumatic coagulopathy induced mortality. s a , a cell surface protein, when shed creats an occult hyperfibrinolytic subtype. annexin a (a ), a multicompartment protein that co-localizes with s a and contains a tissue plasminogen activator (tpa) binding site has been shown to enhance tpa activity -fold and thus behaves as marker of hyperfibrinolysis. we hypothesize that increased concentrations of a in blood will enhance tpa fibrinolysis. material and methods: blood was collected from ( ) healthy volunteers. recombinant a in concentrations , , , , , lg/ ml was added blood and then combined with tpa ng/ml. samples were assessed using thromboelastography (teg). blood samples were collected from trauma activations from -current at a single, urban, level- trauma center. samples were assessed using a combination of rapid, citrated native and tpa challenge teg. a levels were established via proteomic analysis. results: a - (lg/ml) significantly increased tpa mediated ly % vs tpa alone (a ? tpa [ - ] median . % vs tpa . % p \ . ). a without tpa had no significant effect on ly % and was similar to the lysis of control (a lg/ml . % vs control . % p = . ). a - (lg/ml) significantly increased r time from control and tpa alone (control normalized to vs a median . -fold increase in minutes p \ . and tpa . -fold decrease vs a median . -fold increase p \ . ). rapid teg for patient vs patient in our ongoing study was . % vs . % and . % and . % respectively on tpa challenge teg. proteomic analysis of a relative activity found a . -fold a activity in patient compared to patient . conclusions: exogenous cell free a significantly increases tpa mediated fibrinolysis measured by teg. preliminary data from our ongoing trauma study evaluating a levels and hyperfibrinolysis coincide with our in vitro study. introduction: massive transfusion protocol can be activated to mobilize the blood products resource in a timely and effective manner. blood products, however, are still wasted or overused. we aimed to study what proportion of patients who met the abc criteria for massive transfusion received or more units packed rbc (prbc). material and methods: a retrospective study all level i trauma patients admitted with arrival systolic blood pressure of or less (july to may ) was recruited. transfusion was complied with stts. all clinical and laboratory findings, and management procedures were populated from the data registry. results: of admitted trauma patients met the inclusion criteria. of patients who where admitted with hypotension, of patients ( . %), who met the abc criteria for receiving or more prbc were stabilized with or units. in other words, stts enabled us to save units of prbc. arrival data, i.e. blood pressure (cut of point: mmhg and p value: . ), shock index (cut of point: . and p value: . ) and pulse rate (cut of point: beat/min and p value: . ) were significantly different in patients prescribed or more units prbc. after initial resuscitation, blood pressure (cut of point: mmhg and p value: . shock index cut of point: . and p value: . ), pulse rate(cut of poinan beat/min and p value: . ) presence of pelvic fracture, positive fast,and base deficit [ were significantly different in the group received or more units prbc. conclusions: massive transfusion protocol with abc criteria may lead to wasted or overused blood products.consideration of dcr continuation strategy complied with stts along with the findings of this study has resulted in a refined protocol characterized by more effective and efficient blood product resource allocation. references: -chang r, holcomb jb. optimal fluid therapy for traumatic hemorrhagic shock. critical care clinics. jan ; ( ) case history: we present the clinical case of a female patient of years old who had been taking aspirin. mechanism of injury: a fall from her own height, resulting in head trauma. clinical findings: dysphonia and stridor, having underwent an immediate orotracheal intubation. investigation/results: she had a head ct done that was normal; and a cervical column and neck ct that showed a large retropharyngeal hematoma, without an associated vertebrae fracture. diagnosis: large retropharyngeal hematoma. therapy and progressions: she was admitted to the intensive care unit for mechanical ventilation. on nd day, she underwent a surgical tracheostomy. on th day, underwent weaning from mechanical ventilation. on h day, was transferred to the ent ward, had the tracheostomy tube removed and was discharged from hospital. comments: a hematoma in this potential space may constitute an immediately life threatening emergency due to airway compromise. in , thomas et al found only cases described in the literature since . the most common cause is the blunt cervical trauma (in % of the cases). other causes are the cervical hyperextension injury, cervical vertebrae fracture, cough, sneeze, strain, blunt head trauma, swallow a foreign body, retropharyngeal infection, carotid artery aneurism, internal jugular vein puncture, metastatic disease, coagulopathy, anticoagulants, etc. in the setting of trauma, the mechanism of injury generally permits explaining the presenting injuries. in this case, the clinical severity expressed by the patient seemed to be disproportional to the resultant injury. however, the presence of haemorrhage contributing factors associated with the existence of fascial spaces in the neck, should warn us of the possibility of formation of deep cervical hematomas that may cause an occult airway obstruction. case history: a -year-old male with a personal history of consumption of alcohol, cannabis, smoked cocaine and heroin. he was found in decubitus position and in a situation of cardiac arrest. the last time he was seen in his baseline situation was h before. after performing cpr and administration of naloxone and flumacenyl, sinus rhythm was achieved. clinical findings: h after admission, increased tension was observed in left leg, thigh and gluteal region. absence dorsalis pedis, tibialis posterior and popliteal pulse was observed in a doppler examination. investigation/results: intracompartmental pressure measurement revealed a result of mmhg in the deep posterior compartment and mmhg in the superficial (diastolic bp mmhg). at admission k levels were . meq/l, creatinine . mg/dl and ck u/l. diagnosis: opioid-related compartment syndrome. therapy and progressions: urgent fasciotomies of the leg and thigh were performed h after diagnosis with a posteromedial and anterolateral approach in the first case and with a lateral approach in the latter. herniation and signs of poor viability in all the compartments were observed. after the surgery, he persisted with anuria and a ck peak of , u/ l, which was next normalized. debridements were performedfor the next days. subsequently, after the isolation of p. stutzeri and mucor in the wound and the absence of signs of vitality, a supracondylar amputation was performed. after, hemodynamic status improved. weeks after the amputation it was possible to withdraw hemodialysis, which he had required since admission. comments: opioid misuse is a topic of growing interest. recent works have reported a worse prognosis in the case of opioid-related compartment syndrome. a high level of suspicion is necessary to make a prompt diagnose in these patients. introduction: the pelvic binder is a mechanical device designed to compress instable pelvic ring fractures and minimize dead space in order to limit blood loss. it is generally recommended to apply a pelvic binder if an unstable injury is suspected and the patient presents with a ''c-problem''. the effectiveness remains questionable though. material and methods: a total of trauma patients between and were retrospectively evaluated regarding instable pelvic injury. patients were admitted with a pelvic binder applied. the correct application was evaluated using ct scout. four groups were generated: group with correct pelvic binder application, group with incorrect placement, group with no pelvic binder at time of admission, group with pelvic binder applied in er. total outcome was determined based upon iss, age, preclinical time, time to ct, shock index, hemoglobin at admission, survival rate, administration of blood products as well as total hospital and icu days. results: % of all pelvic binders were applied incorrectly. patients ( %) suffered an instable pelvic fracture. patient survival was not influenced by the preclinical application of a pelvic binder ( % group vs. , % group , p = , ). no significant statistical difference was found for total icu days , vs. , , p = , ; total hospital days , vs. , , p = , ; rbc transfusion , vs. , , p = , ; iss , vs. , , p = , . conclusions: the correct application of a pelvic binder seems to pose problems preclinically. while the need to minimize blood loss is crucial, our collective did not benefit from this device. additionally, survival rates of the patients that suffered an instable pelvic fracture were unaffected. the iss remains the strongest predictor of total patient survival in pelvic trauma. trauma resuscitation times in a level trauma center in the netherlands: a prospective overview introduction: in trauma, time is considered to be an important factor influencing patient's outcome. in the first hour after injury, appropriate care has the greatest effect on trauma patient's survival. previous research showed that measuring in-hospital trauma resuscitation times, contributes to insights and improvement of the resuscitation process. however, despite developments of atls guidelines, no recent empirical knowledge regarding resuscitation times exists. the aim of this study is to examine in-hospital trauma resuscitation times in a level trauma center in the netherlands. material and methods: a prospective study was performed in level trauma center amsterdam umc location vumc, between may and august . trauma patients, aged c , presented during daytime at the trauma resuscitation room were included. information regarding patient's characteristics, trauma-and injury type, handover duration, duration till start of diagnostics and intervention, total resuscitation time, patient's disposition and survival were compared. results: in total, patients were analyzed. motorized traffic accident ( %) and blunt injury ( %) were the most common mechanism-and injury types. median prehospital to in-hospital handover time was . min (iqr . ) . median duration till start of diagnostics and intervention were . (iqr . ) and . min (iqr . ) respectively. median total resuscitation time showed to be . min (iqr . background: terrorist attacks and civilian mass casualty events are frequent, and some countries have implemented tourniquets for uncontrollable extremity bleeding in civilian settings. we summarized current knowledge on the use of pre-hospital tourniquets in civilian settings to assess whether their use increases the survival rate in civilian patients with life-threatening hemorrhages from the extremities. methods: using the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines, we searched medline (ovid), embase (ovid), cochrane library, and epistemonikos in january . all types of studies that examined the topic in a pre-hospital setting published after january , , were included. the protocol was registered in prospero (crd ). results: among screened records, studies were identified as relevant. due to a lack of relevant civilian studies, military studies were also included. the studies were highly heterogeneous, with low quality of evidence. most studies reported increased survival in the tourniquet group, but few had relevant comparators, and the survival benefit was difficult to estimate. most studies reported a reduced need for blood transfusion, with few and mainly transient adverse effects from tourniquet use. conclusion: the data suggest that the use of commercial tourniquets in a civilian setting to control life-threatening extremity hemorrhage is probably associated with improved survival, reduced need for blood transfusion, and few and transient adverse effects. the effect of venous infusion by emergency medical service personnel on the prognosis of severe traffic accident patients: a nation-wide study in japan y. katayama , t. kitamura , , t. hirose , y. nakagawa , t. shimazu osaka university graduate school of medicine, department of traumatology and acute critical medicine, suita, japan, osaka university graduate school of medicine, environmental and population science, suita, japan introduction: in japan, the law of paramedic was revised in , and it became possible for paramedic in japan to secure an infusion route before cardiac arrest for severe patients. however, the effect of this treatment on the prognosis of severe trauma patients has not been assessed. we assessed this effect on the prognosis of severe traffic accident patients with using population-based ambulance record and nation-wide hospital-based trauma registry in japan. material and methods: this study was a retrospective observational study and the study periods was years between january to december . we linked the nation-wide hospital based trauma registry (jtdb) and the population-based ambulance record in japan in case. in this study, we included the traffic accident patients with iss score more than and excluded cardiopulmonary arrest patients on the arrival of ems on the scene and missing data cases. the main outcome was cardiopulmonary arrest on hospital arrival. mcnemar's test and conditional logistic regression analysis were used to assess the association between the securing a infusion route by ems personnel and the primary outcome after one-to-one propensity score matching for securing a infusion route or not. results: traffic accident patients were eligible for analysis and patients were dripped by ems personnel. after one-to-one propensity score matching, the proportion of cardiopulmonary arrest on hospital arrival were . % ( / ) in patients dripped by ems personnel and . % ( / ) in patients not dripped by ems personnel, respectively (p = . ). the adjusted odds ratio for securing a infusion route was . [ % confidence interval; . - . , p = . ]. conclusions: in this study, there was no association between the securing a infusion route and outcome of traffic accident patients. the association between trauma patient characteristics and adverse laboratory values: which patient characteristics are most predictive? introduction: in more than countries worldwide, laboratory testing is protocol driven since when it was included in the practice guideline of the advanced trauma life support course (atls). however, it is not clear yet which patient characteristics are associated with unfortunate laboratory values. the aim was to create an overview of the characteristics that were associated with adverse laboratory values. material and methods: this cohort study was performed at amsterdam umc, location amc (level trauma center), including patients during a period of years. data concerning age, gender, asa scores, injury severity scores (iss), glasgow coma scores (gcs), mechanism of injury, type of injury (blunt or penetrating) and the presence of helicopter emergency medical services (hems) were obtained. the hematology panel included hemoglobin, hematocrit, mcv, leucocyte and thrombocyte values. the coagulation panel included inr, pt, aptt, fibrinogen and d-dimer values. other panels include arterial blood gas, kidney and liver panels. the association between trauma patient characteristics and laboratory values were determined by using binary and multinomial logistic regression. results: a total of patients were included, consisting of predominantly men ( %) with a mean age of years old. an increase in age and iss was correlated with abnormal laboratory values (p = . ). additionally, male gender, iss [ , blunt trauma and the absence of hems was associated with a deviation in laboratory values (p \ . ). other patient characteristics did not show a significant correlation with adverse laboratory values. case history: a -year-old man presented with a classic case of pituitary apoplexy with a history of headache, nausea and vomiting. clinical findings: he was found to have a sellar and suprasellar mass with internal cystic and hemorrhagic component consistent with a pituitary macroadenoma. investigation/results: he underwent transsphenoidal sugery for a pituitary macroadenoma. because the tumor was invaded to left cavernous sinus, we left small portion of the tumor. eighth day after surgery, he underwent gamma-knife surgery (gks) for residual tumor. after two weeks, he complained of left ptosis. we considered the rd nerve palsy to be a post-radiation reaction at first. after months, the symptoms had been continuous and mri showed increased size of cystic lesion involving left cavernous sinus. diagnosis: ct angiogram demonstrated a saccular aneurysm at left distal ica. endovascular coil embolization was performed. therapy and progressions: after months of the intervention, the rd nerve palsy was partly improving. comments: our case report emphasizes the necessity of cerebrovascular imaging before surgery for pa. mr angiography/ct angiography is not currently obligatory in patients with pituitary adenoma, but in cases with the symptoms of displacement of the neuro-vascular structures it can be of great value. even in patients without such presentations, it may be helpful to evaluate the vascular involvement. case history: a -year-old boy during the preparation for a fishing session was pierced to the left orbitary region by a high-speed spearfishing steel. clinical findings: upon arrival the patient was conscious and responsive with a gcs of , he followed commands appropriately and there were no motor of sensory deficits. investigation/results: plain skull radiographs showed the spear crossing the skull from the left orbit to the posterior part of the parietal bone. diagnosis: the patient was immediately intubated to prevent involuntary movement of the foreign body. ct scan showed the fracture of the left orbitary roof where a centimetres long metallic object crosses the cerebral parenchyma of the left hemisphere and perforates the left parietal skull. therapy and progressions: under direct visualization via transorbital approach the foreign body was removed together with bone fragments, hemostasis was done and orbitary roof repaired. serial cranial ct scan showed progressive reduction of frontal and parietal hematoma. the movement of the eye improved after a few days, normalizing with the regression of periorbital edema. upon discharge at th postoperative day the patient had a gcs score of , no motor deficit and minimal visual loss. comments: penetrating injury of the skull and brain are relatively uncommon events, representing about , % of all head injuries. orbital roof is relatively thinner part of the skull that can provide easy access to projectile objects, which can penetrate into cranial cavity and damaging the brain parenchyma. the principles of treatment are removal of bone fragments and foreign body, control of persistent bleeding and intracranial hypertension, prevention of infection though debridement of all contaminated and necrotic tissue and at the same time preservation of as much nervous tissue as possible. multitraumapatients whith severe head injury (ais ‡ ) are more quickly carried out ct scan on than a patient without severe head injury v. giil-jensen , k. andersen , t. k. helle haukeland univercity hospital, sugical department, bergen, norway, haukeland univercity hospital, ambulance service, bergen, norway introduction: trauma patients who are prone to severe head injuries during trauma may profit from obtaining a rapid clarification of the injury magnitude when using ct examination. in the case of a delayed ct examination, the consequence of the head injury could be more extensive. in this study, we wanted to see if those with severe head injury (ais c ) received a faster ct survey than those who had no severe head injury. material and methods: retrospective registry study of severely injured patients (iss [ ) which had been hospitalized as a trauma patient at haukeland university hospital in the period - . in the study, we have excluded all patients entered as multitrauma but who have iss \ and all patients who have not defined ct time. it turns out that over half of the patients lacked the registration of accurate time for the ct survey in the national trauma register. the number is still considered large enough to find a result. results: patients were received as multitraumatic at haukeland university hospital during the period. of these, was severely injured. of these, patients had severe head injuries and they again had head injuries as the only serious injury (ais c ). median time from arrival receipt to start ct, for this group was min. in the control group that was severely injured but without severe head injury is the same time min. there was patients in the control group. conclusions: for the patients in this study who had severe injuries (n: ), the median time from the arrival in the emergency department to the ct starts was min shorter for severe head injuries than for the group without severe head injuries. introduction: the patients with severe traumatic brain injury (stbi) who needs surgical intervention often experience acute traumatic coagulopathy (atc). earlier transfusion with high blood product ratios (plasma, platelets, and red blood cells via : : ratio) is recommended for severely injured patients. however, recommended blood product ratio for stbi is still controversial. material and methods: we retrospectively reviewed successive adult stbi who underwent surgical treatment in our hospital between january and december . we have transfused plasma aggressively to maintain blood fibrinogen above - mg/dl. we evaluated the total amount of transfusion and mortality. we exclude cases administered fibrinogen concentrate. results: patients were enrolled. the amount of transfusion for h is rbc . units, ffp . units, pc . units . stbi with severe other trauma needs higher ratio of plasma. discussion: tissue injury of stbi causes severe coagulopathy and : : transfusion was thought to be insufficient for stbi in order to maintain fibrinogen. we agressively transfused plasma but we achieved fibrinogen value above only in % of stbi with severe other trauma. agressive plasma transfusion had limitation for hyperfibrinolysis so we expect other product, for example fibrinogen concentrate. introduction: traumatic brain injury (tbi) remains a leading cause of hospital admission and mortality amongst trauma patients. intracranial hemorrhage (ich) can occur with tbi and presents a severe complication. low complication tolerance in developed countries and uncertainty on actual risk cause excessive diagnostics and hospitalization, considered unnecessary and expensive. methods: tbi cases indicated for cranial computer tomography (ct) according to international guidelines, at our level i trauma center between - were retrospectively included. multivariate logistic regression was performed for ich, progression and mortality predictors. results: tbi patients (m: . ; age at trauma: . ± . ), were included. ct was performed in . %, skull fracture diagnosed in . %, ich in . %, ich progression in . %. in patients \ a, chronic alcohol consumption (p = . ) and neurocranial fracture (p \ . ) were significant ich risk factors in a multivariate analysis. in patients between - a, chronic alcohol consumption (p \ . ) and skull fracture (p \ . ) revealed as significant ich predictors. in patients [ a, age (p = . ), anticoagulation (p = . ) and neurocranial fracture (p \ . ) were significant risk factors for ich, age (p = . ) was an independent risk factor for mortality. late onset ich only occurred in cases with at least of factors: age [ , anticoagulation, neurocranial fracture. overall hospitalization might have been reduced by . % via low risk cases. conclusions: triggered by decreasing error tolerance, international guidelines for mild tbi focus on safety maximization. repeated ct in initially ich negative cases should only be considered in high risk patients. non-ich cases aged \ years do not gain safety from observation or hospitalization. recommendations from our data might, without impact on patient safety, reduce costs by unnecessary hospitalization and diagnostics. references: to be added by the authors. evaluation of low-value clinical practices in acute trauma care: a multi-center retrospective study l. moore , k. soltana , j. clément , a. turgeon , î mercier , r. krouchev , p. a. tardif , s. bouderba , a. belcaid université laval, social and preventive medicine, québec, canada, chu de québec-université-laval, québec, canada, université-laval, québec, canada, introduction: low-value clinical practices have been identified as one of the most important areas of excess healthcare spending and are associated with adverse health outcomes. the objectives of this study were to estimate the frequency low-value practices in injury care and assess inter-hospital variations. material and methods: we identified low-value clinical practices from internationally recognized clinical guidelines. we conducted a population-based retrospective cohort study using data from an inclusive canadian trauma system ( - ) to calculate frequencies and assessed inter-hospital variations with intra-class correlation coefficients (icc). results: we identified low-value practices of which could be measured and validated using trauma registry data. the three lowvalue clinical practices with the highest absolute and relative frequencies were pelvic x-rays in hemodynamically stable patients with a negative physical exam for pelvic injury ( . %), head ct in adults with minor head injury who were negative on a validated clinical decision rule ( . %) and chest x-ray in hemodynamically stable patients with a normal physical exam ( . %). we observed high inter-hospital variation for surgical management of penetrating zone ii neck injury without hard signs (icc = %), and moderate variation for head ct in adults with minor head injury who were negative on a validated clinical decision rule (icc = . %). conclusions: we have developed and validated algorithms to evaluate nine potentially low-value clinical practices using trauma registry data. highest frequencies were observed for imaging in the emergency department and the highest inter-hospital variation was observed for inappropriate surgical management. these data can be used to advance the agenda on low-value care for injury admissions. dysfunction of functional connectivity between default mode network and cerebellar structures in patients with mtbi in acute stage. rsfmri and dti study introduction: mild traumatic brain injury (mtbi) occupies one of the first places in children injuries. among all brain networks at the resting state, the default mode network (dmn) is the most widely studied network. the aim of this study is to examine functional connectivity in normal-appearing cortex in acute period of mtbi using rsfmri. material and methods: mr negative participants were studied in age from to years (mean age- . years). group of patients consisted of children with mild traumatic brain injury in acute stage. age-matched healthy volunteers comprised control group. all studies were performed at phillips achieva . t mri scanner using -channel head coil. fmri data were processed using functional connectivity toolbox conn. seed-based analysis was performed in order to reveal disturbances in functional connectivity. statistical processing was performed using statistica . results: dti analysis didn't show any changes in values of apparent diffusion coefficient (adc) and fractional anisotropy (fa) between two groups (see fig. ). no statistically significant differences in correlation strength between dmn parts were observed in two groups (see fig. ). intergroup seed-based analysis revealed statistically significant (p \ , ) difference in neural correlations between dmn parts and vermis (cerebellum structural part): positive link in control group and negative link in group of patients. conclusions: one of the most common symptoms of mtbi is dizziness as a result of impaired movements coordination. vermis as an essential cerebellum part plays an important role in the vestibuloocular system which is involved in the learning of basic motor skills in the brain. vermis aids in the synchronization of eye and motor functions in order for the visual field and the motor skills to function together.our results show that mtbi appears to be a possible reason of connectivity malfunction in normal-appearing vermis. references: predictors of developing post-traumatic endophthalmitis introduction: h magnetic resonance spectroscopy ( h mrs) allows to study structural and metabolic brain disorders in various pathological conditions in vivo. non-invasive method determines its advantage for use in children in serious condition with acute cerebral injuries. this determined the purpose of the study: to identify criteria of irreversible brain damage based on the h mr spectra analysis in comatose children with acute traumatic brain injury (tbi) or anoxia. material and methods: patients ( months- years) were examined in the acute period of severe cerebral injury (gcs score - ): six were in acute and subacute period of severe tbi, one patient was examined on the seventh day after drowning, and one-a day after acute cerebral blood flow (hemorrhage). all patients died in - days after the study. control group included healthy children aged from to years. single voxel h mrs and d h mrs was performed on t scanner. h spectroscopic voxel (te/tr = / ms, voi = cm , nsa = ) was oriented on mri intact areas: cortex of frontal, parietal and occipital lobes (fig. ) , thalamic nuclei (fig. ) , cerebellum, brainstem (fig. ) . for d h mrs a spin-echo point-resolved spectroscopy (press) sequence was used (te/tr = / ms) with the spectroscopic voi of cm on frontal lobes. results: in all spectra lactate (lac) signal, dominating all other signals, was detected. n-acetylaspartate (naa) was reduced by % and creatine/phosphocreatine (cr)-by %. conclusions: h mrs is a non-invasive prognostic method in patients with acute cerebral brain damage in coma. the cause of patients' death is the shift of cerebral glucose metabolism to an anaerobic type, as evidenced by the accumulation of lac. disturbance of energy metabolism causes a decrease of cr and a decrease in the neuronal marker naa. the combination of these patterns in acute cerebral injury, regardless of etiology indicates irreversible brain tissue damage. introduction: scalds and contact burns are the most common burn injuries both in children and adults. data are conflicting regarding which type of burns are more severe. we compared scalds, contact, and flame/fire burns at our burn center to determine which type were more likely to result in full thickness injuries and prolonged length of stay (los). material and methods: we conducted a structured retrospective medical record review of all patient admissions to a regional burn unit over a -year period between and . data included demographic, clinical, and specific burn characteristics. the association between patient predictor variables and outcomes (full thickness burns, los) was explored using chi-square and stepwise logistic regression. results: there were , patients with either scald (n = , %), fire/flame (n = , %) or contact burns (n = , %). burn depth was not available for cases ( %). mean (sd) age was ( ), % were male. mean (sd) total body surface area (tbsa) was ( )%. % of burns contained areas of full thickness injury. patients with scalds were younger than those with contact or fire burns ( ± vs. ± vs. ± years respectively, p \ . ). the percentage of burns that were full thickness by etiology were contacts ( %), fire/flame ( %) and scalds ( %); p \ . . after adjusting for age, location, and tbsa, scalds were less likely to result in full thickness injuries than contact burns (odds ratio . , %%ci, . - . ). adjusting for multiple testing, univariate analysis (as well as the multivariate analysis) showed no difference in % rd degree burns between fire and contact burns, but scalds were significantly lower than each of those. los for scalds ( ± ) and contact burns ( ± ) was significantly shorter than for fire/flame ( ± days, p \ . ). conclusions: while less common, contact and flame burns were more likely to result in full thickness injuries than scalds. references: epidemiology, treatment, costs, and long-term outcomes of patients with fireworks-related injuries (rocket); a multicenter prospective observational case series introduction: the aim of this study is to provide detailed information about the patient and injury characteristics, medical and societal costs, and clinical and functional outcome in patients with injuries resulting from fireworks. material and methods: a multicenter, prospective, observational case series performed in the southwest netherlands trauma region, which reflects % of the netherlands and includes a level i trauma center, a burn center, and an eye hospital. all patients with any injury from consumer fireworks, treated at a dutch hospital between december , and january , , were eligible for inclusion. exclusion criteria were unknown contact information or insufficient understanding of dutch or english language. the primary outcome measure was injury characteristics. secondary outcome measures included treatment, direct medical and indirect societal costs, and clinical and functional outcome until one year after trauma. results: out of patients agreed to participate in this study. the majority was male (n = ; %), % were children \ years, and % were bystanders. injuries were located to the upper extremity or eyes and were mostly burns (n = ; %) of partial thickness (n = ; %). fifteen ( %) patients were admitted and ( %) patients needed surgery. the mean total costs per patient were € , ( % ci € , to € , ). patient-reported quality of life and functional outcome was not significantly different during follow-up compared with pre-trauma. conclusion: the most common injuries afflicted by consumer fireworks were burns, mostly located to the upper extremity, and eye injuries. fireworks can result in severe injuries, for which ( %) patients needed hospital admission and ( %) patients needed surgical treatment. although some injuries resulted in permanent disability, year after trauma it in general did not have major or longlasting impact on patients'' self-reported quality of life or functional abilities. persistent inflammation, immunosuppression and catabolism syndrome after polytrauma: a rare syndrome with major consequences. l. hesselink , r. spijkerman , r. hoepelman , l. koenderman , l. leenen , f. hietbrink umc utrecht, trauma surgery, utrecht, netherlands, wilhelmina children's hospital, center for translational immunology, utrecht, netherlands introduction: more severely injured patients survive the critical first phase after trauma nowadays. a substantial portion of these patients require long-term critical care support and suffer from recurrent infections. this clinical condition fits in a syndrome referred to as ''persistent inflammation, immunosuppression and catabolism syndrome'' (pics). the aim of this study was to investigate the incidence of pics and clinical outcomes of trauma patients with pics in a level one trauma center. material and methods: all trauma patients c years admitted to the intensive care unit (icu) for c days between and , were included. patients with isolated neurological injuries were excluded. pics patients were identified by icu stay c days, c infectious complications and increased catabolism. infectious complications included infections during hospitalization and readmissions due to an infection. increased catabolism was defined as weight loss [ %, a body mass index. results: of the , polytrauma patients, patients had an icu stay c days. after exclusion of patients with isolated neurological injuries, patients were included. of these patients, developed pics. pics patients sustained infectious complications on average (compared to in the non-pics group, p \ . ) and . % of the pics patients developed sepsis. also, pics patients had a longer hospital stay (mean of days versus days, p \ . ) and sustained more surgical procedures (mean of versus per patient, p \ . ). infectious readmissions occurred until years after the initial trauma. conclusions: patients who develop pics experience long-term inflammatory complications that lead to frequent readmissions and surgical procedures. therefore, despite its low incidence, this clinical condition forms a burden on patients and a substantial financial burden on society. hyperbilirubinemia as a risk factor of the trauma icu patient introduction: hyperbilirubinemia is common in the intensive care unit (icu). hyperbilirubinemia has been considered as a risk factor of the icu patient. hyperbilirubinemia can have various causes. the hyperbilirubinemia has never been studied for the trauma icu patient. the aim of this study is to elucidate the incidence and effects of the hyperbilirubinemia for the trauma icu patient. material and methods: retrospective review of the trauma icu patients from . . to . . . initial bilirubin serum level, h bilirubin level, day bilirubin level, highest bilirubin level, overall morbidity and mortality and other clinical variables were identified and evaluated. the patients who have highest bilirubin level c . mg/dl were defined as hyperbilirubinemia group. results: a total patients were enrolled in this study. hyperbilirubinemia above serum bilirubin c . mg/dl were appeared in patients. the mortality of the hyperbilirubinemia group was higher than the other group ( . % vs . %, p = . ). the icu stay of the hyperbilirubinemia group was longer than the other group ( . day vs . day, p = . ). the hyperbilirubinemia group had more incidences of pneumonia, acute kidney injury, and sepsis than the other group ( . % vs %, p = . / . % vs . %, p = . / % vs %, p \ . ). conclusions: the hyperbilirubinemia is a risk factor of the trauma icu. if the hyperbilirubinemia is appeared, the cause of the hyperbilirubinemia should be evaluated and make an effort to correct hyperbilirubinemia for the each cause of the hyperbilirubinemia. case history: we present the clinical case of a male patient of years old. injury mechanism: a firework burst on his right forearm. clinical findings: injury: a large area of carbonization of the muscles of the flexor compartment. signs and symptoms: intense pain in the hand and forearm with local oedema and tension. diagnosis: deep burn of the forearm. therapy and progressions: surgical debridement and fasciotomy of this compartment; followed by deferred and progressive primary closure by means of rubber bands that were tightened as the oedema diminuished-shoelace technique. evolution: discharged from hospital on the th pos op day; follow-up at rd and th month without functional impairment, with a good healing evolution. comments: deep burns that reach the subfascial planes of the limbs, increase the pressure in the muscular compartments, and may progress to a compartment syndrome. there is no specific cutoff value of pressure for this diagnosis; consequently, the final decision to proceed with a fasciotomy relies on the clinical experience. surgical debridement and fasciotomy may result in large wounds, sometimes difficult to close. grafts and flaps result in another wounds and carry a risk of pain, infection, scar shrinking and necrosis. the diagnosis of a limb compartment syndrome is almost always a clinical one and requires a high index of suspicion so as to the fasciotomy is done in time. the shoelace technique is a simple, reproducible and cost-effective method of deferred closure of a large wound, preserving functionality and resulting in a good final cosmesis. references: johnson ls et al, management of extremity fasciotomy sites prospective randomized evaluation of two techniques, am j surg. . the use of propranolol in the management of acute thermal burn injury: evaluation of the effect of fixed dosages in african patients c. jac-okereke , i. onah , esut teaching hospital, surgery, enugu, nigeria, national orthopaedic hospital, enugu, nigeria introduction: propranolol has been shown to improve outcomes in burn patients. its effects are achieved at doses that reduce the heart rate by - %. africans have a different propranolol pharmacogenetic profile as compared to other races. there is paucity of literary works on the use of propranolol in africans with burns. in our study, we explored the effectiveness of fixed dosages of propranolol in nigerian patients. material and methods: this was a prospective comparative study of adult burn patients; two test groups received propranolol mg/day and mg/day respectively. the average daily pulse rate prior to and after the administration of propranolol were compared. results: patients in the control group had no effective reduction in their pulse rate. patients who received propranolol at a dose of mg/day had a reduction c %. no adverse events were observed. conclusion: it is important to establish the effective dosage of propranolol in burn patients of african-descent and explore its potential benefits in their treatment. although we cannot draw strong case history: the authors present in their paper three cases of blunt abdominal injury caused by seat belt in car accident. in the first two cases there was no diagnostic problem thanks to clear clinical finding. in the third case there was no clinical correlation and even repeated auxiliary examinations did not indicate the need for surgical intervention of the abdominal cavity. clinical findings: case no. -male y. old, haemodynamic stability, thoracic an abdominal pain, fast positivity, on ct free fluid in abdominal cavity, small spleen laceration, positivity of peritoneal symptomatology. case no. -male y. old, haemodynamic stability, bilateral hypogastric pain without peritoneal symptomatology, fast with small perihepatic fluid, on ct fluido-pneumoperitoneum. case no. -female y. old, haemodynamic stability, thoracic pain, massive oedema on the right side of the neck and supraclavicular area, without abdominal symptomatology. fast with small subhepatal fluid collection- mm, ct scan with large neck haematoma and fracture of st rib, apical pneumothorax- mm. intraabdominal only subhepatal fluid stripe- mm, suspected of small hepatic laceration. after days the clinical status rapidly changed, during h peritoneal symptomatology occured. on control ct scan fluido-pneumoperitoneum was detected. investigation/results: all patients underwent surgical procedure diagnosis: bowel mesenteric injury therapy and progressions: the first patient underwent ileo-caecal and hartmann resection, by the second patient was small intestine and col. sigmoideum resection needed, and the last one underwent ileal resection and npwt. comments: despite the current diagnostic methods blunt abdominal injuries, unlike the penetrating ones, can present a certain diagnostic problem especially when they are accompanied by other serious conditions such as manifest chest injuries. introduction: patients with hypertension and peritonitis must undergo a laparotomy. in isolated parenchymal lesions of the liver, the spleen or kidneys interventional or conservative approaches are more frequently used. to miss a hollow viscus organ lesion, that would need an operative procedure, is a constant fear. it is the aim of this study to identify significant predictors of the simultaneous presence of a hollow viscus lesion in patients with parenchymal organ lesions. material and methods: data of over ' inpatients of a levelone-trauma centre between and were analysed. only hemodynamically stable patients with a splenic-, liver-, or kidney injury (independent of grade) after blunt abdominal trauma were included. significant predictors were detected in bi-and multivariant analysis. results: of the patients with an average age of ± years % (n = ) had a splenic-, % (n = ) a liver-and % (n = ) a kidney rupture. the total iss was ± points. in patients ( %) a hollow viscus injury could be found (stomach n = , small bowl n = , colon n = , rectum n = ). injuries of the thorax ( %), the extremities ( %), the head ( %), the vertebra column ( %) and the pelvis ( %) were diagnosed as concomitant injuries. due to multivariant analysis neither age, gender, heart frequency at admission, gcs, base excess, the coagulation parameters, the hemoglobin value nor the separate injury regions could be identified to be predictive factors for the presence of a hollow viscus lesion. conclusions: clinical parameters taken at admission are not useful to predict hollow viscus injuries. the ct-scan is currently seen to be the best possible imaging modality, but it can be false negative, especially within the first min after trauma. repetitive clinical examination is necessary. in doubt a diagnostic laparoscopy or even laparotomy has to be performed. introduction: a heavy abdominal trauma is associated with a high morbidity and mortality. it is the aim of this study to show injury patterns in the abdomen and concomitant injuries in polytraumatized patients as well as to identify risk factors of the decease. material and methods: data of over ' inpatients of a level-one trauma centre between and were retrospectively analysed. only patients with a relevant abdominal trauma (ais abdomen c ) were included. the ais score was determined either with a contrast enhanced computed tomography or intraoperatively. significant risk factors were detected in bi-and multivariate analysis. results: patients with an averaga age of ± years were included. % (n = ) had an ais abdomen of , % (n = ) of and % (n = ) of . the overall iss was ± points. the mechanism of injury was mainly blunt ( %). a splenic rupture was present in % (n = ), a liver rupture in % (n = ) and a kidney rupture in % (n = ). hollow viscus injuries were present in % (small bowl n = , colon n = , stomach n = , rectum n = , bladder n = ). concomitant injuries were determined in % of the patients. of these % were diagnosed a thoracic injury, % injuries at the extremities, % head injuries. % spinal injuries and % pelvic injuries. the mortality was % (n = ). a liver rupture (p = . , or . ), pelvic injuries (p = . , or . ), age (p = . , or . ), hypotension (systolic blood pressure \ mmhg) (p = . , or . ) and a low gcs at admission (p \ . , or . ) were determined to be significant risk factors. conclusions: in our trauma department life threatening abdominal traumata are treated about every days. lethal abdominal injuries were mostly associated with serious liver ruptures or pelvic injuries. due to our experience we recommend the use of an early ct-scan as thereby the injury severity can be fast and precisely assessed. case history: a yo female was tranferred to our icu on day of a severe acute necrotizing alchoolic pancreatitis with mof. crrt with cytosorb was immediately started. on day after onset (dao ) an acs with a new organ failure (lung) showed up. open abdomen (oa) and tac with mesh-mediated/npwt got a temporary improvement. clinical findings: on dao (oa ), reopening of the mesh entailed a sudden fascial retraction of cm. a new larger mesh was positioned. on dao (oa ) the fascial defect measured both on ct slices and in or was cm. provision of a longterm oa was done. therapy and progressions: a new fascial traction device (fas-ciotensÒ, germany) was positioned on dao (oa ), with a continuous traction weight of - kg. revision was scheduled any - days, according to clinical needs, including combined anterior and retroperitoneal necrosectomy. progressive traction allowed to get a cm fascial gap under traction on dao (oa ). anterior cst was thus performed and fascia primarily closed. completion of necrosectomy was done through the bilateral lumbar incisions and npwt. comments: early fascial closure is a goal in oa. mesh-mediated traction/npwt is the most effective strategy, but primary fascial closure is sometimes impossible. the duration of oa is a key point. fasciotensÒ allowed to overcome the failure of mesh-mediated option and avoided fascia retraction in a longterm oa. it was quickly managed by the nurse staff, allowed a easier access to the abdomen and a proper positioning of the protective film. its effectiveness in this demanding case makes it an interesting option for shortening fascial closure in septic oa too. background: small bowel obstruction (sbo) caused by intra-abdominal adhesions is one of the main surgical emergencies. in most of the time, adhesions are created by previous abdominal surgeries. without any severity signs, the medical treatment is first proposed to avoid superfluous surgery. we noticed that the failure of medical treatment is frequently seen in patients previously operated of appendicectomy. the purpose of this study is to determine the eventual relation between a previous appendicectomy and failure of medical treatment in sbo. methods: we conducted a retrospective data collection using a diagnostic code for bowel obstruction in patients who have consulted in emergency from . . to . . at the salengro university hospital in lille. using the administrative database, patients were identified. we excluded all children, patients with wrong diagnosis and those whose outcome was not known. finally, patients with sbo on intra-abdominal adhesions confirmed on ct-scan were reviewed. the patients were separated in two groups. the group (g ) included patients who required surgical management during hospitalization ( patients) and group (g ) patients with successful medical treatment ( patients). we compared the rate of previous appendectomy in these two groups using a pearson's chi-squared test. in a second step, we tried to find out if there were others factor associated with failure of medical management. results: there was significant difference between the two groups with a higher rate of appendectomy in the surgical management group g (p = . ). this difference was even more pronounced if appendectomy was the only surgical history. in the subgroup analysis of patients with previous appendicectomy, the laparoscopic approach or laparotomy didn't influence the outcome of the management of the sbo. conclusion: this study shows the difference between the two groups of sbo, with more surgery sanction in the group of patients previously operated of appendicectomy. perhaps because this surgery involves the very distal part of the small bowel and decrease the efficiency of a proximal nasogastric aspiration. these results should not change the initial management of sbo by medical treatment in absence of severity signs. however, knowing this data, we have to consider that a history of appendicectomy is a risk factor of failure of medical treatment in this situation. introduction: diaphragmatic injuries are a rare consequence of closed thoraco-abdominal trauma that could be difficult to detect due to paucity of clinical signs and frequent erroneous interpretation of radiological images. the overall incidence of diaphragmatic injury is , - , % in blunt trauma. if the injury is not recognized it could lead to considerable risk of late morbidity and mortality. this study reviews our years experience in the management of this patients. material and methods: a retrospective review of trauma registry of our tertiary referral centre was performed. preoperative, intraoperative and postoperative data were analysed to assess determinants of mortality, morbidity and effect of therapeutic delay by univariate analysis models. penetrating injuries were excluded from the study. results: over years patients with diaphragmatic injury due to blunt trauma were identified: had a simple laceration of the diaphragm without hernia, had acute and chronic diaphragmatic hernia. the mean patient age was years (range -- years). overall mortality was %. the site of injury was the left diaphragm in cases, the right diaphragm in cases and bilateral in case.the hernia content was stomach ( ), colon ( ), spleen ( ), liver ( ), omentum ( ) and multiorgan ( ). all acute patients were managed with primary suture repair via laparotomy except for two patients that required additional thoracotomy; chronic patients were treated laparoscopically in cases ( , %), in which a synthetic or a biosynthetic mesh was used to reinforce the suture. higher morbidity and mortality was seen in multiple associated injuries, head injuries associated, right diaprhagm injury, age [ years and treatment delay [ h. conclusions: delayed treatment of diaphragmatic injuries could be dramatic: it is importnat not to misinterpreter the radiological findings and to reassess the patient mantaining a high level of suspicion of these injuries. trauma opposing vector forces resulting in distal avulsion of internal oblique muscle: a case report p. spada , p. fransvea , g. altieri , m. di grezia , v. cozza , g. pepe , a. la greca , g. sganga fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy case history: abdominal muscle injuries after blunt trauma are rare but increasingly recognized. here we report a case of blunt trauma resulting in a complete disinsertion of the distal part of the internal oblique muscle. case report: y.o. male, was involved in a roll over motor vehicle accident. primary survey was carried out according to atlsÒ approach with good response. he had a seatbelt sign. according to the dynamic of the trauma he underwent a ct. diagnosis: a ce-mdct revealed complete disinsertion of the oblique muscles of the left abdomen from their iliac insertion, with herniation of adipose tissue and hematoma of the soft tissues without active blushing. no other traumatic injuries were identified. therapy progressions: a conservative treatment of the hematoma of the left abdominal wall was adopted. the patients was then ischarged from hospital after days. no late complications were observed. comments: the overall incidence in all traumatic admission is . - . %. a deep knowledge of vector force involved in trauma and their influence in the specific anatomical changes of the abdominal wall muscle can lead to suspicious of this rare injuries even if no other lesion are detected. in our opinion this trauma case is useful in reminding us to look for it because the radiologist or a no well experienced trauma surgeon may miss it fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy introduction: the best and correct management of patients with open abdomen (oa) is nowadays still unclear. our algorithm consists of using an intra abdominal negative pressure wound therapy device plus an early medial mesh mediated fascia traction (''step by step'' procedure). the aim of this study was to asses outcomes of this algorithm technique based on patient conditions and open abdomen technique performed. materials and methods: we performed a retrospective analysis of patients treated with open abdomen technique from / / to the / / . variables taken into account were: initial diagnosis, open abdomen technique used, number of surgical interventions, abdominal wall closure technique, length of stay in the icu, inhospital morbidity and mortality rates. we collected also data on the post-operative development of incisional hernias and entero-atmospheric fistula. results: / of open abdomen were done after trauma. in the remaining cases open abdomen was done for non-traumatic disease. patients have been treated following our algorithm (with negative pressure wound therapy abthera device and step by step approach with medial mesh mediated fascia traction). in this group fascial retraction was significant lower and definitive direct abdominal wall closure rate was statistically higher. conclusion: an early fascia traction mediated with a mesh lead to an earlier fascia closure with a lower need of mesh positioning for definitive closure; the rate of post incisional hernia is similar among the two groups references: case history: a year old male presented in the er with malaise, fatigue and loss of appetite. he was recently hospitalised due to a peritonsillar abscess and during investigations he was first-diagnosed with non-hodgkin lymphoma. his medical and surgical history were otherwise unremarkable. clinical findings: on admission the patient was febrile and tachycardic (hr bpm) but remained hemodynamically stable (bp: / mmhg). clinical examination revealed abdominal distention and rebound tenderness in the right abdomen. investigation/results: blood tests were significant for leukocytosis (wbc: . /ll-neut: %), acute kidney injury (urea: mg/dl, cr: . mg/dl), elevated crp ( mg/l) and ldh ( iu/l), hyponatremia (na: mmol/l) and hypoalbuminemia. chest and abdominal x-rays were non-diagnostic, while abdominal ultrasound showed increased air presence along the medial line. investigations concluded with an abdominal ct scan that revealed pneumoperitoneum, small bowel distention and multiple enlarged mesenteric lymph nodes. diagnosis: the patient was transferred to the or for an explorative laparotomy. he was diagnosed with ileo-cecal intussusception causing bowel ischemia and perforation at the ileocecal valve. enlarged lymph nodes were observed along the mesentery. therapy and progressions: the affected ileus and colon were removed and a subtotal colectomy with end ileostomy was performed. the pathology report confirmed infiltration of the dissected bowel and lymph nodes by lymphoma cells. the patient continued treatment in the icu. he was discharged on the th postoperative day. comments: intussusception is rare in adults and, contrary to children, is highly associated with malignancies. resection without reduction has been advocated-wherever possible-in order to ensure better oncological outcomes. introduction: emergency surgeries are oftenly related to contaminated/infected fields, where the implantation of non reabsorbable meshes for reconstruction of the abdominal wall may not be recomendable. we aim to evaluate the results of polyvinylidenfluoride (pvdf) meshes used for complicated ventral hernia in the acute setting material and methods: retrospective analysis of patients with vh undergoing emergency surgery on which a pvdf mesh was required, in a third level hospital (november -september ). we analyzed early and late postoperative complications and -year recurrence rates. association between grade of contamination, mesh placement and infectious complications and recurrences was investigated using binary and multiple regression. results: we collected patients with a mean age of '' years, mean bmi of '' kg/m and mean cedar index of '' . '' % of patients had a grade - ventral hernia according to rosen''s index. concomitant procedures included al least one organ resection in '' % of surgeries and previous contamined mesh explantation in '' %. a pvdf mesh was placed using an intraperitoneal onlay mesh (ipom) technique in '' % of cases and an interposition location in '' %. readmission rate was '' %, one-month recurrence '' % and recurrence after a year '' %. overall mortality rate was . %. risk of recurrence was related with patients with a rosen score over (p \ . ) and also with postoperative ssi (p = . ). higher recurrence rates were not found regarding the pdvf meshes placement. postoperative seroma and hematoma rates were '' % and '' %. enteroatmospheric fistula rate was '' %. conclusions: pvdf prosthesis seems to be an useful material for complicated ventral hernia repair, specially in the acute setting, showing similar recurrence and infectious complication (fistula, chronic mesh infection, surgical site infection) rates with regard to different prosthesis used in the literature. operative vs non-operative management in liver trauma patients in a uk major trauma centre conclusions: the airs can predict the histologic severity and the intra operative findings in patients with a high clinical suspicion of aa. airs could be useful to reduce negative appendectomy and predict the postoperative stay to evaluate the deformity progression in spine injuries (dorsal, dorsolumbar, lumbar) managed by internal fixation. introduction: there continues to be controversy surrounding the management of thoracolumbar burst fractures. numerous methods of fixation have been described for this injury, but to our knowledge, spinal fusion has always been part of the stabilising procedure, whether this involves an anterior or a posterior approach. material and methods: patients with spinal injury (dorsal, dorsolumbar, lumbar) were included. all patients had dorsal, dorsolumbar, lumbar spine injuries managed with posterior short segment pedicle screw fixation and were followed up for at least one year after surgery. preoperative, post operative and follow up lateral radiographs were examined for cobb''s angle, anterior wedge compression angle and upper and lower adjacent intervertebral disc heights anteriorly, middle and posteriorly. results: at final follow up, the mean improvement in cobb''s angle post operatively was . °. the mean loss of correction of cobb''s angle was . °with sd of . °compared to post operative. the mean improvement in anterior wedge compression angle was . °post operatively. the mean loss of reduction in anterior wedge compression angle was . °with sd of . °. the increase in cobb''s angle was statically significant (r = . , p = . ) with the loss of reduction of anterior wedge compression angle at follow up and loss in intervetebral disc height at upper intervetebral disc anteriorly only(r = . , p = . ). the mean period at which sitting and standing was initiated was . months and . months respectively and mean periods for which brace was used was . months. conclusions: pedicle screw fixation is good but related to loss in reduction of anterior wedge compression angle and decrease in upper intervertebral disc height anteriorly. references: p. l. sanderson:short segment fixation of thoracolumbar burst fractures without fusion. introduction: with the newly implemented ao upper cervical spine classification system a modern, pragmatic system has been established. to what extent the simplification is helpful or whether an adjustment of the new ao classification may be discussed, forms the question of this work. material and methods: retrospective analysis of upper cervical spine injuries with ct/mri diagnostics presented to trauma surgeons with several years' experience to do classification and suggest treatment. results: the classification according to the known systems showed a relatively good agreement in the exact classification and therapy. the classification according to the new ao upper cervical spine was simple and consistent but revealed different treatment recommendations for two subtypes (iii type a and iii type b). conclusions: the new ao upper cervical spine classification system leads to a simplification. uncertainties remain with the most frequent fractures on the upper cervical spine, the c fractures. these will be managed under iii type a. however, just these injuries require completely different treatment concepts. further adaptation is required for type iii b because there uncertainties regarding the therapy also remain. case history: a -year-old woman, on treatment with acenocoumarol due to atrial fibrillation, and interatrial communication, suffered a compression fracture of the vertebrae l to l after a lowenergy trauma. due to poor pain control, she underwent a percutaneous transpedicular kyphoplasty, with no intraoperative complications. clinical findings: during the immediate postoperative period, she developed dysarthria and claudication of barré in her right upper limb. investigation/results: an angio-ct scan was performed, showing endovascular material in the left middle cerebral artery (mca) and within the lungs, compatible with cement emboli. mri showed cortico-subcortical ischemic areas in mca territory. cement-embolism stroke after percutaneous kyphoplasty therapy and progressions: conservative treatment was chosen due to the high number of emboli and the favorable evolution of the patient, with resolution of the neurologic symptoms in h without sequelae. days later, she suffered a transient ischemic attack, with no changes in the ct-scan compared to the previous images, which also solved with no residual deficits. one month after this episode, the patient died due to a spontaneous cerebellar hemorrhage related to acenocoumarol overdose. comments: kyphoplasty is a safe technique performed to treat vertebral compression fractures in elderly patients, with good clinical results and a low complication rate. its main complications are related to the leakage of cement from the vertebral body, usually well tolerated. other complications are exceptional, such as cerebral strokes, cardiac perforation, or death. the present case, although infrequent, shows us the need to assess the risk-benefit balance when operating fragile patients, as life-threatening complications may happen in these procedures. references: . marden fa, putman cm. cement-embolic stroke associated with vertebroplasty. ajnr am j neuroradiol. nov; ( ): - . survival rate and application number of total hip arthroplasty in patients with femoral neck fracture: an analysis of clinical studies and national arthroplasty registers g. hauer , a. heri , s. klim , p. puchwein , a. leithner , p. sadoghi medical university of graz, department of orthopaedics and trauma, graz, austria introduction: total hip arthroplasty (tha) is an increasingly popular treatment option for fractured neck of femur (nof) [ , ] . the aim of this study was to systematically review all literature on primary tha after fractured nof to calculate an overall revision rate. furthermore, we wanted to compare primary tha implantations after fractured nof between different countries in terms of tha number per inhabitant. material and methods: all clinical studies on tha for femoral neck fractures between and were reviewed and evaluated with a special interest on revision rate. revision rate was calculated as ''revision per component years'' [ ] . tha registers were compared between different countries with respect to the number of primary implantations per inhabitant. results: twenty-two studies showed a mean revision rate of . % after ten years. we identified eight arthroplasty registers that revealed an annual average incidence of tha for fractured nof of . per , inhabitants (table ) . conclusions: we found similar annual numbers of thas for fractured nof per inhabitant across countries. revision rates in clinical studies are higher compared to registry data [ , , ] . the results of this analysis can be used to rank present and future national tha numbers within an international context. early clinical predictors of pneumonia in patients with acute spinal cord injury without bone injury: a retrospective study t. sakamoto , s. kanezaki , n. notani oita university, oita, japan introduction: pneumonia is still significant complication that associates with mortality and duration of hospitalization in patient with acute spinal cord injury without bone injury (sciwobi). the purpose of this retrospective study is to clarify early clinical predictors of pneumonia in patients with sciwobi. material and methods: we reviewed the medical records of patients with sciwobi who admitted between january and november . spearman's rank-correlation coefficient was used to test the relationship between each parameter. multiple logistic regression analysis was performed to determine the factors that influenced pneumonic morbidity. results: a total of patients with acute sciwobi, who were evaluated for neurological impairment within h after injury, were reviewed. pneumonia occurred in patients ( %), seven patients injured at c and four at c . according to spearman's rank method, asia motor score, beginning period of nutrition, ventilator use, neurological level of injury (nli) ] c , low prognostic nutritional index (pni) were correlated with onset of pneumonia. logistic regression found ventilator use to be most predictive of pneumonia (odds ratio [or] = . , % confidence interval [ci] . - ), followed by nli ] c (or . , % ci . - . ), beginning period of nutrition (or . , % ci . - . ), pni (or . , % ci . - . ). conclusions: in addition nli, low pni increases the risk of pneumonia. we consider that improving nutritional status, especially early initiation of enteral nutrition, decrease the incidence of pneumonia. bicycle-related cervical spine fractures e. helseth , j. ramm-pettersen , s. f. eng , i. naess , m. mejlaender-evjensvold , h. linnerud oslo university hospital, neurosurgery, oslo, norway introduction: the incidence of traumatic cervical spine fractures (cs-fx) in the norwegian population is / , /year, and % of these injuries are bicycle-related ( , ) . materials and methods: prospective cohort study of all bicyclerelated cs-fx in the south-east norwegian population ( . million) in the time period - . the data were retrieved from our quality control database for traumatic cs-fx in south-east norway. in the database all cs-fx patients (c (occipital condyle) to c /th ) are prospectively registered. results: during the four-year study period patients with bicyclerelated cs-fx were registered, ( %) were males, and mean age was years (range - ). the cs-fx was located in the upper cervical segment (c -c ) in ( %) patients, lower cervical segment (c -th ) in ( %), and at both segments in ( %). the most common fx subtype was c -fx. spinal cord injury secondary to cs-fx was registered in patients ( %). fracture stabilization was achieved with open surgery in ( %), external immobilization with a stiff collar alone in ( %,) and without treatment in ( %). conclusions: severe bicycle-related cervical spine injuries are not uncommon. the increasing political desire to move commuting from motorized vehicles to bicycles warrants a heightened focus on road safety. introduction: the need for cervical immobilization is predicted by the atls, the standard of care in trauma since , because cervical trauma is a important cause of disability. however, its discontinuation was linked to x-rays, a fact that has been changed thanks to the development of two algorithms that assess the severity of cervical trauma: the canadian c-spine rule (ccr) and the national emergency x-radigraphy utilization study (nexus). material and methods: this study aims to compare the reduction values in the number of ct scans required after the application of both algorithms in a level- trauma center and to verify the degree of adherence of residents in the use of each. cohort study with randomized application by residents of the algorithms in all patients suffering from blunt trauma with cervical collars who were admitted from august to october . the conducts had their frequencies analyzed to obtain an inference about the efficacy of each method in the abstention of x-rays and case resolution, in addition to verifying if the indicated conduct was followed by the resident, inferring on the confidence in the algorithm. results: cases were evaluated during this period, of which were by the ccr algorithm and by the nexus. the indication rate for ccr imaging was . % and nexus was . %, showing no statistical difference between them (p = , ; ci = %). in the evaluation of the effective conduct, which evaluated the reliability of the algorithm, there was no disagreement between them (p [ , ; ci = %). conclusions: neither method demonstrated superiority to the other in reducing the indication of imaging exams and its uses had equal adherence by resident physicians. panacek case history: a year old lady presented with severe neck pain following a fall and cervical hyper-extension injury. she had previously undergone anterior cervical discectomy and fusion at c / with placement of artificial interbody bone graft. postoperatively, the patient reported an excellent clinical outcome and later imaging confirmed interbody fusion. clinical findings: on examination, the patient was neurologically intact but reported severe mid-cervical neck pain with reduced range of movement. investigation/results: imaging included ct and mri of the whole spine diagnosis: imaging revealed an unstable hyper-extension injury of the cervical spine. a fracture extended through the caudal end of the fused graft-vertebral interface at c / with disruption of the posterior elements. therapy and progressions: given the severity of the injury surgery was recommended. the patient underwent uneventful c -t posterior instrumentation and fusion with excellent outcome (follow up two years). comments: this is the first report of a cervical spine fracture through the site of an anterior cervical discectomy and fusion. it is hypothesised that the fused cervical segment resulted in increased stress at the fused caudal graft-vertebral interface during hyper-extension, this combined with reduced tensile strength at the graft-vertebral interface resulted in this unusual transverse fracture pattern. the clinician should be aware that patients presenting with cervical spine trauma in the context of previous cervical spine surgery are prone to greater mechanical forces. there should be a high index of suspicion for serious injury prompting thorough assessment and investigation. pr s -screw-fixation: computer aided study prevent unguided missile r. krassnig , w. pichler , e. viertler , a. schwarz , r. wildburger , g. hohenberger auva rehabilitation clinic tobelbad, tobelbad, austria, boldin und pichler og, graz, austria, medical university graz, graz, austria, auva unfallkrankenhaus, graz, austria, medical university graz, orthopaedics and trauma, graz, austria introduction: transiliosacral screw fixation of unstable dorsal pelvic ring fractures is not much present neither in literature nor in practice. in cause of the complex anatomy and the varying narrow safe bony corridors its a demanding procedure. limited information is available on optimal placement and the geometry of safe zones for screw insertion in the pelvis. material and methods: d-reconstructions of consecutive ct scans of polytraumatic injured patients ( female, male) were the basis to insert two virtual cad bolts (representing screws) into the first two sacral segments as performing during screw fixation. results: in s the narrowest point was reached after a mean of . mm respectively . mm, depending on the selected way of measurement. for s the mean distance to the tricky constriction area amounted to . mm, respectively . mm. the average height in s measured . mm and the average width . mm. according, the average height for s was . mm and the average width . mm. the measurement results didn't show a significant difference between male and female pelvis bones for any distance of interest. conclusions: an optimal screw position is very important, because in the areas of bony narrowing are the exit points of the sacral nerves, which exit through the foramina anteriorly and posteriorly. damage to this nerve structures can cause severe long-term consequences such as numbness or paralysis. knowledge of predefined distances may aid in preoperative planning, decrease operative and radiation times and may prevent unguided missiles. clinical findings: there were absent breath sounds on the right side of the thorax, ultrasound showed an extensive pleural effusion. a chest tube was inserted and l of bloody-milky fluid was drained. investigation/results: ct scan showed fractured c -c and th -th vertebral bodies, fractured lateral osteophytes of th - and probable injury of the thoracic duct at th - level. pleural effusion analysis showed raised cholesterol and triglyceride levels. diagnosis: traumatic chylothorax; fractures th -th , th -th , c -c therapy and progressions: patient was kept on ventilatory support for days. primarily she was treated with total parenteral nutrition followed by no fat and hypolipidemic diet. the chest tube was removed after days. she was discharged in stable condition the following day. at the month check-up she was stable and eupnoic. comments: traumatic chylothorax caused by blunt chest trauma is extremely rare. there are hypotheses that injuries to the thoracic duct are caused by hyperextension of the spine or by increased thoracic/ abdominal pressure (seat-belt injuries). in our case, chylothorax probably resulted from fractured lateral osteophytes. patients are usually successfully treated with pleural drainage and total parenteral nutrition. if there is no improvement after weeks or if drainage exceeds . l/day or l/day for more than days, thoracic duct ligation should be considered. conservative treatment resulting in t-l or lumbar kyphosis can worsen the quality of life of the patient whereas traditional open surgery may be an overtreatment in some cases, considering blood loss, possible complications, hospital stay and delayed functional recovery. in this setting, a good option can be a percutaneous minimally invasive surgery. the advantages of percutaneous pedicle screw fixation are: preservation of posterior musculature, less blood loss, shorter operative time, lower infection risk, less postoperative pain, shorter hospital stay and easier implant removal after bone union. limitations such as inability to achieve direct spinal canal decompression can be dealed by combination with open techniques. the objective of this study was to report the results of ppsf on these fractures and the technical problems we had to overcome. methods: patients are included, treated with percutaneous transpedicular fixation and stabilization with minimally invasive technique from december to october . patients were males, females; average age was , years (range from to ). in all cases, system pathfinder-nxt (zimmer) was used. results: most of the patients presented an early post-operative mobilization with amelioration concerning pain and a low complication rate. limitations in mobilization were mainly due to coexistent injuries, polytrauma or non-reversible neurological deficit. conclusion: ppsf is a reliable and safe procedure which does not replace the open technique but adds to treatment options by restoring a good sagittal alignment similar to those reported for open surgery. removal of hard material is advocated after fracture healing to preserve the lumbar spinal mobility and avoid zygapophyseal joint osteoarthritis. critical surgery within the first hour of presentation: is it a feasible intervention for better trauma care outcomes in low and middle income countries? introduction: in low and middle-income countries (lmic) golden hour care concept is almost nonexistence due to resource constraints. in this study, we analyzed one novel concept of critical surgery within the first hour of admission as a possible intervention which could be applied in the existing scenario in these countries without much resource requirement. material and methods: a retrospective analysis of a prospectively maintained data registry under a project named titco (towards improved trauma care outcome) was done. registry data from a level - trauma centre in india were analyzed from october to september . all patients who admitted and underwent critical surgical interventions within the first hour of presentation were analyzed. these patients were divided into two groups depending upon primary presentation or referred from another facility. statistical analysis was done between these two groups to compare the outcome. results: sixty-one ( . %) patients were directly admitted from the site of the incident whereas forty-five ( . %) were transferred from other hospitals for surgical needs. the median time from injury to presentation for primary patients was min with interquartile range (iqr) of . in the referred patient median time gap between the injury to our center (not referring center) was min with iqr of . this difference was statistically significant. major outcome indicators in the form of median icu and total stay, as well as mortality, were not significantly different conclusions: proposed concept might be a useful hospital-based intervention in existing trauma system in lmic to improve the outcome of injured patients along with improving prehospital services. oslo university hospital, ullevål, orthopedic department, oslo, norway, extrastiftelsen, oslo, norway introduction: it is well-known that physical activity is good for us. although the skeletal muscle is the main organ which is directly affected, exercise affects the whole body. the mechanisms responsible for these beneficial effects are gradually becoming known to us through extensive research. this might make it easier for physicians to prescribe exercise as a therapy equally and even more beneficial than drugs regarding effect and risk profile. the aim of this thesis was to review the current literature on the molecular mechanisms of exercise-induced health benefits. material and methods: a search in medline and embase resulted in articles. they were sorted by title and abstract, then by reading the full text. relevant articles from the reference-lists were included. sources were found outside of the search. results: when we exercise, the skeletal muscle is subjected to several mechanical and chemical stimuli, which in turn activate a set of kinases and phosphatases. these are molecules that regulate transcription-factors and co-activators, and this leads to adaption of the muscle-cells. i addition, the muscle secretes a number of proteins called myokines, which conduct the effect of exercise to other organs and tissues. some lead to increased cerebral neuroplasticity, hypertrophy and angiogenesis (bdnf, vegf and igf- ). several interleukins have also been identified as myokines, and they mediate an anti-inflammatory effect which is favorable in the prevention and management of conditions like atherosclerosis and type diabetes. lastly, we found that exercise leads to epigenetic changes, altering the genetic expression in several types of tissues. some studies suggest that the epigenome is affected by exercise even before we are born, giving babies born to physically active mothers a favorable epigenetic expression. conclusions: we should use this knowledge to support the implementation of physical activity in treatment and preventive health care. impact on undertriage and mortality after changing from a twotiered to one-tiered trauma team activation protocol costs. prognostic factors may assist in identifying high cost groups with potentially modifiable factors for targeted preventive interventions, hence reducing costs and increase rtw rates. evaluation of long-term follow-up and consequences of gunshot and stab wounds in a french civilian population introduction: the data concerning long-temr follow-up of patients and consequences of gunshot wound (gsw) and stab wound (sw) are almost inexistent in the literature. in finland, a study showed that % of patients with trunk wounds died secondarily from alcohol-related or violent problems [ ] , highlighting the secondary importance of long-term care for these patients. the main objective of our study was to analyze the hospital and posthospital follow-up of patients with gsw or sw and to evaluate late complications and the consequences of these traumas. material and methods: from january to january , patients were hospitalized for gsw or sw management in laveran military hospital. hospital data were collected via informatic patient file and post-hospital data via a telephone questionnaire with the general physician (gp). results: median hospital follow-up was days . seventy-six patients had a follow-up visit with their gp ( %). median follow-up was mois . twenty-four patients were totally lost to follow-up ( . %). global follow-up identified patients with longterm consequences ( . %), psychiatrics and organics. seventeen cases of recurrence were found ( . %). high iss, age, gsw and gp identified in patient medical file were significantly linked to long-term consequences occurrence. conclusion: this study showed a high number of long-term consequences occurrence among patients with gsw or sw. however, the extra-hospital follow-up seems insufficient. it is therefore imperative to strengthen the compliance and adherence to the care network of these patients. awareness and involvement of medical, paramedical teams and gp role seems essential to screening and management of these consequences. introduction: focused assessment with sonography for trauma(-fast) is an effective tool for assessments of severely injured patients, especially in the settings of helicopter emergency medical service(hems) because of limited devices and time. the objective of this study is to investigate accuracy of trauma ultrasound in helicopter emergency service compared with enhanced ct scan. material and methods: we investigated the trauma patients in years which was demonstrated fast and delivered to the advanced critical care center in gifu university by hems. accuracy of the fast was determined by comparison to the presence of injury, primarily determined by computed tomography, and to required interventions. results: patients were included in this criteria. there were and patients in which we found fluids in thoracic or abdominal cavity by enhanced ct scans and ultrasounds in hems, respectively. sensitivity and specificity, positive predictive value, negative predictive value, accuracy were . , . , . , . , . . if we limited the data for abdominal fluids, each data were . , . , . , . , . . in the patients of negative fast with positive ct, no patient died due to hemorrhage in thoracic or abdominal cavity. conclusions: it has been reported that sensitivity of fast in hems was lower compared with in er. in the settings of prehospital trauma care, advantages of portable ultrasound could be limited because of peculiar environments. and also, the thoracic or abdominal fluids could increase with time by organ injuries and it causes fast negative in acute phases.in this series, we could not find cases which has possibility of death because of negative fast and might influence the treatment. repeated fast or careful assessment of patients based on the other findings could be beneficial. references: the sensitivity of fast in hems was low and demonstrating fast for several times could be effective to detect the thoracic or abdominal hemorrhage. pre-hospital trauma care in switzerland and germany: do they speak the same language? los angeles county ? usc medical center, department of surgery, divison of acute care surgery and surgical critical care, los angeles, united states introduction: field amputation can be life-saving for entrapped patients requiring surgical extrication. under these austere conditions, the procedure must be performed as rapidly as possible with limited equipment, often in a confined space, while minimizing provider risk. the aim of this study was to determine the optimal saw for a field amputation. material and methods: this was a prospective cadaver-based study. four saws (gigli, hand pruning, electric oscillating and reciprocating) were tested in human cadavers. each saw was used to transect four separate long bones (humerus, ulna/radius, femur and tibia/fibula). the time required for each saw to cut through the bone, the number of attempts, slippage, quality of proximal bone cut and extent of body fluid splatter as well as the physical space required by each device during the amputation were recorded. univariate analysis (fisher's exact and kruskal-wallis or mann-whitney u-test) was used to compare the outcomes between the different saws. results: the fastest saw was the reciprocating followed by oscillating ( . [ . - . ] sec vs . [ . - . ] sec, p = . ). the number of attempts required to amputate ( . [ . - . ] , p = . ) and the amount of slippage ( . [ . - . ], p = . ) were highest with the pruning saw. the reciprocating saw had the worst proximal bone cut quality ( % poor, p = . ) and the largest blood splatter ( . [ - ] , p = . ). the physical space required to perform an amputation ranged from cm with the oscillating to cm with the reciprocating saw. overall, the oscillating saw outperformed the others in number of attempts, slippage and quality of bone cut and physical space requirements, and was the second fastest ( table ) . conclusions: the speed, precision, safety, space required, as well as the highly adjustable blade in the oscillating saw make it ideal for a field amputation. a gigli saw is an excellent backup for when electrical tools cannot be used or fail. impact of air medical transport on the survival of major trauma patients in thailand e. surakarn , w. siriwanitchaphan bangkok hospital headquarters, bangkok trauma center, bangkok, thailand introduction: air medical transport is an alternative mode of interfacility transfer for injured patients who required a higher level of trauma care in thailand. this study assessed the impact of air medical transport on the survival of major trauma patients transferred from local hospitals to a tertiary care hospital. material and methods: trauma registry of - was reviewed. major trauma patients transferred by air ambulance were identified. injury severity score (iss), predicted mortality and actual survival to hospital discharge were studied and compared between two subgroups, the seriously injured patients (iss - ) and the severely injured patients (iss [ ) . the predicted mortality was calculated from the probability of survival (ps) of trauma and injury severity score (triss). results: there were major trauma patients (iss [ ) transferred by air ambulance in five years period. patients were severely injured (median iss = ), and patients were seriously injured (median iss = ). the range of flight time was - min. the overall survival rate was . %. the predicted mortality in the severely injured group was cases ( . %), but the actual mortality was nine ( . %), . % lower than predicted mortality. the predicted mortality in the seriously injured group was one case ( . %), while the actual number was two ( . %). the eleven deaths in this study were eight cases of severe traumatic brain injury(tbi) patients, two cases of massive bleeding with subsequent multi-organ failure and one drowning. conclusions: air medical transport significantly improved the survival of severely injured patients who need higher level of trauma care. severe tbi and the presence of multi-organ failure associated with unfavorable outcomes. however, a detailed analysis of the trends and epidemiology of rtis affecting the most vulnerable children in qatar, under years of age, has not been conducted. this study's primary objective of is to describe the epidemiology of rtis and deaths in young pediatric patients in qatar. material and methods: data, for all young pediatric [under years] victims of rti''s and rti deaths from january , , through december , , from the trauma registry of the hamad trauma center [htc], the national level trauma referral center of qatar, was analyzed. this data was correlated and compared with data from the hamad general hospital mortuary and vital statistics data from the qatar ministry of development planning and statistics, the vital statistics annual bulletin, for the years - . results: the htc attended to patients, under years, with severe rtis and in-hospital rti deaths were reported during the study period. males made up . % of the injured and % of fatalities.the average age of the injured was years and for fatalities was it was . years. the rti incidence rate per , for both sexes, under years, has been unchanged ( in and in ) . the road mortality rate, per , , has decreased significantly, from . in to . in . since , the proportion of pre-hospital deaths has been increasing, - %, and the in-hospital death rates has been reduced to %. conclusions: rapid improvements in pre and in-hospital post-crash care in qatar have resulted in marked reductions in in-hospital deaths for young children with rtis. the emergence of pre-hospital road deaths of under ''s must be made a priority for road safety in qatar. the implementation of proven prevention programsshould be fast tracked in order to directly address this issue. introduction: despite improving survival of patients in prehospital traumatic cardiac arrest (tca), initiation and/or discontinuation of resuscitation of tca patients remains a subject of debate among prehospital emergency medical service providers. the aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with tca. methods: twenty-five semi-structured interviews were conducted with experienced ambulance nurses, hems nurses and hems physicians individually, followed by a focus group discussion. participants had to be currently active in prehospital medicine in the netherlands. interviews were encoded for analysis using atlas.ti. using qualitative analysis, different themes around decision making in tca were identified. results: the causes of bleeding were grouped into several categories.the most frequent cause with cases in a row is attributed to diverticular bleeding,other causes of bleeding were angiodysplasia,post polypectomy bleeding,gist tumor,rectal ulcers and inflammatory disease.no case presented mortal or serious complications,secondary to the procedure. only cases presented a mild complication: focal mucosal ischemia of the embolized intestinal segment that was resolved with conservative treatment.lesions in charge of bleeding in those cases in which the angiographic treatment failed,were:ulcer in cases,a case of bleeding after endoscopic polypectomy, a case of diverticular bleeding and bleeding secondary to a coagulation disorder.among these patients, the definitive treatment was the following: -a second angiographic treatment was effective in the case of bleeding due to coagulation disorder. -a case of self-limited bleeding. -surgical treatment was the definitive treatment in both cases of bleeding in the context of and patient with bleeding after polypectomy. we have not observed a significant relationship neither the type of lesion or its location with the probability of failure of the angiographic treatment. nor do we observe a significant relationship between the type of material used for embolization and the risk of treatment failure. comments: our data show that angioembolization is an effective and safe technique to treatment lgi bleeding. references: clin endosc . endoscopic therapy for acute diverticular bleeding introduction: the use of resuscitative endovascular balloon occlusion of the aorta (reboa) as adjunct for temporary hemorrhage control in patients with major torso hemorrhage is increasing. specifications and characteristics of available aortic occlusion balloons (aob) are diverse. in order to minimize the risk of failure and complications it is important to choose a device that fits the requirements per medical situation. the aim of this study is to provide guidance in the choice of an aob in a specific situation. material and methods: aob were assessed for characteristics and different properties of each are outlined. the bending stiffness was measured with a three-point bending device. results: although all aob tested are small caliber devices ranging from (er-reboa tm ) to french (codaÒ ), some need large bore access sheaths up to french (fogarty Ò and lemaitre tm ) or even insertion via surgical cut-down (equalizer tm ). the bending stiffness of the aob varied from . n/mm (± . sd) with the codaÒ to . n/mm (± . sd) with the russian prototype. guidewire-free devices are generally stiffer than over-thewire catheters. the tokai rescue balloon tm showed kinking of the shaft at low bending pressures. the er-reboa tm , fogarty Ò , lemaitre tm , reboa balloon Ò , and rescue balloon tm are the only catheters with external length marks to assist blind positioning. the only aob using a non-compliant balloon is the reboa balloon Ò . conclusions: specifications of available aob are diverse. in resource-limited settings, reboa should be performed with a rather stiff device that can be placed without wire and fluoroscopy, such as the er-reboa tm , fogarty Ò , and lemaitre tm . of these aob, the er-reboa tm is the only catheter compatible with a small french sheath. use of non-compliant balloons without real-time fluoroscopy is not advised given the potential risk of aortic rupture. when fluoroscopy is available, a guidewire can be considered. case history: year old male patient presenting with an initially uncomplicated pertrochanteric fracture, treated by an intramedullary nailing system (figs. and ) . days after the operation and mobilization without any adverse events the patient was readmitted. clinical findings: massive swelling, hematoma and pain. investigation/results: sudden fall of hb values down to , g/dl, ct scans showed the lesser trochanter located directly to the deeper femoral artery after mobilization (fig. ) . diagnosis: perforation of the deep femoral artery and several veins by the dislocated lesser trochanter therapy and progressions: blood transfusion, intraoperative cardiopulmonary resuscitation, several revision surgeries to stop the bleeding by oversewing the deep femoral artery and ligation of the veins, removal of the lesser trochanter fragment (fig. ) . admission to intensive care unit. subsequent plastic coverage. comments: according to literature, bleeding complications and injuries of the deep femoral artery can occur even several days after an initially uncomplicated pertrochanteric hip fracture. besides acute life-threatening bleeding, false aneurysm can occur ( ) ( ) ( ) . even if those late complications are very rare, the consequence for the patient can be devastating. these rare cases show the clear obligation to a thorough follow up treatment and regularly dressing changes. investigation/results: arterial colour doppler of the popliteal artery showed hypoechoeic contents and narrowed lumen. biphasic flow was seen in both popliteal and posterior tibial arteries. diagnosis: popliteal artery injury with delayed repair therapy and progressions: two incision and four compartment fasciotomy was done under regional block the next day which revealed a non contractile posterior compartment. superficial and deep muscles of the posterior compartment had doubtful viability. left distal sfa to infragenicular popliteal artery bypass graft was placed on day post injury. blood flow was established upto the ankle and foot, confirmed on check angio. however, foot drop of the patient persisted. after appearance of a healthy granulation tissue at the wound site ( days), a split thickness skin graft was placed to give coverage with % uptake of the graft. comments: blunt popliteal artery injury has been reported to result in amputation rates of nearly - %.the importance of a detailed vascular examination of a blunt trauma patient is emphasized as a limb can be salvaged if timely intervention is done. in this case even with an unfavourable mess score. case history: a healthy -year-old male, with no history of interest, suffers a high-energy trauma as a water bottle rushes over his left knee. clinical findings: go to the emergency room with pain and functional impotence in the left knee, with its anatomical deformity. knee x-ray pa and l are performed and the distal pulses that are present are taken. ankle-brachial index [ . . closed reduction is performed in emergencies under sedation and control x-ray is requested, aiming at correct reduction. it was decided to keep under observation for - h before discharge from hospital to schedule regulated ligament reconstruction surgery after studying with mri. therapy and progressions: at h of evolution after the accident and after having reduced the dislocation, the patient who has the leg with a temperature equal to the contralateral is reassessed, however, there is no palpable dorsal pedis pulse or posterior tibial palpation in the affected leg. it is decided to urgently request an angiotc and it is objective thrombosis of popliteal artery. vascular surgeon is contacted and emergency surgery is decided. a by-pass is performed with vena safena. diagnosis: traumatic knee dislocation and popliteal artery injury comments: in the st century, complementary tests in diagnosis are becoming increasingly important. however, in this case we want to management of aseptic tibial nonunion anastasios g. c. reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. can we expect an optimum result? results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion management of tibial non-union using reamed interlocking intramedullary nailing the radiographic union scale in tibial (rust) fractures: reliability of the outcome measure at an independent centre pelvic trauma: wses classification and guidelines damage control orthopaedics in unstable pelvic ring injuries references: beuran, m. trauma scores: a review of the literature glasgow coma scale, age, and arterial pressure (mgap): a new simple prehospital triage score to predict mortality in trauma patients. critical care medicine. champion hr. a revision of the trauma score proximal femoral nail antirotation versus gamma nail for intramedullary nailing of unstable trochanteric fractures. a randomised comparative study results of the femur fractures treated with the new selfdynamisable internal fixator (sif) dhs helical blade for elderly patients with osteoporotic femoral intertrochanteric fractures the hypermetabolic response to burn injury and interventions to modify this response racial differences in propranolol enantiomer kinetics following simultaneous i.v. and oral administration propranolol dosing practices in adult burn patients the hypermetabolic response to burn injury and modulation of this response: an overview. wound heal south africa management strategies and outcome of blunt traumatic abdominal wall defects: a single centre experience blunt traumatic abdominal wall hernias: a surgeon's dilemma blunt traumatic abdominal wall hernias: associated injuries and optimal timing and method of repair traumatic abdominal wall herniation: case series review and discussion trauma patients with open abdomen: do they differ from others? a single center experience h. fagertun , a. seternes department of circulation and medical imaging, trondheim, norway introduction: treatment with open abdomen is demanding for patients, staff and hospital. a multidisciplinary approach is mandatory. the aim of this study was to compare trauma patients with open abdomen (oa) and patients treated with oa for other reasons, regarding outcome and resources spent. material and methods: retrospective study of patients treated with oa in a tertiary hospital in norway. ten were trauma patients vacuum-assisted wound closure and mesh-mediated fascial traction for open abdomen therapy-a systematic review prospective study examining clinical outcomes associated with a negative pressure wound therapy system and barker's vacuum packing technique thoracic-abdominal trauma with diaphragm lesions n. vlad , i. streanga , a. morar , i st. spiridon'' hospital iasi. we have analyzed clinical data, trauma mechanism, pathology of the lesion, time trauma-diagnostic, associated lesions, treatment, and follow-up. results: there have been patients ( men, women), mean age . location of diaphragmatic tears has been on the left hemidiaphragm ( cases), on the right hemidiaphragm ( cases), or bilateral ( cases). the trauma mechanism has been blunt ( cases) or penetrant ( cases). all patients had associated visceral lesions and had been operated right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literaturereview traumatic diaphrag-matic ruptures: clinical presentation, diagnosis and surgicalapproach in adults traumatic rupture of the diaphragm: experiencewith patients % ( / ) were aast grade or . in the total group, median age was years, . % were male and . % were blunt injuries. median iss in the nom group was and in the om group. median iss for those with grade or injury was . . % ( / ) underwent nom, compared to . % ( / ) of those with aast grade or . for each mmhg increase in systolic blood pressure, patients with grade or injury were % less likely to have an operation (or . , p = . ) and for each beat increase in heart rate intra-operative grade i was revealed in patients ( , %), grade ii in ( , %), grade iii in ( , %) grade iv in ( , %) and grade v in ( , %). histologic finding of catarral appendicitis was found in ( , %) patients, ( %) had phlegmonous appendicitis and ( , %) had gangrenous appendicitis. the airs difference was statistically significant with histological findings quality of publications regarding the outcome of revision rate after arthroplasty swedish hip arthroplasty register annual report joon yung lee: risk factors for failure of nonoperative treatment for unilateral cervical facet fractures in , patients were included in the trauma registry. median iss was and patients had an iss [ . of these patients / ( %) were undertriaged with a mortality of / ( %). the total mortality in was , % ( / ). i , median age was years for the patients with no tta vs years for those patients who did receive a tta (p \ . ) prognostic factors for medical and productivity costs, and return to work after trauma: a prospective cohort study l results: a total of trauma patients ( % of total study population) responded to at least one follow-up questionnaire. mean medical costs per patient (€ , ) and mean productivity costs per patient (€ , ) varied widely. prognostic factors for high medical costs were higher age, female gender, spine injury, lower extremity injury, severe head injury, high injury severity, comorbidities, and pre-injury health status. productivity costs were highest in males, and in patients with spinal cord injury, high injury severity, longer length of stay at the hospital and patients admitted to the icu. prognostic factors for rtw were high educational level, male gender, low injury severity swiss and german (pre-)hospital systems, distribution and organisation of trauma centres differ from each other [ , ]. it is unclear if outcome in trauma patients differs as well. therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both german-speaking countries. material and methods: the traumaregister dguÒ (tr-dgu) was between - and - were included if they required icu care or died. trauma pattern trauma care in germany trauma systems in europe practical assessment of different saw types for field amputation: a cadaver-based test study these themes were: factual information (e.g., electrocardiography rhythm)educational programs and future guidelines. references: rosemurgy as, prehospital traumatic cardiac arrest: the cost of futility blunt vertebral vascular injury in trauma patients: atlsÒ recommendations and review of current evidence treatment-relater outcomes fron blunt cerebrovascular injuries. importance of routine follow-up arteriography provided the catheters used for this study. no other support was provided diagnosis: the probe had perforated the ivc wall. therapy and progressions: open repair was performed through a xifopubic laparotomy and the cattel-braasch maneuver to expose the ivc (fig. ). a retroperitoneal hematoma was observed anteriorly to the infrarenal ivc, without active bleeding. the ivc was dissected out sufficiently to permit proximal and distal vascular control (fig. ), the probe was then removed and the laceration on the infrarenal ivc closed with a running suture. the postoperative course was uneventful. comments: to our knowledge this is the first reported case of symptomatic ivc laceration by an ice probe during ca. references: enriquez a. use of intracardiac echocardiography in interventional cardiology complications of catheter ablation for atrial fibrilla iatrogenic percutaneous vascular injuries: clinical, presentation, imaging, and management vascular complications during catheter ablation of cardiac arrhythmias: a comparison between vascular ultrasound guided access and conventional vascular access false aneurysm of the profunda artery resulting from intertrochanteric fracture. a case report profunda femoris arterial laceration secondary to intertrochanteric hip fracture fragments. a case report with major thoraco-abdominal vascular injuries (aorta, inferior vena cava and main branches). data on demographic, clinical status and imaging was recorded. descriptive and kaplan meir survival analysis was performed. results: patients were included. median age was years (iqr - ), ( . %) were male. aorta was the most frequently damaged vessel ( , %) the median iss was (iqr - )interventional procedure. overall mortality was %, with % of deaths during the first hour, . % in the first h and . % afterwards. median survival was days (ic - ). we compared survival curves in periods abdominal vascular trauma. trauma surg acute care open history: popliteal artery injuries are frequently seen with fractures, dislocations, or penetrating injuries. a thirty one year old pathologies. references: natsuhara, k.m. et al, what is the frequency of vascular injury after knee dislocation knee dislocation and vascular injury: -year experience at a uk major trauma centre and vascular hub can vascular injury be appropriately assessed with physical examination after knee dislocation? introduction: this retrospective cohort study investigated the prevalence of and risk factors for preoperative venous thromboembolism (vte) in patients with a hip fracture and a delay of [ h from injury to surgery. material and methods: this observational study included patients with a hip fracture surgically treated at university hospital. patients underwent indirect multidetector computed tomographic (mdct) venography for preoperative vte detection after admission. overall vte risk and median time from injury to ct scan were calculated. age, sex, fracture type, time from injury to ct scan, body mass index, preinjury mobility score, previous anticoagulation treatment, previous hospitalization for vte, varicose veins, and medical comorbidities were considered potential risk factors. results: the prevalence of preoperative vte was . % ( of patients). the mean time from injury to ct scan was . days. the delay from the time of injury to ct scan averaged . days for patients who developed preoperative vte, compared with . days for patients who had not developed vte. in the adjusted models, female sex, subtrochanteric fracture, pulmonary disease, cancer, previous hospitalization for vte, and varicose veins were risk factors for vte. the final multivariate logistic regression analysis introduction: vertebral compression fractures constitute a large percentage of traumatic injuries of spine. the initial management plays an important role in the final outcomes. the present study aims to study the profile of vertebral injuries in rural & semi urban population & to analyse the role of level two hospitals in initial management of vertebral injuries. material and methods: this study was a retrospective analysis of progressively collected data of patients presenting with vertebral injuries in a level two hospital catering to semi urban & rural population in india. the initial presentation along with the age & sex profile was noted. etiological factors leading to compression fractures were noted. any neurological deficit either at the time of admission or transfer to a tertiary care neurocentre was noted as per asia scale. initial management was carried out in accordance with the atls guidelines. results: a total of out patients admitted with complaints of back pain were diagnosed to have compression fractures of the spine. the mean age was . years. male: female ratio was approx : . the lumbo sacral spine region was the most comply affected region. two patients were incidentally detected to have vertebral fractures as a result of metastatic malignancy. a due note was made regarding patients who had deteriorated during the transfer in terms of neurological deficit & evidence of spinal shock. conclusions: road traffic accidents contribute a significant portion of vertebral trauma . smaller hospitals & general surgeons have an important role to play in terms of initial stabilisation of such patients particularly the ones presenting with neurogenic shock. a good initial management has sigificant bearing on outcomes. analysis of risk factors for tracheostomy in cervical spinal cord injury without bone injury n. notani , s. kanezaki , t. sakamoto , h. tsumura oita university, orthopaedic surgery, yuhu, oita, japan introduction: there are many cases that require tracheostomy in the acute phase of cervical spinal cord injury, and various risk factors have been reported so far. however, there has been no report on cervical spinal cord injury without bone injury. the aim of this study is to evaluate risk factors for tracheostomy in patients with cervical spinal cord injury without bone injury. material and methods: we conducted a retrospective observational study. patients who were treated for cervical spinal cord injury without bone injury in our hospital were divided into groups: tracheostomy (tc) group and no tracheostomy (no tc) group. we compared variables, including age, sex, asia impairment scale (ais), neurological level of injury (nli), injury severity score (iss), vital signs, blood gas analysis, tracheal intubation, chest complication, smoking history between two groups. results: there were patients in tc group, and patients in no tc group. on univariate analysis, there were significant differences in age, ais a, tracheal intubation, nli ] c . on multivariate analysis, nli ] c was an independent predictor of tracheostomy. conclusions: in this study, we demonstrated that nli ] tc could be useful to predict tracheostomy in patients with cervical spinal cord injury without bone injury. case history: many fractures of the articular processes of the cervical spine are associated with displacement and instability, approximately % of all traumatic cervical spine injuries involve isolated fracture of the articular processes non-displaced or minimally displaced. [ ] this case demonstrates a isolated facet fracture of the cervical spine with c radiculapathy treated with minimally invasive spine surgery techniques clinical findings: a -year-old male was admitted to the neurosurgery department due to severe neck pain (vas / ). the pain radiating to the right upper extermity along dermatome c . neck and trunk rotation worsened the pain. investigation/results: furthermore, physical examination revealed hyperaesthesia in the right index finger without muscle weakness. ailments suddenly appeared weeks earlier after getting up in the morning. imaging demonstrated isolated, unilateral fracture of the right superior articular process of c diagnosis: imaging demonstrated isolated, unilateral fracture of the right superior articular process of c therapy and progressions: the patient was treated by microsurgical c decompression and fusion of c - under navigation guidance. intraoperative ct scans were performed to evaluate sufficient bone removal.after the surgery, the neck and upper extremity pain subsided. the patient had returned to his usual job and sport activities. comments: this case illustrates the value of the navigation and intraoperative ct in the evaluation of bony decompression, anatomy and location of implants. navigation minimized iatrogenic injury resulting in reducing postoperative complications like chronic pain, kyphotic deformity and muscular atrophy.introduction: resuscitative endovascular balloon occlusion of aorta (reboa) is a technique initially developed in the military for trauma patients injured in combat . recently, there has been much debate on its role in civilian trauma cases in controlling non-compressible torso haemorrhage (ncth) . this review aims to provide an update on current literature on the outcomes and concerns of this procedure. material and methods: a systematic literature search according to prisma guidelines was performed over the period of january to august across embase, medline and cochrane databases. patient characteristics, mechanism and severity of injury, survival rates and post-reboa complications between survivors and non-survivors were compared. results: a total of studies were included in this review. % and % of the reboa cases were penetrative and blunt cases respectively. the survival rates ranged from to % across the studies. systolic blood pressure (sbp) was significantly elevated post-procedure, from . to . mmhg in the survivor group (p \ . ) and . to . mmhg in the non-survivor group (p = . ). the injury severity score (iss) was lower in the survivor group ( . vs . ; p \ . ) whereas their glasgow coma scale (gcs) was higher ( . vs . ; p = . ). the survivors also had a shorter duration of aortic occlusion ( . vs . min; p = . ). common complications noted following the procedure include renal injury, lower limb ischaemia and thrombosis. conclusions: pre-reboa sbp, iss, gcs and duration of aortic occlusion were found to be associated with survival. complications directly due to the procedure were difficult to ascertain. a prospective study in a multiple trauma centre is needed for further evaluation of the indications, feasibility and complications involved in reboa. references: introduction: traumatic vertebral artery injury (vai) is a wellknown complication of cervical spine injury and often causes posterior circulation stroke. we report preventive effect of acute phase endovascular intervention for traumatic vai. material and methods: all patients with cervical spine injury were surveyed with post-contrast computed tomography for vai. when vai was diagnosed, the affected vertebral artery (va) was occluded with endovascular intervention before spine reduction and fixation. brain ischemic lesion was evaluated before and after the treatment. results: forty-one patients with vai associated with cervical spine injury underwent endovascular intervention. the affected va was occluded with endovascular coils before cervical spine reduction and fixation in patients, and after treatment in one patient. va stenting was done for another two. six presented new brain infarctions after spine surgery. of these, two had endovascular intervention after spine reduction. out of patients who had endovascular embolization before spine reduction, four had newly developed infarctions after spine surgery, of which two were symptomatic. there were no complications related to the endovascular procedure. conclusions: in conclusion, endovascular embolization for traumatic vai before spine reduction and fixation was found to be effective to prevent symptomatic brain infarction. introduction: the use of drug coating balloons (dcb) in primary or secondary angioplasty for peripheral vascular disease is a new tendency. the use of paclitaxel decelerates the growth and hyperplasia of neo-intima tissue which can cause re-stenosis and total occlusion in the spot of pta is a very promising technique in long lasting results of balloon ptas. purpose: to demonstrate our experience and results of the technique of dcb pta with the use of drag coating balloons. material and method: in the period between march and september , patients with sfa lessions were treated with pta with dcb for acute limb ischemia. were males and females. mean age was , y.o (± . ). patients were examined pro operationally and immediate post operationally in abi difference and their post operational follow up included measurement of abi and u/s triplex scan on the st, rd, th and th month(where chronically available) after pta. results: the mean immediate post operative increase of abi was , (± , ). were chronically available the increase of abi remained to , in the months follow up, , in the months and , in the th month follow up while patency of the artery treated remained in all patients. of the patients suffered from acute complications during or short after the pta ( with peripheral embolization and with retroperitoneal hematoma) which were treated immediately and left no consequences. conclusions: the use of dcb for pta in acute ischemia is a quite new, promising technique for maintaining patency of treated arteries for long time post operative period. the medium time results from its use in our clinic seem to be satisfactory. jichi medical university hospital, tochigi, japancase history: a -year-old male hit his neck hard against the fence. thereafter, he experienced difficulty in breathing and severe neck pain. he was brought to the emergency center by ambulance. clinical findings: his vital signs on arrival were gcs: e v m , hr: , bp: / , rr: , spo : ( lo ). significant neck edema and tracheal deviation were noted. inspiratory stridor was not heard with no signs of retracted breathing or subcutaneous emphysema. investigation/results: an enhanced ct scan of the neck revealed tracheal deviation and compression with ruptures of the left thyroid lobe. a large hematoma and arterial extravasation from a branch of the inferior thyroid artery were noted. diagnosis: rupture of the left thyroid lobe and injury around the distal portion of the left inferior thyroid artery. therapy and progressions: after securing the airway by intubation, angiography of the neck was performed; extravasation from a branch of the left inferior thyroid artery was suspected. angioembolization was continued for hemostasis using gelatin sponge. neck edema improved in the intensive care unit. following extubation on the hospital day , the patient was discharged on the th day with no complication. comments: thyroid injury due to blunt neck trauma is rare and surgical intervention such as hemithyroidectomy is generally prescribed. the patient''s condition, in this case, improved by angioembolization without any invasive surgical procedures. catheter procedure may, thus, be effective for hemostasis on thyroid injury after the confirmation of airway placement. introduction: the indication for resuscitative endovascular balloon occlusion of the aorta (reboa) is hemodynamically unstable patients in life-threatening hemorrhage below diaphragm. it was unclear that the difference of indications for reboa affects mortality in trauma.material and methods: this study used data from the japan trauma data bank (jtdb) ( - ), a nationwide trauma registry, to describe the epidemiology of reboa. adult trauma patients used reboa were included. patients were excluded if they had cardiac arrest at the scene or dead on arrival, or had an unsurvivable injury of any region of the body as defined by the abbreviated injury scale. patients were classified by whether patients had indications for reboa. the indications for reboa were defined by indications for hemostasis to intraabdominal, retroperitoneal, pelvic or extremity hemorrhage. the indications were decided by the delphi method with the cooperation of experts in trauma for this study. the contraindications were defined by brain injury needed intervention and hemorrhage above diaphragm. the logistic regression was used to assess the mortality after adjustment for injury severity score. as a sensitivity analysis, a generalized linear mixed model with random effects of a facility was performed. results: of , patients registered in the jtdb, patients underwent reboa. had indications for reboa and underwent reboa without indications. the physiological variables were similar, but the consciousness was worse in the no-indications group. injury severity of brain and chest were higher in the no-indications group. the indications group had . % and the no-indications group had . % contraindications for reboa. the mortality was similar ( . % versus . %, or . , %ci . - . ). a sensitivity analysis showed the same result as the primary analysis (or . , %ci . - . ). introduction: most incident first responders have a primary nonmedical role, but are frequently the only professionals initially at the scene. early hemorrhage control via advanced techniques such as resuscitative endovascular balloon occlusion of the aorta (reboa) can save lives. training first responders these techniques has therefore the potential to improve outcomes. this study evaluates the ability to train quick response team fire fighters (qrt-ff) to gain percutaneous femoral artery access and place a reboa catheter, using a comprehensive theoretical and practical training program. material and methods: six qrt-ff participated in the training. sof medics from a previous training served as control group. a formalized training curriculum included basic anatomy and endovascular materials for percutaneous access and reboa catheter placement. key skills were: ( ) preparation of an endovascular toolkit, ( ) achieving vascular access in the model and ( ) placement and positioning of the reboa catheter. results: qrt-ff had significantly better baseline knowledge of surgical anatomy (p = . ) compared to medics. they also scored significantly better on using endovascular materials (p = . ), performing the procedure without unnecessary attempts (p = . ) and overall technical skills (p = . ). the median time from start to reboa inflation was : min for qrt-ff and : min for medics. procedure times improved in all qrt-ff and of the medics in a second attempt of gaining vascular access and reboa placement. conclusions: our comprehensive theoretical and practical training program proves suitable for percutaneous femoral access and reboa placement training of qrt-ff without prior ultrasound or endovascular experience. repetition reduces procedure times. training in the use of advanced hemorrhage control techniques such as reboa, as a secondary occupational task, has the potential to improve outcomes for severely bleeding casualties in out-of-hospital settings. prytime medical tm devices, inc. provided the reboa access task trainer (ratt) and the catheters used for this study. no other support was provided.the authors declare that there are no conflicts of interest that could inappropriately influence (bias) their work. introduction: angioembolization (ae) has become an important component in the management of bleeding from severe pelvic fractures. timely availablity of ae is required for both, level and trauma centers. the aim of this study was to assess the utilization of this procedure in level and trauma centers and effect on oucomes. material and methods: retrospective, -year ( - ) study using the the american college of surgeons tqip database, including adult patients with isolated severe pelvic facture (ais [ ] [ ] [ ] . patients who underwent laparotomy or preperitoneal packing within h from admission were excluded, operative management for bleeding control between and h was considered as failure. univariate analysis was used to compare patients in level vs centers, multivariate regression analysis was performed to determine factors predictive for mortality and overall complications.results: patients ( in level ; in level centers) met the criteria for inclusion. overall, ( . %) underwent ae, with a trend toward higher ae rate in level centers ( . % vs . %, p = . ). no significant differences were observed in timing and failure rate of ae between the levels. particulary in the ae subgroup there was a significantly lower blood product utilization in the first h in level i centers (prbc . vs . units, p = . ; plasma . vs . units, p = . ). mortality and overall complication rates were similar. table the level of trauma center was not a predictive factor for mortality (or . , p = . ) and overall complications (or . , p = . ). conclusions: in isolated severe pelvic fractures, there was a trend toward higher ae rate and significantly lower utilization of blood products in level centers. there were no significant differences in mortality or complications. the ae subgroup in level centers had a higher blood products use without outcome benefit, suggesting more restrictive transfusion policy may be considered. portal vein thrombosis after distal splenopancreatectomy: successful recanalization using fogarty balloon catheter case history: intraoperative lesion of smv during distal splenopancreatectomy is repaired using peritoneal patch harvested from anterior abdominal wall clinical findings: postoperative increase in serum lactate and d-dimer without signs of peritonitis prompts bedside doppler us showing no blood flood within portal vein (pv) investigation/results: ct angiography is performed suspecting acute mesenteric ischemia, but no abnormal bowel enhancement/ thickness is seen despite complete pv thrombosis. anticoagulation with unfractioned heparin is started, but clinical conditions deteriorate diagnosis: at reintervention, bowel is viable, so the surgeon performs fogarty balloon catheter thrombectomy successfully reestablishing blood flow within pv. no intestinal resection is required therapy and progressions: pv patency is regularly evaluated with us. anticoagulation with low molecular weight heparin is prosecuted for months and then suspended since no recurrence is recorded meanwhile comments: pv thrombosis is uncommon but can follow injury to portal venous axis during surgery. anticoagulation with heparin should be started as soon as the diagnosis is made and maintained for at least - months postoperatively to prevent recurrence. patients with persisting/worsening symptoms - h after initiation of anticoagulation, or those with peritonitis who are poor surgical candidates may be considered for interventional radiological treatment. otherwise, surgical intervention is required and may encompass resection of necrotic bowel. thrombectomy and/or balloon dilation/vascular stent placement may be helpful in recently developed pv thrombosis since risk of recurrence seems to be decreased references: acute mesenteric ischemia: guidelines of the world society of emergency surgery (world j emerg surg ); mesenteric venous thrombosis (j clin exp hepatol ); contemporary management of acute mesenteric ischemia in the endovascular era (vasc endovascular surg ) key: cord- -kptilmi authors: mulatu, h. a.; tesfaye, m.; woldeyes, e.; bayisa, t.; fisseha, h.; asrat, r. title: the prevalence of common mental disorders among health care professionals during the covid- pandemic at a tertiary hospital in east africa date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: kptilmi background: coronavirus disease (covid- ) has resulted in unprecedented morbidity, mortality, and health system crisis leading to a significant psychological distress on healthcare workers (hcws). the study aimed to determine the prevalence of symptoms of common mental disorders among hcws during the covid- pandemic at st. paul hospital, ethiopia. methods: a self-administered cross-sectional study was conducted to collect socio-demographic information and symptoms of mental disorders using validated measurement tools. accordingly, phq- , gad- , isi, and ies-r were used to assess the presence of symptoms of depression, anxiety, insomnia, and distress, respectively. chi-square test, non-parametric, and logistic regression analysis were used to detect risk factors for common mental disorders. results: a total of healthcare workers participated in the survey. the prevalence of depression, anxiety, insomnia, and psychological distress was . %, . %, . %, and . % respectively. frontline hcws had higher scores of mental health symptoms than other health care workers. logistic regression analysis showed that being married was associated with a high level of depression. working in a frontline position was an independent factor associated with a high-level depression, anxiety, and psychological distress. limitations: it is a single-centre cross-sectional study and the findings may not be generalizable or reveal causality. coronavirus disease (covid- ) is a mild to severe respiratory illness that is caused by a coronavirus named severe acute respiratory syndrome coronavirus (sars cov ). it was first recognized in china in late december as an unknown respiratory disease outbreak. due to its high risk of contagiousness and human-to-human transmission, it has reached global pandemic level in a very short time c. lai et al., ) . as of september , , who has reported , , confirmed cases of covid- , and , deaths globally.(who, ) on the same day, the ethiopian ministry of health has also reported , total confirmed cases and , deaths in the country (moh, ) . healthcare workers (hcws) dealing with covid- are under increased psychological pressure, and experience high rates of psychiatric morbidity, resembling the situation during the previous severe acute respiratory syndrome (sars) and influenza epidemics . depression, anxiety, insomnia, and psychological distress are the common mental health disorders that occur during such a dramatic global health crisis pappa et al., ) . a recent study among healthcare professionals in a tertiary hospital in china, revealed a high prevalence of mental health symptoms among hcws. overall, . %, . %, . %, and . % of health workers reported symptoms of depression, anxiety, insomnia, and distress, respectively. nurses, females, and frontline hcws were affected more than others with these mental disorders (bohlken et al., ) . to date, studies on the psychological impact of covid- on hcws are limited in sub saharan africa. the aims of the current study were to determine the prevalence of depression, anxiety, insomnia, and psychological distress among hcws and associated factors during the covid- pandemic at st. paul's tertiary hospital, addis ababa, ethiopia. the study was conducted at st. paul's hospital, the second-largest public hospital in ethiopia located in addis ababa. there are hcws involved in clinical care. the health professionals comprise of specialists, general practitioners, nurses, midwives, and laboratory and pharmacy professionals. the hospital has an inpatient capacity of more than beds and serves an average of emergency and outpatient . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november , . ; https://doi. org/ . org/ . / clients daily. after the first few cases of covid- were reported in march in ethiopia, the hospital has dedicated ward and icu beds to treating only these cases. the study was a cross-sectional, hospital-based survey that was conducted to assess the prevalence of depression, anxiety, insomnia, and mental distress among healthcare workers at st. paul's hospital during the covid- pandemic from august st , up to august , . the sample size was determined based on a single population formula for a finite population of hcws with a % ci, % margin of error, and taking the highest of the prevalence of depression, anxiety, insomnia, and distress of . % sofia et al., ; zhu et al., ) , . % sofia et al., ; zhu et al., ) , . % sofia et al., ; ) , and . % zhu et al., ) respectively from similar studies. by considering a % non-response rate and applying a sample correction formula, a total sample size of hcws will be included in the study. to allow for subgroup analysis, we amplified the sample size by % with a goal of at least completed questionnaires from participants. healthcare workers working in either in-patient or out-patient units or covid or non-covid units of the hospital were included. healthcare workers who had previous mental illnesses, not involved in the diagnosis or treatment of patients, and those who did not give consent were excluded from the study. healthcare worker (hcw): health professionals (medical doctors, nurses, midwives, laboratory professionals and pharmacists) who have close contact with patients in the diagnostic and treatment units of saint paul's hospital millennium medical college. frontline hcws: participants who are directly engaged in clinical activities of diagnosing, treating, or providing nursing care to patients with confirmed covid- . non-firstline (second-line) hcws: participants who are not directly engaged in clinical activities of diagnosing, treating, or providing nursing care to patients with confirmed covid- but could be indirectly exposed while involved in the care of other patients who might be in a pre-symptomatic stage of covid- . healthcare workers of both sexes working in both out-patient and in-patient units of st. paul's hospital were illegible for the study. participants were recruited using a simple random sampling method from their alphabetical list prepared by the human resource . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint development directorate after first stratifying them into four groups (doctors, nurses/ midwives, the laboratory professionals, and pharmacy professionals) using probability proportional to size method. all volunteered study subjects completed a self-administered questionnaire that was used to assess for symptoms of depression, anxiety, insomnia, and distress. data were collected by trained residents and nurses.the data collectors categorized the participants by asking whether they were directly engaged in clinical activities of diagnosing, treating, or providing nursing care to patients with confirmed covid- . those who responded yes were defined as frontline workers, and those who answered no were defined as non-frontline (second-line) workers. data were collected using a pretested and self-administered questionnaire to assess for symptoms of depression, anxiety, insomnia, and distress using amharic versions of validated measurement tools (gelaye, et al., ; hanlon et al., ) . accordingly, the -item patient health questionnaire (phq- ; range, - ), the -item generalized anxiety disorder (gad- ) scale (range, - ), the -item insomnia severity index (isi; range, - ), and the -item impact of event scale-revised (ies-r; range, - ) were used to assess the severity of symptoms of depression, anxiety, insomnia, and distress, respectively. the total scores of these measurement tools were interpreted as follows: phq- , normal ( - ), mild ( - ), moderate ( - ), and severe ( - ) depression; gad- , normal ( - ), mild ( - ), moderate ( - ), and severe ( - ) anxiety; isi, normal ( - ), sub-threshold ( - ), moderate ( - ), and severe ( - ) insomnia; and ies-r, normal ( - ), mild ( - ), moderate ( - ), and severe ( - ) distress. these categories were based on values established in the literature (gelaye b et al., ; hanlon et al., ; greenberg et al., ) . the cut-off score for detecting severe symptoms of depression, anxiety, insomnia, and distress were (johnson et al., ), (ong, & suh, , (ong, j. c., & suh, ; johnson et al., ) , and (creamer et al., ) , respectively. participants who scored greater than or equals to the cut-off threshold were characterized as having severe symptoms. the selected questionnaires had good internal consistency with cronbach's α coefficients of more than . . demographic data were self-reported by the participants, including educational level (graduate, post-graduate), profession (physician, nurse/midwife, the laboratory professional or pharmacy professional), sex (male or female), age ( - , - , - , or > years), marital status, monthly net salary, educational level (undergraduate or postgraduate), and . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint technical title (junior or senior). the different technical titles of respondents refer to the professional titles certificated by the ethiopian food, medicine and health care administration, and control authority (efmhaca). all investigators supervised the data collection process. each completed questionnaire was entered into epi data version , cleaned, and exported into spss version for statistical analysis. all the variables were categorical and presented as numbers and percentages. the original scores of the measurement tools were continuous, not normally distributed, and thus presented as a median and interquartile range (iqr). a nonparametric mann-whitney u test and kruskal-wallis h test were applied to compare the severity of each symptom between two or more groups. the ranked data, which were derived from the counts of each level for symptoms of depression, anxiety, insomnia, and distress were presented as numbers and percentages. to determine potential risk factors for symptoms of depression, anxiety, insomnia, and distress in participants, a multivariable logistic regression analysis was performed, and the associations between risk factors and outcomes were presented as odds ratios (ors) and % cis, after adjustment for confounders, including age, sex, marital status, profession, educational level, technical rank, monthly salary, work experience, and working position (frontline or non-frontline). finally, a p-value < . in a multivariable model was considered as significant. this study was approved by the institutional review board of st. paul's hospital millennium medical college. written informed consent was obtained from all participants. each participant's information was collected by residents and nurses using an anonymous precoded structured questionnaire that was assigned to each selected hcw. the code was blinded to both data collectors and data entry clerks. the information was kept confidential among the investigators. a participant who had severe symptoms of mental disorder was traced by a psychiatrist (one of the investigators) and advised on further evaluation and treatment. those who volunteered were linked to our psychiatric clinic. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint a total of participants were included in the study making a response rate of . %. of these, ( . %) participants were physicians, ( . %) were nurses and midwives, ( . %) were laboratory professionals and ( . %) were pharmacy professionals. the response rates for physicians, nurses or midwives, laboratory professionals, and pharmacy professionals were %, %, %, and % respectively. the mean age of the participants was ± . [range: - ] years. among the participants, ( . %) were in the age range of - years. two-hundred-forty-six ( . %) participants were men and ( . %) were unmarried. the qualification of participants indicated that ( . %) had undergraduate level and ( . %) had a postgraduate level of education. regarding their technical title, ( . %) were junior and ( . %) were senior staff in their professional career. the mean monthly salary of respondents was ± ethiopian birr (etb) and ( . %) respondents earn between - , etb. the majority ( . %) of respondents had a work experience of fewer than five years and ( . %) were frontline healthcare professionals. a significant proportion of respondents working as frontline were aged between - years, unmarried, and nurses or midwives. they had an undergraduate level of education and work experience of fewer than five years (table ) . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint the prevalence of depression, anxiety, insomnia, and psychological distress was found to be . %, . %, . %, and . % respectively. the median (iqr) scores on the phq- for depression, the gad- for anxiety, the isi for insomnia, and the ies-r for distress for all respondents were . ( . - . ), . ( - . ), . ( . - . ), and . ( . - . ), respectively. respondents were categorized based on the severity of symptoms of depression, anxiety, insomnia, and psychological distress. moderate symptoms of depression, anxiety insomnia, and distress were reported in ( . %), ( . %), ( . %), and ( . %) respondents. severe symptoms of depression, anxiety insomnia, and distress were also reported in ( . %), ( . %), ( . %), and ( moderate to severe symptoms of anxiety, insomnia, and distress were also more common among frontline hcws (table ) . measures . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november , . ; https://doi.org/ . regarding perception of threat of covid- , ( %) respondents feel that they might have history of exposure to covid- , ( %) had thought of resigning from work, ( . %) were worried of life-threatening situation, ( . %) feel that families and friends have avoided contact with them due to their work, and ( . %) were worried about their family members being infected by covid- . thought of resigning from work due to covid- was reported in significantly higher proportion of respondents with symptoms of depression, anxiety, insomnia, and psychological distress (p-values < . ). worrying of life-threatening situation once infected was reported in a significant proportion of respondents with symptoms of depression (or, . ; % ci, . - . ; p = . ). the study also assessed whether or not the respondents were satisfied with the psychological protective measures implemented at st. paul's hospital. respondents who were satisfied with the work-shift arrangement, logistic support, and accommodation suffered less from insomnia and psychological distress than those who were not satisfied with these protective measures (p≤ . ) ( table ) . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) a multivariable logistic regression analysis was conducted to determine the demographic and relevant contextual factors that are associated with mental health illnesses. in the adjusted logistic regression analysis, several factors were independently associated with depression (phq- score ≥ ), anxiety (gad- score ≥ ), insomnia (isi score ≥ ), and psychological distress (ies-r score ≥ ). factors that were independently associated with a higher risk of depression included being married (or, . ; % ci, . - . ; p= . ) and working in frontline position (or, . ; % ci, . - . ; p= . ). working in frontline position is also associated with more severe symptoms of anxiety (or, . ; % ci, . - . ; p= . ) and psychological distress (or, . ; % ci, . - . ; p< . ). working as a doctor was associated with a lower risk of experiencing anxiety (or, . ; % ci, . - . ; p = . ) and insomnia (or, . ; % ci, . - . ; p= . ) than working as a laboratory or pharmacy professional (table ) . abbreviation: isi, or, odds ratio; this cross-sectional study aimed to assess the prevalence of common psychiatric disorders during the covid- pandemic among healthcare workers at st. paul's hospital. the survey revealed a significant proportion of mental health symptoms among healthcare workers at st. paul's hospital. overall, . %, . %, . %, and . % of all respondents reported symptoms of depression, anxiety, insomnia, and psychological distress respectively. participants involved in covid- care as frontline had a higher prevalence of mental health symptoms as compared to non-frontline workers. most participants were young (aged between - years), men, married, nurses, educated to the level of an undergraduate degree, junior in their technical title, getting monthly salary between , - , etb, and have working experience of fewer than years. our study further indicates that being married was associated with experiencing severe symptoms of depression. working in the frontline . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november , . ; https://doi.org/ . https://doi.org/ . / was an independent risk factor for worse mental health outcomes in all dimensions of interest. one common risk factor of the perceptions of the threat of covid- in the four outcomes was thought of resigning from work due to ). in addition, fear of life-threatening situations once infected was associated with severe symptoms of depression. the two common protective factors of psychological protective measures in experiencing lesser symptoms of insomnia and psychological distress were satisfaction with a work-shift arrangement and logistic support (both p-values < . ). similarly, doctors were at lower risk of experiencing severe symptoms of anxiety and insomnia as compared to other healthcare professionals. as a result, our findings raise a concern about the psychological well-being of hcws involved in the care and treatment of covid- . our finding is consistent with several other studies (huang and zhao, ; que et al., ; zhu et al., ) after adjusting for confounding factors, working in a frontline position was an independent risk factor for all mental health outcomes, compared to working in a non-frontline position. our finding is in line with other recent studies (alkhamees et al., ; huang and zhao, ; que et al, ; zhu et al., ) , which reported a significantly higher proportion of severe symptoms of mental illness among frontline than non-frontline hcws. frontline medical workers might be exposed to much more physical and mental stresses, which can contribute to their higher rates of mental problems. for example, frontline medical workers have had to be very cautious when working in covid wards. in addition, the rapid increase of the infected patients and shortage of personal protective equipment can increase the enormous workload and psychological burden of medical workers (cai et al., . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint ; xiang et al., ) . our findings revealed poor mental health among frontline medical workers. however, we did not observe a significantly higher rate of seeking help or receiving treatment for mental problems among these subjects. the phenomenon that hcws have difficulty accepting and disclosing mental health issues is not unique to the covid- outbreak (tysser et al,, ; fridner et al., ) . psychological distress is common among hcws, many of whom do not seek psychological support from their colleagues, because they either think they did not need or are embarrassed to seek help and worried about confidentiality (fridner et al., ) . these findings remind that psychologists or psychotherapists should pay more attention to hcws with mental health problems. an interesting finding of our study was that thought of resigning from work due to covid- was associated with higher risk of severe symptoms of depression, anxiety, insomnia, and distress. in contrary, being satisfied with work-shift arrangements, logistic support, and accommodation implemented by the hospital administration were the protective factors associated with lower risk of severe symptoms of mental disorders. a similar finding was recently reported by zhu et al. from a study conducted during the earlier stage of covid- pandemic in china . similar to a study from china , our finding further indicated that hcws who were married reported more severe symptoms of depression. this might be due to increased occupational exhaustion and family responsibilities among married than unmarried hcws. in addition, doctors, nurses, and midwives were at lower risk of experiencing severe symptoms of anxiety and insomnia than laboratory and pharmacy professionals. this could be explained by the fact that higher proportion of doctors and nurses received medical training related to covid- by the hospital administration as compared to laboratory and pharmacy professionals which should be established with further studies. the strengths of the study were the use of random sampling method and adequate number of participants. however, our study has several limitations which should be addressed in the future. first, it was a single-centre study and the findings may not be nationally representative. second, it was a cross-sectional study and was not the best method of determining correlation and causation. third, all the data collected were self-reported by the respondents and could be exposed to social desirability bias and more objective data can be used in future similar research. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint in conclusion, the study demonstrates that a significant proportion of healthcare workers are suffering from symptoms of mental health disorders during covid- pandemic at st. paul's hospital. being married and working in frontline were independently associated with a greater risk of experiencing severe symptoms of mental disorders. strategies to provide psychological support should be implemented by the hospital administration for the mental health of hcws in order to control the impact of the pandemic. long-term surveillance should be implemented to monitor the mental health of frontline and non-frontline medical workers. ham and mt conceived and developed the study protocol and drafted the manuscript. all authors involved in data collection. interpretation and final review were done by ham, mt, ew, and tb. all authors approved the final manuscript. none. directorate under a protocol number pm / . the funder had no role in the design, data collection, analysis, interpretation, and in writing the manuscript. the psychological impact of covid- pandemic on the general population of saudi arabia why don't academic physicians seek needed professional help for psychological distress ? covid- pandemic : stress experience of healthcare workers the mental health of frontline and non-frontline medical workers during the coronavirus disease (covid- ) outbreak in china: a case-control study psychometric properties of the impact of event scale-revised validity of the patient health questionnaire- for depression screening and diagnosis in east africa managing mental health challenges faced by healthcare workers during covid- pandemic early support clinical characteristics of coronavirus disease in china validity of brief screening questionnaires to detect depression in primary care in ethiopia generalized anxiety disorder, depressive symptoms and sleep quality during covid- outbreak in china: a web-based cross-sectional survey psychological impact of the covid- pandemic on healthcare workers: a cross-sectional study in china psychometric properties of the general anxiety disorder -item (gad- ) scale in a heterogeneous psychiatric sample severe acute respiratory syndrome coronavirus ( sars-cov- ) and coronavirus disease- ( covid- ): the epidemic and the challenges factors associated with mental health outcomes among health care workers exposed to coronavirus disease the impact of covid- epidemic declaration on psychological consequences : a study on active weibo users depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic diagnostic tools for insomnia prevalence of depression, anxiety, and insomnia among healthcare workers during the covid- pandemic: a systematic review and meta-analysis help-seeking for mental health problems among young physicians: is it the most ill that seeks help ? a longitudinal and nationwide study update on covid- . situation report the covid- outbreak and psychiatric hospitals in china: managing challenges through mental health service reform covid- in wuhan: immediate psychological impact on health workers. medrxiv we would like to thank st. paul's hospital millennium medical college research directorate for funding the study. we would like to thank all healthcare workers who, despite the increased workload during the covid- crisis, have dedicated their time to answer the survey. key: cord- -x bzrpcu authors: faires, meredith c; pearl, david l; ciccotelli, william a; berke, olaf; reid-smith, richard j; weese, j scott title: the use of the temporal scan statistic to detect methicillin-resistant staphylococcus aureus clusters in a community hospital date: - - journal: bmc infect dis doi: . / - - - sha: doc_id: cord_uid: x bzrpcu background: in healthcare facilities, conventional surveillance techniques using rule-based guidelines may result in under- or over-reporting of methicillin-resistant staphylococcus aureus (mrsa) outbreaks, as these guidelines are generally unvalidated. the objectives of this study were to investigate the utility of the temporal scan statistic for detecting mrsa clusters, validate clusters using molecular techniques and hospital records, and determine significant differences in the rate of mrsa cases using regression models. methods: patients admitted to a community hospital between august and february , and identified with mrsa > hours following hospital admission, were included in this study. between march and february , mrsa specimens were obtained for spa typing. mrsa clusters were investigated using a retrospective temporal scan statistic. tests were conducted on a monthly scale and significant clusters were compared to mrsa outbreaks identified by hospital personnel. associations between the rate of mrsa cases and the variables year, month, and season were investigated using a negative binomial regression model. results: during the study period, mrsa cases were identified and mrsa isolates were spa typed. nine different spa types were identified with spa type /t ( . %) the most prevalent. the temporal scan statistic identified significant mrsa clusters at the hospital (n = ), service (n = ), and ward (n = ) levels (p ≤ . ). seven clusters were concordant with nine mrsa outbreaks identified by hospital staff. for the remaining clusters, seven events may have been equivalent to true outbreaks and six clusters demonstrated possible transmission events. the regression analysis indicated years – , compared to , and months march and april, compared to january, were associated with an increase in the rate of mrsa cases (p ≤ . ). conclusions: the application of the temporal scan statistic identified several mrsa clusters that were not detected by hospital personnel. the identification of specific years and months with increased mrsa rates may be attributable to several hospital level factors including the presence of other pathogens. within hospitals, the incorporation of the temporal scan statistic to standard surveillance techniques is a valuable tool for healthcare workers to evaluate surveillance strategies and aid in the identification of mrsa clusters. in the healthcare setting, the timely identification of healthcare-associated infections (hais) and the institution of infection control measures are crucial steps for the prevention and reduction of transmission events and outbreaks in the patient population. however, the detection of transmission events is based on limited evidence [ ] , and detection of specific pathogen clusters is generally subjective in nature [ ] . furthermore, even well-established infection prevention strategies can be often disregarded [ ] at various levels. overall, these factors may lead to the transmission of pathogens within the hospital, a missed opportunity to investigate a disease cluster, or false ascertainment of a cluster resulting in the misuse of hospital resources for investigational purposes [ ] . statistical methods, such as the scan statistic, may enhance the identification of disease clusters and/or outbreaks in the hospital setting [ , ] . the scan statistic [ ] can be used to detect and evaluate clusters of infectious diseases in space, time, and/or space-time [ ] [ ] [ ] . by understanding the clustering of infectious diseases spatially and/or temporally, potential risk factors can be identified [ ] , detailed investigations determining the association between exposures and disease interventions can be facilitated [ ] , and outbreaks can be detected [ ] . methicillin-resistant staphylococcus aureus (mrsa) outbreaks in healthcare facilities represent a significant burden to public health in terms of ward closures, infection control measures, increased patient morbidity and mortality rates, and healthcare costs [ , ] . in hospitals, identification of outbreaks is routinely based on the examination of microbiological test results and patients' charts [ ] , with the definition of an outbreak generally relying on rule-based criteria [ ] . however, these types of criteria are prone to error since they fail to address changes in population size or random variation [ ] . with the increasing availability of timely surveillance data within the hospital setting, the use of analytical methods may lead to the earlier detection of disease clusters or outbreaks [ ] . in hospitals, the incorporation of the scan statistic for the detection of mrsa disease clusters, spatially and/or temporally, has been limited. in one study, a space-time permutation scan statistic was utilized to detect clusters throughout the hospital [ ] . however, molecular data were not collected to validate mrsa clusters. in another investigation, a temporal scan statistic, incorporating molecular data, was employed to identify mrsa clusters which were used as a gold standard to evaluate other algorithms for cluster detection [ ] . for both investigations, the application of a scan statistic to hospital data resulted in the identification of several significant mrsa clusters that were not identified by hospital personnel. however, as both studies were conducted in academic medical centres, further investigation of the scan statistic for identifying mrsa clusters under different healthcare settings is required [ , ] . the objectives of this study were to investigate the utility of the temporal scan statistic for detecting mrsa clusters in a community hospital and to validate significant clusters using molecular techniques and hospital records concerning known mrsa outbreaks; and to determine if there were significant differences in the rate of mrsa infection and colonization cases by month, season, and year using regression models. located in southern ontario, canada, the participating study hospital has beds, over , in-and outpatient visits annually, and provides an array of services including internal medicine, surgery, emergency, pediatrics, oncology, rehabilitation, intensive care, and psychiatry. both urban and rural populations are served by this facility. this study was approved by the research ethics boards of the university of guelph and the participating hospital. the research ethics approval covered all aspects of the study including the collection of de-identified isolates from the hospital's microbiology laboratory. in the study hospital, targeted surveillance for mrsa is conducted based on recommendations provided by a provincial infectious diseases advisory committee [ ] . briefly, during the study period, at the time of hospital admission, patients identified as having an increased risk for mrsa acquisition are screened. these risk factors include [ ] : previous colonization or infection with mrsa; time spent in any healthcare facility in the previous twelve months (time defined as > continuous hours); recent exposure to a unit/ward/area of a healthcare facility identified with an mrsa outbreak; or individuals receiving home healthcare or treatment with an indwelling medical device. for mrsa detection, specimens are obtained from the anterior nares and the perineal area (surveillance sample); and from any skin lesions, wounds, incisions, ulcers, and exit sites of indwelling devices if present (surveillance and/or clinical sample) [ ] . during an outbreak or for patients located on high risk units (e.g., intensive care unit), universal admission screening is conducted. for patients hospitalized for an extended period of time, weekly mrsa surveillance cultures are performed. in addition, for patients identified with indwelling medical devices or wounds, these sites are monitored by weekly culture. if a patient is identified as an mrsa contact (i.e., roommate of a patient who is found to be mrsa positive), the mrsa contact will have two sets of surveillance cultures taken with at least one set taken seven days following their last exposure to the mrsa patient [ ] . in the participating hospital, mrsa cases were classified as healthcareassociated (ha) if the patient was newly identified with mrsa (infection or colonization) > hours following hospital admission. for a case to be included in this investigation, mrsa was newly identified between august , and february , and > hours following hospital admission. patients that were identified as being either infected or colonized with mrsa were included. only one mrsa isolation event per patient per admissiondischarge period was included in the analyses. the admission-discharge period was defined as the time interval from when a patient was admitted to, and discharged from, the hospital. transfer to another ward within the hospital was not considered a discharge. for a patient to be admitted ≥ times to the hospital, > hours between the discharge and admission dates was required. data from the first bacteriology report per patient per admission-discharge period were obtained. bacteriology reports from mrsa cases located in the emergency and hemodialysis wards were excluded as these departments specifically support outpatients. for mrsa cases identified between march , and february , , the hospital's microbiology laboratory collected and submitted patient mrsa isolates for molecular typing. in the participating facility, mrsa was confirmed from surveillance samples using chromogenic agar (bbl chromagar, mrsa, becton, dickinson and company, sparks, maryland, usa), the penicillin-binding protein a latex agglutination test (mrsa latex agglutination test, oxoid ltd., hants, uk), and vitek® (biomérieux, marcy-l'Étolie, france) according to the manufacturers' instructions. for clinical samples, s. aureus was confirmed using the gram stain and the tube coagulase test and mrsa was confirmed using vitek® . for surveillance and clinical mrsa isolates, a standard panel of antimicrobials was used for susceptibility testing and included rifampin, clindamycin, trimethoprim and sulfamethoxazole, and vancomycin. testing was performed using vitek® and results were based on the standards set by the clinical and laboratory standards institute [ ] . at the hospital level, all specimens submitted for mrsa testing were collected at the discretion of medical personnel. only one mrsa isolate per patient was collected for molecular typing. data collected from the bacteriology report included a unique patient identifier, dates pertaining to patient admission, discharge, and when a specimen was collected for mrsa testing, the ward location of the patient when the specimen was obtained, and the antimicrobial susceptibility profile of the mrsa isolate. for ward location, bacteriology reports provided both service and ward designations. services were defined as specific departments (e.g., internal medicine, surgery) whereas wards were characterized as specific, physically distinct units that comprised a service (e.g., wards s and s constituted the surgery service). information pertaining to the number of patient days per month for each service was obtained. for wards, data on patient days were collected only from those wards that were operational and provided the same service for the complete study period (i.e., months). for descriptive statistics, incidence rates for mrsa were expressed as the number of mrsa cases per , patient days. data pertaining to known mrsa outbreaks that occurred during the study period (e.g., start and end date, ward location, and number of patients involved) were collected from the hospital's infection prevention and control (ipc) department. the molecular identity of mrsa strains involved in previous outbreaks was not available as this healthcare facility does not routinely analyze mrsa strains at the molecular level. in the study hospital, standardized rule-based criteria to identify mrsa outbreaks are not employed. due to the lack of a formal definition, mrsa outbreaks were identified by hospital personnel based on an increase in the baseline mrsa rate over a rapid time period, especially when localized to one patient care area. patient isolates were obtained from the hospital's microbiology laboratory following mrsa confirmation. isolates were collected from culture plates using a sterile culture swab with stuart's media and forwarded to the laboratory at the university of guelph. upon arrival, culture swabs were streaked onto blood agar (oxoid, nepean, ontario, canada) and incubated at °c, aerobically, for hours. colonies were identified as s. aureus by gram stain, catalase test, tube coagulase test, and the s. aureus latex agglutination assay (pastorex staph-plus, bio-rad laboratories ltd., mississauga, ontario, canada). the presence of methicillin-resistance was confirmed by the penicillin-binding protein a latex agglutination test (mrsa latex agglutination test, oxoid ltd., hants, uk). molecular typing of mrsa was conducted using sequence analysis of the x region of the staphylococcal protein a gene (spa typing) [ ] . sequences were then analyzed using two different methodologies; egenomics software [ ] and the ridom system [ ] . based on egenomics, spa types are reported using a numerical system (e.g., spa type ) whereas ridom spa types are reported using a numerical system preceded by a 't' (e.g., t ). the spa types were compared to epidemic mrsa strains that are frequently found in canada [ ] . in addition, all mrsa isolates were investigated for the lukf-pv gene encoding the panton-valentine leukocidin (pvl) toxin by real-time pcr [ ] . to determine the clustering of spa types, all spa typing data were imported into bionumerics (version . ; applied maths, ghent, belgium) and were analyzed using the spa typing plug-in tool. a minimum spanning tree (mst) was constructed using the default distance bin size of %. only spa types that differed by ≤ repeats were considered to be closely related [ ] . all bacteriology reports were provided by the hospital in electronic format. the temporal scan statistic was performed using satscan version . [ ] and all descriptive statistics and model building were conducted using stata . (statacorp, college station, texas, usa). for all hypothesis tests, a % significance level was applied (α ≤ . ), if not stated otherwise. to evaluate the association between the rate of mrsa cases in the hospital and the independent variables year, month, and season, a poisson regression analysis was conducted. for the independent variable season, months were categorized in the following groupings: winter (january -march), spring (april -june), summer (july -september), and fall (october -december). the dependent variable and offset were the number of mrsa cases and the natural log of the population at risk (i.e., patient days), respectively, for a particular month. due to the hierarchical structure of the data, mrsa cases nested in wards, a multilevel poisson model including a random intercept for ward and a fixed effect for service, was used to adjust for clustering. specifically, the variable service was categorized as medicine (intensive care, oncology, pediatrics, internal medicine), surgery, and other (psychiatry, rehabilitation, hospice, childbirth, nursery). the spearman's rank correlation coefficient was used to identify correlations between all independent variables. variables with a correlation above . were investigated for collinearity and the biologically more plausible variable was retained in the model [ ] . univariable multilevel poisson models were fit using marginal likelihood estimation via the adaptive quadrature algorithm (as implemented in the xtmepoisson procedure in stata) to screen each independent variable with the dependent variable using a liberal significance level (α ≤ . ). manual backwards step-wise modeling was applied to fit a multivariable multilevel poisson model to all previously identified significant co-variables. to assess the significance of the independent variables, the likelihood ratio test was utilized. confounding was evaluated by examining the effect of the removed variables on the coefficients of the remaining variables. a variable was considered to be a confounder if it changed the model coefficients by ≥ % [ ] . interaction terms were examined for all independent variables. due to concerns regarding unexplained overdispersion, the poisson random effects model was compared to a negative binomial random effects model using akaike's information criteria (aic). the random effects negative binomial model allowed the overdispersion parameter to vary randomly by cluster based on a beta distribution (using the xtnbreg command in stata) [ ] . the model with the lowest aic was selected. based on the final multivariable model, contrasts for independent variables with > categories were examined to investigate significant differences between any two categories. to identify mrsa clusters, the temporal scan statistic employing a poisson model was used. the scan statistic involves a flexible scanning window that gradually moves across time. the number of observed and expected observations inside the window is compared to outside the window, at each time period, with the greatest excess of observed cases noted [ , ] . under the null hypothesis, the expected number of cases in each time period covered by the scanning window is proportional to its population size; whereas under the alternative hypothesis, there is an elevated risk within the window as compared to outside the window [ ] . for this investigation, the population size was defined as the number of patient-days for each service and ward on a monthly basis. the window identified as least likely due to chance, is subsequently evaluated by a maximum likelihood test with a test decision based on a monte-carlo simulated p-value [ ] . monte carlo replications were set at for this analysis. to detect mrsa clusters, only periods with high rates (i.e., a one-tailed test) were scanned. the maximum temporal window size was set to % of the study period. in addition, the scan test was adjusted for more likely clusters via an iterative test procedure with the identified clusters from previous iterations removed from the data set and a new analysis performed using the remaining data [ ] . data were analyzed on a monthly scale. a cluster was defined as a period where the rate of mrsa cases was statistically higher than expected inside a window compared to outside a window. retrospective monthly scan tests were conducted for the entire study period (i.e., august, to february, ) as well as annually (january st -december st ) from to . for , the time interval was restricted to august st -december st and for , the time interval was limited to january st -february th . for each time interval, temporal scan tests were conducted to identify mrsa clusters at three different levels including hospital wide, services, and wards. for this analysis, services were identified and included acute care, complex care, hospice, the intensive care unit, internal medicine, oncology, pediatrics, psychiatry, rehabilitation, and surgery. five wards were identified and included m (internal medicine), s (surgery), s (surgery), c (complex care), and c (complex care). significant (p ≤ . ) clusters that were identified by the temporal scan statistic were compared to outbreaks identified by the ipc department. for clusters that were characterized with molecular data, mrsa cases that comprised significant clusters were evaluated based on spa type. characteristics of significant clusters (e.g., time frame, observed and expected case numbers, p-value, and spa type) are reported. data on mrsa cases, from patients, were obtained during the study period. a total of ( . %) patients were identified with mrsa during one hospital admission-discharge period and ( . %) patients were identified with mrsa during two or more hospital admission-discharge periods. for the patients, . % (n = ) were male and . % (n = ) were female. for male patients, ages ranged from months to years (mean = . years) and for female patients, ages ranged from to years (mean = . years). the monthly incidence rate of mrsa fluctuated over the study period ( figure ) ranging from . to . mrsa cases (colonization and infection)/ , patient days with a mean of . mrsa cases/ , patient days. summary characteristics of the mrsa incidence rate per month, year, season, service, and ward are presented in table . overall, the highest incidence rates of mrsa occurred during and in (during the first two months in which surveillance data were available). on average, march, april, and may reported the highest mrsa rates on a monthly basis. at the service level, the highest mrsa rates occurred in the surgery, internal medicine, and hospice departments, whereas, the pediatric department reported the lowest mrsa incidence rate in the hospital. from march , to february , , mrsa cases were identified and ( . %) patient isolates were obtained for spa typing (table ) . overall, nine different spa types were identified with spa type /t ( . %) the most prevalent. when spa types were categorized according to the epidemic cmrsa type, the majority ( . %) of spa types were classified as cmrsa- ( table ). only one spa type, /t , was classified as cmrsa- . all isolates were negative for the pvl toxin gene. based on the mst that was constructed for clustering spa types (figure ), one major group was observed with seven different spa types reported as being closely related (i.e., difference is ≤ repeats) to spa type /t . these closely related spa types all corresponded to cmrsa- . for two or more mrsa isolates found with identical spa types, antimicrobial susceptibility profiles of spa types were examined to determine if the molecular findings could be further characterized (table ). for spa types /t , /t , /t , and /t , the antimicrobial susceptibility profiles were identical between spa types. for spa type /t , three different antimicrobial susceptibility profiles were identified. a random effects negative binomial model was chosen over the random effects poisson model based on the aic value. results from the univariable multilevel negative binomial models indicated that year and month were all significantly associated with the rate of mrsa cases in the hospital [see additional file ] . the final multivariable multilevel negative binomial model indicated that year and month were significantly associated with the rate of mrsa cases (table ). interactions between the variables year and month could not be assessed due to the number of categories for each independent variable and the resulting small number of observations per interaction term. for the independent variable year, years - had mrsa rates that were significantly higher than the mrsa rates in . results from model-based contrasts indicate that years - also had significantly higher mrsa rates than years and (table ). in the final model, the rates of mrsa were also significantly higher in months march and april compared to january. results from model-based contrasts demonstrated that significant increased mrsa rates were also noted in march and april compared to june, and for april compared to february. over the study period, the temporal scan statistic identified statistically significant mrsa clusters at the hospital (n = ), service (n = ), and ward (n = ) levels ( table ) . as separate scan tests were performed at various levels, it was observed that several clusters overlapped in time and location (i.e., service and wards). of the clusters identified at the service and ward levels, were classified as unique events. overall, clusters ranged in duration from to months (mean = . months) and involved to patients incidence rate presented is based on an average for that specific period. incidence rate presented is the total for that specific year. incidence rate presented is the total for that service or ward from august , to february , . (mean = . ) per cluster. using routine surveillance, ipc personnel identified nine mrsa outbreaks during the study period. these outbreaks occurred in five wards (equivalent to three services), ranged from weeks to months in duration, and involved to patients (mean = ) per outbreak. seven ( . %) of these previously known outbreaks were identified as significant clusters (cluster id , , , - ) based on the temporal scan statistic. of the seven events that were identified by both ipc personnel and the temporal scan statistic, three clusters (cluster id , , ) were further characterized using molecular data. for all three clusters, more than one spa type was identified; however, spa type /t was the most prevalent mrsa strain in all three events. for the cluster identified in ward s from july to february , further investigation revealed that spa type /t was identified in two different patients in november, . for the remaining mrsa clusters, ( . %) events were considered to be of short duration (i.e., - months in length) and ( . %) events were considered to be of long duration (i.e., - months in length). examination of short duration clusters revealed that seven of the events (cluster id , , , , , , ) may have been potential outbreaks as there were considerably large numbers of mrsa cases detected during a short time span. for two of these clusters, typing data indicated that spa type /t was the prevalent mrsa strain identified in the patient population. for long duration clusters, seven (cluster id , , , , , , ) were further characterized with molecular data. for six of these events (cluster id , , , , , ), several spa types were identified circulating in the patient population. however, like the short duration clusters, spa type /t was the predominant mrsa strain in all seven events. further analysis of the long duration clusters revealed potential transmission of non-spa type mrsa strains. for the complex care cluster (cluster id ), spa type /t was identified in two different patients, both admitted to the same ward, in december . in the internal medicine cluster (cluster id ), two patients were identified with spa type /t , seven weeks apart. for the surgery cluster (cluster id ), two patients, located in the same ward, were identified with spa type /t in november . in the present investigation, a cluster was defined as a statistically significant high rate of mrsa cases within a time period. using the temporal scan statistic, several significant mrsa clusters were identified, during the - surveillance period, in a community hospital. during the same time period, nine mrsa outbreaks were identified by ipc personnel using standardized surveillance techniques. however, only seven of these outbreaks were identified by the temporal scan statistic as significant clusters. this was not surprising, as others have reported similar results regarding the discordance between events identified by hospital staff and the identification of clusters employing a scan statistic [ , ] . investigation of the seven outbreaks identified by both hospital staff and the temporal scan statistic indicated that five (cluster id , , - ) were identified by the scan test with a starting and/or end date that were different from the dates provided by ipc personnel. specifically, clusters identified by the temporal scan statistic were one to seven months longer in duration; consequently, a greater number of mrsa cases per cluster were identified. for four of the clusters (cluster id , - ), the temporal scan statistic indicated that these events occurred prior to dates reported by ipc personnel. this is an important finding as these events demonstrate that there may have been a delay in the institution of infection control strategies. furthermore, two of the clusters (cluster id , ) were identified as being longer in duration by the temporal scan statistic; therefore, premature discontinuation of infection control measures by ipc personnel may have occurred. for the two mrsa outbreaks identified by ipc staff only, one outbreak was located in the intensive care unit (n = patients, month in duration) and the other outbreak was located in a ward in the internal medicine department (n = patients, weeks duration). the outbreak in the intensive care unit was identified by the temporal scan statistic; however, the cluster was not significant. for the outbreak identified in the ward of the internal medicine department, this particular ward was only operational for of the months that the study was conducted, and therefore, did not meet the inclusion criteria for a temporal scan test to be conducted at the ward level. however, temporal scan tests conducted at the hospital and service (e.g., internal medicine) levels did not result in the identification of a cluster that corresponded in time to the mrsa outbreak. in the participating healthcare facility, specific rule-based criteria (e.g., ≥ ha-mrsa cases in a week period) are not used to establish mrsa outbreaks. rather, data pertaining to the number of mrsa cases and the time period (i.e., number of days) are used to ascertain if an outbreak exists in the patient population and if an investigation should be initiated. this type of surveillance is subjective in nature and may be prone to under-reporting or overreporting of mrsa outbreaks. of the short duration (e.g., - months) clusters that were identified during this investigation, seven events were labelled by the investigators as potential outbreaks due to the large number of mrsa cases identified over a short time period. however, only two of these events could be analyzed at the molecular level, with spa type /t as the predominant mrsa strain in each cluster. these molecular findings indicate that transmission events may have occurred and that these clusters may have been equivalent to true outbreaks. for the long duration (e.g., - months) clusters identified, their biological relevance is difficult to discern. these clusters may represent extended outbreaks, temporal trends, changes in pathogen characteristics, or the representation of systematic changes (e.g., cleaning policies) at the hospital level during the surveillance period. for many of the long duration clusters, several non-spa type /t mrsa strains were identified in the patient population. these particular mrsa strains may indicate unique transmission events between patients or be part of an outbreak, as researchers have documented the existence of more than one mrsa strain during an outbreak investigation [ , ] . alternatively, these non-spa type /t strains may represent genetic changes within the spa gene, such as deletions or duplications of repeats and point mutations [ ] , resulting in different spa types. based on the mst that was constructed (figure ) , six of the spa complexes were closely related to spa type /t by a difference in one repeat. for mrsa and s. aureus, research exploring the time required for a genetic event to occur has been conducted [ ] [ ] [ ] ; however, results of these investigations are based on specific strains and specific locations of the genetic event. other plausible explanations for observing diverse spa types in these clusters include the introduction of spa types into the hospital via staff, visitors, and patients which resulted in transmission events, and healthcare workers and patients that may have been colonized with variant mrsa strains. in the study hospital, molecular typing of mrsa isolates is not routinely performed. this was a major limitation of this study, as there was no prior knowledge of the endemic mrsa strains in this facility. furthermore, not all mrsa isolates were collected from the hospital's microbiology laboratory for spa typing. consequently, the true molecular composition for some clusters is not known, and it could not be determined if all cases within clusters were a result of unique transmission events or part of a true outbreak. lastly, with the identification of a predominant spa type circulating in the patient population, the application of spa typing provided very little benefit for elucidating transmission events or recognizing potential outbreaks, especially for long duration clusters. although it was not conducted in this study, the incorporation of whole-genome sequencing may be a viable tool for further elucidating possible transmission events and identify potential/true outbreaks in the hospital setting. whole-genome sequencing provides an inventory of the microevolutionary changes of a bacterium and can be used to map genome-wide single-nucleotide polymorphisms, insertions, and deletions to a reference sequence [ ] . furthermore, this typing technique provides the best discrimination between closely related bacterial isolates in a timely manner [ , ] . for spa types identified with ≥ mrsa isolates, antimicrobial susceptibility profiles were examined to long duration cluster ( - months in length). clusters are potential outbreaks. short duration cluster ( - months in length). cluster was identified as part of a mrsa outbreak identified by infection prevention and control personnel. cluster was also identified in the rehabilitation department for the annual analysis. a-g indicates a cluster identified by > temporal scan at the service and ward levels. determine if differences in antibiograms could provide further characterization of clusters. for spa type /t , nine mrsa isolates were identified as being susceptible to clindamycin whereas all other spa type /t isolates were resistant. further investigation of these nine mrsa isolates revealed that three isolates were identified in the same internal medicine cluster (cluster id ; n = in may, ; n = in december, ) and three isolates were identified in the same surgery cluster (cluster id ; n = in july, ; n = in august, ; n = in september, ). the identification of identical spa types and antibiograms in two long duration clusters, suggests that transmission events among patients, hospital staff, or possibly even the contaminated environment, may have occurred. for spa types /t , / t , /t , and /t , it was noted that these particular spa types had indistinguishable antimicrobial profiles. this demonstrates that for the identification of transmission events and the determination of cases as outbreak or non-outbreak, relying on antibiogram data may result in inaccurate findings and the misclassification of cases as mrsa strains that differ genotypically may display identical antimicrobial susceptibility profiles. during the study period, the incidence rate of mrsa fluctuated considerably, with significant increases noted in years - . starting in december , ontario hospitals were required to report the number of newly acquired ha-mrsa bacteremias on a quarterly basis, to be posted on a web site that is accessible to the public [ ] . although the figures are affiliated with bacteremias only, the public reporting of mrsa did not result in a dramatic decrease in the overall incidence of mrsa in this facility, which is in contrast to c. difficile. in september , monthly data on c. difficile infections (cdis) from ontario hospitals were also posted on a publicly accessed web site [ ] . at the participating hospital, a separate analysis of cdis demonstrated that in and , there were significantly more cases of cdi, compared to and (data not shown). it is theorized that the decrease in c. difficile case rates may be attributable to hospitals adhering to best practices in c. difficile prevention due to the mandatory public reporting of rates [ ] . it was anticipated that this would also apply to mrsa; however, this was not observed. the significant increases in the incidence rate of mrsa cases in years - , based on the final multivariable model and model-based contrasts, are concordant with the findings from the temporal scan statistic as approximately % of the clusters identified spanned - . the increase in the mrsa case rate during this time period may have been due to the presence of respiratory viruses (e.g., influenza) within the hospital. reports of increased hospital mrsa rates during outbreaks of respiratory pathogens have been published [ , ] . in the northern hemisphere, influenza season occurs from october to march [ ] . for - , in addition to the regular influenza season, the h n influenza pandemic was identified in canada [ ] and h n patients were admitted to the participating facility. an increase in the mrsa case rate may have occurred as infection control activities and surveillance were focused on influenza and away from mrsa [ ] , reduced staffing as a result of illness, antimicrobial prescribing practices [ ] especially with fluoroquinolones which may have led to an increase in the risk for acquiring mrsa [ ] , and environmental contamination of mrsa which may have resulted in transmission events among staff and patients. the independent variable season was not found to be significantly associated with the number of mrsa cases in this hospital. seasonal variation in mrsa is debatable with some studies documenting spring [ ] or summer [ , ] with increased mrsa rates. however, in these studies, specific aspects of mrsa infections (e.g., community-acquired, healthcare-acquired, severe only) were investigated. a significant increase in the rate of mrsa cases was observed specifically in the months of march and april. as previously discussed, an increase in the number of mrsa cases in march may have been a result of the presence of influenza, or other respiratory viruses, in the hospital. the application of a temporal scan statistic to historical data from a community hospital resulted in the identification of several significant mrsa clusters. further examination of these clusters revealed several events that may be equivalent to mrsa outbreaks or transmission events that were not recognized by hospital personnel. by adopting a comprehensive approach for mrsa surveillance, clusters were identified at the hospital, service, and ward levels. infection control efforts can be focused at one or more levels to identify risk factors for mrsa acquisition and transmission, establish interventions, and evaluate control measures. the identification of specific time periods that corresponded to significant increases in the rate of mrsa cases in the patient population may have been correlated with other determinants at the hospital level, including the presence of other pathogens. in this investigation, spa typing provided very little information due to the presence of a predominant spa type. therefore, the use of a different typing technique (e.g., whole-genome sequencing) or additional supplementary information may be warranted to decipher transmission events and clusters. application of scan statistics for hospital surveillance of mrsa would probably be most rewarding in facilities with access to higher resolution molecular typing data. future research utilizing the temporal scan statistic, prospectively, with the application of molecular typing, especially whole-genome sequencing, to identify mrsa clusters in real-time and elucidate transmission events in the hospital setting, is warranted. additional file : univariable multilevel* negative binomial regression analyses of variables associated with the rate of mrsa cases. the authors declare that they have no competing interests. authors' contributions mcf contributed to the design of the study, statistical and molecular analyses, and drafting of the manuscript. dlp and ob contributed to study design and statistical analysis. wac contributed to study design and data collection. rrs contributed to study design. jsw contributed to study design and molecular analysis. all authors contributed to the editing and final version of the manuscript. rapid whole-genome sequencing for investigation of a neonatal mrsa outbreak automated detection of infectious disease outbreaks in 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cord- - pumvst authors: himmelstein, david u.; woolhandler, steffie title: the u.s. health care system on the eve of the covid- epidemic: a summary of recent evidence on its impaired performance date: - - journal: int j health serv doi: . / sha: doc_id: cord_uid: pumvst four decades of neoliberal health policies have left the united states with a health care system that prioritizes the profits of large corporate actors, denies needed care to tens of millions, is extraordinarily fragmented and inefficient, and was ill prepared to address the covid- pandemic. the payment system has long rewarded hospitals for providing elective surgical procedures to well-insured patients while penalizing those providing the most essential and urgent services, causing hospital revenues to plummet as elective procedures were cancelled during the pandemic. before the recession caused by the pandemic, tens of millions of americans were unable to afford care, compromising their physical and financial health; deep-pocketed corporate interests were increasingly dominating the hospital industry and taking over physicians’ practices; and insurers’ profits hit record levels. meanwhile, yawning class-based and racial inequities in care and health outcomes remain and have even widened. recent data highlight the failure of policy strategies based on market models and the need to shift to a nonprofit social insurance model. a randomized trial carried out by the u.s. treasury department has again confirmed that health insurance saves lives. in , the internal revenue service sent informational letters to . million taxpayers randomly selected from the . million who had paid tax penalties for failing to comply with the coverage mandate of the affordable care act (aca). the letters provided information about penalties and insurance plan costs, together with instructions on how to investigate the availability of medicaid and aca exchange coverage. in the subsequent years, coverage rates were . percentage points higher among persons who received a letter. moreover, the death rate among adults age to who received a letter (vs those who did not) was . percentage points lower, equivalent to death averted for every , individuals in that age group who were sent a letter. when americans turn and gain medicare coverage, cancer detection rates, particularly for early-stage disease, increase sharply for breast, colorectal, and lung cancer, and mortality rates fall. yet another indicator that americans are struggling to afford care: about million people have started a crowdfunding campaign to pay for medical care for themselves or a household member on sites such as gofundme. another million people started campaigns for someone outside of their household. a new study of the burden of health costs borne by different income groups -the first to encompass costs for institutionalized persons -suggests that the u.s. health care financing system is even more regressive than previous work had indicated. total health care payments, including premiums paid by workers and their employers, taxes paid, and out-of-pocket spending, consumed . % of income for the poorest fifth of the population, but only % for the wealthiest fifth. a new npr/robert wood johnson foundation/ harvard school of public health survey has found that even wealthy americans sometimes have difficulty affording care. among the wealthiest % of adults (those with household incomes above $ , ), % reported a serious problem paying medical bills within the past few years, % had a serious problem paying for prescription drugs, and % reported a serious problem getting health care when needed. among the wealthy, % said they had failed to fill a prescription or had cut back on dosages in the past year due to prescription costs. lower-income adults encountered all of the cost and access problems much more frequently. in the decade ending in , the average premium for an employer-sponsored family plan increased from $ , to $ , ; the employee's share of the premium increased from $ , to $ , ; and the average deductible increased from $ , to $ , . meanwhile, median household income increased modestly, from $ , to $ , (not adjusted for inflation). by eliminating the financial burden of copayments, deductibles, and co-insurance, improved medicare for all would cut the poverty rate by . %, according to data from the u.s. census bureau's march current population survey. out of the . million people living below the poverty line, cutting costsharing for health care would lift million out of poverty. an official estimate from the centers for medicare and medicaid services (cms), released prior to the covid- epidemic, predicted that u.s. health expenditures would grow by . % annually between and , reaching $ . trillion ( . % of gross domestic product) by the end of the period. the harms of copayments providing essential medications without charge increased adherence to treatment and significantly lowered blood pressure among canadians prescribed an antihypertensive drug, according to a randomized, controlled trial in ontario. (canada's single-payer system does not include universal drug coverage, an omission that the ruling liberal party promised to address during the election campaign last fall.) hemoglobin a c and ldl cholesterol levels also fell slightly, but nonsignificantly, in the free medications group. a new study finds that veterans health administration (va) patients, relative to americans with non-va coverage, are only about half as likely to skip a prescribed medication because of costs ( . % vs . % of others), despite va patients having lower average incomes. va coverage especially improved drug adherence among people with chronic illnesses, while shrinking racial/ethnic and income-related disparities. the va provides free prescription drugs to some patients, while charging others copays of $ per month for preferred generics and $ per month for brandname drugs, with annual out-of-pocket drug costs capped at $ . yet despite charging patients less, the va's drug spending is lower than that of private insurers because it pays drug manufacturers lower prices. when the dutch government instituted new copayments for mental health care, the use of mental health services for both severe and mild disorders decreased abruptly and persistently, particularly in low-income neighborhoods. meanwhile, the number of involuntary commitments increased by . % and episodes of acute mental health care rose by . %. while overall costs decreased by $ . million, costs increased $ . million for adults with psychotic or bipolar disorders. a recent study indicates why the us advocacy organization physicians for a national health program calls for improved medicare for all. among seriously ill medicare enrollees (i.e., those who have visited or more physicians and been hospitalized at least twice in the past year), % had a serious problem paying a medical bill, % had used up all or most of their savings, % had been contacted by a collection agency, and % were unable to pay for basic necessities. while almost all persons older than are covered by medicare, % of them lack dental coverage, and each year about % of them skip needed dental care because they cannot afford it. about % of seniors have lost all of their teeth, and many more have tooth and gum problems that compromise their nutritional status and pose other health threats. medicare provides full coverage for the first days of skilled nursing facility care, but after that, patients are responsible for copayments of more than $ (all dollar amounts in u.s. dollars) per day. skilled nursing facility discharge rates for medicare patients spike on the th day of their stay and are especially high for black and hispanic patients and those from low-income zip codes. patients discharged on day also had significantly more comorbidities than those discharged on other days, indicating that financial rather than medical reasons motivated their discharges. recent declines in u.s. life expectancy and deaths due to "diseases of despair" among working-age white people have gained wide attention. but a new study highlights rising mortality rates among working-age people of color and other disturbing trends dating to the s and earlier. population-wide life expectancy improved dramatically between and the early s, but improvement slowed starting in the s, plateaued starting in , and deteriorated between and . midlife mortality has been increasing since , and a wide variety of causes -not just diseases of despair -have contributed to the increase. native americans have suffered the worst midlife mortality increases (a % increase since ), and they now have the highest death rates of any race/ethnicity group ( % higher than non-hispanic whites). midlife mortality for blacks began increasing in and is currently % higher than non-hispanic whites. although each of these groups experienced large increases in fatal drug overdoses (with the largest increase - % since -among the black population), deaths from many other causes also increased. maternal mortality was % higher for blacks than for non-hispanic whites in ( . vs . per , live births), according to new data from the centers for disease control and prevention. hispanics' maternal mortality rate was the lowest, at . per , . many wealthy nations have poverty rates comparable to the united states' before accounting for the effect of social programs. but their more robust safety nets cut their poverty rates to levels far lower than ours. while government programs cut the poverty rate in the united states from . % to . %, comparable figures for finland are . % to . %; for denmark, . % to . %; for france, % to . %; for germany, . % to . %; and for italy, . % to . %. in the united states, the ratio of chief executive officers' (ceos') pay to the average workers' income rose from less than : in to : in . between and , private insurance costs per enrollee grew by . %, far faster than cost growth in medicare ( . %) or medicaid ( . %). for big health insurers, was a banner year. the profits of the largest u.s. publicly traded insurers increased % from , to $ . billion, driven by a wave of mergers and acquisitions. hospitals and outpatient practices may be struggling, but unitedhealth, the nation's largest private insurance firm, is doing just fine. in the quarter ending march , , the company made a profit of $ billion, an increase of $ million over the same quarter in . its "medical loss ratio," the portion of premiums that actually pay for care, fell to % (implying an overhead of %) from % in . yet another medicare advantage (ma) scam: collect premiums from medicare, while patients get their care from the va. about . million veterans are dually enrolled in an ma plan and the va. during a -year period, one quarter of dual ma/va enrollees undergoing coronary revascularization procedures had their procedures at a va facility, increasing costs for the va system -and saving ma plans -$ . million. the justice department has filed suit against anthem (owner of many for-profit blue cross plans) for medicare fraud, charging that the giant insurer combed ma enrollees' charts for additional diagnoses that would boost the ma premiums paid by cms, but then failed to delete inaccurate diagnostic codes that it discovered. anthem's chart reviews generated about $ million annually in extra payments between and . the suit comes after a department of health and human services inspector general's report found that ma plans had increased their risk-adjusted payments by $ . billion in based on chart reviews, and that for % of the chart review-based diagnoses, no visits, procedures, tests, or supplies were recorded in the chart. hence, according to the inspector general, while "beneficiaries may not have received any other services for the . . . diagnoses . . . medicare paid billions in ma risk-adjusted payments to provide care for these beneficiaries." more than in ( . %) privately insured patients undergoing surgery with an in-network surgeon and facility received a "surprise" bill for out-of-network care, most commonly for an out-of-network surgical assistant or anesthesiologist. the bills averaged $ , ; patients covered by aca exchange plans more frequently received out-of-network bills ( % of procedures for aca exchange plans vs % for non-exchange plans). surprise bills are even more likely after an emergency department (ed) visit or overnight hospital stay: . % of visits by privately insured patients to an in-network ed resulted in a "surprise" bill for out-of-network care in , up from . % in . similarly, . % of privately insured inpatient admissions at in-network hospitals resulted in an out-of-network bill, up from . % in . in , the out-of-network bills averaged $ per ed visit and $ , per inpatient stay. the partnership for america's healthcare future, an "astroturf" group funded largely by insurance and drug firms to oppose reforms that threaten their interests, bought half of all political ads in iowa during the runup to the presidential primary in the summer of . most of the ads bashed medicare for all. hospital leaders and policy wonks often claim that the recent wave of hospital mergers and acquisitions will improve efficiency and upgrade quality. however, previous studies found that the consolidation of hospital ownership has raised prices, and a new analysis refutes the claim that mergers improve quality. performance on measures of patient experience declined at hospitals acquired by a larger system between and as compared to other hospitals. neither mortality rates nor hospital readmission rates improved in the newly acquired hospitals. affiliation with a large system has also been trumpeted as a solution to the woes of struggling rural hospitals. but a new study indicates that, although affiliation improved rural hospitals' finances, it led to significant reductions in the availability of diagnostic imaging technologies, obstetric and primary care services, and outpatient care. many "nonprofit" health systems rake in enormous profits. in , kaiser foundation health plan and hospitals had an operating surplus of $ . billion. other big gainers included: mayo clinic ($ million), indiana university health ($ million), intermountain health ($ million), the university of pennsylvania health system ($ million), new york-presbyterian ($ million), and partners healthcare system, now renamed mass general brigham ($ million). many leading academic medical centers are highly profitable, but provide only modest amounts of care for medicaid or uninsured patients. the mayo clinic's record is especially egregious, and its ceo openly instructed employees to prioritize privately insured patients over those covered by medicaid. the clinic realized an operating surplus of $ million in , but charity care accounted for only . % of expenses (half the level of the cleveland clinic), and just % of medical care revenue came from medicaid, versus % at cleveland clinic and . % at cedars sinai in los angeles. hospitals in new york have filed almost , lawsuits against patients since seeking to collect on unpaid bills. the suits included , by new york university's winthrop hospital and , by northwell's north shore university hospital. many eds have closed in recent years, either because hospitals have been shuttered entirely or because hospitals that stayed open wanted to avoid often-unprofitable ed patients. a recent study found that when eds closed and patients' driving time to the nearest ed increased by minutes or more, the proportion of heart attack patients who received a percutaneous coronary intervention fell, and both mortality and readmission rates increased. kidney transplantation is the optimal treatment for most patients with end-stage renal disease (esrd), but only % of u.s. patients newly diagnosed with esrd receive a transplant or are placed on a transplant waiting list within year. esrd patients cared for at nonprofit dialysis facilities are times more likely to be placed on a transplant waiting list and % more likely to actually receive a transplant than patients at for-profit facilities, most of which are owned by giant firms, fresenius and davita. dr. michael apkon has up-close experience with care on both sides of the u.s./canada border. he was the chief medical officer at children's hospital of philadelphia before serving as the ceo of the hospital for sick children in toronto. he returned to the united states to become ceo of tufts medical center in . according to dr. apkon: what i saw was the impact [canada's single-payer system] has on the ease of access, the quality of the outcomes, and the social justice of the system . . . the moral distress [due to] barriers that are there because of the way the system is constructed, those were issues that i never faced in ontario . . . what i came to appreciate in canada is that there are things that markets are just not built to do. pay-for-performance, accountable care organizations, and "paying for value, not volume": more evidence of failure "next generation" accountable care organizations (acos) not only failed to save money, but actually increased medicare's costs by $ . million during and , according to a university of chicago study funded by cms. although the acos cut medicare spending on care by $ . million, the bonuses cms paid them greatly exceeded the savings. the findings add to the growing evidence that acos either increase costs or (at best) achieve only trivial savings. in california, % of the quality measures for medicaid-managed care plans have been stagnant or deteriorated since . three of the child-health measures currently in use have worsened, while others remained stagnant. for-profit plans scored markedly worse than nonprofit or public plans. a new study refuted the assertions of a widely cited new yorker article by atul gawande that a "hotspotting" program in camden, new jersey, markedly reduces health care costs and improves quality among "superutilizers," patients with very high use of health services. the new study randomly assigned patients to either the "hotspotting" intervention in camden or a control group that received usual care. the utilization of care fell markedly over time in both the intervention and control groups, but there was no difference in readmissions, hospital days, or hospital costs over days. another randomized clinical trial found that a chronic disease management program for patients hospitalized with chronic obstructive pulmonary disease (copd) actually worsened outcomes. the study compared usual care to an intervention that included transition support by specially trained nurses for days after hospital discharge to assure adherence with discharge plans and connection to outpatient care, as well as months of help for patients and families with self-management of copd. but the intervention group had more hospital admission and ed visits than the control group, without any improvement in patients' quality of life. primary care doctors and non-surgical specialists spent on average more than minutes per ambulatory encounter using electronic health records (ehrs), according to a study of about million encounters with , physicians who used cerner's ehr. one third of ehr time was spent on chart review, about one quarter on documentation, and % on entering orders; % of the interactions occurred on nights and weekends. the authors estimate that using the ehr took about minutes longer per encounter than using paper records. health care to cut workers' wages by %. palo alto online a mounting casualty of coronavirus crisis: health care jobs covid- hits some health care workers with pay cuts and layoffs. shots: health news from npr table b- . employees on nonfarm payrolls by industry sector and selected industry detail health insurance and mortality: experimental evidence from taxpayer outreach (nber working paper # ) does medicare coverage improve cancer detection and mortality outcomes? (nber working paper # ) straining to pay bills, more patients turn to crowdfunding. modern healthcare accounting for the burden and redistribution of health care costs: who uses care and who pays for it school of public health. life experiences and income inequality in the united states trends in employer health care coverage medicare for all would cut poverty by over percent. people's policy project national health expenditure projections, - : expected rebound in prices drives rising spending growth effect on treatment adherence of distributing essential medicines at no charge: the clean meds randomized clinical trial the effect of veterans health administration coverage on cost-related medication nonadherence association of cost sharing with mental health care use, involuntary commitment, and acute care financial hardships of medicare beneficiaries with serious illness high cost of dental coverage means seniors skip needed care. modern healthcare association between high discharge rates of vulnerable patients and skilled nursing facility copayments life expectancy and mortality rates in the united states maternal mortality in the united states: changes in coding, publication and data release poor america. the economist ceo compensation has grown % since . economic policy institute private insurance's costs are skyrocketing insurers reaped big financial gains from mergers in . modern healthcare unitedhealth group provides expansive support to covid- response efforts, reports balanced first quarter performance federal payments for coronary revascularization procedures among dual enrollees in medicare advantage and the veterans affairs health care system doj sues anthem for medicare advantage fraud office of inspector general. billions in estimated medicare advantage payments from chart reviews raise concerns (oei- - ) out-of-network bills for privately insured patients undergoing elective surgery with in-network primary surgeons and facilities assessment of out-of-network billing for privately insured patients receiving care in in-network hospitals the trailer: signs of change in elizabeth warren's campaign. washington post changes in quality of care after hospital mergers and acquisitions access, quality and financial performance of rural hospitals following health system affiliation most profitable not-for-profit healthcare systems mayo clinic wants to make rochester a global medical destination: but who benefits? modern healthcare new york hospitals have filed thousands of lawsuits against patients emergency department closures and openings: spillover effects on patient outcomes in bystander hospitals association between dialysis facility ownership and access to kidney transplantation q&a: the interest in preserving the status quo is very real. modern healthcare next gen acos aren't saving medicare money. modern healthcare a close look at medical managed care: statewide quality trends from the last decade. california health care foundation health care hotspotting-a randomized, controlled trial effect of a hospital-initiated program combining transitional care and long-term self-management support on outcomes of patients hospitalized with chronic obstructive pulmonary disease: a randomized clinical trial physician time spent using the electronic health record during outpatient encounters: a descriptive study the authors thank clare fauke for assisting in editing and compiling this report. the authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the authors received no financial support for the research, authorship, and/or publication of this article. david u. himmelstein, md, is a distinguished professor of public health at the city university of new york's hunter college, a lecturer in medicine at harvard medical school, and a staff physician at montefiore medical center in the bronx. he graduated from columbia university's college of physicians and surgeons and completed an internal medicine residency at highland hospital in oakland, california, and a fellowship in general internal medicine at harvard. he practiced primary care internal medicine and served as the chief of social and community medicine at cambridge hospital/harvard medical school. he cofounded physicians for a national health program, whose , members advocate for nonprofit, singlepayer national health insurance. key: cord- - xrjddwy authors: liu, xiucheng; zhuang, wei; quan, xiaoyu; zhou, yeqing; qin, hao; zou, chenghang; zhang, hao title: an especial transition phase of hospitals: the adaptation of hospital operations to the development of covid- and policy adjustments date: - - journal: environ health prev med doi: . /s - - - sha: doc_id: cord_uid: xrjddwy the ongoing pandemic coronavirus disease (covid- ) remains a significant issue for global health, economics, and society. in order to balance epidemic control and economic recovery, many countries have successively announced the gradual relaxation of some lockdown restrictions. hospitals and medical staff constitute the backbone in this war against covid- . in response to this serious situation, many hospitals went into emergency and impaired healthcare access to patients with conditions other than covid- . therefore, gradually promoting hospital operations and functions back to the new normal is important, especially when this outbreak has been effectively controlled. in this study, we introduce existing and potential problems that could seriously affect people’s health. additionally, we propose that an especial transition phase between the emergency and regular modes of hospitals can be well adapted to the current situation. on march , , the world health organization (who) declared coronavirus disease (covid- ) to be a pandemic of international concern. to date, it has swept into over countries and resulted in over million cases of infection and more than , deaths. as europe and north america have become the epicenters of the covid- , several countries continue to respond to the coronavirus pandemic with unprecedented rigor [ ] . there is little doubt that the subsequent step after the effective control of the outbreak is to implement measures to bring the society to a new normal. since march, these measures and efforts are being implemented across china including the hubei province, the hardest-hit region. considering, the enormous economic losses, and an increase in unemployment, germany, austria, and italy, among other countries, announced the lifting of some lockdown restrictions in early may . as important as it is to restart the economy, it is equally important to gradually drive hospital operations from the emergency to regular mode once the outbreak has been effectively controlled. therefore, it is an ongoing challenge to balance the normalization of hospital operations and the containment protocols to keep covid- in check. in china, public hospitals have formed the backbone in this war against the epidemic. right from the onset of the outbreak, local governments had immediately designated hospitals exclusively for covid- [ ] . these hospitals have set up temporary fever clinics and isolation sections for suspected and laboratory-confirmed cases of covid- and given priority to providing medical resources, such as protective equipment and respirators, for patients with covid- and the front-line medical staff. in addition, to mobilize healthcare resources and reduce the risk of exposure and crosscontamination, most hospitals have reduced the volumes of surgeries and patients visiting outpatient clinics. in london, the united kingdom's national health service has implemented several interventions in response to the pandemic, such as delaying elective operations and non-urgent radiological scans, and repurposing clinical areas and infusion suites to form novel front-line wards [ ] . these expedient measures would impair access to healthcare and emergency services for non-covid- -related matters to varying degrees and possibly result in the loss of innocent lives. therefore, after the epidemic has been effectively controlled, it is imperative to take measures to re-normalize the operation of hospitals. relaxing restrictions could lead to a strong rebound in the demands of patients regarding healthcare services. in the affiliated hospital of xuzhou medical university, a large public hospital in jiangsu province, the number of patients visiting the outpatient clinic and surgical volume in march increased by . % and . %, respectively, compared to the corresponding figures in february. hospitals are high-risk areas for infection and an excessive increase in surgical and outpatient clinic volumes could potentially lead to the gathering of crowds and disorderly management. recently, it was reported that more than patients were infected with severe acute respiratory syndrome coronavirus- (sars-cov- ), including nurses and doctors from a hospital outbreak in the first affiliated hospital of harbin medical university, harbin, heilongjiang province. normalizing hospital operations too early may increase the risk of exposure and cross-contamination, which may have a catastrophic effect on both the elderly patients and medical staff. studies have shown that the elderly are most vulnerable to mortality from covid- owing to weak somatic function and chronic underlying conditions, such as chronic obstructive pulmonary disease, heart disease, diabetes, and cancer [ , ] . undoubtedly, the evolving covid- epidemic has certainly aroused fear among the general population, especially the elderly. indeed, the fear of being infected in hospitals, "stay at home" policies, and emergency measures taken by hospitals, such as delaying elective operations and non-urgent radiological scans, have inevitably caused adverse consequences on the treatment modalities and day-to-day care of patients with chronic underlying conditions. however, this fear may last and might not disappear immediately following the easing of lockdown restrictions. for instance, after the epidemic was well controlled, some patients scheduled for surgery, including those with lung cancer and valvular heart diseases, voluntarily rescheduled their procedure at the affiliated hospital of xuzhou medical university. these delays in treatment owing to the fear instilled in the minds of patients may come at the expense of their health and lives. during the covid- outbreak, medical staff, especially those in the front-line of the epidemic, have endured enormous work-load and psychological pressure [ , ] . overwork, potential exposure to the virus, and a fear of infection have caused mental health problems such as tension and anxiety. liu s et al. [ ] found that the rates of depression, anxiety, insomnia, and stress symptoms among medical staff involved in epidemic prevention and control were as high as . %, . %, . %, and . %, respectively. with the gradual relaxation of policies, thousands of patients may crowd into hospitals to seek medical services. this would mean that medical staff have to invest more effort in their daily work and the management of the epidemic. however, it may be a terrible thing to push the hospital to function as before when preparation is insufficient, especially for medical workers. therefore, there should be a transition period that offers health workers some time to overcome their existing physical and mental stress. medical staff can continue to work on the premise that they are not infected. it is recommended to reduce unnecessary contact with patients as much as possible, especially for health staff who are not working in the front line, because asymptomatic infections are difficult to diagnose unless tested for nucleic acids [ ] . consequently, patients without covid- have been indicated fewer physical examinations and less sickroom nursing; additionally, humanistic care appears to have declined during this period. the transitional stage between the emergency mode and regular mode of hospitals there is no doubt that hospitals should re-enter the new normal during the post-epidemic period; however, this transition from the emergency to regular mode should be treated with caution. the normalization of hospitals cannot be accomplished in a single step; rather, it should be phased to ensure progressive recovery. an online pre-registration system based on identification cards may be useful for limiting the "compensatory expansion" of outpatients and decreasing surgical volumes. continue to control personnel access and reduce crowd gathering. it is recommended to hire professional nurses and reduce visits from family and friends. administrators should institute fever screening at hospital entrances and only afebrile individuals wearing face masks should be permitted into and out of hospitals. during the current covid- epidemic, taking "containment" measures is merely a temporary stopgap. in the near future, many countries including usa and india may lift lockdown restrictions to some extent, which may potentially lead to the unknown development of this epidemic. hospitals, the cornerstone of the battle against covid- , need to adapt their operation mode to take charge of the situation and make suitable changes in implementing policies and the general social behavior to effectively combat the epidemic. we need the best of science to transform the operation mode of hospitals. the especial transitional stage between the emergency and regular modes of hospitals should be well adapted to the current situation. failure in initial stage containment of global covid- epicenters containing covid- in rural and remote areas: experiences from china caring for our cancer patients in the wake of covid- epidemiology of covid- in a long-term care facility in king county, washington clinical and epidemiological features of children with coronavirus disease (covid- ) in zhejiang, china: an observational cohort study psychological interventions for people affected by the covid- epidemic psychological stress of medical staffs during outbreak of covid- and adjustment strategy online mental health services in china during the covid- outbreak asymptomatic carriers of covid- as a concern for disease prevention and control: more testing, more follow-up publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable. authors' contributions hz designed the study and approved the final version to be published. xl, wz, and xq wrote the manuscript and acquired the data. qz, hq, and cz reviewed and edited the manuscript. the author(s) read and approved the final manuscript. all data generated or analyzed during this study are included in this published article and its supplementary information files.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests. key: cord- - lkcdisr authors: asirvatham, edwin sam; sarman, charishma jones; saravanamurthy, sakthivel p.; mahalingam, periasamy; maduraipandian, swarna; lakshmanan, jeyaseelan title: who is dying from covid- and when? an analysis of fatalities in tamil nadu, india date: - - journal: clin epidemiol glob health doi: . /j.cegh. . . sha: doc_id: cord_uid: lkcdisr background: as the number of covid- cases continues to rise, public health efforts must focus on preventing avoidable fatalities. understanding the demographic and clinical characteristics of deceased covid- patients; and estimation of time-interval between symptom onset, hospital admission and death could inform public health interventions focusing on preventing mortality due to covid- . methods: we obtained covid- death summaries from the official dashboard of the government of tamil nadu, between th may and july , . of the deaths, we included cases for analysis. results: the mean age of the deceased was . years (sd: . ). the crude death rate was . per , population; the age-specific death rate was . among above years and . among less than years, and it was higher among men ( . vs . per , population). around % reported having any one or more comorbidities; diabetes ( %), hypertension ( . %) and cad ( . %) were the commonly reported comorbidities. the median time interval between symptom onset and hospital admission was days (iqr: , ); admission and death was days (iqr: , ) with a significant difference between the type of admitting hospital. one-fourth of ( . %) deaths occurred within a day of hospital admission. conclusion: elderly, male, people living in densely populated areas and people with underlying comorbidities die disproportionately due to covid- . while shorter time-interval between symptom onset and admission is essential, the relatively short time interval between admission and death is a concern and the possible reasons must be evaluated and addressed to reduce avoidable mortality. tamil nadu, india as of th july , the sars-cov- has infected around , individuals with , deaths in india ( ). tamil nadu, a south indian state with a population of around million ( ) , reported around , cases and , deaths which was % of total confirmed cases and . % of total deaths in india ( ). the rapid spread of the disease has undoubtedly become a burden to health systems in several countries, as a significant proportion of elderly, immunosuppressed and those with underlying metabolic, cardiovascular or respiratory diseases continue to develop severe forms of the covid- and are at an increased risk for adverse outcomes ( ) . at the same time, evidence is emerging to caution that young and adult general population are also at considerable risk for critical illness and adverse outcome ( ) . as the number of cases continues to increase, public health efforts must focus on preventing avoidable fatalities. when a health system is burdened beyond its capacity and the morale of health care workers are affected, the standard of care would be compromised, leading to negative health outcomes. current therapeutic strategies to deal with the covid- infection are only supportive, and prevention efforts aimed at reducing transmission in the community is considered as the most effective method ( ) . however, the fatality due to covid- could be reduced, if there is early and accurate diagnosis, identification of clinical features of severe risks, prediction of disease progression and appropriate clinical intervention. further, early seeking of medical care by people with exposure and symptoms, especially the most vulnerable, could substantially reduce the spread of infection, severity and fatality due to this disease and produce better clinical outcome ( ) . currently, the covid- infection has its presence across the globe, generating new information, fresh knowledge and evidence continuously. however, there are still many unknowns and ambiguity about the demographic and clinical characteristics of deceased covid- patients; the different time intervals between the time of infection and outcomedeath or recovery ( ) . the currently available literature indicated, information varying contextually, across regions and countries, emphasizing the need for generating evidence for a specific geography, population, and context. this study aims to understand the demographic and clinical characteristics of deceased covid- patients; and estimate the time-interval between symptom onset, hospital admission and death, which could inform public health interventions focusing on preventing mortality due to covid- . . we obtained covid- death summaries from the official dashboard of the government of tamil nadu (https://stopcorona.tn.gov.in/), a south indian state. each death summary consisted of information such as district, age, gender, type of admitting hospital, presence of comorbidities, presenting symptoms, number of days with symptoms, date of hospital admission and date of death. we collected information from th may to th july . a total of , deaths were reported during the period. we excluded brought dead cases ( ) and finalised , cases of deaths for analysis. for the analysis of comorbidities, we included only the cases that reported the presence or absence with details of comorbidities. for the analysis of presenting symptoms, we included only the death summaries that indicated the presence of symptoms with details, as the absence of symptoms j o u r n a l p r e -p r o o f on admission is not provided in death summaries. for the estimation of time intervals between symptom onset and hospital admission; admission and death, we excluded the cases referred from other hospitals due to the potential influence of the time intervals; and cases who did not have all the information. we summarised the categorical variables as frequency and percentages; and continuous variables as mean, standard deviation (sd), median, and interquartile range (iqr) as appropriate. we analysed the continuous variables using the independent t-tests or mann-whitney test/ kruskal-wallis h test. the proportions for categorical variables were analysed using chi-squared test (χ ) test. the analyses were performed using spss version . (ibm corp., armonk, ny, usa). among cases ( , ) that reported the presence or absence with details of comorbidities, . % reported any one or more comorbidities at the time of hospital admission (table- ). diabetes was found to be the most common comorbidity associated with % of the deceased; hypertension and cad were present among . % and . % of the deceased respectively. the coexistence of diabetes and hypertension; diabetes, hypertension and cad were found among . % and . % of the individuals respectively. as expected, the study found a significantly higher presence of comorbidities among the elderly compared to the younger age groups (p< . ), in terms of the presence of any one or more comorbidities, diabetes, hypertension, chronic obstructive pulmonary disease (copd), coronary artery disease (cad), the coexistence of diabetes and hypertension, and the coexistence of diabetes, hypertension and cad. as age increased, the presence of comorbidities seems to increase significantly. the presence of any one or more comorbidities (p= . ) and comorbidities categorised as others (p< . ) were found to be higher among women. private hospitals reported to have treated a significantly higher proportion of deceased patients with comorbidities such as diabetes (p= . ), hypertension (p< . ), cad (p< . ), asthma (p< . ), the coexistence of diabetes and hypertension (p< . ), and j o u r n a l p r e -p r o o f the coexistence of diabetes, hypertension and cad (p= . ), whereas public hospitals reported to have treated higher proportion of patients with ckd (p< . ). around % of deceased reported having other comorbidities such as hypothyroidism, dementia, encephalopathy, cerebrovascular diseases (cvs), hepatitis etc., however, the presence of these as independent comorbidity was found to be very low ( . %, ). around deaths summaries consisted of the details of presenting symptoms on admission (table- ) . fever was the most common presenting symptom ( . %) reported by . % of the deceased men and . % of women. breathing difficulty was reported by . % of the patients ( . % of men, % of women); around % had cough ( . % of men and . % of women) and . % had fever, cough and breathing difficulty together ( . % of men and . % of the women), however, the differences are not statistically significant. diarrhoea and generalised weakness/myalgia were reported by . %, and . % of the patients respectively, with women reporting significantly higher than men (p= . ; p= . ). fever was reported to be significantly higher among the older population (p= . ). the median time interval between onset of symptoms and hospital admission was days (iqr: , ) without significant difference among gender and age groups (table- ). the patients who were admitted in private hospitals had a median of days of symptoms as compared to public hospital patients with days of symptoms (p< . ). the median time interval between hospital admission and death was (iqr: , ) and there are no significant differences among gender and age groups. however, it was significantly higher, days (iqr: , ) in private hospitals compared to days (iqr: , ) in public hospitals (p< . ). around one fourth of ( . %) of the reported deaths occurred within a day of hospital admission (public . %; private . %), . % between to days (public . %; private . %), . % between to days (public . %; private . %) and . % occurred after days of admission (public . %; private . %) (p< . ). it is well documented that the covid- pandemic takes different shapes and forms with varying mortality levels across geographic regions and countries. though there are several studies from other countries that explained the characteristics of covid- deaths, there is a dearth of peer-reviewed and published literature from india. our study analysed the individual death summaries, and described the demographic and clinical characteristics of deceased covid- patients; and estimated the time intervals between symptoms onset to hospital admission and death, which are critical for developing context and geographicspecific public health interventions focusing on reducing the mortality. our study findings indicated a disproportionate death rate among the categories of age, gender and geography. it is well demonstrated that age is the most significant risk factor for death due to covid- and our study confirms the existing evidence. the increasing death rate with age is expected and it could be due to the higher prevalence of comorbidities, the reduced and less responsive innate and adaptive immune system among the elderly ( , ). the study reported a higher proportion of deaths ( %) among men, though the proportion of j o u r n a l p r e -p r o o f total confirmed male cases was only % in the state ( ) ; and death per , male population was . as compared to . deaths per , female population. the less mortality among women has been reported in many studies which could be due to the protection of x chromosome and sex hormones, which play an important role in providing innate and adaptive immunity ( ) . the higher mortality among men could be due to the behavioral risk factors such as smoking, and alcohol consumption, which are relatively higher among men in india ( ) . around % of deaths occurred in the capital district/city that recorded % of the total cases and just . % of the population of the state. it is also the smallest and densest of all the districts in the state ( ). the possible reasons could be, lack of timely access to healthcare facilities, delayed seeking of care, overwhelming of health system due to sudden surge of cases due to larger and exponential spread of the virus in the city. the disease severity, increased admission rate into the intensive care unit (icu), and increased risk of mortality of covid- are strongly associated with comorbidities such as diabetes, hypertension, obesity, cardiovascular disease, and respiratory system diseases and our study results confirm the previous findings ( , , ) . a study showed a hazard ratio of . among patients with two or more comorbidities compared to . among patients with one comorbidity( ). the centers for disease control and prevention reported times higher deaths among patients with reported underlying conditions compared with those without reported underlying conditions ( . % versus . %) ( ) . in our study, the prevalence of any one or more comorbidities among the deceased was found to be around %, and a significant proportion of deceased having other comorbidities such as diabetes, hypertension, and cad respectively, with a strong association with age. studies in china reported around % of deaths with any one comorbidity ( , ) , south korea and brazil reported % and j o u r n a l p r e -p r o o f . %; and these studies have reported hypertension, cad, and diabetes as the main comorbidities among deaths ( , ) . in our study, fever and breathing difficulty each was reported among / th of the deceased, cough among half of the patients and around / rd had fever, breathing difficulty and cough together, which are in line with the existing literature that fever, dry cough, shortness of breath and fatigue were the common symptoms on admission among the deceased patients ( , ) a meta-analysis of covid- patients, showed fever ( . %) as the most common symptom, followed by dry cough ( %) and fatigue ( ) . another study that reviewed , cases across the world showed % of the cases with fever and % with cough ( ) . though the study found an association between fever as a presenting symptom and age of the deceased, other symptoms and multiple concurrent symptoms did not indicate any association with age, gender and admitting hospital. the median time interval between symptom onset and hospital admission was found to be days, which is within the range mentioned in studies from china ( , days), singapore ( days), italy ( days) that indicated a range of to days ( , ( ) ( ) ( ) . the duration might change during the different phases of the epidemic due to rapid changes in the level of knowledge and awareness, stigma and discrimination, fear of the disease, programmatic interventions, health-seeking behaviors, and access to health care services. as the epidemic progresses and there is continuous scale-up of public health and social interventions, the duration is expected to decrease, which could potentially limit the infection to others. according to our study, the median time interval between hospital admission and death was days with a significant difference between patients admitted in private and public hospitals. other countries reported a slightly higher, but a wide range of to days of time interval j o u r n a l p r e -p r o o f between hospital admission and death ( , ( ) ( ) ( ) . a study that reviewed the length of stay across the world reported a shorter length of stay for those who died in hospital compared to those were discharged alive, with medians between and days compared to and days, respectively ( ) . the shorter period of hospital stay with negative outcome could be due to the delayed seeking of care due to economic reasons and lack of awareness about the disease, shortage of icu facilities and ventilators, and overwhelming of hospitals that affect the capacity to deliver services effectively. the knowledge and awareness level of health workers, especially about the rapid progression to severe illness, treatment protocols, and the availability of effective drugs could also alter the duration of hospital stay. the relatively longer time interval between hospital admission and death in private hospitals, despite the higher proportion of deceased patients with comorbidities and presence of multiple concurrent symptoms could be due to the availability advanced technology and facilities to provide advanced life-supporting critical care, the affordability of those seeking health care and less burden of patients especially for covid- management as compared to public hospitals studies reported an average incubation period of to days, which is the time interval between the exposure/infection and onset of symptoms ( , , ) . considering an average of days between the exposure/infection and onset of symptoms, the estimated time interval between exposure/infection and death is days in the state, whereas the time interval between symptom onset and death is just days. two studies have reported a higher average time interval of . and . days between the first recorded symptoms and death ( , ) , as compared to our study findings. j o u r n a l p r e -p r o o f the study provides evidence from india, emphasizing that the elderly, male and people living in densely populated areas, and patients with underlying comorbidities die disproportionately due to covid- . the study estimated a time interval of days between exposure to infection and death, with days each for symptoms onset to hospital admission; and admission to death. none of the potential factors significantly alter the time interval between the onset of symptoms and hospital admission and death, except the type of treating hospital. the shorter time interval between the onset of symptoms and hospital admission would be critical as early diagnosis, supportive care and treatment could substantially reduce the mortality especially among the elderly and vulnerable population. however, the shorter time interval between admission and death is a concern and the possible reasons must be elucidated and addressed. essentially, as the number of deaths from covid- continues to increase, early diagnosis and timely treatment for moderate and severe cases are of crucial importance to reduce mortality. the analysis is based on data available in the public domain and it is limited to only deaths that were reported in the state, through hospital admission. hospital care can vary from general ward care to intensive care and we do not have disaggregated data for this. the j o u r n a l p r e -p r 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patients with covid- in shanghai investigation of three clusters of covid- in singapore: implications for surveillance and response measures -day mortality in patients hospitalized with covid- during the first wave of the italian epidemic: a prospective cohort study clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid- infection predictors of mortality for patients with covid- pneumonia caused by sars-cov- : a prospective cohort study covid- length of hospital stay: a systematic review and data synthesis the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study. the lancet the authors declare that they have no conflict of interest. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. not required j o u r n a l p r e -p r o o f key: cord- -r gyjxei authors: kim, uh jin; lee, seung yeob; lee, ji yeon; lee, ahrang; kim, seung eun; choi, ok-ja; lee, ji suk; kee, seung-jung; jang, hee-chang title: air and environmental contamination caused by covid- patients: a multi-center study date: - - journal: j korean med sci doi: . /jkms. . .e sha: doc_id: cord_uid: r gyjxei background: the purpose of this study was to determine the extent of air and surface contamination of severe acute respiratory syndrome coronavirus- (sars-cov- ) in four health care facilities with hospitalized coronavirus disease (covid- ) patients. methods: we investigated air and environmental contamination in the rooms of eight covid- patients in four hospitals. some patients were in negative-pressure rooms, and others were not. none had undergone aerosol-generating procedures. on days , , , and of hospitalization, the surfaces in the rooms and anterooms were swabbed, and air samples were collected m from the patient and from the anterooms. results: all air samples were negative for sars-cov- rna. widespread surface contamination of sars-cov- rna was observed. in total, of ( %) environmental surface samples were positive for sars-cov- rna. surface contamination of sars-cov- rna was common in rooms without surface disinfection and in rooms sprayed with disinfectant twice a day. however, sars-cov- rna was not detected in a room cleaned with disinfectant wipes on a regular basis. conclusion: our data suggest that remote (> m) airborne transmission of sars-cov- from hospitalized covid- patients is uncommon when aerosol-generating procedures have not been performed. surface contamination was widespread, except in a room routinely cleaned with disinfectant wipes. coronavirus disease (covid- ) is a respiratory disease caused by the novel coronavirus severe acute respiratory syndrome coronavirus- (sars-cov- ). it was first detected in wuhan, china in december . despite efforts to eliminate the disease, it remains a global health threat and has caused more than six million confirmed infections and , deaths as of june , . the basic reproductive number of sars-cov- is estimated to be between . and . , necessitating aggressive control measures (e.g., active early surveillance and quarantine). it is necessary to understand the modes of transmission of covid- to develop effective control measures. epidemiological studies have led the centers for disease control and prevention (cdc) to posit that person-to-person transmission of sars-cov- is mediated primarily by respiratory droplets or contact with contaminated surfaces. however, remote (> m) airborne transmission has been suggested with increasing frequency. - in high-risk transmission settings, such as healthcare facilities, knowledge of the modes of transmission and adoption of the appropriate respiratory precautions are key factors in infection control. studies of the environmental contamination associated with covid- patients are needed to improve our understanding of the modes of transmission of sars-cov- . however, few case reports are available. , the objectives of the present study were ) to investigate air and environmental contamination caused by covid- patients in a variety of hospital settings; ) to evaluate the effectiveness of environmental cleaning; and ) to examine the potential for remote airborne transmission in the absence of aerosol-generating procedures. eight covid- patients who were not subjected to aerosol-generating procedures were enrolled from march to april , , at four facilities: chonnam national university (cnu) hospital (hospital a; gwangju, korea), cnu hwasun hospital (hospital b; hwasun, korea), cnu bitgoeul hospital (hospital c; gwangju, korea), and keimyung university daegu dongsan hospital (hospital d; daegu, korea). room conditions differed by hospital. hospitals a and b had seven and five designated airborne infection isolation rooms (aiirs), respectively, with a minimum of air changes per hour. hospital c has beds and is a designated covid- hospital. patients in hospital c were admitted to isolation rooms without negative air pressure. hospital d, which is located in an outbreak region, has beds and is also designated for covid- patients. patients are cohorted in common rooms without negative air pressure. the three patients in hospital d shared a room containing five beds. in all hospitals, the surfaces were disinfected before admission and after discharge. in addition, wipes for daily surface disinfection were used in hospital b, and spray disinfectants were used twice a day in hospital d. the wipes used for surface cleaning in hospital b were ed wipes (mh healthcare, gimpo, korea) containing benzalkonium chloride . % and four enzymes (protease, alpha-amylase, lipase, and cellulase). aerosol-generating procedures were defined as open suctioning of airways, sputum induction, cardiopulmonary resuscitation, endotracheal intubation and extubation, noninvasive ventilation, bronchoscopy, manual ventilation, nebulizer administration, and high flow o delivery, following the recommendations of the cdc. all patients were admitted to the hospital within days of the onset of respiratory symptoms. air and surface samples were obtained four times per patient: before admission and on hospital days , , and . to exclude the possibility of droplet and droplet nucleus acquisition in shortdistance during air collection, air flow was taken into account, and room air was sampled m from the patient in the direction of air escape. the md airport portable air sampler (sartorius stedim biotech; göttingen, germany) with a gelatin membrane filter was used to collect , l air over minutes at a rate of l/minute. to obtain a positive control sample, a patient / https://jkms.org https://doi.org/ . /jkms. . .e deposited saliva droplets directly onto the gelatin membrane filter. this produced a sample that was positive for sars-cov- rna. surfaces at - sites in the patients' rooms were sampled using wet cotton swabs immediately before the next scheduled daily surface cleaning. each swab was used to sample an area of . m . the entire surface of toilet door handles, patients' laptops, and patients' mobile phones were swabbed. the swabs were then submerged in ml viral transport medium. each sample was then individually wrapped and transported to the laboratory of cnu hospital within hours of sampling by a contracted car racer. real-time reverse-transcription polymerase chain reaction (rrt-pcr) was performed in the laboratory of cnu hospital, a diagnostic facility for covid- authorized by the korea cdc. first, μl was taken from each sample, and rna was extracted using an automated nucleic acid extraction system (advansure™ e system; lg chem, seoul, korea due to the nature of this study, the institutional review board of chonnam national university hwasun hospital reviewed and approved the research protocol and waived the requirement for informed consent (cnuhh- - ). we enrolled two patients from hospital a (one with an upper respiratory infection and one with pneumonia), one patient with pneumonia from hospital b, two patients from hospital c (one with an upper respiratory infection and one with pneumonia), and three patients with pneumonia from hospital d. the patient characteristics are described in table . in the rooms in hospital a (aiir without routine disinfection), sars-cov- rna was detected in of ( %) surface samples. the surfaces sampled after patient admission included bed rails, medical carts, the floor, door handles, the bathroom sink, the toilet, and other fomites (e.g., cell phones, intercoms, and tv remote controllers) (fig. a) . despite extensive surface sampling, sars-cov- rna was not detected in the room in hospital b (aiir with routine surface cleansing using disinfectant wipes the patient's respiratory samples (ct value . - . ) (fig. b) . detailed ct values are shown in table . sars-cov- rna was detected in of surface samples ( %) from hospital c (isolation room without routine surface cleaning). surfaces sampled included bathroom door handles, the floor, and other fomites (fig. c) . sars-cov- rna was detected in of surface samples ( %) from the five-bed common room in hospital d. surfaces sampled included bed rails, the floor, the bathroom sink, the toilet, and other fomites (fig. d) . appropriate respiratory precautions for covid- are still being established, and airborne precautions have been recommended by some. , however, shortages in personal protective equipment, medical staff, and hospitals equipped with aiir are of major concern during a pandemic. implementing airborne precautions for all patients may not be an option in some regions. this study of environmental contamination in four different hospital settings may aid the implementation of control measures for patients with mild covid- infection in whom aerosol-generating procedures have not been performed. the possibility of airborne transmission of sars-cov- has been demonstrated in vitro. in addition, there have been several reports of air samples testing positive for sars-cov- rna. however, those findings are difficult to incorporate into clinical practice because those studies had small sample sizes, lacked information on patient characteristics, and were conducted in wuhan, where covid- has a higher reproductive number than in other countries. previous studies have reported air samples negative for sars-cov- rna. , a recent publication from hong kong also suggested that aerosol transmission is not a route of transmission from patients in whom aerosol-generating procedures have not been performed. our data are consistent with that study in that remote airborne transmission (≥ m) was found to be uncommon in patients with mild covid- . although viral rna does not necessarily indicate an infectious virus, widespread surface contamination of sars-cov- rna was observed in the patients' rooms. this is consistent with previous case studies. , , frequently touched surfaces tended to have higher percentage of positive sars-cov- rna pcr, and extensive environmental contamination was observed for days after admission. this was true even in the rooms of patients with only upper respiratory symptoms (patients and ). the extent of environmental contamination in our study could be attributable to contamination via direct touching of patients and/or healthcare workers after contact with infected respiratory fluids. however, in this study, sars-cov- rna was not detected in a room routinely cleaned by disinfectant wipes. this demonstrates the importance of environmental cleaning in reducing exposure to sars-cov- . however, sars-cov- rna was detected in a room sprayed with disinfectant, suggesting that disinfectant sprays may not be effective in reducing exposure to sars-cov- . this study has several limitations. first, the number of patients was small, rendering it difficult to establish statistical significance. studies with larger samples and more extensive statistical analyses are needed. our study also excluded patients who had undergone aerosolgenerating procedures, which have the potential to increase airborne transmission. further studies are needed to evaluate the role of aerosols in these cases. in conclusion, our data suggest that remote airborne transmission (> m) from covid- patients is uncommon when aerosol-generating procedures have not been performed. widespread surface contamination was observed in all rooms except one that was routinely cleaned with disinfectant wipes. the reproductive number of covid- is higher compared to sars coronavirus interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease (covid- ) in healthcare settings detection of air and surface contamination by sars-cov- in hospital rooms of infected patients aerosol and surface distribution of severe acute respiratory syndrome coronavirus in hospital wards aerosol and surface stability of sars-cov- as compared with sars-cov- aerodynamic analysis of sars-cov- in two wuhan hospitals airborne or droplet precautions for health workers treating covid- ? airborne transmission route of covid- : why meters/ feet of inter-personal distance could not be enough air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus (sars-cov- ) from a symptomatic patient environment and personal protective equipment tests for sars-cov- in the isolation room of an infant with infection air and environmental sampling for sars-cov- around hospitalized patients with coronavirus disease (covid- ) we express our gratitude to the car racer soo woong hwang (h-motorsports, gwangju) who transported the specimens and instruments necessary for specimen collection between daegu and gwangju.the english in this document has been checked by at least two professional editors, both native speakers of english. for a certificate, please see: http://www.textcheck.com/certificate/ixnwjt. key: cord- - dcp rd authors: bonfá, eloisa; gossec, laure; isenberg, david a.; li, zhanguo; raychaudhuri, soumya title: how covid- is changing rheumatology clinical practice date: - - journal: nat rev rheumatol doi: . /s - - - sha: doc_id: cord_uid: dcp rd the emergence of covid- in early led to unprecedented changes to rheumatology clinical practice worldwide, including the closure of research laboratories, the restructuring of hospitals and the rapid transition to virtual care. as governments sought to slow and contain the spread of the disease, rheumatologists were presented with the difficult task of managing risks, to their patients as well as to themselves, while learning and implementing new systems for remote health care. consequently, the covid- pandemic led to a transformation in health infrastructures and telemedicine that could become powerful tools for rheumatologists, despite having some limitations. in this viewpoint, five experts from different regions discuss their experiences of the pandemic, including the most challenging aspects of this unexpected transition, the advantages and limitations of virtual visits, and potential opportunities going forward. by the largest tertiary public hospital in latin america, consisting of , beds and eight specialized institutes (heart and lung, orthopaedic, psychiatry, children, cancer, central, rehabilitation and radiology institutes). as the clinical director of the hospital and one of the coordinators of the covid- crisis committee, i was involved in the decision to isolate the central institute (containing beds) solely for patients with covid- (ref. ). this decision meant that the other seven institutes remained at low exposure for covid- . all non-covid patients from our general tertiary emergency unit and from more than specialized ward units allocated in the central institute, including the rheumatology unit, were transferred to these covid-cold institutes. patients from the rheumatology unit were transferred to the orthopaedic institute, along with patients from almost all specialized clinical wards. each specialized ward was allocated to one unit that had approximately % as many beds as were previously allocated to that ward. overall, the pandemic resulted in delays in non-emergency hospitalizations. one main challenge during this period was to divide the team between those who would work in the non-covid- area and those who were recruited to exclusively care for patients with covid- in the isolated covid- institute. a safe hospitalization flow for inpatients and employee safety was quickly established and upon suspicion of covid- , the patient was rapidly transferred to the transition area of the isolated covid- institute. another challenge was to increase the number of intensive care unit (icu) beds available in this central institute from to in months. to achieve this goal, we had to convert surgery rooms into icu beds. during the first months of the pandemic (april-july) in são paulo, > , patients with severe covid- were hospitalized in the isolated institute, and icu beds accounted for more than half of these patients. in terms of patients with rheumatic diseases, the number of hospitalizations decreased by ~ % compared with the same period in the previous year and the number of patients in our rheumatology outpatient clinics decreased by ~ %, to travel into health-care facilities, including for diagnostic tests and clinical laboratory monitoring or even infusions. the result was that with the covid- pandemic, many of the tools that we commonly wielded became unwieldy. this issue was particularly problematic for patients seeing us for a first visit, for patients who were failing to respond to therapies, for patients who needed to be seen urgently for concerning new symptoms or for patients who needed a referral to another specialist for evaluation and work-up of related independent diagnoses. in many instances, we used inadequate temporizing measures rather than a durable solution. for example, some patients with newly diagnosed inflammatory arthritic diseases were prescribed courses of prednisone until an in-person visit became possible. covid- has also taken an emotional toll on our patients, as, like many, they struggled to balance their personal lives as our society shifted towards a lockdown and with the anxiety of a pandemic. abstract | the emergence of covid- in early led to unprecedented changes to rheumatology clinical practice worldwide, including the closure of research laboratories, the restructuring of hospitals and the rapid transition to virtual care. as governments sought to slow and contain the spread of the disease, rheumatologists were presented with the difficult task of managing risks, to their patients as well as to themselves, while learning and implementing new systems for remote health care. consequently, the covid- pandemic led to a transformation in health infrastructures and telemedicine that could become powerful tools for rheumatologists, despite having some limitations. in this viewpoint, five experts from different regions discuss their experiences of the pandemic, including the most challenging aspects of this unexpected transition, the advantages and limitations of virtual visits, and potential opportunities going forward. nature reviews | rheumatology reducing from a mean of ~ , patients per month to ~ , patients per month. the rheumatology biological center, a separate unit dedicated exclusively to patients under biologic therapy, remained opened during the pandemic, and the number of appointments reduced by only ~ % compared with the same period in the previous year. zhanguo li. as a rheumatologist practicing at peking university people's hospital, beijing, the biggest challenge during the covid- pandemic has been how to manage patients with rheumatic diseases remotely using online systems, social media platforms (such as wechat) or telephone calls, because the patients simply could not physically attend the hospital. this alternative access to care was unprecedented and was previously even prohibited by our medical systems and insurance policies. the situation was extremely challenging for rheumatologists and patients for quite a few months, as rheumatologists had no existing online, regulated system for prescribing treatments. consequently, the ceasing of medication or inappropriate self-management occurred in many patients across the country, resulting in flares of disease in some patients. was scarce or lacking, and i feared bringing covid- back home. this situation challenged my conviction that my job as a rheumatologist is the best in the world! for me, the second biggest challenge to managing my (non-covid) patients over the past months has been my fear of putting them at risk through my prescriptions. i mainly see patients with inflammatory arthritis, most of whom are treated with biologics or other targeted therapies. initially, we had no information as to the potential risk associated with such treatments, in terms of increasing the risk of or severity of covid- . thus, whereas i have always prescribed such treatments with the conviction of helping my patients, the challenge here is a profound rethinking of the benefit-to-risk balance of my prescriptions. eloisa bonfá. for the first time, the rheumatology outpatient clinics of our hospital provided virtual care over the phone to define which patients could have their visit postponed, which patients needed a change in prescription or which patients had to come to the clinic for an appointment. postponing all previously scheduled rheumatology outpatient appointments was a challenging task owing to the large number of patient appointments per week (approximately ), and it required a team of staff fully dedicated to this assignment. those health-care workers who were at a high risk of severe illness from covid- were selected for this job. this procedure required several adaptations for the medical staff and patients due to the lack of previous experience with virtual care, as telehealth was only endorsed by the federal council of medicine during the pandemic . several measures of care and risk assessment were established for patients who were required to come into the clinic for an appointment, such as screening for covid- symptoms at entry and at the reception as part of the routine clinical assessment. patients were recommended not to attend a face-to-face appointment if they had any symptoms of covid- . other adaptations included reviewing appointment scheduling, physical distancing in waiting rooms, hand hygiene care and appropriate personal protective equipment. mask wearing is still mandatory in brazil for any outside activity during the pandemic and is also compulsory for patients during appointments. david isenberg. managing patients with serious autoimmune rheumatic diseases (who are often on steroids, immunosuppressives and/or biologics) who you cannot see and examine and do blood tests on has been a huge challenge. it is clear that many patients who have been carefully shielding have not wanted to come to hospital (at the university college hospital, situated in the centre of london) and some have clearly tried hard to deny (to themselves as well as to their physicians) the fact that their underlying disease was getting worse. we had a particularly troubling time months into the pandemic when, in a period of about week in april, we had to admit six patients with systemic lupus erythematosus (sle) who were experiencing acute flares -three of whom went straight into the icu and two of whom died. gossec. an overall and overarching challenge to my practice as an academic full-time rheumatologist at sorbonne université and pitié-salpêtrière hospital, paris, france, was my inner turmoil. when i was young, i spent a few months doing volunteer medical work in a developing country, but for me, this role led to less personal risk than the current pandemic, especially as personal protection equipment eloisa bonfá is a full professor of rheumatology and the clinical director of the largest tertiary public hospital of latin america. her main clinical and research interests are systemic lupus erythematosus and autoimmunity, with relevant contributions in the fields of autoantibodies, vaccines and drug monitoring in autoimmune diseases. she graduated at the university of são paulo medical school, brazil, and undertook specialist training in rheumatology in the same university followed by a -year rheumatology research fellowship at the hospital for special surgery, new york. laure gossec is a professor of rheumatology at sorbonne université and pitié-salpêtrière hospital, paris, france. she has a half-time clinical position where she mainly sees patients with inflammatory arthritis, and a half-time teaching and research position. her main research interests are patientreported outcomes and quality of life, as well as e-health and big data in psoriatic arthritis, spondyloarthritis and rheumatoid arthritis and she has authored more than papers. she is a past-chair of the epidemiology standing committee of eular. david isenberg is the academic director of rheumatology at university college london, uk. he has run both general and autoimmune rheumatic disease clinics for over years. his major research interests are in the structure, function and origin of autoantibodies and improving the assessment of patients with autoimmune rheumatic diseases. zhanguo li is a professor and head of the department of rheumatology and immunology at the peking university people's hospital, china. he is the past president of aplar, and the president of the clinical immunology committee at the chinese society for immunology. he is editor-in-chief of the chinese journal of rheumatology. his research interests are the mechanisms and immune therapy of rheumatic diseases, including rheumatoid arthritis and systemic lupus erythematosus. soumya raychaudhuri is a professor at harvard medical school, and a practicing rheumatologist at the brigham and women's hospital arthritis center. he is also appointed at the broad institute, and the university of manchester. he spends most of his time running a lab that is focused on defining mechanisms of disease in rheumatoid arthritis, and other immune-mediated diseases, using computational biology, genetics and functional genomics. www.nature.com/nrrheum zhanguo li. to adapt to the totally unexpected changes to clinical practice, one option in my department of the people's hospital was to set up a consultant team consisting of rheumatologists to provide medical service free to patients with rheumatic diseases, supported technically by an internet company. it was the first rheumatologist team to provide such support to patients in the country. many patients nationwide were helped by this group over a -month period, from early february to late march . in addition, we used a previously developed smartphone application (smart system of disease management (ssdm)) as a patient self-care instrument to evaluate disease activity and remind patients to contact rheumatologists. the ssdm system was designed for a research project , and the clinical value was also clearly shown in the patients who used this ssdm system during the initial months of the covid- pandemic. david isenberg. my practice has changed completely. during the first months of the pandemic, no routine appointments were offered (although an emergency clinic once a week was available) so that all outpatient consultations took place over the phone or occasionally by video conferencing. for patients with longstanding, well-established disease and on low or moderate doses of steroids and immunosuppressives, i was reasonably content to miss seeing the patients at routine follow-up appointments, but increasingly i have become concerned about the inadequacies of what can be done when not seeing patients face-to-face. among the pleasures and responsibilities of running clinics in an academically inclined institution are doing research and educating both undergraduate and postgraduate students. the introduction of more remote patient assessment has had, and will always have, a detrimental effect on both. it will be harder to recruit patients to trials. we cannot, for example, perform acr , acr or acr assessments of our patients with rheumatoid arthritis or british isles lupus activity group (bilag) assessments of our patients with sle, to help determine their eligibility for a clinical trial. the patient cannot agree to have their blood taken remotely for a project. likewise, teaching opportunities are restricted if we cannot, for example, demonstrate the use of the cross fluctuation test to show fluid in the knee of a patient, identify an enlarged liver or spleen or identify an extensor plantar response. these problems will obviously be detrimental for patient care too. to encourage my patients to come in and see me, especially when so many of them are worried about covid- and the personal risk to themselves. although these changes are essential to our ability to see patients in person, they do make the experience of being a doctor somewhat less personal. implementing social distancing has meant that i see fewer colleagues and staff. it also means that many of the spouses and family members that often accompanied my patients are no longer present. i no longer greet my patients in a crowded waiting room, rather they are brought in from an empty waiting room. masks are essential to protect our patients, especially those on immunomodulatory therapies, but they do make non-verbal cues harder to glean. overall, in-person visits continue to be essential, but they do not feel quite as warm or friendly. on the other hand, virtual visits have been much more effective than i might have anticipated. our clinical infrastructure has enabled video visits, which have proven to be far more productive than a simple phone call. the video visits are very practical and effective for my longstanding patients who are doing well on established therapeutics. previously, some patients who live further away might have taken a day off to drive into boston -in some instances from out of state -for a physical visit. for some of these patients, the ability to do a visit virtually has saved them valuable time. the virtual visit is often more efficient as visits can be easily started and ended, and the next visit can be started immediately. but the virtual visit has definite limitations. most obviously, the inability to do an in-person physical examination and joint examinations cannot be reproduced via video. the exam is essential for assessing our patient's disease activities or making diagnoses, and taking care of new patients or patients with active disease can hence be really challenging. video visits expose the digital divide of our society, and some of our patients are unable to fully take advantage of our infrastructure, especially those who are of fewer means, have poorer internet access or are older and less comfortable with technology. david isenberg. although apocryphal, there is a story that the then chinese premier zhou enlai, when asked by henry kissinger, richard nixon's secretary of state, laure gossec. my professional life has profoundly changed since february. my research activities usually involve very frequent travels to other countries, which have completely stopped since february. my academic work as a professor of rheumatology involves face-to-face interactions with students, which likewise have disappeared completely and have been replaced (partly) by online courses, which are by essence much less interactive. as regards my clinical work, my practice has changed because the hospital has become a place of dread and doom. my patients with inflammatory arthritis do not want to come to the hospital anymore, and i myself feel reluctant to ask them to come. for this reason, for months, all of my patient clinics were switched to teleconsultation, where no physical examination is possible and where the quality of care is lower. in the hospital, instead of accommodating patients with severe rheumatic diseases, our beds were taken over for patients with non-rheumatic diseases, for whom my added value and competency is much lower. one of the fun and interesting parts of my work is interactions within the medical and non-medical team as well as with colleagues outside of rheumatology (such as through staff meetings). most of this social interaction has now disappeared, replaced somewhat by e-mail exchanges. soumya raychaudhuri. i spend most of my time running a research lab in an academic setting. that part of my life has completely changed. like many workplaces, we have moved almost entirely to virtual work environments. hence, research and education has become much less interactive and we have had to shift our culture to accommodate this major change. my clinical practice is within the bwh arthritis center, which is a large clinic that hosts , patient visits per year. my practice specifically has shifted to include more virtual visits and fewer in-person visits. from march to july, my practice was almost entirely virtual. for in-person visits, to reduce the risk of infection for our staff and our patients, the bwh arthritis center has made dramatic changes in the way we interact with each other and with our patients, the flow of patients in and out of the clinic and the clinic rooms, how clinic rooms are turned over and many other components. the changes have been well executed and have affected every aspect of our clinical experience. the result is that i feel confident i do think the situation will mostly go back to normal, as my clinics require the use of physical examinations and ultrasonography. i am planning to keep around % of consultations online for patients in the long term. soumya raychaudhuri. i think that some of the changes will be here to stay. boston is a challenging city for many of our patients to get in and out of, particularly those who are coming from far away, or for those for whom driving or navigating public transportation is hard. for these patients, especially for routine follow-up visits, a virtual visit can offer real advantages. there are patients all over new england who would benefit from access to a referral centre. i can imagine if our institution or others are able to build a great virtual care infrastructure, we could be in a position to expand the scope of patients who our physicians are connecting with and caring for. laure gossec. barriers to online consultations include poor access to the internet for some patients, low-quality internet connection on either side, a lack of user-friendly medical files and also a psychological reluctance from patients regarding online consultations (most patients prefer to see me face-to-face). the wearing of masks is also a barrier to my clinical practice. it hinders the interactions with my patients, which makes shared decision-making (probably the most rewarding part of my clinics) more difficult. will it be that masks will push us back in time, to paternalistic prescriptions? who can say? zhanguo li. current barriers are the lack of a 'telehealth' and medical support system for patient care, which can facilitate patients and doctors in terms of consultations, efficient follow-up and clinical studies. if a second wave of covid- comes, we will face the same difficulty as we had a few months ago. eloisa bonfá. the most important adaptation is consolidation of the regulatory framework for telemedicine in brazil, including reimbursement for this activity. another notable barrier that is expected is the serious economic crisis resulting from the covid- pandemic that will limit investment resources in all areas including health. this limitation of resources will hinder the development and implementation of innovations. hopefully, increased solidarity, a hallmark of this crisis, and regional cooperation will help to overcome the challenges we will have during reconstruction. soumya raychaudhuri. i think telemedicine and virtual medical care could become really powerful tools for the right patient with the right infrastructure. i think that we need to make sure that our patients have access to a proper it infrastructure to mitigate access issues. if language is a barrier, we need to have a means of enabling translation services during our virtual visits. to realize the full potential of virtual care, we need to be able to arrange services and testing for our patients within their communities. after the visit, having an integrated health-care system that enables seamless data transfer is essential. with such an integrated health-care system, arranging imaging, lab work, therapeutic infusions and other services near to home becomes possible without cumbersome administrative barriers. currently, for my more distant patients, i often need to bring them into boston for tests and services. in many cases, they have alternative facilities near to their home, but those facilities are not connected to our system, and arranging local testing and services is challenging without extensive administrative effort. david isenberg. i anticipate that it will be even more important to stress to patients, if their disease is worsening and they have not been seen by a physician (or nurse), that they must contact the hospital and arrange a face-to-face appointment as soon as possible. from the administrative point of view, there will need to be greater flexibility about determining whether patients are to be seen face-to-face or via a telephone consultation. closer links with general practices will also be necessary as, in my experience, some general practitioners have been reluctant to take on routine monitoring of patients on immunosuppressive medication. zhanguo li. many opportunities lie ahead, as long as we focus on the needs of patients and rheumatologists. undoubtedly, more patient-associated and doctor-associated activities will be held online, providing opportunities for patient education and for his opinion on the effects of the french revolution, replied "too early to say". i think the same is true for assessing the long-term effects of covid- . the pandemic has highlighted the value (at least in the short term) of fully electronic record systems, which makes it possible to see patient records, including letters, imaging and blood test results, remotely. i can certainly envisage that some routine follow-up appointments can be undertaken remotely and safely (provided local blood tests can be done), which may well reduce the numbers of patients attending specialist clinics. eloisa bonfá. engaging back to 'normal' activities will take time and it will probably have to wait for a vaccine. until then, all adaptations and risk assessments will remain. but one of the major gains the covid- pandemic will bring is the consolidation of telemedicine and televisits in the care of patients. taking into account that many patients with rheumatic diseases have mobility difficulties, telehealth will provide an alternative approach to the care of these patients, when possible. furthermore, in a large city such as são paulo, with chaotic traffic and long distances, the possibility of avoiding public transportation, not only to prevent the spread of covid- but also to avoid other issues beyond the pandemic, will be more convenient for the patient. zhanguo li. covid- has certainly changed rheumatology practice. although the patient volume has now returned to normal in china, the demographics of patients attending outpatient clinics have altered in terms of disease severity and distance of travel. patients with mild diseases who live in remote areas now tend to see their local doctors, rather than come to rheumatology centres. laure gossec. at this stage, i do not really foresee the situation ever fully getting back to normal. it seems to me that social distances will be increased for a long time. in france, we usually hug and kiss a lot, which i do not think will go back to normal anytime soon. as for my professional life, i do not foresee going back to my previous rate of travel related to my research activities. i also think that medical teaching will be profoundly modified now with much more online resource use and much less face-to-face teaching. from that point of view, we were quite late in france in adopting these teaching methods, and this pandemic might well be an opportune moment for this change. as for my patients, www.nature.com/nrrheum virtual conferences, although patients with severe or difficult-to-treat disease will still need face-to-face appointments with their rheumatologist. laure gossec. improving access to best care, through online consultations but also by improving the patient trail (that is, the way in which patients first see their general practitioner before being referred to a rheumatologist) and decreasing the delay before a consultation, is a priority. better use of online resources and maybe of rheumatology nurses, if they are allowed to play a bigger role in france, are options to move forward, which may be facilitated by the covid- pandemic. soumya raychaudhuri. the implementation of effective virtual visits will be really powerful for rheumatology. the need for an in-person visit will always be there, especially for patients with very active disease or for new patients with uncertain diagnoses. but for patients who we know well, managing them to some extent virtually will have great value. i think in practice these are the patients we talk to on the phone informally and e-mail with. so, having a formal mechanism to take care of them will be beneficial to them and to us. david isenberg. by doing more telephone consultations and reducing the numbers of patients attending clinics face-to-face, it should be possible to reduce the waiting times for patients referred to rheumatologists. i am, though, becoming increasingly concerned about the 'downsides' of what has happened in the past months, notably the missed occurrences of increased disease activity in patients, the loss of educational opportunities for physicians and the difficulties in undertaking translational research. eloisa bonfá. innovations associated with self-care, including smartphone apps and wearable technologies, consolidated during the pandemic, are interesting alternatives for the management of several chronic conditions and will certainly also be useful for patients with rheumatic diseases. above all, there is no way back and the acceleration of digital transformation and the improvements in internet speed that occurred during the pandemic will continue and will transform our lives. this change will provide new opportunities for physicians to update their knowledge on the field and for continuing medical education online, without the need for physical travel. in addition, for organizations, a new way of dealing with administrative work took place with changes in workflows, including replacement of meetings with e-mails, increased working from home and accelerated automation that will forever change the way we work. how a premier u.s. drug company became a virus 'super spreader transmission of -ncov infection from an asymptomatic contact in germany overcoming barriers to providing comprehensive inpatient care during the covid- pandemic letter no. / , federal council of medicine, brasilia (mauro luiz de britto ribeiro to luiz henrique mandetta decree no. . , legislative assembly of the state of são paulo covid- in patients with rheumatic disease in hubei province, china: a multicentre retrospective observational study published online xx xx xxxx l.g. receives research grants from amgen, galapagos, janssen, lilly, pfizer, sandoz and sanofi, and receives consulting fees from abbvie, amgen, bms, celgene, gilead, janssen, lilly, novartis, pfizer, samsung bioepis, sanofi-aventis and ucb, all unrelated to the present paper. s.r. is an employee of brigham and women's hospital, and has recently served as a consultant for abbvie, biogen, gilead, merck and pfizer. he is a founder of mestag. he currently receives research funding from biogen. e.b., d.a.i. and z.l. declare no competing interests. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -fnn wshy authors: moccia, giuseppina; motta, oriana; pironti, concetta; proto, antonio; capunzo, mario; de caro, francesco title: an alternative approach for the decontamination of hospital settings date: - - journal: j infect public health doi: . /j.jiph. . . sha: doc_id: cord_uid: fnn wshy background: the increasing emergence and spread of multiresistant microorganisms in hospital wards is a serious concern. traditional protocols are often not sufficient to protect patients susceptible to serious and life-threatening infections, therefore new strategies for decontaminating hospital environments are crucial to reducing microbial transmission and the spread the nosocomial infections. the adoption of modern technologies is indicated to supplement traditional methods and to improve desired levels of surface disinfection. aim: this work aims to report the development, implementation, and validation of cleansing and sanitizing procedure for critical clinical settings through the innovative use of disposable cloths pre-impregnated with solutions containing different active formulations and biocidal agents, relating to the areas to be treated (low, moderate, high-risk). methods: the implementation and validation of the sanitizing system were conducted in different wards of two healthcare structures. the protocol for the study involved a structured selection of representative surfaces, such as the floor, bathroom, desk, and beds. microbiological analyses were performed according to iso - : . findings: the efficiency of the proposed system was measured through the estimation of total microbial count values on the different surfaces before and after the sanitization operations by traditional methods and by the system described here. the results demonstrated a significant reduction in the microbial count that always fell below the threshold value. for the analyzed surfaces such as shower tray, bathroom floor, toilet edge, the traditional system had an effectiveness of less than %, whereas pre-impregnated cloths succeed to eliminate about % of the bacteria present. as an example, on the floor we observed a microbial count reduction from > to cfu/ cm( ) with the new method ( % of colonies were destroyed), while with the traditional one we have a reduction from > to cfu/ cm( ) ( % of microbial colonies). moreover, the advantages of using this sanitization system are not limited to disinfecting surfaces and limiting cross-contamination but involve all activities related to the cleaning and disinfection operations, including the training and education of the operators and traceability of the operations. conclusions: the innovative disinfection and cleaning protocol used in the present study proved to be a highly valuable alternative to the traditional cleaning procedures in healthcare settings for the sanitizing process of all kinds of surfaces. all tools were specifically designed to improve disinfection efficiency and to reduce the problems associated with traditional methods, such as preventing cross-contamination events, limiting the physical efforts of operators, and avoiding incorrect practices. our findings add support to the knowledge that an effective sanitization procedure is critical in minimizing microorganisms' transmission and cross-contamination. the recent public health emergency of coronavirus disease declared by the world health organization (who) introduced the need for new strategies to face the pandemic. in particular, hospitals have to use appropriate protocols to manage their space, staff, suppliers, patients to reduce infection, and in-hospital transmission. the virus aerosol deposition on protective apparel or floor surface and their subsequent resuspension is a potential transmission pathway and effective sanitization is critical in minimizing aerosol transmission of pathogens. cleaning practices are of utmost importance to improve the healthiness of indoor environments and hospitals to prevent further spread and nosocomial infections diffusion [ ] [ ] [ ] [ ] . hospitals and some critical clinical departments, such as intensive care units, oncological units, departments with dialyzed patients, are considered potential points for opportunistic pathogenic microbes [ , ] . pathogens can spread from patient to patient through contact with inanimate surfaces, including medical equipment and the environment close to the patient [ ] [ ] [ ] . there is clinical evidence of a close relationship between environmental hygiene and transmission of microorganisms which produces nosocomial infections such as environmental contamination from methicillin-resistant staphylococcus aureus, the transmission of norovirus, clostridium difficile, pseudomonas aeruginosa, and acinetobacter spp. [ ] [ ] [ ] [ ] [ ] [ ] ] . various approaches have been used to disinfect critical environments but there are still many difficulties related to traditional equipment used and to implementation of procedures. moreover, in many cases, due to lack of formal surveillance, the rate of healthcareassociated infections is high and compliance with hygiene is low. strategies for the decontamination of hospital environments are described in guidelines proposed by various international committees [ ] , in particular, the advisory committee for the practice of controlling sanitary infection underlines the importance of correct cleaning operations to promote decontamination and the necessary use of disinfectants to reduce the microbial contamination in hospitals [ ] [ ] [ ] . although traditional cleaning protocols are applied and appropriate disinfectants are used in the right concentrations, statistical analyses revealed increasing infections and data suggest that traditional protocols are not sufficient to protect patients susceptible to serious and life-threatening infections [ ] . we call for extra care and attention on the proper design, use, and disinfection of the surfaces in hospitals to minimize the potential spread of microorganisms and the risk of cross-contamination thus reducing the infections. traditional cleaning methods in medical and healthcare facilities include dry cleaning and dusting. these methods can disperse dust particles throughout the area surrounding the patient, negatively influencing the quality of the air and promoting contamination. moreover, they cannot be able to contrast the dry deposition of the airborne dispersed microorganisms in a patient room, where it has been hypotized that contamination may come from the resuspension of dust particles from the floors or other hard surfaces [ ] [ ] [ ] . multiple drug resistance (mdr) microorganisms and healthcare-associated infections (hais) remain significant challenges, both in hospitals and in long-term care facilities [ , , , ] . they may cause patients or residents to suffer from additional ailments, and sometimes result in death (in italy it is estimated in . cases per year). the existing problem of mdr microorganisms and hais show us that, in order to properly follow the primum non nocere principle in healthcare, we should take into account all of the epidemiological, biological, organizational, and social aspects of healthcare. in this study, we propose a multidisciplinary approach based on the use of disposable microfibre or spunlace cloths impregnated with different disinfectant solutions to be used in the cleaning operations of healthcare settings. this approach also considers of primary importance the use of a specifically designed trolley and mandatory training and education of the operators. this procedure leads to an improvement in air quality, disinfection of surfaces close to the patient, and a significant reduction in cross-contamination. in addition to the antimicrobial efficacy, the disinfectant products proposed have low toxicity, low flammability index, low skin irritation and no residue are even detectable. the cleaning activity is part of a complex holistic approach that combines the need to ensure the disinfection of the area close to the patient with the safety of the cleaning operator, considering also the right training and education. some studies have highlighted the importance of decontamination processes after the use of reusable detergents and/or cloths to avoid cross-contaminations [ ] . in common cleaning protocols, the same mop is used to clean a large area, without any difference between contaminated and uncontaminated spaces. there is a mandatory practice required for the washing procedure with frequent replacement of disinfectant solutions (e.g. after every three or four chambers, with intervals of no more than min) and high temperature treatment of the mop. however, cloths and mop, subjected to continuous high temperature decontamination treatments, progressively lose their cleaning capability crumbling their texture. on the other hand, disinfection methods used in many intensive care units and other healthcare facilities include the innovative use of antimicrobial wipes. these products seem to be more efficient to remove the microbial load on surfaces [ ] . the use of alcohol wipes has also been shown to reduce the microbial load usually present on toilets [ ] . however, very elaborate procedures are required to ensure maximum effectiveness of the antibacterial wipes, otherwise even these, if not properly used, can favor the spread of microorganisms (e.g. tables, headboards) [ ] . operators should not use the same wipe repeatedly to clean and disinfect different surfaces and have to be correctly trained. disposable wipes pre-impregnated with a disinfectant can also be used for low-level disinfection when spot cleaning of non-critical surfaces is required [ ] . an important question raised by the use of disinfectants for non-critical surfaces, such as wardrobe and bedside table, and in healthcare facilities is the contact time specified on the product label, which is often too long to be practiced. the labels of most products registered by epa (environmental protection agency) to be used against hbv (hepatitis b virus), hiv (human immunodeficiency virus), or mycobacterium tubercolosis specify a contact time of at least min. such a long contact time is not practical for surface disinfection in a healthcare environment, since most healthcare facilities apply a disinfectant leading it to dry for about min [ ] . the method proposed here uses disposable microfiber or spunlace cloths, pre-impregnated with a mixture specifically formulated to ensure a detergent and disinfectant synergic action. according to who guidelines the detergent and disinfectant solutions must meet the requirements for disinfectant/antimicrobial products for contaminated surfaces and may contain different active ingredients or mixtures of these, for example, alcohol, chlorine [ , , ] , phenols, polyphenols [ ] , quaternary ammonium salts [ ] , tertiary amines, chlorhexidine gluconate. the formulations used for the pre-impregnation contain increasing concentrations of the selected disinfectant as required for the sanification of environments in the different areas of a hospital (e.g. low, moderate, and high-risk areas). the staff dedicated to cleaning operations represents the most critical point in the cleaning and sanitizing processes of hospitals. the hospital staff or the company that carries out the cleaning oper- ations must ensure that its manager and all the operators involved in the service, do their work or duties safely, guaranteeing a result capable of satisfying the requirements, the expected quality levels, and the objectives of the activity carried out. the training plans should include, in addition to a general basic course for health service workers, targeted courses on the order to be performed. it is necessary that the staff employed is well trained on the protocols drawn up according to the environment to be cleaned. in particular, it has to be employed personnel who have been properly trained to carry out cleaning activities e.g. in the infectious diseases and nuclear medicine departments, operating rooms, intensive or sub-intensive therapy services, which require greater attention to the cleaning process, avoiding turn-over. employees must perform only the functions for which they were trained; they must receive specific training for the areas of intervention; they also need to be trained on the biological and chemical hazards to which they could be exposed on the intervention site. the environmental intervention program and its actuation mechanism may vary according to the size of the structure and to the services provided. the staff training course programs include mainly the following themes: cleaning (products and procedures) and environmental disinfection; use of work equipment; correct use of the trolley, that is specifically designed to contain separately pre-impregnated cloths for the different surfaces and allows to avoid contact between dirty and clean cloths; definition of internal paths (clean/dirty); personal hygiene; hand washing; adoption of measures to prevent the transmission of infections; use of the supplied devices; staff clothing; disposal of medical waste; risk management; quality plan; significant impact. other training topics in compliance with the safety of the workers themselves may be the prevention of risks from the hospital environment; method of execution of the rooms service; correct use of protective devices; collection, transport, and disposal of dangerous substances and/or preparations, written protocols for daily disinfection activities, traceability cards, checklists. documentation of work and registration of all phases can avoid legal problems and could increase professional credibility according to presidential decree / and ec directive / [ ] . tracing processes helps the operator to identify errors and possibly to remedy. therefore, the processing and use of traceability cards, (see fig. ), represent a medical-legal protection tool for operators and healthcare companies. the traceability system must document the process steps: operator data and signature, date and time, process steps, hospital structure reference, any notes or observations, etc. in order to monitor and make traceable all the phases of the cleaning process and simplify the organization of the operator's work, each activity must be recorded on special cards/checklists and signed by the operator who performed the interventions. the introduction of traceability cards has proven to be a very useful tool integrated with the training and educational programs adopted by the hospitals for the implementation and validation of this new cleaning strategy for the selected hospital settings, leading to an overall improvement in the cleaning and sanitization activities of hospital wards. in order to use measurable outcomes to investigate the hospital cleaning as a scientific process, we performed microbiological analyses in three different environments according to international standard uni en iso - : , which specifies a horizontal method for enumeration of microorganisms able to grow and form colonies in a solid medium after aerobic incubation at • c. a specific quantity of the test samples, or a specified quantity of an initial suspension, was surface plated on a solid agar culture medium contained in petri dishes. other plates were prepared under the same conditions using decimal dilutions either of the test sample or of the initial suspension. the plates were incubated under aerobic conditions at • c for h. the number of microorganisms per gram of sample or the number of microorganisms per milliliter of samples was calculated from the number of colonies obtained on the plates containing less than colonies/plate. all samples were collected before and after disinfection processes, both by the traditional system and the one proposed by us, to evaluate the efficiency of the different cleaning protocols in the same hospital wards. the standard cleaning protocol of the hospitals included cleaning with a reusable mop dipped in a solution of water and a disinfectant, the same sanitization solution used with the innovative system. once dipped the mop was used to clean approximately square meters room, following which the mop was double dipped and reused in adjacent rooms. for the cleaning protocol purpose in this study, microfiber wipes were used that, thanks to their positive charge (containing polyester and nylon), attract negatively charged particles such as dust, liquid, and pathogens. microfiber wipes used had the following characteristics: high density with × surface area than a conventional cotton-loop mop; were split to create gripping "hooks" that make them highly absorbent; weigh of g and specifically g/m ; various dimensions such as × cm for surface cleaning and × cm for floors and larger surface; more than % of disinfectant solution impregnated could be absorbed ( , ml/cm of disinfectant solution). one single cloth was used for each medium surface/room to avoid contamination between different rooms: operator removed the wipe from the packet, seal the packet to avoid other wipes drying out, start wiping surfaces and at the end, it was thrown in the trash. the cleaned surface was allowed to air dry for min and then we collected samples for bacterial culture. for each room - high-touch surfaces, such as sink, desk, shower, bed were chosen for the assessment of the cleanliness, and the cleaning staff was not informed about the sampling. about - samples were collected in triplicate for each room, in different locations, as reported in tables a, b, . statistical analysis was performed with graphpad prism . (graphpad software, inc., san diego, ca). the results were considered significant at p-value < , . disposable pre-impregnated wipes with many different disinfectants were obtained from cle.pr.in. srl and a specially designed cleaning trolley was delivered by femir srl. wipes used in this work were impregnated with a sanitization solution of % alcohol, % chlorine, phenols, % quaternary ammonium salts, % chlorhexidine gluconate, all solutions were tested in the same conditions. all trolleys were designed to prevent cross-contamination events, limit the operators' physical efforts, avoid incorrect postures, and equipped with advanced accessories: • n. closed l bag holders with divider and pedal set; • green base with wheels Ø mm, for outdoors; • n. drawers of l (green, white, gray, cream) for arranging the different types of cloths to be used for cleaning; • gray bar for handle hook; • hooks for storing cleaning tools; • plastic container to hold waste bags; the tray must be inserted interlocking on the handlebar handle of the trolley. • rolled paper holder, completely in plastic, which can be inserted into the edge of the container. it is complete with a transparent plastic cover, to avoid contact of the paper with the work environment. the trolley was designed to separate the storage of cloths from the waste section, to avoid contamination of the material and clean instruments. the surfaces were also made without corners and edges, and caps and covers were affixed to close any holes that are difficult to reach during cleaning operations. furthermore, the basic idea of the project was that for each ward a specific trolley was used that had not to be moved in different wards to avoid cross-contamination events. the advantages of using this innovative cleaning system compared to traditional methods are shown by the results of tables a, b, , which summarize the results of the swabs carried out in different areas of two healthcare facilities, one private and one public. the results showed in these tables were obtained with microfiber wipes pre-impregnated with ethanol %, however all disinfectant solutions were tested and gave the same performance. the significant reduction in the microbial count, that always falls below the threshold value, reported thereafter, demonstrates the effectiveness of the system proposed here. the following tables show that for the analyzed surfaces such as shower tray, bathroom floor, toilet edge, etc. the traditional system has little efficacy, with the effectiveness of less than %, whereas pre-impregnated cloths succeed to eliminate about % of the bacteria present. cross-contaminations, disinfection, and cleaning strategies play an important role in the everyday organization of hospitals and many scientific studies are reporting precise protocols for sanitizing healthcare environments [ ] [ ] [ ] . in the framework of the present international outbreak related to coronavirus disease covid- , rigorous measures are necessary to optimize the qual- ity of care provided to infected patients and to reduce the risk of pathogen transmission to other patients or healthcare operators. regardless of the type of surface (hands, environmental surfaces, fabrics), the objective of a cleaning and sanitizing procedure is to reduce contamination to an acceptable level of safety by applying operating methods designed to remove pathogens from surfaces. the procedure described in this work is based on a holistic approach for the decontamination and sanitization of surfaces in healthcare facilities with different risk levels (low, moderate, high). a careful analysis of the characteristics of the antimicrobial agent chosen to disinfect the critical surface was necessary and it was crucial to define the right composition of disinfectant solutions so that these were not corrosive to the treated surfaces and did not release strong odors. regarding the use of disinfectants, guidelines exist to define the minimum concentration of biocide in an optimal disinfectant solution to control the spread of harmful bacteria and other microorganisms. the disinfectant formulation must contain enough antimicrobial agents to be effective for a given application. the presence of a greater quantity of antimicrobial agent does not provide any advantage to the resulting composition, essentially it could only produce a disadvantage on the treated surface and, more generally, on environmental pollution. on the other hand, having a lower concentration of antimicrobial agent will make the composition less effective than necessary for the required use. results, reported in table a , were obtained using microfiber wipes pre-impregnated with ethanol % to clean different surfaces in a patient room of public healthcare structure and showed a better performance than traditional cleaning protocols: for exam-ple on the floor we observed a microbial count reduction from > to cfu/ cm with the new method ( % of colonies were destroyed), while with traditional one we have a reduction from > to cfu/ cm ( % of microbial colonies). moreover, in literature it was demonstrated that the microfiber system has superior microbial removal efficiency compared to cotton string mops [ , ] , however, there is no experimental data on pre-impregnated wipes with various disinfectant solutions. previous experimental data record efficacy principally for cleaning and disinfection process with microfiber/steam technology or wipes dampened with water, where authors demonstrated that the introduction of microfiber into the hospital sanitization process, in particular into operating room environment, has been environmentally and fiscally beneficial [ ] [ ] [ ] [ ] . the antimicrobial efficacy of a pre-impregnated cloth is also related to the interaction of the disinfectant solution with the support. the interaction of the support with the disinfectant solution could lead to a decreasing amount of biocide in the solution. therefore, in the realization of this work, we used pre-saturated cloths which means cloths that are saturated by the manufacturer with the desired disinfectant solution and delivered to the user in a wet format. saturated pre-impregnated cloths solve, or at least reduce, the problem of decreasing the availability of the active ingredient because they offer the possibility of changing the concentration of disinfectant in the solution during the manufacturing process which is consistent with the desired percentage of biocide agent (solution concentration). the characteristics of the surface to be cleaned have also to be considered when choosing the cleaning support (spunlace or microfiber), in fact, in some cases, the presence of non-uniform surfaces seems to favor the use of microfiber wipes that are more adaptable, even in most hard-toreach spaces. in table results showed that the total microbial load estimated on sampling performed on different surfaces in a staff room of public healthcare structure was reduced more than % cfu/ cm , only for floor attending room we have a reduction of %. a possible weakness related to the use of pre-impregnated spunlace or microfiber could be the quick evaporation of the solvent if the package is not properly closed and there is no good adhesion between wipes and surfaces, with less efficiency of the system. the use of a disinfectant solution pre-impregnated microfiber or spunlace cloth for different kinds of surfaces was supported by an appropriated trolley designed to help the operator during the cleaning procedure. all tools were specifically designed to improve disinfection efficiency and to eliminate the problems associated with traditional methods, such as preventing cross-contamination events, limiting the physical efforts of operators, avoiding incorrect postures and errors. moreover, this innovative method for cleaning and disinfecting floors avoid the risks of falling or tripping because the presence of wet floors is significantly reduced thanks to the use of pre-impregnated microfiber cloths. in addition, this procedure involves the use of ergonomic cleaning tools capable of reaching even difficult-to-reach surfaces, significantly reducing the use of stairs and stools. however all tools must be cleaned and disinfected to improve cleaning procedures, otherwise they could be one of the possible sources for contamination. this system shows several advantages for the operator, for occupation quality and work satisfaction, and helps in protecting the environment [ , ] according to the new parameters provided for by current regulations and international guidelines. the use of pre-impregnated cloths reduces the amount of water to be used and spills into the pipes, also eliminating the disinfectant solutions that are thrown into the sewers daily. this item was also deeply investigated through an lca (life cycle assessment) study that allowed to confirm that the system can be suitably included in an epd (environmental product declaration) system [ ] . the procedure implemented in this work provides evidence on the sanitization of hospital settings and examination of different products in terms of commodity, variety, composition, and chemical nature, demonstrating that pre-impregnated microfiber cloths could be a useful alternative for hospital infection-control program. quantitative assessment of the level of cleanliness by swab cultures revealed the better performance of the proposed method highlighting the vital role that infection prevention and control play in improving healthcare systems. this approach also considers of primary importance the use of a specifically designed trolley and mandatory training and education of the operators. this procedure leads to an improvement in air quality, disinfection of surfaces close to the patient, and a significant reduction in cross-contamination. an additional advantage of this system is the simultaneous dusting, cleaning, and disinfection action which avoids passing three times on the same surface. overall this study showed that the use of disposable preimpregnated cloths has many advantages: • the cleaning operator will be able to achieve higher cleaning and decontamination standards than traditional methods, thanks to the synergistic action of microfiber cloths (which already show high microbicide capacity on their own) and of detergent and disinfectant mixtures. • the use of pre-impregnated cloths for dusting and wet cleaning will prevent phenomena of air dispersion of contaminated particles • the patient who occupies sanitized rooms with disposable cloths will be better protected from accidental cross-contamination diffusion. • the cleaning operator is less exposed to chemical, biological, physical, and postural risks. • the hospital will be less exposed to the risk of contamination and the spread of nosocomial infections and will be able to more easily manage the personnel involved in the cleaning procedures because these will be faster, less tiring, and require fewer extraordinary interventions (weekly, monthly). deaths: leading causes for estimating health care-associate disinfections and deaths in us hospitals bacterial contamination of inanimate surfaces and equipment in the intensive care unit microorganisms in confined habitats: microbial monitoring and control of intensive care units, operating rooms, cleanrooms and the international space station airborne hydrogen peroxide for disinfection of the hospital environment and infection control: a systematic review a renaissance for the pioneering s rrna gene ific basic concepts of infection control. portadown: international federation of infection control study on the effectiveness of disinfection with wipes against methicillin-resistant staphylococcus aureus and implications for hospital hygiene mopping up hospital infection health-care-associated infections: risk factors and epidemiology from an intensive care unit in northern india uses of inorganic hypochlorite (bleach) in health-care facilities new approach for evaluating the public health risk of living near a polluted river determination of c/ c carbon isotope ratio assessment of perchloratereducing bacteria in a highly polluted river healthcare infection control practices advisory committee. guideline for disinfection and sterilization in healthcare facilities rethinking sterile: the hospital microbiome the survival and transfer of microbial contamination via cloths, hand and utensils cleaning for health report how clean is clean? proposed methods for hospital cleaning assessment who wash in health care facilities: global baseline report . world health organization surveillance of nosocomial infections: a preliminary study on hand hygiene compliance of healthcare workers two-years surveillance of fungal contamination in three hospital departments in campania region efficacy of 'sporicidal' wipes against clostridium difficile are toilet seats a vector of transmission of methicillin-resistant staphylococcus aureus the development of a new three-step protocol to determine the efficacy of disinfectant wipes on surfaces contaminated with staphylococcus aureus bacterial contamination of keyboards: efficacy and functional impact of disinfectants treatment of acute hypoxemic respiratory failure caused by chlorine exposure accidental systemic exposure to sodium hypochlorite (clorox) during hemodialysis report of a fatal case, supplemented with an experimental and clinico-epidemiological study potential impact of increased use of biocides in consumer products on prevalence of antibiotic resistance choosing disinfectants a standardized test to assess the impact of different organic challenges on the antimicrobial activity of antiseptics guidance for the decontamination of intracavity medical devices: the report of a working group of the healthcare infection society surface contamination in the operating room: use of adenosine triphosphate monitoring modern technologies for improving cleaning and disinfection of environmental surfaces in hospitals efficacy of disinfectant-impregnated wipes used for surface disinfection in hospitals: a review a laboratory evaluation of the decontamination properties of microfibre cloths improving operating room cleaning results with microfiber and steam technology microfiber and steam for environmental cleaning during an outbreak spread of bacteria on surfaces when cleaning with microfibre cloths new ftir methodology for the evaluation of ( )c/( )c isotope ratio in helicobacter pylori infection diagnosis an improved method for btex extraction from charcoal detection of diagenetic alterations by spectroscopic analysis on archaeological bones from the necropolis of poseidonia (paestum): a case study this work was financially supported by fondi di ateneo per la ricerca di base (farb ), university of salerno. we are grateful to femir srl, cleprin srl, and sanita service srl for technical support and for providing the materials. none declared. not required. key: cord- -ze ay rm authors: daphna-tekoah, shir; megadasi brikman, talia; scheier, eric; balla, uri title: listening to hospital personnel’s narratives during the covid- outbreak date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: ze ay rm healthcare workers (hcws) facing the covid- pandemic are required to deal with unexpectedly traumatic situations, concern about contamination, and mounting patient deaths. as a means to address the changing needs of our hospital’s hcws, we conducted a narrative analysis study in the early stages of the covid- outbreak. a focus group of medical experts, conducted as the initial step, recommended that a bottom-up research tool be used for exploring hcws’ traumatic experiences and needs. we therefore conducted semi-structured in-depth interviews with hospital personnel. the interviews were based on maslow’s pyramid of needs model, and the narratives were analyzed by applying the listening guide methodology. the interviewees expressed a need for physical and psychological security in the battle against covid- , in addition to the need for attachment and meaning. importantly, we also found that the interview itself may serve as a therapeutic tool. in light of our findings, we recommended changes in hospital practices, which were subsequently implemented. further research on hcws’ traumatic experiences and needs will provide evidence-based knowledge and may enable novel approaches in the battle against covid- . to conclude, the knowledge generated by listening to hcws’ narratives may provide suitable support programs for professionals. the moment that i was informed that we had become a covid- department, i was devastated. this coronavirus is so frightening, and i knew that i could die from it. i am a person who needs to be in control, and i had lost control, i was so frightened. this entire new situation was scary-a situation of life or death. moreover, i was in it. at the level of the team, we did not know what to expect, personally and collectively, as a department. i did not know what was expected from me as a social worker and what were the guidelines; everything was new. we created everything from the beginning, and i was scared. studies on outbreaks of infectious diseases reveal the profound and broad-spectrum psychological impacts that disease outbreaks can inflict on healthcare professionals [ , ] . experience with the sars and ebola virus outbreaks suggests that healthcare professionals are subject to extremely high levels of stress and emotional turbulence [ ] [ ] [ ] . in dealing with the sars virus, which is similar in some respects to the novel coronavirus (sars-cov- ), healthcare professionals were troubled by intrusive thoughts and images associated with sars and exhibited symptoms of ptsd and substantial psychological distress [ ] , if not mental illness [ ] . in addition, healthcare professionals feared that they would fall ill from sars but were equally or more worried about infecting family members and other people [ ] . nonetheless, prior experience with pandemics, disasters, and major traumatic events has indicated that enhanced support for healthcare professionals enabled them to remain efficient and focused during these stressful events [ ] . the on-the-job stress and burnout of healthcare workers (hcws) employed in hospitals [ ] [ ] [ ] is one of the key themes in studies of the trauma of these professionals in the corpus of literature on the cost of caring [ ] . this recurring motif is not surprising, since the hospital environment is challenging in that it frequently demands holistic treatment of patients that integrates psychological elements with physical treatment: in the course of their routine hospital work, hcws are required to deal with patients and their families who have experienced traumatic events and life-threatening episodes [ ] . it was against this background that hospital hcws the world over first encountered the global covid- pandemic in december [ ] . facing this global public health event situated hcws in an unbearable situation, with them being required to function under extreme physical and psychological pressure on both the professional and personal levels [ ] . in parallel, they were often required to make impossible decisions, including how to deal with limited equipment, how to balance their own physical and mental welfare needs with those of their patients, and how to bring into line their responsibility to their patients with their responsibility to their family and friends. in addition, their wish to provide optimal care for severely ill patients was often constrained by inadequate resources. thus, in the covid- pandemic, frontline hcws had to work under particularly intense stress levels in unprecedentedly difficult situations [ ] -situations that may indeed cause stress, moral injury, and physical and mental health problems [ , ] . the unfolding pandemic has been compared to war, as described in "'the art of war' in the era of coronavirus disease (covid- )" by maxwell et al. [ ] , who claim that the image of war is often used in the field of infectious diseases. indeed, from the beginning of the pandemic, hcws in the hospital setting have been faced with caring for patients with an incredibly contagious and life-threatening disease about which nothing was known and for which there was no known lifesaving treatment-a situation similar to a war. they were-and still are-handling life-and-death situations while simultaneously putting their own lives at risk. this factor has contributed to a real sense of danger among hospital staff, who have found themselves in the forefront of defense against the pandemic [ ] . in parallel, hcws are being required to deal with emerging challenges [ ] . they are often required to develop, in an extremely short time, novel concepts and new interventions for unpredictable situations. the need for hcws to be proactive results from the fast-growing numbers of critically ill patients, the lack of treatment modalities, and shortages of critical medical resources and staff. like the general population, the hospital staff is struggling with the emotional stressors imposed by the pandemic. however, they are also faced with additional stressors and a rapidly evolving work environment that differs significantly from their pre-covid routines [ , ] . marchand-senécal et al. [ ] point out that specialized, dedicated covid- teams could quickly be overwhelmed as numbers of cases increase markedly. they also hold that longer shifts and increased work intensity may lead to hcw fatigue and lapses in the use of the correct techniques for handling personal protective equipment (ppe). they illustrate this conclusion by citing initial reports indicating that about % of chinese hcws caring for covid- patients were infected, with % of those hcws being classified as severe or critical cases. it is thus not surprising that a survey of frontline nurses, physicians, and other hcws who treated covid- patients in hospitals in china found that the participants carried a psychological burden, with symptoms related to depression, anxiety, and distress [ ] . earlier studies on epidemic outbreaks have indeed revealed that medical personnel, particularly first responders, including physicians, nurses, ambulance personnel, and other hcws, become emotionally affected and traumatized and display heightened stress and higher levels of depression and anxiety [ , ] . these findings are to be expected, since anxiety and the fear of being infected are aggravated as the risk of exposure is elevated. this heightened anxiety is exacerbated even further by the fear of transmission of the infection to loved ones. the need to maintain a sense of balance between professional duty, altruism, and personal fear for oneself and others thus often causes a mental conflict for hcws [ ] . in the guidelines published on march by the world health organization, it was declared that, by virtue of their caring for and close contact with covid- patients, the people most at risk of acquiring the disease are hcws and that protecting hcws is of paramount importance. in light of the above, at the beginning of the covid- outbreak in israel, we arranged a meeting in our hospital of an ad-hoc group of experts from different disciplines in healthcare and with different types of expertise. the recommendations of this focus group and the results of the interviews that were constructed and conducted as an outcome of these recommendations are described below. the theory of how humans usually function in daily life, as embodied in the ideas of abraham maslow, appear to be remarkably relevant to massive crises, especially to the present global crisis resulting from the covid- pandemic [ ] . maslow's theory establishes a hierarchy of human needs [ ] and, as such, provides a framework to describe the needs of hospital personnel [ , ] . maslow's theory divides human needs into five categories. the first category, forming the base of a pyramid of needs, comprises physiological needs, such as air, water, food, shelter, sleep, and clothing. for medical personnel, hale and his colleges [ ] extend this level to include the basic determinants of good physical and mental health and safety. the first category is followed, in order, by four more layers: safety needs, such as personal security, employment, resources, health, and property; love and belonging, which includes friendship, intimacy, family, and a sense of connection; esteem and respect, which includes self-esteem, status, recognition, strength, and freedom; and, finally, at the top of the pyramid, the desire to become the best that one can be, relates to personal growth [ , ] . maslow described each level as a separate need that relies on the previous need. however, modern-day theorists have modified this conceptualization into an overall concept in which each need coexists with the others [ ] . we used semi-structured interviews based on maslow's pyramid to survey hcws in our hospital. we then analyzed the interviews by choosing, from the umbrella of narrative analysis, the listening guide methodology to analyze the recorded interviews and their transcripts [ , ] . this qualitative research methodology was developed as an alternative analysis to conventional coding schemes used to analyze qualitative data [ ] . it differs from other means of analysis in that it places emphasis on the psychological complexities of people through attention to voice as a manifestation of the psyche. the listening guide in its attention to voice-and silence-thus provides a way of exploring the interplay of inner and outer worlds and of bringing the inner world out into the open [ ] [ ] [ ] . by focusing on different voices, on the dynamics and interplay of these voices within the interview transcript, and on the socio-cultural setting of the research, the guide establishes a contextual framework for understanding and/or interpreting the narratives of the interviewees and thereby facilitates psychological discovery. the details of methodology are described in the materials and methods section [ ] . although every analytical process has its advantages and drawbacks, we chose the listening guide, since its intent is to capture the layers of perception and experiences of trauma and stress [ , ] that might otherwise remain unnoticed, thereby broadening the understanding of traumatic situations. by applying this methodology, we aimed to expand knowledge-and to generate new knowledge-regarding the mechanisms and the strategies used by hospital workers to cope with the covid- pandemic. specifically, we sought to reveal the overt and covert voices [ ] emerging from the experiences of front-line workers and to examine how these workers describe and experience their traumas in their struggle to treat patients with covid- . as mentioned above, being aware of the necessity to address the needs of the hospital's hcws, we conducted a study aimed to expand the knowledge of these needs during the first phase of the covid- outbreak. specifically, the goal of the study was to enable the contrapuntal voices emerging from the hospital staff's experiences to be "heard" and thereby to provide recommendations as to how to meet their changing needs as the crisis unfolded. by paying close attention the narratives of the hospital staff, we were able to address an additional aim, namely, to initiate the establishment of a data-based foundation for both immediate and future interventions, thereby expanding knowledge regarding the psychological mechanisms and strategies that front-line personnel use to cope with exposure to traumatic situations. the first step of the research comprised the establishment of a focus group of hcws, all trauma experts, in the hospital. on march , the focus group met to exchange thoughts about the evolving crisis conditions in the hospital and to find the means to evaluate-and indeed alleviate-the situation. the focus group comprised an emergency department physician and five medical-social workers with specializations in mental health and trauma. the decision to constitute a focus group of experts as the opening stage for this research project derived from the perspective that the novel coronavirus poses an unmet challenge to medical treatment and hence challenges hcws in many unknown ways. the focus group was charged with delineating the new situation in the hospital and with deciding on the exact research methodology and research tool(s) that could be applied in a research project and possibly later as adjunct practical tools for dealing with the evolving crisis. the final question put to the focus group was: what is the next step in the research project?" the participants pointed out the need to conduct bottom-up interviews at all levels and sectors in the hospital as a means of understanding the emerging needs of the hospital personnel [ ] . the focus group suggested conducting a survey based on semi-structured in-depth interview based on maslow's pyramid of needs' model. the survey and results are described below. the interview protocol involved questions designed to capture the hcws' ways of describing their unique experiences. to this end, the interview protocol comprised a standard set of questions, beginning with a request to share with the interviewer thoughts on what it meant to be an hcw in a hospital at the time of the corona crisis. this opening question was followed by encouragement to share thoughts on personal needs. more specific questions were used to clarify the stories as the interviews proceeded, such as: what do you need-physically or anything else? what distresses you at work? what would make you feel safer? what helps you to feel better? what helps you to know that you are appreciated? what motivates you to get up every morning for work? in a year from now, what do you think will have changed in your family, at the hospital, within yourself? do you have something that you think important to add to the body of knowledge specifically about coronavirus or about trauma situations in general? four hundred and fifty semi-structured interviews were conducted in three waves: the first in the middle of march , before recognition of covid- as a global pandemic ( staff members; . % of the interviewees); the second, two weeks later ( ; . %); and the third in the middle of may , at the end of israel's national lockdown ( ; . %). interviews were conducted with personnel [ ( . %) men and ( . %) women] serving a variety of functions in the hospital: physicians, nurses, pharmacists, respiratory therapists, department supervisors, laboratory technicians, social workers, and administrative workers from various sectors and with different levels of seniority (average . years; median years, range: - ) the breakdown of sectors and departments is given in table . the interviews each lasted approximately min to h and were conducted under conditions of assured confidentiality. as we indicated above, the interview narratives (in audio form and as transcripts) were analyzed by applying gilligan's listening guide methodology [ ] , which is comprised of four stages, as follows [ , ] . in the first stage, "listening to the plot," attention is paid to the whole story of the interviewee. the researchers' goal in this stage is to analyze the story in its context, similar to the analysis of an unfolding plot of a novel. the researchers identify recurring images and words, key metaphors, and dominant themes. the guide also requires that the researchers document their own reflexive emotional and intellectual responses, thoughts, and feelings, as a means to better recognizing how their responses to the interviewee might affect their understanding of the narrative and the subsequent analysis. this stage is similar to the analysis modes in several of the qualitative thematic methods described in the literature [ ] . the second stage, "i poems," is unique to the listening guide method. the second-stage listening and transcript analysis follows the use of the first-person pronoun "i." within a passage in the transcript, scholars underline every use of "i" together with the attendant verb and any seemingly important accompanying words and then paste these "i voice" phrases together to compose an "i poem." this composite traces how the interviewee views herself/himself and the most prominent themes that preoccupy her/him. . the third step, "listening for contrapuntal voices," concentrates on how the interviewee talks about her/his or relationships with others. in this phase, scholars identify the multiple aspects of the story being told, often in multiple voices, with each voice (e.g., "you voice," "the voice of trauma and stress"; see below) being underlined in a different color. the transcript thus provides a visual way of examining how the different voices change in relation to one another. . in the fourth and final step, "composing an analysis," an interpretation of the interviews is developed that synthesizes what has been learned during the entire process by assembling the evidence drawn from the different instances of listening as the basis for composing the analysis. a summary analysis is then constructed [ , ] . the reported study conformed to internationally accepted ethical guidelines and relevant professional ethical guidelines and was approved by the institutional review board (irb) of kaplan medical center, rehovot, israel. to assure confidentiality, each participant was identified by a pseudonym. step: "listening to the plot" the narratives of the healthcare professionals covered a description of their experiences, explaining in detail their engagement with corona patients and their families and their relationships with members of the hospital staff. two main themes emerged from the analysis of listening to the plot, the first of which was preparing for war in that the participants compared the situation in the hospital to the experience of preparing for war. sara, for example, said: "in our country, we know what a war is, and in the healthcare system we know how to function in the hospital during times of war, but still, this is a new war, a war that we have never handled, an invisible enemy, and it is frightening all of us." in similar vein, doron said: "to be significant, to be at the front is important. before it was the army that was at the front, now it is the turn of the healthcare system to be at the front." the second theme to emerge was that of security and insecurity, which related to two main aspects of the situation-fear of contamination and uncertainties derived from the assignment of hcws to new teams and departments whose purpose and essence were unfamiliar. the idea of working in new and unfamiliar teams distressed the personnel, and their narratives reflected their feelings of insecurity. the changing reality was reflected by dikla a nurse: "in the internal medicine department, i have been working for the past years with my team, physicians, nurses, secretary-we have a common language. i felt especially secure in those days. how i will be able to use, in an efficient way, a new situation and new staff? this is ridiculous." similarly, tania, a social worker, said: "this will increase the feeling of insecurity . . . think that the entire situation is new and scary; so, what will i do without my friends who i have been working with for years?" in particular, the need to be protected during shifts was pronounced. as sara told us: "in order to continue to come here, i need to feel that someone is taking care of me. i do not care who in charge of that in the hospital, but i need to feel safe; it is essential for me." according to the listening guide protocol, at this stage of the analysis, the interviewer should document his/her own reflexive emotional responses. we found that listening to the interviewees and reading the transcripts induced emotional concern for and feelings of empathy with our colleagues who were struggling with unbearable situations and ethical dilemmas. we were full of tears when we heard about the burdens of caring for patients and the cost of that caring. the interviews and the transcript readings thus gave rise to a range of emotions, including sadness, anger, compassion, and frustration, but also to pride in the devoted teams and to an appreciation of their devotion. step: the "i poem" the second phase of the listening guide involves composing the "i poem," which is a core feature of the approach that serves to identify the active self. the process of composing the "i poem" [ ] can best be understood by examining some examples. let us start by examining the transcript of the interview with julie, a nurse in the icu: "i cannot believe it . . . because of the workload . . . it is only because of the workload . . . i have to tell you that i haven't eaten for whole days . . . i grab something. it is not that there isn't any food, but we don't have the time and the needs of the staff draw you and you can't ignore them; you need to respond to each one. at other times its different, of course. here you can't say anything to them. it's the mask; it creates wounds on their noses, so i brought them cream. this kind of mask or any other; so, i saw masks in the grocery store and i bought them pink surgical masks so they would feel joy. every day i am bringing something to make them happy. all the time. yes, the protective equipment is a problematic issue by itself . . . i understand since i am involved in that; it depends on the equipment that comes to israel, but it is not always suitable . . . this equipment is insane." in her "i voice," julie demonstrated her personal difficulties in the corona icu and her difficulties in taking care of herself, even with regard to basic needs, such as food. however, as a manager in the icu, her "i voice," expressed her competency in taking care of her icu staff, as reflected in her "i poem": one can see that, in general, the "i poems" reflect a layer of self-confidence and feeling of empowerment. this voice stands in contrast to other voices in the narratives that describe difficulties, stressors, and chaos, as described below. irrespective of the contrapuntal voices embodied in the narratives, all the hcws who worked in the hospital's corona department stated that the daily routine in the corona department was more complicated than that in the rest of the hospital. the corona team concurred that the reasons for the differences were both physical and emotional and that acknowledgment should be given to the unique characteristics of the department. sharon, a nurse, summed up this opinion very succinctly as: "corona-it is not extra work, it is completely different work." against the background of this commonly held perspective, the third stage of the listening guide analytic technique nonetheless enabled us, the interviewers, to identify multiple voices that revealed different aspects of hcws' experiences and needs, including their attitudes towards the coronavirus pandemic, the staff and the hospital, and their own needs. the listening guide analysis of the focus group and the interviews identified five different contrapuntal voices-trauma and stress, security, knowledge, attachment, and meaningfulness-intertwined not only with one another but also with the "i voice" and the "you voice" (see below). the contrapuntal voices and examples of quotes from the transcripts that represent these voices are described below. the hospital workers' narratives reflected their direct exposure to traumatic events and the pervading presence of death in the hospital, as particularly manifested in the agony of seeing people dying without their families beside them and in the procedures for preparing the deceased for burial by special, double wrapping of the dead body as a precaution against contagion. for example, in response to the interviewer's question "but you are accustomed to the death of patients, what is the difference?" golda, a nurse, shared her feelings about traumatic moments after a patient's death: a deceased is a deceased but the separation from the family is extremely difficult, the wrapping process is a different from what you normally do in the internal ward. in addition to the regular wrap we put them in a nylon wrap and that is horrifying. a really unpleasant sight. it is like you put your patients in a plastic bag and you close it with a zipper. and then you cover with another bag but from the opposite side. an unpleasant wrapping of a patient since it is supposed to be isolated. similarly, marina, a senior physician in the icu, shared her difficulties in dealing with professional uncertainty and the absence of definitive information in the medical literature: look, the coronavirus is something completely new. a whole new disease that we do not have a clue how to treat, how to behave with it . . . and the craziest thing [is] that no-one in the world has the knowledge how to treat this disease, no knowledge-based expertise, no medical literature. so, you are constantly calling your colleagues in the country and around the world. then, you are planning how you will cope with your first coronavirus patient. in discussing the traumatic nature of their work in the icu and the coronavirus department, marina and golda used the personal pronoun "you" in the masculine form when they spoke about taking decisions about life-and-death issues. we note here that in hebrew, this usage of "you" in the masculine form is a generic usage that does not refer to the gender of the user. according to the listening guide methodology, the use of the masculine "you" hints at marina's and golda's difficulties in connecting emotionally to their traumatic experience of treating corona patients in the icu [ , ] . harel-shalev and daphna-tekoah [ ] have defined this voice as the "you voice," a voice that enabled the hcw's to distance themselves from recurring exposure to traumatic and painful experiences. it might represent a symptom of dissociation from traumatic events, not as a dissociative disorder, but rather as a coping mechanism allowing them to keep functioning as professionals. experiences such as these during routine work in unfamiliar situations were balanced by feelings of competency and an ambition to fight and succeed in the mission to conquer the novel coronavirus. these two voices-security and knowledge-are presented together since they are intimately intertwined. at the beginning of the crisis, the hcws expressed their need for security and safety, primarily physical safety, and their need for crucial information and knowledge as a means to help them to feel more secure. with the progression of the pandemic, the hcws became less anxious about physical safety and medical protection, as the hospital management met these basic needs and as the hcws acquired the knowledge about how to protect themselves against contracting the disease. however, they still expressed the fear that, in the future, there could be a lack of equipment. according to maslow, the most fundamental human needs are physiological, namely, air, water, food, shelter, and sleep. for medical personnel, hale and his colleges [ ] extended this level to include the basic determinants of good physical and mental health and safety. orr, a nurse in the corona department, shared the following thoughts with us: at the beginning of the corona outbreak, there was a lack of food, protective gear, and clothes and shielding eyeglasses to protect ourselves. we had to shower between the shifts, and there was a shortage of showers in the hospital, and we had to fight for the basic needs to be protected, especially during the weekends. the fear of being infected and of infecting others inside and outside the hospital, especially family and friends, was expressed vividly by the hcws, mainly those working in the corona department. dorit, a nurse, said: there was constant anxiety and fear that we would infect others; we [at the corona department] felt like lepers . . . and then the isolation from my family since i was so afraid that i would infect them. i was isolated like a leper. my children could not go out to play with other children because i was terrified that i would infect my children and that they would infect their friends with coronavirus. at the beginning of the coronavirus, my daughter was so stressed out from this crazy situation. the interviewees tied knowledge to the feeling of security and protection. dan shared his feelings with us: "the head of the department is constantly updating us . . . i do not feel detached . . . i feel secure, knowing where i stand." in contrast, avi, an administrator, shared with us that: " . . . a lack of communication and information about what is happening at the hospital at the general level and not at the sector level bothers me. i am worried." in answer to the question, what helps you feel better? yoav responded: "uncertainty concerns me-assessments of the situation and updates by my immediate supervisor would help me." and ruth stated: "i feel like i'm in the dark and don't know what's going on." as could be predicted from maslow's hierarchy of needs, the dominant needs for security and knowledge were replaced by the needs for belonging, love, recognition, and respect from supervisors and the hospital management as the pandemic progressed. the hcws stated that a sense of family in the departments and the departments and friendship within their teams provided the much-needed sense of support during the pandemic. moreover, the hcws stated that without friendship, comradery, and a sense of belonging to a larger family, they would not have been able to work under such difficult conditions. for example, sisi, a secretary at the hospital, said: we were all a big family helping each other. i felt so close to all my peers; working together in such a tough time was different from what i had known in the last years that i have been working in the hospital. as a team, we have become closer to each other, and i have discovered additional angels in my team . . . . in our department there is a sense of "togetherness" and comradery. professionally, there will be changes; there are thoughts about modifying procedures in light of the current pandemic . . . . relating to each other, currently feeling that we are a united and cohesive group. tova, a nurse in the icu, said: this period is a mixture of emotions. the reality is that everything is so new and unfamiliar. nevertheless, the staff are so devoted to each other and struggling to do their best to help each other and changing shifts due to the lack of nurses. sometimes they asked about treatment and i did not have an adequate answer. how i will say it? this is the period that we are re-inventing the protocols and rules of treatment. i am telling them that i am so sorry but there are no guidelines yet. in addition, the interviewees expressed a need for recognition-appreciation and reinforcementfrom their direct supervisors. for example, tomer said: "a good word, a compliment, and a positive attitude made me feel valued and . . . reassured." orna said: "a kind word makes my day . . . . it is essential for me to get feedback on my work and to know that i am doing my job well." another narrative relating to attachment was the need for a managerial presence, manifested as "managing by walking around." this practice is considered one of the most important ways to build good manners and performance in the workplace and emphasizes the importance of interpersonal contact, open appreciation, and recognition [ ] . the hcws did indeed voice their desire for appreciation in the form of the need to meet management representatives in the various departments. alma, for example, said: "the presence of management in all departments and during all shifts made the staff aware that there was someone with them." she added: "personal appreciation by the management increases motivation and reduces concern . . . .i would like to see more direct communication with management . . . in my team, i feel appreciated. i don't feel i'm getting feedback from management." lili said that when management came into the corona department to visit the staff and the patients, they asked her personally how she felt, and this was what helped her to feel valued. the hcws were in agreement in their approval of the actions taken by the hospital management, judging the management's conduct during the crisis to be appropriate and effective. opinions of the following type were expressed: management worked well during the crisis; i want to thank the management for the adaptions that were made by mobilization of staff and change of policies and for taking the time to listen; and in my opinion, the hospital and management are doing well. the importance of feeling meaningful was verbalized by hanna: "patients with coronavirus helped me to feel valued and meaningful, [especially] the conversations with the patients and the phone conversations with their families out there in their homes, so worried about their loved ones. i was there for the patients and their families, and it allowed me to feel meaningful and to want to continue treating patients." the global covid- pandemic has challenged scholars and practitioners to find the means to alleviate stress and to treat the trauma experienced by members of the healthcare professions. our study was designed to examine the experiences of hcws during the first weeks of the covid- pandemic, which may be considered as a massive traumatic event. the hcws in this study, like other medical professionals caring for covid- patients [ ] , have found themselves in a battle on two fronts: as hospital-based professionals fighting for their patients' lives, giving rise to their perspective of themselves as combatants fighting on the frontline of a war, and as family members fighting to protect their families from exposure to the virus and paying the price for fighting the "new war." as mentioned in the introduction and results sections, the image of war has become a common motif in discussions about the covid- pandemic. medical experts have even suggested that military strategies to be applied to outbreak management and have highlighted the importance of prioritizing healthcare staff capacity, as is done in military scenarios [ ] . by documenting knowledge about hcws, we thus contribute to a scholarly assessment and understanding of various elements of the new war-that against covid- . by seeking a dialogue with hcws and, particularly, by engaging hospital staff in a genuine dialogue that deepens our understanding of the new battlefield and the "new health combatants," we are now in a position to raise questions about "conventional wisdom" in the health system and to expand the knowledge about understudied topics in the new war [ , ] . we believe that to produce a deeper understanding of the experiences of frontline workers, whoever they may be, we should listen to them attentively [ ] . thus, the listening guide methodology provides a tool that can capture subconscious expressions through investigation of voices that are not usually otherwise revealed. by implementing the listening guide method in this study, we were able to explore more deeply the ways in which the hcw's represent themselves and others-the ways in which they tell their story of the situation. in addition, we suggest that this methodology be integrated into the methods utilized in the healthcare arena and should be further explored in additional healthcare contexts. during the interviews, the hcws emphasized the high level of emotional intensity associated with long hospital shifts, the constant fear of death and of exposure to new and unfamiliar traumatic events, and the constant feeling of insecurity. the hcws indicated that to cope with these emotional facets of their working environment, they needed a secure base. issues of security and insecurity were revealed in different ways at different stages of the evolving crisis: at the beginning of the interviews, a clear majority of the staff emphasized the need for physical protection and the need to fulfill basic requirements, such as adequate food, a place to rest between long shifts, protective equipment, and showers in the corona department for use after their shifts. another level of insecurity was emphasized by the need for personal recognition from direct supervisors and from hospital management. we found, however, that these needs changed as the pandemic progressed. at the beginning of the pandemic, when work environments were subject to change and scheduling remained uncertain, basic needs and physical safety were emphasized. in particular, respondents noted a shortage of protective equipment. the rapidly changing situation and the lack of supplies at the beginning of the pandemic crisis increased feelings of insecurity and intensified the importance of basic needs. however, as the crisis evolved, the need for security at the physical level was supplanted by a basic craving for security at the psychological and spiritual levels: the respondents focused on interpersonal relationships with their peers and their supervisors and their need for appreciation from their colleagues within their departments and beyond and from management. the focus thus transitioned from personal health and well-being to a sense of social belonging, a need for respect and appreciation, and even a sense of personal and professional self-fulfillment as predicted by maslow's theory of needs [ ] . horesh and brown [ ] have encouraged trauma researchers "in the age of covid- " to employ all methods of scientific practice, including unique study designs and creative collaborations between disciplines with the aim to deepen the understanding of the health implications of the global coronavirus crisis. in particular, they indicated the need to develop novel methods for empowering and supporting medical personnel, as was done in the current study. our status as researchers in the field of trauma and health and our particular, and perhaps unique, insider/outsider status as hospital personnel may raise questions about our specific situation and positionalities with regard to this study [ ] . in response to such questions, we note that fieldwork, by its very nature, situates researchers among the community that they are researching, either as active participants or as observers or as a combination of the two [ ] . as "researchers from within" [ ] , who are also hcws, we felt obliged to study the experiences of hcws in this unpredictable crisis. we were surprised by the high volume and the intensity of the traumatic experiences reported by the hospital personnel. we did not anticipate that hcws who are accustomed to treating patients in the healthcare system would experience such insecurity and vulnerability. importantly in this regard, we found that the anonymous qualitative interview-being conducted by skilled social workers-also served as a therapeutic tool and as a proactive means of communication with staff about their needs. the interviews enabled the hcws to express their vulnerability and to acquire a sense of visibility and value. brown [ ] claims that vulnerability is the source of resilience and that vulnerability allows us to feel the emotions that we really crave-the need for human connection and the ability to belong and to "be seen" is something that every human being wants and needs. brown holds that for us to be seen, we need to let others see us in a vulnerable state. thus, the study framework-by enabling hcws to express their concerns about "not been seen by friends or management" during the battle against the coronavirus-instilled a sense of confidence in the personnel with regard to their ability to communicate their vulnerability, needs, and concerns, particularly the need for personal and psychological security [ ] . bowlby [ ] , in his influential book "a secure base," expands on the need for psychological security when he states that a basic component of human nature is the need for intimate emotional bonds and attachment. by enabling the hospital personnel to give voice to their needs and their insecurities, the interview itself became an intimate and emotional tool and a route of communication that ultimately allowed management to tailor various interventions to the needs of the employees and to increase the feeling of security in an extremely nonsecure situation. following the analysis of the data, the following practical interventions were developed by the hospital's social work department: . ad-hoc meetings aimed at strengthening and supporting staff in transition (in that their departments had changed location and/or function to corona-related locations/functions) were arranged. covid- -dedicated teams were approached immediately before or after transition, and a focused, short intervention was conducted with all available staff members. telephone support for teams put in isolation after exposure to the coronavirus was established. calls were made to support employees who were in isolation following exposure to patients infected with coronavirus. . targeted short interventions were initiated for hcws experiencing anxiety symptoms, and various relaxation techniques, such as eye movement desensitization and reprocessing (emdr) treatment, were offered for trauma treatment. basic information was made available to employees exposed to patients hospitalized for covid- . using the current research results, we created a brochure, in question and answer format, designed to provide information on employee health and rights, workplace guidelines, and the procedure that should be followed after an unwitting exposure to a patient with covid- . a / hotline was opened for consultations and questions concerning mental or emotional distress. the rationale for these interventions is embodied in the ideas of santarone, mckenney and elkbuli [ ] that "maintaining the mental resilience of frontline workers involves offering solutions that allow them to perform their duties." the study showed that the interventions reinforced the concept of the hospital as a protective organization, learning from the knowledge and experience of its staff rather than making assumptions to define these needs. we note that the interventions were not the main intention of the research but evolved from the needs of the hcws, as expressed in the interviews. the need to generate immediate solutions to an acute crisis informed our decision to conduct a qualitative narrative analysis study. nonetheless, as a "side-benefit" we have accumulated rich data, which we are now analyzing in greater depth in a mixed-methods study. in light of the findings of this study, we recommend that leaders in the health care system should identify hospital hcws as first responders (similar to combatants in the traditional military environment). listening to hospital staff and exposing the price of the battle against the novel coronavirus may provide knowledge about new 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promote psycho-social wellbeing among health care workers during covid- pandemic the listening guide: a how-to approach on ways to promote educational democracy the listening guide method of psychological inquiry the silenced voice in literacy: listening beyond words to a "struggling" adolescent girl the listening guide: voice-centred-relational analysis of private subjectivities learning to listen: an analysis of applying the listening guide to reflection papers reflexive accounts and accounts of reflexivity in qualitative data analysis listening for voice in narratives of relationship living in a movie"-israeli women combatants in conflict zones. women's stud understanding and addressing sources of anxiety among health care professionals during the covid- pandemic role of bottom-up decision processes in improving the quality of health care delivery: a contingency perspective listening as a path to psychological discovery: an introduction to the listening guide on the listening guide: a voice-centered relational method managing by walking around bringing women's voices back in: conducting narrative analysis in ir beyond binaries: analysing violent state actors in critical studies focus groups and the collective construction of meaning: listening to minority women. women's stud traumatic stress in the age of covid- : a call to close critical gaps and adapt to new realities breaking the binaries in security studies a secure base. parent-child attachment and healthy human development preserving mental health and resilience in frontline healthcare workers during covid- this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors would like to thank sarit avishai-eliner, eitan lavon and lion poles for the productive discussions and their immense efforts in supporting the hospital's staff in the battle during the coronavirus. a special appreciation to inez mureinik for her inspiring remarks and careful editing. the authors declare no conflict of interest. key: cord- - p yr n authors: nan title: poster exhibition date: - - journal: hepatol int doi: . /s - - - sha: doc_id: cord_uid: p yr n nan background: biliary atresia (ba) is one of the most common causes of neonatal cholestasis and the most frequent hepatic cause of death in early childhood. the incidence rate of ba is higher in asian countries, occurring in approximately of , (asian countries ) to of , (european countries) live births. early identification and prompt intervention is very important. to im prove the early diagnosis, we used proteomic technology to screen serum biomarker for ba. methods: two-dimensional electrophoresis ( -de) and matrix-assisted laser desorption /ionization time-of-flight mass spectrometry (maldi-tof-ms) were employed to screen serum biomarkers specific to ba sera from idiopathic neonatal hepatitis. after pretreatment including albumin and immunoglobulin (igg ) depletion, sera were subjected to -de and there after image analysis. the differentially expressed protein spots were identified by maldi-tof-ms. result: from optimized -de gel images, thirty-four spots were differentially expressed and identified by maldi-tof-ms to be eight proteins. overall, kininogen variant was under expressed and alpha- -b-glycoprotein, leucine-rich alpha- -glycoprotein , 'sp , ', a bg protein, vitamin d-binding protein/group specific component , apolipoproteina-, aqgv were over expressed in ba group com pared to idiopathic neonatal hepatitis. conclusion: -de based serum proteome analysis can be useful in detecting protein expression alteration and new discovered biomarkers might be an aid in the diagnosis of ba, though further validation is needed. s. somani , a. somani , a. jain , v. dixit suvidha, navjeevan hospital, ims, bhu, varanasi, india background: a variety of autoreactive antibodies are detected in patients with chronic liver disease. this prospective, nonrandomized study was undertaken to evaluate the nature & prevalence of various autoantibodies in patients with chronic liver disease of diverse etiologies. methods: study population included patients ( % males), who met defined criteria for chronic liver disease. detailed clinical, laboratory and sonographic evaluation was done. sera were tested for asma, anti-lkm type , ama, apa, ana, by standard methods. p< . was considered significant. results: among various etiologies for chronic liver disease, hepatitis b was most common ( %), followed by alcohol ( %), autoimmune hepatitis in %, hepatitis c ( %) and miscellaneous ( %). % of patients were labeled as cryptogenic after detailed investigations. ana (> / ) was positive in % of definite aih, % of hcv related cld but at titer of > / , . % of hcv related cld & % of probable aih were found positive. asma (> / ) was positive in % of hbv related cld, % of alcohol related cld, % of definite aih, % of probable aih, % of hcv related cld but asma in titer of > / was positive only in % oh definite aih. apa was detected in . % of cryptogenic cld, . % of hbv related cld & % of alcohol & probable aih related cld each. ama was detected in % of cryptogenic, hbv, aih (definite) & hcv related cld each, and % of alcohol related cld & % of pbc. conclusions: apart from aih there is high prevalence of ana & sma in hcv related cld while other antibodies has low prevalence in non-aih related clds. this study also suggests that prevalence of various autoantibodies should be borne in mind while considering the diagnosis of cld especially of mixed etiology. conclusions: oa infusion did not lower ammonia levels or improve survival. results: the mortality ( . %) of patients in lamivudine group with meld score from to was lower than that ( . %) of control group ( = . , p= . ). univariate analysis showed that mortality was significantly related to age (p= . ), meld score (p= . ), treatment method (p= . ), pretreatment hbv dna load (p= . ), the decline of hbv dna load during therapy (p= . ) and encephalopathy (p= . ). in multivariate analysis, in patients with meld scores - , treatment method (p= . ), pretreatment hbv dna load (p= . ), decline of hbv dna load during therapy (p= . ) and encephalopathy (p= . ) were independent predictors of mortality; for meld scores above , only meld score (p= . ) was independent predictive. conclusions: lamivudine treatment significantly decreases the month's mortality of patients with meld score - , and a low viral load pre-treatment and quick decline of hbv dna load are good predictors for the survival of lamivudine treatment. background/aims: early identification of patients with fulminant hepatic failure (fhf) who need a liver transplantation is very important. to construct a prediction model for early diagnosis and prognosis of fhf, we studied dynamics of metabolic profiles using a d-galactosamine/lipopolysaccharide (galn/lps)-treated mouse model. methods: balb/c mice were used to construct fhf model and sacrificed for blood collection at , , and hour after treatment, respectively. levels of plasma metabolites were quantified using gas chromatography/time-of-flight mass spectrometry and data were processed using partial least squares discriminant analysis (pls-da). results: distinct clustering differences were observed and h after treatment between survival and dead groups. at h, plasma levels of some metabolites differed significantly between survival, dead and control groups. ketogenesis and the tca cycle were inhibited in both survival and dead groups, but in dead group, the urea cycle was also inhibited and glycolysis was elevated. pls-da indicated that principal component weighting was greatest for plasma levels of phosphate, -hydroxybutyrate, urea, glucose and lactate. the y-predicted scatter plot in pls model assigned samples to survival or dead groups using an apriori cutoff of . with % sensitivity and specificity. similar results were observed in fhf patients with different outcomes. pe association between polymorphisms in the interleukin- gene promoter and hepatitis b-related acute liver failure conclusions: the pls model based on metabonomics analysis can be used to predict outcomes well, and plasma levels of phosphate, -hydroxybutyrate, urea, glucose and lactate may constitute a set of markers for early diagnosis and prognosis of fhf. il- promoter are associated with the susceptibility to hepatitis b-related alf in the chinese population. il- a- c may be a regulatory polymorphism that affects gene regulation. hepatocyte cell death in aclf: mechanism and significance -an immunohistochemical study. p. sakhuja , a. rastogi , s. s hissar , a. singh , a. kumar , r. gondal , s.k. sarin gb pant hospital, institute of liver and biliary sciences, new delhi, india background: acute on chronic liver failure (aclf) is defined as acute hepatic insult complicated within weeks by ascites and/or encephalopathy in a patient with previously diagnosed or undiagnosed chronic liver disease. caspases play an essential role in apoptosis. cox- is an inducible immediate early gene responsible for the release of prostaglandins during inflammatory response. we studied the immunohistochemical expression of cox- and caspase- in liver tissue to assess their role in pathophysiology and in predicting outcome of aclf. method: a retrospective analysis of liver biopsies with clinical diagnosis of aclf was undertaken. patients were divided into two groups a and d based on clinical outcome (alive/died respectively). immunohistochemical analysis for cox- and caspase was performed on and cases respectively and scored from - as per intensity and distribution. score - indicated high intensity with focal to diffuse distribution, and was considered significant. results: etiology of acute liver failure was viral or alcoholic. increased expression of caspase was observed in / cases in group d and none of the cases in group a(n= ) (p= . ). increased expression of cox- was observed in / cases in group d and none of the cases in group a (n= ) (p= . ). conclusion: increased immunoreactivity of caspase in liver biopsies of patients of aclf may indicate worse prognosis and its important role in the pathophysiology of aclf. immunostaining for caspase is useful for assessment of prognosis and possibility of anti-apoptotic and anti-fibrotic therapies in future. conclusion: hhgf expression vector (pcmv-hhgf) has been successfully constructed and repeated hydrodynamic injections can promote sustained and high expression of hhgf in vivo. j.h. kim , k.w. kim asan medical center, seoul, korea background: splenic artery embolization (sae) is performed to increase hepatic arterial flow or to decrease portal venous flow in recipients of liver transplantation (lt). thus, the purpose of this study was to estimate sae effect on the basis of changes in caliber of related vessels and splenic volume on pre-sae and serial post-sae ct scans in lt recipients. methods: between and , among lt recipients who underwent sae and serial follow-up ct, with no compounding factor that may obscure sae effect were included in this study. they underwent ct before and after ( week, month, and year) sae. a radiologist retrospectively measured diameters of ca, cha, sa, sv and splenic volume on serial ct scans. their diameters and splenic volume on each ct were compared with those on the prior and pre-sae ct. the difference was compared using repeated-measures anova tests. results: cas decreased between week and month after sae (p<. ), but were stable before week and after month. chas increased within week (p<. ) but decreased between week and month (p<. ) and remained stable after month. compared with pre-sae ct, chas were larger for month after sae. sas continuously decreased for year (p<. ). svs decreased for month (p<. ) and remained stable after month. compared with pre-sae ct, sas and svs were smaller from week after sae and on. splenic volume continuously decreased for year except a period between week and month. conclusion: the increase of hepatic arterial flow persists for month after sae, but returns to baseline thereafter. the decrease of portal flow may lasts for at least year after sae. poster exhibition -cholangioca and other liver neoplasm poster session, hall b background: now, rfa has becoming an important practice of hcc therapy. in this study, we evaluated whether rfa therapy for metastatic liver tumor has a beneficial effect on patients' survival. methods: forty six patients were treated by rfa for metastatic liver tumor from july through february in our hospital, of the , patients were metastasis either form colon or stomach cancer. these patients were analyzed in this investigation. cumulative survival rate from initial rfa therapy was calculated by kaplan-meier method. predictive factors for survival were identified using cox proportional hazard regression model. results: the mean age of the patients were . (range, - ) . the mean size of the tumor is mm (range, - mm) and the numbers of tumor foci are . nodules range, . the survival rates of patients treated by rfa were . % at years and . % at years in colon cancer, . % at years and . % at years in gastric cancer. in this series of patients, primary cancer: colon (p= . odds ratio . %ci . - . ), younger patients ( ) (p= . odds ratio . %ci . - . ) and multiagent chemotherapy (p= . odds ratio . % ci . - . ) were significantly correlated with better survival. conclusion: the survival of patients treated by rfa for metastatic colon cancers had better survival than those of gastric cancers. in addition, good indication of rfa is for metastatic colon cancers, younger patients and has to be treated by multiagent chemotherapies. utility of contrast enhanced ultrasonography with sonazoid in radiofrequency ablation (rfa) for liver metastasis e. goto , s. shiina , r. tateishi , r. masuzaki , k. enooku , t. sato , j. imamura , t. goto , y. sugioka , h. ikeda , , h. yoshida , m. omata department of gastroenterology, university of tokyo, department of clinical laboratory, tokyo, japan background & aims: contrast enhanced ultrasonography (ceus) with sonazoid is effective for liver metastasis because enhance defect in kupffer imaging is well delineated. the aim of this study is to investigate the detection ability of ceus and the utility of sonazoid in rfa for metastasis liver tumors. material & methods: from january to december , a total of liver metastatic nodules in patients ( colon cancer, breast cancer, gastric cancer, islet cell tumor, and others) admitted to receive rfa were studied. the detection ability of liver metastasis was compared between ceus and conventional us using enhanced ct as reference standard. the mean numbers of treatment session of rfa were compared between patient treated with ceus assistance and historical controls matched for size and number of tumors. results: the detection rate was . % with conventional us and . % with ceus (p= . ). nodules in patients were not detected by conventional us and detected after injection of sonazoid. in addition, nodules in patients were detected not by ct but only by ceus. the mean number of session was . ± . as compared to . ± . in the historical controls (p< . ). conclusions: ceus with sonazoid is useful for detection of liver metastasis. sonazoid is an excellent supportive agent in rfa of liver metastasis. background/aims: carcinogenesis of intrahepatic cholangiocarcinoma (icc)-associated liver fluke infection accumulated genetic and epigenetic alterations. cholangiocarcinoma cell line (kku-m ) is adenosquamous carcinoma which rare variants and not commonly found in icc. however, interactions of liver fluke-associated icc proceed to genetic alterations in adenosquamous carcinoma that have been not elucidated. objectives: to analyze the whole genome-wide genetic alterations in kku-m using microarray comparative genomic hybridization. methods: dna of kku-m and matched-sex reference were differentially labeled with fluorescence dries (cy and cy ) and mixed together with cot- dna. the mixture was hybridized on array with spotting , human bacterial artificial chromosomal (bac) clones in triplicate and mapped these directly onto human genome sequence. the genetic alterations were classified the dna copy-number variations according to the intensities of log ratio (cy /cy ) as dna copy-number loss/gain and deletion/amplification. results: the whole genomic alterations in kku-m , which revealed a variety of chromosomal aberrations with a part and/or entire chromosomal gain and loss. chromosomal amplifications were detected on q . , q . , q . , p tel, and p . , whereas homozygous deletions were detected on q , q , q , q - , q . , q , q , q - q , p - p , p , q . , q . - q . , q . , q . and q . . conclusions: the whole genome-wide genetic alterations were characterized which previously not defined in adenosquamous carcinoma. this recent advance tool is usefulness for discovering novel cancer-related gene (oncogene/tumor suppressor gene) and substitutes in in vivo experiment for functional testing of candidate gene involving liver fluke-associated icc carcinogenesis. artificial chromosomal (bac) clones in triplicate and mapped these directly onto human genome sequence. the genetic alterations were classified the dna copy-number variations according to the intensities of log ratio (cy /cy ) as dna copy-number loss/gain and deletion/amplification. results: the whole genomic alterations in kku-m , which revealed a variety of chromosomal aberrations with a part and/or entire chromosomal gain and loss. chromosomal amplifications were detected on q . , q . , q . , p tel, and p . , whereas homozygous deletions were detected on q , q , q , q - , q . , q , q , q - q , p - p , p , q . , q . - q . , q . , q . and q . . conclusions: the whole genome-wide genetic alterations were characterized which previously not defined in adenosquamous carcinoma. this recent advance tool is usefulness for discovering novel cancer-related gene (oncogene/tumor suppressor gene) and substitutes in in vivo experiment for functional testing of candidate gene involving liver fluke-associated icc carcinogenesis. acknowledgements: this work was supported by faculty of medicine, kku, thailand (grant no. i background/aims: we studied the clinical efficacy of arterial chemoinfusion therapy through an implanted port system for patients with intrahepatic cholangiocarcinoma (icc). thirty patients with unresectable icc or intrahepatic recurrence of icc after surgery were studied. comparison was made between patients who received arterial chemoinfusion therapy through an implanted port system with adriacin and lecithin-added lipiodol emulsion in patients and -fluorouracil ( -fu) in patients. eighteen patients were treated without port system. results: disease was stable in patients with adriacin and lecithin-added lipiodol emulsion and in patients with -fu. disease was progressed in patients with -fu. the mean survival period was . months in patients with adriacin and lecithin-added lipiodol emulsion, . months in patients with -fu, and . months in patients without port system (p= . , p= . ). conclusion: arterial chemoinfusion therapy through an implanted port system is useful for patients with intrahepatic recurrence of icc after surgery. pe s. kaur , t. kaur department of biophysics, panjab university, chandigarh. india background: a number of dietary factors have been involved in the pathogenesis of cholelithiasis. cholesterol overfeeding is the primary means of inducing supersaturated bile and cholesterol gallstones in animal models.aim of the study was to investigate the rate of epithelial cell death and proliferation in gallbladder during gallstones formation. methods: balb/c mice was divided into two groups control in this group animals were fed normal chow diet, high fat diet group in this group ( % cholesterol, . % sodium cholate, % butter fat and % coconut oil) mixed with chow diet was fed to the mice for weeks. cell apoptosis and proliferation was assayed in gallbladder epithelial cells. histological analysis of gallbladder sections were done with hematoxylin and eosin staning. results: mice fed high fat diet had apoptotic as well as necrotic epithelial cells. rate of proliferation was enhanced after and hrs in mice fed high fat diet group as compared to the control group. the histopathological section of control gallbladder has normal morphology whereas gallbladder wall thickness was markedly increased; epithelial cells appeared more elongated in mice fed high fat diet. conclusion: results obtain show that high fat diet markedly induced biliary epithelial cell proliferation and biliary epithelial cell apoptosis. it has been determined that when there is an injurious stimulus that leads to apoptosis, it is later followed by reparative proliferation and when there is no injurious stimulus, apoptosis occurs late in the course as part of remodeling. background: obstructive jaundice can be caused by malignancy. the treatment can be drainage by biliary stenting. in advanced malignant jaundice, the stent placement is often difficult. objective: to evaluate the success rate of malignant obstructive jaundice evaluation of ercp and success rate of stent placement. methods: retrospective study based on data of ercp from october until july . results: we evaluated patients who has done ercp examination, ( , %) patients have clinical diagnosis of obstructive jaundice. there were ( , %) male and ( , %) female, age range - (median age was ). there were no malignancy in ( , %) patients; malignancy in ( , %) patients and ( %) patients need further evaluation.. from patients, ( %) patients attempted to have stent placement, ( , %) patients do not and ( , %) patients have no data. we done descriptive study on patients attempted to have stent placement, ( , %) patients succeed in stent placement whereas ( , %) failed. malignancy was showed to be a factor of stent failure (malignancy: fail and success ( , %) vs non malignancy: fail and success ( , %)). conclusion: ercp can identify the cause of obstructive jaundice in % patients. the success rate of stent placement was , %. the success rate of biliary stenting in malignant obstructive jaundice was , % whereas in non-malignant cases was , %. papillary carcinoma was the most frequent cause of malignant obstructive jaundice. background: in hydatid disease of the liver cystobiliary fisula (cbf) constitutes an entity characterized by the occurrence of a life-threatening cholangitis with increased morbidity. aim: to study the different diagnostic and therapeutic aspects of cystobiliary fistula in hydatid disease of the liver. patients and methods: fourteen patients with complicated cysts were divided into groups; group a: nine patients presented with cholangitis, and group b: five patients had history of jaundice. in all patients, the diagnosis of cbf was confirmed by erc (endoscopic retrograde cholangiography). preoperative endoscopic sphincterotomy (es) was done in group a with retrieval of hydatid daughter cysts. seven patients (subgroup a ) were subsequently submitted to surgery entailing endocystectomy in and hepatic resection in two. the remaining patients in group a (subgroup a ), were managed by endoscopic therapy only. patients of group b (n= ), were not submitted to preoperative es and were subsequently managed by hepatic resection in one patient and endocystectomy in four. results: there was no mortality in the studied group. postoperative bile leak occurred in four cases in group b. in contrast, none of the patients who were submitted to preoperative es (subgroup a ) had bile leak. all patients received albendazole treatment. conclusion: erc is important in confirming the diagnosis of cbf. also, therapeutic erc has a place in the treatment algorithm of cbf as it was found to be a safe and a reliable therapeutic alternative especially in high risk patients for surgery. v. singh , g. singh , g.r. verma , v. gupta , s. ghosh , r. gupta , r. kapoor , n. sharma , a. bhalla , s.k. mahi background: endoscopic palliation in malignant hilar biliary obstruction requires ercp. however, contrast injection leads to cholangitis. recently, contrast-free metal stenting with or without mrcp has shown encouraging results. however, mrcp and metal stents are costly. there have been no reports on the use of air cholangiography in these patients. methods: we prospectively studied the role of air cholangiogaphy assisted unilateral plastic stenting in these patients. results: ten patients with unresectable malignant hilar biliary obstruction were studied. air cholangiography detected type ii obstruction in and type i in patients which is similar to mrcp. all patients underwent unilateral plastic stenting. a successful endoscopic drainange was achieved in % patients. cholanngitis occurred in none and there was no -day mortality. no major complications were observed. conclusion: air cohlangiography assisted plastic stenting in these patients is a safe and effective method of palliation. however, it requires a larger study. introduction: a description of igg -related sclerosing cholangitis (igg -sc) without pancreatic lesion has recently been reported. in addition to imaging, diagnosis relies on findings of elevated serum igg and immunodetection of invading igg -positive cells. here we report a case of igg -sc with only slight common bile duct abnormalities and normal pancreatic findings. case study: a -year-old man suffering from cephalalgia, general malaise and muscle ache was admitted to our hospital. his blood examinations on admission revealed eosinophilia, mild anemia, liver dysfunction and an igg level of mg/dl (igg mg/dl). although ercp did not reveal typical stenosis or irregularities of the bile duct wall, visualization of peripheral bile ducts was slightly impaired. echography revealed thickening of the intrahepatic bile duct and gallbladder walls as well as adenopathy. due to a gradual increase in pleural effusion and a progression of anemia, oxygenation was begun on the seventh day of illness. based on the combination of eosinophilia, elevated serum igg levels, image findings and a negative result for helminth, igg -sc was suspected. liver biopsy was performed on the ninth day of illness and steroid therapy was initiated, after which symptoms and laboratory findings improved. the igg -positive plasmocytic infiltrate present around the portal region at the time of biopsy disappeared within eight months of treatment. summary: this case displayed two unusual features that are not generally observed with igg -sc: complications due to hemolytic anemia, and destruction of the peripheral bile duct with little damage to the common bile duct. introduction: various systemic diseases have been reported to be associated with igg . although steroids are effective in the treatment of igg -related diseases, there are some reports on relapses with their treatment, and cases are often difficult to differentiate from malignant diseases. we encountered a case of autoimmune pancreatitis with sclerosing cholangitis (aip-sc), in whom ca - was elevated with episodes of exacerbation and an elevated serum igg concentration. igg staining was also useful for the diagnosis. case study: an -year-old woman noticed tumors beneath the bilateral jaw and was found to have an elevated level of ca - ( ) seven years previously. her left submandibular gland was removed and diagnosed as sclerosing sialadenitis. four years previously, she was diagnosed as having diabetes mellitus complicated by a recurrence of ca - ( ) elevation and liver dysfunction. cholangiocarcinoma was suspected based on ercp, but was not confirmed by histologic findings of bile duct biopsy. elevated igg and other test results established the diagnosis of aip-sc, so steroid therapy was initiated, after which symptoms and laboratory findings improved. this recurrence of ca - elevation ( ) was diagnosed as a relapse of aip-sc based on an increased igg level and histologic findings. summary: some papers have reported that igg -positive cells are found in liver tissue in this disease, but such cells were not detected in the liver specimens in our case. this might be because intra-liver sites may have differed in the degree of morbidity, and long-term steroid therapy might have suppressed inflammation in the liver tissue. s. kaur , t. kaur department of biophysics, panjab university, chandigarh, india background: cholelithiasis, a gallstone disease is major cause of morbidity affecting millions of people throughout the world. aim of the present study was to investigate the predisposing factors that lead to the formation of gallstones. methods: the study was carried out on gallstones, bile and serum of patients. gallstones and bile were divided into three groups' cholesterol, pigmented and mixed gallstones. blood of the patients was divided into two groups with gallstones and without gallstones patients. trace elements and various biochemical estimations were carried out. clinical history of the gallstones patients was recorded from the hospital records. results: trace elements analysis in bile and gallstones showed that calcium is the main element in all the three types of stones. iron was the main element in mixed gallstones. in pigmented gallstones magnesium and zinc were the major trace elements. liver function tests and lipid peroxidation levels in sera were significantly increase whereas, antioxidant enzymes concentrations in sera were significantly decreased in patients with gallstones. clinical history of the gallstones revealed the cases had jaundice, diabetes mellitus and estrogen replacement therapy respectively. conclusion: results suggest that trace elements in gallstones and bile as well as clinical history of patients with chronic cholelithiasis could be the underlying factor in the pathogenesis of gallstones. the concentration of products derived from the free radicals reactions increases with degree of inflammation. such a condition increases risk of bile saturation which would further contribute to the progress of gallstones formation. background and aims: diseases of the biliary tree and gallbladder are being described with increasing frequency among patients with the acquired immunodeficiency syndrome (aids).therefore there is a need to do a research about the risk factors of gallbladder diseases in hiv/aids patients. so it can be useful to clinicians to predict the possibility of a patient having gallbladder disease and consider the options of further plans. the aim of this study was to find the prevalence and varieties of gallbladder diseases in hiv/aids patients. methods: a cross sectional study was performed in patients with hiv/aids who visited ciptomangunkusumo hospital, jakarta. the risk factors (route of transmision,cd ,arv,hepatitis) and clinical presentations were studied.ultrasonography examinations were performed to detect gallbladder annormalities. results: patients with hiv/aids match the study criteria. there were gallbladder abnormalities in ( . %) subjects, which ( . %) had acalculous cholecystitis and ( . %) had cholecystitis with cholelithiasis. on bivariate analysis, there was a significant association between abdominal pain, jaundice and the use of arv to gallbladder abnormalities (p = . ; . ; . ; . ). however, there was no association between age, sex, transmision route of hiv, hepatitis and cd to gallbladder abnormalities. conclusion: hiv/aids patients are susceptible to opportunistic gallbladder infection. acalculous cholecystitis is the most frequently encountered gallbladder abnormalities of hiv/aids patients in this study. poster exhibition -hbv poster session, hall b long-term stopping therapy t.b. trung , p.h. phiet university medical center, hochiminh city, vietnam background: among the approved nucleos(t)ide analogues therapies for chronic hepatitis b, lamivudine was used widely, sometime inappropriate in practice due to high safe and low price but lamivudine is associated with the highest rate of drug resistance. objectives: the aim of the study was to determine the ymdd variants after long-term stopping treatment in lamivudine-resistant patients using more sensitive technique. methods: blood samples from lamivudine resistant patients were collected after long-term stopping therapy. the ymdd variants are detected using technique pcr restriction fragment length polymorphism (pcr-rflp) at hcmc university medical center results: after stopping lamivudine treatment months ( - months) ymdd mutants were detected in ( , %) of patients. among them ( . %) had the most important m v/i mutant, ( %) had accompanying l m mutant. it means that once drug resistant mutants have been selected, they are archived for the long time even if treatment is stopped. many of patients have the features characterized for the patients in immune tolerance phase (young age, hbeag positive, normal alt). the treatment of this group is not strongly recommended due to low efficacy and high risk of drug resistance. conclusion: the most important m v/i mutant was still detected with significant portion of the virus population after long-term stopping therapy in lamivudine resistant patients. the options of retreatment for this patients when necessary are limited due to cross-resistance. the management of chronic hepatitis b should be followed strickly the recommendations of specialized association to avoid this problem. background/aim: whether liver stiffness measurement (lsm) using transient elastography is reliable to assess liver fibrosis in the settings of severe acute exacerbation of chronic hepatitis b (chb) is uncertain. methods: we prospectively recruited consecutive patients with severe acute exacerbation of chb (alanine aminotransferase or alt > x upper limit of normal). the relationship of alt levels and lsm were serially assessed and liver biopsy was performed after alt normalization. results: eleven patients ( male, median age years) were followed up for weeks; patients received anti-viral therapy. overall, lsm was positively correlated with alt levels (r= . , p< . ). at initial presentation, the median serum alt and lsm was ( - ) iu/l and . ( . - . ) kpa. a progressive reduction in lsm was observed during subsequent visits in parallel with the reduction of alt levels. even after the normalization of alt at week , lsm of patients continued to drop at week . at the last visit, the median alt was ( - ) iu/l and lsm was . ( . - . ) kpa. among the patients who had liver biopsy performed at week , patients had f fibrosis (lsm . - . kpa) and patient had f fibrosis (lsm . kpa). conclusions: lsm using transient elastography may misdiagnose liver cirrhosis in patients suffering from severe acute exacerbation of chronic hepatitis b. lsm should be assessed after normalization of alt levels in order to accurately assess the degree of fibrosis. h.c. lai , s.w. lai , k.f. liao , c.s. liu , t. lin , c.c. lin china medical university hospital, taichung, taiwan background: in , chronic liver disease was the seventh leading cause of death in taiwan. hepatitis b and hepatitis c are two major causes of chronic liver disease in taiwan. the purpose was to investigate the seroepidemiology of hepatitis b surface antigen (hbsag) and hepatitis c virus (hcv) antibody in taiwan. method: this was a hospital-based cross-sectional study. we analyzed viral hepatitis data from subjects who received health checkups at one medical center in taichung from to . all subjects were divided into three age groups, including - , - and . this study emphasized the prevalence of hbsag and hcv antibody by gender and age. the statistical analysis was performed by t test and . result: there were men ( . %) and women ( . %). the mean age was . (standard deviation . , range - ). the overall prevalence of hbsag was . %, with statistically significant difference(ssd) between gender ( . % for men vs . % for women, p < . ). the prevalence of hbsag was decreased with age in men, with ssd (p < . ), and also decreased in women, without ssd (p = . ). the overall prevalence of hcv antibody was . %, without ssd between gender ( . % for men vs . % for women, p = . ). the prevalence of hcv antibody was increased with age both in men and in women, with ssd (p < . ). conclusion: we hope this study can provide the epidemiological data for further studies of hepatitis b and hepatitis c virus infection in taiwan. s.m. wu , x. zhou wuhan medical treatment center, center for gene diagnosis, zhongnan hospital, wuhan university, china e-selectin is revealed to facilitate leukocyte adhension to the endothelium and migration into inflamed tissue in inflammatory diseases. chronic hepatitis b virus infection is regarded as a chronic inflammatory process. to examine the possible involvement of e-selectin in the etiology of chronic hbv infection, we analyzed two polymorphisms of e-selectin and determined the plasma souble e-selectin levels in patients with chronic hbv infection and controls. the frequency of c allele of the a c polymorphism was significantly increased in patients with lc campared with controls. no significant positive association was observed between the g t polymorphism and chronic hbv infection. but in patients with lc, divided according to the child-pugh classification, the frequency of t allele was of significant difference between child'class a and class b plus c. plasma levels of soluble e-selectin were significantly increased in patients with chronic hepatitis and liver cirrhosiscompared with controls. in the liver cirrhosis group, levels of se-selectin were significantly decreased from child' class a to class c. in each group, patients with c allele of the a c polymorphism showed higher soluble e-selectin levels than those with a allele. this is the first report describing the association between e-selectin polymorphisms and hbv-related hepatic fibrosis. our data showed the a c polymorphism of e-selectin gene is associated with disease progression in patients with hbv infection and controls the expression of plasma soluble levels, the g t polymorphism may be related to fibrotic severity in patients with liver cirhosis. background: chronic hepatitis b (chb) patients with high serum hbv-dna and normal serum alanine aminotransferase (alt) levels might be considered for treatment if histopathological findings show fibrosis stage or more. however, to our knowledge there is no recommendation with regard to the therapeutic agents for this group of patients. objective: this study was aimed to evaluate the efficacy of nucleoside analogues (entecavir or telbivudine) in treating chronic hepatitis b patients with high serum hbv-dna and normal serum alt levels. patients and method: this was an open-label study in chb patients with high level serum hbv-dna levels between january and october . patients were included if they showed normal serum alanine aminotransferase (alt) level at two measurements within a -month interval and had fibrosis stage > on liver biopsy specimens. patients were treated with entecavir . mg/day or telbivudine mg/day. the primary endpoint was the reduction or undetectable of serum hbv-dna at week and week of treatment, while the secondary endpoint was hepatitis b e antigen (hbeag) seroconversion. results: during a -year period, chb patients with high level serum hbv-dna with normal alt two times with months interval underwent a liver biopsy. twenty-eight ( . %) of pts showed fibrosis stage on histological findings (metavir score). twelve of these patients received nucleoside analogues, ( . %) of them were men. patients' median age was (range: - ) years. there were patients with stage- , patients with stage- and patient with stage- fibrosis. eleven ( . %) patients had genotype b virus. at baseline, the mean serum alt level was + . u/l and mean hbv-dna level was . x iu/ml, ranging from . x to . x iu/ml. six patients received entecavir and the other six received telbivudine therapy. undetectable hbv-dna was achieved by ( . %) patients at week- and ( . %) patients at week- of treatment. one patient who had the highest hbv-dna level had viral load reduction to . x iu/ml at week- of treatment. two out of patients with positive hbeag achieved hbeag seroconversion at week- of treatment. conclusion: this preliminary study has shown that nucleoside analogues might be considered in the treatment for chronic hepatitis b patients with high serum hbv-dna and normal serum aminotransferases levels. j. chen , x.j.. wu , y. wang , g.q. wang department of infectious diseases, peking university first hospital, beijing, china background: the dysfunction of t cells may represent a mechanism of hepatitis b virus (hbv) persistence. programmed death- (pd- ) and its ligands, pd-l /pd-l , are new members of cd /b family, as co-stimulatory molecules expressing on t cells and antigen present cells (apcs). their engaging can downregulate the t cells function, including proliferation, cytokines secretion and cytotoxicity. in periphery blood, pd- was upreguated on virus specific-t cells, leading to the impairment of t cells. blocking the pd- /pd-l can improve the function of t cells. methods and patients: patients with chronic hepatitis b (chb) were treated by pegylated ifn - b (pegintron from schering-plough, once a week, . or g/kg/weight). the periphery blood were taken at weeks, weeks, weeks, and weeks. periphery blood mononuclear cells (pbmc) were isolated from fresh heparinized blood by ficoll-hypaque (density: . g/l) density gradient centrifugation. then the cells were incubated with apc-conjugated anti-pd- antibodies. the pd- expression on lymphocytes was detected by flow cytometry (fcm). results: the pd- expression on lymphocytes at weeks was . ± . %, at weeks was . ± . %, at weeks was . ± . %, at weeks was . ± . % (p< . ). conclusion: treatment with ifn - b can downregulate the pd- expression on lymphocytes and may partially restore the function of t cells. to investigate the effects of nucleoside analogs therapy in hepatitis b related acute-on-chronic liver failure, we treated hbv related acute-on-chronic liver failure patients with entecavir. as control, the remaining were not treated with nucleoside analogues. results show the survival rate of entecavir therapy group has no significantly difference with none-treated group (p> . ). although entecavir greatly reduced hbv replication during different therapy times (p< . ), the meld score and liver function (alt, albumin, bilirubin, prothrombin time) had no significant changes (p> . ). further more, we analyzed the meld score and liver function in different hbv-dna level patients .no significantly difference was observed (p> . ). there is no significant correlation between hbv-dna level and meld score in different therapy times (p> . ).the hbv-dna level between patients with over months and less than months survival patients showed no significant difference either (p> . ). however, meld score and some parameters of liver function (albumin, bilirubin, prothrombin time) showed significant difference (p< . ). these results suggest hbv-dna loading may not be a direct factor to increased liver injury and suppression of hbv replication may not reduce the severity of liver failure in hbv related acute-on-chronic hepatitis. s. firdoos , u. adeeb , a. mehmood , m. gill islamabad specialists clinic, islamabd, pakistan background: before the availability of etv, it was common to use adv for treatment of chronic hepatitis b patients. primary nonresponse and suboptimal response is a common problem with adv treatment. methods: we wanted to study the outcomes of entacavir therapy in this subset of patients. study was conducted between april to april . we enrolled chb patients who had non response to - weeks of mg adv therapy. non response and suboptimal response was defined as non dimunition of at least one log of hbvdna from baseline after weeks of therapy and persistence of log after weeks of therapy respectively.they were switched to mg entacavir before breakfast daily for at least months.they had serial alt cbc and hbvdna measured every weeks. results: out of patients male and were female. only patients were hbeag(+).mean hbvdna level prior to adv exposure was . log copies/ml.mean duration of exposure to adv was weeks. patients lost to f/u.we did intention to treat analysis. out ( %) patient has, undetectable level of hbvdna after weeks of therapy labelled as group . out of ( %) had hbvdna level reduced by a mean of log copies/ml labelled as group .on week treatment analysis all patients from group was hbvdna undetectable, additional patients from group had undetectable hbvdna. conclusion: entacavir therapy results in rapid suppression of hbvdna levels in majority of patients with primary nonresponse or partial non response to adv therapy. background: except for serum alt level, baseline factors predictive of therapeutic response to lamivudine in patients with hbeag-positive chronic hepatitis b remain largely unknown. we thus studied the influence of pre-therapy viral factors on end-of-treatment responses to lamivudine therapy. methods: a total of treatment-naïve hbeag carriers who had pre-therapy serum alt level> xuln and received lamivudine for months reimbursed by the national health insurance were prospectively enrolled. hbeag seroclearance and combined hbeag seroclearance, alt normalization as well as undetectable hbv dna at the end of therapy were defined as primary and secondary endpoint, respectively. the pre-therapy viral factors including viral load, genotype, precore stop codon (pc)/ basal core promoter (bcp) status, and pre-s deletion were determined to correlate with therapeutic endpoints. results: the frequency of patients with detectable pc mutation (g a), bcp mutation (a t/g a), and pre-s deletion at baseline was . %, . %, and . %, respectively. after completing -month lamivudine therapy, overall hbeag seroclearance rate was . %. patients with hbeag seroclearance had a higher prevalence of baseline pc mutation than those without ( . % vs, . %, p= . ). by multivariate analysis, the odds ratio of patients with pc mutation to develop hbeag seroclearance was . (p= . ). in addition, the presence of pc mutation also correlated with the combined response. conclusions: for hbeag-positive chronic hepatitis b patients with serum alt> xuln, pc mutation could predict a higher hbeag seroclearance rate at the end of -month lamivudine therapy. the efficacy of adefovir dipivoxil against all patterns of lamivudine resistant hepatitis b d.j. kim , y.d. park , y.g. kwon , h.g seo daegu fatima hospital, kunngpook national university hospital, daegu, korea background: our aim was to evaluate the efficacy of adefovir dipivoxil (adv) and determine patient-dependent or laboratoroy variables that are predictive of hbeag loss and ivr for hepatitis b patients resistant to lamiduvine. also we evaluated the activity of adv against all patterns of lamivudine-resistant hbv. method: hbv-infected patients with lamivudine resitance received adv for months. quantitative hbv dna, hbeag/anti hbeag, alt was checked every - months. the hbv polymerase of patients were sequenced for baseline samples to determine the presence of lamivudine resistance mutations. result: there is no significant difference in all patterens of hbv mutation about hbv dna reduction at w, w, w. there is no significant difference in all patterens of hbv mutation about alt normalization at w, w, w. conclusion: adefovir dipivoxil demonstrated similar potent anti-hbv efficacy regardless of the different patterns of lamivudine-resistant hbv mutations. g. novelli , m. rossi , v. morabito , f. pugliese , p. berloco la sapienza university, rome, italy background: hepatitis b (hbv)-related end-stage liver disease is one of the most common indication for liver transplantation (lt). a number of patients dying while on the waiting list or removed because of being too ill is progressively increasing. we valued the possibility to improve the model end-stage liver disease (meld) of patients awaiting liver transplantation using a albumin dialysis: molecular adsorbent recirculating system (mars). methods: we treated patients ( male and female) with a mean age . . inclusion criteria: serum bilirubine > mg/dl, meld , inr > . , encephalopathy grade ii. all patients were treated with mars mean ± . hr cycles and mean treatments (range - ). all patients received standard medical treatment in addition to mars dialysis. the patient survival was valued at six months. results: we obtained a significant change of cytokines levels as interlukine (p< . ) and tumor necrosis factor alfa (p< . ) in association with an improvement of kidney, hepatic and hemodynamic parameters. at the end of mars treatments we observed a significant reduction of meld score (p< . ). the results of meld show a rebound effect between the end of treatment and the follow up at six months without returning at starting values (p< . ). twenty patients lived and dead for clinical complications. conclusion: the improved meld score with mars gave patients on lt waiting list more time of survival, thus allowing them more opportunity for liver transplantation. entecavir for treatment of lamivudine-refractory patients chronic hepatitis b h.t. dat , p.t.t. thuy medic medical centre, ho chi minh, vietnam lamivudine treatment is associated with frequent development of resistant hepatitis b virus. this incidence especially is higher in longer time of treatment and loss of treatment benefit. entercavir is a new antiviral agent shown its high efficacy even in cases of mutations with lamivudine resistance. in this study, we evaluate the efficacy, the safety of entercavir in treatment of lamivudine-refractory patients chronic hepatitis b. sixty chronic hepatitis b patients with evidence of lamivudine resistance were randomly divided into two groups in proportion of : . group i (n= ) used entecavir mg/day, group ii (n= ) used lamivudine mg/day. treatment time was weeks. histology, alt, hbvdna were evaluated in the end of the treatment. age, sex, alt, hbvdna, genotype, hbeag were analyzed to evaluate their influences to the treatment. the results have showed hbvdna< copies/ml in entecavir group . % vs. % lamivudine group (p< . ). hbvdna negative in entecavir group was . % and incidence of seroconversion of hbeag was . %. alt was normal in entecavir group . % vs. . % in lamivudine group (p< . ).histologic improvement in entecavir group was . % vs. . % in lamivudine group (p< . ). patients with hbeag negative, genotype b, low viral load were shown better results. entecavir was shown to be efficacious in treatment for chronic hepatitis b patients experienced with lamivudine resistance. entercavir is safe, with almost no side effects. factors such as hbeag negative, genotype b, low viral load seems to be better in response to treatment. recurrence or mutation of entecavir resistance should be studied further in future. j.m. kim , s.k. hwang , b.h. choe department of pediatrics, kyungpook national university hospital, daegu, korea backgrounds: by analyzing the characteristics of children with chronic hepatitis b who have lost hbsag by long-term lamivudine treatment, the selection of target patients could be relevantly predictable in the treatment of chronic hepatitis b in children. methods: a total of hbeag positive children (< y-o) were recruited who have visited kyungpook national university hospital from mar. , to may , . they were treated with lamivudine for at least months. hbeag seroconversion occurred during lamivudine treatment in out of children. they were divided into hbsag clearance and non-clearance group. parameters influencing treatment results were analyzed according to hbsag loss. result: thirteen out of the ( . %) patients with hbeag seroconversion were classified as hbsag clearance group, while ( . %) as non-clearance group after lamivudine treatment. twenty five of patients with hbeag seroconversion were under years old, in ( / , %) of whom hbsag loss occurred as well. twenty four of patients were over years old, in ( / , . %) hbsag loss occurred, that showed significantly difference (p-value= . , or: . , ci: . - . ) compared to younger group. age was significantly lower in hbsag clearance group ( . ± . years) than non-clearance group ( . ± . years) (p= . ), but no difference was observed in other parameters. anti-hbs appeared in patients. conclusion: in the treatment of hbeag positive chronic hepatitis b with lamivudine, age was significantly lower in hbsag clearance group than non-clearance group. background: dysfunction of t cells may represent a mechanism of hepatitis b virus (hbv) persistence. programmed death- (pd- ) and its ligands, pd-l /pd-l , are members of cd /b family, was reported to transfer inhibitory signal, leading to the dysfunction of t cell. background: hepatitis b viral mutants can emerge in patients as a result of selection pressure from either immune response or treatment options. mutations of hbsag allow mutant virus to propagate in the presence of a neutralizing immune response, while wild-type virus in reduced to undetectable levels. methods: immunohistochemical analysis of tissue samples from patients with chronic hepatitis b (chb), acute hepatitis b (ahb) patients and health controls was performed. results: pd- was positively expressed on lymphocytes infiltrating the portal area.pd-l expression was the same as pd- ,also expressed in interlobular.pd-l expressed on kupffer cells and dendritic cells.pd- -,pd-l -,and pd-l -positive cells express index of chb patients were much more than that of health controls and ahb patients(p . ).between groups in chb,the expression rate increase with the disease progression (p . ). methods: chronic hepatitis b patients with both positive for hbsag and hbsab were studied.serological markers of hbv were detected by elisa and microparticle enzyme immunoassay. hbv dna levels were determined by fluorescent quantitative pcr, s gene fragments were directly sequenced, liver function was analyzed by automatic biochemistry analyzer au . correlation test was conducted to evaluate their dependablity. conclusion: overexpression of pd- and pd-l within liver might be involved in inhibiting the immune response and be a mechanism of chronicity in hbv infection. results: the level of hbsag and hbsab was . ± . s/n and . ± . miu, respectively. hbv dna was detectable in patients. fifty-one mutations of s gene were detected in patients, and the relating amino acid substitution was at the sites of , , , , , , , , , , and . eight ( . %) out of mutations were located at the "a" determinant region in patients, while no mutation was found at the sites of , and . however, the mutation did not affect hbv replication. hbv dna was positive correlated with hbeag. conclusions: change in hbsag antigenicity due to s gene resulted in concurrent hbsag and hbsab. the existence of hbsab did not affect hbv replication. the damage of liver failure in those patients was slight. background: hbv infection is common in bangladesh. we often encounter young patients incidentally detected with hbeag negative chronic hepatitis b (chb) in our clinical practice. however the characteristics of these patients is yet to be studied in this country. the aim of this study was to study the characteristics of young bangladeshis incidentally detected with hbeag negative chb. methods: we did percutaneous liver biopsies of chb patients aged between to years. they were all hbeag negative with persistently normal or raised serum alt values. we did pre-core mutation (pcm) study in patients who were randomly selected. results: % patients had significant necro-inflammation (hai-ni > ), while significant fibrosis (hai-f > ) was seen in . %. serum alt (cut off u/l) was raised in . %, while high hbv dna load (> copies/ml) was observed only in . %. pcm was negative in all . conclusion: although chb patients between - years of age are supposed to be in immune clearance phase, which is characterized by low hbv dna and hbeag positivity, the study shows that hbeag negative chb is an entity that can also be seen in this age group and a significant percentage of such patients may have considerable hepatic involvement. this challenges our current concept about immune clearance state of hbv infection, although much larger study is needed to draw any specific conclusion. background: hbv infection is common in bangladesh, but characteristics of young patients incidentally detected with chronic hepatitis b is yet to be studied in this country. methods: we did percutaneous liver biopsies of chb patients aged between to years. results: significant necro-inflammation (hai-ni > ) was seen in . % patients with hbeag positive and % patients with hbeag negative chb, while significant fibrosis (hai-f > ) was seen in . % and . % patients in these two groups respectively. serum alt (cut off u/l) was raised in % hbeag positive and . % hbeag negative patients, while in these two groups % and . % patients respectively had high hbv dna load (> copies/ml). conclusion: hbeag negative chb is an entity that can also be seen in young population. a significant percentage of both hbeag positive and negative patients may have considerable hepatic involvement. profile of hbeag +ve chronic hbv infection in bangladesh m. mahtab , s. rahman , f. akbar , f. karim , a. shrestha , m. khan , m. kamal bangabandhu sheikh mujib medical university, toshiba general hospital, dhaka, bangladesh background: inactive hbv carriers constitute the major reservoir of hbv. present management guidelines provide inadequate treatment modalities. they are recommended for regular check-up; treatment is only recommended when patients exhibit evidence of liver damage. this is due to lack of information about their extent of liver damage. aim of this study was to assess extent of liver damage in hbeag +ve patients, unaware of their infection. methods: in this retrospective study, records of hbeag +ve chb patients from our pool of chb patients were reviewed. they were tested for hbsag, hbeag, hbv dna, anti-hcv and serum alt. all underwent per-cutaneous liver biopsy. results: . % ( / ) patients were males and . % ( / ) females. they were between - years of age. alt was raised > times unl in % ( / ). . % ( / ) patients had high hbv dna (> copies/ml), while low hbv dna (< copies/ml) was seen in . % ( / ) . in high hbv dna group, significant necro-inflemmation (hai-ni > ) was seen in . % ( / ) and significant fibrosis (hai-ni > ) in . % ( / ) . figures were . % ( / ) and . % ( / ) respectively in low viral load group. none tested positive for hcv infection. conclusion: study indicates that machinery should be developed to characterize undetected hbv carriers in developing countries by conducting multi-center clinical studies. we have shown that considerable number of patients, unaware of their hbv infection, suffer from progressive liver damage. the overall strategy of management of chronic hbv infection should also be revisited. high viral load does not necessarily represent significant liver damage in patients with chronic hbv infection in bangladesh m. mahtab , s. rahman , f. akbar , f. karim , a. shrestha , m. khan , m. kamal bangabandhu sheikh mujib medical university, toshiba general hospital, dhaka, bangladesh background: in general, it is assumed that patients with chronic hepatitis b virus (hbv) infection with high viral load exhibit increased liver damages. treatment guidelines also emphasize on reducing viral load. these observations were mainly accumulated from developed countries. > % chronic hbv carriers live in the developing nations, but little is known about relationship between hbv viral load and extent of liver damage in these countries. in this study, we addressed this issue. methods: in this retrospective study we reviewed records of chb patients from our pool of patients. all had high hbv dna (> copies/ml). . % ( / ) were hbeag +ve and . % ( / ) hbeag -ve. they were alsotested for anti-hcv and serum alt. all underwent per-cutaneous liver biopsy. results: . % ( / ) hbeag +ve patients with high hbv dna had non-significant hepatic necro-inflammation (hai-ni < ); this figure was . % ( / ) in hbeag -ve patients. non-significant hepatic fibrosis (hai-f < ) was observed in . % ( / ) and . % ( / ) in hbeag +ve and -ve patients respectively. none tested positive for hcv. conclusion: correlation doew not exist between viral load and liver damage in chb in bangladesh. many with both hbeag +ve and -ve chb with high hbv dna do not have significant hepatic necro-inflammation and fibrosis. further study may be needed to find out influence of other factors on liver damages in chb in bangladesh. most of these patients have not been characterized and treatment modalities have not been defined for them. background/aims: expression of intrahepatic hepatitis b core antigen (hbcag) is related to the immunopathogenesis of hepatitis b virus (hbv) infection. the role of hbv genotype and basal core promoter (bcp) mutation in expression of hbcag was investigated. methods: seventy hbeag-positive chronic hepatitis patients (genotype b in and c in ; bcp t /a mutation in ) were enrolled. clinical, virologic and histologic features were compared with regard to localization and expression of intrahepatic hbcag. the effects of hbv genotype and bcp t /a mutation on the expression of hbcag were further evaluated by in vitro assays. results: cytoplasmic, mixed cytoplasmic/nuclear, and nuclear localization of intrahepatic hbcag were found in ( . %), ( . %) and ( . %), respectively. fifty-eight ( . %) of these patients expressed a high level of hbcag. in multivariate analysis, cytoplasmic localization of hbcag correlated only with low serum viral load (p= . ) and bcp mutation (p= . ). high expression level of hbcag also correlated with high serum viral load (p= . ) and bcp wild-type sequence (p= . ). in vitro assays supported that hbv bcp mutant had lower subcellular expression of hbcag compared with bcp wild-type strain. conclusions: hbv bcp mutation and viral load but not genotype contributes to the expression of intrahepatic hbcag. hepatitis b virus (hbv) genotypes show distinct geographical distributions and virological and clinical differences. in some of genotypes, specific substitutions and mutations have been described in association with hepatitis b e (hbe) protein expression and viral replication. in this study, genetic characteristics of hbv genotype e (hbv/e) were investigated using clinical samples obtained from hepatitis b e antigen (hbeag)-positive, and anti-hbe-positive asymptomatic carriers (ascs) in west-africa. full-genome analysis of isolated hbv strains revealed strong association between precore (pc) mutation and hbeag to anti-hbe seroconversion. furthermore, using partial genome sequences, correlation among hbeag/anti-hbe status, viral load and key mutations were analyzed. the data showed that pc mutation is associated with hbeag seroconversion and enhanced viral replication efficiency. comparison between hbv/e and hbv/d strains reveals these two genotypes to have an identical sequence in their core-promoter-upstream and basic core promoter (curs/bcp) regions. it has been known from the previous phylogenetic studies, that hbv/d and hbv/e cluster together in trees reconstructed on x and precore/core orfs. in addition, this study, demonstrates that in spite of the high sequence similarity of curs/bcp region, the seroconversion-related mutation patterns are different between hbv/e and hbv/d in asc. further studies are needed to clarify the clinical significance of the regulatory sequence similarity between hbv/e and hbv/d. necro-inflammation and fibrosis p. siddappa , p. kar , b. das , r. gondal , m. asim maulana azad medical college, icpo, new delhi, india background: chronic hepatitis b(chb) is an important cause of morbidity and mortality. methods: pilot study involving patients of chb, were equally randomized to receive either adefovir or lamivudine for months. quantification of serum and hepatic hbv dna levels by real time pcr and liver biopsy done at start and end of months. results: after months there was significant and comparable reduction in serum and hepatic hbv dna viral load and liver biopsy showed significant reductions in hai scores in both the groups. serum alt which was elevated to or more times normalized in both the groups. in the adefovir group patients became hbeag negative and patients who were hbeag negative at the start of therapy remained so. in the lamivudine group one patient became hbeac negative and patients who were negative at the start of therapy remained so. in the adefovir group patients became hbv dna (qualitative test) and in the lamivudine group patients became hbv dna negative. there was strong correlation between serum and hepatic hbv dna levels both before and after the completion of therapy. conclusion: both the drugs bring about biochemical, histological and serological improvement with significant reduction in viral load in serum liver after months without complete clearance of virus. there was not enough evidence to show therapeutic advantage of one drug over the other. the serum and hepatic hbv dna levels correlate well with eachother before and after treatment. aim: assessing efficacy and safety of treatment of chronic hepatitis b in children with pegylated ifn. materials and methods: children ( boys and girls) aged - years with chb treated with peg-ifn alfa- a, g/m /week during weeks, hbeag-positive and hbeag-negative children, previously treated with recombinant interferon. no child had liver disease greater than grade , stage . serum hbv dna was quantified at baseline, tw , ("rvr") tw , tw (etr) and w (svr) with rt pcr method (roche taqman). alt activity, haematology and adverse events were monitored. results: after weeks treatment median hbv dna level decreased from . x iu/ml at baseline to . x iu/ml (p< . ). "rvr" -undetectable hbv dna at tw was observed in / children and associated with lower pretreatment alt levels < iu and pretreatment viral load < iu/ml. all children with "rvr" were hbeag-negative pretreatment. at tw and tw seven children including all with "rvr" had undetectable hbv dna. children achieved svr (undetectable serum hbv dna in w ), among them with "rvr". in / children with "rvr" hbsag disappearance was observed since tw . leukopenia was reported in children, thrombocytopenia in . no adverse events were observed following dose modifications. conclusions: . peg-ifnalfa- a is a good therapeutic option for children with chb, in particular with hbeag-negative chb . low pretreatment viral load and "rvr" seem to be predictive factors of efficient therapy. control by investigating the sanitizing modes among appliances used in the public service places (psp) and hbsag among appliances and practitioners worked in those places. methods: beauty parlors, barber shops and bathing centers selected by stratified randomization sampling, workers were investigated in questionnaire. the hbsag in appliances of psp and employee was detected by ria. results: the rate of hbsag among appliances of psp was . %. the rate of hbsag in large-, medium-and small-sized appliances was . %, . % and . %. the rate of hbsag has different( = . p . ). the rate of hbsag among appliances of beauty parlors, barbering shops and footbath inns was . %, . % and . %. different appliances had different rate of hbsag, such as the rate of acne needle and the forceps was . % and . %. the positive of hbsag amongworkers in psp was . %. the rate of hbsag among workers in large-, medium-and small-sized psp was . %, . % and . %. the rate of hbsag among workers in beauty parlors, barbering shops, footbath inns and bathing centers was . %, . %, . % and . %. the hbsag rate among workers was different in different works, the rate was higher in tattoo workers ( . %), pedicures workers ( . %), massagists ( . %). conclusions: it is important to enhance the sanitizing management in psp and improve workers kap) of hepb. and we should promote health education to enhance the knowledge of hepatitis b control and build up supervision consciousness. background: integration of hepatitis b virus (hbv) dna into host chromosomes is often found in chronic liver disease and hepatocellular carcinoma, which is likely an early event of hbv-related carcinogenesis. however, the molecular mechanism of integration remains unclear. here we describe a potential mechanism of hbv integration and identify that ku and ku , the gatekeepers of non-homologous end-joining (nhej) repair pathway, can serve as targets for anti-hepatitis virus integration. methods: using i-sce endonuclease-based system, we induced a dna double-strand break (dsb) in human hepatoma cell line huh- . the cells were then incubated with serum from patients with chronic hbv infection. pcr amplification and direct sequencing were used to detect the inserted sequence in the site of dsb. finally, we employed taqman-based real-time pcr assay to quantify the integrated hbv dna and evaluate the effects of shrna on hbv integration. result: when huh- were exposed to viral serum and incubated for several days, hbv dna was detected in integrated form at the exact site of dna damage. furthermore, small interference rna (sirna) targeted against gatekeeper genes for nhej can down-regulate nhej repair and even the frequency of hbv integration. conclusion: thus, this project provided us with the first direct evidence that dna double-strand breaks are potential targets for hbv integration. the study has also shown that shrnas targeted against gatekeeper genes for nhej can regulate the frequency of hbv integration. objective: to screen proteins of human pancreas cdna library interacting with hbsag protein. methods: the library was amplifed, purified and evaluated, and then the puried library plasmids were transformed into yeast strain y . the reconstructed plasmid pgbkt -hbsag was transformed into yeast strain ah and screened on the nutrient deficiency medium sd/-trp. the transformed ah mated with y containing the library plasmid. the diploid yeast cells were plated on nutrient deficiency medium sd/-trp/-leu/-his/-ade and sd/-trp/-leu/-his/-ade containing x--gal for selecting. the plasmids in diploid yeast cells were extracted and electrotransformed into e.coli dh . the plasmids in dh were extracted, sequenced and analyzed by bioinformatic methods. results: sixteen proteins interacting with hbsag were founded. conclusions: these results show that hbsag protein may be related with metabolism of glucose and lipid. comparison of the sensitivity and specificity of the elecsys ® hbsag ii assay with other available assays in china for detection of hbsag j.d. jia , l. wei , x.x. zhang , y.l. mao , l.l. wang , z.l. gao , j.l. hou , j. zhang , w. melchior , w. van der helm , beijing friendship hospital, beijing, china, beijing people hospital, beijing, china, ruijin hospital, shanghai, china, beijing hospital, beijing, china, west china hospital, chengdu, china, guangzhou, china, guangzhou nanfang hospital, guangzhou, china, shanghai public health clinical centre, china, roche diagnostics ltd, rotkreuz, switzerland, conclusions: in this patient population the prevalence of hbsag positive and anti-hcv were much higher than reported in community studies. genotypes and accounted for most of hcv. these very high rates of viral hepatitis in a hospital setting challenge to healthcare providers in terms of patient management as well as caregiver's prevention. hepatitis b is one of the major diseases of mankind that kills about one million persons each year in the world. accoring to primary study about % of iranian population is chronic hbv carriers. among iranian cirrhotics, - % has evidence of exposure to hbv and - % is carriers. because increase demand of blood transfusion, high blood dependent patients and long term window period of hbv infection, any controlling hbv infection program in blood donors can enhance the blood safety and public health. pe in this descriptive study included all the blood donors that referred to dezful blood transfusion center during - . all the blood donors screened for hbs ag by using enzyme immuno assay and repeatedly reactive (r.r) samples confirmed by hbc-ab or confirmatory (neutralization) tests. the data analyzed by using spss . . we found that in the first year . % were repeatedly reactive and . % confirmed. the results for other years as the followed: . %(r.r) and . % confirmed and in the last . % (r.r) and . % confirmed. the repeated blood donors increase in this period ( . %, . % and . % respectively). aim: we aimed to evaluate the cost-effectiveness of telbivudine versus entecavir with reference to lamivudine by roadmap model. methods: decision analysis model was used to study the incremental cost-effectiveness ratios (icer), i.e. the additional cost (in usd) required to achieve undetectable hbv dna or hbeag seroconversion for a patient at years in america and hong kong. entecavir was used as a continuous monotherapy. lamivudine and telbivudine would be shifted to entecavir if hbv dna was detectable at month and continued otherwise with drug resistance treated by add-on adefovir. weighted event rates based on previous reports were estimated for analysis. according our study, although the prevalence was higher than other region in our province, the hbv prevalence showed good decrease after stablishment strategies such as of repeated blood donor recruitment , improvement the donor selection and other educational programs . good following up those strategies to enhance the blood safety recommended. results: telbivudine was generally cheaper than entecavir to achieve an incremental case of undetectable hbv dna from lamivudine at years. entecavir was least effective and most costly for hbeag seroconversion. conclusions: telbivudine is a cost-effective alternative to entecavir particularly when its cost is low in hong kong. h. tang , g.l. zhang , y.x. li , r.q. tian , m. liu , x. li tianjin life science research center, tianjin medical university, tianjin , china micrornas (mirnas) are single-stranded noncoding rnas of to nucleotides that play critical roles in a wide spectrum of biological processes. we investigated whether the mirnas-silencing machinery influences hbv replication or antigen expression. on the basis of elisa and mtt, the effect of mirnas on the hbsag expression and cell proliferation was examined. three micrornas efficiently inhibited hbsag expression without significant effect on the proliferation of hepg . . cells compared to lacz control. subsequently, bioinformatics analysis were used to predict targets for the three mirnas, and the prediction results were conformed by cdna microarray analysis. the target region in hbv genome and the 'utr region of one cellular gene were identified by fluorescent reporter assay, semi-quantitative rt-pcr and western blot. the results demontrated that mirna may play an important role in replication and gene expression of hbv. hepatitis b virus (hbv) infection is a global public health problem, which plays a crucial role in the pathogenesis of chronic hepatitis, cirrhosis and hepatocellular carcinoma. although considerable progress has been made, the pathogenesis of hbv infection is still elusive. there's an urgent need to elucidate the mechanisms of hbv-host interactions, to discover novel biomarkers for diagnosis and prognosis and to develop therapeutic targets for anti-hbv treatment. herein, we applied a two-dimensional gel electrophoresis and maldi-tof/ms based comparative proteomics approach to globally analyze the host response to hbv by using an inducible hbv-producing cell line hepad . of the differentially expressed proteins identified, glucose regulated protein (grp ) was one of the most striking proteins elevated by hbv replication, which was confirmed by real-time pcr and western blotting. knockdown of grp expression by rna interference resulted in a significant increase of both intracellular and extracellular hbv virions in hbv-transfected hepg cells. reversely, grp overexpression led to hbv suppression. the expression levels of hepatitis b surface antigen (hbsag) and hepatitis b e antigen (hbeag) were determined by enzyme linked immunosorbent assay (elisa). immunofluoresce further revealed a positive correlation between the expression levels of grp and hbsag in both hbv-transfected hepg cells and hbv-infected human liver tissues. altogether, these data demonstrate for the first time that grp is an endogenous anti-viral factor in hbv-transfected hepg cells and may serve as a potential prognostic indicator of viral status in anti-hbv therapies. background/aims: to evaluate the predictors of response to long-term treatment of adefovir dipivoxil (adv) in patients with emerging lamivudine (lam)-resistant hepatitis b e antigen (hbeag)-positive chronic hepatitis b (chb) patients. methods: one-hundred-thirty-four lam-resistant hbeag-positive chb patients were treated with adv for a median of . months (range, - months), following lam therapy for a median of . months (range, - months). patients ( . %) were switched from lam to adv monotherapy, ( . %) were switched to adv with month of lam overlap therapy, and ( . %) were switched to adv with months of lam overlap therapy. the influence of baseline parameters on treatment response to adv in patients with lam-resistant hbeag positive chb was analyzed. result: during the follow-up period, ( . %) of patients achieved complete response, defined as normalization of alt level, negative hbv dna by a digene hybrid capture assay and achievement of hbeag loss. sixteen ( . %) patients achieved hbeag seroconversion. twenty-eight ( . %) patients developed adv-related mutations during adv treatment. in multivariate analysis, virological response at months (or= . , % ci: . - . , p= . ), defined as serum hbv dna levels less than log copies/ml or a reduction in serum hbv dna levels greater than log copies/ml after months of adv therapy, independently predicted complete response. conclusions: virological response at months was the strongest predictor of adv response in lam-resistant hbeag-positive chb patients. background/aims: to explore the effects of hbv dna level hbv genotype/subgenotype on the pathogenesis of severe liver diseases in chongqing. methods hbv dna level was analyzed in patients with severe liver diseases in retrospect,and hbv genotype/subgenotype hbv dna level and hbeag were determined in patients with hepatocellular carcinoma (hcc,n= ), liver cirrhosis(lc, n= ),chronic hepatitis b(chb, n= ) and acute on chronic liver failure(aclf, n= ). results hbv level from high to low with chb were lc, aclf and hcc in turn(p . ). hbv genotype was mainly genotype b.the rate of genotype b and c were . % and . respectively in hcc patients, . % and . in lc patients, % and in chb patients, % and in aclf patients. the percentage of genotype b/c in aclf patients was higher in compared with other groups. but the distribution of hbv genotype among groups was not statistically different(p . ).subgenotypes of genotype b were almost ba but one. subgenotypes of genotype c were mainly ce in chongqing area, and there was no statistical difference among the groups (p . ). conclusion: hbv dna level seems not to be a determining factor at end point of severe liver disease. both genotype b and c of hbv can lead to severe liver diseases, and there are more mixed infections by different genotypes in aclf. the efficacy of switching to entecavir (etv) monotherapy in japanese lamivudine (lvd)-experienced patients. background: this study aims to determine the efficacy of switching to . mg etv daily in chronic hepatitis b (chb) patients previously treated with lvd. method: retrospective analysis of chb patients (n= ) previously on mg lvd daily and switched to . mg etv daily. results: lvd-experienced patients were divided into three groups based on hbv viral load at time of switching to etv (< . log copies/ml; . - . log copies/ml and > . log copies/ml). detection of lvd-resistant virus at the time of switching was higher in the group with hbv dna . log copies/ml ( % in both . - . and > . log copies/ml groups versus % in < . log copies/ml group) and was higher in patients treated with lvd for years ( % versus % for patients on < year of lvd). a year after switching to . mg etv daily, hbv dna undetectable rates were % ( / ), % ( / ) and % ( / ) for < . , . - . and > . log copies/ml groups, respectively. alt normalization occurred in more than % patients at the end of the first year of switching to etv for all three patient groups. only one patient in the . - . log copies/ml group, who had lvd-resistant mutants at the time of switching, developed etv resistance during follow-up. conclusion: switching from lvd to etv maintains or improves viral suppression and alt normalization, especially in patients with viral load < . log copies/ml. background/aims: we investigated the association between on-treatment hbsag decline and sustained response in patients treated with pegasys±lamivudine. methods: hbsag levels were measured retrospectively pre-treatment and at weeks , , and using the abbott architect hbsag assay in sera from patients ( % asian) treated with pegasys alone ( g qw; n= ) or combined with lamivudine ( mg qd; n= ) alone for weeks as part of a large multinational trial. response was measured months post treatment. results: more patients treated with combination therapy had > log decline in hbsag from baseline to week ( figure) . hbsag level < iu/ml at week was associated with higher rates of response to pegasys±lamivudine months post treatment ( figure) . data comparing hbsag and hbv dna as on-treatment predictors of response will be presented. conclusion: on-treatment hbsag monitoring may be useful for predicting response in patients treated with pegasys. y. wakui , j. inoue , y. ueno , t. shimosegawa division of gastroenterology, tohoku university graduate school of medicine, sendai, japan background/aim: chronic hepatitis b patients are clinically treated with nucleot(s)ide analogues and ifn-. nucleot(s)ide analogues have problems including drug resistance in continuous treatment, and ifn-has disadvantages of limited effectiveness and side effects. therefore, novel antiviral drugs are still needed. in this study, the suppressive effect to the replication of hbv was examined in vitro by using bezafibrate and rosiglitazone, which are ligands of peroxisome proliferator activated receptor (ppar) and , respectively. methods: the cytotoxicity of bezafibrate and rosiglitazone to hepg cells was examined with mts assay, and the concentration of % cytotoxicity (cc ) was calculated. hepg cells were transiently transfected with the plasmid containing . -fold hbv genome of a genotype b strain. after hours of transfection, rosiglitazone and bezafibrate was added to the cells. using the medium at day after the addition of drugs, hbv dna was quantified with real-time pcr. results: the cc of bezafibrate and rosiglitazone in hepg cells were m and m, respectively. the amount of hbv-dna in the medium was decreased when the density of bezafibrate was over m, but the density demonstrated considerable cytotoxicity. in contrast, rosiglitazone of m, which showed no cytotoxicit, decreased the amount of hbv dna. the % effective concentration (ec ) was calculated to be . m. conclusions: in this study, it was suggested that the replication of hbv was inhibited by rosiglitazone of the density without cytotoxicity. the mechanism is uncertain and being investigated now. q. zheng center for liver diseases, the first affiliated hospital, fujian medical university, fuzhou, p. r. china background: the objective of this study was to evaluate the early virologic response for prediction of achievement of hbeag seroconversion and hepatitis b virus (hbv) dna negativity after two years of lamivudine treatment in chronic hepatitis b (chb) patients. methods: in this retrospective study, adult patients with chronic hepatitis b ( hbeag-positive and hbeag-negative) were treated with lamivudine ( mg/day), and followed-up up to months. response and resistance to the treatment were assessed during the treatments with lamivudine. results: it was found that gender, age, baseline levels of alt and hbv dna, serum hbv dna at week (p = . , or = . ) were closely related to the achievement of hbeag seroconversion, undetectable hbv dna level and emergence of drug resistance after years of lamivudine treatment. hbeag positive patients with baseline serum hbv dna in - copies/ml and serum hbv dna copies/ml at week showed high response rate of alt normalization rate ( . %), undetectable hbv dna rate ( . %), hbeag seroconversion rate ( . %), as well as low drug resistance rate ( . %) after years of treatment. similarly, hbeag negative patients with serum hbv dna copies/ml at week could achieve high -year response rate of alt normalization rate ( . %), undetectable hbv dna rate ( . %), and low drug resistance rate ( . %). conclusion: serum hbv dna copies/ml at -week provide the best prediction of -year lamivudine treatment response. background/aims: unlike oral antivirals, a finite course of (peg)interferon can induce sustained post-treatment response in patients with chronic hepatitis b (chb), with increasing rates of hbsag clearance observed in patients who respond during post-treatment follow-up. hbsag clearance is considered to be the closest outcome to a cure, being associated with improved histological outcome, reduced incidence of hcc and increased survival. methods: in a randomised multinational study, patients (hbeag-negative) received µg pegasys+placebo (n= ); µg pegasys+ mg lamivudine (n= ); or mg lamivudine (n= ) for weeks, and were assessed months post-treatment. from this initial study, of those who had received pegasys±lamivudine and patients who had received lamivudine monotherapy participated in a long-term observational study to investigate post-treatment response. hbsag clearance at yearly post-treatment follow-up visits up to years post-treatment was analysed. results: hbsag clearance in patients treated with pegasys±lamivudine increased post-treatment ( % at year to %, %, % and . % at years , , and ). at year , pegasys-treated patients ( . %) had cleared hbsag compared with ( . %) of lamivudine-treated patients (p= . ). / pegasys-treated patients had anti-hbsag (hbsag seroconversion). detailed analysis of the -year follow-up data will be presented. conclusion: the ability of a finite course of pegasys to induce sustained response with increasing hbsag clearance rates in responders during post-treatment follow-up supports its use as first-line therapy in hbeag-negative patients with chb. background/aims: recent studies suggest that quantification of hbsag levels early during treatment can be used to predict post-treatment response to pegasys. elecsys ® hbsag ii (roche) is a sensitive assay for the detection of hbsag. this assay can be used for the quantification of hbsag levels using a simple dilution algorithm. we compared results obtained using the elecsys ® hbsag ii method with those of a commonly used quantification assay. methods: hbsag levels obtained using the elecsys ® hbsag ii assay were compared with those obtained using the abbott architect ® hbsag assay for a total of samples from patients infected with hbv genotypes a (n= ), c (n= ), d (n= ) and f (n= ). samples were diluted : in diluent provided by the manufacturer. samples with hbsag levels > iu/ml were retested at a final dilution of : . samples with hbsag levels < . iu/ml were retested undiluted. results: overall, hbsag levels measured with the two assays correlated well (r = . ) over a wide range ( - x iu/ml). discrepancies in hbsag levels >± % were reported for a minority of the samples (n= ), mainly distributed evenly above and below the ideal line (n= ). in the four low titre (range - x iu/ml) samples with greatest discrepancy elecsys ® underestimated values (in two cases by > %). conclusion: the elecsys ® hbsag ii assay provides a simple and reliable means for determining hbsag levels. this simple assay format could be used to provide useful information during on-treatment monitoring of hbsag levels in patients with chronic hepatitis b undergoing therapy. conclusions: hbv/a has been increasing in chb patients in japan as the consequence of ahb, spreading in the younger generation through promiscuous sexual contacts, thrust by an inclination of hbv/a to induce chronic hepatitis. the spread of hbv/a infection in japan should be prevented by universal vaccination programs. introduction: chronic viral hepatitis is common in end-stage renal disease (esrd), from endemic hepatitis b (chb) and nosocomial hepatitis c (chc). reduced outcomes post-renal transplant were reported thus chb and chc cirrhosis became contraindications to listing. however, these predated effective anti-viral therapies. we reviewed outcomes of patients with chronic viral hepatitis following assessment for renal transplantation. methods: prospective database of esrd patients with viral hepatitis referred for renal transplantation was reviewed. results: patients were assessed. patients underwent kidney transplantation. two were cirrhotic and had liver/kidney transplantation; both died within months. were non-cirrhotics, of whom are alive. / have functioning allografts; predictors were normal alt and low viral load. of the non-transplanted, had cirrhosis; / received anti-virals. mortality was % - liver-related ( hepatoma, bacterial peritonitis, sepsis - inactive cirrhosis); non-liver related ( cerebral, haemorrhage, renal - inactive cirrhosis). / surviving cirrhotics received anti-virals. in non-transplanted non-cirrhotics, mortality was %; % of survivors had inactive disease. chb patients received lamivudine; adefovir (lamivudine resistance). chc patients received ifn-based therapy. conclusion: excellent outcomes are achieved in esrd patients with chb/chc post-renal transplant, in absence of cirrhosis. normal alt/non-detectable viral load can predict graft function. however, cirrhosis is associated with high mortality on dialysis whereas non-cirrhotics with inactive disease do well. the role of kidney transplantation in cirrhotics with suppressed viral replication needs to be reassessed. the truncated hbc interferes with replication of hepatitis b virus j.c. han , , x.b. pan , , l. wei , , k. deng , institute of hepatology, peking university people's hospital, china hepatitis b virus (hbv) capsids play an important role in production of progeny virus and other elements of the virus life cycle. misdirection of capsid assembly and formation of aberrant particles may be an effective approach to interfere with virus replication. hbv capsids can be assembled in vivo and vitro from the dimeric hbv core protein (hbcag). the interaction of single and dimeric hbcag with some truncated hbcag is verified in vitro. the truncated hbcag consists of the first amino acids and lacks the c-terminal, -residue rna-binding domain. method: we transiently transfected hepg . . with pcdna . hbc by fugene .after and h, hbvdna, hbeag and hbsag in culture supernatant were detected and cell subjected to southern blot and immunofluorescence analysis. result: the level of hbsag and hbeag had gentle change, we found that hbvdna decreased at h after transfection( copies/ml p< . ) ,but replication intermediates obviously decreased from h. some positive signal of hbcag located around the nuclear and conglomerated in cytoplasm compared to the control. conclusion: the truncated hbc can inhibit replication of hepatitis b virus. misdirection of capsid assembly and formation of aberrant particles could be an important cause. y.p. li , r.c. li objective: to assess the long-term efficacy of recombinant yeast derived hepatitis b vaccine in infant s born to hbsag and hbeag carrier mother. methods: a total of neonates born to hbsag, hbeag both positive mothers were vaccinated with , , g doses of recombinant yeast derived hepatitis b vaccine by , , and months schedule. they were all followed for years after the primary vaccination. results: twelve infant s ( . %) become hbsag positively conversed in year after primary vaccination ,and the positive rate of hbsag in - year was . %- . % , . % of child in no/ lowly respond become hbsag positively. at the ninth year, the positive rates of anti-hbs were % above. anti-hbs positive rates and immunity level were higher at - year old by repetition immunity than others. conclusion: the recombinant yeast derived hepatitis b vaccine have good immunogenecity and long-term protective efficacy to hbv interruption of perinatal transmission , a booster dose seems necessary in aged - years to the mother with hbsag and hbeag.it is high risk tobecome hbsag positively in the baby of norespones to hepatitis b vaccine. chb patient group-initiated programme to improve awareness, adherence and treatment outcomes in asia pacific n. leung founding chairperson of asiahep background: worldwide, over million people live with chronic hepatitis b (chb); million in asia pacific. regional survey data from , patients in countries showed a lack of knowledge and understanding of chb, its severity and impact on quality of life. this initiative aims to coordinate patient groups in the region and devise programmes to improve knowledge and healthcare outcomes. methods: the patient groups met in hong kong in may and identified common needs to: ( ) improve educational resources; ( ) raise awareness; ( ) increase diagnostic yield; and ( ) enhance treatment compliance through education about the need for sustained viral suppression to reduce long-term complications. results: a patient engagement programme was developed for people with newly diagnosed or known chb. the programme comprises: -detailed information about chb -a health-tracking tool for self-monitoring of blood tests and treatment progress -detailed information for carers/family -a patient-physician communications video (including role-play) -mobile phone text messages providing advice and compliance/appointment reminders conclusion: this programme was developed to address the needs of patients and clinicians. improved knowledge and long-term support, particularly for patients on antiviral medication, is expected to improve quality of life. the programme encourages clinicians and patients to develop enduring therapeutic partnerships to promote optimal outcomes. acknowledgement: the chb patient group meetings and the patient engagement programme are supported by an unrestricted educational grant from glaxosmithkline. serum hbv rna level reflects the potency of nucleos(t)ide analogue y.w. huang , , k. chayama , , m. tsuge , , s. takahashi , , t. hatakeyama , , m.y. lai , , h.l. you , j.t. hu , c.j. liu , , p.j. chen , , d.s. chen , , s.s. yang , j.h. kao , liver unit, cathay general hospital medical center, background and aims: serum hbv rna is detectable in patients treated with lamivudine (lmv) or entecavir (etv) (hatakeyama, and huang, ) . the aim of this study was to determine the clinical significance of serum hbv rna levels in patients treated with nucleos(t)ide analogues of different potency. methods: serum hbv rna was serially determined in patients treated with nucleos(t)ide analogues for to weeks ( with adefovir (adv), with lmv, and with etv). serum hbv rna was quantified by reverse transcription of hbv nucleic acid extract with subsequent real-time pcr. results: hbv rna was detectable in patients as follows: of in adv ( %), of in lmv ( %), and of in etv ( %) (p = . ). mean log serum hbvdna levels at baseline were . ± . for adv, . ± . for lmv, and . ± . for etv, which were comparable between less potent adv and most potent etv (p = . ). during antiviral therapy, peak log hbv rna level of patients with etv was significantly higher than that of those with adv or lmv ( . ± . vs. background: in the phase iii clinical trials, clevudine mg for months showed potent antiviral activity along with a marked post-treatment antiviral effect. the objective of this study is to compare the anti-hbv activity of combination of clevudine and vaccine over clevudine alone in chronic hepatitis b (chb) patients in a randomised way. methods: the patients are received clevudine for weeks and then combination of clevudine and vaccine for another weeks or clevudine alone for weeks. eligible patients were treatment-naïve hbeag(+) chb patients with hbv dna levels , copies/ml. the primary endpoint is the proportion of patients with hbeag loss. preliminary results are presented here. results: thirty-one patients have completed week visits and from them, patients ( in clevudine alone and in combination group) have completed week visits. at week , % of patients had hbeag loss. at week , % in clevudine alone and % in combination group ( months on combination after clevudine monotherapy) had hbeag loss. at week , % of patients had negative hbv dna by amplicor pcr (< copies/ml). at week , all of patients in both groups had negative hbv dna by pcr and % in clevudine alone and % in combination group had normal alt. conclusion: clevudine demonstrated good serologic response as well as significant viral suppression and alt normalization. with this data, we conclude that combination therapy of clevudine and vaccine for short period does not show the superiority over clevudine alone. background/aims: to determine the reasonable number of clones for hbv quasispecies analysis. methods: chronic hepatitis b patients were enrolled with hbvdna levels range from ~ log copies/ml. hbvdna was extracted. hbv reverse transcriptase (rt) gene encompassing the overlapping surface s gene was amplified by polymerase chain reaction, then cloned and sequenced. ten positive clones for each sample were sequenced in the first group, and then additional ten positive clones were sequenced in other groups until up to thirty clones. the characteristics of hbv quasispecies including shannon entropy and genetic distance were calculated. results: the shannon entropy and genetic distance of clones group was higher than those of and clones group, either in rt gene or in s gene (p< . ). while the shannon entropy and genetic distance of clones group showed on difference with those of clones group, neither in rt gene nor in s gene (p> . ). the number of different quasispecies detected in clones group was higher than that of and clones group (p< . ). the shannon entropy and genetic distance in three different clones group had no correlation with hbv dna levels (p> . ). conclusion: although the number of different quasispecies detected was increased with the augmentation of clone number, the quasispecies characteristic didn't changed significantly when the clone number more than . the information contained in clones per sample could well represent the quasispecies characteristics. the clone number was not necessary modulated according to different hbv dna levels. background: recent studies reported that basal core promoter mutation (a t and g a) was associated with more aggressive progression of liver disease from inactive carrier to active hepatitis, and eventually to liver cirrhosis and hcc. but the effect of the double mutations on the activity of enhancer ii/basal core promoter is still uncertain. objectives: to evaluate the influence of nt a/t and nt g/a mutations on hbv enhancer ii/basal core promoter activity. methods: the pcr fragments of hbv enhancer ii/basal core promoter (nt to nt ) from the serum-derived genotype b hbv dnas of one hbv carrier aged and one hbv related hepatocellular carcinoma patient aged were introduced into the pgl -basic-vector from promega via restriction sites of xho i and hind iii. the nt a to t and t to a, the nt g to a and a to g mutations were carried out by genetailor site-directed mutagenesis system from invitrogen. the promoter activity was evaluated by comparing firefly luciferase measurement with renilla luciferase as the internal control using the dual-luciferase reporter assay system from promega. results: the luciferase reporter assay results indicated that the t to a combined with a to g mutations increase (p< . ) while the a to t combined with g to a mutations decrease (p< . ) the hbv enhancer ii/basal core promoter activity significantly. conclusions: associated with increased risk of hepatocellular carcinoma, a t and g a double mutations of hepatitis b virus reduce the enhancer ii/basal core promoter activity. background/aims: a substantial proportion of chronic hepatitis b (chb) patients with mildly elevated alanine aminotransferase (alt) have significant fibrosis. we evaluated the factors associated with significant fibrosis and clinical outcomes in these patients. methods: one hundred five chb patients with alt less than two times the upper limit of normal underwent liver biopsy. multiple clinical, biochemical and virologic variables were evaluated to determine the predictors of significant fibrosis and progressive liver disease. results: there were patients in the low normal alt group, in the high normal alt group, in the low elevated alt group, and in the high elevated alt group. fifty eight patients ( . %) had significant fibrosis ( stage ) and ( . %) had significant inflammation ( grade ). the age, platelet count and grade of inflammation were factors associated with significant fibrosis. progressive liver disease was observed in ( . %) of the followed-up patients. the stage of fibrosis, alt group and antiviral therapy were significant predictive factors for progressive liver disease. conclusion: liver biopsies should be recommended in patients over years with mildly elevated alt levels, and antiviral therapy should be considered in patients with significant fibrosis to prevent progressive liver disease. background: four nucleos(t)ide analogues (nas) are currently approved for the treatment of hbv infection in china. however, long-term benefits are limited by the emergence of drug-resistant viruses. methods: patients accepted the examination based on physician's instruction. hbv reverse transcriptase gene was amplified from serum via nested pcr and sequenced directly. results: well-recognized drug-resistant mutations were detected in of , patients. in patients receiving na monotherapy, corresponding drug-resistant mutations were detected in / for lamivudine (lam), / receiving adefovir (adv), / for entecavir (etv), and / for telbivudine (l-dt). the mutations were detected in / patients receiving kinds of sequential/combined usages of the nas. m i ( %), m v+l m v l ( %), and m i+l m ( %) were identified as major mutant patterns of lam monotherapy. n t a substitution was the dominant adv-resistant mutation. t substitution was the dominant etv-resistant mutation always accompanied with lam-resistant mutation. l-dt-resistant mutation was m i l m exclusively. adv-resistant mutation was frequently seen in lam-resistant patients receiving adv sequential therapy rather than those receiving adv add-on therapy. controversial lam/adv-resistant mutations including a t, v a, q s and i v were detected in some patients singly or with the well-recognized drug-resistant mutations. interestingly, the drug-resistant mutations were also observed in a few of patients naïve to nas. conclusions: the exploration of hbv drug-resistant mutation profile in large clinical samples furthers our understanding of hbv drug-resistant status in china with implications for administrating anti-hbv therapy more reasonably. toll-like receptor (tlr) , tlr and cd +cd +cd low/-regulatory t cells correlate with hepatitis b virus infection y. zhang , j.q. lian , c.x. huang , x. wei , j.p. wang , p.z. wang , x.f. bai center of infectious diseases, tangdu hospital, the th military medical university, xi'an, china background: tlrs play a crucial role in sensing and initiating innate antiviral response and tregs actively suppress immune response, contributing to viral persistence and chronic tissue damage. in this study, we determined tlr and expression and treg frequency, as well as their function in the effect of hbv infection. methods: tlr and tlr expression on monocytes and circulating cd + cd + cd low/-tregs were determined by flow cytometry in ahb, chb, asc and nc. spearman correlation was performed to investigate associated variables on treg or tlrs. pbmcs were stimulated with hbeag or hbcag and the tlrs profile was examined. result: tlr expressions were up-regulated in chb and asc, while tlr were increasingly expressed in ahb and asc. treg frequency in chb was significantly higher than that in nc. in chb, the increased tlr negatively correlated with hbv dna loads and treg frequency negatively correlated with tlr expressions. tlr was up-regulated after hbeag stimulation in both nc and chb. conclusion: increased tregs may be associated with chb and there might be possible interactions between hbeag, tlr signaling and the innate immune response, which may partially explain the mechanism of hbv infection induced immuno-tolerance. ( . ± . ) . hbv-dna was quantitatively determined by polymerase chain reaction (pcr) technique, and hbv genotype was determined by pcr microwave gene chip technique. antiviral efficacy was assessed using measuring the following scales: the alt normalization rate, hbv-dna negative conversion rate and the hbeag/anti-hbe seroconversion rate. results: among serum specimen, hbv genotype distribution was genotype c, genotype b, and genotype non-b or c respectively. in genotype b, alt normalization rate was . %( cases), hbv-dna negative conversion rate was . %( cases) and the hbeag/anti-hbe seroconversion rate was . %( cases). in genotype c, alt normalization rate was . % ( cases), hbv-dna negative conversion rate was . %( cases) and the hbeag/anti-hbe seroconversion rate was . %( cases). the efficacy of adefovir dipiroxil showed no significant differences between genotype b and c in the treatment of chronic hepatitis b p> . . conclusion: adefovir dipiroxil is an effective antiviral drug. hbv genotype is irrelevant to the antiviral efficacy of adefovir dipiroxil in treatment of patients with chronic hepatitis b. the effect of anti-hbv drugs on albumin and bilirubin levels, and platelet count h. yoshida , h. taniguchi , r. nagano , k. sakitani , e. seki , t. serizawa , y. ito , h. mizuno , y. mitsuno , r. nakata , m. omata japanese red cross medical center, university of tokyo, japan background/aim: we assessed the efficacy of anti-hbv drugs on the liver function. methods: patients with hbv-related disease followed at our center between and were enrolled. lamivudine ( mg), lamivudine ( mg) +adefovir ( mg), or entecavir ( . mg) was administered to the patients with detectable hbv dna and elevated alt. liver function (alt, alb, and t.bil) and platelet count were observed. alt, alb, t.bil, and platelet count of treated group at pretreatment, year , and year were compared with untreated group. results: eighty six patients with positive hbsag were enrolled between jan and dec . seven patients ( acute infection, overlap infection with hcv, lost of follow up) were excluded. in total patients were followed up for a median follow up of (range - ) months. of patients, received anti-viral treatment. twenty one patients were treated with lamivudine, with lamivudine+adefovir, and with entecavir. the mean of levels of pre-treatment-year -year were alt: - - (u/l), alb: . - . - . (g/dl), t.bil: . - . - . (mg/dl), and plt: . - . - . (x mcl) respectively. markers of untreated group (n= ) (at baseline-year -year ) were alt: - - (u/l), , t. bil: . - . - . (mg/dl), and plt: . - . - . (x mcl) respectively. although all of four markers in treated group were significantly worse than untreated group at baseline, all of four markers did not showed significant difference from untreated group at year . conclusion: treatment with anti-hbv drugs showed the efficacy not only transaminase levels, but also on albumin, bilirubin, and platelet count improvement-improvement of "hepatic reserve" which is valuable for prevention of cirrhosis. background: currently, hbeag-negative chronic hepatitis b(chb) is increasing. but there are still controversial on the treatment of hbeag-negative chb with alt ×uln. we have investigated the clinical efficacy of nucleotide analogues(nas) in the treatment of hbeag-negative chb with alt ×uln. methods: the data of patients who were treated by nas for more than years and with alt ×uln (n= ) , alt ×uln(n= ) and alt ×uln(n= ) were collected, and w and w virologic response, w and w complete response, virologic breakthrough and clinical resistance were analyzed. results: compared with the base line, hbv dna level in all three groups were significantly decreased (p . ), and there was no significant difference between alt ×uln group and alt ×uln group. the viral load was significant decreased in alt ×uln group at w, w and w (p< . ). virologic response at w and w complete response at w and w was . %, . % , . % and . % respectively in alt ×uln group and was . %, . %, . % and . % respectively in alt ×uln group. there was no significant difference between alt ×uln group and alt ×uln group. virologic response at w and w and complete response at w were significant decreased (p< . ) in alt ×uln group. there was no significant difference among the three groups in virologic breakthrough and clinical resistance. conclusion: hbv replication can be satisfactory inhibited by nas in hbeag-negative chb patients with alt ×uln, which suggests that in these patients the indication of alt is different from hbeag-positive patients. quantitative hbeag assay as a predictive factor of hbeag seroconversion induced by peg-ifn - a therapy to hbeag-positive chronic hepatitis b y.y. zhu , j. dong , y.t. chen , j. chen , j.j. jiang liver diseases research center, the first affiliated hospital of fujian medical university, fuzhou, fujian, china rp, background: to find predictive factor for hbeag seroconversion in the treatment of hbeag-positive chronic hepatitis b (chb) by peg-ifn - a. methods: hbeag-positive chb patients were given peg-ifn - a treatment for weeks. clinical data were collected every months. receiver operator characteristic (roc) curve was employed to calculate positive predictive value (ppv), negative predictive value (npv), sensitivity and specificity. results: sixty-five patients completed peg-ifn - a therapy. among them, ( . %) were found hbeag seroconversion and ( . %) were found hbeag loss at cessation of therapy. none of age, gender, alt level and hbv dna load at baseline had relationship with hbeag seroconversion. hbeag level of baseline was correlated to hbeag seroconversion, with p value as . (table ) . according to roc curve, supposed auc as . and p value as . , the ppv, npv, sensitivity and specificity of hbeag level as at week were . , . , . and . , respectively. supposed auc as . and p value as . , the ppv, npv, sensitivity and specificity of hbeag level as at week were . , . , . and . , respectively. the hbeag level (s/co) and decreased degree (percentage) at week and week were significant related to hbeag seroconversion (table ) . conclusion hbeag level at baseline and at th and th week and its decreased degree (percentage) during the treatment course could be used as predictive factor for hbeag seroconversion. background: it is well documented that perinatal transmission is the major cause of chronic hbv infection in china. the aim of this study was to evaluate the efficacy of interruption of hbv intrauterine infection with hepatitis b immunoglobulin (hbig) in pregnant women with hbeag positive. methods:: a prospective randomized controlled trial was adopted. each subject in the trial group ( cases) was given iu hbig intramuscularly every weeks from -week of gestation, while each subject in the control group ( cases) received placebo in the same way. the cord blood of newborns were collected for detecting hbsag, hbeag and hbv-dna. results: for newborns, hbeag positive rate in trial group was . %( / ).hbeag positive rate in control group was . %( / ). there was significant difference in hbeag positive rate of newborns between the two groups( p < . , rr = . ). hbv-dna positive rate in trial group was %( / ). hbv-dna positive rate in control group was . %( / ). there was significant difference in hbv-dna positive rate of newborns between the two groups( p < . , rr = . ). hbv-dna load of cases of newborns in trial group was lower than that of their mothers(t = ,p = . ). there was no significant difference in hbv-dna load between women and their newborns after delivery in control group (t = . ,p > . ). conclusion: it is effective and safe to prevent hbv intrauterine infection with hbig from the (th) wk in pregnant women with hbeag positive. ), especially, the cirrhosis and hcc cases obviously more in both hbeag and anti-hbe patients are negative than hbeag-negative but anti-hbe positive patients (. . % vs . %; . %vs . %, p ) .the prevale nce of pre-core g a mutate have no significant difference regardless of hbv serum marker status or the state of illness. conclusion: recent years the hbeag-nagative chronic hepatitis b patients are gradually increasing in yunnan province. while the hbeag disappear but no anti-hbe serum transfer, and the virus still active replication -it may be a crucial phase determined the diseases outcome, which should be pay more attention by physicians. the clinical significant of pre-core g a mutate remain unknow. efficacy of interferon for chronic hepatitis b patients with normal or paranormal alt z. liu , j.z. guo , y.j. lin , y.j. zhang , z.w. lang beijing ditan hospital, beijing, china background: we reported interferon treatment for cases with normal or paranormal alt but in which liver histologic exam showed g - and/or s - . methods: patients were male with an average age of years.mean alt was . iu/l and hbv dna level was ~ log copies/ml. two patients were hbeag positive; one patient was both negative for hbeag and anti-hbe and one patient was anti-hbe positive. liver biopsy showed g ~g and s ~s respectively. patients were treated with ifn-alpha, liver biopsy was repeated after year.only one patient had received combination therapy with ifn and adefovir after months treated ifn monotherapy and liver biopsy was taken after . years. results: all patients got normal alt after year treatment. hbv dna was undetectable in patients. patients with initial positive hbeag cleared. but patients still were anti-hbeag negative.liver biopsy showed change fromg s - to g s - in patient; fromg s to g s in patient and no change in the other patients. conclusions: though alt and hbv dna improved after year treatment, histological improvement is not satisfying. patient's improvement in liver histology may be due to seroconversion before treatment and adding adefovir after months of interferon therapy. after months of combination therapy we did liver biopsy again. the other patients were hbeag negative, but hbeab were also negative, liver biopsy was taken year later without combination of nucleoside analogs. evaluation of long term efficacy of hepatitis b vaccination r.c. li , j. gong , j.y. yang objective: to evaluate the long term effectiveness of preventive hbv infection and to monitor the incidence of hepatitis b in children to see possible impact on the program of long an that was launched in . methods: ( ) set up a surveillance systemof hepatitis ,to evaluate the possible impact on incidence of hepatitis b. ( ) to serologically evaluate the effect of the program, a stratified random sampling of subjects in birth cohorts was recruited for long term follow up at the age - years. ( ) cross-sectional seroepidemiolgical survey was carried out in the county in before the program and years later. hbsag , anti-hbs and anti-hbc were tested by ria. results: the average coverage of hepatitis b vaccine was . %. at years after vaccination, the seropositivity for hbsag in population of - years has decreased from . % to . %, the annual effectiveness was . %. hbv accumulated infection rate was . %, protective rate was . %. the incidence of acute hepatitis b was . per , in population aged - years , it decreased by . % as compared with the incidence of . per , in same age group in - . conclusion: mass hepatitis b vaccination program in long an county has proved to be effective in control of hbv chronic infection and incidence of acute hepatitis b. background and aims: although the evolution of viral quasispecies may be related to the pathological condition of disease, little is known about this in hepatitis b virus (hbv), especially during hbeag seroconversion. methods: nucleotide sequences of hbv precore/core genes from time points were analyzed in four cohorts of chronic hepatitis b, interferon-induced seroconverters (is, n= ), interferon non-responders (in, n= ), spontaneous seroconverters (ss, n= ) and non-seroconverters (sn, n= ), followed during months on average. only patients with genotype c were used. viral diversity was then estimated after nucleotide genetic distance was assessed and phylogenetic trees were constructed. results: analysis of nucleotide sequences showed that the nucleotide genetic distance of seroconverters (is and ss; x - substitutions/site and . x - subsititutions/site, respectively) was similar to that of non-seroconverters (in and sn; both x - substitutions/site) before seroconversion. compared to that of nonseroconverters (in and sn; substitutions/site and . x - substitutions/site, respectively) the viral diversity of seroconverters (is and ss; x - substitutions/site and x - substitutions/site, respectively) was significantly higher after seroconversion (p< . ) and it was higher after seroconversion in seroconverters compared with that berore seroconversion (p< . ) while it almost didn't change in non-seroconverters irrespective seroconversion. phylogenetic trees also showed that complex trees appeared in secoconverters and relatively simple in nonseroconverters. conclusions: the distinctly higher viral diversity after seroconversion in hbeag seroconverters could be related to increased hbv-specific t-cell responses and escape mutant which arise from stronger selective pressure caused by host immune activity. adefovir dipivoxil mg (adv) resistance at yrs in chinese hbeag+ve chronic hepatitis b (chb) j.l. hou , y.z. wang , x.q. zhou , j.q. niu , y.m. wang , h. wang , y.m. mao , k.f. barker nanfang hospital, guangzhou, prc, jinan infectious disease hospital, jinan, prc, ruijin hospital, shanghai, prc, st hospital of jilin university, changchun, prc, xinan hospital, chongqing, prc, people's hospital, beijing, prc, renji hospital, shanghai, prc, glaxosmithkine r&d, london, uk background: long term adv provides clinical and histological improvement in chb, but may lead to emergence of treatment associated resistant mutations. we report on adv resistance data from chinese hbeag positive subjects treated for years. methods: hbeag positive chb subjects were randomized in an initial weeks controlled adv study (with a weeks placebo period in half of patients) and then offered open label adv treatment for a further weeks. a total of , , , and subjects completed the st , nd , rd , th and th yr, respectively. at the end of each year samples were analysed from those subjects with protocol-defined hbv dna breakthrough for the rtn t or rta v adv mutations associated with resistance. sera from subjects with breakthrough were analysed at all subsequent yearly timepoints whenever possible. results: at the end of the st yr, none of the subjects with hbv dna breakthrough had either mutation. sera were available for analysis from , , and subjects with viral breakthrough at the end of the nd , rd , th and th yr, respectively, with new mutations identified in , , and subjects at the same timepoints. of the cumulative subjects at the th yr analysis had rtn t, had rta v, and had both mutations. conclusion: treatment with adv in chinese hbeag positive chb subjects for up to yrs resulted in a cumulative rate of . % ( / ) adv resistance-associated mutations with hbv dna breakthrough. background and aims: to evaluate the predictive significance of rapid virologic response (rvr) for achieving an end-of-treatment virologic response (er) or hbeag seroconvertion and the predicting indicator of nonresponse (nr). methods: patients with chronic hepatitis b were treated with adv and prospectively observed to weeks. we assessed the values of virus load reduction at weeks , , and weeks to predict the er and hbeag seroconversion. the association between less reduction of viral load at and weeks and nonresponse was also analyzed. results: of etv-treated patients enrolled in etv- , met criteria for inclusion into year etv treatment analyses. the proportion of patients achieving efficacy endpoints through years of etv therapy is presented the table. results: after weeks of therapy, serum hbv dna levels decreased with a median . ± . log copies/ml. twenty-three( . %) of patients had er. twenty-six ( . %) patients achieved hbeag seroconversion. hbv dna < log copies/ml at week predict both er and hbeag seroconversion. hbv dna> log copies/ml at weeks but decline to < log copies/ml at weeks or weeks both can predict er and hbeag seroconversion. less than log hbv dna reductions at weeks might predict nr. conclusions: the majority of patients experienced durable serum hbv dna suppression ( %) and alt normalization ( %) after years etv therapy. conclusions: the virologic response within weeks could be useful for prediction of er and hbeag seroconversion of adefovir therapy. failing to evr might not predict nr. objectives: to determine the accuracy of hbcigm in diagnosing ahb and the correlation between hbcigm and liver inflammation (alt), bilirubin & biosynthetic functions (albumin,pt). result: a total of patients were included: in patients, adv was added on lam (add-on therapy), and in patients, lam was switched to adv (switch therapy). during . months of follow-up, patients developed adv resistance (rta v and/or rtn t) and all had undergone switch therapy. the cumulative probability of adv resistance at the th month was . %. although add-on therapy induced no adv resistance, it failed to show significant superiority over switch therapy (p= . ). in multivariable analysis, female (odds ratio [or], . ; % confidence interval [ci], . - . ; p= . ), liver cirrhosis (or, . ; % ci, . - . ; p= . ), and age > yr (or, . ; % ci, . - . ; p= . ) were independent risk factors of adv resistance. methods: a retrospective cross-sectional study involving patients with hbcigm positivity between june -december , satisfying the definition for ahb and chbf,and fulfilling the exclusion criteria was performed. hbcigm test were done by using microparticle enzyme immunoassay (meia) and results were expressed as an index value.hbcigm positivity was defined as index value of > . results: patients were positive for hbcigm and fulfilled the criteria( ahb, chbf).hbcigm was significantly higher in ahb compared with chbf(median . vs . ;p < . ).the hbcigm arbitary index value of . was highly sensitive( %) and specific( %) in diagnosing ahb with high accuracy(auroc . ; % ci: . - . ;p< . ).among patients in both groups, there was a weak, but significant negative correlation between hbcigm and pt above control(r = - . ,p = . ).however, among patients with chbf,the negative correlation between hbcigm and pt above control was moderately strong(r = - . ,p = . ).there was also a weak, but significant positive correlation between hbcigm and albumin in with chbf(r = + . ,p = . ). conclusion: adv add-on therapy developed no adv resistance during the observation period. therefore, add-on therapy is recommended to lam-resistant chb patients with genotype c who have any risk factors for development of adv resistance: female, liver cirrhosis, and age > yr. hbcigm-hepatitis b core igm antibody ahb-acute hepatitis b,chbf-chronic hepatitis b flare alt-alanine transaminase,pt-prothrombin time pe detection of emerging drug resistance mutations associated with major approved hbv antivirals using a novel line probe assay (lipa). j. doutreloigne , f. shapiro , r. maertens , e. van assche , e. sablon hepatitis diagnostics unit, innogenetics nv, belgium background: in study etv- , etv demonstrated superior virologic, histologic and biochemical benefit compared to lamivudine (lvd). this study (etv- /- ) presents efficacy and safety results for patients who received years continuous etv treatment. background/aims: an increasing number of antiviral drugs are being used to treat chronic hepatitis b virus (hbv)-infected patients. however, induced viral escape mutants -some potentially cross-resistant -lead to viral non-responsiveness and treatment failure. effective treatment strategies must therefore take possible drug resistance (dr) into account with respect to monitoring and selection of alternative drugs. we evaluated the use of an updated inno-lipa hbv dr v +v reverse hybridization assay versus sequence analysis to detect resistance mutations. methods: the study evaluates etv-treated nucleoside-naïve hbeag (+) patients who completed etv- and enrolled into etv- with a treatment gap days. the proportion of patients with hbv dna < copies/ml, alt normalization, hbeag loss or hbeag seroconversion was evaluated at week . background: etv resulted in improved liver histology compared to lvd at year. histologic data for patients on etv for a median of years is evaluated. methods: clinical samples (from untreated hbv patients or treated with different antivirals; hbv genotypes a-h) were tested for mutations with the lipa assay and sequencing. for lipa, samples were extracted with the qiaamp® dna blood mini kit (qiagen), and then tested on the lipa strips. sequencing-derived reference data were subjected to phylogenetic analysis (kodon version . applied maths, neighbour joining, with kimura- parameter). sequential samples from patients were evaluated as well. methods: etv-treated patients completing etv- or etv- received etv ( . mg daily) in etv- . primary endpoints included -point decrease in knodell necroinflammatory score, no worsening of knodell fibrosis score and improvement in ishak fibrosis score (ifs) ( -point decrease) vs. baseline. secondary endpoints included proportions with hbv dna< copies/ml, alt normalization, and ifs normalization in patients with advanced fibrosis/cirrhosis. results: quasi-perfect concordance (> . %) was obtained between the two assays for the samples tested. no indeterminate results were observed. for one sample, lipa provided additional information (wild-type/mutant mix), whereas sequencing showed only wild type. for sequential samples, lipa was clearly able to detect emerging treatment-resistance mutations associated with viral breakthrough. results: etv treatment led to significant histological improvements and improved ifs in % ( / ) and % ( / ) of patients respectively. of patients with baseline fibrosis/cirrhosis (ifs ), all demonstrated -point improvement in ifs (median change of - ). conclusions: lipa accurately detects the complex quasispecies nature of hbv and can help unravel the dynamics of emerging hbv resistance during treatment with different antiviral drugs. like its predecessor, it is useful for the monitoring and early detection of drug resistance. conclusions: long-term etv therapy in nucleoside-naïve chb patients results in durable virologic suppression, continued histologic improvement and regression of fibrosis/cirrhosis. precore (pc, g a) and basal core promoter (bcp, a t and g a) mutations of hbv are important for predicting the risk of hepatocellular carcinoma (hcc). we developed a new mass spectrometry-based assay using restriction fragment mass polymorphism (rfmp) to detect a and t /a mutations, and applied it to analyze their clinical significance in type b liver diseases (n= ), including hccs, liver cirrhosis (lc), chronic hepatitis b (chb), and hbsag-positive with low level viremia (inactive hbsag carrer, ihc). we devided patients into major groups according to the presence of wild (w) or mutant (m) genes in bcp/pc regions; w/w, w/m, m/w and m/m gene types. each proportion was . %, . %, . % and . %, respectively. mixed infection (x) was also found as minority; w/x, m/x, x/w, x/m and x/x. disease distributions (hcc, lc, chb and ihc) in each group were as follows; [w/w (n= )] . %- . %- . %- ; [w/m (n= )] - . %- . %- %; [m/w (n= )] . %- . %- %- . %; [m/m (n= )] . %- . %- . %- . %. these results suggest that, in korea where only genotype c has been identified, bcp dual mutation is predominant (> . %), while bcp wild alone is only . %. especially, a mutation alone without bcp mutation (w/m type) is uncommon, while bcp mutation alone without a mutation (m/w type) is most common. it might be suggested that prognosis of wild type in bcp and pc region (w/w type) is much better than that of m/w or m/m types. background/aims: entecavir is a potent inhibitor of hbv dna polymerase, which has been shown to be safe and effective for the treatment of chronic hepatitis b (chb) patients. the aim of this study was to evaluate the virologic, biochemical, and serologic responses of entecavir through year in chb patients. methods: from may to october, we reviewed patients (mean age ± years, male:female= : ) who were diagnosed as chb patients (hbeag (+) ). forty-seven patients ( . %) had been treated with . mg of entecavir and ( . %) with mg of entecavir, respectively. mean follow-up period was ± weeks. hbv dna was quantified by bdna assay with a lower limit of detection of , copies/ml. results: median hbv dna levels before therapy was . log copies/ml and the median decreases from baseline in hbv dna were - . , - . , - . , - . , and - . log copies/ml at (n= , p< . ), (n= , p< . ), (n= , p< . ), (n= , p< . ), and (n= , p = . ) weeks of follow-up, respectively. at baseline, overall median alt was iu/l and the proportions of patients with normal alt were %, %, %, %, %, and % at baseline (n= ), (n= ), (n= ), (n= ), (n= ), and weeks (n= ) after entecavir therapy, respectively. thirteen cases ( . %) of hbeag seroconversion were noted. background: hepatitis b virus (hbv) infection is a major risk factor for the progression of liver diseases. because its clinical course varies, it is difficult to detect the predictive factor for the prognosis of patients with hbv infection. the aim of the present study was to determine the risk factors for the occurrence of hcc. methods: a total of patients who tested positive for hepatitis b surface antigen and were referred to chiba university hospital between february and march were included in the study, and their following characteristics were analyzed: age, gender, the status of hbeag, alt, hbv-dna level, and plt. result: hcc was detected in cases during the follow-up period ( . ± . years). multivariate analysis revealed that age [compared with young patients: odds ratio (or) = . , % confidence interval (ci) = . - . ] and plt level (compared with patients with low plt level: or = . , % ci = . - . ) were the predictive factors for hcc occurrence. in patients with age more than years, the hbv-dna level (compared with < . log copies/ml: or = . , % ci = . - . ) and plt level (or = . , % ci = . - . ) were the predictive factors for hcc occurrence. conclusion: advanced age and low plt level were the risk factors for hcc occurrence in patients with hbv infection irrespective of the plt level at baseline. in patients with age more than years, viral load was also a risk factor for hcc. results: before treated by lps, the total mapk p level of pbmcs have no significant difference among the healthy control group, different stage groups with hbv infection, however, after treated with lps, the phosphorylated mapk p (ptpy / ) in healthy control group are significant elevate than hbv infected groups( . ± vs . ± . , p< . ). in the two groups which hbsag, hbv dna are positive, alanine aminotransferase elevate than normal and hbsag positive, but hbv dna lower under the detect limited level, after treated by lps the ptpy / although lower than healthy control yet, but significant elevated than themselves before treated by lps( . ± . vs . ± . , . ± . vs . ± . ; p< . ).otherwise, in the group of both hbsag and hbv dna are positive, but alt is normal, before and after treated by lps, the level of ptpy / have no significant difference. conclusion: mapk p is a important signal transduction pathway which involving in inflammation and immune response, especially, mapk p activated up-regulate the ifn-gamma mrna. according to the result shown, we propose a hypothesis, hbv infection and virus active replication inhibit the mapk p activated, consequent on host immunotolerance and hbv persistence, thus, mapk p may be as a potential therapeutic target to break immnotolerance and establish host anti-viral states. van der helm siriraj hospital, bangkok, thailand, ramathibodi hospital, bangkok, thailand, phyathai hospital, bangkok, thailand, singapore general hospital, singapore, national university hospital, singapore, changi general hospital, singapore, cheil general hospital, korea, hwasun jeonnam university hospital, korea, st mary hospital, korea, roche diagnostics ltd, rotkreuz, switzerland background/aims: hepatitis b virus (hbv) surface antigen (hbsag) is one of the most important markers for diagnosis of acute and hbv infection. high sensitivity of hbsag assays can reduce the diagnostic window during course of disease. in addition, the presence of hbv mutants may be affected by the performance of the hbsag kit. therefore, the technical performance of the elecsys ® hbsag ii assay was explored, using samples (including recombinant mutants), at multiple sites in three countries. methods: nine hbsag screening centers in thailand, korea and singapore compared the sensitivity of elecsys ® hbsag ii assay with that of their routine testing procedure -abbott architect ® ( centers), abbott axsym ® ( center) and bayer advia ® centaur hbsag assays ( center) using preselected seroconversion panels (n= ), recombinant hbv mutant panels (n= ) and routine clinical practice samples (n= , ). results: the sensitivity of elecsys ® in seroconversion samples was equivalent to the architect ® assay, but more sensitive than the axsym ® and advia ® centaur assays ( vs and vs positive bleeds, respectively). there was concordance between the elecsys ® and architect assay results with respect to potentially cross-reactive samples ( . %). the elecsys ® and architect ® assays detected all recombinant mutant samples, whilst axsym ® and advia ® centaur failed to detect three and nine samples, respectively. conclusion: elecsys ® hbsag ii assay was not only highly sensitive and specific when compared with established hbsag screening assays, but also reliably detected hbsag mutants. therefore, this attractive assay is suitable for hbv diagnosis and assessing safety of blood products. background: recent studies have shown a higher rate of adefovir-resistant mutation in lamivudine-resistant chronic hepatitis b (chb) patients treated with switch-to therapy than those treated with add-on therapy. we compared the clinical efficacy of adefovir monothrapy and lamivudine-adefovir combination therapy in lamivudine-resistant chb. methods: a prospective cohort study was performed in patients with lamivudine-adefovir combination therapy and patients with adefovir monotherapy for lamivudine-resistant chb over months. result: biochemical response was achieved in patients ( . %) treated with combination therapy and in patients ( . %) treated with monotherapy (p= . ). virologic response was observed in patients ( . %) in combination therapy and in patients ( . %) in monotherapy (p= . ) and treatment periods for virologic response was significantly shorter in patients with combination therapy than in monotherapy ( . ± . months vs. . ± . month, p= . ). cumulative rate of virologic response was significant higher in patients with combination therapy than monotherapy (p= . ). hbeag loss was found in patients ( . %) in combination therapy and patients ( . %) in monotherapy (p= . ). biochemical breakthrough was found in patients ( . %) with monotherapy significantly more frequent than patients ( . %) with combination therapy (p= . ). genotypic resistance to adefovir was developed in patient ( . %) in combination therapy and patients ( . %) in monotherapy conclusion: to achieve a complete virological response and reduce the risk of adefovir-resistant mutants in lamivudine-resistant chb patients, adefovir in combination with lamivudine is preferable. background/aims: adefovir dipivoxil (adv) effectively inhibits both wild-type and lamivudine (lam)-resistat chonic hepatitis b virus (chb) replication. the aims of this study were to determine the factorts associated with antiviral effect of adv in lam-resistant chb. methods: one hundred-eighteen lam-resistant chb patient ( . % hbeag-positive) were treated with adv plus lam (n= ) or adv monotherapy (n= ) for a mean of . months. restriction-fragment mass polymorphism analysis was used for detection ymdd and adv mutants. results: fifty-eight patients ( . %) achieved complete response(cr) defined as hbv-dna levels < copies/ml and alt normalization. twenty-eight patients ( . %) achieved initial vilologic response(ivr) defined as hbv-dna levels < copies/ml within the first month of treatment. ( . %) of hbeag-positive patients exhibited hbeag loss and % seroconverted to anti-hbe ab. five ( . %) patients developed adv-related mutations. factors associated with ivr were pretreatment level of alt (p= . ), ast (p= . ), pretreatment hbv dna level (p= . ), hbeag negativity (p= . ) and hbeab positivity (p= . ). factors associated with cr were ivr (p= . ), hbeab positivity (p= . ), pretreatment level of alt (p= . ), ast (p= . ) and y-glutamyl transferase (p= . ). age, sex, presence of liver cirrhosis, pretreatment hbv dna level and the type of ymdd mutants were not related to an cr during adv treatment. conclusions: adv therapy achieved cr in more than % of lam-resistant chb. factors associated with cr were ivr, hbeab positive status, high base line alt, ast, ggt levels. q.j. sheng , y. ding , x.g. dou department of infectious disease, shengjing hospital affiliated to china medical university, shenyang, , china objectives: to study a kinetics of hepatitis b virus during -week and -week of treatment with enticavir (ent); to compare the detecting results of hbvdna levels from different detection reagents. methods: thirty-seven cases of chronic hbv infections were selected randomly, treated with daily dose of ent . - . mg ( . mg for nucleoside-naïve patients, . mg for lamivuding-refractory patients). evaluation indexes: serum hbvdna, hbv serological markers, and liver function tests. hbvdna levels were measured by pcr assay, using both domestic reagents and roche cobas amplicor,. the lower limits of measure level of hbvdna were copies/ml and copies/ml, respectively. results: mean baseline of hbvdna was . log copies/ml for detection using domestic reagents and . log copies/ml for that using roche cobas amplicor, (p> . ). the ratios of cases with undetectable (< copies/ml) hbvdna at week- and week- were . % and . %, respectively. the ratios of cases with undetectable (< copies/ml) hbvdna at week- were . %. among the cases whose hbvdna were lower than copies/ml(using domestic reagents), the ratio of hbvdna lower than copies/ml(using roche cobas amplicor) was . %. conclusions: ent can suppress hbv dna rapidly no matter the patients with alt elevation or not. there is a concordance on hbvdna levels detection between domestic reagents and roche cobas amplicor. background the study on the effect of nucleoside analogue therapy on the quantity of hepatocellular cccdna and tdna and sera hbv dna, hbsag to probe reliable marks for evaluation of therapy endpoint. methods the quantity of hepatocellular cccdna and tdna and sera hbvdna were assayed by fq-pcr, and sera hbsag by elisa in chb patients over years nucleoside analogue therapy satisfied the china criteria of therapy endpoint (therapy group)and chb patients without antiviral therapy and sera hbvdna< copies/ml(control group). results: the quantity of hepatocellular cccdna, tdna and sera hbvdna, hbsag in therapy group were lower than that of control group,but low level hepatocellular cccdna in therapy group could be detected. conclusion: long term nucleoside analogue therapy may consume hepatocellular cccdna with decreasing of hepatocellular tdna and sera hbvdna, hbsag; although the patients have satisfied the china criteria of therapy endpoint, low level of hepatocellular hbvcccdna were detected, cessation of therapy may cause relapse. peptides that lead nuclear entry of nucleocapsid of hepatitis b virus in hepg . . cells x.b. pan , , l. wei , , j.c. han , , k. deng , peking university hepatology institute, peking university people's hospital background: the nuclear entry of nucleocapsid is a key step for the hbv life cycle and the formation of covalently closed circled dna (cccdna). it has been supposed that the carboxyl-terminal arginine-rich domain of the core protein contains a signal for nuclear localization (nls). whereas hbcag was primarily distributed in cytoplasm and no marked cccdna was detected in hepg . . cells. methods: we designed peptides containing a cell-penetrating sequence (rrrrrrr) and a nucleocapsid binding sequence (gsllgrmkga) with/without a classic nuclear localization sequence (pkkkrkv) and these sequences were linked by a soft linker acp. hepg . . cells were treated with the peptides at levels of m, m and m for days. results: compared with that of control cells, the results showed hbv dna levels in culture medium decreased at least log both in m of peptide rrrrrrracpgsllgrmkga treatment group and rrrrrrracpgsllgrmkgaacppkkkrkv treatment group; whereas hbsag and hbeag increased at . + . folds and . + . folds respectively. the signal strength of cytoplasmic hbcag increased at about . -fold in both groups. in rrrrrrracpgsllgrmkgaacppkkkrkv treatment group, nuclear hbcag increased about . -fold and obvious cccdna signal was detected by southern blot. conclusion: our results implied that the nls of core protein likely does not expose to surface of nucleocapsid in hepg . . cells, the artificial peptide containning nls binds to the nucleocapsid and leads nuclear entry of nucleocapsids and then facilitates the formation of cccdna. our study presents a tool for study on cccdna formation and nuclear entry of nucleocapsid. b. tang , j. xia , y.m. wang , h.f. wang liver failure treatment and research center, rd military hospital, the dept. aims: to establish a reliable real-time fluorescence quantitative (rfq) pcr method to quantify hbv cccdna, basing on lightcycler system and taqman probe. methods: hbv genotypes a-g were aligned to obtain a conserved sequence, crossing rcdna gap, which was used to design cccdna primers and taqman-mgb probe. also another pair of primers for quantify hbv total dna (tdna) was designed, utilizing the same probe. to increasing specificity, we added plasmid-safe atp-dependent dnase (psad) digestion step just before cccdna pcr amplification. a standard curve from standard plasmid samples, from . × to . × copies, was created to examine our system. hbv cccdna samples with known-amount were quantified by creating standard curve from standard samples. results: the standard curve had clear log-phase and excellent parallelism, which means nice and equal amplification efficiency in all reaction capillarys. the slope (regression coefficient) of standard curve was - . , mean square error was . and regression coefficient was - . . all of these key indexes measured up. in tests, we got right results if the starting templates of cccdna copies were between ~ copies. the range was superior to commercial hbv kits. by quantifying samples containing different amounts of cccdna and rcdna, digested or undigested, psad digestion would eliminate rcdna molecules, leaving cccdna molecules untouched. the test specificity was maintained up to : , ratio of cccdna:rcdna. conclusions: the rfq-pcr based on lightcycler system for hbv cccdna quantification is reliable, sensitive, with high specificity and low cost. background: to study the changes of toll-like receptor (tlr) on dendritic cells derived from peripheral blood mononuclear cells(modc) and its role in the pathogenesis of chronic hepatitis b(chb) and chronic severe hepatitis b(cshb). methods: the expressions of tlr on modc were stimulated by poly i:c, and then were determined by flow cytometry in healthy controls, patients with chb and patients with cshb.the level of interferon ifn-was determined by elisa. the differences of expression of tlr on modc and serum ifn-among the three groups of study subjects were determined by student-t test.the correlation between tlr and ifn-were determined by linear correalation test. results: the values of mean fluorescence intensity(mfi) of tlr on modc of the healthy controls, patients with chb and cshb were . ± . , . ± . ,and . ± . .the serum ifn-(pg/l) of respective groups was . ± . , . ± . and . ± . . there was a gradual decrease of these values from the group of healthy controls to the group of patients with chb and cshb .significant positive correlations between tlr and serum ifn-were found. conclusion: tlr may have a role in the pathogenesis of chb and cshb. background/aim: to evaluate the efficacy and safety of entecavir treatment in patients with hbeag-positive chronic hepatitis b who had not previously received a nucleoside analogue. methods: fifty-five patients received -week entecavir . mg/d therapy. serum hbv dna load was measured with quantitative real-time-pcr. alanine aminotransferase (alt) activity, hbeag, anti-hbe-antibodies, hbv dna level in serum were evaluated at baseline, week , , and during therapy. evaluation of safety and tolerance was based on clinical adverse events and laboratory analyses. results: hbv dna levels declined sharply by around log copies/ml during the first two weeks, with a highly significant reduction (p< . ) at week and thereafter, as compared to those at baseline; %, % and % of the patients had undetectable serum hbv dna levels at week , and respectively. highly significantly decreasing serum alt (p< . ) occurred during the first weeks of the study. at week , alt levels were normalized in % of the patients. hbeag seroconversion (hbeag negative, hbeab positive) was achieved in . % and . % of patients by and week. at the end of th and th weeks, complete response (alt normalization and hbv dna and hbeag loss) was observed in % and %, respectively. there was no evidence of drug resistance or adverse effect in chb patients treated for up to weeks. conclusion: entecavir treatment through weeks was well tolerated and resulted in continued benefit for patients with hbeag-positive chronic hepatitis b. aim: to assess the associations of single nucleotide polymorphisms of the mxa gene promoter and sustained treatment response of chronic hepatitis b or c patients with interferon treatment by meta-analysis of individual dataset from all studies published till date. methods: to clarify the impact of mxa gene promoter polymorphisms on sustained treatment response of chronic hepatitis b or c patients with interferon treatment, we performed a meta-analysis of the published data from eight studies comparing the frequencies of mxa gene promoter polymorphisms at nt - g/g, - g/t, - t/t and nt - c/c, - c/a , - a/a alleles in individuals with interferon treatment. as we identified the heterogeneity between studies, summary statistical data were calculated based on a random-effect model. results: the sustained treatment response rate was higher in patients with the nt - g/t and nt - c/aalleles in the mxa promoter snp . the meta-analyses yielded summary estimatesodds ratio (or) were . [ %ci ( . , . ), p < . ] and . [ %ci ( . , . ), p = . ] of the nt - g/t and nt - c/a alleles, respectively. conclusion: mxa gene promoter polymorphisms at nt - g/t and nt - c/a may be useful as a marker to predict the sustained treatment response of chronic hepatitis b or c patients with interferon treatment, and further investigation regarding their real significance is warranted in a large series of patients. background: to determine whether hbv with the same characteristics causes dissimilar mutations in different hosts. methods: full-length hbv genome was amplified and linked with pmd t vector. positive clones were selected by double-restriction endonuclease digestion (ecori and hindiii) and pcr. twenty seven clones were randomly selected from an asymptomatic mother [at two time points: ( d) and ( mo)] and her son [ (s)]. bioeditor, clustal x and mega software were used to perform phylogenetic and mutational analysis. potential immune epitopes were determined by the stabilized matrix method (smm), smm-align method and emini surface accessibility prediction. result: all of the sequences were genotype c, the inner-divergence for the mother and son was %- . %. specific nucleotides differed from the other pubished genotype c isolates were co-exist in the mother and her son. aa - deletion in pres was the dominant mutation in the mother ( / ). the t/ a double mutation existed in all clones of the mother, of them were also coupled with g a mutation, but none were found in the son. bp deletion starting at nucleotide was the major mutation ( / ) in the son, which caused seven potential hla class i epitopes and one b cell epitope deletion, and produced a presumptive new start codon, downstream from the original one of the p gene. conclusion: the son was infected hbv from his mother, and discrepant mutation occurred in the mother and her son during infection. background/aims: nucleos(t)ide analogues have been recognized as an effective treatment for chronic hepatitis b. this randomized, double-blind trial compared the efficacy and safety of telbivudine and lamivudine after -week therapy in patients with compensated chronic hepatitis b in taiwan. methods: we analyzed taiwanese patients from globe trial receiving telbivudine mg (n= ) or lamivudine mg (n= ) once daily for weeks. the primary efficacy endpoint was therapeutic response with serum hbv dna < log copies/ml and either hepatitis b e antigen (hbeag) loss or alanine aminotransferase (alt) normalization. results: the therapeutic response at week was . % in telbivudine group versus % in lamivudine group (p= . ). more patients with telbivudine achieved nondetectable serum hbv dna (< copies/ml) (p= . ) and alt normalization (p= . ) at the end of treatment. the cumulative resistant rate was significantly lower in those with telbivudine treatment (p= . ). the rate of hbeag seroconversion was comparable in both groups (p= . ). although a lower percentage of patients in lamivudine group ( . %) reported adverse events than those in telbivudine group ( . %), the difference was not significant. conclusions: telbivudine demonstrates a significantly greater efficacy and a lower resistant rate than lamivudine in treatment of chronic hepatitis b in taiwan. background: tumor necrosis factor-(tnf-) plays a pivotal role in the viral clearance and host immune response to hbv, and the capacity for tnf-production in individuals is influenced by a major genetic component. the studies of tnf-- gene promoter polymorphism in chronic hbv infection have reported apparently conflicting results. objective: to derive a more precise estimation of the relationship between the polymorphism of tnf-- gene promoter and chronic hbv infection. method: meta-analysis was done of case-control studies in relation to tnf-- gene promoter, involving a total of chronic hbv infection cases and controls. the pooled odds ratios (ors) for the risk associated with the genotypes of ga, aa, and ga+aa (a-allele carriers) compared with the gg genotype were calculated. results: overall meta-analysis indicated that - a heterozygotes (ga) had % decreased risk of developing chb with a borderline significance (or = . ; % ci: . - . ; p = . ). for the - a allele homozygotes (aa) and carriers (ga+aa), the pooled ors both indicated a significantly decreased risk of chb (or = . ; % ci: . - . ; p = . ; and or = . ; % ci: . - . ; p = . , respectively) ( table ). in the subgroup analyses by ethnicity, significantly decreased risks were associated with - variant genotypes (ga and aa) in mongoloid populations in all genetic models. however, no significant associations were found in caucasoid. conclusion: the meta-analysis suggests that the tnf-- a allele is a low-penetrant protective factor for chronic hbv infection, especially in mongoloid. aim: to define the potential role of pd- /pd-lpathway in different hbv infection status; we examined the expression of pd- on cd + t cells in pbmc of patients with chb and aehb infection. methods: the pd- level on cd + t lymphocytes and the number of hbv specific cd + t lymphocytes in patients and healthy controls were analyzed by flow cytometry. pcr was used to measure the serum hbvdna levels. results: the level of pd- expression on cd + t cells in chb patients was higher than that in aehb patients and healthy individuals. compared to aehb patients, lower frequency of hbv-specific cd + t cells was detected in chb patients. there was an inverse correlation between the strength of hbv-specific cd + t-cell response and the level of pd- expression. besides, there was a significant positive correlation between hbv viral load and the percentage of pd- expression on cd + t cells in chb and aehb subjects. however, pd- expression was not associated with alt levels. conclusion: our results confirm previous reports that hbv specific cd + t-cell response in the peripheral blood is more intense in patients with aehb than in chb with persistent viral infection. moreover, there is a negative correlation between the level of pd- and the intensity of virus specific cd + t cell response. observed in . % of patients with a mean age of . ± . . the ethnic composition was . % chinese; . % malay; % indigenous sabahans; . % indigenous sarawakians; . % indians and . % others. chinese patients were on average, older (mean . ± . years), indians patients had higher mean alanine transaminase and indigenous sarawakian patients had the highest rate of cirrhosis (p< . ). during the study period, . % of patients were on treatment and they were significantly older than those who were not on treatment (mean age . ± . vs . ± . ). lamivudine was the first agent used in . % of cases. conclusions: in malaysia, chb remains a public health issue and significantly afflicts males in the productive age groups and of chinese ethnicity. the observed differences among ethnic groups could point to different disease severity which needs to be addressed in the local treatment guideline and policy. background/aims: liver stiffness measurement (lsm) has been validated for predicting fibrosis stage in patients with chronic hepatitis c. however, studies on lsm for chronic hepatitis b (chb) are few, and the relationship between histologic findings and liver stiffness needs to be further elucidated. this study was conducted to assess the association of histologic activity on liver stiffness in addition to fibrosis in patients with chb methods: thirty three patients who had taken liver biopsy and lsm at korea university ansan hospital between march and october were enrolled. necroinflammatory activity and fibrosis stage were assessed by metavir system. activity, fibrosis, and the sum of both score were included for the correlation analysis with lsm results: among patients, ( . %) were male, and median values were as follows: age, ( ~ ); ast, iu/l ( ~ ); alt, iu/l ( ~ ); total bilirubin, . mg/dl ( . ~ . ); lsm, . kpa ( . ~ . ). fibrosis stages were f in ( . %), f in ( . %), f in ( . %), and f in ( . %) patients. spearman correlation coefficient with lsm were . (p= . ) for activity, . (p< . ) for fibrosis stage, and . (p< . ) for the sum of activity and fibrosis. in linear regression analysis, only the sum of activity and fibrosis remained to be significant. conclusions: not only fibrosis but also activity was an important factor for determining lsm for chb. it would be more appropriate to consider both activity and fibrosis for interpretation of lsm in patients with chb background: hbeag seroconversion is a key goal of chb therapy. hbeag kinetics may predict hbeag seroconversion during treatment. we aim to develop a robust hbeag quantitative method as the value of hbeag quantitation is undefined and data is limited. methods: we evaluated two commercially available qualitative hbeag assays (abbott architect, siemens centaur) for their linear range and validated them against paul-ehrlich institute (pei) standards. hbeag levels were determined from samples of untreated and telbivudine-treated chb patients. results: as a pre-requisite for quantitative use, the linear range for the architect ( . - peiu/ml) and centaur ( . > peiu/ml) assays were defined. architect was selected for further investigation. hbeag levels of untreated patients (mean hbv-dna . log copies/ml, mean alt . iu/ml) varied from . to . peiu/ml (median . peiu/ml). in patients (mean hbv-dna . log copies/ml, alt iu/ml) treated with telbivudine for weeks, baseline hbeag levels varied from . to peiu/ml (median . peiu/ml). after weeks of telbivudine treatment, median hbeag level was . peiu/ml, with % decline from baseline (median decline . peiu/ml, range . - . peiu/ml). individual hbeag decline from baseline varied but occurred in all patients and was not correlated to baseline or decline from baseline hbvdna. conclusion: hbeag quantitation is feasible and robust with architect hbeag assay. hbeag decline occurred in all telbivudine-treated patients, and was not correlated to hbvdna. whether the magnitude of hbeag decline is predictive of future hbeag seroconversion merits further investigation. experience from the combined globe (nv- b- /cldt a ) and (nv- b- ) study clinical safety database. c. avila , r. laeufle , w.b. bao novartis pharma ag, fabrikstrasse , basel, switzerland, novartis pharma ag, basel, switzerland, novartis pharma, east hanover, us background: creatine phosphokinase (ck) is a commonly used marker of muscle damage and is elevated by many factors (e.g. exercise, injury, drugs). normal ck levels are affected by muscle mass and elevated levels are described during the natural course of chb. % of patients in the globe study had pretreatment grade - ck elevations. methods: we reviewed data from this combined study clinical safety database, and describe the experience of ck elevation and its relationship to adverse event reports of muscle related symptoms. results: the frequency of new onset of grade - ck elevations in telbivudine-treated patients (combined database itt population) was . % ( / ), . % ( / ), . % ( / ) and . % ( / ) from weeks - , - , - and - respectively. the frequency of grade - ck elevations for all patients from week - was . % ( / ). the majority of grade - ck elevations were asymptomatic, rarely resulted in discontinuation or interruption, spontaneously declined within or visits and were not associated with more frequent muscle-related adverse events. cumulative data from this combined database showed no relationship of the degree of increased ck to acute or persistent muscle disease. conclusion: ck elevations are associated with hbv disease and were also common during the globe and trials and were not predictive of the development of muscle related symptoms. onset of muscle-related symptoms should prompt clinical and treatment review, including concomitant medications. backgrounds: leptin plays a crucial role in the regulation of energy balance and body weight control by activating the long form of the leptin receptor (ob-rl). epidemiologic studies showed that obesity is one of the factors associated with hbv related hepatocellular carcinoma. methods: huh cells were transiently transfected with . copies of hbv-replicon plasmid. after h, cells were harvested and total rna of the cells were extracted and reverse-transcribed into cdna. long form and short form leptin receptor (ob-rl, ob-rs) mrna transcription levels were assayed by real-time pcr respectively. and mrna transcription levels and protein expression of ob-rl and ob-rs in hepg . . cells were also detected. results: after transfected by . copies hbv-replicon plasmid, the mrna transcription level of ob-rl was inhibited significantly (**p< . ), but the mrna transcription level of ob-rs did not change, and the ob-rl protein expression was reduced. in hepg . . cells, the mrna transcription level of ob-rl was also significantly lower than the mrna transcription level of ob-rl in hepg cells, while the mrna transcription of ob-rs in hepg . . and hepg cells didn't show significant difference. besides, the protein expression level of ob-rl in hepg . . was also lower than it in hepg cells. conclusion: hbv replication down-regulated the expression of long form leptin receptor in cell cultures, which could in part explain the clinical observation of obesity in association with development of serious sequelae in hbv infections. the results of entevavir treatment in patients with chronic hepatitis b s. kose , g. akkoclu , m. turkeri , a. gozaydin the ministery of health tepecik training and research hospital, izmir purpose: we evaluated the short and long term effectiveness of entecavir. patients and methods: those patients had received diagnosis of chronic hepatitis b. their pretreatment transaminases, hbsag, anti-hbs, hbeag, anti-hbe, hbv-dna were checked and a liver biopsy and a resistance test for lamivudine (lam) and adefovir (adv) were performed. a total of patients who were taking entecavir for at least weeks were included in the study. findings: the biochemical and virologic response were observed in . % at and months and in % at months. in hbeag positive patients who had received therapy previously, the biochemical response was observed in . % at and months and in % at months. the virologic response in . % at , in . % at , and % at months. posttreatment hbeag seroconversion did not develop. in hbeag negative patients the biochemical and the virologic responses were observed in . % at months and % and months, respectively. in hbeag negative patients had received therapy previously, the biochemical response was observed in . % at , in % at and months. the virologic response in . % at , in % at and at months. conclusion: in our study, a higher therapy-response rate was achieved, especially in hbeag negative patients. in hbeag positive patients biochemical and virologic response rates were high. background/summary: patients with liver disease are known to have a higher prevalence of glucose intolerance. preliminary studies suggest that viruses can be an additional risk factor for the development of diabetes mellitus. individuals with type ii diabetes have an increased prevalence of cirrhosis, and a proportion of patients with acute and chronic liver disease develop diabetes mellitus. there is now emerging epidemiological data to suggest that hepatitis c virus (hcv) infection may also contribute to the development of diabetes reported to be higher than expected compared with the general population. while these investigations suggest an epidemiological association between hcv infection and diabetes, large controlled studies are required to observe association between hbv infection and diabetes. the present study was designed to study the relative proportion of diabetes mellitus in patients suffering from hepatitis b virus (hbv) infection. background: in easl , we reported significant liver disease among hbeag negative patients with serum hbv-dna level < log copies/ml (i.e. . x log iu/ml) and alanine aminotransferase (alt) < iu/l. this reflects fluctuating nature of these levels. the aim of this retrospective study is to demonstrate the frequency of fluctuation among this group of chb patients. methods: clinical records of hbeag negative treatment naïve chb patients with at least one serum hbv-dna < log copies/ml were reviewed. results: there were ( . % male, median age . years) chb patients with negative hbeag and hbv-dna < log copies/ml (roche cobas amplicor pcr assay, lod< copies/ml). had serial hbv-dna measurements within years; of them ( . %) had increase serum hbv-dna level by > log copies/ml; patients had associated serum alt elevation from normal (normal range < iu/l), had persistent normal alt, and one had persistently raised alt. ( . %) had serum hbv-dna level decrease by > log copies/ml. another patients had hbv-dna levels fluctuating within log copies/ml. hbeag negative patients with single hbv-dna measurement showing < log copies/ml had serial serum alt measurements within years. ( . %) patients had intermittent / persistently raised alt; while ( . %) patients had persistently normal alt. conclusions: hbeag negative chb is common among chinese. serial serum hbv-dna and alt measurements are necessary to detect fluctuating levels and progressive liver disease that may require antiviral therapy. background: to determine the best vaccination strategy, a model that reflects the country-specific infection profile is needed. methods: a model was built in order to obtain the age-specific infection frequency q(t) for neonates(n), infants(i), children(c), and adults(a). the infected group can either become hbsag(+) or anti-hbs(+)* based on f(t). q(t) can be found from p(t) = [q(t) x ( -f(t)) x crs + q(t) x f(t) x ( -cras)], where p(t) represents the proportion of the late anti-hbs(+)** group and crs/cras denote natural conversion of hbsag/anti-hbs. to test the model, cross-sectional serologic marker data in korea were used. because f(t), crs, and cras were known(f(n)= . , f(i)= . , f(c)= . , f(a)= . , crs= . , cras= . ), in order to determine q(t), only p(t) values were needed, which were evaluated from logistic modeling using the glm() function of s-plus. results: the infection frequencies during neonate, infant, children, and adult periods in non-vaccinees were . %, . %, . %, and . %, respectively. each group's likelihood of infection compared to adults was then: neonates . times more likely, infants . times, and children . times, making a strong case for neonatal and infantile vaccination for the studied region. conclusions: the hbv infection model can be used for determining the most cost-effective strategy for hb vaccination in nations where longitudinal data are not available. and where longitudinal data are available, it can be used to determine the appropriate time of transition of vaccination strategy to maintain cost-effectiveness. the effect of telbivudine on peripheral blood regulatory t cells and its significance in patients with chronic hepatitis b x.c. pan , f. yang , m. chen objective: to investigate the effect of telbivudine on peripheral blood regulatory t cells and its significance in patients with chronic hepatitis b. methods: patients with hbeag positive chronic hepatitis b were recruited and receiving telbivudine treatment for months. before and during months of treatment , flow cytometry was used to detect the proportion of peripheral blood tregs; real-time pcr was used to detect the levels of hbv dna in surum, markers of hepatitis b virus infection were detected by elisa assay and levels of alanine aminotransferase in serum were measured. results: the proportion of peripheral blood tregs in patients with chb was significantly higher than that in healthy controls and decreased over or months of treatment to a level comparable to that of healthy controls. after months of treatment, the rate of alt normalization in patients which the proportion of peripheral blood tregs was unreduced was significantly lower than that in patients which the proportion of peripheral blood tregs was reduced (p< . ). , or months of telbivudine treatment resulted in negative hbeag in ( %) patients, ( %) patients or ( %) patients respectively. within months of treatment, ( %) patients seroconverted from hbeag to anti-hbe , in which the proportion of peripheral blood tregs had decreased to a level comparable to that of healthy controls over or months of treatment. conclusion: during antiviral treatment with subsequent reduction of the viral load or alt levels, the proportion of tregs decreased to a level similar to that of normal healthy controls. in addition, seroconversion from hbeag to anti-hbe was prone to be established in patients which the proportion of tregs decreased quickly at the early phase of antiviral treatment with telbivudine. background: in china a part of patients with alt < . ×uln and hbv dna > copies/ml will advance into hepatic cirrhosis even hepatoma. so these patients should not only be monitored but also be treated. this study was made to determine the safety and efficacy of combining therapy of pegylated interferon alpha a (peg-ifn - a) and entecavir in treating naive patients with alt < . ×uln and hbv dna> copies/ml. methods: nine patients with hbsag positive over months and alt< . ×uln hbv dna > copies/ml were taken as research subjects. before treatment,liver biopsy was used to assess histological damage. patients were treated with peg-ifn - a g /week for weeks, and in the first weeks entecavir . mg/day was applied, then it was stopped. results: liver biopsy showed that patients had mild inflammation. after weeks' treatment , hbv dna level in all patients decreased to less than copies/ml, and after weeks' treatment( weeks after entecavir was stopped)hbv dna in all patients was less than copies/ml. normal alt was seen in all patients after weeks' treatment and weeks' treatment. none of the patients had peripheral neuropathy with combining treatment. conclusions: . bulk of patients with alt < . ×uln and hbv dna> copies/ml had mild inflammation and need treatment. combing treatment of peg-ifn and entecavir was safe and effective to this group. it proved that it was safe for patients to stop treatment with entecavir after short time use. background & aims: quantification of serum hbv dna levels is important to monitor viral replication in chronic hepatitis b (chb) patients. both abbott realtime hbv and roche cobas amplicor hbv monitor are updated fully automatic commercial assays for hbv dna quantification. the aim of this study is to compare the performance of these two assays on the hbv dna quantification in chb patients. methods: serial serum samples from chb patients were collected at the baseline and at days , , and and weeks , , and after the commencement of therapy. genotype was determined by sequence alignment. abbott and roche assays were employed for hbv dna extraction and quantification according to the instructions of manufactories. results: hbv dna quantification results of abbott assay was significantly correlated with those of roche assay (r= . , p< . ). for genotype c, the difference in hbv dna levels [median (range): . (- . - . ) log units] measured by these two assays was significantly higher than that for genotype b [ . (- . - . ) log units, p< . ]. moreover, the difference in serum hbv dna levels after weeks antiviral treatment [ . (- . - . ) log units] measured by these two assays was significantly higher than that in baseline serum hbv dna levels [ . (- . - . ) log units, p< . ]. conclusion: the quantification results of abbott realtime hbv showed a good correlation with those of roche cobas amplicor hbv. but the performances of these two assays have significant difference in the quantifications of serum hbv dna levels in genotype c patients and in patients after weeks antiviral therapy. background: guidelines suggest hepatitis b virus (hbv) vaccination to all hepatitis c virus (hcv) infected patients and healthcare workers. we attempted to find out hbv vaccination status in our hcv infected population, and healthcare workers. methods: prospective survey of consecutive hcv infected patients and also doctors and paramedical staff in our hospital. results: major sources of viral infection in study patients ( males; average age years -range to yrs) were reused syringes ( pts). twenty had a household member infected with hcv. twenty were co-infected with hbv. eighty five of hcv infected patients were not vaccinated.against hbv. twenty five of them ( %) had financial reasons and patietns ( %) had lack of awareness. out of doctors, and did not know about their hbv and hcv status respectively, but none was known to have either of these infections. four ( %) were not vaccinated against hbv. out of paramedical staff, was hcv positive, each were unaware of their hbv and hcv status, and remaining were negative for these markers. thirteen of them ( %) were not vaccinated against hbv. conclusion: thirty eight percent hcv infected patients were infected by reuse of syringes. eighty five percent were not vaccinated against hbv, out of which % had no awareness about it, whereas % could not financially afford it. a significant number of paramedical staff and some doctors were also not vaccinated background: early prediction of efficacy could decrease unnecessary interferon exposure of patients with chronic hepatitis b. methods: a multi-center clinical study. patients were injected interferon alpha b million iu subcutaneously every other day for weeks and -week follow-up was followed. results: patients ( male) were enrolled, . ± . years old. hours after administration, hepatitis b virus (hbv) load decreased significantly ( . ± . log copies/ml, p< . ) from baseline ( . ± . log copies/ml). hbv load was . ± . and . ± . log copies/ml at week and , respectively. at the two points upwards, complete response rate was . %( / ) and . %( / ), partial response rate was . %( / ) and . %( / ), respectively. at week and , hbv dna levels of complete responder and partial responder were lower than those of non-responder (p< . ) at week . at baseline, on hour , day , , week , and , hbv dna levels of complete responder were lower than those of non-responder at week (p< . ). multiple linear regression showed that baseline hbv dna was the independent variables to predict the response at week and . conclusions: interferon alpha b was effective in treating patients with hbeag positive chronic hepatitis b. it could decrease the hbv dna level rapidly. early hbv dna levels were predictive to response at the end of treatment and follow-up. baseline hbv dna level was the independent predictor of the response at the end of treatment and follow-up. aim: to investigate features of pd- expression on peripheral tcells and pd-l expression in liver in chronic hepatitis b (chb) patients in immune clearance phase. methods: pd- expression on total peripheral t cells were evaluated by using flow cytometry. immunostaining was performed according to the envision chemmate methods. the degree of pd-l expression was scored and assessed according to the percentage and staining intensity of positive cells. results: compared to health control, the percentage of total peripheral t cells expressed pd- was elevated in chb with repeatedly increasing alt level. no specific association between the percentage of pd- positive and the mean fluorescence intensity mfi of pd- expression on total t cells with serum viral load were found. but alt level was correlated with the mfi of pd- expression on total cd +t cells significantly. pd-l is up-regulated on hepatocytes by viral infection, and high expressed in fibrosis section. conclusion: the mfi of pd- on cd +t cells plays important role in regulating the immune-host interaction in chb in immune clearance phase. and pd- expression on t cells is correlated with high immune inflammatory refection. aim: to study the quantity, characteristic of hbv-specific t-cell and the extent of liver damage in chronic hepatitis b (chb) patients with different hbeag status. methods: chb patients were enrolled and divided into two groups according to the hbeag status, and the liver damage index were analyzed. the frequency and foxp expression of cd + cd + regulatory t cells (treg) were measured, as well as the frequency and phenotypic molecules expression of hbv-pentamer+ t-cell. hbv specific t-cell responses including cellular proliferation and ifn-production, with or without anti-pd-l and/or anti-ctla- blocking, were also observed. results: the demographic characters, serum alt, ast levels, the frequency and foxp expression of cd + cd + treg were similar, while the serum hbv dna levels were higher in hbeag+ patients (p < . ). the liver necroinflammation was comparatively more severe in hbeag-patients (p = . ), but the median percentage of liver cirrhosis was much higher in hbeag+ patients (p < . ). the difference of hbv-specific t-cell frequency was not significant between two groups, while the expression levels of pd- and ctla- on hbv-specific cd t cells were significantly higher in hbeag+ patients (p both < . ). combined using of anti-pd-l and anti-ctla- mab significantly increased the cellular proliferation in either hbeag+ or hbeag-patients, but only markedly enhanced the ifnproduction in hbeag+ patients. conclusion: hbeag persistency could probably induce higher expression of pd- and ctla- on the hbv-specific t cells and result in t-cell impairment, high hbv dna load and high percentage of liver cirrhosis in hbeag+ chb patients. hepatocyte apoptosis in patients with chronic hepatitis b y. liu , k. wang background: to investigate the relationship between hepatocyte apoptosis and the level of inducible nitric oxide synthase (inos) in hepatic tissue in the patients with chronic hepatitis b chb . methods: we observed cases with chb and normal controls. transferase-mediated-utp-biotin nick-end labling ( tunel) technique was used to detect apoptosis cells and immunohistochemical staining were also performed to investigate the expression of inducible nitric oxide synthase (inos) in biopsy samples .the serum level of alt hbv-dna grading of necroinflammatory activity and staging of fibrosis were also assessed. results: hepatocytes in all chb liver tissues were positively stained by tunel in various degree. in contrast, control tissues did not show dna fragmentation. a significant correlation was seen between apoptosis index (ai) and necroinflammatory grading ((r= . , p= . ) and serum inos level r= . , p= . . it did not correlate with fibrosis stage and serum alanine aminotransferase level. conclusion: the oxidative stress.in patients with chb may reflected the apoptosis of hepatocyte. apoptosis involves in liver injury of chb,but with no significant correlation to serum level of alt. objectives: to investigate the genotype-dependent development of lamivudine resistance in hepatitis b virus (hbv). methods: patients with chronic hepatitis b who had been treated with lamviudine for more than year, and become lamviudine resistance were analysed for the hbv genotypes and cumulative rate of rt region mutant with standard dna sequencing technology. results: among the patients, patients were infected with hbv genotype b (hbv/b)( . %), and with genotype c (hbv/c)( . %). in the hbv/b patients, / ( . %) were of subtype ba, and / ( . %) were of of subtype bj. the cumulative type and ymdd mutation rates in patients with genotype c were showed as l m+m v ( / , . %) > l m+m i ( / , . %) > m i ( / , . %), while in patients with genotype b as l m+m v / ( . %) > m i( / , . %), none of l m+m i. conclusions: our results indicated that in patients with lamivudine resistance, hbv genotype c (hbv/c) were higher than genotype b (hbv/b). in both genotypes the combined mutations ( + sites) were found more than the single site, showed some significance for monitoring lamivudine resistance. background & aims: il- , a novel identified inhibitory cytokine specifically produced by regulatory t cells (tregs), is an ebi -il- heterodimer encoded by epstein-barr-virus-induced gene (ebi ) and interleukin- alpha (il ). the aim of the study is to determine the expression levels of il- in peripheral blood mononuclear cells (pbmcs) of chronic hepatitis b (chb) patients in different phases. methods: a total of treatment naïve chb patients, including in immune-tolerant phase [group , alt: ( - ) u/l, serum hbv dna: . x ( . x - . x ) copies/ml] and in immune-clearance phase [group , alt: ( - ) u/l, serum hbv dna: . x ( . x - . x ) copies/ml] were enrolled in the study. the relative mrna expression levels of ebi , il and foxp were determined by semi-quantitative pcr. results: the significant correlations were observed between the expression of ebi and il (r= . , p< . ), ebi and foxp (r= . , p< . ), il and foxp (r= . , p< . ). the relative expression levels of ebi and il in pbmcs were significantly higher in group when compared with those in group ( . ± . vs . ± . and . ± . vs . ± . , p< . , respectively). furthermore, the relative expression levels of ebi and il in group were significantly correlated with alt levels (r= . , r= . , p< . , respectively), but not with serum hbv dna levels. conclusions: the expression levels of il- in pbmcs were significantly higher in chb patients in immune-clearance phase than that in immune-tolerant phase. increased il- expression levels were associated with liver injury. background: there are a number of oral antivirals approved for chronic hepatitis b. lamivudine, the first oral nucleoside analog, is associated with increased rates of drug resistance with prolonged use--from % at one year to % at three years. therefore, an alternative or add-on treatment is necessary. adefovir, an oral nucleotide analog, is used either in combination with lamuvudine or as monotherapy in lamivudine-resistant chronic hepatitis b. we did a meta-analysis to compare the efficacy of adefovir in combination with lamivudine versus adefovir alone in the treatment of lamivudine-resistant chronic hepatitis b infection. methods: a comprehensive literature search was performed using the following databases: medline, cochrane, and embase. a total of randomized controlled trials were retrieved and analyzed. outcomes measured were virologic response, biochemical response and resistance rates. results: meta-analysis on virologic response showed that combination treatment with adefovir and lamivudine is as effective as adefovir monotherapy (or . , % ci . - . , p= . ). likewise, in terms of biochemical response, both regimens were equally effective (or . , % ci . - . , p= . ). one study showed statistically significant increase in adefovir resistance rate in the monotherapy arm compared to combination arm (p= . ) after the first year of therapy. conclusion: in patients with lamivudine-resistant chronic hepatitis b infection and compensated liver disease, adding adefovir to lamivudine is as effective as switching to adefovir alone in terms of virologic and biochemical response. r. safadi , q. xie , y.g. chen , y.k. yin , l. wei , s.g. hwang south korea, bnai zion medical center, haifa, israel, beijing friendship hospital, beijing, china, novartis pharma ag, basel , switzerland background: ldt produces greater viral suppression than lam. we investigated whether patients receiving lam can benefit from switching to ldt. methods: hbeag positive and negative persistently viraemic patients (median hbv dna . (ldt), . (lam) log copies/ml) and lam treated for - months, were randomized to either switch to ldt or continue lam. we report the benefit of ldt switch assessed by primary treatment failure (tf, < log hbv dna decline) and viral breakthrough (vb, > log above nadir). results: % ( / ) of the ldt switch and % ( / ) continuing lam patients had pre-existing m mutations at screening. tf was % (ldt) versus % (lam, p< . ). in patients with > weeks prior lam treatment, tf was % (ldt) versus % (lam). % ldt tf ( / ) was associated with resistance at screening versus % lam tf. in ldt switch with < weeks prior lam, no ldt tf occurred versus % lam. in hbeag positive, tf occurred in % (ldt) versus % (lam). among hbeag positive with > weeks prior lam treatemtn, vb was % (ldt) versus % (lam, p< . ). differences were not significant for hbeag positive with > weeks lam or for hbeag negative regardless of duration of prior lam treatment. conclusions: early switch to ldt is associated with better virological outcomes in these patients. persistent viraemia for > months on lam treatment is associated with a high risk of tf and vb. for these patients, genotypic analysis is recommended prior to screening. objective: the aim of this study is to evaluate the proper endpoint in the treatment of chronic hepatitis b with antivirals by investigating the viral rebound ratio after one year's nucleosides or (three months) sustained treatment with lamivudine, adefovir, entecavir, or interferon when viral response and seroconversion response have been finished . methods: eag positive chronic hepatitis b naïve patients with alanine aminotransferase (alt) more than uln were assigned to receive mg of lamivudine, mg of adeforvir, or . mg of entecavir once daily, respectively. patients in the interferon group were administrated with , , iu of a interferon on every other day, and the therapeutic duration lasted for another three months after eag-ab seroconversion appeared. hbv dna and eag-ab in the serum were tested during the off-treatment period of months. results: thirty four patients in lamivudine group of cases got eag-ab seroconversion after treatment with ± months of average duration, and the viral rebound ratios in the off -treatment an months follow up period were . / and . / , respectively. in adeforvir group were / and . / . in enticavir group were / and . / . in interferon group was . / in the off-treatment months follow up period. conclusions: we conclude that eag-ab seroconversion in the treatment of eag positive chronic hepatitis b patients is the goal but not an endpoint of therapy physicians should aim at. to gain everlasting effect, longer duration of treatment may be needed. background: universal hepatitis b(hb) vaccination of hbsag negative people (especially infants) is widely recommended and practised. objective: to assess whether there is robust evidence of protective efficacy to back such practice. methods: this cochrane review included randomised trials identified from six databases through detailed electronic searches. trials comparing hb vaccine versus placebo/another vaccine, in hbsag negative persons were included without any restrictions. the primary outcome was hb infection (developing hbsag or anti-hbc). robustness of evidence was assessed through comparison of available-case analysis versus intention-to-treat(itt) analysis using four different models: (i)assuming unfavourable event for all missing data, (ii)assuming favourable outcome for all missing data, (iii)best-case-scenario and (iv)worst-case-scenario results: twelve trials were eligible among citations; all were methodologically poor (high risk of bias). data from four trials could be included in meta-analysis. efficacy of vaccination varied with the type of data analysis. available-case analysis suggested efficacy in reducing risk of developing hbsag (rr= . ; %ci= . - . ;n= ) and anti-hbc (rr= . ; %ci= . - . ;n= ). itt analysis results varied depending on the model chosen (table) , but liberal approaches suggested high efficacy, whereas conservative approaches did not. the available evidence on efficacy of hb vaccination in hbsag negative people is not robust; there are serious limitations in quality and quantity. background: open-label rollover study (etv- ) assessed histologic improvement in chb patients on at least years etv therapy. methods: % nucleoside-naïve patients and % lamivudine (lvd)-refractory patients from etv- and etv- studies, respectively, entered etv- study and received etv at . / mg for greater than weeks. improvement in knodell necroinflammatory (ni) score and knodell fibrosis score at weeks and were studied. results: at week , % of nucleoside-na ve patients and % of lvd-refractory patients achieved hbv dna < copies/ml. furthermore, % of nucleoside-na ve patients and % of lvd-refractory patients had normalized alt levels. mean platelet counts in both naïve and lvd-refractory patients were improved at weeks and compared with baseline. conclusions: naïve and lvd-refractory chb patients showed significant improvement in liver histology after year etv therapy, and improved dna and serum alt levels. results: . percent of patients were younger than years old, . percent were older than in this study. . % patients' mothers were hbsag positive. high levels of serum hbv dna were founded in all patients, > copies/ml were . %. only cases ( . %) whose liver inflammation grade were g , the rest patients were mild inflammation, in which g were cases ( . %), g were ( . %); there were patients ( . %) had no signifecant liver fibrosis, the rest cases ( . %) had different fibrosis, among those s were cases ( . % , s were . % , s were . % , none of patients had cirrhosis. the fibrosis stages of higher alt level were markedly severer than lower alt in patients with normal alt p < . . conclusions: most of patients with chronic hepatitis b virus in immune tolerant phase present mild inflammation in liver, part of them have already appeared fibrosis, so some patients determinated by clinics are actually not in immune tolerant phase. although alt testing are in the normal range, but the possibility of liver fibrosis is increased in patients with relative higher alt level, so liver pathology should be recommended to judge illness correctly. background/aims: hepatitis b virus infection (hbv) is a global health problem. in bangladesh, - % of people are hbsag positive. this study was carried out to evaluate the efficacy and safety of peginterferon alfa- a in chronic hepatitis b patients. methods: a total of patients with chronic hepatitis b, ( . %) were hbeag positive (group a) while ( . %) were hbeag negative (group b) were included in this study after meeting the following criteria: age to years, hbsag positive for more than months, serum hbv-dna was > log( ) copies/ml and alt more than two times the upper normal limit. they were given peginterferon alfa- a ( microgram once weekly) for weeks and followed for an additional weeks. results: after weeks of follow-up, the percentage of patients with normalization of alanine aminotransferase levels or hbvdna levels below , copies per milliliter was significantly higher in hbeag positive patients ( percent and percent, respectively) than among hbeag negative patients ( percent and percent). loss of hepatitis b surface antigen occurred in patients in group a, as compared with patients in the group b (p< . ). adverse events including pyrexia, fatigue, myalgia, headache and haematologic abnormalities were similar in both groups. conclusions: patients with hbeag positive chronic hepatitis b had significantly higher rates of response, sustained for weeks after the cessation of therapy, with peginterferon alfa- a. background: the effect of hepatitis b vaccination on individuals with isolated anti-hbc in endemic areas is not clear. we investigated the prevalence of individuals positive for anti-hbc only and their antibody response after hepatitis b vaccination in a single healthcare center. methods: the study included , healthcare workers. after screening for hbsag and anti-hbs, the individuals negative for both hbsag and anti-hbs were examined for anti-hbc and were vaccinated with a recombinant hepatitis b vaccine at , , and months. the serum anti-hbs level was measured after the vaccination. results: of the subjects, ( females) were negative for both hbsag and anti-hbs. forty ( . %) subjects had isolated anti-hbc, including more males ( . % vs. . %) and older people ( . ± . vs. . ± . years), compared with individuals negative for all of the viral markers. the anti-hbs seroconversion rate and anamnestic response in the individuals with isolated anti-hbc after the first vaccine injection were % and . %, respectively. in the persons who were negative for all hepatitis b viral markers, the seroconversion rate after the first vaccination was . %. the anti-hbs seroconversion rate did not differ between the isolated anti-hbc positive individuals and those negative for all hepatitis b markers ( . % vs. . %) after the full course of vaccination. conclusions: serum hbsag and anti-hbs tests are sufficient for screening before hepatitis b vaccination, especially in healthcare workers. objective: to understand the quantity and distribution of cd + mature dendritic cells in patients with hepatitis b virus in immune tolerant phase. methods: there were immune tolerant phase patients with hepatitis b virus infection (fibrosis stages were s ), immune clerance phase patients, non-active status patients and healthy controls involved in our research. the quantity and distribution of cd + mature dendritic cells in liver were determined by immunohistochemical staining. result: the liver inflammation grades were between g -g in patients who in inmmune tolerant phase and non-active status, moreover, patients in immune clerance phase were between g -g . there were a small amount of cd + dendritic cells in healthy liver tissue, scattered in portal areas and hepatic lobules. the quantity and distribution of cd + dendritic cells in patients who in inmmune tolerant phase and non-active status were similar to the healthy, and the quantity were no difference among them p . .the number of cd + cells in patients of immune clerance phase was significant increased compared with other groups, there were differences among them p . , the cd + cells mainly distributed in portal areas infiltrated with inflammatory cells and hepatic lobules with inflammatory necrosis. conclusion: cd + mature dendritic cells are involved in liver immune response in patients of inmmune clerance phase, is likely to related to hepatitis b virus clearance. lack sufficient mature dendritic cells may be one of the mechanisms of immune tolerance. background: local hospitals provide obstetric services including antenatal care to women normally living in the mainland china, whose prevalence of hepatitis b carrier is unknown. objectives: compare prevalence of hbv carrier of pregnant women from the mainland china with local counterparts and discuss the implications of results. materials and methods: antenatal serological results were retrieved from corporate laboratory information system databases. pregnant women from the mainland china were identified by a specific set of temporary-allocated identity number during january -october . results: pregnant local residents and pregnant women from the mainland china underwent antenatal serological tests for hepatitis b surface antigen. positive hepatitis b surface antigen results were more frequent in pregnant women from the mainland china ( . %) than in local pregnant women ( . %) (p< . ). discussion: because infected pregnant women can transmit the hepatitis b virus to the infant at delivery, specific management could entail maternal medication, injection of hepatitis b immune globulin to the infant at birth and immunization later on. however, early repatriation to the mainland china, which is common, will make completion of immunization program difficult. these babies will be at a higher risk to be infected by hbv, particularly when breast-fed by hbv carriers. their return to hong kong later will dilute the effects of local immunization program. the volume of work derived from the provision of obstetric services to women from the mainland chinese is larger with regard to medication, counseling and immunization for babies born to hbv carriers. immunosuppressive or anticancer therapy k. hirano , t. kodani , s. sato , y. narita , t. kikuchi , t. genda , k. iijima , k. ogawa , t. ichida background/aim: we compared the prevention of hbv reactivation in (hbsag)-positive patients with hbsag-negative patients who were positive for antibody to (anti-hbc) and/or (anti-hbs) undergoing immunosuppressive, anticancer or molecular target therapy. methods: from sep to nov hbsag-positive patients and anti-hbc and/or anti-hbs-positive patients were enrolled in this study. we compared with groups about background disease, age, blood examination, and nucleoside analogues. results: in hbsag-positive patients mean age were . ± . years old, median ast levels were ( - ) iu/l, and median alt levels were ( - ) iu/l for ( %) haematological disease and ( %) collagenosis disease. in anti-hbc and/or anti-hbs-positive patients mean age were . ± . years old, median ast levels were ( - ) iu/l, median alt levels were . ( - ) iu/l for ( %) haematological disease and ( %) collagenosis disease. serum hbv-dna levels > . log copies/ml were ( %), . ~ . were ( %), < . were ( %) in hbsag-positive patients, and serum hbv-dna levels < . were all cases in anti-hbc and/or anti-hbs-positive patients. ( %) of hbsag-positive patints received nucleoside analogues ( lam and etv), and ( %) of anti-hbc and/or anti-hbs-positive patients received nucleoside analogues ( lam and etv). mean duration of treatment for . months in hbsag-positive patients, and for . months in anti-hbc and/or anti-hbs-positive patients, the resistance virus occurred to ( %) of hbsag-positive patients treated with lam for collagenosis disease more than two years. conclusion: when hb carriers of collagenaous disease undergoing immunosuppressive therapy required the nucleoside analogues more than two years, we recommended treatment to prevent hbv reactivation with etv. background: adefovir dipivoxil is used for the initial treatment of chronic hepatitis b or rescue treatment of lamivudine-resistant chronic hepatitis b, and exhibits excellent antiviral activity. however, the presence of resistance to adefovir dipivoxil was more frequently in lamivudine-resistant chronic hepatitis b patients than in lamivudine-naïve patients during adefovir dipivoxil monotherapy. but the rate of adefovir resistance related mutations is little known in lamivudine-resistant patients before adefovir dipivoxil treatment. the aim of this study was to investigate the rate of adefovir resistance-related mutations in polymerase gene of hepatitis b virus in lamivudine-resistant patients not treated with adefovir dipivoxil. methods: the existence of adefovir resistance-related mutations was examined in lamivudine-resistant chronic hepatitis b patients with breakthrough hepatitis and antiviral-naïve chronic hepatitis b patients. both polymerase chain reaction restriction fragment length polymorphism (pcr-rflp) and directly sequencing of pcr product were used to detect resistant viruses. results: rta t mutants were detected in only two sera of lamivudine-resistant patients, while none in the antiviral-naïve chronic hepatitis b patients. there was no rtn t detected in the two groups. conclusion: our results suggest that the rta mutant virus were present in a few lamivudine-resistant chronic hepatitis b patients before they have been treated with adefovir dipivoxil, but the rtn t mutant was not detected in any of the two groups. the rate of adefovir resistance-related mutations in polymerase gene of hepatitis b virus was low in such lamivudine-resistant patients before adefovir dipivoxil treatment. objective: in this study, we tried to detect and identify the special protein of hbv related chronic hepatitis, liver cirrhosis and hepatocellular carcinoma. to find new opinion on the developing of chronic liver disease. methods: the sera of health adult, hbv related chronic hepatitis, liver cirrhosis and hepatocellular carcinoma were respectively detected by surface enhanced laser desorption/ionization time-of-flight mass spectrometry (seldi-tof-ms). the arrays of every group were analysised by clustering analysis and to establish disease predictive model. then the sample was eluted with different ph tris, trypsinization on-chip, mass determination and peptide database comparison. results: according cm chip we find protein with obviously deviation (p< . ) among hbv related chronic hepatitis, liver cirrhosis and hepatocellular carcinoma. clustering analysis for the data from seldi-tof-ms confirmed differentially expressed proteins. then we developed disease predictive mathematic models ( decision tree model, dt model ) with average validity up to . . the da protein peak was identified to be chondroitin sulfate synthase (chss ), which is a potential molecule involved in the pathologic process and a potential serum marker for the hbv related hepatic diseases as well. conclusions: our results suggest that seldi-tof-ms is a usefull technique for differential expressed proteins screening and analysis in hbv related chronic liver disease. chss may be useful during the developing of hbv related chronic liver disease. backgound: clevudine is a new nucleoside analogue with potent antiviral activity in chronic hepatitis b patients. however, the efficacy and safety of clevudine in cirrhotic patients are not well recognized. this study was conducted to evaluate the early virologic and biochemical response rate as well as safety of clevudine in cirrhotic patients with chronic hbv infection. methods: patients with chronic hbv infection who visited korea university ansan hospital and guro hospital between may and may were included. patients had chronic hepatitis b (group a) and had liver cirrhosis (group b). early virologic response was defined as hbv dna less than iu/ml at week . early biochemical response was defined to be normalization of alt (< iu/l) at week . result: pretreatment hbv dna levels were higher in group a compared with group b ( . log iu/ml vs . log iu/ml, p= . ). pretreatment alt levels were not significantly different between the two groups ( iu/l vs iu/l, p= . ). the rate of early virologic response was significantly higher in group b compared with groups a ( . % vs %, p= . ). the rate of early biochemical response were not significantly different in both groups ( % vs . %, p= . ). conclusion: clevudine is considered to be safe and effective in cirrhotic patients with chronic hbv infection as well as chronic hepatitis b patients. long term safety and efficacy need to be evaluated in the future. objective: the aim of this study was to evaluate the role of nucleos(t)ide analogues against hbv reactivation in immunosuppression. methods: non-active hbsag carriers suffering from cancer, autoimmune diseases and needing the treatment of immunosuppressants or cytotoxic chemotherapy were enrolled in the study. the outpatients or in-patients from april to july were enrolled. the nucleos(t)ide analogues were used in cancer patients - weeks before chemotherapy, and the duration lasted - months according to patients' compliance after completion of chemotherapy. patients with other diseases used nucleos(t)ide analogues in - months before using glucocorticoids or other immunosuppressive agents, and continued to use for - months after accomplishing the course of immunosuppressant treatment. the characheristics and clinical manifestations about hbv reactivation were investigated. results: of the thirty two patients in prospective group, twenty two patients suffered from cancer, eight patients suffered from idiopathic thrombocytopenic purpura, two patients suffered from chronic nephritis. the amount of hbv dna was detected in the first, third, sixth and th month after the use of nucleos(t)ide analogues. after chemotherapy or immunosuppressant treatment, only . % ( / ) of them suffered from hbv reactivation, which presented with hbv dna positive and abnormal liver function. conclusion: non-active hbsag carriers would appear potential incidence of hbv reactivation during use of chemotherapy or immunosuppressant. nucleos(t)ide analogues could be used in early phase as prophylaxis for reactivation of hepatitis b in immunosuppression and to improve clinical prognosis. background: hbv therapies are evolving toward combination antivirals. this study evaluated the combination of clevudine (clv), a potent nucleoside analog, with tenofovir dipivoxil (tdf). methods: a phase i, single-arm, multi-dose study in healthy adult volunteers to evaluate pharmacokinetic and safety interactions between clv and tdf. subjects received days of clv mg followed by days of clv mg +tdf mg. pk profiles were obtained on days , and . clv auc and cmax were compared on days and . day tenofovir pk was compared to historical data. safety assessments were conducted throughout. results: subjects were enrolled ( m/ f); completed the study. the mean (range) age was y ( - ) and body mass index (kg/m ) was . ( . - . ). aes were reported by subjects, with aes reported during clv-only dosing and aes reported during clv+tdf dosing. aes included nausea ( ) and pharyngolaryngeal pain ( ). the majority of the aes were mild. there were no clinically significant changes in ecgs or laboratory parameters. comparisons of clv auc and cmax on day and revealed no significant impact of tdf upon the plasma clv exposure (d /d auc ratio= . , d /d cmax ratio= . ). there is no significant effect of clv on tenofovir when comparing auc and cmax of tdf to historical values. conclusion: safety and pharmacokinetic results demonstrate that clv and tdf may be safely co-administered, supporting the further study of this drug combination for the treatment of chronic hbv infection. s. kuznecovs , , i. kuznecovs , k. jegina , g. kuznecova background: dolichyl (dol), the main lipid intermediator of dolichyl phosphate cycle (dpc) has been reported to be elevated in urine of patients with multidrug resistance in cancer. drug resistance poses a major threat to nucleoside analogue-based therapies for chronic hbv infection. methods: with focus on a risk predictor for susceptibility to the development of hbv drug resistance the present study was carried out to estimate urinary levels of dol in chronic hbv infection. the samples obtained every week before and during the course of treatment from patients with hbv. the occurrence of exacerbations of chronic hbv were registered for years. dol in urine was assayed by hplc method. results: the normal amounts of dol in healthy persons urine (n= ) are , + , mkg/mmol creatine. during the period of observation ( %) of patients treated with nucleoside analogue-based therapies were diagnosed with exacerbations due to resistance of hepatitis b virus to antiviral drugs. from this group of hbv patients ( %) have had elevated urinal dol excreation ( , ± , g/ml vs . , ± , g/ml, p< . ) in more than months of observation. conclusion: there is a reason to suggest that elevated urinal dol detected in patients with exacerbations during hbv treatment may evidence of possible defect of host mechanism of drug resistance development to nucleoside analogue-based therapies. the interest drawn to the employment of dol as a predictor for exacerbation of chronic hbv is explained by the role of dpc in p-glycoprotein regulation in human hepatocytes. background: a significant proportion chb patients treated with adv have a suboptimal response, increasing the risk of disease progression and development of resistance. we report clinical results from patients who either failed or relapsed following adv therapy and were subsequently switched to etv. methods: study etv- was a randomized, open-label study comparing antiviral efficacy of etv ( . mg/day) vs adv ( mg/day) in nucleoside-naïve hbeag-positive patients. after up to weeks of treatment in etv- , patients treated with adv ( suboptimal responders) rolled over into study etv- ( . mg/day). hbv dna viral suppression and safety was evaluated during weeks of etv treatment. results: at entry to etv- , the median hbv dna was . log copies/ml. median exposure to etv ( . mg) in etv- was weeks and patients currently remain on study therapy. at week , the mean reduction in hbv dna was . log copies/ml and / ( %) reached hbv dna levels < copies/ml. nine patients have achieved week and all have achieved hbv dna < copies/ml and / ( %) had hbv dna levels < copies/ml. no patients experienced virologic breakthrough on etv. the safety profile of etv in adv-treated patients remained consistent with the previously reported experience. conclusions: the majority of patients who were suboptimal responders or virologic rebounders following adv treatment in study etv- , experienced rapid reductions in hbv dna levels when switched to etv. hbv dna levels continued to decline to undetectable levels with weeks of etv treatment. y. li , , t. han tianjin third central hospital, aim:to quantify hepatitis b virus (hbv) total dna and covalently closed circular dna (cccdna) in liver biopsies and sera which from chronic hepatitis b(chb) liver cirrhosis of hepatitis b(lc) and hepatitis b relevance hepatocellular carcinoma(hcc) patients, and analysis hbv replication under the circumstances of different diseases. methods:total hbv dna and cccdna in serum and liver biopsy samples were measured in chb lc and hcc patients by the real-time pcr assay. results: the levels of total hbv dna in serum,intrahepatic total hbv dna, intrahepatic cccdna, as well as the proportion of intrahepatic cccdna in total hbv dna decreased progressively in chb,lc and hcc ,moreover chb had significantly higher levels of total hbv dna in serum and liver biopsy samples than lc (log [total serum hbv dna] p = . ;log [total intrahepatic hbv dna] p = . ); chb and lc had significantly higher levels of intrahepatic cccdna and the proportion of intrahepatic cccdna in total hbv dna than hcc(p < . ); cccdna couldn't be detect in all patients'serum. in chb ,the levels of serum's total hbv dna,intrahepatic total hbv dna and cccdna in hbeag-positive group had significantly higher than the hbeag-negative group(p < . ) ,but in lc only intrahepatic total hbv dna had statistical difference between hbeag-positive and negative group (p= . ) , no statistical difference between hbeag-positive and negative group in hcc. conclusions: the replication activity of hepatitis b virus in chb,lc were higher than hcc, hbv reproduction reduced significantly in hcc. duplication of hbv in lc was lower than chb but had no statistical difference. the levels of hbv reproduce in hbeag-positive group was higher than hbeag-negative group of all three desease. background: clevudine is a pyrimidine analogue with potent and sustained antiviral activity against hbv in the week therapy. the present study assessed the efficacy and viral resistance of week clevudine therapy in patients with chronic hepatitis b. method: a total of patients ( hbeag positive and hbeag negative) who were received clevudine mg once daily for weeks were included in this analysis. serum hbv dna was quantified by real time pcr assay. result: at week , median reductions of serum hbv dna from baseline were . log iu/ml ( . log iu/ml for hbeag positive and . log iu/ml for hbeag negative) and . % of patients showed undetectable serum hbv dna (< iu/ml) ( . % for hbeag positive and . % for hbeag negative). the normalization of alt levels (< iu/l) was achieved in . % ( . % for hbeag positive and . % for hbeag negative). . % of hbeag positive patients showed hbeag loss or seroconversion. hbv dna negativity at week was associated with hbeag negativity (p = . ), hbv dna < , iu/ml at weeks and (p = . and . , respectively). two hbeag positive patients showed viral breakthrough with m i mutation during week. conclusion: clevudine therapy in patients with chronic hepatitis b showed potent virologic responses at week , especially in those with hbeag negativity and complete early virologic response (hbv dna < , iu/ml at weeks and ). but clevudine resistance can occur in hbeag positive patients. background: serum alanine aminotransferase (alt) activity, the variable most commonly measured to assess hepatic disease, fails to identify many patients with hepatic injury. current standards for "normal" alt level were defined by using populations that included persons with subclinical liver disease. there is no study regarding normal level of alt and its modulating factors in healthy thai people. objective: to definitions of normal ranges for serum alt level in thai people. design: prospective observational study setting: phramongkutklao hospital and army institute of pathology pramongkutklao medical center(a.i.p.), bangkok, thailand participants: persons who were first-time blood donors from august through december were negative for anti-hepatitis c virus(hcv), negative hbsag(hbv), and had no contraindications to donation. measurements: univariate and multivariate analyses examined associations between clinical and laboratory factors and alt levels. normal ranges for alt were computed from the population at lowest risk for liver disease. results: serum alt activity was independently related to body mass index, age, alcoholic consumption and to laboratory indicators of abnormal lipid or carbohydrate metabolism. normal ranges for serum alt level in thai people upper limits for men u/l and for women . u/l. conclusion: in men serum alt is strongly associated with body mass index, age, alcoholic consumption and to laboratory indicators of abnormal lipid or carbohydrate metabolism. the normal range of alt should be defined for male and female separately. background: the open-label rollover study etv- was conducted after etv phase ii clinical study etv- for nucleoside-na ve adult chb patients in japan. in this analysis, we report etv long-term efficacy and safety in patients who were switched from -week lvd treatment to etv therapy. methods: ninety-seven percent ( / ) of lvd-treated patients from etv- were rolled over into etv- treated with . mg of etv. thirty patients completed weeks of etv therapy and were evaluated for hbv dna level, alt normalization, hbeag seroconversion, resistance and safety. results: comparing to baseline before switching to etv, after week of etv treatment, the proportion of patients achieving undetectable hbv dna (< copies/ml) increased from % to %. increases were also observed for alt normalization ( % to %) and hbeag seroconversion ( % to %). three patients had detectable hbv dna at week after etv treatment and samples from two were tested for resistance. neither demonstrated substitutions associated with etv or lvd resistance. five patients had grade - laboratory abnormalities, including increased ast/alt and increased lipase levels. conclusions: switching patients from lvd therapy to etv resulted in increased proportions of patients achieving hbv dna suppression, alt normalization and hbeag seroconversion, with no evidence of etv resistance. etv was well tolerated during treatment. backgrounds/aims: hepatitis b virus (hbv) reactivation in patients undergoing chemotherapy hampers an adequate administration of cytotoxic agents and even causes an treatment failure. prophylaxis failure occasionally results from viral breakthrough or withdrawal flare. the aims of this study were to identify predictors of anti-viral prophylaxis failure and to determine the optimal strategy for anti-viral prophylaxis. methods: cancer patients with positive hbsag who underwent cytotoxic chemotherapy in a tertiary medical center from january to june were included. prophylactic lamivudine was started with initiation of chemotherapy, continued during the chemotherapy, and discontinued within months after the completion of chemotherapy. all patients were followed up even after withdrawal of lamivudine. results: patients were enrolled. twenty-nine patients ( . %) had hematologic malignancies and eighty-six ( . %) had solid tumors. median follow-up duration was . months and twenty-six patients ( . %) experienced the prophylaxis failure: viral breakthrough ( patients, . %), withdrawal flare ( patients, . %). ymdd mutation developed in four patients. withdrawal flare occurred at a median . months after discontinuation of lamivudine. using log-rank test and cox multi-variate analysis, our results showed that the type of underlying malignancies (hr . , % ci, . - . ; p= . ) and baseline hbv dna titer (hr . , % ci, . - . ; p= . ) were significant independent risk factors for antiviral prophylaxis failure. conclusion: cancer patients with high viral load of hbv and hematologic malignancies may need more prolonged and potent anti-viral prophylaxis to avoid interruption or delay of chemotherapy. back ground: the usefulness of hepatitis b virus (hbv) dna and hbv core-related antigen (hbcrag) was evaluated for timing hepatitis flare after viral breakthrough or withdrawal of antiviral treatment in chronic hepatitis b. method: a total of events of hbv reactivation due to withdrawal of lamivudine (lam) or emergence of mutants resistant to lam or adefovir dipivoxil (adv) virus were analyzed in patients with chronic hepatitis b ( men, median age years [range: - ]). they were followed monthly for serum alt, hbv dna and hbcrag before, during and after the treatment. result: high alt flare (alt > iu/ml) after viral breakthrough or withdrawal was related with baseline hbeag positivity (p= . ), hbcrag level at hbv dna elevation (p= . ) and duration from hbcrag elevation to salvage therapy (p= . ). in multivariate analysis, hbcrag > . log u/ml (or . , %c.i. . - . , p= . ) and salvage therapy after weeks from hbcrag elevation (or . , %c.i. . - . , p= . ) were selected as related factor with high alt flare. after appearance of resistant-virus or withdrawal of lam or adv therapy, hbv dna re-elevated without increase of hbcrag, then hbcrag elevated with hbv dna. re-elevations of alt occurred in of the ( %) events. in of the ( %) events, alt re-elevated within weeks from the start of hbcrag increase. conclusion: hbcrag was useful for timing the re-elevation of alt after hbv dna re-elevation induced by drug-resistant virus or withdrawal of lam or adv therapy. background and objectives: the aim of the study was to observe the efficacy of a patient's therapy for switching lamivudine + placebo to adefovir dipivoxil (adv), and modeling the viral dynamics. methods: the studied object was a chinese chb patient with lamivudine mutation. used the lvd + placebo for weeks' therapy. then switched adv for another weeks. after that stopping the treatment and following up for weeks. based on our modified basic virus infection model, we introduce a personalized model consisting of four variables: x, y, v, e , representing uninfected cells, infected cells, free virus, and ctl cells, respectively. results: selected the model parameters, the simulation data of hbv dnas of our model are good in agreement with the clinical ones. observe that after weeks' treatment cessation, the benefit (hbv dna < copies/ml) for suppressing hbv replication can still be kept. numerical simulation show that if the patient's immune functions can be kept after therapy stops, it needs years to replace all infected cells by normal ones. conclusion: for lvd mutation patients, lvd+ placebo to avd therapy scheme may help patients to suppressing hbv replication. further researches are promising. acknowledgments: this work is jointly supported by the nnsf of china background: g-a- pre-core mutants (p-c-mt) cause hbeag-negative chronic hepatitis (chb) in genotype d infected mediterranean adults. we studied their emergence during chronic hbv infection in children. methods: eighty consecutive hbsag carriers ( / males/females, age y, range . - y) with vertical ( %) or intra-familial ( %) transmissions were followed-up for . y (range - y). hbv genotype and hbeag status were determined at the admission, hbeag/anti-hbe every years thereafter. during the follow-up, hbv-dna was measured in sera ( - sera/patient) (cobas-amplicor, roche); p-c populations were characterized by direct sequencing (ds), by oligo-hybridization (oha) and allele-specific-pcr (as-pcr) with %, % and . % sensitivities, respectively. results: seven children were genotype a and d; ( . %) were hbeag-positive. fifty-five ( . %) underwent hbeag/anti-hbe seroconversion (median age y, range . - y). baseline hbv-dna (cp/ml) was lower in seroconverters ( . + . vs , + , , anova p= . ). ds/oha p-c-mt were . % at the admission and . % after follow-up; as-pcr p-c-mt . % and % respectively. after seroconversion ( . %) became inactive carriers, ( . %) lost hbsag ( genotype d/p-c-wt); p-c-mt had chb. hbv-dna (cp/ml) was lower in p-c-wt than in p-c-mt inactive carriers ( . + . vs . + . ; anova p= . ). conclusions: in genotype-d infected children p-c-mt is selected progressively after hbeag/anti-hbe seroconversion to become predominant in hbeag-negative chb. early and efficacious immune control of hbv replication avoids p-c-mt selection and leads to hbsag loss. , a, , d, k, u, m, n , k ,k and k . here k , k , and k are the rate of ctl production and dead, killing virus, respectively. results: the patients with hbv dna levels less than copies/ml were reported in . % ( / ). a patient whose hbv dna levels were higher than copies/ml can keep treatment benefits even stopping the therapy for over ten weeks. the simulation data of our model are in agreement with the patient's hbv dna data. our simulation also shows that it needs to spend about years for clearing all infected cells. conclusion: the simulation result implies that some chinese patients may need long term's therapy to clear all infected cells. patients' ctls assays are needed to confirm the effectiveness of the personalized modeling, and help doctors to decide whether stop the drug treatment even patients' hbv dnas are higher than undetectable levels. background/aim: recent reports have shown that programmed death (pd- ) expression is associated with t cell exhaustion and persistent viral infection. we studied longitudinally chronic hepatitis b(chb) patients undergoing treatment with nucleos(t)ide analogues or pegylated interferon-(peg-ifn-) in - weeks to determine the relationship between pd- expression levels on t cells and early reduction of viral load induced by treatment. methods: our investigations were focused on three points: baseline (time point , t ), treatment weeks - (time point , t ) and treatment weeks - (time point , t ). pd- expression on total cd and cd t cells in chb patients during antiviral therapy was detected by flow cytometry. serum hepatitis b virus (hbv)-dna load was measured by real time polymerase chain reaction. results: between t and t , pd- expression on total cd (p< . ) and cd t cells (p< . ) dropped concurrently with treatment-induced hbv-dna decline(p< . ). between t and t , however, only the hbv-dna levels reduced significantly (p< . ). conclusion: early suppression of hbv replication induced by antiviral treatment results in a significant decrease in pd- expression on total cd and cd t cells in chb patients. c. zhao , , w. zhang , , x.c. tian , c.y. fang , , h.j. lu , , p.y. yang , , y.m. wen , background/aims: hepatitis b virus (hbv) is still regarded as one of the major causes of chronic hepatitis, cirrhosis and hepatocellular carcinoma worldwide. the interactions between hepatitis b surface antigen (hbsag) and host cells still remain largely unknown and need to be explored in detail. methods: differential protein expression profiles of hepg -s-g ( stably expressing hbsag cell line) and hepg -neo-f ( control cell line) were compared using two dimensional gel based differential proteomic approach. cell proliferation assay and survival assay were used for further studies on the candidate protein. results: compared with the control down regulation of proteins and up regulation of proteins were found in hepg -s-g cell. all these regulated proteins were identified by ms/ms and could be fell into several categories including metabolism-associated, immune-response-related, protein modification, signal transduction and others. among them, a group of proteins in putative pathways associated with apoptosis were found out and discussed, including glucose-regulated protein kd (grp /bip), heterogeneous nuclear ribonucleoprotein (hnrnp), far upstream element-binding protein (fusebp), rho gdp dissociation inhibitor (gdi), cystatin b and some scaffold proteins. grp , an important chaperone protein involved in multiple functions in host cells, was consistently decreased in hepg -s-g and in huh cell transiently transfected with hbsag expression plasmid. decreased crp inducing by hbsag or blockage of rnai consistently led to the less resistance to staurosporine-induced cell death. conclusions: these results revealed a possible pathogenesis induced by hbsag via grp . background/aim: to evaluate the efficacy of adefovir dipivoxil alone and in combination with lamivudine in treating patients with lamivudine-refractory hbeag-positive chronic hepatitis b. methods: eighty-five hbeag-positive patients who had received lamivudine treatment for various periods and had a lamivudine-resistant liver function abnormality, documented ymdd mutations and persistent viremia were randomized to adefovir dipivoxil mg, lamivudine mg, or addition of adefovir dipivoxil to ongoing lamivudine daily. the primary efficacy measure was virological response. the secondary efficacy measure was serological response (hbeag loss rate and hbeag seroconversion rate) and alt normalization rate. results: after weeks of therapy, mean reduction of hbv-dna level, the percentage of patients with hbv-dna lower than log copies/ml and the percentage of patients with hbv-dna level decrease of more than log copies/ml in patients of adefovir dipivoxil/lamivudine and adefovir dipivoxil monotherapy groups were significantly higher than those in patients of lamivudine group ( . , . log copies/ml vs. . log copies/ml, . %, . % vs. . %, . %, . % vs. . %; p < . , respectively). at the end of weeks, mean reduction from baseline in serum hbv-dna level at was . , . , and . log copies/ml in the lamivudine, adefovir dipivoxil/lamivudine, and adefovir dipivoxil groups, respectively. alt normalization rates were significant hihger in adefovir dipivoxil/lamivudine and adefovir dipivoxil recipients than those in lamivudine recipients ( %, % vs. %, p < . , respectively). a similar pattern was observed in hbeag loss among three groups. conclusions: adefovir dipivoxil is an effective treatment option for patients with lamivudine-refractory hbeag-positive chronic hepatitis b. aim: to find the prevalence of hbv virologic flare as defined by hbv dna viral load of > , iu/ml in inactive chronic hepatitis b (hbv dna less than , iu/ml), hbeag-negative patients who have not received any treatment and to identify if there are any predictors that can predict virologic flare. methods: we retrospectively analyzed medical records of the patients who have attended hepatitis clinic, siriraj hospital from january , to february , . the patients were eligible if they were naïve to any treatment and hbv dna less than iu/ml at entry. co-infection with hiv and/or hepatitis c virus were excluded. hbv dna measurement determine by roche amplicor ® (detection limit of iu/ml). hbv virologic flare was defined as hbv dna more than iu/ml during follow up period. result: there were patients with mean follow up time was days with annual prevalence of hbv virologic flare of . , . , and . % for the first, second and third year of follow up, respectively. initial hbv dna level was the only predictor that can predict reactivation. no patients with hbv dna at entry below detection limit developed flare and the patients with hbv dna above iu/ml had times higher chance to develop flare during follow up. conclusion: hbv dna flare is not uncommon in inactive chronic hepatitis b patients. most of the virologic flares occur in the first year. the most important predictor or virologic flare is higher hbv dna at beginning. background: multi-drug resistant hbv developed with multiple antiviral agents. there existed difficulty in dealing with multi-drug resistant hbv. methods: retrospective analysis of consecutive patients who exhibited chronic hepatitis b associated with multiple drug-resistant mutations to lamivudine and adefovir during antiviral treatment. multiple drug-resistant mutations were detected in those patients by dna direct sequencing. result: before multiple drug-resistant hbv emerged, patients accept sequential antiviral therapy, patients accept na monotherapies. there were cases of rta t/v rtm v/i mutation, cases of m v/i +n t mutation, cases of a t/v+m v/i +n t mutation, case of l m+a t/v mutation. cases received rescue therapy of interfronand hbv dna level of cases decreased; other cases received combination treatment and hbv dna level of cases decreased. conclusion: the main reason of multiple drug-resistant mutations was sequential antiviral therapy. another reason may be pre-exist drug-resistant mutation before nucleoside or nucleotide analogue treatment. de novo combination of antiviral agents should be recommended. combination therapy directed against mutants resistant to each treatment may not be adequate in suppressing multi-drug resistant hbv. interfron may be one choice for hbv of multiple drug-resistant mutations. background: to furnish basis for an accurate evaluation of hbeag negative chronic hepatitis b (e chb), the present study studies the clinical features and hepatic pathology, and analyzes the relation between the data and the grade and stage of hepatic pathology in e chb. methods: a study is performed in chinese e chb patients ( men and women; mean age sd, . . years). the relationship between the clinical features and the grade and stage of hepatic pathology was analyzed by spearman's rank correlation test or kruskal-wallis test by applying stata . software. result: negative correlation is shown between the grade and leucocyte count methods: patients with hbeag-positive compensated chb with hbv dna > log copies/ml, serum alt x uln were divided two groups:one treated with telbivudine and the other treated with entecavir. results: baseline characteristics were well balanced between treatment groups. at wk of the treatment the hbv dna undetectable rates of hbeag-poitive patients in the telbivudine group and the entecavir were respectively . (p . ), the rates of hbeag negative were respectively, the rates of hbeag seroconversion were respectively; at wk of the treatment the hbv dna undetectable rates of hbeag-poitive patients in the telbivudine group and the entecavir were respectively (p . ), the total rates of hbeag negative were respectively, the total rates of hbeag seroconversion were . . respectively(p . ).no adverse reactions were found in both groups conclusion: there was no significant difference in hbv dna undetectable rates between two nucleotide analogs in short-term ( weeks).the telbivudine group has better effect in hbeag seroconversion rate than the entecavir group in early stage,but no statistical significance. j.w. song , , z. xin , j.x. tang , l. yao , b. wu sun yat-sen university, zhuhai sinochips biosci. co.,ltd., china background: to develop a equipment free, and can be widely used in clinical practice biosensor-based microarray for hepatitis b virus pre-c/bcp mutation assay. methods: a thin film optical biosensor were applied for amplification the microarray signal in situ. and hbv sites , , , and were selected as the targets and the microarray were be fabricated. the mutated plasmids contained , , , and sites and hbv sera were be tested in our study and all the plasmids and sera pcr products were be assayed by really time pcr and sequencing. results: the biosensor based microarray signal can be easily record by digital camera or even by the naked eyes and the detection signal for positive discriminated from negative were sharply contrasted as whole yes or no and it looks be significantly superior to classical microarray technique; . the sensitivity of the detection limitation of sera hbv load is x e copies/ml with % reproducibility. the concordance index of times negative and mutated plasmids were %(kappa= . ). . sera samples of hbv> e load and sera of hbv negative tested by pcr fragment sequencing were showing very good agreement between sequencing with our biosensor based microarray and the concordance index kappa was . . conclusion: our biosensor-based microarray for pre-c/bcp mutation assay were a both sensitive and accurate method. and its advantages of equipment free, sharply contracted signal of positive vs negative and easily be perform in testing were make it be a promised assay for clinical application. objective: to investigate the frequencies of cd + cd + regulatory t cells in the cord blood of fetuses whose mothers are patients with chronic hepatitis b, we assayed the differences among hbsag-positive and healthy subjects by flow cytometry. the results might offer some experimental evidence to explain the high rates of hbv persistent infection in vertical transmission of hbv from hbv-infected mothers. methods: newborns born from hbsag positive mothers were recruited , healthy subjects being used as a control group. the cord blood and peripheral blood of mothers were collected respectively .frequencies of cd + cd + regulatory t cells in the cord blood of fetuses whose mothers are patients with chronic hepatitis b were analyzed by flow cytometric analysis. result: the number of cd + cd + regulatory t cells/pbmcs in the cord blood of newborns born from hbsag positive mothers . ± . significantly exceeded that in normal controls . ± . ,p . ;and newborns born from hbsag positive mothers presented a much higher fraction of cord blood cd + cd + /cd + . ± . than those in normal controls . ± . ,p p= . p . . conclusions: the results indicate that the proportion of cd + cd + regulatory t cells in hbsag positive mother cord blood was higher than those of healthy cord blood. objective: to study the clinical features of chronic severe hepatitis b with negative hepatitis b e-antigen (hbeag) and positive hepatitis b e-antigen (hbeag) methods: a total of in-patients with chronic severe hepatitis b were recruited into the study and divided into two groups according to the hbeag status. the serological chemistry data, hepatitis b virus (hbv) dna quantification data were detected, and morbility of cirrhosis, its complications and prognosis were also studied. results: of the in-patients, ( . %) patients were hbeag-negative. ( . %) patients were hbeag-positive. the ratio of hbeag-positive patients was significantly higher than that of hbeag-positive patients (p< . ).the average age of hbeag-negative patients was older than that of hbeag-positive patients (p= . ). the serum hbv dna level of hbeag-negative patients was significantly lower than that of hbeag-positive patients ( . ± . ) vs( . ± . ) log copies/ml (p< . ).the ratio of patients who had a serum hbv dna level less than log copies/ml in hbeag-negative patients was significantly higher than that in hbeag-positive patients ( . % vs . % ,p= . ). there was no significant difference in serological chemistry data, morbility of cirrhosis and its complications on infections, ascites, hepatoencephalopathy, gastrointestinal hemorrhage, as well as prognosis of the patients between those two groups. conclusions: the study suggested that serological chemistry data, morbility of complications and prognosis of the disease of hbeag-negative patients mimics that of hbeag-positive patients. the hbeag-negative patients had a higher level of age, while a lower level of serum hbv dna. to reduce the incidence of liver failure, more frequent monitoring and earlier antiviral therapy prone to be reasonable for chronic hepatitis b patients with negative hepatitis b e-antigen. background: the emergence of lam-resistant virus greatly limits the efficacy of therapy and induces the liver injury. the aims of this study were to assess the related factors of lam-resistant mutation in hbeag positive chb patients. methods: thirty-five patients carrying lam-resistant with hbeag positive were enrolled in this study. all of them underwent percutaneous liver biopsy, histological findings and had detectable viral load. age, viral load, levels of alt, types of mutation and hbv genotype was monitored. result: the median year of mutation found was months. . % were genotype c and . % were genotype b. the mutation of l i, l v, g l, l m, m v and m i were detected. the emergence rates were . %( / ), . %( / ), . %( / ), %( / ), . %( / ), . %( / ) respectively. the rate of patients with two or three mutation were much more than one or four mutation. . % patients were found to have significant histological findings, even had established cirrhosis. two had no histological finding. one had rtl i and rtm i. the other had rtl v, rtl m and rtm v. the number of resistant mutation has no significant finding with histological finding, basic alt level and basic viral load. conclusions: the emergence rate of l m, m v and m i were higher than that of l i, l v, g l in hbeag positive chb patients with lam-resistance. most of them have two or three lam-resistant mutation regardless of histological finding severity, level of basic alt and viral load. we must select the efficacious method to treat the patients with lam-resistant. objective: to investigate the therapeutic efficacy of foscarnet sodium in the treatment of patients with severe chronic hepatitis b. methods: forty four patients were randomly divided into foscarnet sodium treatment and placebo groups.each group consisted of patients, patients in foscarnet sodium group were treated with foscarnet sodium twice daily . g given by intravenous infusions ,in addition to general therapy for days.the other cases were treated without any form of antiviral therapy as control.all patients were followed up for months.the hbv markers, quantification of hbv-dna, serological chemistry data were measured at baseline , during therapy period and the end of follow-up period . results: clinical symptoms were improved in two groups patients, meanwhile alanine aminotransferase (alt) and total serum bilirubin (tbil) decreased. compare alt and tbil at the end of trentment, there were no significant differences between the two groups (p> . ). in foscarnet sodium treatment group, the level of serum hbv-dna descreased from ( . ± . ) log copies/ml to( . ± . ) log copies/ml (p< . ), the rate of hbv-dna descrease of more than two log was . % / . in the control group, the level of serum hbv-dna descreased from( . ± . ) log copies/ml to ( . ± . )log copies/ml, the rate of hbv-dna descrease of more than two log was . % / .a comparison of serum hbv-dna showed significant differences between the two groups(p< . ) conclusion: foscarnet sodium administered can inhibit hbv replication in treating severe chronic hepatitis b.it can rapid lower the level of serum hbv-dna obviously.but the relapse rate was . % in foscarnet sodium treated at the end of follow up period objective: evaluation of efficacy and safety of five years trail of entecavir for chronic hepatitis bpatients failed with lamivudine therapy in the chongqing area. methods: thirty-two eligible patients were enrolled who had documented lvd failure.in the double-blind phase,patients were randomized( : )to etv . mg/d (n= )and placebo (n= ) for weeks.in the open-lable phase ,patients received etv . mg/d for weeks.hbv-dna level,liver function tests,hbv serology and safety assessments were conducted. results: the mean reduction in hbv dna levels at week was logl copies ml in etv group compared to . logl copies ml in placebo group(p< ). the mean of hbv dna levels after weeks of etv treatment decreased to . logl copies m the proportion of hbv dna< log copy/ml raised from at baseline to . % at week ,to . % at week ,to % at week ,and raised to . % at week .there were two patients with hbsag seroconversion and four patients with hbeag seroconversion at the end of study. the mean of alt became normal at week and remained normal throughout week .there was one patient who had a severe adverse event during the trail. conclusion: the findings from this study demonstrated the antiviral activity and safety of etv in adults with chb who have failed lvd pe showing delayed response on t cells as increased on day .the mrna expression of il- and il- showed no response to hbv vaccine but highly regulated in tt after day (p= . , . ).myd andtraf (p= . )upregulated in hbv vaccine group followed by of ifn-( . )no change of ifn found in tt conclusions: i) hbv vaccine stimulates innate response by day which potentiates further cascade,peripheral dendritic cells plays significant role in generating immune flare follows myd pathway and releases ifn-.ii) whereas t cells marjory involved in tt showed delayed immune response.iii) identification of key factors at different time points may prove to be a novel model to study the initial events after vaccination. objective: to compare th /th cytokines' dynamic change and its clinical significance in hepatitis b e antigen-positive patients treated with telbivudine. methods: twelve hepatitis b e antigen-positive patients treated with telbivudine.the blood sample was collected at baseline, week , week , week , week and week and stored at - c; serum il- , il- , il- , il- , tnf-and ifn-were tested at each time point by cytometric bead array (cba), compare th /th cytokines' dynamic change at different time point in each group and compare th /th cytokines' dynamic change cross four different groups: complete response, partial response, non-response and break through . results:the level of th type cytokines in complete response group are obviously higher than the group of partial response non-response and breakthrough,but the level of th type cytokines are lower than the group of partial response, non-response and breakthrough. conclusions: th /th cytokines is essential for the regulation of the immune function of the body. after treated with telbivudine, the level of th -type cytokines in the complete response group increased significantly, while the level of th cytokines declined trend. a. soamni , s. somani , a. jain , v. dixit navjeevan hospital, suvidha, background: chronic infection with hepatitis b virus causes spectrum of manifestations ranging from asymptomatic carrier state (often inactive with low replication) to the development of cirrhosis-related complications.the characterization of asymptomatic state has not been done in this part of the country, which forms important objective of present study. methods: incidentally detected asymptomatic hepatitis b surface antigen positive (idahs) subjects having hbsag positivity for > month presenting to our liver clinic were enrolled after appropriate consent. detailed clinical, laboratory and sonographic evaluation was done. they were divided into two groups according to presence or absence of e antigen. group a -hbeag + (n= ) group b -hbeag -(n= ) results: most of our patients ( %) were young adults ( - years) with male to female ratio of . : . approximately half of our patients were detected during routine medical checkup, followed by family screening of contacts. most of our patients were asymptomatic, and fatigue was most common symptom found in %. all demographic and biochemical parameters other than ast & alt were comparable in both groups. among hbeag negative ( %) subjects, hbv dna level > copies/ml was found in %. subjects with positive hbeag as compared to non-replicative infection (antihbe positive and hbv dna negative) had more frequent elevation of transaminase levels ( % versus %, p< . ). antihbe antibody was positive in all hbeag negative subjects. mean age of seroconverted (antihbe positive) individuals was a decade older than hbeag positive. conclusion: from our study we can suggest that ongoing liver disease is present in approximately one-thirds of incidentally detected asymptomatic hepatitis surface antigen positive subjects previously referred to as carrier state. hbsag testing should be mandatory in all routine medical checkup and family and sexual contacts of index case should be screened. background and objectives: this research was carried out to determine the prevalence of hbcab among the hbsag negative first-time blood donors who had referred to khorramabad and borujerd centers for blood donation. materials and methods: this study was established on a descriptive cross-sectional basis in which hbsag test (elisa) was primarily performed on all of the donors having referred to khorramabad and borujerd blood centers; then, out of all those referred subjects, who were first-time and hbsag negative, were selected for furthur investigation. the information concerning age, gender, job, blood transfusion, and hbv vaccine injection was included in the questionnaire of the study. hbcab (total & igm) and hbsab tests were performed on the selected donors. data were collected and finally the prevalence rate of hbcab was determined. results: the results of the study showed that out of hbsag-negative first-time blood donors, only were hbcab+, from which were hbcab (total)+, and were hbcab (igm)+. were both hbsab+ and hbcab+, and were seropositive only for hbsab. conclusions: it was demonstrated that the first-time blood donors who are seronegative for hbsag marker will be easily identified through hbcab test if they are in the so-called core window period of the virus. meanwhile, this group of donors have been implicated as high-risk for transfusiontransmitted hbv infection. so, detecting this marker will remarkably reduce the chance of latent cases of hbv infection and help promote blood safety. background: tumor necrosis factor-(tnf-) plays a pivotal role in the viral clearance and host immune response to hbv, and the capacity for tnf-production in individuals is influenced by a major genetic component. the studies of tnf-- gene promoter polymorphism in chronic hbv infection have reported apparently conflicting results. objective: to derive a more precise estimation of the relationship between the polymorphism of tnf-- gene promoter and chronic hbv infection. method: meta-analysis was done of case-control studies in relation to tnf-- gene promoter, involving a total of chronic hbv infection cases and controls. the pooled odds ratios (ors) for the risk associated with the genotypes of ga, aa, and ga+aa (a-allele carriers) compared with the gg genotype were calculated. results: overall meta-analysis indicated that - a heterozygotes (ga) had % decreased risk of developing chb with a borderline significance (or = . ; % ci: . - . ; p = . ). for the - a allele homozygotes (aa) and carriers (ga+aa), the pooled ors both indicated a significantly decreased risk of chb (or = . ; % ci: . - . ; p = . ; and or = . ; % ci: . - . ; p = . , respectively) ( table ). in the subgroup analyses by ethnicity, significantly decreased risks were associated with - variant genotypes (ga and aa) in mongoloid populations in all genetic models. however, no significant associations were found in caucasoid. conclusion: the meta-analysis suggests that the tnf-- a allele is a low-penetrant protective factor for chronic hbv infection, especially in mongoloid. method: hbv transgenic mice were randomly divided into physiologic saline group and matrine injection group. another normal mice at the same species and age with hbv transgenic mice were regarded as the normal group. the mice in matrine injection group were administrated at dosage of . mgkg - d - by intraperitoneal for days. the mice in physiologic saline control group and normal group were administrated normal saline with the same volume at same time. the contents of hbv dna in serum and liver were quantitated by pcr. and the spleens were separated for cultivating dendritic cells. the surface molecules of dendritic cells were tested by flow cytometry. ifn-mrna and tnf-mrna in liver were tested by rt-pcr. result: there was no significant difference of the serum hbv-dna level between physiologic saline and matrine injection groups. the content of serum hbv-dna after treatment showed a significant decrease in two groups. the content of serum hbv-dna in matrine injection dropped significantly as compared with that in the physiologic saline group. but there was no significant difference in the content of hbv-dna in liver between physiologic saline and matrine injection groups. the expression level of mhc-ii on dendritic and hepatic ifn-r mrna and tnf-a mrna showed a significant decrease in hbv transgenic mice than normal mice. in comparison with physiologic saline group the expression level of them in matrine injection group showed a significant increase. conclusion: matrine injection was effective on depressing hbv-dna in hbv transgenic mice. its antiviral action may be achieved through regulating mhc-ii on dcs surface and promoting the production of antiviral factor such as ifn-and tnf-. purpose: to stimulate non-specific immune response capacity as the main content of the study to explore the hbv-dna and non-specific immune responses in the relationship between the low response capability, methods: cases of asymptomatic carriers, double-blind, randomized into mycobacterium fu , lamivudine and traditional chinese medicine for the treatment group, mycobacterium fu with traditional chinese and lamivudine with traditional chinese medicine were in the control group, a total of weeks of treatment, follow-up six months after the termination of treatment. results: different treatment of hbv -dna effect of the existence of significant differences; p> . , the performance of different types of asymptomatic carriers negative rate of hbv-dna there is a significant difference; p> . , as well as the performance of the different types of asymptomatic carriers continued application a treatment plan presented hbv-dna rebound rate there is a significant difference; p> . , conclusion: hbv-dna and non-specific immune responses in response to the lower capacity, anti-hbv therapy is not associated with non-specific immune response capacity or improve is the anti-hbv drugs alone can not solve the asymptomatic carriers in anti-hbv therapy where the cause of the problem, solve the asymptomatic carriers in the anti-hbv treatment although the need for anti-hbv drugs with non-specific immune activation synchronous drugs on the basis of the joint application , but the simultaneous combination of two drugs rather than as a result of hbeag and hbv-dna can hbeag-positive asymptomatic carriers receive hbv-dna negative effect of the results. background: adefovir dipivoxil (adefovir) effectively inhibits both wild-type and lamivudine (lam)-resistant hepatitis b virus (hbv) replication and resistance to this drug is infrequent compared with lam. in this study, we tried to identify factors affecting the emergence of resistant mutants after adefovir monotherapy in lam-resistant chronic hepatitis b (chb) patients. methods: the subjects were chb patients with lam-resistance who had received adefovir for more than months (range - months). the initial viral response (ivr) was defined as hbv dna < . log copies/ml. the adefovir resistant mutant was assayed at baseline and every months during adefovir administration. results: ivr was observed in % of patients. the cumulative emergence rates of adefovir resistance were . % at months, . % at year, . % at years and % at years. in univariate analysis, factors contributing to the emergence of adefovir resistant virus were baseline hbv dna > log copies/ml (p= . ) and ivr (p< . ). the presence of precore mutation and type of ymdd mutants were not related. in multivariate analysis, only ivr was an independent factors affecting the emergence of adefovir resistant virus (p< . ). conclusion: ivr is a useful predictor for emergence of adefovir resistant mutants after adefovir monotherapy in lam-resistant chb patients. for ivr-negative patients, the change of therapeutic options such as add-on lam or switch to other drugs should be considered because of the high incidence of the emergence of adefovir resistant mutants. background: elevated hbv dna is strongly associated with the risk of disease progression. this study investigated the early viral suppression effects of etv and lvd in nucleoside-naïve chinese patients with active hbeag (+) chb. methods: this open-label study was conducted in major hospitals in china. at study entry all patients had hbv dna levels copies/ml, elevated alt ( . - xuln) and compensated liver function. patients received either . mg etv or mg lvd daily. hbv dna measurements were taken at baseline and at weeks , , and during treatment, using roche cobas amplicor assay (llod copies/ml). results: a total of patients were enrolled; / etv patients and / lvd patients completed weeks of treatment. at baseline, mean hbv dna levels were . . in etv group and . . log copies/ml in lvd group (p< . ). the mean change in hbv dna from baseline (log copies/ml) was - . ± ngo's/funding-agencies representative at apasl -conference need to address-this-issue. we ngo-representatives from developing-nations need exposure to research treatments used by european/american experts. do we all failed in addressing socio-economic issues of cancer-sufferers? we need to address these socio-economic issues of affected population in resource-poor-nations. background: a garlic derivative s-allylcysteine (sac) has anti-cancer effect in human prostate and colon cancers. we aimed to investigate the effect of sac and combination of chemo-drug on tumorigenesis and metastasis of liver cancer. methods: the orthotopic liver tumor model using a metastatic liver cancer cell line mhcc l labeled with luciferase gene was applied. sac was given at day after tumor implantation at mg/g/day, or mg/g/day combined with low dose cisplatin for weeks. tumor growth and metastasis were monitored by xenogen in vivo imaging system. hepatic stellate cell (hsc) activation and tumor-associated macrophage (tam) in the tumor tissue were detected by -sma and ed /ed staining. tumor micro-vessel density (mvd) and apoptosis were also analyzed. in vitro functional tests including proliferation assay, cell cycle analysis and apoptosis analysis were performed. results: tumor growth was inhibited by sac combined with cisplatin treatment at different time points accompanied by lower incidence of lung metastasis compared with other groups. the observation of xenogen ivis was confirmed by histopathological examination. the hsc activation by -sma staining in the liver tumors was suppressed by sac and cisplatin treatment accompanied with less tam infiltration. consistent with in vivo study, in vitro functional study also demonstrated that sac not only induced cell cycle arrest, apoptosis, and inhibited tumor cell proliferation, but also sensitized the anti-cancer effect of cisplatin. conclusion: sac treatment inhibited liver tumor growth and metastasis by inhibiting tumor cell proliferation, inducing apoptosis and sensitization of chemotherapy. background: anti-angiogenic therapy would be a promising approach against hepatocellular carcinoma (hcc). although a sorafenib has survival benefits in patients at advances stages of hcc, there seem to be several serious concerns to employ this agent for chemoprevention against hcc. branched-chain amino acid (bcaa) reportedly inhibits the incidence of hcc in patients with insulin resistance (ir). however, the possible mechanism is still obscure. the aim of the current study was to examine the effect of bcaa on hepatocarcinogenesis under the condition of ir, especially in conjunction with angiogenesis. methods: the effect of bcaa on the development of liver enzyme-altered pre-neoplastic lesions and angiogenesis in the obese diabetic otsuka long-evans tokushima fatty rats was examined. we also performed an in-vitro study to elucidate the possible mechanisms involved. result: treatment with bcaa markedly inhibited the glutathione-s-transferase placental form (gst-p)-positive pre-neoplastic lesions along with suppression of neovascularization in the liver. the hepatic expression of the vascular endothelial growth factor (vegf), a potent angiogenic factor, was also attenuated. bcaa treatment significantly suppressed the glucose-and insulin-induced in-vitro angiogenesis in the presence of vegf. these results indicate that bcaa exerted a chemopreventive effect under the condition of ir via suppression of vegf-mediated angiogenesis. conclusion: since bcaa is widely used in the clinical practice for patients with chronic liver diseases, this agent may represent a new strategy for chemoprevention against ir-based hcc in the future. background: krüppel-like factor (klf ) is a member of transcription factors. whether and how klf signaling pathways contribute to hepatocellular carcinoma (hcc) development and progression is unknown. this study investigated role of klf in hepatocellular carcinoma cell line hcclm proliferation, invasiveness and epithelial to mesenchymal transition (emt). methods: the expression of klf in different liver cell lines was detected by quantitative real-time pcr and immunocytochemistry. we used small interfering rna (sirna) to down-regulate klf expression in hcclm . the change of proliferation and invasive ability of klf down-regulated hcclm was investigated by mtt reduction assay and trans-well invasive assay respectively. the change of proliferation, invasiveness and emt related gene in klf down-regulated hcclm was evaluated by quantitative real-time pcr. result: klf protein expressed predominantly in the nuclei of cancer cells and its expression is positively correlated with metastatic potential of these cell lines. hcclm has the highest klf level. decreased klf expression can notably inhibit the proliferation (p< . , n= ), mobility and invasiveness of hcclm (p< . , n= ). we found that the mrna level of n-cadherin, fibronectin and vimentin is much higher than that of e-cadherin in hcclm . the expression of cyclin d , focal adhesion kinase (fak) and fibroblast markers including n-cadherin and fibronectin was obviously suppressed in klf down-regulated hcclm . conclusion: klf plays an important role in the process of hcclm proliferation, invasiveness and emt. background: insulin resistance (ir) has shown to play an important role in the progression of chronic liver diseases, including liver fibrosis development and hepatocellular carcinoma. the aim of this study was to elucidate the possible mechanisms of ir on the liver fibrosis development and hepatocarcinogenesis using obese diabetic otsuka long-evans tokushima fatty (oletf) rats. methods: to induce liver fibrosis, . ml/kg of pig serum was injected twice a week for weeks in the oletf and leto rats. in the hepatocarcinogenesis model, glutathione-s-transferase placental form (gst-p)-positive pre-neoplastic lesions were induced by a single injection of mg/kg of diethyl nitrosamine (den). we also performed in-vitro studies to examine the mechanistic insights. results: the liver fibrosis development and gst-p-positive pre-neoplastic lesions were both markedly accelerated in oletf. in the fibrosis experiment, -smooth muscle actin-positive activated hepatic stellate cells (hsc) also increased in oletf along with augmentation of the hepatic collagen content and transforming growth factor-b . in the den model, the neovascularization was up-regulated in oletf almost in parallel with the pre-neoplastic lesions development and a potent angiogenic factor, the vascular endothelial growth factor. our in-vitro study showed that both glucose and insulin stimulated the proliferation of the activated hsc and augmented the neovascularization. conclusion: these results indicated that the ir status directly accelerated the liver fibrosis development and hepatocarcinogenesis at least partly through the stimulation of activated hsc proliferation and hepatic neovascularization, respectively, in the rat. n. wakui , t. ikehara , r. takayama , m. takahashi , k. shiozawa , h. nagai , m. watanabe , k. ishii , k. iida , y. igarashi , y. sumino case: a years old man diagnosed with chronic hepatitis c regularly visited our hospital. in april of , ultrasonography revealed a tumor mm in diameter in s of the liver and another tumor mm in diameter in s / of the liver. the patient was hospitalized for further examination. computer tomography (ct) revealed that the tumor localized in s / presented a pattern of hypervascular hepatocellular carcinoma (hcc). for the tumor localized in s , the following were revealed. ) contrast-enhanced ultrasound findings: a tumor vessel passed from outside the tumor to the center of the tumor in the early vascular phase, then radiated in a wheel-like shape at the center of the tumor; parenchymal phase perfused imaging in the area produced a similar imaging obtained from the area surrounding the liver. ) ct: no tumor was detected. ) spio-mri (t weighted imaging): iso-low intensity images were obtained. although these imaging findings indicated fnh, the patient was hcv positive. in order to disprove the possibility of hcc, a biopsy was performed on the tumor at s in the liver. the resulting diagnosis was well-differentiated hcc. discussion: until now, a characteristic finding of fnh has been spoke-like vasculariation, which is considered diagnostically quite important. however, some recent cases of hcc have been reported to present fnh-like vascularization. from now on, when evaluating a tumor that presents spoke-like vascularization underlining chronic hepatitis, the possibility of hcc should be considered and a close examination may be needed. chronic infection with hcv is problem .clinical management of chronic hcv depend on extent liver fibrosis .liver biopsy gold stander an invasive procedure responsible for severe complications and sample variability interpretation. serum biomarkers for inflammation/fibrosis investigated to wave liver biopsy. diagnostic accuracy panel of non-invasive serum biomarkers for hepatic fibrosis (fibrosure , apri score, forn's score) versus liver biopsy. hcv patients subjected for: apri, forn's , fibrosure scores pcr quantitative hcv-rnaliver functions .lipid profile cbc . ultrasound guided liver biopsy. forns score; auroc ( . ) with % ci( . - . ) for(fof ) vs. (f f f ) while( . )with % ci( . - . )for(fof f ) vs.(f f ). cutoff(> . )sensitivity for significant fibrosis(f f f )and extensive fibrosis (f f )were ( %) and with low specificity ,with accuracy( %) and ( %)respectively.-apri score; auroc( . )with % ci( . - . )comparing(f f ) vs.(f f f )while was( . )with % ci( . - . )for( f f f )vs.(f f ).cutoff(< . ) had low sensitivity and specificity( %)with accuracy( %)for significant fibrosis and( %)for extensive fibrosis.-fibrosure(fibro-acti test); showed best auroc( . )in different fibrotic stages with % ci ( . - . ).cutoff(> . ) sensitivity( %)for significant fibrosis and( %)for extensive fibrosis while specificity( %)in all fibrotic stages. the ppv ( %)for significant and extensive fibrosis .npv and accuracy( %, %)respectively for significant fibroses,while it was ( %) for extensive fibrosis respectively.significant correlation between liver biopsy and fibro-test(p . )and acti-test(p . ).significant correlation between liver biopsy hepatitis activity score and apri (p . )and forns score (p . ). conclusion: forns score wasn't considered since does not discriminate between significant and extensive fibrosis. low sensitivity of apri prohibtes detection of minmal fibrosis and allow undetermined results. fibrosure classified all cases of chronic hcv sufficient to wave liver biopsy pe introduction: hcc is the th common cancer. global increase of hepatitis b and c infection, the incidence of hcc steadily increasing. egypt seroprevalence of hcv in nile delta - %. afp had limited sensitivity % and specificity % for small hcc. gpc- oncofetal protein over expressed in hcc. evaluating validity of glypican- as early detector of hcc.: healthy controls and hcv positive patients: patients chronic hepatitis c virus infection. patients compensated cirrhosis [child-pugh class a and b]. patients decompensated cirrhosis [child-pugh class c]. patients hcc. liver functions: alt, ast, bilirubin(t), albumin, gt.tumor markers: afp and gpc- .viral markers: hcv antibodies, hbs ag and hbc ab. the median value of gpc- in hcc, dc, cc significantly higher than chronic hepatitis and control groups. no significant correlation between afp and gpc- . auroc of afp . & auroc of gpc- . . the diagnostic sensitivity of afp ( ng/ml) % with ppv . %. the specificity % with npv . %. while the diagnostic sensitivity of gpc- ( ng/ml) % with ppv %. the specificity . % with npv %. combined serial approach of afp and gpc- improved specificity to . %. conclusion:gpc- although a serological test for early detection of hcc, showed limited specificity, where detected in different stages of chronic liver disease,it is oncofetal protein produced by regenerating liver cells. the diagnostic signature approach for simultaneous determination of afp and gpc- improve prediction accuracy of hcc patients in those showing seronegativity to afp. results: patients with hcv infection (n= ) were significantly older (mean age, years) than patients with dual virus (n= , years) and hbv infection (n= ; years) (p< . ). the male-to-female ratio for hbv, dual virus and hcv group was . , . and . , respectively (p< . ). patients in the hbv group more often had higher total tumor volume (mean, cm ) than the dual virus group ( cm ) and hcv ( cm ) group (p< . ). no significant differences of the severity of liver cirrhosis, performance status, cancer staging and tumor cell differentiation were noted among the three groups. patients in the hcv group had a significantly poor survival in comparison to the hbv group only in the subset of patients with small tumor volume (< cm ) in the cox proportional hazards model (relative risk: . , p= . ). conclusions: dual hbv and hcv virus infection does not accelerate the speed of hcc formation in patients with chronic hepatitis b, and appears to have a modified course of carcinogenesis pathway diverted away from the biological behavior of hbv and hcv infection. background: patients presenting with hcc is not infrequent in our clinical practice. the aetiology vary ranging from hbv, hcv, nash and alcohol. the aim of this study was to see the aetiology of hcc in bangladeshi patients. methods: in this retrospective study, records of patients who attended our opd between july to august were reviewed. patients having hepatic sol and/or heterogeneous echotexture of liver on usg and/or ct scan were included. diagnosis of hcc was confirmed at usg guided fine needle aspiration cytology with or without elevated serum afp (> ng/ml). results: of the patients, % ( / ) had hbv infection. hcv infection was diagnosed in % ( / ). nash was responsible for % ( / ) cases, alcohol in % ( / ), while in the rest % ( / ) cases no specific aetiology could be established. conclusion: the study shows that hbv is the commonest cause for hcc in bangladesh followed by hcv. background: the aim of this study was to determine whether the hepatitis b virus (hbv) dna viral load and antiviral therapy is associated with hepatocellular carcinoma (hcc) recurrence. methods: this retrospective study involved patients who underwent hepatic resection or radiofrequency ablation for initial hcc curative treatment. the patients were divided into four groups. fifteen patients with low serum hbv dna levels ( log copies/ml) at the time of initial hcc treatment received antiviral therapy (lamivudine, adefovir, dipivoxil, entecavir) before hcc appeared (pre antiviral therapy group; pre-tg). thirty-four had low serum hbv dna levels without antiviral therapy (low virus group; lvg). fourteen had high serum hbv dna levels and received antiviral therapy after hcc appeared (post antiviral therapy group; post-tg). thirty patients had high serum hbv dna levels without antiviral therapy (high virus group; hvg). results: the cumulative hcc recurrence rates at years in the hvg, lvg, pre-tg, and post-tg groups were . %, . %, . %, and . %, respectively. there were significant differences in the hcc recurrence rates between the hvg and lvg groups (p = . ), and between the hvg and pre-tg groups (p = . ). the recurrence rate was lower, though not significantly, in the post-tg group than in the hvg group (p = . ). conclusions: not only hbv dna viral load but also antiviral therapy is associated with hcc recurrence. antiviral therapy before hcc appears is important for patients with high serum hbv dna levels to prevent hcc recurrence. background/aims: few reports have described methods for predicting prognosis in unresectable hepatocellular carcinoma (hcc) patients, especially those treated by repeated transcatheter arterial chemoembolization (tae). to determine risk factors for death and determine prognosis in patients treated with repeated-tae, we evaluated clinical data. methodology: we retrospectively analyzed clinical parameters of unresectable hcc patients treated with repeated-tae from january to december . tae was repeated when recurrence was diagnosed by tumor marker elevation and/or dynamic computed tomography findings. factors affecting survival were evaluated using multivariate analysis after univariate analysis. next, we combined the score for each significant factor into a single prognostic score, after which the results were compared with jis and clip score methods. results: multivariate analysis revealed that bilobular hcc, alpha-fetoprotein ( ng/ml), tumor invasion of the portal vein, tumor size ( cm), and albumin (< . g/dl) were related to poor prognosis, using those factors, we developed a new prognostic scoring system. the % survival period was . months for all subjects, while it was . , . , . , . , and . months for those with scores of , , , , and or over, respectively (p< . ), using our new system. clip score was not useful to predict prognosis, while jis score was better. however, subjects with jis scores of and were difficult to differentiate. conclusion: our scoring system was easy to perform and the results showed that repeated-tae was effective for unresectable hcc with a score of or less. local ablative therapies and intrahepatic pressure c. kawamoto , a. yamauchi , k. kaneko , n. miyagi , k. kani , t. aoyama , k. yakabi saitama medical center, saitama medical university, japan background: some of the unexpected recurrence observed after radiofrequency ablation (rfa) might be caused by increased intratumoral pressure. the present study examined the relationship between local ablative therapies and intrahepatic pressure. methods: a. basic study: under general anesthesia, laparotomy was performed on pigs. a leveen needle and a percutaneous ethanol injection (pei) needle were inserted into the liver and intrahepatic pressure was monitored using an invasive blood pressure monitor. ablation was performed as follows: . rfa. ) single-step method: after fully deploying the electrode, the power was initially applied at w, then increased in increments of w/min until power roll-off. ) multi-step method: the array was deployed in steps. at each step, the power was fixed at w until power roll-off. . pei. injection of ethanol ( ml). b. clinical study: we examined the multi-step rfa and pei for hcc. under local anesthesia, intratumoral pressure was monitored. . rfa. patients with a mean tumor size of . ± . mm were studied. . pei. in patients with a mean tumor size of . ± . mm, to ml of ethanol was injected per session. results : a. basic study: the intrahepatic pressures were: single-step method, . ± . mmhg; multi-step method, . ± . mmhg; and pei, . ± . mmhg. b. clinical study: intratumoral pressure was . ± . mmhg for rfa and . ± . mmhg for pei. conclusion: these results suggest that consideration of intrahepatic pressure is crucial in local ablative therapies. background: a late evening snack (les) is recommended for liver cirrhosis. however, no clinical study has evaluated the nutrition status and the effect of les in cirrhotic patients with hepatocellular carcinoma (hcc). we investigated the effect of les undergoing hepatic arterial infusion chemotherapy (haic) in patients with hcc. method: nineteen patients with hcc were enrolled. ten patients were les group, and nine were control group. in the les group, the patients received les supplementation with a branched-chain amino acid (bcaa)-enriched nutrient mixture. in the control group, the patients received ordinary food. there were no significant differences in relation to age, gender, etiology, child-pugh scores, tumor stage, clinical responses to haic between two groups. blood biochemical data, nutrition status using an indirect calorimeter were evaluated at before and at the end of chemotherapy. results: the non-protein respiratory quotient (nprq) and molar ratio of branched-chain amino acid to tyrosine (btr) were significantly improved in the les group but not in the control group. there were no significant differences in the area under the concentration curve for glucose between before and the end of chemotherapy in two groups. background & aims: hepatocellular carcinomas (hccs) often show hypoor mixed vascularity, and the prognosis of these relatively hypovascular hccs is not fully elucidated. cytokeratin (ck) expression profiles may also be useful prognostic indicators, and specifically ck may reflect metastastic potency in hccs. this study was to assess the prognostic implication of tumor vascularity and its relation to ck expression in hcc patients. methods: a total of patients who underwent surgical resection for hcc were enrolled. tumor vascularity was evaluated according to arterial enhancement pattern on ct scans and ck expression was evaluated using tissue microarray methods. clinicopathologic data were analyzed using kaplan-meier and cox proportional hazard model. results: during follow-up period, ( . %) patients experienced tumor recurrence. forty-five patients ( %) had hypovascluar tumor at the time of diagnosis, and they showed significantly higher positivity for ck expression (p= . ) and shorter disease-free survival (p= . ) than patients with hypervascular hccs. in addition, recurred tumors in these patients showed more frequently hypovascular pattern than in patients with hypervascular hccs (p= . ). hypovascularity at initial diagnosis and microvascualr invasion were independent poor prognostic factors predicting survival. following treatment of recurred hccs, hypovascular tumors showed poor response to transarterial chemoembolization (tace), which resulted in shorter overall survival than hypervascular tumors (p= . ). conclusions: these results demonstrate that tumor hypovascularity in hccs is associated with positive ck expression, early tumor recurrence, poor tace response and poor survival. therefore, tumor vascularity may also be a prognostic indicator in hcc patients. background: hepatic stellate cells (hscs) transdifferentiate to become extracellular matrix-producing myofibroblasts during liver injury. myofibroblasts can also promote invasion and metastasis of hepatocellular carcinoma(hcc). in this study, we determine gene expression changes in two different models of hscs activation and investigate whether induction-activated hscs(ihscs) gene expression changes are different from culture-activated hscs(ahscs). methods: hscs were isolated by density centrifugation and exposed to conditioned medium from rat hcc cell lines c f. twenty-seven thousands and one hundred gene expression between quiescent hscs(qhscs), ahscs and ihscs was analyzed by microarray and confirmed by real-time rt-pcr and western blot. results: sixteen hundreds and seventy-one probe sets were differentially expressed in ahscs, including genes that encode proinflammatory factors, adhesion molecules, cell surface receptors, signaling transduction and immune factors. seven hundreds and eleven probe sets were differentially expressed in ihscs. induction-activated hscs showed specific gene expression patterns including raf , rac , adam , wnt , mmp- and tnf, suggesting that hcc cells can specifically induce hscs activation. induction-activated hscs might play a important role in invasion and metastasis of hcc. conclusions: induction-activated hscs gene expression patterns are different from ahscs. culture-activated hscs does not properly regulate gene expression in hscs, suggesting that ihscs may be considered the model for the study of hscs biology in hcc. background: hepatocellular carcinoma (hcc) is a hypervascular tumor, and angiogenesis is important for tumor growth. ephrin receptors are related with vascular system development and the polymorphism of ephb in the carcinogenesis of digestive tract has been reported. our aim was to examine the polymorphsims of ephb with the occurrence of hepatocelluar carcinoma in korean population. methods: genomic dna was extracted from patients with hepatocellular carcinoma (hcc), healthy subjects. ephb polymorphism was determined by polymerase-chain reaction-based assays, and the association with hcc was investigated. results: with regard to ephb polymorphism, a/a genotype at rs , t/t genotype at rs , a/a genotype at rs , t/t genotype at rs and g/g genotype at rs were significantly associated with hcc but these were not associated with clinical characteristics of hcc. conclusions: five out of seven polymorphisms on ephb gene were statistically associated with hcc, in the korean population. therefore, more studies of ephb gene polymorphisms including various risk factors should be performed to use as genetic markers of hcc occurrence. background: we aimed to compare the results of hepatectomy for hcc in patients older than years old with those for younger patients. methods: clinicopathological data and outcomes for elderly patients and younger patients with hcc who underwent hepatectomy between and were retrospectively compared. results: although postoperative delirium was more common in the elderly group, there were no significant differences between the groups with regard to operative morbidity, hospital death, disease-free survival, and overall survival. the overall recurrence rate was significantly higher in the elderly patients with alcohol abuse than in younger patients with alcohol abuse. multivariate analysis revealed that preoperative alcohol abuse was a prognostic factor for elderly patients. conclusions: elderly patients with preoperative alcohol abuse should be followed closely, even after r surgery, because alcohol abuse is strongly correlated with postoperative recurrence and worse survival. background: little is known about the effect of transfusing fresh frozen plasma on the outcome after hepatectomy for hepatocellular carcinoma. methods: among patients who underwent curative resection between and , patients had perioperative transfusion with whole blood or packed red blood cells and fresh frozen plasma (group a), while patients were only transfused with packed red cells (group b), patients were only transfused with fresh frozen plasma (group c), and patients had no transfusion (group d). results: group c had significantly fewer postoperative complications and a shorter hospital stay than group a. preoperative coagulation was significantly worse in group c. survival was significantly better in groups c and d than in group a. conclusions: perioperative transfusion of fresh frozen plasma improves clotting factors without an adverse influence on the survival of patients with liver dysfunction undergoing resection of hepatocellular carcinoma. background: this study investigated risk factors for postoperative liver failure after resection of hepatocellular carcinoma to detect markers that could identify candidates for hepatectomy. methods: perioperative risk factors for liver failure after hepatectomy were analyzed in patients with hepatocellular carcinoma. results: liver failure occurred postoperatively in patients, of whom died. the hyaluronate/gsa-rmax ratio was a risk factor for postoperative liver failure by univariate analysis and was the only risk factor according to multivariate analysis. all patients who died had a hyaluronic acid/gsa-rmax ratio mg min/dl. conclusions: to reduce postoperative liver failure, preoperative planning should employ various measures of the hepatic functional reserve, including tests of both parenchymal and nonparenchymal liver function. the hyaluronate/gsa-rmax ratio can predict liver failure after hepatectomy, and a ratio greater than mg min/dl is a relative contraindication to liver resection. the patient was a -year old japanese man with chronic hepatitis c(ch-c) who achieved a sustained virological response(svr) to interferon(ifn) therapy. as a result the liver functions were normalized and the histological findings of the liver also improved. however, years after svr, mild liver dysfunction was noticed along with a marked increase of tumor markers. several modalities revealed huge liver tumors about cm in greatest diameter in the left lobe invading the bile ducts and another tumor about cm diameter in segment v. we performed liver biopsy and confirmed that this tumor was well-differentiated hepatocellular carcinoma (hcc). only mild fibrosis development could be observed in the adjacent non-cancerous lesions. we successfully treated these tumors with transcatheter arterial chemoembolization and stereotactic radiosurgery. recent studies revealed that the risk of developing hcc still exists even after svr. since most of hcc that develop in patients with svr are usually detected within years, several investigators speculate that hcc is already present but too small to be detected at the time of completion of ifn therapy. this speculation is not the case in our patient, since svr was achieved years ago and no hcv-rna could be detected when hcc appeared. therefore, another possible mechanism should be considered. an annual follow-up with strict surveillance program for hcc should be performed for more than years after the completion of ifn therapy. background/aims: in order to investigate the role and importance of oxidative stress as to carcinogenecity of hepatocellular carcinoma (hcc) we analyze the expression of -hydroxydeoxyguanosine ( -ohdg) in the liver tissue of the hcc patients with and without hepatitis viral marker. methods: patients undergoing hepatic resection for the first hcc from to were enrolled into the study. only the cases that took no alcohol or small amount of alcohol were enrolled. cases were negative for hepatitis b surface antigen (hbsag) and antibody to hepatitis c virus (hcvab) (nbnc group). were positive for hbsag and negative for hcvab (b group). were positive for hcvab and negative for hbsag and antibody to hepatitis b core antigen (c group). staining with hematoxylin and eosin (h&e) and berlin-blue, and immunohistochemical staining for -ohdg were performed using the non cancerous liver regions. the degree of -ohdg immunostaining was expressed as the labeling index, which means the percentage of positive hepatocytes per hepatocytes. results: the labeling index of -ohdg for nbnc group is . (± . ), significantly lower (p= . ) than that for b group . (± . ), and also lower (p= . ) than that for viral group (b group and c group)( . ± . ). the labeling index of -ohdg had no correlation with grading, staging, fatty and iron deposit among all cases. conclusions: there is possibility that oxidative stress might not associate with the carcinogenesis of hcc in some cases without hepatitis viral infection. background: no effective chemopreventive agent has been approved against hepatocellular carcinoma (hcc) yet. since neovascularization plays a pivotal role in hcc, an angiostatic agent is considered as one of the promising approaches. recently, it has reported that vitamin k (vk) and angiotensin-converting enzyme inhibitor (ace-i) exert anti-angiogenic activity. the aim of the current study was to elucidate the combination effect of the clinically used vk and ace-i on cumulative recurrence after curative treatment, especially in consideration of neovascularization. methods: vk (menatetrenone; mg/day) and/or ace-i (perindopril; mg/day) were administered for to months after the curative therapy for hcc. the cumulative recurrence and several indices were analyzed. results: a -month follow-up revealed that the combination treatment with vk and ace-i markedly inhibited the cumulative recurrence of hcc in association with suppression of the serum level of vascular endothelial growth factor (vegf); a central angiogenic factor. the serum level of lectin-reactive a-fetoprotein was also suppressed almost in parallel with vegf. these beneficial effects were not observed with single treatment of vk or ace-i for months. conclusions: the combination treatment of vk and ace-i may suppress the cumulative recurrence of hcc after the curative therapy, at least partly through suppression of the vegf-mediated neovascularization. aim: the aim of this study was to clarify the cilnicopathologic features and management of hepatocellular carcinoma (hcc) patients surviving more than years after hepatectomy. materials & methods: retrospective study was carried out on hcc patients who underwent curative hepatectomy between and . clinicopathologic factors in -year survivors and patients who died within years were compared. the prognostic factors affecting survival were examined among the -year survivors. results: there were patients who survived for more than years after initial hepatectomy, and of those patients survived for more than years after hcc recurrence. the overall -, -, -and -year survival rates were . %, . %, . %, and . % respectively. in multivariate analysis, absence of underlying cirrhosis, solitary tumor, alfa-fetoprotein less than ng/ml, and absence of microscopic vascular invasion were favorable independent factors associated with -year survival. negative hepatitis c virus antibody status was favorable independent factor associated with longer disease-free interval and survival after tumor recurrence. multimodal treatments such as repeat hepatectomy or percutaneous ablation led to improved survival after recurrence, compared with the survival after transarterial chemoembolization (p<. ). conclusions: the results suggest that patients without underlying cirrhosis who have a solitary hcc that does not demonstrate vascular invasion or high afp levels might survive for longer than years after the initial hepatectomy. close follow-up and multimodal treatment could contribute to prolongation of survival in such patients, even if cancer recurrence occurs. the history of the use of carbon ion radiotherapy (cirt) for treating hepatocellular carcinoma (hcc) goes back to , when clinical trials were initiated at the national institute of radiological sciences. we have already reported that cirt used for the treatment of hcc is safe and effective, and that it causes only minor liver damage. in a phase ii clinical trial, the local control and cumulative overall survival rates were % and % at years, respectively. however, the patients with tumor adjacent to the gastrointestinal tract are thought to be ineligible for cirt because of the high risk of radiation injury of the digestive organs. in order to extend the indication of cirt, we have challenged the cirt for such patients under the use of spacers. a case was a -year-old female with cm tumor in segment . in radiological findings, the tumor revealed typical enhancement pattern for hcc, and was near the ec junction. she had been judged ineligible for hepatectomy because of the high retention rate of indocyanine green. she could undergo the . gye/ -fraction cirt after the placement of gore-tex soft tissue patch under the laparoscopic procedure. up to the present date, no adverse effect due to the spacer has been occurred, and an apparent anti-tumor effect has been observed. this method seems to have a promising efficacy for extension of the indication of cirt to the patients with tumors adjacent to the gastrointestinal tract. background: previously we reported that high ubiquitination was marker of human hepatocellular carcinoma. on the basis of these finding, we firstly analyzed the effect of bortezomib(proteasome inhibitor) on human hcc cell line. we also reported that hhm/dip /gcip was early marker for human hepatocarcinogenesis. hhm was suggested to be a new tumor suppression gene, but the mechanism was not well confirmed. we analyzed change of hhm signal by bortemib. method and result: we used hcc cell line (huh , hlf, hepg ) . the inhibitory effect of bortezomib was evaluated using mtt assay. nm bortezomib significantly inhibited proliferation of hcc cell line. the inhibitory effect by nm bortezomib was similar with m cisplatin. on the other hand, bortezomib has no inhibit effect in isolated hepatocyte from rat. in this condition, we analyzed the expression of cyclin d , phospho-rb and hhm in hcc cell line by western blot analysis. expression of cyclin d , phospho-rb decreased, but hhm was increased with time. next we analyzed cell cycle by facs. bortezomib induced hcc cell line into cell cycle arrest in g /m. the transcriptional activity of hhm was also activated by bortezomib administration using ptimer-promoter-hhm plasmid. conclusion: bortezomib has specific anti-proliferative effect on hepatocellular carcinoma. the induction of hhm by bortezomib might be related with cell cycle arrest. bortezomib will be a useful drug for hcc. neovascularization is required for carcinogenesis of non-alcoholic steatohepatitis: experimental and clinical study m. kitade , h. yoshiji , r. noguchi , k. kaji , t. namisaki , y. aihara , h. background/aim: non-alcoholic steatohepatitis (nash) may progress to liver cirrhosis, and finally hepatocellular carcinoma. recent study suggested that development of hepatic angiogenesis correlates the risk for hepatocarcinogenesis in liver cirrhosis patient. we therefore examined the role of angiogenesis in the hepatocarcinogenesis of nash in both experimental and human study. methods: as an experimental nash model, zucker (z) rats, which naturally develop leptin receptor mutations, and their lean littermate (l) rats were fed a choline-deficient, amino acid-defined (cdaa) diet. in human study, patients with nash-related cirrhosis or pre-cirrhosis, regarded as high risk group of hepatocarcinogenesis, and with simple fatty liver (fl) were enrolled and underwent clinico-pathological examinations. immunohistochemical analysis of -hydroxy- -noneal ( -hne) and cd were employed for detection of reacrive oxidative stress (ros) and angiogenesis in the liver tissues, respectively. results: in experimental nash model, both groups showed marked steatohepatitis by feeding cdaa diet. in sharp contrast, the development of glutathione-s-transferase placental form (gst-p)-positive pre-neoplastic lesions and hcc could be observed only in the l-rats. the hepatic neovascularization was also significantly increased only in the l-rats. in human study, both nash and fl exerted a marked elevation of ros. in sharp contrast, significant development of hepatic neovascularization was observed only in nash, whereas almost no neovascularization could be observed in fl. conclusion: in conclusion, these results suggested that neovascularization might play a important role in hepatocarcinogenesis in nash. background: paternally expressed gene (peg ), which was an imprinted gene with an active paternal allele but silent maternal allele, was highly expressed in a great majority of hepatocellular carcinoma(hcc). the aim of this study was to generate transgene mice expressing peg in the liver under the control of mouse albumin (alb) promoter and study the integration, transcription, expression of peg gene in the transgenic mice methods: the linearized bp transgene fragments, which contained alb promoter and structural gene of peg , were microinjected into fertilized eggs of mice. then manipulated embryos were transferred into the oviducts of pseudo-pregnant female mice. all the newborn mice were screened and identified by pcr detecting genomic dna in tail tissue. as the transgene was driven by the alb promoter, we examined its expression in the liver of transgenic mice by rt-pcr and western blotting. results: the transgene fragment was microinjected into the male pronucleus of fertilized oocytes. the injected eggs were implanted into oviducts of pseudo-pregnant foster mothers, of which mice became pregnant and give birth to offspring. of them died from unknown reason. among the offspring, were identified to carry peg cdna as demonstrated by pcr, and peg transgene could be expressed successfully in the liver of the established transgenic mice. the ratio of transgene integration were . % ( / ) by pcr. conclusions: the peg transgenic mouse model should be valuable for studying the in viro function of this imprinted gene in hcc. background/aims: brivanib alaninate is the l-alanine ester prodrug of bms- , an oral selective dual inhibitor of vascular endothelial growth and fibroblast growth pathway receptors. it is being developed in treating hepatocellular carcinoma (hcc), a disease highly prevalent in asia-pacific region. this analysis investigated whether bms- exposure was different between asian and non-asian subjects. methods: a population pharmacokinetic (ppk) model was developed with data collected in subjects ( non-asian, asian) with advanced and metastatic solid tumors (including hcc) from clinical studies. potential effects of the following covariates on model parameters were examined: age, gender, race, and baseline body weight. model-based simulation was performed to examine bms- exposure in asian and non-asian patients following brivanib doses of mg qd (phase iii dose). results: the ppk of bms- was characterized by a -compartment model with first-order absorption and elimination. clearance was found to slightly increase with body weight (p< . ). however, effects of age, gender and race on clearance were not statistically significant. the median of apparent clearance in asian was . % lower than that of non-asians, which was adequately explained by % lower body weight in asians. there was substantial overlap in steady-state bms- auc of asian and non-asian patients, simulated based on their observed body weight distributions in these patient groups. conclusions: bms- pk can be adequately described by a linear -compartment model; exposures in asian and non-asian subjects are similar following brivanib doses of mg qd. background/aims: hepatic resection is the standard treatment for hepatocellular carcinoma. in some patients with multiple hcc, one-block resection can not be feasible due to either the tumor location or the reserved liver function. in this study, we attempted to analyze the outcome of multiple-site resection or combined resection and rfa in patients with multiple hcc. the prognostic factors for postoperative survival were also investigated. methods: among patients who received resection from january to august , patients had a radiologically detected multiple hcc. patients with multiple hcc were divided into: group a, patients treated with one-block resection (n= ) and group b, patients with multiple-site resection or combined resection and rfa (n= ). results: in group b, received multiple-site resection and underwent combined resection and rfa. the clinicopathological variables and postoperative complication rate were not significantly different between the two groups. the -year disease-free survival rates for group a and b were . % and . %, respectively (p= . ). the overall survival rates were also not significantly different ( . % vs. . %, p= . ). the multivariate analysis revealed that radiological tumor number , edmondsons-steiner grade (iii-iv) and indocyanine green retention rate at minutes> % were adverse prognostic factors for overall survival. conclusions: active treatments including multiple-site resection and combined resection and rfa showed similar treatment outcomes compared with one-block resection in patients with multiple hcc. the prognosis after treatment was associated with tumor number, tumor grade and icg r . background: nasopharyngeal carcinoma (npc) is endemic to southern china. mortalities are mostly associated with secondary metastases. novel treatments for npc metastases are thus urgently needed. we aim to test the efficacy of a physiologically stable gold compound, gold (iii) meso-tetraarylporphyrin a (gold- a), in treating intrahepatic npc metastasis in athymic mice. methods: twenty million of c - human npc cells were injected into the livers of athymic mice to induce primary tumors. gold- a was administrated by intraperitoneal injection. survival times, tumor volumes and degrees of metastasis of the animals were evaluated. intratumoral microvessel density was determined by immunohistochemical staining for cd . tube formation by ms mouse endothelial cells were conducted with an in vitro angiogenesis assay kit. gene expression level was determined by semi-quantitative reverse transcription-polymerase chain reaction. cell proliferation was performed by methylthiazolyldiphenyl-tetrazolium bromide assay. result: gold- a prolonged the survival and inhibited intrahepatic and lung metastasis of the tumor-bearing animals. the compound induced tumor tissue necrosis and reduced tumor microvessel formation. in in vitro studies, gold- a inhibited tube formation and proliferation of ms cells, and downregulated the expression of stanniocalcin (stc ), which plays roles in angiogenesis. furthermore, our preliminary data showed that overexpression of stc in ms cells rescued cells from gold- a-induced death. conclusion: gold- a is a novel anticancer agent that prolongs survival of the npc metastases-bearing mice. it inhibits intrahepatic and lung metastasis in vivo and inhibits angiogenesis in vitro, in part via downregulation of stc . tbx is a transcriptional repressor that is important for embryonic development. overexpression of tbx was found in a large variety of cancers, including breast cancer, ovary cancer, cervical cancer, lung cancer, bladder cancer and liver cancer. tbx promote carcinogenesis by bypass cellular senescence via suppression of p arf . our resent studies revealed that two key motifs composed of + residues are essential for its transcriptional repression. based on this finding, we designed a set of peptides to block its transcriptional repression activity and tested their antiviral effects. we found that tat-tagged peptides (taps) effectively transduced hepatoma hepg and bel cells at almost % efficiency and inhibited cell growth in a dose dependent manner. further studies revealed that the tap treated cells underwent up-regulate apoptosis via suppression of p arf both at mrna and protein levels, demonstrating the potential of novel taps for anti-hcc treatment in the future. safety and long-term outcomes of radiofrequency ablation therapy in elderly and cirrhotic patients with hepatocellular carcinoma k. kakisaka , h. kuroda , k. kasai , y. takikawa , k. suzuki iwate medical university background and purpose: a tendency of the aging in patients with hepatocellular carcinoma (hcc) is predominantly seen in japan. in fact, the mean age of patients with hcc in our institute in was . years old, while that in was . years old. it is not still remained whether the percutaneous radiofrequency ablation (rfa) therapy in elder patients with hcc is safety and equal in therapeutic usefulness compared to the non-elder patients with hcc. subjects and methods: two hundred six cirrhotic patients with hcc ( tumor nodules) received rfa therapy curative intent since august, were enrolled. we divided all patients into two groups: over years (elder group: n= ) and under years (non-elder group: n= ), and compared the patient's characteristics, tumor factors and survival rate and causes of death in two groups. results: the characteristics of patients, tumor factors, cumulative survival rate and recurrence rate were not revealed in two groups. although in elder group two patients complicated aspiration pneumonia and respiratory depression due to sedation under rfa respectively, total occurrence rate of complications did not differ between two groups. conclusion: rfa therapy is safety and effective even in elder patients with hcc, although their care is necessary to prevent any complications which are often occurred during the rfa therapy. background and purpose: the aim of this study is to evaluate whether administration of the branched-chain amino acid (bcaa) enriched nutrient (namely, aminoleban en, ostuka pharmaceutical company, japan) might improve protein-energy malnutrition (pem) status and quality of life (qol) in cirrhotic patients with hcc receiving rfa therapy. subjects and methods: thirty-five cirrhotic patients with hcc who had received rfa therapy from october to october in our institute were randomized into two groups: diet with supplementation of aminoleban en (en group: patients, kcal/day) and diet only (control group; patients). the total intakes of calories ( - kcal/kg) and protein ( . - . g/kg) were equal between tow groups. the primary end point was event-free survival rate (development of liver cancer, rupture of esophageal varices, or progression of hepatic failure) and second end points were serum albumin levels and the health-related qol by shortform- questionnaire (sf- ). results: total intakes of calories and protein were similar during the one year after rfa. no significant differences in event-free survival rate were seen between two groups. however, decreased serum albumin levels and one (general health perception) of domains in sf- were significantly improved in en group compared to the control group. conclusion: supplementation of bcaa-enriched nutrient may improve the impaired liver function and qol after rfa therapy. large scale prospective study should conduct to confirm these results near the future. backgrounds and aims to investigate the effects of selective cox- and cox- inhibitor on proliferation and apoptosis of hcc cell. methods hep b and snu cells were treated with ns- and sc- . mtt assay, caspase / activity assay and tunel assay were performed. cox protein and mrna expression were measured by western blot and real time rt-pcr. results in hep b cell line, cox- , cox- ( , , um) and combination ( + , + , + um) treatment after hr showed a significant dose dependent inhibitory effect on cell growth (p< . ). cox- , cox- ( um) and combination ( + , + um) treatment after hr significantly increased caspase / activity (p< . ) and induced apoptosis (p < . ). however, the combination treatment could not showed a additive effect to cox- or cox- inhibitor (p> . ). in snu cell line, cox- inhibitor and combination treatment showed a inhibitory effect on cell growth (p < . ) similar to hep b cell line but any of treatment could not induce apoptosis significantly (p > . ). in cox protein and mrna expression, snu cell line showed significant cox- predominency (p= . ) but hep b cell line showed cox- predominency (p= . ). conclusions in hcc cells, no additive effect of the combination treatment of cox- and cox- inhibitors could be anticipated. the apoptosis inducing effect of cox inhibitor could be different between hcc cell lines. more studies for the mechanism of different response to cox inhibitor between cell lines is needed. background: the aim of this study was to determine the maximum tolerated dose and recommended dose of combination chemotherapy with mitoxantrone and uracil/tegafur (uft) (phase i part), and to clarify its efficacy (tumor response, overall survival, and progression free survival) and safety in patients with advanced hepatocellular carcinoma (hcc) at the recommended dose (phase ii part). methods: patients eligible for study had histologically confirmed, chemo-naïve advanced hcc, who were unsuitable for resection, local ablation therapy or transcatheter arterial chemoembolization. the therapy consisted of mitoxantrone dosages ( , and mg/m /day) intravenously on day and oral administration of uft mg/m on day through day . the treatment was repeated every four weeks if there was no evidence of tumor progression or unacceptable toxicity. results: a total of patients were entered into the study. all had a good ecog performance status score of - . in phase i part, dose limiting toxicities occurred in all three patients (two patients: grade neutropenia, one patient: grade creatinine elevation) given mitoxantrone at dosage of mg/m /day, and the recommended mitoxantrone dosage was mg/m /day. among patients administered at the recommended dosage, one patient ( . %) achieved a partial response, patients ( . %) had stable disease and patients ( . %) had progressive disease. one-year survival proportion, median survival and median progression free survival were . %, . months and . months, respectively. the most common toxicities were grade - leucopenia ( . %) and neutropenia( . %). conclusion: mitoxantrone mg/m with uft mg/m /day is recommended dose. this regimen is generally well tolerated, but appears to have little activity for advanced hcc. these findings do not support its use in practice, and further trials with this regimen in patients with advanced hcc are not recommended. the study assessed the benefits of -d reconstruction of spiral ct scans for the diagnosis of and surgical guidance to large liver tumors or tumors at the hepatic hilum. we retrospectively analyzed cases of children with such tumors treated in past years.the patients were examined by -d reconstruction using slice spiral ct. in cases, the volume of tissue removed exceeded / the entire volume of the liver. in cases, the excised tissue represented less than / of the total liver volume, but the location of the tumor was adjacent to major hepatic vessels. pathological diagnoses included hepatoblastoma (n = ), hepatocellular carcinoma (n = ), mesenchymal hamartoma (n = ), teratoma (n = ) and adenoma (n = ). all children had curative resections with tumor-free microscopic margins. -d ct imaging can provide high quality images and accurate location of the tumors. it could help the surgeon identify the tumor borders accurately and devise a safe surgical strategy. with its help the surgeon could identify vital hepatic blood vessels before operation, and can avoid massive hemorrhaging during operation. background: to investigate the association between c- t polymorphism of transforming growth factor (tgf)- gene and hbv-related hepatocellular carcinoma (hcc). methods: patients with hbv infection ( cases were hbv carriers, cases were hcc) and healthy volunteers were enrolled. the polymorphism of tgf- gene c- t was identified by polymerase chain reaction-restriction fragment length polymorphism method. the concentrations of plasma tgf- were measured by enzyme linked immunosorbent assay (elisa). tgf- mrna expression was quantified by real-time pcr. a recombinant construct containing - c>t variant as promoter and cat as reported gene was transfected into hepg cells. the reporter gene cat was detected with elisa. results: the ct genotype at position - of tgf- gene prevailed in all three groups, the frequency of genotype cc and allele c at - in hcc were significantly higher than those of the hbv carriers and controls. the plasma tgf- concentration among the three genotypes did not show any significant difference in three groups. however, both the tgf- concentration and liver mrna levels were statistically higher in patients with cc genotype than in those with tt genotype in the hcc group. reporter gene cat was elevated when hepg were transfected with - c-cat recombinant construct compared to that with - t-cat one (p< . ) conclusion: the presence of c allele at position - may play an important role in the development of hbv-related hcc through influencing tgf- expression both at mrna level and protein level. background: to assess diagnostic value of n-glycan markers in identifying hepatocelluar carcinoma (hcc) from liver fibrosis after hbv infection. methods: a total of cases of hbv related liver fibrosis (n= ) and hcc (n= ) patients as well as matched healthy controls (n= ) were recruited. routine liver function and tumor markers were detected by automatic biochemistry or immunological analyzer. n-glycome of serum protein was profiled by dna sequencer-assisted fluorophore-assisted carbohydrate electrophoresis with a capillary electrophoresis-based abi sequencer. results: the abuncance of a single agalacto biantennary glycan (ng a f, peak ) was increased in liver fibrosis and decreased in hcc, while that of a branching triantennary glycan (na fb, peak ) was decreased in fibrosis and increased in hcc. the efficacy of the log ratio of above two n-glycan abundance [log (p / )] was similar to afp in differentiation hcc from fibrotic patients. with logistic regression analysis, the accuracy and sensitivity of the diagnostic model combining afp with n-glycan analysis(cscore b) were increased - % compared to afp. log(p / ) was even more powerful in monitoring the progresison of hcc with the specificity improved % and accuracy improved % compared to that of afp. besides, log(peak / ) was correlated well with other tumor markers and tnm stages. conclusions: the log ration of the abundance of a branching triantennary glycan (na fb, peak ) to a single agalacto biantennary glycan (ng a f, peak ) and the model combining afp with n-glycome markers are promising in hcc diagnosis and progression monitoring. the low incidence of tumor seeding and post-procedure bleeding after radiofrequency ablation (rfa) of hepatic tumors has been attributed to the use of thermocoagulation of the tract, which results in necrosis, upon electrode withdrawal. however, different investigators use different techniques with no experimental evidence of the effectiveness of a particular technique. objective: we aimed to compare the necrotic zone produced using different electrode withdrawal techniques. methods: eighteen tract ablation zones were created in ex vivo porcine livers by withdrawing an internally-cooled rfa electrode (cool-tip radiofrequency system, valleylab) - mm/second using energy-dependent ( vs. vs. vs. watts) and temperature-dependent ( vs. c) techniques. horizontal mathematical modeling suggests an impractical number of radiofrequency ablation (rfa) zones needed in order to ablate a medium-large hepatic tumor. however, overlapping rfa zones may increase the necrotic diameter disproportionately to that deduced from single ablation alone. objectives: to compare the necrotic diameter in single (group ), dual overlapping (group ) and dual non-overlapping (group ) ablation. methods: single (n= ) and dual (overlapping n= ; non-overlapping n= ) ablation zones were created in ex vivo porcine livers using cool-tip rfa electrodes. necrotic diameter was measured at the midpoint (maxd) of the single and the two distinct rfa zones of the dual ablation groups and compared with the necrotic diameter at the tip of the second ablation (maxd-o), corresponding to the point of overlap in group . the rfa electrode was withdrawn . and . cm before re-ablating for group and group , respectively. results: despite no difference in end-rfa temperature between groups (group = . + . cvs.group = . + . cvs.group = . + . c; p= . ), maxd was significantly greater (p= . ) in group ( . + . cm) as compared to group ( . + . cm) and group ( . + . cm), with no difference between group and group (p= . ). further proof of synergism between two overlapping ablations is that the maxd-o in group ( . + . cm) was larger than maxd of group (p= . ) and group (p= . ), and was similar to maxd of group (p= . ). conclusions: overlapping two rfa zones results in incremental increase in necrotic diameter compared to single and dual non-overlapping ablation. this may explain the discrepancy in the number of ablation zones needed between clinical and mathematical modeling studies. background: hepatocellular carcinoma (hcc) is the fourth most common cancer worldwide, main etiological factors being chronic infections with hepatitis b and c viruses. the present study was undertaken to evaluate the association of glutathione-s-transferase (gst) t and m null genotypes and microsomal epoxide hydrolas e(mephx) polymorphisms with hepatitis virus related hcc risk in indian population. subjects and methods: three groups of subjects were considered viz. control (n= ), chronic viral hepatitis (n= ) and hcc (n= ). pcr-rflp was used for this polymorphic study. genotype distributions between categories were compared using the test; odds ratios (ors) and % ci were calculated to express the relative risk. results: presence of gstm null genotype significantly (p< . ) decreased the risk for hcc development among chronic viral hepatitis subjects. however, gstt null genotype was associated with an increased risk for hcc by . and . times among control and hepatitis subjects respectively. in case of mephx, tyr his and his his genotypes significantly (p< . ) reduced the risk of hcc development in both viral hepatitis and control subjects. in case of mephx exon genotypes, arg arg imposed an approximate fold risk for hcc development in the two groups. combination of heterozygous mutant genotypes at mephx exons & also imposed around fold risk (non-significant) for hcc. conclusions: polymorphic forms of gst and mephx share an association with viral related hcc risk in indian population and should be further evaluated as the candidate genes to determine individual susceptibility for viral related hcc. background : the association between type diabetes mellitus (dm ) and hepatocarcinoma (hcc) has been identified in the last ten years. methods: to clarify the temporal relationship between dm and hcc and the possible effects of antidiabetic therapy on hcc risk, we recruited patients with hcc compared with control subjects without liver diseases and cirrhotic patients. results: prevalence of dm was . % in hcc, . % in cirrhotic and . % in control group. in univariate and multivariate analysis, the odds ratio (or) for hcc in diabetic patients were respectively . (ci . - . ; p < . ) and . (ci . - . ; p= . ). or in univariate analysis were higher in male than in female patients. in . % of the patients dm pre-exists the diagnosis of hcc from a mean time of . months. moreover, the insulin treatment was more frequent in diabetic hcc patients than controls and we report an or for hcc of . (ci . - . ; p= . ) in patients treated with insulin or sulfonylureas, and an or of . (ci . - . ; p= . ) in patients treated with metformin. conclusion: our study confirms that male patients with type diabetes mellitus have a significantly increased risk of hcc independently of other cofactor such as hbv, hcv and alcoholic abuse. dm is a pre-existing disease in most hcc patients and suggests that insulin and sulphonylurea treatments in dm are associated with an increased risk of hcc development, while metformin may have a protective effect. background & aims: over the last few years, techniques that allow systematic analysis of chromosome aberrations at a genome-wide level were applied to hcc. the purpose of this study is to apply gene loss expression profiling in the attempt to discover new related genomic regions not revealed by loh or cgh, and search the new tumor suppression genes for hcc. methods: primary hcc and corresponding non-tumor liver tissues were obtained from surgery. serologically, cases were with hepatitis b virus infection and cases were with hepatitis c virus infection. four non-viral infected tissues from four patients receiving surgical resection for hepatic adenoma or focal nodular hyperplasia.affymetrix genechip, u a, was used to compare the loss and gained gene expression in liver needle biopsy samples (n= ). results: after adjusting by chromosome arm length, p, p, p, q and q showed higher gene loss-expression ratio (>= loss / cm) in the comparison between normal samples and tumor samples; q, p and q showed higher gene loss-expression ratio in the comparison between tumor and non-tumor tissues. more than genes showed different loss expression level in this study. for example, cd was loss expression in all non-tumor samples comparing to four normal samples. ficolin and ficolin were loss expression in hcc samples with hbv infection and with hcv infection, respectively. conclusion: our results revealed the potential tumor suppression genes and the genomic region they harbored. further study is needed to validate the observation. background/aims: hepatocellular carcinoma is common malignancy in human, accounting for million deaths in the world annually. caspase , as an initiator caspase, is involved in the induction of apoptosis. survivin, a novel inhibitor of apoptosis is related to the ability to inhibit caspases and involved in critical steps of onset and progression of hcc with unfavorable prognosis. methods: to explore the possibility that the epigenetic alteration of caspase and survivin genes is implicated in the development and progression of hcc, promoter methylation of two genes was analyzed in cases of primary hcc by methylation specific pcr. the relationship between immunohistochemical expression of gene products and proliferative/apoptotic indices, and clinicopathologic parameters was also investigated. results: the methylation of caspase ( . %, / ) and survivin ( . %, / ) demonstrated a negative correlation with immunohistochemical expression of capsase ( . %, / ) and survivin ( . %, / ) (p= . and p= . respectively). methylation of caspase and immunohistochemical expression of its gene product was significantly correlated with apoptosis (p= . and p= . ). survivin nuclear immunoreativity revealed significantly correlated with proliferative activity of tumor cells (p= . ). by survivial analysis, the negative caspase expression and positive survivin expression showed worse prognosis in hcc, that was statistically insignificant (p> . ). conclusion: in conclusion, caspase and survivin may contribute an important regulatory mechanism for tumor cell proliferation and apoptosis, and may be prognostic predictors in hcc. injection was recently reported to be effective against hcc with pvi, though the therapy is not always applicable for the patients with arterial abnormality. therefore we tried combination therapy of transcatheter arterial cisplatin embolization and radiation, and will report the effectiveness and toxicity of the therapy. methods: the combined therapy was conducted in hcc patients with pvi. transcatheter arterial embolization with mg/kg cisplatin powder (ia call) was performed against intralobar lesions, followed by external radiation targeted for pvi ( gy in gy fractions). the following variables were evaluated with the survival rate: gender, age, viral etiology, child's class, performance status, and location of pvi. results: one ( %) patient showed complete response and another two ( %) partial response. two ( %) showed no change, and one ( %) showed progress of disease. the survival rates at six months among overall patients were . %. adverse events were limited to nausea and appetite loss. one of the patients with partial response underwent curative resection, and is still alive without any recurrence for days. conclusions: the combination therapy of cisplatin embolization and radiation is safe, effective and also feasible to the patients with arterial abnormality. this therapy is suggested to be a useful alternative therapy for the patients with extensive pvi. recently, the injection port has been used for hepatic arterial infusion chemotherapy (hai) in japan. hai is usually used for the treatment of multifocal bilobar tumors of the liver or hccs combined with portal vein tumor thrombosis (pvtt), not amenable to tace. this study examined the efficacy and toxicity of repeated hepatic hai using lipiodol suspension mixed with cisplatin powder. methods: from april to september , patients with inoperable advanced hcc were enrolled in this study. all received cisplatin powder ( mg) and lipiodol ( ml) suspension, with an intervening weeks interval. the drugs were delivered from an injection port. patients had hcc with pvtt, and had hcc without pvtt. patients with liver function of child grade a, of grade b, and of grade c were enrolled. result: the mean number of hai given during the follow-up period was . times. we found complete response in case, partial responses in , no change in , and progressive disease in . the overall response rate was . %. the -year survival rate was . % and the -year survival rate was . %. although patients had cisplatin-induced anaphylaxis, no severe adverse events (hepatic failure and renal failure) were observed. conclusion: chemo-lipiodolization using cisplatin powder delivered via an injection port provides some clinical benefits without severe adverse events in patients with far advanced hcc. background: recently, the antitumor efficacy of angiogenesis inhibitors is expected in the treatment to hepatocellular carcinoma. the gene expression relevant to the vascularization, which is a target of these inhibitors, has a difference according to each case and it is thought that it influences the therapeutic effect of them. however, there are still few reports of mrna expression of vascular endothelial growth factor (vegf) receptors in hcc. methods: the relative mrna level of vegf and its receptors (kdr and flt- ) was analyzed using quantitative rt-pcr in patients with hcc. matched samples of hcc (t) and non-tumor liver tissue (nt) were obtained by fine needle ( gauge) biopsy. results: gene expression level of vegf and flt- was significantly higher in hcc than nt (vegf; p< . , flt- ; p< . ). according to the clinicopathological findings, gene expression level of vegf and kdr in hcc was significantly high in hypervascular hcc compared to hypovascular hcc (vegf; p= . , kdr; p= . ). additionally, flt- tended to be expressed higher in hypervascular hcc than hypovascular hcc (p= . ). moreover, gene expression level of vegf, kdr and flt- tended to be higher in advanced-stage hcc than early-stage hcc. conclusion: not only vegf but kdr and flt- were highly expressed in hypervascular and advanced hcc. aims: fibrinogen-like protein /fibroleukin (fgl ) has been reported to play a vital role in the pathogenesis in mhv- (mouse hepatitis virus) induced fulminant and severe hepatitis, spontaneous abortion, allo-and xeno-graft rejection by mediating "immune coagulation". fgl functions as an immune coagulant with the ability to cleave prothrombin to thrombin directly. therefore, this study was designed to examine the role of fgl in tumor development. methods: tumor tissues from patients with six types of distinct cancers and the animal tumor tissues from human hepatocellular carcinoma (hcc) model on nude mice (established from high metastasis hcc cell line mhcc lm ) were obtained. results: hfgl was detected in tumor tissues from out of patients as well as tumor tissues collected from human hcc nude mice. hfgl was highly expressed both in cancer cells and interstitial inflammatory cells including macrophages, nk cells, and cd + t lymphocytes and vascular endothelial cells. hfgl mrna was localized in cells that expressed hfgl protein. fibrin (nogen) co-localization with hfgl expression was determined by dual immunohistochemical staining. in vitro, il- and ifn-increased hfgl mrna by - folds and protein expression in both thp- and huvec cell lines. one-stage clotting assays demonstrated thp- and huvec cells expressing hfgl had increased procoagulant activity following cytokines stimulation. conclusion: the hfg contributes to the hypercoagulability in cancer and may induce tumor angiogenesis and metastasis via cytokine induction. . the therapy was either terminated at the end of the first cycle in cases with progressive disease, or continued for at least cycles, when responses to treatment were evaluated by eastern cooperative oncology group criteria. results: of patients treated (male, %; median age, years), % had child-pugh a, and % had b. % had either metastasis or vascular invasion. % had metastasis and % had vascular invasion. on the basis of independent assessment, three ( . %) patients achieved a complete response, thirteen ( . %) had a partial response, and ( . %) had stable disease. there was no grade / drug related toxicities. median overall survival was . months. conclusion: combination therapy of ifn + -fu has modest efficacy in hcc. background: amt is a mixture of approved pharmaceuticals in low therapeutic doses (human insulin and chlorpheniramine) and herbal components (aqueous camomile extract). preclinical and phase i data in healthy volunteers showed a favourable safety profile for amt. this pilot study should examine efficacy and safety of amt in the patients with advanced hepatocellular carcinoma (hcc). methods: thirteen patients with advanced hcc (tnm stage iii-iv), who did not respond to existing therapy, were treated with i.m. amt at . ml/kg up to a maximum volume of ml twice daily for - months. primary study objectives: clinical benefit response (cbr). secondary objectives: safety of amt, tumor response according to who-recist criteria, quality of life (qol) and iimmunomodulatory effects. the effects were evaluated by cytokine production of pbmcs before and after the treatment. results: there were no significant safety issues. four and patients showed positive and stable responses for cbr, respectively. tumor response was pr, sd and pd. even in the patients with pd, and patients showed positive and stable responses for cbr. qol data showed clear improvement. immune monitoring demonstrated effects of amt on the functional immune parameters in about half of patients. in the patients with pr, histological examination showed tumor necrosis and many lymphocytes including plasmacytes infiltrating in the tumor. conclusion: these results suggest that a promising rate of patients with advanced hcc respond clinically to the amt treatment without significant safety issue and amt has some immuno modulatory capacities. background/aims: dysplastic nodules are important due to premalignant potential. the aim of this study was to evaluate the electron microscopic findings of liver dysplastic nodule in patients with liver cirrhosis. methods: a total of patients (mean age: ± years old, male ) with dysplastic nodules which suspected as malignant nodule (mean size . ± . cm) was enrolled from cases of liver cirrhosis undergone ultrasonography-guided biopsy from december to january . the etiologies of liver cirrhosis were as follows; alcohol ( patient), hepatitis b virus ( ), and hepatitis c virus ( ). results: hepatocytes showed rosette formation of regenerative hepatocyte or degeneration. the nucleus was round or oval shaped and the nucleus membrane was irregular. the nucleolus was prominent and clear, the mitochondria were crowded to one side in the cytoplasm with megamitochondria. glycogen granules and lipofuscin pigments were abundant. sinusoid formation was poorly developed and collagen fiber bundles were increased. the hepatocytes of rosette formation and bile ductules cell made of canal of hering, which was dilated and microvilli was decreased. the number of canal of hering was , which was composed of . ± . with hepatocyte and . ± . with bile ductule cell, respectively. there was no oval cell in the canal of hering, which was relatively well developed. schwann cells were clustered together in nerve plexus. therefore, these electron microscopic findings showed that dysplastic nodule was similar to early hepatocellular carcinoma. conclusions: this study showed that dysplastic nodule in liver cirrhosis is nearly identified to early hepatocellular carcinoma. dcp is an important risk factor for recurrence after radiofrequency ablation of single hepatocellular carcinoma -< cm in diameter r. kuromatsu , a. takata , n. fukushima , s. sumie , m. nakano division of gastroenterology, department of medicine, kurume university school of medicine background and aims: the aim is to analyze the risk factors for local recurrence + intrahepatic metastasis after radiofrequency ablation (rfa) and hepatic resection (hr) for single hepatocellular carcinoma (hcc) < cm in diameter. methods: between and , patients with single nodule < cm in diameter and child-pugh grade a were treated by hr and rfa, and recurrence rate and survival rate using kaplan-meier method, and important risk factors for recurrence using cox's proportional-hazards regression model were analyzed. factors used for multivariate analyses were age, gender, viral marker, tumor diameter, afp, afp-l , dcp, and platelet count. results: mean age was years old, m/f ratio was / , hr/rfa was / , and mean observation period was days. five-year survival rates, and -year local recurrence-free + intrahepatic metastasis-free rates were not significant between hr group and rfa group ( / %, / %). in rfa group, the only independent risk factor for local recurrence-free + intrahepatic metastasis-free survival was dcp (p= . ). tumor diameter was not significant for recurrence. in hr group, there was no risk factor for recurrence. in pathological analyses of hr group, dcp had a tendency to associate with microvascular invasion (p= . ). conclusions: rfa was effective for hcc < cm in diameter and dcp < mau/ml. hepatic resection should be selected for single hcc with dcp > mau/ml even though hcc < cm in diameter. background: radiofrequency ablation (rfa) is now a common treatment for small hepatocellular carcinoma (hcc). however, critical complications after rfa such as rapid intrahepatic dissemination have been reported. in this study, we investigated the method how to estimate the malignant potential of small hcc by dynamic ct before rfa. methods and results: firstly, hccs less than cm in diameter were analyzed. those tissues were classified into groups as followed, small nodular type with indistinct margin (type e), simple nodular type (type ), simple nodular type with extranodular growth (type ), confluent multinodular type (type ). in the type and groups, portal invasion over vp were observed more frequently than those in the type and e groups. at the next step, these hccs were classified into above-mentioned types by two radiologists according to the shape of early stain or defect of delay phase of dynamic ct before operation. the accorded rate was % between those classifications. next, patients, which had solitary hcc less than cm in diameter and treated with rfa, were classified into those types by dynamic ct before rfa. the recurrence rate and prognosis of those patients were examined. in the type and groups, the recurrence rate was higher and significant worse prognosis was showed than those in type and e group . conclusion: it was suggested that hcc with type and might process higher malignant potential and rfa should be carefully performed on those types of hcc. background/aims: hypoxia-inducible factor- (hif- ) is the central transcriptional factor in the cellular response related to various aspects of cancer biology, including proliferation, survival, angiogenesis, and extracellular matrix metabolism to hypoxia. il- became known to replace hif- functions in the other cancer cell lines. the aim of this study was to evaluate whether il- may induce angiogenic factors without hif- by inflammation signal of hypoxic condition. methods: hif- knockdown cell lines of hcc (huh and hepg ) were constructed by rna interference tools, and cultured under normoxia ( %o , hours) and hypoxia ( %o , hours) conditions. following transfection, the amounts of hif- , il- , angiogenic factors and matrix metalloproteinase (mmp) were examined using rt-pcr and western blotting, respectively. results: the expression of hif- , angiogenic factors, mmp, il- was markedly enhanced in wild types that were cultured under hypoxia, and the hypoxic induction of angiogenic factors and mmp was partially blocked in hif- knockdown hcc cell lines. nf-b inhibitor suppressed angiogenic effects by blocking il- activity. conclusion: these data suggest that il- induced tumor angiogenic factors in hif- knockdown hcc cell lines. background there were some reports that liver caner related to the levele of sera hbvdna our research focused on the relationship between the quantity of hepatocellular hbv cccdna , tdna and liver cancer. methods the samples included the liver tissue of chb patients (chb group) and the para-liver cancer tissue of primary liver cancer patients (phc group) the quantity of hepatocellular hbvcccdna, tdna were assayed by fq-pcr in both groups. result: the quantity of hepatocellular hbv cccdna in chb group was . ± . copys/cell higher than phc group( . ± . copys/cell), p= . ; the quantity of hepatocellular hbv tdna in chb group was . ± . copys/cell higher than that of phc group( . ± . copys/cell),p= . .; conclusion: the quantity of hepatocellular hbvcccdna, tdna can not be used as predictors of liver cancer for hepatitis b patients. hepatic cancer predominantly occurs in males. this is almost a commonsense to most of us. but the detailed mechanisms underlying such phenomenon are still not well-known. the average age of liver cancer patients are about - years old. so most female patients have udergone pregnancy at least one time. pregnancy is a very important event before or during the development of liver cancer in females. in this special period, not only sex hormones secrete in a strange manner, but also immune system functions in a special module which is very different from normal. so it is urgent to investigate the impact of process of pregancy on the development of hepatic cancer. in this study, female sd rats are randomly divided into two groups: pregance group and controll group. rats in both groups are injected iv diethylnitrosomine(a chemical carcinogen). in pregnance group, rats are raised together with male rats in : ratio( female, male) to make every rats undergo pregnancy. while in controll group, rats are coupled with spermaduct-ligated male rats. the size and amount of hepatic cancers in pregancy group are smaller and less than those in controll group. the survial rate is also significantly higer than that in controll group. we conclude that the process of pregnancy exerts an inhibitory role in the development of chemical induced hepatic cancer in rats. acknowledgement: this project was sponsed by the national natural science foundation of china. the number of the grant is : the use of alpha-fetoprotein measurement in detection of recurrent hepatocellular carcinoma after living donor liver transplantation n. yamashiki , , y. sugawara , , s. tamura , r. tateishi , h. yoshida , j. kaneko , y. matsui , n. kokudo , , m. omata organ transplantation service, department of gastroenterology, university of tokyo, department of surgery, university of tokyo background: the recurrent hepatocellular carcinoma (rhcc) after liver transplantation (lt) can occur in to % of transplant recipients despite with a careful patient selection. for the surveillance of rhcc, frequent measurement of alpha-fetoprotein (afp) and annual ct scan is commonly used. however, the usefulness of afp is not clear. we report the update of our experience using our surveillance protocol. methods: between and march , adult living donor lt were performed at the university of tokyo. among them, recipients with hcc in their explanted liver were subjected to analysis. we used monthly measurement of afp and des-gamma carboxy prothrombin (dcp) with annual dynamic ct scan. results: met milan criteria pre-operatively and did not. were incidental hcc. rhcc was experienced in patients at ( - ) months after lt. recurrence sites were graft ( ), lung ( ), bone ( ), and multiple organs ( ). rhcc was first suspected from elevation of tumor markers in ; afp in , dcp in , and both afp and dcp in . rhcc was confirmed with ct scan ( ) or mri ( ) in ( - ) months after the first sign of rhcc. when the cutoff level of afp> ng/ml was used, the sensitivity and specificity for rhcc were % and %. six cases were treated surgically of which two achieving prolonged survival. conclusions: although the confirmation of the rhcc sites required multiple imaging studies, afp measurement was useful as for the first sign of rhcc. purpose: to evaluate the therapeutic effect of heated ( c) lipiodol via hepatic artery administration in vx rabbit liver cancer model. materials and methods: thirty male new zealand white rabbits were randomly divided into groups with rabbits for each group. vx carcinoma cells were surgically implanted into the left liver lobe. the tumors were allowed to grow for weeks, and studies were performed until the diameter of tumors detected by ultrasonograph reaching to cm. under the anaesthesia, transcatheter hepatic arterial embolization was performed and doxorubicin-lipiodol ( ºc) ( ml), lipiodol ( ºc) ( ml) and control (physiological saline ( ºc) ( ml)) were injected into hepatic artery of the different groups. one week later, the volume of tumor was measured by ultrasonograph again. the serum of all rabbits was collected before injection and at and days after injection and the level of aspartate aminotransferase (ast) was checked. the survival period of groups of rabbits after treatment was also recorded. during the last course of their disease, the rabbits were given some analgetics to relieve suffering. results: the tumors' growth rate in lipiodol ( ºc) background/aims: hepatocellular carcinoma (hcc) is one of the male-dominant cancers, and hepatitis c virus (hcv) is one of the causes of hcc. it was reported that androgen receptor (ar) is expressed in hcc and its surrounding tissues. androgen signaling and ar may be involved in hepatocarcinogenesis. in this study, we investigated whether hcv interacts with androgen signaling in human hepatocytes. methods: hcv protein expression vectors were co-transfected with ar-expression vectors and ar-responsive element-driven reporter vector into immortalized human hepatocytes (ihhs) and human hepatoma cell lines. kinase inhibitors were used to examine the activation of the akt, mapk, and jak/stat pathways. real-time pcr and western blotting were performed. cell culture grown hcv (hcvcc) were also used, and angiogenesis was evaluated by tubule formation assays in human coronary microvascular endothelial cells in the presence of -androgen- -ol- -one. results: hcv enhances ar-responsive gene expression in the presence of androgen. hcv core protein has the strongest effects and induced ar activation associated with jak/stat signaling. hcvcc enhances vegf mrna expression and angiogenesis. conclusions: hcv core protein is an enhancer in androgen signaling and can be expected to play an important role in hcv-related hepatocarcinogenesis. background: to evaluate the therapeutic outcomes and the toxicity of the combination of arsenic trioxide and the chinese traditional jianpiliqi (jplq) formula in the treatment of advanced hepatocellular carcinoma (hcc). methods: patients with advanced hcc, not suitable for resection but with normal major organ functions, were enrolled to receive a therapeutic regimen consisting of intravenous arsenic trioxide ( mg / m ) administration from days - , and an oral administration of jplq formula twice daily from days - . each cycle was composed of days and treatment could expand up to cycles before evidences of intolerable toxicity or disease progression. result: one patient had partial response, one had minor response, showed stable disease and ( . %) had disease progression. total disease control rate was . %, median survival time was . months ( - . ms), and time to progression was . months ( - . months). the incidences of grade - abdominal distention and nausea/vomiting were . % and . %, respectively. increases in ggt occurred in patients ( grade , grade , and grade ) and increases in serum creatinine in patients ( grade and grade ), respectively. conclusion: compared with the single arsenic trioxide treatment reported in past literature, treatment by arsenic trioxide combined with jplq showed modestly higher anti-tumor activity and tolerable toxicity in patients with advanced hcc; its manageable toxicity and increased tumor response rate may offer a better treatment regimen, and deserve further investigation. aim: to investigate the effect of osteopontin (opn) expressions down-regulated by rna interference (rnai) on the invasion and metastasis of human hepatocelluar carcinoma (hcc). methods: hcc cell line (hcc-lm ) was transfected with the chemically synthesized small interfering rna (sirna) in study arm and with non-specific sirna in control arm. real-time pcr and western blotting were used to quantify the mrna and opn protein levels. the malignant phenotypes including cellular growth rates, colony formation and matrigel invasion activities of the hcc cell line were analyzed. results: in study arm opn mrna expressions decreased % and opn protein decreased % compared to those of blank arm. the number of formed colonies and migrating numbers of the cells in vitro decreased significantly ( . % and . % respectively) in study arm compared to these of blank controls (p< . ). the parameters in the control arm did not differ from those of the blank arm (p> . ). conclusion: the specific sirna was able to reduce opn expressions at both the mrna and protein levels and significantly diminished the invasiveness of hcc cells. methods: the expressions of mif and vegf in hcc and adjacent tissues were detected from patients. specific sirna targeting mif gene was synthesized, and transfected into the hcc cell lines (plc and hepg ) in study group and non-specific sirna was used in controls. the mrna and protein expressions of mif and vegf were examined by pcr and western blot. results: mif and vegf mrnas were overexpressed in the hcc tissues compared with adjacent tissues (rq= . ± . and . ± . , p . ). the mrna and protein expressions of mif and vegf of hcc cell lines significantly decreased in study group compared with controls (p . ). vegf mrna levels decreased . %± . %; . %± . % in plc, and . %± . %; . %± . % in hepg cells when disposed with sirna nm and nm. vegf protein levels also significantly reduced in study group p . . conclusions mif and vegf mrnas were overexpressed in the hcc tissues in vivo, and mif sirna was able to knock down the expressions of mif and vegf in hcc cell lines in vitro. y.y. li, y.c. zhang, y.j. zhou, y.m. wei aim: to identify tumor-associated genes by constructing transcription profiles of pure hepatocellular carcinoma (hcc) tissues and normal liver tissues with the combination of laser capture microdissection and microarray. methods: hcc cells and normal liver cells from resection samples of patients were laser capture microdissected. micro-rna was isolated from them for linear amplification then crna was tested with whole genome microarray. differentially expressed genes were screened. results: the quality control of this technique was satisfactory with rna integrity number> , a /a ratio for crna measurement= . ~ . and good pictures for microarray. compared with normal liver tissues, hcc had differentially expressed genes, with being up-regulated and being down-regulated genes respectively. among the top ten ranked up-and down-regulated genes (total ), genes were known as hcc differentially expressed genes, , known as other tumors expressed genes previously. four unknown tumor related genes (depdc b, aspm, fcn and bbox ) were detected in this study. conclusion: the combination with laser capture microdissection and microarray was effective in screening the differentially expressed genes of hcc. background/objective: young patients present with large hcc on initial presentation are not uncommon. our aim is to study the computed tomography(ct) imaging of hcc and the clinical features of this special group of patients. methods: hcc patients had ct imaging of liver peformed in a three year period, patients had ct imaging peformed at the time of initial hcc diagnosis in our centre and were selected. they were divided into three age groups: young patients with age </= year-old(group ), age to (group ), age > (group ) to study imaging and clinical factors. univariate and multivariate analysis by cox regression model done to look for prognostic predictive factors. results: infiltrative tumour in ct scans, symptomatic presentation, child's and tm staging are prognostic factors in hcc. conclusion: young hcc patients have larger infiltrative tumour in initial ct scans and more being symptomatic. age is not an independent prognostic factor. aim: to investigate the expression change of nk cells receptor nkg d from human peripheral blood in patients with primary carcinoma of liver and study the relationship between nkg d expression and cytotoxicity of nk cells. background/aims: lens culinaris agglutinin-reactive alpha-fetoprotein (afp-l ) is a specific protein produced by hepatocellular carcinoma(hcc), which is more valuable than afp in the diagnosis of hcc. aptamers are oligonucleotide ligands binding to target molecules sensitively and specifically, which are screened from a great capacity of synthetically oligonucleotide library by systematic evolution of ligands by exponential enrichment (selex). our aims were to select the aptamers against afp-l from a self-designed ssdna library for potential application in diagnosis of hcc. methods: a random ssdna library and its corresponding primers were designed and synthesized. aptamers against afp-l were selected by selex. individual aptamers were separated by polymerase chain reaction-single strand conformation polymorphism (pcr-sscp) analysis and characterized. results: a ssdna library of nucleotides with random nucleotides in middle were designed and used for the selection. the binding rate of library against afp-l was increased from . % to . % after round selection. seven aptamers (s to s ) were isolated, and their sequences in random region and secondary structures were different from each other. all aptamers could bind afp-l in a different extent, and the dissociation constants of s and s are nmol/l and nmol/l. conclusions: aptamers for afp-l are successfully screened out and could bind afp-l specifically. methods: flow cytometry was used to determine the number of nk cells and the expression of nk cells receptor nkg d from human peripheral blood in patients with case primary carcinoma of liver case hepatitis b cirrhosis case hepatitis b and healthy cases and enzyme mark instrument was used to detect cytotoxicity of nk cells in all cases. results: killing rate of nk cell for k cell,nkg d expression level of nk cells, and the number of nk cells in the patients with primary carcinoma of liver decreased significantly p< . compared with those in the healthy subjects and hepatitis b group ,and decreased a little compared with those in the hepatitis b cirrhosis (p> . ).the activity of nk cells showed a obvious positive-correlation with the number of nk cell and expression level of nk cell receptor nkg d. conclusion: the cytotoxicity of nk and the nkg d expression of nk cells decreased significantly from human peripheral blood in patients with primary carcinoma of liver .the activity of nk cells is closely related to the nkg d expression level of nk cells. enhancing the nkg d expression level of nk cell may provide a new idea for adoptive immunotherapy of primary carcinoma of liver. and alpha-fetoprotein afp in serum and tissues for primary hepatic cancer(phc). methods: sixty-six phc and cirrhotic patients were enrolled. in phc patients,male /female was : , age was . ± . .of them, patients were defined as stage a-a. in cirrhotic patients, male /female was : , age was . ± . . serumgpc was detected using elisa. serum afp was detected using electrochemiluminescence. the hepatic expressions of gpc and afp were measured using immunohistochemistry in phc and cirrhotic patients. results: the cutoff value of afp diagnosis for phc was g / l or more, afp positive in phc patients was . % ( / ); the cutoff value of gpc diagnosis for phc was ng / l or more, gpc positive was in . % ( / ), p = . . in a-a stage phc patients,the positive of gpc and afp was . % ( / ), ( / ), respectively,p = . . in serum afp negative or positive patients, the positive of gpc was . % ( / ) , . % ( / ), respectively,p = . . the relationship between gpc with age, sex, child-pugh grade, hbv infection, tumor size and metastasis were not observed.the positive expression of gpc and afp in hepatocellular carcinoma tissue was . % ( / ), . % ( / ), respectively, p = . . neither gpc ,nor afp in the paracarcinomatous and cirrhotic tissue, was expressed. conclusions: diagnosis of glypican- protein for primary hepatic cancer is superior to afp.gpc can be regared as a early marker to diagnosis phc. objective: to investigate the effects and the possible mechanism of curcumin on the proliferation and the invasion of human hepatocellular carcinoma in vitro and in vivo. methods: hcclm -rfp cell lines were maintained in dmem medium supplemented with % fetal bovine serum. the fluorescent areas of hcclm -rfp were photographed daily and repeated in consecutive days after curcumin treatment for obtaining cell growth curves. the cell morphologic changes were also observed. cell invasion experiment was performed with boyden chamber array. the rfp-expressing human hcc xenograft model in nude mice was established to study the anti-tumor effects of curcumin. the ctc was detected by facs. the expression of cyclind and mmp- was detected by sybr green real-time pcr. results: after incubation with m, m and m curcumin respectively for , and hours, the growth of hcclm -rfp was significantly inhibited and some morphologic changes were observed. the mean tumor size in nude mice treated with curcumin since day were significantly less than those of the control group(p . ). the mean metastasis area of lung and the number of ctc in curcumin group on day were remarkably less than in the control group(p . ). the mrna levels of cyclin d p . and mmp- p . in curcumin group on day were significantly lower than in the control group. conclusion: curcumin can inhibit the proliferation and invasion of hcclm cell line not only in vitro but also in vivo mainly by down-regulating the expression of cyclin d and mmp- in mrna levels. phosphorylated erk is a potential predictor of sensitivity to therapy with sorafenib in hepatocellular carcinoma -evidence from in vitro study z. zhang , y.h. wang background: sorafenib is the first agent that has demonstrated an improved overall survival benefit in advanced hepatocellular carcinoma (hcc) and thus sets the new standard for the first-line treatment of advanced hcc. however, it remains unresolved to predict the drug sensitivity in treating hcc with sorafenib. pretreatment perk level has been shown to be associated with favorable response to such therapy in a phase preclinical study, indicating that perk may be a potential biomarker for treatment of hcc with sorafenib. methods: the effects of sorafenib and -fluorouracil on cell proliferation were evaluated by cell viability assay in four types of hcc cell line (smmc- , mhcc -l, mhcc -h and hcclm ), with different metastatic potential and basal perk expression. levels of perk expression were determined by immunocytochemical analysis and quantification, along with western blot analysis. correlation analysis was carried out between the ic values of drugs and mean optical density values of perk. results: the basal perk levels increased stepwise in cell lines in accordance with their metastatic potential. sorafenib inhibited erk phosphorylation at a concentration between and m dose-dependently, while no changes were observed after -fu treatment. correlation analysis between the ic values and mod values of perk revealed that the effects of sorafenib were significantly correlated with basal perk levels (spearman r=- . , p= . ). on the other hand, the resistance to -fu were significantly associated with basal perk expression in these hcc cell lines (spearman r= . , p= . ). conclusions: in this vitro study, perk was confirmed to be a useful biomarker predictive of sensitivity in treating hcc with sorafenib. the raf/mek/erk pathway may be involved in invasion, metastasis and drug resistance to traditional chemotherapy in hcc. background: to investigate the dynamic expression of igf-ii and igfbp- and its alteration of bcl- in hcc. methods: hcc models were induced with -faa on male sd rats. morphological changes of livers were observed and the dynamic changes of liver or serum igf-ii, igfbp- , and bcl- were quantitatively analyzed by elisa. the expression and distribution of liver igf-ii were observed by immunohistochemistry. result: hepatocytes from granule-like degeneration to a typical hyperplasia to hcc and the progressing increasing of the levels of hepatic igf-ii after rats induced by -faa. the levels of igf-ii in hepatoma and sera were significantly higher than any of other groups. the positive relationship of igf-ii was found between liver and sera (p< . ). the igfbp- levels in hepatoma were significantly lower than that in other groups (p< . ) and the progressing increasing of the levels of hepatic bcl- expression during the course. the levels of bcl- in hepatoma tissues were significantly higher than those in normal and degeneration ones. the immunohistochemistry evidences indicated the positive expression and hepatocyte distribution of bcl- in rat hepatoma. conclusion: hepatic igf-ii, igfbp- and bcl- may participate in hepatocyte canceration and accelerate the occurrence and development of hcc. the expression of igf-ii and igfbp- could be useful molecular markers for early diagnosis and prognosis of hcc. background: this study was done to assess the etiological role of hepatitis b virus (hbv), hepatitis c virus (hcv) and aflatoxin b (afb ) in development of hepatocellular carcinoma (hcc) in bangladesh. it was also investigated whether alpha-feto protein (afp) and protein induced by vitamin k absence or antagonist ii (pivka-ii) has any diagnostic advantage over each other methods: fifty five histologically proven hcc patients were tested for serological markers of hepatitis b and hepatitis c, and afb -dna adduct. during the diagnosis, they were also investigated for liver function tests, afp pivka-ii. results: out of fifty five hcc patients, ( . %) were found positive for serological markers of hbv, ( %) for hcv and ( %) for both. eight cases ( . %) were negative for the markers of hbv and hcv. however, none had afb -dna adduct above normal range. both pivka-ii and afp is strong marker for hcc with satisfactory level of sensitivity and specificity; but pivka-ii is more sensitive ( . %) and afp is more specific ( %). conclusions: hbv and hcv is the major etiological agent responsible for the development of hcc in bangladesh. background: to investigate the influences on the malignant transformation of hepatocytes through the intervention of nf-b activation pathway. method: hcc models were induced with -faa on sd rats, thalidomide was administered intragastrically and rats were sacrificed fortnightly interval to the twelfth week. morphological changes were observed by he staining. nf-b expressions were detected by ihc. the relationship between nf-b expression and pathological characteristics in hcc and non-hcc were analyzed. results: rat hepatocytes showed vacuole-like denaturations at the early stages, then dysplastic nodules appeared at middle stage, and finally progressed to tubercles of cancerous nest, all of which were highly differentiated hcc. thalidomine can repress the morphologic change of liver cells. there were only punctiform denaturations at the early and middle stage; nodosity hyperplasy and minority atypical hyperplasia were found at the finally stage. the ihc results demonstrated that nf-b level was significantly higher than those in normal ones, and the nf-b level of livers in hcc was higher than those in thalidomide group. an increasing tendency of nf-b was found from normal to hcc. nf-b in hcc were significantly higher than those in nc. the nf-b levels with thalidomide intervence raised first and decreased later. nf-b expressions in hcc were higher than that in their non-cancerous tissues. no positive relationship presented between nf-b expression and histological differentiation grade or the number of tumor, and size of tumor. conclusion: decrease nf-b expression can inhibit hcc development and nf-b is expected to be a new molecular target of hcc therapy. method: the cellular distributions of vegf expression in hcc tissues were investigated by immunohistochemistry. the levels of total rna and vegf were quantitatively detected in hcc, their paracancerous, and distal cancerous tissues, respectively. simultaneitily, serum vegf were analyzed in patients with chronic liver diseases for clinical values. results: the positive expression showed palm-yellow or palm-brown granules and distributed in hepatocyte plasma of hccs. the incidence of vegf was . % in hcc tissues, . % in non-encapsulated hccs, and . % in hccs with extrahepatic metastasis, respectively. no significant difference was found between hepatic vegf and hcc diameter or differentiation degree. the specific concentration (pg/mg liver) of vegf expression was significantly higher (p< . ) in hcc than their paracancerous or distal cancerous tissues, respectively. the circulating vegf was abnormally elevated in hcc. if the cut off values was more than pg/ml, the incidence of serum vegf was . % in hcc, . % in chronic hepatitis, and % in liver cirrhosis, respectively. the combined vegf and afp can increase positive rate up to . % for hcc. conclusion: the vegf overexpression is a useful marker for vascular invasion and metastasis of liver tumors. background: hepatocellular carcinoma (hcc) represents a major health problem world wide. it accounts for % of all primary liver cancers and is the fifth most common malignancy ( ). objectives: evaluation of radiofrequency thermal ablation versus transarterial hepatic chemoembolization with the effect of viscum (fraxini ) on tumour recurrence. methods: patients with hcc were enrolled in the study. group include patients and were treated with radiofrequency thermal ablation ( patients of them received viscum by subcutaneous route for years). group included patients with hcc and were treated by tace ( patients of them received viscum subcutaneously for years). results: group patients showed total ablation in % with persistant inactivity during years follow up. group did not show significant difference from group as regards relapse rate nor the performance status. complications as nausea, vomiting, fever, jaundice, and elevation of transaminases were significantly more encountered with tace. viscum did not significantly arrest tumour recurrence. conclusion: non surgical patients with hcc can achieve curative treatment with radiofrequency with minmal side effects. tace is a palliative treatment option for large hcc. a new technique had been attempted to increase the field of radiofrequency ablation of expandable electrode needles in the treatment of hepatic neoplasms much larger than the routinely covered size of - cm according to the needle size overcoming the technical difficulties usually met with in the overlapping balls technique due to the hyperechoic focus that develops at the needle tip making reinsertion difficult and inaccurate. in this technique, two or three needles were inserted from the start into the mass with accurate estimation of the exact field of ablation of each needle trying to cover the whole extent of the mass before application of radiofrequency waves. patients were included in the study, all presented with hepatic neoplastic mass lesion that range in size between and cm in its maximum diameter. all had a pretreatment helical (triphasic) ct study for accurate delineation of the whole extent and vascularity of the mass. two needles were sufficient to cover the whole extent of the mass in patients ( %) while in the remaining patients ( %) three needles were necessary. the procedure was done under general anathesia and ultra sound guidance, patients tolerated procedure well with smooth recovery. no major complications. follow up spiral (triphasic) ct was done weeks after ablation revealed percentage of tumour necrosis of % or more in patients ( %), - % in patients ( %) while in the remaining four patients ( %) the percentage was - % necrosis. in conclusion this technique should be considered in the treatment of hepatic masses larger than the usual field of the needle. results: the median value of gpc- in hcc, dc, cc was significantly higher than chronic hepatitis and control groups. no significant correlation found between afp and gpc- . auroc of afp was . & auroc of gpc- was . . the diagnostic sensitivity of afp ( ng/ml) was % with ppv . %. the specificity was % with npv . %. while the diagnostic sensitivity of gpc- ( ng/ml) was % with ppv %. the specificity was . % with npv %. combined serial approach of afp and gpc- improved the specificity to . %. conclusion:gpc- although it is a serological test for early detection of hcc, it showed limited specificity, where it is detected in different stages of chronic liver disease, as it is an oncofetal protein produced by regenerating liver cells. the diagnostic signature approach for simultaneous determination of afp and gpc- may improve the prediction accuracy of hcc patients in those showing seronegativity to afp. outcome of inoperable hepatocellular carcinoma patients receiving transarterial chemoembolization: retrospective analysis in an asian regional hospital w.m. yip , k.f. li , k.k. li , m.l. szeto background: hepatocellular carcinoma (hcc) is a common cancer worldwide causing substantial mortality. although surgical resection is a form of curative treatment in hcc, only a minority of patients is suitable for this treatment and the postoperative recurrence remains high. transarterial chemoembolization (tace) is a treatment option for inoperable hcc and it was proven by randomized control trials that tace can prolong survival in selected patients. the aim of this study is to evaluate the survival and the prognostic factors in patients with advanced hcc treated by tace. methods: seventy four patients with inoperable hcc diagnosed from january to december were analyzed retrospectively in this study. only patients with unresectable hcc or who refused operation were included. patients with advanced cirrhosis, extrahepatic metastasis or previously treated hcc were excluded. multiple host, tumor and treatment variables were analyzed in order to evaluate the predictive factors of favorable response to treatment and better survival. results: the median survival of the study patients was . days. the cumulative survival rates at year, year and year were . %, . % and . % respectively. by multivariate analysis, superselective cannulation performed in tace (hazard ratio: . , % ci: . - . , p= . ), embolization with gelfoam (hazard ratio: . , % ci: . - . , p= . ), treatment interval more than days (hazard ratio: . , % ci: . - . , p= . ), child-pugh grade b (hazard ratio: . , % ci: . - . , p= . ), and pre-treatment serum fp level (hazard ratio: . , % ci: . - . , p= . ) were independent predictors of survival. conclusions: survival of patients with inoperable hcc is still grave despite treatment. this study provided information in predicting the survival of patients with inoperable hepatocellular carcinoma treated by transarterial chemoembolization. result: age < , total bilirubin (tb) < . mg/dl, albumin (alb) . g/dl, prothrombin time (pt) %, platelet counts (plt) . /mm , single nodule, and type of treatment (surgery or local ablation therapy) were linked to increased survival at univariate analysis of clip - hcc patients. of clip - hcc patients, tb < . mg/dl, alb . g/dl, des-gamma-carboxy prothrombin (dcp) < mau/ml, absence of vascular invasion, and type of treatment were correlated with survival. the following factors were related to survival by multivariate analysis: clip - hcc patients; age, alb, single nodule, and absence of vascular invasion, clip - hcc patients; age, tb, alb, alpha-fetoprotein (afp) < ng/ml, dcp, absence of vascular invasion, and type of treatment. conclusion: age, albumin, vascular invasion were significant predictors of survival both clip - and clip - hcc patients. clip - hcc patients: single nodule; clip - hcc patients: lower levels of tumor markers and patients receiving promising treatment had a better chance of prolonged survival. the role of gross classification as the predictor of microvascular invasion in hepatocellular carcinoma. s. sumie , r. kuromatsu , k. okuda , e. ando , a. takata , n. fukushima , m. sata background; the presence of microvascular invasion (mvi) as the risk factor in hepatocellular carcinoma (hcc) is controversial. the aim of this study was to determine the outcomes and predictive factors after hepatic resection for hcc with mvi. methods; one hundred and ten patients who underwent curative resection for hcc were included in this retrospective study. the risk factors of these patients for recurrence-free and disease-specific survival were investigated, and the clinicopathological factors predicting the presence of mvi were also evaluated. result; multivariate analysis showed that cirrhosis and mvi were identified as independent risk factors for recurrence-free survival. the -year recurrence-free survival rates for patients with and without mvi were . % and . %, respectively. multivariate analysis showed that the number of tumors, presence of mvi, and im were identified as independent predictors of disease-specific survival. the -year disease-specific survival rates for patients with and without mvi were . % and . %, respectively. by univariate analysis, mvi was significantly associated with greater tumor size, gross classification, histological grade, and intrahepatic micrometastasis (im). gross classification proved to be the only independent predictive factor for mvi by multiple logistic regression analysis. the gross classification could be evaluated by preoperative imaging diagnosis. conclusion; mvi is strongly associated with recurrence and survival in hcc patients after curative resection. furthermore, gross classification of hcc can be helpful in predicting the presence of mvi. background: hcc is a common cause of cancer morbidity and mortality. pxd is a novel, low molecular weight, histone deacetylase inhibitor. this phase i study aims to determine dose limiting toxicity (dlt) and maximum tolerated dose (mtd). methods: patient eligibilities include unresectable disease, ecog , adequate organ functions. pxd was given intravenously on day - every weeks; dose levels were: (level ), (level ), (level ) and mg/m /day (level ). dlts are defined as grade hematological toxicity or grade / non-haematological toxicity during cycle (according to nci ctc v ), or treatment delay > weeks. the mtd is defined as the dose below which > of or > of patients experiencing dlt. results: patients were entered; level ( ), level ( ), level ( ) and level ( ). grade / / toxicities in cycle included: raised alt / / , diarrhea / / , abdominal distension / / , anaemia / / . a total of cycles were administered; overall grade / / toxicities: raised alt / / , bilirubinaemia / / ; cardiac ischaemia / / ; diarrhoea / / , abdominal distension / / , anaemia / / ; variceal haemorrhage / / ; hypercalcaemia / / ; hyperkalaemia / / ; hyponatraemia / / ; infection / / ; liver dysfunction / / ; muscle weakness / / ; abdominal pain / / ; prolonged qtc / / ; syncope / / ; seizure / / . there were sd and pd. conclusion: at the maximum dose of mg/m /day, mtd has not been reached. pxd is very well tolerated. sponsor: the division of cancer treatment and diagnosis, national cancer institute, usa. tumor thrombus (pvtt) is prone to be produced in the portal vein near the main tumor nodule for hepatocellular carcinoma (hcc) patients and its molecular mechanism is still unclear. in this study, we first established a hcc cell line named csqt- from resected tumor thrombus in portal vein in a patient with histopathologically proved to be a moderately differentiated hepatocellular carcinoma . this cell line was composed of polygonal shaped cells and its peaks of the chromosome number was and . study on stem cell biology in this cell line suggests that cd cells represent about one fourth of the tumor cell population and cd (+) cells possess a greater colony-forming efficiency, higher proliferative output, and greater ability to form tumor in vivo. with this cell line model and resected tumor thrombi specimen, we also studied the different expression of proteins in primary tumor and tumor thrombus and found proteins expressed differentially between primary tumor and the pvtt. from these proteins, annexinv, prx , cycb were selected for further analysis to find potential biomarkers of pvtt in hepatocarcinogenesis. for clinical study, we recommended a new tumor thrombus type system ( type i iv) according to anatomic features of portal vein and tumor thrombus of hcc developing modes, then evaluate this type system to predict prognosis of hcc patients. the retrospective data of hcc patients with pvtt underwent resection shows that the y, y, y overall survival rates were . , . and . for type i, . , . and . for type ii, . , . and . for type iii, . , and for type iv, respectively, suggests tumor thrombus type system may be helpful to determine treatments and prognosis of hcc patients with pvtt. polyprenol could decrease the risk of hepatocarcinogenesis in hbv g. kuznecova , , s. kuznecovs , , i. kuznecovs , background: over-expression of p-glycoprotein (pgp) is associated with liver cancer development from hbv . glycoprotein synthesis in malignant tissues is limited by dolichyl phosphate (dolp). the aim of the present study was to investigate the effect of polyprenol (pp) which provides a dolp substitute in regulation of n-glycosylation on pgp over-expression in the development of liver cancer in hbv infection. methods human hepatocytes, infected with hbv and human hepatocarcinoma hep b cell line were used. pgp was assessed by an immunohistochemical technique. dolp fractions were analysed by hplc methods. results it is confirmed that plasmatic membrans of hepatocytes cells contain , - , % of pgp (the total protein amount) as a resistance marker. hbv infected cells differ from normal hepatocytes in pgp content by - times and hep b cells differ by - times the study showed -fold dolp decrease in hbv infected cells and -fold dolp decrease in hep b cells. the investigations demonstrate that the situation can be changed by treatment with dolp and pp. the dolp concentration in hbv infected hepatocytes was returned to the normal level. it is established that dolp in the concentration - m aid - -fold reducing pgp in membranes of hbv infected cells. background: metastasis is one of the most complicated and major pathological processes responsible for poor prognosis of hepatocellular carcinoma. snail was recently highlighted as a critical transcriptional factor for tumor metastasis. method & result: real time rt/pcr and western blot analysis demonstrated that snail mrna and protein, respectively, were induced by -otetradecanoylphorbol- -acetate (tpa) in hepatoma cell hepg . blockade of gene expression of snail by antisense oligodeoxynucleotide and/or sirna technique can prevent not only the tpa-triggered emt/cell migration and growth inhibition of hepg but also tpa-induced down-regulation of e-cadherin and up-regulation of p ink b. moreover, the tpa-triggered promoter activation of p ink b was also prevented. on the other hand, two of the hepg clone overexpressing snail, namely s and s , had a scattered fibroblastic morphology and acquired higher motility than parental hepg . also, the proportion of g /g phase of s and s was higher than that of parental hepg , consistent with the longer doubling time of both cells. semiquantitative rt/pcr analysis demonstrated a greatly elevated gene expression of snail accompanied with decreased e-cadherin and increased p ink b in both snail-overexpressing cells. on the transcriptional level, p ink b promoter activity was . -fold higher in s as compared with parental hepg . furthermore, electrophoretic mobility of dna fragments encompassing proximal p ink b promoter can be retarded by incubation of nuclear extract of s . conclusion: our results demonstrated that snail play diverse trans-regulatory roles in hepg . notably, we suggested that snail may upregulate p ink b gene expression by directly activating its promoter. a. schmitt-graeff , r. fischer , m. grosse-perdekamp , o. skalli universityhospital freiburg , louisiana state university health sciences center, shreveport background/aims: synemin is an intermediate filaments (if) protein which affects the motility of several cell types by modulating the dynamic properties of alpha-actinin and f-actin. we have previously shown that synemin is expressed in resident hepatic stellate cells (hsc) and myofibroblasts (mf) in hepatic inflammation and fibrosis. in the present study we evaluated systematically the expression of synemin in a large cohort of western european hepatocellular carcinoma (hcc). methods: single and double immunolabelin for alpha-smooth muscle actin (sma), vimentin, cd , cd , cd , cea, cd , cellular retinol-binding protein (crbp- ) and synemin were performed on paraffin-embedded hccs and controls. results: synemin-positive hscs/ mfs were a hallmark of non-neoplastic fibrotic liver tissue at the border to the neoplastic lesion but were absent from normal controls. tumour cell plates of the trabecular and pseudoglandular types of hcc were covered by scattered synemin-positive cells outlining sinusoidal structures. a subpopulation of these cells showed features of pericytes while others resembled endothelium. this pattern correlated with the degree of differentiation and was not observed in poorly differentiated hccs which generally contained rare intratumoral mfs. conclusion: the presence of synemin-positive hscs/mfs in the vicinity of hccs suggests a possible contribution of mesenchymal cells to the promotion of liver carcinogenesis. since synemin expression is linked to motility, a migration of this cell type into the tumour and a differentiation in vascular mural cells may be implicated in sinusoidal remodeling and the expansion of the neoplastic population. a.s. butt , a. ahmed , s. hamid , w. jafri , h. ali shah aim: to estimate the prevalence of viral marker negative hcc and to compare the clinical, biochemical, histological, radiological characteristics and initial treatment response among patients with viral marker negative and viral marker positive hcc. methods: medical records of patients diagnosed to have hcc visiting aga khan university hospital, karachi during january to december were reviewed. patients were divided in to nbnc-hcc(those who have negative hbsag and anti-hcv antibody)and viral hcc(those who have positive hbsag and anti-hcv antibody)group. results: out of patients ( . %) had nbnc-hcc. over all mean age was . ± . years and . % were males. the proportion of hcc detected under surveillance was significantly smaller in nbnc-hcc group(p . ). there was no difference in distribution of age, gender, bmi, child score, bilirubin, serum albumin, prothrombin time and alfa feto protein in both groups. however, patients with viral-hcc were found to be more thrombocytopenic( . ± . vs. . ± . ,p< . ) and had hepatopulmonary syndrome. on liver biopsy greater proportion of moderate to poorly differentiated hcc was observed in nbnc group( . %vs. . %,p< . ). hcc measuring cm in diameter( . %vs. . %, p . ), non -solitary hcc(p . ) and portal thromboses(p . ) were strongly demonstrated in nbnc-hcc group. involvement of right hepatic lobe and extra hepatic tumor spread was greater in nbnc-hcc group but that difference was not statistically significant. out of patients who underwent for liver transplantation( . %),tace( . %),resection( %),ethanol ablation( %) and chemotherapy( %), poorer responses were observed in nbnc-hcc group (p . ). conclusion: hcc secondary to nbnc-cirrhosis is not uncommon. patients with nbnc-hcc tended not to be under surveillance that leads to diagnoses at more advanced stage and poor prognosis. background: hepatocellular carcinoma is a common malignancy in asia and is related to the high prevalence of chronic viral hepatitis. we examined the clinical features, treatments and survival rates in asian americans with hcc. methods: retrospective cohort study of hcc patients who presented to the ucla liver cancer center in los angeles, california, usa from september to december . results: two hundred and seventeen of ( %) hcc patients were male, % and % had hbv and hcv infection respectively, and % had cirrhosis. hcc patients detected by surveillance had smaller tumor sizes, more within the milan and ucsf criteria, lower hcc tokyo system scores and had improved , , year overall patient and disease free survival rates compared to hcc patients who presented with symptoms (p< . to p< . ). by multivariate analysis, independent predictors of patient survival were tumor volumes greater than cm (hr . , p= . ), afp per unit log increase (hr . , p= . ), hcc tokyo score per unit increase (hr . , p< . ), liver transplantation (hr . , p< . ), hepatic resection (hr . , p< . ), rfa (hr . , p< . ), tace (hr . , p= . ), and hepatitis b infection (hr . , p= . ). factors associated with disease free survival were age per year increase (hr . , p= . ), meld per unit increase (hr . , p= . ), liver transplantation (hr . , p< . ), and hepatic resection (hr . , p< . ). conclusion: hbv and hcv infection accounts for the majority of hcc in asian americans. hcc detected by surveillance resulted in treatments which improved overall patient and disease free survival. treatment of small ( cm) hcc tumours can be achieved by surgical resection and complete eradication always correlates with good patient's outcome, with low local recurrence and high survival rates. indeed, surveillance program for the early detection of small hcc tumour is imperative to facilitate curative treatment, and hence better survival. discovery of new blood-based biomarkers is obligatory and vimentin is a distinct novel small hcc tumour marker herein identified using proteomics. experimental design: a total of liver tissues were evaluated by -de analysis. differentially expressed proteins were unequivocally identified by maldi-tof/tof and validation of the best candidate from protein to gene levels. indirect elisa assay was developed to detect soluble vimentin from serum samples. results: vimentin was significantly over-expressed in small hcc tumours compared to non-malignant controls and maintained expression in > cm tumours using -de analysis. blind verification displayed over-expression of vimentin in both transcripts and proteins levels. soluble vimentin was significantly detected at high level in small hcc as well as in overt hcc tumours. receiver operating characteristic analysis showed vimentin exhibited . % sensitivity and . % specificity in detecting small hcc at a cutoff of ng/ml. combined diagnostic performance of soluble vimentin and serum afp increases the detection sensitivity and specificity to . % and . %, respectively. conclusion: in this context, over-expression of vimentin is associated with the favourable cm sub-class of hcc thus may potentially be used as an effective serum-based diagnostic marker for cancer surveillance in high-risk cirrhotic patients. purpose: our recent comparative oncogenomic analysis in mouse model has identified yap (yes associated protein) as a novel oncogene in hcc. however, its clinical significance is unknown. in this study, we aimed to investigate the clinical values of yap as an independent prognostic marker in hcc. experimental design: a total of hcc cases with retrospective clinicopathologic and follow-up data were recruited in this study. both tumor and adjacent non-tumor tissues were examined for immunoreactivity of yap expression by immunohistochemistry. clinicopathologic features and yap expression were investigated with pearson test. hcc-specific disease free survival and overall survival with yap expression were analyzed by kaplan-meier curves and log-rank test. cox regression was used to test the independence and magnitude of the effects. results: yap was found over-expressed in hcc ( . %) with nuclear expression pattern. positive yap immunoreactivity was significantly correlated with worse tumor differentiation grade (p= . ) and high serum alpha-fetoprotein (afp) level > ng/ml (p< . ). kaplan-meier plot and cox regression showed that yap was an independent predictor for hcc-specific disease free survival (hazard ratio, . ; % ci, . - . ; p= . ) and overall survival (hazard ratio, . ; % ci, . - . ; p= . ). conclusions: yap expression in hcc is correlated with tumor differentiation and serum afp level. it served as an independent prognostic marker for hcc. background: integrative analysis of global protein and mrna expression patterns could help researchers to understand cancer cell physiology without the need of any prior hypothesis. methods: we used a d-page approach to profile and compared the global protein expression profiles of hepatitis b virus-related hcc tissues, adjacent non-tumor liver tissues, normal liver tissues and hcc cell lines. subsequently, we established the bioinformatic tools for integrative analysis of gene expression and protein expression data. we compared the dysregulated protein list and the dysregulated gene lists obtained by meta-analysis of microarray gene expression data from research centers in different countries. results: we identified proteins dysregulated in hcc. hierarchical clustering analysis revealed that there was a progressive change of protein expression patterns from normal liver, adjacent non-tumor liver tissues, hcc tissue, then to hcc cell lines. according to the biological functions, the differential proteins could be classified into various groups, including heat shock protein, chaperone, kinase substrate, cell signaling, apoptosis regulation, transcription regulation, free-radical scavenger and metabolic enzyme. ontology analysis of the genes with consistent dysregulations at both mrna and protein levels identified specific pathways down-regulated during the progression of hcc. the inhibition of those pathways provides new insights in the hepatcarcinogensis and treatment strategies. results: in pre-s/surface regions, hcc patients had higher frequencies of pre-s deletions, amino acid substitutions at codon , , and in pre-s genes, at the start codon in pre-s genes, and at codon in surface genes. but they had a lower frequency of amino acid substitution at codon in pre-s genes than those without hcc. in bcp/precore regions, hcc patients had higher frequencies of c or g , a /t , t , and a than those without hcc. multivariate analysis showed that pre-s deletions, i t in surface gene, t /a , and a were independent factors for hcc. the hbv with a complex mutation pattern (pre-s deletion, t /a , and a ) rather than a single mutation was associated with hcc. patients with combined mutations of t /a and pre-s deletion, t /a and a , pre-s deletions and a , and t /a , pre-s deletions and a had a . , . , . , and . fold increased risk of hcc, respectively, compared to patients with wild-type at both or three genomic regions. conclusions: pre-s deletions, i t in surface gene, t /a , and a were independent factors for hcc. combination of these viral mutations appeared increasing hcc risks. high peritumoral expression of placental growth factor in hepatocellular carcinoma is a poor factor for survival after curative resection h.x. xu , x.d. zhu , p.y. zhuang , w.zhang , h.chuan sun background/aims: angiogenesis plays a significant role in the metastasis and recurrence of hepatocellular carcinoma (hcc). placental growth factor (plgf), which is one member of the vascular endothelial growth factor family, may have prognostic values in patients after curative resection of hcc. methods: expression of plgf was assessed by immunohistochemistry in tissue microarray containing paired peritumoral liver tissue and tumor from patients underwent hepatectomy for histologically proved hcc. prognostic values of plgf and clinicopathological factors were evaluated. result: plgf staining was mainly on the cytoplasm of tumor cells or hepatocytes. the mean integrated optical densities of peritumoral and intratumoral density of plgf were . ± . and . ± . respectively. peritumoral plgf density was significantly higher than that in tumor (p< . ), and this result was also validated in another cohort of patients by quantitative real-time reverse transcription-pcr (p= . ). intratumoral density of plgf was not correlated with common clinicopathological factors (eg, tnm stage, tumor size, microvascular invasion, intra-hepatic metastasis) or overall survival (os) (p= . ) and time to recurrence (ttr) (p= . ). however, peritumoral density of plgf, which was correlated with tumor size (p= . ) and intrahepatic metastasis (p= . ), was a prognostic factor for both os (p= . ) and ttr (p= . ). in multivariate analysis, peritumoral expression of plgf was also an independent prognostic factor for os (p= . , rr: . % ci: . - . ) and ttr (p= . , rr: . % ci: . - . ). conclusion: peritumoral expression of plgf in hcc patients is an independent risk factor for survival and recurrence, and may be a target of anti-angiogenic therapy in preventing post-operative recurrence. purpose: to further research rfa in combination with hepatic artery-portal vein chemotherapy and ethanol injection for treatment of advanced hepatocelluar carcinoma (hcc). methods: cases were treated with transhepatic artery chemoembolization (tace) + radiofrequency ablation (rfa) + introportal vein chemotherapy (pvc) + percutaneous ethanol injection (pei) (four combined group) and this method was compared with cases that were performed tace + pei (two combined group) . the serum level of afp was measured respectively after and months, ct scan and color doppler ultrasound were measured after treatment for six months. results: the serum level of afp declined in two groups after months. for treatment after six months, afp in four combined groups was rose lower than two combined group (x = . , p< . ). ct and doppler ultrasound examination, four combined groups was superior than two combined groups to the control in tumor shrinkage (x = . , p< . ) and blood supply x = . , p< . ), relapse and mortality are also less. conclusions: rfa in combination with hepatic artery-portal vein chemotherapy and ethanol injection is a safe, effective combined method and has less complication in treatment of advanced hcc. poster exhibition -hcv poster session, hall b on the average, hepatitis c virus infects . % of the population worldwide. in egypt, the prevalence rates reach % in some areas. ability of the virus to persist in about - % of infected individuals is related to the virus higher mutation rate. six major hcv genotypes have been identified. genotype seems to be confined to the middle east and central africa. extra hepatic syndromes have been reported in up to / of hcv patients. we aim in this study to determine the relationship between viral genotypes and specific extra hepatic haematological disease in patients with chronic hepatitis c. the study group included selected patients with chronic hepatitis c having various haematological problems. we studied hepatitis c virus genotypes using rt-pcr. we found among patients , genotype ( %) and patients genotype a ( %). patients ( . %) were diagnosed as chronic hepatitis c with associated thrombocytopenia, patients ( . %) were diagnosed mixed essential cryoglobulinemia(mec), patients ( . %) were diagnosed non-hodgkin's lymphoma, and patients ( %) were aplastic anemia. positive serum cryoglobulins level was found in patients ( . %).no significant correlation was found between the level of viraemia and specific haematologic disease, biochemical liver markers or liver enzymes (p> . ). we did not find correlation between hcv genotype and specific extrahepatic haemological disorder in hcv infected patients. several environmental, genetic and immunological factors may contribute in disease progression. results: in the targeted area shops of barbers were successfully interviewed and total questionnaires were filled by both groups. the mean age were found in both groups of barbers (n= ) and clients (n= ), . years. the both groups showed that there are no any drugs which can protect us from diseases. both of the groups were not vaccinated for hepatitis b diseases. regarding the care providers the barbers replied that they prefer registered medical practitioners and the clients generally prefer the hakeems. those who knew hepatitis as liver disease, were ( . %), out of barbers only ( . %) were knowing about hepatitis-b&c, when we enquired about routes of hbv& hcv transmission only ( %) replied correct routes of transmission in both groups. about hbv vaccination ( . %) were aware, only ( . %) were vaccinated against hbv. % barbers claimed for disinfection of instruments before shaving ( . %) claimed for use of new blades. in the sero-surveillance the hbv found was very low and hcv became epidemic ( . % - . %) respectively. conclusion: the both groups need awareness for transmission. the use of new blade for the clients reduces the burden of hbv and hcv. the study highlights the roles of male sex, older age, and genotype b in the progression from chc infection to hcc. patients with higher hcv viral load potentially tend to develop hcc; however, hcc occurrence could be prevented using antiviral treatment. these two points need to be clarified further by a larger study population with longer follow-up period. an approach have recently been described that retroviral vectors encoding t cell receptor (tcr) genes are used to redirect the specificity of normal peripheral blood lymphocyte (pbl)-derived t cells to recognize the tumor antigens. the therapy in which t cells have been genetically modified with tcr genes to recognize hcv would represent a novel approach for the treatment of hcv infections and hcv-related malignancies. we have previously shown that hcv+ liver transplant patients that have received hla disparate liver allografts have hcv reactive t cells of host origin in their peripheral blood that are restricted by the donor hla molecules. initial studies indicate that the tcrs expressed by hcv reactive t cell clones from these patients have relatively high affinity for their ligands. we have cloned and expressed two tcrs which mediate recognition of the - and - epitopes from the hcv ns protein. the results indicate that these tcr transduced t cells can recognize the wild type epitopes, as well naturally occurring mutant variants of these epitopes. most importantly, the tcr transduced t cells could also recognize hcv+ hepatocellular carcinoma cells. these data suggest this high affinity hcv-specific tcr might have potential new immunotherapeutic implications. background: factors associated with svr in patients without an rvr remains unclear. methods: hcv- ( for and weeks, separately) and hcv- ( for weeks, for weeks) patients were randomized to peginterferon-alpha- a and ribavirin for analysis. results: multivariate analysis showed that treatment duration and a complete evr were the strongest independent factors associated with an svr. a higher svr rate and a lower relapse rate were observed in the standard regimen group than in the abbreviated group in patients who had a cevr (table ). the best levels of viral loads in predicting cevr at week were < iu/ml (table ) . conclusion: it was crucial to achieve a cevr with adequate treatment duration in patients who failed to achieve an rvr. our aim was to evaluate the impact of some biochemical, histological and viral factors on both evr and svr in patients with genotype chronic hepatitis c (chc) treated with peginterferon plus ribavirin. patients and methods: we evaluated retrospectively naïve patients with chc treated with peginterferon plus ribavirin at standard weight-based doses for weeks. biopsies were assessed for inflammatory activity and fibrosis. steatosis was categorized by the proportion of hepatocytes per low-power field with fatty changes: > %, > - %, - %, > %. biopsies were also assessed for stainable iron using the brissot scoring system. all patients were evaluated for metabolic syndrome (ms) using the ncep-atp iii criteria. results: evr was achieved in / pts ( . %) while svr occurred in / ( . %). after adjusting for sex and age, independent factors that negatively interfered with both evr and svr were: fibrosis score, steatosis, iron score, homa-ir index and viral load. after excluding the patients with ms criteria (n= ), evr was observed in / ( . %) and svr in / ( . %). factors that independently influenced both evr and svr were: fibrosis score, steatosis, iron score and viral load. conclusion: fibrosis, steatosis and iron scores, as well as viral load are independent parameters that can affect both evr and svr in genotype chc patients, regardless the presence of ms. if ms is present, high homa-ir index can also additionally impair viral response. issue/argument: asia has rising cases of hepatitisb/c. alcohol/food-habits cause high prevalence in rural/tribal areas. lack of monitoring/follow-up complicates management. vaccines emerge as hope. clinical-trials of vaccines debated-issue. design of hepatitis-vaccine-trials in developing-countries complex ethical-issue. we focus on controversies identified in international/regional/local cme/pharma programs as vulnerability of volunteers to exploitation by foreign/local research-groups/funding-agencies. critical task is protect interests of vaccine-subjects in face of substantial-risks. determine if hepatitis-vaccine-volunteers will have access to treatment during trial. access to vaccine-trial-outcome. interaction with seniors th apasl-congress from developed-countries will give voice to such burning-issues. methodology: researchers/pharmaceuticals/govt-policy planners need to develop forum to solve these problems. ngo's can play pivotal role. obligation on part of researchers to create mechanisms to offset anticipated risks of participation in controversial, risky vaccine-development. conclusion: counselling/right to withdraw from trial be made basic guideline. apart from monetary aspects unsuspected adverse reactions/deaths be properly evaluated/monitored. researchers need to evolve policy-guidelines to overcome barriers as variation in interpretation of essential ethical ideas, legal-system-differences, educational/economic-status. need to develop common consensus between research-community/pharma sector to reduce suffering of hepatitis-affected patients community. recommendations: researchers/ngos should come together at th apasl-congress platform to form workgroup to settle these issues. we shall raise our this burning issue & present hepatitis-prevention-advocacy plan of our ngo graphically to apasl- participants. results: % patients expressed that alternative-medicines-rx most important factor to cope with hepatitis. higher scores of qol (anova p < . ) correlated with alternative-medicines-rx. our ngo-initiative suggests that over % patients will need well trained specialist for home-based-care unit. conclusions: life-span/qol of hepatitis-sufferers depends on appropriate-palliative-care. ngo-personals should be trained in palliative-care-services. our data is being used for palliative care advocacy. field of spiritual/psycho-social/community support is fertile ground for further investigations. such use of complimentary indian medicinal plant extracts needs further evaluation in a large group in multicentre trial. treatment with adacolumn in patients with hepatitis c related who have undergone kidney transplantation: preliminary study g. novelli la sapienza university introduction: patients who have undergone kidney transplant and suffer from hepatic c related (hcv) cannot be treated with standard therapy (peg-ifn combined with ribavirine) due to acute rejection risk. furthermore, immuno-suppressive therapy facilitates progression and infection and chronic hepatopathesis. monocytes and macrophages are known to produce extra-hepatic breeding sites and spread disease. our aim was to lower macrophages, granulocytes,monocytes, pro-inflammatory cells and viremia levels using an extra-corporeal device:adacolumn®(otzuka). methods: the adalcolumn filter is filled with mm. cellulose acetate beads immersed in sterile saline solution. these carriers absorb granulocytes and monocytes/macrophanges through fcr receptors. six patients were treated in our department. all patients were affected by virale genotype b. patients underwent five hour treatments for five consecutive days according to protocol. results: during treatment cycles and successive follow ups we observed a stabilization of kidney parameters and a non significant decrease in transaminase levels. at rd month follow up we observed a significant decrease in plasma hcv-rna in patients (p< . ) associated with attenuation of inflammatory phase (p< . ) and variations in immunomodulation. only one patient presented altered cd + and cd + where positive was observed at rd month. in another patient, even though immunomodulation improved, there was no reduction in viremia. conclusions: considering the results this method should be used on a greater number of patients evaluating successive treatment times in case of viremia increase. background: patients who have undergone kidney transplant and suffer from hepatic c related (hcv) cannot be treated with standard therapy (peg-ifn combined with ribavirine) due to acute rejection risk. furthermore, immuno-suppressive therapy facilitates progression and infection and chronic hepatopathesis. monocytes and macrophages are known to produce extra-hepatic breeding sites and spread disease. our aim was to lower macrophages, granulocytes,monocytes, pro-inflammatory cells and viremia levels using an extra-corporeal device:adacolumn®(otzuka). methods: the adalcolumn filter is filled with mm. cellulose acetate beads immersed in sterile saline solution. these carriers absorb granulocytes and monocytes/macrophanges through fcr receptors. six patients were treated in our department. all patients were affected by virale genotype b. patients underwent five hour treatments for five consecutive days according to protocol. results: during treatment cycles and successive follow ups we observed a stabilization of kidney parameters and a non significant decrease in transaminase levels. at rd month follow up we observed a significant decrease in plasma hcv-rna in patients (p< . ) associated with attenuation of inflammatory phase (p< . ) and variations in immunomodulation. only one patient presented altered cd + and cd + where positive was observed at rd month. in another patient, even though immunomodulation improved, there was no reduction in viremia. conclusions: the treatment was found to be safe without hemodynamic or infective complications. considering the results this method should be used on a greater number of patients evaluating successive treatment times in case of viremia increase. m. sharaf-eldin , h. el batae , n. abd el-ghaffar , w. rasheed tanta faculty of medicine , egypt., national research centre, cairo, egypt aim: we aimed to characterize serum cytokine levels of interleukin- beta (il- ) and interleukin - (il- ) in hcv infected patients & in patients with hepatocellular carcinoma (hcc) in comparison to control group and their possible use as markers of disease progression. patients and methods: sixty patients were divided into three groups: group i: twenty hcv infected patients without cirrhotic changes. group ii: twenty hcv infected patients with liver cirrhosis (lc). group iii: twenty hcv infected patients with hcc and healthy subjects as control group. all patients and control group were subjected to biochemical and serological tests, anti hcv, hcv (rt-pcr) and cytokines measurements of serum il- & serum il- levels. results: showed a high statistically significant elevated serum il- and il- levels in patients with chronic hcv infection in comparison to control group. highly statistically elevated levels of il- and il- in liver cirrhosis and higher levels were found in hcc group in comparison to control group. the levels of il- and il- increased significantly in hcv infected patients as the disease progress. conclusion: serum il- , and il- levels are elevated in patients with hepatitis c-related liver diseases, especially in lc and hcc patients. their levels reflect hepatic dysfunction better than liver inflammation parameters; accordingly, we may use serum il- and il- as markers for liver disease progression in hcv-infected patients instead of invasive techniques. atsushi tanaka , naoko hanawa , mitsuhiko aiso , yoriyuki takamori , hajime takikawa teikyo university school of medicine background and aim: pegylated interferon (peg-ifn) therapy is not indicated for many cases with hcv-related cirrhosis due to various adverse effects. however, patients with hcv cirrhosis are at high risk for development of hepatocellular carcinoma (hcc). thus we have introduced low-dose peg-ifn treatment for patients for compensated hcv cirrhosis. patients and methods: selection criteria for low dose peg-ifn is ) compensated hcv-related cirrhosis, and ) either the elderly (> ) or presence of thrombocytopenia (< . x / l). we have treated patients who met these criteria with low-dose peg-ifn, consisting of either peg- a g/ - w or peg- b . g/kg/w+ribavirin mg/d. [results] twenty patients with compensated hcv cirrhosis (all patients genotype b) have been treated with low-dose peg-ifn (peg- a: , peg - b+rib: . the age, platelet counts (x / l), and alt (iu/l) of patients at baseline were . ± . , . ± . , and . ± . respectively. all patients were well tolerated. low-dose peg-ifn has been continued . ± . weeks on average. although viral response was not detected, biological response (br), defined as maintenance of alt within normal range, was obtained in patients ( / = %). of note, neither development of hcc nor decompensated cirrhosis was observed in these br cases. by contrast, hcc and decompensation developed in and patients respectively among patients who failed to achieve br. conclusion: low-dose peg-ifn treatment was safe and well tolerable, and could potentially prevent hcc or decompensation in patients with liver cirrhosis when br was obtained. aims: to study the efficacy of peginterferon and ribavirin in treating chronic hepatitis c (chc) with genotype a in hong kong chinese. methods: to assess sustained virological response (svr) (serum hcvrna< iu/ml) at -months follow-up. results: nine patients with genotype a chc (included from jan to dec ) received peginterferon and ribavirin. mean age: (range - ). mean alt before treatment: iu/l (range - iu/l). seven patients had liver biopsy performed, only one showed stage - fibrosis and others showed active hepatitis without advanced fibrosis. mean serum hcv-rna: . x iu/ml(range . x - . x iu/ml). six patients had received peginterferon alfa- b ( . mcg/kg/week), other received peginterferon alfa- a ( mcg/week). ribavirin dosage ranged from mg- mg/day depending on body weight and baseline haemoglobin. treatment durations were - weeks in patients, - weeks in patients as one showed rapid virologic response at week and the other was intolerant to side effect of peginterferon. eight patients had early virologic response at week and one had > log drop of hcvrna. eight patients had end-of-treatment response. eight patients ( . %) achieved svr at end of follow-up. two patients who received only - weeks of combination therapy also achieved svr. the one who failed to achieve svr was at older age of and had advanced fibrosis. conclusions: the efficacy of pegylated interferon and ribavirin in treating chinese patients with chronic hepatitis c genotype a can achieve high sustained virologic response rate of . %. t. bharati , , p. kar , a. mohammad , k. mariappan , j. annamalai , r. introduction: hcv is a recognized cause of hcc. information on hcv genotypes in hcc are scanty in india. methods: a total of hcc cases from delhi, hcc cases from madurai and cases of chronic hepatitis without hcc were controls in the study. rt-pcr for hcv rna and genotyping were carried out in all the cases results: in group-i, hcv rna was positive in . % hcc cases in which genotype was found in . % genotype was observed in . % hcc cases. whereas . % cases remained nontypable. in group-ii, hcv rna was positive in . % hcc cases, with genotype in . % cases, genotype in . % cases and genotype in . % cases. however, . % cases remained nontypable. out of the control cases, were ch and were cirrhosis. in ch group, hcv rna was positive in . % cases in which, genotype was detected in . % cases whereas genotype was observed in . % cases . however . % cases remained nontypable. in cirrhosis group, hcv rna was positive in . %cases. genotype was found in . % cases. while genotype was present in . % cases and . % cases remained nontypable. conclusion: genotype in delhi and genotype in madurai were predominant. in hcc cases. our study demonstrates that no particular hcv genotypes were associated with hcc and genotype did not appear to influence the development of hcv-associated hcc. background/aims: the standard treatment for chronic hepatitis c infected with hcv genotype- is a combination of pegylated interferon alfa and ribavirin for a weeks. it is unclear if weeks treatment is possible for patients showing a rapid virologic response (rvr) without compromising the sustained virologic response (svr) in korea. method: between june and july , among patients chronically infected with the hcv genotype- (hcv- ) who were treated with pegylated interferon alfa subcutaneously once weekly plus ribavirin (weight-based), consecutive paients who had low pretreatment viral load ( . x copies/ml) and rvr were treated for weeks and then followed up for weeks. the hcv rna was quantitatively assessed pretreatment, at weeks of treatment and was qualitatively assessed at weeks of treatment, the end of treatment ( weeks), weeks after end of treatment. rvr was defined as undetectable hcv rna at the weeks. results: baseline characteristics of patients was as followed; age ( - years:mean years), bmi ( - kg/m²:mean . kg/m²), hcv rna titer ( . - . × copies/ml:mean . × copies/ml), alt ( - iu/l:median iu/l). among the patients, all patients ( %) had sustained virologic response (svr). conclusions: hcv- infected patients with a low baseline hcv rna concentration ( . × copies/ml) who had hcv rna negative at week of treatment may be treatment for weeks without compromising sustained virlolgic response. however, an additional trial will be needed to optimize the treatment duration. background/aims: acute hepatitis c (ahc) has a high chronicity rate of up to ~ % if it is not treated. although the good treatment response to pegylated interferon (peg-interferon) therapy has reported, there is not definite guideline to treat of ahc in korea yet. the aim of our study was to investigate the clinical course and treatment outcome of ahc in single center of korea. methods: we performed a retrospective analysis of patients who were diagnosed with ahc during the period from may to december . the diagnosis of ahc was based on seroconversion to anti-hcv antibody or the clinical and biochemical diagnostic criteria satisfactory to ahc and on the presence of hcv rna in first serum sample. the spontaneous resolution was defined as loss of hcv rna in serum for -month in untreated group, and in treatment group, the sustained virological response (svr) was defined as a index of treatment success. results : thirteen of thirty-five patients were treated, six of thirty-five were untreated and observed clinical course, and sixteen patients were not followed up after diagnosis. in treatment group, nine of thirteen ( %) acquired svr, and two of six ( %) showed spontaneous resolution in untreated group. ten of thirteen treatment patients used conventional interferon, and another three patients used peg-interferon. conclusion : compared with untreated group, there was higher svr rate in treatment group ( % vs. %). so early interferon treatment in acute hepatitis c should be considered. background: this study was conducted to identify predictors of thyroid dysfunction and to determine whether virologic factors or treatment response affect thyroid dysfunction development during peginterferon (pegifn) therapy in chronic hepatitis c patients. methods: sixty chronic hepatitis c patients treated with pegifn - a or - b in combination with ribavirin from st july to th july were included in this study. treatment responses were evaluated and thyroid functions were assessed every weeks. results: seventeen patients ( . %) experienced thyroid dysfunction during treatment, and that occurred more frequently in women and in patients with a lower body mass index (bmi). the proportion of patients with a high viral load (a serum hcv rna titer > , iu/ml) was significantly higher in the thyroid dysfunction group rather than in the euthyroid group( . % vs. . %, p= . ). among patients with hcv genotype , the rate of sustained virologic response was lower, and relapse occurred more frequently in the thyroid dysfunction group than in the euthyroid function group during pegifn-based therapy(svr, p= . ; relapse, p= . ). the female gender and the high viral load were independent predictors of thyroid dysfunction in multivariable analyses (female, or . , p= . ; high hcv rna titer, or . , p= . ) . conclusion: the risk of thyroid dysfunction during pegifn therapy for chronic hepatitis c was found to be higher for women and for those with a low bmi and a high viral load. background: in peginterferon alpha b (peg-ifn b) and ribavirin (rbv) combination therapy for weeks for patients with chronic hepatitis c, it is still difficult to predict which patients will achieve sustained viral response (svr) at the completion of this therapy. aim: to predict svr and non-svr (relapse) at the end of this combination therapy by determining changes of serum hyaluronic acid (ha) levels. methods: eighteen patients were enrolled and their serum ha levels were measured before therapy, and after the st, nd, rd, and last trimesters during therapy. results: eleven patients achieved svr and became relapsers. all patients showed higher ha levels in the st trimester than the pretreatment levels. in the svr group, of ( . %) patients in the nd, of ( . %) in the rd, and of ( . %) in the last trimester showed lower ha levels than the pretreatment levels. by contrast, in the relapser group, none in the nd, of ( . %) in the rd, and of ( . %) (p< . ) in the last trimester showed lower ha levels than the pretreatment levels. this study revealed that as the -week therapy went on, ha levels were more likely to fall below the pretreatment levels by the last trimester in patients achieving svr. however, ha levels of relapsers tended to continuously be above the pretreatment levels. conclusion: determination of changes of serum ha levels during peg-ifn b and rbv therapy predicts svr and non-svr at the completion of this therapy. results: the most frequent lymphomas were with high malignancy ( %), intermediate ( . %) and low degree ( . %). cryopathy was negative ( . %). the presence of viral markers was performed soon as possible after the nhl diagnosis, at the same time ( . %) or during the first year of evolution ( . %). the prevalence of the hcv infection was %, comparable to the one in the control patients group ( . %), admitted in a gastroenterological clinic. on the other hand, this prevalence is significantly increased compared to the one in the general romanian population ( . %). the patients with nhl and hcv infection belonged especially to the low and intermediate malignancy degrees; the survival was influenced by the malignancy degree and not by the presence of hcv infection. the prevalence of hbv infection in the tested patients was . %, being lower than that of hcv infection ( . % vs. %, p = . ) but comparable to the one in the general population ( . % vs. . %, p = . ). conclusions: the prevalence of hcv infection in the patients having nhl was %, comparable to the one in the control group, but significantly increased compared to the one in the general population, leaving open the issue of a causal relationship between hcv infection and nhl. iron hepatic overload and hepatitis c d. damian , m. grigorescu , m.d. grigorescu , t. zaharie third medical clinic, cluj napoca, romania aim: evaluation of the prevalence and the degree of iron loading and the relationships with the clinical, biological and morphological changes. method: patients with chronic hepatitis c were included, to whom we tested the blood iron level. in order to evaluate the hepatic iron accumulation we performed the perls staining, using a qualitative analysis and a semiquantitative scoring system (deugnier). results: from a total of patients, . % presented increased blood iron level (p = . ). the evaluation of the liver iron loading was performed in patients, some having normal blood iron level (n = ) and others (n= ) increased (p = . ). the stainable iron was observed in patients. the iron loading was usually low, the deposits were observed mostly at the sinusoid cells and the hepatocyte and less in the portal spaces, usually as a pale staining or of small, nonmerging granules. the total iron score deugnier was low. the increased blood iron correlated with the alt and ggt levels, the necroinflamatory activity and fibrosis. no correlationships between stainable iron and increased blood iron. the presence of liver iron accumulation only correlated with the fibrosis degree. conclusions: of the patients to whom we tested the blood iron, . % had increased levels. the perls staining was positive in % of the patients. the iron loading was mainly low, with a more frequent distribution in the sinusoid cells and in the hepatocytes and correlated only with the stage of fibrosis. response patients whose hcv rna became negative at - weeks t. ide , t. arinaga , k. ogata , i. miyajima , k. kuhara , r. kuwahara , m. background/aim: chronic hepatitis patients whose hcv rna became negative at weeks of peg-interferon/ribavirin treatment achieved excellent svr(sustained viral response) rate of almost %. however, in patients whose rna became negative after weeks, the svr rate is very low. since many patients became rna negative at - weeks, it is important to clarify the characteristics of the patients. material and method: among patients, became rna negative at - weeks and the therapy completed (total - weeks). the characteristics were analyzed by using sex, age, weight, bmi, alt, gtp, hemoglobin, platelet counts, ccr, hyaluronic acid, the mutation of hcv core region (aa , ) and interferon sensitivity determining region, adiponectine, home-ir, rna dynamics, dose and the treatment period. result: the svr rate was . %( / ). because all patients of non svr were female, we compared these patients and female svr. the platelets counts were low in non svr (non svr . ± . (x /mm ) vs svr . ± . (p< . )). the mean dose of ribavirin was lower ( ± mg/day) in non svr (p< . ) than in svr ( ± ). conclusion: as for the characteristics of the patients whose hcv rna became negative at - weeks but became non svr, female, low platelet count and low dose of ribavirin were important factors. in the patients who received reduced ribavirin doses, the idea to increase the ribavirin dose and to maintain it are necessary. (ex, use mg and mg alternately) pe background: chronic hepatitis c virus (hcv) infection poses a challenge for a growing number of infected patients who exhibit disease complications, including cirrhosis, hepatocellular carcinoma, and liver failure in china. the combination treatment of peginterferon alpha (peg-ifn alpha) plus ribavirin (rbv) is recommended as a standard care for hcv infections, which can improves hepatic markers and eradicates the virus in about % of patients. however, a significant number of patients do not respond to therapy or relapse following treatment discontinuation. several viral, hepatic, and patient-related factors influence response to therapy. methods: in our clinical practice, a total of interferon-naïve patients ( % male; median age years) with chronic hepatitis c include cirrhotic patients (no genotyping) received peg-ifn alpha- a mcg/week plus rbv - mg/day for weeks and follow up weeks. results: show that the patients have more rvr and evr rate ( % and . % respectively). while the svr (undetectable hcv-rna weeks after treatment completion) rate is only . % in conclusion: comparing with the data of clinical trail, the rvr, evr and eotr were higher, while svr was the same in chinese patient with chronic hepatitis c patients received the combination therapy of peg-ifn plus rbv. the reason of high relapse was still unknow. although optimal duration of retreatment and benefits and safety of maintenance therapy have not been determined, an extended duration is likely needed, even for the patients who achieved evr. s. nakamoto , f. imazeki , k. background/aims: recently amino acid (aa) substitutions in hepatitis c virus (hcv) core region (double wild (dw); arginine at aa , leucine at aa ) were reported to be associated with sustained virological response (svr) in a combination therapy of peginterferon and ribavirin. we evaluated the viral factors influencing treatment response. methods: nucleotide sequences of core region were determined directly in patients with genotype and high viral load ( kiu/ml) treated with peginterferon-alpha b and ribavirin for weeks. rapid virologcal response (rvr) was defined as more than log decrease of hcv-rna during the first four weeks of therapy and early virological response (evr) as that during the first weeks. svr was defined as negative hcv-rna months after the end of treatment and non-virological response (nvr) as less than log decrease of hcv-rna during the treatment. results: dw at aa and was shown in / ( %) patients with rvr and in / ( %) with non-rvr (p= . ), in / ( %) with evr and in / ( . %) with non-evr (p= . ), in / ( %) with svr and in / ( %) with non-svr (p= . ), and in / ( %) with nvr and in / ( %) with non-nvr (p= . ). in multiple logistic regression analysis, dw was significantly associated with rvr, evr, svr and nvr. conclusions: dw at aa and in hcv core region was closely associated with virological response in a combination therapy of peginterferon and ribavirin. medicine and hepatology, henry dunant hospital, athens, greece, biometrics, ist gmbh, mannheim, germany, background: among patients with chronic hcv treated with pegylated interferon and ribavirin, the highest sustained virologic response (svr) rates are achieved in patients with a rapid virological response (rvr). here we investigate how the time taken to become hcv rna undetectable influences the probability of relapse during untreated follow-up. methods: data from patients treated for weeks with peginterferon alfa- a ( kd) µg/week plus ribavirin / mg/day were included in the intent-to-treat analysis. response was classified as rvr, complete early virological response (cevr) slow responder and non-evr. results: there was a correlation between the time required to become hcv rna undetectable and the relapse rate after stopping treatment. patients with an rvr had the lowest relapse rate ( %); this increased among patients with slower responses. conclusion: there was an inverse correlation between the time taken to achieve a virologic response and the probability of relapse. background: rapid virologic response (rvr; hcv rna < iu/ml) at week of treatment with pegylated interferon plus ribavirin can be used to predict the probability of achieving an svr. patients with detectable hcv rna at week have a lower probability of achieving an svr than those with an rvr; further subdivision of these patients may be useful in predicting outcomes. methods: we conducted a retrospective analysis including genotype patients treated for weeks with peginterferon alfa- a ( kd) g/week and ribavirin / mg/day. patients were categorized as rvr and non-rvr. those without an rvr were further subdivided into detectable but unquantifiable, , , or < log drop in hcv rna. the proportion of patients with undetectable hcv-rna at week and achieving an svr was calculated within each category. results: rvr and non-rvr patients had an % and % rate of svr respectively. among non-rvr patients, rates of svr depended on the categorical response at week : detectable but unquantifiable hcv rna, %; log drop in hcv rna, %; log drop, %; log drop, %; and < log drop, %. independent of week response, undetectable hcv rna at week was also highly predictive of svr. conclusions: patients achieving an rvr have high rates of svr. among patients who do not achieve an rvr a more precise prediction of svr can be achieved by considering the extent of viral load reduction at week and week . retrospective japanese validation study of fibrotest and actitest in patients with chronic hepatitis c. n. nagata , t. mine background: fibrotest (ft) and actitest (at) are biochemical markers of fibrosis and activity for use as a non-invasive alternative to liver biopsy in patients with chronic hepatitis c virus. the aim of this study was to perform a validation study the discordances between ft and at(ft/at) and liver biopsy in patients with chronic hepatitis c in japan. methods: serum samples of chronic hepatitis c patients sended at - °c at the biochemistry department of pitié salpetrière hospital were analysed between july and august . ft/at components were assessed on thawed sera for patients. from patients had liver biopsy at the moment of serum analysis. liver biopsy fibrosis and activity scores were assessed by a pathologist in japan according to metavir scoring system. for each individual test-ft/at the following statistical analysis were performed result: ft observed auroc for the diagnosis of advanced fibrosis was . and after adjustment according to the prevalence of different stages of fibrosis the auroc was . . this difference could be explained by the non-homogenous distribution of different stages of fibrosis (low prevalence of extremes stages of fibrosis -f and f -and high prevalence of adjacent intermediate stages -f and f ). the observed auroc of ft for the diagnosis of precirrhosis and cirrhosis was . and the observed auroc of at for the diagnosis of moderate to severe activity was . . conclusion: these results are similar to those observed in all independent validations worldwide. background: accurate monitoring of hcv-rna level throughout anti-hcv therapy is key factor for predicting sustained virological response (svr). real-time detection polymerase chain reaction (rtd-pcr) based methods are sensitive, have wide dynamic range of quantification and carryover contamination caused by classical pcr. aim: to compare rtd-pcr based assays; cobas ampliprep/cobas taqman (cap/ctm) and recently developed abbott realtime hcv for hcv rna quantification and measurements differences by assays in different genotypes. methods: in total, serum samples were used including, , , , , and with genotypes b, a, b, a and respectively were tested quantatively for hcv-rna by cap/ctm and abott realtime. results: good correlation between two assays as overall (r= . ) with correlation coefficient (r) in genotypes b, a, b, a ranged between . to . and least in genotype (r= . ). mean differences between cap/ctm and abott realtime was significnat in genotypes b and . significantly hcv-rna genotype underestimation by cap/ctm ( . + . log iu/ml) than abbott realtime ( . + . log iu/ml; p= . ). in genotype b, significantly higher hcv-rna measurement by cap/ctm ( . + . log iu/ml) than abbott realtime ( . + . log iu/ml, p= . ). two hcv genotype samples showed measurement differences (cap/ctm minus abbott realtime) of - . and - . log iu/ml. studying genotype sequences within utr , target for cap/ctm rt-pcr amplification, revealed nucleotide polymorphisms at positions a , a , t , a , and a . conclusion: different measurement efficiency by commonly used cap/ctm in different genotypes compared to abbott realtime. new york, new york, usa, vertex pharmaceuticals, cambridge, ma, usa, duke clinical research institute , duke university, durham, nc, usa background: prove is a placebo-controlled study of subjects with genotype chronic hepatitis c randomized to weeks of peginterferon-alfa- a ug/week (p) plus ribavirin - mg/d (r) (pr , n= ), or regimens of mg q h telaprevir (tvr) with pr: tvr/pr for wks followed by pr for wks (t /pr , n= ), wks (t /pr , n= ) or wks (t /pr , n= ). the impact of african american race (aa) and bridging fibrosis on sustained virologic response (svr) was examined. methods: subjects with cirrhosis were excluded from study. fibrosis was categorized as mild/minimal, portal, or bridging from biopsy within years. itt analysis was performed. results: overall, svr was achieved by % of subjects in the pr group, % in t /pr group, % in t /pr group, and % in t /pr group. subgroup analyses indicated svr was improved with tvr/pr (tvr/pr arms pooled) vs pr alone in aa subjects ( % ( / ) vs % ( / )), and in subjects with bridging fibrosis ( % ( / ) vs. % ( / )). adverse events leading to discontinuations were more frequent in the tvr/pr groups ( % vs. %). rashes, gastrointestinal events and anemia were more common in the t/pr arms, and rashes were more frequently severe ( % vs %). conclusions: tvr-based treatment for or weeks was associated with an increase in svr rates compared to pr . subgroups with impaired response to standard peg-ifn/rbv therapy appeared to benefit from the addition of telaprevir. adverse events leading to discontinuation were more frequent in tvr-based regimens. background and aims: induction of type i ifns is a core issue in antiviral responses and must be tightly controlled. the protein kinase tbk is critically involved in virus-triggered type i ifn signaling. in previous studies, an alternatively spliced isoform of tbk , termed tbk s, was identified to be induced in both human and mouse cells. bound to rig- , it is able to disrupt the interaction between rig-i and visa. this study was designed to observe the expression of tbk s in hcv-infected patients. methods: total rna was extracted from samples of peripheral blood mononuclear cells obtained from hcv patients, hcv patients treated with ifn-/ribavirin and healthy controls, and subjected to real -time pcr using the primer-probe sets for human tbk s, tbk and ifn-genes. results: the tbk s expression was significantly elevated in hcv-infected patients, while treatment of hcv-infected patients with ifn-/ribavirin resulted in down-regulation of tbk s to the normal level. conclusions: the study strongly supports the idea that expression of tbk s is correlated with hcv infection, and indicates that tbk s may play an important role in the regulation of hcv infection.this work was supported by nsfc( , , background: infringement of iron metabolism is one of fibrosis progressing factors during diffuse liver diseases. the interrelation between the syndrome of iron overload (sio) and svr achievement is studied during chronic hcv infection treatment. methods: patients with chronic hcv infection (genotyping: - ; + - ; - ; - ; - ) are investigated. sio criteria: iron increase-more than mkmol/l, ferritin -more than mkmol/l, percent of transferriny saturation with iron (%tf) -more than %. results: sio revealed in patients ( . %): patients - genotype ( assotiative with a diabetes) and patients-genotype ( -in combination with liver steatosis and obesity). venipuncture series were done up to getting ferritin referential parameter values before therapy beginning. rvr: sio - patients, normal metabolism - ; evr: and , svr: and relatively. nonresponding patients (sio) had steatosis and diabetes, hereditary hemochromatosis (c y/h d) is verified in case. increase of ferritini values and %tf during therapy and positive hla-a and hla-b is registered in nonresponding patients. conclusions: sio in hla-a , hla-b and c y/h d positive patients is independent predictor of nonresponse during peginterferon alpha- a ( kd)" ribavirin treatment. a.p. srivastava , g. dogra , s. sachdeva , n. nigam , a. chakravarty dr. rml hospital, new delhi (india)- , maulana azad medical college & associated hospitals, new delhi, india background: hepatitis c virus (hcv) has emerged as a leading cause of chronic hepatitis, liver cirrhosis and hepatocellular carcinoma worldwide. genotyping and assessment of viral load in hcv patients are vital for designing therapeutic strategies. we aimed to determine the pattern of hcv genotypes and its association with viral load and biochemical profile. methods: hcv rna positive patients were included in the present study attending the medical-opd and wards of dr rml hospital, a tertiary care hospital in new delhi during - . hcv genotyping was carried out by restriction fragment length polymorphism (buoro et al ) followed by the type specific primers from the core region (ohno et al ) . viral load estimation was carried out by taqman real time pcr system using previously described method (martell et al ) . result: . % of cases were having genotype ( a, b, f & i) followed by genotyping ( a & b) in . % and genotype in . %. there was no statistical significant difference seen in the biochemical profile between the three groups of genotypes. genotype one was associated with a significantly higher viral load as compared to the genotypes three and two. parentral mode of transmission was accounted for the % of all the infected cases. conclusion: hcv genotypes and accounted for % of our cases. the genotype is associated with higher degree of disease severity as assessed by viral load. also two unusual subtypes i and f were identified from this geographical region. a.p. srivastava , g. dogra , s sachdeva , n. nigam background: the development and resolution of an inflammatory process is regulated by a complex interplay among cytokines that have pro and anti-inflammatory effects. regulatory mechanisms that control the production of cytokines include genetic polymorphism in particular promoter/leader region. polymorphisms may directly or indirectly affect the binding of transcriptional factors, consequently increasing or decreasing the production of mrna, thus regulating cytokine production. we aimed to determine the polymorphism of tumor necrosis factor-alpha (tnf-alpha) and interleukin- (il- ) genes in chronic hepatitis c patients. methods: hcv rna positive patients were included in the present study conducted during - . healthy controls were also included. genomic dna was extracted by using q a amp dna blood kit protocol according to manufacture's instruction and desired fragment was amplified by using the primer's of vidigal et al . result: genotyping of - -promoter variant of tnf-alpha was performed by pcr. polymorphism in the tnf-alpha (g/g, g/a and a/a allele) was different between hcv patients and healthy controls. il- variants (c/t, c/c) were more frequent among hcv patients as compared to healthy controls. conclusion: genetic polymorphism analysis on il- promoter have indicated that distribution pattern of il- polymorphism was significantly different between controls and hcv patients. furthermore, polymorphism in promoter region of tnf-alpha (- ) was found, though the difference was not significant. since this is a preliminary study, we believe that our findings may stimulate further research on larger number of patients. introduction: the assessment of liver fibrosis provides useful information not only for diagnosis but also for therapeutic decision. although liver biopsy is the gold standard for fibrosis assessment, it is invasive and may have some risks, this has led to the development of non-invasive biochemical markers of liver fibrosis. fibro-test which have five parameters used for the quantitative assessment of liver fibrosis. our aim is to validate the performance of fibro-test in an independent cohort of patients with chronic hepatitis c genotype . methods: subjects were patients with chronic hepatitis c genotype . all biopsies were scored using metavir system by two independent pathologists. fibro-test was done with (biopredictive, houilles, france) for the assessment of liver fibrosis. sensitivity, specificity, ppv and npv were measured for distinguishing between different degrees of severity of fibrosis. results: patients ( male and female) age ranged - years, liver biopsy showed % (f ), % (f ), % (f ), % (f ), % (f ). the efficacy of fibrotest is . %, sensitivity . %, specificity %, positive predictive value % and negative predictive value %. conclusion: fibrofast has a low performance in assessment in fibrosis in chronic hepatitis c genotype . introduction: liver biopsy is the reference method for assessing liver fibrosis. however, it is invasive, costly and has some limitations. european liver fibrosis (elf) markers have shown to be accurate in assessing liver fibrosis in a range of chronic liver disorders. our aim is to test the performance of elf markers in an independent cohort of patients with chronic hepatitis c genotype . methods: subjects were patients with chronic hepatitis c genotype . all biopsies were staged for fibrosis using metavir system by two independent pathologist. elf markers were done by (diagnostic & operations, england) and fibrosis scores were derived using the published elf algorithm. the area under the curve (auc) for receiver operator characteristic curves was measured along with sensitivity and specificity, positive (ppv) and negative (npv) predictive values for distinguishing between different stages. results: patients ( male and female), age was ranged - years, liver biopsy showed % (f ), % (f ), % (f ), % (f ) and % (f ). elf markers had no correlation with fibrosis score where r = - . , p = . , aucs: . , specificity . %, sensitivity only . %, ppv: only . %, npv: . % and efficacy . %. conclusion: the performance of elf marker is low and can not be used for assessment of fibrosis in chronic hepatitis c genotype . background: the prove trial is a randomized, placebo-controlled study that assessed the safety and efficacy of mg q h telaprevir (tvr) combined with g/week peg -ifn alfa- a (p) ± - mg/day ribavirin (r) in chronic hcv genotype -infected treatment-naïve patients without cirrhosis. methods: overall, patients received tvr + pr for weeks (t /pr ; n= ), tvr + pr for weeks then pr for weeks (t /pr ; n= ), tvr + p for weeks (t /p ; n= ), or to pr for weeks (pr ; n= ). primary endpoint: sustained virologic response (svr, undetectable hcv-rna weeks post-treatment). results: baseline characteristics were well balanced across groups. numerically higher svr rates were observed in patients receiving t /pr ( %; p= . for difference vs. pr ) than t /pr ( %), t /p ( %) or pr ( %). relapse rates were lower in the t /pr group ( %) than the t /pr ( %), t /p ( %) and pr ( %) groups. the relapse rate in patients receiving t /pr with -week and -week undetectable hcv-rna was % ( / ). the aes occurring more frequently with the t/pr regimen were pruritus, rash, asthenia, nausea and anemia. in the t/pr arms, patients discontinued due to rash, discontinued due to pruritus, and patients due to anemia. conclusion: these results showed that a telaprevir-based regimen led to significantly higher svr rates than pr, and indicate that this regimen could shorten the overall treatment duration from weeks to weeks for most patients infected with hcv genotype . a.c. cardoso , c. stern , r. moucari , n. giuily , p. bedossa , p. marcellin hopital beaujon background/aim: this study evaluated the effect of the response (svr) to therapy on fibrosis stage, as assessed by ls, in patients with advanced fibrosis (f ) or cirrhosis (f ). methods: hcv patients with f or f who received interferon-based treatment were studded. ls was assessed after treatment (median delay of months, - ) in patients with or without svr. correlations between ls and clinical and treatment characteristics were analyzed. results: patients were included: male gender ( %), mean age ( ± years), diabetes ( %), mean bmi ( ± kg/m ), genotype ( %). % had svr. ls was performed - , - , > years following treatment. by linear regression, the median of the ls was independently associated with svr (p= . ) and diabetes (p= . ). svr patients had lower ls ( . kpa; range . - ) than non svr patients ( . kpa; range . - ) (p< . ). among the svr patients the median ls was lower when the delay between ls and the end of treatment was longer ( . , . , . ) (p= . ). on the opposite, among the non-svr patients the median ls was not significantly different (p= . ). the median of liver stiffness was higher in patients with diabetes (p= . ). bmi and dyslipidemia did not influence the median of the ls. conclusion: in patients with advanced fibrosis or cirrhosis, ls was lower in patients with svr and decreased with time while it was higher and did not decrease in non-svr patients. ls could be important for assessment of fibrosis stage during the post-treatment follow-up. to study peripheral blood and intrahepatic natural killer (nk) cells in patients with chronic hepatitis c in relation to disease activity and severity of hepatic fibrosis. patients & methods: fifteen untreated patients with histologically-proven chronic hepatitis c, and matched healthy subjects. the nk cells and natural killer t (nkt) cells were identified in fresh whole blood samples using two-color flow cytometric assay as cd -cd + and cd + cd + positive cells. immunohistochemical staining of liver biopsies taken from all patients was done using monoclonal antibody against cd for detection of nk cells and rabbit polyclonal antibody against smooth muscle actin (sma) for identification of activated hepatic stellate cells (hscs). results: patients with chronic hepatitis c showed significant decreases in the percentages of nk cells and nkt cells in peripheral blood. a negative correlation was found between serum hcv rna levels and the percentages of peripheral blood nk cells and the intensity of intrahepatic nk cells. the percentages of circulating nk cells and nkt cells and the intensity of intrahepatic nk cells were inversely correlated with the metavir fibrosis stage and the steatosis grade, and also with the intensity of intrahepatic activated hscs. conclusion: patients with chronic hepatitis c had significant deficiency in circulating nk and nkt cells as well as in intrahepatic nk cells. this may provide a possible mechanism for the suppression of innate immunity against hcv. background: hcv infection is the major cause of chronic hepatitis, cirrhosis and hepatocellular carcinoma. the virus is classified in six genotypes and more subtypes, which are related distinct with antiviral therapies reply. in brazilian amazon, epidemiologist's studies in blood donors had pointed high frequency of genotype ( %) followed by genotypes ( %) and ( %). however, epidemiological research in populations of risk to the infection still is scarce. aim: to determine hcv genotypic frequency in blood donors, patients with blood transfusions multiples, patients in hemodialysis and drugs users in the state of pará, brazilian amazon. methods: using real time pcr and nucleotide sequencing followed phylogenetic analysis had been gotten viral diagnosis and genotyping. results: in blood donors, hcv distribution was constituted by genotypes ( . %) and ( . %). in multitransfunded patients occurs maximum prevalence of genotype ( %), probably reflect of genotype specific transmission of blood donors population. on the other hand, in hemodialysis patients had been detected genotypes ( . %), ( . %) and ( . %), result of a bigger diversity of transmission routes (transfusional, interfamilial, nosocomial, etc) . in drug users occurs the biggest frequency of genotype ( . %) with prevalence of genotype ( . %), suggesting that the sharing of abuse machinery is allowing strains diffusion of genotype . conclusions: the genotype possesses the biggest frequency in different population. moreover, through hcv genotypic frequency if it detached the contribution of transmission distinct routes indicated by previous epidemiologists researches. virol. ). we established real-time polymerase chain reaction (pcr) assays for the easy detection of these hcv mutations. methods: plasmids p-core-w, including wild type hcv core coding region ( r and l), and p-core-m, including mutant type hcv core ( q/h and m), were constructed by cloning and pcr-based mutagenesis for control vector of wild type core and that of mutant core, respectively. using serially diluted forms of these vectors, sybr green-based real-time pcr detections with mutation-specific primers were performed. results: analysis of known scalar concentrations of references indicated that the detection limits of these methods were at least copies, copies, copies, and copies of -wild, -mutant, -wild, and -mutant, respectively. each primer could clearly distinguish the difference between p-core-w and p-core-m at the same copy numbers. concerning substitution , the ratios : , : , : , : , and : of p-core-w versus p-core-m could be distinguished. on the other hand, for substitution , the ratios : , : , : , : , : , and : could be distinguished, confirming the sensitivity and specificity of the assay. conclusions: this method could represent a useful alternative for the detection of genotype b hcv core amino acid substitutions and and be reliably applied for rapid screening. efficacy and tolerability of hcv treatment in asian patients according to age and genotype at a tertiary centre in western australia n. saroj , n. kontorinis , t. lorenzo , m. marion , s.l. chen , w. cheng , royal perth hospital, centre for international health, curtin introduction: race and ethnicity can influence efficacy and tolerability to treatment in hcv. the higher response rate in asians is thought to be associated with better adherence and tolerability. objectives: ( ) to evaluate the adherence according to age and genotype ( ) to assess the effect of age on treatment efficacy ( ) background: hepatitis c virus (hcv) infection is a major health problem. there is huge regional variation in its prevalence and genotypic distribution. voluntary blood donors are thought to have somewhat lesser prevalence than the rest of the community. reliable statistics are not available for the entire country, particularly for the rural areas. it is important to know local situation and rationalize use of limited resources. methods: retrospective study of the records of patients attending the free liver clinic (flc) of our hospital located in a rural area of pakistan, and those screened for hcv infection prior to voluntary blood donation. results: patients at flc ( out of [ %; males %] were found to have higher chances of being reactive for hcv antibodies as compared to voluntary blood donors ( / [ %]; p = . ; or . - % ci = . - . ). out of a total of hcv reactive patients, ( %) were found to be positive on hcv rna testing. out of a total of typeable genotypes, ( %; % ci = . - . , estimated odds = . ) were infected with a single genotype, and only patients ( %) were infected with genotype , either alone (n= ) or in combination with a. conclusions: one out of every people tested in our flc is seropositive for hcv, and % of "healthy" voluntary blood donors have the same results. genotype is very rare in our region. s.a. batool , s.z. abbas department of gastroenterology, muhammad hospital, mirpurkhas, pakistan background: hepatitis c viraus (hcv) infection is common in our region. data is not available on success rates of conventional interferon (inf) based products here. we attempted to find out the dominant genotype, and to determine the success rate of conventional inf-based treatment in eradicating hcv. methods: retrospective case series study of hcv infected patients' records treated with different brands of inf. results: / ( %) of all patients tested were positive for hcv antibodies. hcv-rna was tested by pcr for patients, of which ( %) turned out to be positive. genotype type was the dominant genotype -found in / ( %) patients. men and women were treated with various brands of inf with the same manufacturer's brand of ribavirin. the overall etr achieved was / ( %) - / ( %) men and / ( %) women. / ( %) of genotype achieved etr. there was no significant difference in average ages for those who achieved good etr and those who did not ( years each). the etr achieved by different brands ranged from % to %. svr was achieved by / patients. conclusions: % of all people tested positive for hcv antibodies, of which about % had evidence of active hcv infection. etr achieved by different brands averaged %. this was % in female sex, although age did not appear to be a factor in determining a favourable etr. patients & methods: a total of consecutive diabetic patients of either sex were evaluated for hcv and hbv infection by using enzyme linked immunosorbant assay (eliza- ) along with serum alt levels. on the basis of this test, the patients were divided into two groups, sero +ve and sero -ve. different variables were: age, sex, bmi, area of residence (rural or urban), type and duration of dm, smoking, literacy and alt. results: males . % and females . %. age ranged from to . majority were married ( . %), from rural area ( . %), had type- dm ( . %), normal weight ( . %), normal alt( . %) and non-smokers ( . %). seroprevalence for hcv, hbv and both were . %, . % and . %. two groups were made, sero +ve and sero -ve. raised alt ( . %) was significant (p< . ) factor while all others variables were insignificant (p> . ). conclusion: hbv and hcv infections are more prevalent in dm with increased alt levels. while hcv infection is more common than hbv in patients with dm. hepatitis c virus (hcv) envelope proteins (e and e ) mediate the entry of virus into host cells by binding to its cellular receptors and resulting in the fusion of the viral membrane with host cell membrane. the expression and secretion of biologically active envelope proteins in vitro have proven to be a difficult task due to the high degree of glycosylation and the existence of hydrophobic domains within these sequences. in order to obtain glycosylated, correctly-folded hcv envelop proteins in large quantities, we optimized the dna sequences of hcv envelop proteins by substituting the encoded sequence with human preferable codons and expressed them in human embryonic kidney (hek) cells. both proteins were detected intracellularly, with a small portion secreted into supernatant. in order to enhance secretion, truncated forms of envelop proteins including e tm, e - , e - were also expressed. both full-length and truncated forms of envelop proteins were glycosylated and expressed at high level. in addition, we also expressed the codon-optimized hcv receptors cd and claudin- in cells. by comparing the expression level of codon-optimized sequences and the sequences that were obtained from cdna library by pcr, we found that codon-optimization enhance protein expression significantly in cells. these results not only lay solid foundation for further research concerning the mechanism of hcv entry, including the optimal ph and right protein conformation for fusion, cell types that permit viral entry; but also potentiate a useful cell model for testing antiviral agents. background: prolactin (prl) is an immunoregulatory hormone secreted from lymphocytes, however, prl induction in relation to hepatitis c virus (hcv) infection has not been elucidated. methods: serum prl levels were measured in both subjects of our hcv cohort study and male patients of the hospital, who were chronically infected with hcv. furthermore, serum prl levels were compared in male patients before and after interferon therapy. we measured expression of prl mrna level in pbmcs in male patients, and also investigated prl mrna of pbmcs collected from healthy men that stimulated by hcv produced by huh . cells in vitro. result: serum prl levels were significantly higher in the hcv-infected subjects than in the controls (p< . ). they were significantly higher in hcv-infected male subjects than in the controls (p< . ). serum prl levels were significantly higher in male patients than in the controls (p< . ). serum prl levels decreased significantly after interferon therapy in patients with sustained virological response to therapy (p< . ). the levels of prl mrna in pbmcs derived from hcv-infected patients were significantly higher in male patients than in the controls (p< . ). conclusion: the high levels of prl expression are associated with hcv infection in carriers. background and objectives: hepatitis c virus (hcv) is a major cause of chronic liver hepatitis, cirrhosis, and hepatocellular carcinoma.current clinic standard therapy is interferon alpha (ifn-) combination with ribavirin, but this treatment is associated with adverse effects and often fails to induce a sustained response. until recently, development of a hcv cell culture system (hcvcc) provides a suitable tissue culture system to study the complete hcv life cycle. in this study, we tested the effect of ifn omega (ifn-)-a member of type interferon on hcv compared with ifnbased on hcv b replicon and hcvcc. methods: we compared ifn-and ifn- a effects on hcv rna replication and protein expression, as measured by ribozyme protection assay and western blot. we also compared the intracellular protein level of phosphorylated signal transducer and activator of transcription (p-stat ) treated with different interferon type and concentration with western blot analysis. results: hcv rna and protein level were inversely related with ifnconcentration and compared with ifn- a, at the same concentration, the hcv rna and protein levels treated with ifn-were lower than that treated with ifn- a p . .also based on the hcv rna analysis, ec of ifn-was folds lower than ifn- a. ifns increased intracellular p-stat level at a dose dependent manner and compared the same concentration of ifn-and ifn- a, p-stat protein level was higher in ifn-treated group p . . conclusions: these results demonstrate distinct antiviral effect of ifncompared with ifn- a and this difference maybe partly caused by the stronger stimulation of ifn receptor . outstanding antiviral activity of ifnmay be useful for developing new hcv treatment strategies. background & aim: hepatitis b virus (hbv) infection with undetectable levels of hepatitis b surface antigen (hbsag) is called an occult infection, which although has been described among subjects with chronic hepatitis c liver disease in the western world, it's prevalence and clinical significance are still ambiguous in the indian subcontinent. materials and methods: we investigated hbv-dna pcr in serum samples of hbsag negative subjects with chronic hcv-related liver disease, and apparently healthy volunteers negative for hbsag and anti-hcv as control. results: serum samples found positive by at least two independent pcr assays were considered hbv dna positive. hbv-dna was detected among hcv-related chronic liver disease (cld) patients ( . %), which was higher (p = . ) as compared with the control volunteers ( . %). it was more frequent ( . %) in anti-hbs negative/anti-hbc positive patients than in anti-hbs/anti-hbc positive ( %, p < . ). hcv rna by qualitative pcr was significantly (p < . ) higher in occult hbv compare to non-occult. hcv genotype b was predominantly associated with occult hbv ( %), especially among subjects with hepatocellular carcinoma (hcc) (p< . ) as compared to non-occult hbv cases. though not significant, frequency of occult hbv infection was higher than healthy controls and hcv b genotype was significantly associated in patients with hcc. conclusion: this study suggests that in all hbv-endemic areas, the possibility of occult hbv in patients with hcv should be considered and hbv-dna should be performed. j. zhao , , w.d. cai , l. chen , y.x. gan , m.l. he , x.r. wang background: besides hiv and syphilis, hepatitis c virus (hcv) is also rapidly spread among men who have sex with men (msm). this study was designed to identify the prevalence of these sexual transmitted diseases in msms in shenzhen, china. methods: a cross sectional study was conducted by using time location sampling method from april to july, . msm participants (including male sex workers) were recruited and finished guided self-administered questionnaires (or interviews if they have difficulty in reading or understanding) in venue-date-time randomly selected from active venues. results: results were analyzed using spss. blood samples were collected for hiv, syphilis and hcv test. participated msms were between the age of to years ( . ± . ) with a majority of - years ( . %). most of them finished junior high school education ( . %). . % had high level of knowledge on modes of transmission and prevention. likewise, . % msms have ever sold sex to men, . % of them were self identified as gay, . % as bisexual. . % msms had multiple male sexual partners and . % msms always used condom. . % of them had sex with women in the past month, and the condom use rate decline to . % during both male and female sex. hiv positive rate is of . % and syphilis for . %, hcv is only found in cases ( . %). conclusions: a greater number of the participants have both male and female sex partners. this survey shows that hcv infection rate is still low among msms in shenzhen, although the hiv and syphilis rate is high and continuing increased in the past few years. the change of insulin sensitivity in hepatitis c patients with normal insulin sensitivity s.g. park , y.k. cho , j.w. lee , j.w. yun , h.j. kim , w.k. jeon , b.i. background: hepatitis c virus (hcv) infection is associated with a high prevalence of diabetes mellitus (dm). insulin resistance (ir) is known to play a crucial role in the development of dm in chronic hepatitis c (chc) patients. we prospectively investigated the change of insulin sensitivity in chc patients during -year period, and analyzed factors significantly associated with ir. methods: subjects consisted of non-cirrhotic chc patients with normal alanine aminotransferase (alt) and normal insulin sensitivity (chc group), and healthy control group of subjects matched by age, sex, body mass index and life styles. we compared initial baseline insulin sensitivity, metabolic parameters and incidence rate of ir at the end of follow up period in both groups. the change of insulin sensitivity and metabolic parameters and development of ir was analyzed, and factors associated with development of ir were evaluated. results: ir developed in . % of chc patients and . % of normal individuals (p< . ). hcv infection per se and genotype were independent risk factors of ir. initial fasting glucose - mg/dl, fasting insulin uiu/ml, homa-ir . - . were significantly associated with development of ir in chc group. conclusions: hcv infection is independent risk factor of ir. even if chc patients with normal insulin sensitivity, careful monitoring for ir is necessary. prevalence of viral hepatitis c in latvia i. tolmane , , b. rozentale , , j. keiss , f. arsa sa infectology center of latvia, riga stradin's university background and aim: viral hepatitis c (vhc) because of its prevalence and clinical course has become one of the most actual infectious diseases in the world. to date chronic hepatitis c affects over million individuals worldwide. chronic vhc is a leading cause of cirrhosis and hepatocellular carcinoma. the aim of this study was to investigate how many residents of latvia, that are over years of age have been exposed to vhc (anti-hcv prevalence) and how many are infected at the moment (hcv-rna prevalence). until now such research has not been performed in latvia. methods: from the register of general practitioners there were randomly selected gp's from different regions of latvia, persons over years of age were selected out of each gp register and tested for anti-hcv with screening test (elisa). in case of positive result antibodies were confirmed with western-blot reaction and person was tested for hcv-rna (pcr). results: in total person was invited by general practitioners for the test and persons responded (response rate . %). confirming test (western-blot) was positive in participants and out of which hcv rna test was positive in patients. conclusions: there are . % of people exposed to hepatitis c virus in latvia and . % are infected with hepatitis c virus, respectively, infected persons per thousand individuals. genetic variation in the ikk/nf-b pathway and the live fibrosis progression in chronic hepatitis c r. sho , k. ishii , r. ishii , h. watanabe , k. sugahara , y. nishise , k. okumoto , t. saito , s. kawata , a. fukao department of public health, department of gastroenterology, yamagata university faculty of medicine background/aims: i b kinase/nf-b (ikk/nf-b) signaling pathway is thought to play critical roles in liver inflammation and fibrogenesis. we carried out a haplotype-based association study to examine the contribution of common genetic variations in the genes encoding nf b inhibitor kinase alpha and beta (ikbka and ikbkb; the major components of ikk/nf-b pathway) to the progression of live fibrosis in chronic hepatitis c. methods: based upon the common single nucleotide polymorphisms (snps; minor allele frequency(maf) . ) and linkage disequilibrium (ld) information derived from the hapmap, we selected and tag snps from ikbka, and ikbkb, respectively, for genotyping. by using melting curve analysis, snps were genotyped in chronic hepatitis c patients, including patients with hepatocellular carcinoma. association between common genetic variations in ikbka/ikbka and platelet count (plt) was tested by both genotype-and haplotype-based approaches. results: we succeeded in genotyping a total of tag snps that efficiently capture common variation across the kb-block of ikbka and the kb-block of ikbkb. for each of genes tested, haplotypes were found in population studied. all snps were in hardy-weinberg equilibrium, but no significant association was observed between any single tag snp or haplotype and decreased plt in patients analyzed. conclusions: our data suggest that it is unlikely that polymorphisms within the ikbka and ikbkb genes are involved in the progression of live fibrosis in chronic hepatitis c. further studies on genetic variations in other nf-b-related genes in chronic hepatitis c are needed. background: hepatitis c virus infection is a major burden after liver transplantation. the effective treatment for patients who underwent liver transplantation has not been well established. management of these patients is the most challenging task. cyclophilins are essential host factors for hcv replication. we report here the efficacy of divided administration of ifn plus cyclosporine a in the treatment of chronic hepatitis c patients who failed peg-ifn or ifn combined ribavirin. patients and method: we prospectively included patients (median age, ) with genotype b and, failures to combination ifn plus ribavirin or combination pegylated ifn plus ribavirin. the present treatments consisted of an induction therapy, an intensified therapy and a maintenance therapy. the induction therapy comprised intravenous mu ifn every hours for the first days, . mu ifn every hours for the next days and mu ifn every hours for the following weeks, totaling mu of ifn . the intensified therapy was induction therapy shortened to weeks. the maintenance therapy comprised of pegylated ifn b and ribavirin. csa was given times daily during the induction and the intensified therapies. ribavirin was given twice daily during the maintenance therapy. results: the end treatment response and sustained virological response rate of the present study were % ( / ) and % ( / ), respectively. the relapse rate was %( / ). non-responders was % ( / ). all adverse effects were completely reversible. the treatment protocol was well tolerable. conclusion: we concluded that our protocol should be effective in failures to the previous combination therapies. host factor targeting treatment will become a promising treatment option. cyclophilin targeting treatment is a promising new anti-hcv treatment k. inoue , t. watanabe , s. yoshiba background: hepatitis c virus (hcv) is the most common cause of chronic liver disease. however, the efficacy of currently available treatments is limited. we recently reported the effects of combined interferon-/cyclosporin a treatment. cyclophilins are associated with hcv replication and bind cyclosporin a. which cyclophilins are closely associated with hcv replication remains controversial. in this study, several cyclophilins were found to be essential host factors for hcv replication and hcv replication was rescued by overexpression of cyclophilin a in the presence of cyclosporin a. methods: we evaluated the effect of cyclosporin a and its analogues on the replication of hcv in vitro using several types of hcv replicon. the gene expression of representative cyclophilins and pin- was knocked down using small interfering rna (sirna) to identify cyclophilins associated with hcv replication. the specificity of the effect of sirna was confirmed by western blot analysis. the effect of overexpression of cyclophilins on hcv replication in the presence of cycloporin a was also studied. results: cyclosporin a and its analogues suppressed hcv replication in a dose dependent manner. cyclophilin f, cyclophilin lc and cyclophilin lc as host factors which are closely associated with hcv replication, in addition to the previously reported cyclophilin a. knockdown of chclophilin b showed little effect on hcv rna replication. cyclophiln-dependent hcv replication varied among the three hcv replicon cell-lines used. overexpression of cyclophilin a rescued hcv replication in the presence of cyclosporin a. conclusions: these findings suggest several cyclophilins are essential host factors for hcv rna replication. thus potent cyclophilin inhibitors have the potential to be anti-hcv drugs. background/aims: hepatitis c virus (hcv) genotypes - have a worldwide distribution. types a and b are predominant in northern europe and north america, and in southern and eastern europe and japan, respectively. type is endemic in south asia and is variably distributed in different countries. genotype in egypt, genotype in central and south america and genotype is common in china, japan and south east asia. in pakistan a is the commonest genotype, which is associated with the most favorable outcome regarding end treatment response and sustained virological response after weeks of therapy. the aim of this study is to find out hcv genotypes in newly diagnosed chronic hepatitis c patients. methods: this observational study was conducted in chronic hepatitis c patients. all patients had raised alt levels for last months, had positive polymerase chain reaction (pcr) for hcv rna by real time method and liver biopsy was done in all patients under national program for prevention and control of hepatitis during year - . genotyping was done on roche genotyping kit. data was analyzed by spss . results: out of patients, . % (n= ) were genotype a. . % (n= ) were genotype b. . % (n= ) were genotype a. n= had genotype b. . % (n= ) had mixed genotype ( a, b/ a, b, a, b). conclusion: majority ( . %) of chronic hepatitis c patients were genotype a which is associated with favorable outcome after weeks of interferon and ribavirin therapy and only . % had genotype a in this cohort. s.t. zhou , y. zhao , f.j. zhang background/aims: as human immunodeficiency virus (hiv) infected children who are receiving antiretroviral therapy (art) are living longer in china, comorbidities of hepatitis b virus (hbv) and hepatitis c virus (hcv) coinfection should be carefully considered when making management decisions. however, the coinfection rate of either hbv or hcv is unknown in hiv-infected children in china. we evaluated the seroprevalence of hbv and hcv in the china national pediatric art cohort of hiv-infected patients. methods: patients were selected from hiv infected children medically eligible for art who were enrolled into the china national pediatric art cohort since . interviews, medical assessment, serology for hbsag, anti-hcv antibody, transaminase levels, and hiv serostatus and cd counts at baseline of patients were obtained. results: of hiv-infected children were hbsag seropositive ( . %; %ci: . %- . %), and of children were anti-hcv antibody seropositive ( . %; %ci: . %- . %). only age was associated with hbv coinfection. multivariate analysis revealed that children infected with hiv through contaminated blood or transfusion of blood products were . times more likely to be anti-hcv antibody positive than those infected with hiv through other routes. and children from central china provinces, henan, anhui, shanxi, and hubei were . times more likely to be hcv seropositive. conclusion: the high seroprevalence of hbv and hcv coinfection in hiv-infected children attending china national pediatric art cohort calls for routine screening for hepatitis viral coinfection and modification of the management of hiv-infected children in china. background: bms- is a first-in class and highly selective hepatitis c virus (hcv) ns a inhibitor with picomolar in vitro potency against genotypes a and b. in a sad study with healthy subjects, bms- was safe, well-tolerated, and had a pharmacokinetic profile suggestive of once-daily dosing. methods: the objectives of this randomized, double blind, placebo-controlled, sad study were to evaluate the safety, tolerability, antiviral effect and pharmacokinetics of bms- in patients with genotype chronic hepatitis c (chc). treatment naïve or experienced patients were randomized to receive , , or mg of bms- or placebo. results: all bms- single doses were well tolerated and had a safety profile similar to that of placebo. following oral administration, bms- was readily absorbed with dose proportional exposures over the studied dose range. the mean terminal half-life of bms- was approximately hours. mean decline in hcv rna hours after a single , and mg dose of bms- was . log (range . to . log ), . log (range . to . log ) and . log (range . to . log ), respectively. the mg dose resulted in a mean decline of . log (range . to . log ) hours after dosing, which was maintained at hours. conclusions: single doses of up to mg of bms- were safe and well tolerated in patients chronically infected with hcv genotype . bms- produced a robust decline in hcv rna and has a pharmacokinetic profile that potentially supports once-daily dosing. background: the global infection rate of hcv is approximately %, and nearly . % in china. only %- % of patients with genotype b can achieve sustained virological response (svr) after antivirus therapy, nearly half of them experienced treatment failure. the study aimed to determine hcv- b sequence evolution in patients experienced treatment failure during and after therapy, and further analyze relations between the mutations and treatment outcome. methods: patients with genotype b accepted antiviral treatment of ifn plus ribavirin for weeks, and long-term follow-up after therapy. patients experienced treatment failure were further analyzed (one for relapser, another for nonresponder). sera were reserved at baseline, w, w and -year after therapy. hcv-rna was extracted. hcv full-length orf was amplified by rt-nested-pcr and sequencing. result: of the patients achieved svr ( . %). from sequence alignments of relapser at baseline and w, we find that p , ns a and ns a have higher mutation rate both in nucleotide and amino acid level ( . % and . %, . % and . %, . % and . %, respectively). but there is no significant difference in the alignments of w and -year after therapy, the mutation rate is lower. mutation rates of the non-responder among baseline, w, w and -year after therapy are very low. conclusion: antivirus effect is correlated with specific hcv sequences in chronic hepatitis c, mutations in hcv non-structure protein p , ns a and ns a have important impacts on treatment outcome in ifn-based therapy. background: the results of antiviral therapy for hepatitis c (hcv) have improved recently with the use of peg-interferon (peg-ifn)/ribavirin therapy. however, age of patients are concerned because of side effects and safety. as we known, a few studies have targeted therapy in elder with chronic hcv. aim: we reviewed the results of interferon based antiviral therapy in the elderly with chronic hcv at our institution. methods: patients were defined as elderly if they were years and elder who received therapy for hcv. the prescribed treatment duration, end of treatment response were mention. the data recorded included laboratory tests, adverse events (ae), dose modification, and withdrawal rate of therapy. results: of chronic hcv patients treated with peg-ifn/ribavirin between nov and feb . patients were older than years old. the mean age of the elder patients was . ± . years old. were male and were female. histological studies showed with cirrhosis. almost all patients had experienced ae/side effects. the most common abnormalities were anemia and neutropenia. therapy was discontinued in % ( / ). the rate of dose modification was % ( / ) patients who received weeks therapy. transaminases were normalized in % ( / ) after weeks treatment and sustained in % ( / ) one year later. conclusion: the elder patients are more at risk of developing ae while on treatment. most patients should be discontinued or decreased dosage of medication. however, the elder patients with chronic hcv can be treated successfully. background: in the general population the incidence of interstitial lung disease is estimated to be . % and has also been reported with the use of interferons. the higher reporting rate of ip in japan has created interest and warrants further investigation. methods: using both data from randomized clinical trials (ex-japan) and the roche world-wide safety database (advent), the frequency of ip was estimated in patients treated with peginterferon alfa- a ± ribavirin. ip was defined as: interstitial lung disease, alveolitis, pulmonary fibrosis, pneumonitis and pulmonary toxicity. results: one case of ip was reported among the patients included in the clinical trials ( . %). in the advent database considering the estimated , patients with cumulative exposure to peginterferon alfa- a ( , in japan and , us/row) the reported cases of ip represent a rate of . % with a proportional reporting ratio (prr) of . (p< . ). of these cases, were reported in japan (prr . ; p< . ), in the usa (prr . ; p= . ) and row (prr . ; p= . ) representing reporting rates of . % in japan and . % in the usa and row. japanese patients with reported ip were older ( versus - years) and were more likely to have been treated with peginterferon alfa- a monotherapy ( % versus - %). furthermore, the yearly incidence rate has remained unchanged. conclusions: the apparently higher rate of ip reported in japan may result from differences in patient demography, diagnostic criteria and treatment patterns. the overall incidence of ip remains low. background: hepatitis c virus (hcv) infection carries a significant risk for development of insulin resistance (ir) and/or diabetes (dm). recently, retinol-binding protein (rbp ) has been reported as a protein contributing to ir. this study aimed to assess the different expression of serum rbp between chronic hcv infection (chc) patients and non-chc controls. methods: serum rbp was measured in treatment-naïve chc patients and its correlation with the homeostasis model assessment of insulin resistance index (homa-ir), liver histology, virology and metabolic factors was investigated. patients were stratified into different stages of glucose tolerance by oral glucose tolerance test. another sex-and age-matched non-chc adults served as the controls. results: the mean rbp level of controls tended to be higher than that of chc patients ( . ± . vs . ± . g/ml, p= . ). the mean rbp level of igt control-group subjects was . ± . g/ml, which was significantly higher than that of ngt ( . ± . g/ml, p< . ) and dm controls ( . ± . g/ml, p< . ). in contrast, the mean rbp level ( . ± . g/ml) of dm/chc patients was not significantly different from that of ngt/chc ( . ± . g/ml, n= ) and igt /chc ( . ± . g/ml, n= ) patients. amongst chc patients, there was a significant decreasing linear trend of rbp dependent of both histological grading and staging progression, whilst a significant increment of homa-ir was found. conclusion: serum rbp is dysregulated in chc patients. introduction: sustained viral response (svr) in hepatitis c treatment with interferon alfa and ribavirin is affected by adherence and compliance due to severe myalgia, fatigue-anxiety and disturbed sleep. pregabalin, an orally effective gabasergic drug is not metabolized via cytochrome p and is used in fibromyalgia and fatigue-anxiety syndromes without hepatic toxicity.this study evaluates the addition of pregablin to standard agents in achieving svr by reducing side events. methods: thirty patients with chronic hepatitis c {mean age - years, male: female - : ,genotype(g) (n= ), g (n= ), fibrotic score f - (n= ) and f (n= ), mean bmi > kg/m , initial viral load > , iu/ml} were randomized to pregablin mg (n= ) or duloxetine mg (n= ) both orally daily with interferon alfa a mcg sq once a week and ribavirin mg daily for weeks. myalgia anxiety scale, modified quality of life score -evaluated at entry and tri-monthly. all were tested for rapid viral response, early viral response and end treatment viral response and svr. results: at the end of weeks, in the pregablin arm, ( . %) completed the therapy without interruption, one stopped due to excessive somnolence. duloxetine arm - ( . %) completed with interruptions, ( . %) withdrew from the trial due to side events, one left the country. ( . %) achieved svr in pregablin arm and ( . %) with duloxetine. conclusions: pregablin may be considered with ifn and rbv for better adherence and compliance in achieving svr in treatment of chronic hepatitis c. larger randomized studies are needed to confirm the findings. in this study we extended this treatment approach to on treatment nonresponders (defined as having detectable hcv-rna after at least weeks of soc). methods: so far, pts. hcv-rna pos. after weeks of soc ( male, female, genotype : ; genotype a: , with cirrhosis) participated in this protocol; were treatment naïve pts, relapser to two previous therapies ( and weeks). mg/kg/d sil was given for days, soc was continued. hcv-rna was quantified by taqman (roche diagnostics, usa) at monthly intervals on standard treatment and weekly after starting sil. results: all patients received at least weeks of soc, at week had a log drop < , two patients had detectable but unquantifiable hcv-rna (< iu/ml). after days of sil all had undetectable hcv-rna, in one hcv-rna increased to iu/ml and recived after a second course of sil. .all patients are still on soc and are hcv-rna negative. conclusion: sil iv. is an effective "rescue treatment" for on treatment nonresponders to full dose of peginterferon/ribavirin combination therapy. poster exhibition -imaging modalities poster session, hall b background: levovist-enhanced ultrasonography using subtractions makes it possible to depict the perfusion of hyperechogenic nodules. our institution performs sonazoid-enhanced ultrasonography using a toshiba aplio that is set to a ps low images, as generally recommended. the resulting images, however, are difficult to evaluate the kind of staining image that is obtained from a hyperechogenic nodule. these staining images were then compared to advanced dynamic flow (adf) images of a hyperechogenic nodule recorded using levovist-enhanced ultrasonography. methods: the subjects were five nodules who had undergone sonazoid-enhanced ultrasonography. two patients had experienced a recurrence of hcc after tace, while three patients had a hyperechogenic nodule of hcc that had never been treated. one patient with hcc after tace was imaged at a ps low. the second patient with hcc after tace and the three patients with hcc showing a high echoic nodule, were imaged using adf. results: in the patients with hcc after tace, the remaining tumor was difficult to observe in both the vascular phase and the kupffer phase taken at a ps low. in the other patients, however, images taken using adf clearly showed the residual tumor. also, with regard to the findings from the perfused images obtained from the three patients with hyperechogenic nodules of hcc, the hcc was more easily detectable in the adf images than in those taken at a ps low. conclusion: hyperechogenic perfused nodules are easier to identify in images taken using adf than in images taken using ps low. y. komorizono , t. shibatou , k. sako nanpuh hospital background: this study aimed to evaluate the usefulness of sonazoid enhanced radiofrequency ablation under real-time virtual sonography (rvs) guidance in a series of patients with hepatocellular carcinoma (hcc). method: twenty-five patients with a solitary hcc tumor measuring < = . cm in greatest dimension were enrolled in this study. eight patients received an initial treatment, seven also received an additional treatment for local recurrent tumors, and the remaining ten had distant recurrent tumors. all patients were easy to scan by multiple detector ct (mdct), but not by conventional ultrasound ( conclusions: the combination of the rvs system with sonazoid-enhanced us appears to have a high potential for use on patients that are difficult-to-scan by us examinations for percutaneous radiofrequency ablation. background & aims: contrast enhanced ultrasonography (ceus) with sonazoid can be expected to be useful not only for detection of tumor but also for us guided ablation therapy because kupffer imaging lasts for long time. the aim of this study is to investigate the usefulness of sonazoid in rfa for hcc. material & methods: a total of hcc nodules in patients admitted to receive rfa were studied. the detection ability of hcc was compared between ceus and conventional us using dynamic ct as reference standard. the effectiveness in the treatment was assessed by comparing the mean numbers of treatment session of rfa in patient treated with ceus assistance and that in historical controls matched for tumor and background conditions. results: the detection rate was . % in conventional us and . % in ceus (p= . ). sixty-nine nodules in patients were not detected by conventional us and detected after injection of sonazoid. the mean increase in detected tumor number with contrast enhanced us were well correlated with serum albumin level (p= . ). ceus was not superior to conventional us in patients with low albumin level. the mean number of session was . ± . as compared to . ± . in the historical controls (p= . ). conclusions: ceus with sonazoid is useful for detection of tumor in patients with well-conserved hepatic reservoir. the decrease in the mean number of sessions compared to historical controls suggested that sonazoid is an excellent supportive agent in rfa treatment of hcc. direct measurement of peri-operative change in portal blood flow and pressure is difficult in human. in the present study, computational simulation of pre-and post-operative portal blood flow and pressure was performed using computational flow dynamic (cfd) software in patients with primary liver cancers. methods: patients with fibrotic or non-fibrotic livers were analyzed. according to preoperative md-ct, mesh models of portal branches were constructed. cfd software (fluent . , fluent inc.) was employed for flow simulation. on the fluent . , changes in flow dynamics in the remnant portal branches were simulated by virtual cutting of an interested portal branch. the simulation was also performed days after the operation using dicom data obtained at that time. results: relative increase in blood flow in each remnant portal branch was not uniform throughout the liver in each patient. the sudden increase in portal pressure just after the virtual cutting of interested portal branch was almost normalized by day in non-fibrotic liver according to the flow simulation, while the increase in fibrotic liver did not return to the pre-operative values by day . these results suggest that responsive dilatation of remnant portal branches and subsequent regional regeneration could normalize the sudden increase in portal pressure after surgery in non-fibrotic livers, while the mechanism is impaired in fibrotic livers. discussion: computational flow dynamic simulation is useful to analyze the differences in the peri-operative portal flow dynamics and liver regeneration between non-fibrotic and fibrotic livers. aim: to determine if roi analysis can characterize washout in hepatocellular carcinoma (hcc) better than visual analysis. methods: surgically proven hccs from a single institution were studied. the patients' gender, age, date of scan, date of surgery were recorded. patients with pre-operative triphasic (n= ) and quadriphasic ct scans (n= ) were included. a representative section containing the lesion was selected for each case. the hu change between the precontrast and arterial (huabsolute hypervascularity) and the hu change between the peak attenuation and late portovenous phases (huabsolute washout) were recorded. cases were deemed positive if the hu change was more than the standard deviation ( hu). this was compared against visual analysis to determine if our method would increase sensitivity of ct for hcc. results: the mean patient age was . years (range to years); there were males and females. the mean duration between surgery and the scan was . days (range to days). peak enhancement was seen in the early portal venous phase in . % cases. the mean huabsolute washout was . hu (range - - ). roi analysis detected / cases ( . %). this was . % more than visual assessment, which detected / cases. this was statistically significant (p= . ). conclusion: visual assessment of lesion density is subjective. quantitative measurement of lesion attenuation changes between scan phases is a simple and objective method that is more sensitive than visual assessment in determining lesion washout. background: abdominal ultrasonogram(usg) is a common available diagnostic tool to screen and follow up for hepatocellular carcinoma(hcc). but it has been reported that the specificity of ultrasonogram is high but the sensitivity of it is insufficient. we investigated the characteristics of hccs that was missed in the usg but was detected in the ct. methods: total patients who were diagnosed with hcc between december, and february, , were enrolled and analysed retrospectively. all patients were performed with a usg prior to a spiral ct. the period between usg and spiral ct was limited within month. we investigated age, gender, cause(hbv, hcv, alcohol), the size of hcc(the length of long diameter), stage(modified uicc), child-pugh grade, cirrhosis, tumor number, portal vein thrombosis, diffuse type of hcc, regenerative nodules(rns), and the tumor location at segement as the possible related factors. results: the mean period between usg and spiral ct was . ± . days. the diagnostic accuracy rate to hcc was . %( / ). there was no interobserver variation. in analysis of associated factors, there was no statistical significance in age, gender, cause(hbv, hcv, alcohol), stage(modified uicc), child-pugh grade, cirrhosis, portal vein thrombosis, diffuse type of hcc, regenerative nodules(rns) (p > . ). there was statistical correlation in the tumor size less than cm, the solitary tumor and location at segement . (p > . ). conclusion: tumor size less than cm, solitary lesion and location at segment are significant factors to miss hccs in usg diagnosis. s. somani , a. somani , a. jain , v. dixit suvidha, navjeevan hospital, background: histopathological examination is required in the evaluation of various liver diseases for both diagnosis and prognosis. earlier blinded percutaneous liver biopsy was done commonly but now there are various studies suggesting that sonographic guided percutaneous liver biopsy could be more precise and safer. our aim was to compare the safety and diagnostic utility of sonographic guided versus blind percutaneous liver biopsy. methods: it was a retrospective single center study done between june and may . trucut liver biopsy needle was used in all patients. demographic, clinical and histological characteristics between the two groups were evaluated. insufficient biopsy was defined as a sample with less than portal spaces. we reviewed the type of complications and if hospitalization was required, or any mortality related to the procedure. results: out of liver biopsies done in this period after excluding patients we included patients, in group a( %, blind approach) and in group b ( %, sonographic guided approach). mean age was ± . years and male: female ratio was . : . biopsy was sufficient in % in group a and % in group b (p < . ). minor complications occurred in % in group a and % in group b which was not significant. major complications occurred in . % in group a and . % in group b which was statistically significant. mortality was . % in group a and . % in group b which was statistically significant. conclusion: our study suggest that sonographic guided percutaneous liver biopsy is superior in the diagnosis of liver diseases in all aspects when compared to blind approach as it is more safe, has more diagnostic utility with significantly less complications and mortality. poster exhibition -liver fibrosis poster session, hall b background/aims: hmg-coa reductase inhibitors have been shown to reduce hepatic stellate cell proliferation and collagen production and decrease oxidative stress and hepatic vascular tone in cirrhotic patients. therfore, the aim of the present study was to examine whether the lipid lowering agents atorvastatin (ato) or rosuvastatin (ros) would prevent experimentally-induced acute or chronic hepatic damage in rats. methods: liver cirrhosis was induced by thioacetamide (taa, mg/kg, i.p.) twice a week, for weeks. acute damage was induced by two consecutive taa injections ( mg/kg in a h interval). rats were treated concurrently with taa only or taa and either ato or ros daily by nasogastric gavage. another group was treated with taa+pentoxifyline (ptx), an agent with known antifibrotic effect through a different mechanism and served as positive control. results: presented in the conclusions: the lipid lowering agents used in our study had no effect on the development of acute or chronic hepatic damage in rats or on oxidative stress induced by taa. purpose: the development of hepatic fibrosis in patients with chronic liver disease increases the risk of liver cancer. the present study was conducted to determine whether an easily performed myocardial examination technique can be applied to the assessment of hepatic fibrosis. strain rate imaging is a new method based on tissue doppler imaging (tdi). the usefulness of strain rate imaging in assessing the degree of hepatic fibrosis was evaluated. this time, it mede comparative study with fibroscan in cases. methods: strain rate imaging was performed using a diagnostic ultrasound system (aplio tm , toshiba medical systems corporation, tochigi, japan) in a total of subjects: in the chronic hepatitis group, in the cirrhosis group, and in the normal control group. tdi-q, the tissue doppler analysis software installed in the aplio system, was used for analysis. measurement was performed five times from the epigastrium, with the roi size set to mm and the derivative pitch to mm. results: (i): both scores were largely reproducible among the different laboratories. however, compared to the histological findings, the error ratio was % for all results calculated by fibrotest and actitest. (ii): calculated scores varied among f ( %), f ( %), f -f ( %), and f ( %) (fibrotest), as well as a /a ( %), a ( %), a -a ( %), and a ( %) (actitest). results: the mean strain value was . in the chronic hepatitis group, . in the cirrhosis group, and . in the normal control group.the correlation was not thought to be fibroscan. conclusion: the results of the present study suggest that this noninvasive method permits quantitative assessment of the degree of hepatic fibrosis to be performed easily and in a short time. it is expected that the accuracy of the strain rate imaging method in determining the degree of hepatic fibrosis will be improved when it is used in combination with histological examination. conclusion: despite reproducibility of fibro-and actitest results among the six laboratories, large scale investigation (n= ) displayed increasing variability of the results depending on interlaboratory differences that were still in a quality controlled, analytically acceptable range. furthermore, calculated scores coincided with histological findings only in less than % of all cases. thus, the diagnostic accuracy of these tests seems low, if histology is accepted as gold standard. background: current knowledge attributes connective tissue growth factor (ctgf/ccn ) a crucial role in enhancing tgf-actions during hepatic fibrogenesis. recently, we demonstrated that caffeine leads to an upregulation of ppar in hepatocytes, thus sensitizing these cells to the well known inhibitory effect of -deoxy- , -prostaglandin j ( -d-pgj ) on ctgf expression. however, upregulation of the receptor alone is not sufficient per se, its physiological ligand -d-pgj is required for exerting its inhibitory effect on ctgf synthesis. aim and methods: this study compares serum concentrations of -d-pgj in caucasian patients with fibrotic liver diseases (n= ), caucasian controls (n= ) and caucasian non-liver disease sick (n= ), as well as of chinese patients with hepatocellular carcinoma (n= ) and chinese healthy controls (n= ) in order to characterize their suitability for therapeutic approaches with ppar inducing (i.e. ctgf inhibitory) drugs such as caffeine. results: presented data show that caucasian patients with ongoing hepatic fibrogenesis (mean . ± . µg/l) display impressingly higher serum concentrations of -d-pgj than healthy probands (mean . ± . ) and caucasian patients with non-liver disease (mean . ± . µg/l). similar results are found in chinese patients with fully developed hcc (mean . ± . µg/l) compared to chinese healthy controls (mean . ± . µg/l). we identified the predictors of tumor recurrence using cox-regression model. introduction: non-invasive, i.e. serum-based multiparametric panels of biomarkers have been proposed for the diagnostic assessment of liver fibrosis. aims/methods: (i) haptoglobin, alt, ggt, alpha -macroglobulin, apolipoprotein a and bilirubin in sera of patients with histological proven fibrosis (f -f , a -a ) were determined in different quality-controlled laboratories. interlaboratory variations of the calculated fibrotest score for staging and actitest score for grading (both biopredictive tm ), and their error ratios compared to biopsy results were calculated. (ii) the variability of obtained fibrotest/actitest scores depending on differential combinations of the allowed analyt-specific maximum/minimum permissible values as determined by the external quality control of the german association of laboratory medicine was determined and the frequency distribution of the results calculated. results: a total of patients (mean age, . ± . years; male, . %) were included. median follow-up duration was . months (range, . - . ) and patients ( . %) experienced local tumor recurrence during the observational period. multivariable analyses showed that low p /ms level (relative risk, . ; % confidence interval [ci], . - . ; p= . ) and serum alpha-fetoprotein level > ng/ml (relative risk, . ; % ci, . - . ; p= . ) were independent risk factors for tumor recurrence. patients with p /ms level < . revealed . -fold ( % ci, . - . ; p= . ) increase in the risk of recurrence after adjustment for serum alpha-fetoprotein level, as compared to those with p /ms level > . . however, tumor size, child-pugh score, and hepatitis b virus dna level failed to significantly affect the time-to-recurrence. conclusion: our study suggests that lower p /ms value, which means more severe liver fibrosis, is an independent predictor for hcc recurrence after rfa. background/aims: despite of its high prevalence, osteoporosis is an underestimated complication of liver cirrhosis. the aims of this study is to prove the prevalence of osteoporosis and osteopenia in patients with liver cirrhosis and to identify the principal risk factors associated. methods: the prevalence of osteoporosis and osteopenia was studied in patients with alcoholic or viral liver cirrhosis who were admitted to the institute of gastroenterology and hepatology, cnuh between march and september . osteoporosis and osteopenia was evaluated by measuring their bone density using dual energy x-ray absorptiometry (dexa) at lumbar spine and femoral head. the variables taken into consideration were: sex, body mass index (bmi), presence of cholestasis, severity and duration of liver disease. results: total patients (male and female , respectively) were estimated for association of liver disease and osteoporosis. of these, patients were estimated for bone density of lumbar spine and neck of femur by dual x-ray absorptiometry (dexa). morning blood samples were taken for hormonal and biochemical analysis from all patients. among patients, patients ( %) were found to have osteopenia or osteoporosis. there was no statistically significant correlation between age, bmi, severity and duration of liver disease, pth, vitamin d, alp and igf- . conclusion: there is high prevalence rate of osteopenia or osteoporosis in liver cirrhosis. although the causes of osteopathy are heterogeneous, the early diagnosis and treatment of osteopathy in patients with liver cirrhosis is important. background: to build and to evaluate mathematical models for predicting liver fibrosis progression by using conventional laboratory indicators in chronic hepatitis b. methods: liver biopsy and routine laboratory tests were performed in patients with chronic hepatitis b. using multiple logistic regression to analyze evidently relevant indicators, then the predicting models were built and analyzed by roc curve. results: after spearman analysis, factors such as age, platelet count(plt), international rate(inr), total bilirubin(tbil), albumin(alb), aspartate aminotransferase (ast), gamma glutamyltranspeptidase (ggt), total bile acid(tba) and cholinesterase(che) were found to be correlated with liver fibrosis p . . three models (s , s , s= , respectively) were built by plt, inr, alb, ggt and che, which were independent predictors after multiple logistic regression analysis.finally, fibrosis score (fs) was calculated to predict different liver fibrosis stages. roc curve analysis revealed that the auc of fs was . in model (s ), . in model (s ) and . in model (s= ) fig .the cut-off fs in model was at . with . % sensitive, . % specificity and the accuracy was . %. the cut-off fs in model was at . with . % sensitive, . % specificity and the accuracy was . %. the cut-off fs in model was at . with . % sensitive, . % specificity and the accuracy was . %. conclusions: the predicting models, built by using conventional laboratory indicators, have fairly well value for diagnosing hepatic fibrosis or hepatocirrhosis in chronic hepatitis b. background: to investigate the effect of liver cirrhosis on the development of atherosclerosis in the rabbits chronically fed with high fat diet. methods: normal male new zealand white rabbits were randomly divided into four groups: a control group, a high fat diet group, a carbon tetrachloride (ccl ) group and a complex group. pathologic changes in ascending aortas and livers were observed. the levels of serum alanine aminotransferase alt , lipid, c-reactive protein (crp) were also determined. results: significant hepatic steatosis, inflammation and fibrosis could be observed in the three treatment groups; while atherosclerosis and typical arteriosclerotic plaques in ascending aortas could only be observed in the two high fat diet groups. compared with the control group, serum alt and lipid levels in ccl group were increased significantly (p< . ), but no difference of arterial intima-media thickness (imt) and i/m ratio between these two groups. the levels of serum alt, lipid, crp and imt in two high fat diet groups were significantly increased compared with the control group (p< . ). the level of serum alt in the complex group was significant higer than that in the high fat diet group, but the i/m ratio was just opposite (all p< . ), and there was no difference of imt between the two groups. conclusions rabbits treated with ccl can elevate serum lipid levels, but can not induce atherosclerosis. though the activity of liver inflammation was aggravated in the complex model group, it has no effect on atherosclerosis possibly partly because of malnutrition. higher values of liver stiffness in males with mild chronic hepatitis c c. stern , a.c. cardoso , r. moucari , a.d. pumpo , n. giuily , p. bedossa , p. marcellin hopital beaujon background/aim: liver stiffness (ls) measured by fibroscan (echosens) is a noninvasive method to assess liver fibrosis in patients with chronic liver diseases. we evaluated the impact of factors on ls results in mild chronic hepatitis c (chc). methods: chc patients with metavir fibrosis stage at liver biopsy and a reliable ls exam were eligible. all patients had no prior antiviral treatment. the ls values were compared to clinical and biochemical data. results: patients were included with the following characteristics: mean age , male gender ( %), mean bmi . , median ls . kpa ( . - . ), diabetes ( %), genotype ( %), metavir activity a ( %), a ( %), steatosis at biopsy % ( %), mean glucose . , abnormal alt ( %), abnormal ggt ( %), homa ( . ). the ls values were associated wtih male gender (median . in males vs . in females) (p= . ), bmi (p= . ), alt (p= . ), ggt (p= . ) and glucose levels (p= . ). no association was found between ls and activity stage (p= . ) or steatosis (p= . ). in the linear regression, the only factor independently associated with higher ls was gender (p= . ). in men, higher ls was related to levels of alt (p= . ), but not to necro-inflammation grade (p= . ). in women, ls was not associated with alt levels, but with bmi (p= . ) and ggt levels (p= . ). conclusion: in patients with mild chc, liver stiffness values are higher in males. these results suggest that different cut-off for fibrosis stage should be proposed according to gender. aims: to investigate the effects of shuanghu qinggan granule(sqg) on prevention and treatment of hepatic fibrosis induced by carbon tetrachloride in rats. methods: sd rats were divided into groups, normal control groupamodel groupb, sqg largec , middlec small dose groupsc and silymarin positive contrast groupd. the rats of bc c c d were injected with carbon tetrachloride for weeks. the rats of c c c were then administered with sqg for weeks. the rats of d were then administered with silymarin for weeks. results the liver structure of rats of b was severely damagedlarge amount of liver cells became obviously degeneratedand hepatic veins were clearly congested. the hepatic cells fatty degeneration and infiltration of inflammatory cells in rats of c c c d reduced significantly. there was no fiber hyperplasia in liver tissues of rats of c c c d. blood serum ha cp p levels in rats of b were significantly higher than those in ac c c d. conclusion: sqg has remarkable therapeutic effects on rats with hepatic fibrosis induced by carbon tetrachloride, the higher the dosage of sqg was, the more effective the results would be. conclusions: none of sophisticated biomarkers had value in addition to readily available laboratory data for the prediction of significant fibrosis in hbeag positive patients. two markers out of sophisticated biomarkers provide additional diagnostic information in hbeag negative patients. before new biomarkers are accepted, their superiority to routine laboratory data should be meticulously appraised. objective: to evaluate the efficiency and safety of "tinmax" hb- herbal compound (cpd) in treatment of hepatofibrosis and cirrhosis post chronic hepatitis b. methods: a double-blind randomized method was employed. patients of hepatofibrosis or cirrhosis post hepatitis b were separated into study group ("tinmax" hb- group) and control group (natural vitamin group) by randomized method. the course was weeks. patients visited once every weeks and the last visit at weeks after the cessation of treatment. part of patients had liver biopsy before and after treatment. before, during the course and at the end of therapy, clinical symptoms and physical signs were evaluated, hepatic function, and serum markers of hepatofibrosis (such as hyaluronate acid, laminin, serum type iii procollagen and collagen iv) were tested, and ultrasound evaluation was performed. results: patients enrolled in the evaluation. patients completed the evaluation according to the protocol. patients had liver biopsy twice, from the study group and from the other one. at the end of therapy, the total effective rate of hepatofibrosis in histopathology is . % in the study group, much higher than that of . % in the control group (p< . ). the total effective rate of serum markers of hepatofibrosis at the end of therapy in the study group was . %, much higher than that of . % in the control group (p< . ). the total effective rate of non-invasion markers of hepatofibrosis at the end of therapy in the study group was . %, much higher than that of . % in the control group (p< . ). the drugs of adverse event had not happened in both groups. conclusion: "tinmax" hb- herbal compound (cpd) is effective and safe in treatment of hepatofibrosis and cirrhosis post chronic hepatitis b. w.h. sha , xiaohui zeng , yuyuan li gi department, first municipal hospital of guangzhou, guangzhou aim: to investigate the clinical value of serum indices for hepatic fibrosis in chronic liver diseases. methods: competitive radioimmunoassay was used to determine the serum level of collagen type ( c), laminin (ln) and hyaluronic acid(ha) in patients with different severity degree of chronic liver diseases, and in healthy subjects. results: the serum levels of c, ln, and ha in the patients with liver diseases increased to different extent, compared with those in the healthy subjects. of which the highest of c, ln, and ha were found in the patients with primary carcinoma of liver or hepatocirrhosis and the serum level of ha is highlight. the combination detection of serum c, ln, and ha is more valuable than single index. conclusion: joint detection of serum c , ln, and ha is of higher significance in clinical diagnosis and prognosis of hepatocirrhosis, and is also available for successive observation on the development of liver diseases. aims: to investigate the mechanism of fuzheng huayu decoction (fzhy) on hepatic stellate cells (hscs) activation relating to tgf- signal transduction pathway. methods: hscs were isolated from normal rats by in situ pronase/collagenase perfusion followed by density gradient centrifugation. at day after isolation, cells were stimulated with pm tgf- for h, then incubated with % fzhy pharmacological serum or m t r -i inhibitor (sb- ) for h. protein expression of -sma, smad was assayed by immunofluorescent stain; total protein expression of -sma, t r -i, smad / and nuclear expression of smad was analyzed by western blotting. results: fzhy pharmacological serum significantly decreased expression of -sma, t r -i, and inhibited smad nuclear expression and translocation in tgf- stimulated hscs. conclusions: fuzheng huayu decoction can prevent hscs activation through tgf- signaling transduction pathway in hscs, which may be the important molecular pharmacological mechanism of fuzheng huayu decoction action against liver fibrosis. background: fatty liver disease has become a health problem related to metabolic syndrome worldwide although its molecular pathogenesis has remained further studied and it is unclear whether advanced fibrosis induced by steatohepatitis will regress when diet is controlled. aim of this study is ) to study the involvement of endoplasmic reticulum stress (er stress) in the occurrence of seatohepatitis and ) to obtain the evidence of resolution of fibrosis by changing the diet. methods: non-alcoholic steatohepatitis with advanced fibrosis was produced in rats by giving methionine-choline-deficient diet (mcdd) for weeks. methionine-choline-control diet (mccd) instead of mcdd was given for the last weeks in an experimental group. fibrosis and inflammation was determined by several tissue stainings. gene expression related to fibrosis and inflammation was determined by immunoblotting and real-time pcr. expression of caspase- , caspase- , and glucose-regulated protein was evaluated to clarify the presence of er stress aim against liver fibrosis relating to hypoxia and angiogenesis regulation. methods: the rats were divided into normal, model, sa-b and perin control group. rats in sa-b and perindopril group were administrated with sa-b and perindopril respectively. liver fibrosis was induced by ip dimethylnitrosamine (dmn) for w. fibrosis degree was observed by sirius red staining. col-i protein expression was analyzed by western blot; col-i , vcam- , icam- , hif- and vwf expression in liver tissue was checked by immunohistochemistry; gelatinase activities in liver tissue were detected by gelatin zymography and in situ flourescent zymography. result: compared to normal group, col-i, hif- , icam- , results: ) changing the diet from mcdd to mccd triggered the reduction in fat in hepatocytes, the decrease of inflammatory gene expression and oxidative stress, and the regression of fibrosis accompanied by the disappearance of activated stellate cells and macrophages. ) immunohistochemistry, immunoblotting, and rt-pcr analysis all indicated the occurrence of er stress in steatohepatitis while it recovered immediately after changing the diet from mccd to mcdd. vwf protein expression and gelatinase activity in liver tissue were increased obviously in model group, while sa-b and perindopril treatment significantly decreased these protein expressions and gelatinase activity. conclusions: this simple experiment clearly shows that the changing diet from steatohepatitis-causing mcdd to mccd triggers the resolution of inflammatory and fibrotic reaction in the liver, suggesting that food intake is a very important factor for controlling the state of fat and pathology of the liver. er stress is involved in the process. background: liver fibrosis results from chronic damage to the liver in conjunction with the accumulation of extracellular matrix proteins, which is a characteristic of most types of chronic liver disease. under injury conditions, hepatic stellate cells (hscs) are activated to transdifferentiate into myofibroblasts, which are capable of secretion of many connective tissue elements, especially collagens i, iii, and iv. gynostemma pentaphyllum is a popular folk medicine that has been used for treatment of hepatitis in asia. gypenosides are the major saponins derived from g. pentaphyllum. in previous study, gypenosides have hepatoprotective and anti-fibrotic activities in rat chronic liver injury induced by ccl , and anti-proliferative effect in rat isolated hscs. methods: in cultured hscs model, we detected type procollagen protein and mrna by western blot and rt-pcr. result: we found that g. pentaphyllum inhibited type procollagen protein expression in % at hours. furthermore, g. pentaphyllum also inhibited type procollagen and mrna expression in % and % respectively. in addition to transcriptional inhibition, we found that g. pentaphyllum also enhanced the degradation rate of type procollagen protein. base on the effect of enhancing protein degradation, we used some protease inhibitors like ca- me, z-fa-fmk, aebsf, tpck and tlck to identify the potential target of g. pentaphyllum. on the other hand, in the ubiquitin-proteasome system analysis, we quantified the change of some target proteins of proteasome in the presence or absence of g. pentaphyllum. conclusion: g. pentaphyllum reduced type procollagen protein by inhibiting transcription and enhancing protein degradation. aim: excessive oxidative stress in diabetic patients has been implicated in the pathology and complication of liver. the present study was designed to examine whether ginger has a direct hepatoprotective effect in diabetic cases. methods: wistar strain albino rats were selected for this study. the rats were divided into groups: (i) control, (ii) ginger treated ( mg/kg b.w. orally, days) (iii) diabetic ( mg/kg b.w., i.p.) and (iv) diabetic + ginger treatment. the lipid metabolic profiles such as total cholesterol, triglycerides, phospholipids and lipid peroxidation as stress markers and histopathological studies were carried out to assess the damage in hepatic tissue. results: ginger treated diabetic rats demonstrated significant reduction in glucose levels as compared to the nontreated diabetic animals. diabetic rats have shown increased total cholesterol, triglycerides, phospholipids and lipid peroxidation content in hepatic tissue compared to control, indicate prevailing of oxidative stress and alterations in fatty acid metabolism in these rats. further, degenerative changes of hepatic cells in diabetic group are minimized to nearness in structure by administration of ginger as evinced by histopathological examination. conclusion: we summarize that the hypolipidemic and antioxidant compounds present in ginger may be useful in delaying the complicated effects of diabetes. this results also reveal that ginger possess hepatoprotective properties in diabetic cases. anti-fibrotic action m. naime , s. ali hamdard university rhizomes of valeriana jatamansi (family, valerianaceae) have long been used in indian subcontinent by the traditional healers for the treatment of various diseases. this study provides experimental evidence suggesting the therapeutic effect of the crude extract of rhizomes on rat liver fibrosis, and demonstrates its antiproliferative role. crude extract ( % ethanolic) at a dose level of mg/kg body weight was administered to rats to study the effect on biochemical and other markers of liver fibrosis. administration of the extract for weeks could bring down elevated the levels of biochemical markers of liver injury, and modulate several other biochemical responses. morphology and hisopathological examination cooroborated with the biochemical changes, and indicated partial reversal of fibrosis. dpph assay confirmed the antioxidant property of the extract, which is suggested to be due to -ionone, -sitosterol and other chemical constituents. further, treatment could restore depleted glutathione level, inhibit lipid peroxidation, and inhibited elevated xanthine oxidase activity in fibrosis. the study also reports anti-tumour promotion activity of the extract as evident by a significant decrease in [ h]-thymidine incorporation by hepatic dna in extract treated rats. results suggest that v. jatamansi extract has curative effect and can partially reverse biochemical and histological changes associated with liver fibrosis. with chronic hepatitis c c. wongjitrat , s. chainuvati , a. manuyakorn , s. aroonparkmongkol , t. tanwandee mahidol university, background: leptin is a peptide hormone that mainly regulates food intake, energy expenditure and reproductive function. leptin also releases from activated hepatic stellate cells and may have a role in regulation of fibrogenesis and inflammation. in human chronically infected by hcv, the role of leptin-associated fibrosis of the liver is still unclear. there is no data in thai patients chronically infected by hcv regarding leptin level and its correlation with hepatic histology and fibrosis.the purpose of this study was to evaluate the relationship between leptin level and severity of liver fibrosis in thai patients chronically infected by hcv. methods: sixty-six patients ( men, women) with chronic hcv infection and liver biopsy was done within months were enrolled. fasting blood samples were obtained and serum leptin levels were measured by elisa. bmi, blood sugar, liver function test, lipid profile, hcv rna viral load and hcv genotype were also measured and related to histological findings. results: mean serum leptin levels were significantly higher in women than in male. there was a significantly correlation between serum leptin and bmi (r = . , p < . ). leptin levels were not associated with hepatic fibrosis (r = . , p = . ) and necroinflammation (r = . , p = . ). steatosis was significantly associated with severe necroinflammation (r = . , p = . ), but not fibrosis (r = . , p = . ). conclusions: these findings failed to demonstrate correlation of serum leptin and hepatic fibrosis in thai patients chronically infected with hcv. background and aim: liver cirrhosis is one of the leading causes of mortality in our country as well as in our region. even though deterioration of glucose metabolism and existence of insulin resistance in liver cirrhhosis has been well documented in many studies, it is still unclear how insulin resistance mechanism develops. the aim of the present study is to assess insulin resistance, cytokines and crp levels in patients with liver cirrhosis and control subjects. in additon, we aimed to investigate the relation of insulin resistance in liver cirrhosis with such parameters as age, sex, etiology, child-pugh classification, spleen size, tnf-?, il- ?, il- res, il- , il- , il- , crp and hs-crp. material and method: a total of patients with cirrhosis of different etilogy ( male, female) were included into the study. as controls, ( male and female) subjects were taken. the two groups were compared with each other in terms of glucose, insulin, c-peptid, homa-ir, tnf-?, il- ?, il- res, il- , il- , il- , crp and hs-crp levels. in the second part of our study, the liver cirrhosis group was divided into two subgroups: patients with homa-ir value > . as insulin resistance positive, and those with homa-ir value > . as insulin resistance negative. these two groups, i.e. , homa-ir positive and homa-ir negative, were compared in terms of age, sex, etiology, child-pugh classification, spleen size, tnf-?, il- ?, il- res, il- , il- , il- , crp and hs-crp levels. results: in liver cirrhosis group, glucose, insulin, c-peptid, homa-ir, tnf-?, il- res, il- , crp and hs-crp levels were determined to be significantly higher than controls. between patients with homa-ir positive and negative, however, statistically no significant difference was found in terms of age, sex, etiology, child-pugh classification, spleen size, tnf-?, il- ?, il- res, il- , il- , crp and hs-crp levels, but il- level was seen to be significantly low in patient homa-ir positive. conclusion: in patients with liver cirrhosis, the levels of glucose, insulin, c-peptid, homa-ir, tnf-?, il- res, il- , crp and hs-crp increase with respect to normal population. determination of increased homa-ir level in liver cirrhosis supports the view that insulin resistance develops in liver cirrhosis as reported in related studies. in the study, it was also determined that the mechanism of insulin resistance development occurs independent of age, sex, etiology, child-pugh classification, spleen size, tnf-?, il- ?, il- res, il- , il- , crp and hs-crp levels. the determination of statistically lower level of il- in patients with homa-ir positive with respect to those with homa-ir negative does not indicate similarity with the studies carried out earlier. ) in patients ( . %) than in controls( %)in group i hla-b significantly increased in patients ( %)as compared to controls ( %) . in group ii hla -b significantly higher in patients ( . %)than controls ( %) also hla-aw significantly higher ( . %) in patients than controls ( . %).in group iii hla-aw significantly increased in patients ( . %) compared to controls.no significant association between hla antigens and cases with hbv or hcv infection. conclusion: the significantly high association of hla-aw and hla-b in patients with hepatic schistosomiasis as compared to normal controlstogether with the lack of any association with active intestinal schisto . antigens predispose to liver affection.individuals possessing hla-aw appear to be more prone to severeform of liver disease background: atp b mutation is one of the factors that result in cholestasis and progress to chronic liver disease, but has never been reported in the mainland china before. the aim of this study was to elucidate the role of atp b mutation in mainland chinese patients with progressive intrahepatic cholostasis and low ggt. methods: children who presented with progressive intrahepatic cholostasis and low ggt were admitted in a tertiary pediatric hospital in eastern china. abcb gene was analyzed firstly to exclude bsep deficiency. afterwards, all the encoding exons and their flanking areas of atp b gene were sequenced in the remaining patients in whom only one or no mutations of abcb were found. results: mutations of atp b gene were found in patients. i n had been reported in taiwanese patients with pfic , and the others were novel. p t and ivs + t g were linkage and found in of patients, including homozygote and heterozygote. liver biopsy had been performed in patients with atp b mutations and with abcb pe mutations. variety portal fibrosis was showed in patients with atp b mutations and patients with abcb mutations. giant cell transformation was detected in one patient with atp b mutations and patients with abcb mutations. laboratory of exercise biochemistry, taipei physical education college, jhongcheng rd., no. , sec. , taipei city- , taiwan, roc background/aim: generation of reactive oxygen metabolites are depends on the consumption of oxygen and their cumulative effects may be different from lean to obese population. this study was designed to investigate the deleterious effects of oxidants on hepatic antioxidant defence system in lean and obese rats under hypoxic condition. methods: zucker rats lean ( ± gms) and obese ( ± gms) were divided into control and acute hypoxia groups. the acute hypoxia treatment was performed in a hypoxic chamber at % oxygen consumption. objectives: to compare the diagnostic value of morning urine copper to zinc (copper/zinc) ratio and hour urinary copper excretion in wilson's disease (wd) children. results: in the results, acute hypoxia caused a significant (p< . ) decrease in major antioxidant enzymes including superoxide dismutase (sod), catalase (cat), glutathione peroxidase (gsh-px), glutathione reductase (gr) and glutathione (gsh) content in lean groups when compare to their controls. the decrease in the activities of all antioxidant enzymes was also noticed in obese group with hypoxia treatment. however, this decrease was not significant in case of cat, gsh-px activities and gsh content. the mda levels (lipid peroxidation marker) were higher in obese rats compare to lean rats. methods: morning urine and hour urine were collected from patients over three years age who were hospitalized in a tertiary pediatric liver service. each patient was re-evaluated according to wd scoring system, and was assigned to one of the three groups: wd, suspecting wd, and non-wd. , , and cases were assigned to wd, suspecting wd, and non-wd respectively. urine copper and zinc concentration was determined simultaneously by using inductively coupled plasma mass spectrometry. conclusions: the higher hepatic mda values observed in obese rats indicate that accumulation of free radicals may be more in obese rats thus leads to promote the lipids oxidation. from this study it is concluded that decrease of antioxidant enzymes (except gr) with acute hypoxia treatment were more in lean group compared to with that of obese group. results: the morning urine copper/zinc ratio and hr urinary copper excretion correlated well (r= . , p < . ). the median of morning urine copper/zinc ratio, hr urine copper/zinc ratio, h copper excretion, and h zinc urinary excretion were . , . , . and . in wd group, and . , . , . and . in the non-wd group respectively. the differences of morning urine copper/zinc ratio, hr urine copper/zinc ratio, and h copper excretion were significant (z-value - . , - . and - . respectively, all p values < . chd l is a recently discovered oncogene localized at q , one of the most frequently amplified chromosomal regions in hcc. herein, by yeast-two hybrid assay, we demonstrate that the anti-apoptotic ability of chd l is associated with its interaction with nur , a critical member of a p -independent apoptotic pathway. as the first cellular protein identified to bind nur , chd l inhibits the nucleus-to-mitochondria translocation of nur , and subsequently hinders the release of cytochrome c and the initiation of apoptosis ( figure ). further study found that c-terminal macro domain of chd l is responsible for the interaction with nur , and a chd l mutant lacking residues - failed to interact with nur and prevent nur -mediated apoptosis. we also find that chd l confers cellular chemoresistance to drugs that induce apoptosis via the nur -mediated pathway, which may lead to the identification of new therapeutic targets for hcc treatment. background/aim: accumulation of oxidative damage to proteins, lipids and mitochondria could increase with advancing of age. the current study was aimed to test the hypothesis that swimming exercise training could revert the age dependent oxidative damages in liver. methods: sprague-dawley rats of young ( months) and old ( months) were divided into four groups; young control (n= ), young exercise (n= ), old control (n= ) and old exercise (n= ). minutes of swimming exercise was given to the exercise group for a period of two weeks. results: the estimated antioxidant enzyme activities including, superoxide dismutase (sod), catalase (cat), glutathione peroxidase (gsh-px) and glutathione reductase (gr) were decreased with age and significantly (p< . ) increased with exercise training. however, elevated protein carbonyls and mda levels were noticed in old animals, which indicate that old liver had greater accumulated oxidative damages. the significant drop in protein carbonyl content and increase in mitochondrial succinate dehydrogenase (sdh) activity was observed with response to swim training in old rats. conclusions: this data implied that swim exercise training could revert the oxidative damages in liver. this was also proven by enhanced antioxidant enzyme status with response to exercise training in old rats. to sum-up these results it is cleared that age induced detrimental effects to the liver might be reversed by regular swimming exercise training in old rats. results: peg was expressed in l /peg (fig. ) . peg accelerated the growth of l . after treatment with mm h o for h, the inhibitory rate of l /peg cells was . %; the chromosomal condensation and ladder-like dna fragmentation were not observed (fig. ) . methods: hepg or hepg . . were co-cultured with jurkat cells, with blocking test by adding anti-pd- antibody. the pd- expression was detected by flow cytometry (fcm); cytokines in culture supernatant in blocking groups and controls were measured by enzyme-labeled immunosorbent assay (elisa); cytotoxic test of t cells were measured by methyl thiazolyl tetrazolium (mtt). conclusions: over-expression of peg can significantly promot l proliferation and ameliorate apoptosis-inducing effects of h o on l . results: the pd- expression on jurkat cells was induced by hepatoma cells, the expression rate were . ± . % (by hepg ) and . ± . % (by hepg . . ), respectively. the cytokines il- level ( . ± . pg/ml), inf-level ( . ± . pg/ml) and il- level ( . ± . pg/ml) in culture supernatant of blocking groups were significant higher than that of controls (il- , . ± pg/ml, inf-, . ± . pg/ml and il- , . ± . pg/ml, respectively. p < . ). the cytotoxic test (od value) was markedly higher in blocking group ( . ± . ) than that of control group ( ± . p< . ) . conclusion: the pd- expression on lymphocytes can be induced by hepatoma cells, and cytokines expression and cytotoxic test were recovered by blocking pd- /pd-l interaction. background: hedgehog (hh) pathway is well known as a positive regulator for tissue construction( during development) and reconstruction (in adults). our aim to observe the expression change of hh pathway on rat hepatic regeneration . materials and methods: adult male sprague-dawley rats underwent approximately % partial hepatectomy (ph) or sham operation (so). liver specimens were collected at , , , , , , , and h after ph or so. hedgehog expression was determined in mrna level by rt-qpcr as well as in protein levels via immunohistochemical staining and western-blotting. results: so treatment did not induce remarkable changes in hedgehog expression; however, the level of transcript for hedgehog was significantly upregulated after ph. we found sonic hedgehog(shh )and glioblastoma (gli - ) mrna expression in the regenerating liver arrive at its peak at as early as h and returned to its physiologyical level h later. it is similar to the change of proteins (shh and gli ) .as seen from immunohistochemistry experiments; shh protein was expressed uniquely in regenerating hepatocytes. similarly, ph induced over expression for shh protein occurred from h with a peak level at h after surgery. but gli protein mainly located in nucleus and no significantly changes in the phrase of liver regeneration. conclusion: hedgehog pathway may play a role in the activation of hepatic proliferation during liver regeneration induced by physiological stress or pathological states, such as ph. background: to investigate whether peg , an imprinted gene with an active paternal but silent maternal allele, was involved in hydrogen peroxide (h o ) induced cellular apoptosis. methods: peg gene was stable transfected into l . cellular gene expression was determined by rt-pcr, western blot and immunocytochemistry. cell proliferation was analyzed by mtt. after treatment with different concentrations ( - mm) of h o , cell proliferation inhibition rate was measured by mtt. morphological changes of apoptotic cells were determined by hoechst staining, dna fragmentation was observed by agarose gel electrophoresis. hua tang , xiao-yan tang , min liu , xin li tianjin life science research center, tianjin medical university, tianjin , china we determined how afp modulates the proliferation of hepatoma cells. a recombinant adenovirus expressing sirna against afp (adv-afpsirna) was created and found that it reduced expression of afp specifically in hepatoma cells, and markedly inhibited the proliferation of hepatoma cells in vitro. local treatment using adv-afpsirna caused significant repression of the growth of hepatoma derived hepg cells in xenograft in nude mice. knockdown of afp resulted in an obvious delay in the g /s transition of cell cycle, but did not affect apoptosis in hepg cells, as analyzed by flow cytometry and tunel assay. also, differential expressions of some genes related to the cell cycle, including skp , cyclin d , csk and ebag were identified by microarray and rt-pcr in hepg cells and hepg cells with knocked down afp. these results suggest that endogenous afp is a critical determinant of the growth of hepatoma cells. hematopoietic stem cell (cd +) therapy can improve liver function in patients with cirrhosis. these cells can be mobilized into peripheral blood using granulocyte colony stimulating factor (gcsf). this study was undertaken to assess feasibility and safety and of gcsf induced cd + cell mobilization and its impact on liver function in patients with cirrhosis. patients with liver cirrhosis (cryptogenic or alcoholic with m abstinence) with cpt > and < , and splenic diameter < cm were included. gcsf injection was given for days ( mcg/kg/dose). baseline & day- cd + counts in peripheral blood were done by flow cytometry. follow up was weekly for weeks and then monthly. cpt was compared at baseline and months. patients (median age y, range - y, males; etiology: alcohol, cryptogenic; median cpt , range - ) were included. cd + cell counts at baseline and day were ( - ) and ( - ) respectively (median, range). side effects were fever in , allergic reaction in and increase in splenic size in (excluded). in follow up, patients died ( , & m after therapy, after olt), lost to follow-up. patients showed improvement in - ) at -month follow-up. gcsf treatment is safe and yields adequate cd + cells in peripheral blood. in short term it results in improvement in liver function in patients with cirrhosis pe molecular cloning and transcriptional analysis of kctd gene promoter b. pi , j.s. wang , m.f. han , y.y. zhou , x.j. liu , x.p. luo , q. ning department of infectious disease, tongji hospital, tongji medical college, huazhong university of science and technology, department of pediatrics, tongji hospital, tongji medical college, huazhong university of science and technology aim: our previous work has shown that high expression of kctd , a potassium channel associated gene, correlated with the disease severity of patients with severe chronic hepatitis b(schb). to further understand the gene transcription and regulation, kctd promoter was cloned and gene transcription was studied. methods: a full length of isolated promoter and series of ' truncated promoter of kctd gene was subcloned into the luciferase report vector pgl -basic to form the promoter-report constructs. the kctd promoter-report construct upstream of the luciferase report gene was cotransfected with constructs expressing hbv x,c and s protein respectively or stimulated with cytokines (il- , ifn and tnf ) in t cells to investigate kctd gene regulation upon both viral factors and host cytokines. result: a bp kctd segment upstream of atg translation start site was evidenced to contain potential regulative domains. an important regulation site located between - bp and - bp upstream of atg translation start site. based upon the luciferase activity assay, il- was able to upregulate the transcription of kctd whereas there was no effect from neither hbv viral proteins nor ifn and tnf . conclusion: here we first successfully cloned the full length promoter of kctd . il- significantly enhanced the transcription of kctd , a gene which has been shown to be involved in t cell activation and disease severity of schb from our group. this work was supported by nsfc( , , ) istanbul university, cerrahpasa medical school, marmara university, okmeydani teaching hospital, background: the treatment in chronic hepatitis c virus (hcv) is not highly effective, and cost, duration, and side effects are challenging. predicting favorable factors of response to treatment would make it possible to give it only responsive patients. recent studies report more conclusive results about the role of apoptosis in inflammation and fibrosis seen in chronic viral hepatitis. hepatocyte damage in hcv is mediated by cytotoxic t-cells. apoptosis primarily developed by the interaction between fas antigen on hepatocyte and fas ligand on t-cell corresponds to a main mechanism for hepatocyte damage. methods: in this study, we aimed to detect any relationship between apoptotic markers (fas, fas ligand, fas-associated death domain, caspases , , and , insitu apoptosis) in liver biopsy taken before the treatment and response to the treatment of interferon+ribavirin. additionally, any relationship between these parameters and the other ones predicting the response to therapy including alt level, viral load, genotype, and gender were studied. results: the study includes the patients in centers managing chronic hcv infection. all parameters were studied in patients. study results revealed that histological activity index is correlated with cd staining density, caspase intensiveness, and portal and parenchymal fas ligand scores. fibrosis is also seen to be correlated with the same parameters. apoptotic parameters of the responsive cases were not significantly different from unresponsive ones. conclusion: apoptotic parameters studied in the liver tissue is associated with inflammation and fibrosis, however these parameters may not predict the response to the treatment. s. gao , d. xi , j.w. guo , c.l. zhu , x.p. luo , q. ning department of infectious disease, tongji hospital, tongji medical college, huazhong university of science and technology, department of pediatrics, tongji hospital, tongji medical college, huazhong university of science objective: this study was designed to explore the opportunity of microrna interference technique in the inhibitory application of human fgl , human fas and tnfr expression. methods: the eukaryotic expression plasmids of human fgl , fas and tnfri genes were constructed and have successfully expressed hfgl , hfas and htnfri protein. mirna expression plasmids of hfgl , hfas and htnfri complimentary to the sequence responsible for hfgl , hfas and htnfri respectively were also constructed, meanwhile an irrelevant mirna plasmid was used as control. by respective cotransfection of p-hfgl mirna and pcdna . -hfgl , p-hfasmirna and pcdna . -hfas, p-htnfri mirna and pcdna . -htnfri expression construct into t cells, the inhibition of hfgl , hfas and htnfri expression were analyzed by quatitative real time pcr and western blot. results: the experiments showed the significantly inhibitory effect of p-hfgl mirna on hfgl , p-hfasmirna on hfas and p-htnfri mirna on htnfri expression at h post-transfection both at rna level and at protein level, as well in t cell lines the inhibitory efficiency reached as high as . % for hfgl , . % for hfas and % for htnfri, respectively. conclusions: the study demonstrated the constructs of p-hfgl mirna, p-hfasmirna and p-htnfri mirna successfully interfered their target genes expression in vitro, which provides the foundation for further investigation of these constructs' application in vivo and further more as a therapeutic strategy for a targeting intervention in the diseases which the gene fgl , fas and tnfri contribute to. this work was supported by nsfc , , ; cb , cb pe influence of the id on the anti-tumor activity of histone deacetylase inhibitor in hepatocellular carcinoma cells r. tsunedomi , , s. harada , n. iizuka , m. oka dept. of digestive surgery and surgical oncol., yamaguchi univ. , research fellow of the japan society for the promotion of science for young scientists background: our recent study revealed that levels of the inhibitor of dna binding/differentiation (id ) were associated with the progression of hcv-related hepatocellular carcinoma (hcc) and can affect susceptibility of hcc cells to histone deacetylase (hdac) inhibitors. we here aimed to investigate how and whether id expression affected on the anti-tumor activity of sodium butyrate (nab), one of hdac inhibitors. methods: two hcc cell lines, hle and huh- , were used for gene targeting experiments. the id over-expressing and knockdown cells were subjected to mts assay to evaluate the susceptibility to nab. time-course of the expressional change of bcl- and bcl-xl genes after nab administration was measured by real-time rt-pcr. result: upregulation and downregulation of id levels in hcc cells resulted in decreased and increased susceptibility to nab, respectively. we observed that after nab administration, the id expression was induced gently, the bcl- expression was greatly increased immediately, and the bcl-xl expression was decreased to less than half once and then recovered. these increase and recovery of the expression of anti-apoptotic genes were inhibited in the id knockdown cells. in the id overexpressing cells, the bcl- expression was more upregulated than mock-transfected cells. conclusion: in hcc cells, id influences the susceptibility to the hdac inhibitor by regulating the expression of anti-apoptotic genes caused by the hdac inhibitor stimulus. we suggest that id could serve as a fascinating marker predictive of response to hdac inhibitors. the role of zinc finger protein in liver cancer m.m.y. waye , , t.l. yeung , , j.l. zhu , the chinese university of hong kong, croucher laboratory for human genomics background/aims: the aim of this research project is the characterization of a krüppel zinc finger protein, zinc finger protein (znf ) using hepatocellular carcinoma as a disease model. zinc finger protein (znf ), also named as only zinc fingers protein (ozf), is a kda nuclear zinc finger protein consisting solely of ten c h zinc finger motifs of the krüppel type. like most of krüppel proteins, it is assumed to be the transcription factor and involved in the regulation of gene expression. the znf gene is amplified in - % of pancreatic carcinomas and overexpressed in more than half of the tumors including liver cancer. it is thus proposed that overexpression of the znf may contribute to the development or progression of hepatocellular carcinoma. methods: we used flow cytometry, microarray, green fluorescent recombinant protein, rt-pcr site-directed mutagenesis, and transfection to study the effect of expression of znf . results: our results shown that znf was over-expressed in two human hcc cell lines hepg and hep b. expression profiles of znf over-expressing shown that genes related to the p tumor suppressor activity or dna damage, repair response and control were deregulated upon overexpression of znf . conclusions: znf is possibly involved in liver carcinogenesis by affecting dna repair and cell cycle control upon induced dna damage. background: in the present study, we reported the establishment of a real-time monitor system for directly observing the catalytic, kinetic characteristics of dnazyme - in vitro cleavage on the target rna molecules as well as for rapid, accurate, high-throughout evaluation of varied dnazymes on their counterpart rna molecules. methods: dnazyme named dz-hcv- specific to hepatitis c virus (hcv) orf aug were designed and synthesized. dz-hcv-mis- with mismatched substrate-recognition domains, dz-hcv-mut- with mutant catalytic domains, antisense oligonucleotide ason and nonsense oligonucleotide nson were synthesized respectively as controls. a chimeric oligonucleotide of nt containing both rna and dna bases was designed and synthesized as the substrate: ' fam-gt agaccgugcaccaugagcacgaaucct-bhq ', corresponding to the - nt (underline) of hcv genome(gi: ) the reporter fam/bhq was incorporated at the ' and ' end, respectively. under simulated physiological conditions ( ), kinetic characterization of rna-cleaving dnazyme was analyzed in a real-time way. factors that influencing dnazyme cleavage were analyzed. results: dz-hcv- specific to hcv orf aug could cleave target rna at a•u site, a continuous change of fluorescence intensity was monitored. while the control oligonucleotides couldn't cleave rna, there were no change of fluorescence intensity. factors that influencing dnazyme cleavage concluded different substrate-recognition domain, mg + concentration and ph. conclusion: a real-time monitoring system for kinetic characterization of rna-cleaving dnazyme was successfully established in the first time. the study on the apoptosis of hepatoma cells synergeticly induced by plasmid-mediated anti-angiogenesis and immunopotentiation therapy p.y. li , q. zhang , y. chang , j.s. lin , d.a. tian background: angiogenesis is improtant to hepatoma and decreasing of host immunity promotes the development of tumor. we want to study the effect and mechanism of apoptosis of mice implanted hepatoma cells induced by eukaryotic plasmid-mediated anti-angiogenesis and immmunopotentiation therapy. methods: mouse endostatin eukaryotic plasmid (pseces) and mouse il- (interleukin ) eukaryotic plasmid (pmil- ) were extracted and purified from e. coli. h hepatoma cells were inoculated into the leg muscle of mice, which was divided into four groups and injected with pseces, pmil- , pseces+pmil- or pcdna . naked plasmid dna respectively into implantation sites repeatedly. tumor formation and its weight was evaluated. tumor microvessel density, tumor infiltrating lymphocytes and apoptosis of tumor cells were assayed by cd staining, he staining and tunel assay respectively. results: inoculated mice received pseces, pmil- injection formed tumor slowly with less microvessel density, more tumor infiltrating lymphocytes in the latter and more tumor apoptosis cells in both groups compared with pcdna . injection. there were much more tumor apoptosis cells in pseces+pmil- group ( . ± . per × microscope field p< . ) than any other single plasmid injection group ( × microscope field: pseces . ± . , pmil- . ± . , pcdna . . ± . ). conclusion: tumor cells of implanted hepatoma in mice could be synergeticly induced to apoptosis by eukaryotic plasmid-mediated anti-angiogenesis and immunotherapy through inhibiting tumor angiogenesis and promoting tumor lymphocytes to infiltrate, by which mice implanted hepatoma was inhibited. ( , , , , ng/ml) in a serum-free medium for h. cell proliferation was measured by brdu incorporation analysis, untreated wb-f cells were taken as controls. after treatment with wnt a ( ng/ml) for h, subcellular localization and protein expression of -catenin in wb-f cells treated and untreated with wnt a were examined by immunofluorescence staining and western-blot analysis. cyclind mrna expression was determined by semi-quantitative reverse-transcript polymerase chain reaction (rt-pcr). mrna levels of some phenotypic markers (afp, ck- , alb) and two hepatic nuclear factors were measured by rt-pcr. expressions of ck- and afp protein were detected by western-blot analysis. results: wnt a promoted proliferation of wb-f cells. stimulation of wb-f cells with recombinant wnt a resulted in accumulation of the transcriptional activator -catenin, together with its translocation into the nuclei, and up-regulated typical wnt target gene cyclind . after d of wnt a treatment in the absence of serum, wb-f cells retained their bipotential to express several specific phenotypic markers of hepatocytes and cholangiocytes, such as afp, ck- following activation of the canonical wnt signaling pathway. conclusion: the canonical wnt signaling pathway promotes proliferation and self-renewal of rat hepatic oval cells. the expression level of bid and other pro-and anti-apoptotic proteins were detected by immunoblotting. results: hbx/ showed the most sensitive towards dox treatment, and truncated bid (tbid) was also only detected in this cell line. the level of bax was also increased in hbx/ cells. conclusions: the carboxy-terminal of hbx may enhance the processing of bid into tbid, which may contribute to increased sensitivity of the cell towards the dox treatment. cell homeostasis were performed with concentrations of oxysterol ( x - - - m) faraway from the physiological and/or pathological one ( . and x - m). in our study, we asked the effects of oxysterols ( k and ' s) on hepatoma cell lines homeostasis. to this purpose we used concentrations similar to those described in physiological or pathological conditions. sub-physiological ( - m) to pathological ( - m) oxysterol ( k and ' s) concentrations were used to stimulate hepg cells. a surprising pro-proliferative effect of ' s at sub-physiological ( - m) concentration was observed. this behaviour was confirmed by the synergic increase of erk / levels. facs analysis revealed an early progression of cells in s phase at the lowest concentration of ' s, while all the remaining concentrations of the two studied oxysterols induced a weakly accumulation of cells in g /m phase. apoptosis was absent at all concentration used, except for the highest one ( - m). at this point we asked if cells didn't undergo apoptosis but acquired a senescent profile. effectively, both k and ' s, at all concentration used (except for - m), induced cell senescence (revealed by sa-ß-gal staining and sirt and p over-expression). in conclusion the two oxysterols analyzed have different and in same case opposite effects on hepatocellular line. the main effect is surely the senescence induction, but it is important to highlight the proproliferative effects of ' secosterol at low concentration. mortalin, a member of hsp family protein, has been shown to play an important role in hepatocellular carcinoma (hcc). it has been reported that mortalin is binding to the c-terminal of p , which acts as a safety guard and is a commonly mutated gene in hcc. in this study mortalin was silenced by specific shrna in plc/prf/ , a hcc cell line constitutively expressing p ser , and normal liver cells miha, and we found that suppression of mortalin can selectively trigger the mitochondria mediated apoptosis pathway by p dependent way in plc cells. tunel staining positive cells were only found in the plc cells mortalin knockdown group, and apoptosis associated protein, such as p , bax, bcl-xl, cleaved-caspase , have been screened by western blot after transfection. quantitative-pcr data also showed that p mrna level are upregulated about folds in mortalin knockdown group compared with the control groups in liver tumor cells. two p inhibitors, pft-and pft-, which can reverse this apoptosis was applied to demonstrate p dependent way. in summary, knockdown mortalin can selectively kill liver cancer cells through reactive apoptosis by sensitizing mutant p in plc cells, but had no effect on normal cells. the clinical application of this study suggested that motalin specific shrna might be a potential anti-cancer drug for hcc. background: nafld can proceed to nash and are at risk of cirrhosis and hcc. aim was to study profile of bangladeshi nafld patients. methods: patients with nafld were included. of them . % were males and . % females. patients were between - years of age. they presented with dull right upper abdominal ache and/or incidental detection of raised alt/ast and/or fatty liver on ultrasonography. all tested negative for hepatitis b and c. none had history of alcohol. all underwent per-cutaneous liver biopsy for histopathology. they were also tested for dm, dyslipidaemia, insulin resistance, hypothyroidism and hepatitis c. their bmi and bp were recorded. results: . % had nash. . % of them were males and rest . % females. . % had nafl. of them % each were males and females. majority had nash. . % were obese and . % had dyslipidaemia. . % had hypertension, . % insulin resistance and % were diabetics. . % had hypothyroidism. none had hepatitis c. alt was raised in % and ast in %. although all patients with nash did not have elevated alt, it was raised in majority, contrary to ast, which was normal in most. conclusion: majority nash patients in bangladesh are obese. other leading causes of nash include dyslipidaemia, hypertension and insulin resistance. some nash also had diabetes and hypothyroidism. this study also reveals that elevated alt in patients with nafld is suggestive of fibrosis, although normal serum alt does not exclude nash. the study further suggests that alt is superior to ast in predicting nash. background: non-alcoholic fatty liver disease is prevalent in obese patients. liver biopsy remains the best diagnostic tool for confirmation. we tried to find out the correlations of laparoscopic parameters with histology and laboratory data. besides, we also evaluated the effectiveness of laparoscopy in liver disease diagnosis. methods: in the period of one year and five months, morbidly obese patients submitted to laparoscopic bariatric surgeries at our institutions were prospectively studied. results: laparoscopic parameters of significant correlations with histologic steatosis, inflammation and fibrosis were summarized in table . besides, important parameters with relationships to laboratory data were summarized in table department of internal medicine, seoul national university hospital gangnam healthcare center, seoul, south korea, department of internal medicine and liver research institute, seoul national university college of medicine, seoul, south korea background/aims: hepatic fibrosis is associated with poor prognosis in non-alcoholic fatty liver disease (nafld). recently, many non-invasive fibrosis markers have been studied to overcome the limitations of liver biopsy. among them, bard score and guha's simple panel are easy to use in clinical practice. in this study, we evaluated the efficacy of bard score and guha's simple panel as a noninvasive fibrosis marker in korean nafld patients. methods: data from patients with biopsy-proven nafld in seoul national university hospital from to were used. bard score and guha's simple panel were calculated by using clinical and biochemical data and were compared with the histological fibrosis stages. results: stage fibrosis were found in patients, stage in , stage in , stage in and stage in . the relationship between fibrosis stage and bard score ( = . , p < . ) was statistically significant. all patients with advanced fibrosis (stage - ) had bard score greater than . mean values from original guha's simple panel for no fibrosis were not different between the patients with and without fibrosis. however, after adjusting coefficients by logistic regression analysis, the differences in mean values became statistical significant (p < . ). conclusions: our data suggest that bard score may be effective for detecting high risk patients for advanced fibrosis, and modification of coefficients within the guha's simple panel may be needed to use as a fibrosis marker in asian nafld patients. s.k. mohan , s. subramaniam , s. subramaniam assistant professor, department of biochemistry, saveetha medical college & hospital, saveetha university, t.n, india., consultant, department of biochemistry, apollo hospitals, chennai, t.n, india. , department of biochemistry, apollo first med hospitals, chennai, t.n, india. background: non-alcoholic fatty liver disease (nafld) covers a spectrum of liver diseases from simple fatty infiltration to progressive fibrosis. non-alcoholic steato hepatitis (nash) is a severe form of nafld and progresses to the end stage of liver disease. it is becoming the leading cause for referral to liver clinics in most areas. the prevalence of nafld in indian population is estimated around - %. the nafld has the potential to progress to hepatocellular carcinoma or liver failure, both events that ultimately lead to early death. aim: to evaluate the combination of inter cellular adhesion molecule - (icam - ), adiponectin and type-iv collagen, a new biomarker profile for nash in patients with nafld. methods: patients with nafld and age & sex matched normal healthy individuals as controls were selected for this study. levels of serum icam - , adiponectin, type-iv collagen, lipid profile and liver function test parameters were estimated in patients and compared with controls. results: serum icam - & type -iv collagen levels were significantly increased in patients with nash among the nafld patients compared to controls. the serum adiponectin levels were significantly reduced in patients with nash among the nafld patients compared to controls. compared to liver function test parameters and lipid profile levels, nash profile has got positive negative predictive value among the nafld patients. conclusion: in patients with nafld, nash profile test -a simple, noninvasive and reliable to predict the presence or absence of nash. background/aim: oxidative stress and cytokines plays an important role in the pathogenesis of nonalcoholic fatty liver disease (nafld). aim of study was to assess lipid peroxidation, serum levels of transforming growth factor-( tgf-) and tumor necrosis factor-( tnf-) in patients with nafld and compare it with patients of chronic viral hepatitis (cvh) and healthy controls (hc). methods: lipid peroxidation was studied by estimating plasma malondialdehyde (mda) levels as per the methodology described by buege and aust and tgf-& tnf-levels were measured by elisa kits (ray biotech, usa, & diaclone, uk) in the stored sera in biopsy proven patients with nafld (m: , f: , mean age: . ± . yrs), patients with cvh ( m: , f: , mean age: . ± . yrs) and hc (m: , mean age: . ± . yrs). results: there was no difference in mean plasma mda levels amongst patients with nafld ( . ± . mol/l), cvh ( . ± . mol/l) and hc ( . ± . mol/l). serum tgf-levels between nafld ( . ± . ng/ml) and cvh ( . ± . ng/ml) patients and hc ( . ± . ng/ml) were also comparable. though patients with cvh ( . ± . pg/ml) and nafld ( . ± . pg/ml) had higher levels of tnf-than hc ( . ± . pg/ml), the difference was not significant statistically. conclusion: lipid peroxidation, tgf-and tnf-need to be studied in a larger number of patients with nafld. background/aim: burnt out nonalcoholic fatty liver disease (nafld) may be responsible for cirrhosis and hepatocellular carcinoma (hcc) in the absence of other causes. aim of this study was to evaluate the surrogate markers of nafld in patients with cryptogenic cirrhosis (cc) and cryptogenic hcc (chcc). methods: sixty five patients with cc and patients with chcc were analyzed for the presence of abnormal body mass index (bmi) and type diabetes mellitus (dm aim: to investigate the relation of phosphatidylethanolamine n-methyltransferase pemt gene g a single nucleotide polymorphism (snp) with the susceptibility to nonalcoholic fatty liver disease nafld . methods the genotypes and allele frequencies of pemt exon snp g a were analyzed by using pcr-rflp in nafld patients and controls. results: the g to a variation of the pemt gene g a snp was significantly higher in nafld group compared with controls. the frequencies of gg ga and aa genotypes were . . and . in nafld and . . and . % in controls (p= . . the a allele of the pemt gene was significantly more frequent in nafld group ( . %) than that ( . %) in controls p= . .there were significant differences in serum levels of cholesterol, triglyceride, hdl-c and ldl-c between gg and ga/aa genotypes p < . . n. assy , , g. lipez , s. korem , m. grozovski sieff hospital, safed, israel, technion institute, faculty of medicine, haifa, israel, ort braude college, karmiel, israel background: previous studies reported increase in serum protein c and decrease in serum paraoxonase levels in patients with non alcoholic fatty liver diseases (nafld). conclusion people with pemt gene g a snp were more susceptible to develop nafld aim: ) determine whether there is a relationship between nafld, protein c and paraoxonase levels in quiescent and in regenerating rats fatty liver ) determine the effect of isa on hepatic "protein c" and paraoxonase mrna. pe methods: forty-eight sd rats were treated with fructose enriched diet (fed), or fed with metformin ( mg/kg/d), fed with rosiglitazone ( mg/kg/d), or the combination of both drugs for wks. % phx was performed at wk . protein c, paraoxonase mrna expressions, lipids, mda were measured before and hours after phx. results: hepatic "protein c" mrna was higher in rats with fatty liver than control rats (+ %, p< . ) whereas hepatic paraoxonase mrna was lower in rats with fatty liver than control rats (- %, p< . ). hepatic protein c and paraoxonase mrna increased in rats with fatty liver in regeneration (+ %, p< . , and + %, p< . respectively). the combination of metformin and rosiglitazone decreased hepatic protein c expression at hours after phx by - % (p< . ) and increase paraoxonase mrna by + % (p< . ). serum paraoxonase correlates with serum protein c (r=- . ), mda (r= . ), background: non-alcoholic steatohepatitis (nash) is a type of non-alcoholic fatty liver disease (nafld), and may progress to hepatic fibrosis and cirrhosis. the pathogenesis of nash remains unclear. the aim of this study was to explore the arginase change in the progress of steatohepatitis in rats. methods: male sd rats weighing - g were obtained. twenty animals were randomly divided into two groups. in the model group, five animals were fed with high lipid forage that includes % cholesterol and % lard for weeks, five were fed for weeks, while the control group ate normal foods. the animals were sacrificed after weeks. the animals were sacrificed after weeks and weeks. liver and blood serum were collected while the serum levels of alt, ast, tg and tc were measured. the pathology of liver was observed by he staining. western blot was used to investigate the expression of arginase in control and model group. tg (r=- . ). conclusion: hepatic "protein c" mrna levels are high at baseline, up regulated during liver regeneration and decrease after treatment with (isa) whereas hepatic paraoxonase mrna levels are low at baseline, up regulated during liver regeneration and increase after treatment with isa. results: vacuolization were observed extensively in hepatic cells in the model group after weeks and weeks of high-fat diet. it is demonstrated that rats fed with high-cholesterol food are indeed fatty liver models. western blot showed that the level of arginase ii increase in the liver of model group rats as compared to the control group. furthermore, the level of arginase was higher in liver samples obtained from model rats that were weeks on a fat diet as compared to rats that were only weeks on the same diets. conclusion: the level of arginase ii was altered in the progress of non-alcoholic steatohepatitis in rats suggesting that arginase ii is putative biomarkers and may represent new targets in the development of therapeutic strategies against fatty liver disease hepatic fibrosis and cirrhosis. methods: c bl /j mice were fed with mcd diet to induce hepatic fibrosis and rosiglitazone was given in treated group. effect of rosiglitazone was assessed by comparison of the severity of hepatic fibrosis in liver sections, expression of mmp- / , timp- / mrna and protein detected by rt-pcr and western blot respectively. the ethanolic extract of fructus schisandrae chinensis decreased hepatic triglyceride level in mice fed with a high fat/cholesterol diet results at week , fibrosing nash models showed severe hepatic steatosis, infiltration of inflammation and fibrosis, which is associated with down-regulated mmp- / mrna and protein, up-regulated timp- / mrna and protein. rosiglitazone significantly reduced mcd-induced fibrosis by induced mmp- / expression and reduced timp- / expression by activating ppar . s.y. pan , z.l. yu beijing university of chinese medicine, hong kong baptist university effects of the ethanolic extract of fructus schisandrae chinensis (etfsc) on serum and liver lipid contents were investigated in mice fed with normal diet or high fat/cholesterol diet for or days. single dose of etfsc ( or g/kg/day, i.g.) increased the serum triglyceride (tg) level ( and %, respectively), but decreased hepatic total cholesterol (tc) level ( and %, respectively) in normal mice. the hypertriglyceridemia produced by etfsc was suppressed by the co-administration of fenofibrate. the induction of hypercholesterolemia by high fat/cholesterol diet caused significant increases in serum and hepatic tc levels (up to %) and hepatic tg levels (up to %) in mice. etfsc treatment ( or g/kg/day for days, i.g.) significantly decreased the mouse hepatic tg level (by %) and slightly increased the hepatic index (by %). whereas fenofibrate treatment ( . g/kg/day for days, i.g.) significantly lowered the hepatic tg level (by %), it significantly elevated the hepatic index (by %) in hypercholesterolemic mice. the results indicate that etfsc treatment can invariably decrease hepatic tg in hypercholesterolemic mice, suggesting its potential use for fatty liver treatment. aim: to investigate the influence of multiple gene polymorphisms in the susceptibility of nafld. methods: the data of single nucleotide polymorphisms (snps) in nafld patients who had at least one of the genetic variations at the sites of tnf-- , adiponectin - and leptin- were analyzed. the genotypes were determined by using pcr-rflp. our previous studies showed that the variations of these sites increased the susceptibility of nafld. results: the prevalence of nafld in adiponectin variation alone group (n= ) was . %; in tnf-alone group (n= ) . %; in leptin alone group (n= ) . % (p> . ). in comparison with the above groups with single snp, the prevalence of the groups with two gene variations of tnf-plus adiponectin ( . %, n= ) increased significantly (p< . ). however the prevalence of other two groups i.e. adiponectin plus leptin ( . %, n= ) and tnf-plus leptin ( . %, n= ) did not differed significantly from those of groups with single snp (p> . ). the prevalence in the group with three gene variations ( . %) differed significantly from all (p< . ) except that of tnf-plus adiponectin group (p> . ). the metabolic features of the nafld patients in the groups mentioned above were not different significantly (p> . ). conclusion: nafld is a polygenic disease. multiple gene polymorphisms may, but not always, increase the susceptibility of nafld. chronic hepatitis b patients with nonalcoholic fatty liver disease r.d. zheng , c.r. xu , j. chen , b.f. chen southeast hospital background: to investigate clinical pathological characteristic in hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease (nafld). methods: we measured fasting blood glucose, insulin, triglyceride, cholesterol, alanine aminotransferase (alt), aspartate aminotransferase (ast) in hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease (nafld). and we detected hepatitis b virus marker, hbv-dna, counted body mass index, insulin resistance index and observed pathological characteristic. all these patients with diagnosis were confirmed by clinical and pathological evidence. result : the body mass index, homeostatic model assessment (homa) of insulin resistance, fasting blood glucose, insulin, triglycerides, cholesterol, were significantly higher in hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease (nafld) than hbeag negative chronic hepatitis b patients. but the alanine aminotransferase (alt), aspartate aminotransferase (ast), hbv dna levels were significantly lower in hbeag negative chb patients with nafld than in hbeag negative chronic hepatitis b patients. histologic features in hbeag negative chronic hepatitis b(chb) patients with nonalcoholic fatty liver disease (nafld) are in zone predominate macrovesicular steatosis and mild inflammatory infiltrate in portal region. conclusion: the hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease, whose hepatic steatosis changes are mainly caused by the metabolic factors. to carry out liver biopsy selectively for the patients with hbeag negative chronic hepatitis b having metabolic factors, which is helpful for early diagnosis in hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease (nafld). aims: to investigate the preventive effect of cordyceps sinensis and its possible mechanism on apoptosis of nafld. methods: rats were randomly divided into basic diet group (b group), pathologic group (nash group) and cordyceps sinensis group(cs group).the latter two groups were administered with high-fat diet to establish nafld animal models. cs group were treated with cs at the th week after high fat diet. rats were sacrificed at the end of the th week. biochemical examination were used to detect superoxide dismutase (sod) of liver tissue. hepatocyte apoptosis was assessed in each group using the tunel assay and immunohistochemistry for activated bax bcl- caspase- and nf-kb p . results: ( ) compated with the b group, severe hepatosteatosis, inflammative necrosis and local fibrigenisis were showed in liver of nfsh group. sod lever was significantly decreased (p< . ) and tunel-positive cells were significantly increased (p< . ). immuunohistochemistry test demonstrated active bax caspase- was increased (p< . ) while no apparent change was observed in bcl- . ( ) in cs group, only diffusive steatosis but not inflammation or fibrosis was found. sod lever was increased than that of nash group (p< . ). tunel-positive cells and active bax caspase- were significantly decreased (p< . p< . ) that those of nash group. bcl- and nf-kb p were increased (p< . ) than those of nash group. conclusions: hepatocyte apoptosis is a prominent feature of nafld. cordyceps sinensis may be useful as an antiapoptosis theraphy in this syndrome through increasing activity of sod, decreasing express of bax and increasing express of bcl- and nf-kb p . background: non-alcoholic steatohepatitis (nash) is a leading cause of chronic liver disease. insulin-sensitizing , anti-inflammatory and anti-fibrotic effect of thiazolidinediones support their use in the treatment of nash. we aimed to evaluate the efficacy of thiazolidinediones in the treatment of nash. methods: we have identified randomised clinical trials, evaluating the efficacy of thiazolidinediones versus placebo in nash, through medline, embase, ami, cochrane central register of controlled trials. data were abstracted from each study and disagreements were resolved by consensus. dichotomous outcomes were reported as relative risk with % confidence interval based on fixed-effects model. results: we included three trials, two evaluating pioglitazone and another rosiglitazone. a total of patients were involved in the analysis. thiazolidinediones was noted to improve liver function tests. it was effective in the reduction of steatosis among patients with nash (rr . , % ci . - . ). it was found to be beneficial in improving ballooning necrosis (rr . , % ci . - . ). it was also found to improve lobular inflammation (rr . , background: it is well known that the weight reduction is effective for alt normalization in patients with non-alcoholic fatty liver disease (nafld). the necessary condition for alt normalization is still unclear. to clarify the necessary and sufficient condition for alt normalization, we investigated the effects of body fat decrease in nafld patients by body composition analyzer. methods: forty-six nafld patients ( male, female, mean age . ± . years old) with abnormal alt levels were evaluated. the volume of skeletal muscle, body fat and bmr were examined by using the body composition analyzer (in body ; biospace co. ltd., tokyo japan). all patients were received an individualized diet consultation by dietician every weeks for months. daily energy was bmr (basal metabolic rate) x . kcal and protein was . - . g per ideal body weight. result: twenty-eight of patients ( . %) were achieved normal alt level. in alt normalized group, the body weight and fat loss were . ± . kg, . ± . kg ( . ± . %body fat) respectively. on the other hand, in cases with alt remained abnormal level, the body weight and fat loss were . ± . kg, . ± . kg ( . ± . %body fat). conclusion: our results demonstrate that the fat loss of kilograms or more was necessary to normalize alt level in nafld patients. a. somani , s. somani , a. jain , v. dixit navjeevan hospital, suvidha, background : nafld is often clustered within families and the causes include both genetic and environmental factors. family studies done thus far have been limited by small sample size. to examine the familial patterns , we performed a prospective study to see (a) whether nafld is more common in first degree relatives (b) genetically determined risk factors associated for clustering. methods: first degree relatives of histologically confirmed nafld patients and spouses (controls) were included after excluding other causes of fatty liver. those having raised transaminases > months or sonographic examination consistent with fatty liver, had undergone liver biopsy for histological confirmation. they were divided into three groups. group i patients group ii first degree relatives group iii spouses results: nafld was more prevalent among first degree relatives then spouses ( % and %, p< . ). anthropometric measurements, systolic and diastolic blood pressure, lipid profile and liver function tests were comparable in three groups. homa-r was similar in group i and ii (p= . ), but was significantly different in group i and iii (p= . ) and group ii and iii (p= . ) respectively. metabolic syndrome was present in > % of patients and were comparable in three groups except for fasting glucose > , which was present in %, % and % of patients in group i, ii and iii respectively. majority (> %) of our patients among groups i, ii and iii were having only steatosis while nash was present in %, % and % of patients. a. somani , v. dixit , a. jain , s. somani navjeevan hospital, ims, bhu, varanasi, suvidha background: normal levels of alanine aminotransaminase (alt) have been demonstrated in nafld patients. alt levels are also modulated by age, gender, bmi, fasting glucose, and serum triglyceride levels. we performed a prospective study of patients with histologically confirmed nafld and having alt < . times and compared them with those having raised alt to determine (a) clinico-pathologic features of nafld patients with normal alt (b) to observe any differences between them. methods: patients with fatty liver on sonography had under gone biopsy for histological confirmation after excluding other causes of fatty liver. participants were divided into two groups (a) those having alt > . times normal (n= ) (b) those having normal alt (n= ) results: mean age was comparable with slight male predominance. there were significant differences in anthropometric measurements like bmi (p= . ) and whr ( . ± . and . ± . , p= . ). mean bp, lipid profile, fasting glucose, insulin, and homa r were comparable. there were significant differences in both mean ast ( . ± and . ± . , p= . ) and alt ( ± . and . ± . , p= . ) levels. metabolic syndrome was present in > % of patients and individual components were comparable except for increased waist circumference which was significantly more in those with raised alt ( . % and . %, p< . ). majority of our patients were having only steatosis, while nash was present in ( . % and . %, p< . ) of patients. conclusion: nafld can exist in patients with normal alt values. although more work is needed to determine who should be screened for nafld and how such individuals should be evaluated, this study is a step toward the identification and characterization of nafld patients with normal alt. we can suggest that patients having metabolic syndrome or insulin resistance, despite having normal alt, should be screened for nafld. also alt values should be adjusted for variables like bmi to appropriately screen nafld patients. background: scientific evidence has demonstrated that traditional chinese medical (tcm) approaches and products can be beneficial for managing non-alcoholic fatty disease (nafld), but few rigorous criteria of patterns of tcm therapy are available to guide practitioners in deciding the cam interventions. objectives: to evaluate criteria of patterns of tcm therapy for the management of nafld identified by biomedicine. methods: literature research, clinical epidemiological investigation and mathematical statistics were employed to make information collecting tables and to establish database. descriptive analysis, factor analysis, and cluster analysis were involved. results: ( ) background/aim: serum uric acid level has been suggested to be associated with factors that contribute to the metabolic syndrome. the aim of this study was to investigate the association of serum uric acid level with nonalcoholic fatty liver disease (nafld). methods: a cross-sectional study was performed among the employees of zhenhai refining & chemical company ltd., ningbo, china. results: the study included subjects ( men) with a mean age of years. the prevalence rate of nafld and hyperuricemia was . % and . %, respectively. nafld patients had significantly higher level of serum uric acid than controls ( . ± . vs. . ± . mol/l; p < . ). the prevalence rate of nafld was significantly higher in the subjects with hyperuricemia than those without hyperuricemia ( . % vs. . %; p < . ), and the prevalence rate increased along with serum uric acid levels (p value for trend < . ). multiple regression analysis showed that hyperuricemia was associated with increased risk for nafld (odds ratio [or]: . , % confidence interval [ci]: . - . ; p < . ). conclusion: serum uric acid level is significantly associated with nafld, and increased serum uric acid level is an independent risk factor for nafld. background: development of fatty liver is believed to be an early and reversible consequence of excessive alcohol consumption. however, the cellular and molecular events in the early development of alcoholic liver diseases (ald) and the contributory effects of a high fat diet are not fully understood. methods: this study was designed to quantify specific enzymatic and cytokinetic activity as well as the development of hepatic steatosis in a rat model of alchohol-induced liver injury without high fat diet. results: ethanol-fed rats exhibited high blood ethanol levels ( . + . %) and significant increases in serum alt ( . + . unit/l), ast ( . + . unit/l), and alp ( + . unit/l) when compared with control rats (p< . , respectively). histopathological examination found unevenly raised knodell scores ( . + . in the ethanol-fed livers vs. . + . in control), which were characterized by scattered hepatocyte ballooning, portal inflammation and collagen fiber deposition. however, typical steatosis lesions were absent. qpcr demonstrated up-regulation of genes in the ethanol-fed livers, including hepatocyte metabolism enzymes/receptor (adh , p< . ; cytochrome p e , cyp e , p< . ; gsta , p< . ; ppar , p< . ), and genes coding for pro-inflammatory cytokines (il- , p< . vs. control livers; tnf-p< . ; tgf -, p< . ; rantes p< . ), ecm components and proteinases (collagen- , p< . ; sma, p< . ; mmp - , p< . and timp- , p< . ). conclusion: chronic administration of ethanol to rats without high fat diet productively induces alcohol hepatitis in the absence of fatty liver, suggesting that alcohol hepatitis may precede steatosis in the development of ald. the aim of the present study was to evaluate the changes of several cytokines associated with inflammatory liver disease and liver regeneration by molecular adsorbent recirculating system (mars) in aclf patients versus patients treated with medical standard therapy (smt) that presented alcoholic liver disease etiology and similar model end-stage liver disease (meld). methods: mars group: fifteen ( male and female) patients were treated with mars® (gambro). five patients were excluded by study.the number of mars applications was about , the length of applications was about h. smt group: fifteen patients ( male and female) were treated medical standard therapy such as prophylaxis against bacterial infections, albumin and fresh plamsa and judicious use of diuretics. three patients were excluded by the study. the patients were valued during days from inclusion with a survival follow up a three months. results: mars group: we observed a significant changes in levels of il- (p< . ), il- (p< . ), il- (p< . ) and tnf-alfa (p< . ) in association with improvement of hepatic growth factor (p< . ). the patient's survival at three months was %. smt group: we observed only a significant changes in il- (p< . ) and tnf-alfa (p< . ). the patient's survival at three months was %. conclusion: the mars liver support device has corrective effects on disturbed pathophysiology of aclf and may be used to enhance spontaneous recovery or as bridge to transplant. a study of protective effect of centella asiatica in -methyl- phenyl- , , , -tetrahydropyridine (mptp)-induced liver injury n. haleagrahara , s. chakravarthi , p. kumar international medical university, malaysia background: centella asiatica has been used for centuries as a medicinal herb for wound healing, memory enhancement, cancer, vitality, respiratory ailments, psoriasis and eczema, revitalizing connective tissue, burn and scar treatment, skin infections, arthritis, rheumatism, periodontal disease, varicose veins, hypertension, sedative, anti-stress, anti-anxiety, aphrodisiac, and as immune booster. results: ppc significantly reduced hepatocyte damage, hepatitis, and hepatic fibrosis, but did not affect steatosis. phosphorylation of apoptosis signal-regulating kinase , p mitogen-activated protein kinase, and protein kinase c, as well as activation of nuclear factor-kappa b, were markedly suppressed by ppc. these effects were likely a consequence of decreased oxidative stress through down-regulation of reactive oxygen species (ros)-generating enzymes, including cytochrome p e , acyl-coa oxidase, and nadph oxidases, in addition to restoration of ethanol-induced increases in toll-like receptor and cd . ppc also decreased the pro-apoptotic proteins bax and truncated bid, thus inactivating mitochondrial permeability transition. furthermore, ppc suppressed overexpression of transforming growth factor- and hepatic stellate cell activation, which retarded hepatic fibrogenesis. conclusion: ppc exhibited anti-inflammatory, anti-apoptotic, and anti-fibrotic effects on ald as a result of inhibition of alcohol-induced ros production. background: dysctamnus dasycarpus has used for the promotion of health in south korea. but, there were rare a report concerning the hepatotoxicity. we report cilinical features of liver injury by dysctamnus dasycarpus. method: eighteen patients diagnosed as acute toxic hepatitis by dysctamnus dasycarpus in chungnam national university hospital between january and arpil was enrolled. toxic hepatitis was diagnosed by rucam score ( ). the medical records were reviewed, retrospectively. result: eleven patients ( %) were female and the mean age was . . most common symptom was jaundice. initial laboratory findings were as follows(mean value): wbc /ul, hemoglobin . g/dl, platelet × /l,alt iu/l, total bilirubin . mg/dl, alkaline phosphatase u/l, ggt u/l, prothrombin time(inr) . . the mean hospitalization was . days. peak laboratory findings were as follows: alt iu/l, total bilirubin mg/dl. recovery time of each biochemical finding was as follows: alt days, total bilirubin . days. recovery rates of alt and total bilirubin were . % and . %, . % and . % at weeks, weeks, respectively. the main biochemical pattern of hepatotoxicity was hepatocellar ( . %) type. prednisolone was prescribed in six patients. progressive anemia and thrombocytopenia were detected in one patient diagnosed as pure red cell aplasia. other one patient had prolonged jaundice ( days). but, all patients had recovered without sequelae. conclusion: in south korea, liver injury by dysctamnus dasycarpus was more frequent in women. the main pattern of hepatotoxicity was hepatocelluar type. most patients had prolonged icteric phase and hospitalization. patients were recovered by supportive management after drug cessation or prednisolone therapy. in korea, traditional medicine that is based on the use of herbal medicine developed from a long time ago. however, clinical study of the herbal medicine is not conducted in a structured manner. we report three cases of toxic hepatitis caused by the intake of dictamnus albus. the first patient, a year old woman was admitted due to nausea after ingestion of liquor containing dictamnus albus for months. total bilirubin was . mg/dl ast/alt / , iu/l on admission. liver biopsy observed hepatocyte necrosis and cholestasis. the elevated bilirubin and transaminase returned to normal weeks later after cessation of dictamnus albus. the second patient, a year old man was admitted due to jaundice after ingestion of boiling dictamnus albus for months. total bilirubin was . mg/dl ast/alt , / , iu/l on admission. liver biopsy observed pericellular fibrosis and necrosis. the bilirubin decreased slowly compared to the transaminase and normalized months later after cessation of dictamnus albus. the third patient, a year old man was admitted due to jaundice after ingestion of liquor containing dictamnus ablus for month. total bilirubin was . mg/dl ast/alt , / , iu/l the hepatocyte necrosis was observed by liver biopsy. the elevated bilirubin and transaminase levels normalized month later after cessation of dictamnus albus. all patients had negative viral markers and non-specific ultrasonographic findings. the above mentioned three cases demonstrate that liver may have been damaged by dictamnus albus, which indicated clinical characteristics. background/aims: cmili poses a diagnostic challenge as no tests are available to confirm the causality. the aims of this study were ) to evaluate clinical features and patterns of cmili and ) to assess the likelihood of causality among patients with liver impairment and exposure to chinese medicine (cm) by a multidisciplinary approach. method: between / and / , patients who had liver derangement and cm or proprietary cm exposure within six months managed in the united christian hospital were studied. clinical features and the cm were reviewed by a multidisciplinary team involving a hepatologist, a toxicologist and cm experts. literature search of relevant herbs in chinese and western journals were performed. cm samples or residue were sent to toxicology laboratory for analysis to look for any toxic constituents, adulterant or contaminant. the likelihood of causality was ranked by various experts independently and disagreements were settled by a consensus meeting. results: there were forty-six cases of suspected cmili, nineteen cases with alternative causes of liver diseases were excluded. twenty-seven cases of cmili proceeded to detailed analysis. median age of patients was ( - ) with female predominance. the median duration of cm exposure to presentation was ( - ) days. majority of them ( %) had hepatocellular liver injury pattern. one case of adulteration with nsaid and erroneous substitution of herb was identified respectively causality were classified as unlikely, possible, probable and highly probable in , , and patients respectively. conclusion: a multidisciplinary approach allows systemic evaluation of suspected cmili. mouse model i. nassar , t. pasupati , i. segarra , j.p. judson international medical university, kuala lumpur, malaysia background: imatinib, a selective tyrosine kinase inhibitor, exhibits drug interactions with other drugs that are metabolised via the cytochrome p pathway. acetaminophen, a widely used analgesic and anti-pyretic drug is also metabolised via p pathway. this study aimed to evaluate the nature of hepatotoxicity after co-administration of imatinib and acetaminophen in a preclinical mouse model. methods: four groups of male icr mice ( - g) were used. the mice were administered either saline solution orally, imatinib mg/kg orally (control), acetaminophen mg/kg intraperitoneally (positive control) or co-administered imatinib mg/kg and ip acetaminophen mg/kg (study group). the mice (n= per group) were fasted overnight, dosed respectively and sacrificed at pre-determined time intervals of , minutes, , , , and hours and liver samples obtained by dissection. h&e stained liver sections ( µm thick) were histopathologically analysed. results: the liver samples showed reversible cell damage like feathery degeneration, microvesicular fatty change, sinusoidal congestion and pyknosis, with both imatinib and acetaminophen, administered separately. the damage increased gradually with time, peaked at hours and then resolved completely by hours. liver samples showed irreversible damage (cytolysis, karyolysis and karyorrhexis) when both drugs were administered concurrently, the damage increased with time and had not resolved after hours duration. conclusion: co-administration of acetaminophen and imatinib increased the hepatoxicity caused by acetaminophen and imatinib to become irreversible. this may be due to the fact that both drugs are metabolised by the cytochrome p pathway in the liver. background: a higher risk of antituberculosis drug (att) induced hepatotoxicity has been reported in indian subcontinent compared to the western counterparts. slow acetylator genotype of n-acetyltransferase (nat ) and ci genotype of cytochrome p e (cyp e ) gene are two known risk factors associated with this disease. cyp e gene encodes a rifampicin inducible enzyme which increases hepatotoxicity. therefore slow acetylation of isoniazid and simultaneous use of rifampicin may augment the toxicity of isoniazid. objectives: to analyze the allelic distribution of nat and cyp e gene in patients of pulmonary tuberculosis who developed att induced hepatitis materials and methods: the study included cases of pulmonary tuberculosis ( ) and att induced hepatitis ( ). polymorphism of nat and cyp e gene was studied by pcr-rflp method in both these groups. results: occurrence of att hepatotoxicity was . %. there was a higher prevalence of slow acetylator genotype particularly nat * /* and nat * /* in patients with hepatotoxicity compared to patients without hepatotoxicity ( . % vs . %, p value < . ). no association of cyp e rsai polymorphism could be considered with att hepatotoxicity. however, drai c/d genotype of cyp e appears as a risk factor for predicting the occurrence of antituberculosis drug induced hepatitis (or . , p value < . ). conclusion: the study demonstrates that patients with slow acetylator genotype particularly nat * /* and nat * /* and heterozygous mutant c/d genotype of cyp e gene are predisposed to develop antituberculosis drug induced hepatotoxicity. regular monitoring of clinical and biochemical profile may be considered in these patients when they receive antituberculosis treatment. background: drug-induced liver injury is the most common adverse drug reaction. we often use two kinds of diagnostic scales to evaluate suspected patients. however, we still can't diagnose accurately without the direct drugs history and the pathological evidence. methods: twenty-seven drug-induced liver injury cases with liver biopsies from to were reviewed retrospectively by maria and japanese scale. result: there were . % of cases with increasing eosinophils. herbs ( . %) were the most common suspected drug and unknown drugs intake history ( . %) were described in these cases. the high possibility and possibility were . %, . % by maria scale and . %, . % by japanese scale, respectively (p= . ). conclusions: japanese scale seems more sensitive than maria scale in these cases. however, there are still some definite cases ignored as low possibility due to absence of obvious drug using history. early treatment and suspected drugs prohibition interferes the outcomes of the two diagnosis systems and lead to a false result. it is still a clinical challenge without strong drug using history or pathological evidence of liver biopsies to diagnose the drug-induced liver injury quickly and accurately. background: previous study suggested that oxidative stress may be an important mediator of methamphetamine-mediated tissue injury. the study was to examine the mechanism of antioxidant activity and methamphetamine-mediated liver injury. materials and methods: the days old male sprague-dawley rats were subcutaneous injected daily with methamphetamine ( mg/kg body weight) for , , and days. control group received equal volumes of vehicle. the liver tissues were extracted to measure the activities of sod, catalase, glutathion reductase (gr), and glutathione peroxidase (gpx), and the level of glutathione. western blot were used to measure the expression of rho and phosphor-ezrin-radixin-moesin (p-erm). results: compared with vehicle group, treated with methamphetamine for and days, the activities of liver sod, gpx, and catalase were significantly decreased. in and days group, the activities of antioxidant enzymes of methamphetamine-treated liver was not different from that of vehicle group. the levels of glutathione production also had the same trend. the activities of gpx and catalase on vehicle group gradually reduced following the days of treatment. however, administration of methamphetamine resulted to a lower activity of catalase through the treated days. there was no difference on the activity of gr between vehicle and methamphetamine group. the expression of rho and p-erm were also increased by methamphetamine treated for days. conclusion: these results suggested the methamphetamine lead to liver remodeling via decreased antioxidant activity. finally, the situation of mechanism needs taking in advantage discussion. background: to observe intervening effects of preventive and theraptical treatment of radix sophorae tonkinensis's polysaccharides(rstp) on alpha-naphthylisotheganate(anit)-induced cholestasis in mice. methods: kunming mice intoxicated with anit mg/kg orally and treated with rstp mg/kg for days before anit exposure and for days after anit exposure respectively, the general condition,mortality rate and serum alt activity are obeverated. result: it was found that by preventive treatment the general condition and mortality rate were improved, serum alt activity reduced.by therapeutic treatment,the general condition deteriorated,mortality rate and serum alt activity increased. conclusion: the preventive treatment of rstp reduce the liver damage due to increasing the anti-stress ability such as the antioxidant capacity,its therapeutic treatment increase the injuried liver damage due to increasing the non-specific immune response and aggregating the preexisting liver inflammation. background: the product's instruction pointed out that in some patients polyphenolic acids' salt from salvia miltiorrhiza(ppas-sm) may lead to a temporary increase in serum alt activity.so we observe effects of ppas-sm on alpha-naphthylisotheganate(anit)-induced cholestasis in mice. methods: hours after intoxicated with anit mg/kg orally, kunming mice were treated with ppas-sm , , mg/kg/days for days orally, then serum alt activity was measured. result: all doses of ppas-sm led to rise of serum alt activity in mice, most obvious in group of high dose.but the general situation and mortality rate did not increase significantly. conclusion: ppas-sm lead to rise of serum alt activity in mice with damaged liver.the auther suggests as a double-edged sword,the antioxidant ppas-sm may have a prooxidative effect in some condition too. *this project was supported by grants from shanghai municipal education commission under high school high-tech characteristic development programme (no smec finance ( ) ) pe a. somani , a. jain , v. dixit , s. somani navjeevan hospital, ims, bhu, varanasi, suvidha introduction: hepatic encephalopathy, a complex neuropsychiatric syndrome secondary to acute liver failure, chronic parenchymal liver disease or portal-systemic shunting, may possibly develop through mediators of endotoxin and tumor necrosis factor-alpha (tnf-). several studies have shown that serum levels of (tnf-) are significantly elevated in patients with acute and chronic liver diseases, where these elevations are independent of the etiology of the underlying disease. it has been shown that plasma levels of tnf-correlate with the severity of hepatic encephalopathy (he) in fulminant hepatic failure. however, still there is very few published data regarding the relationship between serum levels of tnf-and the presence or severity of he in patients with chronic liver failure. methods: the aim of this study is to determine the relationship between serum levels of tnf-and clinical grades of he in patients with chronic liver failure. this prospective study included consecutive male patients with alcoholic cirrhosis in various clinical grades of he (according to west haven criterion). detailed clinical, biochemical and sonographic examination was done in all patients. circulating levels of tnf-was measured using solid-phase elisa. results: the mean±sem values of serum tnf-at presentation in patients with mhe (n= ), grade (n= ), grade (n= ), grade (n= ), and grade (n= ) were . ± . , . ± . , ± . , . ± . , and ± . pg/ml, respectively. significant positive correlation was found between serum levels of tnf-and severity of he (correlation coefficient = . ). conclusion: from the present study we can suggest that there is significant relationship between tnf-and he in patients with alcoholic cirrhosis and it could be involved in its pathogenesis. background: acute hepatitis a (aha) is one of the most common infectious diseases and usually a self-limiting disease. although extrahepatic manifestations are not common, a few cases associated with acute renal failure (arf) have been reported. methods: we reviewed clinical features of aha patients complicated with arf (group a) and compared with non-complicated aha patients (group b). medical records of patients with aha were reviewed between january and december . we experienced patients ( . %) with arf associated aha. result: there were no differences between group a and group b in sex ratio and age. the peak value of alt (median: iu/l vs iu/l, p< . ), alkaline phosphatase (median: iu/l vs iu/l, p= . ), prothrombin time (inr, median . vs . , p< . ) was significantly higher in group a than b. nine patients ( . %) recovered completely with hemodialysis ( patients, . %) and only conservative management ( patients, . %), while patient underwent liver transplantation and patient died due to fulminant hepatic failure. there were patients who underwent kidney biopsy. two patients were diagnosed as acute tubular necrosis and patient as acute interstitial nephritis and iga nephropathy. conclusion: aha patients with arf had higher alt and more prolonged prothrombin time. the prognoses were poorer than those without arf. however, arf patients with nonfulminant aha had a good prognosis with a proper treatment and should not be confused with hepatorenal syndrome. background/aims: to investigate the hev infection among different animals and people with special profession, and to analyse the genotype of hev isolated in this study. methods: serum and fecal samples were collected from various animals and people with special profession in the south suburbs of beijing. hev antigen and anti-hev antibody were detected by das-elisa. hev rna was extracted from fecal samples and amplified by rt-npcr. the nucleotide sequence homology and phylogenetics of hev strains isolated from swine were analysed. results: the anti-hev antibody positive rate of adult swine, cow, sheep and younger swine were . % ( / ), . % ( / ), . % ( / ) and . % ( / ), respectively. the hev antigen positive rates of adult swine, cow, sheep and younger swine were . % ( / ), . % ( / ), . % ( / ) and . % ( / ), respectively. the hev antigen and anti-hev antibody positive rate of professional group was . % ( / ) and . % ( / ) respectively. the hev rna positive rate of fecal samples from younger swine was . %( / ). of samples were hev rna positive by pcr with primers of hev orf and orf . the sequence analysis of the samples showed that there were groups designated as bj- ( / ) and bj- ( / ). the nucleotide homology of bj- and bj- was %. phylogenetic analysis of hev orf indicated that both of them belonged to genotype d. conclusion: phylogenetic analysis of hev orf indicated that hev isolated in the south suburbs of beijing belonged to genotype d. bracops hospital brussels , st. jan hospital, bruges , chu brugmann, chu sart tilman, liège , gent university hospital , zna middelheim, antwerp hepatitis delta virus is a subviral satellite requiring hepatitis b virus to propagate, usually leading to severe, chronic liver disease. as data on epidemiology and management practice of hdv infection in belgium are lacking, a retrospective and prospective, multi-centric questionnaire-based registry is performed in . results of patients are reported. background/ aims: hepatitis a is an acute infectious disease that is transmitted by fecal-oral root. because the incidence of hepatitis a has been increased in gwangju and chonnam province of korea recently, hepatitis a patients in chonnam national university hospital employees had been increased. so we investigated the seroprevalence of igg anti-hav in hospital empolyees less than years old. methods: we analysed seroprevalence of anti-hav igg from , hospital employees (men: , women: ) . serum alt and bilirubin at admission were , , iu/l and . . mg/dl, respectively. these levels were elevated up to , , iu/l and . . mg/dl, respectively. ana was positive in patients ( . %). age, duration from peak-alt day, duration from peak-bilirubin day, alt level, and peak-bilirubin level were not different between ana(-) patients and ana(+) patients. in the while, sex, duration from symptom-onset day, and bilirubin level, and peak-alt level were significantly different. in ( %) of patients with positive ana, ana was followed after month and ana became negative in patients ( . %). among patients with positive ana after month, titer decreased from the baseline in patients, showed no interval change in , and increased in . conclusions: positive ana result is not rare in patients with acute hepatitis a. it is considered that ana transiently appear during the course of acute hepatitis a and then, disappear with the improvement of acute hepatitis. ( ), ( ). the clinical data such as sex, admission period, ast, alt, total bilirubin, prothrombin time, crp, alt normalization time did not show difference. just wbc and gtp were higher on group. the older age patients were more on group. the patients admitted mainly on april, may, june, july ( %) on while admitted even on past years. conclusion: acute hepatitis a ptients is increasing. it is occurring in older age people and mainly on specific period. the more concern to prevention should be needed. background: we analyzed the ' non-translated region ( 'ntr), non-structural proteins b and c of hepatitis a virus (hav) genome, whose mutations have previously been shown to be important for enhanced replication in cell culture systems, in order to align all of our data and examine whether genomic differences in hav are responsible for the range of clinical severities. methods: our accumulated hav strains of 'ntr (nt and ), entire b and c from japanese patients with sporadic hepatitis a, consisting of patients with fulminant hepatitis (fh), with severe acute hepatitis (ahs), and with self-limited acute hepatitis (ah), in whom the sequences of all regions were available, were subjected to phylogenetic analysis. results: fh patients had fewer nucleotide substitutions in 'ntr, had a tendency to have more amino acid (aa) substitutions in b, and had fewer aa substitutions in c, than ah patients. four fh and ahs with higher viral replication were located in the near parts of the phylogenetic trees, indicating the association between the severity of hepatitis a and genomic variations in 'ntr, b and c of hav. conclusions: our study suggests that genetic variations in some parts of hav might cooperatively influence replication of the virus, and thereby affect virulence. viral factors should be considered and examined when discussing the mechanisms responsible for the severity of hepatitis a. aims: the incidence of acute viral hepatitis a in adults is increasing very much in south korea, . the aim of this study was to the clinical features and course in daejoen and its surrounding area. methods: forty seven patients admitted as acute viral hepatitis a in chungnam national university hospital between january and june were enrolled. the medical records were reviewed, retrospectively. results: the mean age was . . common occupations were company employee and studuents. most common symptom was jaundice. presumptive infection sources were raw fish or shellfish and raw meat. initial laboratory findings were as follows(mean value): wbc /ul, hemoglobin . g/dl, platelet × /l, ast iu/l, alt iu/l, total bilirubin . mg/dl, alkaline phosphatase u/l, ggt u/l, prothrombin time(inr) . . hospitalization was . days. peak laboratory findings were as follows: alt iu/l, total bilirubin . mg/dl. leukopenia (< /ul) and thrombocjtopenia (< × /l) were ocurred in sixteen and six patients, respectively. recovery time of each biochemical finding was as follows: alt . days, total bilirubin days. recovery rates of altand total bilirubin were . % and %, . % and % at weeks, weeks after diagnosis, respectively. prolonged jaundice ( days) was detected in one patient. all patients were recovered by supportive management. conclusions: in south korea, acute viral hepatitis a was more prevalent in young adults, recenlty. presumptive infectious sources were raw fish or guangxi center for disease prevention and control shellfsh and raw meat. if it can not change the food style that many korean enjoy raw seafood, vaccination for adults must be considered to prevent it. objective: to assess the safety and immunogenicity of a new inactivated hepatitis a vaccine (vero cell). pe methods: subjects were selected in gongcheng city of guangxi zhuang autonomous region, and the clinical trail was carried out according to the random, double-blind and parallel principle from january to august, . after vaccination by , schedule, adverse events of the subjects were observed, the seroeonversion rate and geometric mean titer (gmt) were tested by the competitive inhibition elisa. results: after immunization, the systemic and local reaction rates of adults were . % and . %, which was no significantly statistical difference compared with control group, . %and . %; while the rates of children were . and . %%, and no significant statistical difference compared with control group, . %and . %. one month after first dose of vaccination, the seroconversion rates of children and adults were . % and . %, and one month after second dose of vaccination, the rates were all %, the gmts of children and adults were miu/m and miu/ml, which was significant statistical difference in children compared with control group, miu/ml and miu/ml, respectively. methods: igg anti-hav was measured in a total of subjects under the age of , who visited hanyang university seoul and guri hospitals between january and may . results: fig. shows the relatively low positive rates of the antibody in ages of to and the lowest rates of . % and . % in the age group of to , following the ages of to with rates of background: some viruses encode proteins that affect their cap-independent internal ribosomal entry site (ires)-mediated translation and their replication. it was recently reported that hepatitis a virus (hav) proteases interact with intracellular dsrna-induced retinoic acid-inducible gene (rig-i)-mediated signaling, but it remained unknown whether hav proteins have any effects on hav ires-independent translation. in this study, we investigated the effects of hav non-structural proteins on their ires-mediated translation using a reporter assay. pe methods: the bicistronic reporter constructs, termed psv -hm -ires, psv -a -ires, psv -a -ires, psv -f -ires, and psv -f -ires, contain the sv promoter that controls the expression of a bicistronic message coding for renilla and firefly luciferases separated by hav ires, and are derived from strain hm , acute convalescent hepatitis clones a , a , fulminant hepatitis clones f , f , respectively. human hepatoma cell lines were co-transfected with psv -hav-ires and each hav protein-expression vector. luciferase activity was determined h after transfection. were from other countries within asia, africa, middle east, and eastern europe. patients of a wide age range were affected by hepatitis delta (mean age . , median . , range - ). ( %) of were co-infected with hcv. hepatitis b virus (hbv) dna was detectable in ( %) patients and negative in ( %) patients. all hepatitis delta patients were extracted from a prior study conducted by this collaboration. there were , chronic hbv carriers. ( . %) were hbv/ hcv/hdv infected. ( %) of patients carried a diagnosis of cirrhosis compared to ( %) of chronic hbv patients. ( %) hcv co-infected patients had evidence of cirrhosis while ( %) patients did not. conclusion: individuals with hbv/hdv co-infection have higher rates of cirrhosis. individuals with hbv/hcv/hdv infection have rates of cirrhosis significantly higher than individuals with either chronic hbv infection or hbv/hdv co-infection. testing for hdv should be performed in all patients, especially those with advanced liver disease or high risk behavior. clinical characteristics were compared between the patients with significant endoscopic findings (group a) and without such findings (group b). peak ast and alt level were higher in group a (p< . ). there were no statistical differences in age, gender, comorbidity, and etiology of acute hepatitis between group a and group b conclusion: significant endoscopic findings were found in considerable proportion of patients with acute hepatitis. severity of acute liver injury was associated with significant upper gastrointestinal endoscopic findings. in patients with severe acute hepatitis who complain of upper gastrointestinal symptom, esophago-gastro-duoenoscopy should be performed. background: in japan, hepatitis e virus (hev) testing is not allowed as routine one. to study the role of hev testing, we checked sera of the patients diagnosed as etiology-obscure acute liver injury. methods: we have seen cases of acute liver injury from january through december in our hospital and cases of them were etiology-obscure. in cases, were retrospectively tested for hev-igm, hev-iga and hev-rna (rt-pcr) by direct sequence method on stored sera taken at the time of presentation. result: two of cases ( . ) were positive for both hev-igm and hev-iga and one case was positive for hev-rna. in cases of acute liver injury, the cause of virus was cases ( . %) and unknown was cases ( . %). hev was occupied in . % in all cases and . % in the cases caused by virus. one of the two cases had been misdiagnosed as "drug induced hepatitis". hev of genotype was detected in one case and its nucleotide sequences of hev showed quite a high degree of similarity to the reported one at closed city in the same year. conclusion: hev is not rare in japan and the hev testing can reverse the diagnosis of acute liver injury. hev testing sould be used as routine one for acute liver injury. association of progesterone receptor gene with hepatitis e disease severity in pregnancy p.d. bose , b. das , a. kumar , p. kar maulana azad medical college, background/aims: incidence of fulminant hepatic failure (fhf) in hepatitis e is high in pregnancy particularly during rd trimester when there is an altered status of hormone and immunity. progesterone receptor (pr) up regulation provides fetal protection via immunosuppression but lower immune status in pregnancy may add to the disease severity. till now, no data is available whether pr can play any role in hepatitis e disease severity during pregnancy. progins, a haplotype of pr consisting of -bp insertion in intron g together with point mutations in exons and is associated with increased stability and higher transcriptional activity. the aim of the study is to analyze pr mutation (progins) and m rna expression in hepatitis e virus infected pregnant women with avh and fhf. methods: a total of avh and fhf cases were studied. blood and placental tissue were collected from the medicine and gynecology wards of lnjp hospital, new delhi. cases were screened for acute viral markers by commercially available elisa kit. extraction of dna from blood and rna from placental tissue was done by qiagen kit. mutation in pr was detected by pcr-rflp. semiquantitative rt-pcr for pr expression was performed in placental tissue using beta-actin as internal control. results: pr mutation (progins) was significantly more in fhf compared to avh ( . % vs . %, p value< . ). protein expression was found higher in progins carriers. conclusion: progesterone receptor mutation (progins) may have a role in the hepatitis e disease severity in pregnant women. results: the hepatitis e was predominantly sporadic, some patients superinfected with other viral hepatitis, especially hepatitis b. in the old patients, jaundice lasted longer and the length of stay was longer, the incidence of complication was higher than the young men. the incidence of complication in the superinfected group was higher than the simple infection. the transaminase in the simple infection group was obviously raise than superinfected with liver cirrohsis. methods: liver sample were paraform-glutaral fixed, paraffin-embedded, sectioned and immunohistochemical stained, and positive samples were selected for histological analysis and rt-pcr detection. result: positive rate of hev immunohistochemistry ranged from % to % (fig. ) . hepatocyte degeneration, scattered singled karyopyknosis, lymphocytic infiltrate, hyperplasia of bile canaliculus at the portal area and fibrous connective tissue hyperplasia been observed during histological analysis (fig. ) , and two genotype hev which closely related to many strain isolated from patients with sporadic acute hepatitis been detected. conclusion: the patients infected with hepatitis e of young men were frequently. jaundice lasted long in the old patients, the incidence of complication was higher in the superinfected men and the old men. conclusion: additional public-health concerns might be placed on pork safety and the risk of hev infection via the consumption of undercooked pork products. poster session, hall b aim: esophageal varices (ev) recurs frequently after endoscopic variceal ligation (evl) or endoscopic injection sclerotherapy (eis). we retrospectively investigated risk factors for early recurrence of ev after endoscopic treatment. methods: we treated patients with ev, who had no past history of ev, at ehime prefectural central hospital from october to june . of those, ( %) were observed for at least months after treatment and enrolled. we divided them into rupture cases at initial endoscopic treatment [(bleeding group; n= ( %)], and cases with preventive evl or eis performed [preventive group; n= ( %)]. all received periodic upper endoscopy examinations to confirm recurrence or no recurrence of ev. results: recurrence of ev occurred in of all subjects and the average period after treatment was . ± . months. the recurrence rate was significantly higher in the bleeding group ( / ) as compared to the preventive group ( / ) (p= . ). there was a significant relationship between recurrence of ev and hepatic reserve function (child-pugh a+b, c; / , / respectively; p= . ). in logistic multi-variant analysis, ev rupture at initial treatment and child-pugh c were risk factors for recurrence. in contrast, age, sex, hepatocellular carcinoma, portal tumor thrombosis, continuous alcohol consumption, therapeutic modality (evl or eis), number of treatment sessions, and operator experience did not have a significant relationship with recurrence. conclusion: in cases with ev rupture at initial treatment or child-pugh c, the risk for early recurrence must be considered and patients carefully observed in follow-up examinations. endoscopic cyanoacrylate injection: less oil for less ectopic embolism c.z. li , l.f. cheng , z.q. wang , f.c. cai , q.y. huang , e.q. linghu general hospital of chinese pla background and aim: endoscopic injection sclerotherapy with n-butyl- cyanoacrylate (nbca, histoacryl) has been reported to be effective for hemostasis of bleeding gastric varices, but occasionally the gel flows to other organs and causes ectopic embolism. the present study aimed to determine whether less amount of iodized oil preload in nbca injection helps in decreasing ectopic embolism. methods: from january to april , different methods of endoscopic nbca injection, "sandwich method" and "modified sandwich method" (in which iodized oil preload was minimized), were applied on gv cases, to evaluate if decrease of iodized oil preload resulted in less ectopic embolism. results: altogether cases of ectopic embolism occurred in the whole group ( . %), including cases of splenic infarction, case of transient paralysis and case of minor infarction of the lung. the modified sandwich method showed some superiority over original method in decreasing ectopic embolism ( / vs. / , p= . ). less cough during procedure was also found with the modified method ( / vs. / , p= . ). conclusions: less amount of iodized oil preload in endoscopic nbca injection is beneficial to decrease ectopic embolism. background: portal hypertension is closely associated with serious complications of liver cirrhosis which contribute to bad prognosis. hepatocellular carcinoma (hcc) and low serum sodium (sna) are manifestations of end-stage liver disease (esld) and are associated with poor survival in decompensated cirrhosis patients. therefore, we aimed to determine the relationship between hepatic venous pressure gradient (hvpg) and the development of hcc or low sna in decompensated alcoholic cirrhosis patients. methods: child-pugh scores, meld scores, and hvpg at baseline, and the development of low sna (sna < meq/l) or hcc during follow-up were analyzed prospectively in patients with decompensated alcoholic liver cirrhosis. the predictive values of different risk factors for the progression to the esld were investigated by multivariate analysis and the kaplan-meier method results: twenty-four patients developed hcc during the follow-up period. in the multivariate analysis, only baseline hvpg> mmhg was an independent predictive factor for the development of hcc (relative risk (rr)= . , p< . ). those with hvpg > mmhg showed a significantly shorter time for the development of hcc on kaplan-meier analysis. twenty patients developed low sna during follow-up. initial hvpg was also an independent predictive value for the development of low sna in the multivariate analysis (rr= . , p< . ). those with hvpg> mmhg also showed significantly shorter times for the development of low sna on kaplan-meier analysis. conclusions: in decompensated alcoholic cirrhosis, hvpg may be a useful predictive factor for the development of hcc and low sna, both of which are characteristic of esld and poor prognosis. the effectiveness of the treatment of octreotide on chylous ascites after liver cirrhosis d.x. zhou , , h.p. hu , background: octreotide is a crucial drug used for treating patients with chylous ascites; however, there have been few reports related to octreotide that are being used in cirrhotic patients. thus, this thesis is designed to determine the effects of octreotide on patients with chylous ascites after liver cirrhosis. methods: eight patients were diagnosed with chylous ascites, on the basis of laboratory findings on ascites samples, between january and may . octreotide was given to the six patients, while the remaining two were treated as a control. all patients had persistent peritonea drainage with the quantity and quality of the drainage fluid observed once every other day. all the necessary care was individually given to the patients during the therapy results: all patients properly received combined therapy including low fat and sodium diet, and diuretic and peritoneal drainage. the volume of the peritoneal drainage was reduced to zero in one of the six patients who received octreotide therapy, while the other five had the drainage volumes decreased from ml to ml with a clear appearance and negative qualitative analysis of chyle for those two patients who did not receive octreotide therapy, the conditions of peritoneal drainage seldom changed both from the qualitative and quantitative aspects. conclusion: octreotide, along with combined therapy, can rapidly relieve portal hypertension and reduce fat absorption from intestinal mucosa. it appears to be an effective therapy available for the treatment of chylous ascites caused by liver cirrhosis. albumin < g/l were the best predictors of large varices. a model using these predictors in a validation cohort study is planned. background-aim: cirrhosis is associated with raised acute phase proteins (app), irrespective of infection. it is, however, unclear whether their values differ significantly or whether a particular app might be more indicative of infection, and these questions were addressed in our study. methods: we measured serum crp, fibrinogen, ferritin, haptoglobin, -microglobulin, c , c , and c inhibitor in consecutive, cirrhotic patients, on admission. all patients were investigated according to a standard protocol for infection. child-pugh scores (cps) were calculated. results of app were expressed as means sem and compared with the mann-whitney test. results: ( , %) patients, median age years, (cps: a= ; b= ; c= ), were diagnosed with infection (spontaneous bacterial peritonitis= ; pneumonia= ; septic shock= ; extensive cellulitis= ; listeria monocytogenes meningitis= ; viral infection= ), while ( %) patients, median age years, (cps: a= ; b= ; c= ), showed no infection. although most app values were raised, there was no statistically significant difference between patients with or without infection, or among different cps groups, except for crp, which was significantly more raised in patients with infection (p< . ). this difference remained even after cps a cases in the non-infection group were excluded from analysis. interpretation: a significantly raised crp in cirrhosis would seem to be independent of cps staging and should prompt a thorough work up to exclude infection. by contrast, the discriminating power of all other app in the face of possible infection is negligible. the predictive value of crp towards infection is under investigation prospectively. although bleeding from ectopic varices such as duodenal, jejunal, ileal, colonic, and rectal varices is less common, it can also cause life-threatening problem, which is often difficult to diagnose and treat successfully. here we present a novel endoscopic approach for hemorrhagic rectal varices using endoscopic injection sclerotherapy with ligation (eisl). patients and methods: in - , we performed endoscopic treatment in patients with portal hypertensive varices. among those, four cases of hemorrhagic rectal varices were treated with the combined evl and sclerosing technique. the etiology of portal hypertension included oen idiopathic portal hypertension and three hcv cirrhosis. all patients had a history of prior abdominal surgery or endoscopic treatment for gastro-esophageal varices. results: hemostasis was obtained easily by the evl initially. furthermore, to avoid recurrent bleeding, the patients underwent endoscopic varicerography injection sclerotherapy (evis) using % ethanolamine oleate with iopamidol and the feeding vein was sclerosed successfully with no major complication occurred during the entire course of the treatment. conclusions: it is important to recognize the possibility of ectopic varices as a cause of gastro-intestinal haemorrhage especially in patients with a history of variceal therapy or abdominal surgery. the eisl technique is useful to control the initial and recurrent bleeding from rectal varices. t. hirano , t. okada , j. yamanaka , y. iimuro , n. kuroda , k. oh , y. yoshida , j. fujimoto aim: interferon (ifn) therapy is a powerful treatment for hcv-related hepatitis and is known to decrease the incidence of progression of hepatocellular carcinoma (hcc). however, thrombocytopenia is a common side effect of ifn treatment, often leads to discontinuance without insufficient therapeutic effect. in this study, we investigated the efficacy and safety of laparoscopic splenectomy ( ) in reversing thrombocytopenia in patients with hepatitis c cirrhosis and portal hypertension. patients and methods: out of patients who underwent ls in our department during aug and december , patients associated with portal hypertension. among these patients, three patients had hcc, and they were simultaneously underwent partial hepatectomy after splenectomy. platelet count, operative time, blood loss, complications and length of stay were calculated. results: thirteen patients underwent laparoscopic splenectomy; their mean age was years (range to years). six patients were child's class a and seven patients were class b. mean operative time was minutes (range to minutes). blood loss was little, and none required transfusion with packed red cells. a hand-assisted laparoscopic technique was used in four cases ( . %). average length of stay was . days. there have been no major complications during follow-up. platelet counts improved from a preoperative mean of /ul ( to ) to /ul ( to ) postoperatively. six patients are ongoing ifn treatment without remarkable thrombocytopenia. conclusion: laparoscopic splenectomy is safe and in patients with portal hypertension and thrombocytopenia. it may allows these patients by reversing thrombocytopenia. background: hepatic encephalopathy (he) is a significant cause of mortality in advanced cirrhosis patients. l-acyl-carnitine has been suggested as an alternative treatment for patients with he patients. to assess the clinical efficacy of acetyl-l-carnitine in the treatment of hepatic encephalopathy in cirrhotic patient, especially in diminishing the recurrence and reduction serum ammonia level. methods: we performed a randomized placebo-controlled, cross-over study. we administered acetyl-l-carnitine to group during months first then placebo during later months, and administering acetyl-l-carnitine to group alternatively. results: between january and february , thirty two selected cirrhotic patients were enrolled in this study. following randomization, the patients were divided into two groups (group = , group = ). during administering acetyl-l-carnitine period, serum ammonia level was decreased significantly in both groups significantly (p= . , vs. p= . respectively). however, during administering placebo period, serum ammonia level changes were not significant. in group , the first recurrence cases of hepatic encephalopathy were more than group (group = , group = ), and the first recurrences were occurred during first months in all groups. conclusion: our study demonstrates that acetyl-l-carnitine administration reduced serum ammonia level, but not definitely diminishing the recurrence of hepatic encephalopathy. sodium (na + ) and water retention are the most common abnormalities in cirrhotic patients and the magnitude varies from patients to patients. aim: to assess the relationship between the meld score and urinary excretion of na+ in non-azotemic cirrhotic patients. methods: fifty four cirrhotic patients with ascites and normal serum creatinine (< . mg/ml) were admitted and placed on a low sodium diet ( g/day), while all diuretics were withdrawn for days. the electrolytes (na + , k + , na + / k + ) were measured in a random urine and both the volume and na + concentration of urine collected for h after administration of furosemide mg i.v. were determined. results: table. conclusions: the meld score was significantly correlated with the degree of impairment of urinary na+ excretion. the ratio of na + /k + in a random urine specimen and furosemide-induced na+ excretion reflect the degree of impaired natriuresis in non-azotemic cirrhotic patients with ascites. background: portal hypertensive gastropathy (phg) is common finding in patients with liver cirrhosis and portal hypertension. despite portal hypertension remains the crucial trigger for the development of phg, the relationship between portal hypertension and phg has not been widely investigated. methods: fifty-three cirrhotic patients ( males, mean age years) who were performed hepatic vein catheterization between november and august were prospectively included in this study. the degree of phg was assessed according to the third baveno international consensus workshop, and classified three degrees as no, mild and severe. the hepatic venous pressure gradient (hvpg=whvp-fhvp) measurements were performed by triplicate in each case, and results were given as arithmetic means of the three determinations. result: hvpg values did not differ between the patients without phg ( . ± . mmhg) and those with phg ( . ± . , p= . ), nor between those with mild ( . ± . mmhg) or severe phg ( . ± . mmhg, p= . ). the degree of phg and hvpg did not differ regarding the etiology of the cirrhosis(p= . , p= . ) nor regarding the child pugh classification(p= . , p= . ). no correlations were found between the degree of phg and child pugh score, age, with or without ascites, albumin, bilirubin, creatinine, meld score and the degree of gastroesophageal varices. conclusions: our data show that the presence and the severity of phg does not correlate with the degree of hvpg, and that correlate with esophageal varices in patients with liver cirrhosis. introduction: phlebosclerotic colitis is a rare form of ischemic colitis characterized by the thickening of the colonic wall due to fibrous degeneration of the submucosal layer and fibrotic sclerosis of the venous wall. there are a few reports those this entity might be related to portal hypertension with disturbed venous return from the colon and mesentery. case description: a -year old man with alcoholic liver cirrhosis presented with right lower abdominal pain/tenderness and bloody diarrhea. a colonoscopy revealed multiple circumferential ulcerations in the transverse colon and the scope could not get through the ascending colon due to luminal stenosis, showing histologic finding of ulcerative inflammation with inflammed granulation tissue. abdominal computed tomography demonstrated liver cirrhosis with splenomegaly, multiple portosystemic venous collaterals, diffuse vascular engorgement and the wall thickening of right proximal to mid ascending colon with increased density in the surrounding fatty tissue. a follow-up colonoscopy performed one month later showed still remained multiple ulcerations in the transverse colon and could not further advance to ascending colon. superior mesenteric angiography revealed no main branch occlusion but pooling at the venous phase on ascending colon. a right hemicolectomy was performed because of the colonic obstruction. gross findings on operation showed thickening of the cecum and ascending colon. microscopic examination showed fibrous thickening in the submucosa, abundant neurovascular bundles in the mesentery and several intravascular hyaline thrombi of the mesenteric vessels. here we report the first case of early stage of phlebosclerotic colitis in a cirrhotic patient in korea. spontaneous bacterial peritonitis (sbp) is one of the severe complications in advanced cirrhotic patients with a high mortality rate. although a more rapid diagnosis should lead to the better survival, it takes several days to detect the causal bacteria from ascitic fluid cultures. furthermore, despite the use of sensitive methods, ascitic fluid cultures were negative in more than % of patients with suggestive clinical manifestations of sbp. therefore, diagnosis of sbp is based on the polymorphonuclear leucocytes (pmn) cell count in the ascitic fluid. the hybrizep kit (fuso pharmaceutical industries, osaka, japan) detects the dna of bacteria that have been phagocytized in neutrophils and macrophages, using in-situ hybridization method within one day. here we present a case of the patient for whom the hybrizep kit was used to detect the causal pathogen of sbp. a -year-old man had been admitted for the treatment of ascites and esophageal varices. one week after the admission, he complained abdominal pain and fever. because the pmn cell count in ascites fulfilled the criteria of sbp ( /mm ), we started an empirical antibiotic therapy without waiting for a result of the culture, and his symptoms improved within a few days. on the following day of the onset, in situ hybridization showed the positive signals by the ek probe, which detected the genomeic dna of e.coli species. however, the ascitic fluid culture was negative. this case suggested that the hybrizep kit was useful for the rapid diagnosis of sbp with high sensitivity. background: it has not been known that the hemodynamic effect of a portal hypertension for splenomegaly or esophageal and gastric variceal formation. this study was performed to access the parameters of doppler ultrasonography associated with splenomegaly or varices in patients with cirrhosis. patients and methods: from may to may , cirrhotic patients were performed the doppler ultrasonography. of these patients were accessed the severity of varices endoscopically. the three dimensional volume of spleen was measured from a length, width and thickness on sonography. results: the splenic volume ( . ml vs . ml, p= . ) and blood flow of main portal vein ( . cm/s vs . cm/s, p= . ) were statistically significant different in alcoholic ( / ) and non-alcoholic ( / ) cirrhosis groups. the splenic volume ( . ml vs . ml, p= . ), damping index ( . vs . , p= . ), and blood flow of main portal vein( . cm/s vs . cm/s, p= . ) were statistically significant different in esophageal variceal groups ( / ) and non-esophageal variceal groups( / ). the only splenic volume ( . ml vs . ml, p= . ) were statistically significant different in gastric variceal groups ( / ) and non-gastric variceal groups ( / ). the hemodynamic parameters venous ammonia and cff at baseline and after one month of treatment with lactulose. mhe diagnosed by abnormal psychometry and/or p erp.response defined by normalization of abnormal test parameters. results: mhe diagnosed in ( %) patients. of patients ( %) had both abnormal psychometry and p erp whereas ( %) alone had abnormal psychometry, ( %) had abnormal p erp.cff was < hz in ( %) patients. mhe recovered in % with treatment and cff > hz was seen in ( %) of patients. cff sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv) and diagnostic accuracy before and after treatment is shown in table. conclusions: critical flicker frequency is a simple and accurate test without any age or literacy dependence for the diagnosis and recovery of patients with mhe. background/aims: endoscopic injection of n-butyl- -cyanoacrylate (histoacryl) is an effective treatment of varix bleeding. but nontarget embolizations and septicemia are unwanted complications. we evaluate the risk factors for complications. methods: thirty-three patients with esophageal or gastric varix bleeding received endoscopic histoacryl therapies ( procedures). baseline varix size, ctp score were checked. serum leukocyte, blood culture and body temperatures were repeated checked within one week after procedure. average volume of histoacryl per each session was . ml, and dilution volume ratio of histoacryl/lipiodol was / or / . results: average of ctp score was . ± . . three cases of septicemia were correlated with ctp score rather than session frequency or injection volume. two cases of systemic embolizations (pulmonary and splenic arterial embolism) were correlated with high lipiodol dilution ratio ( / ) and lipiodol volume rather than histoacryl volume or ctp score. conclusion: ctp score, lipiodol volume and dilution ratio of histoacryl/lipiodol were significant risk factors for complications. detection of circulating toll-like receptor and and cd +cd + regulatory t cells in patients with hbv-related liver cirrhosis x.q. wang , y. zhang , x.f. bai , j.q. lian background : to detect circulating cd + cd + regulatory t cells and toll-like receptor(tlr) and tlr expression on the peripheral blood mononuclear cells (pbmcs) of patients with hbv-related liver cirrhosis (lc), and to explore the correlation between them. methods: pbmcs isolated from lc patients , chronic hepatitis b (chb) patients and normal controls(nc) were stained with fluorescent labeling anti-tlr -pe, anti--tlr -apc, anti--cd -fitc monoclonal antibodies and anti-cd -percp anti-cd -fitc anti-cd -pe. samples were collected and detected of three-color immunofluo rescence by flow cytometry. results: the expression of tlr and tlr were significantly up-regulated in patients with lc than those in the controls.the expression of tlr was significantly increased in patients with lc than those in patients with chb, but there were no differences of tlr expression between lc and chb.treg/cd + t cells were significantly increased in patients with chb than those in patients with nc and lc, but there were no differences between lc and nc. there were no correlation between the expression of tlr ,tlr and treg in patients with lc . the expression of tlr and tlr on pbmcs in patients with lc were positive correlation.the expression tlr and hbv dna level were negative correlation in patients with lc. conclusion: the expression of tlr and tlr were up-regulated on pbmcs in patients with lc. it seems to be expression of tlr and tlr invovlved in the pathogenesis of lc. evaluation of c-phenylalanine breath test for the measurement of hepatocyte function in patients with chronic liver disease z.j. bao , d.k. qiu , , x. ma , , g.s. zhang , y.q. huang , z.p. fan , , s.m. yin huadong hospital, fudan university, renji hospital, shanghai jiao tong university school of medicine, background: the objective is to investigate whether the c-phenylalanine breath test(pbt) would be useful for the evaluation of hepatic function in patients with chronic hepatitis b, liver cirrhosis and minimal hepatic encephalopathy (mhe). methods: l- [ - c] phenylalanine was administered orally in a dose of mg to patients with liver cirrhosis, with chronic hepatitis b and healthy subjects. the pbt was measured at different time points ( , , , , , , , min) to obtain the values of delta over baseline, percentage co exhalation rate and cumulative excretion (cum). the relationships of the cumulative excretion with the c-%dose/h and blood biochemical parameters were investigated. results: the c dose h - at and min combined with the cumulative excretion at and min showed correlations with the chronic liver diseases, especially child-pugh score and mhe or not. and the data showed correlations with serum albumin hemoglobin platelet and child-pugh score. prothrombin time, total and direct bilirubin were significantly increased, while serum albumin, hemoglobin and platelet, the cumulative excretion at and min values decreased by degrees in healthy controls, child-pugh a, b, and c patients (p< . ). similar results of pbt were in the patients with and without mhe, while only prothrombin time prolonged and total bilirubin increased (p< . ). conclusions: the pbt can be used as a non-invasive assay to evaluate hepatic function in patients with liver cirrhosis and mhe. the % c dose h- at min, % c dose h- at min and cumulative excretion at min may be the key value for determination at a single time-point. branched chain amino acids in improving survival and decreasing risk of liver failure among cirrhotic patients: a meta-analysis h. flores , e.l. ang , n. iv estanislao philippine general hospital background: the state of a patient's nutritional status greatly affects disease outcome. among cirrhotic patients, approximately - % are in a state of protein-energy malnutrition. hence, adequate nutritional support is essential to improve their general medical condition and long term prognosis. several studies have shown than branched chain amino acids (bcaa) may be of benefit for this purpose. it is the aim of this study to evaluate the effectiveness of diet plus bcaa compared to diet alone in improving survival and in decreasing liver failure among cirrhotic patients. methods: pubmed, cochrane, and embase search was done for articles which compared the clinical effects of bcaa supplementation versus diet alone among patients with liver cirrhosis. the following free-text terms and mesh words were used -"branched chain amino acids", "amino acids, branched chain", "bcaa", "liver cirrhosis", "cirrhosis", "randomized controlled trials'" and "meta-analysis". after critical appraisal of the included studies, a random effects model using odds ratio was used to synthesize the results (revman . ). results: rcts were included for analysis with a total study population of . combination of the studies showed a significant decrease in the risk of liver failure (or . , % ci . - . , p= . ) and a trend towards benefit in improving survival (or . , % ci . - . , p= . ). conclusions: the overall trend appears to show benefit in the use of branched chain amino acids for patients with cirrhosis with respect to liver failure and survival. background: the proxisome prolifrator-activated receptor gamma (ppar ) is a member of the nuclear hormone receptor superfamily that is involved in the control of inflammation, carcinogenesis and gastric ulcer. on the other hand, the frequency of gastrointestinal ulceration is higher in cirrhotic patients compared with the normal population. the present study was designed to investigate the effect of specific ppar ligand, pioglitazone, on the mucosal lesions induced by ethanol in cirrhotic rats and the possible involvement of nitric oxide in the pioglitazone effect. methods: cirrhosis was induced by surgical ligation of bile duct and sham-operated rats served as controls. both cirrhotic and sham rats were kept for days after the operation. different groups of sham and cirrhotic animals received saline, or , or mg/kg pioglitazone, daily during last days of the fourth week after the surgery. another groups of bdl or groups of sham rats received l-name, a non selective inhibitor of nitric oxide synthase, alone or along with mg/kg pioglitazone for days. on day , rats were killed hour after ethanol administration and the area of gastric lesions was measured. results: the ethanol-induced gastric mucosal damage was significantly more sever in cirrhotic rats than sham-operated ones (p < . ). pretreatment with pioglitazone dose dependently attenuated gastric lesions induced by ethanol in both sham and cirrhotic rats, but this effect was more significant in cirrhotic ones. concurrent treatment of l-name and pioglitazone decreased the ulcer index in bdl rats more than the groups that received l-name or pioglitazone alone. conclusion: we conclude that chronic treatment with pioglitazone exerts a potent gastroprotective effect on the stomach ulcers of cirrhotic rats probably due to inhibition of nitric oxide synthase. inhibition of phosphodiesterase -a novel therapeutic strategy for portal hypertension l. halverscheid , p. deibert , b. pannen , r. schmidt , m. roessle , w. kreisel university hospital duesseldorf, germany, university hospital freiburg, germany introduction: the no-cyclic gmp system is a key factor in the regulation of splanchnic and hepatic blood flow and may be a target for medical treatment of portal hypertension. clinical data have shown that inhibitors of phosphodiesterase (pde ) lower portal pressure in cirrhotics. methods: we monitored in rats the effects of the pde inhibitors vardenafil and sildenafil on systemic and hepatic hemodynamic parameters up to minutes after the drug. the drugs were administered intravenously into the tail vein at (group a), (group b), and g/kg body weight (group c). . % nacl was the control. n = for each group. results: the most prominent changes were observed in the vardenafil b group: mean arterial and portal venous pressure decreased (- %, - %), as well as portal venous, hepatic arterial, and systemic vascular resistance (- %, - %, - %). portal venous and sinusoidal flow increased (+ %, + %). in the vardenafil c and sildenafil b and c groups there was an increase of portal venous flow by - %, an increase of sinusoidal flow by - %, and a decrease of portal venous resistance by about %. there was a trend for reduction of portal venous pressure. conclusions: vardenafil and sildenafil influence portal hemodynamics in the rat. portal venous flow increases by - %, portal venous resistance decreases by > %. dependent on the dose, portal venous pressure decreases significantly. these data yield further evidence that pde inhibitors may be a novel therapeutic option for portal hypertension. groups of liver cirrhosis e. havrilyuk lviv national medical university introduction: rupture of esophageal varicose resulting in posthemorrhagic anemia is a common life-threatening complication of liver cirrhosis. but it is not clear, why the other patients, having the same degree of sclerosis and histologic activity index, die from hepatocellular failure or other reasons. aims & methods: autopsy cases performed in lviv regional hospital in - were analyzed. screening of slides with liver tissue allow to select cases ( , %) with cirrhosis (complete and incomplete), which are examined in order to evaluate the frequency of lethal portal hypertension complications in the different etiologic groups of liver cirrhosis. results: according to the etiologic factor the following groups of liver cirrhosis were examined: alcoholic disease ( , %), viral hepatitis ( , %), nonalcoholic steatohepatitis ( , %), secondary biliary cirrhosis ( , %), cardiac sclerosis ( , %), combined lesions ( , %) and cryptogenic cirrhosis ( , %). analysis shows that in cases ( , %) patients die from cirrhotic complications (hepatocellular failure, jaundice, portal hypertension) and only in cases ( , %) -from posthemorrhagic anemia caused by rupture of esophageal varicose. in the latter cases correlation between the etiologic types of cirrhosis is almost the same, as in the main group and only alcoholic lesions ( %) and biliary cirrhosis ( , %) are more frequent. conclusion: analysis shows that development of lethal complications of portal hypertension can not be explained only by etiologic factor. probably additional stimuli are more important for morphogenetical variants of cirrhotic transformation. patients with viral cirrhosis k. mumtaz , s. ahmed , h. ali shah , s. hamid , w. jafri background and aims: increased nitric oxide (no) production is incriminated in the pathogenesis of arterial vasodilation and hyperdynamic circulatory state in non cirrhotic models of portal hypertension (pht). we investigated the relative roles of constitutive nos (enos) and inducible nos (inos) isoforms in the development of rabbit models of endotoxemia induced portal hypertension (eipht) methods: eipht was induced by chronic injection of lipopolysaccharide via an indwelling cannula placed in the gastrosplenic vein of rabbit and maintained for months. the concentration of no, expression of nos (enos and inos) mrna and protein was measured in eipht and sham operated control animals. results: rabbits with eipht compared with controls had raised portal pressure (in mmhg- . ± . vs . ± . ;p< . ; mo; . ± . vs . ± . ; p< . , mo; . ± . , vs . ± . ;p< . ), arterial hypotension (in mmhg- . ± . vs . ± . , p< . , mo; . ± . vs . ± . ,p< . , mo; . ± . vs . ± . , p< . , mo), splenomegaly (in g- . ± . vs . ± . , mo; . ± . vs . ± . , mo; . ± . vs . ± . , mo), normal liver functions and preserved hepatic architecture at , and mo. serum levels of no as well as the no were significantly elevated in eipht rabbits as compared to the controls. the expression of enos, at the level of mrna, was significantly increased in eipht rabbits consistent with increased levels of expression of inos as compared to the controls. the enos but not inos protein expression was elevated in eipht than control rabbits. conclusion: vascular dysfunction in the splanchnic circulation during the development of endotoxemia induced portal hypertension is predominantly characterized by enos and partly by inos gene up-regulation. liver cirrhosis contributed to the immunocompromised status by shedding the membranous tnfrii t.n. lin , c.h. chao , i.s. sheen , y.p. ho , w.t. chen , c.j. lin , c.t. yeh , c.y. lin liver research unit, linkou medical center, chang gung memorial hospital, chang gung university, taoyuan, taiwan background & aim: patients with decompensated liver cirrhosis (dlc) were regarded as immunocompromised, reflected by high incidence of bacterial infection. paradoxically, the proinflammatory cytokine like tnfincreased significantly in patients with dlc even in the face of this immunocompromised status. on the other hand, regulatory t cell (treg cell) is believed to play an important role in inhibiting immune responses, including innate immune responses like blockade of tnf-effect through soluble tnfrii. here, we studied the role of treg cells and tnfrii in patients with decompensated liver cirrhosis. patients and methods: healthy volunteers and cirrhotic patients were enrolled. the percentage of treg cells were enumerated by flow and serum levels of il- , tgf-and tnf-by elisa. results: the percentage of treg cells increased significantly in patients with dlc associated with increased serum levels of il- and tgf-. in addition, these treg cells were mainly memory type reflected as high cd ro. furthermore, the tnfrii expression increased significantly on these treg cells of dlc. interestingly, these membranous tnfrii on treg cells could be shed-off. lastly, we found the serum soluble tnfrii concentration increased significantly in patients with dlc when compared with normal volunteers. conclusion: our results demonstrated memory treg cells with high tnfrii expression increased significantly in patients with decompensated liver cirrhosis that could possibly blocked the biological effect of tnf-by shedding membranous tnfrii and contributed to the immunocompromized status of dlc. background: portal pressure measured as hepatic venous pressure gradient (hvpg) correlates with severity of portal hypertension and the development of complications. hvpg measurement is invasive. recently, liver stiffness measurement has been shown to correlate with liver biopsy and helps predict outcome in chronic liver disease patients. this study was conducted with the aim to study the correlation between portal pressure as measured by hvpg and liver stiffness as measured by fibroscan among patients with portal hypertension due to various causes. methods: between august and september , consecutive patients with portal hypertension were included and were subjected to hvpg measurement and fibroscan (echosens, france). results: of the patients with portal hypertension, both hvpg and liver stiffness were measurable in [ ( %) males; mean age . ( . ) years]. the etiological distribution was hbv related cirrhosis in patients, hcv cirrhosis in , cryptogenic cirrhosis in , alcoholic cirrhosis in , hbv and alcoholic cirrhosis in and primary extra-hepatic portal vein obstruction in . the mean hvpg and liver stiffness of this group were . ( . ) mm hg and . ( . ) kpa respectively. there was a strong positive correlation between hvpg and liver stiffness [r = . ; p = . ]. conclusions: non-invasive measurement of liver stiffness correlates well with invasive measurement of portal pressure. liver stiffness measurement could be used as a prognostic indicator to predict the severity of portal hypertension. endpoints were rate of rebleeding and mortality till day after inclusion and to see for any adverse events. results: the bleeding was stopped in all patients ( %). rebleeding till day was observed in ( %) patients ( each in group a and b). total patients ( %) died ( each in both groups) due to rebleeding. transfusion needs were higher in group a ( . ± . versus . ± . , p<. ). serious adverse effects leading to treatment discontinuation were not seen in any patients in both groups. conclusion: prolonging terlipressin treatment did not confer any significant decrease of mortality or bleeding recurrence. however transfusion requirements were significantly decreased in patients receiving prolonged treatment. serious adverse effects leading to treatment discontinuation are rare. poster exhibition -miscellaneous poster session, hall b background: it is important to know the prevalence of atp b gene mutations of different geographical areas to justify the local screening strategies for wilson disease (wd). materials: eleven unrelated lithuanian families, including wd patients were tested. genomic dna was extracted from whole venous blood using a salt precipitation method. firstly, semi-nested pcr technique was used to detect the c. c>a (p.h q) mutation. patients not homozygous for c. c>a (p.h q) mutation were further analyzed. the exons of the wd gene were amplified in a thermal cycler. direct sequencing of the amplified pcr products was performed by cycle sequencing using fluorescent dye terminators in an automatic sequencer. results: total of wd patients (mean age . years; range - ; male/female, / ) presented with hepatic disorders and their first degree relatives were studied. some of wd patients in addition to hepatic symptoms have had extrahepatic disorders (haemolytic anaemia ; fanconi syndrome ; neurophsychiatric and behavioural disorder ). twelve of ( . %) wd patients have had c. c>a (p.h q) mutation, of them in both chromosomes, were presented as compound heterozygotes with additional c. - delggtttaaccat, c. delc or c. g>a (p.r q) mutation. for one patient with liver cirrhosis and psychiatric disorder no mutations were found. out of first degree wd relatives ( . %) were heterozygous for c. c>a (p.h q) mutation. conclusion: c. c>a (p.h q) missense mutation is characteristic for lithuanian wd patients. even . % of wd patients with hepatic presentation of the disease are homozygous or compound heterozygote for this mutation. background: diabetic dyslipidemia is a crucial problem of diabetic patients with inadequate control. we investigated the relationship between glutamic-pyruvic transaminase (gpt) and high-density lipoprotein cholesterol (hdl-c) in diabetic patients. methods: with informed consents, we recruited outpatients with diabetes at a hospital in rural area in taiwan in [ ] [ ] [ ] [ ] . anthropometric measures, blood tests and urine screening were examined in diabetic patients. results: overall, there were diabetic patients aged - years enrolled in this study and ( . %) of them had low hdl-c. diabetic patients with the highest quintile of gpt had higher average of body mass index (p< . ), diastolic blood pressure (p = . ), but lower average of hdl-c (p< . ) compared with diabetic patients with the lowest quintile of gpt. the prevalence of obesity ( . % vs. . %, p< . ) and low hdl-c ( . % vs. . %, p< . ) were higher in diabetic patients with highest quintile of gpt than in diabetic patients with lowest quintile of gpt. in the multivariate logistic regression, diabetic patients with highest quintile of gpt had higher odds ratio (or) of low hdl-c compared with diabetic patients with lowest quintile of gpt (or = . , % confidence interval [ci] = . - . ). the corresponding or of low hdl-c in patients aged years and older was . ( % ci = . - . ). conclusion: high gpt is one of factors associated with low hdl-c in diabetic patients. the effect of desferrioxamine as supplement to cefotaxime in the treatment of spontaneous bacterial peritonitis na. seda , m. el-hamamsy , r. el-wakil , m. al azizi ain shams specialized hospital, faculty of pharmacy,ain shams university, faculty of medicine,ain shams university, faculty of pharmacy ,ain shams university background: oxidative damage lead to cell damage, organ dysfunction and death in sepsis. desferrioxamine (dfx), an antioxidant iron chelators. the aim was to assess the efficacy of desferrioxamine supplemented to cefotaxime in the treatment of spontaneous bacterial peritonitis (sbp) in cirrhotic patients. methods: thirty patients divided into two groups: group i (n= ) with sbp and receiving cefotaxime ( g iv every hours) alone and group ii (n= ) with sbp receiving cefotaxime ( g iv every hours) with desferrioxamine ( mg im twice daily).all patient were monitored for seven days, their vital organs were screened and their ascitic fluid was assessed completely including microbiological investigations. results: the concomitant administration of desferrioxamine with cefotaxime significantly at (p< . )and(p< . ) improved the therapeutic outcome and the cure rate after days of treatment as compared to patients using cefotaxime only. conclusions: desferrioxamine can improve the therapeutic outcome by preventing iron-induced organ damage and inhibiting bacterial growth. oligella ureolytica is a gram-negative, nonfermenting rod that is infrequently recovered from clinical specimens and is most commonly isolated from the urine of patients with chronic indwelling urinary catheters or other urinary drainage systems. bacteremia due to this organism is an extraordinary finding. we describe here a case of oligella ureolytica being detected in the blood of a patient with decompensated cirrhosis. a -year-old male man was admitted to hospital with -month duration of debility, poor appetite and abdominal distension. decompensated cirrhosis was diagnosed based on clinical findings such as hepatic face, ascites, edema of lower limbs and icteric sclera. laboratory results showed positive serum anti-hcv and high serum hcv rna level. the patient received a therapeutic regimen of pegylated interferon alpha a plus ribavirin after being admitted to hospital. during hospital stay, a fever of -day duration with shivering occurred to the patient. three blood cultures were drawn, which all grew oligella ureolytica in pure culture. the organism was identified by the viteck compact (biomerieux, france). additional tests for identification resulted positive for nitrate reduction and urea hydrolysis, strongly positive for phenylalaninedeaminase activity and showed no growth at . c. tests for nitrite reduction and motility resulted negative. the organism was resistant to amikacin, cefoperazone, levofloxacin, piperacillin/tazobactam, trimethoprimsulfamethoxazole, aztreonam, cefotaxime, piperacillin and was susceptible to gentamicin, imipenem, meropenem, and netilmicin. a -day of combined therapeutic regimen with cefminox and isepamicin was administered to the patient. within days, the patient became afebrile. background: endoscopic ultrasound (eus) is often performed in patients with unexplained liver tests to assess the gallbladder, bile ducts and pancreas. an unremarkable eus exam and negative hepatology workup often leads to a liver biopsy. eus may provide histopathologic evaluation of the liver in these cases under direct, real-time visualization. aim: to assess the feasibility and efficacy of eus guided core biopsy of the liver in a porcine model. methods: female pigs were used and live procedures were performed under general anesthesia. a linear echoendoscope was used and the liver identified endosonographically. transgastric core biopsies of the liver were obtained with a gauge quick-core ultrasound biopsy needle (wilson-cook) and sent for histopathologic evaluation. live animals were euthanized at the end of the procedure and necropsy performed. results: core biopsies of the liver biopsy were obtained in animals ( cadaver and live anesthetized). a total of thirteen needle passes were made (mean . ; range - needle passes per animal) and a visible core of tissue obtained. the maximum length of liver tissue obtained was mm and considered adequate for assessment as more than one such specimen could be obtained. microscopic evaluation confirmed liver tissue. no complications were noted. necropsy did not show any evidence of bleeding, perforation or damage to surrounding structures. conclusion: eus-guided liver biopsy is feasible and can be performed at the time of routine echoendoscopic exam in select patients undergoing eus examination for abnormal liver tests. background: as the common indexes, alt, ast and plt play an important role in disease diagnosis, treatment and prognosis. many researchers suggested that there was inflammatory changes and fibrosis in chronic hepatitis b and c patients whose alt level was persistently normal. a large sample investigation showed that the serum level of alt in healthy persons is lower than the normal reference value. this study re-evaluated the normal serum level of alt, ast and plt. methods: people were enrolled in the study between sep. and oct. . the platelet count and serum alt and ast levels were measured. frequencies, one-sample kolmogorov-smirnov test and nonparametric tests were used to analyze the difference between age groups, male and female, glucose groups, cholesterol groups and triglyceride groups. result: in the five groups, there is significant difference in alt and ast levels between male and female. in group , the alt and ast levels showed a significant difference between different age groups, between different glucose groups and triglycide groups. in the three groups the plt level is significantly different between male and female, and the serum level in male is higher than female. there is significant difference between different age groups conclusion: the serum levels of alt, ast and plt are all significantly different between male and femal. there is significant difference between different genders and age groups for plt. the serum level of plt is higher than the reference value. background/aims: myeloproliferative disorders (mpd) (like polycythemia vera, essential thrombocythemia and primary myelofibrosis) are responsible for % cases of hepatic venous thrombosis (hvt) and % of portal venous thrombosis (pvt) in western series. latent form of mpd lacks the characteristic blood picture and may be classified as idiopathic thrombotic disorder. a point mutation at val phe of janus kinase tyrosine kinase gene (jak v f mutation) occurs in high proportion of the patients with mpd. this non-invasive test with high positive predictive value is now considered to be essential for diagnosis of various mpd. this test may be useful in diagnosing latent form of mpd in splanchnic venous thrombosis methods: patients with confirmed pyogenic liver abscesses admitted from to in our institution were included. there were men and women ranging in age from to years. the medical records were reviewed for clinical, laboratory and radiographic characteristics. results: among patients, ( . %) experienced at least one complication. there were pulmonary (pleural effusion, pneumonia, empyema) complications, septic shock, acute renal failure, abscess rupture, pseudomembranous colitis, and pericardial effusion. the predictive factors for its complications were: systemic inflammatory response syndrome (sirs, factors), thrombocytopenia ( , /ml), hypoalbuminemia ( . g/dl), elevated ast or alt (> iu/l), hyperbilirubinemia ( > . mg/dl), k. pneumonia, air within abscess cavity (p< . ). conclusions: the incidence of complications in the pyogenic liver abscess was . %. the various predictive factors of complication should be monitored carefully. further large scaled study should be warranted. background/aims: hepatic iron deposition is a common feature in chronic hepatitis c (ch-c), however, whether it could enhance the progression of fibrosis or not is controversial. the aim of this study was to evaluate the status and significance of hepatic iron deposition in the korean patients with chronic hepatitis c. methods: untreated, ch-c patients who underwent liver biopsy were included. the hepatic iron was assessed by scheuer's scoring system, and activity, fibrosis, and steatosis were scored by a pathologist in a blind manner to the clinical features. clinical and laboratory data including serum iron indices, virological, biochemical results were analyzed to search for significant factors associated with hepatic iron deposition. results: hepatic iron staining was positive in ( %). among patients with hepatic iron deposition, serum levels of ferritin (p= . ) and -fetoprotein (p= . ), and body mass index(bmi) (p= . ) were significantly elevated. there was no significant association between the degree of hepatic iron deposition and fibrosis stage (p= . ), although elevated levels of serum hyaluronic acid (p= . ), -glutamyl transpeptidase (p= . ), and prothrombin time (p= . ) were associated with advanced fibrosis. conclusions: hepatic iron deposition in asian-pacific ch-c patients seemed to be neither frequent nor related to hepatic fibrosis, but related to obesity. therefore, phlebotomy might not commonly applicable to this area. further studies on the pathogenic role of iron in ch-c in asian-pacific countries are warranted. a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture, necrosis of hepatocytes and the formation of regenerative nodules contributes to cirrhosis. limitations like organ donors shortage, high cost, absence of proliferation in cultured hepatocytes, inherent risks of infection, rejection in xenogenic cells and other socio-economical complications emerges advanced regenerative human hepatic stem cells(hhpscs) transplantation. hhpscs are located in the ductal plates in fetal and canals of hering in adult livers [schmelzer et al.( ) ]. hepatoblasts, in turn, give rise to the hepatocytic and biliary lineages, the hepatocytes and cholangiocytes [schmelzere etal( ) ].hhpscs express cd (epcam)marker. scjelzer etal demonstrated that during embryogenesis % of the epcam positive cells had hepatoblast phenotype. in animal study, on transplantation of freshly isolated hhpscs in scid mice results in mature liver tissue expressing human-specific proteins. recently, we(aleem etal )have shown clinical improvement in study in patients with crigler-najjar syndrome, biliary atresia using hhpscs infusion. in the present study we transplanted hepatic progenitors to five subjects of end stage liver cirrhosis with meld score > . hhpscs were sorted using macs with cd antibody microbeads and infused through hepatic artery via femoral artery catheterization, a safe procedure provided portal pressure to monitor cell infusion route in order to prevent vascular thrombosis. all the patients showed improvement clinical and functional biochemical parameters after first month of cell infusion. ascites was decreased and changed encephalopathy grade into normal level was observed. meld score system falling to normal level from > to < after infusion. the aga khan university patients. the apri of . in combination with a cut-off ha of ng/ml can best detect patients with moderate to severe fibrosis (stages - ). it has a ppv of . %. also, for patients without moderate to severe fibrosis, the test is hardly ever positive (specificity of . %). but the apri of . in combination with different ha as cut-off points is not possible to detect patients with no or mild fibrosis. objectives: terlipressin is used in esophageal variceal bleed (evb) along with endoscopic band ligation (ebl) for days (uc). due to its high cost, it was stopped < days (sc) who could not afford & were stable after achieving hemostasis with ebl. we retrospectively assessed the efficacy of sc vs uc of terlipressin for control of evb and length of stay. conclusion: the apri of . in combination with ha ng/ml as cut-off points to predict patients with moderate to severe fibrosis (stages - ) is an easy and accurate method. methods: patients with evb who had achieved hemostatsis with ebl from jan -dec were included. all were managed on standard protocol on hospital variceal bleeding pathway. the course of terlipressin as sc or uc was based on patient's inability to afford the cost of hospitalization and terlipressin. the efficacy of terlipressin in the control of evb was defined based on baveno iii criteria. results: total of patients were admitted during the study period. out of them, received uc & sc of terlipressin. the base line characteristics were comparable except younger age in sc. there were re-bleed ( %) in uc and ( %) in sc terlipressin group. the length of stay was shorter in sc group. ( . ± . vs . ± . days). conclusions: sc seems as effective as uc terlipressin in the control of evb after initial control of hemostatsis with ebl and may reduces the length of hospital stay. rcts are needed to assess this as all stable patients may not need to continue terlipressin for hours. background/aims: to analyze the relationship between conventional laboratory results and death risk in patients with esophageal varices bleeding due to cirrhosis (cevb), and establish a simple model for timely predicting death rsik of the patients. outcome of patients with gastro-oesophageal bleeding in a tertiary center j. wat, w.h. li, m.t. cheung methods: the medical documents of cevb patients were reviewed retrospectively and the data were collected. univariate and multivariate logistic regressions were performed, in which the discharged results (survival or death) as dependent variable and the results of liver function, kidney function, serum electrolytes and blood cell analysis as independent variables. the multivariate regression equation was as the model for the prediction of patient outcome and its predictive performance was evaluated. objectives: to determine the rebleeding rate, mortality and long term survival in cirrhotic patients presented with acute gastro-oesophageal variceal bleeding. method: this is a retrospective review of adult patients who were admitted to our hospital with the diagnosis of acute gastro-oesophageal variceal bleeding for the first time regardless of their underlying causes for cirrhosis. the study period was from january -october . data were collected from our hospital computer system and records. results: in univariate regression, the significant positive variables for death outcome were dbil, akp, k, wbc and plt, and the significant negative variables were tp, ap, a/g, na, cland ca + . the variables entered the multivariate regression are alt, tbil, dbil, gp, a/g, cr, na + , cl -, ca + , wbc, hb, plt. the sensitivity, specificity and accuracy of the regression model for predicting death of cevb patients were . %, . % and . %. results: a total of patients were included in this study, with male and female. their mean age was . . the initial failure rate in endoscopic haemostasis was . %. the -day and -week mortality rates were . % and . %, respectively. poor child's grading, multiple columns of oesophageal varices, high grade of varices, failed initial endoscopic haemostasis, presence of inoperable hcc, low platelet count on admission, and short duration from index bleed to rebleed were factors associating with increased risk of -week mortality (p < . ). mean duration from index bleed to first rebleed was . months. poor child's grading and presence of inoperable hcc were associated with both early or multiple rebleed (p < . ). overall, . % of our patients developed rebleed before their variceal eradication. -year survival in patients with child's a, b and c were %, %, and %, respectively (log rank test p . ). conclusions: the liver function, kidney function, serum electrolytes and blood cell analysis are generally independent factors for cevb patient death risk, especially dbil, a/g and ca + . the established model shows a excellent predictive performance. an imbalance in plasma amino acids of advaced cirrhotic patients impairs the maturation of dendritic cells via mtor/s k signaling pathway e. kakazu , y. ueno , y. kondo , k. fukushima , m. shina , j. inoue , k. tamai , m. ninomiya , t. shimosegawa division of gastroenterology, tohoku university hospital conclusion: although endoscopic haemostasis is an effective treatment modality; rebleeding is still commonly seen among patients with poor child's grading and inoperable hcc. this will result in significant bleeding-related death and poor overall survival. further advancement in treatment strategies for this group of patients are required to improve their outcome and prognosis. background: we have demonstrated that extracellular branched-chain amino acids (bcaas), especially valine, regulate the maturation and function of monocyte-derived dendritic cells (j immunol. : ) . however, it is not clear whether an imbalance in plasma amino acids of advaced cirrhotic patients influence the function of dendritic cells (dcs). methods: we used human pbmcs and cd c+dcs in this study. we made two mediums: a serum free culture medium consistent with the average concentration of the plasma amino acids from a healthy volunteer (n= ) was defined as the healthy control medium (hcm); whereas that from advanced cirrhotic patients (n= ) was defined as the advanced cirrhotic active hepatitis b replication is defined as hbeag + or hbv dna > fibrosis was scored according to the metavir system. alt levels were characterized as being normal, < x normal, and > x normal. conclusions: pe frequency of portal hypertensive gastropathy and its non-invasive predictors in patients with viral methods: medical record of all patients with cirrhosis due to hepatitis b and c who underwent for screening egd for varices in last years was reviewed. phg was defined endoscopically by using mccormack classification. noninvasive markers such as spleen/platelets ratio, meld score and child score of all the patients who underwent for egd were recorded. results: out of patients ( . %) were males. out of ( . %) patients who had phg, ( . %), ( %) and ( . %) had mild, intermediate and severe phg respectively. higher proportion of esophageal varices ( . %) was present among those who have phg (p< . ). ( . %) with phg has child score of . meld score > and were seen in . % and . % of patients with phg, respectively. platelet/spleen ratio was . ± in patients with phg as compared to methods: retrospective analysis of cirrhotics undergoing surveillance endoscopy was undertaken assessing for oesophageal varices. clinical, biochemical and radiological indices were analysed. results: cirrhotics underwent surveillance endoscopy during the study. childs pugh scoring (cps) to assess prognosis of liver disease showed cps a( %), cps b( %) and cps c( %). % were male albumin ( g/l vs g/l significant factors on multivariate analysis were albumin (p= . ) and platelet count (p= . ) conclusion: in our cohort there were significant biechemical and radiological differences in differentiating patients with large varices (grade - ) on surveillance endoscopy aims and objectives: to study the frequency of ev in patients with cirrhosis due to viral etiology and its correlation with different non-invasive markers. methods: medical record of all patients with cirrhosis due to hepatitis b and c who underwent screening egd for varices in last years was reviewed. ev were divided in two grades (small and large) as proposed in consensus development workshop. noninvasive markers such as spleen/platelets ratio, meld and child turcotte pugh (ctp) scores of all patients were recorded. results: out of patients, ( . %) were males on multivariate analysis ctp score of (or . , p< . ), meld score > (or . , p< . ) and platelet/spleen ratio (or . , p= . ) were found as significant predictors of large ev. conclusion: the frequency of ev is high in viral cirrhosis patients on screening egd. meld score> , ctp score and spleen/platelets ratio can be used as non-invasive predictors of large ev. pe treatment outcome and prognostic factors of spontaneous bacterial peritonitis and culture negative neutrocytic ascites in patients with hepatitis b virus-related thirty-seven ( . %) patients had sbp while ( . %) had cnna. except the higher proportion of renal failure at admission in patients with sbp than cnna ( . % vs. . %, p= . ), no significant difference in the clinical and laboratory data related to liver and renal function was observed. overall mortality during hospitalization was higher in patient with sbp than that of cnna evl was repeated every -weeks till varicial eradication.bb dose was titrated to achieve a resting heart-rate of bpm or a maximum dose mg/d or when side-effects began to appear.primary end-points were rebleed and death.secondary end-points were complications as a result of evlor beta-blocker,variceal recurrence afterevl,and decrease in variceal grade inbb limb. results: patients (median age [range - ] yrs, males %) were included (evl arm[n= ]and bb arm[n= ]. median grade of varices was iii(range ii to iv) nitric oxide synthase isoforms play distinct roles in the evolution of hyperdynamic state in endotoxemia induced portal hypertension m.r. rizvi , m. shahid institute of genomics and integrative biology, mall road, delhi , department of physiology a seconderc was performed after two or more years to assess the progression of the disease. results: ehpvo patients(median age [range - ]yr, males %) were studied.history of present or previous jaundice was present in %,ascites % and pain %. on erc, % had portal biliopathy.the type of bile duct involvement was categorized as: type b( %) and type ( %).the pattern of involvement included indentations( %) and dilatation and strictures( %). %of the patients had bile duct stone and % had history of cholangitis.the mdian bilirubin was . (range . - . ) mg/dl and median serum alkaline phosphatase (range - ) iu/l.all patients were treated endoscopically by endoscopic stone extraction, dilations with/without stenting. ( %) patients underwent second erc after a median interval of (range - )months.the type of involvement progressed, % patients developed type- involvement compared to % at the baseline (p=ns).indentations progressed to develop strictures, from % to %.the frequency of new bile duct stones per year was %(p= ns). conclusions: portal biliopathy is very common in ehpvo, often remaining asymptomatic.however,it is slowly progressive leading to development of biliary strictures objective: to investigate the mechanisms of angiotonin ii (angii)-induced ca ( +)-independent pathways mediated by rho kinase in hepatic stellate cells (hscs) various vasoactive drugs that reduce portal pressure are used in treatment of esophageal variceal bleeding alongwith endoscopic treatment. terlipressin use decreases both, recurrent bleeding and mortality. it is given usually for - days, nevertheless there is very little data comparing different time periods. our aim was to compare the efficacy and safety of -days versus days of terlipressin treatment in bleeding esophageal varices. methods: out of patients who presented with variceal bleeding, were randomized to receive terlipressin mg hrly, i.v. daily for first days and placebo for next days (group a) and to receive terlipressin mg hrly, i.v. daily for days (group b). both groups were both age and sex matched. (svt) {consisting of hvt and pvt}. there is no such data from india a comparative study of male vs background: mucosal lesions are frequently observed.gender differences are expected due to food habits, nature of job, mobility related to work, consumption of alcohol, tobacco etc. material and methods: procedure done in m & ( . %) f& duo ( . %) m & %)f.varices ( ) eso varices ( . %) m & ( . %) f & gastric varices (. %) m & (. %) f .growth ( )eso growth (. %) m & (. %) f & stomach growth ( . %)m & (. %) f & laryngeal (. %)m. eso monoliasis ( ) (. %) m & (. %) f.polyp ( ) eso polyp (. %) m & (. %) f & gastric polyp (. %)m & (. %) f & moniliasis and ulcers are more common in female lee department of internal medicine, gyeongsang national university school of medicine background/aims: although the pyogenic liver abscess is a common intraabdominal inflammatory disease, this complications are not rare. however, reports dealing with this complications are not good enough and results are often variable. the aim of this study was to identify the predictive factors of complication in the pyogenic liver abscess. pe effects of saikosaponinsd (ssd) on expression of c-myc and pcna in experimental hepatocarcinoma of all rats were killed in the th week, then general conditions of rats were recorded, the serum alt akp ggt afu was detected and pathological examination was made. the expression of pcna and c-myc were tested by immunohistochemistry. results: he staining showed that rats were induced to hepatocellular carcinoma,the results of liver function in the th week displayed that alt akp ggt and afu of all groups were increased than that of normal control group conclusion: ssd can inhibit development of hepatoma induced by den, possibly by down-regulating the expression of pcna and c-myc protein lethal endotoxic shock was induced by single endotoxin (e.coli) mg/kg injection into abdominal cavity. ppc in % gs was given via tail vein at ml/ g ( . mg/kg) h and h before endotoxin. rats' behavior and h survival were recorded, venous blood taken for ast and alt, liver preserved for he staining and liver/body weight ratio l/b and liver wet/dry weight ratio (w/d) calculated. intercellular adhesion molecule- (icam- ) expression in liver tissue was observed with -step immunohistochemistry assay. results: rats of ns and ppc group demonstrated similar normal activity, histology and other characters (p> . ), while lps group showed sag and less water-intak and severe inflammation in liver including inflammatory cell accumulation, parenchymal cells edema and tissue exudation. p+l group turned tired but could drink water the role of insulin resistance, adipokine and cytokine pro-inflammatory in non-alcoholic fatty liver disease n. ratnasari , , s. anam , p. bayupurnama , , s. maduseno , , s. nurdjanah , dr sardjito general hospital yogyakarta indonesia, background: non-alcoholic fatty liver disease (nafld) is a benign disease during - years period, with %- % survival. nafld can progress to fibrosis, cirrhotic and cancer of the liver. the etiopathogenesis of nafld is still unknown, however genetic and environment factors are predicted. objective: to know the role of insulin resistance, adipokine and cytokine pro-inflammatory on nafld. methods: the cross sectional study was performed on general check-up population at dr. sardjito general hospital yogyakarta, indonesia. the study was begun from january until november at internal medicine outpatient department. inclusion criteria: adult, alcohol consumtion g/day, metabolic syndrome patients, and healthy subjects. exclusion criteria: the diseases with increasing liver enzymes (hbv, hcv, ischemic hepatitis, congestive liver), a "bright liver" on ultrasound examination (malnutrition, rapid weight decreased, post gut surgery on obesity patients, and drug induced). based on liver ultrasound subjects were devided into steatosis group and non-steatosis group. data were analyzed by t-test and non-parametrical test. results: subjects that were enrolled the study steatosis ( . %) and non-steatosis ( . %) and the subjects who completed cytokine and adipokine examination were steatosis and non-steatosis. there were significantly different on homa -ir and adiponectin level in steatosis group (homa-ir . ± . vs. . ± . , p= . ; adiponectin . ± . vs. . ± . , p= . ). there were not significantly different on tnf-, il- , leptin and visfatin level (p> . ). conlusions: there were significantly different on homa-ir and adiponectin level in nafld patients compared non-nafld patients. background: to optimize management of nonalcoholic fatty liver disease (nafld), a simple screening tool is necessary. in this study, we aimed to devise a simple index that reflects the presence of nafld in the korean population. methods: a cross-sectional study was conducted on , health check-up subjects at a healthcare center ( , cases with nafld versus age-and sex-matched controls). study subjects were randomly assigned to a derivation cohort or a validation cohort. an index reflecting the presence of nafld was derived in the derivation cohort and validated in the validation cohort. results: multivariable analysis indicated that body-mass index (bmi), serum alanine aminotransferase (alt) to serum aspartate aminotransferase (ast) ratio, sex, and the presence of diabetes mellitus were independent predictors of nafld. using these variables, a formula was derived using a linear regression model: nafld index (nafldi) = ×alt/ast ratio +bmi (+ , if female; + , if diabetes mellitus).nafldi had an area under receiver-operating curve of . ( % confidence interval, . - . ). at a value < . , nafldi ruled out nafld with a sensitivity of . % and a negative likelihood ratio of . , and at a value > . , nafldi detected nafld with a specificity of . % and a positive likelihood ratio of . . in the validation cohort, the predictive power of nafldi was maintained at similar levels.aim: since nash could progress to liver cirrhosis and hepatocellular carcinoma, it is important to correctly diagnose between nash and simple steatosis (ss). the aim of this study was to determine the prevalence of nash among nafld patients and to clarify differences in clinical features between nash and ss. subjects and methods: thirty-one patients with nafld showing abnormalities in serum transaminase (ast and /or alt > iu/l) were enrolled (sex: male , female ; mean age: . yrs, mean body mass index: . ), after obtaining informed consent. differential diagnosis between nash and ss was performed histologically according to the matteoni classification and clinical features were compared. results: among the patients with nafld, % and % were diagnosed with ss and nash, respectively. no significant differences in the sex, mean age and bmi were seen between nash and ss groups. the levels of ast, alt, homeostasis model assessment-insulin resistance (homa-ir) and hyaluronic acid were significantly elevated in nash patients compared to ss patients. no significant differences in serum levels of adiponectin, as well as the rates of occurrence of diabetes, hypertension and hyperlipidemia were observed between the two groups. conclusion: the prevalence of nash in nafld patients was about %. nash patients showed higher levels of serum transaminase, homa-ir and hyaluronic acid, compared to ss patients. a large-scale biochemical study is required to accurately diagnose nash patients and confirm these results. conclusion: nafldi was a simple, efficient screening tool for nafld that could be utilized for selecting individuals for liver ultrasonography and for determining the need for lifestyle modifications.pe aim: this study was conducted to evaluate the hepatoprotective effects of the centella asiatica extract in -methyl- phenyl- , , , -tetrahydropyridine (mptp)-induced liver injury in rats. methods: sprague dawley rats were treated with alcohol extract of centella asiatica orally in two doses ( and mg/kg/day) for months along with intraperitoneal injection of mptp ( ml/kg). biochemical parameters such as serum total protein, albumin and marker enzymes were estimated. histopathological studies of liver were also carried out to confirm the biochemical changes.results & discussion: mptp -induced hepatotoxic effects were evident by a significant (p < . ) increase in the serum marker enzymes and a decrease in the total serum protein and albumin. administration of extract of centella asiatica effectively inhibited these changes in a dose-dependent manner; maximum effect was with mg/kg. histopathological examination of liver tissue corroborated well with the biochemical changes. hepatic steatosis, hydropic degeneration and necrosis were observed in mptp-treated group, while there was a significant reduction in these changes in the treatment group. conclusion: centella asiatica extract exhibited hepatoprotective action against mptp induced liver injury. further optimization of tuberculosis chemotherapy requires a comprehensive evaluation of the effects of antitubercular drugs on metabolic processes in organism.wistar albino male rats, body weight (b.w.) of - g, were divided into three groups: group i received pyrazinamide per os at a dose of mg/kg b.w./day, whereas group ii received a dose of mg/kg b.w./day, in both groups it was given for days; the control group was composed of intact animals. the contents of free amino acids were determined using an amino acid analyzer - (czech republic). the study of the effects of pyrazinamide administered in different doses on the liver contents of free amino acids showed the largest number of changes at a dose of mg/kg b.w./day. the content of free amino acids at the level of amino acids and total sum of amino acids significantly differed from controls. part of these changes could be regarded as compensatory answer of organism to this drug action. further pyrazinamide dose increasing caused exhaustion of liver adaptive possibilities. the study of the influence of pyrazinamide on liver contents of free amino acids allows to fully estimate the effects of this substance on metabolic processes in this organ. moreover, the effect of pyrazinamide on the majority of free amino acids in the liver is dose-dependent. background: taiwan is an endemic area of hbv and hcv infection, chemotherapy for lymphoma patients who has been hbv infection, may induce serious clinical sequela due to reactivation of hbv. this study want to clarify the difference of the chemotherapy induced hepatitis between hbv and hcv carrier in lymphoma patients. methods: from july, to july , non-hepatocellular carcinoma patients were enrolled, ( . %) cases were lymphoma, in these lymphoma patients, ( . %) cases have been hbv infected, and ( . %) cases have no hbv or hcv infected. ( . %) cases have been infected with hcv. all patients received chemotherapy with the regimen of chop or r-chop. liver function , viral markers, hbv dna, hcv rna were checked before and after chemotherapy. results: hepatitis happened in ( . %) lymphoma patients, ( . %) cases were in hbv infected patients, ( %) cases were in non-hbv infected patients, cases of hcv infected patients suffered from hepatitis. hbv infected hepatitis patients hbv dna elevated more than log as before chemotherapy. non of the hcv infected patient has elevated of hcv rna after chemotherapy. the mortality rate in hbv infected patient is %. no mortality in hcv infected patients after chemotherapy. conclusions: .high rate of hbv reactivation and mortality in chemotherapeutic lymphoma patients who has been hbv infected. screening of hbv viral markers among candidates for cancer chemotherapy is mandatory, especially in lymphoma patients. large number and prospect study for chemotherapy induced hepatitis in hcv carrier are needed. background: excessive drinking leads to social, psychological, physical and other problems. this study investigated the epidemiology of ald and analyses the associated risk factors. methods: from , residents , blood samples were collected. alcohol consumption and the impact of alcohol on liver function, blood lipids, blood pressure and bmi and mcv have been evaluated. results: the drinking rate and average daily alcohol intake was . % and . ± . g respectively. the total alcohol intake was . ± . kg and the average drinking age was . ± . years. the average -gt, ast, alt, mcv, chol, tg, ldl-c, hdl-c and bp increased gradually with increase in alcohol intake. the population ald prevalence was . %. the prevalence of ald among the drinking population and the alcoholic population was . % and . % respectively. conclusion: chol, -gt, ast, alt, and mcv were highly correlated with daily alcohol intake which closely related to the occurrence of ald. n. tanaka , w. okiyama , t. aoyama background: alcoholic liver disease (ald) is one of the leading causes of cirrhosis and yet efficient therapeutic strategies are lacking. polyenephosphatidylcholine (ppc), a major component of essential phospholipids, prevented alcoholic liver fibrosis in baboons. however, its precise mechanism remains uncertain. we examined the effects of ppc on ald using peroxisome proliferator-activated receptor (ppara)-null mice treated with an ethanol-containing diet, which showed pathological features similar to human ald. methods: male ppara-null mice were pair-fed a lieber-decarli control or % ethanol-containing diet with or without ppc at a clinically comparable dose ( mg/kg/day) for months. o. parkash , a. almas , s.h. ali shah , w. jafri , s. hamid , j. akhtar aga khan university hospital karachi .hdv-hbv co-infection presents mostly as moderate to advanced liver disease. background: liver injury due to dengue infection is not uncommon. acute liver injury is a severe complicating factor in dengue, predisposing to life-threatening hemorrhage, dic and encephalopathy. results: there were no significant differences of demographic features and laboratory parameters such as peak serum alt, total bilirubin and creatinine between groups. however, peak ast was higher in superinfected group than control group (median: , iu/l vs iu/l, p= . ,). additionally, the peak serum albumin levels, prothrombin time and platelet counts were lower in superinfected group than control group (median: . mg/dl vs . mg/dl, p= . , . % vs . %, p= . and x /mm vs x /mm , p< . , respectively). of superinfected group, patients were followed over months after resolution of aha. interestingly, serum hbv-dna levels decreased significantly over months following resolution of aha, then rebounded subsequently (median: - . , - . , - . , . and . log copies/ml at , , , and months, respectively).methods: the overlapping fragments of hev isolate swgx were amplified with reverse-transcription nested polymerase chain reaction (rt-npcr) and the ' and ' ends of viral genome were amplified with rapid amplification of cdna ends (race). the pcr products were cloned and sequenced. the phylogenetic analysis of swgx was performed.result: the genome of swgx consisted of , nucleotides, excluding the poly (a) tail of residues. the genome contained three open-reading frames (orfs), orf- encoding amino acids, orf- encoding amino acids and orf- encoding amino acids. the full-length genomic sequencing showed that swgx strain shared similarity with all known hev genotype , and isolates by . % to . %, and with an identity of . % to . % among genotype hev isolates, and a high nucleotide identity as % with chinese guangxi human strain lz- .conclusions: acute hav super-infection may suppress hbv-dna replication in chronic hbv carriers and chronic hepatitis b, although the suppressive effect did not seem to sustain longer than months. conclusion: the swine hev strain swgx was phylogenetically close to the human hev strain lz- , both from the same region in south china. therefore it was concluded that hev sub-genotype b might have existed in south china at least for years and now it was prevalent both in local human and swine, which also strongly supported the zoonosis hypothesis of hepatitis e. associated with splenic volume were damping index (r= . , p= . ) and blood flow of portal vein (r=- . , p= . ). conclusions: the splenomegaly in portal hypertension was more frequent in non-alcoholic groups, and associated with a damping index and a blood flow of portal vein. the measurement of blood flow of portal vein, damping index, and splenic volume by a doppler sonography can be helpful to predict the varices.z.q. zhang , j. cao , w. lu , l.g. shi objective: to appraise the clinical efficacy of simple non-invasive models of ast-to-alt ratio (aar), ast-to-platelet ratio index (apri), spleen-to-platelet ratio index (spri), age-platelet index (api), age-spleen-to-platelet ratio index (aspri) for predicting hepatitis b associated cirrhosis. methods: patients and patients were diagnosed pathologically as non-cirrhosis and cirrhosis, respectively. the simple non-invasive models were calculated as described originally. spss . was used for statistical analyses.background: to reveal the microrna (mirna) expression profile of the hepatic fibrosis inducing cells, rat hepatic stellate cells (hscs), during in vitro activation. results: the areas under roc curve of aar, apri, spri, api, aspri for predicting the cirrhosis were . , . , . , . , . , respectively which were larger than those under the diagnosis reference line (p . , . , . , . , . , respectively).methods: the hscs were isolated from male sd rats by in situ perfusion and density-gradient centrifugation. the quiescent and activated hscs, which were harvested at day and , respectively, were then subjected to immunocytochemical staining (desmin and -sma), oil red o staining and quantitative rt-pcr (desmin, -sma, albumin, cd , cd and cytokeratin- ). after extraction and labeling, the hy -labeled cellular rna samples and hy -labeled reference pool rna samples were mixed pair-wise and hybridized to the lna mercury microarray. differentially expressed mirnas were filtered and randomly verified by stem-loop rt followed by quantitative pcr.conclusion: all of the simple non-invasive models of aar, apri, spri, api, aspri can be used for predicting hepatitis b associated cirrhosis; and aar has the most practical efficacy for predicting hepatitis b associated cirrhosis. results: both the purity and the total activation of hscs were validated. global analysis of the mirna expression profile based on quiescent and activated hscs demonstrated differentially expressed mirnas. among these, mirnas were up-regulated more than -fold in activated hscs as compared to that in quiescent hscs, while mirnas were less than the threshold level ( . -fold) during the hsc activation. furthermore, the expression of mir- , b, , , and had been proved. background/aims: only limited patients with chronic hepatitis b virus (hbv) infection will develop liver cirrhosis, and no effective methods to precisely predict ones who will develop cirrhosis. we try to establish a model to predict the patients with the risk of cirrhosis development basing on a clinical epidemiological factor survey. z.q. zhang , w.y. bao , w. lu , l.g. shi methods: cirrhosis patients with hbv markers (case group) and asymptomatic hbsag carriers (control group) were recruited and inquired by researchers with a specific designed questionnaire including items. a multivariate logistic regression analysis were conducted to establish a predictive model, in which two third patients selected randomly as model sample and another / patients as validating sample, key factors screened out as variables. the predictive performance of the model was evaluated. objective: to explore the practical significance of the peripheral blood corpuscle counts for prediction of hepatitis b associated cirrhosis. methods: and male patients with chronic hepatitis b were pathologically diagnosed as non-cirrhosis and cirrhosis. peripheral blood corpuscle counts were measured by coulter ac•t diff hematology analyzer. results: red blood cell (rbc), platelet (plt), neutrophil (n) counts in cirrhosis were significantly lower than those in non-cirrhosis; and lymphocyte, mid-cell counts were similar to those in non-cirrhosis. the areas under the roc curves of rbc, plt, n counts for prediction of cirrhosis were . , . , . respectively; according the optimal cut-off determined by the roc curves, the sensitivity, specificity, positive predictive value, negative predictive value, accuracy of rbc, plt, n counts for prediction of cirrhosis were . - . method: pbmcs of active chb patients under pyg-interferon treatment were analyzed for their th , treg and pdc by flow cytometry. they were determined by cd /il- for th- , cd /cd /foxp for treg and cd /cd /cd -for pdc. pbmc were collected every weekly during the treatment until end of therapy (week ) and every weekly until the end of follow-up (week ). alt was quantified at every time of the pbmc collection. ifn-gamma release cells were analyzed by elispot to hbv-core and s ag.background: alpha fetoprotein (afp) is a well-recognized tumor marker for hcc; elevated level of afp is found in at least % of hcc. other liver diseases such as cirrhosis and chronic hepatitis are also related with an elevated level of afp. the regulation of afp gene expression has been relatively less studied although the gene has been suggested to play a role in hcc development. in this study, we tried to identify genetic variations in afp gene and analyze its effect on serum afp level and possible hcc progression.results: in parallel with decline in alt for the first weeks, we found decline in both pdc (r= . , p= . ) and elispot (r= . , p= . for hbv-core ag; r= . , p= . for hbv-s ag). although there is trend that th- decline with treg decline, but they are not statistically significant differences in the same period. there is no significant difference between the svp and non-svp patients.methods: direct dna sequencing was carried out to sequence afp promoter and bp upstream and downstream of afp coding regions in dna samples isolated from hcc subjects and controls respectively. for each samples serum afp levels were determined using commercially available elisa kits. conclusions: under pegyintron treatment, pdc, ifn-gamma change in the same trend of alt during weeks of treatment. it implied that pdc take regulatory effects on ifn-gamma releasing cells and be very tightly related to alt. there wasn't a significant difference in both treg and th- , which implies that treg and th might be of important cells in keeping the stability of the immune system.results: a total of snps were detected in the afp genomic region analyzed, including known snps and one novel snp. among the identified snps, the c>g nucleotide change in the position - bp upstream of afp transcriptional start site showed a significant association with hcc (p < . ) and a decrease in afp gene expression level. conclusion: our preliminary results indicated a possible association between serum afp expression and - g allele. the identified snp is located in afp promoter region with possible binding sites for known transcription factors, such as tfiid, coup, apf and nfiii. - °tail-suspension (ts) rats were used as the model to simulate the physiological effects of weightlessness. thirty-two wistar male rats were randomly divided into groups: control for d ( d con), d con, ts for d (ts d) and ts d. histopathological changes of testicle of the rat were observed by he stain. localization and expression of ar and hsp in testicle of rat were observed comparatively by means of immunohistochemistry, and the density of ar and hsp immunoreactivety in four groups were compared. results: signal molecules mrna level are shown in the table (** p< . , * p< . ). tnfa, il , il and il were higher in group , and than those in group . ifna was higher in group than that in other groups. there are no significant difference in infc, il , and il . there was a positive correlation between tnf and myd in group , tnf and nfkb in group and . results: obvious pathological lesions presented in testicle of ts d and ts d rat. germinal epithelium irregularity and malformed spermatozoa were found in seminiferous tubules. degeneration and necrosis of germinal epithelium appeared in testicle of ts d and ts d rat. ar immunoreactive cell density in the ts d and ts d groups were significantly decreased compared with the in-phase normal control groups ( p < . ). while hsp immunoreactive cell density in the ts d and ts d rats were significantly increased than those of control rats( p < . ), and in testicular interstice or extracellular there were very strong ehsp immunoreactive positive staining signals. the results indicate that ground simulated weightlessness induced by d- d tail-suspension in rats can lead to the serious injury , depressed expression of ar and enhanced expression of hsp in testicle. despite the absence of any serologic marker of hbv recurrence, however, it remains unknown whether there is occult reinfection in the liver graft. we aimed to detect and quantify the presence of intrahepatic hbv dna in the liver grafts of patients who remain seronegative for hbsag for more than year after liver transplantation. materials and methods: liver biopsy and blood samples were obtained from patients who had been receiving nucleoside analogue prophylaxis alone and remained persistently seronegative for hbsag for at least year (median . months, range . to . months) after liver transplantation for chronic hepatitis b. quantitative polymerase chain reaction was performed to detect and quantify total and covalently-closed circular (ccc) hbv dna in the liver (lowest detection limit, copies/ml), serum and pbmc. direct sequencing was used for hbv quasispecies screening. results: liver biopsy was performed and intrahepatic hbv dna as measured by quantitative real-time pcr was detectable in of recipients. donors anti-hbc status before liver transplant was significantly related to the presence of intrahepatic hbv dna in the recipient's study biopsy (p= . ). donor intrahepatic hbv cccdna levels correlated with recipient post-liver transplant intrahepatic hbv cccdna levels (p= . ). hepatitis b virus sequencing results and phylogenetic analysis revealed that hbv reinfection in two recipients were of donor origin, four recipients were of recipient origin and four recipients were of both donor and recipient origins. conclusions: our findings demonstrate the presence of occult hbv reinfection with persistence of hbv dna in liver allografts despite long term nucleoside analogue prophylaxis after liver transplantation, suggesting the need to continue indefinite antiviral therapy. the use of liver grafts from anti-hbc-positive donors might increase the risk of occult hbv reinfection. both donor and recipient hbv dna could contribute to occult hbv reinfection in liver transplant recipients. aim: to construct one noninvasive assessment model consisting of routine laboratory data to predict both significant fibrosis and cirrhosis among patients with chronic hepatitis b(chb). methods: we have retrospective analyzed consecutive patients with chronic hepatitis b who underwent percutaneous liver biopsy. we calculated sensitivity, specificity, positive predictive value(ppv), and negative predictive value(npv) of an apri . in combination with different hyaluronic acid(ha) cut-off points medium (acm). we stimulated pbmcs or dcs under hcm and acm, and evaluated the function. results: after adding the stimulants under hcm, the cd and cd expression of dcs from cirrhotic patients (lc) were lower than those from healthy contorols (hc). in both hc and lc, the cd and cd expression of dcs stimulated under acm was lower than that under hcm. the il- production in acm was lower than that in hcm. the expression of cd , which is related to amino acid transport, was not different between hcm and acm. however, dcs cultured in acm expressed lower levels of phospho-p s k than those cultured in hcm. finally, we ascertained that the ifn gamma production by pbmcs was significantly decreased under acm.conclusions: an imbalance in plasma amino acids of advanced cirrhotic patients suppresses the maturation of dcs via mtor/s k signaling pathway. key: cord- - sqbqjm authors: nan title: monday: posters date: - - journal: vox sang doi: . /j. - . . .x sha: doc_id: cord_uid: sqbqjm nan from the perspective of causal inference, there is a hierarchy of evidence, ranging from case-series to large randomized controlled trials (rcts). in addressing a particular clinical or policy problem, clinicians or policy-makers can base their decisions on the types of clinical reports that have been published, along with an assessment of the strengths and weaknesses of each study. rcts are controlled clinical experiments in which patients are randomly allocated by the investigators to receive a treatment under study. if randomization is used, all participants are equally likely to be allocated to either the treatment or the control arm of the study. rcts should be distinguished from observational studies in which investigators passively observe patients who happen to receive a treatment under study. because the allocation of subjects to the treatment and control arms of an rct is random, the play of chance should distribute all confounding factors equally between these two arms. thus, the treatment and control arms of an rct should be equivalent with respect to all confounding factors except for the treatment under study. randomization removes selection bias, because neither the investigator nor the participant knows what the treatment allocation will be before a patient enters a study. moreover, if an rct is double-blind, observation bias is also removed, because preconceived notions about benefit from the treatment cannot color the reporting of symptoms by a patient or the assessment of disease activity by an investigator. when the undertaking of rcts is deemed unlikely, meta-analyses of individual patient data, that is, of the data recorded previously on subjects enrolled in published, small rcts may allow investigators to address issues of possible biases ed- - standardizing blood components would allow better monitoring of the effectiveness of transfusion d davenport university of michigan, ann arbor, mi, usa in routine transfusion of red blood cells (rbc) or platelet concentrates (pc), we have only a very rough idea of the dose we administer. the minimum expected hemoglobin content of rbc should be g (fda criteria). however, actual measurements have found a mean hemoglobin content of . ± . g per unit, with variability between manufacturers. percent of units may contain less than . g of hemoglobin while percent may contain more than . g. the effect of storage senescence can magnify these differences. the resulting hematocrit increase, depending on size of recipient and age of a unit, may be . to percent. apheresis collection of rbc can help standardized unit contents, but this technology is relatively expensive and time consuming. knowledge of actual hemoglobin content can be used to optimize red cell transfusion. one trial, using a simple formula incorporating the desired hemoglobin and estimated blood volume, showed that nearly percent of transfusion orders could be met with one unit while achieving a mean target hemoglobin of . g/dl. for pc transfusion, about percent of transfusions achieve the targeted dose of - ¥ platelets in actual practice, with considerable variability between institutions. without knowledge of the actual content of pc, determination of refractoriness and response to matched pc is problematic. standardization and labeling of rbc and pc units for content will permit accurate dosage and quantification of transfusion practice. are transfusion guidelines evidence-based? jp aubuchon dartmouth-hitchcock medical center, lebanon, nh, usa application of the results of randomized, controlled clinical trials to similar clinical situations should increase the predictability of the outcomes of transfusions. unfortunately, too few such trials have been conducted to investigate all the potential situations where transfusion might be applied. however, the ones that have been reported indicate that, in general, transfusion is unlikely to provide substantial benefit in many of the situations where it is routinely used. in the intensive care setting, transfusing red cells at a trigger point of g/dl rather than g/dl not only did not lead to increased anemic morbidity but was actually associated with a reduction in overall mortality. subgroup analyses indicated transfusion at the higher trigger point did not decrease morbidity in patients with cardiac disease nor decrease the time until weaning from a ventilator. following cardiac surgery, a transfusion trigger of a hematocrit of % yielded the same outcomes as one of %. an observational study suggested that patients with peripheral vascular disease and a post-operative hematocrit below % were more likely to suffer a morbid cardiac event, but this group of patients had more evidence of anemia and cardiac ischemia preoperatively, illustrating the pitfalls of observational studies. most would agree that transfusion is necessary below a hb of g/dl and unlikely to be necessary at a hb above g/dl, but most patients fall between these limits, and there are insufficient data in the and residual confounding factors, and may permit them to make a judgment of a causal relationship. sackett proposed that the evidence generated from meta-analyses of individual patient data be regarded as being equivalent in strength to that generated from rcts. meta-analysis is the structured and systematic integration of information from different studies of a given problem. when the results of individual studies are discrepant, the purpose of an overview is to investigate reasons for disagreements among studies. when the results are concordant, the goal of meta-analysis is to derive, through application of a number of quantitative techniques, a measure of the effect of the intervention across combined investigations. this measure is referred to as the 'summary' effect of the treatment under study. meta-analysis differs from the traditional, narrative reviews of the literature, in that: ( ) all completed investigations of the efficacy of an intervention that meet specific, eligibility criteria are retrieved and included in the overview; ( ) the quality of retrieved studies is assessed systematically; ( ) the degree of agreement among studies is evaluated, both conceptually and based on statistical criteria, and the synthesis of the findings proceeds only if the variation in reported results is sufficiently modest to be attributed to chance; and ( ) quantitative methods are used to calculate the summary effect of the intervention and to test that effect for statistical significance. ed- - biology of stem cell mobilization th papayannopoulou university of washington, seattle, wa, usa at baseline hematopoiesis, the majority of developing hematopoietic cells (precursors, progenitors and stem cells) is actively retained in bone marrow (bm), whereas fully mature cells emigrate to peripheral circulation. a small number of stem/progenitor cells are also present in blood, serving presumed physiologic roles for the repopulation of remote damaged areas. however, in several hematopoietic perturbations, i.e. post irradiation, post chemotherapy or by using empiric treatments, a heightened emigration (mobilization) of progenitor/stem cells was noted over years ago. the introduction of g-csf as an efficient mobilizing agent not only had a major clinical impact, but has triggered a flurry of studies exploring the mechanisms of mobilization. from these studies, significant insight has been gained about the molecular pathways leading to mobilization, especially by studying the altered environment within bm post mobilization, and less so by studying cells mobilized in blood. several attractive scenarios have been proposed and their importance was further bolstered by studying genetic mouse models. a prominent role of the sdf- /cxcr pathway has been emphasized, either by down regulation of cxcr , changes in sdf- gradients, or by disruption of sdf- /cxcr signaling. whether this pathway is disrupted by a proteolytic mechanism prevailing within bm post g-csf or by other protease-independent mechanisms has not yet been settled. in addition to sdf- /cxcr , disruption of other pathways responsible for the retention of primitive cells in bm can lead to mobilization. for example, disengagement of the vla /vcam- pathway by anti-functional antibodies or its genetic deficiency in mice results in egress of stem/progenitor cells. mobilization is also seen following the use of other cytokines (i.e. kit-l, flt- l, il- ) or chemokines (i.e. il- , gro?), complement activation, etc., but the detailed mechanisms or the interdependence of these other pathways with the ones already proposed have not been worked out. finally, efforts to improve mobilization efficiency in man has led to the use of combination treatments with g-csf, either by adding another cytokine (i.e. growth hormone), agonistic sdf- molecules (i.e. ctce ), or cxcr antagonists (i.e. amd ) which have yielded synergistic increments, and these will be discussed. a full understanding of the principles of mobilization, as well as the bm homing characteristics of mobilized cells after their i.v. infusion in transplantation, should lead to targeted, more efficient experimental protocols in the future. the possibility of deriving all kinds of mature cell types from embryonic stem (es) cells for the purpose of cell replacement therapies will probably face a major obstacle; a limited supply of available hla types for an ever growing population in demand. one possible solution is to use adult sources of stem cells such as the haematopoietic stem cells (hsc) that can repopulate the entire haematopoietic system after transplantation in a myeloablated host. however cells with the repopulating ability of hscs are still elusive for tissues such as muscle, heart, cns and pancreas. it was therefore exciting news when it was shown that hscs could repopulate other non-haematopoietic tissues arguing for a general role of bmderived cells in tissue regeneration. the term plasticity was thus coined to describe the phenomenon whereby cells of one lineage could trans-differentiate into cells of another tissue. this in turn implied that a certain degree of developmental plasticity was still available in the adult hsc, or their derived progeny, that allowed them to present with novel phenotypes. how exactly this was accomplished was a matter of speculation. in order to address the mechanism we used an animal model of liver failure where bmt with normal (wild type, wt) hsc was shown to rescue the liver failure; the repopulating hepatocytes apparently differentiated from the sole source of wt cells, the bm compartment. by studying the genetic composition of the regenerating liver nodules we observed that both wt and mutant dna was present in the nodules, a finding that was consistent with bm-derived cells fusing with host hepatocytes. the mechanism of plasticity was therefore directly related to the exposure of the donor bm-derived wt nucleus to the transcriptional environment of the hepatocyte and the expression of hepatocyte-specific genes. this fusion mechanism was also shown to underlie perceived cases of haematopoietic cell transdifferentiation to purkinje cells in the cerebellum and to cardiomyocytes. however, there are carefully executed studies that strongly support the alternative transdifferentiation mechanism in tissues such as epithelia or the epidermis. what these observations may imply is that in tissues with high rates of cell turnover, there may be a potent stem cell niche that can reprogram incoming cells to follow relevant cell lineages. if this hypothesis is correct, then the major research effort should focus on what makes the niche and whether it can be recreated faithfully in vitro so as to educate hscs to diverse lineages opening the way for realistic cell replacement therapies. collection and distribution of blood and its products to meet the medical needs of industrialized countries are typically managed through large-scale national or nationally-supported blood programs. the development, maintenance, and ultimate success of such programs are all components of a process that involves the delicate balance of continuously competing pressures, e.g. social, economic, ethical, political, regulatory/legislative. as with all endeavors that directly affect human life, safety is a central, unifying theme of this process. because transactions of blood inherently involve risks at both donation and reception/transfusion ends, efforts to enhance and maintain an acceptable level of safety generally rely on a focused program of risk management (rm). rm involves three equally important elements: identification/evaluation of risk factors in a process, control of exposure to them, and continuous monitoring to assess the effectiveness of countermeasures and the emergence of new risk factors. specific approaches to rm and quality assurance in transfusion medicine will be presented. examples from blood programs currently in effect in selected countries will be discussed. rm efforts within the corresponding blood program in greece will then be examined. the lack of data to adequately assess the status of this program suggests that at least one of the elements of rm -monitoring -can still be improved. a preliminary research effort aims to survey blood donors, transfusion recipients, and physicians in order to build an understanding of the specific factors that drive the perception of risk in the greek population. the findings form important stepping points upon which specific recommendations can be made for the development and maintenance of a comprehensive, effective rm program in greece. ed- - the use of haemovigilance data to increase safety in transfusion medicine haemovigilance is a surveillance of all the procedures in the transfusion chain. the intension is to collect and assess information on unexpected or undesirable effects in bleeding of donors and transfusion of blood components. in europe haemovigilance was introduced as a concept in the middle of the nineties. the first national reports on haemovigilance appeared in the late nineties, and were only dealing with complications related to transfusion. later on other kind of events like 'near miss' events were added. nowadays national reports are dealing with all steps in the transfusion line, and to some extend also with complications in blood donors. the state of the art is haemovigilance with retrospective registration of unwanted events that has happened, but also a more active prospective part with an early warning in a rapid alert system about new threats in the transfusion world. the aim of the different national haemovigilance systems has been to improve safety in the transfusion line. after the first years with haemovigilance in the european countries, what has been the outcome of this big effort? data from national reports do not signify major improvements, but safety is suggested to have improved due to many minor changes of procedures and awareness of dangerous situations. however, in most countries nothing really effective has been done to avoid failures, the most important cause of serious complications in transfusion of patients. systems which can prevent most of the failures are on the market. the cost of these equals the cost of nat screening for virus introduced in the same period of time. the common perception of transfusion risks is still much more focused on the hypothetical risk of virus transmission than to the demonstrated magnitude of severe complications related to bleeding of donors and transfusion of patients. therefore, to increase safety in transfusion medicine the nature and occurrence of the risks should be revealed by haemovigilance and not less important the results should be published with the aim to get a realistic common perception of the transfusion risks. the role of diagnostic testing to identify congenital vs acquired disorders of hemostasis and to optimize the management of perioperative bleeding g despotis washington university school of medicine, st louis, mo, usa excessive bleeding with trauma or after surgery can result in hypoperfusion and anemia related end-organ dysfunction and mortality as well as transfusion-related complications. several large studies have demonstrated that if bleeding is excessive after cardiac surgery to the point that reexploration is required, that overall mortality increases by - fold. transfusion related complications include the following potentially lethal complications: disease transmission of pathogens, acute hemolytic reactions, allergic reactions, transfusion associated acute lung injury, allo-immunization related disease (e.g. post-transfusion purpura, platelet refractoriness, transfusion-associated graft-vs-host disease) and other potential complications (e.g. increased perioperative infection or multi-organ system failure) related to transfusion associated immune modulation. in addition, blood shortages related to increasing consumption (i.e. expanding geriatric population) and/or a shrinking supply (i.e. related to exclusion of donors related to donor exclusion criteria designed to prevent disease transmission) may limit our ability to adequately manage our anemic and bleeding patients. this highlights the relative importance of accurate diagnosis and optimal management of excessive bleeding to minimize bleeding related complications and conserve our blood supply. patients at risk for excessive bleeding include those with an established hereditary disorder (e.g. vwd, hemophilia, connective tissue disorders), end-stage hepatic or renal disease as well as patients with acquired defects of the hemostatic system. in specific, patients with platelet (i.e. platelet refractoriness) or coagulation factor inhibitors at increased risk, extracorporeal circulation related defects or as related to certain pharmacologic agents). patients who require longer periods of extracorporeal circulation for cardiac surgical procedures (e.g. repeat, combined procedures or use of deep hypothermic circulatory arrest) are at a greater risk of developing excessive bleeding (e.g. cpb-related abnormalities). in addition, patients receiving one or more longacting anti-thrombotic medications in the immediate preoperative period (e.g. plavix, reopro, low molecular weight heparin etc) are at increased risk for bleeding. clinicians in the past have resorted to empiric and 'shot gun' approaches when managing excessive bleeding due lack of immediate availability of results from laboratory-based coagulation tests. on this basis, the use of point-of-care (poc) tests of hemostatic function to facilitate the optimal management of excessive bleeding, help differentiate between microvascular vs surgical bleeding and reduce transfusion have been investigated. five of six recently published studies have demonstrated that implementation of a standardized approach to manage bleeding (e.g. algorithm) which when coupled with either point-ofcare or laboratory tests of hemostatic function can optimize the management of bleeding and reduce total donor exposures by %. ddavp has bee shown to be beneficial with uremia-induced platelet dysfunction and with type i von willbrand's disease. although previous studies have not been able to conclusively show that ddavp can reduce bleeding and transfusion when administered prophylactically, more recent evidence indicates that this agent may be useful in preventing excessive bleeding when a test (point-of-care) reveals platelet dysfunction. recombinant activated factor vii (rfviia) is licensed for use in bleeding episodes in hemophiliac patients with inhibitors. although, only anecdotal reports and results from small clinical studies have shown that this agent can reverse life-threatening bleeding after major surgery, other reports indicate that there is variability in the effectiveness of rfviia as well as highlight lifethreatening thrombotic complications in a subset of high risk patients (i.e. patients with congenital or acquired thrombotic disorders or systemic activation of the hemostatic system such as with dic or after cardiac surgery). therefore, large clinical trials evaluating the efficacy and safety of rfviia are needed before any widespread use can be recommended. in recent years, molecular methods of blood grouping have become routine diagnostic procedures in many laboratories throughout the world. they have proved especially valuable for the determination of fetal blood groups. the ability to detect rhd in pregnancies where the fetus is at risk from haemolytic disease of the newborn represents a significant advance in obstetric care. furthermore, the occurrence of fetal dna in the mothers' peripheral blood has allowed this diagnostic procedure to be carried out without the risks that accompany amniocentesis (lo ymd. ( ) ann med : - ). determination of the coding sequence of all the genes giving rise to antigens within the blood group systems currently recognised is virtually complete. by correlating the coding sequence of these genes with the phenotype of red cells from individuals with different blood groups it has been possible to infer the molecular bases of most of the antigens comprising each blood group system (daniels gl ( ) human blood groups, nd ed. blackwell science). the polymorphic antigens of most systems other than abo and rh, are defined by single nucleotide substitutions (snps) which effect a single amino acid sequence change in the gene product. numerous methods, both manual and automated, are available to determine snps and these have been applied to the determination of blood groups. useful applications of snps detection methods include, determination of the blood group phenotype of patients who have been transfused recently and still have donor blood in their circulation (rozman p, dove t, gassner c et al. ( ) transfusion : - ), and donor screening to find compatible units for patients with multiple blood group antibodies or for the management of patients with diseases like the haemoglobinopathies who are going to be transfusion-dependent over many years (castilho l, rios m, bianco c et al. ( ) transfusion : - ). other applications of molecular methods include zygosity determination for rhd, determination of the blood group phenotype of patients with a positive direct antiglobulin test, selection of donors with rare blood group phenotypes, and as aids to the solution of complex blood grouping problems in the reference laboratory. the molecular bases of abo and rh antigens are complex and cannot be determined reliably by a single snp. nevertheless, methodologies are available that allow the comprehensive sequence analysis of individual genes and could be applied to abo and rh typing. whether or not this will ever be a cost-effective procedure is a moot point. it is clear that molecular methods are a useful addition to the range of diagnostic procedures available to transfusion medicine practitioners but it is important to remember that methods based on dna analysis determine phenotype by inference and not by direct measurement. the results of molecular tests should be interpreted with this caveat in mind. ed- - the hla system g stavropoulos general hospital 'g. gennimatas', athens, greece since its discovery in the mouse in the major histocompatibility complex (mhc) has become one of the most important region in the vertebrate genome with respect to infection, autoimmunity and transplantation. mhc primary function is to provide protection against pathogens. this is achieved through sophisticated pathways in which mhc class i molecules present endogenous antiges to cd + t cells and class ii molecules present exogenous antigens to cd + t cells. an increasing number of other proteins are being found that support these two pathways; many of these proteins, together with the class iii complement proteins, also map to the mhc. the mhc molecules were originally studied for their ability to cxonfer tolerance (histocompatibility) following tissue grafts or later, organ transplants. nowadays, the success of unrelated hematopoetic cell transplantation is influenced by the degree of mhc compatibility between the donor and patient. thus, for patients who lack matched donors, the rules that govern permissibility of mhc mismatching still need to be identified. for patients with high risk disease who lack matched donors, use of donors with a single mhc mismatch may permit early treatment before disease progression. scientific evidence to fully answer the questions 'when are platelet components clinically effective' and 'what do we really know?' is limited. despite this limitation and the level of uncertainty it generates with regard to treatment options and policies, it is reassuring to note that current prophylactic platelet transfusion protocols -mostly derived from empirical observations collected during the 's and 's -protect oncology patients from clinically relevant bleeding in more than % of thrombocytopenic days spent in hospital or at home, even in aggressive conditions such as leukemia, lymphoma and other severe blood diseases. this evidence seems to justify the prevalent policy of transfusing platelets when the patient's platelet count falls below per microliter (or in 'unstable' patients). this policy is based on positive outcomes of prospective and retrospective studies performed during the 's including some hundred non-surgical patients and on the desire of balancing the will of reducing patient exposure to limited, expensive, potentially infectious and immunogenic blood products with the objective of preventing clinically relevant hemorrhage. several national and international organizations endorse the above policy. although the role of platelet support in surgery or in specific clinical situations requiring invasive procedures or in patients affected by multi-organ and system co-morbidity suffers from even more limited evidence, the latter has been carefully collected and summarized in the guidelines for platelet transfusion published in j clin oncol ; : - . additional data on lumbar puncture are reported in ann hematol ; : - . another important topic where there is room for improvement and need for further investigation is platelet refractoriness, a condition developed by a proportion of chronic platelet recipients, which causes high hemorrhage risk if compatible platelets are not provided and in which consensus on the diagnosis and treatment is lacking. with regard to the type of platelet product, it will be necessary to determine the clinical impact of buffy-coat derived platelets, consistently used in europe and current object of increased interest in canada, as compared to the platelet-rich plasma method traditionally used in the us, of viral inactivation procedures and of laboratory methods for detection of bacterial contamination of platelet concentrates. in addition, ongoing studies on the clinical impact of high versus low platelet doses will provide novel elements to determine the relative merits of apheresis versus whole-blood derived platelets. as far as the established procedure of white cell reduction by filtration, which shows high technical efficiency and has been implemented as a standard by a number of institutions, debate is still ongoing on its equivalence with serologic screening for the prevention of cmv transmission, whereas general consensus supports its pre-storage use to prevent febrile, non hemolytic transfusion reactions. finally, although the high cost of filters do not allow a generalized use of this technology in many settings, white cell reduced platelets have been unequivocally shown to reduce alloimmune refractoriness from about % to about % of patients. ed- - ffp: appraisal of the evidence for the clinical use of ffp although the indications for transfusion of plasma (fresh frozen plasma; ffp) are limited, the use of ffp continues to rise in the united kingdom and has risen by over % in the past few years. local uk audits continue to document that a significant proportion of ffp transfusions are not consistent with indications reported in guidelines. a systematic review of the evidence base for the effectiveness of ffp was therefore undertaken to identify, select and appraise all relevant randomised controlled trials, as the most robust form of study to assess effectiveness of ffp. in the systematic review of ffp, the criteria for inclusion of full-published studies were: there must have been at least two groups in the study; • allocation to the groups must have been either by formal randomisation or by a quasi random method e.g. alternation; • one of the arms of trial must include ffp or plasma as an intervention; results on the relevant clinical or laboratory outcome must be presented. the main analysis was qualitative, and differentiated between: . studies of interventions comparing ffp with no ffp; . studies of interventions comparing ffp with a non-blood product e.g. solutions of colloids and/or crystalloids; . studies of interventions comparing ffp with a different blood product; . studies comparing different formulations of ffp, e.g. solvent detergent and methodine blue treated. an evaluation of studies comparing ffp with no ffp would be expected to provide the clearest direct evidence for a positive effect of ffp. studies comparing ffp with colloids or crystalloids were separately appraised because these latter products may have variable effects on coagulation tests. studies comparing different formulations of ffp do not directly evaluate effectiveness of ffp but were included because there is now a uk national policy to use these products in younger patients and therefore these trials might identify negative outcomes. the search strategy identified a total publications. although it may appear that this number of randomised trials might provide a reasonable evidence base to help inform clinical policy and decision making, the review identified a number of important concerns about the published trials. few of the identified studies included details of the study methodology (method of randomisation, blinding of patients and study personnel). the sample size of many included studies was very small (range - patients per arm). few studies took adequate account of the extent to which adverse events might negate the clinical benefits of treatment with ffp. many of the identified trials in groups such as cardiac, neonatal, and other clinical conditions, evaluated a prophylactic transfusion strategy. however, when these trials evaluating prophylactic usage were assessed together as a single grouping in the review, it appeared there was no consistent support for a beneficial effect of prophylactic ffp, irrespective of clinical setting. there is a pressing need to develop new trials to determine the effectiveness of ffp, including for those clinical situations in which it has become an accepted part of current transfusion practice. a law decided upon by the riksdag (the swedish parliament) often sets the general standards as a framework and authorises the central government authority concerned to elaborate and decide upon the more detailed regulations. laws and regulations define the level of quality and safety that has to be reached and state what must be done, while establishments and their managers are kept responsible for fulfilling the requirements and how this is done. guidelines (non-binding) present detailed instructions on ways how to fulfil the requirements. making a law is complicated and time-consuming. the ministry draws up a legislative proposal, refers the proposal to relevant bodies for consideration and comments, and then drafts a bill which is referred to the council on legislation for consideration before it is submitted to the riksdag. a parliamentary committee deals with the bill before it is put to the chamber of the riksdag for approval. when adopted, the bill becomes law. regulations elaborated by central government authorities are handled in a principally similar way. however, regulations are more readily adjusted to scientific and technical progress, and when legislation need requirements for technical details, these are preferably presented in a regulation. the ministry of health and social affairs is responsible for elaborating the bill to be submitted to the riksdag on the blood safety law. two central government authorities, designated as competent authorities, are responsible for preparing the appropriate complimentary regulations as well as for inspecting and licensing the blood establishments: • the national board of health and welfare (nbhw), responsible for requirements related to blood components intended for transfusion, and • the medical product agency (mpa), responsible for requirements related to blood components intended for the manufacture of medicinal products. sweden became a member of the eu ten years ago. since then, experts in transfusion medicine have been appointed by the ministry, nbhw and mpa for advice on scientific and technical issues and for representing sweden at expert meetings arranged by the commission. some of these experts are also members of the handbook committee of the national society for transfusion medicine, preparing and revising the national guidelines. consequently, the requirements of the directives are readily implemented in the daily work of the blood establishments before (due to legal and technical reasons) the new blood safety law and the revised nbhw and mpa regulations can be promulgated. to a great extent, requirements of the blood directives are covered by existing swedish legislation. no major problems or obstacles seem to arise when implementing new requirements into law and regulations and into the blood establishments' daily service. a few detailed requirements have been found difficult to follow precisely in the routine work. these minor difficulties, however, will not compromise the high quality and safety of blood components prepared according to the standards set by the blood directives. the landscape for blood collection and distribution includes availability and safety. true international availability of blood has not been reached. the landscape of safety has been mountainous, if viewed by the degree of frustration among the transfusion specialists. the reasons for frustration have varied from serological problems to those of transmissible infections, to which no end is in sight. mistrust in the safety of blood taken by others is one reason for lack of international landscape in blood collection and distribution. increasing demands on safety, availability and economy force the health care providers to reorganise blood services. national systems are winning ground. this may make it easier to achieve international collaboration. the council of europe has pioneered in creation of international recommendations for blood collection and distribution. in a european agreement on the exchange of therapeutic substances of human origin, including human blood, was published. its purpose was to make blood available to other parties of the agreement in case of urgent need. many countries ratified the agreement rapidly, some did it first in the nineties. in practice little exchange of blood components has taken place. the council of europe recommendations lack legal power. the european union is different, and it has taken on its agenda activities aiming at improving confidence in the safety of the blood transfusion chain in the community (commission communication ) . the agenda is based on an agreement reached at a high level eu meeting in adare, ireland in . first in the commission agenda was a recommendation on donor selection criteria, given in . then came the european blood directive / /ec, the aim of which is to improve the safety of blood and blood components within the union so that enough mutual trust between member countries can be achieved to make the exchange of blood components possible. being a legally binding document the directive is undoubtedly helpful in reaching a harmonised standard in europe. hopefully the european commission has the resources to follow its implementation. there are concerns, however. the epidemiological differences among the eu member countries and frequent appearance of new infectious agents potentially transmitted by blood make it difficult to foresee that even effective viral inactivation of blood components could totally erase the national differences in donor approval. blood collection and preparation of components are already the same in eu member countries and the directive helps in their further standardisation. there has not been much distribution of blood components internationally, with the exception of export of red cell concentrates to the us from switzerland and the netherlands. the european legislation opens new horizons and widens the european landscape as its purpose is to simplify the crossing of borders between the member states, but before true movement of blood components is achieved more work is needed on the eu commission blood agenda. the eu directive implemented into the legal act for polish blood transfusion service blood transfusion service (bts) in poland is an integral part of the public polish health service. in the country of nearly million people, approximately one million units of blood and plasma are collected every year from voluntary, nonremunarated donors, which is statistically over donations per inhabitants. blood and plasma are collected in strictly appointed centers and no private collection sites are permitted. the legal basis for the activity of polish bts is polish blood transfusion act of nd august which came into force as of january st . this act was then updated in november according to eu directive / /ec and came into force as of january th . this act introduced the principles for organization, collection, processing, storage, transport and quality assurance in bts. it specified -among others -the system of accreditation, haemovigilence, as well as requirements for bts employees. according to this act the polish bts is obliged to monitor and supervise immunohematology testing and transfusion procedures in all hospitals where blood and blood products are transfused. polish bts consists of regional blood transfusion centers (rbtc), one military center and one ministry of internal affairs and administration center as well as the institute of hematology and blood transfusion (ihbt) which acts as supervisor. the rbtcs have a uniform organization structure, uniform quality assurance system and act according to uniform guidelines issued by ihbt. they have two financing sources -the central budget and hospital reimbursement for distributed blood and blood products. the polish blood transfusion act of nd august , in force since january st , has been supplemented by decrees: . procedures for external bts audits; . requirements for donor selection; . requirements and procedures for organization and safe management of blood transfusion in hospitals; . requirements for implementing of national and regional donor registers; . employment criteria for bts personnel; . training requirements for hospital personnel involved in blood and blood product administration; . national, uniform price list for blood and blood products; . organization requirements for setting up of a national committee for blood and blood transfusion. introduction: several technical aspects must be considered in pediatric apheresis due to the size of the patient. factors that must be evaluated are extracorporeal circuit volume, blood flow rates, type of anticoagulant and vascular access. adverse events are mainly related either to vascular access or to metabolic or hemodynamic changes. aim of the study: in this study we show our experience using fresenius hemocare com.tec for pbsc collection in children. methods: twelve pediatric patients (median age years, range - ; median weight kg, range . - . kg) with solid tumors at onset or on relapse underwent collections with the p y kit of the fresenius hemocare com.tec blood cell separator. our cd + cells target was ¥ e /kg. collections were started if a peak of at least . e /l cd + cells ( per microlitre) were reached in the peripheral blood. in all the patients, leukapheresis were performed through a central venous catheter and temporary peripheral venous access. acd ratio : - : was combined with heparin u/kg. in children with < kg the separator was initialized with a compatible filtered and irradiated red blood cell unit, suspended in % albumin, up to the patient's hematocrit, to avoid transient hypovolemia, due to the volume sequestered in the separator. results: twenty-five procedures were performed. a median blood volume of ml (range . - . ml) was processed in a separation time of min (range - min). the median product weight was g (range - g) and yield of cd + cells was . ¥ e /kg body weight (range . - . ¥ e /kg body weight). three poor mobilizing patients (peripheral blood cd + peak of - cells per microlitre) underwent more than two apheresis to collect the desired transplantation dose ( . and ). all collection procedures were well tolerated. children never required sedation to perform the leukapheresis. only mild hypocalcemia-related symptoms, promptly responding to small i.v. boluses of calcium gluconate, were reported. no circulatory side effects were observed. blood flow alarms occurred in every procedures but no collection had to be terminated due to insufficient flow. conclusion: in summary, leukapheresis in children can be safely and effectively performed with the fresenius hemocare com.tec separator with minimal technical difficulties even in patients under kg. m-pa- alternative methods for prevention of infection transmission (pathogen inactivation etc.), cost-benefit considerations of the procedure itself. however, one must also take the loss of plasma into consideration -and more difficult: calculate the effects of changes in product quality, as reduced content of factor viii, protein s and other labile proteins. for methods involving pooling, there are also concerns about the risks due to the pool sizes. the major benefit of the methods will be the potential reduction of infectious transmission, but also possible advantages as reduction of allergic transfusion reactions and trali must be evaluated. the study types involved in cost-benefit considerations are costeffectiveness analysis where the cost and effects of an intervention and an alternative are presented in a ratio of incremental cost to incremental effect and cost-utility analysis, where quality-adjusted life years (qaly) are used as the effectiveness endpoint. qualityadjusted life years is a method that assigns a preference weight to each health state and estimates life-expectancy as the sum of these products of each preference weight and time spent for each state. a complete glossary of terms is found at http://www.hsph.harvard.edu/cearegistry. in literature, there are several publications on cost-benefit considerations within the field of transfusion medicine. concerning plasma products, the costeffectiveness of solvent-detergent plasma has been the major focus. however, the conclusions of different authors have been conflicting. in , aubuchon and birkmeyer published a paper (jama ; ( ) : - ) where they concluded that the cost was usd per qaly, which is far above the 'acceptable limit' of usd . this estimate was adjusted to usd . mill. per qaly in a letter to jama (jackson, jama ). in , riedler et al. published (vox sang : - ) that the discounted cost/life year saved for sd-ffp use in the uk was gbp for neonates and gbp for patients aged . the main reason for the differences between the two papers (and others) was considered to be different calculation of non-infectious complications. the papers cited above underline the difficulties of the cost-benefit considerations. the age of the patient, the outcome of the treatment, the quality of life in an infected patient and the cost of side effects will differ. in addition, how much are we willing to pay for protection against emerging viruses? this paper will not provide the answers, but introduction: the photodynamic treatment of therapeutic plasma using methylene blue (mb) in combination with visible light is a well established procedure for the inactivation of blood borne viruses. aim of the study: evaluation of the quality and stability of mb/light-treated plasma (mb plasma) prepared under worst case conditions for routine processing. methods: single donor units (n = ) were treated using the macopharma theraflex mb-plasma system which includes plasma membrane filtration (plas ) and addition of mb prior to illumination followed by mb and photoproduct filtration (blueflex). samples were taken before treatment and from the final product. additionally mb-treated plasma was prepared from four different plasma pools and stored for up to months. treatment was done under worst case conditions for the preservation of coagulation factors: maximum mb concentration during illumination ( . mmol/l), maximum storage time of whole blood before separation ( °c, h), maximum storage time of mb plasma before freezing ( h). several plasma parameters and the concentration of mb and its photoproducts (azure a, azure b, azure c and thionine) were determined. results: mb/light treatment had a significant influence on thrombin time (+ . %), fibrinogen (clauss) (- . %), factor v (- . %), factor viii (- . %), factor xi (- . %) and protein c (- . %). no significant changes were detected for at iii, vwf : rco, vwf cleaving protease, plasmin inhibitor and alpha- -antitrypsin. the entire virus inactivation procedure including the filtration steps for leukocyte depletion and mb and photoproduct depletion had no significant effect on activation markers (prothrombin fragment + , thrombin-antithrombin-complex, d-dimers). no further essential loss of coagulation factor activity was observed during storage of the plasma at °c for months. mb and its photoproducts (azure a, azure b, azure c) were depleted to a final concentration of < . mmol/l. thionine was undetectable in all samples. conclusion: photodynamic treatment of fresh frozen plasma (ffp) using the theraflex mb-plasma system leads to only moderate decreases in the activities of different coagulation factors even under worst case conditions for routine production. mb and its photoproducts were effectively removed from the plasma by the blue-flex-filter integrated in the theraflex-system. the quality of mb plasma is well preserved during storage. pulmonary complications, particularly transfusion-related acute lung injury and circulatory overload, are the most common causes of transfusion-associated morbidity and mortality in the developed world. trali is a syndrome characterized by acute respiratory distress, hypoxemia, hypotension and pulmonary edema, occurring within hours (usually - hours) of transfusion of a plasmacontaining blood product. other signs, including hypertension, leucopenia and hypocomplementemia, are less frequent. all blood products, except for albumin and solvent/detergent plasma, have been associated with trali, but red blood cells, platelets and ffp are the most common. the incidence is unknown, but : plasma-containing transfusions is the most commonly cited figure. in % of patients, recovery is well underway within hours, and leads to complete resolution. death occurs in - %. the profile of the at-risk recipient has not been identified. recurrent cases have been infrequently described. there are two prevailing theories of pathogenesis: ( ) antibody-mediated and ( ) -hit hypothesis. evidence supports both concepts and neither is mutually exclusive. more than % of reported cases are associated with blood components containing either hla-specific (class i or ii) or hnaspecific antibodies. in % these antibodies correspond to at least one epitope in the recipient. most implicated components are donated by multiparous women. five percent of patients have hla or hna antibodies in their pre-transfusion serum. treatment requires prompt, assertive respiratory intervention, frequently necessitating mechanical ventilation. because trali has a much better prognosis than ards, it is an important diagnosis. some blood collectors are diverting plasma from multiparous donors away from ffp production or routinely screening for hla antibodies. the most effective method for identifying 'high risk' components has not been identified. introduction: trali is a life threatening adverse reaction of blood transfusion. it is characterized by noncardiogenic pulmonary edema developed soon after blood transfusion. in japan, we built hemovigilance system in and have been collecting the voluntary reports of severe adverse reactions of blood transfusion including trali cases since . since the diagnostic criteria of trali have not been established until recently and no specific diagnostic markers for trali have been discovered so far, it is very difficult to make proper diagnosis of trali in each reported case. we have been collecting the cases with respiratory distress and pulmonary edema developed after blood transfusion as suspected case of trali. we reevaluated each report whether it meet the recommended diagnostic criteria for trali published in transfusion journal in dec. . aim of the study: purpose of this study is to select trali cases which met internationally recognized criteria so that it will reveal the possible causes of trali with laboratory testing for anti-leukocyte antibodies in donors and recipients. methods: the cases with respiratory failure and pulmonary edema are selected for evaluation from the adverse reaction case reports voluntarily reported to japanese red cross. in order to make a proper diagnosis of trali, we have been utilizing the respiratory distress questionnaire which has recently revised. this helps us eliminate other adverse reactions such as circulatory overload, cardiac failure, anaphylaxis and bacterial contamination, which results in selecting out the internationally recognized trali cases properly. for laboratory testing, flowpra and labscreen for hla antibodies and gift-fcm for hna antibodies are performed. the cross-matching test is also performed if possible. results: during past years, cases of trali and cases of possible trali have been confirmed by critical review of each questionnaire. of cases of definite trali, donor specimens were obtained in cases. of cases, anti-leukocyte antibodies were detected in cases ( %) of donors' blood, which was significantly higher than the positive rate of anti-leukocyte antibodies in donors' blood of other adverse transfusion reactions (< %). of cases of antibody positive donors, anti hla antibodies were detected in cases, anti hna antibodies were detected in cases, and both were detected in cases. of cases of positive anti hla antibodies, class i antibodies were detected in cases, class ii antibodies were detected in cases, and both were detected in cases. on the other hand, the anti-leukocyte antibodies were detected in % of trali recipients, and this rate is almost the same with that of positive rate of other adverse reactions of blood transfusion ( %). these results indicate anti-leukocyte antibodies in the blood donors are one of the prerequisites for developing trali from the antibody-hypothesis-oriented point of view. other cases with no detectable antibodies should be investigated in more detail in the future. thus, reevaluating trali cases based on recommended trali criteria will allow us to reveal new information about trali. of adverse events analysed by the serious hazards of transfusion (shot) scheme ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , ( %) were haemolytic transfusion reactions (htrs). were due to incorrect blood component transfused (ibct): / were abo incompatible and / caused by other red cell antibodies. a further cases were reported as acute htrs (ahtrs; i.e. occurring within hours of transfusion) whilst were recognised more than hours after transfusion and reported as delayed htrs (dhtr). / ( %) patients died and suffered major morbidity. htrs associated with ibct result from clinical or laboratory errors and are all preventable. it has been assumed that other htrs are unavoidable. closer scrutiny reveals that this may not always be the case, though review is hampered by incomplete investigations. / ahtrs occurred in group a ( / ) or group b ( / ) patients given group o platelets. of the ahtrs related to red cell transfusion, were due to errors, were in patients with auto-antibodies, in only of whom alloantibodies had been adequately excluded/identified. at least / dhtrs were potentially avoidable; in cases the antibody was detectable retrospectively in the pre-transfusion sample; in cases the presence of a previous antibody was not communicated to the laboratory. two patient deaths related to dhtr might have been avoided by earlier diagnosis and clinical involvement. % htrs reported to shot would have been avoided by compliance with pretransfusion testing guidelines and provision of group a platelets for all group a recipients. htrs can be clinically overlooked and inadequately investigated. national guidelines are needed for the investigation and management of htr, with focus on the identification of underlying causes to guide the choice of future component therapy. reference laboratories can provide valuable support in elucidating complex serological problems. patients treated with high dose chemotherapy and autologous blood progenitor cell (bpc) support may get malignant cells reinfused together with stem cells. we analyzed bpc products collected from patients suffering from germ cell cancer measuring malignant contamination and followed these patients for up to months after transplantation also with the question if transplanted malignant cells influence survival. aliquots of stem cell apheresis products containing one million mononuclear cells were sedimented on glass slides and by immunocytochemistry quantitation of cytokeratin expressing cells was performed manually with light microscopy and by automated image analysis. in of patients ( %) cytokeratin expressing cells were detected in bpc apheresis products of patients treated for germ cell cancer. we followed the activity of the malignant disease of patients for more than eight years in median months after transplantation. no significant difference in survival was demonstrated for our two patient groups. background: the use of adequate number of peripheral blood stem cells (pbsc), collected by mnc apheresis is essential for effective treatment of hematological malignancies, solid tumors, and other disorders by transplantation. aims: the goals of this study were: (a) to obtain an effective apheretic protocol for mnc harvesting, and (b) to compare the hematopoietic reconstitution after hspc transplantations in different clinical settings. methods: in this study, pbsc transplantations - allogeneic from matched sibling healthy donors and autologous -were performed in the management of patients with severe aplastic anemia, leukemias (all, anll, cml), multiple myeloma, hodgkin's and non-hodgkin's lymphoma, breast and ovarial cancer, and extragonadal non-seminal germ cell tumor. pbsc mobilization was achieved with rhg-csf ( - g/kgbm/day). mnc-apheresis procedures (generally one and occasionally two) were performed using blood cell separator cobe-spectra. the first mnc-apheresis was accomplished when the leukocyte cont was - ¥ e /l (autologous setting) or on the th day - hour after the last rhg-csf administration (allogeneic setting). the processed blood volume during one mnc-apheresis was . - . l, and . l for one pbsc transplantation in average. results: using a minimal target dose of cd + cell count ( ¥ e /kgbm), performing one mnc-apheresis procedure for % recipients sufficient number of pbscs were obtained. the mnc yield was . ¥ e /kgbm in allogeneic and . ¥ e /kgbm in autologous setting in average. the mean cd + yields for allogeneic and autologous transplantations were . ¥ e /kgbm and . ¥ e /kgbm, respectively. hematopoietic reconstitution was achieved on the . th day for leukocytes and the . th day for platelets when pbsc transplantation was applied. summary/conclusion: improved mnc and cd + cell yield, as well as rapid hematopoietic reconstitution were observed when: (a) the intention of auditing any clinical practice is, ostensibly, to improve patient care. the term 'audit' implies comparison against a standard. although absolute indications for transfusion have not been defined by clinical trials applicable to most clinical situations, many institutions have established their own transfusion triggers based on their reading of the literature and common practice at that hospital. assuming these represent prudent guidelines, comparison of actual practice to them may allow physicians to re-assess their pattern of hemotherapy and bring it into conformance with the guideline. there are several common ways of performing transfusion audits. retrospective analysis of transfusions allows appreciation of the clinical situation (and its ultimate outcome) but reviews the event through a 'retrospectoscope' that assesses clinical information in a different manner than that available to the clinician making the decision to transfuse. furthermore, the time lapse between the decision to transfusion and feedback about that decision may render the feedback from the reviewing body (e.g., a transfusion committee or blood utilization review committee) of little practical import. to speed the provision of feedback and emphasize educational rather than any punitive outcomes of the audit, some facilities have abolished attempts at determining whether the decision to transfuse was supportable and have used electronic means to feed back to clinicians a non-judgmental informational message summarizing the literature regarding the indications for transfusion. this appears to be at least as effective as the traditional retrospective audit system. prospective review of requests for blood components have the potential to redirect practice in a manner that immediately helps patients. however, such interactions with clinicians may come at inopportune times, may require considerable (unscheduled) time, and are most likely to be fruitful if a knowledgeable transfusion medicine expert can serve as the intermediary. both approaches (or a combination) have been shown to be beneficial in altering practice, but efforts must be diligent and sustained. providing data comparing a physician's practice to colleagues in the same specialty may prompt additional introspection and practice change, particularly if physician leadership of the institution supports the effort as a quality improvement tool. extending the comparison to a group of physicians and contrasting their transfusion habits with benchmark data from other institutions may also be helpful, but one needs to be ready to counter arguments that differences in patient groups are the reason for the differences in practice (studies have shown that, in general, practice patterns are primarily related to training and habit rather than large differences in patient acuity). increased focus on the performance of hospitals as expressed in outcome data may soon extend to transfusion practices as well. the public or governmental institutions may ask to see data illustrating the transfusion practice of an institution and its improvement over time. carefully conducted, diligent, and ongoing transfusion audits are an integral part of an institution's quality improvement program. informed consent: the term informed consent, appeared for the first time in the late s but it was only in the s that it attracted attention with regard to health care. numerous discussions and publications have attempted to define the meaning and the justification of informed consent in recent years. initially it consisted in the obligation of the physician to disclose information to the patient, regarding the procedure he was to undergo, but more recently, ethicists have emphasized the need to ensure the patient's understanding and his autonomous decision to consent. current institutional rules of ethics demand that the physician must obtain the informed consent of a patient 'prior to any substantial intervention' . what is however the meaning of informed consent? is it a mutual decision making between physician and patient? in 'principles of biomedical ethics' beauchamp and childress claim that' it is critically important to distinguish informational exchanges through which patients elect medical interventions, from acts of approving and authorizing those interventions. the elements of consent include: disclosure, voluntariness, decision and authorization. when applying the concept of informed consent in transfusion medicine one can distinguish it into donors' and patients' consent. donor informed consent: information to blood donors constitutes a sensitive issue. it refers to their protection from side-effects of the donation, as well as to protection of the recipient. with regard to whole blood donors a detailed history and information as to side effects are necessary for first-time donors. for repeat donors one needs mainly an updated history. because of time-pressure, whole blood donors are usually given written information and are asked to answer written questions. donors however differ in literacy and even literate ones do not always understand medical terminilogy; so, during the interview one should probe the degree of understanding of each donor. with first time apheresis donors more time is needed in order to explain the procedure and potential side effects. since granulocyte and stem-cell donors require premedication with growth factors and or corticosteroids, the responsibility for detailed information is even greater. the fact that all donors sign the informed consent does not mean that they are all adequately informed! interviewers must be familiar with side effects, their frequency and sequelae and must pass on this information. misses and near-misses, (serious) adverse events and failures in medical practice seem to be not preventable. in medical interventions, preparing and prescribing of medication, assistance by doctors and nurses, medical treatment and follow-up, unwanted and unexpected events occur (http://www.mederrors.com.). these events happen also in transfusion medicine and focus on safety is not unique. haemovigilance which is defined in the eu blood directive as 'a set of organised surveillance procedures relating to serious adverse or unexpected events or reactions in donors or recipients, and the epidemiological follow-up of donors' (eu directive / /ec off. j. european union. . . :l / -l / ) is established to help in trying to identify and minimise the misses and (serious) adverse events in the chain from donor to recipient of blood components. the causes or reasons should be studied in order to prevent re-occurrence. adverse event reporting in blood transfusion and transfusion medicine is complex. it depends on the cooperation between blood establishments with clinicians and hospitals. it implies knowledge of blood banking, transfusion medicine and routine clinical care of all gender and ages, of potential hazards of transfusion, of immune-haematology, of microbiology, and of epidemiology. an adverse event may have its cause in every single part of the blood chain and reference may take place to a proven problem, a potential problem, or to a justified doubt. in almost all blood transfusion centres, a single donation will be processed into a number of different products, and these units might be divided or processed into more products. blood components are produced from whole blood or apheresis donations, and depending of the blood drawing and processing techniques, a high number of products with different specifications is prepared. the products' shelf life is not equal and therefore the moment in time of actual use of each unit prepared from the same donation may differ. in case the unit of platelets harms the recipient, a rapid alert can warn in order not to issue or to transfuse the unit of red cells or the unit of ffp prepared from the same donation because of the potential adverse reaction, which was detected during or after the transfusion of the first unit used. haemovigilance is not only important to blood establishments and to patients and prescribers, but it is also to clinical scientists, and to the public at large. it should provide a basis for minimising adverse reactions on blood components, and it should enable the therapeutic potential of new or established treatments with components to be maximised, since demonstrations of safety during widespread use may lead to extended usage, and wider availability. it is quite worrisome that underreporting is a general problem in medical care. it might be expected that in transfusion medicine the same rates of underreporting can be found, but also that the same mechanisms for improvement are applicable. although medical misses occur and do not seem to be preventable, the handling of these misses is often quite poor. many patients like to hear a detailed explanation, and the majority expects even apologies from the treating physician. it seems desirable to look for new routes in the prevention of unwanted events of transfusion medicine. for problem solving, analysis and improvement of working methods, where needed and possible, are often the most effective methods. attention should be focused on improvement and not on identification of the person who caused the problem ('bad apple'). lack of communication and insufficient insight in each other work are often the causes of problems and unwanted events. it should be recognised that advices given by the haemovigilance officer or the blood transfusion committee about prevention without the input and commitment of the direct responsible persons will lead in most cases to advices which are not effective or which will not be accepted. setting up a haemovigilance system or appointing of haemovigilance officers or installation of blood transfusion committees will not be sufficient. it will be necessary to develop ways of registration, data collection and analysis, but more importantly to support by giving advice and training to prevent reoccurrence of the adverse events or not optimal use of blood components. the confidentiality of the information should be guarded sufficiently. for a physician-patient relation, even after a medical failure, a 'blame-free culture' with a central role for openness and transparency is necessary. for blood establishments and hospitals, there is an important role in the right assistance and help of the physicians concerned both on a practical and on an emotional way. m-pa- years of shot data - : a view of transfusion safety in the uk and reactions. this will require investment in infrastructure, for which there must be a trade-off in improved transfusion safety. transfusion-transmitted infections and serious immunological reactions are rare; shot has highlighted the need for blood services to implement strategies to minimise bacterial contamination and transfusion related acute lung injury and will monitor their effectiveness. from the inception of shot it has been clear that the most frequent transfusion hazard is 'incorrect blood component transfused' i.e. a patient receiving a blood component intended for another person or not meeting appropriate requirements. only a minority of these events results in patient harm and is reportable under the terms of the directive. haemovigilance schemes such as shot, that analyse no-harm errors and near-misses, can reveal clues as to the root causes of 'wrong blood', which contributed to deaths and cases of major morbidity in the uk between and . analysis of such events shows that most errors occur in clinical areas, the most frequent being failure of the 'bedside check' . clinical audit data indicates that % of patients are transfused without a wristband or other form of identification, whilst anecdotal reports suggest that urgent clinical situations, massive transfusions and nocturnal transfusions are particularly error-prone. strategies aimed at reducing errors include structured education and competency testing, and methodologies, both high and low-tech, to ensure accurate patient identification in all circumstances. onethird of errors occurs in hospital laboratories; denominator data on laboratory workload shows that work done outside of 'core hours' accounts for % of all pre-transfusion testing but % of errors, suggesting that biomedical scientists 'on-call' or on shift work are working under pressure and beyond their competency. % of hospitals reported that they participated in shot in , but only % of eligible hospitals reported adverse events suggesting that transfusion hazards remain under-recognised and under-reported. however, benchmarking of 'wrong blood' incidents against transfusion activity shows that the number of observed incidents is roughly proportional to blood use. if haemovigilance data is to contribute to improved transfusion safety, clinicians must be encour-aged to report all events, thus contributing to an evidence base that can be used to effect change and facilitate learning. barriers to reporting include cumbersome systems, lack of time and resource, lack of feedback and fear of blame. transfusion practitioners have a vital role in the recognition and reporting of adverse events, education and clinical audit, but must be adequately resourced and supported by senior clinicians and managers through an active hospital transfusion committee. *provisional. m-pa- passing the borders: when, how and where d pirc-tiljak croatian institute of transfusion med., zagreb, croatia there may come that moment in professional life when you have to follow a strong professional and ethical need and confront your evidence-based statements with the leadership, passing the border of your own small society. in order to protect patient's health and respect human right to be informed about all possible consequences of irregular medical therapy, insisting on professional dignity and truth, you feel responsible and follow-up processing of your serious error report. once you pass the border, trying to warn authorities and find ethical resonance and critical confirmation of your professional fears, you are 'persona non grata' . methods/results: reality checking, personal experiences and observations studying the path of serious error report. although the qc system functions, yet omissions happen . . . the possible reasons could be: lack of knowledge, lack of experience, lack of independency, personal confront of interest, immature leadership, political influence, even corruption . . . how strict do the authorities manage a fault, bearing in mind the responsibility toward the patients under the risk. there is a need to create an available, effective international expert's board which will react and give professional counselling support-asylum for endangered professionals who found enough power to blow the whistle. who will hear it? transfusion transmitted infections (tti) are a major source of concern given the repercussions of hiv, hepatitis c, bacteria and vcjd transmission by blood components. large amounts of resource have been expended in making products safer and in maintaining public confidence in the blood supply. identifying emerging infections of concern is a major activity for many transfusion services. of the long list of emerging infections identified by disease control agencies around the world, identifying those responsible for tti requires, amongst other things, that: • the agent is identifiable. • it is present in blood • it causes a disease of concern. • it is transmitted by transfusion. • it is present at relatively low frequency. • if a test is available (nat, serology or immunoassay) what the infection window period is. once an agent has been identified various approaches are possible, including: • donor selection by testing, geography or lifestyle e.g. wnv; • product selection e.g. erythrovirus (b ) antibody or bacterial testing; • product treatment e.g. pathogen inactivation; • patient selection e.g. cmv matching, immune status. against this background where should our attentions focus? some agents of initial concern are now known to be ubiquitous and have minimal disease association (ttv, gbv) although transmitted by transfusion. for others (coronavirus -sars or the possible kawasaki disease agent, dengue, flavivirus encephalopathies, avian flu, etc.) this is less certain, with agents arising from species crossover being of particular concern (avian flu, vcjd, hiv). • enhancement of automation/computerisation; • process control to provide an 'error-free pathway'; • (national) surveillance and trend analysis of results, preferably based on national working standards; • significantly increased sensitivity, especially from development of antigen/antibody 'combi' assays (e.g. for hiv, and recently, for hcv); • awareness of hbsag vaccine-escape mutants and design of assays to cope with this; • extension of range of agents and markers tested for (varies in different countries); • increasing range of assays available for testing donors with a relevant history of exposure to malaria or chagas' disease infection (for retrieval of otherwise wasted blood); • european union's in vitro diagnostics directive: this has caused some problems and reduced flexibility. nucleic acid testing (nat): nat continues to increase in blood service usage world wide, although not (as yet) to replace serological methods. trends include: • reduction in sample pool size; • increased automation (and process control); • increased multiplexing to detect or more agents in the same assay; • increased number of agents being tested by nat (varies in different countries); • introduction of rapid and flexible nat to detect west nile virus, in north america. bacterial screening of platelet preparations: several countries have introduced (or will introduce) routine screening of platelet concentrates either with biomerieux, bactalert or pall ebds ( depletion assessment). other bacterial testing methods are under active assessment, some rapid enough for possible 'point of use' testing. m-pa- evaluation of in vivo red blood cell recovery after processing with a new filter designed to reduce prions e nelson*, h taylor † , p whitley † and t lieu* *pall medical, covina, ca, † american red cross and evms, norfolk, va, usa background: a filter, called the leukotrap affinity prion reduction filter (prf b filter, pall medical), has been developed to reduce the level of infectious prions, associated with several fatal neurodegenerative diseases including variant creuztfeldt-jakob disease (vcjd), from leukocyte-reduced red cell products. aim: the objective of this study was to evaluate the quality of leukocyte-reduced red cells (lr-rbc) processed through this filter and stored for days. red cell quality was determined by measuring the in vivo red blood cell recovery hours after re-infusion of the -day stored red cells. storage hemolysis and atp were also determined. methods: units of blood ( ml) were collected from normal volunteers into the leukotrap wb system containing cp d/as- anticoagulant/preservative solutions (pall medical). units were either processed to lr-rbc within hours at room temperature (rt units), or after hours at - °c (cold units). the prion filter set was sterilely connected to the units on day , and the units were filtered and stored for days. samples were taken pre-and post-prion filtration and post-storage for plasma hemoglobin and atp determinations. post-storage samples were taken for labeling with -cr radioisotope, re-infusion, and determination of the -hour in vivo rbc recovery. a donor sample was also labeled with m-tc to allow for red cell mass determination. thus, both single-and double-label -hour recovery values were calculated. results: twelve units were collected. in vitro testing was completed on all units. in vivo testing was completed on units. the mean single-label -hour recoveries were . % and . % for the rt and cold units, respectively. the mean double-label recoveries were . % and . % for the rt and cold units, respectively. the overall combined mean in vivo and in vitro results are shown in the table. conclusion: the -hour in vivo red cell recovery means are well above the fda and council of europe's requirement of achieving a mean post-transfusion survival of no less than % of the transfused red cells, and they are comparable to this center's previous results of red cells filtered using the licensed leukotrap rc system with cp d/as- (pall medical introduction: to reduce the risk of platelet transfusion-associated sepsis (tas), methods to routinely screen for bacterial contamination have been implemented. pathogen inactivation treatment of labile blood components provides an alternative means to prevent tas. the intercept blood system for platelets (baxter healthcare) has received the ce mark and has been introduced into clinical practice. aims: this study compared the efficacy of bacterial screening using a culture method (bact/alert system, biomerieux) with pathogen inactivation (intercept blood system) for prevention of transfusion of platelet components contaminated with bacteria. methods: seven strains of bacteria associated with tas, including gram-positive staphylococcus epidermidis, streptococcus agalactiae, and staphylococcus aureus, gram-negative escherichia coli, and klebsiella pneumoniae, and the anaerobes propionibacterium acnes and clostridium perfringens were studied. for each strain, three double-dose platelet concentrates (~ ¥ e platelets in ml of % plasma and % intersol) were collected using the amicus® cell separator. on day of collection, calibrated stocks of bacteria ( , , cfu) were added to the double units. each double unit was divided into two identical products containing , , or cfu of bacteria and stored overnight under conventional blood bank conditions. the control platelet concentrate was not treated. the test platelet concentrate was treated with the intercept process ( mm amotosalen + j/sq cm uva). both units were cultured using the bact/alert system at the time of bacterial inoculation and on days , and of storage. samples ( ml) were taken for both the aerobic and anaerobic cultures. a platelet sample was considered contaminated with bacteria if a positive signal was registered within hours of culture. results: for control platelet concentrates, cultures failed to detect low-dose inocula. the time to positive culture varied with the bacterial strain, contamination level, and time of sampling. at and cfu per product, strains (s. epidermidis, e. coli, c. perfringens, s. agalactiae) and strains (e. coli, c. perfringens) tested negative after days of platelet storage, respectively. k. pneumoniae tested positive after - hours of culture when sampled on day of platelet storage for both and cfu per product. at cfu per product, p. acnes tested negative in aerobic culture and c perfringens tested negative in anaerobic culture after days of platelet storage. the anaerobic cultures of p. acnes became positive after hours of culture when sampled on day of platelet storage. of the strains studied, only s. aureus consistently tested positive after - hours of culture. in contrast, all test platelet concentrates treated with intercept remained negative by bact/alert cultures throughout the entire -day observation period regardless of the strain and the contamination level. conclusions: bacterial detection using cultures may fail to detect low levels of bacteria typically associated with platelet contamination at time of collection and processing. failure to detect bacteria will result in the release of contaminated platelet products with 'test negative-to-date' status. in contrast, inactivation of bacteria is capable of preventing release of contaminated platelet components. background: since nat implementation for hiv- and hcv rna in france, the residual risk (rr) of transfusion-transmitted infections (tti) has dramatically decreased. the rr estimates, for a threeyear period from to showed a significant decrease from / and / before nat implementation to / and / after nat implementation for hiv and hcv respectively. as for hbv, the serological screening is only based on both hbsag and anti-hbc assays. for the same period, the rr estimate for hbv is / , five times higher than hiv one and times higher than hcv one. aims: as the overall rr of tti is mainly related to hbv, and given the availability of hbv nat assays, a study was conducted to determine whether hbv nat has the ability to further reduce the hbv rr and then should be implemented in blood donor screening in france. we have estimated the wp reduction by nat in comparison with one of the most sensitive hbsag screening assays, on commercial seroconversion panels (bioclinical partners, franklin, ma, usa). the nat test was the procleix ultrio assay (genprobe/chiron, san diego, usa). the hbs ag test was the prism hbsag (abbott, france). the comparison was performed on both neat samples and diluted samples / , / , and / , in order to simulate minipools of different sizes. then, we have calculated the yield of hbv-infected donations detected by nat relative to prism hbsag assay. results: on the basis of a window period (wp) of days, ultrio assay is projected to close the wp by an average of days on undiluted samples, days in minipools of samples, days in minipools of samples and only days in minipools of samples. the projected yield calculated on the basis of . million donations collected per year in france, would be . unit per year for minipool-nat and to units per year for individual donation nat. conclusion: introduction of minipool-nat will offer only a little added benefit to transfusion safety relative to current serological screening strategies based on both hbsag and anti-hbc assays. hbv minipool-nat is then unsuitable for hbv screening in french blood donors. single-sample nat or minipool-nat with smaller pool sizes and/or modified procedures (genome enrichment or test improvement) would be more relevant. automation when technologically and practically feasible is a prerequisite for single-donation nat. therefore, decision has been made not to implement hbv nat in the french transfusion network until fully automated systems will be available. however, as the prevalence of hbv infections is higher in the overseas territories than in continental france, and as nat is performed on individual donations in these sites, hbv-nat has been implemented since december in these territories. combined detection of hepatitis c virus core antigen and antibody as an alternative to nucleic acid testing in blood screening grating the capillary cytometer with a robotic workstation and a small footprint centrifuge. significantly, there was no decrement in system performance following automation: of clinical samples ( . %) typed identically with this system and cat, and of the discrepant results were eventually resolved in favor of the automated cytometry method. testing showed high-throughput capabilities (currently samples/day) and was inexpensive. to demonstrate the flexibility of this testing platform, we also developed a method to perform completely automated counting of residual wbcs (rwbc) following leukoreduction of blood components. there were no significant differences in accuracy and precision when rwbc in analytical controls and authentic clinical samples were quantitated by the automated capillary cytometry method or the leucocount method performed manually. given the flexibility of this system, it is very likely that additional blood bank assays could be modified for high performance automated testing on this platform. noninvasive prenatal genotyping on cell free fetal dna in maternal plasma ce van der schoot sanquin research, amsterdam, netherlands in lo et al. demonstrated that in the maternal circulation small amounts of cell free fetal dna are present, concentrations ranging from on average genome equivalents(geq)/ml early in pregnancy to about geq/ml at the end of pregnancy. most likely this dna is derived fom apoptotic syncitiorophoblasts. the human placenta is hemichorial, which means that the syncitiotrophoblast is in direct contact with the maternal blood flow, and apoptotic nuclei are directly released into the maternal circulation. the cell free dna is very rapidly cleared from the circulation, the t / being only minutes. in we have shown that this cell free fetal dna could be used for rhd genotyping. in the last years many groups have shown the successful application of different prenatal genotyping assays such as fetal sexing, thalassemia, achondroplasia, duchenne's disease, adrenogenital syndrome etc. on this source of dna. importantly, no false positive result have been described due to the presence of fetal dna from previous pregnancies, the main draw back of prenatal diagnostics on circulating fetal cells. at present prenatal rhd genotyping has been introduced in routine diagnostics in the united kingdom, france and the netherlands. in large scale high throughput studies it has been shown that the diagnostic accuracy of prenatal rhd genotyping is over %, and it is to be expected that in the netherlands this screening will soon be introduced to restrict the antenatal anti-d immunoprophylaxis to women carrying rhd-positive fetuses. in a large european project (safe, co-ordinator maj hulten, warwick uk) many researchers collaborate to further explore the possibilities of cell free fetal dna for future diagnostics. standard operating procedures for the isolation of plasma dna have been established. control pcrs for the presence of fetal dna have been developed. recent findings on differences in methylation status of placental genes in fetal dna opens new possibilities. the main technical problem that hampers wide application of prenatal genotyping is the impurity of the fetal dna, only - % of the cell free dna in plasma is from fetal origin. this makes diagnostic assays on numerical chromosomal abnormalities impossible. and also for many single nucleotide polymorphisms (snps) such as almost all blood group antigens, assays are hampered by aspecific amplification from maternal dna. our own preliminary results indicate that this latter problem can be solved by pna clamping. the addition of a pna probe specific for the k-allele partial d feature d antigen alteration, often identified as distinct 'partial' d epitope loss. the clinical impact of partial ds is due to the ability of their carriers to form anti-d antibodies upon confrontation with regular d after transfusion, or pregnancy. this leads to the -naively spoken -contradictory finding of an allo anti-d antibody in a d positive individual in connection with a negative autocontrol. the antibodies themselves include the same fatal clinical potential as anti-d antibodies of d negative individuals, but may be even more hazardous since unexpected in d positive individuals a priori. d categories (ii to vii) represent a nomenclatorily defined subgroup of partial ds. the molecular cause of partial d lies within single (caused by point mutation in the respective rhd gene sequence), or multiple amino acid exchanges (caused by gene conversion events leading to rhd-rhce-rhd hybrid genes) which determines a qualitative d antigen alteration, rendering them distinguishable from regular d by a partial d carriers immune system. nowadays, transfusion specialists and gynaecologists are more or less aware of these facts and are taking them into consideration in the clinical setting. most partial d exhibit decreased d antigen density, enabling principal recognition of them. however, routine serological methods may not properly recognise all partial ds and will identify their carriers after immunisation only, which represents a reactive diagnostic/therapeutic attitude second best to an actively prognostic one. this actively prognostic proceeding with respect to early detection of partial ds became widely feasible by rhd dna typing techniques. currently, routine rhd dna typing techniques offer an affordable, accurate and fast approach to an unambiguous identification of partial ds and their reliable discrimination from weak d types, not at risk for allo anti-d immunisation. a reasonable proactive proceeding could e.g. demand for (once in a lifetime) routine rhd dna typing of all weakly expressed ds as defined by serology, since most partial ds also meet this phenotype. rhd allele frequencies and their geographical and regional prevalence will certainly have an important impact on dna typing strategies and their (mandatory) specificities. fluorescence cytometry for completely automated immunohematology testing d roback*, b barclay † and d hillyer † *emory university school of medicine, atlanta, † transfusion & transplantation technologi, decatur, ga, usa we previously described a methodology for accurate immunohematology testing by fluorescence cytometry [roback, j.d. et al. ( ) transfusion ( ), ]. this system utilized low-speed centrifugation of -well filter plates for red cell staining, and a smallfootprint capillary cytometer for data acquisition. when authentic clinical samples from hospitalized patients were tested for abo group, the presence of d antigen, and red cell alloantibodies, the results were well-correlated with those obtained by commerciallyavailable column agglutination technology (cat). this system determined the correct abo group and d type for . % of samples, compared to . % for cat (p > . ). when samples were tested for unexpected alloantibodies, fc determined the correct result for . % of samples, as compared to . % for cat (p > . ). this novel method was better than cat at detecting weak anti-a (p < . ) and alloantibodies. based on these promising results, we sought to completely automate this method by inte-prevents the aspecific amplification of the k-allele, and makes it possible to detect the fetal k-allele in the presence of excess of maternal k-alleles. furthermore, it has been shown that fetal dna is in the plasma present in shorter fragments (< bp) than maternal dna. size separation of cell free fetal dna can therefore be used to increase the relative concentration of fetal dna, which will help the development of new genotyping assays. in conclusion, cell free fetal dna in maternal plasma is nowadays routinely used for prenatal rhd typing and fetal sexing. new technical developments will make it possible to extend these indications to other blood group antigens in the near future. more insight in the characteristics of fetal dna might finally lead to wider applications, including numerical chromosomal aberrations. furthermore, it might become possible to apply genomic dna microarrays for the screening on many different inherited diseases, including hemoglobinopathies. determination of the affinity of anti-d present in the serum of immunized subjects and in anti-d ig preparations by a method using unlabeled antibodies p lambin*, m debbia* and y brossard † *institut national de la transfusion, † chp hopital saint antoine, paris, france introduction: few data are available concerning the affinity of maternal anti-d responsible for the hemolytic disease of the fetus and the newborn (hdn), and the affinity of anti-d immunoglobulin used for the prophylaxis of that disease. we recently described a method to measure the affinity (ka) of untagged anti-d monoclonal antibodies. aims of the study: in this work, a similar method was applied to determine the affinity constant (ka) of polyclonal anti-d present in the serum from d-immunized mothers and donors and from anti-d ig preparations. methods: a constant amount of o r r rbcs was sensitized with increasing concentrations of anti-d present in the sera from immunized subjects, and in anti-d ig preparations. at equilibrium, the amount of anti-d bound to rbcs was measured by elisa. the scatchard equation (linear regression) and the langmuir equation (hyperbolic regression) were used to determine the ka of anti-d. the experimental data fitted well with the scatchard equation (mean r † = . ) but a better correlation was observed with the langmuir equation (mean r † = . ). in maternal sera, the mean ka of anti-d was . ¥ to the m- (from . to ¥ to the m- ). in the sera from immunized donors, the mean ka was . ¥ to the m- (from . to . ¥ to the m- ) and in lots of anti-d ig, the mean ka was . ¥ to the m- (from . to . ¥ to the m- ). the comparison of anti-d affinity measured in cases of hdn in which infants presented a fetal anemia and in cases of hdn in which infants presented only a postnatal anemia showed no significant difference. the mean value of ka in the cases of fetal anemia was . ¥ to the m- whereas in the cases of postnatal anemia the mean value of ka was . ¥ to the m- . conclusion: the method previously described for monoclonal anti-d was applied to polyclonal anti-d present in the serum of d-immunized subjects and in ig preparations. the experimental data fitted well with the langmuir equation, and the affinity of polyclonal of anti-d was measured with accuracy. in addition, no significant difference was observed (at least in the cases of this study) between the affinities of anti-d measured in the most severe cases of hdn (fetal anemia) and in the less severe cases of hdn (post-natal anemia). introduction: cryopreservation of platelets is widely used in platelet immunology to ensure the availability of well characterised panel cells for the detection of hpa antibodies. but recovered platelets do not express the hpa- alloantigens. aim of the study: here we describe a method for the successful preservation of platelets by lyophilization. we report the value of this new reagent for the detection of hpa alloantibodies and especially anti hpa- alloantibodies. methods: rehydrated lyophilised platelets (lyo p) were tested for their reactivity with monoclonal antibodies against gpiibiiia, gpibix, gpiaiia and cd by flow cytometry. the levels of reactivity were comparable with the ones obtained with fresh platelets. the rehydrated platelets were used in the maipa with a panel of hpa antibodies (anti-hpa- a, ; anti-hpa- b, ; anti-hpa- a, ; anti-hpa- a, ; anti-hpa- b, ; anti-hpa- a, and anti-hpa- b, ). results: all hpa antibodies showed the expected pattern of reactivity and in several cases absorbance reading were well above those obtained with fresh platelets. absorbance values produced by inert sera were comparable with those obtained with fresh platelets (ranges . - . ). interestingly, we used lyophilized platelet with a high expression of cd bearing the hpa- system and we have detected anti hpa antibodies among sera previously negative with fresh platelets. nineteen sera concerned patients suffering from hematological diseases and from pregnancy women. conclusion: lyophilized platelets are possibly an ideal reagent for the platelet immunologist to be used for the detection of hpa antibodies. moreover, this work bring new insights on the hpa- system in platelet transfusion. we are now pursuing more extensive validation studies with a larger number of samples representing all known hpa specificities and several diseases. the diagnosis and treatment of sick infants and children requires a broad knowledge of physiology, biochemistry, genetics and the application of sophisticated testing and treatment options. one of these options is transfusion of blood and blood products. transfusion of the infant, especially the premature infant, and sick child, especially those with major organ dysfunction, requires careful consideration of their unique metabolic, hepatic and renal clearance mechanisms. guidelines that direct the indications for transfusion differ from those in adults. non-invasive measures of oxygen delivery and oxygen offloading may assist in guidelines for red blood transfusion. metabolic complications from massive transfusion and/or the manipulation of blood products must also be considered. evidence from a high quality randomised controlled trial suggests that anaemia is also well tolerated by critically ill patients. a restrictive approach to rbc transfusion that maintained the hb concentration between and g/l was found to be as effective as and possibly superior to a more liberal strategy of maintaining the hb concentration between and g/l. there are concerns that some groups of critically ill patients, such as those with cardiovascular disease and patients who are difficult to wean from mechanical ventilation, may benefit from higher hb levels. rbcs also have a role in primary haemostasis and higher triggers may be appropriate in coagulopathic patients. it is important to realise that blood is not a uniform product and the clinical efficacy of rbc transfusion may vary. one factor that may have a considerable effect on the quality of the rbc product is the storage time. rbcs undergo marked changes during refrigerated storage. the implications of these changes on tissue oxygenation are not known but these concerns have led some clinicians to request 'fresh' blood for critically ill patients. there is insufficient evidence to support such practice. it is of great practical importance to determine if, or when, fresh rbcs could be superior to stored rbcs. background: with a decreasing blood donor base, fully tested, fresh unrefrigerated whole blood (fuwb) has been found to be a more efficient and effective use of a limited resource in place of, or as an adjunct to, traditional blood component therapy in surgical situations associated with massive blood loss. aims: to outline the use of fuwb in situations where there is potential for intractable bleeding associated with major surgery, and evaluate platelet function in fuwb versus platelet components. methods: outcomes of fuwb and traditional blood component use were examined for cases of cardiac bypass surgery. in addition, exclusive use of fuwb for burns debridement cases was analysed. an evaluation of platelet function in whole blood compared to platelet components was also performed by measuring platelet aggregation and activation parameters. results: there was a decreased requirement for blood components following administration of whole blood post cardiac surgery. whole blood usage for burns debridement surgery eliminated the requirement for additional blood components. platelet activation was markedly reduced in whole blood compared to component platelets, and this may be one reason for the increased efficacy of whole blood in these clinical settings. conclusion: fuwb appears to have a role in minimising blood product requirements and consequent donor exposure in situations associated with massive blood loss. m-pa- transfusion practice for coronary artery bypass surgery in greece s lakoumenta, m vassili, g hatzidimitriou, t asteri, p stratigi, s kanellas and g palatianos hellenic society of blood transfusion, athens, greece cardiac surgery is associated with a demand for allogenic blood and blood product availability as well as a considerable consumption. the impact of consensus guidelines for allogenic blood transfusion during coronary artery bypass graft surgery (cabg) in us attracted great attention . the present study is conducted in order to reveal the transfusion practice in greece on a similar population i.e. patients undergoing cabg operations. methods: five participating centers collected data concerning transfusion of allogenic blood and blood products in patients undergoing elective first time cabg procedures, as well as parameters that may influence blood loss, such as duration of the operation, cardiopulmonary bypass time (cpb) etc. the total estimated blood loss was calculated as the sum of red blood cell volume reduction [(body weight in kg ¥ ml/kg) ¥ (admission haematocrit-discharge haematocrit)]+(red blood cell volume transfused). results: results are shown in table : means, standard deviations, and p-values of the wilcoxon test comparisons between the hospitals. a preliminary analysis of data from centres ( patients) showed no difference in patient characteristics (age, body weight, male to female ratio). there is a statistically significant difference (p < . ) between the five centers in duration of the operation, cpb, estimated blood loss and volume of transfused plasma. red cell use showed also a variation which however did not reach statistical significance (p < . ). the center with the highest figure for blood loss has the lowest volume of allogeneic red cell transfusion because of the use of cell salvage. conclusions: although variations, as those observed in greek cardiac surgery centers, have been documented in other countries, the variation in the use of plasma is striking and we are in the process of trying to identify the reasons. our study is in progress and additional data are being collected and will be presented. introduction: premature infants and at term newborns have an higher circulating blood volume per kilogram than the adults ( ml/kg in premature; ml/kg in at term), for this reason, in case of neonatal thrombocytopenia, a specific hemocomponent, with a very high platelet concentration, needs for transfusion therapy. the laboratory criteria for platelet transfusion are the following: (a) a plt count < ¥ cells/l if bleeding is observed; (b) a plt count < ¥ cells/l without bleeding; (c) a plt count < ¥ cells/l in newborns showing critical clinical conditions. aim of this study: in this study, we have monitored the plt transfusion therapy in our neonatal intensive care unit (nicu) in the last four years. methods: effects of plt transfusions have been followed in children ( premature infants and at term newborns). the weight of premature infants ranged from - g and at term newborn from - g. gestation age of premature infants ranged from - weeks and of at term ones, of course, from - weeks. for every platelet transfusion in these newborns, the volume of platelet concentrate has been of - ml/kg, with a plt count < ¥ cells/l. results : in the study period, plt transfusions have been performed: children have been only transfused one time, while multiple plt transfusions (ranged - ) needed for children according to clinical conditions. the observed clinical indications for transfusions have been the sepsis with haemorrhagic syndrome ( cases) , haemorrhagic syndrome without sepsis ( cases) and neonatal alloimmune thrombocytopenia without haemorrhagic syndrome ( cases). after hours from transfusion therapy, the absolute plt count and the correct count increment have increased in all little patients. the highest increase in plt count was ¥ cells/l, while the lowest ¥ cells/l. no difference in the efficacy of therapy has been detected between premature group and at term group. % of children have been discharged from hospital in good general conditions without complications in following controls. in conclusion, we can affirm that plt transfusion in premature infants and in at term newborns is an efficient and safe treatment of severe haemorrhagic conditions. however a collaboration between nicu and transfusion center is necessary to choice the adequate platelet concentrate's volume for transfusion and the best plt donor for the newborn. developing transfusion strategies fusion society of turkey (bbtst) in with contribution of blood transfusion centers. according to these figures % of centers attended operates apheresis procedures. two centers informed us that apheresis in the hospital was carried out at blood bank. there was not enough information from one center, so it was excluded. of the blood banks performing apheresis, were university hospital blood banks. another blood banks were producing both productive and therapeutic, produce only productive and produce only therapeutic procedures. one center did not respond. all centers reported to prepare and separate erythrocyte and plasma. however only centers reported to prepare random platelets as well. each center had apheresis machines between - . a total of centers was carrying out around < procedures, around - , at centers about - , at a further centers around - procedures a year (one center was excluded). of the responders to the survey , all procedure were done at blood banks, whereas at of them all were carried out by the hematology clinics. at other centers, productive procedures were conducted by the blood bank, and therapeutics were performed by the hematology division. a total of blood banks stated that they have not kept the platelet suspensions produced and used them straightaway. productive apheresis center capacities were as shown: centers < , centers - , centers - and centers > units have donations a year. around % of all apheresis procedures were carried out by large well run blood banks. conclusion: as the use and production of random platelets increase, and settle of apheresis devices in big centers will eventually decrease the demand of apheresis procedures and keep the welltrained staff at big centers, decrease the cost thereafter. • planning of resources for the financing of the bts, adoption of a methodology for creating and adjusting the price list of products, adoption of the yearly plan of needs for blood/products and services of health institutions which use blood/products. • achieving recognition of real costs of products and services from the health insurance fund and ministry of health. • harmonization of low level of acclaimed costs and real costs of basic transfusion activities. results: acclaimed costs for activities in transfusion practice (collection, testing, processing, storage, distribution and transport) as a reflection on the price of the products are % lower than real costs. the prices of health services in the official price list are much lower than the proportion of costs of material resources needed for the realization of these services. this especially affects the management of independent blood establishments (bti's in serbia) with core blood transfusion activities as their basic field of work, in comparison with the hospital based transfusion services, which are financed within the budget of the whole hospital. the hospitals with hospital based transfusion services involved partly in core transfusion activities are completely financed by the health insurance fund, while independent blood establishments are financed through the price of products and services they provide. conclusion: in order to provide adequate quantities of safe blood/products for the end user -the patient, it is elementary to create stabile and equal financial management conditions for the whole blood transfusion service in serbia. this can be achieved only by continuous cooperation of the health insurance fund, ministry of health and independent blood establishments. sion centers (rbtc). the activities on promotion and organization of voluntary, nonremunerated blood donation, blood collection and patients' services are carried out in the rbtc and in departments of blood transfusion (dbt), part of the district hospitals. the collected units in dbt are transported by special cars to the ncht and the rbtc for processing, testing and control. the same transport is used for the requested by dbt blood components for storage and distribution to hospital departments. thus the issued components are with an equal quality and safety for all patients throughout the country. lbbdbt introduces hemovigilance as a mandatory system, covering the whole chain of the blood transfusion process. it includes as well the creation of registries at a national, regional and district level of blood donors, recipients of blood products and all activities of the blood transfusion service. . seventy hospitals are exclusively users of blood, blood products and services. the current organization of blood transfusion services faces the following problems: fragmented transfusion service, lack of a national blood policy, the blood program is not nationally coordinated, limited knowledge on quality management, inadequately distributed human resources, limited material resources, lack of it system, lack of planned, continuous skill upgrading. as a direct consequence we have: suboptimal blood collection activities, inadequate blood supplies significantly vary between seasons, high percentage of replacement donors, outdated methodologies, old, even obsolete equipment, the quality of blood products is not standard, there is a lack of traceability. aim of study: to reorganize blood collection activities in serbia to increase collection of safe blood up to % ( blood units). methods: division of responsibilities between blood establishments and hospital based transfusion services by: • optimizing organizational structure • implementing blood collection standards to enhance blood safety and donor care • gradually replacing family donors with a network of voluntary non-remunerated blood donors from low risk population groups • creating and implementing a training strategy. results: through the eu funded project support to a national blood transfusion service in serbia, we are in the effort of integrating the services and standardizing their work. the blood collection working group began by dividing serbia into blood collection regions: north, central, and south. each region is divided into sub regions covering approximately half a million population ( in the north, in the central and in the south region). each sub region will have one standard mobile blood collection team to collect blood units daily, i.e. annually. the blood units per teams provide the blood units ( %) to cover hospital needs in serbia. to this effect, the following has been achieved: • blood collection activities in serbia analyzed • performance analysis of bte and hbts mobile teams in place • two model standard mobile teams tested in the field • national blood collection sop's written • national donor questionnaire form prepared • national set of blood collection standards prepared • list of donor deferral criteria prepared • blood collection equipment renewed • regional reorganization plans in progress. the objectives and results can be achieved by the participation and mutual cooperation of all institutions involved in blood transfusion within an integrated, standardized system with clearly delegated responsibilities. p- years of the national blood transfusion institute in serbia n nedeljkovic national blood transfusion institute, belgrade, yugoslavia nbti was founded in . since and unpaid blood donation is mandatory, organized in cooperation with red cross. blood donation is regulated by the law in , / . codex of voluntary blood donation and health care staff has also been established; blood donors donates blood annually. in the past years, there was over million blood donations, performed in accordance with who regulations. over transfusion medicine specialists and technicians specially trained for the work in blood transfusion service (n = ), perform transfusion medicine doctrine of rational labile blood component and stable blood derivatives therapy, based on the selfsufficiency concept in fr yugoslavia with . million inhabitants in serbia, montenegro and kosovo. plastic blood containers and tests are imported or given as humanitarian aid gift and from . now, they have been regulated by tender. in , test to lues was introduced, to hbsag in , to a-hiv in and to a-hcv in . information system was introduced in . nbti includes: national haemovigilance coordinatoin center, center for medical care of haemophiliacs, tissue typing center, center for prenatal and perinatal protection of pregnant women and newborns. activities of nbti are organized through: center for planning, organization and development of blood transfusion service, center for blood collection, preparation and distribution, center for immunology and immunochemistry, plasma fractionation center for plasma in west balkan countries, center for diagnostics means, center for quality control of drugs and medical and diagnostic means, center for education and training and scientific research work. nbti is the third year of gmp, sop, yus iso implementation. in the current reform of transfusiology system we are aiming for percent of voluntary blood donation. nbti is the publisher of the national bulletin of transfusion medicine and it is included in the education system of the belgrade university medical faculty and the estm in belgarde . the problems of blood service in russia ea selivanov and t danilova russian inst. of hematol. & transfusiol., st. petersburg, russian federation background: the blood transfusion service (bts) development as a platform for providing the hospitals with blood and blood derivatives is an important national problem. aims: russian blood service assessment with international comparison. methods: a study was conducted on the base of the reports from all regions of russia followed by a computer statistical analysis. results: blood and blood components were collected in the russian federation in in stations of blood transfusion and in blood transfusion departments at big hospitals. amount of donors in was equal to , voluntary donors being . % of them. the average number of whole blood donations in relation to the general population is per inhabitants, and on average percent of the donor base consists of first time donors. the average number of blood collected in relation to the general population and health care system is . ml per inhabitant and ml per one bed. an average volume of one blood donation is ml. blood was collected into plastic bags containing domestic or foreign anticoagulants. about . % of collected blood is used for procurement of blood components and preparations, . % of banked blood is used for transfusions. amount of donors and the volume of whole blood have been significantly decreased for the last years. at present in russia all donations are tested for abo blood group, rh(d) type, anti-hiv- / , hbsag, anti-hcv and syphilis. the total percentage of blood discarded after testing for transfusion-transmissible infections is . %. % of plasma is obtained by plasmapheresis. blood components collected are as ffp, rbc, frozen rbc, eukocyte-and platelet-depleted rbc, rbc suspension, and preparations: % albumin, immunoglobulins, and cryoprecipitate. as to blood safety measures -implementation of blood components leucodepletion and ffp and rbc quarantine in process. the new national strategy of bts reorganization has been developed. it includes the following: increasing the visibility and resource commitment to blood issues at the national, regional and municipal levels; the national voluntary donor programme promoting; blood safety increasing; blood collection, testing and pro-cessing concentration in federal and regional bts establishments, appropriate blood and blood components usage. calculating the cost of blood in turkey n solaz, s kemahli and s cin ankara university, ankara, turkey background: like other fields of the medicine cost efficacy is gaining importance in blood banking and transfusion medicine since last few years. since last years even the most developed countries started to discuss about the cost of blood. in turkey ministry of health determines the cost of blood annually. aim: to establish a safe, cost effective and reliable prices for blood components. methods: turkish ministry of health (moh) started to determine the cost of blood components as 'all inclusive' principle. this means that cost of a unit of blood component will cover all conventional expenses such as; blood typing, infectious screening, labour, consumables, etc. this system has provided uniformity to blood component costs but if the system is not controlled and followed properly it will cause serious risks. there might be some blood banks which will not respect the safety regulations and may modify the test standards for decreasing the cost of tests. conclusion: current blood product pricing system looks generally reasonable and reliable but moh should establish close follow up systems for avoiding any abuse on the safety of blood. background: a positive direct antiglobulin test occasionally occurs in normal blood donors, and is often discovered when the donor's red cells are found incompatible in a compatibility test. the incidence of a positive dat was expected to increase since more sensitive techniques (gel test) were installed. the aim of our study was to examine whether dat positive otherwise healthy donors presented any clinical or laboratory abnormalities. methods: in the first . cross-matches last year (in months) were found incompatible due to dat positivity of blood donors' red cells ( . %). dat positive [( +)-( +)] samples were only igg positive in cases, only c d positive in and igm positive and c d positive in case. all blood donors were notified and thirty two of them responded to a request for a further sample. a complete blood count, a reticulocyte count, bilirubin (total, direct, indirect), transaminases, serologic immunological tests (ana, anti-dna, anti-ena, rf, anticardiolipin antibodies), quantitative assessment of immunoglobulins, aptt and lupus anticoagulant were performed, as well as serologic tests for markers of viral infections. dat and iat were performed by gel test (id-diamed) according to the manufacturer's instructions. dat were performed with polyvalent and monovalent reagents (anti-igg, -igm, -iga, -c c, -c d). the blood donors were also examined clinically. the donors who had positive immunological tests were referred to a rheumatologist for further investigation. results: among the thirty one blood donors eight had received medication the last hours before blood donation, two had been vaccinated for hepatitis b recently, four presented signs of a viral infection soon after blood donation, three had evidence of an allergic condition, five had positive tests for anticardiolipin antibodies and ana, two were positive for anticardiolipin antibodies only and two had a positive ana test only. in six blood donors we did not find any abnormality that might be interrelated to dat positivity. conclusions: all blood donors with positive dat should be requested to undergo further investigation. some of them are possibly candidates to long medical follow-up, especially those with other immunologic abnormalities such as positive ana and/ or anticardiolipin antibodies. the eligibility of such donors for future donation of whole blood, platelets or plasma needs to be elucidated. tions: usefulness, frequency and sincerity in answering questions. donors could choose one of the offered answers and elaborate in writing the answer they have chosen. results: of the donors that participated in the survey ( . %) answered the questionnaire, ( . %) men and ( . %) women. that the survey was useful thought % and % that it was not. opinions were elaborated by . %. that the questionnaire should be completed before each blood donation was the opinion of . %, % thought it should be filled out only the first time blood is donated and . % that the questionnaire should not be completed at all. the answers given were sincere in . % of blood donors, % were not and . % were given automaticallywithout comprehension. conclusion: most donors believe that completing the questionnaire before each blood donation is an effective way to increase safety by preventing potentially infected individuals from donating blood. they are also aware of the importance of answering questions truthfully because the end result is protecting the wellbeing of both blood donors and receivers. analysis of blood donor's deferral in national institute for transfusion medicine -skopje for the last five years ( ) ( ) ( ) ( ) ( ) p blagoevska*, i nikolovska † and r grubovik* *national institute for transfusion medic, skopje, † medical center, prilep, macedonia introduction: safety of blood and blood products depends on many different factors, starting with selection of blood donors. the aim of this study is to analyze the number of deferred blood donors and the reasons for their deferral, as well as the total number of blood donors in nitm and their correlation (voluntary/family donors). materials and methods: this is a retrospective, epidemiological study and data were taken from the blood donor's registry in nitm from . . till . . . statistical mass includes blood donors who came to nitm to donate blood in the mentioned period. results: there were total donors in nitm and ( . %) deferrals. . % of deferred ones are male, as well as in the group with donated blood (males are predominant). the most common reason for deferral is low hb level in ( . %) blood donors, use of drugs - ( . %), low blood pressure - ( . %), high blood pressure - ( . %), infections - ( . %), cardiovascular diseases - ( . %) and others. relation voluntary/family donors is almost equal ( . : . ). in the last two years the number of voluntary blood donors is increasing ( : ), which is good sign. conclusion: percentage of deferred blood donors in first three years is ~ %, which is result of insufficient data and it is increasing in the last two years (> %). reasons for deferral are predominantly from temporary character ( . %). permanent deferrals are only ( . %), which is probably due to good education of the population and self-deferral. we should establish the national registry for deferred donors, as well as for the donors with positive markers for tti. we should design a strategy for returning of temporary deferred donors. regruting blood donors in multiethnical environment p blagoevska*, r grubovik* and k elezi † *national institute for transfusion medic, skopje, † medical center, gostivar, macedonia introduction: population in r.macedonia consists of % macedonians, % albanians and % others (serbs, gypsies, turks). over % of blood donors are voluntary non-remunerated and ~ % are family donors. transfusion service and red cross should recognize the values and cultural differences of minors groups and recruiters should developed methods for reaching and motivating them to donate blood. the aim of the study is to present the ethnical structure of our donors and to develop strategy for their regrutation and retention. the study reviews the results from the blood donation actions among the high schools and university students in west part of the country (multiethnical environment) from till . results: there were blood donations for the mentioned period. predominant blood donors are employed and high school students in %. family blood donors are ~ %; between them % are from albanian population. the ratio between blood donors macedonians vs. albanians is : . woman blood donors are presented with %. first time blood donors are %, and regular donors arẽ %. conclusion: first step in planning the blood donation in multiethnic society is creation of special teams of important and devoted volunteers, such as religious leaders, teachers, doctors and businessman. for a successful campaign it is necessary to design special promotional material and address personally to the target population on their mother language. background: pursuit of pharmaceutical purity of the blood in the bag has led to a shrinking donor base and a significantly more expensive product. decisions regarding new infectious marker testing and donor deferrals have typically been made emphasizing decreasing one specific risk without considering the effect the intervention will have on the overall safety of blood transfusion. regulations have been formulated by governmental agencies with limited input from the medical community. the decision making process has lacked risk benefit analyses and has not had the robustness associated with spirited discussions. policies made in this manner may result in certain risks being decreased but can also have adverse unintended consequences. discussion: in the u.s., the fda's implementation of donor exclusions to prevent possible transfusion transmitted vcjd has reduced the donor base by more than %. given the demographics of the deferred donors, the impact on plateletpheresis donations has been even greater. to compensate for the loss of donors, blood services will have to persuade present donors to donate more frequently, to recruit new donors, or both. one study has indicated that two-thirds of donors have no intention of donating more frequently. new donors have higher rates of infectious disease markers with positivity for hiv and hcv twice as high as repeat donors. despite sensitive testing techniques, window periods still exist and not all potentially infectious donors will be excluded. another area of concern is the aggressive use of inducements to attract new donors. some blood services are offering lavish incentives such as enrolling donors into drawings to win automobiles. most donors entering the lottery will be low risk; however, it is reasonable to worry that such extreme tactics might also attract persons who should not be donat- conclusion: (a) blood donors who were patients' relatives were many more than volunteers as well as more were men than women. also people of young ages were more than those from older ages. (b) the frequency of the diseases for which the blood units were tested was found to be in low levels in the population of the area. specifically as concerns hcv, it seems that transmission frequency has been reduced after the obligatory testing of hcv in blood transfusion centres and stations. genotype b of hepatitis c virus is the most frequent in blood donors d, from a to f, from a to k, a and a. these are differently distributed in the world: types and are the most common in europe and in usa. aims: considering that, in our region, anti-hcv antibody positivity is variable from . to % of general population, aim of this study has been to evaluate the prevalence of hcv genotypes in blood donors. methods: in period from may to december , blood units were analyzed by nat for viral rna research. nat has been performed on single sample by tma technique. on rna-positive samples, the hcv genotype has been identified by reverse hybridisation with line probe assay. results: blood donors have resulted hcv-rna positive with identification of the following genotypes: a = cases ( . %); b = ( . %); a + b = ( . %); a/ c = ( . %); = ( . %); = ( . %); none was a or a. we have also analyzed the differences between the two sexes in hcv-genotypes distribution. hcv- a has showed a double prevalence in men ( cases, . %) respect in women ( cases, . %), while genotype b is more frequent in women ( cases, . %) than in men ( cases, . %), moreover genotypes and do not compare in women. although an accurate pre-donation selection, discharging all subjects with alt > iu, our results show that . : donors, apparently healthy and without risk factors, have resulted hcv-positive. analyzing our data, the genotype b has resulted the most frequent in blood donors' population, followed by type , while the others have showed a very low prevalence. the high frequency of genotype in blood donors is explained by the observation that hcv is usually associated with low alt levels, for this reason affected subjects may escape to donor's screening only based on dosage of alt. on the contrary subjects affected by other hcv types, associated with high alt levels, may be deferred increasing the hcv b relative prevalence. at the end, the different distribution of hcv genotypes between men and women and between age's classes probably reflects differences in the pathogenic characteristics of the virus, in the transmission way and in the risk factors. in fact, it has been demonstrated that genotype is principally linked to a not transfusion transmission way; genotype is linked to old age, to female sex and to post-transfusion transmission; genotypes and are associated to young age and to an history of drugs abuse, respectively with high and low viral load; genotypes and are still little known because extremely rare in europe. p- kell blood group system and rare blood donors v fakitsa*, p karyda*, s giannoulea † , c antoniou*, j flesiopoulou*, e haliou*, m papakonstantinou*, h dessilla † , e katsadorou*, g lyrakos* and k sofroniadou* *general hospital of nikea, pireas, † blood transfusion center, athens, greece background: the kell blood group system is a compound antigen system exclusively of red blood cells. some of the kell antigens are highly immunogenic. the commoner kell antibody is anti-kel . the kel (cellano) antigen is a high frequency antigen and the blood donors lacking this antigen are quite rare. the blood donors who have not factor cellano are classified in the rare blood donors. rare blood by its very nature is required rarely, but when needed that blood has to be ensured to specified patients. there are other blood donors in their family - ( . %) students, but the number of persons that donate blood from their neighborhood and close environment is much bigger - ( . %). motives for their donation are the following: their wish to help the ones that need blood - ( . %), concern that some day everyone can be a potential recipient of blood - ( . %), because of offered benefits - ( . %), for a friend or relative - ( . %), care for their health - ( . %), because of citizen duty - ( . %), because the others donate - ( . %), curiosity - ( . %). they want to be invited every months - (%) students, every months - ( . %), every months - ( . %) and ( the mean age of case group was / ± / and the mean weight of them was / ± / , / % was male and the mean number of blood donation was / ± / . the mean age of control group was / ± / and the mean weight of them was / ± / . / % of them was male and the mean number of blood donation was / ± / . the blood donors who were female, first time blood donor low wt the rate of vasovegal rx was higher in female, first time, low weight, younger blood donors (p < . ). the rate of vasovegal rx was higher in blood donor (p < . ) who were fatigue or first time blood donor, low wt blood donation, fatigue of them and starvation of them had higher absolute donation reaction than other donors. when each variable was adjusted for other variable by regression analysis. young age, first time blood donation, anxiety, fatigue, starvation were significant (p < . ) and the others were not. conclusion: donation -related vasovegal syncopal reactions are a multi factorial process. these reaction are more prevalent in blood donors who are young, first time donor, anxiety, fatigue, starvation. these reactions might be predicted vasovegal reaction and these some facth donors need more care. with better donation care, syncopal reaction may be decrease this would be improved donor safety, better donor retention, higher donor satisfaction, and reduce cost and increase regular blood donors. to avoid iron deficiency in blood donors, iron compensation is necessary in most females and males who donate more than - and - whole blood units per year, respectively. we present studies dealing with different dose and duration of iron compensation. in the first randomized placebo controlled study iron decreased continuously in males and females at donation intervals of two (males) and three months (females) without iron compensation. mg and mg daily combined with mg ascorbic acid over months (males) or months (females) compensated for iron loss or even overcompensated in females. in the second open study we reduced iron dose to mg daily over one month for both genders. this iron dose was sufficient for compensation of iron loss. a further reduction of iron dose to mg daily over half a month led to negative iron balance in the majority of donors. in all three studies donors with exhausted iron stores profit more from iron compensation, whereas donors with high ferritin values (> mg/ml) tend to loose storage iron. aim of the study: one of our campaign strategy how to increase blood donation among adolescents are periodical seminars and excursions for students of secondary schools (more than per year). the aim of this study is to analyze impact of our campaign educational system on adolescents in period - . methods: the donation of whole blood and aphaeresis platelets from donors of age from to (max. years for each class) were count for the period of five years ( ) ( ) ( ) ( ) ( ) . the percentage of the man´s donation was calculated for each target class ( ) ( ) ( ) ( ) ( ) . results please see tables and . in the tables there is shown observed data in relation to the total number of births in the czech republic in reviewed years. the study showed that number of donation from donors of age from to decreased during objected years. unfavourable state of total number of births in the czech republic ( birth in republic ( birth in , birth in ) and its decreasing tendency ( birth in !) is with high probability a major demographic factor affected number of young donors. despite energy invested in our campaign educational system our recruitment efforts should be intensified to decrease influence of demographic factors. we should find new ways and methods to attract new blood donors and keep the regular ones, too. the aim of the research was to investigate women's attitudes towards blood donation in cyprus. a statistical sample was selected using stratified sampling and consisted of women from the district of limassol (the second largest urban center of cyprus) between the ages of and . using linear logistic regression, the analysis of the data collected revealed that there is a greater probability for a woman to be a blood donor if she is of a higher educational level, a member of an organized group or association, or if she is acquainted with other blood donors. the percentage of female blood donors is higher in rural areas than in urban centers. % of women do not donate blood and attribute their reluctance to do so to health-related problems, while about % of those who have never donated blood claim to fear the blood donation procedure. in addition, more than half of the women who have stated they would never donate blood again have attributed their denial to healthrelated problems. the research revealed that there could be an increase of up to % of the percentage of female blood donors if they were given time off work for a few hours or one or two days afterwards. even though very few female blood donors expressed a preference for the blood donation to take place on a particular weekday, half of them prefer the donation to take place on the discussion: it is about small group of students. the impression is that the altruistic behaviour is present at most of the questioned students. the fact about free school days is not underestimated because it is one of the most important motives of blood donoring of the young population. families where the blood donoring is a tradition have a great influence for young children because the children in these families are better informed for blood donoring. conclusion: including the children in the process of education for young children is of particular importance because the altruistic behaviour as a higher feeling is from an early age of the child and it is under the influence of the environment (family and friends). active participation of the department for transfusion medicine in the educational process, especially in the education of young children, is a guarantee to achieve longlasted positive results. adverse reactions in blood donors taking betablocking antihypertensive medications l paesano*, m d'onofrio*, s misso † , g fratellanza* and e d'agostino* *university federico ii, naples, † hospital san sebastiano, caserta, italy one aim of blood donor's selection is to avoid an adverse reaction to phlebotomy (as vasovagal reaction, syncope and/or hypovolemic cardiac insufficiency). blood donation is surely contraindicated in various pharmacologic therapies, but not in all. in fact a certain degree of discretionarily exists about the assumption, or the period of suspension, relative to a numerous pharmaceutical products, as the antihypertensive agents. according to literature, the deferral of donors taking antihypertensive medication is not indicated when blood pressure is normal, symptoms are absent, and diuretics or similar agents are the only drugs used. on the contrary, it is a common opinion that an antihypertensive therapy by betablockers is not compatible with blood donation for its cardiac effects. nevertheless, in our daily activity, the observation of a blood donor taking beta-blocking drugs may occur for various causes. a possible error is a superficial pharmacological anamnesis, as it can occur in donations on autohemotheca, for a too fast medical visit (due to a large number of donors), or for the inexperience of the selector (often a not specialist of transfusion medicine young doctor). another possibility of observation is constitute by patients, undergoing to elective surgery, included in a program of autologous blood donation, suffering hypertension treated with betablockers. in fact, in this last case, the risk/benefit balance justify the blood letting procedure. in the last year we have just observed two severe post-donation reactions in donors suffering hypertension treated with atenolol. the reactions have been similar, in fact both donors showed lypotimia followed by convulsions about past half hour by the end of phlebotomy. no prodromic symptoms have been observer or referred. cardiac frequencies (cf) before donation were respectively and beat per minutes and blood pressures (bp) were both in the normal range ( / and / mmhg). after donation, during adverse reaction, cf showed no substantial variations, while bp have been decreased respectively to / and / mmhg. immediate treatment has consisted in putting the donors in the trendeleburg's position and in applying a dolorous stimulation. in the first case this treatment has been sufficient to report the bp to / mmhg (with disappearing of all symptoms) in only half hour time. in the second one, the marked hypotension showed a very slow remission, for this reason the subministration of a plasma expander needed, with the complete resolution of the symptoms after two hours. these two donors were not deferred from donation because they were periodic donors that had modified their antihypertensive therapy, without referring it neither in the questionnaire nor during anamnesis. our experience confirms that the blood donation don't must be permitted to subjects taking betablocking antihypertensive drugs. in fact these medications act on cardiac pump decreasing the cardiac rhythm and limiting the postdonation cardiac recover. this effect is very dangerous because it appears relatively in retard respect to the end of donation, when donor may have just leaved the transfusion center. introduction and aim of the study: in society under transition privatisation and marketisation probe all areas of life. transition to market economy is extremely important and sensitive issue in health and welfare services in general, and specifically in the case of blood transfusion service. the aim of the study was to analyze effects of confusing publicity which introduced possible ways of transforming blood transfusion service in serbia (ideas about privatization of some parts of national blood transfusion institute, buying blood from blood donors, selling blood from voluntary blood donors to private clinics, exporting blood from vbd, stories about tradition of paid blood donations in some european countries). publicity was restricted to a small number of sporadic outbreaks concerted in a limited period of time. table. conclusion: surveillance of adverse reactions and injuries or accidents during or after blood donation is essential for maintaining the well being of active blood donors, as well as for the safety and quality of the donated blood components. information on other activities and parameters affecting the quality of blood including materials, reagents and equipment should be collected and any serious deviations from standard operating procedures should be notified to the competent authority using haemovigilance infrastructures. skae has built up such procedures working along the lines of the european haemovigilance network. improvement of existing national haemovigilance systems is expected to follow from the implementation of the eu directive. although inevitable, blood donor deferrals lead to losses in donated blood supply and may affect donor-return rates and subsequent blood donations. to estimate the scope of blood donor deferrals and their causes, we analyzed the - data from regional blood centers using standardized criteria for temporary and permanent blood donor deferrals. within this period ( ) ( ) , . percent of persons who presented for donation were deferred; . % were temporary deferrals ( % due to laboratory test results, among others low hemoglobin, . % due to risk of acquiring a transfusiontransmissible infection) and . % were permanent ( % due to the infectious diseases markers, . % due to cardiovascular diseases). for regional blood centers the temporary deferral rates varied widely (see the table below ). in the case of individual regional centers, the differences as well as the most common causes were often difficult to explain. according to our analysis, some blood centers have a more restrictive approach to donor acceptance than others and this results in increased donated-blood loss. to some extent such losses could be avoided. further studies are recommended to elucidate the problem and eliminate unnecessary deferrals. caption : percentage of deferrals aims: from our experience in selecting blood donors, a certain number of issues have been noticed that remain obscure and need to clarification since those seem to 'haunt' the whole process of blood donation. methods: many first time blood donors and especially volunteers think that rejection reasons are permanent and they are completely incapable of donating blood their entire life. this is a 'tragic' misunderstanding since the doctor did not explain that the reason of the rejection is only temporary and in the future this man is capable of donating blood. those potential donors will never even approach again blood donation centre and when in the future they are asked why they do not donate blood, they repeat the cause of the past rejection. results: one of these rejection reasons is for example low blood pressure ( . % of total causes of rejection). as we all know blood pressure must be determined according to age, sex, weight and from other factors as sleep, emotional status, food and liquid intake. therefore blood pressure is very important but should be evaluated with all the above factors and must not be alone the only reason for rejection. even when one blood donor is rejected it should be made clear to him that this is only temporary and if in the future he is in better physical condition, he could donate blood. in fact - % of those donors rejected for hypotension are readmitted in blood donation after meeting the above mentioned criteria. another matter of equal importance is anemia ( . % of total causes of rejection), especially concerning young women. since most of those women tend to develop anemia due to depletion of iron stores, they should be advised to donate blood at longer periods than regular, to receive proper medication and diet according to their needs. the doctor must explain the donor the reasons for iron depletion, so blood donation should not be considered as the only cause for this situation from the donor. there are many factors contributing to anemia, menses, specific diets, overwhelming stress and exercise, not to mention other medical reasons. it is the duty of the doctor to correct those factors that resulted in iron depletion or anemia and readmits those donors in blood donation in the future ( - % of those rejected are readmitted in our centre). summary/conclusions: at our blood centre we have created a program of regular tests (blood tests-physical examination) for all our blood donors. our experienced and well taught personnel offers advice and provides useful information in every aspect of blood donation and more. we have created a friendly environment for all our volunteers with love, understanding and appreciation and believe that this is the only way to keep a constant 'flow' of blood in our region. introduction: an innovative perception for blood donation in a new and evolving environment must focus on specific matters and ideas and adopt in a certain level lifestyles and concerns of society. aims: the purpose of this study is to find methods and ideas that can help blood donation centers throughout our country to create new blood donors, give a motive and inspiration for blood donation by adopting new trends of society and finally accomplish national need. methods: by having a personal interview with many volunteers about their feelings for healthier life, their nutritional habits, daily physical activity, sports, vitamins, smoking, weight, cholesterol levels. we investigated whether they believe that blood donation has, if any role towards a more hygienic life. results: we divided blood donor volunteers according to their age, educational level, and number of blood donations per year. our results indicated that there is a tendency among young educated people to adopt a personal lifestyle that includes consuming healthier food, keeping their weight low close to the ideal, having some kind of personal activity, not smoking, watching cholesterol levels, following doctors advice and concerning seriously about their health. this dynamic group of blood donor volunteers considers blood donation as a contributing factor to well being and donates blood at specific intervals. besides the yearly run lab tests that are done by our blood centre they also seek advice and discuss any matter concerning their health with the blood centre doctor. it appears that they are extremely sensitive in those matters and they seem to appear well informed about issues concerning their health, they also believe that blood donation is part of the plan they have to keep fit and being well. in our blood centre we encourage this belief and we also provide information concerning this new trend towards healthier habits. summary/conclusions: this approach has already shown some positive results in our blood centre as many people especially young educated women have joined our blood donorship program and donate blood at scheduled intervals. in order to achieve our goal which is to raise the percentage of blood donors in the region we have to be flexible, innovative according to new habits and lifestyles. we have to move with society and modernize the way we attract various groups of people. blood donation against prejudice as saltamavros*, s dimitrakopoulos † , v zacharaki*, p giannaros*, s markou* and p tseliou* *st. andrews hospital patras greece, patras, † pyrgos general hospital, pyrgos, greece introduction: in order to achieve a greater population to be admitted in blood donation we have to provide information concerning any obscure issues that presents in selecting donors. to examine the accuracy of hb measurements obtained by the noninvasive clinical device, as compared to values detected by standard methods, (cell-dyn , abbott laboratories, usa), in a blood donor setting. methods: the nbm- device utilizes a finger base sensor using occlusion red/near-infrared spectroscopy (o-rnirs) to detect and analyze the hb/hct levels. the clinical trials were conducted at two blood donor centers (israel and usa). studies were carried out on a group of subjects ( females, males) aged - . subjects were healthy volunteers who had come to donate whole blood or aphaeresis components. after obtaining informed consent, hb/hct levels of all the study volunteer participants was tested non-invasively, using the nbm- device, followed by a venous blood sample. additionally, the usa center tested a capillary blood sample using the hematastat hct measurement device ( donors). hb levels were considered normal when readings were equal to or > . g/dl. results: venous hb measurements ranged from . - . g/dl. the mean nbm- hb level was . ± . g/dl, only . g/dl lower than the mean hb result obtained by venous sampling, which reached . ± . g/dl. the standard deviation of the difference between the invasive and noninvasive hb readings was found to be ± . g/dl. the mean absolute error (mae) of their difference was . g/dl. when checked against the cell-dyn in the usa center, where subjects had hb of . g/dl or lower, the nbm- and hematastat devices showed comparable sensitivity results. the nbm- using o-rnirs is a promising noninvasive technique for hb screening in blood donors. the device is easy to use and agreeable for both blood donors and personnel. the technique reduces the need for the invasive finger prick or venous blood sampling, thereby enhancing safety, reducing costs, and improving the experience of blood donation. the effect of short-term, temporary deferral on blood donor return rates and subsequent blood donations background: blood donors are deferred for numerous reasons. some deferrals like intravenous drug use, male homosexual contact or certain positive test results are permanent. the majority of donor deferrals, however, are short-term temporary deferrals (sttds) that are resolved in a matter of days, weeks or months, after which time the person is again an eligible blood donor. the effect of sttds on blood donor return rates and subsequent blood donations is studied. materials and methods: donors given sttds during the december to march were computer-matched with non deferred donors on the basis of age, sex, and donation date (case group: donors -control group: donors). computer records were evaluated during the next years ( march to march to determine donor return rates. significance for comparison between the two groups was based on chi-square analysis. results: the most common reasons sttds were elevated blood pressure ( %), deferred for medication ( %) and colds and/or sore throats ( . ). non deferred donors were a little more likely than donors with sttds to return over the next years ( . % vs. . % pv = . ) and non deferred donors donated more whole blood units. . according to ethnic structure, women -ethnic macedonians donate blood in largest numbers - ( %), while all other ethnic groups are present with only %. the most prevalent is the group of adults aged - ( - . %), with high school education - ( . %) and mostly those who donated blood - times ( - %). conclusion: having in mind that % of the population in macedonia is female, the obtained results reveal a significant, yet insufficient participation of women in blood donation with % in relation to the total number of blood donors surveyed in the period - . this is due to insufficient motivation and education of women from all ethnic groups especially those from the younger population and with elementary education. incorporating them in education and organization would contribute to their more extensive participating in blood donation. comparison of serum beta -microglobulin (b -mg) between hbsag positive donor and healthy control f tarabadi*, m shaeigan*, g babaee † , a talabiean* and m khadir* *iranian blood transfusion center, † tarbiat modarrs university, tehran, iran background: beta -microglobulin (b -mg) is a low molecular weight protein ( daltons) and found in all biological fluids it is light chain of histocompatibility class -human present on the most membranes of cells. in the hepatitis infection the viral antigen presentation on the hepatocyte in the presence of class -hla antigen plays a role in the elimination of the virus. method & samples: beta -micro globulin was measured in serum drawn from hbs ag positive blood donors include ( . %) female and ( . %) male in age between - years, and healthy ( %) female and ( %) male in the same age we detected serumic b -mg by enzyme immunoassay (ela). results: our studies showed b mg level increased in ( . %) hbs ag positive donor that was significant differences with healthy control (p = . ). conclusions: it seems that serum b mg is a good marker for hbs ag replication. the role of b mg in monitoring of response therapy needs to be more evaluated. and ( . %) were contributed by vd, rd and dd respectively. over the last / years, voluntary donations have shown a rising trend from . % to . %, where as rd ( . % to . %) and dd ( . % to . %) have shown a declining trend. the percentage of female donors was maximum in voluntary group as compared to rd and dd ( . % vs. . % vs. . %) respectively. the rates of all tti markers reactivity were significantly higher in rd as compared to others donors. the hbsag and anti hcv reactivity in vd and dd is comparable ( . % vs. . % and . % vs. . %). hiv antibodies was found more frequently in vd as compared to dd [ . % vs. . % (p < . )] whereas, vdrl reactivity was lower in formal as compared to latter [ . % vs. . % (p < . )]. conclusion: voluntary blood donation has shown a rising trend over a last few years, thus highlighting efficient donor motivational strategies. these strategies need to be strengthened to increase the female donor base. the safety of dd is equivalent to vd when the rates of tti are compared. thus, dd should be advised to donate blood regularly as voluntary blood donors. blood safety depends on a number of factors. the chain of safe blood starts with the donor. one of the procedures for obtaining safe blood for transfusion is the medical selection based on the completed questionnaire and the possibility of self-exclusion from the process of blood donation, the medical history of the potential donor and the medical examination. donor selection consists of two sets of information necessary for protection of the blood recipient as well as the donor himself. aim: to present the most frequent reasons for declining volunteer blood donors. material: the materials used for analysis were the questionnaires completed by all the potential blood donors at the transfusion department of the medical center in strumica as well as the record books of the blood donors which contain the results of the analysis we make for the potential donors. these donors donated blood in the period between and . results: during this period people volunteered to donate blood, out of which were allowed to donate blood, while were declined. out of the total number of blood donors were male and female donors. the reasons for declining potential donors were the following: . % had low levels of hb, . % were taking antibiotics, . % were ill, . % had low blood pressure, . % had high blood pressure, . % for other reasons. conclusion: donor selection and their care on one side and obtaining safe blood for transfusion on the other side entails obligatory organized medical control. the obligatory completion of questionnaires, the medical examination of the potential donor and their self-exclusion as a result of the feeling of personal responsibility as well as the obtained information are very important for the selection of quality blood donors and obtaining safe blood for transfusion. questionnaire on subjects-students, their knowledge and motivation on blood donation f vladareanu, a bugner and s sirian national institute of heamatology transf, bucharest, romania the research theme of this questionnaire is as follows: 'what is the level of knowledge and of motivation in the non-remunerated and voluntary blood donation at students?' we also tried to see the practical implications that this study will have and how it will influence the knowledge in this area. the purpose of this questionnaire was not dissimulated. the general theme of the knowledge and motivation on blood donation had been studied before through two big questionnaires applied in and , but the general population was their target. students had never been an investigated lot up to now. the hypothesis referring to this problem is as follows: students are not informed either on the act of donation, or on the crisis of blood. . the lack of information is a first cause of the indifference of the studied lot towards the idea of donation. . the lack of motivation of the studied lot is another cause. the questionnaire was applied on a lot of students from seven different cities: bucharest, iasi, constanta, cluj, sibiu, brasov, timisoara. the number of the questions was limited to , which we consider best for a questionnaire applied on the street or at college. as a conclusion, we can say that a passive-defensive attitude towards the blood donation was revealed after this questionnaire. not knowing the issue caused by their lack of information sometimes determines indifference at the statement of the subject. on a general dissolution environment of the responsibility of the youth, the donation problem is not in their aria of preoccupations, the general attitude being of non-involvement for the moment, at this idea which is not yet in every individual conscience and which is normally administrated at an institutional level. the donor data and the details of blood application of the north west transdanubian region of hungary k vÖrÖs*, c bercsÉnyi † , o petrÓ † , r jÁger † and e miskovits ‡ *hungarian national blood transfusion s., györ, † blood bank, tatabánya, ‡ headquarters hungarian n.b.s., budapest, hungary the ongoing fundamental reorganization of the blood service began on the . . in hungary. as the consequence of reorganization till . . , blood banks had been established instead of existing before, under direction of the hhnbts. the working profile of the regional blood centers and local blood banks will be changed step by step. virus screening, blood group serology and processing will be made in the regional centers. one of the regions is the 'north west transdanubian region' (nwtr, city györ as the center, with about inhabitants and hospital beds). local blood banks (tatabánya, sopron, and szombathely) are belonging to nwtr. the regional center and the local blood banks provide the labile blood products and high level clinical-transfusion service (cross-matching, antibody screening, outpatient immunhematology investigations, etc.) for the hospitals. annually donors donate blood in this region. this donation activity covers about the % of all inhabitants. the acceptance ratio of the donors is good ( - % of the donors were deferred). there are hospitals in our region. the regional demand on rbcc is - . u/year, on ffp is . - . u/year and on pc is - . u/year. the poster shows the donor data and the details of blood application of this region since . p- implementation of rbc collection using haemonetics mcs ® +: medical staff training, donor recruitment and acceptance g woimant, c fretz, d puydupin, e pÉlissier and jl beaumont efs ile de france, paris, france background: single donor rbc collection is an approved apheresis technique in france. aims: our goal was to evaluate the implementation of rbc collection in our center in terms of donor recruitment and acceptance, as well as medical staff training and adaptation. methods: donors were selected according to the french requirements for rbc collection (weight ≥ kg, height ≥ cm, hb ≥ . g/dl, ferritin ≥ ng/ml for repeat rbc donors). all personnel were trained on adequate communication with donors. eligible donors were contacted by mail, by phone or during pre-donation interview. among the recruited donors, all donors were male, % were regular whole blood donors, % were regular whole blood or apheresis donors and % were new donors. the medical staff was trained on rbc collection with the sdr protocol and disposable set ln pf on the mcs ® +. most of the medical staff was already used to autologous rbc donation with similar apheresis devices. blood samples were taken from donors pre-and post-donation, as well as to months later for those returning for a subsequent donation. donors were asked to fill out a post-donation survey for assessing donor comfort and information. results: donor profile and clinical follow-up are summarized in table . six percent of the donors had a ferritin level below ng/ml; these donors were regular whole blood donors. the collections were well tolerated and no changes in vital signs were noted. four reactions were reported: hematomas and citrate reactions. no reaction was observed post-donation and hemoglobin levels measured before next donation were back to normal. the technique was easily implemented by the medical staff and fitted well in the existing blood center processes. the medical staff as well as the donors found collection duration short (average of min). the results of the survey were very favorable as more than % of the donors considered their donation and the information they received as satisfying. most of them agreed to donate again and several actually donated twice during the evaluated period. conclusion: the implementation of rbc collection in our center, using haemonetics mcs ® +, was successful in terms of ease of use of the technique, as well as user and donor acceptance. we now plan to evaluate donor loyalty in the longer term. risk from first-time blood donors e zhiburt, s golosova and p reizman federal blood center, moscow, russian federation introduction: each third dose of whole blood in russia is donated by first-time blood donor. there are two reasons for attention to this kind of donors: ( ) possible risk of infectious disease in seronegative study; ( ) possible risk of donation for person with contraindication. aim of the study: we investigated role of regional deferred donors registry (rddr) in by first-time donor selection. methods: moscow rddr includes parts: hiv, viral hepatitis, syphilis, tuberculoses, malaria, drug users, psychiatry, days after blood donation. rddr was complete and our center began actively work with it since last year. each donor has to be registered in rddr and automatically checked for deferral reason. effectiveness of rddr was investigated. results: first-time donors donate less than % blood in our center. about a quarter of them are deferred before possible donation. part of donors deferred by rddr has been significantly increase in (c = . ; p < . ) at the expense of seropositive people. conclusion: rddr is effective for blood donor selection and decreases necessity in laboratory screening. first-time blood donors have to be examined before blood donation. if they have not contraindications, donation can be performed up to days before examination and screening. the double unite platelet production is important especially if the relatives of patient find the donors. we evaluated the effectiveness two apheresis machine for platelet collection. in our blood bank, one fenvall amicus and one cs + apparatus were used for platelet apheresis. apheresis were performed between / / and / / . including criteria of donors are that estimated process time is smaller than minute and estimated postapheresis platelet count is higher than ¥ /l. donors firstly was enrolled to amicus. if amicus was busy, then it was enrolled to cs. the properties of our donor populations were given in blood and plasma cell components are obtained either by traditional manual method from whole blood or by apheresis. modern medical treatment is based on transfusion of deficient components such as erythrocytes, leukocytes or plasma proteins. this involves new solutions to achieve higher yields and better quality of such components. the aim of our study was to estimate the efficacy of blood cell separator cobe trima in obtaining platelet concentrates (pcs) as compared to older-generation cobe spectra blood separator. apheresis procedures were performed on both these blood cell separators. the quality of platelet concentrates was tested during day storage period (see table below ). we have tested the effect of apheresis procedure on donors and estimated the operating comfort of both separators. the tolerance of both separators was satisfactory except for more frequent hypocalcemia when trima separator was used. most donors were more satisfied with trima procedure because of single venipuncture although it involved special donor selection (good vein access). in general we may say that trima is undoubtedly a more modern and more friendly separator. however, cobe spectra may continue to be used with success especially when a more versatile cell separator is necessary (leukocyte concentrates, peripheral blood stem cells or therapeutic apheresis). methods and results: tls ( procedures on patients) were used successfully in patients with acute or chronic leukemia with hyperleukocytosis (white cell count > ¥ e /l or blast count > ¥ e /l) when high cell count would promote leukostasis with vascular occlusion in the microcirculation. performed tl procedures were rapidly reduced both the white cell count and the whole blood viscosity. average fall in white cell count after treatment was . %. tp-treatments ( procedures on patients with symptomatic thrombocythemia and/or platelet count higher than ¥ e /l) were applied in order to prevent the development of 'thrombotic-hemorrhagic syndrome' . the tps performed resulted with rapid platelet counts reduction ( . % in average) and with clearly noted clinical improvements, subsequently. tes ( procedures on patients) were performed using manually technique in patients with 'cellular hyperviscosity syndrome' induced by high red blood cell count. it was shown that te procedures resulted to red blood cell number lowering and decreasing of blood hyperviscosity. average fall in hemoglobin and red blood cell concentrations after te treatments was from . % till . %. rbcx treatment ( procedures on five patients with malaria and two with severe aiha crysis) was performed on an urgent basis, particularly when clinical symptoms indicate life-threatening situations and resulted with rapid and significant reduction of concentration of unwanted pathogen affected rbcs and summary/conclusion: the effects of tcs depended on the nature and stage of the basic hds, of adequate selection of patients and of timely applied apheresis. rapid cytoreduction is obtained justly in patients with excessively high cell count, and this effect did not associated with bone marrow remission. thus, tc should be looked upon as adjunct to the standard treatment of different cithemias, but not as replacement therapy. the present study indicates that the best therapeutic effects were obtained by rbcx. were carried out with continuous flow blood cell separator cobe spectra and all patients underwent large volume leukapheresis (lvl). in all procedures, a blood warmer was connected to the return line and a continuous calcium infusion was administered preventively. six patients, who were under kg body weight, had the extracorporeal circuit primed with irradiated, filtered packed red cells diluted with % albumin solution. seven children had vital signs and ecg continuously monitored during the procedure. results: each patient underwent a median of collections (range - ). the inlet blood flow ranged between . and . ml/min (median . ml/min). the median blood volume processed was ml (range - ). leukapheresis lasted a median of min (range - ). the median total nucleated cell yield was . ¥ e /kg (range . - . ), mononuclear cell (mnc) yield was . ¥ e /kg (range . - . ) and cd + cell yield was . ¥ e /kg (range . - . ). the median of mnc collection efficiencies was . % (range . - . ). in ( . %) patients, in only one apheresis procedure more than ¥ e cd + cell/kg were collected. during ( . %) procedures patients had experienced apheresis-related side effects. the citrate-induced reactions were most commonly observed. the reactions were mild and cessation of collection was required only in one case, because of catheter related complication. mild sedation was required only in few very small children. post-donation platelet count was less than ¥ e /l in cases and these patients required platelet transfusion before subsequent procedure. our results show that lvl in pediatric patients is relatively safe procedure, well tolerated and with a very low risk of serious adverse events. close monitoring of blood counts, especially platelets, between pbsc collections is necessary. the cessation of procedure was required in only one case and no life threatening side effects occurred. neonatal alloimmune thrombocytopenia (natp) caused by fetomaternal mismatch for human platelet (plt) alloantigens (hpas) worsens approximately / pregnancies and can lead to a serious bleeding diathesis, intracranial hemorrhage (ich) and sometimes death of the fetus or newborns. we describe the successful management of a -year-old pregnant woman, alloimmunized to the hpa- a (p a , zwa) antigen, with a history of two previously children with severe thrombocytopenia and ich. the pregnant woman was at her terminal pregnancy and was suddenly admitted. to evaluate the risk of ich in the fetus, cordocente was performed to demonstrate fetal thrombocytopenia (plt . /mmc). to ensure a rapid provision of compatible negative-antigen platelets, we decide to collect platelets from the mother using apheresis. plateletapheresis was performed using com.tec separator, fresenius. blood processed was . ml in a short time procedure ( minutes). no significant adverse effects were observed in the mother and fetus, during and after the procedure. platelets collected ( . ¥ e ) were transferred to the preparation set and plasma was removed after centrifugation to resuspend the platelets in octaplas ab. then we separated the platelets into two units containing . ¥ e each. the day after the donation, the mother gave birth to a girl by caesarean section. after the transfusion, the plt account increased from . /mmc to . /mmc and after a week the child had plt . /mmc without hemorrhagic complication. according to the literature data and our observations of the patients, there are changes of the hemostasis system indexes in the most patients with the endogenous intoxication syndrome and immune disturbances. in the number of cases medicamentous therapy appears to be not enough to normalize the changes, but it is especially important for pregnant women and women in childbirth, because on the background of these disturbances different complications of pregnancy and postnatal period take place. the aim of our study was the substantiation of plasmapheresis using in complex therapy of purulent inflammatory complications in obstetrics and immunoincompatible pregnancy with hemostasiologic disturbances. patients with hemostasis system disturbances: one woman in childbirth with exacerbation of chronic pyelonephritis, who had in the first hours some signs of hypocoagulation on the background of permissible blood loss (prolonged coagulation time up to - minutes with episodes of its absence on the background of the normal indexes of general coagulogramm, quantity and function of thrombocytes and the dilute fibrin monomer complex level in times higher than the norm) and nine pregnant women with the perinatal losses in anamnesis severed by the pregnancy (threat of abortion, places of fetal egg detachment). these women were examined, the following was revealed: the high antibody titer to chorionic gonadotropin, parameters of partially activated thrombin time were higher than the norm ( - seconds), thrombin time ( - seconds), the dilute fibrin monomer complex ( - mg%), coagulation time ( - min). in all these cases the conservative methods of treatment (antibacterial, hemostatic, hormonal therapy) were effective for a short period of time and they didn't succeed to correct the given parameters of hemostasiogramm. the discrete centrifugation plasmapheresis was included in the complex of medical treatment. the woman in birth operations were done, in the programme of plasma replacement during the first two plasmapheresis procedures donor fresh-frozen plasma was included. six pregnant women on the given stage one course consisting of plasmapheresis procedures for plasma replacement with crystalloids was done, the volume of the removed plasma was - % of the circulating plasma volume. three pregnant women before delivery were required two courses of plasmapheresis more consisting of - procedures each. the system heparin was not used. in all patients already after the first procedure of plasmapheresis the normalization of hemostasis indexes was marked, that allowed to prolong pregnancy, to prevent the coagulopathy bleeding and the development of disseminated intravascular syndrome. four women are discharged from the hospital, the other patients are observed with progressive pregnancy. thus, the using of discrete centrifugation plasmapheresis is effective at the signs of hypocoagulation in patients with isoimmunisation with fetal antigens and infectious pathology, and is the reserve in prevention and treatment of obstetric complications. extracorporeal photochemotherapy: an alternative therapeutic approach to control graft versus host disease after allotransplant with reduced intensity conditioning regimen c del fante*, c perotti*, gl viarengo*, p bergamaschi*, p pedrazzoli † and l salvaneschi* *irccs policlinico s. matteo, pavia, † ospedale niguarda cà granda, milano, italy background: extracorporeal photochemotherapy (ecp) can be defined as an immunomodulatory therapy that demonstrated to be efficacious in treating patients affected with graft versus host disease (gvhd) after allotransplants for oncohematological diseases. reduced intensity conditioning regimen (ricr) for allotransplant is a relatively new practice in patients (pts) ineligible for a conventional myeloablative conditioning regimen. the use of immunosuppressive therapy (ist) to control gvhd is limited for the high risk of developing infections and disease relapse due to the strong reduction of graft versus tumor (gvt) effect. aims: to evaluate the effectiveness and safety of ecp in treating pts affected with gvhd post rcr and the possibility to taper, at the same time, the ist. methods: pts ( females, male), median age . years ( - ), affected with agvhd grade ii ( ) and extensive cgvhd ( ) gtx with median total granulocyte doses of ( - ) ¥ per gtx corresponding to . ¥ granulocytes/kg in children and . ¥ granulocytes/kg in adults. the wbc counts increased from baseline values of . ( - . ¥ ) g/l for both pediatric and adult patients to peak values of . ( . - . ) ¥ g/l (children) and . ( . - . ) ¥ g/l (adults) at one hour after gtx and to . ( . - . ) ¥ g/l (children) and . ( . - . ) ¥ g/l (adults) at hours after gtx. in out of patients ( %), the crp levels significantly declined ( ( - )%; p£ . ) during the granulocyte transfusion period; in almost all cases ( / ; %) after the initial or nd transfusion. thirty-eight patients ( %) were alive at day + after termination of neutropenia and gtx. patients without crp response to gtx ( / , %) and patients with severe viral infections / ( %) were not among the day + survivors. background: in recent years, the use of platelet concentrates obtained from single donors by automated apheresis has grown steadily. plateletpheresis donation is considered to be a safe procedure with modern instruments. so far, no studies have identified donor or procedure specific factors that may be associated with serious adverse events. aim: to evaluate the incidence of adverse events during plateletpheresis procedure, over a five-year period in our hospital. materials and methods: eight hundred single-needle plateletpheresis collections were performed by using two automated intermittent-flow cell separators: of them with mcs p and with mcsplus (haemonetics), according to automatic standard protocols a p and ldplp, respectively (with the collection of an additional plasma unit). acd-a was used as the anticoagulant in all apheresis procedures (acd-a: blood ratio was : ). most of the donors ( % men and % women) were patient´s relatives. half-hour before the initiation of the procedure, mg of calcium ( tablet cal-c-vita) were administered to each donor. the mean platelet yield was . e /unit. the overall rate of the donor related adverse events was . %. feeling faint was the most frequent event, which was occurred in . % of donations. hypotension and citrate related rates were . % and . %, respectively. all citrate related symptoms were only transient perioral paresthesias, which were relieved by slowing the i.v. rate, without additional administration of oral calcium. donor unconsciousness was the only observed severe event, the rate of which was . %. other adverse events were venipuncture related ( . %), machine related ( . %) and miscellaneous complications ( . %). ( ) plateletpheresis using the mcs p and the mcsplus automated cell separators is a safe procedure, with a low risk of serious adverse effects. ( ) with the used acd-a-to-blood ratio ( : ) satisfactory platelet concentrates were obtained with very low incidence of citrate-related events. ( ) the peros administration of calcium before the initiation of the procedure, probably lowers the rate and the severity of hypocalcemia symptoms. quality assessment of ffp collected as a byproduct of plateletpheresis . from the donors immediately with the initiation of the procedure (citrated whole blood) and . from the final platelet concentrates after one hour rest at room temperature without agitation. in vitro platelet response to the aggregation-inducing agonists adp, collagen, ristocetin and arachidonic acid was investigated by means of an aggregometer (pap- c, bio/data). results: there were no significant differences between the groups of donors with respect to age, sex, smoking habits, preapheresis wbc and plt counts and hemoglobin concentration, as well as in the harvesting time between the two cell separators. our findings are shown in the following table. mildly decreased response to all agonists was observed (mainly to adp and arachidonic acid) in the samples taken right after the initiation of the procedure, in both groups. platelets from the final component showed a further slight decrease in response to adp, which was more prominent in the mcs p device (p = . ). on the contrary, an increase in platelet response to the other three agonists was observed in both devices, which, however, was statistically significant upon collagen and ristocetin stimulation. conclusions: reduced response to aggregation stimuli is possibly caused immediately with the initiation of the apheresis process. literature reports regarding further platelet traumatisation due to the procedure, are rather conflicting. in our study, such traumatisation was observed only in the case of adp in the mcs p obtained collections and this could be correlated with the technological differences between the two devices. recovery of platelet aggregability, as it was expressed by the upregulation in platelet response in the other stimuli, could be attributed to the resting period and seems not to be affected by the timing of the leucodepletion procedure. background: lupus erythematosus often is accomplished with severe symptoms, such as polyarthritis, nephritis, pericarditis or dermal alterations. in pregnancy cytostatic therapy affects gestation. on the other hand the course of disease can be refractory to corticosteroid therapy. elimination of autoantibody and immuncomplexes by plasmapheresis could be an efficient way to amend the severity of symptoms. a year old pregnant woman in the th gestation week with systemic lupus erythematosus showed severe symptoms like polyarthritis, nephritis and pericarditis. treatment was initially mg/kg bw prednisolone for weeks and subsequently mg/kg bw for weeks. plasmapheresis was applied daily in the beginning and continued depending on the condition of the patient ( table ) . the eliminated plasma was substituted by fresh frozen plasma. the medium volume was . ml per apheresis. after day plasmapheresis treatment was suspended to avoid problems with coagulation and was followed by a cycle of immunoabsorptions to eliminate circulating immuncomplexes. results: prednisolone therapy alone brought no effect even after changing to high-dose treatment. a significant amelioration of all symptoms could be observed after the first plasmapheresis. good condition of the patient remained stable over the period of daily plasmapheresis for days. intermitting apheresis treatment for one day lead to a significant aggravation of symptoms. apheresis no. again lead to a recovery of the patient which held on until day . conclusions: treatment of systemic lupus erythematosus in pregnancy especially in combination with resistance to corticosteroid therapy, is an effective therapy to ease severe symptoms such as polyarthritis, pericarditis and nephritis. exposure to cytostatic drugs can be avoided and therefore the impairment of the fetus can be reduced. background: the collection of mnc represents the first step of photopheresis procedures and could be of critical importance in achieving a therapeutic goal. in this work we compare the cell yield of two collection programs on cobe spectra device: the mnc versus the autopbsc program using the ecp procedure modified by andreu. methods: procedures were carried out with mnc program and procedures with autopbsc on patients with cgvhd. both hemoglobin increased from . ± . to ± mg/tu, k+ from . ± . to . ± . mmol/l, level of glucose decreased from . ± . to . ± . to . ± . mmol/l, ldh from . ± . to . ± . ukat/, lactate from . ± . to . ± . mmol/l, ph from . ± . to . . . the volume of apheresis units was lower than wb-rbc, the leucocyte count was normal in all units. the rbc loss by filtration was . ± . ml/tu and was lower than at wb-rbc. in apheresis rbc there were the differences in hb and ht value between the day of storage and , in wb-rbc there were no differences. during the storage period we found no differences in k+ increasing value and no change in ph value between apheresis rbc and wb-rbc, the increasing of lactate was higher in wb -rbc, increasing of ldh correlated to hemolysis. the plasma hb value increase was higher at apheresis rbc in contradistinction to literature. hb and ht correlation in apheresis units according to predonate value in donors was lower than at wb -rbc. the method is a useful alternative to conventional whole blood donation, we get rbc units with high standard of quality and low correlation according to predonate hb and ht value in donors. acknowledgement: the study is supported by grant iga ministry of healthy cr n. nr/ - . background: in life-threatening exacerbations of sle a satisfying efficient therapy is lacking. despite intensive immunosuppressive therapy some patients are resistant or contraindicated to conventional treatment. in particular circulating antibodies and immune complexes play an important role in the pathogenesis of sle and mctd. an extracorporeal removal of these pathological substances may be effective in the treatment of active disease. methods: five patients with severe therapy-resistant sle/mctd underwent immunoadsorption onto protein a. blood was drawn from patients by using a jugular catheter or a peripheral intravenous catheter. anticoagulation was performed with acd-a and heparine or acd-a and r-hirudine. plasma was separated by centrifugation. the . to -fold total plasma volume was treated in every immunoadsorption. the columns were floated with a maximal plasma flow of ml/min. the procedure was carried out every second day. additionally supplementary intravenous immunglobulin therapy was given only once. results: remission of the disease was achieved in four patients. see table below . conclusion: pa-ia is highly effective regarding the elimination of autoantibodies and circulating immune complexes, might induce a remission in patients with sle/mctd. it is an acceptable alternative treatment option in patients when other therapies are ineffective or contraindicated. background: purification of bone marrow from erythrocytes is used to prevent early hemolysis in major abo incompatible allogeneic hemopoietic cell transplantations. erythrocyte depletion is strongly recommended to reduce product volume and stem cell purification before storing autologous and even allogeneic bone marrow in order to prevent early hemolysis and dmso toxicity that might develop after thawing. centrifugation, sedimentation with hes, and cell separating devices are methods for erythrocytes depletion. aim: in our center, we prefer to use cell separation device, since it is a reliable method and has a high-yield and risk of contamination with erythrocytes is low. success of the process is retrospectively analyzed for high and low volumes. method: erythrocytes depletion of bone marrow harvest was done in hemapharesis unit with cobe spectra device in the last five years in cases with bone marrow volume over ml, and cases with bone marrow volume under ml. fifteen of these cases were allogeneic, and were autologous procedures; a software uploaded with cobe pbsc coll vers . and (catalog no: - - ) set was used in the procedure, and at the same time, double bag system with intermediate connectors were used to prevent re-circulation (catalog no: - - ). results: the mean volume reduction was . % ( . - . ) for volumes over ml, and . % ( . - . ) for volumes less than ml. regarding the success of the procedure no statistically significant difference was found between procedures with high and low volumes. no complication developed related to the device or product, and waste bag never had to be re-used. in none of the patients early massive intravascular hemolysis was observed. conclusion: erythrocyte depletion and volume reducing with cell separation device is a reliable method. this process is successfully applied with high volumes (over ml); and in low volumes as well for reducing erythrocytes, and gain of mononuclear cells and cd + cells. platelet concentrates obtained by apheresis procedure-correlation between the initial count and the final concentration v srejic*, g bogdanovic*, z garic*, n vavic* and b balint † *national blood transfusion institute, † military medical academy, belgrade, serbia apheresis team of the national blood transfusion institute processed and classified data of donors who donated platelets by apheresis procedure from january till april . procedures were performed in accordance with the ldplp protocol, using haemonetics mcs+. initial donors' platelet count and the absolute platelet concentration in the final preparation were followed, as well as red blood cell and leukocyte contamination and the volume of the processed blood. donors' initial platelet count was not less than ¥ /l and the volume of the processed blood was not less than ml. according to histogram, the most frequent donors' initial platelet value ranged from ¥ /l to ¥ /l ( %). final concentration of the samples of tested donors ranged from . ¥ to . ¥ in the average volume of ml. regression analysis demonstrated that there was a correlation between the initial donors' platelet count and the obtained final concentrate. student's t test showed p < . . leukocyte contamination of the final concentrate prepared without the filter ranged from . ¥ /l to . ¥ /l. presence of red blood cells in the final concentrate ranged from . ¥ /l to . ¥ /l. p- therapeutic apheresis (ta) in croatian hospitalsadherence to respectable guidelines z zivkovic*, b jeren strujic*, s boras † , i bojanic † , b golubic cepulic † and z ivankovic † *clinical hospital dubrava, † clinical hospital center zagreb, zagreb, croatia introduction: besides considerable resources, ta requires high costs and risk for patients. therefore, indication for ta often considers interests of patient, hospital and requesting physician. the most respectable guidelines for the implementation of ta were defined by aabb and asfa, classifying total of diseases into categories (ctg), ranging from 'standard therapy' to 'lack of efficacy' . the objective of this study was to determine indications for ta performed in croatian hospitals in the period - , respecting aabb/asfa guidelines. results: during the observed period in croatia, ta was performed in patients suffering from various diseases. in ( %) patients ta was performed by membrane filtration, while in ( %) separation by centrifugation was used (table ) . according to the ctg, s of the aabb/asfa guidelines, ta was performed in ( %) diseases from ctg i, ( %) ctg ii, ( %) ctg iii, and ( %) ctg iv of patients. the most frequent indications included in ctg i were: myasthenia gravis ( %), collection of pbpcs ( %), sy. guillain-barré ( %), and plasmacytoma ( %). in ctg ii frequent indications were: poisonings ( %), systemic lupus erythematodes ( %), and rapidly progressing glomerulonephritis ( %), and in ctgs iii and iv: cytoreduction-polycythaemia ( %), thyroid storm ( %), gvhd ( %), and reumatoid arthritis ( %). ( ) the time spent for resolving h / , ( ) mtp / , ( ) discarded blood units / . iii group: wrong data input / , donor replacement / , marking errors / , error in determining blood group at the first blood taking / , errors in input medical consulting / and disregard of prohibitions / . the consequences are: ( ) the time spent for resolving h / , ( ) mtp . / . , ( ) discarded blood units / . conclusion: the analysis of errors has showed that the number of errors can be decreased by implementation of corrective/preventative action based on continual education of the staff, appropriate sop, effective organization, qmp for equipment. the conclusion of our study is that reducing the rate of work errors will decrease the waste of material and time, also that will decrease the number of discarded blood units. an iso standard for blood transfusion? background: in our search for an independent, objective assessment at western province blood transfusion service, we were unable to find one single model that met the specific requirements of blood transfusion. we therefore resorted to developing our own model but ask the question: why not have one international standard for blood transfusion? aims: our aim was to have a standardised system for the independent, objective assessment of our blood transfusion service with audits carried out by an internationally recognised body. we wanted a formalised, professional system of accreditation with inspection checklists, reports, certificates etc. methods: having moved away from accreditation by the american association of blood banks in mid 's, we evaluated various other options such as inspection by our government department of health or the world health organisation but neither organisation had trained inspectors or systems in place. we also investigated iso certification but, although this was acceptable on the quality management side, it did not cover the technical parameters relating to blood transfusion. results: we therefore developed our own model for accreditation that consists of three parts: • a quality management section incorporating iso principles; • a technical section incorporating specifications from the south african standards of practice (we also consulted the european, american, canadian and australian guides); • a laboratory section incorporating iso parameters (soon to be updated with iso ). we then chose to be accredited by the south african national accreditation system, sanas, an internationally recognised institution. once we had written a national accreditation checklist, sanas submitted this to two international accreditation bodies (iaf and ilac) for approval. the system has been in place for three years now during which time we have had four successful assessments. summary/conclusions: in developing our system, we reviewed what was being done elsewhere in the world and it became evident that, although there are great similarities between countries, there p- software for the management of the scansystem bacterial detection method the scansystem tm was developed for bacterial detection in blood products. to be implemented in blood banks, a specific software is now available in compliance with blood bank regulation in order to manage sample traceability and data file transfer. the software is divided in main levels: an administrator level to create an application configuration in compliance with customer needs (product bar code characteristics, frequency of the positive controls, manual or automatic data file transfer . . .), a technical level to manage the operators (password, id) and to validate some specific results, an operator level for routine testing. the software assess sample traceability when testing pools of samples from to more than . indeed, bacterial detection is performed for pools of to platelet samples and to red cell samples. each sample in the pool is traced through its barcode until the final result. the system is compatible with most of the barcode standard including isbt . in addition, the system checks each barcode protecting the sample against duplicate testing. the software assists and monitors the bacterial detection process from the sampling to the end of the test (final result), each step of the procedure is identified through its barcode and at each time, it is possible to know the test status for each sample. for a pool of samples, results can be obtained: 'negative' or 'on hold' for a positive result. for a 'negative' pool, each sample constituting the pool are determined as 'negative' . for an 'on hold' pool each sample constituting the pool must be tested as a single sample and the final result is 'negative' or 'positive' . data transfer may be manual or automatic. a final technical validation is necessary before the transfer through an active selection of results to download. final results are provided in a compliant format for an easy import into the blood bank database. all necessary information are displayed: 'machine id' 'product/sample barcode id' 'date' 'time of transfer' 'operator id' 'result' ('negative' or 'positive'). the main advantage of this software is a continuous check of each step reducing the risk of error in testing. it makes the scansystem tm test compatible with a routine use in blood banks according to the current regulations and quality assurance programs. is no overall consistency. we feel it would be of benefit to establish an international working group to investigate the feasibility of writing an iso standard for blood transfusion. the standard would harmonise quality management parameters based on iso principles and technical/laboratory parameters specific to blood transfusion. minimum technical specifications would need to be agreed upon based on the various standards and guidelines available around the world. this iso standard could then be used for the purposes of certification/accreditation or government inspections. this would ensure global standardisation of world-class best practices. first world countries would be able to achieve compliance and a subsequent step could be the establishment of an international forum to assist developing countries to work towards compliance in the longer term. residual leukocytes in leukoreduced cellular blood products -evaluation by flow cytometry web-based outcome review: do you know how productive your trima® can be? background: web-based outcome review is a new software tool developed by gambro bct for the management and the interpretation of data from the trima and trima accel tm automated blood collection systems. aim: does the interpretation of reports obtained through outcome review lead to an increase in the number of products per run and the overall productivity of the apheresis center? method: run data files (rdf) from trimaᮀ were collected and transferred onto the outcome review server. these rdf do not contain any donor related data that can lead to possible donor identification. the reports were generated on the outcome review website (gambro bct intranet), interpreted by a gambro bct employee and presented and discussed with the management of blood centers. results: a total of different reports can be generated on the website as a pdf file. for this study, reports were investigated. they are: doses per collection, doses per collection trend, platelet collection trend, platelet procedure performance, platelet procedure performance trend, product distribution, average procedure time, procedure time, machine productivity trend. the results obtained for a center can be compared to word-wide, national, regional or to other individual trima devices in the centre (benchmarks). this benchmarking allows the management of an apheresis center to compare the results, to draw the right conclusions and to develop and implement corrective actions. implementing successfully these corrective action plans will lead over time to productivity results that are more in line with the figures that are generally accepted to be the optimal production capabilities of trima. the reports also help to monitor the effects of the corrective action plan over time and to adjust this plan if the results are not in line with the expectations. reaching and maintaining the optimal production capabilities of trima will also increase the net revenue by procedure or decrease the cost by procedure for the blood centre. conclusion: web-based outcome review allows getting more products from the existing donor base by interpretation of the multiple reports and implementing the required corrective actions until optimal production capabilities of trima are reached and maintained. introduction: to examine the cell vitality of packed rbc's during storage several parameters like atp, free hb or , -dpg are used. less kits for the determination of atp are available and they need either a large sample volume and/or are time consuming. here we present the modification of a commercial testkit for a time-and cost saving detection of atp. methods: samples were analysed with (a) -phosphoglyceratekinase reaction according to bergmeyer, h. methods of enymatic analysis nd. edition. academic press, new york ; (b) detection via hplc and c) using a commercial testkit (r. greiner bio-chemica, germany). the atp-kit were minimized from ml to a total volume of ml and tests were performed in microtiterplates. results: samples were analysed in hplc and modificated commercial testkits, another samples have been examined in all tests. comparison of the results showed no discrepancies in the above mentioned methods. standard curves have been performed (range - mm atp) and statistical analysis demonstrated a given linearity (r = . ). variability has been calculated as . % (intraassay; n = ) and . % (inter-assay; n = ). the hand-on-time calculated for samples has been decreased from . hours to minutes. at least the costs of atp-determination have been reduced from € . to € . per sample. conclusion: performance of test kits in microtiter format is a fast and rapid method, reliable for high-throughput determination of atp in packed rbc's. background: in order to preserve both blood safety and availability it is mandatory that a minimal amount of blood units would be discarded due to defects in the materials and supplies used for blood collection, or to deviations in blood processing or storage. aims: ( ) to monitor the derangements of different materials and disposables used during blood collection and processing, and to study the suppliers' responses and corrective actions taken. ( ) to asses the relative contribution of different defective materials (dm) to the need to discard valuable blood components. materials and methods: about whole blood units were collected and processed by mda national blood services in [ ] [ ] [ ] . as part of the routine quality control activities, derangements of the dm used were recorded and analyzed. some different types of dm were defined. out of reports sent to the corresponding manufacturers for investigation, responses ( %) were received and analyzed. about % of dm were detected during blood collection. manufacturer defects of different materials were the reason for components discard in nearly % of cases. conclusion: defective materials are one of the major causes of the infringements of blood collection and blood component preparation processes. analysis and monitoring of the different defects and of the suppliers' responses and corrective actions are essential to improve products' safety and availability. establishment of a network for the exchange of information among international blood centers would enable the blood banking community to compare between different suppliers and to use the documented cases for training of personnel of both the blood services and the manufacturers. such a system may contribute to the improvement in quality of materials used and might lower the discard rate of valuable blood units. results: table analysis and characteristics of t ( ) comprehension of the blood bank's processes and the interaction between them and between the processes of the whole hospital. ( ) monitor, measure and analyze these processes, in order to improve their effectiveness continuously. ( ) implementation of internal and external quality controls for blood and blood products and implementation of appropriate statistical techniques for monitoring their results. ( ) identification of interested parties (doctors, donors, patients) satisfaction and taking up the necessary preventive or corrective actions to improve their satisfaction. the qms of our blood bank was certified by tuv rheinland in / / and the scope of the certification is: 'blood collection, testing of infections markers, production of blood components, compatibility screening for blood transfusion and other immunological tests and implementation of therapeutic schemes in thalassaemia patients' . the implementation of the qms based on iso : standards ensures the improvement of services provided by the blood bank and the increase in customer satisfaction, whether donors or patients are concerned. the former enjoy the respect and recognition of their social contribution, while the latter are assured of very high levels of service and health protection. finally, we shall not underestimate the positive impact of qms in the motivation of blood bank personnel. quality becomes integrated both in their professional and personal attitude and allows for achieving increased satisfaction from their work. equipment management in the national blood transfusion service in serbia introduction: new equipment was urgently needed in three blood transfusion establishments (bte) in serbia. equipment was mostly inadequate for core blood transfusion activities, placed in inappropriate facilities, very old without routine maintenance or calibration. also, technical documentation for most of the equipment did not exist, and procedures for equipment management and responsibilities were not defined. further more, coordination on equipment issues with the qa department was not recognized. service funded by the european agency for reconstruction, provided various equipment for the three blood transfusion establishments. the new equipment includes blood collection equipment, centrifuges, refrigerators, incubators, automated testing equipment, genetic analyzer and it equipment of . million euros value. before the new equipment is installed the bte's agreed to have the national procedures on installation, validation, calibration and preventative maintenance in place. this will ensure that the equipment can be properly installed and validated before use. the project has provided training on validation to the working group (wg) on quality. the wg has created national procedures related to the equipment, including quite new term validation. the same problems in implementation of procedures were present in all three bte's. significant efforts are made to explain to the staff how the equipment has an impact on quality, how to ensure that the equipment does what it is supposed to do, how to be confident that the results obtained are accurate and how important it is to generate records. qa managers played an important role in the preparation of facilities for equipment installation, making plans for equipment layouts, creating documents (master cards, instruction for use) and designing the validation protocols. the same procedures and records enable an exchange of results, comparability, sharing information on what works and what does not work between bte's. the qa managers also prepared an introduction of equipment requirements to the heads of departments, with special attention to the validation process so that they are able to fully understand what is required and why to validate their equipment. results: national standards in equipment management in serbia are set and are being implemented. qa managers carefully managed that the new, numerous equipment, delivered in the short period of months was correctly installed, validated, obtained with necessary documentation, followed by previously trained staff, so that equipment can be considered as controlled. the additional, positive effect is that validation is performed in one establishment for all bte in the country, allowing a more prompt response to problems and presenting of joint request to suppliers, as well as an easier way of monitoring equipment performance of the three bte's. organized equipment management has affect on every aspect of blood activities and finally to the quality of blood and blood components. background: the vista information system (vista tm ) is used in centers in europe as an apheresis management system. with vista tm it is possible to increase productivity, donor comfort and loyalty and therefore simultaneously improving the overall process in the center. aim: a calculation tool (microsoft excel) was developed to evaluate the added value of vista tm . three blood centers in different european countries completed a questionnaire using their local data. summarizing these figures gives us an idea about the impact of vista tm on the daily work and budget of a blood centre. method: the excel calculation tool that was used investigated major areas where vista tm could show added value: improvement of regulatory compliance, increase the efficiency in operations and improve productivity. results: regulatory compliance: the number of infringements decreased, causing a considerable direct financial gain because these events are very expensive to deal with. the time spent on regulatory reviews decreased with a mean value of %. operational efficiency: the number of reports is very site dependent: sometimes a report is made for every procedure together with the printout of a blood loss history form. because vista tm tracks all procedure related data, some sites decided to stop printing these types of reports and to go completely paperless. the percent time reduction in reporting is therefore very variable. however the % of errors related to these reports decreased considerably with a mean value of %. efficiency in operations was also obtained because of the number of reports that are available in vista tm . productivity, management and process reports allow verifying and correcting the daily operations of the blood center. increased productivity: depending on the center, also an increase in the number of platelet and plasma products collected was detected. the number of product discards caused by infiltration reduced with a mean value of %, mainly due to the possibility to have customized and more donor adapted trima settings. the percentage of whole blood donors targeted for conversion was very site dependent (min . %-max %). but because with vista any procedure brings between . and . products in general, the financial gain was considerable when donors could be converted from whole blood to apheresis. the use of vista allows the apheresis center to work with a reduced error rate and to increase the operational efficiency and the productivity. the financial impact of this has been estimated by the centers between € and € (mean value €) per procedure. establishment of national quality system in blood transfusion service in serbia introduction: the production of blood products is a semiautomated process in which the manual steps may be difficult to control and standardize. aim of the study: we introduced a specialised team for the blood production to test if this improved the control of the quality of the blood products. methods: the blood products tested for statistical process control were red cells in additive solution, buffy coat removed, and leukodepleted (ld) platelet pools prepared from buffy coats. the products were collected in t&b triple opti-pac from baxter and the platelet pools were ld using plx- filters from asahi and stored in platelet bags from baxter. using control charts, namely x-mrchart, exponentially weighted moving average ewma chart and for autocorrelated stationary data the ewmast chart, we examined if time series of quality control values were in statistical control. if not we examined if autocorrelation and/or differences between the technologists producing the blood products could explain the lack of control. data included approximately biweekly measurements of volume, haemoglobin (hb) concentration, hb/unit, haematocrit and log leukocyte count (wbc)/unit of units of red cells, measurements of volume, platelet concentration and platelet count/pool of ld platelet pools produced by a team of technologists and of ld platelet pools produced by a specially trained team of four technologists. results: log wbc/unit was out of statistical control due to systematic differences between technologists. apparent lack of control of volume, hb-concentration, hb/unit caused by autocorrelation disappeared when the ewmast chart was used. platelet concentration and volume of the platelet pools produced by the technologists were out of control. in that some technologists systematically produced low values. this could be explained by inappropriate handling of the platelet product between centrifugation and separation. systematic differences between the four specially trained technologists could not be demonstrated and they produced platelet pools with a significantly higher platelet count/pool. however, standard deviations of the four technologists differed significantly causing occasional outlying values. conclusion: training and routine in blood production or process automation, and also importantly, feed back to the technologists based on control chart quality control data, is recommended. background: one important principle of the use of blood and blood products is the ability to trace the units from donor to the recipient. this study set out to establish whether or not there was sufficient reporting on transfusions from the hospitals supplied by fort portal regional blood bank in western uganda as a means of establishing sound haemovigilance and look back systems. were reported with no unit number and could not be traced to the patients. there was sufficient reporting on the data requested by the blood bank. these results suggest that it is possible to establish effective 'look back' and haemovigilance systems. capture of data on outcomes and adverse effects will be necessary to fully establish the system. further efforts are required to educate those involved in transfusing blood about the need for adequate and accurate documentation. external quality assessment of blood grouping were misinterpreted as rhd-positive samples without the use of control reagent. rbc phenotyping was made correctly by . % of participants. the remaining . % of participants carried out the phenotyping incorrectly, while false-positive and false-negative results were derived in . % and . % of cases correspondingly. polyspecific human sera and monoclonal antibodies were used for abo, rh and antigens typing. the reason of errors in antigen detection was low quality of reagents. antibodies identification was carried out in six distributed exercises. % of participants detected anti-d-k-c alloantibody correctly. the rest of participants did not found alloantibodies or detected their specificity incorrectly. results of testing depended on quality of screening cells. thus, the participants using homemade pooled screening cells had a significant lower detection rate of antibodies comparing with those using diamed ag cell panel. consequently, the results of the first federal external quality assessment scheme show the necessity of improving the quality of red cell reagents produced in russia. in addition, the more appropriate training of staff is required. the importance of iso -quality system in increasing safety of blood transfusion introduction: hadassah hospital transfusion medicine department received on / iso -quality system accreditation. an essential element of this standard is the development of a reliable system to identify, document, analyze and correct actual and near miss events and assess the effectiveness of corrective and preventive actions. aim of the study: assessment of events and corrective actions following implementation of iso quality system. methods: events in the blood bank were identified by the staff, by internal or external audits and by complaints from the wards. all events were recorded and classified into two categories; quality system and technical. the latter were further classified into preanalytical (sample receipt), analytical (abo rh typing, antibody screen and identification, cross matching and phenotyping) and post-analytical (issue of components to wards). all events were graded into levels; -most severe, potentially harmful to patient. -severe, damage to process and result. -moderatly severe, damage to process only. -benign, no harm. events were corrected and effectiveness of corrective actions was assessed by monitoring recurrence of the event. results: during the years - , events were detected and recorded in the blood bank, they comprised . % of all tests performed ( ). most of the events were technical. all events were detected before causing harm to the patients. results are summarized in the table. *the percent analytical value is a summary of rates of events per test types included in this category. events detected in the quality system were mainly of severity level & , whereas technical events were mainly of severity levels & . analysis of event recurrence in the quality system revealed that % of events were resolved, whereas only %- % of technical problems were completely solved. the main source of event identification and documentation, in the quality system were audits whereas in the technical system, staff members revealed most events. the implementation of iso quality system provided a powerful means for recognition, analysis and study of patterns of near misses and actual events. understanding the root causes of events enables to choose the most effective corrective and preventive action to control event recurrence. evaluation of the frequency of events confined to the blood bank revealed a very low rate of . %. these results are in agreement with data in the literature. creating a non-punitive, non-stressing open environment, motivates personnel to identify and document events, which are regarded as opportunities for improvement and serve as important tools for upgrading transfusion safety. the explosive use of information technology and the speed with which it has spread into all life activities has created vulnerabilities for all organizations. those vulnerabilities are compounded by the complexity of information technology, limited time to market, development constraints, and constantly changing relationships between organizations and suppliers. growth in the sophistication of security threats makes it imperative that organizations remain equally competent in identifying vulnerabilities and mitigating security risks. aim: the goal of this document is to explain how isbt intends to provide guidance to the blood banking community on implementation of effective information security policy. when using information for critical activities, blood banks should consider information security as an important aspect of their management policies. evaluation of existing standards, such as iso and hipaa, allows us to establish a framework for information security without regard to the type of organization. it remains very difficult however, due to the complexities involved, to establish an information security policy without guidance. method: the isbt information task force was created to provide guidelines on information security for blood banking organizations of all sizes. the intent is to help them understand existing standards as well as provide tools for implementing information security policy. these guidelines are based on existing standards that are followed by most worldwide countries: iso and hipaa. results: information security can be defined as the 'protection of systems, information and services from accidental and deliberate threats to confidentiality, integrity and availability' . understanding existing information security standards was the first step for establishing a structure for the guidelines. the core is organized within an implementation framework and presented under the three following layers: . administrative for defining the it security organization, the information security policy, and information security awareness and training. . physical for providing solutions that relate to physical environment protection and access, equipment and it infrastructure security, and control for accessing computerized equipment. . technical for maintaining confidentiality of electronic information and ensuring that authorized access to information systems is maintained (technology relating to identification and authentication, logical access, operating system, network management, application access, etc.). strategy guidance is also included for senior managers in charge of establishing organization policy, including responsibilities and methods to successfully implement policy. further, the task force is addressing both risk analysis and management including identification of potential dangers to information systems (threat-source) and existing controls (risk description), as well as a plan to address identified vulnerabilities and mitigation of specific risks. conclusions: information security standards are prerequisite to understanding the issues involved when considering information vulnerability. international guidelines for information security, specifically directed to the blood banking community, are equally necessary if we are to identify, plan for, and mitigate risks associated with vulnerabilities to critical blood banking information. the isbt task force is committed to providing such guidelines. introduction: the important part of quality planning and quality assurance within production of blood components is measurement system analysis (msa). measurement system analysis was performed on microscopic counting of blood cells in our study. aim of the study: aim of this study is determination if microscopy counting of residual elements in whole blood plasma is suitable for quality control of blood components. methods: we practiced measurement system analysis in counting of residual elements (leukocytes and erythrocytes) in whole blood plasma. the counting performed two lab technicians in ten samples of plasma from whole blood. leukocytes and erythrocytes were measured in naggeotte counting chamber. we used the method of mean and range for the determination of reproducibility and repeatability (r&r) and analysis of variance for complex measurement system analysis. regulation diagrams were applied for the graphic statement. we determined the value of repeatability, reproducibility, coefficient r&r, variability among samples of plasma and total variability of measurement system. the important conclusion was to determinate if the microscopic counting of samples of blood components is sufficient with regard to quality parameters specified in guide to the preparation of blood components (erythrocytes: < . ¥ /l, leukocytes: < . ¥ /l). our results show that microscopy counting of residual elements in whole blood plasma is suitable for quality control of blood components. aim of the study: to provide transfusion services with a tool for proper qms implementation, an international collaborative study on qms applications, employing the 'process approach', has been undertaken by a group of transfusion services of varying sizes and structures with experience of qms, in collaboration with a university institute offering a master in qms implementation in health services, and an expert from a quality association. the 'process approach' serves as a tool to manage transfusion activities as a system based upon a network of processes and their interactions. guide-lines have been produced based upon this principle and will be published (volume and cd-rom) and distributed at no cost to all transfusion services of nations participating in the study. the main contents of the guide-lines' chapters are: through definition/analysis of single processes and the correlation network amongst these, the 'process approach' methodology renders the transfusion centre's functioning units completely interdependent, eliminates process interface barriers, provides personnel with a unified focus on the main transfusion objectives, and lays the basis for improvement of transfusion service quality, organization and performance through efficient control of processes' interactions. the blood screening system automated high-throughput nat system for simultaneous screening of hcv, hbv and hiv nucleic acids: full process surveillance e pfeifer*, b alessandri † , hr bachmann † , t barker † , y ohhashi*, c parkhouse*, j pinsl-ober ‡ , p wenzig ‡ and g ziegler ‡ *roche molecular systems, inc., pleasanton, usa, † roche instrument center ag, rotkreuz, switzerland, ‡ roche diagnostics gmbh, penzberg, germany introduction: the blood screening system combines on one deck both automation of dna/rna extraction from blood/plasma samples and multiplex pcr amplification and detection of nucleic acid targets. the system is designed for high-throughput single unit testing and pooled specimen processing. a data management system supervises and controls the complete process from initial sample pipetting through to result compilation and reporting. the objective of this project was to present the system assay and device built-in quality control measures that guarantee process safety and reliability. the study shows how internal control, external batch controls, pipetting sensors, validation & maintenance procedures, and a controlled development & manufacturing process yield an optimal test method and system stability. method: failure modes and effects criticality analysis (fmeca) was used to evaluate a mathematically derived safety metric for optimizing risk reduction. this method makes use of a system risk objective-function (srof), which provides a multivariate description of sample processing, amplification and detection steps. the method for analyzing system behaviour first employs product classification into risk domains, followed by ranking of process steps that are determined to be linked to known system hazards. this provides objective means for directing system design leading to risk minimization. the srof responses associated with redundant liquid sensing channels were shown to substantially reduce risk during sample or reagent transfer steps. the system liquid flow, airpressure-based (plld) and capacity-coupled liquid (clld) sensors detect aspiration and dispensing inaccuracies. sensor signal tolerance band widths studied for fluid classes representative of system reagents and for plasma samples from lipemic, icteric, and hemolized sample sources were shown to correlate with srof multivariate modelling. the impact of surveillance design elements on the srof response demonstrates that risk is functionally dependent on design elements. additional surveillance examples are presented that describes temperature sensing, robotic positioning and motion control. treatment of residual risk is addressed by introducing external controls that are configurable to specific workflow scenarios. the negative external control (nc) is used to check for contamination of reagents. five low concentration armored external controls, i.e. hiv- group m arna, hiv- group o arna, hiv- arna, hcv arna, and protected hbv dna are run at the beginning of a batch as a run-control measure. in addition to these roche controls the system supports running of user-defined external controls for co-validating the batch. the internal control (ic) is based on armored hiv- group m rna that is co-extracted and co-amplified with the external controls and the target nucleic acids potentially present in the sample. lastly, the system resource management monitors the status of samples, ready-to-use reagents and disposables via rack sensors and bar-coded bottles and tubes. the fmeca methodology provides a risk-minimized, comprehensive system design. redundant sensors with internal and external controls are evaluated through comparison of modelled versus actual run results. the system brings a new level of surveillance and throughput for automated pcr testing, and emphasizes roche's commitment to increasing the safety of the global blood supply. technical standards for safe storage and transport of blood components and blood samples objective: to implement standardization of technical specifications for safe storage, transport and distribution of blood samples and blood components intended for transfusion, as part of a quality system in blood transfusion medicine. methods: in the course of implementing a quality system in our blood establishment (distributing % of the national blood supply), we have developed standard operating procedures (sops) for temperature and hygienic conditions to maintain and control storage of blood components during their shelf life and to ensure their safe distribution to other blood services in the country and abroad, in compliance with eu directives / /ec and / /ec and the recommendations of the council of europe and who. procedures are validated and relevant records are kept. a statistical process control is also in place to monitor deviations from specified temperature and time range throughout the period of transportation. blood components collected and prepared for specific purposes (e.g. directed donations, irradiated units, hla-typed units, anti-cmv negative blood components and blood for neonates) are stored separately, and alarms and warning systems are in place. packing and transport conditions of red cells, platelets and ffp are submitted to the tests and criteria of adr (european agreement concerning the international carriage of dangerous goods by road). in greece, the adr legal framework has applied since . blood samples are classified according to adr in division . under un as diagnostic specimens, and the criteria for safe carriage include packaging, specific labelling and vehicle requirements as well as carrier obligations and personnel training. our blood establishment has a contract with biotrans, a private company accredited for packaging, storing and transporting blood, organs, tissues and cells as well as potentially infectious biologic substances and blood samples for diagnostic purposes. assurance system). the approach is specified in the form of requirements of art. . of the standard: the organization shall: (a) identify the process needed for the quality management system and their application throughout the organization, (b) determine the sequence and interactions of these processes, (c) determine criteria and methods needed to ensure that both the operation and control of these processes are effective. regional centre for transfusion medicine in biaĺystok was the first transfusion service in poland which was certified according to iso : standard. our expected profits from the implementation qms were: possibility to overview organization's pathways of operation and to inspire corrective and improvement actions, emphasis on the role of staff in the system, focus on self-control and responsibility for one's own work as a factor of staff's mentality creation/modification. our one year of experience with iso : standard proved the system to be handy tool of management for the organization collecting, processing, testing blood and releasing of blood products for the hospitals and to be well accepted by the staff. the implementation and certification of the internationally nor-malized quality management system simplify and shorten all accreditation and registration procedures required for legal activities of transfusion service as well as for any supplemental medical activities which may be performed by the centre. the implementation of qms facilitates the implementation of other quality systems and simplifies procedures required for the ce certification for the products. red blood cells stored in blood banks, normally undergo a series of chemical alterations, or storage lesions. the ultimate consequence of these lesions is a decrease in the viability of the red cells following transfusion. the chemical alterations are mainly changes in levels of na+, k+, cl-concentrations, ph and , dpg levels and they affect the electrical impedance of blood. the electrical impedance, cole-cole parameters, is determined mainly by the resistance of the red cell extracellular fluid (re), the resistance of the intracellular fluid (ri) and the capacitance of the cell membranes (cm). in this study we aimed to investigate the relation between blood parameters and electrical impedance changes, and their further clinical implication. all parameters were measured on erythrocyte suspension (es) samples during days of storage at oc on days , , , and . for whole blood (wb) samples during days of storage, same parameters were measured on days , , and . the measurement of the complex impedance of blood samples were performed in the frequency range from khz to mhz. by using the a hp lcr meter, the impedance z, and the phase angle a for each sample were read. these values were corrected according to the gain and phase characteristics of the amplifier; and the resistance r and the reactance x were calculated. each data was first fit to the cole-cole model; hence the cole-cole parameters, intracellular resistance ri, extracellular resistance re, characteristic frequency fc and phase angle a were obtained by using lms software. afterwards, cm was calculated by using ri, re, a and fc. whereas ri and cm decreased progressively with time on both wb and es, re changes showed some differences. the electrical impedance alterations were explained by measurements of na+, k+, clconcentrations, ph and , dpg by indicating days. storage of red cells resulted in a rise in extracellular k+ and a fall in extracellular na+, cl-, ph and , dpg. anova was used to evaluate differences in blood measures in relation to storage time. the results were presented as the mean ± sd. according to the regression analysis in spss, the intracellular resistance (ri) on both es and wb was affected more efficiently from all blood parameters among all other electrical parameters. although ri and re were correlated with na+, k+, cl-, ph and , dpg more significantly, cm measurements were failed to show correlations with blood parameters because of the intervening parameters, a and fc. the best relationship between the parameters mentioned above on both es and wb was ri and k+. ph changes were the same for ri and re both for es and wb. the correlation between parameters on es was better than those on wb, because whole blood consists of several particles that may affect our measurements. our study showed that , dpg has an effect on ri and re as efficiently as other blood parameters and therefore electrical impedance measurements may serve future implications. background: issue of quality blood products and donor safety are the main aims of blood transfusion services. a comprehensive quality system should be in place to fulfill these aims, which can be attained through strict adherence to the established standard operating procedures (sops). the drugs and cosmetics act of india, which controls the licensing of blood transfusion services, does not provide clear guidelines regarding plateletpheresis procedure. aim: we therefore established our own sop and operational flow chart for plateletpheresis that can be easily followed by other centers in india. methods: a total of plateletpheresis procedures performed using two cell separators (cs baxter, usa, mcs p, hemonetics, usa) were evaluated following our established sop. the mean platelet yield in cs was . ± . ¥ and in mcs p, it was . ± . ¥ per unit, however, only - % of sdps showed wbc levels < ¥ . six of donors complained of hypocalcemic symptoms. the operational flow chart designed in this study was found to be simple and easy to adapt by blood transfusion services in this country. the first advanced quality management training course for blood transfusion services in the western pacific region mk tan*, jp yu † and d teo* *health sciences authority, singapore, † who regional office for wpr, manila, singapore background: blood transfusion is a key part of modern medicine. a well-organised blood transfusion service (bts) is a prerequisite for the safe and effective use of blood and blood products. in , the world health organization (who) introduced a new initiative of quality management project (qmp) to achieve the goal of safe and adequate global supply of blood. through qmp, regional training centers were identified and quality management training (qmt) courses were established. in , centre for transfusion medicine (ctm) of health sciences authority singapore was appointed as a collaborating center for qmt in the western pacific region (wpr background: spectrophotometric method according to harboe was traditionally used at our institute for determination of free haemoglobin in supernatants of rbc blood components at the end of storage time. in the year hemocue plasma low hb system (hemocue, sweden) was introduced as a replacement method. aim: the aim of the study was to examine reliability and suitability of the hemocue method for measurement of free haemoglobin in supernatants of rccs. methods: hemocue plasma low hb method was validated and compared with harboe method. supernatants of rbc products were tested by two methods and results compared using regression analysis. additional testing was performed to investigate precision of hemocue method (within-run and between-day variation), trueness using reference material and to define optimal sample handling. results: regression analysis showed high correlation between two methods (r = . ), with higher values obtained with hemocue method. immediately after centrifugation one supernatant was measured times in order to determine within-run imprecision. coefficient of variation (cv) calculated from consecutive measurements was . %. to investigate between-day imprecision of the hemocue method one sample was divided in aliquots and frozen. one sample was thawed each day and measured. cv of five measurements was . %. during the period of validation measurements of reference material (low, medium and high) were performed. cv calculated for these measurements were . % (low), . % (medium) and . % (high). in order to investigate possibility of batch testing, supernatants of different rbc products were divided in aliquots and measured periodically during -month period. cvs calculated from measurements of each sample were in range . - . %. conclusion: hemocue plasma low hb method appears to be an excellent replacement for the harboe method. it is consistent, easy to use, measurements are performed in short time, and errors are minimized by eliminating dilutions and manual calculations. background: determination of haemolysis in red cell concentrates (rccs) at the end of storage time is routine method in quality control of blood components at our institute. for this purpose, haemoglobin concentration in supernatant of rccs is measured using hemocue plasma/low hb system (hemocue, sweden). according to manufacturer recommendation, visually turbid samples should be filtered before analysis with a . mm filter. because visual estimation of turbidity is highly subjective and unreliable, filtration of all supernatants before analysis using appropriate filters is possible solution for standardisation of the method. aim: the aim of the study was to investigate the effect of filtration of visually non-turbid samples on results of free haemoglobin measurement. methods: haemoglobin concentrations were measured in visually non-turbid supernatants before and after filtration using hemocue plasma/low hb photometer ( wb negative controls were used for each blood component. in all blood components tested bacterial contamination was detected using both types of bottles. in comparison with sa/sn bottles, nearly all enrolled microorganisms were detected faster in bpa/bpn bottles (see table ). all negative controls were negative (no false positive). the results of the study performed support the use of bact/alert bpa and bpn plastic bottles in quality control testing of different blood components. objective: management of returned blood products is important part of quality assurance activities in transfusion medicine. blood products are returned most frequently because of routine rotation of stock and because of nonconformities discovered after the product has been received. methods: qa data about returned blood products were retrospectively analysed for the -year period ( - ) . only blood products returned because of nonconformities were taken into consideration. data about the reasons for returns are presented and discussed. the top reasons for returns were positive dat, labelling errors, blood bag defects and visual appearance of blood units (see table ). in all cases positive dat was confirmed in our institute, and blood donors managed accordingly. nonconformities related to visual appearance of blood component and other nonconformities related to the quality of blood products were investigated and corrective actions conducted. in case of blood components returned because of damaged bag, significant problem is to investigate the cause of nonconformity (usually inappropriate transport conditions). conclusion: management of returned blood products is important tool in improving the quality of blood products. introduction: hemovigilance is the systematic monitoring of the blood transfusion chain for side effects and adverse incidents from the moment of blood collection until after administration of the unit to the recipient, and comprises all activities that can lead to a safer and more effective use of blood components. attempts to achieve a more safe and effective use of blood components constitute a huge task given the number of interventions and array of medical and not-medical personnel involved in the transfusion process. registration of the impact of all participants is a tremendous job as such. information management may enhance the chances for a successful hemovigilance. aim: the aim is, to establish a basis for all the information related to the chain, such as standard operating procedures, (inter)national guidelines, local transfusion protocols and forms, and procedures to direct the process. additional factors that contribute to the final results are the profile and role of employees, incidents, points of care, product information, prices, budget, contracts, etc. by clarifying and explaining the basis to all participants by means of an existing infra structure, everyone will gain access to identical, consistent and up-to-date information at all times. the primary activity is to create the basis by an outline of every individual link in the transfusion chain from donor to recipient. secondly, the resources, responsibilities, actions, and internal controls (what task, who is performing, why, which help, where, when) are documented. by creating distinct databases for these 'w's' in combination with a separate database for the hemovigilance process itself, it is possible to establish relations, hyperlinks, between the different databases. all the information collected in the foundation, complete with all the resources, responsibilities, actions, and internal controls is made available to target groups by means of the intranet in our hospital as well as in a printed handbook format. collecting and displaying the information on hemovigilance this way, creates a transparent and more easy-to-manage process. it establishes a basis, which incorporates all resources, responsibilities, actions, and internal controls to all participants and enables the organisation to operate both efficiently and effectively. it allows us to show auditors (both internal and external) which processes are related to which guidelines as well as the results in daily. in addition, it reveals which factors determine the genuine application of the guidelines in clinical practice. conclusion: by outlining the process, followed by defining, analysing, securing, on the 'w ' method, the hemovigilance process offers a stable basis and framework for all participants and may stimulate a more safe and effective use of blood components. background: transfusion medicine is a basic post-graduate specialty for medical doctors with a specific national curriculum in bulgaria. in order to improve the post-graduate training of medical doctors in transfusion medicine, a new curriculum was elaborated in . purpose of the new program: independent work of transfusion medicine specialists on all levels of the blood transfusion service (bts) -organization of bts, promotion of voluntary, nonremunerated blood donation, collection, processing, testing, storage and transport of blood and blood components, immunohematologic testing of patients, laboratory hematology, clinical experience, assistance and advice on diagnostic and therapeutic problems of patients, requiring treatment with blood products, teaching transfusion medicine to bts and clinical personnel. admittance and duration to training -medical doctors are admitted to post graduate specialization after a successful state examination. the overall duration of training is years, of which at least are obligatory for training in the national or regional blood transfusion centers. main sections of the curriculum: . organization of blood donation and blood transfusion, including promotion of voluntary, nonremunerated blood donation; organization, planning and information systems; organization of blood transfusion; quality management. . collection, processing, storage and transport of blood and blood components . laboratory hematology and specialized methods (general laboratory methods, immunology, immunohematology, transmissible infections, hemostaseology, nat techniques, flowcytometry) . clinical use of blood components and plasma products (treatment with blood products, adverse events and reactions, alternatives to blood transfusion). the new curriculum of transfusion medicine guarantees a better training of medical doctors, thus leading to safe and effective blood products their proper clinical use. introduction: transfusion medicine is integrated medical discipline based on clinical and laboratory practice. it is closely connected with molecular biology, genetics, as well as with apheresis, automatically techniques and transplantation. the aim of studies in transfusion medicine is proper education, skills, attitudes and knowledge of students at the medical faculty and of doctors on residency in transfusion medicine and other specialties about blood and its usage. material and methods: there will be presented how transfusion medicine is implemented in educational and health sector in r. results: there is -year specialization in transfusion medicine, established years ago (over specialists finished this specialization till now). we have postgraduate studies in tm started years ago. transfusiology, as subject at the medical faculty, is now included in new curricula of medical student, consists of theoretical and practical lectures. also, medical doctors on specialization in surgery, anesthesiology, obstetrics and gynecology, pediatrics, internal medicine, maxillo-facial surgery and others have obligatory -month education in tm. transfusion medicine is integral part in education of nurses and laboratory technicians; all personnel that work in transfusion field in our country finished -mounths course in tm and get certificate. conclusion: although we have already done so much in educational field, we will continue with our efforts to improve our collaboration with clinicians and to involve ourselves more in clinical disciplines. introduction: in hospitals of saint petersburg donor blood, its components and preparations, autoblood and its components, hemocorrectors are applied with the medical purpose at - % of hospital patients. the service of blood and the existing organization transfusion therapy in hospitals should provide maximal immunological and infectious safety and also its high medical efficiency. it demands special preparation for all doctors: general physicians on clinical transfusiology and doctors of blood service on all sections of the general, industrial and clinical transfusiology. clinical gemostasiology, pharmacology of hemotransfusion means and hemocorrectors, the organization of the blood service, the donor service; the organization, technique and technics of preparation of blood, its components and preparations, quality assurance, transfusion therapy programs, technique and technics of transfusion medicine, a problem of maintenance of immunological and infectious safety, preventive maintenance, diagnostics and treatment of posttransfusion complications, feature transfusion therapy in pediatrics and medicine of accidents). clinical physicians master all basic questions of clinical transfusiology, thus the special attention is given questions of clinical immunohematology and clinical gemostasiology, programs and a technique of transfusion therapy, the prevention of posttransfusion complications. employment are carried out in departments of city blood bank, hospitals blood departments. final examination under the test program and at interview shows sufficient mastering a theoretical and practical material (right answers of - %). the described system of postgraduate studies provides an opportunity of successful independent work of doctors on the workplaces both regular increase and qualifications not less often than time in - years. conclusion: the existing system of postgraduate education for doctors on transfusiology provides the blood services and hospital by the qualified staff. introduction: nowadays in hospitals of saint-petersburg more and more it is frequently applied the extracorporal hemacorrection (haemapheresis, haemasorbtion, plasmasorbtion, krhyoplasmasorbtion, ultrafiltration etc.) and photohemotherapy (optical radiation influence on blood) at various diseases and traumas. they are used at treatment almost % from the general number of patients of hospitals with positive results at % from them. for this purpose in hospitals there are specialized branches or cabinets with staff of the doctors -transfusiologists. therefore an actual problem is organization of postgraduate special education for them. because there is no specific blood banking and transfusion medicine training in either under or post graduate medical education those general practitioners have limited knowledge about this field. aim: to give basic knowledge and practice to those general practitioners moh has established a special training programme with the collaboration of medical schools for years. methods: this is a months programme which has basic components; theoretical education, laboratory and blood banking practice. the trainees are evaluated by a final examination. each group has limited cadets and the training is provided in selected blood banks with the collaboration of universities and moh training hospitals. conclusion: almost general practitioners are trained by this programme in the last years and those doctors helped to increase the quality of blood banking and transfusion service at their hospitals. background: even the history of public blood banking in turkey has dates back to , whole blood was comprising the majority of transfused units (more then %) in turkey until the last few years. aim: the main target was to decrease the whole blood use in a short time and establish countrywide effective blood transfusion practice. methods: there were no specific blood banking and transfusion education either at undergraduate and postgraduate medical education in turkey until the last few years. blood banks and transfusion society of turkey (bbtst) was established at with the main aim of education of the related people about blood banking and transfusion medicine. bbts has organized symposiums, national courses, national and international congresses since . due to increased knowledge about the blood components and improved infrastructure of blood banks whole blood consumption has decreased to national average to %. in most of the university hospitals and training hospitals this is around %. conclusion: like most of the public based behaviours dedicated efforts of civil initiative has changed the traditional habit of blood consumption in turkey by the direct affect of well organized educational activities. training of general practitioners in blood banking and transfusion medicine n solaz*, b keskinkilic † and c oruc † *ankara university, ankara, † ministry of health, ankara, turkey background: turkish ministry of health runs majority of the hospital blood banks in turkey. most of the moh hospital blood banks give service under the medical supervision of general practitioners. because there is no specific blood banking and transfusion medicine training in either under or post graduate medical education those general practitioners have limited knowledge about this field. aim: to give basic knowledge and practice to those general practitioners moh has established a special training programme with the collaboration of medical schools for years. methods: this is a months programme which has basic components; theoretical education, laboratory and blood banking practice. the trainees are evaluated by a final examination. each group has limited cadets and the training is provided in selected blood banks with the collaboration of universities and moh training hospitals. conclusion: almost general practitioners are trained by this programme in the last years and those doctors helped to increase the quality of blood banking and transfusion service at their hospitals. background: it has been accepted that during cardiac surgery the complement-system is activated which enhances ischemia-reperfusion injury, leading to postoperative complications as infections and organ failure. the lectin pathway is one of the mechanisms that can activate the complement-system, this pathway can be mediated by mannose-binding-lectin (mbl). the level of mbl in serum shows a wide variation. a low level of mbl can lead to more infections in some conditions and a high level to tissue damage after ischemiareperfusion injury. the effect of transfusions of erythrocyteconcentrates and plasma on the mbl levels and thereby on complications after cardiac surgery are not known. aim of the study: the role of pre-and postoperative mbl levels and the effect of transfusions on postoperative complications after cardiac surgery. in a randomized controlled trial cardiac surgery patients were included and blood samples were taken pre-and postoperatively. mbl measurements were performed by elisa assays. the data were linked with postoperative complications as mortality, infections and multiple-organ-dysfunction-syndrome-mods and with peri-operative erythrocyte and plasma transfusions. results: the mean pre-operative mbl-level was ± and postoperative ± mg/ml. there were no differences in preand post-operative mbl levels between patients with infections or mods compared with non-infected and non-mods patients. the difference in pre-operative mbl between non-survived ( ± ) and survived patients ( ± ) was not significant (p = . ). postoperative mbl levels between survived and non-survived patients was smaller. conclusions: pre-and postoperative mbl levels in cardiac surgery are not related to postoperative infections, mods and hospitalmortality. whether large amount of blood transfusions are affecting the mbl-levels and thereby the patients outcome is not known. introduction: patients undergoing cardiac surgery are receiving high amount of blood transfusions and are at risk for the development of infections and multiple-organ-dysfunction-syndrome (mods), these complications are influencing the survival of the patients. during cardiac surgery pro-and anti-inflammatory cytokines are released by different mechanisms. we found in a randomized trial in cardiac surgery a significant reduction in infections and mortality due to mods by transfusion of leukocytedepleted erythrocyte concentrates (ld) compared to leukocyte-containing, buffy-coat depleted erythrocytes (pc). aim of the study: the effect of ld on the concentration of proinflammatory cytokine il- and anti-inflammatory cytokine il- in relation to clinical outcome and complications after cardiac surgery. methods: in participating patients blood samples were taken before and after surgery. using elisa il- and il- were measured in these samples. the results were linked with the endpoints of the randomized trial: postoperative infections, mods and in-hospital mortality. results: all pre-operative concentrations of il- and il- were low. mean postoperative level for il- was ± and for il- ± . compared with patients without mods and without infections and survived patients only the il- was significant higher in patients who died and in patients with mods. there were no differences in mean levels related to ld and pc. the levels of il- were higher in patients receiving more then units blood transfusions compared to transfusions. conclusion: there is an association between mods and mortality and il- , not with il- . ld has no influence on mean levels of il- and il- . there is a correlation between transfusion of more then units and il- , not with il- . these cytokine-profiles are not associated with the beneficial effect of ld on the postoperative outcome in cardiac surgery patients. anemia and blood transfusion practice in critically ill patients e grouzi*, e tsigou*, p evagelopoulou † , g baltopoulos † and i spiliotopoulou* *kat general hospital, transfusion service, athens, † athens university school of nursing icu, athens, greece background: anemia is a common problem in critically ill patients admitted to intensive care unit (icu), but the consequences of anemia on mortality and morbidity in the critically ill is poorly defined. aim: to define the incidence of anemia and red blood cell (rbc) transfusion practice in critically ill patients in the icu) of our hospital, and to examine the relationship of anemia and rbc transfusion to clinical outcome. patients and methods: the period study was from july to december . patients were enrolled within h of icu admission. follow-up time was days, hospital discharge or death, whichever occurred first. results: a total of patients ( male, female, mean age . ± . years, range - ) were included in the study. the mean hemoglobin (hb) level at baseline was . ± . , which level was descending during the study. overall . % ( / ) of the patients received one or more rbc units while in the icu stay (mean . ± . units per patients). the mean pretransfusion hb was . ± . g/dl and the mean time to first icu transfusion was . ± . days. more rbc transfusions were given in the first week of the icu stay ( units vs , , units in the second, third and forth week respectively). the number of rbc units which a patient received during the study was positive associated with longer icu length of stay and an increase in mortality (r = . , p < . and r = . , p < . respectively). baseline hb level was significantly related to the number of rbc transfusion (r = . , p < . ), but was not an independent predictor risk factor of length of stay or mortality (r = . , p > . and r = . , p > . respectively). the mean baseline apache ii and saps scores were . ± . and . ± . respectively. furthermore both baseline apache ii and saps scores were significantly higher for patients with a baseline hb level of < g/dl ( . ± . vs . ± . and . ± . vs . ± . respectively), while the apache ii values were positive associated with a significantly increased likelihood of rbc transfusion (pearson correlation p < . ). conclusions: anemia is common in the critically ill patients, it appears early in the icu course and persists throughout the duration of the icu stay. rbc transfusion seems to be associated with worse clinical outcome. despite the intensive research for the transfusion practice, which taken place worldwide during recent years, data from our country is limited. the results of our study suggest that approaches to reduce rbc transfusion would be desirable. however, further well designed prospective studies with large number of patients are required to efficiently explore the risk of anemia, optimal transfusion hb threshold and the risk and benefit of rbc transfusion in the critically ill. consumption of blood products in a large, general hospital he heier*, j pillgram-larsen † , m hestnes ‡ , b gran*, a krog* and no skaga ‡ *ullevaal university hospital, oslo, † ullevaal university hospital, dept. of thoracic surgery, oslo, ‡ ullevaal university hospital, dept. of anestesiology, oslo, norway uuh is the largest general hospital in norway, and trauma referral centre for half of the norwegian population ( . mill) the trauma team performed initial assessment and resuscitation of patients, % males, during the first six months of . the aim of our study was to analyze transfusion practice at uuh with specific focus on trauma. materials and methods: blood consumption during this period was recorded. clinical data of trauma patients were collected from our trauma registry and anonymized before analysis. results: units of erythrocytes (er), of thrombocytes (thr) (buffy coat preparations from donors) and of s/d-treated whole plasma (op) (octaplasÒ) were transfused in uuh during this period. . % of er were given to surgical, . % to medical and . % to gynaecological and obstetric patients. % of er were given to patients above years. er units were given to patients (mean . units/patient; range - ). mean age of trauma patients was ± , median , range - years. for transfusion of this group local guidelines state that haemodynamically unstable patients should receive er if hgb < g/dl, irrespective of age and sex. eighty-eight patients ( . %) received er, of them as massive transfusion ( er units in < hours) ( . %), of these died ( %). altogether trauma patients received units of er ( . % of total uuh consumption), . thr ( . % of total) and units of op ( . % of total). massive transfusion consumed er ( %), . thr ( . %) and op ( . %) units. fourteen adult trauma patients ( . % of those transfused) received or er units only. lowest pre-transfusion hgb was . - . g/dl, median . , mean . ± ; highest post-transfusion hgb . - . g/dl, median . , mean . ± . five patients received er transfusion at higher pretransfusion hgb level than g/dl, but in er were given because of a hyperacute clinical situation. fifty-five% of issued er units had been stored for > days, while only % were issued before days of storage. discussion: life-saving effect of transfusion would seem evident in the massively transfused survivors, while in the other transfused patients documentation of clinical effect is inadequate. transfusion practice in trauma at uuh seems fairly well in accordance with internationally accepted guidelines. the trauma unit consumed a surprisingly small part of total uuh transfusion resources. trauma patients deviate from the general uuh patient population by sex and age; transfusion is otherwise mainly given to more elderly patients. further analysis is needed on transfusion indications and results to optimize the total use of blood products in uuh. special focus should be on transfusion to non-bleeding patients without haematological disease. it seems that only a small part of transfusion efforts results in the saving of life. in croatia national guidelines for the use of rhd gamma globulin were laid down in the year . in accordance with the guidelines, rhd gamma globulin is administered intramuscularly in doses of - mg and should be given to rhd negative women after delivery of rh positive children, after abortions, in week of their first pregnancy, as well as in cases pregnancies with an increased risk of fetomaternal hemorrhage. as to the latter, detection and measurement of fetomaternal hemorrhage are recommended. three years after the issuance of the guidelines a survey was conducted regarding the use of rhd gamma globulin that involved health institutions across the country. as many as deliveries and abortions were reported in . the institutions reported the usage of doses of mg rhd gamma globulin or doses/ deliveries + abortions. we compared our data with those obtained from similar surveys conducted in , i.e. before the issuance of the guidelines. in that year deliveries and abortions were reported, and doses of rhd gamma globulin or doses/ deliveries + abortions were administered. institutions were then divided into four categories: clinical hospitals, general hospitals with the capacity of - beds, general hospitals with the capacity of - beds, and institutions of rather limited capacity with gynaecology department. the range of the consumption of rhd gamma globulin/ deliveries + abortions in the first category was - with the median being ; in the second category there were - doses with the median being , in the third category - doses with the median being , while in the fourth category the range was - doses with the median of doses. the number of pregnancies which should have been protected with rhd immunization in year was obtained by the following formula: (frequency of rhd negative subjects) ¥ (frequency of the r gene) = . ¥ . = . . if a complete antenatal and postnatal preventive measures involving rhd immunization had been taken in , doses of rhd gamma globulin or mg/ deliveries + abortions should have been given. our research has shown that, despite of the national guidelines adopted in , the prevention of the rhd immunization in pregnant women is still not adequate in croatia. in fact, it has not improved since a year prior to the adoption of the guidelines. it has also been established that the category of the institution is a factor influencing the implementation of the protective measures. we consider that much more should be done on informing both women and gynaecologists about the importance of prophylaxis of the rhd immunization. consumption of plasma derivates in croatia g jaklin*, b golubic-cepulic † and m dondur* *general hospital, varazdin, † clinical hospital center zagreb, zagreb, croatia a increasing consumption of plasma derivates, their limited supply and insufficient national reserves are problems that croatia is faced with nowadays, as well as many other countries. in a study was carried out regarding the usage of plasma derivates. as many as health institutions took part having the capacity of acute beds out of a total of . the data regarding the use of plasma derivates were collected as follows: albumin, i.v. gamma globulin, and concentrate of coagulation factor viii in two periods of time. we divided institutions into three categories: clinical hospitals, general hospitals with the capacity of - beds and general hospitals with the capacity of - beds. institutional practice patterns regarding the use plasma derivates were compared among them. the parameters considered were the total consumption of plasma derivates, consumption per bed and consumption per inhabitant. data on the use of plasma derivates was obtained from hospital transfusion departments and pharmacies across the country. we compared our data with similar study carried out in . the consumption of albumin was . kg or kg/million inhabitants in and consumption per bed for the first category institutions was in range . - . kg with the median being . , for the second category the range was . - . kg with the median being . , while for the third category the range was . - . kg with the median being . . in in croatia the consumption of albumin was . kg or kg/million inhabitants. the consumption of i.v. gamma globulin was . kg or . kg/million inhabitants in and the consumption per bed for the first category institutions was in range . g- . g. with the median being . , for the second category was in range . - . g. with the median of . and for the third category was in range . - . with the median . g. in in croatia the consumption of i.v. gamma globulin was . kg or . /million inhabitants. the consumption of the concentrate of factor viii was . iu or . iu per inhabitant in . . iu, i.e. . %, was a recombinant factor viii. in the consumption of factor viii was . iu or . iu per inhabitant. discussion: the use of albumin showed stagnation. however, the use of i.v. gamma globulin increased . times and the use of the concentrate of factor viii increased . times if compared with the results in . self-sufficiency has not been reached in plasma derivates in croatia we needed l plasma for gamma globulin and l plasma for concentrate of factor viii for the level of usage of these plasma derivates in . significant differences in the level of usage among hospitals have been observed. these reflected a considerable difference in hospital policy regarding the use of these products in defined clinical settings. therefore, we would recommend that the national society sets out guidelines for the use of the products. background: blood bank good practice requires avoidance of rh alloimmunization. several studies report a probability of immunization of more than % following transfusion with rhd+ rbc's and as many as % in the case of platelets. aims: the purpose of this study was to investigate the development of anti-d and the causes of alloimmunization in a university hospital ( beds), reviewing our practice on the use of rhd+ blood components in rhd-recipients. method: a retrospective study was performed whereby . rhd-patients, from to , were evaluated for the development of anti-d analysing the data on the blood bank information system. results: from the . rhd-patients we found out identified anti-d, % ( ) detected before any transfusion in our hospital. of the left, nine were excluded because no information was available during some years. had history of pregnancy related to the immunization. patients were exposed to rhd+ blood components: were transfused only with rhd+ platelets (including two women of childbearing age); with rhd + rbc's. the remaining had been exposed exclusively to rhd -rbc's suggesting that some units could be mistyped. this idea was corroborated in three patients where there was a common donor (he was called for investigation). conclusions: transfusion services avoid as far as possible administration of rhd+ blood components to rhd-patients, although there are situations in which such transfusions are necessary. the retrospective review of records revealed the need for specific recommendations regarding the use of rh immunoglobulin to prevent anti-d immunization. the possibility of mistyping blood components also appeared in this review, emphasizing the role of these studies in the evaluation of methodologies used at blood banks. the purpose of the work: to present the usage of whole blood (wb) and blood products (bp) in the treatment of patients who are hospitalized in the internal disease department in gevgelija. material and methods: retrospective analysis is done according the data which were analysed in five years period ( ) ( ) ( ) ( ) ( ) . statistical methods which were taken from the history of the hospitalized patients in the internal department were used for analysis and the data of transfused wb units and units of bp were taken from the department of transfusion medicine. results: from the total hospitalized patients who have been analyzed, ( . %) received wb and bp, and there have been transfused units wb and bp. every patient, on an average, has been transfused with . units wb and bp. at the same time ( . %) units have been transfused as a wb, ( . %) have been transfused as red blood cells (rbcs) and ( . %) units have been transfused as a fresh frozen plasma (ffp). the data for every year particularly will be presented in our paper to the congress. the collaboration between doctors of transfusion medicine and health workers from the other medical branches is the most important thing in the medical practice. our aim is to raise the awareness among the health workers for the importance of blood safety and their role though adequate clinical usage of wb and rbcs, minimizing the non-useful transfusions, evaluation of reflexive information from undesirable reactions in the usage of blood and blood products, use the alternatives etc. the necessity of direct involvement of the doctors in transfusion medicine in the process of healthy workers' education from the other branches for regularly transfusion therapy via meetings and lectures is an imperative for regular function of the department of transfusion medicine. femoral neck fracture repair is one of the commonest orthopedic procedures. it mainly concerns intracapsular or intratrochanteric fractures and it may be considerably hemorrhagic, requiring blood transfusion perioperatively. the aim of our study was to investigate blood transfusion requirement in patients with femoral neck fractures repair at katerini general hospital during - and to compare them with other studies. one hundred sixty five ( ) unselected patients of whom ( %) were women and ( %) were men with a mean age of years (range - years) were studied retrospectively. seventy six ( %) patients had intracapsular fracture and ( %) intratrochanteric fracture. the mean hb concentration on admission was . g/dl (range . - g/dl) and the mean hb concentration at discharge was . g/dl (range . - . g/dl). a total of units of rbc were transfused (a mean of . units per patient). blood transfusion occurred in patients ( . %), ( - % in other studies) with a mean of . units per patient (range - units), ( . - . in other studies). patients with preoperative hb values < g/dl were transfused more often than those with hb values > g/dl ( % versus %) p: . . women were transfused more often men ( . % versus . %) p: . . patients aged > years were transfused more often than those aged < years ( % versus %) p: . . finally patients with intratrochanteric fractures were transfused more often than those with intracapsular fractures ( . % versus %) p: . . conclusions: in our study blood transfusion requirement for femoral neck fracture repair are similar with these reported in other studies. blood transfusion frequency is greater in patients with hb < g/dl, in patients older than years, in women and in intratrochanteric fractures repair. fresh frozen plasma guidelines and practices as saltamavros*, g talampouka*, c koumoundourou*, s dimitrakopoulos † and p tseliou* *st. andrews hospital patras greece, patras, † pyrgos general hospital, pyrgos, greece introduction: fresh frozen plasma transfusions should be done according to specific standards and guidelines. aims: we have reviewed the ffp transfusion practices followed in our hospital in an attempt to provide a set of guidelines and principles that will assist physicians and health care workers to make the right decisions for appropriate use of ffp transfusions. methods: retrospective review of ffp transfusions practices during the entire year of . we classified transfusion practices according to the diagnosis of the patient and also of the clinical depart-ment that demanded transfusion. then we analyzed our results by comparing the requests with the internationally approved guidelines for ffp transfusion and counted the percentage of ffp to rbc units. finally we discussed with our fellow physicians the proper use of ffp and informed them about the accepted guidelines. as we can see from the underneath table, diagnoses and departments with high consumption were: internal medicine %, plasmapheresis to patients suffering from guillain barre and ttp (thrombotic thrombopenic purpura) . % and trauma/surgery . %, cancer . %. summary/conclusions: the use of ffp corresponds to . % of the rbc units transfused in our hospital. plasma units should be used properly and according to internationally accepted standards. plasma use should be justified by the physician, in order to avoid unnecessary risks on behalf of the patient for effective treatment and care. to show gradual discontinuation of using whole blood and increased use of red blood cells (rbc) in the management of patients in the transfusion department of the clinical hospital 'zvezdara' . methods: data of wb and rbc use from to in our hospital. results: our data are presented in table . conclusion: after , wb usage rates systematically decreased from % to . %. however, in the period of - , the wb usage rates increased slightly, and we arrived at a generally very low rate of wb use, namely only in about % of the cases. education about transfusion medicine and rational use of blood in the medical curriculum was generally insufficient and very poor. therefore, we started an education program and we established a hospital transfusion committee (htc) with the task of medical control and monitoring the quality of clinical transfusion practice in our hospital. members of the htc are a specialist in transfusion medicine, an internal medicine specialist, an anesthesiologist, surgeon and gynecologist. we have been organizing courses for the medical staff, doctors and medical technicians since . background: platelet transfusions are given mainly to thrombocytopenic patients with malignant haematological diseases. currently the decision to give a prophylactic platelet transfusion is based almost exclusively on the number of circulating platelets in the patient although it is known that various clinical factors might influence the bleeding tendency. by free oscillating rheometry (for), using a reorox® instrument, it is possible to monitor the coagulation over time in whole blood and obtain information about clotting time and coagulum elasticity. aim of the study: the aim of this study was to find out if for using the reorox® instrument could be used to evaluate the hemostatic status of thrombocytopenic patients. methods: the change in elasticity over time in non-anticoagulated whole blood from leukaemia/lymphoma patients with thrombocytopenia was measured in the reorox® pre and post a platelet transfusion (n = ) and was compared with healthy controls (n = ). the effect of platelet concentration on coagulation was studied by diluting platelet rich plasma from healthy subjects with autologous plasma to various platelet counts whereafter the coagulation was monitored with for (n = ). the change in elasticity per minute (g'max slope) and maximum elasticity (g'max) were evaluated from the elasticity curves. results: the g'max, g'max slope and platelet count increased after transfusion for all patients. the thrombocytopenic patients had significantly lower g'max and g'max slope values both pre and post transfusion compared with healthy control subjects (p < . ). the measurement in platelet rich plasma showed that g'max and g'max slope increased with increasing platelet concentration. however patients with similar platelet count developed different clot elasticity. the reorox ® instrument responds to changes in haemostatic function in form of the clot elasticity. the fact that patients with similar platelet concentration developed different elasticity shows that clot elasticity is a function of not only platelet concentration but also of functional properties. the for method seems promising to evaluate platelet function. quality control of pre-storage leukodepleted red cell concentrates vu urlep salinovic, k perbil lazic and l lokar teaching hospital maribor, maribor, slovenia background: the system of quality assurance including quality control (qc) in transfusion medicine is most important for safe blood supply. the safety and quality of blood components are increased by pre-storage leukodepletion of whole blood (wb). aim: the qc of leukodepleted red cell concentrates (rcc), prepared from pre-storage filtration of wb (quadruple blood bag systems imuflex wb-rp terumo) is performed with the aim to be sure that the quality of leukodepleted rcc is in accordance with the guidelines of council of europe. in three years ( ) ( ) ( ) , units of wb were collected, among them ( . %) units were collected for pre-storage filtration and in ( . %) of these qc was done. within hours after collection, wb was filtered at room temperature. filtered wb was centrifuged at g for minutes and separated in rcc and plasma. the samples for qc were collected before and after filtration. for each unit, volume, hemoglobin, hematocrit, % of hemolysis and residual white blood cells (wbc) count were measured. the number of residual wbc after filtration was determined in the nageotte chambre. for all parameters the mean value and standard deviation were calculated. the results of qc for the following parameters were: volume ± . ml ( % corresponds with the guidelines of council of europe), hematocrit . ± . ( %), hemoglobin . ± . g/unit ( %), number of residual leukocytes . ± . ¥ ( %), hemolysis . ± . % ( %), the test of sterility was % negative. during filtration of wb, wbc were removed in approximately . %, the duration of filtration was ± minutes and the loss of hemoglobin was . ± . %. the pre-storage filtration of wb is highly efficient, . % of wbc were removed and the loss of hemoglobin was small. background: the patients of cardiosurgery use big amount of blood components. there is no uniform approach by treatment with blood components in these patients. the safest and the most rational use of blood is based on the individual treatment of a patient and the evaluation of the most clinical and laboratory factors. aim: the aim of our study is to analyse the use of blood components from , when the cardiosurgery department was founded in our hospital, to . the data about use of red cell concentrates (rcc), platelet concentrates (pc) and fresh frozen plasma (ffp) in the period from to were collected from information system datec. the average use of all three blood components per patient is presented. we were interested, if the average use per patient was diminished in the analysed period. results: the use of three blood components and average use of all blood components are presented in the table. the data from the table shows, that the number of patients increased more than three times, but the average use of blood components per patient was not essentially diminished. conclusion: during seven years period the use of blood components per patient in cardiosurgery was not diminished. for more rational use it is necessary to apply all methods of autologous blood transfusion because of the increasing number of cardiac operations and decreased number of voluntary blood donors. background: the presence of leucocytes in blood components is cause for appearance of various adverse posttransfusion reactions such as nhfptrs, urticary, anaphylactic shock, alloimunization and platelet refractorines, infection with bacteria and leucothropyc viruses (cmv, htlv). the removal of leucocytes from blood components through filtration is especially important in the treatment of patients with malignant diseases who need frequent transfusions of blood and blood components. this is because of their lowered immunologic status which is a result of the disease and received immunosuppressive chemotherapy and radiotherapy. aim: to show the prevention of posttransfusion reactions and the positive effect from transfusion of leucoreduced er. concentrates, produced with filtration in therapy of anaemia in patients with malignant diseases, treated in our daily transfusion hospital at medical center -stip. methods: patients with malignant diseases have been treated in our daily transfusion hospital in the last four years. most of these patients suffer from ca pulmonum, ca collonis, ca uteri, ca mammae. also, because of the secondary anaemia, the same patients were transfunded with at least two doses of leucoreduced er. concentrates. the blood donored by voluntary repeated blood donors was filtrated the same day after the donation, separation and the control of the same one. the blood was collected in baxter and terumo bags, and it was filtrated with baxter -sepacell rs - and pall -purecell rn filters. the analyses of leucoreduction were made for every filtrated and transfunded unit before and after filtration. the analyses samples were taken from the tubing system before and after the filter. haemathologic parameters were automatically made in the central clinic laboratory. results: er. concentrates poor with the leucocytes for about - . % were produced with the use od these filters, and platelets from - % with which side effects from frequent transfusions at these patients were prevented. with the routine monitoring of all patients none posttransfusion reactions were registered. the therapeutic effect is also important because of the fact that the number of er and the level of hg and hct remain almost unchanged. the aim of the blood banks is to help and to increase the safety of the blood components. the leucoreduction through of er. concentrates poor with leucocytes is a regular procedure in the therapy of malignant patients with remarkable clinical picture of anaemic syndrome and prevention the cancer recurrence end infection. the time of filtration is also very important which has to be shorter after collection of blood, because the leucocytes should be removed before they become disintegrated and relapse potentially dangerous substances end metabolites in the blood components. we have been applying so called ' prestorage filtration' because it has been proved that it is more efficient that bed -side filtration. background: the effect of leukocyte reduction of rbcs by filtration has been the topic of several rcts. these rcts investigated the effect of leukocyte reduction on mortality; post-operative infections and hospital stay in different patient populations. some rcts came up with answers that conflicted with the results of other rcts. aim of the study: with including the individual patient datasets of several rcts in one database, combined analyses are possible that may explain the differences in the reported results. using this technique, we may come up with answers (or questions) that cannot be obtained by performing standard meta-analyses of these rcts. methods: we coordinated several rcts comparing the perioperative use of buffy-coat depleted rbcs with the use of filtered rbcs. cardiac surgery patients were included in three rcts ( ¥ cabg and/or valve; ¥ re-cabg and/or valve; ¥ valve with or without cabg). oncologic surgery patients were also included in three rcts ( ¥ colorectal cancer; ¥ gi-oncology or vascular surgery; ¥ gi-oncology, vascular surgery or orthopedic surgery). the electronic data files of these rcts were uniformly recoded and entered in a single database. as different primary endpoints were investigated in the rcts, we focused on common endpoints, recorded in or more of the rcts. multivariate analyses were performed on: in-hospital mortality, -day mortality, hospital stay, stay on icu, postoperative infections, and mods. results: in the rcts, individual datasets from surgery patients were collected ( onco; cardiac; vascular; orthopedic, other). in the multivariate analyses, patients in the buffycoat depleted trial arm showed a higher mortality rate both in-hospital (p = . ) and at days post-surgery (p = . ). no association between randomization and stay in hospital (p = . ) or stay on icu (p = . ) was seen in the combined study population. also, no association of randomization with the incidence or duration of mods was seen. the analyses of post-operative infections in the total population showed the trial arm to be associated (p = . ), and 'hospital' to be far stronger associated (p < . ). however, when the oldest rct, that had not yet used our standard definition list for scoring post-operative infections, was excluded, the association with the hospital was lost (p = . ) and the trial arm became more strongly associated with infections (p = . ). in the analyses of surgery patients, the use of filtered rbcs, compared to the use of buffy-coat depleted rbcs, resulted in reduced mortality (both in-hospital and at days postsurgery) and a reduction in post-operative infections. the association of the variable 'hospital' with post-operative infections, as is frequently reported in literature, was initially confirmed in our analyses. however, when a standard definition for post-operative infections was used (excluding the datasets from one of six studies), this association was lost. background/aims: uk neqas for blood transfusion laboratory practice (btlp) operates an eqa service for uk laboratories (including eire) and participants throughout europe, including major groups in denmark (n = ) and portugal (n = ). in november a questionnaire was distributed to determine the criteria used for selecting phenotyped blood for different patient groups, including pre-menopausal women (pmfs). results were analysed by country to establish any variation in practice relating to the selection of k negative (k-) and rhc negative (c-) blood, since antibodies to these antigens are now the major cause of hdn. results: overall return rate was % (uk) and % (non-uk), although only centres treating pmfs were included in this analysis. k-blood was selected for pmfs by % in wales (n = ) and % in england (n = ), but only % in scotland (n = ), % in northern ireland (n = ) and % in eire (n = ). in mainland europe, variation was also observed: % in denmark (n = ), % in portugal (n = ) and % in other countries (n = from countries). fewer laboratories selected c-blood for pmfs: % in england and northern ireland, % in scotland and eire, rising to % in wales. mainland europe showed similar variation: % in denmark, % in portugal (all ccee matched) and % in other countries. there are no guidelines requiring selection of k-and c-blood for pmfs, but in the uk d negative blood is required for d negative females aged < years. trend analysis of questionnaire data in the uk, using theoretical clinical scenarios, shows a decrease in the number of laboratories that would select k + blood for a year old female (with pre-existing antibodies other than anti-k), from % ( ), % ( ) to % in . in this survey, k + blood was selected for a female aged (no antibodies) by %, whilst % selected a k + unit for a female aged (no antibodies), despite this patient being treated as a pmf for provision of d negative blood. a similar distinction was made between the and year old females in portugal and mainland europe. conclusions: variation in practice may at least in part be due to the availability of blood routinely labelled for rh and k. in the uk all donations are labelled, except for those from new donors, as are most units in portugal. uk questionnaire data ( ) suggested that > % laboratories would change to selecting k-blood for pmfs if all units were labelled. however, labelling alone does not account for the differences seen within the uk, and perhaps the trend towards providing k-(and to a lesser extent c-) blood for pmfs is influenced by advice from transfusion services. it would be of great interest to monitor and compare the incidence of hdn due to anti-k and anti-c in different countries to measure the outcome of differing practices for provision of blood to pmfs and to thereby inform future policy. there is no ultimate in ex-vivo assay described, which can predict the outcome of plt transfusion in vivo. current in ex-vivo assays and animal studies are rather very complicated to carry out, cost effective and time consuming. objective: we hypothesized that the quantitative measurement of gpib expression by facs can be used to predict the outcome of platelet survival post transfusion. in our previous studies we demonstrated that our phagocytosis assay can predict the plt survival sensitively (blood dec- ) . we isolated human washed plts by centrifugation and labelled with mepacrine and then incubated with pma-matured thp- cells ( °c). binding was measured by facs analysis of cd b/cd positive particles, and phagocytosis by counting mepacrine/cd positive particles. we measured gpib expression before and after plt-macrophages interaction by facs flowcytometry. results: gpib expression at surface of c fresh showed ± and after hours storage ± % expression. the gpib expression at surface of plt decreased and showed three populations with different densities high (gpib- ), low (gpib- ) and in-between (gpib- ). the binding and phagocytosis of plt showed an increase of ± % which implicates an indirect and negative relation to gpib- , and direct relation to gpib- expression. anti-human pselectin (cd p) delayed ± % the binding and annexing v ± % the phagocytosis of stored plts, after -hour storage. these results show that gpib expression is rather easy, reproducible test which can be standardised and be used as a very sensitive in vitroassay to predict platelet survival posttransfusion. transfusion and lung injury jd dodig*, d sovic † , m tomicic † and h sager* *university hospital 'sestre milosrdnice', zagreb, † institute for transfusion med, zagreb, croatia background: the respiratory tree has been viewed as an infrequent site of injury arising as serious complication of transfusion. in recent years, this view has changed as investigators have shown that two complications-circulatory overload and transfusion related acute lung injury-are relatively frequent events. case report: a -year-old men was admitted due to chronic macrohematuria. he had no history or current evidence of cardiac failure. the hb level was measured g/l. he received ml . % nacl and ml ringer solutions. after that, he was transfused with units of rbcs. during transfusion second unit he developed following symptoms: tachycardia, dyspnea, hypertension. massive pulmonary edema was noted. he was treated with mechanical ventilation, oxygen, diuretics, aminophillin, antihistaminic and corticosteroides. the patient recovered after being on ventilation for hours. two days after the patient was operated. after surgery he was transfused with units of rbcs. all transfusions were regularly performed. results: chest x-ray confirmed bilaterally pulmonary edema. the samples (patient and donors of first two units rbcs) tested were negative for the presence of hla specific and granulocyte antibodies. granulocyte agglutination and lymphocytotoxicity test were negative. tnf-a in recipient serum was slightly increased. conclusion: our patient is the first reported case suspected of trali, but all of the investigations didn't give us the answer. against neutrophils using flowcytometric detection of cell surface cd b expression and l-selectin shedding. methods: a hundred microl of volunteers' heparinized whole blood were incubated for minutes at °c with fmlp, lps or pma. monoclonal antibodies against hna a and hla-i, or patient serum were incubated with whole blood for min. surface cd b and l-selectin were detected using facscalibur. results: neutrophil activation was detected after fmlp, lps or pma stimulation. p map kinase inhibitor reduced activation induced by fmlp and lps. anti-hna a monoclonal antibodies induced neutrophil activation, which were also inhibited by p map kinase inhibitor. ten serum samples obtained from patients or donors who caused transfusion reactions were evaluated. five sera out of samples having anti-neutriphil and/or hla antibodies exhibited neutrophil activation, while two samples without leukocyte antibodies had no effect on any activation. conclusion: these findings indicate that neutrophils activation is regulated through mak kinase and detection of neutrophil activation may be useful to predict transfusion-related reactions. results: out of transfusion reactions were febrile, were anaphylactic, were due to circulatory overload, out of transfusion reactions concerned the transfusion of incorrect blood component. out of transfusion reactions concerned acute haemolytic reaction. post transfusion purpura or suspected trali was not seen. fatal complication was not seen. the reactions to plasma were predominately anaphylactic. we detected no case of bacterial contamination among the cultures of transfusion bags. conclusions: the incidence of reactions among patients malignancy was high, while among surgical patients was lower. the incidence of transfusion reactions during the months had no statistically significant difference. we suggest that the improvement in prevention of transfusion reactions require a continual vigilance system for rapid recognition and information regarding these complications. measurements of ige immunoglobulin in thalassemic patients, before and after blood transfusion background: many studies have reported the implications of proinflammatory cytokines including interleukin (il)- beta, il- and tumor necrosis factor alpha (tnf-alpha) in febrile nonhemolytic transfusion reactions. il- has been shown to accumulate in packed rbcs even after the procedure of filtration, which is explained by the release of il- from rbc receptors into the packed rbc super-natant. stress induced elevation in tnf-alpha levels was demonstrated in healthy individuals. aim: to assess the level of proinflammatory cytokines in peripheral blood of blood donors. material and methods: immediately upon blood collection, plasma was separated from postdonation blood samples obtained from blood donors and frozen at - °c. upon thawing, the level of the il- beta, il- and tnf-alpha cytokines was determined in plasma samples by elisa method using commercial kits for cytokine determination (roche molecular biochemicals). the level of il- beta was at the test detection limit in all donor plasma samples. in ( . %) bd, the level of il- was . pg/ml, exceeding the test sensitivity limit of . pg/ml. in ( . %) bd, the level of tnf-alpha was within the range of - pg/ml, with a test sensitivity limit of pg/ml. tnf-alpha levels > pg/ml were measured in plasma samples of ( . %) blood donors. the increased activity of blood donor's immune cells, indicated by elevated levels of the proinflammatory cytokines il- and tnf-alpha in peripheral circulation some blood donors, may lead to the occurrence of febrile nonhemolytic transfusion reactions in the recipients of the blood products manufactured from the blood of these blood donors. this hypothesis will be thoroughly investigated in our future studies. background: transfusion-related acute lung injury (trali) is a life-threatening complication of transfusion, under-recognized and underreported possibly lacking a consensus definition. aim: we report here a 'probable' case of trali syndrome in an elderly female patient. case presentation: an eighty-two year old female patient was transferred to the intensive care unit on the third postoperative day (pod) following the abrupt onset of acute pulmonary insufficiency (pao = mmhg, o saturation = %), hypotension (bp = / mmhg) and fever ( °c). this occurred ten minutes after initiation of an infusion of a unit of packed red blood cells (prc). the patient had no history of any cardiac or pulmonary disease. she was intubated and placed on mechanical respiration and supported hemodynamically. the cvp ( cm h o) ruled out fluid overload. the chest x-ray revealed bilateral pulmonary oedema, the echo cardiogram and blood cultures ruled out cardiac and infectious aetiology of the episode. after treatment for hours the patient improved significantly, was extubated and returned to the surgical unit on the th pod. reviewing the transfusion history we discovered that the patient did not receive any blood or blood component prior or during the correction of her ileum, but she was transfused a unit of ffp (fresh frozen plasma) five hours prior to the incident. the donor review revealed that the unit of ffp was from a -year old female with a history of multiple abortions whereas the prc unit was from a -year old male, a volunteer of several years who had no history of transfusions. there are some prerequisites for the implementation of a haemovigilance network and some of them have been met, so we can present the first results. methods: traceability of blood components is possible because there is unique information system in place in the whole country, identifying the donor, donation, each single blood component and identification of the recipient, but feed back information of the performed transfusion is still missing. cooperation between blood transfusion service and hospitals was established by introduction of hospital transfusion committees; the intensity and quality of their work is very different. homogeneity of reporting is achieved by the introduction of unique reporting form. a reporting route was defined: patients physician sends notification of atr to the local blood transfusion service. atr reporting form is prepared there and sent to the national blood transfusion service, where the data is collected for the centre for haemovigilance, which is going to be established very soon. data analysis will be responsibility of the centre for haemovigilance at the governmental level. type of adverse transfusion reactions and events is defined. education and information was passed to the health personnel by inclusion of haemovigilance in under and postgraduate programmes as well as seminars, scientific meetings and some publications. results: in the years - there were . blood components issued in slovenia and atrs were reported ( in blood components issued), in of them the severity grade was ( in . blood components issued). in the year there were considerable differences between the number of atr reports compared to the number of blood components issued among slovenian hospitals, ranging from in to atr in blood components issued. . % of all atr were not classified. conclusions: although the number of reported atrs was increased by % and % a year in and respectively, it can be assumed that the collected data is not complete. feed back reports, much more information and cooperation is needed, especially in some hospitals, which should contribute to a better registration of atrs and events in the future. the slovenian haemovigilance system still needs upgrading, but despite this, some important work has been done in building a national haemovigilance system. . considering the multiplicity groups in cattle and since there was no research on repeated blood transfusions reactions in iran's native cattle, we decided to consider crossmatching in different processes of repeated blood transfusion from a head of blood donor to five recipients and observe the clinical and hematological alterations. six healthy iran's native cow, . years old, with average weight of kg were used. the animals were dewormed by albendazole ( my/kg bw) and were kept for two weeks under uniform managemental condition. three days prior to blood transfusion, vital signs registration (temperature, heart rate and respiratory rate) blood collection via jugular vein was done to indicate the baseline of research parameters. after that, blood transfusions were performed from one donor cow to five recipients three times at one-week intervals. cross matching was done at each transfusion. after each transfusion the research parameters do determined. results indicated that one of the recipients cows experienced anaphylactic shock, in the first step of blood transfusion and another cows in the second step and finally in the third steps two other cows showed the serious shock. this is in the contrary of this opinion that the first transfusion can be given safely without crossmatching in cattle practice ( van der valt, et al. ( ) background and objectives: blood transfusion may lead to the manifestation of anti-hla and platelet-specific antibodies that may in turn bring about different problems like platelet refractoriness. it appears that the study of antibodies against hla-class i and platelet-specific antigens are useful for the selection and success of the appropriate treatment protocol. the aim of this study was to detect anti-hla and anti-platelet-specific antibodies by flowcytometry in patients with hematologic disorders (including acute leukemia, aplastic anemia) and patients with itp. in this descriptive study, anti-hla and platelet-specific antibodies were detected by flowcytometric technique, using sera drawn from patients with different haematological disorders who showed a poor response to platelet transfusion and from patients with itp. the results of anti-hla antibodies were then compared by panel reactive antibodies (pra). results: our results showed ( . %) out of ( . %) patients had anti-hla class-i antibodies in their sera. the frequency of each antibody isotype was found to be as follows: igm ( . %), igg ( . %) and iga ( . %). ( . %) out of patients had platelet specific antibodies and the frequency of each antibody isotype was found to be as follows: igm ( . %), igg ( . %) and iga ( . %). ( . %) out of patients had both antibodies. no difference was found between the two groups in platelet specific antibodies. despite significant correlation between flowcytometry and pra methods, pra can only detect antibodies which react with complement. conclusions: with increase in the number of platelet transfusion, immunization to hla antigens occurs; moreover, immunization against platelet specific antigens may also occur during autoimmunity. the presence of these antibodies may be one of the reasons of poor response to platelet transfusion and platelet refractoriness in patients under study. conducting similar studies with higher number of samples, platelet cross-match, and the use of hlamatched platelets for these patients are recommended. post transfusion purpura (ptp) is a rare, severe thrombocytopenia that results from alloimunization to platelet specific alloantigens, following blood transfusion. in this condition, the patient's own platelets are destroyed by the alloantibody even though they are not supposed to carry the 'guilty ' antigen. the disease is rare occurring mainly in multiparous women. the majority of reported cases involved antibodies against the platelet specific alloantigen hpa- a in a homozygous hpa- b patient. in a minority of cases the offending antibodies were directed against hpa- b, - a, - b, a, - a, - b. although self-limiting, the syndrome is characterized by severe bleeding with high morbidity and mortality; therefore prompt diagnosis and appropriate therapy is crucially important. ptp is a challenging diagnosis, because the patients are often critically ill or post-surgery, and have alternative explanations for thrombocytopenia such as infections or drugs. we present three patients with severe thrombocytopenia initially misdiagnosed. the first patient, a -year old women, had a past history of systemic lupus erythematosus and coombs positive autoimmune hemolytic anemia. at the present hospitalization, after antibiotic therapy for endocarditis, a severe hemolytic episode occurred and she need blood transfusion. when severe thrombocytopenia appeared, she was wrongly diagnosed as evans syndrome. the second patient, a -year old man, suffered from sepsis after vascular surgery and revealed clinical and laboratory picture of dic. the third patient, a -year old women, had end-stage renal failure and received heparin during hemodialysis, thus heparin-induced thrombocytopenia was first suspected. history of recent blood transfusion rose the suspicion of ptp in all this cases, and appropriate therapy with high dose iv immunoglobulin was started. adequate laboratory work-up confirmed the diagnosis. three different anti hpa-antibodies were identified: anti hpa- a, anti hpa- b and anti hpa- b, respectively. the platelets genotype of the first patient was hpa- b/ b, of the second hpa- a/ a and of the third patient, hpa- a/ a. the reported cases emphasized the importance of keeping in mind the possibility of ptp. incorrect diagnosis may lead to wrong treatment and fatal outcome. health sciences authority, singapore, singapore introduction: the haemovigilance programme in singapore was started by the centre for transfusion medicine (ctm) in . the system covers registration of collected, produced and transfused blood components, and monitors adverse transfusion reactions (atr). the programme runs on a voluntary, non-punitive and confidential basis. aims of the study: ( ) to gather and analyse reports of all adverse and untoward events occurring during transfusion of blood and components. ( ) to use the information acquired to determine the morbidity of transfusion. ( ) to provide guidance on corrective measures to prevent the recurrence of some accidents, and to improve transfusion safety. ( ) to improve public confidence by demonstrating to public, patients and professionals the safety of the existing transfusion system. methods: ( ) a common report form is used and made available to all participating hospitals. within the reporting system, the identification of the patient and staff involved are not required, to ensure confidentiality and protection of information belonging to the hospital. ( ) reportable events include immediate reactions during transfusion (haemolysis, non-haemolytic febrile transfusion reaction, urticaria, anaphylactic shock, bacterial contamination, trali), delayed untoward effects after transfusion (haemolysis, post-transfusion purpura, acute gvhd), transfusion-transmitted infections, incorrect components transfused, and near misses. ( ) within the hospitals, a responsible person ensures that all adverse events and untoward effects of transfusion are reported on the haemovigilance forms and provided to ctm for collation. within the ctm, the haemovigilance coordinator is designated to assist hospitals in investigating serious adverse events and advise on the reporting formats. results: ( ) the total number of reported cases has steadily increased since the introduction of the programme. ( ) the number of participating healthcare institutions has also increased to % (n = ). please refer to table entitled 'summary of the haemovigilance report - ' . ( ) the implementation of the haemovigilance programme in singapore is feasible with respect to the asian setting, and can significantly contribute to blood safety. ( ) there has been very good participation from the participating healthcare institutions, signifying greater awareness and willingness to partake in the programme. ( ) the results obtained from the programme have given rise to initiatives and recommendations aimed at reducing ( %) were rated for seriousness. of these, ( . %) were rated as grade (moderate to serious morbidity) or worse. ( . %) were rated for imputability to the blood transfusion. of these, a relationship to the transfusion was graded as 'certain' or 'probable' in ( . %) and as 'possible' in ( . %). overall relatively few errors were reported in comparison to other systems. a small number of reports concern (possibly) infected blood components, and imputability was deemed probable or certain only in a minority of these reports. autologous blood components gave rise to five reports (errors as well as mild transfusion reactions) which shows a relatively high risk associated with their use ( . per the rate of post transfusion hepatitis (pth) in israel in unknown. this information is important in order to learn about the residual infection risk in blood recipients. aim: to summarize the data on reported cases of pth. methods: suspected cases of pth are reported to mda blood services. the investigation procedure includes follow up testing of implicated donors and retesting of an archive sample of the transfused unit, if available. donors involved in suspected pth-b are tested for hbsag and anti-hbc. anti-hbc+ donors are tested for anti-hbs. hbv-dna testing is done if anti-hbs is less than miu/ml. donors involved in suspected pth-c, are tested for anti-hcv and alt. since hcv-ag or hcv-rna are performed, when appropriate. investigation is considered complete if all the involved donors are retested > months following the implicated unit. results: between between - suspected pth cases were reported: ( %) were pth-b, were pth-c ( %) and in patient both hbv and hcv infections were reported. investigation was completed in / ( %) cases, with % of the involved donors ( / ) being retested > months after the implicated donation. hbsag was not detected in any of the retested donors. anti-hbc was detected in donors involved in pth-b cases of which were also positive for anti-hbs. pcr for the detection of hbv-dna was performed on the 'anti-hbc+ only' donors, and none was found positive. only in / donors suspected to be involved in pt-hcv, anti-hcv antibodies were subsequently detected. this donation was collected and transfused before the introduction of anti-hcv testing in israel, which was implemented in . in another pth-c case, the implicated donor is still negative for anti-hcv, in follow up samples of up to months, but was found positive for hcv-ag and hcv-rna. pth investigation of all the donors involved was completed in % ( / ) of the cases where the patient received up to blood components. conclusion: in the past years an average of cases/year of suspected pth were reported to the israeli national blood services. investigation was completed in % of the reported cases. so far, there was no clear evidence of hbv transmission. in cases (out of . million blood units collected nationwide during - ) hcv seemed to be associated with blood transfusion: one caseprior to the implementation of anti-hcv testing and the otherprior to the implementation of hcv-ag testing in a donor that did not develop anti-hcv antibodies. these findings suggest that other modes of hbv and hcv transmission should be sought in blood recipients in israel. - . , p < . ). the seroprevalence for a-hiv in the bd population was . % (se: . ; ci: . - . ; p < . ) whereas in the a-hbc positive bd was . % (p < . ) and in the a-hbc negative bd was . %. from a-hiv positive donations, were also positive for a-hbc, that means that the sensitivity of the a-hbc in the detection of a donation a-hiv positive was . %. the relative prevalence (percentaje of positive donations for a-hiv in the a-hbc positive population divided the percentage of this marker in the donations a-hbc negative: rp) was . , which indicates that the number of bd a-hiv positive is . times higher in the a-hbc positive that in the a-hbc negative population of bd. as regards a-htlv, the seroprevalence in the bd population was . % (se: . ; ci: . - . , p < . ), in the a-hbc positive bd was . % (p < . ) and in the a-hbc negative bd was . %. from a-htlv positive donations, were also positive for a-hbc, that means that the sensitivity of the a-hbc in the detection of a donation a-htlv positive was . %. the rp for a-hbc as regards a-htlv was . , which indicates that the number of bd a-htlv positive is . times higher in the a-hbc positive that in the a-hbc negative population of bd. our results suggest that, in our bd population the screening with a-hbc would be useful to prevent other infections transmissible by blood transfusion, like retroviruses, because of the high sensitivity and the relative prevalence. . despite the high specificity of currently available elisas, the positive predictive value is lower in blood donors. therefore, immunoblot tests and polymerase chain reaction (pcr) have been adopted for routine testing in elisa +ve blood donors, by our service. . our data show that the real anti-hcv prevalence of our donor population is very low ( . %). . the selection and evaluation of appropriate assays of all donated blood for hcv infection ensure good laboratory practice and accurate post-notification counselling of infected donors. . given that donors who are elisa positive but persistently negative or indeterminate probably do not represent a risk for transmission, their deferral from donation increases the problem of availability of blood supply. . donor re-entry in the pool of donors is an issue for further discussion. . the introduction of nat technology may elicit more accurate responses and improve the screening process. background: the introduction of hcv antibody screening of all donor blood in represented a major step in the prevention of transfusion-associated hcv hepatitis and in identification of infected donors. the study of infected individuals provides a unique opportunity to define behavioral factors associated with infection. evaluating risk factors in hcv infected blood donors is essential for monitoring blood supply safety, donor screening effectiveness and developing appropriate prevention programs objectives: . to recognize the epidemiology of hepatitis c and how it differs geographically; . to investigate the risk factors for presence of anti-hcv antibody in blood donors; . to evaluate the effectiveness of our donor selection program in local level. methods: serological testing for hcv was performed according to standard procedures. initial screening was performed using secondgeneration eia and, after january , using third-generation eia. our study included a confirmation test (riba) a questionnaire was used to collect data concerning demographic, social and sexual behaviors, and number and type of donations of blood donors. the study also included testing of sexual partners and family members. changes in rates of hcv infections were evaluated by comparing yearly prevalence estimates. the overall prevalence of anti-hcv (eia) was . % out of blood donations. the average prevalence of hcv infection by riba was . %, which reaffirms the very low risk of transfusion-transmitted disease. the cumulative number of hcv infected donors was , with cases in males and cases in females. most infections were found among older persons ( % were aged - , and % aged - ). the seropositivity was higher in family/replacement donors ( %) than in volunteers ( %). the annual prevalence decreased throughout years. the relative importance of risk factors for hepatitis c was: transfusion %, hospitalization %, immigrants %, occupational %, sexual transmission %, injection drug use %, household contacts %, other %, tattooing %, unknown %. according to the criteria for blood donation, certain donors should have been excluded in the predonation interview but these donors had denied risky behaviour when questioned. the importance of sexual activity in the transmission of hcv has not been well-established as we tested sexual partners and family members and none of them was found positive. conclusions: our results suggest that major improvement in the safety and quality of our blood supply has been made in our area. introduction: apart from immuno-haematological complications, blood transfusion recipients are exposed to the risk of viral and bacterial contamination of donor blood. the latter infectious risks are generally associated with the number of donations that are needed in the production of blood products: the pooling effect. one measure recently being discussed is the generalisation of the use of trombocytapheresis for the production of trombocyte concentrates. normally, the trombocyte product is a concentration of trombocyte extractions from a pool of buffy coats: pooled platelet concentrates (ppc). in case of trombocytapheresis sufficient trombocytes for one transfusion can be collected from one single donor. aim of the study: in this presentation the effect of using % trombocytapheresis for the production of single donor platelets (sdp) instead of pooled platelet concentrates (ppc) on contamination risks will be assessed. these risks can be divided in ) the risk of bacterial contamination, ) the risk of viral contamination (e.g. hcv, hbv, hiv) resulting from window period donations, and ) the risk of contamination with tse or emerging infections for which no screening test exists. the contamination probability of sdp versus ppc is assessed on the basis of the production characteristics of both products, e.g. the presumption that the contamination risk per trombocyte product will be reduced by a factor equal to the number of pooled donations (five in our case). reduction of the bacterial contamination risk was estimated using the results of the bacterial testing of pooled and apheresis platelet products. as patients are likely to obtain multiple blood products during treatment, the contamination risk reduction through sdp is not only dependent on the reduction of risk in trombocyte products, but also will also dependent on the total number of blood products transfused and their associated contamination risks. the platelet recipient risk reduction was calculated on basis of the distribution of blood products received by the patient population of the university medical center utrecht (umcu) in the year . results: in the attached table the estimated risk reduction through % trombocytapheresis is shown for the general blood recipient patient and for the trombocyte recipient patients only. our analysis indicate that in platelet recipients, general application of sdp instead of ppc will reduce the risk for transfusion acquired tse infections by %, the risk of known viral infections by %, and transfusion acquired bacterial infections by %. the confidence intervals surrounding the results were obtained by bootstrapping. the large confidence intervals surrounding the reduction of bacterial infection risk is caused by the fact that only a limited set of apheresis trombocyte products were tested. conclusion: our analysis indicates that general application of sdp instead of ppc will not reduce the risk of transmitting infections to platelet recipients as linearly ( : ) as expected. whether it is a costeffective precautionary measure will have to be evaluated by a costbenefit analyses consideration clinical benefits and additional costs and risks of apheresis donations. introduction: hepatitis b is serious health problem world wide. its prevention, particularly in the population of blood donors is essential for providing good health care and protection. aim: the aim of this study is to present the distribution of hbsag(+) and hbsag(-) blood donors according to their profession. methods: specially designed questionnaires are used for interviewing the blood donors who has previously given signed consent for participation in this study. results: table shows the distribution of the blood donors in different professions. administrative clerks with ( . %) and the workers with ( . %) registered in the group of hbsag(+) blood donors, as well as workers with ( %) and administrative clerks with ( %) from the hbsag(-) group of blood donors are dominantly more frequent than the other categories of professions. health care professionals, housewives and farmers in both groups of blood donors are least frequent. taking in consideration the distribution of blood donors by the given professions in both groups, for u = and p > . there is no significant difference found. the analysis of the differences among the different frequencies, in distribution of blood donors according the profession, for d = . and p < . shows a significant difference, where the workers with ( . %) are the most dominantly represented. in relation to the issue of whether the type of profession of the blood donors is production or non production the results are presented on table . in the group of hbsag(+) blood donors the number of those who work in production profession- ( . %), is dominant over the number of those that has non-production profession- ( . %). in the group of hbsag(-) blood donors there is no significant difference between the types of professions. conclusion: having in consideration the professions of blood donors in both groups, for c = . and p < . there is a significant difference in the presented distribution. according to our study, which shows the horizontal transmission of hbv infection in the family in which there is an index case, the biggest number of participants in the study is workers, and the least number of participants are the farmers. introduction: blood donors, as part of the healthy population are tested for hbsag with each blood unit they give. therefore, they can be an epidemiological model for exploring the appearance of hbv infection in general population. aim: this study aims to show the distribution of hbv infection in blood donors in relation with their living conditions, space and facilities. the material needed for the study consists of the data obtained from confirmed hbsag(+) blood donors and confirmed hbsag(-) blood donors as control group. results: the table shows almost equal number of hbsag(+) blood donors that live in houses or flats. in the hbsag(-) group ( %) donors that live in a flat dominate compared to ( %) of those that live in a house. having in consideration the presented distribution (table ) for c = . and p < . there is a significant difference, that comes from the bigger number of blood donors ( ) that live in flat. as for the distribution of blood donors according the living space they use by member of the family (table ) , we can show that ( . %) of the hbsag(+) donors have less than m living space, in compared to ( %) from the hbsag(-) group. the bigger number of hbsag(+) blood donors with small living space gives bigger possibility for transmission of hbv infection in the family. the differences in the two groups for donors that have between and m , and between and m of living space per person, obviously are not very big. for u = and p > . there is no significant difference in the number of the donors in the two groups, when the available living space in m is discussed. introduction: when one of the sexual partners has hbv infection the other is also infected in from cases. aim: the aim of this study is to outline that the risk from transmission of hbv infection between sexual partners is smaller if they use condom as protection. methods: two groups of blood donors-hbsag(+) and hbsag(-) have been interviewed whether they are using condoms as protection, or not. results: table shows the distribution of blood donors concerning the use of condoms. table : in the group of hbsag(+) blood donors those who have not used condoms dominate with number of ( . %), in compared to those ( . %) who used condoms. these data are in favor of eventually possible sexual transmission of hbv infection in hbsag(+) blood donors. in the group of hbsag(-) blood donors dominate those who have used condom- ( %), compared to ( %) who have not. the given distribution of blood donors concerning the use of condoms for c = . and p < . , shows significant difference, which is due to the prevailing of the number of blood donors ( ), who have not used condom. of er -concentrates are leukodepleted. the choice of bacteriological control of empty bags for blood, bags with er -concentrates in additive solution, universal and iso group plasma, as well as the systems for taking of blood are taken on free choice. the control of the erytrocyte concentrates is performed on the first day after the preservation and dekanting, and again between the th- st day and th- th day after the preservation. the pulled plasma is controlled on the day of pouring (spreading), and the control of the iso group plasma on the day of deplasming. three months later the iso group and the universal plasma kept on the temperature of - °c is bacteriologically controlled again. bacteriological control is performed with standard procedures in the institute for health protection in stip. the transfusion transmitted infections are potentially dangerous complications of transfusion therapy in immunocompromised patients. the aim of this study was to determine the prevalence of transmissible infections in blood donor population in kashan, iran. a total of consecutive sera were tested for cmv-igm antibody, hbsag, hepatitis b core (hbc) antibody, hepatitis c (hcv) antibody, and hiv antibody with standard methods. of the sera tested, specimens ( . %) were cmv-igm positive. the frequency of seropositive revealed no significant differences between male and female donors. the frequency rates of cmv-igm seropositive tests tend to decline with increasing the age. there was no relation between the frequency rates of cmv-igm seropositive with the educational level, socioeconomic status, marital status, urban dweller and rural resident patients. the prevalence of hbv, hcv, and hiv antibody were . %, . %, and %, respectively. these findings implied important clinical applications because detection of cmv positive sera may reduce the risk for transmission of cmv in blood transfusion and thereby decrease the risk on cmv-induced complications. introduction: the worlds problem, aids, steel can't be said that is a problem in these three centers in r. macedonia, in which blood is collected, controlled, and distributed. found negative and of them were found positive for one of the three viruses (hiv- , hcv, hbv). with the elisa/axsym assay of the blood units which were negative by the procleix ultrio assay were positive for anti-hbcag and negative for anti-hbsag and hbsag. from those blood units units were given for transfusion following our blood centre protocol and the remaining units were discarded. the protocol consists of a good medical history, liver enzymes (ast, alt, ggt). we must take into consideration that from those that were found positive by the procleix ultrio assay was positive for anti-hcv and were positive for anti-hbsag. summary/conclusions: despite the fact of the short period of time we perform this method, the ability of the nat technique for rapid use, reliability and sensitivity in detecting three viruses simultaneously, indicates the need for immediate use in blood donation as a screening method. in spite of the high cost of the method, it is clear that this assay is a valuable tool in our blood centre to provide fast and safer blood. bacterial contamination of blood products is a persistent, but often overlooked, problem in transfusion medicine. in greece it is recommended that platelets (plt) must be used or discarded within five days post-collection. recent reports from europe have advocated the use of bacterial culturing of platelets on day or and, in case of negative result, prolongation of their storage time to days. aim of the study: to assess the prevalence of bacterial contamination of standard platelet units from whole blood, and to provide evidence that with the use of bacterial culturing it is feasible to extend the self life of platelets to days. materials and methods: eligible blood donors were bled according to standard operating procedures used in greece. plt were prepared from whole blood, solely for the purpose of the present study, by the platelet-rich plasma method. plts were stored for up to days at to °c with end-over-end agitation. other plts prepared from blood collected in triple-pack container system also provided with a predonation sampling device were also tested. plts were sampled in the bacteriology laboratory. plts were sampled on day , and . both aerobic and anaerobic culture bottles were inoculated with a -ml platelet sample. culture bottles were incubated at °c in an automated microbe -detection system (bact/alert system) until a positive reaction was detected or for days. all samples that were reactive were confirmed by routine culture. each reactive sample with bacteria growth on the routine culture was sub cultured for identification of the bacteria. results: a total of plt concentrates were cultured and bacterial contamination was assessed in each unit at day , and after collection. on of storage day two out of ( . %) plt units were found to be positive for bacterial growth. cases of unconfirmed positive results were noted at the beginning of the study. out of the other units which were negative on day and continued to be cultured for the next days, the assessment at day found no other positive. after further storage, at day , defined as the end of the prolonged incubation period, out of the plt concentrates ( . %) grew bacteria although testing of the same units on day and gave no signal. from the platelets units that were prepared from blood collected with a predonation sampling device, none of the plt concentrates gave a positive signal although pouches were found to be positive, and subculture showed bacterial growth of coagulase -negative staphylococcus. despite the relative small number of tested platelet concentrate units, our findings discourage specialists in attempting platelet storage time prolongation to days. bacterial contamination testing on day and a storage time of maximum days seems to be still the safest practice. bacterial screening of platelet concentrates using bact background: bacterial screening of blood components is a routine measure in the evaluation of blood product quality. at our institute bacterial screening is performed using bact/alert system. sampling and culturing of blood products is performed according to paul-erlich institute recommendations. methods: quality control data on the bacterial screening of platelet concentrates performed from - were retrospectively analysed. an initially positive (ip) and true positive (cp) rate, organisms isolated and time of detection are presented. results: a total of platelet products were tested during the year period. thirty ( . %) were found initially positive by bact/alert. the cultures screening positive were subjected to bac-terial identification to distinguish false positive from real positive signals. bacterial contamination was confirmed in ( . %) plt concentrates. positive cultures were confirmed and identified in an independent laboratory ( hbsag, anti-core, anti-hbs, anti-hcv, anti-hiv i/ii, anti-htlv i/ii, rpr. these patients were transfused with - units of concentrated red cells, depending on their problem. a total units were delivered from the beginning of their problem until december . the control were done using last generation enzyme-linked immunoassay (dade behring, ortho, biomeurieux), as also using automated enzyme-linked immunoassay (axgym). the same patients were checked by their physicians before the initiation of transfusions for the same diseases. results: we found: patients anti-hbc (+) and anti-hbs (+). patients anti-hbc (-) and Ánti-hbs (-) patients anti-hbc (-) and anti-hbs (+) patient anti-hbc (+) and anti-hbs (-) patient hbsag (+), anti-hbc (+) and anti-hbs (-). all patients were negative for hcv, hiv, htlv, and rpr. the same results were found also from patients' physicians. conclusions: we conclude that the blood supply for blood transfusion-transmitted diseases is % safe in our centre. these results are in accordance with current international literature. this is due to careful selection of blood donors, to high quality of corporation between departments as also to internal and external quality control. all these factors contribute to safety of transfusions, the quality of life of the patients and the protection of patient's environment. neither in the pipetor nor in the extractor runs was found contamination. no false positive were detected and all the positive samples confirmed. (see tables and ) . for hiv and hcv the specificity was . %. the validation criterion were met, so the system was implemented routinely in our laboratory. the purpose of our study was to analyse the applicability of the pall enhanced bacterial detection system (ebds) in the routine of our transfusion unit which is totally focused on apheresis platelet collection. methods: apheresis pcs, obtained by trima (cobe) and amicus (baxter) separators and re-suspended in % plasma and % ssp solution (macopharma), were submitted to microbiologic control using pall ebds system which uses oxygen percentage decrease as a surrogate marker of bacterial growth. the working steps were the following: - hour after donation, about ml of pc were sampled into the ebds collection pouch and then incubated at °c under continuous agitation (incubator helmer ) for hours. after this period, oxygen percentage was measured using an oxygen analyser (pall bdso ). the test is based on the 'pass/fail' principle. in case of 'fail' result the microbiology department has drawn up the procedure to follow in order to confirm the data and to allow the micro-organism to be identified. the incidence of post transfusion hepatitis has been reduced by blood donor screening for hbsag, but the hbv infection is still responsible for a certain cases of post-transfusion hepatitis in world-wide. in this study the hbsag negative blood units were evaluated for anti-hbc and hbv dna by pcr method. an extra sample was collected from hbsag, anti-hcv, anti-hiv and rpr-negative blood donors. all of samples were examined by approved anti-hbc assay. all of anti-hbc positive samples were tested by hbsab assay and evaluated for hbv dna (pcr). the sensitivity of the hbv dna (pcr) assay was estimated geq/ml according to vqc proficiency and run control panels. ( . %) out of samples were positive for anti-hbc. ( . %) out of anti-hbc positive samples were hbsab positive, and ( . %) were hbsab negative. all of samples were assayed for hbv dna (pcr) single and all of them were negative for hbv dna (pcr). further study for evaluation of anti-hbc test as a screening assay for blood unites in high hbv infection prevalence area strongly recommended. early detection of hepatitis b surface antigen: a comparison of ten assays hbsag detection is the corner stone of detection of hepatitis b virus infection in blood donors and patients with hbv infection. one of the most challenges is sensitivity of the technique and kit. in this study ten different assays evaluated by seroconversion and performance panels. some of them can not be used as screening assay due to low sensitivity. the sensitivity of ten hbsag assays from biorad, dade behring, biomeriux, diasorn, radim, diesse, thermo. biokit, gb and shanghai companies were evaluated by two or three seroconversion and two performance panels from boston biomedica ink. seroconversion panel is a series of samples that collected over a period of time from individual developing antibodies due to a primary infection. for evaluation of the assay sensitivity who and other notified body in the world-wide recommended the seroconversion and performance panels. the hbsag assays are two groups. group one with high sensitivity included six assays. they can detect ad and ay subtypes from . ng/ml bbi to . - . ng/ml bbi respectively. low sensitivity group included four assays and they can detect ad and ay subtypes more than . and . ng/ml bbi respectively. for blood safety, the high sensitivity hbsag assays recommended for blood screening and all assays should be evaluated by seroconversion and performance panels. diagnosis of chronic hdv infection is usually by antibody testing and hbv dna detected by pcr method. it is rare to find patients with two replicating hepatotropic viruses and if the accompanying hbv is replicating, prognosis will be very poor. to clarify the correlation between hepatitis delta virus infection and hepatitis b virus dna positivity, sensitive hbv dna (pcr) assay was used. the presence of hbv dna was investigated in patients referred during the aug. to dec. . all of them were hbsag positive. all samples were evaluated for hbv dna (pcr). the sensitivity of the hbv dna (pcr) assay was estimated geq/ml according to vqc proficiency panel and run control. anti-hdv was tested by commercial available enzyme immunosorbent assay. ( . %) were hbv dna positive and ( . %) were negative. ( . %) out of patients had evidence of delta infection and ( . %) samples of hbv dna (pcr) negative patients were positive for delta agent. the serum alanine aminotransferase (alt) levels in out of hbv dna (pcr) and anti-hdv positive patients were higher than reference interval, but only in out of hbv dna (pcr) negative and anti-hdv positive samples were higher than reference interval. the present data indicate that . % of patients with chronic hepatitis b have hepatitisdelta infection. patients with hbv dna (pcr) negativity had a significantly higher prevalence of delta marker ( . %) than those with hbv dna (pcr) positivity ( . %). delta rna testing in positive hbv dna and anti-hdv patients is recommended. introduction: reduction of the window period of hepatitis c virus (hcv) infection represents an important goal in the transfusional and diagnostic setting and nucleic acid technology-based tests have been introduced in some developed countries to reduce the potential risk of transfusion-associated infection. a prototype assay designed to simultaneously detect circulating hcv antigen and anti-hcv has been developed by biorad (biorad laboratories limited, marnes la coquette, france). aim of the present study: to define the cut-off (co) value of the assay and to evaluate the specificity and sensitivity of this new assay in the detection both of antibody and antigen comparing its efficacy with commercial assays. methods: in order to establish the co value and to evaluate the specificity of the assay, we tested sera samples from the general population and 'difficult' sera from haemodialysis patients (n conclusion: the new assay shows high sensitivity and specificity and could be a useful tool not only in the diagnostic setting, where procedures to reduce the window period, such as antigen or hcv-rna detection, are not currently recommended, but also in the screening of blood donations, when nucleic acid technologies is not feasible due to costs, organization, emergency and/or logistic difficulties. introduction: in recent years the concern with the blood safety regarding the transmission of blood-borne viruses has been improved. this safety has been achieved with the combining of different strategies, such as a careful selection of donors, the screening for relevant virological markers and the viral inactivation/ removal methods. more recently, the implementation of the nucleic acid amplification technologies for the detection of hiv- , hcv and hbv, has increase this aim by reducing the 'window period' of the infections. other viruses, such as parvovirus b (pb ) and hepatitis a virus (hav), can raise problems to the blood safety. these infections could provoke serious complications in some risk groups, like pregnant women, patients with haematological problems, children and patients with immunodeficiency. material and methods: an observational study was performed to determine the prevalence of pb and hav in portuguese blood donors. we gather, during four months, plasma donations and joined them into pools, with no more than donations each. [ ] [ ] [ ] [ ] [ ] in voluntary donors the anti-hcv prevalence ranged from . % to . %, in family replacement donors from . % to . %, autologous donors from % to . %. we observed that the anti-hcv prevalence has a decline tendency during years in blood donors. according to sex the anti-hcv prevalence in men is . % and women . % (p = . ). over the year periods the prevalence in men has a decline tendency ( . % to . %; p = . ) and increasing tendency in women ( . % to . %; p = . ). according to age group the anti-hcv is . % in - age group, . % in - age group, . % in - age group, . % in - age group (p = . ). the prevalence of anti-hcv is higher in fds than vds, but not statistical significant. [ ] [ ] [ ] [ ] [ ] . a total ftd and ad have been tested for hbsag. a sample was considered as hbsag positive when found repeatedly reactive by rd generation. immunoassay method (elisa). the chi-square test was used for statistical analysis. results: the -year overall hbsag prevalence among first time blood donors was . %. and ad . %. among autologous blood donors was observed a decreasing hbv prevalence from . % to . % in . according to age the prevalence was higher in - year group . %, while according to sex was higher in man ( . %) than female . % (p < . ). among ad, a decreased hbsag prevalence according to age was observed in men and women. the same trends by sex and age were observed in ftd. the prevalence of hbsag in ad was lower than in ftd. however, from - hbsag prevalence has decreased in the same proportion in both population. this decreased can explain by to main factor: the improvement hbsag screening method in blood donors and decreased the hbsag prevalence in general population. ( : ) . the hbv dna-emia in hbsag negative samples was . ¥ - . ¥ copies/ml. in two donors anti-hbc total was positive and in one anti-hbe was also detected. in one donor the glycin alanin mutation in the s region was identified. the frequency of hbv dna pos/hbsag neg donors in poland is high ( . %) therefore the decision to introduce routine hbv nat screening is justified. ( / ) with stored apheresis and whole blood derived platelet concentrates. of these failed results there were confirmed positives (presence of bacteria in both the ebds pouch and the platelet mother bag by culture) representing / . the bacteria detected were staphylococcus or streptococcus sp. of the fail results were false positives (no presence of bacteria in the ebds pouch and the platelet mother bag by culture) representing . % or / , and were not confirmed initial positives (no bacteria in the mother bag by culture, ebds pouch not tested) representing / . there was one reported case of a missed detection with confirmed presence of bacteria (staphylococcus epidermidis) in the mother bag by culture. subsequently, the bacteria strain was isolated and inoculated into platelet units in our laboratory at levels as low as cfu/ml. in all cases the pall ebds was able to detect. this supports the hypothesis that this missed detection was the result of a statistical sampling error rather than a system failure. the results from blood centers routinely using pall ebds demonstrated effective detection of bacteria in platelet products stored under routine conditions with a true positive rate of / , and with a low false positive rate (< . %). this is comparable to a recent survey result with other culture based systems. summary/conclusions: the minority group of pregnant women who come to labor without prenatal testing of hepatitis b and c revealed essentially similar prevalence of anti-hcv with healthy bd even if definitive confirmation is probably increased in this minority group. there is however markedly higher prevalence of hbv infection in the pw so that screening for hbv is essential for the prevention of vertical transmission. the systematic screening of bd with anti-hbc serves as further assurance for the prevention posttransfusion hepatitis eliminating only . % of the possibly infectious, a percentage which can be restored to the blood pool after proving their immunity. methods: blood samples were screened for the presence of hbsag, hcv and hiv antibodies using enzyme immune assay and for syphilis using the tpha test. the results were analysed retrospectively. all samples with results at or above the minimum positive value were considered reactive. the tests for hbsag, anti-hiv and anti-hcv were repeated in duplicate in all reactive donations. blood units that were reactive in the primary or secondary assays were discarded. hiv positivity was confirmed by western blot analysis using hiv blot . (genelab diagnostics) results: results from a total of screened donors were analysed. hepatitis b surface antigen rates was . %; anti-hcv seropositivity was . %; anti-hiv seropositivity was . % and tpha seropositivity was . %. one study calculated this risk to be one in for hbv, one in for hiv and one in for hcv. it is therefore important to take a careful history from blood donors to eliminate those at high risk of infection. in view of the high infectivity of hiv positive blood, it is important not only to screen donated blood but also to exclude donations from high-risk individuals, such as males who have engaged in homosexual activity and intravenous drug users. a careful history should identify those who should not give blood. in turkey, among blood donors the average hbsag prevalence in - was . %. but it had decreased to approximately . % in . anti-hcv positivity has been reported to be . % between and . but it was approximately . % in . rpr positivity in blood donors in turkey was reported to be < . % in and . % in . in , the rpr rates was . %. in our study these rates are . %, . %, . % and . % respectively. anti-hiv seropositivity was found around . introduction: the serological detection of specific antibodies to treponema pallidum (tp) is an effective means of diagnosing syphilis, and an automated chemiluminescent assay is ideally suited to testing large numbers of specimens for the laboratory diagnosis of the disease. aims of the study: to develop a qualitative syphilis assay for the detection of tp immunoglobulin m (igm) and g (igg) antibodies. the assay will be used for the serological diagnosis of syphilis using the architect platform, which has the capacity to test specimens/hour. the two-step assay is based on paramagnetic microparticle chemiluminescent technology, utilising microparticles coated with three recombinant tp antigens (tpn , tpn and tpn ) and acridinium labelled anti-human igg and igm monoclonal antibodies as conjugates. in the first step, specimens, microparticles and diluent are incubated together, prior to a wash step; in the second step, acridinium labelled antibodies are added and after washing, pre-trigger and trigger are added to produce chemiluminescence, which is measured as relative light units (rlu). specimens yielding rlus less than the cut-off are considered negative, while those yielding rlus greater than the cut-off are considered positive. the sensitivity of architect syphilis tp was determined to be %, after testing specimens that were previously screened as syphilis positive in fujirebio tppa; no prozoning was observed with high positive specimens (over titer by tppa). the specificity generated from testing hospitalised patients previously screened as tppa negative, was . %. testing a mixture of sera and plasma from random donor specimens, generated donor specificity figures of . %. the precision (cv%) with a positive control was . % ( % confidence interval: . - . %) by the standard -day nccls analysis (ep a ). in a study conducted at asahikawa medical college hospital, in which, positive and negative specimens were tested, concordance with fujirebio tppa was determined to be %. no significant interference to the assay was observed from bilirubin (conjugated type and free type), haemoglobin or lipid. the architect syphilis tp assay is an automated, specific and sensitive test for the detection of antibodies to t. pallidum. background: hcv exposure of blood donors is serologically determined by the detection of anti-hcv antibodies in serum or plasma. however a 'window' period of - days after exposure exists during which specific antibodies to hcv antigens cannot be detected. hcv rna detection and/or hcv core protein testing result in dramatic reductions in the preseroconversion window period. the new bio-rad test, based on the simultaneous detection of hcv core antigen and anti-hcv (core, ns , ns ) antibodies, improves the detection of hcv infection in the early phase. aims: the aim of this study is to assess the performance characteristics of this new screening microplate immunoassay, monolisa hcv ag-ab ultra, by using the bio-rad evolis automated microplate processor system. methods: this two-step elisa assay is based on the combination of an indirect test for the detection of antibodies (core, ns , ns ) and a sandwich test for core antigen detection. results are available within . hours, with sample addition monitoring and color coded reagents. no specimen pretreatment is required. evolis is a self-contained microplate processor designed for full automation of microplate-based eia techniques. the walkaway system can process four microplates at a time with continuous loading of samples and reagents. positive identification of samples, reagents and microplates, usage of disposable tips with clot detection, integrated quality control and complete traceability provide a high level of safety management. the monolisa hcv ag-ab ultra/evolis system performance is evaluated for clinical sensitivity on commercially available and well-documented seroconversion panels. the results are compared to viral rna detection and conventional hcv ab screening assays. specificity is evaluated by using random blood donor samples. results: among the seroconversion panels that begining with samples negative for hcv rna and anti-hcv antibodies, the monolisa hcv ag-ab ultra assay detects exposure to hcv an average of days earlier than the monolisa hcv plus v test. the mean delay of the monolisa hcv ag-ab assay in detecting hcv infection compared to hcv rna testing is around . days. the monolisa hcv ag-ab ultra/evolis system allows simultaneous detection of hcv core antigen and anti-hcv (core, ns , ns ) antibodies, thus significantly reducing the time gap between the initial detection of hcv rna and the first appearance of detectable anti-hcv antibodies. the fully automated system combines high degree of assay performance with optimization of laboratory workflow and safety management. operational evaluation of pall ebds bacterial detection system l larrea gonzalez, ma soler and rj roig centro de transfusion, valencia, spain introduction: regulatory bodies are increasingly mandating the use of bacterial detection systems for platelet products ( ed standards for blood banks and transfusion services). one system currently available is the pall ebds bacterial detection system which utilises percentage oxygen as a surrogate marker for bacterial growth. aims: to evaluate the pall ebds in routine use in our blood centre. in particular, to assess feasibility and adaptability to daily labour routines. the orbisac (gambro bct) system was used to produce leucocyte depleted buffy coat (bc) platelet pools ( bc/pool) stored in platelet additive solution (ssp macopharma). mean platelet count was . ¥ e /pool with mean leucocyte count . ¥ e /pool. ebds installation and training occurred over a day period. platelet pools were tested for bacterial contamination over the subsequent weeks. ebds pouches were sterile connected onto platelet pools hours after blood donation. platelet samples were taken into the pouches and then the pouches were incubated for hours on a shaking agitator at °c. after this time, percentage oxygen was measured. no positive results were found in this study. this was as expected due to the relatively low number of platelet pools tested and it also highlights the absence of false positive results. minimal training was required to use the ebds. the system was easy to use and did not require the use of a laminar flow cabinet to take samples. it was quick and simple to take samples and perform oxygen measurement. after pouch incubation, technician was able to make oxygen measurements in less than minutes. the data management system allowed full traceability of product and work flow. results were very easy to interpret. conclusion: the pall ebds was found to adapt perfectly to a routine blood centre environment. ( ) was . the percentage collected from volunteer blood donors was % (n = ) and the rest % (n = ) was given from patient-related donors. the age of donors ranged from to years old. the assay used for the detection of hbsag, hbeag, anti-hbc igg/total, anti-hbc igm, anti-hbe and anti-hbs was the automated microparticle enzyme immunoassay (axsym) of the abbot company. all the units were tested for hbsag, and anti-hbc igg. if the anti-hbc igg was detected, the specimens were automatically tested for anti-hbs. the units were wasted if the anti-hbs was negative, and the specimens were manually programmed for the testing of the anti-hbc igm, hbeag, and anti-hbe. from the total of tested units, of them were found to be positive to at least one marker of hbv infection, that means the . % of the health adult population was infected in the past by the hbv. the . % (n = ) was previously infected and now immunized with hbsag(-) and anti-core igg(+) and . % (n = ) were chronic carriers of the hbv with hbsag(+). the . % (n = ) of the positive donors were patient related donors and . % (n = ) were volunteer donors. in other words, of the not volunteers ( . %) and of the volunteers ( . %) were detected to be infectious. the combinations of the serologic markers for hbv are illustrated in the table attached. these results indicate that the incidence of hbv infection in the northeastern department of greece is equivalent to the incidence of hbv in other greek regions ( . %) as it is referred to the national haemovigilance data and moreover, the percentage of infectious donors is bigger among replacement donors, . % compared with the . % of voluntary donors. as a consequence, the best source for safe blood collection is the population of volunteers. earlier detection of human immunodeficiency type , hepatitis c and hepatitis b viruses using the procleix® ultrio tm assay on the procleix® system and the study objective was to assess the ability of the ultrio assay and associated discriminatory assays to reduce the detection windows for hiv- , hcv, and hbv. commercially available seroconversion panels were used for testing. methods: hiv- (n = ), hcv (n = ), and hbv (n = ) seroconversion panels were tested neat and diluted ( : and : ) in the ultrio assay. panels were tested neat in the appropriate discriminatory assay. times to detection of hiv- , hcv, and hbv nucleic acids in seroconversion panels were compared to the vendor's historical data on time to detection of antibody and/or antigen using licensed or validated serologic tests. p- effectiveness and limitations of methods for platelet bacteria screening -how to apply which screening method? the successful concept of virus safety in transfusion medicine is not suitable in bacterial contamination. bacteria can grow up in blood components to enormous amounts, whereas the initial number of contaminating bacteria is typically very low. therefore, sample drawing for bacteria screening must not be done immediately after blood donation. the established concept of relevance of clinical microbiology (pathogenic, non-pathogenic, facultative pathogenic species) is not valid for bacteria contaminating blood. here, the currently discussed criterion of clinical relevance is the ability of bacteria strains (not species!) to grow up in blood components. the paul ehrlich institute (pei) developed pei bacteria standards, which are characterized concerning their behavior in blood components. they contain a defined number of living bacteria, they are deep frozen, ready to use and shippable. there are two strategies to improve bacteria safety of blood: screening and pathogen reduction. neither of them is perfect, but screening methods are successfully established since several years in routine (belgium, the netherlands), and represent the current state of the art. further development and collecting of experience will produce the basis for assessments in the future. it is of high importance to apply the screening methods in dependence on their properties. methods implying an incubation/cultivation step ('early methods') have to be distinguished carefully from 'rapid methods' . for example, it is unreasonable to compare (or to advertise with) different sensitivities of methods not considering their detection principle or their informative value. both principles, cultivation methods as well as rapid methods, show advantages and disadvantages. selection of the method has to consider the respective conditions of the given blood service (including logistics up to time frame between issue and transfusion). results from the procleix hiv- /hcv and hiv- /hcv/hbv (procleix ultrio) assays for the detection of hiv- rna, hcv rna and hbv dna in blood donors of two blood transfusion centers of sw greece in discriminatory assay testing, out of ( % of the positive, . % of total) were reactive for hcv rna only and out of ( % of the positive, . % of total) were reactive for hiv- rna only. none were positive for both hiv- and hcv. the standard serological assays gave the same results for the above positive samples. two samples that tested positive by the standard serological assays tested negative in the procleix hiv- /hcv assay. of the samples tested by the ultrio assay, ( . %) tested reactive for hiv- /hcv/hbv. in discriminatory assay testing, out of ( . % of the positive, . % of total) was reactive for hiv- rna, out of ( % of the positive, . % of total) were reactive for hcv rna, and out of ( . % of the positive, . % of the total) were reactive for hbv dna. all were single positive i.e. none tested positive for more than virus. three out of positive samples for hbv dna tested negative by the standard serological tests. the opposite was not observed. the procleix ultrio assay is a definite improvement over the procleix assay in a region with a high incidence of hbv carriers. up until its use, it is obvious that hbv positive blood with very low antibody titers was transfused into patients. more results will show whether procleix ultrio can eventually replace the standard serological tests. the introduction: patients with hemophilia represent a high-risk group for post-transfusion hepatitis whose frequency is closely linked with the number and quantity of blood products used. in albania, the frequency of hepatitis is also linked with hbsag testing with elisa (introduced in ), and hcv testing (introduced in ). aim of the study: evaluation of the prevalence of the markers of hepatitis b, c, and d in patients with hemophilia. methods: our study included patients with hemophilia treated with cryoprecipitate and commercial clotting factors. blood testing for anti-hcv, anti-hdv, and hbsag was performed with elisa -gen. iii. results: of patients tested, cases ( %) were hbsag positive, cases ( %) were anti-hcv positive, and cases ( %) were anti-hdv positive. co-infection of hbsag and hcv was found in cases ( %), whereas co-infection of hcv, hdv, and hbv was found in persons ( %). the highest rates of infections and coinfections were found in patients above years of age. conclusion: mandatory blood testing has decreased the levels of post-transfusion hepatitis. in albania, hemophilia is also still treated with cryo-precipitation, thus patients are at a particularly high risk during the 'window period' . results: / ( . %) samples from rbd were anti hiv + nonreactive and rr for p ag both being nonreactive in the neutralization test, they were interpreted as false positives. / ( . %) sample from fbd was rr for p ag/anti hiv + nonreactive and it was confirmed positive by neutralization. this bd had been autoexcluded himself after blood donation. he showed seroconvertion days later: p ag nonreactive, anti hiv + reactive and western blot positive. the only bd p ag positive/anti hiv + nonreactive during the analized period, was an first time donor and the post donation autoexclusion was effective en this case. although a larger populations of bd is necessary to be studied and in spite of the low prevalence we have found, we consider p ag screening is an alternative up to implementation of nucleic acid testing and simultaneously we should increase the quantity of altruist repeat blood donors, undoubtedly, the best population to give blood. owing to the rather short interval between successive donations (~ days), this suggests that some - infectious units escape the screening annually. to these, one has to add the (now unknown) proportion of potentially hbsag negative + hbv dna positive ftbds. hcv: since the introduction of the screening in , the general incidence in rbd has dropped from . ‰ to . ‰, suggestive of a : escape rate. the prevalence in ftbd has stabilized at ± ‰. based on reasons similar to these employed for hbv, the residual incidence in rbd suggests that potentially infectious donation in rbd escapes the screening (= to a total of aprox. , annually). a limited investigation using hcv-antigen eia evidenced a ‰ escape rate in ftbds (= to a total of aprox. , annually table and are concerned to the fist two months of the implementation, where we had to adjust the volume of the eluate. conclusion: these system adjusts to the laboratory daily routine in the blood bank, with the pools released after first analysis in less than hours. background: the hbsag, anti-hcv, anti-hiv / , p antigen, alt and syphilis tests are performed for blood donations in czech republic. no nat tests are mandatory in czech republic. the aim of this pilot study was: . hcv rna pcr testing in anti-hcv negative blood donations; . correlation between hcv nat and anti-hcv testing results. methods: blood samples (anti-hcv serologically negative, alt not elevated) were pooled using the guardian plus spii into pools of samples. pools of ml were tested using the cobas ampliscreen hcv test v. . (roche). results: pools of samples from a-hcv serologically negative donations were tested from october to july . no one pool was initially reactive. invalid tests: ( . %) run failures were observed, due to: invalid internal controls ( . %) and invalid positive controls ( . %). invalid tests were repeated. in none of pools a positive hcv nat result was observed. conclusions: no discrepancy between hcv nat and a-hcv results was observed in our study. all of the nat tested donors in our study were regular voluntary whole blood or plasma donors who were repeatedly a-hcv serologically negative. the hcv incidence in the czech republic blood donor population is low but it is slightly growing up in general population. hcv nat testing could improve the safety of blood supply by reducing the window period for hcv. introduction: parvovirus b is the only parvovirus known to be a human pathogen. most commonly, it causes a mild childhood rash, erythema infectiosum, but in some cases more serious symptoms can be linked to b , such as acute or persistent arthropathies, critical failures of red cell production, hydrops fetalis, fetal loss, myocarditis or hepatitis. inactivation of the non-enveloped virus has proven difficult. as a consequence, manufacturers of blood products have implemented screening measures to reduce the load of parvovirus b in manufacturing plasma pools by the use of nucleic acid amplification techniques (nat). in our institute all blood donations were screened for human parvovirus b by nat since april . methods: over the last years . million donations were screened for b by nat. samples with a virus load over iu/ml were defined as positive, whereas samples with a virus load between the detection limit ( iu/ml) and iu/ml were defined as weak positive. weak positive products were released, whereas positive products were discarded. in addition infection markers of b positive donors (case group) were determined over a time period of one year. virus load and b antibody status was compared with b negative donors (randomised control group). b antibodies (igg vp , igm vp , ns ) were analysed by two commercial antibody tests. results: overall b nat-positive donors were identified with a virus load over iu/ml out of . million tested. there was a seasonal accumulation during spring and summer, whereas a large epidemic occurred throughout the last year. vp igg was detected in . % and % of the case and control group, respectively (p = . ). these data demonstrated statistically significance (p = . ). all donor samples which were b nat positive for more than three months developed neutralizing vp antibodies. in contrast, ns antibodies were observed in % of the case group and in % of the control group (p < . ). ns antibodies were detected more frequently in samples, which were b nat positive for more than six months. conclusion: b nat could be implemented in blood donor screening as release criterion without causing a shortage in blood supply. all b positive donors of the case group developed neutralizing antibodies within three months and virus load was dropped rapidly below iu/ml. these data support our testing algorithm all components of high positive donations (virus load over iu/ml) were discarded. donors with ns antibodies showed more often signs of a chronic disease with detectable levels of parvovirus b longer than six months. background: on recent years, the syphilis screening of blood donors has become increasingly important not only because of the transmission risk of this infection but also due to the risk behavior that this implies. on account of the importance of this screening the tests used are becoming more and more sensitive. aims: to evaluate an elisa screening test (the tmpa test recombinant is based on the sandwich principle, an immunoenzymatic technology in solid phase, for the measure of anti-treponema pallidum in serum or plasma). methods: in this study samples from blood donors were tested by the rotine 'cardiolipidic reagent for syphilis screening on microplates' -diagast laboratories as well as with 'hdtmpa recombinant' -hoslab diagnostics. positive samples were then confirmed with fta abs/tpha. results: using the mentioned tests we obtained the following results: . ( . %)cases turned out negative with both technologies; . ( . %) cases were positive in both methods; . cases were positive only using tmpa recombinant [of which ( . %) were confirmed positive by tpha/fta abs. as seen we found samples ( . %) that were only positives by tmpa recombinant test and that were confirmed by tpha/fta abs. we concluded that tmpa recombinant seems to be a suitable test for a quick and automated syphilis screening of blood donors and provides maximum safety for the recipients. background: in recent years, there has been substantial evidence indicating that typing and subtyping for hcv is clinically important in understanding hcv disease and its therapeutycal options. 'naive' viral load also seems to influence disease severity and responsiveness to therapy. therefore, viremia and genotype identification have been done routinely in molecular biology laboratory units. aims: the university hospital of coimbra studies and tests his own patients and patients from other hospitals in the central portugal. we also collect and test blood donor candidates from this region. we proposed to analyse the distribution of hcv genotypes in this region, among patients with cronic hcv infection. we have simultaneously analysed the viremia and correlated it with age and severity of liver disease. methods: nucleic acid extraction was done using the semiautomatic 'xstractor' from biomerieux laboratories (boom method). the genotyping used reverse hybridization and was performed using probes from the ¢ non-coding region (innulipa introduction: bacterial contamination of blood products remains a persistent problem. various techniques for the detection of bacteria in blood products exist but none of them has been widely accepted. bacterial detection systems could be divided into culture systems and rapid technologies. hemosystem has developed a rapid and sensitive technology for bacteria detection named scansystem tm . bacterial contamination of platelet concentrates is a rare event with an incidence between : to : per donation. therefore hemosystem developed a positive control in order to validate the scansystem tm platelet kit before use. aim of the study: the current study was designed to evaluate the performance of the scansystem tm positive control. the scansystem tm positive control is a capsule containing lyophilised lactobacillus casei subsp rhamnosus. the bacteria concentration per capsule is at least ¥ cfu. the positive control has to be stored at room temperature and is stable for years. after dilution in pbs, the preparation has to be used within hour. two capsules were tested for ten consecutive days with scansystem tm platelet kit as well as with optimised scansystem tm platelet kit. in an independent experiment three capsules were diluted in platelets stored in additive solution and were tested each with scansystem tm platelet kit and optimised scansystem tm platelet kit. results: microscopic fields were analysed for bacteria specific fluorescence for each sample. the ratio between bacteria specific fluorescence signals and analysed signals was . in all samples for both scansystem tm platelet kit and optimized scansystem tm platelet kit. therefore by definition all tested capsules were positive. the lyophilized positive control capsules enable the user to validate the scansystem tm platelet kit before use. because bacterial contamination of platelet products occurs rarely, the routine use of positive controls improves safety of the screening method. scansystem tm is currently the only method that provides this safety measure. introduction: whereas implementation of nat for blood donor screening reduced the risk for transfusion transmitted hiv and hcv infections currently below one per million transfusions, the risk for bacterial infections is estimated to be : to : . especially platelet products, which are stored at room temperature, are prone to bacterial contamination. aim of the study: several methods are currently developed to prevent the transfusion of bacterial contaminated platelet concentrates. the study investigates a new rapid bacterial detection method. material/methods: pool platelet concentrates were spiked with seven transfusion relevant bacteria strains under sterile conditions at concentrations of cfu/ml to cfu/ml. bacterial concentration was verified on blood agar plates immediately after spiking. five millilitres of spiked platelet concentrates were centrifuged, stained with thiazole orange dye and analysed directly by facs within five minutes after staining. aliquots of pool platelets spiked with concentration of cfu/ml and cfu/ml of each bacteria strain were incubated for two to eight hours in special bouillon at °c and were analysed by facs immediately after incubation. results: sensitivity of facs analysis differed between cfu/ml for e. coli and cfu/ml for klebsiella pneumoniae without preincubation and was enhanced to cfu/ml when a pre-incubation step of two to four hours was included. conclusion: bacteria detection by facs analysis combined with a short pre-incubation ( - h) at °c is a quick and simple method with sensitivity comparable to other commercially available detection systems. the advantage of this new method is the rapid analysis, easy handling, high sensitivity and less expensive price. introduction: detection of bacterial contamination of platelet concentrates represents a major challenge in transfusion medicine. for blood transfusion services the method must have a high sensitivity, an easy performance and a low price. aim of the study: in this spiking study we evaluated the new optimised scansystem tm platelet kit detection method for use in apheresis platelets. methods: apheresis platelet concentrates (apcs) were spiked with strains of ten different bacteria species. after different incubation periods, apcs spiked with cfu/ml were analysed by the optimised scansystem tm platelet kit. the number of bacteria was monitored by plating on blood agar. results: all bacteria strains were detected with the optimised scansystem tm platelet kit when the sample was collected h after spiking. identity of the spiked bacteria was confirmed by gram staining and dna fingerprints. conclusion: in summary, the optimised scansystem tm platelet kit was able to reliably detect ten transfusion relevant bacteria species in apheresis platelet concentrates within minutes when the sample was taken hours after spiking. background: since year our laboratory started routine screening of hcv-rna in plasma minipools for all plasma intended for fractionation. although nat testing is not yet mandatory all blood products are released depending upon nat results. aim: to test and compare two different methods of rna extraction in order to make all the necessary adjustments to the test procedures while preserving the availability of blood products. methods: plasma minipools of donations are prepared either on a tecan genesis robot or on a hamilton at plus. hcv-rna is isolated from ml plasma by using either the qiagen biorobot and qiamp virus biorobot kit or the manual extraction with cobas ampliscreen hcv pcr kit v . . results: between march and december a total of seronegative donations ( pools) were tested for the presence of hcv-rna. four pools were found to be positive for hcv-rna. of the four nat-positive pools with no eia-positive donor, four were confirmed as true positive by donor follow-up testing and/or testing of an independent sample from the index donation. all the positive donations were detected independently of the extraction method used (manual or automated). our experience shows that although the automated extraction method is 'off label' and it has to be validated, the use of biorobot does not pose a detectable contamination risk and it is possible to achieve a detection level for hcv less than iu/ml. the advantage of the manual method is that it has better recovery of nucleic acids than the qiagen extraction. concerning the time needed for the extraction process the automated method runs samples in hours where the manual method needs hours for samples, needing, prior to extraction, an extra centrifugation step for one hour. the automated extraction method results in an assay with a high sample throughput, fast time, sufficiently sensitive, that can be successfully introduced into routine use in laboratories which have more than samples/day while preserving the availability of blood products. anti-hcv similarly was high till ( . - . %), but in trend to decrease afterwards ( . %). anti-hiv reflected the low endemicity of the disease in public setting and was % through the mentioned years. rpr test for syphilis was around . %. directed donors were % of all and volunteer donors consisted nearly %. donors in our blood center are being informed about donation prior to giving their blood and donor questionnaire forms (dqf) are filled out by the donor candidates. using dqfs have been mandatory at all blood banks in turkey by law since . from that time infectious disease marker rates were dramatically reduced at all centers. donor information about the risks of transfusion and the importance of safe blood supply were detailed by the donation staff and physicians, consequently self-exclusion by the donor candidates who have risky behaviors was encouraged at our center. the interviewing staff was trained specifically for this topic. this steps were particularly emphasized in the last three years and the infectious screening results were displayed the outcome of this efforts. conclusion: education of the prospective donors, and recruit the voluntary, non-remunerated and regular donors will be the utmost goal of all blood banks. rigorous donor selection will contribute this ultimate success. we should spend more efforts to maximize enrolling voluntary donors to lower the serological marker results, consequently achieve safe blood. background: human t cell lymphotropic virus type i is endemic in japan, the caribbean, southeastern united states and parts of south america and africa. in non-endemic areas such as europe, htlv-i is less common and most infections are identified in immigrants. the epidemiology of htlv-ii is different, being predominantly found among indigenous american-indian populations and among ivdus, but the routes of transmission are the same. aim: our study's aim was to ascertain the prevalence of htlv i/ii in blood donors in order to understand the epidemiology of htlv in greece and initiate discussions of an acceptable level of risk and appropriate level of screening for rare transfusion-transmitted diseases. overall, anti-htlv seroprevalence levels among blood donors, are low. although the number of annual donations in this study is relatively small, the data for htlv indicate that rates of this infection are low and that infected donors will be seen infrequently. as all blood donations are screened for htlv i/ii during the last six years, a national survey is necessary in order to define the epidemiology of htlv in greece. introduction: toxoplasma gondii is the causative organism of toxoplasmosis. the disease transmitted by ingestion of either oocysts (in the feces of cats) or bradyzoites (in raw or undercooked meat). the parasite can also be acquired transplacentally by organ transplantation or from blood transfusion. the purpose of this study was survey of toxoplasma antibodies in some iranian blood donors at tehran blood center. blood samples were randomly collected for detecting of igg and igm antibodies (by elisa technique).the total numbers of donors was of (% ) were female and (% ) male in age ranged from to years. results: sera tested, ( %) were found to be positive for toxoplasma igg antibodies and ( . %) were igm antibodies positive and of them ( . %) were borderline for igm antibodies. among males the frequency of positivity was higher than woman but this different was not significant. the most frequency of seropositivity was found in age group to years. conclusions: diagnosis of toxoplasmosis can be aided by serologic or histocytologic examination. the acute infection in healthy individuals is generally asymptomatic and not associated with any morbidity but in an immunocompromised host, toxoplasmosis be a very serious disease, and this can occur if a person is infection with toxoplasmosis before or after his/her immunosystem is compromised. in spite of the progress in the development of diagnostic, therapeutic and prophylactic methods, virus hepatitis still presents a serious global health problem. the possibility of transmission of these infections through transfusion of blood and blood derivates implies obligatory control of the donated blood. post-transfusion hepatitis is an important health problem in everyday practice, especially in patients who have to receive transfusion of erythrocyte concentrates as the only possible treatment for many years. objective: to show the prevalence of hepatitis b (hbsag) and hepatitis c (anti hcv antibodies) in multitransfused thalassemic patients. in our region there are patients suffering from thalassemia major who are aged between and , and who have been receiving erythrocytic transfusion - times a month since the age of one or two. they receive washed red blood cells, and in certain periods filtered red blood cells, controlled for viral markers and they mostly receive blood from voluntary, periodic and regular donors. the patients are tested periodically for the presence of viral markers (hbsag, anti hcv antibodies), using tests for hbsag (abbott auxyme monoclonal eia) and for anti hcv (abbott hcv eia . ). the presence of markers for hepatitis b and hepatitis c has not been detected in any of these multitransfused thalassemic patients who receive at least transfusions a year. the tests in all patients were negative. the blood used for transfusion must be tested for viral markers, and for the patients who have to receive blood for their whole life, the blood should be from voluntary, regular and periodic donors who donate blood at least three times a year, because then the risk of transfusion transmissible infections is very small. introduction: we observe yearly the prevalence of transfusion transmitted diseases following instructions of skae (national coordination haemovigilance centre). aims: to investigate the prevalence of the most important blood borne infections in our blood transfusion centre in the state achaia during the last five years ( ) ( ) ( ) ( ) ( ) . materials and methods: the detection of hbsag, anti-hcv, anti-hiv / was made by automated microparticle enzyme immunoassay (axsym, abbott) and by enzyme-linked immunoassay methods (dade behring, ortho, biomerieux) syphilis tests were made by using rpr kits. confirmation for anti-hcv positive samples was made riba or inno-lia, while the confirmation of anti-hiv / positive samples was made by 'st. andrews' general hospital of patras reference centre. results: all the seropositive donors were first time donors. conclusion: ( ) we observe that there is a decrease in all four infections. ( ) the absence of anti-hiv seropositive donors is due to the high percentage of volunteer blood donation which approaches % in our centre during the last four years. methods: a prospective, one-year study has been set up in order to enrol at least out of the estimate of first-time donors, involving blood transfusion centres from of the italian regions. each centre was required to enrol all first-time donors born before december st, , and thus not included in the hbv mass vaccination campaign. the selected donors were tested for hbsag (mandatory by law) and for anti-hbc by commercial assays. all hbsag and/or anti-hbc positive specimens were stored frozen and sent to a reference laboratory for additional serological testing (anti-hbs, anti-hbe, anti-hbc/igm and anti-hbc avidity index by an experimental procedure) and for the determination of hbv-dna (both qualitative and quantitative) by real-time pcr. results: in the first months of the study the sites saw almost first-time donors, of whom . % belonged to the required age groups. among eligible donors, . % were both hbsag and anti-hbc positive, and . % were hbsag negative/anti-hbc positive. hbv positivity rates were higher in southern than in northern regions, although a high variability in hbv prevalence was observed between neighbouring areas in the north. hbsag positives were mostly males, % were positive for anti-hbe, % had raised alt and % were concurrently positive for anti-hbs. among hbsag negative/anti-hbc positive donors, % were negative and % were positive for anti-hbs. among anti-hbs positives, % showed values < miu/ml and % > miu/ml. the avidity index results suggested that approximately % of anti-hbc positive individuals were recently infected. conclusions: our preliminary data indicate that approximately % of the italian first-time donors are older than years of age and thus not belonging to the age groups who underwent to the mandatory vaccination against hbv, and that . % of them have serological markers of ongoing or past hbv infection. anti-hbc alone was detected in nearly % of the study population. hbv-dna testing is underway at the time of this writing. in our country mandatory tests for each blood donations are: hbsag, anti-hcv, anti-hiv / and tp ab. to c + ns + ns , ( . %) to c + ns , ( . %) to c + ns + ns , ( %) to ns + ns + ns , ( %) to c + ns + ns , ( %) to ns + ns . the use of the hcv core ag elisa test system may provide substantially earlier identification of hcv infection than it is possible with current serological assays. although all of six anti-hcv assays are very sensitive and specific screening assays, they didn't detect hcv infection in one patient. majority of anti-hcv positive patients ( . %) had anti-hcv ab for or more different epitopes of hcv. international comparison of performance of abbott prism assays used for blood donor screening background: the national serology reference laboratory, australia (nrl), coordinates a quality control (qc) programme for laboratories that screen for anti-hiv & , anti-hcv, hbsag and anti-htlv i/ii using the abbott prism assays. nineteen laboratories from australia, belgium, canada, ireland, israel, the netherlands, new zealand, norway, singapore, south africa and thailand have submitted data for this programme. aims: to determine the accuracy and precision of results from laboratories, individual prism instruments and different reagent lots by analysing data accumulated between october and january . the multi-marker qc sample 'pelispy s type ' (s ), produced by viral quality control (now acrometrix-viral quality control), was provided to participants. laboratories tested s in each calibration run, in addition to the manufacturer's controls, on each sub-channel of the instrument. pelispy was used as a 'go/nogo control' and results were required to be reactive (s/co > ) for a test run to be deemed valid. data were collected and analysed using the nrl's internet-based application edcnet (https://www.nrlqa.net). after submission, laboratories were able to compare their results with those submitted by other laboratories and investigate differences in results from reagent lots and instruments. data for five different s lots were exported from edcnet and analysed. results: nearly results were submitted: all results were reactive (s/co > ). fifty of these results ( . %) were excluded from analyses because they were reported from invalid test runs [due to pipetting, aspiration or sampling error (n = ) or due to unacceptable results (n = )]. a further results were excluded because data provided by laboratories were inconsistent or incorrect. a total of results, reported using different prism reagent lots ( for anti-hiv, for anti-hcv, for anti-htlv and for hbsag), were analysed. results from prism hbsag and anti-hiv showed the least variation with coefficient of variations (cv) of < % for all s lots. results from prism anti-hcv and anti-htlv produced cvs between . % and . % for all s lots. data reported for s lot ps (n = , range for anti-htlv to for hbsag) were analysed further to review performance of prism reagent lots. hbsag showed the least variability between prism reagent lots with < % bias for the prism hbsag reagent lots used (bias: the difference between the mean ratio for the reagent lot and the weighted mean ratio for all reagent lots, expressed as a percentage of the weighted mean ratio for all reagent lots). prism anti-htlv showed greater variability between reagent lots with a single reagent lot generating a + % bias. prism anti-hcv showed the greatest variability within reagent lot with results from of reagent lots showing a cv between % and %. conclusion: in results in a qc sample distributed to laboratories the abbott prism performance was found to be consistent over four assays. edcnet was robust in supporting laboratories' abilities to follow precision and accuracy of the assays in real time. introduction: since hcv rna testing of all blood donors started in finland in , the nat screening process has continuously been improved. investments in process automation have made the work more efficient and blood safety has further increased since hiv- rna screening of all blood donors started late . aim of the study: to implement hiv- rna testing in the nat screening program cost effectively, without increasing the throughput time of the samples and delay in the result reporting. to study if the sensitivity for both hiv- rna and hcv-rna will be sufficient when a single extraction is used and when the pool size of donations and the sample volume are kept unchanged. methods: the nucleic acids were isolated from plasma samples of ml with the magna pure lc instrument using the magna pure lc total nucleic acid isolation large volume kit. the internal controls from the cobas ampliscreen multiprep specimen preparation and control kit and the cobas amplicor hcv specimen preparation kit were added to the lysis/binding buffer ( ml/ml of each). from the final volume of the nucleic acid eluate ( ml) ml was used for the detection of hiv- rna (roche cobas ampliscreen) and ml for the detection of hcv rna (roche cobas amplicor). a run control containing both hiv- rna ( iu/ml) and hcv rna ( iu/ml) was included in all extraction runs. sensitivity of the both assays was assessed by testing dilution series of the who standards for hiv- rna and hcv rna. specificity was evaluated by testing fractionation plasmapool samples (n = ) and minipool samples (n = ). results: detection limits of the hiv- and hcv assays ( % hit rate) were calculated to be . iu/ml and . iu/ml respectively. specificity for both assays was % and during the validation phase also the robustness was good. the sensitivity of both assays with a pool size of was below the recommendations by the council of europe for blood donor screening (for hiv- rna iu/ml and for hcv iu/ml per individual donation). specificity of the assays was excellent, false reactive results were not observed. implementation of the hiv- nat assay in the screening program did not increase the throughput time of the donor samples when the pool size of donations, ml sample volume and a single extraction for two assays were used. the the very substantial increase in the number of industry-sponsored clinical trials has created challenges for medical schools, academic hospitals, faculty members of these institutions, and the journals that publish the results of these trials. in many cases, authors of reports of industry-sponsored clinical trials are paid consultants to the sponsor, have been paid by the sponsor to lecture on behalf of its products, or have equity in the sponsoring company. these ties to industry create a tension that actually is or can be perceived as • work internationally; • send young volunteers to international youth forums; • employ young people in your organisation; why use volunteers in blood donor recruitment? • they have networks to scout-groups, sports-organizations, tradeunions, rotary, staff of large companies etc. • they bring in fellow volunteers -with different prospects of society; • often paid recruiters are underpaid (!) and tend not to remain • you can not recruit by telephone! • out of donors are recruited by personal contact! • so you need direct personal contact = need many people (e.g. young ambassadors); • a large number of volunteer recruiters is a gift from heaven! paid donation gives the act of blood donation low status. the act of blood donation should be respected, and praised by role models, queens and presidents. efficient work and close cooperation of blood bank staff and volunteer organisations is the key to success in blood donor recruitment and retention! with such a prospect, it was important to evaluate the practices of blood donor selection in the eu. material and methods: a questionnaire was designed and sent in to the relevant institutions of the eu countries plus switzerland. the questionnaire included questions on the interviewing practices before homologous blood donations, regarding non-specific risks to donors and recipients, identified risks to donors, infectious, bacterial, viral, parasitic and prionic risks to recipients and non-infectious risks to recipients. the questionnaire also inquired about each country's exclusion period for each contraindication (ci) to donation. results: predonation interviews were prepared, in all countries, by circulating informative documents to blood donors. they were supported by written questionnaires in nearly all countries. in half of the countries, those interviews had to be led by physicians (nurses or technologists in the others). the - age limits for blood donation ( - for a first donation) were the rule in countries. in other countries the age limit could be brought forward to and extended to years old. the time interval between donations was identical for men and women in countries, and varied from to weeks according to country. the questions of the questionnaires were very similar as regards the identification of risks to donors and recipients, and very close to the requirements that appeared later in the / /ec directive. this particularly concerned how to meet the expectations of european donors, so that they come back to your blood center! know your donors: make regular donor surveys. age, gender, number of donations, number of first time donors, media consumption, education, job situation, income brackets. use local donor organisations let volunteers help! they work for free, but donor recruitment and -retention costs money. each blood center should have a local donor organisation, run by volunteers. the donor organisation should receive a payment for each bag collected. the reputation of the blood system tell the donors, what the blood is used for. that all blood is tested. and that blood provides safe medical treatment safety of the donor. insurance is a must good quality and efficiency in blood services decentralized blood collection no waste, and minimal outdating efficient service: • a friendly environment, • donor friendly opening hours, • pleasant rooms, beds and well equipped waiting rooms, • parking-spaces, transport, • beverages and food, • letters with correct data etc. donors expect to be serviced by trained, medical professionals and that the medical check-up is taken seriously. donors should be recognized continuously. use directed press-coverage to higher the self-esteem of the donors. donors should be well informed: • leaflets, posters and questionnaires should be % correct; • use e-mail and web-sites for quick up-date of donor information. be visible! • have an offensive and comprehensive media approach; • have a yearly national campaign june up to world blood donor day; • have an attractive home-page, constantly updated; • streamline your lay-out; • mail a donor magazine to all regular donors: • send newsletters regularly to volunteers and the press. • use recruitment cards. • easy phone-and fax numbers, e-mail addresses. directed campaign towards young people: • young ambassadors group; • special training sessions for young volunteers; • advertisements in media catering to young people; • poster competitions; • book and leaflets on blood addressed directly to young people; minimum bodyweight, blood pressure, pulse limits, questions involving viral risks, either sexually transmitted or linked to drug abuse, questions investigating risks of malaria transmission, questions aimed at identifying risk of prionic disease transmission. analyzing ineligibility times, on the other hand, revealed wide differences. for example, ineligibility for current multiple sexual partners, sexual relations with risk individuals, tattooing or body piercing, endoscopy, general anesthesia or invasive surgery, could vary from to months. previous transfusion history could not be a ci or could be one varying from months to indefinite ci (this point recently changed in several countries). the results of that survey have revealed some differences between countries in the questions asked and especially in the ineligibility times. however, the conditions under which donor selection interviews are conducted were similar in all countries. the enquiry tool used in this study proved to be well adapted to evaluate the donor selection practices throughout eu. a next step will be to use it to appreciate their evolutions and especially the impact of the /ec/ directive on these practices in the eu countries and furthermore to evaluate the results of this selection (rates and motives of deferral) which is a major factor of patients' transfusional safety. background: in europe on average whole-blood donations are performed per inhabitants and year. whole-blood donation comprises a puncture of a venous vessel and letting of blood (usually ml), which may be repeated several times a year. like other invasive procedures, blood donation has a range of effects on the individual who is subjected to it. aim: the aim of this paper is to review some aspects of the present state of knowledge on effects and complications of whole-blood donations. results: most studies of the effects of whole-blood donations on the donor have focused on negative or unpleasant events and on time in rather close association to the donation. complications related to percutaneous needle insertion (bruise assessed by inspection . % -bruise assessed using post-donation interview . %, sore arm - . %, nerve irritation . %, arterial puncture/pseudoaneurysm/arteriovenous fistula . - . % etc) are most commonly reported, while negative systemic reactions (vasovagal reactions . - . %, syncope . - . %) occurring in connection to blood donation are less frequent (newman bh: blood donor complications after whole-blood donation. curr opin hematol ; : - .) serious complications requiring hospitalization (myocardial infarction, stroke) are extremely rare ( . %). fatigue ( . %- . %) and diminished physical working capacity ( . %) are reported to occur during days after the donation. a recent study of a consecutive sample of swedish blood donors (nilsson sojka b, sojka p: the blood-donation experience: perceived physical, psychological and social impact of blood donation on the donor. vox sang ; : - .) (with a selfadministered questionnaire with an open-ended question: how does blood donation affect you? physically-bodily/psychologicallyspiritually/ethically-morally/socially during or after blood donation?) revealed that perceived negative effects (fatigue, diminished physical working capacity, vertigo/dizziness, susceptibility to infections etc) were less common ( % of the donors) than positive effects (feeling of satisfaction, being more alert, feeling generally better, less migraine, higher physical working capacity, respect from environment, feeling of relaxation etc; % of the donors). the duration of positive effects was regularly reported to be weeks, while negative effects lasted only days. investigations on the long-term effects of blood donation are scarce. yet, they may indicate that the donation of blood is associated with e.g. lower blood pressure and a reduced risk of myocardial infarction (nilsson sojka b, sojka p: the blood-donation experience: perceived physical, psychological and social impact of blood donation on the donor. vox sang ; : - ). conclusion: both the panorama and the frequency of occurrence of the different effects and complications of whole-blood donations vary as a function of how the information was gathered (openended questions, observations, interviews etc). serious reactions to whole-blood donations are extremely rare. more studies are needed in particular with respect to the long-term effects of regular wholeblood donations. t-pa- establishing a national adverse event reporting system for blood donors -a prospective study of . there was no national system and significant regional variation showed that the data was scientifically unsound. a coincidental initiative to remove the mandatory post donation rest period for regular donors further emphasised the lack of reliable, retrospective data to monitor and compare the impact of this new policy. aims: . to develop and implement a high quality, reliable national donor adverse events reporting (daer) system; . to define and categorise adverse events; . to record data systematically and prospectively using the existing computerised donor database. methods: from summer , a small project team of senior clinical and operational staff took months to agree a detailed policy for capturing and recording all donor adverse events, including precise definitions for grades of vasovagal reactions and bruising. detailed training material was written in may and the new protocol was validated in one region. from july to december a formal one day training programme was delivered to over staff working on mobile collection teams, static sites and blood centres. daer was fully implemented by january . adverse events are assessed by health care professionals on session and the relevant code entered onto the donor's computer record by clerical staff. information received after the session is entered by centre based doctors using the same system. the database is interrogated monthly for statistics. results: in the first months . million donors attended sessions throughout england and north wales. results were very consistent month on month. donors ( : ) had vasovagal symptoms but only % of these suffered syncope. % of all vasovagal reactions occurred in women. % occurred in donors aged - and a further % in donors aged - . (donors aged - represent only % of the total donor base.) donors ( : ) reported a delayed reaction, % of whom did lose consciousness. nerve injury, unrelated to haematoma, occurred in donors ( : ) and, more rarely, arterial puncture was diagnosed in donors ( : ). bruising was reported after the session by : donors. summary: a robust system has been developed and successfully implemented across a large, national blood service. based on the data already accumulated our next phase is to develop strategies to minimise adverse events, confident that any intervention will be effectively monitored. the community role in enhancement of voluntary, non-remunerated blood donation in the new millennium introduction: in the developing countries, about % of the blood supply comes from paid or replacement donors, where a high number of infected persons are in the donors population. only % of the global blood supply is donated as voluntary nonremunerated blood donors in countries with low and medium human development indices. and around % of the global blood population has access to only % of a safe blood supply. conclusion: blood is a national resource, it is the responsibility of governments through it's communities to ensure that the blood supply is safe and adequate to meet the needs of patients population and available to all who needs it. background: in response to a documented increase in the average age of donors, a survey was conducted to explore if young people had more unfavourable attitudes towards becoming blood donors. aim: to identify if the increasing difficulty in recruitment and retention of young people as donors, is linked to a low level of motivation for donating blood in this age group. methods: a national telephone-survey was conducted among a cross-sectional sample of the adult norwegian population ( participants). the survey was performed in november . results: five percent reported being active donors (had donated during the last months), % were passive donors (had not donated during the last months), % were non-donors with a positive attitude towards becoming donors, and % non-donors with no intentions ever to donate blood. in the youngest age group (age - ), % reported being active donors and % were passive donors. however, % of the young non-donors reported having intentions of becoming a blood donor. fifty-five percent of young non-donors had a negative attitude towards ever donating blood. all non-donors were asked why they did not donate. thirty-six percent of all non-donors reported health related reasons for not donating blood. thirty-one percent of all non-donors claimed that they did not donate because no one had requested them to do so personally, and % reported they did not care about blood donation. in comparison only % of young non-donors reported medical reasons for not donating. thirty-eight percent claimed lack of personal request, and % reported of lack of interest as the main reason for not donating. summary/conclusion: although the youngest age group was under-represented among active donors, we found that a great proportion ( %) of young non-donors had a positive attitude towards becoming blood donors. the most important reason why young people do not donate was the lack of a personal request. indifference regarding donation was not very widespread. a relatively high proportion of young people considered themselves as not medically disqualified to donate. in light of these findings, efforts to recruit young people as blood donors are strongly recommended. background: the ever-increasing demand for blood, coupled with emerging new threats to blood safety, motivate the strengthening of the blood banking infrastructure. aim: employing new technology as an instrument for building relationships of trust between blood bank and blood donors. material: . a new software module supporting the management of magnetic cards was added to e-aima blood bank management application. the magnetic card supports the following information: • front-side: donor's photograph, surname, name and blood group (including rhesus phenotype & kell) and sign of blood collection centre. • magnetic stripe where data concerning donor's serial number, medical history (risk factors), test results for infections and the number of donations is stored. . specific hardware allowing reading from and writing to magnetic cards is integrated to the software module: • magnetic card scanners were added to pcs serving to donation collection, including laptop for mobile team collection. • web cameras to capture the photograph of the donor to be printed on the card. • card printer was deemed necessary to produce magnetic cards for donors on a need basis. . consumables: blank plastic magnetic cards, ink cartridges for printer. methods: in order to evaluate the performance of magnetic cards compared to the paper-based system, a questionnaire was distributed to first-time and repeat blood donors, in order to be used as an indicant of donor's satisfaction. . first-time donors increased . % in the months of application. among them, . % were donors 'for relatives or friends' turned into volunteer donors and . % were first-time volunteer donors. the questionnaire analysis further revealed: • % were motivated by the use of magnetic card. • % appreciated the presence of their photo on the card and they confessed that they had used it as a spill for recruiting their friends as donors. • % were persuaded that employing new technology would result in safer and more trustworthy procedures combined with reduced waiting time. • % considered magnetic cards more practical compared to paper cards because of their compact size and improved durability. . the turnover of repeat donors also increased . % after replacing their plain old paper cards with new ones. further analysis revealed that: • % appreciated the quick cross-checking of donor's identity. • % were satisfied with the effectiveness and efficiency of magnetic cards in managing donor's data. conclusions: in , greek health policy provided the legal basis for establishing the electronic national health card. the introduction of the national donor's magnetic card is another step towards this direction, being aligned with the modern national health strategy. apart from the positive impact on the number of both firsttime and repeat blood donors, it should be also pointed out that the use of a unique donor serial number on country level results in less error-prone procedures due to the reduction of administrative process overhead and facilitates interoperability between national blood banks using compatible technological infrastructure. t-pa- emerging technologies in transfusion. dna based assays until the late s, mandatory blood screening for transmissible infectious agents depended entirely on antigen/antibody-based detection assays. recent emergence of nucleic acid technologies (nat) has revolutionized viral diagnosis by not only increasing the sensitivity level but also facilitating the detection of several viruses in parallel, by multiplexing specific primers. however, in more complex biological situations when a broad spectrum of pathogens must be screened, the limitations of these first generation technologies became apparent. high throughput systems such as dna arrays permit a conceptually new approach. these miniaturized microsystems allow the detection of hundreds of different targets simultaneously, inducing a dramatic decrease in reagent consumption, in additional confirmation tests and simplify data interpretation. however, the microsystems actually available require additional instrumentation and reagents for sample preparation and target-amplification prior to detection on the dna array. future technologies such as 'lab-on-a-chip' include channels, fluidics and thermal zones allowing extraction, amplification and detection. another major challenge in the area of dna detection is the development of methods that do not rely on target-amplification systems. almost all blood group antigens are bi-allelic and encoded by single nucleotide polymorphisms (snps). to facilitate the direct availability of typed red cells and platelets, we develop a high-throughput technique to genotype by dna microarray the whole donor cohort for all clinically relevant red cell and platelet antigens. methods: a multiplex pcr was developed to both amplify and fluorescently label gene fragments of red cell and platelet antigens in one reaction. each array contains spots of short ( - nt) allelespecific oligonucleotides to discriminate between the two alleles of an antigen system. results: two blinded panels encompassing donors were genotyped for hpa- through - and ; no discrepancies were found. currently, arrays are prepared for the red cell systems. the fya/fyb, fy-gata mutation, jka/jkb, k/k, kpa/kpb, m/n, rhc/c, rhe/e, rhdpseudogen, rhdvi negative, rs, doa/dob, genotypes can be determined. the set up of genotyping assays for rare genotypes is difficult because of lack or insufficient amount of dna. the latter can be overcome by phi dna polymerase-mediated isothermal genomic dna amplification, from minute amounts of dna present in stored red cell fractions or antiserum. the results show that the blood group typing dna microarray will provide a reliable and fast genotyping procedure. the method can be further improved to obtain the necessary automated throughput for typing of large donor cohorts. and , all other weak d types should be regarded as potential anti-d immunizers. for correct determination of weak d both serological typing (polyclonal and monoclonal), as rhd dna typing are mandatory. when serology indicates weak d, more anti-d antibodies are tested ( epitope model) to distinguish partial d from weak d. in addition, an rhd mpx pcr is performed to detect the presence of rhd exons , , , , and . in all known weak d types, all six rhd specific exons are amplified (except for weak d type which lacks rhd exons and ), whereas partial d phenotypes usually show aberrant patterns. aim: the aim of this study was to evaluate the diagnostic scheme for weak d typing. methods: between and , samples were investigated for weak d characteristics. four pcr-ssp assays were developed for identification of weak d types ( t > g), ( g > c), ( c > g) and ( c > a). weak d type was identified by the combination of serology and absence of exons and by rhd mpx pcr. rhd-specific exon sequencing was performed when serology and molecular typing were inconsistent. results: all samples were subjected to the rhd mpx pcr and sample showed absence of rhd exons and , indicative of a weak d type when combined with serology. the remaining samples were analyzed by the weak d pcr-ssps, resulting in weak d type samples, weak d type samples, weak d type samples and weak d type sample. two samples remained undetermined and were sequenced for all rhd exons and the rhd promotor region. one sample showed the mutations corresponding to the dau partial d phenotype ( g>a, g>a and c>t). the other sample had only one, not previously known mutation ( a>t), which is located intracellularly at the coohtail. extensive serology using the epitope model showed a pattern matching weak d. this new weak d variant was registered as weak d type . conclusions: based on these results it may be concluded that weak d phenotypes should be confirmed on molecular level to avoid misinterpretation of partial d that cannot be detected by rhd mpx pcr analyses. patients with weak d phenotypes, except for types , and should be regarded as being at risk for anti-d immunization after transfusion of rhd-positive blood products and should therefore be treated with rhd-negative bloodproducts. in this evaluation, out of patients carried such alleles. introduction: although kell antigens are expressed very early during erythropoiesis and a . % incidence of anti-kel is found in obstetric patients, this is a relatively rare cause of hdn. anemia is produced by immune destruction of fetal rbcs and suppression of erythropoiesis. maternal antibody titers or amniotic/cord blood bilirubin levels are not relevant indicators of the severity of the disease, and the measurement of the fetal haemoglobin by cordocentesis is a procedure with risks of miscarriage and sensitization. pcr techniques for the determination of blood groups using fetal dna isolated from maternal plasma, allows the application of noninvasive methods. clinical cases: we describe two cases of pregnancies in women with anti-kel acquired by transfusion/previous pregnancies: st case: in july , a -year-old woman (gravida , para ), rhdnegative, kel -negative was referred at weeks gestation. the father's phenotype was rhd-positive, kel -positive. a maternal antibody screen revealed d and kel alloantibodies. dna was extracted from amniotic liquid. the kel genotype was determined by pcr-rflp using the bsm i. pcr-ssp was used to studied intron and exon of the rhd gene. the results showed that the fetus was positive for rhd sequences and showed kel homozygosity; nd case: in august , a -year-old woman (gravida , para ) was referred at weeks gestation. she had a history of transfusion with rbcs units in -one of the donors was kel positive. the woman typed rhd-negative and her husband typed rhd-positive. rbcs from both were kel -negative. the maternal antibody screen revealed anti-kel . doubts existed about the putative father of this child. dna was extracted from maternal plasma using the magna pure lc (roche). real-time pcr was applied to analyse: sequences of intron , exons , , and pseudogene of the rhd gene and the sry gene by sybr green; and the alleles kel /kel by hybridization probes. all rhd sequences were detected (with the exception of the pseudogene) and the kel genotype gave a kel /kel result. in both cases the doctors choose not to use any invasive method to monitoring the fetuses regarding a hdn due to anti-kell antibodies, and the results of the molecular analysis were confirmed by testing the cord rbcs after birth. discussion: these cases illustrate the reliability of the molecular biology results, based on the collection of simple peripheral blood samples. a determination that the fetus lacks the relevant antigen obviates the need for expensive and invasive monitoring throughout the pregnancy. evidence-based medicine (ebm) is defined as: 'the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. the practice of ebm requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research and our patient's unique values and circumstances. ' otherwise healthy individuals without cardiopulmonary dysfunction (cdf) tolerate acute reduction of haemoglobin concentration to about g/dl, provided that blood volume is kept normal by a volume expander. however, individuals experience physical fatigue, and there is faint reduction of perception as measured by neurophysiological tests. symptoms are reversed upon retransfusion of fresh, autologous erythrocytes. acute, normovolemic anemia seems to be progressively less tolerated with increasing age and cdf. controversy has existed on whether or not to correct hypoalbuminemia in asb or icp by infusion of albumin. recently a large trial showed no outcome differences between icp patients treated with albumin or saline. thus in general there is no indication for albumin in asb or icp. however, albumin may yet be advantageous in e.g. patients with head injuries. furthermore, fractionated albumin is not equivalent to native albumin, since fractionation stabilizers remain bound to the albumin molecule. thus more refined albumin preparations may carry advantages still to be investigated. erythrocytes are given to increase the total oxygen transportation capacity of the organism. the effect of blood bank stored erythrocytes may differ from that of fresh, autologous erythrocytes, since changes of presumably important erythrocyte properties occur during storage. in the only large trial available, a transfusion trigger of . g/dl was found to be favourable to one of g/dl in icp, except possibly in icp with unstable angina pectoris or heart infarction. however, the erythrocyte concentrates given were not leukocyte filtered, and side effects of infused leukocytes may have hampered the conclusion. on the other hand, a metanalysis showed transfusion as an independent indicator of unfavourable outcome in coronary bypass patients, but again, leukocyte filtered erythrocyte preparations were not applied. the effect on morbidity and mortality of 'top up' transfusions given e.g. to mobilize patients postoperatively has not been studied by trials, although this effect seems evident to many clinicians. grave anemia may reduce the haemostatic effect of thrombocytes because changes of blood rheology reduces the pressure forcing thrombocytes against the walls of small vessels. the transfusion trigger for thrombocytes in asb or icp remains to be established by clinical trials, however. the same applies for fresh frozen plasma, which is infused as a source of coagulation factors. on the other hand, the haemostatic effect of various fibrinolysis inhibitors is well established in asb and icp, but many clinicians appear hesitant to use them. another interesting haemostatic agent is recombinant fviia, the use of which to control asb in blunt trauma is supported by one well controlled clinical trial. evidence by systematic research is insufficient to decide what is optimal transfusion practice. the procurement of such evidence is one of the greatest current challenges to transfusion medicine research. . concerns about the transfusion-related complications, such as infections, tumour behaviour and immuno-modulatory effects, and the costs, necessitated a re-evaluation of the transfusion practice. aims: the goal of this study is to evaluate if a restrictive transfusion policy (hb transfusion trigger < . mmol/l) reduces the amount of red cell transfusion compared to a liberal transfusion trigger (hb < . mmol/l) without a decrease in hrqol. because of concerns about the feasibility of this study early results were analysed and are presented in this abstract. material and methods: after a run in period of months (hb transfusion trigger of hb < . mmol/l) patients are randomised for the restrictive or the liberal transfusion policy. patients are followed then months. hrqol is measured after inclusion, after randomisation, weeks, , , , and months after randomisation. also anaemia related complications and red cell antibodies are scored. hb values were blinded for the patients during the study period. results: from july till june patients were included ( ra, rars, rcmd, raeb, cmmol) in general hospitals and university hospital. two patients died in the run in period. eight patients were randomised for the restrictive transfusion policy and patients for the liberal transfusion policy. the mean follow up period in the liberal group was . months (inclusive run in period) and . months for the restrictive group. two patients in the liberal group died after randomisation. one patient received growth factors. in the restrictive group patients finished the study, received growth factors and patient withdrew informed consent. the mean hb level was lower in the restrictive group and after randomisation about % reduction in amount of transfused red cells was found ( . units per pt per month in the liberal group vs . in the restrictive group). no anaemia related complications were found, e.g. cardiac failure and cerebro vascular ischemia nor a decrease in activity performance. conclusion: there were some concerns after introduction of the restrictive transfusion policy. this preliminary results show, however, that a restrictive transfusion policy leads to a diminished use of red cell transfusion without an increase of cardiac complications or a decrease in activity performance. this study will be continued to compare hrqol scores in both groups. introduction: strong evidence supports the efficacy of blood conservation strategies such as autologous blood donation (abd) and erythropoietin (epo) for reducing exposure to allogeneic blood. however, use of these interventions is highly variable among institutions and frequently sub-optimal. the program to reduce orthopedic blood exposure (probe) evaluated a blood conservation program in patients undergoing total hip joint arthroplasty (thja) at ontario hospitals. aim of the study: the objective of probe was to determine whether a comprehensive blood conservation algorithm (bca) was more effective than usual care (uc) for reducing exposure to allogeneic blood in patients undergoing thja. methods: we randomized hospitals that perform high volume elective primary thja to implement either a bca or to continue with uc. the bca consisted of three components: physician and patient education, blood conservation interventions (use of abd or epo), and transfusion guidelines. t-pa- table) . mortality for non-transfused patients was significantly lower than for patients receiving either lr-or s-prbc at all time points (p < . ). t-pa- thalassaemia: the impact on blood transfusion services thalassaemia major is a genetically determined disease that causes severe chronic anaemia and further complications. it can be managed successfully in the vast majority of cases, so long as public health and other scientific and organizational infrastructures are adequate. although the progress achieved in the field of bone marrow transplantation and other disciplines promises cure of the genetic defect, regular blood transfusion from early childhood remains the cornerstone of treatment of patients with thalassaemia major. this presents national health authorities with the formidable task of assuring an adequate blood supply of high quality and safety for these patients and ensuring that it is transfused in the appropriate way. the basic principle in the modern management of thalassaemia patients is that of a global approach to care. within this approach, a standardized protocol for regular blood transfusions is a prerequisite for the patient's long survival and quality of life. if thalassaemia patients are not transfused effectively, the severe anaemia and over-expansion of bone marrow due to ineffective erythropoesis can lead to poor growth, bone deformities, organomegaly and impairment of normal physical activities. in countries or regions with large numbers of thalassaemic patients, the organizational and technical aspects of meeting their blood requirements represents a heavy additional workload for the blood transfusion services responsible for providing blood for this group of multi-transfused patients. the acquisition and preparation of blood, genotyping the patients' blood group (including at least rh, kell, kidd and duffy systems) preventing the transmission of infectious diseases and other transfusion associated complications, and assessing the patients' blood transfusion indices all have a tremendous impact on blood transfusion and treatment units. blood transfusion services are thus confronted with major challenges that can only be met if appropriate national transfusion policies are in place, both in the laboratory and the clinical setting of blood transfusion. the availability of safe blood is related to the effectiveness of donation programmes aimed at recruiting and retaining voluntary unpaid blood donors who are at low risk for the transmission of infectious diseases. sufficiency is further related to resources, organization and management of the blood transfusion service and continuous education of its staff. high technical standards for the transfused product and quality management systems are required to ensure that the product meets these requirements, as well as pre-transfusion, transfusion and haemovigilance systems and other more stringent quality measures in the whole chain of blood donation and transfusion. additional measures and continuous care are specifically required for the optimal transfusion therapy of the thalassaemic patient. the patients should be transfused with red cell concentrates, (rccs) preferably not more than one week's old and leucodepleted. other processes i.e washing of rccs, use of nutrient additive solutions, irradiation etc may be used to improve the quality and the safety of the transfused product, while other advances in red cell transfusion are expected to improve blood safety by preventing adverse reactions and reducing exposure of the patient to donor blood. should patients with thalassemia intermedia be regularly transfused? thalassemia major (tm) and thalassemia intermedia (ti) share mostly a common basic molecular mechanism, that is the reduced synthesis of the * globin chains. the consequences of the resulting chronic hemolytic anemia are also common and include growth retardation, bone marrow expansion, extramedular hematopoiesis, splenomegaly, increased intestinal iron absorption, susceptibility to infections and hypercoagulability. what differentiates the two forms of the disease is the severity of the clinical phenotype, which in turn depends on a particularly heterogeneous molecular background and imposes diverse therapeutic strategies. the consequences of the genetic defect as well as the effect of the applied therapy seem to be mainly responsible for the clinical course of the disease. in untreated tm cases, the aforementioned consequences occur fast and patients die early in life mainly due to high output heart failure. over the past decades, the gradual adoption of the current transfusion and iron chelation strategies and the patients' compliance with this therapy have resulted in a significant improvement of survival, that according to recent statistics reaches % at age . this rate is even better in well-treated patients, almost % of whom survive at age . regular therapy extends survival mainly by preventing early development of cardiac complications. in addition, a multi-organ improvement is accomplished while patients' physical appearance is almost indistinguishable from that of the general population, hence permitting a normal social behavior with a high overall quality of life. bone marrow expansion and extramedular hematopoiesis are prevented; hepatosplenomegaly is substantially restricted and usually there is no need for splenectomy, while thromboembolic complications are rare and pulmonary hypertension is practically absent. patients with ti remain as a rule without regular therapy until a number of severe complications arise. the consequences of chronic anemia develop slowly compared to untreated tm cases and dominate patients' clinical picture usually by the third decade of life. at this time, all patients have developed hepatosplenomegaly and most of them have been splenectomized. bone marrow expansion results to bone deformities and fractures often occur. extramedular hemaotpoietic masses and bone deformities may lead to various complications depending on their bulk and location, such as neurological symptoms from masses arising in the paraspinal area or dyspnea from lung restriction. hypercoagulability, resulting from defects of native erythrocyte membrane phospholipids, together with the coexistent thrombocytosis in splenectomized patients lead to a wide spectrum of thromboembolic events. pulmonary involvement with respiratory dysfunction and hypoxemia as well as pulmonary hypertension leading to congestive heart failure are well documented in ti patients. nowadays, the beneficial effects of regular transfusion and chelation therapy in tm are beyond any doubt. the occasional application of transfusions in ti has a transient effect and does not seem to inhibit the consequences of chronic hypoxia. intensive and regular transfusion and chelation therapy in ti has proved effective in ameliorating the established complications such as spinal cord compression, hypercoagulability and pulmonary hypertension, without however reversing them. given the -year experience on intensive therapy in tm and the first encouraging data in ti, the earlier application of such treatment seems to be crucial in ti. the timing however of therapeutic intervention in ti in order to prevent anemia-related complications still remains an open issue that needs to be properly addressed. the impact of prestorage leucodepletion on the immediate transfusion adverse events of patients with thalassaemia major backround: regular blood transfusion therapy in patients with bthalassaemia major decreases the complications of anemia but it is associated to many immediate and delayed side effects. febrile non haemolytic transfusion reactions (fnhtr) are common complications due to alloimmunization of recipients against hla and/or specific antigens on donor's wbcs or to the accumulation during storage of biologic response modifiers (bmrs) that are directly pyrogenic or indirectly by stimulating recipients' white cells to produce pyrogenic mediators. post storage leucoreduction (lr) has reduced the fnhtr in these patients from % to . % per unit. it is unknown whether introduction of prestorage leucodepletion (ld) has reduced the incidence of nhftr further. we analyzed the immediate transfusion reactions of adult patients with b-thalassaemia major transfused with a total of . rbc units from january to december . all units were fresh, stored less than days. . units were lr-rbc, . units were ld-rbc and . were washed lr-rbc. results: the incidence of fnhtr and allergic reactions in patients receiving lr-rbc was . % and . %/per unit respectively, in those receiving ld-rbc was . % and . %/per unit respectively, while in those receiving washed lr-rbcs was . % and . %/per unit respectively. the relative risk (rr) of fnhrt and allergic reactions following transfusion of ld-rbc and washed lr-rbc compared to lr-rbc is shown in table. conclusion: prestorage leucodepletion and washing of rbcs reduced the risk of fnhrt in regularly transfused b-thalassaemia patients . times compared to poststorage filtration. these findings show that fnhtr after rbc transfusions are due not only to alloimmunization but also to accumulation of bmrs even in patients transfused with fresh rbcs. washing is as effective as prestorage leucodepletion in reducing fnhtr. prestorage leucodepletion has no effect on allergic reactions or other immediate adverse events in these patients. t-pa- viral inactivation/elimination of plasma derived medicinal products the safety of medicinal plasma products (mpps) relies on a whole range of measures from the quality of the source material to the release of the products after manufacturing under cgmp conditions. viral safety relies on careful donor selection, viral testing of the source material and viral inactivation and/or elimination during the manufacturing process. mpp manufacturing processes must include viral safety steps capable of inactivating, and/or eliminating, a large range of viruses covering the known blood borne viruses as well as anticipating possible future pathogens. it is recognized that one single step is often not sufficient to satisfy this requirement and manufacturing processes very often include two or even three complementary viral safety steps. very efficient methods have been implemented by manufacturers, for two decades, for the inactivation of major blood borne enveloped viruses (hiv, hcv and hbv). additional safety steps have also been introduced to provide a second step for enveloped viruses and to extend the efficacy to nonenveloped viruses (hav and parvovirus b ). pasteurisation (liquid heat treatment at °c) which has been historically used for viral inactivation of albumin solutions has been applied to some other plasma products. solvent-detergent (sd) treatment which is specific to enveloped viruses is used primarily for coagulation factors. since the introduction of sd-treated products, no hiv, hcv or hbv transmission has been reported. viral inactivation of coagulation factors can also be achieved using various conditions of dry-heating. acidic treatment is also an efficient means of inactivating viruses in igg products. nanofiltration using filters of less than nm pore size was introduced in the early s. this technique for viral elimination is based on the size of the agent and is independent of their resistance to other treatments. this property could be helpful in cases of new emerging pathogenic agents. new inactivation tech-niques are currently under development such as uv treatment or gamma irradiation with efficacy reported on enveloped as well as non-enveloped viruses. these new techniques can complement existing methods after careful validation that they do not have harmful effects on proteins in the product. the efficacy of existing techniques is well documented in controlled clinical studies and pharmacovigilance records. their application to each product is extensively validated at laboratory scale, according to international regulations and then carefully evaluated by health authorities. in this context, a recent european guideline established a viral risk assessment model to quantitatively estimate the theoretical safety margins of mpps, by taking into account the different safety measures, such as viral testing of plasma and the efficacy of viral inactivation/elimination steps. whilst technical limitations and some lack of scientific data lead to very conservative estimates, this model gives an overall assessment of the efficacy of the measures in the manufacture of a given product. developments in viral inactivation/elimination methods, in plasma testing as well as in evaluation procedures have together given mpps an excellent level of safety never previously achieved. to date the important safety measures needed to ensure a high safety margin to pooled plasma products are well understood by the plasma fractionation industry. safety nets rely on carefully done: donor selection to exclude high-risk donors, serological and nat viral testing of single donations and, pooled plasma testing using sensitive validated methods, and most particularly, efficient viral reduction treatments that must be validated and implemented at a large-scale following good manufacturing practices. over the last years, successive key breakthrough in plasma product viral safety have included the use of solvent-detergent treatment to inactivate lipid-enveloped viruses, and nat testing of starting plasma pools and viral nanofiltration of products to reduce the risks associated to small non-enveloped viruses. the excellence of the system currently in place is illustrated by the demonstration that these safety barriers have virtually stopped the transmission of known viruses and avoided that of 'emerging' agents, such as west nile virus (wnv). however, multiple viral reduction treatments have generally decreased product recovery. in addition, although the implementation of viral reduction treatments have forced fractionators to introduce significant changes to product manufacturing methods, this period has been understandably followed by a period of relative conservatism of the plasma fractionation industry against further process changes. as time evolves and market dynamics changes struggle for improved economic balance of the plasma product industry is putting product recovery and diversified product portfolio at the forefront of r&d objectives. these developments in the plasma fractionation scene of the western world have been taking place in a context where many patients in the developing world are still treated with sub-standard, non-virally inactivated crude plasma fractions. in this specific area, one can expect that the developing world will bring innovative thoughts and take actions to find ways to improve the quality and safety of their own local plasma product supply. safety strategies adapted to the infrastructure and economy of less solvable countries may have to be considered. the intercept blood system for plasma uses a synthetic psoralen, amotosalen hcl, and long-wavelength ultraviolet light to photochemically inactivate a broad spectrum of bloodborne pathogens in plasma intended for transfusion (intercept plasma, i-ffp). phase clinical trials have shown that i-ffp retains proteins necessary for hemostasis in the treatment of acquired and inherited coagulopathies, and in support of therapeutic plasma exchange for ttp. a prototype plasma processing set was used for the clinical trials. for commercialization, a new processing set has been developed to improve productivity. the prototype set accommodated approximately ml of plasma, whereas the improved set accommodates up to ml of plasma, resulting in up to three i-ffp doses per treatment. aims: this study was designed to characterize pro-and anti-thrombotic proteins in i-ffp prepared using the improved processing set. proteins of interest included components of the intrinsic and extrinsic coagulation cascade, the fibrinolytic pathway, the contact factor pathway, and the complement system, the vonwillebrand complex, endogenous inhibitors, and markers of thrombin generation. methods: six fresh jumbo ( ml) apheresis plasma units, collected using the haemonetics pcs device (gambro), were photochemically treated. sodium citrate was used as the anticoagulant. plasma samples for analysis were collected before and after photochemical treatment, and were frozen below - °c until batch analysis. standardized clinical assays were used for all analyses. results: (results in the table below are expressed as the percent activity in i-ffp in proportion to the activity in plasma before treatment [mean ± sd]). retention of procoagulant factors in i-ffp plasma ranged from % to %. factor viii and vonwillebrand factor activity, antigen, cleaving protease activity (vwf : cp, adamts- ), and multimeric composition remained within normal ranges after treatment. endogenous inhibitors of coagulation were retained % to %. plasminogen and alpha -antiplasmin were retained % and %, respectively. retention of contact factors was variable; some factors were below the reference range prior to pct. with the exception of tat, all markers of coagulation activation were well within normal ranges. the tat level in one i-ffp unit was slightly above the normal range; all other units had tat levels that were well within the normal range. the significance of this is unclear. cept plasma is similar to conventional plasma. the improved processing set, intended for commercialization, allows up to doses of i-ffp to be produced from a single photochemical treatment. background: guidelines of the european directive / /ec require that fresh plasma prior to freezing contains < residual rbcs per litre. this rbcs content is below the sensitivity limit of the automated cell counters used in routine laboratories. aim of the study: it was therefore essential to make available an alternative method to detect and quantify rbcs in plasma. we implemented a method by flow cytometry using a pe conjugated anti-glycophorin a (gpa) monoclonal antibody that recognises rbcs and erythroid precursors. to quantify residual rbcs in fresh plasma, the method uses the same trucount test tubes (becton dickinson) as those used to quantify wbcs and that contain a known number of fluorescent beads. after addition of plasma and pe-gpa antibody, cell counting is performed on flow cytometer (bd facscalibur). validation of the method: assessment of accuracy, linearity, and reproducibility with different pe-gpa antibodies (immunotech and pharmingen) application of the method: quantification of rbcs in fresh plasmas divided into groups: group : plasmas from leucoreduced whole blood, group : plasmas from packed cells after removal of buffy coat and specific filtration, group : : apheresis plasmas. results: validation of the method: for both anti gpa antibodies, detection threshold is . ¥ residual rbcs/l; linearity study with concentrations of . , . , . , . , . , . , and . ¥ rbcs/l showed excellent correlation between observed and expected values (r > . ); reproducibility study showed c.v of respectively . % and %. for values > ¥ rbcs/l, it appeared necessary to introduce a correction factor of . for the anti gpa pharmingen. quantification of rbcs in plasma: group (plasma from leucoreduced whole blood): . ± . rbcs/l; group (plasma from packed cells after removal of buffy coat and filtration): < . °¥ rbcs/l in all the cases; group (apheresis plasma): < . °¥ rbcs/l in all the cases. conclusion: quantification of rbcs in plasma by flow cytometry is a precise, quick and reproducible test. in addition this study shows that even if there are differences in residual rbcs counts according to the origin of plasma, the obtained values are much lower than regulatory requirements. . improving basic transfusion knowledge amongst health workers; . improving pre-operative preparation for surgery . strategies such as cell salvage autotransfusion combined with a conservative transfusion strategy for the use of allogeneic blood. my presentation will outline the approach adopted to ensure that the use of cell salvage autotransfusion both improves the use of allogeneic blood and preserves allogeneic stores. well-organised training can both minimise the risk of using such advanced techniques and decrease the overall risk involved in undergoing surgery where blood loss may be a significant factor in increasing morbidity and mortality. the various training methods employed to improve knowledge in this area will be described. the increasing current perception that the safety of allogeneic blood transfusion has dramatically been improved during the last decade is challenging autologous haemotherapy methods. in addition, growing concern about the unfavourable cost-effectiveness of most autologous haemotherapy methods requires a refinement of the application of these measures to well defined circumstances. in contrast, newly emerging transfusion-transmissible infections or periods of blood shortage might revive interest in these blood sparing techniques. the first two cases of transfusion transmitted vcjd provide a paradigm for this scenario; not so much with respect to a public fear of infection but rather a waning donor population due to more rigorous recruitment criteria. preoperative autologous blood donation (pabd) still plays a significant role in settings with high individual benefit for the patient, high transfusion probabilities and when all opportunities of cost minimization can be applied. adjustment to the individual situation of the patient is the main aim of a medically reasonable and economic use of autologous haemotherapy. this implies consideration of the patient's haematocrit, blood volume, tolerable blood loss, expected blood loss, etc. in order to choose the optimal method in the individual case. in this respect, double red cell apheresis may play a significant role. with this approach, donation schedules assumed to enhance erythropoiesis can be adopted. moreover, inconveniencies caused by long distances between patient home and donation service can be facilitated by withdrawing two red cell units during one session in selected patients. in conclusion, red cell apheresis can be used to promote the proposed approach towards individualized autologous haemotherapy preoperative plasmapheresis is considered to be a sensible adjunct if intraoperative retransfusion of salvaged and washed red cells is planned. acute normovolaemic haemodilution is valuable when the patient's tolerability of the haemodilution and the expected blood loss are carefully examined beforehand. intraor postoperative salvage of wound blood can also be regarded as useful measures to prevent allogeneic transfusions as long as the specific advantages and disadvantages of the different methods are taken into account. finally, alternative and supplemental measures such as iron or erythropoietin administration should always be considered in order to optimize the efficacy and effectiveness of autologous haemotherapy methods. the goal of a 'bloodless medicine' might not be reached but is supposed to be approached closely with an integrated concept exploiting all measures available. however, in times of restricted health care resources, regular sound costeffectiveness analyses, taking the availability and the cur-rent safety profile of allogeneic blood products into account, are always warranted and needed. compensatory fluid replacement of surgical blood losses: the transfusion of allogeneic blood is expensive and -although safer than ever before -still associated with potential complications. to reduce both, costs and immanent risks, allogeneic transfusion should either be completely avoided or at least minimized during surgical procedures. as a consequence an intraoperative blood loss is initially not replaced by red blood cells, but by erythrocyte-free, i.e. cristalloidal or colloidal solutions. when normovolemia is maintained the resulting dilutional anemia is compensated by an increase of cardiac output and enhanced arterial o extraction. however, once the hb has dropped to values recommended as the lower intraoperative limit, or once compensatory mechanisms of acute anemia become exhausted, as a rule transfusion of red blood cells (rbc) is initiated to increase arterial oxygen content (cao ) and to preserve a margin of safety for tissue oxygenation and organ function. as an alternative to immediate rbc transfusion, ventilation with pure o (hyperoxic ventilation) can be employed to rapidly raise cao by increasing the amount of physically dissolved o in plasma (hyperoxia). however, molecular o causes vasoconstriction, mediated by products of the arachidonic acid metabolic pathway. as a consequence hyperoxia has been shown to increase systemic vascular resistance and to decrease cardiac output and o consumption in subjects with normal hemoglobin concentration ( properly scheduled, three women who did not reach the necessary hct level after the first donation and consequently they got out of the protocol, and one woman who had unexpected intraoperative bleeding and received homologous units in addition. the patients undergoing tkr and the patients undergoing removal of implants predeposited and units respectively, but finally and of them have been used. according to our patients data, the . % of unused autologous blood units belongs to patients with tkr and implant removal. therefore a better schedule is needed for these type of surgery. all the autologous donors were supported by oral iron supplementation throughout the predonation and month past surgery. fourteen of our cases were supported by erythropoietin s.c. in a dose of iu/kg every other day. the majority of these patients was female, only one was male with multiple alloantibodies and was scheduled to predonate autologous units. all of them underwent thr except one woman who also had a tkr months later. the autologous blood donation was well tolerated by all patients and only one woman had a reaction during predonation. furthermore a group of patients matched for age, sex and type of surgery, who did not predeposit blood, received a mean of . homologous units per patient, that is more than the patients on pabd program. our results show that autologous transfusion can be used in scheduled orthopedic surgical procedures and can reduce the need for homologous blood. however, every effort should be made to render the practice of pabd more efficient and to minimize its costs. colloid solutions and their establishment in clinical practice background: various situations like trauma, critical ill patients, sepsis, major surgical procedures and anaphylactic reactions are associated with disturbances in fluid homeostasis. this disturbance is related with reduced oxygen delivery, subsequent lactic acidosis and imbalance in oxidative status. the final result will most likely be an increased mortality and morbidity. aim: the important issue from clinical aspect is to define the optimal volume and type of fluid therapy. the debate for the ideal resuscitation solution lasts a couple of decades due to inconclusive and conflicting results. method: we searched the literature for clinical trials and major met analyses concerning patients undergoing scheduled surgical procedures, trauma patients and critical ill who received resuscitation fluids. results: dextrans reduce blood viscosity and von willebrand factor levels more, for the same degree of hemodilution, compared to other plasma expanders. in clinical setting they are effective in reducing the incidence of deep vein thrombosis and pulmonary embolism. after the initiation of dextran for prophylaxis against anaphylactic reactions, they are considered the safest plasma substitutes, except maybe during pregnancy. dextran % is the most like to cause the 'hyperoncotic acute renal failure' syndrome. gelatins also cause a decrease in circulating levels of vwf : ag, vwf r : co, thrombin-antithrombin complexes and f + . in clinical aspect however, there are contradicted results about the effect of gelatins in bleeding diathesis, although they appear to exert a greater effect on rbcs protection from mechanical stress. in respect to anaphylactoid reactions, they have the greatest relative risk. hes has the same effectiveness in volume expansion with albumin and has the advantage of remaining intravascular even if there is an increased capillary permeability. in addition, it may improve splanchnic blood flow and tissue oxygenation. hes / . subsides the inflammatory response in patients undergoing major surgery, compared to a crystalloid-based volume therapy, but has conflicting results about it's effects on neutrophil respiration burst. clinical trials have so far failed to have a unanimous conclusion about the bleeding diathesis after hes administration, especially. caution must be held when administering hes during renal transplantation. albumin became the scapegoat of transfusion strategy during the past years. resent met analysis have contradicted results about the safety of albumin infusion in variouw settings. a positive effect seems to have the early administration of hypertonic solutions in trauma patients, especially in combination with dextrans. conclusions: although some minor conclusions can be extracted, there is still a great lack of large scale multicentre randomized prospective clinical trials for extracting evidence based criteria. instead, we try to extract conclusions through met analysis. results show no evidence that resuscitation with colloids reduces the risk of death compared with crystalloids in patients with trauma, burns, major surgery or sepsis. also, there is lack of evidence that one colloid solution is safer -in clinical aspect -than any other. recombinant human erythropoietin therapy in critically ill patients -a dose response study* objective: the aim of our study was to assess the efficacy of two dosing schedules of recombinant human erythropoietin (rhuepo) in increasing hemoglobin (hb) level and reducing the exposure to red blood cells (rbc) transfusion in critically ill patients. design: a prospective, randomized, multicenter trial. patients: a total of patients who met eligibility criteria were enrolled. intervention: patients were randomly assigned to receive intravenous (i.v.) iron saccharate alone (control group), i.v. iron saccharate and subcutaneous rhuepo units once per week (group a) and i.v. iron saccharate and subcutaneous rhuepo units three times per week (group b). rhuepo was given for a minimum of weeks or until icu discharge or death. the maximum duration of therapy was weeks. the requirement for rbc transfusions was significantly higher in control group than that in group a and b. no significant difference was observed between group a and b. the mean increase in hematocrit (dhct) and hb (dhb) from baseline to final measurement were significantly higher in group b than these in control group. dhct was significantly higher in group b than that in group a. dhct in group a was significantly higher than that in controls, whereas dhb did not differ significantly between control and group a. conclusion: administration of rhuepo in critically ill patients significantly reduced the need for rbc transfusions. the magnitude of the reduction did not differ between the low and high dose of rhuepo, whereas there was a dose response of hct and hb to rhuepo in these patients. in transfusion medicine, antibodies to antigens in the platelet membrane have traditionally been regarded as less significant compared with antibodies towards red cell antigens. there is an increasing awareness of antibodies towards platelet antigens. detection of autoantibodies to platelets can be a diagnostic challenge, but is seldom a problem in transfusion medicine because patients with such antibodies rarely are candidates for platelet transfusions. also, severe foetal thrombocytopenia is seldom present in pregnancies with autoantibodies to platelet antigens. the real challenge in transfusion medicine is related to patients with severe thrombocytopenia who are refractory to platelet transfusion due to alloantibodies towards platelet antigens. in our department, flow cytometry is used for compatibility testing and the choice of compatible blood donor is done without knowledge of antibody specificity. if crossmatch negative random donors cannot be identified, antibody specificity testing is performed and donors are chosen based on the specificity of the antibodies determined by a modified maipa procedure and with hla class i beads (flowpra from one lambda, usa) in flow cytometry. in some cases both hla class i and human platelet antigen (hpa) specific antibodies are detected and hla class i, hpa matched donors are chosen for crossmatch. if the crossmatch is negative, there is > % chance of successful transfusions. in some cases drug induced anti-platelet antibodies are suspected and flow cytometry based antibody tests are performed in the presence and absence of the drug. in the case of suspected heparin induced antibodies, a beads assay is performed (diamed, switzerland). two percent of caucasian women have the platelet type hpa bb. ten percent of these women make anti-hpa a antibodies in their first hpa a incompatible pregnancy. in - new-born has thrombocytopenia due to maternal alloantibodies which have crossed the placenta (neonatal alloimmune thrombocytopenia, naitp). results from a screening study covering the outcome of pregnancies show that only babies were born with intracranial haemorrhage (ich) and there was no still-born babies in the study. pregnant women with a-hpa a antibodies were diagnosed, received careful clinical follow-up and the delivery was performed by caesarean section in week of the pregnancy with immediate transfusion of hpa compatible platelets if the new-born had platelet count < ¥ e /l. in previous studies, it is reported the ich appears in - % of the pregnancies where antibodies are present and that % of the babies with ich, die. our results are different from what is reported from other studies and this may reflect the prospective approach and the clinical interventions. naitp represent a challenge in transfusion medicine both diagnostically, but also related to compatible blood products for the thrombocytopenic new-born and the mother who may have high level of antibodies towards platelet antigens. methods: apheresis platelets ( ¥ e mean) from donors with same blood group were pooled and divided equally into two bags, po- and control (pl , baxter), which have and ml/m *day*atm of oxygen permeability, respectively. on days , , , , , and of storage, swirling, mean platelet volume, po , pco , ph, glucose, lactate, aggregation, and p-selectin expression were evaluated. six experiments were performed. results: the swirling pattern was preserved better for up to days in po- ( / ) than in control ( / ) bags. dropped ph less than . on day was observed / in po- whereas / in the control. aggressive drop of glucose ( mmol/l) with prominent lactate accumulation ( mg/l) was also observed on day in of control bags. the po level in the control dropped more significantly by % ( . mmhg) on day than in po- ( . mmhg) compared with the initial level ( . mmhg) (p < . ). these results suggest that aerobic metabolism of higher concentration platelets was maintained better in a container with higher oxygen permeability. and less lactate generation with slower glucose consumption is also suggested in po- bags than in control bags. the %hsr and aggregation decreased gradually in a similar manner in both bags until day , and became a detrimental defect in of control bags on day . p-selectin expression was higher in control bags than in po- on days and with no statistical difference. in two control bags p-selectin expression reached > % and was accompanied by a loss of swirling. these functional and biochemical characteristics of platelets at a higher concentration were kept better for - days when stored in a container with higher oxygen permeability than in the best of marketed containers. t-pa- background: maintenance of a neutral ph in the range of . - . is essential for preservation of platelet function and viability during storage. furthermore, studies have also indicated that the presence of glucose in the platelet suspending medium is important for maintenance of platelet quality. however, a platelet additive solution (pas) containing glucose having a ph of . - . cannot be manufactured by steam sterilization due to caramelization of glucose. in order to have optimal ph, the currently available pas such as t-sol does not contain any glucose. this study describes a novel twostep approach to provide a glucose containing additive solution (pas-g) by using an acid, glucose containing electrolyte solution (ph . ) for resuspension and processing of the pooled buffy coats (bc), followed by transfer of the processed platelet concentrate (pc) into a storage bag containing bicarbonate for ph neutralization and maintenance during extended storage. aim: compare the platelet quality of pooled bc pc stored in pas-g with pooled bc pc stored in t-sol. methods: a paired study design was used, where a pool of bcs obtained from standard day -old cpd-wb units, was divided into two equal parts: one part was resuspended and processed with a pall leukoreduction system (atsbc) using t-sol, the other part was processed in a similar manner with the acid part of pas-g. percentage plasma carryover ranged from - %. both processed pc products were transferred and stored in elx tm bags with the pas-g pc elx bag containing a bicarbonate tablet. ten replicate studies were performed. results: the yields ( . ± . vs. . ± . °¥ e ) were similar (pags vs t-sol). statistically significant (p < . with paired ttest) improved platelet quality at days , , and of storage was observed with platelets stored in pas-g as compared to t-sol. the table below shows results at and days of storage for ph, extent of shape change (esc) and hypotonic shock response (hsr). the results for t-sol stored platelets correlated highly with initial glucose (% plasma carry over) level (r = . for esc, and r = . for hsr at days storage), while no significant correlations were found for pas-g stored platelets. conclusion: this study demonstrated the practicality of using a two step procedure to store bc pc in a glucose containing additive solution with neutral ph during storage, and confirmed the importance of glucose in the storage medium as nutrient for optimal platelet storage quality. the effect of irradiation on white cell reduced platelet concentrates, stored for days background: the storage of white cell (wbc)-reduced platelet concentrates (pcs) can be extended from to days provided the quality has been validated and bacterial screening is performed. irradiation up to gray (gy) does not affect platelet quality, but the effect of pre storage irradiation with subsequent storage up to days is not known. method: two wbc reduced pcs, each made from buffy coats and a unit of plasma, were pooled and divided into control group 'a' and study group 'b' . pcs in group 'b' were irradiated immediately after preparation with gy. pcs in both groups 'a' and 'b' were then stored on a continuous flat bed shaker at - °c. swirl, ph and cd p expression were determined on day , and . twelve experiments were performed and compared with a paired t-test, p < . was considered significant. results: see table (day values; mean ± sd; n = ). pooling and dividing of the pcs was successful with respect to volume and platelet number. on day , the ph in group 'b' was slightly lower than in group 'a', but the difference is not significant. in group 'a', ph on day was < . in / pcs, versus / in group 'b' (not significant). the cd p expression in irradiated pcs is not significantly higher than in non-irradiated pcs. conclusion: irradiation had no significant effect on platelet quality when stored for up to days after blood collection. - b, - a, - b, pra %, donors. in patient -three transfu-sions were effective (two crossmatches neg by lct and pift, one pos lct, neg pift) but later on, when the patient was in severe clinical status (shortly before his death) two transfusions were ineffective in spite of neg crossmatches. it is very likely that for the same reason patient and were refractory to two and one hpa compatible platelet units respectively. in patient and compatible platelets were not transfused because they died before the whole procedure (diagnosis and finding a proper donor) was completed. conclusions: . the frequency of occurrence of anti-hpa antibodies in transfused patients was: - b, - b, - b, - a, - a; in three patients they were monospecific, in four polyspecific. . in patients who developed anti-hpa alone, transfusions of platelets without relevant hpa antigens were successful. .the effectiveness of compatible platelets in patients with both anti-hpa and -hla was more difficult to assess because of their severe clinical status, which might have been responsible for transfusion failure. in one of these patients, however, the transfusions of compatible platelets were successful when he was in relatively good clinical status, but shortly before death transfusions were ineffective. t-pa- the successful implementation of nucleic acid testing (nat) for hiv, hbv, hcv and further viruses as well as improved donor selection led to a dramatic risk reduction for viral transmission via blood transfusion over the last years. today, other risks get into the focus of haemovigilance. bacterial contamination of blood products can occur via the donor, suffering from a (clinically unapparent) bacterial infection, or via the donation process itself, storage and handling of the blood product. particularly platelet concentrates (pc) are vulnerable to bacterial growth due to their storage conditions. patients receiving such products have a potential risk of severe complications or even death. modern hygiene regimes, e.g. improved disinfection of the donors´ skin or preparation of blood products in fully closed systems as well as diversion, led to a significant reduction of bacterial contamination risk in the past. however, a small risk remains. therefore, two possible ways of further reducing the risk of bacterial contamination of blood products are feasible: (a) testing and/or (b) inactivation. testing for bacterial contamination is possible by different methods: direct detection methods for bacteria (microscopy, flow cytometry) have disadvantages regarding sample size and detection limit. bacteria might rapidly grow in a contaminated pc, so testing should be performed as close as possible to transfusion to the recipient. biochemical methods like oxygen consumption might not detect anaerobic germs. automated culture methods are still the most sensitive technique, but they have their downsides as well (e.g. time and size of aliquot drawn). novel molecular genetic test methods for detection of bacterial nucleic acid are in different states of development, but still have to proof their suitability for routine use. three different principles of pathogen inactivation can be distinguished: photodynamic reactions produce oxygen radicals which in turn inactivate bacterial structures by oxidation processes. examples for these chemicals are phenothiazines like methylene blue and thionin as well as vitamins like riboflavin (vitamin b ). photochemical reactants penetrate cell boundaries and irreversibly inhibit nucleic acid, thus blocking replication and proliferation of pathogens. chemicals of this group are psoralens like amotosalen as well as pen- or s- . the third method, the solvent detergent (sd) method, is used for pooled plasma only and consists of the combination of both solvents and detergents, which interact with membranes and destroy bacteria. methods for inactivation of bacterial contaminants have to proof, that they effectively inhibit bacterial growth while maintaining full functionality of the blood product at the same time. these two qualities have to be fulfilled up to the end of the storage period. toxic or mutagenic compounds must not remain in the final product. the technology must be easily integrated into the existing work cycle of a blood bank. finally, costs per product must be acceptable. in summary, both testing and inactivation have their advantages and disadvantages, which have to be weighed up against costs and benefits of both procedures. pros and cons of introduction of inactivation methods in a blood donor service producing blood components per year will be discussed. bacterial contamination of blood components, particularly platelets, is now recognized as a serious adverse reaction that is preventable. there are many studies that have documented that these reactions occur from platelets stored at room temperature, most commonly arising from a skin contaminant, but originating from donors with asymptomatic bacteremia in about / of cases. the problem is intensified for patients receiving pools of platelets compared to single donor platelets collected by apheresis. reactions are more commonly noted and more severe with platelets stored for greater lengths of time. previous studies at johns hopkins described a series of reactions in years with reactions more common in platelet pools ( : transfusions) than with single donor platelets ( : transfusions). these reactions caused fatalities in of cases. although our data suggests that these reactions are more common than other studies using hemovigilance systems, our case definition requiring culture of all transfusion reactions to platelets led to a more reliable estimate of the incidence of sepsis from platelets, many potential solutions have been proposed to prevent these reactions. improved skin antisepsis should always be sought but will never eliminate the / of reactions due to asymptomatic bacteremia. the same limitation applies to methods that divert potential skin plugs from the collection bag. antibiotics in the bag would lead to manufacturing concerns or problems for patients with drug allergies. although cold storage of platelets is currently being revisited, it is not yet a practical solution. pathogen eradication systems have been developed but they remain unapproved in most of the world and have led to concerns about toxicity of additives, damage to treated cells, and cost. as a result of increasing recognition of the problem, there has been increased interest in bacterial screening to prevent sepsis from platelets. in march , the aabb standards required testing of platelets for bacterial contamination. testing programs have been implemented in the us widely as a result of the aabb action. licensed systems based upon bacterial culture or growth characteristics are available for single donor platelets and have been commonly employed. although these systems have some difficulty with false positive reactions, the evolving national data suggest an incidence of : true positive reactions. these data suggest that a number of serious reactions have been averted, although some cases have persisted due to incomplete adoption, problems with slow growing bacteria, or the use of inferior testing methods with inadequate sensitivity. whole blood derived platelets have become a more difficult issue, since the approved testing methods are limited. the use of ph monitoring, gram stain, glucose measurements, and inspection for swirling have all been attempted. these methods are not sufficiently sensitive or specific to interdict many contaminated units, so that screening for bacteria in pooled platelets is less effective. it is anticipated that new methods may become available to make screening of whole blood derived platelets easier to perform in a reliable manner. it is also hoped that bacterial screening of platelets may form the basis to permit seven day storage and prestorage pooling in the us. results: twenty four hcv rna (+)/anti-hcv(-) repeat donors were previously tested in routine hcv rna in mini-pools and were negative. twenty available look back samples were individually tested for hcv rna and in one the virus was detected. to make sure that the failure of hcv rna detection in routine nat was not due to the pooling procedure, the hcv rna was tested in undiluted look back sample and dilutions of this sample by hcv negative plasma: / repeats of x dilution and / repeats of x dilution were hcv rna negative, whereas / repeat of x dilution and / repeats of undiluted sample were positive. the results of cobas amplicor monitor (sensitivity iu/ml) were negative, which means that viremia in hcv rna mini-pool negative donation was below iu/ml. in the recipient of red blood cell concentrate from this donation hepatitis c was diagnosed. however, the possibility of pretransfusion hcv infection cannot be excluded as no hcv marker tests were performed before transfusion. the patient and the donor were infected with genotype a. the low hcv viremia (below iu/ml) in the preseroconversion window period was responsible for no hcv rna detection in routine mini-pool hcv rna testing. introduction and aim of the study: bacterial contamination is a life threatening risk of blood transfusion, especially with platelet transfusions. bacterial culturing (bc) of platelets as well as pathogen reduction (pr) reduce the likelihood of such contamination. where the costs of bacterial contamination are far less than the costs of pathogen reduction, the latter will reduce not only the risk of bacterial contamination but also risks of other pathogens. therefore, the question arises whether this additional expenditure can be justified in the light of the additional effect achieved. this question we will answer by cost-effectiveness and sensitivity analyses. methods: the balance between costs and effects of preventing adverse events due to platelet transfusion is assessed using a mathematical model and assuming optimal effectiveness of pr. model parameters and valuations of health states were obtained from literature and information from dutch sanquin blood banks. . while the estimates in comparison to the situation without bc or pr are surrounded with large uncertainties, the conclusion that pr is not cost-effective in comparison to bc is very robust. the cost-effectiveness of bc and pr are very sensitive to the estimates concerning sepsis probability and associated complication rate, the cost-effectiveness of pr relative to bc is not. this conclusion is also insensitive to a wide range of assumptions regarding residual risks and costs associated with hiv, hcv and hbv. the estimates indicate that culturing in the netherlands is cost-effective, even with the deviation bag in place. the estimates however appear to be very sensitivity to the probability of sepsis. a decision to use pr will, after the introduction of bc and the use of a deviation bag, never meet cost-effectiveness criteria. even when assuming perfect protection, the conclusion that it is not cost-effective in comparison to bc is very robust and does not alter when varying underlying parameters within their margins of uncertainty. table) . of cb collection. two collections have been transplanted to date and this represents a . % take-up rate ( . % where a sibling is alive). this compares favourably with the numbers transplanted from unrelated cb banks. dcb collection is therefore at least as efficient a method as unrelated cb collection for transplantation albeit in the limited number of cases where a dcb collection is possible. dcb collection has the benefit of a possible immediate transplant combined with the availability of a sibling donor for future donation of both stem cells and lymphocytes. it is therefore a useful service to provide and complements the work of unrelated cord blood banks. increased yield of mature platelets in cultures of cd -enriched cord blood cells maintained at °c introduction: the future use in transplantation of ex vivo expanded hematopoietic stem (hsc) and progenitors cells will facilitate the transplantation of adult patients and speed up hematologic recovery. also ex vivo cultures of hscs may eventually permit to produce donor-free blood components such as platelets for transfusion. culture of animal cells is routinely done at °c. however there is previous clinical evidence suggesting that hematopoiesis may be more active in hyperthermic patients. we have therefore compared the effect of hyperthermia on the ex vivo expansion and differentiation of cord bloodderived hsc in megakaryocytes (mk) and mature platelets. the cord blood-derived cd cells were cultured continuously at °c or °c for days in cytokine conditions optimized for mk development and maturation. the cultures were regularly monitored for various parameters. results: compared to °c, the cultures maintained at °c produced significantly more total cells ( . fold) and total mks ( fold), and showed accelerated and enhanced mk maturation with increased yield of proplatelets and mature platelets ( . fold). accordingly, the cells cultured at °c contained an increased frequency of cfc-mk ( fold) at day . cultures done at °c and °c were also more efficient than at °c but less than at °c. platelets produced in °c cultures could be normally activated by thrombin. as expected, the cells cultured at °c contained an increased amount of the heat shock protein hsp . control experiments showed that the culture of several cell lines was inhibited or unaffected by the °c temperature. the unexpected resistance of hematopoietic cells to the deleterious effects of heat and the stimulatory effect of > °c temperatures on hsc proliferation and differentiation indicate that the routine culture of normal human cells at °c is a paradigm that needs to be revised. the responsible molecular mechanisms remain to be identified but the observation will facilitate the ex vivo expansion of the progenitors of the mk and possibly other lineages. the synchronous generation of a significant number of mature platelets in vitro will facilitate the study of the mechanisms of platelet formation and ageing and could eventually have important applications in transfusion medicine. it remains to be seen if the stimulatory effects of higher than °c temperatures represent a protective response against sustained body fever that is specific to the hematopoietic system. several countries have, in the past few years, included human tissue banking within a regulatory framework similar to that of blood. indeed, tissue safety has come to the forefront of the preoccupations of regulatory agencies after several well publicised morbidity and mortality cases have been reported in the press. tissue safety has many features similar if not identical to blood safety and a review of those common elements will be reported. as well, arguments in favor of integrating tissue banking within a blood system will be discussed, one of the more important aspect of which being the expertise of the blood centre staff with cgmps. the experience of a blood establishment (héma-québec) with the integration of tissue banking such as bone, skin, heart valves within its operations will be reported, emphasizing the medical as well as the management aspects of such an integration. finally, tissue banking is an activity which brings more expertise to a blood centre, expands its knowledge of its customers and gives more opportunities to its personnel. umbilical cord blood (cb) is an important source of stem cells for clinical transplantation and may cause less gvh disease than non-t-depleted bone marrow (bm). the relatively low numerical cell dose available from cb has usually restricted its use for transplantation in adults. only - % of patients have an hla matched sibling and for others an unrelated bm or a stored unrelated cb donation may also not be available. for some children the collection of cb following the birth of a sibling may be the only opportunity for a transplant. directed cb (dcb) donations from matched siblings have been shown to give better long-term overall results than matched unrelated cb or bm. dcb collection is however not as easy to control as cb for banking where dedicated hospitals and trained staff are used. here we review dcb banking in oxford over a . -year period. requests were received for deliveries from mothers and of these, collections were successful including pairs of twins. failed collection was most often due to a damaged cord at delivery. collections were made for siblings possibly requiring transplant (median age ) with for leukaemia, for erythroid disorders, for immune deficiency, for enzyme deficiency and others. the remaining collections were mostly requested where there was a family history of an inherited disorder (majority scid). three collections tested positive for anti-hcv antibody but negative for hcv by pcr. collections were not excluded on the basis of volume or cell number. mean volume was ml (range - , % exceeded mls) and mean tnc count was . ¥ (range . - . , % exceeded . ¥ ^ ). the mean cd +ve count was . ¥ (range . - . ). all collections were cryopreserved within hours using dmso/dextran/saline without volume reduction. the mean tnc viability prior to freezing was % (range - %) and the mean cd +ve viability post freezing was % (range - %). the reliance on the goodwill of midwives and the logistical difficulties that arise when organising collections from many different hospitals do not appear to reduce the success . rhd and rhce typing was performed by multiplex-pcr with fluorescent primer pairs. positive results were obtained for rhd-exons - , , and polymorphisms associated with antigens c, c, cw, e and e. sequencing of rhce-sequences, including exons to and intron/exon borders, were done by direct taq cyclesequencing using bigdye-terminators v. . in an abi (applied biosystems). background: a number of adverse immune reactions associated with blood transfusion result from contamination of blood products by donor white blood cells. among these reactions, transfusionassociated graft-versus-host disease (ta-gvhd) has a mortality of greater than %. mirasol ® pathogen reduction technology (prt) has been developed for the reduction of viruses, bacteria, parasites and white blood cells loads in blood products. the technology is based on light and riboflavin photochemistry. this study was performed in order to evaluate the effectiveness of the mirasol ® prt process for inactivation of human pbmncs. methods: human pbmncs were collected from trima platelet apheresis disposable sets, purified by ficoll-hypaque discontinuous gradient centrifugation and divided into test and control samples. the test cells were treated with mirasol ® prt in autologous plasma on day . both test and control samples (n = ) were tested on day for cellular immunophenotype, t-cell activation using flow cytometry, proliferation in response to mitogen or allogeneic stimulator cells, ability to stimulate the proliferation of allogeneic responder cells and cytokine synthesis in response to lps stimulation was measured using a cba assay kit. results: although mirasol ® prt treatment did not significantly change the distribution of cd +, cd +cd +, cd +cd +, cd + and cd +cd + human lymphocyte subpopulations there were significant functional change. the expression of the activation marker, cd , was observed in . % (sd = . %) of control t cells upon activation with pma, while only a . % (sd = . %) of the test t cells increased cd expression. proliferation assays showed that h-thymidine incorporation did not increase in the test cells in response to either pha or allogeneic stimulator pbmnc compared to the significant increase in thymidine incorporation levels observed with control cells. the test cells, when compared to the controls cells, demonstrated an inability to stimulate allogeneic responder pbmnc proliferation. the release of il- , il- , il- b and il- cytokines after -h incubation in culture media increased significantly to pg/ml (sd = ), > pg/ml, pg/ml (sd = ) and > pg/ml for control cells, respectively. under the same conditions, these cytokines in test samples remained at background levels of . pg/ml (sd = . ) for il- , . pg/ml (sd = . ) for il- , pg/ml (sd = ) for il- b and pg/ml (sd = ) for il- . addition of lps further stimulated the release of tnf-a, il- , il- , il- b and il- in the control samples, but not in the test cell samples. in vitro studies demonstrate that mirasol ® prt treatment does not change lymphocyte immunophenotype, inhibits tcell activation by pma, abolishes pbmnc proliferative activity, eliminates pbmnc stimulatory activity for responder cell proliferation and suppresses the production of cytokines by pbmnc in both the absence or presence of lps. introduction: it has been discovered that vaccination of dendritic cells (dcs) with tumor antigens is a potential strategy to induce tumor-specific immunity in tumor-bearing patients. aim of the study: the purpose of the study was to investigate whether human monocyte-derived dendritic cells (dcs) were able to present p bcr-abl protein and induce antigen-specific ctl responses in vitro after transfected with total rna of k cells (k -rna). methods: dcs were derived from human pbmncs, which were incubated for days in the presence of gm-csf and il- , and then were transfected with k -rna using electroporation or dotap lipofection. to verify the successful transfection of dcs with k -rna, bcr-abl fusion genes expression of dcs was detected by rt-pcr and western blot. the immune phenotypes of the dcs were analyzed by flow cytometry. the cytotoxicity of ctl was assayed by propidium iodide (pi) staining and flow cytometry. results: it was shown that the bcr-abl fusion gene was detected in the dcs immediately after the transfection, but disappeared hours later, while the cells were expressing p bcr-abl protein and expressing increased cd , cd , cd , hla-dr. moreover, the transfected dcs could significantly promote the t lymphocytes to kill the target k cells. conclusion: human dendritic cells transfected with total rna of k cells in vitro could induce effective p bcr-abl proteinspecific immune responses and be used to induce tumor-specific immunity, which implies potential application of immunotherapy to tumors. appear to be relevant to the clinical response. ivig has a remarkably good safety record for long term administration, however the following side effects have been observed: mild, infusion-rate related reactions such as headaches, myalgia or fever; moderate but inconsequential events, such as aseptic meningitis and skin rash; and severe, but rare, complications such as thromboembolic events and renal tubular necrosis. judicial use of ivig based on results from controlled studies is recommended. t-pl - donor-lymphocyte infusion: transfusion immunotherapy following allogeneic hematopoietic transplantation the notion that bone marrow containing immunocompetent cells is capable of mediating an antitumor effect was determined experimentally almost years ago. subsequently, pooled leukocytes from patients with cml were found to effect responses in patients with advanced leukemia. response correlated with cell dose and with severity of gvhd. in the 's, the graft-versus-leukemia (gvl) effect was defined in the transplant setting using a lethallyirradiated mouse model and splenocyte infusions. such studies suggested that gvl could be enhanced without causing severe gvhd. the era of adoptive immunotherapy in the transplant setting began in the 's with reports of donor lymphocyte infusions (dli) for relapsed acute and chronic leukemias after bone marrow transplant. it is now clear that chronic myelocytic leukemia (cml) in chronic phase is highly susceptible to gvl effects mediated by dli which induce durable remission in - % of relapsed patients. the success rate is % or less in patients with accelerated phase or blast crisis. since dli cell dose appears to be important in this setting, strategies of escalating dose infusions have been investigated to enhance gvl without exacerbating gvhd. unfortunately, the response to dli in relapsed acute leukemia and myeloma is less favorable (< %) and less durable. dli have been used successfully to treat viral infections and virus-associated malignancies following transplant. both unfractionated dli and ex vivo-generated tcell clones have suppressed reactivated cytomegalovirus and eradicated epstein-barr virus-induced lymphoproliferative disease, a polyclonal proliferation of donor-origin b cells that occurs after transplant. where tumor-specific antigens have been defined, efforts to target dli have been undertaken and donor and patient immunization has been investigated. acute or chronic gvhd develops in approximately % of patients receiving dli for relapsed hematologic malignancies and for related, but not unrelated transplants, correlates with the donor t-cell dose. dli-induced pancytopenia occurs in approximately % to % of patients, is generally mild, and transient, but in < % of patients, aplasia is severe and prolonged. complications of aplasia include infection, bleeding, increased transfusion requirements. efforts to limit the adverse effects of dli while retaining the therapeutic effects include insertion of 'suicide genes, ' selection of lymphocyte subpopulations, and targetting lineage-specific minor histocompatibility antigens. available clinical and experimental evidence suggests, that in addition to primary and secondary immune deficiencies, a wide spectrum of immune-mediated conditions could benefit from intravenous immunoglobulin (ivig), including acute and chronic/relapsing diseases, autoimmune diseases mediated by pathogenic autoantibodies or by autoaggressive t cells and inflammatory disorders e.g. an imbalance in cytokine networks. trimar-collected apheresis platelet concentrates (pcs) were exposed to . j/ml uv light in the presence of um riboflavin, followed by storage under blood bank conditions with various concentrations of -deoxyglucose from to mm for days. the control platelets were not stressed by uv light exposure and were stored under the same conditions without -dog presence. all test and control platelets were measured for in vitro cell quality including rates of glycolysis, morphology score and activation levels at days , , and . results: lactate production and glucose consumption increased from . mmol/ cells/h (sd = . ) and . mmol/ cells/h (sd = . ) for control samples to . (sd = . ) and . (sd = . ) for uv-treated platelets, respectively. uv treatment also caused a decrease in ph from . (sd = . ) for controls to . (sd = . ) for treated platelets at day , hsr from % (sd = . ) to % (sd = . ), esc from . % (sd = . ) to . % (sd = . ), swirl from . (sd = . ) to . (sd = . ), and increased p-selectin expression from . % (sd = . ) to . % (sd = . ). addition of -dog up to mm significantly reduced lactate production rate to . mmol/ cells/h (sd = . ) and glucose consumption rate to . mmol/ cells/h (sd = . ), and maintained ph above . (sd = . ) for days of storage. the effect of -dog exhibited a dose-dependent response. however, the addition of -dog had no effects on hsr ( . + . % at day ), esc ( . + . % at day ), swirl ( . + . at day ) and p-selectin expression ( . + . % at day ) during platelet storage. atp contents in both treated and control groups were maintained at a relatively constant level above % of the value seen in fresh platelets. furthermore, an exaggeration of uv-stressed platelet aggregation by addition of -dog was also observed. conclusions: increased glycolytic flux is not a direct cause for platelet morphology changes and spontaneous activation incurred during the development of the storage lesion. the results also suggest that a reduction in glucose utilization may foster an increase in platelet loss during storage. aim of the study: was to evaluate analytical sensitivity, sensitivity and inclusivity for subtypes and genotypes of hiv, hcv and hbv, the assay's effectiveness in closing the pre-seroconversion window period, clinical specificity as well as the effect of endogenous substances and microorganisms on the sensitivity and specificity of the assay. methods: secondary standard traceable to who international standard for hiv- ( / ), international standards for hcv ( / ) and hbv ( / ) were used to determine the analytical sensitivity. sensitivity and inclusivity for hiv- subtypes other than hiv- b, for hiv- and for hepatitis b and c genotypes as well as specificity was evaluated with > specimens. results: results from this study indicate that high analytical sensitivities ( iu/ml hiv- m, cp/ml hiv- o and . cp/ml hiv- , iu/ml hcv and iu/ml hbv) and a specificity of > . % are accomplishable for the mpx test. the % detection rate for hiv- m subtype isolates (a through h) was between to iu/ml, for hcv genotype isolates ( a through ) between to iu/ml and for hbv genotype isolates (a through g and precore mutant) between to iu/ml. investigating seroconversion panels, hiv- rna was detected an average of and days earlier than hiv- antigen with abbott hivag- monoclonal and coulter p antigen tests, respectively, hcv rna an average of or days earlier than hcv antibody with the abbott hcv eia . or ortho eia . tests, hbv dna an average of days earlier than hbsag with the abbott hbsag eia imx test. for all targets, no interference was detected with microorganisms tested as well as elevated levels of triglycerides, albumin, hemoglobin, human dna or bilirubin. conclusion: automated pooling, sample preparation, and real time pcr using the blood screening system taqscreen mpx test is an efficient and sensitive method to simultaneously screen for five important viruses in human plasma. the mpx test is another evolution step in the development of pcr automation by roche molecular diagnostics, and further represents roche's commitment to increasing the safety of the global blood supply. aim of the study: a prospective hemovigilance plan was set up in order to establish a registry for future reference, and to detect any unexpected side effect of ip that may occur with significant frequency in populations and indications that were not studied before and outside of a formal trial environment. methods: this plan is proposed to blood establishments and transfusion prescribers who have already decided to implement ip. this is an observational, non randomized, non controlled plan. no patient selection, inclusion or exclusion criteria are required. all ip transfusions are documented using an internet form, whether or not a reaction is observed. patient population data are collected anonymously, for epidemiological purposes. results: between october and september , apheresis ip units have been transfused in sites and registered in the database. ip platelets were considered leucocyte inactivated and were not irradiated, but were antigen matched as indicated ( . %). the population of patients receiving at least one transfusion (n = ) included . % of males, . % of females, the median age was (range - ). the most frequent broad diagnostic categories were hematology-oncology ( . %) and cardiovascular surgery ( . %). the patients received their transfusions either in regular hospital wards ( . %), intensive care units ( . %) or as outpatients ( . %). the number of transfusions by patient ranged from to (mean . ± . , median ). half of the patients ( . %) had previous transfusion experience and . % had previous history of transfusion reaction. transfusion reactions, defined as any deterioration of the patient's state of health observed following transfusion, were observed in . % (n = ) of the transfusions ( % ci . - . ), and . % of patients. only ( . %) were considered serious. after further causality analysis including biological and clinical investigations by the transfusion physician, . % ( % ci . - . ) of the transfusions were confirmed as having caused reactions in . % of patients, none of them serious. the most often reported symptoms were chills ( . %) and fever ( . %). itching, skin rash or urticaria was observed in . % of transfusions. of the serious reactions, one was hypotensive shock in a patient with liver cirrhosis and haemorrhage, and one was septic shock, in which the platelet unit bacterial culture was negative. none of the reactions occurred in cardiovascular surgery patients. patients were more likely to experience reactions if they had previous transfusion history (odd ratio . , p = . ). the active hemovigilance plan is a valid and feasible method to collect epidemiological data on transfusion safety. the risk profile of ip transfusions appears favorable. quality of theraflex mb-plasma during storage and treatment s reichenberg* and n mÜller † *maco pharma international gmbh, langen, † inst. for transfusion medicine, essen, germany background: although in the last decades thanks to the implementation of several methods like donor selection and testing procedures the risk of virus transmission from plasma has decreased, infection of patients still exists. additionally new viruses like west nile virus enter the transfusion chain. therefore, the treatment of therapeutic plasma with methylene blue (mb) is a technique used in several european countries for pathogen inactivation. macopharma has developed the proprietary theraflex mb-plasma bag system including a mb pill and a final mb filtration step. aims: aim of the study is to show the quality of the mb plasma during the preparation procedure and during storage using the theraflex system. methods: for the preparation process every single step was evaluated using single donor plasma units. for the evaluation of the plasma factors ml were drawn at different stages (before treatment, after plasma filtration with plas , after dissolution of the mb pill, after illumination, after treatment). because the sample volume for single sample measurements would be too low the samples were pooled after drawing and measured for the specified factors. six samples of each stage were pooled at three days. a whole panel of plasma factors was measured for the resulting three pools. global tests: quick, inr, aptt, thrombin time coagulation factors: fibrinogen, factor ii, factor v, factor viii:c, factor ix, factor x, factor xi inhibitors: at iii, protein c, protein s fibrinolysis: plasmin inhibitor, alpha -antitrypsin complement: ch activation: tat, factor xiia, d-dimer stability data were generated using three plasma pools. six plasmas were pooled and afterwards divided into six aliquots. each was treated as single unit and then each was divided into six storage samples. the same plasma factors as for the manufacturing process were evaluated. results: a moderate reduction for some coagulation factors during the preparation was found in the illumination step but not in the other preparation stages. this was mainly fibrinogen ( . %), factor viii ( . %), and factor x ( . %). despite this reduction the values were within the ranges found in non-treated plasma. all investigated plasma factors remained stable during the investigated storage time. summary/conclusions: the investigation showed that plasma treated with the theraflex procedure showed slight reduction during treatment and no reduction during storage. all plasma factors remained within the threshold values. the treatment of therapeutic plasma with mb is a valid technique of pathogen inactivation. validation of intercept treatment of pooled platelets g santos, c silva, f pereira and g sousa lisbon regional blood centre, lisbon, portugal background: intercept blood system for platelets uses amotosalen hcl and uva light to inactivate viruses, bacteria, protozoa and leucocytes that may contaminate platelet products. aims: the purpose of the study was to assess the feasibility of introducing this technology in the routine of lisbon regional blood center (crsl) and validate the procedure in our center. material and methods: whole blood units of ml were collected from volunteer blood donors in quadruple top and bottom blood bags (optipure rc soft t& b baxter), kept in n-butanodiol plates; buffy coats with a volume of ml were obtained in the opipress ii and kept overnight at room temperature before pooling. five buffy coats were pooled with ml intersol using the octopus system intercept buffy coat pooling set with an integrated filter. the pools were treated using the intercept. samples were taken before treatment, after cad remotion, on days , and . the following tests were performed: platelet count, mean platelet volume, ph, swirling. results: all pools met the intercept guardbands. platelet yield pre inactivation was . ¥ ( . - . ¥ ; sd- . ). platelet pool volume was . ml (sd- . ). plasma % was within . % and . %. all pools had leucocytes within council of europe specifications. after photoinactivation the platelet concentrates had . ¥ (± . ). the average platelet loss was . ¥ . the ph was within specifications during all the storage period. conclusions: intercept treatment of pooled buffy coat platelets is feasible in the routine of crsl and in vitro parameters do not show significant changes, allowing us to proceed to clinical use. shown ip and conventional platelets (cp), stored for up to days, exhibit comparable hemostatic efficacy and safety. extension of platelet storage duration to days has the potential to improve platelet availability and reduce outdating and inventory shortages. clinical efficacy and safety of ip stored for days were investigated. methods: a randomized, controlled, single-center, crossover, noninferiority design (pilot) study evaluated efficacy and safety of buffy coat ip vs buffy coat cp, each stored for days. patients were randomized to receive one -day ip transfusion and one -day cp transfusion in random order. after each study transfusion, the hour platelet count, ci, and cci; time to next transfusion; bleeding response; transfusion reactions; and serious adverse events (saes) were assessed. the primary endpoint, -hour cci, was analyzed by a one-sided non-inferiority test for the per protocol population (patients with both transfusions and no major protocol deviations interfering with efficacy evaluation). the per protocol population included patients, randomized to the ip-cp sequence and to the cp-ip sequence. more patients received allogeneic stem cell transplant in the cp-ip sequence than the ip-cp sequence ( % vs %; p = . ). mean platelet dose (¥ e ) was . for ip and . for cp (p = . ). there was a significant period by treatment interaction (p = . ) at the . significance level; therefore, the first period only was also analyzed for the primary endpoint. including both treatment periods, mean (±sd) -hour cci (¥ e ) was . ± . for ip vs . ± . for cp. the mean paired difference for both sequences was . ¥ e (p = . by non-inferiority test; upper bound of the % confidence interval = . ). for the first period only, mean -hour cci (¥ e ) was . ± . for ip vs . ± . for cp) the mean paired difference for the first period sequences was . ¥ e (p = . by non-inferiority test; upper bound of the % confidence interval = . ). the non-inferiority margin for the study was . ¥ e for mean treatment difference in cci (cp-ip). median time to next transfusion was h for ip vs h for cp following the first transfusion (p = . log-rank test; data censored at days after transfusion) and h ip vs h cp after the second transfusion (p = . ). bleeding pre-or post-transfusion was uncommon, usually mucocutaneous, and grade or lower, and responded similarly to ip and cp. no significant transfusion reactions or saes were reported. in this double-blinded, two-treatment crossover study the primary endpoint regarding -hour cci was not met. however, transfusion with -day-old platelets treated by the intercept blood system showed only a marginally and probably clinically insignificantly lower -hour cci compared to -day-old conventional platelets. methods: new zealand white rabbits were transfused with syngeneic blood ( ml/kg), across a major antigen (hgd) mismatch. high anti-s- ab titers (≥ : ) were induced after repeated immunization (days , , , , ) with klh-(s- ) hapten (klhhapten) in complete freund's adjuvant. ab titers against srbc were determined by gel card agglutination, or by facscan with fitc-goat_anti-rabbit_igg. survival of infused rbc ( ml/kg) treated with different methods was assessed by rbc biotinylation. blood samples were taken , , , , and days after transfusion, analyzed using streptavidin_pe and facscan to determine the proportion of circulating biotinylated rbc. results: groups (g) of rabbits were transfused with control rabbit rbc (crbc; n = , g ), or o-srbc (n = , g ). no ab against o-srbc developed after biweekly transfusions over weeks in g rabbits. high ab titers to o-srbc could however be induced by klh-hapten immunization in a different group of animals (n = ; g ). transfused rabbits (g & g ) exhibited no change in hematocrit or body weight and maintained good vital signs. high titer anti-s- abs were then induced by klh-hapten immunization in rabbits from g (n = ) and g (n = ), and in a group (n = , g ) of naïve rabbits. non-immunized rabbits (g , n = ), and (g , n = ) were maintained on the biweekly transfusion schedule of crbc and o-srbc, respectively. all rabbits treated with klh-hapten developed comparably high ab titers. klh-hapten immunization did not affect the viability of crbc in g rabbits. transfusion of o-srbc demonstrated reduced viability in hyper-immune g rabbits, but not any of the g rabbits. g rabbits exposed to o-srbc transfusions prior to hyper-immunization with klh-hapten, had viability of o-srbc comparable to crbc, suggesting induction of immune tolerance by repeated exposure to o-srbc. after depletion of labeled o-srbc from circulation, g and g were transfused with m-srbc. viability of m-srbc in all g rabbits (hyper-immune or not) and the hyperimmune g rabbits was equivalent to crbc circulation in g rabbits. in pre-immunized rabbits with high titer anti-s- ab, o-srbc are cleared faster than control. in contrast, m-srbc survive normally in rabbits with high anti-s- ab titers. repeated transfusion of o-srbc does not result in alloimmunization of naive rabbits. the modified s- rbc process offers the potential for pathogen inactivation with elimination of immunoreactivity and retention of rbc viability. introduction: the bombay phenotype is extremely rare and characterized by complete absence of abh activity both on erythrocytes and in secretions. those individuals can produce anti-h, which is active over a wide thermal range. method: using liss indirect antiglobulin technique, the patient's serum showed + reaction by panel of eleven cells at room temperature phase as well as indirect phase while the auto reaction is negative. a cold adsorption using rabbit erythrocyte stroma was done to remove the cold antibodies from the serum; + reaction of an antibody was detected in the patient serum after five folds of rabbit erythrocyte stroma adsorption. introduction: immunohematology reference laboratory in kuwait central blood bank receives samples from all hospitals in kuwait both governmental and private sector. the laboratory performs the tests according to international standards and it is monitored by internal and external quality assessments on periodic basis. material and method: a tube and gel cards are two methods in the reference laboratory for antibody identification. the laboratory can identify the most commonly encountered clinically significant antibodies and investigates causes of positive direct antiglobulin test that occur mostly in autoimmune hemolytic anemia. there are facilities to phenotype most of rare red blood cell antigens. results: records of all patients investigated in the laboratory since the year are kept in computerized system that has patient's records. central blood bank has the potential to identify rare phenotypes such as kpb-, jsb-, lan-, bombay, rzr , rzr , r¢r¢, r¢r≤, r≤r≤, ge- , , and rare red blood cell antibodies such as high frequency antibodies anti-k, anti-ge , anti-h, anti-lan, anti-kpb, anti-jsb, anti-wrb, anti-ena, anti-csa and low frequency antibodies anti-kpa-, anti-jsa-, anti-dia, anti-lua, anti-cob as well as hightiter-low-avidity antibodies such as anti-chido. samples of rare red blood cells and rare serums are kept frozen either by glycerol or liquid nitrogen technique to be used for pre-transfusion compatibility testing and continuing educational program. purpose of the work: to present the substitution of the blood groups o, a, b, ab in abo blood group system and rh (d) blood group in rh (d) blood group system in the population in the gevgelija-valandovo region. material and methods: a retrospective analysis was done on the data of following the blood groups o, a, b, ab and d in the blood group system abo and rh in the gevgelija-valandovo region. the asked population are voluntary blood donors, candidates for drivers, patients, pregnant women and newborn children. the period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) was analysed. the examinations were done with two standard methods (on the plate and in tube), to define blood groups from the most represented blood group systems abo and rh in the population. tests were done with different series of commercial anti serum tests from domestic and foreign origin. results: totally . examinees were typified. with o blood group were . ( . %); with blood group a were . ( . %); b blood group . ( . %) and ab blood group were . ( . %) examinees. totally . ( . %) were d positive and . ( . %) were d negative. discussion: the given results from our examinations for the frequency of o, a, b, ab and rh (d) blood groups from abo and rh (d) blood group systems in the region gevgelija-valandovo show that the most present is the blood group a from abo blood group system . ( . %) and d blood group in rh system with . ( . ) form examined population. the results are in correlation with data from the literature for other european nations. introduction: the policy of our center is to transfuse all heamatologic multitransfused patients with their own rhesus and kell phenotype. in addition, thalassemic and young leukemic patients are being transfused with compatible phenotype of the most clinical important duffy and kidd systems while all the other patients receive blood compatible only with abo and rhesus system. nevertheless, it is observed a significant positivity of the indirect antiglobulin test, due to alloimmunization. aim of the study: in this study we tried to evaluate the prevalence of alloimmunization in patients of our region. the most frequent detectable alloantibody remains the anti-d, with high prevalence . % of anti-d in females versus . % in males, due to alloimmunization during the pregnancy. as a consequence, the high incidence of anti-d is not transfusion related and anti-e is evidenced to be the most frequent transfusion related alloantibody, followed by anti-kell. care must be taken in order to transfuse as more patients as possible with their own phenotype regarding, at least the most immunogenic antigens, like anti-e and anti-kell. severe hemolytic reaction due to anti-j k background: red blood cell alloantibodies directed against antigens of the kidd system are notorious for causing delayed hemolytic transfusion reactions. the antibodies are formed because of pregnancy or transfusion. blood donors with the red blood cell (rbc) phenotype jk(a-b-) are extremely rare in the white population and exhibit a frequency of less than . %. however, the rare phenotype jk(a-b-) is more common in polynesians ( . %). individuals with jk(a-b-) phenotypes typically form anti-jk with inseparable anti-jka and anti-jkb activity. some jk(a-b-) patients' sera may show an additional distinct anti-jka or anti-jkb component when examined with adsorption studies. case report: a years-old caucasian female with a negative antibody screen, no prior history of transfusion, presented with gastrorrhagia. it is reported four pregnancies with no history of haemolytic disease of the newborn (hdn). on admission, her haemoglobin was . g/dl. she was given units of crossmatchcompatible rbc. on day her haemoglobin was . g/dl, with a total bilirubin of . mg/dl and lactate dehydrogenase of u/l. on th day an unexpected fall in hb ( . g/dl) occurred with an increase of bilirubin to . mg/dl and of lactate dehydrogenase to u/l. a new blood sample obtained for antibody screening and additional crossmatches showed a pan-agglutination and incompatible crossmatch. anti-jk antibody high titer was detected in the plasma by gel-test using liss/coombs cards (id-diamed). the dat was negative and the antibody reacted equally with jk(a-b+), and jk(a-b+) panel cells (jka: / and jkb: / ). other alloantibodies could not excluded, because jk(a-b-) cells are not available. she was started with erythropoietin-a (epo), folic acid, fe iv and high dose intravenous immunoglobulin (ivig). the epo was discontinued after four week of therapy when the haemoglobin was g/dl. two months later her haemoglobin was . g/dl and anti-jk was present in the same titer. a year later her blood cell count was normal and the anti-jk was detected in a lessened titer ( / ). no additional distinct anti-jka or anti-jkb component was shown after two adsorptions at °c using carefully selected phenotyped red cell compatible with patient's rh, fy, mnss, lu, le system and jka(+) and jkb(-), but two additional alloantibodies anti-c and anti-e of low titer ( / ) were revealed. the rare anti-jk alloantibody found in this case displayed the erratic nature of many kidd system antibodies. although anti-jk may cause mild hemolytic disease of newborn, she did not have a history of hdn. our patient was sensitized to a kidd antigen during pregnancy, but showed no serologically detectable antibody until challenged with a massive transfusion following a gastrorrhagia. the use of epo and high dose intravenous immunoglobulin succeeded to avoid transfusion with incompatible rbc unit. background: differential warm adsorption is used in the investigation of patients with red cell autoantibodies for searching of underlying alloantibodies, but it is also useful in the detection of clinically significant alloantibodies in patients with alloantibodies to high frequency antigens such as k, kpb, lub and inb. this technique is especially useful in cases when patients when patient's phenotype cannot be identified due to recent transfusion. purpose: differential warm adsorption is performing on cases presented with an antibody reacting with all red cells of the panel and having a negative auto control test. in these cases, even rare cells panels, which allow the identification of a pan antibody, are available, other more common clinical significant antibodies cannot be excluded. methods and result: case . a years-old caucasian female with preexisting myeloproliferative disorder (polycythemia) presented with pancytopenia. anti-k was detected in the plasma. it is reported two pregnancies and no history of transfusion. the dat was negative and the plasma did not react with one k-cell present on the red cell panel in use. the anti-k specificity was confirmed using additional k-cells. the patient's red cell were group a, d+, k+, k-, c-, e-, fy(a-), s-, le(a-), kp(a-), cw-. she was transfused with two units rbc k-. ten days after the first transfusion the dat became positive and the one k-cell present on the red cell panel reacted with her plasma. two adsorptions were carried out at °c using carefully selected phenotyped red cell (compatible with patient's rh, fy, jk, mnss, lu, le system and k positive). an anti-fya was identified in the presence of ant-k. . an antik (titer / ) was suspected. because k-red cell was not present in the panel in use, adsorptions were carried out at °c using carefully selected phenotyped red cell (compatible with patient's rh, fy, jk, mnss, lu, le system and k positive). after the anti-k antibody was totally removed, no additional alloantibodies were revealed. conclusion: differential adsorption in cases with alloantibodies to high frequency antigens represents a useful application of the technique and helps in the identification of clinical significant antibodies present, allowing a more accurate decision for transfusion. evaluation of validity of the expired enzymetreated . % red cells in antibody identification gel tests using nacl cards p chalkia, s intzepeli, v avgoloupi, a tsoukala, e ntinopoulou and p didoudi ahepa hospital, thssaloniki, greece background: expired red blood cells of required phenotypic profile is often used to identify antibody specificities in patients with multiple anti-erythrocytes antibodies. accurate results depend on the integrity of the antigens. purpose: to validate the expired enzyme-treated . % red cells for use in antibody identification gel tests using nacl cards. the serum of nineteen patients with common specificities antibodies in rhesus, kell, duffy, kidd, and mnss systems tested with commercially prepared . % enzyme treated cells rbc panel (id-diamed). gel tests were performed according to the manufacturer's instructions on in-date rbc and simultaneously on rbc month to months past expiration. reactivity of the expired antigen positive and antigen cells was compared to in-date cells. results: twenty antibodies detected with enzyme treated red cells in neutral gel cards [d( ), c( ), e( ), k( ), cw( )] and were tested with enzyme treated red cells in use and rbc to months post expiration. seventeen antibodies tested with enzyme treated cells gave acceptable results with antigen positive cells to months post-expiration, except anti-k antibodies (negative with k positive cells - months post expiration). conclusion: most rbc antigens studied were detectable months after rbcs expiration date. tests with . % cells were valid in gel test (nacl/enzyme) for at least months after manufacturer assigned expiration date and may be helpful for complex identification studies. studies for more antigens specificities are needed to testify the validity of the expired enzyme-treated . % red cells. background: wr(a) is a low-incidence blood group antigen ( : ) in the caucasian population. despite that anti-wr(a) is a common antibody type, it may cause severe transfusion reactions, haemolytic disease of the new-born. anti-wr(a) may occur as an autoantibody or arise without immune stimulus. we report a case of a naturally occurring anti-wr(a) antibody. case report, methods and results: -year-old non-transfused male patient with acute pancreatitis and severe anaemia had been transferred to surgery from a county hospital. the serological status identified by their blood bank was: b rhd positive, with anti-wr(a) antibody in the serum (cellbind card method). our results: the patient's cells were group b rhd positive (microplate method), dat negative (tube and gel test method). the antibody identification showed positive antibody reaction with all enzyme treated test cells but negative reactions in liss iat (tube test) and gel iat (scangel and diamed). discussion: our routine tests for antibody detection didn't detect any specific antibody in patient's serum. he was transfused several units of blood, that was wr(a) negative and showed negative crossmatch reactions. the patient had no transfusion reactions. days after the transfusion anti-wr(a) specificity was confirmed in the serum with cellbind test. only few test cell panels contain wr (a) positive cells, which are usually not present in commercial screening cells. in our case the cross-match was only performed for this patient because of the detected nonspecific antibody reaction in enzyme. the risk of transfusion reactions caused by rare antigens are particularly high in the type and screen cases. background: according to requirements of the french committee for accreditation (comité français pour l'accréditation cofrac, iso standards), it is essential to use validated and standardised methods in immunohematology. this imposes, among various requirements, the knowledge of metrological tolerances for all the techniques. aim: a multicentre study was carried out to define the maximal acceptable deviations concerning incubation temperature and time, volumes of patient plasma and of tests cells for antibody screening using indirect antiglobulin test (iat) in filtration technique. the antibody screenings were performed manually in blood centres using different filtration systems: id diamed, biovue ortho and scangel biorad, the same tests cells, a standard ng/ml anti rh (provided by cnrgs), a positive control anti kel and a negative control. all equipment used (oven, chronometer, pipettes) were calibrated according to cofrac standards. each antibody sample was tested under the following combined conditions ( tests/sample): results: all the tests of antibody screenings from the multiples combinations of the above parameters gave the same results with a + intensity agglutination for positive samples and the absence of agglutination for the negative control. conclusion: this study allowed us to define a range of tolerance for critical physical parameters involved in the antibody screening in iat using commercial filtration systems maryvonne. the authors present a retrospective study involving blood donors from the university hospital of coimbra during the year . the incidence of weak d and rh (d) phenotype was determined in individuals who were rh (d) negative. the ab and rh(d) blood grouping was performed using a column gel agglutination card (diamed). the rh (d) typing was done using a anti-d polyclonal and a anti-d monoclonal antibodies. all donors that gave negative or poor agglutination results were tested for weak d with an indirect antiglobulin test, with anti-igg (gel matrix card) plus anti-d serum (diamed). within our target group of blood donors the rh (d) negative represented . % of the total sample. we also describe ab , rh(d) phenotype (c, c, d, e, e) group frequencies and establish reliable estimates frequency for weak d and rhesus haplotypes. the background: in s and s several authors tried to assess the relationship between the number od igg molecules per rbc and in vivo haemolysis, but determinations usually concerned small groups of tested patients. some of the investigators suggested that the number of igg autoantibody molecules per rbc was a major determinant of the severity of the haemolysis, whereas others found aiha patients with severe haemolysis and undetectable autoantibodies. aim: presentation of our experience with the quantitative elat performed on a large group of aiha patients during long-term observation. material and methods: six hundred fifty eight blood samples from warm-type aiha patients were randomly tested for the number of igg molecules per rbc. eighty six of the patients were tested periodically from to times at one-month intervals. autoantibodies on rbcs were detected by the direct antiglobulin test (microcolumn technology) and measured by the enzyme-linked antiglobulin test (elat). results: in about / of tested samples the number of igg molecules per rbc was small (< ) and the laboratory signs of haemolysis were present in . % of them as well as in . % samples with moderately coated red cells ( - igg/rbc). the large number of igg molecules per rbc (> ) was significantly associated with high frequency ( . %) of severe haemolysis and it was also associated with presence of multiple igg subclasses on rbcs and c d. in % of patients tested periodically, the number of igg molecules per rbc decreased and it significantly correlated with improvement of haemolysis parameters. in % of aiha patients the number of igg fluctuated and it was a poor prognostic factor. conclusion: in aiha patients the dynamics of the changing number of igg autoantibody molecules per rbc is a more helpful diagnostic and prognostic parameter than the number of igg molecules per rbc evaluated in one test. -b+) , -h-negative (using the anti-h lectin). antibody work-up showed a positive antibody screen (liss and peg-tube methods) reacting + with o rbcs at all phases and + with a rbcs. the direct antiglobulin test (dat) was positive with polyspecific ahg as well as anti-c b,-c d (table ) . prewarming of test system did not change the reactivity ( + at antiglobulin phase). a treatment with dithiothreitol (dtt) was performed and abolished all reactivity of the serum ( table ). autoabsorption of the patient's plasma was performed. the absorbed plasma showed a decrease in reactivity from + to + when tested with o red cells, as well as a significant reduction in antibody titer from : to : tested at immediate spin (table ). the patient remained crossmatch incompatible with o and a rbcs, but was compatible with oh rbcs. summary: we report an unusually strong igm anti-h antibody in this patient, who may require oh phenotype units. the patient is not a para-bombay since her red cells type strongly as group a. the cause for the auto-anti-h remains unknown at this time. if a thermal amplitude test shows that the antibody appears to be clinically significant the patient should receive h-units if transfusion is required. introduction: fetomaternal haemorrhage may determine an alloimmunization, in fact the transplacental passage of antibodies may cause the haemolytic disease of newborn. for this reason, in pregnant women, a screening for irregular antibodies research is routinely performed. however the indirect antiglobulin test (iat) may result falsely positive or negative for various causes, as operative mistakes or low specificity/sensitivity of the used techniques. aim of the study. in this study we have retrospectively evaluated the real incidence of alloimmunizations occurred in women screened by private laboratories. methods: we have studied . women, - years old, resulted iat positive at the first screening and successively assisted by our two hospitals. all women were re-tested, using gel-agglutination technique, for both direct antiglobulin test and iat. results: a positive iat was confirmed only in cases; moreover a rbc autoimmunization was found in women. anti-d ( cases), e ( ), c ( ), k ( ), c ( ), s ( ), d + jka ( ), d + s + e ( ), d + c + k ( ), m ( ), c + e ( ), d + c + g ( ) were the identified alloantibody specificities. anti-s, -e, -k, -c and -jka were the specificities in autoimmunized women. conclusion: in conclusion, a real alloimmunization is occurred only in . % of screened women, while in the remaining cases iat resulted falsely positive: this observation forces us to affirm that, in order to minimize errors and alarmisms, the screening for antibody research in pregnant women must be performed only by immunohematology qualified center. background: one of the problems of the rbc transfusion is the alloimmunisation and the delayed haemolytic reactions (dhtr). besides rhesus and kell systems the antibodies against kidd antigens cause both dhtr and difficulties in their detection. aim and methods: the exact recording of all blood units according to abo rhesus kell and kidd systems. the abo-rh-kell systems are identified through automated microcolumn method (autovue, ortho), while kidd antigens are identified manually using microcolumn gel (diamed). results: the percentage of jka+ and jkb+ found in our department ( . %) and ( %) respectively is similar to that of the caucasian population. conclusions: given the fact that there is lack of available freezing rbc system in greece, detailed recording of all units to the above antigenic systems can be proved extremely useful under circumstances of incompatibility. in the latter case suitable donors can be called and cover the shortage. the identification of all antigentic systems of the donated rbc units is underway. background: in many countries transfusion recipients are currently typed and transfused d-positive, if their red cells are agglutinated by igm monoclonal anti-d that do not react with dvi. the transfusion strategy in weak d patients is not clear defined and it depends on the chosen monoclonal reagents and methods. patients who are carrying dw types , and were prone to develop anti-d. aim: the aim of this pilot study was to estimate capability of commercially available monoclonal anti-d reagents to recognize this weak d types as rhd positive. material and methods: edta anticoagulant blood samples were collected from blood donors, previously typed as weak d positive by indirect antiglobulin test. molecular genotyping of rhd gene and weak d alleles by cde-ssp and d weak-ssp kits (inno-train, germany) were performed. direct agglutination was tested in a tubes and microplates using the following antibodies: rum- , th- , ms- (bioscot/serologicals) and d e / - (immucor). results: out of samples molecular typing results were as follows: in samples dw were not determined, in samples, weak d type ; weak d type ; weak d type , weak d type ; weak d type and weak d type were determined. by all monoclonal reagents % weak d type , % weak d type , % weak d type and % weak d type negative results were given. by all monoclonal reagents weak d type and weak d type positive results were given. conclusion: according to weak d types, which were known to be at risk for anti-d immunization further advances may be brought by improved patient's monoclonal typing reagents with a low and donor's monoclonal typing reagents with high affinity for weak d type , type and type . such improved typing strategies with novel reagents would enhance the transfusion safety. background: vel is a high-incidence antigen found in > % of the population. anti-vel can be igm or igg and reacts optimally at iat, although it can also react at immediate spin and c. anti-vel may or may not cause severe hemolytic transfusion reactions and mild to severe hdn. autoanti-vel has also been reported. the aabb technical manual th edition states that the vel antigen is unaffected by protease and sulfhydryl treatment. we have reason to believe that sulfhydryl treatment may have an effect on the vel antigen as evidenced by a recently referred case. case report: a year-old caucasian female presented with symptoms of anemia and renal vascular hypotension. transfusion history indicated multiple red cell transfusions in . according to the patient, previous attempts to locate compatible units were unsuccessful. the case was referred to our laboratory. the patient's red cells (rbcs) typed as group o, d+ with a negative dat. the serological picture revealed an antibody reacting + - + s at c/liss, as well as at the antiglobulin phase. the antibody reacted with all rbcs tested and the autocontrol was negative. further characterization of the antibody showed similar reactivity using enzyme-treated rbcs ( . % ficin) and no reactivity using . m dithiothreitol-(dtt)treated rbcs. a high incidence negative red cell panel (untreated) was selected that lacked antigens reported to be destroyed by dtt. the antibody reacted with all rbcs tested. additional rbcs were tested that lacked high-incidence antigens, including vel. the antibody did not react with four vel-rbcs tested using liss and peg methods. the patient's rbcs typed as vel-negative. all other clinically significant antibodies were ruled out using vel-or dtt-treated rbcs. based on the unusual reactivity demonstrated by the anti-vel, we tested different examples of anti-vel (frozen in our rare sera inventory) against two sets of known vel+ and vel-rbcs. one rbc set was dtt-treated; the other set was tested neat. liss enhancement was used to test both sets. one of the antisera failed to react with the positive control and one reacted with the negative control. both were disqualified from the study. four of ten remaining antisera demonstrated a decrease in reactivity > grade, between the neat and the dtt-treated rbcs. the remaining six antisera showed no change in reactivity. conclusion: contrary to the statement in the aabb technical manual, we discovered that sulfhydryl treatment ( . m dtttreatment) can have an effect on the vel antigen. our experience has demonstrated that in some cases anti-vel may not react or may show reduced reactivity when tested with dtt-treated rbcs. therefore, the presence of anti-vel should not be ruled out if negative reactivity with dtt-treated rbcs is encountered. additionally, dtt treatment may be a useful tool obtaining rule-outs of other clinically significant antibodies in the presence of anti-vel. additional data is needed to confirm these findings. but with no identified specific antibodies were investigated by repeated screening/crossmatch, papainized panel identification, hla antibody screening by lymphocytotoxicity test (lct) and elisa in some cases. patients' age, sex, department, diagnosis, previous transfusions/pregnancies, techniques, reactions' strength, number of positive cells, urgency, subsequent antibody tests, identification and lct were noted. antibody tests were performed: at pretransfusion testing (pt) by liss-coombs (diamed) and at blood grouping (bg) by biovue polyspecific (ortho) microcolumns -manually in urgency and routinely by sampler iif (diamed) and mitis (ortho) systems. results: investigated reactivity was recorded in samples from patients; ( . %) patients had > episode. these findings comprised . % of unexpected results found at pt and bg. incidences were . % at routine and . % at urgent bg ( and bgs, respectively), and . % both at routine and urgent pt ( and pts, respectively). . % patients were female, . % over , but . % < years, coming mostly from surgery ( . %), internal medicine ( . %), hematology ( . %), ginecology ( . %), cardiac diseases ( . %) and cardiac surgery ( . % patients). frequent diagnosis were solid tumors ( . %), cardiac diseases ( . %), hematologic malignancies ( . %), uraemia ( . %), orthopedic surgery ( . %) and hepatic diseases ( . % patients). . % patients were previously transfused, with only . % patients proved as not transfused or pregnant. subsequently positive antibody test during the study had . % tested patients. at pt positive crossmatch was found in . %, antibody screening in . % and both tests in . % cases. majority of reactions were ' +' ( % at pt and . % at bg); reactions ' +' or ' +' were found in only . % cases at pt, compared to % at bg. one crossmatch only was positive in . % positive crossmatches, with / patients having > crossmatched unit. ahg identification was positive in . % tested patients; in % of them papainized panel was also positive. lymphocytotoxic antibodies were found in . % tested patients; . % ( %- %) of lymphocytes were reactive. finally, the cause of reactivity in antibody tests was determined as 'laboratory mistake' in . %, hla lymphocytotoxic antibodies in . %, 'igg antibodies of unknown specificity' in . % (hla noncytotoxic antibodies in / elisa tested samples!), contaminated sample in . %, anti-bga in . %, non-specific cold antibodies in . %, subsequently recognized specific antibodies in . % ( lua, m, kpa, yka), non-specific autoantibodies in . %, carry-over of dat-positive cells and antibody to reagent in . % cases each, while in . % cases antibody screening and in . % cases crossmatch was repeatedly positive without confirmation in panels. discussion: after introducing of sensitive microcolumns, positive antibody tests without detectable specific antibodies require significant laboratory activities, particularly in older patients with malignancies or surgery. such reactivity was frequently caused by laboratory mistake, but often hla and sometimes specific antibodies were later recognized, or reactivity continued without confirmation in panels. relationships that may be helpful are further discussed in abstract part ii. results: significant differences (p < . ) and relationships of interest were noted. sex. in female vs male patients frequent features were: crossmatch as only reactivity at pt ( . % vs . %), positive lct ( . % vs . %), lymphocytotoxic hla antibodies (lytxab) ( . % vs . %) and reactivity 'positive screening, negative panels' ( . % vs . %); in males non-specific cold antibodies ( . % vs . %) and antibodies to reagents ( . % vs ) were noted. age. in patients > vs < reactivity was often found at pt ( . % vs . %), caused by lytxab ( . % vs . %), anti-bga ( . % vs . %) or 'positive crossmatch, negative panels' ( . % vs ), but rarely by laboratory mistake ( . % vs . %) or later recognized antibody ( of patients). subsequent antibody tests: tests were subsequently positive more often if reactivity was found at pt ( . % vs . % at bg), as positive antibody screening ( . % vs . % if positive crossmatch), with positive panels ( . % vs . % if negative). subsequent tests were positive in only . % patients with lytxab, % with anti-bga, of with antibodies to reagent and in no case with 'positive crossmatch, negative panels' . techniques. lct was positive in % and . % tested samples found at urgent and routine pt (diamed), vs at bg. all cases due to lytxab, of anti-bga and of 'positive antibody screening, negative panels' were found by diamed. at bg (ortho) . % cold antibodies and . % laboratory mistakes were found. positive antibody test: identification was negative in . % screening-only cases; % of them were caused by laboratory mistake. lytxab were found in . % crossmatch-only cases; . % reactivities caused by lytxab were crossmatch-only. identification. ahg panel was positive in % cases with lytxab (in with papainized panel) and often due to 'igg antibodies of unknown specificity' ( . %), anti-bga ( . %), contaminated sample ( . %), but also to later recognized specific antibody ( . % cases). strength of reaction: laboratory mistake was noted in . % of 'w', . % of ' +', . % of ' +' and . % of ' + and +' antibody screenings (ns). diagnosis. in patients with solid and hematologic malignancy reactivity was often found at pt ( % and . % of patients, respectively), due to positive crossmatch ( % and %; and . % patients with liver and cardiac diseases) and caused by lytxab ( . % and . %) or 'crossmatch/screening positive, panels negative' ( . % patients with solid tumors). in patients with liver and cardiac diseases reactivity was often found at bg ( . % and . % of patients), due to laboratory mistake ( % and %) or cold antibodies ( . % and %), respectively. discussion: features of non-specific reactivity depended on sex, age, positive antibody test, diagnosis and, moreover, used techniques, sometimes in very distinctive manner. this analysis might be of considerable help in planning of laboratory tests, but also in quick analysis of unexpected results and choice of further testing, particularly in urgent situations. background: worldwide screen and type is a very usual method for pre-transfusional testing. the ultimate objective is to prevent not only the clinically expressed delayed hemolytic transfusion reactions but also the serologically revealed ones. aim: the aim of this study was to determine the frequency of red blood cell (rbc) alloantibodies in patients undergoing cardiac surgery or cardiac procedure, during the pre-transfusion screening. materials and methods: blood samples of patients ( male and female) were evaluated. the mean age of the patients was years. pre-transfusion samples were examined for clinically significant alloantibodies, using antibody screening with gel test (liss -enzyme). in case of a positive result, identification was performed (panel with autologous control). in addition, the serological testing included cold agglutinins´ detection (tube test), as well as titration (tube test) and identification (gel test) in case of a positive result. when the result was marginal ( / ) a new test was carried out after a seven days period. in the presence of a positive autologous control or an autoantibody, samples were examined with direct antiglobulin test (dat). results: alloantibodies were detected in patients with the incidence of . %. antibodies were registered more frequently in females ( / , . %) than in males ( / , . %). patients ( . %) developed single antibody with anti-kell being the most frequent. the incidence and the specificity of the detected antibodies are summarized in the following table (table ). in patients ( . %) multiple antibodies were detected, with most frequent the anti-d and anti-c combination. patients ( . %) were dat positive. autoantibodies were found in patients ( . %), all of which had specificity to rhesus system. cold agglutinins were positive in patients ( . %). no specificity could be assigned in patients ( . %), while in patients ( . %) non specific reactions in enzyme treated rbcs, were observed. one patient developed delayed haemolytic reaction days post-transfusion, due to anti-jka. the antibody, however, was not detected in the pretransfusion sample re-testing. the frequency of the pre-transfusion detection of red blood cell alloantibodies in our center, was . %. the most frequently identified were the anti-kell and anti-rh. the high rates of unidentifiable antibodies and non specific reactions in enzyme treated rbcs are probably attributed to the kind of medication that most of these patients receive, as well as to the degree of inflammatory process which usually accompanies such diseases. the high frequency of unidentifiable antibodies indicates that a larger and more complex erythrocyte panel would be useful for routine testing. the routine pre-transfusion screening for alloantibodies probably assures the prevention of dhtrs and provides sufficient time for blood selection for transfusion. introduction: in the united kingdom, about % of women form red cell allo-antibodies in pregnancy and . % of all pregnant women produce anti-c. before the introduction of prophylactic anti-d, it was reported that % of the total haemolytic disease of the newborn (hdn) cases were due to anti-c. currently, cases of hdn due to anti-c are half as frequent as anti-d and % of the uk population are rhc negative. we present two unusual cases of pregnant women who are d and c negative and have anti-c and anti-d detected in their serum. case studies and results: case : a -year-old asian woman had three previous uneventful pregnancies. in her th pregnancy she presented with miscarriage at weeks gestation. she was group b, d and c negative. her serum contained anti-c and anti-d. anti-d was detected by liss tube iat and anti-c was only detected by manual polybrene technique ( . iu/ml by quantification using r r cells). in a th pregnancy, no antibodies were detected until weeks gestation when this patient presented in early labour. anti-c was then detected by two-stage papain technique only as well as anti-d. case : a -year-old asian woman had a positive antibody screen post caesarean section in jan . no antibody had been detected during the pregnancy. standard prophylactic anti-d was given at and weeks gestation as this patient was d neg. anti-c and anti-d were confirmed in her serum. the anti-c level was . iu/ml using rr cells and the anti-d level was < . iu/ml using r r cells (prophylactic anti-d ig). she was phenotyped as o r¢r¢. at delivery the baby was found to have a negative dat and was phenotyped as r¢r. discussion: cde/cde (r¢r¢) is an uncommon phenotype in the uk population with a frequency of / . in routine antenatal testing, abo/d grouping is only performed for pregnant women at booking and weeks gestation according to bcsh guidelines. full rh phenotyping is not carried out unless the pregnant women has a positive antibody screen. in routine testing of the above cases, this extremely rare phenotype is missed. prophylactic anti-d was given to both patients and immunisation due to anti-d was prevented. there is currently no prophylactic regime developed to prevent anti-c allo-immunisation by the fetus in pregnancy. antenatal management of patients with anti-c and anti-d during pregnancy can be problematic: (i), problem in antibody identification; (ii) monitoring of antibody level (i.e. quantitation by auto analyser for anti-c and anti-d) with two different cells and ( ) provision of blood during pregnancy, at labour and post delivery for both mother and newborn. study on the frequency of red cell phenotypes (e.g. duffy, kidd and mns blood group system) in our local population l leou, yf wong, mbc koh and d teo health sciences authority, singapore, singapore background: the frequency of various red cell antigens in the caucasian population has been well studied. to date, the frequency of these antigens in the local population composed of a multi-racial mixture of chinese, malay, indian and others is still unclear, especially in the malays with paucity of data in the literature. aims: to investigate the frequency of clinically significant red cell antigens duffy, kidd and mns across the local ethnic groups. to investigate the occurrence of rare phenotypes. to be aware of these rare phenotypes so as to facilitate planning of blood inventories and supplies. typing for the duffy, kidd and ss antigen on blood donors was performed using monoclonal as well as polyclonal anti-sera by manual tube method. a total of blood donor samples were tested using specific anti-sera that will agglutinate red blood cells that have the corresponding antigen. agglutination is demonstrated by the indirect antiglobulin technique. result and discussion: table -a higher frequency of the fy(a+b-) phenotype is seen in chinese, malay and others in contrast to the indian and caucasian population. the clinically significant allo-antibody anti-fya is rarer in our local population. it occurs predominantly in malays and indians and usually in combination with other antibodies. it means that provision of antigen negative blood may be difficult. table -all groups show similarity of distribution of the kidd phenotype with the caucasians and distinct from the american blacks. the jk(a+b-) and jk(a+b+) phenotypes are relatively equal in frequency and there should be no problem looking for such a phenotype in the local population. table -the s-s+ phenotype is most common amongst all races. the indians are more similar to the caucasians with a relatively high frequency of s+s+ phenotype. the chinese and malay distribution are unique with > % being s+. conclusion: there is a unique distribution of red cell antigen groups in the races and the data on malays is especially useful. this data will allow the national blood service in its inventory planning and the potential difficulties of providing antigen negative products due to clinically significant allo-antibodies. miltenberger phenotypes among taiwanese table . conjointly, in order to obtain the frequency of mi.v phenotype, we screened samples among with anti-hil and four additional cases of mi.v were found. conclusion: in this study significant miltenberger polymorphism was seen among the taiwanese population. besides previously described mi.iii phenotype ( . %), there were also mi.i/ii phenotype ( . %), mi.v phenotype ( . %), mi.vi phenotype ( . %), mi.x phenotype ( . %), and most interestingly two miltenberger related not yet classified variants ( %). related variant a ( . %) was phenotypes as mia+, anek+ and hil+. related variant b ( . %) was phenotyped as mia+, anek+. interestingly, both variants were mur-(negative). the total estimated frequency of miltenberger variants in taiwanese population (including related variants a and b) is therefore . % (table ). the discovery of unclassified variants (most likely not yet described in the literature) is of great interest in the field of immunohaematology and warrant further molecular genetic study. introduction: the use of column technologies for the detection of rbc antibodies improved significantly the screen test sensitivity. each column-based method has its advantages and disadvantages. aim: to compare antibody detection by two column agglutination tests; the fully automated ortho auto vue tm method and the manual diamedᮀ id-micro typing system. material and methods: during the study period patient samples were screened, of the positive results were evaluated. blood samples with positive screen tests by the ortho auto vue tm method (av) performed with % cell suspension, and patient samples with antibodies identified by the diamedᮀ system (dm), were reciprocally re-screened, respectively. positive samples were tested by diamed panels for antibody identification. sera samples were divided into categories according to antibody specificity; . rh system antibodies (n = ), . clinically significant non rh system antibodies (n = ), . clinically non significant antibodies (n = ), . auto antibodies (n = ), . not identified (ni) antibodies (n = ), . negative screening results by the diamed technique (n = ). the categories were divided, according to the intensity of agglutination in the screen test, into those exhibiting stronger reactions by the auto vue (av > dm), those exhibiting equal strength reactions (av = dm) and those with weaker reactions by the auto vue (av < dm). statistical analysis was carried out using the wilcoxon signed ranks matched-pairs test. results: a total of samples were compared, . % of them gave stronger reactions by av, . % gave equal reaction strength and . % of them gave weaker reactions by av. positive screen tests by av only were detected in samples, no specific antibodies were identified. in contrast to that, positive screen tests by dm only were detected in samples, were rh system related, kell system related and not identified, results are summarized in the table. discussion and summary: the antibodies detected by dm only, are anti-d and antibodies directed to low frequency antigens. the failure of av to detect rh system antibodies is further sustained by the fact that statistically significant weaker reactions for this antibody system were obtained by av technique. recently ortho-clinical diagnostics modified the screening reagent red blood cells to . % suspension, in order to improve the sensitivity of the method (unpublished data). the possible explanation for the failure to detect low frequency antibodies is that ortho screen cells do not consistently carry the low frequency antigens cw and kpa. positive screen tests detected by av only, can be explained either by the fact that antibody identification was carried out on dm panels, or these are false positive reactions. in order to clarify this question we recently repeated these av only positive samples by the manual ortho bio vue technique. preliminary results indicate that no specific antibodies were detected. it can be assumed that these results are false positive. further study of this issue is required. aim of the study: we have detected blood donor with rohar variant which was mistaken as d-and his donations used for d-recipients. we tested these patients in order to evaluate possible anti-d or anti-lfa immunization. methods: rohar variant was tested serologically (commercial and workshop moabs) and on dna level (pcr-ssp). involved recipients were tested by diamed column agglutination (gliat with normal and enzyme treated rbcs) with commercial rbcs and with rh and rh rbcs. results: rohar variant was confirmed on phenotype and genotype levels. in four d-and two d+ recipients of rohar positive units no anti-d not anti-rh or -rh antibodies were detected. in one case anti-le(a) antibody was found. conclusion: in our cases massive exposition of recipients (whole transfusion unit) by rohar red cells did not lead to production of detectable anti-d or anti-lfa. the immunogenic potential of this variant seems to be low. unusual ab grouping discrepancy -inhibition of anti-b reagent by isolated increase of plasmatic b substance in a patient with group ab and pancreatic cancer m pisacka*, k petrtylova † , m kralova* and h flidrova* *uhkt, prague , † blood bank, faculty hospital m, prague , czech republic introduction: in rare pathological conditions excess amount of blood-group specific substances can be observed and can cause neutralization of grouping reagents. changes in abh and related histo-blood group antigens in malignant tissues were described but there are few information about similar changes in secreted bloodgroup specific substances. aim of the study: we describe a case of isolated increase of b group substance in plasma of a group ab patient with pancreatic cancer. methods: ab grouping was performed with registered immucor reagents (immuclone: anti-a birma , anti-b lb ) by slide and tube tests. neutralizing effect was quantified by (i) inhibition od anti-b reaction by titrated patient's serum; and (ii) inhibition of titrated anti-a and anti-b reagents by patient's serum, compared to ab serum of a healthy donor. results: slide test: unwashed rbcs: group a, washed rbcs: ab. tube test (washed rbcs): ab. titrated patient's serum when added in aliquot to anti-b reagent inhibited agglutination up to titre . titration of reagents /+ aliquot of serum added/: anti-a: titre (both patient's serum and control); anti-b + patient's serum: titre , anti-b + control: titre . conclusion: pancreas is known as rich source of blood group specific substances. malignant transformation is known to be associated with either loss or re-expression of cell-bound abh antigens. reported excessive increase of b substance in group ab patient could be either due to loss of a-transferase activity in malignant pancreas cells or isolated increase of b-transferase activity. further studies on larger groups of pancreatic cancer patients will help to understand this observation. weakened abh reactions of unwashed rbcs could be of diagnostic importance, because in other case this observation preceded several years the pancreatic cancer clinical manifestation. implementation of the autovue innova, an upgraded column agglutination technology (cat) for pre-transfusion testing in a large blood establishment c politis, k armyros, a antypas, v malamou and p katsea g. gennimatas general hospital, athens, greece objective: automated cat testing in a blood transfusion laboratory aims at standardization and savings in labour as well as reagents. a new technology is evaluated in comparison to standard methods. materials and methods: we used column agglutination technology with the innova autovue system, ortho, ratrian n.j. according to the manufacturers this system provides priority to the management of the stat samples while the random access feature of the system enhances the system throughput. it provides an extended test menu as well as automated antibody identification with the red cells panels. the autovue innova system supports the bi-directional communication with the lis interface for all the tests including the crossmatches and it provides a continuous traceability and notifying of the instrument's status concerning either the required and available resources or the proper function of the system's submodules. in this study we performed tests including forward and reverse abo group, rh type and phenotype and kell in randomly selected blood donors, as well tests in haematological patients for antibody screening using an untreated three-cell panel and autocontrol in the indirect antiglobulin test (iat). the results and the time performance (specimen handing, operation of testing and recording of results) were compared with those obtained by the semiautomatic id-diamed gel agglutination microtyping system and by standard manual methods. results: test results showed % agreement between all three methods. samples were tested per min with the autovue innova, compared to min required for the same number of tests performed with manual testing and min with the semi-automated method. the technical execution was easy with the autovue innova procedure and it appears that the consumption of testing reagents is smaller with the automated system comparing with the other methods. computerization of the test results with the autovue innova provides an important advantage in record keeping in the blood establishment. conclusion: standardization of sample collection and tests performance in pre-transfusion testing, as well as computerized records and time saving are advantages offered by the autovue innova, a new automated column agglutination technology, comparing with a semi-automated and the classical manual methods. a heavy workload is expected to significantly decrease time performance. clearance of senescent erythrocytes in young and old individuals al racca, a ensinck, c cotorruelo, s garcÍa borrÁs, l racca and cs biondi universidad nacional de rosario, rosario, argentina introduction: after a lifespan of days, human red blood cells (rbc) are captured and phagocytized by monocytes/macrophages. the accumulation of autologous igg on rbc membrane provides a direct mechanism for the removal of senescent (se) rbc. an alternative pathway, immunoglobulin-independent, with participation of sialic acid, has been proposed. the physiological elimination of serbc might be modified by individual's age. aim of the study: to investigate in young and old individuals, the interaction between monocytes and different erythrocytes suspensions: serbc, rbc stored with or without serum and desialinized rbc. methods: healthy individuals blood samples ( - years old, n = and > years old, n = ) were studied. different suspensions from each sample were obtained: (i) se and young (y) rbc by differential centrifugation; (ii) rbc stored with its own serum (rbcs) and without serum (rbcws); and (iii) rbc desialinized with neuraminidase (ne) and tripsine (t). the suspensions were subjected to the erythrophagocytosis assay: peripheral blood monocytes were incubated with the different erythrocyte suspensions for h at °c. two hundred cells were analyzed to determine the percentage of active monocytes (am) with phagocytosed and adherent red cells. non sensitized rbc (nrbc) and ex vivo sensitized rbc (srbc) were used as negative and positive controls respectively. results: the% of am obtained with old individuals were: serbc: . + . , yrbc: . + . , rbcs: . + . , rbcws: . + . , nerbc: . + . , trbc: . + . , nrbc: . + . ; srbc: . + . . the values of am obtained with young individuals were: serbc: . + . , yrbc: . + . , rbcs: . + . , rbcws: . + . , nerbc: . + . , trbc: . + . . nrbc: . + . ; srbc: . + . . conclusions: no differences in the% of am were found when compared to positive and negative controls, indicating that this assay would not detect variations in the phagocytic activity of monocytes from young and old donors. the values of am with serbc were higher (p < . ) than those obtained with yrbc in both populations analysed. the rate of erythrophagocytosis with serbc in old individuals was significantly higher (p < . ) than that obtained in young donors. the increase observed may be due to agedependent changes of rbc that occur with human ageing. the% of am with rbcs were higher (p < . ) in old individuals. no modifications were observed with rbcws. the significant increase in the rate of erythrophagocytosis with serbc and rbcs show the involvement of autologous igg in the selective removal of erythrocytes. these values were higher in old individuals indicating that this process would increase in aged donors. the tripsine activity was not enough to modify the% am. the values of am obtained with neuraminidase treated rbc were higher than those observed with yrbc (p < . ). however these values were similar between young and old individuals, suggesting that the desialylation would not participate in the increased removal of erythrocytes observed in old donors. cell-cell adhesion is a crucial phenomenon for the relationship between the cell and its environment. therefore, the development of experimental methods to obtain quantitative parameters of cellular adhesion is important. erythrocytes are widely available and their membrane properties are well known, so these cells are used as an ideal model for studying the cellular interaction mechanisms. the study of the formation and break-up of receptor-ligand bonds in sheared erythrocyte suspensions is a subject of considerable importance in the blood circulation, where formation and break-up of blood cell aggregates occur in a variety of physiological and pathological conditions. the main two objectives of this work were to study the cellular adhesion phenomenon using erythrocyte adhesion mediated by monoclonal anti-a antibody as a model and to achieve quantitative values of the parameters involved in the intercellular binding and its possible relationship with cellular deformability parameters. agglutinates of two a erythrocytes (doublets) induced by specific monoclonal antibodies anti-a were used. adhesion energy was indirectly quantified by the study of doublet dissociation under the effect of a given shear stress using a controlled flow chamber system. the chamber was installed on the stage of an optical inverted microscope (union optical, magnification ¥) in such a way that the cover glass was the floor of the microchannel. a ccd (charge coupled device) camera was placed in the ocular tube of the microscope and connected to a digital image processor (ipplus system) to digitize, record and analyze microscopic images. the doublets were initially immobilized inside the chamber, and then put under different shear stress values by a controlled laminar flow during a definite time. in this way, a shear stress parallel to the contact surface between both cells was applied, observing that the upper cell detached progressively with time and also with a gradual rise of the shear stress. the sequential microscopical images were registered and digitally processed, measuring the geometrical dimensions that the cells acquire during the deformation process, and the dissociation of the antigen-antibody bond. digital image processing allows the analysis and the quantification of the red blood cells doublets dissociation phenomenon. these results show that, while the shear stress applied is raised, the contact area between both cells diminishes. the obtained parameters give important information that lead to the estimation of the value of adhesion energy between two red blood cells agglutinated by monoclonal antibodies. as consequence, they will allow the characterization of the antibodies used, since it would evaluate their association capacity with cellular antigens. glycophorins (gp) a, b and c are abundant transmembrane integral proteins in red blood cell (rbc). their highly glycosylated nature and high sialic acid content account for the net negative charge of mature rbc membrane, which is physiologically important because it impedes any tendency to stick together in the circulation. in this study, we have tested anti-gp specific mouse monoclonal antibodies (moab) as primary antibody to directly agglutinate rbc. fret technique has been developed to characterize the hemoagglutination based on the interaction of fluorophores (alexa tm, dio and dii) located in the rbc membrane or combined to secondary antibody directed against the primary agglutining moab. combined intensity (spectral) and lifetime (flim) imaging was used to discriminate the fret signal of molecules on their different lifetimes whereas their emission spectra overlap (alexa tm or dio/dii) as independent phenomena of the fluorophore concentration and photobleaching. furthermore, gp-cytoskeleton interactions were analyzed by d-fluorescence microscopy after lipid extraction with triton x- in red cell. all the antibody used was found to directly agglutinate the human rbc. in view of the fluorescence properties depicted in rbc for the pair of fluorophore alexa- tm (donor) and dii (acceptor), it may be expected that upon agglutination of rbc, effective fret should be observed. flim in dynamic-state provides a discrimination of molecules in their fluorescence lifetime, which allows to evaluate the underlying mechanism of energy transfer process in the agglutinated erythrocytes. the results demonstrate that's upon excitation at nm the flim-fret from alexa tm to dii for the anti-gpb moabs only with a lifetime distribution in the picosecond range. similarly, effective fret was not observed for the anti-gpa moabs. the contrast in measured lifetime image is a reliable indicator for spatial variations in donor-acceptor association. d-fluorescence microscopy images showed interactions between gpc or gpb and cytoskeleton and did not show interactions between gpa and cytoskeleton. all together, these results only revealed by fret-flim and d-fluorescence microscopy strongly support the importance of the specific reactivity with glycophorin a or b of agglutining moab. introduction: the frequency of alloimmunization to red blood cell antigens in transfused sickle cell patients can range from to %, but the development of autoantibodies is much less recognized and descried. aim of the study: in order to evaluate the autoantibody formation and observe the blood transfusion association, we analyzed the direct antiglobulin test (dat) as well as the antibody screening results in transfused sickle cell patients. methods: all the patients included in the study had received at least unit of red blood cell concentrate, on the majority of the cases matched for the c, c, e, e, k antigens. the transfusion range was - units. the dat performed was a polyspecific gel test. in cases of positive dat, was performed the monospecific gel test (igg, iga, igm, c c, c d) . in almost all of cases an acid glicin elution was performed and the eluate was tested against a red cell panel (liss/coombs and papain). an antibody screening by gel test (liss/coombs and papain) was performed in all the patients. the dat was positive in ( %) of the patients. in cases ( %), the dat was igg type, in case ( %) igg + c d and in case ( %) igg + c c + c d. the acid elution was performed in cases. the eluate was positive in cases ( %). in ( %), of the cases, autoantibodies were pointed out whose specificity were specificity public, anti-e (rh ), anti-c (rh ), anti-ce (rh ). in cases ( %) we found alloantibodies whose specificity were anti-e(rh ), anti-k(k ), anti-c (rh ) and anti-jka (jk ). in the cases ( %) no antibody was identified on the eluate and the cause of positive dat is unclear. we could correlate the positive dat with a presence of autoantibodies in ( . %) of the patients. of these, ( %) had a blood transfusion association. the global frequency of red cell alloimmunization in this set of patients was %. seventeen patients ( %) of the patient who had autoantibodies had also alloantibodies associated. conclusion: the mechanism by which erythrocyte antibodies form in association with blood transfusion are not well understood, but even though the medical literature indicates strong association with blood transfusion as well erythrocyte alloantibody formation, we could not find support for this association. the loss of splenic to sickle cell patients could be important because experimental studies suggest that the spleen is involved in the regulation of autoantibody formation. forward and reverse blood grouping with lateral flow based assays p schwind*, i aebischer*, k loester † and p monod* *medion diagnostics gmbh, duedingen, switzerland, † prisma diagnostika gmbh, berlin, germany background: recently, a lateral flow assay for simultaneous typing of abod, rhesus subgroups and kell with stable end-point and without a centrifugation step was presented (loester k, fleischhauer s, schwind p: lateral flow assay for simultaneous typing of of abo, rhesus subgroups and kell. vox sang , (suppl. ), ). in many countries, the determination of isoagglutinins in addition to the red cell antigens is mandatory for abo grouping. aims: to develop a lateral flow test for reverse grouping, supplementing the lateral flow typing assay. a lateral flow device was constructed with a separation membrane equipped in a cassette housing having distinct incubation wells, application zones and detection areas. microliters of % suspensions of reagent red cells for reverse grouping (reverse-cyte a , a , b, , medion diagnostics, switzerland) are mixed in each incubation well with microliters of plasma. the resulting suspensions are incubated for min, followed by the transfer of microliters each to the application zones, where migration starts immediately. results can be read after min in the detection areas. a positive result is recognized as a distinct red dot, a negative result is monitored by the absence of a dot. results: the plasmas of donors, previously determined for the respective blood groups and isoagglutinins by the tube technique, have been tested with this method. the results for both methods were in full agreement. conclusions: a simple, rapid and flexible lateral flow method for reverse grouping is presented, allowing now for the determination of forward and reverse typing in similar formats. both methods give results after min with stable end-points without the need of a centrifugation step and are easily applicable to non-laboratory environments. the performance of the autovuetm system for red cell antibody screening of blood donors during background: in israel every donation is tested for the presence of red cell antibodies (rbc abs). screening is performed on the autovuetm system, using ortho screening rbc since the year . aim: (i) to summarize the performance of the autovuetm system for rbc abs, during years ( ) ( ) ( ) ( ) ( ) . (ii) to evaluate if an initial low positive result, with two negative repeats, could be considered a negative result. methods and results: rbc abs screening was performed using igg cassettes. positive results were confirmed by diamed gel cards, with screening rbc, followed by diamed panels for abs identification. results: summary of the results is presented in the table. (i) in . % of , blood donations that were screened, during - , using the autovuetm system, a positive initial result for rbc abs was detected, which was confirmed in . % ( . % of the donations). an increased percentage of confirmed tests is noted, since , probably due to an improvement in the manufacturing of the cassettes by ortho. (ii) during the validation, samples with low positive results (agglutination degree of . ) were retested twice on the autovuetm. / ( %) gave negative results in both repeats. only / was confirmed positive and anti-m was identified by diamed gel test. the remaining samples had at least one positive repeat. / ( . %) of those samples were confirmed positive. summary: autovuetm can be used as a competent method for rbc abs screening, in blood services which require high thoughput automated systems. samples with a low positive agglutination, which were negative in two repeats, can be considered negative. retesting these samples on the autovuetm, can reduce the number of tests sent for confirmation and allow early release of blood components. rk tagi-zadeh*, aa karimov*, ar hasanov † , ly novruzova* and si donskov ‡ *hematology and transfusiology, baku, † blood transfusion centre, ganja, azerbaijan, † centre for hematology, moscow, russian federation background: the main method of treatment of severe homozygous thalassemia forms at the moment is still an anemia control with regular rbc transfusions. the use of adequate transfusion regime for these patients not only prolongs their lives but also promotes normal physical development of the children and improves the quality of their lives. however, necessity to do multiple transfusions increases a risk of post-transfusion reactions and complications due to alloimmunization to rbc antigens. in order to prevent posttransfusion reactions it is essential to know the frequency of blood group distribution in the region and then implement organizational procedures to enhance the transfusion services for these patients. objective: examine the distribution of rbc antigens among thalassemic patients and blood donors. methods: blood samples of homozygous betta-thalassemia patients (who stayed at the daytime inpatient wards of scientific research institute of hematology and transfusiology baku, azerbaijan) and blood donors of azeri nationality were examined. patients' blood samples were typed on rbc rh (c, c, d, e, e) and kell (k, k) antigens. gel test bio-rad (france) was used to detect rbc antigens. results: phenotyping of the patients' rbc rh antigens (d, c, c, e, e, cw) revealed that frequency of occurrence of the antigens in general was higher than in the donors. studying of rh phenotype distribution showed that the patients' ccdee ( . %) •• ccdee ( . %) phenotypes were twice as much higher than the occurrence of those in the donors ( % and . % respectively). phenotype ccdee occurs more frequently in the donors ( %), whereas it is significantly rare in the patients ( . %). the similar picture was observed in relation to ccdee and ccdee phenotypes, which occurred more frequently among donors ( . % and . %) than in thalassemic patients ( . % and . %). additionally, the results demonstrated that k antigen of the kell system was not detected in the thalassemic patients whereas k antigen was detected in all the patients. the same picture was observed with two other antigens of this system. thus among the patients typed on rbc antigens kpa antigen was detected in just one case whereas kpb was detected in the rest the patients. the results of the analysis showed that for thalassemic patients with phenotypes ccdee and ccdee it is easier to find compatible blood than for patients with phenotypes ccdee, ccdee and ccdee. furthermore, it is known, that some congenital diseases are genetically connected with the specific group systems, for example, the mcleod syndrome is genetically associated with the sharp suppression of the kell alloantigen expression (absence of gene kx). the fact of the discovered absence of antigen k in homozygous bthalassemic patients makes it possible to assume, that this group of patients suffer from scarcity along the kell system, like the scarcity in mcleod syndrome. all the mentioned above make it possible for us to conclude, that prior to blood transfusion to thalassemic patients phenotyping of rbc rh and kell antigens must be carried out. hyperhaemolysis in sickle cell disease due to complement activation. tessa thorp rci national blood service manchester uk tm thorp national blood service, manchester, uk introduction: sickle haemoglobin is caused by a genetic mutation in codon of the beta globin gene, resulting in the conversion of glutamic acid to valine. when critical amounts of polymer accumulate within the sickled erythrocyte cellular injury results. clinically sickle cell disease is characterised by chronic haemolysis and intermittent vaso-occlusion. mold et al. demonstrated that deoxygenation and sickling of erythrocytes is related to membrane phospholipid changes and these changes result in the activation of the alternative complement pathway. aim: the objective of this study was to measure the amount of c c and c d bound in vivo to red cells of homozygous and heterozygous sickle cell patients. these levels were then compared to 'normal' sickle negative blood donors. haemoglobin levels and red cell morphology were also examined for signs of active haemolysis. the hypothesis was that an increase in red cell bound complement in vivo could provide an indication of hyperhaemolysis syndrome is sickle patients. method: flow cytometric analysis using rabbit anti-c c or anti-c d and fitc labelled goat anti-rabbit was developed using a beckman epics xlmcl flow cytometer. control samples were prepared using a fruitstone buffer technique of complement coating. results: a total of heterozygous sickle patients and homozygous patients were analysed. of the homozygous patients analysed only one was undergoing a sickle crisis. a positive result was indicated if the mean trait or homozygous sample was coated with complement to a greater degree that the mean normal donor plus two standard deviations. the results obtained in this research project indicate an increase in c c levels bound to red cells of homozygous sickle patients in vivo. statistical analysis of results obtained suggest that there was no increase in c d levels in either sickle trait or homozygous sickle patients. conclusion: these findings support research carried out by mold et al. ( ) and are present in more than % of caucasian population. it has been reported that anti-chido and anti-rogers don't cause hemolitic reaction but may be responsible for life-threatening anaphylactic reaction during transfusion of plasma proteins. case report: positive iat and dat were detected in a years old swedish woman, a rh negative, at th week of pregnancy. previous iat and dat determinations were negative. at time of detection dat wsa weakly positive and igg subclasses identified. antibody identification revealed the presence of high titre ( : ) anti-chido and anti-rogers antibodies. a slight decrease in platelet count (from . /ul to . /ul) was observed. this pattern showed no variation until the end of the pregnancy. at th week a healthy baby was delivered, dat negative. the mother dat and iat remained positive for four months after delivery. the platelets count raised again to . /ul. the same laboratory findings were detected in a previuos pregnancy in sweden. the patient reported the presence of antibodies at th week that disappeared few months after delivery. a healthy baby, dat negative was delivered in this case too. conclusions: this is the first report of the presence of chido and rogers as autoantibodies during the last months of pregnancy. the association with decrease in platelets count and the lack of evident clinical symptoms need further investigation. p- rbc alloantibody frequency and their prevalence within chinese, malay and indian community in singapore e widjaja, mbc koh and d teo health science authority, singapore, singapore background and aim: there is a recognised existence of different alloantibodies in different ethnic groups. while this has been studied in the caucasian population, their frequencies remain less well documented in the asian population. the frequency of different alloantibodies and their distribution in terms of age, sex in singapore population is studied, as were their prevalence within the chinese, malay and indian races in singapore. design and method: we conducted a retrospective study for the frequency of alloantibodies on blood samples over . these blood samples were largely sent by hospitals where preliminary antibody screening had been done and positive result obtained. they were sent to the centre for transfusion medicine for antibody identification. small number of these samples came from hospitals where preliminary antibody testing was not done. the antibody distribution across different ethnic groups (chinese, malays, indians) age and sex were studied. results: the most frequent alloantibodies in the population is mia ( . %), e ( %), le a ( . %), le b ( . %), p ( . %), m ( . %), d ( . %), c ( . %), jka ( . %) and c ( . %). within the chinese community, the most frequent alloantibodies were similar: mia ( . %), e ( . %), le a ( %), le b ( . %) and p ( . %). in the malays, the most frequent alloantibodies were le a ( %), le b ( . %), mia ( . %), e( . %) and p ( . %); while in the indians, these were mia ( . %), le b ( . %), le a ( . %), d ( . %), and e ( . %), with the anti-d reflecting the higher incidence of rh d negativity in the indians race. for the lower incidence antibodies, anti-c was more common in the malays and indians ( %) compared to chinese ( . %). anti jka tended to occur mainly in the malay race and anti-c was rare in all (< %) reflecting the high prevalence of c in the singapore population (r r phenotype). the ratio of alloimmunised male to female (m : f) is : . most alloantibodies demonstrated significant skewing towards to the female, although relatively less so for mia where m : f ratio is almost equal at : . . alloimmunisation increased with age for mia, e, k, p , jka and fyb while the frequency of alloimmunisation to lea, leb, d, m and c decresed with age. the prevalence of patients with multiple alloantibodies ( or more) within the alloimmunised subjects is . %. conclusion: anti mia is very common within the asian population especially in the chinese. anti d is common in the indians. most antibodies show increased frequency with age except for anti lea + b, d and m. the majority of alloimmunised patients are females. study aim: to identify the present antibodies in newborns, after a positive direct antiglobulin test (dat). material and method: during a years period, from / / - / / , we studied newborns and their mothers. each newborn was examined for abo group, rhesus with phenotype, kell and dat. each mother was also tested for abo group, rhesus with phenotype, kell and indirect antiglobulin test (iat). after each positive dat, the study was continued with the elution test, in order to identify the present antibody. dat test was performed with dc screening i-diamed sa, switzerland. for the laboratorial analysis of newborns the sample used was cord blood and in certain cases venous blood. results: the dat test was positive in ( %) of newborns and the antibodies found were igg type immunoglobulin. anti-a antibody was detected in ( . %) (newborns of group a with mothers of group o), anti-b antibody in ( %) (newborns of group b with mothers of group o), anti-d antibody in ( . %) (newborns d+ from d-mothers), anti-e in one case and anti-jka in another one. the eluate test was found negative in newborns and in the rest , no special antibody could be identified. the results are presented in the following table. conclusion: the majority of antibodies in newborns with a positive dat test, is due to abo incompatibility (the mother belongs to group o and the newborn to group a or b). anti-d ( ), anti-e ( ), anti-k ( ), anti-fya ( ), anti-s ( ), anti-jkb ( ), anti-n ( ), anti-kpb ( ). in two patients antibodies were identified, while in / ( . %) no antibody was identified (unspecific). it is remarkable that only in out of patients with both dat and iat positive, an irregular antibody was identified, while the rest patients had unspecific antibodies. in patients with only iat positive, had an irregular antibody and had unspecific antibodies. in out of patients with both dat and iat negative the cause of incompatibility was the positive dat in the corresponding sample of the blood donor, while in the rest patients the reasons were technical problems that include the inappropriate blood sample of the patient, patients under medication and errors during the crossmatching procedure. the results show that the incidence of red cell incompatibility in our hospital is . % and the most common antibodies are anti-k, anti-e, anti-fya, while anti-d is important for d negative patients. . % of the detected antibodies were unspecific and this is still a problem that possibly was due to the lack of additional panels of reagent red cells or antibodies to low-incidence antigens. finally, in some cases the reasons for incompatibility are due to factors affecting the blood donor or to technical problems in the crossmatching procedure. multiple isoforms excluding normal rhd mrna detected in rh blood group del phenotype with rhd a allele introduction: del phenotype is very common in rh-negative chinese. the rates in hans (more than % in china) were reported from % to %. moreover all del individuals in this population were found mainly carrying a same allele, rhd a, through genomic dna analysis. those individuals always possess one or two of this allele with ccee or ccee phenotypes. aim and the study: we focused on the mrna investigations of del individuals carrying rhd a alleles, in chinese, to expect it could be explained that why a silent mutation is associated with del phenotype. the full-length rhd mrna was analyzed in rh-positive donors with cde/cde and cde/cde genotypes, respectively, and del phenotype individuals carrying rhd a allele with cde/cde, cde/cde, cde/cde and cde/cde genotypes, respectively, through reversed-trancriptase pcrs and cdna direct or cloning sequencing. results: five transcripts and isoforms were detected in rh-positive and del, respectively. among them, isoforms have identical sequences, which are transcripts with exon , exons and , exons and , and exons to spliced out. the normal rhd mrna was only observed in rh-positive, but not in del individuals. in stead, two additional transcripts were found in del individuals. its exon or exons - were spliced out, but both possess a bp segment of sequence from intron of rhd. through additional reversedtrancriptase pcrs, which amplified exon to ¢-region and exon to ¢-region, the results showed that exon did not exist in del anyway. conclusion: (i) a normal rhd protein does not exist in a del individual with rhd a allele since the exon was always spliced out in all isoforms. all transcripts in del maintain a normal open reading frame and encode proteins with different numbers of amino acid residues and different c-terminals (genbank ay , ay , ay , ay , ay , ay ). among them, the sequence of del (isoform with exon spliced) transcript was the most similar as normal rhd mrna. this isoform was first described by chang et al. in taiwan in . it encodes amino acid residues and has amino acids more than normal rhd. it is different from rhd after codon . in normal rhd protein, the amino acids after ( residues) are mainly the trans-membrane and intracellular regions. therefore a further study on if a del red cell possesses all epitopes of normal d antigen may be significative. (ii) a normal rh-positive individual has also the transcript of del that was found in del. (iii) there is only one polymorphism in the region of bp segment between rhd intron and of the del transcripts, which indicated that other polymorphisms may exist in intron of rhd a allele compared rhd to explain that this situation was not happened in normal rh-positive individuals. total wbc were enumerated by flow cytometry and cell counting. wbc subsets were analyzed by flow cytometry with three-color fluorescence. in this study, the third generation bags and filters are used. results: before filtration, the total number of wbc, was significantly higher in fresh units compared with stored units, whereas in postfiltration samples the number of white cells was significantly lower in the fresh compared with the stored units. although absolute numbers were significantly reduced, filtration also induced significant changes in the proportions of subsets in hoth fresh and storod units, the percentage of t cells was decreased, whereas the percentage of b cells and monocytes was increased after filtration. in conclusion, both pre and post storage wbc filtration affect the proportions of wbc in the final product but pre storage wbc filtration of platelet concentrates is superior than post storage wbc filtration. the effect of pre-and post-storage filtration on platelet rich plasma: derived platelet concentrations background and objective: the white blood cells (wbc) within transfusion products are a major stimulus for a number of detrirmental biological reactions, including febrile nonhemolytic transfusion reactions, alloimmunization against hla antigens and cytomegalovirus transmission. in this work, our objective was to study the effect of storage time on the filtration of platelet concentrates (pcs). the total number of white blood cells as well as the distribution of wbc subsets, in units filtered before and after storage were compared. materials and methods: platelet rich plasma -derived pcs were filtered either fresh ( pooled we reported earlier that metabolic arrest followed by incubation at °c reduces the platelet storage lesion (badlou et al. transfusion ) . here we report that this treatment also reduces binding and phagocytosis by macrophages. metabolic suppressed platelets (msp) were prepared by incubation in glucose-free, antimycin a containing medium ( min, °c) followed by storage ( h, °c) and recovery with glucose ( h, °c). controls were (i) platelets in glucose-rich medium stored for h at °c and recovery with glucose (c ) and (ii) platelets stored for h at °c (c ) with rewarming. platelets were labelled with mepacrine and incubated with pma-matured thp- cells ( °c). binding was measured by facs analysis of cd b/cd positive particles, and phagocytosis by counting mepacrine/cd positive particles. binding of msp, c , c was ± , ± , ± % of total platelets. phagocytosis of msp, c and c was ± , ± , ± % of total macrophages (means ± sem, n = ). before recovery of msp, binding/phagocytosis was % higher than thereafter, revealing energy-dependent control of the mechanisms that trigger plateletmacrophage interaction. these data show that metabolic suppression prior to cold storage attenuates binding and phagocytosis by phagocytes and may help to develop means to improve platelet survival post-transfusion. platelet compatibility testing and alloimunization in multiply transfused hematologic patients purpose: multiply transfused patients with heamotological malignancy often become refractory to platelets due to alloimmunization. refractoriness is usually defined as an insufficient platelet increment after consecutive platelet transfusions. two major causes of a decreased platelet increment can be distinguished, immune and nonimmune factors. alloimmunization occurs most frequently against the hla, and rarely against the hpa system. nonimmune factors been identified are splenomegaly, fever, sepsis, and disseminated intravascular coagulation as well as the quality of the transfused platelet concentrates. we performed this study in order to investigate platelet crossmatching, compatibility, and antibody determination among thrombocytopenic patients multiply transfused. we performed crossmatchingcompatibility tests of single donor leucodepleted, abo compatible, platelet concentrates been transfused in patients with leukemia and lymphoma, males and females with mean age ± years old. we also obtained samples from the patients for platelet antibody detection. we evaluated the cci (corrected count increment) h after the transfusion. the solid phase rbc adherence assay (modified capture p system/immucor) was used for platelet compatibility and antibody detection. a total of compatibility tests were performed, of which were compatible. twenty five compatible platelet concentrates out of were clinically evaluated. twenty from compatible crossmatches ( %) were resulted in successful transfusion while only from ( %) in unsuccessful. the incompatible platelets been transfused was resulted in unsuccessful transfusion. we found statistically significant difference among patients successfully transfused with compatible and incompatible platelets (p~ . ). additionally patients out of ( . %) had been alloimmunized against multiple hla antibodies. three patients transfused with compatible platelets, during the study, developed alloantibodies. we found a large number of incompatible platelet concentrates that result in unsuccessful transfusion and clinical response. the platelet compatibility testing as well as alloantibody determination of multiply transfused patients is necessary for the identification and selection of compatible, with the patients, donors in order to result in succesful transfusion and clinical outcome. furthermore compatible platelet concentrates provide optimal support for refractory patients and it is known that they are acceptable as an alternative component. naitp is a rare clinical syndrome characterized by marked thrombocytopenia shortly after birth. it is caused by maternal immunization against paternally inherited antigens present on foetal platelets. screening and identification of antibodies in the maternal blood sample is the main support in the diagnosis and management of naitp. we have evaluated the frequency of maternal alloimmunization, the role of the antibodies involved (hpa and/or hla systems) and the pertinent risk of naitp in neonates using a fully automated system with a solid phase red cell adherence methodology (sprc-capture p) and paternal or random donors (indirect test). screening started in june and is still in course: in january , blood samples were examined. identification of antibodies in maternal serum was carried out using elisa methodologies: maipa and commercial kits (pak-plus and quick screen-gti). of the blood samples analysed, were reactive and the specificity of the antibodies were: anti hpa a: , anti hpa b: , anti hpa a + hla: , anti hpa b. , anti hla: , auto hpa- b: . specificity of hpa antibodies was confirmed by determination of parents' hpa genotype (hpa- , , , , , ) using pcr-ssp or pcr-rflp. the infants with hpa immunization suffered from severe (plt count - /ml) and symptomatic naitp (bleeding and petechiae were present), therefore they were treated with platelet transfusion and administration of high doses of intravenous immunoglobulin. we confirm that naitp due to hpa- and hla immunization is clinically less severe: all neonates had mild and self limiting thrombocytopenia at birth; no therapy was administered. it would be advisable to carry out pre-natal screening, at reasonable cost, using maternal serum versus paternal platelets and to proceed to the identification of antibodies only in presence of positive results. background: fetal or neonatal alloimmune thrombocytopenia (fmait) results from a maternal alloimmunization against fetal platelet antigens. it is the commonest cause of severe thrombocytopenia in the neonatal period. the diagnosis of fmait is made initially on clinical grounds, depending on exclusion of other causes of neonatal thrombocytopenia. in caucasians, hpa- a is the most frequently implicated antigen. other antigens such as hpa- a, or hpa- a are less often implicated. during the past few years fmait has been reported associated with rare or private antigens. the diagnosis is straightforward when a maternal alloantibody with a corresponding parental antigen incompatibility is present. however it could be equivocal in the absence of such an antibody or difficult when a private antigen is implicated. if the father is heterozygous for the considered antigen, the infant's platelet typing should be performed to confirm the diagnosis. due to the risk of hemorrhage, particularly intracranial hemorrhage (ich), during the course of severe thrombocytopenia, specific therapy is mandatory. because subsequent siblings may be more severely affected, accurate diagnosis will allow better management of subsequent pregnancies. study design and methods: since the first documented case of feto-maternal alloimmune thrombocytopenia (fmait) due to anti hpa- bw (maxa+), no additional cases have been reported. we present here a retrospective analysis of the cases referred to our laboratories in recent years. since we have screened for rare or private antigens in suspected cases of fmait when there is no incompatibility for the most frequently implicated antigens. the diagnosis was performed by genotyping and identification of the maternal alloantibody by the maipa technique. results: parental genotyping showed hpa- bw (maxa+) mismatch as the sole antigenic incompatibility in out of families. in the last one, incompatibility was found for hpa- without anti hpa- b maternal alloantibody. as the father was found to be hpa- bw (maxa+) heterozygous in all the cases, the infant or fetus was genotyped to ascertain the diagnosis. the maternal alloantibody was identified in the maipa technique. however, our data strongly suggest that recognition of the hpa- bw (maxa+) epitope is not uniform. the neonatal thrombocytopenia was severe in most cases with bleeding. the outcome was good in all the cases but one. conclusion: this analysis confirms that anti hpa- bw (maxa+) fmait is not uncommon and was found to be around % of our confirmed fmait cases with parental incompatibilities and presence of maternal alloantibodies. it is a clinically severe syndrome which requires prompt diagnosis, albeit difficult, and maternal platelet transfusion therapy. laboratory investigation of a suspected fmait case should be carried out in a specialist laboratory wellexperienced in optimal testing. therapy requires strict collaboration between clinicians and blood bank services. appropriate management and antenatal therapy should be considered for successive pregnancies to prevent fetal bleeding. introduction: the human platelet (plt) antigen (hpa) system is independent of the hla system. therefore, host-or donor derived alloimmune thrombocytopenia can develop after allogeneic haematopoietic stem cell transplantation (hsct) even in hlamatched donor-recipient pairs. we report the first case on a stem cell recipient developing thrombocytopenia due to host-derived hpa- a antibodies after non-myeloablative allogeneic hsct. a year-old male patient was diagnosed with multiple myeloma in / . treatment consisted of cycles vincristin, adriamycin and dexamethason followed by tandem autologous stem cell transplantation. because of progressive disease he received cycles of bortezomib, and after complete remission a stem cell allograft ( . ¥ /kgbw cd + cells) from his histocompatible (hla a,b,c,dr identical) brother after reduced intensity conditioning regimen with fludarabine ( ¥ mg/m ) and alkeran ( mg/m ). he had received only twice packed red blood cell concentrates and one plt concentrate before allogeneic hsct. stable bilinear engraftment occurred around d but was accompanied with a continuous decrease of plt counts. between d and d the patient received seven plt transfusions, containing a median of . ¥ plt/unit (range , - , ¥ plt/unit) from random donors. the corrected plt count increments at to h after these transfusions were < /ml. therefore, and because of even a further decline of platelet counts to /ml on d we investigated the presence of plt antibodies. methods: the patient's serum was tested by antigen capture elisa assays (pakplus® and pak ®, gti) and a solid phase assay (capture-p®, immucor). the maipa assay was used to confirm the results obtained by the above mentioned assays. in addition, we tested the patient's serum by the maspat kit (clb) against plt from the donor and against homozygous hpa- a plt obtained from our donor pool. stored recipient's dna from the time before hsct was used for genotyping. genotyping for hpa- , - , - and - of the donor and the recipient was performed by pcr-ssp (hpa, protrans). the patient's serum obtained on d after hsct reacted strongly with the donor's plt due to anti-hpa- a antibodies and antibodies against hla class i antigens. the patient's genotype before transplantation was hpa- bb, - aa, - ab, and - aa; the donor was hpa- ab, - aa, - aa, and - aa. thus, the antibodies were host derived and directed against the donor's plt. serum samples obtained on d , d and d after hsct contained antibodies against hla class i antigens but hpa- a antibodies were not anymore detectable. no hla antibodies were detectable on d after hsct. the severe thrombocytopenia was caused by hostderived hpa- a antibodies. fortunately, plt counts started to increase on d spontaneously and the patient could be discharged at d (plt . /ml) with a complete donor chimerism. the decrease of the serum antibodies parallel to the increase of the plt count strongly suggests a progressive elimination of residual host cells. we conclude that the hpa mismatch between recipient and host affected thrombopoietic engraftment and the success of plt transfusions. severe neonatal alloimmune thrombocytopenia with anti-hpa- b antibodies: case report p moncharmont, m vignal, y mÉrieux and d rigal efs rhone alpes site de lyon, lyon cedex , france usually, in case of feto-maternal incompatibility, the platelet (plt) specific anti-hpa- b antibodies (ab) induce only sometimes a mild neonatal alloimmune thrombocytopenia (nait). contrary to this observation here is reported the case of a severe nait. a -year old mother, gestation /partum , gave birth to a male neonate by caesarean section at weeks of gestation because of intra-uterine growth retardation (iugr) and anamniotic fetus. five years before, she had had a first pregnancy with iugr of the fetus but no nait. the second neonate weighted . g, was . cm tall and had a head circumference of . cm. the apgar score was , , , at , , and min respectively after birth. no bleeding, hepatomegaly, splenomegaly or infectious signs were noted. five hours after birth, a respiratory distress syndrome appeared and an oxygenotherapy was performed during h. the plt count which was . , . and . giga/l at day (d) , d and d respectively dropped dramatically at . giga/l at d . simultaneously, an intracranial hemorrhage grade ii was diagnosed on ultrasound scan. because of the clinical signs and of the decreasing plt count the mother's serum was tested for plt-specific ab by immunocapture and the ab identified by the monoclonal ab-specific immobilization of plt antigen (maipa) assay. a plt genotyping was performed in the neonate and his parents by sequence-specific primers polymerase chain reaction. the mother was hpa- a/a and anti-hpa- b ab were detected in her serum. the baby was heterozygous, hpa- a/b. plt were transfused to the baby and the plt count rose to . , . and . giga/l at d , and respectively. no further transfusion was needed and the development of the baby was satisfactory with a normal electroencephalogram. in conclusion, when a mild thrombocytopenia with iugr and hypoxia but without bleeding signs is present in a neonate immediately after birth, a maternal plt specific ab screening must be performed in case the thrombocytopenia became severe during the newborn monitoring. anti-hpa- b ab can be detected. partial results of the incidence of heparin induced thrombocytopenia type ii osc oliveira*, ra rached*, c cavalheiro-filho*, jc nicolau*, shgl pasqualucci*, daf chamone † and sp bydlowski † *heart institute, university of são paulo, † university of são paulo, são paulo, brazil heparin induced thrombocytopenia type ii (hit) is a severe side effect of heparin, associated with heparin-platelet factor antibodies. hit type ii occurs in up to % of patients who are exposed to unfractionated heparin (ufh). in our institution patients that are under heparin treatment are mostly cardiac patients. the purpose of this study is to determine the incidence of hit type ii in these patients. material and methods: patients from the intensive care unit and cardiac care unit treated with ufh or low molecular weight heparin (lmwh) for or more days were studied. known causes of thrombocytopenia were excluded. platelet count was monitored pre and post heparin therapy. all selected patients were tested for detection of anti heparin/pf antibody test (diamed id-card). results: from the studied patients, ( . %) developed thrombocytopenia (determined by a decrease in the platelet count below %, after the introduction of heparin therapy); ( . %) did not show decrease in the platelet count. six ( . %) out of thrombocytopenic patients were positive for anti-heparin/pf antibody. three ( . %) out of non thrombocytopenic patients were positive for anti-heparin/pf antibody. the results demonstrate that ( . %) patients were positive for anti-heparin/pf antibody and they were no different from those described in the literature regarding the frequency of heparin induced thrombocytopenia. moreover, a higher frequency of patients with heparin/pf antibody was noted without the presence of thrombocytopenia, indicating that other factors should be considered. introduction: neonatal alloimmune thrombocytopenia (natp) due to maternal immunization against fetal platelet antigens affects . - in live births. although it is usually a self-limiting condition, a major complication in cases of severe thrombocytopenia is the occurrence of intracranial haemorrhage leading to death (in up to % of reported cases). the commonest antibodies are anti-hpa- a. treatment consists of ivig, compatible donor platelet concentrates or washed maternal platelets. the administration of random donor platelet transfusions is controversial but has been used successfully in some urgent cases when compatible platelets were not available. case report: a baby born in week of gestation to a healthy mother after first uneventful pregnancy; birth weight g, apgar score . immediately after birth, severe thrombocytopenia ( ¥ /l) and signs of haemorrhagic diathesis (generalized petechiae and ich gr. ii-iii) were observed. coagulation tests were abnormal and k-vitamin, fresh frozen plasma and random donor platelet concentrate (retrospectively genotyped as hpa- a/a) were given. twenty-four hours later platelet count rose to ¥ /l and no new petechiae were observed. on third day of life the blood platelet count was ¥ /l and the newborn received ivig g/kg and corticosteroides. twenty-four hours later the platelet count rose to ¥ /l and further clinical course was uneventful. natp due to hpa- a was serologically confirmed. conclusion: optimal therapy for an infant with severe thrombocytopenia during the first h of life is the transfusion of platelets that will not be destroyed by the maternal alloantibody in the infant circulation. random donor platelet concentrates are controversial in a setting where optimal treatment is not available, however, in this case they led to a significant platelet count improvement in spite of hpa- a incompatibility. accordingly, random donor platelets may be considered appropriate in emergency situations. background: rhd is the most immunogenic blood group antigen, and its correct identification is essential in the blood bank and in the prevention of the haemolytic disease of the newborn. the weak d phenotype is the most common d variant, with a frequency of . % to % in caucasian individuals. there are several weak d types, with different frequencies in european countries, which may pose serologic problems and have the potential for alloimmunization. the objective of the study was to determine the frequency of the principal weak d types in portugal. study design and methods: lisbon regional centre of the portuguese blood institute and oporto são joão university hospital selected samples from blood donors and patients. rhd was tested by two (oporto) or three (lisbon) distinct anti-sera, in direct agglutination tests, at room temperature. when discrepant results were observed, the samples were tested with panels of monoclonal anti-d by liss-iat. samples that reacted weakly with igm anti-d but positive with igg anti-d were sent to the molecular biology centre. pcr with sequence-specific primers was performed using two commercially available kits (inno-train and bagene). real-time pcr, carried out on a light cycler, was applied when the interpretation was dubious. results: samples were referred after being characterized as weak d. in cases we obtained a positive result, with a preponderance of weak d type ( . %) over type ( . %), ( . %) and ( . %). two samples were not categorized. the high incidence of weak d type in our population is in marked contrast to studies performed in other european populations where weak d type was the most frequent. this might be due to our sample selection criteria or ethnic variation in the causes of weak d. there are advantages in genotyping serologically depressed d samples: to avoid the waste of d-negative rbc units and the use of immunoglobulin in pregnant women, who have no risk of alloimmunization. analysis of rhd zygosity in different rh phenotypes cal except for a -bp t insertion. the deletion of the rhd gene, found in most rhd-negative caucasians, was theoretically due to recombination of the upstream and downstream rhesus boxes resulting in the formation of a hybrid rhesus box. thus, the detection of a hybrid rhesus box in an rhd-positive individual denotes an rhd heterozygous status. aim of the study: to determine the rhd zygosity in different rh phenotypes. methods: blood samples from white trios (father, mother and child) were studied. the rh phenotype was performed by hemmaglutination and the rhd zygosity was inferred in each member of the family groups. the rhd deleted allele was determined by a pcr strategy using a forward primer complementary to ¢ end of the identity region of the upstream and hybrid rhesus boxes and a reverse primer complementary to the ¢ end of identity region of the downstream and hybrid rhesus boxes. these primers selectively amplify a -bp segment of the hybrid rhesus box in rhdnegative and rhd-positive heterozygous samples. serological and pcr inconsistencies were studied by a pcr-rflp method to detect another polymorphic site of the hybrid rhesus box. frequencies were obtained analysing only unrelated individuals (fathers and mothers, n = ). results: ( . %) rhd-positive and ( . %) rhd-negative samples were phenotyped. of the rhd-positive donors, ( . %) were rhd homozygous and ( . %) were rhd heterozygous according to pcr. pcr-rflp analysis confirmed the results of pcr in serological and molecular discrepancies. these results were coherent within each family group and did not differ from those published in the literature for caucasians based on the most probable genotype method. however, the homozygosity indexes were significantly higher in the dccee ( . % vs . %) and dccee ( . % vs . %) phenotypes due to an increase of the dce haplotype. in all samples with the dce haplotype the rhces allele, frequent in individuals of african descent, was investigated by pcr-ssp. this allele was found in . % of the dce haplotypes. . rhd and rhce typing was performed by multiplex-pcr with fluorescent primer pairs. positive results were obtained for rhd-exons - , , and polymorphisms associated with antigens c, c, cw, e and e. sequencing of rhce-sequences, including exons to and intron/exon borders, were done by direct taq cycle-sequencing using bigdye-terminators v. . in an abi (applied biosystems). results: see table . the substitutions of rhce-specific nucleotides in exons , and with their rhd-specific counterparts lead to different new rhc-antigens with weakened expression. since one amino acid change in allele lie in extracellular loop of the antigen suggested that this antigen may be involved in allo-immunization. inheritance of a rhd cat vi type ii in a twin pregnancy: a case report introduction: determination of hdn-relevant fetal blood groups in amniocentic fluid with pcr is a routinely used method. misinterpretation of test results -e.g. overlooking rhd category -decreases depending on the number of examinated rhd-specific exons. case report: a -year old mother (w.o.g. ) pregnant with twins was regularly tested for irregular antibodies and was shown to have an anti-d. after amniocentesis of both foetuses tests for the occurrence of rhd intron , exons and were performed in the hospital's lab. the sample of fetus i showed pcr-products for intron , exon and exon while sample of fetus ii lacked rhd-specific intron . therefore we investigated blood samples from the parents as well as amniocentic fluid of both foetuses. methods: total dna was amplified in a multiplex pcr with fluorogenic primers for rhd exons - , & ; polymorphisms for dweak type - , d-vii, d-hmi and rhce polymorphisms for c, c, cw, e, e. capillary electrophoresis for size fractionation and fluorigeneic analysis was done in an abi . rhd zygosity was determined by quantitative real-time pcr with co-amplification of rhdand rhce-specific exon and subsequent calculation of d ct value (ct rhce minus ct rhd). results: while maternal dna sample has been genotyped as rhdnegative, amplification of paternal dna for rhd-specific exons , , , and were possible and failed only in exon - . determination of rhd-zygosity revealed a homozygous constellation of the rhd-gen. investigation of amniocentic fluid from both foetuses resulted in a rhd-wildtyp for fetus i and a rhd cat. vi type ii for fetus ii which was the reason for missing amplification in rhd intron pcr. results: weak d type was not identified in our research population. weak d type was identified in cn, weak d type was identified in cn and weak d type was found in cn, bsa, be, bc and saa. conclusions: although weak d types to represent the majority of all weak d phenotypes in caucasian populations, none of these weak d alleles were found in black populations. since none of the frequent weak d types were identified in non-caucasians one might not expected to find type in all populations. however, regarding rhd phylogeny, the weak d type mutations ( c > g and t > g) form the basis of a cluster of aberrant alleles that are predominantly observed in blacks. therefore, it is not surprising that weak d type was identified in non-caucasians. based on these results it may be concluded that weak d phenotypes have evolved relatively recently since they are present in caucasian and asian methods: dna was extracted from a, b, ab subgroups, and provisional cis-ab after serological abo typing. allelespecific pcr, rflp, direct sequencing of exon and , and allele separation were performed on these samples. results: abo*a allele was observed in an aint subgroup. two new a alleles that showed g > a base change and c > t of intron and a polymorphism of c > t in a(pro) intron were discovered. o and o alleles were also observed. in b subgroups, a silent substitution c > t (leu leu) was observed as a new b allele. another new b allele which showed g > a was also found in b subgroups. conclusion: we discovered new abo alleles and polymorphisms in korean populations. many other polymorphisms and alleles already reported in japanese were also observed in koreans. evaluation of a multiplex snapshot-pcr method for red blood cell marker genotyping c jungbauer*, c hobel*, em dauber † , pk rabitsch*, dwm schwartz* and wr mayr* *austrian red cross, † medical university vienna, vienna, austria once conventional reagents for identification of rare red blood cell phenotypes are scarce, methods using current nucleic acid testing techniques to identify the patient's genotype and possibly to screen for donors would be desirable. the approach of multiplexgenotyping using pcr-ssp has apparently technical constraints so we are currently analyzing whether a modification using snapshot pcr-technique could provide a routine application for such purposes. compared to ssp-technique, the snapshot pcr only requires one single primer (labeling reaction) for the detection of two (or more) alleles instead of one pair of primers for every single allele. briefly, we perform snapshot pcr as follows: in a first step, dna segments covering the essential polymorphic regions for the abo, rhd, kel, jk and fy genes are amplified using a standard pcr step. after purification treatment of the pcr products (roche high pure pcr product purification kit or shrimp alkaline phosphatase (sap)/exo treatment according to the abi prism snapshot multiplex kit protocol) the labeling reaction is performed using the abi prism snapshot multiplex kit. after a second purification step the products are analyzed on a abi prism genetic analyser in fragment analysis mode. our preliminary results show the feasibility of this approach as reliable typing results can be obtained for all tested single nucleotide polymorphisms corresponding to alleles. generally a better signal quality from controls and samples is obtained compared to the ssp-technique with consecutive gel electrophoresis. we also consider the possibility of the automated interpretation of the results as an important improvement, especially when aiming for an application for a large number of samples (donors) or markers (patients). in contrast, the method involves more manual steps and higher costs. we may conclude that the implementation of snapshot-pcr techniques for red cell marker genotyping is a promising alternative to pcr-ssp. the obvious quality improvements compared to pcr-ssp might be critical for a routine application in blood banks (donor screening) or complex questions in clinical laboratories. quantification and quality control of monoclonal antibody using an optical sensor based on the laser reflectometry technique the monoclonal antibodies (moab) are biological reagents of homogeneous activity. they are generally used in the recognition and quantification of very small amounts of biological substances (hormones, enzymes) present in a solution, ag identification, blood group determination, oncology, organs transplant, etc. moab can be characterized by its specificity and affinity. affinity may be expressed as the equilibrium association constant (k). several techniques are available to determine the equilibrium constant of the ag-ab interaction. in this work, is shown an optical sensor for monoclonal antibody quantification by reflectometry technique. the laser reflectometry technique (null ellipsometry technique) can give information about the kinetic of the interactions, stoichiometry of molecular binding and the concentration of molecules in a solution, and also offers detailed and accurate determinations of real-time adsorption kinetics of protein without labeling. a silicon wafer was chosen as reflectant surface. once fixed the principal angle of incidence, an amount of anti-ab is added to the sample. the reflected laser intensity is registered in real time as the protein is being adsorbed onto the wafer. the mathematical analysis of the results verifies that the antibodies adsorption follows langmuir's kinetics. from the curve analysis, the parameters related to the anti-ab concentration are extracted. from them, the calibration curve is constructed. this curve allows the desired commercial monoclonal antibody quantification. the developed technique shows to be sensible and precise. the obtained graphics are very well approximated (r > . ) verifying that the monoclonal anti-ab associa- study aim: to prevent the sensitization to rh (d), to a d-patient who was transfused with d+ blood. material and method: on september , ( / / ), we admitted to our hospital through air-carriage, a female of years old, badly injured after a car-accident. the patient was on an olighemic shock (ht: %) due to retroperitoneal, paracolic and procystic hematomas, had multiple fractures on the left feet, the main important of which was an acetabulum one. she had a blood group: o, d-and her phenotype was ccdee with du-. after her arrival she was urgently admitted to the surgery room and our blood bank was asked for condensed red cells. initially she was transfused with blood of the same group (o, d-) but when we were short out of dblood, we were asked for more units. the necessity of blood was imperative, the patient was on a critical condition and the mechanism of blood transport, from another blood bank would take some time to be put in motion, and so it was decided that the patient would be provided with d+ blood. the indirect antiglobulin test (iat) and papaine were negative, so there would be no problem with the transfusion with d+ blood. the patient received finally units ( ml) of d+ condensed red cells, out of that were initially asked. before the h from the surgery had passed, it was decided that human anti-d immunoglobulin (rhesogamma p) should be provided, in order to prevent the sensitization of the patient to rh (d). the indicted dose was - iu/ ml of the transfused blood, provided piecemeal during a several days period. analyzed by real-time pcr amplification. based on a published report, we selected primer pairs targeting insertion/deletion polymorphisms which are located on different chromosomes, unrelated to each other and not associated with immunocompatibility. we optimized the amplification conditions for all primer pairs using our sybr green real-time quantitative pcr protocols, and investigated analytical sensitivity for each primer pair by performing spiking studies, in which a single copy of positive dna was added into copies of negative dna followed by allele-specific pcr amplification. we also created a theoretical panel of donor-recipient pairs (n = ) to evaluate the clinical sensitivity for detection of ta-mc using both hla-dr and indel panels. results: for the short-term samples, additional mc cases was identified in non-lr group using indel panel; and one additional mc case was detected in lr group (table ) . for the long-term follow-up samples, additional mc cases were found. when evaluating analytical sensitivity, we were able to detect a single copy of positive dna mixed with copies of negative dna in a single amplification tube for all primer pairs. we were also able to calculated the clinical sensitivity that using donor-recipient pairs. . % of donor-recipient had at least one informative allele for detection of ta-mc if we consider both hla-dr and indel panels. conclusion: using our new indel panel, we were able to detect more instances of mc in this cohort of patients. we conclude that the dr assay underestimates the presence of mc. moreover, the tandem use of both panels provides a powerful tool for the detection of mc with . % of recipients having at least one informative allele. background: we reported severe immunesuppression and longterm transfusion-associated microchimerism (ta-mc) in transfused trauma patients. we have also reported, in a murine transfusion model, that sensitivity to -chloro- - dinitrobenzene could be transferred, albeit transiently, by transfusion of fresh blood from a sensitized donor to a naïve immunecompetent recipient. in order to mimic the immunecompromised status of trauma patients and further investigate the mechanism underlying ta-mc, we established an animal model using immunedeficient knock-out mice. aim: our objective was to test virus-specific immune functionality of the chimeric donor leukocytes in a murine ta-mc model. material and methods: female rag- /common gamma double knock-out mice were transfused with fresh blood collected from male balb/c mice, which were either not infected (non-primed, np) or infected twice (primed, p) with million viral particles of murine cmv (mcmv). at different post-transfusion time-points ( h, weeks, weeks, weeks, weeks), different female recipients plus non-transfused female knock-out controls were challenged with million viral particles of mcmv intra-peritoneally, and then monitored weekly for the concentrations of male donor cells as well as mcmv viral load in recipient's circulation. each female knock-out received only one challenge of mcmv. if the subject died, we quantitated mcmv viral load in the brain, spleen, lung and liver. we used real-time quantitative pcr targeting murine y-chromosome, h k and mcmv to quantitate male donor cells, transfused recipient cell dna input, and mcmv vrial load, respectively. the number of recipient cell dna input served as a denominator to calculate the concentration of male donor cells and the mcmv viral load. results: results of overall mortality are summarized in the table. all female knock-out recipients transfused with primed donor blood, except for the post-transfusion weeks, are able to survive mcmv infection. all non-transfused control and recipients transfused with non-primed donor blood died after mcmv infection; these two groups also had higher mcmv viral load in blood than the recipients transfused with primed donor blood. when the subject died, we were able to detect mcmv in all four organs we analyzed, with liver having the highest mcmv viral load. there was no significant difference for the concentration of donor cells in recipients' blood between recipients transfused with non-primed donor blood and recipients with primed donor blood. the preliminary data of our study showed that chimeric primed donor cells, but not non-primed donor cells, are able to protect immune compromised knock-out recipients from murine cmv infection. the time-point of 'post-transfusion weeks' might represent a weak window for the functionality of chimeric donor cells, which requires further investigation and confirmation. aims: to compare the effectiveness and the cost of epoetin-a and darbepoetin in patients undergoing pabd. methods: seven adult patients scheduled for operations were administered aranesp ( mg sc once or q weeks if needed) for pabd (aranesp group) and they were compared with a historical epoetin-a group of seven age-matched adults (eprex iu/kg biweekly). the two groups were matched according to the ht, ferritin levels, number of the predonated units and type of the operation performed. cbc count and reticulocytes were measured weekly during the donation period, the day before, day and day after surgery while ferritin and biochemical indices were measured during the first visit. erythropoiesis-stimulating factor was administered when ht £ % during blood donations and blood donation was not performed if ht < %. results: there was no statistical significant difference in hematological parameters during the donation period, the pre-operation day and after surgery between the two groups. five of seven patients from both groups received one or two autologous blood units. both factors were well tolerated without any side effects. the cost per patient was . € in the aranesp group and . € in the epoetin group. conclusion: despite the small number of patients and the limitations of this preliminary retrospective trial we believe that subcutaneous darbepoetin-a is equally effective with epoetin-a in patients undergoing pabd. darbepoetin has the advantage of less frequent administration and it is possibly superior that epoetin-a in terms of patient compliance. however smaller doses should be examined in order to reduce the cost. larger prospective randomized trials are needed to estimate the cost-effectiveness of the use of darbepoetin-a in pabd. background: incompatibility with many blood units is a major problem in transfusion therapy. in selective operations, preoperative autologous blood donation could solve many problems, when of course the patient's condition and his haemoglobin levels are appropriate. we present here the experience of our blood transfusion centre from operations in patients with anti-erythroid antibodies. materials: three patients ( male and females), aged between - years old, had to undergo selective operations, total hip replacement surgery and aortic aneurysm. introduction: because of improvements in surgical techniques, preoperative autologous blood donation (pabd) in patients undergoing radical retropubic prostatectomy (rp) is contested. aim of the study: we wanted to develop and validate an algorithm to determine the patients who probably do not benefit from pabd. methods: we calculated the perioperative hb-loss of consecutive patients (group ) who donated two red cell units (rbc) of autologous blood and weeks before undergoing rp: hb-loss (g) = preop-hb ¥ bv + (n rbc ¥ ) -(postop-hb ¥ bv) (bv = blood volume (l) = body weight (kg) ¥ . ; postop-hb = hb ( - h after rp); n rbc = number of transfused autologous and allogeneic rbc). hb of rbc was taken as g. rbc requirement is probably if initial-hb -(hb-loss: bv) -trigger-hb (taken as g/l) < (initial-hb = hb at the first contact with the pabd-unit). this assumption was validated by the next patients who were also assigned for pabd (group ). pabd was refused if the probability of rbc requirement (prr) was < %. between - % one rbc was taken after considering the patient's individual risk of pabd. if prr exceeded % two donations were planned. results: both groups did not significantly differ in age or initial hb. preop-and postop-hb were significantly lower in group ( vs and vs g/l). % of autologous blood of group were discarded, / patients needed additional allogeneic rbc. hb-loss caused by rp was ± g. mean prr in group was . %. / patients donated one rbc, which was later discarded, and no patients donated two rbc. / of group needed allogeneic rbc. mean prr of these patients was % (range . - . ). conclusion: postop-hb were lower in rp-patients with pabd because of the lower preop-hb and the restrictive indication for transfusion of autologous blood. the individual calculation of prr, for which only body-weight and initial-hb of the patient are necessary, shows that pabd in patients undergoing rp is indicated only in rare cases. the algorithm also may be used in other major operations, if hb-loss is known. use of darbepoetin-alpha in preoperative autologous blood donation: preliminary results background: preoperative autologous blood donation (pabd) is an alternative practice to eliminate complications of allogeneic blood transfusion although its cost-effectiveness has been questioned. darbepoetin-a (aranesp, genesis pharma sa) is a novel erythropoiesis-stimulating factor that it has been shown to be equivalent to epoetin-a (eprex, janssen-cilag) in patients with chronic renal failure and cancer. darbepoetin-a has a longer serum half-life and higher relative potency than epoetin-a. this property leads to less frequent administration and may reduce drug cost. so far, no clinical trials with darbepoetin have been published in patients with surgical anemia. other ( . %) patients who required autologous and homologous blood, had average predonation hb level of (sd ± . ) g/l. we found a significant relationship between the need for postoperative transfusion and the predonation hb level (p = . ), predonation htc values (p = . ), weight (p = . ) and gender (p = . ): female patients and patients with lower predonation hb and htc, as well as patients with lower body weight more often needed additional homologous blood transfusion. no relationship was found between age of patients and the need for transfusion (p = . ). ( . %) patients with ptka were transfused with autologous blood only, and had average predonation hb level of (sd ± . ) g/l. other ( . %) patients transfused with autologous and homologous blood had average predonation hb level of (sd ± . ) g/l. the significant relationship was found between the need for postoperative transfusion and weight (p = . ): patients with lower body weight more often needed additional homologous blood transfusion. no relationships were found between predonation hb level (p = . ) predonation htc values (p = . ), gender (p = . ) and age (p = . ) of patients and the need for postoperative transfusion. conclusions: our results show that over % of patients needed only autologous blood. in our patients with ptha predonation hb was significant predictive factor for additional transfusion therapy, while in ptka it was not observed. in both groups of patients body weight was significant predictive factor, thus this feature seems important for planning of transfusion therapy in patients with ptha and ptka. aim: prevention results of loosen anastomoses on colon, with fibrin sealent (fs) application and influence on colagen production. materials and methods: investigations were done on rats, weight - g. in control group, after partial resection of left half of colons termino-terminal anastomosis was derivated. fs was applied in examined group. concentration of colagen was done indirectly, with quantitative l-hydroxyproline determination. place of anastomosis, cm proximal and cm distal of anastomosis, was analyzed iii, v, vii and xiii day postoperatively. results: analysis of hydroxyproline on the place of anastomosis showed higher hydroxyproline value in group with fs application. the highest approximate value of hydroxyproline was registered v day postoperatively. distal, cm of anastomosis, the quantity of hydroxyproline is higher iii day postoperatively in control group but v postoperative day value is intensively growing in group with fs application. electronic microscopical was done v postoperative day in control group at the place of anastomosis detected a defect with detritus and absence of larger colagen fibres. in group with fs application on the place on anastomosis, in the shape of bundle, colagen fibres were grouped and completely fills the place of anastomosis. conclusion: fs application accomplish higher concentration of colagen in all segments of isolated colon, that enables better healing of anastomosis. the study of the use of the safest blood (autologous blood transfusion) through preoperative blood donation (pbd) in surgery patients introduction: the use of the autologous blood is already under consideration in developed countries. thus, it is probable that autologous blood donation would be effective in one way or the other in reducing blood transfusion complications. in this study, pbd as the easiest method to use and the most cost-effective one was selected. aim of the study: it aims at improving blood safety and raising blood inventory. methods: in this study, patients, including males and females, intended to undergo elective surgery were selected as subjects to donate their autologous blood. the subjects with hematocrite level of about - percent as ordered by their physician donated their blood by this method. blood collection procedure was followed at - day intervals. the blood volume taken from patients in every collection differed from - ml according to their weight. results: this study showed that in all patients undergoing plastic, gynaecological, jaw, and ent surgeries autologous blood transfusion was used with no need for allogenic transfusion. in other surgeries, including orthopaedics, the need for allogenic transfusion was estimated to be at about percent of cases. to avoid the complications of allogenic blood transfusion, the safest way is the use of autologous blood which involves low cost and is easy to perform. the introduction: the purpose of this study is to describe a technique to perform labelling of autologous platelet-gel with in-oxine and to evaluate its usefulness, after in vivo graft implant, as a marker of bone osteoinduction by means of scintigraphy, in patients with jaws bone defects following the enucleation of cystic lesions and cystic lesion derived from extraction of deeply impacted lower third molar. methods: agp made. consent was obtained by patient to conduct hiv and hbv testing. briefly, cc to cc of blood is withdrawn from the patient. the blood was separated, by means of successive step of centrifugation, in to platelet-rich plasma (prp) , platelet-poor plasma (ppp), and red blood cells (rbc). the red blood cells were discarded. the prp [comprises of approximately % of the total blood volume withdrawn] had platelet counts of - /mm . the procedures of agp labelling were performed in laminar flow chamber. to seconds the solution will assume a gel-like consistency forming platelet gel. imaging: the scintigraphy was performed h after application of labelled agp (early scan) and at , , , h (delayed scan) by means of a gamma camera equipped with medium energy collimator. a later scan was performed at days after graft. the platelet uptake index (pui) was then calculated by dividing the cpm/pixel in the graft roi (recognized in and planar and trans-axial slice) for cpm/pixel in a mirror background roi. in vitro sampling: the radioactivity of the plasma samples collected at , h and at lapse time = h for days, were used for the plasma clearance determinations and for in vitro studies of the platelet loss from the gel. results: all patients presented early high concentration of in oxine agp, at site of the graft, that was easy recognized at scintigraphy performed as in anteroposterior and lateral planar projection of the jaw as in spet slices reconstructions. all labelled agp was well confined within area of original implant and no activity was seen in the surrounding tissues or in the distant organ. conclusion: all patients studied well tolerate the implant of agp; no adverse reactions were observed and follow up -performed months later -showed bone remodelling activity in the site of the graft. serial blood donations in a ko pregnant woman with the use of recombinant erythropoietin for intrauterine transfusions of severe hemolytic disease of the newborn due to anti-ku biweekly) were administered to the mother to ensure an adequate supply of compatible rbcs for intrauterine transfusions and possible perinatal haemorrhage as well. results: intrauterine transfusions were repeated every - weeks. by the th week of gestation the patient had donated four units of blood, her hematocrit was %, anti-ku titre was / and four intrauterine transfusions had been performed. cesarian section was decided and the apgar of the newborn were and at and min. the newborn was treated with phototherapy but without exchange transfusions and two weeks later he was discharged. by the th day of life rh-epo was administrated to him due to anemia. the maternal red cells completely disappeared from the child's blood by the day . the experience of the use of erythropoietin in pregnancy is minimal. as illustrated by this case treatment with rh-epo and iv fe has effectively increased mother's capacity to donate rbcs' for autologous use and intrauterine transfusions as well, with no adverse effects to the mother or the child. however, further research is necessary to evaluate if rh-epo crosses the placenta. introduction: blood components should be transported by a system which has been validated. the containers used for transport should be well insulated, some form of temperature indicator should be used to monitor the in-transit temperature. whole blood should be stored at different temperatures above °c. aim of the study: bags with whole blood collected in a collection site are transported in containers without active cooling. we tested temperature of blood in containers put into the extreme weather conditions (+ °c, - °c) during loading test for transport. methods: the container without active cooling was filled with the exact number of bags with blood and the exact number of passive cooling elements (frozen water cubes in plastic) placed in the exact positions without close contact with the blood bags. the bags with blood of the temperature + °c, + °c and + °c were used. temperature indicators were situated in the bottom, centre and top of the container. filled container was placed into thermostat (+ °c) or freezer (- °c). the temperature was observed in min intervals for three hours, first measurement was min after putting into freezer or termostat. results: (see table ) nt, non tested; tmp, temperature. in the table there are shown minimum and maximum temperature parametres observed during tested time including increasing or decreasing trend. conclusion: loading test for transport of the bags with collected whole blood helps us to optimize transporting system, especially number of cooling elements in relation to the season and its place in the container. in the light of presented data we corrected transporting system to maintain the recommended temperature during transport. background: since , we have produced pooled and filtered platelet concentrates out of four buffy coats in tsol platelet additive solution and have stored them in pall autostop clx bags made out of pvc/totm. the residual plasma content is between - %, the mean volume about ml and the mean platelet-content is . ¥ per unit. for pathogen inactivation or bacterial screening it is necessary to extent the storage time from to days. new foliage like polyolefin is supposed to maintain a good quality environment for prolonged storage of platelets. aims: storage bags made out of polyolefin (pall autostop elx) were tested to prove their suitability for prolonged storage of platelets. methods: twins made out of pools from buffy coats were produced with the standard method, one twin was stored in the conventional bag (cb) the other in the new foliage bag (nfb). the platelet pools were stored on flatbed shakers at °c, and sampled at day , day and day . ph, glucose, lactate, hypotonic shock response (hsr) and p-selectin expression were measured by standard in-house methods. results: mean ph on day with cb was . , with nfb . ; glucose with cb . mmol/l, with nfb . mmol/l; lactate with cb . mmol/l, and with nfb . mmol/l, hsr with cb %, with nfb %; p-selectin with cb % and with nfb %. the new platelet storage bag showed better results of in vitro quality markers, especially after day of storage. prolonging storage time will make it easier to introduce bacterial screening or pathogen inactivation techniques into platelet transfusion. the possibility to filter rbc either at °c or rt simplifies the preparation process. filtration at + °c enables to achieve a better leukoreduction performance. the nbs has successfully implemented this project which has the potential for improvement in patient safety and is predicated upon practical application and risk reduction rather than elimination. the impact of this work on the incidence of trali will require detailed, long term analysis of hemovigilance data using existing mechanisms. active communication, a team approach, perceived value of the initiative and the hard work of all staff involved were key success factors. quality assessment of buffy coat-derived platelets prepared from leucoreduced whole blood background: whole blood can be separated into; plasma, buffy coat and red-cell conc (rcc) by differential centrifugation and separation on a separation device. because of the high hematocrit of the rcc, % of the process time is needed for expression of the rcc. by increasing the internal diameter of the tubing at the bottom of a t&b system by . mm. a decrease of the process time is expected. methods: units of whole blood were collected with the new t 'wide boring' blood pack and separated on a routine base. quality control parameters were checked and the whole process time was monitored. free hemoglobine was measured up to days. results: process time of a 'wide boring' bag is significant shorter compared to a standard blood bag. average decrease: s. slightly increase in free hemoglobine is measured probably due to the increased express rate of the red cells. bloodproducts produced with the new t meet european guidelines. no significant increase of free hemoglobine due to the faster expression is measured. an significant decrease in process time is measured with the wide boring bloodpack. the new fresenius hemocare rcc in-line system: t can be used for routine production which will speed up the production process considerably. introduction: leukoreduction of blood components is required to prevent several transfusion-associated complications. aim: the aim of this study was the full process validation of the pall leukotrap wb system for the preparation of leukoreduced blood components. we collected whole blood units from donors suitable for donation using a quadruple blood-bag, which includes an wbf in-line filter (pall) for the removal of leukocytes and platelets. mixer balances (baxter) were used and donation occurred within min in all cases. after donation whole blood units were stored at room temperature for h. subsequently, whole blood filtration was performed by gravity at a standard height of cm using a blood leukoreduction cart (baby leuko cart, itl-corporation). filtered units were centrifuged at g ¥ min by an heraeus cryofuge i. an automatic extractor (bag press plus-bioelettronica) was used to prepare red cell concentrates in sag-m solution and fresh plasma units. air in the system was automatically expelled by the extractor. complete cell counts and hemoglobin concentration were evaluated in pre-filtration samples and at the end of the blood components preparation using an automated cell counter (pentra dx -abx). we enumerated residual leukocytes in red cell units by flow cytometry (becton dickinson-leucocount kit). results: pre-filtration data of whole blood and end-of-process data of red cell and plasma filtered units, are summarized in table . results are given as mean and standard deviation. whole blood filtration was completed within min in all cases. red cell units were transfused after a mean of days to patients affected from transfusion dependent ( %), post-surgery ( %), and post chemotherapy anemias ( %). no cases of transfusion reaction were observed. the pall leukotrap wb system was easily introduced in our setting. all blood components prepared by the system fulfilled the council of europe requirements with regards to hemoglobin content in red cell units and post-filtration residual leukocytes. future studies are needed to evaluate its cost-effectiveness in the setting of routine blood component preparation. background: during an evaluation of the compodock (fresenius hemocare) sterile connection device (scd), we observed irregularities on the inside of the tubing at the site of the weld. it was our aim to investigate the effect of these observations on the quality of blood products. methods: three leukoreduced red cell concentrates (rccs) were pooled and divided over bag systems: one without weld in the connecting tubing, one with a compodock-weld, and one with a weld made with the terumo scd. the rcc was transferred times over this tubing to have maximum result if the weld had deleterious effects. the rccs were stored in pvc containers, and sampled on day , , and , and free hemoglobin (hb) was measured. the same procedure was also performed using platelet concentrates (pcs), but these were stored in polyolefin containers, sampled on day , and , and cd expression was measured. ten experiments were performed per blood component. according to who standards processing of blood into labile components are considered an expression of quality of transfusion service. in our practice, modern transfusion principles are successfully applied. they cover blood collection, serological processing of blood units, technological preparation of blood products (gmp, sop) and rational utilization of blood components and blood derivatives. in the past four years ( , .) aberrations from these principles have taken place (self-sufficiency). nbti collected x = ( ) blood units into blood bags. in serbia x = ( ) blood units. retrospective analysis: ldpc-bc was administered x = % with the satisfactory haemostatic effect. increase of the cyta and plasmapheresis-manual procedures was also noted ( %). increase of the use of leukocyte poor red blood cells was also registered ( % introduction: according to the relevant recommendations of the council of europe, whole blood is a source material used for the preparation of blood components and blood products. basic concept of the therapeutic use of blood components is the compensation of the lacking or deficient blood component. in that way, a possibility of the infusion of unrequired or deleterious components of whole blood is eliminated. objective of this presentation is to analyze the reasons of non-utilization of certain blood units, the actual quantity and ratio. aim of the study: the purpose of our in vitro study is to compare storage of platelet concentrates at °c with platelets stored at °c, and to determine the in vitro-effects of pre-incubation at °c for h prior to analysis on the basis of the maintenance of platelet metabolic and cellular integrity. methods: platelets concentrates (pcs) were prepared from pooled buffy coats (bc) for paired studies to be stored into different conditions. (i) at - degree on a flat bed agitator; (ii) at - degree on a flat bed agitator and pre-incubated for h prior to analysis; (iii) at °c; and (iv) at °c and pre-incubated for h prior to analysis. this paired in vitro study (n = ) over days include volume, platelet counts, mpv, volume, ph, po , pco , bicarbonate, glucose, lactate, swirling, leucocytecount, hsr, esc, atp, ldh and release of a-granule content (rantes, ß-thromboglobulin and pf ). results: platelet count (day and ; p < . ), mpv (day ; p < . ), ph (day and ; p < . ), pco (day and ; p < . ), bicarbonate (day ; p < . ), glucose (day , , , and ; p < . ), atp (day and ; p < . ) was significantly higher in platelets stored at °c and platelets stored at °c with preincubation. ldh (day ; p < . ), bicarbonate (day and ; p < . ), lactate (day , , , and ; p < . ), ph (day and ; p < . ), esc (day , , , and ; p < . ), hsr (day , and ; p < . ) was significantly lower in platelets stored at °c and platelets stored at °c with pre-incubation. the concentration of rantes, ß-thromboglobulin and pf was significantly higher in platelets stored at °c than in platelets stored at °c (day , , , and ; p < . ). hsr (day and ; p < . ) and esc (day , , and ; p < . ) was significantly higher in preincubated platelets stored at °c compared with platelets stored at °c. conclusion: platelets stored at °c maintain metabolic and cellular characteristics to a great extent during days of storage. we confirm the loss of platelet discoid shape and have shown that loss of discoid shape in platelets stored at °c is associated with decreased metabolic rate and decreased release of a-granule content. aim: as reference centre of the swiss blood transfusion service for new materials and blood products we evaluated that system for routine use and official registration in switzerland. method: whole blood donations were collected in a whole blood filtration set with cpda- and stored at room temperature for h before filtration at room temperature. the leucodepleted whole blood was stored for days. following parameters were analysed on day , , : free haemoglobin in%, k. in addition leucocyte count was performed on day and a blood culture on day (see table) . blood cultures on day remained negative and all counts of residual leucocytes were below ¥ (exponential) /unit. summary and conclusion: as expected there was a clear increase in k and free haemoglobin after day . however the results were within the required specifications from the european and swiss guidelines up to day . we conclude that autologous leucodepleted whole blood can be stored in cpda- -for days without loss of stability of the red cells. we will introduce the system to the offi-cial material list of the swiss blood transfusion service and then implement the procedure to our daily routine. results of ffp production from whole blood, and of ffp and pc produced by use of cell separator over a -month period before and after the introduction of measures for trali prevention are presented. the following measures were undertaken: ( ) blood of female donors was not used for ffp production, and plasma was only used for fractionation ( ) plasma of female donors was not used for kt-bc pools ( ) platelets and plasma were produced on a cell separator only from the female donors without a history of pregnancy. female donors of whole blood: %*; %** ffp produced by plasmapheresis: %*; . %** female donor units on cell separator: . %*; . %** ffp from total plasma units: %*; %** plasma units used for bc-pc pools: %*; %** *period before and **after the introduction of measures for trali prevention the exclusion of female donors had no major impact on the production of ffp and bc-pc pools from whole blood because of the very low rate of female subjects in the croatian blood donor population. the amount of plasma and pc collected from female donors by use of cell separator was significantly lower (~ %), however, without any major impact on total ffp store because of the small rate of plasma and platelets obtained by apheresis. background: platelet concentrates (pcs) are currently stored for a maximum of days. extended storage to days would increase the supply and reduce the waste of pcs. transfusion-associated graftversus-host-disease (ta-gvhd) is a severe transfusion reaction caused by t-lymphocytes in the transfusion product. the risk of developing ta-gvhd can be prevented by gamma irradiation of the pcs. various in vitro tests can be used to study the quality of pcs such as inspection of the swirling phenomenon, hypotonic shock response (hsr), detection of platelet surface markers (e.g. cd p and cd b), metabolic parameters and blood gases. free oscillation rheometry (for) using the instrument reorox® can be used to monitor the coagulation over time in whole blood, pcs and plasma samples, and to obtain information about clotting time and coagulum elasticity. aim of the study: the purpose of this study was to evaluate the quality of pcs obtained by apheresis technique during storage for days and to study the effect of gamma irradiation by using several in vitro methods including for. methods: platelets were collected from healthy donors (n = ) using apheresis technique. the pc from each donor was divided in units, one served as control and the other was gamma irradiated with gy. the pcs were stored on a flatbed agitator at °c for days. samples were taken on day (= day of collection) for analysis of blood gases, metabolic parameters (glucose and lactate), platelet count and swirling. samples taken on day , and were also analysed for hrs, cd p (p-selectin) and cd b (gpib) expression utilising flow cytometry. evaluation of coagulation by for was performed on day , and . the maximum elasticity (g'max) and the time to g' were evaluated from the for elasticity curves. results: there was no difference between irradiated and nonirradiated pcs regarding any of the tested parameters during the storage period. swirling, hsr, platelet count and percentage of cd b expressing cells were well maintained for days of storage. glucose decreased and lactate increased significantly during the storage period, from . mmol/l to . mmol/l for lactate and from . mmol/l to . mmol/l for glucose. the percent cd p expressing cells increased significantly during storage from % on day to % on day . po was well maintained but ph increased and pco decreased significantly between day and whereafter ph decreased and pco continued to decrease. the for parameters g'max and time to g'max increased significantly between day and and the time to g'max continued to increase significantly between day and . the results indicate a well preserved platelet quality after storage for days. gamma irradiation did not affect the platelet quality. cytokine release during storage of buffy coat platelet concentrates produced manually and automatically background: transfusion reactions following platelet transfusion are still a problem even when leukoreduction is included in the production process. platelet derived cytokines released during storage upon activation or lysis, accumulate in the platelet products and have been suggested to be involved in transfusion reactions. rantes (regulated upon activation, normal t cell expressed and presumably secreted) is a chemokine playing an important role in the inflammatory immune response and causes degranulation of eosinophiles and release of histamines from basophiles, which again can cause allergic reactions. tgf-b (transforming growth factor b ) has been shown to be immunosuppressive, inhibits the proliferation of t-and b-lymphocytes and decreases the secretion of igg and igm from b-lymphocytes. aims: as part of our quality control program, we aimed to quantify the amounts of rantes and tgf-b released during storage in platelet concentrates produced from pooled buffy coats by our manual routine method (m-pcs) and by an automated method using the orbisac system (gambro) (a-pcs). methods: pcs were produced from buffy coats. following overnight storage at - °c, buffy coats were pooled with ml t-sol (baxter). forty-two pcs were produced either manually (n = ) using the imugard iii s-pl set (terumo) with integrated soft leuko-reduction filter or by the automated procedure (n = ) using the orbisac validation bc set (gambro) equipped with the lrp leuko-reduction filter (pall). swirling was scored visually, platelet count and mpv were measured on a cell counter (cobas argos, roche), and blood gas analyses, glucose as well as lactate were measured on an abl series analyser (radiometer). samples for testing of cytokines were centrifuged for min at g, °c; supernatants were harvested and frozen at - °c until analysis. cytokines were quantified using quantikine human rantes immunoassay (r&d systems) and human tgf-b elisa immunosorbent assay (bender medsystems gmbh). all analyses were performed on days , and . results: platelet concentrate volume (mean): m-pcs: ml, a-pcs: ml. platelet yield was found to be . ¥ for m-pcs and . ¥ for a-pcs (p < . ). in all pcs ph levels were between . - . . glucose consumption and lactate production from days - and days - did not differ significantly. rantes levels (pg pr plts) were significantly higher in a-pcs than in m-pcs (p = . , repeated measures analysis of variance), but no significant difference was found in tgf-b levels (pg pr plts). summary and conclusions: preparation of buffy coat platelet concentrates by the automated orbisac system improves platelet yield compared to our manual processing procedure, but the levels of the chemokine rantes were significantly highest in the automatically produced products. the clinical importance of these findings is still unclear, but may be related to the shear stress the platelets are subjected to during the automated production process. the quality of cryopreserved vs liquid stored platelets: a comparative study table . the mismatches can be divided into the two categories. the first of them is characterized by differences in allelic groups, i.e. at low-resolution level. allelic group differences were detected in the group with one mismatch, most of them in hla-c locus (this locus was not concluded in primary donor search). in the other category there are differences in alleles within the same group, i.e. at high-resolution level only. differences within the same group in all tested loci were detected in the group with one mismatch. the mismatches described above were heterogeneous and a correlation of specific mismatch with transplantation outcome was not possible in this group. conclusion: the use of high-resolution dna methods makes the identification of hla match/mismatch more accurate and can affect the outcome of unrelated hsct. this work was supported by the grant iga mz, no. nr/ - . pre-freezing and post-thawing quality controls in umbilical cord blood assigned for transplantation p bergamaschi, c perotti, g viarengo, c del fante, c parisi, a marchesi, l bellotti and l salvaneschi irccs policlinico 'san matteo', pavia, italy background and aims: nowadays umbilical cord blood (ucb) represents a well established source of haematopoietic stem cells for unrelated transplantation in children affected with haematological and inherited diseases. thanks to the large-scale banking of unrelated units and the preliminary encouraging results, ucb employ in adults is quickly growing up. in this context, total nucleated cells (tnc) count of the graft is considered the main predictor for clinical outcome; however, other indicators of the haematopoietic potential, such as cd + cell content and short-term culture clonogenic assay, are recommended in accordance to netcord-fact stan-dards. in order to guarantee the safety and the prompt availability of a ucb unit assigned to a matched recipient, a pattern of rigorous quality controls should be carried out not only at the time of cryopreservation but also before the release for transplant. we report the results of the quality controls performed on thawed cryovials referring to the units delivered by our ucb bank compared to the pre-freezing values. methods: every ucb unit stored in our bank is accompanied by satellite cryovials available for subsequent controls. for each unit issued for transplantation, one cryotube was thawed in °c water bath with gentle agitation without washing out dmso. tnc and mononucleated cells (mnc) were estimated by an automated cell counter; viability and cd + cell count were evaluated by flow cytometry with a no-wash, single-platform technique and aminoactinomycin d. cfu assay was performed using commercial reagents (methocult gf h , stemcell technologies) and colonies were counted after days. the same tests were performed before cryopreservation, taking a sample from each fresh unit. moreover, before the delivery for transplant, a second cryotube was thawed to investigate the bacterial contamination by direct microbial culture, whereas the sterility test before freezing was performed by inoculum into ml media (bact/alert®fa/fn, biomérieux inc). results: the ucb characteristics before freezing and after thawing are detailed in the tables , and . post-thawing tnc and mnc, as well as cd + cells, showed no significant difference in comparison to the pre-freezing values. despite of the expected decrease of the overall viability after thawing, we observed a highly satisfactory viability referred to the cd + cells. the colony forming units (cfu) growth after thawing was documented and was always lower as respect to the pre-freezing assay. finally, the results of microbial cultures were negative for all the units on both fresh and thawed specimens. conclusions: in our experience, well standardized evaluation of ucb content could be obtained with regard to tnc, mnc and cd + cell. concerning the results of short-term cultures, the presence of dmso as inhibiting factor may be advocated to explain the discrepancies between fresh and thawed samples. finally, rigorous quality controls documented that the procedures of manipulation and cryopreservation did not affect the quality of ucb to be infused for transplant and provided to the physician all the parameters necessary for a safe transplant in a close and appropriate time. bone marrow transplantation or bmt transplantation of progenitor blood cells to regenerate blood normal cells in patients with blood disorders. bone marrow has an organized and structured architecture in which close relationships exist between a regulatory microenvironment and primitive hematopoietic cells. in fact, normal hematopoietic cells depends on critical interactions that occur between stem cells and their microenvironment. this microenvironment is a complex meshwork composed of growth factors, stromal cells, and extracellular matrix. marrow injury can occur as a consequence of a variety of diseases. some diseases could be due to a microenvironment that fails to support hematopoiesis. a possibility is that aplasia and leukemia share a common etiology such as drug, chemical, radiation, virus or other environmental hazards. we can say that microenvironmental abnormalities in interactions between stromal cells and hematopoietic progenitors may be important in the pathogenesis and clinical expression of hematopoietic malignancies in humans. background: intrauterine growth retardation, with associated low birth weight, represents one of the most important cause of baby mortality and morbidity. understanding the genetic bases of this adverse event is still an open goal. there is evidence that motherchild hla compatibility and hla-drb foetal genotype are associated with a reduced placental growth and a low birth weight. the recent institution of cord blood banks, with their huge amount of hla types, offers an unique opportunity to look inside the molecular bases of normal birth weight. aims: we investigated whether the baby-linked immunogenetic profile, i.e. hla gene frequencies and homozygosity rate, affects the physiological variance of the size at birth. methods: cord blood units ( from males and from females) were hla typed with pcr-ssp and/or reverse pcr-sso techniques and recorded in the cord blood bank database of pavia-italy. all were defined at low resolution level for hla-a and b genes and at high resolution for hla-drb . blood units were also randomly typed for hla-dqa and dqb at high resolution. results: mean birth weight was g and mean relative birth weight (i.e. corrected for gestational age according to the gender) was . g. babies were < th centile ( g) and were > th centile ( g). comparing the hla allele distribution in these extreme bands we found that hla drb * was significantly associated with high relative birth weight: . % in th centile vs . % in th centile, p = . . on the contrary, hla-drb * and dqb * were associated with low relative birth weight: . % and . % respectively in th centile vs . % and . % in th centile p = . and p = . . all infants were analysed as to the effect of the above mentioned alleles. we confirmed the positive association of hla-drb * and higher relative birth weight (mean . vs . ; p = . ) as well as the association of hla-drb * with lower relative birth weight (mean . vs . , p = . ). no significant association was found as far as hla homozygosity was concerned. conclusions: the present findings confirm the role of foetal hla-drb gene in the intrauterine growth. about the specific involved alleles, one possible explanation comes from the studies of crystallography and amino acid sequencing of hla-dr binding groove. it has been demonstrated that hla-drb * and hla-drb * genes encode for different amino acid sequences in the pocket of the molecule (aa , , ). this implies distinct functional restriction patterns. the sequence motif of hla-dr is characteristic of some autoimmune conditions, such as hashimoto's thyroiditis, and preeclampsia which is associated with intrauterine growth retarda- which provides a high yield and excellent purity without lymphocyte and erythrocyte contamination. in a month period, we studied blood samples from bone marrow transplant patients and from normal subjects. the extraction of leukocyte polymorphonuclear was obtained with a %- % dextran solution in . % saline. after incubation at room temperature with lymphopre solution, the mixture was centrifuged. two clear and separate rings of mononuclear and pmn leukocytes were obtained. to eliminate any red blood cells, pmnl ring was separated and washed three times with cold ammonium chloride. after a short period of incubation °c, mixture was centrifuged and the pmnls were isolated. the purity and viability of total leukocyte population was counted and the percentage of pmnl obtained was established. the total blood samples studied were divided in two groups, i.e., bone marrow transplant patients and normal subjects. in both cases the pmns isolated were of high purity and viability. the overall percentage of pmnls obtained from both groups under study was % to % when stained with gimsa or wright staining method. the viability of isolated pmnls was also % too, which is excellent for numerous immunological or molecular studies. the pmnls isolated by this method were highly pure and viable in comparison with standard methods used to isolate human pmnls. generation a high amount of pmnls is another advantage of the suggested method. this method to separate pmnls is recommended for in vitro studies of different subjects. et al. .) the object of exchange transfusion (et) is to remove bilirubin already present in the plasma or remove alloantibody which can cause hemolytic disease (in order anti-d, anti-c and anti-k are easily the most important) or remove anti-d positive red cells. we have studied exchange transfusion in our hospital in neonatal intensive care unit, during to . at delivery cord samples were taken for determination blood group, rhesus, hb and ht have been counted. also direct antiglobulin test (dat) has been performed. in cases of positive dat, hb and bilirubin levels were monitored. newborn body-weight were weighted (ranged g to g). the blood for et was of group o, d negative and kell negative and was compatible with the serum of mothers; it was less than days old. the blood was screened for hbs and for anti-cmv as well as being submitted to all usual tests. the method has been determined by using the umbilical vein; the multi-way tap makes it possible to draw blood from the infant into the syringe, to discard the blood into a sterile empty vessel, then to draw blood from a donor unit into the syringe and inject this into the infant. results: exchange transfusions were carried out. four out of et due to abo incompatibility mother-newborn. five out of due to rhesus incompatibility mother-newborn and eight out of due to jaundice undetermined origin and immaturity. the last two years only three et were carried out due to immaturity. conclusions: phototherapy, when applied early enough and with sufficient intensity, can avoid the need for exchange transfusion in many infants. phototherapy alone or phototherapy plus high dose igg therapy has been used to minimize exchange transfusions in this population. detection abo blood group system antibodies of neonatal using fully automated column agglutination technology (auto-vue) background: the abo blood group system remains the most important in transfusion practice. this is because of the regular occurrence of the antibodies anti-a, anti-b and anti-a, b reactive at °c, in persons whose red cells lack the corresponding antigens. the regular presence of anti-a and anti-b is used in the routine determination of abo blood groups; in addition to testing red cells for a and b antigens, the group is checked, in serum or reverse grouping, by testing the serum against red cells of known abo groups. methods: samples were taken from newborns at first h of life for abo blood group typing during - . simultaneously the presence of anti-a and anti-b antibodies has been studied using fully automated column agglutination technology (auto vue ortho diagnostic systems) with bio-vue cassettes aborh/reverse. the column agglutination technology is based upon the ability of glass beads to form a physical barrier between agglutinated and unagglutinated red cells. to determine the abo serum group, test serum and abo reagent red cells were added to the top of column containing diluents. the abo grouping columns were centrifuged and examined for agglutination. the presence or absence of agglutination has been recorded. results: in out of newborns were found detected antibodies anti-a, anti-b. in out of newborns no antibodies were found. in out of were found antibodies maternal origin. the automated reader detected all positive reactions. positive results were recorded on a scale from + . to + . conclusions: the technical performance of device allows objectivity and precision to detect abo blood group antibodies of newborn. the origin and the type of antibodies and also factors that influence their presence are to be studied. introduction: diagnosis, management and prevention of red blood cell immunization have improved, so hemolytic disease of the newborn (hdn) has changed from a common to a rare pathology. aim of the study. in this study we have retrospectively evaluated the benefits of the immunohematological screening for the management of pregnancies with alloimmunization. methods: in the last years, we have performed an immunohematological screening on all pregnant women assisted by our hospitals. ab and rh typing, antibody screening and, eventually, identification and titration were performed on maternal specimens by microcolumn technique. results: not considering ab incompatibilities, we have discovered alloimmunized women with the following specificities: anti-d, anti-c, anti-c, anti-e, anti-jka, anti-d + anti-jka, anti-d + anti-s, anti-d + anti-c, anti-d + anti-c + anti-k, anti-s, anti-k, anti-m, anti-c + anti-e and anti-d + anti-c + anti-g. the most severe hdn were the d + c + g, the c + e and out of c newborns, with mean hemoglobin between and g/l, bilirubin = . g/l, reticulocyte count = %. in these exchange transfusion needed at the delivery. other newborns were only treated with phototherapy. conclusion. thanks to the immunohematological monitoring, the diagnosis of alloimmunization, the correct management of pregnancy and the adequate neonatal therapy were possible. in fact all newborns survived and showed no neurological lesions in the following controls. conclusion: in order to provide a highly specialized perinatal care, immunohematologist, obstetric and pediatric should provide a good antenatal and perinatal screening. this is an interesting case of rhd immunisation in rhd negative woman despite the application of rhd immunoprophylaxis. case report: a blood sample of pregnant woman, years of age, in th gestation week, was sent to our laboratory for serological analysis. her blood group was o, ccddee and she had an anti-d antibody reactive only with enzyme treated panel of test erythrocytes. her husband was a, ccdee, and two children were both a, ccddee. on the next visit, she gave the data of one arteficial and one missed abortion before the th gestation week covered with mg of rhd immunoprophylaxis, but without the measurement of fetomaternal haemorrhage (fmh). both of abortions were after the deliveries. until the end of the pregnancy, detailed serological analysis showed anti-d specificity of antibody in her sera which remained reactive only with enzyme treated red blood cells. the fetus was under permanent ultrasound control. she delivered a mature, rhd positive, ccdee male child, without any sign of haemolytic disease. the proper personal history, measurement of the size of fmh, distinguishing the anti-d and anti-g specificity of the antibody, administration of rhd immunoprophylaxis and cooperation between transfusion medicine specialists, gyneacologists and neonatologists still remain major principles of prenatal and perinatal care concerning haemolytic deisease of the fetus and newborn caused by anti-d antibody. anti d antibody, reactive only with enzyme treated red blood cells is usually harmless for fetus and the newborn. introduction: red blood cell (rbc) transfusion is widely used in neonatal intensive care units for acute or chronic pathological conditions. clinical indications for rbc transfusion are shock, sepsis and/or anemia with the following laboratory criteria: a) hematocrit (hct) < % or hemoglobin (hb) < g/dl and reticulocytes < %; b) hct < % or hb < g/dl in these conditions: o required < %, recurrent apnoea and bradicardia, cardiac rate > bpm and respiratory rate > bpm for more h; c) hct < % or hb < g/dl with severe respiratory distress. aim of the study. aim of this study has been to evaluate the effectiveness of rbc transfusion therapy in premature and at term newborns independently of initial pathological conditions. methods: our therapeutic objective has been to achieve an hct of % after the whole cycle of transfusion therapy. for each little patient, the volume of transfused rbc unit has been calculated, according to international guide lines, using the following criteria: weight (kg) ¥ blood volume ( ml per kg if premature or ml per kg if at term newborn) ¥ (hct desired -hct observed)/hct of unit transfused. particularly we have considered that premature infants (with a gestation age of - weeks) show a range of weight from to . g, while at term newborns from . to . g. in order to avoid a circulatory overload, the indicated hemocomponent has been always packed rbc with higher possible hematocrit. for the same reason, the rate of infusion has been always - ml/kg/hour. methods: this is a descriptive study. the name of the neonates who received transfusion was obtained from the blood bank of beheshti hospital. information concerning the type of blood product, frequency and indication of transfusion, sex, gestational age and weight of infants was recorded in questionnaire and analyzed. results: out of neonates admitted during one year, ( male, female) received blood components. fifty four percent received one, % two and % received three types of blood components. the frequency of transfusions were times. the most common used blood products were fresh frozen plasma ( %), red blood cell ( %), whole blood ( %) and platelets ( %). all the blood products except whole blood were used more common in premature and low birth weight infants. appropriateness of transfusion of red cells, fresh frozen plasma, platelets and whole blood were %, %, % and % respectively. (hdn) . in accordance to current regulations, this study is carried out in all pregnant women attending in our service. according to our protocol, when an alloantibody of any specificity is detected through the liss-coombs gel technique, the same determination is made using papain-treated screen cells to detect any association with other antibodies which could be of clinical relevance for a hdn. there are scientific evidences that the use of enzymatic techniques increase the test's sensitivity, though clinical relevance of 'enzyme only antibodies' may be questioned. aims: demonstrate the importance of a routine identification of irregular antibodies in pregnant by two methods (liss-coombs -enzymatic) and the prevalence of anti-d associated antibodies, only detected by using enzymatic technique. analyze the need to carry out a follow up of sensitized patients to determine if the associated antibodies only detected with in an enzymatic medium can be detected with a liss-coombs medium during pregnancy, thus acquiring clinical significance for hdn. materials and methods: between january and december we studied d-negative pregnant women. the studies performed were: abo grouping, d and weak d, rh phenotype, direct antiglobulin test and irregular antibody detection (iad) against commercial screen cells with liss-coombs (diamed) ® gel-medium technique, according to the manufacturer's specifications. when iad were positive, an antibody identification using two commercial cell panels with gel techniques (liss-coombs-enzymatic) was performed. along the pregnancy, periodic controls were carried out to determine the exact moment when antibodies, previously only identified in an enzymatic medium, could be detected in a liss-coombs medium (clinically significant antibodies). results: out of d-negative studied samples, ( . %) had a positive dai and it was only showed anti-d specificity in a liss-coombs medium. after analyzing this specificity against enzymetreated erythrocytes, it was possible to determine that patients ( . %) had in their serum other anti-d associated alloantibodies: anti-k ( . %), anti-c ( . %), anti-e ( . %) and anti-c + e ( . %). during the immunohematologic follow up, it was determined that in / patients some of the antibodies which were previously only detected in an enzymatic medium, could be identified in a liss-coombs medium and later they were identified in the red cell elution of the newborn. conclusions: these results confirm the relevance of a screening for irregular antibodies of clinical importance by means of a conven-tional technique and one of increased sensitivity in all pregnant women. the detection of an association of antibodies provides information for the undertaking of diagnostic and therapeutic measures, both by the obstetrician, as for any eventual transfusional requirements for hdn. it was also concluded that, although antibodies detected in an enzymatic medium are considered of low clinical significance, its investigation and follow up is suggested in pregnant women to determine the moment in which they can be detected in an antiglobulinic medium, thus revealing their clinical significance. background: fibrin glue is one of the most complex human plasma derivatives both in terms of composition and clinical applications. this product mimics the last step of coagulation cascade through activation of fibrinogen by thrombin, leading to the formation of a fibrin clot in the presence of factor xiii. in contrast to synthetic adhesives, the significant advantage of this plasma-derived sealant is its biocompatibility and biodegradability as well as the fact that it does not induce inflammation, foreign body reaction or extensive fibrosis. readsorption of the fibrin clot is achieved during wound healing within days/weeks following application, depending upon the type of surgery, the amount and type of product used or the proteolytic activity of the treated site. the risk of virus transmission by commercial fibrin glue products is still debated and investigators are looking for alternative fibrinogen sources. many of these studies rely on autologous on single donor cryoprecipitate as source of fibrinogen. aims: the aim of this study was to compare single and double methods of cryoprecipitation of fibrin glue. the influence of different plasma preparation methods and plasma storage temperatures (- °c and - °c) on the quality of fibrinogen concentrate was examined. methods: whole blood was collected by standard phlebotomy technique and centrifuged at ¥ g for min within h of collection. plasma was removed. four units of plasma were pooled into a ml bag, mixed, divided into parts (aprox. . ml) and immediately frozen. two of these units were stored at - °c and units of ffp at - °c. after one month the plasma was thawed at °c during - h. the fibrinogen concentrates ( - ml) were received by single and double cryoprecypitation. to compare single and double methods of cryoprecipitation, the levels of fibrinogen, fibronectin, plasminogen and factor xiii were determined. results and conclusion: the levels of fibrynogen were significantly higher in fibrynogen concentration obtained by double cryoprecypitation from plasma stored at - °c. there were no significant differences in the level of plasminogen in both tested groups. double cryoprecipitation of a single unit of plasma (stored - °c) is an efficient, simple and safe method of obtaining fibrin glue. background: talking about professional risk we generally consider the risk of acquiring some kind of infective disease through accidental injury. in this article i would like to point out another side of the problem-the risk of making preventable medical error. with all its consequences. aim: how blood transfusion errors are among the most serious types of medical errors, the final goal is to initiate nationwide, regular, mandatory error reporting. information obtained, distributed and openly discussed at professional meetings will contribute to improving the patient safety. at the same time it would contribute to avoidance of blaming and shaming of many health care providers. prevent what preventable could be! method: retrospective analyze was conducted at the middle size blood transfusion center ( donations per year and utilization of approximately of components). results: after clearly distinguishing adverse events due to underlying patient condition from preventable medical error we fined out that: -great majority of adverse events resulted from medical error -every part of blood transfusion center, from blood donation ward, through laboratory testing to component issuing has it' weak points' or vulnerable places -any educational level is equally liable to error there is no significant difference about occurrence time: -working day/holiday -emergency/routine request -routine h/out of routine h -main error cause were as follows: -donor sample misidentification -rhd typing error -abo typing error -incorrectly performed cross match -recipient misidentification -wrong component prepared -sample confusion during freezing preparation conclusion: the truth incidence of transfusion medical errors is underestimated. mandatory report of fatal or 'only' harmful errors to the referent institution and its periodical announcement is the step ahead in preventing errors. those reports should be discussed at professional meetings (not at the 'yellow pages') and served as educational tool. but, as the most of the errors are system related, the key to reduce them is to focus on improvement of the system and nil for plasma. wastage rate was highest for plasma components. the influence of local practices on such discarding and whether avoidable shall be discussed. audit for blood discarding and corrective actions to minimize discarding is essential for all transfusion services and blood centers. designed technical and economic support. options include importing finished products and/or procuring products made from locally collected plasma. one approach is to consider local fractionation of plasma by building and operating a plasma fractionation facility, which may produce, finished products, or may produce intermediate products that are further manufactured in another facility. an alternative approach is the implementation of a plasma fractionation program where local plasma is sent to an established fractionator, and the plasma is fractionated following preagreed terms. the end products are returned to the country of the plasma supplier. in the national center for the production of blood products was established, under the direction of elias politis and years later in begun the production of dried plasma from greek donors. by the year the center started the production of fibrinogen and by the year the production of antihaemophilc factor. in all the activities of the center settled down due to administrative aspects. at the beginning of s a contract fractionation program was instituted (under the direction of k. sofroniadou) concerning the fractionation of liquid plasma and production of albumin, which by the end of year stopped and was replaced with a new contract for the fractionation of source plasma and the production of albumin. the challenge of adapting to the new and more stringent regulations governing the manufacture of blood products was great and brought a lot of changes in the structure of our center. a new bar-coding system ensuring the traceability of blood donations was instituted together with complex software for packaging and preparation of plasma shipments to the fractionation center together with all necessary paper work. a close collaboration with the medicines regulatory authority in order to be able to fulfill all the requirements that regulate issues associated to the quality and safety of human derived medicinal products. collaboration with blood collection establishments was promoted in order to increase the amount of plasma produced. there is a continuous effort from all the implicated parts in order to follow defined quality assurance procedures as highlighted by international guidelines for the blood donor selection, collection procedures, testing methods, donation handling, storage and transportation of plasma. the plasma contract fractionation program may serve, as an initial step prior to switching production to a locally built facility. this lapse of time may be used to expand the plasma collection potential, and to permit appropriate design, qualification and validation of the facility as well as training of local personnel. background: fibrin glue became a reality in the early s, when techniques for the isolation and concentration of clotting factors were improved. in , matras et al. described successful application of fibrin glue for peripheral nerve repair. this encouraging report prompted the use of fibrin glue in wound closure, skin grafting and bone union of osteotomies. the fibrinogen component of fibrin glue is produced from single unit donations of fresh frozen plasma. such procedure helps to reduce the risk of transfusion transmitted infections encountered by exposure to pools from large numbers of donors or by use of fibrinogen prepared from autologous blood prior to surgery. the second component, a mixture of thrombin and cacl , is commercially available. thrombin is applied to the operation site simultaneously and in equal volume to the fibrinogen but from a separate syringe. there are many methods of fibrinogen concentrate preparation but none of them has been described in detail. aims: the aim of this study was to choose/select the most effective, simple and safe method of obtaining fibrinogen concentrate (basic component of fibrinogen glue) which would also be easy to prepare in blood transfusion centers. methods of precipitation of fibrinogen by polyethylene glycol (peg), ammonium sulphate, ethanol or cryoprecipitation were compared. methods: plasma was obtained after centrifugation ( ¥ g for min) of whole blood. four units of plasma were pooled into a ml bag, mixed, divided into parts and immediately frozen. one of them was stored at - °c and after one month the plasma was thawed at °c during - h. fibrinogen was obtained by cryprecipitation and each of the three remaining units was precipitated with ethanol, peg and ammonium sulphate. the levels of fibrinogen, fibronectin, plasminogen and factor xiii were determined in each fibrinogen concentrate. results and conclusion: the level of fibrynogen ratio in fibrinogen concentration, obtained by peg and ammonium sulphate was significantly higher. cryoprecipitation is a simple, economic and reproducible procedure with the advantage of being performed in a closed system. plasma fractionation program in greece: an unknown history the provision of safe and sufficient plasma derivatives to meet the needs of local population requires special consideration and a well- (light cycler, roche diagnostic systems, nj) was used for the identification of the c y, h d and the s c point mutations of the hemochromatosis gene, and were based on protocols developed, for c y by the unidad de medicina molecular (ingo, santiago de compostela, espanha), and for the other two mutations by bolhalder m et al. the primers and probes were designed by tib molbiol (berlin, germany). results: the analysis of the percentages of genotypes and allele frequencies of the hemochromatosis gene mutations are described in the table. no differences were found between the patients and the controls. when we compared subgroups of patients based on their hepatitis c genotypes, a higher value for the c y allele was obtained ( . %) in individuals with genotype , however without statistical significance. discussion: hereditary hemochromatosis is a common disorder and is associated, in some studies, with a worst prognosis in patients with viral hepatitis. follow-up studies are necessary in order to evaluate if the presence of these mutations can cause a more severe course of the illness (greater risk to develop fibrosis or cirrhosis) and a different outcome when treated with antiviral drugs. also, it will be important to evaluate if aggressive phlebotomies will modify their clinical evolution. introduction: portugal has a higher prevalence of viral hepatitis, with probably more than . patients chronic infected with hepatitis b and/or c. hereditary hemochromatosis (hfe) is one of the most common causes of known hereditary illnesses with hepatic repercussion. hfe mutations are also found in linkage desiquilibrium with particular hla haplotypes, conferring, eventually, a different response to viral agents and antiviral drugs. in this study we evaluated the prevalence of the main mutations c y, h d and s c for the hfe in a population with chronic hepatitis b and/or c and in a cohort control. background: haemolytic disease of the newborn (hdn) is the destruction of the red blood cells of the fetus and neonate by antibodies produced by the mother. although postpartum rhig prophylaxis reduced the incidence of alloimmunization from pregnancy from % to - %, the doubt subsists if it is appropriate to use it as routine antenatal prophylaxis. material and methods: a total of samples ( mothers and newborns), from / / and / / , were studied. all abo, rh typing, antibody tests and dat were carried out in column agglutination tests. results: from the cases studied it was found cases without incompatibility ( %). from the incompatibilities, . % were abo, . % were rhd, . % were other rh incompatibilities, and . % were due to auto-antibodies. % of the mothers were rhd+ and % rhd-. conclusion: of the pregnant women studied, only were rhd-. from this group ( %) delivered rhd-newborns, what revealed that the antenatal prophylaxis they were submitted was unnecessary. from the pregnant women rhd-, % had incompatibility abo, which decreases to near % the risk of development of rhd immunization. being anti-d immunoglobulin a product that has the potential risk of infection transmission, is it appropriate to use indiscriminately as a routine antenatal prophylaxis? the introduction of molecular methods to determine the fetal rhd genotype could rationalize the use of antenatal anti-d immunoglobulin prophylaxis. introduction: the frequency of hla a haplotype expression has been found about - % in caucasian and in greek population particularly, . %. because of the high frequency, it is used widely in anticancer immunization. the immune system plays an important role in the defense against neoplastic disease and immune response show temporal chances related to circadian variation of antibodies and total lymphocytes in the peripheral blood. aim: the probable difference in the frequency of hla a expression and their lymphocyte phenotype into a group of cancer patients and a group of healthy donors, during screening of immunization with hla-combined peptides. materials and methods: healthy donors who proceeded in the department of transfusion medicine, university hospital of heraklion crete were tested for the hla a expression. in of these donors the expression of cd , cd , cd , cd , cd , cd , hla dr, cd +cd +, cd +cd +, cd -cd +, cd +cd -cd +, cd -cd -cd +, cd -cd -cd + was examined. meanwhile, patients with metastatic cancer who were hospitalized in the department of medical oncology, university hospital of heraklion crete, were tested for their hla a expression, while in of them for their lymphocyte phenotype. the antigens expression was examined in flow cytometry. the hla a expression in healthy donors was . % and in cancer patients % (p > . ). in table the mean, standard error, t-test and p of the two groups are included. (see table ). the two groups (healthy donors and cancer patients) revealed no statistical significant difference on lymphocyte phenotype, except of the cd expression, which was higher in cancer patients. summary and conclusion: the expression of hla a in cancer patients and in healthy donors was comparable. also, the lymphocyte phenotype among the two groups has not statistical significant difference, except of the cd (total b-cells). the significance of this result has to be investigated. in the course of original documents research i found out that dr. kalic, head of the first organized blood transfusion institution in the balkan region (at beograd, serbia, in ), set himself a professional goal: blood should be awaiting all patients and transfusion should not be a privilege of large city inhabitants only. dr. kalic's idea was that blood transfusion should be administered according to clearly given instructions and using simple blood sets. encouraged by the conclusions of the congress held in paris in , dr. kalic started preparations for the transport of blood to the inland. he concluded bravely that citrated blood could be sent by regular mail, as an ordinary parcel, without particular protection from the outside temperature. he advised his colleagues to use blood as an intravenous injection. blood was taken from voluntary female donor in belgrade (capital), march . after keeping it for days at storage, blood was forwarded on a two-day journey to a small town, kilometres away from belgrade. there it was kept on a room temperature before its final use for a treatment of a patient suffering from secondary anaemia. the patient underwent the procedure without side effects and responded to the transfusion with blood sent in this manner much better in comparison to earlier methods of direct blood transfused. reminding ourselves of the courage of our ancestors to implement their professional knowledge and personal original ideas in a new way with the desire to help the patient as successfully as possible, we pay them the deserved respect and gratitude for inspiring and encouraging us in this way to try the same. conclusions: automation leads to increased standardization, faster specimen processing and reporting, elimination of manual specimen identification, uniform interpretation of serological reaction patterns and objective reading of haemagglutination endpoints. using auto-vue allowed the staff uninterrupted time to perform quality assurance duties, extended antibody identifications, preventative maintenance, inventory control. the instrument allowed us to leverage current staff to a more productive, less stressful level. introduction: exosomes are - nm secreted vesicles produced by antigen-presenting cells (apcs). the finding that exosomes from dc pulsed with tumor-derived peptides elicited potent antitumor tcell responses and tumor regression in mice has led to the proposal that human exosomes could be effective vectors for antigen delivery in the context of cancer immunotherapy. aim of the study: to establish the method of producing a new kind of tumor vaccine -exosomes secreted by dc, pulsed with tumor peptides. methods: exosomes used in this study were generated from monocyte-derived dc pulsed with peptides from k tumor cell lines. exosomes were purified by the methods of ultrafiltration and ultracentrifugation. the methods of dynal magnetic beads, flow cytometry and western-blotting were used to determine the surface molecules of the exosomes. the function of the exosomes was deter- objective: to develop an immunoheatological technique for the study of erythrocyte hyaluronic acid sodium salt (cd ) receptor expression in red blood cells (rbcs) from adults and newborns. materials and methods: samples of anticoagulated blood from adults (n = ) and umbilical cordon (n = ) were used. several dilutions oh hailuronic acid sodium salt solution % (sigma l- h ) were confronted with % erythrocyte suspension in phosphate saline buffer (pbs) ph . . the rbcs were previously treated with an enzymatic solution of % bromeline in pbs ph . (sigma l h ). agglutination readings' were been by slow sharking after of h incubation at °c. the results were expressed through the sensibility parameter which involves titer and score. this is defined by a mathematical expression a = à si. di- . - (i = , , . . .) where si represent the score and di- is dilution inverse. the adult' rbcs showed a = ± , while en the newborn the parameter was a = ± . our results showed significant differences between both groups. conclusions: in this work, we present a simple immunohematological technique for the hyaluronic acid sodium salt (cd ) receptor expression in red blood cells, which could be a useful tool to evaluate the alterations of the receptor's expression in rbc. a new technology for crossmatching tests adapted to a fully automated system l gaillard, v desvigne, a boulet, l fauconnier and jm pelosin diagast, loos, france we have developed a new automated technology for crossmatching (compatibility) test suitable for automation and high throughput. the method does not require centrifugation steps thanks to the use of magnetised red blood cells (rbc). all the steps described are performed on the fully automated qwalys system. this methodology requires washing steps under magnetic field and is based on the fixation of sensitised rbc on the surface of a well coated with monoclonal anti-human globulins. in a first step, the red blood cells from target blood bags were magnetised during min. then the patient plasma is distributed on a microplate and incubated with the previously magnetised rbc during min at °c. excess of unbound immunoglobulins is removed by washing steps. in a third step, sensitised magnetised rbc were transferred in the antiglobulins coated plate and placed min on a magnet plate. wells in which antigen-antibody interactions have occurred display a confluent layer of rbc (positive reaction). the negative reaction appeared as a pellet in the middle of the well. the test can be read by an automatic reader or by naked eye. the patterns in the well are stable for at least h at room temperature. the plasma samples are provided by the laboratory of haematology of the chru of lille. the red blood cells are collected from segment of tubing of blood bags coming from the laboratory of blood donors of the efs (french blood services) nord de france-lille. the results are obtained in min. comparative studies showed that our new technology, without any centrifugation steps, is reliable and sufficiently sensitive and specific enough to perform cross matching tests using a high throughput automated system. the mechanisms of p -dependent apoptosis involve a set of genes that possess the ability to modulate oxidative stress. one of them pig , is induced by p through a microsatellite in its promoter region. this microsatellite has been proposed to represent an evolutionary adaptation of tumor suppressor mechanisms. microsatellite instability and genetic constitution, comprising the presence of the low repetition allele ( tgycc repeats), at this locus have been hypothesized to provide an increased risk for cancer development. aim: in the present analysis we examined this polymorphism in blood samples from voluntary health donors and compared it with human lung cancer samples, employing two different ethnic groups, greek and british. results: analysis of this locus in both types of samples showed: (i) the homozygous presence of the repeats allele only in the samples from healthy blood donors; (ii) a very low frequency of microsatellite instability (< %) and no loss of heterozygosity in matched normal-tumor tissues; and (iii) a non-significant increase of the most frequent allele ( repeats) in the cancer groups as compared to samples from healthy blood donors. the last two observations were found in both greek and british populations. conclusion: taken together, these data do not support the notion that this pig polymorphism is associated with an increased risk for cancer susceptibility. background: blood group determinations are routinely performed by the sensitive technique 'gel test' for the last few years. many weak d and partial d phenotypes which react as d negative or weak d by slide test, are assigned the rh d + status by gel test. this is most desirable in the case of blood donors but creates concern in case of patients and antenatal women with a partial d phenotype. case report: we report a female patient (blood group o, c+, c+, e-, e+) whose red blood cells gave a positive reaction of different strength and speed with different anti-d antibodies in slide tests. we were asked to type the patient and provide the appropriate blood units. the patient's cells gave a +/ + reaction in the standard screening procedure for the rh d in gel test micro-typing system that contains a polyclonal reagent of human origin (which allows a direct detection of most weak ds), a + reaction in a test with monoclonal anti-d and a +/ + reaction in the gel test micro-typing system destined to detect du and which contains polyclonal anti-d of human origin. however, since the slide test gave a rather slow onset of agglutination with one commercial reagent (made up of a blend of polyclonal and monoclonal anti-d) we tested the patient's red cells against anti-d reagents in the id-partial d typing system. one of these (number ) gave negative reactions and the remaining five gave positive reactions (ranging from +/ + to +), indicative of a partial d category vii phenotype. the patient's red cells were also tested in the id-card 'diaclon abo/d' . this card provides the complete profile for abo/rh d in one single procedure step, including the confirmation of rh d. it contains two different anti-d reagents within the gel matrix in two consecutive microtubes. the first anti-d (polyclonal human) is expected to give a positive result with d+ red cells and partial d category vi, while the second (monoclonal rabbit) is expected to give a negative result with dvi+ red cells. our patient's cells gave a negative reaction with the first and a +/ + reaction with the second anti-d in this system, indicating a d variant other than dvi. finally the patient was assigned the partial d category vii phenotype (according to the pattern of the reactions obtained with the id-partial d typing set) and rhesus d negative blood units were issued. this case illustrates the diversity of reagents used for rhesus typing in different laboratories. failure to disclose some d variants is a disadvantage when typing patients. a combination of techniques is often needed to reveal the real rh d phenotype. the only single system that could have revealed a d variant in our patient from the beginning, is the id-card 'diaclon abo/d' with two different anti-d reagents in two consecutive microtubes as described above. a cost-benefit analysis should be undertaken to show whether it should replace other screening tests for abo and rh d when typing patients. who cares about the quality of life of the chronic patients treated with blood products? d ilcenco*, e hanganu-turtureanu † , c burcoveanu † , c vartolomei ‡ and d azoicai § *blood transfusion center, † hospital 'sfantul spiridon', ‡ institute of hygiene, § university of medicine, iasi, romania quality of life is one of the methods used to appreciate the quality of the health system. romania is going to join soon the european union, so there must be a concern regarding the improvement of the national health system. blood receiver's life quality never been researched before in romania. we have been chosen a batch of chronic ill patients who have been received blood transfusion with blood or blood components, and asked them to complete two types of questionnaires regarding their life. we used nottingham health profile and beck's depresion index. results shows that this kind of patients need special care, because they all (with one single exception) feel frustrated and feel like a burden to the other normal persons. evolution of the pain index, mobility index, energy index, emotions index, sleep index and social isolation index was in concordance with the depression index. in conclusion, this type of patients needs special attention and medical authorities should make more efforts to assure their life quality support. transfusion medicine practice in surgically treated urology patients: our experience il ilincic*, bm bozovic* and ts tadic † *clinical center dr dragisa misovic, † natio. blood transfusion inst., belgrade, serbia objective: multiple studies demonstrate that the use of blood/blood products in patients undergoing elective urology surgeries, as well as the actual needs assessment, present the issue of numerous debates. method: using the retrospective method, utilization of blood/blood products was analyzed, as well as the ratio of prepared/used blood units in urology patients in the surgical ward, in the intensive care unit (icu) and at the urology center within the cc dr dragisa conclusion: due to a rather liberal use of primarily ffp in certain cases (cystectomiae in the first place), and a discrepancy between the prepared and actually used blood units, hospital transfusion committees should be an imperative in order to solve current dilemmas regarding justified use and proper administration of blood and blood products. background: the safe collection, production, distribution and application of blood and blood products in a high quality needs logistic on a high level. since the seventies computers, special software and barcode are used in transfusion medicine and improved the safety of processing data. in the last years a new technology was developed for industrial use, the radio frequency identification (rfid). aim: the aim of our studies was to check whether rfid can use reasonable in transfusion medicine. methods: at first we developed a flow chart, where we can use the technology and where are the problems by introduction. so we tested in the red cross donation centre in saxony about passive rfid smart label under real conditions. in cooperation between the akh vienna and novatech research a new handheld pc software 'labelview' for all steps around the transfusion was developed, including the identification of the patient and the processing of the haemovigilance data, and tested in first time. results: passive and semiactive (with temperature control) rfid labels survives all hard steps during the working up of the whole blood (e.g. centrifugation by g, separation, etc.). as a result of the contactless identification they are help to make easier the documentation of all processing steps according good manufacturing practice. in clinical practice they are a good supplement to bed side transfusion software. conclusion: for all lot of problems by the logistic and the safe identification around the transfusion existing various single point solutions such as patient-wristband, bed-side test, double check of blood group typing and donor -donation registry in software, etc. the lecture will deal with new developments in logistics and data management, which can help to reduce the problems associated with documentation, safe identification and reporting of haemovigilance data. our experiences with the immunohaematological analyser olympus pk applied conventional and no conventional (hemolytic medium time) techniques in sera of patients with ascariasis. results: the ai and hk tests showed: b epithopes in ae from b patients and in ae from ab patients; a epithopes in ae from ab patient and in ae from a patients; p and p epithopes in ae and only p epithopes in ae. these patients had both epithopes in their erythrocytes. the hemolytic techniques showed: anti b immune antibodies in sera and anti a immune antibodies in sera. the presence of abo and p epithopes in ae and immune antibodies in patients with ascariasis show a relation about blood groups and ascariasis. the fact of to find the same abo and p antigens in a. umbricoides and in its hosts suggests that the parasite might absorb them during its life cycle. these epithopes would be involved in the molecular mimicry. the use of filters for leucocyte depletion in anemic patients on maintenance hemodialysis g poposki*, s kovaceski*, b krstanoski*, s mena* and n solaz † *institute of nephrology, struga, macedonia, † ankara university, faculty of medicine, ankara, turkey introduction: renal anemia is one of the major chronic complications in end stage renal disease. it is caused by reduced production of erythropoietin (epo) due to uremic toxin effects, reduced halflife of rbc, iron deficiency, aluminum intoxication, blood loss during hemodialysis, gastrointestinal hemorrhage, epistaxis, infections etc. allogenic blood transfusion is transplantation of certain or all cell types. however, allogenic blood transfusion can contribute to many immune system disturbances with clinical side effects. besides erythrocytes, mononuclear, t and b-lymphocytes, are also transfused, which cause immunomodulatory disturbances in immune system of recipient. leukocytes are responsible for frequent febrile non-hemolytic transfusion reactions, alloimmunization toward leukocytes and hla antigen and transmission of cmv. anti-le antibodies, forming of immune-complexes, complement activation with pirogenic c a and c a immunoinflamatoric citokines cause febrile reactions. commercial use of filters for leukocyte depletion with removal of leukocytes and degraded products of microagregates and cytokines, cause minimum harmful immunomodulatory effects and prevent transmission of cmv. aim: the aim of the study was to present the effects of transfusion of erythrocytes with residual number of leukocytes in anemic patients on chronic hemodialysis at institute of nephrology in struga. matherial and methods: during - period all anemic patients on hemodialysis were divided in groups. the first group pts with febrile non-hemolitic transfusion reaction. the second group- pts immunized toward leukocyte and hla antigen. the third group young candidates for kidney transplantation for prevention of hla immunization. the fourth group pts with sle (for immune-complexes and autoantibodies). total patients ( males and females) received units of rbc with residual number of leukocytes. commercial filters of baxterÔ (lekostop lds) and terumoÔ (imugard iii rc) of second and third generation with microagregate filter and synthetic polyurethane fibers, with - microns pores that remove leukocytes, platelets, microagregates and fibrin were used. erythrocyte concentrates are filtered until days of collection. result: aabb permits maximum < ¥ wbcs/unit for prevention of febrile non-hemolytic reaction. the filters we used reach residual leukocyte number of ¥ the le reduction of - . %. the number of rbc after filtration is minimum % - g hb per unit. in none of the patients who have received the leuco-filtered blood, no adverse post transfusion reactions were noticed. conclusion: the used filters for leucocyte depletion are characterized with superior biocompatibility, excellent elimination of all types of leucocytes and high 'recovery' of erythrocytes. the use of filters for le depletion reduces and minimizes the side effects of allogenic blood transfusion in patients on chronic hemodialysis who are alloimmunized, in patients with sle, and particularly in young patients candidates for kidney transplantation. background: fv leiden, prothrombin g a, mthfr c t are three most common and important prothrombotic inherited mutations. aims: the aim of the case-control study was to assess the prevalence of mutations and their single or combined effects as risk factors for thrombosis. methods: the study included thrombotic patients (venous thromboembolism, chronical venous diseases, different etiology) and asymptomatic healthy individuals as control group. extraction of genomic dna was followed with genotyping of fvl by pcr-ssp, prothrombin and mthfr mutation by pcr-rflp. results: a statistically significantly higher prevalence of fvl mutation was found in thrombotic patients ( . % heterozygous, . % homozygous) compared to controls ( . % heterozygous), p < . . the or for heterozygous carriers was . ( % ci . - . ), confirming the association of fvl mutation with the risk of thrombosis. there was no statistically significant difference in the prevalence of the prothrombin mutation in patients ( . %) and controls ( . %), or . ( % ci . - . ), p = . . although the group of thrombotic patients showed a higher prevalence of homozygous carriers of c t mthfr than the control group ( . % vs . %), or was not significant ( . , % ci . - . ), p = . . analysis of combined effects of mutations showed an additional thrombotic risk for carriers of fvl mutation and both mutated alleles of c t mthfr gene (tt and ct) (or . , % ci . - . ), p < . . conclusions: fv leiden mutation was detected as significant single risk factor for thrombosis in studied patients group. additional prothrombotic risk have carriers of fvl mutation and c t mthfr gene mutation. a female patient in a high fever due to urinary tract infection does not respond being given antibiotics. on the contrary, leukocytes rose (to ¥ /l), anaemia became even deeper, as well as thrombocytopenia. hemocultures were negative. hematologist decided to search for hematological disease. the first citology results of bone marrow aspirate suggested lymphoproliferative disease ( % atipical plasma cells). to treat heavy anaemia (hgb g/l) hematologist asked for red blood cell concentrate. pretransfusion testing revealed warm autoantibodies in the patient serum and on red blood cells. antibodies had no apparent specificity. biochemical parameters (bilirubin, ldh, haptoglobin) suggested mild hemolitic process. electroforesis revealed polyclonal hypergamaglobulinaemia. the th day of hospital treatment, the therapy with corticosteroids was introduced (solu-medrol mg per day). coagulation parameters were tested: pt . inr, aptt s, fibrinogen . g/l, trb ¥ /l, d-dimer mg/l, atiii %. dic was suspected. liver enzymes showed mild liver dysfunction (normal ast, alt, elevated ggt, low che). substitution therapy started with dose of cryoprecipitate, dose of fresh frozen plasma, iu atiii, doses of red blood cells and vitamin k mg. two days after the substitution therapy we saw pt . inr, aptt s, fibrinogen < . g/l, trb ¥ /l, atiii %. during the next few days erythrocytes and thrombocytes rose, but due only to corticosteroid therapy and not to substitution therapy. the patient had neither signs of con-sumptive coagulopathy, nor hypoproduction of coagulation factors, except for fibrinogen. till th day of therapy, fibrinogen was below . g/l. there was no hemorrhagic diathesis. after that, fibrinogen rose, and on the st day the patient was recovered, in both clinical and laboratory terms. the results of immunological tests, collected later, confirm the diagnosis of systemic lupus erythematosus. we did not have any specific test to confirm antibody mediated hypofibrinogenaemia, but in the setting of sle, without any specific treatment except corticosteroids, fibrinogen recovered. we assume it is quite enough for highly suspected immunological hypofibrinogenaemia. results: twenty-four-year-old male patient with severe hemophilia type a suffering from low incoercible digestive bleeding secondary to ischemic colitis caused by autoimmunity (vasculitis) without response to current management. treatment was initiated with mg/kg/dose of rfviia (*) for days, after which there was clinical and endoscopic recovery, and an inh decrease to . ub/ml (fviii dosage %) . he began to take meprednisone ( mg/kg/day) for days, after which the inh titre was . ub/ml. (table a ,b) the patient underwent surgery the following year (correction of equinus foot). he entered the operating room with an inh of . ub/ml and was treated with mg/kg/dose of rfviia (*) for days, obtaining an excellent hemostatic response. he had two autologous blood units, but it was not necessary to be administered. the inh titre decreased again (down to . ub/ml) during the intratreatment stage. thirty-five days after rfviia, the inh titre was . ub/ml. (table a ,b) the presence of high titre inh against fviii is a critical problem in cases of bleeding or surgery need due to the inefficacy of the available therapeutic options and the severity of the events. in this case, we have observed that, apart from inducing hemostasia through the activation of the coagulation extrinsic path, rfviia could reduce the inh titre in sequential dosages. we have introduced the case of a -year-old patient with hemophilia complicated by a high titre inh against fviii. in this case, we have observed that, apart from inducing an effective hemostasia through the activation of the coagulation extrinsic path, rfviia could reduce the inh titre in sequential dosages. there was also a decrease in the inh titre concomitantly with an increase of the plasma fviii level during its use. this phenomenon suggests that rfviia could produce a modulation in the immune response. evaluation of an automated blood collection system with standard ratio of anti-coagulation and integrated filter for whole blood leucodepletion l dadiotis, a kolokytha, m dimou, a perdiou, c alepi, p spyropoulou, e igoumenides, c velidou, v panagopoulou and s matsagos tzaneion general hospital, pireas, greece automated blood collection system (abc) is a device manufactured by macopharma which collects by gravity a preset volume of blood and mixes it with anticoagulant (ac) in standard ratio ( : ). this is managed by passing the ac, which is stored in a special bag, anti-erythrocyte antibodies are immunoglobulins that belong to the igg, igm and iga classes. their common characteristic is a specific reaction with antigens that are located on the erythrocyte surface. they can emerge as auto antibodies and alloantibodies. the blood transfusion in patients may induce a post-transfusion hemolytic reaction (pthr). in order to avoid or reduce the danger of the pthr it is necessary to examine whether there are irregular anti-erythrocyte antibodies in the patient's serum as well as in the serum of the voluntary blood donors. all the irregular anti-erythrocyte antibodies are not clinically relevant. the experience shows that the clinically significant antibodies most often belong to abo, rh, kell, kidd, duffy and ssu blood groups. in the period from april, to november, , we monitored and examined, at the institute for blood transfusion, clinically significant antibodies in the serum of the patients who are treated with blood transfusions as well as in the serum of the voluntary blood donors. we used the following tests for detecting irregular anti-erythrocyte antibodies: enzyme test, indirect coombs test, screening test by the commercial test erythrocytes and gel filtration method. the detected irregular antierythrocyte antibodies are identified by means of the commercial test erythrocytes for identification. our results are the following: voluntary blood donors: anti d, anti c + d and anti-leb antibodies. patients: anti-d, anti-k, anti-fya, anti-c and anti-e antibodies. in nine patients, anti-erythrocyte antibodies were discovered, namely, those that react at the temperature higher than °b ut whose specificity we could not discover with the existing techniques. improved predictive factors of response for myelodysplastic syndrome patients treated by the combination of erythropoietin and g-csf s park*, c kelaidi † , s grabar ‡ , v bardet ‡ , d vassilieff ‡ , f picard ‡ , m guesnu ‡ , mc quarre ‡ , p fenaux § and f dreyfus ‡ *service hématologie, hopital cochin, † hématologie, hopital avicenne, ‡ service hématologie, hopital cochin, § hématologie, hopital avicenne, paris, france it has previously been shown that serum epo level and number of previous red blood cell transfusions are predictive factors of response to epo + g-csf treatment of myelodysplastic syndromes (mds). in a subgroup of patients with mds having sepo < ui/l, known to be good responders to epo + g-cscf, the gfm group wanted to refine the model predicting the response to epo + g-csf, especially with cytology (who classification with dysplasia and percentage of erythroblasts and blasts). in a population of patients (ra, rars and raeb < % blasts) receiving epo ± gcsf between and and having serum epo < ui/l, the response rate at week (iwg criteria) was %. six variables were associated with response to epo ± g-csf for mds: age > years (p = . ), number of prior red blood cell transfusions < packs/months (p = . ), serum epo level < ui/l (p = . ), percentage of blasts < % (p = . ), percentage of erythroblasts > % (p = . ) and low ipss score (p = . ). we did not found any influence of dysplasia, type of rhepo (darbopoietin alfa or epoietin alfa) and karyotype on response rate. in multivariate analysis, age through a rotating pump. the abc can be used with all types of p- pan-european blood safety alliance the pan-european blood safety alliance is a unique alliance of patient organizations, formed to promote the highest level of blood safety for all in europe. it was formerly established on february , during the course of the first general meeting of the pbsa, which comprised of founding patient organizations. the objectives of the pbsa are: . to promote the fundamental right and duty to safety of all patients in need of blood transfusions and blood products. . to ensure the availability of sufficient amounts of safe blood, to meet all treatment need through: -the education of all staff handling blood components, to reduce human error. -the implementation of and access to, proactive blood safety technologies, for each patient across europe. -haemovigilance -the adequate access to blood transfusion services, which should be provided free of charge to the patient. other objectives are to raise awareness on a local and european level regarding blood safety, to promote eu legislation that improves safety standards of blood transfusion services, including stem cell preparation and storage across europe and to lobby for increased patient influence on eu health policy makers. very importantly, the alliance aims at providing a forum for patients, healthcare professionals, health policy makers and relevant industry, as well as acting as a point of reference to the national health authorities, the european commission and other european institutions, when seeking the opinions of patients on blood safety. cerns of insertional mutagenesis and the safety of some viral vectors that randomly insert genes through the genome have been recently resurfaced following the development of a haematological malignancy in a child treated with a retroviral vector. particularly questions also remain as to, whether gene therapy and the production of ectopic factor viii and ix will be a risk for inhibitor development or indeed whether it might promote tolerance in those patients with inhibitors. w-pl - gene therapy for thalassemia: will it become reality? university of washington, seattle, wa, usa experiments aimed to develop gene therapy approaches for the beta chain hemoglobinopathies, sickle cell disease and beta thalassemia started about years ago. in the beginning results were dismal because of the extremely low and variable expression of globin genes contained in the therapeutic vectors. a major development occurred in with the discovery of powerful regulatory elements that could guarantee high level of globin gene expression. these elements when incorporated into viral vectors allow expression of therapeutic levels of the transferred globin genes. a second major progress was achieved with the development of safe lentiviral vectors that can efficiently infect the human pluripotent repopulating hemopoietic stem cells. as a result of this progress, today beta thalassemia and sickle cell disease can be cured in murine models of these disorders. considerable effort is already being devoted into further improvement of lenti viral vectors with emphasis on incorporating elements which will decrease the probability of insertional mutagenesis and leukemogenesis. the major challenge for the clinical application of stem cell gene therapy of thalassemia is the need for genetic correction of large numbers of mutant stem cells. in vivo selection of corrected stem cells is being investigated but there are questions about its safety because of the possibilities of clonal expansion of stem cell lines carrying undesirable integrants. other major challenges have to do with logistics: production of therapeutic vectors, infrastructure required for stem cell gene therapy delivery, and sponsoring and funding of the clinical trials. gene therapy trials on limited number of patients are expected to be initiated relatively soon. if these trials are successful and cures of beta thalassemia ensue, the major challenge will be the delivery of this molecular therapy in the context of medical practice. w-pl - gene therapy for haemophilia haemophilia is an ideal target for gene therapy because only a small rise in factor levels to - u/dl would achieve the goals of prophylaxis without regular infusions of concentrate and deliver a substantial improvement in lifestyle for patients with severe haemophilia. gene therapy for haemophilia today relies upon addition of normal factor viii or ix genes. with present technology gene therapy can offer the prospect of a true 'cure' for haemophilia in animal models, although this may not be currently realizable in man. more than patients with haemophilia have now been treated in phase gene therapy protocols. all studies have failed to conclusively show that therapeutic levels of factor viii and ix can be reliably obtained. the first trial reported used im injection of a factor ix containing recombinant adeno associated virus (raav) in adult patients with severe haemophilia b. only very modest increases in factor ix level, < u/dl rise, in / patients enrolled were observed, although less factor ix concentrate was needed in / subjects. a similar study using the same raav vector via intrahepatic artery infusion has been conducted. this has been complicated by the observation of aav vector in the semen of subjects. in six patients enrolled, no durable levels of ix above u/dl were seen. further development of this raav vector is suspended. for haemophilia a, three systems are have been tried. the first study was an ex vivo addition of factor viii gene to autologous fibroblasts and then laparoscopic reimplantation. preclinical assessments demonstrated durable expression of factor viii (> % of normal) for > year in mice following a single treatment. in / patients treated repeated factor viii rises ( . - . u/dl) were seen, but no improvements lasted beyond months. the second protocol used a murine leukemia retrovirus containing factor viii, injected intravenouslya development of preclinical data in rabbits and haemophilic dogs. / patients enrolled sustained levels of factor viii > u/dl. the third study, using a modified, 'gutless', adenovirus containing factor viii gene has recruited one patient. this patient demonstrated transient liver toxicity and thrombocytopenia at doses lower than those that cause toxicity in primates. sustained levels of factor viii of ~ u/dl have been observed over a number of months. accrual to the study has been poor. haemophilia remains a prime target for gene therapy. however, haemophilia is no longer a life threatening disease with current therapy that is both safe and efficacious. a balance between the benefits and theoretical risks must be borne in mind when considering gene-based approaches to therapy. con- reference: petz ld, garratty g. immune hemolytic anemias. nd ed. philadelphia: churchill livingstone, , pp - . w-pa- autoimmune neutropenia introduction: autoimmune neutropenia (ain), a granulocytic disorder due to the presence of anti-neutrophil antibodies, may present as neutropenia of varying degree with or without recurrent infections un previously healthy individuals (primary or idiopathic ain) or in patients with a known underlying disease such as lupus erythematosus, lymphoid malignancies, etc (secondary ain). the condition affects more frequently infants of small ages while it is rare in adults [ ] [ ] [ ] [ ] [ ] [ ] [ ] . in some patients, diagnosis is established in occasion of a respiratory, urinary or cutaneous infection, but in many cases is simply a finding of cell blood counting performed for unrelated reasons [ ] . clinical and laboratory findings: in general, physical examination is negative. laboratory investigation reveals the existence of isolated neutropenia. association of the disorder with autoimmune hemolytic anemia or autoimmune thrombocytopenia is rarely seen [ ] . blood biochemistry is normal while serologic tests for bacterial, viral or other pathogens may be positive depending on the underlying infection. bone marrow is hypercellular without maturation arrest of granulocytic series. hemopoietic stem cell reserves and function are normal or increased, and stromal cell function is within the range of the normality [ ]. methods for the detection of granulocyte-specific antibodies: serology for the detection of granulocyte-specific antibodies has been marred, compared to erythrocyte serology, because the target cell here, the granulocyte, is short-lived, fragile and becomes easily activated. the former two of these difficulties require absolutely freshly (< h old) isolated neutrophils from a panel of donors to be used every day to run the tests with sera from patients, while the third difficulty is more important since spontaneous cell clumping in vitro is very common and nay mimic the specific aggregation caused by cross-linkage of surface bound antibodies in the granulocyte agglutination test (gat). in order to overcome these problems, the second international granulocyte serology workshop [ ] recommended a combination of two tests as the best screening procedure for the detection of granulocyte autoantibodies in patient sera, gat and granulocyte immunofluorescence test (gift). gat is mainly mediated by igm antibodies and is positive in about % of cases. gift detects igg antibodies and is positive in about % of cases. it is to be noted that flow-cytometry fluorescence may arise not only from the surface but also from the cytoplasm of neutrophils, necessitating assessment of membrane fuorescence by microscopy. a good direct anti-granulocyte test is not available today. this is due to the fact that too few neutrophils can be obtained from the blood of neutropenic patients, and also to the observation that neutrophils are often activated in vivo because if an underlying infection or other inflammatory process, thus expressing fcgrii and fcgriiib to which nonspecific binding of w-pa- practical approach to transfusion in autoimmune hemolytic anemia (aiha) g garratty american red cross blood services, pomona, ca, usa a major problem when transfusing patients with aiha is that often all units are incompatible. this may be due to autoantibodies (autoab) and/or alloantibodies (allo-ab). if the incompatibility is due to only auto-ab, then transfusion of incompatible blood will not usually result in a clinically significant reaction, but if due to alloab, the result may be similar to that seen in any other patient (i.e. a hemolytic transfusion reaction ranging from mild to severe). thus, it is essential (as in any other patient) to exclude the presence of allo-ab. it is wise to phenotype all patients, for as many antigens as possible, before the patient receives transfusion. there are two popular approaches to determine if allo-abs are present but being masked by 'warm' auto-ab activity. the preferred method is to remove the auto-ab by adsorbing the patient's serum with autologous rbcs treated with enzymes, or preferably, with zzap reagent. the latter reagent contains an enzyme leading to optimal adsorption of auto-ab, and dtt. these two chemicals will destroy significant antigens other than rh and kidd (e.g. mns, duffy, kell, lutheran, dombrock, cromer, lw, some yta and ge, inb, jmh, ch, rg, pr antigens), thus will not adsorb alloantibodies to these antigens. if autoadsorption is not possible (e.g. patient has been transfused recently or there are too few rbcs), one has to perform adsorption with enzymes or zzap-treated allogeneic rbcs. one does not have to be concerned with covering any antigens destroyed by zzap (e.g. kell and duffy systems). we use a rough guide relating the strength of the indirect antiglobulin test to the number of adsorptions needed to remove auto-ab ( + = adsorption; + = adsorptions; + = adsorptions; + = or more adsorptions). if there is no activity left after the adsorptions, then one can suspect that the incompatibility was due to auto-ab, but on rare occasions one can be wrong and an allo-ab to a high-frequency antigen has been removed. this is a major disadvantage of using allogeneic adsorptions, and is why adsorptions with autologous rbcs are preferred. if time ( - h) does not allow for adsorptions, one can dilute the patient's serum (e.g. in , or in ) and test the dilution against a panel to see if any alloantibody specificity becomes obvious. another approach is to select units matching the patient's phenotype as closely as possible. when dealing with cold agglutinin syndrome one can usually exclude allo-ab activity by testing strictly at c. this can be helped by performing adsorptions with enzyme-treated autologous rbcs at c, but it is difficult to adsorb all of the powerful cold autoagglutinin activity. it is reported that - % of aiha have allo-abs; the incidence is even higher in patients who have received multiple transfusions. thus, we feel that procedures such as those discussed above must be performed before transfusing incompatible blood if time allows. one should always negotiate with the attending physician regarding the time it will take to perform adsorptions. a decision may be made not to perform adsorptions if the patient has life-threatening hemolysis, and especially if the patient has never been transfused, or pregnant. serum igg may occur (naig). the presence of immune-comlexes in the serum, such as in patients with felty's syndrome, lupus erythematosus and other diseases, as well as the presence of immune aggregates formed in sera stored frozen for long time, may give false-positive tests given that they may bind to fcgriiib molecules expressed on the surface of neutrophils. elimination of immunecomplexes and immune aggregates can be easily obtained by ultracentrifugation [ ] . another cause of false-positive results may be the presence of anti-hla antibodies because of allo-immunization. these allo-antibodies react with hla molecules found not only on neutrophils but also on the surface of many other cells including lymphocytes. these allo-antibodies can be eliminated by platelet absorption. it seems that the best method in the search of true antigranulocyte antibodies is the monoclonal antibody-specific immobilization of granulocyte antigens (maiga) [ ] . with this method one can specify anti-granulocyte antibodies using a panel of known granulocyte antigenic specificity. finally, it is notable that the levels of serum antibodies to neutrophils may vary considerably over the time. one negative test does not exclude ain. usually, two to three tests have to be run over a period of months [ ] . antigenic specificity: human neutrophil antigens (hna) are classified according to an international granulocyte antigen working party [ ] . three glycoproteins have been found to be involved in the determination of antigenic specificity, fcgriiib, gpnb (cd ) and gp - . the respective antigens, frequencies and alleles are illustrated in table . antigenic specificity can also be studied by using methods applied in molecular biology. a promising approach is transfection of mammalian cells by cdna derived from granulocyte antigen specific mrna. cell lines have been established with cells expressing the respective human granulocyte antigen, making the detection of anti-granulocyte antibodies more easier. genotyping of hna antigens can also be stydied with the pcr technique [ ] . references are available from the author upon request. w-pa- a rare case of 'coombs negative' autoimmune haemolytic anaemia due to red cell autoantibodies of iga class warm autoimmune haemolytic anaemia (waiha) is usually associated with red cell auto-antibodies of the igg class, which can be detected by polyspecific direct antiglobulin test (dat). routine polyspecific direct antiglobulin tests contain anti-igg and anti-c d components, and are not standardized to react with iga-or igmsensitized red blood cells. haemolytic anaemia caused by warmreacting auto-antibodies solely of the iga class is exceedingly rare. those cases of autoimmune haemolytic anaemia can be difficult to diagnose because of the negative polyspecific coombs' test, which is a standard in investigation of possible causes of haemolysis. we present a case of severe warm autoimmune haemolytic anaemia caused by iga class autoantibodies. a -yr old male patient was admitted with anaemia, haemoglobinuria, and other signs of severe haemolytic disease. he received multiple transfusions but haemoglobin level did not rise above g/dl. the initial polyspecific direct antiglobulin test, containing an anti-igg and anti-c d antiserum, was negative. tests for cold agglutinins and other possible causes of haemolysis were negative. only by using a monospecific, anti-iga antiserum could we show that the warm iga auto-antibodies against red blood cells were present on patient's erythrocytes. we have not detected signs of complement activation by iga autoantibodies in this patient. the patient received corticosteroids with good initial effect. his haemoglobin level stabilized and he did not require more transfusions. anti-iga direct antiglobulin test became negative about to weeks after the therapy was initiated. however, in spite for the initial effect of steroid therapy haemolysis continued, and splenectomy was performed months after diagnosis was made. it has been shown that human lymphocytes, granulocytes and monocytes contain specific fc receptors for iga, and both monocyte-mediated phagocytosis and antibody-dependent cellular cytotoxicity due to iga auto-antibodies has been demonstrated. there is also increasing evidence that iga auto-antibodies can activate complement, both via the classical and the alternative pathway. a phenomenon of 'reactive haemolysis', which involves c -independent binding of c b complexes to 'bystander' red blood cells, has also been described. we emphasize the importance of performing additional testing in cases of apparent 'coombs' negative' haemolytic anaemia due to iga, igm or 'low affinity' igg autoantibodies, and serological aids that are available for that purpose. described. both siblings were born on term, in good general clinical status, free from any signs of infection, and with isolated severe neutropenia ( and neutrophils/ml). the diagnosis of annanti hna- a was made upon exclusion of other possible causes of neonatal neutropenia, and confirmed by serological testing of granulocyte antigens and antigranulocyte antibodies. in both cases, the course of the disease was mild, with bacterial omphalitis on day and , respectively. omphalitis was successfully treated with -day antibiotic therapy according to antibiotic sensitivity report. the first neonate received standard dosage of intravenous gammaglobulins for days without success. this was followed by an attempt at neutrophil count increase with -week corticosteroid therapy, also without response. the second neonate received no specific therapy for neutrophil count increase. the children were discharged for home care with clinical and laboratory control examinations at -week intervals. in spite of prolonged neutropenia ( and months, respectively), no other infections were recorded. discussion and conclusion: in our patients, the therapeutic approach to ann was individualized, based on standard antibiotic therapy, intravenous gammaglobulins, corticosteroids, available literature data, and our own clinical experience. although in the last few years rh-gcsf is successfully used in patients with neutropenia, we decided to postpone its use in case the neonatal sepsis developed. the reasons for such decision were: ( ) the fact that both neonates were in good general clinical status, with a mild course of the disease with only short-term umbilical infection successfully managed with antibiotic therapy; ( ) literature reports suggesting the unexpected failure to respond to rh-gcsf therapy in patients with neutropenia induced by anti hna- a immunization, and ( ) the unknown effect of rh-gcsf on developing tissues of the neonate. the choice and efficacy of specific therapy for neutrophil count increase in the management of alloimmune neonatal neutropenia have not yet been fully defined and require additional evaluation in the majority of cases. male donors for the production of fresh frozen plasma: a special issue for trali patients trali is a significant cause of transfusion associated morbidity and mortality, and has been reported as the third most common cause of fatal transfusion reactions. there is no good evidence on which to base transfusion support policy for patients who have experienced trali. the hypothesis that there may be patient associated factors that contribute to the risk of trali is generally accepted. for this reason it seems reasonable to try to avoid further transfusion during the period of illness. if this is unavoidable the next best solution to reduce the risk of recurrence seems to be the avoidance of using plasma containing blood components (especially ffp) as there is a high chance of positivity for leucocyte antibodies especially for those coming from female donors. as fresh frozen plasma transfusion accounts for up to half of all trali cases and as our center is the only in greece responsible for the testing and processing of blood from blood donors representing military recruits, the last two years we tried to set up a project in order to provide components from male donors on request. our donor base consists predominantly from males donors ( . %), aged between and years old, with a small chance of having a positive history for transfusion the difficulty of the project consisted on the fact that these donors are assigned to military camps throughout greece, which makes difficult the on time arrival of the units to our establishment in order to be processed for the production of ffp conform the european council quality requirements. this was the main reason why, till now, all plasma produced from these donations was regarded as plasma for fractionation. the first step for implementing the new project was to evaluate the number of donations that, by minor changes on the time of arrival, could be processed for ffp production. the next step was to re-schedule the shifts of the personnel for the on time production of ffp. during , % of donations were fulfilling the specifications for the production of ffp and with the flexibility of the schedule the % of them were successfully processed to ffp. during , % of the donations were fulfilling the specifications and . % of them were processed to ffp. so it is feasible to increase the proportion of male ffp by organizing better the transportation of blood from the donation sites to the blood establishment and by retaining available specialized personnel to cover the extra shifts. maximising the blood supply chain in times of shortage shortages in the blood supply chain may occur for a variety of reasons. they may be temporary e.g. due to a flu epidemic or prolonged e.g. due to the exclusion of a high proportion of donors due to new pre-donation tests or because of a lack of volunteer donors. increasing awareness of the possibility of blood shortages mainly related to increased precautions associated with the possible transmission of vcjd by transfusion has been the driver for the development of blood shortage contingency plans in the uk. in england and north wales, hospitals and the national blood service (nbs) have worked together to develop an integrated blood shortage plan (ibsp) designed to ensure that hospitals and the nbs work together within a consistent, integrated framework giving patients equal access to available blood on the basis of need. an essential element of the plan is the principle that shortages can, in most cases be avoided by reducing the current usage of blood through appropriate use programmes. the impetus for hospitals to implement these programmes was a government circular (hsc / ). hospitals have embraced the circular and have recruited specialist hospital transfusion practitioners, introduced lower hb triggers, cell salvage and hospital transfusion teams and are participating in the blood stocks management scheme (bsms). audits of compliance with the circular have taken place, and a web based tool kit is available. the demand for blood has declined for the last three years, with a decrease of about % during - , suggesting that the drive for improvement has been successful. the shortage plan introduced in england and north wales has two key aims: that the national pool of blood is available for all essential transfusions for all patients and that overall usage is reduced to ensure the most urgent cases receive blood. the plan is structured to provide actions for the nbs and hospitals in three phases, 'normal' circumstances, reduced availability and severe prolonged shortage. hospitals should have documented emergency blood management arrangements for each of the phases. the national plan is activated when the nbs red cell stock level falls to pre-defined levels, hospitals are informed by fax that they should reduce their normal stock holding levels according to guidance in the ibsp and comply with the daily hospital usage budget. the bsms has used its knowledge of hospital inventory levels and demand to provide guidance on appropriate inventory levels for normal and reduced status, it also provides the daily hospital budget. to monitor progress against the recommendations in hsc / hospitals will be benchmarked against a number of performance indicators. these include the presence of emergency blood management arrangements, median red cell usage for a number of surgical procedures and percentage wastage of blood. there have been no shortages within the nbs for more than six years, it is hoped that the implementation of the ibsp will help to ensure that in the unlikely event of reduced availability blood will be available to the maximum number of patients requiring a blood transfusion. w-pa- transfusion during disaster g klein nih, bethesda, md, usa publicity given to blood donation during wartime has created a powerful association between the need for blood and occurrence of a disaster. blood is rarely needed in excessive quantities at the moment a disaster occurs. the outpouring of blood donors, especially at the site of a disaster, often proves counterproductive. the terrorist attacks on the world trade center on september , , with almost deaths and more than injuries, provides an instructive model. more than a million potential donors contacted blood-collection centers. hundreds of thousands of prospective blood donors crowded collection facilities and many waited for hours, often to be turned away. qualified staff were in short supply and screening errors occurred as minimally qualified staff were recruited and as collection personnel fatigued. supplies and storage capabilities were pushed to their limit. some blood was inadequately processed and stored. resources were diverted from needed apheresis collections and component preparation to whole blood collection. in the aftermath of the disaster, blood outdated and volunteer donors became disillusioned as their 'gift of life' was refused or unused. similar responses have occurred numerous times over the -year period since blood-donor programs were introduced. in virtually every civilian disaster in the u.s. during the past century, all the blood that was needed was immediately available from blood inventory. in only four cases were more than units of blood used in the first to h. in in new york, the five hospitals closest to the disaster site admitted only disaster victims. the new york blood center, which supplies percent of blood for the city's hospitals, added units to routine inventory at hospitals. the center received telephone calls and collected more than units of blood in the first h. in the area of the pentagon, the chesapeake and potomac red cross blood center supplemented hospital blood inventories within h of the disaster. meanwhile, spurred by well-meaning media and federal officials, lines of blood donors were being processed at local hospitals, makeshift collection centers, the small research hospital at nih, and at a building next to the white house. in the week after september , america's blood centers collected more units of blood, and the american national red cross collected more units than in the same period the previous year. more than units were collected for the disaster victims, but only units were used. u.s. blood collectors and federal agencies have created a disaster plan that acknowledges the need for altruistic people to volunteer for blood donation in the time of disaster and speaks with a single voice to avoid needless collection activity while harnessing the good will of well-intentioned people to supplement the ongoing need for volunteer blood donation. rehabilitation of blood transfusion service in azerbaijan cd asadov, ga huseynov and ab hagiyev institute of hematology and transfusiolo, baku, azerbaijan at the end of th years of the last century in azerbaijan as well as in other republics of the former ussr began process of progressive deterioration of blood service parameters. in result there was an essential reduction of prepared blood and blood components quantity, manufacture of preparations from blood's plasma has completely stopped. it is connected by that our republic experiences a heavy transition period from scheduled to market economy. after reception by azerbaijan of the sovereignty on development of a national policy the big work has been lead to areas blood transfusion and development of national rules and the standards regulating functioning of establishments of blood service. in the law about ' the donorship of blood and its components in the azerbaijan republic' has been accepted, instructions on physical examination of donors and preparations of blood and its components are authorized, and also the new speciality transfusiology has been entered into the nomenclature of medical specialities. now the national program of blood service development is developed. at drawing up of the program social and economic conditions of the country, ethnic both cultural traditions and a mental potential of the nation are considered. within the framework of this program is planned to refuse gradually a paid blood donation during the certain period of time to reach %s' voluntary unpaid blood donorship. however in connection with limitation of resources, the state is not capable to allocate enough of means for its realization. the big work on attraction of the international organizations has been carried out. now the project of the united nations development program (undp) 'rehabilitation of blood transfusion service in azerbaijan' is carried out at sponsor's support of the norwegian government. realization of this project will lead to reorganization of blood transfusion service in our country according to practice of the european countries. within the framework of project realization it is planned to make changes and additions to a existing law about a blood and its components donorship to bring it into accord with recommendations of the europe council. updating of the russian law 'concerning the donation of blood and blood components' on june , , a law, 'concerning the donation of blood and blood components, ' was signed by the first russian president, boris eltsin. now, after more than ten years of market economy and democratic evolution in russia, this law was significantly changed on august , , as shown in the following sections: . the development of a voluntary blood donor system. . removal of the upper age limit for blood donors. . funding for blood donations. from january , , each level of the state power budgets for a blood donor service to supply blood products for federal, regional, or municipal hospitals. costs of these drugs and the need of prolonged growth factor treatment in these disorders. w-pa- can iron administration reduce peripartum blood transfusion c breymann university of zurich, zurich, switzerland the prevalence of iron-deficiency anemia in different regions of the world ranges from to %. the increased iron requirement in pregnancy and the puerperium carry with it an increased susceptibility to iron deficiency and iron-deficiency anemia and perioperative or peripartal blood transfusion. however, if ever possible administration of blood transfusion should be avoided for several reasons which will be pointed out in the talk. infections: it is well known that various pathogens such as bacteria and virus can be transmitted by administration of blood. around . % of are contaminated by bacteria such as yersinia or pseudomonas species but are not screened routinely for bacteria. in addition there is no donor screening for hepatitis a, herpes species (cmv, ebv, hhv , hhv ), parvovirus b , hepatitis g ( . %) and tt (transfusion transmitted) virus ( . %). numbers for positive testings for 'classic' virus such as hiv, hep. b and hep. c vary from country to country and lie around : to : depending on quality of donor screening programs, pcr sensitivity etc. recently there is increasing evidence that even prions which cause the jakob creutzfeld disease variation ('mad cow disease') might be transmitted by transfusions. therefore the fda has determined that blood donors from countries with high prevalence of prion positive persons are not permitted to give blood in the us (e.g. donors from uk). beside infections, other well known effects of transfusion are problems due to incorrect blood or components transfused, post transfusion purpura, acute and delayed lung injury, graft versus host disease and other acute and delayed allergic reactions. beside these negative effects it was also shown that patients who receive blood transfusion liberally after operations or in icu show higher morbidity and mortality compared to patients with restrictive transfusion policy. this might be due to negative effects on immune functions and inflammatory reactions and lack of stored blood to efficiently improve organ oxygenation. for example it is known that stored blood has worse capillary perfusion and worse viscosity properties compared to fresh blood. taken together there is increasing scientific evidence that blood transfusion is not the gold standard for anaemia management and alternatives such as endogenous blood pooling and efficient treatment of any anaemia must be enforced in the clinical settings. prevention and correction presuppose reliable laboratory parameters and a thorough understanding of the mechanisms of iron therapy. in order to correctly diagnose the type and degree of anaemia, a prerequisite for selection of the proper therapy, one must first of all correctly differentiate between the relative, i.e. the physiological anaemia of pregnancy due to the normal plasma volume increase during pregnancy, and 'real anaemias' with various different pathophysiological causes. when defining the hb cutoff value for anaemia in pregnancy, the extent of the plasma volume changes with respect to the gestational age must be taken into consideration. it has been found that haemoglobin values < . g/dl in the first and third trimesters, and < . g/dl in the second trimester may point to an anaemic situation which should be further clarified. the first important steps for diagnosing anaemia in a pregnant patient include a thorough check of her medical w-pa- impact of epo treatment on transfusion requirements in myelodysplasia c gardin and p fenaux hopital avicenne, aphp, university of paris , bobigny, france myelodysplastic syndromes (mds) are clonal disorders of hematopoeisis, associated with bone marrow failure and an increased risk of evolution to acute myeloid leukemia (aml). despite an normal or increased bone marrow cellularity in most cases, cytopenias worsen with time due to increased apoptosis and defective differentiation of blood lineage precursors. incidence of mds increases with age and reach / above years of age. bone marrow cytogenetics number of cytopenia and percentage of bone marrow blasts are strong predictors of survival and evolution to aml. a composite international prognosis scoring system (ipss) is used in everyday practice to guide the management of these diseases. these disorders are heterogeneous and include 'low risk' patients (less than % bone marrow blasts) with a prolonged evolution marked by chronic anemia, and 'high-risk' patients (excess of bone marrow blasts > %) evolving in a short timespan with severe cytopenias, and to aml in approximately % of cases. at diagnosis, % of mds patients are anemic, with an hemoglobin level less than g/l, and % of them will require chronic blood components transfusion, during the evolution of their disease. chronic anemia and multiple blood products transfusions are associated with an altered quality of life, clinical iron overload, and important health care costs. although transfusion practices and patient's transfusion need are variable, elderly mds patients require a mean of - units/year of follow-up, in recent surveys. therapies able to diminish or abolish the need for rbc transfusion have therefore a major role in the management of mds, as allogeneic bone marrow transplantation, the only curative therapy of these diseases, is limited to a small subset of mds patients. high-doses of recombinant erythropoetin (epo) ( - u/kg tiw, or a - u as single weekly dose) are typically used in low-risk mds. the response rate to epo is - %, including major responses (suppression of rbc dependency or rise of hemoglobin level of more than g/l). absent or low rbc transfusion needs and a serum epo level less than u/l are strongly predictive of response to epo, in patients with low-risk mds. the duration of response is variable ( - months) in most studies, with some long-term responders. the use of higher doses of epo or its prolonged administration may be associated with higher response rates, although no randomized studies are available combination of epo and low-dose granulocyte-colony stimulating factor (g-csf) increases the response rate to - %, including in patients not responding to several weeks of treatment with epo alone. two randomized trials published in , compared g-csf-epo to rbc transfusions and confirmed the efficacy of this combination, and a longer survival of epo-g-csf responding patients. studies are ongoing in mds, including with darbepoetin, a modified erythropoetin with longer half-life, administered once a week. two such studies have been recently reported, (darbepoetin or ug/week) with response rates varying from % to % in low-risk mds. in both studies, a response to darbepoetin was observed in some patients, who failed to respond to previous treatments with alpha or beta epoetin. further assessment of the optimal dosage, administration schedule of these drugs, and validation of their likely impact on qol are required, in order to epo and its derivatives to gain acceptance in mds, due the high history and a medical examination. this procedure often lays the basis for a correct diagnosis. the current gold standard to detect iron deficiency remains the serum ferritin value. to be reliable, this requires the ruling out of an infection (chronic or acute) as a cause of the anaemia. we recommend a complete laboratory test for the exact haematological status as well as the assessment of specific chemical laboratory parameters. these should the hb level alone is insufficient to guide management. a complete work-up (ferritin, transferrin saturation) is essential, preferably with haematological indices such as hypochromic and microcytic red cells and reticulocytes, classified by degree of maturity, in particular, before parenteral therapy is given. since ferritin acts as both an iron-storage and acute-phase protein, it cannot be used to evaluate iron status in the presence of inflammation. a high ferritin level thus requires the presence of an inflammatory process to be eliminated before it can be taken at face value. if the c-reactive protein level is also raised, the soluble tfr concentration can be used, since it is unaffected by inflammation. inadequate understanding of the complex chemistry of parenteral iron administration was previously responsible for serious side effects, such as toxic and allergic reactions, and even anaphylactic shock, in particular with dextran preparations. however, the current type ii iron complexes that release iron to the endogenous iron-binding proteins with a half-life of about h are not only effective but carry a minimal risk of allergic accident and overload, especially after a comprehensive pretreatment work-up. after correct diagnosis, major emphasis should be put on safe and effective treatment of anemia which again depends on severity of anemia, time for restoration and patients characteristics. today effective alternatives to oral iron only or blood transfusion such as parenteral iron sucrose complex and in selected cases also recombinant erythropoietin have been investigated and show promising results concerning effective treatment of anemia during pregnancy and postpartum. our departmental data collected over years and backed by postmarketing experience in countries indicate that iron sucrose complex therapy is a valid first-line option for the safe and rapid reversal of iron-deficiency anemia. w-pa- iron therapy in orthopaedic surgery surgery of the vertebral column, hip or knee is considered a bloody procedure (blood loss > l) and as a consequence represents the main indication for red blood cell transfusion in orthopaedics. because of the non-negligible residual risk of transmission of infectious agents by transfusion, but mainly because of immunologic complications induced by the administration of foreign proteins and cells, an alternative solution has been actively sought. studies have clearly shown that in patients undergoing such surgery, transfusion risk correlates inversely with pre-operative hemoglobin level. correction of even slight preoperative anemia is thus mandatory. in the elderly, iron and vitamin deficiency (b and/or folic acid) should be looked for as a matter of routine. we recommend the use of iron + epo whenever a rapid correction (< weeks) of the anemia is desirable in cases with transferrin saturation < % and ferritin levels < mg/l. with this regime it is possible to collect up to autologous blood units in cases of increased perioperative blood loss (e.g. double hip replacement). in the post-operative period, anemia worsens because of the existing inflammatory state. this inhibits iron absorption from the intestine and iron release from the macrophages while it affects epo function and production. there is increasing evidence that i.v. iron combined with epo induces a rapid correction of post-operative anemia. it is thus recommended to stimulate erythropoiesis by i.v. iron and epo starting on the first post-operative day and to avoid transfusions in asymptomatic patients even in cases with hb as low as g/l. background: hereditary hemochromatosis is one of the most common inherited disorders in which an excessive amount of iron is absorbed from the diet and then deposited in organs. the effective treatment is the regular whole blood removal which causes erythropoesis activation and leads to decrease of iron stores. red cell apheresis is an optional method for removing of higher amount of erytrocytes in one session. we performed red cell apheresis in patients with diagnosis of hereditary hemochromatosis ( ¥ c y homozygotes, ¥ c y + h d heterozygote) using haemonetics mcs p cell separator (protocol tae) in which red cells are removed from patients in - cycles; plasma and buffy-coat are reinfused. collection time, donor convenience, side effects and red cell yield were recorded and analysed. samples for hematology and iron studies in patients were drawn, analyzed and compared to baseline levels. background: the collection of units of red blood cells by apheresis (drbc) has been reported to be safe and effective in increasing the yield of rbc units from a donor population. however several reports demonstrated the risk of inducing iron depletion when the interval between a drbc donation and a subsequent rbc donation is shorter than days. aims: to evaluate the recovery from anaemisation and iron stores depletion after drbc donation. methods: donors who underwent drbc donation between december , and february , have been enrolled in a follow up program to monitor haemoglobin (hb), htc, serum iron and ferritin values. these parameters have been assessed on the day of donation and, thereafter and days after drbc procedure. donors suitable to drbc apheresis had to have: age between and years, weight > kg, hb > . g/dl and serum ferritin between and ng/ml. a written informed consent about the collection procedure and the follow-up program has been obtained from all the enrolled donors. drbc collection procedures have been performed by using a mcs + (haemonetics) cell separators. results: out of donors who donated drbc during the study period, only males completed the follow up program and have been analysed. baseline haematological values and iron metabolism parameters were: mean hb . ± . g/dl, ferritin ± ng/ml, serum iron ± microg/dl. on day mean hb was . ± . g/dl (p < . ). on day mean hb was . ± . g/dl (p < . ), ferritin ± ng/ml (p < . ), serum iron ± (p ns). only out of donors ( %) had a ferritin value > ng/ml. in the studied donors the collection of units of rbcs induced an expected reduction of about grams of hb, however only % of this reduction was recovered after days (p < . ). similarly, also iron stores have not been restored after months from donation, as shown by a % reduction in mean serum ferritin value. according to these data it appear that the amount of iron 'lost' with the donation of units of rbcs (approximately - mg of elemental iron) could not be completely compensated by iron absorption from the diet intake. further data are necessary to define the risk of iron depletion after the donation of a drbc, however, at least in areas where iron intake by diet is not very high, the opportunity to prolong the interval between a drbc and a subsequent rbcs donation beyond six months or to provide adequate iron supplementation therapy should be carefully considered. background: increased transferrin saturation and/or serum ferritin have been observed in italy in approximatively % of subjects at first blood donation and, in these subjects, hfe mutations prevalence was . for c y and . for h d (velati et al., ) . aims: the role of the c y mutation is well known in the patho-genesis of iron overload, whereas the role of the h d mutation remains uncertain. the aims of the present study were first to study the main hfe mutations prevalence in a random group of repeat blood donors and second to evaluate iron parameters and iron depletion in repeat blood donors heterozygous for the h d mutation in comparison to a population of blood donors wt/wt for the h d mutation. methods: a total of repeat blood donors were examined in italian transfusion centers ( in northern italy and in southern) for c y and h d mutations. out of those, blood donors heterozygous for the h d mutation and wt/wt for the same hfe mutation, both groups wt/wt for the c y, were enrolled to evaluate iron parameters and iron depletion. these two groups were similar for number of blood donations (expressed as iron loss) and for sex distribution. serum ferritin (sf) was the iron index recorded at first and second observation. results: table summarizes the allelic frequencies in the blood donors. table reports the haematological evaluation in the subjects heterozigous for h d mutation and the wt/wt for the same mutation. conclusions: these data suggest that subjects with h d mutation of the hfe gene have, at first observation, a higher ferritin levels than subjects wt/wt. this seems to be more evident in blood donors of southern italy than in northern. blood donation induces significant reduction of the iron stores both in h d heterozygous and in wt/wt subjects. although our observation is preliminary and restricted to a limited number of subjects, it seems worthwhile to extend the follow-up of blood donors h d heteroxygotes or even homozygotes when available, in order to get further insights on the h d role in iron metabolism. background: cd is a sialylated glycoprotein expressed on the surface of most hematopoietic cells and has been implicated in cell adhesion and signaling. consequently the levels of soluble cd as well as the expression on the cell surface is a marker of cell activation. furthermore, downregulation of this molecule has been correlated with increased susceptibility to infections. the myelodysplastic syndromes (mds) are a group of stem cell disorders characterized by ineffective hematopoiesis, refractory cytopenias and an increased risk of leukemic transformation. the mds patients are often introduced to transfusions for anemia improvement and present increased susceptibility to infections. aims: we studied cd expression in transfusion-dependent and non-transfused mds patient in an effort to investigate mechanisms of regulation of this molecule. we also studied other activationassociated antigens in the absence of manifest infection. material and methods: forty-two patients were included in the study suffering from refractory anaemia (ra). thirty-one were males and females aged to (median ). twenty of them had never been transfused (group a) and were regularly transfused (group b). nineteen age matched healthy individuals were used as controls (group c). cell surface antigens were detected by direct immuno-fluorescence evaluated by flow cytometer. the following mouse monoclonal antibodies were tested: anti-cd b, anti-cd , anti-cd , and anti-cd . leukocytes were gated according to cd . we used a sensitive sandwich enzyme linked immunoassay to measure the level of soluble vascular adhesion molecule as an indicator of endothelial cell activation. the r&d elisa kit was used according to the manufacturer's instructions. results: the cd was found down-regulated in the transfusiondependent mds patients compared with the non-transfused ones (p < . ) and controls (p = . ). this downregulation concerned the proportion of cd + cells, that was lower in the transfused patients than the non-transfused (p < . ) and controls (p = . ), and the rfi (relative fluorescence intensity) value that was also lower in the group a compared to the group b (p < . ) and group c (p = . ). negative correlation was observed between the cd expression and cd b (p = . ) and cd (p = . ). cd b was found up-regulated in the transfused patients. the rfi value was significantly elevated in the transfused patient compared with the non-transfused and controls (p = . and . respectively) while the percentage of cd b cells did not differ significantly between the various groups. increased expression of cd was also found in the group a compared to group b (p < . ) and c (p = . ). the proportion of cd + cells did not differ between the various groups. the levels of immuno-reactive svcam- as determined by elisa were found . + . in group a, . + in group b and . + . in the control group. conclusions: activated hemopoietic and endothelial cells are found in mds that may be associated to the vascular disorders found in these patients. cd downregulation may also be associated to increased susceptibility to infections in these patients. despite improved safety of the blood supply, allogeneic blood transfusion continues to be associated with risks that can be eliminated or reduced by autologous transfusion. preoperative autologous blood donation (pad) prevents transfusion-transmitted viral infection, red cell alloimmunization, and some adverse transfusions reactions. it may decrease the risk of postoperative wound infection because immunosuppression as a result of allogeneic blood transfusion is avoided. pad also supplements the blood supply, provides compatible blood for patients with alloantibodies and rare red cell phenotypes, accelerates erythropoiesis, and provides peace of mind to patients. as any medical intervention, pad has both advantages and disadvantages. with proper patient selection and dedicated attention to process control and quality assurance, the advantages outweigh. background: prestorage pooling of whole blood derived (wbd-pc's) buffy coat platelet concentrates (pc) is common practice in europe event-free survival was significantly better in patients who responded to epo + g-csf. we have reviewed data in centers and the gfm has the intention to extend the study to a larger population in at least centers in france blood components and preparations. the new law prohibits the mixing of different blood products, i.e. blood components and blood fractions. different methods are necessary for the quality control of blood components and blood preparations privileges for blood donors include: -a paid day off work on the day of blood donation and medical examination for blood donation additional paid day off work after blood donation an extra paid day off work if blood is given during vacation or on a holiday this award will be given to non-remunerated donors after blood donations or plasma donations. before , each 'honoured donor of russia' or 'honoured donor of the ussr' had three privileges: free use of public transportation, receipt of certain pharmaceuticals free of charge, and a discount on apartment utilities previously, municipalities also could have their own blood establishments. this resulted in more than blood establishments in the russian federation. from both administrative and financial points of view, many of these are too small to be costeffective, and should be discontinued. services, and wider implementation of modern technology for blood collection, testing, processing, storage, and distribution acknowledgements: we thank ksw microtec ag, dresden/ germany for sponsoring the rfid-labels and novatech research gmbh, vienna/austria for developing the clinic-software. background: the national preparation human immunoglobulin g % for intravenous use (ivig) that is produced at the serbian institute for blood transfusion is used in therapy of neurological, heartand haemolytic diseases and on patients that have undergone surgery. aims: it is our aim to prove the impact of this national medical preparation human immunoglobulin g % for intravenous use on patients that have been infected with sepsis as a consequence of surgery. material and methods: human immunoglobulin g % for intravenous use (ivig) has been used in the study. the preparation is liquid, % stabilised with glucose of a ph value of . ± . . it is used in those cases where sepsis developed after surgery. both an ivig group (n = ) and a control group (n = ) were viewed; the control group not being treated with ivig. the number of specimens with the ivig therapy cholecystitis is (n = ), and the control group (n = ); pancreatitis (n = ) control group (n = ); intestinal obstruction (n = ) control group (n = ); abdominal organ perforation (n = ) control group (n = ); abdominal perforate injuries (n = ) control group (n = ); serious abdominal interventions (n = ) control group (n = ). the period of hospitalisation of the patients in the ivig group was ± days while the period of hospitalisation in the control group was ± days. the mortality rate in the ivig group was % counter . % in the control group. summary: toxic gram -negative bacteria caused synergistic damage of human tissues and generalized inflammatory responsesepsis. by using human immunoglobulin g % for intravenous use, in cases of severe disease, the mortality rate is significantly lowered, depending of course on the anamnesis of the patient prior to surgery and the presence of other diseases such as diabetes mellitus, neoplasma, cardiac diseases etc. background: manual production pc from buffy coats (bc) is a procedure with some consecutive manipulations. the orbisac system (gambro bct) automates the steps and we assessed its performance. material and methods: pc were produced by this device and some parameters were studied. for the preparation of pc, bc were pooled using the orbisac set, with an integrated filter (pall lrp ). bc pool was resuspended in the additive solution t-sol in order to obtain a final ratio plasma/t-sol / . the pc was stored in a gambro elp bag. results: the average platelet count per unit was . ¥ e . the platelet recovery from pooled bc was . % (range . %- . %). all products of the tested pc containing < ¥ e wbc (by flow cytometry). the values of ph on day and of storage were . and . . the swirling phenomenon was good until day °. the average loss of haemoglobin per bc was . g.conclusions:the orbisac system is very suitable for routine pc preparation and it allows increased productivity and better standardization method for pc preparation. platelet concentrates met the requirements for leucodepleted product. increased production of plasma components from male donors background: we routinely separate whole blood (wb) after hard centrifugation into a red cell concentrate (rcc), a buffy coat (bc) and plasma (pl) by an automated expresser (compomat, fresenius). the bcs are subsequently processed into platelet concentrates (pcs) by soft centrifugation and an additional (manual) expression step. the atreus c system (gambro bct) eliminates several of those hand-on steps by combining them into one integrated process. a processing 'circular' bag is placed in the device and filled with the wb. while the bag is centrifuged, the system expresses pl, pc and rcc into separate containers. the rccs are subsequently leukoreduced (manually) with a filter (lr-rccs). this study was designed to evaluate the storage characteristics of the rccs obtained with a prototype of the atreus system in comparison to rccs obtained by routine procedure. methods: whole blood ( ml) was collected in top-and-bottom bags, and randomly selected to be processed by either ( ) current routine or ( ) atreus c. rccs were leukoreduced with the integrated inline filter: fresenius (routine group) or pall rc d (atreus). lr-rccs were stored at °c and sampled until day . various in vitro measurements were performed (n = per group).results: see table (mean ± sd). the lr-rccs contained significantly more leukocytes in the atreus group. despite the rbc loss in the bc, hemoglobin (hb) content was % lower in the atreus group, but met the requirements. in vitro storage characteristics for the rccs were similar in both groups. the atreus pcs contained ± ¥ platelets in ± ml. although plasma volume was higher in the routine group, subsequent preparation of pcs would have resulted in an additional loss of ml per unit in the control group. atreus plasma had extremely low levels of residual wbc and rbc. . ± . . ± . < < . aims: the aim of this study was to examine platelet quality of prestorage pooled prp-derived pc's for up to days storage. methods: pc's were manufactured from wbd-pc's using in-line filtration of prp on day . on day , either , , , or pc's were pooled into an elx® container using a sterile connecting device. studies were performed on days , and for the following measure of platelet quality. ph, morphology score (ms), extent of shape change (esc), hypotonic shock response (hsr), percent in surface expression of p-selectin (p-sel), phosphatidyl serine (ps), glycoprotein b (gp b) and by thromboelastography of the prp (maximum aplitude, ma). results: a total of pools were studied, each of , , and pc's. the mean platelet yield was . ¥ e with a range of . - . ¥ e . the five pc's had a mean yield of . ¥ e and all maintained a ph > . on day . all products had less than ¥ e residual wbc. platelet quality data is presented in the table. data are the mean ± sd, n = . conclusion: platelet pools manufactured from pc's produced by inline filtered prp and stored in elx® containers show good quality preservation to day over a range of platelet yields. introduction: the big progress in treatment of critically ill children significantly increases the need for blood and blood products. loss of blood (lowering of the total erythrocyte mass), as well as decreasing of oxygen capacity of blood that can influence cardiovascular function, is main indication for the erythrocyte transfusion. aim of the study: to present the number of erythrocyte concentrates (ek) that were issued to the pediatric clinic in skopje, as well as to point out how they were distributed. material and method: this is a retrospective study performed in nitm-skopje from january till may . the following criteria were followed: hemoglobin (hb), hematocrit (htc), as well the clinical evaluation, and then final decision for transfusion was made.results: there were blood units (ek) issued for the mentioned period to pediatric clinic for pediatric patients (~ , % units/per child). the biggest consumers are children at intensive care unit and at the hematology-oncology unit. one unit of leukodepleted erythrocytes (er) was split equally to - bags. for small and prematurely born children and for some other selected patients er unit was filtered and irradiated. the dosage was - ml er (depends on age and body weigh). ek was issued as washed concentrates, ek were filtered and ek were resuspended in ab plasma. distribution among abo system was the following: conclusion: gynecologic patients consumed rbc more than times than obstetric ones ( vs ) and the number of given transfusions is high. the a blood group is the most needed one. we should insist on using the who guidelines for the proper clinical use of blood and try to minimize the percentage of given transfusion. and z. cermakova university hospital, ostrava, czech republic background: fully automated system olympus pk is an immunohaematological analyser for detection of red blood cells antigens of ab , rh (d, c, c, e, e) and kell systems without centrifugation by mam (microplate agglutination method) on unique terraced microplate olympus. in the czech republic analyser pk is used only in blood center ostrava. aim: to evaluate the validity of results, sensitivity of microplate agglutinaton method, cause of abortive tests, requirements for analyst, capacity and reliability. methods: blood samples of donors were tested between july and january . all samples were analysed for ab blood group. samples were tested for rhd antigen and ones for rh (c, c, e, e) and k antigen. the validity of the results was evaluated for ab with parallel testing antigens and antibodies, while for rh (d, c, c, e, e) and k using two diagnostic serums. sensitivity of mam i.e. occurrence false negative or positive results were found out when results were confronted with previous ones in our data bank acquired testing classical manual tube or microplate methods. requirements for analyst were evaluated in according to demands for needful knowledge for new analyst, necessity of control pk during testing and maintenance. capacity were evaluated as a number of samples tested per day. reliability determine by occurrence disorders. results: ab , rh (d, c, c, e, e) and k were investigated truly by first testing at . % samples. two diagnostic serums anti-d olymp igm and totem differentiate directly rhd negative and rhd positive donors. false negative or positive results were not founded out due to mam or quality of diagnostic serums. about . % samples with abortive tests were analysed next time the same testing or manual technique. causes of abortive tests were microagglutination several samples except for anticoagulative edta, weak solution of red blood cells prepared by analyser, damage of microplate, hemolysis due to impurity of microplate. in one case analyser evaluated false ab blood group due to hemolysis. analyser has friendly software, simple maintenance and sound control during testing, capacity about samples per day and minimal occurrence of weighty disorders. conclusion: analyser olympus pk is an effective alternative full automation for medium serological laboratory and together with mam easy and truly proves blood groups of majority samples with minimal necessity repetition due to abortive tests. introduction and aim of the study: the purpose of this study is to establish nested-pcr for the detection of hepatitis b virus (hbv) in blood and blood products. methods: the primer pair set was designed to amplify bp in sregion of hbv genome in the first pcr and bp of first pcr amplicon with rubisco (internal control) in the second pcr. to assess the specificity of pcr results, all the samples were tested cross-reactivity or interference in the assay. results: in case of hbv spiked blood products such as immunoglobulin and coagulation factors, this method could detect hbv dna up to . iu/ml. nested-pcr was compared with pcr-elisa and hybrid capture ii (hc-ii), the pcr-elisa showed a sensitivity of % (hc-ii; %) and a specificity of % (hc-ii; %) (p < . ). the results of the study show that nested-pcr and pcr-elisa could be used equally in the management for hbv detection in blood and blood products. p- blood component therapy: slow improvement a mrdja health center subotica, subotica, serbia background: transfusion department at general hospital was founded in . since that time till now it has answered to all demands in blood and blood components. aim: the aim is to present development of the transfusiology department in the last years, so that we could see how much of scientific knowledge we have adopted and in which direction our department goes at the moment. method: retrospective analysis of blood/component utilization in period from . january to . december . results: in whole blood participated in the consumption with . %, packed red blood cells with (rbc) only . %, washed rbc were used in . % of the cases. in whole blood participated in the consumption with . %, packed rbc with . %, washed rbc with . % and rbc in additive solution with . %. as far as plasma preparations are concerned, there has been, since , a great consumption of plasma -witch was separated from whole blood in period up to five day in . % cases, and small consumption of fresh frozen plasma (ffp) only . %. since , there has completely been cancelled the production of five day old plasma, only ffp is being used. from to for the patients who needed platelets, platelet rich plasma (prp) was prepared and applied right after preparation. the consumption rate was from units to units per year. in , after the purchase of platelet shaker, began the production of platelet concentrates (pc) and consumption suddenly rose from units in to units in . conclusions: it is obvious from the analysis that irrational consumption of whole blood was reduced to more acceptable values and therefore the use of component therapy got increased. variation in blood consumption and its slight increase is obvious though application red blood cells was conducted according to strict indications. in the production of plasma old up to five days was cancelled and instead we produced only ffp. pc we prepared for patients only in agreement of treating physician. although very slow progress in development of transfusion therapy in our department can be seen in accepting scientific knowledge. transfusion specialist are active participants in patient treatment and by accepting scientific achievement are able to set standards and help our colleagues, clinics, in successful hemotherapy. introduction: blood groups may act as receptors of parasites, bacteria and viruses. there is evidence that they perform a function and play a biological role. objective: the aim was to detect abo and p epithopes in ascaris lumbricoides extracts (ae) and to study the presence of immune antibodies in patients with ascariasis. materials and methods: ae were prepared by refrigerated mechanical rupture of adult specimens. agglutination inhibition (ai) and haemogglutination kinetics (hk) tests were made with the ae. the patients´ abo and p blood groups were determined. we total febrile non haemolitic male transfusion reaction f e m a l e alloimunisation on le/hla male antigens f e m a l e kandidates of renal male transplantation female lupus nephritis male f e m a l e total female male introduction: irradiation of blood product has been in routine use to prevent graft-versus-host disease (gvhd) in certain recipients for many yeas. gamma irradiation can abrogate the ability of lymphocytes to proliferate in vitro, cgy of gamma radiation reduce lymphocyte response to mitogens by %.the aim of the study: . to estimate potassium level increment in stored irradiation blood units. . to compare the increment in potassium level between leucodepleted and non leucodepleted, irradiated stored blood units. . to evaluate the expiratory date of blood units post irradiation. the study included units of blood collected in cpd-adsol (as- ). in twenty units the blood collection bag was with inline leucodepletion, while the other units were non leucodepleted. all the units were irradiated using caesium as a source of irradiation, with a dose of - cgy. baseline samples from the bags were obtained for measuring of extra cellular potassium (k+). control samples included. results: there is statistically significant increment in potassium level in the irradiated samples compared to the non irradiated samples starting from st day post irradiation and continues to day post irradiation. comparing the group of irradiated leucodepleted, with irradiated non leuconondepleted, for potassium level estimation during the days of storage post irradiation. there is no statistically significant difference between the two groups during all the days of storage, starting from base line samples and other samples post irradiation until day , p value of more than . . . gamma irradiation of bloods units can cause cell damage that the use of such components needs to be modified. . there is a significant increment in the extra cellular potassium level in irradiated blood units that shows doubling value within h post irradiation. . there is no significant difference in extra cellular potassium level increment post irradiation when prestorage leucodepleted units are compared with non leucodepleted units. . an out date of days post collection (unless they expired before) for irradiated red blood units seems reasonable to ensure transfusion of irradiated units without serious complications, except in neonates and massive transfusion cases where irradiated blood units should be fresh and used within - h post irradiation. . the percentage of irradiated blood units requested by our physicians ( . %) is very less that reflects the needs of physicians awareness of the indications for requesting irradiated components that can prevent serious post transfusion complications. the use of whole blood and blood components in treatment of surgical patients in ten years period was analyzed in iran. in accordance with world trend of using blood component therapy, in medical centers throughout the country in ten years period, there are decreasing trend of using whole blood from % ( ) to . % ( ) and increasing trend of using packed red cells component therapy from . % ( ) to . % ( ) . there is also increasing trend of using fresh frozen plasma (ffp) from . % ( ) to . % ( ) . comparing and year, in use of blood therapy related to hospitalized patients at surgical department who received blood and patients who did not received blood; it appears that there is statistically significant difference between these two years. results: during year period, a total of units of blood and units of f.f.p were used. more specifically, the results can be shown in the following table . a high rate of f.f.p usage is observed both in surgery and pathology clinics. the main causes of its usage are: haemodynamic disorders -volume depletion, and coagulation disorders and low blood protein, for the two clinics respectively. conclusion: the only way for rational usage of f.f.p is the regular reminding of plasma transfusion indications to the clinical doctors, so that undesirable side-effects caused by plasma transfusion will be reduced and the percentage of plasma used for fractionation will increase. acquired factor v inhibitor is extremely rare and is associated with diverse clinical symptomatology that varies from asymptomatic forms of the disease to very severe hemorrhagic episodes with a potentially lethal outcome. it may occur spontaneously or as a result of various clinical conditions. a -year-old man was admitted to our hospital with a diagnosis of left-sided periscrotal abscess and scheduled for an incision procedure. during the routine preoperative procedure screening coagulation tests showed pathologic values: aptt s, pt %, fibrinogen . g/l, fv % (other factors were in normal range), platelet count ¥ /l. factor v inhibitor was detected by a modified bethesda assay. the assay showed a low level of inhibitor of about . bethesda units (bu). the patient's medical history showed no major morbidity except appendectomy performed years ago. the patient was prepared for operative procedure, with preventive preoperative administration of fresh frozen plasma (ffp) in a dose of mg/kg (~ ml). upon ffp transfusion, repeated determination of the factor v plasma was unchanged from the initial finding ( %), indicating a failure of therapeutic response. as the measured level of factor v activity was at the borderline hemostatic level, and the operative procedure was not associated with a high risk of hemorrhage, the patient underwent abscess incision. the procedure and postoperative course were uneventful and without major hemorrhage. laboratory testing for the possible systemic autoimmune disorder produced normal findings. control examination performed two years later revealed no major clinical or laboratory variation, while a low factor v level persisted ( %) along with the presence of factor v inhibitor at a level of . bu. we have evaluated two groups of rcc's, one we routinely use (quadruple leucoflex lcr t/t cpd/sagm) (macopharma) and one using an automated collection device which gives the ability to collect whole blood in cpd with a rate of : respectively during the whole donation. the mentioned system has been evaluated using the suitable, quadruple leu-coflex lcr t/t cpd/sagm (macopharma). whole blood ml in cpd was collected from random donors. in both groups the whole system was stored at scaled r.t. ± °c for to h. after component separation (beckman coulter j mi-optipress i-baxter), the red cell concentrates were filtered immediately at r.t. ± °c. sampling was done after filtration and wbc measurements were determinated using nageotte champer (bright line-detection limit . wbc/ml) with leucoplate solution (sobioda). the other parameters were measured with (celldyne abbott). conclusion: all products met the accordance of national and european norms for blood components quality. leucodepletion with leucoflex lcr and abc leucoflex lcr ( . and . ) is highly efficient. the use of abc leucoflex lcr showed better scaled donation in terms of collection (statistical analysis mann-whitney, minitab p-value = . < . ). additionally less hb-loss occurred, due to the filtration process, most probably due to the total absence of clots (analysis man-whitney, minitab, p-value = . < . ). this new generation of collection gives the ability in blood services to collect well calibrated donations, indoors or outdoors. smaller quantities of donations theoretically can be valid because of the stable : , rate of donation. the abc system gives the ability of fully traceability during donation. macopharma's blood collection bags, with or without integrated filters, provided they have this modified system of storing the ac. the device can keep records for many parameters and can transfer them to the data base server of the blood center. to evaluate the performance of the abc, we conducted a comparative study between abc leucoflex lst system and leucoflex lst system we currently use. the later is a well known macopharma's system for collection of whole blood with integrated whole blood filter and the final production of one unit of leucodepleted crcs and one unit of leucodepleted plasma. the abc was handled with the same system modified with the storage bag for the ac. issues of comparison were the accuracy in donation volume, the duration of filtration, the loss of blood in the filter and the residual wb cells after filtration. we performed donations with the lst system and donations with the abc lst system. all the donors were random male volunteers and they were meant to donate mls of whole blood. our results analysed by mann-whitney, minitab statistical analysis have as follows: . no significant difference was found between the two systems concerning the whole blood volume, but there was broader distribution of the values in the lst system compared to the abc lst system. . the duration of filtration has been found without statistically significant differences between the two systems. . the loss of volume in the filter of lst is higher than in the abc lst (p = . < . , which is statistically significant). . there was very good leucodepletion with the lst systems (median reduction of the wb cells . log) but there was a superiority of the abc lst over the lst concerning the leucodepletion per litter and per unit (p: . and p: . respectively). . the personnel after a very short period of training accepted fully the abc procedure.in conclusion abc is an easy to handle device which provides with high quality blood products in combination with leucoflex lst . evaluation of a post-storage filter for wbcs with an incorporated waste bag for washing rccs leucolab lcg is a system manufactured by macopharma for poststorage filtration of a rcc unit (with or without an incorporated waste bag for further washing of the filtered product). to evaluate the efficiency and reliability of the above system we conducted a study with twenty three random units of rccs stored in cpd/sag-m, aged - days, filtered and consecutively washed with ml of normal saline, span down in the regular way and the supernatant extracted in the waste bag. issues for evaluation were: . the duration of priming and filtering the rccs. . the loss of volume in the filter. . the efficiency of the filtration. . the acceptance of the personnel of a new (to them) filtration system.our results have as follows: . we counted the duration of priming and filtration. median time of priming was s (range - ) and of filtration was min (range - ). . the median volume lost in the filter (as calculated) was . ml (ranging from . to . ). this narrow range is apparently due to the non-flexible cell of the filter. . the efficiency of the leucodepletion was counted by flow cytometry. the median wbc counted per lt was . ¥ (range . - . ¥ ) and per unit was . ¥ (range . - . ¥ ). the median reduction of the wbc count was . log (range . - . ). . the personnel involved in the procedure found the system easy to handle, even without specific training. in conclusion the lcg is a reliable and easy to handle system, for leucodepleting (and washing) rccs, very efficient in removing wbcs with negligible loss of volume. objective: standardization of blood banks and establishing quality assurance are important landmarks in the new era of transfusion medicine. as the number of blood banks grows and the capacities of them changes, centralization need arises and trends to nationally coordinated blood services eventually appear. aim: to investigate the types and capacities of blood bank in the country and evaluate the statistics of them. material and method: blood banks and transfusion society of turkey conducted a nation-wide survey of a comprehensive questionnaire. this is a preliminary report of this investigation and illustrates the capacities of the most blood banks in turkey. it also guides the nationally planned renewing structure of blood banks. results: there are nearly blood banks and blood stations in whole country. the overall blood collected at those centers is about . . units. nearly one in third is being collected at government hospitals ( . %), nearly the same is collected at university hospital blood banks ( . %). the third major group is the red crescent society blood centers-rcsbc ( . %), followed by the social security hospitals ( . %). blood collecting capacities are not appearing in the same order. the major blood banks belong to the rcsbcs, whereas the small ones are mostly government hospitals. the only donor recruitment organization is run by the rcsbcs. yearly blood collecting capacity blood banks (%) > . . . - . . . - . . . - . . < . . conclusion: there are many steps for improving blood safety in a country, and the prior ones are structuring the blood transfusion system and donor organization on a national basis, and then establishing good manufacturing practices. these are only possible after centralization of all existing blood banks. in our country, we should first arrange all small capacity blood banks and standardize them. controversial clinical questions considered in a medical opinion forum by physicians for the advancement of transfusion medicine (patm) patm is a newly formed group of close to physicians drawn from pathology and hematology, transfusion services, hospital blood banks and blood centers. its mission is to address the concern that patient oriented medical opinion and influence has been diminished in transfusion medicine (tm). they believe that a patient oriented voice should be distinct from institutional, commercial or regulatory weight and have a common focus on patients and the therapeutics of transfusion and related therapies. therefore, their first objective is to create a new medical, patient oriented voice that weighs in on national policy pertaining to treatments related to tm. as such, patm held its first medical opinion forum where members of the group debated important questions pertaining to tm clinical practice. the forum was held just prior to the aabb annual meeting and attracted physicians. the questions debated were preselected by patm membership via an email survey. respondents were asked to select their top four preferences from among topics in five broad categories. the top two topics were selected for the forum from the completed surveys. the subjects selected and debated were (i) what are the medical considerations for reducing the rate of mistransfusion? and (ii) what are the medical considerations for managing a limited blood inventory? the participants were divided into four groups, with each topic assigned to two groups. all the groups were given two h to debate and arrive at consensus on their topic. each group then presented a summary of their discussions along with specific recommendations for addressing these clinical practice issues. there was remarkable consensus between the groups debating the same issue. the conclusions and recommendations on these two topics will be presented in detail. patm is a new organization that will add an important medical voice and opinion on current topics in tm. at its first meeting, two topics were successfully discussed and debated with broad consensus achieved on current issues confronting the field. key: cord- - zotqreu authors: dong, fen; zhen, kaiyuan; zhang, zhu; si, chaozeng; xia, jiefeng; zhang, tieshan; xia, lei; wang, wei; jia, cunbo; shan, guangliang; zhai, zhenguo; wang, chen title: effect on thromboprophylaxis among hospitalized patients using a system-wide multifaceted quality improvement intervention: rationale and design for a multicenter cluster randomized clinical trial in china date: - - journal: am heart j doi: . /j.ahj. . . sha: doc_id: cord_uid: zotqreu abstract background venous thromboembolism (vte) is a life-threatening disease that can affect each hospitalized patient. but the current in-hospital thromboprophylaxis remains suboptimal and there exists a large gap between clinical practice and guideline-recommended care in china. methods to facilitate implementation of guideline recommendations, we conduct a multicenter, adjudicator-blinded, cluster-randomized clinical trial, aiming to assess the effectiveness of a system-wide multifaceted quality improvement (qi) strategy on vte prophylaxis improvement and thromboembolism reduction in clinical setting. hospitals are randomized into intervention or control group. in intervention group, hospitals receive the concept of appropriate in-hospital thromboprophylaxis plus a multifaceted qi which encompasses four components: ( ) an electronic alert combining computer-based clinical decision support system and electronic reminders, ( ) appropriate prophylaxis based on dynamic vte and bleeding risk assessments, ( ) periodical audit and interactive feedback on performance, ( ) strengthened training and patient education. in control, hospitals receive the concept of recommended prophylaxis alone without qi. thromboprophylaxis will be at the discretion of hospitals and conducted as usual. with a final sample size of hospitalized patients in hospitals on mainland china, this trial will examine the effect of qi on improvement in thromboprophylaxis and patient-centered outcomes. this is an open-label trial that patients and healthcare professionals will know group allocation after enrollment, but endpoint adjudicators and statisticians will be blinded. rct# nct conclusions the system-wide multifaceted qi intervention is expected to facilitate implementation of recommended vte prophylaxis in hospital, thereafter reducing vte incidence and relevant adverse events among hospitalized patients in china. venous thromboembolism (vte) is an emerging health threat affecting hospitalized patients. approximately - % vte are hospital-associated vte (ha-vte) that occur during hospitalization or within days after discharge , underlying more than % of vte burden on population . it is a global problem faced across countries to enhance healthcare providers' adherence to recommended care and facilitate implementation of appropriate thromboprophylaxis, we develop a system-wide multifaceted quality improvement (qi) strategy. a multidisciplinary group of hospital staff (doctors, nurses, administrators, pharmacists, etc) from a wide range of departments will be engaged to carry out the qi. given that each inpatient has at least one vte risk factor during hospital stay , , qi strategy needs to be comprehensive and systematic for the delivery of thromboprophylaxis to all patients. to examine its effectiveness on vte reduction and determine how best to implement the recommended prophylaxis, we conduct a multicenter cluster randomized trial. eligible hospitals will be selected from chinese prevention strategy for venous j o u r n a l p r e -p r o o f / conduct this multicenter trial to assess effect of qi on thromboprophylaxis in a large-scale patient population. initially, this trial was scheduled to start in february but delayed due to covid- outbreak. currently, the epidemic is under control and hospitals are returning to normal work. we will continue to perform this study with a baseline survey to assess hospital eligibility in april and complete hospital randomization in the following month. the primary objective of this study is to determine whether the system-wide multifaceted intervention increases appropriate vte prophylaxis rate in hospitalized patients and decreases incidence of any hospital-associated vte within days after hospital admission. the secondary objective is to reduce safety events, including death incidence (i.e. all-cause mortality, vte-related mortality) and complications related to prophylactic interventions (e.g. major and clinically relevant non-major bleeding, thrombocytopenia) during the -day follow up. in this multicenter two-armed adjudicator-blinded cluster randomized trial, eligible hospitals are selected from chips-vte study network, which includes secondary and tertiary hospitals across mainland china. randomization and interventions are convened at hospital level. during the study period, hospitals in both arms will receive the concept of appropriate vte prophylaxis. in qi group, a multifaceted j o u r n a l p r e -p r o o f / intervention will be delivered systematically to facilitate implementation of the recommended care while hospitals in control just receive the concept without qi. in-hospital thromboprophylaxis will be at the discretion of hospitals according to usual care. this is an open-label trial that group allocation will not be blinded to either patients or healthcare professionals. to objectively assess outcomes, adjudicators not involving in study design will assess outcomes. the study is anticipated to be completed in months, starting from hospital selection, patient enrollment, intervention in hospital, -day follow up after admission, and data collection of the last patient ( figure ). to ensure implementation of quality improvement intervention during study period, participating hospitals will be selected from tertiary hospitals where electronic information systems are accessible and computer-based clinical decision support system (cdss) can be embedded. the eligible hospitals will be determined within chips-vte network ( figure s ). we plan to select hospitals fulfilling eligible criteria and enroll patients consecutively at each hospital (table ) . see statistical analysis plan section for details on sample size estimation. the enrollment is expected to be completed within the first - months. the study population comprises patients admitted to nine high-risk departments ( enrolled consecutively until the sample size is met. intervention is applied to all inpatients admitted to the target departments. we will conduct a baseline survey for hospital eligibility assessment, including hospital characteristics (hospital grade, availability of his, medical and surgical departments, etc.), hospital directors' willingness to participate in the study, and current status of in-hospital thromboprophylaxis. there are tertiary and secondary hospitals in chips-vte network. we deploy a stratified sampling method to select hospitals from the network ( figure s for details). stratified permuted block randomization will be adopted to assign hospitals into either qi or usual care group. hospitals are units for randomization with group allocated at hospital level. by stratifying hospitals into those above or under the median prophylaxis rate obtained in baseline survey, hospitals alphabetically ordered by names will be randomized into each group with a varying block size of or within strata. the randomization procedures will be organized centrally by statisticians in the randomization center. to guarantee blindness to group allocation, hospital j o u r n a l p r e -p r o o f / enrolment phase, an independent recruiter responsible for enrollment will be masked to hospital allocation. they will not know the allocation sequence until eligible patients are enrolled. afterwards, interventions assigned to the hospital will be delivered to individual patients by doctors. at each hospital, we schedule to enroll eligible patients consecutively with an average number of hospitalized patients enrolled from departments. patients admitted to the targeted departments and signing informed consent will undergo assessment for eligibility in screening phase. the enrolled patients and those with screen failure will be compared to evaluate potential selection bias. after enrollment, patients receive interventions assigned to hospitals. in the newly issued guidelines - , risk stratification is recommended to guide appropriate thromboprophylaxis. each patient needs undergo vte and bleeding risk assessments, particularly when they are admitted, transferred to another department, or their disease conditions change greatly. validated risk score toolkits are utilized for this dynamic risk monitoring. identifying patients at diverse risk for vte and bleeding helps determine appropriate prophylactic interventions. if patients are at risk of vte and have bleeding risk factors (eg, recent bleed, thrombocytopenia, active bleeding) , mechanical intervention, eg. graduated compression stockings, j o u r n a l p r e -p r o o f / intermittent pneumatic compression, and venous foot pumps, is the appropriate prophylaxis approach. it is an alternative for patients contraindicative to anticoagulant prophylaxis, the use of which could lead to bleeding and safety events. if patients have low bleeding risk, pharmacological prophylaxis is preferred over mechanical ones. overall, both thrombosis and bleeding risk assessments are recommended for an optimal decision-making in clinic practice. thromboprophylaxis approaches may need adjustment accordingly due to patients' changing risk during hospital stay ( figure , figure ). to implement the aforementioned recommendations, we design a multifaceted qi intervention, which entails four components that interact mutually. it is applied in a wide variety of inpatient settings, including surgical and medical patients. conditions, transfer to another department and discharge. data in emr will be captured to ascertain the implementation of risk assessment and appropriateness of prophylactic prescriptions. in case of uncompleted risk assessment or improper prophylaxis intervention, medical records submitted by medical staff will be blocked and an e-alert will be sent to remind the staff to correct. performance adjustments are needed until requirements are met. all the computer programs and e-alertness will be well designed and tested in the hospitals assigned to qi group. simultaneously, real-time data monitoring and feedback will be accomplished via the electronic system. a cyclical model of predefined performance measures is designed to automatically analyze and provide feedback on quality of prophylaxis. when administering qi intervention, doctors and nurses' behaviors will be reviewed and audited by health administrators. some in-process metrics (vte and bleeding risk assessments within hours after admission, dynamic risk assessment, appropriate vte prophylaxis) and outcome metrics (ha-vte incidence, clinically relevant bleeding and mortality) will be calculated and sent to medical staff and health j o u r n a l p r e -p r o o f / administrators via cdss for audit. ( ) dynamic vte/bleeding risk assessments risk factors for hospital-associated vte are well characterized, enabling the use of vte risk assessment to identify high-risk population for early and appropriate prophylaxis. according to existing evidence , , we recommend the use of caprini risk score for vte risk assessment in surgical patients while padua risk score be used to assess vte risk in medical patients ( table ). all admitted patients undergo vte assessment. nurses perform the initial assessment and doctors confirm the results. meantime, patients' age, comorbidities, trauma history, medications, invasive procedures and other factors are assessed for bleeding risk by doctors. as disease conditions change during hospital stay, patients need to be assessed for vte and bleeding risk repeatedly. dynamic assessments are scheduled to be done at admission, transfer to another department, a significant change in disease conditions, and at discharge. ( ) regular audit and interactive feedback on performance performances of medical staff (doctors and nurses) are audited monthly by vte prevention committee, which comprises hospital directors, medical and nursing directors, and health administrators. using the audited data, the committee sends reports to medical staff, including the overall thromboprophylaxis, in-process and outcome metrics, root-cause analysis of vte safety events, and measures for quality improvement. in the context of missed risk assessments or inappropriate prophylaxis j o u r n a l p r e -p r o o f / delivered, an electronic alert will remind health administrators, who in return send feedback to responsible medical staff and urge them to administer interventions in accordance with the recommended care. the initial feedback will be followed by an electronic reminder. medical staff's performances may need to be adjusted until the expected prophylaxis is delivered properly. ( ) strengthened hospital staff training and patient education on vte hospital directors and health administrators will receive trainings on the concept of ha-vte prevention, overall goal and operation mechanisms, and challenges that need to be tackled with. the trainings will be provided within days after hospital randomization. medical education focusing on vte risk assessment, prevention, diagnosis and treatment will be convened to doctors, nurses, pharmacists and other medical staff per quarter. the knowledge of vte are based on newly published guidelines and consensus - , - . likewise, education sessions will be offered to patients and family caregivers to increase their awareness on vte general knowledge. doctors or nurses provide the education when patients are admitted and discharged. during hospitalization, nurses will also instruct patients on the use of graduated compression stockings (gcs) or intermittent pneumatic compression (ipc). if not using correctly, patients will receive strengthened education until using these devices correctly. at discharge, guidance on thromboprophylaxis or anticoagulant regimen will be provided for patients or those remaining at high risk of vte. j o u r n a l p r e -p r o o f / in hospitals allocated to control group, patients will undergo usual care at the discretion of hospitals. vte risk assessment and prophylactic interventions will be performed according to existing practice in hospitals. nearly % surgeons responding to the survey routinely prescribed lmwh for patients with lung resection during hospitalization. acetylsalicylic acid was still used as a prophylaxis approach in common practice. time for starting vte prophylaxis was usually day after operation. the two surveys display current prophylaxis for ha-vte in china. to better understand usual care in control group in this study, we will conduct a baseline survey in recruited hospitals before cluster randomization, collecting information on vte and bleeding risk assessment, prophylactic approaches, initiating time for prophylaxis, etc. as our study population are medical or surgical patients admitted to the nine j o u r n a l p r e -p r o o f / departments with high vte incidence, patients in both arms will receive treatments targeted to diseases responsible for the admission. the treatment patterns and disease management will be at the discretion of doctors. additionally, vte incidence and bleeding events within days are important outcomes for effect and safety assessment. to enhance patients' self-reported outcomes, education on signs and symptoms of vte and bleeding will be delivered to patients during hospitalization in both groups. due to the nature of interventions, both doctors administering interventions and patients will know group allocation after enrollment. to ensure equal attention to two arms, data collectors, endpoint adjudicators, and statisticians will be blinded to group allocations. before intervention, a randomization schedule for hospitals will be pre-generated by an independent statistician unaware of hospital identity. during the intervention period, data managers and statisticians remain blinded to group assignment in data collection and monitoring. an independent data monitoring board will evaluate the trial data and safety. in order to objectively evaluate outcomes, adjudicators assessing thromboprophylaxis implemented in hospitalized patients, imaging results for vte diagnosis and other endpoints will be blinded. the primary endpoint is appropriate prophylaxis rate in hospitalized patients, defined bleeding not meeting the criteria for major bleeding but associated with medical intervention, unscheduled contact with a physician, temporary cessation of study treatment, or discomfort of pain or impairment of activities of daily life . hit is a fall in platelet count of > % from the highest platelet count after the start of heparin use with a positive laboratory test . safety events will be collected by phone visits at day and after admission. any endpoint or adverse events occurring during study period will be recorded. during study period, some key in-process and outcome metrics will be regularly monitored (table s ). caprini or padua scores, begun with the initial assessment within hours at admission until the last one at discharge, will be recorded in medical records. bleeding assessments are recorded simultaneously. appropriate prophylaxis is determined by vte and bleeding risk. mechanical or pharmaceutical interventions are adopted accordingly. to enhance medical staff's awareness on appropriate prophylaxis, trainings on indications and contraindications to mechanical prophylaxis or therapeutic anticoagulation treatment will be delivered per quarter. for to mechanical or therapeutic treatment are embedded into cdss system to prompt doctors while prescribing prophylactic regimen. in this study, data collection starts from patient enrollment and continues until completion of the last patient follow up. figures s demonstrates the process of data management and quality control. sample size is estimated based on the primary analysis of group difference in vte prophylaxis rate among hospitalized patients. the nationwide survey on thromboprophylaxis in china demonstrates an appropriate prophylaxis rate of . % in hospitalized patients . assuming a target clinical difference of % absolute increase through qi intervention, we anticipate an appropriate prophylaxis rate of . % in qi group. in this cluster trial with hospitals as unit of randomization, between-cluster variation is indicated by intra-cluster correlation coefficient (icc), one typically used index for such variation . icc is determined as . according to prior studies , . given the same cluster size with an equal number of patients per hospital (cluster), we plan to enroll patients from each hospital and approximately patients from each of the nine target departments. to compare between-group prophylaxis rates with : allocation, % power, % significance level, a cluster size of , . icc and % attrition, the sample size is calculated as patients according to j o u r n a l p r e -p r o o f / accessible to study investigators or authorized personnel. to comply with data safety regulations, only staff at the study center have access to patients' information. this study is approved by ethics committee in china-japan friendship hospital (approval number -ssw- ) and will be approved by ethnic committee in each hospital. it has been registered at www.clinicaltrials.gov (nct ). in this multicenter cluster randomization trial, intervention is applied at hospital level. written consent will be obtained from directors at hospital level with agreement for participation and randomization, avoiding selection bias potentially induced by differences in consent refusal between hospitals [ ] [ ] [ ] . qi intervention is supposed to be beneficial in ha-vte prevention among hospitalized patients through effective implementation of recommended prophylaxis. each participating hospital prefers to receive the qi interventions. to reduce hospital withdrawal, the qi interventions, if proven effective, will be delivered to all hospitals randomized to control group after completion of this study. in patient enrollment process, informed consent will be obtained from patients as well. written consent includes consent for information routinely collected in hospital, willingness to provide complementary data specific to this study, and permission for -day follow up. due to chronology of individual patient recruitment after hospital randomization in clustered randomization trial , this study is prone to selection bias j o u r n a l p r e -p r o o f / induced by unblinded recruiters or patients who are informed or aware of hospital allocation. to prevent such bias, recruiters in each hospital will be blinded to group allocation and enroll patients independently. partial information rather than full information will be provided to patients in enrollment process to avoid opt-out option in patients. the hospital allocation will not be specified to patients until they are enrolled and undergo intervention. chinese hospitalized patients and their unmet need in thromboprophylaxis . the qi can also be introduced into routine clinical practice to enhance care quality and reduce vte-related safety events. a systematic approach for ha-vte prevention in nhs england has been demonstrated to be effective in reducing post-discharge deaths with a . % reduction in -day mortality , indicating importance of a system-wide and multifaceted intervention for effective prevention of ha-vte and its related deaths. given the great disparities in health care systems, hospital protocols and structures across nations and cultures, chips-vte study will provide data on systematic and multifaceted implementation's effect on patient outcomes in developing countries. the present study has the following unique features: ( ) a multi-center cluster randomized trial is designed to minimize contamination across groups; ( ) uses of cdss and e-alertness in a wide variety of inpatient settings increase their applicability in daily practice. application of cdsss in this study will meet the increasing demand for health information technology regarding the growing concerns about quality of medical care in hospital; ( ) real-time and mutually interactive quality control via cdss enable qi intervention implemented properly among multidisciplinary hospital staff; ( ) a pilot study has been done to test the feasibility of multifaceted qi in clinical setting, enhancing feasibility of this multi-center trial; ( ) behavioral intervention in healthcare professionals through qi and usual practice in control will provide real-world evidence on effectiveness of qi on thromboprophylaxis improvement. the pragmatic design increases generalizability of meanwhile, there are several inherent limitations in this study. first, this is a cluster randomization trial with hospitals being randomized as clusters. hospital randomization occurs before patient enrollment, making allocation concealment difficult. selection bias may arise when unblinded recruiters don't enroll patients because their hospitals are not allocated to the group they expect to be in, which may also lead to hospital withdrawal . in addition, consent bias could be induced by patients who have been informed of or get known the group allocation before enrollment , . to minimize these bias inherent in methodology, informed consent needs to be handled differently from traditional randomized trials, in which randomization and intervention are administered at individual level. we will obtain well-informed written consent from hospital directors and agree to provide qi intervention to hospitals in control group after completion of the study. in patient enrollment phase, information on group allocation will not be provided to patients until they are enrolled. a blinded recruiter unaware of hospital allocation will recruit patients independently. with respect to effectiveness evaluation in this study, qi to select representative hospitals, we deploy a stratified sampling method based on geographic regions (northeast, north, east, south central, northwest, and southwest china) and baseline vte prophylaxis quality (median prophylaxis rate by region obtained from the survey). in each region, the number of selected hospitals will be proportional to the number of candidate hospitals. noteworthily, some core hospitals that provide optimal care in the region will be chosen purposively to represent the high quality of care in china. taking non-response into consideration, we increase the sampling rate to approximately %. if directors in selected hospitals decline to participate, the remaining unselected hospitals will be sampled randomly until a total of eligible hospitals are recruited. during the study period, information on patients' demographic characteristics, care provided, risk assessments, interventions and others will be entered into cdss. illogical data entries, ( ) tertiary hospitals with > beds that provide vte diagnosis and care, deliver medical education, and conduct research. ( ) have departments in which admitted patients are at increased risk for vte and thrombotic events can easily occur in routine procedures. the departments that typically have high vte incidence are respirology, icu, neurology, orthopaedics, general surgery, vascular surgery, neurosurgery, oncology, and gynecology. ( ) hospital electronic information system is accessible and cdss can be embedded for real-time monitoring and mandatory implementing qi intervention during the study; ( ) directors of hospitals wish to improve in-hospital vte prophylaxis and are willing to conduct multifaceted qi intervention systematically. ( ) hospitals that have already conducted qi intervention systematically preventing hospital associated venous thromboembolism interventions for implementation of thromboprophylaxis in hospitalized patients at risk for venous thromboembolism the cochrane database of systematic reviews trends in the incidence of pulmonary embolism and deep venous thrombosis in hospitalized patients vte risk profiles and prophylaxis in medical and surgical inpatients: the identification of chinese hospitalized patients' risk profile for venous thromboembolism (dissolve- )-a cross-sectional study trends in hospitalization and in-hospital mortality from vte antithrombotic therapy for vte disease: chest guideline and expert panel report prevention of vte in nonsurgical patients: antithrombotic therapy and prevention of thrombosis antithrombotic therapy for vte disease: antithrombotic therapy and prevention of thrombosis prevention and management of hospital-associated venous thromboembolism prevention, treatment and management of hospital-asociated venous thromboembolism guidelines on the diagnosis, management and prevention of pulmonary thromboembolism heparin-induced thrombocytopenia measures of between-cluster variability in cluster randomized trials with binary outcomes primary care management for optimized antithrombotic treatment [picant]: study protocol for a cluster-randomized controlled trial developments in cluster randomized trials and statistics in medicine. statistics in medicine methods for sample size determination in cluster randomized trials effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: a randomized clinical trial participant informed consent in rationale and design for a multicenter cluster randomized clinical trial in china fen dong admin ; tieshan zhang, md ; lei xia phd , , , ; on behalf of chinese prevention strategy for venous thromboembolism graduate school of peking union medical college, chinese academy of medical sciences and peking union medical college, beijing, china; department of information management formal analysis, writing -original draft, visualization. kaiyuan zhen: investigation, writing -original draft, visualization. zhu zhang: investigation, writing -review & editing. chaozeng si: software, jiefeng xia: software, resources. tieshan zhang: software, resources. lei xia: investigation, resources. wei wang: investigation, resources. cunbo jia: resources. guangliang shan: methodology. zhenguo zhai: conceptualization, methodology effect on thromboprophylaxis among hospitalized patients using a system-wide multifaceted quality improvement intervention: rationale and design for a multicenter cluster randomized clinical trial in china fen dong admin ; tieshan zhang, md ; lei xia phd , , , ; on behalf of chinese prevention strategy for venous thromboembolism graduate school of peking union medical college, chinese academy of medical sciences and peking union medical college, beijing, china; department of information management we thank all hospital directors within chips-vte network to participate in baseline survey and hospital eligibility assessment. doctors, nurses, health administrators, researchers, and patients' engagement in the study will be appreciated. j o u r n a l p r e -p r o o f  unmet clinical need in thromboprophylaxis remains in chinese hospitalized patients  the first pragmatic trial for improving in-hospital thromboprophylaxis in china  multifaceted quality improvement facilitates implementation of thromboprophylaxis  hospitals are randomized to either quality improvement intervention or routine care  real-world effectiveness of intervention on thromboprophylaxis is assessed key: cord- - h fk qt authors: kaur, rajwinder; yadav, bhoomika; tyagi, r.d. title: microbiology of hospital wastewater date: - - journal: current developments in biotechnology and bioengineering doi: . /b - - - - . - sha: doc_id: cord_uid: h fk qt the study of hospital wastewater (hww) microbiology is important to understand the pollution load, growth of particular pathogenic microbes, shift and drift in microbial community, development and spread of antibiotic resistance in microbes, and subsequent change in treatment efficiencies. this chapter investigates the potential microbes such as bacteria, viruses, fungi, and parasites present in hww along with the diseases associated and methods of treatment used. due to the indiscriminate release of antibiotics from hospitals, hww serves as a hotspot for emergence of antibiotic-resistance genes (args) and antibiotic-resistance bacteria. this chapter discusses the args occurrence in hww, their prevalence in the environment, the molecular tools used for identification, and different mechanisms of horizontal gene transfer. thus better understanding of the microbiology of hww could further help in development of advanced treatment technologies for effective removal of microbes and their bioproducts (toxins and infectious nucleic acid) from hww and contaminated water. wastewater includes any type (e.g., from agriculture, domestic means, industries, human excretion, commercial sectors, pharmaceuticals, healthcare units) of water which quality has been deteriorated under anthropogenic influence [ ] . hospital wastewater (hww) is quite different from the wastewater discharged from other sources and is hazardous and infectious. it consists of wide range of several micro-and macropollutants, discharged from operation (surgery) rooms, wards, laboratories, laundry, polyclinics, research units, radiology, and medicine and nutrient solutions used in microbiology laboratories [ ] . the micro-and macropollutants include radioactive isotopes, pharmaceuticals, stock cultures, heavy metals, media, pathogens, drugs, cotton particles, disinfectants, and chemical compounds [ ] . the contraceptive-rich pharmaceuticals present in hww were reported to be associated with effects of endocrine disruption, for instance, exposure to pharmaceutical waste containing estrogen or androgen caused sex reversals in fishes and thus, reproductive impairment [ ] . the hospital effluent discharged directly into the ponds has caused eutrophication, which is evident by oxygen depletion, dense algal blooms, and death of aquatic animals [ ] . the discharge of wastewater depends upon the capacity of hospital and generally water varying from to l/day/bed is consumed by the hospitals [ ] . the hww with many microbes and emerging infectious particles such as prions, viroids, and toxins is hazardous for the environment, and ultimately human health. however, in many countries, hww is directly discharged into sewage water without pretreatment, it then undergoes treatment along with the municipal wastewater but the treatment could not be sufficient to remove micropollutants from hww [ ] . moreover, the pharmaceutical compounds present in hww undergo biological transformation and form conjugate compounds, those toxicity could be even higher than the present metabolite [ ] . thus wastewater pretreatment methods designed for municipal wastewaters are not able to remove the pharmaceutical-related micropollutants or conjugate compounds, which are generally present in low concentration than other macropollutants (chemical oxygen demand, biological oxygen demand, phosphorus, and nitrogen) and thus, could not be removed using conventional wastewater treatment plant (wwtp) operations [ ] . moreover, the pathogens present in hww could cause microbial population imbalance in existing and operating municipal wwtp and metals or heavy metals present in the hww can affect the biological processes like nutrient removal. the heavy metals are in fact nonbiodegradable as compared with other organic pollutants and thus move to other pollutant sources [ ] . the hww can act as an ideal growth medium for various pathogenic microbes including bacteria, viruses, fungi, and parasites. the wastewaters from hospitals also consist of several resistant bacteria and antibiotic residues as well, which could inhibit the growth of susceptible bacteria, thereby increasing the population of resistant bacteria in the receiving water. resistant bacteria discharged into environment either act as vectors to carry a transmissible gene or as the reservoirs for antibiotic-resistance genes (args) that could pose a threat to public health [ ] . in addition, fungi which have capability to grow at faster rate and can spread their spores to external environment also pose a serious threat to environment and human health [ ] . the absence of specific pretreatment technologies for hww also increased the frequency of gastroenteric viruses in aquatic bodies [ ] . the direct discharge of hww into municipal wastewater containing disease-causing parasites has also increased the risk of skin infections and other harmful diseases in humans [ ] . the specific and advanced technologies are required to be developed for hww treatment to prevent the release of harmful contaminants into the environment. therefore the microbial community analysis of hww is utmost importance to assess the pollution load and to develop the specific treatment methods for protection of the environmental health. thus authors explain about the various pathogens present in hww, args, and tools used to study the args. moreover, metagenomics, a recent approach used to study different microbial communities and gene-specific identification, are also explained in this chapter. in addition, horizontal gene transfer (hgt) approach, which can efficiently contribute to spreading of args, is discussed briefly. the hww poses a serious threat to humans with respect to contagiousness and drastic spread of infective diseases in healthcare units, society, hospital employees, and environment [ ] . different solvents, pharmaceuticals, and radionuclides are used in hospitals for purpose of diagnostics, disinfection, and research. after the drug consumption, various drugs remain nonmetabolized or partially assimilate in the human body and thus excrete as such and end up into wastewater. the residual quantities of disinfectants used for treatment of skin microbial infection and to disinfect instruments and surfaces of hospitals, also end up in the hww, resulting in an increase in the population of pathogenic microbes. the pathogenic microflora present in hwws also come from medical devices, atmosphere, and water used in the hospital practice, and the pathogens are released mainly in the form of excreta of patients [ ] . therefore hww consists of a mixture of pathogenic microbes including bacteria, fungi, yeasts, algae, viruses, protozoa, parasites, and bacteriophages. the effluent from hospitals is usually discharged and treated with domestic wastewaters without any prior treatment [ ] . the pathogens in the receiving water, if untreated, survive for a long time in soil or water and enter into the food chain causing infectious diseases and health risks to human beings [ ] . due to the economic reasons and lack of resources for analysis of actual pathogens, certain bacteria have been used as indicators for contamination of water since decades [ ] (box . ). however, it has to be considered that removal of coliforms, which is indicator of fecal contamination, could not be directly correlated with removal of viruses, pathogens, fungi, protozoa, or other bacteria from water (samples) [ ] . in addition, the indicator bacteria such as escherichia coli and clostridium perfringens when compared with pathogenic bacteria, protozoa and viruses are more sensitive to inactivation through processes such as natural competition, wastewater treatment, and high temperature [ ] . traditional detection of pathogenic bacteria involves selective culture media and biochemical characterization methods. these techniques are inexpensive and simple; however, sampling error, time consumption ( À days), tedious, and monospecific detection (detection of only one type of pathogen) are the major limitations [ ] . the enzyme-linked immuno sorbent assay (elisa) is used for laboratory diagnostics of different pathogens. the polymerase chain reaction (pcr) has been adapted in many ways: nested pcr, multiplex pcr, real-time pcr, fluorescence, and digital pcr [ ] (box . ) for analysis of waterborne pathogens. criteria for selection: • should be present only in contaminated water, not in uncontaminated ones • should not be able to grow and proliferate in water • should be present in intestinal tract of warm blooded animals • should have similar survival pattern as pathogens present outside the host • should be easily detectable • should be useful for all types of water • should be relatively cheap to use total coliforms are higher in number than any other pathogens. the subgroup fecal coliforms indicate fecal contamination of water and thus, indicate the presence of other pathogens as well, which are lower in number, hard to detect. however, lower number of pathogens are enough to cause morbidity and mortality to humans. they are detectable by inexpensive cultural methods and do not pose any health risk to laboratory workers. however, there are few limitations of fecal indicator bacteria, which have been discussed in the text. biochemical tests, pcr, and sequencing [ ] (continued) bed-linens, or through infected patients [ ] . the hospital-acquired infections resulted in increase of methicillin-resistant s. aureus (mrsa) isolates. the mrsa is associated with infections of skin and soft tissues and has been a global threat for human health. in the united states, , cases of mrsa infections were reported in [ ] . e. coli and pseudomonas aeruginosa are also commonly found in hww along with other nosocomial pathogens including candida albicans, klebsiella proteus, and enterobacter species [ ] . most of the times, e. coli is harmless and is important part of human intestinal tract, but some of the strains are pathogenic to humans. the e. coli :h is related to many outbreaks of water and food-borne illness and also responsible for , hemorrhagic colitis (bloody diarrhea) cases in the united states annually [ ] . a study reported on hww of brazil also confirmed the presence of other bacterial species including citrobacter freundii, klebsiella ornithinolytica, proteus mirabilis, pantoea agglomerans, and serratia rubidacea [ ] . many c. freundii infections have been reported in bloodstream such as septic shock, pneumonia, hypothermia, oliguria, and thrombocytopenia [ ] . another bacterium p. mirabilis, which is found in hww, is responsible for urinary tract infections and is further accompanied by development of kidney stones [ ] . p. agglomerans mostly affects plants but also causes opportunistic infections in immunocompromised individuals causing skin infections [ ] . an important prospect about fluctuations of pollution was discussed [ ] , according to which, the microbial load present in wastewater was directly correlated to several hospital activities. the higher microbial load was present in hww during the day period as compared with evening and early morning. another study [ ] was also conducted on hww collected during early hours (eh) and late hours (lh) of the day in abia state, nigeria. the microbiological analysis revealed the presence of higher total bacterial count ( . cfu/ ml) at lh as compared with that ( . cfu/ml) at eh of the day. the similar results were also observed for total coliform count, which was also higher ( . cfu/ml) at lh as compared with that ( . cfu/ml) at eh due to the fact that hospital activities at night time were more restricted than day time. according to the recent study, the hww samples were collected from three hospitals in different cities of romania [ ] . three hospitals (h , h , and h ) were having different numbers of beds and inhabitants. the microbial community analysis results revealed that wastewater from h was dominant by . % of the proteobacteria phylum, while from h was dominant by . % of proteobacteria phyla followed by firmicutes ( . %), bacteroidetes ( . %), and actinobacter ( . %) and from h was dominant by . % of proteobacteria, bacteroidetes ( . %), and firmicutes ( . %) [ ] . the similar taxonomic composition was also reported in various studies using wastewater collected from different hospital facilities, nonhospital medical facilities, and municipal treatment plant [ , , ] . the dominant nature of proteobacteria was correlated to their presence in human feces, long-term survival ability in wastewater, and exposure to several antibiotics present in hww. moreover, the dominant nature of firmicutes could be correlated to their capacity to survive in extreme environmental conditions and high contaminant levels [ ] . in buelow et al. [ ] detected abundant bacterial taxa to be different from urban and suburban wwtp influents and comprised of camphylobacteraceae, aeromonadaceae, and carnobacteriaceae. hww also consisted of several different members of human gut microbiota such as of genus streptococcus and family ruminococcaceae due to the sampling location in close proximity of the hospital sanitation areas as compared with wwtp influent. these microbes are not well suited to survive in such complex environment, which results in progressively decreased levels of these bacteria in urban wwtp influent [ ] . another study compared the relative abundances of the most abundant bacterial orders in wwtp for years and showed that the wwtp environment was dominated by phyla actinobacteria, bacteriodetes, and proteobacteria, and the wastewater community was highly stable and unique to its environment [ ] . hospital sewage also contained high levels of anaerobic bacteria including genera such as bifidobacteriales, clostridales, bacteroidales that were likely to originate from the human gut [ ] . the release of antibiotics from hospitals results in creating a selection pressure on bacteria and as a result, effluents from hospitals contain high numbers of resistant bacteria as well as antibiotic residues. prevalence and spread of antibiotic-resistance bacteria (arb) in the environment are a major problem worldwide due to improper antibiotic usage and lack of effective hww management systems. therefore arb and args are particularly studied among the hospital contaminants. for example, one study reported e. coli from hospital effluent to be multiresistant toward ampicillin, streptomycin, sulfamethoxazole, cephalosporin, ciprofloxacin, and tetracycline [ ] . the hospital water environment includes potable water, faucets, wastewater drainage systems, and effluents can be the reservoir of nosocomial pathogens (arb such as mdr enterobacteriaceae, acinetobacter baumannii, and pseudomonas species), thus, increasingly dominating the hww microbiome [ ] . commonly found isolates such as p. aeruginosa, a. baumannii, and enterobacteriaceace in hospital effluents have shown carbepenem resistance and have disseminated around the globe [ ] . baricz et al. [ ] reported antimicrobial effect of a crude bacterial extract of janthinobacterium lividum against mdr bacteria of both clinical and environmental origin, for example, mrsa, methicillin susceptible s. aureus, enterococci, and enterobacteriaceae [ ] . such studies not only help to provide promising candidates for development of new antimicrobials but also to propose new or improved treatment technologies to reduce the burden of antimicrobial resistance (amr) in environment. the microbiological analysis of several hwws showed the prevalence of fungal species along with bacterial and coliform species. the fungi have simpler nutritional requirements and have higher capability to grow at lower water activity as compared with bacteria [ ] . moreover, the fungal populations can easily spread their spores to external environment, hence affecting the human beings directly [ , ] . this is the reason for its prevalence in hospital and clinical environment because if healthcare facilities are even considered free from fungus, but nature and environment factors such as temperature, moisture, and nutrients could provide easy and favorable conditions for the extensive growth of fungal species in storage containers holding clinical waste. the fungal infections could range from moderate to fatal depending upon the infection site as well as immune system of the affecting individual [ ] . the prevalence of invasive fungal species has been reported to increase since three decades, due to increase in number of immunocompromised patients. the moderate fungal infections include athlete's foot and ring worm infections (cutaneous infections) in immunocompetent patients and life-threating infections include mucosal and systemic infections [ ] . the fungal isolates, associated diseases, and treatment methods reported in various studies are presented in table À . the study reported by neely and orloff [ ] stated the prevalence of aspergillus species in the hospital waste collected from the united states and even worse than that, this species was capable enough to survive for more than a month on the hospital waste. the longer survival of aspergillus can result in reoccurrence of fungi and has higher chance to cause disease. moreover, many spores have capacity to remain dormant under adverse conditions and then again develop into fungi, when conditions become favorable. the other fungal species were also detected but the survival capacity of mucar ( . days), paecilomyces ( days), and fusarium ( days) species was lower than that of aspergillus species. the survival efficiency of different fungal species is related to the presence of specific structure of spores. the spores of aspergillus species are spiny and rough and thus capable enough to adhere to any type of waste and can survive longer time. however, spores of fusarium species are smooth and thus have less capability to adhere and survive. the wastewater collected from nigeria revealed the presence of total fungal count of . cfu/ml during the day time activities in the hospital [ ] . the most prevalence fungal species in the hww were aspergillus ( . %), followed by candida ( . %), cryptococcus ( . %), and penicillium ( . %) species. the fungal diversity ( species) was reported to be higher for waste samples collected from hematology section of malaysia hospital [ ] . moreover, gloves waste consisted of the highest number of fungal species ( species) among all the different types of waste collected from hospital. the high fungal count of cfu/ml was also reported in soil collected from hospital dumpsite, which was correlated with the presence of high organic material present in the hospital waste. the fungi are heterotrophic microorganism, which have capacity to consume organic compounds from the surrounding environment [ ] . the common fungal species identified in hospital waste were penicillium rubrum, penicillium viricadum, trichothecium roseum, rhizopus nigricans, aspergillus flavus, aspergillus parasiticus, microsporum canis, and aspergillus niger. among them, a. niger was found to be dominant fungal species with . % due to the fact that it released variety of enzyme such as amylases, pectinases, and proteases and had capacity to utilize number of organic compounds as a substrate [ ] . a. flavus and a. niger can cause disease named as aspergillosis and are considered as pathogens for both humans and animals. they can cause either bronchopulmonary (coughing and wheezing) or invasive aspergillosis (affects the lungs and could spread to throughout the body) [ ] . more than , cases and %À % mortality rate have been reported for aspergillosis infections worldwide. the nonpathogenic black bread mold called r. nigricans was also found in abundance with . %. m. canis can cause infection in upper and dead layer of skin of domestic animals, including dogs and cats and later on the humans can also get affected by the infection [ ] . other fungal species including t. roseum, p. viricadum, and p. rubrum are nonpathogenic fungus, which can only affect the humans with weak immune system. the curvularia species have also been reported to be present in hospital waste and can cause rare infections in the respiratory tract and cornea of human beings. curvularia lunata is also responsible for eumycetoma disease caused in farmers of chandigarh and rajasthan. most of the agricultural regions use azole fungicides (imidazole, metalaxyl, tebuconazole, and propiconazole). therefore the farmers responded poorly to antifungal treatment and were referred for long-term therapies [ ] . the few fungal species of fusarium ( . %) and trichoderma ( . %) have also been reported in hospital waste, but infection caused by these fungal species is difficult to cure [ ] . over . billion people worldwide are reported to be suffered from several fungal infections and . À million people die due to fungal infections each year, which are far superior than malaria or tuberculosis death rate [ ] . antifungal drugs are mostly used for treatment of fungal infections as they target plasma membrane, sterol biosynthesis, dna biosynthesis, and β-glucan biosynthesis of different fungi. however, since past decades, the increased use of antifungal drugs resulted in development of resistance, leading to increase in morbidity and mortality. the drug resistance could be due to several reasons such as alterations of the drug target site, increased efflux of drugs, and biofilm formation. although several studies have reported, antifungal drugs resistance is not at the same level as resistance in bacteria against antibiotics. other reasons of high mortality rate with fungal infections include availability of limited treatment options against invasive fungal diseases and less susceptibility of immunocompromised patients to antifungal drugs [ ] . for instance, in the united states, until , there were reports of , organ transplants, which resulted in increased susceptibility to fungal infections in immunocompromised patients [ ] . in addition, adverse effects of antifungal drugs and lack of effective antifungal therapies are the other reasons, which necessities the development of novel treatment strategies and next-generations of antifungal drugs. the development of ultrahigh-throughput screening techniques could help in advent of novel antifungal drugs by providing rapid, effective, and economical drug screening. presently, the viral infections are in forefront as compared with pathogenic diseases caused by bacteria, fungi, and parasites (table À ) . moreover, the detection, analysis, characterization, and epidemiology of virus is entirely different from bacteria because the bacterial indicators used to represent water contamination cannot actually represent viral contamination. it has been reported that each of the material present in the hospital waste can carry viruses, and thus, viruses are able to survive for À days [ ] . the viral hepatitis is very common and leading disease. moreover, human immunodeficiency virus infections, hepatitis b, and hepatitis c are among the deadly infectious diseases, transmitted by direct contact of blood from infected to another. however, these are yet easy to prevent, once detected at early stages and obligatory precautions are followed by patients [ ] . the samples collected from different wwtps have been analyzed for detection and characterization, and even research has been focused on removal of viruses from wastewater [ ] . however, in spite of all the health risks associated with viruses, very few research [ ] has been conducted specifically for hww, and thus, requires special attention due to the fact that, it is one of the main sources to spread the pathogenic and deadly viral diseases. the modern techniques of molecular biology including pcr assays offer several advantages such as specificity, sensitivity, and wider data analysis for easy and faster detection of viruses. the occurrence of rotavirus a, norovirus genogroup i and ii, human adenovirus (hadv), and hepatitis were detected in samples collected from two different hospital wwtps. the load of rotavirus and hadv present in hospital wwtp was log cycle higher as compared with that present in urban sewage wwtp [ ] . the hadv consists of double-stranded linear dna (fig. À ) and comes under category of nonenveloped viruses, which makes them resistant to heat, dry, and acidic conditions [ ] . the adenovirus consists of outer capsid and inner core with several histone proteins. the elongated fiber proteins on the surface of the virus interact with receptor of host cell such as coxsackie and adenovirus receptor and mcp and start infection in the host cells. after interaction between virus fiber proteins and host cell receptors, uncoating of virus particles takes place resulting in dissolution of viral protein in the endosome. ultimately, the translocation of adenovirus takes place with microtubules through cytoplasm toward the nucleus [ ] . hadv is mostly profound in patients with weak immune system and acute lower respiratory disease [ ] . seventy-nine types of hadv have been reported [ ] , and out of them, hadv / is mostly prevalent in aquatic systems such as sea water, sewage, rivers, surface water, and drinking water [ ] . the hadv is placed among the contaminant candidate list for drinking water by u.s. environment protection agency and is a real factor of concern for the human health [ ] . it can cause several diseases in humans including ocular infections, conjunctivitis, genitourinary infections, pharyngoconjunctival fever, hemorrhagic cystitis, exanthema, encephalitis, and pneumonia [ ] . the hadv is more frequently found in wastewater than any other enteric virus. the hadv is reported to be transmitted through fecal-oral transmission, aerosol droplets, and contaminated materials. it can survive for the extended period of À weeks in the environment without host. due to its stable and persistence nature in aquatic systems, it could also be considered as an indicator of fecal contamination as suggested by various studies [ , ] . the prevalence of hadv species varies according to the hospital environment. according to prado et al. [ ] , the hadv / (species f) was among the most prevalence genotype found during molecular characterization of viruses, detected during analysis of samples collected from two different hospital wwtps. the species f come from the hospitalized children reported with acute gastroenteritis disease. the other reported hadv strains include species c and d, which are associated with conjunctivitis and respiratory tract infections [ ] . the frequency of hadv has also been tested for the samples ( in number) collected throughout year from hospital wwtp located in tunisia city, tunisia and % samples were detected positive for hadv and most prevalent species were species f (hadv / ) [ ] . in the similar way, the prevalence of hadv was detected in samples collected from different regions of the world such as . % in poland, . %À . % in greece, % in norway, and % in brazil, while samples collected from morocco ( . %), italy ( . %), and taiwan ( . %) consisted of low prevalence of hadv [ ] . the high and low prevalence of hadv reported in various countries could be collaborated by the fact that the circulation of virus varied according to the geographical regions and epidemiological community profile. however, whether it was high or low prevalence, still presence of hadv questions the ability of wwtps to remove the gastroenteric viruses and highlights the urgency for development of effective environmental control programs and innovative hww treatment plants before discharging the hww into the sewage system. the detection of hadv includes cell culture method, antigen detection, and pcr method. serology is also used sometimes to detect adenovirus-specific antibodies. there is no effective treatment against hadv, essential precautions should be taken to control infections, which include washing of hands, disinfection of instruments as well as application of infection control protocol in hospitals against adenovirus to prevent outbreaks [ ] . the rotavirus consists of segmented double-stranded rna and its surface is surrounded by three layers: the outer capsid, inner capsid, and central core. there are seven rotavirus groups that have been reported from a to g and studies have revealed that groups a, b, and c affect both humans and animals, while d to g are reported to cause infection mainly in animals. the dual (binary) classification system has been used for detailed classification of rotavirus on the basis of two outer capsid proteins; the glycoprotein vp and protein vp (fig. À ) , where the glycoprotein vp defines for the stereotype g and protein vp defines for stereotype p [ ] . the viral attachment to the host cell surface is by glycoprotein vp or surface protein vp . after interaction with host cell, calcium-dependent endocytosis takes place and thus, uncoating of the particle occurs, resulting in release of double layer of the viral particle into cytoplasm. further, transcription and translation takes place in the cytoplasm and viral proteins are synthesized by cellular ribosomes. after assembly, virus particle is released from the infected cell through cell lysis, and infection is further spread into the host [ ] . rotavirus is associated with around million cases of acute gastroenteritis in the newborn babies and children across the world, and , À , deaths have been reported for children with age of , years globally. after infection and replication, rotavirus is discharged into surface water, groundwater, drinking water, and wastewater, able to transmit effectively through water due to its stable and resistant nature under adverse environmental conditions [ ] . the rotavirus can survive at ambient temperature of cÀ c and can exist on inanimate objects for days without host. the rotavirus is mostly prevalent in humans and %À % of positive samples are associated with group a rotavirus [ , ] . the detection methods of rotavirus include electron microscopy, elisa, passive particle agglutination tests, polyacrylamide gel electrophoresis, and rt-pcr. the vaccination with safety and efficacy profile for rotavirus a has been developed and licensed in after the withdrawn of first ever vaccination, which was associated to cause intestinal intussusceptions in children [ ] . the prevalence of rotavirus in different seasons (summer, autumn, and winter) was detected by collecting different samples in the period of months from hww located in shiraz, iran. enzyme immunoassays (eias) were performed and positive specimens were further investigated with nested-pcr by various primers. moreover, the virus concentration method such as the pellet and two-phase is reported to enhance the concentration of virus by -to -fold before applying eia. about samples ( %) were found to be positive for rotavirus a and the highest prevalence was detected in autumn with frequency of . % followed by . % and % of prevalence in winter and spring, respectively [ ] . other studies also confirmed the prevalence of rotavirus a in cold weather as compared with other seasons [ ] . the molecular characterization of rotavirus further revealed the predominance of g genotype during various clinical investigations followed by mixed genotype of g g , which is associated with frequent water contamination and further generation of novel strains by genetic reassortment. moreover, various studies have reported the prevalence of rotavirus in treated wastewater as well, which is a real concern for public health [ ] . the studies on rotavirus highlight the significance of environmental surveillance tools for detection of novel genotypes and to further analyze the distribution and treatment of the hazardous effects caused by rotavirus in human beings. the norovirus belongs to the family caliciviridae, and is reported to be nonenveloped and contains a positive sense, single-stranded rna, which is organized into three open reading frames (orfs). the three orfs encode three different proteins; orf is of size kb and encodes nonstructural (ns) polyproteins, orf is having . kb size and encodes structural capsid protein vp , while orf with size of . kb encodes a vp protein to maintain the stability of capsid protein [ ] . the norovirus life cycle has been presented in fig. À . the interaction of norovirus with the host cell surface takes place through histoblood group antigens. after release of the vpg-linked rna genome of the virus into cytoplasm of host cell, the viral rna translation takes place. once the translation of the orf polyprotein is done, further co-and posttranslation processing occurs by ns protease of virus, which results in the release of ns proteins for the formation of replication complex. thereafter the viral replication takes place by rna-dependent rna polymerase using de novo and vpg-dependent mechanism. furthermore, the replicated genomes are translated and further packed into the capsid for assembly of virion and exit [ ] . the norovirus is divided into seven genotypes, among them three genotypes gi, gii, and giv are responsible for infection in humans, and gii with genotype (gii. ) is a predominant infectious virus associated with % of the diarrheal diseases and gastroenteritis infections around the world. in addition to gii. , various other non-gii. containing viral strains are also responsible for gastroenteritis infections, for instance, the gastroenteritis emerged in southeast asia in À was associated with g . viral strain. norovirus is associated with million gastroenteritis cases and , deaths annually around the world [ ] . the emission of waterborne norovirus is caused by contamination of water systems including drinking water, surface water, mineral water, and groundwater [ ] . as the infectious individuals shed the virus into the water system, the samples collected from hww are considered useful for study of norovirus epidemiology at population level [ ] . the transmission of norovirus is through fecalÀoral route from person to person or animal to person by contamination food or water intake. depending on the surface temperature and conditions, the norovirus can survive for longer period outside the host. it has capacity to survive for weeks on the hard surface, until days on contaminated fabrics and for years in the contaminated still water [ ] . the norovirus infection in humans can be detected by real-time pcr, multiplex gastrointestinal platforms, eias, and genotyping as well. the development of real-time pcr for detection of norovirus is considered as significant advancement with various environmental applications. the prevalence of norovirus was studied by ibrahim et al. [ ] , where samples were collected form different basins of hospital wwtp located in tunisia. the % of the samples were positive for norovirus gii followed by norovirus g , which was detected in % of the samples collected from wastewater, while frequency of norovirus was lowered moving from one basin to another. however, there is requirement of tertiary wastewater treatment before recycling of water for bathing and other purposes. different studies have revealed the prevalence of norovirus in different seasons, for instance, studies on hww collected from italy and sweden have showed occurrence of norovirus gii in spring and summer seasons [ , ] . however, the study from china has revealed the prevalence of norovirus in winter conditions, which could be explained by variability in temperature during different seasons, immunity level of the host, humidity as well as socioeconomic conditions of different countries [ ] . the emerging recombinant norovirus has been analyzed by illumine miseq and sanger sequencing technique by collecting different clinical and wastewater samples within australia and new zealand. the prevalence of pandemic variant (gii.pe/gii. ) was found in sydney during and , while decline in pandemic virus was observed in with emergence of five new recombinant strains. these new viruses were held responsible for emergence of gastroenteritis outbreaks during november [ ] . the use of new generation sequencing tools has advanced and reformed the genome sequencing of different pathogens present in wastewater. the norovirus has been responsible for , deaths per year. in world health organization (who) identified norovirus as a priority disease for vaccine development. however, several vaccines are still in trails phase and preclinical stages and no licensed vaccine has been available for norovirus infection treatment. the cost effectiveness, target population, and public acceptance are the major considerations for vaccine development [ ] . the public awareness about the norovirus and prevention measurement should be spread for protection of people from norovirus infection due to lack of treatment available. hepatitis a virus (hav) is a nonenveloped virus, belongs to the picornaviridae family, and has positive sense single-stranded rna (fig. À ) . the rna consists of only one orf, which encodes a large polyprotein [ ] . there are six genotypes of the virus reported and genotype i, ii, and iii are infectious to human population and are further subgrouped into a and b, while iv, v, and vi affects other primates than human beings [ ] . there is a genetic nucleotide variation of . % in each of the subgenotypes, which has been evaluated with pcr by vp /vp a junction present in nucleotide fragment [ ] . the interaction of the hav with host cell involves endocytic pathway. the host cell receptor involved in interaction with virus is tim- (havcr ) and it is reported to cycles between plasma membrane and lysosome of host cell with calthrin-mediated endocytosis. the replication, translation, and assembly of virus occurs inside the cytoplasm of host cell [ ] . the genetic analysis of hav could be correlated with the outbreaks of viral infections and transmission mode as well. the main transmission mode for the virus is fecalÀoral route, which could be directly transmitted through one human to another or indigestion of contaminated food as well [ ] . the hav has capacity to survive for months outside the host body, it can survive through freezing temperature but can be killed, when exposed to high temperature of . c. the geographical distribution of the virus has been mainly present in india, africa, middle east, central america, and south america. the hav is considered as one of the most important food-borne pathogens and is a major cause of hepatitis in humans with reported cases of around . million globally. it has been estimated that half of the hepatitis cases are related to hav. the wastewater coming from the hospital could be emerging source of hav due to the fact that human excretion contains enormous amount of virus; moreover, virus is highly resistant to harsh environmental conditions and is able to survive for longer periods [ ] . the hav is also detected in rivers, raw or treated water, and dam water as well [ ] . these viruses are a real cause of concern for human health; moreover, there are no strict regulations in existence related to monitoring of these viruses in environment and water resources [ ] . the consumption of contaminated food has also been directly linked with outbreak of hav at several places. for instance, there were reported cases of hav in michigan between august to october with fatalities and hospitalization. the outbreak was linked to consumption of raw scallops served in sushi chain. in another case at hawaii, cases suffering with hepatitis a infections were reported between june and october , which were linked to contaminated frozen strawberries [ ] . the prevalence of hav was detected in different clinical samples collected over a period of years from patras and alexandroupolis located in greece. the nested real-time pcr revealed the presence of % genotype- and particularly subgenotype a [ ] . the predominance of genotype- and subgroup a has also been reported in wastewater samples collected from brazil [ ] . the prevalence of virus was also reported to be higher during the lower number of cases reported for hepatitis a, which could be directly correlated to the shedding of virus into feces. the detection of igm antibodies and anti-hav in blood is related to hepatitis a infection. the presence of anti-hav in blood indicates infection or past vaccination. the hav vaccination within weeks of infection is the prevention method for hav infection and includes two-dose series for individuals above age of months. the vaccination includes inactivated virus and is safe for immunocompromised persons [ ] . the hww is heavily loaded with pathogens and discharged directly into aquatic bodies could be directly evident by skin infections and intestinal parasites. around the globe, millions of people are affected by deadly parasites infections, for instance, . million suffer from giardiasis, million from amebic dysentery, million affected by hookworm infections, million detected with trichuriasis, and . billion are infected with ascariasis [ ] . these parasites are mostly transmitted through fecalÀoral route under poor hygienic conditions, contaminated water and food sources, and poor wastewater disposal practices. the parasites in their ineffective stages such as cysts, eggs, and oocysts survive under environmental adverse conditions and through many wastewater treatments processes due to the presence of protective outer layer. therefore parasites have capability to survive in wastewater for extended time period in comparison to viruses and bacteria [ ] . the samples collected from hospital sewage treatment plant located in zaria, nigeria contained several eggs, cysts, and oocytes of various parasites. about eggs, cysts, and oocysts were present per liter of wastewater. ascaris lumbricoides was the common parasite found in hww with eggs per liter ( . %) of wastewater followed by eggs ( . %) of taenia spp., eggs ( . %) of schistosoma spp., eggs of toxocara spp., eggs ( . %) of ancylostoma spp., eggs ( . %) of cryptosporidium parvum, and eggs ( . %) of giardia lambila. moreover, eggs ( . %) of trichuris and hymenolepis spp. were also found in hww. the cysts of entamoeba histolytica and a. lumbricoides were found in many studies and remained viable for longer period of time in pond effluents that was further used to irrigate raw vegetables, thus, entering the food chain and then directly to humans [ ] . c. parvum causes the disease cryptosporiadiasis and g. lambila causes giardiasis, both could be life threatening if found in persons with weak immune system. the children diarrhea in many cases is caused by the cryptosporidium species [ ] . taenia species can cause cysticerocosis in humans that can infect muscles, brain and can ultimately cause onset seizures in adults, while it can also cause bovine cysticerocosis in cattle after consumption of contaminated water. the main symptoms of parasitic infection include nausea, vomiting, malabsorption, diarrhea, and stomach cramps [ ] . therefore the wastewater should be treated before discharge into water bodies otherwise they could be a great risk to public health. antibiotics are one of the most successful and important drugs used in therapeutic applications and the indiscriminate use of these compounds has made their way into the environment. the overuse and misuse of antibiotics not only in human therapeutics but also in veterinary, agriculture, and aquaculture applications [ ] has led to the emergence of args and arb compromising or decreasing the effect of antibiotic compounds as they are becoming resistant to multiple drugs thus, causing a major concern. some studies have shown that resistant bacteria can also be present where antibiotic concentrations are low, saying that subinhibitory concentrations can also promote resistance among bacteria as similar to concentrations found in some aquatic and soil environments [ ] . just as natural antibiotics have existed for billions of years, args are also ancient [ ] . there have been occurrences of args in places where anthropogenic activities are minimal such as genes encoding for β-lactamase in a remote alaskan soil suggesting the environment to be a reservoir of args [ ] . antibiotic-resistant bacteria have been reported from lechuguilla cave, new mexico which has been isolated for more than million years including some strains which were resistant to over different antibiotics [ ] and in ancient permafrost samples where communities harbored resistance mechanisms minimum years ago [ ] . such studies improve our understanding of the prevalence of resistance genes in environments much prior to human use of antibiotics. within past years, pieces of evidence have shown mobilization of these resistance genes from the environment into pathogenic bacteria causing health risks to humans and animals and also, demonstrating a link between environmental and clinical resistance [ ] . moreover, due to the introduction of antibiotics from various human activities, the environment has turned into a reactor of arb and args contributing to the evolution and spreading of resistant genes. the phenomenon of emergence and spread of args has increased so intensely that % of all hospital-acquired infections show resistance toward at least one family of antibiotics. hww represents an important source of args and arb and such effluents are highly hazardous due to its infectious and toxic features [ ] . traditionally, resistance was viewed as a healthcare problem but now nonclinical environment has also been reported as an important factor in the dissemination of resistance genes [ ] . a wide range of antibiotics and args are being released from the hospitals and urban wastewaters which are received by wwtps [ ] . the wwtp also serves as a hotspot in the emergence and spreading of args and arb in the ecosystem [ ] . even after the treatment, some of the antibiotics and args are still not completely removed and being released into the receiving water bodies making aquatic ecosystems an ideal place for acquisition and spread of such genes. commensal bacteria of humans and animals also constitute a reservoir of such resistance genes which can enter the environment through sewer systems or use of animal manure [ , ] . other than wwtp effluents, args can reach the soils, sediments, surface water and groundwater bodies including drinking water systems [ , ] by surface runoff or infiltration of water that has been used for agricultural purpose [ ] . it has been estimated by who that arbs are responsible for , , , , and , deaths per year in european union, the united states, and thailand, respectively [ ] . there has been increasing resistance in many human pathogens such as e. coli, a. baumannii, enterococcus sp., klebsiella pneumonia, s. aureus, p. aeruginosa, serratia marcesens, citrobacter sp., and other enterobacter species, and there have been a great number of growing reports concerning the prevalence and dissemination of these pathogens into various environmental settings [ À ]. knapp et al. [ ] reported args from different major classes of antibiotics tested from to had significantly increased since , along with tetracycline args around times more abundant than in the s [ ] . the resistant gene can be specific to one antibiotic, for example, ciprofloxacin or a group of antibiotics such as β-lactums and as a result, hundreds of args are being detected [ ] . genes resistant to antibiotics are commonly observed for aminoglycoside (aac, aad, aph), chloramphenicol (cat, cml), sulfonamide (suli, sulii, suliii, sula), trimethoprim (dfra, dfrb), quinolone (qnra, b, s), tetracycline (teta-e, g, h, j, y, z, etc.), vancomycin (vana, vanb), macrolide (erma-c, e, f, t, v, x), β-lactum, and penicillin (bla, meca, pena) antibiotics in different environments [ , , ] . infections caused by resistant strains are difficult to deal and have led to increasing rates of infections, higher hospital costs, and high rates of morbidity and mortality, for example, strains producing extended-spectrum β-lactamase (esbl) are responsible for higher rates of mortality [ ] . there is a widespread occurrence of args originating from different settings that has contributed to a web of resistance among humans, animals, and the environment and, even after their treatment, they can be still present and can contribute to their spread in the environment. furthermore, there still exists an unexplored pool of genes that may have the potential to be used as args and may be passed to pathogenic bacteria. various hypothesis have been given for the mechanisms of resistance genes to traverse wwtp and their influence by the treatment process [ ] (fig. À ) . thus antibiotic resistance development includes a broader impact on the environment and human health rather than just a local health issue and has to be addressed. the current risk assessment is inadequate and requires advanced biological risk assessment evaluations to detect the proliferation of args and antibiotics. this includes minimizing the resistance emergence and spread in the environment and their transmission to humans. to achieve this, it is necessary to achieve goals such as defining resistance in environmental samples and standardizing testing in those samples which will further require establishment of more comprehensible databases to combine both environmental and clinical metadata. it would help to understand relationships between resistomes of different settings and would improve the risk assessment of args and arb to further develop control strategies [ ] . the need for screening of args present in bacteria is important for the optimal antimicrobial therapy to treat infections in patients and this need is increasing with increasing resistance among bacteria. detection will also predict the spread of resistant organisms and genes throughout the environment. a diversity of detection methods is available for both phenotypic as well as genotypic determination of args in isolates. antibiotic resistance is a selectable phenotype and can be detected using growth inhibition assays using disc diffusion method, broth dilution, gradient strips, or other methods to determine the minimum inhibitory concentration (mic) of antibiotics [ ] . the mic is calculated for each isolate and based on the results, isolate can either be susceptible or resistant to the antibiotic [ ] . however, there remain certain problems associated with this method, such as gradation of resistance, time-consuming (can take several weeks for slow-growing bacteria such as mycobacterium tuberculosis), and culture-dependent method, relate to only concentration of antibiotics (difficult to detect low-level resistance), and give no information about dissemination of resistance via mobile genetic elements (mges) [ , ] . to overcome these disadvantages, genotypic or molecular characterization methods such as pcr, hybridization techniques including microarray, and whole genome sequence (wgs) are used extensively to determine specific resistance genes and providing results within hours. genotypic characterization has led to the identification of args in fastidious bacteria which expresses few phenotypic features, for example, tropheryma whipplei, that causes whipple's disease showed mutations in gyra and parc gene owning to fluoroquinolones resistance [ ] . the wwtp compartments like influent, activated sludge, effluent consist of contrasting conditions including different concentrations of metals, antibiotics, etc. changing stress concentrations may act as drivers for microbial community and resistomes thus, changing biomass per volume and persistence/enrichment of arb this can result in a strong shift in the whole microbial community composition and antibiotic-resistance subset these changes are expected to correlate with the changes of resistome. contigs analysis allows further identification of marker genes for mobile genetic elements finally, horizontal gene transfer may help in the transfer of resistance genes and may act on evolutionary timescales the use of a plethora of pcrs such as standard, real-time, multiplex pcr to detect the presence of genes encoding resistance to aminoglycoside, chloramphenicol, macrolide, β-lactum, penicillin, trimethoprim, and tetracycline in bacteria is quite common [ , , ] . isothermal amplifications using loop-mediated isothermal amplification [ ] pcrs are very rapid, performed at one constant temperature and have been developed to detect esbls genes and carbapenemases genes in bacteria but they cannot be used in multiplex to detect several genes simultaneously. very recently, a paper-based chip which is integrated with lamp and a switch molecule for fluorescent detection of args has been developed to allow more convenient and efficient detection especially in resource-limited conditions [ ] . many other detecting and genotyping techniques based on the pcr have been developed to identify args such as restriction fragment length polymorphism-pcr, mismatch amplification mutation assay-pcr, or pcr-single strand conformation polymorphism that have been used to detect gyra mutations in quinolone-resistant isolates [ ] . schwartz et al. [ ] used pcr technique to detect vana (vancomycin-resistance gene), meca (methicillin-resistant gene), and ampc (ampicillin-resistant gene) in wastewater, surface water, and drinking water biofilms [ ] . recently both pcr and rt-pcr have been used across europe for detection of plasmid-mediated mcr- genes harboring resistance against colistin [ À ] (table À ) . multiplex rt-pcr has been used to identify staphylococci from blood samples by targeting meca and other species-specific genes [ ] . another example of using multiplex pcr is in the detection of prevalent esbls genes in e. coli that encoded mainly bla shv , bla tem , bla ctx-m , and bla oxa [ ] . it is also possible to devise and use multiplex pcr to detect genetically diverse resistance genes for [ ] tetracycline thus, making it one of the most widely used techniques [ ] . however, these methods have low-throughput, sometimes gives false results, mostly ignore potential reservoirs of resistance that are nonculturable bacteria, and depend on primers that leave less room for discovery of novel genes. molecular hybridization is one of the oldest molecular techniques that have been used to detect the presence of specific args and meanwhile several improvements have been done on probe designs and synthesis. southern hybridization demonstrated tet and class-i integrons can be cotransferred from isolates present in soil to e. coli and/or pseudomonas putida [ ] . pcr-southern blot assays were used frequently and reported tetracycline (tet ) and sulfonamide (sulii) resistance genes in acinetobacter species from fish farms in thailand [ ] . probes can be labeled with a variety of reporters including radioactive and nonradiolabeled systems. one nonradiolabeled method is fluorescence in situ hybridization that has been used for rapid detection of macrolide, clarithromycin, linezolidresistances [ ] . high-throughput dna microarray is another technique that has been successfully used to detect args in the test organism in comparison to a reference strain and works with high speed and high delicacy. in this technique, probes specific to the particular gene are spotted on a solid substrate (e.g., glass slide). dna is labeled and hybridized, and the specific targetprobe duplexes are detected. comparison of genomic diversity in a large number of test isolates can be done for which wgs is not available [ ] . it enables detection of a large number of single genes, mutations, mges and also can characterize strain at the molecular level [ ] . it has been used for antimicrobial genes detection in a diverse range of bacteria [ ] . glass-based microarray has been developed for the detection of tetracyclineresistance genes and one β-lactamase gene in multiple bacteria that used microarray probes c. -base pair pcr products [ ] . perreten et al. [ ] developed a rapid and efficient screening of gram-positive bacteria using microarray for the presence of args which was further improved by additional oligonucleotides for detecting args [ , ] . similarly, alere microarrays have been developed capable of detecting clinically relevant antibiotics and can be used in routine diagnostics laboratories [ ] . some of its disadvantages include, low detection limit, high cost (due to use of platforms with probes of short oligonucleotides or pcr products as well as fluorescent dyes) and problems in dealing with complex samples [ , ] . just like pcr and microarray, wgs is another potential method to detect genes and mutations conferring antibiotic resistance. the main advantage is its ability to use and detect different targets simultaneously and to subtype-specific gene variants. one can possibly add new targets to the database for analysis and can perform rapid in silico reanalysis of sequenced isolates. the presence of args within the wgs data has to be determined for which, comprehensive databases containing relevant target dna is required along with the use of appropriate bioinformatics methods for obtaining information about the wgs data. some of the databases that have been used for detection of args in curated wgs data are resfinder, which is a web server and uses blast for identification of args [ ] , comprehensive antibiotic-resistance database that uses blast and resistance gene identifier as two analysis options [ ] , antibiotic-resistance gene-annotation that gives user an opportunity to use local blast in bio-edit software and analysis can be done without web interface [ ] , and antibiotic-resistance gene database that is a manually curated database unifying publicly available information on args such as resistance profile, ontology, mechanism of action, and much more [ ] . other knowledge resources of amr include antibioticresistance genes online, collection of antimicrobial peptides, database of antimicrobial activity and structure of peptides, antimicrobial peptide database, and bacmet which differ from each other on the basis of the knowledge on molecular level of args they reflect and the scope of resistance mechanism they cover [ ] . however, one major drawback of using molecular techniques for arg detection is that new emerging resistances against some antibiotics may be overlooked as observed for ndm- gene encoding resistance to carbapenem antibiotics which was first isolated using phenotypic methods and then characterized on the basis of genotype [ ] . thus, within the number of both phenotypic and genotypic methods, there are limitations involved with each one and one can perform a combination of these screening methods to monitor resistance. thus the use of all these techniques helps in predicting the resistance genes, setting up control measures in hospital infections, adapt to a specific therapy and using them routine detection tools [ ] . the molecular analysis tools such as pcr, quantitative pcr, and s rrna analysis have provided the in-depth knowledge about microbial communities present in wastewater since decades [ ] . however, requirement of gene-specific primers, and species-specific approach used by these tools limit their activity for detection of certain targeted microbes providing incomplete information about microbial communities present in wastewater [ ] . recently, metagenomics analysis has been introduced, which overcomes the limitations related with conventional molecular analysis tools and is able to generate hundreds to thousands of sequences, providing complete profile of microbial communities present in unknown samples, thus high abundance of potential microbes are detected [ ] . the metagenomics analysis consists of four steps; genetic material isolation followed by genetic material cloning, construction of library, and the analysis of genetic material from the metagenomics library. metagenomics along with search engine for amr [ ] can analyze the unknown samples collected from environment and can provide full-length arg data. the hww has been reported to have two overexpressed β-lactam-resistance genes (bla ges and bla oxa ) as compared with the water collected from other aquatic bodies, which could be correlated with antibiotic usage over the time in hospitals and discharge of the residues of antibiotics in the wastewater [ ] . the hww that is derived from clinical speciality ward is determined to be major spot for the amr. the wastewater derived from different wards of the hospital and the final effluent of hospital was tested and compared for resistance genes. the wastewater has a high abundance of class a β-lactamase resistant genes (i.e., bla kpc , bla ctx-m , bla shv , bla tem ) and the wastewater from clinical ward also consists of high level of bla kpc- genes ( , x/gb), encoding for carbapenem resistance. moreover, there was presence of assembled scaffolds of incq and incf plasmids having quinolone-resistance genes (qnrs , qnrs ) and the class a β-lactamase gene (bla tem- ) in wastewater, which further helps in proliferation of amr [ ] . metagenomic functional selection has been integrated with deep metagenomic sequencing to trace validated args in different environments. studies have identified wwtp resistome consisting of novel args thus, throwing the limelight on wwtp reservoir of uncharacterized resistance genes using these selections. using such metagenomic methods relates the number of clinically relevant resistant genes to overall functional resistant genes and thus, helps in improving the risk classification in environments [ ] . metagenomics strategy also revealed the association of isolated p. aeruginosa from hww with amr frequency. the isolated strain was selected as a bio-indicator, due to its ability to survive and colonize in harsh environments and it was used to assess its viability, antibiotic susceptibility, and diversity in hww. the samples collected during different treatment steps of hww revealed that each treatment step was able to decrease the bacterial population by four logarithm cycle; however, the antibiotic resistance profile did not decrease at each treatment level, while, on the contrary, there was increase in amr microbes and genes as well. the microorganism was able to remain survived in the spore form during different treatment steps and again transform into vegetative form when released into surviving environment [ ] . the healthcare clinics and hospitals, where antibiotic use is more common among the major contributor to disseminate the pathogenic microorganism into the environment. in addition, shortgun metagenomics analysis of hww collected from turkey revealed the presence of more than antibiotic resistance determinants and most common genes belongs to aminoglycosides and β-lactameses. the prediction of high resistome diversity in hww raises an alarm for health concern of human population. an important step in coping with the serious problem of emergence and dissemination of args is to understand the pathways for resistance gene spread. the ability of bacteria to respond to selective pressures and new environments can be explained by the acquisition of new genes by cells using horizontal transfer methods. studies have shown around % of the genes in each genome have been transferred by hgt during evolution [ ] . many resistance genes are located on mges such as plasmids, transposons also known as jumping genes, and integrons that are capable of capturing and expressing gene cassettes [ ] , which are responsible for antibiotic resistance that functions as vectors for their dissemination [ ] . horizontal acquisitions might be neutral or have deleterious effects in the chromosome or confer a selective advantage to the host. other than mutations, hgt has been one of the methods which are most responsible for the dissemination of args among different bacterial species. it has caused the spread of antibiotic resistance from commensal and environmental bacteria to pathogenic species. the args transfer by hgt exists much back before the use of antibiotics by humans, for example, oxa β-lactamase genes that confer resistance against β-lactam antibiotics mobilized from chromosomes to plasmid millions of years ago [ ] . but the rate of the resistance gene transfer has increased tremendously due to selective pressure caused by antibiotic use by humans in the last few decades. bacteria employ three mechanisms for hgt, that is, conjugation, transformation, and transduction (fig. À ) . conjugation is said to have the greatest influence over the spread of args. conjugation requires a physical contact between two cells via pili or adhesions to transfer the genetic material. this mechanism has been found in bacterial cells with an exception of agrobacterium species that uses hgt in plants. the conjugative machinery encoded by the genes on plasmids or by integrative conjugative elements on chromosomes facilitates this process. args are mostly associated with conjugative elements like plasmids and transposons, and the transfer of these elements is most likely to occur by conjugation because it provides a more efficient way to enter the recipient cell and gives better protection in the environment [ ] . conjugation can be of various types such as ( ) transfer of a selftransmissible conjugative plasmid, for example, rp plasmid of e. coli. ( ) mobilization of nonself-transmissible plasmids by the action of conjugative plasmid, for example, incq plasmid rsf . ( ) cointegration of two different circular plasmids to fuse to become one. ( ) conjugated transposons which may facilitate mobilization of plasmids or cointegration. the mges conferring agrs transfer have been found in bacteria ranging from soil, water ecosystems to food, and human pathogens [ ] . the transfer of the conjugative elements between bacteria over distant phylogeny indicates the emergence of multiresistance between different reservoirs [ ] . bla ctx-m esbl genes have been disseminated to various plasmids within enterobacteriaceae and other pathogens and can be found in various geographical locations [ ] . the conjugation of plasmids has caused dissemination of args worldwide that encode resistance to β-lactamases, carbapenemases, quinolones, aminoglycosides, colistin, sulfonamide, tetracyclines, and other classes of drugs. conjugation has been also reported between bacteria and eukaryotic cells and is observed in various environments such as soil, aquatic, marine sediment, wastewater, and activated sludge [ ] . the second mechanism is transformation, in which the cells take up the naked dna from the environment. for transformation to take place, there are certain prerequisites like release and persistence of extracellular dna in the environment, the recipient cells must be competent, and the dna translocated must be stabilized by integration into the genome or by recircularizing into self-replicating plasmids [ ] . the process takes place in two steps: first, the dna substrate is transferred from surface to the cytoplasmic membrane which is mediated by type ii secretion system, type iv secretion system, and type iv pili; and second, is the transport of dna across the cytoplasmic membrane using cytoplasmic membrane channels [ ] . with an exception of neisseria gonorrhoeae that is a naturally transformable bacteria which responds to environmental conditions [ ] , most species develop competence under autoinducers, peptides, or stressful conditions, for example, aminoglycoside and fluoroquinolone antibiotics sublethal concentrations induce competence in streptococcus pneumoniae and legionella pneumophila [ ] . mao et al. [ ] developed a method to extract extracellular and intracellular dna from water and sediments. they obtained a higher concentration of extracellular dna than intracellular dna in sediments from a river basin that serves as a major arg reservoir that could be transferred to indigenous bacteria through natural transformation [ ] . also, it has been shown in pneumococcal genome that the conjugated transposon disseminates via transformation in addition to conjugation [ ] . transduction is the process by which dna is transferred with the help of bacteriophages. bacteriophages can transfer dna sequences like chromosomal dna, mges such as plasmids, transposons and genomic islands that are advantageous to their bacterial hosts as well as serves in improving the survival of bacteriophages [ ] . transduction can be generalized where random host dna is incorporated during cell lysis and specialized, where the prophage excises itself from the host genome and also incorporates flanking host dnas [ ] . args transfer by transduction has also been reported in various bacteria, for example, β-lactamase gene transfers by p -like bacteriophages in e. coli [ ] , erythromycin resistance transfer by phage between clostridium difficile strains [ ] , tetracycline and gentamycin resistance between enterococci [ ] , or transfer of resistance plasmids in msra [ ] . bacteriophages can have broad host range, that is, between different species or among different taxonomic groups [ ] thus, indicating dissemination of args via transduction in the environment, a common mechanism. other mechanisms such as gene transfer agents (gtas) and cell fusion have also been described. gtas are delivery systems that carry random pieces of host genome in capsids and get integrated into the host chromosome. the amount of dna that gta contain is insufficient to encode their proteins counterparts, unable to self-propagate thus, they do not necessarily carry gta-encoding genes that is an important distinction from transduction mechanism [ ] . the first gta discovered was in rhodopseudomonas capsulate called as rcgta and they were able to transfer antibiotic resistance to bacteria by a mechanism similar to transduction which does not require cells contact and was resistant to dnases [ ] . apart from the evidence of gta shown in various members of rhodobacterales, for example, ruegeria pomeroyi which contain a complete rcgta-like cluster of these genes, roseovarious nubinhibens and ruegeria mobilis also showed rates of transfer of antibiotic resistance around -fold higher than rates of transformation and transduction when added to microbial communities [ ] . mcdaniel et al. [ ] reported gta frequencies to be much higher, around a million times higher the frequency of transformation and transduction measured previously in the marine environment [ ] . there are several advantages of gtas over other mechanisms such as protection of dna from environmental factors, transfer not constrained to cellÀcell contact, and they contain random dna from host rather than most of the bacteriophage dna as observed in transduction. another mechanism, cell fusion has been observed in haloferax and sulfolobus species [ , ] . symmetric and bidirectional cell fusion has been observed in haloferax volcanii. studies have shown interspecies gene exchange in halophilic archaea where cells fuse forming a diploid state containing two different chromosomes of parental cells thus, facilitating genetic exchange and recombination followed by separation of hybrid parental cells [ ] . although new mechanisms are continuously being developed by bacteria and identification, mapping of these resistance mechanisms provides us with knowledge of sources of resistance and helps in designing new antimicrobial drugs. the prions are infectious protein particles present in brain, which are responsible for degenerative neurological disorders. in humans, the prnp gene present on chromosome produces the prp protein and prions results in transformation of prp protein into abnormal disease causing isoform [ ] . these pathogenic prions cause the functional disruption of neural cells resulting in cell death and leading to memory problems, trouble with movement and personality changes as well. the prions can result in many infectious diseases such as creutzfeldtjakob disease (cjd), variably protease-sensitive prionopathy, gerstmann-sträussler-scheinker disease, scrapie, variant cjd, fatal insomnia, and kuru. these transmissible disease impacts number of mammalian species, including sheep and goats, cattle, deer, moose, elk, and humans. the scrapie and cjd are of particular concern because they can be transmitted horizontally and they remain infectious in the environment for very long time [ ] . for instance, the scrapie infection was persistent even after burial in soil for years. the cjd disease is most common and deadly human prion disease and can cause infection in three ways: sporadic, genetic, and acquired. most of the times ( %À %), cjd occurs sporadically and approximately À . million people are affected annually, because there is no cure available for cjd and other prion diseases [ ] . the recently developed methods for detection of prion infectivity include protein misfolding cycling amplification, quake-induced conversion, and quantitative tandem mass spectrometric techniques [ ] . however, the study of prions is highly challenging due to the fact that the high-resolution structure of prion isotherm is still to be determined and change in structure directly affect infectivity and pathology of disease. prions are likely to enter through live, infected hosts, and can be shred through saliva, urine, feces, mucus, and blood; and they enter in wastewater through hospital effluents, research facilities, homes, slaughterhouses, and mortuaries [ ] . the wwtps are not able to treat prions, for instance, after entering into municipal wwtp, the prions bind to sewage sludge, survive through anaerobic digestion and are further present in treated biosolids. these biosolids are further used for land application, which results in their introduction into environment. thereafter they can be swept by wind and contaminated water with prions could further migrate into lakes, rivers, and oceans and thus, directly affecting the humans, aquatic life, and animals as well [ ] . viroids are small (b À nucleotides), single stranded, circular rna particles, which are distinguished from viruses by smaller size, lack of capsid and also they do not encode any protein. they have capacity to reproduce and are mostly known to cause infection in plants; however, hepatitis δ, which cause infections in humans, has many similar properties with viroids and could be related to viroids [ ] . a total of viroids species has been identified, which are grouped into avsunviroidae and pospiviroidae. the viroids are mainly infectious for plants such as tomatoes, cucumber, avocados, potatoes, apples, coconut palms, and chrysanthemums and are responsible for million dollars' loss in agriculture revenue each year. the most commonly reported viroid plant diseases caused by viroid include apple fruit crinkle, tomato chloric dwarf, and chrysanthemum chlorotic mottle [ ] . the yellowish curled leaves of plants are due to pairing of viroid rna with messenger rna of plants resulting in interference of proper translation. some of the viroids cause devastating effects, for instance, coconut cadongÀcadong viroid has caused lethal effects in coconut palms in philippines, resulting in loss of million coconut palm [ ] . other reported effects of viroids include epinasty, rugosity, necrosis, chlorosis, stem shortening, color alteration of fruits, flowering, and ripening delays. the microarrays are identified as a significant tool for detection of many viroids simultaneously and even has ability to detect emerging or established viroid in new host. potent protein toxins such as tetanus and botulinum toxins, anthrax toxin, epsilon-toxin, and enterotoxin can cause some most significant diseases in humans and animals. these protein toxins are most common virulence factors encoded by plasmids in clostridium and bacillus species, for example, tetanus toxin plasmid and conjugative toxin plasmid of c. perfringens. extracellular vesicles (evs) are also infectious particles said to be produced by all types of microorganisms. these evs can contain nucleic acids, toxins, lipoproteins, adhesins, nutrient scavenging factors, and enzymes that can play major role in pathogenicity in hww. such vesicles from gram-positive bacteria, mycobacteria, and fungi contain virulence factors that can elicit host immune responses. for example, crytococcus neoformans evs have glucuronoxylomannan (capsular polysaccharide) which is a virulence factor [ ] . evs from gramnegative bacteria originate from outer membrane and are called outer-membrane vesicles which have been associated with cytotoxicity, virulence, invasion of host cells, and antibiotic resistance proteins. in addition to these particles, certain factors and conditions may further increase the virulence of evs, for example, a study indicated the role of iron-limiting conditions in the virulence of mycobacterium evs. these emerging infectious particles are not easily removed by conventional treatment technologies. thus there is a requirement of more novel methods and techniques to deal with such infectious particles. therefore these particles have to be readily analyzed for their presence and have to be studied for their removal from hww due to their potential negative effects on human and animal life. the recent years have witnessed the emphasis toward management of hww and various studies focused on the microbial communities present in wastewater have increased immensely. the pathogenic microbes present in hww have affected the human health since decades and antibiotic resistance microbes are also increasing significantly with time. the development of resistance toward antibiotics has been observed worldwide and has challenged both public and animal health. the use and release of various antibiotic agents in different settings have not only led to the prevalence of args in the environment but also spread and emergence of resistant bacteria. this has caused increased resistance in human pathogens and thus, making infections caused by them difficult to deal with, leading to higher mortality rates. however, the surveillance of its spread and prevalence in environment is limited and has to be expanded more due to the broad impact of antibiotic resistance on human health. various culture-dependent and independent techniques have allowed characterization and exploration of args and arb, which have increased our understanding toward the evolutionary pathways for their dissemination within any community. further, metagenomics tools have advanced the research toward analysis of complete microbial profile and increased the knowledge toward microbial abundance present in hww. however, further planning and implementation of strategies, policies, and experimental approaches have to be done by collaboration of scientific community and public authorities to limit the use of antibiotics, detection of microbial communities (resistant and/or sensitive) from wastewaters, and mapping resistance mechanisms to clearly understand the role of mges and extracellular dna in evolutionary process. the microbiome and resistome of hospital sewage during passage through the community sewer system evaluation of wastewater discharge from al-sadr teaching hospital and its impact on the al-khorah channel and 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aspects of using human adenovirus as a viral water quality indicator human adenovirus surveillance-united states detection and molecular characterization of human rotaviruses isolated in italy and albania rotavirus disease mechanisms diarrhea, vomiting and inflammation: how and why occurrence of common pollutants and pharmaceuticals in hospital effluents rotavirus detection in environmental water samples by tangential flow ultrafiltration and rt-nested pcr first molecular detection of group a rotaviruses in drinking water sources in beijing, china first molecular detection of group a rotavirus in urban and hospital sewage systems by nested-rt pcr in shiraz, iran comparative study of enteric viruses, coliphages and indicator bacteria for evaluating water quality in a tropical high-altitude system surveillance of noroviruses in rio de janeiro, brazil: occurrence of new giv genotype in clinical and wastewater samples norovirus gene expression and replication emerging recombinant noroviruses identified by clinical and waste water screening quantification and molecular characterization of norovirus after two wastewater treatment procedures standardized multiplex one-step qrt-pcr for hepatitis a virus, norovirus gi and gii quantification in bivalve mollusks and water prevalence of norovirus and factors influencing virus concentrations during one year in a full-scale wastewater treatment plant detection and molecular characterization of noroviruses from five sewage treatment plants in central italy one-year monthly survey of rotavirus, astrovirus and norovirus in three sewage treatment plants in beijing, china and associated health risk assessment progress on norovirus vaccine research: public health considerations and future directions hepatitis a: epidemiology and prevention in developing countries hepatitis a virus subgenotyping based on rt-qpcr assays type a viral hepatitis: a summary and update on the molecular virology, epidemiology, pathogenesis and 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antibiotic resistance genes in source and drinking water samples from a first nation community in canada prevalence of antibiotic resistance in drinking water treatment and distribution systems antimicrobial resistance: global report on surveillance, world health organization society's failure to protect a precious resource: antibiotics hospital effluents are one of several sources of metal, antibiotic resistance genes, and bacterial markers disseminated in sub-saharan urban rivers identifying antimicrobial resistance genes with dna microarrays evidence of increasing antibiotic resistance gene abundances in archived soils since antibiotic resistance genes in water environment prevalence of antibiotic resistance genes and their relationship with antibiotics in the huangpu river and the drinking water sources multiple drug resistance and biocide resistance in escherichia coli environmental isolates from hospital and household settings wastewater treatment plant resistomes are shaped by bacterial composition, genetic exchange, and upregulated expression in the effluent microbiomes tackling antibiotic resistance: the environmental framework screening methods for the detection of antimicrobial resistance genes present in bacterial isolates and the microbiota culture-based methods for detection of antibiotic resistance in agroecosystems: advantages, challenges, and gaps in knowledge insights into antibiotic resistance through metagenomic approaches molecular evaluation of antibiotic susceptibility: tropheryma whipplei paradigm molecular methods for detection of antimicrobial resistance multi-centre evaluation of real-time multiplex pcr for detection of carbapenemase genes oxa- molecular detection of hepatitis a virus in urban sewage in rio de janeiro, brazil simultaneous detection of antibiotic resistance genes on paper-based chip using molecular detection of antimicrobial resistance detection of antibiotic-resistant bacteria and their resistance genes in wastewater, surface water, and drinking water biofilms occurrence and characterization of mcr- -harbouring escherichia coli isolated from pigs in great britain from to co-occurrence of extended spectrum β lactamase and mcr- encoding genes on plasmids detection of mcr- encoding plasmid-mediated colistin-resistant escherichia coli isolates from human bloodstream infection and imported chicken meat emergence of plasmid-mediated colistin resistance mechanism mcr- in animals and human beings in china: a microbiological and molecular biological study antibiotic resistance elements in wastewater treatment plants: scope and potential impacts, wastewater reuse and current challenges molecular epidemiology of extended-spectrum β-lactamases among escherichia coli isolates collected in a swedish hospital and its associated health care facilities from the tetracycline resistance determinant tet and the sulphonamide resistance gene sulii are common among resistant acinetobacter spp. isolated from integrated fish farms in thailand usefulness of multiplex real-time pcr for simultaneous pathogen detection and resistance profiling of staphylococcal bacteremia tetracycline antibiotics: mode of action, applications, molecular biology, and epidemiology of bacterial resistance, microbiol class integrons and tetracycline resistance genes in alcaligenes, arthrobacter, and pseudomonas spp. isolated from pigsties and manured soil molecular methods for detection of antibiotic resistance, antimicrobial resistance in bacteria of animal origin dna microarray detection of antimicrobial resistance genes in diverse bacteria microarray-based detection of antibiotic resistance genes of gram-positive bacteria a novel universal dna labeling and amplification system for rapid microarray-based detection of antibiotic resistance genes in gram-positive bacteria evaluation of an expanded microarray for detecting antibiotic resistance genes in a broad range of gram-negative bacterial pathogens development of a 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time using the whole genome sequence to characterize and name human adenoviruses characterization of metagenomes in urban aquatic compartments reveals high prevalence of clinically relevant antibiotic resistance genes in wastewaters diversity and antibiotic resistance profiles of pseudomonads from a hospital wastewater treatment plant trends and barriers to lateral gene transfer in prokaryotes plasmid encoded antibiotic resistance: acquisition and transfer of antibiotic resistance genes in bacteria detection of clinically relevant antibiotic-resistance genes in the plasmid metagenome of wastewater treatment plant bacteria showing reduced susceptibility to selected antibiotics phylogenetic analysis shows that the oxa b-lactamase genes have been on plasmids for millions of years antimicrobial-resistant bacteria in the community setting genetic exchange between bacteria in the environment large-scale analysis of plasmid relationships through genesharing networks ctx-m enzymes: origin and 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transfer agents: phage-like elements of genetic exchange genetic recombination in rhodopseudomonas capsulata high frequency of horizontal gene transfer in the oceans cell fusion and hybrids in archaea: prospects for genome shuffling and accelerated strain development for biotechnology a multicopy plasmid of the extremely thermophilic archaeon sulfolobus effects its transfer to recipients by mating current infection control recommendations for prion disease; a difficult problem for the deployed personnel of the armed forces kinetics of ozone inactivation of infectious prion protein epidemiological characteristics of human prion diseases early preclinical detection of prions in the skin of prion-infected animals prions in the environment: occurrence, fate and mitigation persistence of pathogenic prion protein during simulated wastewater treatment processes subviral agents virus taxonomy: ninth report of the international committee on taxonomy of viruses detection of coconut cadang-cadang viroid (cccvd) in oil palm by reverse transcription loop-mediated isothermal amplification (rt-lamp) key: cord- -bie veti authors: nan title: ecc- abstracts date: - - journal: int j antimicrob agents doi: . /s - ( ) -x sha: doc_id: cord_uid: bie veti nan f spain introduction: the prevalence of erythromycin resistance (er-r) in group a streptococci (gas) has increased in spain since early s with current rates exceeding % in some regions. this study determined the emm -types associated to erythromycin resistance in spain. material and methods: isolates belonged to the sauce* surveillance collection. rapid sequence analysis of specific pcr products was used to deduce emm -types corresponding to the majority of the known gas m serotypes. pcr primers used: gasm ( ?-tattgcgct-tagaaaattaa- ?) and gasm ( ?-gcaagttctt-cagcttgttt- ?). sequencing was done with the big dye terminator mix and autosequenator (applied biosystems). dna sequences were subjected to homology searches against the bacterial dna database. results: overall, gas isolates ( er-r) were analysed. three m-types (m , st and m ) accounted for . % of the er-r isolates, whereas they just represented a . % of the ery-s. for er-r isolates the strongest association was seen with m (or / ; % ci . Á/ . ), and m was second after m only in the last temporal period of the study ( Á/ ) . no homogeneous distribution of er-r m-types by centres was seen. conclusions: few m-types (leading by m ) are responsible for the er-r in spain. but for m , the remaining er-r m types (st , m and m ) did not show a temporally nor geographically homogeneous distribution. *sauce is an acronym standing for 'sensibilidad a los antimicrobianos utilizados en la comunidad en espana' (susceptibility to the antimicrobials commonly used in the community in spain ) and is the spanish word for the willow tree. significant increase in the prevalence of erythromycin-resistant, clindamycin and miocamycin-susceptible (m-phenotype) streptococcus pyogenes in spain ( ( Á/ purpose: a variety of methods is used for a molecular typing of enterococcus spp. and related gram-positive bacteria. these include dna-based methods such as macrorestriction analysis using pulsedfield gel electrophoresis (pfge), ribotyping, and amplification-based methods such as rapid amplification of polymorphic dna (rapd) and amplified fragment length polymorphism (aflp). we used a homogeneous strain collection of transconjugants resulting from filter-matings with different antibiotic-resistant e. faecium and a recipient isolate from our lab. the influence of transferred antibiotic-resistance determinants on the outcome of different typing methods was investigated. results: fragment patterns resulting from pfge indicated minor differences between the transconjugants and the recipient. in respect to different primers used for rapd, none or only a single fragment shift was detected in the resulting fragment patterns. aflp clusters all transconjugants into a group of major relatedness, but the result was strongly dependent on the mathematical method used for cluster analysis. fragment patterns of digested plasmids showed the possession of different or only widely related plasmids in the transconjugants. conclusions: the results of this study clearly show that under certain situations typing methods commonly used for enterococci and related gram-positive bacteria come to their limits. the sasss network aims to set up a national surveillance study to obtain standardized information on antimicrobial susceptibility to various bacterial pathogens. currently, hospitals are participating in the project from different geographical regions in saudi arabia. during the st year ( ), the sasss focused on setting up this network. overall, high frequencies of resistance to antibiotics to different bacterial pathogens in saudi arabia were seen. geographical variations of resistance were noticed, which could be related to different prescribing practices. approximately, and % of escherichia coli and k. pneumoniae , respectively, were extended spectrum â-lactamases (ebls) producers. resistance of enterobacteriacae group to carbapenem and pipracillin/tazobactam is low. resistance of pseudomonas aeurginosa to various anti-pseudomonal antibiotics including carbapenem is high and alarming. methicillin resistant staphylococcus aureus (mrsa) comprised % of s. aureus isolates. no vancomycin intermediate s. aureus (visa) was detected. high level resistance to gentamicin in enterococcus were seen in % of the isolates and only % of enterococcus facieum were glycopeptide resistant. resistance of streptococcus pneumoniae to penicillin ranged between % to almost %. surveillance of antibiotic resistance on a national level is necessarily to give guidance to practicing physicians on the best agents to use. the world-wide problem of betalactam resistance (r) in streptococcus pneumoniae (sp) has been complicated by increasing r to macrolides and some older fluoroquinolones (fq) (ciprofloxacin cip). aim of our study was to evaluate rate of acquisition of resistance to different fq: cip, sparfloxacin (spx) and levofloxacin (lev) of sp strains with different levels of susceptibility to penicillin (p). fifteen strains were serially and daily passaged in subinhibitory concentrations of these four antibiotics by a gradient plate method until acquisition of resistance. clinical strains isolated from children in day-care centers were used. five strains were susceptible (s) to penicillin (p) (one reference strain, four clinical isolates: p micsb/ . mg/l): five were intermediate (i) to p (one reference strain: p mic . mg/l, four clinical strains p mics: . Á/ mg/l), five were resistant (r) to p (p mics . mg/l). mean of number of passages (n ) necessary to reach i or r level with each fq as selecting agent are in the following table: spx and lev induced resistance but more slowly than cip. our results show that rate of acquisition of resistance to fq is strongly related to alteration of susceptibility to p, probably by modification of cell wall. these results are concordant with clinical results. clinical relevance of phase variation in pneumococcal opacity: nasopharyngeal (np) colonization in children from day care centers (dcc) soa . carsenti h, mancini g, bensoussan m, dunais b, pradier ch, dellamonica p. archet hospital, infectious disease, nice, france streptococcus pneumoniae (sp) adherence to nasopharyngeal (np) epithelium is a prerequisite for induction of otitis transparent sp (t) have been shown to colonize the np of infant rats better than opaque (o) sp. opaque sp has proven more virulent than the t form during systemic infection in a mouse model. aim of this study was to evaluate phase variation in the nasopharynx of children. sp strains were isolated during a winter epidemiology study of np samples in children from family dcc. mics determinations were performed by e -test for penicillin (p), amoxicilline (amx) and ceftriaxone (cro). serotypes were performed using the quellung reaction. upon oil immersion microscopic examination short chains of six to eight cocci were noted as , '/, '/'/, '/'/'/ for absence, , , !/ chains by field, respectively. phase variation was detected on catalase trypticase soja plates, amx and cro mics and bactericidal activity was determined for pairs of o and t variants with different serotypes and susceptibility to penicillin. seventy strains of sp were screened for phase variation. nine out of with chain length , '/ had o variants while out of strains with chain length '/'/ or '/'/'/ showed o variants. proportion of o variants was predominant when chain length increased. serotype f was prevalent. bactericidal activity of o variants showed a four-to eightfold increase of mbc. o variants may be present in np of children while t are predominant form for colonization. these virulent variants with lower level of autolysis showed less susceptibility to killing by antibiotics. they may persist in np and explain the absence of eradication by active molecules. antimicrobial resistance among clinical strains of s. pneumoniae isolated from patients with community-acquired respiratory tract infections (carti) in russia soa . kozlov rs a , bogdanovitch tm a , sivaya ov a , agapova ed b , ahmetova li b , furletova b , gudkova lv b , gugutsidge b , ilyina vn b , marusina b , multich ig b , ortenberg ea b , schetinin ev b , shturmina purpose: to determine the antimicrobial resistance of pneumococci causing carti in different russian cities. methods: a total of non-duplicate strains isolated in russian cities in were studied. antimicrobials tested included penicillin (pen), amoxicillin (amo), erythromycin (ery), azithromycin (azi), clarithromycin (cla), midecamycin (mid), spiramycin (spi), clindamycin (cli), levofloxacin (lev), vancomycin (van), rifampicin (rif), tetracycline (tet) and co-trimoxazole (sxt). susceptibility testing was performed by broth microdilution with interpretation of the results according to nccls guidelines ( ) a map of bacterial resistance in a hungarian region soa . farkas a a , juhasz a b , orosi p a , miszti c c , balogh m d . a kenezy teaching hospital, hygienie, debrecen, hungary , b kenezy teaching hospital, laboratory, debrecen, hungary , c university of debrecen, microbiology lab, debrecen, hungary , d regional hospital berettyóújfalu, laboratory, debrecen, hungary background: regional trends of microbiological resistance pattern constitute basic data and qualifying criteria for effective infection control. purpose: the aim of our study was to establish an internationally compatible regional database in a hungarian county hajdú -bihar. methods: our model is the national nosocomial infections society publications' format from the u.s. published in . it contains data regarding various icu types, ambulatory patients and hospitalised patients. the same format is used for antibiotic utilisation data and device related infections' rates as well. we collected cleaned data of years Á/ from all the microbiological laboratories of our county. results: ciprofloxacin p e. coli . . . Á/above susceptibilities not significantly different from u.s. data were as follows: mr cns, streptococcus pneumoniae /penicillin and rd generation cephalosporin, pseudomonas aeruginosa /piperacillin and enterobacter spp. and escherichia coli /ceftriaxon. conclusions: this database proved to be a very useful tool for choosing primary wards of active surveillance including places for infectious disease physician's visit (icu, rehabilitation unit). additional analysis is needed at an individual institution's level for other heavily used (or useable) antibiotics and bacteria as well (aminoglycosides, beta-lactam Á/beta lactamase inhibitor combinations, nd generation cephalosporins, corynebacteria . to compare epidemiological, clinical, and immunological features of add before and after haart introduction, between the patients (p) diagnosed in Á/ , and the p detected since , in a case-control study. though the mean number of newly diagnosed aids p had a sharp drop in the haart era, from p/year in Á/ to p/year since (p b/ . ), the distribution of add and underlying immunodeficiency showed limited changes. when excluding a greater frequency of tuberculosis (tb) (p b/ . ) and wasting syndrome (p b/ . ), all other add did not show a different frequency before and after . a tendency towards a higher mean cd count at aids disease was noticed: vs cells/ml (p b/ . ), with a significant difference for candida esophagitis , toxoplasmosis, kaposi sarcoma and tb (p b/ . Á/b/ . ). the limited variation of clinical and immunological presentation are attributable to the poor impact of haart before aids recognition: . % of p detected since did not receive haart or had insufficient compliance to antiretrovirals, so that . % of p were aids presenters. during the haart era, an increase of mean age and sexual transmission was found (p b/ . ). notwithstanding the effects of haart on the natural history of hiv disease, the consequences on add distribution and related immunodeficiency were negligible, since most p could not benefit from haart before aids onset. a high clinical suspicion for add should be maintained when facing p with missed or undertreated hiv disease. radata */communication internet platform management of resistance analysis guided haart switch for implementation in clinical practice of hiv-infected individuals soa . paech v, lorenzen t, stoehr a, plettenberg a. ifi, interdisciplinary infectiology and immunology, hamburg, germany purpose: hiv-resistance analyses are indicated to prepare switch of haart in hiv-infected individuals with failure to ongoing haart regimen. specialists at several responsible sites often feel lack of complementary informations if interpretation of resistance analyses is done independent from each other. clinical benefits from resistance analysis assays are sigfnificantly higher for those physicians, who can access external advice from hiv-experts for possible treatment options. the database concept 'radata' (www.radata.de) was developed in germany to generate expert advice for implementation in haart switch. results: fifteen hiv-treatment centres, seven laboratories and high ranked authorities in hiv-medicine contribute to radata database since it is started in january in germany. hiv-infected subjects are eligible to participate at the project after presentation of failure to haart (viral load !/ c/ml). expert advice is generated after all data are evaluated and based on recommendations of Á/ external hiv-experts. observation after therapy switch is scheduled for a period of months. conclusions: radata is a novel database concept with features for evaluation of data and availability of complementary information to participating sites. the project is designed to provide its proficiency to patients and centres from germany and foreign countries. further information will be provided after the number enclosed subjects have enlarged. in vitro effects of hiv infection on abc transporter expression and antiretroviral drug efficacy soa . therefore, we evaluate in primary cultures of human monocytederived macrophages (mdm) and lymphocytes, effects: ( ) of retroviral infection and haart on the expression and activity of p-gp and mrp; and ( ) of specific inhibitors of these host proteins on antiretroviral activities of nrti, non-nrti and ip. results: on the one hand, we evidenced a transitory increase of p-gp mrna expression in lymphocytes and mdm in response to in vitro hiv infection. this was correlated to an increased p-gp cell surface expression and activity, and an increased tnf-alpha production and mrna. in contrast, no significant modulation of mrp was observed. on the other hand, psc and probenecid potentiated in vitro the anti-hiv activity of azt and indinavir. these effects were accentuated when psc and probenecid were combined. conclusion: these results showed that: ( ) hiv infection by increasing abc transporter expression could favorise the efflux of antiretroviral drugs and decrease their pharmacological effects; and ( ) specific inhibitors of these transporters could reverse these deleterious effects. effects of interferon alpha plus ribavirine therapy on frequencies of hcv, hiv and cmv specific cd -t-cell responses in peripheral blood of hiv/hcv coinfected patients after months of treatment soa . methods: two groups of patients with chronic hcv infection were studied: hiv coinfected progressors with antiretroviral therapy and hiv-negative controls. twelve hcv/hiv and hcv patients have already reached months of ifn-alpha'/ribavirine therapy. virusspecific cd -t-cells in peripheral blood were analyzed by ifngamma-elispot-assays using hiv-p , one cmv and three hcv (core, ns , ns ) antigens. results: ( ) at baseline, hcv-specific cd -th -cells frequencies were significantly lower than hiv-and cmv-specific ones; ( ) frequencies of cd -th -cells against hcv as well as against cmv were similar in the two groups; ( ) in hcv'//hiv'/, hcv specific cd -t-cell frequencies did not change between baseline and th month of anti-hcv treatment, decreased in three and increased in only one case. hiv-and cmv-specific frequencies were decreased in seven patients. similar results were observed in hiv-negative group. conclusion: ( ) hcv-specific immune responses might be more prone to tissue compartmentalization than hiv-specific ones; ( ) immune defects induced by hiv infection might not be responsible for the low level of hcv-specific responses observed in hiv-progressors; ( ) ifn-alpha'/ribavirine therapy influence on hcv-and hivspecific cd -t-cell frequencies after months of treatment will be discussed. frequencies of hiv- -p specific th cells (elispot) are correlated with plasma hiv- viral load in a cohort of lt-np and slow progressors soa . martinez v a , alatrakchi n a , costagliola d b , bonduelle o a , agut h c , autran b a , alt study group a . a hopital pitié-salpêtrière, laboratoire d'immunologie cellulaire, paris, france , b faculté de medecine saint-antoine, inserm sc , paris, france , c hopital pitié-salpêtrière, laboratoire de virologie, paris, france background: hiv- -specific t helper- cell responses have been associated with long-term-non-progression (lt-np) in hiv infection but the correlation between frequencies of hiv- -p -specific th cells and viral load has not yet been studied. we prospectively quantified these frequencies by using an ifn-gamma elispot assay in a cohort of lt-np. methods: a cohort of lt-np and slow progressors (infection !/ years and cd counts !/ /mm ) was analysable. hiv- -p specific t cells were analyzed using: proliferation, ifn-gamma eli-spot assays and ifn-gamma production in cell supernatants. results: wide ranges were observed in the frequencies of hiv- -p -specific cd th cells as assessed by elispot ( - sfc/ pbmc) with a median of sfc/ pbmc. these frequencies were negatively correlated with viral load (r /(/ . , p / . ) but not with cd counts and associated with a low level of t cell activation assessed by cd on cd cells (r /(/ . , p / . ). similar results were obtained with t cell proliferation and ifn-gamma production. conclusion: interestingly, the numbers of hiv- -p -specific th cells correlate with plasma viral load, independently of cd counts indicating that: ( ) the defect in hiv- -specific cd th cells does not reflect the global cd depletion; and ( ) these responses are strongly correlated to the control of virus replication. impact of drug Á/drug interactions on therapeutical management of active tuberculosis in hiv infected patients soa . martinez v a , truffot c b , caumes e c , katlama c c , jarlier v b , bricaire f c , jouan m d . a department of infectious and tropical diseases, pitié salpêtrière hospital, institut pasteur, unité de génétique mycobactérienne, paris, france , b department of bacteriology, pitié salpêtrière hospital, paris, france , c department of infectious and tropical diseases, pitié salpêtrière hospital, paris, france , d institut pasteur, unité de génétique mycobactérienne, paris, france since and the use of haart, management of hiv patients with active tuberculosis raised the question of drug Á/drug interactions and therapeutical management of both infections. retrospective cohort study: follow-up of hiv patients with active tuberculosis diagnosed between and . studied data included evolution of tuberculosis and hiv, cd cell counts, plasma hiv viral loads, antituberculosis and antiretroviral regimens. ninety-four percent of patients were treated by quadruple combination antituberculosis drug with rifabutin for five patients. fourteen patients were treated by double antiretroviral therapy of nucleoside reverse transcriptase inhibitors (nrtis) and by triple or more drugs (nrtis and/or nonnucleoside reverse transcriptase inhibitors nnrtis and/or protease inhibitors pis). the median follow-up was months. there was no difference on cd cell counts and viral loads in the two groups and between the patients treated by nnrtis and pis at the diagnosis of tuberculosis, at the time of antituberculosis drug discontinuation and concerning cure rates of tuberculosis. on the other hand, the plasma hiv viral load was significantly better controlled in patients with nnrtis than with pis (p b/ . ). in hiv patients with active tuberculosis receiving haart, antiretroviral combination including nnrtis allows a better control of viral replication than regimen including pis without impact of the use of rifampin or rifabutin. adherence is essential to the effectiveness of antiretroviral therapy. a pharmacy visit would improve the patient advisement. a survey was carried out over a period of months in the u.m.i.t. a self-report was distributed to patients. ninety were evaluated. for %, information's given by the clinician were sufficient and for % the treatment advice cards were useful. however, % of them would like to attend a pharmacy visit. the topics they would prefer to be tackled were drug interactions ( %), side effects ( %) and effect of forgetting ( %). the treatment was well accepted and tolerated for, respectively and % of the patients. the viral load and the cd count were well known by, respectively and %. however, inaccurate pattern of treatment was frequent ( !/ %) and bad adherence was observed: treatment forgotten occasionally ( %), regularly ( %) or inadequate attitude when the treatment was forgotten ( %). number of pills, dose frequency, length of the treatment would be risk factors of nonadherence. for the majority of patients, a pharmacy visit is necessary and beneficial. the first result shows a better understanding of the treatment, an improvement of the adherence and an enhancement of plasma concentration of antiretroviral drugs. in vivo activity of glycopeptides against s. aureus infection in a rabbit endocarditis model: is mic predictive for in vivo efficacy? soa . asseray n, caillon j, lemabecque v, jacqueline c, batard e, potel g, bugnon d. laboratoire antibiologie, faculte de medecine, nantes, france we have studied the in vivo efficacy of vancomycin (v) and teicoplanin (t) against five staphylococcus aureus (sa) strains: two methicillin-susceptible (mssa and ), two methicillin-resistant (mrsa and ) and one glycopeptide-intermediate (gisa ) strain, in a rabbit endocarditis model. mics of v and t (v/t) were . / . , / . , / , . / . , and / , for mssa , mssa , mrsa , mrsa , and gisa , respectively. the animals were randomly infected with one of these strains, then treated for days by v or t. a continuous infusion of v, simulating a mg/kg/ h human dose was used. t was infused as a continuous infusion allowing simulating a mg/kg human dose, following an initial bolus. these regimens achieved clinically relevant serum steady-state concentrations of glycopeptides ( !/ mg/ l). results were as follows: expressed in log cfu/g of vegetations (mean /sd, followed in parenthesis by the number of rabbits used). purpose: to determine the prevalence of the decreased glycopeptides susceptibility among clinical isolates of staphylococcus aureus collected from patients hospitalized in strasbourg university hospital between / / and / / . the susceptibility to glycopeptides of s. aureus isolates collected from hospital environment during approximately the same period was also investigated. methods: the susceptibility to glycopeptides was studied among the mrsa isolates, using: Á/ detection of the decreased susceptibility to glycopeptides using agar plates containing mg/l teicoplanin, Á/ detection of hetero-visa strains using agar plates containing mg/ l vancomycin, Á/ determination of the mics of vancomycin and teicoplanin using the agar dilution and the e -test strips methods. results: thirty-nine percent of s. aureus clinical isolates ( out of strains) are mrsa. no visa or hetero-visa strain was detected. six percent mrsa isolates are teicoplanin intermediate s. aureus strains. in the environment, % s. aureus isolates are methicillinresistant (five out of ). the five strains are all susceptible to glycopeptides. conclusion: the results regarding vancomycin are reassuring. however, the high rate of mrsa and the presence of teicoplanin intermediate s. aureus isolates prove that prevention and control measures need to be improved. comparative investigation of polymerase chain reaction and a conventional methods for detection of methicilin resistant staphylococcus amont clinical isolates soa . kantardjiev tv a , vacheva-dobrevski rs b , panajotov sv a , bachvarova am a , velinov ti a , levterova vs a . a national center of infectious and parasitic diseases, microbiology, sofia, bulgaria , b military medical academy, clinical microbiology, sofia, bulgaria purpose: identification on methicillin resistant staphylococci has a great clinical implication and significant impact of antibiotic therapy. the aim of this study is to compare the disc-diffusion test (ddt), oxacillin agar screen test (oast) and pcr for detection of mec a gene. fifty selective clinical isolates ( staphylococcus aureus and nine s. epidermidis ) determined as methicillin resistant by ddt were enrolled in the study. ddt was performed with oxacillin disk ( mkg/ml) on mueller-hinton agar (mha) without nacl (nccls, ) . oast was performed on mha with % nacl, oxacillin mkg/ ml, t c. these strains was genotypically characterized for the mec a gene presence by pcr method using the mec a - ?-aaa atc cat ggt aaa ggt tgg c- ? and the mec a Á/ ?-agt tct gca gta ccg gat ttg c- ? primers (gibco, brl) . results: in the group of mrs isolates, detected by pcr, positive results were as follow: s. aureus and six s. epidermidis . for six s. aureus isolates ddt and oast were positive; pcr-negative. for two s. aureus and two s. epidermidis isolates pcr was positive; phenotypic methods-negative. conclusions: accurate and rapid detection of mrs is a constant challenge for laboratories. the pcr assay (first time in our country) appears to be more reliable than routine susceptibility testing for the rapid diagnosis of mrsa infections at hospitals, particularly due to the heterogeneous resistance of many strains. . / . ( ) . / . ( ) . / . ( ) . / . ( ) . / . ( ) v . / . * ( ) . / . ( ) . / . * ( ) . / . ( ) . / . ( ) t . / . * ( ) . / . ( ) . / . * ( ) . / . ( ) . / . ( ) distribution and antibiotic susceptibilities of bacteria isolated from suspected urinary tract infections of inpatients in hungary soa . rozgonyi f, csukás z, kamotsay k, szabó d, ostorházi e, berek z, maródi c. institute of medical microbiology, semmelweis university, budapest, hungary between l january and december , a total of , urine samples were cultured % as native urine (nu) and % as uricult-plus (up) (orion diagnostica, finland) . cultivations were negative in % of nu and % of up specimens, while contamination was revealed in % of nu and % of up. in the clinical bacteriologically evaluable positive nu and up cultures, the distribution of the gram-negatives was very similar with the predominance of escherichia coli ( and %) followed by enterobacter spp. the distribution of gram-positives differed significantly according to the types of specimens. nu resulted in % group-d and % group-b streptococcus while up did and . %, respectively. third generation cephalosporins and fluoroquinolons were equally very effective against e. coli strains, while ampicillin inhibited growth of % only. carbapenems, cefepime and the fluoroquinolons were the most active against enterobacter strains. interestingly, trimethoprim'/ sulfarmetoxazole combination could inhibit more than % of enterobacteriaceae strains. piperacillin'/tazobactam ( %), imipenem ( %), and ciprofloxacin ( %) could be the drog of choice against pseudomonas aeruginosa . enterococcus strains were highly sensitive to glycopeptides ( %), nitrofurantoin ( %), imipenem ( %) and amoxicillin'/clavulanic acid ( %). antimicrobial susceptibility levels of escherichia coli isolates cultured from urine at a tertiary care teaching hospital. temporal trend and comparison between community-acquired and nosocomial urinary tract infection soa . nanetti a, manfredi r, valentini r, calza l, chiodo f. uni versity of bologna, infectious diseases, bologna, italy in order to assess the local temporal trend of antibiotic sensitivity of the most common urinary tract bacterial pathogen, all urine-cultured escherichia coli isolates were reviewed as to susceptibility profile, and specimen source (community-versus hospital-acquired infection). when evaluating sensitivity levels of community-acquired pathogens ( Á/ ), a significant resistance rise was limited to cotrimoxazole (p b/ . ) and nalidixic acid (p b/ . ), while a tendency towards increased resistance regarded norfloxacin (p / . ) (fig. ) . when community-acquired e. coli isolates were compared with nosocomial strains (tested in the years Á/ ), a greater susceptibility of community-acquired e. coli isolates was limited to cotrimoxazole versus all other compounds in the year (p b/ . ), while it was extended to amoxicillin, cephalotin, nitrofurantoin and piperacillin in the year (p b/ . ) (fig. ) . on the whole, e. coli showed an elevated sensitivity rate ( !/ % of tested strains) to nitrofurantoin, gentamicin, amikacin, and nd-and rd-generation cephalosporins, while only amoxicillin and piperacillin had a mean resistance rate !/ %, regardless of the community or nosocomial origin. a permanent surveillance of sensitivity levels of the most common pathogens responsible for infectious diseases enables to identify local antimicrobial activity and its temporal variations, and plays a key role in starting empiric therapy, pending bacterial identification and in vitro assays. conclusion: in uti, the antimicrobial agents such as st cg combined with aminoglycosides are recommended as initial treatment as well as the rd cephalosporin generation at monotherapy. in addition, the fluoroquinolones and aminoglycosides are effective in uti. prevalence of resistance mutations to antirretrovirals and relation to virological failure s . garcia f a , suarez s a , alvarez m a , martinez nm a , valera b b , pasquau j b , hernandez quero j a , maroto mc a . a hospital san cecilio, microbiology, granada, spain , b hospital virgen nieves, microbiology, granada, spain purpose: to investigate the prevalence of resistance mutations in the reverse transcriptase (rt) and protease (p) genes of hiv and to relate it with the type of virological failure (vf), we have studied patients ( % naïve or pregnant women, % were first vf, % were second vf, % more than two vf. resistance mutations were investigated using trugene hiv- genotyping kit (visible genetics). results: global prevalence of resistance mutations for rt inhibitors (rti) has been !/ % for m l, d n, k n, m v, l w, t yf, and for l i, m i, l p, a vt, l m for p inhibitors (pi). the prevalence of resistance mutations for the naïve patients studied was very low (a g, v i for rti and l i, m i, m i */all n / */and l p n / for pi). for patients on first vf only k n, m v, t yf (rti) were !/ %, as well as l i, d n, l p (pi); when patients on second vf were studied, then m l, e d, k n, m v, g a, l w, t yf, k qe (rti) and m i, l p, a t (pi) were !/ % prevalence; finally, when patients with more than two vf were studied, the following resistance mutations were !/ %: m l, d n, k r, k n, v i, y c, m v, g a, l w, t yf (rti), and l i, m i, m il, l p, a t, l m (pi). conclusions: the prevalence of primary resistance in the population studied is very low; the prevalence of mutations in the reverse transcriptase and protease genes increase in parallel to the type of virological failure. genotypic resistance in hiv- rna from patient plasma compared with rapid virus isolation and phenotypic resistance in patient pbmcs s . stuermer m, groeschel b, cinatl j, doerr hw. institute for medical virology, university clinic frankfurt, frankfurt, germany objective: to compare hiv- virus isolation in the presence of antiretroviral drugs with plasma hiv- genotyping. materials and methods: hiv- genotyping was performed using the viroseqtm vers. from applied biosystems. interpretation of genotype was done according to international standards. cd -cells were purified from patient plasma and cultivated in microtiter plates coated with anti-cd and anti-cd antibodies in the presence of different concentrations of antiretroviral drugs. virus production was measured using a p antigen assay. phenotypic activity was expressed as % reduction of p concentrations. results: seventeen samples were analyzed. for samples results were obtained from both methods, two samples could not be analysed by phenotyping and four samples not by genotyping. only / samples showed total and / samples partial concordance, / samples showed discordance between the two assays. in discordant samples the genotype gave a definite interpretation. conclusion: hiv- virus isolation and phenotyping from pbmcs may overcome the problem of currently used resistance assays, which analyse only the reverse transcriptase and the protease gene of hiv- . possible mutations in other regions may influence viral fitness and therefore contribute to the growth of the virus population present. the lack of concordance between the two assays is related to the different blood compartments used. the clinical value of resistance tests using pbmcs is under investigation. interleukin- co-operates with a new type i ifn, ifn-tau to inhibit early steps of hiv-i biological cycle s . rogez c a , clayette p a , martin m a , dereuddre-bosquet n a , martal j b , dormont d c . a cea, drm, fontenay-aux-roses, france , b inra, physiologie animale, jouy-en-josas, france , c cea, crssa, ephe, drm, fontenay-aux-roses, france background: type i interferons (ifn) exhibit efficient antiviral activities notably against hiv, but severe side effects restrict their clinical uses. ifn-tau is an ovine or bovine non-cytotoxic type i ifn which displays higher inhibitory effects towards hiv replication than ifn-alpha, particularly in human monocyte-derived macrophages (mdm). the antiretroviral activity of ifn-tau seems to involve antiviral and immunomodulatory mechanisms: il- synthesis is increased in dose-dependent manner in mdm treated with ifn-tau and a specific inhibition of il- biological activity decreases its antiretroviral efficiency. results: after a -h infection, a significant decrease of intracellular hiv rna amount was found in mdm treated with ifn-tau. in parallel, no additive inhibition was observed with ifn-tau during the elongation of proviral dna. these results suggest either an inhibition of hiv nucleocapsid uptake or an immediate hiv rna degradation, and the expression of ?, ?-oas, mxa protein and pkr was then measured. ifn-tau induced the expression of these three host cell factors. the role of il- on these different steps was evaluated and we showed that il- co-operates with ifn-tau during the very early step of hiv biological cycle. conclusion: altogether, these results evidence that ifn-tau uses the same antiretroviral pathway as others type i ifn in mdm, and that il- takes part to its inhibition of early steps of hiv biological cycle. actinomycin-d as a modulator of resistances due to cell-wall active agents like bacitracin (bc) and lysozyme (lz) s . chakrabarty an a , dastidar sg b . a calcutta university, medical microbiology, calcutta, india , b jadavpur university, pharmaceutical technology, calcutta, india it was observed that development of lzr in the lzr mutants took placed at three different levels and was accompanied with unselected, distinctive and elevated levels of bcr. similarly, bcr in bcr-mutants were also detected at three different levels. although the levels of bcr ( / mg/ml) in the bcr mutants could be raised only by persistent efforts, an increase in the levels of lzr (as cross-resistance) in the same mutants could be easily achieved. a correlation of actinomycin-d resistance with lzr and bcr of the mutant bacteria and the effects of lipase treatment on the same showed a Á/ -fold rise in actinomycin-d resistance of the lzr and bcr mutants of gram-positive bacteria compared with their correspondence wild-types. these findings suggest that lzr and bcr are controlled by several genes accounting for reduced cell-wall and cell-membrane permeability and indirectly, by phenotypic alteration of the lipid content of the cell-wall. thus, the alteration of cell-walls and membranes and a phenotypic extra lipid layer can work in conjunction with the efflux pump mechanisms finally determining the levels of drug-resistance. experimental development of drug resistance to non-antibiotics: a role of alteration of membrane fluidity and efflux systems s . dastidar sg a , mazumdar k a , asok kumar k a , chakrabarty an b . a jadavpur university, pharmaceutical technology, calcutta, india , b department of medical microbiology, calcutta university, calcutta, india drug resistance among clinical strains was studied by selecting mutants resistant to promazine (pr) and methdilazine (md). the results showed that successive step-up mutants of pr and md developed cross-resistance to several unrelated drugs, which in subsequent steps had broader resistance spectra with higher levels of resistance. experiments on the membrane fluidity or permeability of bacterial cells using diphenyl hexatrine (dph), a fluorescent probe on md-mutants showed that three was marked reduction in the membrane fluidity and permeability. when several analogues of the basic phenothiazine structure, e.g. -chlor-methyl-n -methyl-pyrrolidine (cmp), methyl- -methyl- -pyrrolidone- -carboxylate (mmpc), hydroxymethyl-n -methyl-pyrrolidine (hmp) and md with final substitution were tested for antibacterial function on different strains, highest activity was observed with respect to md. with anaerobic bacteria the resistance(s) dependent on efflux pumps showed higher levels of resistance even to md. we have found the non-antibiotic agents triflupromazine, trimeprazine and diclofenac sodium have high degree of activity against vibrios, staphylococci and pseudomonads. the explanation of such a phenomenon in terms of possible efflux pumps will be discussed. csf, plasma and urine pcr in lyme neuroborreliosis s . pícha d a , moravcová l a , lásiková Š a , marešová v a , Ž ïárský e b . a charles university, nd medical school, st clinic for infectious diseases, prague, czech republic , b department of cellular and molecular biology, charles university, rd medical school, st clinic for infectious diseases, prague, czech republic the main reason for high diagnostic value of pcr in neuroborreliosis (nb) is the direct way of spirochete detection. two sets of primers in nested pcr were used: one for plasmide gene encoding ospc protein and second for chromosomal gene s rdna. so far patients with clinically manifested involvement in nb were enrolled into the prospective designed study (being continued). the main including criterion was positive prove of intrathecal specific antibody secretion (in patients) and pcr positivity in csf (in ). all patients were repeatedly examined by neurologist and samples of csf, plasma and urine were taken: ( ) before treatment; ( ) after treatment; ( ) after months. before treatment were patients pcr positive in csf, six in plasma, and in urine. five were parallel positive in csf and plasma and four in all three body fluids. urine after treatment was positive in seven ( %) cases and completely negative after months. the pcr has had relative high sensitivity ( %), but does not rich the sensitivity of antibody index ( %). supported by grant mzcr ; . consumption of imipenem correlates with b-lactam resistance in pseudomonas aeruginosa s . lepper pm a , hö gel j b , trautmann m a , grusa e c . a department of medical microbiology and hygiene, university of ulm, ulm, germany , b department of biostatistics, university of ulm, ulm, germany , c hospital memmingen, central pharmacy, memmingen, germany purpose: in the present study we investigated the monthly consume of three anti-pseudomonas-active antibiotics, namely imipenem, piperacillin/tazobactam (pt) and ceftazidime during a period of years ( Á/ ) . the use of these antibiotics was correlated to the rate of resistance in pseudomonas aeruginosa . results: inspection of the time series for use of imipenem, ceftazidime, and pt, and the corresponding time series for resistance (each available from july to july ) indicates a remarkable coincidence between use of imipenem and resistance against the three antibiotics mentioned. pearsons's coefficient of correlation for the use of imipenem and the resistance against imipenem was . (p b/ . ), between imipenem use and pt resistance was . (p b/ . ), and between imipenem use and ceftazidim resistance . (p b/ . ). we found positive regression coefficients quantifying an association with imipenem use in the same month (p b/ . ) and with the use during the preceding month (p b/ . ). the same was true when checking dependence of ceftadizime resistance (p b/ . ) and pt resistance (p b/ . ) on imipenem use observed during the same month. neither the use of ceftadizime nor of pt could be identified as factors creating resistance to one of the three antibiotics under consideration within a reasonable period of time. conclusion: there might be a strong pressure towards resistance created by carbapenems. this could limit the use of carbapenems for initial empiric therapy. treat hard and fast: short course antibiotic treatment and its relation with patient compliance and effectiveness s . perez-gorricho bpg a , ripoll m b , pechere jc c . a niño jesus hospital, infectious diseases, madrid, spain , b insalud, outpatient consult, madrid, spain , c university of geneve, microbiology, geneve, switzerland 'treat hard and fast ': short course antibiotic treatment and its relation with patient compliance and effectiveness. finding the important implications for the way in which physicians manage patients with mild Á/moderate respiratory tract infections, and the relation of this management with the perception of antibiotic effectiveness, and the compliance with the antibiotic regimen has been the main purpose of the research. in a pan-european market research study of more than patients, designed to determine behaviour to the antibiotic management of mild-moderate respiratory tract infections, patient expectations of antibiotic therapy were identified, particularly those aspects that relate to efficacy and compliance. the study identifies three key drivers of patients perceived antibiotic efficacy: length of antibiotic course, time to onset of symptom relief and time to complete resolution of symptoms. the results demonstrate that once daily treatment for short periods is perceived by patients to be significantly more effective than longer antibiotic courses and thus better meets patient expectations of therapy. in this study, a macrolide, azithromycin, was selected as the drug therapy of shortest course, being the antibiotic with the shortest dosage schedule for common outpatient infections. the perception of efficacy with short course therapy also correlates with overall satisfaction with management by the physician and with patient compliance with antibiotic therapy. purpose of the study: group b streptococci (gbs) remain a major cause of neonatal infections. consensus guidelines have recommended an intrapartum antibioprophylaxis by amoxicillin, which has reduced the incidence of early-onset neonatal gbs infections. however, an increased incidence of beta-lactam-resistant gram-negative neonatal sepsis has been reported. the aim of our study was to analyse the consequences of this antibioprophylaxis on the intestinal microbial colonization of newborns. a study of the fecal flora was carried out on stools samples from days-old newborns divided into groups: group a intrapartum treated mothers (n / ); and group b untreated mothers (n / ). both groups were matched with regards to known factors affecting intestinal microbial colonization: gestational age, type of delivery and feeding. results: colonization by enterobacteria and enterococci was not significantly different and occurrence of amoxicillin-resistant enterobacteria was similar ( / and / in groups a and b, respectively). however, the colonization by clostridia was modified: the number of newborns colonized was significantly less important in group a than in group b (group a: / and group b: / p b/ . ). conclusion: in our study, intrapartum antibioprophylaxis did not affect intestinal colonization by aerobes but reduced significantly colonization by clostridia, potentially anaerobic pathogens. impact of an antibiotic policy restricting the use of b-lactams and macrolides on the incidence of clostridium difficile associated diarrhoea in general medical, renal and elderly patients s . boswell tc a , pacey s b , broomfield s c , westmoreland d c , yates c c . a nottingham city hospital, microbiology, nottingham, uk , b nottingham city hospital, pharmacy, nottingham, uk , c nottingham city hospital, infection control, nottingham, uk the purpose of the study: to investigate the short-term impact of a new antibiotic policy for the treatment of urinary and respiratory infections on the incidence of clostridium difficile associated diarrhoea (cdad) in hospitalised medical, elderly care and renal patients. the results obtained: a policy restricting the use of b-lactams (except parenteral penicillin), and promoting alternative antibiotics including levofloxacin for pneumonia, and doxycycline for non-pneumonic respiratory infections, was launched in july . as a result there was a significant and sustained reduction in use of aminopenicillins, cefuroxime and macrolides, with a corresponding increase in doxycycline and levofloxacin. the incidence of cdad was determined during the st months of the new policy and compared to the last months of the old policy. the incidence of cdad fell from . to . per patients, and from . to . per in-patient days (p b/ . ). in contrast, there was no change in the incidence of cdad in other specialties (surgery, oncology etc.) that had not introduced the new policy. there was no change in the incidence of nosocomial bacteraemia with quinolone-resistant coliforms or mrsa, despite the increased use of levofloxacin. conclusions: hospital-wide reduction of b-lactam and macrolide use in medical patients can result in a significant and immediate reduction in cdad. longer follow-up will determine if this effect is sustained. use of imipenem/cilastatin i.v. (tienam i.v.) for the treatment of low respiratory tract infections in intensive care units s . izzo l a , orsetti r b , boschetto a a , binda b a , della casa u a , caramanico l a , la mazza a a . a department of surgery, universitá degli studi di roma 'la sapienza','p. valdoni', rome, italy , b s. camillo-forlanini, intensive care unit, rome, italy ventilator associated pneumonia (vap) is considered the most frequent infection in the intensive care unit (icu), occurring in Á/ % of patients intubated for longer than h besides nosocomial pneumonia is a common complication in the critically ill surgical or trauma patient. inadequate treatment can lead to the complications of acute respiratory distress syndrome (ards), empyema, and lung abscess. the most important aetiological agents both in vap and in pneumonia which arise as complication in surgical or trauma patients are bacteria, whit a marked predominance of staphylococcus aureus and pseudomonas aeruginosa . the authors present their experience ( cases) on the employment of imipenem/cilastatin i.v. (tienam i. v.) as initial empirical monotherapy at the dose of mg)/ /day or g)/ / day for the treatment of the serious lower respiratory tract infection in an icu. tienam is a well tolerated broad spectrum antibacterial agent that is effective against the majority of gram-positive and gram negative aerobic and anaerobic bacteria including most pseudomonas species. except one patient deceased for causes related to his very poor general conditions and three cases in which has been necessary the addition of an aminoglycoside, in all the other patients the imipenem/ cilastatin (tienam) monotherapy has shown satisfactory clinical and bacteriological responses. clinical auditing of the impact of recommendations on antibiotic treatment s . kinoo j a , david-ouaknine f a , hacquard b a , echard y a , decazes jm b . a centre hospitalier lagny marne la vallée, lagny sur marne, france , b hospital saint louis, paris, france the aim of this study was to assess the impact of curative antibiotic recommendations on suitable prescriptions at lagny-marne la vallée hospital (general hospital, beds). two prospective exhaustive audits were made (all complete hospitalizations, excluding psychiatry, february Á/may and ) of the detailed curative antibiotic prescriptions, before and after distribution of internal recommendations. the same methodology, designed by a multidisciplinary team, was used for both periods. the same antibiotics were available at the pharmacy. the prescriptions were assessed by an infectious diseases specialist and a pharmacist using pre-established criteria: literature recommendations ( audit), internal recommendations ( audit). six hundred and fifty-six prescriptions for patients were collected and analysed in , for patients in . exhaustivity of the recovered prescriptions was over %. patient characteristics, infection sites and microbiological findings were similar for both groups. suitable prescriptions were significantly increased ( Á/ %, p b/ . ). unsuitable prescriptions (economic reasons, too short or too long course, incorrect administration, or underdosage) were significantly reduced. prescriptions for incorrect indications were unchanged and necessary combined treatment not being prescribed, increased. local recommendations improved prescriptions, but efforts have to be done in order to go on the improvement of the practice behaviour. cost-effectiveness analysis of antibiotic therapy in hospitalized patients with copd exacerbations (ae-copd) s . beghi g, aiolfi s, maghini l, patruno v, aiolfi e. s marta hospital, pulmonary rehabilitation unit, a.o., rivolta d'adda, italy antibiotic costs represent a high burden of total drug costs for hospital administrations. a scientific approach considering also the economic aspects of each therapeutic decision may gain optimal treatment objectives at pondered costs. in our study we retrospectively evaluated the clinical effectiveness and costs of antibiotic therapy in patients with ae-copd. from to , our retrospective study results support previous pharmaco-economic considerations according which in choosing an antibiotic regimen for ae-copd we must take into consideration the expected clinical and microbiological results without forgetting to consider the economic burden of our decisions. significant increase in fungaemia due to non-albicans candida species s . shah pm. klinikum der j.w. goethe universitaet, schwerpunkt infektiologie, frankfurt am main, germany until , predominant candida species in blood cultures was candida albicans . it accounted for . % of all candida species cultured from blood. since then we have observed a gradual increase in number of non-albicans candida species. from , onwards nonalbicans candida species out-number c. albicans . this observation is especially important as non-albicans candida species are generally non-susceptible to azole derivatives and empirical use of azoles in suspected candidaemia should not be recommended. amphotericin b is uniformally active against almost all candida species. echinocandin may be an alternative. see figure below. a search for newer antifungal chemotherapeutics s . chakrabarty an a , dastidar sg b , saha b b , basu l b . a calcutta university, medical microbiology, calcutta, india , b jadavpur university, pharmaceutical technology, calcutta, india fungal infections due to the mucor-rhizopus (m-z) group present formidable problems due to lack of appropriate and effective drugs against them, as seen in increasing number of clinical situations; death due to mycoromycosis is nearly inevitable. we analysed the biological 'weak-spots' of the mucor-rhizopus group and attempted to devise suitable drugs using their weak-spots. we have noted that like many free-living fungi, the m-z fungi are facultatively chemoautotrophic (can grow on simple sources of carbon and nitrogen and a solution of mineral salts), like the human pathogenic chemoautotrophic nocardioform bacteria. we devised a minimal medium based on that of davis and mingioli, supplemented with simple chemical compounds as sole sources of carbon and nitrogen. the key chemical here was diphenylamine with trypan blue (dpa Á/tb) and other similar sources of c and n. we found that while media free of these chemicals (controls) allowed good growth of different strains of m-z fungi, a mixture of dpa Á/tb completely prevented their growth over a wide concentration range. experiments with immunocompromised mice showed that these drugs at the concentrations used are well tolerated; mice experimentally infected with several clinical isolates of m-z fungi and receiving these chemicals showed that these fungi could not grow in vivo. in vitro activity of newer fluoroquinolones against multi-drug resistant salmonella typhimurium s . nolones resistance is being also reported. we have studied the in vitro activity of b-lactams and fluoroquinolones against multi-drug resistant s. typhimurium from human sources. material and methods: fifty multi-drug resistant s. typhimurium were tested against cefazolin, cefuroxime, cefotaxime, cefepime, ofloxacin, levofloxacin, and moxifloxacin, by the agar dilution method according nccls guidelines. results and conclusions: all the strains were resistant to four or more of the following antibiotics: ampicillin, tetracyclines, chloramphenicol, streptomycin, sulphonamides and nalidixic acid. a high proportion of strains were intermediate or resistant to amoxicillin/clavulanate. we found no resistance to cephalosporins. nevertheless, % were intermediate to first and/or second gen. cephalosporins. cefotaxime and cefepime were the most active cephalosporins (mic : . mg/l). though increasing fluoroquinolones resistance has been described among this kind of strains, no resistance to fluoroquinolones was found here. levofloxacin was the most active fluoroquinolone (mic : . mg/l), followed by ofloxacin (mic : . mg/l) and moxifloxacin (mic : . mg/l). high rates of resistance to antibiotics by salmonellae from diarrhoeic children in zliten-libya s . ghenghesh ks a , ben ali m b , abuhelfaia a b , dufani ma a . a faculty of medicine, al-fateh university, medical microbiology, tripoli, libyan arab jamahiriya , b faculty of arts and sciences, el-ghomes university, biology, el-ghomes, libyan arab jamahiriya salmonellae are major bacterial cause of diarrhoea in libya particularly in children. included in the present study salmonella species isolated from children with diarrhoea in zliten city-libya. the children aged between a few days to years. the organisms were tested for their susceptibility to antibacterial agents using the disc diffusion method. of the isolates examined, ( %) were resistant to ampicillin, ( . %) to amoxicillin Á/clavulanic acid combination, ( %) to cefoxitin, ( . %) to chloramphenicol, ( . %) to doxycycline, ( . %) to gentamicin, ( . %) to nalidixic acid, ( . %) to trimethoprim Á/sulphamethoxazole and none ( . %) were resistant to norfloxacin. a strong relationship was observed between the availability of antibiotics in the pharmacies of the city and resistance of the isolated salmonellae to these drugs. the misuse of the antibiotics by the community may be an important factor (among others) in the emergence of these high rates of resistance by the salmonellae examined. effect of ceftriaxone along with probiotics administration on intestinal ecosystem and betalactamase activity s . bertazzoni minelli e a , benini a a , zoppi g b . a department of medicine and public health-pharmacology section, university of verona, verona, italy , b department of paediatrics, university of verona, verona, italy oral bacteriotherapy during antibiotic treatment is a much debated topic. aim: to study whether different probiotics can prevent imbalance of the intestinal ecosystem (dysbiosis) in children during therapy with ceftriaxone (cx). methods: fifty-one children (mean age . years) with febrile respiratory tract infections were treated with cx mg/kg/day iv, alone (therapy ) and along with the following preparations: saccharomyces boulardii ( ); enterococcus spp. ( ); lactulose ( ); l. casei gg ( ); l. rhamnosus , l. bifidus and l. acidophilus ( ); b. bifidum and l. acidophilus ( ); and a mixture of various lactobacilli and bifidobacteria at high concentrations ( ). faecal samples, collected before and after treatment, were analysed for microflora composition, cx concentration, and beta-lactamase (bl) activity. results: cx causes intestinal dysbiosis. no c. difficile was found. faecal bl increased after therapy in all treated groups. cx alone increased bl activity in % ( / ) of children (no activity before treatment); a higher incidence ( Á/ %) was found in groups and . after therapies , , , , and , bl activity was found in or more children. cx was detected in % of faecal samples. conclusions: the probiotics administration seems to protect against dysbiosis caused by cx and to contain the increase in faecal bl activity. the effects differ according to the probiotic administered and are peculiar to certain bacterial species. these preliminary data need further studies. comparative study of initial and acquired drug resistance in pulmonary tuberculosis in iran s . mansoori d, arami s, mirabolhasani z. nritld, infectious disease, tehran, islamic republic of iran purpose: resistant to anti-tuberculosis agents particularly multiple drug resistant (mdr) is a major obstacle in treatment tuberculosis in the world. between september and march for smear and culture positive pulmonary tuberculosis patients (old / , new / ) pretreatment susceptibility tests of isolated bacilli to inh, rif, emb and stm were performed by standard proportional method and the results were attributed to three groups: (i) newly diagnosed without any history of treatment; (ii) patients with history of treatment for one course; (iii) patients with history of treatment for two or more courses supposed to be mdr cases. the results were collected for each drug individually and different combinations of two, three and four medications. results: resistance to one, two, three and four drugs was significantly increased in group iii comparing to groups ii and i, also in group ii compared to group i. we observed a high rate of primary resistance to inh and stm in groups i and ii and a high rate of mdr (inh and rif resistance) in groups ii and iii. conclusion: the duration of bacilli exposure to antituberculosis agents in the past is a major factor in developing resistance. in contrast to who's guideline, due to high rate of primary resistance especially to stm in our area, we do not recommend addition of stm for treatment of patients whose initial four-drug regimens have been failed (group ii). donors, to understand host interactions with this bacteria, to develop new methods of diagnosis and define new vaccine candidates. nineteen tb patients and seven healthy donors were enrolled in french hospitals. cellular immune responses were evaluated by lymphoproliferation and ex-vivo quantification of specific th cells by elispot-ifn-gamma assays. four recombinant proteins of m. tuberculosis were tested: esat- , b, erp and tb b . and compared with tuberculin. we confirmed that b (but not esat- in our study) gives higher responses in tb patients compared to donors according to the results in proliferation assay (p / . ). in addition, frequencies of th cd specific cells for esat- and tuberculin were statistical different between the two groups (p / . and . , respectively). . % for b and . % for esat- of the patients tested were responders in elispot-assay versus . % for both in proliferation assay. for the new antigens erp and tb b . , no difference was observed between the two groups. in conclusion, b and esat- are recognised by a large number of our patients. they seem to be promising antigens for the development of new methods of diagnosis or for the development of new vaccines. erp and tb b . are not preferentially recognised by tb patients. other exported antigens will be tested. the incidence of tuberculosis (tb) is increasing worldwide. in recent some years, geographical differences in the incidence of tb in former yugoslavia have been observed. an important rise in tb cases was registered in the bordering region of bosnia. it is likely that poorer living conditions, influenced by war and emotional stress, may promote such rising incidence of tb. renal tuberculosis was diagnosed in patients (female , male ) from district brcko in bosnia, during the period of years, Á/ . at the same time none patient had active pulmonary tb lesions, fibrous lesions were noticed in patients, but we did not diagnose any signs of previous pulmonary tb in seven patients. seven patients developed relapse of renal tb after Á/ years of previous treatment. guided by clinical parameters, precisely done renal echosonography enabled early suspicion and searching for renal tb, by radiological and other methods. bacteriological diagnosis was performed by detection mycobacterium tuberculosis on loewenstein Á/jensen medium in patients. pcr as simple, fast and highly sensitive method enabled diagnosis in incipient stadium of disease, so antituberculous therapy could be instituted some months earlier. prompt diagnosis of renal tuberculosis (using pcr, besides standard methods) is necessary, otherwise delayed diagnosis may be dangerous. a study on resistance to first generation anti-tuberculosis drugs in mycobacterium kansasii s . mirsaeidi sm, farnia p, mohammadi f, mansoori sd, jabbari r, taghizadeh r, masjedi mr, velayati aa. national research inistitute of tuberculosis and lung diseases, infectious diseases and immunology (nritld ), tehran, islamic republic of iran purpose: this research has been performed to determine antibiotic resistance of atypical mycobacteria especially mycobacterium kansasi . results: twenty-three pigmented colonies which indicated atypical agents from nritld's mycobacterium culturebank were selected, they then underwent type identification and antibiogram for inh, rif, etb, stm. nine samples were m. kansasi and were other non-mtb, was m. gordonei , m. xenopi , mac, m. bovis , m. tererra , m. asiatioum , m. marinum and . mean age in m. kansasi cases was '/ . year and in non-kansasi cases '/ . year and in whole society ntm was . '/ . . frequency of resistance in kansasi group were to inh ( %), to rif ( %) to etb ( %), to stm ( %) and prevalence of mdr was ( %) and in non-kansasi group frequency of resistance were ( %) to inh, to rif ( %), to etm ( %) and to stm was ( %), to mdr was ( %). conclusion: a significant difference was seen between the age groups of patients who are affected with m. kansasi and non-kansasi (p b/ . ), also in frequency of resistance to first generation anti-tb drugs. m. kansasi is detected as the most common atypical mycobacterium agent in pulmonary infections and attention to antibiogram is recommended before treatment. buruli ulcer caused by mycobacterium ulcerans , is the third most common mycobacterial after tuberculosis and leprosy in west africa. nowadays, the only effective treatment is surgery. it consists in a large excision of the lesions, often followed by a skin transplant. in this study, the effectiveness of rifampin, amikacin and their combination were estimated in the treatment of mice, which were infected experimentally by m. ulcerans . after weeks of treatment with rifampin, amikacin or their combination, no more viable bacilli were found in infected tissues. the animals were kept for other months. among the mice treated with rifampin alone, two mice out of relapsed. the minimal inhibitory concentration of these isolated strains went from . to mg/ml. the dna sequence, obtained from a -pb of the rpob gene from these strains, showed a missense mutations, which affect a ser- replaced by a phenylalanine. this modification on the gene leads to an important inefficacy of treatment when rifampin was used alone. this study showed that rifampin and amikacin have a bactericidal action on m. ulcerans and that a combination of these antibiotics is necessary to avoid the selection of resistant mutants. histopathologic and electron microscopy studies of a severe isolated hiv enteropathy detected in an aids presenter. favorable response to haart introduction or . manfredi r, calza l, chiodo f. university of bologna, infectious diseases, bologna, italy advanced hiv infection was detected in a heterosexual female with a -year history of chronic diarrhoea and severe wasting, as expressed by a body weight of kg, a cd '/ count of cells/ml, and a plasma viraemia of . million copies/ml. a malabsorption syndrome was confirmed by d-xylose test, but repeated pathogen search tested negative at stool examination and light microscopy, scanning electron microscopy (em), and transmission em study of enteric mucosa. em assays detected an ultrastructural modification of duodenal mucosa never reported to date: an extensive thinning of enterocytic microvilli, disappearance of glycocalix, and large vacuolization of the enterocyte cytoplasm. two weeks after starting an indinavir-based haart, diarrhoea disappeared and our patient significantly gained body weight: kg after months, kg after , and kg after year, paralleling a cd '/ increase to cells/ml, and undetectable hiv viraemia. the subsequent -year follow-up confirmed absence of gut disturbances, a stable body weight, a cd '/ count of Á/ cells/ml, and hiv viraemia persistently b/ copies/ml. repeated endoscopy and related histopathologic and em assays documented a notable improvement of mucosal damage, with complete cure reached after years of haart. a direct intestinal localization of hiv may be responsible for severe diarrhoea, malabsorption, and wasting, though the morphological features of hiv enteropathy are still unclear. haart acts favourably also against isolated hiv-related enteropathy. kaposi's sarcoma in a non-hiv immunocompetent adult: relapsing due to the development of a squamus cell carcinoma or . sioula e a , magira ee a , georgopoulou c a , rontogiani d b , gounaris t a . a evagelismos, internal medicine and infectious diseases, athens, greece , b evagelismos, pathology, athens, greece a -year-old heterosexual hiv negative girl was diagnosed with cutaneous kaposi's sarcoma. the disease was started years earlier with the appearance of lesions on the left feet and on the right knee. absolute number of cd and cd were and cells/dl, respectively with a decreased lymphocyte proliferation. human herpesvirus type had been detected in biopsy specimens and she placed on recombinant interferon alpha- b. follow up few months later the lesions decreased in size. two years after the onset of the disease the patient readmitted because of a mass on the left paratracheal region along with mediastinitis. her body temperature was increased. the patient underwent thoracic ct scan, which demonstrated mediastinal well defined soft tissue infiltration associated with mediastinitis and a well-defined mass in the left paratracheal region. the mass biopsy revealed squamous cell carcinoma. several violaceus lesions were observed on the arms, hands and face. severe bilateral lymphedema of the legs with a reddish papules nodules and tumors from . to cm in diameter on the soles, toes and calves were present. this case illustrates the significant relapsing of the cutaneous kaposi's sarcoma soon after the appearance of and the carcinoma and the mediastinitis. a -year-old male patient with insulin-dependent diabetes underwent cardiac surgery for aortocoronary bypass years ago. two weeks after surgery he developed mediastinitis and sternal osteomyelitis caused by methicillin-resistant staphylococcus aureus (mrsa). twice, revisions and plastic surgery for sternal osteomyelitis were performed. the patient received initially treatment with vancomycin. then the patient received intravenous outpatient treatment with teicoplanin for weeks followed by by treatment with fusidic acid and then trimethoprim/sulfametrol. the fistula was closed. four months later he presented again with substernal pain and purulent discharge. the culture revealed the growth of staphylococci which were first mistaken for coagulase-negative staphylococci. after closer investigation these staphylococci were identified as small variant mrsa. computer tomography (ct) revealed multiple mediastinal abscesses. the patient was treated with intravenous linezolid mg bid for days and then switched to oral linezolid mg bid. the oral therapy was pursued for weeks under close surveillance. the patient improved substantially, the purulent discharge disappeared. the mediastinal abscesses were not detected any longer by ct at the end of treatment. the treatment with linezolid was well tolerated. platelets decreased initially but rose to normal values without treatment modification. nosocomial pneumonia due to stenotrophomonas maltophilia in a profound granulocytopenic patient hospitalized for community-acquired staphylococcus aureus severe sepsis or . radulescu a a , sasca n b , lupse m c , tatulescu d c . a university of medicine and pharmac, epidemiology, cluj-napoca, romania , b the teaching hospital of infectious diseases, laboratory, cluj-napoca, romania , c university of medicine and pharmacy, infectious diseases, cluj-napoca, romania objective: to present the diverse opportunistic infections in immunocompromised patients and treatment difficulties. findings: a -year-old women was admitted to the teaching hospital of infectious diseases cluj with a -day history of fever, myalgia, lumbar pain, hemorrhage syndrome. severe sepsis was diagnosed and the conditions that evolved in it were paronychia in a patient with chronic leukemia having prolonged and profound granulocytopenia due to aggressive treatment with ifn. the condition at admission was critical due to trombocytopenia ( b/ platelets/ml) and hemorrhage syndrome. the evolution was favorable under antimicrobial treatment (imipenem), blood and platelet transfusion, intravenous immunoglobulins, granulocyte colony-stimulating factor, antifungal prophylaxis and supportive care. blood and pus cultures revealed mssa. in the th day of hospitalization she developed bronchopneumonia and respiratory failure. the sputum culture was positive for stenotrophomonas maltophilia susceptible to ceftazidime, fluoroquinolones. treatment was unsatisfactory until introducing ticarcilline Á/clavulanate and ciprofloxacine. she had uneventful recovery despite remaining granulocyto-trombocytopenic. conclusions: treatment of infections with emerging agents in immunocompromised patients is difficult, guidance by results of susceptibility testing being misleading with a poor correlation between the tests and treatment outcome. early disseminated listeriosis in a liver transplant recipient (ltr): a rare case due to an in vitro multiresistant strain or . manfredi r, de ruvo n, vivarelli m, bellusci r, montalti r, la barba g, abtueli aden a, cucchetti a, attard l, calza l, cavallari a. university of bologna, infectious diseases, bologna, italy a ltr receiving cyclosporin, azathioprine and steroids, developed an extraordinary episode of sepsis and pleural effusion due to a multiresistant listeria monocytogenes (lm) isolate. a lm strain serov. showing the same, extensive resistance pattern (all penicillins and stand nd-generation cephalosporins), was isolated from multiple blood cultures and pleural fluid weeks after surgery, while stool exam was negative. our p spent her life in countryside and bred some animals, but denied consumption of uncontrolled food. iv cotrimoxazole administration achieved a complete clinical and microbiological cure in days. underlying immunodeficiency may prompt unusual/severe lm infection, but because of its usual community-acquired origin, lm disease remains infrequent in hospitalized p. only seven anecdotal reports of lm infection were described in ltr, Á/ , all but occurring months Á/years after surgery. an early respiratory and systemic infection caused by a community-acquired lm strain which proved resistant to first-choice antibiotics, but had a favorable response to cotrimoxazole (used only once in a ltr with lm sepsis), characterized our episode. an epidemiological survey retrieved the possible source of this usually community-acquired infection. lm should be regarded as an emerging opportunistic pathogen in ltr, and specific risk factors should be seeked. when immunodeficiency is of concern, the unpredictable sensitivity of lm should prompt in vitro assays to adjust antimicrobial therapy problems for discussion hbv Á/hcv and liver carcinogenesis: where does the viral influence end? or . pappas ga. university hospital, internal medicine, ioannina, greece hepatocellular carcinoma (hcc) is a major clinical problem worldwide, usually evolving over a long-standing liver pathology, in the latter stages in the form of cirrhosis. hbv and hcv chronic infection is a common etiology of cirrhosis, and hence, hcc. a number of studies have attempted to clarify the role of these viruses into the progression towards hcc. does their end in the stage of cirrhosis? is progression towards hcc independent of the etiology of cirrhosis (since alcoholic cirrhosis also proceeds to hcc)? do the trials with interferon alfa for patients with hbv or hcv cirrhosis exhibit a favorable result due to the antiviral properties of interferon, or is interferon exhibiting anti-oncogenic potential?, and is hcc cytokine and hormone sensitive (view ongoing trials with somatostatine analogues versus hcc)? (hence, if we treat alcoholic cirrhosis patients with interferon could we have a favorable response?). which patients with hbv or hcv cirrhosis are eligible for interferon treatment?: interferon treatment is a potential hazard for those with thrombocytopenia. how ethical is it to conduct a randomised trial where one leg of cirrhotic patients is left without antiviral therapy? and on the basis of which classification system should the two legs of such a trial be separated? moreover, do viral proteins with oncogenic potential exist (the controversy over the recently discovered hbv protein is still, unresolved)? a major topic awaiting for a major debate. to assess the role of hiv-associated campylobacteriosis (c) according to haart availability, patients with positive culture were identified since . compared with the Â/ hiv-infected p followed in the last decade, no epidemiological differences were shown, save a greater sexual exposure to hiv (p b/ . ). the introduction of haart caused a drop of frequency of c (from . to . episodes per p-year; p b/ . ), and modified clinical features, with disappearance of dissemination and mortality, reported in and patients before (p b/ . ). hiv-related immunodeficiency and disease stage were significantly related to c features before and after haart availability: p b/ . for cd and neutrophil count, p b/ . for aids diagnosis. most cases ( ) were community-acquired, but alimentary or environmental risk factors were never found. ten patients received cotrimoxazole prophylaxis (nine before ; p b/ . ), while no relationship occurred with steroid or antibiotic use, caused cases out of . a % sensitivity was found to quinolones, followed by cephalosporins ( . %), gentamicin ( . %), macrolides ( . %), and cotrimoxazole ( . %). a Á/ -day antimicrobial therapy cured p , but relapses caused by similar strains occurred in patients within Á/ weeks, all in the pre-haart era (p b/ . ). c still occurs in the haart era, probably due to its varied mode of transmission. the frequency of c is greater in hiv-infected patients, but less frequent visceralization, recurrences, and mortality characterized the haart era. objective: to determine the incidence and risk factors for nosocomial viral respiratory infections (nrvi) and involvement of human coronaviruses (hcov) in a neonatal and pediatric intensive care unit. methods: prospective observational study. nasal samples were obtained by cytological brush at admission and weekly thereafter for all hospitalized infants. nasal samples were taken monthly from staff. virological studies were performed, using immunofluorescence for respiratory syncitial virus (rsv), influenza viruses, paramyxoviruses, and adenoviruses; both immunofluorescence and rt-pcr were used for hcov detection. results: during , hcov related nrvi were detected in nn and six in children. three hcov-related outbreaks were observed (february, august and december), associated with a high prevalence of infection in staff. during august outbreak, hcovinfected nrvi were detected over hospitalized infants. seventy-five of hospitalized preterm nn with gestational age under weeks and . % of staff members were infected. risk factors for nrvi in nn were birth weight, gestational age, ventilation, oxygenation and hospitalization length. ninety-two percent of infected preterm nn were symptomatic, mainly with bradycardia and respiratory worsening. conclusions: these data provide additional evidence for a significant role of hcov in nrvi occurring in hospitalized preterm nn. strain typing and screening of dna targets to assess echinococcus sp transmission in new and old geographic endemic foci or . bart jm a , piarroux r a , dia l b , benchikh-elfegoun mc c , vuitton da a , bardonnet k a . a serf, parasitology, besancon, france , b national centre of veterinary study, parasitology, nouakchott, mauritania , c university of mentouri, parasitology, constantine, algeria purpose: cystic echinococcosis is due to echinococcus granulosus. parasite cycles depending on the main intermediate host species involved in different foci have been described promoting mixed infection in the same definitive host. strain typing is a tool to identify the main intermediate host involved via the dogs in the human infection route and to focus the control measures. many dna targets have been used to compare samples and to access the parasite cycle in different countries. but no study has compared the value of each of these targets. eight targets have been tested in mauritania where echinococcosis is an emergent disease, and in algeria where strain typing has never been done. thirty-five cyst samples from human, ovine, camel and bovine have been tested with six nuclear and two mitochondrial targets. results: the two mitochondrial targets and four out the six nuclear targets have allowed to discriminate the different foci. two strains have been found infectious to human : the 'sheep' strain in algeria and the 'camel' strain in mauritania. conclusion: although overlapping geographically sometimes, this raises the question of the respective genetic evolution of the different strains and of their involving in human infection. alveolar echinococcosis in france: an update or . bardonnet k, bresson-hadni s, bartholomot b, gérard a, watelet j, beytout j, saurin jc, piarroux r, vuitton da, who centre collaborating for prevention and treatment of human echinococcosis, university of franche-comté, besançon, france introduction: the highest prevalence rate for alveolar echinococcosis (ae) in europe has been found in france. in , a french observatory of human ae was done in order to get data that could be used to evaluate presentation, evolution and management of ae. material-methods: french cases were collected for the period Á/ . registration of every case was performed with the subject's agreement. a questionnaire was filled in by referring to the patients' medical files or to practitioners or to patients themselves. completeness of the collection of cases was ensured by multiplying the sources of information. results: two hundred and sixty nine french patients were registered. sex ratio averaged . mean age at diagnostic was . years. . % of diagnosis was performed in 'echinococcosis free' french areas. symptoms, but not always specific liver symptoms, were present at diagnosis in . % of cases. the liver was the main location of lesions in . % of cases. a wide spectrum of management of the patients was observed, accounting for regional differences. conclusion: this french observatory of human ea will facilitate a better management of the disease at the national level. it shows new epidemiological trends, and especially an extension of the endemic area. can coins and paper currency transmit bacillus anthracis ? or . ghenghesh ks. faculty of medicine, al-fateh university, medical microbiology, tripoli, libyan arab jamahiriya anthrax is an often fatal bacterial infection caused by bacillus anthracis . recent events that began in september in us has gained the organism worldwide attention and heightened awareness of and concern about anthrax. many cases of anthrax with a number of deaths have been reported as a result of contact with envelopes, sent through postal mail, containing b. anthracis endospores. a number of studies have shown that currency is colonized with bacterial organisms, that include enteropathogens (e.g. shigella sp.), other enteric flora (e.g. escherichia coli ) and potential pathogens (e.g. staphylcoccus sp. , pseudomonas sp. and bacillus sp.). furthermore, methicillin-resistant s. aureus (mrsa) isolates that produced enterotoxin (seb) and toxic shock syndrome toxin- also been reported. all of these studies do agree on that currency may be considered as a method of spreading potentially pathogenic and pathogenic bacteria in the community. therefore, currency could also be a vehicle for spreading other highly pathogenic organisms that include b. anthracis . in addition, the introduction of the 'euro' could also allow such bacteria greater freedom to travel across the euro zone. the threat of using currency, particularly paper notes, in spreading lethal organisms should be investigated and proper measures to prevent the use of such a method by terrorists should be implemented. salvage of temporary femoral catheters for haemodialysis using antibiotics in ambulatory patients or . gerasimovska v, oncevski a, dejanov p. department of nephrology, clinical centre, skopje, the former yugoslav republic, macedonia the stay of femoral catheters (fc) for haemodialysis is typically short-term for several days. we used fc as a temporary vascular access (va) for a longer period of time in outpatients going on regular ambulatory haemodialysis, who had a problem with their permanent access. we analysed patients who were discharged from hosptal with fc. duration time of fc was between and days (average . days) with cummulative total of days. the incidence of bacteriaemia was . episodes/ catheter days. in six patients we had signs of infection, so according to our protocol we took blood cultures from peripheral vein, and from catheter (at same time) and started with antibiotic therapy (ab) systemically and locally (ab was 'locked' in catheter) with different duration of time. dominant microorganism was staphylococcus coagulasa negative, and much less staphylococcus aureus , and enterococcus.ab that were frequently used were: cefotaxim, vancomycin and ciprofloxacin. at one of six patients we removed catheter at once without trying to save the catheter. catheter tip was sent for microbiological analysis too. criteria for catheter-related bacteriemia (crb) was found in only one patient, and for possible crb in five patients after we removed the catheters. in the absence of clinical signs of infection, ab treatment was not provided for positive tip culture alone or for positive blood culture of the catheter with negative blood culture from peripheral vein. advances in meningitis education or . holt de a , tait mi b , cavanna al b , worgan-brown s a , hart b a . a the meningitis trust, stroud, uk , b the computer-aided learning unit, school of health science, university of wales, swansea, uk background: meningitis remains an important cause of death worldwide despite improvements in diagnosis, treatment and prevention. clinical and lay awareness of the disease relies on education, however educational delivery has changed and the introduction of material suitable for computer and internet application is now necessary. we have developed educational material on cdrom and on the internet applicable both at tertiary university and secondary school level. application: a computer-aided learning program on cdrom, covering all aspects of meningitis has been produced. it is suitable for undergraduate teaching of healthcare professionals from student nurse and doctors to pharmacists. in order to reach school children in a form acceptable to both pupils and teachers, we have developed a curriculum-linked website. these applications are simple to use and can be incorporated into existing courses of study, so that issues raised can be discussed with tutors and group peers. comment: the introduction of new methods of teaching and learning mean that compatible educational material must be produced. we believe that these applications, focusing on meningitis, are the first of their kind and that they offer tutors the opportunity to progress their teaching of the disease both in methodology and content. brivudin compared to famciclovir for improved therapy of herpes zoster: effects on acute disease and postherpetic neuralgia or . potentially treatment-related adverse events occurred in . % of the brivudin recipients and in . % of the famciclovir recipients (p / . ). conclusions: in zoster patients ]/ years, brivudin )/ mg and famciclovir )/ mg showed equivalent effects on prevalence and duration of phn. brivudin is as effective as famciclovir in stopping viral replication in acute herpes zoster. brivudin offers the advantage of a once daily dosage regimen while being as well tolerated as famciclovir. activity of complexes of pt(ii) and pd(ii) with pyridine- -carbaldehyde thiosemicarbazone (hfotsc) (acta virol., , , ) with selectivity index (si) . times higher than that of acyclovir (acv). in order to evaluate virus specific response and structure Á/activity relationships we continue our investigations with three pt(ii) and three pd(ii) complexes. the activity was evaluated against sensitive to acv hsv (strain bja) and resistant strains r- (hsv ) and pu (hsv ) and compared to that obtained against strain victoria (hsv ) infection. si was indicative for activity. the virus specific response was demonstrated by the fact that viruses sensitive to acv were also sensitive to pt(hfotsc) ]cl , while acv resistant viruses were sensitive to [ptcl(fotsc) ]. the structure Á/activity relationship was proved by the fact that the less active against hsv infection was [pd(fotsc)]. influenza diagnosis, treatment, and the impact of new antivirals on current treatment behaviours during influenza outbreaks or . schaetz l a , sessa a b , a hoffman-la roche f. basel, switzerland , b italian college of general practitioners, italy introduction: annual influenza epidemics severely affect individuals, families, health care systems and society. the availability of new and specific antivirals provides an opportunity for better management of influenza. methods: during the / and / influenza seasons, physicians ( Â/ /country) and public ( Â/ /country) in the usa and europe were interviewed to determine perceptions of influenza and behaviours for its treatment. results: patients recognise influenza illness as severe and identify it by symptoms of fever, muscle aches/pains and cough. physicians use these symptoms to diagnose influenza clinically ( % fever, % muscle aches/pains, % cough); their main treatment objective being to reduce complications. antibiotics for influenza treatment are broadly recommended/prescribed by about % of european physicians, whereas currently available antivirals are only recommended by %. the recommendation of antivirals by us physicians increased from % (season / ) to % ( / ) and markedly decreased antibiotic use (from to %). experience from the two influenza seasons shows that influenza antivirals are only used while the virus is circulating and that the volume of use is proportional to the size of the outbreaks. conclusions: experiences in the usa show that with prompt outbreak information antivirals can be used appropriately in times of influenza activity. influenza treatment with oseltamivir: costs and benefits for the individual as well as for society or . objective: to evaluate the effects of treatment of influenza with antivirals (oseltamivir) on health outcomes and costs to patients and society. methods: based on clinical trial data and data from the literature a simulation model has been developed. the underlying clinical pathway covers morbidity and mortality due to influenza and its specified complications. health outcome data and costs were attached to events in the model. the model compares various scenarios, which are defined by treatment schemes within defined populations and other parameters. application of the model is shown using uk unit cost data simulating an otherwise healthy adult population comparing oseltamivir with usual care. results: early treatment results in reduced morbidity, which translates into faster recovery and return to normal activities ( . days). lower morbidity and mortality make this a cost-effective intervention from a societal perspective. the analysis covers more than different scenarios and the incremental cost effectiveness ratios will be discussed. conclusion: antiviral treatment appears to be effective in terms of health outcome and cost for otherwise healthy adults from the perspectives of both the individual patient and society. however, this effect is very sensitive to time when treatment is started and the accuracy of the diagnosis of influenza. oseltamivir is well tolerated by all patient groups or . thakar b a , dutkowski r b , froelich e c , gilbride j a , ward p a . a roche global development, welwyn, uk , b f hoffman-la roche, nutley, usa , c f hoffman-la roche, basel, switzerland introduction: oral oseltamivir, the ethyl ester pro-drug of a potent inhibitor of influenza virus neuraminidase, is licensed for the treatment and prophylaxis of influenza in the usa. patients and methods: safety data [adverse events, laboratory safety evaluations] derived from clinical trials involving !/ subjects (including Â/ children and Â/ high-risk adults) and healthy volunteers in a large study investigating ecg parameters. spontaneous event reports from medwatch or yellow-card reports following use by Â/ individuals worldwide. an observational case-control study of !/ subjects with influenza-like illness treated with oseltamivir. results: oseltamivir was well tolerated in clinical trials; drug-related side-effects were limited to transient gi effects occurring in / : exposed individuals. these resolved spontaneously and caused drop out in b/ % of treated subjects. no effects on ecg parameters were noted at doses ]/sixfold above the licensed regimen. oseltamivir had no adverse effects on pulmonary function. no additional effects were identified among high-risk adults or children, or following prolonged dosing for prophylaxis. occasional reports of liver dysfunction have been documented post-marketing but causal association has not been established. conclusions: oral oseltamivir is an effective and safe antiviral suitable for influenza management in all patient groups. the decision to stop the vaccination against smallpox and the loss of specific immunity of a high proportion of the population made apocalyptic the perspective of a natural or provoked re-emergence of smallpox. therefore, it is important to improve the current capacities to prevent or to treat the orthopoxvirus infections. uracil dna glycosylase (udg) is one viral enzyme indispensable to the replication of poxviruses. udg of the copenhagen strain of vaccinia virus (vv) was characterized with the aim of defining specific inhibitors susceptible to be used as a new class of active antiviral substances on the viruses of the orthopoxvirus genus. the activity of this enzyme was analysed in real time, in an original method, on a pcr quantitative instrument by digestion of amplified dna revealed by fluorescent intercaled molecules. this technique was used to screen and select several active antiviral substances on udg. moreover, the antiviral activity was estimated by the cytopathic effect of the vv on infected vero cells. the cytotoxicity was determined by inhibition of trypan blue exclusion. the specificity of action of each tested compound was estimated by the selective index ( % cytotoxic dose/ % effective dose). two antiviral compounds were selected for their inhibitory effect on udg activity and on vv replication in vero cell culture : ('/)- -iodo- ?-deoxyuridine and -chlorouracil. these compounds are candidates for the chemotherapy of poxvirus infections. objective: to study the efficacy and tolerance of russian antiviral drugs produced from dna in a limited resources context. results: the drug derinat was produced from salmons' milt. mm of dna was Á/ kda, hyperchrome effect !/ %, protein content b/ . %. the conjugation of the dna with fe '/ resulted in a new drug named ferrovir which influences dna and rna synthesis during early stages of hiv- replication by blocking the virus's action on cells' metabolism and reduces cytomegalovirus titre in fibroblast cells for . Á/ . ig tcid . a protective effect of ferrovir against fatal herpes encephalitis mice was found. the drugs are not toxic. ic !/ mg/ml. ec of ferrovir against hiv- was mg/ml. in limited clinical trials patients received mg of drugs twice daily ( Á/ days). administration was well tolerated and no side effects were observed. derinat in . % cases of herpesvirus infection ( patients) improved the healing and shortened duration of illness. hiv-infected patients ( ) treated with ferrovir showed sustained, elevated cd '/ counts and a significant reduction in hiv- viral load (median . ig). the apparent remission was found in patients with concomitant hiv and herpes virus infection. conclusions: antivirals show good antiviral potency against rnaand dna-viruses; are well tolerated by patients and are useful in case of mixed infections; low price makes them accessible to populations with low financial resources. ortho total hcv core antigen assay can aid early prediction of response in patients treated with interferon/ribavirin or . lunel f a , veillon p b , payan c b . a ahu angers, laboratoire de bacterio-virologie, angers, france , b chu angers, laboratoire de bacterio-virologie, angers, france aim: evaluate the predictive value of total hcv core antigen assay and viral kinetics in patients with chronic hcv. methods: one hundred and twenty two patients infected by genotype , , or pretreatment viral load (bdna . , chiron) !/ meq/ml, with no previous treatment, received mu interferon (ifn) during months (m). ribavirin was given with ifn after months therapy, for months in patients with detectable rna. viral load was expressed as log (ui/ml) and hcv ag as log (pg/ml)/ ). results: pretreatment ag values were correlated with viral load (r / . ). we observed a rapid decrease of ag ( . log pg/ml) and viral load ( . log ui/ml) after m in sustained responders (sr). in patients who relapsed (rr) after ifn alone, the fall was less important ( . log pg/ml, . log ui/ml) during m . in sr and rr to combination therapy, the decrease of ag and viral load at m was, respectively, (ag: . and . log pg/ml; rna: . and . log ui/ml). we did not observed significant variation of ag and viral load in nonresponders. the negative predictive value of hcv rna and ag after m of treatment were %, and positive predictive values were and %. after month of ifn alone, the hcv ag decrease was highly predictive of sr, correlated with rna negativation and early reduction of hcv rna ( !/ log). conclusion: early measurements of total hcv core antigen are useful to predict long-term response to treatment. lamivudine in the treatment of acute hepatitis b or . vincenti a, meini m, luchi s, de gennaro m, ricciardi l, moneta s, scasso a. infectious diseases department, infectious diseases, lucca, italy acute hepatitis b is a self-limiting infection, but in some cases its course may be particularly severe. we report a case of a -years-old woman affected by acute hepatitis b treated with lamivudine. on admission in the hospital the alanino-aminotransferase was u/l, the aspartate-aminotransferase u/l, bilirubin , mg/dl, hbsag, hbcigm and hbeag were positive, hbv dna was . copies/ml. during the following days, the levels of ast and alt gradually rose; on the th day prothrombine time was %, bilirubin mg/dl and the patient developed signs of encephalopathy. four plasmapheresis were practiced without benefit, so the patient was treated with lamivudine, mg/day. after days of therapy, lamivudine was discontinued because of the appearance of diffuse maculopapular rash. at this time the results of liver function tests were normal; after four months hbsag and hbv dna were no longer detectable. in our patient lamivudine prevented an acute hepatic failure. our experience suggests a promising role of lamivudine in the treatment of acute hepatitis b, but how long such therapy have to be practiced and in which patients? prospective, controlled, clinical studies using lamivudine in patients with acute-hepatitis b are necessary. the cost-effectiveness of amantadine versus symptomatic care in the treatment of influenza or . morris s a , carman wf b , barber j c . a city university, london, uk , b west of scotland specialist virology centre, glasgow, uk , c alliance pharmaceuticals, chippenham, uk aim: to assess the cost-effectiveness of amantadine versus best symptomatic care in the treatment of influenza in the uk. methods: we constructed an economic model populated with parameters from the published literature. the model structure is the same as that used in the economic evaluation of zanamivir published by the national institute for clinical excellence in the uk. we conducted a cost-utility analysis (incremental cost per qaly gained) of amantadine versus best symptomatic care. the analyses are conducted for all adults (average-risk group) and the at-risk population (high-risk group), based on the prevalence of influenza over an average season and when the virus is circulating. the perspective is that of the nhs. results: in the average-risk group the incremental cost per qaly gained of amantadine relative to best symptomatic care is uk£ , during an average influenza season and uk£ , when the virus is circulating. for high-risk individuals the figures are uk£ , and uk£ , , respectively. the results are sensitive to the hospitalisation rate. conclusions : if the threshold for cost-effectiveness is £ , per qaly gained amantadine represents value for money in the treatment of influenza in a variety of scenarios, including the baseline for both average-risk and high-risk groups when the virus is circulating. background: surveillance studies all over the world have revealed an extraordinary increase in the prevalence of penicillin resistant streptococcus pneumoniae . the newer quinolones are believed to have broad activity against s. pneumoniae . methods: a total of penicillin resistant clinical strains isolated from patients at hacettepe children's hospital, ankara, turkey between and were tested for their in vitro susceptibility to various antibiotics that are commonly used in the treatment of respiratory tract infections. the minimum inhibitory concentrations (mics) of the penicillin, amoxicillin/clavulanic acid, doxycycline, azithromycin, clarithromycin, ceftriaxone, ciprofloxacin, levofloxacin, moxifloxacin and gemifloxacin were determined using the nccls recommended procedure for e -test. results: the range of mics, mic and mic values for all agents tested against the strains are shown in the table. gemifloxacin and moxifloxacin had the highest in-vitro activity among the quinolones tested. all strains tested were susceptible to b/ . mg/ml gemifloxacin, b/ mg/ml moxifloxacin and mg/ml levofloxacin. conclusions: there is some degree of resistance to all the drugs except the newer quinolones which were active against all isolates studied. purpose: stenotrophomonas maltophilia prevalence is growing, mainly in some hospital areas. s. maltophilia is frequently multidrug resistant. fluoroquinolone (fq) resistance varies from one to another study, but in whole resistance is moderate to high. gyra and parc qrdr partial codes have been recently described. we have studied correlations between fq-resistance and mutations in these sequences in s. maltophilia clinical strains. material and methods: gyra and parc qrdr regions from six fqresistant and two fq-susceptible s. maltophilia clinical strains were amplified and sequenced. mics of ciprofloxacin (cfx), gatifloxacin (gfx) and clinafloxacin (cnfx) were determined by the agar dilution method, according guidelines defined by nccls for p. aeruginosa . results and conclusions: mics ranges of cfx, gfx and cnfx for resistant strains were Á/ , Á/ and . Á/ mg/l. susceptible strains had mics of cfx, gfx and cnfx of , . and . Á/ . mg/l, respectively. most susceptible and resistant strains had no significant mutations in the fragments sequenced. only one resistant strain (mic of cfx mg/l) and one susceptible strain (mic of cfx mg/l) had a significant gyra mutation, the same in both strains (ile Á/val). thus, fq resistance in s. maltophilia shall derive from changes in other areas in the topoisomerases or probably from other mechanisms of resistance, such as efflux pumps. purpose: corynebacterium urealyticum is the cause of encrusted cystitis and other inespecific utis and systemic infections. it is frequently multi-drug resistant, with a high rate of resistance to fluoroquinolones (fq). the mechanisms of resistance to fqs have not been described in c. urealyticum . we describe the c. urealyticum parc gene qrdr region and its relationship with quinolone resistance. materials and methods: the activity of ciprofloxacin (cfx), levofloxacin (lfx), gatifloxacin (gfx), clinafloxacin (cnfx) and moxifloxacin (mfx) against c. urealyticum clinical strains was determined following nccls guidelines for enterococci. we amplified and sequenced their parc qrdr by standard methods. results and conclusions: five strains ( . %) were cfx-susceptible (mic . Á/ . mg/l), had mics Á/ mg/l and ( . %) were highlevel cfx-resistant (mic Á/ mg/l). cnfx was -fold more active than cfx. mfx and gfx had mics of and mg/l. all the strains, including the type strain, showed a c to t change at the position referred to wild type s. aureus parc gene, leading to a ser- -phe change, described as the main parc change in fq-resistant s. aureus . this finding suggest that this mutant sequence, as compared with parc sequences from other grampositives, might be the wild-type for this species, and might explain in part its high resistance rate, and its apparent lightness to develop high-level resistance. purpose: during routine surveillance, we identified ciprofloxacinresistant (mic!/ mg/l) pneumococcal isolates and compared clinical details and resistance patterns. results: they were isolated from sputa ( ) and blood cultures ( ) from adults, most with heart or lung disease. hospital admissions were common; half had been inpatients in the previous months. nineteen patients received quinolones in the preceding months, in part reflecting the local policy (introduced in ) of penicillin and ofloxacin for first line treatment of pneumonia. thirteen patients had radiological signs of pneumonia and were pyrexial with raised inflammatory markers. agar dilution mics for quinolones, including norfloxacin with and without reserpine, penicillin and erythromycin were performed. an increase in norfloxacin mics was noted over the period ( Á/ mg/l) to ( mg/l). fluoroquinolone efflux was suggested in three isolates. resistance to moxifloxacin (mic Á/ mg/l) was noted from onwards. all isolates were serotype v and resistant to penicillin (mic!/ . mg/l). thirty-one were resistant to erythromycin (mic!/ mg/l). conclusion: the policy of using quinolones may have contributed to the development of quinolone resistance and this cluster of isolates. the increasing levels of quinolone resistance observed raise concerns about the future use of newer quinolones for the treatment of respiratory infections. s. maltophilia has emerged in the last years as an important nosocomial pathogen, inherently resistant to most of the antimicrobial agents. new quinolones has been proposed as a treatment of choice because their enhanced activity, but several parameters (t a , atmosphere, method) can affect the results of mics. methods: we have performed mics using two different methods (agar dilution and microdilution) and different conditions: and c of temperature; atmosphere of o and co , and incubation times of , and h. a total of strains were assayed with nine quinolones following standard nccls. comparisons were made between results with Á/ and Á/ h using the x -test (a / . ). results: no differences were found between Á/ and Á/ h results with agar dilution, except with atbs in the case of mics at c co . on the contrary, almost all the atbs showed significant differences in the results with and h using microdilution method, at any condition of ta or atmosphere. comparison of mics (p values, significance level / %) with incubation times of and h at different procedure conditions. the incubation time is a parameter that seems to affect significantly the results of mics of quinolones when microdilution method is used, whereas only few differences can be encountered with the agar dilution method. results: breakpoints were used as proposed by nccls . during the study period the pneumococci resistance was noted as follows: % to pc, % to em and % to sxt. the rank order of activity of the five fqs against multi-drug resistant pneumococci was: cip (mic : mg/l), ofx (mic : mg/l), lvx (mic : mg/l), grx (mic : . mg/l), tvx (mic : . mg/l). conclusions: in romania, fluoroquinolones represent alternative treatment to beta-lactams and macrolides for first-line empirical treatment for respiratory tract infections caused by pneumococci but, continued vigilance for emerging resistance to fqs is further indicated. introduction and material/methods: susceptibility testing (semiautomated broth microdilution method, sensititre, trek diagnostics, usa, following nccls recommendations) was performed with six different quinolones to streptococcus pneumoniae isolates with a ciprofloxacin-cip */mic ]/ mg/l collected in two consecutive sauce$ surveillances in spain ( Á/ / Á/ ). nccls resistance (r) breakpoints were used ( ]/ for ofloxacin-ofl and levofloxacin-lev; ]/ for sparfloxacin-spa; ]/ for gatifloxacin-gat */and moxifloxacin-mox), but for gemifloxacin-gem */where ]/ was used. results were as follows. conclusions: for cip-r isolates gem and mox were the most active agents. gem was the only agent not influenced by cip mic increase regarding prevalence of r , with % resistance for strains with cip mic ]/ mg/l. $sauce is an acronym standing for 'sensibilidad a los antimicrobianos utilizados en la comunidad en españ a' (susceptibility to the antimicrobials commonly used in the community in spain) and is the spanish word for the willow tree. in vitro activity of gatifloxacin and seven other antibiotics against respiratory and urinary tract pathogens from the community. first results of the basic */study ps grimm h, on behalf of a european multicenter study group, institute for med. microbiology, weingarten, germany a total of centers in austria, belgium, france, germany, italy, portugal, spain and switzerland are involved in the basic study (bacterial annual susceptibility information collection). the mics of gatifloxacin (gati), ciprofloxacin (cipro), clarithromycin (clari), benzylpenicillin g (pen), amoxicillin (amox), amoxicillin/clavulanic acid (augm), cefuroxime (cur) and cefixime (cix) were determined using the microdilution method. each center is requested to investigate strains each of the following species: s. pneumoniae (spn), s. pyogenes (spy), s. aureus (sau), e. faecalis (efa), m. catarrhalis (mca), h. influenzae (hin), e. coli (eco), k. pneumoniae (kpn), p. mirabilis (pmi) and p. aeruginosa (pae). so far approximately strains are enrolled. some important mic %/percentage resistance were as follows: from the oral antibiotics tested gatifloxacin has the highest activity and broadest spectrum against all relevant respiratory and urinary tract pathogens. gatifloxacin is a promising alternative for therapy of respiratory tract bacterial infections. in vitro activity of gatifloxacin against bordetella pertussis in comparison with erythromycin, ciprofloxacin and levofloxacin ps bourgeois n, pangon b, ghnassia jc, doucet-populaire f, de versailles ch. microbiologie, le chesnay, france purpose of the study: bordetella pertussis infections are far more common in adults and adolescents than is generally estimated. however, they are often not recognised. infected or colonised adults can act as a reservoir of infection, passing it to children. fluoroquinolones are currently recommended for the treatment of respiratory tract infection in adult patients, which is usually empirical. gatifloxacin is a novel -methoxyquinolone, with a potent activity against both gram-negative and -positive bacteria. the in vitro activity of gatifloxacin was compared with those of erythromycin, the drug of choice for both treatment and prophylaxis of pertussis, ciprofloxacin and levofloxacin, against clinical isolates strains of b. pertussis including erythromycin resistant strains. results: we used the agar dilution method on mueller Á/hinton medium supplemented with % horse blood to determine the mic of each antibiotic. gatifloxacin (mic , . mg/l) was as active as ciprofloxacin and levofloxacin (mic , . mg/l) against both sensitive erythromycin (mic , . mg/l) and resistant erythromycin (mic , !/ mg/l) strains. conclusion: gatifloxacin may be an effective drug in the treatment or prophylaxis of adults with suspected or confirmed pertussis. ex vivo serum activity (killing rates) after gemifloxacin mg versus trovafloxacin mg single doses against ciprofloxacin-susceptible andresistant streptococcus pneumoniae ps calvo a a , giménez mj b , alou l a , gó mez-lus ml a , aguilar l b , prieto j a . a microbiology department, universidad complutense, madrid, spain , b glaxosmithkline, medical department, tres cantos, madrid, spain serum bactericidal activity was measured ex vivo after single dose administration of gemifloxacin (gem) mg and trovafloxacin (tro) mg to healthy volunteers in a randomized, cross-over phase i trial. blood samples were collected h (cmax) after dosing and serum killing rates were determined against a serotype penicillin (pen) Á/ciprofloxacin (cip) susceptible strain (s ) (mics of . , , . and . mg/l for pen, cip, gem and tro) and a serotype pen Á/cip resistant strain (s ) (mics of , , . and . mg/l for pen, cip, gem and tro). tubes with . ml of serum sample and . ml broth ( % todd Á/hewitt'/ % hbss) were incubated over h at c. final inocula was cfu/ml. mean colony counts for samples and controls (k ) are shown in the figure: gem exhibited higher colony counting decrease of the initial inocula, versus tro, for both strains. after h incubation, the initial inocula decrease obtained with tro and the cip susceptible strain was similar to that obtained with gem and the resistant strain, showing a lower influence of cip mic increase in the ex vivo bactericidal activity of gem versus tro. urine bactericidal activity after administration of gemifloxacin and trovafloxacin single doses in a phase i study ps garcía-calvo g a , parra a a , giménez mj b , ponte c a , aguilar l b , soriano f a . a fundación jiménez díaz, medical microbiology, madrid, spain , b glaxosmithkline, medical, madrid, spain urine bactericidal activity after o.d. administration of gemifloxacin (gem) mg and trovafloxacin (tro) mg, was assessed in six adult males in a cross-over phase i trial. urine killing rates (ukr) against escherichia coli atcc (mic mg/l of . and . for gem and tro) and s. saprophyticus atcc (mic mg/l . and . for gem and tro) were performed with samples collected at , Á/ , Á/ and Á/ h. a . ml of iso-sensitest broth and . ml of bacterial logarithmic growth were added to ml sample, giving a final inoculum of cfu/ml. colony counting was performed after , , and h incubation. percentages of initial inocula reduction (iir) were calculated. mean urine concentrations measured by bioassay were (mg/l): . , . and . for gem, and . , . and . for tro. against e. coli , an iir of . % was obtained after h incubation with all samples except with tro at Á/ h. against s. saprophyticus an iir of % was obtained after h incubation with all samples except with tro at Á/ h, where bacterial regrowth was found. the maintenance over h of gem urine antibacterial activity suggests its efficacy in the treatment of uncomplicated cystitis. influence of the decreased susceptibility to ciprofloxacin on gemifloxacin versus levofloxacin efficacy in experimental pneumococcal pneumonia in guinea pigs ps garcia-olmos m a , parra a a , gimenez mj b , garcia-calvo g a , ponte c a , aguilar l b , soriano f a . a fundacion jimenez diaz, medical microbiology, madrid, spain , b glaxosmithkline, medical, madrid, spain the efficacy of ciprofloxacin (cip), levofloxacin (lev) and gemifloxacin (gem) in the treatment of pneumococcal pneumonia was assessed in a guinea pig model using three strains (s) with mics (mg/l) of , and . (s ), , and . (s ) and , and (s ) for cip, lev and gem, respectively. intraperitoneal treatments started h after s. pneumoniae intratracheal inoculation, and continued t.i.d up to four doses. ten animals were included in each group. doses (mg/kg) used were , and for cip, lev and gem, respectively, in order to mimic auc - h and cmax obtained in humans after standard doses. animals that survived h after inoculation were sacrificed and colony counts were performed in lungs ( the purpose of the study levofloxacin (lfx) is a fluoroquinolone whose activity against both gram-negative bacilli and gram-positive cocci enables its use in monotherapy for the treatment of nosocomial pneumonia. our aim was to study the pharmacokinetic Á/pharmacodynamic appropriateness of lfx mg iv bid in the treatment of six inpatients with ventilator-associated pneumonia (vap) ( / years; m Á/ f; / kg). blood and urine samples were collected in steadystate conditions at appropriate intervals. lfx concentrations were analysed by hplc. the aetiological agent was identified in all the cases and its in vitro sensitivity to lfx was always assessed. the results obtained mean values ( /sd) of the major pharmacokinetic parameters were: cmax, . / . mg/ml; vdss, . / . l/kg; t / b, . / . h; cl, . / . ml/min/kg; auc -t, . / . mg/ml h. cumulative urinary excretion was . / . %, confirming that lfx clearance is mainly renal. clinical cure and microbiological eradication were obtained in all the patients after a Á/ day therapy. a suprainfection due to acinetobacter anitratus insensitive to lfx occured in case. the major pharmacodynamic parameters of fluoroquinolone efficacy were significantly higher than the proposed threshold (cmax/mic !/ ; auc/mic !/ ) in all the cases. the conclusion reached the findings suggest that lfx mg bid iv may be considered effective in the treatment of vap caused by sensitive bacteria. comparative pharmacokinetics of levofloxacin in patients with lower respiratory tract infections (lrti) being treated with sequential therapy ps pea f a , brollo l a , lugatti e b , di qual e a , dolcet f b , talmassons g b , furlanut m a . a institute of clinical pharmacology and toxicology, dpmsc, university of udine, udine, italy , b division of pneumology, sm misericordia hospital, udine, italy the purpose of the study levofloxacin (lfx) is a fluoroquinolone whose activity against both gram-negative bacilli and gram-positive cocci enables its use in monotherapy for the treatment of lrti. our aim was to study the pharmacokinetic Á/pharmacodynamic appropriateness of a standard switch lfx iv/os regimen ( mg iv od for Á/ days followed by mg os od for Á/ days) in the treatment of seven inpatients with lrti ( / years; m Á/ f; / kg). blood samples were collected in steady-state conditions at appropriate intervals. lfx plasma concentrations were analysed by hplc. the aetiological agent was identified in / cases and its in vitro sensitivity to lfx was assessed. the results obtained absolute oral bioavailability was . / . , with a cmax of . / . vs . / . mg/ml after iv and oral administration, respectively. no significant difference in the main pharmacokinetic parameters was observed between the two routes. the major pharmacodynamic parameters of fluoroquinolone efficacy were significantly higher than the proposed threshold (cmax/mic !/ ; auc/mic !/ ) in the two assessable cases. all the patients were clinically cured after a Á/ day therapy. the conclusion reached the ad interim findings show that lfx mg od may guarantee per os an exposure similar to that achievable after iv administration, suggesting that sequential therapy may be considered effective in the treatment of lrti. levofloxacine in the exacerbations of copd due to pseudomonas ae ps micheletto c, tognella s, pomari c, dal negro r, ospedale orlandi, div.pneumologia, bussolengo, italy development of antibiotic resistance in bacteria is a problem of great concern. gram-negative bacteria, including multidrug-resistant (mdr) pseudomonas aeruginosa (ps), are responsible for a significant proportion of episodes of copd exacerbations, particularly in elderly ( ). aim was to check the susceptibility to common antimicrobial treatments against ps strains isolated from bronchial secretions in patients with severe exacerbations of copd. methods: microbial investigations were conducted on specimens: spontaneous purulent sputum ( . %), and tracheobronchial aspirates ( . %, collected with a protected specimen brush). results: fifty-seven ps pathogen strains ( cfu) were identified ( . %) and tested over a -month period: ps. aeruginosa . %; ps. putida . %; ps. fluorescens . %, and burkholderia cepacia . %. the assessed susceptibility to most common antibiotics was: levofloxacine ( %), ciprofloxacine ( %), ipenem cil. ( %), ceftazidime ( %); amikacin ( %), and piperacillin'/tazobactam ( %). a much lower susceptibility was found for ticarcillin Á/clavulanic acid ( %), gentamicin ( %), and netilmicin ( %). ( ) at present, levofloxacine proves the most effective antimicrobic option for treating copd exacerbations due to ps infection; ( ) a much more efficient policy of antibiotic prescribing should be promoted in order to prevent the selection of resistant strains in these cases. these results confirm the excellent 'in vitro' activity of levofloxacin against nosocomial gram-negative pathogens, including the esbl producing strains ( % of escherichia coli , e. cloacae and k. pneumoniae were inhibited at . mg/l). levofloxacin was more rapid than ciprofloxacin to determine a bactericidal effect particularly against s. maltophilia . moreover, considering the favourable pk/pd profile, levofloxacin can represent a valid therapeutic option for the treatment of severe gram-negative nosocomial infections. moretti f, quiros-roldan e, casari s, chiodera a, viale p, carosi g. university of brescia, institute of infectious and tropical diseases, brescia, italy a -year-old man, ivdu, hiv positive was attended in aur hospital for fever and toracic pain. a x-chest radiography revealed a round lesion of cm near the lingula with central hyper-diaphan area. lymphocytes cd '/ count was cells/mm and viral load . cp/ ml. hospital stay rhodococcus equi was found in cultures of peripheral blood, faecal and sputum specimens. antibiotic treatment with oral rifampin ( mg/qd) and with intravenous imipenem ( mg tid) was started. due to the persisting fever, immodificated radiography and negativity for p. carinii , mycobacteria and bacteria in bal coltures, imipenem was substituted by parenteral vancomycin ( mg bid). after days, because of persisting fever and increase of the diameter of the lung lesion ( cm) vancomycin was sustituted by oral levofloxacyn ( mg bid), continuing rifampin. after a days course of levofloxacyn therapy the fever remitted. the patient was discharged with levofloxacyn ( mg bid) and rifampin and, after months of follow-up, a radiological control pointed-out a remarkable resolution in the lung lesion. we may suppose that levofloxacyn can be effective for the treatment of r. equi infection, even if more studies (particularly controlled studies) are necessary. liberti a a , izzo b a , loiacono l b , calabria g a , patarino t a , izzo e a . a ii department, naples, d. cotugno hospital, italy , b iii department, naples, d. cotugno hospital, italy the increasing prevalence of salmonella typhi strains with reduced susceptibility of chloramphenicol had prompted the search for other antibiotics with the same efficacy.quinolones are a class of antibiotic with an activity in vitro and in vivo against enteropathogenes. we inwestigated the use of levoxacin in two regimens of treatment of typhoid and paratyphoid infection. patients and methods: thirty-two adult patients were incluted in this study from september to april ; patients had positive culture for s. typhi and six had positive cultures for s. paratyphi . all isolated were fully susceptible to levoxacin. we compared treatment with levoxacin for days, mgr b.i.d. (group , patients), with treatment for days, mgr b.i.d. (group , patients). clinical cure was defined as defervescenze of fever by day of treatment, with an absence of complications and no clinical relapse during the followup. results and conclusion: the clinical cure rate was % ( patients) for group and % ( patients) for group ; the difference in these rates was not statistically significant. the blood cultures of all patients were sterile by day of treatment and remained so until the th month of follow-up, no subjects had clinical or microbiological relapse and all stool cultures remained negative, also. the two regimens of treatment was good tollerated and no adverse event was registered; it was concluded that levoxacin treatment for days in enteric fever is not necessary the mulidrug-resistence of s. typhi led to the use of quinolones as the first-line drug in the treatment of enteric fever. pefloxacin in the treatment of patient with acute infectious diarrhoea ps troselj-vukiae tvb a , strahinja v b , poljak i a , stojanoviae d c , nikoliae n d . a department of infectious disease, university hospital center, rijeka, croatia , b glaxosmithkline, marketing, rijeka, croatia , c dept. rijeka, institute of public health, rijeka, croatia , d dept. rijeka, maritime academy, rijeka, croatia the purpose of the study was to investigate clinical and bacteriological efficiency in and days pefloxacin treatment and to compare it with symptomatic therapy. the results obtained in patients treated with pefloxacin the therapy was clinically effective already in the third day while in the control group this happend in the th day. bacteriological eradication was noted in patients ( %) of the first and patients ( %) of second group in the th days of the treatment. they all had negative cultures and weeks after pefloxacin protocols were completed. only patients ( %) in control group had negative stool cultures in the th day of the treatment and all of them weeks after it ended. there was no statistically significant difference in clinical (p / . ) and bacteriological (p / . ) efficiency between and days pefloxacin treatment protocols. both protocols significantly differed in clinical (p b/ . ) and bacteriological (p / . ) eradication from the control group. the conclusion reached is that the efficiency of pefloxacin (quinolones) in the treatment of acute infectiuos diarrhoea and justifies their use in the more severe forms of the disease. dalhoff a a , ullmann u b , schubert s b . a bayer ag, wuppertal, germany , b university of kiel, institute of med. microbiology, kiel, germany background: the antibacterial activity of moxifloxacin (mxf) was compared to levofloxacin (lev), amoxicillin (amx), clarithromycin (cla) and erythromycin (ery) in an in vitro model. method: pharmacokinetics in bronchial mucosa (bm) and serum (s) following single oral doses of mg mxf or cla and mg lev, amx or ery were simulated using a one compartment model. bacteria tested staphylococcus aureus (nos. , ), streptococcus pneumoniae (nos. , ). aliquots were taken ( Á/ h) and plated on to brain heart infusion agar for enumeration. results: s. pneumoniae was eliminated by all agents studied. significant differences were apparent with s. pneumoniae and the s. aureus strains: objective: to compare the safety and efficacy of once-daily moxifloxacin with once-daily ceftriaxone in the treatment of cap in hiv-infected patients (pts). methods and results: in a retrospective survey, oral moxifloxacin ( mg daily)/ Á/ days) was compared to standard regimen of i.v. ceftriaxone ( g daily)/ Á/ days) for treatment of cap in hiv'/ pts. adults pts with clinical signs and symptoms of cap and consistent chest x-ray findings were included. pts had a median age of years (range Á/ and % were male). demographic characteristics were similar in both treatment groups; pts received mxifloxacin and pts ceftriaxone. clinical success rates were % for moxifloxacin and % for ceftriaxone. at a post-study evaluation approximately weeks later, moxifloxacin-treated pts and ceftriaxone-treated pts had relapsed. the adverse events reported were comparable for both treatment groups. there were four-related adverse events ( gi, headache) for moxifloxacin-treated and ( gi, skin) for ceftriaxonetreated pts. conclusion: the results of this study show that moxifloxacin as oral therapy is as effective and well tolerated as i.v. ceftriaxone in the treatment of hiv'/ pts with cap. therapy with moxifloxacin was not associated with any significant clinical or laboratory abnormalities. these data suggest that once-daily oral administration of moxifloxacin is potentially convenient and cost-effective alternative therapy for cap in pts with hiv infection. moxifloxacin in the treatment of acute maxillary sinusitis after first-line therapy failure or acute sinusitis with high risk of complications ps gehanno p a , berche p b , perrin a b , arvis p c . a ent department, bichat claude bernard hospital, paris, france , b microbiology department, necker enfants malades hospital, paris, france , c bayer pharma, medical affairs department, paris, france the efficacy and safety of moxifloxacin (mxf) mg once daily for days was evaluated in the treatment of acute maxillary sinusitis after first-line therapy failure, or acute sinusitis with high risk of complications. in this prospective, multicenter study, a total of patients with acute bacterial sinusitis confirmed by sinus x-ray were valid for efficacy analysis: one hundred and seventy five patients ( . %) had an acute maxillary sinusitis which failed to respond to a previous antibiotic therapy given for a mean duration of . days, and ( . %) had an acute sinusitis with high risk of complications (frontal: , pan-sinusitis: and sphenoid: ). ninety two patients ( . %) were microbiologically valid. clinical cure and continued clinical cure rates at Á/ and Á/ days post-therapy were . and . %, respectively. clinical cure rates at Á/ days post-therapy were . and . % in sinusitis after first-line therapy failure and in sinusitis with high risk of complications, respectively. bacteriological eradication rate during therapy (day Á/ ) was . %. at Á/ days post-therapy. bacteriological success rates were . % in patients who failed to respond to a previous antibiotic and . % of patients who had sinusitis with high risk of complications. . % of patients experienced drug-related adverse events, abdominal pain ( . %), nausea ( . %) being the most frequently reported events. mxf was rapidly effective and a well-tolerated treatment for this kind of infection. neisseria gonorrhoeae with decreased susceptibility to penicillin and ciprofloxacin: novel mutation patterns in the gyr a and par c genes of ciprofloxacin resistant isolates and plasmid profile of penicillin resistant isolates of n. gonorrhoeae in india (delhi) ps chaudhry u, saluja d. dr. b. r. ambedkar center for biomedical research, university of delhi, delhi, india commercial sex workers (csws) serve as the most important reservoir of gonorrhoea. periodic monitoring of the antimicrobial susceptibility profile of neisseria gonorrhoeae in a high-risk population provides essential clues regarding the rapidly changing pattern of antimicrobial susceptibilities. in india, such a surveillance of the in vitro antimicrobial susceptibility of n. gonorrhoeae was established in . significant increasing trend of penicillin and ciprofloxacin resistance with high mic of Á/ and Á/ mg/ml, respectively were found over the years ( Á/ ) . the molecular basis of ciprofloxacin resistance, i.e. mutations in the gyr a and the par c genes of isolates, were analyzed. four isolates (with an mic of mg/ml for ciprofloxacin) harbored triple mutations (ser- to phe, asp- to asn and val- to leu) in the gyr a gene. the third mutation of val- to leu, lies downstream of the quinolone resistance determining region of the gyr a and has not been described before in gonococcus. in addition, these isolates had a phe- to tyr substitution in the par c, a hitherto unknown mutation. the alterations in the par c gene were seen in these isolates only in the presence of changes in the gyr a gene and comprised amino acid changes at codons , , , , and . the presence of b-lactamase plasmid among the penicillinresistant isolates was determined by their plasmid profiles and further confirmation was carried out by a pcr based protocol. our findings suggest that emergence of penicillin and ciprofloxacin resistance in n. gonorrhoeae isolates from a major std center in india, indicates the need for the increased awareness and prudent use of antimicrobials. in vitro activity of newer antibiotics against methicillin-resistant staphylococcus aureus ps gutierrez zufiaurre mn, sanchez hernandez j, munoz-bellido jl, garcia-rodriguez ja. hospital universitario de salamanca, microbiología, salamanca, spain purpose: mrsa are frequently co-resistant to a number of structurally unrelated antibiotics. more than % mrsa are resistant to gentamycin, ciprofloxacin, macrolides and clindamycin. newer antibiotics active against multi-drug resistant grampositives have been developed. we have tested the in vitro activity of newer antibiotics against genetically-characterized, high level ciprofloxacin resistant mrsa. material and methods: thirty-six ciprofloxacin-resistant, gyra/grla mutant mrsa clinical strains were tested against levofloxacin (lfx), ciprofloxacin (cfx), moxifloxacin (mfx), gatifloxacin (gfx), erythromycin (er), telithromycin (tl), linezolid (lin), synercid (syn) and vancomycin (va). mics were determined by the agar dilution method, according nccls guidelines. results and conclusions: all the strains were resistant to cfx, , % were lfx-susceptible and . % were gfx-susceptible. nevertheless, mics of lfx and gfx for all susceptible strains was in the highest extreme of the susceptibility range. mfx was the most active quinolone. almost all the strains were high-level er-resistant with constitutive mlsb phenotype. tl did not improve significantly its behaviour, although it was -fold as active as er against the only er-susceptible strain. va, lin and syn had excellent activity against all the strains. they showed a very homogeneous behaviour against all the strains that were included in a range of Á/ mg/l of lin and va and . Á/ mg/l. sanchez hernandez j, gutierrez zufiaurre mn, munoz-bellido jl, garcia-rodriguez ja. hospital universitario de salamanca, microbiología, salamanca, spain purpose: corynebacterium urealyticum is the etiologic agent of encrusted cystitis and inespecific utis, and can be also involved in systemic infections. c. urealyticum is frequently multi-drug resistant, so only glycopeptide antibiotics and tetracyclines have high susceptibility rates, while fluoroquinolones resistance rates vary significantly. we have tested the in vitro activity of linezolid, telithromycin, synercid and newer fluoroquinolones against multi-drug resistant c. urealyticum clinical strains. material and methods: sixty-four c. urealyticum clinical strains were tested against levofloxacin (lfx), ciprofloxacin (cfx), moxifloxacin (mfx), erythromycin (er), telithromycin (tl), linezolid (lin), synercid (syn) and vancomycin (va). mics were determined by the agar dilution method according guidelines defined by the nccls for enterococci. results and conclusions: results confirm the high resistance rate to older fluoroquinolones and macrolides, with !/ % cfx resistance and % er-resistance. lfx was more active (mic mg/ml). mfx was the most active fluoroquinolones (mic mg/ml). tl improve its behaviour in respect to er (range . Á/ mg/ml). va, lin and syn had excellent antimicrobial activity. no resistant strains were found. mic were , . and mg/ml, respectively. mics were similar for all the strains independently of their resistance to other antibiotics plasma concentrations, urinary excretion and bactericidal activity of linezolid ( mg) versus ciprofloxacin ( mg) in healthy volunteers after a single oral dose ps wagenlehner fme a , wydra s a , onda h a , kinzig-schippers m b , sö rgel f b , naber kg a . a hospital st. elisabeth, urologic clinic, straubing, germany , b institute for biomedical and pharmaceutical research, (ibmp), nürnberg-heroldsberg, germany purpose of the study: in a randomized cross-over study volunteers received a single oral dose of mg linezolid versus mg ciprofloxacin to assess plasma concentrations (up to h), urinary excretion (by hplc), and urinary bactericidal titers (ubt) up to h. the mean maximum plasma concentration of linezolid was . mg/ ml and of ciprofloxacin . mg/ml. the cumulative renal excretion (mean) of parent drug was %/ % for linezolid/ciprofloxacin. ubts were determined for a reference strain and five gram-positive clinical uropathogens with the following mics (mg/ml) for linezolid/ciprofloxacin: s. aureus atcc ( / . ), s. aureus (mssa) ( / ), s. aureus (mrsa) ( / ), s. saprophyticus (msse) ( / . ), e. faecalis ( / ), e. faecium ( / ). results: median ubts measured within the first h for linezolid were : for enterococcal strains and : to : for the four staphylococal strains. median ubts for ciprofloxacin were : for the two enterococcal strains, : to : for the two ciprofloxacin susceptible, : . for the two resistant staphylococcal strains. areas under the ubt Á/time-curve showed statistically significant differences only for the two ciprofloxacin resistant staphylococcal strains in favour of linezolid. conclusion: linezolid exhibited the same bactericidal activity against ciprofloxacin resistant as susceptible strains. linezolid should be tested for treatment of complicated uti due to gram-positive uropathogens in a clinical trial. whitehouse t a , cepeda ja a , tobin purpose: we performed pharmacokinetics within a double-blind, randomised trial comparing linezolid and teicoplanin in intensive care patients with known or suspected gram-positive infection. they received either mg linezolid intravenously -hourly, or mg teicoplanin -hourly for the first three doses and once daily thereafter (or every rd day if renally impaired). blood samples were collected to create serum pharmacokinetic profiles. linezolid was quantitated by hplc and teicoplanin by fluorescence polarization immunoassay. results: twenty two patients were studied in the linezolid group (m Á/f : , mean age years [range Á/ years]). median treatment duration was . days (range Á/ ). eighteen patients were treated with teicoplanin (m Á/f : , mean age years [range Á/ ]) for median days (range Á/ ). steady state peak concentrations (mean / sd) for linezolid and teicoplanin were . / . and . / . mg/l, respectively. trough concentrations at day were . / . mg/l for linezolid and . / . mg/l for teicoplanin. recommended breakpoints of staphylococcus aureus are mg/l for linezolid and mg/l for teicoplanin. accumulation occurred in one -year-old linezolidtreated patient with impaired renal function. conclusion: current recommended dosing regimens for linezolid and teicoplanin are generally appropriate in the critically ill, though a more detailed analysis is required. stamos g, lebessi e, ioannidou s, paleologou n, kallergi k, foustoukou m, 'p. and a. kyriakou ' children's hospital, microbiology, athens, greece the purpose of the study was to investigate the susceptibility of methicillin resistant staphylococcus aureus (mrsa) isolates from a -bed paediatric hospital to quinupristin/dalfopristin (q/d, streptogramin combination) and linezolid (lzd, oxazolidinone). material: we performed a retrospective analysis of mrsa strains, isolated from patients hospitalized in miscellaneous medical departments [neonatal unit ( ) , surgical wards ( ), orthopaedic wards ( ), oncology unit ( ), other wards ( ) and outpatient clinic ( )], during a -year period ( Á/ ) . the sources of isolation were pus ( ), throat ( ), nasal ( ), bronchial ( ), skin ( ), stool ( ) ear ( ) and other ( ) specimens. all isolates were sensitive to glycopeptides, while . % were resistant to gentamicin and . % to erythromycin. methods: the sensitivity testing was performed by a disk diffusion method (bbl sensitivity disks, becton dickinson), according to nccls guidelines. the breakpoint zone diameters for lzd and q/ d were ]/ and ]/ mm for susceptibility and / and / mm for resistance, respectively. results: all isolates were proved to be susceptible to both antibiotics. the mean inhibition zones were . mm for lzd and mm for q/d. conclusions: lzd and q/d are very promising antimicrobial agents, showing excellent activity against mrsa clinical isolates. the prudent therapeutic use is strongly recommended to avoid the emergence of resistance. in vitro activity of streptogramins and oxazolidinones against streptococcus pneumoniae clinical isolates ps stamos g, lebessi e, paleologou n, psatha m, sanida p, zaphiropoulou a, foustoukou m, 'p. and a. kyriakou ' children's hospital, microbiology, athens, greece the purpose of this study was to evaluate the in vitro activity of linezolid (lzd), a member of oxazolidinones and the streptogramin combination quinupristin/dalfopristin (q/d) against clinical isolates of streptococcus pneumoniae from a tertiary care paediatric hospital. material: a total of pneumococcal isolates exhibiting reduced susceptibility to common antibiotics were included in the study. the strains were isolated from middle ear fluid ( ), eye ( ), nasal ( ) blood ( ) and other ( ) cultures during the last years. the percentages of the isolates that were resistant to penicillin, erythromycin, cotrimoxazole and clindamycin were . , . , . and . %, respectively. methods: the susceptibility testing was performed by a standard disk diffusion method (bbl sensitivity disks, becton dickinson). in case of marginal results or intermediate sensitivity to quinupristin/ dalfopristin, the mic was determined using the e -test method (ab biodisk). results: all isolates were found to be sensitive to lzd. q/d was very active as well, except for two isolates that exhibited intermediate susceptibility, showing cross-resistance to macrolides and clindamycin, as well. conclusions: the new antimicrobial agents show excellent activity against resistant to common antimicrobials pneumococcal isolates, but the clinical use is not suggested, unless no other therapeutic solutions are available. linezolid is a new oxazolidinone with excellent activity against gram-positive organisms including glycopeptide-resistant strains of staphylococci and enterococci. in icu linezolid has been used for the treatment of severe gram-positive infections in a control trial. the susceptibility pattern of all gram-positive isolates from icu patients has been studied. methods: a total of specimens from icu patients were processed, were from patients enrolled in the antibiotic trial. all methicillin-resistant staphylococcus aureus (mrsa), coagulase-negative staphylococci (cons), enterococcus sp and methicillin-sensitive staphylococcus aureus (mssa) were tested. the break point for linezolid was mg/l and for teicoplanin mg/l. isolates were tested for susceptibility by e -test. results: linezolid ( isolates) mic / (mg/l) were as follows: mrsa (n / ) . / , cons (n / ) . / . , enterococcus sp (n / ) . / . , mssa (n / ) . / . teicoplanin ( isolates) mic / (mg/l) mrsa (n / ) . / . , cons (n / ) / . , enterococcus sp (n / ) . / . , mssa (n / ) . / . . all grampositive isolates were inhibited by concentrations of linezolid below the breakpoint including eight strains of staphylococci resistant to teicoplanin. conclusions: linezolid was highly active against grampositive isolates. resistance to teicoplanin was similar to other reported series. there was no emergence of resistance to linezolid. mrsa colonization is often a limiting factor for discharge from icu. clearance of mrsa is seldom achieved with conventional glycopeptide treatment. the oxazolidinone, linezolid, has excellent soft tissue and respiratory tract penetration and might be expected to eradicate carriage in some patients. we recently performed a doubleblind randomized trial in icu patients with known/suspected gram positive infection. received intravenous linezolid, mg b.d., and patients received teicoplanin mg o.d. mrsa clearance was assessed at end of treatment (eot), at -and days follow-up. results: in the linezolid and teicoplanin groups, and were known to be colonized with mrsa at study entry, respectively, while and were not. detection of clearance of mrsa colonization at eot was % for linezolid vs % for teicoplanin group (x b p b/ . ), at days it was % vs % (x b p b/ . ), and at days % vs % (ns). conclusion: short-term mrsa clearance can be achieved in significantly more patients treated with linezolid however this was not maintained at days, either because of incomplete initial eradication or recolonization. further analysis will follow when molecular typing of the isolates is completed. penetration of linezolid into bone, fat and muscle during hip arthroplasty ps lovering am, bannister gc, zhang j, macgowan ap, southmead hospital, bcare, bristol, uk there are limited data describing the concentrations and penetration of linezolid (lzd) into tissues, such as bone, that can be used to guide therapy for non-vascular infections. here we report the concentrations and penetration of lzd for bone, fat and muscle in comparison with cefamandole (cmd). twelve patients received mg lzd as a min infusion and mg cmd as a bolus injection immediately before hip arthroplasty. bone, fat, muscle and blood samples were collected at timed intervals after the infusion and assayed by a validated hplc method. for bone, peak levels of both agents occurred min after administration with mean levels of lzd . mg/kg versus cmd . mg/kg, decreasing to lzd . mg/kg versus cmd . mg/kg at min. correction for blood concentrations gave penetration of lzd % versus cmd % at min and lzd % versus cmd % at min. for fat and muscle, peak levels occurred min after infusion. mean levels were lzd . mg/kg versus cmd . mg/kg (fat) and lzd . mg/kg versus cmd . mg/kg (muscle). correction for blood concentrations gave penetration of lzd % versus cmd % (fat) and lzd % versus cmd % (muscle). we conclude that linezolid exhibits rapid penetration into bone and associated soft tissues achieving levels in excess of the mic for sensitive organisms; with a similar distribution and penetration profile to agents currently used for treatment of infections in these tissues. bacqué e a , barrière jc a , berthaud n b , desmazeau p b , dutruc-rosset g b , dutka-malen s b , ronan b b . a aventis pharma, chemistry, paris, france , b aventis pharma, disease group, paris, france xrp is a new oral streptogramin composed of semi-synthetic synergistic components in a / (w/w) association: rpr ( d-( -morpholino)methyl- d, g-dehydro pristinamycin i e ) from pi a and rpr [( r )- -deoxy- -fluoro pristinamycin ii b ] from pii b by original synthetic routes. the association has antibacterial activity against staphylococci including methicillin */mls b -resistant strains (mic range: . */ mg/ml), streptococci (mic : . mg/ml), pneumococci including multidrug resistant strains (mic : . mg/ ml), enterococci including vancomycin-resistant strains (mic : mg/ ml), m. catarrhalis and neisseria spp. (mic : . mg/ml), h. influenzae (mic : mg/ml), legionella spp. (mic : . mg/ml) and anaerobes (mic range: . Á/ mg/ml). xrp is generally bactericidal at the concentration of Á/ )/the mic against s. aureus , s. pneumoniae , h. influenzae and demonstrates consequent pae ( . Á/ !/ . h at Á/ )/mic, following an exposure of . Á/ h). mutants of s. aureus to xrp were isolated at low frequencies ( . )/ ( Á/ . )/ ( ) at )/ and )/mic while no mutant could be isolated at )/mic. these results suggest that xrp ( / w/w) is a promising compound for the treatment of community-acquired infections. ex vivo evaluation of rpr /rpr (xrp ), a new oral streptogramin ps berthaud n, diallo n. aventis pharma sa, infectious disease group, paris, france the intra cellular activity of xrp , was assessed in j murine macrophages containing ingested staphylococcus aureus (three strains) or l. pneumophila (one strain). at the concentration of )/ the mic, growth of s. aureus was strongly inhibited after a -h period of incubation (d log cfu/ml vs t controls range: (/ . Á/(/ . , according to the strain tested). at the concentration of )/ the mic, growth of intracellular l. pneumophila was inhibited after a Á/ -h period of incubation (d log cfu/ml vs t controls about (/ . and (/ . at and h, respectively). rpr and rpr alone had also inhibiting effect on bacterial growth (d log cfu/ml vs t controls after h of incubation about (/ . and (/ . , respectively). the bactericidal activity of xrp was also assessed against slowly growing s. aureus , under experimental conditions mimicking those observed in patients with an infected indwelling device (first step of infection: adherence to inert support; declared infection: biofilm model). under the experimental conditions, xrp demonstrated a rapid and potent bactericidal effect against s. aureus adherent to an inert support or included in biofilm. this effect was observed at each of the three concentrations tested ( , , and , and )/ mic, respectively). in vivo evaluation of xrp (rpr /rpr ), a new oral streptogramin ps berthaud n, huet y, aventis pharma sa, infectious disease group, paris, france the oral efficacy of xrp , was assessed in staphylococcus and pneumococcal murine infections. mice were challenged ip ( )/ , and )/ times ld ). abscesses were established by intramuscular injection of about bacteria into the right thigh of mice. pneumonia was established by intranasal injection of about bacteria. mice were treated twice a day for (staphylococcus aureus septicaemia and abscesses), (s. pneunomoniae septicaemia) or days (s. pneumoniae pneumonia). six to days post infection, for septicaemia and abscesses the results were expressed as ed , whereas for pneumonia they were expressed as the dose yielding an average survival time (ast) significantly longer than that of the untreated infected controls. xrp was efficacious in the treatment of experimental infections in mice caused by mls b -sensitive and -constitutively resistant s. aureus (ed range: Á/ and Á/ mg/kg/administration in septicaemia and abscess models, respectively). it was also efficacious in the treatment of infections caused by s. pneumoniae whatever the serotype and the resistance profile of the strains tested (ed range: Á/ mg/ kg/administration in septicaemia, ast: mg/kg/administration). these results suggest that xrp might be effective for the treatment of staphylococcal and pneumococcal community-acquired infections. xrp (rpr /rpr ), a new oral streptogramin: bactericidal activity and pharmacokinetics in a model of streptococcus pneumoniae mouse pneumonia ps berthaud n, huet y, diallo n. aventis pharma sa, infectious disease group, paris, france the bactericidal activity against streptococcus pneumoniae of xrp , a new oral streptogramin composed of two semi-synthetic synergistic components in a / (w/w) association (rpr , pristinamycin i derivative and rpr , pristinamycin ii derivative), was assessed in lungs of mice with pneumonia. mice were inoculated intranasally with about cfu of strain - (mls bresistant). eighteen hours later (t ), animals received xrp ( mg/kg p.o). the administration was repeated , , , and h afterwards. to study the influence of varying the ratio of pi to pii component administered on activity and pk parameters, ratios of rpr to rpr ranging from / to / were also administered under the same conditions. after an oral unitary administration at mg/kg, xrp , as well as ratios of rpr to rpr ranging from / to / , demonstrated strong and quick bactericidal activity in lungs. lung levels of rpr and rpr were generally equal or two times higher than blood levels. resulting rpr /rpr ratios in blood and lung, although not in accordance with the initial ratio administered, were synergistic for Á/ h in blood and for Á/ h in lungs explaining the activity observed. conclusion: based on in vitro data, telithromycin is a good candidate for the treatment of rti. in vitro evaluation of abt- , telithromycin and azithromycin against streptococcus pneumoniae , moraxella catarrhalis , haemophilis influenzae and methicillin-resistant staphylococcus aureus ps steele-moore l, berg d, barnes i, couch k, klein j, holloway w. christiana care, infectious disease, wilmington, us macrolide resistant streptococcus pneumoniae (sp) is a worldwide concern predominantly because these isolates tend to be multiply drug resistant. new agents with increased activity against these pathogens are clinically important. the ketolide class of antimicrobial agents demonstrate excellent in vitro activity against sp, even those that are macrolide resistant. the in vitro activities of the ketolides abt- (a) and telithromycin (t) were compared to azithromycin (az) against clinical isolates of sp, moraxella catarrhalis (m.cat), haemophilis influenzae (h.flu) and mrsa. organisms tested: strains of sp (including az resistant), h.flu, mrsa and m.cat. microdilution mic tests were performed following nccls recommendations using freshly prepared plates containing haemophilis test medium for h.flu, cation adjusted mueller-hinton broth (camhb) with laked horse blood for sp and camhb for m.cat and mrsa. the new ketolides, a and t had superior activity against sp including the az resistant strains (mic s: a / . mcg/ml, t / . , az / ). all compounds had excellent activity against m.cat while none demonstrated activity against mrsa. h.flu activity was comparable among a, t and az. these new ketolides are not currently approved by the fda; however t has been approved in europe. ló pez h, vidal gi, salomó n jm, scaglione m, zitto tr. centro de infectología, infectious diseases, buenos aires, argentina objective: we evaluated the impact of the initial treatment failure rate, hospitalisation and costs in outpatient treatment of adult cap in argentina comparing amoxicillin, clarithromycin and telithromycin. method: a probabilistic model was implemented in outpatient treatment of cap. we estimated an initial treatment with amoxicillin, clarithromycin or telithromycin. we assumed expected clinical cure at . , . and . %, respectively. for those patients with failure treatment we evaluated a second-line of antibiotics (amoxicillin followed by clarithromycin and clarithromycin followed by new fluorquinolone) or hospitalisation. patients with telithromycin and failure treatment must be hospitalised without a second line of outpatient treatment. costs of cap included drug's costs by days, medical visits, chest radiographies, analysis and hospitalisation. results: we estimated treatments in patients and first-line drug failure in , and patients with amoxicillin, clarithromycin and telithromycin, respectively. costs in outpatient treatment were: hospitalisation $ , and $ , . ; second-line drug $ and $ ; second-line hospitalised $ . and $ with amoxicillin and clarithromycin, respectively and hospitalisation with telithromycin $ . conclusions: telithromycin showed lower clinical failure, hospitalisation and costs in cap. some studies suggest shortening cap telithromycin treatment to days helping adherence to treatment and decreasing costs even more. the new macrolides */a good alternative of tetracycline in the treatment of mediterranean spotted fever ps popivanova nip a , petrov aip a , boykinova obb a , kazakova zkk a , baltadjiev agb b . a medical university, infectious disease, plovdiv, bulgaria , b department of anatomy, medical university, plovdiv, bulgaria mediterranean spotted fever (msf) caused by rickettsia conorii appears an endemic disease for some regions in bulgaria. frequently the disease has a severe course with multiple organ lesions. the early and adequate treatment is of extreme importance for the outcome of the disease. searching an alternative antibiotic treatment of this disease we considered macrolides for their good cell and tissue penetration and dose-dependent bacteriostatic and bactericide effect. we treated msf patients with doxycycline )/ mg/day, patients with clarithromycin )/ mg/day, as well as patients with midecamycin )/ mg/day and midecamycin acetate mg/kg/day. as a surrogate marker for treatment evaluation the effect on the febrile syndrome was used. our findings showed that by the th day of treatment the fever normalized in . , . and . % of the patients treated with doxycycline, clarithromycin and midecamycin, respectively. for the same period the patient fever decreased below c in , and . %, respectively. the intoxication symptoms were influenced within the same period equally in all treated patients. conclusions: we suggest that the new macrolides appear a good alternative of tetracycline on patients with msf. erythromycin resistance of gram /'// cocci in bulgaria. benefits of the new macrolides in the treatment of respiratory infections ps popivanova ni a , yovtchev ip b , dobreva md c , argirova ta c . a medical university, infectious disease, plovdiv, bulgaria , b medical university, ear-nose-throat disease, plovdiv, bulgaria , c medical university, microbiology, plovdiv, bulgaria in the recent years we tested erythromycin sensitivity of species of gram /'// cocci isolated from throat and nose secretions, ear and eye effusions, sputa, cerebrospinal fluid and blood cultures, vaginal and urethral secretions, urine and fecal samples from patients with inflammatory diseases of the listed organs and systems. staphylococcus aureus , staphylococcus coagulase /(//, streptococcus â-haemolyticus , enterococcus were isolated. of these microorganisms s. aureus was the most abundant. our resistograms revealed sensitivity of the gram /'// cocci in . and . % for and , respectively, and resistance of . and . %, respectively. in the tests with midecamycin and midecamycin acetat the same microorganisms showed sensitivity of . % and resistance of . %. the clinical findings showed excellent effect of the new macrolides including clarithromycin and azalides */azithromycin. we conclude the resistance of gram /'// cocci and especially of s. aureus to erythromycin increases very quickly and has reached dramatical extent. by now, the new , , and -membered ring macrolides and azalides show high antibacterial activity and good clinical effect. pappas ga, liberopoulos e, tsiara s, elisaf m, tsianos e. university hospital, internal medicine, ioannina, greece quinupristin/dalfopristin (q/d) is a novel injectable streptogramin antibiotic which initiation in therapeutics was hailed as an important step towards treatment of vancomycin-resistant enterococcus faecium (vref) species. initial reports concluded in an excellent response of vref to q/d. reports of q/d-resistant strains of e. faecium have emerged, both in usa and europe. we report two cases of e. faecium bacteremia in which the responsible isolate was not sensitive to q/d. the first patient was a woman with acute leukemia and septicemia. e. faecium was cultured from blood samples: the species was resistant to almost all antibiotics, exhibiting sensitivity only to tetracycline (!), while its sensitivity to q/d was indermediate. the second patient was a man with endocarditis, in whom blood cultures isolated e. faecium sensitive to a number of antibiotics, including ciprofloxacin and vancomycin; still the sensitivity to q/d was indermediate. q/d has not been officially introduced to the antibiotic arsenal of greek medicine. moreover, the drug has never been used in our hospital, not even experimentally. other e. faecium species isolated in our hospital have been sensitive to q/d. how much hope can be put on a drug that seems to be partly useless before its initiation? increasing reports of v/ q-resistant strains of e. faecium from all over europe raises fears that the v/d story might well end before it begins. varadinova t a , diakov t a , karagiozova d a , genova p a , pardon p b , baudry c b , quideau s b . a sofia university, virology, sofia, bulgaria , b et institut du pin, centre de recherche en chimie moleculaire, universite bordeaux , bordeaux, france vegetable tannins posses a wide range of biological activities. the aim of the present study was to evaluate the cytotoxicity of five purified vegetable tannins against mdbk cells. the maximal nontoxic concentrations (mnc) and the concentrations required to inhibit cell growth by % (cc ) were evaluated after , and h periods of action. mnc values after h indicated that compounds stimulated cell surveillance when applied in concentrations lower than . mm. cc values indicated: (i) a decrease in cytotoxicity after h as cc were up to times lower than those observed after the h period, and (ii) a re-increase in cytotoxicity when the period of action was prolonged up to h as cc were times lower than those observed after the h period. these data thus appear to reveal the capability of the investigated natural polyphenolic products to stimulate cell surveillance in a time-dependent manner. antibacterial effect survey of enoxolone on periodontopathogenic and capnophilic bacteria isolated from specimens of patients with periodontitis ps salari mh a , kadkhoda z b , sohrabi n a . a tehran university of medical sciences, pathobiology, tehran, islamic republic of iran , b tehran university of medical sciences, dentistry, tehran, islamic republic of iran objectives: most of the microorganisms associated with periodontitis are capnophilic and anaerobic bacteria. purpose of this study was to detection of antibacterial effect of enoxolone on periodontopathogenic and capnophilic bacteria. methods: in this study periodontopathogenic and capnophilic bacteria were isolated from specimens of patients with periodontitis by culture method. an anti-bacterial activity of enoxolone against these microorganisms was investigated by minimum inhibitory concentration (mic) and minimum bactericidal concentration (mbc) methods. results: based on our findings the mic, mbc and lethal does (ld ) of enoxolone for actinobacillus actinomycetemcomitans , eikenella corrodens and capnocytophaga were ' , , ', ' , , ', and ' , , ' mg/ml, respectively. conclusion: our results show enoxolone has antibacterial effect on a. actinomycetemcomitans , e. corrodens and capnocytophaga spp. sakalova stn. medical university, microbiology, grodno, belarus we have synthesized diamides of dicarboxylic acids, with components such as -nitrothiazole benzolsulphamides and triazol. all the above compounds exhibited bacteriostatic activity towards some microorganisms. for further studies of bacteriostatic activity of amides and diamides of dicarboxylic acids, as well as for determination of 'structure Á/activity' relationship, we have synthesized a range of monoamides. antibacterial activity of the synthesized compounds was studied in vitro by agar dilution methods. for this purpose, approximately various gram-positive and -negative microorganisms including clinical strains of staphylococcus aureus , bacillus subtilis , serratia marcescens , escherichia coli , proteus morganii , micrococcus lisodeicticus , staphylococcus epidermidis , shigella sonnei , salmonella typhimurium , yersinia enterocolitica . minimum inhibitory concentration was expressed in mg/ml. nitazole was used as a comparison substance. analysis that new derivatives of -nitrotiasole have high antibacterial activity relative towards certain microorganisms included strains obtained from infection department's patients. results will be shown. microbial susceptibility to the essential oil of ziziphora clinopodiodes lam. ps purpose of the study: antimicrobial activities of essential oils vary from oil to oil and from one micro organism to another. the antimicrobial and chemical properties of essential oil from ziziphora clinopodiodes lam. has not been studied and hence the present study was planned to evaluate those properties against a series of micro organisms viz, escherichia coli , staphylococcus aureus , pseudomonas aeroginosa , klebsiella pneumonia , bacillus subtilis , bacillus licheniformis , streptococcus faecalis , candida albicans and saccharomyces cerevisiae . results: z. clinopodiodes lam. essential oil was found to have remarkable antimicrobial property against all the microorganisms but p. aeroginosa . the oil exhibited its best antimicrobial activity within a maximum of min. seventeen components were identified by gas chromatography and mass spectrometry (gc and gc/ms) analysis of the oil, out of which pulegone ( . %), neomenthol ( . %), cyclohexene, -methyl- -( -methenyl)trans ( . %), , -cycloheptadien- -one, , , -trimethyl ( . %), piperitone ( . %), and limonene'/ , -cineole ( . %) constitute major parts of the oil. conclusion: monoterpenes seem to have antimicrobial role. it seems necessary to explore antimicrobial properties of new harmless antimicrobial agents from natural sources as substitutes for common chemical drugs. methanol extract of carpobrotus edulis enhances killing of methicillin resistant staphylococcus aureus phagocytosed by thp- human monocyte derived macrophages and promotes the release of modulators of cellular immunity ps although alkaloids from the family mesembryanthemaceae have anti-cancer activity, species of this family have received little attention. because these alkaloids also exhibit properties normally associated with compounds that have activity at the level of the plasma membrane, we have studied a crude methanol extract of carpabrotus edulis , a common plant found along the portuguese coast, for properties normally associated with plasma membrane active compounds. the results of this preliminary study show that the extract is non-toxic at concentrations that prime thp- human monocytederived macrophages to kill ingested methicillin resistant staphylococcus aureus and promote the release of lymphokines associated with cellular immune functions. the extract also induces the proliferation of thp- cells within day of exposure and days earlier than that induced by phytohemagglutinin. similar results were obtained with monocyte-derived macrophages isolated from human peripheral blood. the active component or components of the plant extract may be exploited as intracellular active anti-bacterials as well as modulators of cellular immunity. enhancing of erythromycin production by saccharopolyspora erythraea nur with common and uncommon oils ps hamedi j a , malekzadeh f a,b saghafi-nia ae b . a department of biology, faculty of science, university of tehran, tehran, islamic republic of iran , b shafe-e-sari co., antibiotic production co., teheran, iran enhancing effect of various oils on the erythromycin production by saccharopolyspora erythraea nur were evaluated in a complex medium consisting soybean flour and dextrin as the main substrates. the biomass, erythromycin, dextrin and oil concentrations, and ph value were measured on a daily basis. also, the kinds and frequencies of fatty acids of the oils used were determined. saturated fatty acids in the shark oil were higher than that of vegetable oils used. erythromycin concentration in the melon (cucumis melo var. inderus cultivar mashhad ) seed oil containing medium was . times higher than that of the control medium (without oil) and . times higher than that of rapeseed oil containing medium. erythromycin concentration in the other oil containing media, including rapeseed, soybean, shark (carcharhinus dussumieri ), and safflower oils was . , . , . , . time higher than that of control medium, respectively. the melon seed oil had the least enhancing effect on the biomass production, and thus decreasing the cost of the biomass separation. can varicella be eliminated by universal childhood vaccination ? */ epidemiological and economic data from germany ps wutzler p a , banz k b , neiss a c , goertz a d , bisanz h d . a institute for antiviral chemotherapy, university of jena, jena, germany , b outcomes international, basle, switzerland , c institute of medical statistics and epidemiology, technical university, munich, germany , d glaxosmithkline, pharma, munich, germany purpose: universal varicella vaccination in childhood is expected to reduce substantially the number of uncomplicated cases of chickenpox and to decrease the number of complicated cases requiring hospitalization. to generate fundamental data for decisions of the health authorities epidemiological and health-economic data were collected in two large studies. using an age-structured decision analytic model the benefits, costs and cost-effectiveness of a varicella immunization program over a period of years were assessed. results: it could be shown, that the vast majority of varicella cases occur in children aged less than years. in . % of the cases a severe course was assessed. overall incidence of complications was estimated to be . %. a routine varicella vaccination program targeting healthy children could prevent . % of varicella cases and over major complications per year provided the coverage rate would be %. under these conditions the elimination of varicella is predicted to be achievable within Á/ years. a combined measles, mumps, rubella and varicella vaccine is expected to provide the required coverage. conclusions: routine childhood varicella vaccination appears to be a highly efficient strategy to significantly reduce the sizeable burden of varicella and leads to significant savings from both societal and payer's perspective. bulgakova va, balabolkin ii, sentsova tb. scientific center of child health, russian academy of medical sciences, scientific research institute of pediatrics, moscow, russian federation objective: to estimate efficacy of vaccine influvac at children with allergic diseases. methods: twenty children aged Á/ years with allergic diseases received vaccine influvac (solvay pharma). for the control group of children, with allergic pathology did not receive this vaccine because of an intolerance of chicken protein ( children). results: all vaccinated children for the observable season of months did not get influenza. general and aboriginal reactions to a vaccine did not occur. in control group for the observable season two children were ill with influenza and four children with acute respiratory virus infection ( %). among vaccinated children there was an increase in titre to a protective level ( : and above) to all to three strains of influenza days after injection. vaccine influvac can be recommended for an immunisation against influenza of children with an allergic pathology because of efficacy and absence of side effects. ló pez h, zitto tr, vidal gi, cánepa mc, salomó n jm, scaglione m. centro de infectología, infectious diseases, buenos aires, argentina objectives: our study examines the possible economic impact of the influenza on health working adults in argentina, and the intervention cost saving with immunization. methods: this is a theoretical study based on a mathematical model. population data was published in s national statistics. the global incidence of influenza infection was estimated at %. we have estimated the direct cost on influenza infection (outpatient visits, drugs and hospitalization) and indirect cost (work absenteeism and productivity loss) and projected net saving for the Á/ year-old vaccinated group. the vaccine effectiveness was estimated at and %. the price of vaccine was $ each. results conclusion: influenza vaccination is effective in diminishing cases of flu and reducing working-day loss. its a safe and cost-effective vaccine. ló pez h, zitto tr, cánepa mc. centro de infectología, infectious diseases, buenos aires, argentina flu infection is a major cause of illness and one of the most common cause of work absenteeism, increasing institution costs, healthcare provider visits, use of drugs, and decreasing work productivity. vaccine against flu has an effectiveness between and %, in health adults. objective: evaluate the impact of flu-like respiratory tract infections in a health institution staff during year, comparing vaccinated with not-vaccinated groups. methods: we evaluated all causes of absenteeism along year ( ), based on the written note made by the professional who has evaluated ill people, selecting flu-like respiratory infection causes. we evaluated age, working days loss related to illness, and cost on vaccinated and not-vaccinated groups. results: one hundred and sixty eight of the total staff ( people) were vaccinated, of them had flu-like infection, resulting in working days lost. for not-vaccinated group, people had flu and lost days. lost cost for vaccinated group was of $ , and for notvaccinated group, $ . conclusion: we observed a decrease in working days loss and money waste related to flu-like infections on the vaccinated group. because of safety and effectiveness of vaccine against flu, the implementation of vaccination will be cost-effective for all institution staff. we studied functioning of the interferon system in children with atopic bronchial asthma (ba) at the age of Á/ years. the control group included healthy children. we investigated the interferon status (method of grigoryan s.) and serum concentrations of ifngamma (ifng) (elisa). there was a decrease in the ifn-producing ability of leukocytes to the synthesis of ifna at % and ifng at % of children with ba. serum level of ifn of children with ba during all period of illness is compared to the children without predisposition to atopy ( . / . and . / . pg/ml accordingly) was significantly decreased. production of ifna increased after using viferon (recombinant a b ifn and antioxidants). decreased ability of gammainterferonogenesis in the most children was not affected by the action of immunomodulators. there was shown interferon system's dysfunction in the development of atopy and increasing predisposition to respiratory infections and to persistent of atypical infections in children with ba. harxhi a, pilaca a, pano k. university hospital center of tirana, infectious diseases, tirana, albania congo-crimean haemorrhagic fever is viral disease with a high rate of mortality that is caused by a nairovirus, bunyaviride species. this is a zoonotic disease, which affects sporadically humans and is geographically distributed even in eastern europe and balkan. during the months of may and june , in northeast of albania were reported eight cases of haemorrhagic fever. serologic tests performed in the laboratory of reference in thesaloniki, greece confirmed the diagnosis of congo-crimean haemorrhagic fever. in the mean time, who reported the outbreak in southwest kosovo of cases suspected for haemorrhagic fever from which were confirmed laboratory as congo-crimean haemorrhagic fever. we are describing here the clinical history of one of eight cases with cchf in albania. from the epidemiological point of view this case was considered peculiar, as it was the only one hospitaly acquired, and due to the gravity of the haemorrhagic syndrome was admitted at the intensive care unit at infectious diseases service, university hospital center of tirana. results: in the study were included patients ]/ years of age with documented hbsag-carrier ]/ months (average age */ . years, male */ %, female */ %). hbv dna in serum was tested by qualitative and quantitative pcr (commercial test-system ampli-sens hbv). hbeag, hbeab, hbsag were detected by elisa (hoffmann la roche). hbv dna by qualitative pcr was detected in % patients, by qualitative pcr was detected in % patients in the concentration ]/ copies/ml, in . % ]/ copies/ml, in . % ]/ copies/ml, in . % ]/ copies/ml ( fig. ). hbv dna level distribution among the hbsag carriers. elevated ( . the upper limit of normal) alt level was determined in . % of the hbv dna negative and . % of the hbv dna positive patients. hbeag was detected in . % of the hbv dna positive patients and had not been determined in the hbv dna negative patient. eleven percent of patient had the combination of the biochemical, serological and virology criteria, which are typical for active chronic hepatitis b (hbsag-carrier !/ months, hbv dna ]/ )/ copies/ml, elevated alt). conclusion: in smolensk % of the hbsag-carriers have viral replication confirmed by qualitative pcr. eleven percent of them have active chronic hepatitis b. kandemir o a , polat a b , kaya a a . a medicine of faculty, mersin university, clinical microbiology and infectious disease, mersin, turkey , b medicine of faculty, mersin university, pathology, mersin, turkey the exact potential of nitric oxide in the pathogenesis of chronic viral hepatitis is not known. the elevated nitric oxide production is assumed to be responsible for the pathological changes in many inflammatory conditions, mainly via peroxynitrite, a potential oxidant that is produced by the reduction of superoxyde anion with nitric oxide. the intensity and the distribution of the immunohistochemical staining of intrahepatic inducible nitric oxide synthase were studied in the biopsy specimens obtained from patients with viral hepatitis and patients with elevated transaminase levels from other etiology. hepatic inducible nitric oxide synthase staining was significantly more intense in the viral hepatitis group (p / . ). inducible nitric oxide synthase staining levels correlated well with the severity of the viral hepatitis using the knodell's liver histological activity index (r / . , p / . ). among the viral hepatitis group, the pathological distribution of the inducible nitric oxide synthase staining favored the periportal regions whereas less staining was observed in the bile duct and parenchyma regions. as nitric oxide mediated nitration of hepatocellular proteins is found to be elevated in the inflamed hepatic tissues and it well correlated with the severity of the disease, we suggest that inducible nitric oxide synthase can possibly have a critical role in the pathogenesis of chronic viral hepatitis. there were patients under observation who were divided into two groups, the first of patients (eight chronic virus hepatitis; three chronic virus hepatitis'/steatosis; four steatohepatitis; three chronic cryptogenic hepatitis; there were men and four women aged from to . the second group consisted of patients, eight with chronic virus hepatitis; four with steatohepatitis; six with chronic cryptogenic hepatitis. there were men and three women aged from to . diagnosis was confirmed with the help of clinical data, biochemical tests, serological markers, psr-diagnostics and ultrasound examination and computer tomography of the abdomen. in the first group of patients the treatment with ursofalk was administered at the dosage of mg/kg of body mass from month to years with improvement in general condition of the patients: heaviness, pain under the right rib, nausea and skin itch have disappeared. in all the cases, improvement in the biochemical blood analysis took place during treatment. the average index of alt activity was before */ . u/l, after */ . u/l and ast */ . and . u/l; alp */ . and . u/l; ggt */ . and . u/l; chol */ . and . mmol/l; tg */ . and . mmol/l. in the second group of patients the treatment was carried out with various hepatoprotectors during the courses from to months. before the average index of alt activity was . u/l, after */ . u/l; ast */ . and . u/l; alp */ . and . u/l; ggt */ . and . u/l; chol */ . and . mmol/l; tg */ . and . mmol/l. treatment of patients suffering from hepatitis of viral and other aetiologies with ursofalk produces a positive effect on both clinical symptomatic and biochemical indices. remission was more stable during a long period of taking the preparation. the hepatoprotective effect of ursofalk during the years was sustained for the whole of the period of the treatment. after stopping, an acute attack of cytolytic syndrome was observed. with other hepatoprotectors we did not get any improvement in clinical scene of the disease or in biochemical indices. shavlov nm, kletsky sk. minsk, belarus hsv- and - have possibility to damage different organs and systems. sometimes they cause damage of the liver, which resemble viral hepatitis. the etiology of such hepatitis may be confirmed only by results of liver biopsy. we have diagnosed cases of herpetic hepatitis: eight children and four adults. clinical course was different. in five cases the acute beginning took place: high temperature, the jaundice at the Á/ day (the level of bilirubin was Á/ mkmol, especially direct), cholestasis, the pain in upper right part of abdomen. the ascites was found in three patients with acute hepatitis during st week from the beginning of disease. in seven cases the beginning was gradual. the temperature was subfebrile, prolonged; malaise and moderate pain in upper part of abdomen were constant complaint. the jaundice was moderate; bilirubin increased until mkmol. the level of alt was moderately increased ( Á/ times). the blood analysis showed moderate leukocytosis with neutrophilia, and increased sre. the serological markers of hepatitis a, b, c, d were negative in all cases. hsv- and - were found in the blood. the diagnosis was defined by the results of hystochemical investigations, when the viruses were found in liver bioptat, and confirmed with the results of specific treatment. specific damage of liver cells was found: protein dystrophy and specific inclusions in cell nucleus. in all cases the treatment with acyclovir were given. the results we have observed during st week: the temperature became normal, the jaundice decreased and bilirubin was normal during Á/ days. in one case the recidive took place weeks later after treatment. the second course of acyclovir with intron a gave good results. nesic z a , delic d b , prostran m a , vuckovic s a , stojanovic r a . a department of pharmacology, school of medicine, university of belgrade, belgrade, yugoslavia , b clinical center of serbia, institute for infection and tropical disease, belgrade, yugoslavia the large number of unsolved cases of acute and chronic hepatitis has most probably the viral etiology. in mid s, two independent groups of authors reported a new human hepatotropic virus, with flavivirus like genomes, hepatitis g virus (hgv). the aim of this pilot study was to determine the prevalence of hepatitis g viral infection among patients at high risk of exposure to blood and blood products, as well as to evaluate if the risk of hgv infection was higher among them than in the general population. immunoenzyme test on microtitration plate for detection antibodies against hgv e antigen in plasma or sera (r&d systems, minneapolis, usa) was used for evidencing anti-hgv igg antibodies in sera. anti-hgv antibodies were detected in the control group (blood donors) in . % ( / ) patients. prevalence of anti-hgv antibodies among i.v. drug users was evidenced in . % ( // ), in hemophiliacs . % ( / ), in patients acquiring multiple blood transfusion . % ( / ), in hemodialyzed patients . % ( / ) and in patients with transplanted organs . % ( / ). our results suggest that patients exposed to blood or blood products have a higher risk of hgv infection than general population. evaluation of ortho total hcv core antigen assay in assessment and follow-up of patients treated for chronic hcv ps lunel f, veillon p, payan c. chu angers, laboratoire de bactério-virologie, angers, france an assay to quantitate 'total' hvc core antigen (hcv ag) in serum or plasma, may reflect viral load, has been developed by ortho-clinical diagnostics. methods: we evaluated hcv ag with two quantitative assays for hcv rna: bdna . (bayer) and monitor . (roche). we studied samples from untreated patients and from patients with chronic hcv treated with ifn or ifn/ribavirin. results: correlation of ag and quantitative assays was high (r / . for bdna . and . for monitor . ). no difference between the levels of rna and ag among hcv genotypes (r / . Á/ . ) was found. ag values, before treatment, were significantly lower in sustained responders (sr) than in other groups ( . log versus log, p b/ . ). in patients treated with ifn or combination therapy, we found very good correlation between decrease and negativation of ag and viral load: log iu/ml decline after m of interferon was significantly correlated with the negativation of hcv ag and sr. thirty-eight/ of sr had a rna load decrease !/ log iu/ml and / had a negativation of hcv ag after m . conclusion: total hcv core ag appears to be a new tool for monitoring patients with hcv infection. hepatitis c virus rna and hcv core antigen kinetics predict the efficiency of interferon-alfa and ribavirin therapy in naive patients infected by hcv genotype or ps fifty-five patients infected by genotype or were treated with a primary dose of (if hepatitis c virus (hcv) rna b/ meq/ml) or million units of interferon alfa- b (ifn) thrice weekly for months. ribavirin was added at month (m), until m if hcv rna was found positive after m of ifn. the viral kinetic was assessed during the follow up by serial measurements of hcv rna (bdna . and monitor . ) and using a new assay from ortho-clinical diagnostics which is able to quantify total hcv core antigen. sustained virologic response was observed in % of the patients ( / ). after month of ifn treatment, sustained responders had a fall of hcv rna and hcv core antigen higher than non-responders ( . / . log ui/ml versus . / . log ui/ml, p b/ . , for hcv rna) and ( . / . log (pg/ml)/ ) versus . / . log (pg/ml)/ ) p b/ . , for hcv core antigen). after month of ifn, the positive and negative predictive values of sustained response were, respectively, and . % for hcv rna negativation and . and . % for hcv antigenemia negativation. these results suggest that both kinetics of viral load and antigenemia are highly predictive of sustained response. theodorou m, petinelli i, pontikaki d, mela c, blana a, papanastasiou a, toliopoulos a, stavrakaki m, sagkana e. microbiology department, western attika general hospital, greece, egaleo, greece greece has accepted a big number of economic immigrants lately. we investigate the prevalence of hepatitis b/c as well as the epidemiological features that might influence the public health. . economic immigrants from: albania , eastern europe and from asiatic-african countries , visited our hospital to be checked in order to get a health certificate to obtain the green card. they where tested for hepatitis b/c. the serological markers were determined by immunoenzymatic method. all hbsag('/) and anti-hcv were further tested for hbv dna and hcv rna by competitive rt pcr. hcv rna('/) were genotyped by strip hybridization immunoassay. in albanians . % were hbsag('/), . % hbv dna('/), . % anti-hcv('/) and . % hcv rna('/). in east europeans . % were hbsag('/), . % hbv dna('/), . % anti-hcv('/) and . % hcv rna. in asians-africans, . % were hbsag('/) and % hbv dna('/). in pakistanis, . % were anti-hcv('/) and . % hcv rna('/). of the rest of asians-africans, . % were anti-hcv('/) and . % hcv rna('/). albanians: higher prevalence of hbv infection ( . %). greek blood donors: % pakistanis: hcv infection is % (predominance of a type), general greek population: %. public health services in greece and europe must take appropriate measures. el zawawy la a , mohamed on b , ali sm a , eissa me a , allam sr a . a faculty of medicine, parasitology, alexandria, egypt , b high institute of public health, microbiology, alexandria, egypt the purpose of the study was to investigate the influence of schistosomal suppression on the antibody response to hepatitis-b vaccine (hbv) and to study if the vaccine has any protective effect on experimental () infection. the results obtained revealed that infection reduced the serum antibody level against hbv. parasitological and histopathological findings showed significant protection against infection. the conclusion reached was; in order to reduce the incidence of virus-b infection especially in schistosomiasis endemic areas, public health officials should evaluate a policy for regulation of hbv booster vaccination to enhance the population immunity against hepatitis-b infection. cooper e, fisher t, shingadia d. newham general hospital, family clinic, london, uk sustained anti-retroviral combination chemotherapy requires excellent adherence to the regimen so as to suppress viral replication sufficiently to delay the emergence of resistance. if chemotherapy were taken to scale, e.g. in africa, erratic adherence might soon lead to multi-resistant circulating virus. we reviewed our experience in a well established london family clinic with a team including community nurses. we reviewed the records of the african immigrant children, aged Á/ , treated with anti-retrovirals exclusively at our centre throughout . whereas had undetectable hiv rna within the year, only four had undetectable rna throughout the year. four failed therapy through proven resistance mutations, but nine were considered through circumstantial evidence to have rising viral loads primarily because of poor adherence. three were known to have stopped taking drugs for extended periods. the three boys over years were unreliable in adherence, but the one girl in this age-group was fully adherent. our preliminary assessment is that for the children in our families, despite a team approach and home visits, nonadherence to haart may be twice as common as selection of a dominant viral mutant as a primary cause of failure to sustain viral suppression. quiros-roldan e, moretti f, castelli f, el-hamad i, carosi g. the prevalence of hiv related lipodystrophy-syndrome depending on the definition and severity of lipodystrophy ranges from to %. we have retrospectively reviewed the medical records of african patients followed. the characteristics are shown in the . % of africans had triglycerides !/ mg/ml and . % had cholesterol !/ mg/ml, none had both metabolic alterations. glycemia !/ mg/ml was observed in . % patients. it is interesting highlight that in any the africans morphological changes were noted and all of them showed weight stable. although the low prevalence of metabolic alterations may be attributed to the different ethnic alimentary behavior if self-body perception by african is not as accurate as by caucasian on the estimation of the body changes have to be investigated. alabaz d a , alhan e a , yaman a b , evliyaoglu n a , kocabas e a , aksaray n a . a division of pediatric infectious diseases, cukurova university, adana, turkey , b department of microbiology, cukurova university, adana, turkey hepatitis a virus (hav) infection is usually asymptomatic in children. however, it may occasionally cause a severe disease with high morbidity and mortality, and loss of school or business days. in a previous study, we have shown that every one of two to three school children from upper social classes living in adana carries high risk of hav infection. it is well known that maternally transmitted anti-hav antibodies interfere with hav vaccination. in an effort to determine the optimal age for hav vaccination, babies ( % girls and . % boys) born in our hospital were prospectively followed up at least months for the presence of maternal antibodies to hepatitis a (anti-hav igg). anti-hav igg titers were measured from the blood specimens obtained at birth from the mothers and from the offsprings at months, , , , , , , , and . the prevalence of positive anti-hav at birth ( %) was similar to those of hav seroprevalance studies carried out in adults in our area. the disappearance of antibodies occurred between the st and st month of life. the prevalence of anti-hav igg among children aged , , , , and months were , , , , and %, respectively. in light of these findings, we suggest that hepatitis a vaccination be given after months of age. earlier vaccination may be ineffective due to interference with maternally transmitted anti-hav antibodies. ghaderi b, alaghebandan r, rastegar lari a. department of microbiology, iran university, tehran, islamic republic of iran diarrhoea is a major public health problem in developing countries. amoebiasis is one of the most common causes of diarrhoea in iran as an endemic area for amoebiasis. little, however, is known about the extent of the condition in our society. the aim of this study is to determine socio-demographic and clinical characteristics of patients with intestinal amoebiasis. during july and august , we collected patients with diarrhoea among patients who visited at a referral hospital in shahriar area (in countryside of tehran), iran. thirty out of patients ( %) had intestinal amoebiasis and were followed up prospectively until the resolution of the illness. nineteen of ( . %) patients were male and the remaining of . % was female. the patients were aged Á/ with mean of . years. most of the patients ( %) were below years of age and the peak of occurrence was between the age of and years. watery diarrhoea with abdominal cramps was the main clinical feature. seventy percent of patients were resident in urban area and the remaining ( %) in rural area. average family income was low and all patients were in low socioeconomic level. water supplying system for all patients was pipeline water. low socioeconomic level associated with poor personal hygiene was the most important factor for highly prevalence of this problem in our society. also it seems that food plays important role in transmission of protozoa then water. the new strategy for allele identification of the genes coding for pertactin and pertussis toxin subunit s in bordetella pertussis ps bordetella pertussis strains demonstrate a significant polymorphism in toxin s subunit and pertactin, which are major protective antigens of the organism. monitoring the changes in prevalence of particular alleles of genes coding for these proteins in local b. pertussis populations is an essential issue in cases of the observed decrease of vaccination effectiveness. we have developed a new method for allele identification of these genes, which eliminates the necessity of dna sequencing. the approach is based on the identification of the number of repeats or the presence of specific nucleotides in the polymorphic regions or residues, respectively, of the genes and utilises products of their full or partial pcr amplification. the nucleotide heterogeneity in each polymorphic site is analysed either by the differential digestion of the amplicons or by the arms (amplification-refractory mutation system) methodology. numbers of repeats in particular regions of the genes are revealed by the size analysis of the adequate pcr products or their restriction fragments. in all cases the presence, size or pattern of dna molecules obtained is visualised by the agarose gel electrophoresis. the preliminary analysis of the recent and archival b. pertussis strains identified in poland was performed using the described approach. the presented strategy provides a much easier, faster and more cost-effective than dna sequencing mean to study the polymorphism of the major b. pertussis antigens. vaccination coverage and history of vaccine preventable infectious diseases among students in second year of medicine and pharmacy of tours university ps borderon jc a , hamed a b , ragot s b . a centre hospitalier universitaire, tours, france , b médecine préventive universitaire, tours, france the purpose of this study was to determine the level of infectious risk in students who will be exposed to patients. information was obtained by a questionnaire for each student, and by checking medical records for immunization coverage and vaccine preventable infectious diseases. answers could be specified for students, of whom females (f) and males (m). the number of non-immunized students was against diphtheria: two, tetanus: three, pertussis: four, poliomyelitis: two, hepatitis b: six, and hepatitis a: , respectively. among the students non-vaccinated against measles, (nine f and five m) had no history of that disease. among ( f and m) non-vaccinated against rubella, ( f and seven m) had no history of that disease, uncertain in seven others (six f and one m). the date of vaccination was often late regarding recommendations. fifteen students had no history of varicella. one student had not received bcg vaccination. fifty-eight students had received two, and three bcg vaccines. post-bcg tuberculin skin testing was missing after first bcg, second and third bcg. the date of the first tuberculin test was often one or several years after bcg vaccination. adverse effects of vaccination were rarely reported: two cases of fever (dt polio, measles); three cases of local reaction (dt polio, dtp polio). one case of contraindication for influenza vaccine: egg allergy. the survey shows failure in immunization coverage actually recommended in health care students. objectives: to present the morbidity of rabies and evaluate the efficiency of our prophylaxis scheme in lasi county. material and method: we made a retrospective study of the rabies cases in the patients admitted in our unit in a th-year period. we have analysed all the clinical, epidemiological and biological aspects. results: in a -year period, cases of rabies were admitted in the clinical infectious diseases hospital lasi. the highest incidence was for Á/ */eight cases ( %); the highest yearly cases were three cases in and . most of the patients were male ( %), came from suburban areas ( patients). eight cases occurred in may Á/june, wild animals were involved in half the cases (fox, wolf). for patients, no prophylaxis was performed and an incomplete course in four cases. the period of time to the appearance of the first symptom was Á/ days. the prophylaxis scheme led to a good protection. conclusions: in lasi county, rabies is a problem with a prevalence of . %/year. trends in the use of antimicrobials in riyadh in were analyzed. data was obtained from a survey of randomly selected families of school children aged Á/ years in a -month period in . one hundred and ninety-nine ( . %) students were on antibiotics in the month preceding the study; ( %) received antibiotics for the diagnosis of pharyngitis; ( %) students antibiotics were prescribed by a physician; and in ( %) the duration of antibiotics was less than week. this study shows a major problem in antibiotics prescription in our community and also the need to establish effective antibiotics policy in general practice to limit the potential emergence of drug resistance bacteria in the community. mir s a , cura a a , erdogan h a , guler s a , sengul gn a , koyu a a , ozinel ma b . a department of pediatrics, ege university medical faculty, izmir, turkey , b department of microbiology, ege university medical faculty, izmir, turkey antibiotic susceptibility spectrum of childhood urinary tract infection agents are geographical variation. the current antibiotic regimens and the selection of antibiotics for prophylaxis should be re-evaluated periodically. the objective of our study was to determine the local resistance rates to antibiotics and to give a direction for the selection of antibiotics in uti treatment. we evaluated urinary culture assays retrospectively, sent from pediatrics and pediatric surgery inpatient and outpatient clinics of our hospital during the last months, and investigated the isolated pathogens and the resistance rates to antibiotics. in addition, the data obtained were compared with of years ago. with respect to the resistance rates to antibiotics of uti pathogens, the resistance rates of e. coli for carbapenems, aminoglycosides and third generation cephalosporins were , and %, respectively as before, but the rates for ampicillin increased from to % and for tmp-smx it increased from to %. we concluded that the resistance profiles to antibiotics should be reviewed every years at least and thus the selection of proper antibiotics would lessen the morbidity as well as the medical expenses. chanturidze tk, tsiklauri r. ministry of labor, health and social affairs, public health, tbilisi, georgia purpose: since infectious diseases (id) are increasing in georgia. this study is aimed to reveal economic barriers of effective id control by assessing financial contribution to id from public and private sources, household's total spending on health and their capacity to pay. sources: ) national household expenditure and revenue survey. ) who fair financial contribution methodology. ) meta-analysis. results: . % of population leaves under the poverty level; % out of total household expenditure (average gel; us$ ) % is spent on food */non-subsistence income covers expenditures on goods and services including health; % of population refuses health services because of inability to pay; public spending on health comprises % of total health expenditures; public spending on id control is below gel per capita; almost all private spending goes to id treatment and equals to . gel per patient. conclusions: insufficient public spending on id control transfers the burden to the population with extremely low capacity to cover health expenses. refusal to utilize health services, and incomplete treatment and increases the threat of id spread and drug resistance. government should increase the allocations to id from public sources for effective id control in georgia. antimicrobial consumption trends in children's university hospital ps ratchina s a , averchenkova l b , jarkova l a . local surveillance of antimicrobial (am) consumption is essential to promote the rational use of this group of drugs. the purpose of this study was to analyze the trends of am use in the children university hospital in and . data on am usage were obtained from the hospital drugstore requests in the -beds multi-ward children university hospital. consumption was expressed as the number of ddd per bed-days (b Á/d). the total am consumption figures were similar in and ( . and . ddds/ b Á/d, respectively) with notable differences in am prescribing patterns. penicillin consumption increased from . to . ddds/ b Á/d mostly due to amoxicillin. the overall aminoglycoside usage remained comparable ( . vs. . ddds/ b Á/d) though amikacin has considerably replaced gentamicin. there was a sevenfold increase of ciprofloxacin ( . vs. . ddds/ b Á/d) along with the evident decrease of tetracycline and co-trimoxazole consumption found ( . vs. . ddds/ b Á/d and . vs. . ddds/ b Á/d, respectively). the tendency to prescribe more effective in respect of the local resistance data and/or more safe am was detected in comparing with that can be explained by the introduction of the local guidelines for infectious diseases management in . clarithromycin in the treatment of chronic prostatitis caused by chlamydia trachomatis */a pilot study ps the aim of this pilot study was to determine the efficacy and tolerability of clarithromycin in the treatment of chronic prostatitis caused by chlamydia trachomatis (ct). fifty-two patients older than years of age with diagnosed chronic chlamydial prostatitis were enrolled. the presence of ct in expressed prostatic secretion or urine specimen voided immediately after prostatic massage was confirmed by isolation on mccoy cells and lugol staining. the majority of patients suffered from suprapubic pain and pain in the groin. twelve patients had no clinical symptoms. according to rectal palpation, prostate gland was normal in patients, tender and soft in and firm in five patients. clarithromycin was administered orally mg twice daily for days. simultaneously the patients' partners received mg orally twice daily for days. clinical efficacy and tolerability of administered clarithromycin were evaluated Á/ days and Á/ weeks after the end of treatment. bactericidal efficacy of administered drug was evaluated Á/ weeks after the end of treatment. the eradication of ct was achieved in out of patients, while patients were clinically cured. two patients had nausea and elevated serum transaminases. in asymptomatic patients, the eradication of ct was achieved in of patients who reported no side effects. this pilot study has shown an excellent efficacy and tolerability of clarithromycin in the treatment of patients with chronic chlamydial prostatitis. women with diagnosis of urinary tract infections (uti) often demonstrate vaginal colonisation with alpha-haemolytic escherichia coli strains. in the present study we decided to evaluate a distribution of virulence genes encoding for cytotoxic necrotizing factor type (cnf ), p-fimbriae, s/f c-fimbriae aerobactin (aer), and afa genes in alpha-haemolytic e. coli strains isolated from gynaecological material in our region and to compare the detected sequences in clinical isolates of other diagnostic groups. of alpha-haemolytic e. coli strains, were isolated from urine, from gynaecological specimen, and were faecal strains. e. coli strains were tested for the production of haemolytic phenotype on blood agar plates. the amplification of virulence factors was performed by pcr according to previously described protocols (le bouguenec et al., ; blanco et al., ; and yamamoto et al., ) . we found that all gynaecological alphahaemolytic strains were positive for cnf , (p b/ . compared to % of urine strains, and p b/ . compared to % of faecal strains). similarly, sfa/foc specific dna sequences were found in % of gynaecological isolates (p / . compared to % of urine strains and p / . compared to % of faecal strains). from this point of view, the female genital tract seems to be a potential reservoir of these uropathogenic e. coli strains. azithromycin in the treatment of pelvic inflammatory disease caused by chlamydia trachomatis ps administered in hospitalized patients with chlamydial pid. the diagnosis was made prior to hospitalization. microbiological analysis of urine, blood and swab specimens collected from endocervix, vagina and urethra confirmed c. trachomatis to be the single suspected causative pathogen of pid. the presence of c. trachomatis in swab specimens from endocervix was examined by dnk/rnk hybridization. azithromycin was administered Á/ days after samples for microbiological analysis were collected in dose of )/ mg iv for days. clinical efficacy and tolerability of therapy were assessed Á/ days after the end of therapy and clinical and microbiological analysis Á/ weeks after completion of therapy. the eradication of c. trachomatis and normalization of gynecological findings were achieved in and disappearance of subjective symptoms in patients. no side effects and deviations from normal values in hematologic and biochemical blood parameters were recorded. this study showed high bactericidal efficacy, rapid clinical effect and good tolerability of once-daily administration of mg azithromycin for days in the treatment of patients with pid caused by c. trachomatis . altindis m a , cevrioglu s b , aktepe oc a , cetinkaya a . a kocatepe university school of medicine, microbiology, afyon, turkey , b kocatepe university school of medicine, obstetrics and gynecology, afyon, turkey diagnosis of the causative organism of the vaginitis is usually based on clinical criteria. a standardized, laboratory based and rapid diagnostic test for the identification of these organisms is desirable. to determine the laboratory method that best predicted the causative organism, we calculated the sensitivity, specificity and predictive value of positive and negative test for clinical criteria, an oligonucleotide probe test (affirm vpiii-bd usa) and compared them with the combination of positive vaginal culture and gram-stained vaginal smear. we evaluated consecutive women aged Á/ years, attending for vaginal discharge. vaginal swab specimens were used for culture of gardnerella vaginalis , trichomonas vaginalis and candida sp, preparation of a vaginal smear for gram-stain interpretation and wet mount evaluation and affirm test. affirm detected g. vaginalis in ( %), candida sp in three ( . %) women and no trichomoniasis case found by any methods. the sensitivity and negative predictive values of affirm test and clinical signs were same ( %) in identifying of bacterial vaginosis. however, affirm test was more specific ( vs %) and also has higher positive predictive value ( vs %) than clinical signs. we did not evaluate the results for patients with candidiasis because of less number. according to these results affirm-microbial identification tests are objective and specific for the rapid diagnosis of the bacterial vaginosis. comparison of efficacy of single dose of tinidazole with standard dose of metronidazole in giardia lamblia infection (preliminary report) ps fallah m a , moshtaghi aa b . a university of medical sciences, parasitology, hamadan, islamic republic of iran , b university of medical sciences, pediatrics, hamadan, islamic republic of iran objectives: giardia lamblia is the most common intestinal protozoa in developing countries. treatment of the infection with metronidazole, the drug of choice, requires a long course of therapy and produced some side effects. the object of this study is to determine efficacy and side effects of tinidazole in g. lamblia infection. this is a preliminary report of an ongoing trial. methods: a randomized controlled clinical trial was carried out and subjects with g. lamblia infection were treated with tinidazole or metronidazole. tinidazole mg/kg single dose and metronidazole mg/kg three times a day for days were given orally to and children, respectively. parasitological cure was documented when there were consecutive negative stool examinations at Á/ weeks after therapy. results: twenty-one of individuals treated with tinidazole and of children treated with metronidazole had parasitological cure. cure rates between two groups were not significant statistically. no major side effects were observed except one case in metronidazole group who had mild headache and abdominal pain for days. conclusions: we concluded, tinidazole at the dose has efficacy equal of metronidazole in the treatment of g. lamblia infection. because of single dose prescription, short course of therapy and good compliance of patients, this preparation is preferred to metronidazole in giardial infection. ebeid fa, seif el-din sh. theodor bilharz research institute, pharmacology, cairo, egypt b-carotein was given in different doses starting from . to mg/kg body weight (b.w.) for different groups of albino mice days before infection with s. mansoni . infection of animals was done by body immersion using egyptian strain of s. mansoni cercariae/mouse. forty-nine days after infection the animals were sacrificed and hepatic and mesenteric worms were extracted and determined. ova count in liver and intestinal tissue and the total number of worms/animals were also determined in experimental groups comparing with infected control animals. the results indicated marked decrease in number of worms and ova count in both liver and intestine comparing with control ones. this reduction increased significantly with increasing dose. it was concluded that b-carotein could be used as a prophylactic agent against s. mansoni infection. barisic z, babic-erceg a, borzic e, zoranic v, carev m, kaliterna v. department of microbiology, public health institute, split, croatia the aim of this study is to determine frequency of pseudomonas aeruginosa urinary tract infection (uti) in outpatient's population in south croatia and to suggest optimal antimicrobial treatment for these patients. during months long observation period, from total number of examined urine specimens, significant bacteriuria was found in specimens. p. aeruginosa was the sixth most common isolate, it was isolated from specimens ( . %). these specimens were taken from different patients. susceptibility testing was performed by disk diffusion method, and the following results were obtained: resistance to cefibuten occurred in . % patients, to norfoxacin in . %, to ciprofloxacin in . %, to gentamicin in . %, to netilmicin in . %, to amikacin in . %, to ceftazidime in . % and to imipenem in . % patients. p. aeruginosa strains showed better susceptibility to tested parenteral antibiotics than to antibiotics for oral use which complicated treatment in outpatients. the best susceptibility was shown to imipenem, but this drug is inappropriate for use in outpatients setting, so the best choice for treatment p. aeruginosa uti in our outpatients is treatment with ceftazidime, and the second choices are aminoglycoside drugs amikacin and netilmicin. silan l a , breza j b , krcmery v jr. c . a department of internal medicine, derer s university hospital, bratislava, slovakia , b department of urology, comenius university school, bratislava, slovakia , c department of pharmacology, st. elisabeth cancer institute, bratislava, slovakia we studied the clinical efficacy of oral treatment with ciprofloxacin/ cpf/ alone and combined with clarithromycin in patients with complicated urinary tract infection/cuti/ with or without an indwelling catherer. patients were randomly allocated to mg cpf/cpf group/ or to mg cpf plus mg cam/combination group/ for days. evaluation was done on day according to the criteria advocated by the japanese urinary tract infection committee. in patients with a urinary catherer, the combination achieved a higher complete bacterial elimination rate / %/ and clinical efficacy rate / %/ than cpf alone / and . %, respectively/. while no significant difference was found in the bacterial elimination rate between the two groups, the clinical effect of the combination / %/ was superior to that of cpf alone / %/ in patients with an indwelling catherer. the better clinical efficacy of the combination may partly be attributed to the antibiofilm effect of cam in the clinical setting. the results also indicated that difficulties still remain in the treatment of cuti in patients with an indwelling catherer. in conclusion, clinical study suggested that cam might have an inhibitory action on biofilm formation in the clinical setting. combination of cam with other appropriate antimicrobial agents may have a favorable effect on the treatment of cuti. vesicoureteral reflux and urinary tract infections */the management of primary vesico-eureteral reflux in children ps the children studied presented with primary vesicoureteral reflux at derer s universitz hospital in bratislava between and . seven hundred and sixty patients, boys and girls, suffering from primary vesicoureteral reflux in age from months to years were tested and systematically analyzed outcomes data for seven treatment alternatives. key outcomes identified were probability of reflux resolution, likelihood of developing pyelonephritis and scarring, and possibility of complications of medical and surgical treatment. available outcomes data on the various treatment alternatives were summarized and the relative probabilities of possible outcomes were compared for each alternative. conclusions: increased of urinary tract infection, vesicoureteral reflux nephropathy includes early diagnosis, appropriate evaluation, effective atb therapy, and surgery indicated. the main determinants of renal damage are bstruction, age, sex, predisposition on renal scarring, reflux grade and laterality, therapeutic delay, individual susceptibility, bacterial virulence and immunogenetic status. ) the one and only absolute indication for surgical management is failure of medical therapy to prevent chronic recurrent pyelonephritis, renal injury or other reflux complications and eliminations of the reflux condition will minimize their likelihood. genetically conditioned immunopathogenic mechanisms are involved in the pathogenesis of the chronic recurrent pyelonephritis in patient suffering from vur. for most children we recommended continuous antibiotic prophylaxis as initial treatment-medical therapy is based on the principle that reflux often resolves with time, and antibiotics maintain urine sterility and prevent infections while the patients awaits spontaneous resolution. ) vur predispose an individual to renal infection, the immunological and inflammatory reaction caused by a pyelonephritic infection may result in renal injury or scarring. silan l a , breza j b . a department of internal medicine, derer s university hospital, bratislava, slovakia , b department of urology, comenius university school of medicine, bratislava, slovakia elderly patients with uti are believed less likely to be cured by antimicrobial therapy than younger patients. the reasons for this poorer outcome have not yet been clarified. we have investigated the efficacy of antimicrobial therapy in elderly patients with complicated uti. five hundred patients, men and women, who had complicated uti/ symptomatic and symptomatic and were Á/ years of age, were treated with one of three different drugs, one was a never quinolone and two were oral cephems. multivariate logistic regression analysis of treatment outcome revealed that the clinical response was significantly related to general underlying diseases and diseases of the urinary tract, but not to age, symptomatic or asymptomatic uti, or infection site such as the kidney or bladder. we concluded that the clinical effectiveness of an antimicrobial agent was not directly related to age, and that urological examination for underlying disease and control of them is quite important for effective treatment and control of complicated utis, especially in elderly patients. the study on the frequency and antimicrobial resistance of escherichia (e ) coli in urine isolates of patients admitted to maribor teaching hospital in and ps rebersek gorisek j a , baklan z a , unuk s a , novak d b . a department for infectious diseases, teaching hospital maribor, maribor, slovenia , b department for microbiology, regional institute of public health maribor, maribor, slovenia purpose: the aim of the study was to determine the frequency and antimicrobial resistance of escherichia coli isolated from urine samples of patients admitted to maribor teaching hospital in and . the frequency and the antimicrobial resistance were compared between years and . methods: in the prospective study going on between and , all urine isolates from patients at maribor teaching hospital were collected and analysed. urine cultures were done using the modified sanford method. the susceptibility testing was performed by disk diffusion method according to nccls. results: in the year , urine isolates and in the year , urine isolates were analysed. e. coli represented . % of urine isolates in and . % of urine isolates in . e. coli resistance rates (%) to amoxycillin was . in the year and . in the year ; to amoxycillin/clavulate was . and . ; to cefalotin was . and . ; to cefaclor . and . ; to trimethoprim sulfamethoxazole was . and . ; to ciprofloxacin was . and . ; to gentamicin was . and . . conclusion: compared to , the frequency of e. coli isolated from urine samples is similar to that in the year . the resistance to amoxycillin, cefaclor and gentamicin is stable. the resistance to trimethoprim sulfamethoxazole and ciprofloxacin is increased and the resistance to amoxycillin/clavulate and cefalotin is decreased. prevalence of the resistance to metronidazole, furazolidone and nitrofurantoin in helicobacter pylori clinical strains ps de la obra sanz p a , roman jl a , lomas e a , villar h b , lopez-brea m a . a hospital de la princesa, microbiology, madrid, spain , b hospital de san agustin, microbiology, aviles, spain the objective of this study was to determine the prevalence of metronidazole, furazolidone and nitrofurantoin resistance in helicobacter pylori clinical isolates. methods: a total of strains of h. pylori were included in this study. all these were tested against metronidazole, and against furazolidone and nitrofurantoin by an agar dilution method. resistance was defined as: metronidazole, mic !/ mg/l; and mic !/ mg/l for furazolidone and nitrofurantoin. results: sixty-eight strains were resistant to metronidazole ( . %). the mic and mic values were and mg/l, respectively. three of strains ( . %) were furazolidone resistant (mic / mg/l), two of these strains were metronidazole resistant (mic / mg/l) and they had mic of mg/l for nitrofurantoin. the mic and the mic were . and . mg/l, respectively for furazolidone. only one of the strains ( . %) was nitrofurantoin resistant (mic mg/l), this strain was metronidazole resistant (mic mg/l) and had a mic / mg/l for furazolidone. the mic and the mic were . and mg/l, respectively for nitrofurantoin. conclusion: the low frequency of furazolidone and nitrofurantoin resistance, compared to metronidazole suggests that the furazolidone and the nitrofurantoin may be good alternatives to metronidazole for treatment of h. pylori infections. antimicrobial resistance of campylobacter isolated from human origins ps zhukhovitsky vg, drabkina iv. department of bacteriology, botkin hospital, moscow, russian federation the purpose of the study was to determine the antimicrobial resistance of thermophilic enteropathogenic campylobacter spp. (tec) isolated from human under acute diarrhoea in in moscow. among tec strains c. jejuni and five c. coli were identified. the antibiotic tested by disk diffusion test on mueller-hinton agar with sheep blood were ampicillin (a), amoxycillin/clavulanate (ac), imipenem (i), meropenem (m), erythromycin (e), clarithromycin (cl), tetracycline (t), doxycycline (d), gentamicin (g), azithromycin (az), chloramphenicol (ch), lincomycin (l), ciprofloxacin (c), nalidixic acid (na). the resistant rate of the tec isolates was highest for na ( %) followed by a ( %), t ( %), d ( %), n ( %) and cl ( %). a moderate resistance rate was obtained for a ( %), ch ( %), az ( %), ac ( %). none of the isolates demonstrated resistance to i, m and g and four of isolates ( %) were sensitive for all the antibiotics tested. mic to na was estimated as mg/l. among na resistant tec strains ( %) were identified as c. jejuni and one ( %) as c. coli . among c. jejuni and c. coli na resistant rate was and %, respectively. one na resistant c. coli and nine na resistant c. jejuni were resistant to ciprofloxacin. ring c, atanassova v. department of food hygiene and microbiology, school of veterinary medicine, hannover, germany aim of the study: poultry meat is known to be often contaminated with salmonella and other foodborne pathogens and thus has to be considered as a possible source for human infections. the aim of the study was to monitor the resistance of salmonella isolates from poultry meat of different european countries to various antibiotics. material and methods: from september to december a total of samples of frozen poultry meat from france, germany, italy, spain, the netherlands and portugal were examined for the prevalence of salmonella using classical cultural detection as well as rflp-pcr. all isolates were tested for their sensitivity towards ampicilline, kanamycine, ciprofloxacine, tetracycline, trimethoprim, sulfamethoxazole, nalidixic acid and erythromycine using standard procedures. results: from . % of all examined samples salmonella spp. were isolated. of these isolates . % were characterized as salmonella , . % as s. hadar and . % as s. typhimurium . nearly % of all isolates were resistant to erythromycin. resistance towards four or more isolates was observed in several cases. discussion: the consumption of poultry meat, if insufficiently prepared, has still to be considered as a major source for human infection with salmonella spp. the question arises whether the resistance of the isolates to various antibiotics is of clinical importance in the treatment of the patients. objective: to provide insight into the epidemiologic situation of salmonellosis for the nis area (the largest area in serbia, with inhabitants */ , ). methods: the material was processed at the institute for public health (epidemiology and microbiology divisions). isolation of microorganisms was performed on apparatus for rapid identification (vitek-biomerieux) and by applying elisa tests and classical microbiological methods. results: in the period Á/ , salmonella laboratory confirmed cases were reported. the greatest number of diseased in the Á/ years group. the most frequent isolated salmonellae were: s. enteritidis ( . %) and s. typhimurium ( . %), s. hadar , s. agona , s. virchow , s. infantis , s. derby , s. enteritidis showed the greatest sensitivity to antibiotics with the infrequent resistance to ampicillin and trimethoprim-sulfamethoxazole. s. typhimurium showed the greater resistance to the wide spectrum of antibiotics and some isolates were resistant to all antibiotics tested. the less common types of salmonella were sensitive to all antibiotics except trimethoprimsulfamethoxazole and ampicillin. conclusion: specific resistance to some antibiotics was related to serotypes. typhoid fever */retrospective study of cases in lebanon ps tohme a, abboud j, ghayad e. hôtel-dieu hospital, internal medicine, beirut, lebanon objectives: to present epidemiological and clinical features of typhoid fever in lebanon. methods: fifty-two patients were seen at hotel-dieu hospital of beirut between and . diagnostic criteria were positive blood culture for s. typhi or paratyphi and/or a somatic o agglutinin titer ]/ / as determined by the widal test with symptoms suggestive of typhoid fever. we also present an epidemiological study of cases registered by the ministry of health during the same period. results: among the cases, % of the patients' ages were between and years and % were less than years. the overall male to female ratio was . and % of cases were seen on january, february and % on august. among the patients, young adults were the most affected. average duration of symptoms before the diagnosis was / days. the main presenting symptoms were: fever ( %), diarrhoea ( %), abdominal pain ( %) and headache ( %). complications were noted in % of cases and digestive complications were the most prevalent. leucopenia was not a helpful diagnostic marker. s. typhi was the most frequent ( %) serotype identified. resistance to ampicilline was %, to cotrimoxazole and chloramphenicol % for each. the mortality rate was %. conclusion: typhoid fever is still an endemic disease in our country and the occurrence of resistant strains of s. typhi will favor ceftriaxone or fluoroquinolones in the treatment. maaloul i a , hammami b a , zambaa f a , elleuch r a , hammami a b , -ben jemaa m a . a chu hedi chaker, service des maladies infectieuses, sfax, tunisia , b chu habib bourguiba, laboratoire de microbiologie, sfax, tunisia although its not very frequent, the psoas abscess is not an exceptional entity. in order to specify its clinical, biological, radiological and evolutionary features, a retrospective study has been led in our service, on a period of years (january Á/december ). on the whole, cases have been listed. they were men and women. the age average was years (extreme Á/ years). the study did not find any underlying diseases, except diabetes mellitus for three patients. the clinical symptoms were dominated by fever with abdomino-lumbar aches ( cases), and psoitis (eight cases). biology showed an inflammatory syndrome in all cases and a hyperleucocytosis in cases. the diagnosis of psoas abscess, evoked on clinical data, has been confirmed by the imagery data: ultra-songraphy ( cases), ct scanning (six cases), magnetic resonance imaging (three cases). the tubercular etiology has been confirmed in six cases, among which two were associated to escherichia coli (one case) and to brucella melitensis (one case). the other etiologic agents were dominated by staphylococcus aureus (eight cases), b. melitensis (two cases), e. coli (one case), bacteroides fragilis (one case), streptococcus anginosus (one case), fusobacterium nucleaticum (one case) and candida glabrata (one case). all patients received an anti-infectious treatment adapted to the micro organism in question. a drainage of the abscess has been realized for patients (percutaneous: nine cases, surgical: six cases). the evolution was favourable for patients. however, two patients had a relapse after stopping the treatment. conclusion: the diagnosis of the psoas abscess, difficult on the clinical data, is based on the imagery techniques (us, ct, rmi). the percutaneous drainage guided by the imagery is recommended (in an etiological and therapeutic aim). associated to an adapted antibiotherapy, it allows to defer a surgical drainage. zezoski mbz, nikolova o, gavriloski pmg. medical center, infectious diseases, prilep, the former yugoslav republic, macedonia purpose: to make a list of the most frequent abdominal changes in patients with human brucellosis. materials and methods: there were new patients with human brucellosis, between and . diagnosis was made using standard clinical, biochemical and serological investigations (bab, wright, coomb's, rvk, -mercaptoethanol, elisa igm and igg), and specially ultrasound examination of the abdomen and retro peritoneum. results: weight loss is the most frequent change, presented in ( . %) patients. follow atypical abdominal pain in ( . %), vomiting in ( . %), diarrhea in ( . %), enlarged liver in ( . %), enlarged spleen in ( . %) and hepatic lesion with increased ast and alt in ( . %). conclusion: although frequent, abdominal changes seldom could be missed in patients with human brucellosis. we recommend routine ultrasound examination with standard biochemical test for liver function, due to avoid unnecessary complications. osteoarticular complications are common in brucellosis. the most common site of involvement is the sacroiliac joint. the osteoarticular complications such as, sacroiliitis and spondylitis are diagnosed with radiologically. in the present study, we aimed to determine the severity (grade) of sacroiliitis by using some laboratory parameters such as esr, crp and tube agg test. seventy-two ( male, female) patients with brucellosis were included in the study. osteoarticular involvement was present in patients. the most common osteoarticular finding was sacroiliitis in the patients ( %). twenty ( ) healthy subjects were formed the control group. there was statistically significant difference between patients and controls regarding esr, crp, and tube agg test (p / . , . , . , respectively). in addition, sacroiliitis has an effect on esr and crp. there was a positive correlation between the grade of sacroiliitis and the value of crp (p / . , r / . ). in conclusion, it has been suggested that, crp may be used as an auxiliary or a secondary parameter in grading sacroiliac joint involvement in brucellosis. magira ee a , papandreoy s a , gounaris t a , spirelis ma a , tasopoulos g a , anagnostopoulou m b , paniara o b , gounari p a , sioulal e a . a evagelismos, internal medicine, athens, greece , b evagelismos, micro- a -year-old greek farmer was admitted to the hospital because of painful scrotal swelling, hepatosplenomegaly, lumbar pain and lowgrade fever accompanied by profuse sweating. his life style included occupational animal exposure ingestion of raw milk and dairy products. the laboratory data were within the normal ranges. focal hypoechoic right testicular lesions, swelling of the concurrent epididimis along with an increase in the vascularity of the right testis were seen on an echo examination. these findings were consisting in unilateral epididimo-orchitis. a ct scan of the lumbar spine area showed a decrease of the signal intensity localized in the anterior aspect of l vertebral body at the diskovertebral junction involving the subchondrial parts of the l and s vertebrae standard tube agglutination test was positive for antibodies to brucella melitensis (titer !/ / ). cultures of blood specimens were positive for b. melitensis . the patient had been given to a combination of antibiotics with doxycycline, streptomycin and rifampin. a remarkable improvement of his clinical condition was showed weeks later. this case illustrates the following point: in areas in which brucellosis is endemic when scrotal abnormalities are seen the possibility of genitourinary tract complications of brucella should be considered. pappas ga a , akritidis nk b , mastora m b , tsianos e a . a university hospital, internal medicine, ioannina, greece , b 'g. hatzikosta ' hospital, internal medicine, ioannina, greece aims and scope: to determine the incidence and forms of complications associated with brucella infection. patients and methods: we studied the most recent patients, in all larger series approaching , diagnosed as suffering from brucellosis, and assessed the presence of signs and symptoms of arthritis and spondylitis, or other forms of bone involvement. the diagnosis of brucellosis was based on serology or isolation of brucella species from blood cultures or cultures from other media. results: osteoarticular complications were noted in patients, presenting with arthritis, and presenting with spondylitis. eight patients presented with genitourinary complications, either orcheoepididymitis (four patients), or hematuria resolving with treatment (four patients). meningitis was present in two patients. gastrointestinal complications (vomit and diarrhea) were present in three patients, while one patient presented with ascites. respiratory tract complications, in the form of pneumonia (four patients) or bronchitis (three patients) were noted in seven patients, while one patient with pneumonia exhibited pleural fluid. skin rashes, of macular type, were present in three patients. no patient presented with complications from the heart. hematologic complications were frequent, in the form of severe (one patient) or moderate (two patients) pancytopenia, isolated thrombocytopenia (three patients), or lymphocytosis (eight patients). akritidis nk a , pappas ga b , mastora m a . a 'g. hatzikosta ' hospital, internal medicine, ioannina, greece , b university hospital, internal medicine, ioannina, greece aims and scope: to determine the incidence and modes of bone and joint involvement in the course of brucellosis. patients and methods: we studied the most recent patients, in all larger series approaching , diagnosed with brucellosis, and assessed the presence of arthritis and spondylitis. the diagnosis of brucellosis was based on serology or isolation of brucella species from blood cultures. results: twenty-three patients exhibited a form of osteoarticular involvement. arthritis was present in patients, most often involving the knees, but also the hips, elbows, even smaller joints as intephalangeal joints of the hand. synovial fluid, when aspirated, was often characterised by an intense mononuclear infiltrate. spondylitis was present in patients, most often involving the lumbar spine, but also the thoracic spine. the characteristic erosion on the upper anterior crest of the vertebral body was visible in plain x-rays in three patients, while mri and bone scan were helpful in other cases. discussion: osteoarticular involvement in the course of brucellosis is the most common focal presentation of the disease. acute brucellosis is often accompanied by bone and joint ache, especially of the lumbar spine, still frank involvement in the form of arthritis and spondylitis is not rare. arthritis usually presents in the acute form of the disease, while spondylitis tends to be characteristic of a chronic form of the disease, often necessitating prolonged use of antibiotics. bosilkovski m, krteva l, caparoska s, grozdanovski k, sajn b. clinic for infectious diseases and febrile conditions, medical faculty, skopje, the former yugoslav republic, macedonia one hundred and twenty-six patients with brucellosis were studied prospectively. seventy-eight ( %) of them had osteoarticular involvement. peripheral arthritis in ( %) patients was the most frequent, followed by spondilitis in ( %), sacroiliitis in ( %), rarely bursitis, tendinitis and osteomyelitis. the overall male to female ratio was : . their average age was (sd ) years. direct contact with animals was the reason for acquisition of the illness in % of patients, in % alimentary or aerogenous route was incriminated, and in % the route of aqisition was unknown. the average duration of the symptoms from the onset to establishing the diagnosis was (sd ) days. the main presenting symptoms were joint pain ( %), sweating ( %), fatigue ( %) and fever ( %). hepatomegaly was present in %. in % of patients, involvement of some other system was evident. comparison with patients, who did not have osteoarticular illness, showed that patients with osteoarticular involvement had significantly more often joint pain, fatigue, weight loss and more prolonged duration of symptoms before the diagnosis was established. doxycycline and chloroquine as combination therapy for chronic q fever endocarditis ps calza l, attard l, manfredi r, chiodo f. division of infectious diseases, university of bologna, s. orsola hospital, bologna, italy introduction: endocarditis is the main clinical manifestation of chronic q fever, occurring in about Á/ % of all reported cases, and it is diagnosed almost exclusively in patients with either cardiovascular abnormalities or an immunocompromised condition. case report: a -year-old caucasian male patient with biological prosthetic aortic valve was first hospitalized because of an interstitial pneumonia. six months later, our patient was re-admitted owing to intermittent fever, chills and weight loss. echocardiographic study showed a small vegetation of mm in diameter on left cusp of aortic valve. serology for coxiella burnetii revealed a complement-fixing igg antibody titer to phase i antigen of more than : , consistent with chronic q fever endocarditis. antimicrobial therapy with i.v. doxycycline and oral chloroquine was started, leading to a clinical and echocardiographical recovery. therapy was continued by oral doxycycline and chloroquine, and the patient remained asymptomatic during a -year follow up. conclusion: the optimal treatment of q fever endocarditis has not been well established: the most effective antimicrobials are fluoroquinolones and rifampin, but chloramphenicol, doxycycline and trimethoprim are also useful. the role of chloroquine in combination with doxycycline seems to be promising, because chloroquine may increase the lysosomal ph, enhancing the doxycycline bactericidal activity. akritidis nk a , pappas ga b , mastora m a , liappis e a , tsianos e b . a 'g. hatzikosta ' hospital, internal medicine, ioannina, greece , b university hospital, internal medicine, ioannina, greece aims and scopes: to review the incidence and the forms of lower respiratory tract infection in patients suffering from q fever, and their clinical and radiological characteristics. patients and methods: twenty-seven patients diagnosed as suffering from q fever, were assessed for the presence of lower respiratory tract infection. the diagnosis was confirmed serologically. results: thirteen patients expressed lower respiratory tract pathology, as confirmed by clinical examination and chest x-ray. in of these patients the main cause of admission was respiratory tract symptoms, ranging from dry cough to hemoptysis. chest x-ray was pathological in patients: patients had lobar pneumonia, two of them multiple nodular opacities, and one of them bronchopneumonia. hepatitis was a common finding. all patients were treated with tetracycline. discussion: although coxiella burnetii infection is acquired via the respiratory tract, it is paradoxical that symptoms attributed to the lung are not invariably positive. q fever pneumonia is an atypical pneumonia that usually follows a benign course. diangostic suspicion is usually raised by the epidemiologic pattern and the accompanying mild hepatitis. pleural effusion is not a common finding. the usual radiologic appearance of q fever pneumonia is that of a lobar or segmental pneumonia. one important aspect of q fever pneumonia is its common presentation in the form of multiple nodular opacities often necessitating the exclusion of malignancy. ( ), culture ( ), and serology'/culture ( ). there were Á/ cases per year, mainly in october ( %). a history of exposition to hare was present in / ( %) and to marmot in / ( %). skinning ( / %), animal contact ( / %), bite ( / ) and wound during bait preparation with frozen meat for hunting ( / ) were noted. the initial clinical presentation was ulceroglandular ( %), glandular ( %) and pneumonic ( %). the involved nodes distribution was axillary ( / ), cubital/axillary ( / ) and cubital ( / ). median incubation period was days (range Á/ ); time to consultation days (range Á/ ), and time for effective treatment days (range Á/ ). an initial diagnosis of tularemia was made presumptively in %. effective antibiotic regimen used was aminoglycosides in % ( / ), and tetracyclines in % ( / ). note that intravenous netilmicin was used in cases. complication rate was % ( / ) with one death ( %), and was associated with delay in effective treatment ( !/ days of illness) (p b/ . ). conclusion: in our area tularemia occured mainly in male population, during autumn, with a short incubation period and history of hare contact. delay before appropriate treatment increased the complication rate. bompolaki i, doukakis s, triantafillidou d, polimili g, kastanakis m, nikiforakis k, vittorakis e, kastanakis s. first medical department, 'saint george ' general hospital, chania, greece a severe frontal and/or retroorbital headache represents the most common neurologic manifestation of murine typhus. other neurologic manifestations as confusion, stupor, nuchal rigidity and in severe cases delirium, extreme agitation or coma appear less commonly. eightyfour patients with compatible clinical status of murine typhus and high serological titers of antibodies against rickettsia typhi, were studied from our team. seventy-four patients ( %) presented headache and nine patients ( %) presented confusion. one patient ( . %) presented nuchal rigidity in combination with severe headache and confusion giving us the suspicion of meningitis. in this case a lumbar puncture was performed emergently and the cerebrospinal fluid (csf) was examined. the findings of csf were proteins: mg/dl, wbc: /ml and glucose: mg/dl and its culture was negative. all patients were treated with a specific anti-rickettsial treatment. the outcome of murine typhus was favorable for all patients ( %). no one patient presented neurologic sequelae. conjunctivitis usually accompany rickettsial diseases such as rocky mountain spotted fever, epidemic typhus and murine typhus. eightythree patients with compatible clinical status of murine typhus and high serological titers of antibodies against rickettsia typhi , were studied from our team, during a period of time between january and the first semester of . the clinical examination of these patients revealed the presence of conjunctivitis in / patients ( . %). in the same time these patients referred retroocular pain and mild photophobia. this study showed that in murine typhus the injection of conjunctivae is rather common. almost a quarter of the patients presented conjunctivitis despite the fact, that this ocular manifestation is less severe than in other typhus and spotted fevers. eighty-three patients with compatible clinical status of murine typhus and high serological titers of antibodies against rickettsia typhi , were studied from our team, during a period of time between january and the first semester of . three blood samples were obtained from each patient for the study of their hematological abnormalities. the first sample was obtained on admission, the second sample weeks after the first, the third sample, month after the second. on admission / patients ( %) presented anemia, / patients ( %) presented leukopenia and / patients ( %) presented thrombocytopenia. the mean value of hematocrit, white blood cells and platelets was . g/dl, . )/ and )/ /ml, respectively. two weeks later anemia was presented in / patients ( %), / patients ( %) presented leukopenia, / patients ( %) presented leucocytosis and / patients ( %) presented thrombocytopenia. the mean value of hematocrit, white blood cells and platelets was . g/dl, . )/ and )/ /ml, respectively. one month later / patients ( %) had anemia and / patients ( %) presented thrombocytopenia. the mean value of hematocrit, white blood cells and platelets was . g/dl, . )/ and )/ /ml, respectively. our study showed that early thrombocytopenia and anemia are frequent in murine typhus and that white blood cells count is usually normal. renal function in murine typhus: a study of cases ps doukakis s, polimili g, triantafillidou d, kastanakis m, vittorakis e, palla k, kastanakis s. first medical department, 'saint george ' general hospital, chania, greece the clinical course of murine typhus is usually uncomplicated and the mortality rate is low ( b/ %). advanced age and prolonged interval before administration of a specific anti-rickettsial treatment are correlated with severity of the disease. renal function in murine typhus is usually unaltered except in elderly patients with prolonged hypotension. eighty-three patients with compatible clinical status of murine typhus and high serological titres of antibodies against rickettsia typhi, were studied from our team, during a period of time between january and the first semester of . three blood samples were obtained from each patient for the study of their renal function. the first sample was obtained on admission, the second sample approximately weeks after the first, the third sample, taken from the half of the patients, was obtained one month after the second. on admission / patients ( . %) presented acute renal failure. the outcome of murine typhus was favourable for all patients ( %). the four patients who presented acute renal failure reversed after the administration of anti-rickettsial treatment and careful administration of fluids. in murine typhus the induction of hypovolaemia insufficiently corrected by normal homeostatic mechanisms may lead to prerenal azotaemia. in these cases the immediate onset of an antirickettsial treatment and the correction of hypovolaemia are essential for the rapid clinical improvement of the patient. experimental ocular toxoplasmosis: clinical, histopathological, immunological and therapeutic studies ps el zawawy lae a , hammoda na a , allam sr a , ali sm a , galal as b . a faculty of medicine, parasitology, alexandria, egypt , b faculty of medicine, ophthalmology, alexandria, egypt the purpose of the study was to investigate clinical, histopathological, immunological and therapeutic features of an experimental model of ocular toxoplasmosis in sensitized and non sensitized rabbits and to assess the influence of treatment by interleukin (il- ) on ocular lesions. the results obtained was that 'toxoplasma' retnochoroiditis developed in both groups of rabbits with more pronounced effect in non sensitized animals. administration of il- improved ocular lesions in both groups with more evident effect in sensitized rabbits. immunological findings were consistent with clinical and histopathological observations. the conclusion reached was that; ocular lesions were manifested in non sensitized rabbits more than in sensitized ones. il- revealed a significant impact on improving the host defense against toxoplasm infection in eye. immunotherapy with il- would open the way for a new range of treatment based on immunomodulation. express-diagnostic of streptococcus antigen for the adequate antibiotic therapy in patients with pharyngitis ps pertseva to, konopkina li, kireeva tv. dsma, internal medicine , dniepropetrovsk, ukraine the purpose of the study: evaluation of effectivness of streptococcus express-diagnostic for the adequate antibiotic therapy in patients with pharyngitis. results: we deal with clinical and microbiological comparison in patients with pharyngitis. using of streptococcus antigen express diagnostic in swabs from the backside of pharynx allowed to get positive results in the seven cases ( . %). following cultural study has confirmed these results. positive test was more probable in patients with pronounced fever (more than c), headache, weakness and in cases associated with chronic tonsillitis. isolated streptococcus pyogenes was susceptible to ampicillin, claritromicin, erytromicin, azytromicin, , clindamicin, ceftriaxon, levafloxacin, oxacillin, cefuroxim, roxytromicin. conclusion: using of the express diagnostic of streptococcus antigen allows to restrict groundless prescription of antibiotic therapy in patients with other types pharyngitis (i.e. viral, candidal etc.). alabaz d a , turgut m a , kocabas e a , tumgor g a , yaman a b , alhan e a . a division of pediatric infectious diseases, cukurova university, adana, turkey , b department of microbiology, cukurova university, adana, turkey chickenpox is a common viral infection that usually follows a benign, self limited course in healthy children. the most common complication in children with varicella is superimposed cutaneous infections with pyogenic bacteria (streptococcus pyogenes and staphylococcus aureus ). varicella gangrenosum, a necrotising soft tissue infection complicating the vesicular eruption of chickenpox, is rare. here we present three cases with necrotising soft tissue infections following chicken pox. these children were admitted because of common crusted lesions and necrotising soft tissue infection over the neck, the back, and the inguinal area. they all had the contact history and ensuing vesiculopapular rush. these infections were caused by group a streptococci in two cases, and s. aureus in one case. after instituting of appropriate antibiotic therapy, each patient underwent a surgical exploration with fasciotomies and debridement. widespread use of varicella vaccine may decrease invasive infections in children, adolescents, and adults, thus decreasing the burden the disease with its complications impose up on the family and the society . cefprozil is a second generation cephalosporin. the aim of this open, multicentre, non-comparative study was to investigate the efficacy and safety of cefprozil in the treatment of streptococcal tonsillopharyngitis. fifty-eight patients were clinically assessed for signs and symptoms of streptococcal infection. laboratory confirma-tion was sought using three tests; culture, rapid strepto test and estimation of antistreptolysin (aso). one or more tests were done in of the patients. treatment was for days, mg/kg per day in children, mg per day in adolescents. patients were again clinically assessed on the th Á/ th day. the results showed clinical success in patients ( . %) and in of the who had laboratory tests ( . %). two patients had treatment withdrawn because of nausea and abdominal pain ( . %). of the patients with laboratory tests at least one test was ositive. the most helpful was the strepto test giving the quickest positive result in % of those tested ( / ). culture was positive in % of those tested ( / ). the aso test was of limited value. in conclusion, cefprozil showed high clinical efficacy and safety in the treatment of streptococcal tonsillopharyngitis. tsiara s, militadou g, milionis c, elisaf m. internal medicine department, university of ioannina, ioannina, greece streptococcus group b agalactiae (gbs) is a rare pathogen for healthy male adults. we present an old man in whom (gbs) was isolated in blood cultures. case report: a -year-old man was admitted to the hospital in order to investigate osteolytic lesions in the lumbar spine. two weeks before, he experienced severe low back pain radiating to the right leg and fever arising to . c with chills and rigors. a gbs was isolated from blood cultures and treatment with penicillin was initiated. a spine ct scan revealed osteolysis in the t and s vertebrae and the patient transferred to us. he was a previously healthy man. he received only antihypertensive therapy. on admission he was afebrile with arthralgias and myalgias. on clinical examination there was tenderness on the right pleurospondylic angle radiating to the right leg. laboratory data on admission: hb: . g/dl, wbc: . )/ /l, esr: mm/h. biochemical values, serum protein electrophoresis, rectal examination and a prostatic specific antigen (psa) were normal. a bone marrow aspiration and biopsy were negative. a transoesophageal ultrasound revealed vegetation on the right cusp of the aortic valve, with low grade regurgitation. an mri of the lumbar spine revealed infectious myositis with concomitant osteomyelitis involving the l , l vertebrae without any evidence of osteolytic lesions. a thorough investigation did not revealed any underlying immunosuppressive disease. treatment with vancomycin and gentamycin iv was initiated and the patient discharged from the hospital in excellent health after weeks. discussion: gbs infections usually occur in neonates and pregnant, or in adults with underlying disease as diabetes mellitus or immunosuppression. the most common site of infection is soft tissue. we present this case because gbs infections are rare in the elderly in the absence of underlying disease. common sites of involvement are soft tissues, while bone, joints, and heart valves account to Á/ % of the involved organs. although our patient had more than one site of involvement he responded well to medical treatment without surgical debriment or heart valve replacement. objective: to evaluate the safety and efficacy of rhugm-csf in combination with broad-spectrum antibiotics for the treatment of ccnf. methods and results: a retrospective review of all patients (pts) with ccnf treated with antibiotics'/rhugm-csf at our hospital from january to december was performed. five patients were identified with the diagnosis of ccnf. ages ranged from to years; there were three women and two men. dental infection was the most common source of ccnf in %. one patient had acute tonsillitis leading to ccnf. all cases studied experienced infection of the neck with spread into the submandibular, submental, sublingual, retropharyngeal, and parapharyngeal spaces. all infections were polymicrobial. diabetes mellitus was a co-morbidity in one case. all pts were treated with dual antibiotic coverage (vancomycin'/meropenem), rhugm-csf ( mcg/kg/daily given s.c.) and aggressive wound care. rhugm-csf was given for Á/ days. in spite of the severity of the infection all pts recovered and do not experienced local or systemic complications. discussion: ccnf is a severe bacterial infection of the cervical fascia resulting in extensive fascial necrosis with widespread undermining of the surrounding tissues. prompt antibiotic therapy combined with rhugm-csf resulted in a % overall survival in our experience. to our knowledge, this is the first report describing the successful treatment of ccnf with use of broad-spectrum antibiotics combined with rhugm-csf. the following case adds to the clinical manifestations and course of meningococcal disease. a previously healthy -year-old girl presented acutely with high fever purpuric rash including conjuctival haemorrhages and hypotension. the child had also neck stiffness. a presumptive diagnosis of meningococcal septicaemia was made and treatment with penicilline, chloramphenicole, fluids and inotropes was initiated. laboratory investigations showed wbc: /ml, hb: . g/dl, hct: . %, esr: mm in the first hour, pt: s, aptt: s. neisseria meningitidis group b was isolated from the blood cultures. csf obtained after antibiotics were started did not grow n. meningitidis . the patient had an adverse outcome. she died after h of hospitalization. this patient developed a fulminating meningococcal septicaemia. shock is a clinical diagnosis arising from the failure of compensatory mechanisms that maintain perfusion of vital organs at the expense of non vital. septic shock results from loss of circulating plasma volume due to increased vascular permeability and maldistribution of intravascular volume. in young children there is a prevalence of serogroup b meningococcal disease which can be explained by the immaturity of the immune system and by the fact the group b capsule synthesis is known to inhibit alternative complement pathway activation. this case emphasizes the need for further protection against n. meningitidis group b. . results: forty-eight patients were included in this study. the etiological agents were: viral (n / , . %, mean ('x ) age / years), streptococcus pneumoniae (n / , . %,'x age / ), neisseria meningitidis (n / , . %, 'x age / ), s. viridans (n / , %, 'x age / ), p. multocida (n / , age ). the peak incidence of bacterial meningitis was in winter (pneumococcal %, meningococcal %, s. viridans %) .the cerebrospinal fluid (csf) findings in viral meningitis were 'x white cells / /mm , 'x pmn / %, 'x glucose csf/ serum . , 'x protein mg/dl and in bacterial meningitis were 'x white cells / /mm , 'x pmn / %, 'x glucose csf/ serum / . , 'x protein / mg/dl, gram stain was positive in %, culture was positive in %. all pneumococcal and meningococcal strains were susceptible to penicillin. the case fatality rates for pneumococcal and meningococcal meningitis were and . %, respectively. conclusions: the cases of bacterial meningitis were according to typical epidemiological features of age and season. the case fatality rate of pneumococcal meningitis appear to be high regardless of susceptibility to penicillin. none had received pneumococcal vaccine prior to becoming ill. diagnosis and therapy of meningococcal meningitis */trend and particularities of a 'romanian model' ps lintmaer i, moroti r, popescu a, popescu c. institute of infectious diseases matei bals , unit , bucharest, romania background: newer diagnosis methods and antimicrobials are expected to change the management of menigococcal meningitis (mm) and to improve its prognosis. objectives: to determine the changes in the diagnosis methods and therapy of mm patients in a infectious diseases hospital. to compare mm management in bucharest with literature data. methods: retrospective rewiew of mm in adult patients hospitalized over a -year period. our results were compared with other studies made in the s, taken from medline. results: there were episodes of mm during the study period ( episodes in Á/ and episodes in Á/ ) . we noticed a defined diagnosis increase and increased blood culture specificity. the antimicrobial monotherapy was maintained but penicilin was replaced by ceftriaxone. hhc was replaced by dexamethasone in pathogenic therapy. we noticed a shorter length of treatment and a reduced lethality. the most important differences between our results and other studies are: monotherapy regimens are less frequent and therapy lengths are longer; however, prognosis is similar. conclusions: the mm management has been modified in the last Á/ years: prognosis is improved, but the changes do not bring clear cost/ effective benefits. tiouiri th, kilani b, amari l, zouiten f, kanoun kf, ghbontini a, ben chaabene t. rabta hospital, infectious diseases, tunis, tunisia objectives: in order to study epidemiological, clinical and therapeutical characteristics of the infective endocarditis (ie). methods: we reviewed all the cases of ie fulfilling the duke criteria. data were collected during a -year period ( Á/ ) in the unit of infectious diseases. results: one hundred and eight cases were identified. the mean age was . years. sex ratio was . . eighty-five ie ( . %) occured in patients with native valve, and ie ( . %) with prosthetic valve. fever was the most common sign, % had a congestive heart failure, . % had cutaneous signs. the most common primary focus of ie was orthodontic. blood cultures were positive in % of cases. in one case, serological test identified rickettsia conori . streptococci and staphylococci were isolated in . and . %, respectively. echocardiography detected abnormalities in . % of cases. rheumatic heart disease was the most predisposing condition. empirical therapy was based on combination of b lactam with aminoglycoside. recovery was obtained for patients. cardiac surgery was performed in cases. overall mortality rate was . %. conclusion: ie affects young persons. prevention needs eradication of acute rheumatic arthritis. a major outbreak of legionnaires' disease in spain: diagnostics aspects ps guerrero c a , toldos cm a , yagü e g b , ramírez c a , rodríguez t a , -segovia m a . a hospital morales meseguer, servicio de microbiología, murcia, spain , b departamento de microbiología, facultad de medicina, universidad de murcia, murcia, spain objective: to evaluate the value of different methods (serological tests, culture of respiratory secretions, blood cultures and urinary antigen testing) for the diagnosis of legionella pneumophila pneumonia during an outbreak in spain. results: we have studied patients from a recent outbreak of legionellosis in murcia (spain). the diagnosis was achieved in patients. urinary antigens were positive in patients. in the patients with urinary antigen negative the serological response was demonstrated by indirect immunofluorescence (ifa) in patients. all blood cultures processed were negative. sputum samples were obtained from patients, of these l. pneumophila was isolated only in six patients. in all of them direct immunofluorescence test (dfa) was positive. conclusions: although the serological diagnosis was the most sensitive method the urinary antigen testing was of great value in the rapid diagnosis of the legionella's outbreak in murcia. the isolation of l. pneumophila by culture showed a poor sensitivity probably because of the low severity of the illness. purpose: to evaluate chloramphenicol for an initial empiric antibiotic treatment of purulent meningitis in adults. study group: one hundred and twenty patients hospitalized for the diagnosis purulent meningitis in the department in years Á/ , males and females, age range Á/ years, mean age . years. children up to years were not included. method: a retrospective analysis of the study group focused on antibiotic treatment both initial and changes during treatment. results: chloramphenicol was used as an initial antibiotic in ( %), rd generation cephalosporin in ( %), penicillin in ( %), ampicillin in five ( %) and other antibiotic in five ( %), respectively. during treatment chloramphenicol was switched for rd gen cephalosporin in seven of patients with streptococcus pneumoniae meningitis and in five of patients with meningitis of unknown etiology. the reason for the change was non-improving csf formula in three, persisting csf culture positivity in two and persisting coma in seven patients. conclusion: because of repeated necessity to switch chloramphenicol for rd gen cephalosporin during treatment of purulent meningitis of pneumococcal and unknown etiology the initial treatment strategy was changed in . third gen cephalosporin is now used as a first choice antibiotic, what is in consent with international recommendation of treatment. to evaluate and compare groups treated initially with chloramphenicol and with rd gen cephalosporin will need several more years. low prevalence of multi-drug resistant mycobacterium tuberculosis in jerez de la frontera-cadiz (spain) ps alados jc, aller ai, de miguel c, de francisco jl, calbo l. hospital del sas-jerez , microbiologia, jerez de la frontera, cadiz, spain introduction and aim: previous reports indicate that multi-drug resistance mycobacterium tuberculosis (mtb) is an worldwide problem. the aim of this study was to review the resistance of mtb to the first-line antimycobacterial agents in our area. material and methods: over a period of years ( Á/ ), strains of mtb isolated from non-treated patients with tuberculosis ( strain in , in , in and in ) were studied. these isolates were tested for in vitro drugs susceptibility to isoniacid-i, rifampicin-r, streptomycin-s and ethambutol-e using the bact/ alert method (organon teknica) as described by the manufacturer. results: our results showed that . % ( / ) strains were resistant to one or more drugs. single drug resistances were detected on nine strains to i ( . %), one to r ( . %), two to s ( . %), one to e ( . %). three mtb strains were resistant to more than one drug but only one was multi-drug resistant (i'/r).the incidence of i-resistant strains over the period fell from % in to . % in . conclusions: ( ) multi-drug resistance is not an important problem in our area. ( ) isoniacid resistance was declined to an admissible level. to investigate the anti-tuberculosis drug resistance pattern of pulmonary tuberculosis isolates in southern taiwan, an area with higher tuberculosis incidence and mortality than other regions of the island, we performed a hospital-based surveillance at a southern taiwan medical center from to . the combined drug resistance rates to at least one of five first-line agents was . %, and to both isoniazid and rifampin (multi-drug resistance, mdr) was . %, indicating high resistance rates compared with those reported in the who/iuatld global project and in northern taiwan. the resistance rates to two second-line drugs, cycloserine, and kanamycin, were . and . %, respectively. a significant decreasing trend in resistance rates to all drugs except streptomycin was observed during the -year period. though combined drug resistance rate may not be the most accurate tool as it includes previously treated cases which inflates the resistance rate, the observation of trends in the susceptibility of pulmonary tuberculosis in accompany with the increasing percentages of tuberculosis patients receiving complete treatment course and the decreasing percentages of cases lost of follow-up in kaohsiung after the institution of new governmental regulations for case management in suggest the usefulness of intervention programs. lipid profile in patients with multidrug resistant pulmonary tuberculosis ps extrapulmonary tuberculosis may sometimes present with confusing clinical manifestations. a -year-old female patient was admitted with a history of recurrent supra-sternal abscess for year. mri confirmed the presence of sternal osteomyelitis and an anterior mediastinal mass. the diagnosis of tuberculosis was proved by histologic examination and acid-fast stain. the patient was treated with first-line agents, which isoniazid, rifampin, pyrazinamide, and ethambutol. tobacco smoking as a factor of the decrease of chemotherapy effectiveness and of the development of the drug resistance in patients with pulmonary tuberculosis ps shprykov as a , zhadnov vz a , shprykova on b . a medical academy, department of tuberculosis and lung diseases, nyzhny novgorod, russian federation , b medical clinic for infectious # , laboratory of bacteriology, nyzhny novgorod, russian federation studies of the effect of smoking on the results of chemotherapy of patients with tuberculosis of lungs. intensive tobacco smoking slowed down clearance of positive sputum and of lung tissue destruction (in smokers . % and . vs. . % and . % in nonsmokers, p b/ . ). drug-resistant mtb strains have been found to be isolated more often in smokers */ . vs. . % in non-smokers, p b/ . . resistance to streptomycin and isoniazid prevailed, reaching in heavy smokers . and . %, respectively. resistance to rifampicin increased . times. the concentration of rifampicin in the blood serum of heavy smokers decreased in . times. clinical data are in complete correlation with the findings of our experiments: % of experimental cultures developed resistance to streptomycin, isoniazid and less to rifampicin in the study of drug sensitivity under the effect of tobacco smoke condensate. thus, our findings show the development of drug resistance in mtb under the effect of components of tobacco smoke and also showed less effectiveness in therapy. kilani kb, ammari la, tiouiri ht , ben chaabène tbc. rabta hospital, infectious diseases, tunis, tunisia guerrero c a actinomycosis is a chronic disease characterized by abcess formation, tissue fibrosis and draining sinuses. it is caused by anaerobic bacteria belonging to the genus actinomyces. thoracic actinomycosis may involve the lungs, pleura, mediastinum or chest wall. the authors present a case of pulmonary actinomycosis complicating a cervicofacial site. a -year-old man with a history of cervicofacial actinomycosis treated by penicillin g years ago was admitted because of right-sided chest pain for months before presentation, cough and fever. physical examination shows a painless indurated mass in the neck with multiple fistula of the sternum. chest radiograph and ct scan revealed a mass in the upper lobe of the right lung with an infiltrate of the upper lobe of the left one. magnetic resonance imaging confirms the previous lesions, with extending process to the sternum and right collar bone. bronchoscopy was performed while patient was on antimicrobial therapy. culture of bronchoalveolar lavage fluid was negative. transbronchial biopsy was not conclusive. fungal serologies were negative for aspergillosis, histoplasmosis, blastomycosis. bacterial examination of purulent drainage from sternal wound shows inclusion bodies identified as actinomyces. he was treated then with penicillin iv for months, than switched to doxycycline. after months of treatment, he is asymptomatic with radiological improvement. kanellopoulou m a , skarmoutsou n a , iglezos i b , mylona e a , martsoukou m a , apostolopoulou f b , papafrangas e a . a laboratory of clinical microbiology, sismanoglio general district hospital of attica, athens, greece , b nd department of pneumology, sismanoglio general district hospital of attica, athens, greece introduction: achromobacter xylosoxidans is a rare human pathogen. it is an important cause of bacteremia in patients with cardiac diseases, malignancies and immunosuppression. it has been recently recognized as an emerging microorganism in cystic fibrosis (cf), whose its pathogenic role is unknown. aim: to investigate the sensitivity to eleven different antibiotics of a. xylosoxidans strains isolated from adults with cf, during . methods: the susceptibility was tested by kirby bauer and microdilution methods (wider i, fransisco soria melguizo, s.a.), according to nccls recomendations. results: the resistance to antibiotics was as follows : gentamicin, tobramycin, aztreonam %, amikacin %, ceftazidime %, ticarcillin %, carbapenems, cotrimoxazole %, colistin % and piperacillin %. conclusions: ( ) a. xylosoxidans isolated from cf patients appeared resistant to the most usually tested antibacterial agents. ( ) colistin which is used as aerolized antibiotic for cf patients seems to be effective in the half of the isolated strains. ( ) piperacillin was the most active antibiotic against a. xylosoxidans . morris ka, perry jd, jain s, gould fk. microbiology department, freeman hospital, newcastle upon tyne, uk alafosfalin, l-alanyl-l- -aminoethylphosphonic acid, is an antibacterial peptide mimetic which inhibits peptidoglycan biosynthesis. we report the in-vitro activity of this compound in combination with ceftazidime, cefsulodin, fosfomycin, piperacillin/tazobactam, aztreonam, ciprofloxacin and timentin. drug combinations were evaluated against burkholderia cepacia strains, and pseudomonas aeruginosa strains isolated from patients with cystic fibrosis. for this purpose a chequerboard technique was adopted using doubling dilutions of each antibiotic incorporated into a highly defined agar medium free of antagonists. the minimum inhibitory concentrations (mics) and fractional inhibitory concentrations (fics) of all the antibiotic combinations were determined which revealed the antibiotic interaction occurring. alafosfalin in combination with ceftazidime, meropenem, piperacillin/tazobactam and timentin demonstrated the highest percentages of synergy in both b. cepacia and p. aeruginosa . synergy was shown to occur in , , and % of b. cepacia strains respectively, and in , , and % of p. aeruginosa strains. these four combinations were re-tested with all isolates and the results were shown to be reproducible. alafosfalin shows potential as a treatment for cystic fibrosis patients colonised with p. aeruginosa and/or b. cepacia , when applied in combination with these agents. community-acquired pneumonia */does its aetiology matter? ps lintmaer i, popescu a, popescu c. institute of infectious diseases matei bals, unit , bucharest, romania the aetiology of a pneumonia is not one of the criteria used to determine pneumonia's severity. however, it is accepted that identified based Á/based therapy is less expensive (and possibly more effective). objectives: our study aims were to: ( ) to evaluate the role of aetiology identification in pneumonia; ( ) to evaluate the first-line therapy in pneumonia. methods: we conducted a retrospective study in an infectious diseases hospital on patients with pneumonia. we excluded all the cases with nosocomial pneumonia. primary end-point was the day clinical failure (deaths, icu admission), secondary end-points were the average time of fever and length of stay and the antimicrobial regimen changes. results: causative agent identification rate was . %. the evolution was different for patients with identified aetiology compared with other patients in terms of: -day failures, length-of-stay and changes of the antimicrobial regimen. the patients with inadequate first-line therapy had a more severe course of illness with a greater rate of day clinical failure, longer fever and length-of-stay. conclusions: pneumonia's treatment was better for the patients with identified causative agent. that is why we should include aetiology among the pneumonia severity criteria, especially at an 'after -day therapy' re-evaluation. results: pneumomococcal aom was detected in children ( . %) and s.pn. was the only pathogen in . %. the resistance rates of the organism to antibiotics were as follows: penicillin . % (micb/ mg/ml; intermediately resistant . %, mic . mg/ml . %, and mic!/ mg/ml; highly resistant . %), erythromycin . %, clindamycin . %, cotrimoxazole . % and chloramphenicol . %. all isolates were uniformly susceptible to rifambicin and vancomycin. the large majority of pneumococcal isolates ( . %) had the mphenotype and the remaining strains ( . %) the constitutive mls phenotype. a various of serogroups were detected; the serogroup was the most predominant one ( . %), followed by serogroups ( . %), ( . %) and ( . %). the non-typable s.pn. strains compromised the . % of the strains. conclusions: high prevalence of resistance to penicillin, macrolides and cotrimoxazole in pneumococcal aom of childhood was recognized. a strategy for preventing aom caused by drug-resistant pneumococci is mandatory to start. material and methods: a total number of strains were examined. the sensitivity test was performed by kirby bauer, microdilution method (pasco, difco) according to nccls guidelines and by e -test. results: a percentage of . % of s. pneumoniae strains revealed high level resistance to penicillin (mic]/ mg/ml), while the % showed intermediate resistance (mic . Á/ mg/ml). the resistance to erythromycin and cotrimoxazole was . % (mic ]/ mg/ml) and . % (mic]/ / mg/ml), respectively. all strains were sensitive to cefotaxime (mic . mg/ml), vancomycin (mic / . mg/ml), meropenem (mic / . mg/ml) and levofloxacin (mic / mg/ml). conclusions: ( ) the prevalence of high resistance s. pneumoniae to penicillin seems to be low in examined strains ( . %). ( ) intermediate resistance to penicillin of s. pneumoniae isolates was high as expected ( %). ( ) most of the strains were sensitive to erythromycin ( . %) and cotrimozaxole ( . %). ( ) s. pneumoniae isolates were completely ( %) sensitive to levofloxacin, vancomycin and meropenem. beghi g, aiolfi s, maghini l, patruno v, aiolfi e. s marta hospital, pulmonary rehabilitation unit, a.o., rivolta d'adda, italy aim: of this study was a retrospective ( Á/ ) evaluation of the more effective and practical antibiotic treatment in ae-copd patients (pts) admitted to our unit. methods: before introducing any antimocrobial drug, sputum specimens were collected for microbiological purposes, while blood analysis, to monitor adverse systemic effects, were performed at the beginning and the end of treatment. antibiotic treatment ranged from to days according to four regimens: regimen a ( pts) /oral therapy only: . % with amc g b.i.d.; . % with cip mg b.i.d.; . % with dox mg u.i.d.; . % with lev mg u.i.d.; . % with cla mg b.i.d.; . % miscellaneous. regimen b ( pts) /sequential therapy (e.v. for days /oral): . % with amc g b.i.d.; . % with cla mg b.i.d. regimen c ( pts) /e.v. therapy only: same drugs. regimen d ( pts) /an association of two antibiotics. results: of evaluated pts, only ( . %) required a second regimen of treatment because of failure of the previous one: . % of regimen a; . % of regimen b; . % of regimen c, and % of regimen d. mild adverse effects were detected only in four pts. our results confirm that oral antibiotic treatment is practical, safe, and effective, and can be considered as the first line regimen also in hospitalized patients with ae-copd. becher g a , gillissen a a , rothe m b . a st. george medical center, robert-koch-hospital, leipzig, germany , b filt, lung and chest diagnostics ltd., berlin, germany patients with severe form of chronic obstructive pulmonary disease (copd) are prone by frequent exacerbations. bacterial infections are judged to cause at least half of exacerbations. haemophilus influenzae and streptococcus pneumoniae are the most frequent isolates, gramnegative bacilli account for the severe cases, aggravating the inflammatory process in the airways eventually leading to respiratory insufficiency. the aim of this ongoing placebo controlled, parallel group, mono center study trial is to evaluate beneficial effect of cefixim to reduce bacterial load and pulmonary inflammation in patients (n / ) with acute bacterial exacerbation of severe copd. thus, patients received in randomized fashion either cefixim ( mg/day) or placebo ( days). on days , , and breath condensate is collected using 'ecoscreen' (jaeger germany) for ltb -, il- -, nitrite-and ph-analysis. in parallel sputum gathered for detection of bacterial strains, and for ltb -, and il- quantification purposes. these data are compared to clinical outcome parameters such as lung function tests, radiographic findings, serum inflammatory markers and length of hospital stay. the preliminary data obtained confirm successful antibiotic therapy with oral cefixim in bacterial related acute exacerbations of copd is a useful approach to reduce bacterial load, and concomitantly lower inflammatory indices of the central and peripheral airways leading to clinical improvement of the patients. soriano garcia f a , fenoll a b , fernandez-roblas r a , coronel p c , gimeno m c , rodenas e c , garcia m a , granizo jj d . a fundacion jimenez diaz, microbiology, madrid, spain , b instituto de salud carlos iii, centro nacional microbiologia, majadahonda, spain , c tedec meiji farma, scientific, alcala de henares, spain , d fundacion jimenez diaz, epidemiology, madrid, spain purpose: to describe the susceptibility of streptococcus pneumoniae against cefditoren and other antimicrobials by serotype a multicenter study in south europe was carried out. a total of strains were collected between september and march from adult patients (more than y.o.) with respiratory tract infection (respiratory tract samples and blood cultures). all the isolates were sent to a central laboratory (fundació n jiménez díaz, madrid, spain) where susceptibility test was performed by broth microdilution (sensititre) following nccls recommendations. serotype was determined by quellung reaction and dot assay in carlos iii institute in strains. results: a total of strains ( . %) were not typable. the most prevalent serotypes were ( . %), ( . %), ( . %), ( . %), ( . %) and ( . %). two hundred and sixty-four strains were grouped in different serotypes. the proportion of susceptible strains by serotype to penicillin, erythromycin and levofloxacin were: serotype ( . , . , %); ( . , . , . %); ( . , . , . %); ( . , . , . %); ( . , . , . %); ( . , . , . %). the mic to cefditoren was / . (serotype ); . (serotype , and ) and mg/l (serotype and ). conclusions: the most prevalent serotype was . the susceptibility was higher in serotype than in serotypes and . community acquired pneumonia */a study among closed military community of young people ps martynova av, turkutyukov vb, vostrikova aa, andryukov bg. vladivostok state medical university, epidemiology, vladivostok, russian federation purpose: the etiology of pneumonia is still partly unknown. we should like to clear up an etiological role of respiratory pathogens in community-acquired pneumonia among youth. and we had chosen for it a model of a closed community both investigation of etiology of disease and for further investigation of mechanisms of transmission drug-resistant mechanisms. methods: we studied adults in age of Á/ from closed military collectives who presented to two public hospitals (one urban and one rural) with acute radiologically confirmed pneumonia during winter Á/ . we did blood and lung-aspirate cultures, mycobacterial cultures, serotype-specific pneumococcal antigen detection, and serology for viral and atypical agents. results: streptococcus pneumoniae is recognized as an important cause of community-acquired pneumonia, it probably accounts for % of cases of community-acquired pneumonia among youth. chlamydia pneumoniae and mycoplasma pneumoniae responsible for approximately % of cases. haemophilus influenzae caused . % sever cases of disease, % of all cases were due to moraxella catharralis . conclusion: pneumococcial infection accounted for % of the cases diagnosed. s. pneumoniae was the most common bacterial infective agent, with a low incidence of both m. pneumoniae and s. pneumoniae . other causative pathogens occurred only within groups of individuals with deficiency of immunological status. berezin en a , cardenuto md a , nobuko e b , guerra ml c , brandileone mc d . a santa casa, pediatrics, s. paulo, brazil , b santa casa, microbiology, s. paulo, brazil , c adolfo lutz, microbiology, s. paulo, brazil , d adolfo lutz, bacteriology, s. paulo, brazil to determine antimicrobial susceptibility of sp isolated from the upper respiratory tract, we collected np swab specimens from children, between months and years old. those children attended the outpatient clinic in s. paulo city, with diagnosis of bacterial infection requiring antibiotic therapy between march , to may , . penicillin susceptibility of isolates was determined by screening with oxacillin mcg disk and performing the minimal inhibitory concentration by the e -test. we performed also susceptibility test for amoxicillin and cefaclor. results: sp was recovered from np of children ( . %). the carriage of sp was more prevalent in children attending day care centers, children with young siblings at home, and children with tobacco users at home. the prevalence of penicillin non-susceptible strains was . % all of them with intermediate resistance. all the strains were susceptible to amoxicillin and . % were resistant to cefaclor. serotypes . b, f, n, , a and were the most common. these findings suggest that nasopharyngeal isolates of streptococcus pneumoniae from children with upper respiratory infections can be used to conduct surveillance for antimicrobial resistance in a defined geographic area. we were able to conclude also that penicillin intermediate resistent strains can be susceptible to amoxicillin. hinojosa rm a , saenz a a , collazo m a , echaniz g b . a universidad autonoma de nuevo leon, infectologia, monterrey, mexico , b instituto nacional de salud publica, epidemiologia, cuernavaca, mexico the emergence of penicillin-and multidrug-resistant pneumococcal strains has become a global concern, necessitating the identification of the epidemiological spread of such strains. material: ninety streptococcus pneumoniae clinical isolates were collected from march through march . typing was done by the capsular reaction with pooled, type, or group antisera. susceptibility testing to antimicrobials was done by the e -test and the disk diffusion method. results: only ( %) s. pneumoniae strains were classified by serotyping; the most frequent types were a/b, f, v, f and . the oxacillin screening test detected . % penicillin-resistant s. pneumoniae strains isolated from children and . % from adults. the susceptibility percentage of s. pneumoniae to ceftriaxone was % in both children and adults. s. pneumoniae isolates from children exhibit a susceptibility of % to azithromycin, while in adults % of the isolates were susceptible. for the rest of the antimicrobial agents, the susceptibility ranged from to %. s. pneumoniae had a lower susceptibility to ceftazidime and ciprofloxacin. conclusions: ceftriaxone and azithromycin had a good in-vitro activity against s. pneumoniae strains. but the percentage of penicillinresistant s. pneumoniae detected in this study is alarming, therefore we conclude that a continuous surveillance system is necessary in mexico. vertkine al, prokhorovitch ea, alexanyan la. a retrospective analyses of cases of ambulant pneumonia with fatal outcome was made. among the patients who died from ambulant pneumonia the prevailing age was over ( . %) and the prevailing sex was male ( . %). . % had pneumonia accompanied with some pathology: chronic lung disease ( . %), alcoholism ( . %), diabetes mellitus ( . %). . % of the patients had a big volume of lungs lesion */ . % of the patients suffered from bilobular pneumonia and . % */from trilobate pneumonia. in . % of the cases pneumonia was complicated with abscess formation and/or exudative pleurisy. we studied the antibiotics therapy used for the patients treatment. the change of antibiotics was made only in cases ( . %) whereas in the other cases no change of preparations was made though the signs of the therapy non-effectiveness were obvious. thus, the rational antibiotics therapy with the timely change of non-effective antibacterial drug is significantly important. while choosing the antibiotics, the patient's age, the accompanying diseases, the volume of the lungs lesion and complications which define pneumonia seriousness are to be taken into consideration. perronne c a , rouveix b b , guillemot d c , zuck p d , reitz c e , tsatsaris a e . a hôpital raymond poincaré, service de maladies infectieuses, garches, france , b hôpital cochin, paris, france , c institut pasteur, paris, france , d hôpital de metz, metz, france , e laboratoires abbott, rungis, france objectives: to describe the management of lower respiratory tract infections (lrti) in healthy adults, by general practitioners (gp). methods: a questionnaire was sent to a representative national sample of gps. this questionnaire assessed their perception and management of lrti, the indication for antibiotics (ab) in a case of lrti in a healthy adult with no focal signs and no signs of severity, knowledge of the micro-organisms responsible for acute bronchitis and knowledge of the afssaps (french agency for the safety of health products) recommendations. results: three thousand seven hundred and thirty-eight gps, who reported seeing an average of patients per week, including . / . patients with lrti, returned the questionnaire. the main results are presented in the following for the majority of gps, the main objective of the visit is to determine the indication for antibiotics. according to gps, alp and whooping cough are rare, while atypical pneumonia is frequent. gps also declare that the diagnosis of alp is often easy right from the first visit, in contrast with that of atypical pneumonia. complementary investigations are not often requested. gps consider that they often delay prescription of antibiotics ( %) and declare that they tend to prescribe a macrolide as first-line treatment. finally, gps have a poor knowledge concerning the micro-organisms responsible for acute bronchitis and the majority of gps declare to be familiar with afssaps recommendations. perronne c a , rouveix b b , guillemot d c , zuck p d , reitz c e , tsatsaris a e . a hôpital raymond poincaré, service de maladies infectieuses, garches, france , b hôpital cochin, paris, france , c institut pasteur, paris, france , d hôpital de metz, metz, france , e laboratoires abbott, rungis, france objectives: to study the management of one case of lower respiratory tract infection (lrti) in adults by general practitioners (gps). methods: prospective study conducted on a representative national sample of gps. each gp had to include the first healthy adult patient seen during the -week data collection period, either on a home visit or in the office for recent cough and acute fever !/ . c. clinical data, the diagnostic perception and the therapeutic approach to the patient were collected by means of a standardised questionnaire, distributed by abbott laboratories. results: three thousand seven hundred and thirty-eight general practitioners included patients. conclusions: during lrti in adults, gps observe few focal signs, confirming the marked predominance of bronchitis compared to pneumonia. in view of the frequency of the signs, the diagnosis of pneumonia appears to be overestimated. one-third of clinical situations were diagnosed as 'bacterial superinfection of acute bronchitis', despite it is not a recognised diagnostic entity. antibiotic prescription was immediate in % of cases and delayed in % of cases. this last point shows that clinical practice differs from the gp's perception of their described prescribing practice shown in a simultaneous survey ( % of gps declared that they prescribed antibiotics immediately, while % delayed this prescription). results: thirty-three patients ( men, mean age b years, mean apache ii score . &bdqup;b . ) during the years Á/ were prospectively studied. thirteen patients ( %) had no identifiable risk factor for severe cap. an etiologic factor was revealed in patients ( %). in of them this was achieved with noninvasive methods. psb cultures were taken from eight patients and were positive in only . the offending organisms included: streptococcus pneumoniae in six cases, gnb as the sole pathogen in six cases, haemophilus influenzae (with s. pneumoniae or klebsialla pneumoniae ) in two cases, s. aureus in two and legionella pneumophila in one patient. initial antibiotic regimen a combination of marcodile '/ rd gen cephalosporin /aminoglycoside was successful in patients who all survived and had to be changed empirically or according to culture results in patients who had a mortality of %. the overall mortality rate was %. the identification of the causative factor did not seem to have any impact on survival. conclusion: severe cap in our icu was most often caused by s. pneumoniae and gbn. the high mortality of this entity seems to be influenced by the immediate use of the appropriate antibiotic combination and not by the identification of the causative organism. this underscores the need for knowledge of topical microbiology which helps in designing an effective empirical initial antibiotic regimen. mily mn a , golubev sa b , lugovoy vy a , voronov gg b . a vitebsk emergency hospital, pharmacotherapy unit, vitebsk, belarus , b basic and clinical pharmacology department, vitebsk state medical university, vitebsk, belarus purpose: the study aims were to assess the spectrum and predictors of the antibiotic use during pneumonia management in a regional emergency hospital in belarus. patients, treatment and physicians characteristics of cases ( Á/ ) were collected and possible associations were examined with using defined daily doses methodology (ddd) and american thoracic society (ats) guidelines. results: the mean treatment duration was . / . days, the total antibiotic ddd/ bed-days was . . the ddd/ bed-days of the most used antibiotics were: penicillins . ; aminoglycosides . ; macrolides . ; cephalosporins . ; tetracyclines . . in manova certain ats categories were associated with ddd/day, but not with frequency of definite antibiotic use. ddd/day was higher in case of multilobar infiltrates ( conclusion: our study indicated the low rate of macrolides and cephalosporins using, and the high one of aminoglycosides. antibiotic prescriptions were associated with disease severity and physician personality rather then with empirical choice rules recommended. acute exacerbation of copd: most frequent infecting agents and their suspectability to the different types of penicillins. analysis of medical documentation ps pertseva to, bogatska ke, gashynova ky. dsma, internal medicine , dniepropetrovsk, ukraine number of copd cases has been increased in ukraine. treatment of acute exacerbation (ae) of copd is not always successful because of inadequate antibiotic therapy. the aim of study was to reveal most frequent infecting agents and their susceptibility to the different types of penicillins in patients with ae of copd. medical documentation of patients with ae of copd (type i) was studied. data of sputum analysis and susceptibility of isolated agents to penicillin, ampicillin, oxacillin and amoxicillin/clavulone acid were evaluated. there were patients with haemophilus influencae/parainfluencae ( . %), klebsiella pneumoniae ( %), staphylococcus aureus ( . %), pseudomonas fluorescens , pseudomonas putida , serratia marcescens , serratia liquefaciens ( . % each), streptococcus agalactiae , acinetobacter baumanii ( . % each) in samples of sputum. in . % cases there was mixt infection. . % had no any bacterial agents. only % of agents were susceptible to penicillin, % */to ampicillin, % */to oxacillin. however, % of microorganisms were susceptible to amoxicillin combined with clavulone acid. this study has shown that most frequent infecting agents caused ae of copd were gram-negative microorganisms and s. aureus . according to antibiogram the prescription of amoxicillin/clavulone acid is most expedient in this case. pertseva to, bogatska ke, konopkina li, kireeva tv, gashynova ky. dsma, internal medicine department, dniepropetrovsk, ukraine we examined patients ( men, mean age . / . years) with acute exacerbation of cob (type i). the most frequently isolated agents were haemophilus influenzae and parainfluenzae */eight patients, gram-negative rods in , staphylococcus aureus in two and mixed in six and one patient had no bacterial agents isolated in their sputum. high susceptibility to azithromycin was found in all cases of gram-positive agents and in h. influenzae and parainfluenzae . other gram-negative agents were resistant to this drug in vitro. however, treatment with mg/day during days was clinically effective in . % of cases. only . % of patients had a further acute exacerbation of cob. there were peculiarities of the infecting agents causing acute exacerbation of cob in this study: klebsiella pneumoniae and s. aureus were found more frequently than in other studies. high efficacy of surnamed in the treatment of acute exacerbation of cob was established in . %. . % had partial positive clinical effect after this therapy. there were no patients with adverse events. efficacy and tolerance of amoxicillin mg/kg bid versus amoxicillin mg/kg tid in the treatment of acute otitis media (aom) in children / years ps borek m a , guggenbichler jp b . a biochemie gmbh, international medical department, kundl, austria , b department of pediatrics, university of erlangen, erlangen, germany five hundred and sixteen patients (mean age / . years) with clinical and otoscopic diagnosis of aom were included in a randomized, double blind, multicentre study, and were treated days either with amox mg/kg bid or amox mg/kg tid. assessments were made during therapy (day Á/ ), after end of therapy (eot, day Á/ ) and follow up (fu, day Á/ ). the primary efficacy endpoint was the clinical response at eot defined as success (cure/improvement) or failure. both regimens were well tolerated; one or more drug-related adverse events (aes) were reported in . % ( / ) of bid patients and in . % ( / ) of tid patients. the most frequently reported drugrelated aes in each group were gastrointestinal symptoms (bid . % vs. tid . %), which were mainly of mild or moderate severity. both regimens were clinically equivalent. the higher cure rates in the bid group suggest a possible higher benefit from bid therapy in children / years. children attending family day-care (fdc) should be less exposed to upper respiratory tract infections than those in group day-care (gdc) and therefore to antibiotic treatment; fewer should thus carry resistant bacteria. to test this hypothesis, np carriage of sp and hi with reduced susceptibility to penicillin (pdsp and hi bl'/, respectively) was investigated among children in fdc (maximum three children) and in gdc ( Á/ children) in the alpes maritimes (france) between november and march . a two stage cluster sample of children attending gdc or fdc was selected. np samples were cultured for sp and hi. penicillin susceptibility was tested by disk diffusion and e -test, and b-lactamase production by api-nh † tests (biomerieux, lyon). two hundred and thirty-five children in fdc and in gdc aged Á/ months were sampled. age and sex distribution were similar in both groups. sp was isolated in children in fdc ( %), and in ( . %) children in gdc (p b/ Á/ ). proportions of pdsp were . and . %, respectively (p / . ). hi was present in . % of children in gdc vs. . % in fdc (p b/ . ). proportions of hi bl'/ were . % vs. . %, respectively (p / . ). antibiotic exposure during the previous months concerned . % of children in gdc vs. . % in fdc (p / . ). there was no correlation between antibiotic use and carriage of pdsp or hi b'/ strains. sp and hi carriage rates are significantly lower among children in fdc than in gdc. advising alternative types of daycare for children attending gdc should reduce exposure and thus limit the spread of resistant bacteria. however, the proportion of pdsp and hi bl'/ is similar in both groups and comparable patterns of antibiotic use are observed. continued efforts must concentrate on parental education and enforcement of recommendations for management of pediatric upper respiratory tract infections. during a period between january and august , invasive haemophilus influenzae (hi) isolates had been collected at the children's hospital of tunis. we used haemophilus test medium to test antibiotic susceptibility. the mic of beta-lactams was measured by e -test. beta-lactamase production was determined by using the cefinase test and biotyping by apinh. presence of capsular antigen was determined by using hi typing anti sera. hi strains were isolated from meningitidis ( ), bacteremia ( ) and arthritis ( ). all strains were serotype b and . % of them belonged to biotypes i and ii. amoxicillin resistance with beta-lactamase producing mechanism occured in . %. mic of beta-lactamase producing strains was vs . mg/l in non-producing one. there is no betalactamasenegative amoxicillin resistant among these invasive isolates. antibiotic resistance concerned chloramphenicol: . %, trimethoprim-sulfamethoxazole: . %, tetracycline: . % and kanamycin: . %. invasive hi infections in tunisian children's were always associated with type b strains. introduction of a hib vaccine programme in tunisia is recommended. the aim of this study was to analyse the clinical picture and treatment of neurological manifestations of neuroborreliosis in children. the study included children ( Á/ years) with neuroborreliosis diagnosed on the basis of the clinical and serologic criteria. symptoms of facial palsy occurred in six children symptoms of iii Á/vi cranial nerves palsy in three children, meningitis in four and paresthesias in three. symptoms of v or viii nerve palsy, mental disturbances, radiculoneuritis or cerebellitis were found in singular cases. all children received ceftriaxone intravenously Á/ weeks. total recovery was obtained in children following the first course of therapy. recovery following the second course of therapy (amoxicillin) occurred in one child with mental disorders and one with vi nerve palsy. improvement was achieved after the second course in the patient with radiculitis, however, muscular atrophy persisted. irreversible, unilateral deafness was found in a child with viii nerve palsy in spite of three courses of therapy applied. infection with borrelia burgdorferi in children causes a wide spectrum of neurological manifestations. facial palsy was the most common sign in our study. applying ceftriaxone in the treatment of neuroborreliosis is characterised by a good effectiveness. double infection by c. pneumoniae and m. pneumoniae as a cause of cystic changes in the lungs ps streharova a, moravcikova d. department of infectious diseases, university of trnava, trnava, slovakia chlamydia pneumoniae and mycoplasma pneumoniae are human respiratory pathogens manifested in early childhood. immunological disbalance could trigger autoaggressive diseases. the authors describe the case of a -year-old girl with development of multiorgan failure and septic state, which followed multiple cystic changes in the lungs. the girl did not have a diagnosis of cystic fibrosis. the authors consider that cystic changes are a consequence of double infection by c. and m. pneumoniae. dzarlieva m, momeva l, temelkovska g, balevska p, pejkovska m. medical centre, neonatology, bitola, the former yugoslav republic, macedonia unicef skopje has supported a nationwide safe motherhood needs assessment in representative samples of hospitals. eighteen of maternity wards and facilities renovated and certified as 'babyfriendly'. all mature newborns with successful adaptation to extra uterine life and satisfactory vital parameters are h during the day with their mothers at rooming-in system. aim: with rooming-in system we reached decreasing of incidence of neonatal infections. material and methods: history records of newborns from our department. for the period of months, neonates have been borne. with suspection of infection there */ babies ( . %). newborns borne through meconium stained liquid */ ( . %). results: microbiological findings: from blood culture */staphylococcus coagulaza negative from swabs */staphylococcus aureus , escherichia coli , staphylococcus epidermidis. conclusion: in , from all babies who had risk factors for infection in newborns ( %) we had positive findings and in year (before rooming-in sistem), in ( . %). after that period (with rooming-in) newborns ( . %). with rooming-in system we reached decreasing in incidence of neonatal infections by breaking the chain of infection */only mothers take care of their babies with help of the staff. newborns are in their micro environment, the same they will have at their home. with this practice we have also reduction of nosocomial infections. a study on antibiotic susceptibility and resistance factor transmissibility among antibiotic resistant salmonellae isolated from children affected to diarrhea ps sharifzadeh a. azad university of shahrekord, microbiology, shahrekord, islamic republic of iran in spite of happened drug resistance, antibacterial therapy still is the best route of treatment of salmonellosis in man and animals. in order to detection of dominants serotypes of salmonellae in children and detection of antibiotic susceptibility and r-factor transmissibility among those isolated salmonellae. this study was conducted on diarrheic stool samples were collected from children affected by diarrhea in ayatollah kashany hospital of shahrekord, during spring of to autumn of . after isolation and identification of salmonellae, seven serotypes were detected. one of those was s. typhi and another six serotypes were s. paratyphi b . in order to detection of antibiotic different antibiotic disks were used in disk diffusion method. best results were taken from ceftizoxim, cephtriaxon, cephazolin and chloramphenichol. the r-factor were transferred from isolated salmonellae to escherichia coli k in all of cases of resistance to penicillin and ampicillin. pharyngeal colonization by streptococcus pneumoniae and group a bhs were evaluated in randomly selected school children aged Á/ years in riyadh, saudi arabia. fifty-six children ( . %) had positive culture for either organisms of the isolates from school children, ( %) were s. pneumoniae , of them ( %) were penicillin-sensitive, three ( %) were penicillin-resistant, and two ( . %) were resistant to two antimicrobials. forty isolates of bhs ( %) were group a bhs. all isolates were penicillin and erythromycin sensitive. the carrier rate among school children for penicillin-resistance s. pneumoniae and resistance to two antimicrobials were ( . %) and ( %), respectively. the carrier rate of group a bhs was ( . %). riyadh has a low rate of antibiotic-resistant s. pneumoniae and a similar rate of group a bhs carriers among school children as that seen in temperate areas. boukadida j a , boukadida n b , hannechi n a , said h b , erraii s a , elmhabrech h a . a chu f. hached, laboratoire de microbiologie, sousse, tunisia , b c s base, sousse, tunisia the acute pharyngitis is a very frequent pathology in which group a streptococcus is the most incriminated bacteria. however, other non a b-haemolytic streptococcus (sbna) could be responsible. the aim of this work is to determine the part of each non a b hemolytic streptococci (sbna) in acute pharyngitis and the related antibiotics susceptibility pattern. the study was realized in sousse-tunisia (north africa) during months from may . the origin materials of isolates are throat swab (transystem venturi, copan, bovezzo). the mean age of patients is years with extremes Á/ years. the samples are cultured on blood agar plates in a delay of h maximum. identification was done to samples that have over than b-hemolytic colonies, groupage with pastorex strep. sanofi pasteur france, susceptibility pattern according to nccls norms, mic is determined by e -test. the control strain is s. pneumoniae atcc . twentyone clinical isolates of sbna are distinguished from clinical isolates of b-hemolytic streptococci recovered from patients with acute pharyngitis without symptoms of viruses' infections (tearing, corysa, sneeze). all b-hemolytic streptococcus represents . % of all collected samples. sbna were . % of the isolates. sbna were strains group g streptococci, seven strains group c streptococci and three strains group f streptococci. susceptibility pattern of each sbna to antimicrobial agents is as follow: group g streptococci: peni g / %, amoxicillin / %, pristinamycin %, clindamycin and erythromycin / . %, tetracyclin / . %, telithromycin . % and levofloxacin / . %. group c streptococci: peni g / %, amoxicillin / %, pristinamycin %, clindamycin / . %, erythromycin / . %, tetracyclin / . %, tel-ithromycin / . %, levofloxacin / %. group f streptococci-peni g / %, amoxicillin / %, clindamycin / . %, erythro / . %, tetracyclin / . %, telithromycin / %, levofloxacin / . %. all sbna have mic to penicillin g under . mg/l. according to available data, penicillin g and amoxicillin still the reference treatment of acute bacterial pharyngitis in spite of the new antibiotics introduction. berezin en a , quevedo sg b , nicolla l b , viegas d c , eizenberg b d , pedrosa f b , santos ag a . a santa casa, pediatrics, s. paulo, brazil , b elly lilly, scientific, s. paulo, brazil , c fac. abc, pediatrics, santo andre, brazil , d university hospital, pediatrics, s. paulo, brazil a multicenter, open label, prospective, randomized trial in which patients Á/ years of age with proven gabhs pharyngitis were randomized to receive either -day course of the broad spectrum oral cephalosporin, cefaclor or a -day course of amoxicillin. patients were included if they have signs and symptoms of streptococcal tonsillopharyngitis and a rapid streptococcal rapid test positive . patients were evaluated at days Á/ , Á/ and Á/ posttherapy. pharyngeal cultures were conducted at baseline and at follow-up visit ( Á/ days). we considered for bacteriologic eradication analysis only patients with positive culture to gabhs. there were patients with a rapid streptococcal rapid test. clinical success were achieved in around % of the patients. for evaluate eradication of the initial pathogen we considered patients of the amoxil arm and patients of the cefaclor arm. thirty-four of patients of the amoxil arm ( . %) and of ( %) patients of the cefaclor arm were considered bacteriological cured at the second culture performed at day Á/ . ten days of a penicillin or amoxicillin therapy may not be the best therapeutic choice for all pediatric patients. in developing countries where rheumatic fever is still an important problem to evaluate the bacterial eradication achieved with the different antibiotics may be important. prophylactic affect of saccharomyces boulardii for antibiotic-associated diarrhea in a paediatric age group ps erdeve o, tiras u, camurdan mo, tanyer g, dallar y. ankara education and research hospital, pediatrics, ankara, turkey the process resulting in antibiotic associated diarrhea is the alteration of enteric flora due to bacteria. saccharomyces boulardii is a yeast, isolated from cover of a kind of hazelnut and its usage became widespread recently. there is no enough study about s. boulardii activity at pediatric ages. we aimed to define s. boulardii activity on azithromycin and sulbactam-ampiciline, and associated diarrhea at pediatric age group. the . % of cases only with antibiotic usage developed diarrhea, whereas rate was . % for probiotic using group (p b/ . ). all of the clostridium difficile toxin a defined cases were from sulbactam-ampiciline using group. the rate of diarrhea for sulbactam-ampiciline using group was . %, while it was . % for group used s. boulardii as probiotic beside sulbactam-ampiciline (p b/ . ). it was observed that probiotic usage decreases diarrhea rate four times (p b/ . ). when age groups considered, the rate of sulbactamampiciline associated diarrhea increased at Á/ ages and s. boulardii effect on preventing diarrhea was significant at Á/ ages (p b/ . ). antibiotic associated diarrhea is a common clinical problem at pediatric age group. s. boulardii is a hope giving probiotic especially for sulbactam-ampiciline associated diarrhea. grey e a bilikova e a , hafed bm a , kovacicova g a , chovancova d b , huttova m b , krcmery v a . a school of health, trnava university, trnava, slovakia , b postgraduate academy of medicine, neonatal clinic, bratislava, slovakia the purpose of the study: the aim of the study was to find out, whether artificial abortion of a mother has impact on neonatal infection of her future baby. the results obtained: therefore, we compared neonates with infection, who were born to mothers with past history of abortion ( Á/ artificial abortions within years), with the babies of mothers, who have not experienced abortion before. control group consisted of neonates hospitalized at the same clinic, at the same time period. according to the analysis of risk factors for neonatal infections, it was found, that prematurity ( Á/ weeks of gestation) ( . vs. . %, p . ) and low birth weight- Á/ g ( . vs. . %, p . ) were significantly more frequently observed in babies of mothers with past history of abortion. drug abuse (heroin) ( . vs. . %, p . ) and nicotine use ( . vs. . %, p . ), were more significantly related to neonatal infections in babies of mothers with past history of abortion. etiological analysis showed that only candida albicans ( . vs. %, p . ) was significantly related to neonatal infections in mothers with past history of abortion. the conclusion reached: in conclusion, artificial abortion has not only direct impact to the health of the mother, but also on her next pregnancy. bacteraemia and patient mortality in a peadiatric intensive care unit ps armenian sh, singh j, arrieta ac. children's hospital of orange county, infectious disease, orange, usa purpose: this study will identify the factors that significantly contribute to mortality in patients with bloodstream infections (bsi) at a pediatric intensive care unit (picu). results: medical records of patients who were admitted to the picu and had a documented bsi were reviewed. there were separate episodes of bsi's, with nine patients having multiple bsi's during their hospital stay. a casecontrol model was used. cases were bsi's with eventual mortality (n / ; . %) and controls were those who survived bsi (n / ; . %). patients who died were older ( . vs. . years; pb/ . ), more likely to have a nosocomial bsi ( . vs. . %; pb/ . ), longer hospitalization prior to bsi ( . vs. . days; pb/ . ), and have a polymicrobial bsi ( . vs. . %; pb/ . ). infection related mortality (irm)-defined as death within days of bsi */was significantly higher in those receiving inadequate antibiotic treatment at the time of diagnosis of bsi ( . vs. . %; p b/ . ), as well as in those with gram negative bacteremia and/or fungemia ( vs. %; p b/ . ). logistic regression was used to adjust for potential confounding variables. conclusions: we found that being older, multiple organisms, and a longer hospitalization prior to the bsi were significantly associated with overall patient mortality. irm was significantly higher for those with inadequate initial antibiotic coverage and in those with gram negative bacteremia and/or fungemia. somer a a , gü r d a , diri s a , yalcýn i a , salman n a , ongen b b , gü rler n b . a department of pediatric infectious diseases, istanbul university istanbul medical faculty, istanbul, turkey , b department of microbiology and clinical microbiology, istanbul university istanbul medical faculty, istanbul, turkey teicoplanin is a glycopeptide antibiotic active against a broad range of gram-positive pathogens including methicillin-resistant staphylococci and offers the advantages of once daily administration, choice of administration route, lack of requirement for routine therapeutic drug monitoring and lower propensity to cause nephrotoxiticy and anaphylactoid-like reactions. in this study the efficacy and safety of teicoplanin were evaluated retrospectively in children with serious bacterial infection. sixty-three children ( girls, boys) aged between month and years were treated with teicoplanin (three loading dosages of mg/kg at h intervals, followed by a maintenance dosage of mg/kg/day). the infections treated were pleural empyema (n / ), joint and bone infections (n / ), septicemia (n / ), skin and soft tissue infections (n / ), and lung abscess (n / ). the pathogens isolated were staphylococcus aureus (n / , of which were methicillin resistant), coagulase-negative staphylococci (n / ), s. pneumoniae (n / ), and group a hemolytic streptococci (n / ). the duration of therapy ranged from to days (median days). clinical success (cure plus improvement) was achieved in . % of cases. no side effects attributable to teicoplanin therapy were encountered. teicoplanin appears to be an effective and well-tolerated treatment for serious gram-positive infections in children. the risk of infection is present in all children with acute leukemia. two hundred and sixty episodes of febrile neutropenia were analyzed in children (aged . Á/ years) with aml */ cases and all */ cases over years during cytostatic therapy (protocols: mbfm */ aml and mbfm */ all). a degree of fn occurred in % of cases in aml, in % */in all. the sites of infection were: blood'/ central venous catheter ( %) and respiratory tract ( %). pathogens isolated from blood were: gram-positive */cns */ %, streptococcus spp. */ . %, gram-negative */enterobacteria */ %, pseudomonas aeruginosa */ %, candida spp. */ . %, aspergillus spp. */ . %, other */ . %. for the treatment of fn we used empirical antibiotics regimens. clinical response was noticed: in st line of therapy */ cephalosporins Á/ generation used */ %, carbapenems used */ % as nd Á/ rd lines */vancomycin */ %, amphotericin b */ %. thirtytwo percent of children with aml and . % children with all died because of sepsis. conclusion: carbapenems are more active in the st line of antibiotics therapy both for patients with aml and all. vancomycin is useful in the nd line for patients with all. amphotericin b and vancomycin are useful in combination in the nd line for patients with aml. pavlenishvili ivp. medical academy, pediatrics, tbilisi, georgia our drug of choice in cases of complicated neonatal sepsis i. pavlenishvili, g, iobashvili tbilisi, medical academy georgian society of pediatrics chemotherapy (gspc) with collaborations of drug and therapeutic committee (dtc) of childers hospital 'republic' finished the observation study about nosocomial infections of neonatal icu in above mentioned hospital. study begins from november . during this period we observe cases of neonatal sepsis, most of them were due gram-negative bacteria. thirty-four cases of neonatal sepsis were cause different stains of escherichia coli , proteus spp. and acinetobacter . we notice that during last years the role of acinetobacter in etiology of neonatal sepsis and nosocomial complications of neonatal sepsis in our hospital is gradually increased. as our observation reveals most optimal in the case of complicated neonatal sepsis was (according criteria of dts) use of ceftasidime. almost in all cases we used ceftasidime with success. we have only one case of mortality. since the macrolide resistance (mr) in streptococcus pyogenes has been increasing in europe, we studied the incidence and genetic basis of mr in s. pyogenes in russia. s. pyogenes isolated at baseline and during follow-up visits from children with acute pharyngitis receiving penicillin or midecamycin ( -membered macrolide) were studied. mr was evaluated by agar dilution (nccls), resistance mechanisms */by pcr. a total of s. pyogenes were obtained at the baseline, ( %) of which were erythromycin-resistant: strains ( %) were erm (a)-positive, one */mef (a)-positive, and one was negative for all primers used. all erm (a)-strains were inducibly resistant to clindamycin and represented seven pfge profiles with one profile found in / strains. in three midecamycin treated patients mr was selected during the therapy (one strain had erm (a), one */mef (a), one */ unknown resistance determinant). mef (a)-strain obtained during follow-up visit had different pfge pattern with mef (a) strain isolated at baseline, while both the baseline and follow-up strains with unknown mechanism of resistance had unique pfge pattern. these data showed moderate incidence of erythromycin-resistant s. pyogenes in smolensk. ribosomal methylation (erm (a)) was the most common mechanism and though the polyclonal nature of mr was established, most erm (a)-strains belonged to only a few clones. bacillus cereus infections in traumatology-orthopaedy department: retrospective study and re-evaluation of healthcare practices ps bacillus cereus was cultured for patients from traumatology department who had developed postoperative wound infections between august and march . all patients presented inferior members open fractures, frequently contaminated with telluric material and requiring external fixators. genomic study of clinical isolates by pulsed field gel electrophoresis and random analysis polymorphic dna, allowed us to eliminate an outbreak. furthermore, the reduced delay in which patients developed the infection ( days'//- ) led us to re-evaluate the procotols used in our institution. indeed, all patients had received amoxycillin '/ clavulanate iv g for antibioprophylaxis during anesthetical induction then relayed per os for hours. because of the production of a potent beta-lactamase by the bacteria, this association could not be efficient. furthermore, accordingly to the afnor en norm, we have tested clinical isolates' sensitivity to the principal antiseptics used for antisepsis and disinfection (iodophors, chloride derivated and biguanidines) and observed a major resistance of all strains tested. even if these postoperative wound infections are considered as nosocomial because of the delay in appearance, we actually think that bacillus cereus were initially present in telluric material. this fact led us to propose a systematic screening for bacillus at admission for this type of wound and to administrate quinolones such as ciprofloxacin for prophylaxis. internal thiols and reactive oxygen species in the candidacidal activity exerted by a n-terminal peptide of human lactoferrin ps the purpose of the study: the emergence of candida albicans strains resistant to current antifungals points to the need for new antifungal agents, e. g. antimicrobial peptides. the results obtained : we report that hlf( - ), a synthetic nterminal peptide of human lactoferrin, displays excellent killing effect against fluconazole-resistant c. albicans and that sub-optimal concentrations of this peptide combined with fluconazole act synergistically. previous investigations revealed that hlf( - ) required an energized mitochondrion, atp release by candida , and ligation of atp receptors for its killing effect. we now report that reactive oxygen species (ros) are involved in the killing effect of hlf( - ). since internal thiols protect cells from oxidative damage, our observation that hlf( - ) caused a % reduction of internal thiols in candida is of interest. as expected, n-acetyl-l-cysteine (nac), which is a precursor of glutathione and a ros scavenger, inhibited the killing effect of hlf( - ). diamide, which oxidizes internal thiols, was candidacidal and hlf( - ) and diamide acted synergistically in killing c. albicans and ros production. moreover, the hlf( - )-induced activation of mitochondria was inhibited by nac, indicating that internal thiols/ros affect mitochondrial activity. the conclusion reached : the candidacidal activity of hlf( - ) involves ros production and reduction of internal thiols. objective : an audit was conducted to explore the observation of increasing resistance to ciprofloxacin in enterobacteriacea isolated from specimens from such patients in the hematology unit. results : enterobacteriacea isolates in specimens from such patients processed over the years to were examined. number of specimens per year was */ , , , and respectively and the annual percent ciprofloxacin resistant enterobacteriacea from these was %, %, %, % and %. conclusion : conclusion drawn from the audit was that rapid rise in ciprofloxacin resistance may possibly be attributed to the use of this fluoroquinolone as a single agent in dose of / mg [cut off patient weight kg] twice a day in neutropenic patients till neutrophils exceed /c.mm. subsequent to the audit, prophylaxis protocol was modified to use of oral colistin -mega units/twice a day in combination with ciprofloxacin / mg twice a day. a prospective audit is proposed to test the benefits of this combination. rhinocerebral zygomycosis: diagnostic dilemma for emergency physician: can the associated morbidity and mortality in this rare but deadly disease be reduced? ps samavedam s, guleri as. western infirmary, clinical microbiology, glasgow, united kingdom rhinocerebral zygomycosis [rcz] is a rare, invasive, rapidly progressive opportunistic infection caused by ubiquitous fungi of the order mucorales. it usually occurs in diabetics or immunocompromised patients. the emergency physician will typically see patients with rcz in its earliest stages masquerading as a variety of other less serious diseases. the key markers like necrotic patch on hard palate, nasal septum or turbinate, marked facial pain, and cellulites with marked eye and neurological signs may present late in disease. we report a case of rcz caused by rhizopus arrhizus [oryzae] in an year old woman with poorly controlled diabetes. she presented with a right-sided facial droop of short origin and being generally unwell. ct scan was non-conclusive and delayed presentation of key markers of rcz permitted disease to rapidly progress. despite an intensive antifungal therapy with ambisome and insulin sliding scale, patient rapidly succumbed within days. fine needle aspiration cytology is less invasive, easier and equally effective alternative to pre op biopsy. the key to successful reduction in morbidity and mortality associated with this rapidly fatal disease is -increasing awareness of the disease, an early diagnosis, correction of underlying metabolic derangement, prompt intensive antifungal therapy with amphotericin b and radical surgical debridement of the necrotic tissue. an 'optimal dosage' of ambisome requires discussion. clinical audit in the haematology ward of a tertiary care hospital: study of degree of correlation between bacteraemia and oro-pharyngeal screens in immunocompromised patients over five years and role of antibiotic prophylaxis ps guleri as, butcher i. western infirmary, clinical microbiology, glasgow, united kingdom introduction : a clinical audit was carried out over -years [ ] [ ] [ ] [ ] [ ] in the immunocompromised patients including neutropenic patients and bone marrow [autograft] transplant recipients in hematology ward of gartnaval general hospital, glasgow, a tertiary care center. objective : it was aimed to establish the degree of correlation between bacterial isolates in oro-pharyngeal screen during bacteraemia episodes and role of antibiotic prophylaxis. methods purpose : to assess whether antiretroviral therapy (art) intensification, gm-csf use and remune initiation before stopping art lead to viremia containment, and long periods off art. methods : ten adults with chronic hiv disease, hiv- rna levels (vl) b/ . log copies/ml and median cd '/ -t cell count of /ml were enrolled. after art intensification with ddi ( months) '/ hydroxyurea [hu]( mo.) '/ gm-csf ( mo.) and a remune dose, art was stopped but remune continued. art was resumed if rebound vl did not decrease to b/ . log in months or if cd '/ counts decreased to b/ . results : vl rebounded in all patients after stopping art, and developed an acute retroviral syndrome (ars). cd '/-t cells decreased, and cd '/ '/ increased ( -fold). after a median stoppage of weeks, art was resumed in patients and vl decreased to b/ . log, cd '/ counts were regained, il- and il- levels rose. at the nd interruption, / patients had a rebound, and / had a nd ars, but peak vl and loss of cd '/ were lower (p / . ). after . weeks off art, patients resumed therapy. the breadth and magnitude of hiv-specific activity increased and thymus size grew. the patients were off art for a median of . out of weeks. two of them are off art for and weeks respectively ( vlb/ log). conclusions : this approach led to a high ars incidence, long periods off art, increases in hiv-specific responses, il- and il- levels, and thymus size. urinary tract infection in hospitalized population is a significant problem. this is a study of catherized patients urinary infection in corfu hospital. in Á/ , urine cultures were sent to our bacteriology laboratory. of them were collected from the catheters. clinical data of age and type of disease were analysed. the samples were cultured on mc conkey agar-urotube and vitek cards. the organisms identified with vitek automatic system. the sensitivity was tested with vitek and kirby-bauer method. results: no growth of organisms in . %. positive cultures %. . % of the bacteria were gram((/) rods ( . % e. coli , pseudomonas spp. %), % were gram('/) cocci (enterococcus spp.) and % was candida spp. the resistance of e. coli was: % to ampicillin , % to co-trimoxazol and % to quinolons. e. faecalis was resistant % to vancomycin . conclusions : ( ) the possible interference of acetaminophen in the amoxicillin/ clavulanic acid (a/c) or erythromycin (ery) efficacy in the treatment of acute otitis media (aom), and its possible role in the evolution to otitis media with effusion (ome), were determined in a gerbil model. a f streptococcus pneumoniae strain exhibiting a mic of a/c and ery of / . and . mg/l, respectively, was used. both antibiotics were tested at . and mg/kg. acetaminophen at mg/kg was administered min before each antibiotic dose. antibiotic concentrations in serum and middle ear exudate were determined. both antibiotics significantly reduced the number of culture-positive ears and colony counts, with serum concentrations over the mic of the microorganism for ]/ % of the dosing interval. antibiotic concentrations in middle ear exudate were almost identical in animals receiving and not receiving acetaminophen. clinical and microbiological efficacy was correlated with antibiotic concentrations in middle ear exudate ]/ . times the mic of the microorganism, for both antibiotics. both antibiotics demonstrated efficacy in the treatment of pneumococcal aom, with the same rate of ome. acetaminophen, concomitantly administered, did not interfere the efficacy of the two antibiotics tested and did not prevent the evolution of aom to ome. parra a a , ponte c a , cenjor c b , garcía-olmos m a , giménez mj c , aguilar l c , soriano f a . a fundación jiménez díaz, medical microbiology, madrid, spain , b fundación jiménez díaz, otorrinolaryngology, madrid, spain , c glaxosmithkline, medical department, madrid, spain a gerbil model of otitis media with effusion (ome) induced by haemophilus influenzae (amoxicillin/clavulanate-a/c-and erythromycin-ery-mics of / . and mg/l, respectively) was used to evaluate the efficacy of a/c ( / and / mg/kg) and ery ( and mg/kg). antibiotics were administered subcutaneously h post-middle ear inoculation, and continued t.i.d for h, with or without acetaminophen (ap), at mg/kg, administered min before each antibiotic dose. antibiotic concentrations in serum and middle ear (me) were measured by bioassay. me samples for colony counting were collected on day . a/c reduced (p / . ) positive me samples and colony counts versus untreated controls or ery: me positive cultures of % for controls, % for a/c , % for a/c , % for a/c '/ap, % for ery , % for ery and % for ery '/ap. this was due to a/c (but not ery) concentrations in me exceeding . times the mic despite the higher percentage of antibiotic penetration of ery versus a/c ( versus / %). animals receiving ap showed less polymorphonuclear cells and more bacteria in me than those receiving only antibiotics, suggesting that the anti-inflamatory drug diminish the phagocytes and therefore, the efficiency in bacterial clearance. amoxycillin treatment for acute otitis media caused by penicillinresistant streptococcus pneumoniae . a pharmacodynamic analysis pm parra a a , ponte c a , cenjor c b , garcía-calvo g a , giménez mj c , aguilar l c , soriano methods: a serotype f streptococcus pneumoniae strain exhibiting a mic of amoxycillin of mg/l was used in an experimental model performed in gerbils (meriones unguiculatus ) following previously described procedures. amoxycillin was tested at the following doses: . , . , . , . , . and mg/kg. amoxycillin concentrations in serum and middle ear exudate were determined after drug administration. results: doses of ]/ . mg/kg significantly reduced the number of culture-positive ears, colony counts and otorrhoea (p / . ) as compared with untreated controls or animals treated with doses lower than . mg/kg. doses of ]/ . mg/kg achieved antibiotic concentrations in the middle ear . Á/ . times higher than the mic of the infecting strain and serum concentrations over the mic for Á/ % of the dosing interval. conclusions: amoxycillin at doses achieving serum concentrations similar to those obtained in children after standard doses, obtained therapeutic and microbiological efficacy regardless the susceptibility of the infecting strain. better correlation was found between antibiotic efficacy and antibiotic concentrations in middle ear exudate than between efficacy and serum concentrations, which were suboptimal from the pharmacodynamic perspective. increasing prevalence of amoxycillin Á/clavulanate-resistance among e. coli strains in a hungarian university hospital pm veréb i, vígh a, urbán e, hajdú e, nagy e. department of clinical microbiology, university of szeged, szeged, hungary background: amoxicillin Á/clavulanate resistance (acr) is an emerging problem in escherichia coli as reported from different parts of europe. the aims of the present study were to evaluate statistically the prevalence of acr among e. coli isolates and to investigate the genetic background of the resistance. methods: all e. coli strains isolated between and were screened for acr by kirby Á/bauer disc diffusion method. the resistance to other beta-lactam Á/beta-lactamase inhibitor combinations and to different beta-lactam antibiotics were also tested. selected strains underwent determination of beta-lactamase activity. confirmatory tests for suspected extended spectrum beta-lactamase were performed. pcr testing for tem and shv genes were carried out on plasmids isolated from selected strains. results: in out of e. coli strains ( . %) were found to be resistant to amoxicillin clavulanate (amc). most of the resistant strains ( %) were obtained from the genitourinary tract and no acr isolate was found in blood cultures. in out of isolates ( %) proved to be acr and . % were isolated from blood cultures and . % from the genitourinary tract. thirty-five selected strains were further analysed. thirty-two were also resistant to (sam) and six were further resistant to tzp. quantitative beta-lactamase determination showed increased activity in strains which were partially susceptible to amc. the presence of esbl could be proved only in three acr isolates. this open parallel-group study compared the efficacy and tolerability of cef with cfix mg once daily in the treatment of community acquired uncomplicated uti. seventy-eight female patients were randomized to receive either oral cef or cfix for or days. the efficacy of treatment was evaluated by clinical response (by symptoms of uti dysuria frequency urgency suprapubian pain and by clinical signs) by bacteriologic response and health status measures at baseline and posttherapy. results: the clinical cure (complete resolution of symptoms and signs) rate for patients receiving cef was . % of the evaluable patients and . % of the patients receiving cfix. bacteriologic response (based on the results of urine cultures obtained posttherapy) the pathogen was eradicated in . % for cef . % for cfix. no drug related side effects have been reported in cef and side effects were experienced by . % of the patients receiving cfix. improvement in health status comparing visual scale scores baseline and poststudy to have detected a higher change in average score from to in cef, from to in cfix. wilcoxon improvement value was significant on the rd day of therapy in case of cef and on the th day of therapy in cfix group. in conclusion, the results of this study indicate that cef course is more effective than cfix in producing a favourable clinical outcome and achieving higher bacteriologic eradication rate, furthermore cef was better tolerated. cefepime is a fourth generation cephalosporine that has a broader spectrum of antibacterial activity than the third generation cepfalosporines and is more active in vitro against gram-positive aerobic bacteria. the purpose of this study was to measure cefepime concentrations in plasma, bile fluid and gall bladder tissue in patients undergoing cholecystectomy. thirty patients male, female, mean age: years had data acceptable for analysis and were included in this study. all patients received iv g of cefepime. several hours after administration and at different time intervals, during surgery, samples were obtained from plasma, bile fluid and gall bladder tissue concomitantly. antibiotic levels were measured by an agar diffusion method. the mean delta time was / min. the values for plasma, bile fluid and gall bladder tissue, were . / . , . / . and . / . mg/ml, respectively. the plasma/bile fluid ratio was . / . . there was a significant correlation between plasma and gall bladder tissue concentration (r / . , p / b/ . ). a correlation between bile fluid and plasma cefepime concentration was not observed. the minimum inhibitory concentration (mic) data from previous in vitro studies indicate that the cefepime concentration observed in plasma bile and tissue samples of this study would be adequate against typical biliary tract pathogens. furthermore, these cefepime concentrations correlated well with the favorable clinical outcome reported in previous clinical studies in biliary tract infections. there was also good correlation between delta time and plasma and tissue concentrations and if the dose were given closer to the time of surgery, cefepime concentration would be higher reducing the possibility of an infection. objectives: the use of antibiotics may lead to decreased colonization resistance and increased formation of resistant bacteria. present concept was developed to overcome these untoward effects. methods: b-lactamase of bacillus licheniformis was overproduced in bacillus subtilis . this targeted recombinant b-lactamase enzyme (trbl) was released in the small bowel from a controlled-release formulation. beagles (n / ) were treated bid with either mg/kg ampicillin (i.v.)'/placebo (p.o.), mg/kg ampicillin (i.v.)'/trbl (p.o.) or only placebo (i.v.'/p.o.). stool was collected at days and . samples were cultured for total and main groups of aerobic and anaerobic bacteria and yeast. temperature gradient gel electrophoresis (tgge) was used to separate the ribosomal rna genes. results: ampicillin'/placebo group had clearly decreased counts of both aerobic and anaerobic bacteria during the treatment, whereas those receiving trbl had only minor overall changes and some occasional changes by single species. intravenous ampicillin decreased the fecal similarity percentage to %. the similarity percentage during treatment with ampicillin'/trbl did not differ from that of placebo ( vs. %). conclusions: according to our results the trbl can maintain the large intestinal microflora almost unchanged. these results indicate that trbl is a promising novel approach for overcoming the ecological adverse effects on gut flora caused by b-lactam antibiotic agents. adamis since broad-spectrum â-lactams combined with amikacin are often applied for nosocomial infections, their pharmacokinetic interactions might be interesting. one gram of aztreonam and . g of amikacin were administered intravenously single and in combination in six healthy volunteers. blood samples were collected at regular time intervals and concentrations of antimicrobials were determined by a microbiological assay applying a strain developing resistance to single agent after serial passages. mean concentrations of amikacin in serum when administered alone and in combination with aztreonam were . and . , . and . , . and . , . and . , . and . and and . mg/ml immediately after and . , , , and h after infusion of antimicrobials. respective concentrations of aztreonam were . and . , . and . , . and . , . and . , . and . and . and . mg/ml. aucs for amikacin when administered alone and in combination with aztreonam were . / . and . / . mg h/l, respectively. respective auc for aztreonam were . / . and . / . mg h/l. it is concluded that the co-administration of aztreonam and amikacin results in earlier clearance of aztreonam and in higher levels of amikacin compared to the administration of each single antimicrobial. molecular modelling of b-lactams reveals the structural basis for their inhibition of penicillin-binding proteins, susceptibility to b-lactamases and oral bioavailability pm grail bm, gupta s, payne jw. school of biological sciences, university of wales, bangor, uk b-lactam antibiotics are peptide mimetics that act as suicide substrates for transpeptidase enzymes that cross link bacterial cellwall peptides. for the first time, the structural and electronic features needed for their recognition by transpeptidase have been fully described, using innovative molecular modelling techniques to compare the conformational forms adopted by cell-wall peptides and blactams. comparison of features in the backbone and c-terminal regions of conformers of active b-lactam antibiotics and model cellwall peptides, has allowed definition of the molecular recognition template required for substrate recognition by transpeptidase. these shared structural features allow both to act as substrates and to acylate the active-site serine. however, a significant difference in a critical backbone torsion between the two substrates, provides an explanation for the inability of the enzyme Á/antibiotic complex to undergo the deacylation step that causes inhibition of transpeptidase. on the other hand, b-lactamases appear to have evolved molecular mechanisms that facilitate the deacylation reaction through compensating for the altered structural orientations in b-lactams caused by the different backbone torsion. finally, analysis of the conformer repertoires of blactams for structural features required for substrate uptake by peptide transporters, provides insights into how their structures can be tailored for optimal oral absorption. antimicrobial susceptibility of proteus mirabilis clinical isolates producing extended spectrum beta-lactamases (esbls) pm objectives: the aim of the present study was to determine in vitro susceptibility to antimicrobials of proteus mirabilis isolated from urinary tract infections. methods: we studied the susceptibility profile of esbl positive p. mirabilis strains in three adopted children from india with age range from months to years. esbl was identified using the synergic effect of clavulanate with betalactams (ceftazidime and cefotaxime the in vivo efficacy of amoxicillin (amx) sub-therapeutic doses ( . mg/kg, t.i.d for h, achieving serum levels over the mic of only % of the dosing interval) and concomitant specific serotherapy (single intraperitoneal dose of / diluted hyperimmune serum (hs) obtained from mice immunized with the heat-inactivated strain) was assessed in a pneumococcal sepsis balb/c mouse model. mice (five mice/ treatment group) were intraperitoneally infected with . )/ cfu/ ml of a serotype b penicillin-resistant strain (mic of and mg/l for penicillin and amx, respectively). treatments started h after bacterial inoculation. study groups were: control (k; receiving nonimmune serum (nhs)), amx'/nhs, hs, and amx'/hs. survival rates (%) over time were: purpose of the study: the study was performed to determine the consumption of imipenem and resistance of gram-negative pathogens (pseudomonas aeruginosa , acinetobacter sp., klebsiella sp., escherichia coli , proteus mirabilis , serratia marcescens , enterobacter sp. ) to imipenem. gram-negative pathogens were isolated at the sestre milosrdnice university hospital from zagreb, croatia, in and . the imipenem sensitivity testing was performed by disk diffusion and e -test methods. the consumption of imipenem was expressed in ddd/ hospital days in the same periods. results obtained: imipenem resistance of acinetobacter sp. decreased significantly in the year (p / . ), especially in the first months (p / . ) when the lowest consumption of imipenem was recorded. imipenem resistance of other gram-negative pathogens did not decrease significantly. conclusion reached: comsumption of imipenem might lead to changes in resistance to imipenem among acinetobacter strains. vacheva-dobrevski rs, savov ez. military medical academy, clinical microbiology, sofia, bulgaria purpose: acinetobacter baumanii is becoming increasingly frequent nosocomial pathogen at our hospital, and beta-lactam resistant strains are on the increase, especially among icu isolates. to study the susceptibility of a. baumanii clinical isolates to beta-lactams and to determine the esbl-producing strains during , year. a total gram-negative nonfermenters (gnnf) isolates was investigated by semiautomated mini api system (bio merieux, france). eighty-four a. baumanii non-repeated isolates was studied for esbl-producing by double-disk synergy test (ddt) and atb-blse test (bio merieux, france). mics for beta-lactams were determined by e -test (ab biodisk, sweden). results: a. baumanii (n / ) showed a multidrug resistance. the isolates were resistant to cefotaxime ( %), cefoxitin ( %), ceftazidime ( %), amoxicillin/clavulanate ( %), piperacillin ( %), aztreonam ( %), imipenem ( %). the ( %) of investigated a. baumanii expressed esbl activity and originated more frequently from icu ( %). esbls producing strains were isolated from endotracheal aspirate ( %), surgery wounds ( %), blood culture ( . %). conclusions: in general resistance levels were higher in clinical isolates a. baumanii to beta-lactams. the ddt seems to be a practical method for esbl-screening; atb-blse method is more sensitive. our study display to be the first report of esbl-producing a. baumanii strains from our country. carbapenems seems to be the most active agents against a. baumanii . salmonella infantis , strain , was isolated from a newborn baby at wassila bourguiba maternity in tunis. it exhibited high resistance to penicillins, extended-spectrum cephalosporines (cefotaxime, ceftriaxone, ceftazidime, cefpirome) and aztreonam but remained susceptible to cefoxitine and imipenem. involvement and characterization of enzymatic mechanism in b-lactam resistance were investigated in strain . isoelectricfocusing revealed that this strain produced a b-lactamase of pi . this enzyme had a broad-substrate profile, hydrolyzing amoxicillin, ampicillin, ticarcillin, cephaloridine, cefuroxime, cefotaxime, ceftriaxone, cefpirome and ceftazidime. the highest specific activity was observed with ampicillin. cefotaxime was hydrolyzed the most efficiently of the extended-spectum cephalosporines. the pi extended-spectrum b-lactamase (esbl) was inhibited by clavulanic acid and sulbactam. no inhibition of the esbl was observed with mm edta. thus, no metal ion is involved in hydrolysis for this b-lactamase. resistance due to the production of the pi esbl was transferred with dna plasmid into escherichia coli . on the basis of substrate and inhibition profiles and isoelectric point, the pi esbl was not previously described in s. infantis in tunisia. the presence of such a resistance on a plasmid raises concer for rapid dissemination among bacteria and loss of effectiveness of blactams. poizot-martin i a , enel p b , benhaïm s c , vion-dury f c , dinh t c , drogoul mp c , gastaut ja c . a assistance publique hôpitaux de marseille, cisih sud, pr ja gastaut, marseille, france , b assistance publique hôpitaux de marseille, cellule santé publique dmi , marseille, france , c assistance publique hôpitaux de marseille, cisih sud, marseille, france objective: to assess liver biopsy (lb) practices in a cohort of co-infected hcv and hiv patients followed up in an hiv specialized medical unit. method: transversal study with questionnaire among patients in pre-therapeutic's evaluation with pcr'/ and without lb at months. results: among the patients, ( %) are lost of follow up, ( . %) have had lb, ( . %) have no lb. the characteristics of these patients are: median age / . / years; sex ratio / . , cdc-stage a / . % b / . % c / . %, undetectable viral load / . %, median cd / / , anti-retroviral therapy / . %, hcv-genotype / . %; a / . %; / . %. causes of non-made lb are: ( ) refusal from patients because of biopsy's fear / . %; ( ) contraindications because of hiv infection / . % (clinical events / . % which contraindicate anti-hcv treatment, grade iii thrombocytopenia / . % which contraindicate biopsy, non-adherence to previous hiv follow up / . %); ( ) other / . % (alcoholism / . %, psychiatric/depressive disorders / . %, decompensated cirrhosis / . %). drug use or methadone/buprenorphine treatment are not considered as contraindication. conclusion: one-third of patients are afraid of lb. alcoholism and psychiatric/depressive disorders are the principal contraindications to anti-hcv treatment. it seems important to improve information of patients about lb and to focus on alcohol and psychiatric/depressive disorders management in such population. kashiwagi kk a , furusyo nf a , nakashima hn a , kashiwagi sk b , hayashi jh a . a department of environmental medicine and infectious disease, kyushu university, fukuoka, japan , b national kyushu medical center, fukuoka, japan the purpose of the study: the aim of this prospective study was to explore the effect of htlv-i co-infection on the development of hcc among patients with chronic hcv viremia. a total of consecutive patients with chronic hcv viremia were studied and followed-up over a mean period of . years: ( . %) were infected with htlv-i infection and ( . %) were not. the results obtained the annual hcc development rate was . % in patients co-infected with hcv and htlv-i and . % in patients infected with hcv alone. hcc was significantly higher in ( . %) of the patients co-infected patients than in ( . %) of the patients infected with hcv alone (p b/ . , logrank test). in patients under the age of years, hcc development was significantly higher in seven ( . %) of patients co-infected with hcv and htlv-i than in eight ( . %) of patients with hcv alone (pb/ . , logrank test), whereas there was no significant difference in hcc development between patients over age with or without htlv-i infection ( ( . %) of and ( . %) of , respectively). the conclusion reached htlv-i infection accelerates the development of hcc in chronic hcv patients, especially among patients under the age of years. to analyze hbv genotype-related clinical differences among patients with chronic hbv infection, all patients were serially tested for serum alanine aminotransferase (alt) and hepatitis b e antigen (hbeag) and followed up for a mean . ( . ) year period. genotypes b and c were found in ( . %) and ( . %) of the patients, respectively. hbeag positivity and alt abnormality rates at the start of the observation period were significantly higher in genotype c patients ( . and . %) than in genotype b patients ( . and . %). the annual rate of spontaneous hbeag disappearance in genotype b patients was much higher than in genotype c patients ( . versus . %, respectively). patients with genotype c who were continuously hbeag negative from entry had significantly higher alt abnormality ( . %) than those with genotype b ( . %). interestingly, patients with genotype c who became hbeag negative by interferon treatment had high alt abnormality ( . %). all patients with alt abnormality were serum hbv dna positive. these findings indicate that hbv genotype c patients are more severe liver deterioration because of the delay of hbeag disappearance and continued hbv replication after hbeag disappearance. nossik nn a , nebolsin ve b , zheltukhina ga c , yevstigneeva rp c . a the d.i. ivanovsky institute of virology, viral reproduction, moscow, russian federation , b pparminterprisis co., chemistry, mocow, russian federation , c moscow state academy of fine chemical technology, piptide chemistry, moscow, russian federation objective: to study the effects of 'gamma'-l-glutamylhistamine (glu-ha) derivates on non-specific immunity ('alfa'-ifn, 'gamma'-ifn and nk cell activity) and antiviral activity on the experimental influenza and herpes virus infections in mice. the glu-ya and its derivate glu-ii were synthesized by peptide chemistry techniques. the glu-ha and glu-ii was administered i.p. . and . mg/kg before and after influenza virus (type a/aichi) and showed a protective effect even at the high infective dose ( ld ) */the rate of protection / Á/ / % in the positive/control group. they were not very effective in the protection of herpes simplex virus encephalitis in mice. the model of the physico-emotional stress in mice was used to investigate the ifn system and nk cell activity. the production of ifns and nk cell activity of splenocytes decreased in h after the stress and back to normal level in Á/ days. it was shown that glu-ha and glu-ii can protect or substantially prevent the decrease in nk cell activity and ifns synthesis in post-stress period (so normally did not induce the ifns' synthesis). conclusions: the glu-ha and glu-ii showed antiviral effect against influenza virus infection in mice. the immunomodulating activity and ability to normalize the ifn synthesis and nk cell activity depressed the post-stress period and probably play an essential role in the antiviral activity. no dose adjustment of an anti-influenza prodrug oseltamivir is required in patients with hepatic impairment pm oo c a , snell pr b , liu b a , martin d b , simkins t b , small i b , ward p b . a hoffmann-la roche inc., global development, nutley, usa , b roche products ltd., global development, welwyn garden city, uk background: oseltamivir (ose; ro - , tamiflu † ) is an oral ethyl ester prodrug of its active metabolite oseltamivir carboxylate (oc: ro - ), a potent and selective neuraminidase inhibitor of the influenza virus. the purpose of the study is to evaluate the need for ose dosage adjustment in hepatic impaired patients (hi). method: healthy volunteers (hv) versus hi (child-pugh score Á/ ) [matched on the basis of age ( / years), gender and weight ( / %)] were compared. each subject received mg ose. results: based on c max (ng/ml) and auc inf (ng h/ml) analysed using nominal times, ls mean ratios and % ci between hi and hv were similar. ose* values in hi were marginally elevated but not sufficiently to require dose adjustment. the aim of this study is to investigate the influence of molecular structure of macrocyclic pyridinophanes and their analogs on antiinfluenza and antiherpetic activity of these compounds. we used d-qsar approaches on the basis of simple representation of molecular structure. such representation for biologically active substances allows the description of the spatial structure of compounds with the complete stereochemical information. it determines spatial structures either promoting or interfering of the concrete biological activity. it is easy to realize the molecular design of compounds with the given level of activity with the help of the combinations of simplexes. statistic characteristics for qsar of partial least-squares models are satisfactory (r / . Á/ . ; cvr / . Á/ . ). the molecular fragments that increase the antiviral activity were defined and will be demonstrated. this information was used for design and directed synthesis of several novel antiviral agents with predicted high anti-influenza or antiherpetic activities. predicted activities were confirmed experimentally. d-qsar approaches are useful for development of antiviral compounds. this work was partially supported by intas foundation (grant intas - ). lozitsky vp. ukrainian mechnikov research anti-plague institute, chemotherapy, odessa, ukraine the purpose of this study was to research the anti-influenza activity of proteolytic inhibitor e-aca. it prevents the enhancement of proteolysis during the interaction of virions with cell membranes and decreases penetration of virions into cells. e-aca brings down proteolytic cleavage of ha-precursor to ha- and ha-polypeptides and reduces the infectious virus harvest. it shows the prophylactic and therapeutic action during the experimental influenza reducing the enhancement of alkaline proteases activity in lungs after infection. e-aca promotes the intensification of specific antibodies production and cell immunity, prevents vessels' permeability and hemorrhagic phenomena, decreases the destruction of bronchi's epithelium. it reduces the duration of intoxication, catarrhal instances and hyperthermia in sick children. e-aca improves the indexes of immunity, non-specific resistance and decreases the rate of bacterial complications. application of e-aca for treatment influenza and other arvi in children is recommended in ukraine on the base of results of our researches. the higher effects demonstrated as a result of combine usage of e-aca with specific ig, or deitiforin, or unithyol, or ribavirin. in our opinion, the study of effectiveness of e-aca combine application with inhibitors of influenza na is the perspective direction of anti-influenza researches development. we should we treat immediately all varicella patients with acyclovir if the patient is older than years pm during past years in institute for infectious and tropical diseases in belgrade, immunocompetent varicella patients were treated and cured. among them were older than years ( . %). x-rays were performed in all patients. diagnosis of pneumonia was made in patients ( . %), but in ( . %) patients older than years. varicella is a benign, self-limited disease, if it strikes early, i.e. preschool, school children and teenagers. at that time there is no need for specific therapy. but in neonates, immunocompetent adults and in all immunocompromised patients it can be difficult and life-threatening disease. in immunocompetent adult population pneumonia is a very serious, sometimes fatal complication. knowing the pathophysiology of primary varicella Á/zoster infection, specific therapy with acyclovir should be started immediately after making the diagnosis in patients older than years, without waiting for x-ray proof of pneumonia. brivudin compared to acyclovir for the treatment of herpes zoster: effects on acute disease and posttherapeutic pain pm objective: comparison of efficacy and safety of brivudin )/ mg and acyclovir )/ mg, both for days, in the treatment of herpes zoster. methods: randomised, double-blind study on immunocompetent patients ]/ years (brivudin: n / , acyclovir: n / ). a subgroup of patients ]/ years (brivudin: n / , acyclovir: n / ) was examined for the occurrence of posttherapeutic pain in a poststudy survey. posttherapeutic pain was defined as any zoster-associated pain, regardless of intensity, after the end of acute zoster. results: brivudin was superior to acyclovir in reducing time to last occurrence of new vesicles (rr(itt): . [ . Á/ . ], p / . ). the advantage of brivudin was more pronounced in patients ]/ years (rr(itt): . , [ . Á/ . ], p / . ). incidence of posttherapeutic pain was significantly lower with brivudin ( . %) than with acyclovir ( . %, p / . ). duration of pain was comparable in both treatment groups (rr: . , [ . Á/ . ], p / . ). potentially treatment-related adverse events occurred in . % of the brivudin recipients and in % of the acyclovir recipients. conclusions: brivudin mg once daily for days is superior to standard acyclovir in stopping viral replication in acute herpes zoster. in patients ]/ years, brivudin is more effective than acyclovir in reducing the risk of developing posttherapeutic pain. brivudin is as well tolerated as acyclovir. varadinova t a , genova p a , garcia-raso a b , terron a b , fiol j b , badenas f b . a laboratory of virology, sofia university, sofia, bulgaria , b chemistry, universitat de les balears, palma de mallorca, spain we have published that cu(ii) complexes of acyclovir (acv) are active against hsv infection (mbd, ) . here we present data on the activity of acv complexes of ni(ii), cd(ii), co(ii) and ag(i) against resistant to acv hsv strain r- in comparison with the effect against acv sensitive strain victoria. selectivity indexes (si) compared to that of acv were indicative for activity. the following data were obtained: (i) was times less selective inhibitor of strain r- than of strain victoria; (ii) under the action of [cd(acv)cl ], [ni(acv) (h o) ]cl ×/ acv and [ni(acv)(no )] ×/ h o was up to % higher than that in the control; (ii) was times less selective inhibitor than acv; (iv) si of was two times higher for strain r- and five times lower for strain victoria then that of acv. these data show that the selectivity of acv against resistant hsv strains can increase when acv is bond to a proper metal ion. methods: an antiviral activity against herpes simplex virus of the type i (hsv-i/leningrad/ / ) and variant hsv- (vvt/ / r) resistant to acyclovir was determined using commonly accepted method. viruses were grown on a continuous culture. maximal toxic dose was determined by the administration of compounds orally ( mg/kg) or intraabdominally ( mg/kg) to white mice that had mass Á/ g. condition of the animals was controlled during h. mice pneumonia model was used for the testing activity in vivo. results: derivatives tested have activity against hsv- and hsv- resistant to acyclovir. maximum protection of the cells up to % was reached at concentration of compounds Á/ mg/kg. tested compounds have low toxicity and animals did not die after intraabdominal and after per oral administration of the substances. using these compounds led to essential relief of diseases in animals. the number and square of virus specific areas of inflammation in lung was decreased to compare with control untreated group. tested compounds protected animals similar to acyclovir that was used as control. conclusion: derivatives of carboalkoxysulfanilic acids are active against hsv in vitro and in vivo and act on the acyclovir resistant variant viruses. markiewicz r a , szepietowski jc b . a jelfa s.a., medical department, jelenia gora, poland , b department of dermatology, university of medicine, wroclaw, poland background: denotivir is a -benzoamino- ?-chloro- -methyl- isothiazolecarboxanilide anti-inflammatory agent with antiviral and immunomodulatory activities. it possesses also mild antibacterial and antifungal action. the purpose of the study: the aim of this presentation is to give an overview of recent studies demonstrating denotivir efficacy in herpetic infections. the results obtained: in vitro studies revealed that denotivir in the doses below its cytotoxicity (about um) significantly inhibited (by Á/ %). herpes simplex virus (hsv)- and hsv- replication in fibroblast and kidney cell cultures. moreover, it was showed that denotivir in the dose of mg/ml markedly inactivated hsv- after min incubation in c. in giunea pigs research, % denotivir in % dmso appeared to be superior to % dmso alone and untreated groups in the therapy of animal skin infected by hsv- . there was no huge difference in eythema and oedema scorings between studied groups, however in the group treated with denotivir, in contrast to others, no vesicles developed. several clinical studies showed usefulness of denotivir in controlling herpetic infections in dermatology, ophthalmology and otolaryngology. in the majority of studies within few hours after the drug application itch and pain relief was noted and within Á/ days the vesicular lesions were dried up. the conclusion reached: in conclusion, denotivir is an effective antiherpetic agent. this study was conducted on cows affected with teat papillomatosis. in the first step, each cow was located on one of three groups. the first group contained four cows from to years that were treated with fig tree (ficus carica) latex. the second group contained four cows from . to years that were treated with a % solution of salicylic acid, and the third group contained four cows as control. in group one and two following treatment with fig tree latex and salicylic acid, superficial necrosis begun from day and all of the warts disappeared by day . in the control group, after day , there were no changes in number of lesions, but some of them were larger than first observation. on day , one of the marked warts disappeared and on day another wart was disappeared but six were present until day . comparison of effects of salicylic acid and fig latex showed similar effects in treatment of udder papillomatosis in cow. laboratory markers of skeletal muscle toxicity in hiv-infected patients: a cross-sectional case-control survey of frequency, potential correlation with antiretroviral therapy, clinical significance, and outcome pm manfredi r, motta r, patrono d, calza l, chiodo f, boni p. to assess skeletal muscle toxicity among Â/ hiv-infected outpatients (p), the p who had ]/ altered cpk assay ( !/ u/l) between may and november , were compared with p randomly selected among those who had ]/ laboratory exams in this -month interval, in a : case-control study. among the p with altered cpk levels only six were females, and received antiretrovirals. the overall frequency of altered cpk among all p who underwent ]/ laboratory workouts in months was . %. cpk alteration was transient in p, with values ranging from to (mean . / . ) u/l, but was recognized ]/ times in Á/ months in p ( %), of them showing concomitant high aldolase levels ( . Á/ . u/l). a myopathy or a rhabdomyolisis were recognized in four p only; a myositis was confirmed in one p by histopathology. in a multivariate logistic regression analysis, when excluding the unexpected prevalence of the male gender (p b/ . ), no significant difference emerged between p and controls as to age, risk for hiv infection, iv drug use, duration of hiv infection, prior anti-hiv therapy and its length, selected drug combinations, administered nucleoside analogues,hiv disease stage, mean cd '/ count and hiv viremia, signs and duration of lipodystrophy, increased glucose, triglyceride and cholesterol levels, and other therapies. muscle abnormalities, though frequently asymptomatic, are underestimated hiv disease complications, and the role of metabolic (i.e. mitochondrial) alterations, deserves investigation. poor efficacy of non-nucleoside reverse transcriptase inhibitor (nnrti)based salvage haart in hiv-infected patients heavily pre-treated with all other classes of antiretroviral compounds pm manfredi r, calza l, chiodo f. infectious diseases, university of bologna, bologna, italy poorly comparable literature series show conflicting results of nnrti-based rescue haart: Á/ % rate of virologic success. to assess the response to a Á/ -drug rescue haart including a nnrti, patients (p) treated with nucleoside analogues (na) and protease inhibitors (pi) for !/ and !/ months, respectively but naïve to nnrti, with a viremia !/ copies/ml, were prospectively followed during Á/ years, provided that they ensured a !/ % adherence. efavirenz was used in p, nevirapine in , and delavirdine in two. most p ( . %) had an early laboratory improvement, but mean peak viral load decrease was . log, and a significant reduction vs baseline (p b/ . ) lasted months only. a mean % increase of zenith cd count was obtained (p b/ . ), but only . % of p remained !/ cells/ml year after switch to nnrti. in a multivariate analysis, the concurrent introduction of novel pi(s) ( p) and/or different na(s) ( p) acted favorably until the th month of follow-up (p b/ . ), while genotypic mutations conferring nnrti cross-resistance, usually associated with a broad resistance profile, predicted failure in all p (p b/ . ), and the response did not vary according to duration and type of prior therapy, and selected nnrti. a deep salvage nnrtibased haart has a poor and transient virologic outcome also in nnrti-naïve p, while a more evident and sustained immunologic response is expected. p who can introduce novel pi/na and have no mutations impairing nnrti activity are entitled to a better outcome. fatal lactic acidosis without elevation of liver-enzymes during the treatment with stavudine, didanosine and efavirenz: a case report pm winzer r, langmann p, väth t, zilly m, klinker h. medizinische poliklinik der universität würzburg, schwerpunkt hepatologie/infektiologie, ürzburg, germany nucleoside reverse transcriptase inhibitors (nrtis) cause various side effects, many of which are thought to be due to their effects on mitochondria. a -year-old hiv positive (hiv rna: copies/ml, cd cell count: /ml), obese (body-mass-index: . ), therapy-naïve female patient, who after months of well tolerated and effective antiretroviral therapy (stavudine, didanosine, efavirenz), had slight gastrointestinal discomfort and suddenly developed a lactic acidosis (arterial-ph . [ . Á/ . she died days later despite intensive care (continuous venovenous haemodiafiltration, sodium-bicarbonate infusion, high doses of vitamins, respiration). the pathologic examination showed an enlarged liver ( g) with yellowish appearance and pasty consistency, which microscopically appeared as a massive macro-and microvesicular fatty degeneration, and only slight signs of terminal pancreatitis. this reported case gives evidence that a massive lactate acidosis may develop without previously disarranged laboratory parameters for liver or pancreatic function. a fatal outcome may evolve without further accompanying-illnesses. efficacy and tolerability of atorvastatin in the treatment of hypercholesterolemia in hiv-infected patients receiving haart pm calza l, manfredi r, chiodo f. division of infectious diseases, university of bologna, bologna, italy introduction: significant increases in plasma triglyceride and cholesterol levels have been reported in patients treated with haart, and prolonged metabolic imbalances could significantly act on the longterm prognosis and outcome of hiv-infected persons. patients and methods: fourteen hiv-infected patients on pi-based haart since at least months and presenting hypercholesterolemia ( !/ mg/dl) of at least -month duration and unresponsive to a hypolipidemic diet and physical exercise, have been treated with a single daily dose of atorvastatin ( mg) for months. results: one patient was ecluded from evaluation due to early dropout. ongoing antiretroviral treatment included ritonavir in four cases, indinavir in four, nelfinavir in three, and saquinavir hard-gel in two. at the close of -month follow-up of atorvastatin therapy, a decrease of total cholesterol level of . % versus respective baseline value was observed; eight out of patients reached normal values for cholesterol. mild gastroenteric symptoms were found in only one of the treated patients, while no skeletal muscle and liver toxicity has been observed. discussion: in our study, pharmacological treatment with atorvastatin proved certainly effective in the management of diet-resistant hypercholesterolemia, and was associated with a favourable tolerability and adherence profile. the effect of combination antiretroviral therapy regimens on hiv- proviral dna level in peripheral blood mononuclear cells (pbmcs) was examined in hiv- -positive patients, using endpoint dilution pcr and serially cloning and sequencing of the gag region of hiv- . the major clone was defined as the most numerous of analyzed clones, and observation periods ranged from to months (mean, . / . months). in five patients (one with primary-stage hiv- infection) receiving three antiretroviral drugs, hiv- rna levels reduced to undetectable (i.e. b/ copies/ml). hiv- proviral dna levels and the number of major clones reduced in four of these patients. hiv- rna levels reduced, but remained detectable, in five other patients. in the two remaining patients (both receiving two rather than three antiretroviral drugs) hiv- rna levels increased. these results suggested that the population of the major clones may be affected when hiv- rna levels reduce following combination regimens of antiretroviral therapy. saquinavir hard gel (shg) as a part of a spontaneous Á/ -month deintensification anti-hiv regimen following successful highly active antiretroviral therapy (haart) pm manfredi r, calza l, chiodo f. infectious diseases, university of bologna, bologna, italy the induction-maintenance concept was poorly studied in hiv'/ patients (p), and shg was never assessed after prolonged response to potent protease inhibitors (pi)-based haart. shg-naïve p who refused indinavir, ritonavir, or nelfinavir-based haart after achieving long-term viral suppression, and resorted to shg'/ nucleoside analogues (na), were followed prospectively. in . % of the p assessed for Á/ months, ]/ na was changed. prior haart was interrupted after . / . months, due to adverse events ( p), or p's request ( p), while a viremia b/ copies/ml was present since . / . months. a viremia of Á/ hiv-rna copies/ml was maintained in p ( . %), while a higher viral load occurred in p after . / . months, and was related to a pre-haart viremia !/ / ml, a more frequent !/ % recovery of cd count, mutations of codons Á/ , and failure to change na (p b/ . Á/ . ). a cd drop !/ %/ cells/ml was found after . / . months in only eight p, who also had virologic failure: immunologic deterioration was earlier and deeper when na were not changed (p b/ . ). all the p who introduced shg'/novel na after a successful !/ -month induction with a potent pi-based haart had a stable Á/ -month outcome. a suboptimal haart including the less effective but better tolerated shg may be effective for !/ year, especially when novel na are introduced, and specific mutations are absent. despite a lower potency, drugs with a good safety and compliance profile may be recovered for simplified regimens. objective: to evaluate efficacy of antiretroviral therapy (art) with two or three drugs in the nervous 'reservoir'. patients: thirteen acute neurological and art naive aids patients underwent a paired and simultaneous sample from plasma and cerebrospinal fluid (csf) for a quantitative detection of hiv- rna (amplicor roche) before art. all patients underwent a ct and/or mr of the brain to perform a diagnosis. all of them had an hiv related neurological acute inflammatory disease. after diagnosis all patients received art: / received two nrti and / received haart including two nrti and one protease inhibitor. all patients underwent a paired and simultaneous follow-up from plasma and csf during the nd month of treatment. results: in all patients baseline levels of hiv-rna were higher (p b/ . ) in the plasma (log . '/ . ) than in the csf (log . '/ . ). the / patients who received dual therapy had undetectable levels (cut-off copies/ml) of viral rna at the follow-up in csf, but not in plasma: three of these seven patients had a detectable plasma hiv- rna. all / patients with haart had undetectable hiv- rna both in plasma and in csf at the follow up. conclusions: dual nrti therapy is rapidly effective in csf (because of an high penetration of drugs through a more permeable blood Á/brain barrier and lower hiv rna baseline levels) but not in plasma. haart is rapidly and equally effective both in csf and plasma. there are no reports of fulminant and fatal hepatic failure after the start of highly active antiretroviral therapy (haart) in an hiv subject without chronic viral hepatitis. case report: a -year-old naive aids woman with clinical symptoms due by a pcp was observed. baseline alt was increased ( . m.n.v.) because of a mild hepatosteatosis and a silent cholelithiasis. serology for hbv, hdv and hcv was negative; igg anti-hav, anti-ebv, anti-cmv and anti-hsv were present. hiv- rna was . log , cd '/ count was /ml. during the pcp treatment with cotrimoxazole alt values increased ( !/ m.n.v.); nevertheless, she completed the treatment. liver enzymes returned to the pre-treatment values over several days. then she started haart with stavudine, lamivudine and efavirenz. after days the patient showed an efavirenz-related skin rush that resolved within days, without treatment discontinuation. fourteen days after the start of haart jaundice appeared. laboratory revealed severe alt increase ( !/ m.n.v.) and hyperbilirubinemia ( mg/dl) and she died because of an acute liver failure syndrome within few days. an haart efavirenzbased regimen can result highly hepatotoxic when given in presence of a hepatosteatosis, of a recent hepatotoxicity caused by a nonantiretroviral treatment and of a previous idiosyncratic reaction to efavirenz. our experience with bulgarian herbal extracts for improving the general condition of hiv-positive patients pm methods: we used a combination of bulgarian herbal extracts and treated six patients, divided in two groups: three with symptomatic and three with asymptomatic hiv-infection. the all three patients with asymptomatic hiv-infection were treated only with herbal extracts, another three patients with symptomatic hiv-infection were treated with combination of herbal extracts and anti-retroviral therapy. the general status of patients has been evaluated by both subjective and objective surveillance. the immunologic monitoring has been performed by absolute count of cd '/ lymphocytes. results: all patients have shown an obvious improvement in their general condition: high spirit and working capacity, good appetite and sleep, a restoration of body weight. the number of cd '/ lymphocytes has been lightly increased or constant. conclusion: the combination of bulgarian herbal extracts has shown significant positive effect on the general condition and improve the quality of life. antifungal activity of in vitro and in vivo combinations of voriconazole with -fluorocytosine and amphotericin b against candida and cryptococcus spp pm hitchcock ca, andrews rj, lewis bgh, pye gw, oliver gp, troke pf. pfizer global research and development, department of discovery biology, sandwich, uk purpose: the present study was designed to determine whether the activity of voriconazole (vor), a novel triazole, was reduced against candidal and cryptococcal infections by the addition of standard antifungal agents, amphotericin b (amb) and -fluorocytosine ( -fc). vor was tested in combination with standard antifungal agents both in vitro, using a checkerboard mic determination test, and in vivo in immune normal guinea pig models of fungal infections. the results indicate that the efficacy of vor against candida albicans and c. neoformans was not antagonised by amb or -fc in vitro. furthermore, in guinea pig models of systemic candidiasis and intracranial cryptococcosis, no antagonism was observed between the lower doses of vor and either amb or -fc on the basis of reductions in tissue fungal loads. at the highest doses of vor, both amb and -fc showed some antagonism, but the combinations were still effective in significantly reducing fungal tissue loads compared with vehicle-treated control animals. conclusion: these results suggest that vor may be used in combination with standard antifungal agents, and future studies to elucidate the clinical potential of vor combination therapies in the management of candida and cryptococcus infections are warranted. itraconazole in the treatment of pityriasis versicolor pm tiodorovic j, jovanovic d, binic i, nikolic lj. faculty of medicine, clinic of dermatovenerology, nis, serbia, yugoslavia a comparison of two short-term dose schedules with itraconazole was carried out in patients with pityriasis versicolor. the patients were divided in two groups. each group consisted of patients who completed the therapy and controls. the clinical diagnosis was confirmed mycologically, by direct microscopic examination. the first group received mg of itraconazole daily for days. the second group received mg daily for days. the patients were controlled clinically and mycologically and days after the initiation of treatment. erythema, scaling and pruritus was evaluated clinically. clinically and mycologically cured patients accepted as cured. the cure rate were % in the first group and % in the second group at day . the effects of these two groups are similar. none of the patients reported side-effects. fungal urinary infections: emerging species, antifungal susceptibility trends and antibody response pm badawi he a , kamel ai b , fam ns a , el-sayed me a , elian sae c . a theodor bilharz medical research institute (tbmri ), microbiology, giza, egypt , b theodor bilharz medical research institute (tbmri ), urosurgery, giza, egypt , c faculty of medicine, medical microbiology and immunology, cairo university, cairo, egypt objectives: to assess the role of candida species in patients with urinary tract infections (utis) with or without schistosomiasis and/or cancer bladder, to compare chromogenic; chromagar (cma), biggy agar; morphologic (corn meal, rice agar-tween ) media and biochemical candifast test for identification of candida species. susceptibility to antifungal agents using e -test and candifast and the performance of elisa test for detection of anticandida antibodies (igm and igg) in serum were evaluated. results: c. albicans was the most frequent ( . %) species responsible for fungal utis. however, non-albicans species, c. glabrata ( . %), c. tropicalis ( %) and c. krusei ( . %) were also isolated. rice agar-tween was found to be cheap, available and sufficient to make a final identification ( %). cma could not identify c. glabrata . biggy agar could not adequately differentiate candida species. candifast biochemical identification showed low sensitivity of . %. e -test on sabouraud dextrose agar (sda) is simple method for mics determination and could detect s-dd strains in case of azoles. conclusion: the emergence of non-albicans species such as c. glabrata , c. tropicalis and c. krusei have contributed to complicated utis. this necessitates accurate isolation and identification of candida to the species level. morphology on rice agar-tween and antifungal susceptibility using e -test on sda is a simle rapid scheme for routine identification of clinically important yeasts. purpose: classification of allergic fungal rhinosinusitis (afr) is based on the immunologic relationship of the host to the fungus. afr must be differentiated from other fungal rhinosinusitis infections, which include acute invasive, chronic invasive, fungal balls and saprophytic colonization. although many cases of fungal rhinosinusitis is caused by species of aspergillis , dermatiaceous moulds have become an emerging pathogen in immunocompetent individuals. results: our case study involved a year male suffering from facial pain, headache, postnasal drip and loss of smell. he was hiv negative and a nonsmoker. the following laboratory tests were performed: ige- . ( . Á/ . ) iu/ml iga- . ( . Á/ . ) g/l igm- . ( . Á/ . ) g/l allergen specific ige for alternaria */ . ( . Á/ . ) ku/l fbc-normal except eosinophils slightly raised . ( . Á/ . ))/ / l. ct scans indicated fungus proliferation, bone erosion and extension of disease into adjacent anatomic area. sinus tissue following debridement was sent for microscopy and culture. hyphae was microscopically observed and cultures yielded two dermatiaceous fungi, bipolaris spp and alternaria spp . conclusion: it is important to differentiate these two species from curvularia , helminthosporum , drechelria and exserohilum . knowledge of these dermatiaceous fungi is important in directing appropriate antifungal therapy and selecting the correct antigens for postsurgical immunotherapy after initial debridement and irrigation. antifungal activity of in vitro and in vivo combinations of voriconazole with -fluorocytosine and amphotericin b against aspergillus fumigatus pm hitchcock ca, andrews rj, lewis bgh, pye gw, oliver gp, troke pf. pfizer global research and development, department of discovery biology, sandwich, uk purpose: a key requisite for a new antifungal drug is to demonstrate that it is devoid of significant antagonism in combination with other agents. combinations of the new triazole, voriconazole (vor), and standard antifungal agents ( -fluorocytosine or amphotericin b; -fc or amb) were tested against aspergillus fumigatus in vitro and in guinea pig models of infections to confirm that antifungal activity was not antagonised by using combination therapies. vor was studied in combination with amb or -fc in vitro, using a checkerboard mic determination test, and in vivo, using immune normal and immunocompromised guinea pig models of systemic aspergillosis. results: the results indicate that the potency of vor was not antagonised by amb or -fc in vivo; indeed, at lower concentrations of vor, significant improvements in reducing fungal burden in both in vivo models were achieved by the addition of amb. in vitro, no antagonism was found between vor and amb, although -fc had a significant antagonistic effect on vor activity. conclusion: these results from in vitro and in vivo models of aspergillosis suggest that vor may be used in combination with standard antifungal agents and, therefore, justify further examinations of vor combination therapies in a clinical setting. in vitro activity of caspofungin compared to that of amphotericin b, fluconazole, and itraconazole against candida species pm arikan s, sancak b, hascelik g. department of microbiology and clinical microbiology, hacettepe university medical school, ankara, turkey purpose: to evaluate the in vitro activity of caspofungin against various candida spp. and particularly against isolates with decreased amphotericin b, fluconazole, and itraconazole susceptibilities. methods: susceptibility tests were done by nccls m a microdilution guidelines for clinical candida strains. the mics (mg/ml) were read at and h. results: caspofungin mics at h are shown in the table. mics at h were similar to h readings. expectedly, no evidence of crossresistance was detected between caspofungin and other drugs tested. caspofungin was similarly active against fluconazole-or itraconazolesusceptible and resistant isolates. conclusions: ( ) caspofungin is active in vitro against all candida spp. tested. ( ) caspofungin mics are slightly higher for c. parapsilosis compared to other species. ( ) its activity against fluconazole-and itraconazole-resistant isolates is noteworthy. ( ) validation of these data require clinical investigations. oropharyngeal microbiological samples of bmt patients were evaluated. weekly cultures (days (/ , and '/ ) revealed presence of fungi in patients ( . %): in four ( %) patients before bmt only, in ( %) after bmt only, and in ( . %) both before and after bmt. in one patient candida norvegensis was isolated from the throat, buccal and palatal surfaces. three c. albicans , two c. krusei , and three c. norvegensis from four patients were chosen to comper their antifungal sensitivities and extracellular virulence factors. using fungitest method we determined the sensitivities of these isolates to flucytosine, amphotericin b, miconazole, ketoconazole and fluconazole. the fluconazole sensitivities were also determined by the e -test. on the basis of the fungitest data the three c. norvegensis isolates were sensitive to flucytosine, amphotericin b, and also to ketoconazole. in case of fluconazole and miconazole they proved to be susceptible dependent upon dose. the mic fluconazole values determined by the e -test for the three c. norvegensis isolates were , ]/ and ]/ mg/ml, respectively. the oropharyngeal isolates of c. norvegensis produced high amounts of extracellular aspartic protease and phospholipase similarly to c. albicans strains. these enzymes may contribute to the pathogenesis of this new emerging candida species. in vitro activities of antifungal and antiseptic agents against rhodotorula sp pm preney l, théraud m, guiguen c, gangneux jp. laboratory parasitologie-mycologie, chu de rennes, france purpose of the study: rhodotorula species are common saprophyte yeasts widespread in nature. since the last years, they have been implicated in several severe infections, especially in immunocompromised patients, and various antifungal therapies were used. however, only limited data are available on the susceptibility of rhodotorula sp. to antifungal and antiseptic agents. material and methods: in this work, we evaluated the in vitro activities of eight antifungal agents against strains of rhodotorula ( strains of r. rubra and nine strains of r. glutinis using atb fungus system (biomerieux) and etest strips (ab-biodisk). beside, the effect of eight antiseptic agents was assessed on a suspension of r. rubra . the quantification of yeasts after exposure to antiseptic agents was performed by subculturings using a microtitration method in well plates. results and discussion: all strains tested were susceptible to amphotericin b, fc, and nystatin. twenty-nine out of strains were susceptible to ketoconazole, out of were intermediate to econazole. all strains were resistant to fluconazole (cmi!/ mg/ml) and itraconazole (cmi!/ mg/ml), and out of were resistant to miconazole, suggesting that antifungal therapy must be adapted when rhodotorula yeasts are implicated in invasive infection. beside, min exposure to sodium hypochlorite , chlorhexidine . % or ecodiol (isopropyl alcohol'/alkylamin) showed fungicidal activities. susceptibility testing of aspergillus fumigatus and emerging aspergillus pathogens by a modification of the nccls m -p method pm logotheti m a , kapsanaki-gotsi e b , velegraki a a , zagoura d b . a department of microbiology, mycology reference laboratory, medical school, university of athens, athens, greece , b biology department, section ecology and systematics, university of athens, athens, greece aspergillosis in high risk groups of patients is still associated with high mortality rate ( Á/ %). aspergillus fumigatus is the primary pathogen, while other opportunistic aspergillus species are emerging. amphotericin b (ab), itraconazole (it), voriconazole (vo) and terbinafine (te) minimum inhibitory concentrations (mic) were determined by modifying the nccls m -p microdilution method. stock drug solutions were prepared in rpmi , dimethyl sulfoxide (dmso), and polyethylene glycol (peg ). inocula, of the a. fumigatus group ( ), a. flavus group ( ) ( ) and the m -p quality control strains were prepared according to, and by modifying, the nccls guidelines. plates were incubated at and c and read at and h. peg effectively dissolved it and vo, while either dmso or peg dissolved te. low and c Á/ h ab, it, vo and te mics ( . Á/ . mg/l) were recorded. a. terreus ( ) and a. parasiticus ( ) were resistant to ab. certain clinical isolates demonstrate clinical and in vitro resistance. standardization of susceptibility testing would offer reliable assistance in selecting and monitoring antifungal therapy. otag f, aslan, g, ozturk c. microbiology department, faculty of medicine, mersin university, mersin, turkey rates of opportunistic fungal infections have risen markedly. because some of these species have potential resistance to antifungal agents, rapid presumptive species level identification is crucial in allowing for directed antifungal therapy. in this study, isolated yeasts from the clinical specimens were identified by atb id c (biomerieux, france). the number of identified yeasts were, respectively; ( %) candida albicans , six ( %) c. glabrata , five ( . %) c. tropicalis , three ( . %) c. parapsilosis , two ( . %) c. krusei , two ( . %) c. kefyr , one ( . %) c. guillermondii , one ( . %) c. dubliniensis . twenty-one of strains were investigated for antifungal sensitivities by atb fungus kit (biomerieux, france). the results are as follows: % sensitivity was detected to myconasol, % to flusitozin, nystatin and econasol, % to amphtericin b and ketokonazol. it is important to achieve empirik treatment of the opportunistic candida infections and the following of resistance to antifungals. shakhmatov da, strelchenco, ov. novosibirsk state medical academy, dermatovenerology, novosibirsk, russian federation at the present stage in russia with a background of a high case rate of syphilis, it becomes necessary to exclude biological false positive serological tests. because the serodiagnosis of syphilis has significant limitations, the direct detection of t. pallidum in suspect blood may serve as an alternate diagnostic strategy. polymerase chain reaction (pcr) has been the most widely used amplification method. the study of patients receiving examination related and treatment for syphilis in std clinic and persons directed from other hospitals where routine serologic examination revealed doubtful results. pcr reaction was carried out with nested primer pairs based on the dna sequence of the Á/ and Á/ kda gene of t. pallidum . pcr was utilized with whole blood. a complex of serological tests: fta-abs and tit was used as the &rdqup; gold standard''. as a result the sensitivity of pcr was . % and specificity was . %. selective comparison of pcr results with vdrl, the fta-abs and treponemal immobilisation test (tit) has shown concurrence . %. in conclusion, the preliminary results of pcr in whole blood in syphilis detection revealed its high sensitivity and specificity; possibility to obtain rapid results in unclear cases. chlamydia pneumoniae (cp) is an atypical pathogen whit intracellular location, whose eradication is very difficult. in the past years it has been objects of many studies that lead to the demonstration of a relationship between its presence and the development of widespread multifactorial pathologies such as atherosclerosis and asthma. the lack of its eradication can become an important clinical and social problem. the study objective is the comprehension of pathogen Á/host interaction mechanism, to characterize therapeutics protocols that cold lead to complete eradication of cp from organism. the research had been principally made on the studying the molecular mechanisms that are at the root of pathogen permanence inside host cell. using proliferation and apoptosis tests we underlined a different behaviour of infected cells towards control cells. in presence of p ( mg/ml), i.e. a peptide that can inhibit the proliferation and induce apoptosis in vitro inhibiting nf-kb, uninfected cells proliferation decreased of % in comparison whit the controls, while the one of infected decreased only of about %. moreover, using various apoptosis-inducers, the infected cells showing apoptosis were about % while the uninfected were about %. the caspace iii activity increased significantly in uninfected cells. in conclusion, cp could delay its elimination from the host inhibiting the apoptosis via nf-kb activation. hryniewiecki t a , gzyl a b , rawczynska-englert i a , a department of acquired valvular heart disease, national institute of cardiology, warsaw, poland , b department of sera and vaccines, national institute of hygiene, warsaw, poland infective endocarditis (ie) frequently causes problems in diagnosis, especially where blood cultures are negative and with fungal etiology (also as a fungal superinfection in bacterial ie). the purpose of the study: the purpose of the study was to evaluate the usefulness of broad-range fungal pcr in diagnosis of fungal superinfection of bacterial ie. twenty-five blood samples were taken for analysis from patients with infective endocarditis. ie was diagnosed according to duke criteria including positive blood cultures. suspicion of fungal superinfection was established on serological investigation in five patients, confirmed by blood culture in two patients. control group consisted of patients without infection. dna was isolated using the commercially available s.n.a.p. kit. amplification products were analyzed by gel electrophoresis stained with ethidium bromide. the results obtained: fungal dna was found in two patients with fungal superinfection of bacterial ie confirmed by culture. in the remaining patients with ie and controls no fungal dna was found. the conclusion reached: broad-range fungal pcr is a fast and inexpensive tool for the detection of fungal dna, but it is more prone to contamination than species-specific pcr. the method may be valuable in the identification of fungal superinfection of bacterial ie or diagnosis of fungal ie. rivanera d, lilli d, lozzi ma, piunno m, mancini c. microbiology, science and public health, rome, italy aim: the aim of this study was to evaluate the eia method for detection of antibody to ttv virus (ttv) and to investigate the anti-tt virus prevalence in patients with hepatitis b (hbv) virus, hepatitis c (hcv) virus, in group of 'high risk'subjects to hepatitis and in healthy subjects. the elisa methods (nuclear laser vienna lab) using ttv s and ns antigens: orf ( aa) and orf ( aa) was applied to detect anti-ttv; the serological screening was performed from samples to italian subjects. results: the positive rates of anti-ttv antibodies were . % in patients with hepatitis b Á/c and . % in 'high risk' hepatitis patients. the anti-ttv was also found in . % in healthy people. conclusions: the anti-ttv were detected in all groups studied, however, its positive rate was similar in patients with hepatitis b Á/c and in 'high risk' hepatitis respect to heathly people. our results shown that tt virus is frequent in italy both in patients infected by others transmitted viruses and in general population. the positivity found in healthy adults included in our studies suggests that the virus might be transmitted non-parenterally. the study of pattern of antibody to ttv may be an infectious marker of ttv similar to that of anti-hcv. a stress test on a miniaturized identification system designed for neisseria and haemophilus pm rich m a , bannatyne rm a , memish za b . a king fahad national guard hospital, division of microbiology, riyadh, saudi arabia , b king fahad national guard hospital, infection prevention and control, riyadh, saudi arabia we report an incident that occurred in our laboratory when the bbl crystal identification system for neisseria and haemophilus was used to identify a haemophilus-like-organism. the numerical profile generated was not in the system database. conventional biochemical tests subsequently revealed an identification of brucella melitensis , a common isolate in our area. as a result of this revelation we subjected this system to a mini 'stress-test' with a collection of isolates of b. melitensis . two numerical profiles were obtained, and , neither of which are listed in the system database. brucella species have been misidentified as moraxella species, moraxella phenylpyruvica , and as haemophilus influenzae biotype iv in various identification systems. two cases of laboratory-acquired brucellosis have been attributed to misidentification. to its credit the bbl crystal identification system for neisseria and haemophilus neither generates a profile number with a misidentified organism nor assigns a confidence level. instead it properly directs the user to resort to conventional methods to secure an identification. if further studies on additional brucella isolates and strains from different geographical sources confirm the unique biochemical profiles identified here, it may be worthwhile to incorporate these into the database where they would be of considerable assistance in areas where brucellosis is widespread. cloning and characterization of aflmp in aspergillus flavus pm chong tk, woo pcy, leung asp, yuen ky. the university of hong kong, microbiology, hong kong, hong kong purpose of the study: to clone and characterize an antigenic protein for serodiagnosis of infection caused by aspergillus flavus which is the commonest aspergillus species causing aspergilloma (ao) and invasive aspergillosis (ia) in asia. result obtained: we cloned the aflmp gene, which encodes the first antigenic cell wall protein in a. flavus . aflmp codes for a protein, aflmp p, of amino acid residues, with sequence features that are present in mp p and afmp p, the antigenic cell wall mannoprotein in penicillium marneffei and aspergillus fumigatus that we described previously. it contains a serine-and threonine-rich region for o glycosylation, a signal peptide, and a putative glycosylphosphatidylinositol attachment signal sequence. specific anti-aflmp p antibody was generated with recombinant aflmp p protein purified from escherichia coli to allow further characterization of aflmp p. indirect immunofluorescent staining indicated that aflmp p is present in the cell walls of the hyphae and conidia of a. flavus . furthermore, it was observed that patients with ao and ia due to a. flavus develop a specific antibody response against aflmp p. conclusion reached: this suggested that the recombinant protein and its antibody may be useful for serodiagnosis in patients with ao or ia, and the protein may represent a good cell surface target for host humoral immunitiy. grape purpose: to investigate the basis for increasing resistance to trimethoprim and sulphamethoxazole. methods: pcr screening for integrons of clinical urinary tract isolates was performed. isolates were tested for resistance to antibiotics. integrons in isolates were sequenced. results: integrons of class were found in isolates and class integrons were found in . eight isolates in the study were resistant to five antibiotics or more and not shown to carry any integron. nineteen of isolates resistant to trimethoprim did not carry integrons. only one of these isolates was shown to carry sul and is thus probably also carrying an integron. none of the isolates were shown to carry dfr , one of five trimethoprim resistance genes known to exist outside integrons. three isolates were resistant to sulphonamides but were not shown to carry neither sul nor sul . only dfr and aad gene cassettes were found in the sequenced integrons. conclusions: resistance to trimethoprim in of trimethoprim resistant isolates is mediated by genes not detectable, as in the case with three sulphonamide resistant isolates. sequenced integrons that contain dfr genes do not carry any gene cassettes mediating resistance to modern antibiotics. unusual diagnosis tool for an unusual presentation of alveolar echinococcosis: report of two cases of local progression after an animal bite pm bardonnet k, bart jm, loiseau j, gérard a, estavoyer jm, heyd b, badet jm, dubiez a, piarroux r, bresson-hadni s. who collaborating centre for prevention and treatment of human echinococcosis, university of franche-comté, besançon, france introduction: the classical human contamination route for alveolar echinococcosis (ae) is ingestion of eggs. two exceptional human cases are reported with extensive local evolution of ae after a bite. case no. : between and , a patient underwent surgery seven times for a muscle growing tumour which developed after a bite. the diagnosis of muscle ae was assessed on histopathological examination. in , serological tests were in accordance with echinococcus sp infection. case no. : in , a man presented 'cat-scratch fever' with a right supraclavicular tumefaction following a cat bite. between and , five recurrences occurred. different surgical explorations indicated multiple abscesses of the cervical muscles. in , serological tests were in favour of echinococcus sp infection and the pathologist described a parasitic wall suggesting hydatidosis, but specific pcr from histological samples prompted the diagnosis of ae. conclusion: in these exceptional observations, the liver which is the most usual location of ae was lesion-free. the chronic inflammatory ae lesions have developed in the local lymphatic chain area of the bite site. to perform diagnosis in these very unusual forms of ae, it is necessary to add unusual tests such as specific pcr to classical tests. antibiotic resistance in foodborne salmonella is an emerging public health concern. integrons are now recognized as the main genetic vehicles of antibiotic resistance in gram-negative bacteria, including in salmonella . the purpose of the present study was to investigate the presence of class i integrons in resistant isolates of several serotypes of salmonella isolated from poultry products and to determine their association with multidrug-resistance phenotypes. a total of isolates of salmonella belonging to seven different serotypes were tested. the most frequent multiresistant phenotype, found alone or together with other resistances, was to streptomycin and tetracycline. all but seven were resistant to three or more antimicrobial agents, including quinolones and amoxicillin. pcr analysis with the ?cs and ?cs primers detected the presence of class i integrons of . kb in one isolate, with the multiresistant phenotype: amoxicillin, chloramphenicol, streptomycin, trimethoprim-sulphametoxazol and tetracycline. our findings suggest that the uncontrolled use of the antimicrobial agents in food animals may have contributed to the development of the pattern of resistance observed in salmonella isolates. also the presence of integrons in low prevalent human salmonella serotypes but associated with food animals underscores the public health problem of antibiotic resistance acquisition and spread. prevalence and antimicrobial resistance of campylobacter jejuni and c. coli isolated from broilers and pigs in france pm avrain l a , humbert f b , sanders p c , kempf i a . a afssa, umb, ploufragan, france , b afssa, hqpap, ploufragan, france , c afssa, lermvd, fougères, france in , caeca from standard, export or free-range broilers and in , fecal samples from pigs, were collected in french slaughterhouses. prevalence of campylobacter jejuni and c. coli strains was . % in standard, . % in export and % in free-range broilers. in standard and export productions, the most often isolated species was c. jejuni , whereas c. coli was predominant in free-range production. . % samples collected from pigs contained c. coli . the sensitivity of strains to ampicillin, nalidixic acid, enrofloxacin (broilers) or ciprofloxacin (pigs), tetracycline, erythromycin and gentamicin was tested by an agar dilution method. in broilers, the percentages of resistant strains were, respectively , , , , . and % for c. jejuni and , , , , and % for c. coli . in pigs the percentages of resistant c. coli were, respectively , , , , and %. in broiler production, significant differences between distributions of species or percentages of resistant strains were observed according to type of production or administrated antimicrobials. the enzyme dhps (dihydropteroate synthase) participates in the folate synthesis pathway, and is well recognized as the target for sulphonamides. the enzyme preceding dhps in this pathway, pppk (dihydropterin pyrophosphokinase), is another interesting candidate drug target. the metabolic role of pppk is to provide one of the substrates for dhps. earlier studies have suggested that pppk and dhps enzymes need to have physical contact with each other for full enzyme activity. studies of potential interactions between the enzymes have been initiated. so far, indication of a weak interaction has been detected in gelfiltration experiments and the two-hybrid system. to confirm these results, we are currently developing a method to study substrate channeling, as interfering with such interactions could lead to impaired growth and thus be used as inhibitory drugs. we have also cloned and sequenced the operons coding for the enzymes in the folate biosynthesis from different clinical isolates of streptococcus pyogenes . comparisons revealed some isolates with a mosaic structure in the operon, suggesting that horizontal transfer of genetic material has occurred. multi-resistance gene cluster on a plasmid in a clinical isolate of e. faecium pm werner g, hildebrandt b, klare i, witte w. department of nosocomial infections, robert koch institute, wernigerode branch, germany purpose: strain uw was isolated from an urine sample of a patient with a permanent catheter. the purpose of our study was to identify and localize the resistance determinants in this isolate. results: isolate uw was resistant to the following antibiotics: penicillin, ampicillin, gentamicin (high-level), streptomycin (highlevel), erythromycin, clindamycin, vancomycin, teicoplanin, ciprofloxacin, moxifloxacin, nourseothricin, rifampicin, and fusidic acid (lowlevel, mic / mg/l); but showed susceptibilities to oxytetracycline, phosphomycin, chloramphenicol, trimethoprim/sulfamethoxazol, linezolid, and quinupristin/dalfopristin. hybridization, pcr and sequencing experiments localized a cluster consisting of several resistance genes in a composite element on a plasmid. the cluster included genes and transposons tn (vana) Á/tn (ermb) Á/tn (aade Á/ sat Á/apha- ). the plasmid itself was not transferable in filter-matings into a fusidic acid high-level resistant enterococcus faecium recipient while selecting either for erythromycin or vancomycin resistances. however, after transposing a tn -related determinant into uw , determinants became mobilizable with the help of the conjugative transposon. transconjugants were, besides others, high-level resistant to fusidic acid, but susceptible to penicillin and ampicillin. pfge of transconjugants demonstrated a pattern almost identical to the recipient but clearly different from the donor. conclusion: resistance genes in e. faecium could be arranged in a cluster and are mobile via mobilizable/transferable plasmids. lilli d, rivanera d, barbacini ig, lozzi ma, mancini c. department of science and public health, university la sapienza, microbiology, rome, italy aim: hepatitis g virus (hgv), a new rna virus that is parenterally trasmitted has frequentley been found in patients with chronic hepatitis c infection but its role in chronic liver desease is unknown. the aim of this study was to determine the prevalence of hgv infection in patients infected with hcv. ninety-eight patients infected with hcv were evaluated for the presence of hgv rna. the hcv genotypes distribution was genotype b, genotype a, genotype a and four genotype c/ d. hcv rna and hgv rna were detected by rt-nested pcr. results: infection with hepatitis g virus was detected in ( . %) patients and ( . %) were hgv rna negative. none of our patients with genotypes a and c/ d results hgv rna positive. prevalence of hgv infection was % in patients infected with hcv genotype b and . % with genotype a. conclusions: infection with hgv occurred frequently ( . %) in this sample of patients with chronic hepatitis c. we observed a height prevalence of hcv/hgv coinfection in patients infected with hcv genotype a. this association with hcv genotype a was indipendent of the source of infection, infact some of our patients have not history of intravenous drug use. characterization of extended-spectrum beta-lactamase (esbl)mediated resistance in salmonella spp. from durban, south africa pm moodley p a , essack s b , gajee k a , sturm w a . a department of medical microbiology, nelson r. mandela school of medicine, school of infection, university of natal, durban, south africa , b school of pharmacy and pharmacology, university of durban westville, durban, south africa background: gastroenteritis is a common condition among the paediatric population presenting to king edward viii hospital in durban, south africa. from july , we noticed that the susceptibility of the salmonella spp. isolated from stool samples among these children were resistant to multiple antibiotics. aim: to characterize the phenotype of the resistance mechanisms involved. methods: minimum inhibitory concentrations (mics) of ampicillin, azithromycin, ciprofloxacin, cefepime, cefuroxime, cefotaxime, ceftazidime, ceftriaxone, cefoxitin, chloramphenicol, cotrimoxazole and gentamicin were determined by means of the agar dilution method. isolates were subjected to the e -test for extended-spectrum betalactamase (esbl) production. isoelectric focusing was performed as a preliminary step in enzyme characterization. results and conclusion: thirty isolates of multiresistant salmonella spp. were obtained. antibiogram typing revealed six different resistance phenotypes. all isolates depicted ceftazidime/ceftazidime Á/clavulanate ratio of !/ and were considered putative esbl-producers. isolates expressed Á/ beta-lactamases each with pi values ranging between and . indicative of tem-, shv-and/or ctx-m-related esbls. nine isolates expressed two beta-lactamases each and two isolates expressed three beta-lactamases each. there was evidence of the simultaneous expression of both tem-and shv-derived esbls as well as the simultaneous expression of multiple tem-or shv-derived esbls in single isolates, a phenomenon reported in esbl-positive klebsiella pneumoniae isolated at the same hospital. neutrophils exhibit reduced chemiluminescence response to serum opsonized klebsiella pneumoniae producing extended spectrum b-lactamases (esbl) pm objective: to investigate the ability of esbl and non-esblproducing klebsiella pneumoniae isolates treated with human serum to induce a chemiluminescence response in neutrophils. methods: oxidative burst induced by the interaction of esbl (n / ) and non-esbl-producing (n / ) klebsiella pneumoniae isolates with neutrophils from healthy individuals was monitored by measuring the chemiluminescence response (cl). pooled sera from healthy individuals served as source of complement for pretreatment of the bacteria. cl responses triggered by serum treated zymosan served as positive control. the serum opsonized klebsiella strains were arbitrarily graded as high (h) and low (l) inducers of cl when the cl response induced by the bacteria was cl b/ and !/ %, respectively, of that induced by opsonized zymosan. results: out of non-esbl-producing klebsiella isolates, . % induced high cl response in neutrophils whereas only % of esbl-producing klebsiella isolates did so (pb/ . ). conclusions: strains harboring the esbl plasmid were more virulent than non-esbl-producing strains by virtue of their higher tendency to escape serum-dependent recognition by neutrophils. osiris */an automated system for susceptibility testing in agar diffusion technique pm chegrani f, kolbert m, shah pm. universitätsklinik frankfurt, zentrum der inneren medizin med iii schwerpunkt infektiologie, frankfurt am main, germany objective: osiris measured zone sizes were compared to manually measured inhibition zones using round (rp) and mm mueller hinton square agarplates (sqp). variations of / mm in zone size measurements were defined as tolerable. 'very major errors' (vme) were defined as classification of a resistant organism as sensitive by osiris. thirty thousand two hundred and ninety-eight single measurements testing antibiotics on staphylococci and enterobacteriaceae were done according to the din recommendations. results: vancomycin, rifampicin, gentamicin gave the best results on rp with a concordance of , and %. vancomycin, rifampicin, teicoplanin performed best with , , % on sqp testing staphylococci . worst results on rp gave cefuroxim ( . %) and fosfomycin ( . %), on sqp fosfomycin ( . %), ofloxacin ( . %). for enterobacteriaceae amikacin ( %), gentamicin ( %), ciprofloxacin ( %) performed best on rp; worst nalidixinacid ( . %), piperacillin ( . %). concordance on sqp amikacin ( %), cefotaxim ( %), gentamicin ( %), nitrofurantoin ( . %), cotrimoxazol ( %). very major errors were seen in b/ % of all test performed. interpretation: osiris is a rapid and reliable system for susceptibility testing with round and square agarplates and has an excellent expert system. altindis m a , aktepe oc a , kocagoz t b . a kocatepe university school of medicine, microbiology, afyon, turkey , b diomed inc. tr, istanbul, turkey dio-bacit, in a two section plate, that contains % sheep blood agar on one side and sheep blood agar with bacitracin ( mg/ml) was compared for its efficiency in identification of group a beta hemolytic streptococcus (gabs) with other two different growth plates, one containing % sheep blood agar with bacitracin (b) and the other containing b-sxt. we used latex-agglutination for this comparision. throat specimens obtained from cases were inoculated to dio-bacit plates, first to one side with % sheep blood agar and to the other side with b. after an overnight inoculation at c, colonies with beta hemolysis an % sheep blood agar but no growth with b, were inoculated to % sheep blood agar again and antibiogram identification discs containing . u b and . and . mg sxt (oxoid, uk) were placed onto the plate and incubated overnight at c. after that, colonies with beta hemolysis were defined as b-sensitive while colonies resistant to sxt were defined to be gabs. all colonies are serologically classified by latex-agglutination (oxoid, uk). seventy-one ( . %) inoculations revealed growth of gabs at dio-bacit plates. after inoculating these colonies to % sheep blood agar, of them were found to be sensitive to b, while were found to be sensitive to b but resistant to sxt and of them were defined as gabs by latex test. when compared with latex-agglutination test, we found dio-bacit method's sensitivity and spesificity to be and . %, respectively. method: agar diffusion technique as recommended by din was used to determine izs (read using aura and manually) for staphylococci and enterobacteriaceae . variations in automated measured zone sizes of / mm to the manual readings were considered to be within acceptable range. results: six thousand and fifty-two zone sizes were determined for staphylococci and for enterobacteriaceae . mha displayed tendency to smaller zone sizes in automated readings than isa, as well in staphylococci and enterobacteriaceae . on the other side automated readings presented on isa more precise results than mha. overall less major discrepancies ( b/ mm) were found on isa. izs were generally smaller on mha. the tables below show differences in manually and automated measured zone sizes on different media and species. we discovered seven more cases of resistance in the case of metronidazole. we did not have such experience with clarithromycin. conclusion: our results show that e -test is comparable to ad for clarithromycin, but for metronidazole our findings confirm nccls recommendantion. classical ad is time consuming for every day use in the laboratory. the use of screening agar plate with mg/ml of metronidazole to detect possible resistance could be the solution. rokosz a a , sawicka-grzelak a a , meszaros j b , luczak m a . a department of medical microbiology, the university medical school, warsaw, poland , b department of bacteriology, state institute of hygiene, warsaw, poland purpose: to identify esbl-positive strains and to compare two methods applied for the detection of extended-spectrum beta-lactamases (esbls). methods: two hundred and sixty strains of gram-negative rods were cultured from clinical specimens from hospitalized patients. identification of strains was performed in the automatic atb system (biomerieux, france). these strains were identified as esbl-positive on the basis of the double-disc synergy test (ddst according to jarlier et al., ) results. all strains were also determined using a novel method of esbl detection (dd, diagnostic disc) according to appleton ( ) . two discs were applied in this test: cpd (cefpodoxime) and cd (cefpodoxime/clavulanic acid) (oxoid, england). results: consistent results of two methods (ddst and dd) were obtained in the case of from among of examined strains ( . %). consistent results concerned out of strains of enteric rods ( . %) and only five from among other strains (mostly nonfermenting rods). conclusions: the novel method of esbl-producers detection (dd) is more objective and easier for interpretation than the double-disc synergy test (ddst). diagnostic disc test should be used as the basic one or to confirm the results of ddst in difficult cases. assessment of e -test for determining penicillin resistance in pneumococci pm sener b, yeniþehirli g, ercis s, hasçelik g. department of clinical microbiology, hacettepe university medical faculty, ankara, turkey there is a greater need for susceptibility testing methods that distinguish between susceptible and resistant pneumococci. an alternative method could be the e -test, which is compared with the reference agar dilution method in this study. penicillin susceptibility of a total of pneumococci was determined by e -test and agar dilution methods. streptococcus pneumoniae atcc and enterococcus faecalis atcc were used as controls. the results were given in the effect of anoxic conditions on the minimum inhibitory concentration of metronidazole in helicobacter pylori pm de la obra sanz p, lomas e, roman jl, alarcon t, lopez-brea m. the objective of this study was to determine the effect of incubation under anoxic conditions on the metronidazole resistance of helicobacter pylori . methods: a total of clinical isolates were used in this study. mics were determined by an agar dilution method using mueller-hinton agar plus % lysed horse blood. three plates series contained twofold dilutions of metronidazole from to . mg/l were prepared. the first one was incubated under microaerophilic conditions (oxoid) for days; second and third series were incubated anaerobically (anaerobic system, oxoid) for and h, respectively, and were then transferred to the microaerophilic enviroment up to complete days of incubation. results: with microaerophilic incubation, of strains were resistant (mic and mic were and , respectively). with h anaerobic preincubation, four of strains were resistant (mic and mic were . and , respectively). with h anaerobic preincubation, of strains was resistant (mic and mic were . and , respectively). conclusions: anaerobic preincubations causes an increase in sensitivity to metronidazole, the extent of which was dependent on the length of the anaerobic period. methods: the susceptibility to antibiotics was performed by microdilution method according to nccls guidelines. the production of b-lactamase was tested by nitrocefin sticks (oxoid). results: the mics /mics (mg/ml) appeared, respectively: ampicillin / , amoxicillin/clavulanic . / . , cefaclor / , ceftriazone . / . , erythromycin . / . , azithromycin / . / . , clarithromycin . / . , ciprofloxacin . / . , imipenem / . / . , tetracycline / . / / . , trimethoprim/sulfamethoxazole . / . . b-lactamase was detected in . % of the strains. conclusions: ( ) m. catarrhalis isolates were uniformly susceptible to all tested antimicrobials except ampicillin. ( ) the production of blactamase was responsible for ampicillin resistance ( . %). ( ) m. catarrhalis strains had almost the same behavior 'in vitro' to the tested microlides (erythromycin, azithromycin, clarythromycin). rokosz a, sawicka-grzelak a, luczak m. department of medical microbiology, the university medical school, warsaw, poland purpose: to isolate, identify and determine the drug-susceptibility of fungal strains cultured from fecal samples routinely submitted for detection of clostridium difficile and its toxins in cases of antibioticassociated diarrhea (aad). methods: one hundred fecal samples from hospitalized patients were examined (may Á/october ). c. difficile toxins a/b were detected directly in stools with c. difficile tox a/b ii test (techlab † , usa). fecal specimens were inoculated on ccca and candida id (biomerieux, france) media. c. difficile and fungi were identified with standard microbiological procedures. susceptibility of fungal strains to anti-fungal agents was determined (atb fungus, biomerieux, france). results: c. difficile toxins were detected in and c. difficile strains were isolated from of examined specimens. sixty-two fungal strains of genera were cultured from stool samples ( c. albicans isolates). massive fungal growths were observed on primary plates in all cases. fifty-five fungal strains were susceptible to nystatin, -to fluorocytosine, -to amphotericin b, -to ketoconazole, -to miconazole and -to econazole. conclusions: in some cases of antibiotic-associated diarrhea fungal strains are responsible for symptoms of this disease. certain persons having aad should be treated with anti-fungal agents. results: a total of isolates ( . %) were penicillin nonsusceptible (intermediate and resistant) and ( . %) were erythromycin non-susceptible. non-susceptibility to both antibiotics was found in ( . %). conclusions: if penicillin administration eliminates all penicillin susceptible strains, the prevalence of penicillin non-susceptible strains will increase as well as the erythromycin non-susceptible ones. this means that the proportion of erythromycin non-susceptible strains should increase from . to . %. at the same time, if erythromycin eliminate all susceptible strains to this antibiotic, the prevalence of penicillin non-susceptible strains would increase from the initial . to . %. these data can explain the co-selection results observed in different surveillance studies. antimicrobial susceptibility and capsular types/groups of streptococcus pneumoniae isolates causing pneumococcal diseases in bulgaria pm setchanova l a , gergova r a , ioneva m b , sredkova v c . a department of microbiology, medical university, sofia, bulgaria , b department of microbiology, ii city hospital-sofia, sofia, bulgaria , c department of microbiology, faculty of medicine, pleven, bulgaria a prospective study of pneumococcal infections was performed in cooperation with five clinical microbiology laboratories in bulgaria. mics values to antimicrobials and serotype/serogroup distribution were determined for strains of streptococcus pneumoniae . pneumococci were isolated from patients with systemic or respiratory infections. the incidence of penicillin g-intermediate and penicillin gresistant isolate was . and . %, respectively. the rates of resistance to other antimicrobials were: cefotaxime/ceftriaxone */ . %; erythromycin */ . %; clindamycin */ . %; tetracycline */ %; chloramphenicol */ . %; trimethoprim/sulfamothoxazole */ %; ciprofloxacin */ . %; rifampin */ . %. the s. pneumoniae isolates belonged to capsular types/groups. the most common serotypes/serogroups in bulgaria are , , , , , , we aimed to determine the pneumococcal antibiotic resistance rates and the serotypes of those resistant isolates in our hospital. the mic values of isolates (year Á/ ) were determined by agar dilution method. serotyping was performed by using pooled antisera of the pneumo-test. the results were as follows (n / ). objectives: to asses the antimicrobial susceptibility of clinical isolates of pseudomonas aeruginosa obtained from to and to monitor trends in antimicrobial resistance. methods: mics were determined by microdilution testing according to nccls. the antibiotics tested were: ceftazidime (caz), aztreonam (atm), imipenem (imp), gentamicin (cn), tobramycin (tb), amikacin (ak) and ciprofloxacin (cip). results: a total of isolates were included. urine was the most common site of isolation for outpatients isolates ( . %) while for hospitalized patients respiratory samples were the most frequent ( . %). susceptibility to antibiotics was: % caz, . % atm, % imp, . % cn, . % tb, . % ak and . % cip. comparison of susceptibility data through Á/ showed that the increase in the resistance rate was significative for caz ( . vs . %), atm ( . vs %), cn ( vs %), tb ( . vs . %), ak ( . vs . %) and cip ( . vs %). significant differences were found under the following circumstances: isolates from intensive care units and from inpatients were significatively more resistant to caz, atm and imp. isolates from respiratory samples were more resistant to caz and atm and isolates from urine samples were more resistant to cip. conclusions: although the antimicrobial susceptibility level has been decreasing p. aeruginosa isolates still show good susceptibility percentages for all antibiotics tested. antimicrobial susceptibility testing of clinical isolates of bordetella pertussis : report on isolates from rouen, france pm lemee l a , nouvellon m a , caron f b , lemeland jf a . a chu rouen, bacteriologie, rouen, france , b chu rouen, maladies infectieuses et tropicales, rouen, france reports of an increased clinical incidence of pertussis and the development of resistance by bordetella pertussis to erythromycin prompted the collection and antimicrobial susceptibility testing of recent clinical isolates from patients, who were hospitalized in rouen between and . mics of nine antimicrobial agents (erythromycin, josamycin, spiramycin, roxithromycin, ketolide hmr , cotrimoxazole, ciprofloxacin, rifampicin and amoxicillin) were measured by agar dilution method on mueller-hinton agar containing % horse blood. mbcs of erythromycin and rifampicin were also determined against four isolates of b. pertussis . all isolates were fully susceptible to the nine antimicrobial agents tested. mics (mcg/ml) were . for erythromycin, ketolide hmr and ciprofloxacin, . for josamycin, . for spiramycin, roxithromycin and rifampicin, . / . for cotrimoxazole, and for amoxicillin. mbcs (mcg/ml) were . Á/ . for eyrthromycin and . Á/ for rifampicin. in conclusion, our isolates of b. pertussis remain extremely susceptible to all antimicrobial agents tested, especially macrolides. no resistance was detected. finally, if erythromycin remains the molecule of choice, other macrolides (c and c ) also confirm their good in-vitro activity. in addition, the good in-vitro potency of rifampicin, together with its great diffusion within the respiratory tract, suggests that rifampicin has potential clinical efficacy in pertussis too. the emergence of streptococcus pneumoniae (sp) with diminished susceptibility to penicillin g (psdp) suggests the use of other antibiotics such as newer fluoroquinolones (fq). the resistance phenotypes of consecutive pneumococcal strains isolated from patients of four hospitals (observatoire régional des pneumocoques du nord-pas de calais) were studied: strains were susceptible to penicillin g and were psdp. reference strains provided from the centre national de réfeacute;rence des pneumocoques were added to the study. the activity of pefloxacin, ciprofloxacin, norfloxacin, sparfloxacin, levofloxacin and moxifloxacin was studied. reserpine was used to detect the efflux phenotype. methods used were performed according to the recommendations of the comité de l'antibiogramme de la société française de microbiologie. for each strain, the resistance phenotype to fq was deduced by comparison of mics or diameters obtained with those obtained with the reference strains of known phenotypes. fq resistance phenotypes were not correlated to blactam agent susceptibilities. wild type phenotype was observed among . and . % of the susceptible and psdp strains, respectively. a 'wild efflux' mechanism, deduced by addition of reserpine to norfloxacin, represented the predominant phenotype. it was detected among sp susceptible to penicillin g ( . %) as well as among psdp ( . %). the aim of this study was to determine macrolide resistance phenotypes of sp isolated in three french departments (alpes maritimes, doubs, nord) from nasopharyngeal aspirates of children aged months to years attending a dcc. a random sample of children attending randomly selected dccs was obtained during three periods (spring, autumn and winter ) in each department ( children attending dccs and children sampled). analysis of macrolide susceptibility of sp strains was performed using the ca-sfm method. out of strains, . % had decreased susceptibility to penicillin (spdp) and . % were resistant to erythromycin. the triple disk diffusion method (erythromycin (e), clindamycin (cl) and spiramycin) was used to determine resistance phenotypes. macrolide resistance is a well known phenomenon in france and is confirmed by our study. these results show that the constitutive phenotype is predominant as in other parts of europe and the frequency of efflux mechanism is lower than that observed in the usa and canada. developing antibiotic resistance surveillance of helicobacter pylori in england and wales pm elviss nc, owen rj. central public health laboratory, laboratory of enteric pathogens, london, uk purpose: helicobacter pylori antibiotic resistance is a key contributing factor in Â/ % of infected patients failing drug treatment. our aim was to survey rates of primary in-vitro resistance at different locations, and links to disease severity. antral gastric biopsies/cultures were received from phls in chelmsford, mid-essex ( isolates Á/ ); london ( isolates Á/ ); and bangor, north wales ( isolates Á/ ). susceptibilities to metronidazole (mtz), clarithromycin (cla), tetracycline (tet) and amoxicillin (amx) were tested by disc diffusion and also by e -test for cla and mtz. results: overall resistance rates ( isolates) were % for mtz and % for cla. all were susceptible to amx and tet. dual resistance rate was %. breakdown by location showed some marked differences. mtz resistance was highest in london ( %) compared to % in chelmsford and % in bangor. by contrast cla rates were % for london, and about % for bangor and chelmsford. in london, the majority of mtz resistant isolates were from non-uk borne individuals ( % non-uk vs % uk). comparison of duodenal ulcer-associated isolates with those from non-ulcer patients indicated similar rates of mtz resistance ( %). conclusion: resistance rates may vary significantly between locations depending on the local population with non-uk birth being a key risk factor for primary resistance with a mtz resistant strain. local resistance rates should be taken into account in test and treat strategies. potrykus j, benetkiewicz m, wegrzyn g. department of molecular biology, university of gdansk, gdansk, poland purpose of the study : because of their ability to extrude a wide range of compounds, multidrug efflux pumps have recently become an important issue in combating bacterial infections. acrab-tolc is the major efflux system of escherichia coli . we investigated the effect of acra on plasmid-borne and intrinsic chloramphenicol, tetracycline and ampicillin resistance. results and conclusions: recently, we reported a chloramphenicol sensitivity of e. coli mutant expressing cat , the chloramphenicol resistance gene. the strain was shown to bear a nonsense mutation in the acra gene. our studies indicate that this mutation is, at least in part, responsible for the observed chloramphenicol sensitivity phenotype. the mutation seems also to influence the strain's susceptibility to ampicillin and teta (c )-mediated (plasmid-borne) tetracycline resistance. although the teta(c) protein retained its biological function, there was a considerable growth impairment of the mutant strain when cultured in tetracycline containing medium. deletion of the acrab locus prevented any growth in the presence of tetracycline. upon the addition of ampicillin, the mutant underwent lysis more rapidly than the control strain. such was also observed in acrab deletion derivatives of other e. coli strains. we are trying to elucidate the role of the acra gene product in the phenomena described above. existence of efflux pumps in wild type isolates of drug-resistance bacteria pm raja ray rr. medical microbiology and parasitology, calcutta university, kolkata, india efflux pumps possessed by the bacterial cells of different kinds of bacteria had presented as a newer mode of drug resistance in many organisms. the capacity of bacterial cells to cause outward flow of noxious agents was known, however, for a considerable time with respect to tetracycline. recently, interest in the efflux pump system has brought to light some previously ill-understood mechanisms of drug resistance, involving noxious agents, toxins or poisons. we have found high level of resistance in pseudomonads towards cetrimide and other germicides for which no definite chromosomal/plasmid-mediated genes/mechanisms could be identified. likewise, occurrence of nonantibiotic sensitive vibrios, staphylococci and pseudomonads in the background of their high level of resistance to most of the common antibiotics suggest a mechanism of interference with the efflux pump, which accounts for such sensitivity in such cases. involvement of multiple resistance of marine isolates of v. parahaemolyticus to numerous clinically used antibiotics to which they have never been exposed also suggests a possible role of efflux pumps in determining such resistance */that these can simultaneously develop against multiple marine toxins/poisons and other noxious agents. interaction between oxacillin and glycopeptides in a teicoplanin-resistant mutant of staphylococcus epidermidis with reduced susceptibility to vancomycin pm greco aa, ben hassen a. laboratory service of national bone-marrow transplant center, tunis, tunisia we selected a laboratory-generated mutant of staphylococcus epidermidis capable of growing in the presence of mg/l of teicoplanin ( b tm ), from a methicillin-resistant (mic!/ mg/l), teicoplanin-sensitive (mic mg/l) and vancomycin-sensitive (mic mg/l) clinical isolate of s. epidermidis ( b so). in a previous work, we studied the different phenotypic characteristics acquired by the teicoplanin-resistant mutant b tm ( th interdisciplinary meeting on anti-infectious chemotherapy, december , poster sessions, /p ). in this work, we examined the interaction between oxacillin and glycopeptides against this teicoplanin-resistant mutant of s. epidermidis with reduced susceptibility to vancomycin. to study the combined antibiotic activity of oxacillin and glycopeptides, we used different methods: a modified disk diffusion test, the e -test, time-kill assays and population analysis profiles. the synergistic activity of glycopeptides in combination with oxacillin against the teicoplaninresistant mutant b tm was demonstrated with a bactericidal effect. no synergy was seen against the parental strain b so. moreover, the synergy between glycopeptides and oxacillin occurred with suppression of the subpopulation with the highest level of glycopeptides resistance. we concluded that combination of glycopeptides and oxacillin may be a possible alternative in the treatment of infections caused by methicillin-resistant, teicoplanin-resistant s. epidermidis . compositional changes in microcosm biofilms induced by application of minocycline: a preliminary study pm the aim of the study was to observe the effect of application of minocycline upon microcosm dental plaques. the plaques were cultivated in a constant departmenth film fermentor (cdff), which produces biofilms under conditions mimicking those present in vivo. the composition of the biofilms was determined by viable counting on selective and non-selective media. the proportion of antibiotic resistant genera within the biofilm was determined by viable counts utilising media containing minocycline ( mg/ml). before commencing antibiotic pulsing, the biofilms had a total viable anaerobic count of . )/ cfu per biofilm, with negligible ( cfu/biofilm) minocycline-resistant bacteria. however, h after introduction of the antibiotic, the total count had been reduced to . )/ cfu/biofilm whilst the number of minocycline-resistant bacteria had risen to . )/ cfu/biofilm. at the final sampling time point ( h) the total viable anaerobic count was . )/ cfu/biofilm whilst the number of minocycline-resistant bacteria was . )/ cfu/biofilm. hence, there is a very low basal level of inherent resistance to minocycline within microcosm dental plaques, but this increases considerably once the biofilms are exposed to minocycline. mechanism of resistance to aminoglycosides (amg) e. coli isolated from children with community-acquired urinary tract infections (cau-tis) pm methods: during the Á/ years nine centers took part in the study. the mics of antimicrobials were determined by the agar dilution method as described in the nccls guidelines. results: a total of consecutive urine isolates from children aged month to years with cauti were collected. the most frequently isolated species from children with cauti was e. coli ( . %), followed by klebsiella spp. ( . %) and proteus spp. ( . %). results of the in vitro susceptibility testing of e. coli to amg are shown in table below. resistance of the strains was conditioned on production of amg-modifying enzymes. there has been found following phenotypes among resistance strains: gentamicin Á/ tobramycin Á/netilmicin ( . % */aac( )-v and . % */aac( )-iv enzymes) and gentamicin Á/tobramycin ( . %, due to ant( ƒ) enzyme). conclusion: amikacin is most active amg against e. coli . resistance to gentamicin and netilmicin was mainly determined by production of aac( )-v enzyme. effect of b-lactamase inhibitors (b-l-i) on the evolution of resistance (r) to b-lactams (b-l) in gram the b-lactams antimicrobials still are the most frequently used. among the bacteria responsible of high resistance to b-lactams are gramnegative rods; its most frequent mechanism is the production of b-lactamase. the use of b-l-i has reversed partially this mechanism of resistance. we expect changes in the frequencies of r using b-lƒci after more than years. since , the venezuelan group of bacterial resistance, with health institution in the country; analyse and publish data on bacterial resistance of isolates from patients with bacterial infection coming from hospitals. it was used diffusion disk, according nccls. the software program whonet (world health organization net) was used. we follow the trends of r of gram-negative rods to b-l alone and with b-l-i during the decade Á/ . statistical analyses were made by evaluating the differences among percentages of resistance between the two series (p / . ). results and discussion: the difference in r between b-l and b-l/b-l-i are: ( ) piperacillin, piperacillin/tazobactam: between and % of r for most isolated, except for escherichia coli ( %) and serratia spp. ( %); ( ) ampicilin, ampicilin/sulbactam: between and %; ( ) cefoperazone, cefoperazone/sulbactam: between and %. how is expected gramnegative rods resistance to b-lactams with a b-l-i is lower than the b-lactam alone; furthermore the difference between both series, grows higher with time. these results are relevant and they were not expected, since b-l-i have been shown to be b-lactamase inductors. trends in the resistance (r) to b-lactams and others antimicrobials in p. aeruginosa in venezuelan medical centres. nosocomial (nos) and communitarian resistance pm in order to approach the infection produced by resistant bacteria, it is convenient to consider the hospital and the community as two separate ecosystems. the hospital ecosystem has special relevance in the infection and r of gramnegative aerobic bacilli. today, they are the main responsible of nos infection, with special reference to pseudomonas aeruginosa . infection by resistant bacteria is a world wide problem, specially related to nos. since , the venezuelan group of bacterial resistance, with health institution in the country; identify, analyse and publish data on bacterial r to antimicrobials: b-lactams, quinolones and aminoglicosides of isolates from patients with bacterial infection coming from hospitals and the community. it was used diffusion disk, according nccls. the software program whonet (world health organiza-tion net) was used. statistical significance (p / . ) was determined by application of the x technique. we show significant differences in the r of p. aeruginosa nos and communitarian (highest differences: piperacilina / %, tobra / %). we also established significant differences between the r arising in public hospitals and private hospitals (highest differences: ceftazidime / %, amika / %). we show the tendency in decreasing of frequency of r since ; this is more evident in private hospitals (b-lactam and aminoglicosides). new antimicrobials and new mechanism of action, and in the future the new technology will solve today's problem. however, the most important tools we have today are prevention and antimicrobials, and we must make them suitable. susceptibility to antibiotics of enterobacter cloacae and citrobacter freundii from drinking water pm quintera sm, sousa jc, peixe l. department of microbiology, faculty of pharmacy, university of oporto, oporto, portugal the increased use of antimicrobials in farming, together with the practice of raw sewage discharge into receiving waters, has resulted in a significant increase in the number of antibiotic resistant bacteria present in aquatic environment. our objective was to determine the antimicrobial susceptibility, with focus on b-lactam resistance, among enterobacteriaceae strains isolated from raw drinking water samples. several isolates (n / ) of enterobacter cloacae and citrobacter freundii obtained from drinking waters were screened for antibiotic susceptibility patterns, using the agar diffusion technique, according to nccls's procedures. only % of e. cloacae strains, as well as % of c. freundii strains show resistance to amoxicillin and amoxicillin/ clavulanic acid. a reduced incidence of resistance to several others antibiotics was also observed. the obtained results suggest that strains isolated from raw drinking water have greater susceptibility to antimicrobial agents than pathogenic strains from hospital or outpatients infections. the 'natural' antimicrobial resistance phenotypes, usually described for c. freundii and e. cloacae , only seem to apply to strains isolated from human infections. notwithstanding the high susceptibility of the tested isolates to b-lactams, the role of environmental bacteria as a reservoir of resistance genes justify its periodical monitoring as a valid index for resistance spreading. a snapshot of the soil. using bacterial communities for tracing the evolution of metal-resistance pm quintera sm a , sousa jc a , peixe l a , monteiro nm b . a department of microbiology, faculty of pharmacy, university of oporto, oporto, portugal , b department of zoology and anthropology, faculty of sciences, university of oporto, oporto, portugal it is well known that pathogenic bacteria, specially those resistant to antimicrobial agents and heavy metals poses public health risks of great concern, and its detection, namely in soils is generally related to pollution. in this study, the heavy metal resistance patterns of the microflora isolated from polluted (dump area) and unpolluted soil environments were examined. the plate growth covering percentage in the soil samples was determined using mueller-hinton plates supplemented with different heavy metal (al '/, cd '/, cu '/, pb '/, hg '/ and zn '/) concentrations. parallelly, using icp-aes, it was possible to ascertain the real heavy metal concentration for each soil sample. we found that the percentage of plate growth covering from the used samples was closely linked to the level of chemical pollution measured for each location. moreover, using anova, we found significant differences between locations. the dump site showed the highest tolerance to all the tested metals (newman Á/keuls test). this pattern of results was consistent when using the data from the icp-aes. furthermore, it was possible to observe that pseudomonas spp., with a relatively high mic for the studied metals, might become a relevant model for both public health issues and eco-toxicological studies. biochemical characteristics of environmental isolates of listeria monocytogenes pm moshtaghi h a , garg sr b , mandokhot uv b . a shahrekord university, food hygiene, shahrekord, islamic republic of iran , b haryana agricultural university, food hygiene, hisar, india purpose: the investigations were carried out to study the biochemical reactions of listeria monocytogenes isolated from different sources in the environment. results: a total of isolates of l. monocytogenes were obtained from samples of agricultural soil, faecal matter of animals and sewage. all the isolates were gram-positive, small rods, catalase positive, oxidase negative, motile with tumbling motility in hanging drop at Á/ c, aerobic, facultative anaerobic, fermentative and produced acid from glucose. all the isolates of l. monocytogenes were beta haemolytic and positive for camp reaction with staphylococcus aureus . all the isolates were negative for phenyl alanine deaminase, ornithine decarboxylase, lysine decarboxylase, malonate utilization and beta galactosidase tests. these were also negative for acid production from arabinose, d-xylose, mannitol, soluble starch and sucrose but acid was produced in rhamnose, salicin, and trehalose. hydrogen sulfide production was recorded in tripticase soy broth with lead acetate paper strips but negative with triple sugar iron agar. all the isolates were found to hydrolyse aesculin. out of isolates of l. monocytogenes only two produced acid from lactose. in serotyping all the isolates were serotype b. conclusion: we can conclude that l. monocytogenes serotype b at least in fermentation of lactose shows different reactions. methods: the samples were pre-enriched in bhi broth with and without vancomycin ( mg/l) and then plated onto m-enterococcus agar with and without antibiotics: vancomycin ( mg/l), gentamicin ( mg/l), kanamycin ( mg/l), and streptomycin ( mg/l). representative colonies of each morphology were isolated and identified as enterococcus sp as previous described. pcr was used to identify e. faecium and e. faecalis and to characterise vancomycin resistant genotype. api strep was also used in the identification. susceptibility testing to antibiotics was performed by an agar dilution method (nccls). results: three hundred and fifty-three enterococci were isolated from of a total of faecal samples ( %, n / / ). the majority of enterococci were identified as e. faecium , e. faecalis and enterococcus sp. resistance to almost all antibiotics studied was observed: vancomycin */ . %; teicoplanin */ . ; ampicillin */ . %; tetracyclin */ . ; erythromycin */ . %; ciprofloxacin */ . %; chloramphenicol */ . %; gentamicin */ . %; streptomycin */ . %; kanamycin */ . %; linezolid */ %. the vancomycin resistant enterococci presented a vana genotype. conclusion: resistance to several common antibiotics used in therapy was observed among enterococci isolated from healthy human from community. many of these isolates presented multi-resistance. of concern is the presence of vana genotype among these populations that may constitute a reservoir of vancomycin resistant genes. antimicrobial resistance in tetracycline-resistant oral bacteria pm mercury release from dental amalgam may select for mercuryresistant oral bacteria. mercury resistance is often associated with multiple antibiotic resistances. the aims of this study were to determine whether tetracycline-resistant oral bacteria from children with and without amalgam fillings were also resistant to: (a) mercury; and (b) multiple antibiotics. tetracycline-resistant organisms were isolated on iso-sensitest/blood agar containing tetracycline ( mg/ml). the mic of hgcl and several antibiotics were determined using agar dilution (bsac). one hundred and three organisms were isolated from patients without amalgam. ninety-one were streptococcus species, seven neisseria species, three veillonella dispar and two rothia species. fifty-seven percent exhibited resistance to at least one antibiotic, % were mercury-resistant, % were penicillin-resistant, % were ampicillin-resistant and % erythromycin-resistant. fiftytwo organisms were isolated from patients with amalgam. forty-five were streptococcus species, five neisseria species, one v. dispar and one staphylococcus aureus . sixty-three percent exhibited resistance to at least one antibiotic, % were mercury-resistant, % penicillinresistant, % were ampicillin-resistant and % showed erythromycin-resistance. statistically, the results showed that in tetracyclineresistant organisms, the presence of dental amalgam did not affect the level of resistance to mercury or to the antibiotics tested. conway-wallace hl a , mullany p a , bedi r b , wilson m a . a eastman dental institute, university college london, microbiology, london, uk , b eastman dental institute, university college london, transcultural oral health, london, uk the purpose of this study: to determine the prevalence of antibioticresistant oral bacteria in children who had not received antibiotics during the months prior to sampling. plaque samples were obtained from children aged Á/ years and plated onto media containing: penicillin, ampicillin, tetracycline, erythromycin and vancomycin. resistant isolates were enumerated, sub-cultured and frozen for subsequent identification. the process was repeated and months later. the results obtained: bacteria resistant to each of the antibiotics were present in all of the children at each sampling time (except in the case of ampicillin and penicillin at months). the proportion of antibiotic-resistant bacteria in the oral microflora ranged from ]/ . (erythromycin) to / . % (ampicillin). the proportions of bacteria resistant to a particular antibiotic remained reasonably constant over the -month sampling period. in only two cases (penicillin and ampicillin) was there a statistically significant change in the proportions of resistant bacteria at different time periods. the conclusion reached: the results of the study have revealed that bacteria resistant to a wide range of antibiotics may be isolated from children who have not been administered these agents during the months prior to sampling. furthermore, in many cases the proportion of bacteria resistant to a particular antibiotic remains constant over a -month period. antimicrobial use in the intensive care unit: results of a pharmacoepidemiological study in italy pm periti p. e.i.f.t. srl, firenze, italy a retrospective survey of antimicrobial chemotherapy use in intensive care units in italy was carried out in using a computerized questionnaire under the auspices of the journal of chemotherapy. of the icus contacted, . % replied, being mainly general or post-surgical and pediatric units having a mean of beds, nine doctors and nurses. the antimicrobial agents used in these wards were almost always polychemotherapy with prevalent use of beta-lactams, aminoglycosides and glycopeptides or as empirical treatment during the first h after hospital admission. the continual use of medium-high dose combinational antimicrobial chemotherapy was justified by microbiological testing, which revealed that more than one-third of bacterial pathogens were resistant. approximately, % of gram-positive bacteria were methicillin-resistant, whereas about % of gram-negative strains were resistant to at least one of the tested antibiotics. forty percent of the responding icus furnished microbiological testing data, of which three quarters indicated the incidence of chemoresistance of the isolated strains. fungal infections were less frequent than bacterial, the most commonly isolated agent being candida spp. in conclusion, the sample of icus examined showed adequate and reasonable use of antimicrobial agents, with heavy reliance on medium-high dose combination therapy due to the elevated incidence of resistant isolates found. plasma concentrations (p), urinary excretion (u) and bactericidal activity of gatifloxacin (gat) mg versus ciprofloxacin (cip) mg in healthy volunteers after a single oral dose pm boy d a , kinzig-schippers m b , sö rgel f b , well naber kg a . a hospital st. elisabeth, urologic clinic, straubing, germany , b institute for biomedical and pharmaceutical research, ibmp, nürnberg-heroldsberg, germany twelve volunteers received a single oral dose of mg gat versus mg cip to assess p up to h, u (by hplc), and urinary bactericidal titers (ubt) in eight intervals up to h. the mean pmax of gat/cip was . / . mg. the ucum (mean) for gat/cip was . / . %. the ubts, i.e. the highest twofold dilution of urine still bactericidal, were determined for nine uropathogens and one reference strain */mics (mg/ml) (microdilution) for gat/cip: escherichia coli atcc ( . / . ); e. coli ( . / . ); klebsiella pneumoniae ( . / . ); proteus mirabilis ( . / . ); pseudomonas aeruginosa ( / . ); s. saprophyticus ( . / . ); two strains of s. aureus ( . / . ); two strains of e. faecalis ( . / and / ). the median ubts measured within the first h for gatifloxacin were between : and : for the five gram-negative strains (incl. p. aeruginosa ) and between : and : for the five gram-positive strains. the median ubts for ciprofloxacin were between : and : for the gramnegative strains (incl. p. aeruginosa ) and between : . and : for the five gram-positive strains. for the ubts up to h, gat was significantly superior to ciprofloxacin in all gram-positive strains, not different in the two e. coli strains, and inferior in the klebsiella , proteus and pseudomonas strains. for the ubts at Á/ h, gat was generally superior to cip, but showed no difference in the proteus and pseudomonas strains. gat showed overall comparable urinary bactericidal activity as cip. this is in agreement with a clinical study performed previously. malaria is one of the most prevalent endemic infectious disease affecting humans. in bichat hospital cases of malaria acute illness were reported during . among them, patients were hospitalised and intravenously treated by quinine. this retrospective study consisted of comparing the therapeutic drug monitoring (tdm) of quinine distinguishing, respectively and patients cured in infectious medical department (imd) and intensive care unit (icu) where a standardised quinine regimen was established ( and % malaria attacks, respectively). in icu, the treatment consisted of an infused loading dose mg/kg/ h of quinine diluted in % glucose followed by mg/kg/day. plasma quinine maximal concentrations were assessed after selective liquid Á/liquid extraction and spectrofluorometry detection. statistical analysis was performed using t -test. results showed that patients had comparable weight ( . / . and . / . kg) but quinine doses and plasma concentrations were significantly different in icu and imd, respectively ( . / . versus . / . mg/kg/day, pb/ . and . / . versus . / . mg/l, p b/ . ). in icu and imd, respectively: and % were in the therapeutic range ( Á/ mg/l) with and % below the requested therapeutic concentration ( mg/l) and and % above the limit of toxicity ( mg/l) conveying the importance of tdm in intravenous quinine treatment to avoid infra-therapeutic or toxic concentrations. simultaneous central nervous system distribution using microdialysis and pharmacokinetic Á/pharmacodynamic modelling of the electroencephalogram effect of norfloxacin in rats pm chenel m, marchand s, dupuis a, bouquet s, couet w. university of pharmacy, pharmacology, poitiers, france purpose: to investigate the epileptogenic activity of norfloxacin by a pharmacokinetic Á/pharmacodynamic (pk Á/pd) modelling approach and to assess the contribution of distributional processes across the blood Á/brain barrier (bbb) to the delayed effect. methods: rats (n / ) received an iv bolus dose of norfloxacin ( mg/kg). convulsant effect was quantified by electroencephalogram (eeg) recording during h post-dose. arterial blood samples were collected for drug assays in plasma. unbound norfloxacin concentrations were monitored in brain extracellular fluid (ecf) using microdialysis with in vivo calibration of the probes by retrodialysis with ciprofloxacin. results: the eeg effect reached its maximum between and min post-dose. a pk/pd effect compartment model was successfully fitted to these data. the relationship between effect and concentration at the effect site was best described by a spline function. norfloxacin concentrations in brain ecf were relatively low compared to plasma levels (ecf/plasma areas under curve (auc) ratio equal to . / . %), but central distribution was rapid. therefore, the effect versus brain ecf concentrations curves still exhibited a marked hysterisis. conclusion: the delay observed between plasma concentrations and norfloxacin convulsant effect cannot be explained by a slow distribution of norfloxacin across the bbb. pagoulatou a a , kanellakopoulou k b , vafiadou m a , kostakopoulos th c , kastriotis i b , giamarellou h c . a department of anesthesia, sismanoglio general hospital, greece , b th department of internal medicine, athens medical school, athens, greece , c department of urology, athens medical school, athens, greece csf kinetics of van and fu were studied in patients who underwent short urological surgery under spinal anesthesia. patients were excluded if they were already receiving an antibiotic or were suffering from renal and hepatic dysfunction. van was administered at g over h infusion. serum and csf samples were collected post-dose and the mean serum levels were as follows: min Á/ h: . mg/ml (five patients), Á/ h: . mg/ml (five patients), Á/ h: . mg/ml (six patients), Á/ h: . mg/ml (six patients) and Á/ h: . mg/ml (seven patients). fu was administered at mg dose over h infusion. serum and csf samples were taken post-dose and the mean serum concentrations were found as follows: Á/ min: . mg/ml (six patients), min Á/ h: . mg/ml (six patients), Á/ h: . mg/ml (five patients), Á/ h: . mg/ml (six patients), Á/ h: . mg/ml (five patients). in csf, both van and fu were undetectable. it is concluded that in the absence of meningeal inflammation van and fu do not penetrate (with the applied microbiological assay) the csf barrier. comparison of the pharmacology of intravenous and orally given moxifloxacin in an in-vitro model pm wiegand i, pfeil e, wiedemann b. university of bonn, pharmaceutical microbiology, bonn, germany purpose: the intravenous form (iv) of mg moxifloxacin (mox), one of the newer fluoroquinolones, has been recently approved by the fda. during the iv treatment higher peak serum concentrations are achieved in comparison to the oral administration (po) of the same dose. the antibacterial activity of fluoroquinolones is concentration dependent. we therefore simulated human pharmacokinetics of single po and iv dosages of mg mox in an in-vitro model using six different gram-negative and -positive pathogens to elucidate the different effect of these two dosing schedules. results: the comparison of the pharmacological parameter auc/ mic shows an increase ( table ) that could predict an enhanced antibacterial effect. however, the analysis of the killing curves with the following parameters, ka.max (maximal killing activity) and aac (area above the killing curve between and h), reveals no major difference between the po and iv dosage. conclusion: the serum concentration after oral administration is already sufficiently high to show the optimal bactericidal effect of mox that can only be slightly increased by higher peak concentrations and higher auc/mic ratios. thus the concentration dependence is not linear but ends already at concentrations achievable by oral dosing and documents that auc/mic calculations cannot easily be translated into dosing schedules. background : bacteria growing in vivo multiply much more slowly than in vitro. whether the bactericidal activity of quinolones may be affected by an increase in generation time (g) was studied in batch cultures. methods: by limiting the nutrient supply, generation times were lengthened from approximately . to . h up to . h. alternatively, the quinolones were added to the bacterial cultures during the lag-, exponential-and stationary phase. recent clinical isolates of escherichia coli were exposed to multiples of the mics of ciprofloxacin or norfloxacin. the 'killing rates' were calculated in analogy to the growth rate. results: the bactericidal activity of the quinolones tested against e. coli was minimally influenced by the reduced generation time. ciprofloxacin concentrations of ]/ )/mic eliminated the test strains within / h from the test system if added during the lag or exponential growth phase; four times higher concentrations were needed to reduce cfus by % within h, if added during the stationary phase. norfloxacin was significantly less active. conclusion: in contrast to norfloxacin, the bactericidal activity of ciprofloxacin is minimally affected by the generation time or growth phase of the bacteria. wiegand i, pfeil e, wiedemann b. university of bonn, pharmaceutical microbiology, bonn, germany purpose: moxifloxacin (mox) is one of the newer fluoroquinolones, now available for parenteral application. the pharmacology of an intravenous once-daily dose (od) of mg mox was determined with five gram-negative and -positive pathogens (streptococcus pyogenes , streptococcus pneumoniae , moraxella catarrhalis , escherichia coli , and klebsiella pneumoniae ). a twice-daily dose (bid) of mg mox was simulated with the gram-positive species in order to increase the bactericidal effect. results: to determine the efficacy, killing curves were analyzed, and following parameters were calculated: ka.max: maximal killing activity [log cfu]; ka. conclusion: an intravenous once-daily dose of mox is active against all tested pathogens. the gram-negative species are rapidly killed (ka. h similar to ka.max). there is no pronounced initial effect on the two gram-positive species but a general slow reduction in the viable cell count (ka.max is reached after h). the efficacy of mox (measured as aac and ka.max) on s. pyogenes and s. pneumoniae is to some extent increased after the second dose. however, the analysis of the killing curves reveals no major difference between od and bid. even the od nearly gives the maximal bacterical activity of mox against gram-positive pathogens. objectives: to evaluate the dose proportionality of amoxicillin and to compare the respective pk/pd parameters of two dosage regimens. methods: the dose proportionality of amoxicillin was evaluated using linear regression of mean auc -inf and c max data of different bioequivalence studies (n / volunteers) performed with formulations containing various amounts of amoxicillin alone or in the combination with clavulanic acid. the volunteers received a single oral dose in the range of Á/ mg. amoxicillin plasma concentrations were determined by hplc/uv or lc/ms/ms methods. time above mic (tmic) expressed in% of dosing interval was calculated with three target mic values ( . , . and . mg/l) for mg hourly and g -hourly dosage regimens. results: the absorption of amoxicillin (auc -inf ) showed a linear dependence with a correlation coefficient of . . the correlation coefficient of the linear regression for the cmax dependence on the actual dose was . . the respective tmic for both dosage regimens were very similar, with largely overlapping confidence intervals, supporting a pd breakpoint of mg/l for the g -hourly regimen (tmic ]/ mg/l: . %, % ci . , . %). conclusion: this analysis shows the dose proportionality of amoxicillin over the dosage range of Á/ mg and supports the pharmacodynamic rationale for a g bid dosage regimen. piperacillin/tazobactam concentration profile after high dose administration pattern in nosocomial pneumonias due to mecanical ventilation pm pedeboscq s a , gruson d b , bassoua v a , hilbert g b , pometan jp a . a st. andré hospital, pharmacy, bordeaux, france , b pellegrin hospital, reanimation, bordeaux, france the piperacillin (p)/tazobactam (t) antibacterial spectrum covers the largest part of bacteria responsible for pneumonias due to mechanical ventilation. but, due to important bacterial inoculum and pharmacokinetic parameter modifications in intensive care patients, high doses of beta-lactamines seem to be necessary to obtain antibiotic concentrations above suspected bacteria's mic (minimal inhibitory concentration) . this led us to compare, in patients with pneumonia due to mechanical ventilation, two intermittent administration patterns: g three times a day (usual pattern) versus g four times a day (high dose pattern). this study is carried out in collaboration with intensive care unit, bacteriological department and pharmacy where antibiotic concentrations are determined. twenty-three takings of blood are executed within a h period, in addition to two bronchial secretion samples. concerning p seric concentrations, the high dose pattern seems to be more adapted because of relatively high residual concentrations ( !/ mg/ml). three hours after each injection, t seric concentrations are lower than the mg/ml activity threshold. first and second day residual bronchial concentrations of p seem to be sufficient although t concentrations are below activity threshold. these results are to be correlated with the mic determined by the bacteriological department, and only this correlation will make us able to conclude the better efficacy of the high dose pattern in intensive care patients. anti-inflammatory drugs interference in absorption and tissue penetration of amoxycillin pm del fiol fs a , menon sz b , caramez th b , celotto tf b , lopes ras b . a university of sorocaba, pharmacology, sorocaba, brazil , b school of pharmacy, university of sorocaba, sorocaba, brazil antibiotics and anti-inflammatories are frequently associated in clinical practice. there is some concern about the quantity of antibiotic that reaches the infection sites, which may be reduced in the presence of an anti-inflammatory drug. the purpose of the present study was to analyse how steroids (dexamethasone (dexa)) and aines (celecoxib (cele)) influence on the penetration of amoxicillin to inflamed tissues. thirty female rats (rattus norvegicus ) were used with surgically implanted pvc sponges on their backs to form granulomatous tissue. one week later the animals were divided into three groups. one group received only amox ( mg/kg), another received amox ( mg/kg) plus cele ( . mg/kg) and the last received amox ( mg/kg) plus dexa ( . mg/kg). one hour later the animals were sacrificed and the concentration of amoxicillin in the serum and tissue investigated. there was no difference among the groups in the quantity absorbed (amox / . / . mg/ml; amox'/cele / . / . mg/ml and amox'/dexa / . / . mg/ml). there was a reduction in the tissue concentration of amoxicillin (p b/ . tukey-kramer) for the group that received the drug with dexamethasone. for the other groups, there was no difference in the tissue concentration of amoxicillin. the results indicated that in inflamed tissue, a significant reduction of antibiotic penetration was induced by sinultaneous dexamethasone therapy. prediction of the optimal amoxicillin dose regimen based on coupling of pharmacokinetic data and bactericidal activity pm background: given its short half-life, amoxicillin (amx) should be administered at least three times a day to patients with acute exacerbations of chronic bronchitis, in order to achieve serum concentrations well above the mic of the responsible pathogen. however, several authors have recommended twice-daily administration of a higher dose for a shorter period. we assessed the relationship between amx sputum concentrations and antibacterial activity following two treatment schedules in healthy volunteers. subjects and methods: twelve healthy volunteers were randomized to receive amx for days at a dose of either g bd or mg bd. serum and sputum were collected every day, h after the morning administration, and again days after the last dose. amx concentrations were determined by hplc with fluorometric detection. sputum killing activity was determined against haemophilus influenzae , streptococcus pneumoniae and moraxella catarrhalis . results: mean serum concentrations measured h after the morning administration were . ( mg bd) and . mg/l ( g bd), and were above the mics of the three microrganisms. in contrast, sputum concentrations were always below . mg/l. in terms of sputum killing activity, g bd was more effective than mg bd against s. pneumoniae and m. catarrhalis , whereas no sputum samples were active on h. influenzae . conclusion: the optimal amoxicillin treatment schedule cannot be established on the basis of serum pharmacokinetics only. galmiche h, louchahi k, tod m, drugeon h, giroud jp, rouveix b. service de pharmacologie clinique, hopital cochin, paris, crepit , hopital avicenne, bobigny, service de microbiologie, hopital laennec, nantes, france background: cysteine-based mucolytics are commonly used in combination with antibiotics to treat patients with acute exacerbations of chronic bronchitis (aecb). they are also used to allow in vitro mic determination in sputum specimens. we conducted an in vitro and ex-vivo compatibility study designed to detect a possible interaction between mucolytics and antibiotics. methods: serial samples of bronchial secretions were collected from aecb patients and from healthy volunteers who received g of amoxicillin twice a day for days. two mucolytics were used to fluidify sputum specimens: , -dihydroxy- , -dithiolbutan (digest-eur † ) and acetylcysteine ( % solution). amoxicillin was assayed using a chromatographic system with fluorometric detection. each sample was also tested in a microbiological assay. results: amoxicillin could not be detected in the presence of the mucolytic agents. conclusions: this mucolytic Á/amoxicillin interaction may be explained by amoxicillin fixation to fluidified mucoproteins, and should be taken into account when assessing antibiotic efficacy in vivo. del fiol fs a , ferro c b , albuquerques et b . a university of sorocaba, pharmacology, sorocaba, brazil , b uniso, school of pharmacology, sorocaba, brazil physicians frequently recommend that macrolides should be administered with milk to decrease the discomfort they cause. thus the objective of this study was to verify the interference of milk in the absorption and distribution of erythromycin (eryt); clarithromycin (clar); roxithromycin (roxi) and azithromycin (azit). forty female rats (rattus norvegicus ) were used with surgically implanted pvc sponges on their backs for granulomatous tissue formation. one week later the animals were divided into groups that received the drugs eryt, clar, roxi and azit with and without milk ( . ml/kg [ca'/'/] / . mg/ml). the animals were sacrificed and the serum and tissue concentration of the drugs was investigated. there was no reduction (pb/ . tukey-kramer) in the serum and tissue concentration in the presence of milk for azit and clar. there was a % reduction for roxi in the serum concentration in the presence of milk ( . / . and . / . mg/ml), but no alteration in the tissue concentration. there was a % reduction for eryt (p b/ . ), in the serum concentration in the presence of milk ( . / . and . / . mg/ml) and a % reduction in the tissue concentration. the milk decreased the effectiveness of treatments with erythromycin and roxithromycin and the bioavailabilities of this macrolides were affected by co-administration with milk. del fiol fs a , souza gp b , duzzi mr b . a university of sorocaba, pharmacology, sorocaba, brazil , b uniso, school of pharmacology, sorocaba, brazil the degree to which tetracyclines are absorbed differs greatly. this absorption is impaired by the concurrent ingestion of divalent and trivalent cations. thus the objective of this study was to investigate the interference of milk in the absorption and distribution of tetracycline (tetr), oxytetracycline (oxyt), minocycline (mino) and doxycycline (doxy). forty female rats (rattus norvegicus ) were used with surgically implanted pvc sponges on their back for granulomatous tissue formation. one week later the animals were divided into groups that received the drugs: tetr; oxyt; mino; and doxy with and without milk ( . ml/kg [ca'/'/] / . mg/ml). the animals were sacrificed and the drug concentrations in the serum and tissue were determined. there was no reduction (pb/ . tukey-kramer) in the serum and tissue concentrations in the presence of milk for mino. there was a % reduction (p b/ . ) for doxy in the serum concentration in the presence of milk ( . / . and . / . mg/ml) and % in the tissue concentration. for oxyt, there was a reduction of % (pb/ . ) in the serum concentration in the presence of milk ( . / . and . / . mg/ml) and % in the tissue concentration. the tetr results show a . % reduction (p b/ . ) in the serum concentration in the presence of milk ( . / . and . / . mg/ml) and % in the tissue concentration. milk decreased tetracycline bioavailability and effectiveness. isotopic studies with oxine labelled platelet. platelet kinetics in thrombocytopenic malaria patients pm introduction : thrombocytopenia is a common feature in human malaria ( ). excessive splenic platelet pooling has been suggested to play a role in uncomplicated cases of malaria, but a moderately shortened platelet life span during the period with decreasing parasitaemia seems the most plausible cause of the frequently observed thrombocytopenia ( , ). consumption coagulopathy, eventually manifested as disseminated intravascular coagulation, has been described in malaria ( ). in uncomplicated malaria, however disseminated intravascular coagulation is rarely found ( ). results: in malaria patients the sequestration was not different to normal. platelet half-life was reduced in patients with p. falciparum malaria to Á/ h (normal Â/ days). in one patient with p. vivax malaria platelet half live was . h. conclusion: no significant differences in the sequestration of platelets when compared to healthy individuals could be detected by in-labelled platelet scintigraphy. especially, no enhanced splenic sequestration, as previously expected, was the cause of the thrombocytopenia. therefore, other mechanisms than sequestration are responsible for the dramatically reduced life span of the platelets during acute malaria. zaharanka ag, rozhdestvensky da. vitebsk state medical university, vitebsk, belarus aim: the studying of chromatingeterogenic test (ct) results in sperm of subjects taking doxycycline (d) and some macrolides (erythromycine (e), jozamycine (j), and azytromycine (a)) in moderate therapeutic doses. methods: forty healthy volunteers ( Á/ years) were studied. daily dose of d was . ; e was administered in dose . four times per day days; j */ . before meals twice daily days; a */ . before meals once daily days. ct for evaluation of dna condition in human spermatozoids was performed before treatment (twice), on the th and th days of treatment, as well as after and months after treatment course completing. results: ct data analysis revealed that the mean amount of defective spermato-zoids before treatment was . '/ . %. by the th day of d treatment the index of de-natured dna was . '/ . % (pb/ . ), by the th day */ . '/ . % (pb/ . ). one and months after the d treatment course the amount of generative cells with denatured dna was . '/ . and . '/ . %, respectively (p b/ . in both case). under e treatment the amount of defective spermatozoids changed as . '/ . ( th day), . '/ . ( th day), . '/ . (after month), and . '/ . % (after months) (pb/ . in any case). under a using the ct results at the same control points were . '/ . , . '/ . , . '/ . , . '/ . % (pb/ . in any case); and under j treatment */ . '/ . , . '/ . , . '/ . , . '/ . %, respectively (p !/ . in any case). conclusions: the data obtained permit to conclude that d demonstrates the high level of toxicity to male generative cells. this effect preserves during months after the course of d treatment. objective: to study the effect of aggressive isolation and decontamination measures to control an outbreak of multi-resistant acinetobacter baumanii (mr-ab) in an icu. the outbreak: the index case was transferred from a mediterranean hospital, directly into an open-plan -bedded icu, with severe injuries to his head and thorax. he died shortly after admission. sputum, bronchoalveolar lavage fluid, blood cultures and a chest drain swab grew mr-ab, resistant to ampicillin, co-amoxiclav, aztreonam, amikacin, ceftazidime, cefotaxime, cefuroxime, ciprofloxacin, gentamicin, meropenem, piptazobactam, tobramycin and sensitive only to colistin. within days, mr-ab was isolated from two further icu patients. all isolates demonstrated identical antimicrobial susceptibility profiles. the icu was closed to admissions and thoroughly cleaned. all patients were isolated and their contacts screened. the icu was reopened, however, mr-ab was isolated from a fourth patient. this patient was isolated, the icu closed, for a second time, thoroughly cleaned, and all contacts isolated until discharge. all subsequent patients screened were negative for mr-ab conclusion: this illustrates the importance of aggressive isolation measures and thorough supervised cleaning in control of an outbreak, and the need to screen patients for resistant bacteria before admission to the intensive care unit in a general hospital. extended spectrum beta-lactamase-positive bacteria isolated in neonatal intensive care unit pm sandorcinova z a , siegfried l a , kmetova m a , viragova s b . a institute of medical microbiology, faculty of medicine, university of p.j. safarik, kosice, slovakia , b hospital, kosice-saca, neonatal intensive care unit, kosice, slovakia extended-spectrum beta-lactamases hydrolyse all penicilins, cephalosporins, including third-generation cephalosporins and aztreonam. esbl are predominantly produced by klebsiella spp. but may be presented in other enterobacteriaceae, too. the aim of present study was to investigate the occurrence of esbl-producing bacteria isolated from patients hospitalized at the neonatal intensive care units (icu). fifty escherichia coli and klebsiella spp. were isolated from rectum of patients hospitalized at the neonatal icu. the mics of antimicrobial agents were determined by the standard agar plate dilution method according to the nccls guidelines. for screening of esbl production we investigated strains showing reduced susceptibility (mic equal and/or more than ml/l) to at least one of third generation cephalosporins. esbl production was detected by double disk synergy test (ddst), e -test for esbl, and pcr employing specific primers for the presence of blashv and blatem genes. by using ddst and e -test, among e. coli isolates, an expression of esbl was detected in the three by the former method, while among klebsiella spp. isolates, a production of esbl was found in the two by the latter method. in esbl-positive e. coli strains the presence of blatem genes fragments was detected while in esbl-positive klebsiella spp. genes encoding for shv-type beta-lactamases were found. isolation of staphylococci from wound swabs and their susceptibility to antibiotics pm markov mij, shopovski e, despotovski v, angelevski a, nikolovski b. military hospital, microbiology, skopje, the former yugoslav republic, macedonia purpose: to determine percent of staphylococci from wound swabs and to establish their susceptibility to antibiotics. material and method: the wound swabs have been evaluated with standards microbiological techniques. bacteria have been identified with strips from the 'atb expression' system. the susceptibility testing has been performed with strips with dilution technique, read by the same system. results: during the last years ( Á/ ), a total of wound swabs have been evaluated in the military hospital in skopje. positive bacterial finding have been determined in ( %) swabs with isolated bacterial species, from which ( . ) were staphylococci: staphylococcus aureus ( . %) isolations ( methycillin resistant s. aureus ); s. epidermidis ( . %); s. haemolyticus ( . %); s. hominis ( . %); s. chromogenes and s. lugdunensis nine ( . %); s. intermedius , s. lentus , s. sciuri and s. warneri all with seven ( . %) isolations. the susceptibility of s. aureus was to: penicillin %, ampicillin %, amoksicillin/clavulonic acid %, ceftazidime %, gentamicin %, tetracycline's %, erythromycin %, lincomycin %, ciprofloksacin %, cotrimoxazole %, vancomycin %, fusidic acid %, cefixime %, and azitromicin %. conclusion: in our study most frequently isolated bacteria from the wound swabs were staphylococci, especially s. aureus . susceptibility, except for the penicillin ( %), was high to other antibiotics. the study went on from january to december . at maribor teaching hospital, staphylococcus aureus isolates were collected. in , ( %) and in , ( . %) were mrsa. mrsa were recovered from routine clinical material and from surveillance swabs (nose, throat, skin). for isolation, conventional culture media were used and for surveillance swabs mrsa-screening plate (manitol salt agar with % oxacillin) and trypticase soy broth with . % nacl were added. s. aureus was identified by catalase, dna-se and tube-coagulase test. antibiotic susceptibility was determined by the disk-diffusion method according to ncci guidelines. all mrsa isolates were tested for sensitivity to the following antimicrobials: gentamicin, netilmicin, ciprofloxacin, erythromycin, chloramphenicol, tetracycline, cotrimoxazol, vancomycin and clindamycin. it was found that all mrsa isolates were sensitive to vancomycin and partially or totally resistant to the rest. there were no important differences between the years and . our mrsa isolates were completely ( %) susceptible to vancomycin, but resistant to the other antimicrobials in use to some extent. although the monitoring of mrsa susceptibility to antimicrobials once a year did not show any important change in antimicrobial resistance, the periodical monitoring of mrsa susceptibility to antimicrobials and revaluation of current treatment regimens of mrsa infections is necessary. staphylococcus aureus strains with reduced susceptibility to vancomycin among clinical isolates in university hospital in warsaw pm the visa and especially h-visa are very difficult to be found in the routine laboratory. in our investigations we examined of s. aureus strains isolated and stored in our laboratory for several last years ( Á/ ) . most strains were isolated in , and some in . for all staphylococcal strains mrsa as well as mssa the mics of vancomycin were performed by the standard dilution method. among strains isolated in the last year three strains were recognized as visa (mic values were mg/l). the frequency of visa was . %. in the aim of founding the h-visa strains the population analysis was used. for this analysis all strains growing on the concentration mg/l of vancomycin from the inoculum were chosen. it was strains, but only of them were recognized as h-visa. the frequency of h-visa among investigated strains was about %. most but not all of the h-visa and all visa strains were methicillin resistant. in vitro activity of vancomycin, teicoplanin and oxacillin against staphylococci isolated from patients of surgical intensive care unit pm kucukates e, karayel n, kansiz e. institute of cardiology, university of istanbul, istanbul, turkey objectives: oxacillin-resistant staphylococci have emerged as a major infection control problem in our hospital. the aim of this study was to evaluate the in vitro activity of vancomycin, teicoplanin and oxacillin against staphylococci. material and methods: this study was performed between january and december , at university of istanbul, institute of cardiology. the antimicrobial susceptibilities of staphylococci isolates for vancomycin, teicoplanin and oxacillin have been investigated by e -test according to nccls guidelines. results: fifty-five ( . %) of clinical isolates were staphylococcus aureus . one hundred and twenty-four ( . %) of clinical isolates were coagulase negative staphylococci (cns). none of staphylococci isolates were resistant to vancomycin. but three of cns isolates were intermediate and six of cns isolates were resistant to teicoplanin. twenty-eight ( . %) of s. aureus were resistant to oxacillin. ninety ( . %) of cns isolates were also resistant to methicillin. conclusions: nosocomial staphylococcal infections, especially in intensive care units increase day by day. staphylococcal infections are a major problem in many hospitals. according to our experiences the rate of oxacillin resistant staphylococci isolates in our hospital has also increased. methicillin-resistant staphylococcus aureus (mrsa) is a clinically significant pathogen because mrsa is resistant to many kinds of antibiotics and causes nosocomial infections around the world. the antiseptics are used for prevention of infections by mrsa. antisepticresistant mrsa strains have been isolated from clinical specimens. antiseptic resistance genes confer resistance to many kinds of drugs structurally and the resistance mechanism is the energy-dependent drug efflux system. in addition, the fluoroquinolone (fq)-resistance gene, nora , confers also resistance to many kinds of antiseptics. we studied the relation of the susceptibility to antiseptics and fqs of mrsa strains isolated in japan. a total of strains of mrsa were isolated from hospitals in japan from to . acriflavin (af), acrinol, benzethonium chloride, benzalkonium chloride and chlorhexidine digluconate were used as the antiseptics. norfloxacin and sparfloxacin were also used in this experiment. the mic was determined by agar double-dilution method as recommended by the nccls. about % of mrsa showed resistance to af (mic: !/ ug/ml). no strain was resistant to a specific antiseptic. fq-susceptible strains were susceptible to all antiseptics. this study showed that antiseptic-resistant mrsa are widely spread at hospitals in japan. the drug of choice in treatment of serious infections caused by mrsa was still vancomycin, however sometimes failures were observed, especially in monotherapy. some conflicting are present in literature about an effect of combined action of vancomycin and betalactams. in the present work, the common effect of vancomycin and methicillin against chosen staphylococcus aureus strains was examined. the investigated strains were characterized as visa, h-visa and clones obtained from h-visa in population analysis. two methods were performed: e -tests with methicillin and vancomycin placed on the media supplemented with the second antibiotic and the chessboard micro-analysis with increasing concentrations of both antibiotics. the fic indexes were calculated for different combinations of concentrations. on the basis of the fic indexes it was shown that the simultaneous action of vancomycin and methicillin was synergistic in all examined strains visa and h-visa, but only in appropriate concentrations. in different combinations the observed effect was addition or indifference. antagonism was never observed. the synergistic effect was not observed in the case of standard s. aureus strain sensitive to methicillin. supplementation of media with % of nacl substantially decreased the observed effect. incidence of antibiotic resistance in staphylococcus aureus strains in hungary with special reference to mrsa pm ghidán Á , maró di c, csukás z, kamotsay k, szabó d, ostorházi e, rozgonyi f. institute of medical microbiology, semmelweis university, budapest, hungary between january and december , a total of staphylococcus aureus strains isolated from patients admitted to the clinics of the semmelweis university were examined for antibiotic sensitivity with the disc diffusion test. resistance to individual antimicrobials were as follows: penicillin %, oxacillin %, erythromycin %, ciprofloxacin %, amikacin %, netilmicin %, tobramycin %, gentamicin %, clindamycin %, mupirocin %, tetracyclines %, chloramphenicol %, teicoplanin % and vancomycin %. all mrsa were b-lactamase producer. they showed coresistance to erythromycin ( %), ciproflxacin ( %), amikacin ( %), netilmicin ( %) and mupirocin ( %). multiple resistant mrsa strains to mupirocin'/tetracyclines'/chloramphenicol amounted to . %. triple resistance to oxacillin'/ciprofloxacin'/netilmicin was %. the detection of meca gene by pcr in randomly chosen mrsa qualified with mg oxacillin disc resulted in only % meca positivity indicating that the traditional disc diffusion test overestimates the frequency of mrsa strains particularly in such an environment where the usage of penicillins and cephalosporins is so liberal as in hungary. consequently, the selective pressure for blactam-resistance and b-lactamase induction exists everywhere. this conclusion is coherent with the relatively low frequency of multiple resistant mrsa strains and urge the need of a routinely available genetic method to apply for mrsa detection. objectives: the main objectives of this study were to monitor antibiotic resistance, identify new/emerging resistance mechanisms at an early stage, prevent their dissemination, early detection and prevent the outbreaks. methods: our laboratory used antibiotic disc sensitivity testing methodology (nccls ) . zone sizes were measured objectively using a biomic automated radius zone reader. results: throughout years (january till december ) we have surveyed organisms collected from outpatient departments ( , . %), radio-oncology department ( , . %), medical department ( , . %), obg department ( , . %), surgical-oncology non icu department ( , . %), icu department ( , . %). from ( %) strains of enterobacteriaceae ( . %) were resistant to th generation fluoroquinolone and ( . %) strains were esbl positive. from ( %) strains of staphylococcus aureus were only five ( . %) strains resistant to methicilin (mrsa). we collected ( %) strains of enterococci, whereabout only two ( . %) were resistant to glycopeptides (vre). from ( %) strains of pesudomonas aeruginosa , ( . %) were resistant to aminoglycosides. conclusions: national restrictive antibiotic policy hand in hand with local hospital antibiotic policy and regular rotation of antibiotics used in prevention and treatment on all departments is leading in our case in positive situation in antibiotic resistance in comparing with other slovakian and european centers. antimicrobial resistance of nosocomial strains of staphylococcus aureus pm dekhnich av, stratchounski ls, edelstain ia, narezkina ad. institute of antimicrobial chemotherapy, smolensk, russian federation purpose: to determine the antimicrobial resistance of staphylococcus aureus causing nosocomial infections in smolensk regional hospital. results: a total of s. aureus strains isolated during Á/ were studied. antimicrobials tested included oxacillin (oxa), erythromycin (ery), clindamycin (cli), gentamicin (gen), vancomycin (van), linezolid (lnz), tetracycline (tet), chloramphenicol (chl), rifampicin (rif), fusidic acid (fus), trimethoprim/sulfamethoxazole (ts), ciprofloxacin (cip), mupirocin (mup), quinupristin/dalfopristin (qd). susceptibility testing and its interpretation were performed by agar dilution according to nccls guidelines where applicable. results are presented in the conclusions: the most active antimicrobials were vancomycin, linezolid, quinupristin/dalfopristin, fusidic acid, mupirocin, followed by co-trimoxazole, rifampicin. beta-lactams, macrolides, lincosamydes, tetracyclines and chloramphenicol should not be used for the treatment of nosocomial s. aureus infections. we investigated all staphylococcal infections within years among neonates hospitalized for infection in the neonatal icu in a tertiary neonatal referral center. univariate analysis, to assess risk factors for neonates infected with staphylococcus aureus ( ) vs. without s. aureus ( ) was performed. from the total number of cases, in cases s. aureus was isolated from various samples; in cases from blood cultures, in cases from urine, in cases from eye swabs and in cases from gastric content (no significant differences in comparison with control group). colonization with s. aureus , was a predictor of infection: nasal swabs, throat swabs, ear swabs, skin swabs and umbilical swabs were significantly more commonly observed in neonates infected with s. aureus , than with other infections. etiological analysis showed that co-pathogens escherichia coli and viridans streptococci were significantly more frequently associated with neonatal infection caused by s. aureus , in comparison to other organisms. according to localization of infection site, conjunctivitis and thrush stomatitis was the commonest s. aureus neonatal infections. outcome was similar to other infections and without any significant differences between both groups. mortality was similar to other infections, probably because: initial therapy in our centre contains an antistaphylococcaly active agent (cefuroxime or cefotaxime plus aminoglycosides). morozova ot, semina na. laboratory of hospital infections, central research institute of epidemiology, moscow, russian federation purpose is to study the role of enterococcus spp. in the aetiology of nosocomial infections among the patients of the childrens clinical hospital and susceptibility of these strains to antibiotics. methods: the strains of enterococci were isolated from patients with hospital infections in Á/ . results: the aetiological structure of enterococcus -infections showed the predominance of skin and soft tissue infections ( . %), urinary tract infections ( . %), bloodstream infection ( . %), pneumoniae ( . %), infection of central nervous system, gastrointestinal tract, eye, surgical wound infections were of rare incidence ( Á/ . %). various nosological forms of infections were caused more often by e. faecalis than e. faecium ( . , . %). the antibiotic resistance to ampicillin and other beta-lactams occured in % of e. faecium isolates, but all strains of e. faecalis were susceptible to these drugs. high-level gentamicin resistance demonstrated e. faecalis isolates */ . %, e. faecium */ %; and high-level streptomycin resistance showed e. faecalis */ . %, e. faecium */ . %. all the e. faecalis were active against fluoroquinolones, but e. faecium were resistant in . %. there were no vancomycin resistant enterococci. conclusion: e. faecalis predominated in the aetiological structure of nosocomial infections due to enterococcus spp. antibiotic resistance patterns for two species of enterococci were different, all the strans were susceptible to vancomycin. evaluation of antimicrobial resistance of enterococcus spp. experience of years ( Á/ ) pm lopez-barba j, jesus de la calle i, solino-ocañ a i, rodríguez-iglesias m, perez-ramos s. microbiology laboratory, puerto real university hospital, cádiz, spain objective: determination of quantitative changes in antimicrobial resistance of enterococcus isolated from clinically significant not urinary samples of patients remitted to the laboratory of microbiology during a years period ( Á/ ) . material: the period of the study was comprised between and . the samples has been processed for the isolation of enterococcus following conventional methods. were isolated enterococci strains. the identification and susceptibility to antibiotics have been performed in automated system microscan(c) dade-behring(c) through panels combo cgp. the data were processed by the statistical system statgraphics plus . . results: of the enterococcus , have been identified e. faecalis and e. faecium . the resistance is shown in table . conclusions: the resistance to va and tei of e. faecalis remains through last years ( Á/ %). the high resistance to erythromycin and tetracilin ( !/ %) and the resistance ( Á/ %) to quinolones, antibiotics all of them used in community-acquired infections justify the susceptibility testing to the clinical strains isolated of this group of microorganism. in e. faecium the antimicrobial resistances was high and increasingly to imipenem, meropenem, erythromycin and quinolones. characteristics of strains e. faecium colonizing the neutropenic patients pm abbassi ms, achour w, gréco a, ben hassen a. laboratory of bone marrow transplant center, tunis, tunisia digestive colonization by enterococcus faecium in the neutropenic patients under gut decontamination is important. seventeen multiresistant strains of e. faecium isolated from stools of seven neutropenic patients were the target of an epidemiological analysis through the determination of the mics of amoxicillin, gentamicin, vancomycin, the transferability gentamicin resistance to the recipient strain e. faecalis jh - by filter-mating assay, analysis of plasmid profiles of e. faecium -strain and of transconjugants and the amplification by pcr of the gene aac( ?)-aph( ??) coding for the bifunctional enzyme by using primer m who gives a fragment of kb. among the seventeen strains, eleven had the same antibiotype a , had a gentamicin mic!/ mg/l. the mic of the amoxicillin was of mg/l. all the strains were sensitive to vancomycin. ten strains harbored a plasmid of kb transfered at a frequency of . Á/ , also found in gentamicin-resistant transconjugants. however, strains belong to nine distinguished plasmids profiles. all high-level gentamicin resistant-strains had a positive pcr amplification of the aac ( ?)-aph ( ƒ) gene. the features of the studied strains establish their endogen origin, specific for every patient, sharing only high-level resistance to gentamicin. gut decontamination treatment with gentamicin enhance either the spread and the preservation of easy-transferable plasmid carrying genetic transposable element. frequency and antibiotic resistance of bacteria isolated from patients suffering infectious complications following the implantation of prosthetic devices pm kristó f k, rozgonyi f. institute of medical microbiology, semmelweis university, budapest, hungary for patients with indwelling joint prosthesis, early recognition and prompt therapy for infection in any location may be critical to reduce the risk of seeding the joint implant heamatogenously. a year period ( ) a total of swabs of aspiration from patients with infectious complications following the implantation of prosthetic devices were cultured. cultivation and identification of the strains were performed by conventional methods and by vitek system (biomȇrieux) and susceptibility testing by disc diffusion. potentional pathogens were recovered in cases ( . %). gram positive cocci, in particular staphylococcus spp. proved to be the most commonly isolated bacteria. coagulase-negative staphylococcus (cns) was isolated more frequently ( %), followed by s. aureus ( %), enterococcus faecalis and e. faecium ( %), gram-negatives ( %), anaerob isolates ( . %). resistance to individual antimicrobials of s. aureus and cns were as follows: methicillin and %, clindamycin . and . %, fluoroquinolones and %. mupirocin resistant strains of s. aureus were not found, while . % were among the cns strains. our results could be essential for the rational selection of treatment at our orthopedic wards. results: in the analysed period the percentage of isolated enterococcus sp. strains among all non-repetitive clinical isolates in , and was . , . and %, respectively. cultured strains were identified as e. faecalis, e. faecium, e. gallinarum and e. avium . the most prevalent was e. faecium strains, isolated with a frequency of , and %, respectively. vancomycin-resistant strains were all identified as e. faecium and in they comprised % of all isolates of this species. conclusions: ( ) the frequency of isolation of enterococcus sp. in blood cultures of haematological patients remained relatively stable in Á/ . ( ) the predominant enterococcal species isolated from these patients was e. faecium . ( ) in we recorded for the first time an emergence of vancomycin-resistant e. faecium , which comprised % of all isolates of this species. kalai s, ben hassen a, achour w, greco a. laboratory of microbiology, national bone marrow transplantation center, tunis, tunisia from april to june , non-repeated strains of pseudomonas aeruginosa were isolated from immunocompromised patients. thirty-six percent of strains were isolated from abscess, % from blood culture and % from urine. susceptibility to antibiotic was studied by the routine disk diffusion method (ca-sfm). mics were determined using agar dilution to antibiotics ( b-lactams, four aminosides and two fluoroquinolones). serotyping of the different trains was performed using antisera to the international antigenic typing systems serotypes. the study showed % of resistance to c cochin port royal hospital, service de gynecologie-obstetrique site st vincent-de-paul, paris, france , d cochin port royal hospital, cclin, paris, france aims: to determinate risk markers of an outbreak of postpartum endometritis due to group a streptococcus . design: a case-control study using data collected with a structured form. setting: the cases of postpartum endometritis were diagnosed in the department of obstetric of the paris hospital network during days (december Á/january ). the group of controls consisted of women delivered in the same department during the same period. participants: cases (n / ) and controls (n / ). findings: cases had smoked more often during pregnancy ( vs. %; p / . ) and received more often immunosuppressive treatment than controls ( vs. %; p / . ). instrumental delivery has been needed more often for cases than controls ( vs. %; p / . ). cases had been hospitalized after delivery in a ward z of the department more often than controls ( vs. %; p / . ). they had been examined after delivery more often by a midwife x ( vs. %; p / . ) and a nurse y has provided care to cases and not to controls ( vs. %; p / . ). conclusion: smoking, receiving immunosuppressive treatment during pregnancy, and instrumental delivery were significantly associated with postpartum endometritis (pb/ %). a midwife and a nurse might be involved in the transmission of the infection. petoukhova i a , sokolova e a , dmitrieva n a , nummaev b b . a laboratory microbiology, cancer research center of russia, moscow, russian federation , b department of oncogynecology, cancer research centre, moscow, russian federation the aim of the study was to assess efficacy of perioperative ap. total pts were included. two hundred and one pts with cervical cancer (cc) undergone extensive hysterectomy, pts with cancer of vulva (cv)-extensive vulvoectomy, pts with ovarian cancer (oc) Á/ extensive/combined operations. fifty-one pts (group ) received ap with amoxicillin/clavulanate (am/cl) . g iv min prior to operation, then . g iv thrice per day for Á/ days. fifty pts (group ) received cefotaxime (ctx) g iv min prior to operation, then g four times per day for Á/ days'/metronidazole (mtz) mg two times per day for the same period. one hundred and forty pts were retrospective control (they received ii Á/iii generation cephalosporins or linkosamides only after operation). the rate of swi in pts with cc, cv and oc was . , , %, respectively; dwi */ . , and %, respectively; uti */ , , . %, respectively. the ap with am/cl was more effective compared to ctx'/mtz (swi */ vs %, respectively, pb/ . , dwi */ . vs %, respectively, p b/ . ). the rate of postoperative uti was equivalent in two groups ( vs %, p /n.s.). thus, ap with am/cl is preferrable option in extensive operations in og pts. fifty-eight patients were randomized into two groups. group , a treatment consisting of patients and group , consisting of patients as a control. the patients were at the age of / . and had had different surgical interventions with general anaesthesia from to h and accompanying copd ( %). artificial pulmonary ventilation was used in cases. in the early post-surgery period the patients of group were administered inhalation therapy, including ipratopium of bromide in the combination with fenoterol (atrovent, berodual) and ambrocsol (lazolvan) through a nebulizer. the inhalation therapy was not administered to the patients of group . under the influence of the inhalation therapy pulmonary ventilation and respiratory metabolism was restored faster in all the resuscitation patients (in group */by the end of the first h, in group */on the rd Á/ th day). the percent rate of pef was . '/ . and . '/ . , respectively. artificial pulmonary ventilation ended in . and . h, respectively. the time of the patients' stay in the resuscitation department was . days in group and . days in group . by the end of the st week pneumonia developed in one patient from group and in eight patients in group . aerosol therapy application accelerates medication delivery to the respiratory tracts, increases the local activity and effects good prophylaxis for surgical hospital pneumonia. variation in ethiology of early and late onset ventilator associated pneumonia pm nikolopoulos j, daganou m, michailidou m, karabela e, kavada k, retsou s, antoniadou a, rasidakis a. department of respiratory abstracts s failure and icu, sotiria general and chest disease hospital, athens, greece purpose: to compare the distribution of causative microorganisms, their susceptibility to antibiotics and outcome of 'early' and 'late' vap in a greek icu. methods and results: retrospective study of mechanical ventilated (mv) patients (pts) with early and late vaps during a -month period. diagnosis of vap was made by clinical, radiographic criteria and quantitative cultures of bronchial secretions. vap was diagnosed in pts ( %) out of consecutive admissions in icu. all pts before the development of vap received antibiotics. three episodes of vap ( . %) were developed before the th day of mv (early vap) and were caused: ( ) by multi-resistant acinetobacter; and ( ) by antibiotic-susceptible pseudomonas aeroginosa . in this group one pt died from septic shock related to vap and two pts survived. fourteen pts ( . %) developed vap after the th day of mv (late vap). five cases were caused by multi-resistant p. aeroginosa , two cases by mrsa, two cases by multi-resistant acinetobacter, two cases by susceptible to antibiotics klebsiella pneumoniae , and three were polymicrobial and caused by multi-resistant microorganisms (mrsa and gnb). four pts died ( . %) from septic shock related to vap, five pts ( %) died because of another cause and five pts ( %) survived. conclusions: early and late onset episodes of vap were caused by 'potentially drug-resistant bacteria'. p. aeroginosa as a cause of early vap was susceptible. mortality attributed to early and late vap was similar. antibiotic prophylaxis in oncological and major reconstructive orthopaedic surgery pm de biase p, ciampalini l, astone a, capanna r. azienda ospedaliera careggi, oncological and reconstructive centre, aoc, florence, italy during last year patients scheduled for oncological surgery or major reconstructive procedures were randomised to either vancomycin or teicoplanin prophylaxis. prophylaxis was performed with either vancomycin g i.v. twice daily or teicoplanin once daily i.v. two hundred patients were included. four patients did not agree the study protocol and were excluded. we treated patients with teicoplanin and patients with vancomycin. out of the patients were operated for oncological disease, while the remaining underwent major orthopaedic procedures. we experienced cases of red man syndrome, and five cases of moderate hypotension. five patients had postoperative complications: two deep venous thrombosis, one pulmonary embolism, two postoperative haematoma. in five patients we observed a wound dehiscence; two of these patients showed clinical sign of ssi and microbiological examinations were positive for mrsa. one patient recovered from infection with medical therapy, while the other patient showed a local tumour recurrence and was amputated at the thigh. at last surgery infection was still present clinical and at microbiological examination. in conclusion we had an infection rate of . % which is comparable to the infection rate of a 'clean' surgery in patients with normal risk of infection. teicoplanin showed lower toxicity, has a longer half-life and has a simpler way of infusion and it is our current choice in high risk surgery. injuries with contaminated sharp articles in health care workers in general hospital celje, slovenia pm lesnicar g, sibanc b. department of infectious diseases, medical center celje, celje, slovenia in a prospective study carried out from january till june , we registered subcutaneous injuries with sharp objects, mostly in nurses and cleaning service workers. in % of cases the incident occurred outside the hospital, in persons who were not medical workers. in cases the injury causing object was a needle that had been used in known patients, of which were hepatitis b positive. fifty-five ( . %) of the injured health workers had been previously vaccinated against hepatitis b; the protective antibodies to hepatitis b in the blood were found in / ( . %) health workers only, while the tests for antibodies to hepatitis c and hiv were negative in all cases. following the incident, the majority of the injured persons, i.e. , were vaccinated against hepatitis b, while persons ( . %) also received passive prophylaxis with human immunoglobulin against hepatitis b. none of the injured persons have developed the disease or showed evidence of sero-conversion. in the year the general as well as specific preventive measures practised in our hospital became more rigorous. thus, approximately % of our health workers at risk have already been vaccinated against hepatitis b. to improve measures preventing dissemination of multidrug-resistant bacteria (mrb), a cross-sectional survey ( ) was conducted to analyse healthcare workers' (hcws) isolation precaution knowledge for mrb infection at investigation and outpatient departments excluding four declaring not to be involved in care to mrb patients (emergency, obstetrics, nuclear medicine, and bacteriology). two hundred and eight hcws answered ( % of the paramedical staff, % of the physicians). thirty-three percent of them reported they do not know frequently or always the patient mrb status. they ( %) wish mrb status to be mentioned on the test form or on the advice request letter. mrb patient visit or test was appropriately timed in % answers. gowns ( %) or masks ( %) use were not systematically reported. other hcws ( %) reported better isolation precaution knowledge than physicians ( %) and nurses ( %) than investigation assistants ( %). physicians declared lower compliance with use of gowns, gloves or draw-sheets than other hcws. they had also lower education in isolation precautions and were less interested in education programs. this study suggests the necessity to improve mbr infection information. physicians and investigation assistants seem to be insufficiently aware of hospital infection control. therefore, education strategies targeted at physicians and investigation assistants working at outpatient and investigation departments should be developed. outbreak of clostridium difficile -associated diarrhoea in infectious disease department: risk factors and hygiene measures assessment pm henoun loukili n, martin m, remy v, hansmann y, christmann d. hôpitaux universitaires de strasbourg, maladies infectieuses et tropicales, strasbourg, france (shock)'/ * (bedridden status)'/ * (age !/ years)'/ * (previous antibiotic treatment) and points (women) / * (shock)'/ * (bedridden status)'/ * (age !/ years)'/ * (immunosuppression). the vast majority of patients ( and % of males and females, respectively) could be classified in the subgroups with lower scores (six points or less) which had a very limited risk of death ( Á/ . and Á/ . % for men and women, respectively), whereas for patients in the highest score subgroup ( points or more), the risk was % for men and % for women. conclusion: risk stratification of patients with ap is possible from simple clinical variables available on admission. procalcitonin (pct) and c-reactive protein (crp) for differentiation of systemic inflammatory response syndrome (sirs), sepsis and severe sepsis pm lupse m a , ursu l b , slavcovici a a , carstina d a . a clinical department, teaching hospital of infectious diseases, cluj-napoca, romania , b laboratory department, teaching hospital of infectious diseases, cluj-napoca, romania objectives: to evaluate the value of pct in the differentiation of patients with sirs, sepsis, severe sepsis and bacteremia in comparison to crp. design: prospective study including patients who meet criteria for sirs, sepsis or severe sepsis (consensus conference of the accp/ sccm) admitted over -month period. patients and method: a total of patients were included: eight with sirs, with sepsis and with severe sepsis. sixteen from patients had bacteremia. pct and crp were evaluated in the first h after admission: pct by brahms pct-q test and crp by turbidimetric assay. the sensitivity, specificity, predictive value of different cutoff points for crp and pct were determined. results: with a cut off point of . ng/ml for pct and . mg/dl for crp sensitivity and specificity for sepsis were %, respectively % (ppv . , npv . ) and %, respectively % (ppv . , npv ). a cutoff point of ng/ml for pct accurately predict severe sepsis (sensitivity %, specificity %, ppv ). a pct level of at least ng/ml was a good predictor for bacteremia (sensitivity %, specificity %, ppv . and npv ). conclusion: pct is a good discriminating marker to characterize the level of inflammation caused by infection and can predict bacteremia . giamarellou h a , aoun a b , klastersky j b , anagnostopoulos n c , galani l c , grecka p c , panaretou e c , papageorgiou e c , repoussis p c , syrseloudis pct has been considered as a useful diagnostic marker in neutropenic patients with bacteremia and/or severe sepsis (giamarellos-bourboulis ej et al. clin infect dis ; : ) . in an attempt to define its value in the diagnosis of localized infections in neutropenic hosts, daily determinations of pct and of c-reactive protein (crp) were performed before and after the onset of fever in subjects male and female aged . / . years with various haematologic malignancies (aml , nhl , mds , all ) developing neutropenia ( b/ pmns/mm ) after chemotherapy. thirty-three patients were presented with fever of unknown origin (fuo) and with localized bacterial infections (lbi; pneumonia , acute pyelonephritis , soft tissue infections , acute pharyngitis ). pct was determined by an immunoluminometric assay and crp by nephelometry. it is concluded that febrile neutropenia followed by a localized bacterial infections is accompanied by significantly higher levels of pct than in case of fuo ( . / . vs . / . ng/ml). similar differences are not observed with crp, which lacks the appropriate specificity. our study included patients who were categorized as having proven ( ), probable ( ), or possible ( ) systemic fungosis according to eortc criteria; showed no sign of infection, and were used as controls. blood samples were received on the st, rd, and th day from the onset of signs of a fungal infection, and then twice a week. pct levels were determined by an immunochemioluminent assay, and candida and aspergillus antigen levels by elisa. in only five patients pct indicated early signs of infection, albeit at barely detectable limits. six patients, however, showed significantly increasing titres preceding time of death. positive antigens titres were observed only in patients who had proven or probable systemic fungosis. only half of the control group had negative antigen titres; a high rate of false negatives was also observed. both pct and antigens titres increased in parallel in / patients with unfavorable outcome. pct and antigens titres cannot reliably indicate early diagnosis of systemic fungal infections although may be used as a prognostic tool of severity. lactulose, a factor that decreases endotoxaemia, in obstructive jaundice? pm koutelidakis im a , papaziogas v a , makris i a , giamarellos-bourboulis ej b , giamarellou h b , papaziogas t a . a thessaloniki med school, nd surgical clinic, thessaloniki, greece , b th department internal medicine, athens medical school, athens, greece bacterial translocation is a process implicated in the pathogenesis of spontaneous peritonitis. in order to evaluate the impact of lactulose administration on systemic endotoxaemia, obstructive jaundice was induced in rabbits by common bile duct ligation. animals were divided into two groups, group a of five rabbits not receiving lactulose and group b of six rabbits, which received . ml/kg of lactulose orally by an oral catheter. blood was collected daily, before and after operation for a total duration of four days. samples were applied for culture and for determination of endotoxins (lps) by the lal qcl- assay. concentrations of lps (mean /sd) of group a were . / . , . / . , . / . and . / . eu/ml on the st, nd, rd and th day, respectively. respective concentrations of lps (mean /sd) of group b were . / . , . / . , . / . and . / . . all blood cultures were sterile in both groups. differences activity of linezolid against nosocomial strains of staphylococcus aureus in russia: results of multicentre study pm were included in the study. antimicrobial susceptibility testing was performed by agar dilution method in accordance with the nccls recommendations. all tested strains including mrsa strains ( . % of all strains) were found to be susceptible to linezolid with the mic ranged from . to mg/l. both mic and mic were mg/l. conclusions: linezolid had excellent in vitro activity that was not affected by resistance to other classes of antimicrobials susceptibility to antiseptics of mrsa isolated in japan during Á % to piperacillin, % to ceftazidime, % to cefepime, % to imipenem, % to amikacin and % to ciprofloxacin. fiftythree percent of p. aeruginosa strains were multiresistant ( strains) and were isolated in patients. wild phenotype to b-lactams was observed in % of strains. the most frequent b-lactams resistance phenotypes were: cephalosporinase over production ( %) and penicillinase ( %). imipenem, ceftazidime and piperacillin-tazobactam were the most active b-lactams (mic of . and mg/l, respectively) these results showed high rates of antibiotic resistance and predominance of o serotype in multiresistant strains compared to the o serotype in europe. infectious complications sustained by stenotrophomonas (xanthomonas ) maltophilia in hiv at present, very limited informations are available about s. maltophilia infections in the setting of hiv disease. patients and methods: a retrospective survey of clinical and microbiological records of hiv-infected patients referring to out tertiary care centre between and was performed, in order to identify all episodes of s. maltophilia infections, and analyze its epidemiological, clinical, and microbiological variables. results: sixty-one episodes of s. maltophilia infection were observed in patients: sepsis/bacteraemia in cases ( . %), lower airways infection in five, urinary tract infection in four, pharyngitis in two, lymphadenitis and liver abscess in one case each. forty-seven out of episodes of s. maltophilia infections ( %) occurred as nosocomial disease, generally in association with advanced immunodeficiency, neutropenia, instrumentation, and prior antimicrobial therapy. bacterial isolates showed an elevated resistance profile against many betalactam compounds, aztreonam, imipenem, and aminoglycosides. conclusion: s. maltophilia represents an emerging opportunistic pathogen in hiv-infected patients extended spectrum beta-lactamases producing germs in intensive care units pm university of medicine and pharmacy 'victor babes ', microbiology, timisoara, romania injury and complications lasted months, demanded for surgical procedures and total cost was comparison of different methods for detection of extended spectrum beta lactamases (esbls) and their genetic relatedness among enterobacteriaceae clinical isolates in a research medical institute pm methods: one hundred out of isolates that were screened positive for esbls were tested with double disk synergy test (ddst), three dimensional test (tdt), e -test-esbl and vitek-esbl test. pulsed field gel electrophoresis (pfge) analysis was applied to esbls; five klebsiella pneumoniae and eight escherichia coli . results: revealed the prevalence of esbls in . % of clinical isolates. the sensitivities of the ddst, tdt, e -test and vitek were , , . and . %, respectively. in the ddst, aztreonam was the most sensitive indicator ( . %). pfge demonstrated that % of k. pneumoniae were derived from a single clone whereas . % of e. coli isolates were derived from two different clones. non-clonal origin was demonstrated in % of k. pneumoniae and . % of e. coli . conclusion: there is an increased prevalence of esbls. the ddst is the most sensitive, practical and cost effective diagnostic method reliable for routine use in our laboratory. both clonal spread and plasmid dissemination contributed to the concurrent nosocomial outbreaks caused by esbl-producing k severe nosocomial infections due to stenotrophomonas maltophilia pm the teaching hospital of infectious diseases total og pts after extensive hysterectomy ( pts), extensive vulvoectomy ( pts) and extensive/combined operations for ovarian cancer ( pts) were analysed. ic developed in pts. one hundred and sixtyseven pts had no ic. twenty-eight of rf analysed were independent rf of ic. most important included: age !/ years (p / . ), grade Á/ obesity (p / . ), diabetes mellitus (p / . ), diagnosis of cervical cancer (p / . ), history of pre-cancer of vulva postpartum endometritis due to group a streptococcus : a case-control study pm unite operationnelle d 'hygiene all isolates were sensitive to vancomycin. among gram-negative bacteria klebsiella spp. was isolated in . % of cases, acinetobacter baumanii in . %, enterobacter spp. in . %, providencia spp. in . %. of the klebsiella spp. isolates % were resistant to amikacin, % to cephalosporins, % to piperacillin/ tazobactam. all were sensitive to imipenem. of the a. baumanii isolates % were resistant to amikacin, aztreonam, cefoperazone, cefotaxime, ceftriaxone, piperacillin; % to ampicillin-sulbactam, % to ceftazidime, and % sensitivity to imipenem antimicrobial activity of selected pharmacopoeial antiseptics analysed according to european standards pm european committee for standardisation approved several european standards (en), describing test methods establishing, whether an antiseptic has or does not have a bactericidal or fungicidal activity under the laboratory conditions defined by en. the aim of the study was to investigate, if some chemical compounds in concentrations recommended by polish pharmacopoeia for skin disinfection, comply european standards requirements. methods: basic bactericidal (en ) and fungicidal (en ) activity were investigated as well as bactericidal activity of products for hygienic and surgical handrub and hand wash used in human medicine (pren ). all methods and used neutralizers were validated. standard strains: staphylococcus aureus , pseudomonas aeruginosa , escherichia coli , e. hirae , candida albicans and a. niger were used, when en standards were evaluated. results: ethanol, izopropanol and n -propanol caused viable microbial count reduction required by ens in pharmacopoeial concentrations the purpose of the study: we collected bacteriological samples from adult and neonate patients who were admitted in intensive care units (icu) . the aim was to observe the colonization status with microbes that may have a nosocomial potential and to establish circulating phenotypes in icus. the results obtained from a total of samples strains of gram negative bacteria (enterobacteriaceae family) were isolated. fourteen strains showed extended spectrum beta-lactamases (esbl) phenotype (eight strains of klebsiella pneumoniae , three of escherichia coli , two of klebsiella ornithynolitica , one of klebsiella oxytoca ). we used both disc diffusion test (extended antibiotic susceptibility test and synergy test to visualize 'champagne stopper' pattern) and mini api † system.the conclusion reached: we put in evidence a massive colonization with germs that may have a nosocomial potential especially microbes that produce esbl ( . % from all enterobacteriaceae isolated) which implies a rational policy in prescribing antibiotics in hospitals from western part of romania.carbapenem activity against nosocomial gram-negative rods pm sawicka-grzelak a a , rokosz a a , meszaros j b , luczak m a . a department of medical microbiology, university medical school, warsaw, poland , b department of general and transplantation surgery, university medical school, warsaw, poland purpose: to determine a susceptibility of nosocomial gramnegative rods to carbapenems.methods: two hundred strains of gram-negative rods were cultured from clinical specimens from hospitalized patients (july Á/november ). identification of strains was performed in the automatic atb system (biomerieux, france). susceptibility of strains to carbapenems: imipenem and meropenem was determined with disc diffusion method according to nccls recommendations. esbl-producing strains were detected with double-disc synergy test (ddst according to jarlier et al., ) or a novel method of esbl detection (dd, diagnostic disc) according to appleton ( ) . two discs were applied in this test: with cefpodoxime (cpd) and with cefpodoxime/clavulanic acid (cd ) (oxoid, england) .results: one hundred and ten strains of enteric rods and strains of non-fermenting rods were cultured. twenty eight ( %) esblpositive strains were detected. carbapenems were active against % of enteric rods. the percentage of non-fermenting rods susceptible to imipenem was and to meropenem */ .conclusions: carbapenems: imipenem and meropenem demonstrated high activity against clinical strains of enteric rods. however, the antibiotics were less active against nosocomial strains of nonfermenting rods.inhaled antibiotics against multiresistant bacteria in bronchial secretions of icu patients: a preliminary report pm horianopoulou m a , kanellopoulou m b , paraskevopoulos i a , valakis k a , kyriakidis a a , lambropoulos s a . a intensive care unit, sismanoglio general hospital, athens, greece , b department of microbiology, sismanoglio general hospital, athens, greece purpose: the aim of this study was to assess the effectiveness of aerosolized ampicillin/sulbactam, ceftazidime and colistin, in icu patients with multiresistant acinetobacter baumannii or pseudomonas aeruginosa colonization of the respiratory tract.methods: fifty-three intubated, mechanically ventilated patients participated in the study. multiresistant a. baumannii , sensitive only to ampicillin/sulbactam, or p. aeruginosa , sensitive to ceftazidime or colistin, were isolated from the bronchial secretions ( Á/ cfu/ ml). all patients were subsequently treated with intravenous ampicillin/sulbactam, ceftazidime or colistin, whereas of them were also given the same antibiotic in aerosolized form.results: a decrease in the number of colonies by Á/ cfu/ml was observed, following Á/ days of combined treatment with both intravenous and inhaled antibiotic. none of the patients developed vap. in the patients who only received the antibiotic intravenously, the decrease ranged from zero to cfu/ml, after days of treatment. two of patients developed vap.conclusions: our results suggest that the administration of aerosolized antibiotics represents an effective means of preventing ventilator-associated pneumonia caused by a. baumanni and p. aeruginosa . introduction: pseudomonas aeruginosa is an important nosocomial pathogen. resistance to certain beta-lactam antimicrobial agents among p. aeruginosa is increasing. despite the development of new antibiotics multiresistant strains of p. aeruginosa represent an important therapeutic problem. the aim of this study was to investigate the activity of imipenem, amikacin, piperacillin, ciprofloxacin, ceftazidime, against clinical isolates of p. aeruginosa . methods: a total of isolates by tracheal aspiration from hospitalized patients, admitted to intensive care units were identified as p. aeruginosa using an algorithm that included: gram stain, pigment, oxidaze ('/ ,) and gram negative identifications microscan walkaway- (dade behring) were used according to the manufactures instructions. minium inhibitory concentrations were determined using walkaway, interpretation based on ncclsm -s , january ' .results: the respiratory tract was the single site of isolation for this study. the best activity was showed by imipenem %, followed by amikacin %, piperacillin, pip/tazobactam, ciprofloxacin had the same sensitivity %.conclusion: a high level resistance to antibiotics was observed to p. aeruginosa isolated from tracheal aspiration. carbapenems seem to be the most active against p. aeruginosa in this study. materials and methods: clinical samples were collected from patients admitted to this hospital. only one isolate per patient was included. antimicrobial susceptibility testing was performed as recommended by the nccls. all bacterial isolates were tested by dd and ad to provide a comparison of both test results. very major error was considered when the strains were resistant (r) by ad and susceptible (s) by dd and major error when s by ad and r by dd. categories of s and r were stablised using the breakpoints suggested by mensura ( ) . colistin r strains was typed by rep-pcr.results: among the strains included in this study ( . %) were s to colistin and five ( . %) were colstin r by ad, of this five colistin r strains four ( . %) were s to colistin by dd and one was r by both methods. all r isolates were similar by rep-pcr.conclusions: most of the ad colistin resistant strains were s when tested by dd indicating that this method is not useful to determine the resistance to colistin. rep-pcr patterns show that the spread of a colistin r clone seems to be involved. methods: gnb were isolated from per-operative biopsies (pob) and/ or from articular punction (ap). patients (pts) received cfp, g bid'/ ofl, mg tid or cip, mg bid intravenously for days, followed by a prolonged oral fq monotherapy. cure was defined as: resolution of all clinical signs of infection, normalization of the biological inflammatory profile at the end of treatment (eot) and absence of infection at the same site during the post-treatment followup period (ptfu).results: all of the studied patients [mean age / years] had hospital acquired bji. seventeen/ had an infected orthopedic device (prosthetic joints / , other orthopedic prosthetic devices / ). culture of pob and ap yielded to pseudomonas sp. ( ), enterobacter cloacae ( ), others ( ). vancomycin was added for six pts co-infected by gnb-mrsa. nineteen/ pts underwent a surgical intervention (debridement / , removal-replacement / , amputation / ). after ptfu period of months (range Á/ ), the overall success rate was / ( . %) without serious adverse events.conclusion: cfp Á/fq combination was safe and efficient in the treatment of hypercase gnb, bji.treatment of posttraumatic mrsa osteomyelitis of the femur with longterm cotrimoxazole */a case report pm the authors report a case of posttraumatic osteomyelitis of the femur caused by methicillin-resistant staphylococcus aureus (mrsa), following the shot injury. relapses of the infection occured in months interval and were treated by revision, debridement, lavage and vancomycin. because of laboratory signs of renal insufficiency vancomycin became contraindicated for treatment of the third relapse of infection and the different approach was employed: classic open treatment of bone infection sec. orr was combined with a long-term administration of high-dose cotrimoxazole. the patient was given cotrimoxazole mg daily divided in four doses ( mg/kg/ h) for months, then for gastrointestinal complaints with lowered dose of g daily for next months. the wound completely healed. during months after the final surgery there was no relaps of infection, but the atrophic pseudoarthrosis of the femur resulted. the patient can walk with a rigid orthesis and two crutches. the whole treatment of the objective: to present a variety of severe nosocomial infections due to stenotrophomonas maltophilia in patients hospitalized in tertiary medical units from cluj.results: during the last year nine strains of s. maltophilia obtained from patients with severe infections and hospitalized in different wards were isolated. all but one were considered nosocomial infections: four cases of pneumonia, one urinary tract infection, three cases of surgical wound infections and one case of endocarditis under surgical treatment. the cases of pneumonia were either primary occurring in a granulocytopenic patient with leukemia or secondary in patients that underwent surgical treatment. in the case of endocarditis the ethiology was established after surgery from the damaged valve in a negative hemoculture patient with a poor outcome under medical treatment. in all cases of surgical wound infection bacteremia occurred diagnosed on clinical basis in the presence of severe sepsis or hematogenous dissemination in the lung. the urinary tract infection occurred in a patient after urinary surgery and having a catheter in place. the immediate evolution was favorable in all cases but treatment was difficult due to the highly resistant strains and to underling diseases.conclusions: s. maltophilia should be considered in nosocomial severe infections and prophylaxis by interrupting environmental transmission has to be promoted. sawicka-grzelak a, rokosz a, luczak m. department of medical microbiology, university medical school, warsaw, poland purpose: to identify and determine the drug-susceptibility of esblpositive strains isolated from urine samples.methods: seven hundred and twelve strains of gram-negative rods were cultured from urine samples from hospitalized patients during months (july Á/november ). identification and susceptibility were performed in the automatic atb system (biomerieux, france) using id e, id gn and atb ur strips. esbl-activity was detected with double-disc synergy test (ddst according to jarlier et al., ) or using a novel method of esbl detection (dd, diagnostic disc) according to appleton ( ) . two discs were applied in this test: with cefpodoxime (cpd) and with cefpodoxime/clavulanic acid (cd ) (oxoid, england).results: five hundred and ninety-five strains ( . %) belonging to enterobacteriaceae family, strains ( . %) of non-fermenting rods and two strains ( . %) of other gram-negative rods were isolated. eighty-two esbl-producing strains ( . % of all strains) were detected. fifty-nine esbl-positive strains were susceptible to nitrofurantoin, -to norfloxacin and ciprofloxacin and -to fosfomycin.conclusions: esbl-positive strains were detected most frequently among enteric rods ( strains). nitrofurantoin and quinolones were the most active in vitro antibacterial agents against examined esblpositive uropathogens. results: the mechanisms of resistance were evaluated phenotypically using different aminoglycosides. a total of aminoglycoside resistant gram-negative strains were studied. one hundred fifty-eight strains were collected in Á/ , in and in . the resistant profiles were determined: enterobacteriaceae */ ; pseudomonas aeruginosa */ ; acinetobacter spp. */ . the most frequently phenotypes were gt (gentamicin, tobramycin) */ % and gtnet (gentamicin, tobramycin, netilmicin) */ %. the gt phenotype due to production ant( ƒ)-i enzyme, the gtnet Á/aac( )-v ( strains), aac( )-iv */one strain and aac( ƒ)-i */one strain. the resistance to amikacin in % strains was due to production aac( ?)-i ( %) and aph( ?)-vi ( %). the most of examined strains were simultaneously resistant to kanamycin and neomycin caused by production of aph( ?)-i ( %). only seven strains were resistant to all aminoglycosides due to impermeability of outer membrane. no substantial differences were observed between years.conclusions: the main mechanism of aminoglycoside resistance is fermentative modification. the high rate to gentamicin and tobramycin was due to production of ant( ƒ)-i and aac( )-v. amikacin and isepamicin were the most active aminoglycosides against gramnegative nosocomial isolates.the incidence of clostridium difficile associated diarrhoea (cdad) increased in our department from january to june .objective: to confirm the out break of cdad, to identify the risk factors and assess the effectiveness of the measures implemented for controlling this outbreak.methods: cdc definitions were used to identify the cases. the scope of the outbreak was defined. cdad incidences during the outbreak period and during the same period in were compared. risk factors (reduced mobility, antibiotic treatments . . .) were studied for patients whom length of hospital stay (lhs) was more than days. contact precautions and environmental cleaning with clona implemented were assessed.results: seventeen episodes of cdad were identified. sex ratio: . , mean age / . , mean lhs / days, mean delay for cdad occurring / days. one hundred and fifty-two patients involved in the study of risk factors. relative risk (r.r.) evaluated were: blactams (r.r. / . , ic %: . Á/ . ), reduced mobility (r.r. / . , ic %: . Á/ . ). incidence of cdad was less than two cases per days of hospitalisation after june .conclusion: we confirmed the outbreak of cdad in our department b-lactams and reduced mobility were identified as risk factors for cdad. measures implemented to control the outbreak were effectiveness.positive heart transport fluid cultures associated with severe infections in heart transplant recipients pm at the mount sinai hospital in new york city heart transplants were performed between and june . cultures were routinely performed on all heart transplant transport fluids. culture data was available for of these patients. in total / ( . %) were positive for bacteria, fungi or both. the organisms isolated included coagulase negative staphylococci ( ), pseudomonas aeruginosa ( ), staphylococcus aureus ( ), acinetobacter baumanii ( ), serratia mercescens ( ), enterobacter cloacae ( ), escherichia coli ( ), proteus mirabilus ( ), enterococcus faecalis ( ), viridans streptococci ( ), and fungi (aspergillus fumigatus ( ), penicillium species ( ), and rhodotorula rubra ( ). two heart transplant recipients had two organisms isolated from the transport fluid. isolation of resistant gram-negative bacilli in the transport fluid was associated with significant infection in / patients ( %) with the same organism. the observed infections were pneumonia secondary to e. cloacae , sternal wound infection secondary to p. aeruginosa , and bacteremia secondary to p. aeruginosa . it appears prudent to provide prophylaxis against resistant gram negative bacilli to prevent infections. zacharof ak, flevaris c, petrogianopoulos c, karachalios g, vroulis j, chartzoulakis g, drakogiorgos g, loizidou a, svoukas g. nd department of internal medicine, hellenic red cross hospital, athens, greece objective: we studied the trends of nosocomial bloodstream infection and calculated the population-attributable risk for death among hospitalized patients. methods: we perform a -year retrospective study for all patients (n / ), admitted to our department between and .results: between and , a total of patients developed episodes of nosocomial bloodstream infection. the crude infection rates increased linearly from . to . per discharges ( . Á/ . episodes per patient-days) during the -year study period. increases in the infection rates were due to gram-positive cocci, yeasts and essentially explained by infections caused by coagulasenegative staphylococci, staphylococcus aureus , enterococci, and candida species, respectively. although the crude mortality in patients with nosocomial bloodstream infections decreased from % in to % in , the in-hospital population-attributable mortality among infected patients increased from . deaths per discharges in to . per discharges in . the etiologic fraction or the proportion of deaths in patients with bloodstream infection to all deaths occurring in the hospital increased from . % in to . % in .conclusions: the incidence and the population-attributable risk for death among patients experiencing nosocomial bloodstream infections increased progressively during the last years in our department.ventilator-associated pneumonia before and after intensive care unit temporary closure pm results: we compared the incidence, causative organisms and mortality of vap in two different time periods. period june to december . period june to december . between those two periods the icu remained closed for months because of reconstruction works.period : sixty-seven consecutive patients (pts) were studied with bronchial secretions cultures at least days after mechanical ventilation (mv) initiation. the vap was diagnosed by clinical, radiological and microbiological criteria in pts ( %). causative organisms included: pseudomonas aeruginosa , acinetobacter , staphylococcus aureus , klebsiella pneum. , enterobacter . in three cases vap was proved polymicrobial. fourteen ( ) episodes of vap ( %) were developed after days mv (late vap) and were attributed to multiresistant microorganisms. mortality of vap was %.period : among consecutive pts, vap was diagnosed in ( %). causative organisms included: acinetobacter , p. aeruginosa , s. aureus , k. pneumoniae , escherichia coli . five ( ) cases were polymicrobial and cases were 'late vap' ( %). causative microorganisms had similar patterns of sensitivity to antibiotics (compared to period one). mortality of vap was %.conclusion: temporary icu closure had no significant influence on the incidence, distribution of causative organisms, their sensitivities to antibiotics and mortality of the vap. efstathiou sp a , pefanis av a , tsioulos di a , tsiakou ag a , zacharos id a , kanavaki s b , mountokalakis td a . a third university department of medicine, sotiria general hospital, athens, greece , b microbiology laboratory, sotiria general hospital, athens, greecepurpose: the aim of this study was to derive a scoring system for the prediction of outcome in adult patients with acute pyelonephritis (ap) severe enough to need hospitalization. therefore, the charts of patients ( men, median age years) were reviewed.results: logistic regression analysis identified in both sexes four independent correlates of in-hospital mortality, the coefficients of which divided by . and rounded to the nearest interval, resulted in the following integer-based scoring system: points (men) / * between concentrations of lps of the two groups were statistically significant on the nd and the th day (p b/ . ). it is concluded that the administration of lactulose may decrease systemic endotoxaemia in the field of obstructive jaundice.nosocomial infections: a prevalence study in the island of crete pm doukakis s a , tzimis l b , perogambrakis g a , kalloniatou m a , christodoulakis n a , evaggelopoulos a a , koutsoumba d a , kastanakis s a . a first medical department, 'saint george ' general hospital, chania, greece , b pharmacy department, 'saint george ' general hospital, chania, greeceprevalence surveillance is a rapid and inexpensive mode to estimate the problem of hospital-acquired infections (hais). to study the problem of nosocomial infections in our hospital, a prevalence study was made from our team in . the study included patients (the total number of hospitalized patients at the time of the study). from these patients were males ( . %) and females ( . %). one hundred and ninety-one patients ( . %) belonged in the groups of age between and years. fifty-seven patients had a urine catheter ( . %). one hundred and fifty-five/ patients ( %) received antibiotics and from these patients received one antibiotic and the remaining patients two or more. a nosocomial infection was found in patients and consequently the prevalence of hais was . %. among these, urinary tract infections were six ( . %), lower respiratory tract infections were three ( . %), surgical site infections were three ( . %), and bloodstream infections was one ( . %). the incidence of multiresistant bacteria was primarily enterococcus spp and secondary, pseudomonas aeruginosa , enterobacter spp, klebsiella pneumoniae , escherirchia coli , staphylococcus aureus , enterobacter cloacae . unfortunately prophylactic chemotherapy of long duration was found despite the suggestions of the infection control committee. regarding age the highest incidence of hais occurred in the third age group. bagirova ns, dmitrieva n. laboratory of microbiology, cancer research center of russia, moscow, russian federation objectives: to determine the pathogens and susceptibility to antimicrobials.methods: blood samples were collected from adult pts ( Á/ ). the bacteraemic episodes were classified according to the definitions of the cdc. laboratory detection of bacteraemia and fungaemia was performed according to cumitech b (blood cultures iii, ). susceptibility testing was performed by disk diffusion method (nccls).results: the total number of blood samples */ , -positive ( . % episodes of significant bacteraemias). bsi was confirmed microbiologically in of febrile pts ( . %). the most frequent pathogens were gram('/) cocci ( . %) (p b/ . ), gram((/) bacilli */ . %, fungi */ . %. coagulase-negative staphylococci (cns) represented . %, staphylococcus aureus . %, streptococcus spp. . %, enterococcus spp. . %, enterobacteriaceae . %, pseudomonas aeruginosa . %, other non-fermenting */ . %, yeast . %, mould . %, anaerobes . %. one hundred percent cns were resistant to penicillin, . % to oxacillin, . % to clindamycin, . % to cefazolin, . % to ceftazidime, . % to ciprofloxacin, . % to gentamicin, and no isolate was resistant to vancomycin. the predominant pathogens in all types of hm were gram('/) cocci (mainly cns). all gram('/) microorganisms were sensitive to vancomycin. katashinsky o a , opriatova t b , tchuev p c . a state clinical hospital, anaesteziology, odessa, ukraine , b state clinical hospital, bacteriology, odessa, ukraine , c medical university, anaesteziology, odessa, ukrainethis investigation was carried out in odessa state clinical hospital during Á/ . of the patients with post-operation complications, % of gram-negative cultures were sensitive to ceftazidime and % to amikacin. sixty-nine percent of gram-positive cultures were resistant to penicillin g, but they were sensitive to vancomycin and nitrofurantoin in and % of cases, respectively. sixty percent of isolates of pseudomonas aeruginosa were sensitive to ceftazidime and % to amikacin. rates of resistance to carbenicillin and gentamicin were and %, respectively. one hundred and fortythree isolates of escherichia coli were studied and % of them were resistant to ampicillin % to cephalothin and % to tetracycline. of the isolates tested against ciprofloxacin, all were sensitive. one hundred and eight isolates of staphylococcus aureus were studied and they were resistant only to penicillin g ( %). staphylococcus aureus was sensitive to erythromycin ( %), tetracycline ( %), oxacillin ( %) and vancomycin ( %). all isolates enterococcus faecalis were sensitive to nitrofurantoin and % to ciprofloxacin. the majority of s. aureus and e. faecalis isolates were susceptible to most other antibiotics, but the majority of e. coli isolates were resistant to the studied antibiotics expect ciprofloxacin.campylobacter foetus bacteraemia in an immunocompromised patient: a case report pm monno r a , ierardi e b , rendina m b , ceci g a , luzzi i c , de vito d a , rizzo g a , francavilla a b . a department of internal medicine and public health, university of bari, bari, italy , b department of emergency and organ transplantation, university of bari, bari, italy , c istituto superiore di sanità, rome, italy a -year-old woman was admitted for recurrent fever. the patient underwent a liver transplantation and splenectomy in . she had followed immunosuppressive therapy until when tacrolimus was added for chronic rejection. in non-hodgkin lymphoma was diagnosed and chemotherapy was started. six months later because of the presence of two metastatic encephalic foci affecting the optic chiasm, a new chemotherapy course was started with the regression of lesions. in january she was treated with steroid recycle and cyclosporine Á/azathioprine Á/prednisone reintroduction. fever occurred after months and cytomegalovirus (cmv) infection was diagnosed. treatment with ganciclovir was started with clinical remission. in november cmv infection recurred and blood cultures were positive for a bacterium that was identified as campylobacter fetus . the patient was successfully treated with intravenous ciprofloxacin. bacteremia frequently occurs in cancer patients. bacteremia due to c. fetus are rare, occurring mainly in immunocompromised patients. c. fetus expresses a proteinaceous surface layer that confers serum resistance. in our patients steroid and immunosuppression may have contributed to the development of lymphoma. all of these factors and chemotherapy have contributed to cmv infection and all have made the patient susceptible to bacteremia with this infrequently found bacterium. the clinical microbiologist should be aware of this infection in immunocompromised host. minenko sv, dmitrieva nv, sokolova en, ptushkin vv. bone marrow transplantation department, n.n. blokhin cancer research center, moscow, russian federation c'/a is the standard regimen as empirical therapy for febrile neutropenia (fn). activity of c against g'/ bacteria and g(/ bacteria, producing chromosomally-mediated b-lactamases (e.g. ampc) is suboptimal. cep is active against a broad range of g'/ and g(/, including ampc producing bacteria. the purpose of the study was to compare the efficacy of two regimens in the treatment of fn.methods: patients with fn received either cep ( g/ h) or c ( g/ h) plus amikacin ( mg/kg/day) or netilmicin ( mg/kg/day). data were collected prospectively.results: a total of pts with episodes ( / ) of fn were included. fifteen/ in cep group and / in c'/a group. the median duration of neutropenia grade , distribution of age, sex and underlying disease were comparable in both arms. mdi was in and %, cdi in and % fuo in and % in fep and c'/a groups correspondingly. response to the initial empirical regimen according to ihs criteria was in % of cep and . % of c'/a groups (p / . ). modification of therapy with a change of cep or c to carbapenem took place in and % of cep and c'/a groups (p / . ). no patient in either treatment group died due to the presenting infection. tolerability of cep was good and no laboratory abnormalities took place. transient elevation of serum creatinin level was observed in two patients c'/a group.conclusions: cep monotherapy is as effective as c'/a combination in the treatment of patients with fever and granulocytopenia purpose of the study: retrospectively, we analysed patients with intraabdominal infection for aetiology, risk factors, and outcome from hospitals in slovak republic within year (march Á/march ). results: in this group significantly more frequent were older patients ( !/ years) with cancer ( vs. %, p b/ . ). acinetobacter spp. ( vs. %, p b/ . ) and enterobacteriaceae ( vs. %, pb/ . ) were predictive for monoinfection. pre-treated patients with other antibiotics had inferior prognosis and more risk factors: permanent urinary catheter ( vs. %, pb/ . ), ventilation or intubation ( vs. %, pb/ . ) and polymicrobial infection ( vs. %, pb/ . ). the risk factors with poor prognosis were enterobacteriaceae ( vs. %, pb/ . ), diabetes mellitus as underlying disease ( vs. %, p b/ . ) and uraemia ( vs. %, p b/ . ). surprisingly, negative prognostic factor was also non-effective previous antibiotic therapy. failed patients died significantly more frequently patients due to underlying disease. cefoperazone/sulbactam was shown to be useful, effective and well tolerated also in one group of patients with % efficacy of treatment, and it belongs to a group of antibiotics suitable for treatment of nosocomial infections. key: cord- -phsr jp authors: nan title: abstracts tps date: - - journal: allergy doi: . /all. sha: doc_id: cord_uid: phsr jp nan (either in men or women) between metabolic syndrome and incident asthma. conclusion: this study confirmed the significance of obesity as a risk factor for incident asthma. moreover, obesity appeared to be a stronger risk factor than metabolic syndrome. | relationship between helminth infection, blood eosinophils and asthma symptoms in a rural community from the tropics peñaranda d; alvarez l; sierra n; lopez j; zakzuk j; caraballo l institute for immunological research. university of cartagena, cartagena, colombia background: immune response to helminths shares many features with the allergic response. in tropical regions where helminths are highly prevalent, asthma is still a major public health burden. large clinical cohorts suggest that high blood eosinophils (hbe=> cells/ mm ) are associated with asthma exacerbations. however, the association between hbe and asthma severity in rural communities with prevalent helminthic infections is unclear. method: patients with wheezing symptoms in the last year living in a rural tropical community (santa catalina, colombia) where helminths are highly prevalent, were recruited for this study. blood eosinophils were assessed by complete blood count. parasitic infection was evaluated with two serial coprological exams (kato-katz method) and skin prick tests were conducted to determine reactivity to ascaris. results: seventy-three patients (mean age: ; range: - years old) were recruited in this study. a. lumbricoides and t. trichuria active infection ( . % and . %, respectively) were not related to age or gender. a positive spt to ascaris extract, aba- and d. pteronyssinus was observed in %, . % and . %, respectively. mean eosinophil count was cells/mm ; . % had hbe. rate of patients with at least one emergency department visit was . % and hospitalization, . %. blood eosinophil counts (as a continuous variable) were inversely associated with age (p = . ) and higher in helminth infection (p = . ). in crude univariate analysis, exacerbations (er and/or hospitalization) were associated with age (or: . ; % ci: . - . , p < . ) and hbe (or: . ; %ci: . - . , p = . ), but not with helminth infection. for a better definition of asthma, multivariate analysis done in those > years old indicated that hbe, helminth infection and positive ascaris spt were not associated with asthma exacerbations. conclusion: uncontrolled asthma is common in rural places of the tropics. since helminth infection influences eosinophilia, the clinical value of hbe to predict exacerbations is limited in helminth-endemic populations. castro mc ; ferreira j ; sarmento d ; carvalho c ; matos a ; bicho m chln-immunoallergy; lisbon medical school-genetic department, lisboa, portugal; lisbon medical school-genetic department, lisboa, portugal background: the bioavailability of no and endothelial homeostasis depends on the functional polymorphism of -bp del/ins within intron- of dhfr (dihydrofolate reductase enzyme) (rs ) that could interfere in the regeneration of bh (tetrahydrobiopterin) from bh ( , -dihydrobiopterin) and contributes to endothelial dysfunction in asthma. method: asthmatics (n = ) compared with control group (n = ).the polymorphism was analyzed by pcr. control of asthma assessed by (acq and paqlq). statistical analysis with spss . establishing a significance level of p < . . results: there are women and males in asthmatics and women and males in controls (p = . ). in asthmatics: age ( x ± sd): . ± . ; and in control group: age ( x ± sd): . ± . . the genotype frequencies in asthmatics are: dd ( . %); id ( . %); ii ( . %); in control group: dd ( . %); id ( . %); ii ( . %); there is no statistical difference between groups (p = . ). the allelic frequencies in asthmatics are: allele d ( . %); allele i ( . %); in control group: allele d ( %); allele i ( %); there is no statistical difference between groups (p = . ). the genotype frequencies in the uncontrolled asthmatics are: dd ( . %); id ( . %); ii ( . %) ; in the controlled asthmatics are: dd ( . %); id ( . %); ii ( . %); there is statistical difference between groups (p = . ). genotypes id and ii are more frequent in the uncontrolled asthmatics. the allelic frequencies in the uncontrolled asthmatics are: allele d ( . %); allele i ( . %); in the controlled asthmatics are: allele d ( . %); allele i ( . %); there is a trend to have differences between groups (p = . ). allele i is more frequent among uncontrolled asthmatics. the uncontrolled asthmatics are older than the controlled asthmatics (p < . ). there is no differences in gender distribution (p = . ). the genotype ii confers a risk of being uncontrolled asthmatic of . times when compared with controlled asthmatics and adjusted for age: or b : . [ . - . ]; p = . . physiopathology and the emergence of evidence-based clinical guidelines. however, variation still exists among some diagnostic aspects of asthma in real life. it is unknown to what degree diagnosis is affected by the treating physician's medical specialty. results: a total of gps, pediatricians, allergists, pulmonologists and otolaryngologists (orls) replied. although for general application of diagnostic clinical criteria all physicians rated similarly, in general accordance with the mag suggestions, a third of non-pulmonologist practitioners don't recognize chest discomfort as one of the clue symptoms of asthma, but they erroneously believe crackles are (p = . ). we found agreement in almost half of all physicians to erroneously believe that viral illness' induced wheezing in non atopic children predisposes asthma. conversely, - % are aware that allergic sensitization predisposes to asthma. most specialists -except pulmonologists (p = . )-incorrectly listed fev as the best parameter to identify airflow obstruction (ao) and fev /fvc to assess ao severity. % of gps do not know peak expiratory flow (pef) measurements could be valuable, and % of all specialists are not aware that changes in pef can also be used to confirm ao reversibility. to classify asthma, only pulmonologists adequately considered the level of control in similar proportion than severity ( % and %, respectively), which is uniformly the preferred method by most other specialists. conclusion: although in general many clinical aspects of asthma diagnosis seem to be accurately assessed, there is a wide specialityspecific variation regarding some aspects of phenotyping and classification, diverging from mag's recommendations. as such, our results can help to detect knowledge-gaps and to guide the development of more focused specialty-specific learning tools to improve clinical impressions, process medical evidence, and apply it to patient care. | issues, continuous medical education on treatment of acute asthma, exercise induced asthma and asthma in pregnancy should include, per medical specialty background: to unify and improve the management of asthma, including asthma exacerbations, the mexican guideline on asthma ( . %) of employees who stated increased symptoms with flour exposure. among all workers ( . %) employees were diagnosed as asthma and ( . %) workers were diagnosed as ba. conclusion: wheat flour sensitivity is high among workers who are exposed to wheat flour, however the prevalence of ba is similar to the previous data in the literature. johnsen cr ; callesen kt ; jensen bm ; poulsen lk clinic of allergy, dept. of dermato-allergology, gentofte hospital, copenhagen, denmark; laboratory of allergy, gentofte hospital, copenhagen, denmark background: enzymes are well known as sensitizers and causes of occupational allergy primarily in the industries producing and using the products. we present a case of occupational contact urticaria, rhino-conjunctivitis and asthma in a year male chef who was using a transglutaminase enzyme powder obtained from fermentation of streptomyces mobaraense as meat glue in processing of fine culinary dishes. this transglutaminase has been used for protein food preparation in industrial settings since to improve the texture of protein rich foods such as surimi or ham. in this case it was used in small scale in a gastronomy restaurant kitchen spraying enzyme powder with a sieve over raw meat without any protective equipment in contrast to the producer's recommendation. the chef was also found allergic to dried, edible mushrooms also forming part of the meat dish prepared with the transglutaminase enzyme powder. in one occasion he experienced an oral reaction with itching and swelling of the mucosa in the mouth, stridor, angioedema of the face, and urticaria after ingestion of beef meat treated with transglutaminase and rolled in horn of plenty dried mushroom powder. no other symptoms of food allergy were reported but a known cat allergy was. background: formaldehyde and xylene are occupational skin and respiratory irritant and/or sensitizer, exposure to those may be associated with dermatitis, rhinitis and asthma. health care workers, as nurses, laboratory technicians, doctors could be exposed in different tasks in operating rooms, endoscopy and in pathology laboratory. we describe three cases of work-related rhinitis in technicians employed in the same unit of hospital pathology . first case: a woman of years old underwent medical examination in our occupational allergy unit because allergy respiratory symptoms. she has been working for years in pathology laboratory and was exposed to xylene and formaldehyde. she developed rhinitis, rhinosinusitis, hyposmia and cough with sputum after years started work. she had negative skin prick test for common aeroallergens. lung function was normal with a fev /fvc ratio of % of predict. blood cells count reveled % of eosinophils ( /mmc) with total leucocytes. second case: a woman of years old was affected by moderate persistent allergic rhinitis with positive skin prick tests to house dust mite, dog and cat. in the last year rhinitis symptoms worsened in relation to work and improved during vacation. when she was exposed mostly to formaldehyde during shift at the end of it she usually experienced face skin and conjunctival erythema. she developed work-related symptoms after years of exposure in the pathology unit. third case: a woman of years old, who has been working for years in the pathology unit and was exposed to formaldehyde and xylene, in the last year developed moderate-severe persistent rhinitis with hyposmia and chronic cough. she referred to otorhinolaryngologist and an irritant induced rhinitis was diagnosed. she had negative skin prick test for common allergens and normal lung function. results and conclusion: the workers experienced respiratory symptoms in relation to work exposure to formaldehyde and xylene. the suspected causal agents were monitored in the work environment and an exceeding of the recommended limit values was found. preventive measure were adopted with a reduction of exposure and symptoms improve only in the second and third case. challenge test with mannitol is considered to be more specific than test with methacholine. also, duration of procedure is shorter and safer. therefore the study aim was to compare the usefulness of these two tests in monitoring of sict. method: four bakery workers with suspicion of oa underwent single-blind, placebo-controlled sict with workplace allergens accompanied by evaluation of nsbhr with mannitol and methacholine before and after sict. clinical examination, spirometry, skin prick tests (spts) to common aeroallergens and occupational allergens, serum specific ige antibodies to occupational aeroallergens were also performed. results: positive spts results to occupational aeroallergens were found in all bakery workers, specific ige to flours were detected only in two subjects. three out of the four patients displayed positive sict reaction (in two cases early spirometric response). in all of these patients, airway response to methacholine increased significantly. in the first two patients also airway reaction to mannitol was significant, whereas in one subject with early reaction there was no increase in nsbr after mannitol inhalation. the patient with negative sict results did not reveal any changes in nsbr before and after the test, neither to methacholine nor mannitol. | rice-induced occupational anaphylaxis and socio-economic impact-case report method: in this prospective study, a total of students completed a self-administrated questionnaire that comprised different questions and gave information about the participants and their glove use, working habits, signs and symptoms related to these gloves, precautions taken to minimize it, etc. skin prick test is performed through commercial extract latex gloves (stallergenes), while patch test is prepared through latex gloves and adhesives. two types of gloves are used: gloves that contain latex and gloves without latex (vinyl gloves), which are used also as e negative control. results: questionnaire items and diagnostic tests revealed that one-fourth of subjects were suspicious for latex gloves hypersensitivity. their mean value for skin reactions like irritant or allergic dermatitis or contact urticaria was between % and %, while for other symptoms the mean value was under %. logistic regression analysis revealed an association between different questionnaire items and positive allergy tests among suspected cases and diagnosed cases of latex allergy. approximately % of people who work with laboratory animals experience some allergic symptoms and about % of animal technicians go on to develop serious symptoms of asthma. uk government guidelines state that employers must prevent or adequately control exposure of employees to animal allergens and should undertake monitoring to ensure that suitable controls remain effective. the most widely used monitoring method is personal iom filters. however, these need to be attached to a pump and carried by the technician which can be cumbersome and awkward. previous data has demonstrated that allergens from dust mite, cat, dog and pollen could be captured and quantified by a novel type of nasal filter. in this current study, we sought to assess the feasibility of using the nasal filters for the assessment of exposure to mouse allergen in a laboratory facility. method: technicians working in a laboratory animal facility were asked to wear the filters during normal routine work. for comparison, they were also asked to wear an iom filter for the same duration. allergen was extracted from nasal and iom filters by gentle rocking in pbs-tween for two hours. levels of the major mouse urinary protein (mus m ) were quantified using our multiplex array technology, which is highly sensitive and allows for quantification of mus m down to . ng/ml. results: significant levels of mus m were detected in the nasal filter extracts and these levels correlated with the type of activity that was being performed by the technician, as well as the housing environment of the mice. levels were compared to the suggested 'safe' limit of allergen exposure of ng/m . we also found that the technicians grew accustomed to the nasal filters quickly and found them far more practical for every day monitoring that wearing the iom filter and pump. conclusion: these data indicate that nasal filters may be considered a simple and easily wearable method for monitoring laboratory animal allergen exposure. future studies are planned to assess the feasibility of wearing the filters for analysing exposure to other laboratory animal allergens from rat and guinea pig. havana university lower co emission, water and feed consumption and limited waste production. insects are currently allowed both for human and animal feeding in some eu countries, including italy and the risk profile related to production and consumption of insects as food and feed, including risk of allergenicity, is currently under evaluation by efsa. both food and feed products derived from insects require multiple manipulations by the breeder and/or by the workers who transform the insect into the commercial products, thus the occupational exposure have to be considered too. the aim of this work is to evaluate the allergenicity of tenebrio molitor, one most used species for animal feeding. method: t. molitor proteins were extracted from intact dried larvae and from flour of dried larvae. the protein extracts were separated in one-dimensional electrophoresis conclusion: according to these results, the larva flour seems to be less immunoreactive than the intact counterpart, probably due to the processing that causes the degradation of protein bands over kda. working in gastronomy is associated with exposure to many factors with an irritating and allergic potential influencing respiratory system. food products and organic dust are the source of inhaled allergens which may cause sensitization during apprenticeship. the study aim is a prospective observation of incidence of sensitization to selected environmental and occupational allergens among culinary school apprentices and identification of work-related allergic diseases in this group. method: the cohort comprised apprentices. they were examined in the first and the second year of education. questionnaire and allergological tests [(skin prick test) spt to common and occupational allergens, ige level evaluation (total and specific for occupational allergens) and pulmonary tests] were performed]. results: the most frequent symptoms reported by examined apprentices were rhinitis ( . %), conjunctivitis ( %), skin symptoms ( . %), dyspnea ( . %) and cough ( . %). subjects developed nasal symptoms during the second year of education, while in cases the skin symptoms and in subjects conjunctivitis appeared. in cases the work-related symptoms were reported. the most frequent positive results of spts were obtained with dermatophagoides pteronyssinus . %, dermatophagoides farinae . %, grass pollens . %. positive spt to rye and barley flour were found in respectively . % and . % apprentices. . % of apprentices had specific ige to flours. the preliminary results indicate that work-related allergy symptoms and hypersensitivity to occupational allergens are rarely found among culinary school apprentices in the first years of education. the further observation will allow to evaluate the trends in incidence of allergy to occupational allergens, as well as the clinical presentation of allergy in that group. | how multifaceted the clinical presentation and etiology of allergic diseases could be? method: the study was done in children from west georgia randomly and on based of questionnaire of representative cohort. ( ) ( ) ( ) . the cohort was children, - years old, risk factors were studied by way of interviewing, clinical-laboratory dates. for assessing the risk factors, was used 'case control' method. the statistical processing of material was done with computer program sps/sv . inclusion criteria for enrolment were: collectors of dust, gender, existence of moisture and mold consuming of tabasco, atopic dermatitis and seasonality. results: the groups, which we have studied, prevalence of acute respiratory viral infection was %, bronchitis − . %, allergic rhinitis . %, atopic dermatitis . %, food allergy . %. the reliability was high (p < . ) in families with bronchial asthma compared with healthy population. bronchial asthma was detected in . % of population. the hereditary load of allergic diseases in patients with bronchial asthma was . % and in healthy cohort it was . % (p < . ). conclusion: based on the results, we can conclude that, ecological factors and genetic predisposition significantly influences on prevalence of sensibilisation of house dust mite, molds and formation of bronchial asthma. as the genetic and environmental factors that act on an immune system are better elucidated and their roles established, the implementation of more enduring preventive efforts will be developed. however, at present, the best approach to the child at high risk for the development of allergies is to institute dietary and environmental control measures early to decrease sensitization, and to recognize and appropriately treat the evolving signs and symptoms of allergic disease. background: plantation of road-side avenue trees has become a major part of the urbanization programme in kolkata metropolis of india for megacity beautification and environmental management. due to evergreen habits, gulmohor (delonix regia) and chhatim (alstonia scholaris) are frequently selected for plantation programme to generate green belts. however, an increasing incidence of seasonal pollinosis was observed among the inhabitants living in close vicinity to these trees suggesting a possible link between the airborne pollen load and the concomitant respiratory hazards. this prompted us to investigate the allergens in the pollen of these two dominant avenue trees. method: aerobiological surveys were conducted at multiple sites of kolkata for a period of two years using seven-day volumetric burkard sampler to record the pollen concentration in the outdoor ambient air. clinical data and residual blood of pollinosis patients were collected from a public hospital. allergens were detected in the pollen proteome fractionated in d gel by ige-serology. the major igereactive proteins were partially purified by ammonium sulphate fractionation followed by ion-exchange chromatography. the allergenic activity of the fractions was tested by histamine release assay. results: a clear correlation was observed between the pollinosis related morbidity and the aeropollen load especially during the peak flowering period of these two trees. about % and % of the patients displayed positive spt response and ige-reactivity using pollen extracts of gulmohor and chhatim respectively. immunoproteomic analyses revealed the presence of - ige-reactive components in the d pollen proteome of these species. hierarchical cluster analysis with patient immunoblot data identified a kda and a kda protein as major allergens of gulmohor and chhatim respectively. the purified fractions containing each of these two major allergens induced histamine release from granulocytes within a range between and %. method: immortalized human keratinocyte cell line (hacat) and primary normal human epidermal keratinocytes (nheks) were differentiated with calcium chloride for and days, respectively. following the differentiation, the cells were treated with il- ( ng/ml), il- ( ng/ml), and/or hcho ( × ^- %) for hours. the mrna expression of flg, ivl, lor, dsg , dsg , dsc , dsc , as well as tslp was analyzed using quantitative real-time pcr. results: hcho exposure decreased the mrna expressions of structural components (flg, ivl, and lor) and cell adhesion molecules (dsg , dsg , dsc , and dsc ) in a short-period time of exposure ( hours). we also found that hcho exposure significantly enhanced il- -and/or il- -induced tslp production in nheks as well as hacat. interestingly, exposure to hcho alone is enough to increase the tslp mrna expression in both cells. conclusion: our results suggest that hcho exposure might synergistically damage the skin barrier function with il- and il- by increasing tslp expression and decreasing structural components as well as cell adhesion molecules. | skin prick test reactivity to aeroallergens in adult allergy clinic in a tertiary hospital: a -year retrospective study results: five different human sera were screened for specific ige level against different allergen sources using test methods of three different suppliers. the sensitivity of the three different methods can be arranged in the ascending order manufacturer a < manufacturer c < manufacturer b. with the test of manufacturer a, % of the measurements were below the detection limit ( . ku/l), with the test of manufacturer c, % of the measurements were below the detection limit, whereas the test of manufacturer b leads to values below the detection limit in % of the cases. in terms of variation coefficient, the test system of manufacturer c had the best performance. test systems of manufacturers a and b exhibited comparable variation coefficients, which were considerably higher than that of manufacturer c. conclusion: based on these test results, only the test of supplier c is recommendable for determination of levels of specific ige for diagnostics of allergic patients. with the test of manufacturer a, elevated levels of specific ige antibodies for many allergens cannot be detected due to the poor sensitivity of the test system. the test system of supplier b exhibits a good sensitivity but the coefficient of variation is rather high for a diagnostic test. this drawback could be circumvented by multiple determination of one test parameter. although this is an advisable strategy in general, the routine in diagnostic laboratories is incompatible with this approach, since throughput would decrease while costs would increase. this study is another good example for the need of the implementation of a characterized standard material with known values of sige, as demanded by wojtalewicz et al. method: cd c and cd expression on basophils were monitored upon exposure of whole blood samples (< hours) to anti-ige and/or allergenic extracts. staining was conducted on exposed samples using dry room temperature stable antibody panels (dura innovations format) coated in well plates, eliminating all antibody pipetting steps from the workflow. red blood cells were lysed and data was acquired (without further wash steps) on a cytoflex flow cytometer (beckman coulter). staining and lysing were automated using a biomek (beckman coulter). results: the described no-wash preparation protocol, already established for manual preparation mode in tubes, could be trans- conclusion: the hr-test was significantly less likely to be positive, if a patient suffered from monosymptomatic ae than in ae patients with concomitant urticaria. this could signify a higher likelihood of treatment response to antihistamine and other anti-allergic medication in the latter group. background: pathogenetic mechanisms of allergy are polymorphic. they include ige-dependent and ige-independent, allergen-specific granulocyte-mediated and lymphocytic reactions, as well as nonspecific hypersensitivity, which are realized through a variety of mediators: histamine, tryptase, etc. allergen bucal challenge mimics the natural situation and is useful for understanding the mechanisms of allergic airway inflammation and airway hyperresponsiveness (ahr).saliva used as a non-invasive readily available bio-sample for diagnosis instead of blood. biomarkers in saliva are associated with the pathogenesis and clinical outcome of allergic diseases method: aim: to examine mediators for ahr with buccal(mucosal) challenge tests. we examined patients with allergic asthma(the history, positive skin prick test, serum specific ige) and healthy volunteers. saliva were collected. then, both groups were subjected to buccal(mucosal) allergen challenge by a water-salt solution of the mite allergen dermatophagoides pteronyssinus. saliva was recollected in minutes and hours after the provocation. the level of myeloperoxidase, elastase, tryptase in saliva were determined by the elisa. that provocative test did not cause clinical symptoms development or reduction in nasal bronchial patency in any patient. results: in patients with allergopathology, an initially increased level of myeloperoxidase and tryptase in minutes after the provocation, elastase increased in hours (table ) . tryptase in saliva after minutes increased till . ( . ; . ) (me, pg/ml (lq;uq)), p = . . increased tryptase is presence of increased cellular inflammation, e.g. mast cells. its ige-dependent hypersensitivity, because there was the correlation between the elevated level of tryptase and positive prick tests. elevated levels of myeloperoxidase and elastase in saliva may be the criteria for the neutrophil hypersensitivity and ige-independent reactions. in healthy volunteers this increase was not observed. the identification of tryptase, myeloperoxidase, elastase can be used for diagnosis of types of ahr. tryptase is a mediator of early (immediate) response to allergen. increased myeloperoxidase and elastase indicates the involvement of the eosinophils and neutrophils in the oral mucous membrane in the allergic process. these mediators have additional roles in the late phase response. elevated levels of myeloperoxidase and elastase in saliva may be the criteria for the neutrophil hypersensitivity. conclusion: safe and acute in vitro methods allow to conduct early etiological diagnosis of allergy, which contributes to the effectiveness of therapy; the detection of polyvalent sensitization dictates the need for molecular diagnostics to single allergens, which has a higher prognostic level and the clinical significance of predicting the appropriateness and effectiveness of allergen-specific therapy; laboratory diagnostics of the allergy allows to reveal sensitization at the ( , ) ( , ) ( , . ) *p = . ; **p = . ; ***p = . . subclinical level, which increases early diagnosis and identify persons with a predisposition to allergy; the establishment of causal aller- background: antibacterial chemicals like parabens and triclosan have been associated with allergic disease in children. parabens are also suspected to affect metabolic functions, possibly due to their weak endocrine disrupting properties. furthermore, a possible link has been suggested for eczema and adiposity, and thus, how body burden of chemical exposures affect both of these outcomes are of interest. we aimed to describe the association between exposure to parabens and eczema and body mass index (bmi) in an adult population in norway. method: urine biomarkers of butyl-, ethyl-, methyl-and propylparabens were quantified by mass-spectrometry in adult participants (median age= years) from the rhinessa study in bergen, norway. linear regression models adjusted for gender, age and bmi (for eczema outcomes) and with clustering for siblings, were applied to model possible association between specific gravity standardized urine biomarker concentrations of parabens with bmi and eczema. results: propyl-(ppb) and methyl-parabens (mpb) were detected in % of the urine samples; ethyl (epb) in % and butyl (bpb) in % of the samples. in women, epb and bpb were detectable in % and %, respectively. participants with current eczema ( %) had lower level of several parabens compared to those without eczema (bpb for both genders; epb in women only and sum of all parabens in men only). body burden of epb (geometric mean (gm)) was . μg/l in women with current eczema compared to . μg/l in women without eczema (p = . ). body burden of parabens (mpb and epb) were inversely associated with obesity (bmi> , ( . %) ), as compared to normal range bmi (bmi= . - ( . %)) in both men and women. the concentration of mpb for obese women was gm= μg/l compared to μg/l in women with normal range bmi. for men, the gm for mpb was . μg/l in obese compared to . μg/l in normal weight men (p = . ). conclusion: person with eczema or obesity had lower paraben levels in urine. we speculate that these chemicals might be stored in adipose tissue, and therefore excreted in urine in lower levels among the obese. eczema and obesity was not strongly associated in the current study. method: we retrospectively analysed medical records of patients who were patch-tested with our dental screening series of substances. adverse reactions to dental materials were suspected based on subjective complaints in the oral cavity and/or objective conditions of the oral mucosa. square plastic chambers on hypoallergenic tape were used. patch tests were applied to the upper back and removed by the patient after hours. readings were performed and days after application (d and d ). results were evaluated according to the international contact dermatitis research group guidelines. positive patch test reactions fulfilled the criteria of at least a one plus (+) reaction on d and/or d . the term »contact allergy« is usually used for such reactions. we prefer the term »contact sensitization«. clinical relevance of positive reactions to dental materials was not systematically assessed in this analysis. conclusion: we report a high frequency of positive reactions on d that were not seen on d . this finding demonstrates the importance of an additional late patch test reading in patients with suspected contact allergy to dental materials. background: psoriasis is a chronic inflammatory skin disease. its etiopathogenesis is not exactly known. it is believed that the disease occurs in people with genetic tendency with the effect of a triggering factor. in some studies it is observed that contact dermatitis in psoriasis is increased with respect to normal population. for this reason it is proposed that allergen materials could trigger psoriasis. in this study it is aimed to determine contact allergy frequency in psoriasis cases using patch test. results: of the cases were plaque, of them were guttate, of them were palmoplantar and of them were inverse type. more positivity rate is observed in psoriasis cases ( . %) than control ( %). the positively responsed materials with respect to decreasing number of patients are found as follows: nickel sulphate ( . %), thimerosal ( . %), peru balsam( %), p-phenylenediamine( . %), colophony( . %), n-isopropyl-n-fenil- -fenilendiamin( . %), mercaptobenzothiazole( . %), benzocaine( . %), most frequently plaque type and following guttate type positive responses are observed in evaluations with respect to clinical types. no statistical significance is found between patch test results and pasi values in psoriasis cases. conclusion: patients with psoriasis should be carefully evaluated. sometimes some materials may trigger psoriasis. the composition of the pigments that professional tattooists use are varied inorganic salts of metals or organic vegetable pigments. red tattoos, especially those that contain mercury, are the most common cause of late reactions. method: year-old male patient with no previous allergy history known, who gets a tattoo on his right leg and develops within months, cutaneous erythema and pruritus on the same location as the tattoo. true test ® for skin allergy patch epicutaneous testing is performed. results: and hours reading: showed positiveness for mercury ++, with no late positive reactions after that. conclusion: as allergists we should be familiar with the different types of tattoos available, and know the possible cutaneous complications that each of these decorative techniques can present. it is our responsibility to be able to diagnose any complications at an early stage, establish the most appropriate treatment and, if possible, prevent them by informing the possible users. background: within otorhinolaryngological pathology chronic eczematous otitis externa is one of the most common, usually treated with topical medication successfully; however, there are cases in which the poor response to treatment, or the recurrence thereof, may be due to causes secondary to the medication itself, as observed in cases of allergic contact dermatitis caused by these drugs. case report: we present a -year-old male patient without relevant pathological antecedents or known allergies, who consulted the otorhinolaryngology service of our center for otorrhea of days of evolution, bilateral external otitis is diagnosed and a topical otological combination is recommended (beclomethasone dipropionate . % and clioquinol %, excipient: macrogol) with improvement. however, during the following years the patient presents exacerbations and remissions of the condition, with negative or inconclusive microbiological studies. during all that time he was using the prior topical treatment and other combination treatments of topical antibiotics, corticosteroids and local antiseptics. more aggressive causes of external otitis such as malignant external otitis were ruled out. during the third year of follow-up, a clear relationship of exacerbations was observed with the use of the first combination of topical drugs, so it was decided to investigate allergic sensitization. material and methods: we perform patch tests using true test ® , standard spanish series (geidac -spanish group for investigation of contact allergy dermatitis), topical corticosteroid battery, antiseptic, as well as topical medications used by the patient. results: from the first reading on day two, positivity was observed for: mixture of quinolines ++ patient's otological combination ++ and chlorquinaldol ++; being confirmed in the reading at day four. eczematous external chronic otitis is diagnosed with allergic sensitization to quinolines (clioquinol, chlorquinaldol). we conclude that in the case of chronic external otitis, allergic contact dermatitis should also be investigated as a possible cause, and it is important to perform epicutaneous tests with the patient's own products to evaluate non-common or hidden allergens that may be relevant to their current pathology. most common causes of acd. it is important to distinguish local findings of infection from acd caused by topical antibiotic treatments. here we present a patient with acd with topical use of bacitracin and neomycin combination therapy due to recurrent blepharitis. an -year-old male patient presented with the complaints of itching, redness, swelling of the eyelids and facial edema. he had used various topical ophthalmic antibiotherapy and eye shampoo for years due to recurrent blepharitis. five days ago, due to the redness of the eyelids, burning sensation in the eye, itching of the eyes; he was examined by an ophthalmologist. the eyelids and eyelashes were scaly and dry. the patient was treated with warm water soaked cloth dressing, mechanical eyelash cleaning and topical antibiotherapy (neomycin-simple combination therapy). after the second day of treatment, the patient's topical ophthalmic antibiotherapy was discontinued due to an augmentation of the redness in the eye- | contact allergy after exposure to ivy (hedera helix l) potent steroid treatment associated with systemic antihistamines, but with no improvement. on dermatological examination a small, well delineated, eczema-like plaque was noticed on a digital finger, as a new finding striking with her old burn scars. she denied any symptoms and was in good health condition. a mm punch biopsy was performed and histological report established the diagnosis of squamous cell carcinoma. the patient was transferred to oncology department for further investigation and treatment. conclusion: early diagnosis and prompt surgical therapy are recommended to all patients with chronic wounds and scars who develop malignant transformation. *written informed consent for the publication of potentially identifiable personal details of patient (gender, age, illness, location) was obtained. **in relation to this presentation, i declare that there are no conflicts of interest. ertugrul a; hizli demirkale z; bostanci i dr sami ulus maternity and children training and research hospital, ankara, turkey introduction: the incidence of contact sensitization among adolescent has been increasing. nickel is one of the important causes of allergic contact dermatitis (acd) in this age group. increased exposure to nickel and deterioration of the skin barrier are among the important risk factors in children. the gold standard for diagnosis is skin patch test. we report here an adolescent patient who has allergic sensitization to nickel and cobalt. case: a -year-old female patient admitted in our clinic with a complaint of edema on her face. the patient had applied chickpea water to her face at least once a day for one week because of her acnes. her medical history revealed that she had experienced similar edema on her face after applications of clay mask one year ago. she was diagnosed with cellulitis and she had been treated with antibiotics for five days. on her physical examination, angioedema was observed on her face, especially on the glabellar region. eosinophilia was not found on her laboratory data. c-reactive protein (crp), c and c esterase inhibitor protein levels were also normal. the skin prick test was performed with aeroallergens, chickpea, lentil, bean and nuts, and no reaction had been observed. the patch test was performed with 'thin-layer-rapid-use-epicutaneous' (t.r.u.e) test and chickpea. the patient had positive reactions to nickel and cobalt. detailed questioning disclosed that the patient was preparing the chickpea water in a metal pot. result: chickpea water and clay mask contain varying amounts of nickel. it was thought that the edema of the patient is due to nickel allergic contact sensitization. an increased exposure to nickel and cobalt raises the frequency of sensitization. nickel allergy can cause different clinics ranging from localized lesions to systemic reactions. we want to emphasize that a detailed medical history and the patch test would enable clinicians to demonstrate hidden allergens and then make a correct diagnosis. case report: autoimmune progesterone dermatitis is a condition of hypersensitivity to progestogens. it is not an easy diagnosis given the variety of clinical presentations it may have, ranging from eczema, urticaria, erythema multiforme, folliculitis, to angioedema or even anaphylaxis. manifestations are cyclical, occurring when the levels of progesterone are higher, this is, at the luteal phase of the menstrual cycle, and disappear during menses, with the physiological decrease of the hormone. it can also be triggered by exposure to exogenous progestins. we report the case of a -year-old woman with a cyclical erythematous and violaceous rash related to the menstrual period. the symptoms typically began - days before the onset of menses and ended - days before. the diagnosis was based in the clinical history and intradermal skin tests: skin prick testing with levonorgestrel and medroxyprogesterone were negative, but the intradermal skin test with medroxyprogesterone was positive at a concentration of mg/ml. we performed intradermal testing with the same concentration in three other women with no symptoms to exclude an irritative reaction, which were negative. autoimmune progesterone dermatitis is, perhaps, not so rare, but rather poorly recognized and reported, and thus, underdiagnosed. clinicians should be aware and include always this condition in the differential diagnosis, especially in cases of atypical or intractable skin eruptions. case report: a year old male was referred to a community allergy clinic for assessment of chronic urticaria (cu). allergy assessments for foods, inhalant and inducible physical triggers revealed no association. an autoimmune workup followed, with treatment consisting of standard dose antihistamines (h and h ). blood work revealed a persistently low hemoglobin with low-normal ferritin. hematology consulted and followed attempted iron replacement to no avail. skin biopsy revealed neutrophilic rich urticaria with the presence of eosinophils. serum protein electrophoresis (spep) revealed a monoclonal gammopathy with elevated igm, felt to be of undetermined significance (mgus). c-reactive protein (crp) was consistently elevated ( , ) in conjunction with anemia. rheumatology consulted and cleared of any evidence of vasculitis. hematology considered the anemia to be of chronic disease linked to cu. the cu was resistant to treatment including high dose antihistami- background: isolated head and neck angioedema (ae) can be mediated by bradykinin (bk) or histamin (hi) . the objective of our study was to determine which etiology was most frequent in cases of death by asphyxiating ae in france. we sought all cases of death by isolated asphyxiating ae reported in france between and via death certificates and/or the national pharmacovigilance database. results: the overall mortality by asphyxiating ae for all causes was . / million inhabitants. the death rate of bkae per million inhabitants was . and lethality of . per thousand patients per year. the death rate of hiae per million inhabitants was . and lethality of . per thousand patients per year. we found a times higher risk of death in case of bkae than hiae. conclusion: consequently, particularly severe episodes must be initially considered as bradykinin mediated and quickly reassess any first-line treatment that is inappropriate. case report: we present the case of a -year-old man who suffered recurrent abdominal pain since age of eight, leading to unnecessary emergency surgical interventions and endoscopies before hereditary angioedema due to c inhibitor deficiency (c -inh-hae) was diagnosed at the age of . rare subcutaneous swellings were considered allergic reactions preventing proper diagnosis. family history, positive for recurrent abdominal pain and swellings was totally neglected until diagnosis of c -inh-hae type i was established through appearance of severe oro-facial symptoms in the propositus' grandson. the diagnosis was suggested by the boy's mother, directed by educational materials available in the international hae patients' association website (www.haei.org). this report highlights and emphasizes the importance of accurately evaluated personal and family history to suspect condition that are scarcely known to the majority of physicians. highlights: diagnostic delay in hae and iatrogenic procedures are an underestimated problem, hiding undefined consequences, possibly destructing an entire lifetime. correct, publically available information provided by patients' associations raise awareness about the disease and could put the milestone of establishing correct diagnosis. de luque v ; lara p ; guardia p ; jimenez ar virgen macarena hospital, seville, spain; hospital virgen macarena sevilla, seville, spain background: in the protocol for the study of patients who consult for recurrent acute angioedema with facial involvement, the contactant battery is included (epicutaneous test). we review the results in our patients with facial angioedema to evaluate the contactants to which these patients present sensitization, some of them coexisting with contact dermatitis clinic. we reviewed the patients referred to the clinic for recurrent acute angioedema with facial involvement and to whom a standard battery epicutaneous test was requested. in all these patients, other habitual triggers included in the diagnostic protocol (food, medications, autoimmune diseases, bradyinergic aea/complement deficit …) were ruled out. conclusion: it seems to be profitable to continue including in the diagnostic battery of patients who consult for aea with facial affectation, study of epicutaneous with standard battery. it is a small sample, but the data correlate with what has been published, being more frequent the sensitization to contactants in women and the contactant more frequently involved nickel sulphate. | ace inhibitor-related angioedema-the value of history taking background: angioedema is a well-recognized side effect of angiotensin-converting enzyme (ace) inhibitor therapy. although it occurs in < % of the patients who take these drugs, it seems to be responsible for % of the episodes of angioedema. this entity is underdiagnosed and failure to recognize it leads to recurrence of episodes, with an impact on morbidity and increased risk of serious reactions. our objective is to analyze the clinical, therapeutic and orientation approach of patients diagnosed with ace inhibitor-related angioedema, evaluated at the outpatient consultation (oa) of immunoallergology (ia). a -year retrospective study was performed by analyzing the clinical files of all patients diagnosed with angioedema observed in oa of ia. the following variables were analyzed: gender; age; clinical data; evaluation in emergency department (ed); therapy in the episode; evolution and orientation. the chi-square test was used to study the association between categorical variables: "established therapy"/"disease evolution" and "place of reference"/"withdrawal of ace inhibitor". results: review of cases of patients referred for angioedema. only in % the final diagnosis was "ace inhibitor-related angioedema". the mean age of the patients was . years and % were male. the location of angioedema occurred in the tongue in % and in the remaining sites (lip, hemiface, tongue and hemiface, tongue and lip) appeared in the same frequency, %. none of the patients had airway obstruction. during the episode of angioedema, % of patients were not referred to ed and the therapeutic approach was done with antihistamines in %. in patients who were referred to ed ( %), antihistamines and corticosteroids medications were administered in %. regarding the evolution, it was verified that the duration of the episode was independent of the established therapy (p > . ). regarding the place of reference, % of the patients were referred form hospital (ec or ed) and, in these, the ace inhibitor was suspended in %. in patients referred from general practitioners ( %), in none of them the ace inhibitor had been withdrawal. a causal association between the use of ace inhibitors and the episode of angioedema becomes crucial, since drug withdrawal is indicated. a reference for ai oa should be weighed. therapy with antihistamines and corticosteroids has no proven efficacy. hereditary angioedema (hae) seen by physicians belonging to the hae scientific committee of the aaaeic background: patients with c -inh-hae frequently suffer from anxiety and stress. the impact of prophylactic treatment on anxiety and stress in c -inh-hae patients is largely unknown. here, we analyzed data from the apex- study, a phase ii study that investigated the effects of the oral kallikrein inhibitor bcx . method: c -inh-hae patients with a history of at least hae attacks per month were randomized to receive four different doses ( , , , . mg) of bcx or placebo for days. the depression anxiety stress scale (dass) was administered at baseline and at day . the dass consists of three self-reported scales designed to measure the negative emotional states of anxiety and stress. subjects used a -point severity/frequency scale to rate the extent to which they have experienced each state. results: baseline dass total scores as well as anxiety and stress domain mean (sd) scores for the mg treatment arm (n = ) were . ( . ), . ( . ), and . ( . ) points respectively. placebo scores were generally similar or slightly lower at baseline than for the mg treatment arm. the dass questionnaire data showed statistically significant improvements in total score vs. placebo at day (− . method: a two-phase mixed methods approach was used to develop the hae-rt tool including: phase : delphi study [hae specialists (n = ) and national patient advocacy group members (n = )] was conducted to reach consensus ( % agreement) on predictor variables to include in the tool. phase : retrospective chart review was conducted to assess the predictive findings of the decided variables. a convenient patient sample presenting with angioedema (with and without hae) between january -january were included in the study. results: nine of invited experts ( %) participated in the delphi study. of hae-specific predictive variables, reached consensuses including: (i) recurrent angioedema; (ii) absence of urticaria; (iii) recurrent abdominal pain/swelling; (iv) lack of response to allergic therapy. the retrospective study included patients (n = with hae; n = non-hae; overall % female). hae patients were significantly more likely to have a family history of hae ( % vs %; p < . ); previous recurrent angioedema ( %; p < . ); present with no hives ( %; p < . ); previous recurrent abdominal pain ( %; p < . ); and % responded to allergy treatments (p < . ). a regression analysis categorized observed frequencies (actual patient outcomes from chart review) versus predicted (by model); plotted on a by table and calculated the sensitivity and specificity of the hae-rt which resulted in one hundred percent for both. conclusion: our study demonstrated that expert involvement led to the identification and prioritization of variables that when included an hae-rt tool, were associated with a high level of sensitivity and specificity when applied to known patients. the next step is to observe the effect of the hae-rt tool on patient care in the ed. method: evaluation of cardiovascular manifestation included morphology, serum level of troponin t, electrocardiography (ecg) and echocardiography. evaluation of pulmonary manifestation included spirometry, diffusing capacity of the lung for carbon monoxide (dlco) and evaluation for mastocytosis included bone marrow biopsy and serum total tryptase measurements. results: in the study there were patients - women and men between and years old (the average age was ). there were ( . %) patients with mpcm, ( . %) with bmm, ( . %) with ism and ( . %) with ssm. the average level of serum tryptase was . μg/l ( . - ) . troponin levels was within the normal range in all patients. one patient had lowered the ejection fraction (eflv= %). no one patient had restriction. the average value of a forced lung capacity was . l ( %) and a total here, we describe a case series of twelve mis patients seen at our department over a -year period and report how many of these patients have sm. common phenotypical manifestations of acute hae episodes in this region, to review therapeutic challenges in a rural setting in comparison with world standards, and lastly to evaluate the socio-economic burden inflicted by the disease. method: a sample of individuals from a total of . the exclusion criteria was the inability to attend booked appointments more than times in year ( ). the following methods were used: an interview to formulate a family tree identifying affected individuals in contiguous generations, and review of the acute presentations in the past year ( ) . a questionnaire to obtain the relevant hae associated socio-economic burdens. a chart review to identify the therapeutic strategies in this region. c inh levels, and complement c to confirm the diagnosis. results: polygamy as a local culture was found to be an important factor that perpetuated the genetic burden of the disease. c inh and c levels confirmed hae in all participants individually. clinical features during acute attacks included swelling of extremities ( %), facial swelling ( %), neck swelling ( %), and laryngeal swelling ( %). therapeutic strategies for acute attacks included fresh frozen plasma or fresh dried plasma. danazol was used for prophylaxis. hae has had a significant negative impact upon the socioeconomic status of the affected individuals. conclusion: hae is a newly identified disorder in the broad spectrum of allergy medicine in kwazulu-natal. the diagnosis is simple to confirm but requires an initial high index of suspicion, and therapeutic management still poses a challenge in this region due to lack of resources. genetic counselling is of paramount importance during intervention since polygamy forms part of most cultures in this region. a support strategy is highly recommended in order to help alleviate the socio-economic burden posed by the disease in this region. the socio-economic burden secondary to hae ( participants/ identical questions each) question ( - points) question ( - points) question ( - points) question ( - points) question ( - point) method: a total of medical faculty senior year students were included to study on a voluntary basis. students are divided into two groups. one group was given visual user guide that has not been modified, and a visual user guide on which we have modified to the other group ( figure ). then they were asked to show how to use the inhaler spacer. results: the mean age of the volunteers was . ± years and ( . %) were male. there were students in the group without modification of the visual user guide and students in the other group with modified the visual user guide. sixty-four per cent of the modified user guide group showed correct use of the inhaler spacer, while % of the unmodified group showed correct use (p = . ). the group that given modified visual user guide was more successful in all of the display steps of the inhaler spacer. conclusion: modification of the currently available visual user guide of inhaler spacer in our country will increase the correct usage rate. results: mean fev , fvc, fev /fvc z-score were . ( . - . ), . ( . - . ), . ( . - . ), respectively. restriction had ( . %) and obturation ( . %) patients. fev (p < . , r = . ) and fvc (p = . , r = . ) decreased with age (%pv and z-score). background: children who were treated for leukemia are known to have developed long term impairment of lung function. the reasons that complication are only partially known. the aim of this study was to asses pulmonary function in children treated the lower dlco is the most frequent abnormality in childhood leukemic survivors. hsct and pulmonary infection (in particular cmv pneumonia) is a strong risk factor for impairment of dlco in children. clinical manifestation of dlco impairment is poor exercise tolerance. a screening for respiratory abnormalities in survivors following treatment for childhood haematologic malignancies, seems to be of significant importance. | phenotyping allergic respiratory diseases: an unsupervised classification using latent class analysis allergen groups was significantly associated to uawi (aor[ % ci]: . [ . - . ] ), compared to uasi. results: . % of br and % of py were women, median age was years, % br and % py reported having more than four years of training. although they recognized the main symptoms of ar, % br and % py never asked whether the patient had a medical diagnosis of ar; . % br and . % py did not ask whether the symptoms occurred when close to animals or allergens; % br and % of py did not ask if the patient had a medical diagnosis of asthma; % br and % py did not ask if rhinitis worsens asthma symptoms and . % br and . % py did not ask whether symptoms of rhinitis interfere with their daily activities. results: there was a predominance of female (br: %, py . %, uy: %) median age years old, / worked in the community and / in the emergency departments, % of the br had more than years of education, % from py had between and years, and % from uy had been graduated for less than year. br/uy recognize the main symptoms of ar, however % of those from uy do not ask: if the patient has physician diagnosis of ar, % present shortness of breath, and % a medical diagnosis of asthma, % if rhinitis worsens asthma symptoms and % if symptoms of rhinitis interfere with the patient's daily activities. the prescribed treatment varied a lot, the intranasal corticosteroid use rate was: bd: %, pd: % and ud: %. % of doctors in py, . % in br and % of uy never refer the patient to the specialist. . % of pcd of br, % of py and . % of uy are aware of aria guideline. conclusion: although ar is largely attended by pcp, recognition of symptoms and their impact on asthma, as well as the knowledge about aria guide is low and treatment is not always prescribed according to best practice. allergy education programs, with an emphasis on ar and aria guide, need to be directed to pcp in la for the better assistance of ar patients. | assessing knowledge of allergic rhinitis among final year medical and pharmacy students in croatia-curriculum change necessity? the two factor structured questionnaire was formed by the authors regarding the topics mentioned. t-test was used for statistical analysis. the global results were formed as composites of ( ) ar general characteristics, ( ) ar treatment approach, and ( ) the participants' overall knowledge. of the respondents, ( . %) were female and ( . %) were male (p < . ). medical students had a median score of of correct answers on ( ), of on ( ), and of on ( ), whereas pharmacy students had median score of of correct answers on ( ), of on ( ), and of on ( ). there were no significant differences in knowledge between two student groups. the results indicate an inadequate level of knowledge of ar in both groups, especially regarding the therapy approach. since general practitioners and community pharmacists have a major role in providing treatment to patients suffering from ar, it is important to develop advanced knowledge on this topic during medical and pharmacy degree courses. despite a relatively small study population, it would be advisable to introduce change by improving the core curriculum regarding ar with more emphasis on treatment, but additional research on this topic is necessary. tan r ; cvetkovski b ; kritikos v ; price d ; yan k ; smith p ; bosnic-anticevich s woolcock institute of medical research; university of sydney, sydney, australia; observational pragmatic research institute pte ltd, singapore, singapore; royal prince alfred hospital, sydney, australia; clinical medicine, southport, australia; griffith university, sydney, australia background: people with allergic rhinitis symptoms frequently selfselect over-the-counter medications from community pharmacies without seeking advice from a health care professional. this increases the incidence of complications due to delayed diagnosis and suboptimal treatment. this study aims to (i) compare the demographics, clinical characteristics and medication selected, between pharmacy customers who choose to self-select and those who interacted with a pharmacist when purchasing medication for allergic rhinitis symptoms, and (ii) identify the key factors associated with allergic rhinitis patients' medication self-selection behaviour. a cross-sectional observational study was conducted in a convenience sample of community pharmacies from the sydney metropolitan area. data were collected using a researcher administered questionnaire that included: demographics, pattern of allergic rhinitis symptoms, their impact on quality of life, factors triggering allergic rhinitis symptoms and medication(s) selected. logistic regression was used to identify key factors associated with participants' medication self-selection behaviour. results: of the recruited participants, were identified with allergic rhinitis, of which . % were female, . % were aged more than years old, . % had a diagnosis of allergic rhinitis, and . % self-selected medication(s). significant differences were noted in allergic rhinitis symptoms, impact of allergic rhinitis on quality of life and medication(s) selected between participants who chose to self-select and those who interacted with a pharmacist. participants who experienced moderate-severe wheeze were times more likely to self-select allergic rhinitis medication(s), and those who had allergic rhinitis symptoms impacting on their quality of life were . times less likely to self-select allergic rhinitis medication(s). conclusion: there is a high incidence of self-selection of over-thecounter treatments for allergic rhinitis symptoms in community pharmacy, with the majority of allergic rhinitis sufferers failing to seek pharmacist advice. this research identified predictors of medication self-selection behaviour in community pharmacy among people with allergic rhinitis, which can inform the design of tools/strategies and targeted interventions, aimed at improving pharmacist engagement and future practice in optimising allergic rhinitis management. the weir family health clinic, cork, ireland; university college, cork, ireland background: allergic rhinitis is a common condition that is predominantly managed in primary care. the incidence of allergic rhinitis is increasing. it is frequently under diagnosed, misdiagnosed and mistreated. it has a significant impact on patients' health related quality of life and represents a huge cost both to healthcare systems and society. the aim of this study was to implement appropriate guidelines regarding the management of allergic rhinitis in primary care and evaluate the effect on patients' health related quality of life. method: patients with a history of allergic rhinitis were selected from three general practice bases in west cork, ireland and quality of life of patients was assessed initially in year one and followed up one year later in a general practice setting using the standardised rhinoconjunctivitis quality of life questionnaire (rqlq). allergic rhinitis and its impact on asthma (aria) guidelines and appropriate prescribing were implemented during this year and patient education and structured follow up was arranged in the intervention group. this was compared with the control group who received usual care. results: valid responses were received, from the control group and from the intervention group. the study demonstrated a statistically significant difference in quality of life in the intervention group. in the adult intervention group the quality of life score decreased between and representing an improvement in their quality of life, (t = . ; df= ; p < . ). the difference in the score between the control and intervention groups in was also statistically significant.(t = . ; df= ; p < . ). the numbers in the adolescent groups and paediatric group also demonstrated an improvement in quality of life but the sample size was too small to demonstrate a statistically significant difference. conclusion: as the majority of patients rely on their general practitioners for treatment and diagnosis of allergic rhinitis, primary care represents an important area to target in the management of allergic rhinitis to improve patients' quality of life. the implementation of guidelines has been shown to improve patients' quality of life. this study demonstrates this care can be delivered in a primary care setting with an improvement in patients quality of life but substantial investment in education and resources available to primary care physicians is needed. | the predictive value of allergy tests in the diagnosis of peanut allergy in adults rey-garcia h; gunawardana n; wheeler k; scadding g; durham s; skypala i royal brompton hospital, london, united kingdom background: adults presenting with either new-onset symptoms attributed to peanuts or with early-onset peanut allergy, often wish to know whether they should continue to avoid peanuts. clinical history and standard tests may be sufficient to provide an answer, but for many the tests are inconclusive and an oral food challenge is required. this review was undertaken to determine the most accurate tests. conclusion: these data suggests that peanut spt and ara h provide the most accurate prediction of the outcome of oral food challenge in adults. should components not be available, then spt would be the test of choice being more accurate in all aspects than sige. combining spt and sige improves the sensitivity and negative predictive value of spt alone. however, the best combination is spt and ara h , which increases the overall accuracy to %. further studies are needed before it can be determined whether peanut diagnostic tests can replace the oral food challenge in adult patients. method: retrospective chart review was carried out in a community allergy clinic. patients with rap, bloating and altered stools who underwent bt were characterized by age, gender and atopic status. a separate study to assess patients' outcome post-dietary counselling was carried out to determine impact on symptom management. results: thirty-four patients were assessed for fi from january to december . female gender predominated ( / , %) with an average age of years at presentation. results of fi were positive in / ( %), borderline in / ( %) and negative in / ( %). the average age of patients with a positive, borderline and negative tests were , and , respectively. of the patients who tested positive for fi, ( . %) had comorbid inhalant allergies alone, ( . %) had comorbid (unrelated) food allergies alone, ( . %) had inhalant and food (unrelated) allergies, and ( . %) were non-atopic. of the patients who tested negative for fi, ( . %) had comorbid inhalant allergies alone, ( %) had comorbid (unrelated) food allergies alone, ( . %) had inhalant and food (unrelated) allergies, and ( . %) were non-atopic. conclusion: patients investigated for carbohydrate intolerance with rap, bloating and altered stools were predominantly female ( %). fi was confirmed in half. atopic status did not help differentiate between the fi positive or negative groups. results of a fod-map elimination diet are separately reported. conclusion: post-bt, % of patients reported symptom improvement. patients who implemented fructose or fodmap avoidance reported symptom improvement. one patient who tested negative for fi reported symptom improvement with a low fodmap diet. patients suspected as being fructose intolerant may benefit from a fructose restriction or fodmap diet, while awaiting bt confirmation. this form of dietary intervention may assist and shorten the natural history of non-specific chronic gi symptoms. inappropriate referrals to a uk paediatric tertiary allergy clinic demonstrate lack of allergy education and knowledge in primary care marriage de bristol royal hospital for children, bristol, united kingdom background: up to % of children have a food allergy. allergy has become an explanation for all manner of nebulous symptoms and self-diagnosis is common. sham allergy tests are easily available giving incorrect results and resulting in unnecessary, potentially harmful abstracts | parentally-imposed dietary exclusions. there are million allergyrelated google searches per year. the rising prevalence of perceived allergic disease has led to an increase in health service utilisation, including increased referrals to secondary care. clinic waiting lists are long and children with severe food allergies have to wait longer than necessary to be seen method: uk paediatric tertiary allergy clinic referrals were prospectively reviewed over three months. five inappropriate referrals deemed most reflective of poor knowledge in primary care were selected as case summaries to highlight this gap in knowledge. results: : schoolchild referred for investigation of allergic cause for a red, watery eye after splashing juice in her eye whilst cutting a kiwi, despite having a co-existent dendritic ulcer. : schoolchild referred for peanut allergy testing after inhaling a peanut and developing wheeze, with all respiratory symptoms resolving following peanut removal. : young child referred for peanut allergy testing after developing a rash on leg following skin contact with faeces hours after ingestion of peanut butter. : teenage boy referred for investigation of likely peanut allergy despite eating peanut butter and tree nuts almost every day. the family were concerned he was allergic to peanut butter. : toddler referred for milk allergy investigation after developing urticaria lasting hours minutes after drinking a bottle of milk. the child had consumed cow's milk formula since birth, and continued to consume milk daily for a further five months following the episode of urticaria. conclusion: provision of allergy services in the uk is poor and lack of investment in allergy services has led to suboptimal recognition and management of food allergy in primary care. allergy education provision for primary care practitioners is inadequate and fails to empower healthcare professionals to discern between allergy requiring full investigation and management, parentally-diagnosed allergy or symptoms which clearly have no association with allergy. progress to improve primary care training for allergy needs to be optimised to prevent further unnecessary referrals and lengthening clinic waiting lists. background: in case of allergic reactions to food or insect venom, quick and adequate treatment, based on clear instruction for use of emergency medication and calling for help, is necessary. however, daily practice shows that patients do not use the prescribed emergency medication because they are afraid to use the epinephrine auto-injector or they do not know how to use it. information and instruction offered by a reliable app could be a useful aid. we aim to develop an app for adult patients and children older than years with allergy to food or insect venom, which offers a step-wise approach to support patients, their relatives or acquaintances in case of an allergic reaction. method: first, the content of the app, including a step-wise approach to treat the allergic reaction has been determined, based on literature, a survey about needs of patients and on consultations of healthcare professionals. subsequently, a web-based prototype has been developed with an adult profile and children profile. the content and flow of this prototype was tested by the project group, as well as by selected healthcare professionals and patients and improved according to the test results. next, the revised prototype was submitted to representatives of patient and professional organizations for final approval. currently the procedure for ce approval is ongoing. finally, the app will be built and offered to the market for ios and android. results: a web-based prototype of the allergy app is available with two profiles: adult and older children. the app is useful for patients with a doctor's diagnosed allergy to food or insect venom, who received emergency medication and instructions to use prescribed medication in case of an allergic reaction. based on severity of complaints, the user is informed about the steps to treat the allergic reaction. in case of a moderate to severe reaction, the patient is advised to use an epinephrine auto-injector, to call the emergency number and, if prescribed, to use medication such as antihistamines, prednisone or inhaler. besides that, the app provides links to websites of expertise centres and patient organisations and includes instructions how to use the epinephrine auto-injector. conclusion: the allergy app will help patients, their relatives or acquaintances to adequately treat an allergic reaction to food or insect venom. involving patients and professionals in the development of the app will contribute to its acceptability and usability. | electronic documentation of drug allergies in a tertiary hospital in singapore: are we relying too much on it? choo kjl; garuna murthee k; naing cs singapore general hospital, singapore, singapore background: singapore has hospitals shared between public and private healthcare system. its healthcare system, ranked # in the world by who in serves a multi-racial population of . million of which % are above years old. drug allergy alert cards (medik awas) were started in s by singapore medical association to improve patient safety. work on computerisation of drug allergy and medical alerts started in the s, a precursor to today's critical medical information system (cmis). cmis serves as a platform across all public hospitals in singapore. it promotes uniform reporting of drug allergy and notification of adverse drug events to the health science authority. yet, we found that there is a lack of awareness of one's own drug allergies. method: all patients admitted to ward (general medicine ward) at singapore general hospital from july to oct were screen for any previously documented drug allergies. consenting patients who had previously documented drug allergies on cmis were interviewed to document their demographics, education level, current medications, knowledge of their own drug allergies and possession of a drug medication alert card. the answers were then compared with their electronic documentation of drug allergies for accuracy. we interviewed patients aged - with documented drug allergies during the recruitment period. % had secondary school education or higher. the majority ( %) spoke english and ( . %) mandarin. almost half had medical problems and are on long term medications (mean . medications); hypertension and diabetes being the top two common diseases. % of the patients could accurately relay their drug allergies; antibiotics and analgesia being the most labelled. only % had a drug allergy alert card while the rest both rely on the hospital's electronic documentation and/or their caregivers to record and relay their allergies to future prescribers. about % received prescription from multiple healthcare sites in both the public and private healthcare system. we found patients' knowledge of their own drug allergies dismal. the cmis electronic documentation provided a false sense of security. unfortunately, the cmis platform is not available to all private hospitals, increasing the risk of mis-prescription due to the lack of information. unless this is made available nationally, patients with drug allergies should be given some written documentation, either a letter or medik awas. how frequent are they and how are they treated? method: for this cross-sectional study, participants were recruited in the waiting rooms of local doctors in the rural bavarian forest region of southern germany (q / ). a paper questionnaire was handed out to the participants, asking for allergies (pollen, animal hair, bee and wasp venom, drugs, food, house dust mites, contact allergies and other allergies) and how or rather by whom (e.g. general practitioner, specialist, self-treatment) these allergies are treated. results: participants with a mean age of . years (sd= . ) and % women were included in this study. . % indicated to have at least one allergy, including pollen allergy most frequently ( . %). women had significantly more often at least one allergy than men (rr= . ; ci [ . ; . ] ) and for almost all examined allergies a significant higher risk of disease. younger age groups indicated more often to have at least one allergy ( - [. ; . ]) seemed to be affected less. participants indicated most frequently that their allergy was treated by a general practitioner ( . %), except of the - -yearold young adults who indicated "no treatment" most frequently ( . %). conclusion: there is a high self-reported prevalence of allergies in the examined rural bavarian region, that increases with decreasing age and is significantly higher among women. moreover, the data on the absence of an appropriated treatment for allergies is alarming. therefore, medical care needs to be improved in rural regions to lower the burden of allergies. | the prevalence of the burnout syndrome among medical professionals involved in allergology education programmes astafieva n ; kobzev d ; gamova i ; perfilova i ; udovichenko e ; skuchaeva l ; michailova i ≥ ) and rpa (low ≥ - , subscales were calculated and analyzed. results: on average students demonstrated: moderate/high ee scores ( - ); moderate/high dp scores ( - ) and moderate rpa scores ( ); higher rpa scores were common ( . %) among junior students, which is also linked with their levels of engagement, and lower ( %) among senior students. junior specialist (starting specialization) had very low scores in all subscales and expressed a very high motivation in their course and new profession. clinical allergologists with significant experience demonstrated moderate / high ee scores ( - ); low dp ( ) ( ) ( ) ( ) ( ) and rpa (below ) scores. high ee scores associated with pressures of service were compensated by a substantial loyalty to their profession and positive assessment of the outcomes of their work. clinical academics demonstrated the highest level of ee scores ( + among + % of the group) with low to moderate dp and rpa scores, the latter being associated with a loyalty to their profession. it was also possible to identify a correlation between engagement in research activities and lower rpa scores. conclusion: burnout is a complex and multifaceted phenomena, which requires further investigation. however, this research identified that students and junior specialists involved in allergology and clinical immunology programmes with higher levels of engagement and motivation to acquire new specialist knowledge had lower levels of ee, while loyalty to the profession and positive assessment of the outcomes of clinical and research work allows to compensate high levels of ee among experienced practitioners and clinical academics and to reduce burnout effects overall. | appeal (allergy to peanuts impacting emotions and life): the first pan-european study to evaluate the psychosocial burden of living with peanut allergy deutscher allergie-und asthmabund (daab)/german allergy and asthma association, mönchengladbach, germany; food allergy italia, padua, italy; aepnaa asociación española de personas con alergia a alimentos y látex, madrid, spain; afpral association pour la prevention des allergies, paris, france; asthma-allergy denmark, roskilde, denmark; anaphylaxis campaign ireland, cork, ireland; brainsell ltd, london, united kingdom; aimmune therapeutics, london, united kingdom background: peanut allergy, one of the most common and rapidly growing food allergies, is most frequently a lifelong condition. current management is limited to avoidance and symptomatic treatment of allergic reactions when accidental exposures occur. peanut allergy can affect the quality of life (qol) of individuals and also that of parents/caregivers and family members. appeal was designed to assess the impact of peanut allergy on qol in peanut-allergic individuals and their parents/caregivers and families. method: the first, quantitative part of appeal is described here and consisted of a pan-european, cross-sectional online survey of approximately minutes in length. the study was conducted in the uk, republic of ireland, france, spain, germany, italy, the netherlands and denmark. over participants were recruited via patient advocacy groups or directly through a specialist survey recruitment panel. ethics committee approval was obtained and all participants provided their informed consent. eligible participants were: ( ) parents or caregivers of a child/adult with peanut allergy; ( ) parents or caregivers responding as a proxy for a child aged under ; ( ) adults. all allergic subjects had self-reported diagnosed peanut allergy. after several screening questions, eligible participants answered a set of clinical questions about their (or their child's) allergies and other conditions, details on the peanut allergy diagnosis, contact with healthcare professionals, worst allergic reaction to date and use of emergency medicine. depending on whether they were an allergic adult, a parent responding on behalf of the child, or a parent/caregiver recounting their own experience, they then answered specific questions on restrictions on life choices, coping strategies and the impact of peanut allergy on feelings and emotions of families, friends and other people. sociodemographic questions completed the questionnaire. the results of the survey are being summarized using descriptive statistics and the data are being analysed on a pan-european level, by country, and according to the participant's perspective (parent, caregiver or individual). conclusion: this comprehensive, pan-european online survey has been specifically designed to uncover the psychosocial burden and effect on qol of peanut allergy in terms of individuals' lives and those of their families. results: pediatric patients were included in the study. . % (n = ) were male. the median age of onset of symptoms (interquartile range) was months ( - ).the median age (interquartile range) of diagnosis was months ( - ). initial reactions associated with cmpa were observed in . % of patients before months old. patients' diagnoses were atopic dermatitis ( %), urticariaangioedema ( %), anaphylaxis ( . %), proctocolitis ( . %), atopic dermatitis and urticaria ( . %), food protein induced enterocolitis ( . %) and eosinophilic esophagitis ( . % method: the study involved patients, who are two years old (and above), diagnosed with cow milk allergy and are observed for at least six months in our hospital. socio-demographic features of the patients, their symptoms, symptom-start ages, age of diagnosis, clinical findings at diagnosis and during observation were recorded in data collection questionnaires. results: the samples were ( . %) boys. the average symptomstart age was observed to be months , average diagnosis age months ( - ) and average age of final check months . when symptoms at entry were observed, . % of the patients had dermal system, . % gastrointestinal system, respiratory system disorders, and % were detected to have developed anaphylaxis. among the patients diagnosed with cow milk allergy, . % showed food reaction to nutrients with lge agents, . % to mixed types, and % to nutrients with non-lge agents. it was also observed that, in the end of . ± . -month observations, sensitivity to cow milk was observed to continue in ( . %) of our patients. when tolerance improvement rates among the patients were compared, anaphylaxis (p < . ) during entry were observed to be influential in continued allergic state. ( . %) patients were able to consume yoghurt, ( . %) patients could consume dairy products and ( . %) patients could not consume dairy products. conclusion: in the end of our investigation, it was observed that ( . %) of the patients developed cow milk tolerance before the age of . when the factors enabling the continuation of sensitivity in cow milk allergy were investigated, anaphylaxis during entry, entry specific lge and pasteurized milk antigen as well as high skinprick test results were detected to be significant. | initial lower threshold was a risk factor of severe adverse reaction during oral immunotherapy for cow's milk anaphylaxis results: before oit, median age was . years old, median threshold to induce initial reaction was . ml, to induce anaphylaxis was . ml of cm and median milk specific ige was . ku/l. twentyseven subjects ( %) dropped out from the protocol, subjects | investigation of heat and matrix effect on milk proteins' allergenicity and the development of hypoallergenic food products reduce some milk proteins' allergenicity (ß-lactoglobulin) . in this project we aimed to investigate the effect of heat and matrix on different milk protein fractions through maillard reaction and eventually develop hypoallergenic food products that have milk protein with low reaction risk. method: milk cake matrix is prepared in different flour/sugar (f/s) ratio ( f/ s, f/ s, . f/ s) and baked minutes at °c. proteins that cake contains are separated using sds page and stained with coomassie blue to check total protein. in parallel specific proteins are detected by western blotting using pooled sera from patients with milk specific ige> ku/l for incubation results: in normal milk cake recipe ( f/ s) ß-lactoglobulin bands are disappeared but casein bands did not differ in size. in order to investigate the matrix effect f/s ratio is changed and it is found that when this ratio decreases, with the affect of heat and maillard reaction, milk casein bands' intensities also decrease in sds gel coomassie staining. in western blot experiments it is also shown that milk specific ige bound weakly to casein bands in low f/s ratio cake ( . f/ s) whereas in cakes that have high f/s ( f/ s) ratio it bound significantly higher. and ß-lactoglobulin proteins' structure and lower the milk specific ige bindings to milk proteins in low f/s ratio cake through maillard reaction. | extensively hydrolyzed formulas for the management of cow's milk protein allergy in infants: is extensive hydrolysis sufficient to guarantee success? method: to better understand the range of ehfs, we aimed to analyse samples of commercially available ehfs from countries and various manufacturers, with a focus on suitability for cmpa management. samples were de-identified and coded for the analyses. molecular weight (mw) distribution of hydrolysates and residual proteins and peptide profiling were assessed with sds-page gel and size exclusion-high-performance liquid chromatography (se-hplc), as they reflect both the design of the formula and the quality management applied during production. osmolarity, nitrogen fractions, lactose content, total and free amino acids, β-lactoglobulin, and casein content were quantified and β-lactoglobulin residual allergenicity was assessed. results: peptide mw distribution displayed significant variation, with the percentage of peptides with mw > . kda varying from % to %. mw distribution was shown to be positively correlated with β-lactoglobulin specific in vitro degranulation. twenty % of samples had non-measurable β-lactoglobulin content (smaller than or at the limit of quantification (loq): . mg/kg); however, % of samples had β-lactoglobulin content greater than the loq, with high variability from . to mg/kg. surprisingly, even in samples featuring a high degree of hydrolysis, significant levels of residual β-lactoglobulin were quantified. conclusion: lack of consensus over the definition of 'extensively hydrolysed' is reflected in the wide range of degree of hydrolysis in commercially available ehfs, and can result in products that are mislabelled as 'extensively hydrolysed' and may be high-risk or even unsuitable for the management of cmpa. results of these analyses also highlight that degree of hydrolysis alone is not sensitive enough to characterise ehfs, and that whilst a high degree of hydrolysis is desirable, further quality control measures are essential to ensure clinically safe and suitable products. actionable guidelines to better define hypoallergenic formulas based on extensively hydrolysed milk proteins are warranted. background: assessing the effect of baked milk products on accelerating unheated milk tolerance in patients with cow's milk allergy. method: a randomized clinical trial was done on patients ( months- years old) divided randomly to case and control groups matched for age and sex. baked milk in form of muffin for months followed by baked cheese in form of pizza for next months was given to the patients in case group. skin prick test and serum ige (sige) levels (immunocap) of milk, casein and betalactoglobulin were measured before and after the study. the ones having milk sige less than ku/l and being asymptomatic during the study underwent oral food challenge test for evaluating unheated milk tolerance. chualalongkorn university, bangkok, thailand; kk women's and children's hospital, singapore, singapore; university of the philippines, philippine general hospital, manila, philippines background: problems in recognising cow's milk allergy (cma) and lactose intolerance (li) in infancy may lead to a delayed or incorrect diagnosis, as well as inappropriate dietary interventions. method: between january and november , a survey was conducted online in china, india, singapore, thailand, mexico, kuwait, united kingdom, australia, and paper-based in the philippines. the survey consisted of multiple-choice questions on cma and li in infants aged under months, two case scenarios (non-ige cma and anaphylaxis) and questions on educational needs (likert scale [ ] [ ] [ ] [ ] [ ] . data on the type of medical practitioner and clinical setting were collected. responses were summarised as percentages and categorised by country. results: responses were received from general practitioners ( . %), paediatricians ( . %), paediatric allergists ( . %), paediatric gastroenterologists ( . %) and other specialities ( . %). there were significant misconceptions about the clinical importance of primary li in infancy. while primary li rarely manifests before years of age, . % of participants felt it was a significant clinical problem in the first year of life. regarding secondary li, % of respondents recommended lactose restriction for viral gastroenteritis, and % for cow's milk protein-induced enteropathy. while the management of ige cma was relatively well understood, there were greater knowledge gaps for non-ige cma. % of practitioners appropriately identified extensively hydrolysed formula (ehf) as first-line treatment of cma in formula-fed infants. however, the distinction between lactose-free and lactose-containing ehf appeared to be an area of uncertainty. in india, . % used soy-based formulas as first- results: patch tests were positive in ( . %) and negative in others. positivity to milk was seen in patients ( . %), to soy in ( . %), to egg white in / ( . %), to wheat in / ( %), to potatoes / ( . %), to corn (maize) in / ( . %), to rice in / , and to peanut in / ( . %). patients were requested to withdraw the suspected food(s) from their diets during a months period. preliminary follow-up data show the improvement of one or more symptom in / patients (gastroesophageal reflux in , appetite in , stool consistency in , respiratory symptoms in , pain in , eczema in ). conclusion: patch tests are informative, easy to use tools in order to identify potential causes of common lasting symptoms in children with negative or weak rast results and introduce beneficial changes in the daily diet. longer follow-up is necessary in order to refine and assess the benefit of such strategy. background: currently in the us, in children suffer from food allergies. at present, there is no cure and strict avoidance of the relevant foods is the only way to prevent allergic reactions. elimination diets put infants and children at risk for nutritional deficiencies and impaired growth. we examined the role of the registered dietitian (rd) in advising patients and families of food allergic children. method: a retrospective review of clinical notes was performed for the first consecutive children who required a dietetic consultation in a dedicated food allergy clinic. we examined common questions from parents that were addressed by the dietician during the consultation. results: patients were aged months - years (median: months) and were diagnosed with the following food allergies: cow's milk: . %, egg: %, tree nut: %, peanut: %, wheat: %, soy: %, fruit/vegetable: %, legume: %, fish: %, sesame: %. the most common questions for the dietitian included: ways to meet nutritional needs following a prescribed allergen-restricted diet ( %), meeting vitamin d and calcium requirements on a milk protein-free diet ( %), suitable oral supplements and recommended serving sizes ( %), appropriate order of solid foods introduction in food protein-induced enterocolitis syndrome (fpies) ( %), cautionary food ingredient statements ( %), baked milk protein introduction ( %), cross-reactivity risk of milk protein with soy ( %) and crossreactivity of nuts in retail bakeries ( %). conclusion: parents of children with food allergies have multiple questions with regards to nutrition. dietetic input in the food allergy clinic addresses important issues for children and families including successful avoidance of allergen-containing foods while ensuring optimal nutrition, decreased exposure to high-risk situations and avoidance of allergen cross-contamination. | multicenter prospective study of a stepwise single dose oral food challenge of egg background: oral food challenges (ofcs) are necessary for allergy management. we previously reported that a low-dose ofc can avoid complete elimination, even if patients react to higher doses of causative foods. nevertheless, this approach has only been validated in a retrospective single-center trial. we have previously reported that the median time for initial symptom onset is minutes for egg ofc using a single exposure. therefore, this study aimed to confirm the safety and effectiveness of a stepwise single-dose ofc in a multicenter, prospective study. who showed a positive reaction to low-dose ofc, only patient ( %) showed a severe reaction: barking cough immediately improved with adrenaline inhalation. among patients with a positive reaction to medium-dose ofc, none had a severe reaction. the median times to symptom onset were and minutes following low-dose and medium-dose ofc, respectively. patients in the three groups, divided according to threshold doses, differed significantly in sige levels against egg white and ovomucoid. conclusion: this multicenter prospective study confirmed that stepwise single-dose ofc to egg will help to clarify the severity of egg allergy, and will contribute to improved food allergy manage- method: the study design was a retrospective cohort study extracting data from the electronic chart of children older than years who visited our out-patient clinic for egg or milk allergy and who underwent an oral food challenge test (ofc) twice within months between november and december . the patients were divided into five groups according to their treatment schedule, which consisted of those who: a) started from / of the first ofc reaction threshold and maintained / till the end of oit; b) started from / of the threshold and maintained / ; c) started from / of the threshold and maintained / , d); conventional slow oit (started from just below the first ofc reaction and increased . - . times every few weeks); or e) continued elimination. we determined the presence or absence of an increase in threshold reacted to the allergen, any adverse events during oit, and food-specific ige reduction. results: the number of participants was and their median age was years. the number of patients in groups a, b, c, d, and e was , , , , and , respectively. the percentage of patients in groups a, b and c showing an increase in reaction threshold to the allergen was higher than that in group e (p < . ), and that in group b was higher than that in group d (p < . ). the number (percentage) for group a, b, c, d, and e was ( . %), ( . %), ( . %), ( . %), and ( . %), respectively. there was a significant difference in the frequency of adverse events during oit between group a-c and d, which was as follows: ( . %), ( . %), ( . %), and ( . %), for the respective groups (p < . ). there was no significant difference in the percentage of patients showing a decrease in food-specific ige in each group. conclusion: the regimen starting from / of the ofc reaction threshold and maintaining the dose at / was safer and more effective for increasing the threshold reacted to the allergen than the 'conventional slow oit' regimen. elimination continuation was not effective for increasing the threshold reacted to the allergen. legumes allergy was presented in different clinical features; urticaria and angioedema in ( %) patients, anaphylaxis in ( . %) patients, atopic dermatitis in ( . %) patients, eosinophilic esophagitis in ( . %) patients and as food-related enterocolitis in ( . %) patient. thirteen ( . %) of the patients had asthma, ( . %) had allergic rhinitis. fourteen ( . %) of the patients with single legume allergy showed improvement. the patients who developed tolerance, of these ( . %) had peanut allergy, ( . %) had lentil allergy and ( . %) had chickpea allergy. two of patients with multiple legumes allergies, it developed tolerance to all the legumes they are allergic. conclusion: peanut and lentils were the most frequent legumes that displayed allergic reactions in our study. in these patients the rate of allergy to non-legumes food is high. in patients who were allergic to single legumes, the symptoms were ameliorated in . %. conclusion: cashew nut is a potent allergen and can cause quite severe reactions. avoidance of pistachio nut and other related allergens should be advised to patients after allergologic investigation. in the majority of the patients, presence of atopic dermatitis with food allergy is noteworthy. therefore, it would be useful to investigate these patients for cashew and other tree nut allergy before they present with a serious clinical reaction. and jellyfish sting. serum allergen-specific ige test was negative; skin prick test was positive for natto and pork. we performed an oral food challenge with natto, pork, crustaceans, and wheat, and she developed a general itchy rash after hours of eating natto. h blocker was administered and she recovered soon. however, the general itchy rash relapsed after hours. hence, we intramuscularly injected epinephrine, h -blocker, and steroids; then, her symptoms did not relapse. based on these findings, we inferred that anaphylaxis caused by natto could be associated with a jellyfish sting. discussion: although association between japanese fermented soybeans (natto) allergy and jellyfish sting has been previously reported, its anaphylaxis is a rare event. in this case, we suggest that anaphylaxis was caused by natto allergy, which was perhaps related to jellyfish sting. hence, further investigation is essential to elucidate the association between fermented soybeans allergy and jellyfish sting. introduction: non-celiac gluten sensitivity (ncgs) is a syndrome characterized by intestinal and extra intestinal symptoms related to the ingestion of gluten-containing food, in subjects that are not affected by either celiac disease (cd) or wheat allergy (wa).once the gluten-containing foodstuff is removed from the diet, the patients will have relief of their symptoms. case: a -year-old girl was referred by his general practitioner with history of occasional constipation and abdominal pain (especially after main meals and defecation), short stature and low weight. the growth indices were proper for her age till she was . then after there was a stunting. she had short stature and low weight. despite different types of supplementation, there was no improvement in growth indices, so she was referred to a pediatric endocrinologist for gh therapy. primary investigations and anti-ttg, iga, anti-ema all were normal. after a consultation with a pediatric gastroenterologist, a genetic study of hladq and were done because of the highly suspicion of celiac disease. the results were also negative. at last she was referred to immunology-allergy clinic for evaluation of probable food allergy. ige level was checked and a prick test was performed which they were not indicative of any suggestive food allergy. because of the history of the abdominal pain and constipation which was more prominent after meals, negative results of genetic study, spt to wheat, and serologic markers, a gluten free diet was suggested for her with the suspicious of non celiac gluten sensitivity. a significant improvement in her symptoms was noticed within weeks of starting gluten free diet. she has kg of weight gain and height improved from cm to cm in months. she continued to improve on a gfd and when seen in the follow-up clinic months later reported complete resolution of symptoms and another cm and kg gain in her height and weight. conclusion: non-celiac gluten sensitivity syndrome is a diagnosis made by excluding celiac disease and wheat allergy. it should be taken into consideration especially in patients who have the suspicious symptoms of celiac without supporting lab data, and also negative spt to wheat. the young man in question along with his parents were keen to proceed, so with some hesitation we proceeded to a hazelnut oral provocation challenge, having very carefully explained the risks of undertaking such a challenge. he successfully completed the challenge and experienced no allergic symptoms and is now able to have hazelnuts in his everyday diet. discussion: this young man wanted to confirm if indeed he was allergic to hazelnuts. not being hazelnut allergic would mean that he would be no longer allergic to any nut and would not have to take precautions prior eating products. positive results to both cor a and cor a , hazelnut storage proteins are associated with the patient possibly experiencing systemic reactions, at a higher risk of experiencing anaphylaxis it they were to ingest hazelnut. these facts in conjunction with his specific ige to hazelnut would have prevented us from proceeding to challenge was it not for this young man's persistence that he wanted to proceed to challenge despite the risks. conclusion: appearances are deceptive, as this case demonstrates; allergen-specific ige and component testing can only predict the probability of an allergic reaction, the final test in the diagnostic process is the oral provocation challenge. the patient and his family were happy for me to share the above with other health care professionals. method: we present the case of a female of years old diagnosed of acu with poor control of the symptoms at maximum doses of antihistamines. we decided to associate omalizumab treatment. the patient had a good control of the symptoms with omalizumab at dose of mg/ weeks, but in the th month she presented an erythematous, raised and pruritic lesion in the area of injection together with localized abdominal edema at hours of the administration, with two weeks of evolution without symptomatic treatment. we decided to discontinue omalizumab alter a second episode with half doses. results: we performed a skin biopsy of the lesion and epicutaneous tests with the drug. immediate hypersensitivity tests were not taking due to the impossibility of stopping antihistamines. skin biopsy showed a perivascular lymphocytic inflammation of the superficial and deep dermis with frequent presence of perivascular and interstitial eosinophils, suggestive of a hypersensitivity reaction. results: nine months before presentation at our clinic, the patient had been hospitalized and treated with imipenem and tmp/smx for pulmonary nocardiosis. once discharged, she had been prescribed oral tmp/smx alone, according to antimicrobial susceptibility. at our first evaluation, the patient presented with fever, macular erythematous non-pruritic (vasculitic-like) skin lesions on the upper limbs, polyarthralgia and bilateral ankle arthritis. tmp/smx was transiently stopped. after four days, there was a dramatic improvement, with resolution of all signs and symptoms. she was tentatively diagnosed with a viral infection and thus tmp/smx was started again. however, after three days, the symptoms (fever, arthritis and skin lesions) recurred. laboratory investigations showed increased levels of inflammatory markers. complete blood count with differential, serum creatinine, urinary sediment, liver enzymes, rheumatoid factor, antinuclear antibody, c , c , immune complexes, serology for rickettsia, borrelia and coxiella were all negative. hence, tmp/smx was stopped again and cutaneous lesions, fever and arthritis resolved spontaneously in five days. conclusion: given the clinical course and the resolution after the withdrawal of tmp/smx, we diagnosed a sslr due to sulfonamides. to the best of our knowledge, this is the first case of sslr occurring after a nine-month therapy with tmp/smx and allergists/immunologists should be aware of the possibility of such a reaction even after months. case report: * we received written informed consent for publication of these clinical details and/or clinical images included in my abstract was obtained from the patient. drug rash with eosinophilia and systemic symptoms (dress) syndrome is a severe adverse cutaneous reaction that usually appears - weeks after treatment with the causative drug. this syndrome is characterized by severe dermal rash, fever, eosinophilia, and internal organ involvement, and clinically, diffuse maculopapular eruption, exfoliative dermatitis, and facial edema are often observed. we performed blood tests and laryngeal fiberscopy for the diagnosis of the patient. intradermal test with delayed reading and patch test were performed months after the end of treatment. a -year-old man had begun treatment with carbamazepine for epilepsy. after weeks of treatment, he observed skin rash with pruritus on both lower extremities, and after weeks, his skin lesions had begun to spread over his whole body, and he complained of several new symptoms, including hoarseness, dyspnea at rest, and dysphagia. an examination revealed maculopapular rash, facial edema, and bilateral cervical lymphadenopathy. laryngeal fiberscopy revealed both arytenoid and epiglottic swelling. laboratory studies revealed eosinophil counts of /μl and increase in alanine aminotransferase level to u/l. a diagnosis of dress syndrome was definite according to the regiscar group criteria. carbamazepine, the suspected culprit drug, was withdrawn, and systemic corticosteroid was initiated. the patient experienced rapid improvements in hoarseness, dyspnea, and dysphagia. after days of treatment, laryngeal fiberscopy revealed complete resolution of both arytenoid and epiglottic swelling. to the best of our knowledge, our case is the first reported case of dress syndrome to manifest with laryngeal edema. case report: bortezomib (velcade Ⓡ ), a targeted therapy works by blocking the action of proteasomes in side cells, is commonly used to treat newly diagnosed as well as relapsed/refractory myeloma. bortezomib has been reported to have gastrointestinal symptoms, peripheral neuropathy, neuropathic pain and thrombocytopenia as its most common side-effects. although several cases of skin lesion caused by bortezomib have been reported, severe cutaneous adverse reaction (scar) such as stevens-johnson syndrome (sjs) is very rare. we here report a case of bortezomib induced sjs. a -year-old female patient, who was diagnosed with multiple myeloma, received bortezomib and melphalan /dexamethasone therapy. after the th dose of bortezomib, she presented with fever and maculopapular skin rashes spreading from face to the trunk. erosive lesions in the oral mucosa and corneal ulceration with conjuntival injection were observed. she was diagnosed as sjs. the symptoms of sjs improved after bortezomib was discontinued and systemic steroids and intravenous immunoglobulin were administered. drug patch test was performed, the result was positive in bortezomib. this is the first case report of bortezomib induced sjs in this country, which was diagnosed by a patch test. although the scar by bortezomib is generally considered very rare, we suggest that clinicians be aware of potential adverse reactions, including sjs. case report: we report the case of a healthy -year-old woman with history of red erythematous macules in both hands, one hour after taking a fluconazole ( mg) tab for a vaginal candidiasis. it faded spontaneously. she didn't recall if she had ever taken that medicine, but denied known drug allergies. although fde is primarily a clinical diagnosis, we conducted an oral challenge test with fluconazole ( mg). two hours after intake of the drug the patient started complaints of pain and erythema in both hands and the challenge was stopped. two days after the challenge, she developed red painful erythematous macules on the same sites of the first episode. due to the specificity of the challenge, local patch testing was not performed. introduction: the classic form of a fixed drug eruption is one or more anular or oval erythematous patches as a result of systemic exposure to a drug. these skin lesions normally resolve with hyperpigmentation and may recur in the same location with re-exposure to the drug. other types of fixed drug eruptions have been described, being fixed drug urticaria a rare form of presentation. ( , ) case report: in the last years, a year old woman has developed more than episodes of a wheal in the right supraciliary region minutes after taking mg of oral ibuprofen. the symptoms resolved in less than hours without treatment and without leaving residual lesion. after the last episode, she refers good tolerance to g of oral paracetamol. she denies local traumas. she also refers mild spring rhinoconjunctivitis well controlled with antihistamine, and sneezing with house dust. a -year-old-m patient had psoriasis vulgaris for years, and had been using methotrexate at intervals of years. despite the addition of phototherapy, he underwent a new treatment with biological agent (antitumor-necrosis-factor; anti-tnf), since the disease control was insufficient. before anti-tnf, preventive treatment against latent tuberculosis (tb) activation was indicated with positivity in tuberculin skin test ( mm). he was given inh mg/day, and at the th day of treatment, desquamation, erythema, and subsequent exfoliation developed in his hands and foots dorsum. inh was withdrawn. in order to distinguish the lesions from psoriasis attack, skin biopsy was performed and reported as erythema multiforme-like dermatitis with no relation to psoriasis. the lesions were completely improved at weeks of topical steroids, and inh was re-initiated at the same dose. a week after the initiation of the drug, skin lesions similar to previous reoccurred with more severity and progression from distal to proximal extremities. cell counts, renal and hepatic function tests, and hepatitis markers in blood were in normal limits. skin lesions were retracted after weeks of topical steroids, and withdrawal of inh. there was positivity in skin patch test with inh at hours. finally, for tb prevention an alternative drug rifampicin ( mg/kg/day) was given, and the patient successfully completed with no adverse event. his psoriasis lesions were improved with anti-tnf which was started after month of tb prevention with rifampicin. in these days which the use of biologic agents is increasingly widespread, inh use will be more prevalent than the past. even tough, it is effective and safe in most of the patients, its adverse event dermatitis may be a reason to withdraw in patients with dermatological diseases. in this case, diagnostic drug allergy evaluation should be performed to optimize the second-line treatment of tb infection, in addition to early withdrawal of the culprit drugs. background: around % of cancer patients will receive radiotherapy (ionizing radiations) as a treatment, either as a single therapy or as an adjuvant to chemotherapy and surgery. several side effects have been described due to radiotherapy, of which we can mention erythema multiforme and stevens johnson syndrome, but in lower prevalence. erythema multiforme can be described as an acute skin condition and may be present within a wide spectrum of severity. erythema multiforme minor represents a localized eruption of the skin with minimal or no mucosal involvement. the papules evolve into pathognomonic target or iris lesions that appear within a -hour period and begin on the extremities (see the following image). lesions remain in a fixed location for at least days and then begin to heal. it is considered to be a type iv hypersensitivity reaction associated with certain infections, medications, and other various triggers precipitating factors and complex interactions may trigger the appearance of signs and symptoms. these include especially recurrent herpes simplex virus (hsv), epstein-barr virus (ebv), histoplasmosis, alcohol, systemic diseases and immunological factors. method: -year-old male diagnosed with prostate adenocarcinoma who underwent transurethral resection and was taking trinomia (ramipril, atorvastatin, acetyl-salicylic acid) after his th rte external radiotherapy session, he presented erythematous maculo-papular lesions in the suprapubic area with some vesicles. therefore, withdrawal of treatment was decided and the performance of a skin biopsy. days later, regarding the improvement of the lesions, rte was continued, presenting incipient exacerbations of the lesions but it allowed us to end the cycle of treatment. results: skin biopsy results (anatomical pathology): basal keratinocytes, which blur the dermoepidermal interface, with lymphocyte exocytosis at this level, associated with isolated images of spongiosis. the dermis shows a superficial perivascular lymphocytic inflammatory infiltrate of moderate intensity. compatible with erythema multiforme. conclusion: radiotherapy is a technique of increasing use, so it is important to recognize the associated cutaneous lesions that appear less frequently and are sometimes underdiagnosed. diagnosis is both clinic and pathological and is usually late in most cases so it is vital to take into account this skin disease complication in order to be properly managed. including chinese herbal medicine is usually considered to be without any allergic and adverse reaction. method: visits were made to pharmacies in hong kong and luoyang, china and a martial art monastery/temple in dengfeng, china. some cam were found to have ingredients with potential allergic and adverse reaction. results: three cam, one from hong kong ( ), one from shaolin martial art monastery/temple in dengfeng ( ) and one from luoyang ( ), china were found to contain chinese herbal medicine with potential allergic and adverse reaction. ( ) cordyceps ling-zhi complex ingredients: cordyceps sinensis "caterpillar fungus", tremella fuciformis "snow fungus", ganoderma lucidum (ling-zhi) "reishi mushroom" and others years old female patient who has ulcers in oral mucosa and purple, itchy lesions on her right hand palmar area, little finger, index finger, on her left hand palmar area, pollex finger. in her history, she has relapsing vaginal yeast and she hasn't any hypersensitivity reaction with fluconazole before month ago she started to take fluconazole because of vaginal candidiasis. after using fluconazole she started to itch from described areas and dark redpurple eruptions appeared. she was prescribed oral methylprednisolone and topical pomade which included corticosteroid for four days but she didn't aware of fluconazole related drug reaction. lastly four days ago she took fluconazole and metronidazole for severe vaginal yeast. hours later pruritus, same eruption appear on the same area, lip and tongue angioedema than she had dyspnea, dizziness, hypotension, arrhythmia and consciousness. she had admitted to the emergency department and performed adrenalin. after a day bullae and ulcers came into existence in her oral mucosa. in her blood analysis there was mild increase in white blood cell count ( . /mm ), eosinophil count was normal ( /mm ), biochemistry parameters were in normal limits, crp and sedimentation rate were in normal limits, total ige was iu/l. introduction: tuberculosis is a disease that most commonly affects the lungs, which is transmitted by the respiratory tract and drugs are the most important factor in the treatment. non-resistant tuberculosis infection is usually treated with hrze. in rare cases, a hypersensitivity reaction may develop against one or more of the drugs during treatment. case: a -year-old female patient was diagnosed with culturepositive pulmonary tuberculosis and hrez treatment was started by the related department. seven days later she referred to the policlinic with edema and itchy erythematous lesions which are common in her extremities, which developed after hours of taking her medication. liver and kidney function tests and eosinophil count were normal. drug eruption was considered with current physical examination findings. the treatment was interrupted, short time systemic corticosteroids and antihistamine treatment started. desensitization planned. there was no feature in the prick and patch tests with drugs. desensitization was performed with isoniazid, no reaction was observed during the procedure. six hours after the procedure, the patient applied to the emergency department with painful edema and pruritic erythematous lesions in the extremities. desensitization procedures with rifampicin, ethambutol, pyrazinamide were performed without any problems after the lesions were regressed. isoniazid was withdrawn from the treatment protocol. outcome: we would like to present on this case that drug eruption may develop in the form of maculopapular rash after desensitization. this study aims to compare ethmoid mucosa and nasal polyp regarding density of tissue eosinophil and its sensitivity, specificity, and correlation with clinical characteristics for diagnosing ecrs. method: patients with crs with polyps scheduled for endoscopic sinus surgery were enrolled. specimens were collected from polyp apex, polyp pedicle and ethmoid mucosa. tissue eosinophil from these three sites in the same patient were compared. using eosinophilic mucin as a reference, sensitivity, and specificity of each site for diagnosing ecrs was assessed. correlations between tissue eosinophilia (defined as greater than / hpf) and clinical characteristics of ecrs including asthma, serum eosinophilia, and eosinophilic mucin were analyzed using each site of specimens. results: thirty patients with crs with polyps were enrolled. polyp apex, polyp pedicle and ethmoid mucosa gave similar results regarding tissue eosinophilia in patients ( . %). eleven ( . %) patients were ecrs (having tissue eosinophilia at all sites) and five ( . %) were non ecrs (no tissue eosinophilia at any sites). median tissue eosinophil was significantly greater in polyp apex ( , and polyp pedicle ( , iqr: - ) than ethmoid mucosa ( , iqr: - ), p = . . sensitivity of polyp apex, polyp pedicle and ethmoid mucosa for diagnosing ecrs were %, % and % respectively. specificity were %, % and % respectively. correlations between tissue eosinophilia and asthma were significant when assessing ethmoid mucosa (p = . ), and polyp pedicle (p = . ) but not polyp apex (p = . ). correlations with serum eosinophilia, and eosinophilic mucin were not significant (p > . ) when assessing any specimens. gov/pubmed/) was performed using the following key words: "obstructive sleep apnea syndrome"; "allergy rhinitis"; "hypoxia"; "intermittent hypoxia"; "fluctuating hypoxia"; "cyclic hypoxia"; and "hif- α" results: osas may affect the prognosis of ar patients based on the following evidence: ) ar is thought to be a cause of osas. ) exposure to hypoxia could mediate immune activation in ar and affect the response to treatment. ) hif- α expression may be a risk factor for ar. ) intermittent hypoxia can induce robust expression of hif- α. conclusion: first, improvement of ventilation during sleep represents an efficient strategy for treating ar. therefore, continuous positive airway pressure or nasal surgery to resolve a nasal obstruction could be added to ar treatment. finally, medications that target hif- α, such as digoxin, can be tested as adjuvant therapy. method: forty patients diagnosed with allergic rhinitis and olfactory dysfunction were recruited in current study in the group and . patients of group were administered with no treatment and patients administered with the traditional chinese acupuncture therapy were incorporated into the group . before the treatment, all of them underwent t&t olfactory testing, nasal sinus computer tomography scanning and visual analog scale (vas; - ), and repeated the assessment after four-week treatment. results: improved total t&t olfactory testing scoring averages and vas scoring averages was observed in eleven patients treated with traditional chinese acupuncture compared with four patients in the observation group. no side effect was found. no significant differences in olfaction recovery were found according to age, gender, or duration of disease between the two groups. the observation group underwent nasal endoscopic sinus surgery and the control group underwent external approach surgery, and the therapeutic effect of the two groups were investigated. results: the total effective rate was % in observation group and % in control group, the total effective rate of observation group is significantly higher than control group (p < . ). the recurrence rate was % in observation group and % in control group, the recurrence rate of observation group is significantly lower than control group (p < . ). complication occurrence rate of observation group was % which is significantly lower than control group % (p < . ). the therapeutic effects of endoscopic sinus surgery on chronic sinusitis in geriatric patients are better than conventional external approach surgery which is worth clinical application. results: (descriptive). the equick app is user-friendly even for vkc patients with sub-optimal reading ability. home use between clinic appointments allows responsive temporal data gathering of qol, symptoms, medication scores and impact of medical interventions. equick may be used in future as a research tool in gathering outcome data following interventions for vkc. ectoine, a substance deriving from halophilic micro-organisms, is a strong water structure forming solute exerting cell protective antiinflammatory and antiallergic properties. method: purpose of our study was to assess the efficacy of the preventive administration of % ectoine eye-drops ( times a day for months) to shorten the duration of vkc relapses (which begin, in our country, very early in spring and usually end in october), or to mitigate the attacks, which are only controlled by topical corticosteroids or cyclosporine resulting in an important burden of side-effects. in this retrospective study, we included children of both sexes ( males and females), under the age of years (mean age . years), affected by vkc from more than years/seasons and treated for more than months during a year, with cyclosporine eye-drops. these patients underwent, from february to september , the additional-to-the-usual protocol treatment with % ectoine eyedrops. results: % of the included subjects astonishingly had no relapse of vkc, % needed topical cs or cyc treatment but it was started months later compared to previous years, % needed the topical drugs months later and % had a similar to previous years course (no ectoine efficacy). the treatment was well tolerated and only child had to stop it because of local allergy to the eye-drops. the preventive administration of % ectoine eyedrops was able to stabilize and to delay vkc attacks in more than % of the selected patients showing the importance of anti-inflammatory and anti-allergic properties of this product. following international criteria we considered normal levels of vitamin d the levels between nmol/l ( ng/ml) and nmol/l ( ng/ml), a potential deficiency between nmol/l and nmol/l and a severe deficiency less than nmol/l. results: . % ( children) of akc group patients presented vitamin d low levels, among them children showed a potential deficiency and a severe deficiency. . % ( subjects) of vkc patients suffered a deficiency in vitamin d which was mild in and severe in patients. . % ( children) of sac group showed a deficiency in vitamin d which was potential in and severe in subjects. conclusion: our study shows that in different forms of allergic conjunctivitis many children are suffering a vit. d deficiency and it can be supposed that a correlation between the severity of the allergic form and the level of vit. d deficiency exists. we recommend allergists and ophthalmologists to check vit. d levels in children suffering from allergic conjunctivitis because its deficiency is very common and many are unaware of it; in case of a vit. d insufficiency it is fundamental to give a vit. d suitable-to-the-case supplementation. method: children ( males and females, mean age . ± months) affected by vkc and allergic rhinitis from more than years were treated with mometasone furoate nasal spray spray bid × weeks in a month, for consecutive months as a co-seasonal treatment at the beginning of eye allergic symptoms. other systemic or topical treatments did not vary compared to the previous years. results: a quick questionnaire administered to children and their care-givers showed that nasal symptoms regressed after a mean period of . days from their beginning but, impressively, in more than % of them, these patients did not show a vkc typical relapse along the months of mometasone treatment, moreover the following summer period was milder in subjective ocular symptoms in more than % of the patients. our experience pointed out that incs adjunctive treatment was positively associated with a regression of eye and nose symptoms in children suffering from vkc, confirming previous literature data which concern milder forms (seasonal allergic conjunctivitis or allergic rhino-conjunctivitis) compared to the severe forms (like vkc) we analyzed in our work. one of the involved mechanisms of action can be the alleged effect on the reduction of substance p in tears; it is supposed to reflect the neuropeptides levels in ocular tissues. | patient response to mp-azeflu in an allergen exposure chamber onset of action (ooa) timing may impact treatment adherence. mp-azeflu, intranasal azelastine hydrochloride (aze) and fluticasone propionate (fp) in a single device, has proven to have greater efficacy and faster ooa than a combination of oral loratadine and intranasal fp (lora/infp), but the clinical relevance for patients is unclear. this single-center (ontario, canada), randomized, double-blind, double-dummy, three-period crossover trial examined by which extent mp-azeflu provides clinically relevant symptom improvements according to different efficacy parameters. method: ar symptoms were induced in asymptomatic, ragweedsensitive patients via ragweed pollen challenge in an environmental exposure chamber. patients received a single dose of mp-azeflu, lora/infp, or placebo and were monitored for hours. symptoms were assessed using total nasal symptom score (tnss) and total ocular symptom score. responder analyses included the number of patients to achieve relevant response (rr) to therapy ( % or % reduction in tnss), time to rr (ie, first time point at which rr was reached), and minimal clinically important difference (mcid) in ooa. background: nasal allergen provocation test (napt) is a standardized diagnostic tool indicated in the diagnosis of allergic rhinitis, to design and monitoring allergen immunotherapy, and to study the pathophysiology of airway allergy. unfortunately, until now very few studies have evaluated its reproducibility and safety. in this study we wanted to analyse the safety and reproducibility of napt in a large group of rhinitis patients and healthy controls. unit until december . a bilateral saline challenge followed by a bilateral napt were performed in symptoms-free individuals. the response was assessed by nasal-ocular symptoms and acoustic rhinometry. all subjects signed a written informed consent. the safety of napt was checked by the occurrence of extra-nasal/ ocular reactions (enor), severe adverse events (sae), and use of rescue medication (rm). enor was assessed by clinical symptoms, physical examination, cardiopulmonary auscultation, spirometry, and oxygen saturation. the reproducibility of napt was tested by comparison of the results in or more sessions with≥ -month interval. background: nasal hyperreactivity (nhr) is self-reported by a majority of patients with allergic rhinitis (ar) and is likely mediated by neural-immune interactions. the combination of fluticasone propionate (fp) and azelastine (aze) hydrochloride administered in a single spray (mp-azeflu) has been shown to be superior to fp or aze alone in patients with seasonal ar (sar). we hypothesize mp-aze-flu may reduce neuro-immune mediators in ar with nhr. in a post hoc analysis of three pivotal studies of mp-azeflu, we analyzed the efficacy of mp-azeflu, fp, and aze in patients with ar with and without nonallergic triggers. method: in three randomized, double-blind, controlled trials, patients with sar were randomized : : : to mp-azeflu, fp, aze, or placebo (pbo). patients self-reported sensitivity to nonallergic triggers. change from baseline in total nasal symptom score (tnss) and treatment differences between active agents and pbo were calculated. results: across patients in three studies, mean age was . years and mean age at ar symptom onset was . years. overall, % reported ≥ nonallergic trigger, which included sudden temperature/humidity change ( %), tobacco smoke ( %), perfumes/fragrances ( %), incense/candles ( %), and cleaning products ( %). change from baseline in tnss for patients with ar and nonallergic triggers was greater with mp-azeflu than with fp or aze (table) , and patients with nonallergic triggers improved slightly less than patients without nonallergic triggers in both the mp-azeflu and fp groups. background: in low-income countries (lics), assessment of phenotypes, prevalence and risk factors for allergy-related diseases (ards) using allergen-specific ige may be complicated by environmental exposures such as helminths. these exposures may also induce cross-reactive carbohydrate-specific ige profiles that could inhibit allergic effector responses. we sought to elucidate the molecular basis of ige sensitisation among individuals in uganda, using a component-resolved approach to ige measurement. we employed the isac ® allergen microarray to assess plasma ige reactivity to purified natural and recombinant allergen components in participants of three studies: a trial of intensive versus standard anthelminthic treatment in the rural helminth-endemic lake victoria islands (n = ), a parallel urban survey of allergy outcomes in a lower helminth exposure community (n = ) and a study on asthma risk factors in children from the urban setting and from nearby rural schools (n = ). data on sensitisation to crude allergen extracts were obtained by skin prick testing (spt) with cockroach and house dust mites (hdm), and by immunocap ige testing (cockroach, hdm, and peanut). results: the rural setting was characterised by high prevalence (≥ %) of sensitisation to crude extracts (immunocap ige> . ku/ l) but low sensitisation to the major, established, allergenic components on the microarray (≤ %, ige> . isu). however, sensitisation to cross-reactive carbohydrate determinant (ccd)-bearing components and venoms was more common in rural (up to %) versus urban (up to %) individuals, and was associated with helminth infection. urban individuals mounted higher responses to allergenic components of dust mites but responses to other components were similar between the two settings. sensitisation to allergenic components was higher among asthmatics and spt+ children but ccd sensitisation profiles were similar between asthmatics and nonasthmatics, and between spt+ and spt-school children. conclusion: we show that, in lics, ige to crude allergen extracts (detected in standard immunocap assays) reflects sensitisation to a myriad of environmental exposures (absent in more developed countries), such as ccds expressed by helminths, and may not accurately define ard phenotypes in this setting. however, our data does not seem to indicate that ccd-specific ige detected by isac ® microarray protects against ards. considered minor allergens. due to their sequence homology and conserved structure, they show a high cross-reactivity. the objectives were to study the ige/igg binding properties of polcalcin in relation to the calcium ions, and the ige cross-reactivity between purified polcalcin from olea europea (ole e ) and two recombinant polcalcins (rphl p and rbet v ). method: ole e was purified by immune-affinity chromatography using polyclonal antibodies anti-rche a . serum samples were obtained from patients allergic to grasses recruited at hospital de guadalajara (spain), all of them positive to phl p with sige values ranging from . to . ku/l. equal volumes of all sera were used to prepare a pool. calcium binding assay was performed either by addition or not, or depletion of ca + . ole e was incubated with . mm cacl or with mm egta ph . (ca + chelator agent) at the same time as the antibody in immunoblot or elisa assays with the pool of sera or with anti-che a polyclonal antibody. crossreactivity assay was performed by immunocap inhibition. aliquots of the pool of sera were previously incubated with amounts of ole e ranging from . to . ng. the same dilution of the pool of sera without ole e was used as a control. after hours of incubation, sige (ku/l) binding to rbet v or rphl p was determined. results: a kda protein was purified from the o. europea extract and identified by lc/ms-ms as ole e . in the calcium binding assay there were no differences between the samples with or without ca + . however, the addition of egta to the reaction completely inhibited the binding of the polyclonal antibody by immunoblot and also produced a . % reduction of ige binding by elisa. in the cross-reactivity assay, a % inhibition of ige binding was obtained with . ng of ole e for rbet v and . ng for rphl p . the maximum rate of achieved inhibition was . % for rbet v and . % for rphl p . conclusion: native purified ole e contains the ca + necessary to bind to the specific antibodies and the depletion of ca + inhibited this binding. high cross-reactivity of ole e with rphl p and rbet v was demonstrated. | effect of glutathione-s-transferase pi on the cysteine protease activity of the house dust mite allergen der p background: environmental proteases have been proposed to be involved in the pathogenesis of allergic disorders via different mechanisms, such as the disruption of epithelial tight junctions, the cleavage of surface proteins, the activation of damage and pathogen-associated molecular patterns receptors, and the alteration of redox status. der p from house dust mite is one of the most clinically relevant indoor allergens worldwide, which exhibits cysteine protease activity and has been linked to allergenic rhinitis and asthma. however, it is unknown whether the host microenvironment could regulate der p activity once it reaches the mucosal surface. glutathione-s-transferase pi (gstpi) is an anti-oxidant and detoxification enzyme. gstpi is the predominant gst in human lung epithelial cells, where it is expressed in high levels. polymorphic variants of gstpi have been associated to various inflammatory lung disorders such as allergic asthma. more recently, gstpi has been identified as a redox regulator through protein s-glutathionylation, a post-translational modification where glutathione (gsh) is conjugated to cysteine residues. method: this work aimed at determining if gstpi affects the cysteine-protease activity of der p , compared to gstmu -a different gst isoform-by using different in vitro approaches. results: we found that gstpi increased der p -activity, but not gstmu. our results suggested a potential role of gstpi in upregulating the protease activity of der p allergen. however, the clinical implications of these findings in allergic airway diseases needs for further investigations. | cari p , a novel polygalacturonase allergen from papaya acting as respiratory and food sensitizer biswas sarkar m; sircar g; ghosh n; das ak; jana k; dasgupta a; gupta bhattacharya s bose institute, kolkata, india background: papaya was globally reported to elicit ige-mediated hypersensitivity. certain papaya sensitive patients with food allergic symptoms were found to experience recurrent respiratory distresses at peak flowering period of papaya even after quitting the consumption of papaya fruits. the immunoreactive protein present both in pollen and fruit proteome was detected by ige-serology and identified by mass spectrometry. one such allergen, designated as cari p was cloned, and purified as recombinant protein. the ige-reactivity of rcari p was examined by immunoblot using patient sera. the allergenic activity of rcari p was evaluated by histamine release assay from ige-sensitized granulocytes. the aggregation and folding pattern of rcari p was assessed by size exclusion chromatography and circular dichroism spectroscopy respectively. the presence of cari p in papaya fruit was searched by igg-immunoblot using allergen-specific rabbit antisera. a mouse model of papaya allergy was established to study the role of rcari p in eliciting respiratory and food hypersensitivity. results: a kda ige reactive protein commonly present in pollen and fruit proteome of papaya was identified as endopolygalacturonase. recombinant cari p remained monomer and the cd-spectra revealed predominantly β-sheet characters. the melting curve of the allergen showed partial refolding from a fully denatured state indicating the possible presence of conformational ige-epitopes in addition to the linear ige-epitopes of food allergens. out of papaya allergic patients displayed ige reactivity to rcari p . rcari p at μg/ml, induced histamine release from challenged granulocytes within a range of % to % (i.e. ± . %; n = patients). expression of cari p was detected in the peel and pulp tissues of papaya fruits at two edible stages of fruit maturation. in mouse model, rcari p exhibited a comparable level of eosinophil infiltration and goblet cell hyperplasia in lung and duodenum histology. conclusion: cari p the first major allergen reported from papaya with a dual role in respiratory sensitization via pollen inhalation and sensitization of gut mucosa via fruit consumption. the recombinant allergen can be used as marker allergen for molecular diagnosis and immunotherapeutic management of papaya allergy. background: lipids can be potent stimulators of the immune system, and their role in allergy is highly investigated and debated. since many allergens bind lipids, one question that arises is the relative importance of the lipids versus the lipid-allergen complex in eliciting the immune response. also of interest is an evaluation of the importance of the allergen-lipid complex. in our characterization of the structure of the cockroach allergen bla g , we discovered that it could promiscuously bind a variety of lipids in a large central cavity. this suggested that bla g could be used as a prototypical allergen and lipid delivery vehicle to test in various models of sensitization. method: cd spectroscopy. nmr spectroscopy. molecular modeling. we have developed an hplc procedure to strip the phospholipids derived from the e. coli-based expression system, and reconstitute the allergen with a variety of lipids. using cd spectroscopy and nmr, we have verified that the protein conformation is highly similar in the presence and absence of lipids. temperature dependent cd spectroscopy revealed that unloaded bla g is the least stable, and the melting temperature increased with increasing fatty acid chain length up to c . similar cd melting experiments revealed that bla g could bind lipoteichoic acid (lta) from gram positive bacteria, but did not interact with lipopolysaccharide (lps) from gram negative bacteria. molecular modeling studies have suggested that the stoichiometry of phospholipid binding is likely phospholipids per bla g and give insight as to the different binding characteristics that would allow bla g to bind lta but exclude conclusion: these biophysical studies will allow the design of bla g -lipid systems to test a variety of sensitization models. | sal k , a new allergen from salsola kali sola jp; pedreño y; fernández j; cerezo a; peñalver m probelte pharma, murcia, spain background: the polcalcin from salsola kali was identified and sequenced (genbank kt ) and the recombinant protein was characterized as a minor allergen with a prevalence of % of patients with a spt positive to s. kali. the objective of this study was to purify the polcalcin from s. kali pollen and to include the allergen in the website for the systematic allergen nomenclature (www.allergen.org). method: the native polcalcin from s. kali (npsk) has been purified from pollen after a first step of protein extraction and then diverse chromatographic steps: a size exclusion chromatography to remove particles minor than kda, an ionic exchange chromatography, a hydrophobic interaction chromatography and a final step of size exclusion chromatography to obtain the purified sample of polcalcin. the purity of the npsk has been determined by sds-page and the binding capacity to a specific polcalcin antibody from rabbit serum was tested by immunoblot. the specific antibody had previously been obtained by immunization with the recombinant polcalcin from s. kali. the allergenicity of the npsk has been assayed by immunoblot with a pool of sera of patients sensitized to s. kali. the identity of the purified npsk has been analyzed by peptide footprint in hplc-ms/ms after digestion with trypsin. all the information about the polcalcin from s. kali was sent to who/iuis allergen nomenclature sub-committee. the npsk showed a high purity in sds-page with a molecular weight of approximately kda and this purified protein reacted with the specific polcalcin antibody from rabbit serum. the ige binding capacity of the npsk was confirmed by immunoblot using a pool of sera from patients sensitized to s. kali. the analysis of peptide footprint confirmed that the purified protein is a polcalcin. the who/iuis allergen nomenclature sub-committee included the polcalcin from s. kali in the website for the systematic allergen nomenclature as a new minor allergen named sal k . conclusion: the polcalcin from s. kali has been purified from pollen and tested for its ige binding. it is included in the website for the systematic allergen nomenclature as the new allergen sal k . background: alt a protein is the major allergen from the fungus alternaria alternata and responsible for chronic asthma, yet little is known about its physiological role and immunological activity. our main purpose was to investigate the mechanism through which alt a induces an allergic response in bronchial epithelium. method: although alt a has a unique topology, we studied the structural relationship by in silico procedures consisting of three distinct structural alignment methods in order to understand its nature. the immunological properties of the allergen were investigated by using monocyte cell line thp and human peripheral blood mononuclear cells. results: its crystal structure has been recently reported and claimed to be exclusively in fungi without equivalent in the protein data bank. data obtained in silico show that this allergen shows some structural relationships with a number of other β-barrel proteins such as human lipocalin (lcn ). besides, our experimental data demonstrate that alt a is also able to interact with lcn , human lipocalin. in this way, the results obtained from several immunological assays showed that alt a is able to produce a response of the immune system through different immune innate receptor pathway inducing the th cytokines. background: increasing evidence of cross reactivity syndromes between pollen grains and fruits, with immediate or delayed reactions, has been reported. while some syndromes such as the birch pollen/apple syndrome are well documented, some other such as the cypress pollen/peach syndrome remain to be understood. for the latter, significant progress has recently been made with the discovery of a new allergen family, the gibberellin regulated proteins (grps), which has been shown to be responsible for the observed cross reactivity i.e. pru p and bp ( , ) for the peach and the cypress pollen respectively. grps are small cationic proteins with anti-microbial properties and have been shown to be over produced in response to a stress. herein, the case of a patient, born and raised in the south of france but currently living in paris, has been studied. this patient has been suffering since childhood from allergic rhinoconjunctivitis to cypress pollen and from some oral symptoms to peach and other fruits (including pomegranate). method: in addition to the clinical exploration and cutaneous tests, a very thorough biological characterization of the patient samples has been performed through various specific ige quantitation techniques, western blotting after one and two-dimensional gel electrophoresis and flow cytometry based basophil activation testing (bat). results: specific iges to cypress pollen, birch pollen, peach, orange and apple have been found. pr allergenic proteins are recognized by iges but no ltps. the presence of specific iges to cypress pollen bp , peach peamaclein (pru p ) and a cationic kda protein from pomegranate has been shown through western blotting after gel electrophoresis separation of the protein extracts. the use of bat finally enabled to demonstrate that the basophils of this patient were, ex vivo, strongly activated with protein extracted from orange and cypress pollen and also with purified proteins such as bp and pru p . conclusion: these results unambiguously show that the cypress pollen grp, bp , is clinically relevant, similarly to its homologous protein in peach, pru p . it can be proposed that these two allergens are at the basis of the observed cross-reactivity syndrome. the search for new cross-reactive allergenic grps in pollen, fruits or vegetables may enable to better understand other pollen/food associated syndromes that still remain unexplained. background: nine allergens of phleum pratense have been described until now (iuis database) and classified into groups based on their function and cross-reactivity. group and allergens are considered the most immunodominant, due both to their greater ige-binding capacity and the number of patients ige-reactive to them. previously published studies have estimated that group is recognized by almost % of grass pollen-allergic patients, and group by %. however, until now a comparative of the ability of these allergens to provoke an immune response has not been performed. the objective was to study the immunogenicity of the major allergens phl p and phl p , by analyzing the ability of the recombinant forms (rphl p and rphl p a) to induce a humoral immune response. method: five mice were immunized with the same amount of each recombinant protein: rphl p and rphl p a (indoor biotechnologies) ( μg plus two boosters of μg). the specific igg antibodies produced by each mouse were tested against the recombinant proteins by direct elisa and the title of each of them was determined by optical density (o.d.). additionally, the recognition of both allergens in native and depigmented-polymerized (dpg-pol) extracts of p. pratense was studied by direct elisa using these generated antibodies. results: preimmune sera were negative. all mice produced antibodies against the corresponding recombinant protein. the immune response (sigg) was statistically significant higher in mice immunized with rphl p than in those immunized with rphl p ; it was needed times more rphl p serum than rphl p a serum to obtain the same o.d. values. the difference in responses was higher in the group of mice immunized with rphl p than with rphl p a. differences in the recognition of phl p and phl p in native and depigmented-polymerized extracts of phleum pratense was also observed. it was necessary times more rphl p serum to produce the same signal than rphl p a serum in native extract and it was necessary times more rphl p serum to produce the same signal than rphl p a serum in dpg-pol extract. conclusion: rphl p a is more immunogenic than rphl p , which was also probed with native and dpg-pol extracts. background: glioblastoma (gbm) is an incurable primary malignant brain tumour with a median life span of less than months despite multimodal treatments. therefore, there is a serious need for the development of innovative medications. several epidemiological studies underlined an inverse correlation between pre-existing igemediated allergy and gbm risk, where having such an allergy decreased the odds of developing gbm by to %. we aim to delineate the intrinsic immuno-biological and molecular mechanisms that can be responsible for these correlations, based on the hypothesis that allergies may promote a state of increased immuno-surveillance in the brain through the presence of immunological factors such as immunoglobulins, cytokines and cells involved in th -driven allergic reactions. we consider that as the major immune cell type of the brain, microglia should be implicated in this beneficial association and may favour the elimination of the nascent tumour in brain parenchyma in an allergic context. we implemented a long term allergic airway inflammation by repeated nasal instillation of house dust mite (hdm) extract in a syngeneic orthotropic mouse model of gbm. we followed animal survival and the tumour growth by mri. in addition, we purified microglia from allergic vs non-allergic mice in order to assess their cytotoxic function against the gbm cell line ex vivo and their secretory capacities. finally, we investigated immunoglobulin reactivity against gbm antigens in the context of allergic reactions by reverse phase protein array (rppa). we demonstrated an increase of the animal survival that was correlated with a delayed tumour engraftment and a reduced tumour growth. these phenotypes were associated with functional modification of microglia from sensitized mice. indeed, these microglia showed a rise in the production of il- and tnf-a as well as an increase in cytotoxic functions against a gbm cell line ex vivo. in parallel, we observed an increase in serum igg reactivity against gbm antigens in mice sensitized with hdm compared to control mice. results: in patients ( %) with cvid we recorded at least one temporary platelet count decrease below × /l compared to only patient ( %) with xla (p = . ). more importantly in patients ( %) with cvid this decrease was observed in a period longer than months compared to patient ( %) with xla (p = . ). in patients ( %) with cvid we recorded at least one temporary platelet count decrease below × /l and only in patients ( . %) with cvid this decrease was observed in a period longer than months. we did not record any platelet count decrease bellow × /l in patients with xla however the difference with cvid did not reach statistical significance. no thrombocyte count decrease bellow × /l was observed in either group. none of patients required immunosuppressive treatment for immune thrombocytopenia (itp). conclusion: although the statistical significance was documented only in temporary platelet count decrease below × /l it is obvious that numbers of thrombocytes commonly fluctuate in some patients with cvid. the mechanism leading to these temporary decreases is unclear. monitoring of complete blood count is a basic follow-up investigation in patients with cvid. introduction: wegener's granulomatosis (wg) is a systemic disease that may affect all organs, most frequently the ears, noses, throats, sinuses, lungs and kidneys. it is a rare autoimmune disease, also called granulomatosis with polyangiitis, and characterized by necrotizing granulomatous inflammation in small and medium sized blood vessels. anti-neutrophil cytoplasmic antibody against to proteinase (c-anca) is thought to be responsible for autoimmune inflammation. the coexistence of wg and common variable immunodeficiency (cvid) is extremely rare. in this report, we describe a patient with wg and cvid who was treated with immunosuppressive drugs and intravenous immunoglobin concomitantly. case report: a twenty-four-year-old male patient was referred to our clinic for immunological evaluation due to recurrent infections, fever of unknown origin and neutropenia. the patient had been diagnosed with wg and taking immunosuppressive therapy for three years. he had chronic renal failure due to wg and had also been on peritoneal dialysis for three years. serum igg, iga levels, peripheral blood cd + b cell percentage and absolute count of the patients were found to be low according to reference limits. he was diagnosed with cvid after excluding secondary reasons for hypogammaglobulinemia and he started to receive mg/kg intravenous immunoglobulin (ivig) therapy once in a month. also, the treatment that consists of mycophenolate mofetil (mmf) and glucocorticoids was continued to decrease c-anca levels in serum. he has been accepted as a candidate for kidney transplantation, and prepare for this purpose. discussion: the management of the patient with cvid and wg may be complicated. it is considerably difficult and needs competency and courage. moreover, the cases similar to ours, are extremely rare. therefore, the authors should share their own experiences on cvid and discuss them by comparing the data obtained from other cases. background: leukocyte adhesion deficiencies (lads) are a group of three genetic disorders leading to defective leukocyte adhesion to the endothelium and as a consequence decreased leukocyte recruitment and immune defense. lad-i is caused by mutations in the gene encoding the ß -integrin cd on chromosome .lad-iii is a rare primary immunodeficiency syndrome, characterized by homozygous mutations in the kindlin- gene (official symbol fermt ). we have aimed to evaluate our patients who were followed up with lad for the last years, retrospectively. method: all data of the cases were obtained from the file records of age at diagnosis. results: seven patients from separate families were included in the study. four patients were lad-iii and patients were lad-i. the female to male rate was / . the age of diagnosis is ranged from days to years. the median umbilical cord detachment was days ( - days groups: up to times ( people) and from to times ( people). healthy donors were examined as a control. flow cytofluorometry method was used to study peripheral blood and assess the parameters of innate and adaptive immunity results: it was found that at a frequency of edema up to times a year there are changes in the t-system of adaptive immunity, which are shown by a decrease in the expression of late activation markers (cd + hladr+ . ± . %, in control . ± . %), an increase in the number of cd + cd + cytotoxic lymphocytes ( . ± . x /l, in control . ± . x /l) and as an increase in their functional activity (cd + gr+ . ± . x /l, in control . ± . x /l). the nature of disorders of cellular factors of the innate immunity is manifested by decrease in the adaptive resources of neutrophils (kstnbt . ± . u.e., in control . ± . u.e.). patients with hae with a frequency of edema up to times a year, we observed the disorders of the humoral link of adaptive immunity, which consist in an increase in the number of circulating b lymphocytes ( . ± . x /l, in control . ± . x /l). in addition, with the strengthening of the hae clinic, changes in the system of innate immunity progressed very fast and consisted in increasing the amount (cd + . ± . x /l, in control . ± . x /l), and functional activity (cd + gr+ . ± . x /l, in control . ± . /l) of natural killer cells results: we included children, mostly males ( %), aged between month and years. . % of patients (n = / ) showed abnormal absolute results of lymphocyte count for age. we found more patients evaluated in the age group of to years ( . %), followed by - years ( . %), lymphopenia was found in . % of patients. b lymphocyte deficiency was the most common pattern ( %) followed, in decreasing order, by low cd , t cd , tcd and nk. many patients have more than one affected population ( . %) . some patients were affected in all three series ( . %). the cd / cd ratio decreased in . % of the patients. the majority of the children were males between the ages of month and years. . % of patients showed abnormal absolute lymphocyte count for age. b-cell deficiency was the most common pattern followed, in decreasing order, by low cd , t cd , tcd and nk. many patients have more than one affected population. | indicators of the humoral immunity in the mechanical jaundice of benign genesis the aim of the investigation was to study the indices of humoral immunity in patients with benign mj, depending on the level of bilirubin. method: patients with mj and practically healthy volunteers were examined. patients with a level of bilirubin less than μmol / l - , with a bilirubin level of - μmol / l - and with a bilirubin level of more than μmol / l - patients. the concentration of immunoglobulin classes a, m, e and g in serum was determined by enzyme immunoassay. the statistical significance of the differences was determined using the ranked mann-whitney test. the critical level of significance in checking statistical hypotheses was assumed to be p < . . results: of the contacted dermatologists, participated ( women, men; mean age . ± . ) which results in a response rate of . %. the guideline compliant prescription rate of biologicals in patients with csu was . %. the most prevalent barriers in the prescription were the high cost of the treatment ( . %), low reimbursement for doctors ( . %) and the fear of a recourse claim ( . %). however, a lack of evidence or an insufficient efficiency were not con- case report: eosinophil associated gastrointestinal disorders (egids) including eosinophilic colitis are commonly associated with atopy. aeroallergen sensitization may accompany food allergy in these patients. a case with eosinophilic colitis responsive to anti-ige monoclonal antibody (omalizumab) treatment is presented. an eleven-year-old boy had bloody diarrhea lasting nearly one month in autumn for last years. this year diarrhea lasted more than months. colonoscopic biopsy revealed lymphoplasmacytic inflammatory cells including eosinophils leading to a diagnosis of ulcerative colitis. corticosteroid and mesalazine treatment was started with a good clinical response. recurrence of diarrhea during corticosteroid dose reduction suggested corticosteroid dependent ulcerative colitis. eosinophilic/allergic colitis was an alternative diagnosis when seasonal recurrence, lack of weight loss, eosinophils in biopsy and high serum ige level were considered. colonoscopy done after cessation of therapy for one month, revealed exudative ulcerous lesions, lacerations, loss of haustration compatible with colitis (inflammatory/allergic?). presence of significant mucosa associated lymphoid tissue in biopsy supported any inflammatory, reactive process. he had recurrent bronchiolitis until age six and allergic rhinitis in spring for three years. total ige and mix aeroallergen specific ige were high ( iu/ml, . kua/l), absolute eosinophil count was normal ( /mm ). food skin prick and patch tests were negative. he had positive skin reactions with dermatophagoides, grass and olea pollens (induration diameter: , , mm, respectively). pulmonary function test was normal. he was considered as eosinophilic/allergic colitis and omalizumab was started according to manufacturer's dosing table ( mg/ weeks). rectal bleeding decreased after first dose and ceased after the second dose. early colonoscopy examination after rd month of therapy showed that exudations disappeared and haustrations became evident. microscopy revealed mild nonspecific colitis. few patients with eosinophilic colitis improved with omalizumab were reported before. ige-mediated processes are responsible from eosinophilic inflammation in egids, making anti-ige therapy as a promising treatment option. | design of liposomal carriers modified by glycoconjugates for liver cell delivery of nucleic acids used. the surface of liposomal nanoparticles can be modified to increase the selectivity of intracellular delivery. it is well known that asialoglycoprotein receptors of hepatocytes have a strong affinity to galactose carbohydrate. therefore, the aim of this study was to assess the effect of the modification of the liposome surface by glycoconjugates on the selectivity of intracellular transport of nucleic acids into the liver cells. method: liposomes based on ornornglu(c ) were chosen previously as the effective nucleic acid delivery system. we modified liposomes with novel lactose-based derivatives. every of four glycoconjugates was added to ornornglu(c ) in an amount of , and %. as a result, variants of modified liposomes were obtained. to determine the cytotoxicity, an mtt test was used. using luciferase test, the selectivity of penetration was evaluated on nonspecific t (human embryonic kidney) and specific hepg (human liver cells) cell lines. results: modified liposomal compositions ornornglu(c ) - + lacc ( %) and ornornglu(c ) - + lacggg ( %) had the lowest cytotoxicity similar to that for unmodified ornornglu(c ) . the ic , calculated based on the data of mtt test, was . and . , vs. . mg/ml, respectively. ornornglu(c ) - + lacggg ( %) showed a . -fold increase in transfection activity on the nonspecific t cells, compared to unmodified ornornglu(c ) , whereas the modification of ornornglu(c ) - + lacc ( %) resulted in a -fold decrease in transfection activity. however, the ability of these variants to penetrate the specific liver hepg cell was significantly higher by and times, respectively, than for unmodified ornornglu(c ) . results: the greatest inhibitory effect of sbfhd was observed in mdm infected with hiv- bal: % and % suppression of hiv replication was achieved at concentrations of . μg/ml and . μg/ ml, respectively. the activity in pbmc and dc was less pronounced (the respective ic values were . μg/ml and . μg/ml). studies in endometrial hec- a cells demonstrated that sbfhd suppressed cd -independent entry of hiv- ( tcid /ml) by %, %, and %, respectively, at , , and μg/ml. the effect was also observed after increasing the dose of the virus. at tcid /ml, sbfhd suppressed hiv infection by % ( μg/ml) and % ( μg/ml). the cytotoxicity of sbfhd in this system was low. similar results were obtained with colorectal caco- cells. sbfhd exhibited no spermicidal activity at concentrations of up to mg/ml. combining within a single microbicide two agents that target distinct steps of hiv life cycle will maximize its efficacy (via synergistic effects and/or interference with multiple stages of the transmission). we therefore explored the synergistic potential of combinations of sbfhd and azt, the classical nucleoside rt inhibitor. in these experiments, % suppression of hiv infection was reached at concentrations of sbfhd and azt, which were significantly lower than the respective ic values of each component (determined in parallel experiments). the synergistic effect was most pronounced for the combination of . μg/ml sbfhd (which is times less than the ic ) and . nm azt (which is times less than its ic ). cd expression was increased after the co-culture with reishi, shiitake and boletus mushrooms (c - . ( . - . )%; pma - . ( . - . )%; )%; shiitake - . ( . - . )%; boletus - . ( . - . )%). method: the study included men (mean age ± . years) before and immediately after staying in countries with a hot climate. results: the development of lymphopenia observed in the first week of observation. this was accompanied by a decrease in the number cd + lymphocytes expressing the markers of late activation (cd + hladr+ . ± . x /л и . ± . x /л). revealed significant decrease of cd + cd + foxp + regulatory cells in the first week after returning from the area of adverse climatic conditions, as well as a significant sustained decrease in the number cd + cd + hladr+(p < . ). change of the effector link of innate immunity was determined in significant reliable decrease in relative (cd + . ± % and . ± . %, respectively, p < . ) and absolute (cd + . ± . x /l and . ± . %, respectively, p < . ) in the number of a population of natural killer cells in the first week of observation. in the context of acute stress marked a significant increase in relative and absolute numbers of b lymphocytes ( ± . % ( . ± . × /l) before a trip to countries with a hot climate and ± . % ( . ± . × /l) in the first week after returning, p < . ). the activity is the production of antibodies was not changed. (ast) which is the intramuscular injection of patients own serum, is a promising therapy with a substantial efficiency on ciu patients. in this study we aim to assess the efficacy of ast on chronic urticaria patients by dlqi questionnaire. method: this was a single-blind randomized clinical trial which evaluated the efficacy of autologous serum therapy compared to oral antihistamines in patients with ciu. ciu patients received the ast. every session cc of each patient's blood was centrifuged at the speed of rpm for minutes and . cc of the serum was injected intramuscular into the patient's deltoid muscle weekly for weeks. the control group consisted of ciu patients took mg of cetirizine daily for weeks. patients answered the dlqi questionnaire at the first session of treatment as baseline and weeks after the last session(week ) as response to treatment. the mean baseline score of dlqi for ast group was conclusion: pharmacotherapeutic and inpatient costs for patients with prevalent ar and asthma were lower in those prescribed ait than in those not prescribed ait in all years, both with and without including the cost of ait itself. this indicates that treatment with ait is associated with lower cost burden for health services. background: immunotherapy with peptides rather than conventional whole allergens is being developed to improve the benefit/risk balance of subcutaneous immunotherapy (scit). lolium perenne peptides (lpp) demonstrated reduced allergenicity following ex-vivo analyses, allowing higher doses to be given over a shorter period to improve treatment adherence and compliance. such treatment resulted in significant reduction in symptoms and rescue medication intake during the grass pollen season. here we report the safety of lpp immunotherapy in adults. background: a new allergoid from alternaria alternata was characterized to determine its reduced allergenicity in vitro. the objective of this study was to determine the skin response to the allergoid and to evaluate the clinical tolerance of the immunotherapy with the allergoid product using a rush schedule. method: to assess the skin response (sr) two groups of patients were included: group with patients sensitized to a. alternata and with respiratory disease caused by this mold; group (control) with patients sensitized to others allergens and non-atopic patients. the sr was determined by spt using three concentrations of the allergoid: p (lowest concentration), p (four times higher than p ) and p (estimated to obtain a wheal area similar to histamine mg/ml). in spt was also used a native extract of a. alternata (n) and histamine mg/ml (h). all products were tested in duplicate in all patients and the sr was evaluated by comparing the median of the wheal area produced by different products. to evaluate the clinical tolerance to immunotherapy the patients of group were treated with the allergoid product using a rush schedule consisting in a dose of . + . ml the first day and . ml after one month (maintenance dose). the clinical tolerance was determined as the percentage of adverse reactions (ar) to the treatment and the classification of ar was established according to eaaci. the number of patients included to evaluate the sr was (group : ; group : , atopic and non-atopic) with an average age of . (range . the spt data from group were expressed as median and interquartile range of wheal area (mm ): h: . ( . - . ); n: . ( . - . ); p : . ( - . ); p : . ( - . ); p : . ( . - . ). it was determined that sr of allergoid was reduced in % respect to the native. the products n, p , p and p did not produce any response in patients of group . to evaluate clinical tolerance, patients of group were treated with the allergoid product with a rush schedule and only two ar were registered ( . % of doses). these were retarded local reactions with a wheal diameter higher than cm. no systemic reactions were registered and all patients continued the treatment. the allergoid from a. alternata produces a significant reduced response to spt due to its reduced allergenicity. the treatment with an allergoid product in a rush schedule is safety and clinically well tolerated. background: in our study we aim to determine the more effective, the total cost of years of patients using scit was tl per person whereas the total cost of years of patients using slit was tl per person. when we compare the total cost data of both groups, we found that they are close to each other. while the greatest portion of the cost data of patients with scit treatment was direct costs associated with the treatment itself ( %); the remaining part of the total cost was indirect ( %) with non-medical expenses such as transportation ( %). in the slit group, direct costs including drug expenditures have a larger percentage ( %) and it was significantly more costly compared to the direct costs of the scit group ( %). transportation costs were found to be more costly in the scit group ( %) when compared to the slit group ( %). similarly loss of parent work days in the scit group(% ) was found to be significantly more expensive compared with slit group ( %). our study results show that slit is a similar treatment for clinically and laboratorially and has a similar efficacy to scit to reduce the patients' complaints and to the need for medication. for cost-effectiveness however medicines for treatment of scit are less costly; when long term total treatment costs are calculated slit and scit treatment are economically close treatments. the protein content of the new acd was . μg/mg and the protein profile in sds-page and sec-hplc confirmed the presence of proteins with high molecular weight and the absence of smaller proteins. the content of free lysine in acd, involved in glutaraldehyde modification, was reduced in . % respect to ncd and it can be considered as the polymerization degree. regarding to the allergenic profile, through elisa inhibition was determined a reduction of times in the capacity to bind ige of the proteins in acd respect to ncd, whilst the igg binding capacity was maintained. in immunoblot there was no reaction of acd proteins to specific ige from sera. the analysis by peptide footprint determined the presence of fel d and others allergens in acd. the content of major allergen fel d in acd was determined as . μg/mg. the new developed and characterized allergoid from cat dander has an excellent safety profile and will allow a safer immunotherapy to treat the allergy to felis domesticus. results: the protein content of the new aaa was . μg/mg and the protein profile in sds-page and sec-hplc confirmed the presence of proteins with high molecular weight and the absence of smaller proteins. the content of free lysine in aaa, involved in glutaraldehyde modification, was reduced more than % respect to naa and it can be considered as the polymerization degree. regarding to the allergenic profile, in immunoblot there was no reaction of aaa proteins to specific ige from sera and by elisa inhibition was determined a reduction of % in the capacity to bind ige of the proteins in aaa respect to naa. the igg binding capacity in aaa was maintained. the analysis by peptide footprint determined the presence of alt a and others allergens in aaa. the content of major allergen alt a in aaa was determined as . μg/mg. a. alternata shows an excellent safety profile and allows a safer immunotherapy to treat the allergy to this mold. she was an otherwise healthy woman: she took no drugs and she did not have any remarkable concomitant diseases. the distribution and appearance of the remaining body hair was normal and the hormonal level profiles (lh, fsh, estrogens, progesterone and testosterone) did not show any significant alteration according to her age. a year old woman with allergic rhinitis underwent sq glutaraldehyde-modified ait to house dust mites (d pteronyssinus and g domesticus) without any incidences and complete tolerance to maintenance dose without local reactions during a year period. two years after ait discontinuation, patient first experienced a local urticarial reaction with multiple hives at previous sq ait injection sites minutes after mg of ibuprofen intake. these symptoms recurred at least in seven occasions when patient was exposed to ibuprofen (in five) and metamizol (in two). results: case : dermatologist diagnoses localized hypertrichosis. case : a single blind, placebo controlled oral challenge (sbpcoc) with ibuprofen mg was performed and elicited multiples hives in the circumscribed area in the arm where ait was conducted. subsequently, sbpcoc with aspirin was carried out showing the same reaction although a controlled challenge with celecoxib was negative. conclusion: local hypertrichosis is a very rare injection-disease associated with injected allergen vaccine treatment. we also firstly described a recall urticaria phenomenon after allergen immunotherapy which has been only elicited after different nsaids intake. results: there were included patients, in five spanish hospitals. following aria guidelines, . % of patients were diagnosed of persistent moderate/severe rhinitis. the mean age was . ± . years, being . % female. moreover, . % of the patients had concomitant mild/moderated asthma. the period between the diagnosis of rhino-conjunctivitis and the informed consent signing was . ± . years. according to international guidelines, eight systemic reactions were registered, representing . % of the administered doses: five reactions grade , (described as nonspecific ocular pruritus, nasal herpes, general discomfort, localized non-specific pruritus plus nausea and non-specific pruritus in throat), a grade i reaction described as rhinoconjunctivitis and two reactions grade ii, registered as generalized urticaria and asthma. all reactions were classified of mild or moderate intensity and only two required symptomatic treatment. there were five clinically significant delayed local reactions, which were higher than cm or involved modifications in next dose. regarding efficacy parameters, immunoglobulin titers between baseline and final visit according to specific igg and igg significantly increased. cutaneous reactivity also decreased significantly in the dose response skin prick test. results: patients were included, to accelerated and to polymerized cluster group schedules. according to aria criteria, . % of patients presented persistent moderate/severe rhinitis. the mean age was . ± . years, being . % male. moreover, . % had concomitant mild/moderated asthma. immunoglobulin titers method: the quantification of total proteins in the products was carried out by means of a colorimetric technique using the bradford reagent (sigma-aldrich™, us) in accordance with the manufacturer's instructions. the absorbances of each standard and samples were obtained in a scinco™ s- spectrophotometer (seoul, korea) at nm. all samples were analyzed in duplicate. the electrophoretic profile of the proteins in the tested allergens was obtained according to the procedure described by laemmli, under denaturing conditions in a polyacrylamide gel at . % concentration and stained in silver. in each lane approximately μg of total proteins were applied. commercial extracts of the main allergens marketed in mexico were obtained, rossel ® , alk ® , alerquin ® , alergomex ® , allerstan ® , ipi asac ® ; and they were assigned randomly with the numbers , , , , and . results: the following protein concentrations were found in the various extracts analyzed: see table conclusion: differences were found in the protein profiles ana- background: a new allergoid from cat dander was developed and characterized to determine its reduced allergenicity in a % and the maintenance of igg binding capacity. the objective of this study was to develop an immunogenicity assay in mice with the new allergoid and a native extract from cat dander. the study included female balb/c mice separated in three groups of mice each: group , immunized with a mold allergen extract (control); group , immunized with a native extract from cat dander with a fel d content of . μg per dose; group , immunized with the new allergoid from cat dander with a fel d content of . μg per dose. all mice were immunized four times by subcutaneous injections with a volume corresponding to / of the recommended human maintenance dose with an interval between injections of weeks. one week after the last injection the mice were sacrificed and the serum was obtained. to determine the specific antibody title indirect elisa were performed using a cat dander extract as antigen, sera from mice as primary antibody and antimouse igg or igg as secondary antibody. elisa assays were performed using serial dilutions of sera or a simple dilution by duplicate to determine the specific antibody title as arbitrary units/ml (au/ml). the data were analyzed by one-way anova and tukey hsd test to compare the averages of specific antibodies in each group. results: the immunization with both the native extract and the allergoid from cat dander produces specific igg and igg . regarding to igg, a higher title was observed in group respect to group in a curve obtained after elisa with serial dilutions of sera. the specific igg title obtained in terms of au/ml was . ± . in group , . ± . in group and . ± . in group . concerning to igg the au/ml obtained was . ± . in group , . ± . in group and . ± . in group . the increase of specific igg or igg in mice from group respect to mice from group and control group was statistically significant (p ˂ . ). the safety profile of the allergoid from cat dander allows a treatment with higher dose of allergens to produce a greater response to immunotherapy to induce formation of specific this was an open, multicenter clinical trial, in patients aged between to years with rhinoconjunctivitis with or without concomitant mild asthma sensitized to house dust mites (hdm). the aim was to evaluate the safety and tolerability of the vaccine. secondary endpoints included were: changes in immunoglobulin levels (specific ige, igg and igg ) versus d. pteronyssinus and d. farinae and changes in cutaneous reactivity. patients were under study treatment for weeks: five for the induction phase (weekly injections) and for the maintenance phase (monthly injections). results: patients were included. there were withdrawals from the trial; no one was related to treatment. the patients mean age was . years, being % female. . % were diagnosed of persistent moderate/severe rhinitis according to aria guidelines and . % presented concomitant mild asthma. regarding to safety results, systemic adverse reactions were registered which corresponded to . % from a total of administered doses. the most of systemic reactions were grade i, ( . %) described as rhinitis or urticaria, grade or nonspecific ( . %) and reaction ( . %), was grade ii. all of them were mild or moderate and only needed treatment. among local reactions, ( . %) were clinically relevant late local reactions, meaning a wheal at injection site > cm and /or requiring a dose readjustment in the next administration; ( . %) were clinically relevant immediate local reactions meaning a wheal > cm. concerning the efficacy parameters, cutaneous reactivity at the final visit versus baseline was, in average, significantly decreased, and specific titers of igg and igg against tested hdm increased significantly at final visit. patients completed the study. mean values in rqlq questionnaire (total score) decreased from . to . points ( . % score reduction) in final visit, reflecting a statistically significant improvement (p < . ). annual episodes of rhinoconjunctivitis decreased from . to . (p < . ). . % of patients improved from persistent to intermittent rhinoconjunctivitis (p < . ) and . % from moderate/severe to mild intensity (aria) (p < . ). moreover, . % of asthmatic patients at baseline, did not have any bronchial symptoms after -year treatment (p < . ). mean value of treatment satisfaction was . (sd= . ) and . (sd= . ) for patients and physicians respectively. | evaluation of safety and tolerability of "allergovac poliplus" in polysensitized patients with allergic rhinitis-rhinoconjunctivitis with or without asthma: an observational prospective study (apolo) background: the objetive of this study was the safety and tolerance assessment of "allergovac poliplus" scit treatment, with allergen combination-mixtures in polysensitized patients, as well as the evaluation of the clinical improvement and patients' satisfaction after treatment. method: this is a prospective observational clinical study. allergovac poliplus treatment is being administered in a " -day" or in an abbreviated schedule. polysensitized patients (to pollens or mites), with rhinitis or rhinoconjunctivitis, with or without asthma, and between - years have been included. all adverse events are being recorded. visual analog scales (vass) are being used to evaluate clinical improvement, tolerance and satisfaction after treatment ( months). results: a total of patients have been included, with an aver- results: in all groups prevailed severe forms of the disease and the phenotype of frequent exacerbations. groups were comparable in age composition and structure of severity. observations in the group of vaccinated pcv continue the dynamics of decreased dyspnea up to . ( . ; . ) results: of a total of pts under scait, were excluded due to data unavailability, and included (♀ ( %), mean age ± years (minutes: max md ), age range [ - ] being most prevalent ( %). the most frequent diagnosis was rhinitis/rhinosinusitis ( %), followed by asthma ( %), diagnosis coexisting in abstracts | pts ( %). other diagnosis such as conjunctivitis ( %), atopic eczema ( %) and food allergy ( %) were also found. mite sensitization occurred in patients ( %) of which ( %) were monosensitized. the pollen sensitization was verified in ( %) with monosensitized pts ( %). the double sensitization mitespollens was displayed in ( %). sensitization to epithelia and fungi occurred respectively in ( %) and pts ( %). it was found that pts ( %) presented sensitization to the groups of allergens (mites, pollens, fungi, dander). an average of ± pts started this treatment per year. prescription included laboratories with the following %: a- . ; b- . ; c- . ; d- . ; e- . ; f- . ; g- . ; h- . ; i- . ; j- . . option for extract of physical modification ( %), physical-chemical ( %) and chemical ( %). table shows the frequency of distribution of scait composition. conclusion: in this population sensitization to mites was predominant being the most prescribed scait followed thru sensitization to grasses with the respective scait. the majority of the population was polysensitized. however, in composition preference the choice of group of allergens prevailed and only % had more than one sort of pollen and % pollen+mites. polysensitization is a reality, nonetheless the choice of ait composition should be guided thru scientific criteria and not through the availability of mixtures encouraged by laboratories. background: allergen immunotherapy (ait) has been proven to be an effective treatment of allergic diseases in numerous studies. however, its use in seniors remains limited and questionable, due to common comorbidities and limited evidence of efficacy and safety of ait in aging population. the aim of presented study was to assess the safety of ait in patients over years of age undergoing subcutaneous immunotherapy (scit) and analyze the potential risk factors of adverse reactions in this population, compared to younger adults. we followed subcutaneous immunotherapy in a group of patients treated in the outpatient clinic of medical university of lodz, of whom were aged and older ( between the age of - , aged - and patients above the age of ). we recorded detailed information of each administration and corresponding adverse reactions over the period of years. we compiled results of our observations with patients' medical records to compile a database, which we then analyzed using statistical software. method: a total of cases with seasonal allergic rhinitis undergoing pre-seasonal immunotherapy and cases followed with conventional drug treatment were included in the study. immunotherapy and control groups were divided into monosensitized (only pollen) and polysensitized (at least additional allergen except pollens) patient groups according to skin prick test reactivity. all patients were followed between march-september with symptom and medication scores, and visual analogue scale (vas). the quality of life was assessed using the mini-rqlq questionnaire. phleum pratense (phl p) specific ige and specific igg (uni-cap , phadia) measurements were performed before and after weeks of immunotherapy in all patients. gramineae pollens were counted during the grass pollen seasons. results: mean age was . ± . and . ± years, female/ male ratio was / and / , the number of monosensitized/polysensitized patients were / and / in immunotherapy and control groups, respectively. in the immunotherapy group, june-july symptom scores, may-june-july-august vas scores and june combined symptom-medication scores were lower than the control group (p = . ). furthermore, improvements in activities-practical problems and other quality of life scores were significantly different between two groups (p < . ). in immunotherapy group, phl p specific ige and phl p specific igg levels measured after immunotherapy were significantly higher compared to those before immunotherapy (p < . , p < . , respectively). phl p specific igg levels measured after immunotherapy were also significantly higher in the immunotherapy group than in the control group (p < . ). there was no difference in terms of clinical and immunologic parameters in monosensitized and polysensitized patients (p > . ). conclusion: clinical improvement with pre-seasonal allergoid immunotherapy is accompanied by an important increase in specific igg blocking antibodies despite short-term injections. our findings show that pre-seasonal allergoid immunotherapy has similar clinical efficacy and b cell response in polysensitized subjects compared to monosensitized patients. | the safety trial of sequential sublingual immunotherapy with japanese cedar droplet and house dust mite tablet matsuoka t ; kuroda y ; igarashi s ; fukano c ; natsui k ; ohashi-doi k ; masuyama k university of yamanashi, yamanashi, yamanashi, japan; torii pharmaceutical co. ltd., tokyo, japan background: sublingual immunotherapy (slit) is recognized as the only treatment option with the potential to provide long-term posttreatment benefits. in japan, the prevalence of japanese cedar (jc) pollinosis is very high, about % of the population, of which the majority are co-sensitized to hdm. slit is now well established, safe and convenient treatment form for allergic disease, and recently, jc slit-droplet and hdm slit-tablet products were approved in japan for treatment of jc and hdm induced allergic rhinitis, respectively. however, the safety of sequential jc slit-droplet and hdm slittablet has not yet been investigated. therefore, we investigated the safety trial on slit combined with jc droplet and hdm tablet in allergic patients. method: eleven subjects with jc pollinosis and hdm rhinitis were enrolled. patients were treated once-daily with jc slit-drops for weeks, followed by weeks of sequential slit treatment where the jc slit-drops and the hdm slit-tablets were administered daily with a minute interval ( st: jc-slit drops, nd: hdm slit-tablet). the primary endpoint was the frequency and severity of adverse events (aes) during sequential slit by common terminology criteria for adverse events (ctcae) v . and slit grading system. serum antibodies were measured as the secondary endpoint. results: eleven patients were recruited. aes after jc slit-drops administration were found in patients out of cases ( %). aes after sequential slit were found in patients out of cases ( %). all aes were graded or . no severe aes were observed during the study period. the levels of jc-and hdm-specific ige and igg in serum were increased during treatment. conclusion: sequential-administration of jc slit-drops and hdm slit-tablets was well tolerated by patients suffering from both jc pollinosis and hdm rhinitis. background: according to the ema guideline on the clinical development of products for specific immunotherapy products should be tested in phase ii at different doses in several study-arms to establish a dose-response relationship for clinical efficacy before confirmatory trials can be initiated. allergen exposure in an aec may be used as primary endpoint. the study was a single-center, randomized, double blind, placebo-controlled, phase ii trial, treatment duration months. grass pollen allergic patients ( - years of age) with seasonal rhinitis/rhinoconjunctivitis (arc) with (mild, gina i) or without concomitant asthma were randomized to three different dosages of a liquid phase iii study is in preparation. as part of an effort to prepare the analysis plan using the csms as primary endpoint, the grass pollen data of the european aeroallergen network (ean) was used to identify the window within the grass pollen season (gps) with optimal correlation between the grass pollen counts and the csms. method: ean currently includes information from more than active and historical pollen-monitoring stations in europe including countries. the ean database used for analysis included grass pollen data collected during - . the daily allergy symptoms and medication were recorded spontaneously using an app questionnaire on the subject's smart phone. the csms was re-calculated using the ean database, using the recorded symptom scores with estimation of the medication score using similar methods as recently published. the correlation between the daily grass pollen count and the daily csms was analyzed with a mixed effects model accounting for patient-specific correlations and symptom levels. conclusion: these results confirm a statistically significant correlation between grass pollen counts and the csms. importantly, these findings suggest that the optimal window to observe treatment effects after immunotherapy may be a short interval after start of the gps and during the peak gps, due to generally higher csms values. this provides sufficient basis to consider additional sensitivity analyses to evaluate the treatment effect of grass mata mpl scit on the primary csms endpoint during a shortened window after the start of the gps and to consider excluding the overlapping period between the bps and gps from the primary analysis. | combo-vas as a tool to assess efficacy of allergen immunotherapy ciprandi g ; silvestri m ; olcese r ; tosca ma ospedale policlinico san martino, genoa, italy; istituto g. gaslini, genoa, italy background: allergen immunotherapy (ait) is at present the unique cure for respiratory and venom allergy. usually, ait lasts for some years, but its efficacy is longstanding. criteria for assessing ait efficacy are mainly based on symptom severity improvement and saving of symptomatic medications. in this regard, there are different score grading for both measuring symptom severity and drug use. visual analogue scale (vas) is a well-defined and validated method widely used in many diseases, including allergic disorders. vas is a psychometric tool measuring the patient's perception of symptoms, emotions, pain, drug use, etc. recently, it has been published an eaaci position paper concerning the recommendations for the standardization of clinical outcomes used in ait trials for allergic rhinoconjunctivitis, but it is complex. so we would propose a simpler way to measure ait efficacy by vas, in particular a combo-vas based on one vas for symptom and one for medications. results: globally patients were retrospectively evaluated. all of them were treated with a -year ait course: were defined as responders and as non-responders. in responders group the combo-vas mean value was (iqr - ) at baseline and (iqr - ) after ait treatment. in non-responders group combo-vas mean value was at baseline and (iqr - . ) at the end of ait. the difference was significant (p = . ). the d combo-vas was − . % in responder group and − % in non-responders group (p < . ). conclusion: combo-vas, i.e. the sum of vas for symptoms and medications, could be an easy and quick tool for assessing ait efficacy and reflects the patient's perception. therefore, it could be very fruitful in clinical practice. | rapid up-dosing in sublingual specific immunotherapy is safe, well-tolerated and effective in patients suffering from tree pollen allergic rhinitis background: an optimised up-dosing period of specific immunotherapy (sit) is desirable for better patient compliance because a long or complicated up-dosing scheme is sensitive to disruption. the aim of this study was to compare the safety, tolerability and effectiveness of an optimised up-dosing scheme with two preexisting schemes of sublingual sit (slit) in patients under standard medical care. method: this was a prospective, open, active controlled, multi-center non-interventional study in germany and austria to document the treatment of children and adults with allergic rhinoconjunctivitis and/or allergic asthma treated with a slit containing purified, aqueous extracts of birch, alder and hazel pollen. the investigators were free to select an up-dosing scheme for included patients: scheme a consisted of an up-dosing period of up to days at the patient's home using three different solution strengths to reach the maximum dose; ultra-rush scheme b performed only with the highest solution strength at the physician's office within hours, and the optimised scheme c which was initiated at the physician′s office and continued at home using exclusively the highest solution strength within (long-term) or (pre-seasonal) days. data on up-dosing and maintenance treatments were documented by physicians during patient visits and by patient diaries. the study was approved by ethic committees, and all patients or parents gave their informed consent. results: in total, patients aged - years were included into this study. scheme a was applied by patients, patients decided on regimen b, and patients on the optimised scheme c. conclusion: one-day ur-scit conducted in an outpatient clinic was safe and well-tolerated in patients with ad sensitized to hdm. ur-scit can be a safe and useful option to start a subcutaneous allergen immunotherapy for ad. | factors affecting on adherence to allergen specific immunotherapy results: among enrolled patients, ( . %) patients failed to complete at least years of ait, which were regarded to be nonadherent in this study. univariate analysis revealed that male, younger age group less than years, cluster and ultra-rush schedules, atopic dermatitis, the absence of associated diseases, and follow up of other department were found to be associated with nonadherence to ait. in multivariate analysis, younger age group less than years (or . , % ci . - . ), cluster ( . , . - . ) and ultra-rush schedules ( . , . - . ) , and absence of follow up of other department ( . , . - . ) were independently associated with non-adherence to ait. no association was found in gender, diagnosis of allergic diseases, kind of allergen extracts, and patients' distance from hospital. conclusion: various factors are related with ait non-adherence to interfere the effectiveness of immunotherapy. clinicians need to be aware of the factors associated with non-adherence to ait and consider them when choose to maximize ait adherence. | cost-effectiveness of allergen immunotherapy to grass in patients with allergic rhino-conjunctivitis and asthma background: allergen immunotherapy (ait) has been shown to reduce symptoms and medication use in subjects with rhino-conjunctivitis and asthma. however, long-term cost effectiveness of this therapy needs to be evaluated. our aim was to assess cost effective of ait, both subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit), vs. pharmacotherapy alone in subjects with rhino-conjunctivitis, with or without allergic asthma, to grass pollens. method: a markov cohort state-transition model with a time horizon of years was used to assess the costs and effects of -year ait in adults. relative efficacy of the treatments expressed as standardized mean difference was estimated using an indirect comparison on symptom and medication score extracted from available meta-analyses. the rhinitis symptom utility index was used as a proxy to estimate utility values for symptom score. the societal perspective, through the human capital technique, was used to estimate indirect costs, to represent the scenario of a country with nationalized medicine. data on drug and other medical costs were derived from published sources as well as ait duration and asthma occurrence. additional sensitivity analyses were performed to test the robustness of our results. results: in the base case analysis, using italy clinical practice patients with moderate-to severe allergic rhino-conjunctivitis (ss ranging from to points) and a mean age at entry of years, both scit and slit were associated with increased cost but superior efficacy compared to pharmacotherapy alone. the results were most sensitive to variation in efficacy estimates and ait persistence rates. conclusion: this analysis suggests that ait is cost effective relative to pharmacotherapy alone. scit, despite significantly higher indirect cost burden, seems to be the most cost effective option. the results should be interpreted in the context of the data input and modelling assumption used. | ielisa as a tool to measure ige binding towards single modified peanut allergens background: immunotherapy has shown to be a potential treatment for food allergies but needs further research to improve safety. modification of peanut allergens to reduce their allergenicity is a promising approach to develop a safe and effective immunotherapy as shown by the successful completion of a first-in-human safety and tolerability study using hal-mpe in adult patients with peanut allergy (eudract - - ) . in order to assess the impact of modification on individual peanut allergens and to assess its impact on ige binding by individual patient sera, we have developed peanut allergen-specific inhibition elisas. with this methodology we are able to identify patients with residual ige binding to modified peanut allergens. method: ige inhibition elisas (ielisas) were developed and performed to test ige binding towards purified ara h and ara h and their reduced and alkylated (modified) versions, using the individual responses of single patient sera. results: ara h -specific ielisas showed that modification of ara h results in > % reduction in ige-binding for all individual sera tested. ara h -specific ielisas showed that modification of ara h also results in > % reduced ige-binding for most of the sera, but some sera were identified which showed residual, %- % ige binding to mara h . in some of the latter sera, the presence of ige binding to a linear hydroxyproline-containing peptide could be confirmed as a possible source for the residual ige binding to mara h . we have developed a methodology to assess residual ige binding to modified peanut allergens. the sensitivity of the allergen-specific ielisas allowed us to discriminate between patient sera in which ige binding to mara h and to mara h was virtually completely absent and sera in which - % residual ige binding to ara h was observed. the clinical importance of these observations is yet unknown. future clinical studies will need to reveal whether the patient-specific ige binding profiles to individual modified peanut allergens do correlate with the adverse events profile of immunotherapy with modified peanut extract. | design of a phase ii allergen immunotherapy study to determine the optimally effective and safe dose of subcutaneously administered tyrosine adsorbed modified grass allergen+mpl (mpl) adjuvants for the treatment of allergic rhinoconjunctivitis (arc) due to grass pollen. there is increasing evidence that the effectiveness of allergy immunotherapy to control arc symptoms is related to the cumulative allergen (or allergoid) dose administered. previously, two clinical studies have been conducted using a conjunctival provocation test (cpt) as primary efficacy measure for a similar scit mata mpl product for birch allergy [eudract - - and - - ] . these studies showed a . fold increase in cumulative dose to achieve~ % increase in efficacy, with a relative reduction in total symptom score (tss) of . % compared to placebo and no safety signals of concern. the shape of the dose response curve was curvilinear, where this high dose almost reached plateau. method: this is a multi-center (~ clinical study centers across europe), randomized, double-blind, placebo-controlled, parallel-group study in~ adult patients with moderate to severe seasonal arc with or without mild asthma. a positive cpt is to be achieved at screening and verified prior to randomization. the primary outcome is the post-treatment tss following cpt. a wide range of cumulative dose regimens is used ( , , and su) applied over weekly injections to establish the shape of the dose response to support dose selection for phase iii. the design of the current phase ii grass allergoid scit study will be discussed, including the rational of using cumulative dose regimens and placebo and the pre-selected shapes of the dose response curves. in addition, the number of patients screened and randomized will be presented by country, gender and/or age category and screen failures will be categorized. conclusion: this phase ii study was initiated to establish the dose response of a grass mata mpl scit product, using cpt to measure the effect of a wide range of cumulative dose regimens. the achievement of its aim will be an important milestone in the development of an efficacious and safe state-of-the-art grass scit. conclusion: we observed that the specific nasal challenge with house dust mite generates an inflammatory response within the first hours, but we did not demonstrate any correlation with the response to immunotherapy after six months. | tolerability of a two week rush updosing with modified allergens in pollen allergic subjects in the day-to-day practice background: in two phase iv studies the tolerability of a subcutaneous rush up-dosing, using three injections in two weeks, has been tested and proven to be save in adults. in the course of a non-interventional study (nis) now the tolerability of this treatment scheme was tested in the day-to-day practice. conclusion: over % of the patients could reach the highest dose of . ml. the overall tolerability is very good. the data from daily practice confirm the data that were previously obtained in two phase iv studies. siges from patients, evaluated during the st semester of at an outpatient clinic. all patients presented persistent moderatesevere allergic rhinitis, in pollen season and had not been submitted to it. all patients had positive spt for grasses (grass) and olive (olea). sige-tot for phleum pratense and olea europaea and some sige-crd (rphl p , rphl p , rphl p , rphl p , role and nole ) were determined. physicians were divided into groups (group if < years of practice and group if≥ years of practice) and were asked to choose which it to prescribe for each patient (none, only grass, only olive or both grass and olive), according to spt and sige results. results: fifteen physicians ( % with ≥ years of practice) participated in the survey. considering only the sige-tot results, the it choice (group / ) was: no vaccine in %/ %; grass vaccine %/ %; olive vaccine %/ % and both grass and olive vaccines in %/ % of the patients (p = . ), the intergroup agreement was % (kappa . ). according to the sige-crd results the physicians chose (group / ): no vaccine at %/ %; grass vaccine in %/ %; olive vaccine in %/ % and both vaccines in %/ % of patients however, data on control of allergic rhinitis (ar) after discontinuation of therapy are insufficient. the aim of our study was to assess sustained control of ar in three consecutive years after grass-pollen slit discontinuation. method: a total number of patients [ ( . %) males; mean age years, age range - ] well-controlled after a three-year course of slit with grass pollen extract were prospectively evaluated in three consecutive years after discontinuation of therapy. conclusion: a three-year course of grass-pollen slit seemed to have a long-term effect on control of symptoms in patients with ar. the authors declare no conflict of interest. results: all patients showed a positive sensitization profile by skin prick test to either betula and/or alnus. in % of patients this profile was furtherly confirmed with serum specific ige levels to betv , (mean . ku/l). allergic symptoms in patients with birch/alnus pollen allergy after ingestion of certain food can result from crossreactivity of bet-v -specific ige to homologous pathogenesis-related proteins, particularly the pr- protein. conclusion: within the allergy history we emphasize on focusing on sao symptoms as many patients under-recognize them. among the sensitization profile of these patients it is quite important to highlight cross reactivity between bet v and alnus. the other patient suffered from anaphylaxis(grade ii) induced by minimum amount of lettuce consumption without co-factors. both patients suffered from oral allergy syndrome to peach and allergic rhinitis. spts to foods and pollens were performed with commercial extracts, prick-through-prick with fresh plant foods, while specific ige was determined accordingly. ltp syndrome was defined as a sensitization to pru p and symptoms elicited by at least unrelated plant foods. co-factors were also investigated. results: the first patient was sensitized to lettuce, peanut, hazelnut, sunflower's seed, peach and banana, and plane tree, olive tree, grasses, parietaria and mugwort. sige to lettuce was . kua/l, to pru p was . kua/l and total ige was . u/ml. co-factors, such as exercise, were involved. the second patient was sensitized to peanut, walnut, hazelnut, almond, sunflower's seed, cashew, lettuce and peach, and, plane tree, olive tree, grasses, parietaria, mugwort and willow. sige to lettuce was . kua/l, to pru p was and total ige was . ku/l. no co-factors were identified. background: garlic (allium sativum) is a vegetable that belongs to amaryllidaceae's family. hypersensitivity to garlic is not very common. it has been mainly reported in occupational allergy but it also may cause contact dermatitis, rhinoconjunctivitis, asthma, urticaria, gastrointestinal symptoms and anaphylaxis after its ingestion. some studies have identified alliin lyase, a kda protein, as a major garlic allergen and it seems to be a heat-sensitive allergen. we report on a -month-old infant who presented, minutes after an accidental ingestion of garlic sauce, generalized erythema and cough. she was still breastfeeding and she had never abstracts | eaten garlic before (although the mother usually consumed garlic). the patient had never tasted other vegetables belonging to amarylidaceae's family either but zucchini, with good tolerance. we performed skin tests and specific ige (sige) to different vegetables. a raw garlic extract was also carried out and analysed in the patient by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). results: prick by prick with garlic was positive ( mm) and negative to onion, leek, asparagus, zucchini and saffron. skin prick tests to commercial extracts of mugwort, grass pollen, peach ltp and profilin were negative as well. specific ige to garlic was . ku/l (out from a total ige ku/l) and ku/l to onion and asparagus. sds-page immunoblotting assay with patient′s serum revealed ige reactivity with proteins of kda and kda. conclusion: we report a garlic ige-mediated anaphylaxis case in an infant with proteins of and kda as the relevant allergens. the mechanism of sensitization in the present case remains unclear. the authors hypothesized that breastfeeding, cutaneous contact or inhalation might be possible mechanisms involved. chong kw ; saffari se ; chan n ; seah r ; tan ch ; goh sh ; goh a ; loh w allergy service, department of paediatric medicine, kk women's and children's hospital, singapore, singapore; centre for quantitative medicine, office of clinical sciences, duke-nus medical school, singapore, singapore; yong loo lin school of medicine, national university of singapore, singapore, singapore background: the predictive decision points for both peanut skin prick test (spt) wheal size and serum ige concentrations, in peanutsensitized children, have not been evaluated in singapore. we aim to assess these for purposes of risk stratification and prediction of oral food challenge (ofc)s' outcomes by means of a retrospective chart review. results: the number of patients evaluated was , of which had clinical diagnosis of peanut allergy based on recent immediate reaction to peanut (pa group) and were tolerating peanuts regularly (pt group). the mean age of both groups were similar, . ± . and . ± . years in pa and pt groups respectively. there was a high prevalence of atopic diseases in both groups, with atopic dermatitis ( . % in pa, . % in pt), and other food allergies ( . % in pa, . % in pt). presence of rhinitis was statistically higher in the pa group compared to the pt group, with odds ratio of . ( % ci: . - . ) . a wheal size of ≥ mm and a peanutspecific ige of ≥ ku/l provided for a % positive predictive value. the larger the wheal size on spt, the higher the probability of a clinical reaction to peanuts. the results will help us in deriving preliminary cut-off values when conducting future prospective studies with ofcs in our peanut-sensitized cohort (whom had no prior peanut exposure), and to eventually reduce the need for expensive and potentially risky food challenges. | ginger: flavory, spicy …allergenic? a report of four patients with allergy to ginger background: ginger (zingiber officinale) belongs to the family zingiberoidae, along with cardamom and turmeric. the edible portion is the horizontal rhizome, and it is very appreciated for its aroma and spicy flavor. it also presents great interest for its therapeutic and culinary use. hypersensitivity to ginger is rare and has been scarcely reported. we report cases (p , p , p , p ) of adverse reactions to ginger after its ingestion and with good tolerance to cardamom and turmeric. method: skin prick tests (spt) to environmental allergens and prick-by-prick with ginger were carried out. total ige, and specific ige to ginger were also determined. a raw ginger extract was prepared. this extract was analyzed in all the patients by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). background: food allergy is divided into groups according to pathophysiology: ige-mediated, ige-and non-ige (mixed type), and non-ige (cellular type). however, in clinical practice, patients who fall under more than one group may be observed. method: patients who were diagnosed with food allergy at our clinic from january to december were included in the study. the medical files of patients were retrospectively evaluated, their symptoms and findings after consumption of foods were recorded, and they were categorized into groups (ige-mediated type, non-ige type, and mixed type) according to their symptoms and findings. results: a total of patients ( . % male) with food allergies were included in the study. according to categorization via symptoms and findings, the distribution of patients was as follows: ( . %) ige-mediated type, ( . %) non-ige type, ( . %) mixed type. the remaining ( %) patients were found to show various combinations of symptoms and findings that fit more than one group. in this study, we observed that food allergy symptoms and findings were distributed in a broad range which caused difficulties in the categorization of more than one-third of our patients. background: fish allergic patients suffer a lifetime of strict dietary restrictions. crocodile meat is a nutritious alternative choice in many countries around the world; however, it has recently been reported to also trigger severe allergic reactions. in these two case reports from pediatric patients were sensitised to the major fish allergen parvalbumin (pv), a potential cross-allergen. bony fish contain predominantly pvs of the β-lineage, which are the most common trigger of allergic reactions in fish allergic patients. in most other vertebrates, pvs of the α-lineage are most abundant, which have been reported as a causal allergen in frog, cartilaginous fish, and chicken allergies. we aimed to evaluate the allergenicity of crocodile meat in fish allergic children, with focus on pv. method: over children with clinical history of ige-mediated fish allergy were identified, skin tested to commonly consumed fish species using commercial and in-house preparations, and serum samples were collected. a sub-cohort was skin tested to crocodile using heat-treated tail muscle tissue from saltwater crocodile (crocodylus porosus). extracted proteins and purified pvs were analysed by sds-page, immunoblotting, and mass spectrometry. serum from all fish allergic children was analysed for ige reactivity to the crocodile pv. this reactivity was compared to those of raw and heated crocodile protein extracts as well as protein extracts and purified pvs from frequently consumed fish species. results: more than fish allergic children were positive on skin testing to crocodile (wheal size> mm), demonstrating its clinical reactivity. in vitro analyses revealed ige reactivity to crocodile pv in serum from more than half of all patients. two βand one α-crocodile-pv isoforms were identified. pvs constituted approximately % of total proteins in heated crocodile extracts, with β-pv ( kda) being times less abundant, but up to times more ige-reactive than α-pv ( kda). αand β-pvs from crocodilians, including alligators and crocodiles, share more than % and % of their amino acid sequence, respectively. conclusion: crocodile pv is a new allergen as per the iuis guidelines. fish allergic patients may be at risk of severe allergic reactions upon ingestion of crocodile meat due to strong ige cross-reactivity of β-pvs. this study suggests that fish allergic individuals and health professionals need to be aware of potential allergic reactions to meat from crocodilians, termed 'fish-crocodile syndrome'. background: we present a -year-old nonatopic woman that in december after eating a seafood paella with green pepper presented asthenia, nasal obstruction, incoercible vomiting and diarrhea. later she ate a grilled loin sandwich in a bar and she had the same symptoms (she asked the waiter at the bar and the chef had cooked her sandwich in the same pan where he had cooked green pepper just before). after that, she suffered from abdominal pain, nausea, abdominal distension without diarrhea two hours after she ate an omelet sandwich with certain flavor of green pepper. at present even the casual smell of pepper causes her nausea. the woman eats everything including spices and just avoids pepper. method: skin prick tests were performed using extracts from food (nuts, fish, mollusk, fruits, vegetables, legumes), aeroallergens (mites, abstracts | pollens and epithelia) and purified proteins (pru p , profilin, polcalcin, alfalactoalbumin, betalactoglobuline, casein). we also performed prick by prick to raw and cooked green pepper. sds-page immunoblotting according to laemli under reducing conditions (with -mercaptoethanol) was performed to study the molecular mass of the ige-reactive proteins. extracts from green pepper and green pepper seed were used. the prick tests were all negative and the prick by prick test to raw and cooked green pepper was positive in both cases. blond was taken from all patients to specify the levels of allergenspecific ige against allergen components of immunocap isac test, the result≥ . isu-e was assumed as positive. results: in the study group, in patients ( %) specific antibodies against ltp were detected, the isu-e level range . - average . isu-e on average, in patients with detected ltp ige was detected for . components belonging to the ltp, however the highest number % patients were detected ige only for ltp. in subjects ( % of respondents with detected ltp), ige was detected against art v and this is the only ltp component whose occurrence was statistically significant (p = . ). in patients ige was detected against pru p , jug r , pla a ,; patients ige to ara h ; patients cor a ; patients ole e , patients tri a , and in person para j . background: the birch pollen-associated oral allergy syndrome (oas), an ige-mediated local allergic reaction, is the most common manifestation of pollen-associated food allergies. its origin is explained by cross-reactions between birch pollen-and food-allergens belonging to the pathogenesis-related protein subfamily (pr- ). [ ] so far, there is no marker available for its detection and no standardized test established to evaluate objectively the subjective feelings experienced by oas. the diagnosis is based on a characteristic history and on detecting the sensitization to triggering allergens in skin prick test (spt) and laboratory examination. method: the aim of this study was to evaluate whether the food skin prick test could be a helpful marker in the diagnosis of a birch pollen-associated oas. for this exploratory study, data from - was collected retrospectively at the dermatological outpatient department of the ordensklinikum linz elisabethinen. patients with positive spt results for birch pollen were included. the variables age, gender, tree pollen-(birch, alder, hazel) and food-spt, laboratory tests (ige, bet v , bet v , gly m ) and symptoms (oas, rhinoconjunctivitis allergica, atopic dermatitis, anaphylaxis) for statistical analysis. results: there was an association between food-spt and oas but also between the negative oas patients and food-spt (p = . - . ). all of the bet v sensitized patients with positive gly m results had also a positive food-spt result. conclusion: there was no evidence for a possible role of food-spt as helpful markers in the diagnosis of birch pollen associated oas. maybe gly m could be a helpful marker, but more data are needed. bet v seems to be the cause of birch-pollen associated oas, due to the dominant sensitization pattern to major allergens in austria. background: eggs are among the foods most frequently causing allergy. the most common one is hen egg, although we may consume other bird's eggs such as duck's, those of goose, quails and seagulls. clinical and serological crossreactivity between hen egg proteins and those of other birds eggs have been described. allergy to other species eggs are less frequent and are usually described in patients allergic to hen eggs. we report a case of food allergy after ingestion of duck egg in an adult patient without hen egg allergy. the patient was a year-old man who had symptoms of generalized itching, swelling uvula, erythema neck and deglutition difficulty immediately after he ate eggs from duck and hen. he claimed to have eaten hen eggs almost daily without clinical symptoms and he had not previously ingested duck egg. he denied allergic reactions to any other food but did complain of seasonal allergic rhinoconjunctivitis in the spring. we performed skin prick test with extracts of egg and feathers, prick by prick test with cooked and fresh yolk and white from duck and hen egg and oral challenge with hen eggs. specific serum ige was measured to hen proteins and we carried out a western blot with the proteins of allergenic extracts from different eggs (white and yolk of quail, chicken, goose and duck) and an inhibition of western blot with ovalbumin as inhibitor allergen. results: skin test with extracts of eggs and feathers, cooked and fresh hen and duck eggs were positive. total serum ige was . ku/l. specific ige to hen's egg was class two for hen egg white, ovoalbumin and class one for yolk and ovomucoid. oral challenge with heated egg yolk negative and with egg white was positive. the patient's serum recognized mainly and intensely several proteins of white and egg yolk of quail and duck with a molecular mass around to kda respectively. on the other hand a protein around and - kda was unique recognized in white eggs of hen and goose. the western blot inhibition revealed ovalbumin inhibited the protein recognized in the egg white but not egg yolk involved in. background: management of tree nut allergy is usually based on the avoidance of the suspected tree nut (tn), as well as peanuts and seeds, either because of the risk of cross-reactivity and/or contamination, or due to the clinical severity. objective: to assess the sensitization pattern and clinical reactivity patterns to different tn, peanut and sesame seeds (ss) in patients with a history of reaction to at least one of these foods. results: a total of patients with confirmed nut allergy were included; % female, median age [interquartile range] of years; % were atopic. the most frequently involved foods were walnuts ( %), hazelnuts ( %), almonds ( %) and peanuts ( %). anaphylaxis was the clinical presentation in % of the patients. in those with a history of reaction to only one nut ( ), the most prevalent was peanut ( %). in the patients that reacted to more than one nut, the most frequent combinations were walnut/hazelnut ( ), walnut/almond ( ) and almond/ hazelnut ( ). of these patients, tolerated other nuts. two had sesame seed allergy, one reacted only to ss. nine patients ( %) were sensitized to foods that they tolerated. fourteen ( %) patients were sensitized to ltp and of them reacted to more than one nut. conclusion: these data concur with the existence of different sensitization profiles (primary, concomitant or cross-reactive), which may predict different clinical reactivity patterns and therefore, influence dietary recommendations. background: buckwheat (fagopyrum esculentum) is a polygonaceae weed, not a cereal, which is increasingly been consumed and used as an alternative food in the diet of celiac patients. despite its wide use, allergy to buckwheat has unfrequently been reported in our setting. method: two female patients, aged and , suffered an immediate severe allergic reaction after eating a bread and a pancake containing buckwheat among its ingredients. the first patient presented generalized urticaria, palpebral angioedema and pharyngeal occupation. the second one showed those same symptoms, as well as abdominal pain, nausea, dyspnea, dizziness, hypotension and loss of consciousness. skin tests and specific ige determination to aeroallergens and food allergens were carried out, including prick-prick test with buckwheat and all other components contained in the food involved. buckwheat allergens were studied by sds-page and ige-immunoblotting of one of the patients. results: prick-prick tests yielded strongly positive results to the food itself and buckwheat, and negative to the remaining food components in both cases. cap was positive to buckwheat ( . ku/l and > ku/l, respectively). basal serum tryptase levels were normal. both patients were not sensitized to cereals, ltps, profilins or pr- proteins. for the first patient, the skin tests were negative for other foods, seeds and nuts. the cap was negative for ltps, profilins and storage proteins of peanut and other nuts. the second patient who had the most severe reaction, was also sensitized to hazelnut(cap . ku/l), pistachio ( . ku/l), almond( . ku/l), walnut( . ku/l) and sesame( . ku/l), which were not included in the pancake. the buckwheat immunoblot of the first case, under non-denaturing conditions, revealed a ige-binding protein of -kda. ige-immunoblotting under reducing condition showed protein bands of , , and kda in the buckwheat extract. conclusion: two cases of anaphylaxis by buckwheat flour contained in two frequently consumed foods are presented. the absence of sensitization to ltps, together with the pattern of specific ige binding in the immunoblot in one of the cases suggests that the responsible allergen could correspond to a storage protein of buckwheat, without cross-reactivity with other seed and nut allergens. buckwheat must be taken into account as an unsuspected food allergen capable of causing severe allergic reactions. background: allergy to linseed (linum usitatissimum) has infrequently been reported despite of its wide use in bread and in a range of "health food" products. linseed contains potent allergens which have not yet been characterized. we studied three patients who presented allergic reaction after eating different foods which contain linseed. two of them (patient p and patient p ) had anaphylaxis and the third one (patient p ) had oral syndrome, abdominal pain and diarrhoea. p was also allergic to mustard and p to sesame seed. all of them tolerated the remaining seeds, nuts and food. baseline tryptase levels were in normal range in all patients. skin tests and specific ige determination to inhalants and food allergens were carried out. linseed allergens were studied by sds-page and ige-immunoblotting. skin tests: patient : prick tests were positive to pollens and linseed, and negative to ltp, profilin, nuts, seed and the remaining food; patient : prick tests were positive to linseed and mustard and negative to other food and inhalants; patient : prick tests were positive to linseed, pollens, sesame and nuts (peanut, hazelnut, almond, pistachio). we present three cases of severe allergic reactions to linseed. the pattern of specific ige binding in the immunoblot seems to lead to storage proteins as the responsible allergens. | pr- sensitization-looking it up in food allergy background: pr- protein group sensitization is found in patients with respiratory allergy, mainly in areas inhabited by trees of the betulacea or fagacea families. its role in food allergy is, however, more frequently described in the context of cross reactivity. our aim was to characterize the pattern of molecular sensitization of food allergic patients sensitized to pr- protein group with immu-nocap isac ® (isac). the remaining patients, with more severe reactions, were all co-sensitized to either ltp and/or storage proteins (sp). only of the patients without pfa were co-sensitized to ltp or sp versus of with pfa (p < . ). conclusion: pr- sensitization is rare in our population. approximately half of the patients had allergy to plant foods, but the majority were co-sensitized to ltp and/or sp. the few patients only sensitized to pr- had minor reactions. among the patients without plant food allergy, co-sensitization to ltp and sp was significantly less common. according to these results, in our population, pr- seems to be less relevant to food allergy, when compared to reported results from other european countries. gür Çetinkaya p; uysal soyer Ö; esenboga s; sahiner Üm; sekerel be hacettepe medical school, ankara, turkey background: pistachio is a tree nut belonging to "anacardiacea" family, and constitutes % of tree nut allergies. this nut most often abstracts | cross-reacts up to % with cashew which is located in the same family. pistachio allergy is mostly seen in iran, turkey, the united states, and china where this tree nut is frequently consumed. in this study, we analyzed age and cut-off values for development of tolerance to pistachio. method: children who had reported allergic reactions with pistachio, and who have not consumed pistachio, but had positive spt and/or specific ige levels were enrolled into the study. spt and specific ige levels were measured in all patients. oral provocation(op) tests with pistachio were performed by patients, and of them had positive test result. the median age of tolerance development was months (iqr: . - . months). the most commonly involved systems during op tests were skin ( %, n = ), gastrointestinal system ( %, n = ), and lower respiratory tract ( %, n = ). concomitant allergic diseases were atopic dermatitis ( %), asthma ( %) and allergic rhinitis ( %). there was a positive correlation between skin prick test diameter (spt) and specific ige levels (spige) (r = . , p = . ). spt of≥ . mm to pistachio nut was found as highly predictive of clinical allergy (auc: . , %ci: . - . , p < . ). any relation was not determined between eosinophil, basophil counts, triptase levels, and op test positivity. conclusion: pistachio allergy is one of the frequently seen nut allergies in turkey which may cause serious allergic reactions including anaphylaxis. op test showed that tolerance was achieved by the median age of months, and a cut-off level of . mm was best predictor for positive reaction. in an oral challenge test, the patient responded with generalized urticaria, swelling of the lips and difficulty breathing at a cumulative dose of . g peanut protein, however, without blood pressure drop. (grade , moderate symptoms). the patient was treated with anti-ige for months (with mg every weeks sc). oral desensitization began with ingestion of μg peanut, escalating to mg, on the first day and escalating weekly doses of peanut from mg to mg ( peanuts). then anti-ige was discontinued while the patient ingested peanuts every day. we have followed the patient's sensitivity to peanuts from before anti-ige treatment to after anti-ige washout with basophil testing. results: the patient completed desensitization without side effects, and continues to ingest peanuts a day. basophil sensitivity was reduced -fold by anti-ige treatment, but returned to baseline levels after anti-ige washout. conclusion: anti-ige allows rapid desensitisation of peanut allergic subjects with peanut oral immunotherapy. in the majority of subjects, this desensitization is sustained after anti-ige is discontinued. additional studies will help clarify which patients would benefit most from this approach. the return of basophil response to pre-treatment levels suggests that the patient is desensitised, and depends on the daily ingestion of allergen. what do we (not) know? background: the use of biologic prosthesis is a well-established surgical procedure. acute and delayed complications may occur, but accurate epidemiologic data about allergic reaction to graft tissue is lacking. methods: a years old boy referred to our unit for urticaria and gastrointestinal symptoms which developed a few years before. he received a biologic porcine vascular duct during a cardiovascular surgery at days of life. at the age of urticarial episodes occurred, and a diagnosis of beef allergy was made. after the exclusion of beef meat from the diet, most symptoms resolved, but the child began to complain about occasional episodes of vomit and diarrhoea. results: skin prick tests confirmed the beef meat sensitization and prick-prick test resulted positive against raw pork meat but not against cooked pork meat. in vitro tests demonstrated the presence of pork meat specific iges ( . kua/l). component-resolved diagnostic tests revealed allergy sensitization toward bos d (bovine serum albumin, bsa; porcine serum albumin was not tested due to lack of a specific test). after accurate exclusion of pork meat from diet, a complete remission was achieved, and the diagnosis of pork meat allergy was confirmed. conclusion: bsa is a major beef allergen, responsible for the raw beef-cow milk cross-reactivity but with a scarce importance in milk allergy. it is highly homologous with human serum albumin and other mammalian serum albumins, including porcine albumin. porcine albumin is also highly homologous with cat serum albumin and therefore responsible for cross-reactivity in patients affected by cat-pork syndrome. we hypothesize that the implanted porcine tissue was the trigger for pork meat allergy in our patient, as this condition is exceptional in childhood and that our patient never owned a cat. few cases of pork allergy due to porcine tissue implantation have been reported so far. of interest, pig sensitization was recognized as a rare but possible cause of blood-culture negative endocarditis in patients with porcine bioprosthesis according with anamnesis, increased ige level against pork, tissue eosinophilia during autopsy. background: desensitization to foods is assuming a new paradigm in food allergy. this technique is becoming widespread especially for patients with egg and milk allergy, but the effect of desensitization on the consumption of similar but not identical foods is still uncertain. material and methods: we describe the case of a -year-old patient, with a history of chicken egg allergy, who had been successfully desensitized tolerating cooked and raw chicken eggs for a year. the patient came to the office after presenting an episode of anaphylaxis immediately after eating fried quail eggs. an immunological study was carried out. we performed skin prick test with chicken egg′s proteins (white, yolk, ovoalbumin and ovomucoid). an immunoblotting to detect specific ige to egg proteins was also performed. for this purpose, the following extracts were used: chicken egg white and yolk (commercial extract form alk) and quail egg white and yolk prepared following a similar procedure (extracted in % phosphate buffer (w/v)). conclusion: we present the case of a patient with specific allergy to quail egg white and yolk, probably through ovotransferin, but not to chicken egg. the desensitization against chicken eggs does not allow the consumption of eggs of other species of birds, such as quail eggs, and this indication must be made specifically to patients after a protocol of desensitization against chicken′s eggs. case report: seven years ago we presented the case of a year-old male, who suffered two acute episodes of oral pruritus, lip angioedema, epigastric pain, generalized urticaria and dizziness after ingesting lettuce. he previously tolerated salads (including lettuce). he was later diagnosed with non-ltp-dependent lettuce anaphylaxis and an aspartyl protease was identified as a new lettuce allergen with cross-reactivity with other members of the compositae family. since the diagnosis he has avoided lettuce and all the other compositae. we present the patient's curious outcome after years of follow up. methods: total ige, basal tryptase, specific ige to lettuce by immu-nocap, prick-prick and oral challenge tests with lettuce and other compositae. sds-page, immunoblotting and molecular characterization of ige binding bands by mass spectrometry. skin prick tests and specific ige to lettuce were repeated on several occasions in the following years. after years an oral challenge test with lettuce was carried out. results: prick-prick test was positive to fresh lettuce ( × mm) and to other compositae (raw endive, chicory, thistle, artichoke and chamomile). prick-prick test was negative with these boiled compositae. basal tryptase was . μg/l. total ige in serum was ul/ml. specific ige by immunocap was positive to lettuce ( . ku/l) and negative to profilin, ltps and thaumatin. oral challenge test with endive was positive and negative with cooked compositae (artichokes and thistle). sds-page and immunoblotting detected an intensely binding ige band about kda, common for endive and chicory, which was identified by mass spectrometry as an aspartyl protease. no bands were detected at ltp ( kda) and profilin ( kda) . in the first two years after the diagnosis, prick-prick test and specific ige to lettuce remained positive (cap . ku/l and . ku/l, respectively). after years, prick-prick test and specific ige to lettuce became negative (cap . ku/l). with this findings a new oral challenge test with lettuce was carried out which result turned out negative. we report the first case of spontaneous tolerance to lettuce in a patient who previously presented lettuce anaphylaxis and identify an aspartyl protease as the causative allergen. introduction: eosinophilic esophagitis (eoe) is an emergent allergic inflammatory disease that is triggered by food allergens and characterized by progressive esophageal dysfunction. recently, it has been seen that eoe develops in up to . % of patients with ige-mediated food allergy undergoing oral immunotherapy (oit). ingestion of baked milk and egg was associated with increased development of tolerance to regular milk and immunologic changes have been reported in subjects ingesting baked milk and egg, similar to those seen in food oral immunotherapy studies. case description: we present the case of a -year-old girl, with history of ige mediated cow′s milk allergy and rhino conjunctival and bronchial asthma symptoms. prick test against milk proteins showed: milk mm, alpha-lactalbumin mm, casein mm and to beta-lactoglobulin: negative. total ige: ku/l. specific ige to milk: , alpha-lactalbumin: , ku/l; casein: ku/l and beta-lactoglobulin: . ku/l. we performed an oral food challenge with baked milk which was well tolerated. then, we performed an oral food challenge with fresh milk and she presented facial urticaria and pharyngeal pruritus. after months eating baked milk every day, she had symptoms of dysphagia and esophageal food impaction. for this reason, we performed an esophagogastroduodenoscopy (egd) and biopsies which showed white exudates and vertical furrows. the histological study showed eosinophil count> per high-power field. eosinophilic esophagitis was diagnosed and she started treatment with esomeprazole mg. the egd was repeated weeks later with similar results in the biopsy. she was treated with a comprehensive diet free of cow′s milk proteins. after weeks she was asymptomatic and endoscopy and biopsy findings were normal. we report the case of a cow′s milk allergic patient who developed eoe after introduction baked cow′s milk which apparently was tolerated in her diet. the avoidance proved efficacy in inducing the remission of eoe. method: we examined bottle-feeding infants with food allergy aged from to months. serum vitamin levels were measured by immunoassay methods (retinol binding protein (rbp), vitamin b , hydroxy vitamin d), biochemistry methods (vitamin c, vitamin e) and microbiology methods (vitamin b , vitamin b ). as criteria for complete sufficiency standards adopted in the russian federation were used (the lower limit of normal levels: rbp - . μmol/l; b - ng/ml; -hydroxy vitamin d- ng/ml; vitamin c - . mg/dl, vitamin e - . mg/dl; vitamin b - μg/ml; vitamin b - ng/ ml). results: complete sufficiency were observed in infants ( . % cases), one vitamin deficiency in infants ( . %), two vitamins deficiency in infants ( . %), three and more vitamins deficiency in infants ( . %). should be used after vitamin status asses, mainly using monovitamin medication. results: patients were followed with the diagnoses of cma and asthma. age at the beginning of symptoms and start of oit were in the range of - months and - years, respectively. they had high total ige ( - iu/ml), milk spige ( . - kua/l), casein spige background: food allergies may affect up to % of school-aged children. it has been shown that approximately % of all anaphylactic reactions caused by food allergy are firstly presented at (pre) school. therefore, it is of high importance that (pre)schools have a policy on food allergy management and the use of an epinephrine auto-injector (eai). to our knowledge, limited is known on the policies of food allergy management at (pre)schools. the aim of this study was to investigate the policy on food allergy management in preschools and primary schools in the northern part of the netherlands. results: we included preschools and primary schools in this study. we showed that . % of the preschools and . % of the primary schools had a child(ren) with food allergy. only . % of the participating preschools and . % of the primary schools had a policy on allergen avoidance and only . % of the preschools and . % of the primary schools had a policy for the use of an eai. the majority of the pre-and primary schools in the northern part of the netherlands have children with food allergy. however, only a limited number of (pre)schools do have written guidelines for food allergy management in (pre)schools. additionally, there is limited experience how to use an eai at (pre)schools. therefore, an evidence-based policy on food allergy management in (pre) schools is needed. background: food allergies are the most common cause of anaphylaxis in childhood. here we present cases had anaphylaxis due to cow 's milk allergy, and treated with specific oral tolerance induction (sotİ) to cow' s milk. method: soti protocol was administered according to previously published by longo et al. skin prick test were performed according to standard methods with allergens. cow's milk specific ige was investigated with immunocap system. in all cases, the wheal size of the cow's milk in skin prick tests or the specific ige levels was higher than level of positive predictive value of %. results: case : a years old male patient who had anaphylaxis after milk consumption. soti treatment was started one year ago. there was no complications during the dose increasing phase. however, he had two episodes of anaphylaxis during the maintenance phase. in the final visit, we observed that he could drink ml milk and could consume dairy products. case : eight-year-old male patient has an intensive care-of-hospitalization story due to anaphylaxis three times after milk consumption. his accordance to strict diet was bad, and had frequent asthma attack. anaphylaxis developed times during the dose increasing phase in soti protocol. after soti treatment, he could consume ml cow's milk and dairy products without problems. case : a -year-old male patient followed-up for asthma and cow's milk allergy. it was learned that anaphylaxis developed times after milk consumption. he was fed in accordance with the milk-free diet. he has used fluticasone nebules, montelukast, mometasone nasal spray, and cetirizine. anaphylaxis developed times during the dose increase phase of soti administration. there were many mild to moderate anaphylactic episodes during the maintaining phase. after the soti treatment, he could consume ml milk and dairy products. background: cow's milk protein allergy (cmpa) is one of the most common food allergies in early childhood. small dietetic group sessions for parents of infant with non-ige mediated cmpa were held to meet increasing demands and reduce waiting times. parents were given information on cmpa, advice on weaning and milk reintroduction using a locally designed milk ladder. parents were also advised to contact the dietitians via telephone if they had further questions. we aim to evaluate the sustained effectiveness and patient satisfaction of the group sessions. method: parents and carers who attended the group dietetic sessions held between november and july were included in the survey. feedback were obtained via a self-designed questionnaire using a likert-type scale, rating several questions from (least satisfied) to (most satisfied). initial feedback was obtained directly after the session. we followed these patients up a year after the initial session via telephone and postal questionnaire. results: overall attendance rate of the group sessions held was % (n = ). during the initial survey, participants found the group session useful (mean score . out of ) and felt more confident in managing cmpa (mean score . ). we successfully obtained follow up feedback from participants. majority agreed that the group sessions have been informative (mean score . ). they also said they felt confident weaning their child on milk-free diet (mean score . ), and in reintroduction of cow's milk in diet (mean score . ). % (n = ) said that they would have preferred an individual session. % (n = ) have contacted the dieticians via telephone after the initial session, and % (n = ) had requested individual consultations. % (n = ) have attempted reintroduction of cow's milk in their child's diet using our local milk reintroduction guide. the mean age at first challenge was months (age range to months), with average of two attempts. % (n = ) have been successfully challenged and are managing well on a normal diet. we recognised the limitation in obtaining feedback via telephone and postal questionnaire, which resulted in the poor follow-up response rate. overall, parents felt more confident in managing cmpa and the positive responses were sustained a year on, highlighting the success of these group sessions. follow up opt-in sessions could be offered to provide additional support and allay parental anxiety in challenging their child with cow's milk at an appropriate age. results: goats and rabbits were immunized with specific allergoids, the allergoid-specific igg titer determined and sera pools produced. the allergoid reference material was comprehensively characterized. while ige reactivity of the allergoids was not detectable anymore, igg reactivity was maintained. allergoid-specific assay parameters as serum dilution, reference dilution and sample dilution factor to obtain at least six data points within the pseudo-linear range of the inhibition curve were determined. with these set parameters the evaluation of the analytical method was performed. the assay showed very good results in terms of linearity, accuracy, precision, reproducibility and robustness for all investigated allergoids as well as aluminum-adsorbed allergoid-preparations. conclusion: with the developed immunological inhibition assay, it is possible to determine the specific igg reactivity of allergoids in different preparations. the performance of the analytical method met all pre-defined acceptance criteria, which will be confirmed in the next step by a validation procedure according to ich-guidelines. case report: we present the case of a -year-old patient, diagnosed with rhinitis and asthma due to sensitization to pollens, as well as dyshidrosis and allergic contact dermatitis to cobalt. the patient presented a cutaneous pattern consisting of erythematous papules, some scaly, very pruritic, of initial appearance in the upper limbs - days after initiation of administration of specific immunotherapy extract (depigoid forte grasses, leti ® ). subsequently generalize lower limbs and neck. she presented them repeatedly and late after - days of the first doses administered. she referred partial control of pruritus with oral antihistamines, without total resolution of lesions for weeks. immunotherapy was suspended persisting the skin lesions for more weeks. according to the personal history of sensitization to metals, and the clinic presented in a temporal relationship with the use of an extract of immunotherapy with aluminum hydroxide, a study was requested with epicutaneous tests with aluminum hydroxide as well as with epicutaneous tests with immunotherapy extract. aluminium hydroxide and depìgoid forte grasses extract epicutaneous test were negative. in subsequent visits the patient reported that coinciding with the start of immunotherapy, presented at home and mainly in her bedroom a plague of cimex lectularius, popularly known as bedbugs, proving that they had been the cause of bites on their skin, and later skin reaction. patient reported that with the elimination of said pest the skin lesions disappeared. the administration of its immunotherapy extract was tolerated. cimex lectularius, commonly known as bed bugs, is a hemiptera insect of the family cimicidae. the clinical picture usually corresponds to multiple pruriginous lesions from the prurigo type, to multiple erythematous plaques, some infiltrated and others with a urticarial appearance, or even bullous. the lesions last for to weeks without treatment, and while the older ones heal, new ones may appear. in our patient it was not considered as an initial diagnosis, having considered immunotherapy as an etiological factor, but we must not forget that although in our country it is not a reason for frequent consultation, either due to underdiagnosis, because of the transitory nature of the pathology or because of scarce number of causative agents, it is important to consider insect bites in the differential diagnosis of dermatosis. di cara g; salvatori c; testa i; pacitto a; bizzarri i; isidori c; tarsia m; esposito s università degli studi di perugia-dipartimento di scienze chirurgiche e biomediche, perugia, italy background: house dust mites (hdm) are one of the most important allergens involved in childhood respiratory diseases, and the most frequently prescribed extract for sublingual immunotherapy in children (slit). despite the improvement of standardization methods for the production of slit, the differences in cultivation and purification processes used to produce raw materials for specific immunotherapy extracts may still impact on the final composition of mite allergen extracts. our study investigated the total protein and main allergen content of five commercial hdm sublingual immunotherapy extracts using sds-page and immunoblotting. recombinant allergens of group and group major allergens were used to test the immunogenicity of such extracts. method: hdm slit extracts were purchased from five italian suppliers (alk-abellò, allergy therapeutics, anallergo, lofarma, stallergenes). the protein composition of extracts was evaluated analysing equal volumes ( ml/lane) by sds-page ( % separating gel) and subsequent immunoblotting. for identification of allergens in the extracts, western blot analyses were performed with rabbit monoclonal antibodies (raybiotech) against der p and der p . the total protein content in the five tested commercial extracts showed a relevant variability. the protein contents ranged from . to . μg/mg for what concerns der p , while der p showed a greater variability, ranging from . to . μg/mg. sds-page showed a similar pattern of distribution in of the tested extracts, which showed protein bands of comparable intensity, while extracts showed a lower total protein count. extract showed a higher intensity band corresponding to the molecular weight of tropomyosin. western-blotting showed a similar concentration of der p in most extracts, while der p was more variable. conclusion: our analysis of five commercial extracts commonly used for sublingual specific immunotherapy against hdm showed important variations in term of total protein content. a less evident but still relevant difference was also evidenced when testing the major allergen content, with up to % variation in der p and up to a -fold variation in der p concentration. this differences, likely related to the different production and extraction methods, could still be responsible of a different immunological response in children who underwent slit. method: we evaluated children who had completed their immunotherapy treatment. along with demographic data we were able to record skin prick test (spt) results and mrqlq at start and end of treatment. we only included patients who had completed pre and post treatment questionnaires in the study to allow a comparison. the scores were evaluated using a student t test. results: patients' starting age ranged from to years (mean years). of the children had completed pre and post treatment questionnaires. all had grass pollen allergy confirmed on spt at the start of treatment. patients ( %) had isolated grass pollen allergy on spt and ( %) had multiple allergies. mean start treatment score for all patients was on mrqlq. mean score at end of treatment was , indicating a % reduction in total mrqlq score (p value < . ). for those with multiple allergies the mean total mrqlq scores were at start of treatment and at end of treatment, indicating a % reduction (p value . ). for those with isolated grass pollen allergy scores were at start of treatment and at end of treatment indicating a % reduction (p value < . ). conclusion: for children with uncontrolled symptoms of allergic rhinoconjunctivitis, grass pollen immunotherapy is associated with statistically significant improvement in quality of life. this improvement is most beneficial for patients with isolated grass-pollen sensitivity on spt. those with multiple aeroallergen sensitivities on spt did show an improvement (not statistically significant) post-treatment. grass-pollen immunotherapy is an effective treatment for rhinoconjunctivitis to offer patients in a rural dgh setting. background: allergic asthma is a common clinical refractory disease, most patients with asthma are accompanied by varying degrees of allergy. in clinical practice, treatment of this disease using specific immunotherapy has proven effective. in the current study, we examined the effectiveness of specific immunotherapy in a total of patients admitted to our hospital from to . method: to investigate the clinical efficacy of allergic asthma-specific immunotherapy. patients were selected, of which were males, aged to years, females, aged between to years old, all patients were clinically diagnosed only as allergic asthma. the patients were randomly divided into two groups, including the observation group containing cases, the control group of cases. all patients were first treated with conventional basic treatment. the observation group was subsequently treated with specific immunotherapy. both groups were followed-up and the treatment efficiency were analyzed. results: after treatment, both two groups of patients showed improvement, in the observation group, the effective rate was %, while for the control group, the effective rate was %. observation group showed significantly better outcomes than the control group. conclusion: in allergic asthma treatment, adding specific immunotherapy on the basis of routine treatment is beneficial and could be widely used in clinic. case report: atopic dermatitis(ad)is the most common itchy dermatosis that affects millions of children and adults. during recent years, diagnosis and treatment based on component resolved diagnostics (crd)is recommended. we report a -year-old boy with severe atopic dermatitis. he had positive family history of atopy. the atopic dermatitis was developed since infancy. he was referred to our clinic when he was years old. he had generalized xerosis with ulcerative eczematous lesions on his neck, popliteal and antecubital areas. he had mild eosinophilia and his serum total ige level was iu/ml. daily bleach bath, moisturizing agents, topical steroids and systemic antibiotics in addition to antihistamine were prescribed. he had multiple food and aeroallergen sensitization in skin prick test (spt). he started to eliminate some foods according to the spt results. he was suffering from recurrent relapse even after strict food avoidance; so treatment with cyclosporine was initiated for him, with partial response. crd showed sensitization to alternaria alternata (alt a specific ige: . ku/l). allergen immunotherapy by alternaria alternata was started. after accomplishment of buildup phase, he had significant improvement and we were successful to taper and finally discontinue cyclosporine. now he is on maintenance phase of immunotherapy, his skin is in optimal condition only by hydration and moisturization. result: a -year-old thai girl is a known case of severe asthma since one year old. her asthma was uncontrolled asthma even treatment with high dose combination of inhaled corticosteroid and long acting beta agonist (ics/laba), montelukast and omalizumab. spirometry revealed the force expiratory volume in one second (fev ): % predicted, fev /forced vital capacity (fvc): % predicted and % improvement of fev after salbutamol ug inhalation. allergic sensitization showed specific ige to cat: . kua/l. slit with cat allergen started at the dose of au per month and increased to au per month (scit dose is au per month) for three-year-and-six-month course. after slit, her asthma symptom improved significantly. she can exercise without exacerbation and plays sport at school. her last episode of asthma exacerbation was . year ago. her fev (% predicted) was improved from % predicted to % and the fev bronchodilator response decreased from % to %. conclusion: an improvement of pulmonary function and asthmatic symptoms of the presenting case would support the efficacy of slit of cat allergen in a patient with severe asthma. ra developed during pollen scit in this case might be related with immunomodulation effect of immunotherapy. background: we report a case of -year-old woman with allergic rhinoconjunctivitis and mild persistent asthma due to sensitisation to seasonal pollens and molds with bad clinical evolution and not response to conventional drug therapy. we decided to start subcutaneous allergen specific immunotherapy with alternaria extract in our immunotherapy unit in accordance with the guidelines of the european academy of allergology and clinical immunology (eaaci) and we used a cluster regimen. the immunotherapy was not well tolerated: the patient had two grade systemic reactions with the first dose in two attempts. method: sensitisation was diagnosed through skin prick test with aeroallergens standard panel and serum specific ige by elisa. due to the bad tolerance to immunotherapy, molds molecular diagnosis by immunocap, study of the molecular weight to specific ige binding proteins by sds-page ige immunoblotting, and cross-reactivity study by means of immunoblotting-inhibition assay were performed. a. fumigatus extract was able to produce a total ige binding inhibition on the kda band of a. alternata extract when ige immunoblotting assay was performed. conclusion: respiratory allergic disease due to alternaria is difficult to control, the use of subcutaneous specific immunotherapy could be of significant benefit. most of the allergic patients to a. alternata are sensitized to alt a , major allergen from a. alternata. however, our patient is sensitized to a kda alternaria protein due to cross-reactivity with a. fumigatus allergens, this sensitization could explain the bad tolerance to the alternaria immunotherapy. background: the association between natural pollen exposure, clinical symptoms as well as allergen-specific immune responses has not been investigated at a molecular level. our aim was to monitor the effect of seasonal birch and grass pollen exposure on clinical symptoms as well as specific b cell and t cell responses to defined allergen molecules in sensitized subjects during two consecutive years. method: grass pollen sensitized (n = ) and birch pollen sensitized (n = ) subjects were included in this study and were followed for two consecutive years ( ) ( ) . subjects were taking part in a clinical trial for the recombinant grass pollen vaccine (bm ) but did not receive immunotherapy for the allergen they were sensitized to. before, during and after the respective seasons ige and igg levels as well as t cell responses to the major birch pollen allergen bet v and the major grass pollen allergens phl p , , and were measured. pollen counts were recorded throughout the year and patients kept a daily diary including symptom medication score (sms) and visual analogue scale (vas). results: we noted that ige levels specific for bet v and the grass pollen allergens increased most in the seasons in which patients experienced the highest peak symptoms according to vas and sms but not depending on cumulative pollen counts. increases in allergen-specific t cell responses were observed in the pollen seasons as compared to shortly before the pollen seasons in the grass pollenallergic patients also in association with vas and sms but not in the birch pollen allergic subjects. no relevant changes of allergen-specific igg levels were observed during the two years observation in grass and birch pollen allergic patients. we found an association of increases of allergen-specific ige increases shortly after the pollen season with clinical symptoms in the pollen season as reflected by vas and sms which was not necessarily reflected by cumulative pollen counts in the season. these results may be important for the analysis of allergen-specific immunotherapy trials. background: the morbidity and mortality of severe asthma is much higher than that of mild to moderate asthma. this study was performed to understand the clinical characteristics of severe asthma in korea. results: data from the questionnaire showed that bronchial asthma was diagnosed before pregnancy only in women ( . %). patients ( . %) were diagnosed with chronic bronchitis at the pregestation stage. asthma attacks were experienced repeatedly during a lifetime in . % of patients, . % of patients noted long periods of dry cough at night, among them . % had wheezing. the cold did not precede the wheezing breathing in . % of patients. difficulty in breathing on waking was noted in . % of patients, at night- . %. after examination, the diagnosis of asthma was confirmed in . % of the respondents ( people). symptoms of rhinitis are noted in % of women surveyed, % of rhinitis was allergic. before examination, the diagnosis of ar was only in . % of patients. the incidence of symptoms of asthma and ar in pregnant women is significantly higher than the reported cases of these diseases, which leads to untimely initiation of treatment. method: a total of nonsmoker asthmatic patients without concomitant pulmonary pathology are recruited to our study. all patients underwent spirometry tests, measurement of fraction of exhaled nitric oxide and sputum induction to asses sputum cell counts, demographic features and current medications were recorded. using the variables of age at onset, bmi, allergy status, fev %, fev /fvc, asthma severity and induced sputum cytology cluster analysis is performed. results: clusters are identified. cluster : (n = ) early onset atopic asthma, consists of mild asthmatics with a good asthma control and lower bmi. cluster : (n = ) severe atopic asthma, consists of lowest spirometry measurements with a least act scores. induced sputum cytology shows a neutrophilic character, while having also the highest percentage of eosinophils. cluster (n = ) late onset obese asthma, nonatopic asthmatics having high spirometry measurements, with a lower act scores. cluster (n = ) nonatopic mild asthma, consists of patients with the best respiratory functions and least inflammation in means of lowest total ige, feno, sputum cell counts. conclusion: identification of asthma phenotypes in different countries will improve our understanding on the heterogeneity of the disease among the different geographies. results: results and discussion. in the course of analysis, obesity was more common in children with bronchial asthma − % than in the comparison group-in . %. obesity of the st degree was diagnosed in patients of the main group, ii degree-in , and iii degree- and iv degree-in patients e diagnosis of obesity, the sds indices of body mass index (bmi) were determined. obesitymore than + . (i degree: sds bmi . - . , ii degree: sds bmi . - . , iii degree: sds bmi . - . , iv degree: sds bmi ≥ . ). conclusion: thus, the results obtained indicate a high prevalence of constitutional-exogenous obesity in children with bronchial asthma and precedes the formation of the underlying disease e diagnosis of obesity, the sds indices of body mass index (bmi) were determined. obesity-more than + . (i degree: sds bmi . - . , ii degree: sds bmi . - . , iii degree: sds bmi . - . , iv degree: method: postal questionnaires were distributed to an unselected group of asthma patients (n = ). healthy non-asthmatic volunteers were recruited amongst university and hospital co-workers (n = ). the presence of self-reported nhr, the type of triggers evoking nasal symptoms, asthma phenotype, medication use and environmental factors were evaluated. results: patients and controls completed the questionnaire (responder rate of % and % respectively). nhr was reported in % of asthma patients and % in non-asthmatic controls (p < . ), with changes in temperature being the most important inducer of nasal symptoms ( % of asthmatics), followed by strong odours ( %) and cigarette smoke ( %). interestingly, nhr was more prevalent in patients with severe ( %) compared to mild ( %) asthma symptoms (p = . ), and more prevalent in atopic ( %) compared to non-atopic ( %) asthmatics (p = . ). most asthma patients reported more than one trigger evoking nasal symptoms, with % of patients reporting or more triggers evoking nasal symptoms. results: the mean score of cbcl questionnaire in case group with . ± . was significantly higher than in comparison with a control group with . ± . (p = . ). the mean scores of the subscales of social isolation (the case group: . vs control: . , p = . ), anxiety-depression ( . vs , p = . ), intellectual problems ( . vs . , p = . ), and aggressive behaviors ( . vs . , p = . ) were significantly higher in children with asthma than in healthy children. the study showed a significant correlation between the mean duration of asthma and a general score of cbcl (p = . , cc= . ). moreover, there was also a significant correlation between asthma severity and cbcl scoring (p = / , cc= . ). conclusion: behavioral disorders in children with asthma are significantly more than healthy children. the duration of asthma and the severity of asthma, are related to and can predict behavioral disorders in children with asthma. background: assessment of asthma control is an integral part of the management of asthma. whilst asthma control test (act) is a commonly used questionnaire to assess symptom control, its utility in predicting long term risk of exacerbation has not been well studied. aim: to analyze the factors associated with uncontrolled asthma symptoms using act and its impact on predicting future exacerbation. method: severe asthma patients on at least step background: most of the asthma-scoring tools detect the asthma severity from patients' symptoms but there is no scoring tool using parameters to define risk of asthma exacerbation. thus, this study use factor analysis to evaluate the relationship of parameters in childhood asthma. method: the descriptive study using factor analysis in asthmatic children aged less than years old, who attended thammasat university, the center of excellence for allergy, asthma and pulmonary diseases, thailand. the participants or caregivers were inter- the factors which have the major impact on asthma control are changing bed sheets less than once per month and using dust mite-proof bed sheets. this study is supporting non-pharmacological strategies but further studies are needed to create a more efficient asthmatic symptom checker. were not different between the controlled and uncontrolled group. the act score in the controlled group was significantly higher than the uncontrolled group (p < . ). the study showed that cigarette smoke is one of the significant factors that can trigger asthma exacerbation (p < . ) and mosquito repellent coil smoke is also significantly associated with asthma exacerbation (p < . background: experimental studies have demonstrated that tumor necrosis factor family member (tnfsf /light) plays an important role in airway remodeling. there is little data available concerning in vivo regulation of tnfsf /light expression in humans. the aim of this study was to evaluate serum concentration of tnfsf / light in different subsets of asthmatic patients. the study was performed on nonsmoking asthmatic patients (a), including mild-moderate-severe asthmatics controlled on inhaled corticosteroids (aics) and asthmatics evaluated twice during asthma exacerbation (aex) and during subsequent remission (arem). in addition age and sex matched nonsmoking healthy controls were included (hc). serum tnfsf /light concentration was evaluated using elisa method. in asthmatic patients lung function tests, exhaled nitric oxide concentration (feno), serum total ige concentration (t-ige), allergen-specific ige concentration (s-ige) and peripheral blood eosinophilia were evaluated. ( + /- pg/ml) was significantly greater than that in hc ( + / - pg/ml; p < . ). among all asthmatic patients studied the greatest tnfsf /light serum concentration was demonstrated in aex ( + /- pg/ml), which was significantly greater than that in aics ( + /- pg/ml p < . ). during resolution of asthma exacerbation a significant decrease in serum tnfsf /light concentration ( + /- pg/ml; p < . ) was demonstrated. in arem the mean serum tnfsf /light concentration was comparable to that seen in aics (p = . ) but was still significantly greater than in hc (p < . ). no significant correlation could be demonstrated between serum tnfsf /light concentration and baseline lung function parameters, exhaled nitric oxide concentration, serum t-ige or s-ige concentration or peripheral blood eosinophilia. conclusion: enhanced production of tnfsf /light seen in asthmatic patients, which is further upregulated during asthma exacerbations may play an important role in asthma pathogenesis. method: two models of aspergillus fumigatus-induced allergic airway inflammation were used in the study: long terms ( weeks) and short terms ( weeks background: chalcone is identified as an inhibitor of the interaction between cxcr or cxcr and their ligand cxcl . therefore it is called a neutraligand. the chemokine cxcl , interacting with the cxc-receptor (cxcr ) can play a role in the progression and development of bronchial asthma. asthma is defined as a chronic disease characterized by episodes of obstructive events which affects about million people over the world. the aim of this study is to approach the mechanism of the anti-inflammatory effect of the cxcl neutraligand chalcone and also to assess its impact on the migration of dendritic cells in a murine model of allergic airway inflammation. method: chalcone is administered intranasally to balb/c ovalbumin (ova) asthma mice and control groups as well. our results indicate that the cxcl neutraligand chalcone can modify the inflammatory reaction in an airway allergic hypereosinophilia model. furthermore, found out that cxcl neutraligand chalcone prevents dc migration to the airways and airway jnc ganglia during allergic airway inflammation. the detection of the cxcr -cxcl pathway and its role in the pathophysiological actions of asthma offers a promising target for allergic diseases treatments. method: four groups of balb/c mice were defined: control and asthmatic, with and without treatment. asthmatic groups were sensi- overexpression of ptgdr in pulmonary cells associated to a generalized increase of cytokine expression. conclusion: in a mouse model we confirmed the involvement of ptgdr in allergic asthma by the increase of its expression levels after ovalbumin sensitization. we also identified a reduction of ptgdr levels in response to dexamethasone treatment. the in vitro model suggests that ptgdr induces an inflammatory response, increasing the cytokines levels. | immune imbalance between transcription factor t-bet/gata and allergic asthma results: t-bet mrna expression of peripheral blood lymphocytes in patients with allergic asthma was lower than that of the normal control group, and the expression level of gata- mrna was higher than that of the normal control group (p < . ). the th percentage of peripheral blood lymphocyte subsets was lower than that of the normal control group (p < . ), the percentage of th cells was significantly higher than that of the normal control group (p < . ), and the changes in t-bet/gata expression and th /th ratio was highly correlated. our objectives were to assess the changes of bmp and bmp serum levels in the response to allergen and methacholine challenge tests and the correlation between bmp and bmp serum levels and fev before and after allergen and methacholine challenge tests. method: study group consisted of patients with asthma and healthy volunteers. spirometry, skin prick tests, allergen and methacholine challenge tests were performed in compliance with eaaci, ers and ats guidelines. personalized clinic surveys including act ™ were performed. venous blood was collected before and after hour, and hours afterwards the provocation to edta-ke-filled test tubes. evaluation of bmp and bmp serum protein levels was performed using specific elisa immunoassay kits according to the manufacturer's protocol. results: the increase in bmp and bmp serum level hours after provocation test correlates significantly with the concentration methacholine during provocation time (p < . ). bmp serum level before the provocation, hour and hours after provocation, correlates negatively with fev change (p < . ). the median bmp level hours after provocation was significantly lower in patients with negative methacholine challenge test compared to the control group (p = . ). the median bmp level hours after provocation was higher in patients with positive allergen provocation test than in patients with negative test results (p = . ). the bmp serum level hours after positive methacholine test is lower and correlates inversely with fev change in every time point, which could indicate that serum level of bmp is a predictive factor of fev change. the higher bmp serum level, the lower fev change was observed. this could suggest the protective influence of bmp in patients with obstructive pulmonary disease, i.e. asthma. the higher bmp serum level hours after positive allergen provocation test result shows that the bmp could be an indicator of the response to a specific trigger. background: inflammation and coagulation are closely linked events. thrombin is the key enzyme in coagulation system. besides its well-known functions in hemostasis, thrombin plays a role in inflammation. the aim of our study was to evaluate thrombin generation in children with mild asthma and demonstrate associations between thrombin levels and control of asthma. method: forty-two children with mild asthma and forty-nine healthy children included in the study. asthmatic children had no asthma exacerbation during the last months. patients (n = ) who had mild persistent asthma, were using either inhaled steroid or montelukast. all patients performed spirometry. thrombin levels were measured by thrombin generation test. thrombin peak levels, endogenous thrombin potential, thrombin lag time, time to thrombin peak and thrombin tail time were recorded. results: thrombin lag time was significantly longer in children with asthma ( . ± . ) compared to those in control group ( . ± . ) (p < . ). children with asthma also had longer thrombin tail time compared to control group ( . ± . vs . ± . , p = . ). thrombin peak was inversely correlated with fef - (- . , p < . ). thrombin lag time was inversely correlated with fef - (- . , p < . ). thrombin generation parameters did not show difference according to asthma control treatment, asthma control scores and having atopy. conclusion: coagulation/anticoagulation balance is disturbed in mild asthma but this disturbance may not be as strong as to increase thrombin levels. factors increasing inflammation may cause an increase in lag time, and increase in inflammation and excessive fibrin deposition may contribute to airway narrowing. background: cytokines represent key mediators in the onset and persistence of inflammatory process, in both asthma and copd. il- , which belongs to il- family, it might act in a similar way with il- at the beginning of the inflammatory process. its role in atopic skin diseases has already been demonstrated, but there are conflicting results related to its role in respiratory allergic diseases. the aim of the study was the evaluation of il- plasmatic level in patients with asthma and copd and the its correlation with clinical and lung function parameters. method: fifty consecutive patients with bronchoobstructive diseases were included in the study. thirty-two patients presented asthma and patients had copd. the evaluation included: number of exacerbation in the last year, disease's severity, spirometry. plasmatic levels of il- and il- were determined in all patients. results: the mean age was higher in patients with copd dermatophagoides pteronyssinus [house duste mite (hdm), ug/ mouse] were administered oro-tracheally on days , , , , , , and . at was performed in a treadmill during weeks in moderate intensity, from day until day . results: at inhibited hdm-induced total cells (p < . ), eosinophils (p < . ), neutrophils (p < . ) and lymphocytes (p < . ) in bronchoalveolar lavage (bal), and eosinophils (p < . ), neutrophils (p < . ) and lymphocytes (p < . ) in peribronchial space. at also reduced bal levels of il- (p < . ), il- (p < . ), il- (p < . ), cxcl (p < . ), il- (p < . ), il- (p < . ), il- (p < . ), while increased il- (p < . ). airway collagen fibers (p < . ), elastic fibers p < . ) and mucin (p < . ) were also reduced by at. at also inhibited hdm-induced airway hyperresponsiveness (ahr) to methacholine . mg/ml (p < . ), . mg/ml (p < . ), mg/ml (p < . ) and mg/ml (p < . ). mechanistically, at reduced the expression of stat (p < . ), stat (p < . ), stat (p < . ) and jak (p < . ), similarly by peribronchial leukocytes and by airway epithelial cells. socs expression (p < . ) was upregulated in leukocytes and in airway epithelial cells, socs (p < . ) was upregulated in leukocytes and socs down-regulated in leukocytes (p < . ) and in airway epithelial cells (p < . ). conclusion: at reduces asthma phenotype which is followed by positive modulation of socs-jak-stat signaling in peribronchial leukocytes and in airway epithelial cells. rodolfo a ; paciência i ; rama t ; leão l ; silva d ; rufo j ; mendes f ; padrão p ; oliveira fernandes e ; moreira p ; delgado l ; moreira a porto, portugal; potentially irritating chemicals that may have a cutaneous drying side effect. this study aimed to evaluate if skin barrier function, as measured by transepidermal water loss (tewl), is affected by a training session in swimmers compared with football players. environment impact on the human respiratory health (clinicaltrials.gov identifier: nct ) and football players were invited to participate. due to the lack of prior information no sample size calculation was possible and all athletes that provided informed consent were included in the analysis (n = , females, aged to years). tewl was measured using the tewameter ® tm before, immediately after, and minutes after a hours training session. the probe was held on the dorsum of hand, the volar forearm and the antecubital flexure for s. the average of two consecutive measurements was recorded. non-parametric statistic was used were appropriate. ethical approval was obtained from the university clinical research ethics committee and informed consent provided. results: mann-whitney u test showed significantly higher baseline median tewl level on football players hand's dorsum compared with swimmers, median (p -p ) respectively . ( . to . ) and . ( . to . ); p = . . friedman test revealed a significant effect of swimming on tewl on the hand's dorsum, volar forearm and antecubital flexure (p < . ) while football training affected only the hand's dorsum (p = . ). differences in changes after swimming and football training were significant only for tewl in volar forearm (p = . ). in conclusion, our exploratory findings do not provide support for a specific deleterious effect of swimming, compared with football training, on the training induced changes in tewl. background: exercise-induced bronchoconstriction (eib) is defined as transient, reversible airway narrowing occurring during or after exercise, is common among elite athletes and associated with epithelial damage. however, little is known about the existence of eib in young athletes. the goal of this study is to investigate the presence and to evaluate potential (bio)markers of eib in young high-school elite athletes in different sport disciplines versus age-matched control subjects. method: high-school selected elite athletes ( - years) from different sport disciplines: basketball (n = ), football (n = ) and swimming (n = ) performing at least hours of sport per week (median= h) and control subjects (performing less than hours of sport per week) were recruited. the eucapnic voluntary hyperventilation (evh) test was performed according to ats guidelines and adapted for this age group. lung function was measured before, immediately after and , , minutes after the evh test. the test was considered positive if a maximal fall in fev of % was measured on at least one time point and exhaustion was excluded. a blood sample was obtained at baseline. sputum induction and skin prick test for the most common allergens were performed after the evh test. results: fifteen swimmers had a positive evh test ( . %), which is higher than in basketball players ( . %), football players ( . %) and controls ( . %). . % of the swimmers were atopic which is also higher than in basketball players ( . %), football players ( . %) and controls ( . %). serum clara cell secretory protein (cc ) levels are significantly higher in swimmers ( . ± . ng/ml) compared to indoor athletes ( . ± . ng/ml) and controls ( . ± . ng/ml). a significant positive correlation was found between the magnitude of maximal fall in conclusion: young elite swimmers have a higher prevalence of eib compared to basketball and football players. atopy and/or chlorine is a risk factor for the development of eib in young elite athletes. cc levels and sputum uric acid levels are increased in athletes compared to control subjects suggesting the presence of epithelial damage already at young age. this is especially observed in young elite swimmers, pointing to a probable role of exposure to chlorineby-products in combination with intensive exercise. results: data from subjects ( females, . %) were analyzed. frast was positive in ( . %) patients ( females, median age of years (iqr - )). in this group, ( . %) had a previous diagnosis of asthma, ( . %) practiced federated sports, ( . %) had smoke cigarette exposition and ( . %) had a bmi > kg/m . . % of patients showed a Δfev % > % in the first minutes after finishing the challenge. median fev reduction was . % ) and ml . frast was more frequently positive in patients with previous diagnosis of asthma (p < . ). there were no differences related to conclusion: frast is an important tool to diagnose exerciseinduced bronchospasm without asthma (eib wa ), as well as to diagnose asthma. in our study, frast was fundamental to access eib wa in % of patients with rsee, and confirmed asthma diagnosis in % of cases with previous asthma diagnosis and negative sbt. there was no difference in the prevalence of atopy between patients with positive and negative frast. patients older than years-old presented higher Δfev % compared to younger patients (p = . ). higher levels of feno were observed in patients with positive frast (p = . , p = . ), both in patients with and without previous diagnosis of asthma. a positive correlation was observed between feno levels and Δfev % in the whole sample (r = , p = . ); when these data were analyzed considering a previous diagnosis of asthma, only patients with this condition showed a positive correlation of feno and Δfev % (r = . , p = . ). conclusion: our results evidenced that higher feno was associated with atopy and a positive frast, both in patients with and without previous diagnosis of asthma. higher feno seems to correlate with Δfev % in patients with previous diagnosis of asthma. background: specific immunotherapy is the casual treatment for allergic rhinitis. a year old professional footballer suffer from severe allergic rhinitis since two years. during may, june and july his level of playing, concentration and durability decreased about %. patient was complaining of runny nose, nasal blockage, each eyes, sneezing, tearing. method: we did skin prick tests -which showed greatest allergy to grass pollen. we confirmed the allergy by specific ige and nasal provocation tests. spirometry was done-fev %. the patient was qualified to undergo specific immunotherapy. however, because of his profession, it was hard to find a day without trainings to get the vaccine. after long discussion, patient decided to start specific immunotherapy-scit. results: the patient start the immunotherapy. he was attuning very irregularly, because of matches, injuries, trips, trainings, and lack of time. several times we had to call the patient to remind him about the immunotherapy. after one year of scit the patient felt big improvement. during grass pollen season he suffered from mild allergic symptoms, and just for few days. after next year of immunotherapy, the patient had no symptoms of allergic rhinitis during the grass pollen season. however, it was the reason for him, to stop sit, before rd year of immunotherapy. conclusion: such a treatment-specific immunotherapy-is a burdensome method for both, for professional athletes and doctors. such a patients need to be on special observation, and cooperation with trainers must be obtained, if we want to see results. to improve compliance we have to keep in touch with patients, to remind them about next visit. gherasim a ; choual i ; radu c ; khayath n ; beck n ; jacob a ; schoettel f ; domis n ; de blay f alyatec, strasbourg, france; hôpitaux universitaires de strasbourg, strasbourg, france background: late allergic response (lar) is a good asthma model. it has been shown, in individual challenge tests that mite allergen induces more frequently late allergic responses (lar) than cat allergen. the aim of this study is to compare the frequency of lar in asthmatic subjects allergic to mite with asthmatic subjects allergic to cat. method: asthmatic subjects allergic to mite were compared to subjects allergic to cat (gina or ). the subjects had prick tests≥ mm compared to the negative controls and specific ige ≥ . ku/l. the dose selected for the mite and cat allergen was the airborne allergen concentration inducing the most frequently early asthmatic response (ear) (a % drop in fev ) and lar (a % drop in fev ). results: the frequency of lar with mite allergens was . % and % with cat allergens (p = . ). the frequency of ear for mites was . %; of . % for ear or lar, and % for ear and lar. in contrast, with cat allergens, % of patients had an ear, % had ear or lar and % had an ear and lar. no significant differences was observed between cat and mite allergen regarding the severity and the time necessary to obtain an ear and lar. no significant differences was observed between cat and mite allergen regarding the severity and the time necessary to obtain an ear and lar. the frequency of lar in asthmatic subjects allergic to dust mite exposed in alyatec ® eec was higher than in asthmatics sensitized to cats. our results confirmed previous results with individual bronchial challenge. therefore, it appears that the mite model is more interesting in the study of asthma. exposure chamber in strasbourg (alyatec ® ) in asthmatic patients allergic to cat allergens gherasim a ; choual i ; radu c ; khayath n ; beck n ; jacob a ; schoettel f ; domis n ; de blay f alyatec, strasbourg, france; hôpitaux universitaires de strasbourg, strasbourg, france background: as recommended by the task force on environmental exposure chamber (eec), allergenic and non-allergenic exposure must be better controlled in eec. it is the aim of alyatec's eec. the aim of the study is to validate alyatec's eec by determining the concentration of fel d inducing % of early asthmatic response (ear) and/or late phase asthmatic response (lar) in subjects sensitized to cat. method: it was a randomized, double blind, cross-over study including group a: asthmatic subjects allergic to cat and group b: asthmatic subjects allergic to another allergen. all subjects were first exposed to placebo. group a was exposed to fel d concentrations. the number and size of particles were recorded online during the exposure. group b was exposed to the concentration of fel d which fulfills the objective of the study. the mean age of subjects was years (± ). for the concentrations of fel d , we obtained more than % ear and/or lar. the mean time necessary to obtain an ear was: . ± minutes and . ± minutes for the lar. the mean fall in fev during ear and lar was − . % and − . % respectively. we didn't observe any severe reaction. no subjects in group b experienced any symptoms during exposure. we have validated alyatec's eec in asthmatic subjects allergic to cat allergens. we also demonstrated its specificity. background: the best test and strategy for diagnosing asthma especially in those patients with negative bronchodilator reversibility tests still remains unclear. in this study we aimed to investigate the diagnostic yield of peak expiratory flow (pef) variability for the patients with symptoms suggesting asthma but negative bronchodilator reversibility tests. method: subjects referred to our outpatient clinic with suspicion of asthma were enrolled in this study. demographics and referral symptoms were recorded, asthma control test (act) scores and health related quality-of-life scores (aqlq, sf ) were calculated. monitoring of pef variability during -weeks and bronchial challenge test with methacholine (bpt) were analyzed. asthma was diagnosed by having pef variability ≥ % and/or positive bpt. results: thirty out of enrolled patients were diagnosed as having asthma. when we compare asthmatic patients with nonspecific respiratory symptomatic subjects there were statistically-significant differences regarding to wheezing (p = . ), activity limitation (p = . ), total symptom score (p = . ) and basal fef (p = . ) in the favor of asthma cases. multiple logistic regression analysis revealed that lower basal fef - was an independent predictive factor of asthma diagnosis (p = . ). when the bpt positivity was assessed as gold standard for the diagnosis of asthma, the sensitivity and specificity of pef variability for different cut-offvalues (≥ %, > % and >% ) were . - . %, . - . % ve - . %, respectively. conclusion: fef - is an important diagnostic parameter for asthma. although current guidelines recommend pef variability of % for the diagnosis of asthma in general, this cut off level may not be appropriate for this defined group of subjects. our results suggest to use a cutoff level of > % while excluding asthma and ≥ % while confirming the diagnosis of asthma for patients with asthma suspicion but without shown reversibility. de barayazarra s background: in recent years obesity has been considered as a factor that contributes to the development of asthma, increases exacerbations and leads to poor control of it due to resistance to drugs to control this pathology. it is known that obesity produces chronic systemic inflammation; one of the markers that are affected is the levels of c-reactive protein (crp), which are increased. objective: evaluate, lung function, the use of medications to control asthma and systemic inflammation, after bariatric surgery. results: obese asthmatic patients with surgery, non-asthmatic obese patients with surgery, obese asthmatic patients without surgery. a significant difference was found between the severity of obesity and forced expiratory volume in patients with asthma and without asthma of second (fev ) before surgery with an average of . % at the beginning of the study and . % at months (p: . ). in the non-operated group, fev at the beginning was % and . % at months (p: . ). the crp, before surgery in all operated patients had crp: , at months after surgery they became negative, crp: (p: . ). in obese asthmatics with surgery at the beginning, % used medication, and at months only % in obese asthmatic patients without surgery, . % used the medication at the beginning, at months . % (p: . ). method: patients with asthma aged to and a predetermined positive methacholine pc were recruited and underwent a single challenge to cause bronchoconstriction of~ % comparing the outcome of the device with spirometry. the subjects were monitored at baseline, after a~ % fall in fev and after bronchodilation back to baseline. the study protocol allowed for an interim analysis of the initial subjects at which point the sensor was calibrated to optimise sensitivity. a further subjects were studied using the optimised sensor. results: all subjects successfully completed the study. the device was found to be straightforward to use by both operator and subject with no concerns regarding safety. the initial sensitivity of the device was found to be suboptimal in the first eight patients to reliably detect changes in lung function. after adjustment to the device the tests results of the remaining subjects were analysed. . % of subjects were female. the mean age of all subjects was . years. an average baseline fev value of . (s.d. . ) was observed. changes in lung function were detected in % of subjects. a baseline value, drop in lung function and reversal were measured in % of subjects. the mean percentage drop observed in % of subjects using the investigational device was . %. the mean percentage increase observed using the investigational from drop to reversal was . %. the device (using ebc ) was able to detect changes in lung function tracked using fev . this provided proof of concept that the device could potentially be used to monitor lung function more effectively in the home than peak flow and supports further development to optimise the device and demonstrate functionality in clinical asthma. method: ninety four patients under years of age seen in the allergy department due to common asthma symptoms (wheezing, dyspnea, cough, chest tightness) with normal spirometry and negative bronchodilator response, underwent mct during and . the variables studied were: sex, age, body mass index (bmi), asthma symptoms, exercise symptoms, rhinoconjunctivitis, family history of atopy, sensitization to respiratory allergens, spirometric data and fractional exhaled nitric oxide (feno). results: of the total sample, half were women ( . %) and the other half were males ( . %). mean age was . years. bmi was normal in most of them (with an average of . kg/m ). the most common symptom among the patients with positive mct was cough ( . %), followed by dyspnea ( . %), wheezing ( %) and chest tightness ( . %). . % had symptoms of asthma with exercise and . % had rhinoconjunctivitis. . % had a family history of atopy. . % were sensitized to aeroallergens, mainly to pollens (grass and olive tree). . % of the mct′s were positives, with a mean pc of . mg/ml. . % had a moderate-severe result (pc ≤ mg/ml), . % mild (pc - mg/ml) and . % bordering (pc - mg/ml). the mean feno was . ppb. conclusion: in our series, the completion of a test of hrb was decisive to confirm the diagnosis of asthma in most patients of a pediatric population with symptoms of suspicion (cough, mainly), normal spirometry and negative bronchodilator response (with normal feno in most of them). therefore, we consider it important to include in the routine clinical practice hrb tests in the pediatric population with suggestive symptoms of asthma, despite normal functional and/or inflammation tests. | cut-points of the ′control of allergic rhinitis and asthma test′ (carat) asthma subscale based on an international survey patients with asthma) in kashan, iran. the data collection tool was a questionnaire with questions, designed to gather information on demographic asthma patients, the current use of mobile functionalities, and the willingness to use these functionalities to receive selfmanagement services, which was distributed among patients with informed consent. the collected data were analyzed by descriptive statistics method using spss software. results: the most use of patients from mobile phone functionalities was to receive information about asthma symptoms and allergens and irritants via mobile internet ( . %). patients were most likely to use social networking ( . %) in comparison with other mobile phone functionalities, to receive reminders about appointments and medication. the respondents were most likely to use social networks through mobile phone functionalities, to receive asthma self-management information ( . %), to communicate with other patients ( . %), to receive reminders about medication use, and to perform a peak flow meter test ( . %) and to get an alert when the asthma is not controlled ( . %). the findings show that asthma patients are currently using the internet search for educational information and they have a tendency to use social networks to receive asthma-related services. patients believe that mobile health is an appropriate intervention for providing educational information, reminders, and alerts and communication with other patients. | concordance between the determination of asthma control through the gina guidelines and the act questionnaire-results of the efimera study background: the exacerbation of asthma, progressive worsening of acute episodes, is one of the most frequent attending reasons at hospital emergency unit . several factors causing poor control of asthma, such as inadequate therapy, have been described. in the present study, estimations of asthma severity by researchers were assessed by comparing the concordance between the assessment of asthma control through the gina guidelines and the act questionnaire method: cross-sectional observational study on the evaluation of factors related to treatment that influence the poor control of asthma was assessed through the gina guidelines and the act questionnaire. patients referred to a pneumologist or allergist by a primary care for the first time were evaluated. two variables were collected for the assessment of asthma control: one derived from the gina guidelines and another derived from the act questionnaire. regarding the gina assessment, researchers' evaluations guidelines were compared with the scoring calculated from the variables registered in the crd. both measures were compared in terms of sensitivity-specificity to determine their ability to classify patients. the patients included in this study (n = ) had a mean age of ± years, with a % of women and an average disease evolution of . ± . . the control of asthma according to "gina results: pts were reasonably representative of those in sls asthma (at sls baseline: . % male; mean age . yrs; mean asthma control test [act] score . ) . the most frequently reported symptoms during sls asthma for these pts were cough/ breathlessness, followed by wheeze, phlegm and chest tightness; breathlessness and wheeze were perceived as the biggest impactors on pts' lives. the aspects of daily life most impacted by asthma were reported as walking at a hurried pace, strenuous physical activity, and asthma-related frustration. since sls began, % of pts in this subset reported improvements in overall asthma ( % no change; % worsening). perceived changes in symptoms are shown (table) . most pts ( . %) reported avoiding places with dust, smoke or fumes. most pts ( . %) perceived no change in overall qol; . % reported improvement. being an act responder during sls (total act score ≥ or ≥ change at end of sls) was associated with reported improvements in overall asthma symptoms, lower impact of asthma on qol, and higher perceived confidence/control in managing asthma. more pts ( . %) in the ff/vi arm reported an overall improvement in asthma vs uc ( . %); the most evident differences between treatment groups were for breathlessness, wheezing and chest tightness. improvements in confidence/control in managing asthma were reported by . %/ . % of pts (ff/vi) vs . %/ . % (uc). conclusion: breathlessness and wheezing were key symptoms in sls asthma and had the biggest impact on pts' daily lives. this patient-centred study enriches the findings of sls asthma. funding: gsk (study ) | asthma and copd treatment adherence and breach using tai questionnaire suarez-vergara m; fuentes-soltero f; garcia-nunez i; ignacio-garcia j background: adherence is defined as medication (inhalator) intake following the dosage and schedule prescribed. adherence mistakes are a public healthy problem according to the big morbi-mortality presented in patients with an incorrect intake. our aim is to evaluate the adherence level and fulfillment in patients with asthma or copd using tai (inhalators adherence test) questionnaire. method: patients with a diagnosis of persistent asthma or copd were selected. we used to size adherence and breach type the tai questionnaire. adherence is defined as good when patient′s test reaches points, medium ( - points) and bad (less than points). breach type is defined as erratic when points between questions to are less than , deliberate when questions to are less than , and unconscious when questions and are less than points. a correct fulfillment is defined when questionnaire reaches points plus points of conscious fulfillment. results: fifty-five patients more than years old (mean age . years and . % males) were selected. a . % of them were asthmatics, . % copd and . % a mix phenotype. a . % presented a correct fulfillment with conscious fulfillment, and the other . % presented good, medium or bad adherence with a breach type. according to adherence level, a medium adherence was defined in patients ( . %), with an erratic mistake in patients ( %). bad adherence was seen in patients ( . %) , with the three breach types in patients ( %). good adherence with unconscious breach type was defined in patients ( . %). conclusion: tai questionnaire confirms a good adherence and fulfillment in less than % patients. an erratic mistake is the most frequent breach type defined in our patients. educational protocols should be applied to improve adherence and fulfillment. | what is adhesion to treatment of asthmatic patients like in argentina according to the tai questionnaire? background: asthma is a chronic inflammatory disease of the airways, which requires an adequate treatment and control. the adhesion of a patient to an asthma treatment is a critical factor in order to achieve and maintain control. this adherence arises from a consensual agreement of the doctor-patient relationship; it is a complex multifactorial variable in which the variability in human behaviour in relation to its environment influences. background: the association between ambient pollen and asthma has been studied intensively with inconsistent results, attributed to differences in study population, geographic factors (geoclimatic features), data sources, measurement of pollen (different types of traps), and different outcome occurrence (hospitalizations or emergency department visits). we investigated the associations between daily sales of short-acting β -agonists (saba) and outdoor pollen concentrations in the central france area. the relationship between daily changes in pollen concentrations and daily saba sales obtained from the social security database was analysed with generalized additive models, taking into account confounding factors such as air pollution, weather conditions, and day of the week. results: the daily saba sales (mean, sd) rose from . ( . ) conclusion: this study indicates that outdoor pollens contribute to asthma morbidity in the general population. it confirms the highly allergenic role of fraxinus, betula and quercus pollens, but also shows a relatively unknown association between treated asthma and carpinus and platanus pollens, despite their counts being less than % of overall pollen concentration. results: of asthma patients (mean age . years, female . %), regular ocs use was identified for patients ( . %), periodic ocs use for patients ( . %), and no ocs use for patients ( . %) -year post-index. regular ocs users had a greater mean age, were more often male, and had greater eosinophil counts, lower lung function, and greater prevalence of comorbidities than did the periodic and no ocs users (p < . ). total yearly cost was greatest for the regular ocs users (€ ), followed by periodic ocs users (€ ) and no ocs users (€ ) (p < . ). among regular ocs users, hospital admissions were the main cost driver ( . % of total cost), while gp consultations were driving the total cost in periodic and no ocs users ( . % and . % of total cost, respectively). conclusion: in this sample of patients with asthma in sweden, the total yearly cost of health care resource utilization for a regular ocs user is twice as high as for a patient with no ocs use, demonstrating substantial economic and clinical burden in asthma patients on regular oral steroid treatment. method: children with physician-diagnosed asthma who attended to an outpatient pediatric allergy and asthma center were enrolled in the study along with control subjects. asthma severity and control status of the patients were evaluated according to recent gina guidelines. laboratory investigations including skin prick tests, complete blood counts with differential, total ige levels, serum periostin levels and pulmonary function tests were performed. results: a total of children ( with asthma and age and sex-matched control subjects) with a median age of . years (range . - . ) were enrolled. asthma severity was mild in ( . %), moderate in ( . %) and severe in ( . %) children. children with asthma had significantly higher periostin levels than controls ( . ± . vs . ± . ng/ml; p < . ). the mean serum periostin levels of children with severe asthma ( . ± . ) were significantly higher than in children with moderate asthma ( . ± . ) and mild asthma ( . ± . ) (p < . ). serum periostin levels were found to be significantly correlated with asthma severity (spearman's rho [r]=. , p < . ). analysis using roc curves identified the role of periostin levels in determining children with severe asthma (auc: . , % ci: . - . , p < . ]. conclusion: serum levels of periostin, a novel asthma biomarker, were higher in asthmatic children, and were associated with asthma severity. adam i ; selevestru r ; rogut v ; sciuca s background: nowadays, data from several epidemiological studies confirm the important role of fungi in respiratory disease in the indoor as well as in the outdoor environment. in general, exposure to fungi occurs via inhalation, skin contact, or ingestion. alternaria alternata is one of the most common fungi associated with presence asthma and persistence and severity of asthma. although exposure to a. alternata is also may represent a risk factor for development of asthma. in ukraine has been an increase in the number of the mold sensitized children for the last few years. at the same time we can see increasing frequency ba at the children of pre-school age. method: thirty five children aged - years with allergic rhinitis and high level of asthma predictive index (api) sensitized to a. alternata were included in a -year cohort study of the efficacy and safety of slit (diater laboratories, spain) using standardized sublingual extracts containing molds (alternaria alternata). treatment efficacy was analyzed using the score of symptoms such as difficulty in nasal breathing, rhinorrhea, sneezing, itching of the nasal mucosa (upper palate) and discharge from the nose and recurring wheezing. we also have analyzed the level api during the period investigation. symptoms were measured before starting treatment, and at , and months after starting immunotherapy. results: slit significantly reduced both symptoms and medication score: nasal symptoms ( % vs. control group) and the use of rescue medications ( % vs. control group), and improved fev (in children aged≥ years). in the slit group, api decreased by % for the first year, by % for the second year. no patient had a systemic reaction during therapy. our results have shown that slit is an effective treatment in pediatric patients suffering from allergic rhinitis and high api with significantly improved clinical outcomes (less symptoms and less medication intake) in comparison with children treated with symptomatic drugs only. in this study, large and statistically significant differences in symptom and medication scores were demonstrated in patients receiving slit compared to control group. sublingual immunotherapy is effective for allergic rhinitis in children especially early age and is generally advantageous because of the convenient administration and safety profile and ensure prevention of developed ba. bednarek a background: the classification of asthma based on the severity of its clinical course has been recommended by gina since . this division is useful for the patient's initial assessment when asthma is being diagnosed and essential decisions concerning an appropriate therapy are made. the objective of the work is to evaluate the influence of a clinical form of asthma on vaccine immunity in preschoolers following three years after the programme of mandatory vaccination has been realised. the study encompassed preschool children (mean age of . ± . years old) with asthma being newly diagnosed, including patients with mild asthma and ones with moderate asthma, whose vaccine immunity (igg specific antibody titer) was assessed after the mandatory early childhood vaccines had been administered. monovalent vaccines (hbv+ipv+hib) along with a three-component combined vaccine (dtwp) were given to children while a six-component vaccine (dtap+ipv+hib+hbv) was given to the remaining children. the vaccine doses were consistent with the polish immunisation programme and manufacturers' recommendations. the elisa immunoenzymatic method was applied to assess titer of specific antibodies to diphtheria, tetanus, pertussis, poliomyelitis and h. influenza type b. the level of hbv antibodies was measured chemiluminescently. the immunity class for particular vaccinations was assessed according to the test manufacturers' instructions. results: children suffering from mild asthma had considerably more frequently vaccinations on time (p < . ) and the type of vaccines (monovalent, highly-combined) administered to them did not have a significant influence on a clinical form of asthma in the children examined (p > . ). apart from the vaccines against hepatitis b and rubella where considerably more frequently a high antibody titer occurred in children with mild asthma, the titers of antibodies to other vaccines, namely diphtheria, tetanus, pertussis, hib and mumps, were not associated with a clinical form of asthma. the protective antibody titers in the children with asthma were found in % after vaccinating them against poliomyelitis (≥ u/ ml) and measles (≥ ml u/ml). significantly higher current weight was solely found in the children with mild asthma (m = . , sd= . ; p < . ). conclusion: there are some clinical and cultural differences among the four southern chinese cities within the canton province. this study identifies potentially modifiable environmental and treatment factors associated with poor asthma control and qol for healthcare interventions. having a smoker in the family is independently associated with poor asthma control and qol. were classified into two groups (levocetirizine group (l) and montelukast group (m)) and we treated each group for another week. to evaluate the therapeutic effectiveness, we used symptom score (ss) and ebc leukotriene e (lte ). ebc samples were collected with rtube. each parameter was checked at , , week therapeutic period. results: most ar patient showed clinically improvement with and week fluticasone therapy ( wk ss= . , wk ss= . , wk ss= . p < . in l group; wk ss= . , wk ss= . , wk ss= . p < . in m group). lte levels of ar were higher than control ( wk vs. pg/ml), and were reduced after week fluti- mic were: md allergic rhinitis, wheezing apart from colds, eosinophilia ≥ %. outcome was defined as md asthma and at least episode of asthma during the previous year or more than episodes of wheezing during the months regardless of asthma diagnosis. results: from a total of of parents approached, ( %) agreed to participate in a phone interview. ( %) children were diagnosed with asthma. the age at the time of admission (mean, abstracts | (sd)) was . ( . ), at the time of phone survey . ( . ) months, respectively. positive loose api at - years of age had sensitivity of . %, specificity %, positive predictive value (ppv) . %, negative predictive value (npv) . %. positive stringent api at - years of age had sensitivity of %, specificity %, ppv . %, npv %. background: asthma is the most common chronic airway disease in childhood, with a high unmet need for new treatments due to insufficient symptom control in a relevant percentage of patients. ethics and resource factors limit the feasibility of large, long pediatric trials required to assess outcomes such as exacerbations and symptoms. for diseases like asthma, where the disease process is largely similar in children and adults, with the same expected therapy outcome, the international council for harmonisation advise extrapolating adult data to those of a younger age, reducing unnecessary pediatric trials. here we assess the partial extrapolation used in the clinical development of tiotropium. phase trials in adults (aged - ), adolescents (aged - ) and children (aged - ) with symptomatic severe (primotina-/pensie-tina-/vivatina-asthma) or moderate asthma (mezzotina-/rubatina-/ canotina-asthma), respectively. trials lasted - weeks, all with tiotropium respimat μg add-on vs placebo as two puffs once daily. results: in adult trials, lung function, symptoms and exacerbation endpoints were evaluated in a confirmatory manner: tiotropium significantly improves lung function and asthma control, and reduces risk of exacerbation, vs placebo ( conclusion: based on similarities in disease profile and magnitude of treatment responses between age groups, it is reasonable to expect tiotropium add-on to produce clinically meaningful improvements in exacerbation and symptom endpoints in children and adolescents, as in adults. the robust tiotropium clinical program supports using a partial extrapolation to avoid overly long and large trials in pediatrics. | clinical state of treatment and examination during last years before remission about asthmatic children in long-term remission cases method: remission cases (no symptom and no therapy) for years of asthmatic children were studied. clinical background and treatment (drugs) was studied during last years before remission annually. acetylcholine inhalation test by standard method was performed, and respiratory threshold of acetylcholine (rt-ach) was obtained. fev %, and serum ige also examined. these data were compared before remission with years after remission. results: mean age of cases at year before remission was . years old. male to female ratio was . . severity of asthma was all mild type, and number of attack was to times in a year. there was no admitted case during this study. the long-term therapeutic drugs were leukotriene receptor antagonist (anti lt) in cases, and/or inhaled corticosteroids (ics) in cases, but cases had no treatment for the control. geometric mean of rt-ach (after then: years before and after remission) was μg/ml and μg/ml. the mean fev % was % and %. geometric mean of serum ige level was iu/l and iu/l. complicated cases of atopic dermatitis decreased after remission, but the incidence of allergic rhinitis increased slightly. conclusion: characteristics of asthmatic children during last years before remission were mild type, had several times of attack in a year, and the treatment was mainly anti lt and/or ics. fev % was within normal range, and serum ige level was not changed after remission. rt-ach had the tendency to improve during years before and after remission. these data is supposed that airway hyperresponsiveness is one of the indicators for quitting treatment. | clinical aspects of polyvalent mechanic bacterial lysate (pmbl) treatment in children with uncontrolled asthma our results indicate that long-term treatment with omalizumab in children can help to achieve better asthma control and reduce the amount doses of basic therapy. method: allergic rhinitis (ar) and allergic rhinoconjunctivitis (arc) diagnosed-patients' demographic information, accompanying-asthma, the allergic history of the family, the onset of symptoms, types of aeroallergens sensitivity were noted from patients' files in our hospital's pediatric allergy clinic. results: in this study, patients were evaluated. the mean age of the patients were . ± . years and % (n = ) were male. ( %) patients had ar and ( %) patients had arc. background: allergic rhinitis (ar) is a disease characterized by symptoms of nasal discharge/congestion, sneezing, and pruritus, and is caused by an ige-mediated immunological response to inhaled allergens. we aimed to evaluate pollen season and out of pollen season pulmonary function tests (sft) of patients with ar in our study. method: in our study, the demographic characteristics and aeroallergens were recorded from patients' files with ar diagnosed. in addition, pollen season and out of pollen season sfts were evaluated and compared. conclusion: in patients with ar, fev and fvc values are seen to be lower during the season even though there is no lower respiratory symptom. therefore, sfts of patients with ar should be evaluated during pollen season. results: among the clinical manifestations, the most common combination of allergic rhinitis (ar) and conjunctivitis (ac) is noted in . % of adults and . % of children, but in children aged - , the combination of ar and ac is observed only in . %, among - years old- . %, while in the remaining age groups it is encountered in more than %. higher percentage of isolated ar is also observed among young children- . %, and those of the results: allergic rhinitis was a main symptom in . % of children with pollen-food sensitization. in all of them concomitant allergic disorders were noticed: bronchial asthma ( . %), atopic dermatitis ( . %). only in . % temporal association between ingestion of pollen-related foods and nasal symptoms was observed (mainly apple and peanuts); occurring also outside the pollen period. the simultaneously sensitization to animal origin food allergens was stated in . % of children with sar, but only in two of them milk and white egg proteins were an additional exacerbation factor of nasal symptoms. in . % anaphylactic reactions to food allergens were registered. . % of children were asymptomatic despite pollen-food sensitization. the statistically significant differences were noticed in comparison to the control group. conclusion: . allergic rhinitis in children, similar to adults, is a common manifestation of pollen-food syndrome and this type of sensitization should be taken into account regardless to age. . children with pollen-related food allergy have the predisposition to multiorgan clinical manifestation. . the lack of association of symptoms with plant-origin foods in the majority of cases and the asymptomatic course of food sensitization in more than one third of patients indicate the need for follow-up. | clinical benefit of the screening of suspected food allergen using multiple allergen simultaneous test in the patient with pollen-food allergy syndrome (pfas) background: the quantitative fluoresce enzyme immunoassay immunocap (ic) system has been widely used for detection of allergen-specific ige for the diagnosis of allergy. however, the system can only detect ige against a single allergen, the multiple antigen simultaneous tests has been developed such as the fluorescence enzyme immunoassay view allergy (va) or chemiluminescent enzyme assay mast iv (ma) and both assay detect more than allergen-specific ige. in this study we examined the diagnostic capability of these two systems for screening test in the patient with pfas. method: total number of participants are (male/female: / ), aged . ± . (range ~ ) years old. all the patients showed oral allergy syndrome (oas) to rosaceae family plants (apple, peach) and/ or kiwi and/or banana, also showed tree pollen allergy. specific ige assay were performed using ic, ma or va. results of greater than class were to be regarded as positive, and the concordance rates between the assays were assessed. results: the correlation of sensitivity between pr- (rbet v , rmal d , rpru p , measured by ic) and specific ige to apple (measured by va), specific ige to peach (measured by ma) in oas patients to rosaceae family plants were assessed. rbet v , rmal d , rpru p were found to be . %, . %, . % positive measured by ic while the specific ige to apple (supposed to be including pr- ) were found to be % positive measured by va. on the other hand, the specific ige to peach (supposed to be including pr- ) were found to be only . % positive measured by ma, this detection rate was lower than that of va (p < . ). also, the correlation of sensitivity between pr- (ract d , measured by ic) and specific ige to kiwi in patients with oas to kiwi were assessed. ract d were found to be . % positive measured by ic while the specific ige to kiwi (supposed to be including pr- ) were found to be . % and . % measured by va and ma, respectively (p < . ). additionally, all the oas patients to banana found to be positive for the specific ige to banana measured by va, but only patient was detected as positive measured by ma. conclusion: in this study, we found that va showed better agreement of sensitivity and specificity with ic compared to ma in the oas patients to rosaceae family plants, kiwi, or banana. therefore, it may be clinically useful for screening of allergen specific background: the hygiene hypothesis for autoimmune and allergic diseases, which exists nowadays, shows that human immune system is dependent on various environment factors. we consider the effects of humic substances (hs) to be important in understanding the hygiene hypothesis. due to urbanization, the amount of human interaction with hs found in soil has significantly dropped. the goal of our work was to study allergenic potential and antimicrobial activ- conclusion: hs appear to be exogenous immunocorrectors, and also to have an ability of suppressing propagation of allergic reactions and sensibilization, which leads to conclusion that they seem to play a major role in hygiene hypothesis. moreover, hs selectively interact with bacterial cell wall, and this effect could be used in order to create antimicrobial drugs based on hs. background: peach tree pollen has been identified as having relevant allergens (the third most prevalent after olive tree and grass pollen) in areas of high cultivars (murcia, east-spain). when analyzing molecular components in sensitized patients, along with pru p , we have identified other relevant inhalant allergens one of which was named pru p x. because pollen of different species share allergens and with plantderived food, we have also studied peach tree pollen sensitization in a non-exposed population (madrid, central-spain). the aim was to study the association between peach tree pollen and several panallergens, as well as the relevance of pru p x in our area (madrid). method: a total of patients who came to our allergy unit in those patients with positive spt to at least one pollen we also performed peach tree pollen spt. if positive, we tested pru p , pho d , pho d and pru p x. to study the clinical relevance of these findings, we also performed nasal provocation test (npt) with peach tree pollen and pru p x. results: a total of patients were sensitized to peach tree pollen. from these, % had also positive spt to pru p and none of them to pru p x. positive spt to polcalcin were found in the % of the cases and to profilin in the %. in patients sensitized to peach tree pollen npt was performed being cases positive to peach tree pollen and none to pru p x. conclusion: peach tree pollen sensitization in non-exposed patients with allergy to other pollens is high although primary sensitization is unlikely. these patients present clinical response when exposed to that pollen that needs further evaluation. in our study, one third of the patients were also sensitized to polcalcin and pru p and none to pru p x. we have not found clinical response to this new inhalant allergen identified in highly exposed peach tree pollen population. results: the bet v elisa . -ep complete kit format (including pre-coated plates and all buffers and reagents) allowed for the consistent measurement of bet v in birch pollen extracts within the same lab (intralab cv= . %) and between different labs (interlab cv= . %). the average recovery from matrix spiked samples (crs in birch pollen extracts) ranged from - %, with an average recovery of % (n = ). assay time was reduced from several days to two hours compared to the original method. the performance of the bet v elisa . -ep kit was comparable to that of the stallergenes greer candidate standard method and has been successfully cross-validated. this will enable allergen manufacturers and regulatory authorities to adopt a standard method for bet v determination, which, ultimately, may be included in the european pharmacopoeia. the development of a certified elisa represents a major step forward in the standardization and quality control of allergen products. | an isoform of the ole e allergen assembled by proteomics could explain the cross-reactivity with pollen and food nsltps results: a total of peptides were obtained by de novo sequencing. ten of them allowed the completion of the full-length amino acid sequence of the allergen. after purification, role e was obtained with a yield of . mg/l of cell culture. immunological assays confirmed that the recombinant isoform of ole e shared most of the allergenic and antigenic properties of the natural allergen. moreover, we observed its implication in cross-reactivity with pollen extracts, and plant-derived food extracts. conclusion: these results suggest that the presence of this isoform in the olive pollen could explain the co-sensitization observed in some allergic patients between ole e and nsltps from foodderived extracts and might be used for a more effective clinical diagnosis of olive pollen sensitized patients. background: penicillium oxalicum, one of the prevalent airborne fungi in india, was selected to detect its spores as potential source of allergens and also to identify and characterise its major ige-reactive component. the airborne spores of penicillium oxalicum was detected by andersen -stage air sampler at different parts of west bengal. the allergenic potency of p.oxalicum was tested by spt, elisa and immunoblotting. total protein was resolved in -d and -d gel electrophoresis and allergens were identified by -d and -d immunoblots. identification of major ige-reactive protein spots was made by mass spectrometry based maldi-tof-tof. major allergen was partially purified by ion exchange chromatography. results: aerobiological investigation clearly indicated the predominance of p. oxalicum spores ( cfu m − ) in the air of west bengal, india. sensitivity of patients to spore antigens was highly correlated with rhinitis. in sds-page, bands were detected with molecular weight range of - kda. the allergenic potency of spores was confirmed by skin-prick test, elisa and dot-blotting. eleven ige-reactive proteins were detected as allergens by -d and -d immunoblots, of which % patients were sensitized to kda allergen. this kda protein was found to be the major allergen which was further characterized by mass spectrometry based maldi-tof-tof. this major allergen (pi . ) was partially purified by ion exchange chromatography. the eleven allergens were identified from spore of penicillium oxalicum fungi for the first time from india. immuno-proteomic identification of major ige-reactive protein ( kda background: airway epithelium (ae) is one of the largest cellular surfaces exposed to the environment. ae constitutes a physical barrier due to the presence of intercellular apical junctional complexes between neighboring cells. in the past years evidence indicates an association between epithelial airway dysfunctionality and allergic asthma. it is still unclear if an impaired epithelial barrier could be the cause of allergy development as opposed to the consequence. one of the most common comorbidities of asthma is house dust mite (hdm) allergy. it has been shown that hdm allergen der p can disrupt the epithelial airway due to its protease action against cellular apical junction complexes damaging the epithelial monolayer. in the last decade, metabolomics has been successfully employed as a new approach to describe metabolic changes in biological systems. metabolomics focuses on describing and identifying small molecules to explain complex biological processes. we theorized that metabolomics could be used as a new tool to detect damage of epithelial barrier in vitro after der p exposure. method: human cell line calu- cultured at air-liquid interphase (ali) was used as an in vitro model of bronchial epithelium. ali culture system allows establishing different compartments, mimicking the conditions found in the human airways: a basolateral compartment in which basolateral surface of the cells is in contact with the culture medium, and an apical compartment where the apical cellsurface is exposed to air. after days in ali, the cells were exposed to either der p or pbs as a control in the apical side for hours. then, apical and basolateral media were collected and processed for metabolomics analyses. results: metabolic profiles from samples were obtained, these were composed by and features for apical and basolateral media, respectively. of these, using mann-whitney unpaired test as statistical analysis, and features were found changed within the apical and basolateral compartments, respectively. specifically, in the apical compartment there were signals significantly increased and decreased after der p exposure; whereas for the basolateral compartment, signals were found to be significantly decreased and increased after exposure. background: mites are one of the major causes of allergies. it is known that allergen concentration varies depending on the species of mites and the degree of allergy induction is different, but the difference in microbiota according to mite species is not known. in addition to allergen, endotoxin or bacterial dna, adjuvants of allergen derived from the microbiota in the mites, are also present in the feces. bacterial endotoxin is found in gram-negative bacteria, acting on tlr and acting as an adjuvant to allergies. method: three species of mites (d. farinae, d. pteronyssinus, and t. putrescentiae), known to cause allergies, are cultured in same condition(autoclaved media, %rh, °c)and analyzed for microbiota of each species. using the next generation sequencing that complements the existing sanger sequencing, we analyze the difference of microbiome according to the dust mite species and measure the level of endotoxin. method: six hundred and thirty five patients ( . % males and . % females, mean age . years old, range to years old) were included. all of them referred respiratory symptoms (rhinitis, conjunctivitis or bronchial asthma) and had skin prick tests positive with any pollen. patients were skin prick tested with a battery of common pollens in our area, including three species of chenopodiaceae: chenopodium album, salsola kali and salsola oppositifolia. results: three hundred and forty tree ( %) patients were sensitised to pollen of any chenopidaceae species: ( . %) to chenopodium album, ( . %) to salsola kali and ( . %) to salsola oppositifolia. the prevalence of skin sensitisation to pollen of salsola oppositifolia was . % in the population studied and . % in patients sensi- results: in patients aged - years of age in . % of the cases ige reactivity was at least to one allergen tested. the majority of patients (more than / ) had a complex sensitization profile and reacted on average to more than allergens. the highest frequency of sensitization in ukraine among patients who turned to the clinic among adults was found phl p ( . %), amb a ( . %), fel d ( . %), bet v ( . %) and children ( . %, . %, . %, . %), respectively. when analyzing the results of tests for the source of the allergen, most often among house dust mites (hdm) allergens in adults and children is sensitization to fel d ( . %), as well as to hdm: in adults (der f - . % der p − . %, der f - . %, der p - . %) and in children ( . %, . %, . %, . %), respectively. among fungal allergens the most common is sensitization to alt a and varies from . % in adults to . % in children. among pollen allergens in adults is sensitization to phl p ( . %), amb a ( . %), bet v ( . %), cynd ( . %), art v ( . %), bet v ( . %) and in children ( . %, . %, . %, . %, . %, . %), respectively. tests for food allergens in adults and children are more common on pr- proteins. in children, sensitization to milk and egg proteins is more common than in adults. conclusion: most patients who came to the clinic have a complex ige reactivity profile in which pollen sensitization predominates. among hdm allergens, more than / of the examined have sensitization to the cat's proteins. sensitization to mold alternaria alternata in children occurs times more often than in adults. results: total children were examined, aged - years (median years). % children were sensible to two and more components . %to and more components. the frequency of sensitization to inhalation components was . %, to food abstracts | components- . %. among the most frequent inhalation components were feld - %, betv - %, amba - %, phlp - %, alta - %, the sensitization to house dust mites (hdm) was most often observed to der p - %. however, the analysis of these protein by the level of isu showed that the highest levels were for der f median (iqr . - . ), whereas for fel d - . (iqr . - . ). among food allergens, sensitization was most commonly observed to pr- proteins - %. children sensitized to pr- proteins were in most cases sensitized to -mal d ( %), cor a . ( %), pru p ( %).this co-sensitization was accompanied by a high correlation of isu levels among these components. sensitization to celery and kiwi was less common, the level of these proteins was also low. the frequency of sensitization to storage proteins was %, among which the highest level of isu was in ara h median . sensitization to ltp proteins was detected in % of children, among which the most commonly detected pru p protein was . %. the sensitization to profilins, which was evaluated at the level of bet v , was found in % of children, but the levels of these proteins were not high. among the food products of animal origin, the most frequent was sensitization to egg component gal d − . %, however, isu levels were the highest to milk component bos d − . (iqr . - . ). the most frequent causative inhalation allergens were epidermal allergens and weed pollen, however, the highest level of isu was to hdm and mould. among food allergens, the most commonly observed sensitization was to pr- proteins. hypereosinophilia of peripheral blood was observed in children under study, which was % ( . %). as a result of testing patients with a wide panel of allergens, % of the patients had diagnostic levels of antibodies to allergens siged , . %to allergens siged . in % of cases, a significant level of antibodies to plantain allergens sige w was detected, . % to dandelion allergens sige w , . % to evergreen trees sige t , to maple sige t to . %, to allergens of olive tree sige t - %, to the banana allergens sige f - . %, to the egg protein sige f in . %, in % to the milk allergens sige f , to the food mixture sige f x - . %, to allergens of mold fungi mx − . %. among the leading household allergens were registered in the st group and in the nd group of the investigated children -d pteronyssinus ( . %, . %), and d. farinae results: the prevalence results are expressed in the table . we have not observed any significant association in allergic rhinitis patients group with any ltp or pr- molecules. for atopic dermatitis only rara h (or with % ci - . ( . - . ) and njug r (or with % ci - . ( . - . )) were associated significantly. for asthma, the most important molecules were rbet v , raln g , rcor a . , rcor a . , rmal d , rpru p and rapi g (p-values for or less than . ). conclusion: future studies focusing on the evaluation the association of cross-reactive molecules with allergy phenotype should be done. background: the fuzzy/green kiwifruit (actinidia deliciosa), widely grown commercially, contains various pulp allergenic molecules, including the major allergen cysteine protease actinidin. methods. this case report is about a -year-old male patient with house dust mite allergic persistent rhinitis and intermittent asthma, presenting a convincing history of anaphylaxis immediately after eating a kiwifruit on empty stomach, followed, a few months later, by a severe oral allergy syndrome after licking a slice of raw kiwi. previously, the patient ate kiwi without any problems and had no manifestations of pollen or latex allergy. skin prick testing was done with commercial allergen extracts, while prick-prick testing was performed with raw kiwifruit, avocado and banana. molecular approach consisted in assessment of serum specific ige to native extracts and molecular allergen components using patient-friendly allergen nanobead array multiplex test and singleplex capsule-enclosed activated cellulose solid phase fluorescence enzyme immunoassay. results. regarding kiwifruit allergy, the patient presented positive prick-prick tests with raw edible kiwifruit components: outer pericarp and inner pericarp (each mm wheal) and columella/core ( mm wheal) and negative with kiwifruit whole seeds, avocado and banana, and pollen extracts. serum specific ige to kiwifruit were detected ( . ku/l), but specific ige values were negative (≤ . fiu/ml) for actinidin act d , thaumatin act d , kiwellin act d , nsltp type act d , bet v -like major latex/ripening-related protein act c , act c chitinase_iv, act d cross-reactive profilins bet v (birch pollen profilin) and hev b (latex profilin), and also negative (< . ku/ l) for pr- ract d . moreover, specific ige to avocado were nor found (≤ , fiu/ml). although ige against seed proteins cupin/ s globulin act d and s albumin act d were not determined, this was not considered of great importance since allergic symptoms were also induced by licking kiwi pulp, in which abundantly expressed actinidin enzymatically degrades seed storage proteins, and prick-prick test was negative to kiwifruit seeds. conclusion: in a patient with anaphylaxis to kiwifruit, positive skin tests to its pulp and detectable serum specific ige to actinidia deliciosa, a detailed molecular allergy diagnosis is necessary, including assessment for act d glycoallergen or other molecules, not performed in this patient. | is pr- sensitization a portuguese phenomenon as well? background: bet v , a major allergen found in birch pollen, belongs to the pr- protein group. in our practice, some bet v sensitized patients have been identified, residing in areas without this tree genus in its flora. our aim was to characterize a portuguese patient population with pr sensitization. method: a group of patients in whom immunocap isac ® (isac) study was performed, between january and june , were analyzed. all subjects with one or more pr- sensitizations were selected, and their clinical records reviewed. a sequential sample of the last subjects (n = ) who underwent isac study, was then used for comparison. results: out of isac studies performed, only were positive for pr- protein group. median age was . years, % (n = ) were male. pr- sensitized individuals were more likely to live in portalegre district compared to the control group ( / vs / ; p < . ). patients were positive for pr- family pollens ( . %), frequently bet v (n = ), followed by aln g (n = ) and cor a (n = ). out of the patients were sensitized to pr- foods, mostly cor a . (n = ) and mal d (n = ). skin prick tests revealed birch as the main sensitizing pollen as well ( / ). moreover, only four patients were skin prick tested for fagaceae trees which were positive for oak ( ), chestnut tree ( ) and cork tree ( ) . all patients were co-sensitized to other pollens, namely grass and all had respiratory allergy. nine patients were food allergic, although seven of them were co-sensitized to other cross reactive (ltp/profilin) or species specific proteins. conclusion: although pr- sensitization is known to be rare in our population, mostly alto alentejo inhabitants showed sensitization to this protein family in our sample, either by in vitro and/or in vivo methods. this phenomenon is consistent with the native plant species of this region, which should be taken into account when studying the allergic profile of these patients. in our sample, all pr- sensitized patients had respiratory allergy while this protein didn't seem to be relevant when it comes to food allergy. further studies are needed to characterize which plant species belonging to this protein family are more significant for our country's aerobiology context and to determine its clinical relevance. included. allergic asthma, rhinitis, conjunctivitis and eczema allergic symptoms were diagnosed. all patients were tested by immunocap with mugwort pollen extract and the natural components nart v , nart ar , nart v , and nart an . results: the positive frequency and sige levels of the four components in the artemisia allergic patients from southwestern china were significantly lower than that from the north. art v and art an were the highest recognized allergens, followed by art v and art ar . patients from northern china were more likely to have abstracts | asthma ( %) than patients from southwestern china ( %), and being sensitized to more than two allergens increased the risk of asthma. sensitization to art v , art v and art an played a significant role in the development of asthma. artemisia pollen allergic patients is helpful to assess the potential risk of asthma. conclusion: a small but significant part of the population react to ragweed pollen extract and are not identified as disease-positive by standard sige tests. there is a need for targeted tests towards a larger spectrum of allergen molecules. in ragweed allergic individuals, this allergy can be the main cause of overall sige levels and also of in vivo reactions (tested by spt). | molecular profile of pollen sensitization of tashkent residents with respiratory allergy background: in paediatric cohorts, a correlation between specific ige (sige) levels to house dust mite extract or allergen components and the occurrence of asthma has been shown. higher levels of sige to mite extract were associated with a higher risk of wheezing. moreover, asthmatic children recognized more allergens and had higher sige levels to nder p as well as rder p , and . we sought to investigate potential differences in sige levels or sensitization patterns between asthmatic and non-asthmatic patients in a mixed paediatric and adult house dust mite allergic cohort. method: total ige and specific ige against house dust mite extracts (dermatophagoides pteronyssinus and farinae) and allergen components (rder p , , , and ) were determined in house dust mite allergic patients. patients had diagnosed asthma ("asthmatic", % females, mean age ± years, % younger than years), whereas had rhinitis (and conjunctivitis) without respiratory symptoms ("non-asthmatic", % females, mean age ± years, % younger than years). results: total ige levels were markedly higher in asthmatic compared to non-asthmatic patients ( vs. ku/l, p = . ). positivity to rder p ( vs. %, p = . ) as well as rder p ( vs. %, p = . ) differed between both groups. specific ige levels to house dust mite extracts and allergen components (rder p , , , and ) and positivity to rder p and did not differ between both groups. conclusion: in contrast to previously published data, sige levels to house dust mite extracts or allergen components were not statistically different between asthmatic and non-asthmatic patients in our mixed paediatric and adult house dust mite allergic cohort. only higher total ige levels and a higher reactivity to rder p and were found in asthmatic patients. however, larger studies are needed to confirm clinical relevance of these findings. results: prior treatments reported at baseline (bsl) included: . % of pts were receiving or more second-generation h -ah at approved dose (recommended first-line), . % were receiving them at increased dose (second-line); . % were receiving omalizumab (third-line); . % had no treatment. the majority of pts ( . %) had uncontrolled csu (uct< ) at bsl (table) . treatment changes were most evident at the bsl visit, with an increase in pts receiving omalizumab ( . %) and a decrease in those receiving no treatment ( . %) vs. prior therapy. these changes were associated with improvements in rates of hives and/or angioedema, uct and qol scores at month , but only modest improvements thereafter (table) . a sub-analysis of pts with uct< and who were receiving the approved ( . %) or increased dose h -ah ( . %), revealed that few pts had recommended escalation from the approved to increased dose h -ah ( . - . %) or from increased dose h -ah to omalizumab ( . - . %) (table) . conclusion: poor physician adherence to guidelines was evident throughout aware. initial improvements in disease activity and qol plateaued after month , possibly owing to fewer changes to recommended therapies. greater physician adherence to guidelines is needed for better symptom control in pts with uncontrolled csu. results: we revealed that in russians urticaria is associated with rs *arg/gln genotype of the il gene (p = . ) and rs *cc genotype of tlr (p = . ) gene polymorphism. in tatars the association with disease development was shown for rs *tt genotype of tlr gene snp (p = . ). the rs *c allele of tlr gene polymorphism is associated with acute and chronic forms of urticaria (p = . and p = . , respectively) and rs *c allele of il gene polymorphismwith acute urticaria (p = . ). method: csu patients from the urtica cohort (clinicalttrials.gov number: nct ) participated in the study. a questionnaire was carried out evaluating the triggers identified by the patients, the comorbidities and the treatments received. patients with a self-report of skin exacerbation by foods, nonsteroidal antiinflammatory drug (nsaid) or physical triggers were subjected to a controlled provocation test with the suspect food, medication or physical stimuli report by the patient. the levels of anti-tpo ige were measured during a period of clinical control and during two exacerbations in all patients. results: % of the patients had at less one inducible urticaria demonstrated by provocation tests ( % dermographism, % cold, % pressure). self-reported exacerbation for a food ( %) or medication ( %) were high, but positive provocation tests were low ( % and % respectively). patients had (+) anti-tpo ige during the baseline period. among them, % presented a significant elevation of anti-tpo ige during at less one of the two exacerbations. . % of patients (n = ) with (−) anti-tpo ige, presented elevation of anti-tpo ige one of the two exacerbations. conclusion: foods, drugs and physical triggers must be verified by challenge tests to avoid unnecessary lifestyle restrictions in patients with csu, nevertheless self-report is usually greater than positive provocation tests. increase concentrations of anti-tpo ige seems to be implicated in urticaria exacerbations in some patients with csu. brzoza z ; adamczyk k ; wcislo-dziadecka d ; zbiciak-nylec m ; brzezinska-wcislo l adipokines. the aim of the study was to evaluate the possible contribution of leptin to chronic spontaneous urticaria pathophysiology. the study included chronic spontaneous urticaria patients and healthy subjects. the leptin level in both examined groups was measured. results: no statistically significant difference in leptin level was determined between the studied subgroups. we are among the first to present the effects of exploration aimed at assessment of the possible role of adipokines in chronic spontaneous urticaria pathogenesis. in this study we did not prove any difference in leptin level. in our opinion it is valuable to perform further studies in this area. the microorganisms were inactivated with phenol, and the concentration was adjusted to microbial cells/ml (labeled as a / ). dilutions / and / were made from the product labeled / . the dot blot technique was used to detect the presence of specific ige to the different microbial antigens and controls (anti ige / and fold dilution ½ and ¼). the dot blot images were processed with a documentation system (gel doc ez, bio-rad), and the different microbial antigens in different dilutions were compared with the positive anti-ige controls. results: all patients have specific anti ige to microbial antigens (see table below). the presence of microorganism-specific ige could explain, the relationship between the infections and / or microorganisms in ciu, as well, the urticaria control by omalizumab, even when it has not been detected ige sensitizations to common allergens. finally, these findings, showed that the bacterial allergy could be one line of research to understand the unresolved etiology of urticaria. background: dermographism is the most common form of inducible urticaria. it shows itself as hives made by scratching or rubbing on the surface where it has been produced and with the same morphology. the pathogenesis has not been clarified nor has it been associated until now with the sensitization to allergens. we have studied the relationship between the presence of dermographism and domestic mites sensitization. we have selected patients older than years old. all of them had symptoms compatible with dermographism at the moment of medical evaluation. at least one third of patients additionally showed rhinitis and/or asthma symptoms. we performed:: -skin prick tests with our basic neumoalergens (mites d. pteronyssinus y lepidoglyphus destructor, pollen, molds, dog, cat and horse dander, latex and anisakis simplex). -determination of specific ige levels for dermatophagoides pteronyssinus, lepidoglyphus destructor, and anisakis were measured in serum by using the immunocap (thermo fisher scientific). -blood count, serum immunoglobulins, antithyroid antibodies, serine tryptase and proteinogram. results: blood count, serum immunoglobulins, antithyroid antibodies, serine tryptase and proteinogram were normal. we divided patient in different groups. background: urticaria results from the appearance of pruritic papules and/or erythematous plaques caused by substances from mastocytes present in the skin, notably histamine. chronic urticaria is defined as flare-ups that occur at least two or three days per week over a six-week period. in addition, affected subjects are often prone to an atopic or auto-immune profile that promotes urticaria [ ] . the association of polyphenols (ambora, green tea) and the soothing active ingredients slow down the itching biological process from the outset by reducing the release of pruritic mediators (e.g. histamine, cytokines, etc.) of immune cells such as mastocytes and lymphocytes, involved in urticaria. in this context, the purpose of the study was to evaluate the efficacy and the tolerance of an anti-pruritic spray containing the polyphenols and the soothing ingredient. the tested product aims to quickly calm the itching in subjects with chronic urticaria. results: on average, the product was applied . times per day with a significant decrease of d-pruritus scale (- %) and sensations of itching (- %) between d and d . in terms of quality of life, a significant decrease of the skindex score was observed (- %). the product soothed the pruritus within seconds for all subjects and the anti-pruritic effect lasts at least hours for % of subjects. the product also showed very good cosmetic properties and was well tolerated; no intolerance case was reported. showed near complete remission. in the week before omalizumab and for a few days after, her urticaria flared but on of weeks she was largely asymptomatic (uas - ). after years of successful treatment she reported an increase in csu activity. no trigger factors could be identified. add-on treatment with cyclosporine was refused, montelukast showed no, and prednisolone only transient benefit. over a period of months wheals occurred almost daily and a maximal score of was achieved on uas . we replaced omalizumab with cyclosporine but this was subsequently discontinued due to side effects. months later the patients' csu remained poorly controlled with up to wheals occurring almost daily despite rupatadine mg/d. due to the good initial response to omalizumab and lack of good treatment alternatives, a trial of re-treatment was considered. results: within week of re-commencing omalizumab she once again achieved near complete remission of csu with uas ≤ on of weeks. the mechanism of action of omalizumab and the development of resistance to it in csu, are incompletely understood. our case shows that some csu patients developing resistance to omalizumab may benefit from a subsequent trial of re-treatment, particularly if treatment alternatives are poorly tolerated. manipulate and store data by electronic means. this includes e-mail, sms text messaging, video chat and online social media as well as all the different computing devices that perform a wide range of communication and information functions. a rapid increase in the use icts in recent decades is an enormous contributing factor in the development of a number of novel clinical and public health intervention strategies. the aim of the present study is to assess the level of ict use and to examine patterns of preferences among patients with chronic urticaria (cu). method: we will conduct an anonymous multicentre cross-sectional study, starting from january , to investigate the use of icts in patients with cu, using a questionnaire as a survey method. this questionnaire will assess the frequency of use of social media and icts in patients, and their preferences for receiving and asking disease-related information. the survey will consist of items, evaluating demographical information, time with disease, medication currently used, and additional aspects of social network use. results: we will use a chi-squared test to assess the association between internet access or owning a cell or smartphone, and age, gender, type of urticaria, educational level and number of years since diagnosis. we will employ the same test to assess the association between the independent variables previously introduced and the frequency of use of each ict type (short messaging service [sms], facebook, twitter, youtube, email, internet, linkedin and skype) as well as agreement in receiving and seeking information (i.e. asking questions to the practitioner) through such icts. we will perform adjusted regression analyses between categories of age, gender, educational level, type of urticaria, years since diagnosis and the use and level of interest shown in communicating through icts. our aim is to report on remarkable findings from a registry of a large sample of patients, potentially providing clues for its approach and results: patients with a median length of months suffering from urticaria were registered, being % women; mean age . years. in % of patients no causal agent was identified. parasites were found in . % and thyroid peroxidase antibodies in . %, while autologous serum skin test was positive in % and igg to mycoplasma in % of evaluations. two thirds of patients reported wheals on uas , with just / having concomitant angioedema. almost / reported significant affection on quality of life because of itch by cu-q ol. just % of patients achieved total control on first anti-histamines provided, and less than half had good control of urticaria. cetirizine was the first choice in %, followed by fexofenadine ( %) and first generation anti-histamines ( %). method: cases at - years of age which were being followedup in our clinic with diagnosis of chronic urticaria and were not receiving any antihistaminic medication for last one month were included in the study. cu-q ol, uas- , psqi and psg results of the patients were evaluated. correlation of data with each other in regard to sleep disturbances was evaluated. results: patients were included in the study. patients' mean total score in cu-q ol was . ± . . patients' mean uas- value was . ± . . mean total psqi was . ± . , the ratio of total scores ≥ and those with poor quality of sleep was . %. mean epworth sleepiness scale (ess) score was . ± . , with total score ≥ in . %. in psg, mean apnea-hypopnea index (ahi) was . ± . , with . % of the patients having ahi ≥ . when patients having ahi< were compared with patients having ahi ≥ , no significant difference was determined in regard to total cu-q ol score, mean score for questions concerning status of sleep, uas- and psqi. when correlation analysis was performed between cu-q ol and total score for questions concerning status of sleep, a positive correlation was determined with psqi (p = . ). conclusion: it was demonstrated in our study that patients with chronic urticaria had poor quality of sleep and this disturbance was independent from ahi. omalizumab was discontinued due to absence of improvement in csu symptoms after three consecutive doses. the plasmapheresis without intravenous immunoglobulin replacement was initiated. results: the symptoms were relieved during the first procedure and the disease improved shortly thereafter. the following weeks the symptoms still occurred but with lower intensity and severity. (angioedema was gone). the second attempt with omalizumab was successful after this course ( procedures of plasmapheresis). case report: rosacea is a chronic skin disorder associated with flushing, erythema, dryness, burning and stinging, and inflammatory papules and pustules. new treatments available or in development target the inflammatory and erythematous components of the disease. these agents include the selective alpha- receptor agonist brimonidine. allergic contact dermatitis to brimonidine is an unusual condition. in addition to this, urticarias due to brimonidine are rarely reported. we report on a -year-old woman who, immediately after apply a thin layer of brimonidine gel as preparation for a rosacea treatment on her face developed facial urticaria, which reverted in approximately four hours with systemic steroids. she had previously tolerated this product without any problems, but has not use it again ever since. skin prick-tests with brimonidine ( . mg/ml) and latex were realized in the patient. skin prick-tests with brimonidine were realized in eleven healthy control subjects. results: skin prick-tests with latex was negative in the patient. skin prick-tests with brimonidine were positive in the patient ( x mm). the prick-test with brimonidine was negative in teen healthy control subjects. we report on a case of immediate urticaria due to brimonidine and triggered by an immediate, probably ige-mediated, hypersensitivity mechanism. we highlight this case because it is the only case described in the literature with a positive prick-test. method: the study was in accordance with the helsinki declaration and was previously approved by the national comity of ethics. this was a one dose study conducted on fasting young healthy volunteers, of which were females and five males. the mean age was ± years old and the body weight . + . background: cetirizine is a potent h -receptor antagonist indicated in the treatment of allergic rhinitis and urticaria. cetirizine is widely used due to its potent antihistaminic effects in yielding strong and fast relief of itchy sensation, sneezy and rhinorrhea and its unlikely probability to manifest anticholinergic side effects in therapeutic doses. histamine flare and wheal inhibition by anti-h are widely used as a standard to test and compare the effect intensity and duration. our study aimed to test these effects of cetirizine in young healthy adults. method: this was a double-blind, single dose study in healthy young adults, previously approved by the national comity of ethics. eleven females and five males with a mean age ± years participated in this study. histamine skin pricks were tested before and after they received a tablet of mg cetirizine as previously scheduled. twenty minutes after each test flare and wheal were drawn in a transparent paper which was then scanned and measured with a software. wilcoxon signed ranks test two-sided with significance at % level was used to analyze the differences. claims that the preparation relieves itch within seconds of its application. we performed a simple study to verify this claim. we used irp in consecutive subjects, males, median age , range - years, whose workup implied ast. their preliminary diagnoses were "asthma" ( subjects), "allergic rhinitis" ( subjects), "atopic dermatitis" ( subjects) and "food allergy" ( subjects). all of them had refrained from systemic antihistamines for at least one week. standard skin prick tests (spt) were applied as appropriate, including histamine controls to assess the level of their skin sensitivity. subjects were asked to mark their sense of itch in the area of the skin to be tested on mm visual-analogue scales (vas) starting from " "-"no itch" to " "-"unbearable itch". vas assessments were repeated minutes after ast was done; then irp was applied according to the manufacturer's instructions, and the vas assessments were repeated after seconds and minutes. results: there vas assessments are shown in table format: table irp did not affect the wheal and flare of the histamine control, nor did it abolish positive spt. no differences were outlined between subjects with different diagnoses. the commercially available itch relieving preparation not containing defined pharmacological antihistamine is effecting in relieving itch associated with allergen skin testing. before ast ( ) . ± . vs ( ) p < . represent the first-line treatment for osteoporosis-related mastocytosis. we report a case of sm with bone pain and with an area of osteolysis in the femur as first sign and symptom. we had to consider the risk of adverse reaction when we decided to treat the patient with bp, but the patient was under antihistaminic treatment and also we made a premedication to reduce the risk. the pk/pd model available was informed by data from clinical trials. the pd endpoint data was available from two studies and used to characterize the effect of bilastine on wheal and flare. moreover, food effect had been characterized in pk studies and the data was used to model the effect of food in the pk of bilastine. the pk parameters relative to the fed state were then used to simulate the temporal evolution of the wheal effect using the pk/ pd model. all analyses were conducted by nonlinear mixed effect modeling (nonmem v . ). using the pk model developed (food effect model) and the pk/pd model already available, monte-carlo simulations for plasma concentrations and pd over time were performed for both the fed and the fasting states. results: . a reduced bioavailability (f) and a slow absorption constant characterized the pk of bilastine when administered concomitantly with food (f = % relative to the fasting state and ka = . hour − , a -fold reduction compared to fasting conditions). the rest of the pk parameters remained unchanged. onset of action was hour for bilastine both in fed and fasted conditions. maximum wheal inhibition occurred at . hours (fasted % and fed %). from to hours, the percentage reduction with bilastine for both fasted and fed was between % and % after the third day of treatment. a % inhibition in wheal effect was maintained during hours for both conditions after the third day. the results of the simulations show that even if the pk is altered with food, the pd is maintained unchanged. conclusion: even if a significant food effect was described for bilastine at a pk level, the difference is not translated directly into the pd. therefore, the antihistaminic effect of bilastine remains unaffected by the concomitant administration with food. the results of these simulations will be further confirmed in a dedicated clinical trial. results: we also found no correlation between the different tgt parameters and other clinical and analytical parameters associated with uc (table ) results: both cetirizine products have no differences in respect to the pharmacodynamic and pharmacokinetic parameters analyzed. the % confidence interval of the mean ratios of the auc - , auc -inf , cmax, auce - , and e max , between the test and the reference, were within the bioequivalence ranges ( %- %) in both cases. no statistical difference was revealed when comparing the respective t max and te max too. the two cetirizine products tested were bioequivalent. the bioequivalence was evident even when tested with the pharmacodynamic parameters. there is strong evidence that supports the use of histamine skin prick test for the bioequivalence evaluation of different cetirizine products. | bradykinin-mediated angioedema associated with combination of angiotensinconverting enzyme and dipeptidyl peptidase iv inhibitors: a disproportionality analysis from the who database method: we performed a disproportionality analysis using data from the who pharmacovigilance database by a case-noncase study, until the / / . we extracted all individual cases safety reports (icsrs) included in the high level term "angioedemas", according to the medical dictionary for regulatory activities classification. given the absence of term "bma", we selected only the icsrs of angioedema without associated symptoms evoking another underlying mechanism, such as histamine angioedema (e.g. pruritus, urticaria, rash, etc.). drug class exposure was "acei" and "dpp i", considered suspect or concomitant, using the atc classification. we results: there was no correlation between mother's disorders such as periodontitis, rhinitis, diabetes etc. and the onset of ar (p > . ). a multivariate analysis showed, neonatal jaundice (p < . ), respiratory system infection (p < . ), diarrhea (p < . ), eczema (p < . ) in the first months of life and home environmental factors (house decoration (p < . ), mold environment (p < . ), keeping flowers (p < . ), passive smoking (p < . )) increased the risk of ar. besides, there was no significant difference in current height and birth weight of the participants between ar and control group. however, ar group had significantly lower current weight (p = . ) and age (p < . ) compared with the control group. paternal age and maternal age in the ar group were significantly higher than the control group (p < . ). conclusion: diseases in the first months of life and home environmental factors increased the risk of sequential ar. the older parents increased the possibility of ar in the offspring. the data of general characteristics of participants were statistic analysis by z text analysis. *significance at p < . . results: anosmia was more frequent in crs than in rhinitis ( . % vs . %, p < . ) and in crswnp than in crssnp ( . % vs . %, p < . ). lms was higher in crs than in rhinitis ( [ - ] vs [ - ], p < . ) and in crswnp than in crssnp ( [ - ] vs [ ] [ ] [ ] [ ] [ ] [ ] [ ] , p < . ). in addition, lms was associated with loss of smell in patients with hyposmia (or = . [ . , . clinics. patients were submitted to confirmatory exams including oral provocation test with aspirin. nasal polyps were removed by functional endoscopic sinus surgery and eosinophils in this tissue were quantitated. eosinophil counts in peripheral blood was obtained. serum periostin was measured by elisa and total ige was determined using immunocap. as control groups, ( f/ m) patients with par and healthy subjects ( f/ m) were selected. samples of nasal tissue and blood were collected from these subjects during elective surgery for correction of anatomical variations, and compared with the patients with aerd. results: ar symptoms were significantly improved in the treatment group compared with the control group ( . % ( / ) vs . % ( / ); p < . ). furthermore, the mean total vas score for patients in the treatment group was reduced from . ± . before treatment to . ± . after treatment (p < . ). moreover, the reduction in free ige levels was greater in the treatment group than in the control group. the results of this study suggest that the chinese herbal medicine ber may be effective for improving the symptoms of ar. a multicenter clinical trial is needed to confirm this finding. results: in patients with "eosinophilic" polypoid rhinosinusitis, mucociliary transport was . ± . minutes, ph . ± . , suction- . ± . minutes, excretory- . ± . mlg and in patients with "neutrophilic" polypous rhinosinusitis, mucociliary transport was . ± . minutes, ph . ± . , suction- . ± . minutes, excretory- . ± . ml. the study showed that disruption of the transport function, changing the concentration of hydrogen ions method: this prospective controlled study was carried out on crs patients underwent ess. patients participating in the study were divided into two groups-group : partial middle turbinectomy (n = ) and group : partial middle turbinectomy and middle turbinate fenestration (n = ). objective assessment of olfactory function using the university of pennsylvania smell identification test (upsit) and subjective assessment of symptom using visual analogue score (vas) were performed before and months after surgery. results: there were significant improvement comparing postoperative and preoperative upsit in both group ( . ± . vs . ± . , p = . ) and group ( . ± . vs . ± . , p = . ). the vas were also significantly improved postoperatively compared to preoperatively in both group ( . ± . vs . ± . , p = . ) and group ( . ± . vs . ± . , p = . ). patients undergoing partial middle turbinectomy and middle turbinate fenestration were more likely to show improvements in upsit ( . ± . vs . ± . , p = . ) and vas ( . ± . vs . ± . , p = . ) compared to those with only partial middle turbinectomy. conclusion: partial middle turbinectomy and middle turbinate fenestration during ess is an effective method for improving postoperative olfactory function. | nasal irrigation for the alleviation of nasal symptoms in pregnant women with allergic rhinitis we sought to determine specific ige responses to bacterial pathogens in sera from cystic fibrosis patients and analyze their kinetic during disease course. genes, respectively. in contrast, most of healthy donors had normal homozygous genotype with tt- . ± . %(n = ) and cc- . ± . %(n = ) with low frequency of mutations; gg- . ± . %(n = ) and tt- . ± . %(n = ) and heterozygous genotype tg- . ± . %(n = ) and ct- . ± . %(n = ) for il- and il- genes, respectively. following a month treatment, there was a significant reduction of cytokine levels in the il - . ± . and increased in the il - . ± . , when compared to the beginning of therapy and after months (p < . ) results: at baseline the st group had serum levels of il- ( . ± . ) pg/l; il- ( . ± . ) pg/l and ifn-γ ( . ± . ) pg/ l; nd group had il- ( . ± . ) pg/l; il- ( . ± . ) pg/l and ifn-γ ( . ± . ) pg/l vs il- ( . ± . ) pg/l; il- ( . ± . ) pg/l; ifn-γ ( . ± . ) pg/l in the control group. after months, there was a significant decrease in pro-inflammatory cytokine levels in the st (il- : ± . ; ifn-γ: . ± . ) pg/l and nd group (il- : . ± . ; ifn-γ: . ± ) pg/l, respectively. conversely, il- increased in st and nd groups to . ± . pg/l and . ± . pg/l (p < . ). conclusion: prior to the study initiation patients with tuberculosis had higher il- , ifn-γ and lower il- content than healthy controls. two-month chemotherapy produced significant reduction in proinflammatory cytokines and increase in anti-inflammatory il- , with levels approaching those of healthy controls. thus, tuberculosis drugs appear to have the anti-inflammatory effect in tuberculosis patients, which was predictive of positive clinical outcome. | antibiotic resistance: ligands of innate immunity take the challenge in this work, we aimed to perform an ex vivo hrsv infection in precision-cut lung slices (pcls) from human, rhesus, and cynomolgus macaques, comparing whenever possible the response with the viral surrogate poly i:c. method: pcls containing airways were prepared from lung sections of human, rhesus, and cynomolgus macaques. the slices were inoculated with hrsv-a iu/ml, uv-inactivated hrsv, or vehicle control for hours. macaque slices were also incubated with poly i:c μg/ml with and without the immunosuppressive dexamethasone μg/ml. viral replication, tissue viability, and immune response assays were assessed in supernatants, lysates, or slices. the inoculum infectivity of iu/ml as well the uv-inactivation were confirmed by plaque-assay on hep- cells. immunofluorescence staining using a fitc-labeled anti-rsv showed the presence of infected macrophages in pcls, but not in mock infected samples. hrsv stimulation slightly decreased tissue viability, as seen by live/dead staining and ldh assay. the viral infection increased ip- production in pcls of human, rhesus, and cynomolgus macaques, reaching respectively . , . , and . fold-increase in comparison to the vehicle controls. poly i:c stimulation caused ip- response comparable to hrsv in rhesus and cynomolgus pcls. the ip- production ratio comparing hrsv/poly i:c was . in rhesus and . in cynomolgus pcls. conclusion: hrsv infects ex vivo pcls of human and non-human primates, inducing the release of the pro-inflammatory chemokine ip- . this response is comparable to the viral surrogate poly i:c. in the future, these systems can be used to further investigate host response to hrsv, especially in the context of asthma development. however, a relatively small number of reports are related to the association of ebv with allergic diseases, in particular atopic ones. we found that among patients with activated ebv infection, polysensitization was found to be . times more frequent, chest syndrome was . times more common and hyper-ige syndrome occurred . times more frequently. in most of these patients, atopy was not detected in medical history. method: we evaluated the laboratory test results of five boys ( . %) and six girls ( . %), children ( with hbov and with cov). their average age at the study time was . ± months. nasal swab specimens were taken from these patients who admitted to our hospital with respiratory symptoms between - . patients are recalled after an average of ± . months. isaac questionnaire and skin prick test to common inhalated allergens were performed. results: only one patient had family history of atopy. forty percent of the patients with cov and % of the patients with hbov developed rhinitis. one patient with cov and one patient with hbov developed recurrent wheezing. one patient with cov developed atopic dermatitis. all skin prick tests were negative. it was noteworthy that . % of the patients were passive smokers. conclusion: hbov and cov may be associated with rhinitis but there is a need for more patient groups for a clear result. rna_lig (ccg-agg-aug-cga-ggc-uug-uu) . to study chemotaxis in vitro, a boyden chamber was used -wellfiltrationplatemultiscreentm -mic with a pore size of μm (millipore, usa). chemotaxis was studied in dynamics after , minutes and a day using the above ligands. as control, rpmi- medium without glutamine was used (paneco, russia). the statistical analysis was carried out using the computer statistical program biostat conclusion: with all the data provided, a drug induced hypersensitivity was diagnosed. we present a case of immediate allergic reaction with eosinophilia due to carbapenems, with tolerance to other beta-lactams antibiotics. written informed consent of patient has been obtained in the two cases. discussion: the first case shows cutaneous immediate hypersensitivity response to infbeta a. literature reports a few cases of urticaria and anaphylaxis but this is the first for the pegylated formulation. polyethylene glycol (peg) confers to a drug modified pharmacokinetics, solubility and immunogenicity. immediate reaction to peg (macrogol) have been described when combinated in vaccines or drug pils. dmf is a known cause of contact dermatitis related to footwear, wallets and furniture. flushig is a reported side effect of dms in ms managed with dose reduction. this case shows the possibility to immediate sensitization to dmf. as the armamentarium to treat ms now combines immunomodulatory and biologic drugs, the avaliability of diagnostic and desensitization protocols for hypersensitivity reactions must be keeped in mind. case report: drug rash with eosinophilia and systemic symptoms (dress) syndrome is an uncommon but serious hypersensitivity drug reaction, manifested with rash, fever, lymphadenopathy and visceral organ involvement. table) . drug withdrawal and prednisolone treatment leaded to attenuating of mentioned skin symptoms within days, associated by occurrence of a exfoliative dermatitis. one week after admission, the patient developed fever that lasted for days with enlarged lymph nodes on submandibular, paracervical, axillar and inguinal regions. a preventive antibiotic therapy is started and weeks later, the lymph nodes were not palpable and the skin got the normal appearance. corticoid therapy is reduced gradually according to symptoms resolvement. case : a -year old woman presented to our department with a -day history of pruritic, macular rash, periorbital swelling, cheilitis and fever. she had started some weeks ago the allopurinol for asymptomatic hyperuricemia, had longer history for treatment of arterial hypertension and type- diabetes mellitus (olmersartan, nitrendipine, methyldopa, furosemide, regular and glargine insulin), and experienced nephrectomy and cholecystectomy. the patient was febrile, while blood tests revealed eosinophilia, increased seric creatinine/urea levels (due to nefrectomy), and severely-altered liver parameters (see table) . the allopurinol withdrawal, topical and systemic corticoid therapy, and the liver protectors attenuated serologic transaminases levels and patient's skin lesions within few days, followed by substantial improvement of laboratory findings one week after therapy start. the treatment dosage was gradually tapered and finally stopped within a period of months in accordance with attenuating and complete resolvement of the clinical and laboratory abnormalities. our case demonstrated that dress syndrome is a severe drug reaction, but the immediate introduction of treatment and supportive measures can improve disease's outcome even after a temporary exacerbation or severe affection of internal organs. case report: a -years-old woman, diagnosed of ischemic cardiopathy, developed an anaphylactic shock minutes after the administration of ml sulphur hexafluoride intravenous during an echocardiogram. she was treated in emergency room with a total recovery. months earlier, she had developed an extensive erythematous-maculopapular rash converging in plaques in relation with adhesive dressings which had been placed during a hospitalization due to thoracic pain. an allergic contact dermatitis was suspected and recommendations thereon were given. interestingly, an arteriogram with iodixanol (icm) was carried out one week before skin reaction with good immediate tolerance. methods: blood test: blood count and serum chemistry were done during both reactions to contrast media. serum tryptase level was not measured during the anaphylaxis, but its baseline level was quantified later. conclusions: we present a patient with a double sensitization to parenteral contrast media: an anaphylactic shock due to sulphur hexafluoride and an atypical delayed exanthema related to iodixanol, and diagnose was obtained with st in both cases. this is the first documented case with a positive immediate st to sulphur hexafluoride. with the culprit drugs mixed with % and % petrolatum resulted negative. patient was suspected to have behcet's disease, and consulted to rheumatology department. oral colchicum dispert twice a day was prescribed. afterwards, patient achieved to take oral amoxicillin-clavulanate for a week without any hypersensitivity; and has been following by oral colchicum dispert maintenance therapy since then. the reported patient had one anaphylactic perioperative reaction to morphine and another anaphylactic reaction to tramadol during her diagnostic investigation. remain the question if this patient had two allergic anaphylactic reactions with cross-reaction between morphine and tramadol, or two non-allergic anaphylaxis due to "hypersensitive" mast cells. case presentation: a -year-old female was diagnosed with rectal adenocarcinoma. one year after radical surgery, progression with pulmonary metastasis was shown. in first line of systemic therapy she received premedication with pantoprazole, metoclopramide, clemastine and dexamethasone, followed by cetuximab infusion. during first minutes of infusion, grade anaphylactic reaction occurred. a reaction started with generalized pruritus, urticaria, rhinitis, followed by hypotension, bradycardia and loss of consciousness. she was treated with fluids, clemastine and methylprednisolone. next day she received same premedication followed by panitumumab. during first minutes she had grade reaction with generalized urticaria. the third day she had generalized urticaria minutes after metoclopramide application. skin prick tests with cetuximab ( mg/ml) were negative, but intradermal test were posi- bat response was highly positive for both cetuximab and alpha-gal, with comparable values and dose response curves. thus, we showed %, %, %, % and % of cd positive basophils for stimulation with cetuximab ( - . μg/ml), and %, %, %, and % for stimulation with alpha-gal ( . - . ng/ml). bat response to panitumumab was negative (< %; - . μg/ml). drug provocation with panitumumab was negative and patient received treatment with panitumumab. in the operating theatre, the skin is disinfected using povidoneiodine and pupil dilation is carried out with tropicamide (showing no immediate reaction in the surgery). method: as we are dealing with a late cutaneous reaction, the study of the medicine involved is carried out by means of epicutaneous medicine testing. in order to do the study of aflibercept, we wore gowns, two sets of gloves, a mask, eye protection and in a containment hood in the outpatients hospital. the patient diagnosed himself with dermatitis when in contact with povidone-iodine and despite the fact that the cutaneous provocation was negative, it is known that when there is surgery involved, there needs to be moistness and occlusion for it to show up clinically. the application of this antiseptic seems to lose its irritation and allergic properties when it dries on the skin and therefore tends to give a negative result in these patients, but this does not mean that they are not allergic to this antiseptic. we report the case of a year old man who experienced erythema and pruritus immediately after an intravenous injection of ranitidine and hyoscine butylbromide given for gastric pain treatment. results: spt and idt were performed for ranitidine ( mg/ml and . mg/ml respectively) and hyoscine butylbromide ( . mg/ml and . mg/ml respectively) being exclusively positive for ranitidine at idt dose with a × mm papule (histamine control × mm). oral provocation test for hyoscine butylbromide was negative. bat for ranitidine and famotidine were carried out, being negative for both drugs. conclusion: skin tests for h ra are the best option when studying a suspected reaction to h ra and are also useful for assessing cross-reactivity between other h ra. the sensitivity for bat in diagnosis of drug allergy is about %, and the specificity up to %, although these percentages make reference to the common drugs studied (beta-lactams, quinolones, pyrazolones, etc). specific studies for h ra are still to be done. in our case we had a negative result for the bat test, although we proved ranitidine was responsible for the reaction. conclusion: gentamicin is an aminoglycoside antibiotic used systemically for septicemia and as prophylaxis during surgery. immediate type allergy (type i) to gentamicin is rarely reported. since , approximately only five cases have been reported in literature. in our case, initial theories were pointed towards cefazolin as beta-lactams report a higher rate of allergic reactions. after an exhaustive allergological study, results disproved our initial theory indicating gentamicin as the responsible drug. giangrande n ; bobadilla-gonzález p ; garcía-menaya jm ; cámara-hijón c allergy department, infanta cristina university hospital, badajoz, spain; clinical immunology department, san pedro de alcántara hospital, cáceres, spain background: polyethylene glycol (otherwise known as macrogol or peg) is a polymer with a wide application as an excipient, solvent and dispersing agent in food, cosmetic and pharmaceutical industry. it presents distinct length polymer chains with a molecular weight from to g/mol conferring them specific properties. macroglol with a molecular mass between and g/mol is commonly used as osmotic laxative previously to colon endoscopy and radiologic examinations. after the introduction, anaphylactic reactions to macroglol are rarely reported, considering it safe and well tolerated. we report on a -year-old man who, immediately after of the topical application of benzindamine in left inferior limb developed acute urticaria in this limb, which reverted in approximately hours with systemic steroids. she had previously tolerated this product without any problems. skin prick-tests with benzindamine ( . mg/ml) and latex were realized in the patient. skin prick-tests with benzindamine were realized in eleven healthy control subjects. results: skin prick-test with latex was negative in the patient. skin prick-test with benzindamine was positive in the patient ( × mm). the prick-tests with benzindamine were negative in eleven healthy control subjects. we report on a case of contact urticaria due to benzindamine and triggered by an immediate, probably ige-mediated, hypersensitivity mechanism. some of the drug used in daily clinical practice can cause allergic contact urticaria and should therefore be borne in mind. background: the use of new oral anticoagulants which act as direct inhibitors of activated factor x is constantly increasing, due to lower rates of serious and fatal bleeding events than warfarin/acenocoumarol. rivaroxaban, the first commercialized drug in this group, is the most used for prevention of thromboembolic events. however, < cases of hypersensitivity reactions have been described so far, most of them delayed and severe. to present a case of delayed hypersensitivity to rivaroxaban, diagnosed by a positive ltt (lymphoblastic transformation test). a year old woman with hypertension and chronic atrial fibrillation (af) was referred to our clinic for suspected drug allergy. she reported that months before, for af she was started on oral amiodarone and rivaroxaban, presenting on the seventh day with both of them generalized erythema, pruritus, micropapular rash and facial angioedema. no oral or other mucosal were observed, neither pustules, vesicles or blisters. blood eosinophilia, enlarged lymph nodes, renal and hepatic injury were discarded in emergency, where the new drugs were discontinued and replaced by acenocoumarol. the rash subsided one week later, with oral antihistamines. before and after the episode the patient also has been taking losartan and hydrosalurethyl, with good tolerance. she denied other adverse reactions. in allergy department we performed skin prick tests and intradermal tests with amiodarone ( . mg/ml and . mg/ml) and rivaroxaban ( . mg/ml and mg/ml), and a ltt with both drugs, months after the reaction. background: patients with history of beta lactam allergy, often self-reported, are commonly encountered in the hospital setting. this frequently leads to increase use of broad spectrum and more expensive antibiotics that may be unnecessary or even less efficacious at times due to fear and concerns about potential disastrous outcomes. nonetheless, with increasing awareness, many patients are now being referred to allergy service for formal evaluation. we aim to look at patients who underwent evaluation for beta-lactam hypersensitivity and determine the number of patients that were successfully de-labelled. method: a retrospective analysis was conducted with patients referred for evaluation of questionable beta-lactam allergy to the allergy service in our institution from the years - . initial evaluation process included a thorough history to determine the type of hypersensitivity reaction and suitability for further testing. patients underwent skin prick test (spt) and intradermal (idt) with either (a) both major and minor determinants of penicillin, benzyl penicillin, amoxicillin and ampicillin, and/or (b) the culprit drug itself. if skin testing was negative, oral or intravenous (iv) drug challenge was then performed after informed consent. clinical details and reactions were documented. patients were also contacted post challenge to ensure no delayed reaction had occurred. results: a total of patients were evaluated for beta-lactam allergy in the year period, of these were females and were males. of the referred patients had presumed penicillin group allergy and had cephalosporin group allergy ( patients had both penicillin group+cephalosporin allergy). cases ( %) were successfully de-labelled. beta-lactam allergy was confirmed in patients ( %); identified by positive spt in two patients, positive idt in six patients and positive drug challenge in patients ( patients developed rash/urticaria, had respiratory symptom and patients developed anaphylaxis). patients were referred before any drug allergy labelling was done, out of which were confirmed not to have beta-lactam allergy. conclusion: in our study, % of patients were confirmed not to have true beta-lactam allergy. we were able to successfully remove beta-lactam allergy label from the electronic record for % of the patients. results: a total of % referred amoxicillin-clavulanic acid (ax-clv) as trigger for the hypersensitivity reactions (hrs), followed by ax ( %), penicillin ( %) and cephalosporins ( %). almost % of hrs were immediate (< minutes). positivity of skin tests was observed in % subjects, of bat in % and of rast in %. in conclusion: the label of penicillin allergy is quite often erroneous. this involves using of more expensive and less effective therapeutic alternatives, which also facilitate the emergence of multi-resistant micro-organisms. hence the importance of confirming the diagnosis of allergy. finally, we did not find differences in the study of penicillin allergy in patients older than years compared with the general population. background: severe cutaneous delayed drug reactions (toxic epidermal necrolysis -ten-, stevens-johnson syndrome -sjs-, acute generalized exanthematous pustulosis -agepand drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome -dress/dihs-) among others, are a rare but potentially fatal complications of drug treatment. although its epidemiology has been described in different latitudes, it is unknown in latin america. our aim was to describe the epidemiological characteristics of severe cutaneous reactions to drugs in countries of latin america. method: an online questionnaire was designed to report new and old cases (since ). it was a modified and adapted version of enda questionnaire for drug allergy interesting group. sociodemographic data, type of reaction (ten, sjs, dress-dihs, agep), culprit drug (s), treatment, complications, mortality and sequelae, were described. three centers from colombia, one from argentina, one from brazil and one from paraguay were included. an excel database was created, in which cases were recorded and analyzed. results: thirty seven cases were reported. ( %) were women. the median age was years. ( %) had dress/dihs, ( %) ten, ( %) sjs, ( %) agep, ( %) other not classified scars, and ( . %) overlapping ten/sjs. the main culprit drugs were aromatic anticonvulsants in cases ( %), beta lactam antibiotics in ( %), non-beta lactam antibiotics in ( %) and allopurinol in ( . %). in % of the patients the suspect drug was withdrawn. thirty one patients ( . %) received systemic corticosteroids. complications occurred in cases ( %) and death in one patient ( . %). seven patients ( %) had some type of sequelae. countries, dress/dihs was the most frequently reported clinical entity, and the anticonvulsants were the main triggers. complications were frequent, but mortality was low. | drug-induced cough: analysis of nationwide spontaneous reports in korea over ten years using who-adverse reaction terminology (who-art) indicative of cough. results: from cases of spontaneously reported adverse drug event cases, a total of cases ( . %) were identified as drug-induced cough. most cases occurred in adults ( . % of the subjects) and females were more common than males ( . % vs . %). regarding severity, only cases ( . %) were classified as serious based on who criteria. the most common causative drug category was antineoplastic and immunomodulating agents ( . %), followed by cardiovascular drugs ( . %). the most common causative drugs were ace inhibitors including perindopril and ramipril. conclusion: in the nationwide spontaneous reports of adverse drug events, many cases of drug-induced cough have been reported so far. much attention is needed to find new causative drugs of cough in the future. background: allergological assessment to determine the mechanism of the perioperative reaction and to identify the agent responsible and recommendation of a range of drugs or agents likely for future surgery is essential, but it often poses a significant challenge. in this study, we analyze our experience in the investigation of adverse reactions during anesthesia in the last years. method: a total of patients who attended our allergy unit with suspected perioperative reactions between january and december were reviewed retrospectively. the severity of the perioperative allergic reactions was graded according to ring and messmer system. results: grade iii, ii and i reactions were observed in , and patients, respectively. in patient we didn't know the reaction suffered. tryptase measurements were available for patients. of those, and patients had elevated and normal levels respectively and suffered grade reaction. ige mediated reactions was diagnosed in patients ( %): for ßlactam antibiotics ( . %), for patent blue ( . %), for neuromuscular blocking agents-nmbas ( . %), for latex ( . %), for colloids ( . %) and for ranitidine ( . %) . cefazolin was the ß-lactam antibiotics causing the largest number of reactions. non-ige-mediated reactions was diagnosed in patients ( %). the allergy tests were negative and tryptase levels were normal. conclusion: in our series, among the patients who suffered allergy reactions during anaesthesia and the cause was subsequently identified, ß-lactam antibiotics were the most common causative agent ( . %), followed by patent blue ( . %), nmbas, latex, colloids and ranitidine ( . % each agent). in contrast, data from other authors indicated that nmbas were the most common cause of anaphylaxis, followed by latex, hypnotics, antibiotics, plasma substitutes and opioids. these differences might be due to the small size of our study, which was limited to our centre over the last years and thus may not be representative. diagnostic evaluation. all patients signed an informed consent. we made a retrospective analysis of their clinical records and excluded patients whose records were missing or incomplete. it was analyzed each patient's medical history (focusing allergic disease) and clinical reaction to the suspect drugs. signals/symptoms at pcc were characterized. we also studied the variation of the dpt's results when it was performed after a pcc. aim: to define and quantify the ongoing pharmacy needs in sustaining a large drug allergy assessment program. method: a retrospective review of pharmacy files was used to identify and quantify the drugs and dosages most frequently used and to determine prescription trends within the allergy testing program over the last years. results: initially, this reaction was thought to be a result of a drug allergy, but upon further review and the onset of fever, we determined that it met the diagnostic criteria of jhr. his twin brother was diagnosed with penicillin and betalactamic allergy. neutrophilia % was to be underlined in the blood test. after this, drug oral challenge with penicillin was performed, ruling out penicillin allergy. conclusion: it is not uncommon to confuse drug allergy with jhr. jhr should be an anticipated reaction to early doses of antibiotic treatment for treponemal diseases, such as syphilis. antibiotic treatment should be continued; it is not a warrant to stop treatment. clinicians should be aware and anticipate jhr as a potential complication to early doses of antibiotic for spirochetal diseases such as syphilis or lyme, leptospirosis. the patient was unresponsive in oral drug provocation tests with amoxicillin-clavulanic acid, clarithromycin and trimethoprim sulfamethoxazole for months. the patient could use these drugs. results: chronic abacterial inflammation of the prostate gland was accompanied by a significant increase in concentration of slpi, il- , tnf-α, il- in the seminal plasma and serum concentration, and a decrease in the concentration of il- and tgf-β compared to healthy men (p < . ). there was no statistically significant difference between slpi, il- , tnf-α, il- , il- , and tgf-β in the ejaculate of patients with inflammatory and non-inflammatory forms of cap (p < . ). the concentration of il- in ejaculate of patients with inflammatory forms of cap was significantly greater than in patients with non-inflammatory form of cap (p = . ). the inflammatory and non-inflammatory forms of cap are pathologically similar with changes in the concentration of the studied cytokines except for il- in both forms with signs of inflammation. the terms "leukocytic" vs "non-leukocytic" chronic abacterial prostatitis are more correct than "inflammatory" and "non-inflammatory" when describing chronic abacterial prostatitis. results: the status of all patients after dc immunotherapy was evaluated as satisfactory. heart rate, blood pressure in patients remained within the age norm. skin had normal color without rash or peripheral edema. there were no local or systemic allergic reactions. the body temperature after the injection did not exceed °c. conclusion: these results show, for the first time, that among mastocytosis patients, besides the already known periodontal disease risk factors that include diabetes, age, osteoporosis and alcohol consumption, the bone marrow mast cell burden is also associated with increased periodontal disease severity. results: metformin at relatively low doses ( - μm) was shown to mildly suppress ige-mediated responses, including degranulation ( % reduction, p = . ), tnf-α ( % reduction, p = . ) and il- ( % reduction, p = . ) secretions in bmmcs. importantly, metformin at the same doses potently inhibited mast cell responses in all parameters ( % reduction, p < . for degranulation; % reduction, p < . for tnf-α; % reduction, p < . for il- ) in mast cells treated with an ahr ligand, , -dihydroindolo[ , -b]carbazole- -carbaldehyde (ficz). mechanistically, its inhibitory effect was mediated through the suppression of ficz-induced mapk activation, intracellular calcium release and ros generation. metformin also blocked ahr-mediated pca in vivo ( % reduction, p < . ). conclusion: metformin, a common anti-diabetic agent, was shown to exert inhibitory effect on ahr-mediated mast cell activation in vitro and in vivo, suggesting its potential utility as a newer form of therapy for asthma and allergic diseases; this is particularly relevant when considering the adverse effect of the exposure to environmental polycyclic aromatic hydrocarbons. gasser p ; brigger d ; zbären n ; jardetzky t ; pennington l ; eggel a results: in one of affected family members, we were able to identify the c. a>g mutation in the plasminogen (plg) gene that was recently described to be associated with hereditary angioedema. this mutation leads to a missense mutation with an amino acid exchange p.lys glu in the rd kringle domain of plasminogen. there is no direct relationship between the earlier described cases with this mutation and the family we report here. in all affected members of the family, the symptoms manifested in early adulthood, with swelling of the face, the tongue and the larynx. the frequency of attacks was variable, between once in a year to once in a month. in one of the three family members, we found a slightly decreased level of coagulation factor xii and of plasminogen. icatibant proved to be very effective for the treatment of acute attacks in the affected family. the occurrence of the same c. a>g (p.lys glu) mutation in the plg gene in many families with no or only unknown distant relationship suggests that the disease might have been inherited through the generations without being purged from the population. the mutated amino acid exchange appears to be significant for the function of plasmin or plasminogen. we found a decrease in plasma levels of coagulation factor xii and plasminogen, which may be beneficial markers for diagnosis and monitoring of this disease. several biomarkers are useful in the diagnosis (fibrin degradation products (fdps), d dimer (dd), and fragments of prothrombin + ). also, a correlation between the levels of biomarkers and activity phases of the disease has been detected. alterations in coagulation parameters have an etiopathogenic role in the ae attack, but have not been considered as biomarkers of activity phases. tgt is a global coagulation test which quantifies in vitro the ability of plasma to generate thrombin and estimates alterations in coagulation parameters. the objective is to assess the usefulness of the thrombin generation test (tgt) to characterize patients with hereditary angioedema (hae). method: seventeen hae patients from hospital la fe were recruited to obtain blood samples in remission and during ae attacks. none of them experienced thromboembolic events. plasma was collected in citrate tubes to obtain platelet rich plasma. hemostatic parameters were analyzed:. tgt was conducted using a calibrated automated thrombogram (cat) method and a fluoroskan ascent as a reader. results were analyzed via thrombinoscope v . citrated plasma was incubated with calcium, tissue factor, phospholipids and a fluorogenic substrate. a thrombin generation curve is generated, obtaining parameters: latency time (lagtime), thrombin generation maximum speed (vo), maximum peak of thrombin generated (peak), time to generate the maximum peak of thrombin (ttpeak), total quantity of generated thrombin (etp), and the end time of thrombin generation (starttail). tgt parameters from healthy donors were used as controls. results: thirty-eight samples were collected from seventeen hae patients ( . % female). fifteen ( . %) samples were collected during ae attacks. tgt parameters and fdps were significantly higher in hae patients compared with controls (p < . ), although no significant differences were found in tgt between acute attacks and remission. a decrease trend in tgt is observed in ae attacks. fdps were increased during ae attacks, but normalized at remission periods. these results support the involvement of coagulation in the pathophysiology of hae, although no increase in prevalence of thrombosis is observed during acute attacks. method: the repeated measures design study included patients in two groups: the slit group, patients- follow-ups per allergen (p), and the vit group, patients- p. the slit group had patients treated for hdm ( p), and patients on pre-coseasonal pollen ait (grass p, ragweed p, birch p). the vit group had patients on rush protocol ( for bee and for wasp) and patients on conventional protocol ( bee, wasp, and for both). the ige and igg levels were measured by the immunocap method. the friedman test was used to compare data. results: when compared to placebo group, slit+vitamin d group therapy was more effective in the reduction of nasal symptoms (p = . ), asthma symptoms (p = . ) and combined symptommedication score (p = . ); there was no significant difference between groups in medication and ocular scores. we observed a significant improvement of fev (vitamin d group p = . , placebo group p = . ) and fev %vc levels (vitamin d group p = . , placebo group p < . ), within both groups, between visits. feno results did not differentiate statistically significantly the study participants in terms of receiving slit along with vitamin d or placebo. significant increase in the percentage of cd + cd + foxp + and in tlr positive cells in children receiving slit+ vitamin d was observed compared to placebo group. increase in cd + cd + fox-p + induction, and in tlr positive cells recruitment were independently associated with better clinical effect of slit in children. conclusion: overall, ait with a high-polymerized ash pollen extract was well tolerated. as ash pollen are supposed to be an important allergen during spring time, it is recommended to include spt and npt with ash pollen in the test panel for allergological diagnostic. additionally, determination of ash pollen specific ige could be applied. furthermore, appropriate ait should be considered for ash pollen allergic patients. a | impact of sublingual immunotherapy with a five-grass pollen tablet on grass pollen allergic rhinitis and asthma: a real-life, long-term analysis in france background: data on the fulfilment of prescriptions of symptomatic medications in patients with grass pollen allergy were analysed to evaluate the long-term effectiveness of sublingual immunotherapy (slit) on allergic rhinitis (ar) and asthma. method: by using data in the lifelink ™ treatment dynamics database (iqvia, paris, france), we compared two cohorts of patients with ar: a group treated with oralair® (stallergenes greer, antony, france) slit tablets (n = ), and a matched control group having received symptomatic medications only (n = ). oralair®'s effectiveness was assessed as the change in symptomatic medication fulfilments between the pre-index period (before the initiation of slit) and the follow-up period (after slit), and as the onset of asthma or the progression of pre-existing asthma (based on fulfilments of prescriptions for asthma medication). the number of fulfilments per year was calculated for each patient and each period. results: in line with prescribing guidelines, the mean duration of treatment with oralair® was . months per season for either seasons or seasons. the mean number of symptomatic medications for ar fulfilled per patient and per year in the pre-index period was . ± . in the slit tablet group and . ± . in the control group. in the follow-up period, this value fell for the slit tablet group (to . ± . ) but did not change significantly in the control group ( . ± . ). when considering individuals not taking any asthma medications in the pre-index period, asthma onset during the treatment period was observed in . % of those in the slit tablet group and in . % of those in the control group. the corresponding values for the follow-up period were . % in the slit tablet group and . % in the control group. when considering individuals already taking asthma medications in the pre-index period, the mean ± sd number of asthma medication fulfilments in the pre-index period was lower in the slit tablet group ( . ± . ) than in the control group ( . ± . ). the corresponding values for the treatment period were . ± . and . ± . , respectively. in the follow-up period, the number of asthma medication fulfilments fell more in the slit tablet group (to . ± . ) than in the control group ( . ± . ). oralair® tablets have long-term effectiveness by relieving allergic rhinitis and slowing a progression to asthma. b | a real-life, retrospective analysis evidencing slower long-term progression of asthma in grass pollen allergy patients treated with sublingual immunotherapy tablets | an examination of the reasons for treatment discontinuation and non-compliance to allergen immunotherapy background: allergic rhinitis (ar) patients treated with subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit) may be non-compliant or discontinue treatment too early, which can negatively impact efficacy. therefore, understanding the reasons for non-compliance and treatment discontinuation is vital to help improve compliance, persistence and thus outcomes. this study reported reasons for treatment discontinuation to scit and slit and non-compliance to slit in patients with ar in published real-world studies. method: a literature review was conducted in embase, medline, ebm reviews, psycinfo and econlit ( - ) using key search terms for allergic rhinitis, scit, slit, non-compliance and non-persistence. across all studies,~ % of patients were non-compliant, and -year drop-out rates ranged from % to %. reasons for noncompliance and treatment discontinuation in this subset of patients were stratified according to the who dimensions for adherence (patient-related, treatment-related, or socio-economic). results: from the publications identified, six studies reported reasons for non-compliance to slit (n = ) or treatment discontinuation (n = ) to scit or slit, and the results were grouped for analysis. the majority of patients cited treatment-related factors as the primary reason for discontinuation ( % for slit, % for scit). common reasons were a length of treatment for slit and frequency of injections for scit. % of patients discontinued scit due to patient-related factors such as travel to doctors and waiting time for administration. only % of slit patients discontinued due to patient-related factors. socio-economic reasons for discontinuation were low for both therapies ( % slit and % scit). conversely, for non-compliance to slit, socio-economic factors were the most frequently cited reasons ( %), and included taking time off work and financial concerns. conclusion: of patients who discontinued therapy, treatmentrelated factors were the most cited reasons for scit and slit, reflecting concerns with administration and treatment length. noncompliant slit patients cited socio-economic factors as common reasons for non-compliance, suggesting financial concerns over a long treatment course. differences in reasons for non-compliance and treatment discontinuation may be due to patients assigning differing importance for compliance (a day-to-day decision) compared to the long-term decision to discontinue treatment. results: % of patients had monosensitization to rbet v component. the rest % had combinations ige to rbet v and ige to one, two or even three minor allergens ( %, %, % accordingly). after courses of slit by standardized pollen extracts symptoms of arc and pfas decreased in % and % patients accordingly. in group patients with monosensitization to rbet v : patients had a reduction of arc ( % had - degree by ado); patients had reduction of pfas. patients hadn't finished treatment due to allergic reactions. among patients with sensitization to rbet v /v : patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patient hadn't finished treatment due to allergic reactions. in patients with sensitization to rbet v /v : patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patients with sensitization to rbet v /v /v showed the similar results: patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patients had sensitization to all cra, and only patient who also received slit with grass allergens had reduction of arc only ( degree by ado). as the result of the study it was identified that beneficial effect of slit is highest in patients with monosensitization to rbet v . the increase of sige sensitization profiles to minor birch allergens caused less efficacy of slit treatment. dermatophagoides pteronyssinus immunotherapy is independent of sensitization to blomia tropicalis among children with allergic rhinitis and asthma method: children ( - years old) with allergic rhinitis and asthma sensitised to both dp and bt received years dp-scit. clinical symptom and medication scores, serum specific ige and specific igg were evaluated during dp-scit. in order to investigate whether the treatment outcome was dependent on the sensitisation pattern between dp and bt, patients were further grouped into dp and bt co-sensitisation and cross-reaction, according to positive or negative ige against bt major allergen (btma) blo t and blo t . btma+ group, with specific ige to either blo t or blo t , was defined as the co-sensitized group; btma-group, with no detectable ige to both blo t and blo t , was defined as the cross-reactive group in this study. results: all the recruited patients completed year of dp-scit, ( %) patients completed years of treatment. after years of dp-scit, compared to baseline, all patients had significant reduction in symptom and medication scores. lung function (fev ) was significantly improved as well. % of the patients were free of medication use and asthma symptoms, % of them were free of rhinitis symptom, and the fev % in all patients were higher than % of predicted. dp-scit induced significant increases in dp and bt specific igg . in % of patients, dp specific igg increased more than fold and bt specific igg increased more than . fold. further investigation in btma groups showed moderate correlation (spearman r = . , p = . ) between specific ige against dp and bt in the btma-group (n = ), indicating specific ige cross-reactivity. no specific ige correlation (spearman r = . , p = . ) was found in the btma+ group (n = ) indicating co-sensitisation to both dp and bt. the two groups showed almost identical change in clinical responses. dp and bt specific igg significantly increased during dp-scit, no difference was found between the two btma groups. conclusion: dp-scit can induce specific igg cross-reacting with bt allergens. patients with specific ige sensitisations to both dp and bt may have clinical benefit from dp-scit treatment. moreover, the clinical benefit of scit was independent of ige cross-reactivity or co-sensitisation to dp and bt. method: we investigated allergic rhinitis children who were basically sensitized to house dust mite and received house dust mite slit for year and months. among patients, patients were mono-sensitized to house dust mite (group ) and patients were poly-sensitized aside from house dust mite (group ). we also assigned another allergic rhinitis children who were only treated by medication as control group. nasal symptoms (rhinorrhea, sneezing, nasal obstruction, nasal itching, sleep disturbance) and anti-allergic medications use were assessed at every -month visit. results: the symptoms of allergic rhinitis started to improve after months of slit and significantly improved after a year and a half in group and group compared with control group. there was no significant difference between group and group . anti-allergic medication use in group and group significantly decreased after a year and a half compared with control group and there was no significant difference between group and group . conclusion: house dust mite slit was more effective than treatment only by medication. the effect of house dust mite slit was similar between mono-sensitized and poly-sensitized allergic rhinitis children. house dust mite slit could also be recommended to polysensitized allergic rhinitis children. method: a prospective, randomized, double-blind, controlled, multicenter phase ii study was conducted with four different concentrations of cluster allergoid clustoid wiesenlieschgras (group : tu/ml; group : tu/ml; group : tu/ml; group : tu/ml). out of patients screened, grass pollen allergic patients ( - years) were randomized. the cluster build-up phase was followed by four monthly maintenance injections of . ml. the efficacy was evaluated by the change of the threshold concentration step needed to induce a positive reaction in a titrated nasal provocation test (tnpt) before start and after end of the study (pre-post analysis). the safety profile was assessed for each treatment group by analyzing treatment-related adverse events. background: allergen immunotherapy relies on the consistent administration of allergen extract, therefore compliance to these treatments (subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit) tablets and drops) is vital for efficacy. as scit is administered as an injection by a healthcare professional, and slit is self-administered, compliance to scit may be perceived as superior. therefore, a review of real-world studies investigating compliance to scit, slit-tablets or slit-drops was conducted. real-world studies, instead of clinical trials, were included in this review as they are more likely to reflect actual clinical practice and patient compliance. method: a literature review was conducted in embase, medline, ebm reviews, psycinfo and econlit ( - ) using key search terms for ar, scit, slit-tablets and slit-drops, and real-world compliance. compliance was reported according to ispor medication compliance and persistence work group definitions. results: from the publications identified, eight studies (seven slit [one slit-tablets, two slit-drops, four unspecified], one both scit+slit-tablets) reported compliance rates and were included in the analysis. real-world compliance rates ranged from % to % for slit administration and % for scit administration. only one study compared compliance of slit to scit, with similar rates reported over three years ( % and % respectively). three studies reported "good" compliance (physician-reported or patients consuming > % of allergen extract) to slit-drops or slit-tablets. the good compliance rates were higher for slit-drops ( %- %) compared to slit-tablets ( %- %). observed compliance to slit-drops or slittablets did not vary by country or geographical region. the percentage of patients defined as having "good" compliance to slit-tablets or slit-drops did not vary by study length or patient population. conclusion: whilst compliance to scit may be perceived as superior to slit-tablets and slit-drops, comparable compliance rates between scit, slit-tables and slit-drops were identified across real-world studies. differences between perception and real-world results may be explained by a lack of direct comparisons between scit and slit administration. limitations included discrepancies in definitions of compliance, as well as methodology between studies. however, these are common to reviews analysing compliance, regardless of therapy area. conclusion: in the allergic rhinitis patients, successful compliance for -year slit compared with control was approximately %. method: igg inhibition elisa: rabbit igg antibodies specific for grass allergen allergoids are pre-incubated with different concentrations of alum-adsorbed grass pollen allergoid. the mix is added to an allergoid coated microtiter plate. unbound igg will bind to the allergoid coat and is subsequently incubated with anti-igg hrp labeled conjugate and stained with tmb. results are expressed as percentage inhibition relative to the uninhibited value. the concentration of alum-adsorbed allergoid that is required to inhibit % igg is used as read-out. circular dichroism: far-uv cd spectra ( - nm) were recorded on a j- spectropolarimeter. a cuvette with a stirring compartment was used to keep the suspension homogeneous during measurement. results: the igg inhibition elisa assay is specific for grass pollen allergoids (not for other allergen allergoids), has a good inter-and intra-assay precision and is robust for assay variation. thermally stressed alum-adsorbed grass pollen allergoids were used to show that the igg inhibition assay can be used as a stability indicating method. severe thermal stressing resulted in a higher % inhibition value, indicating a loss of igg epitopes. furthermore, far-uv cd analyses showed that there is a close relation between the decreasing igg binding capacity ( % inhibition values) and the loss secondary protein structures by unfolding (cd-ratio / nm values). the igg inhibition assay was demonstrated to be a valuable method to determine the stability of alum-adsorbed grass pollen allergoid preparations. in addition, a relation was shown between the igg binding capacity and the change in secondary protein structures. | design of a pivotal phase iii trial of allergen specific immunotherapy (ait) using a high-dose house dust mite (hdm) allergoid in patients with allergic bronchial asthma method: male and female outpatients (age - years) asthmatics allergic to hdm are enrolled. during the baseline phase, the patient's minimal dose of ics required to achieve asthma control will be assessed. after the baseline period, approx. patients will receive double-blind placebo-controlled treatment for approx. months, followed by a nd period of weeks to assess the minimal ics dose and further months of observation for the assessment of asthma exacerbation. based on the results of the dose finding study regarding the efficacy endpoints and the safety profile, the optimal allergoid dose is considered to be pnu. results: competent authorities and ethic committees in all participating eu countries, serbia, russia and ukraine approved the study design. the primary endpoint of the trial is the change in predefined dose steps of the minimal daily ics dose required to achieve asthma control after approximately months of subcutaneous ait. all efficacy data will be determined using daily questionnaires and the acq by e-diary for months from october to january. the aim of this clinical trial is to demonstrate efficacy and to evaluate safety of ait with an allergoid preparation of major allergens of dermatophagoides pteronyssinus in patients suffering from allergic bronchial asthma caused by house dust mites. asthma increases the burden of allergic disease and health care costs, especially when uncontrolled. with the development of a high-dose preparation we intend to treat asthmatic patients highly efficiently. romantowski j; jassem e; lata j; wasilewska e; chelminska m; specjalski k; niedoszytko m background: specific immunotherapy (sit) is the only causal treatment in patients allergic to airborne allergens. it has been proven to be widely effective in allergic populations, but individual patients vary in terms of response to the therapy. the aim of the study was to assess the factors that might affect the efficacy of sit. method: patients treated with sit for grass pollen or house dust mites were included. the efficacy of sit was assessed with the use of allergy control score (acs), performed before and at least after one year of sit. the following variables were assessed as potential risk factors for a poorer response to sit: age, gender, type of allergy, type of allergen, type of vaccine, type of sit and smoking history. background: specific immunotherapy (sit) is a suitable treatment option for asthma and allergic rhinitis (ar), but it is not commonly used in korea. in the achievement of the treatment, it is important that immunotherapy is applied with ideal dose and regular intervals and it is essential for the patient compliance. the aim of this study is to investigate evaluate compliance with immunotherapy protocols of patients who were treated with sit in clinic and their satisfaction of the treatment. we performed a multicenter, cross-sectional survey using a specially designed questionnaire that was given to allergy specialists and patient in korea. a member of the trained research group conducted face-to-face questionnaire interviews with each respondent. conclusion: this study shows that most patients are ar with asthma. in our study sit compliance and satisfy are found to be high in both groups. aim: to identify the frequency of regress claims in a dermatological setting and to assess its impact on general prescription behaviour and immunotherapy. method: all physicians of the psoriasis-praxisnetz süd-west e.v. (n = ) were invited to participate in a web based questionnaire study on the topics of dermatology and medical law. the survey was separated into two sub-polls which were carried out after a first poll deciding whether the topic of medical law is of any interest for the dermatological practice. the topic of interest was located in the second poll. results: overall, dermatologists participated in this study. most participants were form bavaria, baden-wuerttemberg or rhineland-palatinate and had more than years of experience as a dermatologist. out of the participating physicians . % (n = ) already experienced a previous regress claim. of these, . % (n = ) stated, that the experienced regress claim changed their prescription behaviour. half of these participants (n = ) further stated, that the fear of a possible recourse affects their prescription behaviour, whereas only out of the other participants declared a possible influence. missing values excluded, this leads to a substantial hesitation in physicians who experienced a prior recourse ( . % vs . %). nevertheless, this seems not to affect the usage of allergen immunotherapy, as all physicians who already experienced a regress claim, stated to use allergen immunotherapy. the fear of a possible regress can change physicians' prescription behaviour but does not seem to have an effect on the prescription of allergen immunotherapy. therefore, the topic should be addressed from another perspective such as providing trainings on relevant regulations for physicians who experienced a prior recourse claim. this approach could also improve patient centred care related to modern treatments. results: the sds were significantly reduced in patients subjected to slit (p < . ) year after the onset it. vas also was significantly reduced (p < . ) with satisfied control of sar and the same time with translation from moderate-severe to mild-moderate sar, after slit. nbh was also significantly reduced (p < . ) year after the onset slit. in patients receiving pht only, sds, vas and severity of sar did not change and significantly higher (p < . ) from the value obtained in the experimental group. nbh also remained unchanged and significantly higher (p < . ) then in experimental group. precoseasonal slit added to pht shows short-term beneficial clinical effects in polysensitized patients with sar and scuad phenotype. results: ten studies ( children, adults; median sample size, ) met the inclusion criteria. the risk of bias was moderate to high in all but one studies. low strength evidence supports the assumption that ait is effective in reducing symptoms and medication use, with only out of studies reporting higher benefit in the ait group vs comparator group. subgroup analyses of studies sharing similar characteristics did not explain inconsistency. safety does not appear was not major concern for alternaria ait. conclusion: this is not enough strength of evidence to suggest that mold ait is efficacious for the treatment of respiratory allergies. high-quality studies with an adequate sample size are needed. abstracts | | tolerability of a two week rush updosing with modified trees, modified grasses or modified grasses/trees mixture in pollen allergic subjects in the day-to-day practice table) severe systemic reactions (grade iii and iv) did not occur. conclusion: rush immunotherapy is an effective therapeutic method for patients with allergic rhinitis. it seems that in cases requiring faster response to treatment, this immunotherapy can be considered as a substitute for conventional immunotherapy. | design of a pivotal phase iii allergen immunotherapy study to assess the efficacy and safety of subcutaneously administered tyrosine adsorbed modified birch allergen+mpl results: the design of this study, including sample size and primary and secondary endpoints, will be discussed based on prior experience gained in two dose finding studies. in addition, the number of patients screened and randomized will be presented by country, gender and/or age and screen failures will be categorized. results: the primary analysis showed an absolute difference in tcs between placebo and du of . ( %, p < . ). the odds of experiencing a severe day during the bps were approximately doubled in the placebo group compared to the du group (or = . , p < . ) and the odds of experiencing a mild day were halved (or = . , p < . ). similar results were seen for the tree pollen season (tps), covering both alder, hazel and birch pollen seasons. the total rqlq score was improved for du compared to placebo during the bps and tps (p < . , except for the last week of the tps), with the most pronounced effects during week - of the bps (absolute difference: . - . , p < . ). treatment was well tolerated. the most frequent adverse reactions were mild or moderate local reactions related to the sublingual administration. no deaths were reported and no serious adverse events were assessed as related to the sq tree slit-tablet. conclusion: treatment with the sq tree slit-tablet improved arc symptoms and need for symptomatic treatment. the du group had less "severe days" and more "mild days" during the pollen seasons. the quality of life was similarly improved. these findings substantiate the clinical relevance of the sq tree slit-tablet for patients with arc induced by pollen from the birch homologous group. nagaraju k ; nagaraju k ; katare s ; kapatkar v ; shah a ; rathod r results: total n = subjects (mean age . ± . years, . % males) completed entire study. the mean incidence of artis reduced from . ± . episodes at baseline to . ± . (p < . ), with . % subjects not suffering from any episode. the mean duration of episodes reduced from . ± . to . ± . days (p < . ). % of episodes (vs % at baseline, p < . ) required antibiotics for mean duration of . ± . days (vs. . ± . days, p < . ). none of arti episodes in follow-up period required hospitalization as against . % episodes, (mean duration ± . days; p < . ) before pidotimod therapy. the number of school days lost & work days lost showed reduction of . ± . days(p < . ) & . ± . days(p = . ) respectively. the average expenses incurred in treatment of artis shows significant reduction of rs. ± (p < . ). adverse events were reported in ( %) subjects, which were mild in nature. a statistically significant increase in absolute counts of t-& nk cells was seen in explorative assessment of immune markers. the study shows pidotimod to be well-tolerated effective therapy in reducing the incidence and severity of recurrent artis, thereby providing additional benefit of reduction in discomfort & healthcare cost due to recurrent artis. thus, pidotimod can be considered as potential therapeutic option for treatment of recurrent artis in children. martignago i ; ridolo e ; incorvaia c department of medicine and surgery, university of parma, parma, italy; cardiac/pulmonary rehabilitation, asst pini/cto, milan, italy background: two registered sublingual immunotherapy (slit) products are available to treat grass-pollen induced rhinoconjunctivitis, consisting of the -grass (phleum pratense) and the -grass pollen tablets. no study of direct comparison of the efficacy of the two products was performed. we report the case of a patient who was treated in different years with the -grass or the -grass tablets with contrasting efficacy. the patient was a -year old woman suffering from years of grass pollen induced rhinoconjunctivitis. in slit was started with the -grass pollen tablets, but in , due to unavailability of the product, slit was performed by the -grass pollen tablets. in the third year of treatment slit with the -grass pollen tablets was resumed. for the -grass tablets slit was initiated before the pollen season and stopped after months of treatment, while for the -grass tablets the treated was prescribed to be continuous. the efficacy of slit was evaluated by symptom-medication scores as reported in diary cards by the patient during the month of may, when the grass pollen usually reach the higher concentration in the atmosphere in lombardy, where the patient lives. results: the mean symptom-medication score in the first year of treatment ( -grass tablets) was . , compared with a mean score of . in the second year ( -grass tablets). the patient was unsatisfied of the symptoms control and asked to resume for the last year of slit the -grass tablets. the mean symptom-medication score in such year was . . no clinically relevant adverse event was reported with any slit product. conclusion: based on the momentary unavailability of the -grass pollen tablet, it was possible to assess in a same patient the clinical outcome associated to either of the two registered slit products. a significantly different efficacy of slit with the -grass tablets compared with the -grass tablets was observed. | fusion proteins consisting of bet v and phl p form ige-reactive aggregates with reduced allergenic activity najafi n ; hofer g ; gattinger p ; smiljkovic d ; blatt k ; selb r ; stoecklinger a ; keller w ; valent p ; niederberger v ; thalhamer j ; valenta r ; flicker s background: bet v and phl p representing major allergens in birch and grass pollen, occur as monomeric proteins with high allergenic activity as assessed by clinical provocation testing in patients. she did not suffer more hymenoptera stings after the last reaction. one bee sting several years before bst resulted in no reaction. she has no symptoms with honey, vegetable or other food ingestion. methods: total ige and specific ige were determined using inmu-nocap system (thermofisher, scientific inc). apis, vespula and polistes (hørsholm, denmark) were also performed. prick tests showed negative results for all extracts tested. intradermal skin tests were positive for apis at μg/ml, but negative for vespula and polistes. our patient was diagnosed of anaphylaxis due to apis venom, thus bst was contraindicated and an epinephrine autoinjector was prescribed. she rejected hymenoptera venom immunotherapy. conclusion: to our knowledge, this is the first case of anaphylactic reaction after bee sting therapy. bee sting therapy should be considered a risk factor for anaphylaxis. patient reported good control of their disease, improved their quality of life, tolerating contact and exposure to numerous horses as well as contact with clothes of people who had been exposed. although ita is absolute contraindication on uncontrolled asthma with a degree of evidence ia, our case had only "transitory" con- and immunocap among wasp allergen components-i , i , i were %; . , %; . and %; . respectively and honey bee allergen components-i , i , i were %; . , %; . and %; . respectively. agreement between polycheck and immuno-cap i and i allergen components were %; . and %; . respectively. agreement between polycheck and euroline i and i allergen component were %; . and %; . respectively. based on wasp and bee components in all three systems, sensitization pattern was analyzed. similar test results were found between euroline and immunocap systems. the comparative studies carried out showed a markedly higher compliance of results with the euroline tests compared to polycheck with the immunocap system. percent agreement was extremely high and kappa value was substantial or almost perfect in the case of bee venom allergy between euroline results: a total of patients were included; ( %) males, with a mean age of (± ) years; ( %) beekeepers, ( %) were atopic, ( %) had asthma, ( %) rhinitis and ( %) cardiovascular disease, and of these patients were on ace/beta blockers. vit with honeybee was proposed in ( %), wasp ( %) and polistes ( %). the mean duration of vit was (± ) months. however, completed less than months. of the total, patients ( %) were not treated with vit. eighty-eight patients ( %) participated in the telephone interview: completed vit ( %), were still on vit ( %) and did not undergo vit ( %). of those who completed vit, ( %) were restung and went to the emergency department (er). twenty-four patients ( %) were stung while still on vit. of those never on vit, ( %) were re-stung and went to er. the severity of the reactions according to mueller of the patients who completed vit (mean follow-up time was months ( - months)) and were stung again was: local reaction in ( %), grade i in ( %); grade iii in ( %). one had a toxic reaction after multiple stings. in those who were stung during vit, ( %) had local reactions, ( %) grade i and ( %) grade iii. of those who were not treated and were re-stung: ( %) had grade i, ( %) grade iii and ( %) grade iv. in this series, the patients who did not undergo vit presented a greater number of systemic reactions when re-stung as well as more severe reactions (p < . ). conclusion: in this group with indication for vit, the reactions of the re-stings were less severe in the patients who had completed or who were on venom immunotherapy, as expected. three quarters of those who did not undergo treatment had severe anaphylactic reactions when they were stung again. this study reinforces the importance and the efficacy of immunotherapy in the treatment of hymenoptera venom allergy. method: this is a retrospective, descriptive study of cases diag- method: data were issued from the reference centre in mastocytosis of toulouse university hospital. ms diagnosis was determined using world health organization diagnostic criteria. hymenoptera venom immunotherapy was performed with an ultra-rush protocol (table) . results: seven patients were included ( women, men), median age years old. during the anaphylactic reaction, cutaneous signs missed in all cases. the reaction was most often severe: grade (n = ), grade (n = ), grade (n = ). three patients suffered from digestive symptoms and one from respiratory manifestations. basal tryptase in serum reached . - . μg/l. hymenoptera venom specific ige were low ( . - . kui/l) except for one patient ( . kui/l). ait was initiated with vespula venom in patients, polistis in patient, apis mellifera and vespula in patient, vespula and polistis in patients. no reaction was observed during ait. four restringing accidents led to increase the cumulative dose to μg and μg in patients. in these patients, the diagnosis of mastocytosis was made due to the resting. conclusion: hymenoptera venom ait using ultra-rush protocol seems well tolerated in patients with systemic mastocytosis. specific studies are necessary to determine the real tolerance profile of this protocol. collaboration with reference centres for mastocytosis should be considered for all patients with mastocytosis associated to hymenoptera venom allergy. dose (μg/ml) results: see table. conclusion: there is a shift or immunomodulation in terms of sige to vespids. even in patients double sensitised who were receiving venom of only one of the vespids. albanesi m background: slit has been suggested as an alternative route for allergen-specific immunotherapy. aim of this study was to investigate allergen-specific antibody responses in birch pollen allergic children who had received slit for two years using recombinant allergens. method: children (n = ; - y o) with respiratory symptoms of birch pollen and oral allergic syndromes (oas) were studied. ten children received slit with staloral, were treated by slit with microgen, and children received only symptomatic therapy (control group). sige and sigg levels to rbet v , rbet v , rbet v were measured twice (before therapy started and after two years) using quantitative immunocap and a panel of more than microarrayed allergens using immunocap isac technology. clinical efficacy of slit was evaluated by recording symptoms upon allergen contact and need of rescue medication. results: all children were sensitized to the major birch pollen allergen, bet v and one patient from each of the groups showed to bet v , no patient had sige to bet v . after two years of slit clinical improvement was observed in the slit patients. in the staloral group there were no respiratory symptoms in patients and a decrease of symptom severity in the other cases as well as a partial or complete tolerance to pr allergen-containing food in the patients. microgen treatment had no influence on oas symptoms but decreased of pollinosis severity in children. however, there were no statistically significant differences of bet v -specific levels measured before and after treatment in the slit and control groups (mann-whitney, p > . ). in this real-life study we found that birch allergic children who had been treated with slit showed a reduction of clinical symptoms but we did not find a significant induction of allergen-specific igg levels in the slit-treated group when compared with children who had only symptomatic treatment. conclusion: our study confirms the scarcity of food additives allergy. it also suggests that even when the diagnostic of allergy was excluded with a negative oral food challenge, families remain suspicious about industrials feeding products containing food additives. these results should reassure health professionals and parents who incriminate too frequently food dyes and conservators when a manifestation which mimics allergic reactions occurs. background: autumn/winter birth has been reported to be a risk factor of food allergy (fa) development. a putative mechanism is that dry/cold weather causes and exacerbates infant atopic dermatitis (ad), which is a major risk factor for food sensitization through inflamed/damaged skin. we investigated prevalence of fa among infants under well skin care in relation with seasons of birth (sob). we recruited full-term newborn infants without perinatal diseases at an obstetric/pediatric clinic. participants were followed up for skin status and food allergy symptoms until months of age. sob were defined as spring (march-may), summer (june-august), autumn (september-november) and winter (december-february). ad was diagnosed based on the united kingdom working party's criteria. use of moisturizer (mo) and topical corticosteroids (tcs) was recorded. primary outcome was fa based on apparent immediate allergic reaction after ingestion of causative food. we classified infants who avoided any food because of sensitization or mother's anxiety as suspected fa. results: six hundred and thirty-one infants were screened for month-period and infants were enrolled in this study. of them, infants were born in spring-summer (s-born) and infants were born in autumn-winter (w-born). fa developed in ( . %) infants and ( . %) infants had suspected fa. there was no difference (p = . ) in prevalence of fa and suspected fa between s-born and w-born. multivariate analysis revealed ad at and months of age was a significant risk factor for fa with or= . ( %: . - . ) and or= . ( % ci: . - . ), respectively. prevalence of ad at months of age was higher in w-born than s-born but prevalence promptly decreased thereafter and stayed low with early use of mo and tcs. prevalence of ad was rather higher at months in s-born than w-born. results: cases and controls were included. the median age was years, (q -q - ). men and women were almost equally represented ( . % males). alcohol consumption associated with the intake of mammalian meat or innards as the trigger factor. the overall prevalence of a positive result of sige to α-gal was abstracts | . % ic % ( . , . ); cases _ . % ic % ( . , . ) controls _ . % ic % ( . , . )_. among cases sige anti α-gal positivity rate ranged from . % (rural), to . % (half-urban) and . % (urban). the rates of positivity were . %, (northern) . % (center) and % (mediterranean). a positive result of sige to α-gal was more frequently observed among men ( . %) than women ( . %) and associated with history of tick bites, practice of outdoor activities, pet's ownership and the antecedent of having eaten mammalian meats or innards previously to the development of symptoms background: a special challenge in the st century for allergists is allergy to food, which is considered "the second wave" of epidemics of allergic diseases. panallergens occur in unrelated organisms and perform a similar function in them. in their structure, they have highly conserved amino acid sequence regions and a similar three-dimensional structure, and thus meet the requirements for cross-recognition by ige. results: in patients ( %) isac test has been shown to have specific ige for panallergen components. mostly, the presence of ige for pr- proteins has been shown in patients. in patients ige to ltp; patients ige to ccd; patients to profilin; patients to tropomyosin; patients to serum albumin, person to tlp. an important aspect is undoubtedly the occurrence of simultaneous sensitization to several panallergens. analysis of data from the study group showed that isolated sensitization to one panallergen concerned only pr proteins ( patients), tropomyosin ( patients) and profilin ( patient). in the remaining patients, the analysis of the isac test results showed that two or more panallergens were allergic. in the study group, asige for the component responsible for the occurrence of real food allergy was detected in ( %) patients. mostly, the presence of ige for jug r has been shown in patients. in the study group, panallergens were more likely to be responsible for food intolerance than specific food allergens. results: of children, children had peanut allergy only, children had tree nut allergy only, and children had both. the mean age was . ± . years in peanut allergy, . ± . years in tree nut allergy, and . ± . years in both. male to female ratio was significantly higher in tree nut allergy ( . %) than peanut allergy ( . %). among tree nut allergens identified, walnut ( . %) was most frequent, followed by almond ( . %), hazelnut ( . %), pine nut ( . %), chestnut ( . %), cashew ( . %), pistachio ( . %), and macadamia ( . %). mean serum total ige level was kua/l in tree nut allergy and kua/l in peanut allergy. mean serum specific ige level to peanut, walnut, almond, hazelnut, and pine nut was . , . , . , . , . , and . kua/l, respectively. children with peanut allergy had higher rate of co-sensitization with soybean and higher soybean-specific ige levels than children with tree nut allergy. however, there was no difference in co-sensitization rate with tree pollen between peanut and tree nut allergy. children with peanut allergy showed significantly increased co-sensitization rate with egg white and wheat compared to children with tree nut allergy. a . % of the children with peanut allergy and . % of tree nut allergy showed co-sensitization with aeroallergens. a total of % of the children with peanut allergy showed decreased specific ige levels within - years. conclusion: prevalence of peanut and tree nut allergy is similar. tree nut allergy develops later than peanut allergy and more common in male. children with peanut allergy showed higher co-sensitization rate with soybean, egg white and wheat compared to children with tree nut allergy. | natural history of egg allergy in a large cohort of infants with food allergy shows its high prevalence but also its transient nature in a months of follow-up background: the cohort of infants ( boys, girls, - months) with the food allergy has been followed for months. as more than % of infants manifested atopic dermatitis (ad), a condition closely linked to egg sensitisation, we focused our attention on egg allergy, following its natural history as well as a development of atopic march. method: the diagnosis of food allergy was based on a personal history, clinical examination, skin prick tests and/or atopy patch tests with native foods. laboratory tests were performed within year of age the latest. the specific ige levels against food allergens were measured using immunocap or immulite. patients with ad were scored according to scorad system. the oral food challenges (ofcs) with cooked/baked egg were done in children at the age of months except for children at risk of anaphylaxis. results: within the whole cohort the allergy to cow milk proteins was confirmed in pts ( . %), to egg in pts ( . %), to wheat in pts( %), to lentil in pts ( . %) to banana in pts ( . %), to soya in pts ( . %) and to potatoes in pt ( . %). in a cohort of egg allergy patients we found out that: % of pts presented the early onset of allergy-up to months of age, % of pts presented severe ad (scorad > ), % of pts showed cosensitisation to peanuts, % of pts had early sensitisation to inhaled allergens, and majority % of pts presented with early onset allergic rhinitis and/or asthma. we proved that egg allergy is closely linked with the early onset of allergy symptoms, with severe forms of ad, co-sensitization to peanuts, early sensitisation to inhaled allergens and an early onset of allergic rhinitis and/or asthma. we also proved that the egg allergy in infancy is transient. the tolerance to baked/cooked egg was achieved in about % of pts at the age of years, unlike previously published results claiming the reach of tolerance in % of pts at the age of years. in these patients we studied: sex, personal history, type of reaction they presented, time of onset of symptoms and food involved. results: out of a total of patients over years of age (from to years old) who have been attended the consultation for the first time during these period, patients ( . %) ask about possible allergic food allergies. of these patients who came for possible allergic pathology, patients ( %) presented positive results. these are the other item we have studied: . sex of patients: % of the patients are women. these patients because of that, it is important to remember that food allergy can also appear in old people. the food that is mainly involved in our population is fish and seafood. a much higher percentage than in other populations, probably due to the mediterranean diet of spain. the symptoms mainly involved are itching and skin lesion, which is the characteristic symptom of a mild allergic reaction. in our population, there was patients with a anaphylactic shock, a much higher percentage than in other studies. the experience with this group of patients is still limited. more studies are needed to know better this patient profile. background: cow's milk allergy (cma) is the first atopic disease in children. diagnosis suspicion in the emergency room (er) is increasingly frequent, however, further assessment by an allergist is often difficult to schedule. therefore, screening for cma through a blood test (specific ige) while the infant is still in the er has gained momentum in recent years. we set out to analyse (a) symptoms which had led the emergency physician to prescribe specific ige, (b) the prevalence of confirmed cma among infants screened in the er, and (c) the long-term outcome of the screened infants. method: a retrospective study of medical records and laboratory results was performed. patients were infants under months, without a previous diagnosis of cma, attending one of the two pediatric er of the university hospitals of marseille, france. allergy blood tests were specific ige to cow's milk extract (immuno-cap, thermofisher, sweden). in infants with specific ige to cow's milk extract of . kua/l or higher, ige directed to the main three individual proteins (casein, alpha lactalbumin et beta lactoglobulin) were also measured. results: infants were included from december to june . the sex ratio was . . % of infants were atopic et % were currently or had been breastfed. the most prevalent symptoms were vomiting and reflux. one third of infants were hospitalized after the er visit. following the er visit, % of infants attended a specialized consultation with an allergist. % of infants with a follow-up visit were diagnosed with an ige mediated cma. infants with cma developed further food allergies (egg, nuts, cashew…). it is difficult to diagnose it. the emergency pediatrician are increasingly confronted to infant with symptoms evoking cma. thus they prescribe sige and extensively hydrolysed proteins because they know that ige-positive infants can be ige-negative during the interval between the er visit and the follow-up one. after bad results interpretation of blood assay after er visit, cma was probably over diagnosed without prick test for ige positive allergy and no eviction/ reintroduction test for non ige. the lack of allergist is probably leading to over prescription of blood assay in er to diagnose cma and prolonged eviction of milk. results: a total of patients were included ( % female) aged from to yo with an average . ± years. % of patients had history of atopic disease: % rhinitis, % asthma, % prior food allergy, % eczema, % drug allergy, % eosinophilic esophagitis (ee) and % chronic urticaria. mean serum total ige was . ui/ml. sensitization to aeroallergens was present in % of patients, the most common were dust mites ( . %), pollen ( . %) or both ( %). in ( %) patients, first symptoms of fa appeared ≥ yo, with an average age of ± . yo. in this group, were diagnosed with ee, with eosinophilic colitis and with eosinophilic gastritis. from the remaining patients, had history of reaction with more than food group (fg). cutaneous reactions were referred in % of patients followed by anaphylaxis ( %) and gastrointestinal symptoms ( %). the fg most commonly implied were: fresh fruits (n = ), seafood (n = ) and tree nuts (n = ). fa diagnosis was confirmed in % of patients, the remaining had negative ofc. in ( %) patients, their symptoms started under yo, with an average age of . ± yo. from this group, ( %) were diagnosed ee. from the remaining patients, cutaneous complaints were the most frequent ( %) followed by gastrointestinal ( %) and respiratory symptoms ( %). the most common fg implied were: fresh fruits(n = ), seafood(n = ) and tree nuts(n = ). only one anaphylaxis was referred. fa was confirmed in %, the remaining had negative ofc. in patients with history of anaphylaxis of had positive st and/ or sige; one had negative sp and sige, with ofc positive. the blood donors were classified based on their clinical symptoms related to possible as contact via fish intake: allergic to as ( %), chronic urticaria ( . %), unspecific dyspepsia ( . %) and asymptomatic ( . %). the prevalence of sensitization (anti-as ige > . kua/l) were . % (ic: . - . %; mean . kua/l; median . kua/l) with a maximum value of . kua/l. raw fish consumption was the only variable associated with statistical significance (p < . ) to as sensitization ( . % vs . %, respectively). albacore and codfish were the most consumed species associated to seropositive results ( %), followed by hake ( %). coastal population ( . % vs . %), non-previously frozen fish consumption ( . % vs . %) and > times per week fish consumption ( . %) were other seropositive associated factors. background: oral allergy syndrome (oas) is an ige-mediated allergy caused by raw fruits and vegetables in patients with pollen allergy, which is known as the most common food allergy in adults. however, there has been no nation-wide study on oral allergy syndrome in korea. the aim of this study is to investigate the prevalence and clinical manifestations of oas in korea. method: twenty two investigators from hospitals and private clinics participated in this study. the patients with allergic rhinoconjunctivitis and/or bronchial asthma with pollen allergy were enrolled to the survey. the questionnaires include demographics, a list of fruits and vegetables, and clinical manifestations of food allergy. pollen allergies were diagnosed by positive results of one or more pollen allergens including birch, alder, hazel, beech, oak, willow, poplar, bermuda, meadow, orchard, rye, timothy, mugwort, ragweed, hop japanese on allergy skin prick tests (allergen/histamine ratio ≥ +) and/or serum specific ige levels using multiple allergen simultaneous tests (mast ≥ +) or immunocap (≥ . ku/l). conclusion: this is the first nation-wide study for oas in korea. the prevalence of oas in korea was . %, in which substantial proportion had anaphylaxis. these results will provide useful information for clinicians to apply in clinical practice. we conducted a self-administered, questionnaire-based survey in - during the -month checkup. children were considered to have food allergies if they were diagnosed by a physician or if they had been instructed to avoid a causative food after medical examination by interview. we divided the year into three periods. the months of march-june were considered spring, july-october as summer/fall, and november-february as winter. while the season of onset for the boys occurred in . %, . %, and . % in spring, summer/fall, and winter, respectively, it was . %, . %, and . %, respectively, for the girls. thus, the onset rate was the highest in winter for both genders. in boys whose mothers did not consume folic acid (fol − ), the food allergy onset rate was significantly higher for boys whose mothers ate no eggs and for boys whose mothers ate - eggs per week than for those whose mothers ate eggs daily according to the dunnet multiple comparison test. however, no relationship was observed with egg intake if the mother had consumed folic acid (fol + ). on the basis of seasons, fol − and egg intake by mothers affected only children born in winter, with a significant difference in the dunnet multiple comparison. among mothers who did not eat eggs, fol + was . % and fol − was . %; for mothers who ate - eggs per week, fol + was . % and fol − was . %; and for mothers who ate eggs every day, fol + was . % and folwas . %. thus, consumption of folic acid seemingly annulated the effects of eating eggs. however, for girls, neither folic acid nor eating eggs had any effect on the onset rate. conclusion: since this effect varied according to the birth season, consumption of folic acid, a methyl group donor, appeared to affect the allergy onset in children. results: skin prick test with commercial extracts of tuna ( mm), cod ( mm), rooster ( mm), hake ( mm), salmon ( mm), trout ( mm) and anisakis ( mm ige to shrimp, lobster, crab and mixed seafood were all undetectable. dermatophagoides pteronyssinus , to assess for tropomyosins was negative. outcome: the patient continues to react to both hdm and shrimp, despite undetectable ige levels to tropomyosin associated components. this is the only testing available in south africa currently and hence we are unable to look at other proteins. the relationship between tropomyosins in shellfish allergy and mite allergy has been well documented and investigated, but other allergens are now also being implicated in cross-reactions. we also established the level of ige specific to allergen components using the immunocap isac method. allergen-specific ige was not elevated to any shrimp allergens available in immunocap isac: n pen m (tropomyosin), n pen m (arginine kinase) and n pen m (calcium binding sarcoplasmic protein). the patient was diagnosed with a shrimp allergy. the molecular diagnostics used did not explain which allergen component is the patient allergic to. it is possible that the patient is allergic to hemocyanin, which can also cross-react with house dust mite allergens, but confirmation of this diagnosis requires further investi- results: the groups were identical in terms of the age and sex (table ) . ara h ige correlated (spearman test) with the cumulative protein dose (threshold dose) r = − . (p = . ) but not with reaction severity r = . (p = . ), or the use of adrenaline r = . (p = . ). patients with ara h ige < ku/l had higher threshold doses ( vs mg) than children whose ara h ige was ≥ ku/l (p = . ). there were no significant differences in severity of the reaction or in use of adrenaline (table ) . the level of ara h ige is relevant in predicting the threshold dose at peanut exposure. a low reaction threshold dose increases the risk of reaction at an accidental exposure leading potentially to a severe reaction. flaxseed allergy is uncommon and most of the cases reported involved anaphylaxis. cross reactivity has been described with other seeds. case report: a -year-old atopic girl diagnosed with egg allergy and rhinoconjunctivitis and asthma due to pollens. when she was eight, she presented two reactions consisting of conjunctival, periorbicular, malar erythema and abdominal pain after eating egg free french toasts cooked with flaxseed. she was treated with oral antihistamines. the allergic workup included prick-by-prick test with flaxseed which was positive and skin prick tests with mites, molds, cockroach, cat, dog, profilin, ltp and pollens with positive results for olive and grass pollens. the serum total immunoglobulin (ig) e was u/l, and specific ige to flaxseed was . kua/l. the flaxseed extract was resolved with sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page) and an ige immunoblotting was performed under nonreducing conditions. the patient's serum showed specific recognition of a -kda band in the immunoblot. proteins were identified using mass spectrometry (maldi-tof) that showed results highly consistent with conlinin, a s storage protein of flaxseed. we described for the first time a patient with allergy to flaxseed due to conlinin, a s storage protein of flaxseed. background: cyperus esculentus is an herbaceous plant that has edible tubers called tiger nuts. in spain, they are used mainly in the elaboration of the well-known "horchata" or tiger nut milk, which is obtained by macerating tiger nuts with water and sugar. tiger nut allergy has rarely been reported, despite of its widespread consumption. case report: we present the case of a -year-old male with a history of oral syndrome allergy with several fruits (peach, melon, banana, kiwi, apple, pear and plum) and seasonal allergic rhinoconjunctivitis due to grass pollen. he reported oral pruritus, vomiting and cutaneous itching in both arms and hands immediately after drinking tiger nut milk. he became asymptomatic without treatment after - hours. the allergic workup included skin prick tests with profilin, ltp, latex and fruits that were positive to melon and watermelon and negative to profilin, ltp, latex and the rest of the fruits. prick-by-prick tests with melon, banana, kiwi, apple, pear, tiger nut and tiger nut milk were positive. the serum total immunoglobulin (ig) e was . μg/l, and specific ige was negative to profilin, ltp, bet v and all the tested fruits. background: specific blood ige tests for food allergens are mainly used to confirm a suspect food allergy than to diagnose such an allergy. this is due to the low positive predictive value and the high negative predictive value they have. nevertheless, they are very helpful when they are interpreted in the context of medical history by an experienced allergist. we analyzed the prevalence of sige in children with suspected food allergies. we retrospectively analyzed the all the consecutive laboratory tests of sige for food allergens during the two-year period ( ) ( ) ( ) . tests were of children diagnosed or suspected to have food allergies. a quantitative immunoblot assay was used to measure the circulated different sige. t-test, wilcoxon signed rank test, and chi-square were used to make comparisons. results: fifty-six ( . %) men and ( . %) females, . + . years old with a maximum of years and a minimum of months old were part of children whose tests were analyzed. one-third of the tests ( . %) reveals more than one sige present and . % of the tests resulted negative for the sige for the allergens tested (table) . only ( . %) children have very high concentrations (> iu/ml) of egg whites sige, and ( . %) have egg yolk sige. concentrations of . % of sige positive cases were . - . iu/ml. in our study more than half of the children suspected of food allergies resulted negative for sige for most common food allergens. seventy-nine percent of the positive cases had relatively low sige. only a few positive cases have higher sige than iu/ml. our data support the recommendation that sige couldn't be decisive in food allergic diagnosis, but they may help if they are interpreted cautiously. method: seven patients with a mean age of . years and female to male ratio of: : , with a background history of hypertension treated with an acei presented with oro-pharyngeal irritation (itch, tingling), face and tongue angioedema and laryngeal constriction, on ingesting fresh fruits (cherries, apples, plums, peaches, apricots, strawberries, grapes), vegetables (parsnips) and/or nuts (peanuts, hazelnuts). two patients required admission to emergency department and three received adrenaline auto-injector. six out of seven patients underwent skin prick testing to common aeroallergens and the index foods. in five cases, immunocap/isac testing was undertaken. in one case the diagnosis was based on the history and in one other case it was based on history and skin prick tests. results: a diagnosis of pfas was confirmed in all patients through the clinical history, spt and/or specific ige serology to the offending food confirming predominant sensitisation pr- allergens. primary food allergy and spontaneous angioedema was excluded in all patients. in the cohort studied, the pfas symptoms were unusually severe. we therefore postulate that this was secondary to concurrent use of acei. the management of these patients to sensitization to a β-casein with high homology between only the first milks. more precisely, the allergen candidate could be γcasein, which is derived from β-casein by proteolysis, whose abundance increases during cheese production from fresh milk, and which is absent in cow's milk. a lactoglobulin specific to buffalo's milk may also be responsible. in case of ewe's and goat's milk allergy without cow's milk allergy, sensitization to buffalo's milk should systemically be seeked out. we recommend inclusion of all mammalian milks in the list of the mandatory allergens for declaration on food products. method: prick tests with fruit battery, ltp and profilin was made. analytical with blood count, immunoglobulins, triptasa, total ige and specific ige to banana, apple and orange. finally, open oral provocation with fruits was performed. the diagnostic key was given by the mother of the patient who attended consultations because the infant had erythema in the temporary zone after drinking sea water on the beach. associated with salivation, the patient presented erythema in the malar area lasting a few seconds many times. the prick tests with fruits, ltp and profilin were negative. hemogram: eosinophils/μl, total ig e: . iu/ml, specific ige to fruits were negative. triptase: . μg/l. method: here we describe a variety of cases of nsltp allergy presenting to a tertiary allergy centre in the north west of england. results: nsltps have been found to be major allergens in various foods and they are likely to produce severe and systemic allergic reactions. this is reflected in the cases we present here. these proteins are highly cross-reactive due to extensive sequence homology and are panallergens. nsltps are remarkably heat stable and retains its allergenicity in processed foods. it is assumed that nsltps may sensitise both by inhalation and ingestion. an intriguing aspect in nsltp hypersensitivity is the extreme variability of its clinical expression. co-factors are often needed for the clinical expression of nsltp hypersensitivity. conclusion: patients regardless of where they are from, presenting with multiple severe/systemic food allergies need to be investigated for nsltp allergy. these patients require specific dietary advice on foods to avoid and a tailored management plan on how to deal with their allergic reactions. cow's milk as well as cow's milk products are tolerated. material and methods: skin prick tests with different sorts of milk, cheese and milk proteins were performed, specific ige antibodies were measured, a basophil activation test with cow's and goat's milk was performed and an oral provocation test (opt) with cow's milk, cow's milk cheese, raw milk and raw milk cheese was conducted. results: skin prick tests were positive for sheep's milk, goat's milk, goat's milk casein, feta, pecorino and parmesan cheese. elevated specific ige against goat's milk ( . ku/l) and sheep's milk ( . ku/ l) were detected. activation of basophil granulocytes after incubation of the patient's blood with cow's milk and goat's milk was measurable but also in the non-incubated control blood. all cow's milk products were tolerated in the opt. conclusion: despite consistent homologies between whey and casein proteins of mammals and high cross-reactivity between cow's, goat's and sheep's milk an isolated goat's and sheep's milk allergy with tolerance of cow's milk is possible. skin testing and specific ige help to distinguish from allergy against cow's milk proteins. diet counseling is possible after opt. introduction: salmon roe's allergy, without concomitant fish allergy, is rarely described in western countries. there are few studies on its allergenicity. objective: to report of a case of salmon roe allergy without concomitant fish allergy in a western country. case report: a -year-old male with house dust mite allergic rhinitis and asthma, describes for the st time, in , an acute episode of dyspnoea, rhinorrhoea, ocular pruritus, epigastric pain and nausea, a few minutes after the ingestion of a sushi meal with rice, salmon, salmon roe, wasabi, soy and ginger. these complaints motivated observation in the emergency room, where it was still documented uvular oedema. he was prescribed intramuscular adrenaline, intravenous steroids and anti-histamines with complete symptoms resolution. the patient declares not had eaten other foods, taken any drugs including nsaid, been infected or practised exercise. skin prick tests with food extracts (salmon and other fish, shellfish, soy, rice, egg total, egg white, egg yolk, ovalbumin and ovomucoid) were negative. skin prick-prick tests were positive for salmon roe ( × mm) and negative for egg (white and yolk), ginger, salmon, flying fish roe (tobiko), sturgeon roe (caviar) and black scabbard fish roe. specific-ige (sige) to salmon roe extract was . kua/l (immu-nocap-phadia) and negative against extracts from salmon fish and other fish (< . kua/l). sds-page immunoblotting with salmon roes extract showed a kda-ige binding band, that may correspond to a lipovitelin. after the allergic reaction the patient have tolerated abstracts | salmon fish and other fish roes (tobiko, caviar and black scabbard fish). no oral provocation test with salmon roes was performed given the severity of the reaction. conclusion: this report is an example of a severe allergic reaction to salmon roe without concomitant fish allergy, where the clinical history and the in vivo and in vitro tests were important to an accurate diagnosis. the authors believe this is the first report of a salmon roe anaphylaxis in our country and highlight the importance of this allergen in the western countries, given the increase of sushi consumption in these countries. case report: the prevalence of food allergy is increasing worldwide and consumer habits are changing. pomegranate (punica granatum) was commonly consumed in the mediterranean area but in the last few years became also popular in the different parts of europe. a -year-old boy was admitted to our emergency department suffering from allergic reaction within minutes after consumption of pomegranate. he presented with skin pruritus, generalized urticaria and eyelid edema. symptoms resolved within an hour after oral intake of cetirizine. prick-to-prick test with pomegranate was positive (wheal diameter × mm). he had a history of anaphylaxis with egg (urticaria and wheezing) at the age of month, meanwhile consumption of egg is well tolerated. an episode of anaphylaxis with unknown origin appeared at the age of years (urticaria, wheezing and abdominal pain). skin prick tests with aeroallergens revealed birch pollen allergy and he was diagnosed with allergic rhinoconjunctivitis. dietary elimination of pomegranate was suggested and adrenaline auto-injector was provided. we have analyzed omalizumab effectiveness and safety in patients with csu from our database. clinical response was categorized as: no response, partial or complete response by using the urticaria activity score (uas ). furthermore, the dosage, administration frequency and any side effects were recorded. results: effectiveness: out of patients ( %) achieved complete response. ( . %) after a single dose of mg ( patients) or mg ( ); patients ( . %) after two doses of mg ( patients) or mg ( ) results: multi-ethnic adolescents accounted for approximately . % of the total sample of adolescents. prevalence of asthma was significantly higher in multi-ethnic group than non multi-ethnic group. we examined if maternal or paternal foreign born status had a differential effect: in multi-ethnic family with foreign-born father, prevalence of asthma was significantly higher. parental region of country at birth had a significant influence on the prevalence of asthma. adjusted logistic regression analysis was used to determine risk factors for occurrence of allergic disease. residential area, perceived household economic status, parental region of country at birth, and body mass index (bmi) had a significant effect on prevalence of asthma. conclusion: population admixing appears to have significant effect on the prevalence of asthma. further study will be needed to clarify the effect of population admixing on prevalence of allergic disease. several studies have aimed to explore the possibility of mirs as biomarkers for various diseases. in our study we examined six different mirs, previously shown to be involved in eosinophil development and other immune responses, in serum from non-allergic and allergic asthmatics and healthy control subjects in order to determine their potential ability to be used as biomarkers for varying forms of asthma. method: serum from healthy individuals as well as age matched non-allergic asthmatics (naa) and allergic asthmatics (aa) were utilized. additionally, the naas and aas subjects had high eosinophila (≥ . × cells/l) compared to healthy controls (≤ . × cells/l) and eosinophil cationic protein (ecp) in serum was measured. asthmatic subjects were included irrespective of inhaled corticosteroid usage. rna was extracted from serum, reverse transcribed and subjected to qpcr analysis. expression changes in six candidate mirs, mir- , - , - a, - , - , and - , were investigated. results: two mirnas, mir- and mir- a, were significantly upregulated in aas as compared to naa or healthy subjects. additionally, mir- was upregulated in naa, but not aa or healthy subjects. furthermore, the expression change observed in the aa mirs appeared to correlate with the use of inhaled corticosteroids, but not in the naa mirs. finally, mir- and mir- expression levels were altered based on the number of eosinophils, which correlated to ecp levels, in naa subjects. conclusion: using six mirs found in the literature to be involved in eosinophila or immune responses, we were able to detect expression changes in the serum of healthy and asthmatic individuals. moreover, were able to distinguish between healthy individuals, aas, and naas on inhaled corticosteroids or with differing eosinophil levels, leading to the possibility that these mirs may be valuable future biomarkers for asthma. background: some studies report that certain sensitization profiles may increase the risk of a more serious allergic respiratory disease. the aim of this study was to describe the sensitization patterns to major allergens of dust mites in our area and investigate the association of these patterns with a specific clinical picture. method: multicenter study performed in hospitals for months. we recruited patients older than years with rhinitis and/or bronchial asthma, with a history of allergy to dust mites and both skin test and specific ige to d. pteronyssinus, d. farinae or l. destructor positive. der p and der p were determined to all of them. we analyzed patients with an average age of . years, . % women, . % smokers, . % rhinitis and asthma, . % only rhinitis and . % only asthma. % of patients presented sensitization to d. pteronyssinus, . % to d. farinae and . % to l. destructor. the detected sensitization patterns were: both der p /der p positive . %; der p positive . %, der p positive . % and both der p /der p negative . %. it was observed that patients with higher specific ige levels had more severe forms of respiratory disease, with isolated asthma or associated with rhinitis. for d. pteronyssinus, d. farinae, der p and der p > ku/l there is a greater number of cases of asthma associated with rhinitis, while for l. destructor > . ku/l greater number of cases of asthma. no relationship was observed between a specific sensitization pattern and an increased risk of asthma. conclusion: . specific ige values greater than ku/l for d. pteronyssinus, d. farinae, der p and der p , were significantly associated with a higher probability of asthma and this association was significant for l. destructor> . ku/l (class ). . there are four well-defined sensitization patterns in our population that are influenced by geographic location, being the double sensitization to der p and der p the most prevalent and allowing the correct characterization of % of the cases. none of them increased the risk of asthma. kobori t ; nagao m ; ekenkrantz t ; borres m ; sjölander a ; fujisawa t national mie hospital, tsu-city, japan; thermo fisher scientific, uppsala, sweden background: reliable biomarkers for diagnosis and management of asthma in young children are needed since pulmonary function test and exhaled no measurement, good biomarkers for asthma in older children and adults, are difficult to perform in young age. we have developed a sensitive and stable assay system to measure eosinophil-derived neurotoxin (edn), an eosinophil granule protein, that is released upon activation, and that may serve as a marker for eosinophilic inflammation also in young children. method: volunteer children from - years old were recruited and an isaac-based questionnaire was filled out by their caregivers. venous blood was obtained to measure serum and plasma edn and eosinophil count. edn was measured with a research assay developed on the immunocap ® platform. conclusion: blood edn may be a reliable biomarker for diagnosis of asthma in preschool children. conclusion: feno measurement as an add-on option in asthma management to identify asthma patients with th driven airway inflammation is less costly than the use of standard diagnostic methods. new biologics may have an additional impact on overall asthma treatment costs. our model demonstrates that incorporating feno measurement may help to optimize asthma medication and reduction in physician visits as well hospitalizations due to severe exacerbations. | peripheral airway inflammation assessed by fractional measurement of the exhaled breath temperature is a leading feature of asthma background: airway inflammation is considered to be a hallmark of asthma. the potential clinical benefits of assessing it non-invasively has led us to develop a method and device for measuring the temperature of the exhaled breath (ebt=exhaled breath temperature) reflecting the thermal state of the airway mucosa. studies have demonstrated that ebt is increased in asthma, proportionately to the level of control of the disease. in an attempt to further increase the usefulness of this approach, we have further developed a device to allow the assessment of the relative contribution of the central and peripheral airways (caw and paw). now we present the frebt data gathered from patients with suboptimal control of their asthma and from healthy subjects. method: in this cross-sectional study we included volunteers: patients with suboptimally controlled asthma of mild to moderate severity (median age , range - years, men) and nonsmoking subjects without respiratory disease (median age , range - years, men). we measured the fractions corresponding to caw and paw sampled with a fast reacting inflatable balloon valve system operated by a computer during a single breathing cycle. it allows steering of the expired airflow through channels with sensitive temperature sensors. during an initial deep inhalation, the inspired volume is measured and the sequence of valve openings is adjusted so as to yield volumes of air characteristic of caw or paw during expiration. the ratios between [pawebt-cawebt] over the total ebt [%] measured during the same manoeuvre (fractional ebt, frebt) were calculated and compared between asthmatics and controls. results: there was high statistically significant difference between the frebt ratios of asthmatics and controls: . ± . (mean ± sem) vs . ± . , p < . . as the magnitude of the ratio depends on the difference between pawebt and cawebt, higher values of the frebt ratio point to bigger contribution of the peripheral lung tissues, presumably indicative of peripheral inflammation. multiple regression analysis with frebt ratio as dependent variable identified only asthma diagnosis as significant predictor (p < . ) and excluded all other anthropometric indices. conclusion: peripheral airway inflammation assessed by frebt measurement appears to be a leading characteristic in asthmatics compared to healthy subjects. method: we examined outpatients ( % male, aged - year, mean age . years) with severe asthma according to ers/ ats ( ) definition treated with high dose of ics/laba± tiotropium, antileukotrienes and omalizumab. some patients (n = ) had orally steroid-dependent asthma. they referred to our secondary care center by gps. pulmonary function tests were measured by dry spirometer ( , vitalograph ltd., uk). skin prick tests or serum specific ige to common inhalant allergens (house dust mite, animal dander, pollen) were used to assess atopic status. results: seventy five percent (n = ) of patients with severe asthma had fao in % of those was diagnosed concomitant copd. duration of asthma was . years in patient with reversible airway obstruction (rao) and . years in those with iao (p > . ). early (before age years) onset of asthma was established in % of patients with rao and in % of patients with fao (p > . ). prevalence of atopy did not differ between both groups ( % vs %, p > . ) but total ige level in serum was higher in severe asthmatics with rao than fao ( me/ml vs me/ml respectively, p < . ). most of atopic patients with severe asthma both with fao ( %) and roa ( %, p > . ) were sensitized to house dust mites (d. pteronyssinus and d. farinae). hypersensitivity to pollen was diagnosed in % patients with foa and in % with rao (p > . ), to cat and dog dander in % and % respectively (p < . ). the majority ( %) of patients with severe asthma had fao. hypersensitivity to house dust mites was most common in severe atopic asthmatics with foa and roa where as sensitization to animal danger was associated with presence of foa. | loss of smell as a clinical marker of severe asthma and its association with upper airway inflammatory diseases background: asthma is frequently associated with rhinitis and chronic rhinosinusitis (crs) while severe asthma is more associated with crs with (crswnp) than without (crssnp) nasal polyps. loss of smell (los) is associated with crs, mainly with crswnp. we aimed to assess loss of smell as a clinical marker to discriminate crs from rhinitis and severe from non-severe asthma. method: in a cross-sectional multicentric study, asthmatic patients (n = ) were evaluated by pulmonologists and ent specialists using gina, aria, and epos definitions. los was evaluated by severity [vas scale, - mm, median (iqr,inter-quartil range)] and by prevalence of anosmia (hyposmia vas > - mm, anosmia vas> mm). results: los was present in . % of asthmatics (hyposmia . %, anosmia . %). los was more severe [ mm ( - ), p < . ] and anosmia more frequent ( . %, p < . ) in severe persistent asthma than in moderate [ mm ( - ); . %] mild [ mm ( - ); . %], or intermittent [ mm ( - ); . %] asthma. in addition, los was more severe [ mm ( - ) vs mm ( - ), p < . ] and anosmia more frequent [ . % vs . %, p < . ] in crs than in rhinitis patients. in those asthmatic patients with crs, los was even more severe [ mm vs mm ( - ) p < . ] and anosmia more frequent ( . % vs . %, p < . ) in crswnp than in crssnp. conclusion: loss of smell and specially anosmia may clearly discriminate severe from non-severe asthma and crs (specially with np) from rhinitis alone in asthma patients. thus, los may be considered a significant clinical marker of severe asthma and its association with upper airway inflammatory diseases. | last station in the eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis march: eosinophilic asthma with radiological findings associated with blood eosinophilia yilmaz i ; nazik bahçecioglu s ; türk m ; tutar n ; oymak fs ; gülmez i erciyes university school of medicine, kayseri, turkey; department of chest diseases, kayseri, turkey; division of immunology and allergy, kayseri, turkey background: eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis (eacrs/np) is a subphenotype of adult-onset eosinophilic asthma. blood eosinophil levels are shown to be highly elevated in patients with ea-crs/np and have potential for tissue infiltration. we aimed to demonstrate the clinical features of the patients who have a blood eosinophil level above % and have thorax computed tomography findings due to blood eosinophilia. results: we identified patients who met the above criteria. we defined this group as "eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis with radiological findings related to blood eosinophilia" (earr). the mean age was . ± years and % was female. nasal polyps, aspirin exacerbated respiratory disease and atopy was present in %, % and % of the patients, abstracts | respectively. the mean blood eosinophil count was . cells/mm ( %). the majority of earr patients had upper lobe dominant ground-glass opacities. the mean follow-up period was . ± . years. earr patients did not evolve into eosinophilic granulomatous polyangiitis in the follow-up. method: we aimed to identify features more probably associated with asthma in a unselected group of patients with diagnostic criteria for aco. we consecutively selected the first consecutive patients with diagnostic criteria for aco. all patients were evaluated by accurate clinical history interview, assessment of asthma control test (act) and copd activity test (cat), lung function and exhaled nitric oxide (fe no ) measurements, sputum cytology, blood eosinophil count, serum total ige and periostin levels, methacholine and adenosine-mono-phosphate (amp) bronchial challenges. all these measures were repeated after an oral corticosteroid (ocs) trial of methylprednisolone mg/day for days. we defined parameters that we expected improved after the ocs trial, and therefore considerable as markers of asthma: fev , fef - , fev /fvc, fe no , act, sputum and blood eosinophilia, methacholine and amp challenges. patients with improvement of at least of these parameters after ocs trials were defined as "responders" to the treatment, and therefore more likely to be asthmatic than copd or aco. results: five ( %) patients were classified as responders and they were characterized by having basal higher fe no values ( . ± . vs . ± . ppb, p = . ), greater bronchial reversibility basal values of serum periostin and total ige, and blood eosinophils were higher in responders but without reaching the statistical significance. conclusion: fe no and the degree of bronchial reversibility (and possibly also the degree of response to an amp challenge) are reliable biomarkers to distinguish asthmatics among those with suspect aco. method: the preliminary case-control study included obese persons with asthma who were matched for age and sex and nonobese asthma subjects. non fasting serum levels of adiponectin, and leptin were measured by commercially available immune assay kits, and routine biochemical parameters were analyzed in both the study groups. the results show statistically significant lower levels of serum adiponectin and higher serum leptin levels in obese asthma subjects with respect to non-obese asthma patients (p < . ). moreover, an inverse correlation was also observed between serum adiponectin and serum leptin in obese asthma subjects (p < . ). our results indicate the association of these hormones might act as a significant predictor in the progression of asthma. moreover, the role of serum adipokines is promising and might potentially act as a meaningful drug target in the pathogenesis of asthma. background: overweight/obesity is known to be a possible factor for poor asthma control. the aim of the study is to determine the serum concentrations of leptin in atopic asthmatic patients and its relationship with body mass index (bmi), asthma severity defined by medical treatment and asthma control defined by the asthma control test (act). method: we randomly selected adult patients previously diagnosed with allergic asthma based on gina (global initiative for asthma) guidelines, returning for follow-up to an outpatient allergy/ immunology clinic during november . following an informed consent, the patients were asked to fill act, their bmi was recorded, and elisa blood assays for leptin were drawn. exploratory data analysis, spearman's correlation ( % ci by bootstrapping), and partial correlations were performed. results: female/male ratio was / , mean bmi was . ± . conclusion: leptin was significantly associated with overweight/ obesity in asthmatic subjects, and showed higher values for women. leptin inverse correlation with act did not reach statistical significance, likely owing to underpowered estimates, in a small sample characterized by an elevated mean bmi and severe allergic asthma. background: immunoglobulin lowering may be associated with recurrent wheezing symptoms and clinic by increasing the tendency to viral respiratory tract infections. in this study, it was aimed to investigate the frequency of immunoglobulinemia in preschoolers with wheezing. the study was conducted between . . and . . between. university of health sciences, ankara child hospital, the children allergy and immunology clinic included patients who had been followed up and treated for at least one year with recurrent wheezing attacks within younger than months. the immunoglobulin (g, a, m) values of the patients were retrospectively analyzed. immunoglobulin levels were determined to be normal and low according to age limits. the study included patients ( . % male, . % female) under the age of years with a mean age of . months. the mean follow-up period of the patients is . years. in . % of these patients, at least one immunoglobulin was found to be low. none of these patients had any signs or symptoms of immunodeficiency. immunoglobulin a was low in % of the patients, immunoglobulin g in %, and immunoglobulin m in . % of all patients. conclusion: immunoglobulin was found to be low in these patients when there was no immunodeficiency and preschool wheeze was diagnosed. this should be etiologically investigated as to whether if this is a special group in preschoolers with recurrent wheezing and hypogammaglobulinemia combination. method: asthma severe unit is formed by allergists, pneumologists, pediatricians and otorhinolaryngologists. hematologists and immunologists make specific collaborations. we present the partial results of our data collection, which include patients with severe asthma according to ers/ats task force, selected by peripheral eosinophils > according to wagener et al. we followed them up to assess control for year. we obtained cellularity in sputum using induced sputum technique. values of il of th , th , th pathway, periostin and ilc were not yet available. results: median age was ± , feno ± , exacerbations previous year . ± . , act . ± , fev % ± and dose of inhaled corticoids (budesonide equivalent) ug ± . most of the patients were sensitized ( %) and . % were polysensitized. the most frequent sensitization was dust mites ( %). % had received immunotherapy of whom . % with lack of response. not sensitized patients were older. sputum cell analysis of patients was performed, % had sputum eosinophils> %, mean sputum eosinophil value was . ± . and peripherally ± . correlation among sputum and peripheral eosinophilia was . (p = . ). the peripherally eosinophil value > had a sensitivity of % and a specificity of % for the detection of sputum eosinophils > %. no differences were observed in sputum cell count depending on allergic sensitization. % had an uncontrolled asthma. presence of polysensitization, rhinitis or polyposis were not statistically related with the control. different patterns were observed in function of cause of poor control: patients with obstructive pattern (fev < %) were older and received more inhaled treatment. patients with high rate of exacerbations had more sputum eosinophilia and neutrophilia. both groups had worse act and received more oral steroids. patients who received oral steroids were more often sensitized to fungi in some follow-up visits. not significant differences were observed in control according to the act. asthma had more sputum neutrophilia, were older, received higher inhaled steroids dose and had adult onset asthma. the only control variable related with sputum eosinophilia was exacerbation. fungi sensitization was more frequent among patients with oral steroids. method: a randomized, double blind, placebo controlled study with patients from the de la salle university medical center with a mean age of with partly or uncontrolled asthma. they were assigned to either cm glucan or placebo group for two months. act score and %fev postbronchodilator were assessed at the st visit, th week follow up, and th week follow up visits. an independent and paired t-test were used to determine mean changes in act scores and %fev between the groups. results: in the two treatment groups, those in the cm glucan group had a greater % fev mean change of − . compared to placebo which had only − . , a mean difference of − . , and a trend toward significance with a t-test p value of . . in terms of changes in act score, those in the cm glucan group had a mean change of . and . for placebo, a mean difference of . and was not significant at t test p value of . . the result of the emanuel trial showed a trend of improvement among patients on both groups in terms of act score and %fev postbronchodilator. however, it was not statistically significant. | lung function improvements with tiotropium in patients across all ages: impact of episodes of asthma worsening during phase trials vogelberg c ; casale tb ; bleecker er ; goldstein s ; szefler s ; engel m ; el azzi g ; dewberry h ; hamelmann e method: post hoc analyses involved phase iii, randomized, double-blind, placebo-controlled trials: in patients aged - years (rubatina-/canotina-/vivatina-/pensietina-asthma) who received tiotropium ( or . μg) or placebo, as two puffs once-daily via the respimat, as add-on to ics ± other controllers; and in adults (pri-motina-asthma replicate trials) who received once-daily tiotropium μg or placebo, as add-on to ics/laba ± other controllers. we analyzed change from baseline for peak fev ( - h) and trough fev at week in vivatina-and pensietina-asthma, and week in pri-motina-/rubatina-/canotina-asthma, comparing patients with and without episodes of asthma worsening during the trials. asthma worsening was defined as an episode of progressive increase in dayto-day asthma symptoms (recorded by patients and confirmed by the investigator) or a decrease of patient's best morning pef ≥ % from mean for ≥ consecutive days. as a post hoc analysis, p values are nominal. results: there were no differences in baseline disease characteristics between those who experienced episodes of asthma worsening and those who did not, within specified age and asthma severity groups. placebo-adjusted lung function improvements were observed with tiotropium μg in patients who experienced episodes of asthma worsening and those who did not during the trials (table ) . there was some variability in subgroups with low numbers of patients. conclusion: once-daily tiotropium add-on had a similar efficacy in adult and pediatric patients with symptomatic asthma, irrespective of whether they experienced episodes of asthma worsening or not during the trials. these data support the broad efficacy of tiotropium and show largely consistent improvements in lung function even in patients who experience episodes of disease worsening. | cochrane review of the use of antibiotics for acute exacerbations of asthma method: we searched the cochrane airways trials register, trial registries and reference lists of primary studies. we extracted outcome data and assessed risk of bias in duplicate and used current cochrane methodology throughout. our primary outcomes were intensive care unit (itu) admission, duration of symptoms/exacerbation and adverse events. we included six studies, including a total of adults and children. trials were of varied methodological quality and we were able to perform only limited meta-analysis. one study reported a single itu admission but no other studies reported admissions to itu. two studies investigating macrolides reported diary card symptom score and showed antibiotics improved symptoms (md − . , % ci − . to − . ). one study including participants reported more symptom-free days in the macrolide group than usual care. one study of a penicillin including participants reported asthma symptoms at hospital discharge; the between group difference was reported as non-significant. serious adverse events were rare; events were reported across the three trials (n = ). the pooled effect estimate for all adverse events from three studies was imprecise (or . , % ci . - . ). no deaths were reported. conclusion: our results confirmed that omalizumab significantly improves disease control and is a safe add-on therapy. also in appropriate patients with controlled disease over time, efforts to stepdown other asthma medications will be appropriate. ( ) aerd: aspirin exacerbated respiratory disease; sd: standard deviation. data are n (%), mean ± sd or n/n (%). c-act: asthma control test for children, fev : forced expiratory volume in one second; fev /fvc: the ratio of forced expiratory volume in one second to forced vital capacity, pef: peak expiratory flow; feno: fractional exhaled nitric oxide, vas: visual analogue scale *these included allergic rhinitis, asthma, eczema, atopic dermatitis, food allergy, etc. **there were , and missing data in treatment a, b, and c, respectively. this study examines the potential treatment effects of sq ® hdm slit-tablet on qol measured by sf- v in people with aa and ar. the analyses are based on data from the mt- trial (eudract no. - - ) and utilize data from the sq-hdm treatment group ( subjects) and the placebo group ( subjects). throughout the trial, qol was measured at each of visit - via sf- v . this yielded psychometrically-based physical and mental health summary measures, as well as a sf- v total score. according to trial design, the use of inhaled corticosteroid (ics) was reduced by % for a three months period (visit and ) and completely withdrawn for the last three months of the trial (visit and ). results: by estimating a simple regression on differences in sf- v total score from baseline measurements (visit ), a positive and statistically significant treatment effect on the overall qol of the sq-hdm treatment compared to the placebo group in visit and was found. further analyses show that the qol improvements are mainly driven by increases in the general mental health score, which are carried through to visit . in particular, the mental health and role emotional domains show statistically significant improvements. the results show that the sq ® hdm slit-tablet improves qol measured by sf- v in patients with hdm induced aa and that this effect is driven by improvements in the mental health domains. | impact of treatment prescription, adherence to treatment and use of inhalers in asthma control-results of the efimera study method: cross-sectional multicenter observational study conducted with patients who use any type of medication with inhaler devices. patients referred from primary care and seen by a pneumologist or allergist for the first time were evaluated. the following data was collected in a single visit: adequate prescription according to gina guidelines (gina); specific and general treatment adherence using morisky-green questionnaire (mg) and inhaler adherence test (tai); disease control with asthma control test (act) and assessment of inhaler use technique were measured with the extended tai. results: patients included in this study (n = ) had a mean age of ± years, an average disease evolution of . ± . years, % of which were women. according to gina recommendations, . % of patients have insufficient or inadequate prescription. when measured by the mg test the . % of patients showed bad adherence, meanwhile measured by the tai test adherence was . % measurements of inhaler use technique resulted in % of patients having one or more mistakes regardless of whether the device was a mdi or dpi. several factors showed to be related with bad asthma control: inadequate prescription (or: . [ . - . background: it is well known that the constant and prolonged tobacco smoking affects the natural history of asthma. vaping is the act of inhaling and exhaling the vapor produced by an electronic device called e-cigarette (e-cig), whose basic structure includes a power source and an atomizer. two types of vaping are the most popular ("mtl" and "cloud chasing"). we have created a web-survey with questions concerning epidemiological data, quality of life and symptoms worsening in asthmatic vapers. the survey has been advertised through various social networks and local press. people responded, including asthmatics ( %). the asthmatics were: males %, under %, - years %, - years %, - years % and over %. % used ecig-only, % smoked and vaped together, %. those who preferred mtl-type of vape were % and "cloud chasing" were %. results: to the question: "has vaping ever worsened asthma symptoms?" % answered no, % yes. to the question: "as asthmatic, would you suggest to an asthmatic smoker to start vaping instead of smoking?" . % answered no, . % yes. to the question: "how much nicotine do your vaping liquids have?" % answered mg/ml, % . mg/ml, % mg/ml, % mg/ ml, % mg/ml, % mg/ml and % mg/ml. to the question: "do you take medications for your asthma?" % declared to use a drug as needed, % used a single drug daily, % used more than one drug daily and % declared "i don't take any asthma medication". we related (χ test) the worsening of asthma symptoms with the nicotine content (p = . ), the type of vaping (p = . ), the current therapy (p = . ) and we did not find a statistically significant correlation. vaping has undoubtedly shown an advantage in terms of improvement of symptoms compared to cigarette smoking (p = . ), in particular . % subjects who smoke and vape did not have a worsening of symptoms, while . % of them had a worsening. the vaper-only users who never worsened were ( . %) and ( . %) had a worsening. conclusion: despite the limits related to the online survey as a data source, e-cigs seem to be a useful tool in the pathway to quit smoking. in fact, % of the asthmatics who smoked traditional cigarettes would recommend switching to e-cig and % did not worse their asthma symptoms. background: despite the success of pharmacotherapy, more than half of patients with persistent bronchial asthma (ba) do not achieve disease control. in recent years, the issue of approaches to treatment based on the identification of phenotypes of the disease has been increasingly discussed. this approach becomes the key to optimizing therapy for asthma, allowing the personification of treatment. anti-ige-therapy using omalizumab is one of the most researched variants of phenotype-specific treatment. method: aim of our study was to investigate of the causes of uncontrolled predominantly atopic asthma, the frequency and effectiveness of the personalized therapy in real clinical practice. patients with uncontrolled severe atopic asthma were examined in outpatient department of the city hospital during . all patients underwent physical examination, pulmonary function testing, and total serum ige evaluation. results: % of patients had uncontrolled asthma due to inadequate basic therapy of the disease. the change in therapy allowed them to achieve control of the disease. obstructive sleep apnea syndrome (osas) was revealed in . % of patients. these patients underwent cpap (continuous positive airway pressure) therapy. % of patients had gastroesophageal reflux disease (gerd). % of patients had an elevated level of serum ige level and needed anti-ige therapy. in . % of cases, the initial serum ige level was more than iu/ml which was a contraindication to therapy of omalizumab. patients received omalizumab therapy. this therapy led to relief of symptoms and decreased frequency of asthma exacerbations. results: it was found that the prevalence of obesity among the patients with asthma and being treated in inpatient conditions in - was . % of patients, which is comparable to the prevalence of obesity among the population in general. the data of the patients suffering from asthma and obesity treated both in inpatient and outpatient conditions, was analyzed and it is set that obesity does not affect the severity of the clinical course of asthma. it is shown that obesity does not affect the control of symptoms of asthma. thus, the control of asthma symptoms depends on timeliness of diagnosis, the adequacy and terms of appointment of basic asthma therapy, the presence, severity and adequate treatment of concomitant diseases, psychoemotional background of patients, their compliance and adherence to therapy. results: the causes of smoking in asthmatics were not significantly different from the control (p > . ). patients most often used smoking as "support for emotional stability". the motivation to smoking cessation was higher in the asthmatics group ( %) than in the control group. the main reason for smoking cessation was a deterioration in health - %. the majority of smokers - %, performed attempts for smoking cessation. low level of br was revealed in % asthmatics ( % non-smoking asthma patients and . % of cases in the control group, p < . ), cf had low values and was lower in asthmatics group in compare to the control group (p < . ). the pac values correlated with the level of br: a low level was determined in % in smoking asthmatics, in % in nonsmokers with asthma and . % in smokers of the control group obstructive sleep apnea (osa). all of the patients were on regular treatment with low dose inhaled corticosteroids for at months and start treatment with continuous positive airway pressure (cpap) .to assess quality of life, we used asthma symptom control tools (asthma control test) .patients performed daily peak flow meter and spirometry (once a week) during period of weeks after start using cpap. results: during the study, of the followed patients had no exacerbation of asthma. four of patients during this period had exacerbation, due to upper airway infection so they were excluded from study. results of following showed that there was improvement in quality of life in all patients included in study but there no statistically significant improvement in pulmonary function tests fpt. huang y ; yao t ; huang y ; chiu c ; tsai z ; kao p ; lu k ; fang h ; lin c ; gau c ; lee w ; tsai h results: the rate of preterm birth among the study subjects was . %. the prevalence of physician-diagnosed rhinitis was . %. there was no significant association between preterm birth and physician-diagnosed rhinitis (p = . ). when stratifying by atopy status, we found that preterm birth was associated with physiciandiagnosed rhinitis among children without atopy (adjusted or [aor] = . , % ci = . - . , p = . ), but not among children with atopy (p = . ). when further classifying by gender, greater protective effect of preterm birth on rhinitis was only found in boys without atopy (aor = . , % ci = . - . , p = . ). the results suggest that preterm birth may have a protective effect against the development of childhood rhinitis in our study population. the protective effect is only observed in boys without atopy. further investigations will be merited to confirm these findings and to investigate underlying mechanisms. background: folic acid supplementation (fas) during pregnancy has been suggested due to its protective effect against neural tube defects. at present the effect of fas during pregnancy on childhood rhinitis has remained unclear. we aimed to investigate the relationship between fas during pregnancy and childhood rhinitis. logistic regression analysis with covariate adjustment was performed. adjusted covariates included sex, age, number of older siblings, breast feeding duration, maternal smoking during pregnancy, maternal allergy, maternal education level, maternal age and socioeconomic status results: the prevalence of physician-diagnosed rhinitis was . %. there is a significant association between fas and physician-diagnosed rhinitis (adjusted odds ratio [aor] = . ; % confidence interval [ci] = . - . for fas ≥ months) compared to the group of never use. in the stratified analysis by atopy status, maternal fas during pregnancy was significantly associated with physician-diagnosed rhinitis in the atopic group (aor = . , % ci = . - . for fas < months; and aor = . , % ci = . - . for fas ≥ months), but not in the non-atopic group. when further stratified by gender, significant association between maternal fas during pregnancy and physician-diagnosed rhinitis was only found in boys with atopy (aor = . , % ci = . - . for fas < months; and aor = . , % ci = . - . for fas ≥ months). the results demonstrate that maternal folic acid supplementation during pregnancy might increase the risk of childhood rhinitis, especially among boys with atopy. further investigation will be needed to validate our findings and to understand potential underlying mechanisms. according to sequence data from detected adv (in all groups of patients) belongs to species f type and samples to species c type (rei group). bv type was identified in strongly positive (ct ≤ ) swab samples in ari group. conclusion: simultaneous testing of respiratory and stool samples together shown that at least . %/ . % of study subjects had dual/mixed infections, respectively, including %/ . % of respiratory disease patients, . %/ % of gastroenteritis patients and . %/ . % of patients with combined respiratory/enteric infections. we found no virus combination specific for different groups of patients. | neonatal respiratory supports and future asthma-like presentation in prematurity with bronchopulmonary dysplasia results: of all the tests analyzed . % were males and . % females with a mean age . ± . years old. half of the tests ( . %) reveals positive specific-ige to more than one allergen and . % ( ) have no serum specific-ige for the tested allergens (table ) . sixteen patients ( . %) have very high concentrations (> iu/ml) of derm. pteronyssinus specific ige, ( . %) of derm. farina, ( . %) of rey pollen and ( . %) of oak and timothy grass pollen. further studies are needed in order to elucidate the effect of these cytokines on allergy development and protection. shinohara m ; matsumoto k department of pediatrics, ehime university hospital, toon, japan; department of allergy and clinical immunology, national research institute for child health and development, tokyo, japan background: probiotics consumption during perinatal and postnatal periods reportedly reduces the risk of atopic dermatitis in the offspring, whereas such probiotics consumption did not affect ige levels or the risks of other allergic diseases; the precise mechanism how probiotics consumption reduces the risk of atopic dermatitis remains unknown. we hypothesized that probiotics consumption may reduce skin hypersensitivity to histamine. to test this hypothesis, we investigated whether perinatal/postnatal consumption of yogurt associates with skin hypersensitivity to histamine or not. method: this was a cross-sectional study enrolled motherinfant (≥ -months-old) pairs. physician-diagnosed allergic diseases and food consumption, such as milk, fermented drinks, and yogurt, by mothers during the third trimester of pregnancy and by infants during the first months of life were assessed using self-questionnaires. skin prick tests (spts) to saline and mg/ml histamine were performed using bifurcated needles, and wheal sizes were measured minutes after the puncture. the spt wheal sizes in infants with eczema/atopic dermatitis (n = ) were significantly larger than those in infants without eczema/atopic dermatitis (n = ; . ± . mm vs . ± . mm, respectively, p = . ), and thus these infants were excluded from the further analyses. the spt wheal sizes to histamine in infants with daily yogurt consumption during the first the aim of this study was to evaluate the prevalence and clinical relevance of sensitization to profilins in atopic patients with food allergy. the study was performed on a group of children age - years with sensitization to at least one plant-derived food allergen (ige > . ku/l). the included patients had never been treated with allergen immunotherapy before the study. the presence of ige to recombinant (r) rbet v , rart v and ramb a in serum was evaluated using elisa method as previously described (jbc ; : ) . in addition serum level of igg to rbet v , rart v and ramb a was also evaluated. results: sensitization to profilins was found in out of ( . %) patients (p+). sensitization to all studied profilins was demonstrated in each p+ patient. the remaining children, with pollenfood sensitization, were not sensitized to any of the studied profilins and they served as a comparator group (p−). analysis of the clinical status revealed that asymptomatic patients in regard to plant-derived food hypersensitivity were found more frequently among p+ ( %) than p− ( . ; p < . ) patients. sensitization to profilin was associated with positive ige to the same food allergens as in the control group. clinical manifestation of pollen-food sensitization expressed as allergic rhinitis, bronchial asthma and atopic dermatitis was comparable between groups, except of oral allergy syndrome, which was not seen among p+ children. similarly, history of anaphylaxis to plant-derived foods was registered only among p− ( . %) patients. interestingly, all patients with sensitization to profilins had also elevated level of serum igg against rbet v , rart v and ramb a . results: no significant difference of physician-diagnosed eczema (p = . ) or current eczema (p = . ) was observed between children born full-term and preterm. after stratifying by atopy status, we found that children born preterm had a more than three-fold higher risk of having physician-diagnosed eczema (adjusted or (aor) = . ; % ci = . - . ; p = . ) and current eczema (aor = . ; % ci = . - . , p = . ) than their counterpart in the non-atopic group. no statistical significance was observed for the association between preterm birth and eczema in the atopic group. no association between preterm birth and eczema was found when stratifying by gender. our results reveal that non-atopic children born preterm have a higher risk of developing eczema. the results suggest potential modifiable effect of atopy on the association between preterm birth and eczema. further studies with a larger sample size are needed to validate the findings in this study. background: there is a need for more knowledge about factors of importance for a successful transition from childhood to adulthood among adolescents with allergic disease and especially those with severe allergy. therefore the aim of this study was to describe experiences of living with severe allergy from the adolescents and their parent's perspective and thereby identify factors of importance for transition from pediatric to adult care. method: a qualitative study was performed based on six focus groups interviews, two with adolescents and four with their parents. in total adolescents (age - years old) and parents participated. the interview guide contained questions about experiences of living with severe allergy. the transcribed data was analysed using systematic text condensation. results: in total four themes were presented, two themes occurred in both the adolescent and the parent's focus groups, to be special and to be prepared. for two themes there was a difference between the adolescents and their parents. the theme, the importance of the parents, only occurred in data from the adolescents and the theme the meetings with health care only occurred in the parent's data. the adolescents felt that they had low priority in the class and several stated they were teased at school and their parents felt that focus on their child often was in a negative way. the adolescents described that they took responsibility for their diseases while their parents expressed a need to protect. the adolescents stated that one of the parents were always present or had been during the years, the reason being safety and security. only the parents mentioned experiences from healthcare. parents who described that they had continuity in healthcare meetings and where met by high competence and with a professional approach were more satisfied with the support from the health care. one factor that was felt to be important was whether the doctor involved the youth in the conversation or not. the teenagers in this study relied on their parents while also taking responsibility for their illness at the same time. parents, on the other hand, showed a tendency to overprotect their adolescents. for healthcare professionals it is important to involve the adolescents in the care to facilitate the transition. results: . % of the children used antibiotics currently and . % out of them used antibiotics ≥ times yearly. current wheeze (w) was established in . %, sleep-disturbing w in . %, exerciseinduced w in . %, dry night cough apart from a cold in . %, and asthma in . %. current antibiotics use ≥ times yearly was positively associated with current w (aor: . ; . - . ; p < . ), sleep-disturbing w (aor: . ; . - . ; p < . ), exercise-induced w (aor: . ; . - . ; p = . ), dry night cough (aor: . ; . - . ; p < . ), and diagnosed asthma (aor: . ; . - . ; p = . ) while antibiotics use < times yearly was positively associated only with current w (p = . ) and dry night cough (p = . ). the results suggest an aggravating role of antibiotics use on asthma in school age thus further supporting the recommended restriction of antibiotics exposure. results: after questioning . % % ci, . - . were suffering from respiratory diseases, having symptoms of chronic disease: cough- . %, wheezing- . %, tightness in the chest- . %. the risk factors (passive smoking, open fire house warming and no air conditioning) were commonly met in major cases at ill children rather than healthy ones ( . % % ci, . - . ). as a result of studies made of the equal to . ± . , comparative the end of lessons equal . ± . (p ≤ . ); air relative humidity varies during lessons equal with . ± . (norma toilet %- %); co concentration exceeds allowable limits − . ± . (mac − . %). conclusion: respiratory morbidity in high school examined has a tendency to increase. we noticed deviations from the hygienic norms: the indoor temperature and relative humidity was lower and the co level was twice higher than the normal one. the "asthma ever" outcome was reported in cohorts. cohorts defined this as parental reported asthma (with or without specifying that it was doctor-diagnosed), cohorts used gp records as the only source of diagnosis, and used parental report or gp records. the "current asthma" outcome was reported in cohorts. there was little consistency with how current asthma was defined or worded, with different definitions used. the most common definition of current asthma, reported times, was "asthma ever and either asthma symptoms in the last months or asthma medication in the last months". other criteria included in asthma definitions were bronchial hyper-responsiveness, reversible airway obstruction, positive exercise test, and asthma symptoms reported at a previous questionnaire. only one "current asthma" definition was based exclusively on prescription data: "dispensed two asthma medication during the past year". nine cohorts reported asthma outcomes without specifying how it was defined, and were categorized as "asthma unspecified". conclusion: "asthma ever" and "current asthma" are two main asthma outcomes used to define asthma in child cohort studies. definitions of asthma vary substantially across cohorts. case report: thereby we present two case reports of two children with impairment verbal communication as part of asd and allergic diseases. the first patient was a year old boy with sneezing, rhinorrhea night cough and eye redness. he had been suffering for almost years from the above mentioned symptoms. he had family history for atopic diseases and was for month breastfed. specific ige revealed sensitization to birch, alder, hazel, oak, mugwort pollen and dog epithelia and dermatophagoides farinae. specific ige resulted positive for nuts and rye flour. the second patient was almost year of age in the tame that he presented in our hospital. he cried and screamed all the time because of severe atopic dermatitis and typical symptoms such as itching all over the body and his impairment of verbal communication. specific sensitization showed sensibilization to egg white and egg yolk, to nuts, rye and wheat flour. the food specific ige leaded to positive results to alder, birch, hazel and oak pollen, but also to grasses, ragweed and mugwort. prick by prick test showed positivity to egg white and egg yolk. atopy patch test to pollens resulted negative. results: the first patient symptoms were well controlled after treatment with antileukotrienes. his verbal communication was also improved after a year or more. the second three year old patient after required a combination of specific treatment with antihistamines, corticosteroids, immunosuppressive drugs and diet recommendation. afterwards he had a reduced level of itching and anxiety but compared to other children he had a severe eczema. erythema multiforme (em) is an acute, immune-mediated, mucocutaneous condition that is most commonly caused by infection and drugs. it is characterized by targetoid lesions, sometimes accompanied by oral, genital or ocular mucosal erosions. there was no pediatric patient that had previously been reported in the literature with development of type reaction after omalizumab treatment. we presented a case who developed em to omalizumab therapy. an year-old female patient was admitted to pediatric allergy clinic with complaints of fever and rash. she had been diagnosed with chronic spontaneous urticaria (csu) years ago and she was planned to treat with omalizumab ( mg, subcutaneously every week) because of the inadequate response of antihistamines at a medical center. her complete blood counts, liver, renal, thyroid function tests and serum c ,c ,c esterase inhibitor protein levels introduction: celiac disease is an autoimmune disease triggered by exposure to gluten in genetically predisposed individuals and characterized by chronic inflammation of the small intestine. chronic urticaria is a skin disease, characterized by the appearance of pruritic wheals with or without angioedema, whose underlying mechanism cannot be identified. objective: to report a sporadic case of an -year-old boy with chronic urticaria associated with celiac disease. methods: an -year-old boy(weight kg, rd- th percentiles) was admitted to our clinic with a -year history of chronic urticaria. during the first three years, he was under antihistamine treatment(of incremental doses)and occasionally received preparations of cortisone according to the eaaci guidelines. he was asymptomatic for years until treatment was discontinued. eight months earlier, after a viral infection, a recurrence of urticaria, involving the trunk and extremities without angioedema was noted. subsequently, he was under antihistamine treatment with cetirizine but had an uas- score of . total laboratory investigations were performed. results: laboratory control was negative except for positive antibodies to celiac disease(anti-transglutaminase > u/ml, anti-endomysial, gliadin antibodies).further control with colonoscopy and biopsies (from duodenum and stomach) were obtained. the histopathological findings along with the clinical findings indicate celiac disease, type b marsch-oberhuber and grade b corazza-villanacci. in the past, similar cases have been reported. efforts have been made to associate chronic urticaria with celiac disease, although the mechanism remains unclarified. evidence suggests that the duration of gluten exposure, among otherwise asymptomatic patients with celiac disease, is related to the development of other autoimmune mechanisms. this can be explained by resolution of urticaria manifestations after the onset of gluten-free diet. in our case, three months after gluten-free diet, an improvement of urticaria with decreased uas- score of was observed. conclusion: he specific case of subclinical diagnosis of celiac disease in a child with chronic resistant urticaria further reinforces the suggestion that screening for celiac disease should be included in the diagnostic approach of chronic urticaria. | allergy to gingival balm in an infant with cow's milk protein allergy we report a case of an infant with a diagnosis of cmpa with an allergic reaction to a gingival balm caused by the presence of cmp in its constitution. furthermore, it is important to reinforce that milk proteins were labeled in an unusual form which might increase the risk of misunderstanding. these findings illustrate the difficulty in implementing total avoidance of common food allergens as well as the need to improve their labeling, particularly in non-food products. bakiri ah results: after specific treatment with corticosteroids, antihistamines, emollient creams, disinfectants and antileukotriens he was feeling better, he was smiling again and wished to have the chance to play with his classmates again. conclusion: this case report shows an association between level of stress and risk for atopic dermatitis. as previously showed children with low educational level parents and boys with higher stress have increased risk of having severe atopic dermatitis as compared to "no stress" boys. so early treatment and diagnoses are key important factors improving the children`s social life. results: the data cover immigrants (mean age . , range - ) and locals (mean age . , range - ). a slight difference in male prevalence ( . % vs %, p = . ), and pet possession ( . % vs . %, p = . ) were found between immigrants and locals, respectively. no differences were find in term of age and symptoms at presentation. the pattern of sensitization to the different allergens showed no statistically significant differences between migrants and controls. the rate of monosensitization resulted slightly higher in migrants ( . %) than controls ( . %). pollen-only sensitization was statistically higher among migrants than control ( . % vs . %, p < . ). monosensitization was more frequent among patients who have been living in italy for less than years ( . % vs %, p = . ). the opposite phenomena can be seen among polysensitized patients. conclusion: migrants are more frequently monosensitized than locals and tends to cluster towards either a pollen or dust mite sensitization. sensitization to house dust mite tends to appear early (< years of stay). pollen or mixed sensitization is more frequent the longer the residence time. | allergenonline.org: update of comprehensive allergen and celiac protein searchable databases for risk assessment of novel food proteins goodman re ; baumert jl ; taylor sl ; ebisawa m ; ferreira f ; bohle b ; van ree r ; kleine-tebbe j ; abdelmoteleb m ; koning f ; amnuaycheewa p conclusion: allergen and cd databases have been updated following a described review process. they can be used to identify proteins that might represent risks of food allergy or cd for affected consumers. han dh ; lee jw ; yim hj ; ko yk ; kim d ; rhee c seoul national university hospital, seoul, south korea; seoul national university bundang hospital, seoul, south korea background: stress can change the immune response and aggravate various allergic diseases. we already demonstrated in previous allergic rhinitis cohort (arco) kids study that stress might be a risk factor for pediatric allergic rhinitis (ar). the aim of this arco study is to investigate relationship between stress intensity, symptoms severity and quality of life as well as allergic markers in adult ar patients. results: as stress intensity increased, the proportion of moderatesevere ar patients was significantly increased. ar patients in high stress group was likely to belong to moderate-severe group (or, . ; % ci, . - . ). global vas of ar symptom was . ± . in high stress group and . ± . in low stress group, respectively. the each rqlq domain score was significantly higher in high stress group than in low stress group. total rqlq scores were . ± . in high stress group and . ± . in low stress group, respectively. however, as the level of stress increased, there were no significant changes in serum levels of allergic markers. our results suggest that stress may affect ar symptom severity and quality of life in ar patients. | skincare and synbiotics for the prevention of atopic dermatitis or food allergy in newborn infants: a × factorial randomized non-treatment controlled trial dissanayake e ; tani y ; sahara m ; mitsuishi c ; nagai k ; sato y ; suzuki y ; nakano t ; yamaide f ; shimojo n (n = ). the skin care group was advised to apply an emollient - times/day especially on cheeks and peri-oral area. the synbiotics group consumed a mixture of fos ( g) and bifidobacterium bifidu-mol ( × )/day. the last group received both. emollient application was not prohibited in the no-intervention group. interventions were carried out from birth to months of age. the development of ad was assessed at month, months and months by a pediatrician and at year by a questionnaire. ad was diagnosed using guidelines of the japanese society of dermatology. sensitization to food allergens was assessed by allergen-specific ige levels at months of age. results: skin care and synbiotics, alone or in combination, did not prevent the development of ad at year of age or the sensitization to food allergens at months of age. conclusion: our data suggest that skin barrier protection using emollients may be insufficient to prevent the development of ad as other factors affecting skin barrier integrity and trans-epidermal water loss such as the method of skin washing may have an additional effect. the probiotic bacterial species used may also affect the outcome as lactobacilli have been shown to be more beneficial. more studies are required to confirm the effects of skin care and synbiotics on ad. results: in the population number of girls exceeded the one of boys (p < . ), especially within the age group from to years. questioning, for months, symptoms of allergic rhinitis (rhinorrhea, sneezing, nose itch, nasal obstruction and eyes' itch) were identified in . (p < . ); symptoms of bronchial asthma (wheezing ( %), episodes of cough at night ( . %), intolerance to physical load ( . %), indoor and outdoor ( . %), coughing and rales in response to stimulus ( . %)) in . % of the population; atopic dermatitis (dermatitis, itch, revelation in early age, involvement of large areas in early age, damage of extremities bending and stretching surfaces in adults)- . % (p < . ); food allergy- . % (p < . ) etc. at the second stage of clinical studies, on the basis of prick-testing, average ige, in our case, was - times greater than normal level. results of study of allergens showed sensibilization to domestic dust (d.f. and d.p.) ( , %) (p < . ). in . % of cases there was stated sensibilization conditioned by cat and dog epidermal allergens results: among the women with available serum, . % were sensitized of whom . % were monosensitised, and . % polysensitised (to two or more allergens). sensitisation to inhalant allergens dominated ( . %), with grass being most common ( . %). only . % were sensitized to food allergens, most often to peanuts ( . %), while among the . % who reported ddfa, ige reactivity to foods were identified in . %. compared to women with no asthma, women with dda ( . %) were in a significantly higher background: regular exercise has been known as beneficial that it reduces the risk of chronic diseases including allergic diseases. however, little has known regarding the relationship between exercise and allergic diseases in korean adolescents. we analyzed the national data whether exercise is related to the prevalence of allergic diseases in the population of korean adolescents method: data from sixth korean national health and nutrition examination survey ( - ) that included adolescents from to years old was analyzed. we defined regular exercise according to physical activity guidelines for americans. multivariate regression analysis was performed to find whether lack of exercise could be a risk factor for allergic diseases. results: the prevalence of asthma, allergic rhinitis (ar) and atopic dermatitis (ad) were . %, . % and . % in korean adolescents, respectively. after adjusting for factors, lack of exercise was not associated with asthma and ar, but was significantly related to ad in korean adolescents (adjusted odd ratio . , . - . , results: it was found that over % of ch up to y.o. having the ad within allergic disease (ads). the most significant symptom was a long-lasting itchy rash lasting for month in . ± . % of g and . ± . % of g. the first morbidity of ad was noticed at the age of up to y.o. among . ± . %. at the age of ch - y.o. and older than y.o. the skin ads onset was noticed for . ± . % and . ± . % accordingly. the ad sl was determined as follows: %moderate (mo), %severity (s), % were ± kua/l, ± iu/l respectively. skin prick tests were positive in . % of the patients ( . % multiple allergens). grass pollens ( %) and dermatophagoides ( . %) were the most common allergens. average vitamin a and d levels were . ± μg/l ( - ), . ± . ( - ) respectively. thirty percent of the patients vitamin d levels were mildly low, . percent was low. in control group % was mildly low, vitamin a levels was low in . % of the patients. none of the children in control group had low vitamin a levels. we didn't find any statistical significant difference for both vitamin levels between patient and control groups. vitamin a deficiency was mostly found in asthma patients whereas vitamin d deficiency was mostly in allergic rhinitis and asthma groups. passive smoking and vitamin d deficiency was significantly related (p = . ). there wasn't any relation between asthma attacks and vitamin levels. conclusion: in conclusion vitamin a and d levels weren't found significantly related with allergic diseases but was found lower than control group. patients having chronic diseases are one of the population groups that are chronically exposed to drugs. this study aims at evaluate the impact of this factors in developing drug allergies in the medical staff. method: this was a cross-sectional study that included nurses from the uhc "mother theresa" of tirana. they were asked to fill up a questionnaire where questions about chronic diseases and drug allergies were included. . % were females and the mean age was . (+ . ) years old. relative risks with % ci were calculated for different groups. results: . % ( ) nurses reported to have at least a chronic disease. the most common non-atopic disease was hta followed by the groups of autoimmune and thyroid diseases. nurses who had one chronic disease have a rr of . ( % ci = . - . , p < . ) to develop a drug disease higher than those who didn't had any chronic disease, and those who have more than one chronic disease have a rr of , p < . ) to develop a drug disease. the presence of chronic diseases can be a risk factor to develop a drug allergy probably through the increased risk to drug exposure. these patients may be exposed to drugs not only through therapy but also through hospitalizations and other forms of health care. lapeere h ; oosterlinck p ; vermeir p ; vermeire i ; coppens m ; gevaert p ghent university hospital/ghent university, ghent, belgium; ghent university hospital, ghent, belgium; ghent university hospital/ghent university, ghent, belgium background: the key to managing latex allergies in healthcare professionals and patients lies in correct recognition and appropriate action. . million people are employed in the health care sector. while there are no overall statistics on the prevalence of latex allergy in that work force, studies do indicate that %- % of health care workers regularly exposed are sensitized, compared with %- % of the general population. latex allergy is defined as an immune mediated reaction to latex products (e.g. balloons, contact dermatitis for gloves, condoms, surgical catheters); these encompass immediate and delayed hypersensitivity reactions. method: based on the experience of the belgian dutch pathway network, a -phase method to develop, implement, evaluate and continuously follow up a care pathway for latex allergy was designed and implemented. the purpose of the study was to develop and implementation of latex allergy clinical care pathways to provide all staff at ghent university hospital with appropriate knowledge and skills to identify and manage patients who have a known latex allergy or those at risk of developing latex allergy. results: care pathways, also known as clinical pathways, are used all over the world to implement and monitor patient-centered care processes in a transparent way. care pathways are defined as a complex intervention. -phase method consists of: ) screening phase; ) project management phase; ) diagnostic-and objectification phase; ) development phase; ) implementation phase; ) evaluation phase and ) continuous follow-up phase. this phased approach is based on the deming cycle, better known as the "plando-study-act" (pdsa)-cycle. conclusion: this method can offer support to multidisciplinary teams (re)designing and implementing safe, efficient, effective, person-centered, timely, equitable, continuous and integrated care processes. however, the method is no guarantee to success. the key to success is the collaboration and critical attitude of the entire multidisciplinary team when implementing pathways. background: cord blood ige (cb-ige) were considered to be a useful predictive tool for allergic symptoms especially in early childhood. there is only sparse knowledge about their importance for health in later life. the aim of our work was to determine the importance of cb-ige for allergic symptoms in young adults. we also studied the possible modifying factors for cb-ige concentration. results: resutls shown as daily mean, pollen grains/m³: table . the daily means of pollen concentrations of cupressus arizonica, platanus acerifolia and plantago lanceolata in our area differs from other sites in madrid city. although cupressus arizonica and platanus acerifolia counting were lower, plantago lanceolata counts were higher, representing a relevant pollen in our area. the clinical relevance of these findings is under evaluation by our group. method: grass pollen counts were performed since - using a burkard days spore trap located in our allergy center in madrid. the beginning of the algid period of pollination was considered the first of three consecutive days with more than grains/m and the end, the last day of three consecutive days with more than grains/m . madrid, barajas meteorological station data, was used. skin prick tests (pt) to grass pollen was also studied in comparison conclusion: total grass pollen concentration did not suffer any increase or decrease in its counts despite the dramatic increase of the temperature. an advance at the beginning and the end of the season was seen. these changes significantly correlate with the temperature increase during may and july. discrete decrease in the sensitization prevalence. since several years, the reference method to monitor the biological particles concentrations has been the hirst method: a volumetric pollen trap, located on the roof of building for background measurements, sucks continuously l of air per minute, particles depositing by impaction on a coated tape. the tape is then analyzed by optical microscopy. the hirst method produces accurate but past data. nowadays, many researches are focused on the development on new devices to get real time information. method: rapid-e from plair sa is a device using red laser beam to determine the size and the shape of sucked particles and an ultraviolet ray to measure the fluorescence of these particles. the results: the correlation coefficients got between rapid-e and hirst trap are higher than % for most of calibrated pollens, this correlation reaching % for all pollen taxa: • plane % • pine % • birch % • oak % • plantain % • dactylus % • urticaceae % conclusion: new calibrations are planned for and a real time information will be set up. results: the quinquennial media concentrations since - were . ; . ; . ; . ; . ; . ; . and . grains/m . the quinquennial media temperatures were . ; . ; . ; . ; . ; . ; . and . °c. increase of . °c (r s = . p < . ). the beginning and the end of the actual season advanced days respectively in regard to the period from to . the annual prevalence of positive pt to platanus in was % an % in . the quinquennial media from to was , , and %. conclusion: platanus pollen counts had a dramatic increase that meaningfully correlates with the dramatic increase of the temperature. a discreet advance at the beginning and the end of the season was seen. these changes did not influence in a longer duration of the season. we observed a significant increase in platanus pollen sensitization prevalence whiting madrid pollinosis patients. results: the quinquennial media concentrations since - were , , , , , , and grains/m . the quinquennial media temperatures were . ; . ; . ; . ; . ; . ; . and . °c. increase of . °c (r s = . p < . ). the actual season beginning advanced in days and the end has results: over % of house dust samples collected between april and may from central european countries were found to contain bet v allergen at levels well above the limit of detection of . μg/g for elisa . ep kit and . μg/g on maria. samples were found to have much higher levels of bet v allergen from midto-late april, particularly those that were collected in germany, belgium and hungary. samples taken from outside of the pollination season were tested and found to be negative for bet v . in conclusion, we found that bet v allergen can be detected and quantified in house dust samples. these data suggest that household dust is a source of pollen allergen and could therefore be contributing to asthma and allergic rhinitis symptoms in individuals affected by pollen allergy. household dust may also be considered as a source of bet v allergen which could contribute to allergic sensitization. | cupressaceae pollen in the atmosphere of alentejo: disruption of pollen grain during air transport spring, depending on the temperature. despite being considered moderately allergenic, it might be responsible for winter allergic outbreaks. as ornamental trees, they are found scattered throughout the territory but are more abundant in pockets of wild forest, outside alentejo. despite being more common in mountain, this pollen type is captured in considerable amounts in alentejo, portugal, where its aerobiological features and allergenic impacts are poorly characterized. the aim of this work is to characterize the aerobiology of cupressaceae pollen, to evaluate the effect the meteorological conditions and the source of this allergenic pollen type in the atmosphere of evora, alentejo. method: pollen were collected using a hirst type -day pollen trap and pollen was identified following standard methodology. background: allergic rhinitis caused by pollen is one of the most common allergic diseases. the presence of pollen in the air is currently centrally monitored at roof top levels, and not in the direct living environment of sensitized subjects. in the current project we aimed to develop a handheld pollen sampler, called pollensniffer, that can collect pollen in the living environment of the allergic subjects. as a first step this device was validated against the standard burkard pollen sampler and used to monitor local pollen concentrations at street level in the city of leiden. method: rooftop level pollen were monitored routinely by a hirst type pollen sampler (burkard, uk). the pollensniffer ( | does the allergy risk due to pollen exposure information is useful for the allergy sufferers? sindt c; oliver g; thibaudon m background: in france the information for the allergy sufferers is not made with pollen counts, which have not a real signification, but with the allergy risk due to pollen exposure. method: since more than years, rnsa (réseau national de surveillance aérobiologique), the french aerobiology network, has measured the pollen exposure in the main cities of france, using background: the effect of environmental factors on allergic sensitizations is still unclear. rural areas vs cities have different exposure levels to pollutants and aeroallergens. these differences could give clues on the causes of higher allergic sensitization rates in children exposed to city air. method: two studies with children aged years old were initialized to analyse the airborne drives of allergic sensitization: seal (günzburg, children) and ae r kids (munich, children). capillary blood was collected and the parents filled in a questionary. sensitization rates were quantified using the immunocap ® isac sige array. pollen data were measured at both locations. results: in günzburg more children were sensitized to aeroallergens, however munich children showed significant higher sensitization to phl p (p < . ), despite the lower concentration of pollen. in günzburg % children had no sensitization at all compared to % in munich. % of the children in munich spend at least hour per day outside and % of the total have no animals at home. % felt symptoms of hay fever in the last months, the majority between march and june, which correlated with the pollen flight. results: the total rate of atopy in crd patients was . %, and asthma patients was the highest ( . %). the positive rate of phadiatop in urban asthma patients ( . %) was significantly higher than that in rural areas ( . %, p < . ) and the phadiatop positive rate of office staff ( . %) was significantly higher than that of outdoor workers ( . %, p < . ). the total rate of atopy in copd patients was . %, and in patients with acute exacerbation was . %. beside, atopy is a risk factor for dyspnea (or = . , p < . ), and the fvc levels in copd patients with atopy were significantly lower than those without ( . l vs . l, p < . ). optimal scaling analysis show that, there were a correlation between the tige and smoking coefficient (cronbach's alpha = . %). in addition, the correlation between the level of tige and phadiatop sige was so strong in the patients with mild to moderate asthma (r s = . , p < . ), but it was weak in severe asthma patients (r s = . , p < . ), and up to . % of the gold iii iv patients with low phadiatop level (≤ ku/l) had a high level of tige (≥ ku/l) compared gold i ii ( . %). conclusion: the rate of atopy in patients with crd is high, and atopy is an important factor affecting the process of crd. the patients with severe copd or asthma is likely to has high serum tige level but the level of common allergen sige is low, so the allergy screening strategy should be adjusted and we should pay attention to those patients, therefore, it is necessary to screen the sensitization situation of crd patients at first, and the results can guide the treatment, management and prevention of crd. background: due to a limited amount of epidemiological data [ ] it has been thought that many severe allergic asthmatics in germany remain unidentified and are therefore not adequately treated. a pilot project demonstrated that more than % of patients, having been mean total ige (sd) was . ( . ) ku/l. . % of the patients had no sensitization towards any of the specific iges tested, whereas % were positively tested on - allergens and further . % showed sensitizations towards > allergens. conclusion: approximately % of online recruited (severe) asthmatics had a total ige level of > ku/l and ≥ sensitization (allergen-specific ige) towards atopic allergens. this further supports the high prevalence of atopy in asthma. results: patients (mean age: ± . years, range - years, m/f ratio: . ) who suffered from allergic rhinitis or allergic rhinoconjunctivitis enrolled in this study. highest rate of skin sensitivity was for weeds/grasses pollen including salsola kali, amaranthus retroflexus, chenopodium album and compositae family ( . %, . %, . % and . % respectively). among tree's pollen; ash ( %), walnut ( . %) and mesquite ( . %) were the most common. less than % of patients showed skin reactivity to indoor allergens and storage mites, mix of cockroaches and house dust were the most common ( . %, . % and . % respectively). the results of current study confirmed the importance of weed/grass and trees pollen as the major source of allergic sensitization in our area. interestingly the rate of sensitization to indoor allergens was low which can be explained by geo-climatic situation. background: there are few studies of cutaneous sensitivity to gramineae in our region. mostly of them use allergens of foreign species. the study aims to estimate the prevalence of skin sensitivity to widespread grasses in our region. method: this is a retrospective observational study of patients with seasonal allergic rhinitis. patients were studied using skin tests with pollens extracts from pooideae, chloridoideae and panicoideae grass species. results: the prevalence of positive reaction to pollen from pooideae subfamily was . % (ic: . %- . %). in turn, prevalence of allergy to panicoideae subfamily pollens was . % (ic: . %- . %) and positive reaction to chloridoideae subfamily reach . % (ic: . %- . %). cochran test suggests that prevalence in those three groups is different (χ = . , p < . ). when comparing just the groups of allergens from pooideae and panicoideae differences are also significant (χ = . , p < . ). in particular, . % (ic: . %- . %) of patients were allergic to paspalum notatum. regarding cross-reactivity between subfamilies, we find a no crosscorrelation between pooideae and panicoideae (χ = . , p = . ). conclusion: in bahia blanca, patients with seasonal rhinitis are sensitive to pooideae, chloridoideae and panicoideae. paspalum notatum, belonging to panicoideae, has a significant prevalence, high reactivity and low cross-reactivity within the group of species studied. this last species is relevant because it is a native grass from the northwest region of our country, paraguay and the south of brazil. prevalence of grass positive skin tests in patients with seasonal rhinitis by species. allergen frequency percentage % ci results: correlation analyzes were performed between sige and spt and area results. the concentration with the highest correlation by diameter and area for blo t was μg/ml and for der f of μg/ml. in the case of der p the concentration with the highest correlation for the diameter was μg/ml and for the area of μg/ml. when evaluating the reproducibility of the results according to the area and the greater diameter of the spt, a strong agreement was observed for blo t in the concentrations of μg/ml and . μg/ml. results: among the patients, the majority of allergens-positive was t , accounting for . %, followed by f ( . %), f ( . %), ds ( . %) and ccd ( . %). the prevalence of plant-related allergens (t , w , f , f , w and u ) in ccd-positive patients were significantly higher than those in ccd-negative patients (all results: with our new point-of-care methods using a selected recombinant protein e other markers, we were able to detect the disease early as days post-infection and more than % of positive cases from chronic and low endemicity areas (which are characterized by hard to detect patients with extremely low parasite load, < eggs per gram of feces) were obtained. plus, chromatography poc-cca ® test was improved by our group with a urine concentration step that turned its sensibility from % to %. conclusion: monoclonal antibody and recombinant protein technologies allowed superior detection methods when comparing it to the conventional ones. in conclusion, data showed % of sensitivity of chronic patients and % of acute patients. marton c county hospital, oradea, romania background: allergic rhinitis is a disease that affects about a quarter of the population, a disease with an important negative impact on daily activities, both on learning and working ability, as well as spending leisure time or sleeping. in the western part of romania, the most popular and blamed allergen is ambrosia, in the late summer months. it is a plant of the compositae/asteraceae family, along with goldenrod, sunflower, dandelion, cocklebur, chamomile, wormwood, daisy, etc. allergen identification is important for applying prophylactic measures, but especially for determining the allergen to be desensitized. considering the possible cross-reactivity within the compositae plant family, as well as the possibility of co-sensitization, as well as the number of patients sensitized to these pollens, which is steadily increasing, i considered is necessary a broad screening for a more precise identification of the allergen and increase chances for a successful desensitization. method: the observational study includes patients who presented on october for testing with standardized allergen extracts, as recommended. criteria for inclusion: patients with specific symptoms of rhinoconjunctivitis in august and september, with or without asthma symptoms, who returned for allergic prick test after the end of treatment. criteria for exclusion: patients who disagreed with cutaneous testing, who did not discontinue antihistamine treatment or who had been treated for other diseases with drugs that influence skin testing. background: in recent years, cationic liposomes are thought to be the most effective and non-toxical nucleic acids`transport system, so most of gene therapy drugs are developed on their base. however, lipoplexes are quickly captured by reticuloendothelial system cells after the injection and taken out of a blood stream. there are many modification methods of liposomal surface for liposomes with prolonged pharmacokinetic properties production. addition of hydrophilic polymers (peg) is seemed to be the most promising approach, that is able not only to create steric barrier on the particle`s surface and prevent the interaction with blood plasma lipoproteins, but also inhibits the protein adsorption, opsonisation and subsequent degradation in human body. the aim of this study is the evaluation of liposomal surface modification by hydrophilic polymers influence on nucleic acids`lipoplexes conjugation and on their physico-chemical and biological properties. method: liposomes preparation (including peg-modified liposomes), size determination by photon-correlation spectroscopy, examination of transfection efficacy by luciferase assay. (c h ) ) were obtained. also the modified liposomes were produced by addition of % of peg (by mass) during thin lipid layer preparation step. the size distribution was analysed by photon-correlation spectroscopy. it was shown that peg addition does not increase the par- conclusion: it can be noted that addition of peg can change the lipoplex formation but the cationic liposomes still remain an effective rna delivery system. and peg modification will be able to impart prolonged properties for the vehicle in bloodstream. foundation (grant № - - ). ory c may cause a cross reaction with fel d (cat), can f (dog), equ c (horse), mus m (mouse) and rat n (rat). february eight patients that were treated at our institution were diagnosed with rabbit allergy. results: all eight patients with the diagnosis of rabbit allergy presented with signs of upper respiratory involvement. two patients had itching teary eyes, watery nasal discharge and sneezing while feeding farm rabbits. one of those also presented with dyspnea. four patients developed problems whenever in contact with domestic rabbits. one patient developed allergic rhinoconjunctivitis whenever she was home-her parents own a rabbit, but while away in her college room she had no problems. another patient had dyspnea whenever visiting his girlfriend's house. she owned a rabbit. two patients developed asthma-like symptoms, one also presented with angioedema. the other two had developed allergic rhinoconjunctivitis. two patients have problems in contact with cats, one of them also with cows, however skin prick tests were also positive to rabbit. three out of eight patients developed allergic asthma with a positive methacholine test. six patients had a positive house dust mite prick test. all patients were diagnosed with a positive prick tests to rabbit allergens. all were treated with a nasal steroid and antihistaminesic. they were also advised to avoid contact with the animal. conclusion: domestic rabbit-induced asthma and/or allergic rhinoconjunctivitis is possible, however it is still rare in our environment. it is very important to always ask the patient about their pets in general, not just focusing on cats or dogs. only with a thorough examination and history we can find the true cause of the patient's allergy where pets play an important role. korea. changes of protein and major allergen concentration were measured over one year by bradford assay, two-site elsia, and sds-page after reconstitution of the lyophilized allergen extracts in various buffer (normal saline, . % phenol saline, and or % glycerol with saline) and stored at room temperature (rt, ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) or refrigerated ( °c). results: more than % of the initial protein concentration in all four extracts examined was detected over one year when % glycerol was added and refrigerated, whereas . %- . % remained in the extracts at rt. the addition of % glycerol to the storage buffer was found to prevent protein degradation at rt. all four extracts were found to be stable when reconstituted in % glycerol. amb a , a major allergen of ragweed, was almost completely degraded in weeks at rt when reconstituted in a buffer without % glycerol. however, . %- . % of amb a content was detected after one year of incubation at °c in all buffer conditions except . % phenol. conclusion: addition of % glycerol as well as refrigeration was found to be the important to increase the shelf-life of allergen extracts from pollens of allergenic importance. results: this is the first genetic study of the bulgarian hae patients. genetic defects were identified in hae families are: nonsense, splice-site defects, frameshift mutations, indel non frameshift, missense, and large deletion of exon . novel mutations, not previously reported in human gene mutation databases were discovered, and were predicted to be deleterious due to the expected effect on dna transcript and protein. descriptive statistics were used to summarize the eq- d-y descriptive system responses and vas scores by treatment and visit. results: twelve patients with hae type i and a median (range) age of . ( ) ( ) ( ) ( ) ( ) years were enrolled, ( . %) of whom were female. during bop, treatment with u c inh, and u c -inh, ≤ . %, ≤ . %, and none of the patients, respectively, reported having problems with mobility, self-care, doing usual activities, pain or discomfort, and feeling worried, sad or unhappy. the mean [sd] eq- d vas scores increased from . ( . results: overall, the model-derived median exposure and peak concentration across all weight ranges in paediatric patients is predicted to be higher with wb vs weight-based dosing (table) . the effect was most pronounced in patients aged - years, where the wb dosing achieved approximately % higher values than weight-based dosing for median auc - ( ng hour/ml vs ng hour/ml, respectively) and c max values ( ng/ml vs ng/ml, respectively). the wb levels are closer to those in adults receiving mg icatibant (median auc - ng hour/ml; median c max ng/ ml) but never exceed them. results: samples from patients were analysed. lanadelumab concentrations in plasma increased with higher doses and dosing frequencies. steady state was reached around week (range week to week as evaluated by predose concentrations). at baseline, mean (sd) chmwk levels were . % ( . ), . % ( . ), . % ( . ) and . % ( . ) for patients in the placebo and lanadelumab mg q wks, mg q wks and mg q wks treatment arms, respectively. by week , mean (sd) chmwk levels decreased to . % ( . ), . % ( . ), and . % ( . ) following treatment with lanadelumab mg q wks, mg q wks, and mg q wks, respectively, and remained reduced throughout the treatment period. conversely, chmwk levels remained elevated at . % ( . ) at week in patients who received placebo. patients in the placebo group had the highest attack rates over the -week treatment period (mean . attacks/month), whereas the rates were markedly lower in patients treated with lanadelumab mg q wks ( . attacks/month), mg q wks ( . attacks/month) and mg q wks ( . attacks/month). dose-and frequency-dependent manner. exposure to lanadelumab was associated with decreased chmwk levels (indicating inhibition of plasma kallikrein activity) and lower hae attack rates, corroborating the efficacy findings and utility of chmwk as a bioactivity marker in the help study. with cyklokapron (tranexamic acid) since she was years old and took the medication very irregularly due to lack of efficacy. one year before presentation at our clinic, she married and moved to vienna. we started a treatment with the bradykinin- receptorantagonist icatibant sc at the beginning of the menses and if needed a second time at the time of ovulation. she responded well until she got pregnant. during pregnancy, she developed weekly attacks with increasing severity. therefore, a weekly treatment with humanplasma-derived, pasteurized, nanofiltered c -inhibitor (inh)-concentrate, units iv once a week was started and had to be increased to twice per week after one month of therapy due to increasing number and severity of attacks. results: with this treatment attack frequency and severity attenuated. in january she had a normal delivery at term and gave birth to an otherwise healthy son. treatment had to be continued during year of lactation period and also thereafter due to persistent attack severity. conclusion: there are only limited data for the use of humanplasma-derived, pasteurized, nanofiltered c -inh concentrate during pregnancy and lactation period. this case confirms the safety and efficacy of the named drug during these periods. wheals are yet classified. the best characterized stem from hereditary or acquired c inhibitor deficiency (c -inh-hae and c -inh-aae) . last year, the french angioedema network (creak) joined the registry of angioedema without wheals (cloud-r hae). here we present the contribution of the grenoble alpes university hospital (chuga) to this disease registry. the study population is composed of patients with a proved diagnosis of c -inh-hae/aae. the following items are collected: patients' personal-demographic data, clinical/laboratory/genetic characteristics, major comorbidities, treatments (prophylaxis/acute attacks). data from existing registries at chuga are merged into cloud-r hae and missing data obtained at follow-up visits. as from cloud-r hae structure, patients can directly provide information on angioedema attacks and their treatment through a dedicated electronic app, web connection or paper support, which is then transferred into the registry at chuga. method: in a retrospective study, we included a total number of patients, suffering from a chronic skin disease, whose lesions did not improve or even worsened under immunosuppressive treatment ( chronic ulcers/pyoderma gangrenosum, bullous autoimmune diseases, skin lymphomas). ffpe tissue was examined for the presence of cmv dna by pcr. next, within the framework of a small prospective study (n = ) we analyzed the seroprevalence of cmv as well as the presence of cmv dna in lesional skin in patients that had been diagnosed with a chronic skin disease and in whom longterm immunosuppressive therapy had been initiated. results: in the retrospective study cmv dna could only be detected in / chronic ulcers/pyoderma gangrenosum ( . %), but not in bullous autoimmune diseases and skin lymphomas. / patients ( . %) of the prospective study group were seropositive for anti-cmv-igg, as compared to / patients ( . %) in an ageand sex-matched control group. anti-cmv-igm could be detected in method: in this study, we aimed at testing the diagnostic potential of skin function measurements in ss. sixteen patients with conformed diagnosis ss were enrolled in the study. skin fibrosis was assessed by conventional rss and involvement of inner organs and serum inflammation parameters were determined. four objective criteria, namely transepidermal water loss (tewl), corneometry, ph and elasticity, were assessed at nine predefined sites of the body. results were compared to patients with atopic dermatitis (n = ) and acne vulgaris (n = ). method: a multicenter prospective observational study was conducted to investigate the clinical significance of serum scca in children as a biomarker for ad. patients with ad younger than years old and age-matched healthy children without any allergic disease were enrolled in this study. the severity of ad was evaluated using the objective scorad (o-scorad). the serum levels of scca , tarc and total ige were also measured. results: in total, patients with ad and non-allergic healthy children were recruited. the serum levels of scca had the strongest significant correlation with o-scorad, compared with tarc and ige (r = . , and . , respectively). after standard treatment with topical steroids and emollients resulting in an improvement of symptoms, the serum levels of scca and tarc decreased significantly. the area under the curve (auc) for the roc curve was higher for scca ( . ) than for tarc ( . ) or ige ( . ). the difference in aucs between a single cut-off value and age-dependent cut-off values was not significant for scca , compared with that for tarc ( . and . , respectively). conclusion: scca is a more reliable biomarker than tarc for the diagnosis of ad and for determining the clinical severity of ad in children. challenges in predicting severity of atopic eczema patients results: before modeling, we checked for significant differences between patients and controls. these were detected for the levels of ccl , ccl , cxcl , ige and ldh. next, we assessed whether single serum proteins already explain disease severity by calculating correlations. twelve of the proteins, namely gcsf, il- , il- , il- , ccl , il- ra, cxcl , ifng, ccl , il- ß, ccl , and il- , significantly correlate with severity (r range: . - . ). finally, we built a model for the severity of ae based on all measured serum proteins. ten of the proteins are included in the best-fit model (adjusted r = . ). the overall correlation between original and predicted severity scores is high (r = . ) nevertheless the cross validation prediction error is substantial with %. conclusion: applied in daily practice, a prediction error of % translates to a possible miscalculation of scorad points in both directions and therefore the model is of no practical use. aside from using model-based quality measures like cross validation prediction errors to infer the usefulness of predictive models, testing them in independent cohorts could validate these models. collaborations among scientists working on similar approaches would lead to an increase in statistical power and ideally to more robust models. only robust and validated models are going to have the chance to take the step forward from being a result of computational modeling to being applied in the clinical practice of assessing disease severity in patients. jargosch m ; lauffer f ; pätzold k ; krause l ; garzorz-stark n ; schmidt-weber c ; eyerich s ; eyerich k preclinical studies in cell cultures, mice, guinea pigs and rabbits, comprising sterility, cytotoxicity, systemic toxicity, skin irritation, delay contact sensitization and phototoxicity tests, demonstrated safety of this therapeutic agent. we next conducted a single-blinded, intra-individually controlled, phased clinical trial on patients with keloids. the aim was to determine the effects of -month therapy on keloid volume and symptoms of pain and itch. two similar keloids on each subject were selectedone was treated with once-daily, self-administered application of triamcinolone-loaded ( . mg/patch) microneedles for weeks, while the other served as control with no intervention. outcome measures were (a) keloid volume using a -dimensional high-resolution ( . mm) scanner and (b) pain and itch scores on - numerical rating scales. evaluations were performed at baseline, and weeks. in phase of the trial, the whole process was repeated using microneedles loaded with a higher dose of triamcinolone ( . mg/patch). case report: a -year-old girl was admitted to our department with a single round-shaped lesion in the popliteal fossa which spread to extremities, trunk and face and persisted for several weeks and then faded slowly to residual hyperpigmented patches. courses of antihistamines, antibiotics, cyclosporine a, fluconazole, hydroxychloroquine, prednisolone and topical steroids were ineffective. also patient has had history of itchy urticarial rash and angioedema since -year-old, suffered from the flares triggered by physical exertion, stress, cold air and water, spicy food, which resolved within - hours. the patient's father and -year-old brother also had chronic urticaria induced by the same stimuli. the physical examination revealed multiple pink-to-red non-scaly, non-pruritic papules coalescing into annular, arcuate, polycyclic plaques ( - cm) with central clearing, centrifugal spread, indu- | the role of humoral immunity in the pathogenesis of psoriasis results: we found significantly increased levels of iga in the serum of treatment-naïve psoriasis patients correlating with disease score. however, iga was only observed in dermal vessels of skin sections. we next performed in-depth analysis of peripheral b cell subsets using flow cytometry. among all investigated subsets, we only found a moderate positive correlation of cd + plasma cells with iga levels and disease score in untreated psoriasis patients. however, in the group of treated psoriasis patients, neither did iga levels drop nor did plasma cells correlate with iga levels and disease score, rather hinting at an epiphenomenal finding. confirming our hypothesis that psoriasis can develop in the absence of proper humoral immunity, we present a patient who suffered concomitantly from both psoriasis and a hereditary common variable immune defect (cvid). conclusion: here, we provide new insights in the immunology of psoriasis, demonstrating the clear dominance of t cells over shifts in b cell subsets. conclusion: allergic diseases show an increasing incidence in geriatric age. this is partly due to the growing emphasis on a more accurate and careful diagnosis of the aging population. we must also take into consideration the influence of other factors, besides comorbidities and therapeutic regimens in elderly that might affects the immune response, such as environmental pollution as well as food contamination and changing dietary habits of elderly such as easy access to exotic food. one of the challenges in the decades to come is recognizing and fulfilling the need for accurate and timely diagnostics of allergic manifestations in elderly patients, as important part of achieving the best possible quality of life for this growing age group. method: sixty-eight patients with various forms of psoriasis and healthy subjects (healthy control group) were assessed after informed consent was obtained. all subjects were asked to complete a questionnaire including age, gender, duration of psoriasis, concomitant diseases and medications. in the group of patients psoriasis was with only skin involvement with skin plus joints involvement ranging from moderate to severe. psoriaticplaques were evaluated by a specialized medical team using the psoriasis area and severity index (pasi). all patients were seen by a dermatologist and clinical immunologist, who collected data considering the demographic, health status and any other relevant details. blood samples included serum levels of -hydroxycholecalciferol and tnf-α using an elisa kit (germany). method: % ethanolic extract of sp (sp etoh ) and its five major chemical constituents are prepared. to elucidate whether human orai modulated by sp etoh and its chemical constituents, conventional whole-cell patch clamp performed in horai -overexpressing hek t cell. we also assessed whether sp etoh and its constituents could inhibit mast cell degranulation and t cell activation. results: in jurkat t lymphocytes, we found that mg/ml sp etoh inhibited orai current (i orai ) by . ± . %, while one of its constituents (compound v (com v ); μm) inhibited i oria by . ± . %. investigation of human primary t cell proliferation induced by co-stimulation with antibodies to cluster of differentiation and , and of rbl- h mast cell degranulation following ige-antigen complex stimulation, revealed that μm com v inhibited both t cell proliferation (by . ± . %) and mast cell degranulation (by . ± . %); these effects were concentrationdependent, and no cytotoxicity was observed. conclusion: considering that most regional plants have not been investigated chemically or pharmaceutically, they remain as untapped potential sources of topical agents for drugs and other application. our findings suggest that com v , which derived from sp etoh , represents a promising candidate compound for the development of therapeutic agents for the prevention and treatment of allergic diseases. results: the cohort consists of caucasian patients. eight of them ( %) are women. the mean age (and range) at the clinical presentation of disease was years ( - years). the mean age at diagnosis for men was years and years for women. all patients have a positive history of recurrent and/or persistent lip swelling, of them ( %) report oral ulceration, cases ( %) have history of previous or current facial palsy and patients ( %) present tongue fissuring. concurrent cd has been diagnosed in one patient. biopsy reports were available for patients ( %); in cases ( %) non-caseating granulomas were seen. various therapeutic approaches have been described: intralesional corticosteroids had a good response in patients, infliximab was partially effective in cases; oral corticosteroids and/or methotrexate seem to cause a partial symptoms improvement. conclusion: this is the first attempt, in our knowledge, to (a) centralize all data of patients with ofg in a national registry with the aim of carrying out epidemiological data and (b) develop italian guidelines including a diagnostic-therapeutic flow chart, shared by the participating centers. the registry will guide the clinicians in the identification and management of the ofg patients, reducing the diagnostic delay and hopefully improving quality of life. case report: a -year-old girl without personal history of atopy, got a temporary tattoo with henna. after three days, she developed a local exudative, erythematous eruption with painful blisters lesions that followed the contours of the tattoo. she had neither fever nor other lesions. she was treated with topic methylprednisolone-gentamicin showing an important improvement days after. as a liquenoid scar remained in tattoo area, trofolastin ® (centella asiatica, αtocopherol, hydrolysed collagen, elastin) patch was prescribed to be placed on the scar. forty-eight hours later, the patch was removed and was newly observed an exudative, erythematous and painful wound that required oral treatment with amoxicillin-clavulanic. after three days, the girl developed on a maculopapular, generalized and itching rash. she was treated with dexchlorpheniramine and methylprednisolone with a complete resolution in days and she was referred to our allergy unit to be studied because of a suspicion of drug allergy to amoxicillin-clavulanic acid. an allergy workup was performed after obtaining an informed consent. case report: it may be sometimes difficult to find the causing allergen in allergic contact dermatitis. face is a region on which various materials contact. in this manuscript a woman case is presented who shows patch test positivity to her husband's shaving product. a years old woman applied because of allergic contact dermatitis on her face. it is learnt that lesions have been continuing for a long time, occasionally getting well with corticosteroid creams; but continuing again. patch test was performed with european standard series and cosmetic products she was using. negative result was observed. following, patch test was performed for the products her husband was using. positive results were obtained for the shaving cream of her husband was using. in detailed anamnesis, it is learnt that the lesions developed approximately month after her husband started to use this cream. it is advised not to use this product to her husband. the disease did not repeat again. it should not be forgotten that cases with allergic contact dermatitis could get in touch with allergenic materials via individuals in close contact. gül Ü akdeniz university faculty of medicine, department of dermatology, antalya, turkey case report: tnf-alpha plays role in etiopathogenesis of allergic contact dermatitis (acd). in mice which lack tnf-alpha, the response of late type hypersensitivity is spoiled. in addition, tnfalpha blocker are also used in some cases with acd. in this poster the results of european standard patch test is given in which acd is observed and tnf-alpha blocker are used without dermatological indication. cases who use tnf-alpha blocker applied because of acd: there was lesion in one case on face, in other case on face and hand, and in the last case only on hand. european standard patch test was performed to patients who were continuing to use tnf-alpha blocker. in one case no positive response was observed, while in two cases positive response to more than one allergen were obtained. in conclusion, tnf-alpha blockages cannot suppress the response of delayed type hypersensitivity. | case of allergy to nickel on the background of its intake in food peredelskaya m case report: nickel is one of the most commonly used metals; it is used for the manufacture of jewelry, plates and dishes, and medical products. a patient n, years old, female, complains of pruritic rash on the body skin with the itch intensity up to - points and the number of lesions more than . allergic background: for quite some time now the patient noted occasional eruptions on her skin after a contact with jewelry made of non-precious metals. previously patch skin tests with nickel showed a positive reaction. the patient sought emergency medical care with complaints of a number of itchy lesions erupted on her whole body during the last hours. on admittance: state of moderate severity, the patient was emotionally labile, focused on her body sensations, tearful. on the skin of face, upper and lower extremities and torso a punctuate purpura with lesions up to . cm diameter, prone to confluent. a physical status was within normal limits. in order to control the itching, as well as to sedate the patient, antihistamines of the first generation were administrated parenterally; but the eruptions kept to progress and to intensify; lesions were spread throughout the whole body, merged in gigantic areas. system glucocorticosteroids therapy was administrated, with mg of prednisolone, but then new lesions kept appearing in a large number, including after-meal rash. water, tea, bakery products, thin yoghurts did not impact the skin condition, whereas the intake of pasta, cereals, and similar products provoked intensifying of eruptions. the patient observation revealed a sharp increase in the rash after such manipulations as intravenous injections or blood sampling from the vein, the process spreading from the injection site to the entire arm. a detailed anamnesis of the disease: on the eve of the start of hives, the patient purchased a coffee machine (with metal nickel-plated parts) and started to use it. diagnosis: a systemic contact dermatitis. an allergy to nickel. the injection treatment was discontinued and a therapy with per oral gcs and antihistamines of the second generation was administrated. a recommendation was given to cook and to eat food using ceramic or wooden utensils. three days later marked positive dynamics of the skin process has been noted. the episode of systemic contact dermatitis has developed due to exposure to nickel from ingestion in food, as well as during the parenteral treatment. background: anaphylaxis reactions during anesthesia can have a mortality of %- %. / of the anaphylaxis in the operating room are due to the use of neuromuscular blockers. rocuronium is frequently involved because is oftenly used. we present a case of a years old man with an anaphylaxis shock due to the administration of rocuronium. method: years old man with no personal history of interest that is going to undergo vertebral surgery. minutes after anesthetic induction with fentanyl, propofol and rocuronium he started with lowering of oxygen saturation. orotracheal intubation is performed and, with the suspicion of anaphylaxis shock, adrenaline, antihistamines and corticoids were administered. after minutes without improvement, mg of sugammadex was administered, given the possibility that the condition was secondary to the use of rocuronium. tryptasa level was . results: skin test to fentanyl, propofol, látex and rocuronium were done weeks after and only rocuronium test was positive. conclusion: in summary, the occurrence of anaphylactic shock after neuromuscular blockers is widely described in medical literature. there are conflicting data about the use of sugammadex as coadjutant treatment in case of anaphylaxis due to the use of rocuronium. we believe is a good option when conventional treatment is not useful. case report: a -year-old woman with past history of allergic rhinitis and hypertension was admitted to the obstetrics service in labor of first child in april . epidural anesthesia with ropivacain and sufentanil was administered. as there was no labor progression, eighteen hours later she was admitted to undergo cesarean section and epidural anesthesia was re-administered. metoclopramide, ampicilin and ranitidine were given intravenously. during ranitidine perfusion, the patient presented general cutaneous erythema and pruritus, tongue, lips and eyelids angioedema and dyspnea. perfusion was suspended and hydrocortisone and supplementary oxygen administered. she denied any type of previous adverse reaction to drugs and any symptoms with use of latex-containing material. allergic evaluation revealed negative latex skin prick test (spt) and negative penicillin, amoxicillin and ampicillin specific ige assay. skin prick and intradermal tests with sufentanil, ppl, mdm, amoxicillin and ampicilin were negative. oral amoxicilin and metoclopramide provocation challenge were negative. spt and subcutaneous provocation challenge with ropivacain were negative. spt with ranitidine was negative but skin intradermal test proved to be positive. the patient was taught to avoid histamine h receptor antagonists and use as a safe alternative proton pump inhibitors. conclusion: anaphylaxis during anesthesia is an unpredictable, severe, and rare reaction. the identification of responsible drugs is a complex task. we report a case in which a commonly used and generally safe drug caused a severe reaction, which demonstrated that even the least obvious culprit should not be disregarded. epidemiologic data suggest that the number of cases of chx allergy appears to be increasing. background: chlorhexidine is a synthetic chemical with excellent antiseptic and disinfectant quality frequently used in everyday products and medical devices. the prevalence of allergic reactions towards chlorhexidine is rare, though there is increasing evidence for its allergenic potential. in this case we report about a patient with serious perioperative anaphylaxis. next to multiple potential allergens that he was exposed to, a chlorhexidine containing lubrication gel has been used for urinary catheterisation. within minutes post-exposure, the patient developed generalized urticaria, bronchospasm, tachycardia and hypotension. material and methods: we performed skin prick tests and intradermal tests with all substances documented in the anaesthesia chart, further we analysed specific immunoglobulin e (sige) antibodies and performed oral provocation challenges for exclusion. results: in the skin tests all substances except for chlorhexidine (spt: mm wheal diameter/ mm erythema) were negative. a sensitization for chlorhexidine was further corroborated by chlorhexidine-specific ige antibody ( . ku/l) in the patient's serum. in addition, the challenges for the drugs without sensitization (cefuroxime, lidocaine) were tolerated. considering all potentially relevant allergens that the patient was exposed to and the proof of specific sensitization, we diagnosed an immediate-type allergy towards chlorhexidine. conclusion: with the ubiquitous use of chlorhexidine an increase in hypersensitivity reactions including immediate-type allergic reactions is observed. anaphylactic reactions are rare, but potentially life-threatening, the diagnosis is crucial. as a warning declaration in medical devices is missing, the diagnosis of chlorhexidine allergy might be easily under-recognized or misdiagnosed. unfortunately, until now validated provocation tests are not existent, but the evaluation of combined skin tests and sige is sensitive and specific. | an approach to incidence of death due to anaphylaxis in spain ( spain ( - background: reports about death due to anaphylaxis are still scarce because of its rarity and limited information to few countries. also, data source analysis is usually not included. we report incidence of death due to anaphylaxis in spain using two databases. method: we used a hospital series of anaphylaxis deaths from the spanish hospital system and a series from the national institute of toxicology and forensic sciences (intcf) predominantly formed by extra-hospital deaths. deaths from the spanish hospital system were extracted using codes from icd- -cm, related to anaphylaxis among all deaths occured in the - period. for extracting deaths due to anaphylaxis at the intcf in the same period, two allergist researchers identified these deaths among cases with suspicion of anaphylaxis cause. a regression logistic was run to discriminate the probability of anaphylaxis death belonging to each database. incidence rates were calculated for the different groups (age, sex) using the spanish population as the denominator. temporal trends were calculated from the hospital database using poisson regression models with the number of cases of anaphylaxis detected each year as the dependent variable, and age and sex as covariates. results: there were four positive predictors of fatal anaphylaxis after the logistic model (usual allergen, positive specific ige, suggestive symptoms and previous reaction to the same allergen case report: we were informed that a girl was admitted to the pediatric endocrinology department due to early breast development. she had been diagnosed as central precocious puberty (pp). later, triptorelin acetate (ta) therapy had been started monthly. within minutes after first sc injection of ta at home, she had developed shortness of breath, decreased air entry, and coughing for ten minutes and lastly she had developed vomiting for minutes. her symptoms were accompanied by a pruritic blanchable maculopapular rash on her ears, cheeks, lips, and eyelids approximately for two hours. although they had applied emergency department of the local hospital. based on the diagnosis of anaphylaxis she was immediately treated with adrenalin. she was subsequently hospitalized for possible recurrence and discharged next day without any further events. treatment with another preparation, leuprolide aseptate(la-lucrin), as an alternative treatment was started with premedication against anaphylaxis risk only at first time and the patient did not develop any reactions. the patient is still on this treatment with no complications. anaphylaxis is diagnosed in the presence of a detectable allergen accompanied by symptoms of two systems. our patient had symptoms of the three systems as described above, that is, dyspnea with coughing, hives, nausea, and vomiting. main treatment of anaphylaxis is the epinephrine use. early usage maximizes the likelihood of survival. diagnostic tests with culprit drug were not performed in our hospital if the patient had the anaphylactic drug reaction and grouped as "physician diagnosed anaphylaxis". there has been only one report regarding anaphylaxis to ta treatment in cpp in turkey. in the literature, anaphylactic reactions against ta have been reported only in few pediatric cases. gnrh analogues are important to ensure the physiological growth in precocious puberty. because anaphylaxis can be lethal, and gnrh analogues are similar structure; the present case suggests that one should bear in mind the possibility of anaphylaxis in all patients who receive gonadotropin-releasing hormone and anologs and monitor such patients carefully as needed. furthermore, we must provide sufficient information of adverse reactions, including anaphylaxis, to patients. hence, managements against anaphylactic shocks should be recognized and treatment should be given immediately. | an anaphylactic shock induced by the rocuronium anesthesia: a case report cabrera v; barrios j; callero a; gonzález ce; pérez e; martínez ja hospital universitario nuestra sra de la candelaria, santa cruz, spain background: the anesthetic act is a unique pharmacological situation, where the patient is exposed to a multitude of substances.among them, neuromuscular blocking agents are the leading cause of preanesthetic anaphylaxis, with a frequency of between %- %.followed by latex in second place and antibiotics in third place. among the neuromuscular relaxants, most reactions are due to suxamethonium or succinyl-choline in . %, followed by atracurium, rocuronium and verocuronium.the one that produces the least reactions is cisatracurium. method: a -year-old woman presented a type iii anaphylaxis of the brown classification during the anesthetic induction in a surgery scheduled for laparoscopic cholecystectomy. for which adrenaline, dexchlorpheniramine, hydrocortisone, ranitidine and sugammadex was administered and was transferred with orotracheal intubation to the anesthetic resuscitation room. due to good evolution of the patient, she was extubated within three hours. the drugs involved in the reaction were: rocuronium, amoxicillin-clavulanic, fentanyl, propofol, midazolam, lidocaine and atropine. there was a high suspicion by the anesthesiology and resuscitation service that the abstracts reaction could have been due to the neuromuscular relaxant used, in this case rocuronium, since the reaction was reversed with sugammadex. the patient had undergone surgeries under general anesthesia previously without incidents. a specific allergy study was performed with laboratory tests with tryptase, skin tests with drugs and basophil activation test for rocuronium, sugammadex-rocuronium mixture and cisatracurium. • serial measurement of serum tryptase: . u/l, . u/l y . u/l there is no activation of basophils for sugammadex-rocuronium mixture and cisatracurium. the patient is diagnosed with rocuronium allergy. sugammadex not only acts as an antidote to reverse the neuromuscular block against rocuronium, but also has antiallergic properties by inhibiting mast cells. as an alternative for future interventions, the patient can use cisatracurium, as the skin tests and the basophil activation test are negative. unal d yedikule chest disease, istanbul, turkey case report: tetracycline hydrochloride may rarely cause hypersensitivity reactions. (hrs). immediate type reactions are at the level of case presentations and anaphylaxis is reported. we report a patient with late onset anaphylaxis caused by tetracycline. a -year-old woman referred to our allergy outpatient clinic because of urticaria due to an antibiotic that she does not remember the name of. the patient reported that many years before she had presented urticaria on her arms and legs one hour after taking the drug. to confirm drug allergy invivo and invitro testing have to performed. for many drugs there was no validated skin test. for all that invitro tests are often less sensitive and more expensive. therefore single blind placebo controlled drug provocation tests (sbpcdpt) is the gold standard in the diagnosis of drug hypersensitivity reactions. we did not know which group of antibiotics were allergy to the patient. because the patient had history of asthma and atypical pneumonia we were performed the allergy tests with clarithromycin and she had tolerated. it was necessary to use tetracycline because of patient had vaginal infection. skin tests have not yet been validated for tetracyclines. for skin prick tests of tetracycline that is only available as tablet, not in a soluble form. therefore, the tablet was smashed and diluted with . % nacl. it was also tested. healthy controls to exclude irritation. because of skin prick tests with tetracycline negative. sbpcdpt was planned. sbpcdpt was performed by progressively increasing four divided doses at minute intervals. two hours after last dose the patient experienced dyspnea, palpitations, and hypotension. as the reaction was considered to be anaphylaxis, she was given . mg of intramuscular epinephrine, intravenous mg of pheniramine, and mg of methylprednisolone. the reaction resolved within hours. blood tryptase level was . ug/l taken at the nd hour of the reaction approximately months after the anaphylaxis, serum tryptase level was . ug/l the serum tryptase level and the patient's clinic confirmed anaphylaxis due to tetracycline. we had proved late onset anaphylaxis due to tetracycline with the patient's clinic and serum tryptase level. anaphylaxis due to tetracycline is limited to case reports and small series but to our knowledge, there is no previous report of late onset tetracycline anaphylaxis. | case series of ige mediated anaphylactic shock due to polysorbate case : an -year-old male patient with hypertension, hypothyroidism and episodes of sustained monomorphic ventricular tachycardia (smvt), developed an anaphylactic shock after the administration of injectable amiodarone due to smvt. serum tryptase levels reached . μg/l during the reaction (baseline . μg/ l). skin tests were positive to injectable amiodarone (prick mg/ ml, intradermal . mg/ml) and polysorbate and (prick-prick). skin prick-prick to amiodarone and dronedarone tablets were negative. the patient tolerated oral amiodarone. we report an anaphylactic reaction during the first intravenous administration of amiodarone in a female patient being treated for supraventricular tachycardia. bat was positive, suggesting a direct effect on basophil activation, as the patient was not previously exposed to the drug. | anaphylaxis during labor: don't forget to think of an amniotic fluid embolism case report: a -year old primigravida ( weeks of gestational age) was admitted with signs of pre-eclampsia and labor was induced. benzylpenicillin and ropivacaine (epidural anesthesia) was administered > hours before the event. eighteen minutes after starting an infusion with oxytocin ( ml/h) and a vaginal toucher, the patient developed a decreased level of consciousness, generalized edema/erythema and thoracic pain, followed within minutes by fetal bradycardia and maternal collapse. after resuscitation, an urgent sectio was performed, and a baby girl was born. patient was extubated the same day. serum tryptase, hours after the event, was . μg/l (basal tryptase level . μg/l). allergy workup demonstrated negative specific ige and skin tests for latex and chlorhexidine, negative skin and provocation testing for ropivacain. however, skin testing was hampered by dermographism: intradermal (idr) testing of benzylpenicillin ( iu/ml, / - / ) and oxytocin ( ie/ml, / - / ) showed extensive erythema. idr testing of oxytocin in healthy volunteers showed pallor around the injection site (n = ). intravenous provocation with benzylpenicillin was uneventful. a basophil activation test with oxytocin (patient and control) was negative. an additional bone marrow evaluation showed no evidence for mastocytosis. although clinical criteria for anaphylaxis were fulfilled, a diagnosis of an amniotic fluid embolism (afe) was concluded. no drugs were prohibited. patient gave consent for publication. conclusions: afe is one of the most devastating conditions in obstetrics, occurring typically during labor and delivery or immediately postpartum. the pathogenesis remains incompletely understood, however, it has been suggested that afe involves an anaphylactic reaction to fetal tissue exposure associated with breaches of the maternal-fetal physiological barrier, supported by transiently increased serum tryptase levels. the diagnosis is primarily clinical, and generally one of exclusion. no specific antemortem diagnostic tests are available to confirm afe. postmortem identification of fetal squames in the maternal pulmonary circulation gives final diagnosis. differential diagnosis includes drug-induced anaphylaxis or mastocytosis, which were ruled out in our case. method: the patient presented after hymenoptera stings dyspnoea, generalized erythema with pruritus, edema of the face that required emergency therapy in episodes. results: an angio-ct was performed at the inferior limbs with optiray and minutes after the end of the investigation, the patient presented an anaphylactic shock requiring admission to the icu for days. conclusion: the patient's progression was slowly favorable. results: thirty seven cases were reported. ( %) were women. the median age was years. ( %) had dress/dihs, ( %) ten, ( %) sjs, ( %) agep, ( %) other not classified scars, and ( . %) overlapping ten/sjs. in % of the patients the suspect drug was withdrawn. thirty one patients ( %) received systemic anti-inflammatory treatment. twenty six patients ( %) received intravenous (iv) corticosteroids alone, ( %) iv corticosteroids plus ivig, ( . %) iv corticosteroids plus ivig, infliximab and colchicine, and ( . %) iv corticosteroids plus infliximab and cyclosporin. there were complications in cases ( %), and death occurred in the patient with overlapping ten/sjs who had received corticosteroids plus immunoglobulin. in this study, our aim was to evaluate severe ihr to icm. method: we retrospectively analysed patient who consulted to our allergy unit between july and july reporting symptoms within hour after icm administration. from a total of patients, we selected eight that had suffered an anaphylactic reaction. a written informed consent had been obtained for diagnostic procedures. introduction: immediate type hypersensitivity reactions to pemetrexed have been reported as very rare case reports. as limited availability of alternative therapies in chemotherapeutic allergy, desensitization plays an important role in ensuring reuse of the culprit drug. we report a case of pemetrexed anaphylaxis and successful desensitization. case: years old female patient with lung adenocarcinoma had been treated with cisplatin-pemetrexed as second-line therapy. during the th cycle within minutes after the end of pemetrexed infusion she had chest pain, shortness of breath, cough, swallowing difficulty, erythema on face and body, nausea and vomiting. she was diagnosed as anaphylaxis and adrenaline was administered besides antihistamine and methylprednisolone. symptoms and findings of the patient were improved within minutes. oncologists decelerated no suitable alternative therapy for the patient. although skin tests (prick test with / concentration, intradermal test with / - / concentration) were negative with pemetrexed, taking into account the severity of the reaction, pemetrexed desensitization was applied with the consent of the patient. no reaction was observed during the procedure result: desensitization is a successful and safe method of reusing the culprit drug. successful desensitization of pemetrexed with immediate type hypersensitivity reaction is described. the years old man was admitted emergency department with fever, rash (maculo-papular) and pain in joints. it was the th day of taking of amoxicillin. the hematological abnormalities were revealed -eosinophilia, increased erythrocytes sedimentation rate. the level of serum ecp was μg/l. the liver functional tests were increased too. hepatomegaly and cervical lymphadenopathy were observed. the patient was treated as a dress syndrome (infusion therapy, systemic steroids) and discharged after weeks with improvement. all hematologic parameters were in normal limits. lymphadenopathies were resolved. the level of ecp was retaken - μg/l. patient was prescribed oral steroids till normalization of limits of ecp. it lasted weeks after discharging. the serum level of ecp can play key role in the management of dress syndrome and in the making of diagnostic processes. until now, allergic or anaphylactic reactions to peg have been rarely reported. although patient with hypersensitivity to peg should avoid peg-containing drugs or products, patient who needs colonoscopy has few alternative bowel cleansing methods. no successful desensitization to peg has been reported to date. we report a case of successful desensitization and subsequent safe colonoscopic examination in patient with allergic reaction to peg. method: a -year-old woman developed generalized urticaria, pruritus, throat swelling, and shortness of breath immediately after taking a bowel preparation solution for colonoscopy. she had the first symptoms years ago, and has had more experiences so far. the symptoms appeared within - minutes of taking cleansing solution, and the endoscopy was no longer possible. seven years ago, she underwent endoscopy with no specific symptom. when the last symptom occurred a year ago, she was treated at emergency room because of severe dyspnea and dizziness. the patient came to our clinic for the proper diagnosis of allergy reaction and possible colonoscopic evaluation. objectives: to describe a successful desensitization to vedolizumab in one patient diagnosed with ulcerative colitis, refractory to infliximab and intolerant to azathioprine and sulfasalazine. methods: our patient was a year old woman receiving treatment with intravenous vedolizumab ( mg/cycle). cycles and were well tolerated, but in cycles , and she experienced hypotension and dyspnea, in spite of premedication with oral dexamethasone and metoclopramide. during cycle , she also showed facial angioedema, systemic urticarial reaction and oropharyngeal pruritus treated with methylprednisolone and ebastine. the results of prick (vedolizumab concentration mg/ml) and intradermal skin tests ( : and : ) with vedolizumab were negative in our patient and in ten healthy controls. total ige level was . ui/ml and specific ige against dermatophagoides were positive, being negative for hamster epithelium and latex. since vedolizumab was the only therapeutic alternative, the patient was planned to undergo vedolizumab desensitization according to an -step protocol. patient informed consent was obtained previously. premedication consisting of ebastine, acetylsalicylic acid, montelukast and methylprednisolone one hour before desensitization was administered. desensitization protocol was performed with a total duration of hours and minutes and a total dose of mg. dose steps were . , . , . , . , . , , and . mg. conclusions: our -step protocol desensitization to vedolizumab resulted safe and effective in our patient and it has allowed the continuation of treatment with vedolizumab for her ulcerative colitis. montelukast, anti h and h blockers were used for the pretreatment of desensitization. all procedures (skin and blood tests, desensitization) were carried out with the informed consent of the patient. we present an exceptional, non-immediate case of fever after cisplatin and etoposide infusion with positive skin test. case report: a -year-old man, recently diagnostic of lung cancer stadium iv, in first line of treatment with cisplatin and etoposide, started hours after finishing the nd infusion: facial erythema that becomes generalized after - hours from infusion. twelve hours later, developed warmth sensation, shivering and fever ( °c) that persisted despite the use of several oral antipyretics treatment. infectious disease was discarded, so he was referred to our department in order to assess further administration of cisplatin and etoposide. methodology: skin testing was performed days after the last reaction to minimize false-negative results, as follows (a) cisplatin prick test ( mg/ml) and intradermal tests ( . mg/ml); (b) etoposide prick test ( mg/ml) and intradermal tests ( mg/ml); with histamine as the positive control and nacl-diluent as the negative control. the results of skin test were negative for immediate reading. but two hours later, intradermal test for cisplatin turned into red and itchy and hours later, still associated a wheal. the patient was classified as high-risk (lung diseases, forced expiratory volume in second < l) and underwent programmed inpatient desensitization according to the standardized birmingham women's hospital protocol. desensitization was performed in the medical intensive care unit. the patient received only standard oncology premedication. he tolerated the final dose of cisplatin with no breakthrough reactions followed by etoposide standard infusion. two additional desensitization procedures were performed, with no breakthrough reactions. therapy ended when the disease worsened. the importance of this case, lies in the fact that fever has not been described as a clinical hypersensitivity reaction for cisplatin but for oxaliplatin. although a non-immediate reaction at the nd infusion of cisplatin could scarcely suggest a hypersensitivity reaction, the positive skin test and successful desensitization with this drug, could suggest it. introduction: propylthiouracil is commonly used as the first treatment option in patients with hyperthyroidism. although it is generally a well-tolerated drug, it may lead to some side effects including liver damage, leucopenia and skin rash. among skin rash findings, urticaria is considerably common. nevertheless, in cases that developed urticaria, a rapid desensitization protocol specific to propylthiouracil has not been encountered. we represented a case in which we applied successful oral desensitization via a scheme in accordance with general desensitization principles in a case that developed propylthiouracil-induced urticaria. case report: propylthiouracil at a dose of mg/day was initiated for a year-old female patient with diagnosis of hyperthyroidism in internal diseases clinic. the patient developed widespread itching and swelling in the body - hours after she took the first dose of the drug. she had experienced a similar reaction with use of propylthiouracil in . the patient who was breastfeeding a baby and did not have any treatment option other than propylthiouracil was referred to us with pre-diagnosis of drug allergy. the patient was thought to have propylthiouracil-induced hypersensitivity reaction and desensitization was planned. we prepared a desensitization scheme in accordance with general desensitization principles (table ). in accordance with this prepared scheme, we successfully applied the desensitization protocol with propylthiouracil for the patient. the patient gave informed consent before testing and desensitization. results: spt was negative, but idt reaction was positive at : method: we present a desensitization protocol to intravenous etoposide used in a -year-old male for non-hodgkin's lymphoma who was referred to the department of allergy at sotiria general hospital of athens. within minutes after receiving the first dose of the drug, the patient complained for flushing, retrosternal pain, difficulty in breathing and weakness. the infusion was ceased immediately and the patient received proper treatment with gradual recovery of the symptoms. the next day, skin prick test (spt) and intradermal test (id) were performed with etoposide at dilution : ( mg/ml). both of the tests, spt and id, were negative. histamine and nacl . % were also used as positive and negative controls, respectively. a desensitization protocol of three-day cycle with intravenous etoposide was conducted. premedication for days was administered including methylprednisolone, cetirizine, ranitidine, paracetamol and montelukast. results: the desensitization protocol of the first day consisted of steps of rapid pulses administered at increasing infusion rates every minutes, and step of drip infusion at a final rate of ml/hour ( mg/ . ml) until completion of the infusion. the following days, the patient received a modified rapid protocol consisting of the administration of the calculated dose of mg in only one step of infusion rate of ml/hour completing in only hours and minutes. the same protocol was applied in another three-day cycle with no adverse reactions. conclusions: hsrs to etoposide are rarely described in the literature. we propose a three-day modified rapid desensitization protocol to intravenous etoposide that could be particularly useful compared to other time-consuming desensitization protocols. case report: imatinib, a tyrosine kinase inhibitor, sometimes causes cutaneous reactions that can be of various severity. we present a case of a patient who was started on imatinib mg daily and after months developed diffuse mildly pruritic rash with some desquamation of palms of the hands. the dose of imatinib was reduced to mg daily and therapy with prednisone mg was started. after resolution of rash, the dose of prednisone was tapered to mg daily, but the rash reappeared, although milder in intensity. the dose of prednisone was increased and levocetirizine added and rash resolved. prednisone was slowly discontinued and rash did not appear. in the case of reactions to imatinib the dose of drug can be reduced and short course of oral corticosteroid given. milder reactions can be treated with antihistamine or topical corticosteroid. therefore, when adverse skin reaction to imatinib occurs, induction of tolerance to this important drug should be attempted. method: the exosomes were collected from in vitro primary human sinonasal epithelia cell, which derived from three different groups (normal control, chronic rhinosinusitis and chronic rhinosinusitis with asthma). generation of exosomes in epithelia was confirmed by nanosight, tem and western blot. the proteins of exosomes were identified by proteomics analysis. the cellular proliferation and ciliogenesis were analyzed by cck and qpcr.the ciliary beat frequency was detected by sava system. we found that epithelial cellular exosomes from chronic rhinosinusitis and chronic rhinosinusitis with asthma could reduce the multiplication rate of normal epithelial cell at a certain concentration (≥ μg/ml).we found that exosomes from chronic rhinosinusitis with or without asthma could interrupt the cellular ciliogenesis and ciliary beat frequency. using mass spectrometric analysis we demonstrated that the epithelial exosomes contained different proteins in different disease states. conclusion: our findings first identified that exosomes could be secreted by nasal epithelial cells. we also demonstrated exosomes from chronic rhinosinusitis with or without asthma could be a pathogenic factor in the remodeling of sinonasal mucosa. it could be considered as a significant biomarker for detecting the progress of chronic rhinosinusitis and a alternative therapy target. background: mucociliary transport (mct) is a major respiratory tract host defense mechanism and chronic exposure to allergen can deteriorate the these defense mechanism. the aim of this study was to investigate the effects common allergen (dp/df) on human nasal mucociliary transport in allergic rhinitis patients, and to determine the pathophysiology of ciliary beat frequency (cbf) during allergeninduced change method: allergic nasal mucosa cells of allergic rhinitis patients were exposed to common allergen (dp/df), and cbf was analyzed using an optical flow technique with the peak detection method results: the allergen(dp/df) exposed group showed a decreased cbf when compared to the control group. in the cytotoxicity assay, difference in survival rates was not found between the two groups. in the allergen(df/df)-exposed group, protein kinase c (pkc) activity was increased during a pkc activity assay. the broad pkc inhibitor, calphostin c abolished the allergen(dp/df)-induced decrease of cbf. the allergen-induced decrease of cbf was abolished by gf x, a novel pkc (npkc) isoform inhibitor, whereas the decrease was not attenuated by g€o- , a specific inhibitor of conventional pkc (cpkc) isoform. conclusion: allergen may inhibit cbf via an npkc-dependent mechanism. therefore, we have confirmed that chronic exposure to allergen could decrease cbf by increasing pkc activity. method: ova-alum allergic rhinitis mouse model (ar model) and poly(i:c) induced il- dominant mouse model (neutrophil dominant model) were used. both mouse models were exposed to tio particles for hours twice daily for days, while the controls (n = ) were not. sirius red staining for eosinophil infiltration, immunohistochemistry for neutrophil and il- a, serum immunoglobulin (ig) g and e were assayed by using enzyme-linked immunosorbent assay. in addition, the expression of interleukin (il)- , il- , and interferon (ifn)-γ in the nasal mucosa and cervical lymph nodes was measured by immunohistochemistry, and real-time reverse transcription-polymerase chain reaction (rt-pcr), il- monoclonal antibody (secukinumab) was administered in vivo to evaluate il- a dependency. results: tio exposure did not influence eosinophil infiltration in both ar and neutrophil dominant model. however, tio exposure increased neutrophil infiltration in both models and neutrophil infiltration was correlated with il- expression in the nasal mucosa. serum igg and ige levels were changed significantly in the tio exposed group. th cytokines (il- , il- ) and th cytokine, ifn-γ were not changed significantly in both models after tio exposure, however, il- were increased in tio exposure group. and these increased type pathway and neutrophil infiltration were reversed after il- monoclonal antibody administration. conclusion: exposure to airborne tio induced neutrophil infiltration in the nasal mucosa. the type response seems to play a dominant role in the nasal immune response following airborne tio exposure. | toll-like receptor ligands increase type i interferon induced b-cell activating factor expression in chronic rhinosinusitis with nasal polyposis results: first: paf-r mrna expression was very low in fibroblasts from nm and np (data not shown). paf-r mrna expression was detected in whole sinonasal tissue, submerged and ali epithelial cell cultures from both controls nm and np. paf-r mrna was also detected in peripheral blood eosinophils. although no differences were found between nm and np tissues and cultures, paf-r mrna expression was significantly higher (p < . ) in eosinophils than in upper airway tissues and cells. second: protein paf-r was found expressed in whole tissue (predominantly in the epithelium and submucosal glands), submerged and ali epithelial cell cultures from both nm and np. peripheral blood eosinophils also showed paf-r protein expression. conclusion: both paf-r mrna and protein expression was found in sinonasal nm and np tissues (epithelium and submucosal glands) and in peripheral blood eosinophils. these findings suggest the paf/ paf-r system could play a pathophysiological role in crswnp through the modulation of structural and inflammatory cell functions. "this study was funded with a research grant from uriach group". background: allergic rhinitis (ar) is an increasingly more common nasal inflammatory disease in which an antigen such as pollen or dust mites triggers symptoms such as itching, sneezing, and rhinorrhea, which can lead to nasal obstruction. ar is mediated by thelper type cells together with mast cells, eosinophils, and several inflammatory cytokines and chemokines. for example, recent abstracts | research indicates that hypoxia-inducible factor α (hif- α) is involved in the mechanism of ar development. the anti-heart failure drug digoxin has a specific inhibitory effect on hif- α, and thus, the aim of the present research was to explore the anti-hypertensive effect and mechanism of digoxin in ar. method: an animal model of ovalbumin-induced ar was established in guinea pigs. the experimental group was treated with digoxin through the tail vein. for the comparison of symptoms between the experimental and control groups, the incidence of sneezing was recorded, and the eosinophilic interleukin il- and il- levels in nasal secretions were measured by enzyme-linked immunosorbent assays. western blotting and reverse transcription polymerase chain reaction analyses were conducted to evaluated hif- α expression in guinea pig nasal mucosa. results: the ar symptoms of guinea pigs in the experimental group were significantly improved after administration of digoxin. specifically, the experimental group exhibited a significantly lower numbers of sneezing times(average . ± . vs . ± . , p < . ) and lower il- and il- secretion levels (p < . ) compared with the control group. moreover, guinea pigs of the experimental group showed less severe nasal mucosa edema, lower hif- α production, and reduced eosinophil infiltration in nasal mucosa compared with the control group. conclusion: the anti-heart failure drug digoxin may ameliorate the symptoms of ar by inhibiting hif- α production. campo p ; eguiluz i ; bogas g ; gomez f ; ariza a ; espino t ; torres mj ; rondon c allergy unit-regional hospital of malaga-ibima, malaga, spain; allergy laboratory_regional hospital of malaga-ibima, malaga, spain background: similarly to what has been described in allergic rhinitis, there is an important association of local allergic rhinitis (lar) with lower airway symptoms suggestive of asthma, being selfreported in . % of lar patients after five years of follow-up, and increasing to . % after years. however, clinical suspicion alone it is not enough for asthma diagnosis and could overstate its real prevalence. the aim was to evaluate the real prevalence of asthma in lar patients based on validated objective methods. method: seventy-five patients ( with lar, with non-allergic rhinitis (nar), with allergic rhinitis (ar)), and healthy controls (hc) were included. all patients had perennial history of rhinitis and bronchial symptoms suggestive of mild-moderate asthma for at least two years. non-specific airways hyperresponsiveness (methacholine challenge test, using tidal breath method following ats guidelines) was performed in all subjects. results: subjects were mostly young females, non-smokers. median μg/day of inhaled corticosteroids (budesonide/equivalent dose) was similar in all groups. median fev % in ar group ( . %) was significantly lower compared to lar ( %, p = . ), nar ( %, p = . ) and hc ( %, p = . ). in the lar group, / ( . %) had a positive methacholine, / ( %) in the nar, / ( . %) in ar group and / ( %) in hc. patients with lar had a significant lower percentage of confirmed asthma than ar (p = . ) and similar to nar (p = . ). no differences were detected between ar vs nar (p = . ). conclusion: presence of objectively demonstrated asthma was lower in lar compared to ar, and with better lung function. conclusion: ambient air pollution influenced the hospital visit of patients with rhinitis, even, the level of pollutants, below the national standard. so , o , no , and pm could increase an incidence of rhinitis and/or induce an aggravation of rhinitis symptoms. health care provider might expect upraising patients with rhinitis in the clinic with increase of air pollutants, even under the standard levels. results: during relapse of erosive oral lichen planus mononuclear cells obtained from peripheral blood of patients showed increased number of nk-cells cd + cd + in acute ( . ± . %) and chronic ( . ± . %) disease periods, and cd + grb cells in acute ( . ± . %) and chronic ( . ± . %) disease periods, p < . . in patients with the non-erosive forms of olp there were cd + cd + and cd + grb cells in acute ( . ± . %) and ( . ± . %) and chronic disease ( . ± . %) and ( . ± . %), p < . . the number of cd + cd + and cd + grb cells in the controls were ( . ± . %) and ( . ± . %), p < . . conclusion: acute relapse of erosive oral lichen planus, unlike nonerosive forms, is characterized by increases in the number of cd + cd + and cd + grb cells. chronic disease in patients with erosive oral lichen planus showed a steady increase in the number of cd + cd + killer cells and cd grb lymphocytes. bite", were observed in patients ( %). typical hyper-and hypopigmentation were observed in six patients mainly on the fingers and the cheekbones. fibrosis of the skin of the fingers often leads to flexion contractions, which we observed in patients. we were watching two-sided swelling of the fingers, but it was very pronounced in patients ( %). % of our patients have impaired motility of the esophagus. accelerated esr and c-reactive protein were found in patients as follows- intensively accelerated and moderate. in our patients with positive ana, we observed patients -at low titer : at and titration : in patients. the spectrum of ana found by us in raynaud's syndrome patients is closer to scleroderma than to lupus. we underline the importance of ana ( %) and anti-cc antibodies ( %) for the early diagnosis of raynaud's syndrome and scleroderma, which is also seen in our patients. anti-scl- antibodies were observed in patients coinciding with other publications describing about % of the patients. low levels of complement were observed in patients. low hemoglobin levels were observed in patient, with no iron deficiency. conclusion: . we observed a typical fibrinoid necrosis and polymorphonuclear infiltration, and collagen accumulation in the walls of small and medium-sized blood vessels. results: statistically significant increase of il level ( . pg/ml [ . ; . ]; . pg/ml [ . ; . ] respectively) was determined in patients with uc both in acute stage and remission compared to controls ( . pg/ml [ . ; . ] , (p = . ; . respectively). statistically significant increase of il a level ( pg/ml [ . ; . ] ); . pg/ml [ . ; . ] respectively) was also observed in patients both in acute stage and remission compared to controls ( . pg/ml [ . ; . ], p = . , p = . respectively). besides statistically significant increase of ifnγ both in acute stage ( . pg/ml [ . ; . ] ) and remission ( . pg/ml [ . ; . ]) compared to controls ( . pg/ml [ . ; . ], p = . ; . respectively) was revealed. background: the presence of antinuclear antibodies (ana) is commonly associated with a broad spectrum of connective tissue diseases. low titres might be detected rarely also in healthy individuals, especially in higher age. an indirect immunofluorescence (iif) detection of ana antibodies on hep- cells is the most frequently used laboratory method in this respect. the method is quite reliable regarding sensitivity, however the specificity of this test is lower. we would appreciate a biomarker for clinical discrimination of ana- other autoantibodies were tested in relation to basic diagnosis. results: a cohort of patients was divided into groups according to main diagnosis: immunodeficiency, connective tissue diseases, bronchial asthma and allergic rhinitis, recurrent infectious diseases, gastrointestinal diseases, endocrinopathy and others and the last group was generated from healthy subjects. the presence of anti dfs antibodies was highest in the group of recurrent infections, mostly in females. in these subjects homogenous pattern of ana antibodies by iif was also detected quite often, probably induced by non-specific activation of immune system. on the other hand, in a group of connective tissue diseases, we have not found any anti dfs positive patient. the clinical impact of anti-dfs antibodies is not yet finally confirmed, but their low frequency in connective tissue diseases and presence in %- % of healthy subject suggests their potential role as a new biomarker to be used as a negative predictive factor in non aard. confirmation of presence or absence of anti-dfs antibodies seems to be helpful to exclude potential diagnostic errors in iif ana positive patients. background: multiple sclerosis is a debilitating autoimmune and degenerative condition of the central nervous system, that predominantly affects young adults. both genetic and environmental factors are associated with increased risk for this disease. we propose that the effect of environmental factors, particularly latitude of childhood, is mediated through epigenetic mechanisms. specifically, we propose that unfavourable gene methylation predisposes individuals to multiple sclerosis, that this is set in childhood and adolescence, and transmitted from haematopoietic stem cells to progeny. method: cd + , cd + and cd + cell subsets were isolated from peripheral blood of healthy controls. libraries enriched for cpg islands and promoter regions were generated using modified reduced representation bisulfite sequencing and subjected to next generation sequencing. site specific methylation profiling of genome wide cpg islands, including ms susceptibility genes was conducted using methpipe software. results: genomic coverage was consistent with other published methylomes using modified reduced representation bisulfite sequencing. the methylation signature of peripheral blood derived subsets showed greater differences in methylation compared to buccal cells than with each other. individuals displayed differences in cd + methylomes, and these were recapitulated in the progeny cd + and cd + cells for those individuals. methylation of specific genes regions (e.g. prf ), were consistent with the known biological function of these genes and their potential contribution to ms risk. the vast majority of cpg islands interrogated show recapitulation of their methylation signature from cd + to progeny. however, individual differences and cell subset differences identified, likely reflect the known biological function of these genes in progeny cells. our preliminary results are consistent with the hypothesis that the epigenetic signature (that predisposes to ms risk) is set in childhood and adolescence. the physiological basis underlying the setting of this epigenetic signature is still to be elucidated, but may involve uv light and/or vitamin d, and may provide novel therapeutic targets, especially at a personalised level, for treatment of ms. background: auto-inflammatory diseases are rare disorders characterized by recurrent episodes of fever/inflammation affecting serosal surfaces, joints, eyes and skin without autoantibody production or an underlying infection. innate immunity is implicated in their pathogenesis and the underlying genetic defect has been identified in a fraction of the syndromes. during last years, the increased knowledge about auto-inflammatory diseases and the difficulty in their characterization aroused great interest to better understand these pathologies. the acidic soluble fraction of salivary proteome of patients and controls (hc) were analyzed by rp-hplc-esi-ms. known salivary proteins (salivary acidic proline-rich phosphoproteins (aprps), histatins (hst), salivary cystatins s, sn and sa, statherin, p-b peptide, α-defensins - , cystatins b, c, thymosin β- , s a , s a , s a , and s a proteins) and several derivatives (acetylated, glutathionylated, phosphorylated, and oxidized forms) were searched in the chromatographic profiles by xic (extracted ion current) procedure. adult patients (mean age ± sd: . ± . ; f, m) were enrolled and compared with sex/age matched healthy controls (mean age ± sd: . ± . ; f, m). patients are classified on the base of clinical manifestations as follows: patients with fmf (mean age ± sd: ± . ; f, m), and with unclassified fever syndrome (uc) (mean age ± sd: . ± . ; f, m). results: fmf patients showed low levels of α-defensins , and , this last was absent, with respect hc, and high levels of the glutathionylated proteoforms of cystatin b, and s a , and of antileukoproteinase (slpi). similar results were obtained on saliva of unclassified patients, which showed also levels of cystatin c higher than controls. interestingly, proteins and peptides typically secreted by salivary glands (cystatin c, histatins, statherin, aprps) were found more abundant in uc patients than in controls, and in some cases also than fmf patients (see table) . an evaluation of relative abundance of phosphorylation of phosphorylated proteins/peptides highlighted a significant hypophosphorylation of hst- , prp- and prp- in uc patients with respect to controls, probably due to a less active fam c kinase responsible for their phosphorylation conclusion: we show by a top-down proteomics approach a wide salivary modification, highlighting dysregulation in neutrophil-derived proteins and significant differences between fmm and uc patients. the control group consisted of healthy donors aged - years. immunological methods of investigation included determination of membrane antigens b cells: cd − cd + cd + , cd + cd + cd + , cd + cd + cd , cd + cd + cd + , cd + cd + cd + , cd + cd + cd + , cd + cd + cd l + cd + , cd + cd ra + cd + cd + , by flow cytometry. results: in the study subpopulation composition of lymphocytes in seropositive variant form of ra visceral a statistically significant increase in relative amount as b -cells with immunophenotype cd + cd + cd + ( . ± . % . ± . %) and b lymphocytes with the phenotype cd + cd − cd − cd + ( . ± . % and . ± . %). in the analysis of the processes of maturation and differentiation of b cells detected statistically reliable increase of the relative number of mature cd + cd − cd + naïve b cells cd + cd ra + cd number of mature cd + cd − cd + naïve b cells cd + cd ra + cd − cd + ( . ± . % and . ± . %) compared to the control group. in the study of surface markers b lymphocytes revealed an increase of expression of costimulatory cd + cd + ( ± . % and . ± . %) molecules and increasing the relative amount of cd l . ± . % ( . ± . %) ligand on cd + cd + cd + subpopulation of t-lymphocytes. analysis of surface antigenic receptor b cells in the visceral form of ra showed an increased expression of early markers of cd + cd + cd + ( . ± . % and . ± . %), cd + cd + cd + ( . ± . % . ± . %) activation in comparison with the control group. case: a year-old male patient who works as a dental technician with a history of lung silicosis and recurrent sinusitis applied to an orthopedics clinic for left hip pain and difficulty in walking. he has a history of keeping a dog during childhood. hip mri revealed a × cm sized mass on left iliac wing extended to gluteus muscle and subcutaneous tissue. incisional biopsy was reported as chronic granulomatous osteomyelitis. the lesion was considered as tuberculous abscess. despite anti-tuberculous (fourdrug regimen) treatment for one year, the lesion showed no regression. excisional biopsy was carried out by the same orthopedics clinic. chronic inflammatory reaction and fibrosis was considered to be due to cyst hydatid in the detailed evaluation. antiechinococcus igg and igm was performed with elisa and found positive. no other lesion was detected in lungs and liver. albendazole mg twice a day was initiated and substantial regression observed after three months. atypical and sustained infections made us think of primary immunodeficiency disorders. immunoglobulin subgroups were as follows: iga: < mg/dl ( - case description: year-old male was firstly admitted to gastroenterologist due to intermittent diarrhea, abdominal pain and reactive lymphadenopathy. celiac disease was suspected as genetic test showed hla dq (hla-dqa * and hla-dqb * ), histological evaluation of duodenum biopsy provided picture of lymphoid hyperplasia and marsh iiia variant. however, laboratory testing for celiac disease showed very low amount of antibodies against transglutaminase. gluten free diet for almost one year was ineffective as patient had a continuous problem of gaining weight due to chronic diarrhea. additional questioning revealed recurrent respiratory tract infections with a need of antibiotics more than two times/year during last decade. lymphocyte phenotyping by flow cytometry showed that cd , cd , cd , cd are in normal ranges, but amounts of all immunoglobulins are low: igm < . g/l, igg . g/l and iga . g/l. based on clinical symptoms and immunological evaluation diagnosis of cvid was confirmed, and replacement therapy with subcutaneous immunoglobulin ( mg/kg/month) was initiated. after six months of treatment patient affirmed reduction of gastrointestinal symptoms; he gained kg of weight, has no more infections and stable sufficient level of igg ( . g/l). conclusions: this clinical case shows the importance of immune testing for primary immunodeficiency in all subjects (despite age) with unusual symptoms of autoimmune and/or infectious disorders. cvid may have manifestation of various symptoms, which can lead to misdiagnosis, as well as inadequate treatment. results: in our sample, all patients who progressed to hypogammaglobulinemia were receiving lymphomas. there is no immunoglobulin dosage record prior to treatment. of the cases, mean age was years ( men and women), lost follow-up, and of them also presented neutropenia. seventeen patients who continued in followup required ivig replacement, due to infectious exacerbations, mainly pneumonia and sinusitis. the mean serum igg dosage at the time of onset of ivig replacement was g/dl. the mean time between the first dose of rtm and the need for ivig replacement ranged from to years, with an average of years. the iga dosage was used as a parameter for the recovery of hypogammaglobulinemia, and it was observed that only of the patients presented recovery of the condition up to the moment. conclusion: given the data, we considered the immunoglobulin dosage to be important before initiating rtm treatment and periodically, in order to indicate the replacement of ivig or igsc in a timely manner avoiding complications such as potentially serious infections. background: steinert's disease, also known as type myotonic dystrophy (md ), is the most common dystrophy of the adult. it is inherited with an autosomal dominant mechanism. it causes myotonia, progressive muscles atrophy, muscular weakness, and problems at the heart's conduction tissue and at the respiratory muscles. in patients with myotonic dystrophy, hypogammaglobulinemia is frequently described. the associations and the pathogenesis between those affections are not totally clear, but it is recognized an increased catabolism of the immunoglobulin in these patients. in most of the cases, hypogammaglobulinemia affects only the igg class and does not become clinically manifest. however, replacement treatment is not always successful in these patients. we report the case of a patient with myotonic dystrophy and hypogammaglobulinemia. case report: a -years-old man with md came to our attention for a history of recurrent infections of the upper respiratory tract and persistent infection by helicobacter pylori. at the laboratory tests, we documented low serum igg levels ( mg/dl), normal igm and iga levels and protective antibodies against tetanus consisting with the diagnosis of hypogammaglobulinemia. due to the recurrent infections, he started replacement therapy with ivig ( . g/kg/ months), switched one year ago to facilitated subcutaneous ig (fscig) with achievement of protective serum igg levels (> mg/dl) and significantly reduction of infectious episodes. conclusion: hypogammaglobulinemia is frequently reported in patients with md . in literature most of the cases described does not become clinically manifest, but in our case, the patient was symptomatic with recurrent infections. the replacement therapy with fscig showed both clinical effectiveness and safety. | real-world experience of a novel, highly purified % liquid iv human immunoglobulin for the treatment of antibody deficiencies guidelines for immunoglobulin use (july ). a highly purified % liquid iv human immunoglobulin (ig), with low levels of iga, anti-a and anti-b haemagglutinins, factors xia, xiia, kallikrein and aggregates (i e) was recently approved for use in the uk. here i report our centre's experience in using this novel % i e in three patients with antibody deficiencies. case presentations: a patient who presented in clinic with a first diagnosis of pid, was initiated on % i e at g infused every four weeks. after starting i e, they experienced a decrease in the rate and frequency of infections, in line with expectations for igrt. a young patient on home therapy with a % subcutaneous ig for pid presented in clinic with low trough igg levels. non-compliance was identified as the cause of these low trough levels and therapy was switched to % i e at g infused every four weeks in a clinical setting. both the rate and severity of infections reduced and trough igg levels normalised. an older patient on igrt for sad was reviewed in clinic due to discontinuation of their current igrt product. they were switched to % i e at g infused every four weeks. the efficacy and tolerability of i e was comparable to their previous therapy. a detailed analysis of patient, clinical and safety parameters associated with the initiation of % i e will be presented, including infection rates, white cell counts, c-reactive protein levels, tolerability and infusion-related adverse events. conclusion: these cases highlight the real-world use of % i e in two patients with pid and one patient with sad. they show that i e was well-tolerated and efficacious in one treatment-naïve, and two previously-treated patients. method: prospective study of families with one or more members with c -inh-hae followed in hospitals in the northern area of spain. a cohort of patients from families with c -inh-hae was evaluated for familiar diagnosis of c -inh-hae one or several patients from the same family were chosen and were given a questionnaire to identify the total family members from the family branch affected by c -inh-hae that had been already studied (members with diagnosis of c -inh-hae and healthy members) and those that had not been previously studied. we also register the difficulties for obtaining these data. family members not previously studied and that consent to be contacted were asked for study of c -inh-hae. for c -inh-hae screening we use c blood levels results: we have studied families with c -inh-hae, ( %) type and ( %) type ii; families had all their known members already studied for c -inh-hae ( %): families have all their members studied ( . %), families have % or their known members studied ( . %) and families had less than % of their total known members studied. we have identified members from unrelated families that had not been previously studied for hae, healthy, had low c levels and had presented symptoms of hae; had not presented symptoms of angioedema, had normal c levels, and low antigenic and functional c -inh levels. difficulties for a complete family testing study have been: family dispersion, scarce or no family relationship, do not wish to know their possible pathology conclusion: it is crucial to insist on the study of the relatives of patients with hae. we propose to include a questionnaire to identify all patient's relatives at medical reviews of hae patients. case: a- year old boy was admitted to our clinic with the history of recurrent respiratory tract infections. his all immunoglobulins were low (igg < mg/dl, iga < . mg/dl, igm < . mg/dl) associated with the absence of b cells. his aunt cousin also had xlaa missense point mutation, c c>t in exon of the btk gene was identified in both affected cousins. the patient was commenced on regular ivig treatment every weeks. at the age of , he suffered from intermittent fever attacks, abdominal pain and weight loss. tests for giardia lamblia, clostridium difficile and cryptosporidium, noro virus or parasites were negative. mr-enterography revealed intra-abdominal fluid and thickened walls of his jejunum and cecum. histopathological examination of the biopsy material obtained from terminal ileum, colon and cecum showed crohn disease. initially, he was treated with prednisolone and infliximab. because of the lack of response, infliximab treatment was switched to adalimumab. terminal ileum was resected to relieve obstruction complication. although he had been treated with adalimumab for year, a significant improvement was not observed. vedolizumab (entyvio ™ ), is a humanized monoclonal antibody α β integrin-receptor antagonist, was commenced. induction dosing was mg infusions at , , and weeks followed by a maintenance phase at week intervals. at the month of the treatment, fever and abdominal pain attacks reduced, while his weight and oral intake increased. no side effects were observed. discussion: vedolizumab is effective for inducing and maintaining remission in adults with inflammatory bowel disease (ibd); however, there is limited pediatric data. this is the first immunocompromised child treated with vedolizumab. the symptoms of the patient receded and no side effect observed during months of the treatment. results: louis-bar syndrome is a multisystem progressive disease with polymorphic manifestations which varies by age. the locomotor disability of these children is determined by neurological disorders, the exitus being caused by respiratory infectious and malignancies. the children involved in the study, had frequent episodes of respiratory infectious (bronchitis, pneumonia, atelectasis, empyema, lung abscess), ent infections (otitis, mastoiditis, sinusitis), chronic pulmonary disease (pulmonary fibrosis, bronchiectasis). index of death in this group is high ( . %). in one of the boy, the pulmonary ct showed lymphadenopathy, later was confirmed non-hodgkin lymphoma, with subsequent death. another child died from pulmonary and systemic infectious complications. results: in this paper we present the clinical and morphological analysis of children with nezelof syndrome diagnosed post-mortem. clinically were predominantly the generalized intrauterine infections or their development in the postnatal period. at macroscopic examination all patients had thymic hypoplasia. later on the microscopic study of the thymus specimens determined dysplastic changes, defined by the presence of concentrically arranged epithelial cells. in all patients, was determined the total lack of hassall corpuscles and its predecessors. besides the above-mentioned modifications in all specimens, there was no cortico-medullary segregation. thymic parenchyma outside pseudorrhagia was made up of a reticular stroma with total lymphocyte depletion. conclusion: nezelof syndrome is a severe primary immunodeficiency associated with thymic dysplasia and alymphocytosis, which is manifested early with generalized infections and major risk of death in neonatal and infant. background: the study was aimed to evaluate the cytokine profile in nasal secretion and blood serum in patients with seasonal (sar) and perennial allergic rhinitis (par) with a potential for additional sensitization with microbial allergens. method: the inclusion criteria for ar were as follows: a diagnosis of ar for more than years, the absence of nonallergic disorders of the nasopharynx, age of patients from years to years.control group: healthy volunteers at the age of - years without any allergic disorders at examination.in order to evaluate the innate and adaptive immunity, the cytokine profile of blood serum (il- , il- , and tgf-β) and nasal secretion (tslp, il- β, tnf-α, and gm-csf) was determined. to determine tslp, tgf-β, il- , and gm-csf concentrations, enzyme-linked immunosorbent assay kits were used (ebioscience, bender medsystems, r&d systems, mn, usa). we have noticed a significant correlation (r = , p = ) between the tslp concentration in nasal secretion and as-ige level to staphilococcus aureus enterotoxin (allergen component m ) in patients with par. there was a significant correlation conclusion: staphylococcal superantigens might be one of the stimuli of local tslp hyperproduction by the epithelium. there was a significant correlation between gm-csf concentrations in nasal secretion and the intensity of sensitization to a staphylococcal enterotoxin (seb) in the patients with ar. seb is one of the polyclonal t cells activators, which may account for increased concentrations of cytokines such as gm-csf locally within the system of mucosal immunity. the patients with ar and additional high sensitization to ses demonstrated a higher tnf-α production profile due to macrophage and tcell activation by these toxins. | evaluation of circulating osteopontin level as potential biomarker of allergic asthma in patients with caucasian and south-east asian ethnicity background: osteopontin (opn) is a pleomorphic cytokine known to influence a wide range of immune cells; allergic asthma was previously associated with high circulating opn levels. in the present study, we aimed to verify if opn may qualify as biomarker of activated immune response in allergic patients belonging to two different ethnic groups: caucasians and south-east asians. method: serum opn levels were measured by elisa test (human osteopontin duoset, r&d systems) in a series of italian adult patients affected by extrinsic asthma, allergic rhinitis, hymenoptera venom allergy, food allergy, allergic contact dermatitis and ige mediated hypersensitivity to beta lactams. healthy subjects served as controls. ethnic chinese subjects were recruited at the national university of singapore (nus) as cross-sectional cohort of an ongoing epidemiological study on the national prevalence of allergic diseases, and opn levels were detected by luminex (milliplex map, merck) and elisa assays (r&d systems). results: in the italian cohort, opn levels were significantly higher in cases compared to controls (p = . by the mann-whitney test). statistically higher opn levels were found in asthma (p = . ) and food allergy (p = . ) groups in comparison to controls. no significant differences were found (p = . ) between singaporeans with lifetime asthma and healthy controls, only the highest opn levels were heterogeneously found to correlate with asthma. however, a strong gender effect was shown, in both cases (p < . ) and controls (p < . ), with males presenting higher opn levels in comparison to females. consequently, we checked the mrna expression levels of opn gene (spp ) with illumina chips in whole blood of males and females, and no difference was found (p < . ). several experiments with western blots and different gel types were performed to verify if possible post-transcriptional/posttranslational modifications of opn could explain these findings. conclusion: opn seems to be a promising biomarker for current, active allergic asthma in caucasians even though technical difficulties, due to opn intrinsically disordered structure, the complex enzymatic metabolism, and the low circulating levels, significantly affect the experiments. further studies are needed to confirm these data. | mortality, intubation, and healthcare cost in patients with allergic bronchopulmonary aspergillosis in a hospital setting: a nationwide study fan x; luo y; yue b background: abpa is a complex hypersensitivity reaction to aspergillus fumigatus that colonize in airways, it is almost exclusively seen in patients with asthma or cystic fibrosis(cf). this study is to estimate hospitalization outcomes and healthcare cost of hospitalized patients with abpa. method: we conducted the study using data from national inpatient sample(nis) from to . diagnosis were identified using icd- -cm codes. hospitalization with a primary diagnosis of abpa and hospitalization with a primary diagnosis of acute respiratory failure/acute and chronic respiratory failure/respiratory distress/ asthma/cf and a secondary diagnosis of abpa were included. the study population was divided into groups including abpa with asthma, and abpa with cf. mortality and intubation rate were the primary outcomes; length of stay and total hospitalization cost(adjusted to cost in based on medical care cpi) were secondary outcomes. student t-test and chi-square were used for univariable analysis, linear and logistic regression were used for multivariable analysis. results: a total of hospitalizations with abpa were included, with hospitalizations with abpa and asthma, and hospitalizations with abpa and cf. the overall mortality rate was . % ( % ci: . %- . %), the mortality for abpa with asthma was . % ( % ci: . %- . %) and for abpa with cf was . % ( % ci: . %- . %). the overall intubation rate was . % ( % ci: . %- . %); the intubation rate for abpa with asthma was . % ( % ci: . %- . %) and . % were early intubation (< days); the intubation rate for abpa with cf was . % ( % ci: . %- . %) and . % were early intubation. the overall mean length of stay(los) was . ( % ci: . - . ) days, while the los for abpa with asthma was . ( % ci: . - . ) days and the los for abpa with cf was . ( % ci: . - . ) days. the overall total cost was million usd, the total cost for abpa with asthma was . million usd with a mean of , while the total cost for abpa with cf was million usd with a mean of . conclusion: mortality among hospitalized patients with abpa is low< %. intubation rate is relatively low, intubation, especially early intubation (< days), is more common in patients with asthma. although abpa is not a common disease in inpatient population, it does have a high health care cost and despite lower intubation rate, patients with abpa and cf generally have a longer hospital stay with a higher hospitalization cost. | frequent exacerbations of bronchitis with wheezing in adults: is it possible to predict and prevent asthma? case report: frequent episodes of bronchitis, accompanied by wheezing and dry with a prolonged duration in adults, the clinical course may be similar to bronchial asthma. the aim is to assess the risk of asthma in adult patients with or more episodes of acute bronchitis per year, had a prolonged duration and accompanied by a dry wheezing. for years in two regional clinical pulmonology centers were observed in patients ( men and women) with average age ± . years. each had at least episodes of acute bronchitis per year, which was accompanied by prolonged cough and presence of wheezes. average number of acute episodes per year was . ± . . in the course of the observation the patients were divided into equal groups. the first group consisted of persons treated in acute episodes of the disease symptomatic therapy, including inhaled β -agonists short-acting short course. in the second group to the corresponding treatment added montelukast mg per day lasting for month. in all cases of exacerbation had a viral nature. held in the period of remission of allergic sensitization, the survey revealed. starting from the first year of follow-up all patients were vaccinated against influenza annually. by the end of the fifth year of observation in the first group in cases was diagnosed of bronchial asthma- cases easy persistent asthma and case moderate. the diagnosis was exhibited in accordance with the gina criteria. in the second group, the diagnosis of bronchial asthma were exposed to patient (hazard ratio of . ). prospective observation suggests that the use of anti-inflammatory potential antileukotriene medicines in complex therapy of recurrent acute episodes of bronchitis accompanied by a dry wheezing in adults may be a factor preventing the development of asthma. for more conclusive results require more extensive research. background: chemokine receptors play an important role in regulating the migration of t lymphocytes, monocytes and neutrophils from the peripheral blood into inflamed tissue, such as lung. however, little is known about their expression on natural killer (nk) and natural killer t (nkt) cells in patients with chronic obstructive pulmonary disease (copd). therefore the aim of the study was to determine the chemokine receptor profile of peripheral blood nk and nkt cells of copd patients. method: for analysis of lymphocytes subtypes the flow cytometry method was used. the study population consisted of smokers with copd, healthy smokers and healthy non-smokers. results: we observed an increase in blood nk cells expressing cxcr receptors in smokers with copd compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). the percentage of nkt cells containing cxcr receptors was also significantly higher in blood of smokers with copd compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). copd smokers had significantly higher proportion of ccr + nk cells than smokers without copd (p = . ) and healthy non-smokers (p < . ). increased proportion of blood nkt cells expressing ccr on their surface was observed in smoking copd patients compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). there were no significant changes in the percentage of cxcr + and ccr + nk and nkt cells between healthy smokers and non-smokers. in addition, no differences were seen in the proportion of nk and nkt cells expressing cxcr , cxcr , ccr and ccr among all studied groups. method: patients with copd in stable condition (gold stage ) aged - years old, smoking history of ≥ pack-years, were studied. bmi of patients were divided into groups: obese (n = ) (bmi- . - . kg/m ) and non-obese (n = ) (bmi- . - . kg/ m ). ten subjects with normal lung function and bmi were the control group. the level of il- assessed in induced sputum (pg/ml) was measured using an elisa (raybiotech ® ). serum levels of crp were measured using the "vector-best" (russia federation). spirometry was performed according to american thoracic society and the european respiratory society (ats/ers) guidelines. results: obese copd patients had significantly increased concentrations of il- compared with healthy subjects and non-obese copd patients by . fold ( . ± . pg/ml vs . ± . pg/ ml) (p < . ) and . fold, ( . ± . pg/ml vs . ± . pg/ml)(p < . ), respectively. non-obese copd patients had higher levels of il- by . fold compared with healthy subjects ( . ± . pg/ml vs . ± . pg/ml) (p < . ). results: among these three groups, the level of cer in lung cancer patients ( . ± . g/l) was significantly higher than that in ild patients ( . ± . g/l) and healthy individuals ( . ± . g/l) (p < . ). meanwhile, the levels of c and c in healthy individuals, which are . ± . g/l and . ± . g/l respectively, were both significantly higher than that in lung cancer patients (c : . ± . g/l, c : . ± . g/l) and ild patients (c : . ± . g/l, c : . ± . g/l), (c : p < . , c : p < . ). results from optimal scaling demonstrated that lung cancer was closely associated with immune factors including crp, cer, c and c (cronbach's alpha = . %). conclusion: for ild patients, when the level of crp and cer is increased and the level of c and c is decreased simultaneously, the risk of the development of lung cancer should be considered for these patients. results: among pbmc subpopulations, endurance exercises impacted the number of nkt and activated t cells with nkt cell numbers greater in male bobsledders vs bullet shooting and biathlon ( . % and . %, respectively). the number of activated t cells (cd + ) was greater in bullet shooting and bobsleigh athletes vs the biathlon group ( . % and . %, respectively). in female athletes the number of cd + cells in the shooting and bobsled groups was greater by . % and . %, respectively vs the biathlon group (p < . ). increased il- occurred in bobsleds in comparison to bullet shooting and biathlon: % and % in male and . % and % in female, respectively (p < . ). the concentration of il- in male bobsledders and biathlon was % and % greater, respectively, compared with bullet shooting (p < . ). serum concentrations of ifnγ in male as well as female athletes showed an increase of . % and . %, respectively vs biathletes (p < . ). increased il- occurred in the male biathlon group by . % and %, respectively, vs the bullet shooting and bobsleigh athletes (p < . ). il- was increased in the male biathlon group, compared to bullet shooting and bobsledders by . % and . %, respectively (p < . ). conclusion: prolonged endurance exercises impacts secretion of pro-and anti-inflammatory cytokines in athletes of different sport specializations. concentrations of studied cytokines did not exceed reference values perhaps due to specialized sport nutrition, which may restore immune function during endurance exercises. background: oral immunotherapy (oit) is a promising therapeutic approach to treat food allergic patients. recently, we have shown that the use of a mixture of short-chain-and long-chain fructo-oligosaccharides (scfos/lcfos) improves the efficacy of oit in cow's milk and peanut allergic mice. however, concerns with regard to safety and long-term efficacy of oit remain and there is a need to identify novel biomarkers (panels) that predict, monitor and/or evaluate the effects of oit. here we present a method for the selection of candidate biomarkers by using the computational approaches bayesian networks (bn) and topological data analysis (tda). method: data were used from scfos/lcfos diet-supported oit studies performed in independent cow's milk allergy (cma) and independent peanut allergy (pna) experiments in mice. first, a subset of the data was used for learning the data structure and their interactions in terms of a bn. this bn was used to compare the key parameters in both experimental food allergy models. finally, the relations within the dataset in combination with the bn were explored to identify and rank candidate biomarkers for the effect of oit by applying tda. the bn was able to predict the efficacy of oit in the cma and in the pna model with % and % accuracy respectively, thereby identifying a set of parameters (allergen-specific ige and igg , body temperature, mmcp- , earswelling) being key in the mechanisms involved in both scfos/lcfos-aided oit food allergy models. the tda zoomed in on the full set of previously analyzed parameters and identified clusters of biomarkers closely linked to biologically relevant clinical symptoms but also unrelated and redundant parameters within the network. taken together, this enables the prioritization of candidate biomarkers. moreover, the tda indicated differences between pna and cma models in how the data are related to each other. here we provide promising bioinformatics methods to compare mechanistic features between two different food allergies and to determine the biological relevance of biomarker (panels) of oit for food allergy. we have shown that the key drivers that influence pna and cma are similar, but that these phenotypically similar diseases show mechanistic differences in their subnetworks. these new insights provide excellent starting points to generate new hypotheses to explain why cma has a different disease pattern than pna and to select biomarkers that are useful in future clinical studies. | functional and immunoreactive levels of igg correlate with clinical responses during the maintenance phase of house dust mite immunotherapy basophils were identified as ssc low cd high , and cd was used as an activation marker. reactivity was confirmed by anti-ige as a positive control. results: in patients, basophil reactivity and sensitivity was comparable for grass pollen extract and recombinant phl p , while phl p only caused a lower basophil activation. in one patient, recombinant phl p did not cause any basophil activation, while phl p elicited an even higher sensitivity and reactivity than grass pollen extract. conclusion: in patients, basophil reactivity was comparable for grass pollen extract and recombinant phl p , while phl p only caused a minor basophil activation. in one patient, recombinant phl p did not cause any basophil activation, while phl p elicited an even higher sensitivity and reactivity than grass pollen extract. reactivity of extract and the main sensitizing components correlated, while sensitivity did not. | in vitro assessment of hypersensitivity to allergen before and after allergen immunotherapy with whole blood basophil histamine release assay wbbhr assay in these patients was performed - days before and - days after ait. heparinized whole blood samples ( ml) of each patient after substitution of plasma with pipes buffer were incubated one hour at °c with different concentrations of birch pollen extract (t ) in u-shape -well micro-titer plates. after incubation plates were centrifuged and supernatants from each well of the plate were directly analyzed for histamine content by reversedphase high performance liquid chromatography with electro-spray ionization mass-spectrometry (rp-hplc-esi-ms). results were expressed as ng/ml released histamine. sensitivity (limit of quantification) was - ng/ml. to compare results of histamine release in patients before and after ait data were calculated as area under the curve (auc) values. results: in contrast to pre-immunotherapy activity of blood basophils there were significant decreases in hr induced by t extract after ait. according to auc values all patients demonstrated decrease in hr after ait in compare to hr before ait in a range of %- % demonstrating a decrease of hypersensitivity to birch allergens. analysis of basophil hr in patients received s.c. or s.l. the asthma and rhinoconjunctivitis symptom scores during and after pollination season decreased significantly and showed correlation with histamine release by t . | immunotherapy with the recombinant b cell epitope-based grass pollen allergy vaccine bm induces a biphasic allergen-specific igg and igg response background: immunotherapy with the recombinant b cell epitopebased grass pollen allergy vaccine has been shown to reduce symptoms of grass pollen allergy in a multicenter, double-blind, placebocontrolled study. aim of this study was to investigate the levels and kinetics allergen-specific igg responses in a double-blind, placebocontrolled phase iib combined field and exposure chamber trial studying the effects of three, four and five pre-seasonal injections of bm as compared to placebo. method: a quantitative elisa assay based on purified human monoclonal allergen-specific igg as well as igg antibodies as standards was developed to measure allergen-specific igg and igg concentrations induced by ait with bm . results: we found rises in levels of both tested allergen-specific igg subclasses in the actively but not placebo-treated patients. phl p -and phl p -specific igg levels up to μg/ml and μg/ml, respectively and phl p -and phl p -specific igg levels of up to μg/ml and μg/ml, respectively were measured in bm treated patients. five pre-seasonal injections induced the highest allergen-specific igg levels. interestingly, allergen-specific igg and igg antibodies showed a biphasic response with early rises of allergen-specific igg which declined quickly after the pollen season and a delayed but very sustained allergen-specific igg response. conclusion: treatment with bm induces a biphasic allergen-specific igg response consisting of an early igg and a sustained allergen-specific igg response which may be responsible for early and sustained protection against allergic symptoms. | t reg cd + cd high in peripheral blood in patient with grass pollen allergy during sublingual specific immunotherapy slit the aim of this study was to evaluate t reg cd + cd high in peripheral blood in patients with grass pollen allergy during sublingual immunotherapy slit. method: we examined adult patients, aged - , female and male. patients were qualified to slit after confirmation of allergy-by skin prick tests, specific ige and nasal provocation tests. we determined t reg cd + cd high from blood sampling of those patients (by flow cytometry method), before the slit, after reaching the maintenance dose, before the grass pollen season, during the grass pollen season, and after one year of slit. results: during slit the percentage of t reg cd + cd high increase after reaching the maintenance dose, then it decreased before and during the grass pollen season, and again increase after one year os slit. we observed, that in the group with significant improvement of symptoms, t regcd + cd high decreased during grass pollen season, comparing to group without clinical improvement. conclusion: slit as a method of immunotherapy influence on levels of t reg cd + cd high cells. the observed decreased levels of these cells during the grass pollen season might be consider as a prognosing marker of clinical improvement. | t reg cd + cd high from peripheral blood during subcutaneous specific immunotherapy (scit) for grass pollen hofman a; hofman j; hofman t centrum alergologii, poznan, poland background: specific immunotherapy is the only causal method for grass pollen allergic rhinitis. however, we don't observe in every patients satisfying clinical effects. because the treatment of allergic rhinitis takes - years, and is quite expensive, everyone is constantly looking for a perfect parameter, which may prognose the effectiveness of specific immunotherapy (sit). the aim of this study was to evaluate t reg cd + cd high lymphocytes from peripheral blood in patients during subcutaneous specific immunotherapy (scit) for grass pollen . method: we examined adult patients ( female, male), age - , who undergo scit for grass pollen allergy. we have done skin prick tests and specific ige in those patients. additionally, we confirmed the allergy by nasal provocation tests. we have determined lymphocytes t reg cd + cd high from blood sampling from those patients, with flow cytometry method: before immunotherapy, after reaching the maintenance dose of scit, before and during the grass pollen season, and after one year of scit. our control group was represented by adult healthy volunteers. after one year of scit we divided patients into two groups-with and without clinical improvement. results: in allergic patients we have observed decreased levels of t reg cd + cd high compared to control group before the start for scit. during immunotherapy, the percentage of t reg cd + cd high increased after reaching the maintenance dose, however it did not reached the level of healthy volunteers. again, levels of t reg cd + cd high decreased before and during the grass pollen season, and increased after one year of scit. we compared also patient with significant improvement of clinical symptoms, and without. and we observed that the level of t regs cd + cd high decreased during pollen season in improved group, and increased in the group without clinical improvement. conclusion: in patients with grass pollen allergy, during the grass pollen season, decrease of t reg cd + cd high cells might be con- results: in the group of patients treated with sit gene expression analysis revealed significant change in ifng expression (p = . ) (comparison between sample a and b). comparison between samples a and c showed significantly different expression in genes: afap l (p = . ), commd (p = . ), pik cd (p = . ), and twist (p = . ). duncan's multiple range test confirmed difference between sample a and c for commd (p = . ) and also revealed new significant difference in tbx in samples a and b (p = . ; in wilcoxon's test p = . ). k nearest neighbors algorithm was built based on ifng, pik cd, commd expression. the results of the study indicate, that there is a significant change in the expression of a few genes during the build-up phase of sit. it may be suspected, that this change contribute to the mechanisms involved in the building tolerance to allergen. k nearest neighbors algorithm may be useful for sit efficacy prediction. | regulation of cytokine thymic stromal lymphopoietin (tslp) in modulating tgf-ß induced interstitial inflammation and cellular fibrosis background: thymic stromal lymphopoietin (tslp) has previously been linked to allergic inflammatory diseases, tissue fibrosis and organ dysfunction. it remains unclear, however, whether tslp plays any role in the occurrence of renal fibrosis, so this study investigated that underlying mechanism. method: an in vitro fibrosis model was established by treating normal rat kidney fibroblast (nrk- f) cells with transforming growth factor-β (tgf-β ), after which the levels of various fibrogenic markers (e.g., fibronectin) and downstream fibrogenic signal proteins (e.g., smad ) were investigated. also, tslp shrna was used to silence the effects of tslp, while an elisa was conducted to evaluate the fibronectin secretions. results: the level of fibronectin in the nrk- f cells was doseand time-dependently increased by the administration of exogenous tslp (p < . ). tslp also significantly increased the level of fibrosis signaling, in addition to inducing a marked decrease in the down-regulation of smad . interestingly, the application of tslp shrna caused a dramatic reversal of the tgf-β -induced cellular fibrosis while simultaneously leading to the suppression of fibronectin and fibrogenic signal proteins. conclusion: taken together, these observations provide insights into how extracellular matrices develop and could lead to potential therapeutic interventions for the suppression of renal inflammation and fibrosis. abstracts | | effects of two years treatment with the recombinant b cell epitope-based grass pollen allergy vaccine bm on allergen-specific b and t cell responses background: bm contains recombinant fusion proteins of nonallergenic peptides from ige-binding sites of the four major timothy grass pollen allergens phl p , , and and pres protein from the hepatitis b virus as a carrier. in a multicentre, double-blind, placebocontrolled trial, grass pollen allergic subjects were treated for two years either with bm or placebo. here we investigated in detail the effect of immunization with bm on allergen-specific t and b cell responses. during the study from subjects treated in the vienna centre (bm : n = , placebo: n = ) were investigated regarding proliferation using h thymidine incorporation and cytokine production in response to various recombinant allergens at different time points. grass pollen allergen-specific ige, igg and igg levels were determined by immunocap and elisa. results: a significant increase of allergen-specific igg and igg levels was found in the bm -but not in the placebo group in both years (year > year ) after treatment. there was no difference regarding t cell proliferation in response to phl p and phl p after first grass pollen season between actively and placebo-treated patients whereas proliferation in particular of phl p -specific responses seemed to be blunted in the active group in the second year. no significant differences regarding allergen-specific th , th and tolerogenic (i.e., il- ) cytokines were observed between bm and placebo-treated patients. the findings indicate that the bm induces high levels of allergen-specific blocking antibodies which may reduce allergen-specific t cell proliferation but does not induce significant increases of regulatory cytokines in t cells. this study was supported by grants f , f and dk -b of the austrian science fund (fwf). hospital universitario ramón y cajal, madrid, spain; department of immunology iis-fundación jiménez díaz, uam, madrid, spain background: shiitake mushroom (sm) (lentula edodes) is an edible fungi native to east asia. it is traditionally cultivated and used in many asian countries and its consumption is increasing worldwide. direct skin exposure to sm can cause cutaneous reactions, including allergic contact dermatitis and urticaria, while its oral intake may prompt "shiitake flagellate dermatitis" (sfd), which is a distinctive itching linear erythematous eruption. sfd is usually considered a toxic reaction to lentinan, a thermolabile polysaccharide that increases interleukin- . we report cases (p , p , p ) of shiitake flagellate dermatitis studied in our centre. method: skin prick tests (spt) to environmental allergens-including moulds -, prick-by-prick and patch test with raw and cooked sm were carried out. total ige and specific ige to mushroom, white mushroom and environmental moulds were also determined. a raw and cooked shittake mushroom extracts were prepared. both extracts were analyzed in all the patients by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). results: skin prick tests, prick-by-prick, patch tests and specific ige were all negative except for p , who had positive prick-by-prick to raw shiitake mushroom. sds-page ige immunoblotting assays with the patient's sera revealed ige-reactivity with proteins ranging from kda to kda for p , p and p . we report cases of shiitake flagellate dermatitis with demonstrated ige-sensitization. physicians should take into account that some cutaneous reactions considered as toxic might be allergic reactions. vorozhko i ; sokolnikov a ; sentsova t ; donnikov a ; ilyenko l ; denisova s background: allergic diseases such as asthma, rhinitis and food allergy have increased in recent decades in tropical countries. the tropics has climatic, environmental and ecological peculiarities that allow us to emit several hypotheses that could explain this phenomenon. in one of them, it is postulated that the increase of the sensitization to food, is due to the presence of lower serum levels of vitamin d, product of the adoption of a western lifestyle, with lower sun exposure, which in its turn diminishes the immunomodulatory action of this vitamin at intestinal level, favoring the sensitization against food antigens. we evaluate differences between the titers of serum antibodies against food antigens between two populations with african ancestry but different environment (rural vs urban) and investigate the influence of vitamin d levels. method: an observational, cross-sectional and descriptive study was carried out on afro-descendant children living in san basilio de palenque (rural) or in the city of cartagena, bolivar (urban). the sensitization was determined by a positive skin prick test to allergen extracts, including foods, and, specific ige, iga and igg to egg, milk and peanut extract, as well vitamin d, were measured by elisa. antibody and vitamin d titers were correlated by spearman's test and comparisons between groups were done using the wilcoxon rank sum test. a p < . was considered significant. results: atopy was more prevalent in the urban population ( % vs %, p < . ). however, none participant tested was positive for food allergens. regarding vitamin d levels, these were found to be higher in the rural population compared to the urban group (p < . ). among the antibodies analyzed, only ige against peanut showed differences, which were higher in rural population (p < . ) as well as those of iga to peanut, which were higher in the urban population (p < . ). we observed only a significant correlation between peanut specific ige (rho . , p < . ) and iga (rho - . , p < . ) response and vitamin d. conclusion: in our study, we found differences between the peanut specific ige and iga response in urban and rural populations. the correlation between the levels of specific ige and iga to peanut and vitamin d, suggest that this vitamin may influence peanut sensitization in this population, besides other components like diet and genetic and environmental factors. | evaluation of inhaled allergen sensitivity in patients with food allergies younger than two years of age kulhas celik i ; aldemir es ; buyuktiryaki b ; ginis t ; toyran m ; dibek misirlioglu e ; kocabas cn ; civelek e carbohydrates and pyruvate was observed in the severe group compared to the rest of allergic groups. in addition, an increment in lactate was noticed. these metabolites were closely associated with the energy metabolism. other metabolic changes included increased levels of fatty acids such as myristate, palmitate and laureate. these fatty acids might be precursors of arachidonic acid, a key molecule in inflammation. finally, alterations in some amino acids and adenosine were found method: to evaluate these critical processes, five-week old germ-free c h/hen mice were split into two groups; were intraperitoneally sensitized to the peanut allergen ara h and remained ns. upon reaching weeks of age, mice were intragastrically challenged with purified ara h . mice were harvested in two groups: -minutes and -minutes post-gavage. upon harvest, the left lobe of the liver was collected and sera were removed. sera and livers were evaluated for drp-ara h using an in-house quantitative sandwich enzyme-linked immunosorbent assay (elisa). a sample of the proximal small intestine was monitored for drp-ara h using immunohistochemistry (ihc) and for mast cell degranulation using toluidine blue stain. results: sensitization does not have a large effect on the concentration of allergen present in the sera or liver. however, s mice allowed to digest ara h for -minutes were more likely to display tissues positive for detection of drp-ara h than ns mice at the same time point. conclusion: there is drastic biological variation among mice in their capacity to absorb and transport allergens. the elisa used in these analyses proved effective in the quantitative detection of drp-ara h in both liver and sera samples, while ihc provided inconsistent results for the detection of drp-ara h in tissues. however, in positive ihc samples, staining was indicative of paracellular transport across the epithelial barrier. | eczema induces a high ovalbuminspecific ige/igg ratio and affinity maturation during the lactation period irahara m; kido h; shinahara w inst. for enz. res., tokushima university, tokyo, japan background: recent articles have revealed that ingestion of foods induces oral tolerance and cutaneous sensitization induces food allergy. relationships with levels of immunoglobulin subclasses, affinity of allergen-specific ige, and development of food allergy have also been indicated. however, relationships with levels and affinity of specific immunoglobulins and eczema during early infancy remain poorly understood. therefore, the present study aimed to elucidate these relationships. method: this study enrolled women who visited naruto hospital (tokushima prefecture, japan) in late pregnancy and their children. blood samples and information on skin condition were taken every months from neonate to months old. egg white and milk allergen-specific immunoglobulin subclasses and affinity of ovalbumin (ova)-specific ige levels were measured using the densely carboxylated protein (dcp) microarray with μl of serum. results: this study included infants whose parents agreed to join this study. of these, infants ( %) were diagnosed with eczema by months old. egg white (ew) and milk-specific igg were detected in a few subjects at months old. however, these specific ige and igg were detected in some subjects at that time ew-and ova-specific ige levels and ige/igg ratios were significantly higher in participants with eczema than in those without eczema at months old. moreover, subjects with high ova-specific ige/igg ratios showed higher affinity ova-specific ige antibodies than subjects with low ova-specific ige/igg ratios. these results were not reflected in milk-specific ige levels. the milk-specific ige level differed between breast feeding and formula-fed infants, with no difference in the ige/igg ratio. conclusion: eczema contributed to high ew-and ova-specific ige levels and ige/igg ratios. high ova-specific ige/igg ratios involved high affinity ova-specific ige antibodies. however, the milk source during early infancy had no effect on the specific ige/igg ratio with eczema. these results suggest different sensitization routes provoke different results in levels and affinity of immunoglobulins. | purification and characterization of naturally occurring post-translationally cleaved ara h , an allergen that contributes substantially to the peanut allergome background: the s albumin ara h is one of the most important peanut allergens. a post-translationally cleaved ara h isoform has been described in the past but had not been characterized in detail, nor had its relevance for peanut allergy been investigated. method: post-translationally cleaved ara h (para h ) and intact ara h (intact ara h ) were purified from virginia type peanuts and the cleavage site was mapped using high-resolution mass spectrometry. biochemical characteristics were determined by sds-page, uv absorbance spectroscopy, far uv cd spectroscopy, and immunochemical reactivity of both forms of ara h was compared by igg immunoblotting and ige-elisa using sera from individuals sensitized to peanut. reversed-phase liquid chromatography was applied to study the occurrence and abundance of para h in various peanut types. results: compared to intact ara h , para h lacks a -amino acid stretch, resembling amino acids - (uniprot accession number q g ) in the non-structured loop. consequently, para h consists of chains; a n-terminal chain of approximately kda, and a c-terminal chain of approximately kda, held together by disulfide bonds. intermediate post-translationally cleaved products, in which this stretch is cleaved but not removed, are also present. the secondary structure and ige-binding of para h resembles that of intact ara h , indicating that the loss of the non-structured loop is not critical for maintaining conformational ige-epitopes. both forms of ara h were reactive with several commercially available igg antibodies. the peanut cultivars runner, virginia, valencia, and spanish contained para h at equivalent levels, suggesting para h is a consistent and important constituent of the peanut proteome. conclusion: a post-translationally cleaved form of ara h is abundant in the main peanut market types, and has ige-binding comparable to intact ara h . this should be taken into account when ara h is investigated in peanut-containing products. | release of major peanut allergens from their matrix at various ph and at saliva conditions; ara h and ara h are quickly bioaccessible background: the oral mucosa is the first immune organ that encounters allergens upon ingestion of food. peanut is often consumed in solid form, and it is not known if peanut allergens are released from the food already in the mouth. we set out to investigate the solubility of individual peanut allergens at conditions that mimic the first exposure site, i.e. the mouth. method: light roast peanut flour was suspended in buffers of various ph mimicking saliva. protein concentration was measured in supernatant, and release of major allergens ara h , ara h , ara h , and ara h was assessed by sds-page. also, the allergen profile of un-dissolved material was assessed. results: peanut protein solubility is poor in the ph range - , while at low ph ( . ) and at moderately high ph (> ), the solubility is higher. at all conditions tested, there was a substantial amount of un-dissolved protein. this indicates that the ph range of saliva, between . and . in healthy individuals, may be critical for the release of peanut protein from its matrix. in this ph range from . to . , ara h and ara h are readily released, while ara h and ara h are poorly released. increasing the ph from . to . slightly increased the release of ara h and ara h , but still the recovery was low (approximately % for both ara h and ara h ) compared to that of ara h and ara h (approximately % and %, respectively). this remarkable difference in extraction kinetics suggests that ara h and ara h are the first allergens an individual is exposed to upon ingestion of peanut-containing food. conclusion: based on our observations, we conclude that the peanut allergens ara h and ara h are quickly bio-accessible in the mouth upon ingestion of peanut. this new insight may contribute to the understanding of the extraordinary allergenicity of ara h and ara h compared to other peanut allergens. background: in proven cases of non-ige mediated cow's milk allergy clinical response can be partial even when treated with amino acid formulae e.g pain in infants. residual intestinal symptoms can be related to ongoing nerve hypersensitivity, changes in microbiome or motility disturbance. mast cells are thought to play crucial role in non-ige mediated food allergy. ketotifen is a first generation h antihistamine which has mast cell stabilising properties with pain blocking and anti tnf-a effect. hence ketotifen could have important role in symptom resolution where diet elimination has not been successful. we aim to find out effectiveness of ketotifen to unresponsive/partially responsive symptoms such as pain in non-ige mediated cow's milk allergy infants. method: children who presented to single specialist centre over years had their case notes reviewed retrospectively. inclusion criteria were those children with confirmed non-ige mediated cow's milk allergy by elimination of cow's milk with improvement of symptoms and worsening of symptoms on reintroduction of dairy. where symptoms partially responded e.g pain, ketotifen was used at . - mg once at night for weeks and symptoms were reassessed. statistical analysis was performed using r v . . with significance was set at p = . . results: patients were identified with patients excluded due to unconfirmed non-ige mediated allergy. of the case ( males, age - months), atopic co-morbidities were found in % children. common symptoms were abdominal pain ( %), vomiting ( %), back arching ( %), constipation ( %), bloating ( %), food aversion ( %) and diarrhoea ( %). we compared the children who had symptom improvement on ketotifen and cow's milk elimination against children who improved on cow's milk elimination alone. significant difference of symptom improvement was found with abdominal pain; % using ketotifen compared to % who did not use results: a total of analysis for ttgiga have been performed for a total of patients during the study period ( , , , ) . patients showed at least once a positive ttgiga. among these, had a negative result at first testing, and were positive at the second (n = ) or third testing (n = ). despite an increasing number of ttgiga requests, the number of positive results decreased. wige were rarely requested but were positive in about % of tested sera (table a and b). the amount of laboratory requests for ttgiga has increased, while those for wige remains stable and is rare. wheat allergy seems to be rarely investigated in our center and may deserve more attention. case report: eosinophil-associated gastrointestinal disorders (egids), including eosinophilic gastroenteritis (eog), are a inflammatory diseases, characterized by gastrointestinal symptoms and eosinophilic infiltration. patients with eoe have an increased incidence of allergy, with increased ige mediated food and inhalant sensitivities. use of either a targeted food allergen avoidance approach (based on allergy testing) or untargeted approach (based on food allergen avoidance) results in the resolution of eosinophilia in the gastrointestinal tract of %- % of adult. we describe a case of a -year-old patient diagnosed with eosinophilic enteritis, associated to protein-losing enteropathy. the patient experienced severe diarrhea, nausea, vomiting and weight loss, that caused a severe dysproteinaemia and electrolytes abnormalities. an upper and lower endoscopy was performed, showing an ulcerative ileitis. the histological pattern was characterized by eosinophilic infiltration of ileum and duodenum> hpf. she presented also high levels of total ige ( k/ui), high serum tryptase ( μg/l, n.v. ≤ . ) and sensitization to the lipid transfer protein (ltp) of peach. the patient was prescribed to a six-food elimination diet (sfed) and underwent high doses of oral and intravenously corticosteroids, but a satisfactory therapeutic response was not achieved. we hypothesized that ige has a role in the mechanism of aeg and that blocking ige would have improved disease symptoms and reduced allergic inflammation, as measured by a decrease in intestinal tissue eosinophilia. we started off-label administration of omalizumab mg/month subcutaneously, the same dosage schedule used in allergic asthma and, by other authors, in eosinophilic gastrointestinal disease after achieving informed consent by patient. except for an exacerbation of symptoms occurred months after starting the therapy, when a further endoscopy, showing a gastrointestinal eosinophilic infiltration> hpf, was performed, a significant improvement of both gastrointestinal and cutaneous symptoms was observed during therapy, together with a normalization of laboratory parameters. after months a clinical remission of disease was obtained and administration was stopped. although a histological remission during the first few months of treatment was not obtained, in a subset of aeg patients, ige plays a role in the pathophysiology of the disease and that anti-ige therapy with omalizumab may result in disease remission. | fullerene c reduces the allergic inflammation in food allergy mouse model background: a food allergy (fa) is an abnormal immune response to food. the signs and symptoms may range from mild to severe. they may include itchiness, swelling of the tongue, vomiting, diarrhea, hives, trouble breathing, or low blood pressure. food allergy is becoming increasingly common. fullerene c has the unique electronic properties making it an attractive candidate for allergic diseases therapy. the main purpose of our research was to assess therapeutic effect of fullerene c in a mouse model of fa. method: new efficient method for producing a water-soluble fullerene c has been developed. fa experimental model was induced in balb/c mice by the intragastrical (ig) ova administration after subcutaneous (sc) sensitization. fullerene c was administrated ig once a week, or twice a week, or daily. ova-specific antibodies were assessed by elisa. splenocytes cytokine production upon ova in vitro stimulation was detected by elisa. samples of jejunum of the small intestine were removed for histological examination immediately after the last ig allergen administration. results: it was shown that ova-specific ige and il- level were significant decreased in groups treated with water-soluble fullerene c . the greatest effect was observed in mice receiving fullerene c daily. the ifn-gamma level was significantly higher in ig c treated groups. the histologic analysis of jejunum of the small intestine samples showed that c -therapy improved the histologic picture. the greatest effect was observed in mice receiving fullerene c daily too. conclusion: taken together, these results demonstrate that the water-soluble fullerene c exhibits a significant anti-inflammatory effect in a mouse model of fa, and possesses a high therapeutic potential. background: a -year-old male reported eight episodes of anaphylaxis after exercise. all the ingested food eight hours before each episode was analyzed. before each episode, he had always eaten chicken or turkey meat, and he tolerated these foods without exercising. in one of the episodes the patient had taken a tablet of dexketoprofen a few hours before. since several years, he referred chest tightness after eating some fish (emperor, salmon and whiff), however he tolerated others. the patient denied having eaten fish before any of the episodes of anaphylaxis. method: commercial skin prick tests (spts) and prick by prick tests (pp) with all food ingested and fishes were performed. tryptase, total serum ige (ige) and specific ige (sige) (immunocap. thermo-fisher scientific, uppsala, sweden) to the foods involved were determined. a controlled oral provocation test (opt) with dexketoprofen was performed. results: spt was positive to tuna extract ( mm) and negative ( mm) for the rest of fish extracts. it was also negative for chicken meat extract and other foods tested. pps were positive for raw and cooked turkey meat ( mm), raw and cooked tuna ( and mm), raw emperor ( mm), raw and cooked whiff ( and mm) and raw hake ( mm). pps were negative to raw and cooked chicken meat. ige was ui/ml and tryptase . ng/l. sige was slightly positive to hake, cod and chicken meat. dexketoprofen opt was negative. at that moment, we recommended the patient to avoid chicken and turkey, as well as the fishes which he had symptoms with. since then, he has not suffered any new episode of anaphylaxis despite exercising daily. protein extracts from turkey meat, tuna, emperor, salmon, hake and whiff were prepared and analyzed by sds-page. conclusion: recently, triosephosphate-isomerase ( kda) has been identified as a new chicken meat allergen. this allergen could be responsible for the cross-reactivity between bird and fish meat and the episodes of anaphylaxis after exercise in our patient. the triosephosphate-isomerase has not been implicated previously as a cross-reactive allergen involved in the fish-chicken syndrome. results: twenty-three patients were included, % male, median age years (iqr . ), % atopic, % asthmatic. non-specific lipid transfer proteins (nsltp) were implicated in % (n = ) and ω- -gliadin in % (n = ). eighteen ( %) patients referred anaphylaxis in the reaction with co-factor, ( %) urticaria/angioedema, had both depending on the co-factor. all patients in which ω- -gliadin was the allergen involved had anaphylaxis in the presence of co-factor, with tolerance to wheat without it. in patients in which nsltp was the allergen involved, ( %) had anaphylaxis in the presence of co-factor. reaction with co-factor was more severe than without in ( %) patients; patients had no previous history of reaction and subsequently tolerated the culprit food. only patient had anaphylaxis in the absence of co-factor; the remaining presented oral allergy syndrome and/or urticaria. exercise was the main co-factor, present in patients. nonsteroidal anti-inflammatory drugs (nsaids) were the only co-factor in patients; all of them had anaphylaxis, with allergy to ω- -gliadin, to nsltps. all subsequently tolerated the nsaids involved. conclusion: nsltps and ω- -gliadin were the most frequently involved allergens in cefa, with exercise being the most frequent co-factor. nsaids were relevant co-factors, even when ω- -gliadin was the allergen involved. several patients subsequently tolerated culprit foods and nsaids, difficulting the diagnosis and further emphasizing the importance of a correct cofactor evaluation. molecular allergens had an important role in the diagnosis, avoiding unnecessary ofc. information about co-factors must be included in all patients with allergy to nsltps and ω- -gliadin. | allergy to wheat-dependent exerciseinduced anaphylaxis (wdeia) proteins, without? -gliadins as responsible ferreira a ; castillo m ; martins s ; pineda f unidade de imunoalergologia hospital das forças armadas., lisbon, portugal; departamento de aplicaciones. diater laboratorios, madrid, spain background: the second well-characterized form of allergy to wheat proteins is wheat-dependent exercise-induced anaphylaxis (wdeia), with the ω -gliadins (part of the gluten protein fraction) being the major group of proteins which are responsible, but other forms of food allergy have also been reported, with the proteins responsible including gluten proteins, cm proteins and non-specific lipid transfer proteins. the patient was a -year-old man who visited the hospital with acute urticaria just eat bread before run ( minutes). according the components of bread. it was formed by a mixture of wheat, rye and barley. with a history (for several years) of episodes of severe urticaria after intake a mixture of cereals and/or different kinds of beer. results: prick test and specific ige with wheat, rye and barley were negative and the proteins from allergenic extract from these cereals, and also the gliadins and glutenins fractions were transferred onto a pvdf membrane to carried out a western blot technique with the patient's serum. the patient's serum recognized several proteins from wheat and millet gliadins not compatible in molecular mass with a ω -gliadins. the association of w gliadin as responsible for the symptoms produced after the intake of products containing wheat and exercise is well referenced but in the case of this patient could have other proteins involved as triggers of their symptoms. suksawat y phramongkutklao hospital, bangkok, thailand background: food-dependent, exercise induced anaphylaxis (fdeia) is an anaphylactic condition that develops in patients who ingest specific food followed by exercise. a variety of foods have been described to be the cause including shellfish, wheat and vegetables. the mechanisms of fdeia is believed that exercise increases allergen absorption or decreases threshold of mast cell. the investigations such as skin prick test or specific ige for food are useful because food sensitization is demonstrated. however, a challenge test including ingestion of suspected food followed by exercise is the only method to diagnose this disease. we report a case of fdeia in a -year-old adolescent male. result: he presented with generalized urticaria and hypotension after eating a barbecue buffet which was one hour followed by playing taekwondo. after treatment with intramuscular adrenaline, antihistamine and systemic steroid, his condition was improved. the barbecue buffet consists of many kinds of food including shrimp, squid, salmon and pork meat which were previously tolerated. he had no past history of anaphylaxis or drug allergy. he was referred to our allergy unit for investigation. we performed skin prick test with food allergens and many kinds of fresh foods that he ate on that day and the result was positive to shrimp ( mm. in diameter). three-day challenge protocol was set up a month after recovery and we used aspirin as a cofactor. on the first day, open challenge for gram of shrimp was administered and the result was negative. on the second day, exercise challenge test based on the american thoracic society guideline was also negative. however, on the last day, he developed generalized urticaria five minutes after the same exercise challenge test which was hour preceded by aspirin intake and gram of shrimp ingestion. but his vital signs appeared to be stable. the patient was administered intramuscular adrenaline and antihistamine with full recovery. he was strongly advised to avoid shrimp for - hours before exercise and carry an adrenaline autoinjector. the-three day challenge protocol is a definite tool to confirm the diagnosis of fdeia. a correct diagnosis is important to avoid unnecessary restricted diet. | food dependent exercise induced anaphylaxis in peach allergic patient-case report consumption of different types of food (pancakes with cream cheese and fruit, peach, chinese dish, sandwiches-all eaten on other occasions without symptoms) and co-occurring physical exercise (dancing, shopping, walking). during diagnosis we performed spt with inhaled and food allergens (allergopharma), prick by prick tests with peach, banana, apple, pear and bread. we established the concentration of allergen specific ige (peach, wheat flour, peanuts, hazelnuts) and the level of ige specific to allergen components (immunocap isac). we performed exercise provocation test and open food challenge with peach. results: spt were negative with all tested food and inhaled allergens (inc.egg; milk; cocoa; tomato; carp; apple; banana; strawberry; rye flour; wheat flour; peanuts; hazelnut; citrus, d. farinae; d. pteronyssinus; grass; weeds; clad. herbarium; alt. tenuis; dog; cat; poplar; hazel; alder; birch; mugwort). prick by prick tests were positive with fresh peach. concentration of peach specific ige was . ku/l. in immunocap isac we found elevated levels of ige specific to ltps from different allergen sources (jug r - . ; pru p - . ; pla a - . ; tri a - . [isu-e]). open food challenge with a medium size peach was negative. exercise provocation test without allergen exposition was negative. exercise provocation test after eating a medium size peach concluded with severe lip and eyelids edema, followed by whizzing, dyspnea and urticarial. patient received adrenaline . mg im, steroids and antihistamines with good clinical effect. conclusion: patient was diagnosed with food dependent exercise induced anaphylaxis (fdeia) due to ltp allergy. she was advised to eat peeled fruit and vegetables, avoid cofactors of allergic diseases and carry rescue set (adrenaline, steroids and antihistamines). cases reports: we report case of fdeia and cases of wdeia. case : -year-old woman with intermittent severe allergic rhinitis and food allergies since childhood. in the last years she registered weekly episodes of fdeia (urticaria, angioedema, wheeze, drop of bp) especially when during effort and after alcohol intake. prick tests were positive for grass pollen, mugworth, ragweed, dust mites, celery, soy, sesame, pistachio, mango, honey and shellfish. she followed years of subcutaneous immunotherapy for grasses pollen. the fdeia episodes frequency and severity diminished during it. provocation test for celery and mango were positive, for alcohol, soy, sesame, pistachio, honey and shellfish were negative. case : -year old man with a -year history of acute gluten induced urticaria, recently developed episodes of wdeia (flushing, severe urticaria and angioedema, wheeze) when he went for gym. skin test was highly positive for wheat flour and dust mites, in vitro tests for omega gliadin and wheat-specific ige were positive. food challenge for wheat was positive. he followed oral immunotherapy for wheat. the wdeia episodes were rare and mild. case : -years old female with mild allergic rhinitis and controlled asthma, with wdeia (urticaria, angioedema, wheeze, drop of bp) in the last years. skin tests showed positive results for wheat flour, dust mites and dog hair. omega- gliadin and wheat specific ige were high, but the provocation test for wheat was negative meanwhile combined wheat and effort provocation test was positive. -year-old female athlete, otherwise healthy, experienced three episodes of fdeia following running sessions. two reactions were preceded by intake of salad containing lettuce, tomato and sunflower seeds and the third one occurred after eating celery salad. the patient denied occurrence of any symptoms with physical exertion or food ingestion alone. physical examination and blood testing did not reveal any abnormalities. the differential diagnosis was performed. in skin prick test and specific serum ige antibodies sensitization to house dust mite, grass and mugwort were found. the spt and specific ige assay to culprit and most common food allergens were negative. the molecular diagnostic has been applied (faber, caam, rome, italy). the test scored positive for art v, blo t, der f, der p, eur m, lol p, phl p. no positive results for available food molecules including celery, tomato, sunflower seeds and lettuce were found. the detection of culprit food in fdeia is of crucial meaning as the syndrome can be life-threatening. the molecular diagnostic has been applied already in diagnosis of wheat-dependent exercise-induced anaphylaxis (wdeia) proving ω- -gliadin sensitization in the majority of the cases. as the presented case did not reveal sensitization to culprit food in traditional allergy tests the molecular diagnostic was performed. this test did not show sensitization to culprit food either. however, not all of the molecules are available in molecular assays yet. cross-reactivity reaction to mugwort and grass has to be considered. the pathophysiological components of physical exertion has to be taken into consideration as well. this could contribute to the assessment of reasonability of molecular approach in diagnostic work-up for fdeia and to the establishment of standardized protocols for diagnosis and management of that syndrome. case report: food allergy to wheat is rare in adults, often reported in exercise-induced anaphylaxis. food-dependent exercise-induced anaphylaxis (fdeia) is a form of food allergy induced by exercise. fdeia symptoms can include urticaria/angioedema, respiratory and gastrointestinal manifestations and hypotension/shock. a -year-old male patient presented to the emergency department, was admitted after an episode of hives, hypotension and loss of consciousness. his consciousness was restored after treatment with epinephrine, glucocorticoids as well as fluids, and thereafter, the patient reported that the anaphylactic episode occurred when he started rapidly walking hour after eating a slice of pizza. he mentioned that the offended food was tolerated always when it was not followed by a physical exercise. review of his past medical history and family one were non-contributory with respect to this episode. the allergy skin prick testing for common foods revealed a positive response only to wheat, while and other laboratory test values were within normal ranges. the patient is discharged after instructions on the use of epinephrine auto-injector. he was also advised to avoid wheat containing products up to hours prior to physical exercise. our case demonstrated that fdeia can be characterized by the onset of anaphylaxis soon after physical exercise, when preceded by the ingestion of the responsible food. avoidance of the combination of the exposure to respective allergen and exercise is the most efficient precautive measure toward subsequent fdeia episodes. | residual exercise-induced allergic reactions after successful rush oral immunotherapies for milk and wheat method: we conducted roit for children (median . years old) with milk allergy and children (median . years old) with wheat allergy during - . after - days of the rush phase in the hospital and a slow-increasing phase at home, patients consumed the maintenance dose ( . g milk protein or g wheat protein). after at least three months of the maintenance phase without allergic symptoms, we conducted an exercise provocation test (ept) after eating the target food. if the ept was positive, we repeated it after a couple of years to check for remission. the presence or absence of eiars was based primarily on the results of epts but also on the clinical history in some cases. results: as of december , milk-and wheat-allergic patients were able to continue ingesting the maintenance dose (desensitization). in these patients, milk-and wheat-allergic patients underwent the first ept at a median of ( - ) days after roit, and the result was positive in ( . %) and ( . %) patients, respectively. among these ept-positive patients, milk-and wheat-allergic patients conducted a second ept at a median of ( - ) days after the first ept. the result of the second ept was positive in milk-and wheat-allergic patients. in addition, clinical histories of eiars were subsequently observed in milk-and wheat-allergic patients after negative results on an ept. altogether, ( . %) milk-and ( . %) wheat-allergic patients still had eiars even after getting desensitization as of december conclusion: patients with persistent milk and wheat allergy often have residual eairs even after three to five years of desensitization due to the administration of successful roit. abstracts | | anaphylaxis caused by omega- -gliadin initially diagnosed as idiopathic anaphylaxis: a case report tziotou m ; syrigos k ; syrigou e ; sinaniotis a department of allergy,, athens, greece; gpp,, athens, greece case report: we report the case of a -year-old man who experienced two episodes of wheat dependent exercise induced anaphylaxis, initially diagnosed as idiopathic anaphylaxis. first episode: the patient woke up in the morning and drove to his resort. while driving, he ate a piece of cheese and ham pie. when he arrived, he walked some meters to the garden and started feeling pruritus and dizziness. he lost consciousness and recovered by himself. he was carried to hospital where his vital signs were normal. the patient has a history of atrial fibrillation and has been on flecainide bid and aspirin at noon for the last four years. a month after the first episode he visited an allergist. skin prick tests to aeroallergens and prick to prick tests to the ingredients of the pie were negative. tryptase levels were within normal limits and skin biopsy was negative for mastocytosis. an endocrinology workup was also negative. the patient was prescribed an epinephrine autoinjector and was asymptomatic for eight months. second episode: that morning he had a cup of milk and two slices of toast for breakfast and started working in the garden. two hours later he experienced pruritus and urticaria and fell unconscious. his wife had to administer two epinephrine autoinjectors before he regained consciousness. after the second episode it was decided to start treatment with omalizumab. two months later he experienced an episode of urticaria while working in the garden. he could not recall what he had eaten before. based on history, we thought that a cofactor might contribute to the occurrence of anaphylaxis. we performed skin prick tests with peach (ltp) and gliadin, allergens associated with food dependent exercise induced anaphylaxis in our region. the test to gliadin was positive. specific ige in serum to omega- -gliadin was also positive, while specific iges to all ltps tested were negative. the patient was advised to avoid wheat and has been asymptomatic ever since. cases diagnosed with idiopathic anaphylaxis may actually be cases in which the culprit allergen has not been identified. detailed history and extensive workup may contribute to the successful management of these patients. written informed consent has been obtained from the patient. | wheat-dependent exercise-induced anaphylaxis (wdeia) and nsaids: clinical history is crucial conclusions :we present a case clinically compatible with wdeia with nsaids intake as augmenting factor. this case emphasizes that a carefully and thoroughly taken medical history is of crucial importance, otherwise wdeia can easily be unrecognized. as a result, non-allergic hyperreactivity to nsaids could be excluded and the diagnose of selective allergy to arylpropionic acids was made. exercise challenge test could not be performed in our case. case report: kounis syndrome (ks) has been defined as an acute coronary syndrome that manifests as unstable vasospastic or non-vasospastic angina, and even as acute myocardial infarction. it is triggered by the release of inflammatory mediators following an allergic insult. a -year-old woman with type ii diabetes and hypertension, and unstable angina pectoris as cardiovascular risk factors, has consumed chamomile tea. thirty minutes later, she developed generalized itching, skin rash, swelling of the face and the throat, chest tightness, dyspnea and syncope. the patient was transferred immediately to the emergency department, and sodium chloride, mg prednisolone, mg dexamethasone, mg methylprednisolone, ui heparin, mg voltaren were intravenously administered along the subsequent minutes under simultaneous treatment with oxygen therapy. an ekg examination is performed based on the patient disease's history, showing a . - mm st-depression on d -d leads, mm on v , and . mm on the v -v ones. in addition, . mm st-elevation on the avr and mm on the v derivation was observed, associated by a negative t-wave on the v , v , and avr leads. blood tests revealed a normal troponin i level (of . ng/ml). five hours later in the ekg was noticed: isolined st-segments, and negative t waves on the d , avr, and v leads. ultrasound examination revealed normal heart kinetics and function. following the heart changes, the patient was administered sol. heparin ui twice i.v., nebivolol mg, plavix mg, atorvastatin mg, abstracts | monocinque mg, ordinary insulin ui s.c., glargine insulin ui s.c., and sol. furosemide mg i.v. the patient progressed favorably, and four days after the anaphylactic episode the ekg revealed a . mm st-depression on leads v , and v , negative t-wave on avl lead, and normalized one on the v one. this case emphasizes the role of serious allergic reactions as cause of acute coronary syndrome in patients with altered coronary arteries and food intake as cause of kounis syndrome. | recall urticaria in two young patients with alpha-gal-syndrome after tick bites case report: patient a (m, age ) had suffered from - anaphylactic reactions (hives, nausea, dyspnea and dizziness) within the past months. all episodes occurred - hours after ingestion of red meat, once with alcohol as a co-factor. all episodes started with a wheal measuring about . cm in exact the same spot where he had been bitten by a tick one year before. specific ige to galactose-alpha- , -galactose (alpha-gal) was positive ( . ku/l). skin prick testing using raw pork kidney suspension and intradermal testing with gelafundin ® % diluted : also showed positive reactions. we performed an oral challenge with cooked pork kidney under careful monitoring being able to reproduce the recall urticaria as described above with a cumulative dose of g pork kidney. we stopped the challenge and treated the patient with antihistamines and corticosteroids. patient b (m, age ) reported on several anaphylactic reactions within the past years with symptoms including abdominal pain, diarrhea, as well as dyspnea and loss of consciousness in one of the episodes. all episodes occurred several hours after ingesting food. furthermore the patient remembered a tick bite about years before the first anaphylactic reaction, which repeatedly became inflamed and only healed completely over months. every episode started with pruritus and a wheal in the area of the former tick bite (in loco). specific ige to galactose-alpha- , -galactose was positive ( . ku/l) as well as the skin prick testing with cooked pork kidney and intradermal testing with gelafundin ® % diluted : . this patient refused performance of oral challenge tests. an elimination diet of red meat for months resulted in the absence of the symptoms as described. the diagnosis of alpha-gal-syndrome with recall urticaria in loco was made in both cases. this symptom may also be useful in evaluating results of oral challenge tests as well as an important clinical sign in medical history. pali-schöll i ; meinlschmidt p ; purschke b ; hofstetter g ; einhorn l ; mothes-luksch n ; jensen-jarolim e ; jäger h background: insects have gained interest as alternative nutrient source for humans and animals. however, being a "novel food" in the industrialized part of the world, several safety aspects, like allergenicity, need to be thoroughly addressed. in the present work we evaluated the cross-recognition of ige from patients allergic to crustaceans, house dust mite or stable flies, using house cricket acheta domesticus (ad), desert locust schistocerca gregaria (sg) and mealworm tenebrio molitor (tm). we further investigated changes of immune-recognition in terms of ige-binding in differently processed insect extracts. method: migratory locust locusta migratoria (lm) was subjected to different extraction methods, enzymatic hydrolysis or thermal processing, whereas tm larvae (tml) were evaluated after different centrifugation modes and ph levels. results: we revealed that ige from patients with crustacean allergy shows cross-recognition of acheta domesticus, schistocerca gregaria and stable flies. ige from house dust mite allergic individuals binds to acheta domesticus and schistocerca gregaria. importantly, the cross-reactivity to lm can be deleted by enzymatic hydrolysis with different enzymes or heat treatment (cooking, autoclaving), but not by different extraction methods. changes of ph and varying centrifugation steps are not sufficient to reduce ige-binding to tml. our results show that patients allergic to crustaceans, house dust mite or stable flies-allergic patients cross-recognize desert locust and house cricket proteins, and crustacean-allergic patients also flies proteins. furthermore, we confirm that the appropriate food processing method of insect proteins can reduce the risk of cross-reactivity for crustaceans-and house dust mite-allergic patients. the study was supported by the austrian science fund fwf (grant sfb f -b to ejj). results: the mean age at diagnosis was years in children and years in adults, more frequent in males ( : ). in the pediatric group, three had first-degree relatives with eoe and three had celiac disease. two children had performed milk oral immunotherapy and five adults aeroallergens subcutaneous immunotherapy. most of them were atopics with sensitization to aeroallergens ( . % of children and . % of adults) and food allergens ( % of children and . % of adults), without statistically significant differences. the most frequent foods were fruits and nuts in both groups. we found significant statistical differences in fruits ( % of children abstracts | and . % of adults; p = . ) and cereals sensitization ( % of children and . % of adults; p < . ). in the clinical presentation we observed significant statistical differences in impaction ( . % of children and . % of adults; p < . ), dysphagia ( . % of children and . % of adults; p < . ) and abdominal pain ( % of children and . % of adults; p = . ). in the endoscopic findings children had more frequently exudates ( . %; p < . ) and adults had esophageal trachealization ( %; p < . ). significant statistical differences were found in the treatment with topical corticosteroids ( % of children and . % of adults; p < . ) obtaining a variable positive response. . % of patients in both groups received food elimination diet, % with four or more foods. conclusion: eoe presents differences in the sensitization profile, clinical manifestations and endoscopic findings according to the age of presentation. the response to pharmacological treatment is variable and a high percentage of patients receive food elimination diets. it is a pathology difficult to control, therefore new non-invasive techniques would be useful in order to facilitate its management. | modulation of gut microbiota in patients with nickel allergy and ibs after diet and probiotics supplementation mb ; garcía-figueroa be department of allergy department of allergy fang l united states | bcx improves health-related quality of life in hereditary angioedema with c -inhibitor deficiency bygum a fang l former yugoslav republic of; division of clinical immunology huissoon a bygum a ; panovska vg united states callejas fdb alobid i ; muñoz-cano r izquierdo i icahn school of medicine at mount sinai method: the case report form was developed by experienced allergists, and the web-based registry was established in cooperation with a professional medical software team. twenty-two departments from hospitals took part during the first year %), whereas in adults, drugs ( . %) were more common than foods ( . %). the most common food triggers were eggs ( . %), milk ( . %), and walnut ( . %) in children, and shrimps ( . %), wheat ( . %), and crab ( . %) in adults. among drug triggers in adults, antibiotics ( . %) were the most common cause followed by nsaids ( . %), and h -blockers ( . %). the onset time was≤ minutes in . %. in children, home was the place of occurrence in more than half of the cases, whereas adults experienced anaphylaxis in out-of-home settings more often than children. cofactors were present in %. among the cases registered via the emergency department of participating hospitals, epinephrine was administered in . % ( . % in adults, . % in children) and the route of administration was im in . %, iv in . %, both im and iv in . %, and subcutaneous in . %. the number of epinephrine administration was single in % conclusion: this multicenter prospective registry would provide a better understanding of anaphylaxis, and provide visionary modalities to improve the management and prevention of anaphylaxis in future a case of kounis syndrome after chamomile tea consumption characterized by symptoms related to esophageal dysfunction and esophageal mucosal infiltration by eosinophils objective: characterize patients (pts) with eoe diagnosis and analyze the differences between pts with diagnosis at pediatric (ch, < years old) and adult age epicutaneous tests(epict)], serum total ige and eos, findings in upper digestive endoscopy (ude) and biopsies. the correlation between food sensitization, clinical severity (visits to er services or hospitalization due to complications of eoe, sclin) or severe histology results: pts ( % male, average age ± years) ad and , respectively. % ch and % ad were atopics. the most frequent symptoms of eoe were dysphagia ( %) and gastroesophageal reflux( %) in ch; impaction( %) and dysphagia( %) in ad. % ch and % ad had aeroallergens sensitization. % ch and % ad had food sensitization. the most frequent positive tests were for ch: spt to milk( %) and shellfish( %), epict to shellfish( %) and meat( %); for ad: spt to milk( %), fresh fruits and nuts both %), epict to shellfish( %) and meat( %). ude showed: % striation and white plaques in % ch shist ( %) was associated with sclin ( %), p = . in ch; but this was not observed in ad group there was no correlation between food sensitization and sclin or shist in both groups(p > . ). the average values of serum total ige (kua/l) were in ch and in ad; eos were and , respectively in ch and ad allergy unit-fondazione policlinico universitario a. gemelli, università cattolica del sacro cuore conclusion: ltp with a fixed dose ( iu in ml) of ready-touse shp led to fewer severe attacks, a higher proportion of attack-free patients, and a clinically meaningful and statistically significant reduction in cumulative attack severity and daily severity in hae patients relative to placebo. background: c -inh-hae is a rare, potentially life-threatening disease characterized by episodes of subcutaneous and/or submucosal swelling. apex- was a phase , double-blind, placebo-controlled study to evaluate the prevention of attacks with bcx , a once daily oral kallikrein inhibitor, in patients with c -inh-hae.method: patients with c -inh-hae with a history of at least hae attacks per month were randomized to receive four different doses of bcx ( mg, mg, mg, . mg) or placebo for days. blood samples for bcx concentrations and kallikrein inhibition were obtained from patients before dosing and for hours post-dose on day . pk analyses and pk-pd modeling were done in phoenix winnonlin v . and sas v . . the pk population included , , , and subjects in the mg, mg, mg, and . mg groups respectively.after daily dosing achieved steady state, c max was reached at a median of - hours after dosing. there was a greater than dose proportional increase in exposure (auc tau and c max ) over the . -mg to -mg dose range, with an approximate -fold increase in exposure with a . -fold increase in dose. at doses ≥ mg, which showed statistically significant and clinically meaningful reductions in hae attack rates, geometric mean plasma trough concentrations (c tau ) were maintained at or above the minimum target concentration ( -fold ec ) estimated to be required for adequate plasma kallikrein inhibition. percentages of study subjects at steady-state with bcx plasma concentrations> -fold ec were %, %, % and % in the . , , , and mg dose groups, respectively. a -mg dose provided a mean c tau of slightly above . fold ec , with a corresponding reduction in hae attack rate of % (p < . ) compared with placebo. consistent with the exposure data, a dose dependent inhibition of kallikrein was observed with bcx treatment over the dose range. the drug effect on kallikrein inhibition was highly correlated with exposure (r = . ). in patients with c -inh-hae, bcx treatment at doses ≥ mg resulted in clinically meaningful reductions in the mean weekly hae attack rate. concentrations of bcx at doses ≥ mg were maintained at or above a c tau of -fold the kallikrein inhibition ec in most patients, and kallikrein inhibition was highly correlated with bcx plasma concentrations.background: c -inh-hae is a rare, life-threatening disease characterized by recurrent episodes of subcutaneous and/or submucosal swelling that lead to considerable morbidity and a poor quality of life (qol). apex- was a phase , double-blind, placebo-controlled study to evaluate the prevention of attacks with bcx , a once daily oral kallikrein inhibitor, in patients with c -inh-hae.method: patients with c -inh-hae with at least hae attacks per month were randomized to four different bcx doses ( mg, mg, mg, . mg) or placebo. subject-reported qol assessments were conducted at the start and end of treatment using the disease specific angioedema quality of life (ae-qol) questionnaire that measures domains (function, fatigue, nutrition, fear/ shame) and has minimal clinically important difference (mcid) of points. the changes from baseline in total and domain scores was compared between the treatment and placebo groups. modified angioedema activity score (aas) values across domains (daily activities, appearance, physical discomfort, overall severity) were calculated for each attack and a total score was derived for each subject by summing scores from each attack. total scores were compared to placebo using an ancova model with adjustment for qualifying attack rate. reduction of attacks was statistically significant for all top doses and there was a dose related increase in adverse events.results: in the mg dose group, qol assessed by ae-qol was significantly improved after weeks of treatment compared to placebo for ae-qol total score (- . , p < . ) as well as across all domains (function: - . , p = . ; fatigue: - . , p = . ; fears/shame: - . , p < . ; nutrition: - . , p = . ). all other treatment groups showed a trend towards improvement. qol improved the most in the mg group, and % of subjects in the mg group showed ae-qol reduction of more than points. disease activity as assessed by the aas was significantly reduced in the mg, mg and mg dose groups as compared to placebo, whereas there was no significant reduction in the . mg dose group. results: there were no marked differences in the age, sex, total ige titer, comorbidity of bronchial asthma and atopic dermatitis or the starting dose of rush oit among the groups. all patients in the low-bmfi group achieved ≥ % of the target dose, whereas . % of the middle-bmfi group and % of the high-bmfi group failed to achieve the target dose (p < . ). results: a total of infants were diagnosed with food allergy (ige-mediated and mixed type) at our center during the study period, of these patients underwent prick test for inhalant sensitivity, and ( . % male) of these were younger than years of age. conclusion: sensitivity to inhaled allergen were found in of ( . %) patients with food allergy. therefore, we believe that inhalant sensitivity should be evaluated in these patients. there is also a requirement for further studies to identify the influence of inhaled antigens on the disease activity of patients with allergic conditions. method: in this study, we aimed to perform the metabolic profiling of severe profilin mediated food allergic patients looking for biomarkers that might both, predict the prognosis of the disease and understand the molecular mechanisms of inflammation underneath. other allergic patients (mild and moderate) and non-allergic were recruited in the study as comparative groups. the allergic patients class was predicted using a mathematical algorithm from non-allergic vs severe model results: plasma samples from non-allergic subjects, mild, moderate and severe allergic patients were measured using gas chromatography coupled to mass spectrometry (gc-ms). the samples were from different hospitals in spain covering the areas with the highest pollen exposure. the metabolic profile was composed of metabolites for each sample. results after the statistical analysis showed differences between the groups. firstly, a clear reduction of several abstracts conclusion: we found, as expected, a predominance of males with eoe diagnosis. ch were more frequently atopic and had aeroallergen and food sensitization. impaction and esophageal stenosis were more frequent in ad than ch. shist was associated with sclin only in ch. method: three children with ee, boys aged . - years, were assessed over months to years. results: cases developed in infancy. one had dyspepsia and low weight gain in infancy soon after feeding began. another had symptoms in infancy but not diagnosed until age with dysphagia and esophageal stricture.. the third case was diagnosed at years old after episodes of food impaction in the esophagus beginning at age . all cases had allergic comorbid diseases including atopic dermatitis in all and allergic rhinitis in . skin prick tests were positive to several food allergens (cow's milk, egg protein) in , to dust mite in and to pollens in . serum total ige levels ranged from to iu/ml. eosinophils in peripheral blood were elevated in all , reaching %- %. treatment included restricted diet and topical budesonide - mg daily depending with periodic endoscopic biopsy.in all cases clinical improvement occurred by one month of treatment, with endoscopic confirmation. morphological improvement fol- the study aimed to evaluate the effects of probiotic supplementation, in addition to diet, in ibs and snas patients, in terms of modulation of faecal microbiota population, reduction of gi and cutaneous symptoms, increase of patient's quality of life and modification of gut dysbiosis.method: forty patients aged between and years, affected by ibs, ni sensitization and ltp sensitization were enrolled to evaluate gut dysbiosis. dna extraction method (next generation sequencing) with commercial kit (microbiopassport ® ) was performed on stool samples. ibs patients were divided in two groups, according a gluten free diet prescription or a low fodmaps diet prescription for three months. similarly, (suspected) snas patients (confirmed by % ni sulfate in petrolatum patch test) were prescribed a low ni diet ( μg/kg nickel content during the first four weeks and then up to μg/kg up to three months). two ltp (lipid transfer protein) sensitized patients underwent a ltp free diet.gut dysbiosis was re-assessed after a fixed probiotic supplementation. a sex-age matched group of individuals without history of ibs, snas or any gastrointestinal disease was considered as control.gastrointestinal symptoms were evaluated using the visual analogue scale before and after treatment. conclusion: our preliminary findings suggest that probiotic implementation could be useful in patients with snas on a low-ni diet to increase population diversity, which could contribute to restore the intestinal homoeostatic conditions. key: cord- -ut gczm authors: nan title: education day monday: plenary session monday: parallel sessions date: - - journal: vox sang doi: . /j. - . . .x sha: doc_id: cord_uid: ut gczm nan from the perspective of causal inference, there is a hierarchy of evidence, ranging from case-series to large randomized controlled trials (rcts). in addressing a particular clinical or policy problem, clinicians or policy-makers can base their decisions on the types of clinical reports that have been published, along with an assessment of the strengths and weaknesses of each study. rcts are controlled clinical experiments in which patients are randomly allocated by the investigators to receive a treatment under study. if randomization is used, all participants are equally likely to be allocated to either the treatment or the control arm of the study. rcts should be distinguished from observational studies in which investigators passively observe patients who happen to receive a treatment under study. because the allocation of subjects to the treatment and control arms of an rct is random, the play of chance should distribute all confounding factors equally between these two arms. thus, the treatment and control arms of an rct should be equivalent with respect to all confounding factors except for the treatment under study. randomization removes selection bias, because neither the investigator nor the participant knows what the treatment allocation will be before a patient enters a study. moreover, if an rct is double-blind, observation bias is also removed, because preconceived notions about benefit from the treatment cannot color the reporting of symptoms by a patient or the assessment of disease activity by an investigator. when the undertaking of rcts is deemed unlikely, meta-analyses of individual patient data, that is, of the data recorded previously on subjects enrolled in published, small rcts may allow investigators to address issues of possible biases ed- - standardizing blood components would allow better monitoring of the effectiveness of transfusion d davenport university of michigan, ann arbor, mi, usa in routine transfusion of red blood cells (rbc) or platelet concentrates (pc), we have only a very rough idea of the dose we administer. the minimum expected hemoglobin content of rbc should be g (fda criteria). however, actual measurements have found a mean hemoglobin content of . ± . g per unit, with variability between manufacturers. percent of units may contain less than . g of hemoglobin while percent may contain more than . g. the effect of storage senescence can magnify these differences. the resulting hematocrit increase, depending on size of recipient and age of a unit, may be . to percent. apheresis collection of rbc can help standardized unit contents, but this technology is relatively expensive and time consuming. knowledge of actual hemoglobin content can be used to optimize red cell transfusion. one trial, using a simple formula incorporating the desired hemoglobin and estimated blood volume, showed that nearly percent of transfusion orders could be met with one unit while achieving a mean target hemoglobin of . g/dl. for pc transfusion, about percent of transfusions achieve the targeted dose of - ¥ platelets in actual practice, with considerable variability between institutions. without knowledge of the actual content of pc, determination of refractoriness and response to matched pc is problematic. standardization and labeling of rbc and pc units for content will permit accurate dosage and quantification of transfusion practice. are transfusion guidelines evidence-based? jp aubuchon dartmouth-hitchcock medical center, lebanon, nh, usa application of the results of randomized, controlled clinical trials to similar clinical situations should increase the predictability of the outcomes of transfusions. unfortunately, too few such trials have been conducted to investigate all the potential situations where transfusion might be applied. however, the ones that have been reported indicate that, in general, transfusion is unlikely to provide substantial benefit in many of the situations where it is routinely used. in the intensive care setting, transfusing red cells at a trigger point of g/dl rather than g/dl not only did not lead to increased anemic morbidity but was actually associated with a reduction in overall mortality. subgroup analyses indicated transfusion at the higher trigger point did not decrease morbidity in patients with cardiac disease nor decrease the time until weaning from a ventilator. following cardiac surgery, a transfusion trigger of a hematocrit of % yielded the same outcomes as one of %. an observational study suggested that patients with peripheral vascular disease and a post-operative hematocrit below % were more likely to suffer a morbid cardiac event, but this group of patients had more evidence of anemia and cardiac ischemia preoperatively, illustrating the pitfalls of observational studies. most would agree that transfusion is necessary below a hb of g/dl and unlikely to be necessary at a hb above g/dl, but most patients fall between these limits, and there are insufficient data in the and residual confounding factors, and may permit them to make a judgment of a causal relationship. sackett proposed that the evidence generated from meta-analyses of individual patient data be regarded as being equivalent in strength to that generated from rcts. meta-analysis is the structured and systematic integration of information from different studies of a given problem. when the results of individual studies are discrepant, the purpose of an overview is to investigate reasons for disagreements among studies. when the results are concordant, the goal of meta-analysis is to derive, through application of a number of quantitative techniques, a measure of the effect of the intervention across combined investigations. this measure is referred to as the 'summary' effect of the treatment under study. meta-analysis differs from the traditional, narrative reviews of the literature, in that: ( ) all completed investigations of the efficacy of an intervention that meet specific, eligibility criteria are retrieved and included in the overview; ( ) the quality of retrieved studies is assessed systematically; ( ) the degree of agreement among studies is evaluated, both conceptually and based on statistical criteria, and the synthesis of the findings proceeds only if the variation in reported results is sufficiently modest to be attributed to chance; and ( ) quantitative methods are used to calculate the summary effect of the intervention and to test that effect for statistical significance. ed- - biology of stem cell mobilization th papayannopoulou university of washington, seattle, wa, usa at baseline hematopoiesis, the majority of developing hematopoietic cells (precursors, progenitors and stem cells) is actively retained in bone marrow (bm), whereas fully mature cells emigrate to peripheral circulation. a small number of stem/progenitor cells are also present in blood, serving presumed physiologic roles for the repopulation of remote damaged areas. however, in several hematopoietic perturbations, i.e. post irradiation, post chemotherapy or by using empiric treatments, a heightened emigration (mobilization) of progenitor/stem cells was noted over years ago. the introduction of g-csf as an efficient mobilizing agent not only had a major clinical impact, but has triggered a flurry of studies exploring the mechanisms of mobilization. from these studies, significant insight has been gained about the molecular pathways leading to mobilization, especially by studying the altered environment within bm post mobilization, and less so by studying cells mobilized in blood. several attractive scenarios have been proposed and their importance was further bolstered by studying genetic mouse models. a prominent role of the sdf- /cxcr pathway has been emphasized, either by down regulation of cxcr , changes in sdf- gradients, or by disruption of sdf- /cxcr signaling. whether this pathway is disrupted by a proteolytic mechanism prevailing within bm post g-csf or by other protease-independent mechanisms has not yet been settled. in addition to sdf- /cxcr , disruption of other pathways responsible for the retention of primitive cells in bm can lead to mobilization. for example, disengagement of the vla /vcam- pathway by anti-functional antibodies or its genetic deficiency in mice results in egress of stem/progenitor cells. mobilization is also seen following the use of other cytokines (i.e. kit-l, flt- l, il- ) or chemokines (i.e. il- , gro?), complement activation, etc., but the detailed mechanisms or the interdependence of these other pathways with the ones already proposed have not been worked out. finally, efforts to improve mobilization efficiency in man has led to the use of combination treatments with g-csf, either by adding another cytokine (i.e. growth hormone), agonistic sdf- molecules (i.e. ctce ), or cxcr antagonists (i.e. amd ) which have yielded synergistic increments, and these will be discussed. a full understanding of the principles of mobilization, as well as the bm homing characteristics of mobilized cells after their i.v. infusion in transplantation, should lead to targeted, more efficient experimental protocols in the future. the possibility of deriving all kinds of mature cell types from embryonic stem (es) cells for the purpose of cell replacement therapies will probably face a major obstacle; a limited supply of available hla types for an ever growing population in demand. one possible solution is to use adult sources of stem cells such as the haematopoietic stem cells (hsc) that can repopulate the entire haematopoietic system after transplantation in a myeloablated host. however cells with the repopulating ability of hscs are still elusive for tissues such as muscle, heart, cns and pancreas. it was therefore exciting news when it was shown that hscs could repopulate other non-haematopoietic tissues arguing for a general role of bmderived cells in tissue regeneration. the term plasticity was thus coined to describe the phenomenon whereby cells of one lineage could trans-differentiate into cells of another tissue. this in turn implied that a certain degree of developmental plasticity was still available in the adult hsc, or their derived progeny, that allowed them to present with novel phenotypes. how exactly this was accomplished was a matter of speculation. in order to address the mechanism we used an animal model of liver failure where bmt with normal (wild type, wt) hsc was shown to rescue the liver failure; the repopulating hepatocytes apparently differentiated from the sole source of wt cells, the bm compartment. by studying the genetic composition of the regenerating liver nodules we observed that both wt and mutant dna was present in the nodules, a finding that was consistent with bm-derived cells fusing with host hepatocytes. the mechanism of plasticity was therefore directly related to the exposure of the donor bm-derived wt nucleus to the transcriptional environment of the hepatocyte and the expression of hepatocyte-specific genes. this fusion mechanism was also shown to underlie perceived cases of haematopoietic cell transdifferentiation to purkinje cells in the cerebellum and to cardiomyocytes. however, there are carefully executed studies that strongly support the alternative transdifferentiation mechanism in tissues such as epithelia or the epidermis. what these observations may imply is that in tissues with high rates of cell turnover, there may be a potent stem cell niche that can reprogram incoming cells to follow relevant cell lineages. if this hypothesis is correct, then the major research effort should focus on what makes the niche and whether it can be recreated faithfully in vitro so as to educate hscs to diverse lineages opening the way for realistic cell replacement therapies. collection and distribution of blood and its products to meet the medical needs of industrialized countries are typically managed through large-scale national or nationally-supported blood programs. the development, maintenance, and ultimate success of such programs are all components of a process that involves the delicate balance of continuously competing pressures, e.g. social, economic, ethical, political, regulatory/legislative. as with all endeavors that directly affect human life, safety is a central, unifying theme of this process. because transactions of blood inherently involve risks at both donation and reception/transfusion ends, efforts to enhance and maintain an acceptable level of safety generally rely on a focused program of risk management (rm). rm involves three equally important elements: identification/evaluation of risk factors in a process, control of exposure to them, and continuous monitoring to assess the effectiveness of countermeasures and the emergence of new risk factors. specific approaches to rm and quality assurance in transfusion medicine will be presented. examples from blood programs currently in effect in selected countries will be discussed. rm efforts within the corresponding blood program in greece will then be examined. the lack of data to adequately assess the status of this program suggests that at least one of the elements of rm -monitoring -can still be improved. a preliminary research effort aims to survey blood donors, transfusion recipients, and physicians in order to build an understanding of the specific factors that drive the perception of risk in the greek population. the findings form important stepping points upon which specific recommendations can be made for the development and maintenance of a comprehensive, effective rm program in greece. ed- - the use of haemovigilance data to increase safety in transfusion medicine haemovigilance is a surveillance of all the procedures in the transfusion chain. the intension is to collect and assess information on unexpected or undesirable effects in bleeding of donors and transfusion of blood components. in europe haemovigilance was introduced as a concept in the middle of the nineties. the first national reports on haemovigilance appeared in the late nineties, and were only dealing with complications related to transfusion. later on other kind of events like 'near miss' events were added. nowadays national reports are dealing with all steps in the transfusion line, and to some extend also with complications in blood donors. the state of the art is haemovigilance with retrospective registration of unwanted events that has happened, but also a more active prospective part with an early warning in a rapid alert system about new threats in the transfusion world. the aim of the different national haemovigilance systems has been to improve safety in the transfusion line. after the first years with haemovigilance in the european countries, what has been the outcome of this big effort? data from national reports do not signify major improvements, but safety is suggested to have improved due to many minor changes of procedures and awareness of dangerous situations. however, in most countries nothing really effective has been done to avoid failures, the most important cause of serious complications in transfusion of patients. systems which can prevent most of the failures are on the market. the cost of these equals the cost of nat screening for virus introduced in the same period of time. the common perception of transfusion risks is still much more focused on the hypothetical risk of virus transmission than to the demonstrated magnitude of severe complications related to bleeding of donors and transfusion of patients. therefore, to increase safety in transfusion medicine the nature and occurrence of the risks should be revealed by haemovigilance and not less important the results should be published with the aim to get a realistic common perception of the transfusion risks. the role of diagnostic testing to identify congenital vs acquired disorders of hemostasis and to optimize the management of perioperative bleeding g despotis washington university school of medicine, st louis, mo, usa excessive bleeding with trauma or after surgery can result in hypoperfusion and anemia related end-organ dysfunction and mortality as well as transfusion-related complications. several large studies have demonstrated that if bleeding is excessive after cardiac surgery to the point that reexploration is required, that overall mortality increases by - fold. transfusion related complications include the following potentially lethal complications: disease transmission of pathogens, acute hemolytic reactions, allergic reactions, transfusion associated acute lung injury, allo-immunization related disease (e.g. post-transfusion purpura, platelet refractoriness, transfusion-associated graft-vs-host disease) and other potential complications (e.g. increased perioperative infection or multi-organ system failure) related to transfusion associated immune modulation. in addition, blood shortages related to increasing consumption (i.e. expanding geriatric population) and/or a shrinking supply (i.e. related to exclusion of donors related to donor exclusion criteria designed to prevent disease transmission) may limit our ability to adequately manage our anemic and bleeding patients. this highlights the relative importance of accurate diagnosis and optimal management of excessive bleeding to minimize bleeding related complications and conserve our blood supply. patients at risk for excessive bleeding include those with an established hereditary disorder (e.g. vwd, hemophilia, connective tissue disorders), end-stage hepatic or renal disease as well as patients with acquired defects of the hemostatic system. in specific, patients with platelet (i.e. platelet refractoriness) or coagulation factor inhibitors at increased risk, extracorporeal circulation related defects or as related to certain pharmacologic agents). patients who require longer periods of extracorporeal circulation for cardiac surgical procedures (e.g. repeat, combined procedures or use of deep hypothermic circulatory arrest) are at a greater risk of developing excessive bleeding (e.g. cpb-related abnormalities). in addition, patients receiving one or more longacting anti-thrombotic medications in the immediate preoperative period (e.g. plavix, reopro, low molecular weight heparin etc) are at increased risk for bleeding. clinicians in the past have resorted to empiric and 'shot gun' approaches when managing excessive bleeding due lack of immediate availability of results from laboratory-based coagulation tests. on this basis, the use of point-of-care (poc) tests of hemostatic function to facilitate the optimal management of excessive bleeding, help differentiate between microvascular vs surgical bleeding and reduce transfusion have been investigated. five of six recently published studies have demonstrated that implementation of a standardized approach to manage bleeding (e.g. algorithm) which when coupled with either point-ofcare or laboratory tests of hemostatic function can optimize the management of bleeding and reduce total donor exposures by %. ddavp has bee shown to be beneficial with uremia-induced platelet dysfunction and with type i von willbrand's disease. although previous studies have not been able to conclusively show that ddavp can reduce bleeding and transfusion when administered prophylactically, more recent evidence indicates that this agent may be useful in preventing excessive bleeding when a test (point-of-care) reveals platelet dysfunction. recombinant activated factor vii (rfviia) is licensed for use in bleeding episodes in hemophiliac patients with inhibitors. although, only anecdotal reports and results from small clinical studies have shown that this agent can reverse life-threatening bleeding after major surgery, other reports indicate that there is variability in the effectiveness of rfviia as well as highlight lifethreatening thrombotic complications in a subset of high risk patients (i.e. patients with congenital or acquired thrombotic disorders or systemic activation of the hemostatic system such as with dic or after cardiac surgery). therefore, large clinical trials evaluating the efficacy and safety of rfviia are needed before any widespread use can be recommended. in recent years, molecular methods of blood grouping have become routine diagnostic procedures in many laboratories throughout the world. they have proved especially valuable for the determination of fetal blood groups. the ability to detect rhd in pregnancies where the fetus is at risk from haemolytic disease of the newborn represents a significant advance in obstetric care. furthermore, the occurrence of fetal dna in the mothers' peripheral blood has allowed this diagnostic procedure to be carried out without the risks that accompany amniocentesis (lo ymd. ( ) ann med : - ). determination of the coding sequence of all the genes giving rise to antigens within the blood group systems currently recognised is virtually complete. by correlating the coding sequence of these genes with the phenotype of red cells from individuals with different blood groups it has been possible to infer the molecular bases of most of the antigens comprising each blood group system (daniels gl ( ) human blood groups, nd ed. blackwell science). the polymorphic antigens of most systems other than abo and rh, are defined by single nucleotide substitutions (snps) which effect a single amino acid sequence change in the gene product. numerous methods, both manual and automated, are available to determine snps and these have been applied to the determination of blood groups. useful applications of snps detection methods include, determination of the blood group phenotype of patients who have been transfused recently and still have donor blood in their circulation (rozman p, dove t, gassner c et al. ( ) transfusion : - ), and donor screening to find compatible units for patients with multiple blood group antibodies or for the management of patients with diseases like the haemoglobinopathies who are going to be transfusion-dependent over many years (castilho l, rios m, bianco c et al. ( ) transfusion : - ). other applications of molecular methods include zygosity determination for rhd, determination of the blood group phenotype of patients with a positive direct antiglobulin test, selection of donors with rare blood group phenotypes, and as aids to the solution of complex blood grouping problems in the reference laboratory. the molecular bases of abo and rh antigens are complex and cannot be determined reliably by a single snp. nevertheless, methodologies are available that allow the comprehensive sequence analysis of individual genes and could be applied to abo and rh typing. whether or not this will ever be a cost-effective procedure is a moot point. it is clear that molecular methods are a useful addition to the range of diagnostic procedures available to transfusion medicine practitioners but it is important to remember that methods based on dna analysis determine phenotype by inference and not by direct measurement. the results of molecular tests should be interpreted with this caveat in mind. ed- - the hla system g stavropoulos general hospital 'g. gennimatas', athens, greece since its discovery in the mouse in the major histocompatibility complex (mhc) has become one of the most important region in the vertebrate genome with respect to infection, autoimmunity and transplantation. mhc primary function is to provide protection against pathogens. this is achieved through sophisticated pathways in which mhc class i molecules present endogenous antiges to cd + t cells and class ii molecules present exogenous antigens to cd + t cells. an increasing number of other proteins are being found that support these two pathways; many of these proteins, together with the class iii complement proteins, also map to the mhc. the mhc molecules were originally studied for their ability to cxonfer tolerance (histocompatibility) following tissue grafts or later, organ transplants. nowadays, the success of unrelated hematopoetic cell transplantation is influenced by the degree of mhc compatibility between the donor and patient. thus, for patients who lack matched donors, the rules that govern permissibility of mhc mismatching still need to be identified. for patients with high risk disease who lack matched donors, use of donors with a single mhc mismatch may permit early treatment before disease progression. scientific evidence to fully answer the questions 'when are platelet components clinically effective' and 'what do we really know?' is limited. despite this limitation and the level of uncertainty it generates with regard to treatment options and policies, it is reassuring to note that current prophylactic platelet transfusion protocols -mostly derived from empirical observations collected during the 's and 's -protect oncology patients from clinically relevant bleeding in more than % of thrombocytopenic days spent in hospital or at home, even in aggressive conditions such as leukemia, lymphoma and other severe blood diseases. this evidence seems to justify the prevalent policy of transfusing platelets when the patient's platelet count falls below per microliter (or in 'unstable' patients). this policy is based on positive outcomes of prospective and retrospective studies performed during the 's including some hundred non-surgical patients and on the desire of balancing the will of reducing patient exposure to limited, expensive, potentially infectious and immunogenic blood products with the objective of preventing clinically relevant hemorrhage. several national and international organizations endorse the above policy. although the role of platelet support in surgery or in specific clinical situations requiring invasive procedures or in patients affected by multi-organ and system co-morbidity suffers from even more limited evidence, the latter has been carefully collected and summarized in the guidelines for platelet transfusion published in j clin oncol ; : - . additional data on lumbar puncture are reported in ann hematol ; : - . another important topic where there is room for improvement and need for further investigation is platelet refractoriness, a condition developed by a proportion of chronic platelet recipients, which causes high hemorrhage risk if compatible platelets are not provided and in which consensus on the diagnosis and treatment is lacking. with regard to the type of platelet product, it will be necessary to determine the clinical impact of buffy-coat derived platelets, consistently used in europe and current object of increased interest in canada, as compared to the platelet-rich plasma method traditionally used in the us, of viral inactivation procedures and of laboratory methods for detection of bacterial contamination of platelet concentrates. in addition, ongoing studies on the clinical impact of high versus low platelet doses will provide novel elements to determine the relative merits of apheresis versus whole-blood derived platelets. as far as the established procedure of white cell reduction by filtration, which shows high technical efficiency and has been implemented as a standard by a number of institutions, debate is still ongoing on its equivalence with serologic screening for the prevention of cmv transmission, whereas general consensus supports its pre-storage use to prevent febrile, non hemolytic transfusion reactions. finally, although the high cost of filters do not allow a generalized use of this technology in many settings, white cell reduced platelets have been unequivocally shown to reduce alloimmune refractoriness from about % to about % of patients. ed- - ffp: appraisal of the evidence for the clinical use of ffp although the indications for transfusion of plasma (fresh frozen plasma; ffp) are limited, the use of ffp continues to rise in the united kingdom and has risen by over % in the past few years. local uk audits continue to document that a significant proportion of ffp transfusions are not consistent with indications reported in guidelines. a systematic review of the evidence base for the effectiveness of ffp was therefore undertaken to identify, select and appraise all relevant randomised controlled trials, as the most robust form of study to assess effectiveness of ffp. in the systematic review of ffp, the criteria for inclusion of full-published studies were: there must have been at least two groups in the study; • allocation to the groups must have been either by formal randomisation or by a quasi random method e.g. alternation; • one of the arms of trial must include ffp or plasma as an intervention; results on the relevant clinical or laboratory outcome must be presented. the main analysis was qualitative, and differentiated between: . studies of interventions comparing ffp with no ffp; . studies of interventions comparing ffp with a non-blood product e.g. solutions of colloids and/or crystalloids; . studies of interventions comparing ffp with a different blood product; . studies comparing different formulations of ffp, e.g. solvent detergent and methodine blue treated. an evaluation of studies comparing ffp with no ffp would be expected to provide the clearest direct evidence for a positive effect of ffp. studies comparing ffp with colloids or crystalloids were separately appraised because these latter products may have variable effects on coagulation tests. studies comparing different formulations of ffp do not directly evaluate effectiveness of ffp but were included because there is now a uk national policy to use these products in younger patients and therefore these trials might identify negative outcomes. the search strategy identified a total publications. although it may appear that this number of randomised trials might provide a reasonable evidence base to help inform clinical policy and decision making, the review identified a number of important concerns about the published trials. few of the identified studies included details of the study methodology (method of randomisation, blinding of patients and study personnel). the sample size of many included studies was very small (range - patients per arm). few studies took adequate account of the extent to which adverse events might negate the clinical benefits of treatment with ffp. many of the identified trials in groups such as cardiac, neonatal, and other clinical conditions, evaluated a prophylactic transfusion strategy. however, when these trials evaluating prophylactic usage were assessed together as a single grouping in the review, it appeared there was no consistent support for a beneficial effect of prophylactic ffp, irrespective of clinical setting. there is a pressing need to develop new trials to determine the effectiveness of ffp, including for those clinical situations in which it has become an accepted part of current transfusion practice. a law decided upon by the riksdag (the swedish parliament) often sets the general standards as a framework and authorises the central government authority concerned to elaborate and decide upon the more detailed regulations. laws and regulations define the level of quality and safety that has to be reached and state what must be done, while establishments and their managers are kept responsible for fulfilling the requirements and how this is done. guidelines (non-binding) present detailed instructions on ways how to fulfil the requirements. making a law is complicated and time-consuming. the ministry draws up a legislative proposal, refers the proposal to relevant bodies for consideration and comments, and then drafts a bill which is referred to the council on legislation for consideration before it is submitted to the riksdag. a parliamentary committee deals with the bill before it is put to the chamber of the riksdag for approval. when adopted, the bill becomes law. regulations elaborated by central government authorities are handled in a principally similar way. however, regulations are more readily adjusted to scientific and technical progress, and when legislation need requirements for technical details, these are preferably presented in a regulation. the ministry of health and social affairs is responsible for elaborating the bill to be submitted to the riksdag on the blood safety law. two central government authorities, designated as competent authorities, are responsible for preparing the appropriate complimentary regulations as well as for inspecting and licensing the blood establishments: • the national board of health and welfare (nbhw), responsible for requirements related to blood components intended for transfusion, and • the medical product agency (mpa), responsible for requirements related to blood components intended for the manufacture of medicinal products. sweden became a member of the eu ten years ago. since then, experts in transfusion medicine have been appointed by the ministry, nbhw and mpa for advice on scientific and technical issues and for representing sweden at expert meetings arranged by the commission. some of these experts are also members of the handbook committee of the national society for transfusion medicine, preparing and revising the national guidelines. consequently, the requirements of the directives are readily implemented in the daily work of the blood establishments before (due to legal and technical reasons) the new blood safety law and the revised nbhw and mpa regulations can be promulgated. to a great extent, requirements of the blood directives are covered by existing swedish legislation. no major problems or obstacles seem to arise when implementing new requirements into law and regulations and into the blood establishments' daily service. a few detailed requirements have been found difficult to follow precisely in the routine work. these minor difficulties, however, will not compromise the high quality and safety of blood components prepared according to the standards set by the blood directives. the landscape for blood collection and distribution includes availability and safety. true international availability of blood has not been reached. the landscape of safety has been mountainous, if viewed by the degree of frustration among the transfusion specialists. the reasons for frustration have varied from serological problems to those of transmissible infections, to which no end is in sight. mistrust in the safety of blood taken by others is one reason for lack of international landscape in blood collection and distribution. increasing demands on safety, availability and economy force the health care providers to reorganise blood services. national systems are winning ground. this may make it easier to achieve international collaboration. the council of europe has pioneered in creation of international recommendations for blood collection and distribution. in a european agreement on the exchange of therapeutic substances of human origin, including human blood, was published. its purpose was to make blood available to other parties of the agreement in case of urgent need. many countries ratified the agreement rapidly, some did it first in the nineties. in practice little exchange of blood components has taken place. the council of europe recommendations lack legal power. the european union is different, and it has taken on its agenda activities aiming at improving confidence in the safety of the blood transfusion chain in the community (commission communication ) . the agenda is based on an agreement reached at a high level eu meeting in adare, ireland in . first in the commission agenda was a recommendation on donor selection criteria, given in . then came the european blood directive / /ec, the aim of which is to improve the safety of blood and blood components within the union so that enough mutual trust between member countries can be achieved to make the exchange of blood components possible. being a legally binding document the directive is undoubtedly helpful in reaching a harmonised standard in europe. hopefully the european commission has the resources to follow its implementation. there are concerns, however. the epidemiological differences among the eu member countries and frequent appearance of new infectious agents potentially transmitted by blood make it difficult to foresee that even effective viral inactivation of blood components could totally erase the national differences in donor approval. blood collection and preparation of components are already the same in eu member countries and the directive helps in their further standardisation. there has not been much distribution of blood components internationally, with the exception of export of red cell concentrates to the us from switzerland and the netherlands. the european legislation opens new horizons and widens the european landscape as its purpose is to simplify the crossing of borders between the member states, but before true movement of blood components is achieved more work is needed on the eu commission blood agenda. the eu directive implemented into the legal act for polish blood transfusion service blood transfusion service (bts) in poland is an integral part of the public polish health service. in the country of nearly million people, approximately one million units of blood and plasma are collected every year from voluntary, nonremunarated donors, which is statistically over donations per inhabitants. blood and plasma are collected in strictly appointed centers and no private collection sites are permitted. the legal basis for the activity of polish bts is polish blood transfusion act of nd august which came into force as of january st . this act was then updated in november according to eu directive / /ec and came into force as of january th . this act introduced the principles for organization, collection, processing, storage, transport and quality assurance in bts. it specified -among others -the system of accreditation, haemovigilence, as well as requirements for bts employees. according to this act the polish bts is obliged to monitor and supervise immunohematology testing and transfusion procedures in all hospitals where blood and blood products are transfused. polish bts consists of regional blood transfusion centers (rbtc), one military center and one ministry of internal affairs and administration center as well as the institute of hematology and blood transfusion (ihbt) which acts as supervisor. the rbtcs have a uniform organization structure, uniform quality assurance system and act according to uniform guidelines issued by ihbt. they have two financing sources -the central budget and hospital reimbursement for distributed blood and blood products. the polish blood transfusion act of nd august , in force since january st , has been supplemented by decrees: . procedures for external bts audits; . requirements for donor selection; . requirements and procedures for organization and safe management of blood transfusion in hospitals; . requirements for implementing of national and regional donor registers; . employment criteria for bts personnel; . training requirements for hospital personnel involved in blood and blood product administration; . national, uniform price list for blood and blood products; . organization requirements for setting up of a national committee for blood and blood transfusion. introduction: several technical aspects must be considered in pediatric apheresis due to the size of the patient. factors that must be evaluated are extracorporeal circuit volume, blood flow rates, type of anticoagulant and vascular access. adverse events are mainly related either to vascular access or to metabolic or hemodynamic changes. aim of the study: in this study we show our experience using fresenius hemocare com.tec for pbsc collection in children. methods: twelve pediatric patients (median age years, range - ; median weight kg, range . - . kg) with solid tumors at onset or on relapse underwent collections with the p y kit of the fresenius hemocare com.tec blood cell separator. our cd + cells target was ¥ e /kg. collections were started if a peak of at least . e /l cd + cells ( per microlitre) were reached in the peripheral blood. in all the patients, leukapheresis were performed through a central venous catheter and temporary peripheral venous access. acd ratio : - : was combined with heparin u/kg. in children with < kg the separator was initialized with a compatible filtered and irradiated red blood cell unit, suspended in % albumin, up to the patient's hematocrit, to avoid transient hypovolemia, due to the volume sequestered in the separator. results: twenty-five procedures were performed. a median blood volume of ml (range . - . ml) was processed in a separation time of min (range - min). the median product weight was g (range - g) and yield of cd + cells was . ¥ e /kg body weight (range . - . ¥ e /kg body weight). three poor mobilizing patients (peripheral blood cd + peak of - cells per microlitre) underwent more than two apheresis to collect the desired transplantation dose ( . and ). all collection procedures were well tolerated. children never required sedation to perform the leukapheresis. only mild hypocalcemia-related symptoms, promptly responding to small i.v. boluses of calcium gluconate, were reported. no circulatory side effects were observed. blood flow alarms occurred in every procedures but no collection had to be terminated due to insufficient flow. conclusion: in summary, leukapheresis in children can be safely and effectively performed with the fresenius hemocare com.tec separator with minimal technical difficulties even in patients under kg. m-pa- alternative methods for prevention of infection transmission (pathogen inactivation etc.), cost-benefit considerations of the procedure itself. however, one must also take the loss of plasma into consideration -and more difficult: calculate the effects of changes in product quality, as reduced content of factor viii, protein s and other labile proteins. for methods involving pooling, there are also concerns about the risks due to the pool sizes. the major benefit of the methods will be the potential reduction of infectious transmission, but also possible advantages as reduction of allergic transfusion reactions and trali must be evaluated. the study types involved in cost-benefit considerations are costeffectiveness analysis where the cost and effects of an intervention and an alternative are presented in a ratio of incremental cost to incremental effect and cost-utility analysis, where quality-adjusted life years (qaly) are used as the effectiveness endpoint. qualityadjusted life years is a method that assigns a preference weight to each health state and estimates life-expectancy as the sum of these products of each preference weight and time spent for each state. a complete glossary of terms is found at http://www.hsph.harvard.edu/cearegistry. in literature, there are several publications on cost-benefit considerations within the field of transfusion medicine. concerning plasma products, the costeffectiveness of solvent-detergent plasma has been the major focus. however, the conclusions of different authors have been conflicting. in , aubuchon and birkmeyer published a paper (jama ; ( ) : - ) where they concluded that the cost was usd per qaly, which is far above the 'acceptable limit' of usd . this estimate was adjusted to usd . mill. per qaly in a letter to jama (jackson, jama ). in , riedler et al. published (vox sang : - ) that the discounted cost/life year saved for sd-ffp use in the uk was gbp for neonates and gbp for patients aged . the main reason for the differences between the two papers (and others) was considered to be different calculation of non-infectious complications. the papers cited above underline the difficulties of the cost-benefit considerations. the age of the patient, the outcome of the treatment, the quality of life in an infected patient and the cost of side effects will differ. in addition, how much are we willing to pay for protection against emerging viruses? this paper will not provide the answers, but introduction: the photodynamic treatment of therapeutic plasma using methylene blue (mb) in combination with visible light is a well established procedure for the inactivation of blood borne viruses. aim of the study: evaluation of the quality and stability of mb/light-treated plasma (mb plasma) prepared under worst case conditions for routine processing. methods: single donor units (n = ) were treated using the macopharma theraflex mb-plasma system which includes plasma membrane filtration (plas ) and addition of mb prior to illumination followed by mb and photoproduct filtration (blueflex). samples were taken before treatment and from the final product. additionally mb-treated plasma was prepared from four different plasma pools and stored for up to months. treatment was done under worst case conditions for the preservation of coagulation factors: maximum mb concentration during illumination ( . mmol/l), maximum storage time of whole blood before separation ( °c, h), maximum storage time of mb plasma before freezing ( h). several plasma parameters and the concentration of mb and its photoproducts (azure a, azure b, azure c and thionine) were determined. results: mb/light treatment had a significant influence on thrombin time (+ . %), fibrinogen (clauss) (- . %), factor v (- . %), factor viii (- . %), factor xi (- . %) and protein c (- . %). no significant changes were detected for at iii, vwf : rco, vwf cleaving protease, plasmin inhibitor and alpha- -antitrypsin. the entire virus inactivation procedure including the filtration steps for leukocyte depletion and mb and photoproduct depletion had no significant effect on activation markers (prothrombin fragment + , thrombin-antithrombin-complex, d-dimers). no further essential loss of coagulation factor activity was observed during storage of the plasma at °c for months. mb and its photoproducts (azure a, azure b, azure c) were depleted to a final concentration of < . mmol/l. thionine was undetectable in all samples. conclusion: photodynamic treatment of fresh frozen plasma (ffp) using the theraflex mb-plasma system leads to only moderate decreases in the activities of different coagulation factors even under worst case conditions for routine production. mb and its photoproducts were effectively removed from the plasma by the blue-flex-filter integrated in the theraflex-system. the quality of mb plasma is well preserved during storage. pulmonary complications, particularly transfusion-related acute lung injury and circulatory overload, are the most common causes of transfusion-associated morbidity and mortality in the developed world. trali is a syndrome characterized by acute respiratory distress, hypoxemia, hypotension and pulmonary edema, occurring within hours (usually - hours) of transfusion of a plasmacontaining blood product. other signs, including hypertension, leucopenia and hypocomplementemia, are less frequent. all blood products, except for albumin and solvent/detergent plasma, have been associated with trali, but red blood cells, platelets and ffp are the most common. the incidence is unknown, but : plasma-containing transfusions is the most commonly cited figure. in % of patients, recovery is well underway within hours, and leads to complete resolution. death occurs in - %. the profile of the at-risk recipient has not been identified. recurrent cases have been infrequently described. there are two prevailing theories of pathogenesis: ( ) antibody-mediated and ( ) -hit hypothesis. evidence supports both concepts and neither is mutually exclusive. more than % of reported cases are associated with blood components containing either hla-specific (class i or ii) or hnaspecific antibodies. in % these antibodies correspond to at least one epitope in the recipient. most implicated components are donated by multiparous women. five percent of patients have hla or hna antibodies in their pre-transfusion serum. treatment requires prompt, assertive respiratory intervention, frequently necessitating mechanical ventilation. because trali has a much better prognosis than ards, it is an important diagnosis. some blood collectors are diverting plasma from multiparous donors away from ffp production or routinely screening for hla antibodies. the most effective method for identifying 'high risk' components has not been identified. introduction: trali is a life threatening adverse reaction of blood transfusion. it is characterized by noncardiogenic pulmonary edema developed soon after blood transfusion. in japan, we built hemovigilance system in and have been collecting the voluntary reports of severe adverse reactions of blood transfusion including trali cases since . since the diagnostic criteria of trali have not been established until recently and no specific diagnostic markers for trali have been discovered so far, it is very difficult to make proper diagnosis of trali in each reported case. we have been collecting the cases with respiratory distress and pulmonary edema developed after blood transfusion as suspected case of trali. we reevaluated each report whether it meet the recommended diagnostic criteria for trali published in transfusion journal in dec. . aim of the study: purpose of this study is to select trali cases which met internationally recognized criteria so that it will reveal the possible causes of trali with laboratory testing for anti-leukocyte antibodies in donors and recipients. methods: the cases with respiratory failure and pulmonary edema are selected for evaluation from the adverse reaction case reports voluntarily reported to japanese red cross. in order to make a proper diagnosis of trali, we have been utilizing the respiratory distress questionnaire which has recently revised. this helps us eliminate other adverse reactions such as circulatory overload, cardiac failure, anaphylaxis and bacterial contamination, which results in selecting out the internationally recognized trali cases properly. for laboratory testing, flowpra and labscreen for hla antibodies and gift-fcm for hna antibodies are performed. the cross-matching test is also performed if possible. results: during past years, cases of trali and cases of possible trali have been confirmed by critical review of each questionnaire. of cases of definite trali, donor specimens were obtained in cases. of cases, anti-leukocyte antibodies were detected in cases ( %) of donors' blood, which was significantly higher than the positive rate of anti-leukocyte antibodies in donors' blood of other adverse transfusion reactions (< %). of cases of antibody positive donors, anti hla antibodies were detected in cases, anti hna antibodies were detected in cases, and both were detected in cases. of cases of positive anti hla antibodies, class i antibodies were detected in cases, class ii antibodies were detected in cases, and both were detected in cases. on the other hand, the anti-leukocyte antibodies were detected in % of trali recipients, and this rate is almost the same with that of positive rate of other adverse reactions of blood transfusion ( %). these results indicate anti-leukocyte antibodies in the blood donors are one of the prerequisites for developing trali from the antibody-hypothesis-oriented point of view. other cases with no detectable antibodies should be investigated in more detail in the future. thus, reevaluating trali cases based on recommended trali criteria will allow us to reveal new information about trali. of adverse events analysed by the serious hazards of transfusion (shot) scheme ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , ( %) were haemolytic transfusion reactions (htrs). were due to incorrect blood component transfused (ibct): / were abo incompatible and / caused by other red cell antibodies. a further cases were reported as acute htrs (ahtrs; i.e. occurring within hours of transfusion) whilst were recognised more than hours after transfusion and reported as delayed htrs (dhtr). / ( %) patients died and suffered major morbidity. htrs associated with ibct result from clinical or laboratory errors and are all preventable. it has been assumed that other htrs are unavoidable. closer scrutiny reveals that this may not always be the case, though review is hampered by incomplete investigations. / ahtrs occurred in group a ( / ) or group b ( / ) patients given group o platelets. of the ahtrs related to red cell transfusion, were due to errors, were in patients with auto-antibodies, in only of whom alloantibodies had been adequately excluded/identified. at least / dhtrs were potentially avoidable; in cases the antibody was detectable retrospectively in the pre-transfusion sample; in cases the presence of a previous antibody was not communicated to the laboratory. two patient deaths related to dhtr might have been avoided by earlier diagnosis and clinical involvement. % htrs reported to shot would have been avoided by compliance with pretransfusion testing guidelines and provision of group a platelets for all group a recipients. htrs can be clinically overlooked and inadequately investigated. national guidelines are needed for the investigation and management of htr, with focus on the identification of underlying causes to guide the choice of future component therapy. reference laboratories can provide valuable support in elucidating complex serological problems. patients treated with high dose chemotherapy and autologous blood progenitor cell (bpc) support may get malignant cells reinfused together with stem cells. we analyzed bpc products collected from patients suffering from germ cell cancer measuring malignant contamination and followed these patients for up to months after transplantation also with the question if transplanted malignant cells influence survival. aliquots of stem cell apheresis products containing one million mononuclear cells were sedimented on glass slides and by immunocytochemistry quantitation of cytokeratin expressing cells was performed manually with light microscopy and by automated image analysis. in of patients ( %) cytokeratin expressing cells were detected in bpc apheresis products of patients treated for germ cell cancer. we followed the activity of the malignant disease of patients for more than eight years in median months after transplantation. no significant difference in survival was demonstrated for our two patient groups. background: the use of adequate number of peripheral blood stem cells (pbsc), collected by mnc apheresis is essential for effective treatment of hematological malignancies, solid tumors, and other disorders by transplantation. aims: the goals of this study were: (a) to obtain an effective apheretic protocol for mnc harvesting, and (b) to compare the hematopoietic reconstitution after hspc transplantations in different clinical settings. methods: in this study, pbsc transplantations - allogeneic from matched sibling healthy donors and autologous -were performed in the management of patients with severe aplastic anemia, leukemias (all, anll, cml), multiple myeloma, hodgkin's and non-hodgkin's lymphoma, breast and ovarial cancer, and extragonadal non-seminal germ cell tumor. pbsc mobilization was achieved with rhg-csf ( - g/kgbm/day). mnc-apheresis procedures (generally one and occasionally two) were performed using blood cell separator cobe-spectra. the first mnc-apheresis was accomplished when the leukocyte cont was - ¥ e /l (autologous setting) or on the th day - hour after the last rhg-csf administration (allogeneic setting). the processed blood volume during one mnc-apheresis was . - . l, and . l for one pbsc transplantation in average. results: using a minimal target dose of cd + cell count ( ¥ e /kgbm), performing one mnc-apheresis procedure for % recipients sufficient number of pbscs were obtained. the mnc yield was . ¥ e /kgbm in allogeneic and . ¥ e /kgbm in autologous setting in average. the mean cd + yields for allogeneic and autologous transplantations were . ¥ e /kgbm and . ¥ e /kgbm, respectively. hematopoietic reconstitution was achieved on the . th day for leukocytes and the . th day for platelets when pbsc transplantation was applied. summary/conclusion: improved mnc and cd + cell yield, as well as rapid hematopoietic reconstitution were observed when: (a) the intention of auditing any clinical practice is, ostensibly, to improve patient care. the term 'audit' implies comparison against a standard. although absolute indications for transfusion have not been defined by clinical trials applicable to most clinical situations, many institutions have established their own transfusion triggers based on their reading of the literature and common practice at that hospital. assuming these represent prudent guidelines, comparison of actual practice to them may allow physicians to re-assess their pattern of hemotherapy and bring it into conformance with the guideline. there are several common ways of performing transfusion audits. retrospective analysis of transfusions allows appreciation of the clinical situation (and its ultimate outcome) but reviews the event through a 'retrospectoscope' that assesses clinical information in a different manner than that available to the clinician making the decision to transfuse. furthermore, the time lapse between the decision to transfusion and feedback about that decision may render the feedback from the reviewing body (e.g., a transfusion committee or blood utilization review committee) of little practical import. to speed the provision of feedback and emphasize educational rather than any punitive outcomes of the audit, some facilities have abolished attempts at determining whether the decision to transfuse was supportable and have used electronic means to feed back to clinicians a non-judgmental informational message summarizing the literature regarding the indications for transfusion. this appears to be at least as effective as the traditional retrospective audit system. prospective review of requests for blood components have the potential to redirect practice in a manner that immediately helps patients. however, such interactions with clinicians may come at inopportune times, may require considerable (unscheduled) time, and are most likely to be fruitful if a knowledgeable transfusion medicine expert can serve as the intermediary. both approaches (or a combination) have been shown to be beneficial in altering practice, but efforts must be diligent and sustained. providing data comparing a physician's practice to colleagues in the same specialty may prompt additional introspection and practice change, particularly if physician leadership of the institution supports the effort as a quality improvement tool. extending the comparison to a group of physicians and contrasting their transfusion habits with benchmark data from other institutions may also be helpful, but one needs to be ready to counter arguments that differences in patient groups are the reason for the differences in practice (studies have shown that, in general, practice patterns are primarily related to training and habit rather than large differences in patient acuity). increased focus on the performance of hospitals as expressed in outcome data may soon extend to transfusion practices as well. the public or governmental institutions may ask to see data illustrating the transfusion practice of an institution and its improvement over time. carefully conducted, diligent, and ongoing transfusion audits are an integral part of an institution's quality improvement program. informed consent: the term informed consent, appeared for the first time in the late s but it was only in the s that it attracted attention with regard to health care. numerous discussions and publications have attempted to define the meaning and the justification of informed consent in recent years. initially it consisted in the obligation of the physician to disclose information to the patient, regarding the procedure he was to undergo, but more recently, ethicists have emphasized the need to ensure the patient's understanding and his autonomous decision to consent. current institutional rules of ethics demand that the physician must obtain the informed consent of a patient 'prior to any substantial intervention' . what is however the meaning of informed consent? is it a mutual decision making between physician and patient? in 'principles of biomedical ethics' beauchamp and childress claim that' it is critically important to distinguish informational exchanges through which patients elect medical interventions, from acts of approving and authorizing those interventions. the elements of consent include: disclosure, voluntariness, decision and authorization. when applying the concept of informed consent in transfusion medicine one can distinguish it into donors' and patients' consent. donor informed consent: information to blood donors constitutes a sensitive issue. it refers to their protection from side-effects of the donation, as well as to protection of the recipient. with regard to whole blood donors a detailed history and information as to side effects are necessary for first-time donors. for repeat donors one needs mainly an updated history. because of time-pressure, whole blood donors are usually given written information and are asked to answer written questions. donors however differ in literacy and even literate ones do not always understand medical terminilogy; so, during the interview one should probe the degree of understanding of each donor. with first time apheresis donors more time is needed in order to explain the procedure and potential side effects. since granulocyte and stem-cell donors require premedication with growth factors and or corticosteroids, the responsibility for detailed information is even greater. the fact that all donors sign the informed consent does not mean that they are all adequately informed! interviewers must be familiar with side effects, their frequency and sequelae and must pass on this information. misses and near-misses, (serious) adverse events and failures in medical practice seem to be not preventable. in medical interventions, preparing and prescribing of medication, assistance by doctors and nurses, medical treatment and follow-up, unwanted and unexpected events occur (http://www.mederrors.com.). these events happen also in transfusion medicine and focus on safety is not unique. haemovigilance which is defined in the eu blood directive as 'a set of organised surveillance procedures relating to serious adverse or unexpected events or reactions in donors or recipients, and the epidemiological follow-up of donors' (eu directive / /ec off. j. european union. . . :l / -l / ) is established to help in trying to identify and minimise the misses and (serious) adverse events in the chain from donor to recipient of blood components. the causes or reasons should be studied in order to prevent re-occurrence. adverse event reporting in blood transfusion and transfusion medicine is complex. it depends on the cooperation between blood establishments with clinicians and hospitals. it implies knowledge of blood banking, transfusion medicine and routine clinical care of all gender and ages, of potential hazards of transfusion, of immune-haematology, of microbiology, and of epidemiology. an adverse event may have its cause in every single part of the blood chain and reference may take place to a proven problem, a potential problem, or to a justified doubt. in almost all blood transfusion centres, a single donation will be processed into a number of different products, and these units might be divided or processed into more products. blood components are produced from whole blood or apheresis donations, and depending of the blood drawing and processing techniques, a high number of products with different specifications is prepared. the products' shelf life is not equal and therefore the moment in time of actual use of each unit prepared from the same donation may differ. in case the unit of platelets harms the recipient, a rapid alert can warn in order not to issue or to transfuse the unit of red cells or the unit of ffp prepared from the same donation because of the potential adverse reaction, which was detected during or after the transfusion of the first unit used. haemovigilance is not only important to blood establishments and to patients and prescribers, but it is also to clinical scientists, and to the public at large. it should provide a basis for minimising adverse reactions on blood components, and it should enable the therapeutic potential of new or established treatments with components to be maximised, since demonstrations of safety during widespread use may lead to extended usage, and wider availability. it is quite worrisome that underreporting is a general problem in medical care. it might be expected that in transfusion medicine the same rates of underreporting can be found, but also that the same mechanisms for improvement are applicable. although medical misses occur and do not seem to be preventable, the handling of these misses is often quite poor. many patients like to hear a detailed explanation, and the majority expects even apologies from the treating physician. it seems desirable to look for new routes in the prevention of unwanted events of transfusion medicine. for problem solving, analysis and improvement of working methods, where needed and possible, are often the most effective methods. attention should be focused on improvement and not on identification of the person who caused the problem ('bad apple'). lack of communication and insufficient insight in each other work are often the causes of problems and unwanted events. it should be recognised that advices given by the haemovigilance officer or the blood transfusion committee about prevention without the input and commitment of the direct responsible persons will lead in most cases to advices which are not effective or which will not be accepted. setting up a haemovigilance system or appointing of haemovigilance officers or installation of blood transfusion committees will not be sufficient. it will be necessary to develop ways of registration, data collection and analysis, but more importantly to support by giving advice and training to prevent reoccurrence of the adverse events or not optimal use of blood components. the confidentiality of the information should be guarded sufficiently. for a physician-patient relation, even after a medical failure, a 'blame-free culture' with a central role for openness and transparency is necessary. for blood establishments and hospitals, there is an important role in the right assistance and help of the physicians concerned both on a practical and on an emotional way. m-pa- years of shot data - : a view of transfusion safety in the uk and reactions. this will require investment in infrastructure, for which there must be a trade-off in improved transfusion safety. transfusion-transmitted infections and serious immunological reactions are rare; shot has highlighted the need for blood services to implement strategies to minimise bacterial contamination and transfusion related acute lung injury and will monitor their effectiveness. from the inception of shot it has been clear that the most frequent transfusion hazard is 'incorrect blood component transfused' i.e. a patient receiving a blood component intended for another person or not meeting appropriate requirements. only a minority of these events results in patient harm and is reportable under the terms of the directive. haemovigilance schemes such as shot, that analyse no-harm errors and near-misses, can reveal clues as to the root causes of 'wrong blood', which contributed to deaths and cases of major morbidity in the uk between and . analysis of such events shows that most errors occur in clinical areas, the most frequent being failure of the 'bedside check' . clinical audit data indicates that % of patients are transfused without a wristband or other form of identification, whilst anecdotal reports suggest that urgent clinical situations, massive transfusions and nocturnal transfusions are particularly error-prone. strategies aimed at reducing errors include structured education and competency testing, and methodologies, both high and low-tech, to ensure accurate patient identification in all circumstances. onethird of errors occurs in hospital laboratories; denominator data on laboratory workload shows that work done outside of 'core hours' accounts for % of all pre-transfusion testing but % of errors, suggesting that biomedical scientists 'on-call' or on shift work are working under pressure and beyond their competency. % of hospitals reported that they participated in shot in , but only % of eligible hospitals reported adverse events suggesting that transfusion hazards remain under-recognised and under-reported. however, benchmarking of 'wrong blood' incidents against transfusion activity shows that the number of observed incidents is roughly proportional to blood use. if haemovigilance data is to contribute to improved transfusion safety, clinicians must be encour-aged to report all events, thus contributing to an evidence base that can be used to effect change and facilitate learning. barriers to reporting include cumbersome systems, lack of time and resource, lack of feedback and fear of blame. transfusion practitioners have a vital role in the recognition and reporting of adverse events, education and clinical audit, but must be adequately resourced and supported by senior clinicians and managers through an active hospital transfusion committee. *provisional. m-pa- passing the borders: when, how and where d pirc-tiljak croatian institute of transfusion med., zagreb, croatia there may come that moment in professional life when you have to follow a strong professional and ethical need and confront your evidence-based statements with the leadership, passing the border of your own small society. in order to protect patient's health and respect human right to be informed about all possible consequences of irregular medical therapy, insisting on professional dignity and truth, you feel responsible and follow-up processing of your serious error report. once you pass the border, trying to warn authorities and find ethical resonance and critical confirmation of your professional fears, you are 'persona non grata' . methods/results: reality checking, personal experiences and observations studying the path of serious error report. although the qc system functions, yet omissions happen . . . the possible reasons could be: lack of knowledge, lack of experience, lack of independency, personal confront of interest, immature leadership, political influence, even corruption . . . how strict do the authorities manage a fault, bearing in mind the responsibility toward the patients under the risk. there is a need to create an available, effective international expert's board which will react and give professional counselling support-asylum for endangered professionals who found enough power to blow the whistle. who will hear it? transfusion transmitted infections (tti) are a major source of concern given the repercussions of hiv, hepatitis c, bacteria and vcjd transmission by blood components. large amounts of resource have been expended in making products safer and in maintaining public confidence in the blood supply. identifying emerging infections of concern is a major activity for many transfusion services. of the long list of emerging infections identified by disease control agencies around the world, identifying those responsible for tti requires, amongst other things, that: • the agent is identifiable. • it is present in blood • it causes a disease of concern. • it is transmitted by transfusion. • it is present at relatively low frequency. • if a test is available (nat, serology or immunoassay) what the infection window period is. once an agent has been identified various approaches are possible, including: • donor selection by testing, geography or lifestyle e.g. wnv; • product selection e.g. erythrovirus (b ) antibody or bacterial testing; • product treatment e.g. pathogen inactivation; • patient selection e.g. cmv matching, immune status. against this background where should our attentions focus? some agents of initial concern are now known to be ubiquitous and have minimal disease association (ttv, gbv) although transmitted by transfusion. for others (coronavirus -sars or the possible kawasaki disease agent, dengue, flavivirus encephalopathies, avian flu, etc.) this is less certain, with agents arising from species crossover being of particular concern (avian flu, vcjd, hiv). • enhancement of automation/computerisation; • process control to provide an 'error-free pathway'; • (national) surveillance and trend analysis of results, preferably based on national working standards; • significantly increased sensitivity, especially from development of antigen/antibody 'combi' assays (e.g. for hiv, and recently, for hcv); • awareness of hbsag vaccine-escape mutants and design of assays to cope with this; • extension of range of agents and markers tested for (varies in different countries); • increasing range of assays available for testing donors with a relevant history of exposure to malaria or chagas' disease infection (for retrieval of otherwise wasted blood); • european union's in vitro diagnostics directive: this has caused some problems and reduced flexibility. nucleic acid testing (nat): nat continues to increase in blood service usage world wide, although not (as yet) to replace serological methods. trends include: • reduction in sample pool size; • increased automation (and process control); • increased multiplexing to detect or more agents in the same assay; • increased number of agents being tested by nat (varies in different countries); • introduction of rapid and flexible nat to detect west nile virus, in north america. bacterial screening of platelet preparations: several countries have introduced (or will introduce) routine screening of platelet concentrates either with biomerieux, bactalert or pall ebds ( depletion assessment). other bacterial testing methods are under active assessment, some rapid enough for possible 'point of use' testing. m-pa- evaluation of in vivo red blood cell recovery after processing with a new filter designed to reduce prions e nelson*, h taylor † , p whitley † and t lieu* *pall medical, covina, ca, † american red cross and evms, norfolk, va, usa background: a filter, called the leukotrap affinity prion reduction filter (prf b filter, pall medical), has been developed to reduce the level of infectious prions, associated with several fatal neurodegenerative diseases including variant creuztfeldt-jakob disease (vcjd), from leukocyte-reduced red cell products. aim: the objective of this study was to evaluate the quality of leukocyte-reduced red cells (lr-rbc) processed through this filter and stored for days. red cell quality was determined by measuring the in vivo red blood cell recovery hours after re-infusion of the -day stored red cells. storage hemolysis and atp were also determined. methods: units of blood ( ml) were collected from normal volunteers into the leukotrap wb system containing cp d/as- anticoagulant/preservative solutions (pall medical). units were either processed to lr-rbc within hours at room temperature (rt units), or after hours at - °c (cold units). the prion filter set was sterilely connected to the units on day , and the units were filtered and stored for days. samples were taken pre-and post-prion filtration and post-storage for plasma hemoglobin and atp determinations. post-storage samples were taken for labeling with -cr radioisotope, re-infusion, and determination of the -hour in vivo rbc recovery. a donor sample was also labeled with m-tc to allow for red cell mass determination. thus, both single-and double-label -hour recovery values were calculated. results: twelve units were collected. in vitro testing was completed on all units. in vivo testing was completed on units. the mean single-label -hour recoveries were . % and . % for the rt and cold units, respectively. the mean double-label recoveries were . % and . % for the rt and cold units, respectively. the overall combined mean in vivo and in vitro results are shown in the table. conclusion: the -hour in vivo red cell recovery means are well above the fda and council of europe's requirement of achieving a mean post-transfusion survival of no less than % of the transfused red cells, and they are comparable to this center's previous results of red cells filtered using the licensed leukotrap rc system with cp d/as- (pall medical introduction: to reduce the risk of platelet transfusion-associated sepsis (tas), methods to routinely screen for bacterial contamination have been implemented. pathogen inactivation treatment of labile blood components provides an alternative means to prevent tas. the intercept blood system for platelets (baxter healthcare) has received the ce mark and has been introduced into clinical practice. aims: this study compared the efficacy of bacterial screening using a culture method (bact/alert system, biomerieux) with pathogen inactivation (intercept blood system) for prevention of transfusion of platelet components contaminated with bacteria. methods: seven strains of bacteria associated with tas, including gram-positive staphylococcus epidermidis, streptococcus agalactiae, and staphylococcus aureus, gram-negative escherichia coli, and klebsiella pneumoniae, and the anaerobes propionibacterium acnes and clostridium perfringens were studied. for each strain, three double-dose platelet concentrates (~ ¥ e platelets in ml of % plasma and % intersol) were collected using the amicus® cell separator. on day of collection, calibrated stocks of bacteria ( , , cfu) were added to the double units. each double unit was divided into two identical products containing , , or cfu of bacteria and stored overnight under conventional blood bank conditions. the control platelet concentrate was not treated. the test platelet concentrate was treated with the intercept process ( mm amotosalen + j/sq cm uva). both units were cultured using the bact/alert system at the time of bacterial inoculation and on days , and of storage. samples ( ml) were taken for both the aerobic and anaerobic cultures. a platelet sample was considered contaminated with bacteria if a positive signal was registered within hours of culture. results: for control platelet concentrates, cultures failed to detect low-dose inocula. the time to positive culture varied with the bacterial strain, contamination level, and time of sampling. at and cfu per product, strains (s. epidermidis, e. coli, c. perfringens, s. agalactiae) and strains (e. coli, c. perfringens) tested negative after days of platelet storage, respectively. k. pneumoniae tested positive after - hours of culture when sampled on day of platelet storage for both and cfu per product. at cfu per product, p. acnes tested negative in aerobic culture and c perfringens tested negative in anaerobic culture after days of platelet storage. the anaerobic cultures of p. acnes became positive after hours of culture when sampled on day of platelet storage. of the strains studied, only s. aureus consistently tested positive after - hours of culture. in contrast, all test platelet concentrates treated with intercept remained negative by bact/alert cultures throughout the entire -day observation period regardless of the strain and the contamination level. conclusions: bacterial detection using cultures may fail to detect low levels of bacteria typically associated with platelet contamination at time of collection and processing. failure to detect bacteria will result in the release of contaminated platelet products with 'test negative-to-date' status. in contrast, inactivation of bacteria is capable of preventing release of contaminated platelet components. background: since nat implementation for hiv- and hcv rna in france, the residual risk (rr) of transfusion-transmitted infections (tti) has dramatically decreased. the rr estimates, for a threeyear period from to showed a significant decrease from / and / before nat implementation to / and / after nat implementation for hiv and hcv respectively. as for hbv, the serological screening is only based on both hbsag and anti-hbc assays. for the same period, the rr estimate for hbv is / , five times higher than hiv one and times higher than hcv one. aims: as the overall rr of tti is mainly related to hbv, and given the availability of hbv nat assays, a study was conducted to determine whether hbv nat has the ability to further reduce the hbv rr and then should be implemented in blood donor screening in france. we have estimated the wp reduction by nat in comparison with one of the most sensitive hbsag screening assays, on commercial seroconversion panels (bioclinical partners, franklin, ma, usa). the nat test was the procleix ultrio assay (genprobe/chiron, san diego, usa). the hbs ag test was the prism hbsag (abbott, france). the comparison was performed on both neat samples and diluted samples / , / , and / , in order to simulate minipools of different sizes. then, we have calculated the yield of hbv-infected donations detected by nat relative to prism hbsag assay. results: on the basis of a window period (wp) of days, ultrio assay is projected to close the wp by an average of days on undiluted samples, days in minipools of samples, days in minipools of samples and only days in minipools of samples. the projected yield calculated on the basis of . million donations collected per year in france, would be . unit per year for minipool-nat and to units per year for individual donation nat. conclusion: introduction of minipool-nat will offer only a little added benefit to transfusion safety relative to current serological screening strategies based on both hbsag and anti-hbc assays. hbv minipool-nat is then unsuitable for hbv screening in french blood donors. single-sample nat or minipool-nat with smaller pool sizes and/or modified procedures (genome enrichment or test improvement) would be more relevant. automation when technologically and practically feasible is a prerequisite for single-donation nat. therefore, decision has been made not to implement hbv nat in the french transfusion network until fully automated systems will be available. however, as the prevalence of hbv infections is higher in the overseas territories than in continental france, and as nat is performed on individual donations in these sites, hbv-nat has been implemented since december in these territories. combined detection of hepatitis c virus core antigen and antibody as an alternative to nucleic acid testing in blood screening grating the capillary cytometer with a robotic workstation and a small footprint centrifuge. significantly, there was no decrement in system performance following automation: of clinical samples ( . %) typed identically with this system and cat, and of the discrepant results were eventually resolved in favor of the automated cytometry method. testing showed high-throughput capabilities (currently samples/day) and was inexpensive. to demonstrate the flexibility of this testing platform, we also developed a method to perform completely automated counting of residual wbcs (rwbc) following leukoreduction of blood components. there were no significant differences in accuracy and precision when rwbc in analytical controls and authentic clinical samples were quantitated by the automated capillary cytometry method or the leucocount method performed manually. given the flexibility of this system, it is very likely that additional blood bank assays could be modified for high performance automated testing on this platform. noninvasive prenatal genotyping on cell free fetal dna in maternal plasma ce van der schoot sanquin research, amsterdam, netherlands in lo et al. demonstrated that in the maternal circulation small amounts of cell free fetal dna are present, concentrations ranging from on average genome equivalents(geq)/ml early in pregnancy to about geq/ml at the end of pregnancy. most likely this dna is derived fom apoptotic syncitiorophoblasts. the human placenta is hemichorial, which means that the syncitiotrophoblast is in direct contact with the maternal blood flow, and apoptotic nuclei are directly released into the maternal circulation. the cell free dna is very rapidly cleared from the circulation, the t / being only minutes. in we have shown that this cell free fetal dna could be used for rhd genotyping. in the last years many groups have shown the successful application of different prenatal genotyping assays such as fetal sexing, thalassemia, achondroplasia, duchenne's disease, adrenogenital syndrome etc. on this source of dna. importantly, no false positive result have been described due to the presence of fetal dna from previous pregnancies, the main draw back of prenatal diagnostics on circulating fetal cells. at present prenatal rhd genotyping has been introduced in routine diagnostics in the united kingdom, france and the netherlands. in large scale high throughput studies it has been shown that the diagnostic accuracy of prenatal rhd genotyping is over %, and it is to be expected that in the netherlands this screening will soon be introduced to restrict the antenatal anti-d immunoprophylaxis to women carrying rhd-positive fetuses. in a large european project (safe, co-ordinator maj hulten, warwick uk) many researchers collaborate to further explore the possibilities of cell free fetal dna for future diagnostics. standard operating procedures for the isolation of plasma dna have been established. control pcrs for the presence of fetal dna have been developed. recent findings on differences in methylation status of placental genes in fetal dna opens new possibilities. the main technical problem that hampers wide application of prenatal genotyping is the impurity of the fetal dna, only - % of the cell free dna in plasma is from fetal origin. this makes diagnostic assays on numerical chromosomal abnormalities impossible. and also for many single nucleotide polymorphisms (snps) such as almost all blood group antigens, assays are hampered by aspecific amplification from maternal dna. our own preliminary results indicate that this latter problem can be solved by pna clamping. the addition of a pna probe specific for the k-allele partial d feature d antigen alteration, often identified as distinct 'partial' d epitope loss. the clinical impact of partial ds is due to the ability of their carriers to form anti-d antibodies upon confrontation with regular d after transfusion, or pregnancy. this leads to the -naively spoken -contradictory finding of an allo anti-d antibody in a d positive individual in connection with a negative autocontrol. the antibodies themselves include the same fatal clinical potential as anti-d antibodies of d negative individuals, but may be even more hazardous since unexpected in d positive individuals a priori. d categories (ii to vii) represent a nomenclatorily defined subgroup of partial ds. the molecular cause of partial d lies within single (caused by point mutation in the respective rhd gene sequence), or multiple amino acid exchanges (caused by gene conversion events leading to rhd-rhce-rhd hybrid genes) which determines a qualitative d antigen alteration, rendering them distinguishable from regular d by a partial d carriers immune system. nowadays, transfusion specialists and gynaecologists are more or less aware of these facts and are taking them into consideration in the clinical setting. most partial d exhibit decreased d antigen density, enabling principal recognition of them. however, routine serological methods may not properly recognise all partial ds and will identify their carriers after immunisation only, which represents a reactive diagnostic/therapeutic attitude second best to an actively prognostic one. this actively prognostic proceeding with respect to early detection of partial ds became widely feasible by rhd dna typing techniques. currently, routine rhd dna typing techniques offer an affordable, accurate and fast approach to an unambiguous identification of partial ds and their reliable discrimination from weak d types, not at risk for allo anti-d immunisation. a reasonable proactive proceeding could e.g. demand for (once in a lifetime) routine rhd dna typing of all weakly expressed ds as defined by serology, since most partial ds also meet this phenotype. rhd allele frequencies and their geographical and regional prevalence will certainly have an important impact on dna typing strategies and their (mandatory) specificities. fluorescence cytometry for completely automated immunohematology testing d roback*, b barclay † and d hillyer † *emory university school of medicine, atlanta, † transfusion & transplantation technologi, decatur, ga, usa we previously described a methodology for accurate immunohematology testing by fluorescence cytometry [roback, j.d. et al. ( ) transfusion ( ), ]. this system utilized low-speed centrifugation of -well filter plates for red cell staining, and a smallfootprint capillary cytometer for data acquisition. when authentic clinical samples from hospitalized patients were tested for abo group, the presence of d antigen, and red cell alloantibodies, the results were well-correlated with those obtained by commerciallyavailable column agglutination technology (cat). this system determined the correct abo group and d type for . % of samples, compared to . % for cat (p > . ). when samples were tested for unexpected alloantibodies, fc determined the correct result for . % of samples, as compared to . % for cat (p > . ). this novel method was better than cat at detecting weak anti-a (p < . ) and alloantibodies. based on these promising results, we sought to completely automate this method by inte-prevents the aspecific amplification of the k-allele, and makes it possible to detect the fetal k-allele in the presence of excess of maternal k-alleles. furthermore, it has been shown that fetal dna is in the plasma present in shorter fragments (< bp) than maternal dna. size separation of cell free fetal dna can therefore be used to increase the relative concentration of fetal dna, which will help the development of new genotyping assays. in conclusion, cell free fetal dna in maternal plasma is nowadays routinely used for prenatal rhd typing and fetal sexing. new technical developments will make it possible to extend these indications to other blood group antigens in the near future. more insight in the characteristics of fetal dna might finally lead to wider applications, including numerical chromosomal aberrations. furthermore, it might become possible to apply genomic dna microarrays for the screening on many different inherited diseases, including hemoglobinopathies. determination of the affinity of anti-d present in the serum of immunized subjects and in anti-d ig preparations by a method using unlabeled antibodies p lambin*, m debbia* and y brossard † *institut national de la transfusion, † chp hopital saint antoine, paris, france introduction: few data are available concerning the affinity of maternal anti-d responsible for the hemolytic disease of the fetus and the newborn (hdn), and the affinity of anti-d immunoglobulin used for the prophylaxis of that disease. we recently described a method to measure the affinity (ka) of untagged anti-d monoclonal antibodies. aims of the study: in this work, a similar method was applied to determine the affinity constant (ka) of polyclonal anti-d present in the serum from d-immunized mothers and donors and from anti-d ig preparations. methods: a constant amount of o r r rbcs was sensitized with increasing concentrations of anti-d present in the sera from immunized subjects, and in anti-d ig preparations. at equilibrium, the amount of anti-d bound to rbcs was measured by elisa. the scatchard equation (linear regression) and the langmuir equation (hyperbolic regression) were used to determine the ka of anti-d. the experimental data fitted well with the scatchard equation (mean r † = . ) but a better correlation was observed with the langmuir equation (mean r † = . ). in maternal sera, the mean ka of anti-d was . ¥ to the m- (from . to ¥ to the m- ). in the sera from immunized donors, the mean ka was . ¥ to the m- (from . to . ¥ to the m- ) and in lots of anti-d ig, the mean ka was . ¥ to the m- (from . to . ¥ to the m- ). the comparison of anti-d affinity measured in cases of hdn in which infants presented a fetal anemia and in cases of hdn in which infants presented only a postnatal anemia showed no significant difference. the mean value of ka in the cases of fetal anemia was . ¥ to the m- whereas in the cases of postnatal anemia the mean value of ka was . ¥ to the m- . conclusion: the method previously described for monoclonal anti-d was applied to polyclonal anti-d present in the serum of d-immunized subjects and in ig preparations. the experimental data fitted well with the langmuir equation, and the affinity of polyclonal of anti-d was measured with accuracy. in addition, no significant difference was observed (at least in the cases of this study) between the affinities of anti-d measured in the most severe cases of hdn (fetal anemia) and in the less severe cases of hdn (post-natal anemia). introduction: cryopreservation of platelets is widely used in platelet immunology to ensure the availability of well characterised panel cells for the detection of hpa antibodies. but recovered platelets do not express the hpa- alloantigens. aim of the study: here we describe a method for the successful preservation of platelets by lyophilization. we report the value of this new reagent for the detection of hpa alloantibodies and especially anti hpa- alloantibodies. methods: rehydrated lyophilised platelets (lyo p) were tested for their reactivity with monoclonal antibodies against gpiibiiia, gpibix, gpiaiia and cd by flow cytometry. the levels of reactivity were comparable with the ones obtained with fresh platelets. the rehydrated platelets were used in the maipa with a panel of hpa antibodies (anti-hpa- a, ; anti-hpa- b, ; anti-hpa- a, ; anti-hpa- a, ; anti-hpa- b, ; anti-hpa- a, and anti-hpa- b, ). results: all hpa antibodies showed the expected pattern of reactivity and in several cases absorbance reading were well above those obtained with fresh platelets. absorbance values produced by inert sera were comparable with those obtained with fresh platelets (ranges . - . ). interestingly, we used lyophilized platelet with a high expression of cd bearing the hpa- system and we have detected anti hpa antibodies among sera previously negative with fresh platelets. nineteen sera concerned patients suffering from hematological diseases and from pregnancy women. conclusion: lyophilized platelets are possibly an ideal reagent for the platelet immunologist to be used for the detection of hpa antibodies. moreover, this work bring new insights on the hpa- system in platelet transfusion. we are now pursuing more extensive validation studies with a larger number of samples representing all known hpa specificities and several diseases. the diagnosis and treatment of sick infants and children requires a broad knowledge of physiology, biochemistry, genetics and the application of sophisticated testing and treatment options. one of these options is transfusion of blood and blood products. transfusion of the infant, especially the premature infant, and sick child, especially those with major organ dysfunction, requires careful consideration of their unique metabolic, hepatic and renal clearance mechanisms. guidelines that direct the indications for transfusion differ from those in adults. non-invasive measures of oxygen delivery and oxygen offloading may assist in guidelines for red blood transfusion. metabolic complications from massive transfusion and/or the manipulation of blood products must also be considered. evidence from a high quality randomised controlled trial suggests that anaemia is also well tolerated by critically ill patients. a restrictive approach to rbc transfusion that maintained the hb concentration between and g/l was found to be as effective as and possibly superior to a more liberal strategy of maintaining the hb concentration between and g/l. there are concerns that some groups of critically ill patients, such as those with cardiovascular disease and patients who are difficult to wean from mechanical ventilation, may benefit from higher hb levels. rbcs also have a role in primary haemostasis and higher triggers may be appropriate in coagulopathic patients. it is important to realise that blood is not a uniform product and the clinical efficacy of rbc transfusion may vary. one factor that may have a considerable effect on the quality of the rbc product is the storage time. rbcs undergo marked changes during refrigerated storage. the implications of these changes on tissue oxygenation are not known but these concerns have led some clinicians to request 'fresh' blood for critically ill patients. there is insufficient evidence to support such practice. it is of great practical importance to determine if, or when, fresh rbcs could be superior to stored rbcs. background: with a decreasing blood donor base, fully tested, fresh unrefrigerated whole blood (fuwb) has been found to be a more efficient and effective use of a limited resource in place of, or as an adjunct to, traditional blood component therapy in surgical situations associated with massive blood loss. aims: to outline the use of fuwb in situations where there is potential for intractable bleeding associated with major surgery, and evaluate platelet function in fuwb versus platelet components. methods: outcomes of fuwb and traditional blood component use were examined for cases of cardiac bypass surgery. in addition, exclusive use of fuwb for burns debridement cases was analysed. an evaluation of platelet function in whole blood compared to platelet components was also performed by measuring platelet aggregation and activation parameters. results: there was a decreased requirement for blood components following administration of whole blood post cardiac surgery. whole blood usage for burns debridement surgery eliminated the requirement for additional blood components. platelet activation was markedly reduced in whole blood compared to component platelets, and this may be one reason for the increased efficacy of whole blood in these clinical settings. conclusion: fuwb appears to have a role in minimising blood product requirements and consequent donor exposure in situations associated with massive blood loss. m-pa- transfusion practice for coronary artery bypass surgery in greece s lakoumenta, m vassili, g hatzidimitriou, t asteri, p stratigi, s kanellas and g palatianos hellenic society of blood transfusion, athens, greece cardiac surgery is associated with a demand for allogenic blood and blood product availability as well as a considerable consumption. the impact of consensus guidelines for allogenic blood transfusion during coronary artery bypass graft surgery (cabg) in us attracted great attention . the present study is conducted in order to reveal the transfusion practice in greece on a similar population i.e. patients undergoing cabg operations. methods: five participating centers collected data concerning transfusion of allogenic blood and blood products in patients undergoing elective first time cabg procedures, as well as parameters that may influence blood loss, such as duration of the operation, cardiopulmonary bypass time (cpb) etc. the total estimated blood loss was calculated as the sum of red blood cell volume reduction [(body weight in kg ¥ ml/kg) ¥ (admission haematocrit-discharge haematocrit)]+(red blood cell volume transfused). results: results are shown in table : means, standard deviations, and p-values of the wilcoxon test comparisons between the hospitals. a preliminary analysis of data from centres ( patients) showed no difference in patient characteristics (age, body weight, male to female ratio). there is a statistically significant difference (p < . ) between the five centers in duration of the operation, cpb, estimated blood loss and volume of transfused plasma. red cell use showed also a variation which however did not reach statistical significance (p < . ). the center with the highest figure for blood loss has the lowest volume of allogeneic red cell transfusion because of the use of cell salvage. conclusions: although variations, as those observed in greek cardiac surgery centers, have been documented in other countries, the variation in the use of plasma is striking and we are in the process of trying to identify the reasons. our study is in progress and additional data are being collected and will be presented. introduction: premature infants and at term newborns have an higher circulating blood volume per kilogram than the adults ( ml/kg in premature; ml/kg in at term), for this reason, in case of neonatal thrombocytopenia, a specific hemocomponent, with a very high platelet concentration, needs for transfusion therapy. the laboratory criteria for platelet transfusion are the following: (a) a plt count < ¥ cells/l if bleeding is observed; (b) a plt count < ¥ cells/l without bleeding; (c) a plt count < ¥ cells/l in newborns showing critical clinical conditions. aim of this study: in this study, we have monitored the plt transfusion therapy in our neonatal intensive care unit (nicu) in the last four years. methods: effects of plt transfusions have been followed in children ( premature infants and at term newborns). the weight of premature infants ranged from - g and at term newborn from - g. gestation age of premature infants ranged from - weeks and of at term ones, of course, from - weeks. for every platelet transfusion in these newborns, the volume of platelet concentrate has been of - ml/kg, with a plt count < ¥ cells/l. results : in the study period, plt transfusions have been performed: children have been only transfused one time, while multiple plt transfusions (ranged - ) needed for children according to clinical conditions. the observed clinical indications for transfusions have been the sepsis with haemorrhagic syndrome ( cases) , haemorrhagic syndrome without sepsis ( cases) and neonatal alloimmune thrombocytopenia without haemorrhagic syndrome ( cases). after hours from transfusion therapy, the absolute plt count and the correct count increment have increased in all little patients. the highest increase in plt count was ¥ cells/l, while the lowest ¥ cells/l. no difference in the efficacy of therapy has been detected between premature group and at term group. % of children have been discharged from hospital in good general conditions without complications in following controls. in conclusion, we can affirm that plt transfusion in premature infants and in at term newborns is an efficient and safe treatment of severe haemorrhagic conditions. however a collaboration between nicu and transfusion center is necessary to choice the adequate platelet concentrate's volume for transfusion and the best plt donor for the newborn. developing transfusion strategies fusion society of turkey (bbtst) in with contribution of blood transfusion centers. according to these figures % of centers attended operates apheresis procedures. two centers informed us that apheresis in the hospital was carried out at blood bank. there was not enough information from one center, so it was excluded. of the blood banks performing apheresis, were university hospital blood banks. another blood banks were producing both productive and therapeutic, produce only productive and produce only therapeutic procedures. one center did not respond. all centers reported to prepare and separate erythrocyte and plasma. however only centers reported to prepare random platelets as well. each center had apheresis machines between - . a total of centers was carrying out around < procedures, around - , at centers about - , at a further centers around - procedures a year (one center was excluded). of the responders to the survey , all procedure were done at blood banks, whereas at of them all were carried out by the hematology clinics. at other centers, productive procedures were conducted by the blood bank, and therapeutics were performed by the hematology division. a total of blood banks stated that they have not kept the platelet suspensions produced and used them straightaway. productive apheresis center capacities were as shown: centers < , centers - , centers - and centers > units have donations a year. around % of all apheresis procedures were carried out by large well run blood banks. conclusion: as the use and production of random platelets increase, and settle of apheresis devices in big centers will eventually decrease the demand of apheresis procedures and keep the welltrained staff at big centers, decrease the cost thereafter. • planning of resources for the financing of the bts, adoption of a methodology for creating and adjusting the price list of products, adoption of the yearly plan of needs for blood/products and services of health institutions which use blood/products. • achieving recognition of real costs of products and services from the health insurance fund and ministry of health. • harmonization of low level of acclaimed costs and real costs of basic transfusion activities. results: acclaimed costs for activities in transfusion practice (collection, testing, processing, storage, distribution and transport) as a reflection on the price of the products are % lower than real costs. the prices of health services in the official price list are much lower than the proportion of costs of material resources needed for the realization of these services. this especially affects the management of independent blood establishments (bti's in serbia) with core blood transfusion activities as their basic field of work, in comparison with the hospital based transfusion services, which are financed within the budget of the whole hospital. the hospitals with hospital based transfusion services involved partly in core transfusion activities are completely financed by the health insurance fund, while independent blood establishments are financed through the price of products and services they provide. conclusion: in order to provide adequate quantities of safe blood/products for the end user -the patient, it is elementary to create stabile and equal financial management conditions for the whole blood transfusion service in serbia. this can be achieved only by continuous cooperation of the health insurance fund, ministry of health and independent blood establishments. sion centers (rbtc). the activities on promotion and organization of voluntary, nonremunerated blood donation, blood collection and patients' services are carried out in the rbtc and in departments of blood transfusion (dbt), part of the district hospitals. the collected units in dbt are transported by special cars to the ncht and the rbtc for processing, testing and control. the same transport is used for the requested by dbt blood components for storage and distribution to hospital departments. thus the issued components are with an equal quality and safety for all patients throughout the country. lbbdbt introduces hemovigilance as a mandatory system, covering the whole chain of the blood transfusion process. it includes as well the creation of registries at a national, regional and district level of blood donors, recipients of blood products and all activities of the blood transfusion service. . seventy hospitals are exclusively users of blood, blood products and services. the current organization of blood transfusion services faces the following problems: fragmented transfusion service, lack of a national blood policy, the blood program is not nationally coordinated, limited knowledge on quality management, inadequately distributed human resources, limited material resources, lack of it system, lack of planned, continuous skill upgrading. as a direct consequence we have: suboptimal blood collection activities, inadequate blood supplies significantly vary between seasons, high percentage of replacement donors, outdated methodologies, old, even obsolete equipment, the quality of blood products is not standard, there is a lack of traceability. aim of study: to reorganize blood collection activities in serbia to increase collection of safe blood up to % ( blood units). methods: division of responsibilities between blood establishments and hospital based transfusion services by: • optimizing organizational structure • implementing blood collection standards to enhance blood safety and donor care • gradually replacing family donors with a network of voluntary non-remunerated blood donors from low risk population groups • creating and implementing a training strategy. results: through the eu funded project support to a national blood transfusion service in serbia, we are in the effort of integrating the services and standardizing their work. the blood collection working group began by dividing serbia into blood collection regions: north, central, and south. each region is divided into sub regions covering approximately half a million population ( in the north, in the central and in the south region). each sub region will have one standard mobile blood collection team to collect blood units daily, i.e. annually. the blood units per teams provide the blood units ( %) to cover hospital needs in serbia. to this effect, the following has been achieved: • blood collection activities in serbia analyzed • performance analysis of bte and hbts mobile teams in place • two model standard mobile teams tested in the field • national blood collection sop's written • national donor questionnaire form prepared • national set of blood collection standards prepared • list of donor deferral criteria prepared • blood collection equipment renewed • regional reorganization plans in progress. the objectives and results can be achieved by the participation and mutual cooperation of all institutions involved in blood transfusion within an integrated, standardized system with clearly delegated responsibilities. p- years of the national blood transfusion institute in serbia n nedeljkovic national blood transfusion institute, belgrade, yugoslavia nbti was founded in . since and unpaid blood donation is mandatory, organized in cooperation with red cross. blood donation is regulated by the law in , / . codex of voluntary blood donation and health care staff has also been established; blood donors donates blood annually. in the past years, there was over million blood donations, performed in accordance with who regulations. over transfusion medicine specialists and technicians specially trained for the work in blood transfusion service (n = ), perform transfusion medicine doctrine of rational labile blood component and stable blood derivatives therapy, based on the selfsufficiency concept in fr yugoslavia with . million inhabitants in serbia, montenegro and kosovo. plastic blood containers and tests are imported or given as humanitarian aid gift and from . now, they have been regulated by tender. in , test to lues was introduced, to hbsag in , to a-hiv in and to a-hcv in . information system was introduced in . nbti includes: national haemovigilance coordinatoin center, center for medical care of haemophiliacs, tissue typing center, center for prenatal and perinatal protection of pregnant women and newborns. activities of nbti are organized through: center for planning, organization and development of blood transfusion service, center for blood collection, preparation and distribution, center for immunology and immunochemistry, plasma fractionation center for plasma in west balkan countries, center for diagnostics means, center for quality control of drugs and medical and diagnostic means, center for education and training and scientific research work. nbti is the third year of gmp, sop, yus iso implementation. in the current reform of transfusiology system we are aiming for percent of voluntary blood donation. nbti is the publisher of the national bulletin of transfusion medicine and it is included in the education system of the belgrade university medical faculty and the estm in belgarde . the problems of blood service in russia ea selivanov and t danilova russian inst. of hematol. & transfusiol., st. petersburg, russian federation background: the blood transfusion service (bts) development as a platform for providing the hospitals with blood and blood derivatives is an important national problem. aims: russian blood service assessment with international comparison. methods: a study was conducted on the base of the reports from all regions of russia followed by a computer statistical analysis. results: blood and blood components were collected in the russian federation in in stations of blood transfusion and in blood transfusion departments at big hospitals. amount of donors in was equal to , voluntary donors being . % of them. the average number of whole blood donations in relation to the general population is per inhabitants, and on average percent of the donor base consists of first time donors. the average number of blood collected in relation to the general population and health care system is . ml per inhabitant and ml per one bed. an average volume of one blood donation is ml. blood was collected into plastic bags containing domestic or foreign anticoagulants. about . % of collected blood is used for procurement of blood components and preparations, . % of banked blood is used for transfusions. amount of donors and the volume of whole blood have been significantly decreased for the last years. at present in russia all donations are tested for abo blood group, rh(d) type, anti-hiv- / , hbsag, anti-hcv and syphilis. the total percentage of blood discarded after testing for transfusion-transmissible infections is . %. % of plasma is obtained by plasmapheresis. blood components collected are as ffp, rbc, frozen rbc, eukocyte-and platelet-depleted rbc, rbc suspension, and preparations: % albumin, immunoglobulins, and cryoprecipitate. as to blood safety measures -implementation of blood components leucodepletion and ffp and rbc quarantine in process. the new national strategy of bts reorganization has been developed. it includes the following: increasing the visibility and resource commitment to blood issues at the national, regional and municipal levels; the national voluntary donor programme promoting; blood safety increasing; blood collection, testing and pro-cessing concentration in federal and regional bts establishments, appropriate blood and blood components usage. calculating the cost of blood in turkey n solaz, s kemahli and s cin ankara university, ankara, turkey background: like other fields of the medicine cost efficacy is gaining importance in blood banking and transfusion medicine since last few years. since last years even the most developed countries started to discuss about the cost of blood. in turkey ministry of health determines the cost of blood annually. aim: to establish a safe, cost effective and reliable prices for blood components. methods: turkish ministry of health (moh) started to determine the cost of blood components as 'all inclusive' principle. this means that cost of a unit of blood component will cover all conventional expenses such as; blood typing, infectious screening, labour, consumables, etc. this system has provided uniformity to blood component costs but if the system is not controlled and followed properly it will cause serious risks. there might be some blood banks which will not respect the safety regulations and may modify the test standards for decreasing the cost of tests. conclusion: current blood product pricing system looks generally reasonable and reliable but moh should establish close follow up systems for avoiding any abuse on the safety of blood. background: a positive direct antiglobulin test occasionally occurs in normal blood donors, and is often discovered when the donor's red cells are found incompatible in a compatibility test. the incidence of a positive dat was expected to increase since more sensitive techniques (gel test) were installed. the aim of our study was to examine whether dat positive otherwise healthy donors presented any clinical or laboratory abnormalities. methods: in the first . cross-matches last year (in months) were found incompatible due to dat positivity of blood donors' red cells ( . %). dat positive [( +)-( +)] samples were only igg positive in cases, only c d positive in and igm positive and c d positive in case. all blood donors were notified and thirty two of them responded to a request for a further sample. a complete blood count, a reticulocyte count, bilirubin (total, direct, indirect), transaminases, serologic immunological tests (ana, anti-dna, anti-ena, rf, anticardiolipin antibodies), quantitative assessment of immunoglobulins, aptt and lupus anticoagulant were performed, as well as serologic tests for markers of viral infections. dat and iat were performed by gel test (id-diamed) according to the manufacturer's instructions. dat were performed with polyvalent and monovalent reagents (anti-igg, -igm, -iga, -c c, -c d). the blood donors were also examined clinically. the donors who had positive immunological tests were referred to a rheumatologist for further investigation. results: among the thirty one blood donors eight had received medication the last hours before blood donation, two had been vaccinated for hepatitis b recently, four presented signs of a viral infection soon after blood donation, three had evidence of an allergic condition, five had positive tests for anticardiolipin antibodies and ana, two were positive for anticardiolipin antibodies only and two had a positive ana test only. in six blood donors we did not find any abnormality that might be interrelated to dat positivity. conclusions: all blood donors with positive dat should be requested to undergo further investigation. some of them are possibly candidates to long medical follow-up, especially those with other immunologic abnormalities such as positive ana and/ or anticardiolipin antibodies. the eligibility of such donors for future donation of whole blood, platelets or plasma needs to be elucidated. tions: usefulness, frequency and sincerity in answering questions. donors could choose one of the offered answers and elaborate in writing the answer they have chosen. results: of the donors that participated in the survey ( . %) answered the questionnaire, ( . %) men and ( . %) women. that the survey was useful thought % and % that it was not. opinions were elaborated by . %. that the questionnaire should be completed before each blood donation was the opinion of . %, % thought it should be filled out only the first time blood is donated and . % that the questionnaire should not be completed at all. the answers given were sincere in . % of blood donors, % were not and . % were given automaticallywithout comprehension. conclusion: most donors believe that completing the questionnaire before each blood donation is an effective way to increase safety by preventing potentially infected individuals from donating blood. they are also aware of the importance of answering questions truthfully because the end result is protecting the wellbeing of both blood donors and receivers. analysis of blood donor's deferral in national institute for transfusion medicine -skopje for the last five years ( ) ( ) ( ) ( ) ( ) p blagoevska*, i nikolovska † and r grubovik* *national institute for transfusion medic, skopje, † medical center, prilep, macedonia introduction: safety of blood and blood products depends on many different factors, starting with selection of blood donors. the aim of this study is to analyze the number of deferred blood donors and the reasons for their deferral, as well as the total number of blood donors in nitm and their correlation (voluntary/family donors). materials and methods: this is a retrospective, epidemiological study and data were taken from the blood donor's registry in nitm from . . till . . . statistical mass includes blood donors who came to nitm to donate blood in the mentioned period. results: there were total donors in nitm and ( . %) deferrals. . % of deferred ones are male, as well as in the group with donated blood (males are predominant). the most common reason for deferral is low hb level in ( . %) blood donors, use of drugs - ( . %), low blood pressure - ( . %), high blood pressure - ( . %), infections - ( . %), cardiovascular diseases - ( . %) and others. relation voluntary/family donors is almost equal ( . : . ). in the last two years the number of voluntary blood donors is increasing ( : ), which is good sign. conclusion: percentage of deferred blood donors in first three years is ~ %, which is result of insufficient data and it is increasing in the last two years (> %). reasons for deferral are predominantly from temporary character ( . %). permanent deferrals are only ( . %), which is probably due to good education of the population and self-deferral. we should establish the national registry for deferred donors, as well as for the donors with positive markers for tti. we should design a strategy for returning of temporary deferred donors. regruting blood donors in multiethnical environment p blagoevska*, r grubovik* and k elezi † *national institute for transfusion medic, skopje, † medical center, gostivar, macedonia introduction: population in r.macedonia consists of % macedonians, % albanians and % others (serbs, gypsies, turks). over % of blood donors are voluntary non-remunerated and ~ % are family donors. transfusion service and red cross should recognize the values and cultural differences of minors groups and recruiters should developed methods for reaching and motivating them to donate blood. the aim of the study is to present the ethnical structure of our donors and to develop strategy for their regrutation and retention. the study reviews the results from the blood donation actions among the high schools and university students in west part of the country (multiethnical environment) from till . results: there were blood donations for the mentioned period. predominant blood donors are employed and high school students in %. family blood donors are ~ %; between them % are from albanian population. the ratio between blood donors macedonians vs. albanians is : . woman blood donors are presented with %. first time blood donors are %, and regular donors arẽ %. conclusion: first step in planning the blood donation in multiethnic society is creation of special teams of important and devoted volunteers, such as religious leaders, teachers, doctors and businessman. for a successful campaign it is necessary to design special promotional material and address personally to the target population on their mother language. background: pursuit of pharmaceutical purity of the blood in the bag has led to a shrinking donor base and a significantly more expensive product. decisions regarding new infectious marker testing and donor deferrals have typically been made emphasizing decreasing one specific risk without considering the effect the intervention will have on the overall safety of blood transfusion. regulations have been formulated by governmental agencies with limited input from the medical community. the decision making process has lacked risk benefit analyses and has not had the robustness associated with spirited discussions. policies made in this manner may result in certain risks being decreased but can also have adverse unintended consequences. discussion: in the u.s., the fda's implementation of donor exclusions to prevent possible transfusion transmitted vcjd has reduced the donor base by more than %. given the demographics of the deferred donors, the impact on plateletpheresis donations has been even greater. to compensate for the loss of donors, blood services will have to persuade present donors to donate more frequently, to recruit new donors, or both. one study has indicated that two-thirds of donors have no intention of donating more frequently. new donors have higher rates of infectious disease markers with positivity for hiv and hcv twice as high as repeat donors. despite sensitive testing techniques, window periods still exist and not all potentially infectious donors will be excluded. another area of concern is the aggressive use of inducements to attract new donors. some blood services are offering lavish incentives such as enrolling donors into drawings to win automobiles. most donors entering the lottery will be low risk; however, it is reasonable to worry that such extreme tactics might also attract persons who should not be donat- conclusion: (a) blood donors who were patients' relatives were many more than volunteers as well as more were men than women. also people of young ages were more than those from older ages. (b) the frequency of the diseases for which the blood units were tested was found to be in low levels in the population of the area. specifically as concerns hcv, it seems that transmission frequency has been reduced after the obligatory testing of hcv in blood transfusion centres and stations. genotype b of hepatitis c virus is the most frequent in blood donors d, from a to f, from a to k, a and a. these are differently distributed in the world: types and are the most common in europe and in usa. aims: considering that, in our region, anti-hcv antibody positivity is variable from . to % of general population, aim of this study has been to evaluate the prevalence of hcv genotypes in blood donors. methods: in period from may to december , blood units were analyzed by nat for viral rna research. nat has been performed on single sample by tma technique. on rna-positive samples, the hcv genotype has been identified by reverse hybridisation with line probe assay. results: blood donors have resulted hcv-rna positive with identification of the following genotypes: a = cases ( . %); b = ( . %); a + b = ( . %); a/ c = ( . %); = ( . %); = ( . %); none was a or a. we have also analyzed the differences between the two sexes in hcv-genotypes distribution. hcv- a has showed a double prevalence in men ( cases, . %) respect in women ( cases, . %), while genotype b is more frequent in women ( cases, . %) than in men ( cases, . %), moreover genotypes and do not compare in women. although an accurate pre-donation selection, discharging all subjects with alt > iu, our results show that . : donors, apparently healthy and without risk factors, have resulted hcv-positive. analyzing our data, the genotype b has resulted the most frequent in blood donors' population, followed by type , while the others have showed a very low prevalence. the high frequency of genotype in blood donors is explained by the observation that hcv is usually associated with low alt levels, for this reason affected subjects may escape to donor's screening only based on dosage of alt. on the contrary subjects affected by other hcv types, associated with high alt levels, may be deferred increasing the hcv b relative prevalence. at the end, the different distribution of hcv genotypes between men and women and between age's classes probably reflects differences in the pathogenic characteristics of the virus, in the transmission way and in the risk factors. in fact, it has been demonstrated that genotype is principally linked to a not transfusion transmission way; genotype is linked to old age, to female sex and to post-transfusion transmission; genotypes and are associated to young age and to an history of drugs abuse, respectively with high and low viral load; genotypes and are still little known because extremely rare in europe. p- kell blood group system and rare blood donors v fakitsa*, p karyda*, s giannoulea † , c antoniou*, j flesiopoulou*, e haliou*, m papakonstantinou*, h dessilla † , e katsadorou*, g lyrakos* and k sofroniadou* *general hospital of nikea, pireas, † blood transfusion center, athens, greece background: the kell blood group system is a compound antigen system exclusively of red blood cells. some of the kell antigens are highly immunogenic. the commoner kell antibody is anti-kel . the kel (cellano) antigen is a high frequency antigen and the blood donors lacking this antigen are quite rare. the blood donors who have not factor cellano are classified in the rare blood donors. rare blood by its very nature is required rarely, but when needed that blood has to be ensured to specified patients. there are other blood donors in their family - ( . %) students, but the number of persons that donate blood from their neighborhood and close environment is much bigger - ( . %). motives for their donation are the following: their wish to help the ones that need blood - ( . %), concern that some day everyone can be a potential recipient of blood - ( . %), because of offered benefits - ( . %), for a friend or relative - ( . %), care for their health - ( . %), because of citizen duty - ( . %), because the others donate - ( . %), curiosity - ( . %). they want to be invited every months - (%) students, every months - ( . %), every months - ( . %) and ( the mean age of case group was / ± / and the mean weight of them was / ± / , / % was male and the mean number of blood donation was / ± / . the mean age of control group was / ± / and the mean weight of them was / ± / . / % of them was male and the mean number of blood donation was / ± / . the blood donors who were female, first time blood donor low wt the rate of vasovegal rx was higher in female, first time, low weight, younger blood donors (p < . ). the rate of vasovegal rx was higher in blood donor (p < . ) who were fatigue or first time blood donor, low wt blood donation, fatigue of them and starvation of them had higher absolute donation reaction than other donors. when each variable was adjusted for other variable by regression analysis. young age, first time blood donation, anxiety, fatigue, starvation were significant (p < . ) and the others were not. conclusion: donation -related vasovegal syncopal reactions are a multi factorial process. these reaction are more prevalent in blood donors who are young, first time donor, anxiety, fatigue, starvation. these reactions might be predicted vasovegal reaction and these some facth donors need more care. with better donation care, syncopal reaction may be decrease this would be improved donor safety, better donor retention, higher donor satisfaction, and reduce cost and increase regular blood donors. to avoid iron deficiency in blood donors, iron compensation is necessary in most females and males who donate more than - and - whole blood units per year, respectively. we present studies dealing with different dose and duration of iron compensation. in the first randomized placebo controlled study iron decreased continuously in males and females at donation intervals of two (males) and three months (females) without iron compensation. mg and mg daily combined with mg ascorbic acid over months (males) or months (females) compensated for iron loss or even overcompensated in females. in the second open study we reduced iron dose to mg daily over one month for both genders. this iron dose was sufficient for compensation of iron loss. a further reduction of iron dose to mg daily over half a month led to negative iron balance in the majority of donors. in all three studies donors with exhausted iron stores profit more from iron compensation, whereas donors with high ferritin values (> mg/ml) tend to loose storage iron. aim of the study: one of our campaign strategy how to increase blood donation among adolescents are periodical seminars and excursions for students of secondary schools (more than per year). the aim of this study is to analyze impact of our campaign educational system on adolescents in period - . methods: the donation of whole blood and aphaeresis platelets from donors of age from to (max. years for each class) were count for the period of five years ( ) ( ) ( ) ( ) ( ) . the percentage of the man´s donation was calculated for each target class ( ) ( ) ( ) ( ) ( ) . results please see tables and . in the tables there is shown observed data in relation to the total number of births in the czech republic in reviewed years. the study showed that number of donation from donors of age from to decreased during objected years. unfavourable state of total number of births in the czech republic ( birth in republic ( birth in , birth in ) and its decreasing tendency ( birth in !) is with high probability a major demographic factor affected number of young donors. despite energy invested in our campaign educational system our recruitment efforts should be intensified to decrease influence of demographic factors. we should find new ways and methods to attract new blood donors and keep the regular ones, too. the aim of the research was to investigate women's attitudes towards blood donation in cyprus. a statistical sample was selected using stratified sampling and consisted of women from the district of limassol (the second largest urban center of cyprus) between the ages of and . using linear logistic regression, the analysis of the data collected revealed that there is a greater probability for a woman to be a blood donor if she is of a higher educational level, a member of an organized group or association, or if she is acquainted with other blood donors. the percentage of female blood donors is higher in rural areas than in urban centers. % of women do not donate blood and attribute their reluctance to do so to health-related problems, while about % of those who have never donated blood claim to fear the blood donation procedure. in addition, more than half of the women who have stated they would never donate blood again have attributed their denial to healthrelated problems. the research revealed that there could be an increase of up to % of the percentage of female blood donors if they were given time off work for a few hours or one or two days afterwards. even though very few female blood donors expressed a preference for the blood donation to take place on a particular weekday, half of them prefer the donation to take place on the discussion: it is about small group of students. the impression is that the altruistic behaviour is present at most of the questioned students. the fact about free school days is not underestimated because it is one of the most important motives of blood donoring of the young population. families where the blood donoring is a tradition have a great influence for young children because the children in these families are better informed for blood donoring. conclusion: including the children in the process of education for young children is of particular importance because the altruistic behaviour as a higher feeling is from an early age of the child and it is under the influence of the environment (family and friends). active participation of the department for transfusion medicine in the educational process, especially in the education of young children, is a guarantee to achieve longlasted positive results. adverse reactions in blood donors taking betablocking antihypertensive medications l paesano*, m d'onofrio*, s misso † , g fratellanza* and e d'agostino* *university federico ii, naples, † hospital san sebastiano, caserta, italy one aim of blood donor's selection is to avoid an adverse reaction to phlebotomy (as vasovagal reaction, syncope and/or hypovolemic cardiac insufficiency). blood donation is surely contraindicated in various pharmacologic therapies, but not in all. in fact a certain degree of discretionarily exists about the assumption, or the period of suspension, relative to a numerous pharmaceutical products, as the antihypertensive agents. according to literature, the deferral of donors taking antihypertensive medication is not indicated when blood pressure is normal, symptoms are absent, and diuretics or similar agents are the only drugs used. on the contrary, it is a common opinion that an antihypertensive therapy by betablockers is not compatible with blood donation for its cardiac effects. nevertheless, in our daily activity, the observation of a blood donor taking beta-blocking drugs may occur for various causes. a possible error is a superficial pharmacological anamnesis, as it can occur in donations on autohemotheca, for a too fast medical visit (due to a large number of donors), or for the inexperience of the selector (often a not specialist of transfusion medicine young doctor). another possibility of observation is constitute by patients, undergoing to elective surgery, included in a program of autologous blood donation, suffering hypertension treated with betablockers. in fact, in this last case, the risk/benefit balance justify the blood letting procedure. in the last year we have just observed two severe post-donation reactions in donors suffering hypertension treated with atenolol. the reactions have been similar, in fact both donors showed lypotimia followed by convulsions about past half hour by the end of phlebotomy. no prodromic symptoms have been observer or referred. cardiac frequencies (cf) before donation were respectively and beat per minutes and blood pressures (bp) were both in the normal range ( / and / mmhg). after donation, during adverse reaction, cf showed no substantial variations, while bp have been decreased respectively to / and / mmhg. immediate treatment has consisted in putting the donors in the trendeleburg's position and in applying a dolorous stimulation. in the first case this treatment has been sufficient to report the bp to / mmhg (with disappearing of all symptoms) in only half hour time. in the second one, the marked hypotension showed a very slow remission, for this reason the subministration of a plasma expander needed, with the complete resolution of the symptoms after two hours. these two donors were not deferred from donation because they were periodic donors that had modified their antihypertensive therapy, without referring it neither in the questionnaire nor during anamnesis. our experience confirms that the blood donation don't must be permitted to subjects taking betablocking antihypertensive drugs. in fact these medications act on cardiac pump decreasing the cardiac rhythm and limiting the postdonation cardiac recover. this effect is very dangerous because it appears relatively in retard respect to the end of donation, when donor may have just leaved the transfusion center. introduction and aim of the study: in society under transition privatisation and marketisation probe all areas of life. transition to market economy is extremely important and sensitive issue in health and welfare services in general, and specifically in the case of blood transfusion service. the aim of the study was to analyze effects of confusing publicity which introduced possible ways of transforming blood transfusion service in serbia (ideas about privatization of some parts of national blood transfusion institute, buying blood from blood donors, selling blood from voluntary blood donors to private clinics, exporting blood from vbd, stories about tradition of paid blood donations in some european countries). publicity was restricted to a small number of sporadic outbreaks concerted in a limited period of time. table. conclusion: surveillance of adverse reactions and injuries or accidents during or after blood donation is essential for maintaining the well being of active blood donors, as well as for the safety and quality of the donated blood components. information on other activities and parameters affecting the quality of blood including materials, reagents and equipment should be collected and any serious deviations from standard operating procedures should be notified to the competent authority using haemovigilance infrastructures. skae has built up such procedures working along the lines of the european haemovigilance network. improvement of existing national haemovigilance systems is expected to follow from the implementation of the eu directive. although inevitable, blood donor deferrals lead to losses in donated blood supply and may affect donor-return rates and subsequent blood donations. to estimate the scope of blood donor deferrals and their causes, we analyzed the - data from regional blood centers using standardized criteria for temporary and permanent blood donor deferrals. within this period ( ) ( ) , . percent of persons who presented for donation were deferred; . % were temporary deferrals ( % due to laboratory test results, among others low hemoglobin, . % due to risk of acquiring a transfusiontransmissible infection) and . % were permanent ( % due to the infectious diseases markers, . % due to cardiovascular diseases). for regional blood centers the temporary deferral rates varied widely (see the table below ). in the case of individual regional centers, the differences as well as the most common causes were often difficult to explain. according to our analysis, some blood centers have a more restrictive approach to donor acceptance than others and this results in increased donated-blood loss. to some extent such losses could be avoided. further studies are recommended to elucidate the problem and eliminate unnecessary deferrals. caption : percentage of deferrals aims: from our experience in selecting blood donors, a certain number of issues have been noticed that remain obscure and need to clarification since those seem to 'haunt' the whole process of blood donation. methods: many first time blood donors and especially volunteers think that rejection reasons are permanent and they are completely incapable of donating blood their entire life. this is a 'tragic' misunderstanding since the doctor did not explain that the reason of the rejection is only temporary and in the future this man is capable of donating blood. those potential donors will never even approach again blood donation centre and when in the future they are asked why they do not donate blood, they repeat the cause of the past rejection. results: one of these rejection reasons is for example low blood pressure ( . % of total causes of rejection). as we all know blood pressure must be determined according to age, sex, weight and from other factors as sleep, emotional status, food and liquid intake. therefore blood pressure is very important but should be evaluated with all the above factors and must not be alone the only reason for rejection. even when one blood donor is rejected it should be made clear to him that this is only temporary and if in the future he is in better physical condition, he could donate blood. in fact - % of those donors rejected for hypotension are readmitted in blood donation after meeting the above mentioned criteria. another matter of equal importance is anemia ( . % of total causes of rejection), especially concerning young women. since most of those women tend to develop anemia due to depletion of iron stores, they should be advised to donate blood at longer periods than regular, to receive proper medication and diet according to their needs. the doctor must explain the donor the reasons for iron depletion, so blood donation should not be considered as the only cause for this situation from the donor. there are many factors contributing to anemia, menses, specific diets, overwhelming stress and exercise, not to mention other medical reasons. it is the duty of the doctor to correct those factors that resulted in iron depletion or anemia and readmits those donors in blood donation in the future ( - % of those rejected are readmitted in our centre). summary/conclusions: at our blood centre we have created a program of regular tests (blood tests-physical examination) for all our blood donors. our experienced and well taught personnel offers advice and provides useful information in every aspect of blood donation and more. we have created a friendly environment for all our volunteers with love, understanding and appreciation and believe that this is the only way to keep a constant 'flow' of blood in our region. introduction: an innovative perception for blood donation in a new and evolving environment must focus on specific matters and ideas and adopt in a certain level lifestyles and concerns of society. aims: the purpose of this study is to find methods and ideas that can help blood donation centers throughout our country to create new blood donors, give a motive and inspiration for blood donation by adopting new trends of society and finally accomplish national need. methods: by having a personal interview with many volunteers about their feelings for healthier life, their nutritional habits, daily physical activity, sports, vitamins, smoking, weight, cholesterol levels. we investigated whether they believe that blood donation has, if any role towards a more hygienic life. results: we divided blood donor volunteers according to their age, educational level, and number of blood donations per year. our results indicated that there is a tendency among young educated people to adopt a personal lifestyle that includes consuming healthier food, keeping their weight low close to the ideal, having some kind of personal activity, not smoking, watching cholesterol levels, following doctors advice and concerning seriously about their health. this dynamic group of blood donor volunteers considers blood donation as a contributing factor to well being and donates blood at specific intervals. besides the yearly run lab tests that are done by our blood centre they also seek advice and discuss any matter concerning their health with the blood centre doctor. it appears that they are extremely sensitive in those matters and they seem to appear well informed about issues concerning their health, they also believe that blood donation is part of the plan they have to keep fit and being well. in our blood centre we encourage this belief and we also provide information concerning this new trend towards healthier habits. summary/conclusions: this approach has already shown some positive results in our blood centre as many people especially young educated women have joined our blood donorship program and donate blood at scheduled intervals. in order to achieve our goal which is to raise the percentage of blood donors in the region we have to be flexible, innovative according to new habits and lifestyles. we have to move with society and modernize the way we attract various groups of people. blood donation against prejudice as saltamavros*, s dimitrakopoulos † , v zacharaki*, p giannaros*, s markou* and p tseliou* *st. andrews hospital patras greece, patras, † pyrgos general hospital, pyrgos, greece introduction: in order to achieve a greater population to be admitted in blood donation we have to provide information concerning any obscure issues that presents in selecting donors. to examine the accuracy of hb measurements obtained by the noninvasive clinical device, as compared to values detected by standard methods, (cell-dyn , abbott laboratories, usa), in a blood donor setting. methods: the nbm- device utilizes a finger base sensor using occlusion red/near-infrared spectroscopy (o-rnirs) to detect and analyze the hb/hct levels. the clinical trials were conducted at two blood donor centers (israel and usa). studies were carried out on a group of subjects ( females, males) aged - . subjects were healthy volunteers who had come to donate whole blood or aphaeresis components. after obtaining informed consent, hb/hct levels of all the study volunteer participants was tested non-invasively, using the nbm- device, followed by a venous blood sample. additionally, the usa center tested a capillary blood sample using the hematastat hct measurement device ( donors). hb levels were considered normal when readings were equal to or > . g/dl. results: venous hb measurements ranged from . - . g/dl. the mean nbm- hb level was . ± . g/dl, only . g/dl lower than the mean hb result obtained by venous sampling, which reached . ± . g/dl. the standard deviation of the difference between the invasive and noninvasive hb readings was found to be ± . g/dl. the mean absolute error (mae) of their difference was . g/dl. when checked against the cell-dyn in the usa center, where subjects had hb of . g/dl or lower, the nbm- and hematastat devices showed comparable sensitivity results. the nbm- using o-rnirs is a promising noninvasive technique for hb screening in blood donors. the device is easy to use and agreeable for both blood donors and personnel. the technique reduces the need for the invasive finger prick or venous blood sampling, thereby enhancing safety, reducing costs, and improving the experience of blood donation. the effect of short-term, temporary deferral on blood donor return rates and subsequent blood donations background: blood donors are deferred for numerous reasons. some deferrals like intravenous drug use, male homosexual contact or certain positive test results are permanent. the majority of donor deferrals, however, are short-term temporary deferrals (sttds) that are resolved in a matter of days, weeks or months, after which time the person is again an eligible blood donor. the effect of sttds on blood donor return rates and subsequent blood donations is studied. materials and methods: donors given sttds during the december to march were computer-matched with non deferred donors on the basis of age, sex, and donation date (case group: donors -control group: donors). computer records were evaluated during the next years ( march to march to determine donor return rates. significance for comparison between the two groups was based on chi-square analysis. results: the most common reasons sttds were elevated blood pressure ( %), deferred for medication ( %) and colds and/or sore throats ( . ). non deferred donors were a little more likely than donors with sttds to return over the next years ( . % vs. . % pv = . ) and non deferred donors donated more whole blood units. . according to ethnic structure, women -ethnic macedonians donate blood in largest numbers - ( %), while all other ethnic groups are present with only %. the most prevalent is the group of adults aged - ( - . %), with high school education - ( . %) and mostly those who donated blood - times ( - %). conclusion: having in mind that % of the population in macedonia is female, the obtained results reveal a significant, yet insufficient participation of women in blood donation with % in relation to the total number of blood donors surveyed in the period - . this is due to insufficient motivation and education of women from all ethnic groups especially those from the younger population and with elementary education. incorporating them in education and organization would contribute to their more extensive participating in blood donation. comparison of serum beta -microglobulin (b -mg) between hbsag positive donor and healthy control f tarabadi*, m shaeigan*, g babaee † , a talabiean* and m khadir* *iranian blood transfusion center, † tarbiat modarrs university, tehran, iran background: beta -microglobulin (b -mg) is a low molecular weight protein ( daltons) and found in all biological fluids it is light chain of histocompatibility class -human present on the most membranes of cells. in the hepatitis infection the viral antigen presentation on the hepatocyte in the presence of class -hla antigen plays a role in the elimination of the virus. method & samples: beta -micro globulin was measured in serum drawn from hbs ag positive blood donors include ( . %) female and ( . %) male in age between - years, and healthy ( %) female and ( %) male in the same age we detected serumic b -mg by enzyme immunoassay (ela). results: our studies showed b mg level increased in ( . %) hbs ag positive donor that was significant differences with healthy control (p = . ). conclusions: it seems that serum b mg is a good marker for hbs ag replication. the role of b mg in monitoring of response therapy needs to be more evaluated. and ( . %) were contributed by vd, rd and dd respectively. over the last / years, voluntary donations have shown a rising trend from . % to . %, where as rd ( . % to . %) and dd ( . % to . %) have shown a declining trend. the percentage of female donors was maximum in voluntary group as compared to rd and dd ( . % vs. . % vs. . %) respectively. the rates of all tti markers reactivity were significantly higher in rd as compared to others donors. the hbsag and anti hcv reactivity in vd and dd is comparable ( . % vs. . % and . % vs. . %). hiv antibodies was found more frequently in vd as compared to dd [ . % vs. . % (p < . )] whereas, vdrl reactivity was lower in formal as compared to latter [ . % vs. . % (p < . )]. conclusion: voluntary blood donation has shown a rising trend over a last few years, thus highlighting efficient donor motivational strategies. these strategies need to be strengthened to increase the female donor base. the safety of dd is equivalent to vd when the rates of tti are compared. thus, dd should be advised to donate blood regularly as voluntary blood donors. blood safety depends on a number of factors. the chain of safe blood starts with the donor. one of the procedures for obtaining safe blood for transfusion is the medical selection based on the completed questionnaire and the possibility of self-exclusion from the process of blood donation, the medical history of the potential donor and the medical examination. donor selection consists of two sets of information necessary for protection of the blood recipient as well as the donor himself. aim: to present the most frequent reasons for declining volunteer blood donors. material: the materials used for analysis were the questionnaires completed by all the potential blood donors at the transfusion department of the medical center in strumica as well as the record books of the blood donors which contain the results of the analysis we make for the potential donors. these donors donated blood in the period between and . results: during this period people volunteered to donate blood, out of which were allowed to donate blood, while were declined. out of the total number of blood donors were male and female donors. the reasons for declining potential donors were the following: . % had low levels of hb, . % were taking antibiotics, . % were ill, . % had low blood pressure, . % had high blood pressure, . % for other reasons. conclusion: donor selection and their care on one side and obtaining safe blood for transfusion on the other side entails obligatory organized medical control. the obligatory completion of questionnaires, the medical examination of the potential donor and their self-exclusion as a result of the feeling of personal responsibility as well as the obtained information are very important for the selection of quality blood donors and obtaining safe blood for transfusion. questionnaire on subjects-students, their knowledge and motivation on blood donation f vladareanu, a bugner and s sirian national institute of heamatology transf, bucharest, romania the research theme of this questionnaire is as follows: 'what is the level of knowledge and of motivation in the non-remunerated and voluntary blood donation at students?' we also tried to see the practical implications that this study will have and how it will influence the knowledge in this area. the purpose of this questionnaire was not dissimulated. the general theme of the knowledge and motivation on blood donation had been studied before through two big questionnaires applied in and , but the general population was their target. students had never been an investigated lot up to now. the hypothesis referring to this problem is as follows: students are not informed either on the act of donation, or on the crisis of blood. . the lack of information is a first cause of the indifference of the studied lot towards the idea of donation. . the lack of motivation of the studied lot is another cause. the questionnaire was applied on a lot of students from seven different cities: bucharest, iasi, constanta, cluj, sibiu, brasov, timisoara. the number of the questions was limited to , which we consider best for a questionnaire applied on the street or at college. as a conclusion, we can say that a passive-defensive attitude towards the blood donation was revealed after this questionnaire. not knowing the issue caused by their lack of information sometimes determines indifference at the statement of the subject. on a general dissolution environment of the responsibility of the youth, the donation problem is not in their aria of preoccupations, the general attitude being of non-involvement for the moment, at this idea which is not yet in every individual conscience and which is normally administrated at an institutional level. the donor data and the details of blood application of the north west transdanubian region of hungary k vÖrÖs*, c bercsÉnyi † , o petrÓ † , r jÁger † and e miskovits ‡ *hungarian national blood transfusion s., györ, † blood bank, tatabánya, ‡ headquarters hungarian n.b.s., budapest, hungary the ongoing fundamental reorganization of the blood service began on the . . in hungary. as the consequence of reorganization till . . , blood banks had been established instead of existing before, under direction of the hhnbts. the working profile of the regional blood centers and local blood banks will be changed step by step. virus screening, blood group serology and processing will be made in the regional centers. one of the regions is the 'north west transdanubian region' (nwtr, city györ as the center, with about inhabitants and hospital beds). local blood banks (tatabánya, sopron, and szombathely) are belonging to nwtr. the regional center and the local blood banks provide the labile blood products and high level clinical-transfusion service (cross-matching, antibody screening, outpatient immunhematology investigations, etc.) for the hospitals. annually donors donate blood in this region. this donation activity covers about the % of all inhabitants. the acceptance ratio of the donors is good ( - % of the donors were deferred). there are hospitals in our region. the regional demand on rbcc is - . u/year, on ffp is . - . u/year and on pc is - . u/year. the poster shows the donor data and the details of blood application of this region since . p- implementation of rbc collection using haemonetics mcs ® +: medical staff training, donor recruitment and acceptance g woimant, c fretz, d puydupin, e pÉlissier and jl beaumont efs ile de france, paris, france background: single donor rbc collection is an approved apheresis technique in france. aims: our goal was to evaluate the implementation of rbc collection in our center in terms of donor recruitment and acceptance, as well as medical staff training and adaptation. methods: donors were selected according to the french requirements for rbc collection (weight ≥ kg, height ≥ cm, hb ≥ . g/dl, ferritin ≥ ng/ml for repeat rbc donors). all personnel were trained on adequate communication with donors. eligible donors were contacted by mail, by phone or during pre-donation interview. among the recruited donors, all donors were male, % were regular whole blood donors, % were regular whole blood or apheresis donors and % were new donors. the medical staff was trained on rbc collection with the sdr protocol and disposable set ln pf on the mcs ® +. most of the medical staff was already used to autologous rbc donation with similar apheresis devices. blood samples were taken from donors pre-and post-donation, as well as to months later for those returning for a subsequent donation. donors were asked to fill out a post-donation survey for assessing donor comfort and information. results: donor profile and clinical follow-up are summarized in table . six percent of the donors had a ferritin level below ng/ml; these donors were regular whole blood donors. the collections were well tolerated and no changes in vital signs were noted. four reactions were reported: hematomas and citrate reactions. no reaction was observed post-donation and hemoglobin levels measured before next donation were back to normal. the technique was easily implemented by the medical staff and fitted well in the existing blood center processes. the medical staff as well as the donors found collection duration short (average of min). the results of the survey were very favorable as more than % of the donors considered their donation and the information they received as satisfying. most of them agreed to donate again and several actually donated twice during the evaluated period. conclusion: the implementation of rbc collection in our center, using haemonetics mcs ® +, was successful in terms of ease of use of the technique, as well as user and donor acceptance. we now plan to evaluate donor loyalty in the longer term. risk from first-time blood donors e zhiburt, s golosova and p reizman federal blood center, moscow, russian federation introduction: each third dose of whole blood in russia is donated by first-time blood donor. there are two reasons for attention to this kind of donors: ( ) possible risk of infectious disease in seronegative study; ( ) possible risk of donation for person with contraindication. aim of the study: we investigated role of regional deferred donors registry (rddr) in by first-time donor selection. methods: moscow rddr includes parts: hiv, viral hepatitis, syphilis, tuberculoses, malaria, drug users, psychiatry, days after blood donation. rddr was complete and our center began actively work with it since last year. each donor has to be registered in rddr and automatically checked for deferral reason. effectiveness of rddr was investigated. results: first-time donors donate less than % blood in our center. about a quarter of them are deferred before possible donation. part of donors deferred by rddr has been significantly increase in (c = . ; p < . ) at the expense of seropositive people. conclusion: rddr is effective for blood donor selection and decreases necessity in laboratory screening. first-time blood donors have to be examined before blood donation. if they have not contraindications, donation can be performed up to days before examination and screening. the double unite platelet production is important especially if the relatives of patient find the donors. we evaluated the effectiveness two apheresis machine for platelet collection. in our blood bank, one fenvall amicus and one cs + apparatus were used for platelet apheresis. apheresis were performed between / / and / / . including criteria of donors are that estimated process time is smaller than minute and estimated postapheresis platelet count is higher than ¥ /l. donors firstly was enrolled to amicus. if amicus was busy, then it was enrolled to cs. the properties of our donor populations were given in blood and plasma cell components are obtained either by traditional manual method from whole blood or by apheresis. modern medical treatment is based on transfusion of deficient components such as erythrocytes, leukocytes or plasma proteins. this involves new solutions to achieve higher yields and better quality of such components. the aim of our study was to estimate the efficacy of blood cell separator cobe trima in obtaining platelet concentrates (pcs) as compared to older-generation cobe spectra blood separator. apheresis procedures were performed on both these blood cell separators. the quality of platelet concentrates was tested during day storage period (see table below ). we have tested the effect of apheresis procedure on donors and estimated the operating comfort of both separators. the tolerance of both separators was satisfactory except for more frequent hypocalcemia when trima separator was used. most donors were more satisfied with trima procedure because of single venipuncture although it involved special donor selection (good vein access). in general we may say that trima is undoubtedly a more modern and more friendly separator. however, cobe spectra may continue to be used with success especially when a more versatile cell separator is necessary (leukocyte concentrates, peripheral blood stem cells or therapeutic apheresis). methods and results: tls ( procedures on patients) were used successfully in patients with acute or chronic leukemia with hyperleukocytosis (white cell count > ¥ e /l or blast count > ¥ e /l) when high cell count would promote leukostasis with vascular occlusion in the microcirculation. performed tl procedures were rapidly reduced both the white cell count and the whole blood viscosity. average fall in white cell count after treatment was . %. tp-treatments ( procedures on patients with symptomatic thrombocythemia and/or platelet count higher than ¥ e /l) were applied in order to prevent the development of 'thrombotic-hemorrhagic syndrome' . the tps performed resulted with rapid platelet counts reduction ( . % in average) and with clearly noted clinical improvements, subsequently. tes ( procedures on patients) were performed using manually technique in patients with 'cellular hyperviscosity syndrome' induced by high red blood cell count. it was shown that te procedures resulted to red blood cell number lowering and decreasing of blood hyperviscosity. average fall in hemoglobin and red blood cell concentrations after te treatments was from . % till . %. rbcx treatment ( procedures on five patients with malaria and two with severe aiha crysis) was performed on an urgent basis, particularly when clinical symptoms indicate life-threatening situations and resulted with rapid and significant reduction of concentration of unwanted pathogen affected rbcs and summary/conclusion: the effects of tcs depended on the nature and stage of the basic hds, of adequate selection of patients and of timely applied apheresis. rapid cytoreduction is obtained justly in patients with excessively high cell count, and this effect did not associated with bone marrow remission. thus, tc should be looked upon as adjunct to the standard treatment of different cithemias, but not as replacement therapy. the present study indicates that the best therapeutic effects were obtained by rbcx. were carried out with continuous flow blood cell separator cobe spectra and all patients underwent large volume leukapheresis (lvl). in all procedures, a blood warmer was connected to the return line and a continuous calcium infusion was administered preventively. six patients, who were under kg body weight, had the extracorporeal circuit primed with irradiated, filtered packed red cells diluted with % albumin solution. seven children had vital signs and ecg continuously monitored during the procedure. results: each patient underwent a median of collections (range - ). the inlet blood flow ranged between . and . ml/min (median . ml/min). the median blood volume processed was ml (range - ). leukapheresis lasted a median of min (range - ). the median total nucleated cell yield was . ¥ e /kg (range . - . ), mononuclear cell (mnc) yield was . ¥ e /kg (range . - . ) and cd + cell yield was . ¥ e /kg (range . - . ). the median of mnc collection efficiencies was . % (range . - . ). in ( . %) patients, in only one apheresis procedure more than ¥ e cd + cell/kg were collected. during ( . %) procedures patients had experienced apheresis-related side effects. the citrate-induced reactions were most commonly observed. the reactions were mild and cessation of collection was required only in one case, because of catheter related complication. mild sedation was required only in few very small children. post-donation platelet count was less than ¥ e /l in cases and these patients required platelet transfusion before subsequent procedure. our results show that lvl in pediatric patients is relatively safe procedure, well tolerated and with a very low risk of serious adverse events. close monitoring of blood counts, especially platelets, between pbsc collections is necessary. the cessation of procedure was required in only one case and no life threatening side effects occurred. neonatal alloimmune thrombocytopenia (natp) caused by fetomaternal mismatch for human platelet (plt) alloantigens (hpas) worsens approximately / pregnancies and can lead to a serious bleeding diathesis, intracranial hemorrhage (ich) and sometimes death of the fetus or newborns. we describe the successful management of a -year-old pregnant woman, alloimmunized to the hpa- a (p a , zwa) antigen, with a history of two previously children with severe thrombocytopenia and ich. the pregnant woman was at her terminal pregnancy and was suddenly admitted. to evaluate the risk of ich in the fetus, cordocente was performed to demonstrate fetal thrombocytopenia (plt . /mmc). to ensure a rapid provision of compatible negative-antigen platelets, we decide to collect platelets from the mother using apheresis. plateletapheresis was performed using com.tec separator, fresenius. blood processed was . ml in a short time procedure ( minutes). no significant adverse effects were observed in the mother and fetus, during and after the procedure. platelets collected ( . ¥ e ) were transferred to the preparation set and plasma was removed after centrifugation to resuspend the platelets in octaplas ab. then we separated the platelets into two units containing . ¥ e each. the day after the donation, the mother gave birth to a girl by caesarean section. after the transfusion, the plt account increased from . /mmc to . /mmc and after a week the child had plt . /mmc without hemorrhagic complication. according to the literature data and our observations of the patients, there are changes of the hemostasis system indexes in the most patients with the endogenous intoxication syndrome and immune disturbances. in the number of cases medicamentous therapy appears to be not enough to normalize the changes, but it is especially important for pregnant women and women in childbirth, because on the background of these disturbances different complications of pregnancy and postnatal period take place. the aim of our study was the substantiation of plasmapheresis using in complex therapy of purulent inflammatory complications in obstetrics and immunoincompatible pregnancy with hemostasiologic disturbances. patients with hemostasis system disturbances: one woman in childbirth with exacerbation of chronic pyelonephritis, who had in the first hours some signs of hypocoagulation on the background of permissible blood loss (prolonged coagulation time up to - minutes with episodes of its absence on the background of the normal indexes of general coagulogramm, quantity and function of thrombocytes and the dilute fibrin monomer complex level in times higher than the norm) and nine pregnant women with the perinatal losses in anamnesis severed by the pregnancy (threat of abortion, places of fetal egg detachment). these women were examined, the following was revealed: the high antibody titer to chorionic gonadotropin, parameters of partially activated thrombin time were higher than the norm ( - seconds), thrombin time ( - seconds), the dilute fibrin monomer complex ( - mg%), coagulation time ( - min). in all these cases the conservative methods of treatment (antibacterial, hemostatic, hormonal therapy) were effective for a short period of time and they didn't succeed to correct the given parameters of hemostasiogramm. the discrete centrifugation plasmapheresis was included in the complex of medical treatment. the woman in birth operations were done, in the programme of plasma replacement during the first two plasmapheresis procedures donor fresh-frozen plasma was included. six pregnant women on the given stage one course consisting of plasmapheresis procedures for plasma replacement with crystalloids was done, the volume of the removed plasma was - % of the circulating plasma volume. three pregnant women before delivery were required two courses of plasmapheresis more consisting of - procedures each. the system heparin was not used. in all patients already after the first procedure of plasmapheresis the normalization of hemostasis indexes was marked, that allowed to prolong pregnancy, to prevent the coagulopathy bleeding and the development of disseminated intravascular syndrome. four women are discharged from the hospital, the other patients are observed with progressive pregnancy. thus, the using of discrete centrifugation plasmapheresis is effective at the signs of hypocoagulation in patients with isoimmunisation with fetal antigens and infectious pathology, and is the reserve in prevention and treatment of obstetric complications. extracorporeal photochemotherapy: an alternative therapeutic approach to control graft versus host disease after allotransplant with reduced intensity conditioning regimen c del fante*, c perotti*, gl viarengo*, p bergamaschi*, p pedrazzoli † and l salvaneschi* *irccs policlinico s. matteo, pavia, † ospedale niguarda cà granda, milano, italy background: extracorporeal photochemotherapy (ecp) can be defined as an immunomodulatory therapy that demonstrated to be efficacious in treating patients affected with graft versus host disease (gvhd) after allotransplants for oncohematological diseases. reduced intensity conditioning regimen (ricr) for allotransplant is a relatively new practice in patients (pts) ineligible for a conventional myeloablative conditioning regimen. the use of immunosuppressive therapy (ist) to control gvhd is limited for the high risk of developing infections and disease relapse due to the strong reduction of graft versus tumor (gvt) effect. aims: to evaluate the effectiveness and safety of ecp in treating pts affected with gvhd post rcr and the possibility to taper, at the same time, the ist. methods: pts ( females, male), median age . years ( - ), affected with agvhd grade ii ( ) and extensive cgvhd ( ) gtx with median total granulocyte doses of ( - ) ¥ per gtx corresponding to . ¥ granulocytes/kg in children and . ¥ granulocytes/kg in adults. the wbc counts increased from baseline values of . ( - . ¥ ) g/l for both pediatric and adult patients to peak values of . ( . - . ) ¥ g/l (children) and . ( . - . ) ¥ g/l (adults) at one hour after gtx and to . ( . - . ) ¥ g/l (children) and . ( . - . ) ¥ g/l (adults) at hours after gtx. in out of patients ( %), the crp levels significantly declined ( ( - )%; p£ . ) during the granulocyte transfusion period; in almost all cases ( / ; %) after the initial or nd transfusion. thirty-eight patients ( %) were alive at day + after termination of neutropenia and gtx. patients without crp response to gtx ( / , %) and patients with severe viral infections / ( %) were not among the day + survivors. background: in recent years, the use of platelet concentrates obtained from single donors by automated apheresis has grown steadily. plateletpheresis donation is considered to be a safe procedure with modern instruments. so far, no studies have identified donor or procedure specific factors that may be associated with serious adverse events. aim: to evaluate the incidence of adverse events during plateletpheresis procedure, over a five-year period in our hospital. materials and methods: eight hundred single-needle plateletpheresis collections were performed by using two automated intermittent-flow cell separators: of them with mcs p and with mcsplus (haemonetics), according to automatic standard protocols a p and ldplp, respectively (with the collection of an additional plasma unit). acd-a was used as the anticoagulant in all apheresis procedures (acd-a: blood ratio was : ). most of the donors ( % men and % women) were patient´s relatives. half-hour before the initiation of the procedure, mg of calcium ( tablet cal-c-vita) were administered to each donor. the mean platelet yield was . e /unit. the overall rate of the donor related adverse events was . %. feeling faint was the most frequent event, which was occurred in . % of donations. hypotension and citrate related rates were . % and . %, respectively. all citrate related symptoms were only transient perioral paresthesias, which were relieved by slowing the i.v. rate, without additional administration of oral calcium. donor unconsciousness was the only observed severe event, the rate of which was . %. other adverse events were venipuncture related ( . %), machine related ( . %) and miscellaneous complications ( . %). ( ) plateletpheresis using the mcs p and the mcsplus automated cell separators is a safe procedure, with a low risk of serious adverse effects. ( ) with the used acd-a-to-blood ratio ( : ) satisfactory platelet concentrates were obtained with very low incidence of citrate-related events. ( ) the peros administration of calcium before the initiation of the procedure, probably lowers the rate and the severity of hypocalcemia symptoms. quality assessment of ffp collected as a byproduct of plateletpheresis . from the donors immediately with the initiation of the procedure (citrated whole blood) and . from the final platelet concentrates after one hour rest at room temperature without agitation. in vitro platelet response to the aggregation-inducing agonists adp, collagen, ristocetin and arachidonic acid was investigated by means of an aggregometer (pap- c, bio/data). results: there were no significant differences between the groups of donors with respect to age, sex, smoking habits, preapheresis wbc and plt counts and hemoglobin concentration, as well as in the harvesting time between the two cell separators. our findings are shown in the following table. mildly decreased response to all agonists was observed (mainly to adp and arachidonic acid) in the samples taken right after the initiation of the procedure, in both groups. platelets from the final component showed a further slight decrease in response to adp, which was more prominent in the mcs p device (p = . ). on the contrary, an increase in platelet response to the other three agonists was observed in both devices, which, however, was statistically significant upon collagen and ristocetin stimulation. conclusions: reduced response to aggregation stimuli is possibly caused immediately with the initiation of the apheresis process. literature reports regarding further platelet traumatisation due to the procedure, are rather conflicting. in our study, such traumatisation was observed only in the case of adp in the mcs p obtained collections and this could be correlated with the technological differences between the two devices. recovery of platelet aggregability, as it was expressed by the upregulation in platelet response in the other stimuli, could be attributed to the resting period and seems not to be affected by the timing of the leucodepletion procedure. background: lupus erythematosus often is accomplished with severe symptoms, such as polyarthritis, nephritis, pericarditis or dermal alterations. in pregnancy cytostatic therapy affects gestation. on the other hand the course of disease can be refractory to corticosteroid therapy. elimination of autoantibody and immuncomplexes by plasmapheresis could be an efficient way to amend the severity of symptoms. a year old pregnant woman in the th gestation week with systemic lupus erythematosus showed severe symptoms like polyarthritis, nephritis and pericarditis. treatment was initially mg/kg bw prednisolone for weeks and subsequently mg/kg bw for weeks. plasmapheresis was applied daily in the beginning and continued depending on the condition of the patient ( table ) . the eliminated plasma was substituted by fresh frozen plasma. the medium volume was . ml per apheresis. after day plasmapheresis treatment was suspended to avoid problems with coagulation and was followed by a cycle of immunoabsorptions to eliminate circulating immuncomplexes. results: prednisolone therapy alone brought no effect even after changing to high-dose treatment. a significant amelioration of all symptoms could be observed after the first plasmapheresis. good condition of the patient remained stable over the period of daily plasmapheresis for days. intermitting apheresis treatment for one day lead to a significant aggravation of symptoms. apheresis no. again lead to a recovery of the patient which held on until day . conclusions: treatment of systemic lupus erythematosus in pregnancy especially in combination with resistance to corticosteroid therapy, is an effective therapy to ease severe symptoms such as polyarthritis, pericarditis and nephritis. exposure to cytostatic drugs can be avoided and therefore the impairment of the fetus can be reduced. background: the collection of mnc represents the first step of photopheresis procedures and could be of critical importance in achieving a therapeutic goal. in this work we compare the cell yield of two collection programs on cobe spectra device: the mnc versus the autopbsc program using the ecp procedure modified by andreu. methods: procedures were carried out with mnc program and procedures with autopbsc on patients with cgvhd. both hemoglobin increased from . ± . to ± mg/tu, k+ from . ± . to . ± . mmol/l, level of glucose decreased from . ± . to . ± . to . ± . mmol/l, ldh from . ± . to . ± . ukat/, lactate from . ± . to . ± . mmol/l, ph from . ± . to . . . the volume of apheresis units was lower than wb-rbc, the leucocyte count was normal in all units. the rbc loss by filtration was . ± . ml/tu and was lower than at wb-rbc. in apheresis rbc there were the differences in hb and ht value between the day of storage and , in wb-rbc there were no differences. during the storage period we found no differences in k+ increasing value and no change in ph value between apheresis rbc and wb-rbc, the increasing of lactate was higher in wb -rbc, increasing of ldh correlated to hemolysis. the plasma hb value increase was higher at apheresis rbc in contradistinction to literature. hb and ht correlation in apheresis units according to predonate value in donors was lower than at wb -rbc. the method is a useful alternative to conventional whole blood donation, we get rbc units with high standard of quality and low correlation according to predonate hb and ht value in donors. acknowledgement: the study is supported by grant iga ministry of healthy cr n. nr/ - . background: in life-threatening exacerbations of sle a satisfying efficient therapy is lacking. despite intensive immunosuppressive therapy some patients are resistant or contraindicated to conventional treatment. in particular circulating antibodies and immune complexes play an important role in the pathogenesis of sle and mctd. an extracorporeal removal of these pathological substances may be effective in the treatment of active disease. methods: five patients with severe therapy-resistant sle/mctd underwent immunoadsorption onto protein a. blood was drawn from patients by using a jugular catheter or a peripheral intravenous catheter. anticoagulation was performed with acd-a and heparine or acd-a and r-hirudine. plasma was separated by centrifugation. the . to -fold total plasma volume was treated in every immunoadsorption. the columns were floated with a maximal plasma flow of ml/min. the procedure was carried out every second day. additionally supplementary intravenous immunglobulin therapy was given only once. results: remission of the disease was achieved in four patients. see table below . conclusion: pa-ia is highly effective regarding the elimination of autoantibodies and circulating immune complexes, might induce a remission in patients with sle/mctd. it is an acceptable alternative treatment option in patients when other therapies are ineffective or contraindicated. background: purification of bone marrow from erythrocytes is used to prevent early hemolysis in major abo incompatible allogeneic hemopoietic cell transplantations. erythrocyte depletion is strongly recommended to reduce product volume and stem cell purification before storing autologous and even allogeneic bone marrow in order to prevent early hemolysis and dmso toxicity that might develop after thawing. centrifugation, sedimentation with hes, and cell separating devices are methods for erythrocytes depletion. aim: in our center, we prefer to use cell separation device, since it is a reliable method and has a high-yield and risk of contamination with erythrocytes is low. success of the process is retrospectively analyzed for high and low volumes. method: erythrocytes depletion of bone marrow harvest was done in hemapharesis unit with cobe spectra device in the last five years in cases with bone marrow volume over ml, and cases with bone marrow volume under ml. fifteen of these cases were allogeneic, and were autologous procedures; a software uploaded with cobe pbsc coll vers . and (catalog no: - - ) set was used in the procedure, and at the same time, double bag system with intermediate connectors were used to prevent re-circulation (catalog no: - - ). results: the mean volume reduction was . % ( . - . ) for volumes over ml, and . % ( . - . ) for volumes less than ml. regarding the success of the procedure no statistically significant difference was found between procedures with high and low volumes. no complication developed related to the device or product, and waste bag never had to be re-used. in none of the patients early massive intravascular hemolysis was observed. conclusion: erythrocyte depletion and volume reducing with cell separation device is a reliable method. this process is successfully applied with high volumes (over ml); and in low volumes as well for reducing erythrocytes, and gain of mononuclear cells and cd + cells. platelet concentrates obtained by apheresis procedure-correlation between the initial count and the final concentration v srejic*, g bogdanovic*, z garic*, n vavic* and b balint † *national blood transfusion institute, † military medical academy, belgrade, serbia apheresis team of the national blood transfusion institute processed and classified data of donors who donated platelets by apheresis procedure from january till april . procedures were performed in accordance with the ldplp protocol, using haemonetics mcs+. initial donors' platelet count and the absolute platelet concentration in the final preparation were followed, as well as red blood cell and leukocyte contamination and the volume of the processed blood. donors' initial platelet count was not less than ¥ /l and the volume of the processed blood was not less than ml. according to histogram, the most frequent donors' initial platelet value ranged from ¥ /l to ¥ /l ( %). final concentration of the samples of tested donors ranged from . ¥ to . ¥ in the average volume of ml. regression analysis demonstrated that there was a correlation between the initial donors' platelet count and the obtained final concentrate. student's t test showed p < . . leukocyte contamination of the final concentrate prepared without the filter ranged from . ¥ /l to . ¥ /l. presence of red blood cells in the final concentrate ranged from . ¥ /l to . ¥ /l. p- therapeutic apheresis (ta) in croatian hospitalsadherence to respectable guidelines z zivkovic*, b jeren strujic*, s boras † , i bojanic † , b golubic cepulic † and z ivankovic † *clinical hospital dubrava, † clinical hospital center zagreb, zagreb, croatia introduction: besides considerable resources, ta requires high costs and risk for patients. therefore, indication for ta often considers interests of patient, hospital and requesting physician. the most respectable guidelines for the implementation of ta were defined by aabb and asfa, classifying total of diseases into categories (ctg), ranging from 'standard therapy' to 'lack of efficacy' . the objective of this study was to determine indications for ta performed in croatian hospitals in the period - , respecting aabb/asfa guidelines. results: during the observed period in croatia, ta was performed in patients suffering from various diseases. in ( %) patients ta was performed by membrane filtration, while in ( %) separation by centrifugation was used (table ) . according to the ctg, s of the aabb/asfa guidelines, ta was performed in ( %) diseases from ctg i, ( %) ctg ii, ( %) ctg iii, and ( %) ctg iv of patients. the most frequent indications included in ctg i were: myasthenia gravis ( %), collection of pbpcs ( %), sy. guillain-barré ( %), and plasmacytoma ( %). in ctg ii frequent indications were: poisonings ( %), systemic lupus erythematodes ( %), and rapidly progressing glomerulonephritis ( %), and in ctgs iii and iv: cytoreduction-polycythaemia ( %), thyroid storm ( %), gvhd ( %), and reumatoid arthritis ( %). ( ) the time spent for resolving h / , ( ) mtp / , ( ) discarded blood units / . iii group: wrong data input / , donor replacement / , marking errors / , error in determining blood group at the first blood taking / , errors in input medical consulting / and disregard of prohibitions / . the consequences are: ( ) the time spent for resolving h / , ( ) mtp . / . , ( ) discarded blood units / . conclusion: the analysis of errors has showed that the number of errors can be decreased by implementation of corrective/preventative action based on continual education of the staff, appropriate sop, effective organization, qmp for equipment. the conclusion of our study is that reducing the rate of work errors will decrease the waste of material and time, also that will decrease the number of discarded blood units. an iso standard for blood transfusion? background: in our search for an independent, objective assessment at western province blood transfusion service, we were unable to find one single model that met the specific requirements of blood transfusion. we therefore resorted to developing our own model but ask the question: why not have one international standard for blood transfusion? aims: our aim was to have a standardised system for the independent, objective assessment of our blood transfusion service with audits carried out by an internationally recognised body. we wanted a formalised, professional system of accreditation with inspection checklists, reports, certificates etc. methods: having moved away from accreditation by the american association of blood banks in mid 's, we evaluated various other options such as inspection by our government department of health or the world health organisation but neither organisation had trained inspectors or systems in place. we also investigated iso certification but, although this was acceptable on the quality management side, it did not cover the technical parameters relating to blood transfusion. results: we therefore developed our own model for accreditation that consists of three parts: • a quality management section incorporating iso principles; • a technical section incorporating specifications from the south african standards of practice (we also consulted the european, american, canadian and australian guides); • a laboratory section incorporating iso parameters (soon to be updated with iso ). we then chose to be accredited by the south african national accreditation system, sanas, an internationally recognised institution. once we had written a national accreditation checklist, sanas submitted this to two international accreditation bodies (iaf and ilac) for approval. the system has been in place for three years now during which time we have had four successful assessments. summary/conclusions: in developing our system, we reviewed what was being done elsewhere in the world and it became evident that, although there are great similarities between countries, there p- software for the management of the scansystem bacterial detection method the scansystem tm was developed for bacterial detection in blood products. to be implemented in blood banks, a specific software is now available in compliance with blood bank regulation in order to manage sample traceability and data file transfer. the software is divided in main levels: an administrator level to create an application configuration in compliance with customer needs (product bar code characteristics, frequency of the positive controls, manual or automatic data file transfer . . .), a technical level to manage the operators (password, id) and to validate some specific results, an operator level for routine testing. the software assess sample traceability when testing pools of samples from to more than . indeed, bacterial detection is performed for pools of to platelet samples and to red cell samples. each sample in the pool is traced through its barcode until the final result. the system is compatible with most of the barcode standard including isbt . in addition, the system checks each barcode protecting the sample against duplicate testing. the software assists and monitors the bacterial detection process from the sampling to the end of the test (final result), each step of the procedure is identified through its barcode and at each time, it is possible to know the test status for each sample. for a pool of samples, results can be obtained: 'negative' or 'on hold' for a positive result. for a 'negative' pool, each sample constituting the pool are determined as 'negative' . for an 'on hold' pool each sample constituting the pool must be tested as a single sample and the final result is 'negative' or 'positive' . data transfer may be manual or automatic. a final technical validation is necessary before the transfer through an active selection of results to download. final results are provided in a compliant format for an easy import into the blood bank database. all necessary information are displayed: 'machine id' 'product/sample barcode id' 'date' 'time of transfer' 'operator id' 'result' ('negative' or 'positive'). the main advantage of this software is a continuous check of each step reducing the risk of error in testing. it makes the scansystem tm test compatible with a routine use in blood banks according to the current regulations and quality assurance programs. is no overall consistency. we feel it would be of benefit to establish an international working group to investigate the feasibility of writing an iso standard for blood transfusion. the standard would harmonise quality management parameters based on iso principles and technical/laboratory parameters specific to blood transfusion. minimum technical specifications would need to be agreed upon based on the various standards and guidelines available around the world. this iso standard could then be used for the purposes of certification/accreditation or government inspections. this would ensure global standardisation of world-class best practices. first world countries would be able to achieve compliance and a subsequent step could be the establishment of an international forum to assist developing countries to work towards compliance in the longer term. residual leukocytes in leukoreduced cellular blood products -evaluation by flow cytometry web-based outcome review: do you know how productive your trima® can be? background: web-based outcome review is a new software tool developed by gambro bct for the management and the interpretation of data from the trima and trima accel tm automated blood collection systems. aim: does the interpretation of reports obtained through outcome review lead to an increase in the number of products per run and the overall productivity of the apheresis center? method: run data files (rdf) from trimaᮀ were collected and transferred onto the outcome review server. these rdf do not contain any donor related data that can lead to possible donor identification. the reports were generated on the outcome review website (gambro bct intranet), interpreted by a gambro bct employee and presented and discussed with the management of blood centers. results: a total of different reports can be generated on the website as a pdf file. for this study, reports were investigated. they are: doses per collection, doses per collection trend, platelet collection trend, platelet procedure performance, platelet procedure performance trend, product distribution, average procedure time, procedure time, machine productivity trend. the results obtained for a center can be compared to word-wide, national, regional or to other individual trima devices in the centre (benchmarks). this benchmarking allows the management of an apheresis center to compare the results, to draw the right conclusions and to develop and implement corrective actions. implementing successfully these corrective action plans will lead over time to productivity results that are more in line with the figures that are generally accepted to be the optimal production capabilities of trima. the reports also help to monitor the effects of the corrective action plan over time and to adjust this plan if the results are not in line with the expectations. reaching and maintaining the optimal production capabilities of trima will also increase the net revenue by procedure or decrease the cost by procedure for the blood centre. conclusion: web-based outcome review allows getting more products from the existing donor base by interpretation of the multiple reports and implementing the required corrective actions until optimal production capabilities of trima are reached and maintained. introduction: to examine the cell vitality of packed rbc's during storage several parameters like atp, free hb or , -dpg are used. less kits for the determination of atp are available and they need either a large sample volume and/or are time consuming. here we present the modification of a commercial testkit for a time-and cost saving detection of atp. methods: samples were analysed with (a) -phosphoglyceratekinase reaction according to bergmeyer, h. methods of enymatic analysis nd. edition. academic press, new york ; (b) detection via hplc and c) using a commercial testkit (r. greiner bio-chemica, germany). the atp-kit were minimized from ml to a total volume of ml and tests were performed in microtiterplates. results: samples were analysed in hplc and modificated commercial testkits, another samples have been examined in all tests. comparison of the results showed no discrepancies in the above mentioned methods. standard curves have been performed (range - mm atp) and statistical analysis demonstrated a given linearity (r = . ). variability has been calculated as . % (intraassay; n = ) and . % (inter-assay; n = ). the hand-on-time calculated for samples has been decreased from . hours to minutes. at least the costs of atp-determination have been reduced from € . to € . per sample. conclusion: performance of test kits in microtiter format is a fast and rapid method, reliable for high-throughput determination of atp in packed rbc's. background: in order to preserve both blood safety and availability it is mandatory that a minimal amount of blood units would be discarded due to defects in the materials and supplies used for blood collection, or to deviations in blood processing or storage. aims: ( ) to monitor the derangements of different materials and disposables used during blood collection and processing, and to study the suppliers' responses and corrective actions taken. ( ) to asses the relative contribution of different defective materials (dm) to the need to discard valuable blood components. materials and methods: about whole blood units were collected and processed by mda national blood services in [ ] [ ] [ ] . as part of the routine quality control activities, derangements of the dm used were recorded and analyzed. some different types of dm were defined. out of reports sent to the corresponding manufacturers for investigation, responses ( %) were received and analyzed. about % of dm were detected during blood collection. manufacturer defects of different materials were the reason for components discard in nearly % of cases. conclusion: defective materials are one of the major causes of the infringements of blood collection and blood component preparation processes. analysis and monitoring of the different defects and of the suppliers' responses and corrective actions are essential to improve products' safety and availability. establishment of a network for the exchange of information among international blood centers would enable the blood banking community to compare between different suppliers and to use the documented cases for training of personnel of both the blood services and the manufacturers. such a system may contribute to the improvement in quality of materials used and might lower the discard rate of valuable blood units. results: table analysis and characteristics of t ( ) comprehension of the blood bank's processes and the interaction between them and between the processes of the whole hospital. ( ) monitor, measure and analyze these processes, in order to improve their effectiveness continuously. ( ) implementation of internal and external quality controls for blood and blood products and implementation of appropriate statistical techniques for monitoring their results. ( ) identification of interested parties (doctors, donors, patients) satisfaction and taking up the necessary preventive or corrective actions to improve their satisfaction. the qms of our blood bank was certified by tuv rheinland in / / and the scope of the certification is: 'blood collection, testing of infections markers, production of blood components, compatibility screening for blood transfusion and other immunological tests and implementation of therapeutic schemes in thalassaemia patients' . the implementation of the qms based on iso : standards ensures the improvement of services provided by the blood bank and the increase in customer satisfaction, whether donors or patients are concerned. the former enjoy the respect and recognition of their social contribution, while the latter are assured of very high levels of service and health protection. finally, we shall not underestimate the positive impact of qms in the motivation of blood bank personnel. quality becomes integrated both in their professional and personal attitude and allows for achieving increased satisfaction from their work. equipment management in the national blood transfusion service in serbia introduction: new equipment was urgently needed in three blood transfusion establishments (bte) in serbia. equipment was mostly inadequate for core blood transfusion activities, placed in inappropriate facilities, very old without routine maintenance or calibration. also, technical documentation for most of the equipment did not exist, and procedures for equipment management and responsibilities were not defined. further more, coordination on equipment issues with the qa department was not recognized. service funded by the european agency for reconstruction, provided various equipment for the three blood transfusion establishments. the new equipment includes blood collection equipment, centrifuges, refrigerators, incubators, automated testing equipment, genetic analyzer and it equipment of . million euros value. before the new equipment is installed the bte's agreed to have the national procedures on installation, validation, calibration and preventative maintenance in place. this will ensure that the equipment can be properly installed and validated before use. the project has provided training on validation to the working group (wg) on quality. the wg has created national procedures related to the equipment, including quite new term validation. the same problems in implementation of procedures were present in all three bte's. significant efforts are made to explain to the staff how the equipment has an impact on quality, how to ensure that the equipment does what it is supposed to do, how to be confident that the results obtained are accurate and how important it is to generate records. qa managers played an important role in the preparation of facilities for equipment installation, making plans for equipment layouts, creating documents (master cards, instruction for use) and designing the validation protocols. the same procedures and records enable an exchange of results, comparability, sharing information on what works and what does not work between bte's. the qa managers also prepared an introduction of equipment requirements to the heads of departments, with special attention to the validation process so that they are able to fully understand what is required and why to validate their equipment. results: national standards in equipment management in serbia are set and are being implemented. qa managers carefully managed that the new, numerous equipment, delivered in the short period of months was correctly installed, validated, obtained with necessary documentation, followed by previously trained staff, so that equipment can be considered as controlled. the additional, positive effect is that validation is performed in one establishment for all bte in the country, allowing a more prompt response to problems and presenting of joint request to suppliers, as well as an easier way of monitoring equipment performance of the three bte's. organized equipment management has affect on every aspect of blood activities and finally to the quality of blood and blood components. background: the vista information system (vista tm ) is used in centers in europe as an apheresis management system. with vista tm it is possible to increase productivity, donor comfort and loyalty and therefore simultaneously improving the overall process in the center. aim: a calculation tool (microsoft excel) was developed to evaluate the added value of vista tm . three blood centers in different european countries completed a questionnaire using their local data. summarizing these figures gives us an idea about the impact of vista tm on the daily work and budget of a blood centre. method: the excel calculation tool that was used investigated major areas where vista tm could show added value: improvement of regulatory compliance, increase the efficiency in operations and improve productivity. results: regulatory compliance: the number of infringements decreased, causing a considerable direct financial gain because these events are very expensive to deal with. the time spent on regulatory reviews decreased with a mean value of %. operational efficiency: the number of reports is very site dependent: sometimes a report is made for every procedure together with the printout of a blood loss history form. because vista tm tracks all procedure related data, some sites decided to stop printing these types of reports and to go completely paperless. the percent time reduction in reporting is therefore very variable. however the % of errors related to these reports decreased considerably with a mean value of %. efficiency in operations was also obtained because of the number of reports that are available in vista tm . productivity, management and process reports allow verifying and correcting the daily operations of the blood center. increased productivity: depending on the center, also an increase in the number of platelet and plasma products collected was detected. the number of product discards caused by infiltration reduced with a mean value of %, mainly due to the possibility to have customized and more donor adapted trima settings. the percentage of whole blood donors targeted for conversion was very site dependent (min . %-max %). but because with vista any procedure brings between . and . products in general, the financial gain was considerable when donors could be converted from whole blood to apheresis. the use of vista allows the apheresis center to work with a reduced error rate and to increase the operational efficiency and the productivity. the financial impact of this has been estimated by the centers between € and € (mean value €) per procedure. establishment of national quality system in blood transfusion service in serbia introduction: the production of blood products is a semiautomated process in which the manual steps may be difficult to control and standardize. aim of the study: we introduced a specialised team for the blood production to test if this improved the control of the quality of the blood products. methods: the blood products tested for statistical process control were red cells in additive solution, buffy coat removed, and leukodepleted (ld) platelet pools prepared from buffy coats. the products were collected in t&b triple opti-pac from baxter and the platelet pools were ld using plx- filters from asahi and stored in platelet bags from baxter. using control charts, namely x-mrchart, exponentially weighted moving average ewma chart and for autocorrelated stationary data the ewmast chart, we examined if time series of quality control values were in statistical control. if not we examined if autocorrelation and/or differences between the technologists producing the blood products could explain the lack of control. data included approximately biweekly measurements of volume, haemoglobin (hb) concentration, hb/unit, haematocrit and log leukocyte count (wbc)/unit of units of red cells, measurements of volume, platelet concentration and platelet count/pool of ld platelet pools produced by a team of technologists and of ld platelet pools produced by a specially trained team of four technologists. results: log wbc/unit was out of statistical control due to systematic differences between technologists. apparent lack of control of volume, hb-concentration, hb/unit caused by autocorrelation disappeared when the ewmast chart was used. platelet concentration and volume of the platelet pools produced by the technologists were out of control. in that some technologists systematically produced low values. this could be explained by inappropriate handling of the platelet product between centrifugation and separation. systematic differences between the four specially trained technologists could not be demonstrated and they produced platelet pools with a significantly higher platelet count/pool. however, standard deviations of the four technologists differed significantly causing occasional outlying values. conclusion: training and routine in blood production or process automation, and also importantly, feed back to the technologists based on control chart quality control data, is recommended. background: one important principle of the use of blood and blood products is the ability to trace the units from donor to the recipient. this study set out to establish whether or not there was sufficient reporting on transfusions from the hospitals supplied by fort portal regional blood bank in western uganda as a means of establishing sound haemovigilance and look back systems. were reported with no unit number and could not be traced to the patients. there was sufficient reporting on the data requested by the blood bank. these results suggest that it is possible to establish effective 'look back' and haemovigilance systems. capture of data on outcomes and adverse effects will be necessary to fully establish the system. further efforts are required to educate those involved in transfusing blood about the need for adequate and accurate documentation. external quality assessment of blood grouping were misinterpreted as rhd-positive samples without the use of control reagent. rbc phenotyping was made correctly by . % of participants. the remaining . % of participants carried out the phenotyping incorrectly, while false-positive and false-negative results were derived in . % and . % of cases correspondingly. polyspecific human sera and monoclonal antibodies were used for abo, rh and antigens typing. the reason of errors in antigen detection was low quality of reagents. antibodies identification was carried out in six distributed exercises. % of participants detected anti-d-k-c alloantibody correctly. the rest of participants did not found alloantibodies or detected their specificity incorrectly. results of testing depended on quality of screening cells. thus, the participants using homemade pooled screening cells had a significant lower detection rate of antibodies comparing with those using diamed ag cell panel. consequently, the results of the first federal external quality assessment scheme show the necessity of improving the quality of red cell reagents produced in russia. in addition, the more appropriate training of staff is required. the importance of iso -quality system in increasing safety of blood transfusion introduction: hadassah hospital transfusion medicine department received on / iso -quality system accreditation. an essential element of this standard is the development of a reliable system to identify, document, analyze and correct actual and near miss events and assess the effectiveness of corrective and preventive actions. aim of the study: assessment of events and corrective actions following implementation of iso quality system. methods: events in the blood bank were identified by the staff, by internal or external audits and by complaints from the wards. all events were recorded and classified into two categories; quality system and technical. the latter were further classified into preanalytical (sample receipt), analytical (abo rh typing, antibody screen and identification, cross matching and phenotyping) and post-analytical (issue of components to wards). all events were graded into levels; -most severe, potentially harmful to patient. -severe, damage to process and result. -moderatly severe, damage to process only. -benign, no harm. events were corrected and effectiveness of corrective actions was assessed by monitoring recurrence of the event. results: during the years - , events were detected and recorded in the blood bank, they comprised . % of all tests performed ( ). most of the events were technical. all events were detected before causing harm to the patients. results are summarized in the table. *the percent analytical value is a summary of rates of events per test types included in this category. events detected in the quality system were mainly of severity level & , whereas technical events were mainly of severity levels & . analysis of event recurrence in the quality system revealed that % of events were resolved, whereas only %- % of technical problems were completely solved. the main source of event identification and documentation, in the quality system were audits whereas in the technical system, staff members revealed most events. the implementation of iso quality system provided a powerful means for recognition, analysis and study of patterns of near misses and actual events. understanding the root causes of events enables to choose the most effective corrective and preventive action to control event recurrence. evaluation of the frequency of events confined to the blood bank revealed a very low rate of . %. these results are in agreement with data in the literature. creating a non-punitive, non-stressing open environment, motivates personnel to identify and document events, which are regarded as opportunities for improvement and serve as important tools for upgrading transfusion safety. the explosive use of information technology and the speed with which it has spread into all life activities has created vulnerabilities for all organizations. those vulnerabilities are compounded by the complexity of information technology, limited time to market, development constraints, and constantly changing relationships between organizations and suppliers. growth in the sophistication of security threats makes it imperative that organizations remain equally competent in identifying vulnerabilities and mitigating security risks. aim: the goal of this document is to explain how isbt intends to provide guidance to the blood banking community on implementation of effective information security policy. when using information for critical activities, blood banks should consider information security as an important aspect of their management policies. evaluation of existing standards, such as iso and hipaa, allows us to establish a framework for information security without regard to the type of organization. it remains very difficult however, due to the complexities involved, to establish an information security policy without guidance. method: the isbt information task force was created to provide guidelines on information security for blood banking organizations of all sizes. the intent is to help them understand existing standards as well as provide tools for implementing information security policy. these guidelines are based on existing standards that are followed by most worldwide countries: iso and hipaa. results: information security can be defined as the 'protection of systems, information and services from accidental and deliberate threats to confidentiality, integrity and availability' . understanding existing information security standards was the first step for establishing a structure for the guidelines. the core is organized within an implementation framework and presented under the three following layers: . administrative for defining the it security organization, the information security policy, and information security awareness and training. . physical for providing solutions that relate to physical environment protection and access, equipment and it infrastructure security, and control for accessing computerized equipment. . technical for maintaining confidentiality of electronic information and ensuring that authorized access to information systems is maintained (technology relating to identification and authentication, logical access, operating system, network management, application access, etc.). strategy guidance is also included for senior managers in charge of establishing organization policy, including responsibilities and methods to successfully implement policy. further, the task force is addressing both risk analysis and management including identification of potential dangers to information systems (threat-source) and existing controls (risk description), as well as a plan to address identified vulnerabilities and mitigation of specific risks. conclusions: information security standards are prerequisite to understanding the issues involved when considering information vulnerability. international guidelines for information security, specifically directed to the blood banking community, are equally necessary if we are to identify, plan for, and mitigate risks associated with vulnerabilities to critical blood banking information. the isbt task force is committed to providing such guidelines. introduction: the important part of quality planning and quality assurance within production of blood components is measurement system analysis (msa). measurement system analysis was performed on microscopic counting of blood cells in our study. aim of the study: aim of this study is determination if microscopy counting of residual elements in whole blood plasma is suitable for quality control of blood components. methods: we practiced measurement system analysis in counting of residual elements (leukocytes and erythrocytes) in whole blood plasma. the counting performed two lab technicians in ten samples of plasma from whole blood. leukocytes and erythrocytes were measured in naggeotte counting chamber. we used the method of mean and range for the determination of reproducibility and repeatability (r&r) and analysis of variance for complex measurement system analysis. regulation diagrams were applied for the graphic statement. we determined the value of repeatability, reproducibility, coefficient r&r, variability among samples of plasma and total variability of measurement system. the important conclusion was to determinate if the microscopic counting of samples of blood components is sufficient with regard to quality parameters specified in guide to the preparation of blood components (erythrocytes: < . ¥ /l, leukocytes: < . ¥ /l). our results show that microscopy counting of residual elements in whole blood plasma is suitable for quality control of blood components. aim of the study: to provide transfusion services with a tool for proper qms implementation, an international collaborative study on qms applications, employing the 'process approach', has been undertaken by a group of transfusion services of varying sizes and structures with experience of qms, in collaboration with a university institute offering a master in qms implementation in health services, and an expert from a quality association. the 'process approach' serves as a tool to manage transfusion activities as a system based upon a network of processes and their interactions. guide-lines have been produced based upon this principle and will be published (volume and cd-rom) and distributed at no cost to all transfusion services of nations participating in the study. the main contents of the guide-lines' chapters are: through definition/analysis of single processes and the correlation network amongst these, the 'process approach' methodology renders the transfusion centre's functioning units completely interdependent, eliminates process interface barriers, provides personnel with a unified focus on the main transfusion objectives, and lays the basis for improvement of transfusion service quality, organization and performance through efficient control of processes' interactions. the blood screening system automated high-throughput nat system for simultaneous screening of hcv, hbv and hiv nucleic acids: full process surveillance e pfeifer*, b alessandri † , hr bachmann † , t barker † , y ohhashi*, c parkhouse*, j pinsl-ober ‡ , p wenzig ‡ and g ziegler ‡ *roche molecular systems, inc., pleasanton, usa, † roche instrument center ag, rotkreuz, switzerland, ‡ roche diagnostics gmbh, penzberg, germany introduction: the blood screening system combines on one deck both automation of dna/rna extraction from blood/plasma samples and multiplex pcr amplification and detection of nucleic acid targets. the system is designed for high-throughput single unit testing and pooled specimen processing. a data management system supervises and controls the complete process from initial sample pipetting through to result compilation and reporting. the objective of this project was to present the system assay and device built-in quality control measures that guarantee process safety and reliability. the study shows how internal control, external batch controls, pipetting sensors, validation & maintenance procedures, and a controlled development & manufacturing process yield an optimal test method and system stability. method: failure modes and effects criticality analysis (fmeca) was used to evaluate a mathematically derived safety metric for optimizing risk reduction. this method makes use of a system risk objective-function (srof), which provides a multivariate description of sample processing, amplification and detection steps. the method for analyzing system behaviour first employs product classification into risk domains, followed by ranking of process steps that are determined to be linked to known system hazards. this provides objective means for directing system design leading to risk minimization. the srof responses associated with redundant liquid sensing channels were shown to substantially reduce risk during sample or reagent transfer steps. the system liquid flow, airpressure-based (plld) and capacity-coupled liquid (clld) sensors detect aspiration and dispensing inaccuracies. sensor signal tolerance band widths studied for fluid classes representative of system reagents and for plasma samples from lipemic, icteric, and hemolized sample sources were shown to correlate with srof multivariate modelling. the impact of surveillance design elements on the srof response demonstrates that risk is functionally dependent on design elements. additional surveillance examples are presented that describes temperature sensing, robotic positioning and motion control. treatment of residual risk is addressed by introducing external controls that are configurable to specific workflow scenarios. the negative external control (nc) is used to check for contamination of reagents. five low concentration armored external controls, i.e. hiv- group m arna, hiv- group o arna, hiv- arna, hcv arna, and protected hbv dna are run at the beginning of a batch as a run-control measure. in addition to these roche controls the system supports running of user-defined external controls for co-validating the batch. the internal control (ic) is based on armored hiv- group m rna that is co-extracted and co-amplified with the external controls and the target nucleic acids potentially present in the sample. lastly, the system resource management monitors the status of samples, ready-to-use reagents and disposables via rack sensors and bar-coded bottles and tubes. the fmeca methodology provides a risk-minimized, comprehensive system design. redundant sensors with internal and external controls are evaluated through comparison of modelled versus actual run results. the system brings a new level of surveillance and throughput for automated pcr testing, and emphasizes roche's commitment to increasing the safety of the global blood supply. technical standards for safe storage and transport of blood components and blood samples objective: to implement standardization of technical specifications for safe storage, transport and distribution of blood samples and blood components intended for transfusion, as part of a quality system in blood transfusion medicine. methods: in the course of implementing a quality system in our blood establishment (distributing % of the national blood supply), we have developed standard operating procedures (sops) for temperature and hygienic conditions to maintain and control storage of blood components during their shelf life and to ensure their safe distribution to other blood services in the country and abroad, in compliance with eu directives / /ec and / /ec and the recommendations of the council of europe and who. procedures are validated and relevant records are kept. a statistical process control is also in place to monitor deviations from specified temperature and time range throughout the period of transportation. blood components collected and prepared for specific purposes (e.g. directed donations, irradiated units, hla-typed units, anti-cmv negative blood components and blood for neonates) are stored separately, and alarms and warning systems are in place. packing and transport conditions of red cells, platelets and ffp are submitted to the tests and criteria of adr (european agreement concerning the international carriage of dangerous goods by road). in greece, the adr legal framework has applied since . blood samples are classified according to adr in division . under un as diagnostic specimens, and the criteria for safe carriage include packaging, specific labelling and vehicle requirements as well as carrier obligations and personnel training. our blood establishment has a contract with biotrans, a private company accredited for packaging, storing and transporting blood, organs, tissues and cells as well as potentially infectious biologic substances and blood samples for diagnostic purposes. assurance system). the approach is specified in the form of requirements of art. . of the standard: the organization shall: (a) identify the process needed for the quality management system and their application throughout the organization, (b) determine the sequence and interactions of these processes, (c) determine criteria and methods needed to ensure that both the operation and control of these processes are effective. regional centre for transfusion medicine in biaĺystok was the first transfusion service in poland which was certified according to iso : standard. our expected profits from the implementation qms were: possibility to overview organization's pathways of operation and to inspire corrective and improvement actions, emphasis on the role of staff in the system, focus on self-control and responsibility for one's own work as a factor of staff's mentality creation/modification. our one year of experience with iso : standard proved the system to be handy tool of management for the organization collecting, processing, testing blood and releasing of blood products for the hospitals and to be well accepted by the staff. the implementation and certification of the internationally nor-malized quality management system simplify and shorten all accreditation and registration procedures required for legal activities of transfusion service as well as for any supplemental medical activities which may be performed by the centre. the implementation of qms facilitates the implementation of other quality systems and simplifies procedures required for the ce certification for the products. red blood cells stored in blood banks, normally undergo a series of chemical alterations, or storage lesions. the ultimate consequence of these lesions is a decrease in the viability of the red cells following transfusion. the chemical alterations are mainly changes in levels of na+, k+, cl-concentrations, ph and , dpg levels and they affect the electrical impedance of blood. the electrical impedance, cole-cole parameters, is determined mainly by the resistance of the red cell extracellular fluid (re), the resistance of the intracellular fluid (ri) and the capacitance of the cell membranes (cm). in this study we aimed to investigate the relation between blood parameters and electrical impedance changes, and their further clinical implication. all parameters were measured on erythrocyte suspension (es) samples during days of storage at oc on days , , , and . for whole blood (wb) samples during days of storage, same parameters were measured on days , , and . the measurement of the complex impedance of blood samples were performed in the frequency range from khz to mhz. by using the a hp lcr meter, the impedance z, and the phase angle a for each sample were read. these values were corrected according to the gain and phase characteristics of the amplifier; and the resistance r and the reactance x were calculated. each data was first fit to the cole-cole model; hence the cole-cole parameters, intracellular resistance ri, extracellular resistance re, characteristic frequency fc and phase angle a were obtained by using lms software. afterwards, cm was calculated by using ri, re, a and fc. whereas ri and cm decreased progressively with time on both wb and es, re changes showed some differences. the electrical impedance alterations were explained by measurements of na+, k+, clconcentrations, ph and , dpg by indicating days. storage of red cells resulted in a rise in extracellular k+ and a fall in extracellular na+, cl-, ph and , dpg. anova was used to evaluate differences in blood measures in relation to storage time. the results were presented as the mean ± sd. according to the regression analysis in spss, the intracellular resistance (ri) on both es and wb was affected more efficiently from all blood parameters among all other electrical parameters. although ri and re were correlated with na+, k+, cl-, ph and , dpg more significantly, cm measurements were failed to show correlations with blood parameters because of the intervening parameters, a and fc. the best relationship between the parameters mentioned above on both es and wb was ri and k+. ph changes were the same for ri and re both for es and wb. the correlation between parameters on es was better than those on wb, because whole blood consists of several particles that may affect our measurements. our study showed that , dpg has an effect on ri and re as efficiently as other blood parameters and therefore electrical impedance measurements may serve future implications. background: issue of quality blood products and donor safety are the main aims of blood transfusion services. a comprehensive quality system should be in place to fulfill these aims, which can be attained through strict adherence to the established standard operating procedures (sops). the drugs and cosmetics act of india, which controls the licensing of blood transfusion services, does not provide clear guidelines regarding plateletpheresis procedure. aim: we therefore established our own sop and operational flow chart for plateletpheresis that can be easily followed by other centers in india. methods: a total of plateletpheresis procedures performed using two cell separators (cs baxter, usa, mcs p, hemonetics, usa) were evaluated following our established sop. the mean platelet yield in cs was . ± . ¥ and in mcs p, it was . ± . ¥ per unit, however, only - % of sdps showed wbc levels < ¥ . six of donors complained of hypocalcemic symptoms. the operational flow chart designed in this study was found to be simple and easy to adapt by blood transfusion services in this country. the first advanced quality management training course for blood transfusion services in the western pacific region mk tan*, jp yu † and d teo* *health sciences authority, singapore, † who regional office for wpr, manila, singapore background: blood transfusion is a key part of modern medicine. a well-organised blood transfusion service (bts) is a prerequisite for the safe and effective use of blood and blood products. in , the world health organization (who) introduced a new initiative of quality management project (qmp) to achieve the goal of safe and adequate global supply of blood. through qmp, regional training centers were identified and quality management training (qmt) courses were established. in , centre for transfusion medicine (ctm) of health sciences authority singapore was appointed as a collaborating center for qmt in the western pacific region (wpr background: spectrophotometric method according to harboe was traditionally used at our institute for determination of free haemoglobin in supernatants of rbc blood components at the end of storage time. in the year hemocue plasma low hb system (hemocue, sweden) was introduced as a replacement method. aim: the aim of the study was to examine reliability and suitability of the hemocue method for measurement of free haemoglobin in supernatants of rccs. methods: hemocue plasma low hb method was validated and compared with harboe method. supernatants of rbc products were tested by two methods and results compared using regression analysis. additional testing was performed to investigate precision of hemocue method (within-run and between-day variation), trueness using reference material and to define optimal sample handling. results: regression analysis showed high correlation between two methods (r = . ), with higher values obtained with hemocue method. immediately after centrifugation one supernatant was measured times in order to determine within-run imprecision. coefficient of variation (cv) calculated from consecutive measurements was . %. to investigate between-day imprecision of the hemocue method one sample was divided in aliquots and frozen. one sample was thawed each day and measured. cv of five measurements was . %. during the period of validation measurements of reference material (low, medium and high) were performed. cv calculated for these measurements were . % (low), . % (medium) and . % (high). in order to investigate possibility of batch testing, supernatants of different rbc products were divided in aliquots and measured periodically during -month period. cvs calculated from measurements of each sample were in range . - . %. conclusion: hemocue plasma low hb method appears to be an excellent replacement for the harboe method. it is consistent, easy to use, measurements are performed in short time, and errors are minimized by eliminating dilutions and manual calculations. background: determination of haemolysis in red cell concentrates (rccs) at the end of storage time is routine method in quality control of blood components at our institute. for this purpose, haemoglobin concentration in supernatant of rccs is measured using hemocue plasma/low hb system (hemocue, sweden). according to manufacturer recommendation, visually turbid samples should be filtered before analysis with a . mm filter. because visual estimation of turbidity is highly subjective and unreliable, filtration of all supernatants before analysis using appropriate filters is possible solution for standardisation of the method. aim: the aim of the study was to investigate the effect of filtration of visually non-turbid samples on results of free haemoglobin measurement. methods: haemoglobin concentrations were measured in visually non-turbid supernatants before and after filtration using hemocue plasma/low hb photometer ( wb negative controls were used for each blood component. in all blood components tested bacterial contamination was detected using both types of bottles. in comparison with sa/sn bottles, nearly all enrolled microorganisms were detected faster in bpa/bpn bottles (see table ). all negative controls were negative (no false positive). the results of the study performed support the use of bact/alert bpa and bpn plastic bottles in quality control testing of different blood components. objective: management of returned blood products is important part of quality assurance activities in transfusion medicine. blood products are returned most frequently because of routine rotation of stock and because of nonconformities discovered after the product has been received. methods: qa data about returned blood products were retrospectively analysed for the -year period ( - ) . only blood products returned because of nonconformities were taken into consideration. data about the reasons for returns are presented and discussed. the top reasons for returns were positive dat, labelling errors, blood bag defects and visual appearance of blood units (see table ). in all cases positive dat was confirmed in our institute, and blood donors managed accordingly. nonconformities related to visual appearance of blood component and other nonconformities related to the quality of blood products were investigated and corrective actions conducted. in case of blood components returned because of damaged bag, significant problem is to investigate the cause of nonconformity (usually inappropriate transport conditions). conclusion: management of returned blood products is important tool in improving the quality of blood products. introduction: hemovigilance is the systematic monitoring of the blood transfusion chain for side effects and adverse incidents from the moment of blood collection until after administration of the unit to the recipient, and comprises all activities that can lead to a safer and more effective use of blood components. attempts to achieve a more safe and effective use of blood components constitute a huge task given the number of interventions and array of medical and not-medical personnel involved in the transfusion process. registration of the impact of all participants is a tremendous job as such. information management may enhance the chances for a successful hemovigilance. aim: the aim is, to establish a basis for all the information related to the chain, such as standard operating procedures, (inter)national guidelines, local transfusion protocols and forms, and procedures to direct the process. additional factors that contribute to the final results are the profile and role of employees, incidents, points of care, product information, prices, budget, contracts, etc. by clarifying and explaining the basis to all participants by means of an existing infra structure, everyone will gain access to identical, consistent and up-to-date information at all times. the primary activity is to create the basis by an outline of every individual link in the transfusion chain from donor to recipient. secondly, the resources, responsibilities, actions, and internal controls (what task, who is performing, why, which help, where, when) are documented. by creating distinct databases for these 'w's' in combination with a separate database for the hemovigilance process itself, it is possible to establish relations, hyperlinks, between the different databases. all the information collected in the foundation, complete with all the resources, responsibilities, actions, and internal controls is made available to target groups by means of the intranet in our hospital as well as in a printed handbook format. collecting and displaying the information on hemovigilance this way, creates a transparent and more easy-to-manage process. it establishes a basis, which incorporates all resources, responsibilities, actions, and internal controls to all participants and enables the organisation to operate both efficiently and effectively. it allows us to show auditors (both internal and external) which processes are related to which guidelines as well as the results in daily. in addition, it reveals which factors determine the genuine application of the guidelines in clinical practice. conclusion: by outlining the process, followed by defining, analysing, securing, on the 'w ' method, the hemovigilance process offers a stable basis and framework for all participants and may stimulate a more safe and effective use of blood components. background: transfusion medicine is a basic post-graduate specialty for medical doctors with a specific national curriculum in bulgaria. in order to improve the post-graduate training of medical doctors in transfusion medicine, a new curriculum was elaborated in . purpose of the new program: independent work of transfusion medicine specialists on all levels of the blood transfusion service (bts) -organization of bts, promotion of voluntary, nonremunerated blood donation, collection, processing, testing, storage and transport of blood and blood components, immunohematologic testing of patients, laboratory hematology, clinical experience, assistance and advice on diagnostic and therapeutic problems of patients, requiring treatment with blood products, teaching transfusion medicine to bts and clinical personnel. admittance and duration to training -medical doctors are admitted to post graduate specialization after a successful state examination. the overall duration of training is years, of which at least are obligatory for training in the national or regional blood transfusion centers. main sections of the curriculum: . organization of blood donation and blood transfusion, including promotion of voluntary, nonremunerated blood donation; organization, planning and information systems; organization of blood transfusion; quality management. . collection, processing, storage and transport of blood and blood components . laboratory hematology and specialized methods (general laboratory methods, immunology, immunohematology, transmissible infections, hemostaseology, nat techniques, flowcytometry) . clinical use of blood components and plasma products (treatment with blood products, adverse events and reactions, alternatives to blood transfusion). the new curriculum of transfusion medicine guarantees a better training of medical doctors, thus leading to safe and effective blood products their proper clinical use. introduction: transfusion medicine is integrated medical discipline based on clinical and laboratory practice. it is closely connected with molecular biology, genetics, as well as with apheresis, automatically techniques and transplantation. the aim of studies in transfusion medicine is proper education, skills, attitudes and knowledge of students at the medical faculty and of doctors on residency in transfusion medicine and other specialties about blood and its usage. material and methods: there will be presented how transfusion medicine is implemented in educational and health sector in r. results: there is -year specialization in transfusion medicine, established years ago (over specialists finished this specialization till now). we have postgraduate studies in tm started years ago. transfusiology, as subject at the medical faculty, is now included in new curricula of medical student, consists of theoretical and practical lectures. also, medical doctors on specialization in surgery, anesthesiology, obstetrics and gynecology, pediatrics, internal medicine, maxillo-facial surgery and others have obligatory -month education in tm. transfusion medicine is integral part in education of nurses and laboratory technicians; all personnel that work in transfusion field in our country finished -mounths course in tm and get certificate. conclusion: although we have already done so much in educational field, we will continue with our efforts to improve our collaboration with clinicians and to involve ourselves more in clinical disciplines. introduction: in hospitals of saint petersburg donor blood, its components and preparations, autoblood and its components, hemocorrectors are applied with the medical purpose at - % of hospital patients. the service of blood and the existing organization transfusion therapy in hospitals should provide maximal immunological and infectious safety and also its high medical efficiency. it demands special preparation for all doctors: general physicians on clinical transfusiology and doctors of blood service on all sections of the general, industrial and clinical transfusiology. clinical gemostasiology, pharmacology of hemotransfusion means and hemocorrectors, the organization of the blood service, the donor service; the organization, technique and technics of preparation of blood, its components and preparations, quality assurance, transfusion therapy programs, technique and technics of transfusion medicine, a problem of maintenance of immunological and infectious safety, preventive maintenance, diagnostics and treatment of posttransfusion complications, feature transfusion therapy in pediatrics and medicine of accidents). clinical physicians master all basic questions of clinical transfusiology, thus the special attention is given questions of clinical immunohematology and clinical gemostasiology, programs and a technique of transfusion therapy, the prevention of posttransfusion complications. employment are carried out in departments of city blood bank, hospitals blood departments. final examination under the test program and at interview shows sufficient mastering a theoretical and practical material (right answers of - %). the described system of postgraduate studies provides an opportunity of successful independent work of doctors on the workplaces both regular increase and qualifications not less often than time in - years. conclusion: the existing system of postgraduate education for doctors on transfusiology provides the blood services and hospital by the qualified staff. introduction: nowadays in hospitals of saint-petersburg more and more it is frequently applied the extracorporal hemacorrection (haemapheresis, haemasorbtion, plasmasorbtion, krhyoplasmasorbtion, ultrafiltration etc.) and photohemotherapy (optical radiation influence on blood) at various diseases and traumas. they are used at treatment almost % from the general number of patients of hospitals with positive results at % from them. for this purpose in hospitals there are specialized branches or cabinets with staff of the doctors -transfusiologists. therefore an actual problem is organization of postgraduate special education for them. because there is no specific blood banking and transfusion medicine training in either under or post graduate medical education those general practitioners have limited knowledge about this field. aim: to give basic knowledge and practice to those general practitioners moh has established a special training programme with the collaboration of medical schools for years. methods: this is a months programme which has basic components; theoretical education, laboratory and blood banking practice. the trainees are evaluated by a final examination. each group has limited cadets and the training is provided in selected blood banks with the collaboration of universities and moh training hospitals. conclusion: almost general practitioners are trained by this programme in the last years and those doctors helped to increase the quality of blood banking and transfusion service at their hospitals. background: even the history of public blood banking in turkey has dates back to , whole blood was comprising the majority of transfused units (more then %) in turkey until the last few years. aim: the main target was to decrease the whole blood use in a short time and establish countrywide effective blood transfusion practice. methods: there were no specific blood banking and transfusion education either at undergraduate and postgraduate medical education in turkey until the last few years. blood banks and transfusion society of turkey (bbtst) was established at with the main aim of education of the related people about blood banking and transfusion medicine. bbts has organized symposiums, national courses, national and international congresses since . due to increased knowledge about the blood components and improved infrastructure of blood banks whole blood consumption has decreased to national average to %. in most of the university hospitals and training hospitals this is around %. conclusion: like most of the public based behaviours dedicated efforts of civil initiative has changed the traditional habit of blood consumption in turkey by the direct affect of well organized educational activities. training of general practitioners in blood banking and transfusion medicine n solaz*, b keskinkilic † and c oruc † *ankara university, ankara, † ministry of health, ankara, turkey background: turkish ministry of health runs majority of the hospital blood banks in turkey. most of the moh hospital blood banks give service under the medical supervision of general practitioners. because there is no specific blood banking and transfusion medicine training in either under or post graduate medical education those general practitioners have limited knowledge about this field. aim: to give basic knowledge and practice to those general practitioners moh has established a special training programme with the collaboration of medical schools for years. methods: this is a months programme which has basic components; theoretical education, laboratory and blood banking practice. the trainees are evaluated by a final examination. each group has limited cadets and the training is provided in selected blood banks with the collaboration of universities and moh training hospitals. conclusion: almost general practitioners are trained by this programme in the last years and those doctors helped to increase the quality of blood banking and transfusion service at their hospitals. background: it has been accepted that during cardiac surgery the complement-system is activated which enhances ischemia-reperfusion injury, leading to postoperative complications as infections and organ failure. the lectin pathway is one of the mechanisms that can activate the complement-system, this pathway can be mediated by mannose-binding-lectin (mbl). the level of mbl in serum shows a wide variation. a low level of mbl can lead to more infections in some conditions and a high level to tissue damage after ischemiareperfusion injury. the effect of transfusions of erythrocyteconcentrates and plasma on the mbl levels and thereby on complications after cardiac surgery are not known. aim of the study: the role of pre-and postoperative mbl levels and the effect of transfusions on postoperative complications after cardiac surgery. in a randomized controlled trial cardiac surgery patients were included and blood samples were taken pre-and postoperatively. mbl measurements were performed by elisa assays. the data were linked with postoperative complications as mortality, infections and multiple-organ-dysfunction-syndrome-mods and with peri-operative erythrocyte and plasma transfusions. results: the mean pre-operative mbl-level was ± and postoperative ± mg/ml. there were no differences in preand post-operative mbl levels between patients with infections or mods compared with non-infected and non-mods patients. the difference in pre-operative mbl between non-survived ( ± ) and survived patients ( ± ) was not significant (p = . ). postoperative mbl levels between survived and non-survived patients was smaller. conclusions: pre-and postoperative mbl levels in cardiac surgery are not related to postoperative infections, mods and hospitalmortality. whether large amount of blood transfusions are affecting the mbl-levels and thereby the patients outcome is not known. introduction: patients undergoing cardiac surgery are receiving high amount of blood transfusions and are at risk for the development of infections and multiple-organ-dysfunction-syndrome (mods), these complications are influencing the survival of the patients. during cardiac surgery pro-and anti-inflammatory cytokines are released by different mechanisms. we found in a randomized trial in cardiac surgery a significant reduction in infections and mortality due to mods by transfusion of leukocytedepleted erythrocyte concentrates (ld) compared to leukocyte-containing, buffy-coat depleted erythrocytes (pc). aim of the study: the effect of ld on the concentration of proinflammatory cytokine il- and anti-inflammatory cytokine il- in relation to clinical outcome and complications after cardiac surgery. methods: in participating patients blood samples were taken before and after surgery. using elisa il- and il- were measured in these samples. the results were linked with the endpoints of the randomized trial: postoperative infections, mods and in-hospital mortality. results: all pre-operative concentrations of il- and il- were low. mean postoperative level for il- was ± and for il- ± . compared with patients without mods and without infections and survived patients only the il- was significant higher in patients who died and in patients with mods. there were no differences in mean levels related to ld and pc. the levels of il- were higher in patients receiving more then units blood transfusions compared to transfusions. conclusion: there is an association between mods and mortality and il- , not with il- . ld has no influence on mean levels of il- and il- . there is a correlation between transfusion of more then units and il- , not with il- . these cytokine-profiles are not associated with the beneficial effect of ld on the postoperative outcome in cardiac surgery patients. anemia and blood transfusion practice in critically ill patients e grouzi*, e tsigou*, p evagelopoulou † , g baltopoulos † and i spiliotopoulou* *kat general hospital, transfusion service, athens, † athens university school of nursing icu, athens, greece background: anemia is a common problem in critically ill patients admitted to intensive care unit (icu), but the consequences of anemia on mortality and morbidity in the critically ill is poorly defined. aim: to define the incidence of anemia and red blood cell (rbc) transfusion practice in critically ill patients in the icu) of our hospital, and to examine the relationship of anemia and rbc transfusion to clinical outcome. patients and methods: the period study was from july to december . patients were enrolled within h of icu admission. follow-up time was days, hospital discharge or death, whichever occurred first. results: a total of patients ( male, female, mean age . ± . years, range - ) were included in the study. the mean hemoglobin (hb) level at baseline was . ± . , which level was descending during the study. overall . % ( / ) of the patients received one or more rbc units while in the icu stay (mean . ± . units per patients). the mean pretransfusion hb was . ± . g/dl and the mean time to first icu transfusion was . ± . days. more rbc transfusions were given in the first week of the icu stay ( units vs , , units in the second, third and forth week respectively). the number of rbc units which a patient received during the study was positive associated with longer icu length of stay and an increase in mortality (r = . , p < . and r = . , p < . respectively). baseline hb level was significantly related to the number of rbc transfusion (r = . , p < . ), but was not an independent predictor risk factor of length of stay or mortality (r = . , p > . and r = . , p > . respectively). the mean baseline apache ii and saps scores were . ± . and . ± . respectively. furthermore both baseline apache ii and saps scores were significantly higher for patients with a baseline hb level of < g/dl ( . ± . vs . ± . and . ± . vs . ± . respectively), while the apache ii values were positive associated with a significantly increased likelihood of rbc transfusion (pearson correlation p < . ). conclusions: anemia is common in the critically ill patients, it appears early in the icu course and persists throughout the duration of the icu stay. rbc transfusion seems to be associated with worse clinical outcome. despite the intensive research for the transfusion practice, which taken place worldwide during recent years, data from our country is limited. the results of our study suggest that approaches to reduce rbc transfusion would be desirable. however, further well designed prospective studies with large number of patients are required to efficiently explore the risk of anemia, optimal transfusion hb threshold and the risk and benefit of rbc transfusion in the critically ill. consumption of blood products in a large, general hospital he heier*, j pillgram-larsen † , m hestnes ‡ , b gran*, a krog* and no skaga ‡ *ullevaal university hospital, oslo, † ullevaal university hospital, dept. of thoracic surgery, oslo, ‡ ullevaal university hospital, dept. of anestesiology, oslo, norway uuh is the largest general hospital in norway, and trauma referral centre for half of the norwegian population ( . mill) the trauma team performed initial assessment and resuscitation of patients, % males, during the first six months of . the aim of our study was to analyze transfusion practice at uuh with specific focus on trauma. materials and methods: blood consumption during this period was recorded. clinical data of trauma patients were collected from our trauma registry and anonymized before analysis. results: units of erythrocytes (er), of thrombocytes (thr) (buffy coat preparations from donors) and of s/d-treated whole plasma (op) (octaplasÒ) were transfused in uuh during this period. . % of er were given to surgical, . % to medical and . % to gynaecological and obstetric patients. % of er were given to patients above years. er units were given to patients (mean . units/patient; range - ). mean age of trauma patients was ± , median , range - years. for transfusion of this group local guidelines state that haemodynamically unstable patients should receive er if hgb < g/dl, irrespective of age and sex. eighty-eight patients ( . %) received er, of them as massive transfusion ( er units in < hours) ( . %), of these died ( %). altogether trauma patients received units of er ( . % of total uuh consumption), . thr ( . % of total) and units of op ( . % of total). massive transfusion consumed er ( %), . thr ( . %) and op ( . %) units. fourteen adult trauma patients ( . % of those transfused) received or er units only. lowest pre-transfusion hgb was . - . g/dl, median . , mean . ± ; highest post-transfusion hgb . - . g/dl, median . , mean . ± . five patients received er transfusion at higher pretransfusion hgb level than g/dl, but in er were given because of a hyperacute clinical situation. fifty-five% of issued er units had been stored for > days, while only % were issued before days of storage. discussion: life-saving effect of transfusion would seem evident in the massively transfused survivors, while in the other transfused patients documentation of clinical effect is inadequate. transfusion practice in trauma at uuh seems fairly well in accordance with internationally accepted guidelines. the trauma unit consumed a surprisingly small part of total uuh transfusion resources. trauma patients deviate from the general uuh patient population by sex and age; transfusion is otherwise mainly given to more elderly patients. further analysis is needed on transfusion indications and results to optimize the total use of blood products in uuh. special focus should be on transfusion to non-bleeding patients without haematological disease. it seems that only a small part of transfusion efforts results in the saving of life. in croatia national guidelines for the use of rhd gamma globulin were laid down in the year . in accordance with the guidelines, rhd gamma globulin is administered intramuscularly in doses of - mg and should be given to rhd negative women after delivery of rh positive children, after abortions, in week of their first pregnancy, as well as in cases pregnancies with an increased risk of fetomaternal hemorrhage. as to the latter, detection and measurement of fetomaternal hemorrhage are recommended. three years after the issuance of the guidelines a survey was conducted regarding the use of rhd gamma globulin that involved health institutions across the country. as many as deliveries and abortions were reported in . the institutions reported the usage of doses of mg rhd gamma globulin or doses/ deliveries + abortions. we compared our data with those obtained from similar surveys conducted in , i.e. before the issuance of the guidelines. in that year deliveries and abortions were reported, and doses of rhd gamma globulin or doses/ deliveries + abortions were administered. institutions were then divided into four categories: clinical hospitals, general hospitals with the capacity of - beds, general hospitals with the capacity of - beds, and institutions of rather limited capacity with gynaecology department. the range of the consumption of rhd gamma globulin/ deliveries + abortions in the first category was - with the median being ; in the second category there were - doses with the median being , in the third category - doses with the median being , while in the fourth category the range was - doses with the median of doses. the number of pregnancies which should have been protected with rhd immunization in year was obtained by the following formula: (frequency of rhd negative subjects) ¥ (frequency of the r gene) = . ¥ . = . . if a complete antenatal and postnatal preventive measures involving rhd immunization had been taken in , doses of rhd gamma globulin or mg/ deliveries + abortions should have been given. our research has shown that, despite of the national guidelines adopted in , the prevention of the rhd immunization in pregnant women is still not adequate in croatia. in fact, it has not improved since a year prior to the adoption of the guidelines. it has also been established that the category of the institution is a factor influencing the implementation of the protective measures. we consider that much more should be done on informing both women and gynaecologists about the importance of prophylaxis of the rhd immunization. consumption of plasma derivates in croatia g jaklin*, b golubic-cepulic † and m dondur* *general hospital, varazdin, † clinical hospital center zagreb, zagreb, croatia a increasing consumption of plasma derivates, their limited supply and insufficient national reserves are problems that croatia is faced with nowadays, as well as many other countries. in a study was carried out regarding the usage of plasma derivates. as many as health institutions took part having the capacity of acute beds out of a total of . the data regarding the use of plasma derivates were collected as follows: albumin, i.v. gamma globulin, and concentrate of coagulation factor viii in two periods of time. we divided institutions into three categories: clinical hospitals, general hospitals with the capacity of - beds and general hospitals with the capacity of - beds. institutional practice patterns regarding the use plasma derivates were compared among them. the parameters considered were the total consumption of plasma derivates, consumption per bed and consumption per inhabitant. data on the use of plasma derivates was obtained from hospital transfusion departments and pharmacies across the country. we compared our data with similar study carried out in . the consumption of albumin was . kg or kg/million inhabitants in and consumption per bed for the first category institutions was in range . - . kg with the median being . , for the second category the range was . - . kg with the median being . , while for the third category the range was . - . kg with the median being . . in in croatia the consumption of albumin was . kg or kg/million inhabitants. the consumption of i.v. gamma globulin was . kg or . kg/million inhabitants in and the consumption per bed for the first category institutions was in range . g- . g. with the median being . , for the second category was in range . - . g. with the median of . and for the third category was in range . - . with the median . g. in in croatia the consumption of i.v. gamma globulin was . kg or . /million inhabitants. the consumption of the concentrate of factor viii was . iu or . iu per inhabitant in . . iu, i.e. . %, was a recombinant factor viii. in the consumption of factor viii was . iu or . iu per inhabitant. discussion: the use of albumin showed stagnation. however, the use of i.v. gamma globulin increased . times and the use of the concentrate of factor viii increased . times if compared with the results in . self-sufficiency has not been reached in plasma derivates in croatia we needed l plasma for gamma globulin and l plasma for concentrate of factor viii for the level of usage of these plasma derivates in . significant differences in the level of usage among hospitals have been observed. these reflected a considerable difference in hospital policy regarding the use of these products in defined clinical settings. therefore, we would recommend that the national society sets out guidelines for the use of the products. background: blood bank good practice requires avoidance of rh alloimmunization. several studies report a probability of immunization of more than % following transfusion with rhd+ rbc's and as many as % in the case of platelets. aims: the purpose of this study was to investigate the development of anti-d and the causes of alloimmunization in a university hospital ( beds), reviewing our practice on the use of rhd+ blood components in rhd-recipients. method: a retrospective study was performed whereby . rhd-patients, from to , were evaluated for the development of anti-d analysing the data on the blood bank information system. results: from the . rhd-patients we found out identified anti-d, % ( ) detected before any transfusion in our hospital. of the left, nine were excluded because no information was available during some years. had history of pregnancy related to the immunization. patients were exposed to rhd+ blood components: were transfused only with rhd+ platelets (including two women of childbearing age); with rhd + rbc's. the remaining had been exposed exclusively to rhd -rbc's suggesting that some units could be mistyped. this idea was corroborated in three patients where there was a common donor (he was called for investigation). conclusions: transfusion services avoid as far as possible administration of rhd+ blood components to rhd-patients, although there are situations in which such transfusions are necessary. the retrospective review of records revealed the need for specific recommendations regarding the use of rh immunoglobulin to prevent anti-d immunization. the possibility of mistyping blood components also appeared in this review, emphasizing the role of these studies in the evaluation of methodologies used at blood banks. the purpose of the work: to present the usage of whole blood (wb) and blood products (bp) in the treatment of patients who are hospitalized in the internal disease department in gevgelija. material and methods: retrospective analysis is done according the data which were analysed in five years period ( ) ( ) ( ) ( ) ( ) . statistical methods which were taken from the history of the hospitalized patients in the internal department were used for analysis and the data of transfused wb units and units of bp were taken from the department of transfusion medicine. results: from the total hospitalized patients who have been analyzed, ( . %) received wb and bp, and there have been transfused units wb and bp. every patient, on an average, has been transfused with . units wb and bp. at the same time ( . %) units have been transfused as a wb, ( . %) have been transfused as red blood cells (rbcs) and ( . %) units have been transfused as a fresh frozen plasma (ffp). the data for every year particularly will be presented in our paper to the congress. the collaboration between doctors of transfusion medicine and health workers from the other medical branches is the most important thing in the medical practice. our aim is to raise the awareness among the health workers for the importance of blood safety and their role though adequate clinical usage of wb and rbcs, minimizing the non-useful transfusions, evaluation of reflexive information from undesirable reactions in the usage of blood and blood products, use the alternatives etc. the necessity of direct involvement of the doctors in transfusion medicine in the process of healthy workers' education from the other branches for regularly transfusion therapy via meetings and lectures is an imperative for regular function of the department of transfusion medicine. femoral neck fracture repair is one of the commonest orthopedic procedures. it mainly concerns intracapsular or intratrochanteric fractures and it may be considerably hemorrhagic, requiring blood transfusion perioperatively. the aim of our study was to investigate blood transfusion requirement in patients with femoral neck fractures repair at katerini general hospital during - and to compare them with other studies. one hundred sixty five ( ) unselected patients of whom ( %) were women and ( %) were men with a mean age of years (range - years) were studied retrospectively. seventy six ( %) patients had intracapsular fracture and ( %) intratrochanteric fracture. the mean hb concentration on admission was . g/dl (range . - g/dl) and the mean hb concentration at discharge was . g/dl (range . - . g/dl). a total of units of rbc were transfused (a mean of . units per patient). blood transfusion occurred in patients ( . %), ( - % in other studies) with a mean of . units per patient (range - units), ( . - . in other studies). patients with preoperative hb values < g/dl were transfused more often than those with hb values > g/dl ( % versus %) p: . . women were transfused more often men ( . % versus . %) p: . . patients aged > years were transfused more often than those aged < years ( % versus %) p: . . finally patients with intratrochanteric fractures were transfused more often than those with intracapsular fractures ( . % versus %) p: . . conclusions: in our study blood transfusion requirement for femoral neck fracture repair are similar with these reported in other studies. blood transfusion frequency is greater in patients with hb < g/dl, in patients older than years, in women and in intratrochanteric fractures repair. fresh frozen plasma guidelines and practices as saltamavros*, g talampouka*, c koumoundourou*, s dimitrakopoulos † and p tseliou* *st. andrews hospital patras greece, patras, † pyrgos general hospital, pyrgos, greece introduction: fresh frozen plasma transfusions should be done according to specific standards and guidelines. aims: we have reviewed the ffp transfusion practices followed in our hospital in an attempt to provide a set of guidelines and principles that will assist physicians and health care workers to make the right decisions for appropriate use of ffp transfusions. methods: retrospective review of ffp transfusions practices during the entire year of . we classified transfusion practices according to the diagnosis of the patient and also of the clinical depart-ment that demanded transfusion. then we analyzed our results by comparing the requests with the internationally approved guidelines for ffp transfusion and counted the percentage of ffp to rbc units. finally we discussed with our fellow physicians the proper use of ffp and informed them about the accepted guidelines. as we can see from the underneath table, diagnoses and departments with high consumption were: internal medicine %, plasmapheresis to patients suffering from guillain barre and ttp (thrombotic thrombopenic purpura) . % and trauma/surgery . %, cancer . %. summary/conclusions: the use of ffp corresponds to . % of the rbc units transfused in our hospital. plasma units should be used properly and according to internationally accepted standards. plasma use should be justified by the physician, in order to avoid unnecessary risks on behalf of the patient for effective treatment and care. to show gradual discontinuation of using whole blood and increased use of red blood cells (rbc) in the management of patients in the transfusion department of the clinical hospital 'zvezdara' . methods: data of wb and rbc use from to in our hospital. results: our data are presented in table . conclusion: after , wb usage rates systematically decreased from % to . %. however, in the period of - , the wb usage rates increased slightly, and we arrived at a generally very low rate of wb use, namely only in about % of the cases. education about transfusion medicine and rational use of blood in the medical curriculum was generally insufficient and very poor. therefore, we started an education program and we established a hospital transfusion committee (htc) with the task of medical control and monitoring the quality of clinical transfusion practice in our hospital. members of the htc are a specialist in transfusion medicine, an internal medicine specialist, an anesthesiologist, surgeon and gynecologist. we have been organizing courses for the medical staff, doctors and medical technicians since . background: platelet transfusions are given mainly to thrombocytopenic patients with malignant haematological diseases. currently the decision to give a prophylactic platelet transfusion is based almost exclusively on the number of circulating platelets in the patient although it is known that various clinical factors might influence the bleeding tendency. by free oscillating rheometry (for), using a reorox® instrument, it is possible to monitor the coagulation over time in whole blood and obtain information about clotting time and coagulum elasticity. aim of the study: the aim of this study was to find out if for using the reorox® instrument could be used to evaluate the hemostatic status of thrombocytopenic patients. methods: the change in elasticity over time in non-anticoagulated whole blood from leukaemia/lymphoma patients with thrombocytopenia was measured in the reorox® pre and post a platelet transfusion (n = ) and was compared with healthy controls (n = ). the effect of platelet concentration on coagulation was studied by diluting platelet rich plasma from healthy subjects with autologous plasma to various platelet counts whereafter the coagulation was monitored with for (n = ). the change in elasticity per minute (g'max slope) and maximum elasticity (g'max) were evaluated from the elasticity curves. results: the g'max, g'max slope and platelet count increased after transfusion for all patients. the thrombocytopenic patients had significantly lower g'max and g'max slope values both pre and post transfusion compared with healthy control subjects (p < . ). the measurement in platelet rich plasma showed that g'max and g'max slope increased with increasing platelet concentration. however patients with similar platelet count developed different clot elasticity. the reorox ® instrument responds to changes in haemostatic function in form of the clot elasticity. the fact that patients with similar platelet concentration developed different elasticity shows that clot elasticity is a function of not only platelet concentration but also of functional properties. the for method seems promising to evaluate platelet function. quality control of pre-storage leukodepleted red cell concentrates vu urlep salinovic, k perbil lazic and l lokar teaching hospital maribor, maribor, slovenia background: the system of quality assurance including quality control (qc) in transfusion medicine is most important for safe blood supply. the safety and quality of blood components are increased by pre-storage leukodepletion of whole blood (wb). aim: the qc of leukodepleted red cell concentrates (rcc), prepared from pre-storage filtration of wb (quadruple blood bag systems imuflex wb-rp terumo) is performed with the aim to be sure that the quality of leukodepleted rcc is in accordance with the guidelines of council of europe. in three years ( ) ( ) ( ) , units of wb were collected, among them ( . %) units were collected for pre-storage filtration and in ( . %) of these qc was done. within hours after collection, wb was filtered at room temperature. filtered wb was centrifuged at g for minutes and separated in rcc and plasma. the samples for qc were collected before and after filtration. for each unit, volume, hemoglobin, hematocrit, % of hemolysis and residual white blood cells (wbc) count were measured. the number of residual wbc after filtration was determined in the nageotte chambre. for all parameters the mean value and standard deviation were calculated. the results of qc for the following parameters were: volume ± . ml ( % corresponds with the guidelines of council of europe), hematocrit . ± . ( %), hemoglobin . ± . g/unit ( %), number of residual leukocytes . ± . ¥ ( %), hemolysis . ± . % ( %), the test of sterility was % negative. during filtration of wb, wbc were removed in approximately . %, the duration of filtration was ± minutes and the loss of hemoglobin was . ± . %. the pre-storage filtration of wb is highly efficient, . % of wbc were removed and the loss of hemoglobin was small. background: the patients of cardiosurgery use big amount of blood components. there is no uniform approach by treatment with blood components in these patients. the safest and the most rational use of blood is based on the individual treatment of a patient and the evaluation of the most clinical and laboratory factors. aim: the aim of our study is to analyse the use of blood components from , when the cardiosurgery department was founded in our hospital, to . the data about use of red cell concentrates (rcc), platelet concentrates (pc) and fresh frozen plasma (ffp) in the period from to were collected from information system datec. the average use of all three blood components per patient is presented. we were interested, if the average use per patient was diminished in the analysed period. results: the use of three blood components and average use of all blood components are presented in the table. the data from the table shows, that the number of patients increased more than three times, but the average use of blood components per patient was not essentially diminished. conclusion: during seven years period the use of blood components per patient in cardiosurgery was not diminished. for more rational use it is necessary to apply all methods of autologous blood transfusion because of the increasing number of cardiac operations and decreased number of voluntary blood donors. background: the presence of leucocytes in blood components is cause for appearance of various adverse posttransfusion reactions such as nhfptrs, urticary, anaphylactic shock, alloimunization and platelet refractorines, infection with bacteria and leucothropyc viruses (cmv, htlv). the removal of leucocytes from blood components through filtration is especially important in the treatment of patients with malignant diseases who need frequent transfusions of blood and blood components. this is because of their lowered immunologic status which is a result of the disease and received immunosuppressive chemotherapy and radiotherapy. aim: to show the prevention of posttransfusion reactions and the positive effect from transfusion of leucoreduced er. concentrates, produced with filtration in therapy of anaemia in patients with malignant diseases, treated in our daily transfusion hospital at medical center -stip. methods: patients with malignant diseases have been treated in our daily transfusion hospital in the last four years. most of these patients suffer from ca pulmonum, ca collonis, ca uteri, ca mammae. also, because of the secondary anaemia, the same patients were transfunded with at least two doses of leucoreduced er. concentrates. the blood donored by voluntary repeated blood donors was filtrated the same day after the donation, separation and the control of the same one. the blood was collected in baxter and terumo bags, and it was filtrated with baxter -sepacell rs - and pall -purecell rn filters. the analyses of leucoreduction were made for every filtrated and transfunded unit before and after filtration. the analyses samples were taken from the tubing system before and after the filter. haemathologic parameters were automatically made in the central clinic laboratory. results: er. concentrates poor with the leucocytes for about - . % were produced with the use od these filters, and platelets from - % with which side effects from frequent transfusions at these patients were prevented. with the routine monitoring of all patients none posttransfusion reactions were registered. the therapeutic effect is also important because of the fact that the number of er and the level of hg and hct remain almost unchanged. the aim of the blood banks is to help and to increase the safety of the blood components. the leucoreduction through of er. concentrates poor with leucocytes is a regular procedure in the therapy of malignant patients with remarkable clinical picture of anaemic syndrome and prevention the cancer recurrence end infection. the time of filtration is also very important which has to be shorter after collection of blood, because the leucocytes should be removed before they become disintegrated and relapse potentially dangerous substances end metabolites in the blood components. we have been applying so called ' prestorage filtration' because it has been proved that it is more efficient that bed -side filtration. background: the effect of leukocyte reduction of rbcs by filtration has been the topic of several rcts. these rcts investigated the effect of leukocyte reduction on mortality; post-operative infections and hospital stay in different patient populations. some rcts came up with answers that conflicted with the results of other rcts. aim of the study: with including the individual patient datasets of several rcts in one database, combined analyses are possible that may explain the differences in the reported results. using this technique, we may come up with answers (or questions) that cannot be obtained by performing standard meta-analyses of these rcts. methods: we coordinated several rcts comparing the perioperative use of buffy-coat depleted rbcs with the use of filtered rbcs. cardiac surgery patients were included in three rcts ( ¥ cabg and/or valve; ¥ re-cabg and/or valve; ¥ valve with or without cabg). oncologic surgery patients were also included in three rcts ( ¥ colorectal cancer; ¥ gi-oncology or vascular surgery; ¥ gi-oncology, vascular surgery or orthopedic surgery). the electronic data files of these rcts were uniformly recoded and entered in a single database. as different primary endpoints were investigated in the rcts, we focused on common endpoints, recorded in or more of the rcts. multivariate analyses were performed on: in-hospital mortality, -day mortality, hospital stay, stay on icu, postoperative infections, and mods. results: in the rcts, individual datasets from surgery patients were collected ( onco; cardiac; vascular; orthopedic, other). in the multivariate analyses, patients in the buffycoat depleted trial arm showed a higher mortality rate both in-hospital (p = . ) and at days post-surgery (p = . ). no association between randomization and stay in hospital (p = . ) or stay on icu (p = . ) was seen in the combined study population. also, no association of randomization with the incidence or duration of mods was seen. the analyses of post-operative infections in the total population showed the trial arm to be associated (p = . ), and 'hospital' to be far stronger associated (p < . ). however, when the oldest rct, that had not yet used our standard definition list for scoring post-operative infections, was excluded, the association with the hospital was lost (p = . ) and the trial arm became more strongly associated with infections (p = . ). in the analyses of surgery patients, the use of filtered rbcs, compared to the use of buffy-coat depleted rbcs, resulted in reduced mortality (both in-hospital and at days postsurgery) and a reduction in post-operative infections. the association of the variable 'hospital' with post-operative infections, as is frequently reported in literature, was initially confirmed in our analyses. however, when a standard definition for post-operative infections was used (excluding the datasets from one of six studies), this association was lost. background/aims: uk neqas for blood transfusion laboratory practice (btlp) operates an eqa service for uk laboratories (including eire) and participants throughout europe, including major groups in denmark (n = ) and portugal (n = ). in november a questionnaire was distributed to determine the criteria used for selecting phenotyped blood for different patient groups, including pre-menopausal women (pmfs). results were analysed by country to establish any variation in practice relating to the selection of k negative (k-) and rhc negative (c-) blood, since antibodies to these antigens are now the major cause of hdn. results: overall return rate was % (uk) and % (non-uk), although only centres treating pmfs were included in this analysis. k-blood was selected for pmfs by % in wales (n = ) and % in england (n = ), but only % in scotland (n = ), % in northern ireland (n = ) and % in eire (n = ). in mainland europe, variation was also observed: % in denmark (n = ), % in portugal (n = ) and % in other countries (n = from countries). fewer laboratories selected c-blood for pmfs: % in england and northern ireland, % in scotland and eire, rising to % in wales. mainland europe showed similar variation: % in denmark, % in portugal (all ccee matched) and % in other countries. there are no guidelines requiring selection of k-and c-blood for pmfs, but in the uk d negative blood is required for d negative females aged < years. trend analysis of questionnaire data in the uk, using theoretical clinical scenarios, shows a decrease in the number of laboratories that would select k + blood for a year old female (with pre-existing antibodies other than anti-k), from % ( ), % ( ) to % in . in this survey, k + blood was selected for a female aged (no antibodies) by %, whilst % selected a k + unit for a female aged (no antibodies), despite this patient being treated as a pmf for provision of d negative blood. a similar distinction was made between the and year old females in portugal and mainland europe. conclusions: variation in practice may at least in part be due to the availability of blood routinely labelled for rh and k. in the uk all donations are labelled, except for those from new donors, as are most units in portugal. uk questionnaire data ( ) suggested that > % laboratories would change to selecting k-blood for pmfs if all units were labelled. however, labelling alone does not account for the differences seen within the uk, and perhaps the trend towards providing k-(and to a lesser extent c-) blood for pmfs is influenced by advice from transfusion services. it would be of great interest to monitor and compare the incidence of hdn due to anti-k and anti-c in different countries to measure the outcome of differing practices for provision of blood to pmfs and to thereby inform future policy. there is no ultimate in ex-vivo assay described, which can predict the outcome of plt transfusion in vivo. current in ex-vivo assays and animal studies are rather very complicated to carry out, cost effective and time consuming. objective: we hypothesized that the quantitative measurement of gpib expression by facs can be used to predict the outcome of platelet survival post transfusion. in our previous studies we demonstrated that our phagocytosis assay can predict the plt survival sensitively (blood dec- ) . we isolated human washed plts by centrifugation and labelled with mepacrine and then incubated with pma-matured thp- cells ( °c). binding was measured by facs analysis of cd b/cd positive particles, and phagocytosis by counting mepacrine/cd positive particles. we measured gpib expression before and after plt-macrophages interaction by facs flowcytometry. results: gpib expression at surface of c fresh showed ± and after hours storage ± % expression. the gpib expression at surface of plt decreased and showed three populations with different densities high (gpib- ), low (gpib- ) and in-between (gpib- ). the binding and phagocytosis of plt showed an increase of ± % which implicates an indirect and negative relation to gpib- , and direct relation to gpib- expression. anti-human pselectin (cd p) delayed ± % the binding and annexing v ± % the phagocytosis of stored plts, after -hour storage. these results show that gpib expression is rather easy, reproducible test which can be standardised and be used as a very sensitive in vitroassay to predict platelet survival posttransfusion. transfusion and lung injury jd dodig*, d sovic † , m tomicic † and h sager* *university hospital 'sestre milosrdnice', zagreb, † institute for transfusion med, zagreb, croatia background: the respiratory tree has been viewed as an infrequent site of injury arising as serious complication of transfusion. in recent years, this view has changed as investigators have shown that two complications-circulatory overload and transfusion related acute lung injury-are relatively frequent events. case report: a -year-old men was admitted due to chronic macrohematuria. he had no history or current evidence of cardiac failure. the hb level was measured g/l. he received ml . % nacl and ml ringer solutions. after that, he was transfused with units of rbcs. during transfusion second unit he developed following symptoms: tachycardia, dyspnea, hypertension. massive pulmonary edema was noted. he was treated with mechanical ventilation, oxygen, diuretics, aminophillin, antihistaminic and corticosteroides. the patient recovered after being on ventilation for hours. two days after the patient was operated. after surgery he was transfused with units of rbcs. all transfusions were regularly performed. results: chest x-ray confirmed bilaterally pulmonary edema. the samples (patient and donors of first two units rbcs) tested were negative for the presence of hla specific and granulocyte antibodies. granulocyte agglutination and lymphocytotoxicity test were negative. tnf-a in recipient serum was slightly increased. conclusion: our patient is the first reported case suspected of trali, but all of the investigations didn't give us the answer. against neutrophils using flowcytometric detection of cell surface cd b expression and l-selectin shedding. methods: a hundred microl of volunteers' heparinized whole blood were incubated for minutes at °c with fmlp, lps or pma. monoclonal antibodies against hna a and hla-i, or patient serum were incubated with whole blood for min. surface cd b and l-selectin were detected using facscalibur. results: neutrophil activation was detected after fmlp, lps or pma stimulation. p map kinase inhibitor reduced activation induced by fmlp and lps. anti-hna a monoclonal antibodies induced neutrophil activation, which were also inhibited by p map kinase inhibitor. ten serum samples obtained from patients or donors who caused transfusion reactions were evaluated. five sera out of samples having anti-neutriphil and/or hla antibodies exhibited neutrophil activation, while two samples without leukocyte antibodies had no effect on any activation. conclusion: these findings indicate that neutrophils activation is regulated through mak kinase and detection of neutrophil activation may be useful to predict transfusion-related reactions. results: out of transfusion reactions were febrile, were anaphylactic, were due to circulatory overload, out of transfusion reactions concerned the transfusion of incorrect blood component. out of transfusion reactions concerned acute haemolytic reaction. post transfusion purpura or suspected trali was not seen. fatal complication was not seen. the reactions to plasma were predominately anaphylactic. we detected no case of bacterial contamination among the cultures of transfusion bags. conclusions: the incidence of reactions among patients malignancy was high, while among surgical patients was lower. the incidence of transfusion reactions during the months had no statistically significant difference. we suggest that the improvement in prevention of transfusion reactions require a continual vigilance system for rapid recognition and information regarding these complications. measurements of ige immunoglobulin in thalassemic patients, before and after blood transfusion background: many studies have reported the implications of proinflammatory cytokines including interleukin (il)- beta, il- and tumor necrosis factor alpha (tnf-alpha) in febrile nonhemolytic transfusion reactions. il- has been shown to accumulate in packed rbcs even after the procedure of filtration, which is explained by the release of il- from rbc receptors into the packed rbc super-natant. stress induced elevation in tnf-alpha levels was demonstrated in healthy individuals. aim: to assess the level of proinflammatory cytokines in peripheral blood of blood donors. material and methods: immediately upon blood collection, plasma was separated from postdonation blood samples obtained from blood donors and frozen at - °c. upon thawing, the level of the il- beta, il- and tnf-alpha cytokines was determined in plasma samples by elisa method using commercial kits for cytokine determination (roche molecular biochemicals). the level of il- beta was at the test detection limit in all donor plasma samples. in ( . %) bd, the level of il- was . pg/ml, exceeding the test sensitivity limit of . pg/ml. in ( . %) bd, the level of tnf-alpha was within the range of - pg/ml, with a test sensitivity limit of pg/ml. tnf-alpha levels > pg/ml were measured in plasma samples of ( . %) blood donors. the increased activity of blood donor's immune cells, indicated by elevated levels of the proinflammatory cytokines il- and tnf-alpha in peripheral circulation some blood donors, may lead to the occurrence of febrile nonhemolytic transfusion reactions in the recipients of the blood products manufactured from the blood of these blood donors. this hypothesis will be thoroughly investigated in our future studies. background: transfusion-related acute lung injury (trali) is a life-threatening complication of transfusion, under-recognized and underreported possibly lacking a consensus definition. aim: we report here a 'probable' case of trali syndrome in an elderly female patient. case presentation: an eighty-two year old female patient was transferred to the intensive care unit on the third postoperative day (pod) following the abrupt onset of acute pulmonary insufficiency (pao = mmhg, o saturation = %), hypotension (bp = / mmhg) and fever ( °c). this occurred ten minutes after initiation of an infusion of a unit of packed red blood cells (prc). the patient had no history of any cardiac or pulmonary disease. she was intubated and placed on mechanical respiration and supported hemodynamically. the cvp ( cm h o) ruled out fluid overload. the chest x-ray revealed bilateral pulmonary oedema, the echo cardiogram and blood cultures ruled out cardiac and infectious aetiology of the episode. after treatment for hours the patient improved significantly, was extubated and returned to the surgical unit on the th pod. reviewing the transfusion history we discovered that the patient did not receive any blood or blood component prior or during the correction of her ileum, but she was transfused a unit of ffp (fresh frozen plasma) five hours prior to the incident. the donor review revealed that the unit of ffp was from a -year old female with a history of multiple abortions whereas the prc unit was from a -year old male, a volunteer of several years who had no history of transfusions. there are some prerequisites for the implementation of a haemovigilance network and some of them have been met, so we can present the first results. methods: traceability of blood components is possible because there is unique information system in place in the whole country, identifying the donor, donation, each single blood component and identification of the recipient, but feed back information of the performed transfusion is still missing. cooperation between blood transfusion service and hospitals was established by introduction of hospital transfusion committees; the intensity and quality of their work is very different. homogeneity of reporting is achieved by the introduction of unique reporting form. a reporting route was defined: patients physician sends notification of atr to the local blood transfusion service. atr reporting form is prepared there and sent to the national blood transfusion service, where the data is collected for the centre for haemovigilance, which is going to be established very soon. data analysis will be responsibility of the centre for haemovigilance at the governmental level. type of adverse transfusion reactions and events is defined. education and information was passed to the health personnel by inclusion of haemovigilance in under and postgraduate programmes as well as seminars, scientific meetings and some publications. results: in the years - there were . blood components issued in slovenia and atrs were reported ( in blood components issued), in of them the severity grade was ( in . blood components issued). in the year there were considerable differences between the number of atr reports compared to the number of blood components issued among slovenian hospitals, ranging from in to atr in blood components issued. . % of all atr were not classified. conclusions: although the number of reported atrs was increased by % and % a year in and respectively, it can be assumed that the collected data is not complete. feed back reports, much more information and cooperation is needed, especially in some hospitals, which should contribute to a better registration of atrs and events in the future. the slovenian haemovigilance system still needs upgrading, but despite this, some important work has been done in building a national haemovigilance system. . considering the multiplicity groups in cattle and since there was no research on repeated blood transfusions reactions in iran's native cattle, we decided to consider crossmatching in different processes of repeated blood transfusion from a head of blood donor to five recipients and observe the clinical and hematological alterations. six healthy iran's native cow, . years old, with average weight of kg were used. the animals were dewormed by albendazole ( my/kg bw) and were kept for two weeks under uniform managemental condition. three days prior to blood transfusion, vital signs registration (temperature, heart rate and respiratory rate) blood collection via jugular vein was done to indicate the baseline of research parameters. after that, blood transfusions were performed from one donor cow to five recipients three times at one-week intervals. cross matching was done at each transfusion. after each transfusion the research parameters do determined. results indicated that one of the recipients cows experienced anaphylactic shock, in the first step of blood transfusion and another cows in the second step and finally in the third steps two other cows showed the serious shock. this is in the contrary of this opinion that the first transfusion can be given safely without crossmatching in cattle practice ( van der valt, et al. ( ) background and objectives: blood transfusion may lead to the manifestation of anti-hla and platelet-specific antibodies that may in turn bring about different problems like platelet refractoriness. it appears that the study of antibodies against hla-class i and platelet-specific antigens are useful for the selection and success of the appropriate treatment protocol. the aim of this study was to detect anti-hla and anti-platelet-specific antibodies by flowcytometry in patients with hematologic disorders (including acute leukemia, aplastic anemia) and patients with itp. in this descriptive study, anti-hla and platelet-specific antibodies were detected by flowcytometric technique, using sera drawn from patients with different haematological disorders who showed a poor response to platelet transfusion and from patients with itp. the results of anti-hla antibodies were then compared by panel reactive antibodies (pra). results: our results showed ( . %) out of ( . %) patients had anti-hla class-i antibodies in their sera. the frequency of each antibody isotype was found to be as follows: igm ( . %), igg ( . %) and iga ( . %). ( . %) out of patients had platelet specific antibodies and the frequency of each antibody isotype was found to be as follows: igm ( . %), igg ( . %) and iga ( . %). ( . %) out of patients had both antibodies. no difference was found between the two groups in platelet specific antibodies. despite significant correlation between flowcytometry and pra methods, pra can only detect antibodies which react with complement. conclusions: with increase in the number of platelet transfusion, immunization to hla antigens occurs; moreover, immunization against platelet specific antigens may also occur during autoimmunity. the presence of these antibodies may be one of the reasons of poor response to platelet transfusion and platelet refractoriness in patients under study. conducting similar studies with higher number of samples, platelet cross-match, and the use of hlamatched platelets for these patients are recommended. post transfusion purpura (ptp) is a rare, severe thrombocytopenia that results from alloimunization to platelet specific alloantigens, following blood transfusion. in this condition, the patient's own platelets are destroyed by the alloantibody even though they are not supposed to carry the 'guilty ' antigen. the disease is rare occurring mainly in multiparous women. the majority of reported cases involved antibodies against the platelet specific alloantigen hpa- a in a homozygous hpa- b patient. in a minority of cases the offending antibodies were directed against hpa- b, - a, - b, a, - a, - b. although self-limiting, the syndrome is characterized by severe bleeding with high morbidity and mortality; therefore prompt diagnosis and appropriate therapy is crucially important. ptp is a challenging diagnosis, because the patients are often critically ill or post-surgery, and have alternative explanations for thrombocytopenia such as infections or drugs. we present three patients with severe thrombocytopenia initially misdiagnosed. the first patient, a -year old women, had a past history of systemic lupus erythematosus and coombs positive autoimmune hemolytic anemia. at the present hospitalization, after antibiotic therapy for endocarditis, a severe hemolytic episode occurred and she need blood transfusion. when severe thrombocytopenia appeared, she was wrongly diagnosed as evans syndrome. the second patient, a -year old man, suffered from sepsis after vascular surgery and revealed clinical and laboratory picture of dic. the third patient, a -year old women, had end-stage renal failure and received heparin during hemodialysis, thus heparin-induced thrombocytopenia was first suspected. history of recent blood transfusion rose the suspicion of ptp in all this cases, and appropriate therapy with high dose iv immunoglobulin was started. adequate laboratory work-up confirmed the diagnosis. three different anti hpa-antibodies were identified: anti hpa- a, anti hpa- b and anti hpa- b, respectively. the platelets genotype of the first patient was hpa- b/ b, of the second hpa- a/ a and of the third patient, hpa- a/ a. the reported cases emphasized the importance of keeping in mind the possibility of ptp. incorrect diagnosis may lead to wrong treatment and fatal outcome. health sciences authority, singapore, singapore introduction: the haemovigilance programme in singapore was started by the centre for transfusion medicine (ctm) in . the system covers registration of collected, produced and transfused blood components, and monitors adverse transfusion reactions (atr). the programme runs on a voluntary, non-punitive and confidential basis. aims of the study: ( ) to gather and analyse reports of all adverse and untoward events occurring during transfusion of blood and components. ( ) to use the information acquired to determine the morbidity of transfusion. ( ) to provide guidance on corrective measures to prevent the recurrence of some accidents, and to improve transfusion safety. ( ) to improve public confidence by demonstrating to public, patients and professionals the safety of the existing transfusion system. methods: ( ) a common report form is used and made available to all participating hospitals. within the reporting system, the identification of the patient and staff involved are not required, to ensure confidentiality and protection of information belonging to the hospital. ( ) reportable events include immediate reactions during transfusion (haemolysis, non-haemolytic febrile transfusion reaction, urticaria, anaphylactic shock, bacterial contamination, trali), delayed untoward effects after transfusion (haemolysis, post-transfusion purpura, acute gvhd), transfusion-transmitted infections, incorrect components transfused, and near misses. ( ) within the hospitals, a responsible person ensures that all adverse events and untoward effects of transfusion are reported on the haemovigilance forms and provided to ctm for collation. within the ctm, the haemovigilance coordinator is designated to assist hospitals in investigating serious adverse events and advise on the reporting formats. results: ( ) the total number of reported cases has steadily increased since the introduction of the programme. ( ) the number of participating healthcare institutions has also increased to % (n = ). please refer to table entitled 'summary of the haemovigilance report - ' . ( ) the implementation of the haemovigilance programme in singapore is feasible with respect to the asian setting, and can significantly contribute to blood safety. ( ) there has been very good participation from the participating healthcare institutions, signifying greater awareness and willingness to partake in the programme. ( ) the results obtained from the programme have given rise to initiatives and recommendations aimed at reducing ( %) were rated for seriousness. of these, ( . %) were rated as grade (moderate to serious morbidity) or worse. ( . %) were rated for imputability to the blood transfusion. of these, a relationship to the transfusion was graded as 'certain' or 'probable' in ( . %) and as 'possible' in ( . %). overall relatively few errors were reported in comparison to other systems. a small number of reports concern (possibly) infected blood components, and imputability was deemed probable or certain only in a minority of these reports. autologous blood components gave rise to five reports (errors as well as mild transfusion reactions) which shows a relatively high risk associated with their use ( . per the rate of post transfusion hepatitis (pth) in israel in unknown. this information is important in order to learn about the residual infection risk in blood recipients. aim: to summarize the data on reported cases of pth. methods: suspected cases of pth are reported to mda blood services. the investigation procedure includes follow up testing of implicated donors and retesting of an archive sample of the transfused unit, if available. donors involved in suspected pth-b are tested for hbsag and anti-hbc. anti-hbc+ donors are tested for anti-hbs. hbv-dna testing is done if anti-hbs is less than miu/ml. donors involved in suspected pth-c, are tested for anti-hcv and alt. since hcv-ag or hcv-rna are performed, when appropriate. investigation is considered complete if all the involved donors are retested > months following the implicated unit. results: between between - suspected pth cases were reported: ( %) were pth-b, were pth-c ( %) and in patient both hbv and hcv infections were reported. investigation was completed in / ( %) cases, with % of the involved donors ( / ) being retested > months after the implicated donation. hbsag was not detected in any of the retested donors. anti-hbc was detected in donors involved in pth-b cases of which were also positive for anti-hbs. pcr for the detection of hbv-dna was performed on the 'anti-hbc+ only' donors, and none was found positive. only in / donors suspected to be involved in pt-hcv, anti-hcv antibodies were subsequently detected. this donation was collected and transfused before the introduction of anti-hcv testing in israel, which was implemented in . in another pth-c case, the implicated donor is still negative for anti-hcv, in follow up samples of up to months, but was found positive for hcv-ag and hcv-rna. pth investigation of all the donors involved was completed in % ( / ) of the cases where the patient received up to blood components. conclusion: in the past years an average of cases/year of suspected pth were reported to the israeli national blood services. investigation was completed in % of the reported cases. so far, there was no clear evidence of hbv transmission. in cases (out of . million blood units collected nationwide during - ) hcv seemed to be associated with blood transfusion: one caseprior to the implementation of anti-hcv testing and the otherprior to the implementation of hcv-ag testing in a donor that did not develop anti-hcv antibodies. these findings suggest that other modes of hbv and hcv transmission should be sought in blood recipients in israel. - . , p < . ). the seroprevalence for a-hiv in the bd population was . % (se: . ; ci: . - . ; p < . ) whereas in the a-hbc positive bd was . % (p < . ) and in the a-hbc negative bd was . %. from a-hiv positive donations, were also positive for a-hbc, that means that the sensitivity of the a-hbc in the detection of a donation a-hiv positive was . %. the relative prevalence (percentaje of positive donations for a-hiv in the a-hbc positive population divided the percentage of this marker in the donations a-hbc negative: rp) was . , which indicates that the number of bd a-hiv positive is . times higher in the a-hbc positive that in the a-hbc negative population of bd. as regards a-htlv, the seroprevalence in the bd population was . % (se: . ; ci: . - . , p < . ), in the a-hbc positive bd was . % (p < . ) and in the a-hbc negative bd was . %. from a-htlv positive donations, were also positive for a-hbc, that means that the sensitivity of the a-hbc in the detection of a donation a-htlv positive was . %. the rp for a-hbc as regards a-htlv was . , which indicates that the number of bd a-htlv positive is . times higher in the a-hbc positive that in the a-hbc negative population of bd. our results suggest that, in our bd population the screening with a-hbc would be useful to prevent other infections transmissible by blood transfusion, like retroviruses, because of the high sensitivity and the relative prevalence. . despite the high specificity of currently available elisas, the positive predictive value is lower in blood donors. therefore, immunoblot tests and polymerase chain reaction (pcr) have been adopted for routine testing in elisa +ve blood donors, by our service. . our data show that the real anti-hcv prevalence of our donor population is very low ( . %). . the selection and evaluation of appropriate assays of all donated blood for hcv infection ensure good laboratory practice and accurate post-notification counselling of infected donors. . given that donors who are elisa positive but persistently negative or indeterminate probably do not represent a risk for transmission, their deferral from donation increases the problem of availability of blood supply. . donor re-entry in the pool of donors is an issue for further discussion. . the introduction of nat technology may elicit more accurate responses and improve the screening process. background: the introduction of hcv antibody screening of all donor blood in represented a major step in the prevention of transfusion-associated hcv hepatitis and in identification of infected donors. the study of infected individuals provides a unique opportunity to define behavioral factors associated with infection. evaluating risk factors in hcv infected blood donors is essential for monitoring blood supply safety, donor screening effectiveness and developing appropriate prevention programs objectives: . to recognize the epidemiology of hepatitis c and how it differs geographically; . to investigate the risk factors for presence of anti-hcv antibody in blood donors; . to evaluate the effectiveness of our donor selection program in local level. methods: serological testing for hcv was performed according to standard procedures. initial screening was performed using secondgeneration eia and, after january , using third-generation eia. our study included a confirmation test (riba) a questionnaire was used to collect data concerning demographic, social and sexual behaviors, and number and type of donations of blood donors. the study also included testing of sexual partners and family members. changes in rates of hcv infections were evaluated by comparing yearly prevalence estimates. the overall prevalence of anti-hcv (eia) was . % out of blood donations. the average prevalence of hcv infection by riba was . %, which reaffirms the very low risk of transfusion-transmitted disease. the cumulative number of hcv infected donors was , with cases in males and cases in females. most infections were found among older persons ( % were aged - , and % aged - ). the seropositivity was higher in family/replacement donors ( %) than in volunteers ( %). the annual prevalence decreased throughout years. the relative importance of risk factors for hepatitis c was: transfusion %, hospitalization %, immigrants %, occupational %, sexual transmission %, injection drug use %, household contacts %, other %, tattooing %, unknown %. according to the criteria for blood donation, certain donors should have been excluded in the predonation interview but these donors had denied risky behaviour when questioned. the importance of sexual activity in the transmission of hcv has not been well-established as we tested sexual partners and family members and none of them was found positive. conclusions: our results suggest that major improvement in the safety and quality of our blood supply has been made in our area. introduction: apart from immuno-haematological complications, blood transfusion recipients are exposed to the risk of viral and bacterial contamination of donor blood. the latter infectious risks are generally associated with the number of donations that are needed in the production of blood products: the pooling effect. one measure recently being discussed is the generalisation of the use of trombocytapheresis for the production of trombocyte concentrates. normally, the trombocyte product is a concentration of trombocyte extractions from a pool of buffy coats: pooled platelet concentrates (ppc). in case of trombocytapheresis sufficient trombocytes for one transfusion can be collected from one single donor. aim of the study: in this presentation the effect of using % trombocytapheresis for the production of single donor platelets (sdp) instead of pooled platelet concentrates (ppc) on contamination risks will be assessed. these risks can be divided in ) the risk of bacterial contamination, ) the risk of viral contamination (e.g. hcv, hbv, hiv) resulting from window period donations, and ) the risk of contamination with tse or emerging infections for which no screening test exists. the contamination probability of sdp versus ppc is assessed on the basis of the production characteristics of both products, e.g. the presumption that the contamination risk per trombocyte product will be reduced by a factor equal to the number of pooled donations (five in our case). reduction of the bacterial contamination risk was estimated using the results of the bacterial testing of pooled and apheresis platelet products. as patients are likely to obtain multiple blood products during treatment, the contamination risk reduction through sdp is not only dependent on the reduction of risk in trombocyte products, but also will also dependent on the total number of blood products transfused and their associated contamination risks. the platelet recipient risk reduction was calculated on basis of the distribution of blood products received by the patient population of the university medical center utrecht (umcu) in the year . results: in the attached table the estimated risk reduction through % trombocytapheresis is shown for the general blood recipient patient and for the trombocyte recipient patients only. our analysis indicate that in platelet recipients, general application of sdp instead of ppc will reduce the risk for transfusion acquired tse infections by %, the risk of known viral infections by %, and transfusion acquired bacterial infections by %. the confidence intervals surrounding the results were obtained by bootstrapping. the large confidence intervals surrounding the reduction of bacterial infection risk is caused by the fact that only a limited set of apheresis trombocyte products were tested. conclusion: our analysis indicates that general application of sdp instead of ppc will not reduce the risk of transmitting infections to platelet recipients as linearly ( : ) as expected. whether it is a costeffective precautionary measure will have to be evaluated by a costbenefit analyses consideration clinical benefits and additional costs and risks of apheresis donations. introduction: hepatitis b is serious health problem world wide. its prevention, particularly in the population of blood donors is essential for providing good health care and protection. aim: the aim of this study is to present the distribution of hbsag(+) and hbsag(-) blood donors according to their profession. methods: specially designed questionnaires are used for interviewing the blood donors who has previously given signed consent for participation in this study. results: table shows the distribution of the blood donors in different professions. administrative clerks with ( . %) and the workers with ( . %) registered in the group of hbsag(+) blood donors, as well as workers with ( %) and administrative clerks with ( %) from the hbsag(-) group of blood donors are dominantly more frequent than the other categories of professions. health care professionals, housewives and farmers in both groups of blood donors are least frequent. taking in consideration the distribution of blood donors by the given professions in both groups, for u = and p > . there is no significant difference found. the analysis of the differences among the different frequencies, in distribution of blood donors according the profession, for d = . and p < . shows a significant difference, where the workers with ( . %) are the most dominantly represented. in relation to the issue of whether the type of profession of the blood donors is production or non production the results are presented on table . in the group of hbsag(+) blood donors the number of those who work in production profession- ( . %), is dominant over the number of those that has non-production profession- ( . %). in the group of hbsag(-) blood donors there is no significant difference between the types of professions. conclusion: having in consideration the professions of blood donors in both groups, for c = . and p < . there is a significant difference in the presented distribution. according to our study, which shows the horizontal transmission of hbv infection in the family in which there is an index case, the biggest number of participants in the study is workers, and the least number of participants are the farmers. introduction: blood donors, as part of the healthy population are tested for hbsag with each blood unit they give. therefore, they can be an epidemiological model for exploring the appearance of hbv infection in general population. aim: this study aims to show the distribution of hbv infection in blood donors in relation with their living conditions, space and facilities. the material needed for the study consists of the data obtained from confirmed hbsag(+) blood donors and confirmed hbsag(-) blood donors as control group. results: the table shows almost equal number of hbsag(+) blood donors that live in houses or flats. in the hbsag(-) group ( %) donors that live in a flat dominate compared to ( %) of those that live in a house. having in consideration the presented distribution (table ) for c = . and p < . there is a significant difference, that comes from the bigger number of blood donors ( ) that live in flat. as for the distribution of blood donors according the living space they use by member of the family (table ) , we can show that ( . %) of the hbsag(+) donors have less than m living space, in compared to ( %) from the hbsag(-) group. the bigger number of hbsag(+) blood donors with small living space gives bigger possibility for transmission of hbv infection in the family. the differences in the two groups for donors that have between and m , and between and m of living space per person, obviously are not very big. for u = and p > . there is no significant difference in the number of the donors in the two groups, when the available living space in m is discussed. introduction: when one of the sexual partners has hbv infection the other is also infected in from cases. aim: the aim of this study is to outline that the risk from transmission of hbv infection between sexual partners is smaller if they use condom as protection. methods: two groups of blood donors-hbsag(+) and hbsag(-) have been interviewed whether they are using condoms as protection, or not. results: table shows the distribution of blood donors concerning the use of condoms. table : in the group of hbsag(+) blood donors those who have not used condoms dominate with number of ( . %), in compared to those ( . %) who used condoms. these data are in favor of eventually possible sexual transmission of hbv infection in hbsag(+) blood donors. in the group of hbsag(-) blood donors dominate those who have used condom- ( %), compared to ( %) who have not. the given distribution of blood donors concerning the use of condoms for c = . and p < . , shows significant difference, which is due to the prevailing of the number of blood donors ( ), who have not used condom. of er -concentrates are leukodepleted. the choice of bacteriological control of empty bags for blood, bags with er -concentrates in additive solution, universal and iso group plasma, as well as the systems for taking of blood are taken on free choice. the control of the erytrocyte concentrates is performed on the first day after the preservation and dekanting, and again between the th- st day and th- th day after the preservation. the pulled plasma is controlled on the day of pouring (spreading), and the control of the iso group plasma on the day of deplasming. three months later the iso group and the universal plasma kept on the temperature of - °c is bacteriologically controlled again. bacteriological control is performed with standard procedures in the institute for health protection in stip. the transfusion transmitted infections are potentially dangerous complications of transfusion therapy in immunocompromised patients. the aim of this study was to determine the prevalence of transmissible infections in blood donor population in kashan, iran. a total of consecutive sera were tested for cmv-igm antibody, hbsag, hepatitis b core (hbc) antibody, hepatitis c (hcv) antibody, and hiv antibody with standard methods. of the sera tested, specimens ( . %) were cmv-igm positive. the frequency of seropositive revealed no significant differences between male and female donors. the frequency rates of cmv-igm seropositive tests tend to decline with increasing the age. there was no relation between the frequency rates of cmv-igm seropositive with the educational level, socioeconomic status, marital status, urban dweller and rural resident patients. the prevalence of hbv, hcv, and hiv antibody were . %, . %, and %, respectively. these findings implied important clinical applications because detection of cmv positive sera may reduce the risk for transmission of cmv in blood transfusion and thereby decrease the risk on cmv-induced complications. introduction: the worlds problem, aids, steel can't be said that is a problem in these three centers in r. macedonia, in which blood is collected, controlled, and distributed. found negative and of them were found positive for one of the three viruses (hiv- , hcv, hbv). with the elisa/axsym assay of the blood units which were negative by the procleix ultrio assay were positive for anti-hbcag and negative for anti-hbsag and hbsag. from those blood units units were given for transfusion following our blood centre protocol and the remaining units were discarded. the protocol consists of a good medical history, liver enzymes (ast, alt, ggt). we must take into consideration that from those that were found positive by the procleix ultrio assay was positive for anti-hcv and were positive for anti-hbsag. summary/conclusions: despite the fact of the short period of time we perform this method, the ability of the nat technique for rapid use, reliability and sensitivity in detecting three viruses simultaneously, indicates the need for immediate use in blood donation as a screening method. in spite of the high cost of the method, it is clear that this assay is a valuable tool in our blood centre to provide fast and safer blood. bacterial contamination of blood products is a persistent, but often overlooked, problem in transfusion medicine. in greece it is recommended that platelets (plt) must be used or discarded within five days post-collection. recent reports from europe have advocated the use of bacterial culturing of platelets on day or and, in case of negative result, prolongation of their storage time to days. aim of the study: to assess the prevalence of bacterial contamination of standard platelet units from whole blood, and to provide evidence that with the use of bacterial culturing it is feasible to extend the self life of platelets to days. materials and methods: eligible blood donors were bled according to standard operating procedures used in greece. plt were prepared from whole blood, solely for the purpose of the present study, by the platelet-rich plasma method. plts were stored for up to days at to °c with end-over-end agitation. other plts prepared from blood collected in triple-pack container system also provided with a predonation sampling device were also tested. plts were sampled in the bacteriology laboratory. plts were sampled on day , and . both aerobic and anaerobic culture bottles were inoculated with a -ml platelet sample. culture bottles were incubated at °c in an automated microbe -detection system (bact/alert system) until a positive reaction was detected or for days. all samples that were reactive were confirmed by routine culture. each reactive sample with bacteria growth on the routine culture was sub cultured for identification of the bacteria. results: a total of plt concentrates were cultured and bacterial contamination was assessed in each unit at day , and after collection. on of storage day two out of ( . %) plt units were found to be positive for bacterial growth. cases of unconfirmed positive results were noted at the beginning of the study. out of the other units which were negative on day and continued to be cultured for the next days, the assessment at day found no other positive. after further storage, at day , defined as the end of the prolonged incubation period, out of the plt concentrates ( . %) grew bacteria although testing of the same units on day and gave no signal. from the platelets units that were prepared from blood collected with a predonation sampling device, none of the plt concentrates gave a positive signal although pouches were found to be positive, and subculture showed bacterial growth of coagulase -negative staphylococcus. despite the relative small number of tested platelet concentrate units, our findings discourage specialists in attempting platelet storage time prolongation to days. bacterial contamination testing on day and a storage time of maximum days seems to be still the safest practice. bacterial screening of platelet concentrates using bact background: bacterial screening of blood components is a routine measure in the evaluation of blood product quality. at our institute bacterial screening is performed using bact/alert system. sampling and culturing of blood products is performed according to paul-erlich institute recommendations. methods: quality control data on the bacterial screening of platelet concentrates performed from - were retrospectively analysed. an initially positive (ip) and true positive (cp) rate, organisms isolated and time of detection are presented. results: a total of platelet products were tested during the year period. thirty ( . %) were found initially positive by bact/alert. the cultures screening positive were subjected to bac-terial identification to distinguish false positive from real positive signals. bacterial contamination was confirmed in ( . %) plt concentrates. positive cultures were confirmed and identified in an independent laboratory ( hbsag, anti-core, anti-hbs, anti-hcv, anti-hiv i/ii, anti-htlv i/ii, rpr. these patients were transfused with - units of concentrated red cells, depending on their problem. a total units were delivered from the beginning of their problem until december . the control were done using last generation enzyme-linked immunoassay (dade behring, ortho, biomeurieux), as also using automated enzyme-linked immunoassay (axgym). the same patients were checked by their physicians before the initiation of transfusions for the same diseases. results: we found: patients anti-hbc (+) and anti-hbs (+). patients anti-hbc (-) and Ánti-hbs (-) patients anti-hbc (-) and anti-hbs (+) patient anti-hbc (+) and anti-hbs (-) patient hbsag (+), anti-hbc (+) and anti-hbs (-). all patients were negative for hcv, hiv, htlv, and rpr. the same results were found also from patients' physicians. conclusions: we conclude that the blood supply for blood transfusion-transmitted diseases is % safe in our centre. these results are in accordance with current international literature. this is due to careful selection of blood donors, to high quality of corporation between departments as also to internal and external quality control. all these factors contribute to safety of transfusions, the quality of life of the patients and the protection of patient's environment. neither in the pipetor nor in the extractor runs was found contamination. no false positive were detected and all the positive samples confirmed. (see tables and ) . for hiv and hcv the specificity was . %. the validation criterion were met, so the system was implemented routinely in our laboratory. the purpose of our study was to analyse the applicability of the pall enhanced bacterial detection system (ebds) in the routine of our transfusion unit which is totally focused on apheresis platelet collection. methods: apheresis pcs, obtained by trima (cobe) and amicus (baxter) separators and re-suspended in % plasma and % ssp solution (macopharma), were submitted to microbiologic control using pall ebds system which uses oxygen percentage decrease as a surrogate marker of bacterial growth. the working steps were the following: - hour after donation, about ml of pc were sampled into the ebds collection pouch and then incubated at °c under continuous agitation (incubator helmer ) for hours. after this period, oxygen percentage was measured using an oxygen analyser (pall bdso ). the test is based on the 'pass/fail' principle. in case of 'fail' result the microbiology department has drawn up the procedure to follow in order to confirm the data and to allow the micro-organism to be identified. the incidence of post transfusion hepatitis has been reduced by blood donor screening for hbsag, but the hbv infection is still responsible for a certain cases of post-transfusion hepatitis in world-wide. in this study the hbsag negative blood units were evaluated for anti-hbc and hbv dna by pcr method. an extra sample was collected from hbsag, anti-hcv, anti-hiv and rpr-negative blood donors. all of samples were examined by approved anti-hbc assay. all of anti-hbc positive samples were tested by hbsab assay and evaluated for hbv dna (pcr). the sensitivity of the hbv dna (pcr) assay was estimated geq/ml according to vqc proficiency and run control panels. ( . %) out of samples were positive for anti-hbc. ( . %) out of anti-hbc positive samples were hbsab positive, and ( . %) were hbsab negative. all of samples were assayed for hbv dna (pcr) single and all of them were negative for hbv dna (pcr). further study for evaluation of anti-hbc test as a screening assay for blood unites in high hbv infection prevalence area strongly recommended. early detection of hepatitis b surface antigen: a comparison of ten assays hbsag detection is the corner stone of detection of hepatitis b virus infection in blood donors and patients with hbv infection. one of the most challenges is sensitivity of the technique and kit. in this study ten different assays evaluated by seroconversion and performance panels. some of them can not be used as screening assay due to low sensitivity. the sensitivity of ten hbsag assays from biorad, dade behring, biomeriux, diasorn, radim, diesse, thermo. biokit, gb and shanghai companies were evaluated by two or three seroconversion and two performance panels from boston biomedica ink. seroconversion panel is a series of samples that collected over a period of time from individual developing antibodies due to a primary infection. for evaluation of the assay sensitivity who and other notified body in the world-wide recommended the seroconversion and performance panels. the hbsag assays are two groups. group one with high sensitivity included six assays. they can detect ad and ay subtypes from . ng/ml bbi to . - . ng/ml bbi respectively. low sensitivity group included four assays and they can detect ad and ay subtypes more than . and . ng/ml bbi respectively. for blood safety, the high sensitivity hbsag assays recommended for blood screening and all assays should be evaluated by seroconversion and performance panels. diagnosis of chronic hdv infection is usually by antibody testing and hbv dna detected by pcr method. it is rare to find patients with two replicating hepatotropic viruses and if the accompanying hbv is replicating, prognosis will be very poor. to clarify the correlation between hepatitis delta virus infection and hepatitis b virus dna positivity, sensitive hbv dna (pcr) assay was used. the presence of hbv dna was investigated in patients referred during the aug. to dec. . all of them were hbsag positive. all samples were evaluated for hbv dna (pcr). the sensitivity of the hbv dna (pcr) assay was estimated geq/ml according to vqc proficiency panel and run control. anti-hdv was tested by commercial available enzyme immunosorbent assay. ( . %) were hbv dna positive and ( . %) were negative. ( . %) out of patients had evidence of delta infection and ( . %) samples of hbv dna (pcr) negative patients were positive for delta agent. the serum alanine aminotransferase (alt) levels in out of hbv dna (pcr) and anti-hdv positive patients were higher than reference interval, but only in out of hbv dna (pcr) negative and anti-hdv positive samples were higher than reference interval. the present data indicate that . % of patients with chronic hepatitis b have hepatitisdelta infection. patients with hbv dna (pcr) negativity had a significantly higher prevalence of delta marker ( . %) than those with hbv dna (pcr) positivity ( . %). delta rna testing in positive hbv dna and anti-hdv patients is recommended. introduction: reduction of the window period of hepatitis c virus (hcv) infection represents an important goal in the transfusional and diagnostic setting and nucleic acid technology-based tests have been introduced in some developed countries to reduce the potential risk of transfusion-associated infection. a prototype assay designed to simultaneously detect circulating hcv antigen and anti-hcv has been developed by biorad (biorad laboratories limited, marnes la coquette, france). aim of the present study: to define the cut-off (co) value of the assay and to evaluate the specificity and sensitivity of this new assay in the detection both of antibody and antigen comparing its efficacy with commercial assays. methods: in order to establish the co value and to evaluate the specificity of the assay, we tested sera samples from the general population and 'difficult' sera from haemodialysis patients (n conclusion: the new assay shows high sensitivity and specificity and could be a useful tool not only in the diagnostic setting, where procedures to reduce the window period, such as antigen or hcv-rna detection, are not currently recommended, but also in the screening of blood donations, when nucleic acid technologies is not feasible due to costs, organization, emergency and/or logistic difficulties. introduction: in recent years the concern with the blood safety regarding the transmission of blood-borne viruses has been improved. this safety has been achieved with the combining of different strategies, such as a careful selection of donors, the screening for relevant virological markers and the viral inactivation/ removal methods. more recently, the implementation of the nucleic acid amplification technologies for the detection of hiv- , hcv and hbv, has increase this aim by reducing the 'window period' of the infections. other viruses, such as parvovirus b (pb ) and hepatitis a virus (hav), can raise problems to the blood safety. these infections could provoke serious complications in some risk groups, like pregnant women, patients with haematological problems, children and patients with immunodeficiency. material and methods: an observational study was performed to determine the prevalence of pb and hav in portuguese blood donors. we gather, during four months, plasma donations and joined them into pools, with no more than donations each. [ ] [ ] [ ] [ ] [ ] in voluntary donors the anti-hcv prevalence ranged from . % to . %, in family replacement donors from . % to . %, autologous donors from % to . %. we observed that the anti-hcv prevalence has a decline tendency during years in blood donors. according to sex the anti-hcv prevalence in men is . % and women . % (p = . ). over the year periods the prevalence in men has a decline tendency ( . % to . %; p = . ) and increasing tendency in women ( . % to . %; p = . ). according to age group the anti-hcv is . % in - age group, . % in - age group, . % in - age group, . % in - age group (p = . ). the prevalence of anti-hcv is higher in fds than vds, but not statistical significant. [ ] [ ] [ ] [ ] [ ] . a total ftd and ad have been tested for hbsag. a sample was considered as hbsag positive when found repeatedly reactive by rd generation. immunoassay method (elisa). the chi-square test was used for statistical analysis. results: the -year overall hbsag prevalence among first time blood donors was . %. and ad . %. among autologous blood donors was observed a decreasing hbv prevalence from . % to . % in . according to age the prevalence was higher in - year group . %, while according to sex was higher in man ( . %) than female . % (p < . ). among ad, a decreased hbsag prevalence according to age was observed in men and women. the same trends by sex and age were observed in ftd. the prevalence of hbsag in ad was lower than in ftd. however, from - hbsag prevalence has decreased in the same proportion in both population. this decreased can explain by to main factor: the improvement hbsag screening method in blood donors and decreased the hbsag prevalence in general population. ( : ) . the hbv dna-emia in hbsag negative samples was . ¥ - . ¥ copies/ml. in two donors anti-hbc total was positive and in one anti-hbe was also detected. in one donor the glycin alanin mutation in the s region was identified. the frequency of hbv dna pos/hbsag neg donors in poland is high ( . %) therefore the decision to introduce routine hbv nat screening is justified. ( / ) with stored apheresis and whole blood derived platelet concentrates. of these failed results there were confirmed positives (presence of bacteria in both the ebds pouch and the platelet mother bag by culture) representing / . the bacteria detected were staphylococcus or streptococcus sp. of the fail results were false positives (no presence of bacteria in the ebds pouch and the platelet mother bag by culture) representing . % or / , and were not confirmed initial positives (no bacteria in the mother bag by culture, ebds pouch not tested) representing / . there was one reported case of a missed detection with confirmed presence of bacteria (staphylococcus epidermidis) in the mother bag by culture. subsequently, the bacteria strain was isolated and inoculated into platelet units in our laboratory at levels as low as cfu/ml. in all cases the pall ebds was able to detect. this supports the hypothesis that this missed detection was the result of a statistical sampling error rather than a system failure. the results from blood centers routinely using pall ebds demonstrated effective detection of bacteria in platelet products stored under routine conditions with a true positive rate of / , and with a low false positive rate (< . %). this is comparable to a recent survey result with other culture based systems. summary/conclusions: the minority group of pregnant women who come to labor without prenatal testing of hepatitis b and c revealed essentially similar prevalence of anti-hcv with healthy bd even if definitive confirmation is probably increased in this minority group. there is however markedly higher prevalence of hbv infection in the pw so that screening for hbv is essential for the prevention of vertical transmission. the systematic screening of bd with anti-hbc serves as further assurance for the prevention posttransfusion hepatitis eliminating only . % of the possibly infectious, a percentage which can be restored to the blood pool after proving their immunity. methods: blood samples were screened for the presence of hbsag, hcv and hiv antibodies using enzyme immune assay and for syphilis using the tpha test. the results were analysed retrospectively. all samples with results at or above the minimum positive value were considered reactive. the tests for hbsag, anti-hiv and anti-hcv were repeated in duplicate in all reactive donations. blood units that were reactive in the primary or secondary assays were discarded. hiv positivity was confirmed by western blot analysis using hiv blot . (genelab diagnostics) results: results from a total of screened donors were analysed. hepatitis b surface antigen rates was . %; anti-hcv seropositivity was . %; anti-hiv seropositivity was . % and tpha seropositivity was . %. one study calculated this risk to be one in for hbv, one in for hiv and one in for hcv. it is therefore important to take a careful history from blood donors to eliminate those at high risk of infection. in view of the high infectivity of hiv positive blood, it is important not only to screen donated blood but also to exclude donations from high-risk individuals, such as males who have engaged in homosexual activity and intravenous drug users. a careful history should identify those who should not give blood. in turkey, among blood donors the average hbsag prevalence in - was . %. but it had decreased to approximately . % in . anti-hcv positivity has been reported to be . % between and . but it was approximately . % in . rpr positivity in blood donors in turkey was reported to be < . % in and . % in . in , the rpr rates was . %. in our study these rates are . %, . %, . % and . % respectively. anti-hiv seropositivity was found around . introduction: the serological detection of specific antibodies to treponema pallidum (tp) is an effective means of diagnosing syphilis, and an automated chemiluminescent assay is ideally suited to testing large numbers of specimens for the laboratory diagnosis of the disease. aims of the study: to develop a qualitative syphilis assay for the detection of tp immunoglobulin m (igm) and g (igg) antibodies. the assay will be used for the serological diagnosis of syphilis using the architect platform, which has the capacity to test specimens/hour. the two-step assay is based on paramagnetic microparticle chemiluminescent technology, utilising microparticles coated with three recombinant tp antigens (tpn , tpn and tpn ) and acridinium labelled anti-human igg and igm monoclonal antibodies as conjugates. in the first step, specimens, microparticles and diluent are incubated together, prior to a wash step; in the second step, acridinium labelled antibodies are added and after washing, pre-trigger and trigger are added to produce chemiluminescence, which is measured as relative light units (rlu). specimens yielding rlus less than the cut-off are considered negative, while those yielding rlus greater than the cut-off are considered positive. the sensitivity of architect syphilis tp was determined to be %, after testing specimens that were previously screened as syphilis positive in fujirebio tppa; no prozoning was observed with high positive specimens (over titer by tppa). the specificity generated from testing hospitalised patients previously screened as tppa negative, was . %. testing a mixture of sera and plasma from random donor specimens, generated donor specificity figures of . %. the precision (cv%) with a positive control was . % ( % confidence interval: . - . %) by the standard -day nccls analysis (ep a ). in a study conducted at asahikawa medical college hospital, in which, positive and negative specimens were tested, concordance with fujirebio tppa was determined to be %. no significant interference to the assay was observed from bilirubin (conjugated type and free type), haemoglobin or lipid. the architect syphilis tp assay is an automated, specific and sensitive test for the detection of antibodies to t. pallidum. background: hcv exposure of blood donors is serologically determined by the detection of anti-hcv antibodies in serum or plasma. however a 'window' period of - days after exposure exists during which specific antibodies to hcv antigens cannot be detected. hcv rna detection and/or hcv core protein testing result in dramatic reductions in the preseroconversion window period. the new bio-rad test, based on the simultaneous detection of hcv core antigen and anti-hcv (core, ns , ns ) antibodies, improves the detection of hcv infection in the early phase. aims: the aim of this study is to assess the performance characteristics of this new screening microplate immunoassay, monolisa hcv ag-ab ultra, by using the bio-rad evolis automated microplate processor system. methods: this two-step elisa assay is based on the combination of an indirect test for the detection of antibodies (core, ns , ns ) and a sandwich test for core antigen detection. results are available within . hours, with sample addition monitoring and color coded reagents. no specimen pretreatment is required. evolis is a self-contained microplate processor designed for full automation of microplate-based eia techniques. the walkaway system can process four microplates at a time with continuous loading of samples and reagents. positive identification of samples, reagents and microplates, usage of disposable tips with clot detection, integrated quality control and complete traceability provide a high level of safety management. the monolisa hcv ag-ab ultra/evolis system performance is evaluated for clinical sensitivity on commercially available and well-documented seroconversion panels. the results are compared to viral rna detection and conventional hcv ab screening assays. specificity is evaluated by using random blood donor samples. results: among the seroconversion panels that begining with samples negative for hcv rna and anti-hcv antibodies, the monolisa hcv ag-ab ultra assay detects exposure to hcv an average of days earlier than the monolisa hcv plus v test. the mean delay of the monolisa hcv ag-ab assay in detecting hcv infection compared to hcv rna testing is around . days. the monolisa hcv ag-ab ultra/evolis system allows simultaneous detection of hcv core antigen and anti-hcv (core, ns , ns ) antibodies, thus significantly reducing the time gap between the initial detection of hcv rna and the first appearance of detectable anti-hcv antibodies. the fully automated system combines high degree of assay performance with optimization of laboratory workflow and safety management. operational evaluation of pall ebds bacterial detection system l larrea gonzalez, ma soler and rj roig centro de transfusion, valencia, spain introduction: regulatory bodies are increasingly mandating the use of bacterial detection systems for platelet products ( ed standards for blood banks and transfusion services). one system currently available is the pall ebds bacterial detection system which utilises percentage oxygen as a surrogate marker for bacterial growth. aims: to evaluate the pall ebds in routine use in our blood centre. in particular, to assess feasibility and adaptability to daily labour routines. the orbisac (gambro bct) system was used to produce leucocyte depleted buffy coat (bc) platelet pools ( bc/pool) stored in platelet additive solution (ssp macopharma). mean platelet count was . ¥ e /pool with mean leucocyte count . ¥ e /pool. ebds installation and training occurred over a day period. platelet pools were tested for bacterial contamination over the subsequent weeks. ebds pouches were sterile connected onto platelet pools hours after blood donation. platelet samples were taken into the pouches and then the pouches were incubated for hours on a shaking agitator at °c. after this time, percentage oxygen was measured. no positive results were found in this study. this was as expected due to the relatively low number of platelet pools tested and it also highlights the absence of false positive results. minimal training was required to use the ebds. the system was easy to use and did not require the use of a laminar flow cabinet to take samples. it was quick and simple to take samples and perform oxygen measurement. after pouch incubation, technician was able to make oxygen measurements in less than minutes. the data management system allowed full traceability of product and work flow. results were very easy to interpret. conclusion: the pall ebds was found to adapt perfectly to a routine blood centre environment. ( ) was . the percentage collected from volunteer blood donors was % (n = ) and the rest % (n = ) was given from patient-related donors. the age of donors ranged from to years old. the assay used for the detection of hbsag, hbeag, anti-hbc igg/total, anti-hbc igm, anti-hbe and anti-hbs was the automated microparticle enzyme immunoassay (axsym) of the abbot company. all the units were tested for hbsag, and anti-hbc igg. if the anti-hbc igg was detected, the specimens were automatically tested for anti-hbs. the units were wasted if the anti-hbs was negative, and the specimens were manually programmed for the testing of the anti-hbc igm, hbeag, and anti-hbe. from the total of tested units, of them were found to be positive to at least one marker of hbv infection, that means the . % of the health adult population was infected in the past by the hbv. the . % (n = ) was previously infected and now immunized with hbsag(-) and anti-core igg(+) and . % (n = ) were chronic carriers of the hbv with hbsag(+). the . % (n = ) of the positive donors were patient related donors and . % (n = ) were volunteer donors. in other words, of the not volunteers ( . %) and of the volunteers ( . %) were detected to be infectious. the combinations of the serologic markers for hbv are illustrated in the table attached. these results indicate that the incidence of hbv infection in the northeastern department of greece is equivalent to the incidence of hbv in other greek regions ( . %) as it is referred to the national haemovigilance data and moreover, the percentage of infectious donors is bigger among replacement donors, . % compared with the . % of voluntary donors. as a consequence, the best source for safe blood collection is the population of volunteers. earlier detection of human immunodeficiency type , hepatitis c and hepatitis b viruses using the procleix® ultrio tm assay on the procleix® system and the study objective was to assess the ability of the ultrio assay and associated discriminatory assays to reduce the detection windows for hiv- , hcv, and hbv. commercially available seroconversion panels were used for testing. methods: hiv- (n = ), hcv (n = ), and hbv (n = ) seroconversion panels were tested neat and diluted ( : and : ) in the ultrio assay. panels were tested neat in the appropriate discriminatory assay. times to detection of hiv- , hcv, and hbv nucleic acids in seroconversion panels were compared to the vendor's historical data on time to detection of antibody and/or antigen using licensed or validated serologic tests. p- effectiveness and limitations of methods for platelet bacteria screening -how to apply which screening method? the successful concept of virus safety in transfusion medicine is not suitable in bacterial contamination. bacteria can grow up in blood components to enormous amounts, whereas the initial number of contaminating bacteria is typically very low. therefore, sample drawing for bacteria screening must not be done immediately after blood donation. the established concept of relevance of clinical microbiology (pathogenic, non-pathogenic, facultative pathogenic species) is not valid for bacteria contaminating blood. here, the currently discussed criterion of clinical relevance is the ability of bacteria strains (not species!) to grow up in blood components. the paul ehrlich institute (pei) developed pei bacteria standards, which are characterized concerning their behavior in blood components. they contain a defined number of living bacteria, they are deep frozen, ready to use and shippable. there are two strategies to improve bacteria safety of blood: screening and pathogen reduction. neither of them is perfect, but screening methods are successfully established since several years in routine (belgium, the netherlands), and represent the current state of the art. further development and collecting of experience will produce the basis for assessments in the future. it is of high importance to apply the screening methods in dependence on their properties. methods implying an incubation/cultivation step ('early methods') have to be distinguished carefully from 'rapid methods' . for example, it is unreasonable to compare (or to advertise with) different sensitivities of methods not considering their detection principle or their informative value. both principles, cultivation methods as well as rapid methods, show advantages and disadvantages. selection of the method has to consider the respective conditions of the given blood service (including logistics up to time frame between issue and transfusion). results from the procleix hiv- /hcv and hiv- /hcv/hbv (procleix ultrio) assays for the detection of hiv- rna, hcv rna and hbv dna in blood donors of two blood transfusion centers of sw greece in discriminatory assay testing, out of ( % of the positive, . % of total) were reactive for hcv rna only and out of ( % of the positive, . % of total) were reactive for hiv- rna only. none were positive for both hiv- and hcv. the standard serological assays gave the same results for the above positive samples. two samples that tested positive by the standard serological assays tested negative in the procleix hiv- /hcv assay. of the samples tested by the ultrio assay, ( . %) tested reactive for hiv- /hcv/hbv. in discriminatory assay testing, out of ( . % of the positive, . % of total) was reactive for hiv- rna, out of ( % of the positive, . % of total) were reactive for hcv rna, and out of ( . % of the positive, . % of the total) were reactive for hbv dna. all were single positive i.e. none tested positive for more than virus. three out of positive samples for hbv dna tested negative by the standard serological tests. the opposite was not observed. the procleix ultrio assay is a definite improvement over the procleix assay in a region with a high incidence of hbv carriers. up until its use, it is obvious that hbv positive blood with very low antibody titers was transfused into patients. more results will show whether procleix ultrio can eventually replace the standard serological tests. the introduction: patients with hemophilia represent a high-risk group for post-transfusion hepatitis whose frequency is closely linked with the number and quantity of blood products used. in albania, the frequency of hepatitis is also linked with hbsag testing with elisa (introduced in ), and hcv testing (introduced in ). aim of the study: evaluation of the prevalence of the markers of hepatitis b, c, and d in patients with hemophilia. methods: our study included patients with hemophilia treated with cryoprecipitate and commercial clotting factors. blood testing for anti-hcv, anti-hdv, and hbsag was performed with elisa -gen. iii. results: of patients tested, cases ( %) were hbsag positive, cases ( %) were anti-hcv positive, and cases ( %) were anti-hdv positive. co-infection of hbsag and hcv was found in cases ( %), whereas co-infection of hcv, hdv, and hbv was found in persons ( %). the highest rates of infections and coinfections were found in patients above years of age. conclusion: mandatory blood testing has decreased the levels of post-transfusion hepatitis. in albania, hemophilia is also still treated with cryo-precipitation, thus patients are at a particularly high risk during the 'window period' . results: / ( . %) samples from rbd were anti hiv + nonreactive and rr for p ag both being nonreactive in the neutralization test, they were interpreted as false positives. / ( . %) sample from fbd was rr for p ag/anti hiv + nonreactive and it was confirmed positive by neutralization. this bd had been autoexcluded himself after blood donation. he showed seroconvertion days later: p ag nonreactive, anti hiv + reactive and western blot positive. the only bd p ag positive/anti hiv + nonreactive during the analized period, was an first time donor and the post donation autoexclusion was effective en this case. although a larger populations of bd is necessary to be studied and in spite of the low prevalence we have found, we consider p ag screening is an alternative up to implementation of nucleic acid testing and simultaneously we should increase the quantity of altruist repeat blood donors, undoubtedly, the best population to give blood. owing to the rather short interval between successive donations (~ days), this suggests that some - infectious units escape the screening annually. to these, one has to add the (now unknown) proportion of potentially hbsag negative + hbv dna positive ftbds. hcv: since the introduction of the screening in , the general incidence in rbd has dropped from . ‰ to . ‰, suggestive of a : escape rate. the prevalence in ftbd has stabilized at ± ‰. based on reasons similar to these employed for hbv, the residual incidence in rbd suggests that potentially infectious donation in rbd escapes the screening (= to a total of aprox. , annually). a limited investigation using hcv-antigen eia evidenced a ‰ escape rate in ftbds (= to a total of aprox. , annually table and are concerned to the fist two months of the implementation, where we had to adjust the volume of the eluate. conclusion: these system adjusts to the laboratory daily routine in the blood bank, with the pools released after first analysis in less than hours. background: the hbsag, anti-hcv, anti-hiv / , p antigen, alt and syphilis tests are performed for blood donations in czech republic. no nat tests are mandatory in czech republic. the aim of this pilot study was: . hcv rna pcr testing in anti-hcv negative blood donations; . correlation between hcv nat and anti-hcv testing results. methods: blood samples (anti-hcv serologically negative, alt not elevated) were pooled using the guardian plus spii into pools of samples. pools of ml were tested using the cobas ampliscreen hcv test v. . (roche). results: pools of samples from a-hcv serologically negative donations were tested from october to july . no one pool was initially reactive. invalid tests: ( . %) run failures were observed, due to: invalid internal controls ( . %) and invalid positive controls ( . %). invalid tests were repeated. in none of pools a positive hcv nat result was observed. conclusions: no discrepancy between hcv nat and a-hcv results was observed in our study. all of the nat tested donors in our study were regular voluntary whole blood or plasma donors who were repeatedly a-hcv serologically negative. the hcv incidence in the czech republic blood donor population is low but it is slightly growing up in general population. hcv nat testing could improve the safety of blood supply by reducing the window period for hcv. introduction: parvovirus b is the only parvovirus known to be a human pathogen. most commonly, it causes a mild childhood rash, erythema infectiosum, but in some cases more serious symptoms can be linked to b , such as acute or persistent arthropathies, critical failures of red cell production, hydrops fetalis, fetal loss, myocarditis or hepatitis. inactivation of the non-enveloped virus has proven difficult. as a consequence, manufacturers of blood products have implemented screening measures to reduce the load of parvovirus b in manufacturing plasma pools by the use of nucleic acid amplification techniques (nat). in our institute all blood donations were screened for human parvovirus b by nat since april . methods: over the last years . million donations were screened for b by nat. samples with a virus load over iu/ml were defined as positive, whereas samples with a virus load between the detection limit ( iu/ml) and iu/ml were defined as weak positive. weak positive products were released, whereas positive products were discarded. in addition infection markers of b positive donors (case group) were determined over a time period of one year. virus load and b antibody status was compared with b negative donors (randomised control group). b antibodies (igg vp , igm vp , ns ) were analysed by two commercial antibody tests. results: overall b nat-positive donors were identified with a virus load over iu/ml out of . million tested. there was a seasonal accumulation during spring and summer, whereas a large epidemic occurred throughout the last year. vp igg was detected in . % and % of the case and control group, respectively (p = . ). these data demonstrated statistically significance (p = . ). all donor samples which were b nat positive for more than three months developed neutralizing vp antibodies. in contrast, ns antibodies were observed in % of the case group and in % of the control group (p < . ). ns antibodies were detected more frequently in samples, which were b nat positive for more than six months. conclusion: b nat could be implemented in blood donor screening as release criterion without causing a shortage in blood supply. all b positive donors of the case group developed neutralizing antibodies within three months and virus load was dropped rapidly below iu/ml. these data support our testing algorithm all components of high positive donations (virus load over iu/ml) were discarded. donors with ns antibodies showed more often signs of a chronic disease with detectable levels of parvovirus b longer than six months. background: on recent years, the syphilis screening of blood donors has become increasingly important not only because of the transmission risk of this infection but also due to the risk behavior that this implies. on account of the importance of this screening the tests used are becoming more and more sensitive. aims: to evaluate an elisa screening test (the tmpa test recombinant is based on the sandwich principle, an immunoenzymatic technology in solid phase, for the measure of anti-treponema pallidum in serum or plasma). methods: in this study samples from blood donors were tested by the rotine 'cardiolipidic reagent for syphilis screening on microplates' -diagast laboratories as well as with 'hdtmpa recombinant' -hoslab diagnostics. positive samples were then confirmed with fta abs/tpha. results: using the mentioned tests we obtained the following results: . ( . %)cases turned out negative with both technologies; . ( . %) cases were positive in both methods; . cases were positive only using tmpa recombinant [of which ( . %) were confirmed positive by tpha/fta abs. as seen we found samples ( . %) that were only positives by tmpa recombinant test and that were confirmed by tpha/fta abs. we concluded that tmpa recombinant seems to be a suitable test for a quick and automated syphilis screening of blood donors and provides maximum safety for the recipients. background: in recent years, there has been substantial evidence indicating that typing and subtyping for hcv is clinically important in understanding hcv disease and its therapeutycal options. 'naive' viral load also seems to influence disease severity and responsiveness to therapy. therefore, viremia and genotype identification have been done routinely in molecular biology laboratory units. aims: the university hospital of coimbra studies and tests his own patients and patients from other hospitals in the central portugal. we also collect and test blood donor candidates from this region. we proposed to analyse the distribution of hcv genotypes in this region, among patients with cronic hcv infection. we have simultaneously analysed the viremia and correlated it with age and severity of liver disease. methods: nucleic acid extraction was done using the semiautomatic 'xstractor' from biomerieux laboratories (boom method). the genotyping used reverse hybridization and was performed using probes from the ¢ non-coding region (innulipa introduction: bacterial contamination of blood products remains a persistent problem. various techniques for the detection of bacteria in blood products exist but none of them has been widely accepted. bacterial detection systems could be divided into culture systems and rapid technologies. hemosystem has developed a rapid and sensitive technology for bacteria detection named scansystem tm . bacterial contamination of platelet concentrates is a rare event with an incidence between : to : per donation. therefore hemosystem developed a positive control in order to validate the scansystem tm platelet kit before use. aim of the study: the current study was designed to evaluate the performance of the scansystem tm positive control. the scansystem tm positive control is a capsule containing lyophilised lactobacillus casei subsp rhamnosus. the bacteria concentration per capsule is at least ¥ cfu. the positive control has to be stored at room temperature and is stable for years. after dilution in pbs, the preparation has to be used within hour. two capsules were tested for ten consecutive days with scansystem tm platelet kit as well as with optimised scansystem tm platelet kit. in an independent experiment three capsules were diluted in platelets stored in additive solution and were tested each with scansystem tm platelet kit and optimised scansystem tm platelet kit. results: microscopic fields were analysed for bacteria specific fluorescence for each sample. the ratio between bacteria specific fluorescence signals and analysed signals was . in all samples for both scansystem tm platelet kit and optimized scansystem tm platelet kit. therefore by definition all tested capsules were positive. the lyophilized positive control capsules enable the user to validate the scansystem tm platelet kit before use. because bacterial contamination of platelet products occurs rarely, the routine use of positive controls improves safety of the screening method. scansystem tm is currently the only method that provides this safety measure. introduction: whereas implementation of nat for blood donor screening reduced the risk for transfusion transmitted hiv and hcv infections currently below one per million transfusions, the risk for bacterial infections is estimated to be : to : . especially platelet products, which are stored at room temperature, are prone to bacterial contamination. aim of the study: several methods are currently developed to prevent the transfusion of bacterial contaminated platelet concentrates. the study investigates a new rapid bacterial detection method. material/methods: pool platelet concentrates were spiked with seven transfusion relevant bacteria strains under sterile conditions at concentrations of cfu/ml to cfu/ml. bacterial concentration was verified on blood agar plates immediately after spiking. five millilitres of spiked platelet concentrates were centrifuged, stained with thiazole orange dye and analysed directly by facs within five minutes after staining. aliquots of pool platelets spiked with concentration of cfu/ml and cfu/ml of each bacteria strain were incubated for two to eight hours in special bouillon at °c and were analysed by facs immediately after incubation. results: sensitivity of facs analysis differed between cfu/ml for e. coli and cfu/ml for klebsiella pneumoniae without preincubation and was enhanced to cfu/ml when a pre-incubation step of two to four hours was included. conclusion: bacteria detection by facs analysis combined with a short pre-incubation ( - h) at °c is a quick and simple method with sensitivity comparable to other commercially available detection systems. the advantage of this new method is the rapid analysis, easy handling, high sensitivity and less expensive price. introduction: detection of bacterial contamination of platelet concentrates represents a major challenge in transfusion medicine. for blood transfusion services the method must have a high sensitivity, an easy performance and a low price. aim of the study: in this spiking study we evaluated the new optimised scansystem tm platelet kit detection method for use in apheresis platelets. methods: apheresis platelet concentrates (apcs) were spiked with strains of ten different bacteria species. after different incubation periods, apcs spiked with cfu/ml were analysed by the optimised scansystem tm platelet kit. the number of bacteria was monitored by plating on blood agar. results: all bacteria strains were detected with the optimised scansystem tm platelet kit when the sample was collected h after spiking. identity of the spiked bacteria was confirmed by gram staining and dna fingerprints. conclusion: in summary, the optimised scansystem tm platelet kit was able to reliably detect ten transfusion relevant bacteria species in apheresis platelet concentrates within minutes when the sample was taken hours after spiking. background: since year our laboratory started routine screening of hcv-rna in plasma minipools for all plasma intended for fractionation. although nat testing is not yet mandatory all blood products are released depending upon nat results. aim: to test and compare two different methods of rna extraction in order to make all the necessary adjustments to the test procedures while preserving the availability of blood products. methods: plasma minipools of donations are prepared either on a tecan genesis robot or on a hamilton at plus. hcv-rna is isolated from ml plasma by using either the qiagen biorobot and qiamp virus biorobot kit or the manual extraction with cobas ampliscreen hcv pcr kit v . . results: between march and december a total of seronegative donations ( pools) were tested for the presence of hcv-rna. four pools were found to be positive for hcv-rna. of the four nat-positive pools with no eia-positive donor, four were confirmed as true positive by donor follow-up testing and/or testing of an independent sample from the index donation. all the positive donations were detected independently of the extraction method used (manual or automated). our experience shows that although the automated extraction method is 'off label' and it has to be validated, the use of biorobot does not pose a detectable contamination risk and it is possible to achieve a detection level for hcv less than iu/ml. the advantage of the manual method is that it has better recovery of nucleic acids than the qiagen extraction. concerning the time needed for the extraction process the automated method runs samples in hours where the manual method needs hours for samples, needing, prior to extraction, an extra centrifugation step for one hour. the automated extraction method results in an assay with a high sample throughput, fast time, sufficiently sensitive, that can be successfully introduced into routine use in laboratories which have more than samples/day while preserving the availability of blood products. anti-hcv similarly was high till ( . - . %), but in trend to decrease afterwards ( . %). anti-hiv reflected the low endemicity of the disease in public setting and was % through the mentioned years. rpr test for syphilis was around . %. directed donors were % of all and volunteer donors consisted nearly %. donors in our blood center are being informed about donation prior to giving their blood and donor questionnaire forms (dqf) are filled out by the donor candidates. using dqfs have been mandatory at all blood banks in turkey by law since . from that time infectious disease marker rates were dramatically reduced at all centers. donor information about the risks of transfusion and the importance of safe blood supply were detailed by the donation staff and physicians, consequently self-exclusion by the donor candidates who have risky behaviors was encouraged at our center. the interviewing staff was trained specifically for this topic. this steps were particularly emphasized in the last three years and the infectious screening results were displayed the outcome of this efforts. conclusion: education of the prospective donors, and recruit the voluntary, non-remunerated and regular donors will be the utmost goal of all blood banks. rigorous donor selection will contribute this ultimate success. we should spend more efforts to maximize enrolling voluntary donors to lower the serological marker results, consequently achieve safe blood. background: human t cell lymphotropic virus type i is endemic in japan, the caribbean, southeastern united states and parts of south america and africa. in non-endemic areas such as europe, htlv-i is less common and most infections are identified in immigrants. the epidemiology of htlv-ii is different, being predominantly found among indigenous american-indian populations and among ivdus, but the routes of transmission are the same. aim: our study's aim was to ascertain the prevalence of htlv i/ii in blood donors in order to understand the epidemiology of htlv in greece and initiate discussions of an acceptable level of risk and appropriate level of screening for rare transfusion-transmitted diseases. overall, anti-htlv seroprevalence levels among blood donors, are low. although the number of annual donations in this study is relatively small, the data for htlv indicate that rates of this infection are low and that infected donors will be seen infrequently. as all blood donations are screened for htlv i/ii during the last six years, a national survey is necessary in order to define the epidemiology of htlv in greece. introduction: toxoplasma gondii is the causative organism of toxoplasmosis. the disease transmitted by ingestion of either oocysts (in the feces of cats) or bradyzoites (in raw or undercooked meat). the parasite can also be acquired transplacentally by organ transplantation or from blood transfusion. the purpose of this study was survey of toxoplasma antibodies in some iranian blood donors at tehran blood center. blood samples were randomly collected for detecting of igg and igm antibodies (by elisa technique).the total numbers of donors was of (% ) were female and (% ) male in age ranged from to years. results: sera tested, ( %) were found to be positive for toxoplasma igg antibodies and ( . %) were igm antibodies positive and of them ( . %) were borderline for igm antibodies. among males the frequency of positivity was higher than woman but this different was not significant. the most frequency of seropositivity was found in age group to years. conclusions: diagnosis of toxoplasmosis can be aided by serologic or histocytologic examination. the acute infection in healthy individuals is generally asymptomatic and not associated with any morbidity but in an immunocompromised host, toxoplasmosis be a very serious disease, and this can occur if a person is infection with toxoplasmosis before or after his/her immunosystem is compromised. in spite of the progress in the development of diagnostic, therapeutic and prophylactic methods, virus hepatitis still presents a serious global health problem. the possibility of transmission of these infections through transfusion of blood and blood derivates implies obligatory control of the donated blood. post-transfusion hepatitis is an important health problem in everyday practice, especially in patients who have to receive transfusion of erythrocyte concentrates as the only possible treatment for many years. objective: to show the prevalence of hepatitis b (hbsag) and hepatitis c (anti hcv antibodies) in multitransfused thalassemic patients. in our region there are patients suffering from thalassemia major who are aged between and , and who have been receiving erythrocytic transfusion - times a month since the age of one or two. they receive washed red blood cells, and in certain periods filtered red blood cells, controlled for viral markers and they mostly receive blood from voluntary, periodic and regular donors. the patients are tested periodically for the presence of viral markers (hbsag, anti hcv antibodies), using tests for hbsag (abbott auxyme monoclonal eia) and for anti hcv (abbott hcv eia . ). the presence of markers for hepatitis b and hepatitis c has not been detected in any of these multitransfused thalassemic patients who receive at least transfusions a year. the tests in all patients were negative. the blood used for transfusion must be tested for viral markers, and for the patients who have to receive blood for their whole life, the blood should be from voluntary, regular and periodic donors who donate blood at least three times a year, because then the risk of transfusion transmissible infections is very small. introduction: we observe yearly the prevalence of transfusion transmitted diseases following instructions of skae (national coordination haemovigilance centre). aims: to investigate the prevalence of the most important blood borne infections in our blood transfusion centre in the state achaia during the last five years ( ) ( ) ( ) ( ) ( ) . materials and methods: the detection of hbsag, anti-hcv, anti-hiv / was made by automated microparticle enzyme immunoassay (axsym, abbott) and by enzyme-linked immunoassay methods (dade behring, ortho, biomerieux) syphilis tests were made by using rpr kits. confirmation for anti-hcv positive samples was made riba or inno-lia, while the confirmation of anti-hiv / positive samples was made by 'st. andrews' general hospital of patras reference centre. results: all the seropositive donors were first time donors. conclusion: ( ) we observe that there is a decrease in all four infections. ( ) the absence of anti-hiv seropositive donors is due to the high percentage of volunteer blood donation which approaches % in our centre during the last four years. methods: a prospective, one-year study has been set up in order to enrol at least out of the estimate of first-time donors, involving blood transfusion centres from of the italian regions. each centre was required to enrol all first-time donors born before december st, , and thus not included in the hbv mass vaccination campaign. the selected donors were tested for hbsag (mandatory by law) and for anti-hbc by commercial assays. all hbsag and/or anti-hbc positive specimens were stored frozen and sent to a reference laboratory for additional serological testing (anti-hbs, anti-hbe, anti-hbc/igm and anti-hbc avidity index by an experimental procedure) and for the determination of hbv-dna (both qualitative and quantitative) by real-time pcr. results: in the first months of the study the sites saw almost first-time donors, of whom . % belonged to the required age groups. among eligible donors, . % were both hbsag and anti-hbc positive, and . % were hbsag negative/anti-hbc positive. hbv positivity rates were higher in southern than in northern regions, although a high variability in hbv prevalence was observed between neighbouring areas in the north. hbsag positives were mostly males, % were positive for anti-hbe, % had raised alt and % were concurrently positive for anti-hbs. among hbsag negative/anti-hbc positive donors, % were negative and % were positive for anti-hbs. among anti-hbs positives, % showed values < miu/ml and % > miu/ml. the avidity index results suggested that approximately % of anti-hbc positive individuals were recently infected. conclusions: our preliminary data indicate that approximately % of the italian first-time donors are older than years of age and thus not belonging to the age groups who underwent to the mandatory vaccination against hbv, and that . % of them have serological markers of ongoing or past hbv infection. anti-hbc alone was detected in nearly % of the study population. hbv-dna testing is underway at the time of this writing. in our country mandatory tests for each blood donations are: hbsag, anti-hcv, anti-hiv / and tp ab. to c + ns + ns , ( . %) to c + ns , ( . %) to c + ns + ns , ( %) to ns + ns + ns , ( %) to c + ns + ns , ( %) to ns + ns . the use of the hcv core ag elisa test system may provide substantially earlier identification of hcv infection than it is possible with current serological assays. although all of six anti-hcv assays are very sensitive and specific screening assays, they didn't detect hcv infection in one patient. majority of anti-hcv positive patients ( . %) had anti-hcv ab for or more different epitopes of hcv. international comparison of performance of abbott prism assays used for blood donor screening background: the national serology reference laboratory, australia (nrl), coordinates a quality control (qc) programme for laboratories that screen for anti-hiv & , anti-hcv, hbsag and anti-htlv i/ii using the abbott prism assays. nineteen laboratories from australia, belgium, canada, ireland, israel, the netherlands, new zealand, norway, singapore, south africa and thailand have submitted data for this programme. aims: to determine the accuracy and precision of results from laboratories, individual prism instruments and different reagent lots by analysing data accumulated between october and january . the multi-marker qc sample 'pelispy s type ' (s ), produced by viral quality control (now acrometrix-viral quality control), was provided to participants. laboratories tested s in each calibration run, in addition to the manufacturer's controls, on each sub-channel of the instrument. pelispy was used as a 'go/nogo control' and results were required to be reactive (s/co > ) for a test run to be deemed valid. data were collected and analysed using the nrl's internet-based application edcnet (https://www.nrlqa.net). after submission, laboratories were able to compare their results with those submitted by other laboratories and investigate differences in results from reagent lots and instruments. data for five different s lots were exported from edcnet and analysed. results: nearly results were submitted: all results were reactive (s/co > ). fifty of these results ( . %) were excluded from analyses because they were reported from invalid test runs [due to pipetting, aspiration or sampling error (n = ) or due to unacceptable results (n = )]. a further results were excluded because data provided by laboratories were inconsistent or incorrect. a total of results, reported using different prism reagent lots ( for anti-hiv, for anti-hcv, for anti-htlv and for hbsag), were analysed. results from prism hbsag and anti-hiv showed the least variation with coefficient of variations (cv) of < % for all s lots. results from prism anti-hcv and anti-htlv produced cvs between . % and . % for all s lots. data reported for s lot ps (n = , range for anti-htlv to for hbsag) were analysed further to review performance of prism reagent lots. hbsag showed the least variability between prism reagent lots with < % bias for the prism hbsag reagent lots used (bias: the difference between the mean ratio for the reagent lot and the weighted mean ratio for all reagent lots, expressed as a percentage of the weighted mean ratio for all reagent lots). prism anti-htlv showed greater variability between reagent lots with a single reagent lot generating a + % bias. prism anti-hcv showed the greatest variability within reagent lot with results from of reagent lots showing a cv between % and %. conclusion: in results in a qc sample distributed to laboratories the abbott prism performance was found to be consistent over four assays. edcnet was robust in supporting laboratories' abilities to follow precision and accuracy of the assays in real time. introduction: since hcv rna testing of all blood donors started in finland in , the nat screening process has continuously been improved. investments in process automation have made the work more efficient and blood safety has further increased since hiv- rna screening of all blood donors started late . aim of the study: to implement hiv- rna testing in the nat screening program cost effectively, without increasing the throughput time of the samples and delay in the result reporting. to study if the sensitivity for both hiv- rna and hcv-rna will be sufficient when a single extraction is used and when the pool size of donations and the sample volume are kept unchanged. methods: the nucleic acids were isolated from plasma samples of ml with the magna pure lc instrument using the magna pure lc total nucleic acid isolation large volume kit. the internal controls from the cobas ampliscreen multiprep specimen preparation and control kit and the cobas amplicor hcv specimen preparation kit were added to the lysis/binding buffer ( ml/ml of each). from the final volume of the nucleic acid eluate ( ml) ml was used for the detection of hiv- rna (roche cobas ampliscreen) and ml for the detection of hcv rna (roche cobas amplicor). a run control containing both hiv- rna ( iu/ml) and hcv rna ( iu/ml) was included in all extraction runs. sensitivity of the both assays was assessed by testing dilution series of the who standards for hiv- rna and hcv rna. specificity was evaluated by testing fractionation plasmapool samples (n = ) and minipool samples (n = ). results: detection limits of the hiv- and hcv assays ( % hit rate) were calculated to be . iu/ml and . iu/ml respectively. specificity for both assays was % and during the validation phase also the robustness was good. the sensitivity of both assays with a pool size of was below the recommendations by the council of europe for blood donor screening (for hiv- rna iu/ml and for hcv iu/ml per individual donation). specificity of the assays was excellent, false reactive results were not observed. implementation of the hiv- nat assay in the screening program did not increase the throughput time of the donor samples when the pool size of donations, ml sample volume and a single extraction for two assays were used. the the very substantial increase in the number of industry-sponsored clinical trials has created challenges for medical schools, academic hospitals, faculty members of these institutions, and the journals that publish the results of these trials. in many cases, authors of reports of industry-sponsored clinical trials are paid consultants to the sponsor, have been paid by the sponsor to lecture on behalf of its products, or have equity in the sponsoring company. these ties to industry create a tension that actually is or can be perceived as • work internationally; • send young volunteers to international youth forums; • employ young people in your organisation; why use volunteers in blood donor recruitment? • they have networks to scout-groups, sports-organizations, tradeunions, rotary, staff of large companies etc. • they bring in fellow volunteers -with different prospects of society; • often paid recruiters are underpaid (!) and tend not to remain • you can not recruit by telephone! • out of donors are recruited by personal contact! • so you need direct personal contact = need many people (e.g. young ambassadors); • a large number of volunteer recruiters is a gift from heaven! paid donation gives the act of blood donation low status. the act of blood donation should be respected, and praised by role models, queens and presidents. efficient work and close cooperation of blood bank staff and volunteer organisations is the key to success in blood donor recruitment and retention! with such a prospect, it was important to evaluate the practices of blood donor selection in the eu. material and methods: a questionnaire was designed and sent in to the relevant institutions of the eu countries plus switzerland. the questionnaire included questions on the interviewing practices before homologous blood donations, regarding non-specific risks to donors and recipients, identified risks to donors, infectious, bacterial, viral, parasitic and prionic risks to recipients and non-infectious risks to recipients. the questionnaire also inquired about each country's exclusion period for each contraindication (ci) to donation. results: predonation interviews were prepared, in all countries, by circulating informative documents to blood donors. they were supported by written questionnaires in nearly all countries. in half of the countries, those interviews had to be led by physicians (nurses or technologists in the others). the - age limits for blood donation ( - for a first donation) were the rule in countries. in other countries the age limit could be brought forward to and extended to years old. the time interval between donations was identical for men and women in countries, and varied from to weeks according to country. the questions of the questionnaires were very similar as regards the identification of risks to donors and recipients, and very close to the requirements that appeared later in the / /ec directive. this particularly concerned how to meet the expectations of european donors, so that they come back to your blood center! know your donors: make regular donor surveys. age, gender, number of donations, number of first time donors, media consumption, education, job situation, income brackets. use local donor organisations let volunteers help! they work for free, but donor recruitment and -retention costs money. each blood center should have a local donor organisation, run by volunteers. the donor organisation should receive a payment for each bag collected. the reputation of the blood system tell the donors, what the blood is used for. that all blood is tested. and that blood provides safe medical treatment safety of the donor. insurance is a must good quality and efficiency in blood services decentralized blood collection no waste, and minimal outdating efficient service: • a friendly environment, • donor friendly opening hours, • pleasant rooms, beds and well equipped waiting rooms, • parking-spaces, transport, • beverages and food, • letters with correct data etc. donors expect to be serviced by trained, medical professionals and that the medical check-up is taken seriously. donors should be recognized continuously. use directed press-coverage to higher the self-esteem of the donors. donors should be well informed: • leaflets, posters and questionnaires should be % correct; • use e-mail and web-sites for quick up-date of donor information. be visible! • have an offensive and comprehensive media approach; • have a yearly national campaign june up to world blood donor day; • have an attractive home-page, constantly updated; • streamline your lay-out; • mail a donor magazine to all regular donors: • send newsletters regularly to volunteers and the press. • use recruitment cards. • easy phone-and fax numbers, e-mail addresses. directed campaign towards young people: • young ambassadors group; • special training sessions for young volunteers; • advertisements in media catering to young people; • poster competitions; • book and leaflets on blood addressed directly to young people; minimum bodyweight, blood pressure, pulse limits, questions involving viral risks, either sexually transmitted or linked to drug abuse, questions investigating risks of malaria transmission, questions aimed at identifying risk of prionic disease transmission. analyzing ineligibility times, on the other hand, revealed wide differences. for example, ineligibility for current multiple sexual partners, sexual relations with risk individuals, tattooing or body piercing, endoscopy, general anesthesia or invasive surgery, could vary from to months. previous transfusion history could not be a ci or could be one varying from months to indefinite ci (this point recently changed in several countries). the results of that survey have revealed some differences between countries in the questions asked and especially in the ineligibility times. however, the conditions under which donor selection interviews are conducted were similar in all countries. the enquiry tool used in this study proved to be well adapted to evaluate the donor selection practices throughout eu. a next step will be to use it to appreciate their evolutions and especially the impact of the /ec/ directive on these practices in the eu countries and furthermore to evaluate the results of this selection (rates and motives of deferral) which is a major factor of patients' transfusional safety. background: in europe on average whole-blood donations are performed per inhabitants and year. whole-blood donation comprises a puncture of a venous vessel and letting of blood (usually ml), which may be repeated several times a year. like other invasive procedures, blood donation has a range of effects on the individual who is subjected to it. aim: the aim of this paper is to review some aspects of the present state of knowledge on effects and complications of whole-blood donations. results: most studies of the effects of whole-blood donations on the donor have focused on negative or unpleasant events and on time in rather close association to the donation. complications related to percutaneous needle insertion (bruise assessed by inspection . % -bruise assessed using post-donation interview . %, sore arm - . %, nerve irritation . %, arterial puncture/pseudoaneurysm/arteriovenous fistula . - . % etc) are most commonly reported, while negative systemic reactions (vasovagal reactions . - . %, syncope . - . %) occurring in connection to blood donation are less frequent (newman bh: blood donor complications after whole-blood donation. curr opin hematol ; : - .) serious complications requiring hospitalization (myocardial infarction, stroke) are extremely rare ( . %). fatigue ( . %- . %) and diminished physical working capacity ( . %) are reported to occur during days after the donation. a recent study of a consecutive sample of swedish blood donors (nilsson sojka b, sojka p: the blood-donation experience: perceived physical, psychological and social impact of blood donation on the donor. vox sang ; : - .) (with a selfadministered questionnaire with an open-ended question: how does blood donation affect you? physically-bodily/psychologicallyspiritually/ethically-morally/socially during or after blood donation?) revealed that perceived negative effects (fatigue, diminished physical working capacity, vertigo/dizziness, susceptibility to infections etc) were less common ( % of the donors) than positive effects (feeling of satisfaction, being more alert, feeling generally better, less migraine, higher physical working capacity, respect from environment, feeling of relaxation etc; % of the donors). the duration of positive effects was regularly reported to be weeks, while negative effects lasted only days. investigations on the long-term effects of blood donation are scarce. yet, they may indicate that the donation of blood is associated with e.g. lower blood pressure and a reduced risk of myocardial infarction (nilsson sojka b, sojka p: the blood-donation experience: perceived physical, psychological and social impact of blood donation on the donor. vox sang ; : - ). conclusion: both the panorama and the frequency of occurrence of the different effects and complications of whole-blood donations vary as a function of how the information was gathered (openended questions, observations, interviews etc). serious reactions to whole-blood donations are extremely rare. more studies are needed in particular with respect to the long-term effects of regular wholeblood donations. t-pa- establishing a national adverse event reporting system for blood donors -a prospective study of . there was no national system and significant regional variation showed that the data was scientifically unsound. a coincidental initiative to remove the mandatory post donation rest period for regular donors further emphasised the lack of reliable, retrospective data to monitor and compare the impact of this new policy. aims: . to develop and implement a high quality, reliable national donor adverse events reporting (daer) system; . to define and categorise adverse events; . to record data systematically and prospectively using the existing computerised donor database. methods: from summer , a small project team of senior clinical and operational staff took months to agree a detailed policy for capturing and recording all donor adverse events, including precise definitions for grades of vasovagal reactions and bruising. detailed training material was written in may and the new protocol was validated in one region. from july to december a formal one day training programme was delivered to over staff working on mobile collection teams, static sites and blood centres. daer was fully implemented by january . adverse events are assessed by health care professionals on session and the relevant code entered onto the donor's computer record by clerical staff. information received after the session is entered by centre based doctors using the same system. the database is interrogated monthly for statistics. results: in the first months . million donors attended sessions throughout england and north wales. results were very consistent month on month. donors ( : ) had vasovagal symptoms but only % of these suffered syncope. % of all vasovagal reactions occurred in women. % occurred in donors aged - and a further % in donors aged - . (donors aged - represent only % of the total donor base.) donors ( : ) reported a delayed reaction, % of whom did lose consciousness. nerve injury, unrelated to haematoma, occurred in donors ( : ) and, more rarely, arterial puncture was diagnosed in donors ( : ). bruising was reported after the session by : donors. summary: a robust system has been developed and successfully implemented across a large, national blood service. based on the data already accumulated our next phase is to develop strategies to minimise adverse events, confident that any intervention will be effectively monitored. the community role in enhancement of voluntary, non-remunerated blood donation in the new millennium introduction: in the developing countries, about % of the blood supply comes from paid or replacement donors, where a high number of infected persons are in the donors population. only % of the global blood supply is donated as voluntary nonremunerated blood donors in countries with low and medium human development indices. and around % of the global blood population has access to only % of a safe blood supply. conclusion: blood is a national resource, it is the responsibility of governments through it's communities to ensure that the blood supply is safe and adequate to meet the needs of patients population and available to all who needs it. background: in response to a documented increase in the average age of donors, a survey was conducted to explore if young people had more unfavourable attitudes towards becoming blood donors. aim: to identify if the increasing difficulty in recruitment and retention of young people as donors, is linked to a low level of motivation for donating blood in this age group. methods: a national telephone-survey was conducted among a cross-sectional sample of the adult norwegian population ( participants). the survey was performed in november . results: five percent reported being active donors (had donated during the last months), % were passive donors (had not donated during the last months), % were non-donors with a positive attitude towards becoming donors, and % non-donors with no intentions ever to donate blood. in the youngest age group (age - ), % reported being active donors and % were passive donors. however, % of the young non-donors reported having intentions of becoming a blood donor. fifty-five percent of young non-donors had a negative attitude towards ever donating blood. all non-donors were asked why they did not donate. thirty-six percent of all non-donors reported health related reasons for not donating blood. thirty-one percent of all non-donors claimed that they did not donate because no one had requested them to do so personally, and % reported they did not care about blood donation. in comparison only % of young non-donors reported medical reasons for not donating. thirty-eight percent claimed lack of personal request, and % reported of lack of interest as the main reason for not donating. summary/conclusion: although the youngest age group was under-represented among active donors, we found that a great proportion ( %) of young non-donors had a positive attitude towards becoming blood donors. the most important reason why young people do not donate was the lack of a personal request. indifference regarding donation was not very widespread. a relatively high proportion of young people considered themselves as not medically disqualified to donate. in light of these findings, efforts to recruit young people as blood donors are strongly recommended. background: the ever-increasing demand for blood, coupled with emerging new threats to blood safety, motivate the strengthening of the blood banking infrastructure. aim: employing new technology as an instrument for building relationships of trust between blood bank and blood donors. material: . a new software module supporting the management of magnetic cards was added to e-aima blood bank management application. the magnetic card supports the following information: • front-side: donor's photograph, surname, name and blood group (including rhesus phenotype & kell) and sign of blood collection centre. • magnetic stripe where data concerning donor's serial number, medical history (risk factors), test results for infections and the number of donations is stored. . specific hardware allowing reading from and writing to magnetic cards is integrated to the software module: • magnetic card scanners were added to pcs serving to donation collection, including laptop for mobile team collection. • web cameras to capture the photograph of the donor to be printed on the card. • card printer was deemed necessary to produce magnetic cards for donors on a need basis. . consumables: blank plastic magnetic cards, ink cartridges for printer. methods: in order to evaluate the performance of magnetic cards compared to the paper-based system, a questionnaire was distributed to first-time and repeat blood donors, in order to be used as an indicant of donor's satisfaction. . first-time donors increased . % in the months of application. among them, . % were donors 'for relatives or friends' turned into volunteer donors and . % were first-time volunteer donors. the questionnaire analysis further revealed: • % were motivated by the use of magnetic card. • % appreciated the presence of their photo on the card and they confessed that they had used it as a spill for recruiting their friends as donors. • % were persuaded that employing new technology would result in safer and more trustworthy procedures combined with reduced waiting time. • % considered magnetic cards more practical compared to paper cards because of their compact size and improved durability. . the turnover of repeat donors also increased . % after replacing their plain old paper cards with new ones. further analysis revealed that: • % appreciated the quick cross-checking of donor's identity. • % were satisfied with the effectiveness and efficiency of magnetic cards in managing donor's data. conclusions: in , greek health policy provided the legal basis for establishing the electronic national health card. the introduction of the national donor's magnetic card is another step towards this direction, being aligned with the modern national health strategy. apart from the positive impact on the number of both firsttime and repeat blood donors, it should be also pointed out that the use of a unique donor serial number on country level results in less error-prone procedures due to the reduction of administrative process overhead and facilitates interoperability between national blood banks using compatible technological infrastructure. t-pa- emerging technologies in transfusion. dna based assays until the late s, mandatory blood screening for transmissible infectious agents depended entirely on antigen/antibody-based detection assays. recent emergence of nucleic acid technologies (nat) has revolutionized viral diagnosis by not only increasing the sensitivity level but also facilitating the detection of several viruses in parallel, by multiplexing specific primers. however, in more complex biological situations when a broad spectrum of pathogens must be screened, the limitations of these first generation technologies became apparent. high throughput systems such as dna arrays permit a conceptually new approach. these miniaturized microsystems allow the detection of hundreds of different targets simultaneously, inducing a dramatic decrease in reagent consumption, in additional confirmation tests and simplify data interpretation. however, the microsystems actually available require additional instrumentation and reagents for sample preparation and target-amplification prior to detection on the dna array. future technologies such as 'lab-on-a-chip' include channels, fluidics and thermal zones allowing extraction, amplification and detection. another major challenge in the area of dna detection is the development of methods that do not rely on target-amplification systems. almost all blood group antigens are bi-allelic and encoded by single nucleotide polymorphisms (snps). to facilitate the direct availability of typed red cells and platelets, we develop a high-throughput technique to genotype by dna microarray the whole donor cohort for all clinically relevant red cell and platelet antigens. methods: a multiplex pcr was developed to both amplify and fluorescently label gene fragments of red cell and platelet antigens in one reaction. each array contains spots of short ( - nt) allelespecific oligonucleotides to discriminate between the two alleles of an antigen system. results: two blinded panels encompassing donors were genotyped for hpa- through - and ; no discrepancies were found. currently, arrays are prepared for the red cell systems. the fya/fyb, fy-gata mutation, jka/jkb, k/k, kpa/kpb, m/n, rhc/c, rhe/e, rhdpseudogen, rhdvi negative, rs, doa/dob, genotypes can be determined. the set up of genotyping assays for rare genotypes is difficult because of lack or insufficient amount of dna. the latter can be overcome by phi dna polymerase-mediated isothermal genomic dna amplification, from minute amounts of dna present in stored red cell fractions or antiserum. the results show that the blood group typing dna microarray will provide a reliable and fast genotyping procedure. the method can be further improved to obtain the necessary automated throughput for typing of large donor cohorts. and , all other weak d types should be regarded as potential anti-d immunizers. for correct determination of weak d both serological typing (polyclonal and monoclonal), as rhd dna typing are mandatory. when serology indicates weak d, more anti-d antibodies are tested ( epitope model) to distinguish partial d from weak d. in addition, an rhd mpx pcr is performed to detect the presence of rhd exons , , , , and . in all known weak d types, all six rhd specific exons are amplified (except for weak d type which lacks rhd exons and ), whereas partial d phenotypes usually show aberrant patterns. aim: the aim of this study was to evaluate the diagnostic scheme for weak d typing. methods: between and , samples were investigated for weak d characteristics. four pcr-ssp assays were developed for identification of weak d types ( t > g), ( g > c), ( c > g) and ( c > a). weak d type was identified by the combination of serology and absence of exons and by rhd mpx pcr. rhd-specific exon sequencing was performed when serology and molecular typing were inconsistent. results: all samples were subjected to the rhd mpx pcr and sample showed absence of rhd exons and , indicative of a weak d type when combined with serology. the remaining samples were analyzed by the weak d pcr-ssps, resulting in weak d type samples, weak d type samples, weak d type samples and weak d type sample. two samples remained undetermined and were sequenced for all rhd exons and the rhd promotor region. one sample showed the mutations corresponding to the dau partial d phenotype ( g>a, g>a and c>t). the other sample had only one, not previously known mutation ( a>t), which is located intracellularly at the coohtail. extensive serology using the epitope model showed a pattern matching weak d. this new weak d variant was registered as weak d type . conclusions: based on these results it may be concluded that weak d phenotypes should be confirmed on molecular level to avoid misinterpretation of partial d that cannot be detected by rhd mpx pcr analyses. patients with weak d phenotypes, except for types , and should be regarded as being at risk for anti-d immunization after transfusion of rhd-positive blood products and should therefore be treated with rhd-negative bloodproducts. in this evaluation, out of patients carried such alleles. introduction: although kell antigens are expressed very early during erythropoiesis and a . % incidence of anti-kel is found in obstetric patients, this is a relatively rare cause of hdn. anemia is produced by immune destruction of fetal rbcs and suppression of erythropoiesis. maternal antibody titers or amniotic/cord blood bilirubin levels are not relevant indicators of the severity of the disease, and the measurement of the fetal haemoglobin by cordocentesis is a procedure with risks of miscarriage and sensitization. pcr techniques for the determination of blood groups using fetal dna isolated from maternal plasma, allows the application of noninvasive methods. clinical cases: we describe two cases of pregnancies in women with anti-kel acquired by transfusion/previous pregnancies: st case: in july , a -year-old woman (gravida , para ), rhdnegative, kel -negative was referred at weeks gestation. the father's phenotype was rhd-positive, kel -positive. a maternal antibody screen revealed d and kel alloantibodies. dna was extracted from amniotic liquid. the kel genotype was determined by pcr-rflp using the bsm i. pcr-ssp was used to studied intron and exon of the rhd gene. the results showed that the fetus was positive for rhd sequences and showed kel homozygosity; nd case: in august , a -year-old woman (gravida , para ) was referred at weeks gestation. she had a history of transfusion with rbcs units in -one of the donors was kel positive. the woman typed rhd-negative and her husband typed rhd-positive. rbcs from both were kel -negative. the maternal antibody screen revealed anti-kel . doubts existed about the putative father of this child. dna was extracted from maternal plasma using the magna pure lc (roche). real-time pcr was applied to analyse: sequences of intron , exons , , and pseudogene of the rhd gene and the sry gene by sybr green; and the alleles kel /kel by hybridization probes. all rhd sequences were detected (with the exception of the pseudogene) and the kel genotype gave a kel /kel result. in both cases the doctors choose not to use any invasive method to monitoring the fetuses regarding a hdn due to anti-kell antibodies, and the results of the molecular analysis were confirmed by testing the cord rbcs after birth. discussion: these cases illustrate the reliability of the molecular biology results, based on the collection of simple peripheral blood samples. a determination that the fetus lacks the relevant antigen obviates the need for expensive and invasive monitoring throughout the pregnancy. evidence-based medicine (ebm) is defined as: 'the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. the practice of ebm requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research and our patient's unique values and circumstances. ' otherwise healthy individuals without cardiopulmonary dysfunction (cdf) tolerate acute reduction of haemoglobin concentration to about g/dl, provided that blood volume is kept normal by a volume expander. however, individuals experience physical fatigue, and there is faint reduction of perception as measured by neurophysiological tests. symptoms are reversed upon retransfusion of fresh, autologous erythrocytes. acute, normovolemic anemia seems to be progressively less tolerated with increasing age and cdf. controversy has existed on whether or not to correct hypoalbuminemia in asb or icp by infusion of albumin. recently a large trial showed no outcome differences between icp patients treated with albumin or saline. thus in general there is no indication for albumin in asb or icp. however, albumin may yet be advantageous in e.g. patients with head injuries. furthermore, fractionated albumin is not equivalent to native albumin, since fractionation stabilizers remain bound to the albumin molecule. thus more refined albumin preparations may carry advantages still to be investigated. erythrocytes are given to increase the total oxygen transportation capacity of the organism. the effect of blood bank stored erythrocytes may differ from that of fresh, autologous erythrocytes, since changes of presumably important erythrocyte properties occur during storage. in the only large trial available, a transfusion trigger of . g/dl was found to be favourable to one of g/dl in icp, except possibly in icp with unstable angina pectoris or heart infarction. however, the erythrocyte concentrates given were not leukocyte filtered, and side effects of infused leukocytes may have hampered the conclusion. on the other hand, a metanalysis showed transfusion as an independent indicator of unfavourable outcome in coronary bypass patients, but again, leukocyte filtered erythrocyte preparations were not applied. the effect on morbidity and mortality of 'top up' transfusions given e.g. to mobilize patients postoperatively has not been studied by trials, although this effect seems evident to many clinicians. grave anemia may reduce the haemostatic effect of thrombocytes because changes of blood rheology reduces the pressure forcing thrombocytes against the walls of small vessels. the transfusion trigger for thrombocytes in asb or icp remains to be established by clinical trials, however. the same applies for fresh frozen plasma, which is infused as a source of coagulation factors. on the other hand, the haemostatic effect of various fibrinolysis inhibitors is well established in asb and icp, but many clinicians appear hesitant to use them. another interesting haemostatic agent is recombinant fviia, the use of which to control asb in blunt trauma is supported by one well controlled clinical trial. evidence by systematic research is insufficient to decide what is optimal transfusion practice. the procurement of such evidence is one of the greatest current challenges to transfusion medicine research. . concerns about the transfusion-related complications, such as infections, tumour behaviour and immuno-modulatory effects, and the costs, necessitated a re-evaluation of the transfusion practice. aims: the goal of this study is to evaluate if a restrictive transfusion policy (hb transfusion trigger < . mmol/l) reduces the amount of red cell transfusion compared to a liberal transfusion trigger (hb < . mmol/l) without a decrease in hrqol. because of concerns about the feasibility of this study early results were analysed and are presented in this abstract. material and methods: after a run in period of months (hb transfusion trigger of hb < . mmol/l) patients are randomised for the restrictive or the liberal transfusion policy. patients are followed then months. hrqol is measured after inclusion, after randomisation, weeks, , , , and months after randomisation. also anaemia related complications and red cell antibodies are scored. hb values were blinded for the patients during the study period. results: from july till june patients were included ( ra, rars, rcmd, raeb, cmmol) in general hospitals and university hospital. two patients died in the run in period. eight patients were randomised for the restrictive transfusion policy and patients for the liberal transfusion policy. the mean follow up period in the liberal group was . months (inclusive run in period) and . months for the restrictive group. two patients in the liberal group died after randomisation. one patient received growth factors. in the restrictive group patients finished the study, received growth factors and patient withdrew informed consent. the mean hb level was lower in the restrictive group and after randomisation about % reduction in amount of transfused red cells was found ( . units per pt per month in the liberal group vs . in the restrictive group). no anaemia related complications were found, e.g. cardiac failure and cerebro vascular ischemia nor a decrease in activity performance. conclusion: there were some concerns after introduction of the restrictive transfusion policy. this preliminary results show, however, that a restrictive transfusion policy leads to a diminished use of red cell transfusion without an increase of cardiac complications or a decrease in activity performance. this study will be continued to compare hrqol scores in both groups. introduction: strong evidence supports the efficacy of blood conservation strategies such as autologous blood donation (abd) and erythropoietin (epo) for reducing exposure to allogeneic blood. however, use of these interventions is highly variable among institutions and frequently sub-optimal. the program to reduce orthopedic blood exposure (probe) evaluated a blood conservation program in patients undergoing total hip joint arthroplasty (thja) at ontario hospitals. aim of the study: the objective of probe was to determine whether a comprehensive blood conservation algorithm (bca) was more effective than usual care (uc) for reducing exposure to allogeneic blood in patients undergoing thja. methods: we randomized hospitals that perform high volume elective primary thja to implement either a bca or to continue with uc. the bca consisted of three components: physician and patient education, blood conservation interventions (use of abd or epo), and transfusion guidelines. t-pa- table) . mortality for non-transfused patients was significantly lower than for patients receiving either lr-or s-prbc at all time points (p < . ). t-pa- thalassaemia: the impact on blood transfusion services thalassaemia major is a genetically determined disease that causes severe chronic anaemia and further complications. it can be managed successfully in the vast majority of cases, so long as public health and other scientific and organizational infrastructures are adequate. although the progress achieved in the field of bone marrow transplantation and other disciplines promises cure of the genetic defect, regular blood transfusion from early childhood remains the cornerstone of treatment of patients with thalassaemia major. this presents national health authorities with the formidable task of assuring an adequate blood supply of high quality and safety for these patients and ensuring that it is transfused in the appropriate way. the basic principle in the modern management of thalassaemia patients is that of a global approach to care. within this approach, a standardized protocol for regular blood transfusions is a prerequisite for the patient's long survival and quality of life. if thalassaemia patients are not transfused effectively, the severe anaemia and over-expansion of bone marrow due to ineffective erythropoesis can lead to poor growth, bone deformities, organomegaly and impairment of normal physical activities. in countries or regions with large numbers of thalassaemic patients, the organizational and technical aspects of meeting their blood requirements represents a heavy additional workload for the blood transfusion services responsible for providing blood for this group of multi-transfused patients. the acquisition and preparation of blood, genotyping the patients' blood group (including at least rh, kell, kidd and duffy systems) preventing the transmission of infectious diseases and other transfusion associated complications, and assessing the patients' blood transfusion indices all have a tremendous impact on blood transfusion and treatment units. blood transfusion services are thus confronted with major challenges that can only be met if appropriate national transfusion policies are in place, both in the laboratory and the clinical setting of blood transfusion. the availability of safe blood is related to the effectiveness of donation programmes aimed at recruiting and retaining voluntary unpaid blood donors who are at low risk for the transmission of infectious diseases. sufficiency is further related to resources, organization and management of the blood transfusion service and continuous education of its staff. high technical standards for the transfused product and quality management systems are required to ensure that the product meets these requirements, as well as pre-transfusion, transfusion and haemovigilance systems and other more stringent quality measures in the whole chain of blood donation and transfusion. additional measures and continuous care are specifically required for the optimal transfusion therapy of the thalassaemic patient. the patients should be transfused with red cell concentrates, (rccs) preferably not more than one week's old and leucodepleted. other processes i.e washing of rccs, use of nutrient additive solutions, irradiation etc may be used to improve the quality and the safety of the transfused product, while other advances in red cell transfusion are expected to improve blood safety by preventing adverse reactions and reducing exposure of the patient to donor blood. should patients with thalassemia intermedia be regularly transfused? thalassemia major (tm) and thalassemia intermedia (ti) share mostly a common basic molecular mechanism, that is the reduced synthesis of the * globin chains. the consequences of the resulting chronic hemolytic anemia are also common and include growth retardation, bone marrow expansion, extramedular hematopoiesis, splenomegaly, increased intestinal iron absorption, susceptibility to infections and hypercoagulability. what differentiates the two forms of the disease is the severity of the clinical phenotype, which in turn depends on a particularly heterogeneous molecular background and imposes diverse therapeutic strategies. the consequences of the genetic defect as well as the effect of the applied therapy seem to be mainly responsible for the clinical course of the disease. in untreated tm cases, the aforementioned consequences occur fast and patients die early in life mainly due to high output heart failure. over the past decades, the gradual adoption of the current transfusion and iron chelation strategies and the patients' compliance with this therapy have resulted in a significant improvement of survival, that according to recent statistics reaches % at age . this rate is even better in well-treated patients, almost % of whom survive at age . regular therapy extends survival mainly by preventing early development of cardiac complications. in addition, a multi-organ improvement is accomplished while patients' physical appearance is almost indistinguishable from that of the general population, hence permitting a normal social behavior with a high overall quality of life. bone marrow expansion and extramedular hematopoiesis are prevented; hepatosplenomegaly is substantially restricted and usually there is no need for splenectomy, while thromboembolic complications are rare and pulmonary hypertension is practically absent. patients with ti remain as a rule without regular therapy until a number of severe complications arise. the consequences of chronic anemia develop slowly compared to untreated tm cases and dominate patients' clinical picture usually by the third decade of life. at this time, all patients have developed hepatosplenomegaly and most of them have been splenectomized. bone marrow expansion results to bone deformities and fractures often occur. extramedular hemaotpoietic masses and bone deformities may lead to various complications depending on their bulk and location, such as neurological symptoms from masses arising in the paraspinal area or dyspnea from lung restriction. hypercoagulability, resulting from defects of native erythrocyte membrane phospholipids, together with the coexistent thrombocytosis in splenectomized patients lead to a wide spectrum of thromboembolic events. pulmonary involvement with respiratory dysfunction and hypoxemia as well as pulmonary hypertension leading to congestive heart failure are well documented in ti patients. nowadays, the beneficial effects of regular transfusion and chelation therapy in tm are beyond any doubt. the occasional application of transfusions in ti has a transient effect and does not seem to inhibit the consequences of chronic hypoxia. intensive and regular transfusion and chelation therapy in ti has proved effective in ameliorating the established complications such as spinal cord compression, hypercoagulability and pulmonary hypertension, without however reversing them. given the -year experience on intensive therapy in tm and the first encouraging data in ti, the earlier application of such treatment seems to be crucial in ti. the timing however of therapeutic intervention in ti in order to prevent anemia-related complications still remains an open issue that needs to be properly addressed. the impact of prestorage leucodepletion on the immediate transfusion adverse events of patients with thalassaemia major backround: regular blood transfusion therapy in patients with bthalassaemia major decreases the complications of anemia but it is associated to many immediate and delayed side effects. febrile non haemolytic transfusion reactions (fnhtr) are common complications due to alloimmunization of recipients against hla and/or specific antigens on donor's wbcs or to the accumulation during storage of biologic response modifiers (bmrs) that are directly pyrogenic or indirectly by stimulating recipients' white cells to produce pyrogenic mediators. post storage leucoreduction (lr) has reduced the fnhtr in these patients from % to . % per unit. it is unknown whether introduction of prestorage leucodepletion (ld) has reduced the incidence of nhftr further. we analyzed the immediate transfusion reactions of adult patients with b-thalassaemia major transfused with a total of . rbc units from january to december . all units were fresh, stored less than days. . units were lr-rbc, . units were ld-rbc and . were washed lr-rbc. results: the incidence of fnhtr and allergic reactions in patients receiving lr-rbc was . % and . %/per unit respectively, in those receiving ld-rbc was . % and . %/per unit respectively, while in those receiving washed lr-rbcs was . % and . %/per unit respectively. the relative risk (rr) of fnhrt and allergic reactions following transfusion of ld-rbc and washed lr-rbc compared to lr-rbc is shown in table. conclusion: prestorage leucodepletion and washing of rbcs reduced the risk of fnhrt in regularly transfused b-thalassaemia patients . times compared to poststorage filtration. these findings show that fnhtr after rbc transfusions are due not only to alloimmunization but also to accumulation of bmrs even in patients transfused with fresh rbcs. washing is as effective as prestorage leucodepletion in reducing fnhtr. prestorage leucodepletion has no effect on allergic reactions or other immediate adverse events in these patients. t-pa- viral inactivation/elimination of plasma derived medicinal products the safety of medicinal plasma products (mpps) relies on a whole range of measures from the quality of the source material to the release of the products after manufacturing under cgmp conditions. viral safety relies on careful donor selection, viral testing of the source material and viral inactivation and/or elimination during the manufacturing process. mpp manufacturing processes must include viral safety steps capable of inactivating, and/or eliminating, a large range of viruses covering the known blood borne viruses as well as anticipating possible future pathogens. it is recognized that one single step is often not sufficient to satisfy this requirement and manufacturing processes very often include two or even three complementary viral safety steps. very efficient methods have been implemented by manufacturers, for two decades, for the inactivation of major blood borne enveloped viruses (hiv, hcv and hbv). additional safety steps have also been introduced to provide a second step for enveloped viruses and to extend the efficacy to nonenveloped viruses (hav and parvovirus b ). pasteurisation (liquid heat treatment at °c) which has been historically used for viral inactivation of albumin solutions has been applied to some other plasma products. solvent-detergent (sd) treatment which is specific to enveloped viruses is used primarily for coagulation factors. since the introduction of sd-treated products, no hiv, hcv or hbv transmission has been reported. viral inactivation of coagulation factors can also be achieved using various conditions of dry-heating. acidic treatment is also an efficient means of inactivating viruses in igg products. nanofiltration using filters of less than nm pore size was introduced in the early s. this technique for viral elimination is based on the size of the agent and is independent of their resistance to other treatments. this property could be helpful in cases of new emerging pathogenic agents. new inactivation tech-niques are currently under development such as uv treatment or gamma irradiation with efficacy reported on enveloped as well as non-enveloped viruses. these new techniques can complement existing methods after careful validation that they do not have harmful effects on proteins in the product. the efficacy of existing techniques is well documented in controlled clinical studies and pharmacovigilance records. their application to each product is extensively validated at laboratory scale, according to international regulations and then carefully evaluated by health authorities. in this context, a recent european guideline established a viral risk assessment model to quantitatively estimate the theoretical safety margins of mpps, by taking into account the different safety measures, such as viral testing of plasma and the efficacy of viral inactivation/elimination steps. whilst technical limitations and some lack of scientific data lead to very conservative estimates, this model gives an overall assessment of the efficacy of the measures in the manufacture of a given product. developments in viral inactivation/elimination methods, in plasma testing as well as in evaluation procedures have together given mpps an excellent level of safety never previously achieved. to date the important safety measures needed to ensure a high safety margin to pooled plasma products are well understood by the plasma fractionation industry. safety nets rely on carefully done: donor selection to exclude high-risk donors, serological and nat viral testing of single donations and, pooled plasma testing using sensitive validated methods, and most particularly, efficient viral reduction treatments that must be validated and implemented at a large-scale following good manufacturing practices. over the last years, successive key breakthrough in plasma product viral safety have included the use of solvent-detergent treatment to inactivate lipid-enveloped viruses, and nat testing of starting plasma pools and viral nanofiltration of products to reduce the risks associated to small non-enveloped viruses. the excellence of the system currently in place is illustrated by the demonstration that these safety barriers have virtually stopped the transmission of known viruses and avoided that of 'emerging' agents, such as west nile virus (wnv). however, multiple viral reduction treatments have generally decreased product recovery. in addition, although the implementation of viral reduction treatments have forced fractionators to introduce significant changes to product manufacturing methods, this period has been understandably followed by a period of relative conservatism of the plasma fractionation industry against further process changes. as time evolves and market dynamics changes struggle for improved economic balance of the plasma product industry is putting product recovery and diversified product portfolio at the forefront of r&d objectives. these developments in the plasma fractionation scene of the western world have been taking place in a context where many patients in the developing world are still treated with sub-standard, non-virally inactivated crude plasma fractions. in this specific area, one can expect that the developing world will bring innovative thoughts and take actions to find ways to improve the quality and safety of their own local plasma product supply. safety strategies adapted to the infrastructure and economy of less solvable countries may have to be considered. the intercept blood system for plasma uses a synthetic psoralen, amotosalen hcl, and long-wavelength ultraviolet light to photochemically inactivate a broad spectrum of bloodborne pathogens in plasma intended for transfusion (intercept plasma, i-ffp). phase clinical trials have shown that i-ffp retains proteins necessary for hemostasis in the treatment of acquired and inherited coagulopathies, and in support of therapeutic plasma exchange for ttp. a prototype plasma processing set was used for the clinical trials. for commercialization, a new processing set has been developed to improve productivity. the prototype set accommodated approximately ml of plasma, whereas the improved set accommodates up to ml of plasma, resulting in up to three i-ffp doses per treatment. aims: this study was designed to characterize pro-and anti-thrombotic proteins in i-ffp prepared using the improved processing set. proteins of interest included components of the intrinsic and extrinsic coagulation cascade, the fibrinolytic pathway, the contact factor pathway, and the complement system, the vonwillebrand complex, endogenous inhibitors, and markers of thrombin generation. methods: six fresh jumbo ( ml) apheresis plasma units, collected using the haemonetics pcs device (gambro), were photochemically treated. sodium citrate was used as the anticoagulant. plasma samples for analysis were collected before and after photochemical treatment, and were frozen below - °c until batch analysis. standardized clinical assays were used for all analyses. results: (results in the table below are expressed as the percent activity in i-ffp in proportion to the activity in plasma before treatment [mean ± sd]). retention of procoagulant factors in i-ffp plasma ranged from % to %. factor viii and vonwillebrand factor activity, antigen, cleaving protease activity (vwf : cp, adamts- ), and multimeric composition remained within normal ranges after treatment. endogenous inhibitors of coagulation were retained % to %. plasminogen and alpha -antiplasmin were retained % and %, respectively. retention of contact factors was variable; some factors were below the reference range prior to pct. with the exception of tat, all markers of coagulation activation were well within normal ranges. the tat level in one i-ffp unit was slightly above the normal range; all other units had tat levels that were well within the normal range. the significance of this is unclear. cept plasma is similar to conventional plasma. the improved processing set, intended for commercialization, allows up to doses of i-ffp to be produced from a single photochemical treatment. background: guidelines of the european directive / /ec require that fresh plasma prior to freezing contains < residual rbcs per litre. this rbcs content is below the sensitivity limit of the automated cell counters used in routine laboratories. aim of the study: it was therefore essential to make available an alternative method to detect and quantify rbcs in plasma. we implemented a method by flow cytometry using a pe conjugated anti-glycophorin a (gpa) monoclonal antibody that recognises rbcs and erythroid precursors. to quantify residual rbcs in fresh plasma, the method uses the same trucount test tubes (becton dickinson) as those used to quantify wbcs and that contain a known number of fluorescent beads. after addition of plasma and pe-gpa antibody, cell counting is performed on flow cytometer (bd facscalibur). validation of the method: assessment of accuracy, linearity, and reproducibility with different pe-gpa antibodies (immunotech and pharmingen) application of the method: quantification of rbcs in fresh plasmas divided into groups: group : plasmas from leucoreduced whole blood, group : plasmas from packed cells after removal of buffy coat and specific filtration, group : : apheresis plasmas. results: validation of the method: for both anti gpa antibodies, detection threshold is . ¥ residual rbcs/l; linearity study with concentrations of . , . , . , . , . , . , and . ¥ rbcs/l showed excellent correlation between observed and expected values (r > . ); reproducibility study showed c.v of respectively . % and %. for values > ¥ rbcs/l, it appeared necessary to introduce a correction factor of . for the anti gpa pharmingen. quantification of rbcs in plasma: group (plasma from leucoreduced whole blood): . ± . rbcs/l; group (plasma from packed cells after removal of buffy coat and filtration): < . °¥ rbcs/l in all the cases; group (apheresis plasma): < . °¥ rbcs/l in all the cases. conclusion: quantification of rbcs in plasma by flow cytometry is a precise, quick and reproducible test. in addition this study shows that even if there are differences in residual rbcs counts according to the origin of plasma, the obtained values are much lower than regulatory requirements. . improving basic transfusion knowledge amongst health workers; . improving pre-operative preparation for surgery . strategies such as cell salvage autotransfusion combined with a conservative transfusion strategy for the use of allogeneic blood. my presentation will outline the approach adopted to ensure that the use of cell salvage autotransfusion both improves the use of allogeneic blood and preserves allogeneic stores. well-organised training can both minimise the risk of using such advanced techniques and decrease the overall risk involved in undergoing surgery where blood loss may be a significant factor in increasing morbidity and mortality. the various training methods employed to improve knowledge in this area will be described. the increasing current perception that the safety of allogeneic blood transfusion has dramatically been improved during the last decade is challenging autologous haemotherapy methods. in addition, growing concern about the unfavourable cost-effectiveness of most autologous haemotherapy methods requires a refinement of the application of these measures to well defined circumstances. in contrast, newly emerging transfusion-transmissible infections or periods of blood shortage might revive interest in these blood sparing techniques. the first two cases of transfusion transmitted vcjd provide a paradigm for this scenario; not so much with respect to a public fear of infection but rather a waning donor population due to more rigorous recruitment criteria. preoperative autologous blood donation (pabd) still plays a significant role in settings with high individual benefit for the patient, high transfusion probabilities and when all opportunities of cost minimization can be applied. adjustment to the individual situation of the patient is the main aim of a medically reasonable and economic use of autologous haemotherapy. this implies consideration of the patient's haematocrit, blood volume, tolerable blood loss, expected blood loss, etc. in order to choose the optimal method in the individual case. in this respect, double red cell apheresis may play a significant role. with this approach, donation schedules assumed to enhance erythropoiesis can be adopted. moreover, inconveniencies caused by long distances between patient home and donation service can be facilitated by withdrawing two red cell units during one session in selected patients. in conclusion, red cell apheresis can be used to promote the proposed approach towards individualized autologous haemotherapy preoperative plasmapheresis is considered to be a sensible adjunct if intraoperative retransfusion of salvaged and washed red cells is planned. acute normovolaemic haemodilution is valuable when the patient's tolerability of the haemodilution and the expected blood loss are carefully examined beforehand. intraor postoperative salvage of wound blood can also be regarded as useful measures to prevent allogeneic transfusions as long as the specific advantages and disadvantages of the different methods are taken into account. finally, alternative and supplemental measures such as iron or erythropoietin administration should always be considered in order to optimize the efficacy and effectiveness of autologous haemotherapy methods. the goal of a 'bloodless medicine' might not be reached but is supposed to be approached closely with an integrated concept exploiting all measures available. however, in times of restricted health care resources, regular sound costeffectiveness analyses, taking the availability and the cur-rent safety profile of allogeneic blood products into account, are always warranted and needed. compensatory fluid replacement of surgical blood losses: the transfusion of allogeneic blood is expensive and -although safer than ever before -still associated with potential complications. to reduce both, costs and immanent risks, allogeneic transfusion should either be completely avoided or at least minimized during surgical procedures. as a consequence an intraoperative blood loss is initially not replaced by red blood cells, but by erythrocyte-free, i.e. cristalloidal or colloidal solutions. when normovolemia is maintained the resulting dilutional anemia is compensated by an increase of cardiac output and enhanced arterial o extraction. however, once the hb has dropped to values recommended as the lower intraoperative limit, or once compensatory mechanisms of acute anemia become exhausted, as a rule transfusion of red blood cells (rbc) is initiated to increase arterial oxygen content (cao ) and to preserve a margin of safety for tissue oxygenation and organ function. as an alternative to immediate rbc transfusion, ventilation with pure o (hyperoxic ventilation) can be employed to rapidly raise cao by increasing the amount of physically dissolved o in plasma (hyperoxia). however, molecular o causes vasoconstriction, mediated by products of the arachidonic acid metabolic pathway. as a consequence hyperoxia has been shown to increase systemic vascular resistance and to decrease cardiac output and o consumption in subjects with normal hemoglobin concentration ( properly scheduled, three women who did not reach the necessary hct level after the first donation and consequently they got out of the protocol, and one woman who had unexpected intraoperative bleeding and received homologous units in addition. the patients undergoing tkr and the patients undergoing removal of implants predeposited and units respectively, but finally and of them have been used. according to our patients data, the . % of unused autologous blood units belongs to patients with tkr and implant removal. therefore a better schedule is needed for these type of surgery. all the autologous donors were supported by oral iron supplementation throughout the predonation and month past surgery. fourteen of our cases were supported by erythropoietin s.c. in a dose of iu/kg every other day. the majority of these patients was female, only one was male with multiple alloantibodies and was scheduled to predonate autologous units. all of them underwent thr except one woman who also had a tkr months later. the autologous blood donation was well tolerated by all patients and only one woman had a reaction during predonation. furthermore a group of patients matched for age, sex and type of surgery, who did not predeposit blood, received a mean of . homologous units per patient, that is more than the patients on pabd program. our results show that autologous transfusion can be used in scheduled orthopedic surgical procedures and can reduce the need for homologous blood. however, every effort should be made to render the practice of pabd more efficient and to minimize its costs. colloid solutions and their establishment in clinical practice background: various situations like trauma, critical ill patients, sepsis, major surgical procedures and anaphylactic reactions are associated with disturbances in fluid homeostasis. this disturbance is related with reduced oxygen delivery, subsequent lactic acidosis and imbalance in oxidative status. the final result will most likely be an increased mortality and morbidity. aim: the important issue from clinical aspect is to define the optimal volume and type of fluid therapy. the debate for the ideal resuscitation solution lasts a couple of decades due to inconclusive and conflicting results. method: we searched the literature for clinical trials and major met analyses concerning patients undergoing scheduled surgical procedures, trauma patients and critical ill who received resuscitation fluids. results: dextrans reduce blood viscosity and von willebrand factor levels more, for the same degree of hemodilution, compared to other plasma expanders. in clinical setting they are effective in reducing the incidence of deep vein thrombosis and pulmonary embolism. after the initiation of dextran for prophylaxis against anaphylactic reactions, they are considered the safest plasma substitutes, except maybe during pregnancy. dextran % is the most like to cause the 'hyperoncotic acute renal failure' syndrome. gelatins also cause a decrease in circulating levels of vwf : ag, vwf r : co, thrombin-antithrombin complexes and f + . in clinical aspect however, there are contradicted results about the effect of gelatins in bleeding diathesis, although they appear to exert a greater effect on rbcs protection from mechanical stress. in respect to anaphylactoid reactions, they have the greatest relative risk. hes has the same effectiveness in volume expansion with albumin and has the advantage of remaining intravascular even if there is an increased capillary permeability. in addition, it may improve splanchnic blood flow and tissue oxygenation. hes / . subsides the inflammatory response in patients undergoing major surgery, compared to a crystalloid-based volume therapy, but has conflicting results about it's effects on neutrophil respiration burst. clinical trials have so far failed to have a unanimous conclusion about the bleeding diathesis after hes administration, especially. caution must be held when administering hes during renal transplantation. albumin became the scapegoat of transfusion strategy during the past years. resent met analysis have contradicted results about the safety of albumin infusion in variouw settings. a positive effect seems to have the early administration of hypertonic solutions in trauma patients, especially in combination with dextrans. conclusions: although some minor conclusions can be extracted, there is still a great lack of large scale multicentre randomized prospective clinical trials for extracting evidence based criteria. instead, we try to extract conclusions through met analysis. results show no evidence that resuscitation with colloids reduces the risk of death compared with crystalloids in patients with trauma, burns, major surgery or sepsis. also, there is lack of evidence that one colloid solution is safer -in clinical aspect -than any other. recombinant human erythropoietin therapy in critically ill patients -a dose response study* objective: the aim of our study was to assess the efficacy of two dosing schedules of recombinant human erythropoietin (rhuepo) in increasing hemoglobin (hb) level and reducing the exposure to red blood cells (rbc) transfusion in critically ill patients. design: a prospective, randomized, multicenter trial. patients: a total of patients who met eligibility criteria were enrolled. intervention: patients were randomly assigned to receive intravenous (i.v.) iron saccharate alone (control group), i.v. iron saccharate and subcutaneous rhuepo units once per week (group a) and i.v. iron saccharate and subcutaneous rhuepo units three times per week (group b). rhuepo was given for a minimum of weeks or until icu discharge or death. the maximum duration of therapy was weeks. the requirement for rbc transfusions was significantly higher in control group than that in group a and b. no significant difference was observed between group a and b. the mean increase in hematocrit (dhct) and hb (dhb) from baseline to final measurement were significantly higher in group b than these in control group. dhct was significantly higher in group b than that in group a. dhct in group a was significantly higher than that in controls, whereas dhb did not differ significantly between control and group a. conclusion: administration of rhuepo in critically ill patients significantly reduced the need for rbc transfusions. the magnitude of the reduction did not differ between the low and high dose of rhuepo, whereas there was a dose response of hct and hb to rhuepo in these patients. in transfusion medicine, antibodies to antigens in the platelet membrane have traditionally been regarded as less significant compared with antibodies towards red cell antigens. there is an increasing awareness of antibodies towards platelet antigens. detection of autoantibodies to platelets can be a diagnostic challenge, but is seldom a problem in transfusion medicine because patients with such antibodies rarely are candidates for platelet transfusions. also, severe foetal thrombocytopenia is seldom present in pregnancies with autoantibodies to platelet antigens. the real challenge in transfusion medicine is related to patients with severe thrombocytopenia who are refractory to platelet transfusion due to alloantibodies towards platelet antigens. in our department, flow cytometry is used for compatibility testing and the choice of compatible blood donor is done without knowledge of antibody specificity. if crossmatch negative random donors cannot be identified, antibody specificity testing is performed and donors are chosen based on the specificity of the antibodies determined by a modified maipa procedure and with hla class i beads (flowpra from one lambda, usa) in flow cytometry. in some cases both hla class i and human platelet antigen (hpa) specific antibodies are detected and hla class i, hpa matched donors are chosen for crossmatch. if the crossmatch is negative, there is > % chance of successful transfusions. in some cases drug induced anti-platelet antibodies are suspected and flow cytometry based antibody tests are performed in the presence and absence of the drug. in the case of suspected heparin induced antibodies, a beads assay is performed (diamed, switzerland). two percent of caucasian women have the platelet type hpa bb. ten percent of these women make anti-hpa a antibodies in their first hpa a incompatible pregnancy. in - new-born has thrombocytopenia due to maternal alloantibodies which have crossed the placenta (neonatal alloimmune thrombocytopenia, naitp). results from a screening study covering the outcome of pregnancies show that only babies were born with intracranial haemorrhage (ich) and there was no still-born babies in the study. pregnant women with a-hpa a antibodies were diagnosed, received careful clinical follow-up and the delivery was performed by caesarean section in week of the pregnancy with immediate transfusion of hpa compatible platelets if the new-born had platelet count < ¥ e /l. in previous studies, it is reported the ich appears in - % of the pregnancies where antibodies are present and that % of the babies with ich, die. our results are different from what is reported from other studies and this may reflect the prospective approach and the clinical interventions. naitp represent a challenge in transfusion medicine both diagnostically, but also related to compatible blood products for the thrombocytopenic new-born and the mother who may have high level of antibodies towards platelet antigens. methods: apheresis platelets ( ¥ e mean) from donors with same blood group were pooled and divided equally into two bags, po- and control (pl , baxter), which have and ml/m *day*atm of oxygen permeability, respectively. on days , , , , , and of storage, swirling, mean platelet volume, po , pco , ph, glucose, lactate, aggregation, and p-selectin expression were evaluated. six experiments were performed. results: the swirling pattern was preserved better for up to days in po- ( / ) than in control ( / ) bags. dropped ph less than . on day was observed / in po- whereas / in the control. aggressive drop of glucose ( mmol/l) with prominent lactate accumulation ( mg/l) was also observed on day in of control bags. the po level in the control dropped more significantly by % ( . mmhg) on day than in po- ( . mmhg) compared with the initial level ( . mmhg) (p < . ). these results suggest that aerobic metabolism of higher concentration platelets was maintained better in a container with higher oxygen permeability. and less lactate generation with slower glucose consumption is also suggested in po- bags than in control bags. the %hsr and aggregation decreased gradually in a similar manner in both bags until day , and became a detrimental defect in of control bags on day . p-selectin expression was higher in control bags than in po- on days and with no statistical difference. in two control bags p-selectin expression reached > % and was accompanied by a loss of swirling. these functional and biochemical characteristics of platelets at a higher concentration were kept better for - days when stored in a container with higher oxygen permeability than in the best of marketed containers. t-pa- background: maintenance of a neutral ph in the range of . - . is essential for preservation of platelet function and viability during storage. furthermore, studies have also indicated that the presence of glucose in the platelet suspending medium is important for maintenance of platelet quality. however, a platelet additive solution (pas) containing glucose having a ph of . - . cannot be manufactured by steam sterilization due to caramelization of glucose. in order to have optimal ph, the currently available pas such as t-sol does not contain any glucose. this study describes a novel twostep approach to provide a glucose containing additive solution (pas-g) by using an acid, glucose containing electrolyte solution (ph . ) for resuspension and processing of the pooled buffy coats (bc), followed by transfer of the processed platelet concentrate (pc) into a storage bag containing bicarbonate for ph neutralization and maintenance during extended storage. aim: compare the platelet quality of pooled bc pc stored in pas-g with pooled bc pc stored in t-sol. methods: a paired study design was used, where a pool of bcs obtained from standard day -old cpd-wb units, was divided into two equal parts: one part was resuspended and processed with a pall leukoreduction system (atsbc) using t-sol, the other part was processed in a similar manner with the acid part of pas-g. percentage plasma carryover ranged from - %. both processed pc products were transferred and stored in elx tm bags with the pas-g pc elx bag containing a bicarbonate tablet. ten replicate studies were performed. results: the yields ( . ± . vs. . ± . °¥ e ) were similar (pags vs t-sol). statistically significant (p < . with paired ttest) improved platelet quality at days , , and of storage was observed with platelets stored in pas-g as compared to t-sol. the table below shows results at and days of storage for ph, extent of shape change (esc) and hypotonic shock response (hsr). the results for t-sol stored platelets correlated highly with initial glucose (% plasma carry over) level (r = . for esc, and r = . for hsr at days storage), while no significant correlations were found for pas-g stored platelets. conclusion: this study demonstrated the practicality of using a two step procedure to store bc pc in a glucose containing additive solution with neutral ph during storage, and confirmed the importance of glucose in the storage medium as nutrient for optimal platelet storage quality. the effect of irradiation on white cell reduced platelet concentrates, stored for days background: the storage of white cell (wbc)-reduced platelet concentrates (pcs) can be extended from to days provided the quality has been validated and bacterial screening is performed. irradiation up to gray (gy) does not affect platelet quality, but the effect of pre storage irradiation with subsequent storage up to days is not known. method: two wbc reduced pcs, each made from buffy coats and a unit of plasma, were pooled and divided into control group 'a' and study group 'b' . pcs in group 'b' were irradiated immediately after preparation with gy. pcs in both groups 'a' and 'b' were then stored on a continuous flat bed shaker at - °c. swirl, ph and cd p expression were determined on day , and . twelve experiments were performed and compared with a paired t-test, p < . was considered significant. results: see table (day values; mean ± sd; n = ). pooling and dividing of the pcs was successful with respect to volume and platelet number. on day , the ph in group 'b' was slightly lower than in group 'a', but the difference is not significant. in group 'a', ph on day was < . in / pcs, versus / in group 'b' (not significant). the cd p expression in irradiated pcs is not significantly higher than in non-irradiated pcs. conclusion: irradiation had no significant effect on platelet quality when stored for up to days after blood collection. - b, - a, - b, pra %, donors. in patient -three transfu-sions were effective (two crossmatches neg by lct and pift, one pos lct, neg pift) but later on, when the patient was in severe clinical status (shortly before his death) two transfusions were ineffective in spite of neg crossmatches. it is very likely that for the same reason patient and were refractory to two and one hpa compatible platelet units respectively. in patient and compatible platelets were not transfused because they died before the whole procedure (diagnosis and finding a proper donor) was completed. conclusions: . the frequency of occurrence of anti-hpa antibodies in transfused patients was: - b, - b, - b, - a, - a; in three patients they were monospecific, in four polyspecific. . in patients who developed anti-hpa alone, transfusions of platelets without relevant hpa antigens were successful. .the effectiveness of compatible platelets in patients with both anti-hpa and -hla was more difficult to assess because of their severe clinical status, which might have been responsible for transfusion failure. in one of these patients, however, the transfusions of compatible platelets were successful when he was in relatively good clinical status, but shortly before death transfusions were ineffective. t-pa- the successful implementation of nucleic acid testing (nat) for hiv, hbv, hcv and further viruses as well as improved donor selection led to a dramatic risk reduction for viral transmission via blood transfusion over the last years. today, other risks get into the focus of haemovigilance. bacterial contamination of blood products can occur via the donor, suffering from a (clinically unapparent) bacterial infection, or via the donation process itself, storage and handling of the blood product. particularly platelet concentrates (pc) are vulnerable to bacterial growth due to their storage conditions. patients receiving such products have a potential risk of severe complications or even death. modern hygiene regimes, e.g. improved disinfection of the donors´ skin or preparation of blood products in fully closed systems as well as diversion, led to a significant reduction of bacterial contamination risk in the past. however, a small risk remains. therefore, two possible ways of further reducing the risk of bacterial contamination of blood products are feasible: (a) testing and/or (b) inactivation. testing for bacterial contamination is possible by different methods: direct detection methods for bacteria (microscopy, flow cytometry) have disadvantages regarding sample size and detection limit. bacteria might rapidly grow in a contaminated pc, so testing should be performed as close as possible to transfusion to the recipient. biochemical methods like oxygen consumption might not detect anaerobic germs. automated culture methods are still the most sensitive technique, but they have their downsides as well (e.g. time and size of aliquot drawn). novel molecular genetic test methods for detection of bacterial nucleic acid are in different states of development, but still have to proof their suitability for routine use. three different principles of pathogen inactivation can be distinguished: photodynamic reactions produce oxygen radicals which in turn inactivate bacterial structures by oxidation processes. examples for these chemicals are phenothiazines like methylene blue and thionin as well as vitamins like riboflavin (vitamin b ). photochemical reactants penetrate cell boundaries and irreversibly inhibit nucleic acid, thus blocking replication and proliferation of pathogens. chemicals of this group are psoralens like amotosalen as well as pen- or s- . the third method, the solvent detergent (sd) method, is used for pooled plasma only and consists of the combination of both solvents and detergents, which interact with membranes and destroy bacteria. methods for inactivation of bacterial contaminants have to proof, that they effectively inhibit bacterial growth while maintaining full functionality of the blood product at the same time. these two qualities have to be fulfilled up to the end of the storage period. toxic or mutagenic compounds must not remain in the final product. the technology must be easily integrated into the existing work cycle of a blood bank. finally, costs per product must be acceptable. in summary, both testing and inactivation have their advantages and disadvantages, which have to be weighed up against costs and benefits of both procedures. pros and cons of introduction of inactivation methods in a blood donor service producing blood components per year will be discussed. bacterial contamination of blood components, particularly platelets, is now recognized as a serious adverse reaction that is preventable. there are many studies that have documented that these reactions occur from platelets stored at room temperature, most commonly arising from a skin contaminant, but originating from donors with asymptomatic bacteremia in about / of cases. the problem is intensified for patients receiving pools of platelets compared to single donor platelets collected by apheresis. reactions are more commonly noted and more severe with platelets stored for greater lengths of time. previous studies at johns hopkins described a series of reactions in years with reactions more common in platelet pools ( : transfusions) than with single donor platelets ( : transfusions). these reactions caused fatalities in of cases. although our data suggests that these reactions are more common than other studies using hemovigilance systems, our case definition requiring culture of all transfusion reactions to platelets led to a more reliable estimate of the incidence of sepsis from platelets, many potential solutions have been proposed to prevent these reactions. improved skin antisepsis should always be sought but will never eliminate the / of reactions due to asymptomatic bacteremia. the same limitation applies to methods that divert potential skin plugs from the collection bag. antibiotics in the bag would lead to manufacturing concerns or problems for patients with drug allergies. although cold storage of platelets is currently being revisited, it is not yet a practical solution. pathogen eradication systems have been developed but they remain unapproved in most of the world and have led to concerns about toxicity of additives, damage to treated cells, and cost. as a result of increasing recognition of the problem, there has been increased interest in bacterial screening to prevent sepsis from platelets. in march , the aabb standards required testing of platelets for bacterial contamination. testing programs have been implemented in the us widely as a result of the aabb action. licensed systems based upon bacterial culture or growth characteristics are available for single donor platelets and have been commonly employed. although these systems have some difficulty with false positive reactions, the evolving national data suggest an incidence of : true positive reactions. these data suggest that a number of serious reactions have been averted, although some cases have persisted due to incomplete adoption, problems with slow growing bacteria, or the use of inferior testing methods with inadequate sensitivity. whole blood derived platelets have become a more difficult issue, since the approved testing methods are limited. the use of ph monitoring, gram stain, glucose measurements, and inspection for swirling have all been attempted. these methods are not sufficiently sensitive or specific to interdict many contaminated units, so that screening for bacteria in pooled platelets is less effective. it is anticipated that new methods may become available to make screening of whole blood derived platelets easier to perform in a reliable manner. it is also hoped that bacterial screening of platelets may form the basis to permit seven day storage and prestorage pooling in the us. results: twenty four hcv rna (+)/anti-hcv(-) repeat donors were previously tested in routine hcv rna in mini-pools and were negative. twenty available look back samples were individually tested for hcv rna and in one the virus was detected. to make sure that the failure of hcv rna detection in routine nat was not due to the pooling procedure, the hcv rna was tested in undiluted look back sample and dilutions of this sample by hcv negative plasma: / repeats of x dilution and / repeats of x dilution were hcv rna negative, whereas / repeat of x dilution and / repeats of undiluted sample were positive. the results of cobas amplicor monitor (sensitivity iu/ml) were negative, which means that viremia in hcv rna mini-pool negative donation was below iu/ml. in the recipient of red blood cell concentrate from this donation hepatitis c was diagnosed. however, the possibility of pretransfusion hcv infection cannot be excluded as no hcv marker tests were performed before transfusion. the patient and the donor were infected with genotype a. the low hcv viremia (below iu/ml) in the preseroconversion window period was responsible for no hcv rna detection in routine mini-pool hcv rna testing. introduction and aim of the study: bacterial contamination is a life threatening risk of blood transfusion, especially with platelet transfusions. bacterial culturing (bc) of platelets as well as pathogen reduction (pr) reduce the likelihood of such contamination. where the costs of bacterial contamination are far less than the costs of pathogen reduction, the latter will reduce not only the risk of bacterial contamination but also risks of other pathogens. therefore, the question arises whether this additional expenditure can be justified in the light of the additional effect achieved. this question we will answer by cost-effectiveness and sensitivity analyses. methods: the balance between costs and effects of preventing adverse events due to platelet transfusion is assessed using a mathematical model and assuming optimal effectiveness of pr. model parameters and valuations of health states were obtained from literature and information from dutch sanquin blood banks. . while the estimates in comparison to the situation without bc or pr are surrounded with large uncertainties, the conclusion that pr is not cost-effective in comparison to bc is very robust. the cost-effectiveness of bc and pr are very sensitive to the estimates concerning sepsis probability and associated complication rate, the cost-effectiveness of pr relative to bc is not. this conclusion is also insensitive to a wide range of assumptions regarding residual risks and costs associated with hiv, hcv and hbv. the estimates indicate that culturing in the netherlands is cost-effective, even with the deviation bag in place. the estimates however appear to be very sensitivity to the probability of sepsis. a decision to use pr will, after the introduction of bc and the use of a deviation bag, never meet cost-effectiveness criteria. even when assuming perfect protection, the conclusion that it is not cost-effective in comparison to bc is very robust and does not alter when varying underlying parameters within their margins of uncertainty. table) . of cb collection. two collections have been transplanted to date and this represents a . % take-up rate ( . % where a sibling is alive). this compares favourably with the numbers transplanted from unrelated cb banks. dcb collection is therefore at least as efficient a method as unrelated cb collection for transplantation albeit in the limited number of cases where a dcb collection is possible. dcb collection has the benefit of a possible immediate transplant combined with the availability of a sibling donor for future donation of both stem cells and lymphocytes. it is therefore a useful service to provide and complements the work of unrelated cord blood banks. increased yield of mature platelets in cultures of cd -enriched cord blood cells maintained at °c introduction: the future use in transplantation of ex vivo expanded hematopoietic stem (hsc) and progenitors cells will facilitate the transplantation of adult patients and speed up hematologic recovery. also ex vivo cultures of hscs may eventually permit to produce donor-free blood components such as platelets for transfusion. culture of animal cells is routinely done at °c. however there is previous clinical evidence suggesting that hematopoiesis may be more active in hyperthermic patients. we have therefore compared the effect of hyperthermia on the ex vivo expansion and differentiation of cord bloodderived hsc in megakaryocytes (mk) and mature platelets. the cord blood-derived cd cells were cultured continuously at °c or °c for days in cytokine conditions optimized for mk development and maturation. the cultures were regularly monitored for various parameters. results: compared to °c, the cultures maintained at °c produced significantly more total cells ( . fold) and total mks ( fold), and showed accelerated and enhanced mk maturation with increased yield of proplatelets and mature platelets ( . fold). accordingly, the cells cultured at °c contained an increased frequency of cfc-mk ( fold) at day . cultures done at °c and °c were also more efficient than at °c but less than at °c. platelets produced in °c cultures could be normally activated by thrombin. as expected, the cells cultured at °c contained an increased amount of the heat shock protein hsp . control experiments showed that the culture of several cell lines was inhibited or unaffected by the °c temperature. the unexpected resistance of hematopoietic cells to the deleterious effects of heat and the stimulatory effect of > °c temperatures on hsc proliferation and differentiation indicate that the routine culture of normal human cells at °c is a paradigm that needs to be revised. the responsible molecular mechanisms remain to be identified but the observation will facilitate the ex vivo expansion of the progenitors of the mk and possibly other lineages. the synchronous generation of a significant number of mature platelets in vitro will facilitate the study of the mechanisms of platelet formation and ageing and could eventually have important applications in transfusion medicine. it remains to be seen if the stimulatory effects of higher than °c temperatures represent a protective response against sustained body fever that is specific to the hematopoietic system. several countries have, in the past few years, included human tissue banking within a regulatory framework similar to that of blood. indeed, tissue safety has come to the forefront of the preoccupations of regulatory agencies after several well publicised morbidity and mortality cases have been reported in the press. tissue safety has many features similar if not identical to blood safety and a review of those common elements will be reported. as well, arguments in favor of integrating tissue banking within a blood system will be discussed, one of the more important aspect of which being the expertise of the blood centre staff with cgmps. the experience of a blood establishment (héma-québec) with the integration of tissue banking such as bone, skin, heart valves within its operations will be reported, emphasizing the medical as well as the management aspects of such an integration. finally, tissue banking is an activity which brings more expertise to a blood centre, expands its knowledge of its customers and gives more opportunities to its personnel. umbilical cord blood (cb) is an important source of stem cells for clinical transplantation and may cause less gvh disease than non-t-depleted bone marrow (bm). the relatively low numerical cell dose available from cb has usually restricted its use for transplantation in adults. only - % of patients have an hla matched sibling and for others an unrelated bm or a stored unrelated cb donation may also not be available. for some children the collection of cb following the birth of a sibling may be the only opportunity for a transplant. directed cb (dcb) donations from matched siblings have been shown to give better long-term overall results than matched unrelated cb or bm. dcb collection is however not as easy to control as cb for banking where dedicated hospitals and trained staff are used. here we review dcb banking in oxford over a . -year period. requests were received for deliveries from mothers and of these, collections were successful including pairs of twins. failed collection was most often due to a damaged cord at delivery. collections were made for siblings possibly requiring transplant (median age ) with for leukaemia, for erythroid disorders, for immune deficiency, for enzyme deficiency and others. the remaining collections were mostly requested where there was a family history of an inherited disorder (majority scid). three collections tested positive for anti-hcv antibody but negative for hcv by pcr. collections were not excluded on the basis of volume or cell number. mean volume was ml (range - , % exceeded mls) and mean tnc count was . ¥ (range . - . , % exceeded . ¥ ^ ). the mean cd +ve count was . ¥ (range . - . ). all collections were cryopreserved within hours using dmso/dextran/saline without volume reduction. the mean tnc viability prior to freezing was % (range - %) and the mean cd +ve viability post freezing was % (range - %). the reliance on the goodwill of midwives and the logistical difficulties that arise when organising collections from many different hospitals do not appear to reduce the success . rhd and rhce typing was performed by multiplex-pcr with fluorescent primer pairs. positive results were obtained for rhd-exons - , , and polymorphisms associated with antigens c, c, cw, e and e. sequencing of rhce-sequences, including exons to and intron/exon borders, were done by direct taq cyclesequencing using bigdye-terminators v. . in an abi (applied biosystems). background: a number of adverse immune reactions associated with blood transfusion result from contamination of blood products by donor white blood cells. among these reactions, transfusionassociated graft-versus-host disease (ta-gvhd) has a mortality of greater than %. mirasol ® pathogen reduction technology (prt) has been developed for the reduction of viruses, bacteria, parasites and white blood cells loads in blood products. the technology is based on light and riboflavin photochemistry. this study was performed in order to evaluate the effectiveness of the mirasol ® prt process for inactivation of human pbmncs. methods: human pbmncs were collected from trima platelet apheresis disposable sets, purified by ficoll-hypaque discontinuous gradient centrifugation and divided into test and control samples. the test cells were treated with mirasol ® prt in autologous plasma on day . both test and control samples (n = ) were tested on day for cellular immunophenotype, t-cell activation using flow cytometry, proliferation in response to mitogen or allogeneic stimulator cells, ability to stimulate the proliferation of allogeneic responder cells and cytokine synthesis in response to lps stimulation was measured using a cba assay kit. results: although mirasol ® prt treatment did not significantly change the distribution of cd +, cd +cd +, cd +cd +, cd + and cd +cd + human lymphocyte subpopulations there were significant functional change. the expression of the activation marker, cd , was observed in . % (sd = . %) of control t cells upon activation with pma, while only a . % (sd = . %) of the test t cells increased cd expression. proliferation assays showed that h-thymidine incorporation did not increase in the test cells in response to either pha or allogeneic stimulator pbmnc compared to the significant increase in thymidine incorporation levels observed with control cells. the test cells, when compared to the controls cells, demonstrated an inability to stimulate allogeneic responder pbmnc proliferation. the release of il- , il- , il- b and il- cytokines after -h incubation in culture media increased significantly to pg/ml (sd = ), > pg/ml, pg/ml (sd = ) and > pg/ml for control cells, respectively. under the same conditions, these cytokines in test samples remained at background levels of . pg/ml (sd = . ) for il- , . pg/ml (sd = . ) for il- , pg/ml (sd = ) for il- b and pg/ml (sd = ) for il- . addition of lps further stimulated the release of tnf-a, il- , il- , il- b and il- in the control samples, but not in the test cell samples. in vitro studies demonstrate that mirasol ® prt treatment does not change lymphocyte immunophenotype, inhibits tcell activation by pma, abolishes pbmnc proliferative activity, eliminates pbmnc stimulatory activity for responder cell proliferation and suppresses the production of cytokines by pbmnc in both the absence or presence of lps. introduction: it has been discovered that vaccination of dendritic cells (dcs) with tumor antigens is a potential strategy to induce tumor-specific immunity in tumor-bearing patients. aim of the study: the purpose of the study was to investigate whether human monocyte-derived dendritic cells (dcs) were able to present p bcr-abl protein and induce antigen-specific ctl responses in vitro after transfected with total rna of k cells (k -rna). methods: dcs were derived from human pbmncs, which were incubated for days in the presence of gm-csf and il- , and then were transfected with k -rna using electroporation or dotap lipofection. to verify the successful transfection of dcs with k -rna, bcr-abl fusion genes expression of dcs was detected by rt-pcr and western blot. the immune phenotypes of the dcs were analyzed by flow cytometry. the cytotoxicity of ctl was assayed by propidium iodide (pi) staining and flow cytometry. results: it was shown that the bcr-abl fusion gene was detected in the dcs immediately after the transfection, but disappeared hours later, while the cells were expressing p bcr-abl protein and expressing increased cd , cd , cd , hla-dr. moreover, the transfected dcs could significantly promote the t lymphocytes to kill the target k cells. conclusion: human dendritic cells transfected with total rna of k cells in vitro could induce effective p bcr-abl proteinspecific immune responses and be used to induce tumor-specific immunity, which implies potential application of immunotherapy to tumors. appear to be relevant to the clinical response. ivig has a remarkably good safety record for long term administration, however the following side effects have been observed: mild, infusion-rate related reactions such as headaches, myalgia or fever; moderate but inconsequential events, such as aseptic meningitis and skin rash; and severe, but rare, complications such as thromboembolic events and renal tubular necrosis. judicial use of ivig based on results from controlled studies is recommended. t-pl - donor-lymphocyte infusion: transfusion immunotherapy following allogeneic hematopoietic transplantation the notion that bone marrow containing immunocompetent cells is capable of mediating an antitumor effect was determined experimentally almost years ago. subsequently, pooled leukocytes from patients with cml were found to effect responses in patients with advanced leukemia. response correlated with cell dose and with severity of gvhd. in the 's, the graft-versus-leukemia (gvl) effect was defined in the transplant setting using a lethallyirradiated mouse model and splenocyte infusions. such studies suggested that gvl could be enhanced without causing severe gvhd. the era of adoptive immunotherapy in the transplant setting began in the 's with reports of donor lymphocyte infusions (dli) for relapsed acute and chronic leukemias after bone marrow transplant. it is now clear that chronic myelocytic leukemia (cml) in chronic phase is highly susceptible to gvl effects mediated by dli which induce durable remission in - % of relapsed patients. the success rate is % or less in patients with accelerated phase or blast crisis. since dli cell dose appears to be important in this setting, strategies of escalating dose infusions have been investigated to enhance gvl without exacerbating gvhd. unfortunately, the response to dli in relapsed acute leukemia and myeloma is less favorable (< %) and less durable. dli have been used successfully to treat viral infections and virus-associated malignancies following transplant. both unfractionated dli and ex vivo-generated tcell clones have suppressed reactivated cytomegalovirus and eradicated epstein-barr virus-induced lymphoproliferative disease, a polyclonal proliferation of donor-origin b cells that occurs after transplant. where tumor-specific antigens have been defined, efforts to target dli have been undertaken and donor and patient immunization has been investigated. acute or chronic gvhd develops in approximately % of patients receiving dli for relapsed hematologic malignancies and for related, but not unrelated transplants, correlates with the donor t-cell dose. dli-induced pancytopenia occurs in approximately % to % of patients, is generally mild, and transient, but in < % of patients, aplasia is severe and prolonged. complications of aplasia include infection, bleeding, increased transfusion requirements. efforts to limit the adverse effects of dli while retaining the therapeutic effects include insertion of 'suicide genes, ' selection of lymphocyte subpopulations, and targetting lineage-specific minor histocompatibility antigens. available clinical and experimental evidence suggests, that in addition to primary and secondary immune deficiencies, a wide spectrum of immune-mediated conditions could benefit from intravenous immunoglobulin (ivig), including acute and chronic/relapsing diseases, autoimmune diseases mediated by pathogenic autoantibodies or by autoaggressive t cells and inflammatory disorders e.g. an imbalance in cytokine networks. trimar-collected apheresis platelet concentrates (pcs) were exposed to . j/ml uv light in the presence of um riboflavin, followed by storage under blood bank conditions with various concentrations of -deoxyglucose from to mm for days. the control platelets were not stressed by uv light exposure and were stored under the same conditions without -dog presence. all test and control platelets were measured for in vitro cell quality including rates of glycolysis, morphology score and activation levels at days , , and . results: lactate production and glucose consumption increased from . mmol/ cells/h (sd = . ) and . mmol/ cells/h (sd = . ) for control samples to . (sd = . ) and . (sd = . ) for uv-treated platelets, respectively. uv treatment also caused a decrease in ph from . (sd = . ) for controls to . (sd = . ) for treated platelets at day , hsr from % (sd = . ) to % (sd = . ), esc from . % (sd = . ) to . % (sd = . ), swirl from . (sd = . ) to . (sd = . ), and increased p-selectin expression from . % (sd = . ) to . % (sd = . ). addition of -dog up to mm significantly reduced lactate production rate to . mmol/ cells/h (sd = . ) and glucose consumption rate to . mmol/ cells/h (sd = . ), and maintained ph above . (sd = . ) for days of storage. the effect of -dog exhibited a dose-dependent response. however, the addition of -dog had no effects on hsr ( . + . % at day ), esc ( . + . % at day ), swirl ( . + . at day ) and p-selectin expression ( . + . % at day ) during platelet storage. atp contents in both treated and control groups were maintained at a relatively constant level above % of the value seen in fresh platelets. furthermore, an exaggeration of uv-stressed platelet aggregation by addition of -dog was also observed. conclusions: increased glycolytic flux is not a direct cause for platelet morphology changes and spontaneous activation incurred during the development of the storage lesion. the results also suggest that a reduction in glucose utilization may foster an increase in platelet loss during storage. aim of the study: was to evaluate analytical sensitivity, sensitivity and inclusivity for subtypes and genotypes of hiv, hcv and hbv, the assay's effectiveness in closing the pre-seroconversion window period, clinical specificity as well as the effect of endogenous substances and microorganisms on the sensitivity and specificity of the assay. methods: secondary standard traceable to who international standard for hiv- ( / ), international standards for hcv ( / ) and hbv ( / ) were used to determine the analytical sensitivity. sensitivity and inclusivity for hiv- subtypes other than hiv- b, for hiv- and for hepatitis b and c genotypes as well as specificity was evaluated with > specimens. results: results from this study indicate that high analytical sensitivities ( iu/ml hiv- m, cp/ml hiv- o and . cp/ml hiv- , iu/ml hcv and iu/ml hbv) and a specificity of > . % are accomplishable for the mpx test. the % detection rate for hiv- m subtype isolates (a through h) was between to iu/ml, for hcv genotype isolates ( a through ) between to iu/ml and for hbv genotype isolates (a through g and precore mutant) between to iu/ml. investigating seroconversion panels, hiv- rna was detected an average of and days earlier than hiv- antigen with abbott hivag- monoclonal and coulter p antigen tests, respectively, hcv rna an average of or days earlier than hcv antibody with the abbott hcv eia . or ortho eia . tests, hbv dna an average of days earlier than hbsag with the abbott hbsag eia imx test. for all targets, no interference was detected with microorganisms tested as well as elevated levels of triglycerides, albumin, hemoglobin, human dna or bilirubin. conclusion: automated pooling, sample preparation, and real time pcr using the blood screening system taqscreen mpx test is an efficient and sensitive method to simultaneously screen for five important viruses in human plasma. the mpx test is another evolution step in the development of pcr automation by roche molecular diagnostics, and further represents roche's commitment to increasing the safety of the global blood supply. aim of the study: a prospective hemovigilance plan was set up in order to establish a registry for future reference, and to detect any unexpected side effect of ip that may occur with significant frequency in populations and indications that were not studied before and outside of a formal trial environment. methods: this plan is proposed to blood establishments and transfusion prescribers who have already decided to implement ip. this is an observational, non randomized, non controlled plan. no patient selection, inclusion or exclusion criteria are required. all ip transfusions are documented using an internet form, whether or not a reaction is observed. patient population data are collected anonymously, for epidemiological purposes. results: between october and september , apheresis ip units have been transfused in sites and registered in the database. ip platelets were considered leucocyte inactivated and were not irradiated, but were antigen matched as indicated ( . %). the population of patients receiving at least one transfusion (n = ) included . % of males, . % of females, the median age was (range - ). the most frequent broad diagnostic categories were hematology-oncology ( . %) and cardiovascular surgery ( . %). the patients received their transfusions either in regular hospital wards ( . %), intensive care units ( . %) or as outpatients ( . %). the number of transfusions by patient ranged from to (mean . ± . , median ). half of the patients ( . %) had previous transfusion experience and . % had previous history of transfusion reaction. transfusion reactions, defined as any deterioration of the patient's state of health observed following transfusion, were observed in . % (n = ) of the transfusions ( % ci . - . ), and . % of patients. only ( . %) were considered serious. after further causality analysis including biological and clinical investigations by the transfusion physician, . % ( % ci . - . ) of the transfusions were confirmed as having caused reactions in . % of patients, none of them serious. the most often reported symptoms were chills ( . %) and fever ( . %). itching, skin rash or urticaria was observed in . % of transfusions. of the serious reactions, one was hypotensive shock in a patient with liver cirrhosis and haemorrhage, and one was septic shock, in which the platelet unit bacterial culture was negative. none of the reactions occurred in cardiovascular surgery patients. patients were more likely to experience reactions if they had previous transfusion history (odd ratio . , p = . ). the active hemovigilance plan is a valid and feasible method to collect epidemiological data on transfusion safety. the risk profile of ip transfusions appears favorable. quality of theraflex mb-plasma during storage and treatment s reichenberg* and n mÜller † *maco pharma international gmbh, langen, † inst. for transfusion medicine, essen, germany background: although in the last decades thanks to the implementation of several methods like donor selection and testing procedures the risk of virus transmission from plasma has decreased, infection of patients still exists. additionally new viruses like west nile virus enter the transfusion chain. therefore, the treatment of therapeutic plasma with methylene blue (mb) is a technique used in several european countries for pathogen inactivation. macopharma has developed the proprietary theraflex mb-plasma bag system including a mb pill and a final mb filtration step. aims: aim of the study is to show the quality of the mb plasma during the preparation procedure and during storage using the theraflex system. methods: for the preparation process every single step was evaluated using single donor plasma units. for the evaluation of the plasma factors ml were drawn at different stages (before treatment, after plasma filtration with plas , after dissolution of the mb pill, after illumination, after treatment). because the sample volume for single sample measurements would be too low the samples were pooled after drawing and measured for the specified factors. six samples of each stage were pooled at three days. a whole panel of plasma factors was measured for the resulting three pools. global tests: quick, inr, aptt, thrombin time coagulation factors: fibrinogen, factor ii, factor v, factor viii:c, factor ix, factor x, factor xi inhibitors: at iii, protein c, protein s fibrinolysis: plasmin inhibitor, alpha -antitrypsin complement: ch activation: tat, factor xiia, d-dimer stability data were generated using three plasma pools. six plasmas were pooled and afterwards divided into six aliquots. each was treated as single unit and then each was divided into six storage samples. the same plasma factors as for the manufacturing process were evaluated. results: a moderate reduction for some coagulation factors during the preparation was found in the illumination step but not in the other preparation stages. this was mainly fibrinogen ( . %), factor viii ( . %), and factor x ( . %). despite this reduction the values were within the ranges found in non-treated plasma. all investigated plasma factors remained stable during the investigated storage time. summary/conclusions: the investigation showed that plasma treated with the theraflex procedure showed slight reduction during treatment and no reduction during storage. all plasma factors remained within the threshold values. the treatment of therapeutic plasma with mb is a valid technique of pathogen inactivation. validation of intercept treatment of pooled platelets g santos, c silva, f pereira and g sousa lisbon regional blood centre, lisbon, portugal background: intercept blood system for platelets uses amotosalen hcl and uva light to inactivate viruses, bacteria, protozoa and leucocytes that may contaminate platelet products. aims: the purpose of the study was to assess the feasibility of introducing this technology in the routine of lisbon regional blood center (crsl) and validate the procedure in our center. material and methods: whole blood units of ml were collected from volunteer blood donors in quadruple top and bottom blood bags (optipure rc soft t& b baxter), kept in n-butanodiol plates; buffy coats with a volume of ml were obtained in the opipress ii and kept overnight at room temperature before pooling. five buffy coats were pooled with ml intersol using the octopus system intercept buffy coat pooling set with an integrated filter. the pools were treated using the intercept. samples were taken before treatment, after cad remotion, on days , and . the following tests were performed: platelet count, mean platelet volume, ph, swirling. results: all pools met the intercept guardbands. platelet yield pre inactivation was . ¥ ( . - . ¥ ; sd- . ). platelet pool volume was . ml (sd- . ). plasma % was within . % and . %. all pools had leucocytes within council of europe specifications. after photoinactivation the platelet concentrates had . ¥ (± . ). the average platelet loss was . ¥ . the ph was within specifications during all the storage period. conclusions: intercept treatment of pooled buffy coat platelets is feasible in the routine of crsl and in vitro parameters do not show significant changes, allowing us to proceed to clinical use. shown ip and conventional platelets (cp), stored for up to days, exhibit comparable hemostatic efficacy and safety. extension of platelet storage duration to days has the potential to improve platelet availability and reduce outdating and inventory shortages. clinical efficacy and safety of ip stored for days were investigated. methods: a randomized, controlled, single-center, crossover, noninferiority design (pilot) study evaluated efficacy and safety of buffy coat ip vs buffy coat cp, each stored for days. patients were randomized to receive one -day ip transfusion and one -day cp transfusion in random order. after each study transfusion, the hour platelet count, ci, and cci; time to next transfusion; bleeding response; transfusion reactions; and serious adverse events (saes) were assessed. the primary endpoint, -hour cci, was analyzed by a one-sided non-inferiority test for the per protocol population (patients with both transfusions and no major protocol deviations interfering with efficacy evaluation). the per protocol population included patients, randomized to the ip-cp sequence and to the cp-ip sequence. more patients received allogeneic stem cell transplant in the cp-ip sequence than the ip-cp sequence ( % vs %; p = . ). mean platelet dose (¥ e ) was . for ip and . for cp (p = . ). there was a significant period by treatment interaction (p = . ) at the . significance level; therefore, the first period only was also analyzed for the primary endpoint. including both treatment periods, mean (±sd) -hour cci (¥ e ) was . ± . for ip vs . ± . for cp. the mean paired difference for both sequences was . ¥ e (p = . by non-inferiority test; upper bound of the % confidence interval = . ). for the first period only, mean -hour cci (¥ e ) was . ± . for ip vs . ± . for cp) the mean paired difference for the first period sequences was . ¥ e (p = . by non-inferiority test; upper bound of the % confidence interval = . ). the non-inferiority margin for the study was . ¥ e for mean treatment difference in cci (cp-ip). median time to next transfusion was h for ip vs h for cp following the first transfusion (p = . log-rank test; data censored at days after transfusion) and h ip vs h cp after the second transfusion (p = . ). bleeding pre-or post-transfusion was uncommon, usually mucocutaneous, and grade or lower, and responded similarly to ip and cp. no significant transfusion reactions or saes were reported. in this double-blinded, two-treatment crossover study the primary endpoint regarding -hour cci was not met. however, transfusion with -day-old platelets treated by the intercept blood system showed only a marginally and probably clinically insignificantly lower -hour cci compared to -day-old conventional platelets. methods: new zealand white rabbits were transfused with syngeneic blood ( ml/kg), across a major antigen (hgd) mismatch. high anti-s- ab titers (≥ : ) were induced after repeated immunization (days , , , , ) with klh-(s- ) hapten (klhhapten) in complete freund's adjuvant. ab titers against srbc were determined by gel card agglutination, or by facscan with fitc-goat_anti-rabbit_igg. survival of infused rbc ( ml/kg) treated with different methods was assessed by rbc biotinylation. blood samples were taken , , , , and days after transfusion, analyzed using streptavidin_pe and facscan to determine the proportion of circulating biotinylated rbc. results: groups (g) of rabbits were transfused with control rabbit rbc (crbc; n = , g ), or o-srbc (n = , g ). no ab against o-srbc developed after biweekly transfusions over weeks in g rabbits. high ab titers to o-srbc could however be induced by klh-hapten immunization in a different group of animals (n = ; g ). transfused rabbits (g & g ) exhibited no change in hematocrit or body weight and maintained good vital signs. high titer anti-s- abs were then induced by klh-hapten immunization in rabbits from g (n = ) and g (n = ), and in a group (n = , g ) of naïve rabbits. non-immunized rabbits (g , n = ), and (g , n = ) were maintained on the biweekly transfusion schedule of crbc and o-srbc, respectively. all rabbits treated with klh-hapten developed comparably high ab titers. klh-hapten immunization did not affect the viability of crbc in g rabbits. transfusion of o-srbc demonstrated reduced viability in hyper-immune g rabbits, but not any of the g rabbits. g rabbits exposed to o-srbc transfusions prior to hyper-immunization with klh-hapten, had viability of o-srbc comparable to crbc, suggesting induction of immune tolerance by repeated exposure to o-srbc. after depletion of labeled o-srbc from circulation, g and g were transfused with m-srbc. viability of m-srbc in all g rabbits (hyper-immune or not) and the hyperimmune g rabbits was equivalent to crbc circulation in g rabbits. in pre-immunized rabbits with high titer anti-s- ab, o-srbc are cleared faster than control. in contrast, m-srbc survive normally in rabbits with high anti-s- ab titers. repeated transfusion of o-srbc does not result in alloimmunization of naive rabbits. the modified s- rbc process offers the potential for pathogen inactivation with elimination of immunoreactivity and retention of rbc viability. introduction: the bombay phenotype is extremely rare and characterized by complete absence of abh activity both on erythrocytes and in secretions. those individuals can produce anti-h, which is active over a wide thermal range. method: using liss indirect antiglobulin technique, the patient's serum showed + reaction by panel of eleven cells at room temperature phase as well as indirect phase while the auto reaction is negative. a cold adsorption using rabbit erythrocyte stroma was done to remove the cold antibodies from the serum; + reaction of an antibody was detected in the patient serum after five folds of rabbit erythrocyte stroma adsorption. introduction: immunohematology reference laboratory in kuwait central blood bank receives samples from all hospitals in kuwait both governmental and private sector. the laboratory performs the tests according to international standards and it is monitored by internal and external quality assessments on periodic basis. material and method: a tube and gel cards are two methods in the reference laboratory for antibody identification. the laboratory can identify the most commonly encountered clinically significant antibodies and investigates causes of positive direct antiglobulin test that occur mostly in autoimmune hemolytic anemia. there are facilities to phenotype most of rare red blood cell antigens. results: records of all patients investigated in the laboratory since the year are kept in computerized system that has patient's records. central blood bank has the potential to identify rare phenotypes such as kpb-, jsb-, lan-, bombay, rzr , rzr , r¢r¢, r¢r≤, r≤r≤, ge- , , and rare red blood cell antibodies such as high frequency antibodies anti-k, anti-ge , anti-h, anti-lan, anti-kpb, anti-jsb, anti-wrb, anti-ena, anti-csa and low frequency antibodies anti-kpa-, anti-jsa-, anti-dia, anti-lua, anti-cob as well as hightiter-low-avidity antibodies such as anti-chido. samples of rare red blood cells and rare serums are kept frozen either by glycerol or liquid nitrogen technique to be used for pre-transfusion compatibility testing and continuing educational program. purpose of the work: to present the substitution of the blood groups o, a, b, ab in abo blood group system and rh (d) blood group in rh (d) blood group system in the population in the gevgelija-valandovo region. material and methods: a retrospective analysis was done on the data of following the blood groups o, a, b, ab and d in the blood group system abo and rh in the gevgelija-valandovo region. the asked population are voluntary blood donors, candidates for drivers, patients, pregnant women and newborn children. the period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) was analysed. the examinations were done with two standard methods (on the plate and in tube), to define blood groups from the most represented blood group systems abo and rh in the population. tests were done with different series of commercial anti serum tests from domestic and foreign origin. results: totally . examinees were typified. with o blood group were . ( . %); with blood group a were . ( . %); b blood group . ( . %) and ab blood group were . ( . %) examinees. totally . ( . %) were d positive and . ( . %) were d negative. discussion: the given results from our examinations for the frequency of o, a, b, ab and rh (d) blood groups from abo and rh (d) blood group systems in the region gevgelija-valandovo show that the most present is the blood group a from abo blood group system . ( . %) and d blood group in rh system with . ( . ) form examined population. the results are in correlation with data from the literature for other european nations. introduction: the policy of our center is to transfuse all heamatologic multitransfused patients with their own rhesus and kell phenotype. in addition, thalassemic and young leukemic patients are being transfused with compatible phenotype of the most clinical important duffy and kidd systems while all the other patients receive blood compatible only with abo and rhesus system. nevertheless, it is observed a significant positivity of the indirect antiglobulin test, due to alloimmunization. aim of the study: in this study we tried to evaluate the prevalence of alloimmunization in patients of our region. the most frequent detectable alloantibody remains the anti-d, with high prevalence . % of anti-d in females versus . % in males, due to alloimmunization during the pregnancy. as a consequence, the high incidence of anti-d is not transfusion related and anti-e is evidenced to be the most frequent transfusion related alloantibody, followed by anti-kell. care must be taken in order to transfuse as more patients as possible with their own phenotype regarding, at least the most immunogenic antigens, like anti-e and anti-kell. severe hemolytic reaction due to anti-j k background: red blood cell alloantibodies directed against antigens of the kidd system are notorious for causing delayed hemolytic transfusion reactions. the antibodies are formed because of pregnancy or transfusion. blood donors with the red blood cell (rbc) phenotype jk(a-b-) are extremely rare in the white population and exhibit a frequency of less than . %. however, the rare phenotype jk(a-b-) is more common in polynesians ( . %). individuals with jk(a-b-) phenotypes typically form anti-jk with inseparable anti-jka and anti-jkb activity. some jk(a-b-) patients' sera may show an additional distinct anti-jka or anti-jkb component when examined with adsorption studies. case report: a years-old caucasian female with a negative antibody screen, no prior history of transfusion, presented with gastrorrhagia. it is reported four pregnancies with no history of haemolytic disease of the newborn (hdn). on admission, her haemoglobin was . g/dl. she was given units of crossmatchcompatible rbc. on day her haemoglobin was . g/dl, with a total bilirubin of . mg/dl and lactate dehydrogenase of u/l. on th day an unexpected fall in hb ( . g/dl) occurred with an increase of bilirubin to . mg/dl and of lactate dehydrogenase to u/l. a new blood sample obtained for antibody screening and additional crossmatches showed a pan-agglutination and incompatible crossmatch. anti-jk antibody high titer was detected in the plasma by gel-test using liss/coombs cards (id-diamed). the dat was negative and the antibody reacted equally with jk(a-b+), and jk(a-b+) panel cells (jka: / and jkb: / ). other alloantibodies could not excluded, because jk(a-b-) cells are not available. she was started with erythropoietin-a (epo), folic acid, fe iv and high dose intravenous immunoglobulin (ivig). the epo was discontinued after four week of therapy when the haemoglobin was g/dl. two months later her haemoglobin was . g/dl and anti-jk was present in the same titer. a year later her blood cell count was normal and the anti-jk was detected in a lessened titer ( / ). no additional distinct anti-jka or anti-jkb component was shown after two adsorptions at °c using carefully selected phenotyped red cell compatible with patient's rh, fy, mnss, lu, le system and jka(+) and jkb(-), but two additional alloantibodies anti-c and anti-e of low titer ( / ) were revealed. the rare anti-jk alloantibody found in this case displayed the erratic nature of many kidd system antibodies. although anti-jk may cause mild hemolytic disease of newborn, she did not have a history of hdn. our patient was sensitized to a kidd antigen during pregnancy, but showed no serologically detectable antibody until challenged with a massive transfusion following a gastrorrhagia. the use of epo and high dose intravenous immunoglobulin succeeded to avoid transfusion with incompatible rbc unit. background: differential warm adsorption is used in the investigation of patients with red cell autoantibodies for searching of underlying alloantibodies, but it is also useful in the detection of clinically significant alloantibodies in patients with alloantibodies to high frequency antigens such as k, kpb, lub and inb. this technique is especially useful in cases when patients when patient's phenotype cannot be identified due to recent transfusion. purpose: differential warm adsorption is performing on cases presented with an antibody reacting with all red cells of the panel and having a negative auto control test. in these cases, even rare cells panels, which allow the identification of a pan antibody, are available, other more common clinical significant antibodies cannot be excluded. methods and result: case . a years-old caucasian female with preexisting myeloproliferative disorder (polycythemia) presented with pancytopenia. anti-k was detected in the plasma. it is reported two pregnancies and no history of transfusion. the dat was negative and the plasma did not react with one k-cell present on the red cell panel in use. the anti-k specificity was confirmed using additional k-cells. the patient's red cell were group a, d+, k+, k-, c-, e-, fy(a-), s-, le(a-), kp(a-), cw-. she was transfused with two units rbc k-. ten days after the first transfusion the dat became positive and the one k-cell present on the red cell panel reacted with her plasma. two adsorptions were carried out at °c using carefully selected phenotyped red cell (compatible with patient's rh, fy, jk, mnss, lu, le system and k positive). an anti-fya was identified in the presence of ant-k. . an antik (titer / ) was suspected. because k-red cell was not present in the panel in use, adsorptions were carried out at °c using carefully selected phenotyped red cell (compatible with patient's rh, fy, jk, mnss, lu, le system and k positive). after the anti-k antibody was totally removed, no additional alloantibodies were revealed. conclusion: differential adsorption in cases with alloantibodies to high frequency antigens represents a useful application of the technique and helps in the identification of clinical significant antibodies present, allowing a more accurate decision for transfusion. evaluation of validity of the expired enzymetreated . % red cells in antibody identification gel tests using nacl cards p chalkia, s intzepeli, v avgoloupi, a tsoukala, e ntinopoulou and p didoudi ahepa hospital, thssaloniki, greece background: expired red blood cells of required phenotypic profile is often used to identify antibody specificities in patients with multiple anti-erythrocytes antibodies. accurate results depend on the integrity of the antigens. purpose: to validate the expired enzyme-treated . % red cells for use in antibody identification gel tests using nacl cards. the serum of nineteen patients with common specificities antibodies in rhesus, kell, duffy, kidd, and mnss systems tested with commercially prepared . % enzyme treated cells rbc panel (id-diamed). gel tests were performed according to the manufacturer's instructions on in-date rbc and simultaneously on rbc month to months past expiration. reactivity of the expired antigen positive and antigen cells was compared to in-date cells. results: twenty antibodies detected with enzyme treated red cells in neutral gel cards [d( ), c( ), e( ), k( ), cw( )] and were tested with enzyme treated red cells in use and rbc to months post expiration. seventeen antibodies tested with enzyme treated cells gave acceptable results with antigen positive cells to months post-expiration, except anti-k antibodies (negative with k positive cells - months post expiration). conclusion: most rbc antigens studied were detectable months after rbcs expiration date. tests with . % cells were valid in gel test (nacl/enzyme) for at least months after manufacturer assigned expiration date and may be helpful for complex identification studies. studies for more antigens specificities are needed to testify the validity of the expired enzyme-treated . % red cells. background: wr(a) is a low-incidence blood group antigen ( : ) in the caucasian population. despite that anti-wr(a) is a common antibody type, it may cause severe transfusion reactions, haemolytic disease of the new-born. anti-wr(a) may occur as an autoantibody or arise without immune stimulus. we report a case of a naturally occurring anti-wr(a) antibody. case report, methods and results: -year-old non-transfused male patient with acute pancreatitis and severe anaemia had been transferred to surgery from a county hospital. the serological status identified by their blood bank was: b rhd positive, with anti-wr(a) antibody in the serum (cellbind card method). our results: the patient's cells were group b rhd positive (microplate method), dat negative (tube and gel test method). the antibody identification showed positive antibody reaction with all enzyme treated test cells but negative reactions in liss iat (tube test) and gel iat (scangel and diamed). discussion: our routine tests for antibody detection didn't detect any specific antibody in patient's serum. he was transfused several units of blood, that was wr(a) negative and showed negative crossmatch reactions. the patient had no transfusion reactions. days after the transfusion anti-wr(a) specificity was confirmed in the serum with cellbind test. only few test cell panels contain wr (a) positive cells, which are usually not present in commercial screening cells. in our case the cross-match was only performed for this patient because of the detected nonspecific antibody reaction in enzyme. the risk of transfusion reactions caused by rare antigens are particularly high in the type and screen cases. background: according to requirements of the french committee for accreditation (comité français pour l'accréditation cofrac, iso standards), it is essential to use validated and standardised methods in immunohematology. this imposes, among various requirements, the knowledge of metrological tolerances for all the techniques. aim: a multicentre study was carried out to define the maximal acceptable deviations concerning incubation temperature and time, volumes of patient plasma and of tests cells for antibody screening using indirect antiglobulin test (iat) in filtration technique. the antibody screenings were performed manually in blood centres using different filtration systems: id diamed, biovue ortho and scangel biorad, the same tests cells, a standard ng/ml anti rh (provided by cnrgs), a positive control anti kel and a negative control. all equipment used (oven, chronometer, pipettes) were calibrated according to cofrac standards. each antibody sample was tested under the following combined conditions ( tests/sample): results: all the tests of antibody screenings from the multiples combinations of the above parameters gave the same results with a + intensity agglutination for positive samples and the absence of agglutination for the negative control. conclusion: this study allowed us to define a range of tolerance for critical physical parameters involved in the antibody screening in iat using commercial filtration systems maryvonne. the authors present a retrospective study involving blood donors from the university hospital of coimbra during the year . the incidence of weak d and rh (d) phenotype was determined in individuals who were rh (d) negative. the ab and rh(d) blood grouping was performed using a column gel agglutination card (diamed). the rh (d) typing was done using a anti-d polyclonal and a anti-d monoclonal antibodies. all donors that gave negative or poor agglutination results were tested for weak d with an indirect antiglobulin test, with anti-igg (gel matrix card) plus anti-d serum (diamed). within our target group of blood donors the rh (d) negative represented . % of the total sample. we also describe ab , rh(d) phenotype (c, c, d, e, e) group frequencies and establish reliable estimates frequency for weak d and rhesus haplotypes. the background: in s and s several authors tried to assess the relationship between the number od igg molecules per rbc and in vivo haemolysis, but determinations usually concerned small groups of tested patients. some of the investigators suggested that the number of igg autoantibody molecules per rbc was a major determinant of the severity of the haemolysis, whereas others found aiha patients with severe haemolysis and undetectable autoantibodies. aim: presentation of our experience with the quantitative elat performed on a large group of aiha patients during long-term observation. material and methods: six hundred fifty eight blood samples from warm-type aiha patients were randomly tested for the number of igg molecules per rbc. eighty six of the patients were tested periodically from to times at one-month intervals. autoantibodies on rbcs were detected by the direct antiglobulin test (microcolumn technology) and measured by the enzyme-linked antiglobulin test (elat). results: in about / of tested samples the number of igg molecules per rbc was small (< ) and the laboratory signs of haemolysis were present in . % of them as well as in . % samples with moderately coated red cells ( - igg/rbc). the large number of igg molecules per rbc (> ) was significantly associated with high frequency ( . %) of severe haemolysis and it was also associated with presence of multiple igg subclasses on rbcs and c d. in % of patients tested periodically, the number of igg molecules per rbc decreased and it significantly correlated with improvement of haemolysis parameters. in % of aiha patients the number of igg fluctuated and it was a poor prognostic factor. conclusion: in aiha patients the dynamics of the changing number of igg autoantibody molecules per rbc is a more helpful diagnostic and prognostic parameter than the number of igg molecules per rbc evaluated in one test. -b+) , -h-negative (using the anti-h lectin). antibody work-up showed a positive antibody screen (liss and peg-tube methods) reacting + with o rbcs at all phases and + with a rbcs. the direct antiglobulin test (dat) was positive with polyspecific ahg as well as anti-c b,-c d (table ) . prewarming of test system did not change the reactivity ( + at antiglobulin phase). a treatment with dithiothreitol (dtt) was performed and abolished all reactivity of the serum ( table ). autoabsorption of the patient's plasma was performed. the absorbed plasma showed a decrease in reactivity from + to + when tested with o red cells, as well as a significant reduction in antibody titer from : to : tested at immediate spin (table ). the patient remained crossmatch incompatible with o and a rbcs, but was compatible with oh rbcs. summary: we report an unusually strong igm anti-h antibody in this patient, who may require oh phenotype units. the patient is not a para-bombay since her red cells type strongly as group a. the cause for the auto-anti-h remains unknown at this time. if a thermal amplitude test shows that the antibody appears to be clinically significant the patient should receive h-units if transfusion is required. introduction: fetomaternal haemorrhage may determine an alloimmunization, in fact the transplacental passage of antibodies may cause the haemolytic disease of newborn. for this reason, in pregnant women, a screening for irregular antibodies research is routinely performed. however the indirect antiglobulin test (iat) may result falsely positive or negative for various causes, as operative mistakes or low specificity/sensitivity of the used techniques. aim of the study. in this study we have retrospectively evaluated the real incidence of alloimmunizations occurred in women screened by private laboratories. methods: we have studied . women, - years old, resulted iat positive at the first screening and successively assisted by our two hospitals. all women were re-tested, using gel-agglutination technique, for both direct antiglobulin test and iat. results: a positive iat was confirmed only in cases; moreover a rbc autoimmunization was found in women. anti-d ( cases), e ( ), c ( ), k ( ), c ( ), s ( ), d + jka ( ), d + s + e ( ), d + c + k ( ), m ( ), c + e ( ), d + c + g ( ) were the identified alloantibody specificities. anti-s, -e, -k, -c and -jka were the specificities in autoimmunized women. conclusion: in conclusion, a real alloimmunization is occurred only in . % of screened women, while in the remaining cases iat resulted falsely positive: this observation forces us to affirm that, in order to minimize errors and alarmisms, the screening for antibody research in pregnant women must be performed only by immunohematology qualified center. background: one of the problems of the rbc transfusion is the alloimmunisation and the delayed haemolytic reactions (dhtr). besides rhesus and kell systems the antibodies against kidd antigens cause both dhtr and difficulties in their detection. aim and methods: the exact recording of all blood units according to abo rhesus kell and kidd systems. the abo-rh-kell systems are identified through automated microcolumn method (autovue, ortho), while kidd antigens are identified manually using microcolumn gel (diamed). results: the percentage of jka+ and jkb+ found in our department ( . %) and ( %) respectively is similar to that of the caucasian population. conclusions: given the fact that there is lack of available freezing rbc system in greece, detailed recording of all units to the above antigenic systems can be proved extremely useful under circumstances of incompatibility. in the latter case suitable donors can be called and cover the shortage. the identification of all antigentic systems of the donated rbc units is underway. background: in many countries transfusion recipients are currently typed and transfused d-positive, if their red cells are agglutinated by igm monoclonal anti-d that do not react with dvi. the transfusion strategy in weak d patients is not clear defined and it depends on the chosen monoclonal reagents and methods. patients who are carrying dw types , and were prone to develop anti-d. aim: the aim of this pilot study was to estimate capability of commercially available monoclonal anti-d reagents to recognize this weak d types as rhd positive. material and methods: edta anticoagulant blood samples were collected from blood donors, previously typed as weak d positive by indirect antiglobulin test. molecular genotyping of rhd gene and weak d alleles by cde-ssp and d weak-ssp kits (inno-train, germany) were performed. direct agglutination was tested in a tubes and microplates using the following antibodies: rum- , th- , ms- (bioscot/serologicals) and d e / - (immucor). results: out of samples molecular typing results were as follows: in samples dw were not determined, in samples, weak d type ; weak d type ; weak d type , weak d type ; weak d type and weak d type were determined. by all monoclonal reagents % weak d type , % weak d type , % weak d type and % weak d type negative results were given. by all monoclonal reagents weak d type and weak d type positive results were given. conclusion: according to weak d types, which were known to be at risk for anti-d immunization further advances may be brought by improved patient's monoclonal typing reagents with a low and donor's monoclonal typing reagents with high affinity for weak d type , type and type . such improved typing strategies with novel reagents would enhance the transfusion safety. background: vel is a high-incidence antigen found in > % of the population. anti-vel can be igm or igg and reacts optimally at iat, although it can also react at immediate spin and c. anti-vel may or may not cause severe hemolytic transfusion reactions and mild to severe hdn. autoanti-vel has also been reported. the aabb technical manual th edition states that the vel antigen is unaffected by protease and sulfhydryl treatment. we have reason to believe that sulfhydryl treatment may have an effect on the vel antigen as evidenced by a recently referred case. case report: a year-old caucasian female presented with symptoms of anemia and renal vascular hypotension. transfusion history indicated multiple red cell transfusions in . according to the patient, previous attempts to locate compatible units were unsuccessful. the case was referred to our laboratory. the patient's red cells (rbcs) typed as group o, d+ with a negative dat. the serological picture revealed an antibody reacting + - + s at c/liss, as well as at the antiglobulin phase. the antibody reacted with all rbcs tested and the autocontrol was negative. further characterization of the antibody showed similar reactivity using enzyme-treated rbcs ( . % ficin) and no reactivity using . m dithiothreitol-(dtt)treated rbcs. a high incidence negative red cell panel (untreated) was selected that lacked antigens reported to be destroyed by dtt. the antibody reacted with all rbcs tested. additional rbcs were tested that lacked high-incidence antigens, including vel. the antibody did not react with four vel-rbcs tested using liss and peg methods. the patient's rbcs typed as vel-negative. all other clinically significant antibodies were ruled out using vel-or dtt-treated rbcs. based on the unusual reactivity demonstrated by the anti-vel, we tested different examples of anti-vel (frozen in our rare sera inventory) against two sets of known vel+ and vel-rbcs. one rbc set was dtt-treated; the other set was tested neat. liss enhancement was used to test both sets. one of the antisera failed to react with the positive control and one reacted with the negative control. both were disqualified from the study. four of ten remaining antisera demonstrated a decrease in reactivity > grade, between the neat and the dtt-treated rbcs. the remaining six antisera showed no change in reactivity. conclusion: contrary to the statement in the aabb technical manual, we discovered that sulfhydryl treatment ( . m dtttreatment) can have an effect on the vel antigen. our experience has demonstrated that in some cases anti-vel may not react or may show reduced reactivity when tested with dtt-treated rbcs. therefore, the presence of anti-vel should not be ruled out if negative reactivity with dtt-treated rbcs is encountered. additionally, dtt treatment may be a useful tool obtaining rule-outs of other clinically significant antibodies in the presence of anti-vel. additional data is needed to confirm these findings. but with no identified specific antibodies were investigated by repeated screening/crossmatch, papainized panel identification, hla antibody screening by lymphocytotoxicity test (lct) and elisa in some cases. patients' age, sex, department, diagnosis, previous transfusions/pregnancies, techniques, reactions' strength, number of positive cells, urgency, subsequent antibody tests, identification and lct were noted. antibody tests were performed: at pretransfusion testing (pt) by liss-coombs (diamed) and at blood grouping (bg) by biovue polyspecific (ortho) microcolumns -manually in urgency and routinely by sampler iif (diamed) and mitis (ortho) systems. results: investigated reactivity was recorded in samples from patients; ( . %) patients had > episode. these findings comprised . % of unexpected results found at pt and bg. incidences were . % at routine and . % at urgent bg ( and bgs, respectively), and . % both at routine and urgent pt ( and pts, respectively). . % patients were female, . % over , but . % < years, coming mostly from surgery ( . %), internal medicine ( . %), hematology ( . %), ginecology ( . %), cardiac diseases ( . %) and cardiac surgery ( . % patients). frequent diagnosis were solid tumors ( . %), cardiac diseases ( . %), hematologic malignancies ( . %), uraemia ( . %), orthopedic surgery ( . %) and hepatic diseases ( . % patients). . % patients were previously transfused, with only . % patients proved as not transfused or pregnant. subsequently positive antibody test during the study had . % tested patients. at pt positive crossmatch was found in . %, antibody screening in . % and both tests in . % cases. majority of reactions were ' +' ( % at pt and . % at bg); reactions ' +' or ' +' were found in only . % cases at pt, compared to % at bg. one crossmatch only was positive in . % positive crossmatches, with / patients having > crossmatched unit. ahg identification was positive in . % tested patients; in % of them papainized panel was also positive. lymphocytotoxic antibodies were found in . % tested patients; . % ( %- %) of lymphocytes were reactive. finally, the cause of reactivity in antibody tests was determined as 'laboratory mistake' in . %, hla lymphocytotoxic antibodies in . %, 'igg antibodies of unknown specificity' in . % (hla noncytotoxic antibodies in / elisa tested samples!), contaminated sample in . %, anti-bga in . %, non-specific cold antibodies in . %, subsequently recognized specific antibodies in . % ( lua, m, kpa, yka), non-specific autoantibodies in . %, carry-over of dat-positive cells and antibody to reagent in . % cases each, while in . % cases antibody screening and in . % cases crossmatch was repeatedly positive without confirmation in panels. discussion: after introducing of sensitive microcolumns, positive antibody tests without detectable specific antibodies require significant laboratory activities, particularly in older patients with malignancies or surgery. such reactivity was frequently caused by laboratory mistake, but often hla and sometimes specific antibodies were later recognized, or reactivity continued without confirmation in panels. relationships that may be helpful are further discussed in abstract part ii. results: significant differences (p < . ) and relationships of interest were noted. sex. in female vs male patients frequent features were: crossmatch as only reactivity at pt ( . % vs . %), positive lct ( . % vs . %), lymphocytotoxic hla antibodies (lytxab) ( . % vs . %) and reactivity 'positive screening, negative panels' ( . % vs . %); in males non-specific cold antibodies ( . % vs . %) and antibodies to reagents ( . % vs ) were noted. age. in patients > vs < reactivity was often found at pt ( . % vs . %), caused by lytxab ( . % vs . %), anti-bga ( . % vs . %) or 'positive crossmatch, negative panels' ( . % vs ), but rarely by laboratory mistake ( . % vs . %) or later recognized antibody ( of patients). subsequent antibody tests: tests were subsequently positive more often if reactivity was found at pt ( . % vs . % at bg), as positive antibody screening ( . % vs . % if positive crossmatch), with positive panels ( . % vs . % if negative). subsequent tests were positive in only . % patients with lytxab, % with anti-bga, of with antibodies to reagent and in no case with 'positive crossmatch, negative panels' . techniques. lct was positive in % and . % tested samples found at urgent and routine pt (diamed), vs at bg. all cases due to lytxab, of anti-bga and of 'positive antibody screening, negative panels' were found by diamed. at bg (ortho) . % cold antibodies and . % laboratory mistakes were found. positive antibody test: identification was negative in . % screening-only cases; % of them were caused by laboratory mistake. lytxab were found in . % crossmatch-only cases; . % reactivities caused by lytxab were crossmatch-only. identification. ahg panel was positive in % cases with lytxab (in with papainized panel) and often due to 'igg antibodies of unknown specificity' ( . %), anti-bga ( . %), contaminated sample ( . %), but also to later recognized specific antibody ( . % cases). strength of reaction: laboratory mistake was noted in . % of 'w', . % of ' +', . % of ' +' and . % of ' + and +' antibody screenings (ns). diagnosis. in patients with solid and hematologic malignancy reactivity was often found at pt ( % and . % of patients, respectively), due to positive crossmatch ( % and %; and . % patients with liver and cardiac diseases) and caused by lytxab ( . % and . %) or 'crossmatch/screening positive, panels negative' ( . % patients with solid tumors). in patients with liver and cardiac diseases reactivity was often found at bg ( . % and . % of patients), due to laboratory mistake ( % and %) or cold antibodies ( . % and %), respectively. discussion: features of non-specific reactivity depended on sex, age, positive antibody test, diagnosis and, moreover, used techniques, sometimes in very distinctive manner. this analysis might be of considerable help in planning of laboratory tests, but also in quick analysis of unexpected results and choice of further testing, particularly in urgent situations. background: worldwide screen and type is a very usual method for pre-transfusional testing. the ultimate objective is to prevent not only the clinically expressed delayed hemolytic transfusion reactions but also the serologically revealed ones. aim: the aim of this study was to determine the frequency of red blood cell (rbc) alloantibodies in patients undergoing cardiac surgery or cardiac procedure, during the pre-transfusion screening. materials and methods: blood samples of patients ( male and female) were evaluated. the mean age of the patients was years. pre-transfusion samples were examined for clinically significant alloantibodies, using antibody screening with gel test (liss -enzyme). in case of a positive result, identification was performed (panel with autologous control). in addition, the serological testing included cold agglutinins´ detection (tube test), as well as titration (tube test) and identification (gel test) in case of a positive result. when the result was marginal ( / ) a new test was carried out after a seven days period. in the presence of a positive autologous control or an autoantibody, samples were examined with direct antiglobulin test (dat). results: alloantibodies were detected in patients with the incidence of . %. antibodies were registered more frequently in females ( / , . %) than in males ( / , . %). patients ( . %) developed single antibody with anti-kell being the most frequent. the incidence and the specificity of the detected antibodies are summarized in the following table (table ). in patients ( . %) multiple antibodies were detected, with most frequent the anti-d and anti-c combination. patients ( . %) were dat positive. autoantibodies were found in patients ( . %), all of which had specificity to rhesus system. cold agglutinins were positive in patients ( . %). no specificity could be assigned in patients ( . %), while in patients ( . %) non specific reactions in enzyme treated rbcs, were observed. one patient developed delayed haemolytic reaction days post-transfusion, due to anti-jka. the antibody, however, was not detected in the pretransfusion sample re-testing. the frequency of the pre-transfusion detection of red blood cell alloantibodies in our center, was . %. the most frequently identified were the anti-kell and anti-rh. the high rates of unidentifiable antibodies and non specific reactions in enzyme treated rbcs are probably attributed to the kind of medication that most of these patients receive, as well as to the degree of inflammatory process which usually accompanies such diseases. the high frequency of unidentifiable antibodies indicates that a larger and more complex erythrocyte panel would be useful for routine testing. the routine pre-transfusion screening for alloantibodies probably assures the prevention of dhtrs and provides sufficient time for blood selection for transfusion. introduction: in the united kingdom, about % of women form red cell allo-antibodies in pregnancy and . % of all pregnant women produce anti-c. before the introduction of prophylactic anti-d, it was reported that % of the total haemolytic disease of the newborn (hdn) cases were due to anti-c. currently, cases of hdn due to anti-c are half as frequent as anti-d and % of the uk population are rhc negative. we present two unusual cases of pregnant women who are d and c negative and have anti-c and anti-d detected in their serum. case studies and results: case : a -year-old asian woman had three previous uneventful pregnancies. in her th pregnancy she presented with miscarriage at weeks gestation. she was group b, d and c negative. her serum contained anti-c and anti-d. anti-d was detected by liss tube iat and anti-c was only detected by manual polybrene technique ( . iu/ml by quantification using r r cells). in a th pregnancy, no antibodies were detected until weeks gestation when this patient presented in early labour. anti-c was then detected by two-stage papain technique only as well as anti-d. case : a -year-old asian woman had a positive antibody screen post caesarean section in jan . no antibody had been detected during the pregnancy. standard prophylactic anti-d was given at and weeks gestation as this patient was d neg. anti-c and anti-d were confirmed in her serum. the anti-c level was . iu/ml using rr cells and the anti-d level was < . iu/ml using r r cells (prophylactic anti-d ig). she was phenotyped as o r¢r¢. at delivery the baby was found to have a negative dat and was phenotyped as r¢r. discussion: cde/cde (r¢r¢) is an uncommon phenotype in the uk population with a frequency of / . in routine antenatal testing, abo/d grouping is only performed for pregnant women at booking and weeks gestation according to bcsh guidelines. full rh phenotyping is not carried out unless the pregnant women has a positive antibody screen. in routine testing of the above cases, this extremely rare phenotype is missed. prophylactic anti-d was given to both patients and immunisation due to anti-d was prevented. there is currently no prophylactic regime developed to prevent anti-c allo-immunisation by the fetus in pregnancy. antenatal management of patients with anti-c and anti-d during pregnancy can be problematic: (i), problem in antibody identification; (ii) monitoring of antibody level (i.e. quantitation by auto analyser for anti-c and anti-d) with two different cells and ( ) provision of blood during pregnancy, at labour and post delivery for both mother and newborn. study on the frequency of red cell phenotypes (e.g. duffy, kidd and mns blood group system) in our local population l leou, yf wong, mbc koh and d teo health sciences authority, singapore, singapore background: the frequency of various red cell antigens in the caucasian population has been well studied. to date, the frequency of these antigens in the local population composed of a multi-racial mixture of chinese, malay, indian and others is still unclear, especially in the malays with paucity of data in the literature. aims: to investigate the frequency of clinically significant red cell antigens duffy, kidd and mns across the local ethnic groups. to investigate the occurrence of rare phenotypes. to be aware of these rare phenotypes so as to facilitate planning of blood inventories and supplies. typing for the duffy, kidd and ss antigen on blood donors was performed using monoclonal as well as polyclonal anti-sera by manual tube method. a total of blood donor samples were tested using specific anti-sera that will agglutinate red blood cells that have the corresponding antigen. agglutination is demonstrated by the indirect antiglobulin technique. result and discussion: table -a higher frequency of the fy(a+b-) phenotype is seen in chinese, malay and others in contrast to the indian and caucasian population. the clinically significant allo-antibody anti-fya is rarer in our local population. it occurs predominantly in malays and indians and usually in combination with other antibodies. it means that provision of antigen negative blood may be difficult. table -all groups show similarity of distribution of the kidd phenotype with the caucasians and distinct from the american blacks. the jk(a+b-) and jk(a+b+) phenotypes are relatively equal in frequency and there should be no problem looking for such a phenotype in the local population. table -the s-s+ phenotype is most common amongst all races. the indians are more similar to the caucasians with a relatively high frequency of s+s+ phenotype. the chinese and malay distribution are unique with > % being s+. conclusion: there is a unique distribution of red cell antigen groups in the races and the data on malays is especially useful. this data will allow the national blood service in its inventory planning and the potential difficulties of providing antigen negative products due to clinically significant allo-antibodies. miltenberger phenotypes among taiwanese table . conjointly, in order to obtain the frequency of mi.v phenotype, we screened samples among with anti-hil and four additional cases of mi.v were found. conclusion: in this study significant miltenberger polymorphism was seen among the taiwanese population. besides previously described mi.iii phenotype ( . %), there were also mi.i/ii phenotype ( . %), mi.v phenotype ( . %), mi.vi phenotype ( . %), mi.x phenotype ( . %), and most interestingly two miltenberger related not yet classified variants ( %). related variant a ( . %) was phenotypes as mia+, anek+ and hil+. related variant b ( . %) was phenotyped as mia+, anek+. interestingly, both variants were mur-(negative). the total estimated frequency of miltenberger variants in taiwanese population (including related variants a and b) is therefore . % (table ). the discovery of unclassified variants (most likely not yet described in the literature) is of great interest in the field of immunohaematology and warrant further molecular genetic study. introduction: the use of column technologies for the detection of rbc antibodies improved significantly the screen test sensitivity. each column-based method has its advantages and disadvantages. aim: to compare antibody detection by two column agglutination tests; the fully automated ortho auto vue tm method and the manual diamedᮀ id-micro typing system. material and methods: during the study period patient samples were screened, of the positive results were evaluated. blood samples with positive screen tests by the ortho auto vue tm method (av) performed with % cell suspension, and patient samples with antibodies identified by the diamedᮀ system (dm), were reciprocally re-screened, respectively. positive samples were tested by diamed panels for antibody identification. sera samples were divided into categories according to antibody specificity; . rh system antibodies (n = ), . clinically significant non rh system antibodies (n = ), . clinically non significant antibodies (n = ), . auto antibodies (n = ), . not identified (ni) antibodies (n = ), . negative screening results by the diamed technique (n = ). the categories were divided, according to the intensity of agglutination in the screen test, into those exhibiting stronger reactions by the auto vue (av > dm), those exhibiting equal strength reactions (av = dm) and those with weaker reactions by the auto vue (av < dm). statistical analysis was carried out using the wilcoxon signed ranks matched-pairs test. results: a total of samples were compared, . % of them gave stronger reactions by av, . % gave equal reaction strength and . % of them gave weaker reactions by av. positive screen tests by av only were detected in samples, no specific antibodies were identified. in contrast to that, positive screen tests by dm only were detected in samples, were rh system related, kell system related and not identified, results are summarized in the table. discussion and summary: the antibodies detected by dm only, are anti-d and antibodies directed to low frequency antigens. the failure of av to detect rh system antibodies is further sustained by the fact that statistically significant weaker reactions for this antibody system were obtained by av technique. recently ortho-clinical diagnostics modified the screening reagent red blood cells to . % suspension, in order to improve the sensitivity of the method (unpublished data). the possible explanation for the failure to detect low frequency antibodies is that ortho screen cells do not consistently carry the low frequency antigens cw and kpa. positive screen tests detected by av only, can be explained either by the fact that antibody identification was carried out on dm panels, or these are false positive reactions. in order to clarify this question we recently repeated these av only positive samples by the manual ortho bio vue technique. preliminary results indicate that no specific antibodies were detected. it can be assumed that these results are false positive. further study of this issue is required. aim of the study: we have detected blood donor with rohar variant which was mistaken as d-and his donations used for d-recipients. we tested these patients in order to evaluate possible anti-d or anti-lfa immunization. methods: rohar variant was tested serologically (commercial and workshop moabs) and on dna level (pcr-ssp). involved recipients were tested by diamed column agglutination (gliat with normal and enzyme treated rbcs) with commercial rbcs and with rh and rh rbcs. results: rohar variant was confirmed on phenotype and genotype levels. in four d-and two d+ recipients of rohar positive units no anti-d not anti-rh or -rh antibodies were detected. in one case anti-le(a) antibody was found. conclusion: in our cases massive exposition of recipients (whole transfusion unit) by rohar red cells did not lead to production of detectable anti-d or anti-lfa. the immunogenic potential of this variant seems to be low. unusual ab grouping discrepancy -inhibition of anti-b reagent by isolated increase of plasmatic b substance in a patient with group ab and pancreatic cancer m pisacka*, k petrtylova † , m kralova* and h flidrova* *uhkt, prague , † blood bank, faculty hospital m, prague , czech republic introduction: in rare pathological conditions excess amount of blood-group specific substances can be observed and can cause neutralization of grouping reagents. changes in abh and related histo-blood group antigens in malignant tissues were described but there are few information about similar changes in secreted bloodgroup specific substances. aim of the study: we describe a case of isolated increase of b group substance in plasma of a group ab patient with pancreatic cancer. methods: ab grouping was performed with registered immucor reagents (immuclone: anti-a birma , anti-b lb ) by slide and tube tests. neutralizing effect was quantified by (i) inhibition od anti-b reaction by titrated patient's serum; and (ii) inhibition of titrated anti-a and anti-b reagents by patient's serum, compared to ab serum of a healthy donor. results: slide test: unwashed rbcs: group a, washed rbcs: ab. tube test (washed rbcs): ab. titrated patient's serum when added in aliquot to anti-b reagent inhibited agglutination up to titre . titration of reagents /+ aliquot of serum added/: anti-a: titre (both patient's serum and control); anti-b + patient's serum: titre , anti-b + control: titre . conclusion: pancreas is known as rich source of blood group specific substances. malignant transformation is known to be associated with either loss or re-expression of cell-bound abh antigens. reported excessive increase of b substance in group ab patient could be either due to loss of a-transferase activity in malignant pancreas cells or isolated increase of b-transferase activity. further studies on larger groups of pancreatic cancer patients will help to understand this observation. weakened abh reactions of unwashed rbcs could be of diagnostic importance, because in other case this observation preceded several years the pancreatic cancer clinical manifestation. implementation of the autovue innova, an upgraded column agglutination technology (cat) for pre-transfusion testing in a large blood establishment c politis, k armyros, a antypas, v malamou and p katsea g. gennimatas general hospital, athens, greece objective: automated cat testing in a blood transfusion laboratory aims at standardization and savings in labour as well as reagents. a new technology is evaluated in comparison to standard methods. materials and methods: we used column agglutination technology with the innova autovue system, ortho, ratrian n.j. according to the manufacturers this system provides priority to the management of the stat samples while the random access feature of the system enhances the system throughput. it provides an extended test menu as well as automated antibody identification with the red cells panels. the autovue innova system supports the bi-directional communication with the lis interface for all the tests including the crossmatches and it provides a continuous traceability and notifying of the instrument's status concerning either the required and available resources or the proper function of the system's submodules. in this study we performed tests including forward and reverse abo group, rh type and phenotype and kell in randomly selected blood donors, as well tests in haematological patients for antibody screening using an untreated three-cell panel and autocontrol in the indirect antiglobulin test (iat). the results and the time performance (specimen handing, operation of testing and recording of results) were compared with those obtained by the semiautomatic id-diamed gel agglutination microtyping system and by standard manual methods. results: test results showed % agreement between all three methods. samples were tested per min with the autovue innova, compared to min required for the same number of tests performed with manual testing and min with the semi-automated method. the technical execution was easy with the autovue innova procedure and it appears that the consumption of testing reagents is smaller with the automated system comparing with the other methods. computerization of the test results with the autovue innova provides an important advantage in record keeping in the blood establishment. conclusion: standardization of sample collection and tests performance in pre-transfusion testing, as well as computerized records and time saving are advantages offered by the autovue innova, a new automated column agglutination technology, comparing with a semi-automated and the classical manual methods. a heavy workload is expected to significantly decrease time performance. clearance of senescent erythrocytes in young and old individuals al racca, a ensinck, c cotorruelo, s garcÍa borrÁs, l racca and cs biondi universidad nacional de rosario, rosario, argentina introduction: after a lifespan of days, human red blood cells (rbc) are captured and phagocytized by monocytes/macrophages. the accumulation of autologous igg on rbc membrane provides a direct mechanism for the removal of senescent (se) rbc. an alternative pathway, immunoglobulin-independent, with participation of sialic acid, has been proposed. the physiological elimination of serbc might be modified by individual's age. aim of the study: to investigate in young and old individuals, the interaction between monocytes and different erythrocytes suspensions: serbc, rbc stored with or without serum and desialinized rbc. methods: healthy individuals blood samples ( - years old, n = and > years old, n = ) were studied. different suspensions from each sample were obtained: (i) se and young (y) rbc by differential centrifugation; (ii) rbc stored with its own serum (rbcs) and without serum (rbcws); and (iii) rbc desialinized with neuraminidase (ne) and tripsine (t). the suspensions were subjected to the erythrophagocytosis assay: peripheral blood monocytes were incubated with the different erythrocyte suspensions for h at °c. two hundred cells were analyzed to determine the percentage of active monocytes (am) with phagocytosed and adherent red cells. non sensitized rbc (nrbc) and ex vivo sensitized rbc (srbc) were used as negative and positive controls respectively. results: the% of am obtained with old individuals were: serbc: . + . , yrbc: . + . , rbcs: . + . , rbcws: . + . , nerbc: . + . , trbc: . + . , nrbc: . + . ; srbc: . + . . the values of am obtained with young individuals were: serbc: . + . , yrbc: . + . , rbcs: . + . , rbcws: . + . , nerbc: . + . , trbc: . + . . nrbc: . + . ; srbc: . + . . conclusions: no differences in the% of am were found when compared to positive and negative controls, indicating that this assay would not detect variations in the phagocytic activity of monocytes from young and old donors. the values of am with serbc were higher (p < . ) than those obtained with yrbc in both populations analysed. the rate of erythrophagocytosis with serbc in old individuals was significantly higher (p < . ) than that obtained in young donors. the increase observed may be due to agedependent changes of rbc that occur with human ageing. the% of am with rbcs were higher (p < . ) in old individuals. no modifications were observed with rbcws. the significant increase in the rate of erythrophagocytosis with serbc and rbcs show the involvement of autologous igg in the selective removal of erythrocytes. these values were higher in old individuals indicating that this process would increase in aged donors. the tripsine activity was not enough to modify the% am. the values of am obtained with neuraminidase treated rbc were higher than those observed with yrbc (p < . ). however these values were similar between young and old individuals, suggesting that the desialylation would not participate in the increased removal of erythrocytes observed in old donors. cell-cell adhesion is a crucial phenomenon for the relationship between the cell and its environment. therefore, the development of experimental methods to obtain quantitative parameters of cellular adhesion is important. erythrocytes are widely available and their membrane properties are well known, so these cells are used as an ideal model for studying the cellular interaction mechanisms. the study of the formation and break-up of receptor-ligand bonds in sheared erythrocyte suspensions is a subject of considerable importance in the blood circulation, where formation and break-up of blood cell aggregates occur in a variety of physiological and pathological conditions. the main two objectives of this work were to study the cellular adhesion phenomenon using erythrocyte adhesion mediated by monoclonal anti-a antibody as a model and to achieve quantitative values of the parameters involved in the intercellular binding and its possible relationship with cellular deformability parameters. agglutinates of two a erythrocytes (doublets) induced by specific monoclonal antibodies anti-a were used. adhesion energy was indirectly quantified by the study of doublet dissociation under the effect of a given shear stress using a controlled flow chamber system. the chamber was installed on the stage of an optical inverted microscope (union optical, magnification ¥) in such a way that the cover glass was the floor of the microchannel. a ccd (charge coupled device) camera was placed in the ocular tube of the microscope and connected to a digital image processor (ipplus system) to digitize, record and analyze microscopic images. the doublets were initially immobilized inside the chamber, and then put under different shear stress values by a controlled laminar flow during a definite time. in this way, a shear stress parallel to the contact surface between both cells was applied, observing that the upper cell detached progressively with time and also with a gradual rise of the shear stress. the sequential microscopical images were registered and digitally processed, measuring the geometrical dimensions that the cells acquire during the deformation process, and the dissociation of the antigen-antibody bond. digital image processing allows the analysis and the quantification of the red blood cells doublets dissociation phenomenon. these results show that, while the shear stress applied is raised, the contact area between both cells diminishes. the obtained parameters give important information that lead to the estimation of the value of adhesion energy between two red blood cells agglutinated by monoclonal antibodies. as consequence, they will allow the characterization of the antibodies used, since it would evaluate their association capacity with cellular antigens. glycophorins (gp) a, b and c are abundant transmembrane integral proteins in red blood cell (rbc). their highly glycosylated nature and high sialic acid content account for the net negative charge of mature rbc membrane, which is physiologically important because it impedes any tendency to stick together in the circulation. in this study, we have tested anti-gp specific mouse monoclonal antibodies (moab) as primary antibody to directly agglutinate rbc. fret technique has been developed to characterize the hemoagglutination based on the interaction of fluorophores (alexa tm, dio and dii) located in the rbc membrane or combined to secondary antibody directed against the primary agglutining moab. combined intensity (spectral) and lifetime (flim) imaging was used to discriminate the fret signal of molecules on their different lifetimes whereas their emission spectra overlap (alexa tm or dio/dii) as independent phenomena of the fluorophore concentration and photobleaching. furthermore, gp-cytoskeleton interactions were analyzed by d-fluorescence microscopy after lipid extraction with triton x- in red cell. all the antibody used was found to directly agglutinate the human rbc. in view of the fluorescence properties depicted in rbc for the pair of fluorophore alexa- tm (donor) and dii (acceptor), it may be expected that upon agglutination of rbc, effective fret should be observed. flim in dynamic-state provides a discrimination of molecules in their fluorescence lifetime, which allows to evaluate the underlying mechanism of energy transfer process in the agglutinated erythrocytes. the results demonstrate that's upon excitation at nm the flim-fret from alexa tm to dii for the anti-gpb moabs only with a lifetime distribution in the picosecond range. similarly, effective fret was not observed for the anti-gpa moabs. the contrast in measured lifetime image is a reliable indicator for spatial variations in donor-acceptor association. d-fluorescence microscopy images showed interactions between gpc or gpb and cytoskeleton and did not show interactions between gpa and cytoskeleton. all together, these results only revealed by fret-flim and d-fluorescence microscopy strongly support the importance of the specific reactivity with glycophorin a or b of agglutining moab. introduction: the frequency of alloimmunization to red blood cell antigens in transfused sickle cell patients can range from to %, but the development of autoantibodies is much less recognized and descried. aim of the study: in order to evaluate the autoantibody formation and observe the blood transfusion association, we analyzed the direct antiglobulin test (dat) as well as the antibody screening results in transfused sickle cell patients. methods: all the patients included in the study had received at least unit of red blood cell concentrate, on the majority of the cases matched for the c, c, e, e, k antigens. the transfusion range was - units. the dat performed was a polyspecific gel test. in cases of positive dat, was performed the monospecific gel test (igg, iga, igm, c c, c d) . in almost all of cases an acid glicin elution was performed and the eluate was tested against a red cell panel (liss/coombs and papain). an antibody screening by gel test (liss/coombs and papain) was performed in all the patients. the dat was positive in ( %) of the patients. in cases ( %), the dat was igg type, in case ( %) igg + c d and in case ( %) igg + c c + c d. the acid elution was performed in cases. the eluate was positive in cases ( %). in ( %), of the cases, autoantibodies were pointed out whose specificity were specificity public, anti-e (rh ), anti-c (rh ), anti-ce (rh ). in cases ( %) we found alloantibodies whose specificity were anti-e(rh ), anti-k(k ), anti-c (rh ) and anti-jka (jk ). in the cases ( %) no antibody was identified on the eluate and the cause of positive dat is unclear. we could correlate the positive dat with a presence of autoantibodies in ( . %) of the patients. of these, ( %) had a blood transfusion association. the global frequency of red cell alloimmunization in this set of patients was %. seventeen patients ( %) of the patient who had autoantibodies had also alloantibodies associated. conclusion: the mechanism by which erythrocyte antibodies form in association with blood transfusion are not well understood, but even though the medical literature indicates strong association with blood transfusion as well erythrocyte alloantibody formation, we could not find support for this association. the loss of splenic to sickle cell patients could be important because experimental studies suggest that the spleen is involved in the regulation of autoantibody formation. forward and reverse blood grouping with lateral flow based assays p schwind*, i aebischer*, k loester † and p monod* *medion diagnostics gmbh, duedingen, switzerland, † prisma diagnostika gmbh, berlin, germany background: recently, a lateral flow assay for simultaneous typing of abod, rhesus subgroups and kell with stable end-point and without a centrifugation step was presented (loester k, fleischhauer s, schwind p: lateral flow assay for simultaneous typing of of abo, rhesus subgroups and kell. vox sang , (suppl. ), ). in many countries, the determination of isoagglutinins in addition to the red cell antigens is mandatory for abo grouping. aims: to develop a lateral flow test for reverse grouping, supplementing the lateral flow typing assay. a lateral flow device was constructed with a separation membrane equipped in a cassette housing having distinct incubation wells, application zones and detection areas. microliters of % suspensions of reagent red cells for reverse grouping (reverse-cyte a , a , b, , medion diagnostics, switzerland) are mixed in each incubation well with microliters of plasma. the resulting suspensions are incubated for min, followed by the transfer of microliters each to the application zones, where migration starts immediately. results can be read after min in the detection areas. a positive result is recognized as a distinct red dot, a negative result is monitored by the absence of a dot. results: the plasmas of donors, previously determined for the respective blood groups and isoagglutinins by the tube technique, have been tested with this method. the results for both methods were in full agreement. conclusions: a simple, rapid and flexible lateral flow method for reverse grouping is presented, allowing now for the determination of forward and reverse typing in similar formats. both methods give results after min with stable end-points without the need of a centrifugation step and are easily applicable to non-laboratory environments. the performance of the autovuetm system for red cell antibody screening of blood donors during background: in israel every donation is tested for the presence of red cell antibodies (rbc abs). screening is performed on the autovuetm system, using ortho screening rbc since the year . aim: (i) to summarize the performance of the autovuetm system for rbc abs, during years ( ) ( ) ( ) ( ) ( ) . (ii) to evaluate if an initial low positive result, with two negative repeats, could be considered a negative result. methods and results: rbc abs screening was performed using igg cassettes. positive results were confirmed by diamed gel cards, with screening rbc, followed by diamed panels for abs identification. results: summary of the results is presented in the table. (i) in . % of , blood donations that were screened, during - , using the autovuetm system, a positive initial result for rbc abs was detected, which was confirmed in . % ( . % of the donations). an increased percentage of confirmed tests is noted, since , probably due to an improvement in the manufacturing of the cassettes by ortho. (ii) during the validation, samples with low positive results (agglutination degree of . ) were retested twice on the autovuetm. / ( %) gave negative results in both repeats. only / was confirmed positive and anti-m was identified by diamed gel test. the remaining samples had at least one positive repeat. / ( . %) of those samples were confirmed positive. summary: autovuetm can be used as a competent method for rbc abs screening, in blood services which require high thoughput automated systems. samples with a low positive agglutination, which were negative in two repeats, can be considered negative. retesting these samples on the autovuetm, can reduce the number of tests sent for confirmation and allow early release of blood components. rk tagi-zadeh*, aa karimov*, ar hasanov † , ly novruzova* and si donskov ‡ *hematology and transfusiology, baku, † blood transfusion centre, ganja, azerbaijan, † centre for hematology, moscow, russian federation background: the main method of treatment of severe homozygous thalassemia forms at the moment is still an anemia control with regular rbc transfusions. the use of adequate transfusion regime for these patients not only prolongs their lives but also promotes normal physical development of the children and improves the quality of their lives. however, necessity to do multiple transfusions increases a risk of post-transfusion reactions and complications due to alloimmunization to rbc antigens. in order to prevent posttransfusion reactions it is essential to know the frequency of blood group distribution in the region and then implement organizational procedures to enhance the transfusion services for these patients. objective: examine the distribution of rbc antigens among thalassemic patients and blood donors. methods: blood samples of homozygous betta-thalassemia patients (who stayed at the daytime inpatient wards of scientific research institute of hematology and transfusiology baku, azerbaijan) and blood donors of azeri nationality were examined. patients' blood samples were typed on rbc rh (c, c, d, e, e) and kell (k, k) antigens. gel test bio-rad (france) was used to detect rbc antigens. results: phenotyping of the patients' rbc rh antigens (d, c, c, e, e, cw) revealed that frequency of occurrence of the antigens in general was higher than in the donors. studying of rh phenotype distribution showed that the patients' ccdee ( . %) •• ccdee ( . %) phenotypes were twice as much higher than the occurrence of those in the donors ( % and . % respectively). phenotype ccdee occurs more frequently in the donors ( %), whereas it is significantly rare in the patients ( . %). the similar picture was observed in relation to ccdee and ccdee phenotypes, which occurred more frequently among donors ( . % and . %) than in thalassemic patients ( . % and . %). additionally, the results demonstrated that k antigen of the kell system was not detected in the thalassemic patients whereas k antigen was detected in all the patients. the same picture was observed with two other antigens of this system. thus among the patients typed on rbc antigens kpa antigen was detected in just one case whereas kpb was detected in the rest the patients. the results of the analysis showed that for thalassemic patients with phenotypes ccdee and ccdee it is easier to find compatible blood than for patients with phenotypes ccdee, ccdee and ccdee. furthermore, it is known, that some congenital diseases are genetically connected with the specific group systems, for example, the mcleod syndrome is genetically associated with the sharp suppression of the kell alloantigen expression (absence of gene kx). the fact of the discovered absence of antigen k in homozygous bthalassemic patients makes it possible to assume, that this group of patients suffer from scarcity along the kell system, like the scarcity in mcleod syndrome. all the mentioned above make it possible for us to conclude, that prior to blood transfusion to thalassemic patients phenotyping of rbc rh and kell antigens must be carried out. hyperhaemolysis in sickle cell disease due to complement activation. tessa thorp rci national blood service manchester uk tm thorp national blood service, manchester, uk introduction: sickle haemoglobin is caused by a genetic mutation in codon of the beta globin gene, resulting in the conversion of glutamic acid to valine. when critical amounts of polymer accumulate within the sickled erythrocyte cellular injury results. clinically sickle cell disease is characterised by chronic haemolysis and intermittent vaso-occlusion. mold et al. demonstrated that deoxygenation and sickling of erythrocytes is related to membrane phospholipid changes and these changes result in the activation of the alternative complement pathway. aim: the objective of this study was to measure the amount of c c and c d bound in vivo to red cells of homozygous and heterozygous sickle cell patients. these levels were then compared to 'normal' sickle negative blood donors. haemoglobin levels and red cell morphology were also examined for signs of active haemolysis. the hypothesis was that an increase in red cell bound complement in vivo could provide an indication of hyperhaemolysis syndrome is sickle patients. method: flow cytometric analysis using rabbit anti-c c or anti-c d and fitc labelled goat anti-rabbit was developed using a beckman epics xlmcl flow cytometer. control samples were prepared using a fruitstone buffer technique of complement coating. results: a total of heterozygous sickle patients and homozygous patients were analysed. of the homozygous patients analysed only one was undergoing a sickle crisis. a positive result was indicated if the mean trait or homozygous sample was coated with complement to a greater degree that the mean normal donor plus two standard deviations. the results obtained in this research project indicate an increase in c c levels bound to red cells of homozygous sickle patients in vivo. statistical analysis of results obtained suggest that there was no increase in c d levels in either sickle trait or homozygous sickle patients. conclusion: these findings support research carried out by mold et al. ( ) and are present in more than % of caucasian population. it has been reported that anti-chido and anti-rogers don't cause hemolitic reaction but may be responsible for life-threatening anaphylactic reaction during transfusion of plasma proteins. case report: positive iat and dat were detected in a years old swedish woman, a rh negative, at th week of pregnancy. previous iat and dat determinations were negative. at time of detection dat wsa weakly positive and igg subclasses identified. antibody identification revealed the presence of high titre ( : ) anti-chido and anti-rogers antibodies. a slight decrease in platelet count (from . /ul to . /ul) was observed. this pattern showed no variation until the end of the pregnancy. at th week a healthy baby was delivered, dat negative. the mother dat and iat remained positive for four months after delivery. the platelets count raised again to . /ul. the same laboratory findings were detected in a previuos pregnancy in sweden. the patient reported the presence of antibodies at th week that disappeared few months after delivery. a healthy baby, dat negative was delivered in this case too. conclusions: this is the first report of the presence of chido and rogers as autoantibodies during the last months of pregnancy. the association with decrease in platelets count and the lack of evident clinical symptoms need further investigation. p- rbc alloantibody frequency and their prevalence within chinese, malay and indian community in singapore e widjaja, mbc koh and d teo health science authority, singapore, singapore background and aim: there is a recognised existence of different alloantibodies in different ethnic groups. while this has been studied in the caucasian population, their frequencies remain less well documented in the asian population. the frequency of different alloantibodies and their distribution in terms of age, sex in singapore population is studied, as were their prevalence within the chinese, malay and indian races in singapore. design and method: we conducted a retrospective study for the frequency of alloantibodies on blood samples over . these blood samples were largely sent by hospitals where preliminary antibody screening had been done and positive result obtained. they were sent to the centre for transfusion medicine for antibody identification. small number of these samples came from hospitals where preliminary antibody testing was not done. the antibody distribution across different ethnic groups (chinese, malays, indians) age and sex were studied. results: the most frequent alloantibodies in the population is mia ( . %), e ( %), le a ( . %), le b ( . %), p ( . %), m ( . %), d ( . %), c ( . %), jka ( . %) and c ( . %). within the chinese community, the most frequent alloantibodies were similar: mia ( . %), e ( . %), le a ( %), le b ( . %) and p ( . %). in the malays, the most frequent alloantibodies were le a ( %), le b ( . %), mia ( . %), e( . %) and p ( . %); while in the indians, these were mia ( . %), le b ( . %), le a ( . %), d ( . %), and e ( . %), with the anti-d reflecting the higher incidence of rh d negativity in the indians race. for the lower incidence antibodies, anti-c was more common in the malays and indians ( %) compared to chinese ( . %). anti jka tended to occur mainly in the malay race and anti-c was rare in all (< %) reflecting the high prevalence of c in the singapore population (r r phenotype). the ratio of alloimmunised male to female (m : f) is : . most alloantibodies demonstrated significant skewing towards to the female, although relatively less so for mia where m : f ratio is almost equal at : . . alloimmunisation increased with age for mia, e, k, p , jka and fyb while the frequency of alloimmunisation to lea, leb, d, m and c decresed with age. the prevalence of patients with multiple alloantibodies ( or more) within the alloimmunised subjects is . %. conclusion: anti mia is very common within the asian population especially in the chinese. anti d is common in the indians. most antibodies show increased frequency with age except for anti lea + b, d and m. the majority of alloimmunised patients are females. study aim: to identify the present antibodies in newborns, after a positive direct antiglobulin test (dat). material and method: during a years period, from / / - / / , we studied newborns and their mothers. each newborn was examined for abo group, rhesus with phenotype, kell and dat. each mother was also tested for abo group, rhesus with phenotype, kell and indirect antiglobulin test (iat). after each positive dat, the study was continued with the elution test, in order to identify the present antibody. dat test was performed with dc screening i-diamed sa, switzerland. for the laboratorial analysis of newborns the sample used was cord blood and in certain cases venous blood. results: the dat test was positive in ( %) of newborns and the antibodies found were igg type immunoglobulin. anti-a antibody was detected in ( . %) (newborns of group a with mothers of group o), anti-b antibody in ( %) (newborns of group b with mothers of group o), anti-d antibody in ( . %) (newborns d+ from d-mothers), anti-e in one case and anti-jka in another one. the eluate test was found negative in newborns and in the rest , no special antibody could be identified. the results are presented in the following table. conclusion: the majority of antibodies in newborns with a positive dat test, is due to abo incompatibility (the mother belongs to group o and the newborn to group a or b). anti-d ( ), anti-e ( ), anti-k ( ), anti-fya ( ), anti-s ( ), anti-jkb ( ), anti-n ( ), anti-kpb ( ). in two patients antibodies were identified, while in / ( . %) no antibody was identified (unspecific). it is remarkable that only in out of patients with both dat and iat positive, an irregular antibody was identified, while the rest patients had unspecific antibodies. in patients with only iat positive, had an irregular antibody and had unspecific antibodies. in out of patients with both dat and iat negative the cause of incompatibility was the positive dat in the corresponding sample of the blood donor, while in the rest patients the reasons were technical problems that include the inappropriate blood sample of the patient, patients under medication and errors during the crossmatching procedure. the results show that the incidence of red cell incompatibility in our hospital is . % and the most common antibodies are anti-k, anti-e, anti-fya, while anti-d is important for d negative patients. . % of the detected antibodies were unspecific and this is still a problem that possibly was due to the lack of additional panels of reagent red cells or antibodies to low-incidence antigens. finally, in some cases the reasons for incompatibility are due to factors affecting the blood donor or to technical problems in the crossmatching procedure. multiple isoforms excluding normal rhd mrna detected in rh blood group del phenotype with rhd a allele introduction: del phenotype is very common in rh-negative chinese. the rates in hans (more than % in china) were reported from % to %. moreover all del individuals in this population were found mainly carrying a same allele, rhd a, through genomic dna analysis. those individuals always possess one or two of this allele with ccee or ccee phenotypes. aim and the study: we focused on the mrna investigations of del individuals carrying rhd a alleles, in chinese, to expect it could be explained that why a silent mutation is associated with del phenotype. the full-length rhd mrna was analyzed in rh-positive donors with cde/cde and cde/cde genotypes, respectively, and del phenotype individuals carrying rhd a allele with cde/cde, cde/cde, cde/cde and cde/cde genotypes, respectively, through reversed-trancriptase pcrs and cdna direct or cloning sequencing. results: five transcripts and isoforms were detected in rh-positive and del, respectively. among them, isoforms have identical sequences, which are transcripts with exon , exons and , exons and , and exons to spliced out. the normal rhd mrna was only observed in rh-positive, but not in del individuals. in stead, two additional transcripts were found in del individuals. its exon or exons - were spliced out, but both possess a bp segment of sequence from intron of rhd. through additional reversedtrancriptase pcrs, which amplified exon to ¢-region and exon to ¢-region, the results showed that exon did not exist in del anyway. conclusion: (i) a normal rhd protein does not exist in a del individual with rhd a allele since the exon was always spliced out in all isoforms. all transcripts in del maintain a normal open reading frame and encode proteins with different numbers of amino acid residues and different c-terminals (genbank ay , ay , ay , ay , ay , ay ). among them, the sequence of del (isoform with exon spliced) transcript was the most similar as normal rhd mrna. this isoform was first described by chang et al. in taiwan in . it encodes amino acid residues and has amino acids more than normal rhd. it is different from rhd after codon . in normal rhd protein, the amino acids after ( residues) are mainly the trans-membrane and intracellular regions. therefore a further study on if a del red cell possesses all epitopes of normal d antigen may be significative. (ii) a normal rh-positive individual has also the transcript of del that was found in del. (iii) there is only one polymorphism in the region of bp segment between rhd intron and of the del transcripts, which indicated that other polymorphisms may exist in intron of rhd a allele compared rhd to explain that this situation was not happened in normal rh-positive individuals. total wbc were enumerated by flow cytometry and cell counting. wbc subsets were analyzed by flow cytometry with three-color fluorescence. in this study, the third generation bags and filters are used. results: before filtration, the total number of wbc, was significantly higher in fresh units compared with stored units, whereas in postfiltration samples the number of white cells was significantly lower in the fresh compared with the stored units. although absolute numbers were significantly reduced, filtration also induced significant changes in the proportions of subsets in hoth fresh and storod units, the percentage of t cells was decreased, whereas the percentage of b cells and monocytes was increased after filtration. in conclusion, both pre and post storage wbc filtration affect the proportions of wbc in the final product but pre storage wbc filtration of platelet concentrates is superior than post storage wbc filtration. the effect of pre-and post-storage filtration on platelet rich plasma: derived platelet concentrations background and objective: the white blood cells (wbc) within transfusion products are a major stimulus for a number of detrirmental biological reactions, including febrile nonhemolytic transfusion reactions, alloimmunization against hla antigens and cytomegalovirus transmission. in this work, our objective was to study the effect of storage time on the filtration of platelet concentrates (pcs). the total number of white blood cells as well as the distribution of wbc subsets, in units filtered before and after storage were compared. materials and methods: platelet rich plasma -derived pcs were filtered either fresh ( pooled we reported earlier that metabolic arrest followed by incubation at °c reduces the platelet storage lesion (badlou et al. transfusion ) . here we report that this treatment also reduces binding and phagocytosis by macrophages. metabolic suppressed platelets (msp) were prepared by incubation in glucose-free, antimycin a containing medium ( min, °c) followed by storage ( h, °c) and recovery with glucose ( h, °c). controls were (i) platelets in glucose-rich medium stored for h at °c and recovery with glucose (c ) and (ii) platelets stored for h at °c (c ) with rewarming. platelets were labelled with mepacrine and incubated with pma-matured thp- cells ( °c). binding was measured by facs analysis of cd b/cd positive particles, and phagocytosis by counting mepacrine/cd positive particles. binding of msp, c , c was ± , ± , ± % of total platelets. phagocytosis of msp, c and c was ± , ± , ± % of total macrophages (means ± sem, n = ). before recovery of msp, binding/phagocytosis was % higher than thereafter, revealing energy-dependent control of the mechanisms that trigger plateletmacrophage interaction. these data show that metabolic suppression prior to cold storage attenuates binding and phagocytosis by phagocytes and may help to develop means to improve platelet survival post-transfusion. platelet compatibility testing and alloimunization in multiply transfused hematologic patients purpose: multiply transfused patients with heamotological malignancy often become refractory to platelets due to alloimmunization. refractoriness is usually defined as an insufficient platelet increment after consecutive platelet transfusions. two major causes of a decreased platelet increment can be distinguished, immune and nonimmune factors. alloimmunization occurs most frequently against the hla, and rarely against the hpa system. nonimmune factors been identified are splenomegaly, fever, sepsis, and disseminated intravascular coagulation as well as the quality of the transfused platelet concentrates. we performed this study in order to investigate platelet crossmatching, compatibility, and antibody determination among thrombocytopenic patients multiply transfused. we performed crossmatchingcompatibility tests of single donor leucodepleted, abo compatible, platelet concentrates been transfused in patients with leukemia and lymphoma, males and females with mean age ± years old. we also obtained samples from the patients for platelet antibody detection. we evaluated the cci (corrected count increment) h after the transfusion. the solid phase rbc adherence assay (modified capture p system/immucor) was used for platelet compatibility and antibody detection. a total of compatibility tests were performed, of which were compatible. twenty five compatible platelet concentrates out of were clinically evaluated. twenty from compatible crossmatches ( %) were resulted in successful transfusion while only from ( %) in unsuccessful. the incompatible platelets been transfused was resulted in unsuccessful transfusion. we found statistically significant difference among patients successfully transfused with compatible and incompatible platelets (p~ . ). additionally patients out of ( . %) had been alloimmunized against multiple hla antibodies. three patients transfused with compatible platelets, during the study, developed alloantibodies. we found a large number of incompatible platelet concentrates that result in unsuccessful transfusion and clinical response. the platelet compatibility testing as well as alloantibody determination of multiply transfused patients is necessary for the identification and selection of compatible, with the patients, donors in order to result in succesful transfusion and clinical outcome. furthermore compatible platelet concentrates provide optimal support for refractory patients and it is known that they are acceptable as an alternative component. naitp is a rare clinical syndrome characterized by marked thrombocytopenia shortly after birth. it is caused by maternal immunization against paternally inherited antigens present on foetal platelets. screening and identification of antibodies in the maternal blood sample is the main support in the diagnosis and management of naitp. we have evaluated the frequency of maternal alloimmunization, the role of the antibodies involved (hpa and/or hla systems) and the pertinent risk of naitp in neonates using a fully automated system with a solid phase red cell adherence methodology (sprc-capture p) and paternal or random donors (indirect test). screening started in june and is still in course: in january , blood samples were examined. identification of antibodies in maternal serum was carried out using elisa methodologies: maipa and commercial kits (pak-plus and quick screen-gti). of the blood samples analysed, were reactive and the specificity of the antibodies were: anti hpa a: , anti hpa b: , anti hpa a + hla: , anti hpa b. , anti hla: , auto hpa- b: . specificity of hpa antibodies was confirmed by determination of parents' hpa genotype (hpa- , , , , , ) using pcr-ssp or pcr-rflp. the infants with hpa immunization suffered from severe (plt count - /ml) and symptomatic naitp (bleeding and petechiae were present), therefore they were treated with platelet transfusion and administration of high doses of intravenous immunoglobulin. we confirm that naitp due to hpa- and hla immunization is clinically less severe: all neonates had mild and self limiting thrombocytopenia at birth; no therapy was administered. it would be advisable to carry out pre-natal screening, at reasonable cost, using maternal serum versus paternal platelets and to proceed to the identification of antibodies only in presence of positive results. background: fetal or neonatal alloimmune thrombocytopenia (fmait) results from a maternal alloimmunization against fetal platelet antigens. it is the commonest cause of severe thrombocytopenia in the neonatal period. the diagnosis of fmait is made initially on clinical grounds, depending on exclusion of other causes of neonatal thrombocytopenia. in caucasians, hpa- a is the most frequently implicated antigen. other antigens such as hpa- a, or hpa- a are less often implicated. during the past few years fmait has been reported associated with rare or private antigens. the diagnosis is straightforward when a maternal alloantibody with a corresponding parental antigen incompatibility is present. however it could be equivocal in the absence of such an antibody or difficult when a private antigen is implicated. if the father is heterozygous for the considered antigen, the infant's platelet typing should be performed to confirm the diagnosis. due to the risk of hemorrhage, particularly intracranial hemorrhage (ich), during the course of severe thrombocytopenia, specific therapy is mandatory. because subsequent siblings may be more severely affected, accurate diagnosis will allow better management of subsequent pregnancies. study design and methods: since the first documented case of feto-maternal alloimmune thrombocytopenia (fmait) due to anti hpa- bw (maxa+), no additional cases have been reported. we present here a retrospective analysis of the cases referred to our laboratories in recent years. since we have screened for rare or private antigens in suspected cases of fmait when there is no incompatibility for the most frequently implicated antigens. the diagnosis was performed by genotyping and identification of the maternal alloantibody by the maipa technique. results: parental genotyping showed hpa- bw (maxa+) mismatch as the sole antigenic incompatibility in out of families. in the last one, incompatibility was found for hpa- without anti hpa- b maternal alloantibody. as the father was found to be hpa- bw (maxa+) heterozygous in all the cases, the infant or fetus was genotyped to ascertain the diagnosis. the maternal alloantibody was identified in the maipa technique. however, our data strongly suggest that recognition of the hpa- bw (maxa+) epitope is not uniform. the neonatal thrombocytopenia was severe in most cases with bleeding. the outcome was good in all the cases but one. conclusion: this analysis confirms that anti hpa- bw (maxa+) fmait is not uncommon and was found to be around % of our confirmed fmait cases with parental incompatibilities and presence of maternal alloantibodies. it is a clinically severe syndrome which requires prompt diagnosis, albeit difficult, and maternal platelet transfusion therapy. laboratory investigation of a suspected fmait case should be carried out in a specialist laboratory wellexperienced in optimal testing. therapy requires strict collaboration between clinicians and blood bank services. appropriate management and antenatal therapy should be considered for successive pregnancies to prevent fetal bleeding. introduction: the human platelet (plt) antigen (hpa) system is independent of the hla system. therefore, host-or donor derived alloimmune thrombocytopenia can develop after allogeneic haematopoietic stem cell transplantation (hsct) even in hlamatched donor-recipient pairs. we report the first case on a stem cell recipient developing thrombocytopenia due to host-derived hpa- a antibodies after non-myeloablative allogeneic hsct. a year-old male patient was diagnosed with multiple myeloma in / . treatment consisted of cycles vincristin, adriamycin and dexamethason followed by tandem autologous stem cell transplantation. because of progressive disease he received cycles of bortezomib, and after complete remission a stem cell allograft ( . ¥ /kgbw cd + cells) from his histocompatible (hla a,b,c,dr identical) brother after reduced intensity conditioning regimen with fludarabine ( ¥ mg/m ) and alkeran ( mg/m ). he had received only twice packed red blood cell concentrates and one plt concentrate before allogeneic hsct. stable bilinear engraftment occurred around d but was accompanied with a continuous decrease of plt counts. between d and d the patient received seven plt transfusions, containing a median of . ¥ plt/unit (range , - , ¥ plt/unit) from random donors. the corrected plt count increments at to h after these transfusions were < /ml. therefore, and because of even a further decline of platelet counts to /ml on d we investigated the presence of plt antibodies. methods: the patient's serum was tested by antigen capture elisa assays (pakplus® and pak ®, gti) and a solid phase assay (capture-p®, immucor). the maipa assay was used to confirm the results obtained by the above mentioned assays. in addition, we tested the patient's serum by the maspat kit (clb) against plt from the donor and against homozygous hpa- a plt obtained from our donor pool. stored recipient's dna from the time before hsct was used for genotyping. genotyping for hpa- , - , - and - of the donor and the recipient was performed by pcr-ssp (hpa, protrans). the patient's serum obtained on d after hsct reacted strongly with the donor's plt due to anti-hpa- a antibodies and antibodies against hla class i antigens. the patient's genotype before transplantation was hpa- bb, - aa, - ab, and - aa; the donor was hpa- ab, - aa, - aa, and - aa. thus, the antibodies were host derived and directed against the donor's plt. serum samples obtained on d , d and d after hsct contained antibodies against hla class i antigens but hpa- a antibodies were not anymore detectable. no hla antibodies were detectable on d after hsct. the severe thrombocytopenia was caused by hostderived hpa- a antibodies. fortunately, plt counts started to increase on d spontaneously and the patient could be discharged at d (plt . /ml) with a complete donor chimerism. the decrease of the serum antibodies parallel to the increase of the plt count strongly suggests a progressive elimination of residual host cells. we conclude that the hpa mismatch between recipient and host affected thrombopoietic engraftment and the success of plt transfusions. severe neonatal alloimmune thrombocytopenia with anti-hpa- b antibodies: case report p moncharmont, m vignal, y mÉrieux and d rigal efs rhone alpes site de lyon, lyon cedex , france usually, in case of feto-maternal incompatibility, the platelet (plt) specific anti-hpa- b antibodies (ab) induce only sometimes a mild neonatal alloimmune thrombocytopenia (nait). contrary to this observation here is reported the case of a severe nait. a -year old mother, gestation /partum , gave birth to a male neonate by caesarean section at weeks of gestation because of intra-uterine growth retardation (iugr) and anamniotic fetus. five years before, she had had a first pregnancy with iugr of the fetus but no nait. the second neonate weighted . g, was . cm tall and had a head circumference of . cm. the apgar score was , , , at , , and min respectively after birth. no bleeding, hepatomegaly, splenomegaly or infectious signs were noted. five hours after birth, a respiratory distress syndrome appeared and an oxygenotherapy was performed during h. the plt count which was . , . and . giga/l at day (d) , d and d respectively dropped dramatically at . giga/l at d . simultaneously, an intracranial hemorrhage grade ii was diagnosed on ultrasound scan. because of the clinical signs and of the decreasing plt count the mother's serum was tested for plt-specific ab by immunocapture and the ab identified by the monoclonal ab-specific immobilization of plt antigen (maipa) assay. a plt genotyping was performed in the neonate and his parents by sequence-specific primers polymerase chain reaction. the mother was hpa- a/a and anti-hpa- b ab were detected in her serum. the baby was heterozygous, hpa- a/b. plt were transfused to the baby and the plt count rose to . , . and . giga/l at d , and respectively. no further transfusion was needed and the development of the baby was satisfactory with a normal electroencephalogram. in conclusion, when a mild thrombocytopenia with iugr and hypoxia but without bleeding signs is present in a neonate immediately after birth, a maternal plt specific ab screening must be performed in case the thrombocytopenia became severe during the newborn monitoring. anti-hpa- b ab can be detected. partial results of the incidence of heparin induced thrombocytopenia type ii osc oliveira*, ra rached*, c cavalheiro-filho*, jc nicolau*, shgl pasqualucci*, daf chamone † and sp bydlowski † *heart institute, university of são paulo, † university of são paulo, são paulo, brazil heparin induced thrombocytopenia type ii (hit) is a severe side effect of heparin, associated with heparin-platelet factor antibodies. hit type ii occurs in up to % of patients who are exposed to unfractionated heparin (ufh). in our institution patients that are under heparin treatment are mostly cardiac patients. the purpose of this study is to determine the incidence of hit type ii in these patients. material and methods: patients from the intensive care unit and cardiac care unit treated with ufh or low molecular weight heparin (lmwh) for or more days were studied. known causes of thrombocytopenia were excluded. platelet count was monitored pre and post heparin therapy. all selected patients were tested for detection of anti heparin/pf antibody test (diamed id-card). results: from the studied patients, ( . %) developed thrombocytopenia (determined by a decrease in the platelet count below %, after the introduction of heparin therapy); ( . %) did not show decrease in the platelet count. six ( . %) out of thrombocytopenic patients were positive for anti-heparin/pf antibody. three ( . %) out of non thrombocytopenic patients were positive for anti-heparin/pf antibody. the results demonstrate that ( . %) patients were positive for anti-heparin/pf antibody and they were no different from those described in the literature regarding the frequency of heparin induced thrombocytopenia. moreover, a higher frequency of patients with heparin/pf antibody was noted without the presence of thrombocytopenia, indicating that other factors should be considered. introduction: neonatal alloimmune thrombocytopenia (natp) due to maternal immunization against fetal platelet antigens affects . - in live births. although it is usually a self-limiting condition, a major complication in cases of severe thrombocytopenia is the occurrence of intracranial haemorrhage leading to death (in up to % of reported cases). the commonest antibodies are anti-hpa- a. treatment consists of ivig, compatible donor platelet concentrates or washed maternal platelets. the administration of random donor platelet transfusions is controversial but has been used successfully in some urgent cases when compatible platelets were not available. case report: a baby born in week of gestation to a healthy mother after first uneventful pregnancy; birth weight g, apgar score . immediately after birth, severe thrombocytopenia ( ¥ /l) and signs of haemorrhagic diathesis (generalized petechiae and ich gr. ii-iii) were observed. coagulation tests were abnormal and k-vitamin, fresh frozen plasma and random donor platelet concentrate (retrospectively genotyped as hpa- a/a) were given. twenty-four hours later platelet count rose to ¥ /l and no new petechiae were observed. on third day of life the blood platelet count was ¥ /l and the newborn received ivig g/kg and corticosteroides. twenty-four hours later the platelet count rose to ¥ /l and further clinical course was uneventful. natp due to hpa- a was serologically confirmed. conclusion: optimal therapy for an infant with severe thrombocytopenia during the first h of life is the transfusion of platelets that will not be destroyed by the maternal alloantibody in the infant circulation. random donor platelet concentrates are controversial in a setting where optimal treatment is not available, however, in this case they led to a significant platelet count improvement in spite of hpa- a incompatibility. accordingly, random donor platelets may be considered appropriate in emergency situations. background: rhd is the most immunogenic blood group antigen, and its correct identification is essential in the blood bank and in the prevention of the haemolytic disease of the newborn. the weak d phenotype is the most common d variant, with a frequency of . % to % in caucasian individuals. there are several weak d types, with different frequencies in european countries, which may pose serologic problems and have the potential for alloimmunization. the objective of the study was to determine the frequency of the principal weak d types in portugal. study design and methods: lisbon regional centre of the portuguese blood institute and oporto são joão university hospital selected samples from blood donors and patients. rhd was tested by two (oporto) or three (lisbon) distinct anti-sera, in direct agglutination tests, at room temperature. when discrepant results were observed, the samples were tested with panels of monoclonal anti-d by liss-iat. samples that reacted weakly with igm anti-d but positive with igg anti-d were sent to the molecular biology centre. pcr with sequence-specific primers was performed using two commercially available kits (inno-train and bagene). real-time pcr, carried out on a light cycler, was applied when the interpretation was dubious. results: samples were referred after being characterized as weak d. in cases we obtained a positive result, with a preponderance of weak d type ( . %) over type ( . %), ( . %) and ( . %). two samples were not categorized. the high incidence of weak d type in our population is in marked contrast to studies performed in other european populations where weak d type was the most frequent. this might be due to our sample selection criteria or ethnic variation in the causes of weak d. there are advantages in genotyping serologically depressed d samples: to avoid the waste of d-negative rbc units and the use of immunoglobulin in pregnant women, who have no risk of alloimmunization. analysis of rhd zygosity in different rh phenotypes cal except for a -bp t insertion. the deletion of the rhd gene, found in most rhd-negative caucasians, was theoretically due to recombination of the upstream and downstream rhesus boxes resulting in the formation of a hybrid rhesus box. thus, the detection of a hybrid rhesus box in an rhd-positive individual denotes an rhd heterozygous status. aim of the study: to determine the rhd zygosity in different rh phenotypes. methods: blood samples from white trios (father, mother and child) were studied. the rh phenotype was performed by hemmaglutination and the rhd zygosity was inferred in each member of the family groups. the rhd deleted allele was determined by a pcr strategy using a forward primer complementary to ¢ end of the identity region of the upstream and hybrid rhesus boxes and a reverse primer complementary to the ¢ end of identity region of the downstream and hybrid rhesus boxes. these primers selectively amplify a -bp segment of the hybrid rhesus box in rhdnegative and rhd-positive heterozygous samples. serological and pcr inconsistencies were studied by a pcr-rflp method to detect another polymorphic site of the hybrid rhesus box. frequencies were obtained analysing only unrelated individuals (fathers and mothers, n = ). results: ( . %) rhd-positive and ( . %) rhd-negative samples were phenotyped. of the rhd-positive donors, ( . %) were rhd homozygous and ( . %) were rhd heterozygous according to pcr. pcr-rflp analysis confirmed the results of pcr in serological and molecular discrepancies. these results were coherent within each family group and did not differ from those published in the literature for caucasians based on the most probable genotype method. however, the homozygosity indexes were significantly higher in the dccee ( . % vs . %) and dccee ( . % vs . %) phenotypes due to an increase of the dce haplotype. in all samples with the dce haplotype the rhces allele, frequent in individuals of african descent, was investigated by pcr-ssp. this allele was found in . % of the dce haplotypes. . rhd and rhce typing was performed by multiplex-pcr with fluorescent primer pairs. positive results were obtained for rhd-exons - , , and polymorphisms associated with antigens c, c, cw, e and e. sequencing of rhce-sequences, including exons to and intron/exon borders, were done by direct taq cycle-sequencing using bigdye-terminators v. . in an abi (applied biosystems). results: see table . the substitutions of rhce-specific nucleotides in exons , and with their rhd-specific counterparts lead to different new rhc-antigens with weakened expression. since one amino acid change in allele lie in extracellular loop of the antigen suggested that this antigen may be involved in allo-immunization. inheritance of a rhd cat vi type ii in a twin pregnancy: a case report introduction: determination of hdn-relevant fetal blood groups in amniocentic fluid with pcr is a routinely used method. misinterpretation of test results -e.g. overlooking rhd category -decreases depending on the number of examinated rhd-specific exons. case report: a -year old mother (w.o.g. ) pregnant with twins was regularly tested for irregular antibodies and was shown to have an anti-d. after amniocentesis of both foetuses tests for the occurrence of rhd intron , exons and were performed in the hospital's lab. the sample of fetus i showed pcr-products for intron , exon and exon while sample of fetus ii lacked rhd-specific intron . therefore we investigated blood samples from the parents as well as amniocentic fluid of both foetuses. methods: total dna was amplified in a multiplex pcr with fluorogenic primers for rhd exons - , & ; polymorphisms for dweak type - , d-vii, d-hmi and rhce polymorphisms for c, c, cw, e, e. capillary electrophoresis for size fractionation and fluorigeneic analysis was done in an abi . rhd zygosity was determined by quantitative real-time pcr with co-amplification of rhdand rhce-specific exon and subsequent calculation of d ct value (ct rhce minus ct rhd). results: while maternal dna sample has been genotyped as rhdnegative, amplification of paternal dna for rhd-specific exons , , , and were possible and failed only in exon - . determination of rhd-zygosity revealed a homozygous constellation of the rhd-gen. investigation of amniocentic fluid from both foetuses resulted in a rhd-wildtyp for fetus i and a rhd cat. vi type ii for fetus ii which was the reason for missing amplification in rhd intron pcr. results: weak d type was not identified in our research population. weak d type was identified in cn, weak d type was identified in cn and weak d type was found in cn, bsa, be, bc and saa. conclusions: although weak d types to represent the majority of all weak d phenotypes in caucasian populations, none of these weak d alleles were found in black populations. since none of the frequent weak d types were identified in non-caucasians one might not expected to find type in all populations. however, regarding rhd phylogeny, the weak d type mutations ( c > g and t > g) form the basis of a cluster of aberrant alleles that are predominantly observed in blacks. therefore, it is not surprising that weak d type was identified in non-caucasians. based on these results it may be concluded that weak d phenotypes have evolved relatively recently since they are present in caucasian and asian methods: dna was extracted from a, b, ab subgroups, and provisional cis-ab after serological abo typing. allelespecific pcr, rflp, direct sequencing of exon and , and allele separation were performed on these samples. results: abo*a allele was observed in an aint subgroup. two new a alleles that showed g > a base change and c > t of intron and a polymorphism of c > t in a(pro) intron were discovered. o and o alleles were also observed. in b subgroups, a silent substitution c > t (leu leu) was observed as a new b allele. another new b allele which showed g > a was also found in b subgroups. conclusion: we discovered new abo alleles and polymorphisms in korean populations. many other polymorphisms and alleles already reported in japanese were also observed in koreans. evaluation of a multiplex snapshot-pcr method for red blood cell marker genotyping c jungbauer*, c hobel*, em dauber † , pk rabitsch*, dwm schwartz* and wr mayr* *austrian red cross, † medical university vienna, vienna, austria once conventional reagents for identification of rare red blood cell phenotypes are scarce, methods using current nucleic acid testing techniques to identify the patient's genotype and possibly to screen for donors would be desirable. the approach of multiplexgenotyping using pcr-ssp has apparently technical constraints so we are currently analyzing whether a modification using snapshot pcr-technique could provide a routine application for such purposes. compared to ssp-technique, the snapshot pcr only requires one single primer (labeling reaction) for the detection of two (or more) alleles instead of one pair of primers for every single allele. briefly, we perform snapshot pcr as follows: in a first step, dna segments covering the essential polymorphic regions for the abo, rhd, kel, jk and fy genes are amplified using a standard pcr step. after purification treatment of the pcr products (roche high pure pcr product purification kit or shrimp alkaline phosphatase (sap)/exo treatment according to the abi prism snapshot multiplex kit protocol) the labeling reaction is performed using the abi prism snapshot multiplex kit. after a second purification step the products are analyzed on a abi prism genetic analyser in fragment analysis mode. our preliminary results show the feasibility of this approach as reliable typing results can be obtained for all tested single nucleotide polymorphisms corresponding to alleles. generally a better signal quality from controls and samples is obtained compared to the ssp-technique with consecutive gel electrophoresis. we also consider the possibility of the automated interpretation of the results as an important improvement, especially when aiming for an application for a large number of samples (donors) or markers (patients). in contrast, the method involves more manual steps and higher costs. we may conclude that the implementation of snapshot-pcr techniques for red cell marker genotyping is a promising alternative to pcr-ssp. the obvious quality improvements compared to pcr-ssp might be critical for a routine application in blood banks (donor screening) or complex questions in clinical laboratories. quantification and quality control of monoclonal antibody using an optical sensor based on the laser reflectometry technique the monoclonal antibodies (moab) are biological reagents of homogeneous activity. they are generally used in the recognition and quantification of very small amounts of biological substances (hormones, enzymes) present in a solution, ag identification, blood group determination, oncology, organs transplant, etc. moab can be characterized by its specificity and affinity. affinity may be expressed as the equilibrium association constant (k). several techniques are available to determine the equilibrium constant of the ag-ab interaction. in this work, is shown an optical sensor for monoclonal antibody quantification by reflectometry technique. the laser reflectometry technique (null ellipsometry technique) can give information about the kinetic of the interactions, stoichiometry of molecular binding and the concentration of molecules in a solution, and also offers detailed and accurate determinations of real-time adsorption kinetics of protein without labeling. a silicon wafer was chosen as reflectant surface. once fixed the principal angle of incidence, an amount of anti-ab is added to the sample. the reflected laser intensity is registered in real time as the protein is being adsorbed onto the wafer. the mathematical analysis of the results verifies that the antibodies adsorption follows langmuir's kinetics. from the curve analysis, the parameters related to the anti-ab concentration are extracted. from them, the calibration curve is constructed. this curve allows the desired commercial monoclonal antibody quantification. the developed technique shows to be sensible and precise. the obtained graphics are very well approximated (r > . ) verifying that the monoclonal anti-ab associa- study aim: to prevent the sensitization to rh (d), to a d-patient who was transfused with d+ blood. material and method: on september , ( / / ), we admitted to our hospital through air-carriage, a female of years old, badly injured after a car-accident. the patient was on an olighemic shock (ht: %) due to retroperitoneal, paracolic and procystic hematomas, had multiple fractures on the left feet, the main important of which was an acetabulum one. she had a blood group: o, d-and her phenotype was ccdee with du-. after her arrival she was urgently admitted to the surgery room and our blood bank was asked for condensed red cells. initially she was transfused with blood of the same group (o, d-) but when we were short out of dblood, we were asked for more units. the necessity of blood was imperative, the patient was on a critical condition and the mechanism of blood transport, from another blood bank would take some time to be put in motion, and so it was decided that the patient would be provided with d+ blood. the indirect antiglobulin test (iat) and papaine were negative, so there would be no problem with the transfusion with d+ blood. the patient received finally units ( ml) of d+ condensed red cells, out of that were initially asked. before the h from the surgery had passed, it was decided that human anti-d immunoglobulin (rhesogamma p) should be provided, in order to prevent the sensitization of the patient to rh (d). the indicted dose was - iu/ ml of the transfused blood, provided piecemeal during a several days period. analyzed by real-time pcr amplification. based on a published report, we selected primer pairs targeting insertion/deletion polymorphisms which are located on different chromosomes, unrelated to each other and not associated with immunocompatibility. we optimized the amplification conditions for all primer pairs using our sybr green real-time quantitative pcr protocols, and investigated analytical sensitivity for each primer pair by performing spiking studies, in which a single copy of positive dna was added into copies of negative dna followed by allele-specific pcr amplification. we also created a theoretical panel of donor-recipient pairs (n = ) to evaluate the clinical sensitivity for detection of ta-mc using both hla-dr and indel panels. results: for the short-term samples, additional mc cases was identified in non-lr group using indel panel; and one additional mc case was detected in lr group (table ) . for the long-term follow-up samples, additional mc cases were found. when evaluating analytical sensitivity, we were able to detect a single copy of positive dna mixed with copies of negative dna in a single amplification tube for all primer pairs. we were also able to calculated the clinical sensitivity that using donor-recipient pairs. . % of donor-recipient had at least one informative allele for detection of ta-mc if we consider both hla-dr and indel panels. conclusion: using our new indel panel, we were able to detect more instances of mc in this cohort of patients. we conclude that the dr assay underestimates the presence of mc. moreover, the tandem use of both panels provides a powerful tool for the detection of mc with . % of recipients having at least one informative allele. background: we reported severe immunesuppression and longterm transfusion-associated microchimerism (ta-mc) in transfused trauma patients. we have also reported, in a murine transfusion model, that sensitivity to -chloro- - dinitrobenzene could be transferred, albeit transiently, by transfusion of fresh blood from a sensitized donor to a naïve immunecompetent recipient. in order to mimic the immunecompromised status of trauma patients and further investigate the mechanism underlying ta-mc, we established an animal model using immunedeficient knock-out mice. aim: our objective was to test virus-specific immune functionality of the chimeric donor leukocytes in a murine ta-mc model. material and methods: female rag- /common gamma double knock-out mice were transfused with fresh blood collected from male balb/c mice, which were either not infected (non-primed, np) or infected twice (primed, p) with million viral particles of murine cmv (mcmv). at different post-transfusion time-points ( h, weeks, weeks, weeks, weeks), different female recipients plus non-transfused female knock-out controls were challenged with million viral particles of mcmv intra-peritoneally, and then monitored weekly for the concentrations of male donor cells as well as mcmv viral load in recipient's circulation. each female knock-out received only one challenge of mcmv. if the subject died, we quantitated mcmv viral load in the brain, spleen, lung and liver. we used real-time quantitative pcr targeting murine y-chromosome, h k and mcmv to quantitate male donor cells, transfused recipient cell dna input, and mcmv vrial load, respectively. the number of recipient cell dna input served as a denominator to calculate the concentration of male donor cells and the mcmv viral load. results: results of overall mortality are summarized in the table. all female knock-out recipients transfused with primed donor blood, except for the post-transfusion weeks, are able to survive mcmv infection. all non-transfused control and recipients transfused with non-primed donor blood died after mcmv infection; these two groups also had higher mcmv viral load in blood than the recipients transfused with primed donor blood. when the subject died, we were able to detect mcmv in all four organs we analyzed, with liver having the highest mcmv viral load. there was no significant difference for the concentration of donor cells in recipients' blood between recipients transfused with non-primed donor blood and recipients with primed donor blood. the preliminary data of our study showed that chimeric primed donor cells, but not non-primed donor cells, are able to protect immune compromised knock-out recipients from murine cmv infection. the time-point of 'post-transfusion weeks' might represent a weak window for the functionality of chimeric donor cells, which requires further investigation and confirmation. aims: to compare the effectiveness and the cost of epoetin-a and darbepoetin in patients undergoing pabd. methods: seven adult patients scheduled for operations were administered aranesp ( mg sc once or q weeks if needed) for pabd (aranesp group) and they were compared with a historical epoetin-a group of seven age-matched adults (eprex iu/kg biweekly). the two groups were matched according to the ht, ferritin levels, number of the predonated units and type of the operation performed. cbc count and reticulocytes were measured weekly during the donation period, the day before, day and day after surgery while ferritin and biochemical indices were measured during the first visit. erythropoiesis-stimulating factor was administered when ht £ % during blood donations and blood donation was not performed if ht < %. results: there was no statistical significant difference in hematological parameters during the donation period, the pre-operation day and after surgery between the two groups. five of seven patients from both groups received one or two autologous blood units. both factors were well tolerated without any side effects. the cost per patient was . € in the aranesp group and . € in the epoetin group. conclusion: despite the small number of patients and the limitations of this preliminary retrospective trial we believe that subcutaneous darbepoetin-a is equally effective with epoetin-a in patients undergoing pabd. darbepoetin has the advantage of less frequent administration and it is possibly superior that epoetin-a in terms of patient compliance. however smaller doses should be examined in order to reduce the cost. larger prospective randomized trials are needed to estimate the cost-effectiveness of the use of darbepoetin-a in pabd. background: incompatibility with many blood units is a major problem in transfusion therapy. in selective operations, preoperative autologous blood donation could solve many problems, when of course the patient's condition and his haemoglobin levels are appropriate. we present here the experience of our blood transfusion centre from operations in patients with anti-erythroid antibodies. materials: three patients ( male and females), aged between - years old, had to undergo selective operations, total hip replacement surgery and aortic aneurysm. introduction: because of improvements in surgical techniques, preoperative autologous blood donation (pabd) in patients undergoing radical retropubic prostatectomy (rp) is contested. aim of the study: we wanted to develop and validate an algorithm to determine the patients who probably do not benefit from pabd. methods: we calculated the perioperative hb-loss of consecutive patients (group ) who donated two red cell units (rbc) of autologous blood and weeks before undergoing rp: hb-loss (g) = preop-hb ¥ bv + (n rbc ¥ ) -(postop-hb ¥ bv) (bv = blood volume (l) = body weight (kg) ¥ . ; postop-hb = hb ( - h after rp); n rbc = number of transfused autologous and allogeneic rbc). hb of rbc was taken as g. rbc requirement is probably if initial-hb -(hb-loss: bv) -trigger-hb (taken as g/l) < (initial-hb = hb at the first contact with the pabd-unit). this assumption was validated by the next patients who were also assigned for pabd (group ). pabd was refused if the probability of rbc requirement (prr) was < %. between - % one rbc was taken after considering the patient's individual risk of pabd. if prr exceeded % two donations were planned. results: both groups did not significantly differ in age or initial hb. preop-and postop-hb were significantly lower in group ( vs and vs g/l). % of autologous blood of group were discarded, / patients needed additional allogeneic rbc. hb-loss caused by rp was ± g. mean prr in group was . %. / patients donated one rbc, which was later discarded, and no patients donated two rbc. / of group needed allogeneic rbc. mean prr of these patients was % (range . - . ). conclusion: postop-hb were lower in rp-patients with pabd because of the lower preop-hb and the restrictive indication for transfusion of autologous blood. the individual calculation of prr, for which only body-weight and initial-hb of the patient are necessary, shows that pabd in patients undergoing rp is indicated only in rare cases. the algorithm also may be used in other major operations, if hb-loss is known. use of darbepoetin-alpha in preoperative autologous blood donation: preliminary results background: preoperative autologous blood donation (pabd) is an alternative practice to eliminate complications of allogeneic blood transfusion although its cost-effectiveness has been questioned. darbepoetin-a (aranesp, genesis pharma sa) is a novel erythropoiesis-stimulating factor that it has been shown to be equivalent to epoetin-a (eprex, janssen-cilag) in patients with chronic renal failure and cancer. darbepoetin-a has a longer serum half-life and higher relative potency than epoetin-a. this property leads to less frequent administration and may reduce drug cost. so far, no clinical trials with darbepoetin have been published in patients with surgical anemia. other ( . %) patients who required autologous and homologous blood, had average predonation hb level of (sd ± . ) g/l. we found a significant relationship between the need for postoperative transfusion and the predonation hb level (p = . ), predonation htc values (p = . ), weight (p = . ) and gender (p = . ): female patients and patients with lower predonation hb and htc, as well as patients with lower body weight more often needed additional homologous blood transfusion. no relationship was found between age of patients and the need for transfusion (p = . ). ( . %) patients with ptka were transfused with autologous blood only, and had average predonation hb level of (sd ± . ) g/l. other ( . %) patients transfused with autologous and homologous blood had average predonation hb level of (sd ± . ) g/l. the significant relationship was found between the need for postoperative transfusion and weight (p = . ): patients with lower body weight more often needed additional homologous blood transfusion. no relationships were found between predonation hb level (p = . ) predonation htc values (p = . ), gender (p = . ) and age (p = . ) of patients and the need for postoperative transfusion. conclusions: our results show that over % of patients needed only autologous blood. in our patients with ptha predonation hb was significant predictive factor for additional transfusion therapy, while in ptka it was not observed. in both groups of patients body weight was significant predictive factor, thus this feature seems important for planning of transfusion therapy in patients with ptha and ptka. aim: prevention results of loosen anastomoses on colon, with fibrin sealent (fs) application and influence on colagen production. materials and methods: investigations were done on rats, weight - g. in control group, after partial resection of left half of colons termino-terminal anastomosis was derivated. fs was applied in examined group. concentration of colagen was done indirectly, with quantitative l-hydroxyproline determination. place of anastomosis, cm proximal and cm distal of anastomosis, was analyzed iii, v, vii and xiii day postoperatively. results: analysis of hydroxyproline on the place of anastomosis showed higher hydroxyproline value in group with fs application. the highest approximate value of hydroxyproline was registered v day postoperatively. distal, cm of anastomosis, the quantity of hydroxyproline is higher iii day postoperatively in control group but v postoperative day value is intensively growing in group with fs application. electronic microscopical was done v postoperative day in control group at the place of anastomosis detected a defect with detritus and absence of larger colagen fibres. in group with fs application on the place on anastomosis, in the shape of bundle, colagen fibres were grouped and completely fills the place of anastomosis. conclusion: fs application accomplish higher concentration of colagen in all segments of isolated colon, that enables better healing of anastomosis. the study of the use of the safest blood (autologous blood transfusion) through preoperative blood donation (pbd) in surgery patients introduction: the use of the autologous blood is already under consideration in developed countries. thus, it is probable that autologous blood donation would be effective in one way or the other in reducing blood transfusion complications. in this study, pbd as the easiest method to use and the most cost-effective one was selected. aim of the study: it aims at improving blood safety and raising blood inventory. methods: in this study, patients, including males and females, intended to undergo elective surgery were selected as subjects to donate their autologous blood. the subjects with hematocrite level of about - percent as ordered by their physician donated their blood by this method. blood collection procedure was followed at - day intervals. the blood volume taken from patients in every collection differed from - ml according to their weight. results: this study showed that in all patients undergoing plastic, gynaecological, jaw, and ent surgeries autologous blood transfusion was used with no need for allogenic transfusion. in other surgeries, including orthopaedics, the need for allogenic transfusion was estimated to be at about percent of cases. to avoid the complications of allogenic blood transfusion, the safest way is the use of autologous blood which involves low cost and is easy to perform. the introduction: the purpose of this study is to describe a technique to perform labelling of autologous platelet-gel with in-oxine and to evaluate its usefulness, after in vivo graft implant, as a marker of bone osteoinduction by means of scintigraphy, in patients with jaws bone defects following the enucleation of cystic lesions and cystic lesion derived from extraction of deeply impacted lower third molar. methods: agp made. consent was obtained by patient to conduct hiv and hbv testing. briefly, cc to cc of blood is withdrawn from the patient. the blood was separated, by means of successive step of centrifugation, in to platelet-rich plasma (prp) , platelet-poor plasma (ppp), and red blood cells (rbc). the red blood cells were discarded. the prp [comprises of approximately % of the total blood volume withdrawn] had platelet counts of - /mm . the procedures of agp labelling were performed in laminar flow chamber. to seconds the solution will assume a gel-like consistency forming platelet gel. imaging: the scintigraphy was performed h after application of labelled agp (early scan) and at , , , h (delayed scan) by means of a gamma camera equipped with medium energy collimator. a later scan was performed at days after graft. the platelet uptake index (pui) was then calculated by dividing the cpm/pixel in the graft roi (recognized in and planar and trans-axial slice) for cpm/pixel in a mirror background roi. in vitro sampling: the radioactivity of the plasma samples collected at , h and at lapse time = h for days, were used for the plasma clearance determinations and for in vitro studies of the platelet loss from the gel. results: all patients presented early high concentration of in oxine agp, at site of the graft, that was easy recognized at scintigraphy performed as in anteroposterior and lateral planar projection of the jaw as in spet slices reconstructions. all labelled agp was well confined within area of original implant and no activity was seen in the surrounding tissues or in the distant organ. conclusion: all patients studied well tolerate the implant of agp; no adverse reactions were observed and follow up -performed months later -showed bone remodelling activity in the site of the graft. serial blood donations in a ko pregnant woman with the use of recombinant erythropoietin for intrauterine transfusions of severe hemolytic disease of the newborn due to anti-ku biweekly) were administered to the mother to ensure an adequate supply of compatible rbcs for intrauterine transfusions and possible perinatal haemorrhage as well. results: intrauterine transfusions were repeated every - weeks. by the th week of gestation the patient had donated four units of blood, her hematocrit was %, anti-ku titre was / and four intrauterine transfusions had been performed. cesarian section was decided and the apgar of the newborn were and at and min. the newborn was treated with phototherapy but without exchange transfusions and two weeks later he was discharged. by the th day of life rh-epo was administrated to him due to anemia. the maternal red cells completely disappeared from the child's blood by the day . the experience of the use of erythropoietin in pregnancy is minimal. as illustrated by this case treatment with rh-epo and iv fe has effectively increased mother's capacity to donate rbcs' for autologous use and intrauterine transfusions as well, with no adverse effects to the mother or the child. however, further research is necessary to evaluate if rh-epo crosses the placenta. introduction: blood components should be transported by a system which has been validated. the containers used for transport should be well insulated, some form of temperature indicator should be used to monitor the in-transit temperature. whole blood should be stored at different temperatures above °c. aim of the study: bags with whole blood collected in a collection site are transported in containers without active cooling. we tested temperature of blood in containers put into the extreme weather conditions (+ °c, - °c) during loading test for transport. methods: the container without active cooling was filled with the exact number of bags with blood and the exact number of passive cooling elements (frozen water cubes in plastic) placed in the exact positions without close contact with the blood bags. the bags with blood of the temperature + °c, + °c and + °c were used. temperature indicators were situated in the bottom, centre and top of the container. filled container was placed into thermostat (+ °c) or freezer (- °c). the temperature was observed in min intervals for three hours, first measurement was min after putting into freezer or termostat. results: (see table ) nt, non tested; tmp, temperature. in the table there are shown minimum and maximum temperature parametres observed during tested time including increasing or decreasing trend. conclusion: loading test for transport of the bags with collected whole blood helps us to optimize transporting system, especially number of cooling elements in relation to the season and its place in the container. in the light of presented data we corrected transporting system to maintain the recommended temperature during transport. background: since , we have produced pooled and filtered platelet concentrates out of four buffy coats in tsol platelet additive solution and have stored them in pall autostop clx bags made out of pvc/totm. the residual plasma content is between - %, the mean volume about ml and the mean platelet-content is . ¥ per unit. for pathogen inactivation or bacterial screening it is necessary to extent the storage time from to days. new foliage like polyolefin is supposed to maintain a good quality environment for prolonged storage of platelets. aims: storage bags made out of polyolefin (pall autostop elx) were tested to prove their suitability for prolonged storage of platelets. methods: twins made out of pools from buffy coats were produced with the standard method, one twin was stored in the conventional bag (cb) the other in the new foliage bag (nfb). the platelet pools were stored on flatbed shakers at °c, and sampled at day , day and day . ph, glucose, lactate, hypotonic shock response (hsr) and p-selectin expression were measured by standard in-house methods. results: mean ph on day with cb was . , with nfb . ; glucose with cb . mmol/l, with nfb . mmol/l; lactate with cb . mmol/l, and with nfb . mmol/l, hsr with cb %, with nfb %; p-selectin with cb % and with nfb %. the new platelet storage bag showed better results of in vitro quality markers, especially after day of storage. prolonging storage time will make it easier to introduce bacterial screening or pathogen inactivation techniques into platelet transfusion. the possibility to filter rbc either at °c or rt simplifies the preparation process. filtration at + °c enables to achieve a better leukoreduction performance. the nbs has successfully implemented this project which has the potential for improvement in patient safety and is predicated upon practical application and risk reduction rather than elimination. the impact of this work on the incidence of trali will require detailed, long term analysis of hemovigilance data using existing mechanisms. active communication, a team approach, perceived value of the initiative and the hard work of all staff involved were key success factors. quality assessment of buffy coat-derived platelets prepared from leucoreduced whole blood background: whole blood can be separated into; plasma, buffy coat and red-cell conc (rcc) by differential centrifugation and separation on a separation device. because of the high hematocrit of the rcc, % of the process time is needed for expression of the rcc. by increasing the internal diameter of the tubing at the bottom of a t&b system by . mm. a decrease of the process time is expected. methods: units of whole blood were collected with the new t 'wide boring' blood pack and separated on a routine base. quality control parameters were checked and the whole process time was monitored. free hemoglobine was measured up to days. results: process time of a 'wide boring' bag is significant shorter compared to a standard blood bag. average decrease: s. slightly increase in free hemoglobine is measured probably due to the increased express rate of the red cells. bloodproducts produced with the new t meet european guidelines. no significant increase of free hemoglobine due to the faster expression is measured. an significant decrease in process time is measured with the wide boring bloodpack. the new fresenius hemocare rcc in-line system: t can be used for routine production which will speed up the production process considerably. introduction: leukoreduction of blood components is required to prevent several transfusion-associated complications. aim: the aim of this study was the full process validation of the pall leukotrap wb system for the preparation of leukoreduced blood components. we collected whole blood units from donors suitable for donation using a quadruple blood-bag, which includes an wbf in-line filter (pall) for the removal of leukocytes and platelets. mixer balances (baxter) were used and donation occurred within min in all cases. after donation whole blood units were stored at room temperature for h. subsequently, whole blood filtration was performed by gravity at a standard height of cm using a blood leukoreduction cart (baby leuko cart, itl-corporation). filtered units were centrifuged at g ¥ min by an heraeus cryofuge i. an automatic extractor (bag press plus-bioelettronica) was used to prepare red cell concentrates in sag-m solution and fresh plasma units. air in the system was automatically expelled by the extractor. complete cell counts and hemoglobin concentration were evaluated in pre-filtration samples and at the end of the blood components preparation using an automated cell counter (pentra dx -abx). we enumerated residual leukocytes in red cell units by flow cytometry (becton dickinson-leucocount kit). results: pre-filtration data of whole blood and end-of-process data of red cell and plasma filtered units, are summarized in table . results are given as mean and standard deviation. whole blood filtration was completed within min in all cases. red cell units were transfused after a mean of days to patients affected from transfusion dependent ( %), post-surgery ( %), and post chemotherapy anemias ( %). no cases of transfusion reaction were observed. the pall leukotrap wb system was easily introduced in our setting. all blood components prepared by the system fulfilled the council of europe requirements with regards to hemoglobin content in red cell units and post-filtration residual leukocytes. future studies are needed to evaluate its cost-effectiveness in the setting of routine blood component preparation. background: during an evaluation of the compodock (fresenius hemocare) sterile connection device (scd), we observed irregularities on the inside of the tubing at the site of the weld. it was our aim to investigate the effect of these observations on the quality of blood products. methods: three leukoreduced red cell concentrates (rccs) were pooled and divided over bag systems: one without weld in the connecting tubing, one with a compodock-weld, and one with a weld made with the terumo scd. the rcc was transferred times over this tubing to have maximum result if the weld had deleterious effects. the rccs were stored in pvc containers, and sampled on day , , and , and free hemoglobin (hb) was measured. the same procedure was also performed using platelet concentrates (pcs), but these were stored in polyolefin containers, sampled on day , and , and cd expression was measured. ten experiments were performed per blood component. according to who standards processing of blood into labile components are considered an expression of quality of transfusion service. in our practice, modern transfusion principles are successfully applied. they cover blood collection, serological processing of blood units, technological preparation of blood products (gmp, sop) and rational utilization of blood components and blood derivatives. in the past four years ( , .) aberrations from these principles have taken place (self-sufficiency). nbti collected x = ( ) blood units into blood bags. in serbia x = ( ) blood units. retrospective analysis: ldpc-bc was administered x = % with the satisfactory haemostatic effect. increase of the cyta and plasmapheresis-manual procedures was also noted ( %). increase of the use of leukocyte poor red blood cells was also registered ( % introduction: according to the relevant recommendations of the council of europe, whole blood is a source material used for the preparation of blood components and blood products. basic concept of the therapeutic use of blood components is the compensation of the lacking or deficient blood component. in that way, a possibility of the infusion of unrequired or deleterious components of whole blood is eliminated. objective of this presentation is to analyze the reasons of non-utilization of certain blood units, the actual quantity and ratio. aim of the study: the purpose of our in vitro study is to compare storage of platelet concentrates at °c with platelets stored at °c, and to determine the in vitro-effects of pre-incubation at °c for h prior to analysis on the basis of the maintenance of platelet metabolic and cellular integrity. methods: platelets concentrates (pcs) were prepared from pooled buffy coats (bc) for paired studies to be stored into different conditions. (i) at - degree on a flat bed agitator; (ii) at - degree on a flat bed agitator and pre-incubated for h prior to analysis; (iii) at °c; and (iv) at °c and pre-incubated for h prior to analysis. this paired in vitro study (n = ) over days include volume, platelet counts, mpv, volume, ph, po , pco , bicarbonate, glucose, lactate, swirling, leucocytecount, hsr, esc, atp, ldh and release of a-granule content (rantes, ß-thromboglobulin and pf ). results: platelet count (day and ; p < . ), mpv (day ; p < . ), ph (day and ; p < . ), pco (day and ; p < . ), bicarbonate (day ; p < . ), glucose (day , , , and ; p < . ), atp (day and ; p < . ) was significantly higher in platelets stored at °c and platelets stored at °c with preincubation. ldh (day ; p < . ), bicarbonate (day and ; p < . ), lactate (day , , , and ; p < . ), ph (day and ; p < . ), esc (day , , , and ; p < . ), hsr (day , and ; p < . ) was significantly lower in platelets stored at °c and platelets stored at °c with pre-incubation. the concentration of rantes, ß-thromboglobulin and pf was significantly higher in platelets stored at °c than in platelets stored at °c (day , , , and ; p < . ). hsr (day and ; p < . ) and esc (day , , and ; p < . ) was significantly higher in preincubated platelets stored at °c compared with platelets stored at °c. conclusion: platelets stored at °c maintain metabolic and cellular characteristics to a great extent during days of storage. we confirm the loss of platelet discoid shape and have shown that loss of discoid shape in platelets stored at °c is associated with decreased metabolic rate and decreased release of a-granule content. aim: as reference centre of the swiss blood transfusion service for new materials and blood products we evaluated that system for routine use and official registration in switzerland. method: whole blood donations were collected in a whole blood filtration set with cpda- and stored at room temperature for h before filtration at room temperature. the leucodepleted whole blood was stored for days. following parameters were analysed on day , , : free haemoglobin in%, k. in addition leucocyte count was performed on day and a blood culture on day (see table) . blood cultures on day remained negative and all counts of residual leucocytes were below ¥ (exponential) /unit. summary and conclusion: as expected there was a clear increase in k and free haemoglobin after day . however the results were within the required specifications from the european and swiss guidelines up to day . we conclude that autologous leucodepleted whole blood can be stored in cpda- -for days without loss of stability of the red cells. we will introduce the system to the offi-cial material list of the swiss blood transfusion service and then implement the procedure to our daily routine. results of ffp production from whole blood, and of ffp and pc produced by use of cell separator over a -month period before and after the introduction of measures for trali prevention are presented. the following measures were undertaken: ( ) blood of female donors was not used for ffp production, and plasma was only used for fractionation ( ) plasma of female donors was not used for kt-bc pools ( ) platelets and plasma were produced on a cell separator only from the female donors without a history of pregnancy. female donors of whole blood: %*; %** ffp produced by plasmapheresis: %*; . %** female donor units on cell separator: . %*; . %** ffp from total plasma units: %*; %** plasma units used for bc-pc pools: %*; %** *period before and **after the introduction of measures for trali prevention the exclusion of female donors had no major impact on the production of ffp and bc-pc pools from whole blood because of the very low rate of female subjects in the croatian blood donor population. the amount of plasma and pc collected from female donors by use of cell separator was significantly lower (~ %), however, without any major impact on total ffp store because of the small rate of plasma and platelets obtained by apheresis. background: platelet concentrates (pcs) are currently stored for a maximum of days. extended storage to days would increase the supply and reduce the waste of pcs. transfusion-associated graftversus-host-disease (ta-gvhd) is a severe transfusion reaction caused by t-lymphocytes in the transfusion product. the risk of developing ta-gvhd can be prevented by gamma irradiation of the pcs. various in vitro tests can be used to study the quality of pcs such as inspection of the swirling phenomenon, hypotonic shock response (hsr), detection of platelet surface markers (e.g. cd p and cd b), metabolic parameters and blood gases. free oscillation rheometry (for) using the instrument reorox® can be used to monitor the coagulation over time in whole blood, pcs and plasma samples, and to obtain information about clotting time and coagulum elasticity. aim of the study: the purpose of this study was to evaluate the quality of pcs obtained by apheresis technique during storage for days and to study the effect of gamma irradiation by using several in vitro methods including for. methods: platelets were collected from healthy donors (n = ) using apheresis technique. the pc from each donor was divided in units, one served as control and the other was gamma irradiated with gy. the pcs were stored on a flatbed agitator at °c for days. samples were taken on day (= day of collection) for analysis of blood gases, metabolic parameters (glucose and lactate), platelet count and swirling. samples taken on day , and were also analysed for hrs, cd p (p-selectin) and cd b (gpib) expression utilising flow cytometry. evaluation of coagulation by for was performed on day , and . the maximum elasticity (g'max) and the time to g' were evaluated from the for elasticity curves. results: there was no difference between irradiated and nonirradiated pcs regarding any of the tested parameters during the storage period. swirling, hsr, platelet count and percentage of cd b expressing cells were well maintained for days of storage. glucose decreased and lactate increased significantly during the storage period, from . mmol/l to . mmol/l for lactate and from . mmol/l to . mmol/l for glucose. the percent cd p expressing cells increased significantly during storage from % on day to % on day . po was well maintained but ph increased and pco decreased significantly between day and whereafter ph decreased and pco continued to decrease. the for parameters g'max and time to g'max increased significantly between day and and the time to g'max continued to increase significantly between day and . the results indicate a well preserved platelet quality after storage for days. gamma irradiation did not affect the platelet quality. cytokine release during storage of buffy coat platelet concentrates produced manually and automatically background: transfusion reactions following platelet transfusion are still a problem even when leukoreduction is included in the production process. platelet derived cytokines released during storage upon activation or lysis, accumulate in the platelet products and have been suggested to be involved in transfusion reactions. rantes (regulated upon activation, normal t cell expressed and presumably secreted) is a chemokine playing an important role in the inflammatory immune response and causes degranulation of eosinophiles and release of histamines from basophiles, which again can cause allergic reactions. tgf-b (transforming growth factor b ) has been shown to be immunosuppressive, inhibits the proliferation of t-and b-lymphocytes and decreases the secretion of igg and igm from b-lymphocytes. aims: as part of our quality control program, we aimed to quantify the amounts of rantes and tgf-b released during storage in platelet concentrates produced from pooled buffy coats by our manual routine method (m-pcs) and by an automated method using the orbisac system (gambro) (a-pcs). methods: pcs were produced from buffy coats. following overnight storage at - °c, buffy coats were pooled with ml t-sol (baxter). forty-two pcs were produced either manually (n = ) using the imugard iii s-pl set (terumo) with integrated soft leuko-reduction filter or by the automated procedure (n = ) using the orbisac validation bc set (gambro) equipped with the lrp leuko-reduction filter (pall). swirling was scored visually, platelet count and mpv were measured on a cell counter (cobas argos, roche), and blood gas analyses, glucose as well as lactate were measured on an abl series analyser (radiometer). samples for testing of cytokines were centrifuged for min at g, °c; supernatants were harvested and frozen at - °c until analysis. cytokines were quantified using quantikine human rantes immunoassay (r&d systems) and human tgf-b elisa immunosorbent assay (bender medsystems gmbh). all analyses were performed on days , and . results: platelet concentrate volume (mean): m-pcs: ml, a-pcs: ml. platelet yield was found to be . ¥ for m-pcs and . ¥ for a-pcs (p < . ). in all pcs ph levels were between . - . . glucose consumption and lactate production from days - and days - did not differ significantly. rantes levels (pg pr plts) were significantly higher in a-pcs than in m-pcs (p = . , repeated measures analysis of variance), but no significant difference was found in tgf-b levels (pg pr plts). summary and conclusions: preparation of buffy coat platelet concentrates by the automated orbisac system improves platelet yield compared to our manual processing procedure, but the levels of the chemokine rantes were significantly highest in the automatically produced products. the clinical importance of these findings is still unclear, but may be related to the shear stress the platelets are subjected to during the automated production process. the quality of cryopreserved vs liquid stored platelets: a comparative study table . the mismatches can be divided into the two categories. the first of them is characterized by differences in allelic groups, i.e. at low-resolution level. allelic group differences were detected in the group with one mismatch, most of them in hla-c locus (this locus was not concluded in primary donor search). in the other category there are differences in alleles within the same group, i.e. at high-resolution level only. differences within the same group in all tested loci were detected in the group with one mismatch. the mismatches described above were heterogeneous and a correlation of specific mismatch with transplantation outcome was not possible in this group. conclusion: the use of high-resolution dna methods makes the identification of hla match/mismatch more accurate and can affect the outcome of unrelated hsct. this work was supported by the grant iga mz, no. nr/ - . pre-freezing and post-thawing quality controls in umbilical cord blood assigned for transplantation p bergamaschi, c perotti, g viarengo, c del fante, c parisi, a marchesi, l bellotti and l salvaneschi irccs policlinico 'san matteo', pavia, italy background and aims: nowadays umbilical cord blood (ucb) represents a well established source of haematopoietic stem cells for unrelated transplantation in children affected with haematological and inherited diseases. thanks to the large-scale banking of unrelated units and the preliminary encouraging results, ucb employ in adults is quickly growing up. in this context, total nucleated cells (tnc) count of the graft is considered the main predictor for clinical outcome; however, other indicators of the haematopoietic potential, such as cd + cell content and short-term culture clonogenic assay, are recommended in accordance to netcord-fact stan-dards. in order to guarantee the safety and the prompt availability of a ucb unit assigned to a matched recipient, a pattern of rigorous quality controls should be carried out not only at the time of cryopreservation but also before the release for transplant. we report the results of the quality controls performed on thawed cryovials referring to the units delivered by our ucb bank compared to the pre-freezing values. methods: every ucb unit stored in our bank is accompanied by satellite cryovials available for subsequent controls. for each unit issued for transplantation, one cryotube was thawed in °c water bath with gentle agitation without washing out dmso. tnc and mononucleated cells (mnc) were estimated by an automated cell counter; viability and cd + cell count were evaluated by flow cytometry with a no-wash, single-platform technique and aminoactinomycin d. cfu assay was performed using commercial reagents (methocult gf h , stemcell technologies) and colonies were counted after days. the same tests were performed before cryopreservation, taking a sample from each fresh unit. moreover, before the delivery for transplant, a second cryotube was thawed to investigate the bacterial contamination by direct microbial culture, whereas the sterility test before freezing was performed by inoculum into ml media (bact/alert®fa/fn, biomérieux inc). results: the ucb characteristics before freezing and after thawing are detailed in the tables , and . post-thawing tnc and mnc, as well as cd + cells, showed no significant difference in comparison to the pre-freezing values. despite of the expected decrease of the overall viability after thawing, we observed a highly satisfactory viability referred to the cd + cells. the colony forming units (cfu) growth after thawing was documented and was always lower as respect to the pre-freezing assay. finally, the results of microbial cultures were negative for all the units on both fresh and thawed specimens. conclusions: in our experience, well standardized evaluation of ucb content could be obtained with regard to tnc, mnc and cd + cell. concerning the results of short-term cultures, the presence of dmso as inhibiting factor may be advocated to explain the discrepancies between fresh and thawed samples. finally, rigorous quality controls documented that the procedures of manipulation and cryopreservation did not affect the quality of ucb to be infused for transplant and provided to the physician all the parameters necessary for a safe transplant in a close and appropriate time. bone marrow transplantation or bmt transplantation of progenitor blood cells to regenerate blood normal cells in patients with blood disorders. bone marrow has an organized and structured architecture in which close relationships exist between a regulatory microenvironment and primitive hematopoietic cells. in fact, normal hematopoietic cells depends on critical interactions that occur between stem cells and their microenvironment. this microenvironment is a complex meshwork composed of growth factors, stromal cells, and extracellular matrix. marrow injury can occur as a consequence of a variety of diseases. some diseases could be due to a microenvironment that fails to support hematopoiesis. a possibility is that aplasia and leukemia share a common etiology such as drug, chemical, radiation, virus or other environmental hazards. we can say that microenvironmental abnormalities in interactions between stromal cells and hematopoietic progenitors may be important in the pathogenesis and clinical expression of hematopoietic malignancies in humans. background: intrauterine growth retardation, with associated low birth weight, represents one of the most important cause of baby mortality and morbidity. understanding the genetic bases of this adverse event is still an open goal. there is evidence that motherchild hla compatibility and hla-drb foetal genotype are associated with a reduced placental growth and a low birth weight. the recent institution of cord blood banks, with their huge amount of hla types, offers an unique opportunity to look inside the molecular bases of normal birth weight. aims: we investigated whether the baby-linked immunogenetic profile, i.e. hla gene frequencies and homozygosity rate, affects the physiological variance of the size at birth. methods: cord blood units ( from males and from females) were hla typed with pcr-ssp and/or reverse pcr-sso techniques and recorded in the cord blood bank database of pavia-italy. all were defined at low resolution level for hla-a and b genes and at high resolution for hla-drb . blood units were also randomly typed for hla-dqa and dqb at high resolution. results: mean birth weight was g and mean relative birth weight (i.e. corrected for gestational age according to the gender) was . g. babies were < th centile ( g) and were > th centile ( g). comparing the hla allele distribution in these extreme bands we found that hla drb * was significantly associated with high relative birth weight: . % in th centile vs . % in th centile, p = . . on the contrary, hla-drb * and dqb * were associated with low relative birth weight: . % and . % respectively in th centile vs . % and . % in th centile p = . and p = . . all infants were analysed as to the effect of the above mentioned alleles. we confirmed the positive association of hla-drb * and higher relative birth weight (mean . vs . ; p = . ) as well as the association of hla-drb * with lower relative birth weight (mean . vs . , p = . ). no significant association was found as far as hla homozygosity was concerned. conclusions: the present findings confirm the role of foetal hla-drb gene in the intrauterine growth. about the specific involved alleles, one possible explanation comes from the studies of crystallography and amino acid sequencing of hla-dr binding groove. it has been demonstrated that hla-drb * and hla-drb * genes encode for different amino acid sequences in the pocket of the molecule (aa , , ). this implies distinct functional restriction patterns. the sequence motif of hla-dr is characteristic of some autoimmune conditions, such as hashimoto's thyroiditis, and preeclampsia which is associated with intrauterine growth retarda- which provides a high yield and excellent purity without lymphocyte and erythrocyte contamination. in a month period, we studied blood samples from bone marrow transplant patients and from normal subjects. the extraction of leukocyte polymorphonuclear was obtained with a %- % dextran solution in . % saline. after incubation at room temperature with lymphopre solution, the mixture was centrifuged. two clear and separate rings of mononuclear and pmn leukocytes were obtained. to eliminate any red blood cells, pmnl ring was separated and washed three times with cold ammonium chloride. after a short period of incubation °c, mixture was centrifuged and the pmnls were isolated. the purity and viability of total leukocyte population was counted and the percentage of pmnl obtained was established. the total blood samples studied were divided in two groups, i.e., bone marrow transplant patients and normal subjects. in both cases the pmns isolated were of high purity and viability. the overall percentage of pmnls obtained from both groups under study was % to % when stained with gimsa or wright staining method. the viability of isolated pmnls was also % too, which is excellent for numerous immunological or molecular studies. the pmnls isolated by this method were highly pure and viable in comparison with standard methods used to isolate human pmnls. generation a high amount of pmnls is another advantage of the suggested method. this method to separate pmnls is recommended for in vitro studies of different subjects. et al. .) the object of exchange transfusion (et) is to remove bilirubin already present in the plasma or remove alloantibody which can cause hemolytic disease (in order anti-d, anti-c and anti-k are easily the most important) or remove anti-d positive red cells. we have studied exchange transfusion in our hospital in neonatal intensive care unit, during to . at delivery cord samples were taken for determination blood group, rhesus, hb and ht have been counted. also direct antiglobulin test (dat) has been performed. in cases of positive dat, hb and bilirubin levels were monitored. newborn body-weight were weighted (ranged g to g). the blood for et was of group o, d negative and kell negative and was compatible with the serum of mothers; it was less than days old. the blood was screened for hbs and for anti-cmv as well as being submitted to all usual tests. the method has been determined by using the umbilical vein; the multi-way tap makes it possible to draw blood from the infant into the syringe, to discard the blood into a sterile empty vessel, then to draw blood from a donor unit into the syringe and inject this into the infant. results: exchange transfusions were carried out. four out of et due to abo incompatibility mother-newborn. five out of due to rhesus incompatibility mother-newborn and eight out of due to jaundice undetermined origin and immaturity. the last two years only three et were carried out due to immaturity. conclusions: phototherapy, when applied early enough and with sufficient intensity, can avoid the need for exchange transfusion in many infants. phototherapy alone or phototherapy plus high dose igg therapy has been used to minimize exchange transfusions in this population. detection abo blood group system antibodies of neonatal using fully automated column agglutination technology (auto-vue) background: the abo blood group system remains the most important in transfusion practice. this is because of the regular occurrence of the antibodies anti-a, anti-b and anti-a, b reactive at °c, in persons whose red cells lack the corresponding antigens. the regular presence of anti-a and anti-b is used in the routine determination of abo blood groups; in addition to testing red cells for a and b antigens, the group is checked, in serum or reverse grouping, by testing the serum against red cells of known abo groups. methods: samples were taken from newborns at first h of life for abo blood group typing during - . simultaneously the presence of anti-a and anti-b antibodies has been studied using fully automated column agglutination technology (auto vue ortho diagnostic systems) with bio-vue cassettes aborh/reverse. the column agglutination technology is based upon the ability of glass beads to form a physical barrier between agglutinated and unagglutinated red cells. to determine the abo serum group, test serum and abo reagent red cells were added to the top of column containing diluents. the abo grouping columns were centrifuged and examined for agglutination. the presence or absence of agglutination has been recorded. results: in out of newborns were found detected antibodies anti-a, anti-b. in out of newborns no antibodies were found. in out of were found antibodies maternal origin. the automated reader detected all positive reactions. positive results were recorded on a scale from + . to + . conclusions: the technical performance of device allows objectivity and precision to detect abo blood group antibodies of newborn. the origin and the type of antibodies and also factors that influence their presence are to be studied. introduction: diagnosis, management and prevention of red blood cell immunization have improved, so hemolytic disease of the newborn (hdn) has changed from a common to a rare pathology. aim of the study. in this study we have retrospectively evaluated the benefits of the immunohematological screening for the management of pregnancies with alloimmunization. methods: in the last years, we have performed an immunohematological screening on all pregnant women assisted by our hospitals. ab and rh typing, antibody screening and, eventually, identification and titration were performed on maternal specimens by microcolumn technique. results: not considering ab incompatibilities, we have discovered alloimmunized women with the following specificities: anti-d, anti-c, anti-c, anti-e, anti-jka, anti-d + anti-jka, anti-d + anti-s, anti-d + anti-c, anti-d + anti-c + anti-k, anti-s, anti-k, anti-m, anti-c + anti-e and anti-d + anti-c + anti-g. the most severe hdn were the d + c + g, the c + e and out of c newborns, with mean hemoglobin between and g/l, bilirubin = . g/l, reticulocyte count = %. in these exchange transfusion needed at the delivery. other newborns were only treated with phototherapy. conclusion. thanks to the immunohematological monitoring, the diagnosis of alloimmunization, the correct management of pregnancy and the adequate neonatal therapy were possible. in fact all newborns survived and showed no neurological lesions in the following controls. conclusion: in order to provide a highly specialized perinatal care, immunohematologist, obstetric and pediatric should provide a good antenatal and perinatal screening. this is an interesting case of rhd immunisation in rhd negative woman despite the application of rhd immunoprophylaxis. case report: a blood sample of pregnant woman, years of age, in th gestation week, was sent to our laboratory for serological analysis. her blood group was o, ccddee and she had an anti-d antibody reactive only with enzyme treated panel of test erythrocytes. her husband was a, ccdee, and two children were both a, ccddee. on the next visit, she gave the data of one arteficial and one missed abortion before the th gestation week covered with mg of rhd immunoprophylaxis, but without the measurement of fetomaternal haemorrhage (fmh). both of abortions were after the deliveries. until the end of the pregnancy, detailed serological analysis showed anti-d specificity of antibody in her sera which remained reactive only with enzyme treated red blood cells. the fetus was under permanent ultrasound control. she delivered a mature, rhd positive, ccdee male child, without any sign of haemolytic disease. the proper personal history, measurement of the size of fmh, distinguishing the anti-d and anti-g specificity of the antibody, administration of rhd immunoprophylaxis and cooperation between transfusion medicine specialists, gyneacologists and neonatologists still remain major principles of prenatal and perinatal care concerning haemolytic deisease of the fetus and newborn caused by anti-d antibody. anti d antibody, reactive only with enzyme treated red blood cells is usually harmless for fetus and the newborn. introduction: red blood cell (rbc) transfusion is widely used in neonatal intensive care units for acute or chronic pathological conditions. clinical indications for rbc transfusion are shock, sepsis and/or anemia with the following laboratory criteria: a) hematocrit (hct) < % or hemoglobin (hb) < g/dl and reticulocytes < %; b) hct < % or hb < g/dl in these conditions: o required < %, recurrent apnoea and bradicardia, cardiac rate > bpm and respiratory rate > bpm for more h; c) hct < % or hb < g/dl with severe respiratory distress. aim of the study. aim of this study has been to evaluate the effectiveness of rbc transfusion therapy in premature and at term newborns independently of initial pathological conditions. methods: our therapeutic objective has been to achieve an hct of % after the whole cycle of transfusion therapy. for each little patient, the volume of transfused rbc unit has been calculated, according to international guide lines, using the following criteria: weight (kg) ¥ blood volume ( ml per kg if premature or ml per kg if at term newborn) ¥ (hct desired -hct observed)/hct of unit transfused. particularly we have considered that premature infants (with a gestation age of - weeks) show a range of weight from to . g, while at term newborns from . to . g. in order to avoid a circulatory overload, the indicated hemocomponent has been always packed rbc with higher possible hematocrit. for the same reason, the rate of infusion has been always - ml/kg/hour. methods: this is a descriptive study. the name of the neonates who received transfusion was obtained from the blood bank of beheshti hospital. information concerning the type of blood product, frequency and indication of transfusion, sex, gestational age and weight of infants was recorded in questionnaire and analyzed. results: out of neonates admitted during one year, ( male, female) received blood components. fifty four percent received one, % two and % received three types of blood components. the frequency of transfusions were times. the most common used blood products were fresh frozen plasma ( %), red blood cell ( %), whole blood ( %) and platelets ( %). all the blood products except whole blood were used more common in premature and low birth weight infants. appropriateness of transfusion of red cells, fresh frozen plasma, platelets and whole blood were %, %, % and % respectively. (hdn) . in accordance to current regulations, this study is carried out in all pregnant women attending in our service. according to our protocol, when an alloantibody of any specificity is detected through the liss-coombs gel technique, the same determination is made using papain-treated screen cells to detect any association with other antibodies which could be of clinical relevance for a hdn. there are scientific evidences that the use of enzymatic techniques increase the test's sensitivity, though clinical relevance of 'enzyme only antibodies' may be questioned. aims: demonstrate the importance of a routine identification of irregular antibodies in pregnant by two methods (liss-coombs -enzymatic) and the prevalence of anti-d associated antibodies, only detected by using enzymatic technique. analyze the need to carry out a follow up of sensitized patients to determine if the associated antibodies only detected with in an enzymatic medium can be detected with a liss-coombs medium during pregnancy, thus acquiring clinical significance for hdn. materials and methods: between january and december we studied d-negative pregnant women. the studies performed were: abo grouping, d and weak d, rh phenotype, direct antiglobulin test and irregular antibody detection (iad) against commercial screen cells with liss-coombs (diamed) ® gel-medium technique, according to the manufacturer's specifications. when iad were positive, an antibody identification using two commercial cell panels with gel techniques (liss-coombs-enzymatic) was performed. along the pregnancy, periodic controls were carried out to determine the exact moment when antibodies, previously only identified in an enzymatic medium, could be detected in a liss-coombs medium (clinically significant antibodies). results: out of d-negative studied samples, ( . %) had a positive dai and it was only showed anti-d specificity in a liss-coombs medium. after analyzing this specificity against enzymetreated erythrocytes, it was possible to determine that patients ( . %) had in their serum other anti-d associated alloantibodies: anti-k ( . %), anti-c ( . %), anti-e ( . %) and anti-c + e ( . %). during the immunohematologic follow up, it was determined that in / patients some of the antibodies which were previously only detected in an enzymatic medium, could be identified in a liss-coombs medium and later they were identified in the red cell elution of the newborn. conclusions: these results confirm the relevance of a screening for irregular antibodies of clinical importance by means of a conven-tional technique and one of increased sensitivity in all pregnant women. the detection of an association of antibodies provides information for the undertaking of diagnostic and therapeutic measures, both by the obstetrician, as for any eventual transfusional requirements for hdn. it was also concluded that, although antibodies detected in an enzymatic medium are considered of low clinical significance, its investigation and follow up is suggested in pregnant women to determine the moment in which they can be detected in an antiglobulinic medium, thus revealing their clinical significance. background: fibrin glue is one of the most complex human plasma derivatives both in terms of composition and clinical applications. this product mimics the last step of coagulation cascade through activation of fibrinogen by thrombin, leading to the formation of a fibrin clot in the presence of factor xiii. in contrast to synthetic adhesives, the significant advantage of this plasma-derived sealant is its biocompatibility and biodegradability as well as the fact that it does not induce inflammation, foreign body reaction or extensive fibrosis. readsorption of the fibrin clot is achieved during wound healing within days/weeks following application, depending upon the type of surgery, the amount and type of product used or the proteolytic activity of the treated site. the risk of virus transmission by commercial fibrin glue products is still debated and investigators are looking for alternative fibrinogen sources. many of these studies rely on autologous on single donor cryoprecipitate as source of fibrinogen. aims: the aim of this study was to compare single and double methods of cryoprecipitation of fibrin glue. the influence of different plasma preparation methods and plasma storage temperatures (- °c and - °c) on the quality of fibrinogen concentrate was examined. methods: whole blood was collected by standard phlebotomy technique and centrifuged at ¥ g for min within h of collection. plasma was removed. four units of plasma were pooled into a ml bag, mixed, divided into parts (aprox. . ml) and immediately frozen. two of these units were stored at - °c and units of ffp at - °c. after one month the plasma was thawed at °c during - h. the fibrinogen concentrates ( - ml) were received by single and double cryoprecypitation. to compare single and double methods of cryoprecipitation, the levels of fibrinogen, fibronectin, plasminogen and factor xiii were determined. results and conclusion: the levels of fibrynogen were significantly higher in fibrynogen concentration obtained by double cryoprecypitation from plasma stored at - °c. there were no significant differences in the level of plasminogen in both tested groups. double cryoprecipitation of a single unit of plasma (stored - °c) is an efficient, simple and safe method of obtaining fibrin glue. background: talking about professional risk we generally consider the risk of acquiring some kind of infective disease through accidental injury. in this article i would like to point out another side of the problem-the risk of making preventable medical error. with all its consequences. aim: how blood transfusion errors are among the most serious types of medical errors, the final goal is to initiate nationwide, regular, mandatory error reporting. information obtained, distributed and openly discussed at professional meetings will contribute to improving the patient safety. at the same time it would contribute to avoidance of blaming and shaming of many health care providers. prevent what preventable could be! method: retrospective analyze was conducted at the middle size blood transfusion center ( donations per year and utilization of approximately of components). results: after clearly distinguishing adverse events due to underlying patient condition from preventable medical error we fined out that: -great majority of adverse events resulted from medical error -every part of blood transfusion center, from blood donation ward, through laboratory testing to component issuing has it' weak points' or vulnerable places -any educational level is equally liable to error there is no significant difference about occurrence time: -working day/holiday -emergency/routine request -routine h/out of routine h -main error cause were as follows: -donor sample misidentification -rhd typing error -abo typing error -incorrectly performed cross match -recipient misidentification -wrong component prepared -sample confusion during freezing preparation conclusion: the truth incidence of transfusion medical errors is underestimated. mandatory report of fatal or 'only' harmful errors to the referent institution and its periodical announcement is the step ahead in preventing errors. those reports should be discussed at professional meetings (not at the 'yellow pages') and served as educational tool. but, as the most of the errors are system related, the key to reduce them is to focus on improvement of the system and nil for plasma. wastage rate was highest for plasma components. the influence of local practices on such discarding and whether avoidable shall be discussed. audit for blood discarding and corrective actions to minimize discarding is essential for all transfusion services and blood centers. designed technical and economic support. options include importing finished products and/or procuring products made from locally collected plasma. one approach is to consider local fractionation of plasma by building and operating a plasma fractionation facility, which may produce, finished products, or may produce intermediate products that are further manufactured in another facility. an alternative approach is the implementation of a plasma fractionation program where local plasma is sent to an established fractionator, and the plasma is fractionated following preagreed terms. the end products are returned to the country of the plasma supplier. in the national center for the production of blood products was established, under the direction of elias politis and years later in begun the production of dried plasma from greek donors. by the year the center started the production of fibrinogen and by the year the production of antihaemophilc factor. in all the activities of the center settled down due to administrative aspects. at the beginning of s a contract fractionation program was instituted (under the direction of k. sofroniadou) concerning the fractionation of liquid plasma and production of albumin, which by the end of year stopped and was replaced with a new contract for the fractionation of source plasma and the production of albumin. the challenge of adapting to the new and more stringent regulations governing the manufacture of blood products was great and brought a lot of changes in the structure of our center. a new bar-coding system ensuring the traceability of blood donations was instituted together with complex software for packaging and preparation of plasma shipments to the fractionation center together with all necessary paper work. a close collaboration with the medicines regulatory authority in order to be able to fulfill all the requirements that regulate issues associated to the quality and safety of human derived medicinal products. collaboration with blood collection establishments was promoted in order to increase the amount of plasma produced. there is a continuous effort from all the implicated parts in order to follow defined quality assurance procedures as highlighted by international guidelines for the blood donor selection, collection procedures, testing methods, donation handling, storage and transportation of plasma. the plasma contract fractionation program may serve, as an initial step prior to switching production to a locally built facility. this lapse of time may be used to expand the plasma collection potential, and to permit appropriate design, qualification and validation of the facility as well as training of local personnel. background: fibrin glue became a reality in the early s, when techniques for the isolation and concentration of clotting factors were improved. in , matras et al. described successful application of fibrin glue for peripheral nerve repair. this encouraging report prompted the use of fibrin glue in wound closure, skin grafting and bone union of osteotomies. the fibrinogen component of fibrin glue is produced from single unit donations of fresh frozen plasma. such procedure helps to reduce the risk of transfusion transmitted infections encountered by exposure to pools from large numbers of donors or by use of fibrinogen prepared from autologous blood prior to surgery. the second component, a mixture of thrombin and cacl , is commercially available. thrombin is applied to the operation site simultaneously and in equal volume to the fibrinogen but from a separate syringe. there are many methods of fibrinogen concentrate preparation but none of them has been described in detail. aims: the aim of this study was to choose/select the most effective, simple and safe method of obtaining fibrinogen concentrate (basic component of fibrinogen glue) which would also be easy to prepare in blood transfusion centers. methods of precipitation of fibrinogen by polyethylene glycol (peg), ammonium sulphate, ethanol or cryoprecipitation were compared. methods: plasma was obtained after centrifugation ( ¥ g for min) of whole blood. four units of plasma were pooled into a ml bag, mixed, divided into parts and immediately frozen. one of them was stored at - °c and after one month the plasma was thawed at °c during - h. fibrinogen was obtained by cryprecipitation and each of the three remaining units was precipitated with ethanol, peg and ammonium sulphate. the levels of fibrinogen, fibronectin, plasminogen and factor xiii were determined in each fibrinogen concentrate. results and conclusion: the level of fibrynogen ratio in fibrinogen concentration, obtained by peg and ammonium sulphate was significantly higher. cryoprecipitation is a simple, economic and reproducible procedure with the advantage of being performed in a closed system. plasma fractionation program in greece: an unknown history the provision of safe and sufficient plasma derivatives to meet the needs of local population requires special consideration and a well- (light cycler, roche diagnostic systems, nj) was used for the identification of the c y, h d and the s c point mutations of the hemochromatosis gene, and were based on protocols developed, for c y by the unidad de medicina molecular (ingo, santiago de compostela, espanha), and for the other two mutations by bolhalder m et al. the primers and probes were designed by tib molbiol (berlin, germany). results: the analysis of the percentages of genotypes and allele frequencies of the hemochromatosis gene mutations are described in the table. no differences were found between the patients and the controls. when we compared subgroups of patients based on their hepatitis c genotypes, a higher value for the c y allele was obtained ( . %) in individuals with genotype , however without statistical significance. discussion: hereditary hemochromatosis is a common disorder and is associated, in some studies, with a worst prognosis in patients with viral hepatitis. follow-up studies are necessary in order to evaluate if the presence of these mutations can cause a more severe course of the illness (greater risk to develop fibrosis or cirrhosis) and a different outcome when treated with antiviral drugs. also, it will be important to evaluate if aggressive phlebotomies will modify their clinical evolution. introduction: portugal has a higher prevalence of viral hepatitis, with probably more than . patients chronic infected with hepatitis b and/or c. hereditary hemochromatosis (hfe) is one of the most common causes of known hereditary illnesses with hepatic repercussion. hfe mutations are also found in linkage desiquilibrium with particular hla haplotypes, conferring, eventually, a different response to viral agents and antiviral drugs. in this study we evaluated the prevalence of the main mutations c y, h d and s c for the hfe in a population with chronic hepatitis b and/or c and in a cohort control. background: haemolytic disease of the newborn (hdn) is the destruction of the red blood cells of the fetus and neonate by antibodies produced by the mother. although postpartum rhig prophylaxis reduced the incidence of alloimmunization from pregnancy from % to - %, the doubt subsists if it is appropriate to use it as routine antenatal prophylaxis. material and methods: a total of samples ( mothers and newborns), from / / and / / , were studied. all abo, rh typing, antibody tests and dat were carried out in column agglutination tests. results: from the cases studied it was found cases without incompatibility ( %). from the incompatibilities, . % were abo, . % were rhd, . % were other rh incompatibilities, and . % were due to auto-antibodies. % of the mothers were rhd+ and % rhd-. conclusion: of the pregnant women studied, only were rhd-. from this group ( %) delivered rhd-newborns, what revealed that the antenatal prophylaxis they were submitted was unnecessary. from the pregnant women rhd-, % had incompatibility abo, which decreases to near % the risk of development of rhd immunization. being anti-d immunoglobulin a product that has the potential risk of infection transmission, is it appropriate to use indiscriminately as a routine antenatal prophylaxis? the introduction of molecular methods to determine the fetal rhd genotype could rationalize the use of antenatal anti-d immunoglobulin prophylaxis. introduction: the frequency of hla a haplotype expression has been found about - % in caucasian and in greek population particularly, . %. because of the high frequency, it is used widely in anticancer immunization. the immune system plays an important role in the defense against neoplastic disease and immune response show temporal chances related to circadian variation of antibodies and total lymphocytes in the peripheral blood. aim: the probable difference in the frequency of hla a expression and their lymphocyte phenotype into a group of cancer patients and a group of healthy donors, during screening of immunization with hla-combined peptides. materials and methods: healthy donors who proceeded in the department of transfusion medicine, university hospital of heraklion crete were tested for the hla a expression. in of these donors the expression of cd , cd , cd , cd , cd , cd , hla dr, cd +cd +, cd +cd +, cd -cd +, cd +cd -cd +, cd -cd -cd +, cd -cd -cd + was examined. meanwhile, patients with metastatic cancer who were hospitalized in the department of medical oncology, university hospital of heraklion crete, were tested for their hla a expression, while in of them for their lymphocyte phenotype. the antigens expression was examined in flow cytometry. the hla a expression in healthy donors was . % and in cancer patients % (p > . ). in table the mean, standard error, t-test and p of the two groups are included. (see table ). the two groups (healthy donors and cancer patients) revealed no statistical significant difference on lymphocyte phenotype, except of the cd expression, which was higher in cancer patients. summary and conclusion: the expression of hla a in cancer patients and in healthy donors was comparable. also, the lymphocyte phenotype among the two groups has not statistical significant difference, except of the cd (total b-cells). the significance of this result has to be investigated. in the course of original documents research i found out that dr. kalic, head of the first organized blood transfusion institution in the balkan region (at beograd, serbia, in ), set himself a professional goal: blood should be awaiting all patients and transfusion should not be a privilege of large city inhabitants only. dr. kalic's idea was that blood transfusion should be administered according to clearly given instructions and using simple blood sets. encouraged by the conclusions of the congress held in paris in , dr. kalic started preparations for the transport of blood to the inland. he concluded bravely that citrated blood could be sent by regular mail, as an ordinary parcel, without particular protection from the outside temperature. he advised his colleagues to use blood as an intravenous injection. blood was taken from voluntary female donor in belgrade (capital), march . after keeping it for days at storage, blood was forwarded on a two-day journey to a small town, kilometres away from belgrade. there it was kept on a room temperature before its final use for a treatment of a patient suffering from secondary anaemia. the patient underwent the procedure without side effects and responded to the transfusion with blood sent in this manner much better in comparison to earlier methods of direct blood transfused. reminding ourselves of the courage of our ancestors to implement their professional knowledge and personal original ideas in a new way with the desire to help the patient as successfully as possible, we pay them the deserved respect and gratitude for inspiring and encouraging us in this way to try the same. conclusions: automation leads to increased standardization, faster specimen processing and reporting, elimination of manual specimen identification, uniform interpretation of serological reaction patterns and objective reading of haemagglutination endpoints. using auto-vue allowed the staff uninterrupted time to perform quality assurance duties, extended antibody identifications, preventative maintenance, inventory control. the instrument allowed us to leverage current staff to a more productive, less stressful level. introduction: exosomes are - nm secreted vesicles produced by antigen-presenting cells (apcs). the finding that exosomes from dc pulsed with tumor-derived peptides elicited potent antitumor tcell responses and tumor regression in mice has led to the proposal that human exosomes could be effective vectors for antigen delivery in the context of cancer immunotherapy. aim of the study: to establish the method of producing a new kind of tumor vaccine -exosomes secreted by dc, pulsed with tumor peptides. methods: exosomes used in this study were generated from monocyte-derived dc pulsed with peptides from k tumor cell lines. exosomes were purified by the methods of ultrafiltration and ultracentrifugation. the methods of dynal magnetic beads, flow cytometry and western-blotting were used to determine the surface molecules of the exosomes. the function of the exosomes was deter- objective: to develop an immunoheatological technique for the study of erythrocyte hyaluronic acid sodium salt (cd ) receptor expression in red blood cells (rbcs) from adults and newborns. materials and methods: samples of anticoagulated blood from adults (n = ) and umbilical cordon (n = ) were used. several dilutions oh hailuronic acid sodium salt solution % (sigma l- h ) were confronted with % erythrocyte suspension in phosphate saline buffer (pbs) ph . . the rbcs were previously treated with an enzymatic solution of % bromeline in pbs ph . (sigma l h ). agglutination readings' were been by slow sharking after of h incubation at °c. the results were expressed through the sensibility parameter which involves titer and score. this is defined by a mathematical expression a = à si. di- . - (i = , , . . .) where si represent the score and di- is dilution inverse. the adult' rbcs showed a = ± , while en the newborn the parameter was a = ± . our results showed significant differences between both groups. conclusions: in this work, we present a simple immunohematological technique for the hyaluronic acid sodium salt (cd ) receptor expression in red blood cells, which could be a useful tool to evaluate the alterations of the receptor's expression in rbc. a new technology for crossmatching tests adapted to a fully automated system l gaillard, v desvigne, a boulet, l fauconnier and jm pelosin diagast, loos, france we have developed a new automated technology for crossmatching (compatibility) test suitable for automation and high throughput. the method does not require centrifugation steps thanks to the use of magnetised red blood cells (rbc). all the steps described are performed on the fully automated qwalys system. this methodology requires washing steps under magnetic field and is based on the fixation of sensitised rbc on the surface of a well coated with monoclonal anti-human globulins. in a first step, the red blood cells from target blood bags were magnetised during min. then the patient plasma is distributed on a microplate and incubated with the previously magnetised rbc during min at °c. excess of unbound immunoglobulins is removed by washing steps. in a third step, sensitised magnetised rbc were transferred in the antiglobulins coated plate and placed min on a magnet plate. wells in which antigen-antibody interactions have occurred display a confluent layer of rbc (positive reaction). the negative reaction appeared as a pellet in the middle of the well. the test can be read by an automatic reader or by naked eye. the patterns in the well are stable for at least h at room temperature. the plasma samples are provided by the laboratory of haematology of the chru of lille. the red blood cells are collected from segment of tubing of blood bags coming from the laboratory of blood donors of the efs (french blood services) nord de france-lille. the results are obtained in min. comparative studies showed that our new technology, without any centrifugation steps, is reliable and sufficiently sensitive and specific enough to perform cross matching tests using a high throughput automated system. the mechanisms of p -dependent apoptosis involve a set of genes that possess the ability to modulate oxidative stress. one of them pig , is induced by p through a microsatellite in its promoter region. this microsatellite has been proposed to represent an evolutionary adaptation of tumor suppressor mechanisms. microsatellite instability and genetic constitution, comprising the presence of the low repetition allele ( tgycc repeats), at this locus have been hypothesized to provide an increased risk for cancer development. aim: in the present analysis we examined this polymorphism in blood samples from voluntary health donors and compared it with human lung cancer samples, employing two different ethnic groups, greek and british. results: analysis of this locus in both types of samples showed: (i) the homozygous presence of the repeats allele only in the samples from healthy blood donors; (ii) a very low frequency of microsatellite instability (< %) and no loss of heterozygosity in matched normal-tumor tissues; and (iii) a non-significant increase of the most frequent allele ( repeats) in the cancer groups as compared to samples from healthy blood donors. the last two observations were found in both greek and british populations. conclusion: taken together, these data do not support the notion that this pig polymorphism is associated with an increased risk for cancer susceptibility. background: blood group determinations are routinely performed by the sensitive technique 'gel test' for the last few years. many weak d and partial d phenotypes which react as d negative or weak d by slide test, are assigned the rh d + status by gel test. this is most desirable in the case of blood donors but creates concern in case of patients and antenatal women with a partial d phenotype. case report: we report a female patient (blood group o, c+, c+, e-, e+) whose red blood cells gave a positive reaction of different strength and speed with different anti-d antibodies in slide tests. we were asked to type the patient and provide the appropriate blood units. the patient's cells gave a +/ + reaction in the standard screening procedure for the rh d in gel test micro-typing system that contains a polyclonal reagent of human origin (which allows a direct detection of most weak ds), a + reaction in a test with monoclonal anti-d and a +/ + reaction in the gel test micro-typing system destined to detect du and which contains polyclonal anti-d of human origin. however, since the slide test gave a rather slow onset of agglutination with one commercial reagent (made up of a blend of polyclonal and monoclonal anti-d) we tested the patient's red cells against anti-d reagents in the id-partial d typing system. one of these (number ) gave negative reactions and the remaining five gave positive reactions (ranging from +/ + to +), indicative of a partial d category vii phenotype. the patient's red cells were also tested in the id-card 'diaclon abo/d' . this card provides the complete profile for abo/rh d in one single procedure step, including the confirmation of rh d. it contains two different anti-d reagents within the gel matrix in two consecutive microtubes. the first anti-d (polyclonal human) is expected to give a positive result with d+ red cells and partial d category vi, while the second (monoclonal rabbit) is expected to give a negative result with dvi+ red cells. our patient's cells gave a negative reaction with the first and a +/ + reaction with the second anti-d in this system, indicating a d variant other than dvi. finally the patient was assigned the partial d category vii phenotype (according to the pattern of the reactions obtained with the id-partial d typing set) and rhesus d negative blood units were issued. this case illustrates the diversity of reagents used for rhesus typing in different laboratories. failure to disclose some d variants is a disadvantage when typing patients. a combination of techniques is often needed to reveal the real rh d phenotype. the only single system that could have revealed a d variant in our patient from the beginning, is the id-card 'diaclon abo/d' with two different anti-d reagents in two consecutive microtubes as described above. a cost-benefit analysis should be undertaken to show whether it should replace other screening tests for abo and rh d when typing patients. who cares about the quality of life of the chronic patients treated with blood products? d ilcenco*, e hanganu-turtureanu † , c burcoveanu † , c vartolomei ‡ and d azoicai § *blood transfusion center, † hospital 'sfantul spiridon', ‡ institute of hygiene, § university of medicine, iasi, romania quality of life is one of the methods used to appreciate the quality of the health system. romania is going to join soon the european union, so there must be a concern regarding the improvement of the national health system. blood receiver's life quality never been researched before in romania. we have been chosen a batch of chronic ill patients who have been received blood transfusion with blood or blood components, and asked them to complete two types of questionnaires regarding their life. we used nottingham health profile and beck's depresion index. results shows that this kind of patients need special care, because they all (with one single exception) feel frustrated and feel like a burden to the other normal persons. evolution of the pain index, mobility index, energy index, emotions index, sleep index and social isolation index was in concordance with the depression index. in conclusion, this type of patients needs special attention and medical authorities should make more efforts to assure their life quality support. transfusion medicine practice in surgically treated urology patients: our experience il ilincic*, bm bozovic* and ts tadic † *clinical center dr dragisa misovic, † natio. blood transfusion inst., belgrade, serbia objective: multiple studies demonstrate that the use of blood/blood products in patients undergoing elective urology surgeries, as well as the actual needs assessment, present the issue of numerous debates. method: using the retrospective method, utilization of blood/blood products was analyzed, as well as the ratio of prepared/used blood units in urology patients in the surgical ward, in the intensive care unit (icu) and at the urology center within the cc dr dragisa conclusion: due to a rather liberal use of primarily ffp in certain cases (cystectomiae in the first place), and a discrepancy between the prepared and actually used blood units, hospital transfusion committees should be an imperative in order to solve current dilemmas regarding justified use and proper administration of blood and blood products. background: the safe collection, production, distribution and application of blood and blood products in a high quality needs logistic on a high level. since the seventies computers, special software and barcode are used in transfusion medicine and improved the safety of processing data. in the last years a new technology was developed for industrial use, the radio frequency identification (rfid). aim: the aim of our studies was to check whether rfid can use reasonable in transfusion medicine. methods: at first we developed a flow chart, where we can use the technology and where are the problems by introduction. so we tested in the red cross donation centre in saxony about passive rfid smart label under real conditions. in cooperation between the akh vienna and novatech research a new handheld pc software 'labelview' for all steps around the transfusion was developed, including the identification of the patient and the processing of the haemovigilance data, and tested in first time. results: passive and semiactive (with temperature control) rfid labels survives all hard steps during the working up of the whole blood (e.g. centrifugation by g, separation, etc.). as a result of the contactless identification they are help to make easier the documentation of all processing steps according good manufacturing practice. in clinical practice they are a good supplement to bed side transfusion software. conclusion: for all lot of problems by the logistic and the safe identification around the transfusion existing various single point solutions such as patient-wristband, bed-side test, double check of blood group typing and donor -donation registry in software, etc. the lecture will deal with new developments in logistics and data management, which can help to reduce the problems associated with documentation, safe identification and reporting of haemovigilance data. our experiences with the immunohaematological analyser olympus pk applied conventional and no conventional (hemolytic medium time) techniques in sera of patients with ascariasis. results: the ai and hk tests showed: b epithopes in ae from b patients and in ae from ab patients; a epithopes in ae from ab patient and in ae from a patients; p and p epithopes in ae and only p epithopes in ae. these patients had both epithopes in their erythrocytes. the hemolytic techniques showed: anti b immune antibodies in sera and anti a immune antibodies in sera. the presence of abo and p epithopes in ae and immune antibodies in patients with ascariasis show a relation about blood groups and ascariasis. the fact of to find the same abo and p antigens in a. umbricoides and in its hosts suggests that the parasite might absorb them during its life cycle. these epithopes would be involved in the molecular mimicry. the use of filters for leucocyte depletion in anemic patients on maintenance hemodialysis g poposki*, s kovaceski*, b krstanoski*, s mena* and n solaz † *institute of nephrology, struga, macedonia, † ankara university, faculty of medicine, ankara, turkey introduction: renal anemia is one of the major chronic complications in end stage renal disease. it is caused by reduced production of erythropoietin (epo) due to uremic toxin effects, reduced halflife of rbc, iron deficiency, aluminum intoxication, blood loss during hemodialysis, gastrointestinal hemorrhage, epistaxis, infections etc. allogenic blood transfusion is transplantation of certain or all cell types. however, allogenic blood transfusion can contribute to many immune system disturbances with clinical side effects. besides erythrocytes, mononuclear, t and b-lymphocytes, are also transfused, which cause immunomodulatory disturbances in immune system of recipient. leukocytes are responsible for frequent febrile non-hemolytic transfusion reactions, alloimmunization toward leukocytes and hla antigen and transmission of cmv. anti-le antibodies, forming of immune-complexes, complement activation with pirogenic c a and c a immunoinflamatoric citokines cause febrile reactions. commercial use of filters for leukocyte depletion with removal of leukocytes and degraded products of microagregates and cytokines, cause minimum harmful immunomodulatory effects and prevent transmission of cmv. aim: the aim of the study was to present the effects of transfusion of erythrocytes with residual number of leukocytes in anemic patients on chronic hemodialysis at institute of nephrology in struga. matherial and methods: during - period all anemic patients on hemodialysis were divided in groups. the first group pts with febrile non-hemolitic transfusion reaction. the second group- pts immunized toward leukocyte and hla antigen. the third group young candidates for kidney transplantation for prevention of hla immunization. the fourth group pts with sle (for immune-complexes and autoantibodies). total patients ( males and females) received units of rbc with residual number of leukocytes. commercial filters of baxterÔ (lekostop lds) and terumoÔ (imugard iii rc) of second and third generation with microagregate filter and synthetic polyurethane fibers, with - microns pores that remove leukocytes, platelets, microagregates and fibrin were used. erythrocyte concentrates are filtered until days of collection. result: aabb permits maximum < ¥ wbcs/unit for prevention of febrile non-hemolytic reaction. the filters we used reach residual leukocyte number of ¥ the le reduction of - . %. the number of rbc after filtration is minimum % - g hb per unit. in none of the patients who have received the leuco-filtered blood, no adverse post transfusion reactions were noticed. conclusion: the used filters for leucocyte depletion are characterized with superior biocompatibility, excellent elimination of all types of leucocytes and high 'recovery' of erythrocytes. the use of filters for le depletion reduces and minimizes the side effects of allogenic blood transfusion in patients on chronic hemodialysis who are alloimmunized, in patients with sle, and particularly in young patients candidates for kidney transplantation. background: fv leiden, prothrombin g a, mthfr c t are three most common and important prothrombotic inherited mutations. aims: the aim of the case-control study was to assess the prevalence of mutations and their single or combined effects as risk factors for thrombosis. methods: the study included thrombotic patients (venous thromboembolism, chronical venous diseases, different etiology) and asymptomatic healthy individuals as control group. extraction of genomic dna was followed with genotyping of fvl by pcr-ssp, prothrombin and mthfr mutation by pcr-rflp. results: a statistically significantly higher prevalence of fvl mutation was found in thrombotic patients ( . % heterozygous, . % homozygous) compared to controls ( . % heterozygous), p < . . the or for heterozygous carriers was . ( % ci . - . ), confirming the association of fvl mutation with the risk of thrombosis. there was no statistically significant difference in the prevalence of the prothrombin mutation in patients ( . %) and controls ( . %), or . ( % ci . - . ), p = . . although the group of thrombotic patients showed a higher prevalence of homozygous carriers of c t mthfr than the control group ( . % vs . %), or was not significant ( . , % ci . - . ), p = . . analysis of combined effects of mutations showed an additional thrombotic risk for carriers of fvl mutation and both mutated alleles of c t mthfr gene (tt and ct) (or . , % ci . - . ), p < . . conclusions: fv leiden mutation was detected as significant single risk factor for thrombosis in studied patients group. additional prothrombotic risk have carriers of fvl mutation and c t mthfr gene mutation. a female patient in a high fever due to urinary tract infection does not respond being given antibiotics. on the contrary, leukocytes rose (to ¥ /l), anaemia became even deeper, as well as thrombocytopenia. hemocultures were negative. hematologist decided to search for hematological disease. the first citology results of bone marrow aspirate suggested lymphoproliferative disease ( % atipical plasma cells). to treat heavy anaemia (hgb g/l) hematologist asked for red blood cell concentrate. pretransfusion testing revealed warm autoantibodies in the patient serum and on red blood cells. antibodies had no apparent specificity. biochemical parameters (bilirubin, ldh, haptoglobin) suggested mild hemolitic process. electroforesis revealed polyclonal hypergamaglobulinaemia. the th day of hospital treatment, the therapy with corticosteroids was introduced (solu-medrol mg per day). coagulation parameters were tested: pt . inr, aptt s, fibrinogen . g/l, trb ¥ /l, d-dimer mg/l, atiii %. dic was suspected. liver enzymes showed mild liver dysfunction (normal ast, alt, elevated ggt, low che). substitution therapy started with dose of cryoprecipitate, dose of fresh frozen plasma, iu atiii, doses of red blood cells and vitamin k mg. two days after the substitution therapy we saw pt . inr, aptt s, fibrinogen < . g/l, trb ¥ /l, atiii %. during the next few days erythrocytes and thrombocytes rose, but due only to corticosteroid therapy and not to substitution therapy. the patient had neither signs of con-sumptive coagulopathy, nor hypoproduction of coagulation factors, except for fibrinogen. till th day of therapy, fibrinogen was below . g/l. there was no hemorrhagic diathesis. after that, fibrinogen rose, and on the st day the patient was recovered, in both clinical and laboratory terms. the results of immunological tests, collected later, confirm the diagnosis of systemic lupus erythematosus. we did not have any specific test to confirm antibody mediated hypofibrinogenaemia, but in the setting of sle, without any specific treatment except corticosteroids, fibrinogen recovered. we assume it is quite enough for highly suspected immunological hypofibrinogenaemia. results: twenty-four-year-old male patient with severe hemophilia type a suffering from low incoercible digestive bleeding secondary to ischemic colitis caused by autoimmunity (vasculitis) without response to current management. treatment was initiated with mg/kg/dose of rfviia (*) for days, after which there was clinical and endoscopic recovery, and an inh decrease to . ub/ml (fviii dosage %) . he began to take meprednisone ( mg/kg/day) for days, after which the inh titre was . ub/ml. (table a ,b) the patient underwent surgery the following year (correction of equinus foot). he entered the operating room with an inh of . ub/ml and was treated with mg/kg/dose of rfviia (*) for days, obtaining an excellent hemostatic response. he had two autologous blood units, but it was not necessary to be administered. the inh titre decreased again (down to . ub/ml) during the intratreatment stage. thirty-five days after rfviia, the inh titre was . ub/ml. (table a ,b) the presence of high titre inh against fviii is a critical problem in cases of bleeding or surgery need due to the inefficacy of the available therapeutic options and the severity of the events. in this case, we have observed that, apart from inducing hemostasia through the activation of the coagulation extrinsic path, rfviia could reduce the inh titre in sequential dosages. we have introduced the case of a -year-old patient with hemophilia complicated by a high titre inh against fviii. in this case, we have observed that, apart from inducing an effective hemostasia through the activation of the coagulation extrinsic path, rfviia could reduce the inh titre in sequential dosages. there was also a decrease in the inh titre concomitantly with an increase of the plasma fviii level during its use. this phenomenon suggests that rfviia could produce a modulation in the immune response. evaluation of an automated blood collection system with standard ratio of anti-coagulation and integrated filter for whole blood leucodepletion l dadiotis, a kolokytha, m dimou, a perdiou, c alepi, p spyropoulou, e igoumenides, c velidou, v panagopoulou and s matsagos tzaneion general hospital, pireas, greece automated blood collection system (abc) is a device manufactured by macopharma which collects by gravity a preset volume of blood and mixes it with anticoagulant (ac) in standard ratio ( : ). this is managed by passing the ac, which is stored in a special bag, anti-erythrocyte antibodies are immunoglobulins that belong to the igg, igm and iga classes. their common characteristic is a specific reaction with antigens that are located on the erythrocyte surface. they can emerge as auto antibodies and alloantibodies. the blood transfusion in patients may induce a post-transfusion hemolytic reaction (pthr). in order to avoid or reduce the danger of the pthr it is necessary to examine whether there are irregular anti-erythrocyte antibodies in the patient's serum as well as in the serum of the voluntary blood donors. all the irregular anti-erythrocyte antibodies are not clinically relevant. the experience shows that the clinically significant antibodies most often belong to abo, rh, kell, kidd, duffy and ssu blood groups. in the period from april, to november, , we monitored and examined, at the institute for blood transfusion, clinically significant antibodies in the serum of the patients who are treated with blood transfusions as well as in the serum of the voluntary blood donors. we used the following tests for detecting irregular anti-erythrocyte antibodies: enzyme test, indirect coombs test, screening test by the commercial test erythrocytes and gel filtration method. the detected irregular antierythrocyte antibodies are identified by means of the commercial test erythrocytes for identification. our results are the following: voluntary blood donors: anti d, anti c + d and anti-leb antibodies. patients: anti-d, anti-k, anti-fya, anti-c and anti-e antibodies. in nine patients, anti-erythrocyte antibodies were discovered, namely, those that react at the temperature higher than °b ut whose specificity we could not discover with the existing techniques. improved predictive factors of response for myelodysplastic syndrome patients treated by the combination of erythropoietin and g-csf s park*, c kelaidi † , s grabar ‡ , v bardet ‡ , d vassilieff ‡ , f picard ‡ , m guesnu ‡ , mc quarre ‡ , p fenaux § and f dreyfus ‡ *service hématologie, hopital cochin, † hématologie, hopital avicenne, ‡ service hématologie, hopital cochin, § hématologie, hopital avicenne, paris, france it has previously been shown that serum epo level and number of previous red blood cell transfusions are predictive factors of response to epo + g-csf treatment of myelodysplastic syndromes (mds). in a subgroup of patients with mds having sepo < ui/l, known to be good responders to epo + g-cscf, the gfm group wanted to refine the model predicting the response to epo + g-csf, especially with cytology (who classification with dysplasia and percentage of erythroblasts and blasts). in a population of patients (ra, rars and raeb < % blasts) receiving epo ± gcsf between and and having serum epo < ui/l, the response rate at week (iwg criteria) was %. six variables were associated with response to epo ± g-csf for mds: age > years (p = . ), number of prior red blood cell transfusions < packs/months (p = . ), serum epo level < ui/l (p = . ), percentage of blasts < % (p = . ), percentage of erythroblasts > % (p = . ) and low ipss score (p = . ). we did not found any influence of dysplasia, type of rhepo (darbopoietin alfa or epoietin alfa) and karyotype on response rate. in multivariate analysis, age through a rotating pump. the abc can be used with all types of p- pan-european blood safety alliance the pan-european blood safety alliance is a unique alliance of patient organizations, formed to promote the highest level of blood safety for all in europe. it was formerly established on february , during the course of the first general meeting of the pbsa, which comprised of founding patient organizations. the objectives of the pbsa are: . to promote the fundamental right and duty to safety of all patients in need of blood transfusions and blood products. . to ensure the availability of sufficient amounts of safe blood, to meet all treatment need through: -the education of all staff handling blood components, to reduce human error. -the implementation of and access to, proactive blood safety technologies, for each patient across europe. -haemovigilance -the adequate access to blood transfusion services, which should be provided free of charge to the patient. other objectives are to raise awareness on a local and european level regarding blood safety, to promote eu legislation that improves safety standards of blood transfusion services, including stem cell preparation and storage across europe and to lobby for increased patient influence on eu health policy makers. very importantly, the alliance aims at providing a forum for patients, healthcare professionals, health policy makers and relevant industry, as well as acting as a point of reference to the national health authorities, the european commission and other european institutions, when seeking the opinions of patients on blood safety. cerns of insertional mutagenesis and the safety of some viral vectors that randomly insert genes through the genome have been recently resurfaced following the development of a haematological malignancy in a child treated with a retroviral vector. particularly questions also remain as to, whether gene therapy and the production of ectopic factor viii and ix will be a risk for inhibitor development or indeed whether it might promote tolerance in those patients with inhibitors. w-pl - gene therapy for thalassemia: will it become reality? university of washington, seattle, wa, usa experiments aimed to develop gene therapy approaches for the beta chain hemoglobinopathies, sickle cell disease and beta thalassemia started about years ago. in the beginning results were dismal because of the extremely low and variable expression of globin genes contained in the therapeutic vectors. a major development occurred in with the discovery of powerful regulatory elements that could guarantee high level of globin gene expression. these elements when incorporated into viral vectors allow expression of therapeutic levels of the transferred globin genes. a second major progress was achieved with the development of safe lentiviral vectors that can efficiently infect the human pluripotent repopulating hemopoietic stem cells. as a result of this progress, today beta thalassemia and sickle cell disease can be cured in murine models of these disorders. considerable effort is already being devoted into further improvement of lenti viral vectors with emphasis on incorporating elements which will decrease the probability of insertional mutagenesis and leukemogenesis. the major challenge for the clinical application of stem cell gene therapy of thalassemia is the need for genetic correction of large numbers of mutant stem cells. in vivo selection of corrected stem cells is being investigated but there are questions about its safety because of the possibilities of clonal expansion of stem cell lines carrying undesirable integrants. other major challenges have to do with logistics: production of therapeutic vectors, infrastructure required for stem cell gene therapy delivery, and sponsoring and funding of the clinical trials. gene therapy trials on limited number of patients are expected to be initiated relatively soon. if these trials are successful and cures of beta thalassemia ensue, the major challenge will be the delivery of this molecular therapy in the context of medical practice. w-pl - gene therapy for haemophilia haemophilia is an ideal target for gene therapy because only a small rise in factor levels to - u/dl would achieve the goals of prophylaxis without regular infusions of concentrate and deliver a substantial improvement in lifestyle for patients with severe haemophilia. gene therapy for haemophilia today relies upon addition of normal factor viii or ix genes. with present technology gene therapy can offer the prospect of a true 'cure' for haemophilia in animal models, although this may not be currently realizable in man. more than patients with haemophilia have now been treated in phase gene therapy protocols. all studies have failed to conclusively show that therapeutic levels of factor viii and ix can be reliably obtained. the first trial reported used im injection of a factor ix containing recombinant adeno associated virus (raav) in adult patients with severe haemophilia b. only very modest increases in factor ix level, < u/dl rise, in / patients enrolled were observed, although less factor ix concentrate was needed in / subjects. a similar study using the same raav vector via intrahepatic artery infusion has been conducted. this has been complicated by the observation of aav vector in the semen of subjects. in six patients enrolled, no durable levels of ix above u/dl were seen. further development of this raav vector is suspended. for haemophilia a, three systems are have been tried. the first study was an ex vivo addition of factor viii gene to autologous fibroblasts and then laparoscopic reimplantation. preclinical assessments demonstrated durable expression of factor viii (> % of normal) for > year in mice following a single treatment. in / patients treated repeated factor viii rises ( . - . u/dl) were seen, but no improvements lasted beyond months. the second protocol used a murine leukemia retrovirus containing factor viii, injected intravenouslya development of preclinical data in rabbits and haemophilic dogs. / patients enrolled sustained levels of factor viii > u/dl. the third study, using a modified, 'gutless', adenovirus containing factor viii gene has recruited one patient. this patient demonstrated transient liver toxicity and thrombocytopenia at doses lower than those that cause toxicity in primates. sustained levels of factor viii of ~ u/dl have been observed over a number of months. accrual to the study has been poor. haemophilia remains a prime target for gene therapy. however, haemophilia is no longer a life threatening disease with current therapy that is both safe and efficacious. a balance between the benefits and theoretical risks must be borne in mind when considering gene-based approaches to therapy. con- reference: petz ld, garratty g. immune hemolytic anemias. nd ed. philadelphia: churchill livingstone, , pp - . w-pa- autoimmune neutropenia introduction: autoimmune neutropenia (ain), a granulocytic disorder due to the presence of anti-neutrophil antibodies, may present as neutropenia of varying degree with or without recurrent infections un previously healthy individuals (primary or idiopathic ain) or in patients with a known underlying disease such as lupus erythematosus, lymphoid malignancies, etc (secondary ain). the condition affects more frequently infants of small ages while it is rare in adults [ ] [ ] [ ] [ ] [ ] [ ] [ ] . in some patients, diagnosis is established in occasion of a respiratory, urinary or cutaneous infection, but in many cases is simply a finding of cell blood counting performed for unrelated reasons [ ] . clinical and laboratory findings: in general, physical examination is negative. laboratory investigation reveals the existence of isolated neutropenia. association of the disorder with autoimmune hemolytic anemia or autoimmune thrombocytopenia is rarely seen [ ] . blood biochemistry is normal while serologic tests for bacterial, viral or other pathogens may be positive depending on the underlying infection. bone marrow is hypercellular without maturation arrest of granulocytic series. hemopoietic stem cell reserves and function are normal or increased, and stromal cell function is within the range of the normality [ ]. methods for the detection of granulocyte-specific antibodies: serology for the detection of granulocyte-specific antibodies has been marred, compared to erythrocyte serology, because the target cell here, the granulocyte, is short-lived, fragile and becomes easily activated. the former two of these difficulties require absolutely freshly (< h old) isolated neutrophils from a panel of donors to be used every day to run the tests with sera from patients, while the third difficulty is more important since spontaneous cell clumping in vitro is very common and nay mimic the specific aggregation caused by cross-linkage of surface bound antibodies in the granulocyte agglutination test (gat). in order to overcome these problems, the second international granulocyte serology workshop [ ] recommended a combination of two tests as the best screening procedure for the detection of granulocyte autoantibodies in patient sera, gat and granulocyte immunofluorescence test (gift). gat is mainly mediated by igm antibodies and is positive in about % of cases. gift detects igg antibodies and is positive in about % of cases. it is to be noted that flow-cytometry fluorescence may arise not only from the surface but also from the cytoplasm of neutrophils, necessitating assessment of membrane fuorescence by microscopy. a good direct anti-granulocyte test is not available today. this is due to the fact that too few neutrophils can be obtained from the blood of neutropenic patients, and also to the observation that neutrophils are often activated in vivo because if an underlying infection or other inflammatory process, thus expressing fcgrii and fcgriiib to which nonspecific binding of w-pa- practical approach to transfusion in autoimmune hemolytic anemia (aiha) g garratty american red cross blood services, pomona, ca, usa a major problem when transfusing patients with aiha is that often all units are incompatible. this may be due to autoantibodies (autoab) and/or alloantibodies (allo-ab). if the incompatibility is due to only auto-ab, then transfusion of incompatible blood will not usually result in a clinically significant reaction, but if due to alloab, the result may be similar to that seen in any other patient (i.e. a hemolytic transfusion reaction ranging from mild to severe). thus, it is essential (as in any other patient) to exclude the presence of allo-ab. it is wise to phenotype all patients, for as many antigens as possible, before the patient receives transfusion. there are two popular approaches to determine if allo-abs are present but being masked by 'warm' auto-ab activity. the preferred method is to remove the auto-ab by adsorbing the patient's serum with autologous rbcs treated with enzymes, or preferably, with zzap reagent. the latter reagent contains an enzyme leading to optimal adsorption of auto-ab, and dtt. these two chemicals will destroy significant antigens other than rh and kidd (e.g. mns, duffy, kell, lutheran, dombrock, cromer, lw, some yta and ge, inb, jmh, ch, rg, pr antigens), thus will not adsorb alloantibodies to these antigens. if autoadsorption is not possible (e.g. patient has been transfused recently or there are too few rbcs), one has to perform adsorption with enzymes or zzap-treated allogeneic rbcs. one does not have to be concerned with covering any antigens destroyed by zzap (e.g. kell and duffy systems). we use a rough guide relating the strength of the indirect antiglobulin test to the number of adsorptions needed to remove auto-ab ( + = adsorption; + = adsorptions; + = adsorptions; + = or more adsorptions). if there is no activity left after the adsorptions, then one can suspect that the incompatibility was due to auto-ab, but on rare occasions one can be wrong and an allo-ab to a high-frequency antigen has been removed. this is a major disadvantage of using allogeneic adsorptions, and is why adsorptions with autologous rbcs are preferred. if time ( - h) does not allow for adsorptions, one can dilute the patient's serum (e.g. in , or in ) and test the dilution against a panel to see if any alloantibody specificity becomes obvious. another approach is to select units matching the patient's phenotype as closely as possible. when dealing with cold agglutinin syndrome one can usually exclude allo-ab activity by testing strictly at c. this can be helped by performing adsorptions with enzyme-treated autologous rbcs at c, but it is difficult to adsorb all of the powerful cold autoagglutinin activity. it is reported that - % of aiha have allo-abs; the incidence is even higher in patients who have received multiple transfusions. thus, we feel that procedures such as those discussed above must be performed before transfusing incompatible blood if time allows. one should always negotiate with the attending physician regarding the time it will take to perform adsorptions. a decision may be made not to perform adsorptions if the patient has life-threatening hemolysis, and especially if the patient has never been transfused, or pregnant. serum igg may occur (naig). the presence of immune-comlexes in the serum, such as in patients with felty's syndrome, lupus erythematosus and other diseases, as well as the presence of immune aggregates formed in sera stored frozen for long time, may give false-positive tests given that they may bind to fcgriiib molecules expressed on the surface of neutrophils. elimination of immunecomplexes and immune aggregates can be easily obtained by ultracentrifugation [ ] . another cause of false-positive results may be the presence of anti-hla antibodies because of allo-immunization. these allo-antibodies react with hla molecules found not only on neutrophils but also on the surface of many other cells including lymphocytes. these allo-antibodies can be eliminated by platelet absorption. it seems that the best method in the search of true antigranulocyte antibodies is the monoclonal antibody-specific immobilization of granulocyte antigens (maiga) [ ] . with this method one can specify anti-granulocyte antibodies using a panel of known granulocyte antigenic specificity. finally, it is notable that the levels of serum antibodies to neutrophils may vary considerably over the time. one negative test does not exclude ain. usually, two to three tests have to be run over a period of months [ ] . antigenic specificity: human neutrophil antigens (hna) are classified according to an international granulocyte antigen working party [ ] . three glycoproteins have been found to be involved in the determination of antigenic specificity, fcgriiib, gpnb (cd ) and gp - . the respective antigens, frequencies and alleles are illustrated in table . antigenic specificity can also be studied by using methods applied in molecular biology. a promising approach is transfection of mammalian cells by cdna derived from granulocyte antigen specific mrna. cell lines have been established with cells expressing the respective human granulocyte antigen, making the detection of anti-granulocyte antibodies more easier. genotyping of hna antigens can also be stydied with the pcr technique [ ] . references are available from the author upon request. w-pa- a rare case of 'coombs negative' autoimmune haemolytic anaemia due to red cell autoantibodies of iga class warm autoimmune haemolytic anaemia (waiha) is usually associated with red cell auto-antibodies of the igg class, which can be detected by polyspecific direct antiglobulin test (dat). routine polyspecific direct antiglobulin tests contain anti-igg and anti-c d components, and are not standardized to react with iga-or igmsensitized red blood cells. haemolytic anaemia caused by warmreacting auto-antibodies solely of the iga class is exceedingly rare. those cases of autoimmune haemolytic anaemia can be difficult to diagnose because of the negative polyspecific coombs' test, which is a standard in investigation of possible causes of haemolysis. we present a case of severe warm autoimmune haemolytic anaemia caused by iga class autoantibodies. a -yr old male patient was admitted with anaemia, haemoglobinuria, and other signs of severe haemolytic disease. he received multiple transfusions but haemoglobin level did not rise above g/dl. the initial polyspecific direct antiglobulin test, containing an anti-igg and anti-c d antiserum, was negative. tests for cold agglutinins and other possible causes of haemolysis were negative. only by using a monospecific, anti-iga antiserum could we show that the warm iga auto-antibodies against red blood cells were present on patient's erythrocytes. we have not detected signs of complement activation by iga autoantibodies in this patient. the patient received corticosteroids with good initial effect. his haemoglobin level stabilized and he did not require more transfusions. anti-iga direct antiglobulin test became negative about to weeks after the therapy was initiated. however, in spite for the initial effect of steroid therapy haemolysis continued, and splenectomy was performed months after diagnosis was made. it has been shown that human lymphocytes, granulocytes and monocytes contain specific fc receptors for iga, and both monocyte-mediated phagocytosis and antibody-dependent cellular cytotoxicity due to iga auto-antibodies has been demonstrated. there is also increasing evidence that iga auto-antibodies can activate complement, both via the classical and the alternative pathway. a phenomenon of 'reactive haemolysis', which involves c -independent binding of c b complexes to 'bystander' red blood cells, has also been described. we emphasize the importance of performing additional testing in cases of apparent 'coombs' negative' haemolytic anaemia due to iga, igm or 'low affinity' igg autoantibodies, and serological aids that are available for that purpose. described. both siblings were born on term, in good general clinical status, free from any signs of infection, and with isolated severe neutropenia ( and neutrophils/ml). the diagnosis of annanti hna- a was made upon exclusion of other possible causes of neonatal neutropenia, and confirmed by serological testing of granulocyte antigens and antigranulocyte antibodies. in both cases, the course of the disease was mild, with bacterial omphalitis on day and , respectively. omphalitis was successfully treated with -day antibiotic therapy according to antibiotic sensitivity report. the first neonate received standard dosage of intravenous gammaglobulins for days without success. this was followed by an attempt at neutrophil count increase with -week corticosteroid therapy, also without response. the second neonate received no specific therapy for neutrophil count increase. the children were discharged for home care with clinical and laboratory control examinations at -week intervals. in spite of prolonged neutropenia ( and months, respectively), no other infections were recorded. discussion and conclusion: in our patients, the therapeutic approach to ann was individualized, based on standard antibiotic therapy, intravenous gammaglobulins, corticosteroids, available literature data, and our own clinical experience. although in the last few years rh-gcsf is successfully used in patients with neutropenia, we decided to postpone its use in case the neonatal sepsis developed. the reasons for such decision were: ( ) the fact that both neonates were in good general clinical status, with a mild course of the disease with only short-term umbilical infection successfully managed with antibiotic therapy; ( ) literature reports suggesting the unexpected failure to respond to rh-gcsf therapy in patients with neutropenia induced by anti hna- a immunization, and ( ) the unknown effect of rh-gcsf on developing tissues of the neonate. the choice and efficacy of specific therapy for neutrophil count increase in the management of alloimmune neonatal neutropenia have not yet been fully defined and require additional evaluation in the majority of cases. male donors for the production of fresh frozen plasma: a special issue for trali patients trali is a significant cause of transfusion associated morbidity and mortality, and has been reported as the third most common cause of fatal transfusion reactions. there is no good evidence on which to base transfusion support policy for patients who have experienced trali. the hypothesis that there may be patient associated factors that contribute to the risk of trali is generally accepted. for this reason it seems reasonable to try to avoid further transfusion during the period of illness. if this is unavoidable the next best solution to reduce the risk of recurrence seems to be the avoidance of using plasma containing blood components (especially ffp) as there is a high chance of positivity for leucocyte antibodies especially for those coming from female donors. as fresh frozen plasma transfusion accounts for up to half of all trali cases and as our center is the only in greece responsible for the testing and processing of blood from blood donors representing military recruits, the last two years we tried to set up a project in order to provide components from male donors on request. our donor base consists predominantly from males donors ( . %), aged between and years old, with a small chance of having a positive history for transfusion the difficulty of the project consisted on the fact that these donors are assigned to military camps throughout greece, which makes difficult the on time arrival of the units to our establishment in order to be processed for the production of ffp conform the european council quality requirements. this was the main reason why, till now, all plasma produced from these donations was regarded as plasma for fractionation. the first step for implementing the new project was to evaluate the number of donations that, by minor changes on the time of arrival, could be processed for ffp production. the next step was to re-schedule the shifts of the personnel for the on time production of ffp. during , % of donations were fulfilling the specifications for the production of ffp and with the flexibility of the schedule the % of them were successfully processed to ffp. during , % of the donations were fulfilling the specifications and . % of them were processed to ffp. so it is feasible to increase the proportion of male ffp by organizing better the transportation of blood from the donation sites to the blood establishment and by retaining available specialized personnel to cover the extra shifts. maximising the blood supply chain in times of shortage shortages in the blood supply chain may occur for a variety of reasons. they may be temporary e.g. due to a flu epidemic or prolonged e.g. due to the exclusion of a high proportion of donors due to new pre-donation tests or because of a lack of volunteer donors. increasing awareness of the possibility of blood shortages mainly related to increased precautions associated with the possible transmission of vcjd by transfusion has been the driver for the development of blood shortage contingency plans in the uk. in england and north wales, hospitals and the national blood service (nbs) have worked together to develop an integrated blood shortage plan (ibsp) designed to ensure that hospitals and the nbs work together within a consistent, integrated framework giving patients equal access to available blood on the basis of need. an essential element of the plan is the principle that shortages can, in most cases be avoided by reducing the current usage of blood through appropriate use programmes. the impetus for hospitals to implement these programmes was a government circular (hsc / ). hospitals have embraced the circular and have recruited specialist hospital transfusion practitioners, introduced lower hb triggers, cell salvage and hospital transfusion teams and are participating in the blood stocks management scheme (bsms). audits of compliance with the circular have taken place, and a web based tool kit is available. the demand for blood has declined for the last three years, with a decrease of about % during - , suggesting that the drive for improvement has been successful. the shortage plan introduced in england and north wales has two key aims: that the national pool of blood is available for all essential transfusions for all patients and that overall usage is reduced to ensure the most urgent cases receive blood. the plan is structured to provide actions for the nbs and hospitals in three phases, 'normal' circumstances, reduced availability and severe prolonged shortage. hospitals should have documented emergency blood management arrangements for each of the phases. the national plan is activated when the nbs red cell stock level falls to pre-defined levels, hospitals are informed by fax that they should reduce their normal stock holding levels according to guidance in the ibsp and comply with the daily hospital usage budget. the bsms has used its knowledge of hospital inventory levels and demand to provide guidance on appropriate inventory levels for normal and reduced status, it also provides the daily hospital budget. to monitor progress against the recommendations in hsc / hospitals will be benchmarked against a number of performance indicators. these include the presence of emergency blood management arrangements, median red cell usage for a number of surgical procedures and percentage wastage of blood. there have been no shortages within the nbs for more than six years, it is hoped that the implementation of the ibsp will help to ensure that in the unlikely event of reduced availability blood will be available to the maximum number of patients requiring a blood transfusion. w-pa- transfusion during disaster g klein nih, bethesda, md, usa publicity given to blood donation during wartime has created a powerful association between the need for blood and occurrence of a disaster. blood is rarely needed in excessive quantities at the moment a disaster occurs. the outpouring of blood donors, especially at the site of a disaster, often proves counterproductive. the terrorist attacks on the world trade center on september , , with almost deaths and more than injuries, provides an instructive model. more than a million potential donors contacted blood-collection centers. hundreds of thousands of prospective blood donors crowded collection facilities and many waited for hours, often to be turned away. qualified staff were in short supply and screening errors occurred as minimally qualified staff were recruited and as collection personnel fatigued. supplies and storage capabilities were pushed to their limit. some blood was inadequately processed and stored. resources were diverted from needed apheresis collections and component preparation to whole blood collection. in the aftermath of the disaster, blood outdated and volunteer donors became disillusioned as their 'gift of life' was refused or unused. similar responses have occurred numerous times over the -year period since blood-donor programs were introduced. in virtually every civilian disaster in the u.s. during the past century, all the blood that was needed was immediately available from blood inventory. in only four cases were more than units of blood used in the first to h. in in new york, the five hospitals closest to the disaster site admitted only disaster victims. the new york blood center, which supplies percent of blood for the city's hospitals, added units to routine inventory at hospitals. the center received telephone calls and collected more than units of blood in the first h. in the area of the pentagon, the chesapeake and potomac red cross blood center supplemented hospital blood inventories within h of the disaster. meanwhile, spurred by well-meaning media and federal officials, lines of blood donors were being processed at local hospitals, makeshift collection centers, the small research hospital at nih, and at a building next to the white house. in the week after september , america's blood centers collected more units of blood, and the american national red cross collected more units than in the same period the previous year. more than units were collected for the disaster victims, but only units were used. u.s. blood collectors and federal agencies have created a disaster plan that acknowledges the need for altruistic people to volunteer for blood donation in the time of disaster and speaks with a single voice to avoid needless collection activity while harnessing the good will of well-intentioned people to supplement the ongoing need for volunteer blood donation. rehabilitation of blood transfusion service in azerbaijan cd asadov, ga huseynov and ab hagiyev institute of hematology and transfusiolo, baku, azerbaijan at the end of th years of the last century in azerbaijan as well as in other republics of the former ussr began process of progressive deterioration of blood service parameters. in result there was an essential reduction of prepared blood and blood components quantity, manufacture of preparations from blood's plasma has completely stopped. it is connected by that our republic experiences a heavy transition period from scheduled to market economy. after reception by azerbaijan of the sovereignty on development of a national policy the big work has been lead to areas blood transfusion and development of national rules and the standards regulating functioning of establishments of blood service. in the law about ' the donorship of blood and its components in the azerbaijan republic' has been accepted, instructions on physical examination of donors and preparations of blood and its components are authorized, and also the new speciality transfusiology has been entered into the nomenclature of medical specialities. now the national program of blood service development is developed. at drawing up of the program social and economic conditions of the country, ethnic both cultural traditions and a mental potential of the nation are considered. within the framework of this program is planned to refuse gradually a paid blood donation during the certain period of time to reach %s' voluntary unpaid blood donorship. however in connection with limitation of resources, the state is not capable to allocate enough of means for its realization. the big work on attraction of the international organizations has been carried out. now the project of the united nations development program (undp) 'rehabilitation of blood transfusion service in azerbaijan' is carried out at sponsor's support of the norwegian government. realization of this project will lead to reorganization of blood transfusion service in our country according to practice of the european countries. within the framework of project realization it is planned to make changes and additions to a existing law about a blood and its components donorship to bring it into accord with recommendations of the europe council. updating of the russian law 'concerning the donation of blood and blood components' on june , , a law, 'concerning the donation of blood and blood components, ' was signed by the first russian president, boris eltsin. now, after more than ten years of market economy and democratic evolution in russia, this law was significantly changed on august , , as shown in the following sections: . the development of a voluntary blood donor system. . removal of the upper age limit for blood donors. . funding for blood donations. from january , , each level of the state power budgets for a blood donor service to supply blood products for federal, regional, or municipal hospitals. costs of these drugs and the need of prolonged growth factor treatment in these disorders. w-pa- can iron administration reduce peripartum blood transfusion c breymann university of zurich, zurich, switzerland the prevalence of iron-deficiency anemia in different regions of the world ranges from to %. the increased iron requirement in pregnancy and the puerperium carry with it an increased susceptibility to iron deficiency and iron-deficiency anemia and perioperative or peripartal blood transfusion. however, if ever possible administration of blood transfusion should be avoided for several reasons which will be pointed out in the talk. infections: it is well known that various pathogens such as bacteria and virus can be transmitted by administration of blood. around . % of are contaminated by bacteria such as yersinia or pseudomonas species but are not screened routinely for bacteria. in addition there is no donor screening for hepatitis a, herpes species (cmv, ebv, hhv , hhv ), parvovirus b , hepatitis g ( . %) and tt (transfusion transmitted) virus ( . %). numbers for positive testings for 'classic' virus such as hiv, hep. b and hep. c vary from country to country and lie around : to : depending on quality of donor screening programs, pcr sensitivity etc. recently there is increasing evidence that even prions which cause the jakob creutzfeld disease variation ('mad cow disease') might be transmitted by transfusions. therefore the fda has determined that blood donors from countries with high prevalence of prion positive persons are not permitted to give blood in the us (e.g. donors from uk). beside infections, other well known effects of transfusion are problems due to incorrect blood or components transfused, post transfusion purpura, acute and delayed lung injury, graft versus host disease and other acute and delayed allergic reactions. beside these negative effects it was also shown that patients who receive blood transfusion liberally after operations or in icu show higher morbidity and mortality compared to patients with restrictive transfusion policy. this might be due to negative effects on immune functions and inflammatory reactions and lack of stored blood to efficiently improve organ oxygenation. for example it is known that stored blood has worse capillary perfusion and worse viscosity properties compared to fresh blood. taken together there is increasing scientific evidence that blood transfusion is not the gold standard for anaemia management and alternatives such as endogenous blood pooling and efficient treatment of any anaemia must be enforced in the clinical settings. prevention and correction presuppose reliable laboratory parameters and a thorough understanding of the mechanisms of iron therapy. in order to correctly diagnose the type and degree of anaemia, a prerequisite for selection of the proper therapy, one must first of all correctly differentiate between the relative, i.e. the physiological anaemia of pregnancy due to the normal plasma volume increase during pregnancy, and 'real anaemias' with various different pathophysiological causes. when defining the hb cutoff value for anaemia in pregnancy, the extent of the plasma volume changes with respect to the gestational age must be taken into consideration. it has been found that haemoglobin values < . g/dl in the first and third trimesters, and < . g/dl in the second trimester may point to an anaemic situation which should be further clarified. the first important steps for diagnosing anaemia in a pregnant patient include a thorough check of her medical w-pa- impact of epo treatment on transfusion requirements in myelodysplasia c gardin and p fenaux hopital avicenne, aphp, university of paris , bobigny, france myelodysplastic syndromes (mds) are clonal disorders of hematopoeisis, associated with bone marrow failure and an increased risk of evolution to acute myeloid leukemia (aml). despite an normal or increased bone marrow cellularity in most cases, cytopenias worsen with time due to increased apoptosis and defective differentiation of blood lineage precursors. incidence of mds increases with age and reach / above years of age. bone marrow cytogenetics number of cytopenia and percentage of bone marrow blasts are strong predictors of survival and evolution to aml. a composite international prognosis scoring system (ipss) is used in everyday practice to guide the management of these diseases. these disorders are heterogeneous and include 'low risk' patients (less than % bone marrow blasts) with a prolonged evolution marked by chronic anemia, and 'high-risk' patients (excess of bone marrow blasts > %) evolving in a short timespan with severe cytopenias, and to aml in approximately % of cases. at diagnosis, % of mds patients are anemic, with an hemoglobin level less than g/l, and % of them will require chronic blood components transfusion, during the evolution of their disease. chronic anemia and multiple blood products transfusions are associated with an altered quality of life, clinical iron overload, and important health care costs. although transfusion practices and patient's transfusion need are variable, elderly mds patients require a mean of - units/year of follow-up, in recent surveys. therapies able to diminish or abolish the need for rbc transfusion have therefore a major role in the management of mds, as allogeneic bone marrow transplantation, the only curative therapy of these diseases, is limited to a small subset of mds patients. high-doses of recombinant erythropoetin (epo) ( - u/kg tiw, or a - u as single weekly dose) are typically used in low-risk mds. the response rate to epo is - %, including major responses (suppression of rbc dependency or rise of hemoglobin level of more than g/l). absent or low rbc transfusion needs and a serum epo level less than u/l are strongly predictive of response to epo, in patients with low-risk mds. the duration of response is variable ( - months) in most studies, with some long-term responders. the use of higher doses of epo or its prolonged administration may be associated with higher response rates, although no randomized studies are available combination of epo and low-dose granulocyte-colony stimulating factor (g-csf) increases the response rate to - %, including in patients not responding to several weeks of treatment with epo alone. two randomized trials published in , compared g-csf-epo to rbc transfusions and confirmed the efficacy of this combination, and a longer survival of epo-g-csf responding patients. studies are ongoing in mds, including with darbepoetin, a modified erythropoetin with longer half-life, administered once a week. two such studies have been recently reported, (darbepoetin or ug/week) with response rates varying from % to % in low-risk mds. in both studies, a response to darbepoetin was observed in some patients, who failed to respond to previous treatments with alpha or beta epoetin. further assessment of the optimal dosage, administration schedule of these drugs, and validation of their likely impact on qol are required, in order to epo and its derivatives to gain acceptance in mds, due the high history and a medical examination. this procedure often lays the basis for a correct diagnosis. the current gold standard to detect iron deficiency remains the serum ferritin value. to be reliable, this requires the ruling out of an infection (chronic or acute) as a cause of the anaemia. we recommend a complete laboratory test for the exact haematological status as well as the assessment of specific chemical laboratory parameters. these should the hb level alone is insufficient to guide management. a complete work-up (ferritin, transferrin saturation) is essential, preferably with haematological indices such as hypochromic and microcytic red cells and reticulocytes, classified by degree of maturity, in particular, before parenteral therapy is given. since ferritin acts as both an iron-storage and acute-phase protein, it cannot be used to evaluate iron status in the presence of inflammation. a high ferritin level thus requires the presence of an inflammatory process to be eliminated before it can be taken at face value. if the c-reactive protein level is also raised, the soluble tfr concentration can be used, since it is unaffected by inflammation. inadequate understanding of the complex chemistry of parenteral iron administration was previously responsible for serious side effects, such as toxic and allergic reactions, and even anaphylactic shock, in particular with dextran preparations. however, the current type ii iron complexes that release iron to the endogenous iron-binding proteins with a half-life of about h are not only effective but carry a minimal risk of allergic accident and overload, especially after a comprehensive pretreatment work-up. after correct diagnosis, major emphasis should be put on safe and effective treatment of anemia which again depends on severity of anemia, time for restoration and patients characteristics. today effective alternatives to oral iron only or blood transfusion such as parenteral iron sucrose complex and in selected cases also recombinant erythropoietin have been investigated and show promising results concerning effective treatment of anemia during pregnancy and postpartum. our departmental data collected over years and backed by postmarketing experience in countries indicate that iron sucrose complex therapy is a valid first-line option for the safe and rapid reversal of iron-deficiency anemia. w-pa- iron therapy in orthopaedic surgery surgery of the vertebral column, hip or knee is considered a bloody procedure (blood loss > l) and as a consequence represents the main indication for red blood cell transfusion in orthopaedics. because of the non-negligible residual risk of transmission of infectious agents by transfusion, but mainly because of immunologic complications induced by the administration of foreign proteins and cells, an alternative solution has been actively sought. studies have clearly shown that in patients undergoing such surgery, transfusion risk correlates inversely with pre-operative hemoglobin level. correction of even slight preoperative anemia is thus mandatory. in the elderly, iron and vitamin deficiency (b and/or folic acid) should be looked for as a matter of routine. we recommend the use of iron + epo whenever a rapid correction (< weeks) of the anemia is desirable in cases with transferrin saturation < % and ferritin levels < mg/l. with this regime it is possible to collect up to autologous blood units in cases of increased perioperative blood loss (e.g. double hip replacement). in the post-operative period, anemia worsens because of the existing inflammatory state. this inhibits iron absorption from the intestine and iron release from the macrophages while it affects epo function and production. there is increasing evidence that i.v. iron combined with epo induces a rapid correction of post-operative anemia. it is thus recommended to stimulate erythropoiesis by i.v. iron and epo starting on the first post-operative day and to avoid transfusions in asymptomatic patients even in cases with hb as low as g/l. background: hereditary hemochromatosis is one of the most common inherited disorders in which an excessive amount of iron is absorbed from the diet and then deposited in organs. the effective treatment is the regular whole blood removal which causes erythropoesis activation and leads to decrease of iron stores. red cell apheresis is an optional method for removing of higher amount of erytrocytes in one session. we performed red cell apheresis in patients with diagnosis of hereditary hemochromatosis ( ¥ c y homozygotes, ¥ c y + h d heterozygote) using haemonetics mcs p cell separator (protocol tae) in which red cells are removed from patients in - cycles; plasma and buffy-coat are reinfused. collection time, donor convenience, side effects and red cell yield were recorded and analysed. samples for hematology and iron studies in patients were drawn, analyzed and compared to baseline levels. background: the collection of units of red blood cells by apheresis (drbc) has been reported to be safe and effective in increasing the yield of rbc units from a donor population. however several reports demonstrated the risk of inducing iron depletion when the interval between a drbc donation and a subsequent rbc donation is shorter than days. aims: to evaluate the recovery from anaemisation and iron stores depletion after drbc donation. methods: donors who underwent drbc donation between december , and february , have been enrolled in a follow up program to monitor haemoglobin (hb), htc, serum iron and ferritin values. these parameters have been assessed on the day of donation and, thereafter and days after drbc procedure. donors suitable to drbc apheresis had to have: age between and years, weight > kg, hb > . g/dl and serum ferritin between and ng/ml. a written informed consent about the collection procedure and the follow-up program has been obtained from all the enrolled donors. drbc collection procedures have been performed by using a mcs + (haemonetics) cell separators. results: out of donors who donated drbc during the study period, only males completed the follow up program and have been analysed. baseline haematological values and iron metabolism parameters were: mean hb . ± . g/dl, ferritin ± ng/ml, serum iron ± microg/dl. on day mean hb was . ± . g/dl (p < . ). on day mean hb was . ± . g/dl (p < . ), ferritin ± ng/ml (p < . ), serum iron ± (p ns). only out of donors ( %) had a ferritin value > ng/ml. in the studied donors the collection of units of rbcs induced an expected reduction of about grams of hb, however only % of this reduction was recovered after days (p < . ). similarly, also iron stores have not been restored after months from donation, as shown by a % reduction in mean serum ferritin value. according to these data it appear that the amount of iron 'lost' with the donation of units of rbcs (approximately - mg of elemental iron) could not be completely compensated by iron absorption from the diet intake. further data are necessary to define the risk of iron depletion after the donation of a drbc, however, at least in areas where iron intake by diet is not very high, the opportunity to prolong the interval between a drbc and a subsequent rbcs donation beyond six months or to provide adequate iron supplementation therapy should be carefully considered. background: increased transferrin saturation and/or serum ferritin have been observed in italy in approximatively % of subjects at first blood donation and, in these subjects, hfe mutations prevalence was . for c y and . for h d (velati et al., ) . aims: the role of the c y mutation is well known in the patho-genesis of iron overload, whereas the role of the h d mutation remains uncertain. the aims of the present study were first to study the main hfe mutations prevalence in a random group of repeat blood donors and second to evaluate iron parameters and iron depletion in repeat blood donors heterozygous for the h d mutation in comparison to a population of blood donors wt/wt for the h d mutation. methods: a total of repeat blood donors were examined in italian transfusion centers ( in northern italy and in southern) for c y and h d mutations. out of those, blood donors heterozygous for the h d mutation and wt/wt for the same hfe mutation, both groups wt/wt for the c y, were enrolled to evaluate iron parameters and iron depletion. these two groups were similar for number of blood donations (expressed as iron loss) and for sex distribution. serum ferritin (sf) was the iron index recorded at first and second observation. results: table summarizes the allelic frequencies in the blood donors. table reports the haematological evaluation in the subjects heterozigous for h d mutation and the wt/wt for the same mutation. conclusions: these data suggest that subjects with h d mutation of the hfe gene have, at first observation, a higher ferritin levels than subjects wt/wt. this seems to be more evident in blood donors of southern italy than in northern. blood donation induces significant reduction of the iron stores both in h d heterozygous and in wt/wt subjects. although our observation is preliminary and restricted to a limited number of subjects, it seems worthwhile to extend the follow-up of blood donors h d heteroxygotes or even homozygotes when available, in order to get further insights on the h d role in iron metabolism. background: cd is a sialylated glycoprotein expressed on the surface of most hematopoietic cells and has been implicated in cell adhesion and signaling. consequently the levels of soluble cd as well as the expression on the cell surface is a marker of cell activation. furthermore, downregulation of this molecule has been correlated with increased susceptibility to infections. the myelodysplastic syndromes (mds) are a group of stem cell disorders characterized by ineffective hematopoiesis, refractory cytopenias and an increased risk of leukemic transformation. the mds patients are often introduced to transfusions for anemia improvement and present increased susceptibility to infections. aims: we studied cd expression in transfusion-dependent and non-transfused mds patient in an effort to investigate mechanisms of regulation of this molecule. we also studied other activationassociated antigens in the absence of manifest infection. material and methods: forty-two patients were included in the study suffering from refractory anaemia (ra). thirty-one were males and females aged to (median ). twenty of them had never been transfused (group a) and were regularly transfused (group b). nineteen age matched healthy individuals were used as controls (group c). cell surface antigens were detected by direct immuno-fluorescence evaluated by flow cytometer. the following mouse monoclonal antibodies were tested: anti-cd b, anti-cd , anti-cd , and anti-cd . leukocytes were gated according to cd . we used a sensitive sandwich enzyme linked immunoassay to measure the level of soluble vascular adhesion molecule as an indicator of endothelial cell activation. the r&d elisa kit was used according to the manufacturer's instructions. results: the cd was found down-regulated in the transfusiondependent mds patients compared with the non-transfused ones (p < . ) and controls (p = . ). this downregulation concerned the proportion of cd + cells, that was lower in the transfused patients than the non-transfused (p < . ) and controls (p = . ), and the rfi (relative fluorescence intensity) value that was also lower in the group a compared to the group b (p < . ) and group c (p = . ). negative correlation was observed between the cd expression and cd b (p = . ) and cd (p = . ). cd b was found up-regulated in the transfused patients. the rfi value was significantly elevated in the transfused patient compared with the non-transfused and controls (p = . and . respectively) while the percentage of cd b cells did not differ significantly between the various groups. increased expression of cd was also found in the group a compared to group b (p < . ) and c (p = . ). the proportion of cd + cells did not differ between the various groups. the levels of immuno-reactive svcam- as determined by elisa were found . + . in group a, . + in group b and . + . in the control group. conclusions: activated hemopoietic and endothelial cells are found in mds that may be associated to the vascular disorders found in these patients. cd downregulation may also be associated to increased susceptibility to infections in these patients. despite improved safety of the blood supply, allogeneic blood transfusion continues to be associated with risks that can be eliminated or reduced by autologous transfusion. preoperative autologous blood donation (pad) prevents transfusion-transmitted viral infection, red cell alloimmunization, and some adverse transfusions reactions. it may decrease the risk of postoperative wound infection because immunosuppression as a result of allogeneic blood transfusion is avoided. pad also supplements the blood supply, provides compatible blood for patients with alloantibodies and rare red cell phenotypes, accelerates erythropoiesis, and provides peace of mind to patients. as any medical intervention, pad has both advantages and disadvantages. with proper patient selection and dedicated attention to process control and quality assurance, the advantages outweigh. background: prestorage pooling of whole blood derived (wbd-pc's) buffy coat platelet concentrates (pc) is common practice in europe event-free survival was significantly better in patients who responded to epo + g-csf. we have reviewed data in centers and the gfm has the intention to extend the study to a larger population in at least centers in france blood components and preparations. the new law prohibits the mixing of different blood products, i.e. blood components and blood fractions. different methods are necessary for the quality control of blood components and blood preparations privileges for blood donors include: -a paid day off work on the day of blood donation and medical examination for blood donation additional paid day off work after blood donation an extra paid day off work if blood is given during vacation or on a holiday this award will be given to non-remunerated donors after blood donations or plasma donations. before , each 'honoured donor of russia' or 'honoured donor of the ussr' had three privileges: free use of public transportation, receipt of certain pharmaceuticals free of charge, and a discount on apartment utilities previously, municipalities also could have their own blood establishments. this resulted in more than blood establishments in the russian federation. from both administrative and financial points of view, many of these are too small to be costeffective, and should be discontinued. services, and wider implementation of modern technology for blood collection, testing, processing, storage, and distribution acknowledgements: we thank ksw microtec ag, dresden/ germany for sponsoring the rfid-labels and novatech research gmbh, vienna/austria for developing the clinic-software. background: the national preparation human immunoglobulin g % for intravenous use (ivig) that is produced at the serbian institute for blood transfusion is used in therapy of neurological, heartand haemolytic diseases and on patients that have undergone surgery. aims: it is our aim to prove the impact of this national medical preparation human immunoglobulin g % for intravenous use on patients that have been infected with sepsis as a consequence of surgery. material and methods: human immunoglobulin g % for intravenous use (ivig) has been used in the study. the preparation is liquid, % stabilised with glucose of a ph value of . ± . . it is used in those cases where sepsis developed after surgery. both an ivig group (n = ) and a control group (n = ) were viewed; the control group not being treated with ivig. the number of specimens with the ivig therapy cholecystitis is (n = ), and the control group (n = ); pancreatitis (n = ) control group (n = ); intestinal obstruction (n = ) control group (n = ); abdominal organ perforation (n = ) control group (n = ); abdominal perforate injuries (n = ) control group (n = ); serious abdominal interventions (n = ) control group (n = ). the period of hospitalisation of the patients in the ivig group was ± days while the period of hospitalisation in the control group was ± days. the mortality rate in the ivig group was % counter . % in the control group. summary: toxic gram -negative bacteria caused synergistic damage of human tissues and generalized inflammatory responsesepsis. by using human immunoglobulin g % for intravenous use, in cases of severe disease, the mortality rate is significantly lowered, depending of course on the anamnesis of the patient prior to surgery and the presence of other diseases such as diabetes mellitus, neoplasma, cardiac diseases etc. background: manual production pc from buffy coats (bc) is a procedure with some consecutive manipulations. the orbisac system (gambro bct) automates the steps and we assessed its performance. material and methods: pc were produced by this device and some parameters were studied. for the preparation of pc, bc were pooled using the orbisac set, with an integrated filter (pall lrp ). bc pool was resuspended in the additive solution t-sol in order to obtain a final ratio plasma/t-sol / . the pc was stored in a gambro elp bag. results: the average platelet count per unit was . ¥ e . the platelet recovery from pooled bc was . % (range . %- . %). all products of the tested pc containing < ¥ e wbc (by flow cytometry). the values of ph on day and of storage were . and . . the swirling phenomenon was good until day °. the average loss of haemoglobin per bc was . g.conclusions:the orbisac system is very suitable for routine pc preparation and it allows increased productivity and better standardization method for pc preparation. platelet concentrates met the requirements for leucodepleted product. increased production of plasma components from male donors background: we routinely separate whole blood (wb) after hard centrifugation into a red cell concentrate (rcc), a buffy coat (bc) and plasma (pl) by an automated expresser (compomat, fresenius). the bcs are subsequently processed into platelet concentrates (pcs) by soft centrifugation and an additional (manual) expression step. the atreus c system (gambro bct) eliminates several of those hand-on steps by combining them into one integrated process. a processing 'circular' bag is placed in the device and filled with the wb. while the bag is centrifuged, the system expresses pl, pc and rcc into separate containers. the rccs are subsequently leukoreduced (manually) with a filter (lr-rccs). this study was designed to evaluate the storage characteristics of the rccs obtained with a prototype of the atreus system in comparison to rccs obtained by routine procedure. methods: whole blood ( ml) was collected in top-and-bottom bags, and randomly selected to be processed by either ( ) current routine or ( ) atreus c. rccs were leukoreduced with the integrated inline filter: fresenius (routine group) or pall rc d (atreus). lr-rccs were stored at °c and sampled until day . various in vitro measurements were performed (n = per group).results: see table (mean ± sd). the lr-rccs contained significantly more leukocytes in the atreus group. despite the rbc loss in the bc, hemoglobin (hb) content was % lower in the atreus group, but met the requirements. in vitro storage characteristics for the rccs were similar in both groups. the atreus pcs contained ± ¥ platelets in ± ml. although plasma volume was higher in the routine group, subsequent preparation of pcs would have resulted in an additional loss of ml per unit in the control group. atreus plasma had extremely low levels of residual wbc and rbc. . ± . . ± . < < . aims: the aim of this study was to examine platelet quality of prestorage pooled prp-derived pc's for up to days storage. methods: pc's were manufactured from wbd-pc's using in-line filtration of prp on day . on day , either , , , or pc's were pooled into an elx® container using a sterile connecting device. studies were performed on days , and for the following measure of platelet quality. ph, morphology score (ms), extent of shape change (esc), hypotonic shock response (hsr), percent in surface expression of p-selectin (p-sel), phosphatidyl serine (ps), glycoprotein b (gp b) and by thromboelastography of the prp (maximum aplitude, ma). results: a total of pools were studied, each of , , and pc's. the mean platelet yield was . ¥ e with a range of . - . ¥ e . the five pc's had a mean yield of . ¥ e and all maintained a ph > . on day . all products had less than ¥ e residual wbc. platelet quality data is presented in the table. data are the mean ± sd, n = . conclusion: platelet pools manufactured from pc's produced by inline filtered prp and stored in elx® containers show good quality preservation to day over a range of platelet yields. introduction: the big progress in treatment of critically ill children significantly increases the need for blood and blood products. loss of blood (lowering of the total erythrocyte mass), as well as decreasing of oxygen capacity of blood that can influence cardiovascular function, is main indication for the erythrocyte transfusion. aim of the study: to present the number of erythrocyte concentrates (ek) that were issued to the pediatric clinic in skopje, as well as to point out how they were distributed. material and method: this is a retrospective study performed in nitm-skopje from january till may . the following criteria were followed: hemoglobin (hb), hematocrit (htc), as well the clinical evaluation, and then final decision for transfusion was made.results: there were blood units (ek) issued for the mentioned period to pediatric clinic for pediatric patients (~ , % units/per child). the biggest consumers are children at intensive care unit and at the hematology-oncology unit. one unit of leukodepleted erythrocytes (er) was split equally to - bags. for small and prematurely born children and for some other selected patients er unit was filtered and irradiated. the dosage was - ml er (depends on age and body weigh). ek was issued as washed concentrates, ek were filtered and ek were resuspended in ab plasma. distribution among abo system was the following: conclusion: gynecologic patients consumed rbc more than times than obstetric ones ( vs ) and the number of given transfusions is high. the a blood group is the most needed one. we should insist on using the who guidelines for the proper clinical use of blood and try to minimize the percentage of given transfusion. and z. cermakova university hospital, ostrava, czech republic background: fully automated system olympus pk is an immunohaematological analyser for detection of red blood cells antigens of ab , rh (d, c, c, e, e) and kell systems without centrifugation by mam (microplate agglutination method) on unique terraced microplate olympus. in the czech republic analyser pk is used only in blood center ostrava. aim: to evaluate the validity of results, sensitivity of microplate agglutinaton method, cause of abortive tests, requirements for analyst, capacity and reliability. methods: blood samples of donors were tested between july and january . all samples were analysed for ab blood group. samples were tested for rhd antigen and ones for rh (c, c, e, e) and k antigen. the validity of the results was evaluated for ab with parallel testing antigens and antibodies, while for rh (d, c, c, e, e) and k using two diagnostic serums. sensitivity of mam i.e. occurrence false negative or positive results were found out when results were confronted with previous ones in our data bank acquired testing classical manual tube or microplate methods. requirements for analyst were evaluated in according to demands for needful knowledge for new analyst, necessity of control pk during testing and maintenance. capacity were evaluated as a number of samples tested per day. reliability determine by occurrence disorders. results: ab , rh (d, c, c, e, e) and k were investigated truly by first testing at . % samples. two diagnostic serums anti-d olymp igm and totem differentiate directly rhd negative and rhd positive donors. false negative or positive results were not founded out due to mam or quality of diagnostic serums. about . % samples with abortive tests were analysed next time the same testing or manual technique. causes of abortive tests were microagglutination several samples except for anticoagulative edta, weak solution of red blood cells prepared by analyser, damage of microplate, hemolysis due to impurity of microplate. in one case analyser evaluated false ab blood group due to hemolysis. analyser has friendly software, simple maintenance and sound control during testing, capacity about samples per day and minimal occurrence of weighty disorders. conclusion: analyser olympus pk is an effective alternative full automation for medium serological laboratory and together with mam easy and truly proves blood groups of majority samples with minimal necessity repetition due to abortive tests. introduction and aim of the study: the purpose of this study is to establish nested-pcr for the detection of hepatitis b virus (hbv) in blood and blood products. methods: the primer pair set was designed to amplify bp in sregion of hbv genome in the first pcr and bp of first pcr amplicon with rubisco (internal control) in the second pcr. to assess the specificity of pcr results, all the samples were tested cross-reactivity or interference in the assay. results: in case of hbv spiked blood products such as immunoglobulin and coagulation factors, this method could detect hbv dna up to . iu/ml. nested-pcr was compared with pcr-elisa and hybrid capture ii (hc-ii), the pcr-elisa showed a sensitivity of % (hc-ii; %) and a specificity of % (hc-ii; %) (p < . ). the results of the study show that nested-pcr and pcr-elisa could be used equally in the management for hbv detection in blood and blood products. p- blood component therapy: slow improvement a mrdja health center subotica, subotica, serbia background: transfusion department at general hospital was founded in . since that time till now it has answered to all demands in blood and blood components. aim: the aim is to present development of the transfusiology department in the last years, so that we could see how much of scientific knowledge we have adopted and in which direction our department goes at the moment. method: retrospective analysis of blood/component utilization in period from . january to . december . results: in whole blood participated in the consumption with . %, packed red blood cells with (rbc) only . %, washed rbc were used in . % of the cases. in whole blood participated in the consumption with . %, packed rbc with . %, washed rbc with . % and rbc in additive solution with . %. as far as plasma preparations are concerned, there has been, since , a great consumption of plasma -witch was separated from whole blood in period up to five day in . % cases, and small consumption of fresh frozen plasma (ffp) only . %. since , there has completely been cancelled the production of five day old plasma, only ffp is being used. from to for the patients who needed platelets, platelet rich plasma (prp) was prepared and applied right after preparation. the consumption rate was from units to units per year. in , after the purchase of platelet shaker, began the production of platelet concentrates (pc) and consumption suddenly rose from units in to units in . conclusions: it is obvious from the analysis that irrational consumption of whole blood was reduced to more acceptable values and therefore the use of component therapy got increased. variation in blood consumption and its slight increase is obvious though application red blood cells was conducted according to strict indications. in the production of plasma old up to five days was cancelled and instead we produced only ffp. pc we prepared for patients only in agreement of treating physician. although very slow progress in development of transfusion therapy in our department can be seen in accepting scientific knowledge. transfusion specialist are active participants in patient treatment and by accepting scientific achievement are able to set standards and help our colleagues, clinics, in successful hemotherapy. introduction: blood groups may act as receptors of parasites, bacteria and viruses. there is evidence that they perform a function and play a biological role. objective: the aim was to detect abo and p epithopes in ascaris lumbricoides extracts (ae) and to study the presence of immune antibodies in patients with ascariasis. materials and methods: ae were prepared by refrigerated mechanical rupture of adult specimens. agglutination inhibition (ai) and haemogglutination kinetics (hk) tests were made with the ae. the patients´ abo and p blood groups were determined. we total febrile non haemolitic male transfusion reaction f e m a l e alloimunisation on le/hla male antigens f e m a l e kandidates of renal male transplantation female lupus nephritis male f e m a l e total female male introduction: irradiation of blood product has been in routine use to prevent graft-versus-host disease (gvhd) in certain recipients for many yeas. gamma irradiation can abrogate the ability of lymphocytes to proliferate in vitro, cgy of gamma radiation reduce lymphocyte response to mitogens by %.the aim of the study: . to estimate potassium level increment in stored irradiation blood units. . to compare the increment in potassium level between leucodepleted and non leucodepleted, irradiated stored blood units. . to evaluate the expiratory date of blood units post irradiation. the study included units of blood collected in cpd-adsol (as- ). in twenty units the blood collection bag was with inline leucodepletion, while the other units were non leucodepleted. all the units were irradiated using caesium as a source of irradiation, with a dose of - cgy. baseline samples from the bags were obtained for measuring of extra cellular potassium (k+). control samples included. results: there is statistically significant increment in potassium level in the irradiated samples compared to the non irradiated samples starting from st day post irradiation and continues to day post irradiation. comparing the group of irradiated leucodepleted, with irradiated non leuconondepleted, for potassium level estimation during the days of storage post irradiation. there is no statistically significant difference between the two groups during all the days of storage, starting from base line samples and other samples post irradiation until day , p value of more than . . . gamma irradiation of bloods units can cause cell damage that the use of such components needs to be modified. . there is a significant increment in the extra cellular potassium level in irradiated blood units that shows doubling value within h post irradiation. . there is no significant difference in extra cellular potassium level increment post irradiation when prestorage leucodepleted units are compared with non leucodepleted units. . an out date of days post collection (unless they expired before) for irradiated red blood units seems reasonable to ensure transfusion of irradiated units without serious complications, except in neonates and massive transfusion cases where irradiated blood units should be fresh and used within - h post irradiation. . the percentage of irradiated blood units requested by our physicians ( . %) is very less that reflects the needs of physicians awareness of the indications for requesting irradiated components that can prevent serious post transfusion complications. the use of whole blood and blood components in treatment of surgical patients in ten years period was analyzed in iran. in accordance with world trend of using blood component therapy, in medical centers throughout the country in ten years period, there are decreasing trend of using whole blood from % ( ) to . % ( ) and increasing trend of using packed red cells component therapy from . % ( ) to . % ( ) . there is also increasing trend of using fresh frozen plasma (ffp) from . % ( ) to . % ( ) . comparing and year, in use of blood therapy related to hospitalized patients at surgical department who received blood and patients who did not received blood; it appears that there is statistically significant difference between these two years. results: during year period, a total of units of blood and units of f.f.p were used. more specifically, the results can be shown in the following table . a high rate of f.f.p usage is observed both in surgery and pathology clinics. the main causes of its usage are: haemodynamic disorders -volume depletion, and coagulation disorders and low blood protein, for the two clinics respectively. conclusion: the only way for rational usage of f.f.p is the regular reminding of plasma transfusion indications to the clinical doctors, so that undesirable side-effects caused by plasma transfusion will be reduced and the percentage of plasma used for fractionation will increase. acquired factor v inhibitor is extremely rare and is associated with diverse clinical symptomatology that varies from asymptomatic forms of the disease to very severe hemorrhagic episodes with a potentially lethal outcome. it may occur spontaneously or as a result of various clinical conditions. a -year-old man was admitted to our hospital with a diagnosis of left-sided periscrotal abscess and scheduled for an incision procedure. during the routine preoperative procedure screening coagulation tests showed pathologic values: aptt s, pt %, fibrinogen . g/l, fv % (other factors were in normal range), platelet count ¥ /l. factor v inhibitor was detected by a modified bethesda assay. the assay showed a low level of inhibitor of about . bethesda units (bu). the patient's medical history showed no major morbidity except appendectomy performed years ago. the patient was prepared for operative procedure, with preventive preoperative administration of fresh frozen plasma (ffp) in a dose of mg/kg (~ ml). upon ffp transfusion, repeated determination of the factor v plasma was unchanged from the initial finding ( %), indicating a failure of therapeutic response. as the measured level of factor v activity was at the borderline hemostatic level, and the operative procedure was not associated with a high risk of hemorrhage, the patient underwent abscess incision. the procedure and postoperative course were uneventful and without major hemorrhage. laboratory testing for the possible systemic autoimmune disorder produced normal findings. control examination performed two years later revealed no major clinical or laboratory variation, while a low factor v level persisted ( %) along with the presence of factor v inhibitor at a level of . bu. we have evaluated two groups of rcc's, one we routinely use (quadruple leucoflex lcr t/t cpd/sagm) (macopharma) and one using an automated collection device which gives the ability to collect whole blood in cpd with a rate of : respectively during the whole donation. the mentioned system has been evaluated using the suitable, quadruple leu-coflex lcr t/t cpd/sagm (macopharma). whole blood ml in cpd was collected from random donors. in both groups the whole system was stored at scaled r.t. ± °c for to h. after component separation (beckman coulter j mi-optipress i-baxter), the red cell concentrates were filtered immediately at r.t. ± °c. sampling was done after filtration and wbc measurements were determinated using nageotte champer (bright line-detection limit . wbc/ml) with leucoplate solution (sobioda). the other parameters were measured with (celldyne abbott). conclusion: all products met the accordance of national and european norms for blood components quality. leucodepletion with leucoflex lcr and abc leucoflex lcr ( . and . ) is highly efficient. the use of abc leucoflex lcr showed better scaled donation in terms of collection (statistical analysis mann-whitney, minitab p-value = . < . ). additionally less hb-loss occurred, due to the filtration process, most probably due to the total absence of clots (analysis man-whitney, minitab, p-value = . < . ). this new generation of collection gives the ability in blood services to collect well calibrated donations, indoors or outdoors. smaller quantities of donations theoretically can be valid because of the stable : , rate of donation. the abc system gives the ability of fully traceability during donation. macopharma's blood collection bags, with or without integrated filters, provided they have this modified system of storing the ac. the device can keep records for many parameters and can transfer them to the data base server of the blood center. to evaluate the performance of the abc, we conducted a comparative study between abc leucoflex lst system and leucoflex lst system we currently use. the later is a well known macopharma's system for collection of whole blood with integrated whole blood filter and the final production of one unit of leucodepleted crcs and one unit of leucodepleted plasma. the abc was handled with the same system modified with the storage bag for the ac. issues of comparison were the accuracy in donation volume, the duration of filtration, the loss of blood in the filter and the residual wb cells after filtration. we performed donations with the lst system and donations with the abc lst system. all the donors were random male volunteers and they were meant to donate mls of whole blood. our results analysed by mann-whitney, minitab statistical analysis have as follows: . no significant difference was found between the two systems concerning the whole blood volume, but there was broader distribution of the values in the lst system compared to the abc lst system. . the duration of filtration has been found without statistically significant differences between the two systems. . the loss of volume in the filter of lst is higher than in the abc lst (p = . < . , which is statistically significant). . there was very good leucodepletion with the lst systems (median reduction of the wb cells . log) but there was a superiority of the abc lst over the lst concerning the leucodepletion per litter and per unit (p: . and p: . respectively). . the personnel after a very short period of training accepted fully the abc procedure.in conclusion abc is an easy to handle device which provides with high quality blood products in combination with leucoflex lst . evaluation of a post-storage filter for wbcs with an incorporated waste bag for washing rccs leucolab lcg is a system manufactured by macopharma for poststorage filtration of a rcc unit (with or without an incorporated waste bag for further washing of the filtered product). to evaluate the efficiency and reliability of the above system we conducted a study with twenty three random units of rccs stored in cpd/sag-m, aged - days, filtered and consecutively washed with ml of normal saline, span down in the regular way and the supernatant extracted in the waste bag. issues for evaluation were: . the duration of priming and filtering the rccs. . the loss of volume in the filter. . the efficiency of the filtration. . the acceptance of the personnel of a new (to them) filtration system.our results have as follows: . we counted the duration of priming and filtration. median time of priming was s (range - ) and of filtration was min (range - ). . the median volume lost in the filter (as calculated) was . ml (ranging from . to . ). this narrow range is apparently due to the non-flexible cell of the filter. . the efficiency of the leucodepletion was counted by flow cytometry. the median wbc counted per lt was . ¥ (range . - . ¥ ) and per unit was . ¥ (range . - . ¥ ). the median reduction of the wbc count was . log (range . - . ). . the personnel involved in the procedure found the system easy to handle, even without specific training. in conclusion the lcg is a reliable and easy to handle system, for leucodepleting (and washing) rccs, very efficient in removing wbcs with negligible loss of volume. objective: standardization of blood banks and establishing quality assurance are important landmarks in the new era of transfusion medicine. as the number of blood banks grows and the capacities of them changes, centralization need arises and trends to nationally coordinated blood services eventually appear. aim: to investigate the types and capacities of blood bank in the country and evaluate the statistics of them. material and method: blood banks and transfusion society of turkey conducted a nation-wide survey of a comprehensive questionnaire. this is a preliminary report of this investigation and illustrates the capacities of the most blood banks in turkey. it also guides the nationally planned renewing structure of blood banks. results: there are nearly blood banks and blood stations in whole country. the overall blood collected at those centers is about . . units. nearly one in third is being collected at government hospitals ( . %), nearly the same is collected at university hospital blood banks ( . %). the third major group is the red crescent society blood centers-rcsbc ( . %), followed by the social security hospitals ( . %). blood collecting capacities are not appearing in the same order. the major blood banks belong to the rcsbcs, whereas the small ones are mostly government hospitals. the only donor recruitment organization is run by the rcsbcs. yearly blood collecting capacity blood banks (%) > . . . - . . . - . . . - . . < . . conclusion: there are many steps for improving blood safety in a country, and the prior ones are structuring the blood transfusion system and donor organization on a national basis, and then establishing good manufacturing practices. these are only possible after centralization of all existing blood banks. in our country, we should first arrange all small capacity blood banks and standardize them. controversial clinical questions considered in a medical opinion forum by physicians for the advancement of transfusion medicine (patm) patm is a newly formed group of close to physicians drawn from pathology and hematology, transfusion services, hospital blood banks and blood centers. its mission is to address the concern that patient oriented medical opinion and influence has been diminished in transfusion medicine (tm). they believe that a patient oriented voice should be distinct from institutional, commercial or regulatory weight and have a common focus on patients and the therapeutics of transfusion and related therapies. therefore, their first objective is to create a new medical, patient oriented voice that weighs in on national policy pertaining to treatments related to tm. as such, patm held its first medical opinion forum where members of the group debated important questions pertaining to tm clinical practice. the forum was held just prior to the aabb annual meeting and attracted physicians. the questions debated were preselected by patm membership via an email survey. respondents were asked to select their top four preferences from among topics in five broad categories. the top two topics were selected for the forum from the completed surveys. the subjects selected and debated were (i) what are the medical considerations for reducing the rate of mistransfusion? and (ii) what are the medical considerations for managing a limited blood inventory? the participants were divided into four groups, with each topic assigned to two groups. all the groups were given two h to debate and arrive at consensus on their topic. each group then presented a summary of their discussions along with specific recommendations for addressing these clinical practice issues. there was remarkable consensus between the groups debating the same issue. the conclusions and recommendations on these two topics will be presented in detail. patm is a new organization that will add an important medical voice and opinion on current topics in tm. at its first meeting, two topics were successfully discussed and debated with broad consensus achieved on current issues confronting the field. key: cord- -a j ce authors: verlicchi, paola title: trends, new insights and perspectives in the treatment of hospital effluents date: - - journal: curr opin environ sci health doi: . /j.coesh. . . sha: doc_id: cord_uid: a j ce recently, investigations of hospital effluent management and treatment have not only interested research groups with acquired experience in the field but have also attracted the interest of new groups over the world. the most recent literature provides new insights into the occurrence of pharmaceuticals and other contaminants of emerging concern, pathogens, viruses, antibiotic resistant bacteria and genes in hospital effluent in various new developing and developed countries. it also provides information on the effective removal of key compounds (mainly antibiotics, analgesics, beta-blockers and chemotherapy drugs) by means of enhanced biological treatments and advanced oxidation processes. the current debate among the scientific community is mainly about the proper treatment to reduce the spread of antibiotic resistant bacteria and genes, and about the feasibility (from a technical and economic point of view) of treatment trains tested at lab and pilot scale. the management and treatment of hospital effluent are issues of current concern in an increasing number of countries worldwide. at the same time, the increasingly widespread awareness that the effluent produced in healthcare structures may contain conventional pollutants and micro-pollutants -due to the different activities occurring within the structure (diagnosis, laboratories, clinics, surgeries, medications and presence of patients in different types of wards) -has led to discussion on how to improve the management and enhance the treatment of such effluent. a snapshot of the current situation is provided in a recently-conventional contaminants (the so-called macropollutants) and contaminants of emerging concern (cecs) (mainly pharmaceuticals) in hospital effluent, including antibiotic resistance genes and bacteria (among them ( ), ( ) . more recently, the efficacy of pathogen and virus removal was at the centre of many debates and studies, and efforts were made to evaluate whether (further) measures should be adopted, and if so which, to reduce the risk of environmental contamination and to guarantee a higher level of hygienisation in the hospital effluent treatment ( ), ( ) . many studies aimed to improve the removal of key cecs by means of enhanced biological treatments or by combining biological, chemical and physical technologies. some investigations aimed to better understand the removal mechanisms of key compounds and their interactions with the treatment environment. this is the case of the investigations by ( ) countries where studies or investigations on hospital effluent have also been carried out, but also in new ones, such as ethiopia ( ), columbia ( ), india ( ), iran ( ), ( ), costa rica ( ) and thailand ( ). this contact time of . min. the poor removal of doc during ozonation showed that any remaining recalcitrant compounds were not completely removed or mineralised and could produce transformation products requiring further investigations, as suggested by ( ). interesting results have been achieved in the removal of a selection of antibiotics with the system tested by ( ) consisting of an enhanced mbr (equipped with hallow fibre membranes) coupled with ozonation. the mbr system is that originally proposed by ( ) and then investigated by ( ) for the effluent of trung vuong hospital in vietnam. its novelty consists of the presence of polyester-urethane sponge media with high porosity in its aerobic compartment in order to promote micropollutant removal and at the same time reduce membrane fouling, which is still the most critical operational factor for this biological system. it operated with a biomass concentration of around , mg/l, a ratio between volatile and total suspended solids of . , and a sludge retention time of days. mbrs coupled with granular or powder activated carbons (gac or pac), or characterised by modified membranes, or operating under specific and controlled conditions. the spanish group at the university of santiago of compostela ( ) applied their patented system sempac© to hospital effluent and evaluated its performance with regard to cecs: ibuprofen, α-ethynylestradiol, diclofenac, carbamazepine, and trimethroprim. it consists of a sequential batch reactor followed by an external submerged microfiltration membrane tank where pac is added to enhance the sorption of residues of cecs. they found that the addition of pac improves the removal of all the compounds, including the most recalcitrant carbamazepine and trimethoprim. the results also showed that it is important to identify when pac must be added due to powder saturation in order to guarantee a constant removal of all the key compounds (every days in their investigation). promising results have been obtained with moving bed biofilm reactors (mbbr) for the removal of specific pollutants such as anionic detergents as in the study by ( ) regarding effluent from an iranian hospital (removal achieved around % of las with a filling rate of % of kaldness carriers, a biomass effluent. they found that the chemical (radical attacks) and physical (suspended solids disaggregation) effects due to the sonochemical step improved the removal of the recalcitrant compounds showing a pondered average removal of around %. the reduction of the pharmaceutical load increased up to % when fe + ( ppm) and uvc light ( w) were added to the sonochemical system, thus generating a sono- photo-fenton process. the study showed the promising results that can be achieved by these treatment trains but also the high energy costs: if future research is able to reduce them, this solution could become economically feasible. electrochemical technologies have also been tested for the degradation and mineralisation of specific compounds occurring in hospital effluent. in this context, ( ) investigated the degradation of the chemotherapy drug doxorubicin (which could reach concentrations as high as µg/l) by nanostructured graphite electrodes with metallic oxides (grphite, tio @graphite and auo-tio @graphite electrodes). the lab scale experiments showed complete degradation with the auo-tio @graphite electrode and no undesired compound was formed. as to ecotoxicological effects, the tested treatment did not cause any effect on embryo-larval development of zebrafish, but dna damage was observed after hours' exposure. tank, the chemical disinfection of raw hospital effluent by means of high doses of sodium hypochlorite (up to g/m ) is not sufficient to remove sars-cov- viral rna. the authors highlight that the current recommended doses by the world health organization (free chlorine ≥ . mg/l for at least min) and china centers for disease control and prevention (free chlorine above . mg/l after . -h contact) are not sufficient to reduce the content of the virus in hospital effluent. overdoses of the disinfectant seem to be able to remove the virus but they lead to significant concentrations of disinfectant by-products. suggestions provided by ( ), ( ), ( ) suggest the importance of the proper management of waste and wastewater within a hospital, which becomes absolutely necessary during a public health emergency. the debate on the most suitable treatment of hospital effluent is ongoing and constantly fed by new insights. it allows to identify the fields that require urgent research and recommendations for a suatainable hospital effluent management and treatment. the covid- pandemic has highlighted the need for further investigations into how to reduce the risk of spreading coronaviruses and, more generally, that the reduction of arg, arb and pathogens should be among priority research areas to preserve and protect the water environment, improve sanitation, and guarantee clean and safe water for a wide range of activities, in accordance with the united nations sustainable development goals sars-cov- from faeces to wastewater treatment: what do we know? a review hospital effluent: a reservoir for carbapenemase-producing enterobacterales? sci total environ antibiotic resistance in urban and hospital wastewaters and their impact on a receiving freshwater ecosystem evaluation of factors influencing the environmental spread of pathogens by wastewater treatment plants removal and monitoring acetaminophen-contaminated hospital wastewater by vertical flow constructed wetland and peroxidase enzymes ozonation of nursing home wastewater pretreated in a membrane bioreactor high rate treatment of hospital wastewater using activated sludge process induced by high-frequency ultrasound occurrence of pharmaceuticals, hazard assessment and ecotoxicological evaluation of wastewater treatment plants in costa rica the impact of on-site hospital wastewater treatment on the downstream communal wastewater system in terms of antibiotics and antibiotic resistance genes evaluation of a full-scale wastewater treatment plant upgraded with ozonation and biological post-treatments: abatement of micropollutants, formation of transformation products and oxidation by-products hospital wastewater treatment by sponge membrane bioreactor coupled with ozonation process evaluation of a novel sponge-submerged membrane bioreactor (ssmbr) removal of pharmaceuticals, toxicity and natural fluorescence through the ozonation of biologically-treated hospital wastewater, with further polishing via a suspended biofilm fungal treatment of metoprolol and its recalcitrant metabolite metoprolol acid in hospital wastewater biotransformation, sorption and ecotoxicological impact effective elimination of fifteen relevant pharmaceuticals in hospital wastewater from colombia by combination of a biological system with a sonochemical process ecotoxicological assessment and electrochemical remediation of doxorubicin screening of metal and antibiotic resistance in beta-lactamase . who. global priority list of antibiotic-resistant batceria to guide research, discovery, and development of new antibiotics the prevalence and characterization of extended- spectrum β-lactamase-and carbapenemase-producing bacteria from hospital sewage key: cord- - w zepx authors: bassareo, pier paolo; melis, maria rosaria; marras, silvia; calcaterra, giuseppe title: learning from the past in the covid- era: rediscovery of quarantine, previous pandemics, origin of hospitals and national healthcare systems, and ethics in medicine date: - - journal: postgrad med j doi: . /postgradmedj- - sha: doc_id: cord_uid: w zepx after the dramatic coronavirus outbreak at the end of in wuhan, hubei province, china, on march , a pandemic was declared by the who. most countries worldwide imposed a quarantine or lockdown to their citizens, in an attempt to prevent uncontrolled infection from spreading. historically, quarantine is the -day period of forced isolation to prevent the spread of an infectious disease. in this educational paper, a historical overview from the sacred temples of ancient greece—the cradle of medicine—to modern hospitals, along with the conceive of healthcare systems, is provided. a few foods for thought as to the conflict between ethics in medicine and shortage of personnel and financial resources in the coronavirus disease era are offered as well. in december , a series of pneumonia cases of unknown origin were reported in wuhan, hubei province, china. on january , after ascertaining the viral origin of the disease, the who recognised a coronavirus responsible for the disease and named it as the novel coronavirus ( -ncov). again, based on its genetic similarity to already known coronaviruses, the international committee on taxonomy of viruses renamed the previously termed -ncov as severe acute respiratory syndrome coronavirus (sars-cov- ). conversely, the first coronavirus or coronavirus was responsible for sars epidemic in . on january , the who released a public health emergency of international concern. on february , the who formally named the disease as covid- . on march , the who formally recognised the global spread of covid- as a pandemic: the second in this century and the first to be caused by a coronavirus. the first description of human coronavirus was published by the scottish virologist june hart almeida in the british medical journal in , while working in st thomas's hospital medical school (london). since the spokes around the viral edge reminded researchers of a crown, the virus was named corona (crown in latin) in a subsequent paper published in nature ( ). since march , sars-cov- has changed our daily life, behaviour and maybe the whole human history. sars-cov- has spread throughout our nightmares with the same strength as it has had in breaking into our lives. quarantine, spread, isolation, lockdown, cocooning, masking, social distancing, hand hygiene, blood tests, vaccine, immunity: all these words are now part of our daily speeches, pervading the most subconscious of our thoughts. our healthcare system is now facing huge challenges with the spread this virus, and so it is getting a favourable occasion to review the history of the previous infections which the human being had to face in the past, with the ultimate aim of educating young doctors to learn from those events. in daily conversations, people often use the term 'quarantine' to refer to separating sick people with a contagious disease from the healthy ones in various ways. quarantine or lockdown is a forced segregation to prevent a communicable disease from spreading. the term 'quarantine' comes from the italian word 'quarantena', which means a period of days (in italian, is 'quaranta'; the latter derives from the latin word quadrāgintā). during the th century, days was the length of strict isolation required for ships suspected of carrying an infectious or contagious illness before their passengers and crew were allowed to land. this practice was usual in venice in the s, in an effort to stave off plague ('black death'). it entered english language in the early s. an early mention of 'isolation' dates back to the th century b.c. or maybe earlier in the leviticus, the third book of the old testament in the bible. in that book, the procedure of separating infected from healthy people to prevent leprosy from spreading, according to mosaic law was described, (if the shiny spot on the skin is white but does not appear to be more than skin deep and the hair in it has not turned white, the priest is to isolate the affected person for seven days. on the seventh day the priest is to examine him, and if he sees that the sore is unchanged and has not spread in the skin, he is to isolate him for another seven days). however, nowhere in these forerunner reports was the term 'quarantine' used. after arriving in southern europe in , plague spread rapidly and reached england, germany and russia by . over these years, one-third of the european population passed away. the dramatic impact of the epidemic led governments to put in place extreme infection control measures. for instance, in , viscount bernabo of reggio, italy, declared that every person with plague was to be taken out of that city into the fields, where to die or to recover. the date, july , is one of the highest achievements in the history of medicine. originally, the period of isolation was limited to days. as reported in the first available documents, before entering the seaside city-state of ragusa in dalmatia (now dubrovnik in croatia), newly arrived people had to spend days (a 'trentine') in a restricted place in the islands in front of the city (see box ), [ ] [ ] [ ] waiting to see whether the symptoms of black death would develop. the city chief doctor jacob of padua was responsible for the decision. at that time, ragusa was an important adriatic harbour belonging to the maritime republic of venice. a specific decree (veniens de locis pestiferis non intret ragusium nel districtum) was published in dubrovnik's book of laws, the so-called green book (latin: liber viridis). the -day period outlined in the 'quarantine' edict was known in italian as a 'trentino' ('thirty' in english). four were the outlined point in the edicts, namely: ( ) those coming from black death-endemic regions would not be admitted into ragusa until they had waited in isolation for days; ( ) none from ragusa was allowed to access the isolation area, under penalty of being compelled to stay there for days; ( ) subjects not indicated by the great council as responsible of those being isolated were not allowed to bring them food, under penalty of remaining with them for days; and ( ) whoever did not accomplish with the above stated regulations would be fined and subjected to isolation for . in , the great council of ragusa released a new decree (de ordinibus contra eos qui veniunt de locis pestiferis anno factis), which specified again the -day duration of quarantine and determined the place. penalties were imposed for those breaking rules, and three healthcare officers (called kacamorti) were appointed to supervise the compliance with quarantine provisions. the penalties for not complying with the provided regulations were represented by a money fine or prison sentence or severe corporal punishment. the penalties were applied only to common people but not to aristocracy. in addition, the importation of goods from the countryside for the entire duration of the epidemic was forbidden. in , the venetian senate, the main deliberative and legislative body of the republic of venice, prolonged the waiting period to days, thus giving birth to the term 'quarantine'. over the next years, similar edicts were published in marseilles, venice, pisa and genoa. since disease was considered as a divine punishment for sinners, the biblical -day period of purification had crossed over into health practices and the term 'quarantine' had great symbolic and religious significance to medieval christians. in the sacred scripture, when god flooded the earth, it rained over days and nights; moses stayed on mt. sinai for days; jesus fasted and was tempted by the devil in the desert for days; after childbirth, a new mother was expected to rest for days. on the basis of a th-century tale by the genoese gabriele de' mussi, the devasting black death came over italy carried by genoese sailors who sailed from caffa/kaffa (now feodosija, ukraine) to their home city ( / ). in fact, in , the tartar forces captained by jani beg khan had laid a military operation in which his forces surrounded caffa, in an attempt to cut off essential supplies, with the aim of compelling the genoese to surrender and removing them from one of the cornerstones of europe's defence against eastern attack. after several unsuccessful assaults due to the outbreak of the black death, jani beg khan's army catapulted infected bodies over the city walls into caffa, using the plague to weaken the defenders. that is the first known example of biological warfare in the human history. a caffa street (via caffa in italian) is still present in the city centre of genoa to remember that event (figure ). however, the number of crimean harbours under mongol army control suggest that caffa is unlikely to have been the only source of plague-infested ships heading to europe. in addition, the overland caravan routes from mongol territories might be considered responsible for infecting europe as well. this plague was well described by one of the most famous italian authors of the th century, giovanni boccaccio ( - ), in his book the decameron written in tuscan vernacular (italian). the book is a collection of short stories told by a group of seven young women and three young men sheltering in a villa just outside florence to escape the black death that afflicted that city. boccaccio probably conceived his masterpiece of classical italian renaissance prose after the plague epidemic of , which came to a standstill by . the black death in the th century resulted in more than million deaths and is considered one of the greatest public health disasters in recorded history as well as one of the most dramatic examples ever of a periodically re-emerging disease. between and , the black death box origin of the term 'lazaret' ► all merchants, sailors and goods coming from 'suspicious lands' could not enter ragusa, unless they have spent a month on quarantine on uninhabited islands of mrkan, bobara and supetar in front of the city. a few wooden shelters (wooden so that they could be burned if needed) were built on them because of the unfavourable weather. this sort of simple dwelling was called lazaret (italian: lazzaretto). the term derives from the biblical story of beggar lazarus, who was raised from the dead out of the tomb by jesus christ. following that, another lazaret was built on a small island in the lagoon in front of venice in . in , the maritime republic of genoa followed the example of venice, and in , the old leper hospital in marseille was turned into a black death hospital. the great lazaret of marseille, perhaps the most complete of its kind, was built in on the island of pomègues. the procedures in the lazarets in the mediterranean sea did not differ a lot from those of the british empire in the levantine and north african trade. as soon as cholera arrived ( ), a few new lazarets were built, especially near the harbour of bordeaux in the human history, similar isolation centres were built for those with leprosy (leprosarium) or tuberculosis (tubercolosarium). killed about one-third of the european population, and a significant percentage of that in asia. only a few centuries later, it was discovered that plague or black death is a bacterial disease caused by the gram-negative pathogen yersinia pestis, discovered in by the swiss/ french physician alexandre yersin and later ( ) renamed 'yersinia' in his honour. it is mainly spread by infected fleas from rats. according to current knowledge, the bubonic plague has an averaged -day period from infection to death; therefore, the european quarantines would be highly successful in determining the health of crews from potential trading and supply ships. ('when leaving his surgery on the morning of april , dr. bernard rieux felt something soft under his foot. it was a dead rat lying in the middle of the landing.' albert camus , french writer, in his book the plague). following that, in the human history, quarantine was declared many times when an infectious disease threated the population of a town, region or country. the most dangerous pandemics in the human history are summarised in box . as a general rule, the more the human beings became civilised -leaving agrarian life, building towns, forging trade routes to connect remote regions one another and fighting wars for supremacy-the more pandemics showed up. in the usa, the process of developing national quarantine policy required many years. originally, as to many other matters, the single federal states were responsible for handling the influx of infectious illnesses. however, repeated outbreaks of yellow fever induced the congress to release the national quarantine act in , thus creating the premises for federal involvement. in , a cholera outbreak led officials giving the federal government more authority to impose the requirements. by , the quarantine system was totally nationalised. according to the us centres for disease control and prevention, there is a marked distinction between quarantine and isolation. as to the first term, people are put in 'quarantine' when they have neither signs nor symptoms, as they are not infected, but have been or may have been exposed to a communicable disease. this can help preventing the disease from spreading. conversely, people are put in 'isolation' when they are symptomatic or are reasonably believed to be infected with a communicable disease. this is to totally separate them from those who are not infected. isolation may be voluntary or imposed by a federal, state or local public health order. the history of quarantine in the usa is summarised in box . covid- widespread is putting healthcare systems under significant pressure worldwide. a large number of patients are needing to be admitted to hospitals at the same time for intensive care. available beds, ventilators and personnel are often not enough to face this ongoing emergency. the first facilities for sick people were not hospitals but temples dedicated to 'healing gods', such as imhotep for ancient egyptian, asclepius for the greek and aesculapius in ancient rome. at that time, prayers, sacrifices and dream interpretations played a crucial role in the healing pathway, but the ancient doctors also stitched cuts, set broken bones and administered opium for pain. the foundations of medicine are in the island of delos, which belongs to the cyclades archipelago in the greek sea. according to local mythology, delos was the birthplace of apollo, who is acknowledged as the original source of health and healing. he taught the art of surgery to chiron, the centaur, who in turn taught the same to asclepius, the greek healing god: his daughters were hygieia ('hygiene', the goddess of cleanliness), iaso (the goddess of recovery from illness), aceso (the goddess of the healing process), aegle (the goddess of good health) and panacea (the goddess of universal remedy). religious worship of asclepius was in the island of kos, which was also the birthplace of hippocrates, who is recognised as the father of 'rational' medicine. in athens, the temple dedicated to asclepius ( th century b.c.) had a large room for inpatient to be healed (pure in the body and spirit). greek physicians treated patients on the basis of house calls as well, which was a practice that continued for hundreds of years. the temples became medical practice schools in greece in the th century b.c. the word 'hospital' derives from the latin word 'hospes' for host or 'hospitium' for a place to entertain. the roman military hospitals were often used as healthcare facilities. each room was provided with three beds, thus representing a kind of ancient ward. similar hospitals were likely to be available also for gladiators and slaves, owing to their financial value. however, public hospitals were not at patients' disposal, and physicians examined them at home after being called. claudius galenus, who was born in greece and then moved to rome, was initially a surgeon for gladiators (coerusicus) and after that a physician and a philosopher. he became the emperor marcus aurelius' personal doctor and wrote about the plague, which afflicted rome during his reign. since marcus aurelius' family name was antonine, the pandemic disease was called 'antonine plague'. galenus contributed widely to the progress in medicine and his books were considered fundamental up the middle ages. as the roman empire got converted to christianity, the church's role in providing for the sick persons became firmly established. many monasteries were built, and generally they included rooms for pilgrims, the poor and the sick. the emperors from the th century onward, including charlemagne, decided that a hospital should be built beside every cathedral and provided with large, open wards. in the meantime, doctors kept on making house calls to the upper class. the strong religious influence in early healthcare is testified by the duties of the warden of st mary's hospital in england in . not only he was required to guarantee the quality of the care but also to hear the confession of the patient before admission ('pure in the body and spirit'). the wards, housing multiple patients, kept on being expanded and became the standard of care for public hospitals over centuries. the cross-shaped plan, which is thought to have had origin in florence (italy) during the italian renaissance, was conceived with an altar in the middle and multiple wards radiating from it. florence was well recognised for the high level of its hospitals and doctors, as testified by martin luther, during his visit. as the wards became larger, they often became the repository of infections. by the mid- s, one of the largest hospitals in paris had deteriorated to awful conditions, with wards which had over beds with multiple patients per bed. the wards were dark, poorly ventilated and dirty. a significant improvement was reached, thanks to florence nightingale, the founder of modern nursing, after seeing a mortality rate of over % at a military hospital in turkey during the crimean war. a new type of hospital, made up of pavilions rather than wards, was conceived. pavilions provided patients with fresh air and daylight, thus improving their recovery and reducing infections. this approach is sometimes called 'the nightingale ward' and was used first in st thomas' hospital in london. even at the old religious hospitals, nobles could have better housing bed by making donations. this approach was expanding in the late s, so that in , the first 'pay' hospital was opened in london with eight private single-bed rooms. as time passed, each country set up its arrangements for meeting and keeping people healthy, treating the sick and protecting from infectious diseases. healthcare innovation is a challenging topic for legislators and governments worldwide. only the most developed, industrialised countries (about of the in the world) have established healthcare systems, while the others are too poor for providing their citizens with any kind of mass medical care. healthcare system models are usually summarised in terms of three main models (or their combination), with expected different opinions in relation to which is the best of them. the first model is called bismarck model. germany has the world's oldest national social health insurance system, whose origin dates back to with the otto von bismarck's sickness insurance law. it uses an insurance system-the insurers are called 'sickness funds'-which are usually financed jointly by employers and employees by means of payroll deduction ('mutualistic' system). the bismarck model-based system is not aimed at making profits. doctors and hospitals tend to be private in bismarck countries. for example, japan has way more private box summary of the history of quarantine in the usa ► : in the harbour of philadelphia, the first quarantine station was built after a previous yellow fever outbreak in . ► : release of the national quarantine act, which shifted quarantine power from single states to federal government. ► : the federal government quarantine authority was set up. ► : the national communicable disease centre replaced the federal government quarantine authority. ► s: the number of quarantine stations was reduced from to . hospitals than the usa. the bismarck model does not provide with universal health coverage, since it requires employment for health insurance and stores its resources only for those who contribute financially. the second is the beveridge model. it was developed by sir william beveridge in in the uk. it is a centralised system working through the establishment of a national healthcare service (in the uk, it is the national health service). in summary, the government acts as the single-payer, because of taking off all competition in the market to maintain costs low and standardise benefits. the national healthcare service being the single-payer controls what doctors can do and what they cannot. this model is funded only by taxes, and there are no out-of-pocket fees for patients or any cost-sharing. everyone who is a tax-paying citizen is guaranteed the same access to care, so that this model is also defined as 'universal'. one criticism of the beveridge model is its potential risk of overuse. owing to the lack of restrictions, free access can potentially allow patients to demand healthcare services that are unneeded or wasteful. the result leads to increasing costs and taxes. the third model is the free market model. health is considered as a consumer good, in a free market for insurance companies aimed at making profits. it is the model adopted in the usa, where healthcare is not provided and financed by the government. those who have no health insurance have to pay the bill out-of-pocket at the time of a treatment is provided. as told, especially in europe, a combination of the abovestated models is possible. what is sure is the fact that, due to covid- rapid widespread, all these systems are facing an enormous funding crisis so far, whose consequences are also ethical. the word 'deontology' comes from the greek word 'deon', which means 'duty'. thus, deontology is also named as duty-based ethics. in deontology, reason is used to reach an agreement as to ethical standards to follow, so one has the duty to act according to those ethical principles. deontology is also called non-consequentialist ethics, because the rightness or wrongness (morality) of an action is judged on the basis of how it fits with ethical principles, not on its practical result. in this respect, the influence of the philosopher emmanuel kant is evident. according to kant, the moral law or 'categorical imperative' is an ethical principle, a universal law for all people. the essence of morality is in these principles. one of the oldest ethical code in the human history is the hippocratic oath. it was written by the ancient greek physician hippocrates ( b.c.- b.c.). the traditional hippocratic medical principle is 'primum non nocere' (first of all, avoid any harm) and doing good. its modern version, released in by lasagna, dean of the school of medicine at tufts university (usa), is still considered as a guide to conduct by the medical profession in modern ethics of deontology. since the introduction of the current bioethical paradigm by beauchamp and childress in , there has been much controversy about whether its four principles are universally and effectively applicable. these principles are ( ) respect for autonomy, ( ) justice, ( ) beneficence and ( ) nonmaleficence. the reported issues as to applicability are related to many factors, including the continuous changing of social structures and conditions, and the ongoing advances in technology. as to ethics, doctors have often to face other subjects who may have had no medical training, such as bioethicists, moral philosophers, theologians, clergy, hospital administrators, lawyers, attorneys, judges. living in a country with limited economic resources is another factor sometimes hampering the practical application of these ethical obligations. persad et al suggested four ethical principles to guide the distribution (allocation) of the available scarce medical resources, namely ( ) treating people equally, ( ) giving priority to the worst off, ( ) maximising benefits and ( ) promoting and rewarding social usefulness. within each of these four principles, there are two further contrasting ethical sub-principles (for a total of eight sub-principles). for example, regarding 'maximising benefits', two sub-principles are provided, that is, 'saving the most lives' and 'saving the most life years'. during covid- pandemic, this is one of the new challenges faced by doctors on the front line. since our medical systems have often only a limited amount of available resources (in terms of nurses, physicians, beds, treatments, equipment, money), doctors may have to choose whether treating a patient or another, based on his/her life expectancy. in addition to clinical responsibilities, the covid- outbreak is posing a very real ethical dilemma: what is a doctors' responsibility to serve patients despite personal risk? is this risk eventually to extend to medical trainees? the american medical association code of ethics states that a physician's responsibility to provide urgent care during disaster situations holds 'even in the face of greater than usual risk to the physicians' own safety, health or life'. there are also other new and still unanswered questions. how can a doctor maintain a patient's humanity during an overwhelming pandemic with limited resources and time? is the principle of delivering 'empathetic care' to be redefined under the current circumstances, and, if so, what does that look like? is sacrificing personal freedom with lockdown to protect the safety of communities justified? is sacrificing the individual healing and dignity of patients to protect the health and welfare of the general population allowed? should individual rights be limited in favour of supporting more vulnerable people? we are social creatures and the principle of 'solidarity' implies that we act supporting the most vulnerable members of our society and that we must not left them alone in scary times. in a more personal way, all of us have a friend or beloved one who is at risk in case of covid- . what would we want others to do to protect them? an interesting ethical perspective is represented by the immunity-based licences recently suggested, similarly to those for drivers or aeroplane pilots. however, one may argue that the latter are a certification of ability to work, not of health or personal state. unlicenced people should be subject to social or economic exclusion as well as personal liberty limitations. never the current restrictions were applied before in western societies. in ancient greece, crisis had also the meaning of 'change'. the covid- outbreak found most of countries unprepared, with scarce resources stored to afford the sars-cov- emergency. coronavirus has been dismantling our daily life in all its features (health, behaviour, economy). in a catastrophic perspective, since a second outbreak cannot be excluded, we should be ready to cope with it by building new specific covid- hospitals and preparing nurses and general practitioners to face the emergency at the very early beginning, thus preventing patients from the need to be admitted to hospitals. all the above have strong ethical consequences and imply a new way to allocate resources. there are two possible long-term strategies: 'long-term mitigation' and 'suppression'. the first implies sustained or intermittent social distancing until herd immunity is reached or a vaccine discovered. conversely, the second is aimed at identifying and isolating cases until a vaccine is available. suppression requires dropping case numbers quickly to be effective, by using excellent testing and contact tracing infrastructure. nowadays, a new pandemic is threatening our hypertechnological, but even so defenceless world. due to its sudden and too recent appearance, evidence-medicine on this issue is still poor to provide clinicians with reliable data. a new viral disease (the great invader) has surprised an unarmed world. it causes pneumonia, extrapulmonary complications and often death. the first case was reported in china on november but was not recognised soon. eight more cases appeared in early december , with researchers starting to think about a still unknown virus as their possible cause, but only on december, they were reported to the who country office. on february , the infection was officially named covid- . following that, the virus spread beyond chinese borders and, by mid-march, reached more than countries. on march , the who announced that covid- was officially a pandemic. the spread is anywhere near finished. without a vaccine available and due to the lack of a reliable therapy, a vast majority of the countries identified persistent lockdown as the only way to limit contagion from spreading without control. overall, the -century-old 'quarantine' word has back in fashion. doctors are now facing new challenges, which involve ethics and may lead to make difficult and painful choices for their patients and themselves, owing to the paucity of the available resources. the current healthcare systems are unlikely to be prepared to cope with this sudden and unexpected emergency and should be reformed or updated (from lazareth/leprosarium/ tuberucolosarium to 'covid-sarium', ie, a specialised centre with personnel for swabs and immunology tests). we should be careful that the 'cure' for covid- is not worse than the disease itself. the universal and unprecedented public health preventive measures, including lockdown and social distancing, are damaging our economy and increasing unemployment worldwide. lastly, as doctors, the current covid- age is emphasising some of the moral problems of modern medicine, which is more than ever split between ethics and financial rationalisation. epidemiology of sars-cov- : numbers matter! a pneumonia outbreak associated with a new coronavirus of probable bat origin a novel coronavirus from patients with pneumonia in china covid- : first coronavirus was described in the bmj in the story of quarantine some historical comments on quarantine: part one some historical comments on quarantine: part two the holy bible. old testament historical sketches of quarantine the origin of quarantine small oversights that led to the great plague of marseille ( - ): lessons from the past people with leprosy (hansen's disease) during the middle ages a state of deference: ragusa/dubrovnik in the medieval centuries the origin of the word "quarantine a short history of quarantine (victor c. vaughan) biological warfare at the siege of kaffa the medieval plague: the black death of the middle ages boccaccio as therapist: plague literature and the soul of the city alexandre yersin: discoverer of the plague bacillus biology of plagues: evidence from historical populations encyclopedia of pestilence, pandemics, and plagues disease and history quarantine in times of emergency: the scope of s (ix) of the constitution the rod and the serpent: history's ultimate healing symbol a review of the principle mythical gods in ancient greek medicine the hospitalized legionnaire at the rhine front at the outset of the roman principate the evolution of the hospital from antiquity to the end of the middle ages the mediaeval hospitals of england (illustrations) hospitals' evolution through the ages infection control, from hippocrates to protocols nightingale and the war the history of hospitals and wards a view of health care around the world the birth of medical deontology the hippocratic oath and the ethics of medicine principles of biomedical ethics principles for allocation of scarce medical interventions fair allocation of scarce medical resources in the time of covid- medical ethics: four principles plus attention to scope the code of medical ethics of the american medical association the ethics of covid- immunity-based licenses ten reasons why immunity passports are a bad idea clinical and health policy challenges in responding to the covid- pandemic importance of suppression and mitigation measures in managing covid- outbreaks making evidential claims in epidemiology: three strategies for the study of the exposome new coronavirus outbreak: framing questions for pandemic prevention coronavirus disease infection and the cardiovascular system burnout in the age of covid- contributors ppb and gc conceived and wrote the paper; mrm and sm contributed to reference research and final approval for the paper to be published.funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.competing interests none declared.patient consent for publication not required.provenance and peer review not commissioned; internally peer reviewed.this article is made freely available for use in accordance with bmj's website terms and conditions for the duration of the covid- pandemic or until otherwise determined by bmj. you may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. pier paolo bassareo http://orcid.org/ - - - key: cord- - baof z authors: yan, aihua; zou, yi; mirchandani, dinesh a title: how hospitals in mainland china responded to the outbreak of covid- using it-enabled services: an analysis of hospital news webpages date: - - journal: j am med inform assoc doi: . /jamia/ocaa sha: doc_id: cord_uid: baof z objective: many countries have implemented quarantine rules during the global outbreak of covid- . understanding how hospitals can continue providing services in an effective manner under these circumstances is thus important. in this study, we investigate how information technology (it) helped hospitals in mainland china better respond to the outbreak of the pandemic. materials and methods: we conducted a content analysis of pages published on the websites of the top hospitals in mainland china between january , and february , . in total, we analyzed pages that the hospitals published during the initial days of the covid- pandemic. the purpose was to identify common themes related to the utilization of it by these hospitals in response to the pandemic’s outbreak. results: we identified five focal themes across the webpages published by the hospitals during our study period including ( ) popular medical science education, ( ) digitalized hospital processes, ( ) knowledge management for medical professionals, ( ) telemedicine, and ( ) new it initiatives for healthcare services. our analysis revealed that chinese hospitals spent greater effort in promoting popular medical science education in the initial stages of our study period and more on telemedicine in the latter stages. discussion: we propose a configurational approach for hospitals to design response strategies to pandemic outbreaks based on their available resources. conclusion: our study provides rich insights for hospitals to better utilize their it resources and some recommendations for policy makers to better support hospitals in the future. on december , , the first case of covid- was confirmed in wuhan jinyintan hospital in hubei, china. [ ] on january , , nanshan zhong, a well-known respiratory expert in china, announced in the mass media that there was a possibility of limited people-topeople transmission of covid- . [ ] on january , , wuhan was placed in lockdown at am and residents were told to remain in the city unless they had special reasons for leaving. figure summarizes the key statistics of covid- confirmed cases, suspected cases, and deaths between january , and february , , using data from china's national health commission (nhc). [ ] as illustrated, around % of the reported cases were critical and severe patients and around % of the mortalities occurred in hubei province. in response to the pandemic's spread, china's central government launched a national effort aimed at implementing prevention and control mechanisms and cities started to implement quarantines. hospitals responded to the outbreak of covid- by creating new rules and procedures for hospital management, redesigning the physical layout of outpatient services, and setting up specific areas for inpatient services for confirmed or suspected cases. they utilized information technology to facilitate these changes. in this paper, we seek to answer two research questions: to address these two questions, we integrated two divergent streams of research, i.e., itenabled healthcare services and pandemic response actions. extant literature on it-enabled healthcare services has primarily focused on adoption and usage of electronic health records (ehrs), [ ] [ ] [ ] [ ] clinical decision support systems, [ , ] mobile healthcare app, [ , ] web-based platform such as patient portals, [ , ] and remote healthcare service such as remote patient monitoring. [ ] these empirical studies have investigated multi-dimensional factors that may influence the adoption and usage of it-enabled healthcare services. another stream of research has focused on the prevention or/and control measures of outbreak of epidemic or pandemic diseases, including the implementation of real-time outbreak and disease surveillance systems, [ ] [ ] [ ] development of algorithms for computerized epidemic early detection systems, [ , ] and response strategies for the public health system. [ ] the response strategies include ( ) standardized terminologies for patients to effectively communicate their symptoms and medical histories, ( ) threat detection using healthcare data spanning time and location, and ( ) response actions such as designing and disseminating guidelines, directing reminders to physicians for worrisome cases, and educating physicians in the application of these guidelines. [ ] content analysis was used to code and categorize news webpages published by hospitals in our study. as recommended by weber [ ] , content analysis can be used to identify and describe meaningful classifications, reveal patterns, and therefore gain new insights through a systematic analysis of a volume of written communication. [ ] our content analysis included three phases: preparation, organization, and reporting. [ , ] in the preparation phase, we collected all the it-utilization related news webpages published in the top hospitals in mainland china [ ] between january , and february , (appendix a). five hospitals did not publish such news webpages during this one-month time window and were excluded. in total, we retrieved news webpages that identified events. the detailed coding procedure is described in appendix b. in the organization phase, we adopted an emergent coding approach and followed the steps outlined in haney et al [ ] . first, two authors independently reviewed all the hospital news webpages and came up with a set of codes to form a checklist. second, they compared notes and reconciled any differences in the initial checklists. third, a consolidated and mutuallyagreed upon checklist was used to independently code the pages. the inter-rater reliability was excellent using percentage agreement ( . %) and cohen's kappa ( . ). [ ] in the reporting phase, we used descriptive statistics, tables, and figures to interpret the common themes of how it helped chinese hospitals better respond to the pandemic. based on the events identified in the published hospital pages, five themes emerged on how it was used to respond to covid- , including theme (t ): dissemination of popular medical science education, theme (t ): digitalized hospital processes, theme (t ): knowledge management for medical professionals, theme (t ): telemedicine, and theme (t ): new it initiatives for healthcare services. the events in theme and theme were nonrecurring, but some of the events in themes - were recurring such as publishing popular science articles. figure shows the distribution of these five themes from january , to february , . from figure , we can observe the evolutionary patterns among these five themes. at the early stage of the study, hospitals focused more on publishing popular medical science articles on their websites (t ) and also digitalized hospital processes (t ), but in latter stages of the study they focused more on knowledge management for medical professionals (t ) and telemedicine (t ). table summarizes the coding underlying five themes. we also examined the changing patterns under each theme during this one-month study period and presented our finding in figure (for themes and ) and figure (for themes to ) respectively. more than % of events were related to dissemination of popular medical science education. many hospitals used websites to share popular medical education with the public. we classified these events into four types, see table . some hospitals reprinted articles related to covid- from other sources such as who or china nhc (i.e. t -pear). for example, the peking university people's hospital (ranked # ) reprinted a series of articles related to covid- prevention such as how to wear a mask, how to wash hands, and how to self-isolate at home in february . in contrast, some hospitals invited their medical experts from different departments to write original articles about covid- prevention and control measures (t -peao). a good example comes from tongji hospital in wuhan, hubei (ranked # ). it invited medical experts from infectious disease, respiratory medicine, neurology, and many other areas to write educational articles to the public. another type of event is popular science article related to special needs people (t -pesn), such as chronic disease patients, seniors, pregnant women, and children. because of the quarantine and isolation policies, many patients with special needs were unable to see their doctors for follow-up visits. therefore, some hospitals used their websites to provide medical guidelines for this group of patients to take care of themselves at home. for instance, fuwai hospital (ranked # ) published a series of articles for patients with heart diseases to deal with some symptoms during the quarantine period. lastly, as people had to stay at home due to the quarantine and isolation policies, some began to exhibit symptoms of anxiety or stress. hospitals thus rolled out professional advice on how to stay at home healthily and happily. for instance, on january , , west china hospital of sichuan university (ranked # ) published an online book for reducing the level of anxiety and shared it freely with the public. popular medical education raised awareness in the population and reduced the infection risks. furthermore, quarantine and isolation policy increased the level of stress and anxiety among people and people with special needs were unable to see doctors. the dissemination of medical information by hospitals helped address these issues. as shown in figure , hospitals published more reprinted articles (t -pear) at the early stage, but later added more originally written articles (t -peao). the number of medical guidelines for special needs patients (t -pesn) also increased significantly during the middle to latter stages. more articles related to psychological issues appeared at the latter stage (t -pepi). this is quite understandable because people were likely more anxious after being quarantined for a long term and thus psychological issues related articles were more suitable at that time point. the second theme relates to the hospitals' digitalized processes to reduce the covid- infection risk. our findings indicate that hospitals requested all their outpatients to use online methods (e.g. hospital's mobile app, hospital's service account on social media, and official website) to make appointment (t -oa ). three hospitals used robots or mobile devices to support their medical processes (t -rpa). a good example is guangdong provincial people's hospital (ranked # ). on january , , the hospital welcomed two new robotic employees to help deliver medicines from the pharmacy to the nurse workstation, as well as from the nurse workstation to the isolation ward. these robots are able to take the elevator, open and close doors, avoid obstacles, and recharge themselves. the utilization of these robots reduced close contact between healthcare workers, as well as between healthcare workers and confirmed covid- patients. later, on february , , guangdong provincial people's hospital added three new robots to their medical service team. these three new robots were mainly responsible for guiding patients to appropriate departments and answering questions related to covid- prevention. hospitals also adopted it-enabled services for administration (t -vo). online meeting tools were used for conferencing and social media apps such as wechat were used for creating communication groups among healthcare workers and patients. a wide variety of digitized measures were also used for security control in the hospitals (t -dsc). for instance, almost all the hospitals asked their visitors to report health status. some hospitals used paper-based forms, but ruijin hospital (ranked # ) used qr code to capture this information. patients could scan the qr code published on the website to fill in a form on wechat. then they could simply present the form to the security staff when they visited the hospital. many hospitals also used infrared thermometers to detect visitor temperatures without touching the body. furthermore, in order to save medical protective clothing and reduce the risk of human contact, only one doctor made the rounds of isolation wards and then used wechat to communicate with other healthcare workers outside the wards. the final event in this theme is systems integration (t -si). hospitals integrated their it-infrastructure or information systems to better support diagnosis and clinical decision-making during the outbreak of covid- . one example comes from shanghai ninth people's hospital (ranked # ). on january , , the hospital integrated its laboratory information systems (lis) to support its fever department. after the lis integration, all the outpatients with fever symptoms could complete their doctor visits only in the fever department without visiting other departments in the hospital. from figure , we can also observe that within the one-month study period, hospitals started with digitalized security controls (t -dsc), then added more measures in coordinating administrative activities online (t -vo), followed by emphasizing the usage of online appointments (t -oa ). interestingly, we also found that in the initial stages, the majority of hospitals suggested that outpatients use online appointments but not mandatorily (t -oa ), then they implemented partial online appointments (t -oa ), and by the end of the study period they had fully implemented online appointments for all the outpatient services (t -oa ). our findings also reveal many events related to knowledge management, including knowledge discovery, knowledge capture, knowledge sharing, and knowledge application. [ ] medical knowledge is primarily tacit and procedural. [ ] thus, the dominant medical education and training method is learning by doing and medical training typically consists of lecture and practice. medical training is extremely important to reduce the infection risk to healthcare workers. training topics such as how to wear protective clothing appropriately, how to take care of confirmed or suspected covid- patients, and how to provide professional counselling advices to anxious patients are thus critical. a pattern we observed in our data was that many hospitals recorded training videos and then shared them online internally and externally (t -ot). by doing so, the duration of onsite training was shorter, reducing the infection risk. moreover, the onsite training could focus more on the practice of medical skills. another major event in this theme was that many highly-ranked hospitals shared their treatment we can observe some evolutionary patterns in this theme in figure . at the early stage, hospitals paid more attention to launching online consultation services related to covid- (t -omc), but then complemented the t -omc services with online prescription refills and follow-up consultation services (t -omf). online psychological intervention services appeared in the early to middle stage but became more significant in the latter stage (t -omp). during the outbreak of covid- , seven hospitals recognized the significance of it in healthcare services. they began to make large investments in new it platforms (t -itp) and promoted the concept of "internet plus healthcare services" (t -phi). for instance, west china hospital of sichuan university (ranked # ) initiated two projects related to it platforms on february , . these two projects were a platform for precision diagnostics and a big data platform for disease epidemic research. also, xiangya hospital of central south university (ranked # ) collaborated with a private company to develop a covid- prevention and popular science education system on february , . the concept of " internet plus healthcare services " has been promoted by china's central government since . in our sample, we found that four hospitals promoted this concept on their websites. from figure , we can tell that the majority of theme events happened in the latter stage of the one-month study window showing a learning curve. [ ] our findings revealed five themes related to it-utilization in hospitals to better respond to the covid- pandemic. based on these five themes, we have developed an integrated framework for hospitals to better configure their pandemic response strategies using it-enabled services. as depicted in figure , first, an effective control and prevention strategy highly relies on the it-infrastructure. this infrastructure may be constructed and maintained at the hospital level, provincial level, or country level. a hierarchy may exist for these three levels of infrastructure. the more robust the it-infrastructure is, the better will be the delivery of the itenabled healthcare services. second, the response strategy may contain one or more of these four categories of it-enabled services, i.e., disseminating popular medical science education, knowledge management for healthcare workers, telemedicine, and digitalized hospital processes. last, the success of the response strategy may be influenced by the hospital's vision and government policy. government policies such as china's "internet plus healthcare services" can have a significant impact on the resources that hospitals receive as well as their outlook. our study provides some recommendations for policy makers, medical professionals, and hospital managers. first, our study can help policy makers better prepare for similar medical crises. as suggested by our research, it infrastructure is extremely important for implementing an "internet plus healthcare services" program in mainland china's hospitals. it-infrastructure at the provincial or divisional level can provide greater benefits compared to isolated hospital it-infrastructures. for instance, sichuan province and henan province have implemented provincial level online collaboration systems among hospitals. as such, online collaboration activities among hospitals in these two provinces was more compared to the others. in the future, provincial or divisional policy makers may consider allocating more resources for it infrastructure development such as big data platforms or online collaboration systems. second, for medical professionals, our study suggests that medical training should place more effort on procedural training and incorporate more it elements in the training. during the outbreak of covid- disease, medical procedural training has become extremely important. [ ] inappropriate medical procedural taken by doctors or nurses can increase the infection rate. our findings reveal that it-enabled training such as flipped-classrooms were suitable during the outbreak of covid- . because of the rushed schedule, many medical professionals who were supporting wuhan had to attend the training session right after they arrived. in a flipped-classroom training, the hospitals posted online training videos to a platform like wechat and then used the in-classroom format for practice training. under a pandemic outbreak, medical professionals are highly motivated to receive appropriate training. as such, watching training videos online might improve training efficiency. third, digitalization of hospital processes is a trend. our findings confirm that ai technologies can be used for online self-assessment systems, robots can be used in guiding patients and delivering medicines within the hospital, and qr-code can be used for collecting patient and visitor information. all these digitalized processes can also be integrated into daily routines, and not just for preventing and controlling epidemic disease. this study has some limitations. first, it only focuses on the news webpages on the hospital websites. however, because of the popularity of social media service accounts (e.g., hospital's wechat service account), hospitals may update their news more frequently on the social media platforms than their official websites. future research can extract the news from the social media platforms and examine whether there are any differences compared to the present study. another limitation is that we did not analyze the sequence of events in this study. event sequence analysis is an approach to study the unfolding process of response events. [ ] it can be used to identify emerging response strategies. future research can thus investigate common patterns of event sequences in hospitals. this study aimed to investigate the role of it in helping hospitals respond to the outbreak of covid- . based on a content analysis of news webpages from top hospitals in mainland china, we identified five common themes where it was utilized by the hospitals between january , and february , . these five themes are: ( ) dissemination of popular medical science education, ( ) digitalized hospital processes, ( ) knowledge management for medical professional, ( ) telemedicine, and ( ) new it initiatives. we also developed an integrated framework for hospitals to configure their response strategies to disease outbreaks using it-enabled services. our study offers some rich insights for policy makers, medical professionals, and hospital managers to better prepare for other medical crisis in the future. this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. the authors have no competing interests to declare. ay conceived of and designed the project and was responsible for data acquisition, analysis, interpretation, and writing. yz contributed to the data acquisition, analysis, and interpretation, and editing. dam made substantial contribution to the data interpretation, writing and editing. all the authors made substantial contributions to the revision and gave approval for the final version of manuscript to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. report of the who-china joint mission on coronavirus disease china focus: china at "crucial stage" to control novel coronavirus paperless healthcare: progress and challenges of an it-enabled healthcare system the impact of transitioning from availability of outside records within electronic health records to integration of local and outside records within electronic health records electronic health records and burnout: time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians just tell me what ' s going on " : the views of parents of children with genetic conditions regarding the research use of their child ' s electronic health record learning curves of agents with diverse skills in information technology-enabled physician referral systems measuring implementation feasibility of clinical decision support alerts for clinical practice recommendations comparison of traditional versus mobile app self-monitoring of physical activity and dietary intake among overweight adults participating in an mhealth weight loss program quantifying usability: an evaluation of a diabetes mhealth system on effectiveness, efficiency, and satisfaction metrics with associated user characteristics patient reported barriers to enrolling in a patient portal design simplicity influences patient portal use: the role of aesthetic evaluations for technology acceptance emotion sharing in remote patient monitoring of patients with chronic kidney disease technical description of rods: a real-time public health surveillance system healthmap: global infectious disease monitoring through automated classification and visualization of internet media reports the epicanvas infectious disease weather map: an interactive visual exploration of temporal and spatial correlations modeling the effects of epidemics on routinely collected data wtw-an algorithm for identifying "who transmits to whom " in outbreaks of interhuman transmitted infectious agents the contributions of biomedical informatics to the fight against bioterrorism basic content analysis (no. ) healthcare data scientist qualifications, skills, and job focus: a content analysis of job postings the qualitative content analysis process the most comprehensive recommendation! china hospitals ranking list by fudan university drawing on education: using student drawings to promote middle school improvement an application of hierarchical kappa-type statistics in the assessment of majority agreement among multiple observers knowledge management: systems and processes. routledge the acquisition of tacit knowledge in medical education: learning by doing bounded rationality and organizational learning preparing and responding to novel coronavirus with simulation and technology-enhanced learning for healthcare professionals an empirical taxonomy of implementation processes based on sequences of events in information system development key: cord- -bqw ks a authors: zhang, shuai; guo, mengfei; duan, limin; wu, feng; hu, guorong; wang, zhihui; huang, qi; liao, tingting; xu, juanjuan; ma, yanling; lv, zhilei; xiao, wenjing; zhao, zilin; tan, xueyun; meng, daquan; zhang, shujing; zhou, e; yin, zhengrong; geng, wei; wang, xuan; zhang, jianchu; chen, jianguo; zhang, yu; jin, yang title: development and validation of a risk factor-based system to predict short-term survival in adult hospitalized patients with covid- : a multicenter, retrospective, cohort study date: - - journal: crit care doi: . /s - - -x sha: doc_id: cord_uid: bqw ks a background: coronavirus disease (covid- ) has become a public health emergency of global concern. we aimed to explore the risk factors of -day and -day mortality and develop a model for predicting -day and -day survival probability among adult hospitalized patients with covid- . methods: in this multicenter, retrospective, cohort study, we examined hospitalized patients with confirmed covid- hospitalized in wuhan union hospital and central hospital of wuhan between january and february , . among the patients, and consecutive patients admitted in wuhan union hospital were enrolled in the training cohort and the validation cohort, respectively. a total of patients hospitalized in central hospital of wuhan were enrolled in a second external validation cohort. demographic, clinical, radiographic, and laboratory measures; treatment; proximate causes of death; and -day and -day mortality are described. patients’ data were collected by reviewing the medical records, and their -day and -day outcomes were followed up. results: of the patients, deaths were recorded until may , . in the training set, multivariate cox regression indicated that older age, lactate dehydrogenase level over u/l, neutrophil-to-lymphocyte ratio higher than . , and direct bilirubin higher than . μmol/l were independent predictors of -day mortality. nomogram scoring systems for predicting the -day and -day survival probability of patients with covid- were developed and exhibited strong discrimination and calibration power in the two external validation cohorts (c-index, . and . ). conclusion: older age, high lactate dehydrogenase level, evaluated neutrophil-to-lymphocyte ratio, and high direct bilirubin level were independent predictors of -day mortality in adult hospitalized patients with confirmed covid- . the nomogram system based on the four factors revealed good discrimination and calibration, suggesting good clinical utility. since december , an ongoing outbreak of coronavirus disease (covid- ) has struck wuhan, hubei province, china [ ] [ ] [ ] [ ] . human-to-human transmission has occurred through respiratory droplets or likely feces [ , ] . epidemiological and clinical characteristics of patients with covid- in china have been reported [ ] [ ] [ ] ] . the number of cases grew quickly since january . as of june , , , , confirmed cases of covid- have occurred, resulting in , deaths [ ] . outbreaks of covid- infection imposed a great burden on the healthcare system of many countries. to guide the allocation of limited healthcare resources, as well as the timely recognition and intervention of patients who were at high risk of mortality, efficient prognosis of the disease is needed. previous reports have shown age, sequential organ failure assessment (sofa) score, d-dimer, preexisting concurrent cardiovascular or cerebrovascular diseases, amounts of cd + cd + t cells, and cardiac troponin i to be risk factors for mortality of adult inpatients with covid- [ ] [ ] [ ] . meanwhile, several prognostic models for predicting mortality risk have been developed [ , ] . the most common predictors included in this prognostic model were age, sex, c-reactive protein (crp), lactate dehydrogenase (ldh), and lymphocyte count. however, most of these studies have relatively few outcome events, showed a high risk of model overfitting, and failed to clearly describe the intended use of these models. in this study, we investigated patients with confirmed covid- who were admitted to wuhan union hospital west area and central hospital of wuhan between january and february , . since the median time to death from illness onset was reported to be . days, we believed -day could be an appropriate time point for the inclusion of mortality events and administrative censoring [ ] . we aimed to explore the risk factors of -day mortality and develop a nomogram scoring system for predicting -day survival probability among patients with covid- . this multicenter, retrospective, cohort study (clinical trial identifier chictr ) was conducted at wuhan union hospital west area and central hospital of wuhan. the study was approved by the institutional ethics committee of union hospital, tongji medical college, huazhong university of science and technology ( ); the requirement for informed consent was exempted by the ethics committee. the inclusion criterion was adult patients with confirmed covid- . those who lacked laboratory findings and ct images or lost -day follow-up were excluded. besides, patients with hematological diseases had abnormal blood routine test due to their hematologic disorders, which made the analysis of blood routine test unfeasible, and were also excluded. in the training cohort, we retrospectively analyzed consecutive patients with confirmed or suspected covid- who were admitted in wuhan union hospital west area between january , , and february , . eighty-eight of the cases were excluded from the study; among them, were suspected cases, lacked laboratory findings and ct images due to their death or being transferred to other hospitals within h after admission, and patients were with hematological diseases. finally, a total of patients were enrolled in the training cohort (union hospital training cohort, survivors and non-survivors, patients died within days of admission, fig. ). next, another consecutive patients were admitted in wuhan union hospital west area between february , , and february , . among them, were suspected cases, lacked laboratory findings and ct images due to their death within h after admission, and one patient had hematological diseases; patients were excluded from the study. finally, patients with confirmed covid- were included as external validation cohort (union hospital external validation cohort, survivors and non-survivors, patients died within days of admission). a total of patients with confirmed or suspected covid- who were admitted in central hospital of wuhan between january , , and february , , were selected by simple random sampling. of the patients, were suspected cases and one died within h after admission, all of whom were excluded from the study, and the remaining confirmed patients were included as the external validation cohort (central hospital external validation cohort, survivors and non-survivors). a total of deceased patients had been reported in a previous submission, and patients participated in a phase randomized, double-blind, placebo-controlled, multicenter study for evaluating the efficacy and safety of remdesivir in hospitalized adult patients with severe covid- [ , ] . the diagnosis and clinical classification of covid- were based on the guidelines of the diagnosis and clinicians from the hospital identified patients who satisfied the study inclusion criteria through surveillance of all patients. we collected all available information from patients, their families, physicians, and the electronic medical records in the hospital, including the epidemiological history; clinical, laboratory, and ct findings; treatment (i.e., antiviral therapy, corticosteroid therapy, respiratory support, kidney replacement); and outcomes. all clinical data used in this study were collected from the first day of hospital admission unless indicated otherwise. electronic medical data were inputted onto a local server. a team of trained physicians searched the patient charts for all the information recorded. for patients discharged within days after admission, patients or their families were followed up to obtain the information about their -day and -day outcomes by telephone interviews. the primary outcome of this study was mortality at days and days after admission. to avoid overfitting in our model, we calculated the numbers of variables allowed to enroll in our multivariable cox regression model based on a previous study for guidance on sample size requirements for prediction models [ ] . in our multivariable model, by setting nagelkerke's r = . , we found that our sample size was sufficient to estimate the overall outcome risk and variables could be enrolled in the multivariable analyses. considering a total number of patients (with decreased patients within days after admission), the final nagelkerke's r = . , the cox-snell r squared statistic (r cs ) = . , and the candidate predictor parameter (epp) = . , with % ci for overall risk = . and . . among a dozen of indicators, which were associated with -day mortality in unavailable cox regression analyses (p < . ), variables included into the multivariable cox regression model were selected mainly based on the previous evidence, clinical significance, the correlation between predictors, and availability of data [ ] . previous studies have shown older age, dyspnea, and higher levels of ldh, crp, and direct bilirubin (dbil) to be associated with severe disease at admission [ , ] . elevated neutrophil-to-lymphocyte ratio (nlr) value was observed in patients who died of covid- and found to be able to predict severe cases of covid- at its early stage [ , ] . meanwhile, these risk factors, including older age and higher ldh levels, have been reported to be associated with adverse clinical outcomes in adults with sars [ , ] . other important indicators such as ct images, d-dimer, and ferritin might be unavailable in emergency circumstances. therefore, we chose age, nlr, ldh, crp, and dbil as the five variables for our multivariable cox regression model. all these variables included in the cox regression analyses were measured at admission. we converted these indicators including respiratory rate, breaths per minute, nlr, platelets count, alanine aminotransferase (alt), prothrombin time (pt), and ldh to binary variables and converted these indicators including total bilirubin, white blood cell count, dbil, urea nitrogen, d-dimer, and crp to trichotomous variables when performing univariable cox regression analyses in the training cohort. in addition, variables including ldh and nlr were dichotomized, and direct bilirubin was trichotomous when performing multivariate cox regression analyses to obtain risk factors for -day mortality in the training cohort. these predictors were eventually selected by forward stepwise regression. categorical variables were presented as frequency rates and percentages, and continuous variables were expressed as mean ± standard deviation (sd) if they were normally distributed or median (interquartile range [iqr]) if they were not. proportions for categorical variables were compared using the χ test or fisher's exact test. means for continuous variables were compared using independent group t test when the data were normally distributed. otherwise, the wilcoxon rank-sum test was employed. % confidence interval (ci) of mortality was analyzed by wilson score ci. for the training cohort and the union hospital validation cohort, missing data have been mentioned in the relevant tables, and there was no other missing data, unless otherwise noted. and for the central hospital external validation cohort, out of missed ldh information, and these missing data were handled by multiple imputations [ ] . the nomogram was used to visually score the patients' various parameters according to the results of multivariable cox regression analyses, and then to compute the probability of the event based on the patients' total score. c-index was calculated to evaluate the distinguishing power, and the calibration curve was used to evaluate the calibration of the nomogram. all statistics were two-tailed, and a p value less than . was considered as significant. all statistical analyses were performed by using the sas software package (version . ). the demographic and clinical characteristics at admission for the union hospital training cohort (n = ), union hospital external validation cohort (n = ), and central hospital of wuhan external validation cohort (n = ) are listed in table . among the patients, were females and were males. on admission, were mild and were severely ill cases. the median age of non-survivors was older than that of survivors in both cohorts. the median duration from illness onset to admission for all the patients was estimated to be days (iqr, . - . ), and no difference was seen between the non-survivor and survivor groups (p = . ). the treatments, outcomes, and complications of the cases were shown in table . a total of ( . %) patients received oxygen therapy, ( . %) patients received mechanical ventilation, and ( . %) patients received invasive mechanical ventilation. antiviral therapies were used in ( . %) patients, systematic corticosteroids in ( . %) patients, and hydroxychloroquine in ( . %) patients. as of may , , ( . %) patients have been discharged and ( . %) patients died. the median duration from illness onset to death in deceased patients was estimated to be . days (iqr, . - . ). figure shows the -day kaplan-meier survival curves for all patients and the two subgroups categorized by the severity of illness. of non-survivors, ( . %) of the non-survivors developed ards; the most common complication was acute cardiac injury ( , . %) followed by acute renal injury ( , . %), septic shock ( , . %), and acute liver injury ( , . %). next, we analyzed the risk factors for -day mortality in the training cohort by using cox regression model. eighty-seven decreased patients within days were enrolled in the cox regression analyses. univariable cox regression analyses showed age, male, dyspnea, respiratory rate, curb- pneumonia severity score (curb- score), quick sepsis related organ failure assessment (qsofa) score, reticular patterns, and laboratory factors were associated with -day mortality ( table ). the comparison between survivors and non-survivors in laboratory and ct findings were also displayed in table s and figure showed the temporal changes of the three independent laboratory risk factors from hospital admission in survivors and nonsurvivors. compared with survivors, non-survivors showed a significantly higher nlr, ldh, and dbil value at all time points. development and validation of nomogram for -day and -day mortality next, we worked out a nomogram scoring system for predicting the -day and -day survival probability of patients with covid- on the basis of the four independent predictors of mortality (fig. a) . to help physicians better understand the scoring system, we explained how to calculate the score in the legend of fig. . figure b and c shows the calibration plot for the prediction model, in which the predicted probability of -day and -day survival is plotted against the observed data. the curves of predictive -day and -day survival probability were closely approximated to the observed probability, which means the nomogram scoring system exhibited good calibration. the discrimination of the constructed nomogram was evaluated with the c-index ( . , % ci, . - . ), suggesting a favorable discriminative power. we also compared the nomogram score in our study with the curb- score and qsofa score. in the training cohort, the discrimination c-index of curb- and qsofa scores were . ( % ci, . - . ) and . ( % ci, . - . ), respectively. as indicated by the lack of overlap in the confidence intervals, the discrimination power of the nomogram score developed in the training categorical variables were presented as frequency rates and percentages continuous variables were expressed median (iqr) ci confidence interval cohort was significantly higher than that of the curb- and qsofa scores. to further verify the nomogram scoring system, two external cohorts were included. the external validation cohort was performed by using the union hospital external validation set. in the union hospital external validation set, the final multivariable model for -day mortality showed strong external validity, with a discrimination c-index of . ( % ci, . - . ) indicating an . % correct model identification of the -day survival probability across all possible pairs of patients. in the central hospital of wuhan validation set, the nomogram also exhibited a good discrimination power (c-index, . , % ci [ . - . ]). calibration of the nomogram predicted -day and -day survival probability corresponding with the actual survival in both external validation cohorts (fig. d-g) . in this study, we employed the clinical and laboratory features of covid- patients to work out an effective and easy tool for predicting -day mortality. univariate analyses revealed that these factors including age, male sex, dyspnea, respiratory rate, curb- score, qsofa score, reticular patterns, leukocyte count, lymphocyte count, nlr, and several other biochemical parameters were associated with mortality. multivariate analyses found that older age, nlr over . , dbil levels higher than . μmol/l, and ldh levels higher than u/l at admission were four independent predictors of -day mortality in adult hospitalized patients with covid- . many more patients developed fever and had comorbidities including hypertension and diabetes than those in guan et al.'s study with a relatively large sample size [ ] . however, patients in our study were all from wuhan city, while patients in guan et al.'s study were from provinces, autonomous regions, and municipalities in mainland china. since a great shortage of medical resources existed in wuhan city, the hardest-hit area of the covid- outbreak at the early stage of this pandemic, this regional difference should be noted. when compared with other studies, patients in which were also from wuhan, the proportions of patients with fever and comorbidities were comparable [ , ] . the overall crude mortality rate in our series was higher than that in the previous report [ ] . on the basis of a statistical model involving , patients, zhong and his colleagues estimated that the case mortality rate was . % in patients with confirmed covid- , . % in hubei province, and % in severely ill patients. however, shang et al. reported that the mortality rate in severely ill patients with covid- was about % [ ] . the discrepancies in the mortality rates might be ascribed to proportions of patients of different severities in different cohorts, given that all death events in our cohort were observed in severely ill patients. thus, the proportion of severe cases in our study should be taken into account. in fact, after a mandatory hierarchical management was introduced, more severe covid- patients were transferred to our hospitals, while mild cases were re-directed to the "mobile cabin hospitals." compared with survivors, more non-survivors were older, male, and were complicated with more chronic conditions. this result was coincident with the finding of a previous study focusing on critically ill covid- patients [ ] . as aforementioned, all the non-survivors except two were those who were categorized as severely ill at admission in our study. this result suggested that mild patients could be treated by home quarantine or in our mobile cabin hospitals, given their satisfactory survival and the shortage of medical resources. of note, reticular patterns were more frequently found on ct images at presentation in non-survivors and were reportedly the predominant imaging finding on ct images weeks after symptom onset [ ] . previous studies have reported that older male patients were more subject to covid- infection, and severe patients were older than their non-severe counterparts [ , ] . compared with survivors, non-survivors were reported to be older in two observational studies [ , ] . in this study, we found that age was an independent risk factor for -day mortality in patients with covid- . a higher level of ldh was suggested to indicate more extensive lung tissue injury and reported to be linked with poor outcomes in patients with severe acute respiratory syndrome (sars) [ , ] . in patients with covid- , plasma ldh level was reported to be higher in severe, icu, and deceased covid- patients than in mild, non-icu-patients, and survivors [ , ] . our study showed that ldh could serve as a valuable predictor of mortality in covid- patients, with its hazard ratio being the highest. reminiscent of a previous mortality prediction model developed by yan et al., ldh higher than u/l was also reported to be a risk factor for mortality in patients with covid- [ ] . meanwhile, this previous model highlighted the crucial role of [ , ] . this study confirmed that it could act as a predictor of mortality in covid patients. dbil was reported to be associated with severe covid- in a multicenter retrospective study [ ] , now identified as one independent risk factor for -day mortality. although the presence of preexisting comorbidities seems to increase the odds of death, the association was not significant in our study. we also employed the four independent predictors to construct a predictive model which was shown in a form of nomogram scoring system. our prediction mode was constructed based on a reasonable size and consecutive cohort of adult patients with confirmed covid- . this kind of sample selection minimized the selection bias. however, the proportion of severely ill patients was large in our hospital since wuhan union hospital was a designated hospital for severely ill covid- patient treatment. this made the cohort in our study less representative of adult hospitalized patients with confirmed covid- in wuhan. however, it should be highlighted that our model not only showed good discrimination and calibration in an external validation from the same hospital, but also performed well in an external validation cohort consisting of patients from another hospital, which was not a designated hospital for severely ill covid- patient treatment. therefore, our prediction models are based on and validated in wuhan hospitalized populations with covid- infection and should therefore be applicable to other sites within wuhan. compared with the curb- and qsofa scores, our scoring system displayed better discrimination ability in the training cohort. by employing our model, once the fig. the nomogram scoring system for predicting patients' survival probability based on age, ldh level, dbil, and nlr. a nomogram for predicting the probability of -day and -day survival. the number of points for each factor is in the top row. for each factor, the absence is assigned points. the presence of factors is associated with the number of points. the points for each factor are summed together to generate a total point score. the total points correspond to the respective -day and -day survival probabilities. the ability of this model to distinguish between low-risk and high-risk patients can be demonstrated by considering two hypothetical individuals who might be encountered in practice: patient a is years old with nlr of , dbil of μmol/l, and ldh of u/l, getting a total score of . ; patient b is years old with nlr of , dbil of μmol/l, and ldh u/l, getting a total score of . . our model predicts that patient a's -day survival probability is %, and his -day survival probability is %. for patient b, his -day survival probability and -day survival probability are more than %. b-g the calibration plot of survival probabilities at days and days. nomogram-predicted survival probability is plotted on the x-axis, with observed survival probability on the y-axis. dashed lines along the °line through the origin point represent the perfect calibration models in which the predicted probabilities are identical to the actual probabilities. the training cohort calibration plot of survival probabilities at days (b) and days (c). d, e the external validation cohort calibration plot of survival probabilities at days (d) and days (e). f, g the external validation cohort calibration plot of survival probabilities at days (f) and days (g) target patients' data on the four risk factors were measured at admission, their risk of -day and -day mortality can be calculated by our model to guide the decision of clinical physicians. considering that the outcome events outside wuhan are different, when trying to apply this prediction mode into other provinces in china or other countries, this mode might need to be updated and adjusted to the local setting before it can safely be applied. our study had several limitations. first, it was of retrospective nature, and all data were collected from case records. therefore, important information might be missed and further prospective studies are needed. second, it is worth pointing out that the amount of missing data differed between the survivor and non-survivor groups, especially for ferritin and d-dimer. even though we believe these differences were attributed to different physicians' decisions in their clinical practice due to the absence of guideline recommendations, the resulting potential bias should be noted and further prospective studies can be also helpful to decrease this discrepancy in missing data. third, this study included a high population of patients who were severely ill; there may be a selection bias when identifying the risk factors of mortality. since physicians should evaluate the patients' condition at admission, we focused on the information of patients at admission, other important factors during hospitalization that might influence case mortality, such as the use of non-invasive assisted ventilation or other medications and timing, as well as longitudinal observations of clinical and laboratory variables, were not covered. more detailed analyses involving these factors should be undertaken. in conclusion, our study demonstrated that older age, high lactate dehydrogenase level, evaluated neutrophilto-lymphocyte ratio, and high direct bilirubin level were independent predictors of -day mortality in adult hospitalized patients with confirmed covid- . the new 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jx, ym, zl, dm, xw, and jz collected the epidemiological and clinical data. sz, mg, ld, gh, zw, qh, tl, zz, xt, sz, ez, zy, and wg summarized all the data. sz, mg, and ld analyzed and drafted the manuscript. all authors revised the final manuscript. the authors read and approved the final manuscript. the data that support the findings of this study are available from the corresponding authors upon reasonable request. the study was approved by the institutional ethics committee of union hospital, tongji medical college, huazhong university of science and technology ( ); the requirement for informed consent was exempted by the ethics committee. no individual participant data is reported that would require consent to publish from the participant. the authors declare no competing interests. supplementary information accompanies this paper at https://doi.org/ . /s - - -x. key: cord- - lqlx rv authors: nan title: poster sessions date: - - journal: j diabetes doi: . / - . _ sha: doc_id: cord_uid: lqlx rv nan polycystic ovarian syndrome (pcos) is the most common endocrinopathy in women before menopause, the purpose of this study was to determine the effects of a diet and physical activity trial for improving pcos clinical and laboratory findings in obese women. this semi-experimental single-blind controlled trial was conducted among women with pcos ( cases and controls). initially, all the patients′ information was evaluated in terms of: demographic, menstrual status, clinical characteristics of hyperandrogenemia, as well as biochemical, hormonal and abdominal ultra-sonography. the intervention plan consisted of a -week exercise and diet program for the experimental group. all baseline assessments were repeated in both groups within months after beginning of the trial, and the results were analyzed. the comparison between the two groups revealed that in the experimental group, the interventions have been effective for the following variables: follicle stimulating hormone (p = . ), the luteinizing hormone (p = . ), total testosterone (p = . ), free testosterone (p = . ), estradiol (p = . ), selfglobulin band sex hormone (p = . ), triiodotyronine (p = . ), thyroxine (p = . ), tsh (p = . ), hydroxy progesterone (p = . ), triglycerides (p = . ), total cholesterol (p = . ), body mass index (bmi; p = . ), the ultrasound exam (p < . ), oligomenorrhea (p < . ), of hirsutism (p < . ), acne (p < . ) and alopecia (p = . ). it seems that regular exercise and dietary intervention are effective to improve pcos among obese women. a series of studies have recently demonstrated that the oxidative stress, nuclear factor-kappa b (nf-jb) activation and the subsequent coordinated inflammatory responses played an important role in the pathogenesis of urate nephropathy (un). polydatin has been suggested to have the properties of anti-oxidative, anti-inflammatory and nephroprotective effects. however, the possible protective and beneficial effects of polydatin on un are not fully elucidated. therefore, we investigated the potential beneficial effects and possible mechanisms of polydatin on un. in this study, polydatin showed inhibitory activities on xanthine oxidase to repress the level of serum uric acid in vivo and in vitro. further investigations revealed that polydatin displayed little toxic effects and significantly ameliorated the renal function in fructose-induced un mice. the nephroprotective activities of polydatin was not only due to the effects on remarkably attenuating the oxidative stress induced by uric acid, but also on markedly suppressing the oxidative stress-related inflammatory cascade, including decreasing the expressions of nf-jb p , cox- and inos proteins and inhibiting the productions of tnf-a, pge and il- β. these findings elucidated that polydatin exhibited prominent nephroprotective activities and low toxic effects. drug discovery, obetherapy, evry, france many obesity related genes have been proposed as targets for the treatment of obesity. however, these obesity genes did not provide efficient drug therapy for obesity treatment. this is mainly due to the redundancy of the biochemical pathway involved in obesity and the lack of specificity of the gene targets. it is therefore a challenge to identify crucial gene(s) targets involved in energy metabolism associated with "lean or starvation phenotype". congenital enteropeptidase defficiency is an extremly rare pathology which answer to all these criteria. enteropeptidase catalyzes the conversion of inactive trypsinogen into active trypsin via the cleavage of the acidic propeptide from trypsinogen. we have generated knock out transgenic mice for enteropeptidase which shows the same phenotype like in human. these data and in vivo preclinical data using per os small molecule for long term treatment ( weeks) will be presented. f. nasiri amiri , f. ramezani tehrani , m. simbar babol medical sciences university, babol, shahid beheshti university of medical sciences, tehran, iran polycystic ovary syndrome (pcos) is the most common chronic endocrine disorder with a prevalence estimated at - % depending on the diagnostic criteria used. it has significant and diverse clinical consequence including reproductive, metabolic, psychological morbidity and some cancer. it is unclear how pcos symptom influences such women's experiences of their bodies. this study aimed to explain women's experiences of their health concerns when living with pcos. this research is a qualitative study. semi-structured opened interviews were conducted with women aged - years who were diagnosed with pcos. interviewing the participants were continued to reach data saturation. all the interviews were recorded and transcribed. the data were analysed using content analysis. four closely intertwined themes were disclosed: physical consequences of pcos, fear of future, economic burden of desease and coming to terms with a chronic condition. our findings suggest that healthcare professionals working with pcos patients should consider providing peer support groups as a means to alleviate patients concern and to promote self management activities such as lifestyle modification. ideally, groups should be designed to meet patients support needs and expectations, and should be evaluated regularly. m. kidron , e. arbit oramed pharmaceuticals, jerusalem, israel, biomedical engineering, nyu -oramed pharmaceuticals, englewood, nj, usa introduction: the major cause of hyperglycemia in t dm is inappropriate, non-suppressible hepatic glucose production due to hepatic insulin resistance (hir)) and elevated glucagon levels. hir is a result of fat deposition in the liver which in turn begets a local inflammatory process, a common thread observed in t dm, the metabolic syndrome and obesity which are all known risk factors for morbidity. the only antidiabetic drug that addresses specifically hir, up to now is metformin and its effects wanes over time. there is an unmet need for other drugs that target the liver specifically. insulin has a direct effect on hepatocytic receptors and thus has shown to be capable to reduce hepatic steatosis and improve glycemic control, as well as reduce hepatic insulin resistance. insulin administered orally is absorbed into the portal-hepatic vein and reaches the liver at high concentrations. this route of administration may confer physiologic advantages over systemic insulin administration and lower the risk of hypoglycemia. results: bmi, hdl and cu levels were found to be significantly higher in women compared to men (p < . ). _ it was established that blood copper levels, similar to hscrp, predicted ms and ms parameters, but predicted different ms parameters at different sensitivities and specifities. we obereved that there was a more significant correlation between tg level, blood pressure and cu, compared to hscrp (tables , and ). conclusion: based upon these results, it may be stated that cu predicts ms and ms parameters as well as hscrp does and that it is even a better predictor for ms and atherosclerosis since it is less influenced from inflammatory events than crp. short-chain fatty acids which then up regulate proglucagon (precursor to glp ) and pyy gene. these gut hormones are collectively known as "incretin" and they primarily regulate insulin level after eating. very recently, two new classes of drugs based on incretin action have been approved for lowering blood glucose levels in type diabetes milliets. one is exenatide, long-acting agonist of the glp- receptor and other is incretin enhancer known as sitagliptin, a dpp inhibitor. however, glp- agonist reduces body weight (anti-obesity therapy) and leads to hypoglycemia. similarly, liraglutide, dpp-iv-resistant glp- receptor agonists is also synthesized using glp- sequence with prolongs half-life. in conclusion, polysaccharides might be a way to decrease the hurdle in diabetes managements and special attention should be paid to naturally derived polysaccharides. ms is often associated with inflammation caused by latent infections or sibo. we investigated whether treatments of such items may help to control ms. method: we prospectively studied patients presenting with ms and three concomitant causes of inflammation [helicobacter pylori (hp = cases); oral papillomavirus virus (hpv = ) or ebv ( ); sibo (h or ch breath tests: cases)] who were all successfully treated for hp, hpv or ebv, and sibo (decrease of h or ch > % and decrease of circulating th cells > % which are correlated with intestinal chronic inflammation). patients were followed-up months. conclusion: treatment of latent infection and sibo benefits mainly to patients younger than , without methanogenic flora and with few circulating th cells. and increases the gastric emptying time, intestinal transit time, gastric acid secretion in the ms bark juice treated group. there was significant (p < . ) decrease in the t max , t / and increase in the c max of met in ms bark juice treated group as compare to diabetic group. present study suggests that the bark juice of ms shows significant effects in the treatment of gastroparesis and it improves the pharmacokinetic of met compared to diabetic group of rat. type diabetes mellitus (t dm) is a complex metabolic disorder. its prevalence is expected to increase exponentially around the world. insulin resistance, inflammation and dysregulation of adipokines play a major role in the pathogenesis of t dm. among the huge growing adipose secretome, nicotinamide phosphoribosyl transferase (nampt) and vaspin emerged as novel interesting adipokines having insulinmimetic and -sensitizing effects, respectively. however, their role in t dm is still controversial. accordingly, this study was designed to investigate their levels in t dm patients compared to healthy control subjects, and to study the correlation between these two novel adipokines and the correlation between each of them with anthropometric parameters, insulin resistance, hyperglycemia, dyslipidemia, and also the inflammatory marker interleukin- (il- ). the levels of these two novel adipokines and other parameters were measured in non-obese and obese t dm patients together with matched healthy non-diabetic control subjects. the nampt, vaspin and il- levels were measured by elisa while insulin levels by chemiluminescence technique. the nampt and vaspin levels were found to be significantly elevated in non-obese ( . ae . and . ae . ng/ml, respectively) and obese t dm patients ( . ae . and . ae . ng/ml, respectively) compared to control subjects ( . ae . and . ae . ng/ml, respectively) at p < . . furthermore, nampt as well as vaspin were found to be significantly correlated with one another and with various metabolic parameters. in conclusion, nampt and vaspin are potential candidates to play important role in the development and progression of t dm. . to compare insulin resistance in sub-clinical and overt thyroid hypo-function. methods: one hundred eighteen patients with the diagnosis of hypothyroidism based on their clinical and thyroid function test profile were included in this cross sectional hospital based descriptive study with their informed consent. homa-ir as an index of insulin resistance was calculated for each subject from their fasting plasma glucose and serum insulin levels. autoimmunity against thyroid was evaluated by estimating anti tpo antibodies. results: homa-ir as an index of insulin resistance was comparable in overt ( . ae . ) and subclinical hypothyroidism ( . ae . ) but was above the reference range for this population. hypothyroid anti tpo positive cases has high tsh compared to negative cases in both overt hypothyroidism and subclinical hypothyroidism. conclusions: hypothyroidism induces insulin resistance but the degree of insulin resistance is not dependent on severity of thyroid hypofunction however is associated with autoimmunity against thyroid. . ae . in smoker and . ae . in non-smoker, insulin: . ae . and . ae . (p < . ), control: glucose level was . ae . in and . ae . mmole/l, insulin level: . ae . and . ae . mkiu/ ml, respectively. both growth in height and weight gain are accelerated during puberty. they are mainly affected by sex hormone, growth hormone and igf- , and influenced by various factors either directly or indirectly. the aim of this study is to find out the association of various cytokines with obesity and early-or precocious puberty in female children. twenty-eight female children with breast budding before years old, who underwent the lhrh stimulation test as well as cytokine analysis in their blood, were included in this study. the height, weight, and bmi were measured. we defined obesity when the bmi was percentile or more, and puberty when the maximum lh level was iu/l or more during lhrh stimulation test. adiponectin, leptin, ghrelin, il- β, il- , il- , resistin, and tnfa levels in the blood were analyzed by luminex multiple bead technology (milliplex; millipore co., billerica, ma, bio-plex; bio-rad laboratories, hercules, ca). nineteen out of children were categorized as having early-or precocious puberty. their mean il- level was lower in pubertal children than that in prepubertal state ( . ae . vs. . ae . , p = . ). the leptin and resistin levels were significantly higher in obesity group (n = ) than in non-obesity group, while the ghrelin was significantly lower in obesity group (p < . ). in conclusion, the female children younger than years of age in early-or precocious puberty did not show the increment of leptin or resistin comparing with the female prepubertal children, although the obesity group showed significantly higher levels of leptin and resistin. aims: arterial stiffness is independent risk factor of cardiovascular events. suggest that the statins benefit associated with improvement in arterial stiffness parameters beyond lipidslowering effects. to evaluate changes in pulse-wave shape in obese high risk patients with ah and dyslipidemia treated with rosuvastatin compared with atorvastatin. methods: eighty-two obese patients (age . ae years) with ah, dyslipidemia were randomized to atorvastatin group (n = ) or rosuvastatin (n = ). acei and thiazide diuretics added blood pressure control. pulse-wave characteristics measured before and after weeks of treatment using finger photoplethysmographic device. stiffness index (si), reflection index (ri), augmentation index (aix), systolic bp in aorta (spa), digital pulse amplitude augmentation (paa) were accessed. results: before the treatment impared si, elevated ri, aix, spa were shown. lipids and bp goals were achieved in all patients validating further analysis. decrease in si (d si, м/c À . atorva and À . rosuva), ri (dri, % À . atorva and À . rosuva) were revealed in both treatment arms (p > . ), whereas significant trends towards aix decrease were demonstrated only in rosuvastatin-treated patients (dai, % À . atorva and À . rosuva, p < . ) rosuvastatin group demonstrated better increasing in paa than atorvastatin group (paa (atorva): before treatment . ae . and after weeks: . ae . , p = . vs. paa (rosuva): before . ae . and after weeks . ae . , p < . ). conclusions: pulse-wave analysis in obese ah patients demonstrated increasing vascular stiffness. both atorvastatin and rosuvastatin treatment resulted in arterial stiffness parameters, whereas only rosuvastatin treatment was significantly associated with trends in aix and paa improvement in short-term follow-up. z. wang , m. xu methods: four thousand two hundred and twenty-six adults above years of age and adults under years from a cohort investigated in - at the medical examination center of zhongnan hospital were recuited. cases of fld was identified through ultrasound imaging. the risk factors measured were bmi, and plasma concentrations of alt, ast, tc, tg, hdl, ldl and serum uric acid (sua). the probability of steatohepatitis with advanced fibrosis was calculated according to the body mass index, age, alt, and triglyceride (baat) and ast/alt ratio (aar). results: the prevalence of fld was higher in elderly ( . %) than in non-elderly ( . %) and similar in elderly between men and women ( . % vs. . %, p > . ). multiple regression analyses showed that obesity, high tc, tg, sua, low hdl, and elevated alt, aar < were closely related to the elderly fld the prevalence of steatohepatitis estimated as baat index ! was . % in all subjects, and was higher elderly fld patients than in the non-elderly fld patients. conclusion: the prevalence of fld is higher in the elderly, and is broadly related to the same metabolic risk factors as in the nonelderly. however, female-sex is no longer protective with increasing age, and the prevalence of steatohepatitis with advanced fibrosis is estimated to be considerably higher in the elderly fld patients than in the non-elderly fld controls. vanderbilt, nashville, tn, usa bariatric surgery improves glucose tolerance and may be a viable strategy to prevent the progression from obesity-induced insulin resistance to overt diabetes; however, the recurrence of diabetes is significant following the surgery. we sought to determine whether gastric bypass surgery protected pancreatic beta cells and prevented disease progression to overt diabetes. gastric bypass (roux-en-y gastric bypass, rygb) was performed in young ( weeks old) prediabetic blks db/db null (bks-db) mice, young ( weeks old) new zealand obese (nzo) male mice that were fed high-fat diet (hfd) post-surgery, c bl/ db/db null (b -db) mice that developed insulin resistance, and streptozotocin (stz)-induced diabetic mice. rygb resulted in sustained normoglycemia and improved glucose tolerance in pre-diabetic bks-db mice and hfd-fed nzo mice. remarkably, rygb preserved beta-cell mass and increased plasma insulin with reduced beta-cell apoptosis which was independent of weight loss and body fat reduction. rygb neither reversed hyperglycemia when performed in diabetic bks-db and nzo mice nor resulted in resolution of diabetes in stz-induced diabetic mice. the results demonstrate that gastric bypass prevents beta-cell failure if performed prior to onset of severe beta-cell damage in genetic obese mice. l. ruzic , g. sporis , m. prasek sport and exercise medicine, applied kinesiology, faculty of kinesiology, university of zagreb, vuk vrhovac university clinic, zagreb, croatia the aim of the study was to examine the influence of strength training program on pre-and post workout glycemia. twelve able-bodied diabetic patients using insulin pump (mean age . ae . , m/ f) were enrolled into gym programs /week ( min warm-up aerobic workout, intensity at % hrmax plus strength training exercises involving different muscle groups) for months. no other interventions were introduced. we were interested in effects of the programe on pre-and post workout glycemia, so the comparisons between the first weeks and the last weeks of the study were performed. also the subjects were asked about hypoglycemic episodes. there was a great variability observed in pre-and post glucose concentration within and between subjects. the mean pre-workout glucose concentration in the first weeks of the program was . ae . vs. . ae . mmol/l in last weeks of the program and the difference was not significant (p = . ). nevertheless, the mean glucose decrease after workout was higher in the last weeks of the program (deltaglu: . ae . vs. . ae . mmol/l; p < . ). no hypoglycemic episodes were reported. the months strength training program did not influence large variability in glucose levels before the workout as it depends on many other factors. the only observed effect were larger pre-to post workout glucose differences. it seems that over the time, the strength training may stimulate the body to use more glucose during the workout, which might be explainable with the expected increase of lean body mass. aim: the aim of this study was to evaluate the level of c-reactive protein in gestational diabetes mellitus. materials and methods: sixty-five healthy pregnant women aged . ae . years between the th and th weeks of gestation were studied. all women referred for a -g oral glucose tolerance test following an abnormal result on a screening. the demographic data, waist circumference, height, and weight of the participants were recorded. fasting levels of insulin, triglycerides (tg), c-reactive protein (crp), fasting blood glucose (fbg) and hba c were measured. results: based on oral glucose tolerance testing participants were divided into two groups: normal glucose tolerance (ngt; n = ) and gestational diabetes mellitus (gdm; n = ). the mean crp level was highest in gdm group ( . ae . mg/l), followed by ngt ( . ae . mg/l), (p < . ). the mean fbg ( . ae . vs. . ae . mmol/l, p < . ), homa-ir ( . ae . vs. . ae . , p < . ) and tg levels ( . ae . vs. . ae . mmol/l, p < . ) in the women with gdm were significantly higher than those in the ngt group. methods: in , an observational, prospective study started in france on request of the health authorities (has). one thousand seven hundred and two type diabetic patients treated by vildagliptin were recruited through a national representative sample of gps and diabetologists. we report the data of interim analyses after months of follow-up. results: one thousand four hundred and sixty-three patients are included in this interim analysis: % males, aged ae years, with mean bmi of kg/m . hba c was equal to . ae . % at vildagliptin initiation, then . ae . %, . ae . % and . ae . %, while mean weight decreased from to , and kg at , and months respectively. vildagliptin, rarely prescribed when not recommended, was well tolerated: asat and/or alat were > ui in . % at initiation of vildagliptin then . % at months, with a slight decrease for mean asat and alat. mean gfr was ml/mn at initiation of vildagliptin then ml/mn at months, with a stable percentage of gfr < ml/mn ( %) and < ml/mn ( . %). six severe hypoglycemic episodes occurred in six patients (incidence = . / patient-years), all treated by insulin and/or sulfonylurea in addition to vildagliptin. the proportion of patients still treated by vildagliptin at months was . %. conclusions: over months, in real-life conditions of care, vildagliptin showed a sustained effectiveness in terms of hba c reduction, a good tolerance, very few severe hypoglycemic episodes, rare treatment discontinuations and was most often prescribed as recommended. background: hdl lipoproteins are known to play a causative role in atherosclerosis and its clinical manifestation-coronary artery disease (cad). carotid intima media thickness (imt) is considered as a marker of atherosclerosis and in prediction clinical coronary events. aim: to determine the associations between plasma lipids and subclinical atherosclerosis measured by the common carotid intimamedia thickness (imt) in cad patients. methods: hdl subclasses were separated with - % pag electrophoresis, and imt was determined using high-resolution b-mode ultrasound in cad patients, with normal levels of traditional lipid risk factors. results: mean value of left and right carotid artery measurement was selected as value for correlation with hdl subclass size in each patient. the mean hdl size was . ae . nm, and the mean imt in all patients was . ae . mm ( . - . mm). hdl size was not correlated with imt (r = À . ; p > . ). by univariate analyses, carotid imt was the most closely related to systolic pressure (r = . , p < . ), followed by diastolic pressure (r = . , p < . ) and age (r = . , p < . ). stepwise multiple linear regression analysis revealed that diastolic pressure (β = . , p < . ), systolic pressure (β = . , p < . ) and age (β = . , p < . ) were independent predictors of determining carotid imt (adjusted r < . , p < . ). conclusion: these results indicate that diastolic pressure, systolic pressure and age are an important, independent determinants of carotid imt in cad patients. no other traditional risk factors imparted imt. objective: antinuclear antibodies (ana) are present in approximately - % of patients with non-alcoholic steatohepatitis (nash). a recent study implied the relationship between obesity and autoimmunity. the purpose of this study was to investigate the relationship between seropositivity for ana and metabolic abnormalities including insulin resistance, obesity and hepatic steatosis in patients with nash. methods: the severity of hepatic steatosis and fibrosis was scored by the nafld activity score system. seropositivity for ana was defined as titers of : or higher by an indirect immunofluorescence method using hep- cells. insulin resistance and obesity were evaluated by the value of homa-ir and bmi, respectively. the diagnosis of autoimmune hepatitis (aih) was based on the simplified scoring system. results: nine ( %) of patients with nash had ana. overall bmi in nash patients with ana was higher than that in those without ana. laboratory analyses revealed significantly higher mean igg level ( ae vs. ae mg/dl, p = . ) and the mean value of homa-ir ( . ae . vs. . ae . , p = . ) in nash patients with ana than those in those without ana. histological examinations exhibited that nash patients with ana had higher scores in hepatic steatosis ( . ae . , vs. . ae . , p = . ) and fibrosis ( . ae . vs. . ae . , p = . ) than those without ana. however, none of nash patients fulfilled the criteria for "definite" aih. conclusion: nash patients with ana had clinical characteristics of significantly higher serum igg levels and severe insulin resistance, and they tended to have more severe obesity, hepatic steatosis and fibrosis than nash patients without ana. r.f. alponti , , p.f. silveira pharmacology, instituto butantan, physiology, instituto de biociencias/universidade de sao paulo, sao paulo, brazil introduction: although irap (ec . . . ) is well-known, the existence of other aminopeptidases (aps) related to energy homeostasis remains unclear. objectives: to search a diverse array of aps in high (hdm) and low (ldm) density microsomes and in plasma membrane (mf) of retroperitoneal adipocytes from healthy control (c), monosodium glutamate (msg) obese and food deprived (fd) rats with their in vitro responses to insulin (is), vasopressin (avp), angiotensin (ang)-ii and ang-iv. methods: ultracentrifugation and spectrofluorometry. results: dipeptidyl-peptidase-iv (dppiv) and aps basic (apb), neutral puromycin-sensitive (psa) and -insensitive (apm), and methionyl (metap) were found. compared with non-stimulated, these aps were unaffected by is; avp increased apb/apm (ldm) and dppiv/psa (hdm) of msg-fd and metap/psa (hdm) of c; ang-ii increased apm (fm-ldm) of c, dppiv (fm) of msg and psa (fm) of fd; ang-iv increased apb (fm) of fd, apm (hdm) of msg and dppiv (fm) of c and msg. aps were modulated by avp in hdm-ldm, by ang-ii in fm-ldm and by ang-iv in fm-hdm. compared with ldm, metap decreased in fm of c and increased in fm of msg-fd without peptide stimuli; and only diabetes-related enzyme dppiv exhibited peptide-mediated intracellular translocation, which was from ldm to hdm (stimulated by avp) in msg-fd, and from ldm and hdm to fm in msg and msg-fd (stimulated by ang-ii) and in c and msg (stimulated by ang-iv). conclusion: novel peptide-modulated apb, apm, psa, metap and dppiv are found in adipocyte, this last with altered subcellular trafficking under metabolic distress. supported by fapesp, cnpq and capes. nutritional and environmental sciences, university of shizuoka, shizuoka city, japan previous studies have suggested that (-)-epigallocatechin- -gallate (egcg) exerts antioxidative and anti-inflammatory actions in various tissues, which might be beneficial for reducing risks of development of diabetes. however, an optimum intake level of egcg is unknown. in this study, we have examined the effect of a diet containing egcg on the expression of inflammation-related genes in various tissues including visceral adipose tissue and the muscle of non-obese type- diabetes animal model, goto-kakizaki (gk) rats. gk rats at weeks of age were fed a control high-fat diet ( energy% as fat) or the high-fat diet containing . %, . % or . % egcg for weeks. the mrna and protein levels of il- β, il- , mcp- , cd s, il- , tnf-a, resistin and pai- were significantly reduced in the adipose tissue of rats fed a diet containing . % egcg, but not in those fed diets containing . % or more egcg, as compared with control. the mrna levels of tnf-a, ifn-g, il- b, il- and il- in the muscle of rats fed a diet containing . % egcg were also significantly lower than those in the control. these results suggest that there is an optimum range of intake of egcg, which may suppress the expression of genes involved in inflammation in the adipose tissue and the muscle. diabetes and hypertension are the most relevant factors leading to vascular disease and cardiovascular problems. since both pathologies are greatly increasing nowadays, there is a need to detect at early stages the occurrence of target organ damage associated with them. this is the relevance of identifying biomarkers that can detect or predict the onset of cardiovascular and renal damage associated with diabetes and hypertension. given that the role of osteoprotegerin in bone metabolism is well known, and some evidence of its putative relationship with diabetes-associated pathologies has been found, to this date there is no evidence linking this molecule with target organ damage associated with diabetes. in this study, we analyze whether osteoprotegerin may be used to detect and evaluate cardiovascular and renal pathologies associated with diabetes in an in vivo model. we used normotensive and hypertensive rats, a subset of rats of each group receiving a single streptozotocin injection in order to induce diabetes. we performed an -month followup, periodically collecting blood and urine samples and monitoring both blood pressure and blood flow in the lower limbs. our results showed that osteoprotegerin was associated with the presence of diabetes, suggesting that it might be used as a biomarker for the occurrence of cardiovascular damage or to detect cardiovascular risk under these circumstances. blood flow in the lower limbs decreased soon after diabetes onset, as osteoprotegerin levels increased. our data suggest the potential use of serum levels of osteoprotegerin as a biomarker for diabetes and hypertension-associated endothelial dysfunction. purpose: this study examined whether breakfast meal composition alters the incretin response and glycemic control following both the breakfast and lunch meal. methods: seven subjects with t d completed two conditions where they consumed either a kcal high protein (pro: % carbohydrate, % protein, % fat) or high carbohydrate (cho: % cho, % protein, % fat) breakfast for days of acclimatization. on day , they underwent meal testing in which they consumed the respective breakfast followed by a lunch meal ( kcal: % cho, % pro, % fat). blood samples were collected over the -h period and analyzed for glucagon, insulin, glucagon-like peptide- (glp- ) and glucose-dependent insulinotropic polypeptide (gip) concentrations. incremental area under the curve (iauc) for the -h post-breakfast and -h post-lunch period was calculated. results: the iauc for insulin, glucose and glp- were not significantly different between conditions or between meals. the gip response to the pro breakfast ( ae pg/ml*min for -h) was lower (p = . ) compared to the cho breakfast ( ae pg/ ml*min for -h), with the opposite effect occurring in response to the lunch meal (pro: lunch ae ; cho: lunch ae pg/ ml*min for -h, p < . ). conclusion: despite no differences in glucose and insulin levels, a pro breakfast, compared to a cho breakfast, resulted in lower gip levels for the initial meal with a greater second meal effect after a lunch meal. however, a pro breakfast potentiates gip levels after a lunch meal. further research is needed to determine the physiological role of changes in circulating gip. high risk pregnancy, kasralainy university, cairo, egypt background: pregnancy tends to reset the glucose homeostasis in the direction of diabetes. about - % of all pregnant women develop an abnormal glucose tolerance in pregnancy, but most often glucose tolerance returns to normal postpartum. this condition is called gestational diabetes mellitus (gdm). aims: comparative study between gestational and pregestational diabetes in relation to glycemic control as regarding fetal and neonatal outcome. methods: this study was conducted in kasralainy maternity hospital from september to march and it included pregnant women complicated by dm attending outpatient clinic or inpatient. patients were classified into two groups, gestational diabetes: pregnant women complicated by dm which is diagnosed for the first time during pregnancy and pregestational diabetes: pregnant women who have dm that has been diagnosed prior to pregnancy. the two groups were compared according to fetal (macrosomia and intrauterine fetal death) and neonatal (respiratory distress syndrome and birth injuries) complications. all patients were - years old, singltone pregnancy, with time of termination after completed weeks. results: fetal macrosomia occurred more with gdm, on the otherhand birth injuries and rds occurred more with pre-gdm. macrosomia and rds were commoner among poor glycemic control in pregnant diabetic females than birth injuries and iufd. conclusions: glycemic control started as early as possible (the best being preconceptional) is important to decrease the incidence of birth injuries, macrosomia, fetal mortality, the need for nicu admission (rds). adiponectin, an adipocyte-derived hormone, is implicated in type diabetes and atherosclerosis. this study was designed to investigate whether serum adiponectin levels in coronary artery disease (cad) patients with type diabetes (t dm) are lower than in patients with cad alone and healthy controls. we measured serum adiponctin levels in subjects, patients with cad ( subjects of whom had both cad and t dm), and also healthy subjects were selected as controls. all patients were subjected to anthropometric indexes assessment and biochemical measurement of serum adiponectin, interleukin six (il- ), insulin, lipid profile and glucose by standard methods. the results revealed significant differences in serum adiponectin levels between cad patients with t dm and cad patients without t dm ( . ae . vs. . ae . lg/ml, p = . ), between patients with cad and healthy controls ( . ae . vs. . ae . lg/ml, p = . ), and between men and women ( . ae . vs. . ae . , p = . ). serum adiponectin levels were correlated significantly with insulin, total cholesterol, low density lipoprotein, body mass index, glucose, homa-ir, il- (r = À . , p = . , r = À . , p = . ; r = À . , p = . ; r = À . , p = . ; r = À . , p = . ; r = À . , p = . ; r = À . , p = . , respectively). adiponectin was correlated positively only with high density lipoprotein (r = . , p = . ). conclusions: we conclude that low serum adiponectin levels and insulin resistance coexist in cad patients with t dm. it is speculated that subjects who have very low levels of serum adiponectin may be at increased risk of developing both t dm and cad. objective: to simultaneously examine the impact of self-reported and newly-identified hypertension upon subsequent type diabetes (t d). methods: two community-based adult prospective cohort studies, with the same protocols, instruments and questionnaires, were conducted during - and - in urban areas of nanjing, china. data from these two cohorts were pooled and analyzed. t d (outcome variable) was identified using the world health organization diagnosis criteria. based on status of blood pressure (independent variable), participants were categorized into three groups: (i) people with normal blood pressure at baseline survey and during follow-up period (normal blood pressure), (ii) subjects with self-reported hypertension at baseline survey (self-reported hypertension) and (iii) those who did not report hypertension at baseline but were diagnosed having hypertension during follow-up period (newly-identified hypertension). all covariates were assessed at baseline and in the third-year follow-up survey. results: among participants, the -year cumulative incidence of t d was . %, . % and . % for participants with newly-identified hypertension, self-reported hypertension and normal blood pressure, respectively. after adjustment for potential confounders, compared to people with normal blood pressure, participants with newly-identified (or = . ; %ci = . , . ) or self-reported (or = . ; % ci = . , . ) hypertension were more likely to develop t d. furthermore, subjects with newly-identified hypertension (or = . ; % ci = . , . ) were at elevated risk of developing t d relative to their counterparts with self-reported hypertension. the similar associations of hypertension with t d were also found in both men and women, separately. hypertension, either self-reported or newly-identified, is an independent risk factor for developing t d among urban chinese adults. methods: a total of patients with type diabetes receiving standard glucose-lowering therapy were enrolled. efficacy of the lowcalorie diet ( kcal/day) with inclusion of specialized nutrison advanced diason product was assessed in two similar groups in during weeks: main group patients (n = ) received diet with nutrison advanced diason in the amount of ml as the only food for the day twice a week for weeks; control group patients (n = ) received a low-calorie diet with the inclusion of a standard meal at calories twice a week. results: the average weight loss in the main group was ae g, in the control group - ae g per day. according bioimpedance complex therapy with specialized product increased the content of lean mass by an average of . ae . kg and decreased fat mass by an average of . ae . kg. in main droup was a reduction of the basal level of glucose to . ae . - . ae . mmol/l (p = . ), in control groupfrom . ae . to . ae . mmol l (p = . ). total cholesterol level in the main group decreased from . ae . to . ae . mmol/l (p = . ), in the control groupfrom . ae . to . ae . mmol/l. the inclusion of the specialized product nutrison advanced diason in the standard low-calorie diet allows to raise the efficacy of dietary therapy in patients with type diabetes. liver injury and regeneration involve complicated processes and are affected by various physio-pathological factors. this study was designed to investigate the mechanisms of steatosis-associated liver injury and impaired regeneration in a mouse partial hepatectomy model. male c bl/ j and db/db mice were used as mice with normal and steatotic liver, respectively. liver regeneration and injury were evaluated chronologically after hepatectomy. initial regeneration of the steatotic liver was markedly impaired after hepatectomy. although hepatocyte proliferation was not significantly suppressed, intense liver injury with oxidative stress occurred immediately. fasl/fas expression was up-regulated in the steatotic liver, whereas the expression of anti-oxidative and anti-apoptotic molecules (catalase/mn-sod/ref- and bcl- /bcl-xl/flip, respectively) and p /sqstm , a steatosis-associated protein, were down-regulated. interestingly pro-survival akt was not activated/phosphorylated in response to hepatectomy though it was sufficiently expressed/ phosphorylated even before hepatectomy. suppression of p /sqstm increased fasl/fas-expression and reduced nrf- -dependent are activity and anti-oxidative responses in steatotic and non-steatotic hepatocytes. exogenously added fasl induced intense cellular oxidative stress and necrosis/apoptosis in steatotic hepatocytes, only the necrosis being inhibited by pretreatment with anti-oxidants, suggesting that fasl/fas-induced oxidative stress mainly leads to necrosis. furthermore, p /sqstm re-expression in the steatotic liver markedly reduced liver injury and improved tissue regeneration. in the steatotic liver, reduced expression of p /sqstm induced fasl/fas expression and suppressed anti-oxidant genes through nrf- inactivation, which together with hypo-responsiveness of akt, caused post-hepatectomy necrotic and apoptotic liver injury in redoxdependent and -independent manners, respectively. p /sqstm may be a key molecule in post-hepatectomy acute liver injury and impaired regeneration in fatty liver in mice. objective: mastication can accelerate satiety sensation and lipolysis through activation of histamine neurons; however, the data on antiobesity effects of mastication are limited. we therefore examined the effect of chewing on postprandial satiety and energy metabolism in humans. methods: satiety, energy expenditure, and fat oxidation were measured in lean young women on separate occasions, before and h after consumption of a solid meal with chewing per bite or after swallowing the same mashed meal without chewing, in a randomized, crossover design. each test meal consisting of kj ( % of energy as carbohydrate, % of energy as protein, and % of energy as fat) was consumed between and min regardless of texture difference. the thermic effect was greater after the solid meal ( . ae . %) than after the mashed meal ( . ae . %, p < . ). time course of fat oxidation tended to be higher after the solid meal than after the mashed meal (p = . ). in addition, solid meal was more satiating than mashed meal (p = . ). the results suggest that mastication contributes to postprandial satiety and thermic effect of meal. chewing meal thoroughly could be a useful eating behavior for preventing weight gain. introduction: raven noted an association between insulin resistance and cardiovascular consequences and type dm. mathew prescribed the method of insulin resistance designation using mathematic model homa-ir. aim: to estimate insulin resistance homa-ir in adult population according to gender, assess selected parameters in people with homa-ir ! . (i group) and homa-ir < . (ii group) and determine dependence between homa-ir and the above parameters. materials and methods: one hundred and fifty-four people medium age . years, from tarnawa city constituted the material. bp was examined. blood samples were obtained for plasma glycaemia, lipidogram and serum insulinaemia. all people were measured and weighed, bmi and homa ir were calculated, waist circumference was obtained. the cut-off point . for homa-ir was accepted. results: . % of the examined population had insulin resistance without a difference between women and men. significant differences between i and ii group were observed according to tg and waist circumference. in women all examined parameters were significantly different except hdl. in men bmi, waist circumference and hdl were significantly different in i and ii group. in the female group correlations between homa ir concerned all examined parameters, in the male group-hdl and waist circumference. conclusions: there was no significant difference between women and men according to insulin resistance in the whole study group. the difference between selected parameters in the two examinated groups were more strongly in women. body mass was the main factor determining insulin resistance in the whole study group as well as in men and women. background: the immune system is altered in obesity and diabetes, through changes in adipocytes, liver, pancreatic islets, vasculature and circulating leukocytes, with increased cytokine and leukocytes activation, suggesting inflammation participation in diabetes. minocycline presents a potent anti-inflammatory activity, as evaluated in vivo and in vitro. objectives: minocycline anti-diabetic effects were assessed in alloxaninduced diabetes through biochemical parameters measurements, histological and immunohistochemistry analyses. methods: alloxan was injected to rats, blood collected h later and after oral treatments ( , and days) for glycemia, triglycerides, cholesterol and transaminases measurements. diabetic controls and diabetic plus minocycline ( and mg/kg) or glibenclamide ( mg/ kg) were used. furthermore, pancreas, liver and kidney were submitted to histological and immunohistochemistry (cox- and tnf-a) analyses. results: decreases in glycemic and triglyceride levels, at the th and mainly th days after minocycline treatments, were observed. he staining showed that minocycline partly reversed tissue alterations, and decreased expressions of cox- and tnf-a, as compared to untreated animals. conclusions: beneficial minocycline effects in diabetes could be due to its anti-inflammatory and antioxidant properties and, by inhibiting microglial activation, it may be an important therapeutic strategy in diabetes where inflammation plays a significant role. methodology: forty-eight hours after alloxan-induced diabetes, blood from male wistar rats was collected for biochemical measurements. then, diabetic rats untreated or treated ( week, or months) with pentoxifylline ( , , and mg/kg, p.o.) or glibenclamide ( or mg/kg, p.o., alone or associated to pentoxifylline) were divided into eight groups with - animals each. after treatments, biochemical measurements were repeated. glycated hemoglobin determinations, and histological and immunohistochemistry analyses for inos were also performed. results: pentoxifylline brought hyperglycemia and triglycerides towards normality. glycated hemoglobin was improved. the use of diazoxide showed the mechanism of action of pentoxifylline partly related to atp-dependent k + channels. pentoxifylline improved histological alterations in pancreas, liver and kidney, and decreased inos cell expression. conclusions: pentoxifylline effects are probably related to its action on oxidative stress and inflammation, decreasing pro-inflammatory cytokines. thus, pentoxifylline is a potential candidate for diabetes mellitus therapy, since patients with vascular complications present beneficial effects, as shown in clinical practice. recently, a close relationship between the development of adiposity and gut-derived hormonal dysregulation has been clearly established. for instance, studies of gut-derived peptides such as pyy - , glp- , oxyntomodulin, discovered more than years ago and, later on ghrelin have significantly improved our understanding of mechanisms underlying ectopic lipid infiltration in organs and tissues. the etiology of non-alcoholic fatty liver disease (nafld) is intimately related to the capacity of hepatocytes to acquire an "adipocyte-like" phenotype. we previously reported that unacylated ghrelin (uag) is more potent than acylated ghrelin (ag) to stimulate adipogenesis. the present study intends to investigate the relevance of uag and ag as mediators of lipid accumulation in hepatocytes. hepg hepatocytes were treated with a control, uag or ag ( nmol/l and pmol/l) in the presence or absence of oleate ( nmol/l) to measure lipid droplet (ld) number and size. gene expression analyses were performed for key mediators of pre-adipocyte differentiation or liver functions. in response to uag or ag treatment in the presence or absence of oleate, ld number was markedly increased in hepg cells. similarly, increased ld size was noted following the treatment of hepg cells with uag or ag. however this effect could not be detected in the presence of oleate. gene expression of ppar-c and c/ebp-a was increased while that of ppar-a was decreased in response to ag treatment. these results are first to describe mechanisms through which uag and ag could promote the development of lipid infiltration in liver. deakin university, melbourne, vic., australia the world health organization believes that type diabetes mellitus is an important public health problem in the world. however some statistics showed that only . % of all world population had diabetes in , but the health professionals argue, this amount will reach to % in . diabetes australia -nsw estimates that almost million australians have diabetes and also around . million australian populations are at risk of this disease and unfortunately, the number of australian with diabetes will be approximately . millions in . obviously, direct and indirect medical costs due to health care of diabetic's patients are very high and % of the australian government's health budget is spent on health care of type diabetes. therefore, the health professionals have tried to provide the optimal public health programs for control and management of type diabetes. many researchers and health professionals argue that control of weight by change diet habits and exercise are major keys in lifestyle programs for prevention of type diabetes. in this case, the results of several studies like the finnish study, american study, the swedish malmo study and chinese study showed that the focus on diet and exercise programs are significant approaches in type diabetes prevention, while some other studies claim that the change diet habits and exercise may not sufficient and some medicines for control of insulin sensitivity and energy expenditure may also be necessary. therefore, lifestyle intervention programs and pharmacologic intervention programs are the major prevention programs. objectives: metabolic responses to acute endurance exercise may be affected by time of day because the nervous and endocrine systems have circadian rhythms clearly. the purpose of this study was to investigate the influence of acute endurance exercise in the morning and evening on metabolic responses in young men. methods: ten healthy young men completed two trials in a randomized cross-over design: . morning ( : - : ) and . evening ( : - : ) trials. in the morning and evening trials, participants walked for min at % of maximal oxygen uptake on a treadmill. pulmonary gas exchange was determined breath-by-breath by a gas analyzer. blood samples were collected to determine hormones and metabolites at preexercise, immediately and h after exercise. results: plasma interleukin- and adrenaline concentrations were significantly higher immediately after exercise in the evening trial than in the morning trial (p < . and p < . , respectively). serum growth hormone concentrations were significantly higher immediately after exercise in the evening trial than in the morning trial (p < . ). serum free fatty acids concentrations were significantly higher in the evening trial than in the morning trial at h after exercise (p < . ). however, there was no significant difference in fat oxidation between the morning and evening trials. conclusion: these findings suggest that acute endurance exercise in the evening is more effective on lipolysis compared to that in the morning in young men. nutrition, school of public health, university of sao paulo, sao paulo, brazil background: the rs snp of fto (t>a) has been associated with obesity and its comorbidities. in a allele carriers, physical activity (pa) minimizes the deleterious impact on body weight, which could reduce cardiovascular risk. objectives: to investigate whether pa level and television viewing modulate the effects of a allele of fto on adiposity and markers of inflammation in individuals at high cardiometabolic risk. methods: this cross-sectional study included prediabetic individuals ( women, . ae . years, bmi . ae . kg/m²). physical activities were measured by the long-version of ipaq; individuals were genotyped and stratified according to total pa (< or ! min/week) and television watching (< or ! h/week). anthropometric, biochemical and inflammatory data were obtained. subgroups of individuals with or without a allele were compared by student's t test. results: among individuals who watched tv < h/week, those carrying the a allele had significantly higher concentrations of total and ldl-cholesterol, apolipoprotein b ( . ae . vs. . ae . mg/dl) and interleukin- ( . ae . vs. . ae . pg/ ml), but did not differ regarding anthropometric measures. among those who watched tv ! h/week, no difference in any clinical data was detected comparing carriers and non-carriers of a allele. regarding pa, the presence of the variant allele did not influence the metabolic profile. the presence of the variant allele at fto gene seems to favor a deleterious metabolic and inflammatory profiles particularly for individuals less exposed to sedentary activities such as watching tv. for inactive individuals, the allele presence might not affect predisposition to adiposity-induced disturbances. cardiovascular disease is the leading cause of death in brazil and in the world and its development is directly related to lifestyles and habits acquired in childhood. the objective of this study was to evaluate the anthropometric data and blood pressure levels of schoolchildren to verify that the body mass index and waist circumference maintain a relationship with blood pressure. the descriptive study was conducted with schoolchildren of both sexes in schools of cruzeiro do oeste, a small town in southern of brazil. the evaluations consisted of: measurement of weight (w) and height (e) to calculate the body mass index (bmi), waist circumference (wc) and blood pressure (bp). associations between variables were determined using the chi-square test. we observed a high percentage of overweight, wc modified and high pressure measurements. both bmi and wc showed significant association with the high pressure measurements. there is an association between increased blood pressure and increasing age. increases in bmi and central adiposity are associated with higher risks of high pressure measurements, and consequently other chronic diseases in - years old children. this study, descriptive and cross-sectional, had as objective to evaluate the relationships between anthropometric measures and lifestyle habits with the lipid profile of brazilian schoolchildren (n = ). the variables obtained were: weight and height to calculate body mass index (bmi), waist circumference (wc), blood pressure (bp), physical activity and dietary habits, serum lipid profile and glycemia. the results were analyzed by the mann-whitney test, the chi-square test and a relative measure of effects odds ratio. the significance was set at % (p < . ). anthropometric variables showed . % of schoolchildren are overweight, . % showed elevated levels of total cholesterol. there was no significant association between nutritional status and lipid profile. this evidence suggests that an appropriate bmi is not indicative of the absence of changes in lipid profile components. the risk factors associated with the development of cardiovascular disease among the children evaluated were: absence of mean meals, lack of daily physical activity, physical activity < times a week, and the consumption of salty snacks more than four times a week. the physical activity was negatively associated with dyslipidemia, suggesting that physical activity may underlying mechanisms by which zinc and magnesium influence glucose metabolism involved oxidative stress and inflammation. this crosssectional study investigated whether intakes of zinc and magnesium are useful to indicate oxidative stress, inflammation and insulin resistance in individuals at cardiometabolic risk. two hundred and five individuals ( . ae . years) with pre-diabetes were evaluated regarding dietary ( -h food recalls) and clinical variables and compared according to zinc and magnesium intake tertiles by anova. multiple linear regression analysis was employed including adjustments for age, gender and bmi (model ), and saturated fat acid intake, smoking status and physical activity (model ). stratified according to tertiles of magnesium intake, no significant differences in anthropometric, plasma glucose, lipid variables, superoxide dismutase (sod), oxidized ldl, inflammatory markers and homa-ir were found. mean values of fat mass ( . ae . . ae . . ae . %) and homa-ir ( . ae . . ae . . ae . ) were significantly lower in the highest tertile of zinc intake; significant trends to decrease fat mass, homa-ir and c-reactive protein were also observed (p-trend < . ). in linear regression models, intakes of both micronutrients were inversely associated with homa-ir but not with inflammatory markers. direct associations were found between magnesium intake and sod concentrations in adjusted models. our findings suggest that assessment of zinc and magnesium intakes may indicate oxidative stress, inflammatory status and insulin resistance in at risk individuals. our design does not allow establishing cause-effect relationship. longitudinal studies are needed to clarify if increased consumption of these micronutrients would ameliorate these pathophysiological processes. a. cezaretto, b. almeida-pititto, c.r. barros, a. siqueira-catania, s.r.g. ferreira nutrition, school of public health/university of sao paulo, sao paulo, brazil introduction: lifestyle changes remain a major challenge for reducing cardiometabolic risk. psychological disorders coexist with risk factors such as unhealthy life habits, decreasing quality of life (qol) and favoring dropouts during interventions. objectives: to compare clinical and psychological characteristics of individuals who dropped or not from lifestyle interventions, traditional or interdisciplinary. methods: one hundred and eighty-three prediabetic individuals ( . ae . years; bmi . ae . kg/m²) were allocated to month interventions on diet, physical activity and stress management. traditional intervention was based on quarterly medical visits, while participants of interdisciplinary intervention also had psychoeducative group sessions. depressive symptoms were assessed by the beck depression inventory (score ! ) and qol by the sf- . independent t-test was used to compare dropouts and non-dropouts. results: body adiposity, blood pressure, fasting glycemia, lipids, depression and qol improved in both interventions, but, in general, improvements were greater in the interdisciplinary intervention. comparing baseline data of dropouts and non-dropouts at the th month, dropouts of traditional intervention had higher bmi ( . vs. . ; p = . ), depression score ( . vs. . ; p = . ) and lower qol ( . vs. . ; p = . ) than non-dropouts. however, no difference between individuals who dropped or not was found in the interdisciplinary intervention. conclusion: interdisciplinary approach may be more effective to improve clinical features and qol. in addition, this intervention avoids dropout of individuals with worse risk profile concerning adiposity, depression and qol when compared with those having only medical visits. interdisciplinary approach may favor the retention of a subset of individuals at higher risk, which may result in long-term cardiovascular protection. aims: consumption of high fat diet (hfd) leads to accumulation of intramuscular bioactive lipids: long-chain acyl-coa (lcacoa), diacylglycerols (dag) and ceramides (cer) which are implicated in induction of muscle insulin resistance. the aim of this study was to elucidate the role of hfd, myriocin (an inhibitor of ceramide de novo synthesis) and metformin on skeletal muscle lcacoa, dag, cer and acyl-carnitine content and their impact on proteins of insulin pathway. the experiments were performed on male wistar rats: -fed standard rodent chow (control), -fed hfd, -fed hfd treated with myriocin, (hfd/myr) and -fed hfd treated with myriocin and metformin (hfd/myr/met). muscle bioactive lipids were analyzed by lc/ms/ms and plasma glucose and insulin concentration by standard assays. content and phosphorylation of akt and glycogen synthase (gs) was measured by western blot. results: compared to control, all measured lipids were elevated in hfd group. these changes were accompanied by decreased phosphorylation of akt and gs and impaired glucose disposal. myriocin caused a decrease in cer but an increase in the other lipids content as compared to hfd. introducing metformin to hfd/myr group attenuated levels of lipid metabolites known to interfere with insulin signaling (cer, dag, lcacoa) and increased acyl-carnitine content as compared to hfd/myr. in hfd/myr and hfd/myr/met groups insulin-sensitizing effects were accompanied by enhanced akt and gs phosphorylation when compared to hfd. conclusions: simultaneous treatment with myriocin and metformin redistributes fatty acids to β-oxidation which attenuates muscular content of bioactive lipids and improves glucose tolerance by promoting akt phosphorylation. pro-inflammatory state leading to abnormal production of hormones like leptin and adiponectin. the present study was designed to explore endocrine dysfunction of adipose tissue in metabolic syndrome. the study included subjects; metabolic syndrome cases as defined by international diabetes federation and age and sex matched controls. the blood samples were collected for estimation of serum triglycerides, hdl-c, insulin, leptin, adiponectin and fasting plasma glucose. leptin and adiponectin were estimated by elisa and insulin by electrochemiluminescence immunoassay. other biochemical parameters were estimated on clinical chemistry analyzer by standard methods. homa-ir as an index of insulin resistance was calculated from fasting plasma glucose and serum insulin levels. results: serum leptin level was significantly higher in metabolic syndrome patients ( . ae . ng/ml) in comparison to control group ( . ae . ng/ml). serum adiponectin was significantly lower in metabolic syndrome patients ( . ae . lg/ml) in comparison to control group ( . ae . lg/ml) levels. significant difference of homa-ir was between metabolic syndrome cases and controls (p < . ). conclusions: it is concluded that altered endocrine functions of adipocytes are associated with metabolic syndrome and leptin and adiponectin has potential to be incorporated as components of diagnostic criteria of metabolic syndrome. aim: to devise noninvasive method to diagnose nafld. methods: one hundred and eight patients were examined: biochemical blood analysis, endotoxin and nitric oxide in blood, shortchain fat acids (sfa) in faeces, biopsy of liver. patients have been divided into two groups depending on activity of hepatitis: . steatosis; . steatohepatitis, and into three groups according to the therapy: . statin; . probiotic; results: we didn′t revealed direct correlation between biochemical parameters of liver function and heaviness of morphological changes in liver. however patients with steatohepatitis had increased level of endotoxin ( . ae . ) and nitric oxide ( . ae . ) in blood. total quantity of sfa in faeces was also decreased in those patients. there was more effective decrease of lipids, endotoxin and nitric oxide in those patients, who received probiotic in combination with statin. if patient received only probiotic there was not any changes of lipids, but the level of endotoxin and nitric oxide became lower. if nafld progressed in steatohepatitis and there was high level of c-gtp and transaminases we didn′n notice such effective decrease of cholesterol. . the increase level of endotoxin and nitric oxide in blood is the marker of steatohepatitis. . application of statin in combination with probiotic is more effective in achievement of target levels of lipids and decreasing endotoxin and nitric oxide. . if patient has steatohepatitis, effectiveness in the hypolipidemic therapy decreases (in comparison with steatosis), because the metabolism of drugs in liver decrease. methods: one hundred and eight patients with nafld were examined: biochemical blood analysis, endotoxin and no in blood, shortchain fat acids (sfa) in faeces, biopsy of liver (index of steatosis (is) and index of histological activity (iha)). patients have been divided into two groups: . steatosis; . steatohepatitis. results: total quantity of sfa in faeces was decreased in all patients, but there wasn′t difference between i and ii groups. all patients with had increased level of endotoxin ( . ae . ) and nitric oxide ( . ae . ). there was correlation between alt and ggtp with endotoxin and no (ast/endotoxin r = . ; ggtp/endotoxin r = . ; ast/no r = . ; ggtp/no r = . ; p < . ). the biopsy of liver showed all signs of nafld including changes of tiny bilious ductules. we didn′t revealed direct correlation between biochemical parameters of liver function and heaviness of morphological changes in liver (appearance of morphological attributes of steatohepatitis precedes development of cytolytic and cholestatic syndrome). however there was reliable direct correlation between endotoxin and no with histological parameters of nafld (is and iha): is/endotoxin r = . ; iha/endotoxin r = . ; is/no r = . ; iha/no r = . ; p < . . . endotoxin and no may be used in diagnosing of nafld. . increase of level of endotoxin and no in blood in patients with nafld is associated with progression of inflammation in liver. thereby blood analysis for endotoxin and no can be used in diagnosing of nafld progression. . we also can judge about effectiveness of treatment of nafld by the level of endotoxin and no in blood. of this study was to analyze incidence obesity and insulin resistance in patients with fatty liver. the study involved patients with diagnosis non alcoholic fatty liver at the clinical centre pristina. there were analyzed demographic and anthropometric characteristics of the examined patients. of clinical characteristics, there were determined smoking habit, arterial pressure. routine biochemical analyses were carried out by a standard laboratory procedure. homa-ir was used to evaluate insulin resistance. results: in the study group, fatty liver was demonstrated by ultrasound in ( . %) subjects and in the control group there were respondents ( . %) without pathological findings of ultrasound and with the level of p < . . the values of bmi ( . ae . kg/m vs.; p < . ), waist circumference ( . ae . vs. . ae . cm; p < . ) and glucose ( . ae . vs. . ae . mmol/l; p < . ), level of insulin ( . vs. . mu/i; p < . ) and homa-ir ( . vs. . ; p < . ) were significantly higher. conclusions: these results confirm that obesity and insulin resistance are associated with fatty liver infiltration. background and aim: this study was designed to determine the impairment of the skin structure in experimentally-induced diabetes with injection of streptozotocin (stz). material and methods: experimental groups consisted of controls (group , n = ) and diabetes groups (group , n = ). dorsal skin was removed for routine histological tissue procedures. hematoxylene and eosin (he), masson's trichrome and periodic acid schiff (pas) stainings, immunohistochemical connexin (cx ) and type iv collagen stainings were applied. morphometry of epidermal thickness were also determined. results: group revealed decrease in epidermal thickness with disintegration of epithelium and decrease of dermal collagen fibers. stratum spinosum were morphologically abnormal for group . measurements of epidermal thickness revealed statistically significant decrease (p . ). pas staining for group revealed disruption of the basement membrane. epithelial scar formation, deterioration of transformation in the polyhedral cells, degradation of epidermis and decrease in pas staining for vascular structures were observed, whereas the reticular dermis and hair follicles were normal. collagen fiber density in group were found to be prominently decreased in dermis with masson's trichrome staining. evident decrease in immunostaining of cx and type iv collagen were also shown in diabetic group in comparison to the controls. conclusion: diabetes not only induced impairment of the epidermal integrity and deterioration in the epidermis via loss of gap junctions (the most prominent cellular junctional complex), but also caused dramatically negative impact on the dermal collagen content, and integrity of the basement membrane. background and aims: obesity, a major obstacle in the improvement of human health, is associated with an increased risk of development of numerous diseases. on the other hand, plant metabolites showed various bioactivities on affecting food intake, lipase activity, energy expenditure and lipid metabolism that may have potential on preventing body weight gain. therefore, this study aims to discover a new metabolite with anti-obesity efficiency. brief methods: adipocyte differentiation was induced by dexamethasone, -iso-butyl- -methylxanthine and insulin in t -l preadipocyte. in vivo, male c bl/ mice were fed a normal diet (nd), high-fat diet (hfd), a lucidone-supplemented hfd in lower dosage of mg/kg of diet (lsh/l) or in higher dosage of mg/ kg of diet (lsh/h) for weeks. record the changes of body weight and food consumptions. physiological parameters in plasma were determined after sacrificed. epididymal and perirenal adipose tissues were collected for further histological analysis. results: lucidone at mmol/l suppressed adipogenesis in t -l cells by reducing transcription levels of adipogenic genes, including pparg, c/ebpa, lxr-a, lpl, ap , glut and adiponectin. lsh/ h mice showed lowered body and liver weights, decreased food efficiency, and lowered plasma cholesterol, triglyceride, glucose, and insulin levels. dissection of adipose tissue from lucidone-fed mice showed reductions in the average fat-cell size and percentage of large adipocytes. conclusion: these results provided evidence that dietary intake of lucidone alleviates high fat diet-induced obesity in c bl/ mice and reveals the potential of lucidone as a nutraceutical on preventing obesity and consequent metabolic disorders under unhealthy eating habits. introduction and aim: obesity and type diabetes (t d) are accompanied by intramyocellular lipid accumulation which might lead to mitochondrial dysfunction and insulin resistance. our aim was to compare changes in peripheral insulin sensitivity and mitochondrial respiration after a diet-and subsequently a gastric bypass induced weight loss in obese patients with or without t d. materials and methods: sixteen subjects ( m/ f; with (t dm) and (ob) without t d) reported thrice to the lab after an overnight fast: prior to weight loss (a), mo later just prior to operation (b) and mo after operation (c). at each visit tree tests were performed: day : dexa scan for body composition and stationary graded bicycle test for vo max. day : hyperinsulinaemic euglycemic clamp for peripheral insulin sensitivity. prior to the clamp a vastus lateralis muscle biopsy for high resolution respirometry was obtained. respiration protocol is shown in fig. . results: anthropometric, body composition and vo max data are shown in fig. . insulin sensitivity (gir ffm ) and maximally coupled respiration (gmso ) data are shown in fig. . conclusion: in spite of a marked difference in insulin sensitivity, maximally coupled mitochondrial respiration was similar in the two groups. moreover, with marked improvements in t dm insulin sensitivity, due to the massive weight loss, mitochondrial respiration remained unchanged. these results speak against an association of mitochondrial respiratory capacity and insulin resistance in skeletal muscle in obese and t d patients. introduction: increased circulating levels of resistin was proposed as a possible link between obesity and insulin resistance. we investigated if increased resistin expression in adipose tissue affected age-related changes in insulin resistance of peripheral tissues, including brown adipose tissue (bat), and oxidative stress parameters in the spontaneously hypertensive rats (shr). methods: sixteen months old male shrs expressing the mouse resistin gene under control of adipose tissue specific ap promoter (shr-tg) and age matched non-transgenic shrs were used. results: transgenic expression of resistin was associated with impaired glucose tolerance measured during ogtt (auc ae vs. ae mmol/l/ h, p < . ); elevated serum insulin ( . ae . vs. . ae . nmol/l, p < . ) and triacylglycerols ( . ae . vs. . ae . mmol/l, p < . ) levels. shr-tg exhibited lower insulin sensitivity measured as insulin stimulated incorporation of c-glucose into lipids in epididymal adipose tissue ( ae vs. ae nmol gl./g/ h, p < . ) and into skeletal muscle glycogen (p < . ). glucose oxidation in soleus muscle (p < . ), and bat (p < . ) were reduced. shr-tg displayed decreased c-palmitate oxidation to co in bat ( . ae . vs. . ae . nmol/g/ hod, p < . ). in adipose tissue of shr-tg rats was increased concentration of lipid peroxidation products (conjugated dienes and tbars), reduced activity of antioxidant enzymes: superoxide dismutase ( . ae . vs. . ae . u/ mg protein, p < . ) and glutathione peroxidase ( ae vs. ae lmol nadph/min/mg protein, p < . ). conclusion: chronic transgenic expression of resistin gene might contribute to insulin resistance and associated metabolic disorders suggesting possible involvement of reduced bat metabolic activity in age-induced prodibetogenic effect of resistin. examination of patients with type diabetes mellitus (t dm) revealed patients ( . %) with non-alcoholic fatty liver disease (nafld). nafld met more often in the patients with obesity ( . %) and overweight ( . %) and only in . % patients with normal body weight. all the patients had abdominal type of adipose tissue distribution regardless of body weight. in patients with t dm and normal body weight the nafld met more often in women, and in overweight and obesity in men. in the examined patients with t dm and nafld complaints peculiar to dyspepsia and asthenovegetative syndrome prevailed. the average level of hba c corresponded the state of subcompensated carbohydrate exchange ( . %). these patients had marked dyslipidemia with predominance of ii and iib types of hyperlipidemia. cytolytic, cholestatic, mesenchymal-inflammatory syndromes were marked out as well as syndrome of hepatic-cellular insufficiency. increased level of immunoreactive insulin iri ( . ae . ) mu/ml and index of homa ir ( . ae . ) mu/ml testified the presence of expressed insulin resistance in the patients with t dm and nafld. the patients revealed the increase of free fatty acids level ( . ae . ) mmol/l/ml, that meaningfully differed from such indexes in the control group (p < . ) and low level of adiponektin ( . ae . ) mg/ml that confirms their role in development of nafld even for persons with normal body weight after the presence of abdominal type of adipose tissue distribution. study object: diene (dc), triene (tc), oxydien (odc), tetraen (trc) conjugates, malondialdehyde (mda), aspartate aminotransferase (ast), alanine aminotransferase (alt). the study involved patients with type diabetes mellitus and non-alcoholic fatty liver disease (nafld) - men and women among them and diabetes women without nafld. all subjects are representative on age and diabetes duration. correlation analysis has been conducted with the calculation of spierman rank correlation coefficient. study results: the increase of tc and odc levels has been marked in type diabetes men with nafld vs. women -( . ae . ); ( . ae . ) and ( . ae . ); ( . ae . ), respectively, p < . , as well as ast and alt levels -( . ae . ); ( . ae . ) and ( . ae . ); ( . ae . ), respectively, p < . , p < . . the positive correlation of ast, alt with odc and trc has been found among type diabetes women with nafld (r = . , r = . , p < . ) and (r = . , r = . , p < . ) unlike women without nafld -(r = À . ) between ast and trc and (r = . ) between alt and trc. ast, alt are in positive correlation with ct in men (r = . , r = . , p < . ). in type diabetes men with nafld the oxidative stress displays are more clearly seen. it is expressed in increasing of tc and odc combined with ast and alt hyperactivity. trc levels are increased in women group with ast and alt increasing vs. type diabetes women without nafld. the above mentioned can serve as a diagnostic marker of nafld in type diabetes women. i. kara, b. bonardo, f. peiretti umr , inserm, marseille, france gamma secretase and the triggered notch signalling are involved in the regulation of the differentiation/proliferation equilibrium of progenitor cells. gamma secretase consists of four subunits: presenilin or , nicastrin, pen- and aph (stoichiometry : : : ). in humans, there are two aph proteins (aph a and aph b). in rodents there is an additional protein, aph c issued from a duplication of the aph b gene. it has been reported that inhibition of c-secretase improves insulin resistance and stimulates adipogenesis. these data led us to study the impact of obesity in the regulation of the c-secretase composition. expression of c-secretase subunits was measured by quantitative pcr (tissues and cells) and western blot (cells). the expression of aph b is significantly increased in the adipose tissue of obese mice whereas the expression of the other subunits of the c-secretase is not altered. the increased expression of aph b is not observed in muscles and liver of obese mice. the expression of aph b is also increased in visceral adipose tissue of human obese subjects. in addition, the expression of aph b/c increases during adipocyte differentiation of t l cells. in conclusion, the c-secretase composition is specifically altered in hypertrophied adipocytes. this result provides the first evidence of a pathophysiological regulation of aph b/c expression. an approach to knockdown adipocyte expression of aph b/c is in progress. the analysis of the consequences of this manipulation on csecretase activity, notch signalling and the biology of the adipocyte will help assess the importance of the alteration of c-secretase composition during adipocyte differentiation. background and aim: certain legumes and barley kernels may favorably modify metabolic risk parameters in semi-acute studies in healthy subjects. this investigation assessed the medium-term effect of a diet combining specific legume and whole grain barley products on markers associated with the metabolic syndrome (mets) in mature women. design and methods: randomized crossover intervention in women ( - years-old, bmi - , normal fasting glycemia), comparing a diet rich in kernel-based barley products, brown beans and chickpeas (d ) with a control diet (d ) of similar macronutrient composition but lacking legumes and barley. d included g (as eaten)/day legumes, g whole grain barley kernels and g barley kernel bread. both diets followed the nordic nutrition recommendations and provided similar amounts of dietary fiber ( . g/day, d ; . g/ day, d ), with wheat-based products as main fiber supplier in d . each diet was consumed for week under weight-maintenance conditions. blood lipids, glucose, insulin, crp, gamma-glutamyl transferase (ggt) and blood pressure were the measured outcomes. results: both diets decreased serum cholesterol fractions, but d had greater effect (p < . ) on total and ldl-cholesterol (changes from baseline: À % and À %, respectively) than d . d also reduced ggt (À %, p < . ), diastolic blood pressure (À %, p < . ) and the framingham cardiovascular risk estimate (À %, p < . ), while d had no effect. methods: group i (n = )women with ms were examined proinflammatory cytokines polymorphisms, group ii (n = )testing for hereditary and acquired forms of thrombophilia. all subjects had the fetal loss syndrome, fetoplacental insufficiency, severe preeclampsia in previous pregnancies. results: group ipolymorphisms il- β - t/c in . %, il- - g/c-in . %, tumor necrosis factor-a - g/ain . % of cases. in ii group the multigenic defects were verified in % of cases; the feature of multigenic defects is that the g/ g polymorphism of plasminogen activator inhibitor- (pai- ) gene was found in . % of cases, the g/ g phenotype of the gene pai- was verified in . % of cases. the polymorphism in the tissue-type plasminogen activator i/d gene, in the angiotensin-converting enzyme i/d gene, in the fibrinogen g/a gene were found in . %, . %, . % respectively. acquired antiphospholipid antibodies were verified in . % of cases. all women received antithrombotic therapy from the fertile cycle involved low molecular-weight heparin (enoxaparin sodium, daily dose . - . ml), vitamins b, folic acid. pregnancy was achieved in %. there were not recurrent fetal loss, severe pre-eclampsia, placental abruption in the study groups. live births was in all cases. conclusions: we suggest that proinflammatory and thrombophilic status is an important pathogenetic factor of recurrent fetal loss, severe pre-eclampsia and other obstetric complications in women with ms. timely antithrombotic prophylaxis may be a key of successful outcome of pregnancy. the prescription of an individualized rehabilitation program based on the crossover point of substrate utilization (cop) could be particularly relevant in patients with metabolic syndrome (ms). the aim of the study was to examine: . the effects of a week rehabilitation program at an intensity corresponding to cop on the anthropometric characteristics of women with ms, and . these effects after a month follow-up period without supervision. nineteen women with ms ( . ae . years; . ae . kg; bmi = . ae ) performed an indirect calorimetry test to determine their cop and then participated in a supervised rehabilitation program ( min/week at cop on cycle-ergometer over weeks). afterward, they were instructed to continue to practice a physical activity without supervision over months. the target exercise intensity at cop was . ae . % maximal aerobic power. mass, body mass index, waist and hip circumferences, waist-hip ratio, relative fat mass and fat-free mass were significantly decreased whereas energy balance was significantly increased after the rehabilitation program. there were no significant differences at the end vs. months after the rehabilitation program. two months after the rehabilitation program, only both circumferences, waist-hip ratio and energy balance were not significantly different from baseline values. an individualized rehabilitation program over weeks at cop allowed to improve the anthropometric characteristics in women with ms. however, although the energy balance remains unchanged during the month follow-up period, only the effects on circumferences are maintained months after the rehabilitation program. objective: hypoxia contributes to adipose tissue inflammation and fibrotic remodeling in obesity. we have recently shown that longchain n- polyunsaturated fatty acids (pufa) ameliorate adipose tissue inflammation in obese subjects. here we investigated, whether long-chain n- pufa also reduce adipose tissue hypoxia and may prevent adipose tissue remodeling. patients and methods: in a randomized controlled clinical trial we treated severely obese subjects (bmi > kg/m ) with either . g/ day highly purified long-chain n- pufa or control for weeks. at the end of the treatment we sampled visceral and subcutaneous adipose tissue (vat and sat) during elective bariatric surgery. we quantified gene expression of hypoxia and fibrosis markers in tissue specimen by real-time quantitative rt-pcr. statistical analyses were performed by one-way anova. results: adipose tissue gene expression of hif a correlated positively with cd expression, a m macrophage marker and expression of both genes was significantly reduced after n- pufa treatment in sat (p < . ). furthermore, hif a expression correlated negatively with the anti-inflammatory fatty acid index in the treatment group. n- pufa significantly downregulated the pro-fibrotic markers tgfb, mmp and col a in sat. conclusions: mitigation of adipose tissue inflammation by n- pufa is paralleled by the amelioration of hypoxia and prevention of tissue remodeling as estimated by marker gene expression. these data emphasize beneficial effects of high-dose n- pufa in obesity. biochemistry, university of medicine and pharmacy "carol davila", faculty of medicine, university "titu maiorescu", delta hospital, nidnmd "n.c. paulescu," bucharest, romania background and aim: the diabetes "epidemic" nowadays appeared at the same time with the obesity "epidemic", their relationship being a causal one. weight gain cannot be conceived without a good sensitivity to insulin. all three paraoxonases have antioxidant properties. these protect vascular tissues from oxidative damage by modulating the effects of the main actors in the atherosclerotic process, namely the hdl and ldl particles and the macrophage. in this study we aimed to investigate the role of paraoxoanse (pon ) in the relationship between obesity and type diabetes. materials and methods: ten obese patients with type diabetes mellitus were compared with non-diabetic obese subjects. we determined the pon in preadipocytes cells obtained from bariatric interventions and in differentiated adipocytes (day , , , , ) . elisa method was used for leptin and adiponectin measurements. results: the obesity antropometric markers (waist and hip circumference, visceral fat index) were positively correlated with the value for leptin and negatively with the value for adiponectin (p < . ). the intracellular pon tented to be lower with the degree of diferentiation and these was associated with adipokines changes both in serum and cell lysates. conclusion: resuming our data, we presume that pon is present in pre/adipocytes and could be implicated in prevention of type diabetes obesity associated complications. acknowledgements: this work was supported by a grant of the romanian national authority for scientific research, cncs-uefiscdi, project numer pn-ii-id-pce- - - ". dr. lixandru was supported by the postdoctoral program posdru/ / . /s/ , from european social fund. . the effects of a week individualized rehabilitation program (irp) coached at an intensity corresponding to the crossover point of substrate utilization (cop) on hqrol, peak of oxygen uptake (vo peak ) and power out peak (p peak ); . the effects on hqrol after a month follow-up period without coach. nineteen women with metsyn ( . ae . years; . ae . kg) performed a test to exhaustion to estimate the vo peak and p peak , and an indirect calorimetry test to determine their cop used during a irp ( min/week) on cycle-ergometer over weeks. afterward, they were instructed to continue their physical activity without coach over months. vo peak and p peak were increased after the irp (p < . ). hrqol were no different in every domain at the end and months after the irp. only the question about their change of health compared to year ago has improved but it was at the verge of significativity (p = . ). women with metsyn undergoing irp coached at cop improved vo peak and p peak, but showed no improvement in hrqol after a week coached irp nor after the month follow-up period without coach. consequently, physical fitness seems not be associated with self-perceived quality of life in women with metsyn. t.b. domagala , k. kotula-horowitz , r. januszek , m. janczura , j. zagajewski , j. musial micronized fenofibrate ( mg/day) for months. fifty cardiovascular risk male volunteers (mean age years) with no prior myocardial infarction or stroke were enrolled as the controls. brachial fmd and homocysteine levels were measured at baseline and after months. the respective groups also differed in: bmi (p < . ), plasma total (p = . ), hdl cholesterol (p = . ) and triglycerides (p = . ), but not in baseline plasma homocysteine levels ( . ae . vs. . ae . lmol/l; p = ns). at baseline, mean brachial fmd were lower in the subjects with metabolic syndrome ( . ae . % vs. . ae . %; p < . ). in those subjects fenofibrate therapy significantly improved fmd ( . ae . % vs. . ae . %; p < . ) and increased plasma homocysteine levels ( . ae . vs. . ae . lmol/l; p < . ). no such differences were noted in the controls, neither before nor after months. conclusions: fenofibrates improve endothelium-dependent fmd of the brachial artery, irrespective of the simultaneously induced hiperhomocysteinemia. a. picu , l. petcu , d. lixandru , i. stoian , c. cristescu , e. rusu , c. ionescu-tirgoviste nidnmd "n.c. paulescu", biochemistry, university of medicine and pharmacy "carol davila", "titu maiorescu" university, bucharest, romania background and aims: oxidative stress leading to macrophage foam cell formation is the hallmark of the early atherosclerotic lesion. the aim of these study was to assess the relationship between clinical, biochemical and oxidative stress risk factors with obesity in newly diagnosed type diabetes (n-dm). materials and methods: one hundred and forty-five patients with n-dm registered in the nidnmd ambulatory, "n.c.paulescu" and healthy volunteers were included. the n-dm patients were divided into two subgroups according to the bmi (body mass index): group overweight (bmi = . - . kg/m²) and group -obese (bmi ! kg/m²). in circulating monocytes, the ability to produce free radicals vs. their neutralizing capacity was determined by measuring nadph oxidase activity (respiratory burst; rb) and intracellular activity of pon . we also determined the serum leptin and adiponectine by elisa, total antioxidant capacity (teac) and the concentration of non-protein thiols (shneproteic) by spectrophotometric methods. results: in diabetic patients vs. normal subjects, leptin, proinsulin and rb were increased (p < . ), while adiponectin and pon decreased (p < . ). the differences were accentuated in the obese group. the strongest correlation was between proinsulin and leptin (r = . , p < . ) and both contribute for the high cardiovascular risk in type diabetes. our results showed imbalance pro/antioxidant of obese diabetic patients, low pon activity and increased rb being influenced by the degree of obesity. introduction: cardio-protective role of human hdl-associated serum paraoxonase (pon ) is believed to be due, at least partly, to its antioxidative properties. pon activity is genetically determined by major polymorphism q r. brachial flow-mediated dilation (fmd) is a non-invasive physiological measurement used to quantify endothelial dysfunction. fibrates are known to exert hypolipidemic effects, while their effect on pon activity remains unclear. aim: to assess pon activity and fmd in the subjects with metabolic syndrome on fenofibrate treatment. methods: forty male subjects (mean age years) with hipertriglicerydemia, as well as metabolic syndrome, were treated with micronized fenofibrate ( mg/day) for months. pon activity in serum and brachial fmd were measured at baseline and after months. pon q r polymorphism was determined by pcr amplification and restricted digestion; serum pon activity was assayed spectrophotometrically. results there were subjects with qq genotype (group a) and carriers of r allele (group b). at baseline both groups differed in pon activity only ( ae vs. ae u/l; p < . ). fenofibrate treatment reduced pon activity in all subjects, nonetheless significantly in those with qq genotype ( ae vs. ae u/l; p = . ), unlike in the r allele carriers (p = ns). at baseline mean brachial fmd did not differ between groups a and b. fenofibrate therapy significantly improved fmd ( . ae . % vs. . ae . %; p = . ) in group a subjects, unlike group b ( . ae . % vs. . ae . %; p = ns). this study was to investigate the effect of nicotine on insulin sensitivity and explore the underlying mechanisms. treatment of sprague-dawley rats with nicotine ( mg/kg/day) for weeks significantly reduced blood insulin level but had no effect on blood glucose level. both insulin tolerance test and glucose tolerance test demonstrated that nicotine treatment enhanced insulin sensitivity. pretreatment of rats with hexamethonium ( mg/kg/day) to antagonize peripheral nicotinic receptors except for a nicotinic acetylcholine receptor (a -nachr) had no effect on the insulin sensitizing effect of nicotine. however, the insulin sensitizing effect of nicotine was totally abrogated in a -nachr knockout mice, indicating the involvement of a -nachr. further, chronic treatment with pnu- ( . mg/kg/day), a selective a -nachr agonist, significantly enhanced insulin sensitivity not only in normal mice but also in amp-activated kinase-a knockout mice, an animal model of insulin resistance with no sign of inflammation. moreover, pnu- treatment enhanced phosphorylation of signal transducer and activator of transcription (stat ), a molecule involved in regulating insulin signaling, in skeletal muscle, adipose tissue and liver in normal mice. pnu- treatment also improved glucose uptake in c c myotubes and this effect was totally abrogated by stat inhibitor, s i- . all together, these findings indicate that nicotine enhances insulin sensitivity in animals with or without insulin resistance, at least in part via stimulation of a -nachr-stat pathway independent of inflammation. our results not only contribute to the understanding of the pharmacological effects of nicotine, but also identify new therapeutic targets against insulin resistance and type diabetes. calorie restriction (cr) is one of the most reproducible treatments for weight loss and slowing aging. however, how cr induces these alterations is still unclear. this study was designed to understand whether nicotinamide phosphoribosyltransferase (nampt, also known as visfatin) plays a role in the beneficial effects induced by cr using a specific chemical inhibitor of nampt (fk ). sprague-dawley rats were treated for weeks in four groups: ad libitum (al), cr, al + fk and cr + fk groups. al and al + fk animals were allowed unlimited access to standard chow, while the cr and cr + fk animals were restricted to % of the food intake consumed by al and al + fk animals. fk ( mg/kg/ day) was given via drinking water. we found cr upregulated nampt mrna and protein levels in rat skeletal muscle and white adipose tissue. inhibition of nampt did not affect the sirt upregulation by cr but suppressed the cr-induced sirt activity and deacetylation of foxo- . furthermore, inhibition of nampt not only weakened the cr-induced decrease of oxidative stress (ros, superoxide o À˙a nd mda levels), but also greatly abolished the crinduced improvements of anti-oxidative activity (total-sod, gsh and gsh/gssg ratio) and mitochondrial biogenesis. in addition, inhibition of nampt blocked the cr-induced insulin sensitization, akt signaling activation and enos phosphorylation. collectively, our data demonstrate that cr-induced beneficial effects in oxidative stress, mitochondrial biogenesis and insulin sensitivity require functional nampt. background: the anti-diabetic effect of camel milk (cmk) gained increasing recognition in folk medicine and recent clinical and experimental studies. however, the mechanism(s) by which cmk influence the glucose homeostasis is yet unclear. objectives: to investigate the effects of cmk on the blood glucose regulatory mechanisms in control and diabetic animals. materials and methods: experimental diabetes was induced by intrapertional injection of streptozotocin in wistar rats divided into (d & d-cmk) groups. two healthy (c& c-ckm) groups served as control. camel milk ( ml/rat/day) was administered orally to the (d-cmk) and (c-cmk) groups for weeks. the (d) and (c) groups received no treatment. the changes in body weight, blood glucose, glucose tolerance, serum insulin, blood lipids, incretin hormones (glp- and gip), tnf-a, tgf-β , homa-ir and atherogenic index (ai) were investigated. results: the untreated diabetic animals (d-group) exhibited significant hyperglycemia, hyperlipidemia, increased homa-ir and ai, elevated serum icretins, tnf-a and tgf-β levels. this was associated with weight loss and high mortality. camel milk administration to the d-cmk group inhibited the weight loss and mortality and caused significant hypoglycemia, hypolipidemia, insulin secretion, low homa-ir and ai. serum glp- and gip levels show significant elevation but tnf-a and tgf-β were reduced. conclusion: augmented insulin release and decreased insulin resistance together with enhanced incretin hormones release are anticipated to contribute to the anti-diabetic effect of cmk. besides, the peculiar composition of cmk and its anti-inflammatory properties propose it as a valuable adjuvant anti-diabetic therapy. however large-sized clinical studies are still needed. prediabetics reflect dysregulation in glucose homeostasis with obesity is known risk factor in western countries. different degree of obesity contribution toward prediabetics is observed in lean populations. aim: to investigate the role of plasma leptin as a predictor of prediabetics in lean subjects. method: plasma leptin were measured in non-diabetic subjects aged - years old with bmi < . prediabetes (n = ) was defined based on fasting plasma glucose and -h oral glucose tolerance test. plasma leptin were measured in all subjects using commercial elisa kit. binary logistic regressions were used to estimate the age and sex adjusted odds ratio of leptin and other metabolic parameters. results: plasma leptin levels were significantly and positively correlated with bmi, percent total body fat, fasting plasma insulin and blood sugar and homa-ir values. plasma leptin were significantly higher in lean prediabetics ( . ae . ) compared to euglycemic lean subjects ( . ae . ; p < . ). increase in plasma leptin value by one increases the risk of prediabetics with or . ( % ci: . - . ). discussion: in a population of relatively lean and non-diabetic subjects, plasma leptin levels were associated with insulin resistance and prediabetes. furthermore, plasma leptin levels increases risk of prediabetics in non-obese subjects independent of age and sex. our data suggest that leptin as biomarker for screening individuals at high risk for prediabetes in lean population. f. al-zadjali, r. bayoumi latest update from the international diabetes federation shows that the prevalence of type diabetes (t dm) in the arabian gulf countries is among the top worldwide. the rapid increase in t dm prevalence in these countries suggests that psychological and behavioral factors, more than genetic factors, are primarily responsible for this trend. aim: to estimate heritability of plasma levels of adipocytokines in a large isolated arab pedigree. method: blood samples and anthropometric data were obtained from a large arab pedigree of individuals with high level of consanguinity. plasma levels of il- , il- b, leptin, total adiponectin, svcam- were measured using commercial kits. heritability parameters were measured using measured genotype analysis. results: fout hundred and sixty-nine individuals were structured in a large pedigree which consisted of interrelated nuclear families founded by founders. the heritability values were adjusted using age and gender as covariates. percentage of variation of plasma adipocytokines attributed to genetic factors were as following: leptin ( %), total adiponectin ( %), il- b ( %), il- ( %) and svcam- ( %). discussion: adipocytokines play central role in the development of t dm. our data shows high degree of heritability of leptin, il- and svcam- indicating their production is under tight genetic control. furthermore, our heritability values are different from previously reported heritability values of these adipocytkines studied in different ethnic populations. therefore, our results suggests that arab population are distinct and further genetic association and behavioral studies should be conducted for better understanding of the nature of t dm and its increasing trend in middle-east region. results: all treatments were well tolerated and no subjects was withdrawn from the study. compared to the baseline, the group treated with chrome picolinate only experienced a mild but significant decrease in fpg (À . ae . mg/dl). compared to the baseline, the group treated with chrome picolinate-berberine experienced a mild but significant decrease in bmi (À . ae . kg/m ), tc (À . ae . mg/dl), tg (À . ae . mg/dl), non-hdl cholesterol (À . ae . mg/dl), and fpg (À . ae . mg/dl). compared to the baseline, the group treated with chrome picolinate-berberine-banaba experienced a significant reduction in bmi (À . ae . kg/m ), waist circumference (À . ae . cm), sbp (À . ae . mmhg), tc (À . ae . mg/dl), tg (À . ae . mg/dl), ldl-c (À . ae . mg/dl), non-hdl cholesterol (À . ae . mg/dl), fpg (À . ae . mg/dl), insulin (À . ae . mu/l), homa index (À . ae . ) and hba c (À . ae . %), while hdl-c increased (+ . ae . mg/dl). waist circumference, sbp, ldl-c, hdl-c, insulin, homa index and hba c, also significantly improved when compared with other groups. the tested combined nutraceutical appears to significantly improve insulin-sensitivity and a large number of related parameters in subjects with ifg and metabolic syndrome. antioxidative mechanisms prevent human body from the damaging action of free radicals and reactive oxygen species. glutathione and related to it enzyme systems detoxicate h o and hyperoxide and from there, reduced glutathione is a potential marker of oxidative stress level. purpose: to investigete glutathione of erythrocytes in patients with prediabetes (igt and ifg) and type diabetes. matherial and methods: we examined patients with t d and concomitant coronary heart disease (chd) and atherosclerosis (group ), patients with prediabetes (igt and ifg) newly diagnosed and the same co-morbidity (group ) and almost healthy person (group ). examinations included clinical laboratory evaluation, fasting glicose, hba c. total glutathione (gsht) and oxidized glutathione (gssg) were measered by use of glutathione reductase reaction. redox potential (e h ) of glutathione was evaluated by use of nernst equation. results: concentrations of gsht and gsh were greater in group to compare with groups and (by . times, p = . and by . times, p = . respectively). inrease of concentration of gssg in group may change extracellular redox condition. calculation of e h revealed its change to oxidized condition in group to compare with group ( . mv greater) and group ( . mv greater). conclusion: antioxidant defense in red-cells is overactivated during prediabetes (igt and ifg) with concomitant chd and atherosclerosis while in patients with t d was noticed depletion of compensatory mechanisms with increased gssg and e h . reduction in gsh/gssg suggests that intracellular antioxidant is lost; herewith cells become sensitive to oxidative stress. clozapine increases meal size and meal duration, effects similar to the pharmacological blockade or congenital deficiency of cck- (cck- r) receptor. we aimed to investigate the role of cck- r in clozapine-induced weight gain (wg) and insulin sensitivity (is) in cck- r deficient, male otsuka long evans tokushima fatty rats (oletf). long evans tokushima otsuka (leto) rats served as healthy control. animals were orally treated with either clozapine or its vehicle over days. daily food intake was measured by means of metabolic cages. the is was determined by hyperinsulinemic euglycemic glucose clamping (hegc). hypothalamic mrna expression of cck- r and cck- r was measured by real-time pcr, plasma insulin was determined by radioimmunoassay. clozapine failed to induce wg or increment in food intake in either oletf or leto rats. the fasting plasma insulin and blood glucose level was significantly higher in oletf than in leto rats, but clozapine failed to modify these parameters. the glucose infusion rate during the steady state of the hegc was lower in oletf than in leto rats and clozapine did not modify it. the insulin sensitivity index (isi) was lower in oletf rats than in leto and the isi was further decreased by clozapine. the metabolic clearance rate of insulin changed parallel with isi indicating the possible source of the surplus of insulin, which is responsible for the decrement in is. clozapine induced insulin resistance without hyperphagia and wg in male leto and oletf rats. changes in cck- r and cck- r expression were inconsistent with the changes in the isi. clinical biochemistry & immunology, peterborough and stamford nhsft, peterborough, uk the national institute for clinical evidence has published guidelines for the treatment of prediabetes. these stress diet and exercise as shown by the dpp study a decade ago. however, recently published dpp follow-up data show how difficult it is for patients to follow that advice long-term. metformin was also found to be effective and is cheap and generally well-tolerated. this study shows the long-term effectiveness of routine metformin use in patients with igt. all patients attending two rural lipid clinics from who were found to have igt after a standard g ogtt were offered metformin mg bd or given diet and exercise advice if they did not wish medication. metformin was preferred over diet and exercise despite being shown to be inferior in dpp because of the extra cardiovascular benefits shown in ukpds. in , after a mean (range) follow-up of . ( . - . ) years, it was decided to review the data to see if the (off-label) treatment was effective. metformin significantly reduced t dm threefold after years ( % v %). further, it was possible to estimate that metformin could prevent / ever becoming diabetic (p = . ). the effect was due to restoring normoglycymia (fbg < . mmol/l) as the patients' weights and triglyceride levels did not change significantly. patients regularly present to lipidologists with fasting hypertriglyceridaemia. those with igt appear particularly likely to revert to normoglycaemia with metformin. routine use of this inexpensive and well-tolerated drug reduces the lifetime risk of developing t dm by over %. k. salehzadeh, m. shirmohammad zadeh azarbaijan shahid madani university, tabriz, iran as a fermented drink probiotic doogh [ ] can help promote the health of the society. studying crp [ ] changes as an important inflammatory index that predicts coronary-heart diseases such as arteriosclerosis has received attention in medical and nutrition studies. the present study was carried out to study the effects of week drinking different types of dough (probiotic and plain) on the changes of liver crp and other blood factors of male athletes with normal weight. the research sample of this study included healthy male athlete students with equal bmi characteristics that were divided into two testing groups ( each) and were homogenized and randomly divided and went through some exercises. the results of the paired t test showed that drinking plain doogh resulted in significant reduction of blood's urea ( . %) and crp ( . %) and significant increase of hdl ( . %; p < . ). the probiotic doogh also resulted in significant reduction of crp ( . %) and significant increase of hdl ( . %). the comparison of the two groups showed that the only statistically significant difference was in the amount of crp and the reduction effect of probiotic doogh on crp was more compared to the plain doogh (p < . ). also the amount of record changes in the probiotic group (À s) was significantly better than the plain doogh (+ s). background and aims: nutrition has significant effects on human health and diseases. diabetes is a chronic disease that can be affect by nutritional status. therefore, monitoring of nutritional status in these patients is one of the main components of prevention and controlling of complications. therefore, in this study the nutritional status of patients that referred to health center in songhor city was assessed. materials and methods: this descriptiveanalytical study was done on patients with type diabetes ( ae years old) with no insulin therapy. anthropometric mesearments and dietary intake assessment were done. ffq and three recall quessionare were filled with face to face interview. n software were used for analysis. mean ae sd of variables were reported. background: the aetiology of type diabetes and obesity may involve dysregulation of brain appetite control networks. we explored the impact of systemic insulin resistance, common to both conditions, on the effect of meal ingestion on brain responses to food cues. methods: eight insulin resistant (ir, homa -ir . ae . ) and insulin sensitive (is, homa -ir . ae . ) non-obese non-diabetic right-handed men were studied twice, min after consuming ml water (fasted) or kcal mixed meal (fed) in random order. brain responses upon viewing high (hc) and low (lc) calorie food images vs. non-food object (nf) and gaussian blurred (gb) images presented in a block design paradigm were measured using blood oxygenation level dependent functional magnetic resonance imaging. results: the meal reduced hunger (f = . , p = . ) and increased fullness (f = . , p < . ). meal ingestion had no specific impact on responses to lc in either group. in contrast, on viewing hc, there were decreased precuneus responses (vs. gb and nf) and superior temporal gyrus/insula responses to hc (vs. nf) in ir subjects, whilst in is subjects, meal ingestion increased responses to hc (vs. gb) in somatosensory cortex and to all food images vs. gb in putamen/insula, with a trend towards increased dorsolateral prefrontal cortex activity. conclusions: meal ingestion augmented activity in brain regions involved in sensation, interoception and inhibitory control in is subjects during food cue exposure. by diminishing activity in regions involved in imagery and interoception, insulin resistance may influence central appetite control networks to promote further eating after consuming a satiating meal. methods: we examined children with obesity in the endocrinological department of university hospital (minsk) over the year . the number of boys (b) ( . %), mean ae sd age . ae . years; girls (g) ( . %), mean ae sd age . ae years (p = . ). ultrasound (u/s) of the abdominal cavity; the levels of insulin (i); total cholesterol (tc); triglycerides (tg); high-density (hdlc), low-density (ldlc), very low-density (vldlc) lipoprotein cholesterol; atherogenic coefficient (ac); standart oral glucose tolerance test (ogtt) with the calculation of homa-ir and caro indexes; the levels of blood pressure (bp) and body mass index (bmi) were held to all patients. results: sds bmi b was . ae . , g . ae . (p = . ). bp more than th percentile was in ( . %) b and ( %) g (p = . ). the signs of steatohepatosis were determined in ( . %)b, ( %)g. the average levels of tc and tg were in normal limits, gender differenses weren′t noted (p = . ), (p = . ). the concentration of vldlc . ae . mmol/l ( . - . ), . ae . (p = . ). hdlc b and ldlc b didn′t exceed normal limits in boys and girls (p = . ), (p = . ). ac b . ae . ( - ), g . ae . (p = . ). basal and postprandial plasma glucose levels didn′t exceed normal limits regardless of gender (p = . ), (p = . ). the levels of i b . ae . mu/ml ( . - ), g . ae . (p = . ). homa-ir b . ae (< . ), g . ae (p = . ), caro . ae . (> . ), . ae . (p = . ). conclusions: obesity in children was accompanied with arterial hypertension, steatohepatosis and dyslipidemia. the development of insulin resistance with maintaining the basal and postrandial normoglycemia was noted by conducting ogtt in all patients regardless of gender. objective: to evaluate the effect of short-term, moderately high-fat diets on body weight, lipid profile and serum leptin levels. the study was undertaken to create a model with an acute metabolic stress without marked obesity. design: the laboratory mice were fed either a moderately high-fat diet or control diet. body weight, energy intake, body composition, and fasting plasma leptin were compared after and week of dietary treatment. results: after week, abdominal fat mass was % greater in mice fed the high-fat diet than in those fed the control diet (p < . ). however, plasma leptin concentrations did not change much in animals fed the high-fat diet. from to week, animals fed the highfat diet gained weight twice the normal diet group and consumed kj/day more than controls (both p < . ). at week, plasma leptin concentrations per unit abdominal fat mass were % lower in mice fed the high-fat diet (p = . ) and there was a significant negative association between leptin concentrations per unit abdominal fat mass and body weight (r = . , p < . ). conclusions: feeding for weeks moderately high-fat diet is associated with lower than expected circulating leptin concentrations, which correlate with a higher body weight. a high-fat diet may therefore contribute to weight gain by reducing leptin secretion in adipose tissue. the significance of these findings will be discussed. objective: to describe diabetes-related risk factors associated with lower respiratory tract infection (pneumonia) complications among children. methods: we obtained claims data on all hospital admissions to acute care hospitals for children patients with diabetes and pneumonia who were aged - years in bosnia and herzegovina and sarajevo between november , , and november , . these data are checked for accuracy and validity by the pulmologist and diabetologist pediatricians that oversee data collection. in both data sets, we linked diabetic kids patient charts to allow for calculation of previous admission and rehospitalization diabetic kids rates with complications of pneumonia in children. children prescribed more than one antibiotic class contributed to determining the rates of each class. objectives: to examine the extent to which adherence with multiple concomitant healthy lifestyle traits will be associated with the avoidance of the future development of t d. methods: five independent cohorts comprising , men and , women aged - and free of diabetes and cvd at baseline were examined in , , , objective: to investigate the effects of raloxifene on the insulin sensitivity and lipid profile in insulin sensitive and insulin resistant postmenopausal women. study design: this placebo-controlled, double-blind, randomized study involved postmenopausal women aged between and years. all subjects were screened with the insulin resistance homeostasis model assessment (ir-homa) and those patients in the lowest quartile (n = ) were assigned as insulin sensitive and those in the highest quartile as insulin resistant (n = ). patients in both groups received either raloxifene hydrochloride ( mg/day) or a placebo, for a period of weeks. insulin sensitivity, the serum lipid profile, and anthropometric measurements were established before and after therapy. results: women with the highest ir-homa scores were associated with a significantly higher weight, body mass index, waist, and waistto-hip ratio (p < . ). raloxifene significantly reduced the ir-homa scores from . ae . to . ae . (p = . ) and modified the lipid profile in insulin resistant patients when compared to the placebo group and those patients receiving raloxifene in the insulin sensitive group. conclusion: raloxifene reduced insulin resistance and modified the lipid profile in insulin resistant postmenopausal women. diseases, smoking, alcohol consumption, the use of sleeping pills and other potential confounders was also gathered. statistical analyses were done by spss ver. . the average age of the participants was . years old; % was reported current pet ownership. mean hba c was . %, bmi was , and systolic and diastolic blood pressure was and mmhg respectively. pet owners were significantly younger and slightly more overweight; and dog owners were much younger and more overweight than cat owners. in unadjusted analyses, dog owners had a lower rate of taking sleeping tablets than cat owners (p = . %), and dog owners were more likely to be smokers than cat owners (p = . %). however, pet ownership was not associated with hba c, systolic or diastolic blood pressure, bmi, or the prevalence of diabetic complications. conclusions: our results suggest that pet ownership may be associated with insomnia and smoking habits. however, pet ownership is not independently associated with control of diabetes, obesity and prevalence of diabetic complications. objectives: to non-invasively assess the muscular oxygenation response using near-infrared spectroscopy (nirs) and to determine the association between increasing levels of a c and oxygenation response in subjects with type diabetes. materials and methods: forty-five subjects with uncomplicated type diabetes were categorized into two groups: group i (a c < ) and group ii (a c ! ). nirs measurement of vastus lateralis was performed at rest and during a symptom-limited maximal treadmill exercise test to determine muscular oxygenation response. at rest and during peak exercise, deoxygenated hemoglobin (deoxy-hb), oxygenated hemoglobin (oxy-hb) and total hemoglobin (total-hb) were measured with characteristics of light absorptance from nirs. muscle saturation (%) was expressed as the ratio of oxy-hb to total hb volume, an index of tissue de-oxygenation. results: group i subjects (n = with females, . ae . years) were older than subjects in group ii (n = with females, aged . ae . years). the peak vo was comparable between groups. significant lower muscle saturation ( . ae . % vs. . ae . %, p < . ) and more decline (À . ae . % vs. À . ae . %, p < . ) at peak exercise, was noted in group ii. a significant correlation between a c and decline of saturation (r = À . , p < . ) was noted in this study, whereas no other significance were demonstrated in deoxy-hb or oxy-hb. conclusions: this study provided evidence of imbalance of oxygen supply to exercising muscle in asymptomatic and uncomplicated diabetic subjects with elevated a c levels. the insufficient perfusion occurred before vasculopathy and might develop metabolic impairments even myopathy in diabetic subjects with poor glycemic control. study design and method: the lifestyle intervention was conducted as a cluster randomized trial (n = ) in semi-urban setting in sri lanka. the intervention group ( ) received a family centered lifestyle intervention package from family health workers while the control group ( ) received a brief advice from a doctor. duration of the study was -months. results: this study has shown effectiveness in reduction in fasting blood glucose (p < . ), systolic blood pressure (p = . ), diastolic blood pressure (p = . ), weight (p = . ), added sugar (p = . ) and fat consumption (p < . ) while improving physical activity (p < . ) and insulin sensitivity (p < . ) in the intervention group when compared with the control group at follow up assessment. this lifestyle intervention sessions ( ) were carried out by family health workers during their routine house visits. aim: we aimed to compare an experimental type diabetic animal model generated by applying high fat diet combined with single shot of streptozotocin (stz) at mg/kg bw sprague-dawley (sd) rats. methods: we generated and selected rats based on fasting glucose, oral glucose tolerance, and %hba c. once sever type diabetic rats were identified, serum proteins were subjected to d-dige proteomics or comparative d-proteomics after phosphorylation or glycation. results: seven protein targets differentially expressed in severe type diabetic rats (st d) were identified as albumin, vitamin d-binding protein precursor, and transthyretin, respectively. in terms of serum proteins extracted by affinity columns for phosphorylation and glycation, the affinity of phosphorylated protein targets and glycated protein targets were modified under st d condition. results of the ingenuity pathway analysis (ipa) for those targets indicated that antigen presentation, humoral immune response, and inflammatory response are associated networks highly modified in st d group. kidney and liver damages under those st d rats were proposed by ipa and validated by histopathology. polymorphism of patatin-like phospholipase- (pnpla ) has been associated with susceptibility to non-alcoholic fatty liver disease (nafld); whereas genetic studies of nafld in asian indians are not investigated. we investigated the association of polymorphism rs of pnpla with clinical, anthropometric and biochemical profiles in asian indians with nafld. methods: in this case-control study, cases and controls were recruited. abdominal ultrasound, clinical, anthropometry and biochemical profiles were determined. fasting insulin levels and value of homeostasis model assessment of insulin resistance (homa-ir) was determined. polymerase chain reaction and restriction fragment length polymorphism of pnpla gene was performed. the associations of this polymorphism with clinical, anthropometric and biochemical profiles were investigated. results: higher frequency of c/g and g/g genotypes of rs polymorphism was obtained in cases as compared to controls (p = . ), as a consequence frequency of the minor allele g was significantly higher in cases (p = . ). the c/g+g/g genotypes was associated with significantly higher fasting insulin (p = . ), homa-ir (p = . ), alanine transaminase (p = . ) and aspartate transaminase (p = . ). using a multivariate logistic regression model after adjusting for age, sex, body mass index and fasting insulin, subjects with g/g genotype showed higher risk of nafld (or, . , % ci: . - . , p = . ). results: group ; before diet: bg- . ae . mmol/l; months on diet: ae . mmol/l ( . - . mmol/l) months: . ae . mmol/l ( . - . mmol/l); histology: marked necrosis and destruction of bcells on - % islet's surface in islets from ( %); in % not marked necrobiosis or without changes; decreasing of insulin content in b-cells: ig- . ae . (intact- . ae . ); histology: without changes; group : before diet: bg- . ae . mmol/l; months on diet + vitamin b : -bg- . ae . ( . - . mmol/l); months diet + vitamin b : bg- . ae . mmol/l ( . - . mmol/l); histology: partial necro-biosis on - % islet surface in islets from ( %); in other % -without changes; ig- . ae . (intact- . ae . ). conclusions: . months prolonged administration of vitamin b result not marked decreasing of insulin content in b-cells of animals contained on diabetogenic diet and treated by pyridoxin but not protect b-cells of part islets of necrobiosis. aim of this study: to determine the behavior of oxidative stress markers and mitocondrial dysfuncton in non-proliferative diabetic retinopathy. patients and methods: a cross-sectional study was designed with four groups: group : healthy-volunteer subjects. group : patients with mild-non-proliferative diabetic retinopathy (npdr). group : patients with moderate-npdr. group : patients with severe-npdr. serum oxidative stress markers: lipid-peroxidation (lpo measured by malondialdehyde and -hidroxyalkenals), nitric oxide (no metabolites measured by nitrites/nitrates), total antioxidant capacity (tac), activities of antioxidant-scavenger-enzymes in erythrocytes (gpx glutathione-peroxidase and catalase), and mitochondrial dysfunction (expressed in erythrocyte/platelet membrane fluidity and platelet hydrolytic activity of adenosine-thriphosphatase enzyme; atpase). the markers were quantified by colorimetric method. results: patients with npdr had a significant increased serum lpo and no metabolites levels compared to the group . the tac in patients with npdr had a significant decreased compared to the control group. a significant increased in the activities of gpx, catalase and atpase was shown in the experimental groups compared to healthy-volunteer subjects. a significant reduction was shown in membrane fluidity in patients with npdr. the results show that oxidative stress and mitochondrial dysfunction are associated to npdr and its severity. background: weight loss after rous-y gastric bypass (rygb) surgery is associated with alteration of body composition and visceral fat mobilization. we analyzed the amount of fat and fat-free mass reduction in order to identify factors that induce more favorable adiposity change. methods: morbidly obese patients (age = ae years) underwent rygb between september and july . anthropometry, dual-energy x-ray absorptiometry (dexa), computed tomography (ct), life style report, and laboratory test results were registered prior to and year after rygb. results: follow-up rate was . %. dexa demonstrated . ae . of %ffml (percentage of weight lost as fat-free mass) with reduction of % of total fat amount. ct demonstrated higher rate of visceral adipose tissue (vat) reduction rather than subcutaneous adipose tissue with . of %dv/%ds (percentage change in vat vs. sat). patients with diabetes mellitus preoperatively showed more favorable visceral fat reduction (%dv/%ds were . in dm and . in non-dm) even though they lost more fat-free mass. objective: prader-willi syndrome (pws), a genetic disorder characterized by childhood-onset obesity, is reported to have elevated levels of adiponectin. the actions of adiponectin are mediated by adiponectin receptors (adipors) which include adipor and adipor . several cytokines such as adiponectin, tnf-a, and il- , have been known to be involved in insulin sensitivity. methods: thirty pws children (median age . year, boys, girls) who were being receiving growth hormone (gh) therapy and obese children not receiving gh therapy (median age . year, boys, girls) were compared. the relative expression of adiponectin, adipors, several proinflammatory cytokines including tnf-a, and il- measured in peripheral blood mononuclear cells (pbmcs) using real-time pcr. their correlation was analyzed by homeostasis model assessment insulin resistance index (homa-ir). the pws children showed increased expression of adipor (p = . ) and decreased expression of il- (p = . ) compared to the obese children. there was a significant positive correlation between the adipors and tnf-a (adipor vs. tnf-a: r = . , p < . in pws, r = . , p < . in control group; adipor vs. tnf-a: r = . , p < . in obese group). the adipors in the obese group showed significant negative correlation with homa-ir (adipor vs. homa-ir; q = . , p = . , adipor vs. homa-ir; q = . , p < . ). conclusion: in result, inflammatory cytokine expression was closely associated with the expression of the adipors in the pbmcs of both the children with pws and the obese group. adipor expression was highly expressed in the pbmcs of the children with pws. august to november , homeostasis model assessment of insulin resistance (homa-r) were calculated. as a control, subjects were selected, who received oral glucose tolerance test (ogtt) between the same period showing normal glucose tolerance pattern. we used mann-whitney u-test and p-values < . were considered statistically significant. results: there was no significant difference in sex, age ( . ae . vs. . ae . ), bmi ( . ae . vs. . ae . ), hba c ( . ae . vs. . ae . ) and fasting plasma glucose level ( . ae . vs. . ae . ) between the gd group (n = : two males and four females) and control group (n = : one male and five females). the gd group showed significantly higher homa-r than control group ( . ae . vs. . ae . , p < . ). discussion: this study showed that gd patients with normal thyroid function had insulin resistance independent of bmi and hba c. conclusion: gd, even in euthyroid state, is associated with insulin resistance. introduction: it is still remain uninvestigated the correlation of prebiotics and leptin and ghrelin level in frame of inflammatory process in liver. aims and methods: the aim of our study was investigation of nifuroxazide and prebiotic therapy influence on leptin and ghrelin levels in nonalcoholic fatty liver disease patients. determination of leptin and ghrelin (elisa), insulin, il -β, tnf-a were performed in all patients. results: n = patients, female, age ae years, bmi ae kg/m . nafld in %, nash in % and ir in %. leptin was higher in women ( . ae . vs. . ae . ng/dl, p = . ), but ghrelin was similar ( . ae . vs. . ae . pg/ml). leptin positively correlated with bmi (r = . , p = . ) and ghrelin correlated (r = . , p = . ). ghrelin correlated with glycaemia (r = . , p = . ) and correlated to homa (r = . , p = . ). both hormones positively correlated to il -β and tnf-a (ghrelin: r = . , p = . ; r = . , p = . , respectively; leptin: r = . , p = . ; r = , p = . , respectively). prebiotic (npc bic) consumption significantly decreased ghrelin, insulin, il -β, tnf-a level and had no influence on leptin level. the results of liver biopsy (histological examination) and fibromax test showed, that in patients additionally treated by prebiotics, the progress of hepatic fibrosis was significantly slowly, then in cg (fibromax test result: f vs. f ; p < . ). conclusion: our data showed that nifuroxazide and prebiotic therapy decreased inflammation activity and ghrelin level in nafld. cardiology, physiology, medical university of białystok, bialystok, poland aim: ceramide (c) is considered to be an important factor reducing insulin sensitivity. the aim of the present study was to investigate the effect of reduction of the sphingolipid synthesis in the solid tissues on the level of c, and other bioactive sphingolipids, namely sphingosine- -pohosphate (s p) sphingosine (sp), sphinganine (sa) and sphinganine- -phosphate (sa p) in different blood compartments. the experiments were carried out on three groups of male wistar rats, - g of body weight fed ad libitum on a commercially available diet: (i) control, (ii)treated with myriocin (an inhibitor of sphingolipid de novo synthesis) and (iii) treated with nicotinic acid (it reduces the level of plasma free fatty acids). the level of the above mentioned bioactive sphingolipis was determined with the use of mass spectrometry. results: both treatments reduced profoundly the level of each of the examined compounds in the plasma. treatment with nicotinic acid did not affect the level of either compound in erythrocytes but reduced it to a great extend in the platelets. treatment with myriocin reduced the level of each compound, with the exception of sh, in erythrocytes. the compound reduced the level of each compound in the platelets to the level comparable to nicotinic acid. . the level of the examined sphingolipids in the plasma, erythrocytes and platelets depends thoroughly on their supply from solid tissues. . short-term reduction in the plasma free fatty acids level very efficiently reduces the level of bioactive sphingolipids in different blood compartments. background: maternal nutrition plays major role in fetal growth and development. low birth weight and impaired early postnatal growth predispose the offspring to an increased risk for future chronic diseases such as metabolic syndrome. stunting in south african children has previously been documented. the study aimed to investigate effects of maternal nutrition on fetal and early postnatal growth in the population of black urban pregnant south african women, employing ffq, ultrasound and anthropometry measurements. results: based on the z-scores (at birth, weeks and month), babies in the current study were born lighter (À . ) and shorter (À . ) with larger head circumference (+ . ) in comparison with the who child growth standards. the z-scores for both the weight and the lengthfor-age decreased after birth with subsequent increase at months, being significant for length (À . , p = . ) after birth and for weight (+ . , p < . ) at months. maternal intake of polyunsaturated fat in early pregnancy and of total protein in late pregnancy were found associated with the fetal head-to-abdomen circumference (β = À . , p = . and β = À . , p < . respectively) and with the lengthfor-age z-score at weeks (β = . , p = . and β = . , p = . respectively). early plant protein intake significantly correlated with fetal growth rate (β = . , p = . ). conclusion: low maternal pregnancy intake of protein, namely of plant protein, and of polyunsaturated fat affected fetal linear growth, and resulted in a possible "brain sparing effect" in fetus. maternal dietary manipulation during pregnancy may therefore affect fetal and postnatal growth and thus modulate the risk of chronic disease later in life. aims and methods: to assess the efficacy of hb in cp patients in a two centre randomised, double-blind, placebo-controlled, crossover trial. one hundred and twenty-six patients with chronic pancreatitis were exposed to screening blood tests and test of elastase in stool before randomization to placebo or hb (buscopan, boehringer ingelheim) for weeks. all patients followed the basic treatment scheme include dietary and physical regimen. drug effect was optimized by dose titration during weeks - starting at mg daily, increasing (max mg t.d.s) or decreasing as required. methods: brown beans, or white wheat bread (wwb, reference product) were provided as evening meals to healthy young adults in a randomized crossover design. markers of glucose-and appetite regulation, glp- , and markers of inflammation were measured at a following standardized breakfast, i.e. - h after the evening meals. colonic fermentation activity was estimated from measurement of plasma short chain fatty acids (scfa) and breath hydrogen (h ) excretion. results: an evening meal of brown beans, in comparison with wwb, lowered blood glucose (À %, p < . )-and insulin (À %, p < . ) responses, increased satiety hormones (pyy %, p < . ), suppressed hunger hormones (ghrelin: À %, p < . ), and hunger sensations (À %, p = . ), increased glp- ( . %, p < . ) and suppressed inflammatory markers (il- À %, and il- À . %, p < . ) at a subsequent standardized breakfast. breath h ( %, p < . ) and plasma scfa (propionate % and isobutyrate %, p < . ) were significantly increased after brown beans. results: the present study revealed significantly lower levels of adiponectin in diabetic children compared to the controls ( . ae . vs. . ae . lg/ml). it also showed significantly increased carotid intima media thickness (cimt) in diabetic children compared to the control group ( . ae . vs. . ae . mm). there was also positive correlation between the mean cimt and age of the patient, age of onset of diabetes mellitus, hba c, and bmi measurements in diabetic children. there was negative correlation between mean cimt and adiponectin level. conclusions: subclinical microvascular disease in type diabetes mellitus begins early in diabetic children, which emphasize the importance of early detection and control of vascular risks in diabetic children. the study also suggests that adiponectin may prove to be useful marker of cardiovascular risks, and potential therapeutic target for risk prevention in diabetics. in overweight and obese individuals ( f/ m; age ae years, bmi = ae kg/m ). an intra-venous glucose tolerance test, hyperinsulinaemic-euglycaemic clamp and circulating markers relevant to age signalling were performed before and after each diet. results: the high age diet was fivefold higher in age content than the low age diet. the high age diet reduced insulin sensitivity by À . mg/kg/min ( % ci, À . to À . ; p = . ) while the low age diet improved insulin sensitivity by + . mg/kg/min (+ . to + . ; p = . ). the overall change in insulin sensitivity was . mg/ kg/min ( . - . , p = . ). the change insulin secretion was correlated inversely with the change in plasma age (cml) concentration (r = À . , p = . ). to investigate the level of transforming growth factor (tgfbl) and basic fibroblast growth factor (bfgf), non-specific markers of inflammation: interleukin- (il- ), tumor necrosis factor-a (tnf-a) in patients with coronary heart disease (chd) depending on the presence of dm . the study involved people: one group À patients with chd without carbohydrate metabolism disorders, two group - patients with dm and chd. blood samples were taken from the cubital vein and the aorta during coronary angiography. . )], as in arterial and venous blood in the presence of chd and dm (p < . ). . availability dm in patients with chd was associated with significant increase in the level of tgfb , il- . these observation reflect the effect of chronic hyperglycemia on the restructuring of the connective tissue and the vascular wall. . tgfb direct correlation with lipid markers confirms the relationship of connective tissue disorders and lipid metabolism in the pathogenesis of atherosclerosis. obesity can be induced with high fat diets (hfd) and is associated with inflammation in white adipose tissue (wat) and liver. the factors that control the early metabolic responses to hfd and that trigger inflammatory gene expression are only poorly understood. a time-resolved analysis of differentially expressed genes in expanding adipose tissue of mice ( weeks hfd feeding) identified specific clusters of lipid metabolism-related genes and inflammation-related genes with similar time expression profiles. subsequent promoter analysis of the clustered genes revealed that specific master regulators (among which fos, esr , hnf a, jun, ppara, pparg, nr h /lxrb, nfkb, srebf and , sfpi , smad , sp ) orchestrate metabolic adaptations and early inflammatory responses in wat. some of these transcription factors (esr , jun, fos, pparg, sp ) have a dual role and regulate the adjustment of lipid metabolism as well as expression of inflammatory genes such as cxcl /kc, ccl /rantes, complement factors, asc, granzyme a ccl /rantes, ccl , ccl /mcp . subsequent analysis of corresponding livers revealed comparable molecular responses on the level of transcription factors. more specifically, many master regulators identified in wat were also involved in the liver response to hfd as demonstrated by analysis of hepatic target gene expression in conjunction with transcription factor binding activity analysis. our findings support the view that metabolic and inflammatory processes are interlinked in wat and liver, and that responses to hfd are controlled in a similar way on the transcription factor level. distortions of the mechanisms which control metabolic homeostasis in these organs may thus also affect their inflammatory tone. aim: to investigate the effects of iptakalim, a novel sur b/kir . type atp-sensitive potassium channel opener, on endothelial dysfunction induced by insulin resistance (ir) and to determine whether iptakalim improved ir associated with hypertension in fructose-fed rats (ffrs) and spontaneously hypertensive rats (shrs). methods: the levels of endothelial vasoactive mediators and enos protein expression were determined usingelisas or western blot. in both ffrs and shrs, hyperinsulinemic-euglycemic clamp was used to evaluate ir states. . cultured human umbilical vein endothelial cells (huvecs) incubated with the pi -kinase inhibitor wortmannin ( nmol/l) and insulin ( nmol/l) induced endothelial dysfunction characterized by reduced release of no and expression of enos protein, and increased production of et- . pretreatment with iptakalim ( . - lmol/l) could potently prevent the endothelial dysfunction by increasing no production and inhibiting et- release. . in ffrs, the levels of sbp, fasting plasma glucose and insulin were elevated, whereas the glucose infusion rate (gir) and insulin sensitive index (isi) were significantly decreased, and the endothelium-dependent vascular relaxation response to ach was also impaired. these changes could be prevented by administration of iptakalim for weeks. the imbalance between serum no and et- was also ameliorated by iptakalim. . in - month-old shrs (ir was established at the age of months), oral administration of iptakalim for weeks significantly ameliorated hypertension and increased the gir to the normal level. conclusion: iptakalim could protect against ir-induced endothelial dysfunction, and ameliorate ir associated with hypertension, via restoring the balance between no and et- signaling. m. ste z pie n , a. ste z pie n , r.n. wlazeł , m. paradowski , m. banach , j. rysz material and methods: patients (f , m ) were divided according to bmi into three groups: a-obesity i (n = ); b-obesity ii (n = ) and c-obesity iii (n = ) and into other four groups: females and males and patients treated with statins or fibrates (n = ) or untreated (n = ). results: leptin was significantly higher in group c compared to group a and b [ . ( . - . ) vs. . ( . - . ) ng/ml, p < . and vs. . ( . - . ) ng/ml, p < . respectively]; hs-crp were higher in group c than in group a [ . ( . - . ) vs. . ( . - . ) mg/ l, p < . ]. adiponectin and leptin were higher in females [ . ( . - . ) vs. . ( . - . ), p < . and . ( . - . ) vs. . ( . - . ), p < . , respectively]. resistin, hs-crp and il- were higher in untreated patients' group [ . ( . - . ) vs. . ( . - . ) ng/ ml, p < . ; . ( . - . ) vs. . ( . - . ) mg/l, p < . and . ( . - . ) vs. . ( . - . ) pg/ml, p < . respectively]. leptin positively correlated with hs-crp in the whole population (r = . , p < . ), in treated patients' group (r = . , p < . ) and with tnf-a in group c (r = . , p = . ). conclusions: leptin may be associated with chronic inflammation in obese hypertensive patients. serum leptin and adiponectin levels are sex dependent. hypolipemic treatment has impact on chronic inflammation and resistin. lean body mass in genetically obese (ob/ob) or anorectic/cachectic subjects is severely reduced. similar outcomes of two different pathological states prompted us to wonder if leptin, adipokine well known from its control of appetite interacts with myogenesis. apparently, recombinant leptin ( ng/ml) stimulated dna synthesis in mononuclear myoblasts together with the increase of t /y p-erk / protein expression levels. additionally, leptin reduced cell viability and muscle fiber formation from c c mouse myoblasts. detailed short-and long-term examination with the use of metabolic inhibitors revealed that both jak/stat and mek/mapk but not pi -k/akt/gsk- beta signaling pathways were stimulated by leptin, and that stat (y p-stat ) and mek (t /y p-erk / ) control these effects. in turn, insulin promoted pi -k-dependent phosphorylation of akt (s ) and gsk- beta (s ) and insulin overruled leptin-dependent inhibition of myogenic differentiation in pi -k-dependent manner. gsk- beta might play dual role in muscle development. insulin-induced effect on gsk- beta (s p-gsk- beta) facilitated myotube formation. in contrast, leptin through mekdependent manner led to gsk- beta phosphorylation (y p-gsk- beta) with resultant retardation of myoblast fusion. in summary, to some extent opposite effects of insulin and leptin on skeletal muscle development emphasize the importance of intercellular signaling between adipose tissue and skeletal muscle. insulin and leptin determine how muscle mass is gained or lost, respectively. objective: obesity is linked to both increased metabolic disturbances and increased adipose tissue macrophage infiltration. however, whether macrophage infiltration directly influences human metabolism is unclear. the aim of this study was to investigate if there are obesity-independent links between adipose tissue macrophages and metabolic disturbances. methods: expression of macrophage markers in adipose tissue was analyzed by dna microarrays in the sos sib pair study and in patients with type diabetes and a bmi-matched healthy control group. results: the expression of macrophage markers in adipose tissue was increased in obesity and associated with several metabolic and anthropometric measurements. after adjustment for bmi, the expression remained associated with insulin sensitivity, serum levels of insulin, c-peptide, high density lipoprotein cholesterol (hdl-cholesterol) and triglycerides. in addition, the expression of most macrophage markers was significantly increased in patients with type diabetes compared to the control group. conclusion: our study shows that infiltration of macrophages in human adipose tissue, estimated by the expression of macrophage markers, is increased in subjects with obesity and diabetes and associated with insulin sensitivity and serum lipid levels independent of bmi. this indicate that adipose tissue macrophages may contribute to the development of insulin resistance and dyslipidemia. hp gene has been demonstrated to be a major determinant of susceptibility to cvd and in the development and progression of dn. hp allele is defective in its ability to protect against oxidative stress cvd and dn. we decide to assess the intracellular localization of iron in the pctcells and its potential toxicity in the development and progression of dn. methods: wild type c b / mice have only an hp allele. we genetically engineered a murine hp allele and inderted it in the murine hp locus by homologous recombinatiobn. we induced dm, by stz for days, at weeks of age we assessed lysosomal membrane integrity, redox-active iron in kidney lysosomes. . increased iron-rich deposits in lysosomes of pct cells in hp - dm vs. hp - dm ( ae % of all lysosomes) compared with hp - dm mice ( ae % of all lysosomes, p < . ). . intralysosomal redox-active iron concentrations are markedly increased in hp - dm mouse kidneys lysosomes of hp - dm mice ( . ae . lmol/l) as compared with those from hp - dm mice ( . ae . lmol/l, p = . ). lysosomal membrane lipid peroxides are increased in hp - dm proximal tubule cell (p < . ). vitamin e supplementation resulted in a % reduction in lysosomal redox-active iron in hp - dm mice (p < . ). conclusion: a novel mechanism whereby the hp genotype may predispose to renal injury in the setting of dm via increased iron deposition in the lysosomes of pct. purpose: we aimed to use other less hazardous route of insulin injection to prevent pharmacokinetic problems of sc insulin and find out response categories in diabetics and prediabetic patients. besides, fbs and hba c are markers for treatment evaluation; we wondered whether aitt could be a marker of residual pancreatic activity regeneration or decelerating progression of type ii diabetes. methods: five hundred diabetic and patients with impaired glucose tolerance were enrolled to this trial. three hours after breakfast they receive - unit equivalents of insulin into the external auditory cannel. blood glucose level was measured every min for h. this was repeated months later in both groups; while prediabetic patients received some sorts of therapy while the other patients remained on their previous lifestyle. auc and best fit curve were evaluated by partial mathematical integration. results: six different prototypic curves were extrapolated from diabetic patients with the possibility of excellent theoretic explanations about etiology and multifactoriality, lifestyle change, drug(s) of choice and prognosis. parallel to this prediabetic patients showed comparable curves. the area under curve in treated prediabetics showed a small but significant reduction compared to untreated ( vs. , p = . ). conclusions: as shown elsewhere the area under curve after an auditory insulin tolerance test is a nice marker in diabetes response evaluation and prognosis and an excellent marker for progression to diabetes and effectiveness of treatment in prediabetics (< compared to > ). introduction: type ii dm is generally regarded as a progressive disease with control of bs becoming more difficult with time. we wondered whether optimal therapy with "mega-treatments" that can let the pancreas rest could reverse the disease. materials and methods: thirty five patients received optimal doses of insulin through the auditory channel for months. contributing factors such as obesity, anxiety, h. pylori infection and reduced physical activity were treated appropriately. at beginning and every month they were evaluated by way of auditory insulin tolerance test after h of drug vacation. the general appearance of the curve, the partial integration of it and the overall area under curve were compared monthly. results: auc declined from a mean of - from first to sixth month meaning reduced insulin resistance (p < . ). this decline was steady during the whole months and minor variations in different patients were not significant. with mathematical calculation it seems very unlikely that this decline becomes asymptotic so that on extension of the curve for - years at least % of the patients eventually fall into the nondiabetic range with auc under . (p < . ) although different definitions exist for dm, auditory insulin tolerance test might be functionally more illuminating. these results are in concordance with available literature that denotes early aggressive treatment might be better. we add to this notion that early aggressive treatment can possibly reverse type ii diabetes. physiology, universidad de guadalajara, guadalajara, mexico background: c-reactive protein (crp) is an acute stage protein whose serum levels become raise by infection or because an undergoing metabolism disruption. our group has found crp variable serum levels in hypertensive patients that course with obesity and dyslipidaemia. the crp polymorphism rs g>a has been associated to lowered crp serum levels in autoimmune diseases. the role of c-reactive protein (crp), a marker and mediator of inflammation, in the pathogenesis of metabolic syndrome and its complications such as non-alcoholic fatty liver disease (nafld) remains to be elucidate. in this study we investigated whether increased levels of human crp itself can promote increase of glucose and lipid metabolism disorders associated with metabolic syndrome. materials and methods: spontaneously hypertensive rats (shr) with transgenic expression of human crp gene under apolipoprotein e promoter (shr-tg) in age -year and age matched non-transgenic shr controls were used. both groups were fed a high fructose diet ( % cal fructose) for weeks. parameters of insulin resistance and oxidative stress were measured by commercially available kits. results: transgenic expression of crp was associated with significant increase of serum triacylglycerols ( . ae . vs. . ae . mmol/l, p < . ) and insulin levels (p < . ), markedly decrease in insulin stimulated c-glucose incorporation into muscle glycogen ( ae vs. ae nmol/g/ h, p < . ), reduced serum adiponectin ( . ae . vs. . ae . mmol/l, p < . ), and microalbuminuria (p < . ). transgenic expression of crp was associated with increased liver triglyceride concentrations ( . ae . vs. . ae . lmol/g, p < . ), decreased liver glutathione peroxidase activity (p < . ) and reduced glutathione concentration (p < . ). liver lipidperoxidation were elevated in shr-tg rats: tbars (p < . ). conclusion: overexpression of human crp induced insulin resistance, oxidative stress and liver steatosis in shr rats. these finding indicate that chronically inflammation might directly contribute to the pathogenesis of metabolic syndrome and nafld. one of the most topical issues of modern pediatrics is obesity in children and adolescents, which has a tendency to doubling every three decades in almost all countries. the aim of our research was to investigate the fatty acid composition of the blood in children with obesity. patients and method: we investigated children aged from to years, divided into two groups: group i - children ( % boys and % girls) who are overweight or obese (bmi . ae . kg/ m ), group ii - persons ( % boys and % girls) with normal body weight (bmi . ae . kg/m ). research methods: quantitation of omega- and omega- polyunsaturated fatty acids, determination of the total amount of fatty acids, the total content of eicosapentaenoic and docosahexaenoic acids by gas chromatography with mass selective detection and determination of the omega- index (the ratio of the sum of eicosapentaenoic and docosahexaenoic acids to total content of fatty acids in %). results: there was a direct correlation between the value of bmi and the increasing of omega- index and the omega- pufas in children with obesity, while for the children with normal body weight the connection of bmi with the change of the fatty acid composition of blood was not obtained. thus changes of the quantitative and qualitative fatty acid composition of blood in obesity children and adolescents had multidirectional nature and require further dynamic study. a. kopp, a. schmid, m. mü ller, a. schä ffler internal medicine i, university hospital regensburg, regensburg, germany introduction: proteins secreted by adipocytes (adipokines) play an important role in the pathophysiology of type diabetes mellitus and the associated chronic and low-grade state of inflammation. it was the aim to characterize the anti-inflammatory potential of the new adipokine, c q/tnf-related protein- (ctrp- ), which shows structural homologies to the pleiotropic adipokine adiponectin. in earlier studies, recombinant ctrp- has been shown to inhibit lps and lauric acid induced release of pro-inflammatory cytokines and chemokines dose-dependently in monocytes and adipocytes. methods: for in vivo analysis, male c bl/ mice were treated by intraperitoneal lps administration for h. anti-inflammatory effects were tested by pre-treatment ( min) with ctrp- . after killing, epididymal adipose tissue was collected for cytokine mrna expression analysis (real-time rt-pcr) and blood for measurements of circulating cytokine levels (elisa). the anti-inflammatory potential previously found in vitro is also seen in lps-treated c bl/ mice. animals pre-treated with ctrp- have lower levels of inflammatory cytokines such as interleukin- (il- ) and macrophage inflammatory protein- (mip- ). furthermore, mrna expression of il- and mip- in the epididymal adipose tissue is significantly reduced by ctrp- . conclusion: ctrp- acts anti-inflammatory in cells and tissues that are involved in obesity and type diabetes mellitus. therefore, it might be an interesting drug target in treating obesity-related chronic inflammation. objective: the aim of the study was to assess the burden of some metabolic syndrome (ms) risk factors in polish adolescents from two less-urbanized regions as well as the relationship between abdominal obesity, dyslipidemia and hypertension incidence. the study involved adolescents aged - . all subjects lived in two less-urbanized regions of poland (small towns and villages in the central and north-eastern regions). the concentration in blood of triglycerides (tg) and hdl-cholesterol (hdl-c), as well as systolic blood pressure (sbp) and waist-to-height ratio (whtr) were determined. using logistics regression, an odds ratio (or) of the incidence of high whtr ( ! percentiles), high tg ( ! mg/dl), high spb (> percentiles) and low hdl-c (boys: < mg/dl; girls: < mg/dl) was calculated. results: high whtr was found in % of adolescents, high tg in %, high spb in % and low hdl-c in %. adolescents with abdominal obesity (whtr ! percentiles) had an or rated as high spb at . ( % ci = . - . ; p < . ), an or rated as high tg at . ( % ci = . - . ; p > . ) and an or rated as low hdl-c at . ( % ci = . - . ; p > . ) in comparison to adolescents with normal whtr (between and percentiles). adolescents from north-eastern poland had an or rated as high spb at . ( % ci = . - . ; p < . ) and an or rated as high tg at . ( % ci = . - . ; p < . ) in comparison with the central region (or = . ). conclusions: dyslipidemia and hypertension were the main metabolic syndrome risk factors in polish adolescents from less-urbanized regions, especially in central poland. the risk of hypertension rose over times in adolescents with abdominal obesity. objective and aims: as employment has become more sedentary in nature, there is a potential for more working individuals to be at risk of developing the metabolic syndrome (mets). physical activity (pa) is recommended for prevention of such chronic conditions. this study investigates self-reported pa and presence of mets in the workplace as part of the established "prosiect sir gâr" initiative in south wales, uk. methods: two hundred and twenty-one male steel workers (sw) and male local health board (lhb) employees were screened and their data analysed. anthropometric data, blood pressure and self-reported physical activity (gppaq) were all recorded alongside obtained blood samples which were subsequently analysed for high-density-lipoprotein cholesterol (hdl-c). presence of the mets was determined based on the following idf criteria: central obesity (waist circumference: ! cm), reduced hdl-c levels (< . mmol/l) and either systolic ( ! mmhg) or diastolic ( ! mmhg) hypertension. results: the proportion of males diagnosed with mets was comparable between worksites (sw: . % vs. lhb: . %; p = . ) despite the sw reporting being more physically "active" or "moderately active" than their lhb counterparts ( . % vs. . %; p < . ). central obesity, reduced hdl-c levels and diastolic hypertension were comparable between worksites (p > . ), although systolic hypertension was higher amongst lhb employees ( . % vs. . %; p < . ). however, more sw were found to be clinically obese ( . % vs. . %; p = . ). introduction: diabetes mellitus is often a silent disease and its prevalence is increasing rapidly worldwide. nonalcoholic steatohepatitis is certainly the less estimated complication of diabetes in frequency and severity. the aim of our study was to evaluate the prevalence of steatohepatitis and to identify its clinical and biological risk factors. materials and methods: the prospective transversal study was comparative between type diabetics (group ) and healthy people (group ) with no chronic hepatopatic diseases, no alcoholism and no intake of hepatotoxic drugs. all have benefit from a clinical exam, biological assay and abdominal echography seeking for steatohepatitis. results: group has statistically a higher frequency of android obesity, insulin resistance, steatohepatitis, high blood pressure, hypertriglyceridemia, chronic inflammation and silent myocardial ischemia in comparison with group . the steatohepatitis was present in % of patients vs. . % of healthy people; p < . . also, patients from group with steatohepatitis (group a) had a body mass index (bmi), waist circumference, a percentage of fat mass, a level of triglycerides, of alanine aminotransferase (alat) higher than diabetics without steatohepatitis (group b), with a risk of metabolic syndrome multiplied by three. with multivariate analysis, we found that in group , alat and bmi were directly associated to steaohepatitis. our study notifies the frequency of steatohepatitis in diabetics. it could be prevented and treated by loss of weight and regular physical activity in order to reduce insulin resistance. objectives: vascular dysfunction and complications are the major cause of mortality in diabetic patients. arterial stiffness has been known as a useful predictor of atherosclerosis and lipoprotein level is one of major risk factors of atherosclerosis. to investigate the association of lipoprotein level with arterial stiffness, we studied the vascular characteristics of patients with diabetes. methods: fifty patients (male:female = : , mean age . ae . years), with diabetes and without coronary artery disease, were enrolled and evaluated. all patients have been taking angiotensin receptor blocker or angiotensin converting enzyme inhibitor. arterial stiffness was assessed by measuring the carotid-radial pulse wave velocity (pwv). the cardiovascular risk factors, including body mass index, lipid profile, pulse pressure, c-reactive protein, flow-mediated vasodilatation (fmd) were also measured. the pwv was significantly higher in patients with metabolic syndrome than those without metabolic syndrome ( ae vs. ae cm/s, p = . ) in diabetic patients. multivariate analysis revealed that hdl cholesterol level, body mass index and metabolic syndrome were highly associated with pwv (p = . ). pulse pressure, crp, hdl cholesterol level and metabolic syndrome were significantly associated with fmd. conclusion: in diabetic patients, metabolic syndrome and hdl cholesterol level were highly associated with arterial stiffness and fmd as in non-diabetic patients. objective: our goal was to compare a weight loss diet with high caloric intake during breakfast to an isocaloric diet with high caloric intake at dinner. research design and methods: obese women (bmi . ae . kg/m ) with metabolic syndrome were randomized into two isocaloric (~ kcal) weight loss groups, a breakfast (bf; kcal breakfast, kcal lunch, kcal dinner) or a dinner (d) group ( kcal breakfast, kcal lunch, kcal dinner) for weeks. anthropometric measurements, oral glucose tolerance test (ogtt) and meal tests were performed. the bf group showed greater weight loss (À . ae . vs. À . ae . kg) and waist circumference reduction (À . ae . vs. À . ae . cm) compared with the d group. although fasting glucose, insulin and ghrelin were reduced in both groups, fasting glucose, insulin and homa-ir decreased significantly to a greater extent in the bf group. mean triglyceride levels decreased by . % in the bf group, but increased by . % in the d group. after ogtt, the extent of reduction of aucglucose and aucinsulin was greater in the bf (À % and À %, respectively) compared with the d group (À % and À %, respectively). in response to meal challenges, the overall daily aucglucose aucinsulin, aucghrelin and mean hunger scores were significantly lower, whereas mean satiety scores were significantly higher in the bf group. conclusions: an isocaloric diet with switched caloric intake during breakfast or dinner differentially influences weight loss and metabolism. high-calorie breakfast with reduced intake at dinner might be a useful alternative for the management of obesity and metabolic syndrome. centre for biomedical sciences, cardiff metropolitan university, cardiff, uk introduction: we have reported that exercise alters markers of monocyte/macrophage polarisation in peripheral polymorphonuclear cells, decreasing the m :m marker ratio. since the m phenotype is considered "anti-atherosclerotic", this may be beneficial in reducing cardiovascular disease risk. this study aimed to determine whether exercise specifically promotes m marker expression in purified monocytes, and to elucidate the molecular mechanisms involved in this process. methods: twenty-six healthy, sedentary individuals ( ae years) participated in a low-intensity exercise programme (walking, min, thrice weekly for weeks). peripheral monocytes were isolated using magnetic immuno-separation, and gene expression was determined by rt-pcr. serum lipids, insulin and glucose levels were measured by standard biochemical methods. the presence of serum pparc ligands was determined by gene reporter assay. results: during the -week exercise programme, pparc ligand generation and cox- gene expression were increased [ . ae . -and . ae . -fold, respectively (p < . )]. similarly, pparc-dependent genes (e.g. cd ) and m marker (e.g. dectin- ) expression increased ( . ae . -(p < . ) and . ae . -fold (p < . ), respectively), while exercise-associated increases in pro-inflammatory m markers were blunted [e.g. mcp- . ae . -fold (p < . conclusion: low-intensity exercise may prime monocytes for differentiation into m -polarised macrophages (possibly via pparcdependent events) and contributes to improved insulin sensitivity. this data supports exercise prescription for the prevention and management of inflammatory-linked diseases such as atherosclerosis and diabetes. quantify and determine possible differences and their correlation with plasma leptin and ghrelin levels. for this study, male rats were underwent a case control study. the fecal bacteria composition was investigated by pcr-denaturing gradient gel electrophoresis and realtime qpcr. in restricted eaters, we have found a significant increase in the number of proteobacteria, bacteroides, clostridium, enteroccoco and prevotella and a significant decrease in the quantities of actinobacteria, firmicutes, bacteroidetes, b. coccoides-e. rectale group, lactobacillus and bifidobacterium with respect to unrestricted eaters. we also found a significant positive correlation between the quantity of bifidobacterium and lactobacillus and plasma leptin levels, and a significant and negative correlation among the number of clostridium, bacteroides and prevotella and plasma leptin levels in all the experimental groups. furthermore, plasma ghrelin levels were negatively correlated with the quantity of bifidobacterium, lactobacillus and b. coccoides-eubacterium rectale group and positively correlated with the number of bacteroides and prevotella. in conclusion, nutritional status and physical activity may have an impact on the gut microbiota composition affecting the diversity and similarity. the significant increase in the quantity of lactic acidproducing bacteria and butyrate-producing bacteria that would also implied an increase in their bacterial metabolites in the exercise rats without dietary restriction could be responsible of the plasma ghrelin levels decrease found in these rats which affect the food intake and the body weight. the aim of this study was to evaluate the relation between weight gain classified according to iom recommendations and macronutrient intake. methods: a cross-sectional study was conducted on women hospitalized in the maternity during august-september . prepregnancy weight was self-reported. gestational weight gain and weight rate gain was determined by means of the weight registered in the maternity before delivery. nutrient intake during pregnancy was evaluated with a -item food frequency questionnaire. results: on average, protein provided . % ( %ci: . - . ), carbohydrate . % ( %ci: . - . ) and fat . % ( % ci: . - . ) of the total energy intake. there was a positive and consistent association between energy intake and maternal weight gain among the pregnant women (p = . ). the percent of energy from protein was associated with maternal weight gain rate (p = . ). women with a weight gain higher then media + sd had a higher intake of protein compared with those with medium (p = . ) and lower (p = . ) weight rate gain. no significant differences regarding fats and carbohydrates intake was noted. similarily, women with weight gain above the iom recommendations had a significant higher protein intake compared with those with a lower weight gain (p = . ). conclusion: a strong association was found only between protein intake and weight gain in the studied sample. a dietary pattern analyses would clarify the relation with weight gain during pregnancy. excessive weight gain and obesity before pregnancy was associated with large for geastational age newborns and prematurity. the aim of the study was to analyse the relation between maternal anthropometric indicators and apgar score. a cross-sectional study was conducted on women hospitalized in the maternity during august-september . multiple pregnancy and obstetrical pathology represented exclusion criteria. self-reported weight was used to estimate prepregnancy bmi. gestational weight gain was determined by means of the weight registered in the maternity before delivery. apgar score was determined by the neonatologist immediately after birth. results: in the sample studied, . % newborn had an apgar score lower than , thus indicating neonatal distress. there weren't noticed significant differences according to weight gain during pregnancy. among the mothers with newborns which had an apgar score lower than , . % had a weight gain lower, . % higher and . % within the iom′ s recommendations. however, excessive prepregnancy weight was associated with neonatal distress (p = . ): . % of women with prepregnacy bmi ! kg/m ; . % of the normal weight and % of the underweight gave birth children with low apgar score. conclusion: prepregnancy excesive weight was associated with neonatal distress, strenghtening the importance of achieving an ideal weight before conception. patients and methods used: six obese women (age . ae . years, bmi . ae . kg/m ) had fasting metabolic measurements taken via indirect calorimetry before and after weeks of a low starch diet. respiratory gases were collected for min using standard procedures in order to determine resting metabolic rate (rmr), respiratory exchange ratio (rer), and macronutrient oxidation (carbohydrate and fat). a paired sample t-test was used to evaluate significant mean differences from pre-to post-diet. results: after weeks on a low starch diet, subjects lost an average of . ae . kg despite the fact that this was not designed as a weight loss diet. rer decreased from . ae . to . ae . (p = . ) from pre-to post-diet measurements. further, carbohydrate oxidation decreased from . ae . to . ae . g/min (p = . ), and fat oxidation increased from . ae . to . ae . g/min (p = . ). changes in rmr were not significantly different. background: weight loss improves insulin resistance and hyperandrogenism in obese women with pcos but is unnecessary in lean women with pcos; however, meal timing and composition may influence glucose metabolism and hyperandrogenism. objective: to investigate the effects of two isocaloric diets with different meal timing on insulin resistance and hyperandrogenism in lean women with pcos. methods: sixty lean women with pcos were randomized to one of two kcal isocaloric diets with different meal timing: the number of young adults with ms is steadily increasing, but ms in children mainly incomplete according to the pediatricians' reports. so it was suggested that there are some flaws in the diagnostic criteria that lead to ms hypodiagnosis. hypothesis: using the clarified criteria may improve quality of ms detection in children. methods: in obese adolescents the ms components were analyzed by idf and clarified criteria. additionally abdominal obesity was analyzed by bmi sd and waist to height ratio; glucose intolerance by ogtt and homa-ir; dyslipidemia by fasting tg, ldl, hdl, tc (according to percentiles by ncep for children); blood pressure by the fourth report on the diagnosis, evaluation and treatment of high blood pressure in children and adolescents. results: the total number of detected ms components by idf vs. clarified ones: " " in . ae . % by idf; " " in . ae . % vs. . ae . % (p < . ); " " in . ae . % vs. . ae . % (p < . ); " " - . ae . % vs. . ae . % (p = . ); " " in . ae . % vs. . ae . % (p < . ); " " in . ae . % vs. . ae . % (p < . ). conclusion: using clarified criteria improves the quality of ms detection in children, which corresponds to a ms global concept of identifying high cardiovascular risk group. aim: polycystic ovary syndrome (pcos) is the most common endocrinopathy among women of reproductive age. pcos is connected with ovulatory disorders, oligomenorrhea, hyperandrogenism, infertility, and an increased miscarriage rate, and is frequently associated with insulin resistance (ir). multiple factors in the follicular fluid affect the fertilization and early embryonic development, including in women with pcos. the aim of this study is to evaluate the predictive value of follicular adiponectine regarding pregnancy outcomes in pcos vs. non pcos patients who underwent in vitro fertilization. material/methods: we designed a prospective study. group : (n: ) non pcos and group : (n: ) pcos patients according to roterdam criteria were included the study. basal ovarian reserve parameters, endometrial thickness, follicular luid adiponectine levels, clinical and laboratory ivf outcomes, pregnancy rates were studied. results: there were statistically significant differences in used gonadotropine dose, total oocyte number, mii oocyte number in non pcos vs. pcos groups (p: . ). but there were no statisticaly significant differences between the groups according to follicular fluid adiponectine levels (p > . ). we evaluated the correlation with adiponectine and ivf outcomes as endometrial thickness, mii oocytes number, fertilization rates and pregnancy rates, but there were no statisticaly significant correlation (p > . ). we could not find differences of follicular fluid adiponectine levels in the pcos vs. non pcos groups. although we could not find correlation with adiponectine and pregnancy rates, further investigations with larger numbers of cases are needed to clarify this subject. hypothesis: using the clarified criteria may improve quality of cardiovascular risk (cvr) evaluation in pediatric group. methods: comparative ms components detection in obese children by idf and clarified criteria as well as prognostic value relative to the myocardial remodeling and diurnal blood pressure patterns. results: it was established that the idf criteria (> ) are highly specific (sp = . ), but low sensitive (se = . ) with deterioration negative predictive value (npv = . ). clarified criteria (sum score > ) correspond to higher sensitivity (se = . ) without loss of specificity (sp = . ). conclusion: using the clarified criteria improves screening sensitivity and helps determine exact cvr. obesity is a global problem associated with numerous health issues includes type diabetes. bariatric surgery provides sustained weight loss and partial or complete diabetes resolution. micrornas (approximately nucleotides long) are post transcription regulators, which play important roles in conditions such as obesity and diabetes. the aim of this study is to investigate whether microrna profile is changed by bariatric surgery in postprandial state and if the altered microrna expression could contribute to long term post bariatric surgery benefits. both bariatric and sham-operated rats were given g of food min before sacrifice. total plasma and tissue rna from post-operative bariatric and sham operated rats were isolated and the microrna component was examined. principle component analysis clearly showed that bariatric surgery dramatically changed circulating microrna expression. correlation between microrna expression and metabonomics data indicated that certain plasma metabolites (for example, ketone bodies) are highly correlated. we also investigated liver microrna expression, microrna targeted mrna and metabonomics profile. mirna regulated key metabolic enzymes and receptors involved in the tca cycle, pentose phosphate pathway, gluconeogenesis and amp-activated protein kinase pathway. liver alanine, pyruvate and glucose levels were altered in bariatric compared to sham-operated rats. in summary, our data show that bariatric surgery changed both circulating and tissue microrna expression. we suggest that these alterations contribute to post bariatric surgery benefits by regulating key metabolic enzymes and receptors. the purpose of the study was to investigate serum concentrations of the asymmetric (adma) and symmetric dimethylarginine (sdma) and high sensitivity c-reactive protein (hs-crp) in hyperuricemic adolescents. patients and methods: the study group consisted of hyperuricemic patients aged median . years. the control group (c) contained healthy individuals with normal serum uric acid (sua) level. serum adma and sdma were measured by immunoenzymatic elisa commercial kits and were expressed in lmol/l. serum hs-crp was determined using nephelometric method (behring) and expressed in mg/l, sua was measured on the hitachi apparatus. results: hyperuricemic patients showed increased sdma (median: . q -q ( . - . ) lmol/l vs. controls . q -q ( . - . ) lmol/l, p < . ). serum adma values did not differ between two estimated groups (p > . ). the positive correlation was observed between adma and sua (r = . , p < . ) and sdma with sua and hs-crp concentrations (r = . , p < . ; r = . , p < . , respectively). we demonstrated that in adolescents with hyperuricemia increased serum sdma, but not adma levels were observed. no significant differences for adma and sdma between hypertensive and normotensive patients with hyperuricemia were found. the large, multicentre, prospective studies are needed to confirm if sdma might play a role in chronic inflammation in patients with hyperuricemia. objective and aim: supplementation of n- polyunsaturated fatty acids expresses anti-diabetic effect by enhancing insulin sensitivity and improving lipid metabolism. in this study we wanted to assess whether supplementation of n- can improve antioxidant status, preferably pon level, in the serum of type diabetic (t dm) patients. subjects and methods: twenty t dm patients ( females, eight males, age . ae . years, bmi . ae . kg/m ) were randomized to intake g marine oil ( . g epa and dha) during weeks, after weeks washout period. anthropometry, blood pressure measurements and fasting blood samples for metabolic parameters (glucose, hba c, insulin, cholesterol, hdl-cholesterol, triglycerides), hscrp, as well as oxidative stress enzymes [pon- , catalase (cat), superoxide dismutase (sod), glutathione peroxidase (gsh-px)] were obtained before and after treatment period. results: serum pon- activity response was increased by % from . to . (p < . ) as well as sod from . to . (p < . ) by epa and dha supplementation. it was associated with serum n- pufa increase by % (p < . ). there were no changes in anthropometry, glycemic control, insulin resistance index, the levels of total cholesterol, triglycerides and parameter of chronic inflammation (hscrp). only hdl-cholesterol increased after supplementation, from . to . mmol/l, with borderline significance (p = . ). conclusion: supplementation with . g n- pufa improves antioxidative status, pon activity and sod level, and repairs dyslipidemia in t dm patients. aim of this study: to determine the behavior of endogenous antioxidants markers and metabolic profile in non-proliferative diabetic retinopathy patients and methods: a cross-sectional study was designed with four groups: group : five healthy-volunteer subjects. group : patients with mild non-proliferative diabetic retinopathy (npdr). group : patients with moderate npdr. group : patients with severe npdr. serum endogenous antioxidants markers (determined by ua and b), glycemic profile (measured by fasting plasma glucose and hemoglobin a c), lipid profile (measured by total colesterol, triglycerides, high and low density lipoproteins-cholesterol), arterial pressure, renal profile (urea and creatinine analysis). serum-markers were quantified using enzymatic-colorimetric methods. results: patients with npdr had a significant increased serum lipid profile, glycemic profile and renal profile levels compared to the control group. ua and b levels showed increased trend in retinopathy groups compared with group . introduction: bone tissue has been recognized as an endocrine organ. recently it′s been found that levels of osteocalcin, a protein produced by osteoblast, is associated with glucose metabolism and lipids in human being. experimental studies showed associations between adiposity and levels of osteocalcin, however in the adolescent population is not quiet elucidated. objective: to establish the association between adiposity indexes and serum levels of osteocalcin in children and adolescents. materials and methods: in this study we included children and adolescents participants of the project "health worker cohort study" adiposity index were establish through bmi, waist circumference and dexa. the total concentration of osteocalcin was determined by chemiluminescence. through multiple lineal regression we evaluated the association between osteocalcin levels and the adiposity index. results: prevalence of overweight and obesity was . % abdominal obesity . %. it was observed a negative correlation between bmi, percentage of fat mass, waist circumference (p < . ). independently of the adiposity index included in the model, have obesity increases the risk of presenting low levels of osteocalcin (or: . ; % ci: . - . , p < . ) and adolescents with higher percentage of fat mass have five times more risk than adolescents with less fat mass of present low levels of osteocalcin (or: . ; % ic: . - . , p < . ). conclusions: adolescents with higher adiposity have more probability of have low levels of osteocalcin. objective: to evaluate the association between physical activity (pa) with presence of burnout syndrome (bs) and its three dimensions: emotional exhaustion, despersonalization and low personal accomplishment in health workers and educational sector. methods: a sample of imss workers, insp and uaem was obtained. after signing informed consent subjects answer a lifestyle questionnaire that included a pa questions and the burnout scale designed by maslach. anthropometric measurements were performed by previously standardized personnel (concordance coefficient of . - . ), with conventional stadiometer and calibrated scales previously tanita brand. we determined body mass index (bmi) based on the criteria of the center for disease control (cdc). pa was considered sufficient to perform or more minutes of daily pa. the data analysis was performed in the stata statistical package version . results: from the analysis of health workers and educational study participants′ cohort health workers. "female sex predominated by %. the mean age was ae years. seven out of ten participants performed < min of pa per day. a trend of higher prevalence of bs in those performing < min of pa per day was showed, to perform ! min of pa reduces the likelihood of developing bs in a % according to grunfeld criteria and % according to the ramı´rez's criteria. conclusions: to perform at least min a day is a protective factor to avoid the presence of bs, but only three out of ten participants to perform af. aims: with research showing that more than one third of this current generation of australian teenagers likely to become obese in adulthood, the need to arm our children with the skills to maintain a healthy weight has never been so urgent. the need for feed cooking program has been developed for teenagers to improve their ability to prepare and cook healthy food, and boost their knowledge about nutrition and support them to develop healthy habits for the future. methods: need for feed is delivered using school facilities and home economics teachers, but is delivered outside of school hours in an informal and engaging format. the program, which delivers h of tuition, focuses on improving participants' food preparation and cooking skills, budgeting and meal planning, basic nutrition knowledge, and attitudes and behaviours associated with healthy eating. results: evaluation demonstrates that participants improve in both skills and confidence in preparing and cooking healthy food, improve their knowledge of healthy eating guidelines and make tangible changes to their eating habits through increased consumption of fruit and vegetables, and reduced consumption of sugary soft drinks, cakes, chocolate and potato chips. conclusion: while the factors contributing to the obesity epidemic and growing rates of type diabetes are complex, the importance of arming the community with skills and confidence in cooking at home is being increasingly recognised. this program has shown that teenagers can develop the necccessary skills to support healthy eating through a targeted and engaging cooking education program. postprandial hyperglycemia is an early defect of type diabetes and the one of primary antidiabetic targets. the therapeutic approach for the treatment of postprandial hyperglycemia can be achieved by inhibiting a-amylase and a-glucosidase, key enzymes for starch digestion and further glucose absorption. in this study, the inhibitory activities of microalgal fucoxanthin against a-amylase and aglucosidase were determined as well as antidiabetic effect to induce differentiation in t -l preadipocytes using oil red-o staining. fucoxanthin exhibited weak inhibitory activity against rat-intestinal aglucosidase, while strong inhibitory activity against pancreatic aamylase in a concentration-dependent manner with ic values of . mmol/l and lmol/l, respectively. microalgal fucoxanthin significantly increased glucose uptake in t -l cell by . % at lmol/l. fucoxanthin inhibited lipid accumulation during adipocyte differentiation of t -l cell and no cytotoxicity was recorded for preadipocytes up to lmol/l. these results suggested that fucoxanthin may be useful approach for the prevention of type diabetes by inhibiting carbohydrate-hydrolyzing enzymes. university of vermont, burlington, vt, usa aims: we compared the effects of ad libitum low-fat, high-fiber and low-carbohydrate diets on caloric intake, anthropometry, and cardiometabolic risk markers in adults with the metabolic syndrome. methods: twenty-three women and men ( - years) with the metabolic syndrome completed a randomized crossover comparison of two -week diets. all meals (low-fat, high-fiber: - % carbohydrate, - % fat, - % protein, - g fiber/day; low-carb: - % carbohydrate, - % fat, - % protein, - g fiber/day) were prepared by a research dietician and consumed ad libitum. results: caloric intake was lower on low-carb ( ae vs. ae kcal/day; p = . ). only low-carb reduced body fat (À . ae . %; p = . ) and tended to produce greater weight loss (À . ae . kg vs. À . ae . kg; p = . ). both diets reduced fasting insulin (À . % to À . %; p < . ) and non-hdl cholesterol (À . % to À . %; p < . ). low-fat, high-fiber reduced serum cholesterol (À . %), while triglycerides (À . %) and vldl cholesterol (À . %) were reduced on low-carb (all p < . ). plasma ffa were elevated on low-carb (+ . %; p = . ). although flow-mediated dilation (fmd) was unchanged after low-fat, high-fiber ( . ae . % vs. . ae . %; p = . ), a trend for reduced fmd was observed after low-carb ( . ae . % vs. . ae . %; p = . ), producing a significant diet interaction (p = . ). introduction: better insulin schedules are needed to prevent hypoglycemic attacks. materials and methods: bs/time curve was plotted in a series of diabetic patients with and without treatment. the best fit curve was used by partial integration and mathematical extrapolation. the first and second derivatives of these curves were plotted by the use of special software and modified matlab. points of major mathematical and lifestyle interest were marked within the curve for correlation. daily variations were also registered. based on mathematical results, patients received auditory insulin and were compared with themselves and other patients under the same dose of insulin. results: although the bs/time curve and its first derivative are completely chaotic due to daily activity and unplanned meal intake the second derivative has some regularities and in regard to cutting the x axis every lambda minutes ( min ( min under % confidence interval. this shows that the innate glucose reducing potential of the body is exhausted after this time giving us the opportunity to treat with lower doses at these points. with this schedule patients needed less insulin and showed extremely better bs control. conclusion: preventing superimposition of innate bs reducing potency and external drugs can give rise to smoother bs control and less hypoglycemic attacks. besides, this can also be exploited in the management of prediabetic patients. introduction: type ii dm is generally regarded as a progressive disease with control of bs becoming more difficult with time. we wondered whether optimal therapy of the disease with "megatreatments" that can let the pancreas rest could reverse the disease. materials and methods: ten patients received optimal doses of insulin through the auditory channel for months. they were previously on oral hypoglycemic agents and relatively in good control. their bs were measured daily for months during the oral regimens before and after the auditory instillation. these two sets of measurements in addition to other subjective and objective parameters such as weight, sense of well being and hba c were compared. results: insertion of a strict insulin regimen in the form of auditory insulin instillation between two intervals of the same oral hypoglycemic agents (sandwich effect) causes a significant improvement in glycemic control and possibly needed dose. conclusion: as fairly good controlled patients were selected there is probably no doubt that more strict control of bs can reverse type ii diabetes progression. we have postulated that rest of the pancreas in the form of auditory insulin or strict diet can restore normal pancreatic response in a later occasion. based on a mathematical model of extrapolation we suggested that strict bs control for - years with a mean bs of mg/dl and possibly no attacks above mg/dl can reverse type ii diabetes in at least % of the patients. the diabetes epidemic could be controlled with effective prevention programs. these programs require accurate identification of subjects at risk. unfortunately, current prediction models have several deficiencies and are not being used. we present results comparing a novel model using association rule mining (arm) against three traditional models applied to data from the electronic medical record (emr). we used a cohort of , adults olmsted county, mn, residents without diagnosis of diabetes who visited mayo clinic between and . we collected pertinent baseline characteristics available as structured data in the emr. we assessed -year incidence of diabetes; a total of subjects developed diabetes during the follow up period. we used c-statistic (mean ae sd) to compare risk of diabetes estimated by framingham score, san antonio index, finrisk index and our arm model. results: some variables used by traditional risk models were not available as structured data in the emr. they were imputed as the mean of the variable as measured on the population in which the index was developed. with the exception of finrisk, all indices preformed similarly. the c-statistic for framingham score, san antonio index, finrisk index and arm model was . ae . , . ae . . , . ae . and . ae . , respectively. conclusions: our novel risk model using arm compares favorably to traditional models and has the advantage that it does not depend on a limited number of risk factors. this model is implementable at the point-of-care or population-based care where emr is in use, assuring universal utilization and improving implementation of preventive management. this study aimed to compare the effects of two types of interventions: diet vs. diet plus sea buckthorn pulp oil intake, in childhood obesity. the results were focused on fmd and imt values and risk factors for endothelial dysfunction. two groups of matched age, sex and bmi obese children (n = , - years old) and controls were enrolled. the measurements in the obese children were done before and after interventions: diet (low caloric, lipid, sugar intake for months) or diet plus sea buckthorn pulp oil intake ( mg/day for months). ultrasounds were used for fmd and imt measurements and colorimetric and elisa methods for biochemical parameters. obese children vs. lean ones had significantly increased values for imt, leptin, apob/apoa ratio, fasting c peptide, c reactive protein (crp), and reduced values for fmd and adiponectin. in the obese group treated only with diet, a light reduction in weight was observed, but no modification of atherosclerotic markers or metabolic improvement. in the obese group treated with diet and sea buckthorn pulp oil, fmd and adiponectin were unchanged, while imt was significantly reduced (p < . ), together with the other atheroscleroric risk factors: fasting c peptide (p < . ), leptin (p < . ). in conclusion, this study shows that sea buckthorn pulp oil intake has beneficial effects by preventing atherosclerosis in obese children. aims: as the rates of type diabetes continue to skyrocket across the globe, public health measures to reduce obesity appear to have limited success. while social marketing campaigns for obesity prevention have their place amongst a suite of strategies, their impact can be limited due to the gap between the campaign messages and individual's ability to identify opportunities for change in their own life. in queensland, a group of peak health agencies are working together to bridge that gap. methods: swap it, don′t stop it is an australian social marketing campaign promoting simple, everyday food and activity changes people can make to improve overall health. a multi channel health promotion and public relations strategy has been implemented to integrate the key messages of the swap it don't stop it campaign with grassroots healthy lifestyle opportunities to support individuals to make changes. this has been achieved by harnessing the collective actions of the non-government health sector to promote clear and consistent obesity prevention messages and by implementing a communications strategy that has connected community and stakeholders with tangible opportunities for healthy lifestyle changes at the local level. outcomes: through collaborative action amongst a broad network of service providers, the national campaign messages have been amplified through community events, radio, print and television stories that have highlighted examples of personal success and provided information that has inspired queenslanders to make small steps towards better health and reduce the risk of type diabetes and other chronic diseases. background and aims: proposed changes to gdm diagnostic criteria are anticipated to increase diagnosis rates leading to rising demand for support during pregnancy. lack of awareness of risks associated with gdm acts as a barrier to healthy lifestyle adaptation and postpregnancy screening ( , ) . the you program delivers a range of strategies to support women at diagnosis, facilitate behaviour modification ( ) and re-enforce importance of post pregnancy screening. methods: newly diagnosed women and their support networks are educated about gdm, risk reducing behaviours and the health care system through a purpose built website and a suite of print resources. specific resources were developed for at risk groups including indigenous australians and women from non-english speaking backgrounds. women are encouraged to join a national register to receive post pregnancy screening reminder letters and text messages in conjunction with regular newsletters containing family-friendly information on healthy lifestyle behaviours and screening. nominated gp's are also sent screening reminders to prompt women to attend screening. results: engagement with the website and newsletters is high, screening reminders evaluated positively with focus groups and participants indicated that they intended to attend their post natal screening. conclusion: you delivers a multi-strategy approach that engages and supports women at diagnosis and re-enforces the importance of screening and behaviour modification during and post pregnancy. family members and peers were recognised as important sources of support and educated to encourage screening and behavioural changes. these low-cost interventions can help reduce prevalence or morbidity in women affected by gdm associated type diabetes. however smoking cessation has many benefits for smokers, but the most important challenge for smoking cessation is withdrawal symptoms during the first days and months of cessation which can be an important reason for unsuccessful in the smoking cessation process. however, many methods are available to help quit smoking, but acupuncture is used for the treatment of nicotine dependency with the aim of reducing of withdrawal symptoms experience. therefore, the aim of this study is to determine the role of acupuncture in success at quit smoking in the iranian samples. methods: one hundred and thirty-two men smokers who were ready to quit smoking were participated in the study. the participants were divided to two groups by randomized sample method. one group was for acupuncture and another group was for acupuncture in shame points. the mean age of smokers was ae years. all participants followed for year and the quit rate evaluated in , , months of the study. the results show, while . % in case-control and . % in control group could quit smoking in the first month of study; but in the month of the study . % in case-control and . % in control group were at quit rate. the quit rate short and long term in case group was higher than control group. therefore, physicians should play an active rate in control of smoking by ensuring and counseling and use of various pharmacology and non pharmacology methods for increase quit rate. panjab university, pgimer, chandigarh, india introduction: , -dimethylhydrazine (dmh)-induced colon carcinogenesis in rats is a reliable model to explore molecular mechanism involved in progression of colorectal cancer from adenoma to carcinoma sequence. objective: to study the transcriptional and translational levels of various genes involved in tumorigenesis pathway of dmh induced rat model. methods: two groups of chow-diet-fed, male sprague-dawley rats, aged weeks (n = /group) were fed a normal diet and injected subcutaneously for two time durations of and weeks dmh at a dose of mg/kg body weight/week or with ethylene diamine tetraacetic acid (edta)-saline. macroscopic and microscopic analyses were performed for confirmation of adenoma and carcinoma. mrna expression of nfkb and caspase- genes were determined by real-time pcr. immunohistochemistry was also performed for expression of above genes. results: gross examination of weeks dmh treated colon showed polypoid lesions and multiple tumors were formed after weeks dmh treatment. histopathological studies confirmed the colon carcinogenesis from adenoma-carcinoma sequence by type of tumor, degree of differentiation and invasion of tumors. in adenomatous and carcinomatous colonic tissues, mrna expression of nfkb was increased by . and . fold respectively, whereas expression of caspase- was reduced by . and . fold respectively. immunohistochemistry studies showed the increase expression of nfkb and reduced expression of caspase- in colonic tissues of dmh induced rat model as compared to controls. the observed data strongly implicates that dmh induced colon carcinogenesis altered the apoptotic machinery by modulating the expression of various genes involved in this pathway. objective: identify anthropometric indicators that present the greatest correlation in the diagnosis of some metabolic syndrome components in adolescents and its association with gender, age, and family history. methods: cross-sectional study with adolescents between and years of age of a public high school in the mexico city. bmi was used to diagnose overweight and obesity according to cut-offs proposed by the international obesity task force. waist circumference (wc) and waist-to-height ratio (whr) were used as fat distribution indexes. results: . % of the students were male. the prevalence of overweight and obesity were . % and . %. there were association between overweight-obesity and the average values of wc, whr, and blood pressure (p < . ). the correlation between waist circumference and bmi and waist-height were the strongest (r = . and r = . , respectively). we recommend using wc and whr in clinical practice as simplified indicators to predict risk of metabolic syndrome in mexican adolescents. c. saely, a. muendlein, a. vonbank, k. geiger, p. rein, h. drexel background: the novel adipocytokine chemerin has been suggested to be linked to insulin resistance and to the metabolic syndrome (mets). its association with coronary artery disease (cad) is unclear. we hypothesized that chemerin is associated with both angiographically determined cad and with the mets. we measured serum chemerin in patients undergoing coronary angiography for the evaluation of established or suspected stable cad; the mets was defined according to ncep-atpiii criteria; significant cad was diagnosed when coronary stenoses ! % were present. results: chemerin was higher in mets patients (n = ) than in subjects without the mets ( ae vs. ae ng/ml; p < . ). it did not differ significantly between patients with significant cad (n = ) and those without significant cad (p = . ). when both, mets and cad status were considered, chemerin was higher in mets patients both among those who had significant cad ( ae vs. ae ng/ml; p = . ) and among those who did not have significant cad ( ae vs. ae ng/ml; p < . ); it did not differ significantly between patients with significant cad and subjects without significant cad among mets patients (p = . ) nor among subjects without mets (p = . ). analysis of covariance (ancova) showed that a large waist circumference as well as elevated trigylcerides were independent predictors of elevated serum chemerin (f = . ; p < . and f = . ; p = . ). we conclude that chemerin is significantly associated mets but not with angiographically determined cad. the overall association of chemerin with the mets is carried by its association with visceral obesity and elevated triglycerides. objective: resistin is a novel adipocyte-secreted hormone proposed to link obesity with diabetes. the role of resistin gene polymorphism in insulin resistance and metabolic syndrome is controversial till date. the present study was attempts to investigate the relationship between resistin gene polymorphism with circulating resistin level, metabolic risk factor and insulin resistance in north indian population. methods: this is a case-control study; total healthy subjects were selected for the study. out of which (age . ae . years) were with metabolic risk factor and age matched control (age . ae . years) were without metabolic risk factors. we estimated homeostatic model assessment (homa) index, circulatory resistin, and lipid profiles. the genotyping of resistin-c g were carried out using pcr-rflp method digested with bbsi restriction enzyme. results: homozygous mutant genotype (cc) (cc v/s cg + gg) (p = . : or = . : % ci = . - . ) and mutant allele (g) (p = . : or = . : % ci = . - . ) of the c/g polymorphism was significantly less frequently observed in the control population as compared to study group. furthermore, on dividing the subjects into two groups according to the absence (resistin - ) or presence (resistin- ) of the mutant g allele, significantly high levels of resistin (p = . , or = . , %ci = . - . ) and insulin resistance (p = . , or = . , %ci = . - . ) were observed in resistin- group as compared to resistin- group. conclusion: our results suggest that the c/g mutation of the resistin gene is likely to play an important role in the development of metabolic syndrome and metabolic abnormalities. king george's medical university, lucknow, rims, saifai, etawah, india objective: adiponectin has been shown to be an insulin-sensitizing hormone and negatively associated with components of metabolic syndrome. present study was attempted to investigate the adiponectin polymorphism in metabolic syndrome and insulin resistance. methods: the adiponectin t g and g t polymorphism has been studied in females with metabolic syndrome and control without metabolic syndrome according to ncep atp iii criteria, . circulating adiponectin and leptin levels were determined by sandwich elisa method and insulin resistance by the homeostasis model assessment (homa) index. the polymorphism of adiponectin t/g and g/t gene were determined by pcr-rflp method. results: significant difference were found for circulating leptin level except adiponectin level ( . ae . vs. . ae . ), and in metabolic risk factors among metabolic syndrome and without metabolic syndrome females. homozygous mutant genotype (gg) (tt vs. tg + gg) (p = . : or = . : % ci = . - . ) and mutant allele (g) (p = . : or = . : % ci = . - . ) of the -t g gene and mutant allele (t) (p = . : or = . : % ci = . - . ) of the g t polymorphism were significantly less frequently observed in the control population as compared to study group. the results of the present study concluded that the mutation of the adiponectin t/g and g/t gene might play a important role in obesity associated metabolic syndrome and metabolic abnormalities except insulin resistance, glucose level and insulin levels in the north indian women due to mutation of the adiponectin gene is associated with decreased adiposity which is protective one for metabolic syndrome design: cross-sectional study of patients with good (excess body mass index lost (ebl) > %) and poor weight loss (ebl %) > months after rygb. material and methods: sixteen patients with good weight loss and patients with poor weight loss were included in the study. the patients underwent dual energy x-ray absorptiometry scan, indirect calorimetry and a -h multiple-meal test with measurements of glucose, insulin, total bile acids (tba), glucagon-like peptide (glp)- , peptide yy - (pyy), cholecystokinin (cck), ghrelin, neurotensin, and pancreatic polypeptide (pp) as well as assessment of early dumping and appetite. results: suppression of hunger was more pronounced in the good than the poor weight loss group in response to the multiple-meal test (p = . ). in addition, the good weight loss group had a larger release of glp- (p = . ) and a greater suppression of ghrelin (p = . ) during the test, whereas the postprandial secretion of cck was highest in the poor weight loss group (p = . ). pyy, neurotensin, pp and tba release did not differ. early dumping was also comparable. differences in resting energy expenditure between the groups were entirely explained by differences in body composition. conclusion: favorable meal-induced changes in hunger and gut hormone release in patients with good compared to poor weight loss support the role of gut hormones in the weight loss after rygb. background: the objective of this study is to explore changes in the vascular tone over the endothelial, neurogenic and myogenic frequency ranges during a contralateral cold pressor test by performing the wavelet analysis of skin temperature fluctuations and to compare the results obtained in healthy subjects and in patients with metabolic syndrome (ms) and type diabetes. methods: thirteen adults with type diabetes aged - years (average diabetes duration of . ae . years) and adults with ms aged - years participated in this pilot study. the control group included practically healthy men and women aged - . the lowfrequency fluctuations of skin temperature in the appropriate frequency ranges, registered during contralateral cold test, were used as a characteristic reflecting the mechanisms of vascular tone regulation. results: the response to cold pressor test in patients with type diabetes and with ms differs essentially from that of healthy subjects. patients with ms show changes in the amplitude of skin temperature fluctuations similar for patients with type diabetes in the endothelial range. the endothelial dysfunction occurs in the pre-clinical stage of diabetes and manifests, in particular, as a disturbance of the endothelial part of vascular tone regulation. with progression of the glucose metabolic disorders the pathological process is worsened due to violation of the neurogenic vasodilatation mechanisms. fetal metabolic programming states that early life nutrition is implicated with the risk of later disease development and both underand overnutrition during gestation might predispose individuals to develop obesity or diabetes later in life. obesity operations called "gastric bypass" operations have shown unexpected involvement of the small intestine in diabetes pathophysiology as it in most cases result in a complete resolution of the diabetes before weight loss. therefore we hypothesize that the small intestine is a subject of metabolic programming and that this programming can predispose for diabetes development. twin-pregnant ewes where fed a normal, a low or a high diet during the last weeks of gestation and the twin lambs where fed either a conventional or a high fat, high carbohydrate (hchf) diet during the first months of life. feeding challenge tests were performed on all lambs and some were slaughtered with collection of intestinal tissue for qpcr. the hchf diet increased the blood level of glucose, insulin and tg and increased the intestinal expression of a range of genes involved in growth, vascularization as well as digestion and absorption. the maternal low and high diet had effects on gene-expression, however the results vary between genes. these observations suggest that small intestine function has been programmed by the late-gestation low or high diet at gene expression level, whereas the physiological metabolic functions has mainly been affected by the hchf diet at such a young age. further investigations on the long-term effects of early nutrition are required. background: liposuction is considered as the treatment for the metabolic complications of obesity. the aim of this study was to evaluate the effect of abdominal liposuction on leptin and interleukin- (il- ) expression in adipose tissue and serum concentration. material and methods: the study included consecutive patients ( females, seven males) aged ae years with bmi ae kg/m , non-diabetic, apparently healthy, who underwent liposuction in mandala beauty clinic in pozna n, poland. the patients were examined clinically and the blood was withdrawn for routine laboratory tests (hematology, glucose, lipids, coagulation). leptin (r&d) and high sensitivity il- (hsil- ) (abcam) were analyzed in the supernatant of adipose tissue homogenate and in serum, by means of elisa. results: the expression of leptin in adipose tissue positively correlated with white blood cells count before liposuction (rs = . , p = . ). it was also higher (p = . ) in patients with bmi ! . ( . ; . - . ng/mg protein; median, interquartile range) than in subjects with bmi < . ( . ; . - . ng/mg protein). following liposuction, after month, serum leptin levels were lowered in smokers ( . ; . - . ng/ml), when comparing with baseline ( . ; . - . ng/ml). serum level of the adipokine, both before (rs = . , p = . ), and after (tau kendall = . , p = . ) liposuction correlated with tissue expression of leptin. no differences in adipose tissue expressions and serum levels of hsil- were observed month after liposuction. conclusion: a count of circulating leukocytes, even presented within references, affects the increasing adipose tissue expression of leptin. smoking status favorably affected the influence of liposuction on serum leptin levels. liposuction has no short-term effect on serum il- concentrations. r.a.l. sertié , s.a. sertié , a.r.g. proenc ßa, t. lima-salgado, a.c. oliveira, f.b. lima introduction: all adaptations acquired through physical training are reversible during inactivity. significant reductions in maximal oxygen uptake (vo max ) are observed within two-four weeks of detraining. conversely, the consequences of detraining on adipose tissue are poorly known. aim: to investigate the physical detraining effects on metabolism and cellularity of rat periepididymal adipose tissue. methods and results: male wistar rats, ageing weeks, were divided in three groups: trained (t) for weeks; detrained (d), (trained for weeks and detrained for weeks), and age-matched sedentary (s). training consisted in treadmill running sessions ( h/day, day/week, - % of the maximal capacity). the morphometric analysis of pe tissue disclosed significant differences between the groups. the adipocyte sectional area of group d was significantly bigger than t and s ( ae . lm vs. . ae . lm vs. . ae . lm , respectively). compared to t the cells of d animals showed % increased ability to perform: lipogenesis, either spontaneously or insulin stimulated and isoproterenol-stimulated lipolysis. basal lipolysis did not change. a % reduction in apoptosis was observed in groups t and d in relation to s. some gene expressions were changed in d vs. s: adiponectin (three-fold up) and ppar-gamma (two-fold up). pref- gene was three-fold higher in t vs. s. conclusions: these results suggest that adipogenesis was stimulated in this group. detraining causes significant increase in adipocyte size and lipogenic capacity. as pe fat cell apoptosis was reduced in d and t. background: chronic red wine (rw) consumption has been associated with a decreased cardiovascular disease risk, mainly attributed to an improvement in lipid profile. rw intake is also able to change gut microbiota composition. high-fat intake has recently been reported to increase metabolic endotoxemia. the gut microbiota has been proposed as the main resource of plasma lipopolysaccharides (lps) in metabolic endotoxemia. objective: to analyze the effect on lps concentrations of chronic rw consumption and acute rw intake in relation to high-fat intake in middle-aged men. design: for the chronic study middle-aged male volunteers were randomized in a crossover trial and after a washout period all received rw, dealcoholized red wine (drw), or gin for days. the serum lps concentration and changes in fecal microbiota were quantified before and after the treatments. for the acute study, five adult men underwent a fat overload or a fat overload together with rw, drw or gin. baseline and postprandial serum lps concentrations and postprandial chylomicron lps concentrations were measured. results: chronic rw consumption led to a significant decrease in lps concentrations compared to baseline. in addition, lps concentrations correlated negatively with bifidobacterium and prevotella levels. there were no differences in postprandial serum or chylomicron lps concentrations between acute rw, drw or gin intake together with a fatty meal. postprandial chylomicron lps concentrations correlated positively with the increase in triglyceride concentrations. conclusions: chronic rw consumption decreases lps concentrations, but it is not able to attenuate the postprandial lps increase induced by a fat overload. physical inactivity increases the risk of metabolic disease, associated with perturbations of muscle energy metabolism. the aim of this study was to assess the effect of exercise training on adiposity, physical fitness and muscle energy metabolism in obese individuals with attributes of ms. methods: sedentary individuals (m/f / ; age . ae . years, bmi . ae . kg/m ) completed -months endurance or strength (n = / ) training program ( h, -times/week). subcutaneous and visceral adiposity was measured by mri. phosphorus mr spectroscopy ( p-mrs) was used to assess the energetic status of muscle in vivo by measuring phosphocreatine (pcr), atp, inorganic phosphate (pi) and maximal oxidative flux (q max ), after exercise-or magnetic-induced equilibrium perturbation (n = ). the samples of skeletal muscle were taken by needle biopsy (vastus lateralis). cytochrome c oxidase (cox) activity of permeabilized muscle fibers was measured by oxymetry and maximal aerobic capacity (vo max) by bicycle ergometry. free-living ambulatory activity was monitored by accelerometers. results: subcutaneous adiposity did not change with training. however, strength training decreased visceral adiposity (p < . ). training increased physical fitness (vo max, n = , p = . ) and in vivo muscle energy metabolism ( p-mrs: q max , pcr, atp, n = , p < . ), without a significant effect on cox activity (n = . ). depletion of muscle pcr was negatively associated with cox activity (p = . ). vo max was not associated with muscle metabolism (p > . ). free-living activity increased during training (p < . ). conclusions: three months training of obese individuals was sufficient to increase both cardiorespiratory fitness and muscle metabolism, assessed by p-mrs. strength training was more efficient in decreasing visceral adiposity. background: the amelioration of metabolic complications of excessive body mass by liposuction is intensively discussed, as the metabolic surgery is proposed for future diabetes therapy. we have undertaken the study on the short-term effect of liposuction on insulin resistance parameters. material and methods: we included in the study consecutive patients ( females, seven males) aged ae years with bmi ae kg/m , who underwent liposuction in mandala beauty clinic in pozna n, poland. the non-diabetic, apparently healthy patients were examined clinically, blood was withdrawn for baseline routine laboratory tests (hematology, glucose, lipids, coagulation). insulin levels in serum and its content in adipose tissue were evaluated by means of elisa (diasource, sunrise tekan). insulin resistance/ sensitivity indexes: homa-ir, quicki and mcauley were calculated. one month observation included re-evaluation of glucose, lipids and insulin along with the indexes. data are presented as mean ae sd or median; interquartile range. we have observed the decrease in glucose concentrations ( ae vs. ae mg/dl, p = . ) and insulin levels ( ; - vs. ; - mu/l, p = . ) month after liposuction, comparing to baseline. homa-ir ( . ae . vs. . ae . , p = . ) and mcauley index ( . ae . vs. . ae . , p = . ) were improved month after liposuction, however no effect on quicki has been found. triglycerides concentrations month after liposuction were lowered comparing to baseline ( ; - mg/dl vs. ; - mg/dl; p = . ). in multiple regression analysis age was independent factor that affected insulin content in adipose tissue in males (b = . , p = . ). conclusion: liposuction causes beneficial effect on insulin resistance parameters in short-term observation of non-diabetic patients. background: a large number of studies showed that community-based health promotion is an effective way of preventing and treating chronic diseases. however, participation rate is very low for health education programs in community health centers (chcs); that of the program is not attractive, in part, because it is not individualized. using diabetes risk assessment tool based on electronic health records (ehr) data for diabetes risk prediction could help to early identify high-risk groups and reduce the incidence of diabetes through health education and lifestyle changes to control risk factors. objectives: to conduct community research to understand the situation of community diabetes prevention and control; to initially established prediction model of diabetes risk factors based on ehr data in chcs. the project randomly selects four districts in shanghai, using a combination of quantitative research and qualitative research method. get ehr data from each chc, attempts to establish the predicted model for diabetes, and test the sensitivity and specificity of the model. outcome measures: the prediction model include age, gender, blood pressure, smoking, drinking, body mass index, family history of diabetes based on ehr data. as pr(d) ! . , the sensitivity is . %, specificity is . % and area under roc curve (auc) is . . the empirical results will contribute to a better understanding of how the diabetes management in chc is important and provider the targeted self-management materials to improve health outcomes as well as evidences directly applicable in improving china's health policy reforms. a. schmid, a. kopp, m. bala, s. leszczak, i. ober, m. mü ller, a. schä ffler internal medicine i, university hospital regensburg, regensburg, germany introduction: the adipokine chemerin has an important role in insulin sensitivity and insulin secretion. elevated systemic chemerin concentrations correlate with obesity and insulin resistance. this study investigated chemerin serum levels of healthy volunteers undergoing an oral fat tolerance test (oftt) and their correlations with gender and markers of insulin sensitivity and inflammation. we further tested effects of the sex hormones estradiol and testosterone on chemerin secretion from adipocytes in vitro. methods: hundred overnight fasted healthy volunteers participating in the study underwent an oftt. after oral uptake of lipid suspension, venous blood was drawn at , , and h. subjects were characterized by anthropometric and standard laboratory parameters. chemerin levels were measured by elisa. mature murine t -l adipocytes were stimulated with estradiol and testosterone. concentrations of secreted chemerin were measured by elisa. results: while there were no significant changes in individual chemerin concentrations resulting from the lipid load, mean chemerin levels in sera of female probands were found to be significantly higher when compared to males ( . ae . vs. . ae . ng/ml, p = . ). the correlation of chemerin with insulin and c-peptide concentrations also was gender-specific. along with these findings, chemerin secretion from mature t -l adipocytes was shown to be affected by estradiol and testosterone treatment. conclusion: human chemerin concentrations are higher in females and there is a gender specific regulation upon stimulation with sex steroids. chemerin is not responsive to an oral lipid load. objective: to study the predictors of change in bmi with respect to time among physically active subjects. methodology: the present study was conducted among physically active individuals in delhi. data was collected longitudinally with a monthly follow up of months. various anthropometric and physiological measurements were taken using standard protocol. the analysis has been performed with mixed effect modeling to assess subject's variation for parameters with respect to time. r . . software with nlme package was used. an akaike information criterion (aic) was applied to find the consistency and measure the relative goodness of fit of a statistical model. : bmi as an important factor was taken as dependent variable and using aic, gender, blood pressure and weight were independent variables or fixed and random variables for months of longitudinal study. using generalized linear model (glm), bmi was dependent variable and other parameters i.e. gender, systolic blood pressure (sbp), diastolic blood pressure (dbp) and weight were independent variables. the regression coefficient obtained for gender with respect to bmi (as response variable) was À . . the estimated values for sbp, dbp and weight were À . , . and . respectively. the reduction of bmi among females was more in comparison to males. the reduction rate of sbp, dbp and weight with bmi was very low with respect to time. a.e. andreazzi , s. grassiolli , j.c. de oliveira , r. torrezan , s.t. paes , m.s. silva , r.m.g. garcia , p.c.d.f. mathias department of physiology, federal university of juiz de fora, juiz de fora, biology, state university of maring a, maring a, biology, federal university of juiz de fora, juiz de fora, brazil obesity is a worldwide epidemic and the most important factor in metabolic syndrome onset. the involvement of sympathoadrenal axis activity in obesity onset was investigated using the experimental model of treating neonatal rats with monosodium l-glutamate (msg). to access general sympathetic nervous system activity, we recorded the firing rates of sympathetic superior cervical ganglion nerves in animals. catecholamine content and secretion from isolated adrenal medulla were measured using the trihydroxyindole fluorescence method. high-performance liquid chromatography (hplc) was used to measure plasmatic adrenaline. intravenous glucose tolerance test was performed, and isolated pancreatic islets were stimulated with glucose and adrenergic agonists. msg treatment increased the epididymal and retroperitoneal fat pad mass by . % and . %, respectively, compared with control animals (p < . ). the nerve firing rate of obese rats was decreased . % compared to the rate for lean rats (p < . ). pre-diabetic rats showed a % reduction in basal catecholamine secretion from the adrenal medulla and % lower plasma adrenaline concentration compared with the control animals (p < . ); whereas catecholamine secretion induced by carbachol, elevated extracellular potassium and caffeine in the isolated adrenal medulla were all increased in obese rats compared to control. both glucose intolerance and hyperinsulinaemia were observed in obese rats. adrenaline strongly inhibited glucose-induced insulin secretion in obese animals ( %, p < . ). these findings suggest that low sympathoadrenal activity contributes to impaired glycaemic control in pre-diabetic obese rats. objective: the aim of the present study was to evaluate the influence of physical activity patterns on cardiovascular health. the study was conducted in delhi, among adult punjabi males and females. total sample of subjects was taken for the study. data was collected crosssectionally using multistage stratified sampling. according to pattern of physical activity using self administered proforma, two groups were formed, one regular physical activity group (rpa; at least days/week brisk walk for min, doing yoga for min), and the other irregular physical activity group (ipa; < days a week with no consistency). various anthropometric and physiological measurements were taken using standard protocol. results: higher percentage of subjects with irregular pattern of pa was at risk of developing high bp, obesity and triglycerides. higher values of whr, whtr among them showed that group was more disposed to cardiovascular health problem. males with ipapattern had . times, . times and . times more risk of increasing regional adiposity using whtr, whr and wc respectively. among females, whtr, whr and wc respectively showed . times, . times and . times higher risk of developing regional adiposity with irregular pattern of pa. the increased risk of being obese was . times more among males with irregular pattern of physical activity while among females fat percentage and obesity level using bmi category were found to be at a risk of . times and . times respectively. conclusion: subjects with regular pattern of pa showed higher percentage of normal values of various cardiovascular and obesity markers. irregular pattern of pa increased the risk of regional and general adiposity markers besides that of high bp. materials and methods: serum glycemia, insulin and c-peptide level were measured at ogl hours - st- nd in: seven healthy controls, patients with ms and with cushing; mean age was . - . - . , bmi - - , ogl glycemia: . - . - . ; . - . - . ; . - . - . respectively. all patients had bp > / mmhg and triglyceride level > . mmol/l. homa assessment: (fasting insulin, pmol/l fasting glucose, mmol/l): . . c-peptide and insulin increase above fasting level (in pmol) per g of ingested glucose was calculated. results: (*p < . vs. control). homa was . - . *- . * and fasting c-peptide and insulin level were / , / *, / * pmol/l in control, ms and cushing respectively. to the st hour of ogl the corresponding data were: / , / * and / * and increase of c-peptide and insulin concentration per g of ingested glucose was almost equal: / . - / . - / . pmol/l. the degree of c-peptide increase to the st hour was twice less than in control and increased fasting hepatic insulin clearance lowered almost to control level (judging by c-peptide/insulin ratio). to the nd hour of ogl c-peptide and insulin level became similar to fasting data. conclusion: ir characteristics were similar in ms and cushing disease. insulin requirement increase on the top of ogl was equal to control. judging by c-peptide/insulin changes ir stops manifesting on the top of glycemia during ogl (probably due to normalizing hepatic insulin clearance). introduction: ir is atfr of high potential, but also one of the first signs of a ateroscl. process. condition when the body has too much insulin at in the same time too much glucose is the resistance of peripheral tissues to the action of insulin. objectives: to investigate the relationship of concentrations of insulin and glucose in the peripheral blood, but also the conc. of gh, becose normalisation of gh secretion could corrects hiperinsulinemia and insulin resistance. on the other hand reduced gh secretion often points to the high expression of somatostatin and the presence of stress, which leads to secretion of somatostatin. further increase in visceral adipose tissue and ffa relise under stress can worsen the condition of and insulin resistance. aims of study: conducted therapeutic program (combination of dietary and physical activity), in which only the group edu implemented and behavioral therapy. monitoring parameters of glycemic control: fasting glucose, fasting insulin and gh and insulin sensitivity of peripheral tissues to insulin, always from in one blood sample, parallely in two different phases of therapy. we used anova-manova statistics to determine the significance of an differencies. material and methods: determining of glucose, insulin, and growth hormone. as and qucki index for determining od insulin sensitivy conclusion: ours finding indicate that the synergistic effects of dieting and increased physical activity improves glucoregulation, reduce excessive insulin secretion and restoration of gh secretion. but only behavioral therapy may lead to permanent changes in nutritional habits and lifestyle. the metabolic and endocrine dysfunctions that may occur with polycystic ovary syndrome (pcos) can be associated with future comorbidities such as diabetes, cardiovascular disease, and endometrial cancer. although a definitive link between pcos and these chronic illnesses has not been demonstrated, there is significant overlap in the clinical characteristics of these disorders. consequently, the issue of identifying and measuring potential conditions that may be associated with pcos is a priority and should be the standard of practice in its management. hiperhomocysteinemia has been shown as independent predictor of cardiovascular events in patients with atherosclerosis. the aim of our study was to determinate levels of homocysteine in woman with polycystic ovary syndrome compared with healthy woman. thirty patients (age, , ae . ) with pcos and (age, . ae . ) healthy woman were involved in the study. blood samples were collected in early follicular phase. total homocysteine was measured using fluorescent immunoassay. statistically significant differences in serum concentration of homocysteine were observed between groups. mean homocysteine level we found as ( . ae . vs. . ae . ) in pcos and normal group respectively (p < . ). for macedonian population we found statistically significant increased homocysteine levels in woman with pcos. although the mean homocysteine levels are within normal limits, there are significant higher mean homocysteine concentrations between these two groups. because an increased concentration of thcy has been shown as and independent risk factor for cardiovascular alterations, it is essential in this group of woman to be taken measures for early prevention. a. alkandari, n.j. gooderham, h. ashrafian surgery and cancer, imperial college london, london, uk globally million people are obese and prevalence is increasing. obesity and its many co-morbidities are leading causes of mortality and morbidity and pose substantial socioeconomic burdens on health services. bariatric surgery is a form of gastrointestinal surgery that leads to sustained weight loss, a decrease in cancer risk and resolution of type diabetes. micrornas are a family of small, endogenous, non-coding rnas that regulate gene expression at the posttranscriptional level. micrornas control expression of over half the human transcriptome and are involved in processes fundamental to both normal physiology and disease, including obesity, diabetes and cancer. we hypothesise that urinary micrornas are biomarkers for bariatric surgery reduction of type diabetes. here, we looked at expression of micrornas involved in diabetes in urine samples prior to bariatric surgery and at months and year postoperatively. urinary rna was obtained using the mirvana paris kit and microrna expression was determined through quantitative pcr. we found significant increases of two to three fold postoperatively in the expression of three micrornas involved in diabetic nephropathy. these findings are consistent among patients undergoing laparoscopic roux-en-y gastric bypass and sleeve gastrectomy. our results indicate that bariatric operations can modulate post-translational effects in end-organs postoperatively and may contribute to the beneficial effects noted after these procedures. hepatic insulin resistance and the ensuing impairment of hepatic glucose metabolism is a major contributor to hyperglycemia in metabolic syndrome. various factors appear to act in parallel to elicit hepatic insulin resistance. while impaired fatty acid handling with a resulting activation of pkc isoforms is one established route, a subacute inflammation also appears to contribute and the impact of cytokines on the insulin signaling cascade is well established. by contrast, the role of small lipid mediators e.g. prostaglandins and sphingolipids, which are also affluent in inflamed tissue, is not well characterized. the current study addressed this question. in a wide array of genetic and diet-induced mouse models of the metabolic syndrome, hepatic expression of key enzymes of prostaglandin formation was induced. prostalgandin e , which is released predominantly from kupffer cells, directly attenuated insulindependent hepatic glucose utilization by an erk / -dependent serinephosphorylation of irs and hence attenuation of insulin-dependent akt-phosphorylation. in addition, pge enhanced lipid accumulation in hepatocytes by inhibiting mitochondrial fatty acid oxidation and vldl formation. furthermore, pge in an autokrine feed forward loop increased the formation of oncostatin m in kupffer cells, which in turn inhibited insulin signaling in hepatocytes by inducing socs . similar to pge , sphingosine- -phosphate, whose production was strongly enhanced by exposing hepatocytes to palmitate, attenuated insulin-stimulated glucose use and the induction of glycolytic enzymes in hepatocytes. in summary, the study provides first evidence that in addition to the established mechanism, small lipid mediators like prostaglandins and sphingolipids may impact on hepatic insulin resistance. background: the progression of childhood cardio-metabolic risk factor to adulthood suggests early origin of pathogenic pathways leading to chronic non-communicable disease as diabetes. objective: we sought to examine the distribution of insulin resistance (homa-ir) among children inhabiting delhi and clustering of cardio-metabolic risk variables among them. research design and methods: a cross sectional study was conducted among children aged - years. estimates of insulin resistance were derived on the basis of homeostatic model assessment. the th percentile of homa-ir for normal weight subjects with normal fasting glucose was considered as cutoff for insulin resistance. total body fat was assayed using body composition analyser (tbf- h a) employing bioelectric impedance technique. bmi was converted to age-and sex-standardized percentiles and subjects were classified as underweight if bmi < th and overweight if bmi was > th percentile. children with blood pressure > th percentile, adjusted for age and sex were categorised as hypertensive. information on socio-demographic features and family history of diabetes was obtained through standardized questionnaire. result: independent student t-tests showed significantly higher percentage of body fat among girls ( . %) as compared to boys ( . %). mann-whitney u-test analysis depicts significantly higher level of fasting sugar among girls ( . mmol/ml) than boys ( . mmol/ml). out of children ( . %) were insulin resistant. among them five were underweight while seven were overweight, / (sbp/dbp) were hypertensive and had family history of diabetes. conclusion: high prevalence of insulin resistance, a precursor of diabetes among these children foreshadows a worrisome trend for the burden of type diabetes in near future. both aims, losing weight as well as improving metabolic conditions, should be reached within the first weeks of an intervention program already. therefore, results of a short-time intervention concept should be presented. in answer to a regional tv-report dealing with "successful weight loss", overweight adults contacted the freiburg institute of preventive medicine (ipm) to participate in a -week intervention program. after looking for exclusion criteria, patients ( . ae . years, . ae . m/kg bmi) could be included. the ipm concept consists of an initial consultation in energy balance and life style changes, the use of a soy-yoghurt-honey product (almased â , per day as meal replacement), and the facility for guidance by phone. forty patients completed the program attending the exit examination. starting from a comparable bmi, the females were younger (n = ; . ae . years) than the males (n = ; . ae . years) and showed less associated risk factors. of significantly older age was the subgroup of patients with metabolic syndrome (ms) or type diabetes mellitus (t dm) (n = ; . ae . years). all completers were successful in losing weight (pre-post diff. . ae . kg) and showed a comparable weight reduction after intervention: females À . %, males À . %, ms/t dm patients À . %. the weight reduction was impressively accompanied by improvements of the metabolic milieu (tg, ldl-c, fbg, hba c) particularly in the ms/ t dm patients. the results confirm that the ipm concept is a successful way to lose weight initially and to improve the metabolic milieu within a shorttime period using a product with a high impact of bioactive compounds. objective: menopause-related changes in female body are associated with the greater risk of metabolic syndrome (ms), which includes obesity, dyslipidemia, impaired glucose tolerance, hypertension. the purpose of our study: was to reveal peculiarities of fat and lean mass distribution between postmenopausal women with abdominal obesity and with ms. design and method: the sample consisted of postmenopausal - years old women (age: mean = . ; sd = . ); duration of menopause: mean = . ; sd = . ). the diagnosis of ms was considered according to idf ( year) criteria. lean and fat mass distrubution were measured by dual-energy x-ray absortiometry, and were compared for the cohorts with and without ms. data were analyzed using statistical package . (statsoft). background and aims: attempts to curb the ongoing epidemic of obesity and diabetes in the us and other developed countries will benefit from better understanding of the broad and upstream determinants of the population prevalence of these conditions. this study explores how individual psychosocial characteristics in addition to the social and physical community environment correlate with prevalent obesity and markers of pre-diabetes in a statewide representative sample of the population of wisconsin, usa. methods: we used cross-sectional data from the to cycles of the ongoing survey of the health of wisconsin (show) a geographically diverse population-based research study of adults, age - years (n = ). obesity (bmi ! kg/m ) and hemoglobin a c levels were the main outcomes. independent variables included individual socioeconomic status (ses), food insecurity, psychosocial status (depression, anxiety and stress), perceived discrimination and neighborhood resources, and access to health are. contextual predictors included county and census-block group socioeconomic nutrition, and built environment indicators. results: the prevalence of obesity and prediabetes was positively associated with lower ses, food insecurity, markers of depression and anxiety, perceptions about lower access to healthy food and physical activity resources in the neighborhood, and poor health care access. lower community-level ses and a poor nutritional and built environment were also associated with higher frequency of obesity and prediabetes. conclusion: our findings on the psychosocial and contextual correlates of obesity and prediabetes offer insights regarding the profile of individuals and subgroups and where tailored individual and community level interventions are most needed. objective: gastric bypass (gbp) is currently the most effective way of treating obesity. interestingly, the majority of type diabetes (t d) patients display remission of the disease after gbp. the underlying mechanisms behind this remission are not known. we used a porcine model to study how hormonal and metobolite profiles are affected by gbp. in addition we studied the impact of gbp on endocrine cell populations in the gut and pancreatic islets. methods: gbp-pigs were subjected to oral (ogtt) and intravenous (ivgtt) glucose tolerance tests before and after surgery. shamoperated, pair-fed pigs served as controls. results: during ivgtt gbp-pigs displayed lower glucose and higher insulin levels compared to controls. during ogtt, gbp-pigs displayed higher glucose and a more rapid and robust insulin response than controls. in line with this, gbp-pigs had higher beta cell mass and more extra-islet beta cells. further, during ogtt gbp-pigs displayed robustly elevated gip levels, whereas glp- levels were unchanged. furthermore, gbp-pigs displayed elevated density of gipproducing k-cells, but reduced density of glp- -producing l-cells in the gut. metabolomic analyses revealed a difference in the metabolite pattern between the two groups, mainly explained by the fact that gbp provoked lower levels of free fatty acids (ffa) and higher levels of branch-chain amino acids (bcaa). conclusions: gbp in pigs provokes, . enhanced insulin secretion and increased beta cell mass. background: several authors have recently reported that both hiv replication and antiretroviral therapy (art) may influence adiponectin expresion which is correlated with insulin sensitivity via glucose transporter type recruitment to plasma membrane. we assessed serum adiponectin patterns in a cohort of hiv- positive caucasian patients undergoing cart in relation to insulin resistance (ir) and hiv replication. a cross-sectional study was performed in a cohort of hiv- infected patients attending the national institute of infectious diseases, bucharest. blood samples were tested for hiv viral load and adiponectin. insulin resistance was estimated by homoeostasis model assessment. in order to evaluate differences between groups we used mann-whitney-wilcoxon and t-tests. results: eighty patients ( . % males) with a median age of years (iqr years) were included in the study. the median time from hiv diagnosis was . months and the median time on cart was . months. most patients ( . %) had undetectable serum hiv loads. median adiponectin serum value was . lg/ml (iqr ). most patients ( . %) had insulin resistance. insulin resistant patients had significantly lower median levels of adiponectin ( . vs. . lg/ ml, p = . ). there were no significant differences between median adiponectin serum levels in groups with persistent and undetectable hiv replication (p = . ). no significant correlation was noted between insulin resistance and hiv replication. conclusions: in our cohort of young hiv- patients with a high prevalence of ir decreased adiponectin serum levels were associated with decreased insulin sensitivity. hiv replication may not influence in vivo adiponectin expression. objective: to examine obesity and metabolic disorders associated with vitd deficiency/insufficiency in children older people. methods: cross sectional study in community-dwelling subjects - year ( women) residing in santiago chile. plasma levels of (oh)d were determined by radioimmunoassay. glucose, insulin and crpus, were measured in a fasting blood sample. blood pressure and complete anthropometry were measured. results: mean serum (oh)d was . ae . nmol/l (men . ae . ; women . ae . , p < . ). (oh)d levels were under nmol/l in . % of men and . % of women (p = . ). insulin resistance was present in . % of all subjects and obesity in . % of women and . % of men (p < . ). significant negative crude association between (oh)d across bmi categories was found in the total sample (p < . ). crude association of vitd < nmol/l with obesity (p = . ), waist circumference (p = . ), insulin resistance (p < . ), metabolic syndrome (p = . ), hta (p < . ) and age ! year (p < . ) was observed. after age, sex, waist circumference and season adjustment, vitd < nmol/l was associated with increased risk of insulin resistance, or . (ic % . - . ) p = . . conclusion: high prevalence of vitd deficiency/insufficiency was observed in the chilean older people. vitd deficiency is associated with insulin resistance. in the future, randomized controlled trials are needed to establish a cause-effect relationship between vitd deficiency, obesity and its metabolic consequences. surrogate markers are used to estimate degree of steatosis and liver fibrosis in nafld. oxidative stress is important in the pathophysiology of nafld. the aim of this study is to find correlations between blood antioxidants and laboratory variables that are routinely determined in patients with nafld in clinical practice and used in fibrosis test. thirty-five obese children ( - years old) with increased liver echogenicity on ultrasounds and healthy lean children were enrolled. other causes of chronic hepatitis, such as chronic viral hepatitis, were excluded. erythrocyte superoxid dismutase (sod), glutathione peroxidase (gpx) activities and plasma levels for albumin, uric acid and bilirubin were measured as antioxidants. the nafld fibrosis score was calculated by an altgoritm including: age, bmi, glycaemia, platelet number, albumin, ast/alt. pearson correlations were calculated. none of the obese children had fibrosis according to the test score. obese children with nafld had lower levels for albumin (p < . ), but higher levels for uric acid (p < . ), sod and gpx activities (p < . ) vs. lean children. all the measured antioxidants were related with variables included in the fibrosis test. for p < . , the calculated correlations were: sod activity with alt activity (r = À . ) and albumin (r = . ), gpx activity with ast/alt ratio (r = . ), uric acid with alt activity, age and bmi (r = . ). this study demonstrates strong relations between blood antioxidant defence systems with fibrosis test variables in nafld in obese children. women; diabetes prevention programs (dpp) are only available for adults at high risk of developing t d. . to develop a dpp for post-gd women. . to assess the feasibility/acceptability of this dpp through a pilot rollout. methods: a working group was formed to develop a dpp that incorporated the needs of a mother with a young family around established lifestyle modification goals. this program was piloted with a group of nine post-gd women. the pilot had high attendance levels ( - % for group sessions), but only % of participants attended all sessions (illness and travel commitments causing non-attendance). the original magda dpp was restructured to: an individual session, five group sessions and two follow-up telephone conversations. childcare arrangements were investigated, but participants elected to have their children attend sessions. participants reported the program to be acceptable and suited to their needs. the pilot determined that the program was feasible and met the needs of the target population. currently, recruitment is underway for post-gd women from three hospital sites for the magda study, which uses a dpp designed for post-gd women and has a whole-of-family focus and tackles common barriers to success. objectives: assess the risk factors associated to physical inactivity (pi). a cross-sectional study was performed in in subjects aged ! years, in the urban area of montes claros, brazil. the physical inactivity level was determined by the international physical activity questionnaire short version. the subjects were classified in active ( ! min per week) and sedentary (< min per week). the univariate analysis was first performed and were included in the model when associated with p < . . the poisson regression with robust variance was realized and the prevalence ratio (pr)-crude and adjusted-and % confidence intervals (ci) were estimated to determine the relationship between pi and risk factors like sex, age group, skin color, marital status, income, education, hypertension, dyslipidemia and overweight. the variables that remained significant when adjusted. the statistic was performed in stata. results: a sample of individuals were studied ( . % women). the prevalence of pi was of . %. the variables were associated with pi were sex, the age group, marital status, education, hypertension, dyslipidemia and overweight with p < . . the following variables were significantly associated with pi after adjustment for confounding variables were: sex, female (rp = . ; ic: . - . ) and marital status, separated/divorced/widowed (rp = . ; ic: . - . ). the gender and marital status were associated with pi with pr higher for these variables in this population, which shows the need for development of effective public policies, integrated to investigate the biological causes, but also the social risk factors. objective: to determine whether an interactive mhealth exercise intervention is more effective than standard of care exercise in patients with metabolic syndrome. methods: participants [n = , mean age . (sd . ) year, % female] reported to the laboratory at baseline (v ) and follow-up [ (v ) and (v ) weeks]. anthropometrics, heart rate (hr) and blood pressure (bp) were measured and blood drawn to examine fasting glucose (fg) and glycated hemoglobin (hba c ). fitness (vo max ) was assessed and individualized exercise programs were prescribed. the intervention group received a smartphone data portal and bluetooth tm enabled biometric tracking. differences between groups in outcomes (v -v ) were examined using analyses of covariance, which adjusted for baseline levels of the outcome of interest. group differences from v to v were examined with two-way repeated measures anovas. results: at v , systolic bp was reduced in both groups but significantly more in the control group (difference in mean change: À . ; % ci: À . , À . , p = . ). there were no differences between groups at v for other outcomes. across the follow-up period, systolic bp, diastolic bp, resting hr, weight, body mass index, waist circumference and hba c were decreased, and vo max and target hr were increased for the entire study population (p < . ) with no difference in rate of change between groups. fg was significantly higher in the intervention group across the entire follow-up period (p = . ) and both groups had increasing levels over time (p = . ). conclusion: over weeks, cardio-metabolic risk factors improved with both standard and mhealth supported exercise interventions. background and aims: breastfeeding improves glucose tolerance in the early postpartum period of women with prior gestational diabetes (gdm), but it is unclear whether future risk of metabolic alterations, like type diabetes, is reduced. the aim of this study was to investigate the effect of lactation, years after pregnancy, on glucose metabolism and beta cell function in women with prior gdm. material and methods: women with prior gdm (carpenter and coustan criteria) were evaluated with comparison of results for "lactating" [bf] vs. "non lactating women" [non bf]. breastfeeding was defined exclusive if lasting more than weeks. each woman performed a -g ogtt to analyze glucose tolerance, insulin sensitivity/resistance and b-cell function. lipid and inflammatory profile was also studied. statistics: paired and un-paired t-test, mann-whitney and v tests. methods: subjects completed three randomly ordered conditions: mie ( % vo peak), hie ( % vo peak), and seated rest (control). exercise energy expenditure was equated to -kcal. one-hour postexercise (or control), subjects received a -g oral glucose tolerance test (ogtt). plasma glucose and insulin concentrations were measured before and at frequent intervals after glucose ingestion. si was derived using the following models (i) oral minimal model (omm), (ii) matsuda composite index, (iii) cederholm index, and (iv) stumvoll index. exercise induced changes in insulin action were expressed relative to the control condition (exercise-control). spearman correlation coefficients and rm-anova were used to compare relative changes in insulin sensitivity. results: si calculated during the control condition was moderately correlated among the various indices (r-value range: . - . , pvalues: . - . ). relative to control, si after mie ranged from % higher (cederholm) to % higher (omm), and after hie ranged from % lower (matsuda index) to % higher (omm excess caloric intake leads to metabolic overload and is associated with development of type diabetes (t dm). current disease management concentrates on risk factors of the disease such as blood glucose, however with limited success. we hypothesize that normalizing blood glucose levels by itself is insufficient to treat the disease and the development of complications, and that dietary interventions which diminish metabolic overload may be more efficacious in retarding the disease. we explored the efficacy and systems effects of pharmaceutical interventions vs. dietary lifestyle interventions (dli) in developing t dm and complications. high fat diet (hfd)-fed ldlr À/À mice with already established disease phenotype, to mimic the human situation, were treated with different drugs mixed into hfd or subjected to dli (switch to lowfat chow), for weeks. interventions were compared to untreated reference mice kept on hfd or chow only. although most of the drugs improved hfd-induced hyperglycemia, drugs only partially affected other risk factors and also had limited effect on disease progression towards microalbuminuria, hepatosteatosis and atherosclerosis. by contrast, dli normalized t dm risk factors, fully reversed hepatosteatosis and microalbuminuria, and attenuated atherosclerosis. the comprehensive beneficial effect of dli was reflected by normalized metabolite profiles in plasma and liver. analysis of disease pathways in liver confirmed reversion of the metabolic distortions with dli. this study demonstrates that the pathogenesis of t dm towards complications is reversible with dli and highlights the differential effects of current pharmacotherapies and their limitation to resolve the disease. introduction: obesity may induce an oxidative stress in adipose tissue, leading to deregulated expression of inflammatory cytokines which could be an early instigator of obesity-associated diabetes and cardiovascular diseases. thus, the biological effect of natural micronutrients such as plant polyphenols that may increase the antioxidant capacity of the body is of high interest. aim: our objective was to explore the antioxidant polyphenol content of three medicinal plants (gouania mauritiana, antirhea borbonica, doratoxylon apetalum) and their impact on the viability, production of reactive oxygen species (ros) and inflammatory response of preadipocytes exposed to oxidative stress. methods: polyphenol-rich extracts from plants were analyzed for their radical-scavenging capacity by dpph method. then, their ability to modulate t -l preadipocyte viability and protection against h o induced oxidative stress was assessed by both mtt viability and ldh death assays, as well as by dcfh-da test evaluating intracellular ros production. finally, il- secretion was measured by elisa. results: all plant extracts exhibited high levels of antioxidant polyphenols which protected preadipocytes against oxidative stress by decreasing ros generation and modulating the inflammatory response. such an antioxidant activity of plant extracts could be partly mediated through their radical-scavenging capacity. we identified three medicinal plants naturally rich in antioxidant polyphenols which exerted antioxidant and antiinflammatory properties on preadipocytes exposed to oxidative stress. further studies are in progress to clarify the molecular mechanism as well as in vivo potential effects of such medicinal plants to protect against metabolic and inflammatory disorders known to play a key role in obesity-related insulin resistance. background: increased fasting plasma glucose is known to lead to diabetes, and diabetes associated complications often manifesting prior to the identification of type diabetes. we aimed to determine the association of fasting plasma glucose levels with cholesterol levels and oxidative stress markers. methods: one hundred and sixty two participants attended the diabetes screening clinic, at charles sturt university, australia between february and june . participants were investigated based on the american diabetes association′s diagnostic criteria of diabetes mellitus and prediabetes, i.e. fasting bgl. results: atherogenic index of plasma (aip) was elevated in the prediabetes group ( . ae . ) and continued to increase in the diabetes group ( . ae . ) compared to controls (À . ae . ; p < . ). serum -hydroxy- -deoxy-guanosine ( -ohdg) level was greater in the prediabetes ( . ae . pg/ml) compared to controls ( . ae . pg/ml; p < . ). the diabetes group ( . ae . pg/ml) had the highest level of -ohdg. these changes paralleled by a reduction in erythrocyte reduced glutathione (gsh) from controls ( . ae mg/ ml, p < . ) to prediabetes ( . ae mg/ ml; p < . ) and the diabetes group ( . ae . mg/ ml, p < . ). conclusion: this increase in -ohdg may be related to the decrease in erythrocyte gsh antioxidant capacity. a statistical significant positive correlation (pearson's r = . ; p < . ) between aip and -ohdg suggests that -ohdg may be a useful additional biomarker to determine the degree atherogenic risk in the presence of elevated lipids. rowett institute of nutrition and health, university of aberdeen, aberdeen, uk, ilsi europe, brussels, belgium, lund university, lund, sweden, mechanistic evidence suggests that elevated blood glucose levels contribute to the development of t dm. adoption of a nutritional approach to manage postprandial glycaemia could deliver a cost-effective t dm prevention and management strategy, applicable across the population. to implement a successful strategy it is essential to understand the impact of dietary modulation on the postprandial rise in blood glucose concentrations. for this reason, a systematic and comprehensive literature review was undertaken, using the highest quality data. included were the major macronutrients (carbohydrate, protein, fat), micronutrient vitamins and minerals, non-nutrient phytochemicals and additional foods including low-calorie sweeteners, vinegar and alcohol. the strongest corroboration of efficacy for improving glucose homeostasis was for insoluble and moderately fermentable cereal-based fibre and monounsaturated fatty acids as replacement of saturated fat. postprandial glucose levels were decreased by intake of viscous soluble fibre and this was considered to be predominantly by delaying absorption of coingested carbohydrates. weaker but substantial evidence demonstrated that certain phytochemical-rich foods were likely to be effective and this may be associated with the suggestion that the gut microbiota plays an important role in metabolic regulation, including provision of phytochemical and other metabolites. it is clear that dietary components have significant and clinically relevant effects on blood glucose modulation. this suggests that employing a dietary regimen to attenuate the postprandial rise in blood glucose levels along with previously identified targets (reducing excess body weight and an increase in physical activity) will benefit the health of the population and limit the increasing worldwide incidence of t dm. knowing their metabolic control, and lipid profile, through an early intervention, we can reduce their risk factors for cardiovascular disease, and diabetes complications. the aim of our study was to determine the lipid profile of patients newly diagnosed with type diabetes. patients and methods: hundred patients, selected at the outpatient policlinic nr. in tirana, the capital of albania. all the patients had completed anthropometric measures, hba c and lipid profile after a -h fast. the persons younger than years, diabetes diagnosed prior to months, or uncompleted data were excluded from the study. results: we obtained all the data for patients. males ( %), mean age . ae . years, mean bmi . ae . kg/m², mean hba c . ae . %. . % of the patients had a total cholesterol > mg/dl, % of the patients had triglycerides > mg/dl, and . % of them had tg < mg/dl, and % had the ldl > mg/ dl . % of males had hdl < mg/dl and % of women had hdl < mg/dl respectively. conclusions: in our study the lipid profile of albanian patients was somehow different from the common profile of patients newly diagnosed with t diabetes. even in the previous studies we have found a lipid profile with high total cholesterol levels, and especially very low hdl levels, probably due to the sedentary lifestyle, which needs further evaluation, because the metabolic control of our patients was not very bad. background and aims: physical activity (pa) in people with type diabetes helps to improve metabolic control, lipid profile, and to reduce weight. the aim of our study was to demonstrate the effect of a single session of pa to the glycaemic profile, and the effect of increasing daily physical activity on the weight and lipid profile. patients and method: fifty patients were recruited for a weeks training session. every pa session lasted min of fast walking. the number of daily steps was measured through a pedometer, and all the participants were encouraged to complete at least , steps/day. all the patients had completed anthropometric measures, fat body composition and lipid profile at the beginning and the end of study period. background: homocysteine is a cardiovascular risk factor for the development of vascular pathology. large population studies have been conducted demonstrating a positive association between homocysteine levels and risk of developing cardiovascular disease. paradoxically in type diabetes, if renal function is within a normal range, homocysteine levels are either similar or reduced when compared to levels in the normal non-diabetic population. whether the same is true for pre-diabetes has not been previously explored. our study examines the plasma levels of homocysteine in controls, and participants with prediabetes and diabetes from a screening program in regional new south wales. methods: seven hundred and forty-four participants attended the diabetes screening clinic, at charles sturt university, australia. participants were investigated based on the american diabetes association′s diagnostic criteria of diabetes mellitus and prediabetes, i.e. fasting blood sugar levels. venous plasma homocysteine samples were measured using the fluorescence polarization immunoassay on the imx â analyzer (abbott laboratories, abbott park, il). results: median age across the three groups ranged from to years. the median levels for plasma homocysteine between groups were not significantly different. there was a trend for plasma homocysteine (μmol/l) levels to be higher in the prediabetic group . ae . (sd) compared to the control group with . ae . (sd) and in the diabetic group of . ae . (sd). conclusion: there is a non-significant median increase in homocysteine in the pre-diabetes group. further larger cross-sectional population studies would be able to address whether this is a chance effect and also establish statistical significance if present. clinical endocrinology, institute for endocrine pathology problems, kharkiv, ukraine introduction: active acromegaly is associated with increased morbidity attributed by systemic complications such as carbohydrate dysfunction. aims: to evaluate the effects of chronic excess of gh and igf-i on prevalence and structure of carbohydrate dysfunction in patients with active acromegaly. subjects and methods: ninety-seven patients ( men and women; aged - years) with macroadenoma of hypophysis ( somatotropinoma, -somatomammo-tropinoma) were under investigation. blood samples for gh, igf- , immuno-reactive insulin (iri), glucose were taken in fasting state and on min ottg. insulin sensitivity and b-cell function were estimated by homa calculator v. . data are given as m ae se and coefficient of determination (r ) of multiple regression analysis. results: in . % of patients with acromegalia (gh - . ae . ng/ ml; igf- - . ae . ng/ml) different types of carbohydrate dysfunctions (cd) were found out: fasting hyperglycemia ( . %); impaired glucose tolerance ( . %), and diabetes mellitus ( . %). . % of patients have had hyperinsulinemic state. it was no sex differences in the cd structure. iri level was . ae . mu/ml, insulin sensitivity - . ae . %, β-cell activity - . ae . %. homa _ir was positively associated with gh (r = . %, p = . ) and igf- (r = . %, p = . ). homa _b% was positively associated with gh (r = . %, p = . ) and igf- (r = . %, p = . ), and negatively with disease duration (r = . %, p = . ). the gh hypersecretion and length of its pathologic action predetermine the stage of carbohydrate dysfunction from fasting hyperglycemia, impaired glucose tolerance to overt diabetes mellitus. a. vlassopoulos, m. lean, e. combet human nutrition, school of medicine, university of glasgow, glasgow, uk background: protein glycation is a key mechanism behind chronic diseases in both diabetic and non-diabetic individuals. about - % of circulating proteins are glycated in vivo in normoglycaemic blood, but in-vitro studies have hitherto failed to demonstrate glucose-driven glycation below concentration of mmol/l. methods: albumin, mercaptalbumin ( g/l) and plasma was incubated with glucose at different concentrations ( - mmol/l) for weeks at °c. to investigate the effect of oxidation on protein glycation, all protein models were used as native proteins or oxidized proteins (exposed to nmol/l h for h prior to incubation with glucose and throughout the incubation period). fructosamine was measured at and weeks (nitroblue tetrazolium method). oxidised mercaptalbumin and plasma had higher fructosamine concentrations at weeks at mmol/l glucose compared to native controls (p < . ). at mmol/l glucose, the same effect was observed for albumin and mercaptalbumin but not plasma. only oxidized albumin was significantly glycated at weeks with mmol/l glucose (compared to glucose-free control) when native was not. at weeks no effect of oxidation was observed. the current study has for the first time demonstrated the importance of oxidative stress in physiological protein glycation, interacting with glucose and promoting glycation in the early stages of the process. k. elksne , z. paunina , a. jurka , d. rezeberga , p. tretjakovs obstetrics and gynecology, physiology, rigas stradins university, riga, latvia introduction: a growing number of obese women in their reproductive years increases their risk for obstetric complications, but still the exact mechanisms is not known. we created a prospective study in which clinical data were collected from antenatal visits in pregnant women. obstetric outcomes were assessed at delivery. obstetrical outcomes depending on fetal macrosomia and maternal bmi were analysed using the fisher exact test. relationships between pre-pregnacy bmi, gestational weight gain and fetal weight were analysed using spearman rank correlations. results: overweight women had lower total weight gain during pregnancy, but higher risk for obstetric complications such as fetal macrosomia, uterine dysfunction, ceasarean section and ruptures of the birth canal. fetal macrosomia positively correlated with pre-pregnancy weight, but not with gestational weight gain during pregnancy. also male gender is a risk factor for birth weight above g. it is important to increase the number of planned pregnancies, pre-pregnancy visits to doctor in order to inform women about the impact of excess weight on perinatal outcome as fetal macrosomia is associated with impaired maternal bmi. women with bmi normal before pregnancy increased their weight above recommendations during gestation. as excessive weight gain may be a risk factor for long term complications, more information about diet should be provided in antenatal visits. obesity and fetal macrosomia correlate with complications during labour, so additional attention in birth conducting should be paid. background: the obesity epidemic is widely blamed for the rise in type diabetes, but new research suggests it is also linked to the increase in type diabetes (t d). the combination of obesity and t d has a negative impact on metabolic control in patients with t d in particular during pregnancy. aim: to evaluate the rate of overweight or obese women with t d at pregnancy onset according to their body mass index (bmi) and its relation to metabolic control. we performed an analysis of singleton pregnancies of women with t d, who consulted our diabetes outpatient clinic since . results: all women were caucasians with mean age of ae years and average diabetes duration of ae years. only % of all women with t d had a bmi of < kg/m , % were overweight with bmi between . % and . % and % were obese. the metabolic control was similar between the group with normal bmi and bmi > kg/m ( . ae . % vs. . ae . %). in the patients with normal bmi only % started the pregnancy with a hba c < %, which was mainly due to unplanned pregnancies. conclusion: our data revealed a high proportion of overweight women with t d at onset of their pregnancy, confirming the worldwide trend of rising obesity rates and which calls for preventive measures in the preconception counseling. hypertension is more prevalent in hivinfected subjects than in general population, contributing to increased cardiovascular risk in hiv+ patients. moreover, hiv patients more frequently showed metabolic alteration than general population. aim of this study was to evaluate the effect of weeks of administration with telmisartan mg daily in hiv+ patients. we enrolled hiv+ caucasian male patients treated with combined antiretroviral therapy (cart) and discovered to be na€ ıve hypertensive. systolic (sbp) and diastolic (dbp) blood pressure, viro immunological parameters and triglycerides, cholesterol, insulin resistance (homa-ir), inflammatory markers, c-reactive protein (crp), indexes of renal function and cardiovascular risk, microalbuminuria, cystatin c, were measured at baseline (t ), and after (t ), (t ), (t ), (t ), (t ) and (t ) weeks. treatment with telmisartan decreased sbp and dbp levels during the weeks of observation. we also observed improved in totalcholesterol, triglycerides, and in total cholesterol/hdl cholesterol ratio. we also observed an microalbuminuria and cystatin c improvement at the end of study. throughout in the course of the trial our patients showed a significant improvement of the percentage of cd + and cd . telmisartan doesn't interfere with the recovery of immunological parameters in this patients. telmisartan has confirmed durability and effectiveness, excellent tolerability and an high persistance with a good blood pressure control. therefore telmisartan should be the first choice in the treatment of hypertension in hiv+. methods: the subjects studied were patients diagnosed with gdm at ska˚ne university hospital, lund, sweden, - . sera were analyzed for antibody positivity (gada, ia- a and znt a) with commercially available elisa and snps were studied with restriction fragment length polymorphism. results: combinations of two or more autoantibodies ( . %) were less frequent than single positivity for gada ( . %) or znt a ( . %), but not ia- a ( . %). patients that developed t d postpartum often had combinations of autoantibodies. heterozygosity for r w was increased ( %) in patients that developed znt a compared to znt a negative patients ( %). however this was not statistically significant (p = . ). conclusions: the previously reported prevalence of znt a in gdm was confirmed. positivity for znt a did not seem to be a good independent predictor for development of t d. the tendency of increased r w heterozygosity in znt a positive gdm patients is a novel finding and of interest since the snp has been suggested to be of importance in both t d and t d. among several consequences, obesity seems to have detrimental effects on reproductive function, causing low levels of sex hormones and reduced sperm concentration. the excess of lipids on diet influences metabolism and affects testis reproductive function. the relationship between obesity, reproductive changes and metabolic syndrome is not yet fully clarified. thus, the aim of the study was evaluate the effect of high fat diet, containing soybean oil, on body composition and male reproductive system of young rats. wistar rats, at days, received diet containing % (control diet) or % (high fat diet, hf) of soybean oil, until and days of age. food intake and body mass were monitored. at the end, body composition was evaluated by dexa and blood, liver, adipose tissue, testis and epidydimis were collected. glucose, triglycerides, cholesterol, hdl, vldl, insulin and leptin were measured. food intake, body mass gain, lean mass, total fat mass and bone mineral content did not differ between the groups at and days. at days, glycemia and epidydimal adipose tissue mass were increased in rats fed with hf. at days, glycemia, leptinemia and the mass of mesenteric adipose tissue, liver and epidydimis were high after hf ingestion, while tg was low. the excess of lipids reflected negatively on intra-abdominal adipose tissue since days, accompanied by hyperglycemia. the hf ingestion maintained high glucose and leptin concentrations without insulin alteration. at the same time, it could predict some testis function change, once epidydimis mass increased in these young animals. adipose tissue is linked to cardio-vascular and metabolic complications of obesity by increased local production of adipokines.to investigate serum levels of adipokines (adiponectin and leptin) and relationship with obesity anthropometric markers and insulin resistance in overweight/obese patients with type diabetes. two groups of subjects were selected: group with type diabetes mellitus (n = ) and control group (n = ). the first group was subdivided in two subgroups, according with bmi (overweight and obese). in all individuals were assessed bmi, waist and hip circumference, visceral fat index, serum levels of adiponectin, leptin, insulin and proinsulin and homa-ir was calculated. the determined parameters were modified significantly in the diabetic patients vs. control. comparing the obese diabetic patients with the overweight, serum levels of leptin were higher on obese/overweight (p < . ) and levels of adiponectin were lower (p < . ). also, serum levels of insulin and proinsulin were higher in diabetic vs. control group maintained their statistical significance difference in the subgroups of overweight/obese (p < . and, respectively, p < . ). bmi was positively correlated with leptin (p < . ) and adiponectin negatively (p < . ). moreover, leptin was positively correlated with visceral fat index (p < . ), waist circumference (p < . ) and homa-ir (p < . ); adiponectin was negatively correlated with waist circumference (p < . ), visceral fat index (p < . ) and homa-ir (p < . ). in conclusion positive correlation (leptin) and negative (adiponectin) with anthropometric markers of obesity and homa-ir, demonstrating the role of adipokines in the pathogenesis of peripheral insulin resistance in patients with "diabesity." materials and methods: based on research institute of nutrition we randomly chose patients with varying class obesity, who were outpatient for this disease. all patients were tested on the personal scale manifestations of anxiety (d. teylor in adapting t. nemchina). patients were asked to read a set of sentences ( questions) about their traits. if they agreed with the statement they should answer "yes" if they did not agree -"no". the test had a ball-evaluation, in which anxiety is defined as very high, high, medium and low. objectives: the process of converting prediabetes to diabetes remains a matter of debate. the aim of the study was to assess insulin sensitivity/resistance indices and markers of oxidative stress in prediabetic persons. methods: obese non-smoking caucasians, using neither special diet nor medication, without acute and chronic disorders, were qualified for ogtt and assigned to groups: normal glucose tolerance-ngt, impaired fasting glycemia-ifg, impaired glucose tolerance-igt and newly diagnosed type diabetes-t dm, each group n = subjects: f/ m; age : - (median: quartiles - ). plasma glucose (siemens) and insulin (biosource) were determined during ogtt ( ', '). plasma total antioxidant status-tas (randox), thiobarbituric acid-reacting substances-tbars (sigma), lipids and hscrp (siemens), as well as hba c (hplc) were assayed fasting. different indices of insulin sensitivity/resistance, fasting steady-state and derived from ogtt, were calculated. results: the groups did not differ according to age, bmi, waist, blood pressure, lipids and hscrp. insulin sensitivity/resistance indices presented variety of sensitivities and specificities for prediction of dysglycaemia categories, as well as different correlations with metabolic parameters, including oxidative stress, i.e. isi , &tas (r = . ), isi , &tbars (r = À . ) in the population n = . the comparison of ngt-ifg-igt-t dm, showed the highest tas in ifg and the lowest in t dm (p = . ), together with increasing tbars from ngt to t dm (p = . ). the results of roc curves analysis pointed isi , ( % sensitivity; % specificity) for prediction of igt, and tas ( % sensitivity; % specificity) in differentiation between igt and t dm. conclusions: insulin-sensitivity indices predict prediabetes in obese subjects near perfectly, while the development of diabetes is preceded by antioxidant insufficiency rather. m. smiraglia , g. bott a , e. orsi endocrinology and diabetolgy, fondazione ca' granda irccs -ospedale maggiore policlinico di milano, biomolecular sciences and biotechnology, university of milan, milan, italy t dm is a metabolic disorder and evidences show that medical nutrition therapy improving glucose metabolism reducing the risk of complications, leads to an improvement in life quality and increase life expectancy. the aims of diabetes management are normalize blood glucose levels and weight control. obesity influences the development of t dm and complicates its management. the study aim was to value the effect of two different nutritional treatments (nt) on the anthropometric parameters and glucose metabolism in patients with t dm and obesity. the two nt are: the "low gi diet" that promotes the carbohydrates quality and the food choice is made on the glycemic index; the "low-carbohydrate diet" is based on the concept that glucose metabolism is influenced also by the carbohydrates amount. subjects, selected on including and excluding criteria, were randomly divided in two groups, to each of which one of the two nt was assigned. during the study participants were measured three times. all statistic differences in the values were analyzed with the use of anova test. the "low-gi group" showed a significant decrease in hba c (À . %; p = . ). data suggest that this nt positively influences the glycemic control. the "low-carb group" showed a significant decrease in insulin level (À . %; p = . ), a greater reduction in bmi and whr and a homa-insulin resistance index reduction (À . %; p = . ). the daily reduction of carbohydrate intake influenced positively the blood glucose response and significantly reduced plasmatic insulin levels. data suggest that either nt improves glycemic control and peripheral insulin sensitivity. aims of study: the use of metformin to control glucose in pregnant women with gestational diabetes mellitus (gdm) to evaluate its safty use during the first trimester of pregnancy. design: cases report of four patients with gdm from the first trimester of pregnancy non smoking with no family history of congenital malformation disease, aged between ( and ) and have no liver diseases put on metformin were participated in this study and who had indicating good comliance at more than one visit over several month until delivery. result: all four patient in oure study delivered healthy babies. internal medicine, ist medical clinic, umf iuliu hatieganu cluj-napoca, immunology laboratory, emergency county clinical hospital, cluj-napoca, romania introduction: the potential role of oxidative stress (os) in metabolic syndrome (mets) is rapidly evolving. reported results support the concept that increased os may play a key role in the development of atherosclerosis, hypertension and diabetes. study aim: the purpose of the present study was to analyze the impact of mets and its individual components on os and on the antioxidant status. material and methods: seventy-two hospitalized patients with a mean age . ae . years were taken under study between october and june . mets was diagnosed based on aha/nhlbi/idf definition. os was assessed by urinary iso-prostaglandinf a ( iso-pgf a) (immunometric assays) and plasmatic uric acid. antioxidant status was evaluated by plasmatic gluthatione peroxidase (gpx). these data were compared to those of biologically and clinically healthy subjects (mean age . ae . years). results: all biomarkers were significantly higher in mets patients as compared with healthy individuals (p < . ), except gpx which was significantly lower (p < . ). gpx and uric acid were statistically significant correlated. in multivariate analysis iso-pgf a concentrations were influenced by hypertension, fasting glucose and triglycerides, uric acid levels were directly influenced by hypertension, waist circumference, fasting glucose and triglycerides. gpx levels were inversely correlated with blood pressure (all p < . ). only gpx was influenced by the number of mets components. objective: the purpose of this study was to compare changes in the plasma metabolome during an intravenous glucose tolerance test (ivgtt) among persons with low or high insulin sensitivity (si < . or > . ). methods: ivgtts were performed in men and women, ae years, with low si ( . ae . ) and men and women, ae years, with high si ( . ae . ). targeted electrospray ionization, tandem mass spectrometry was used to measure plasma concentrations of amino acids and acylcarnitines during the first phase of the ivgtt. other metabolites (glucose, insulin, etc.) were measured by conventional methods. results: fasting glucose, insulin, triglycerides, glycerol, free fatty acids, leucine/isoleucine, tyrosine, glutamate/glutamine, -hydroxypalmitoleylcarnitine (c : -oh)/dicarboxytetradecanoylcarnitine (c : -dc), and docosanoylcarnitine (c ) were significantly higher in the low si group, whereas ornithine was significantly lower. in response to glucose infusion, rates of disappearance of alanine, proline, valine, leucine/ isoleucine, methionine, and phenylalanine were %, %, %, %, %, and % lower, respectively, in the low si group. there were no group differences in changes in circulating concentrations of free fatty acids, glycerol, triglycerides, or acylcarnitines. conclusions: insulin resistance is associated with lower rates of disappearance of neutral, non-polar amino acids during the first phase of the ivgtt, suggesting insulin-mediated clearance of amino acids and/or suppression of protein catabolism may be impaired. cigarette smoking is worrisome in adults and also in adolescents. actually, smoking rates have grown, especially among girls, and little is known about the damages caused in these organisms still young or the consequences in adulthood. this study aim evaluates the influence of smoking in puberty and the consequences of withdrawal, body composition of female and male mice. at days, mice were exposed to r f cigarette (tobacco and health research institute) smoke, h/day for days (s, n = ). then, half of animals were evaluated and the other half was maintained and evaluated days after stop exposure ( d as). an unexposed group accompanied the events (ns, n = ). body mass, body composition (dexa), food intake, blood, ipgtt and adipose tissue were evaluated. during exposure food intake was similar all groups, however, s groups showed low body mass gain. das, s groups increased body mass and food intake in females. no alterations body composition were in males, while in females, increased total body and trunk fat during exposure and lean mass das. fat was high epidydimal and retroperitoneal in females. in regard blood, males did not alter insulin or ipgtt during exposure whilst females had high insulin levels and glycemia at min. withdrawal induced in males, high insulin and low glycemia the ipgtt and in females normal insulin and low glycemia. the set of results indicates different response cigarette smoke in young that seem to start in females and lead malefic metabolic alterations in adulthood. methods: this retrospective study included children and youths ( boys) from the children's obesity clinic. data were measured at the time for inclusion and included values of body mass index (bmi) standard deviation score (sds), blood pressure, gender, and biochemical measures, including the fasting concentrations of blood glucose, serum insulin, hba c, and serum lipids. the bmi sds was median . (range . - . ) and the age was median . (range . - . ) years. prediabetes was classified as a fasting blood glucose ! . and < . mmol/l. the mann-whitney-wilcoxon test was used for the analyses. results: prediabetes was present in ( boys) patients. these patients were older, age median . vs. . years (p = . ), had a higher bmi sds median . vs. . (p = . ), an increased fasting hba c median vs. mmol/mol (p < . ), an increased fasting serum insulin median . vs. pmol/l (p < . ), and an increased median homa-ir . vs. . (p < . ), respectively, compared to the patients with a fasting plasma glucose < . mmol/l. no differences were found in any of their fasting serum lipid levels or blood pressure (p > . ). in this large group of overweight and obese children prediabetes is prevalent. thus it seems important to identify obese subjects with prediabetes in order to prevent development of diabetes during childhood. introduction: epidemiological spreading of diabetes and developing in early age urge for finding causes and prevention before manifestation. aim of the study was testing accelerator hypothesis t. wilkin and colleges. method: the study is combined retrospective prospective. we examined history and follow up till age of years children who were referred to pediatrician endocrinologist because of obesity or diabetes. results: children from obese mothers and children with lower birth weight have more metabolic disturbances (insulin resistance, neonatal hypoglycemia, obesity, diabetes, precocious puberty, menstrual irregularity). subjects and methods: twenty-two obese women (bmi ae kg/m ) were followed during di that consisted of a days′ very-low-caloriediet (vlcd) and subsequent months low-calorie-diet followed by a months′ weight maintenance diet (wm). mrna expressions of adipokines (leptin, adiponektin, interleukines (il) - ,- ,- , tnfa, macrophage-chemoattractant-protein (mcp- ), haptoglobin) were measured, using rt-pcr, in samples obtained from abdominal scat at baseline and at the end of vlcd and wm, respectively. results: body weight (bw) and plasma crp decreased during vlcd and at the end of wm (bw: . ae . vs. . ae . vs. . ae . kg (p < . ), crp: . ae . vs. . ae . vs. . ae . mg/l (p < . ), respectively). the decrease of plasma crp during the entire months′ di correlated positively with the decreases of mrna expression of mcp- . (r = . , p < . ) and il- (r = . , p < . ) during the entire di and with the decrease of leptin mrna during initial vlcd (r = . , p < . ). no correlations were found for other adipokines. objective: to determine associations between change in lean body mass (lbm), fat mass and muscle strength with is following month of resistance training in obese postmenopausal women. methods: thirty-four ( with and without metabolic syndrome) non-diabetic obese postmenopausal were recruited. participants completed a month resistance training program ( times/week). body composition (dxa), handgrip strength and quadriceps strength were measured. fasting glucose and insulin levels as well as ogtt derived is indices (stumvoll, matsuda) and homa were also measured. non parametric correlations were performed with spss ( . ). results: significant increases in muscle strength, is and lbm as well as decreases in fat mass were observed after the intervention. however, no correlations were observed between changes in is with changes in muscle strength, lbm or fat mass in all participants as well as in subjects with or without the metabolic syndrome. conclusion: our results suggest that the changes in muscle strength, lbm and fat mass may not be associated with changes of is in obese postmenopausal women. therefore, other potential variables seem to be implicated in the changes of is in our cohort. objective: to examine the relation between total work (tw) performed and total heart rate work performed (trimps) with changes in cardiometabolic risk factors after resistance training in obese postmenopausal women. methods: thirty seven postmenopausal women (age: ae . , bmi: . ae . ) completed a month resistance training program ( times/week). body composition (dxa), blood pressure, metabolic risk factors (insulin sensitivity, h glucose, lipid profile and crp) and muscle strength were measured before and after the intervention. moreover, tw was calculated in each session by multiplying the number of repetitions, sets, weight and range of motion. thereafter, we added all training sessions. a heart rate monitor was used to assess trimps during each session. subjects were also categorized into two groups based on the top or lower th percentile of tw and trimps (high (n = ) vs. low (n = )). results: we showed that tw negatively correlated with systolic blood pressure and h glucose levels (p < . ). in addition, crp was negatively associated with trimps (p < . ). furthermore, high workers had lower levels of fat mass percentage and h glucose as well as higher lean body mass content than low workers. as for the high trimps group, we observed lower levels of crp compared to the low tripms group (p < . ). conclusion: results indicate that the quantity of work performed during resistance training is associated with better changes in metabolic risk factors in obese postmenopausal women. research design and methods: this cross sectional study included gestational diabetes patients who were diagnosed with gdm by a g ogtt and who underwent a standardized mixed meal tolerance test (mmtt). patients were divided into three groups according to the number of abnormal hyperglycemic values (group i for values, group ii for values, and group iii for values). glycemic parameters were compared to assess glycemic control (glucose, a c, ga) and gluco-metabolic homeostasis (homa-β, homa-ir). results: a total of gdm patients were recruited for this study. subjects whit a greater number of hyperglycemic values were also more hypertensive and obese, and had decreased insulin secretory functions than those with a lower number of hyperglycemic values (lnhoma-β, . ae . vs. . ae . , . ae . , p < . ). those with higher hyperglycemic values tended to have increased insulin resistance, but this result was not significant (lnhoma-ir, . ae . vs. . ae . , . ae . , p = . ). lnhoma-β correlated negatively with fasting glucose, a c, ga and ga/a c. multivariable regression analysis revealed that age and ga were significant independent predictors for lnhoma-β (standardized β = À . , À . , respectively, p < . ) but not a c. conclusions: korean women with dysfunctional pancreatic β-cells and increased insulin resistance are prone to gestational diabetes. ga, but not a c, is significantly correlated with pancreatic β-cell function. conclusion: altered adipokine profile is associated with increased cvd risk in pcos patients. these markers can serve as potential therapeutic target for decreasing their cv risk. objective: to determine the prevalence and determinants of nonalcoholic fatty liver disease (nafld) in a sample of adult iranian general population. method: this was a cross-sectional study being performed in shiraz, southern iran during a -month period from november to september through cluster random sampling of iranian general population in shiraz region. all individuals underwent anthropometric and blood pressure measurements and thorough medical history and physical examinations. laboratory measurements included fasting blood glucose (fbs), lipid profile, complete blood count (cbc) and liver function tests. nafld was diagnosed by transabdominal ultrasonography. result: overall we included subjects in this study among which there were males ( . %) and females ( . %) with the mean age of . ae . years. nafld was diagnosed in ( . %) subjects. patients with nafld were significantly older (p < . ), had higher proportion of male gender (p = . ) and had higher bmi (p < . ). they also had higher prevalence of hypertension (p < . ), high fbs (p < . ), high cholesterol (p = . ), high triglyceride (p < . ) and high waist circumference (p < . ). taking all these together, patients with nafld had significantly higher prevalence of metabolic syndrome when compared to healthy subjects (p < . ). conclusion: the prevalence of nafld in this group of iranian adult general population is . %. nafld in iranian population is associated with male gender, old age, obesity, and features of metabolic syndrome. a. othman , t. hornemann university hospital zü rich, clinical chemistry, university hospital zü rich, zü rich, switzerland -deoxysphingolipds (dsl) are atypical and neurotoxic sphingolipids which are formed by the enzyme serine-palmitoyltransferase (spt) due to a promiscuous use of l-alanine over its canonical substrate l-serine. pathologically elevated dsl levels were identified as a cause for the rare and inherited sensory neuropathy hsaniwhich is associated with several missense mutations in spt. significantly elevated dsl levels were also found in patients with mets or t dm as demonstrated in various clinical studies. principal component analysis identified the dsls as important descriptors for the mets statecomparable to triglycerides and superior to conventional mets biomarkers like fasting glucose or wcf. partial correlation analysis showed an independent correlation to plasma glucose and triglycerides. strikingly, recent data from prospective clinical studies identified plasma dsls as highly significant and independent predictors for the risk to develop t dm. elevated dsl levels were also confirmed in plasma and liver of stz rats. the dsls are therefore clinically relevant blood biomarkers for an impaired glucose homeostasis but might also be directly involved in the pathology of diabetes related sequelae. like observed in hsan the -dsl formation is significantly suppressed in response to an oral l-serine supplementation. feeding an l-serine enriched diet to stz rats resulted in a significant reduction of plasma dsls, a significant improvement of neuropathic symptoms and reduced cataract formation. our findings strongly support the value of dsls as novel and clinically relevant biomarkers in mets and t dm but also as therapeutic targets for the treatment of the diabetic neuropathy and other sequelae. objectives: prevention of cardiovascular disease focused on the early stages of atherosclerosis, including endothelial dysfunction, should arouse attention of clinicians in dysglycaemia patients especially. the aim of the study was to assess plasma e-selectin concentrations in newly diagnosed type diabetes (t dm) and in t dm patients treated with metformin, comparing with normoglycaemic individuals. material and methods: excess body mass non-smoking males and females, - years old, presented with neither acute nor chronic disease, were enrolled into the study. oral glucose tolerance test (ogtt) was performed to find normal glucose tolerance, group- (n = , age: median ; interquartile range - ) and newly diagnosed t dm, group- (n = , age: ; - ). group- consisted of t dm patients who take medication (metformin) for at least year (n = , age: ; - ) and present no retinopathy, nephropathy and neuropathy, as well as no history of coronary incident or stroke. all participants were measured plasma glucose (g- , g- ), fasting lipids and insulin, and hba c level. e-selectin concentration in plasma was assessed using elisa method (r&dsystems). data are shown as median and interquartile range. results: groups - - did not differ in respect to their age and bmi. the comparison among groups, followed by post hoc analysis, revealed different (p = . ) e-selectin concentrations, ng/ml: group- : . ( . - . ), group- : . ( . - . ), group- : . ( . - . ). in combined group + (n = ) the correlation e-selectin&g- ' was observed independently from bmi and triglycerides (multiple regression β = . ; r = . ; p = . ). conclusion: metformin therapy may limit early stages of atherosclerosis in t dm patients not only works to decrease plasma glucose. aim: to evaluation clinical efficacy of candesartan and its effect on parameters of vascular elasticity, lipid profile, lipid peroxidation and antioxidative protection against a background of single-candesartan therapy in females with arterial hypertension (ah) and abdominal obesity (ao) during menopause. methods: forty-six patients were divided into two groups. group ( subjects) were given candesartan and group ( subjects)enalapril. twenty-four hour blood pressure monitoring (bpm), pulse wave velocity; plasma lipids, diene conjugates (dc), malonic dialdehyde, superoxide dismutase (sod) and homocysteine, uric acid were estimated. the dynamics of all parameters was evaluated initially and in weeks. results: candesartan is a more effective hypertensive drug that has a valid effect on the readings of systolic blood pressure (sbp) and diastolic blood pressure (dbp) measured in the doctor's office and on the parametrs of bpm (daily sbp and dbp, daytime and nighttime sbp and dbp, sbp and dbp variability, the rate of morning rise in sbp and dbp). we revealed a favorable effect of the medication on vascular wall elasticity, valid reduction of cholesterol, low-density lipoprotein cholesterol, triglycerides, dc, homocysteine and uric acid increase in sod in group . the proved antihypertensive effect of the candesartan therapy against a background of normalization of vascular wall elasticity, plasma lipids and processes of lipid peroxidation, in the presence of differently directed correlations between clinical and biochemical characteristics, shows that candesartan has pathogenetic mechanisms of correcting ah in females with ah and ao during menopause. background: high intensity interval training (hiit) may improve insulin action in skeletal muscle, but this has never been shown. objective: to study the effect of hiit on insulin mediated glucose uptake rate in skeletal muscle. methods: four healthy sedentary males [age ae years (mean ae se), bmi . ae . kg/m ] were included. a total of eight one-legged training sessions were performed on an ergometer bicycle as min high intensity exercise (workload > % of one-legged vo -peak, and heart rate > % of maximal heart rate) with min recovery between each interval. lean leg mass before and after the training period was assessed using dual-energy x-ray absorptiometry. forty hours after the last training session, a two-step isoglycemic, hyperinsulinemic clamp was performed in combination with arteriofemoral venous catheterization. blood flow was measured with doppler ultrasonography. data were expressed per kg lean leg mass, and differences were tested by t-test. results: insulin stimulated glucose clearance rates were significantly higher in trained compared with untrained legs in both steps of the clamp (figure). the lean mass of the trained legs did not significantly differ from the untrained legs (p = . ). conclusion: hiit increases insulin stimulated glucose uptake in skeletal muscle in the leg after a very short training period. it is a time-effective training modality which may be attractive in the treatment of insulin resistance and type diabetes. (htgpos) and that this htgpos is related with the degree of insulin resistance. our aim was to characterize the adipose tissue of morbidly obese patients with mild or severe htgpos after a fat overload though the expression of a battery of genes involved in lipid metabolism. methods: we studied morbidly obese patients who had mild or severe htgpos after fat overload (patent p ). measurements of anthropometric and biochemical variables and oxidative stress biomarkers were done. samples of visceral adipose tissue were obtained during bariatric surgery in the morbidly obese patients. the rna isolation from adipose tissues was done using rneasy lipid tissue mini kit and the gene mrna expression levels were assessed by real-time pcr using an abi prism sequence detection system. results: no significant differences were observed in biochemical variables except in triglyceride levels between the two groups of morbidly obese patients with postprandial mild or severe htgpos. the morbidity obese patients with severe htgpos had a higher oxidative stress levels. genes involved in the management of triglycerides or lipid metabolism were up-regulated in morbidly obese patients with severe htgpos. conclusion: morbidly obese patients with severe htgpos had a more active adipose tissue regarding the expression of genes involved in lipid metabolisms, these data could indicate a greater flow of lipids and a greater insulin resistance in these patients. patients and methods: three hundred and nine workers ( m/ f; aged ae ; bmi . ae . kg/m ), without previous cardiovascular events, were enrolled. all subjects were evaluated for biochemical analytes (fibrinogen, c-reactive protein, uric acid, creatinine, triglycerides, t-cholesterol, hdl, ldl, homocysteine, glucose, insulin, hba c, (oh) d). all parameters were routinely assayed in corelab. these parameters together with homa-ir, systolic and diastolic blood pressure, bmi, age, percent of fat and waist circumference were processed by neural networks (autocm). the autocm matrix of connections preserves non linear associations among variables, while at the same time capturing elusive connection schemes among clusters that are often overlooked by traditional cluster analyses. results: with an appropriate pre-processing able to handle each variable according to its high and low values, auto-cm showed a clear association between (oh) d and metabolic status with graph links suggesting a protective role of high (oh) d against increase in bmi, waist circumference and abdominal fat. these associations were not clearly visible with traditional data mining tool. the neural networks map identifies the key role of vitamin d respect to all metabolic parameters considered in our study in the development of prediabetes drawing a physiopathologic road map for obesity and type diabetes. patients and methods: the study included type diabetic patients and healthy volunteer of the same age and sex. blood sample was taken for assessment of omentin and oxldl by elisa technique. also blood sample were taken for analysis of glycosylated hemoglobin, lipid profile and urine sample was taken for assessment of albumin/creatinine ratio. twenty-four hour holter was also done. the study included patients with type diabetes, their mean age were . ae . years ( . - . years), and mean duration of diabetes were . ae . years ( . - . years). omentin was significantly lower, while oxldl was significantly higher than controls. omentin had a significant negative correlation with oxldl and albumin/creatinine ratio and h holter (minimal hr, rms) and positive correlation with vldl. conclusion: a significant reduction of omentin and elevation of oxldl imply that they influence glucose metabolism in type diabetes. omentin had a significant relation to h holter may reflect its role in cardiac affection. while, albumin/creatinine ratio had a significant negative correlation with omentin and positive correlation with oxldl reflect their role in renal affection. patients and methods: the study included type diabetic patients and healthy volunteer of the same age and sex. blood sample was taken for assessment of chemerin, vaspin, adma and oxldl by elisa technique. also blood sample were taken for analysis of glycosylated hemoglobin, lipid profile and urine sample was taken for assessment of albumin/creatinine ratio. twenty-four hour holter was also done. the study included patients with type diabetes, their mean age were . ae . years ( . - . years), and mean duration of diabetes were . ae . years ( . - . years). chemerin, vaspin and oxldl were significantly higher, while adma was significantly lower than controls. chemerin had a significant positive correlation with vaspin, adma and oxldl. vaspin had a significant positive correlation with waist/height ratio, sdann, sdrr and sddrr. albumin/creatinine ratio had a significant positive correlation with chemerin, adma and oxldl. conclusion: a significant reduction of adma and elevation of chemerin, vaspin and oxldl imply that they influence glucose metabolism in type diabetes. vaspin had a significant relation to h holter may reflect its role in cardiac affection. while, albumin/ creatinine ratio had a significant positive correlation with chemerin, adma and oxldl reflect their role in renal affection. patients and methods: the study included type diabetic patients and healthy volunteer of the same age and sex. blood sample was taken for assessment of apelin, nitrous oxide and preptin by elisa technique. also blood sample were taken for analysis of glycosylated hemoglobin, lipid profile and albumin/creatinine ratio in urine. m mode echocardiography was also done. results: the study included patients with type diabetes, their mean age were . ae . years ( . - . years), and mean duration of diabetes were . ae . years ( . - . years). nitrous oxide was significantly lower, while apelin, preptin and albumin/creatinine ratio were significantly higher than controls. nitrous oxide had a significant positive correlation with lvedd, lvesd, pwt and lv mass and negative correlation with preptin and albumin/creatinine ratio. conclusion: a significant reduction of nitrous oxide and elevation of apelin and preptin and their relation to echocardiographic data imply that early assessment of these markers may unmask the initial endothelial dysfunction in type diabetic patients before overt microalbumin and renal impairment supervenes. obesity co-morbidities may appear already early in life in high-risk individuals. today we have no means to identify which obese children who are at highest risk. consequently, we have implemented a study with the objective to identify factors in obese children that could indicate early development of related co-morbidities. in this abstract we have concidered fasting glucose, h ogtt, and degree of obesity as predictors. severely obese children and adolescents treated for obesity between and (n = ), but not undergone bariatric surgery, are included. currently, follow-up measurements have been conducted in subjects. study participants undergo extensive examinations during days including e.g. cardio respiratory fitness, body composition, both oral and intravenous (ivfsgtt) glucose tolerance tests. average age of the first subjects is . years ( . - . ). follow-up time varies from . to . with an average of . years. bmissds at baseline . ( . - . ) correlates with bmi at follow-up (y = . x + . , r = . ). no other correlations with degree of obesity at baseline could be found. fasting glucose at baseline correlates with crp . years later. however, fasting glucose was not correlated with h ogtt, insulin sensitivity, diabetes, or prediabetes at follow-up. no correlations between h ogtt value at baseline and later co-morbidity was found. in the first studied subjects all, but one, of the severely obese children remained obese in early adulthood. higher level of fasting glucose at baseline predicted higher crp at follow-up. analyses from more collected data will be presented. background: obesity acts as an independent cardiovascular risk factor by mechanisms that are not fully understood. elevated levels of the pro-inflammatory cytokines interleukin(il)- , il- and plasminogen activator inhibitor (pai)- are found in obese patients. recent studies suggest that inflammation could be an adaptive response to hypoxia within the expanding adipose tissue mass. in this study we investigated the impact of hypoxia on pai- , il- and il- regulation in human adipose tissue ex vivo and in vitro. methods: primary human preadipocytes and adipocytes were prepared from subcutaneous and visceral adipose tissue. explants, preadipocytes and adipocytes were cultured under hypoxic conditions. pai- , il- and il- antigen were quantified by elisas, mrna levels were determined by realtimepcr. results: pai- , il- and il- secretion was significantly increased under hypoxic conditions in subcutaneous and visceral adipose tissue explants. hypoxia significantly upregulated il- production in preadipocytes and adipocytes up to -fold and -fold. il- and pai- were significantly increased by hypoxia in preadipocytes and adipocytes up to -fold and -fold (il- ) and . -fold and . -fold (pai- ), respectively. these results were confirmed on the level of mrna expression. conclusion: our data show that hypoxia increases il- , il- and pai- production in adipose tissue explants and in cultured human preadipocytes and adipocytes. we therefore hypothesize that hypoxia promotes the pro-inflammatory state seen in obese patients and thus could contribute to the elevated risk for cardiovascular diseases. this study sought to characterize the antioxidant properties and interaction of phenolic (free and bound) extracts from clerodendrum volubile (a leafy vegetable commonly grown and consumed in south eastern part of nigeria), with key enzymes relevant to non-insulin dependent diabetes mellitus (a-amylase and a-glucosidase) in vitro. the free phenolics of clerodendrum volubile were extracted with % acetone, while the bound phenolics were extracted from the alkaline and acid hydrolyzed residue with ethyl acetate; and their interaction with the enzymes were assessed. the phenolic extracts inhibited a-amylase, aglucosidase and fe + -induced lipid peroxidation in pancreas (in vitro) in a dose-dependent manner. however, bound phenolics had significantly higher (p < . ) a-glucosidase inhibitory activities, than free phenolics while there was no significant difference (p > . ) in their a-amylase inhibitory activities. the stronger inhibition of a-glucosidase when compared to a-amylase in both extracts is of pharmacological relevance. the stronger action of the bound phenolic extract on a-glucosidase may explain the possible bioactivity of the phenolics at the brush border end. the phenolic profile in both extracts revealed the presence of phenolic acids and flavonoids. moreover, the inhibitory properties of phenolic rich extracts from clerodendrum volubile on a-amylase, a-glucosidase and fe + -induced lipid peroxidation in pancreas could be attributed to the antioxidant properties of the extracts. from the study, clerodendrum volubile could serve as functional foods and nutraceuticals for early intervention and management of non-insulin dependent diabetes mellitus. department of kinesiology and nutrition, university of illinois at chicago, chicago, il, usa background: alternate day fasting (adf), consisting of a feed day ( -h ad libitum food intake) alternated with a fast day ( % energy restriction), is effective in reducing body weight and modulating adipose tissue physiology. however, the ability of adf in combination with endurance exercise to improve the above variables has never been tested. objective: accordingly, this study examined whether the combination of adf plus exercise produces superior changes in body weight and plasma adipokine levels, when compared to each treatment alone. methods: obese subjects (n = ) were randomized to one of four groups for weeks: . combination (adf + endurance exercise), . adf, . exercise, or . control. results: body weight was reduced (p < . ) by ae , ae , and ae kg, and fat mass decreased (p < . ) by ae , ae and ae kg in the combination, adf and exercise group, respectively. fat free mass was retained in all groups. adiponectin and resistin values did not change in any group post-treatment. leptin levels significantly decreased (p < . ) by ae , ae and ae ng/ ml in the combination, adf, and exercise group, respectively. conclusion: these findings suggest that the combination of adf plus exercise produces superior changes in body weight, body composition and leptin levels, when compared to each intervention alone. the plasma total cholesterol and triglycerides concentration were higher than other groups. adipokines results were that resistin, adiponectin, leptin, and tnf-a were significantly lower than [hf], [br] and [hc] . so it had a effect on anti-obesity. these results showed that functional rice especially giant embryonic components will probably be useful in the management of high fat diet-induced chronic disease. m.g. watve , m.s. diwekar , p. patil biology, indian institute of science eduction and research, physiology, bharati vidyapeeth medical college, pune, india a crucial link in the classical thinking of type diabetes (t d) is that insulin resistance (ir) is primary and hyperinsulinemia develops to compensate. high levels of insulin are associated with an insulin resistant state. there have been alternative suggestions that insulin overproduction is primary and ir develops to compensate it. it is also likely that both are secondary effects of an unknown primary cause. we critically examine the alternative possibilities in the light of theory and evidence. temporally hypoglycemia and/or hyperinsulinemia precede insulin resistance in human and animal iugr models. various gene knockouts show that primary muscle and adipose insulin resistance does not lead to hi. in insulinomas, where hyperinsulinemia is primary, insulin resistance develops almost invariably and removal of such tumors increases insulin sensitivity. if ir sets in first, pancreas must sense the ir and increase the insulin production accordingly. if raised blood glucose mediates the response, we expect a positive correlation between fasting glucose and fasting insulin in prediabetic individuals. however, such a correlation is not seen in a large set of data on normoglycemics. no other mechanisms have been postulated that can measure the level of ir and in turn regulate the insulin secretion by beta cells. on the other hand many pathways exist that can induce ir when beta cells overproduce insulin. overall there is substantially more evidence for the hyperinsulinemia-first hypothesis. this can potentially undermine our current understanding of t d and the entire chain of processes leading to t d needs to be re-examined. non-alcoholic fatty liver disease (nafld) is emerging as the most common liver disease in industrialized countries. the discovery of food components that would ameliorate nafld is therefore of interest. betulinic acid (ba) is a pentacyclic triterpenoid showing many pharmacological activities, but effect of ba on fatty liver is largely unknown. to explore the anti-fatty liver activity and mechanism of ba, insulin resistant hepg cells, primary rat hepatocytes and liver tissue of icr mice fed on hfd were utilized. oil red o staining revealed that ba significantly suppressed the excessive triglyceride accumulation in hepg cells and liver of mice fed on hfd. ca + -calmodulin dependent protein kinase kinase (camkk) and amp-activated protein kinase (ampk) were both activated by ba treatment. in contrast, protein expression of sterol regulatory element-binding protein (srebp ), mammalian target of rapamycin (mtor) and s kinase (s k) were all suppressed when hepatocytes were treated with ba for up to h period. ba activated ampk by phosphorylation, suppressed srebp mrna expression and nuclear translocation and repressed srebp target gene expression in hepg cells and primary hepatocytes, leading to reduced lipogenesis and lipid accumulation. these effects were completely abolished in the presence of sto- (a camkk inhibitor) or compound c (an ampk inhibitor), indicating that bainduced anti-hepatic steatosis was mediated through modulation of camkk-ampk-srebp signaling pathway. taken together, our results suggest that ba can effectively ameliorate intracellular lipid accumulation in liver cells, and thus it may be a potential therapeutic agent for treating fatty liver disease. blood glucose concentration, insulin level, glucokinase, g pase and pepck were significantly decrease relative to the [hf] . in addition, antioxidantresults were that cat, sod and gpx were higher than [hf] . effect of rice supplementation type of giant embryonic on erythrocyte tbars and plasma tbars showed significantly decrease than other groups. these experiments suggest that components of giant embryonic help to lower the level of and blood glucose which reduces the risk of heart disease and diabetes. method: a g o-gtt was performed in normal-weight (n) healthy females, females with overweight and females with obesity (grades - ), with measurements of glucose and insulin. homa-insulin resistance (ir) and belfiore-insulin sensitivity (is) were caldulcated. the th percentile in the n group was used as cut-off. results: ir was present in . % of women with normal weight and in . % of women with overweight/obesity. . %, . % and . % of women have ir in the obesity grade , and , respectively. further risk factors for ir are age, hip-waist ratio, triglycerides, hdl, uric acid, pai- and fibrinogen (p < . ). hba c is irrelevant for the detection of ir. hormonal imbalances (hyperandrogenemia, igf deficiency, hypothyroidism, elevated estradiol) play a major role in obese women. postmenopausal women receiving hormone replacement therapy (hrt) develop hyperglycemia, as expected by age, but not ir. hrt improves is. discussion: ir is the common pathogenetic factor for risk components summarized as "metabolic syndrome": dyslipidemia, hypertension, hyperandrogenism and obesity. the vicious circle is intensified with the degree of ir. during the to -year interval between the onset of ir and the manifestation of dm, significant micro-and macroangiopathies can develop. early detection of ir is therefore crucial for the prevention of dm and cvd. the costs involved for diagnosis are minimal ( - €) compared to the cost of treatment for dm and cvd. the effect of dietary feeding of "superjami" on the glucose metabolism and antioxidative status in mice under high fat diet conditions was investigated. the mice were randomly divided and given experimental diets for weeks: normal control (nc group), high fat (hf group), and high fat supplemented with heukjinju (hf + hj group), suwon (hf + sw group) and superjami (hf + sj group). at the end of the experimental period, the hf group exhibited markedly higher blood glucose level. however, diet supplementation of superjami was found to counteract the high fatinduced hyperglycemia and oxidative stress via regulation of antioxidant and hepatic glucose-regulating enzyme activities. these findings illustrate that superjami was similarly effective in improving the glucose metabolism and antioxidant defense system in high fat-fed mice and they may be beneficial as functional biomaterials in the development of therapeutic agents against high fat diet-induced hyperglycemia and oxidative stress. objective: to evaluate the effectiveness of two types of intervention: personal and group therapy in preventing or delaying diabetes. methods: two hundred and twenty-two pre diabetes adults were assigned to both interventions, which included physicians, dietitians, social workers and physical activity consultants, to modify patients' lifestyle and reduce weight. glucose, total cholesterol, ldl, hdl; tryglesirides and bmi were measured before (t ), immediately after (t ) and post months (t ) of the intervention. mix linear; logistic regression and cox models were employed. results: mean age was . and . (p = . ) for the personal and group therapy, respectively. no significant differences in time trends for all the clinical measurements between the groups were observed. however, (i) reduction (À . p < . ) in glucose for the personal therapy group between t and t ; (ii) reduction in total cholesterol (À . p = . ; À . p < . ) in personal and group therapy, respectively, between t and t ; (iii) significant hdl increase in both groups between t , t and t ; and (iv) significant decline in ldl, triglycerides and bmi between t t and t . . % and . % of the group and personal therapy, respectively (p = . ), developed type diabetes during the study period. no differences to time to onset of the disease between the two groups. conclusion: for patients with pre diabetes, both types of intervention were effective in delaying and preventing the disease. group therapy is recommended since it requires fewer resources and can be implemented for the benefit larger population. methods: the present population-based case-control study was performed in shiraz, southern iran, over a -month period from december to , on a randomly selected study population group consisting of inhabitants of the metropolis of shiraz in southern iran. all the patients underwent anthropometric and blood pressure measurements as well as thorough medical history and physical examinations. laboratory parameters including fasting blood glucose, lipid profiles, liver enzymes and ferritin, in addition to liver ultrasonography and cimt, were performed for all subjects. the cutoff value for the cimt was set at . mm and the measured values were correlated with other risk factors. we evaluated patients with nafld and the same number of controls. subjects with nafld had a significantly higher prevalence of increased cimt (or: . , p < . ). in patients with nafld the age of years represented an appropriate cut-off value for predicting increased cimt. a systolic blood pressure (sbp) of mmhg and a diastolic blood pressure (dbp) of mmhg were shown to be appropriate cut-off values for predicting increased cimt. conclusion: cardiovascular risk factors such as increased intimamedia thickness (imt) occur more frequently among nafld patients when compared to healthy individuals. we recommend a careful evaluation of not only the liver, but also of the cardiovascular system in these patients, in order to prevent later morbidity related to atherosclerosis. mitochondrial capacity of oxidizing fatty acids and increased mitochondrial ros production. the peroxisomal β-oxidation, which starts the oxidation of the long-chain fatty acid and contributes with approximately % of all oxygen peroxide produced in the cell, was increased in ovx mice. these effects could lead to oxidative damage, a condition that was, in fact, evidenced by the reduced levels of reduced glutathione and elevated levels of tbars found in livers of ovx mice. the decreased mitochondrial capacity of oxidizing fatty acids could contribute, at least in part to development of hs in ovx mice. besides, the higher mitochondrial and peroxisomal ros generation resulted in oxidative damage in livers from ovx mice. background: elevations in high-sensitivity c-reactive protein (hs-crp) are associated with an increased risk of insulin resistance (ir). investigation of relationship between hs-crp, parameters of glucose metabolism and leptin in patients with t dm and igt could be help to assess the role of hs-crp in development of ir. aim: of the study was investigation of relationship between hs-crp and hepatic glucose production (hgp), leptin and hba c in women with t dm and igt. materials and methods: forty-eight women with igm ( newly diagnosed t d and igt were observed). hs-crp and leptin were assessed in fasting states. intravenous glucose tolerance test was performed ( . г glucose on kg of body mass). mathematical analysis of results with definition of hgp (the h-index, mmol/l) was done with the special program (accessible in internet: www.diabet.ru/ivgtt). results: bmi was significantly correlated with hs-crp, r = . , p < . and the level of hs-crp in women with bmi > kg/m was almost four times greater compare to hs-crp in women with bmi > kg/m [ . ( . - . ) and . ( . - . ) accordingly, (p < . )]. between hs-crp and hgp and between hs-crp and leptin direct correlation (r = . , p < . ) and (r = . , p < . , accordingly) was revealed. correlation between hs-crp and hba c wasn't found. conclusions: association between hs-crp and leptin level, hs-crp and hgp could be demonstrate the role of hs-crp in development of insulin resistance. institute for sport and physical activity research (ispar), university of bedfordshire, bedford, uk objective: hypertriglyceridemic waist (hw) and waist-to-height ratio (whtr) are simple clinical tools that identify adults at risk of cardiometabolic disorders and cardiovascular disease. whether this applies in youth is under-researched and this study therefore investigated whether the hw phenotype and whtr are associated with cardiometabolic disorders in children and adolescents. methodology: this was a cross-sectional design study. anthropometry, biochemical variables, and cardiorespiratory fitness were assessed in participants ( girls) aged - years from bedfordshire, united kingdom. the hw phenotype was defined as a waist circumference ! th percentile for age and sex, and triglyceride concentrations ! . mmol/l, and a high whtr defined as > . . ancova and logistic regression were used in the analysis. results: in participants with the hw phenotype, clustered risk score was lower (p < . ), the odds of having high cardiorespiratory fitness (ml/kg/min) lower ( . ; % ci . , . ), and the odds of having low hdl-cholesterol ( . ; . , . ), impaired fasting glucose ( . ; . , . ), and ! ( . ; . , . ) and ! risk factors ( . ; . , . ) higher than those without the phenotype. those with a high whtr had lower clustered risk (p < . ), higher odds of having low hdl-cholesterol ( . ; . , . ), high diastolic blood pressure ( . ; . , . ) , and ! risk factors ( . ; . , . ) than those with normal whtr. conclusion: the hw phenotype may be a better simple marker than whtr for identifying children and adolescents at risk for cardiometabolic disorders. treatment with ace inhibitors (acei) and at receptor blockers (arbs) has been shown to reduce the number of new-onset dm , improve insulin sensitivity and reduce adipocyte size , . we investigated additional metabolic effect of renin-angiotensin system (ras) blockade with arb in comparison with acei. specifically we studied the effect of candesartan cilexetil therapy on glucose metabolism and parameters of subcutaneous adipose tissue (sat) in hypertensive subjects. antihypertensive treatment with acei was replaced by candesartan for months in subjects with essential hypertension. experimental procedures involved measurements of anthropometric data, blood pressure, oral glucose tolerance test, ras components and adipokines gene expression in sat obtained by biopsy. intersticial fluid from sat was collected by using microdialysis. six months after replacement acei by candesartan, the systolic blood pressure decreased by . ae . mmhg (p < . ), diastolic blood pressure decreased by . ae . mmhg (p < . ) and fasting plasma glucose decreased by . ae . mmol/l (p < . ). insulin sensitivity index (matsuda) tended to increase (p = . ). among the adipokine and ras genes studied in sat only pparc expression tended to increase (p = . ) after candesartan treatment. as expected, candesartan had blood pressure lowering effects comparable to those of acei. seeing that candesartan reduced fasting glycemia and strongly tended to increase pparc expression in sat, we speculate that arbs treatment might have additional positive effect on glucose metabolism compared to acei. the study is continuing and samples of serum and microdialysate are currently under analysis of ras peptide content. purpose: diastolic dysfunction in the metabolic syndrome/type diabetes (d) is an epidemic without evidence-based treatment strategies. studies on dietary interventions are scarce. we tested the hypothesis, that a low-carbohydrate diet (lc) improves cardiac function in overweight-obese d more than the traditionally recommended low-fat diet (lf). methods: two groups of d without cardiac disease (bmi ae kg/m ) were studied in a parallel and partial cross-over design during a -week rehabilitation program with either lc or lf. the group on lf (carbohydrate %, fat %, protein %) had subsequent weeks on lc ( %, %, %, respectively). cardiac function was assessed as myocardial velocity during systole and diastole (e′) and metabolic control before and h after (pp) a standardized breakfast ( kcal). both groups had supervised aerobic training h a day. results: in the parallel groups, both diets induced similar and significant reductions of weight, hba c and cholesterol. lc considerably improved insulin resistance, triglycerides, systolic and diastolic blood pressure and e′ ( . ae . - . ae . cm/s, p = . ), but lf did not whereas all these variables improved significantly after subsequent lc (e′ from . ae . to . ae . cm/s, p = . ). intact proinsulin was unchanged with lf but decreased with subsequent lc fasting and pp (p = . and . ). conclusions: these data indicate, that a lc but not lf nutrition modulates diastolic dysfunction in overweight diabetics, improves insulin resistance and may prevent or delay the onset of diabetic cardiomyopathy and the metabolic syndrome. methods: we studied adolescents, males (n = ) and females (n = ), who were collected waist circumference, office bp, serum glucose and lipids. they underwent a -h abp monitoring (abpm) to record -hs, awake and sleep bp, and the bpv was calculated as the standard deviation bp. the ms was defined according to the national cholesterol education program, adult treatment panel iii modified for adolescents. statistical analysis: the variance ratio test (f-test) was applied to compare the bpv between adolescents with ms and those without ms. results: the ms prevalence was . % (n = ) in all, . % (n = ) in males and . % (n = ) in females (p < . ). the abp values (systolic/diastolic) were the following: / , / and / mmhg in adolescents with ms; and / , / and / mmhg in adolescents without ms, for -hs, awake and sleep periods, respectively. the highest statistically significant values in systolic and diastolic abp during -hs and awake and systolic abp in sleep were showed by ms group. likewise, adolescents with ms showed significant higher -hs systolic bpv than those without ms ( . vs. . mmhg, p < . ). the ms has important effects on the abp values in adolescents. also, systolic bp variability during -hs is associated with ms. these findings suggest that ambulatory blood pressure monitoring is important in adolescents with ms to detect subjects in cardiovascular risk. montfort hospital research institute, university of ottawa, ottawa, on, canada organochlorine compounds (oc), are chemicals that were mostly used historically as pesticides, solvents, flame retardants, and other applications. oc have been recognized to be of environmental and potential toxicologic concern. due to their persistence and lipophilicity, these compounds will remain present in the environment for decades and accumulate in living organisms. the presence of oc is a major concern since they could act as endocrine disruptors and have recently been associated with the development of hepatic steatosis and lipotoxicity. the objective of this project is to define intra-hepatic molecular mechanisms implicated in the development of hepatic steatosis and lipotoxicity in oc exposed hepatocytes and rats. results: lipid quantification was assessed in human hepatocytes using steatosis colorimetric assay (cayman chemical company). lipid accumulation was higher in hepatocytes exposed to pcb [ . lmol/l] for h compared to chloroquine ( %), a potential lipid droplet infiltration inducer, as well as our control group treated with dmso ( %). conclusion: understanding the emerging role of oc in the physiology of hepatic steatosis and lipotoxicity is of great importance as it is becoming clear that chronic lipotoxicity is strongly related to the suppression of insulin receptor signaling in the liver and activation of the apoptotic pathway. these results only represent the necessary first step on oc and their impact on the liver metabolic activity. experiments in oc-contaminated rats are presently undertaken, as well as protein quantification involved in intra-hepatic mechanisms in cells. nutrition, nutrition research institute, the university of north carolina at chapel hill, kannapolis, nc, usa insulin a precursor of t dm, various cardiocerebrovascular disorders, non-alcoholic fatty liver, alzheimer's disease, and many other major health problems associated with excess calories. to study the mechanism of insulin resistance, we investigated the role of insulin and each category of macronutrients (glucose, fat, and amino acids) in the development of insulin resistance. our results show that glucose (hyperglycemia) does not cause insulin resistance in the absence of insulin in cultured cells or animals. dietary carbohydrate is not necessary for high fat diet (hfd) induction of insulin resistance but a small amount of it can promote insulin resistance in the maximal level in animals on hfd. our results also show that fat is necessary for the development of insulin resistance although fat can't induce insulin resistance in the absence of insulin. supplementation of amino acids such as leucine does not necessary cause insulin resistance in animals on hfd. finally, our results show that insulin can cause insulin resistance through (i) accumulation of long-chain acyl coas and cholesterol in mitochondria, (ii) inhibition of production of new mitochondria; and (iii) turnover of aged/damaged mitochondria. in summary, our results show that insulin and each category of macronutrients are necessary for the development of persistent insulin resistance. wellness institute, cleveland clinic, cleveland, oh, usa background: lifestyle factors are key in the development and progression of chronic disease. here we report outcomes for prediabetic participants in the lifestyle â program, a -month intervention for patients with chronic diseases that integrates education in cooking, nutrition, exercise, and stress management. methods: pre-post changes in biometric, laboratory, and psychosocial variables were evaluated by paired student's t-test or wilcoxon test. results: of participants who met ada criteria for prediabetes (n = ), most were female ( %) and obese ( %) and had hyperlipidemia ( %) or hypertension ( %). one fifth ( %) had depression. average age was ae years. at month , biometric, laboratory, and psychosocial data were available for ( %), ( %) and ( %) participants, respectively. average bmi decreased by % ( . ae . - . ae . ) and there were decreases in waist circumference, blood pressure, resting heart rate, fasting glucose, and hba c (p < . for all). insulin decreased from . ae . - . ae . μu/ml (À . %; p < . ). more diabetic medications were stopped or reduced in dose than were started or increased in dose (ratio . : ). average depression (ces-d ) and perceived stress (pss- ) scores decreased by % and % respectively (p < . for both). physical, mental, and perceived health (measured by veterans rand item health survey) improved from % to % (p < . ). conclusion: participation in a comprehensive lifestyle modification program of adults with prediabetes results in significant and clinically meaningful improvements in biometric, laboratory, and psychosocial outcomes. diabetes is frequently associated with both extracellular and intracellular magnesium (mg) depletion. epidemiologic studies found high prevalence of hypomagnesaemia in subjects with type diabetes, especially with poorly controlled glycemic control. erythrocyte and serum magnesium levels were measured in healthy control subjects, non-diabetic normal glucose tolerant offspring of type diabetic subjects and non-diabetic impaired glucose tolerant offspring of type diabetic subjects in addition to routine laboratory investigations, hba c, lipid profile, fasting insulin by elisa and homa-ir. our study showed that fasting, h postprandial plasma glucose, serum insulin level, hba c, homa-ir index, serum ldl-c, serum triglycerides, serum cholesterol and serum malondialdehyde levels were higher and serum hdl-c and both serum and erythrocyte magnesium levels were lower in impaired glucose tolerant offspring of type diabetes as compared to each of normal glucose tolerant group and control group, while there was no significant difference in those parameters between normal glucose tolerant and control groups. we can conclude that the magnesium depletion and the increase in malondialdehyde level in non diabetic impaired glucose tolerant offspring of type dm were associated with increasing severity of insulin resistance and dyslipidemia and, this may increase the risk of development of type diabetes complications in there offspring. possily use of mg suplemenaion in those subject may delay and prevent the development of type diabetes. obstetrics and gynaecologist, catholic university of sacred heart, rome, italy background and aims: gdm, overweight and gestational weight gain (gwg) are important determinants for an adverse pregnancy outcome and particularly for having large for gestational age (lga) newborn. the aim of this study was to evaluate the pregnancy outcome among women affected by a gdm, belonging four different classes of pre-pregnant bmi and to investigate the specific role of the anthropometric parameters and therapeutic regimen on the foetal growth. material and methods: this was a prospective study including pregnancies affected by gdm. only women with a mean pre-prandial glucose level < mg/dl and h post-prandial values < mg/dl were enrolled. we considered other variables such as gwg, excessive gwg (egwg), therapeutic regimen used and maternal age to investigate their role in foetal growth. results: at the linear univariate analysis, a dependence of neonatal birth weight from pre-pregnant bmi class, egwg, gwg and gestational week at delivery was found (p < . ). the dependence from the pre-pregnant bmi (p = . ) and the egwg (p = . ) was confirmed even when the percentile was considered. at the multivariate analysis the birth percentile resulted associated both with the prepregnant bmi (p < . ) and the gwg (p = . ). conclusions: pre-gestational bmi, gwg and egwg are important parameters involved in fetal growth. their control during pregnancy could be an important way to improve pregnancy outcome even in women with gdm. obstetrics and gynaecologist, internal medicine, catholic university of sacred heart, rome, italy background and aim: continuous subcutaneous insulin infusion (csii) may be an alternative treatment to multiple daily injections (mdi) in pregnant subjects with type diabetes(¹). the aim of this study was to compare metabolic control and obstetric outcome of these pregnancies treated with csii vs. pregnancies treated with different type of insulin analogs administrated by mdi. material and methods: we studied pregnancies in women, three twin pregnancies, affected by type diabetes. thirty-four pregnancies treated with csii and treated with mdi treatment were evaluated. in the group of women treated with mdi women used human analogs, used insulin aspart and used insulin lispro. metabolic control and obstetric outcome were compared between the groups. statistically significant differences were found in metabolic control in term of hba c mean level for each trimester of pregnancy. conclusion: no clear advantage of csii vs. mdi treatment is shown in our study for pregnancies complicated by type diabetes in term of metabolic control or obstetric outcome(²). however, it might be that some selected patients with unstable metabolic control or high hba c levels, who become pregnant with a better metabolic profile after csii treatment, may have a better pregnancy outcome. poblations and methods: a cross-sectional study was performed on children and adolescents ( female and male) between and years old, without cardiovascular, metabolics, oncology and immunology diseases. were excluded all subjects who took drugs with effects on glucose, insulin, lipids or weight. each subject was determined: weight, height, bmi, neck, waist, hip circumferences, adiposity, blood pressure and glucose, insulin, cholesterol, tryglicerides, c-ldl, c-hdl. was performed oral glucose tolerance test to glucose and insulin postprandial. was estimated insulin secretion and insulin sensitivity. conclusi on: neck circumference is a potential marker for to identify children and adolescents with metabolic and cardiovascular risk factors. aim: to assess the efficacy of a lifestyle modification in preventing diabetes mellitus type (dm ) among subjects with risk factors of dm including impaired glucose tolerance and impaired fasting glucose (igt/ifg), obese adults and first-degree relatives of patients with diabetes. materials and methods: the study included patients ( m, f) - years old at risk factors of dm . all patients received recommendation on a balanced diet and physical activity. we measured fasting plasma glucose (fpg), -h plasma glucose concentrations. fasting serum insulin (fi) levels were detected by sensitive elisa. index homa-r were used as the index of insulin resistance. results: in weeks our study patients carried out this recommendations (research group) and patients did not it (control group). patients of the research group demonstrated mean reduction of weight (À . kg), bmi (À . kg/m ) and whr (À . ) (p < . ) and persons of the control group had significant increase these parameters (p < . ). among subjects with igt, glucose levels normalized in % of patients from the research group and . % in control group (p < . ). fi and homa-r in research group decreased from . ae . to . ae . lu/ml and from . ae . to . ae . accordingly (p < . ). in control group the specified parameters had increased significantly (p < . ). the risk reduction of development dm among patients of the research group was . % comparer the control group. conclusion: thereby, lifestyle modifications are effective in preventing dm development in individuals at risk living in belarus. objectives: it is suggested that the kind and frequency of snacks as well as dairy consumption can influence body weight and composition. as the number of students are increasing rapidly in iran and regarding their unhealthy food habits, we decided to carry out this study. methods: one hundred and twelve female students who were selected from university dormitories inhabitants randomly, participated in this cross-sectional study. weight, height and waist circumference (wc) of the participants were measured. demographic and food frequency questionnaires were filled face to face. data were analyzed using spss # . the results showed that . % of participants were under weight, % normal and . % overweight. besides, . % and . % had normal and above normal wc respectively. sixty-one percent of female students had just one snack. fruits ( %) and confectionaries ( %) were the most popular snacks. mean ae sd of the dairy consumption was . ae . serving per day. there were no correlations between bmi and wc and snacking pattern or dairy intake. conclusion: it is assumed that as most of our subjects had normal weight and wc, we did not find any correlation between bmi and wc and snacking pattern or dairy intake. conducting similar studies, using both overweight and normal weight subjects is suggested. obstetrics and gynaecologist, catholic university of sacred heart, rome, italy background and aims: the management of pregnancies complicated by t dm has changed with the introduction of new short acting insulin analogs. the aim of this study was to have a comparison of obstetric outcome among the different insulin regimens. methods: one hundred and sixty singleton pregnancies were assessed. seventy-four women were treated with human analogs, with insulin aspart and with insulin lispro. results: no significative differences were found in term of incidence of pre-eclampsia, iugr, large for gestational age newborn, cesarian sections, preterm delivery, apgar score < , mean week at delivery, mean birth percentile. a significative difference was found in term of incidence of newborn infants with a birth weight ! g ( . % in the human analogs group, . % in the aspart group t and . % in the lispro group; p = . ); a trend (p = . ) was observed comparing the mean birth weight among the groups ( . ae . g in human analogs group, . ae . g in aspart group and . ae . g in lispro group). no significative differences were found in term of hba c mean levels for each trimester of pregnancy. conclusions: the use of insulin aspart is correlate with a lower incidence of fetal macrosomia and with a lower mean birth weight. in vitro observations highlighted that lispro and aspart have a similar affinity for insulin receptor; regarding the affinity for igf- receptor lispro is . fold more potent than human insulin in binding igf- receptor. further investigations are necessary to explain the correlation between insulin affinity for igf- receptor and fetal growth. methods: this study was performed on women diagnosed with gdm (gestational dm) - months after delivery. the jewish and bedouin women were divided into, intervention and control groups. the intervention group was instructed in healthy lifestyle habits every several months by a dietician and sports instructor. the control group was informed of the potential risks for diabetes following gdm and advised to improve lifestyle. all women had fasting insulin, glucose and lipid level tests - months post partum. height, weight, bmi, blood pressure, waist circumference were measured. food frequency and exercise questionnaires were filled. the same tests were repeated at and years follow up. results: the prevalence of gdm was . % in jewish and . % in bedouin women. lack of pregnancy care was greater among the bedouin. all the metabolic tests post gdm period improved in the intervention group in both ethnicities compared to control. there was a decrease in insulin, glucose, ldl, triglycerides and homa-ir (homeostasis model assessment) values and an increase in hdl. a significant decrease in carbohydrate consumption, calorie consumption, fat consumption and increase in protein consumption was observed and an increase in physical activity. the intervention program significantly improved the metabolic indices measured in both jewish and bedouin populations. the results underscore the need to provide lifestyle optimization guidance to women with gdm in order to reduce the risk of type diabetes. introduction: fatty liver is strongly associated with type diabetes. however, it is unclear whether hepatic triglyceride accumulation causes diabetes, or merely is a consequence of excess adipose tissue, that is related to insulin resistance. we aimed to investigate the association between hepatic triglyceride content (htgc) and insulin resistance, and whether this association could be explained by measures of adiposity. methods: in this cross-sectional analysis of the netherlands epidemiology of obesity (neo) study, fasting glucose and insulin concentrations were measured. abdominal fat depots were measured using mri, htgc using mrs. we performed linear regression analysis of htgc with the updated homeostasis model assessment (homa -ir), adjusting for age, sex, ethnicity, education, smoking, alcohol consumption, visceral adipose tissue (vat) and total body fat (tbf). results: after exclusion of participants with missing data (n = ) or known diabetes (n = ), alchohol consumption > glasses/day (n = ), participants were included with a median (iqr) age of ( . ) years, mean fasting glucose: . ae . mmol/l, % men. per sd htgc ( . %), the homa -ir increased with % ( % ci: %, %), this attenuated to % ( % ci: %, %) after adjustment for vat and to % ( % ci: %, %) after additional adjustment for tbf. per sd vat ( . dm ) the homa -ir increased with % ( % ci: %, %), this attenuated to % ( % ci: %, %) after adjustment for htgc and to % ( % ci: %, %) after additional adjustment for tbf. the association between hepatic fat and insulin resistance was for a large part explained by vat. vat may be most important in the etiology of insulin resistance. the aim was to carry out complex estimation of mutual relations between the proinflammatory condition and basic components of the metabolic syndrome (ms) in patients with ischemic heart disease hospitalized for coronary artery bypass grafting. forty-three patients were examined by standard methods and were divided into three groups depending on presence of separate ms components: st group with abdominal obesity (ao), arterial hypertension (ah), type ii diabetes, dyslipidemia; nd group with ao, ah, hyperglycemia; rd group with ao, ah, dyslipidemia. indicators of chronic subclinical inflammation have been revealed before operation in all groups of patients. the strongest ones have appeared in the nd group of patients. hyperuricemy was more frequently registered in patients of the rd group ( . %). the correlation analysis revealed authentic interrelations of uric acid level with lipid profile and inflammation markers. a strong inverse relation with triglycerides, a strong direct relation with low density lipoprotein cholesterol and inverse one with total amount of leukocytes were revealed in the st group. the strong direct relations with segmented neutrophils and the inverse ones with lymphocytes were registered in the nd and rd groups. the average direct correlation with crp was revealed in the rd group. activation of inflammatory process was noted in patients of all groups after operation, and it was already of acute nature in the rd group that allows attributing it to a risk group. the study of expressiveness of inflammatory reaction depending on presence of the ms components allows revealing risk groups among patients. introduction: the soft drink intake has increased worldwide and its high consumption is associated with the development of metabolic syndrome. objective: to estimate the association between the consumption of sugar-sweetened beverages (ssb) and the burden metabolic syndrome diseases (bmsd). a cross-sectional telephone survey was conducted with adults ( . % men and . % women, mean age . years) in the urban area of belo horizonte, brazil. data from the telephone-base brazilian surveillance system for chronic diseases was used (vigitel - / ). burden metabolic syndrome diseases were defined as the self-reported of at least two of the following factors: diabetes, dyslipidemia, hypertension and obesity. the intake of ! days/week soft drinks and artificial juices was assessed. sociodemographic, selfreported health status and lifestyle habits were also used. odds ratios (or) and % confidence intervals were estimated by multivariate logistic regression. results: in this sample, . % of participants consumed ! days/ week sugar-sweetened beverages (ssb). the prevalence of bmsd in the sample was . %. the prevalence of bmsd in people who consumed ssb ( ! days/week) was lower than people didn't consume the beverages (or: . ; % ci: . - . ) five or more days per week. the final model was also adjusted for physical activity, education, marital status, poor self-reported health and poor consumption of fruits and vegetables. obesity is an heterogeneous condition due to fat distribution and storage. the aim of our study was to compare the predicting role of homa index and of bmi on early vascular impairment in morbidly obese subjects (bmi . ae kg/m ) before and after sleeve gastrectomy (sg). glycemia, insulinemia, lipids, flow mediated dilatation (fmd), carotid intima media thickness (imt) and visceral fat area (vfa) by ultrasound were performed in all subjects. patients were divided on the basis of homa-ir median values: ! . group , < . group . group had significantly higher values of bmi (p < . ), waist circumference (p < . ), vfa (p < . ), triglycerides (p < . ), glycemia (p < . ), and lower hdl-c (p < . ) than group ; fmd was significantly lower (p < . ) and imt significantly higher (p < . ) than in the group . the same population divided on bmi median values did not show any difference in lipids, imt and fmd. at stepwise regression analysis vfa was the independent predictor of reduced fmd (β À . , p . ). homa-ir (beta . p < . ) was the independent predictor of imt (beta . , p = . ). in patients, re-evaluated months after sg, bmi, vfa and homa were significantly reduced (p < . ); fmd significantly increased only in the subgroup with homa-ir pre intervention ! . (p . ). bmi, index of overall adiposity, seems less useful in the prediction of early atherosclerosis in morbidly obese; homa-ir, strictly related to visceral fat, is expression of metabolic impairment thus able to predict early vascular damaging. methods: swiss albino mice were given a high fat diet containing lard (h) ( . % wt/wt), supplemented with as or f and in combination alongwith h (f + as + h) for weeks. the control mice (c) were fed with normal diet. after the treatment period the physical, physiological and cellular parameters were evaluated by body weight, liver weight, biochemical estimation, western blot, pcr or ihc. results: the h mice exhibited increased body and liver weight; treatment with f or as and (f + as + h) in the diet significantly counteracted the hfd induced body and liver weight gain, hyperlipidemia; hepatic lipid profile; level of ros; hyperglycemia; hyperinsulinemia; tnf-a, il- level; nuclear translocation of nf-jb; lipid peroxidation. activities of antioxidant enzymes (sod, cat, gsh, frap) were up regulated significantly in f or as and (f + as + h) mice. therefore simultaneous treatment with as or f and their combination protected against hfd induced weight gain and oxidative stress. conclusion: this novel approach of combinatorial preventive medicine is validated not only with the parameters of metabolic syndromes yet it is evidenced with oxidative stress and crucial molecular targets. this study illustrates for the first time that as and f has relatively similar hypolipidemic, antioxidative, anti inflammatory actions and the as + f combination along with hfd has shown prominent preventive effects as compared to other treated groups. s. sivapraksh , i. shabir , n. gupta , j. john , a. ammini aiims, department of endocrinology, aiims, new delhi, india background: insulin resistance/hyperinsulinemia is associated with a variety of reproductive endocrine dysfunction in girls. however, there is a scarcity data regarding hypothalamic pituitary testicular axis functioning among boys with hyper insulinemia. aim: aim of this study was to assess effect of hyper insulinemia on pubertal development in boys. subjects and methods: children of subjects with type diabetes mellitus (t dm) were invited to participate in this study. children and adolescent with any chronic medical condition were excluded. detailed medical history, physical examination including anthropometry, haemogram, liver, renal functions, oral glucose tolerance test (ogtt), insulin, lh, fsh, prolactin and testosterone were done for all subjects. results: seventy-four boys, - years of age participated in this study. results are given in table . thirty boys (all except were overweight) had gynaecomastia. objectives: to find out the prevalence and factors associated with dyslipidemia among adults aged years and above in a resettlement colony located in central delhi. a cross sectional study, that included a random sample of adults, was designed. a study tool based on the world health organisation (who) stepwise approach to surveillance of noncommunicable diseases and their risk factors (steps) questionnaire was used. fasting venous blood sample was collected. criteria based on the third report of the national cholesterol education program expert panel on detection, evaluation and treatment of high blood cholesterol in adults (ncep atp iii), were used to define the cut offs for dyslipidemia. data was analysed using the statistical package for social sciences (spss) version . results: out of a total of study subjects, % had raised cholesterol levels ( ! mg%). thirty-eight percent had raised low density lipoprotein (ldl) levels ( ! mg%), % had raised triglyceride levels (triglycerides ! mg%) and % had low high density lipoprotein (hdl) levels (< mg%). age, hypertension, alcohol consumption and abdominal obesity were found to be associated with increased odds of dyslipidaemia, using the logistic regression model. aim: in the present study we explored whether oral consumption of the probiotic lactobacillus casei shirota bacteria in form of the yakult probiotic drink has any effects on energy metabolism in patients with impaired metabolic functions. a cross-over-study with daily intake of one portion yakult light during weeks was carried out in patients with impaired glucose regulation or metabolic syndrome. fasting blood samples were collected, anthropometric parameters were measured and a frequently sampled oral glucose tolerance test was performed at time points (week , and ). effects on the human gut bacterial communities were studied via t-rflp fingerprinting of s rrna genes amplified from microbial dna preparations from fecal samples. our results reveal a significant increase of total cholesterol (mean increase: . mg/dl; p = . ), triglycerides (mean increase: . mg/dl; p = . ) and a significant decrease of hdl-cholesterol (mean decrease: . mg/dl; p = . ) after weeks of daily intake of yakult. no significant influence of yakult light consumption on indices of insulin sensitivity, hba c and ldl-cholesterol could be demonstrated. a small decrease of fasting glucose levels after yakult consumption was revealed (mean decrease: . mg/dl; p = . ). no consistent changes in the community profiles of the gut microbiota were observed following weeks of yakult light consumption. in mexico, breakfast is one of the most important meals during the day, but changes in food consumption habits, also known as nutritional transition have been associated with a poor food quality intake. scholars, during the recess use to buy some food in internal shops of schools and this food are not generally the healthiest. the aim of this study was to evaluate the quality of the food consumed during the recces by scholars in tepic nayarit, mexico. scholars ( , about - years) from different public schools were evaluated by means of food register questionnaires during days, there has determined the ingestion of nutrients and nourishment healthy index (ias) using the nutrition program dial. anthropometric data were measured for weight and height, and body mass index (bmi) was calculated. the bmi showed that . % of children have low weight for height, . % have normal weight and . % overweight/obesity. twenty percent of scholars declared that they did not take breakfast until the hour of recess. energy intake during recess was on average % of the daily requirement. the foods most frequently consumed were sweetened beverages ( ml) containing g of simple sugars, fried-wheat snacks ( g/ g fat), candies ( g/simple sugars) and some fruit such as mango, apple or watermelon ( g/portion) with chilli. these combinations of foods are risk factors to the development of diabetes in scholars were the prevalence of overweight/obesity is in high levels. introduction: incidence of type , and gestational diabetes mellitus (gdm) are increasing worldwide. given that women with previous gdm have a higher risk of diabetes development later in life compared to women with a physiological pregnancy, the aims of our study were (i) to ascertain a frequency of early postpartum conversion of gdm into permanent diabetes or persistent impaired glucose tolerance and (ii) to find an eventual significant predictive factors from those routinely measured during the gdm follow up. methods: we carried out a retrospective epidemiological analysis of anamnestic, anthropometric, biochemical and clinical data of female patients (n = ) from faculty hospital brno with gdm diagnosis during the - period that underwent repeated ogtt up to year after the delivery. results: any degree of impairment of glucose tolerance postpartum was detected in . % subjects, of those . % had manifest dm ( . % t dm and . % t dm). glycaemia in all three time-points of baseline ogtt, area under the curve (auc ogtt ) and baseline hba c were significantly associated (p < . , mann-whitney) with the postpartum disorder. using regression analysis predictive risk model was developed using these baseline parameters. conclusions: parameters of glucose metabolism measured during - th week of pregnancy fulfilling criteria of gdm diagnosis exhibited highly statistically significant differences between women with and without persistent postpartum glucose metabolism abnormality and conferred significant predictive potential. considering generally lowcompliance of gdm women any more specific assessment of future risk stratifying gdm population could enable more effective screening of postpartum glucose metabolism disorder. institute of molecular biomedicine, comenius university medical faculty, department of health, bratislava self-governing region, regional public health office, bratislava, slovak republic background and aims: in the adults, microalbuminuria is considered as biomarker of present/future cardiovascular and/or renal disease. the roots of these diseases extend back into childhood/adolescence. data on prevalence of microalbuminuria, renal excretion of albumin (albumin/creatinine ratio, acr) and its relationship to obesity and blood pressure in apparently healthy adolescents are scares. methods and results: fourteen to -years-old apparently healthy students of secondary schools in bratislava district were enrolled (n = , boys: %). acr was determined in a spot urine sample. in underaged subjects overweight/obesity was classified according to age-and sex-based slovak population tables from . blood pressure values were recorded. acr (iqr: . - . mg albumin/ mmol creatinine vs. . - . mg albumin/mmol creatinine, p < . ), and the prevalence of microalbuminuria ( . % vs. . %, chi-square: p = . ) were higher in girls than in boys. prevalence of overweight ( . % vs. . %) and obesity ( . % vs. . %), as well as blood pressure values in pre-hypertensive ( . % vs. . %) and hypertensive ( . % vs. . %) ranges were higher in boys if compared with girls. in underweight subjects, particularly boys, acr was significantly higher if compared with the overweight/obese subjects. acr correlated inversely with the markers of peripheral and central obesity. conclusions: our data suggest the need of specific interpretation of data on acr in the adolescents, and the need of further analysis of this (in the adults risk) marker in population of adolescents with regard to other important determinants of acr, such as insulin sensitivity and other metabolic syndrome risk factors. inclusions criteria were bmi between and kg/m , morbidities as diabetes type more than years in oral treatment and without control, hypertension in oral treatment too, moderate or severe liver steatoses diseases and lipid diseases. results: all patients in a both of groups (laparoscopic and robot approach) had a effective loss of weight, with mean about - kg ( - %) after year period. one case of robot approach presented a staple line bleeding at first postoperative day, without transfusion. morbidity rate after rasg was %, but no gastrointestinal leaks occurs. conclusions: rasg can be a safely and feasible tool to the surgical treatment of obese patients and co-morbidities, with good results and satisfactory outcomes. results: patients were nine males and six females with mean age of years (range - ). seven patients were under insulin treatment and with oral medications only. glycemia at months post-surgery ( . ae . mg/dl; n = ) was significantly reduced (p = . ) compared to time ( . ae . mg/dl). the same occurred with hba c at months ( . ae . %; n = ) compared to time ( . ae . %) (p = . ). bmi was also reduced at month ( . ae . ; n = ) compared to time ( . ae . ) and months ( . ae . ; n = ) compared to time ( . ae . ) (p = . ). only one patient remained under insulin after surgery. the procedure was considered safe and significantly improved metabolic control of non-obese t dm patients, although moderate weight loss was also observed. recent studies have shown that the practice of a proper diet provides health benefits. also, it has been observed that the body weight gain is associated with consumption of unbalanced diets. the objective of this study was to evaluate the quality of the diet in adult residents of tehcnological institute of tepic and establish differences for normal weight (nw) and overweight/obesity (ow/ob). forty two adults > years were evaluated, they were taken anthropometric data for weight, height and body mass index (bmi, kg/m ) was calculated. for the diagnosis of nw and ow/ob, were taken established by world health organization (who). it was used a -day dietary record, for diet analysis was used dial software, which contains tables of food composition mexicans. dietary data were adjusted for the degree of discrepancy between energetic intake and energy expenditure obtained estimate. for statistical analysis was used the program rsigma babel and statistical differences were established < . . the caloric profile was unbalanced in % of the study population: a high consumption of fat in detriment of carbohydrates. the difference between groups were not significant (p > . ) in the caloric profile, but nor in lipidic profile. the analysis of the discrepancy intake/energy expenditure describes a probable undervaluing of the diet in both groups, but higher in adults with ow/ob compared to nw ( patients with long standing diabetes had a higher leptin, hsp , hba c and triglyceride than controls. serum leptin levels were significantly lower in patients with newly diagnosed diabetes. women with type diabetes had a higher leptin levels compared to men, both before and after treatment. we showed a positive correlation between leptin-hsp in women with type diabetes. the correlation was highest in women with newly diagnosed diabetes (r = . ) and was attenuated in women who were on treatment (r = . ). the significance of this correlation was only observed in women with type diabetes. there was no correlation between leptin and hsp in men. the positive correlation between leptin and hsp is observed in chronic inflammation such as type diabetes. it could be hypothesized that the observed correlation between serum hsp and leptin imply a higher state of chronic inflammation. materials and methods: carotid atherosclerosis (measurement of intiamedia thickness -imt) and the presence of steatosis were assesed using ultrasonography in subjects ( . % men and . % women, mean age . ae . years), selected from a rural population (were excluded those with known liver disease and those with alcohol consumption > g/day). results: . % of subjects had different degrees of steatosis: . % mild, . % moderate, . % severe. the metabolic syndrome and all its individual traits, were significantly more frequent in nafld patients, especially in those with severe steatosis (p < . ). the mean value for imt was . ae . mm, increasing in parallel with the severity of steatosis. also, subjects with ms had significantly higher imt values than those without ms (p < . ). in the group without ms, imt mean was significantly higher in patients with steatosis than in those without steatosis (p = . ), and in patients with moderate/severe steatosis than in those with mild steatosis (p = . ). by multiple regression analysis, larger waist circumferince (r = . ), increasing alcohol consumption (r = . ) and the presence of steatosis (r = . ), were significant predicting factors for increased imt. conclusions: these data confirm the hypothesis that the presence of steatosis, independently of the ms, is associated with a significant risk for development of atherosclerosis and its detection should be an alert for the existence of an increased cardiovascular risk. the prevalence of the metabolic syndrome (ms), a cluster of central obesity, hyper/dyslipidemia, hyperglycemia, and hypertension is constantly increasing worldwide. although, the exact mechanisms underlying the development of the ms are not completely understood, modern lifestyle of physical inactivity and unhealthy nutrition, obesity, and their interaction with genetic factors are considered largely responsible. this study was carried out to identify the association between physical inactivity and burden metabolic syndrome diseases (bmsd) in an urban brazilian population. a cross-sectional telephone survey was conducted with adults ( . % men and . % women, mean age . years) in the urban area of belo horizonte, brazil. data from the telephone-base brazilian surveillance system for chronic diseases (vigitel - / ) was used. burden metabolic syndrome diseases (bmsd) was defined as the self-reported of at least two of the following factors: diabetes, dyslipidemia, hypertension and obesity. physical activity (pa) indicators were evaluated in free time (leisure), work, home and transportation domains. sociodemographic, health status and lifestyle habits were also used. odds ratios (or) and % confidence intervals were estimated by multivariate logistic regression. in this sample, . % of participants were physically inactive in all domains and the prevalence of bmsd in the sample was . %. physical inactivity was independently associated with bmsd (or = . ; %ci: . - . ), adjusted to age, schooling, poor selfreported health and gender. in this sample, bmsd is a significant public health problem. the evidence from this study shows that physical inactivity was independently associated with proxy of metabolic syndrome. aim: to assess the prevalence of insulin resistance (ir) and glucose homeostasis alterations (gha) in overweight and obese children and the risk factors for ir and gha. method: we collected data from subjects: girls and boys aged . - . years (median: . ). gha was measured by fasting glucose. glucose ! mg/dl was treated as high normal fasting plasma glucose (hnfpg). ir was estimated by homeostasis model assessment (homa-ir), quantitative insulin sensitivity check index (quicki) and fasting glucose/insulin ratio (fgir). we adopted the following cut-off points for diagnosing ir: homa-ir ! . , quicki . and fgir . . results: table . fasting glucose, insulin and ir-indexes. in obese children we observed a significant (p < . ) positive correlation between homa-ir and age (r = . ), bmi (r = . ), fasting insulin (r = . ), triglycerides (r = . ), crp (r = . ) and a negative correlation with birth weight (r = À . ) and hdl the results provide evidence for an association between pd and sm in the adolescent population, which would mean that depression may influence ms in this group that is more vulnerable to pd due to hard changes typical of their life stage. the aim of this study was to evaluate the electrical activity of the pelvic floor muscles (pfm) in women with polycystic ovary syndrome (pcos) diagnostic and insulin resistance (ir). through a crosssectional study, it was recruited women with pcos. the total pcos patients was divided into two groups according to the presence of ri (group a) and without ir (group b). the diagnosis of ri was made through fasting insulin. the muscle tone (mt) and maximal voluntary contraction (mvc) was evaluated by electrical activity, that it was measured by surface electromyography. among the pcos patents, . % had insulin resistence. there was significant difference between the tone (p = . ) and cvm (p = . ) between groups a and b. the correlation test showed a strong negative correlation between muscle tone and fasting insulin levels in group b (r = À . , p = . ). considering the results, it seems that the presence of insulin resistance may adversely affect the electrical capacity of the pelvic floor muscles. central hospital of the army, cpmc, algiers, algeria the polycystic ovary syndrom is a disorder affecting approximatively - % of reproductive age women. hyperinsulinemia and insulinore´sistance are common features of a larger number of patients affected by pcos. objective: the objective of this study was to characterized the prevalence of the insulinore´sistance in a cohort of algerian women with pcos. methods: a total of patients with evidence of pcos defined by the rotterdam consensus were recruted for a prospective study. all women had a standard oral glucose tolerance test with the mesure of glycemia, insulinemia and shbg. the prevalence of insulinore´sistance grows significantly with bmi (p = . ) but didn't change with age (p = . ). the non hyperandrogenic phenotype is less insulinoresistant ( . % vs. . %). conclusion: in our population of pcos near half of them are insulinresistant and need to be treated in order to avoid metabolic features. the aim of this study was to analyze the parameters of glycemic index (ig) in foods intended for feeding patients with impaired glucose metabolism. for this purpose, a new design selected food products, characterized by a higher nutritional value, that pass attempts technological and toxicological studies and have been classified as human food. the food consisted of inulin, buckwheat, pumpkin seeds, buckwheat hulls, the addition of mulberries, kale and beans. the products were characterized by nutritional value and composition. designed food products were the nature of small snacks, designed to supplement the basic diet and enriching it with ingredients desirable from the standpoint of prevention of civilization diseases. characterized by elevated natural origin and health-related properties. the study took part of healthy, non smokers volunteers between and years of age, with proper blood biochemical parameters. the results allow to characterize these foods as relative low glycemic index and possible to use to enrich the diet in the components with pro-health effect. for all the products the dose and single-serving size consumption was described and proposed. the possible potential changes in glucose levels after consumption were characterized. the results are the test pilot study of the project aimed to the creation of the increased food with bioactive healthy properties and are the result of the first stage of the researchclinically-nutritional studies of those products. financial supported by the ue project nr po ig . . . - / . one of the fastest growing trend in food production is designing of health promoting foods, including so-called bioactive food. only food products enriched with bioactive components of natural origin might be perceived as bioactive. it is highly possible that well established technological process of bioactive foods production leads to obtain products useful in prevention and non-pharmacological treatment of metabolic diseases. the project aims to designing these kind of prohealth food, which would simultaneously be organoleptically attractive to the consumer and be an equivalent of conventional, habitually eaten products. the important aspect of bioactive foods is their antioxidant potential, which positive impact on various diseases (obesity, diabetes mellitus and hypertension) is already well known from prior literature. in the studies the antioxidant capacity of the selected bioactive foods designed in the project was assessed. the method used for assessment of antioxidant potential was orac, as the most widely applied and the most reliable one. the analysis included products from three following groups of enriched foods: fruit and vegetable juices, bakery products and confectionery, and meat products, as well as the corresponding placebo products. most of the products enriched in bioactive components was characterized by significantly higher orac values in comparison to placebo correspondents. the results support the correctness of applied production technology and proper selection of bioactive components. based on the antioxidant potential of new products, one can decided which of them should be use for further controlled clinical trial. background: obesity in adolescent tends to persist into adulthood which associated to metabolic disease thereby increasing mortality and morbidity. objective: to investigate the association between central obesity and inflammation marker, insulin resistance and dyslipidemia in adolescent with central obesity. methods: this study was case-control study, compared central obesity adolescent and normal to hscrp, homa-ir, triglyseride, ldlcholesterol, hdl-cholesterol, and sdldl-cholesterol. results: sixty two adolescent were included, were central obesity and were normal. we found that they were with bmi > kg/m had hscrp level higher compared with non obesity, p-value < . (or: . ; % ci: . - . ) and homa ir, p-value < . (or: . ; % ci: . - . ). adolescent with wc ! cm for boys and ! cm for girls, had hscrp levels, homa-ir and hdlcholesterol higher than they were with wc < cm, p-value < . (or: . ; %ci: . - . ), p < . (or: . ; %ci: . - . ) and p-value < . (or . ; %ci: . - . ), respectively. the visceral fat was associated with hscrp levels, p < . (or: . ; %ci: . - . ), and hdl cholesterol p < . (or . ; %ci: . - . ). triglyceride and sdldlcholesterol had not significanty for bmi, wc and visceral fat, however ldl-cholesterol significantly association with visceral fat, p < . (or: . ; %ci: . - . ). conclusion: central obesity adolescents showed increased inflammatory markers and insulin resistance with consequent increased the risk of metabolic diseases so that early intervention in obese adolescents should be done. aims: consumption of high fat diet (hfd) leads to accumulation of intramuscular ceramide (cer). cer is implicated in induction of muscle insulin resistance. the initial step in the de novo cer synthesis is catalyzed by serine palmitoyltransferase (spt). the aim of the present study was to elucidate the role of hfd, myriocin (an spt inhibitor) and metformin on the content of skeletal muscle cer and key proteins implicated in lipid and glucose metabolism in hfd insulin resistant rats. the experiments were performed on male wistar rats, divided into groups: cfed standard rodent chow (control); hfdfed high fat diet; hfd/myrfed hfd and treated with myriocin; hfd/myr/metfed hfd and treated with both the myriocin and metformin. muscle cer and plasma free fatty acids (ffa) were analyzed by lc/ms/ms. content of spt, carnitine palmitoyltransferase (cpt a), fatty acid transporters (cd , fabppm) and glucotransporter (glut ) was measured by wb. results: compared to control values, plasma ffa and muscle cer content and expression of all lipid-related proteins were elevated in hfd group. myriocin decreased muscular cer but increased plasma ffa and the expression of both the spt and cpt a. introducing metformin to hfd/myr group decreased the plasma ffa and muscular cer, lowered the expression of spt, cpt a, cd and fabppm, but increased muscular glut expression as compared to hfd and hfd/myr group. conclusions: simultaneous treatment with myriocin and metformin decreases the plasma ffa and muscular cer and improves glucose tolerance by augmentation of muscle glut expression. internal medicine, new london hospital, new london, nh, usa hyperglycemia, and hyperlipidemia. understanding whether side effect profiles differ between the most commonly prescribed agents could greatly inform prescribing decisions. objectives: to quantify differences in weight gain and metabolic side effects between aripiprazole, quetiapine, and risperidone in adults and children requiring chronic antipsychotic therapy. selection criteria: randomized controlled trials that compared at least two of the three atypical antipsychotics of interest and reported change in weight. all dosing ranges were included and there were no age or diagnosis restrictions. data collection and analysis: two blinded clinicians independently completed data extraction with a piloted, standardized data collection form. study quality was assessed through the cochrane risk of bias tool. we calculated weighted mean differences (wmd) and % confidence intervals (ci) using random effects models on review manager . main results: of studies identified through our search, published trials involving study participants met full inclusion criteria. quetiapine resulted in more weight gain than risperidone and risperidone resulted in more weight gain than aripiprazole). no trials directly compared aripiprazole to quetiapine, but an indirect method of comparison demonstrated that quetiapine causes more weight gain than aripiprazole. similarly, quetiapine led to a greater increase in glucose levels, a greater increase in blood pressure, and a greater increase in total cholesterol than risperidone. non insulin dependent diabetes mellitus (niddm) as a most common form of diabetes is a major public health problem; there is a subgroup of niddm patients which develops the disease at an early age and shows a dominant mode of inheritance. this type is nominates maturity onset diabetes of the young (mody). the prevalence of mody is difficult to access as patients with mody genes mutations are often identified during routine screening for other purposes. mody was linked to mutations in glucokinase gene (gck), and account for - % of mody, with the highest prevalence being found in the southern europe. the aim of this study was to examine the prevalence and nature of mutations in gck gene in iranian paients. we have screened gck mutations by single stranded conformation polymorphism (sscp) technique of polymerase chain reaction (pcr) in iranian families with clinical diagnosis of mody, included patients (eight males and females) and their family members. pcr products with abnormal mobility in denaturing gradient gel electrophoresis (dgge) were directly sequenced. we identified six novel mutations in gck gene in iranian families (corresponding to . % prevalence). our findings and the last study on mody highlight that in addition to gck, other mody genes such as mody and modyx may play a significant role for diabetes characterized by monogenic autosomal dominant transmission. this is clear that the knowledge of the specific defect can be used to pre-symptomatically identify family members at risk for developing mody. background: several epidemiological studies proposed an association between helicobacter pylori (h. pylori) infection with insulin resistance (ir) and metabolic syndrome (mets). however, up to date there is no conclusive evidence regarding this association. objectives: to investigate the prevalence and correlates of h. pylori infection among lebanese adults and to evaluate its association with ir and mets. materials and methods: stored blood samples of adults participating in the national nutrition and non-communicable diseases risk factors survey conducted in lebanon were used for this study (n = ). h. pylori-specific immunoglobulin g antibody titers were measured by elisa. data available included, in addition to anthropometric measurements, sociodemographic and lifestyle characteristics, blood pressure, biochemical indices (serum insulin, hdl, ldl, tag, glucose). a homa -ir level was used to assess insulin resistance. the international diabetes federation criteria were used to classify study participants with mets. results: the prevalence of h. pylori infection in the study sample was % ( % ci: . - . %). a higher crowding index was associated with a % increase in the odds of infection (or: . , ci: . - . ). blood pressure, waist circumference, serum hdl, ldl, tag, and glucose levels were comparable between h. pylori positive and negative subjects. the odds of ir and mets were not significantly different between the two groups. comparable to other developing countries. furthermore, our findings suggested no association of h. pylori infection with ir or mets. eradication of h. pylori infection to prevent ir or mets is not warranted. the economic burden resulting from diabetic neuropathy (dn) consumes a major portion of resources allocated for health-care services. the present study was undertaken to assess the costeffectiveness of medical intervention in patients with dn. two hundred patients with dn were purposively selected from out-patient department of birdem hospital, bangladesh. of them were late in detection of dn (ldn) and were detected early (edn). in ldn group, % had diabetic peripheral neuropathy (dpn), % had diabetic autonomic neuropathy (dan), % had diabetic proximal neuropathy (dpxn) and % had diabetic focal neuropathy (dfn). in edn group, % had dpn and % had dan. the average annual cost of care was us$ (direct us$ and indirect us$ ), with an average us$ per patient. among the average annual cost ldn consumed us$ (us$ per patient) and edn us$ (us$ per patient). the annual medical costs increased with the increased number of complications from us$ to to and to in ldn with one, two, three and more than three complications which is increasing at a rapid rate and us$ to to and to in edn respectively, increasing at a diminishing marginal rate. the regression equation showed that medical cost is significantly related to complications tested in both univariate (p < . ) and multiple linear regression analyses (r = . ; f- . , p < . ). proper management with regular screening substantially reduces the expenditure related to care and complications. a. alizadeasl , z. ojaghi-haghighi , r. azarfarin tabriz university of medical sciences, tabriz, rajaei hospital, tehran, iran background: metabolic syndrome (ms), the combination of hypertension obesity, dyslipidemia, and insulin resistance, is a precursor of diabetes mellitus (dm) and highly prevalent among patients with acute myocardial infarction (ami). diabetes mellitus is associated with larger infarct size and worse outcomes after ami. this study examind the clinical presentation and hospital outcomes among nondiabetic patients with ms following ami. this investigation is prospective analytic study (cohorts type) in consecutive infarct survivors who admitted to our heart centers through years ( ) ( ) ( ) . patients with diabetes (n = ) were excluded. those with ms (n = ) included patients with three or more of the following criteria: hypertension, elevated fasting blood glucose, hypertriglyceridemia, low high-density lipoprotein, and obesity [body mass index (bmi) >or = ]. the control group (n = ) included patients without ms or dm. results: baseline characteristics were similar except for hypertension, bmi, and dyslipidemia, which by study desing were higher in the ms group. the nondiabetic ms group had larger left ventricular dimension (p = . ), left atrium dimension (p = . ) and higher rate of ejection fraction % ( % vs. %, p < . ). also nondiabetic ms patients had higher rates of in-hospital death ( . % vs. . %, p < . ); post infarction angina ( . vs. . , p < . ) and more frequent left main coronary artery or three-vessel disease than the control group ( . % vs. . %, p < . ). conclusion: nondiabetic metabolic syndrome is common in patients with ami and strongly associated with poor outcome of them. background: this study assessed the prevalence of the metabolic syndrome (ms) and its impact on hospital outcomes in patients with acute myocardial infarction (ami) using both ncep atp iii and idf definitions. this investigation is propective analytic study (cohort type) in consecutive ami survivors (mean age: . ae . years; men and women), who admitted to our heart centers through years ( ) ( ) ( ) . results: q-wave myocardial infarction (mi) was present in . % of patients and non-q-wave mi, in . %. the ms was found in . % of the patients and was significantly more common in women than in men ( . % vs. . %, p = . ). one component of the ms was found in . % of patients; two, in . %; and none, in . %. . % of the patients had four or five components. hypertension was the most common component of the ms ( . %). . % of ms patients had triple-vessel disease on coronary angiography in comparing with . % in non-ms, ami patients (p < . ). the ms group had larger infarct size as determind by peak creatine kinase-mb ( . ae . vs. . ae . , p < ). overal inhospital complications (mechanical and electrical) were higher in patients with ms ( . % vs. . %, p = . ). ms is associated with a . -fold increased risk of acute renal failure after mi (p = . ). conclusion: ms in patients with ami is prevalent and associated with larger infarct size, more in-hospital complications, and marked increase of acute renal failure. background and aims: according to current views metabolic syndrome (ms) and obesity, especially with increased amount of visceral fat is characterized by prothrombogenic changes of hemostasis and fibrinolysis. methods: cross-sectional observational study included postmenopausal women (age - ) with ms. coagulant system was assessed by measurement of parameters of plasma haemostasis [activated partial thromboplastin time (aptt), fibrinogen concentration], and the activities of coagulant factors vii (fvii), viii (fviii) and ix (fix) in plasma. in order to investigate the functioning of anticoagulant system the activities of antithrombin iii. also we assessed adiponectin (adp) and homocysteine (hm) concentrations in plasma. results: prothrombotic alterations were observed in . % women. the aptt was decreased in . %, hyperfibrinogenemia was revealed in . %, the increased activity of: fviiin . %, fviiiin . %, fixin . %, and the decreased activity of antithrombin iiiin . %. the hm levels was increased in . %, the adp levels was decreased in . %. there were a significant positive associations between some of revealed prothrombotic alterations (fvii, fviii and fibrinogenemia) and anthropometric markers of visceral obesity and ms (weight, body mass index, and waist circumference). the adp levels were inversely correlated with the hm levels (r = À . , p < . ) and the activity of fvii (r = À . , p < . ). conclusion: results of our study demonstrate high prevalence of various prothrombogenic abnormalities in coagulation and anticoagulation systems in patients with visceral obesity and ms. plasma b-type natriuretic peptide (bnp) and blood urea nitrogen (bun) are elevated in heart failure. renal function is known to be an important factor related to bnp and bun determination. the aim of the present study was to examine whether bnp and bun are associated with left ventricular diastolic dysfunction (lvdd) in patients with type diabetes (t dm) without chronic kidney disease (ckd). the subjects in this study were consecutive patients with t dm [ men ( %); age ae years old (mean ae sd); diabetic duration ae years; hba c . ae . %]. subjects with overt heart failure or nyha class > , history of coronary artery disease, severe valvulopathy, chronic atrial fibrillation, and estimated glomerular filtration rate < ml/min/ . m were excluded from the study. all patients underwent clinical evaluation, laboratory tests including bnp determination, and echocardiographic examination. doppler echocardiographic indices including peak early diastolic mitral annular velocity (e′) and early diastolic myocardial velocity (e) were obtained in each patient. none of the patients exhibited systolic impairment of left ventricular function (ejection fraction > %), whereas lvdd (e/e′ > ) was detected in cases ( . %). e/e′ correlated with age (r = . , p < . ), sex (r = . , p = . ), diabetic retinopathy stage (r = . , p = . ), systolic blood pressure (r = . , p = . ), bnp (r = . , p = . ), and bun (r = . , p = . ). in multiple regression analysis, age (b = . , p = . ), sex (b = . , p = . ), bnp (b = . , p = . ), and bun (b = . , p = . ), correlated independently with e/e′. bnp and bun could be useful tools to screen for preclinical ventricular diastolic dysfunction in patients with t dm without ckd. h. kawano, y. nagayoshi, y. kinoshita objective: this study compared the effects of combination statin and fibrate therapy with either statin or fibrate monotherapy on lipid profiles in patients with impaired glucose tolerance (igt) and a high risk for cardiovascular disease. methods and patients: forty-five patients with igt and dyslipidemia (men , women , mean age . ae . years) were assigned randomly to the three treatment groups for a -month period. results: after months of treatment, low density lipoprotein levels decreased in every group, especially the statin and statin + fibrate groups. triglyceride levels also decreased in all three groups, especially the fibrate and statin + fibrate groups. high density lipoprotein cholesterol and fasting blood glucose levels did not change in any group. the levels of remnant like cholesterol particles decreased in the fibrate and statin + fibrate groups. there was no change during the study in the levels of creatine phosphokinase, lactate dehydrogenase, or creatinine. conclusion: combination statin and fibrate therapy results in greater improvement in lipid profiles than monotherapy with either drug. no marked adverse effects were observed with combination therapy during the study. background: gout is considered a metabolic disease and ranked among the diseases connected with obesity, such as an arterial hypertension, coronary artery disease, stroke, and type diabetes mellitus (who, ) . it has been proven that intake of a considerable quantity of meat products is predictor of acute gouty arthritis. for this reason there is great interest in studying the prevalence of gout among inhabitants of the republic of sakha (yakutia) where a lipid-protein diet prevails. this is a preliminary report on the incidence of gout requiring hospitalization in - . objectives: patients hospitalized in the yakut city hospital with gouty arthritis were studied. methods: patients are being studied by means of a questionnaire developed by the institute of rheumatology (moscow). results: forty-four patients were registered ( men and two women). the majority of patients (n = ) are inhabitants of yakutsk city. median age of the subjects is years, with a range of - years; four patients are over . secondary forms of gout and relapses of disease are common. accompanying pathology includes: ah in patients, cad in seven patient, type dm in four patients, glucose intolerance + obesity in one patient, metabolic syndrome + obesity in one patient, uncomplicated obesity in one patient, metabolic syndrome without obesity in one patient, chronic renal insufficiency in one patient, and cardiovascular accidents in three patients. the research proceeds. results will be used for characterization of the incidence and diagnostic features of gout in yakutia especially among young patients with accompanying metabolic abnormalities. background: the prevalence of obesity, a major public health problem, is rising in many countries including iran. non-drug dependent interventions for obesity management include physical activity, dietary restriction and acupuncture. primary study objective: we examined the effects of body electroacupuncture and low-calorie diet on plasma leptin in obese and overweight individuals with the excess or deficiency pattern (according to chinese medicine). methods/design: the case group received authentic electroacupuncture and the placebo group received sham acupuncture. both groups consumed a low-calorie diet for weeks. settings: this study was conducted in nutritional clinic of ghaem hospital, mashhad, iran. participants: people (n = ), aged between and years with body mass indexes (bmi) between and kg/m were randomized into two groups. interventions: comparison of either real or shame electro acupuncture combined with a low caloric diet was investigated in this trial. primary outcome measures: plasma leptin, body fat mass (bfm), body weight and body mass index were measured before and after treatment. results: in volunteers in the case group with both the excess and the deficiency patterns, we found a significant reduction in plasma leptin ( . %, p = . ) and bfm ( . %, p = . ). in the placebo group, we found a less significant reduction in leptin and bfm. the difference between the two groups was significant for leptin (p = . ) but not for bfm (p = . ). conclusions: body electroacupuncture with a low-calorie diet may reduce plasma leptin concentration; through a mechanism that will require further clarification. m. darbandi , , s. darbandi , , a.a. owji , p. mokarram , m. ghayour mobarhan effects of auricular acupressure combined with low-calorie diet on the leptin hormone level. methods: volunteers (n = ) with body mass indexes (bmi) between and kg/m were randomised into a case (n = ) or a control (n = ) group. the participants in each group received a low-calorie diet for weeks. the case group was treated with auricular acupressure and the control group received a sham procedure. plasma leptin levels, body fat mass, body weight (bw) and bmi were measured before and after treatment. results: participants who received auricular acupressure showed significant reductions in their plasma leptin levels ( . %, p < . ) as well as in their body fat mass ( %, p < . ). these changes were not observed in the control group. the reduction in leptin was significantly greater in the acupressure group than the controls. conclusion: auricular acupressure combined with a low-calorie diet significantly reduced plasma levels of leptin. however, the mechanism of this reduction is not clear. background: premature arteriosclerosis may be one of the mechanisms linking pre-diabetes mellitus (pre-dm) and cardiovascular disease. we assessed premature arteriosclerosis in pre-dm using arterial stiffness indices and analyzed the associated contributors of this process. methods: we collected clinical data of patients without dm, pre-dm patients, and dm patients. both the compliance index (ci) and stiffness index (si) were measured to indicate large and peripheral arterial stiffness. results: patients with pre-dm and dm had lower ci ( . ae . vs. . ae . units; p < . and . ae . vs. . ae . units; p < . , respectively) and higher si ( . ae . vs. . ae . m/s; p < . and . ae . vs. . ae . m/s; p < . , respectively) than patients without dm. both pre-dm and dm patients had higher glucose and hemoglobin a c , higher homa index, higher hscrp, and a lower adiponectin level than patients without dm. using multivariate linear regression analysis, age, heart rate and homa index were independent determinants for si (whole model: r = . , p < . ), whereas male gender, hscrp, and homa index were independent determinants for ci (whole model: r = . , p < . ). conclusions: homa index was an independent determinant for arterial stiffness. increased insulin resistance may associate with increased arterial stiffness both at large and peripheral arteries in pre-dm patients. king's college london, london, uk, uppsala university, regional cancer centre, uppsala, sweden, guy's & st thomas' nhs foundation trust, london, uk, karolinska institute, stockholm, sweden background: impaired glucose metabolism has been linked with increased cancer risk, but the association between serum glucose and cancer risk remains unclear. we used repeated measurements of glucose and fructosamine to get more insight into the association between the glucose metabolism and risk of cancer. methods: we selected , persons (> years old) with four prospectively collected serum glucose and fructosamine measurements from the apolipoprotein mortality risk (amoris) study. multivariate cox proportional hazards regression was used to assess standardized log of overall mean glucose and fructosamine in relation to cancer risk. similar analyses were performed for tertiles of glucose and fructosamine and for different types of cancer. results: a positive trend was observed between standardized log overall mean glucose and overall cancer risk (hr = . ; % ci: . - . ). including standardized log fructosamine in the model resulted in a stronger association between glucose and cancer risk and a statistically significant protective effect of fructosamine (hr = . ; % ci: . - . and hr: . ; % ci: . - . , respectively). the highest risk for cancer was among those in the highest tertile of glucose and lowest tertile of fructosamine. similar findings were observed for prostate, lung, and colorectal cancer. the contrasting effect between glucose, fructosamine, and cancer risk suggests the existence of distinct groups among those with impaired glucose metabolism, resulting in different cancer risks based on individual metabolic profiles. further studies are needed to clarify whether glucose is a proxy of other lifestyle-related or metabolic factors. patients in two groups were compared according to age, parity, prepregnancy weight, family history of diabetes mellitus, history of macrosomia in their previous pregnancies, history of hypertension, previous malformed fetus, history of iufd and abortion. based on the obtained results there was a statistically significant difference between two groups in terms of age (p < . ), parity (p < . ), prepergnancy weight (p < . ), family history of diabetes mellitus (p < . ), previous macrosomia (p < . ), history of hypertension (p < . ), previous malformed fetus (p < . ) and previous iufd (p < . ), but abortion was not significantly different. older age, parity (three or more) obesity, family history of diabetes mellitus, history of macrosomia, hypertension, malformed fetus and also previous iufd are risk factors for gestational diabetes. therefore, these women should be screened and handled for gestational diabetes in their pregnancies, and controlled for possible diabetes mellitus in the future. methods: this family based study was conducted on nuclear families from among tehran lipid and glucose study with two biological parents and at least two offspring ( parents and offspring), aged - years. selected families had at least one person with overweight or obesity. all obesity-related variables (height, weight, hip, waist circumference (wc), body mass index (bmi), body size (bs), resting energy expenditure (ree), waist to hip ratio (whr)) were measured and calculated. the heritability estimate of continuous variables was calculated using a standard quantitative genetic variance-components model which was implemented in the solar software. results: the heritability estimates for obesity-related variables such as height, weight, hip, wc, whr, bmi, bs, and ree, after adjustment for sex, age were %, %, %, %, %, %, %, and %, respectively. the h for the above mentioned variables, expect of bs, after adjustment for sex, age, and body size varied to %, %, %, %, %, %, and %, respectively (p < . ). we clearly demonstrated a significant heritability of obesity-related variables among tlgs families. the results of the present study confirmed the important impress of genetic factors on the obesity-related variables phenotype. method: pwv determined with bpuls apparatus using left external carotid and left dorsalis pedis arteries as "central" and "peripheral" points respectively. pulses picked up by infrared sensors and recorded simultaneously with single lead ecg. time difference between pulses measured. shorter time delay or faster pwv indicates decreased arterial elasticity. materials: nine hundred and fifty-seven asymptomatic filipinos studied. males- , females- . age - years. three hundred and twenty-seven hypertensives. classified into groups according to bmi and wc. average pwv time (adjusted for height) for each group noted. relationship of increased bmi and wc to variations in pwv time determined. results: elevated bmi does not significantly influence pwv time in: all subjects-(p < . ); females-(p < . ); normotensives-(p < . ); and, hypertensives -(< . ). however, for every centimeter increase of wc there is a corresponding decrease of pwv time by: . s (p < . ) in all subjects; . s (p < . ) in females; . s (p < . ) in normotensives; and, . s (p < . ) in hypertensives. discussion: abnormal pwv is a high cvd risk factor. in four groups above, elevated bmi does not significantly influence pwv time. however, in the very same groups, increased wc significantly affects pwv time. this indicates that if we rely solely on bmi to predict cvd we will miss cases which are at high risk as shown by abnormal wc. correlation (r = . ). an increased risk of cvd and cancer was identified with elevated levels of ggt or crp or both markers (ggt-crp score ! ); the greatest risk of cvd and cancer was found when ggt-crp score = (hr: . ( %ci: . - . ) and . ( . - . ) compared to ggt-crp score = , respectively). conclusion: while ggt and crp have been shown to be associated with metabolic abnormalities previously, their association to the components investigated in this study (hyperglycaemia and dyslipidaemia) was limited. results did demonstrate that these markers were predictive of associated diseases, such as cancer and cvd. metabolic syndrome is the aggregation of conditions that together increases the risk of cardiovascular disease and diabetes mellitus in both normal glucose tolerance (ngt) and impaired glucose tolerance (igt) subjects. it is estimated that around - % of the world′s adult population have the metabolic syndrome. over the last years the prevalence of metabolic syndrome has steadily increased in all populations, and making it one of the major global public health challenge. the objective of this study is to estimate the prevalence of metabolic syndrome and cardiovascular risk factors in impaired glucose tolerance (igt) subjects. two hundred and four impaired glucose tolerance and normal glucose tolerance subjects of both genders were selected for the present study according to the american diabetes association ada criteria, on the base of h glucose tolerance test. anthropometric characteristics like waist circumference, bmi, systolic blood pressure, and diastolic blood pressure were measured with standard techniques. biochemical parameters like fasting blood sugar, fasting insulin, cholesterol, triglycerides, hdl-c, and ldl-c were determined by standard techniques, the homa-ir values were calculated with the help of formula. it is concluded from the present study that the prevalence of metabolic syndrome is significantly increased according to aace, atpiii definition criteria's in impaired glucose tolerance subject, the study emphasizes strongly that ms is major factor to enhance the incidence of type diabetes and cardiovascular diseases in impaired glucose tolerance subjects. it is suggested that preventive measures and treatment can reduce incidence of cvd, type diabetes in our population. anthropology, vidyasagar university, midnapore, india waist circumference (wc) and waist-hip ratio (whr) were reported as imperative abdominal obesity related measures having influence on many cardiovascular disease (cvd) risk factors. present study attempts to evaluate the possible association of abdomen circumference (ac) with hypertension and dyslipidaemia among the bhutias, a tribe residing the sub-himalayan state of sikkim, india. five hundred and eleven bhutias of both sexes aged ! years inhabiting gangtok, the state capital and its neighbourhood were systematically selected to participate in the study. after providing informed consent data on blood pressures, blood lipids, anthropometrics and other lifestyle related variables such as perceived stress, diet, energy expenditure, socioeconomic status and so on were collected following standard methods. the results evidently indicate that the ac is the best predictor of the selected cvd risk factors. after log transformation, the effect of age on cvd risk factor variables and anthropometrics was found and regressed out through linear regression. data was pooled for sex as significant sex difference was absent for most of the variables. after adjusting for significant lifestyle related predictors, multiple logistic regression was carried out to evaluate the significant obesity related predictors of hypertension and dyslipidaemia. receiver operating characteristic (roc) curve finally showed ac as the best predictor of hypertension and dyslipidaemia. although wc and whr were found to be important abdominal obesity related predictors of cvd risk factors in many studies, present population based cross sectional study has proved the importance of considering ac as a central obesity related predictor of different cvd risk factors. the achievement of therapeutic goals is of great importance in patients with chronic diseases such as diabetes mellitus (dm), because of its impact on morbidity and mortality. objective: to explore the relationship between therapeutic adherence and metabolic control in patients with dm- , who were seen at a hospital in the city of medellı´n (colombia). methods: cross-sectional study involving patients with the following selection criteria: age ! years, diagnosis of dm- ! months, who signed informed consent. the summary of diabetes self-care activities (sdsca) score was applied for the measurement of therapeutic adherence and duke-unc score for the assessment of perception of social support. glycosylated hemoglobin (hba c) was processed by turbidimetric inhibition immunoassay (tinia) cobas c- equipment. adequate metabolic control was defined as value of hba c %. version . of the spss program was used for the statistical analysis. results: seventy patients studied: % are female, % suffer from hypertension, % have dyslipidemias and % smoke. in addition, % are insulin dependent, % have inadequate glycemic control and % has no social support. items with the highest proportion of adherence were: medication ( %), foot care ( %) and diet ( %). whereas the lowest were: hba c ( %) and exercise ( %). hba c correlated significantly (p < . ) with adherence to diet, blood glucose monitoring, foot care, social support and sex. conclusion: therapeutic adherence was associated with metabolic control in patients with dm- . mellitus. however, it is unclear if severity of dr is associated with lvdd, which is recognized to result in subsequent heart failure. the subjects in this study were consecutive patients with type diabetes mellitus (t dm). all patients underwent clinical evaluation, laboratory tests, and echocardiographic examination. doppler echocardiographic indices including peak early diastolic mitral annular velocity (e′) and early diastolic myocardial velocity (e) were obtained in each patient. the patients were divided into three groups according to presence of dr and its severity: no diabetic retinopathy (n = ), simple retinopathy (n = ), and preproliferative or proliferative retinopathy (n = ). no patients showed systolic impairment of left ventricular ejection fraction (lvef > %), whereas impaired lv diastolic function (e/e′ > ) was detected in cases ( %), furthermore lvdd (e/e′ > ) was detected in cases ( %). e/e′ was correlated with age (r = . , p = . ), sex (r = . , p = . ), diabetic duration (r = . , p = . ), dr stage (r = . , p = . ), systolic blood pressure (r = . , p = . ), and serum creatinine level (r = . , p = . ). in multiple regression analysis, age (b = . , p < . ) and dr stage (b = . , p = . ) were independently correlated with e/e′. in this study, we showed that almost all subjects had asymptomatic lvdd, and severity of dr was associated with lvdd in patients with type diabetes mellitus. objectives: this study explores the contribution of the sasang constitutional types as a risk factor for hypertension by examining the prevalence and risk for hypertension across different constitutional types (se, sy, te, and ty types) and investigating whether certain constitutional types can increase the risk of hypertension in an individual. design: this retrospective chart review evaluated the charts of patients who had visited the clinic for routine physical check-up. subjects: among , visitors, those aged between and , with complete data concerning the past medical and social history, blood pressure and body size measurements, results of blood test, and confirmatory constitutional typing (excluding the ty type) were included in the final analysis group (n = ). results: especially, even after adjusting for the different variables, the odds ratio for hypertension in the te type was found to be . (ci . - . ) (taking the se type as the reference group), indicating that the te constitutional type can act as a risk factor for hypertension. moreover, when comparing the te type to non-te types, the odds ratio was found to be . (ci . - . ), implying a weak but valid contribution of the te constitutional type toward increasing the risk of hypertension. the results of this study show that the prevalence of hypertension differs across different constitutional types, and that the constitutional type (the te type) can act as a risk factor for hypertension independently of other possible variables. a.b. shetty , p.k. roy physical therapy, university of st mary, leavenworth, ks, bon secours hospital, baltimore, md, usa introduction: the purpose of this research was to determine whether habits of individuals contributed to changes in metabolic rate. as the daily physical activity levels increase, there is an increase in the metabolic rate and caloric expenditure. it can be inferred that people who are overweight may not participate in physical activities due to social, psychological, and physical reasons. they may spend more time in less physically demanding activities during their leisure time. hypothesis: it was hypothesized that the individuals who like to read for pleasure during leisure will have higher body-mass-index. subjects: a group of college aged, - , females volunteered to be the subjects for the study. method: each subject's weight and height were collected to determine bmi. the leisure time activities that were included were reading, sleeping, watching television, use of computers, and sports and physical activities. a likert scale questionnaire was developed and had four levels of answers for each of the leisure time activities. a person-product moment correlation was used to determine the relationship between bmi and five leisure time activities. the results indicate that a positive correlation of . between bmi and leisure time reading habits. there is a negative correlation of À . between bmi and sports and physical activities. conclusion: this research demonstrates that the bmi is significantly higher for individuals who like to read during their leisure time activities. therefore, it is also important to develop physical activities as habits during early years that may carry into adulthood. objectives: the main goal of this retrospective cohort study was to compare the incidence of over-all and site-specific cancers among israeli arabs with diabetes mellitus (dm) with that of israeli arabs without dm. methods: a retrospective cohort study was conducted in northern israel, involving all arab subscribers of clalit healthcare services (chs), which is the major hmo service in the region, serving over % of the concerned population. results: during a period of years ( - ) of follow-up, and incident cases of cancer were found among , people with dm and , adults free of dm, respectively. the follow-up time involved , person years. dm was associated with a standard incidence ratio (sir) of . ( %ci: . - . ) and . ( %ci: . - . ) for pancreas cancer in men and women, respectively. a significantly reduced sir was observed for esophageal, stomach and intestine cancer . ( %ci: . - . ) in men. our findings support an association between dm and increased risk cancer of the pancreas in arab men and women. a significantly reduced risk of all other cancers was observed only in arab men. a.e. berezin , o.a. lisovaya methods: seventy-two mild-to-moderate arterial hypertension patients within - weeks after ischemic stroke were enrolled to the scrutiny at baseline. both vegf- and mmp- plasma levels were measured at the study entry and in months after baseline by elisa. we has been assessed all new cardiovascular events including myocardial infarction (mi), unstable angina (ua), recurrence stroke (rs), tia, advance heart failure (hf) during study period. results: analysis of obtained outcomes have been shown that all cases (n = ) of new cardiovascular events identified during first weeks after start of observation are correlated well with vegf- plasma levels (r = À . ; p < . ) measured at baseline. on the other hand, -weeks survival rate was . % and . % respectively for group subjects (p < . ) with top and low quartile of vegf- plasma level at baseline. however, lack of tightly interrelationship between cardiovascular outcomes and vegf- (r = . ; p = . ) in months after study entry. the mean mmp- plasma levels were significantly higher in dead patients in comparison to survival subjects of the study end. both new events associated with rs and tia incidences independently study period are correlated well with vegf- (r = À . ; p < . and r = À . ; p < . respectively) only. we has been proposed that circulating vegf- might have more predicting value in comparison with mmp- concentration among hypertensive patients during early ischemic stroke period. introduction: clinician should change the health care system from on diseases treatment to prevention of diseases. obesity increase mortality, morbidity and psychological problems through life but beneficial effects of risk reduction by changing life style have been documented. objective: sedentary life style is the most important factor for promoting weight gain in people. it's clear that obesity occurs when calorie intake exceeding calorie output. obesity is common in families but seems environmental factors can affect body weight beside genes role. a main factor of life style change is energy balance. we recommend one simple healthy life guideline for managing of environmental factors in obese people that includes a diet and physical activity program. body weight should be reduced - % during first year by following of this guideline and continued until achieving to optimal body weight. obese people are visited and monitored some parameters for program adjusting and changed each item basis on individual response. objective: to assess trend and associations between blood sugar level, blood pressure, overweight/obesity and lifestyle among tribe of northeast india experiencing transition. method: cross-sectional study was carried out among tangkhul nagas, aged between and years. subjects were divided into five decadal age groups to assess age trend in biological and socioeconomic variables. height, weight, waist circumference, hip circumference, random blood sugar level, bp, bmi, wsr and whr were evaluated. result: the prevalence of prediabetes and diabetes were . % and . % respectively. diabetes was found among older age groups only. hypertension was highly prevalent with higher percentage among males ( %) than females ( . %). mean bp was higher among males but sugar level among females, which corresponds to their higher adiposity level. prevalence of overweight/obesity in females was . % while in males, it was . %. sugar level and bp had positive correlation with age, bmi, wsr and whr. the prevalence of hypertension and prediabetes/diabetes were higher among centrally obese subjects. central obesity indices were stronger predictors of diabetes and hypertension than general obesity. odds ratio showed urbanization, higher socioeconomic status and sedentary lifestyle as significant risk factors for development of overweight/obesity, which in turn was risk factor for development of diabetes and hypertension. conclusions: tangkhul nagas has been experiencing socioeconomic and lifestyle change which led to the increasing prevalence of overweight/obesity and cardiometabolic health problems, contributing to the escalating global epidemic of obesity and metabolic syndrome. there was close associations between socioeconomic status, age, overweight/obesity, hypertension and blood sugar level. background and aims: trace elements play an essential role in metabolism of carbohydrates, lipids, etc. these results stipulated the present work. we studied patients (eight females, males, age - years) with type diabetes mellitus. duration of the disease varied from month to years. as a control data the hair composition of practically healthy individuals (n = ) were used. as an analytical method instrumental neutron activation analysis (inaa) was used. results: data obtained shows statistically significant decrease of cu, cr, and zn and increase of na, fe, br, and sb levels in hair in the group with a blood glucose concentration < mmol/l. in the group with a blood glucose concentration more than mmol/l levels of cu and la were decreased and na, fe, co, br, and i levels increased. in the group with a blood glucose concentration more than mmol/l glucose concentration correlates with sc (r = . ), cr (r = À . ), and mn (r = + . ). conclusion: it was found that mn level in blood increases with diabetes. this may be a manifestation of mn metabolism dysfunction in diabetes and excretory role of hair. it is also confirms the important role of some elements, especially cr, in diabetes. concentration of this element significantly decreases especially in the first year of illness. unexpected are correlations for sc. usually sc is considered as an element that has no biological role. these findings are additional reasons to study the biological role of less studied ultra trace elements. objective: investigate the prevalence of hyperglycemia in patients undergoing coronary angiography. methods: six hundered and ninety-five consecutive brazilian subjects undergoing coronary angiography were assessed for fasting plasma glucose and hba c (hplc) levels and for previous history of diabetes mellitus (dm). we classified those without previous diagnosis in three groups according to hba c levels (hplc): normoglycemic (n); hba c -< . %; prediabetes (pd) -hba c . % À . %; and dm (d) -a c ! . %. cad defined by any visible lesion ! %. we also classified glycemic status using fasting glucose levels by ada criteria. results: patients were aged . ae . years, . % male. the group had a high prevalence of cardiovascular risk factors: dyslipidemia - %, hypertension - %, % overweight/obese, metabolic syndrome (idf) in % of subjects. cad was detected in . % of them. dm was newly diagnosed using hba c in . % of the whole sample ( individuals) and pd in ( %). in those without dm according to hba c, ( . %) had glucose levels ! mmol/l and ( . %) had glucose ! . mmol/l. in this particulary population with coronary artery disease and/or cardiovascular risk factors we observed a high prevalence of undiagnosed hyperglycemia -dm or prediabetes ( - %) depending on the criteria used for identification/diagnosis (fasting glucose or hba c). this finding reinforces the importance of implementing a systematic screening for hyperglycemia in this high risk population. national university of singapore, singapore, singapore, university of sydney, sydney, nsw, australia objectives: to evaluate associations between metabolic syndrome (mets) components and mortality and whether these associations change over time. methods: three thousand eighty-six eligible residents aged ! years were prospectively followed in the blue mountains eye study, west of sydney, australia. mets components were measured at baseline ( - ) , and after -years and -years ( - ) . using cox proportional hazards and competing risks models with mets as a time-dependent covariate, we estimated effects of mets on all-cause and cause-specific mortality. receiver operating characteristic (roc) curve analyses were used to identify which individual or combined mets components best predicted mortality. . roc analysis suggested that glucose, body mass index (bmi) and blood pressure (bp) best predicted all-cause and chddeath, bmi and bp best predicted stroke-death and glucose and triglycerides best predicted cancer-death. national university of singapore, singapore, singapore, university of sydney, sydney, nsw, australia objectives: to investigate the effect of metabolic syndrome (mets) and its components on the incidence of different sub-types of cataract (cortical, nuclear and posterior subcapsular cataract (psc)) over years and whether these associations change with time. methods: a prospective cohort of elderly aged ! years were followed up over a period of -years in the blue mountains eye study, west of sydney, australia. mets components were measured at baseline ( - ), -years ( - ) and -years ( ) ( ) ( ) . the incidence of different types of cataract was obtained from standard photographic grading at -and -year (n = ). using random-effect complementary log-log regression model with cataract status as interval-censored data, we estimated the effect of mets on the incidence of different types of cataract at different time-intervals. results: after taking into account the changes in mets (components) and controlling for possible confounders, mets was found to be associated with increased -year incidence of cortical cataract [hazard ratio (hr) . , % confidence interval (ci) . - . ] and psc (hr . , % ci . - . ). amongst the five components of the mets, high glucose and obesity predicted the -year incidence of cortical cataract and at -year, high glucose and low-hdl was associated with increased incidence of psc and cortical cataract, respectively. conclusions: changes in mets predicted the -year incidence of cortical cataract and psc. different mets components predicted the incidence of different sub-types of cataract at varying time-intervals. material and method: this study was a done on a sample of isfahan cohort study (ics) participants. subjects which met atpiii criteria, entered in our study. aobesity indices such as body mass index (bmi), waist circumference (wc), waist to hip ratio (whr) and waist to height ratio (whtr) measurements were done by trained nurses. serum lipids, fasting blood glucose, interleukin- (il- ) and interleukin- (il- ), adiponectin ghrelin, and crp were measured. the mann-whitney u-test was used for comparisons between the level of inflammatory markers in obese subjects with and without mets. then subjects with mets were selected and correlation between inflammation biomarkers and obesity indices correlation coefficients were obtained by pearson correlation test. results: wc and bmi were significantly higher in subjects with mets (p < . ). the median (iqr) of crp was significantly higher in subjects with mets (p < . ). the correlation between inflammatory markers and obesity indices was determined by nonparametric analysis. mets subjects had a significantly positive correlation between il and whtr (r = . , p = . ). no significant relationship found between il- , ghrelin, adiponectin and crp with, bmi, whtr and waist. significant negative correlation was observed for adiponectin and the waist (r = À . , p = . ). negative correlation between adiponectin with whr, whtr and bmi among subjects without mets (r = À . , r = À . and À . respectively). conclusion: present study indicate that the observed inflammatory concentrations cannot be explained by type of obesity. objective: the incretin effect is known to be decreased in type diabetes (t d). however, no study has directly measured the incretin effect in non-caucasian subjects. because asian patients with t d are characterized by decreased insulin secretion, this study set out to examine the incretin effect in korean subjects with normal glucose tolerance (ngt) or t d. research design and methods: we performed g ogtts and corresponding isoglycemic intravenous glucose infusion (iigi) studies in subjects with ngt (n = ) or t d (n = ). the incretin effect was calculated based on the incremental area under the curves (iaucs) of insulin, c-peptide, or insulin secretion rate (isr). the plasma levels of total glucagon-like peptide- (glp- ) and glucosedependent insulinotropic polypeptide (gip) were measured by elisa. results: the incretin effect was not different between the subjects with ngt and t d ( ae % vs. ae %, p = . by insulin; ae % vs. ae %, p = . by c-peptide; ae % vs. ae %, p = . by isr, respectively). however, the gastrointestinally mediated glucose disposal (gigd) was decreased in t d ( . ae . % vs. . ae . %, p < . ). the plasma levels of the total glp- and gip during the ogtts were comparable between the two groups. conclusions: in koreans, the secretion of glp- or gip during ogtts and the incretin effect were comparable between subjects with ngt and t d, whereas the gigd was significantly decreased in patients with t d. a.e. berezin , a.a. kremzer internal medicine, clinical pharmacology, state medical university, zaporozhye, ukraine the aim of this study was to evaluate the interrelation between circulating osteoprotegerin (opg) and coronary vasculature damage in type diabetes mellitus patients. methods: one hundred and twenty-six subjects with stable diabetes mellitus type with previously angiographic documented asymptomatic cad were enrolled to the study. vessel-wall and plaque geometrical and compositional parameters were measured on contrast-enhanced ct angiography. the volume of intramural calcium of > hu in major coronary vessels was measured in coronary segments with a highly standardized method. coronary artery calcification was quantified by calculating the agatston' score index and calcification mass measurement. opg plasma levels were measured with elisa. results: circulating opg level was increase in patients [ pg/ ml [ % confidence interval (ci) = - pg/ml] and was normal in subjects ( pg/ml; % ci = - pg/ml; p < . ). the relationship between coronary artery calcium by agatston' score index and percent atheroma volume (pav) was determined by linear regression. pav and remodeling index were significantly higher in patients with elevation of opg plasma level when compared with those who have normal opg [adjusted odds ratio (or) = . ( % ci = . - . ); p = . ]. there was significant correlation between agatston' score index and pav [r ( ) = . , p = . ]. in conclusion, we demonstrated that opg plasma level can associate with vessel-wall thickening, percent atheroma volume, and agatston' score index value in type diabetes mellitus patients with previously angiographic documented cad. along with the prevalence of diabetes continues to grow, the occurrence of microvascular chronic complications caused by diabetes has increasingly become a serious social problem. diabetic cardiomyopathy, a microvascular disease, results in chronic heart failure and causes a heavy economic burden. endoplasmic reticulum as an intracellular organelle, which occurs the stress leads to cell apoptosis. recent studies indicate that bis(maltolato)oxovanadium can alleviate the endoplasmic reticulum stress to protect cell function. in this study, stz ( mg/kg)-induced diabetic rats were divided into two groups, the diabetic control group, and diabetes + vanadium group; the normal group without diabetes were randomly divided into two groups, normal group and the normal + vanadium group. the bis(maltolato)oxovanadium significantly improve the endoplasmic reticulum stress in stz-induced diabetic rat heart cells and reduce the cardiac damage. in this study, bis(maltolato)oxovanadium can reduce the endoplasmic reticulum stress in diabetic myocardial cells delay the development of diabetic cardiomyopathy. it can be a new way to explain the mechanism in the function of bis(maltolato)oxovanadium. between mets and type diabetes families without diabetic family related. subjects and methodology: forty-three mets subjects with type diabetes parental ( st group), mets subjects without type diabetes parental ( nd group) and no mets subjects but with type diabetes parental ( rd group). this study was conducted over months at diabetologia department hospital. diabetes screening was achieved by oral glucose tolerance testing (ogtt). metabolic parameters were determined by spectrophotometry, insulin by radioimmunoassay. insulin sensitivity was also assessed by the homeostasis model assessment (homa) approach (glucose insulin/ . ). results: in the st and the nd groups there is a significant hyperinsulinemia and to a lesser extent in the rd group ( %, % and %, respectively). the homa model confirms an acute insulin resistance ( %, % and % increase respectively). hypertriglyceridemia was observed only in the nd group. hdl dyslipidaemia has been identified in women of the nd group (< . g/l). our study seems to confirm that type diabetes genetic predisposition is not the only factor, but also environmental factors with or without diabetes family. aims: to examine, the predictors of incident chronic kidney disease (ckd) in a community-based cohort of middle east population, during a mean follow-up of . years. methods: in a sample of non-ckd iranian adults ! years the estimated glomerular filtration rate (egfr) was calculated at baseline and at year intervals during three consecutive phases. the egfr < ml/min/ . m was defined as ckd. multivariate logistic regression analysis was used to determine the independent variables associated with incident ckd. results: the incidence density rates of ckd were . and . per , person-year, among women and men, respectively. female gender per se was associated with higher risk of ckd, compared with males. among women, age, egfr, known diabetes, being single or divorced/widowed, hypertension (marginally significant) and current smoking were independent risk factors for ckd; however the intermediate degree of education and family history of diabetes decreased the risk by % (p < . ). among male subjects, independent predictors of developing ckd included aging and hypertension (with significantly higher risk than in women, p for interaction < . ), egfr, new diagnosed diabetes, high normal blood pressure; abdominal obesity decreased the risk of ckd about % which was marginally significant. in the iranian population, > % of individuals develops ckd each year. our findings confirmed that sex-specific risk predictors should be considered in primary prevention for incident ckd. introduction: obesity is a silent killer and a forerunner of many complications if persists long. various studies with animal model have identified the role of leptin, the hormone of adipose tissue; in obesity and its associated complications like diabetes and atherosclerosis inlater stages. the exact mechanism to know how leptin influences insulin action in body and thereby leading to diabetes or post diabetic atherosclerosis is still not completely evaluated. hypercholesterolemia was only found common to all these three states. aim and objectives: the present study, therefore, evaluated the role of obesity on the expression of ldlr receptor, insulin receptor and leptin receptor. method: receptor expression was done by immunohistochemistry/ western blot. the serum level of lipids were measured by enzyme based kit method. the serum level of insulin and leptin and its soluble receptor were measured by elisa based kit. the blot for insulin expression shows no chamge with body weight; the blot for leptin receptor shows decrease expression with weight gain and blot for ldlr shows decrease expression with weight gain. the serum levels of insulin and leptin are increased with weight gain but soluble receptor for leptin did not change significantly. even the obese group showed decrease tyrosine phosphorylation of insulin receptor. background: visfatin and apelin are two new adipokines that recently gained special interest in diabetes research. however, the relationship between them has not been elucidated and their role in coronary artery disease (cad) complication of diabetes has not been adequately studied. objective: this study was conducted to study the interplay between these two novel adipokines and to study their correlation with other inflammatory and biochemical parameters in type diabetic (t d) postmenopausal women with cad. the levels of visfatin, apelin and other parameters were measured in t d patients without cad, both nonobese and obese t d patients with cad, together with healthy nondiabetic control subjects. visfatin and apelin were measured by enzyme-linked immunoassay (elisa). results: visfatin was found to be significantly higher in the following groups: t d patients without cad, non-obese and obese t d patients with cad, ( . ae . , . ae . and . ae . ng/ml respectively) when compared to control group ( . ae . ng/ml) at p < . . apelin was found to be significantly lower in both non-obese and obese t d patients with cad ( . ae . and . ae . ng/ ml respectively) when compared to control group ( . ae . ng/ml) at p < . . furthermore, visfatin and apelin were found to be significantly associated with each other and with other biochemical parameters in both simple and multiple regression analyses. the current study provides evidence for the novel interplay between visfatin and apelin through the inflammatory milieu characteristic of t d and sheds light on their possible role in the pathogenesis of cad complication of t d. aim: the aim of this study was to investigate the relationship between hscrp, il- , and hcy levels and cardio metabolic risk factors in subjects with and without mets in a sample of tehranian population. in this cross-sectional study, individuals including men and women, aged ! years were selected randomly from among participants of tlgs. the sera of il- , hscrp and hcy were determined using elisa method. results: of the total subjects, aged mean . ae . year, mets was presented in ( . %) individuals. the levels of hscrp, hcy, and il- were higher in subjects with mets compared to normal group. a gradual significant increase just in the level of hscrp with increasing number of mets components was found after adjustment for sex and age. a strong linear augmentation in hscrp levels was observed as the number of mets components increase from to ! with median hscrp levels of . , . , and . (ng/ml) (p trend = À ). also, an increase of . in hscrp levels (ci %: . - . ; p = À ) was observed with an increase in each components of mets in linear regression analysis adjusted for age and sex. the best predictor for hscrp, il- , and hcy, in subjects with mets was hip, whtr, and height, respectively, compared with whtr and wrist which were the best predictors for hscrp and hcy levels in the subjects without mets. conclusion: hip and whtr are significant predictors of the hscrp and il- elevation associated to mets, respectively. methods: in a nested case-control study, conducted on a group selected from participants of the tehran lipid and glucose study, those cases with new diagnosed type diabetes during the . year follow-up ( subjects) were matched to controls for age, sex, body mass index andseason of entrance to study. multivariate conditional logistic regression analysis was used tocalculate the odds ratio (or) with % confidence interval of type diabetes for vitamin dcategories, vs. the first quartile ( . ng/ml) as reference. results: the unadjusted ors of type diabetes were . ( . - . ), . ( . - . ) for the second and third tertiles, respectively. after adjustment for family history of diabetes, systolicblood pressure, triglycerides to high density lipoprotein cholesterol ratio, and fasting plasmaglucose, the corresponding ors were . ( . - . ) and . ( . - . ) for second and third tertiles respectively. multivariate cubic spline modeling analysis indicated that ng/ml hydroxyvitamin d levels was the optimal cut point for distinguishing those who were at risk ofdeveloping diabetes and those who were not. also addition of vitamin d to multivariate model, improved the net reclassification by cut-point based nri of %. discussion: in a prospective cohort study, we demonstrated a nonlinear independent associationof vitamin d with incident diabetes, with prominent increase in risk at a cut-off < ng/ml. research department-ayush projects, svyasa university, bangalore, india type diabetes mellitus (t dm), the seventh leading cause of death, is a biggest challenge for mankind. despite of fascinating advances in pharmaco-therapeutic agents, the prevalence of t dm is growing every year. complementary and alternative medicine (cam) as classified by national centre of cam have documented various positive results of t dm. whole ancient medical systems like ayurveda, siddha, and tcm etc use natural herbs either as a single drug therapy or in the form of formulations, depending upon principles of respective medical system. studies done on various herbs and mind body intervention like, yoga, acupuncture etc are found to be beneficial for t dm. this resulted, large number of physicians either referring to or practicing some of the more prominent and well known forms of cam. the concepts proposed and used by these cam systems (that are kept alive by cam practitioners for thousands of years) appear very mysterious to the present day biomedical practitioners. these models of therapies seem to have evolved through several phases of internal research just like the present day drug trials that go through four phases of intensive statistical evaluation. it appears that today's scientists need to follow the footsteps of research used by the ancient seers of tcm, ayurveda, siddha, yoga or homeopathy to unravel these mysterious theories. this review talks about generating evidence not only for the efficacy of these holistic systems but also in carrying out systematic research by biomedical scientist who have the knowledge of both the western and eastern sciences. background: the epidemic of obesity, over the last two decades, in the middle and high income countries is associated with marked rise in the incidence of metabolic syndrome. objective: to measure the prevalence of metabolic syndrome (ms) and determine its association with ratio of omega- /omega- fatty acids in the diet. design and methods: cross-sectional surveys were conducted in urban streets in the city of moradabad, india. randomly selected subjects with ms aged years and above were evaluated and graded according to omega- /omega- ratio in the diet. physical examination, sphygmomanometer, questionnaire and blood tests were done. results: the overall prevalence of ms was . % (n = ) without any gender difference. the prevalence of ms, type diabetes, cad and hypertension showed a higher rate, in relation to omega- /omega- ratio in the diet. subgroup analysis showed that subjects eating low omega- /omega- ratio (< . ) diets had significantly lower prevalence of ms, and related components compared to higher ratio diets, among both sexes. multivariate logistic regression analysis after adjustment of age showed, that hypertriglyceridemia (odds ratio . in men, . in women) was strongly (p < . ) associated with ms. hypertension, hdl-c, and central obesity were weakly associated with ms in both sexes. hypercholesterolemia was weakly associated with ms only in women. conclusion: ms has become a public health problem in india. higher w- /w- ratio is a major risk factor of ms and cad. it is possible that a low w- /w- ratio in the diet (< . ) may be protective against ms. objective: investigate the differences in clinical and laboratory features (including some adipocytokines) among hyperglycemic patients with or without cad. methods: five hundred and sixty-one consecutive hyperglycemic subjects undergoing coronary angiography. hyperglycemia [diabetes mellitus (dm)/pre-diabetes (pd)] previously known dm or diagnosed at the moment of recruitment by an hba c (hplc) levels-! . - . %-pd, ! . %-dm (ada criteria). cad defined by any lesion ! % on angiography. results: . % were men. age was . ae . (mean ae sd), cad was detected in . % of individuals. patients with cad were older ( ae vs. ae years, p = . ), more often male ( % vs. %, p = . ). additionally, they showed a worse metabolic profile, with higher hba c ( . ae . % vs. . ae . %, p = . ), fasting plasma glucose ( ae vs. ae mg/dl, p = . ), triglyceride [ ( - mg/dl) vs. ( - mg/dl), (p = . )] and plasma visfatin/nampt levels [( . ( . - . ng/ml) vs. . ( . - . ng/ml), (p = . ), median/interquartile range], and lower hdl-cholesterol levels ( ae vs. ae mg/dl, p < . ), even after correction for statin use (except for hdl and visfatin/nampt). diabetic patients with cad had greater diabetes duration than diabetic individuals without cad: . ( . - ) vs. . ( - ) years, median and interquartile range, (p = . ). systolic and diastolic blood pressure, homa%-s, homa-ir, total and high-molecular weight adiponectin levels were similar in both groups. conclusions: patients with hyperglycemia and cad have a worse glycemic and lipid profile and higher visfatin/nampt levels as compared to those without cad. one hundred and sixty-nine patients (p) with the mets were studied to find out the incidence of cardiovascular events, especially myocardial infarction and strokes. the mean age was years. fifty-five percent were males and females. the mean body mass index was kg/m . the mean fasting blood sugar was mg/dl. ninety-seven percent were diabetic type ii and % diabetic type i and the lipid profile was normal. the studied population showed a higher incidence of atrial fibrillation, when compared with a comparison group of diabetics ( % vs. . %) p < . . no ventricular tachycardia was observed. the mets group showed a subnormal ejection fraction ( ae %) when compared with a comparison group ( ae %) p < . . no myocardial infarctions or strokes were detected. coronary angiography was done in % of the (p) all were negative except one. the lower ejection fraction was explained on basis of diabetic cardiomyopathy. the genetics profile of the puertorrican, a hispanic population, is more of an european, indian and african. probably, this produces a culture less sensitive to the atherosclerotic factors, producing a less aggressive mets syndromeless myocardial infarcts or strokes. this suggest that genetics and culture is an important aspect of the expression of mets, especially in the hispanic world. objectives: controversy surrounds the annual progression from prediabetes (impaired glucose regulation) to type diabetes. current uk statistics suggest a % progression rate. our aim was to assess subjects in our locality at high-risk of progression from pre-diabetes to type diabetes within a month period. this will establish whether current recommendations for follow-up of high-risk subjects successfully identify those with pre-diabetes. methods: analysis was performed on data from high-risk subjects who underwent ogtt with baseline clinical and biochemical measurements. the ogtt and biochemical measures were repeated at months. results: of the subjects, ( . %) developed diabetes within the month period, significantly higher than the estimated annual progression rate (p . ). as expected, baseline fasting plasma glucose was higher for subjects that progressed to diabetes (diabetes vs. no diabetes: . ae . vs. . ae . mmol/l; p . ), as was h post-prandial plasma glucose (diabetes vs. no diabetes: . ae . vs. . ae . mmol/l; p . ). additionally, baseline hba c was higher for those that developed diabetes [diabetes vs. no diabetes: . ( . - . ) vs. . ( . - . ) %; p = . ]. interestingly, both sbp and dbp were significantly higher at baseline in those that developed diabetes (sbp: ae . vs. ae . mm hg; p = . ) (dbp: ae . vs. ae . mm hg; p = . ). conclusions: within this cohort, progression to type diabetes was almost twice the current estimated annual rate. fasting, h-glucose, hba c and blood pressure were associated with progression from prediabetes to type diabetes over months. methods: tissue lysates from visceral fat samples of subjects undergoing abdominal surgery (predominantly bariatric and routine non-acute for non-malignant conditions) were collected from subjects categorised as l ( ), o ( ) or odm ( ). a commercially available comet assay (cell biolabs, inc) was used to assess cellular dna damage using a single cell gel electrophoresis method. additionally, results indicate a greater percentage of dna migration from the comet "head" to its "tail" within odm samples (l vs. o vs. odm: . vs. . vs. . %; p = . ). in conclusion, results suggest that visceral fat from obese subjects with type diabetes are subject to higher levels of oxidative burden resulting in a higher proportion of damaged dna. community medicine, faculty of medicine, kuwait university, jabriya, kuwait background: the prevalence of overweight and obesity are high in kuwait. metabolic syndrome is associated with both. it is expected to find the syndrome to higher than in other countries. objective: to assess the prevalence of ms using two different diagnostic criteria, the international diabetes federation (idf) and the national cholesterol education program-third adult treatment panel modified for age (ncep-atp iii). study design: a multi-stage random sample study. methods: the analysis of data for this study was based on a sample of male kuwaiti adolescents, - years of age selected from intermediate and high schools. anthropometric measurements and biochemical tests on blood samples were carried out. the idf criterion requires waist circumference (wc) plus two of the following criteria: triglycerides (tg), high density lipoprotein (hdl), fasting blood sugar (fbs) and blood pressure (pb). the atp iii criterion requires three of the above parameters. the parameters mentioned must show increase in their values except for hdl which must show decrease in either criterion used. results: each of the two criterion revealed that the prevalence of ms was . % and . %, using the idf and the atp iii criteria, respectively. hdl decreased in each of the two diagnostic criteria and the other four parameters increased, satisfying the diagnostic requirements of either criterion. conclusions: significant implications may be drawn from these results, especially when it comes to being at risk of type diabetes (t d) and cardiovascular disease (cvd). m. saghebjoo , j. shabanpour omali , r. fathi university of birjand, birjand, mazandaran university, babolsar, iran background and aims: resistance training has been shown to be beneficial in older adults. however, very little data exist on the effects of resistance training in older diabetics. chemerin is a adipokine that has been shown to induce insulin resistance in skeletal muscles. here we investigate the role of weeks of progressive resistance training (prt) on plasma chemerin levels in older men. methods: a total of sedentary men with type diabetes, aged between and years, were randomized to the weeks supervised prt (n = ) and control (n = ) groups. chemerin, insulin, glycosylated hemoglobin (hba c), and fasting blood glucose (fbg) were measured before and h after the training period. results: plasma chemerin levels decreased significantly (p = . ) in the , and exhibited significant reductions in plasma insulin (p = . ) and fbg (p = . ). fbg decreased by . % in prt group. conclusion: reduced plasma chemerin concentration may contribute to improved insulin sensitivity. these results recognize that increased intensity of exercise may produce greater benefits, but may not be appropriate for some individuals. some studies have demonstrated the presence of metabolic syndrome in children and adolescents, but few have investigated this syndrome in brazilian children. the aim of this study was to investigate the prevalence of metabolic syndrome in children and its association with gender and nutritional status. this transversal epidemiological study involved children of both genders between . and . years old. there were collected sociodemographic, anthropometric, metabolic and hemodynamic data. the nutritional status was obtained according to the body mass index. to diagnose metabolic syndrome was used the criteria proposed by the national cholesterol education program′ s adult treatment panel iii adjusted for age. there were used two separate proposals (cook et al., ; ferranti et al., ) . the prevalence of metabolic syndrome ranged from . % to . %, depending on the criterion. the nutritional status showed . %, . % and . % of children with normal weight, overweight and obesity, respectively. significant association was observed between the metabolic syndrome and nutritional status, but not in relation to gender. metabolic syndrome was present in different nutritional status of children, especially those with excess body weight, thus indicating the importance of early diagnosis and the adoption of primary prevention measures already in pediatric patients. introduction: ifg (fpg . - . mmol/l) is a risk-factor for developing type diabetes and cardiovascular disease. we quantified changes in ifg prevalence (post-hoc analysis) from a double-blind, placebo-controlled trial investigating the effects of liraglutide . mg on maintenance of diet-induced weight loss (primary endpoint). methods: overweight/obese adults ( ! years, bmi ! or ! kg/m with comorbidities) who lost ! % weight after - week run-in with low-calorie diet ( - kcal/day) and exercise were randomised to once-daily subcutaneous liraglutide (n = ) or placebo (n = ), plus kcal/day deficit diet and exercise. the full-analysis-set comprised of randomised individuals [age . ae . years, bmi . ae . kg/m (mean ae sd)]. during run-in, participants lost . ae . kg weight and ifg prevalence decreased from % ( / ) to % ( / ). at week , liraglutide-treated participants lost an additional . kg from randomisation (table ) , whereas placebo-treated participants lost no additional weight [treatment-difference À . kg ( %ci À . ; À . ); p < . ]. moreover, the proportion of participants with ifg at week was lower for liraglutide ( . %) than placebo ( . %; odds-ratio . [ . ; . ]; p < . ). at week , after weeks off treatment, the liraglutide group regained~ kg lost weight and ifg prevalence increased. mean weight loss remained greater for liraglutide vs. placebo [treatment-difference À . kg (À . ; À . ); p < . ] but ifg prevalence did not differ (odds-ratio . [ . ; . ]; p = . ). conclusion: liraglutide decreases ifg prevalence in overweight/obese individuals who have already lost weight by diet and exercise, potentially due to additional weight loss and weight-loss independent mechanisms. objective: we wanted to explore the association between polymorphisms of irs (rs ), tcf l (rs and rs ), adrb (rs ), pparg (rs ), and hhex (rs ) genes with insulin resistance, lipid profile and atherogenic risk in mets patients from the mexican social security institute. methodology and results: four hundred and thirty-one mets patients and controls were selected. the association between the snps and the atherogenic index was evaluated by multiple linear regression and multinomial logistic regression models. adrb c/g were associated with an increase in ldl-c levels (β = . , % ci = . , . p = . ), the hhex t/c variant were statistically associated with an increase in total cholesterol levels (β = . , % ci = . , . p = . ), and with an increase in ldl-c levels (β = . , % ci = . , . p = . ). the adrb gene showed a statistically significant association with high-risk atherogenic index, (or = . , ic % . - . ; p = . ) for the arg/gly variant and for the dominant model (or = . , ic % . - . ; p = . ). conclusions: the arg gly polymorphism of the adrb gene may be a good biological marker to predict the risk of developing cardiovascular diseases given a high-risk atherogenic index. aims: describe the knowledge of major risk factors for type diabetes held by primary health care (phc) nurses involved in the community management of diabetes. methods: random sample ( %) of phc nurses in auckland. information was collected from postal and telephone questionnaires, on education, experience, knowledge and diabetes management practice. results: responses were received from phc nurses ( % response) comprising practice nurses (pns), district or homecare nurses (dns) and specialist nurses (sns). most nurses ( %) were able to identify excess body weight as a major risk factor for type diabetes. only % of sns and a third of pns and dns identified lack of physical activity, and fewer than % of sns and pns, and only % of dns identified hypertension as risk factors. even fewer respondents were able to identify individual lipidsalthough significantly more sns identified elevated triglycerides ( %, p = . ) and reduced high-density-lipoprotein cholesterol ( %, p = . ) as major risk factors compared with only - % of pns and no dns. risk factors for diabetes-related complicationsapart from hyperglycaemia identified by %were not well identified, particularly smoking ( %), hypertension ( %), triglycerides ( %) and reduced high-density-lipoprotein cholesterol ( %). in general, phc nurses had a good knowledge of overweight as a risk factor for type diabetes and hyperglycaemia as a risk factor for diabetes-related complications, but poor knowledge of cardiovascular risk factors, particularly smoking. yoga and life sciences, swami vivekanand yoga anosandhana samsthana (s-vyasa university), bangalore, india metabolic syndrome is clustering of different metabolic abnormalities which encompass central obesity, insulin resistance and hypertension. it is characterized by an overdrive of the sympathetic nervous system, increased oxidative stress, elevated pro-inflammatory enzymes, and impaired circadian cycle. lack of physical exercise, improper eating habits, and psychological stress are also common contributing factors to this condition. thus, life style change which includes adequate exercise, proper diet and stress management are the keys in prevention control and treatment of metabolic syndrome. yoga, one of the ancient sciences on earth, is known to bring balance at all aspects of human existence. its different components like asana (physical postures), pranayama (breathing techniques), meditation and relaxation techniques (yoga nidra) etc have been proven to influence body and the mind towards balance and equanimity. recent scientific studies on yoga have proven its safety and efficacy in the management of many metabolic disorders which includes diabetes mellitus, obesity, hypertension and atherosclerosis. yoga therapy has also caused reduction in the pro-inflammatory cytokines in such conditions. yoga reduces sympathetic tone as well as oxidative stress; it helps in reducing insulin resistance by enhancing secretion of melatonin and hepatic insulin sensitizing substance through bringing the parasympathetic dominancy. thus, we propose that yoga has an important role in prevention and treatment of metabolic syndrome as a complementary or as an alternative to conventional line of treatment. s. debnath , s. addya medical laboratory technology, women's polytechnic, medical officer, government of tripura health services, agartala, india introduction: saliva is an excellent biological matrix that offers several opportunities for scientific inference of diagnostic, toxicological and in forensic importance. numerous salivary metabolites proffer great potential in clinical and epidemiological research. sample collection is non invasive and analysis require simple modifications. establishing good correlates is the need. objective: our objective was to study the association between anthropometric measures (ams) with salivary metabolites in a subsample (n = ) of college women in suburban north east india. method: saliva and blood samples were photometrically analyzed for glucose, protein and urea. ams as bmi and waist circumference (wc) were measured in female students of menstruating age ( - years) following who guidelines. ams were correlated (pearson's correlation, ′r′) to salivary biochemistry. results are reported with intra assay coefficient of variation (cv < % all assays) in the text. ′ four day diet dairy′ was maintained over the period. results: salivary biochemistry found to be significantly correlated to ams in the studied subsample. salivary protein was negatively correlated (′r′ = À . ) with bmi and with wc (′r′ = À . ) whereas salivary glucose (′r′ = . with bmi and ′r′ = . with wc) and urea (′r′ = . with bmi and ′r′ = . with wc) had positive correlation. all assays performed in triplicates .we observed very good repeatability of results. medicine -cardiology, massachusetts general hospital, boston, ma, usa introduction: obesity is an independent risk factor for cardiovascular disease. supine bike stress echocardiography is suggested to be of particular utility for evaluating for coronary artery disease (cad) in obese individuals given the lack of mechanical impact with this modality. database for all recumbent bicycle stress echocardiography examinations performed between january , and july , . all tests performed to evaluate for cad were reviewed. two groups were formedpatients achieving ! % of maximum predicted heart rate (mphr) and those achieving < % mphr. medical records of these patients were then reviewed. comparisons between groups were made using unpaired t-tests and correlations between patient characteristics and hr were assessed using pearson's correlation. results: four hundred and sixty tests were done to evaluate for cad. one hundred and eighty-one ( . %) patients failed to reach % mphr during testing. forty-three percent of patients failing to achieve % mphr were obese (bmi > ) vs. % of all patients referred for stress testing. image quality among obese patients was not notably worse compared to leaner patients. those failing to achieve % mphr had a significantly higher bmi ( . vs. . ; p = . ) than those with adequate hr response. bmi exhibited a negative correlation with percent mphr (r = À . , p = . ). conclusion: obesity is associated with failure to achieve ! % mphr during supine bike stress echocardiography done to evaluate for cad. use of adjunctive pharmacologic agents should be considered when evaluating an obese patient for cad with stress echocardiography. ( ): - ), though the extent to which body weight may act as a confounder or as mediator in this relationship is uncertain. the aim of this study was to analyze whether the association between crf and mets risk is mediated by body mass index (bmi). methods: cross-sectional study including schoolchildren, - years old from the province of cuenca, spain. we measured height, weight and crf ( -m shuttle run test). a validated mets index (diabetes care ; : - ) was estimated by summing standardized z scores of waist circumference, triglyceride-to-hdl-c ratio (tg/hdl-c), mean arterial pressure (map), and fasting insulin. to test whether the association between crf and mets index and its components was mediated by bmi, linear regressions models were estimated according to baron and kenny procedures for mediation analysis (j pers soc psychol. ; : - ) . results: in girls, bmi acts as a fully mediator for the relationship between crf with mets index and all its components, except for tg/ hdl-c ratio. in boys, bmi acts as a fully mediator for the relationship of crf with tg/hdl-c ratio and map; and partial mediator for the relationship between crf with mets index and the rest of components. the obesity mediates the association between crf and mets in schoolchildren. good levels of crf are associated with lower mets risk, but only when accompanied by weight reduction. pre intervention measurement was applied. no statistical differences were found for prediabetes knowledge, physical activity, eating habits, bmi, weight, waist circumference and clinical parameters (glucose, triglycerides and total cholesterol) between both groups in basal measurement. the control group received the usual care from health centers. in the study group, the intervention was developed during months per patient (received usual care plus remote care model′s components). the rct will end at january , and the final results will be presented. chronic conditions. this study compares the prevalence of the metabolic syndrome (mets) between genders in the workplace. methods: as part of the established "prosiect sir gâr" initiative in south wales, uk, female and male employees from either the local steel works or local health board were screened and their data analysed. anthropometric data, blood pressure, self-reported physical activity (gppaq) and smoking status were all recorded. in addition, blood samples were obtained and analysed for high-densitylipoprotein cholesterol (hdl-c). presence of the mets was determined based on the following idf criteria: central obesity (females waist circumference: ! cm; males waist circumference: ! cm), reduced hdl-c levels (females: < . mmol/l; males: < . mmol/l) and either systolic ( ! mmhg) or diastolic ( ! mmhg) hypertension. results: a higher proportion of males were diagnosed with mets than females ( . % vs. . %; p < . ) despite the males being more physically "active" or "moderately active" ( . % vs. . %; p < . ). rates of central obesity and systolic hypertension were comparable between genders (p > . ), however prevalence of diastolic hypertension, reduced hdl-c levels, current smokers and individuals either overweight or obese were higher in the male cohort (p < . ). conclusion: despite being more physically active, males were more susceptible to the mets than females, likely due to a higher percentage of smokers and either overweight or obese. conclusions: the addition of glp analogues to insulin therapy seemed to be superior to the enhancement of insulin therapy regarding to weight loss, decreases of hba c, hypoglycemic episodes and requirements of insulin. it was also observed a significant improvement in insulin sensitivity and in beta cell function. background and aims: type diabetes is often associated with nonalcoholic fatty liver disease (nafld). patients with nafld may be at greater risk for cvd than those without. the relationship between nafld and metabolic syndrome (ms) is very well recognized. the aim: to determine the association of nafld and cvd between type diabetic patients with and without ms. materials and methods: one hundred and thirty type diabetic patients (m: , f: , mean age . + . ), were studied. all subjects were assessed for diabetes duration, the obesity degree, cv risk factors, hba c, c reactive protein and lipid profile. nafld was assessed by patient history and ultrasound. ms was defined based on ncep-atp criteria. the previous and current cvd (myocardial infarction, angina or revascularization) was assessed. we categorized four groups: ms (À) and nafld(+), ms(À) and nafld(À), ms(+) and nafld(+), ms(+) and nafld(À). results: the prevalence of cvd in type diabetic patients with nafld was higher than in those without nafld ( . % vs. . %). the prevalence of chd in type diabetic patients with ms was higher than in those without ( . % vs. . %). the risk of chd in patients with ms was significantly increased by the presence of nafld ( . % vs. . %). in type diabetic patients with ms(+) and nafld(+) the number of components of ms, bmi, and systolic bp were positively associated with chd. conclusions: what this study suggests to us is that the presence of nafld increases the risk of cvd in type diabetic patients with ms. and to determine associations between the levels of fasting blood sugar and its comorbid conditions. this is a retrospective study and uses chart review in the outpatient section of the family medicine clinic. it also uses percentages, means and its standard deviations, and chi square to detect associations. there were patients with impaired fasting glucose aged between and years old (mean age . ae ) and all were of filipino ethnicity. there were more females than males. the mean body mass index was . ae . kg/ m and the mean fasting blood sugar (fbs) was . ae . mg/dl. there was no association between the fbs level and obesity (p > . ) and hypertension (p > . ) in this study. however, fbs > mg/dl was associated with the presence of family history of diabetes in this population (p < . ). it seemed that ifg can occur to young, nonobese patients with family history of diabetes. this study recommends that screening for ifg among filipinos should be done to all patients with a strong family history of diabetes regardless of age, gender, bmi status or presence of hypertension. h. hasan, v.l. raigangar, a.r. abdullah methods: a cross-sectional study of young females (mean age . ae . years. leptin, insulin, high sensitivity c-reactive protein (hs-crp), c-peptide, ua, bg, hdl-cholesterol and triglycerides were estimated from a fasting blood sample. anthropometric parameters (wc, height and weight) and bp were measured. homa-insulin resistance was also calculated. results: mean wc of the studied population was . ae . cm, % (n = ) had wc > cm. for the subjects, all studied parameters were within normal limits except leptin which was high; . ae . ng/ml. ua showed highly significant positive correlation with wc (r = . , p < . ), significant positive correlations with cpeptide, hs-crp and leptin with (r = . , p = . ), (r = . , p = . ) and (r = . , p = . ) respectively. ua demonstrated significant negative correlation with hdl only (r = À . , p = . ). multiple linear regression revealed that wc was the only significant predictor of ua levels (b = . , p = . , ci %: . - . ). conclusion: this study stresses the importance of ua levels in cvd particularly due to its strong association with wc, the main indicator of abdominal obesity in mets that is often missed. ua may hence be considered a valuable biomarker for early prediction/detection of mets in young females. background: adipocyte-secreted cytokines are associated with inflammation and metabolic disturbances but it is unclear how their snps interfere on the response to lifestyle interventions. we assessed associations of selected snps with the changes induced by interventions. methods: this -month intervention on diet and physical activity included brazilians at cardiometabolic risk (prediabetes or metabolic syndrome without diabetes). changes in clinical variables were analyzed according to the presence of the tnfa- g/a, il- - g/c and adipoq t/g snps; individuals with at least one variant allele were grouped and compared with the reference genotype. afterwards, individuals carrying simultaneously the genotypes associated with no glycemic response were grouped and compared to the remainder sample. results: the entire sample ( . ae . years) had lower energy intake, higher physical activity, and improved anthropometric and metabolic variables after intervention. carriers of the tnfa variant allele but not the reference group decreased plasma glucose. il- and adipoq variant allele carriers had worse glucose, lipid and inflammatory responses. grouping the subset of carriers of tnfa- g + il - c + adipoq g, they showed a significant increase in mean fasting glucose after intervention. this increment differ significantly from the behavior of the remainder sample (+ . % vs. À . %, p = . ). the tnfa- g/a but not the adipoq t/g and il- - g/c may predispose a better response of glucose metabolism to a lifestyle intervention. the combination of three worst genotypes can maximize the adverse effect on glucose metabolism in at-risk brazilians. further studies are needed to direct lifestyle interventions to specific subgroups of individuals. obesity is a metabolic disorder, which is associated with an increased risk of various conditions, including sexual dysfunction. objective: to investigate anthropometric indicators of body fat in postmenopausal women influencing their quality of life. material and methods: the study was performed at the scientific and clinical study of endocrinology, uzbekistan public health ministry. a total of women (mean age of years) was examined. bmi, waist circumference and waist to hip ratio were obtained for anthropometric evaluation. lipid specters, glycemia and insulin were the parameters to evaluate. we have used a menopause quality of life questionnaire and female sexual function index questionnaire (fsfi). the quality of life of the obese and overweight patients was compared by age, education, marriage and matched with healthy normal weight controls. results: overweight and obesity were observed in of women. values of wc > cm were above normal levels in %, . %, respectively, and hdl was normal in . %. homa -ir was measured in . % of the women. women with overweight and obesity had worse general health-related quality of menopausal symptoms, life and psychological and sexuality scores than athletic and lean women (bmi ! ). in fsfi it was significant differences in such as scales as desire and orgasmic disorders in women with metabolic syndrome (ms) in comparison with the controls (p < . ). aim: to determinate groups of high cardiovascular risk and start early hypolipidemic therapy due to genetic polymorphism of lipoproteidlipaseone of the main enzymes of lipid metabolism in metabolic syndrome and nafld patients, treating with combined therapy of statins and ursodeoxycholic acid (udca). background: health staff receive more health messages and information in working hours than others. moreover, they are supposed to be healthy models for the community. we conducted a screening of metabolic syndrome on shahid beheshti university health department staff (who are responsible for health affairs of more than million people in tehran province, iran) to assess their health level. we invited all of the health staff for screening on "the world heart day". weight, height, waist circumference, systolic and diastolic blood pressure were measured and a fasting blood sample was taken for lipid and glucose level testing. results: fifty percent of the staff ( person) participated in the screening. the mean age was . ae . years. only % were in normal weight range. overweight, obesity class and class rates were %, . % and . %, respectively. . % of all and . % of normal bmi cases had a high waist circumference. metabolic syndrome was identified in . % of men and . % of women. high blood pressure was detected in . % of the cases. in . % of all and . % of overweight or obese cases fasting blood glucose was elevated. these rates for blood total cholesterol level were . % and . %, for triglyceride were . % and . %, and for ldl were . % and . %, respectively. conclusions: contrary to our expectations, a high rate of metabolic syndrome was identified in this group. it seems that interventional programs targeting nutritional habits and physical activity of the staff are needed along with routine educational programs. introduction: physiologically, brain natriuretic peptides (bnp) and lipolysis are closely linked. obesity is been identified as a major risk factor for the development of cardiovascular diseases (cvd) and has been reported to have an impact on bnp in apparently healthy subjects but also in cvd patients. thus, we speculate that bnp could play an important role in lipid metabolism and may affect the pathophysiology of obesity in cvd patients. methods: serum samples were obtained from cvd elderly patients distributed in two groups: i-non-obese and ii-obese. the plasma mature form of brain natriuretic peptide (nt-probnp) was measured by a sandwich enzyme immunoassay with spectrophotometric detection at nm. conclusion: overall, these data demonstrates that obesity is an important and independent determinant of bnp expression in patients with cvd. inverse relationship between bnp and body mass index may suggest "beneficial" effects of obesity, but clearly lower levels did not confer a more favourable prognosis. the precise mechanisms linking obesity to cvd remain unsolved and may be due either to release attenuation or increases in clearance receptors. these effects should be taken into account for appropriate bnp reference values, so lower cut-points should be used for obese patients and a higher cutpoint for lean patients to increase specificity. v. mladenovic , a. djukic , s. djukic , n. arsenijevic , s. zivancevic simonovic aim: the aim of this study was to investigate dynamic of changes of oxidative stress during acute myocardial infarction depending on development phases of metabolic syndrome x. method: the research included patients; inclusion criteria were diagnosed metabolic syndrome and acute myocardial infarction. according to the movements of glycemia and insulinemia all patients were divided in four development phases of metabolic syndrome x. to evaluate oxidative status we determinated: lipid peroxids (malonyldialdehide), total antioxidative status, as well as oxidative stress coefficient. results: during hospitalisation in patients with acute myocardial infarction concentration of lipid peroxids increased, with maximum in the day th of hospitalisation, mostly in hyperinsulinemic phases of metabolic syndrome. at the st day of myocardial infarction total antioxidant status increased, and decreased during next days. these changes are independent on the phase of metabolic sindrome x. as result of inverse dynamic changes of these parametars, during period of exam came to progressive increase of oxidative stress coefficient, particularly in patients in hyperinsulinemic phase of metabolic syndrome x. conclusion: during first days after acute myocardial infarction lipid peroxids concentration progressively increased, with decrease of total antioxidant status, that results in increase of oxidative stress. these changes are most distinctive in patients with hyperinsulinemic phases of metabolic syndrome x. introduction: glp- (exenatide -lilly) is a good therapy for overweight or obese type diabetic patients, but bid administration might not be effective over h. aim: we intended to evaluate h effectivness of this drug in our outpatients using continuous glucose monitoring (gcm-medtronic). methods: we asked our outpatients to undergo a continuing glucose monitoring for days. twelve of them accepted [ f and mol/l, median age (range - ), median disease lenght years (range - )] and signed an informed consense; they had stable metabolic control with hba c < mmol/mol and had been on therapy with exenatide for months at least. results: glycemic profile demonstrates that no patient had experimented prolonged hypoglycemia and all subjects, expept for one, had mainteined a long period of euglycemia in range - mg/ dl during the blood glucose monitoring. conclusions: it′s our opinion that these data demonstrate exenatide can be surely used in type patients to obtain a good and stable metabolic control during all h inspite of the bid somministration and, moreover, the age or the disease lenght are not to be considered a contraindication to its use. several parameters of vascular function and structure have a predictive value for cardiovascular morbidity-mortality and for the presence of associated target organ damage in diabetic and hypertensive patients. superoxide dismutase (sod) is an intracellular antioxidant defense mechanism, which catalyses the dismutation of superoxide radical into h o and oxygen, and it is easily detectable in human plasma; oxidative stress is associated with cardiac and vascular defects leading to hypertension and atherosclerosis and with diabetic cardiomyopathy. on the other hand, osteoprotegerin (opg) is an indicator of diabetes-associated vascular pathologies as hypertension, endothelial dysfunction and cardiovascular risk. we have assessed the relationship between serum levels of sod, opg and parameters of vascular function and structure as well as cardiovascular risk in type diabetic patients with and without hypertension. there are negative correlations between sod and endothelial dysfunction (evaluated by pressure wave velocity, peripheral and central augmentation index and ambulatory arterial stiffness index), pulse pressure, diastolic and systolic night/day ratio, serum opg and plasma hdl-cholesterol, as well as positive correlations between sod and plasma uric acid, liver enzymes got, gpt and ggt, triglycerides and haemoglobin. on the other hand, serum opg is correlated to endothelial dysfunction, intima media thickness, pulse pressure, systolic night/day ratio and d′agostino cardiovascular risk index. our study shows that both sod and osteoprotegerin plasma levels are indicators of cardiovascular events and target organ damage associated with diabetes and hypertension. objective: we investigated the future coronary artery disease (cad) event rate in diabetic patients with and without chest pain in a prospective cohort study performed in a korean population. we also investigated the impact of chest pain on cad risk according to the presence or absence of diabetes mellitus. research design and methods: the ansung-ansan cohort was established for a prospective large-scale community-based epidemiologic study to investigate chronic diseases in korea. the data from a baseline survey performed from to and two subsequent prospective biennial surveys were analyzed. results: among subjects ( men and women) without a history of cad, . % and . % of non-diabetic and diabetic subjects, respectively, reported newly developed cad events during years of follow-up. diabetic patients had a significantly higher risk of future cad events (age-and sex-adjusted odds ratio, . ; % confidence interval, . - . ; p = . ). although the presence of chest pain at baseline was also significantly associated with an increased risk of cad of more than -fold in both non-diabetic and diabetic subjects (p < . ), the hazard ratio for cvd event in asymptomatic diabetic patients compared to non-diabetic subjects with chest pain was not significantly different from . (hazard ratio, . ; % confidence interval, . - . ). conclusions: diabetes and the presence of chest pain are independently and significantly associated with future cad event risk. asymptomatic subjects with diabetes have a comparable risk of cad events to non-diabetic subjects presenting chest pain. aim: the aim of the study was to select and analyze patients with diabetes mellitus and acute stemi or nstemi myocardial infarction from all patients hospitalized in cardiology department in . results: more patients with nstemi underwent pci in the history than patients with stemi (n = , . % vs. n = , . %); p = . and more pci and cabg (n = ; . % vs. n = ; %); p = . . concentrations of cpk (nstemi vs. stemi) (u/l) ( ae vs. ae ) p < . , ckmb (u/l) ( ae vs. ae ), p < . , glucose on admission (mg/dl) ( ae vs. ae ), p < . . patients with nstemi had less critical changes in the left anterior descending artery (lad) ( . % vs. . %); p = . , less bare metal stents (bms) implanted to the lad ( . % vs. . %one stent), and ( % vs. . %two or more stents), p = . . management of this patients shows figure . patients with stemi require more intensive treatment of more advanced concomitant metabolic disturbances. revascularization should by performed urgently because of higher death rate. during qualification for invasive diagnostic and treatment (pci and/or cabg), not only the risk of death and cardiovascular events should be taken into account, but also a history of revascularization modalities (pci and cabg). methods: a total of diabetic patients both sexes aged . ae . years were studied. the levels of total cholesterol (tc), triglycerides (tg), hdl-cholesterol (hdl-c), ldl-cholesterol (ldl-c), vldl-cholesterol (vldl-c), hba c and renal function tests were assessed. patients were classified as normoalbuminuric (albumin excretion rate < mg/ h, n = ), microalbuminuric (albumin excretion rate - mg/ h, n = ) and proteinuric (albumin excretion rate > mg/ h, n = ). results: the duration of diabetes was . ae . years. the level of tc was significantly highest in proteinuric ( . ae . mmol/l), followed by microalbuminuric ( . ae . mmol/l) and followed by normoalbuminuric ( . ae . mmol/l), (p = . , p = . , respectively). patients with proteinuria had significantly higher level of ldl-c compared to the patients with normoalbuminuria ( . ae . vs. . ae . mmol/l, p = . ). patients with microalbuminuria had significantly higher level of ldl-c compared to the patients with normoalbuminuria ( . ae . vs. . ae . mmol/l, p = . ), as well. the level of hba c in normoalbumiuric patients was significantly lower than in microalbuminuric ( . ae . vs. . ae . %. p = . ). there were no significant differences in levels of tg, hdl-c, vldl-c between patients with normoalbuminuria, microalbuminuria and proteinuria. conclusion: we showed that higher levels of ldl-cholesterol and tg were associated with microalbuminuria and proteinuria in patients with type diabetes. lowering atherogenic lipids may retard nephropathy progression in these patients. s. bonakdaran , b. kharaqani endocrine research center, mashhad university of medical sciences, mashhad, iran background: the relationship between elevated serum uric acid level and metabolic syndrome (ms) has been debated. we aimed to determine the prevalence of hyperuricamia and its association with ms in type diabetes mellitus (dm). methods: this was a cross-sectional study in diabetic patients. hyperuricamia was defined as uric acid ! and ! . mg/dl for men and women respectively. diagnosis of metabolic syndrome was based on atpiii criteria. clinical and biochemical parameters in hyperuricaemic and normouricaemic patients compared with other. results: the prevalence of hyperuricaemia and metabolic syndrome was . % and . % respectively. the prevalence of ms significantly increased in the highest quartile of uric acid levels compared with lowest quartile ( . % vs. . %, p < . ). serum uric acid had positive association with cholesterol, triglyceride, non-hdl cholesterol and a negative association with fasting blood sugar (fbs), glycosylated hemoglobin (hba c) and hdl cholesterol. possible biochemical predictors of hyperuricamia were cholesterol, triglyceride, creatnine and fbs. conclusion: the prevalence of ms and its components increase with increasing levels of uric acid in type diabetes. regular assessment of uric acid could give information for predicting of ms and prevention of atherosclerosis in type diabetes. materials and methods: in subjects (aged . ae . ) who have received recommendations on hypotensive and hypoglycemic therapy at diabetes school. psycho-correctional work has been carried out with people (group ) in order to increase treatment motivation and the work has not been carried out with people (group ). the effect has been evaluated after months according to the results of -h blood pressure monitoring ( -h bpm). results: according to moriski-green test % appear to be nonadherent to treatment. as a result only in group there has been recorded reduction in variability indices sbp (mm hg) at night ( . ae . vs. . ae . ; p = . ), daily index sbp ( . ae . vs. . ae . %; p < . ) and dbp ( . ae . vs. . ae . %; p = . ), rate in morning increase sbp ( . ae . vs. . ae . mm hg; p = . ) and dbp ( . ae . vs. . ae . mm hg; p < . ), which are high risk indicators of cardiocerebral catastrophe. after months of patients have become adherent to treatment in group (p = . ), only patients of in group (p = . ) (moriski-green test). conclusion: psycho-correctional training improves adherence to treatment, which is accompanied by positive dynamics of -h bpm indicators. introduction: quality of life is particular decreased in elderly with diabetes mellitus (dm), even not associated with other chronic illness. the purpose of the study was to analyze the quality of life in a group of elderly diabetic patients without major complications. the study group consisted of patients, males and females, aged over years old [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , diagnosed with type dm. they had no severe dm complication, nor other debilitating chronic diseases. the romanian version of the sf- questionnaire was used to measure quality of life (qol). diabetic subjects were compared with age-and gender-matched controls from a random standard population sample of the romanian population. results: reliability of scales by coefficient alpha cronbach was > . for all scales except social functioning. qol scores for study group were significantly lower compared with controls. there are no significant differences between patients following insulin therapy and patients with other therapeutic protocols. role limitations due to emotional problems correlate with disease duration and female gender. there is a significant correlation between energy/fatigue scores and female gender, hba c, fasting plasma glucose and obesity. there are no other statistically significant correlations between sf- scores and analyzed variables. discussions and conclusions: patients with dm have statistically significant impairment of all aspects of qol. dm put a substantial burden on affected individuals. insulin use didn't seem to have a negative impact upon qol. glycemic control is crucial in preventing long terms complications and provides better qol for diabetic patients. the study involved patients with nstemi and with ua hospitalized in cardiology department in . the data obtained from patients were statistically analyzed to determine the significance of the differences between the groups. results: glucose on admission was lower in patients with ua ( ae mg/dl) than with nstemi ( ae mg/dl), p = . . treatment of dm in patients with nstemi and ua shows figure . patients with nstemi presented lower left ventricular ejection fraction ( ae %) vs. ua ( ae %); p < . and higher mortality during hospitalization. seven patients ( . %) with nstemi died, whereas no patient died in ua group (p = . ). . to determine whether aaa patients found to be at higher risk of osa were also at increased risk for cardiometabolic disease, compared to those at low or no risk of osa. design: the berlin questionnaire to estimate osa was administered to elderly patients with or at increased risk of aaa disease along with several measures of cardiometabolic risk, including the lipid accumulation product (lap), a measure that combines triglyceride levels with central obesity (waist circumference), also known as hypertriglyceridemic waist. results: in this sample (n = ), subjects ( . %) scored clinically positive for risk of osa on the berlin questionnaire. next, individuals were separated into groups based upon the three subclasses of the berlin questionnaire: snore (frequent loud snoring), eds (excessive daytime sleepiness), and htn-bmi (hypertension and high bmi). the combination of snore + eds subclasses, when used to differentiate subject's risk levels for osa, was highly accurate for discriminating low, moderate, and high cardiometabolic risk, based upon significant differences in bmi, insulin (lu/l), waist circumference (cm), waist/hip ratio, low density lipoprotein cholesterol (ldl-c mg/dl), and lap (anova; p < . ). conclusions: these results give credence to the clinical use of the snore + eds portions of the berlin questionnaire to provide simple estimates of increased risk of t dm and cvd and/or need for further evaluation such as polysomnography or oral glucose tolerance. materials and methods: from to , t dm were cumulatively collected for study. accordingly, anthropometric and biochemical data, lifestyle measurements (lifestyle i : no smoking, no alcoholic and regular exercise; lifestyle ii : smoking and/or alcoholic and/or no exercise), total daily caloric intakes and macronutrient consumptions were recorded. the eating habits were classified by fat consumption, high fat diet (fat > %) and low fat diet (fat %). the mets defined was based on the atp iii criteria. patients were obligatorily classified into six groups, mets with waist component, waist required and non-waist required; mets without waist component, with two and more than two components; non-mets with waist and without waist component. each component of mets in these six groups with different combination of lifestyle and eating habit, were presented by case number and percentage distribution. or for the clustering of each metabolic component in these six groups were analyzed. results: the case number, percentage distribution and corresponding or for the clustering of each metabolic component in these six groups were shown in table and . the clustering of metabolic components of tg, hdl-c and bp were significantly higher in lifestyle ii, lifestyle i and high fat diet eaters respectively. objectives: early detection of metabolic syndrome is important in minimizing morbidity and motility. we conducted a study to detect wether serum leptin can be used as a biological marker to detect metabolic syndrome. methods: a group of healthy pre-menopausal females, aged - years was selected from the local community, randomly, stratified according to their bmi. leptin was assessed by the elisa method and, blood pressure was measured using digital blood pressure monitor and chemical analysis for fasting blood, glucose and lipid level were conducted using colorimetric method. body weight and height, hip and waist circumferences were measured, using standard protocols. in subjects with and without metabolic syndrome mean serum leptin values were . (ae . ) and . (ae . ) ng/ml respectively. compared with subjects without metabolic syndrome, subjects with metabolic syndrome had a higher serum leptin level (mean difference À . , and % confidence interval À . to À . , p = . ). conclusion: subjects with metabolic syndrome had a higher serum leptin level in comparison with subjects without metabolic syndrome therefore leptin can be utilized as a surrogate marker to predict metabolic syndrome. conducted a study to detect relationship between serum leptin and cardiovascular risk factors in obese and non obese individuals. methods: a group of healthy pre-menopausal females, aged - years was selected from the local community, randomly, stratified according to their bmi. body weight and height were measured, using standard protocols. serum leptin was assessed by elisa and, blood pressure was measured using digital blood pressure monitor and chemical analysis for fasting blood, glucose and lipid level were conducted using colorimetric method. results: there was a statistically significant inverse correlation between serum leptin level and mean blood pressure in obese (bmi ! ) individuals and subjects with systolic blood pressure > mmhg. corresponding r values were r = À . and r = À . (p < . for both). in subjects with bmi < or in normotensive subjects, there were no statistically significant correlations between serum leptin and mean blood pressure. correlations between serum leptin and total cholesterol, triglycerides, hdl, ldl, cho/hdl and fasting plasma glucose were . , . , . , . , . , . respectively and not statically significant (p . for all). conclusion: due to the presence of inverse correlation between serum leptin and mean blood pressure in obese, and individuals with high systolic blood pressure, it can be concluded that serum leptin may play a different role in pathogenesis of cardiovascular diseases in such individuals. r. irzma nski, j. błaszczyk, l. pawlicki, j. kowalski the aim: the aim of our study was to assess the influence of metabolic syndrome (ms) risk factors on vascular complications in patients with ms. material and methods: the study comprised patients ( women and men, avg. age . ae . years) with ms, which was diagnosed according to idf criteria . results: the prevalence of micro and macrovascular complications was assessed: vascular changes in the fundus of the eye - %, ischaemic heart disease - . %, egfr < ml/min - . %, diabetic foot - . %, cerebro-vascular accident - . % of patients. the negative correlation between hdl concentration, creatinine levels and level of vascular changes in the fundus of the eye was found. moreover the level of obesity and fasting glucose level had positive correlation with the intensitz of vascular changes in the fundus of the eye. objectives: to estimate malnutrition prevalence among newly hospitalized overweight/obese patients; to characterize malnutrition by body weight category; and to assess associations between bmi, duration of hospitalization and in-hospital death in malnourished patients. methods: this cross-sectional survey assessed nutrition status in all adults newly admitted to internal medicine and surgical departments at the e. wolfson medical center, holon, israel. data were recorded during the -week data acquisition period and screening for malnutrition risk was performed using the nrs . an age-adjusted score of ! on the nrs defined malnutrition. malnutrition was compared across body weight categories: underweight (bmi < . kg/m ), normal (bmi . - . kg/m ), overweight (bmi - . kg/m ) and obese (bmi ! kg/m ). overweight/obese subjects were compared by malnutrition status. results: a total of individuals were analyzed, of whom were overweight/obese (bmi ! kg/m ). of these, ( . %) were malnourished. compared to adequately nourished overweight/obese subjects, malnourished overweight/obese patients had significantly prolonged duration of hospitalization: . ae . (median , - days) vs. . ae . (median , - days), (p = . ). in-hospital mortality was . % among malnourished vs. . % among adequately nourished overweight/obese patients, p = . . malnutrition increased duration of hospitalization and in-hospital mortality risk in both overweight/obese and normal weight patients. discussion: malnutrition is a frequent finding in newly hospitalized overweight/obese adults. elevated bmi does not affect duration of hospitalization. in-hospital mortality rates are similar for normal weight and overweight/obese individuals. background: the purpose of this study was to examine differences in rmr in lean and obese subjects and to determine correlation between rmr and cardio metabolic risk factors. methods: ninety nine healthy subjects ( normal; obese and over weights) participated in this case-control study. sex and physical activity were matched. blood pressure, plasma insulin, glucose, homa-index, lipid profile, uric acid and c-reactive protein concentrations, anthropometric measurements, body composition, rmr and macronutrient intake were measured. result: fpg (p = . ), uric acid (p = . ), crp (p = . ), insulin (p < . ), homa index (p < . ), systolic and diastolic blood pressure (p = . ; p = . ), anthropometric measurements (except height and whr) (p < . ) and body composition (p < . ) were significantly higher in case group. there were no significant differences between both groups by the means of dietary intake. in obese and overweight group, rmr was statistically higher than control group (p = . ). there were no significant difference between both groups in adjusted rmr for ffm and fm (p = . ). with multiple linear regression, rmr was significantly associated with ffm (p < . ) and uric acid (p < . ) and negative significant correlation was observed between rmr and waist circumference (p = . ) and hdl (p = . ). the finding of a similarly specific metabolic rate in obese and lean subjects at first sight contradicts the idea that a low rmr is a main cause of obesity. one reason for the undetected association between low rmr and obesity may be that obesity-related metabolic risk factors mask the lower metabolic rate that initially contributed to weight gain. background: pain may cause some patients to avoid self-monitoring, which could impair glucose control. cooling the fingertip prior to puncture may reduce pain. objectives: to examine the efficacy of coolsense, a device designed to cool the fingertip prior to puncture for glucose self monitoring. methods: adults with type diabetes treated at the e. wolfson medical center diabetes unit outpatient clinic were randomized to treatment with the coolsense device or a sham device which appeared identical to the active intervention but did not cool the fingertip. patients completed a demographic and medical history interview and were asked to rate the device for discomfort and satisfaction. results: a total of patients were recruited and randomized to intervention group (coolsense vs. sham, n = in each group). participants were ae . years of age, had been diagnosed with diabetes ae . years prior to study onset and had mean hba c of . ae . %. patients reported performing . ae blood glucose checks per day. the extent to which glucose checking caused pain was rated at . ae . out of a possible five points, one being most severe. the coolsense device was a significant independent predictor of pain reduction, even after controlling for age, sex, hba c, aspirin, neuropathy and baseline rating of pain associated with glucose check. conclusions: cooling the fingertip with the coolsense device significantly reduced pain at the puncture site compared to a sham device. it is possible that this reduction in pain will increase glucose self monitoring events in patients with diabetes. f. saad , , a. yassin , , g. doros results: after years the following changes were observed: weight (kg) decreased by . kg from . introduction: testosterone treatment in hypogonadal men is standard therapy, particularly in younger men with congenital forms of hypogonadism. methods: three hundred thirty-three patients ( with primary hypogonadism including patients with klinefelter's syndrome, with secondary hypogonadism and with late-onset ("mixed" or "metabolic") hypogonadism aged - years (mean ae years) received intramuscular injections of mg of testosterone undecanoate during a maximal treatment time of years, overall corresponding to treatment years. hypogonadism was defined as total testosterone below nmol/l and occurrence of symptoms. physiological functions of bile salts include modulation of cholesterol and triglyceride metabolism, insulin sensitivity, the intestinal endocrine response to meals and energy homeostasis. several of these functions are mediated via the membrane g-protein coupled receptor tgr (also called gpbar and gpr ) which has been shown to promote release of glucagon like peptide- from enteroendocrine cells and increase energy expenditure in brown adipose tissue. methods: based on comprehensive discovery platform developed at satrx several in vivo active tgr inhibitors were discovered. active scaffolds were identified during the high throughput screening campaign of , tgr biased small heterocyclic molecules library that was optimized for medchem parameters and cell permeability. confirmed selective hits were evaluated for functional activity of glp secretion in nci-h endocrine cell line. in vivo activity was confirmed in db/db mice diabetes model. active compounds were administered chronically at doses , and . mg/kg and produced stable and statistically significant anti-diabetic effect. results: the most active compound showed efficacy comparable to mg/kg doses of sitagliptin. the actual activity data and experimental details will be provided. the interaction between excess of body fat (total and abdominal) and increased cardiovascular risk is well established in all age groups [ , ] . however, there are few studies that analyze the pattern of body fat distribution and its association with cardiovascular risk factors (crfs) in a population with more advanced age. objective: to analyze the presence of crfs according to the pattern of body fat distribution, in brazilian aged years or older. methods: one hundred and thriteen subjects, randomly selected, . ae . years, of both sexes. the percentage of total and abdominal body fat, hypertension and lipid profile were used for characterization of crfs. the chi-square test was used to assess proportions of crfs and mann-whitney test was used to compare the results between distributions of adiposity. results: eutrophic subjects showed lower triglycerides (p = . ), total cholesterol (p = . ) and prevalence of hypertension (p = . ) and hypertriglyceridemia (p = . ). subjects with higher abdominal adiposity showed higher total cholesterol (p = . ) and prevalence of hypertriglyceridemia (p = . ) and hypercholesterolemia (p = . ) than no excess of abdominal adiposity. higher value of one outcome already reflects the higher prevalence of hypertension (p = . ) and, the higher values of both outcomes reflect the high values of total cholesterol (p = . ) and triglycerides (p = . ). conclusion: that obesity, whether abdominal or total, is associated, in the same way, with dyslipidemia and hypertension in the subjects aged years. background/aim: there is growing consensus in the literature that inflammation plays a central role in the pathophysiology of obesity and type diabetes mellitus (t dm) and cardiovascular complications. neutrophil-to-lymphocyte ratio (nlr) provides a simple method for assessment of inflammatory status and it is a new, inexpensive marker. the aim of the present study was to investigate the predictive value of preprocedural (before the ogtt) nlr on development of prediabetes (pd) and type diabetes (t dm) in morbid obesity patients (mop). methods: mop and normal weight patients with normal ogtt [fasting plasma glucose (fpg) < mg/dl. two-hour glucose during ogtt < mg/dl] were evaluated in this study. results: the mean ae sd nlr of mop were significantly higher than that of patients with normal weight healthy patients ( . ae . vs. . ae . , p < . , respectively). in receiver operating characteristics curve analysis, nlr > . had % sensitivity and % specificity in predicting pd and nlr > . had % sensitivity and . % sepesifity in predicting t dm. logistic regression analysis showed that elevated nlr (or: . , % ci: . - . , p < . ) was an independent variable for predicting t dm in mop. conclusion: mop have higher nlr than healthy controls. high nlr is a powerful and independent predictor of pd and t dm in mop. elevated nlr levels are usually considered as an inflammatory marker. the results of this study suggested that inflammation plays a role in the pathogenesis of pd and t dm with mop. division of human nutrition, wageningen university, wageningen, general surgery, rijnstate hospital, arnhem, gastroenterology, rijnstate hospital, arnhem, the netherlands objective: endoscopic implantation of a duodenal-jejunal bypass liner (djbl), or endobarrier, is a novel bariatric technique to induce weight loss and remission of type diabetes (t d). placement of the djbl mimics the duodenal-jejunal bypass component of the roux-en-y gastric bypass (rygb) procedure. as gut hormones are known to change substantially after rygb surgery, in our study we now evaluated gut hormone responses after implantation of the djbl. methods: fourteen (eight male, six female) obese t d subjects (bmi . ae . kg/m , duration of type diabetes . ae . years) were selected for implantation of a djbl. fasting plasma levels of glucose, c peptide, hba c and gut hormones ghrelin, gip and glp- were analysed before and at and days after djbl implantation. results: plasma hba c levels were significantly decreased after djbl implantation and a % reduction was found in diabetes medication usage (p < . ). ghrelin was found significantly elevated, with the highest induction in the first days post-implant. although the gip response showed high variation between subjects, gip tended to decrease days after implantation (p = . ). glp- levels showed a significant "dip" at day post-implant, which correlates with the intake of solely pureed/liquid food in the first week post-implant. conclusions: implantation of a djbl results in an early substantial remission of t d, comparable to results seen after rygb surgery. interestingly, in contrast to rygb surgery, implantation of the djbl seems to preserve normal physiological responses of gut hormones that are related to nutritional status. conflicting data exists as to the association between body mass index (bmi) and the rate of chronic kidney disease (ckd). in a cross sectional analysis of database from a screening center in israel we assessed the rate of ckd defined as estimated glomerular filtration rate (egfr) < ml/min per . m in relation to increasing bmi subcategories. the study population included , subjects, % women aged - , out of whom men and women had ckd. subjects with a bmi of - . (kg/m ) compared to subjects with bmi < (kg/m ), had an odds ratio (or) [ % confidence intervals (ci)] for ckd of . ( . - . ) and . ( . - . ) for men and women respectively. for subjects with a bmi of - (kg/m ) the or were . ( . - . ) and . ( . - . ) for men and women respectively. for subjects with bmi > (kg/m ) the or rose to . ( . - . ) and . ( . - . ) for men and women respectively. this association became insignificant in men after multivariate adjustment for age, hypertension and diabetes mellitus but persisted in women even after multivariate adjustment. the correlation between bmi and ckd in women was attributed to the subcategory of severely obese women with bmi above (kg/m ). our study suggests that for both men and women a positive correlation exists between the degree of bmi and the rate of ckd. this correlation persisted in severely obese women even after multivariate adjustment, suggesting that in women, obesity may be an independent risk factor for developing ckd. the enteroendocrine cell line pgip/neo stc- was used to evaluate the effects of gspe on glp- secretion in different nutrient conditions. a cytotoxicity detection kit (ldh) and brdu labelling and detection kit iii (roche) were used to determine cytotoxicity and cell proliferation, respectively. glp- levels in cell culture medium were determined using a glp- (active) elisa kit (millipore). cytotoxicity and proliferation cell assays (n = ) demonstrated that the maximum non-toxic gspe treatment for these cells was mg/l gspe over a period of h. surprisingly, after h of gspe treatment, glp- secretion (n = ) was significantly inhibited. this inhibitory effect was observed at concentrations as low as mg/l. furthermore, inhibition of glp- was also observed when stc- cells were co-incubated gspe and lmol/l dihomo-ϒ linoleic acid. in conclusion, acute gspe incubation decreases glp- secretion in cultured enteroendoncrine cells. interestingly the effect occurs under either on basal or nutrient (fatty acid) stimulated conditions. c. higa , f. novo , m.s. donato , n. rizzo , g. ciambrone , e. korolov , p. comignani coronay unit, hospital aleman, buenos aires, argentina introduction and aim: there is no data available respect of the prognostic value of albumin:creatinin ratio (acr) in non-st-segment elevation acute coronary syndrome (nseacs). the purpose of our study was to evaluate the long term prognostic value of acr in patients with nseacs. methods: we analyzed a prospective cohort of nseacs in whom acr was determined at admission. roc curves were constructed to determine best cut off value associated with primary end-point of death or nonfatal myocardial infarction (d/ami). independent variables for d/ami were assessed by a cox regression model. : seven hundred ten patients with nseacs were analyzed. thirty percent were female and median age was years. median follow up time was months. best cut-off point of acr for primary end point was mg/g. thirty-four percent of patients had acr ! mg/g. acr correlated with higher incidence of primary end point both in diabetics and in non-diabetic patients: or . (ic . - ), p = . and or . (ic % . - ), p = . , respectively. by multivariable cox regression analysis, acr was an independent predictor of d/ami at long-term follow up: hr . (ci % - ), log rank p < . in a model that included age, female gender, diabetes mellitus, serum creatinine, creatinine clearance, glucemia at admission a, elevated cardiac markers and st segment deviations. conclusions: acr was an independent predictor of adverse outcomes in nseacs. this simple and accesible marker should be considered for risk stratification in this high risk setting. aim of the work was to examine possible connection of methabolic syndrome with endothelium dysfunction in pre and postmenopausal women with and without ischemic heart disease (ihd). methods: hundred and eight-nine pre and postmenopausal women with ihd were examined and in same age without ihd. all women were measured arterial pressure using korotkov method (according to jnc- recommendations). vasa regulating function of endothelium examined with ultrasound in triplex scanning using reactive hyperemia probe (method by d. celermajer). willebrant factor determined in blood plasma. results: in group of women with ihd ( %) had arterial hypertension: among them ( %) in pre and ( %) postmenopausal. among women without ihd ( %) had hypertension: ( %) were pre-and ( %) postmenopausal. during reactive hyperemia probe diameter of radial artery was: women with ihd . ae . mm; speed of blood flow . ae . m/s, willebrant factor . ae . ; women without ihd corresponding . ae . mm (p < . ) and . ae . m/s (p < . ), willebrant factor . ae . (p < . ) where there significant difference was noted. findings allows us to suppose, that women with ihd have higher abundance of arterial hypertension, that in connection with other components of metabolic syndrome, specify development of endothelium dysfunction, in comparison with women without ihd, which have arterial hypertension, endothelium dysfunction infrequently. objective: recently, incretin-related drugs are widely used for improving blood glucose level in clinical practices. in this study, we tried to examine the efficacy and safety of these drugs of the japanese approved dose. we compared the efficacy and safety of the human glp- analogue liraglutide (the approved dose . mg) with the dipeptidyl peptidase- (dpp- ) inhibitor sitagliptin (the approved dose mg) once daily in the obese adults with type diabetes, over weeks. methods: japanese obese out-patients whose glycemic control was inadequately controlled with oral hypoglycemic agents received either maximum weeks of treatment with . mg lilaglutide (n = ) or mg sitagliptin (n = ) once daily within the period from march to october , at chubu-rosai hospital. the primary endpoint was change in body weight. other measurements were hba c, lipid profiles, body weight, body mass index, serum creatinine, estimated gfr, and adverse events before and at , , , weeks after liraglutide or sitagliptin administration. results: at the japanese approved dose, the greater reduction of mean body weight was achieved with liraglutide than with sitagliptin (À . kg, p < . , + . kg, p = n.s. vs. baseline). the degrees of lowering hba c (both . % at baseline) were À . % for liraglutide and À . % for sitagliptin (both p < . at baseline). the egfr of the sitagliptin group worsened from . to . ml/min/ . m (p < . at baseline). the most common adverse events were gastrointestinal symptoms ( ( %) patients on . mg liraglutide). conclusion: liraglutide provides greater body weight reduction over weeks even at the japanese approved dose of . mg. objective: to examine prevalence of cardiovascular risk factors in patients with type diabetes and stroke in primary care setting. methods: study was conducted at primary health center tuzla and included all patients with type diabetes and stroke who were registered in one family medicine team. we also calculated absolute cardiovascular risk according to the european guidelines on cardiovascular disease prevention in clinical practice. results: prevalence of stroke in diabetic patients was . %. significantly more women had stroke than men ( . % vs. . %; p = . ). mean age of patients was . ae . years. men were significantly older than women ( . ae . vs. . ae . ; p = . ). majority of participants belonged to age group > years ( . %). mean duration of diabetes was . ae . years. more than half of patients ( %) had diabetes - years, . % had diabetes - years, and . % patients had diabetes > years. family history for diabetes had . % patients. the most prevalent cardiovascular risk factors were hyperlipidemia ( . %) and hypertension ( . %). obesity was present in % patients, and . % patients had family history for premature cardiovascular disease. unhealthy diet had . % patients, . % were physically inactive, and % diabetic patients were smokers. mean absolute cardiovascular risk was . ae . %; . ae . % in men, . ae . % in women. men had significantly higher absolute cardiovascular risk than women (p = . ). conclusion: prevalence of cardiovascular risk factors in patients with type diabetes and stroke were very high. it indicates more effective strategies in primary care setting to reduce risk of macrovascular and microvascular complications. the prevalence of metabolic syndrome was determined as a crosssectional study among healthy saudi adults ( % males and % aged - years) attending national guard clinics using the definition proposed by ncep atpiii. the prevalence of metabolic syndrome was %. only one third of the participants had normal weight (bmi = . - . ). central obesity based on waist circumferences was noted in % of males and % of females. low hdl-c showed the highest prevalence ( %) followed by high tg ( %). about % of participants had impaired fasting blood glucose ( ! mg/dl). only % had high blood pressure ( ! / mmhg). more than three quarters ( . %) of the respondents had ! component of metabolic syndrome. in conclusion, metabolic syndrome needs to be addressed as an important health problem in the gulf region. background/aim: adequate treatment and monitoring of diabetes can significantly improve quality of life and extend life expectancy in diabetic subjects. aim of this study was to examine metabolic control in patients with type diabetes in primary care setting. methods: study was conducted at primary health center tuzla and included randomly selected patients with type diabetes, aged years and over, from one family medicine team. we evaluated parameters of metabolic control in patients with type diabetes according to the european guidelines on cardiovascular disease prevention in clinical practice. results: there were significantly more women than men ( . % vs. . %; p < . ). mean age of patients was . ae . years. mean duration of diabetes was . ae . years. only ( . %) patients had blood glucose < . mmol/l, and ( . %) patients had hba c < . %. controlled blood pressure / mmhg had ( . %) patients. only ( . %) patients had total cholesterol < . mmol/l, while ( . %) patients had triglycerides < . mmol/l. normal body mass index (bmi) < kg/m had ( . %) patients and recommended waist circumference ( . %) patients. mean blood glucose was . l ae . mmol/l, hba c . ae . %, systolic blood pressure . ae . mmhg, diastolic blood pressure . ae . mmhg, total cholesterol . ae . mmol/l, triglyceride . ae . mmol/l, bmi . ae . kg/m , waist circumference . ae . cm. conclusion: metabolic control of type diabetes in family medicine practice was inadequate which indicates more effective interventions in order to achieve appropriate metabolic control of diabetes and reduce risk of complications. aim: the aim of the study was to determine the metabolic responses to two different liquid milk protein diets in prediabetic and healthy volunteers. the diets were composed of . g whey or casein protein, g maltodextrin and g lactulose or . g maltodextrin and g lactulose (control). procedures: fifteen prediabetic and healthy volunteers consumed all liquid test diets with blood sampling over a h time period. blood glucose, incretin hormones, nefas, hydroxybutyric acid and plasma amino acids were analyzed. the feeling of hunger was determined using a visual analog scale. results: in both, prediabetic as well as healthy volunteers, postprandial blood glucose levels were significantly decreased and plasma insulin levels were significantly elevated with the protein diets compared to the control diet. gip and glp- levels also increased after the protein-contaning test-diets. in the prediabetic volunteers, changes in glucose, insulin, amino acids, non-esterified fatty acids and hydroxybutyric acid displayed time delayed changes. a reduced feeling of hunger was reported in the prediabetic compared to the control group. conclusion: both protein components elevate insulin secretion and cause reduced blood glucose auc and these effects are more pronounced in prediabetics. however, despite differences in the amino acid composition, casein and whey protein did not reveal significantly different effects. postprandial changes in plasma metabolites in prediabetics suggest more metabolic pertubations than just impaired glucose disposition. methods: ins- e cells or freshly isolated rat islets were incubated for h in the presence of either leptin or tnf-a at lower ( . nmol/l or ng/ml) or higher concentration ( nmol/l or ng/ml) individually or in combination. proinsulin mrna was detected by real time-pcr, insulin by radioimmunoassay kit, β cell proliferation were tested with mtt assay and β cell apoptosis was determined with annexin v-fitc/pi by fluorescent activated cell sorting. results: higher leptin ( nmol/l) or tnf-a ( ng/ml) significantly suppressed gsis (p < . ) and reduced the intracellular proinsulin mrna level and insulin content (p < . ) in ins- e cells and primary islets. whereas, lower leptin ( . nmol/l) or tnf-a ( ng/ml) did not show such effects. however, the inhibition effects were compromized when two factors were simultaneously administrated in either cultured ins- e cells or pancreatic islets. similarly, higher leptin or tnf-a was able to inhibit ins- e cell proliferation and promote cell apoptosis. again, these effects were alleviated in the presence of both factors. furthermore, western blotting showed that tnf-a inhibited leptin receptor (ob-rb) expression, decreased the phosphorylation of stat . conclusion: tnf-a exerts antagonistic effects on leptin actions in pancreatic β cells by interfering with ob-rb/jak/stat signaling pathway. increased tnf-a level may contribute to the pathogenesis of hyperinsulinemia and disturbed glucose metabolism in people with obesity. aims: identifying socioeconomic factors associated with the metabolic syndrome (mets) is useful to target preventive measures. our objective was to estimate, in france, the prevalence of metabolic syndrome (mets) and to investigate the association between socioeconomic position and mets. methods: the french national nutrition and health survey (enns) cross-sectional national multistage sampling was carried out from february to march . data included waist circumference and blood pressure measurements, blood sample and sociodemographic and medication information. the prevalence of mets was assessed using several definitions, including the most recent joint interim statement (jis). association with sociodemographic covariates was assessed using logistic regression models. results: among the participants - years of age, mets prevalence was found to vary from . % according to the national cholesterol education program definition to . % according to the jis definition, without difference between genders. after adjustment for other covariates, risk of mets increased with age in both men and women (for year: ora = . , p < À and ora = . , p < À ; respectively). in women, mets risk was inversely associated with education level; women with the lowest education level facing a six fold greater risk of mets (ora = . , p < À ). in men, risk of mets was higher in men born outside of france (ora = . , p = . ) than in french-born males. conclusions: mets prevalence is lower in france than in most industrialized countries. lifestyle modifications, targeted to migrants and persons living in low socioeconomic conditions, should contribute to further reducing mets. folate. patients were divided into two groups: group (homocysteine < lmol/l) and group (homocysteine ! lmol/l). results: the mean age was . ae . years. homocysteinemia was . ae . mmol/l. a significant correlation was found between homocysteine levels and the number of criteria for ms (p = . ). besides, a significant decrease of hyperhomocysteinemia (from . % to . %, p = . ), systolic blood pressure (from . ae . mmhg to . ae . mmhg, p = . ), uric acid (from . ae . lmol/l to . ae lmol/l; p < . ) and a significant improvement of hdl levels ( . ae . mmol/l to . ae . mmol/l, p < . ) were reported. a non significant improvement was observed for the other parameters. furthermore, a correlation was noted between the variation of homocysteine and hdl levels (p = . ). the association found between homocysteine and the severity of ms suggests a reflection on the cardiovascular risk caused by such association and on the importance of hyperhomocysteinemia screening in patients with ms. object of study and method: the patients with ms: of them presented with the recurrent form of af, had no arrhythmia. the groups were comparable in terms of age, concomitant disorders, arterial hypertension duration, arterial pressure, and severity of chronic heart failure. patients with permanent af, hemodynamically significant heart disease, myocardial infarction with wave q in the medical history, were excluded from the study. in a review of the diagnostic efficiency parameters showed statistically significant differences in the two groups, with the evaluation of their specificity (se), sensitivity (sp) and or (odds ratio). results: patients with ms having abdominal obesity and arterial hypertension over years (se . ; or . ( % . - . ); x = . ; p = . ); homa ir index more than . (se . ; or . ( % . - . ); x = . ; p < . ); reduced hdl cholesterol level below . mmol/l (se . ; or . ( % . - . ); x = . ; p < . ); left atrial dilation (se . ; or . ( % . - . ); x = . ; p = . ); albuminuria more than mg/day (sp . ; or . ( % . - . ); x = . ; p < . ); waist circumference more than cm (sp . ; or . ( % . - . ); x = . ; p = . ) were at high risk of af. the duration of abdominal obesity and hypertension for years, insulin resistance index > . , reduced hdl < . mmol/l, an increase in albuminuria > mg/day, an increase in waist circumference > cmrisk factors for af in ms. patients and methods: fifty-three patients with ms over , comparable in duration af, comorbidity and treatment. patients with permanent af, hemodynamically significant heart disease, myocardial infarction with wave q in the medical history, were excluded from the study. following a successful cardioversion all patients assigned amiodarone. group (n = ) in the adjuvant therapy prescribed metformin over - mg/day; group (n = ) metformin < mg/day, group (n = ) metformin is not assigned. the observation period is months. results: in group homairind decreased to . ae . (p < . compared with baseline), in the nd to . ae . (p > . ) and rd to . ae . (p > . ) (p - < . ), and improvement of lipid profile and increased gfr ( . ae . (p < . compared with baseline), . ae . and . ae . ml/min, in the st, nd and rd groups, p = . between groups); decreased volume of the left index atria ( . ae . (p < . compared with baseline), . ae . and . ae . ml, in the st, nd and rd); reduction in waist circumference ( . ae . (p < . compared with baseline), . ae . and . ae . cm, in the st, nd and rd). patients in group was maintained sr for much longer ( . ae . days) than in patients of the nd ( . ae . ) and the d group ( . ae . ) (p = . ; p - < . ; p - < . ). aims: metabolic syndrome (mets) is the serious health problem worldwide and is associated with increased risk of cardiovascular disease. mets has a significant genetic component which is estimated on - %. apolipoprotein a (apoa , omim acc. no ) gene and its variants have been associated with the plasma lipids, mainly triglycerides and its role in mets development is recently discussed. we have analyzed, if there is the association between the apoa gene haplotypes (based on the rs and rs variants) and mets in middle european -slavic population. methods: apoa haplotypes based on the presence of either common or at least one minor apoa allele (rs , c- and rs , g ) and the presence of mets were analysed in adults ( males and females, - years old) selected according the monica protocol and examined at / and / . the presence of mets was analysed according the ncep-atp iii criteria. results: in females with at least one minor apoa allele, the prevalence of mets was significantly higher both at / ( . % vs. . %, p < . ) and at / ( . % vs. . %, p < . ). in males, association between apoa gene and mets was not detected neither at / ( . % vs. . %, p = . ) nor at / ( . % vs. . %, p = . ). a. blazquez , o. garcia-sanchez , y. quiros , v. blanco-gozalo , m.j. montero , j.m. lopez-novoa , c. martinez-salgado , f.j. lopez-hernandez universidad de salamanca, ibsal, iecscyl-ibsal-university of salamanca, salamanca, spain diabetes commonly causes a type of chronic nephropathy, namely diabetic nephropathy (dn). diagnosis of dn is presently accomplished late in the course of disease. microalbuminuria anticipates progression towards dn only in a subset of patients. another subset of diabetic, microalbuminuric patients never develop dn. accordingly, new biomarkers are necessary to more accurately identify diabetic patients progressing towards dn. ngal has also been associated to progression to dn. on the other hand, hypertension is a well-known factor of co-morbidity in diabetic nephropathy. we decided to study the capacity of ngal to detect the additive effect of hypertension on progression to diabetic nephropathy. in the present work we aimed at unraveling the origin of the increased urinary ngal. spontaneously hypertensive rats (shr) or normotensive wistar rats were rendered hyperglycemic by a single administration of streptozotocin, or not (as controls). renal function was monitored and ngal was measured in urine, plasma and tissue samples. their kidneys were perfused in situ with krebsdextran solution (containing or not exogenous ngal), and urine was collected. plasma and renal tissue ngal was also measured by western blot, and renal ngal expression was determined by rt-pcr. our results suggest that the urinary ngal is increased by the coexistence of diabetes and hypertension, but not by each of these conditions. ngal excretion results from its altered tubular handling. this subtle and primary renal alteration might be studied further as an early marker of the increased risk of chronic renal disease posed by the co-morbidity of hypertension and diabetes. the increasing prevalence of obesity is a major public health concern. more than . billion adults, and older, were overweight, over million men and nearly million women of whom were obese in . large-scale studies have demonstrated that overweight and obesity increase the risk of developing several forms of cancer, including several that are not classically viewed as hormonedependent. in both men and women, increasing bmi is significantly associated with higher death rates from cancers of the oesophagus, colon and rectum, liver, gall bladder, pancreas and kidney, as well as non-hodgkin lymphoma and multiple myeloma. the associations between obesity and particular maignancies may be affected by body fat distribution, and may result from diverse factors including diet and abnormal levels of hormones and inflammatory cytokines. recently, there is more and more sufficient evidence that excess body weight is an avoidabl e cause of excess cancers including gastrointestinal, endometrial, esophageal adenocarcinoma, colorectal, postmenopausal breast, prostate, and renal cancers. the mechanism that obesity association with cancer is remains not well understood. there are some most studied hypothesized mechanisms such as, high levels of insulin and free levels of insulin-like growth factors (igfs), sex hormones, adipocytokines, inflammatory cytokines, c-myc oncogenic transcription factor, obesity-induced hypoxia and warburg effect, and so on. in the future, the potential mechanisms and conclusions in obesity associated with increased risk for developing cancer, and the underlying cellular and molecular mechanisms will be studied. results: among patients with ms (mean age: years; % male), ( %) had abdominal obesity, ( %) had a c > . %, ( %) had fpg > mg/dl and ( %) had homa > . . if we consider as ir indicators: . presence of prediabetes criteria (fpg > mg/dl and/or a c > . %); and/or . homa > . , patients ( %) met at least one marker of ir, but of them ( %) had homa < . [ ( %) of them were on therapy with metformin, an insulin-sensitivity drug]. in the multivariate analysis, presence of type diabetes (hr . ; p < . ) and presence of prediabetes criteria (hr . ; p < . ) were associated with homa > . discussion: although most of the patients with ms have clinical markers of ir (fpg > mg/dl, a c > . %), only a third part of them have homa levels associated with ir. these observations suggest that: of spilberger's test. from to women were followed for the incidence of ah. results: high level of anxiety (hla) in studied cohort revealed in . % of women. women with hla more often tried unsuccessfully to quit smoking compared to lower levels of anxiety ( . % and . %, respectively; x = . , p < . ). women with hla in twotimes less likely to follow the diet (x = . , p < . ) and assess their physical activity more passive (x = . , p < . ). relative risk (hr) of development of ah in women with hla during the first years of study was in . -fold higher ( . % ci: . - . ; p < . ), over years it was . ( . % ci: . - . ; p < . ) and hr was . ( . % ci: . - . ; p < . ) over years of follow-up compared to those with lower anxiety levels. depending on age groups the risk of ah incidence within years was highest in older group with hla aged - years (hr = . ; . % ci: . - . , p < . ). conclusions: there is high prevalence of hla in russian female population aged - . during years of follow-up women with hla have significantly higher risk of ah especially in older age groups. material and methods: under the third screening of the who "monica-psychosocial" (mopsy) program random representative sample of women aged - years (n = ) were surveyed in novosibirsk. d was measured at the baseline examination by means of test "mmpi". from to women were followed for years for the incidence of ah. results: the prevalence of d in women aged - years was . %. women with major d ( %) significantly extended negative behavioral habits: smoking and unsuccessful attempts to give it up, low physical activity, they were less likely to follow a diet. relative risk (hr) of ah in women with d during the first years of study was higher in . -time compared to women who had no d ( . % ci: . - . ; p < . ). with regard to age groups hr was significant in oldest age category - years (hr = . ; % ci: . - . ; p < . ). hr of incident ah in persons with d within years was . ( . % ci: . - . ; p < . ) and there were no significant differences in age groups. we did not have risk of ah over years of follow-up in women with d (p > . ). the prevalence of d in women aged - years is more than %. women with d had unfavorable lifestyle and higher relative risk of ah over the first - years of the study. purpose: study the association of high level of anxiety (hla) with vntr polymorphisms d and dat genes; determine the relative risk (hr) of arterial hypertension in men with hla. the who " monica-psychosocial" in monica-psychosocial" in , monica-psychosocial" in , surveyed a random representative sample of men aged - years ( men). to assess the level of anxiety was used spielberger's test. cox proportional regression was used for hr assessment. results: the hla in an open population of men aged - years was . %. since hla genotype was significantly associated / drd gene and genotype / gene dat. for years hla maximizes the hr of hypertension in the first years. conclusion: there is high prevalence of hla at male aged - in russian. hla were significantly associated with certain vntr polymorphisms of genes drd , dat; hla increases the hr of hypertension in the first years. inhibiting beta cell proliferation and promoting its apoptosis which concomitantly leads to decreased β cell mass. dermatology, faculty of medicine, cairo university, cairo, egypt background: psoriasis is a disorder with genetic and immunologic background. leptin can regulate the t-helper response. objective: our primary goal is to study the functional polymorphism (g- a) of the leptin (lep) gene in the genetic predisposition of psoriasis, and our secondary goal is to examine factors affecting plasma leptin levels in psoriasis, and to compare patients with and without metabolic syndrome (ms). methods: the study involved psoriatic patients and healthy controls. analysis of g- a polymorphism of the lep gene was made by the pcr and restriction fragment length polymorphism technique. the relationship between lep gene polymorphism and the clinical features of the patients was analyzed. plasma leptin levels and proportions of comorbidities in patients vs. controls were compared. results: in controls the ga, aa and gg frequencies were %, % and % respectively, while in patients the distribution of genotypes was . %, . % and . % respectively, with significant difference (p = . ) between patients and controls. in patients with ms the gg, ga and aa frequencies were . %, . % and . % respectively, while in patients without ms the distribution of genotypes was . %, % and . % respectively, with significant difference (p = . ) between both groups. plasma leptin showed a significant higher levels in the patients vs. the controls (p < . ), and among the different lep genotypes (p < . ) in the patients′ group. conclusion: lep g- a polymorphism could be a predictor for higher plasma leptin and increased risk of psoriasis and could be used as a marker for psoriasis-related comorbidity risk. introduction: contractile dysfunction, associated with disturbances in excitation-contraction coupling, has been widely demonstrated in diabetic heart. aims: the aim of this study was to investigate the pattern of mrna encoding cardiac muscle proteins that are involved in the process of excitation-contraction coupling in early onset type diabetic goto-kakizaki (gk) rat. methods: experiments were performed in gk and wistar control rats aged - weeks. gene expression was assessed in ventricular muscle with real-time rt-pcr, shortening and intracellular ca + were measured in ventricular myocytes with video edge detection and fluorescence photometry, respectively. results: expression of genes encoding some membrane pumps and exchange proteins were unaltered (atp a / , atp b , slc a ) whilst others were either upregulated (atp a ) or downregulated (slc a ) in gk ventricle compared to control. expression of genes encoding some calcium (cacna c/ g, cacna d / d , cacnb /b ), sodium (scn a) and potassium (kcna / , kcnj / / / / , kchip , kcnab , kcnb , kcnd / / , kcne / , kcnq , kcng , kcnh , kcnk , kcnn ) channel proteins were unaltered whilst others were either upregulated (cacna h, scn b, hcn ) or downregulated (hcn , kcna , kcna , kcnj ) in gk ventricle compared to control. the amplitude of ventricular myocyte shortening and intracellular ca + transients were unaltered however, the tpk shortening was prolonged and thalf decay of the ca + transient was shortened in gk myocytes compared to controls. conclusions: early changes in expression of genes encoding various cardiac muscle proteins are associated with disturbances in myocyte shortening and intracellular ca + transport. results: analysing level of tnf-alpha, we found that in group , there were significantly higher values than the control group by . times ( . ae . pg/ml: . ae . pg/ml, respectively), and significantly higher than patients without insulin resistance ( . ae . pg/ml). analyzing level of il- , the presence of ir, level of this cytokine increases by only a factor of ( . ae . pg/ml) relative to that of the control group ( . ae . pg/ml). in the second group, the level of il- ( . ae . pg/ml) was significantly higher than in group and exceeded the performance of control group by . times. analyzing the ratio of the level of tnf-alpha and il- , we have detected a significant increase in the coefficient tnf-alfa/il- in group ( . ae . ) compared with group patients ( . ae . ). that is, ir in chc patients gives a significant shift in balance of cytokines toward proinflammatory interleukins, which can be observed by increase of tnfalfa/il- over . (p < . by mann-whitney). conclusions: progression of ir in patients with chc is accompanied by an increase in ratio tnf-alfa/il- serum. beyond the value of . , chc patients will an require in-depth study for carbohydrate metabolism. cardiovascular medicine, international university of health and welfare sanno hospital, tokyo, japan background: hyperglycemia has been suggested as a significant factor in coronary microangiopathy in patients with type diabetes (t dm), but whether it can be reversed through treatment of hyperglycemia is unknown. aim: to clarify whether glycemic control can improve coronary microangiopathy in t dm. methods: subjects were t dm who underwent coronary angiography and age-matched controls. myocardial segments perfused by angiographically normal coronary arteries were studied. baseline myocardial blood flow (mbf, ml/min/ g) and mbf during dipyridamole administration ( . mg/kg/min) were measured using positron emission tomography (pet). myocardial flow reserve (mfr) was calculated by the ratio of mbf during dipyridamole administration to the baseline mbf. after the first pet study, patients were subdivided into an additional intensive therapy group (atg) and no-additional therapy (natg) group. second pet scan was performed - months later. results: baseline mbf was comparable among the atg ( . ae . ), natg ( . ae . ) and controls ( . ae . ). however, mbf during dipyridamole administration was significantly lower in both the atg ( ae . ) and natg ( ae . ) than in controls ( ae , p < . ) as was the mfr (atg, . ae . ; natg, . ae . ; controls, . ae . ; p < . respectively). mfr was significantly improved in the atg ( . ae . ; p < . ), but not in the natg ( . ae . ; p = ns). there was a significant inverse relationship between percent change in mfr and percent change in glycemic control. however, no significant relationships were seen between the percent change in mfr and percent change in plasma lipid fractions. conclusion: coronary microangiopathy in t dm can be reversed by intensive therapy for hyperglycemia. l. drimba, r. s ari, j. né meth, z. szilv assy, b. peitl background: our aim was to investigate the effect of "sui generis" hyperinsulinaemia on proarrhythmogenic electrophysiological changes and on cardiac arrhythmias. methods: euglycaemic hyperinsulinaemia was induced in chronicallyinstrumented conscious rabbits equipped with a right ventricular pacemaker electrode catheter. hyperinsulinaemia was induced by either or mu/kg/min insulin infusion and a variable rate of glucose infusion ensured the maintenance of euglycaemia ( . ae . mmol/l). the effect of hyperinsulinaemia on cardiac electrophysiological parameters and arrhythmia inducibility was studied by means of -lead surface ecg recording and by programmed right ventricular stimulation (prvs). the role of adrenergic activation was investigated by determination of plasma catecholamine level and by intravenous administration of beta adrenergic blocking agent, propranolol. results: both and mu/kg/min insulin infusion prolonged the pq and the tpeak-tend intervals and shortened the rverp, but no significant changes on other measures of ecg (hr, qt, qtc) were observed. the incidence of prvs-induced ventricular premature beats and non-sustained ventricular tachycardia was higher during euglycaemic hyperinsulinaemia than that of fasting state. we found that higher plasma level of insulin was occurred, the more inducibility of arrhythmias was seen. no change in plasma catecholamine level was observed, but the propranolol restored the prolonged tpeak-tend interval. our results indicate the "sui generis" proarrhythmic effect of hyperinsulinaemia due to reduction of the repolarization reserve in otherwise healthy rabbits. propranolol can be used safely for prevention of arrhythmia in patient with hyperinsulinaemia. euglycaemic hyperinsulinaemia is suitable method to induce acquired long qt syndrome in healthy rabbits. objective: this study investigated the prevalence of metabolic syndrome (mets) and its association with demographic, socioeconomic and behavioral factors in shift workers. a cross-sectional study was conducted on a sample of shift workers of both sexes in a poultry processing plant in southern brazil. the diagnosis of mets was determined according to the recommendations from "harmonizing the metabolic syndrome". the distribution of each of the components of mets was evaluated according to the demographic, socioeconomic and behavioral characteristics of the sample. the multivariate analysis followed a theoretical framework for determining mets on shift workers. the prevalence of mets on the sample was . % (ic % : . - . ). the most frequent altered component was waist circumference (rp . ; ic % . - . ). after adjustment, the prevalence of mets was positively associated with women (rp . ; ic % . - . ), workers of over years of age (rp . ; ic % : . - . ) and those who reported sleeping five or less hours per day (rp . ; ic % : . - . ). on the other hand, mets was negatively associated with higher educational level (rp . ; ic . - . ) and having more than three meals per day (rp . ic % . - . ). in addition, most of the altered components of mets were associated with sociodemographic characteristics, whereas only waist circumference and altered blood pressure were associated with behavioral characteristics. conclusion: sex, age, educational level, eating habits and duration of sleep appeared as independent risk factors for mets. arab world covers a vast geographic area, consists of countries with an approxiimate population of about million people. geographically, arab world is variable ranging from dry desert areas to heavily raining green land. this part of the globe is also unique for its wide cultural, social and ethnic variations. most of the countries are well-heeled with significant natural resources including oil, gas and are benefited from high income. the socio-economic progress has brought benefits in the region such as improved access to health care, education, and safe drinking water. this rapid economical change has also set the scene for the modern lifestyles activities, people are eating more and exercising less. these changes in the lifestyle cause variuos metabolic syndromes including obesity, diabetes mellitus. in spite of marvelous advancement in medical sciences, the most of the metabolic syndromes are still an incurable life-long disease and swiftly increasing in all over the world. presently, six countries including saudi arabia, bahrain, united arab emirates, kuwait, oman and egypt are among the world's highest for the prevalence of metabolic syndromes especially the diabetes mellitus. metabolic syndromes placed a great burden on the public health and clinical practice in the region. v. negrean , o. mislea , i. cheta , t. alexescu , i. chisalita internal medicine, umf iuliu hatieganu cluj-napoca, cluj-napoca, umf 'victor babes' timisoara, timisoara, romania introduction: it is known that type diabetes is a major cardiovascular risk factor, but the relationship between impaired fasting glucose (ifg) and the occurrence of cardiovascular events is still undefined. objectives: to determine whether the ifg is a risk factor for cardiovascular disease. results: twenty-four percent of the patients with ifg progressed to diabetes and % from the control group were diagnosed with this condition. twenty-one percent of the patients with ifg and % from the patients in the control group were diagnosed with hbp. sixty percent from the patients with ifg and % of the patients in the control group were obese, % from the subjects with ifg and % from the subjects in the control group show ischemic heart disease. fifty-five from the patients with ifg and % from the patients in the control group declared that they practice no physical activity. there was a significant correlation between the presence of ifg and the hbp (or = , p < . ), the absence of physical activity (or = , p < . ), obesity (or = , p < . ), ischemic heart disease (or = , p < . ). conclusions: our study shows that ifg is correlated with the cardiovascular risk: patients with ifg have three times higher risk to develop hbp, six times higher risk to be obese and three times higher risk to have ischemic heart diseses. introduction: : the most common investigated factors in chronic inflammation in type diabetes are increased c-reactive protein level, erythrocyte sedimentation rate. the matrix metalloproteinases are a family of proteolytic molecules which contribute to adipose tissue abnormalities. metalloproteinase (mmp- ) has a significant contribution to development of complications of diabetes. aim: : the assessment of the inflammation intensity in patients with type diabetes mellitus and the examination of mixed meal influence on mmp- plasma level. materials and methods: : twenty subjects were qualified to this study. all of them were diabetics on insulin treatment. concentrations of mmp- were estimated at fasting state and after mixed meal challenge (elisa). we also measured body mass, bmi, systolic and diastolic blood pressure and: esr, crp, daily average glucose, hba c. results: : mmp- concentration values were higher in fasting state in comparison to in postprandial state. mmp- correlates with esr, crp, bmi, average daily glucose level and body weight. however, there are no significant correlations between mmp- and hba c. conclusions: : there was a statistically significant positive correlation between serum metalloproteinase and exponents of inflammation, such as erythrocyte sedimentation rate, c-reactive protein. after the mixed meal we observed a significant decrease of metalloproteinase concentration in relation to its concentration in the fasting state. it was shown that the concentration of metalloproteinase depends on short-term metabolic control of type diabetes, not depending on long-term control of the disease. background: several studies suggest increased oxidative stress and reduced endothelial function in obstructive sleep apnoea syndrome (osas). we assessed the association between osas, endothelial dysfunction and oxidative stress. the effect of nasal continuous positive airway pressure (ncpap) on oxidative stress and arterial dysfunction was also evaluated. we studied consecutive patients with heavy snoring. patients underwent overnight home polysomnography. ten patients with severe osas were revaluated after months of ncpap therapy. oxidative stress was assessed by measuring urinary -iso-pgf a and serum levels of soluble nox -derived peptide (snox -dp). serum levels of nitrite/nitrate (nox) were also determined. flow-mediated brachial artery dilation (fmd) was measured to asses endothelial function. results: polysomnographic indices were correlated with the metabolic score, insulin levels and central obesity indices. severe osas had higher urinary -iso-pgf a (p < . ) and serum nox and lower nox. a negative association was observed between fmd and osa severity. apnea/hypopnea index was correlated with urinary isoprostanes (r = . , p < . ). metabolic syndrome (t = À . , p < . ) and urinary -isoprostanes (t = À . , p < . ) were the only independent predictors of fmd. after -months of ncpap treatment, a significant decrease of serum nox , (p < . ) and urinary -iso-pgf a (p < . ) was observed, while serum nox showed only a minor increase. a statistically significant increase of fmd was observed (from . % to . %). conclusions: our study indicates a strong association between osas and metabolic syndrome. patients with osas and cardiometabolic comorbidities have increased oxidative stress and arterial dysfunction that are partially reversed by ncpap treatment. pendyffryn medical group, prestatyn, diabetes centre, royal liverpool university hospital trust, liverpool, uk introduction: metabolic syndrome (mets) and low testosterone levels are independently associated with increased all-cause and cardiovascular mortality. low testosterone levels are associated with obesity, insulin resistance and an adverse lipid profiles in men and the metabolic syndrome and type diabetes have a high prevalence of testicular hypogonadism. the relationship and interaction between these conditions and the potential affect they have on each other is not fully understood. method: this study examined the correlation between testosterone and the criteria of the metabolic syndrome in subjects (age . years, ae . ,( - . ) (mean, sd (range)), total-testosterone . nmol/l, ae . ,( . - ), free-testosterone . nmol/l, ae . , ( . - . ), sex hormone-binding globulin level . nmol/l, ae . , ( - ). correlation and significance statistical testing used the pearson correlation coefficient. results: diabetes was present in . % and a further . %( / ) had the metabolic syndrome. total-testosterone, free-testosterone and shbg had significant and the strongest correlations with age (r = À . , À . . . respectively, p < . ). shbg had the strongest negative correlations with triglycerides (r = À . ), waist circumference (r = À . ) and hba c (r = À . ), (total-testosterone, triglycerides (r = À . ), wc (r = À . )), all significant p < . . there were positive correlations with hdl (r = . shbg, r = . tt, p < . ). there were no significant correlations with blood pressure and free-testosterone had no correlation with mets criteria. conclusion: lower testosterone levels have the greatest correlation with ageing but are also associated with detrimental changes in central adiposity and dyslipidaemia. shbg rises with age, however lower levels have a stronger association with cardiovascular risk. this study suggests that cardiovascular risk and androgen abnormalities might be methods: group (gr ) was composed of normal subjects (age = . ae . ; means ae sem). group (gr ) consisted of non-obese type ii dm pts with hypertriglyceridaemia (type iv hlp) and ath (age = . ae . ). group (gr ) consisted of nonobese type ii dm pts with mixed hyperlipidaemia (type iib hlp) and ath (age = . ae . ). following have been determined in serum, in fasting state: total cholesterol (ch), hdl-cholesterol (hdl-ch), atherogenicity coefficient (hac), triglycerides (tg), lipolytic activity (la), lipoprotein fractions, prostaglandins a and e , prostaglandins f alpha (pgf). following have been determined in plasma, during standard ogtt: glucose, insulin, insulin/glucose index (igi), glucagon, c-peptide, sth, somatostatin, acth, cortisol, aldosterone, beta-endorphin. results: both gr and gr pts, compared to gr , had higher body mass, ch, tg, hac, and lower hdl-ch, la, insulin (at ogtt hour ), igi, sth (hour ), basal aldosterone. gr pts, compared to gr , had lower sth (hours and ). gr pts, compared to gr , had higher glucagon (hour ), somatostatin (hours and ), cortisol (hours and ), pgf, and lowerc-peptide (hour ), sth (hours and ). conclusions: altered hormonal-metabolic patterns have been observed in non-obese type ii dm pts with ath and dyslipidaemias, including decreased sth and elevated cortisol. hyperlipidemia has been indicated as an important factor of contributing to diabetes progression. however, whether native ldl or modified ldl causes dysfunctional effect of insulin secretion in islet cells is still elusive. the present study aims to identify the mechanisms of electronegtive ldl (l ) and l (less electronegtive ldl) acting on the insulin secretion of pancreatic β-cells. rin-m f cells, were cultured in the complete medium with human native l , l , or oxldl. the intracellular concentration of reactive oxygen species (ros) measured by use of dcfhda was significantly increased after loading l ( lg/ml) or oxldl ( lg/ml), but not effected after loading l ( lg/ml). the cell viability assayed by prestoblue tm reagent was suppressed to % after loading l or oxldl; however, l did not inhibit the cell viability. the insulin release of rin-m f cells was determined by elisa kit. our results demonstrated that % decrease of secretion ratio in the phase of high glucose-induced response after the β-cells were exposed in l for h as comparison with in normal medium. we also found that phosphor-c-jun was activated after loading l or oxldl, but not after loading l . the activation of c-jun may modulate the gene expression or the process of insulin secretion. thus we suggest that l , not l , is the main subparticle which induces oxidative stress and then lead to dysfunction of insulin secretion responding to high glucose stimulation in β-cells. target group for diet and physical activity interventions due to their increased risk of post-natal weight gain, type diabetes and related health problems. postpartum weight gain and/or retention, particularly in the first months are commonly due to lack of nutrition knowledge, poor dietary habits and physical inactivity. mothers are also integral to the shaping of attitudes and eating and activity behaviours of their children. the proposed study will evaluate whether an individualized weight management program with nutrition and physical activity advice and support enhances weight loss compared with standard care in overweight and obese women and women with a history of gdm. it is hypothesized that, compared with individuals given standard diet and physical activity advice, overweight and obese women, and women with a history of gdm prescribed exercise energy expenditure targets and using heart rate (hr) and dietary intake monitoring with electronic reminders, are better able to achieve a target weight loss ( % reduction from prepregnancy weight for overweight or obese pregravid ( ! . kg/m ), for overweight women ( . - . kg/m ) to achieve a weight loss that places them in the healthy-weight range, and for women who were in the healthy-weight range pregravid to return to their prepregnancy weight) through changes in eating and activity behaviours. objective: diabetes is associated with moderate cognitive deficits and neurophysiological and structural changes in the brain, a condition that may be referred to as diabetic encephalopathy. we used high-fat and sugar diet and streptozotocin induced diabetic rats to observe the changes of proteins of insulin signaling which closely correlate with learning and memory. we try to illuminate the possible mechanisms of learning and memory decreased in t dm. methods: a total of rats were randomly divided into two groups: control group (c), diabetes mellitus group (dm). after weeks, morris water maze was used to perform training trial and probe trial in order to detect spatial learning and memory abilities. and we detected proteins of insulin signaling such as ir, irs- , akt, p-creb and bcl- in the hippocampus of the rats by western blot and immunohistochemistry staining. results: . water maze experiment: compared with the c group, the escape latency increased significantly in dm from the nd day. in the spatial probe experiment, the first time passing hidden platform prolonged significantly and the distance swimming in the quadrant of hidden platform decreased significantly in the dm. . immunohistochemistry staining: compared with the c group, the positive neurons of ir, irs- , akt, p-creb, bcl- increased in the dm group. . western blot: compared with the c group, the expression of ir, irs- , akt, p-creb, bcl- increased in the dm group. conclusions: the learning and memory ablities decreased, while the expression of ir, irs- , akt, p-creb, bcl- abnormal increased in t dm model rats. the results indicate that insulin signal transduction were impaired in t dm. objectives: niacin, a widely used lipid-modifying drug, is known to induce hyperglycemia during prolonged and high-dose treatments. however, its potential mechanism (s) whereby the islets are involved remains to be determined. we thus aim to investigate the potential role of niacin and its receptor gpr a involved in regulating islet beta-cell function and insulin resistance. methods: hfd-induced obese mice were employed to study the in vivo effects of niacin. blood glucose/serum insulin levels, oral glucose tolerance test (ogtt)/insulin tolerance test (itt), and homeostasis model of assessment-insulin resistance (homa-ir) were performed to assess glucose homeostasis. real-time pcr, western blot and immunefluorescent assays were used to study the expression of genes of interest. cyclic adenosine monophosphate (camp) and glucosestimulated insulin secretion (gsis) from isolated islets and ins- e beta cells were determined. knockdown of the gpr a in ins- e cells was also examined and compared. results: eight-week treatment with niacin increased blood glucose levels by % in hfd-induced obese mice while the areas under curve of ogtt and itt, and homa-ir index were consistently enhanced. in addition, niacin treatment significantly decreased gsis in isolated pancreatic islets. ex vivo and in vitro studies showed niacin decreased gsis, increased mrna expression of ucp and gpr a as well as inhibited intracellular camp accumulation in ins- e cells. in corroboration, the decrease in gsis and camp levels were abolished by the knockdown of gpr a. our data indicate that niacin treatments leads to hyperglycemia and impaired pancreatic islet function, which is probably via the activation of islet niacin receptor gpr a-induced pathway. a once daily glp- analogue, liraglutide, is emerging world-wide as a drug for the treatment of diabetes and also, potentially, obesity. this agent not only acts on glycemic control, but also exerts an effect on body weight control, because liraglutide inhibits gastric emptying, resulting in appetite reduction and lower energy intake. herein, we treated type diabetic obese subjects with . mg/day liraglutide and examined glycemic control and body weight changes over a month period. glycemic control was markedly improved (baseline hba c . ae . %, endpoint hba c . ae . %) with liraglutide. based on subgroup analysis, the good responders to liraglutide were ( ) bmi < . ( ) diabetes duration < years. ( ) postprandial cpr < . ng/ml. while liraglutide-induced gastric symptoms, specifically nausea, occurred in nearly all patients at baseline, it had disappeared in about half by the end of the study. unexpectedly, the hba c improvement was not associated with the presence of nausea. while acute body weight loss ( . ae . kg) was observed at month, there were no significant body weight changes at the end of the study. individual body weight change was associated with the presence or absence of nausea at the end of the study. in conclusion, the effects of liraglutide on body weight loss lasted only a short period and no chronic effects were observed. thus, the hba c lowering effect of liraglutide is not due to reduced energy intake, but rather, to recovery from defects in postprandial insulin secretion. background and aims: durability of good glycaemic control may delay development of diabetic complications. early initiation of combination treatment with oral anti-diabetic drugs (oads) having complementary mechanisms of action may increase durability of glycaemic control compared with stepwise addition of oads. dpp- inhibitors such as vildagliptin are good candidates for early use in combination with metformin as they are weight neutral with no additional risk of hypoglycaemia. materials and methods: about drug-na€ ıve patients with type diabetes mellitus (t dm) with hba c between . and . %, will be randomised in verify, a -year, multinational, double-blind, parallel group study. the study will test the hypothesis whether early combination therapy with vildagliptin/metformin will result in lower treatment failure rate or in lower rate of loss in glycaemic control over time than with metformin alone. other objectives include evaluation of rate of fasting plasma glucose progression, change in hba c over time, time to insulin initiation, development/progression of diabetic complications, changes in weight, changes in homa-β/ir, safety and tolerability. insulin secretion rate and insulin sensitivity will be assessed in annual standard meal-test. patients will also be evaluated for early changes in the vasculature, microalbuminuria and retinal microaneurysms. results and conclusions: verify is the first study to investigate the long-term clinical benefits of early combination treatment vs. the standard-of-care metformin followed by addition of oads. verify will provide valuable data on the durability of glycaemic control, βcell function, insulin resistance, safety and tolerability and explore early changes in the vasculature of patients with t dm. patients with metabolic syndrome are at high risk for developing atherosclerosis. recent studies have suggested glucagon-like peptide- (glp- ) signaling to exert anti-inflammatory effects on endothelial cells, although the precise underlying mechanism remains to be elucidated. on the other hand, pparc activation was demonstrated to inhibit the transcription of factors, such as nfjb, resulting in atherosclerosis prevention via suppression of the expressions of cytokines and adhesion molecules in endothelial cells. we investigated whether pparc activation is involved in the glp- -associated antiinflammatory action in endothelial cells. we constructed an adenovirus expressing the ppre (+)-luc reporter gene for use with the reporter assay system. when we treated huvec cells with . nmol/l exenatide, endogenous pparc translational activity was significantly elevated by % as compared with control cells. the maximum pparc activity enhancing effect of exenatide was observed h after the initiation of exenatide incubation and was approximately % of that induced by lmol/l pioglitazone. when incubated with exenatide and pioglitazone simultaneously, pparc activity was additively promoted, suggesting that these two agents synergistically stimulate pparc activity. as h , a pka inhibitor, abolished glp- induced pparc enhancement, the signaling downstream from glp- cross-talks with pparc activation. in conclusion, our results suggest that glp- has the potential to induce pparc activity, partially explaining the anti-inflammatory effects of glp- on endothelial cells. cross-talk between glp- signaling and pparc activation would confer major impacts on treatment of patients at high risk for cvd events. in the rat hypothalamus by adenovirus-mediated gene transfer and then examined phenotypes of the rats. dnlkb significantly inhibited the thr phosphorylation of ampk alpha subunits, while wtlkb did not alter phosphorylation, suggesting that hypothalamic ampk is activated in basal states and negatively regulated by dnlkb . dnlkb -overexpressing rats exhibited body weight gain and slight insulin resistance as compared with wtlkb -overecpressing or sham operation-rats. taking into consideration that food intakes did not differ among these rats, this effect was probably due to reduced energy expenditure. in fact, the adipose tissue in dnlkb -overexpressing rats produced smaller amounts of pgc alpha and ucp , resulting in increased adipose tissue weights, as compared with wtlkb overexpresing rats. neither hepatic fatty acid synthesis nor gluconeogenesis was significantly altered. the phenotypes observed in dnlkb -overexpressing rats appear to be like those of ampk alpha deficient pomc neuron mice. in conclusion, our findings demonstrated inhibition of hypothalamic lkb to lead to reduced energy expenditure and body weight gain, suggesting that central lkb is involved in bodyweight regulation probably via ampk modification. material and method: anthropometric variables and lipid related factors concentration were measured. pcr and rflp were performed. the distributions of a polymorphic site and its relationship with mentioned factors were examined. result: in normal subjects there wasn't any relationship between these three polymorphism and studied profile, but in females with mets, presence of g allele in rs significantly increase diastolic blood pressure, low density lipoprotein and apolipoprotein a (apo a ) level and the c allele in rs , increase waist circumference, triglyceride and apo a level. while previous studies in adults demonstrated that snps in apoa , have primarily been associated with plasma lipoprotein levels and associated downstream consequences, such as weight gain and heart disease risk, in present study we find that there are some relation between this variation and lipid profile in female with metabolic syndrome and this relationship is sex dependent. tryglicerides mean value was mg/dl and cholesterol mg/dl; the mean value was slightly elevated but inside the lot of the patients the variations were wide probably due to liver inssuficiency (low values) and alcooholic etiology of underlying liver disease (higher values). serum uric acid had a mean value of . mg/dl. no large variations inside the lot. medium level of serum creatinine . mg/dl; higher values in child c cirrhosis and hcc. conclusions: most of the metabolic disturbancies in hcc are correlated with the underlying liver disease. in a few cases of small lesions but mostly in large and complicated hcc these are significant and require specific treatment. background: a significant inter-individual variability in statin treatment efficacy is likely to have a strong genetic background. gene for slco b belongs to the candidates with potential to influence the statin treatment efficacy. slco b codes for solute carrier organic anion transporter, which has been shown to regulate the hepatic uptake of statins and some other drugs. materials and methods: slco b rs (t>c) polymorphism was successfully analysed in the group of patients with dyslipidemia (treated with simvastin or atorvastatin, or mg per day) and healthy normolipidemic controls. the polymorphism was analysed using nested pcr-rflp. lipid values (total-, ldl-and hdl-cholesterol, triglycerides) were analysed before and after - weeks of treatment. results: after treatment, as expected, there was a significant decrease both in total ( . self-care management), were applied to all patients at baseline and month follow-up. t-test and chi-square test were used to analyze the data. after months, (out of ) and (out of ) patients remained in the study. main findings revealed, a significant difference in a c level between the groups (p < . ). the self-care management score increased in both groups, but the increase was significantly higher in the intervention group (p < . methods: after the treatment decision was final, patients were assigned to either vildagliptin or other oads (sulphonylurea, thiazolidinedione, glinide, a-glucosidase inhibitor or metformin except dipeptidyl peptidase- inhibitor or glucagon-like peptide- mimetic/ analogue). demographic data and patient history, especially risk factors and macro-and microvascular complications, were collected and reported by the investigators. results: in total, , patients were enrolled in countries across the world. baseline characteristics are presented in the table. hba c was better controlled in east asia and europe than in india, latin america or middle east. patients in europe had higher bmi and longer duration of diabetes than patients in east asia and india. prevalence of risk factors such as hypertension and lipid disorders was high overall, but particularly higher in europe. macro-and microvascular complications were reported in . % and . % of the overall study population, respectively, and their prevalence was higher in europe. conclusions: data from edge study show that the hba c goal of % as recommended by international guidelines is not achieved worldwide and metabolic control varies remarkably between regions. in addition to the high prevalence of concomitant risk factors, complications were reported already after years of diabetes in a substantial proportion of patients. aim: sudomotor dysfunction due to small fiber neuropathy can be observed very early in pre-diabetes. the aim of this study was to assess the predictive power of ezscan, a non invasive, quick and simple measurement of sudomotor function to identify glucose impairment. research design and methods: the study was performed in german subjects at risk of diabetes. glucose metabolism was assessed by using, oral glucose tolerance test (ogtt) at baseline and after year follow-up. sudomotor function was evaluated by measuring hand and foot electrochemical sweat conductances to calculate a risk score. results: at baseline, patients had normal glucose tolerance (ngt), had pre-diabetes (impaired fasting glucose, ifg and/or impaired glucose tolerance, igt) and four had newly diagnosed type diabetes. the auc values for fpg, h-ogtt glucose, h-ogtt glucose, hba c and ezscan score to predict pre-diabetes were . , . , . , . and . respectively. subjects having a moderate or high ezscan score (> ) at baseline had a substantially increased risk for having ifg and/or igt at follow-up visit presented by an odds ratio of . [ . - . ], the or for having h-ogtt ! . mmol/l at follow-up was . [ . - . ] and for having hba c ! . % was . [ . - . ] compared to subjects with low ezscan risk. conclusions: this preliminary study, which must be confirmed in a larger population, shows that ezscan measurement is associated with diabetes progression which may have implications for prevention and disease management. methods: two groups are involved to the studies -the group of patients with metabolic syndrome (ms) and control group (c)- healthy, age matched volunteers. volunteers were expose to -h ogtt (according to who) and -h oltt (contained g of fat: % saturated, % monounsaturated and % pufa). during both tests the blood glp- , gip, glucose, insulin and free fatty acids (ffa) levels were assessed. results: fasting level of incretins do not statistically differ between ms vs. c participants. only ffas were elevated during whole oltt, when the glucose concentrations decreased in early postprandial period. secretion of gip was activated by ogtt as well as by oltt, however concentration of gip in oltt was higher. output of glp- during whole ogtt was significantly lower in patients with ms. in patients with ms amount of gip released during oltt was lower compared to control patients. conclusion: low level of incretins during oxidative stress connected with fat food intake, may not provide the protective effect for metabolically stressed pancreatic beta-cells. background: who estimates that . million deaths worldwide are due to hypertension, approximately . % of all deaths. this is an important risk factor forcardiovascular disease. argane oil is an integral part of the moroccan diet. several studies showed that an argane oil supplemented diet decreased systolic and diastolic blood pressure measurments in animals and suggested that consumption of argan oil may have a beneficial effect in preventing cardiovascular disease. objective: to study the effect of a regular consumption of argane oil on hypertension in healthy postmenopausal women. methods: seventy-seven postmenopausal women ( . ae . years) were assigned to consume ml of argane oil during weeks of nutritional intervention. anthropometric (weight, height and bmi) and clinical profile (blood pressure) have been determined at and weeks. results: showed that systolic blood pressure was significantly reduced ( . ae . to . ae . mmhg) after weeks (p = . ). diastolic blood pressure underwent a slight decrease ( . ae . to . ae . mmhg) but not significantly (p = . ). conclusion and perspective: these results suggest that consumption of argane oil can be relevant to prevent cardiovascular disease into postmenopausal women and help to decrease cardiovascular risk. the positive impact on blood pressure recorded by a significant decrease in sbp and hypertension is a significant result, however, the mechanisms involved in obtaining this result need to be defined more accurately, focusing mainly on the effects of certain constituents of argane oil as gamma-tocopherol on the mechanisms regulating blood pressure. the epidemic of obesity is associated with multiplication of prediabetic patients. recognition of them is essential as this state is considered to be the last chance to prevent the manifestation of diabetes. our aim was to determine metabolic alterations in healthy men with (dr: n = ) or without (h: n = ) first degree dm relatives. volunteers were adjusted according to age and bmi, insulin resistance was determined with hyperinsulinaemic-normoglycemic clamps and ßsejt function by iv glucose tolerance test. fasting glucose, insulin and ffa values were not different among the groups, but at the and of ivgtt, glucose levels were higher (h: . ae . , vs. dr: . ae . mmol/l, p < . ), injected glucose did not suppressed ffa levels (h: . ae . vs. dr: . ae . mmol/l, p < . ) and first phase insulin secretion was decreased in dr group (h: ae vs. dr: ae ; p < . ). there were no differences among the groups in total body-, muscle and fat tissue glucose disposal, leptin and resistin levels, but the adiponectin levels were significantly lower in dr group (h: . ae . vs. gd: . ae . mg/ml, p < . ) and the ffa/adiponectin ratios were higher (h: . ae . vs. gd: . ae . , p < . ). in conclusion the impairment of insulin secretion and fatty acid metabolism are the earliest sign of diabetes risk in men with first degree dm relatives. the measurement of ffa/ adiponectin ratio could be a simple parameter to screen adult male relatives of diabetic patients for identification of genetic risk of diabetes. the original reaven′s definition from , which has been revised in , missed the abdominal obesity. the definition accepted by who in was not applied due to difficult evidence of the insulin resistance. a new definition of the ms formulated by idf and ead was published in . in this case, the abdominal obesity was the necessary condition of the ms diagnosis. in order to unify the criteria, five essential parameters of the ms were put on the same level by the international medical organizations in . it is not easy to define the ms. it cannot be identified as a single disease, as it consists of a complex of problems. that is why the definitions of the ms were rearranged several times during past years and the used parameters are much stricter. we can assume that in the future this process will proceed. aims: the metabolic syndrome (ms) represents an obesity-related severe health problem, and its prevalence is world-wide increasing in parallel with the growing obesity epidemiology. gwa studies have shown that many single nucleotide polymorphisms (snps) in several genes are involved in common obesity. the aim of this study was to look for associations between snps in the mc r (rs , rs , rs ), sirt (rs , rs , rs , rs , rs ) and fto (rs , rs , rs , rs ) genes and obesity and/or ms in a southern italy population. methods: one-thousand unrelated non diabetic severely obese patients (mean bmi . kg/m , mean age . years) and controls (mean bmi . kg/m , mean age . years) entered the study. mc r, sirt and fto were genotyped by real time taqman assay. anthropometric, clinical and biochemical data were collected for all enrolled subjects. ms was diagnosed according to the american heart association criteria. results: metabolic syndrome was diagnosed in . % of our patients. the four fto snps were significantly associated with the obese phenotype ( . < p < . ). at binomial logistic regression analysis, only snp rs was significantly associated to obesity after correction for sex and age (or/ %ci: . / . - . and . / . - . , for the heterozygous and the homozygous mutated genotypes, respectively) and to ms presence (or/ %ci: . / . - . ) . conclusions: this study confirms that fto is a susceptible gene for obesity risk, and patients bearing the polymorphic allele in the rs snp could be at high risk of ms insurgence, possibly to be addressed toward preventive programs. results: number of patients who achieved hba c goals according age and presence of cvd are shown in table . conclusion: t d patient of middle age reached hba c goals in lowest percentage of cases. among different treatment groups percentage of patients reached hba c goals were the lowest in group treated by insulin with oad. the prevalence of diseases arising mainly due to the bad lifestyle is increasing. it is necessary to find optimal tools to lower the prevalence of the metabolic syndrome (ms). there is no network of institutions that systematically cooperate in the field of education and treatment of the ms. for students and academics the possibility of establishing ( ) and deepening the cooperation in this scientific field is therefore limited. the role of the project is to strengthen relations between the institutions in the form of cooperating network, which will meet the essentials principles of the primary, secondary and tertiary prevention of the metabolic syndrome. the key role of the project is to open an professional discussion and deepen the communication and professional relationship across the cooperating institutions which are realized primarily through internships of students (bachelor and doctoral degree), academic staff, roundtable discussions with experts and partners from the collaborating institutions, organizing workshops and doctoral and scientific conferences. czech society of sports medicine ( cstl) is a professional guarantor of creating a network of cooperating institutions in terms of the objectives and scientific credibility. background and aims: tissue ages accumulation is thought to be a specific marker of long-term glycaemic control, oxidative stress and cardiovascular risk. prediabetes -impaired fasting glucose (ifg) and impaired glucose tolerance (igt), are considered as risk categories for the development of both type diabetes and cardiovascular disease. the aim of the present study was to assess advanced glycation end products (ages) in prediabetes and their relation to anthropometric and glycaemic control parameters. material and methods: subjects (mean age . ae . years, mean bmi . ae . kg/m ) were enrolled. according to glucose tolerance they were divided into two age-matched groups - subjects with ngt and with prediabetes (ifg and igt). glucose tolerance was studied during ogtt applying who criteria. plasma glucose was measured by a hexokinase method, hba c was assessed immuno-turbidimetricaly. tissue ages accumulation was assessed non-invasively measuring the skin fluorescence of ultraviolet light on the ventral side of the lower arm (age-reader-diagnopticstm). antropomethric measurements -weight, height, waist circumference, were performed. visceral fat area was estimated by bioimpedance method (inbody ). results: no significant difference in ages accumulation was found between the groups with prediabetes and ngt. significant positive correlation was observed between ages accumulation, age (r = . ) and visceral fat area (r = . ). the non-invasive assessment of tissue ages accumulation probably is not a sensitive enough method for identifying subjects with prediabetes and increased cardiovascular risk. at the early stages of glucose homeostasis impairment ages accumulation appears to be related to age and visceral obesity rather than to glucose tolerance. this study is an observation study for mild diabetic males with bmi of or higher with subsequent month-follow-up based on single administration of exenatide and dietary and exercise intervention. method: subjects were cases of male patients (age: . ae . , bmi ae . ) with apnea hypopnea index (ahi)≧ /hr and . >hba c> . %. based on polysomnography and measurements of ct abdominal visceral fat area and various biomarkers before and and months after exenatide administration, the observation study was conducted for months. results: decrease in bodyweight was observed by . ae . kg on average during the months with no cases to gain in bodyweight and bmi. ahi was significantly improved from . ae . /h to . ae . /h. improvement was observed in hba c, -ohdg, pro-bnp, high molecular weight adiponectin and visceral fat areas but not in hs-crp and subcutaneous fat area. conclusion: not only diabetes but also sleep apnea syndrome was improved by exenatide administration in japanese mild diabetes patient. weight reduction may have played the primary role. effect of weight reduction provided by the pharmacological property of exenatide is useful to improve sleep apnea syndrome. currently, changes in individual calorie intake and nutrient composition during the study period have been analyzed. [ . - . ], p = . in igt group. no significant association was found between baseline fasting insulin level and progression from either ifg or igt to type diabetes. conclusions: individuals with ifg or igt identified through high-risk strategies in a bulgarian population, have a rather high risk of developing diabetes within year. baseline proinsulin and proinsulin: insulin ratio, known to reflect beta-cell dysfunction, appear to be independent predictors for progression to diabetes in both ifg and igt. introduction: the insulin receptor substrate (irs- ) seems to be an important factor involved in the modulation of insulin signalling in adipose tissue. in this study we want to check the expression of irs- in visceral and subcutaneous adipose tissue, its relationship with insulin resistance and with the metabolic syndrome. material and methods: we measured irs- expression in visceral and subcutaneous adipose tissue from morbidly obese patients. we have determined the level of insulin resistance with the homa-ir index. patients were classified into two groups based on whether or not to have metabolic syndrome (according to the idf criteria) results: irs- expression in subcutaneous adipose tissue is significantly higher than in visceral adipose tissue (p = . ). homa-ir was significantly correlated with the irs- expression in subcutaneous adipose tissue (r = À . , p = . ), but not in visceral adipose tissue (p = . , p = . ). the morbidly obese patients with metabolic syndrome have significantly lower irs- expression levels in subcutaneous adipose tissue than those without metabolic syndrome (p = . ). in visceral adipose tissue, the levels of irs- are lower but not significant (p = . ) in the morbidly obese patients with metabolic syndrome. the presence of metabolic syndrome in morbidly obese patients is associated with a lower irs- expression level in subcutaneous adipose tissue. in the general population and in hiv+ subjects the hypertension is the major risk factor worldwide for cardiovascular morbidity and mortality. this condition has been accompanied by several complication, including dyslipidemia and impaired glucose metabolism. for all these reasons identification of hypertension is of pivotal importance in hiv infected patients. aim of this study was to evaluate the incidence of hypertension and comorbidity in male hiv+ patients. we enrolled only male patients attending two clinics of the infectious diseases in center of italy (chieti and ancona). three hundred and four patients accepted to participate at the study. viroimmunological, lipid and metabolic parameters, including triglycerides, cholesterol, hcv/hbv co-infection, tabacco use were measured at the time of enrollment. the study has shown an incidence of hypertension (esh guidelines) % ( / patients), dyslipidemia % ( / ), diabetes % ( / ), hcv or hbv co-infection % ( / ) and tobacco use % ( / ). patients with hypertension showed dyslipidemia in % of cases ( / )and diabetes in % ( / ). remarkable that only % of patients with hypertension were treated for hypertension. in addition, the average age of the patients in the study was . ae . years. the study has shown a high incidence of hypertension in hiv+ men, even considering the young age of the patients. furthermore, hypertension is associated with a high incidence of co-mobility. hypertension is associated with evidence of under treatment, it showing a poor perception of the problem in this context. method: this study was a -weeks', prospective trial in subjects with metabolic syndrome. metabolic syndrome was defined as the presence of at least three out of five risk factors according to the ncep-atp iii with the asian criteria of abdominal obesity (abdominal circumference; > cm in men, > cm in women). all participants received individualized education by skilled personnel with information about tlc. blood chemistry including lipoprotein profiles and anthropometric data were collected before and after weeks' tlc. result: eighty-six subjects were screened, and subjects with metabolic syndrome were enrolled. body weight was not significantly changed after tlc. fasting blood glucose levels were not significantly changed (from . ae . to . ae . mg/dl, p = ns). therapeutic lifestyle change did not result in significant changes in total cholesterol (from . ae . to . ae . mg/dl, p = ns) and triglyceride (from . ae . to . ae . mg/dl, p = ns). but, weeks' tlc resulted in significant reduction in ldl-cholesterol levels (from . ae . to . ae . mg/dl, p < . ), increase of hdl cholesterol levels (from . ae . to . ae . mg/dl, p = . ). conclusion: four weeks' therapeutic lifestyle change improved lipoprotein profile (especially ldl-c and hdl-c) in metabolic syndrome. our findings indicate that the importance of tlc with education should be emphasized for the control of metabolic syndrome. nutrition, hasanuddin university, school of medicine, makassar, indonesia obesity in major public health and economic problem of global significance. the prevalence of obesity in children has increased significantly, although less rapidly in indonesia. from the public health view, it is disconcerting that the prevalence of adolescent obesity has increased by nearly % in the past two decade. case and control study design was done in makassar, the participant is senior high school students. the study aim to identify the risk factors of adolescent obesity to premetabolic syndrome by measuring body mass index, waist circumference, lipid profile (cholesterol, trigliceride, hdl, ldl and apo b) and fasting oral glucose. data was analyzed using spss program, the relationship among variables was calculated with pearson correlation and regression test. the indicators for obesity using waist circumferences and bmi, energy intake using h food recall and was analysed using wfood . the study showed, a positive correlation between waist circumference and small density ldl, apo b, cholesterol (p < . , p < . , p < . ). student with abnormal waist circumference tend to have abnormal biochemical markers (or . , . , and . ) as a risk premetabolic factors conclusion: nutrition education and food balance diet should be given to adolescent obesity to prevent metabolic syndrome in later of life. l. mundbjerg , g.f. thomsen , r. holst , c. juhl department of endocrinology, department of occupational medicine, hospital of south western denmark, esbjerg, institute of regional health research, region of south denmark, odense, denmark introduction: severe obesity is associated with reduced worker productivity and chronic absence from work. gastric bypass surgery is the most effective treatment of severe obesity. the objective of this study was to measure employment status in danish gastric bypass patients before and after surgery. methods: the study is a nation-wide retrospective case-control register study. data were extracted from three sources: cases were identified in the danish national patient register according to the operational code for laparoscopic gastric bypass surgery and matched on a : basis with respect to age, gender and residence municipality with control subjects. the employment status was calculated from the danish national labour market authority's databasedatabase (dream) which includes information on all public transfer incomes. by linking the databases we achieved a valid measure of the amount of working days. results: the amount of working days was significantly lower in cases compared to controls. there was a significant decline in employment status during the observational period in both groups. this decline corresponded with the timing of the financial crisis (employment data collected over the period january st to december st ). there was no significant difference in the decrease of employment status between groups. conclusion: gastric bypass surgery patients are affected by the economic recession in a similar degree as the general population. thus, the patients do not seem to benefit from the operation nor do they appear particularly vulnerable in periods of recession. excessive accumulation of fatty tissue in obesity associated with fat and glucose metabolism. fish oil contains n- pufas epa and dha had been demonstrated in several studies had effects on the expression of genes ppar-a and srebp- c, the pathomechanism still controversial. this study aims to determine the effect of fish oil on insulin resistance in mice obesity. clinical trials using c bl/ j mice was conducted in animal laboratory medical faculty of hasanuddin university. the mice was giving a normal diet (nd) or high fat diet (hfd) for weeks. mice was divided by four groups; normal diet (nd), high-fat diet (hfd), hfd + g/ g fish oil (hfd-fo), hfd + metformin g/kg diet (hfd-met) as a positive control for weeks. gene expression of ppar-a and srebp- c from the liver were measured by rt-pcr. the study showed, hfd mice had significantly higher body weight compared to nd. hfd-fo have higher blood glucose levels than other groups. ppar-a expression in liver was lower in hfd than nd, but increased in the hfd-fo and hfd-met compared with hfd alone. srebp- c expression decreased in hfd-fo and hfd-met, glucose metabolism of hfd_fo tended to decrease, while the hfd-met is likely to increase. we conclude, fish oil improved insulin resistance, decreased expression of srebp- c and increased expression of ppar-a in the liver tissue through decreasing lipogenesis and increased fat oxidation in the liver. methods: total subjects were divided into two groups having whr > . as obese and whr < . as non-obese. circulating il- and resistin level, fasting blood glucose, insulin and lipid profile were estimated. insulin resistance was calculated by the homeostasis model assessment (homa) index. the genotype and allele frequency of il -g c gene polymorphism was determined by pcr-rflp method in obese and non-obese adult women from north india. results: the genotype distribution of il -g c gene polymorphism was statistically significant in obese women (p = < . ; or = . ; % ci = . - . ) compared to non-obese women. the circulating level of serum resistin was highly significant in obese women ( . ae . vs. . ae . , p = < . ) compared to nonobese. significant association was found with cc + gc genotype of il -g c promoter gene polymorphism in case of waist circumstance, serum triglyceride, homa index and serum resistin level (p = . ; or = . , % ci = . - . ). conclusion: serum resistin is associated with the disorder of metabolism of glucose and lipid in metabolic syndrome. the relationship between this hormone with cc + gc genotype of il -g c promoter gene polymorphism suggests that they may take part in the development of metabolic syndrome in north indian adult women. the comorbidities associated with excessive weight are major causes of morbidity and mortality, thus causing further reduction in quality of life. the dysfunction of excessive fat and its peculiar distribution plays a decisive role in the development of metabolic disorders. the aim of the study was to estimate the prevalence and the correlates of obesity and dysglycemia in a rural community. overweight and obesity were defined according to world health organization criteria, considering both the value of body mass index (bmi) and waist circumference (wc). dysglycemia (impaired fasting glucose -ifg and diabetes) was established based on ada recommendations. the study included people, . % men and . % women, with the mean age of . ae . years. more than half of them ( %) had an excessive weight: . % were overweight and . % were obese. the crude prevalence of overweight and obesity was . % and . % respectively for men, and % and . % respectively for women. the prevalence of diabetes was . % and for ifg of %. the prevalence of dysglycemia increased with the bmi value, with the highest frequency in the grade iii obesity group ( . % prevalence of diabetes, ifg . %). large wc was identified in . % of the studied population ( . % in men, . % women). the individuals with diabetes had a significant higher mean wc ( . cm vs. . cm, p < . ). these results show that excessive weight and abdominal obesity could become a public health problem in romania, thus requiring national screening and educational programs. objective: hyperuricemia is associated with obesity; however, few studies reported the effects of surgery types on uric acid metabolism for severe obesity. the current study was aimed to explore the effects of gene and bariatric surgery on uric acid reduction and to identify the potential pathways. subjects: all participants were han chinese, aged from to years old. a total of severely obese patients with at least body mass index (bmi) of were recruited in the beginning of the study, where cases received laparoscopic adjustable gastric banding (lagb) and cases received laparoscopic mini-gastric bypass (lmgb). a -month follow-up was ensued after surgery to identify the effects of bariatric surgery and estrogen receptor-a (esr ) gene on serum uric acid reduction. results: a tagsnp (rs ) of esr could influence serum uric acid reduction. bariatric surgery effect on serum uric acid reduction was greater in lmgb as compared with lagb at the th month of post-surgery (À . ae . mg/dl vs. À . ae . mg/dl, p = . ). obese patients carrying risk genotype (tt) on rs and exhibiting better glycemic control had a greater serum uric acid reduction at the th month of post-surgery. synergic effect of rs and lmgb exhibited the highest serum uric acid reduction at the th month of post-surgery (À . ae . mg/dl). conclusion: for severely obese han chinese, bariatric surgery appears to reduce serum uric acid levels by mediating different factors, including esr gene and gender, ameliorating glycemic control, and changing dietary patterns. remained significantly lower. compared to mgc, mgr but not mgrc male offspring had higher body fat % and visceral adiposity at months of age. results: the average age of patients was . years, more dominant were females with . %. patients with ms characterizes increased values of bmi ( . kg/m²), which is statistically significantly more that in the control group, where is average value of bmi . kg/m², waist . cm in the study group, and . cm within control group (p < . ), blood pressure . / . mmhg, homa index . , average value of insulinemia . (lu/ml), (within control group homa index was . ), the average value of insulimenia . (lu/ml), average values of: total cholesterol . mmol/l, hdl cholesterol . mmol/l, ldl cholesterol . mmol/l, triglycerides . mmol/l, relation between ldl/hdl . . arterial hypertension was present in . %, hypercholesterolemia in . %, reduced hdl in . %, increased ldl in . %, trigliceridemia in . %. conclusion: abdominal obesity is characterized by manifested insulin resistance and distinct hyperinsulinemia. arterial hypertension as one of the components of metabolic syndrome represents significant cardiovascular risk factor, increased level of triglycerides represents significant risk factor which favors atherosclerosis, in our study the presence of this parameter was . %. introduction: diabetes is the most feared disease because it leads to a variety of complications including end-stage vascular disease, cardiovascular damage and retinal abnormalities. the increased risk of atherosclerotic disease in diabetic subjects may be due to enhanced foam cell formation following an increased susceptibility of low density lipoprotein to oxidative modification. cardiovascular disease (cvd) is the most prevalent complication of diabetes mellitus. methods: the aim of this study was to assess the ldl susceptibility to lipid peroxidation (ldl ox) in two study groups of elderly patients (aged ae years): a group of patients with cardiovascular disease and a group of patient with cardiovascular disease associated with type diabetes mellitus. the ldl susceptibility to in vitro induced lipid peroxidation was evaluated following its incubation with a prooxidant system. : results obtained showed the susceptibility of ldl to in vitro oxidation was increase in diabetic group ( . %) compared with a cardiovascular disease group. conclusion: this study indicates that low-density lipoprotein from diabetic subjects is more susceptible to oxidation. patients with diabetes have a greatly increased relative risk of developing cardiovascular disease when compared with patients without diabetes. much of this risk is related to insulin resistance and is associated with both traditional and nontraditional cardiovascular risk factors. therefore, measurement of ldlox may be helpful for identifying high-risk patients with type diabetes and cvd. janus kinase (jak) and signal transducer and activator of transcription- (stat ) in several cell lines. objective: we sought to determine the role of hypothalamic s pr in the control of jak /stat signaling and food intake in vivo. materials and methods: western blot, immunohistochemistry, gas analyzer, dissection of the hypothalamic nuclei and intrecerebroventricular (icv) infusion of s p ( ng), leptin ( À ) and cucurbitacin ( lmol/l) were combined to evaluate the role of s pr on leptin signaling and on food intake in lean and obese wistar rats and in ob/ob mice. results: high expression of s pr was found in the hypothalamus when compared to other peripheral tissues. s pr is mainly expressed the arcuate nucleus of the hypothalamus, in the same neurons that possess stat . icv infusion of s pr activator, s p, increased jak and stat phosphorylation and the energy expenditure and reduced the food intake in lean rats. in addition, s p potentiated the effects of leptin in the reduction of food intake. conversely, the pharmacological inhibition of stat , blocked the anorectic effect of s p. interestingly, low expression of s pr was observed in the hypothalamus of ob/ob mice and wistar rats fed on high fat diet, whereas, s p infusion reduced the food consumption and increased leptin signaling and action in obese rats. these results indicate that hypothalamic s pr has a key role in the control of leptin signaling and on food intake. aim: the adifit program is an intensive -week multidisciplinary treatment program which promotes weight reduction among obese. during the first weeks behavior change, physical exercise, and nutritional counseling is offered three times a half a day per week, thereafter once a week half a day. the aim was to evaluate efficacy of the adifit program in weight reduction, and its effect on eating behavior, and body image. methods: patients were evaluated at baseline (t ) and after month (t ). bmi was assessed. psychometric instruments such as the german versions of the eating behavior questionnaire (fev), and the body image questionnaire were used at both time points. paired-sample t-test and wilcoxon signed rank test were used for statistical analyses. results: fifty patients participated, % were female. bmi was significantly reduced from t to t (mean ae sd: . ae . vs. . ae . ; t = . , p < . ). results discerned significant improvements from t to t in fkb scale (negative attitudes towards one′s own body) ( . ae . vs. . ae . ; t = À . , p < . ), and scale (restricted body dynamics) ( . ae . vs. . ae . ; t = À . , p < . ). on the other hand, fev scale (cognitive restraint of eating) improved significantly from t to t ( vs. , z = À . , r = À . , p < . ). fev scale (disinhibition) was significantly lower at t ( vs. , z = À . , r = À . , p < . ) as was fev scale (hunger) ( vs. ; z = À . , r = À . , p < . ). after weeks patients showed significant reduction in weight, improvements in body image and eating behavior. metabolic peptides in serum and plasma samples contain status information for diabetes. previously, we have demonstrated that intrinsic protease activity caused instability of plasma and serum peptides. other reports have described that metabolic peptides, including glp- , gip, glucagon, and oxytomodulin, are subject to instability caused by proteolytic and other enzymatic degradation intrinsic to plasma. the variability may result in inaccurate quantitative measurements of the peptides creating challenges when interpreting pharmacokinetic and pharmacodynamic data. using both mass spectrometry and elisa based detection methods; we investigated the instability of metabolic peptides in whole blood, serum, and plasma under a variety of routine clinic conditions. first, the same subjects blood was drawn into different blood collection devices including serum and edta, citrate, heparin, and an edta tube containing enzyme inhibitors. the metabolic peptides of interest were spiked into plasma for time incubation at different temperatures. samples were quenched and processed for both maldi-tof ms and elisa analyses. quantitative analysis of each marker was used to characterize the kinetics of the peptide digestion ie stability (halflife). further a blood collection tube was developed to minimize degradation using enzymatic inhibitors specifically for the stabilization of glp- , gip, glucagon, and oxytomodulin. the addition of specific enzyme inhibitors for stabilization of each peptide reveals more insight regarding enzymatic degradation and stabilization of the peptide biomarkers. our data clearly demonstrates the need of enzymatic inhibitors for peptide stabilization, especially in a clinical setting. ( . ae . mg/dl) . subjects underwent a standardized meal test: g of bread, a boiled egg, g of apple, in the morning after h fasting. venous blood glucose samples:before meal test (sample ), h (sample )and h (sample ) after ingestion of standardized meal. neuropathy (p = . ). women had higher prevalence of neuropathy (p = . ). people with sensory neuropathy had lower weight and bmi than those with autonomic neuropathy and those without neuropathy (p = . ). fasting blood glucose was higher in subjects with neuropathy (p = . ). value of sample was increased in people with neuropathy (p = . ). other parameters cardiometabolic risk factors were not associated with diabetic neuropathy at onset of t d. conclusions: diabetic neuropathy is a frequent complication at diagnosis of t d. people with higher fasting or postprandial glycemia may associate more frequently diabetic neuropathy at onset. m. metalla , m. carcani , g. qirjako , e. demiraj durre regional hospital, endocrinology, durre regional hospital, durres, statistical, mother teresa university hospital center, tirana, internist, durre regional hospital, durres, albania background: metabolic syndrome is a risk factor for cardiovascular diseases and is associated with abnormal cardiac structure and function. the aim of the study: to evaluate the left ventricular structure and function in patients with metabolic syndrome, without installation of diabetes mellitus or arterial hypertension. material and methods: it was analyzed a total of consecutive adults ( -{ %} males and -{ %} females) with metabolic syndrome and healthy ( -males and females) without metabolic syndrome. metabolic syndrome was defined using the atp lll criteria. assessment is done with classic echocardiography, pulsed wave doppler and tissue doppler. results: there was difference in two groups in bmi, in waist circumference, in systolic and diastolic arterial presure in total colesterol, in level of triglicerid and hdl colesterol p < . . there was no diference in age, fasting serum glucose level, lvedd, sw, pw, lvm, lvmi, lav, lvef, early trans mitral inflow (e), late trans mitral inflow (a) and in the rate e/a (p = . ). echokardiografic measurements by tdi in peak mitral anular velocity in early diastole ea were . ae . vs. . ae . cm/sec (p < . ) in the metabolic syndrome and controll grups respectively. average values of sa were significantly lower in the ms than in controll group, . ae . vs. . ae . (p < . ). the ratee/ea mitral was . ae . vs. . ae . (p < . ) in metabolic syndrome and controll group respectivly. the early identification of isolated syndrome in non diabetic, non hypertensive adults may be an indication of an aggressive preventive measure. the fasting glycaemia altered and hyperinsulinemia are strong predicting factors of type dm (dm ) and sedentary habits can lead to this disease, mainly associated with obesity. objectives: verify the influence of physical activity, vo max and anthropometric measurements on glycaemia and insulin fasting in active military over the age of of the brazilian army (ba) serving in rio de janeiro. methods: two hundred and fifty subjects (aged . ae . years), in active duty in the ba, volunteered to participate in the study. the insulin and glycemic levels were measured as well as body mass, stature and waist circumference. body fat (bf) was measured by hydrostatic weighing, when body density was obtained. vo max was measured by maximal cardiopulmonary treadmill exercise test (cpet) using an individualized ramp protocol. oxygen consumption and carbon dioxide production were measured using a cpx-d metabolic cart. results: the prevalence of type dm found was . % and afg was . %. vo max showed an inverse correlation (p < . ) with insulin levels, homa-ir and fasting glycaemia and also with anthropometric measures and %bf. the bmi and %bf presented direct correlation (p < . ) with insulin, homa-ir and fasting glycaemia. subjects in the highest quartiles of vo max and in the lowest quartiles of wc and of %gc also presented lower levels of fasting glycaemia and insulin and homa-ir. the data suggest that vo max was an inverse and nutritional state a direct relationship between glycaemia and fasting insulin. subjects with an active lifestyle have less prevalence of alterations in glycaemia and fasting insulin levels. the increase in prevalence of cardiovascular conditions, and metabolic syndrome (ms) observed in the last decades was accompanied by increase in dietary fructose (fr) consumption (also as sucrose). the aim was to assess the prevalence of fructosemia in cardiovascular patients with or without ms and to investigate the possibility of treatment of hyperfructosemia and other components of ms with oral acarbose. material and methods: fasting serum fr concentration in cardiovascular patients with metabolic syndrome (group ) and in cardiovascular patients without ms (group ) was measured by colorimetric method with commercially available biovision set. patients of the first group were treated with acarbose (glucobay, bayer) increasing the dose from to mg per day to normalize the glucose metabolism. fasting and post oral sucrose load ( g) serum levels of glucose, fr, insulin, nefas and uric acid (ua) were measured at baseline and in days. results: fasting serum fructose concentration varied widely and among patients in both groups, and was significantly higher in group ( . ae . vs. . ae . lmol/l). the data after days and weeks of acarbose use is presented in the conclusions: dyslipidaemia is found to be the risk factor for ischemic stroke in diabetic subjects, with statistically significant differences compared to nondiabetics. hdl-cholesterol was found as a protective factor for haemorhagic stroke in nondiabetic subjects. agave tequilana weber variety azul is an economically important in mexican people because it is the sole plant allowed for tequila production but because it is a potential source of prebiotics, the inulin-type agave are nondigestible/fermentable carbohydrates which are able through the modification of the gut microbiota, the pos content of agave inulin differs from inulin extracted from chicory root. the aim was to assess the efficacy and safety of inulin type agave on lipid profile in dyslipidemic obese subjects. a clinical trial, open was carried out in obese, hypertrygliceridemic and hypercholesterolemic subjects between and years old. all the subjects received g/day of inulin in the morning, during days. biochemical and metabolic profiles before and after pharmacological intervention were performed. after inulin administration, there was a significant reduction of the trygliceride concentrations ( . ae . and . ae . mg/dl; p = . ). glucose serum ( . ae . and . ae . mg/dl; p = . ), and hba c ( . ae . and . ae . % p = . ). there was not a significant reduction of total cholesterol, low density lipoprotein and very low density lipoprotein. anthropometric parameters did not change in the group and soluble fiber intake did not produce any gastrointestinal adverse effect. the increase of fiber intake (inulin type agave) are efficacy and safety to reduced trygliceride concentrations levels in dyslipidemic obese patients. stress and strain have long been associated with the work people do. we aimed to investigate occupational stress index and influence of several different work stressors on cardiometabolic risk factors: diabetes, lipid levels in hypertensive workers in south serbia methods: we studied persons (professional drivers, construction workers, production line workers and bankers): composed group with hypertension ( - years of age, majority males), were age and sex matched controls without hypertension. clinical examination was performed and blood was sampled. we analyzed work stressors by using questioners with different factors and occupational stress index (osi) was calculated with permission of dr belkic. comparison was made regarding total burden and the nature stress burden (underload, high demand, strictness, extrinsic time pressure, aversive/noxious exposures, threat-avoidant vigilance/disaster potential, conflict/uncertainty) results: diabetes was highly present in bankers ( %) and glucose levels were significantly higher in this subgroup. the incidence of diabetes in construction workers was %. total cholesterol, ldl, triglycerides were higher and hdl lower in bankers and contraction workers (p < . ) and linearly correlated with osi (p < . ). previous myocardial infarction suffered . % of bankers. total osi was significantly higher in diabetic hypertensive bankers and construction workers (p < . ), as well as high demand, strictness and extrinsic time pressure (p < . ). conclusion: hypertension appearance in working population is related to high osi, especially when other cardiometabolic risk factors added. further steps are needed to reduce the level of work stressor and provide a better quality of live in individuals. background and aim: plasma levels of adipocytokines in healthy individuals or diabetes mellitus patients have been previously reported as well as salivary levels of many adipocytokines. nevertheless, salivary levels of some adipocytokines in patients with metabolic syndrome have not been investigated. the aim of this study was to evaluate salivary and plasma levels of leptin and adiponectin in patients with metabolic syndrome. results: compared with healthy individuals, leptin levels in patients with metabolic syndrome were significantly increased, both in plasma ( . ae . vs. . ae . ng/ml, p < . ) and in saliva ( . ae . vs. . ae . pg/ml, p = . ). whereas plasma adiponectin levels were decreased significantly in patients with metabolic syndrome ( . ae . vs. . ae . lg/ml, p = . ), salivary adiponectin levels were inversely increased ( . ae . vs. . ae . ng/ml, p = . ). conclusion: this study showed that, similarly to plasma, there was an elevated change in salivary leptin levels in patients with metabolic syndrome compared to healthy individuals. however, for salivary adiponectin levels, the opposite result to plasma adiponectin levels was revealed. replacing saliva to plasma for detecting altered leptin and adiponectin should be concerned in patients with metabolic syndrome. objective: to examine dietary intake in family members with diabetes type (dt ) to identify contributing factors to glycemic control and development dt . design: descriptive and prospective study involving members of families who provided food intake from days, weeks days and weekend day. inclusion criteria were proband member diagnosed with dm with ! siblings and living parents. methods: data were collected at the participants' homes or at the university clinic. the biometric measures were glucose and hemoglobin glucose (hba c). data was entered into nutritional data system to research, the "gold standard" for nutritional analysis. also, the data entry into spss v was done. : of , ( % women, mean age . ae . ; , mean blood glucose . mg/dl ae . ; - and mean (hba c) . % ae . ; . preliminary data indicate intake total fat was higher than the recommendations % of participants, while carbohydrate intake was higher in %. method: this was a retrospective, observational study of consecutive cardiac bypass patients that underwent surgery at sultan qaboos univesity hospital in muscat, oman, between and . analyses were performed using descriptive statistics. the study included a total of cardiac bypass surgery patients with an overall mean age of ae years and % ( / ) were males. mean body mass index was kg/m ranging from to kg/m . twenty-seven percent of the patients were either past or current smokers while % ( / ) had a family history of coronary artery disease. all but of the patients ( %) were on statins pre-op. the most prominent co-morbidities were hypertension ( %), angina ( %), diabetes mellitus ( %), myocardial infarction ( %), and congestive heart failure ( %). the mean average pre-op total cholesterol, low-density lipoprotein cholesterol (ldl-c), high-density lipoprotein cholesterol (hdl-c), triglycerides, apolipoprotein a (apo a ), and apolipoprotein b (apo b) were . ae . mmol/l, . ae . mmol/l, . ae . mmol/l, . ae . mmol/l, . ae . g/l, and . ae . g/l, respectively. eighty-one percent, %, and % of the patients had or or diseased heart vessels, respectively. there was a total of %, %, and % of the patients that had on-pump, off-pump, and on-pump beating coronary artery bypass surgeries, respectively. mortality was recorded in two patients ( %) in an approximately -year period. conclusions: patients undergoing cardiac bypass surgery were observed with a high prevalence of cardio-metabolic risk factors. aim: to evaluate the association between osteocalcin and phenotypic characteristics of metabolic syndrome. material and methods: data of children and adolescents participants of the project "health worker cohort study" was analyzed. to each participant we determined: insulin, glucose, triglycerides, hdl, waist circumference and blood pressure. glucose and insulin were evaluated by glucose-oxidase method and homa. total osteocalcin concentration was determined by chemiluminescence. body mass index (bmi) was evaluated according to cdc chart′s for children and adolescents according to age and sex. using multiple lineal regression and logistic regression we evaluated the association between osteocalcin values and components of metabolic syndrome. results: the proportion of male in the study population was . %. the prevalence of overweigh and obesity was . % and abdominal obesity was . %. the proportion of elevated glucose, hypertriglyceridemia, low levels of hdl, hypertension and metabolic syndrome were . %, . %, . %, . % and . % respectively. difference of medians according to ages groups, was observed for glucose, insulin, homa and osteocalcin (p < . ). the study showed a negative correlation between bmi, fat percentage, waist circumference, glucose levels and crp with ostelcalcin levels (p < . ). conclusions: serum osteocalcin levels were associated with some phenotypic characteristics of metabolic syndrome and measures of adiposity. background: previous studies show that hyperuricemia precede the development of the metabolic syndrome and can be a risk factor to diabetes type , cardiovascular disease and heart failure, independently of obesity. aim: to identify the association between hyperuricemia and cardiovascular risk factors (crf). the study population included adolescents, all of them participants from the "cohort study of health workers". crf were evaluated according to idf pediatrics criteria. the cut-off points for hyperuricemia was levels of uric acid > mg/dl, for hyperinsulinemia > mu/l, insulin resistant (ir) have homa > . . a multivariate regression analyses was used to evaluate the association between hyperuricemia and crf. resultados: the proportion of female in the study population was %. mean age was ae . years, prevalence of bmi >p was %, abdominal obesity ( . %), hypertension ( . %), hyperuricemia ( . %), glucose ! ( . %), hypertrigliceridemia ( %), low levels of hdl ( %), hyperinsulinemia ( %), ir ( %), crp ( . %) and ms ( . %). proportion of hyperuricemia was six times higher in men, ( vs. . , p < . ). the study show association between hyperuricemia and age (or: . ;ic % . - . ), hypertrigliceridemia (or: . ;ic % . - . ) hyperglucemia (or: . ;ic % . - . ), hyperinsulinemia (or: . ;ic % . - . ), ir (or: . ;ic % . - . ), abdominal obesity (or: . ;ic % . - . ) and ms (or: . ;ic % . - . ). conclusions: hyperuricemia is associated to crf. hyperuricemia is not considered for adolescent health diagnostic. however early diagnostic is important for avoid the presence of several crf. method: pancreas of fetuses and offspring from diabetic and nondiabetic sprague-dawley rats were obtained and processed for histological and morphometric studies and for inmunohistochemical analysis of pdx. , insulin and glut . results: fetuses of diabetic mothers, showed a significant delay in the morphogenesis of the islets, with a significant reduction of the diameter, area and beta cell mass and expression of pdx , insulin and glut . these fetal alterations had an impact on postnatal life and offspring of diabetic rats had significantly higher glucose levels. in offspring of days, the alterations persisted and the expression of insulin and glut was significantly lower. at days the islets were mature but the size, beta cell mass and expression of insulin, glut and pdx. were still significantly lower. at days the structure of the islets was normal, but the reduction in size, beta cell mass and expression of glut persisted, but with no significant reduction in the expression of insulin and pdx. conclusions: in utero hyperglycemia induced a delay on the differentiation of beta cells and morphogenesis of islets, a reduction of the beta cell mass and in the expression of insulin, glut and pdx. . these alterations persisted up to adulthood causing hyperglycemia to offspring. g. yoshino , t. an , s. nakano , k. kuboki center for diabetes, shinsuma general hospital, kobe, division of diabetes, metabolism and endocrinology, department of internal medicine, toho university, tokyo, japan background and aim: it has been a matter of debate whether the intervention is necessary even for elderly metabolic syndrome subjects. present study is therefore conducted to explore whether the elderly subjects with metabolic syndrome show increased cad risk measuring plasma small, dense ldl-cholesterol, hs-crp and plaque score of the carotid artery. methods: a total of subjects including male ranging from to years-old, were recruited for this study. they are divided into four groups according to their age (below and above years-old) and an association of metabolic syndrome. blood sampling was done after overnight fast. small, dense ldl-cholesterol was measured employing direct assay method. results: in the non-elderly subjects, plasma triglyceride, small, dense ldl-c, hs-crp and plaque score of carotid artery were all increased in the metabolic syndrome group compared to that of non-metabolic group, while there was no significant difference in either hs-crp or the plaque score between the two groups within elderly subjects. within the elderly metabolic syndrome group, subgroup with type diabetes had higher fasting blood glucose, hs-crp, small, dense ldl-c and plaque score than the subgroup without type diabetes. conclusion: metabolic syndrome is an important factor for progression of subclinical atherosclerosis in the non-elderly subjects, but it cannot be a significant determinant of subclinical atherosclerosis if the subjects are limited within elderly group without type diabetes. thus, intervention for metabolic syndrome may not be obligatory for elderly metabolic syndrome subjects if they are not diabetic. methods: a retrospective cross-sectional study of randomly selected patients on antihypertensive drugs at the outpatient clinic at sultan qaboos university hospital, muscat, oman. the recorded variables included age, gender, history of diabetis mellitus, weight, fasting blood glucose, creatinine level, systolic blood pressures (sbp), diastolic blood pressure (dbp), and type of medication. all parameters were collected of the last two visits from (january and december ) for each patient who had been labeled with persistent hypertension using the hospital information system (his). analyses were conducted using descriptive statistics. results: overall mean age of the cohort was ae years, % were male, % were diabetic, mean sbp ae , dbp ae , weight ae , and fbg . ae . on visit , % were on b-blockers, % patients were on calcium channel blocker, % on angiotensinconverting enzyme inhibitor and % were on diuretics either as a monotherapy or in combination. target bp was attained in . % patients with diabetes mellitus compared to . % in non diabetics after the second visit. the mean body weight in patients with controlled hypertension was . kg compared to . kg in patients with uncontrolled hypertension. the study showed that diabetes mellitus, increased body weight and high fasting blood glucose reduces the attainment of blood pressure goal in patient on antihypertensive therapy. purpose: comparable evaluation of lipid profile and inflammatory markers between patients with stable angina (sa) and patients with sa and diabetes mellitus of type (dm). material and methods: a total of patients with sa (mean age . ae . years) with coronary stenosis < % were examined. group i included patients with sa and dm; group ii - patients with sa without dm. lipid profile parameters; inflammatory markers (hs-crp, tnf-alpha, homocysteine, interleukine β, , ; scd l, mmp- , timp- ); endothelial dysfunction markers (endothelin- , nitrites) were measured initially and in year. results: there were high levels of hs-crp, tnf-alpha, lipoprotein (a), mmp- , triglycerides, and endothelin- in both groups. the level of timp- reduced in both groups. patients in group had significantly elevated levels of total cholesterol, ldl cholesterol, homocysteine, apo-b, apo-b/apo a- ratio, il- β. in group the following positive correlations were found: between glycohemoglobin and apo-b, apo-b/apo a- ratio, homocysteine; il- and hs-crp; homocysteine and ldl cholesterol, mmp- , duration of coronary artery disease; endothelin- and scd l, tnf-alpha. reliable increasing homocysteine, tnf-alpha mmp- , ldl cholesterol were revealed in both groups. conclusions: prospective study showed that both groups had similar blood biochemical abnormalities. however in patients with dm there was an increase in the levels of atherogenic lipid fractions as well as homocysteine, tnf-alpha and mmp- which may indicate a higher risk of developing coronary events even in the absence of significant coronary stenosis. objectives: il- is a pleotropic cytokine and is reported to be involved in various inflammatory and immune-mediated disorders. previous data in apo e-/-mice demonstrated that il- accelerates atherosclerosis via ifn-c and cxcl expression and the effect was independent of t-cells. we therefore investigated whether il- is involved in cholesterol efflux and plaque stability. methods: two groups of chow-diet-fed, male apolipoprotein e-/mice, aged weeks (n = /group) were fed a normal diet and injected intraperitoneally for days with either recombinant il- ( ng/g/ day) or with phosphate buffer saline (pbs). mrna expression of il- , scavenger receptor cd , mmp- and lxr-a genes was determined by real-time pcr. immunohistochemistry was also performed for expression of above genes. results: il- administration led to a significant increase in serum cholesterol and lipoproteins except hdl-c which was decreased. in heart and aortic tissues, expression of il- , scavenger receptor cd and mmp- genes increased . , and fold respectively, whereas expression of lxr-a gene was reduced by . fold. atherosclerotic lesion size was quantified in the ascending aorta and the aortic arch. exogenous il- administration significantly increased frequency of atherosclerotic lesions and lesion area in il- treated mice vs. control animals ( . ae . % vs. . ae . % (p < . ; pbs vs. il- group). the observed data strongly implicates il- as a proatherogenic and proinflammatory molecule which not only enhances inflammation but augments cd and mmp- expression which may lead to enhanced foam cell formation and plaque instability and thereby aggravate atherosclerosis. objective: the present study was attempted to found the association between tnf-a promoter gene g- a polymorphism with metabolic syndrome and insulin resistance. the g- a tnf-a polymorphism has been studied in subject with metabolic syndrome according to ncep atp iii criteria (age . ae . ; bmi . ae . ) and healthy control without metabolic syndrome (age . ae . ; bmi . ae . ). the g- a variant was detected by pcr amplification and nco- digestion. furthermore insulin resistance, serum leptin and tnf-alpha levels were also measured in both the groups. polymorphism was significantly less frequently observed in the control population as compared to study group. furthermore, on dividing the subjects into two groups according to the absence (homozygous for the wild type g allele) (tnf- allele) or presence of the mutant a (tnf- ) allele, significantly high levels of tnf-a (p = . , or = . , % ci = . - . ) and leptin (p = . , or = . , %ci = . - . ) were observed in tnf- group as compared to tnf- group. whereas, there was a non-significant tendency toward insulin resistance in the tnf- group. conclusions: our results suggest that the g- a mutation of the tnf-a gene is likely to play an important role in the development of metabolic syndrome and metabolic abnormalities. metabolic syndrome is associated with residential-area crime rates for men and perceived crime for women: gender differences in social vulnerability to metabolic syndrome introduction: crime rates and perception of crime within neighbourhoods have been linked to residents' cardiometabolic outcomes. men and women vary in their perception of crime but share exposures to residential-area crime. it is unclear whether gender differences exist in the nature of crime-related vulnerability to metabolic syndrome. aim: to assess gender-specific associations between perceived and reported crime, and metabolic syndrome (mets) methods: cross-sectional data from a biomedical cohort study of adults randomly selected from the north-west region of adelaide, south australia, were analysed (n = . ) (mean age = . , standard deviation = . ). clinically measured mets was defined using international diabetes federation criteria. perceived crime was expressed as a standardised factor score reflecting six items related to neighbourhood safety and crime. reported crime rates were obtained from police data, aggregated at the statistical local area level (n = ) and standardised. associations were evaluated using multilevel regression models accounting for area-level clustering and covariates including area-level income and participant sociodemographic factors. results: the prevalence of mets was, for men (n = ), . % ( % ci = . - . ), and for women (n = ), . % ( %ci = . - . ). for men, mets was associated with rates of violent crime (or = . , %ci = . - . ) and total crime (or = . , % ci = . - . ), but not perceived crime. for women, mets was associated with perceived crime (or = . , %ci = . - . ), but not reported crime. conclusions: crime is an adverse social exposure. mets is associated with perceived crime in women and reported crime rates in men. these differentials suggest gender-specific causal pathways by which awareness and perception of adverse social exposures relate to mets independent of socioeconomic factors. background: epidemiological studies suggest that the resting heart rate (rhr) is an independent predictor of cardiovascular and all cause mortality. however, the power of the rhr to predict cardiovascular events in patients with the metabolic syndrome (mets) is not known. methods: we prospectively investigated the relationship between rhr and cardiovascular events in consecutive patients undergoing coronary angiography for the evaluation of coronary artery disease (cad) over a follow-up period of . ae . years. the mets was defined according to ncep-atpiii criteria. results: in the total study population, both all cause and cardiovascular mortality were increased with an increasing rhr (standardised adjusted hrs . [ . - . ]; p = . and . [ . - . ]; p = . , respectively). from our patients, ( . %) had the mets and did not have the mets. among patients without the mets, a higher baseline rhr indicated a significantly higher risk of total mortality (h = . [ - . ], p = . ) and cardiovascular mortality (hr = . [ . - . ], p = . ) after multivariate adjustment. however, the rhr did not significantly affect total mortality (p = . ) or cardiovascular mortality (p = . ) in patients with the mets. interaction terms rhrxmets were significant for both total and cardiovascular mortality (p = . and p = . , respectively), indicating that the respective risks conferred by a high rhr were significantly higher in patients without the mets than in patients with mets. conclusion: we conclude that among angiographically characterized coronary patients, the metabolic syndrome status significantly affects the association of the rhr with total and cardiovascular mortality: rhr is a strong predictor of both total and cardiovascular mortality among subjects without the mets, but not among mets patients. aim: to estimate influence of diet therapy, physiotherapeutic treatment to body mass reduction and prevention of cardiovascular and metabolic risks. patients and methods: were surveyed patients with a metabolic syndrome aged of - years: women ( %) and men ( %): ( %) pts were overweight, ( %) pts had bmi . ae . kg/sq.m, pts ( %) -bmi . ae . kg/sq.m. % pts had hypercholesterolemia, % -glucose intolerance, % -high arterial blood pressure. all patients were undergone by the assessment of nutrition status, biochemical researches. there was executed food allowance correction and added complex of physiotherapeutic treatment. control examination was carried out in weeks by body structure definition by bioimpedance analysis and biochemical blood tests. results: there were noted that level of cholesterol decreased from . ae . mmol/l to . ae . mmol/l (p . ), level of blood glucosefrom . ae . mmol/l to . ae . mmol/l. there was registered decreasing systolic arterial pressure of % of patients to . ae . mmhg (p . ) and diastolic at % pts -to . ae . mmhg (p . ). there were fined reduction of a fatty component on . ae . by kg, with preservation of active cellular weight - . ae . in kg (p < . ) in patients. conclusions: physical exercises, physiotherapeutic procedures jointly balanced food allowance promote more considerable decrease in weight of body and decrease in cardiovascular and metabolic risks. results: after adjustment for sociodemographic and lifestyle factors, the relative risk (rr) of pd comparing subjects with metabolic syndrome to those without it was . and the % confidence interval ( % ci) . - . . this association was especially due to high serum triglyceride levels ( ! . vs. < . mmol/l, rr . , % ci . - . ), and high plasma glucose levels ( ! . vs. < . mmol/l, rr . , % ci . - . ). the results remained after excluding the first years of the follow-up. after this exclusion and further adjustment for other components of the metabolic syndrome, the suggestive association between pd and bmi was strengthened ( ! kg/m vs. < kg/m , rr . , % ci . - . ). conclusions: high serum triglycerides and plasma glucose levels predicted low pd incidence, even after excluding the presumable preclinical disease phase. also, the suggestively increased pd risk in subjects with high bmi varied according to the follow-up time, proposing that an adequate time period should be considered to account for the preclinical disease phase in pd. pancreatic intrinsic nervous system (pins) maturation goes on postnatally and is involved in the control of pulsatility and amplitude of insulin secretion (is), both altered in obese and diabetic patients. the aim of our study was to determine the impact of obesity in infancy on pins maturation and control of is. c bl/ j mice aged weeks received a normal (nd) or a western diet (wd) for weeks. weeks old mice were used as initial controls (t ). after sacrifice, pancreases were placed in organ incubators for h. the impact of pins upon is was studied by adding to the culture the nicotinic receptors agonist dmpp in presence or absence of l-name (inhibitor of nos) or snp (no donor). insulin was assayed in culture supernatants. pins density and phenotype were determined by ihc. pins density was less in nd compared to t mice, whereas there was no difference between wd and t mice. cholinergic innervation significantly increased with age in both wd and nd mice whereas nitrergic innervation increased in nd mice and decreased in wd. pins stimulation by dmpp induced a time-dependent increase in is, significantly larger in nd compared to wd mice. is profile was identical in wd and t mice. addition of l-name inhibited dmppinduced is in nd mice while snp tended to reduce it. neither l-name nor snp altered is in wd mice. our study suggests that wd induces neuroplastic changes in the pins that could be involved in pancreatic dysfunctions observed during obesity. purpose: inflammation drives the progression from central obesity to insulin resistance, metabolic syndrome and hypertension. whether inflammation caused by allergic diseases such as allergic rhinitis can predispose to hypertension is controversial. therefore, we studied the association between hay fever and hypertension in the united states national health and nutrition examination survey (nhanes). we analyzed data on men and women in nhanes nhanes - . we included participants aged years or older who had valid data on hay fever and hypertension. results: . % of the participants had a previous diagnosis of hay fever and . % of them had hypertension. there were ethnic differences in the prevalence of previous hay fever diagnosis (p < . ) and hypertension (p < . ). overall, there was no significant association between previous hay fever diagnosis and hypertension. in women aged - , there was an association between previous hay fever diagnosis and hypertension (or = . , % ci = . - . , p = . ). this association was not diminished after adjustment for age, race and body mass index (or = . , % ci = . - . , p = . ). after further adjustment for physical activity, alcohol consumption, smoking, liver enzymes, c-reactive protein and ige level, the association remained significant (or = . , %ci = . - . , p = . ). conclusions: in this nationally representative population-based survey, previous hay fever diagnosis is not significantly associated with hypertension in adults, except for women aged - . further work is needed to confirm that this is a true association. the university of hong kong, hong kong, hong kong s.a.r. objective: beta- microglobulin (b m) is the light chain of the major histocompatibility complex class molecule. glycation of b m renders it toxic. serum b m level predicts mortality in chronic kidney disease and some malignancies such as multiple myeloma. we hypothesized that it also predicts mortality in people with diabetes. research design and methods: participants of the third national health and nutrition examination survey aged or above who had diabetes or were on medication for diabetes were included in the analysis. results: during a median follow-up of . years (range . - . years) and . person-years, ( . %) and ( . %) participants died from diabetes-related causes and all causes, respectively. tertile of b m was significantly associated with allcause (hazard ratio (hr) = . , % ci: . - . ) and diabetesrelated mortality (hr = . , % ci: . - . ). the association was independent of cardiometabolic risk factors, cancer, microalbuminuria and impaired glomerular filtration rate. conclusions: serum b m level is a novel independent predictor of diabetes and all-cause mortality in people with diabetes. an elevated level is associated with a substantially increased risk of death. metabolic syndrome (ms) refers to a constellation of factors that increase risk of cardiovascular diseases (cvd) and diabetes. insulin resistance and associated abnormalities is considered to be a link between obesity and cvd. our ongoing study investigates relationship of anthropometric, metabolic and cardiovascular parameters in young patients with incipient ms (young lean subjects with essential hypertension; ht) and obese otherwise healthy subjects (ob) in comparison to healthy lean controls (c) similar for age and sex. methods: all subjects underwent the oral glucose tolerance test. the insulin sensitivity index according matsuda (isimat) and ir homa were calculated. fasting serum concentration of total cholesterol (tchol), hdl cholesterol, triglycerides (tg), and uric acid as well as fasting and post load plasma glucose and insulin concentrations were measured. results: young lean ht patients had comparable bmi but higher body fat percentage (p = . ), higher fasting plasma insulin (p = . ), slightly higher uric acid (p = . ), and higher t-chol (p = . ) than c. despite ngt, ht patients had lower isimat (p = . ) and higher ir homa (p = . ) than controls., but these parameters were comparable to the ob group. / of young lean ht patients similarly to ob otherwise healthy subjects exhibited three and or more features of ms. conclusions: young lean patients with hypertension displayed signs of insulin resistance comparable to obese subjects and metabolic abnormalities typical for metabolic syndrome. early life style interventions might prevent theto development of complete ms in these young ht and ob subjects. increased prevalence of overweight in male patients, whereas women had increased prevalence of obesity (grade ii and iii). hypertensive diabetic subjects with other metabolic risk factors are more prone to microvascular and macrovascular complications. methods: eighty-six patients were divided into two groups. the group included subjects (mean age . ae . years) with ah and ao (mass body index (mbi) . ae . kg/m ) and the group - subjects (mean age . ae . years) without metabolic disorders. the parameters of -hour bp monitoring; microalbuminuria and mdrd; total cholesterol, low-density lipoprotein cholesterol, highdensity lipoprotein cholesterol, triglyceride, diene conjugates (dc), malonic dialdehyde (md), catataze and inflammatory markershomocysteine, high-sensitivity c-reactive protein (hs-crp) and fibrinogen were estimated. results: in group there was registered increase in mean -h and daytime systolic bp, time and square indices, in night time systolic and diastolic bp variability. in renal function factors there was registered increase mdrd. in biochemical parameters there was detected increase in total cholesterol, triglyceride level, md and dc level, fibrinogen and hs-crp level; and decrease of catalase level; high density lipoprotein cholesterol compared to group . besides in group positive correlation between lipid and inflammatory markers against each other and with parameters of -h bp monitoring, microalbuminuria, mdrd and mbi was found. conclusion: we revealed relationship between blood pressure profile parameters, renal function parameters, atherogenic lipid profile parameters, inflammatory markers and mbi, that is indicative of development of cardiovascular and cardiorenal risk in patient with ah and ao. there is considerable interindividual variation in therapeutic response to metformin in women with pcos and obesity. genetic factors may play an important role in therapeutic response to metformin and tcf l gene could be one of such factors. tcf l marker is one of the strongest risk factors known for predicting increased likelihood of conversion from prediabetes to t d. tcf l belongs to a subfamily of tcf -like hmg box-containing transcription factors. tcf l is a component of the wnt-signaling pathway and determine the glucoseinduced insulin secretion and regulates the maturation of β-cells of the pancreas from pluripotent stem cells. in addition, this gene plays an important role in adipogenesis and differentiation of adipose tissue. the aim of our study was to evaluate the efficacy of using metformin in patients with pcos and obesity in relation to their rs polymorphism of the tcf l gene. patients with pcos and obesity receiving therapy with metformin were examined. comparative analysis revealed a significant increase in the frequency of genotype c/t (v = . ; p < . ; or = . ; % ci = . - . ) and t/t (v = . ; p < . ; or = . ; % ci = . - . ) in the group of patients with positive dynamics of treatment with metformin compared with the group without positive dynamics of treatment. thus, patients with pcos and obesity who possess the genotype c/t and t/t of the tcf l gene are more likely to have positive therapeutic response to metformin. objective: to investigate the relationship between resistin gene polymorphism with its circulating level, metabolic risk factor and insulin resistance in adult women. design: total healthy subjects were enrolled for the study, (age . ae . years) were with metabolic syndrome and were age matched control (age . ae . years) without metabolic syndrome. circulatory resistin, insulin, plasma glucose and lipid profiles fasting level were estimated along with insulin resistance. resistin-c g promoter region polymorphism were done by rflp method digested with bbsi restriction enzyme. results: homozygous mutant genotype (cc) (cc v/s cg + gg) (p = < . : or = . : % ci = . - . ) of the c/g resistin gene polymorphism was significantly less frequently observed in the control population. on dividing the subjects further in to two groups according to the abscence (resistin- ) and presence (resistin- ) of the mutant g allele, significantly high levels of resistin (p = . , or = . , % ci = . - . ), triglyceride (tg) (p = . ), plasma glucose (p = . ), systolic blood pressure (sbp) (p = . ), diastolic blood pressure (dbp) (p = . ), whr (p = < . ) were observed in resistin- group . conclusion: our results conclude that the c/g mutation of the resistin gene is likely to play an important role in metabolic syndrome and metabolic abnormalities. background: in both obesity and allergy, inflammation occurs. therefore, we examined the association between body mass index (bmi), a measure of general obesity, and serum ige level, a measure of allergy. excluded from this study. using the complex sampling function of spss, the unstandardized regression coefficient, b, for the relationship between bmi and the natural logarithm of ige level was calculated. results: there was a sex difference in ige level (p < . ). before adjustment, ige was associated with bmi in women (b = . , p = . ) and in the overall population (b = . , p = . ). after adjusting for race/ethnicity, age and sex except in sex-specific analysis, the association in women (b = . , p = . ) and the overall population (b = . , p = . ) remained significant. after further adjustments for physical activity, alcohol consumption and smoking, the association was still significant in women (b = . , p = . ) and the overall population (b = . , p = . ). the association was attenuated but remained significant in women (b = . , p = . ) and the overall population (b = . , p = . ) after further adjustment for levels of liver enzymes and c-reactive protein. conclusions: in this nationally representative population-based survey, ige level is associated with bmi. the attenuation in the association after controlling for liver enzymes and c-reactive protein suggests that hepatic inflammation accounts for some of the association. background: janus kinase (jak) is involved in cytokine receptormediated intracellular signal transduction. inhibition of jak protects beta-cells from cytokine toxicity and has been shown to delay the onset of diabetes in the mouse model. the influence of jak single nucleotide polymorphisms (snps) on diabetes risk or on diabetesrelated metabolic traits is unknown. methods: we therefore investigated the association of jak tagging snp rs (c>t) with metabolic phenotypes and type diabetes (t dm) in a cohort of coronary patients including non-diabetic subjects and patients with t dm, totally comprising individuals. results: among non-diabetic subjects snp rs was significantly associated with hba c (cc: . ae . , ct: . ae . , tt: . ae . %; p = . ), fasting glucose (cc: . ae . , ct: . ae . , tt: . ae . mmol/l; p = . ), and hdl-cholesterol (cc: ae , ct: ae , tt: ae mg/dl; p = . ), as well as with total cholesterol (cc: ae , ct: ae , tt: ae mg/dl; p = . ) and ldl-cholesterol (cc: ae , ct: ae , tt: ae mg/dl; p = . ). in patients with t dm, the jak variant was significantly associated with fasting glucose (cc: . ae . , ct: . ae . , tt: . ae . mmol/l; p = . ). the association between snp rs and t dm did not reach statistical significance (allelic odds ratio = . [ . - . ]; p = . ). we conclude that jak tagging snp rs is significantly associated with phenotypes conferring an increased cardiometabolic risk, at least in non-diabetic coronary patients. the association between rs and the risk of t dm warrants further investigation. l. garrido-s anchez , x. escoté , l. coín-aragü ez , j.c. fren andez-garcía , r. el bekay , j. background: munc c is associated to glucose metabolism and could play a relevant role in the insulin resistance. however, little is known on the regulation of munc c expression. we analyze munc c gene expression in human visceral (vat) and subcutaneous adipose tissue (sat) and their relationship with obesity and insulin. we evaluated subjects distributed in non-obese lean subjects, overweight subjects, obese subjects and nondiabetic morbidly obese patients ( with low insulin resistance and with high insulin resistance). results: the lean, overweight and obese persons had a greater munc c expression in adipose tissue than the morbidly obese patients (p < . ). vat and sat munc c correlated negatively with weight (p = . , p = . ) and bmi (p = . , p = . ). vat munc c correlated negatively with glucose (p = . ). sat munc c correlated negatively with insulin (p = . ) and homa-ir (p = . ), and was the main determinant of the improvement in homa-ir index at days after bariatric surgery (b = À . , p = . ). sat explants cultures show that insulin produced a significant down-regulation of munc c expression (p = . ). this decrease is also obtained when explants are incubated with a liver x receptors alpha (lxra agonist, either without (p = . ) or with insulin (p = . ). however, munc c expression is not affected when explants are incubated with insulin plus a sterol regulatory element-binding proteins- c (srebp- c) inhibitor (p = . ). conclusions: munc c gene expression in human adipose tissue is down-regulated in obesity and is inversely associated with insulin resistance. insulin may have an effect on the munc c expression, probably through lxra and srebp- c. lab., faculty of medical technology, endocrin, tripoli-university of medical sciences, biochemstry, cdc, biotechnology, research centre, tripoli, a protective factor for obesity, type- diabetes mellitus (t dm), polycystic ovary (pcos), and lacunars infarction. objectives: the objective of this study was to investigate the association between this polymorphism and t dm, gestational diabetes (gdm), and obesity. methods: genotyping was achieved by pcr-relp in individuals chosen randomly from the out patient's clinics of al-jala maternity hospital of tripoli and gharian hospital, including: t dm patients, gdm patients, obese, healthy control individuals from libyan pregnant women population (north-west region). the results revealed that this polymorphism has no association with t dm, gdm, and obesity in comparison with the control sample. conclusion: t a polymorphism of sorbs gene is not associated with the pathological conditions studied. r. parhimovich, n. konovalova, r. tishenina, n. mylov moscow regional research clinical institute named after m.f. vladimirskiy, moscow, russia area ( . ) of bmi ! . kg/m (bmi ) had significant larger areas than those of wcm ( . ). wci and bmi had good sensitivity ( . % and . %). wci and wci had good specificity ( . % and . %) and classification ( . % and . %). the proposed cutoff values were wci . further cohort study is needed to confirm these values. for national reference, we recommend measuring at umbilical due to its feasibility. servicio de endocrinologia y nutricion, hospital regional universitario carlos haya, ciberdem, servicio de cirugía, hospital regional universitario carlos haya, m alaga, spain introduction: the fndc gene encodes a membrane protein which is proteolytically cleaved, glycosylated and secreted into the blood as irisin. it has been described that causes a significant increase in total body energy expenditure, reduces body weight and improves dietinduced insulin resistance in mice. however, little is known in human. the aim of this study was to analyze the irisin levels in morbidly obese subjects undergoing bariatric surgery at baseline and months after surgery. material and methods: we measured serum irisin levels in morbidly obese subjects undergoing roux-en-y gastric bypass and in healthy controls. we have analyzed anthropometric variables and the level of insulin resistance with the homa-ir index. results: morbidly obese patients have a lower serum irisin levels that control subjects ( . ae . vs. . ae . ng/ml, p = . ). serum irisin levels were similar before and after bariatric surgery in morbidly obese subjects ( . ae . vs. . ae . ng/ml; p = . ). there were no significant differences between morbidly obese subjects according to the homa-ir levels, neither before nor after surgery. irisin levels correlated negatively before surgery with glucose (p = . ), triglycerides (p = . ), cholesterol (p = . ), homa-ir (p = . ) and waist to hip ratio (p = . ). in a multiple lineal regression model, irisin levels were associated with waist to hip ratio (p = . ) after adjusting for fasting glucose, cholesterol, triglycerides, homa-ir and age. no significant correlations were found at months after surgery. conclusions: irisin levels in decreased in morbidly obese subjects and is mainly related to waist to hip ratio. results: the level of uric acid increased with age in women and had a significant difference in women of - years (r = . , p < . ). in men, the maximal level of uric acid was in the group - years. incidence of hyperuricemia among women was %, in men - %. we determined that the highest level of triglyceride, cholesterol, systolic and diastolic pressure was among women and men with hyperuricemia. the higher level of uric acid was found in patients with maximal body mass index (bmi > ). incidence of hyperuricemia among women in the i group was . %, in ii - . %; in iii - . %, in iv - . %. conclusions: it was determined that the level of uric acid was increasing with age and the highest level of some components of metabolic syndrome (triglyceride, cholesterol, systolic and diastolic pressure) was among patients with hyperuricemia. introduction: cushing's disease (cd) is the most common reason of endogenous hypercortisolaemia. the cortisol excess leads to serious metabolic and cardiovascular complications which significantly increase the morbidity and mortality in cd. objective: to assess the prevalence of preoperative glucose homeostasis alterations in cd and their influence on the effectiveness of surgical treatment. material and methods: a prospective study that included patients ( women; six men) with cd. the prevalence of prediabetes (impaired fasting glucose, impaired glucose tolerance) and overt diabetes was assessed. the relationship was evaluated between duration of cd symptoms and the presence of glucose homeostasis alterations as well as their impact on the efficacy of surgical treatment for cd. the proportion in the study group of overt diabetes was . %, whereas the prevalence of prediabetes was . %. . % of patients were obese (bmi ! ) and additional . % were overweight (bmi ! ). there was confirmed the association between duration of cd symptoms and occurrence of diabetes (p < . ) and any type of glucose homeostasis alterations (p = . ). there was no relationship confirmed between the presence of glucose homeostasis alterations and efficacy of transsphenoidal surgery for cushing's disease. conclusion: a longer duration of cd symptoms was associated with greater risk of metabolic complications such as: prediabetes and secondary diabetes. the efficacy of surgical treatment for corticotroph adenoma does not depend directly on the presence of preoperative glucose homeostasis alterations. objective: the study objective was to identify factors associated with depressive symptoms in elderly with metabolic syndrome. material and methods: it was a case-control study to check sociodemographic and lifestyle influencing depressive symptoms in elderly patients with metabolic syndrome. the cases were attended in program family health strategy, classified as having metabolic syndrome and depressive symptoms and the control group consisted of individuals with metabolic syndrome who didn′t have depressive symptoms. it was used as a measure of association, odds ratio (or) with confidence interval of % and p-value, obtained by conditional logistic regression model. conclusions: in the population studied showed that depression was associated with individuals at higher stress levels, those who had shown the mourning, elderly older than years, those with cognitive deficits and negative perception of health. the results reinforce the need to train health professionals so that they can identify and intervene in this population, to improve the quality of life for seniors. introduction: vascular endothelial growth factor (vegf) is said to play key role in pathogenesis of diabetic nephropathy by upregulating the expression of endothelial nitric oxide synthase (enos). human vegf gene, located on chromosome and is highly polymorphic. insertion/deletion (i/d) polymorphism of the bp fragment at position of the promoter region of vegf gene has been implicated in many diseases of angiogenic origin. aim of the study: to investigate i/d polymorphism of vegf gene in patients with type diabetes mellitus and to assess their possible role in diabetic nephropathy. materials and method: fifty subjects with diabetic nephropathy, subjects with diabetes mellitus without nephropathy and normal controls were evaluated for i/d polymorphism of the bp fragment at position of the promoter region of vegf gene by polymerase chain reaction. the frequency of vegf alleles and genotype distribution were compared in diabetic subjects, diabetic nephropathy subject and control groups. results: distribution of vegf genotype was found to be significantly (p < . ) different amongst diabetic nephropathy subjects, diabetic subjects and controls by fisher's exact test and chi square test. statistically significant association (p < . ) of d allele was also found with diabetic nephropathy. conclusion: our study shows that i/d polymorphism of the bp fragment at position of the promoter region of vegf gene is associated with diabetic nephropathy. university of delhi, new delhi, india between bai, bmi and percent body fat (pbf) in an endogamous population of india. design: data was collected on adults with respect to bodyweight, height, skinfolds, hip and waist circumference, and blood pressure. pearson correlations was calculated for bai and bmi with pbf. differences in correlation for baivsbmi were examined using fisher z-tests. receiver operating characteristic (roc) analysis was used to compare the predictive validity, and to determine optimal cut-off values. ors were calculated to assess the risk of having hypertension using the proposed cut-off points. results: the correlation of pbf with bmi (men: r = . ; women: r = . ) were stronger than those with bai (men; r = . ; women: r = . ). the regression model for bai explained . % of the variance in pbf in men and . % in women whereas the corresponding regression model for bmi explained . % variance in men and . % in women. in men, the sensitivity and specificity of bai to predict hypertension was higher than wc, whr and whtr but lower than bmi. in women, the sensitivity of bai was higher than bmi and wc. in men, odds of hypertension on bai were lower than other anthropometric markers while in women, it was higher for other anthropometric markers. conclusions: bai can be used as an additional marker for screening population, however its validity needs to be demonstrated on other populations too. obesity is a multifactorial syndrome characterized by a chronic state of positive energetic balance. the experimental model of treating neonatal rats with monosodium l-glutamate (msg) was used. amino acids, which also participate in the formation of proteins, are precursors of signaling molecules as local hormones and mediators; indeed, glycine can induce catecholamine secretion of adrenal medulla. catecholamines of the adrenal medulla have an important role in the regulation of the metabolism, affecting the mobilization of fats. therefore, abnormalities in catecholamines secretion can contribute for obesity development. thus, the purpose of our work was verify if glycine administration has an inhibitory effect on hypothalamic obesity development. animals were treated with tap water added to glycine ( . g/kg). catecholamine content and secretion from adrenal medulla were measured using the trihydroxyindole fluorescence method. msg treatment induced . % enhancement of perigonadal fat pad when compared to control animals (p < . ). however, glycine treatment caused a reduction of almost % on perigonadal pad in obese group (p < . ); control-glycine group presented a decrease of . % in perigonadal fat pad related to control (p < . ). msg treatment reduced . % basal catecholamine secretion (p < . ). obese animals that received glycine presented an increase in basal catecholamine secretion ( . %, p < . ). in conclusion, we showed that glycine treatment did not inhibit obesity development, but the decrease in adiposity observed in obese and control rats treated with glycine may be consequence, at least in part, of the enhacement in basal catecholamine secretion due to stimulatory effect of the glycine. background: increased high sensitivity c-reactive protein (hscrp) and c-glutamyl transferase (ggt) have been reported to be associated with metabolic syndrome (mets) and its components. the aim of this study is to determine whether these two biomarkers independently predict new occurrences of mets in koreans. methods: on-going prospective cohort study, korea health examinee study (koex), has recruited . individuals since . among them, repeated survey was done in approximately years for individuals. only newly occurring mets cases during follow-up was included in this study. odds ratios (or) and % confidence intervals (ci) for the risk of mets were estimated using multivariate logistic regression analysis. results: three hundred seventy-six newly occurring mets cases were ascertained in the follow-up survey. two years' cumulative incidence of mets was . % and was higher among men than women ( . % vs. . %). after adjustment for potential covariates, an increased risks for newly occurring mets were observed among those with higher hscrp measured at baseline examination in men (or = . , % ci . - . ; ! . (mg/l) vs. < . (mg/l)) and in women (or = . , % ci . - . ; ! . (mg/l) vs. < . (mg/l)). also higher risk was observed in those with higher ggt in women (or = . , % ci . - . ; ! (iu/l) vs. < (iu/l)) and in men (or = . , % ci . - . ; ! (iu/l) vs. < (iu/l)). conclusions: metabolic markers such as hscrp and ggt are clearly predicted new occurrence of mets. clinical usefulness of these markers needs to be more investigated in the extended follow-up study. objective: thyroid dysfunctions are supposed to be implicated in metabolic risk. we assessed the effects of hyper-, hypo-and euthyroidism on patients′ lipid metabolism and oxidative stress from a month follow-up clinical pilot study. methods: a study cohort of probands was grouped into hyper-(n = ), hypo-(n = ) and euthyroid (n = ) patients and healthy controls (n = ). patients received their individual medication and underwent a month follow-up. routine thyroid parameters, inflammatory status, lipid metabolism and oxidative stress were analyzed in patients before and after months of medication and in healthy controls. additionally, we measured the body weight, length, waist and hip circumference, bmi as well as blood pressure (bp). results: analyses of routine thyroid parameters confirmed patient's status. anthropometric baseline characteristics were comparable between groups. bp was significantly higher in all baseline patient groups compared to controls. baseline vs. follow-up analyses revealed that euthyroid follow-ups had a significant increased bmi, waist circumference and waist-to-length ratio. further, euthyroid and hypothyroid follow-ups had a significantly lower bp. observations on lipid metabolism revealed that hypothyroid and euthyroid follow-ups showed declined hdl levels and significant higher hld-ldl ratios compared to their pre-treated state. cholesterin, ldl, tg, oxldl levels and inflammatory markers were comparable in baseline and follow-ups. concerning oxidative stress we found significantly declined asymmetric dimethylarginine (adma) levels in all three follow-up groups. results: in the elderly group without metabolic syndrome, autonomy was associated with increasing age, sedentary behavior, and depressive symptomatology. in the presence of metabolic syndrome, in addition to these factors, the lowest level of education, being insufficiently active in physical activities, and have at least one chronic disease is not transmissible, also correlated with worse autonomy. the strong association between obesity and cardiovascular disease stresses the necessity of elucidation the underlying molecular mechanisms linking these pathologies. adrenergic over-activation can promote cardiac hypertrophy and progression to heart failure. our aim was to evaluate a novel sensor for camp namely epac (exchange protein directly activated by camp) and downstream signalling pathways in the development of cardiac hypertrophy and susceptibility to ischaemia/reperfusion injury in a rat model of obesity-induced insulin resistance. methods: wistar rats on a hyperphagia-inducing diet, hid (supplementing normal rat chow with sucrose and condensed milk) for and weeks were compared to age matched controls. isolated working hearts were subjected to min global ischaemia and functional recovery was measured after min reperfusion. hearts were also freeze-clamped at different time points during ischaemia and reperfusion. epac activation was determined by rap activation kit. nfat, p mapk, erk / , pkb and creb were determined by western blotting using appropriate antibodies. results: the heart weight increased significantly after weeks on hid along with an increase in the hypertrophic marker, nuclear nfat. the weeks hid hearts recovered significantly after ischaemia compared to controls, along with a significant increase in phospho-pkb after min reperfusion, compared to week hid hearts. however, results on epac activation showed variable responses. type diabetes mellitus (t dm) and hypertension (htn), both illnesses share pathogenic mechanisms that predispose to micro/ macrovascular complications. it is well known the role of hyperglycemia and insulin resistance of diabetes in vascular endothelial dysfunction. several studies have shown the association of serum concentrations of osteocalcin (oc) in the metabolism of glucose. oc a marker of bone formation by osteoblasts and produced hormone that regulates energy metabolism, was found recently in arteries with atherosclerosis, suggesting their direct association with vascular disease. we analyzed the relationship between serum oc concentrations and cardiovascular risk factors. a cross-sectional analytical study was carried out in patients with t dm plus htn and healthy subjects (hs). oc serum levels were measured and also statistically correlated with cardiovascular risk parameters. total osteocalcin serum levels in t dm + htn subjects were significantly higher than those in hs (p < . ), whereas the uncarboxylated oc concentrations were lower in t dm + htn subjects than in hs (p < . ). body mass index, waist circumference, fat percentage, fasting plasma glucose, high-density lipoprotein cholesterol, fasting serum insulin, homeostasis model assessment-insulin resistance and high sensitivity-c reactive protein were negatively correlated with uncarboxylated osteocalcin (p < . ). in addition, carboxylated oc was also positively correlated with systolic and diastolic blood pressure (p < . ) and homeostasis model assessment-insulin resistance (p < . ). oc serum concentrations are associated with cardiovascular risk factors in patients with t dm + htn. the oc forms (uncarboxylated/carboxylated) might play different roles in cardiovascular and endocrine physiology and hence be of different value as cardiovascular risk markers. aim: to evaluate the prevalence of ms in a group of medical students from bucharest and their habits related to nutrition and physical activity. cross-sectional study: ms was defined according to international diabetes federation criteria. medical students from bucharest were included in the survey, based on their informed consent. they were examined clinically (weight, height, waist, blood pressure), provided a blood sample (glycaemia, lipids, triglycerides, cholesterol, high and low-density lipoproteins) and answered to block adult questionnaire for food and physical activity. results: students enrolled, . % females. . % of subjects were free of signs of ms, . %, . % and . % met one, two and three criteria for ms diagnosis. the highest prevalence of abnormality was found in waist (above the limit in . % cases), followed by hdl (decreased in . % cases). significant differences among genders were found in waist. food habits: boys were found to eat significantly more calories, fats, carbohydrates and proteins compared to girls. no differences for fibres, transfats, free sugar, fruits and vegetables. physical activity: boys consumed significantly more energy through physical activity, recreational activities and vigorous physical activity compared to girls. only in % of cases the energetic consume was higher than the ingestion (no difference by gender). conclusion: high prevalence of unhealthy habits related to nutrition and physical activity in a particular highly educated young group are concerning for the occurrence of ms in the future. triphala an age old commonly used powered preparation of three medicinal dried plant fruits amla (emblica officinalis), harad (terminalia bellirica) and bahera (terminalia chebula) in equal proportionsis used in indian systems of medicine. present work evaluated the anti-hyperglycemic, anti-hyperlipidemic, and antioxidant potentials of 'triphala' formulation viz., (emblica officinalis: terminalia bellirica: terminalia chebula:: : : ) in subjects with igt and tiidm. the therapeutic effect of 'triphala' administration ( gm bd) in tiidm, igt and healthy individuals was assessed by monitoring blood glucose at days intervals, hba c, lipid profile, oxidative stress markers, and liver & kidney function markers at days intervals. dna damage was assessed by comet assay, flow cytometry and hoechst nuclear stain. molecular markers were determined in the beginning and at the end of therapy. results: 'triphala' ( : : ) administration for year significantly brought down blood glucose levels with a marked improvement in lipid profile in all the groups, this was further supported by increased protein expression of ampk and adiponectin. triphala provided resistance to oxidative stress generated not only by the increasing the antioxidant enzymes activity, but also by shortening comet tail length and number of cells in g phase of cell cycle. our results indicated that diabetes is strongly associated with elevated levels of ar, tnf-a, il- and il- , but triphala down regulated the same, proving its anti-inflammatory potential. conclusion: these observations raise the prospects of using triphala formulation for treatment of diseases associated with oxidative stress and imbalanced cytokine production. introduction: glucoregulation disorders are a state of pre-diabetes increasingly diagnosed in the general population. its association with hypertension, increases the risk of cardiovascular morbimortality objective: identify the blood pressure profile in patients with disorders of carbohydrate. patients and methods: this monocentric study has permitted the prospective recruitment of patients. all had an oral glucose tolerance test (ogtt) with a mesure of plasma glucose level immediately before and h after taking g of glucose. clinical examination with taking blood pressure to two arms and a cardiovascular evaluation were performed. results: the glucoregulation disorders were concerned with patients ( %) with an average age of . years ( - years). sexratio: . . ifg was found in patients. ogtt revealed diabetes, igt. only patients with glucoregulation disorders have normal blood pressure. seventy-two patients have been followed for high blood pressure and five patients are newly diagnosed. more than a half of these hypertensive patients has an igt and a third is diabetic. in the family, the high blood pressure is reported in %, the early cardiovascular events are dominated by myocardial infarction and stroke. in high blood pressure group, patient/ is dyslipidemic and metabolic syndrom, as defined by idf , is concerned with patients/ . as for as cardiovascular events, they are reported in patients/ . (t dm) is an ongoing concern and adequate treatment remains an important issue. thiazolidinediones (tzds) are a class of drugs that initially showed great promise as unique receptor-mediated oral therapy for t dm. the tzds, rosiglitazone (rosi) and pioglitazone (pio) were widely used as hypoglycemic drugs in patients with t dm, but a host of serious side effects, primarily cardiovascular, have limited their use. aim: in the present study we have used a systems biology approach to assess specific gene expression profiles underlying the pathological processes in the heart of pre-diabetic mice treated with rosiglitazone or pioglitazone. results: our data demonstrate that both rosi and pio efficiently decreased high fat diet-induced plasma glucose and insulin levels. analysis of the heart demonstrated that rosi, but not pio, led to an increase in atherosclerotic plaque formation and an increase in heart weight to body weight ratio. a combined transcriptomics and bioinformatics approach revealed specific regulatory pathways that may explain the adverse heart effects associated with rosiglitazone but not pioglitazone treatment. conclusion: our data provide new insights into the mechanisms underlying rosiglitazone and pioglitazone action within the cardiovascular system, including drug efficacy and cardiotoxicity. a. vlassopoulos , m. lean , e. combet human nutrition, school of medicine, university of glasgow, glasgow, uk introduction: the new hba c criteria for diagnosis of pre-diabetes have been criticised for overdiagnosis, because many more people are diagnosed than with the old ogtt criteria. it is possible that some elevation of hba c is not driven by hyperglycaemia. aims: this study assesses associations of hba c, commonly assumed to relate solely to glucose concentration, with, . smoking, a major source of reactive oxygen species (ros) and . fruit & vegetables consumption associated with improved redox status. methods: one-way anova, chi-squared and multivariate linear regressions, adjusted for all known confounders were used to explore associations of hba c with self-reported smoking status and fruit & vegetables consumptions in the scottish health surveys - , among individuals without known diabetes and hba c < Á %. results: compared to non-smokers (n = ), smokers (n = ) were younger, consumed less fruit & vegetables, had lower physical activity levels, lower bmi, higher hba c and crp (p < Á ). hba c was higher in smokers (p < Á ) by two sds ( Á %), and . sds higher ( Á %) in heavy smokers (> cigarettes/day) than nonsmokers. smokers were twice as likely to have hba c in the 'prediabetic' range ( . - . %). pre-diabetes and low grade inflammation did not affect the associations. for every extra g vegetable portion consumed, hba c was . sds ( . %) lower (p = . ), but fruit consumption did not impact on hba c, within the low range of consumptions in this population. conclusion: this study adds evidence for a neglected link between oxidative stress and protein glycation, with implications for individuals exposed to ros and for epidemiological interpretation of hba c. v. aursulesei, i.c. roca, l. mihalache objective: to assess the relation between the traits of metabolic syndrome (ms) and the parameters with independent prognostic significance for cardiovascular risk. material and methods: hundred and forty-three patients were included according to the number of traits of ms ( . % arterial hypertension, . % abdominal obesity, . % low hdl-cholesterol, . % high tryglicerides, . % abnormal oral glucose tolerance). the markers of cardiovascular damage were assessed: pulse wave velocity (pwv -complior method), carotidian intima media thickness (imt), left ventricular hypertrophy (index of mass -lvmi and geometric patterns), flow mediated vasodilation (fmd), microalbuminuria (absent/present), ankle-brachial index (abi). results: in our study the cardiovascular damage is present in . %. pwv values increase with number of traits of ms (t-test) after adjusting for confounders/other cardiovascular risk factors (ancova). decreased abi is related with each of ms traits; the power of correlation depends on criteria association. pwv and abi are both related with postprandial hyperglicaemia and systolic blood pressure (p < . ), while imt is strongly related with hdlcholesterol (r = . , p = . ). lvmi and concentric hypertrophy pattern are also related with systolic blood pressure (r = . , p < . ), while eccentric pattern relates to waist circumference (r = . , p < . ). we cannot establish a relation between traits of ms and fmd or microalbuminuria. conclusions: hyperglicaemia and systolic blood pressure are best related with parameters of cardiovascular risk, but the clustering of ms components may interact to synergistically affect the extent of cardiovascular damage. pwv, abi and left ventricular hypertrophy should be systematically used for defining cardiovascular risk in ms. interleukin- (il- ) is pleiotropic cytokine with a key impact on immunoregulation and nonimmune events. sudies have investigated the role of action/lack of action of il- in the pathogeneses obesity, insulin resistance, type diabetes. aim of the study: to evaluate il- activity in hypertensive patients depend on prediabetes presence. materials and methods: hypertensive patients were examined. common clinical investigations were provided. il- plasma levels were detected using elisa. data is represented as me (q -q ). median test were used, p < . . results: prediabetes was observed in . % of hypertensive patients in % insulin resistance in hypertensive patients with prediabetes vs. % insulin resistance in hypertensive patients were detected. hypertensive patients with prediabetes ( . ( . - . ) %) characterized by significantly higher glycated haemoglobin levels as compared hypertensive patients ( . ( . - . ) %, p < . ). hypertensive patients were characterized by increased il- activity ( . ( . - . ) pg/ml). in hypertensive patients with prediabetes decrease il- activity ( . ( . - . ) pg/ml) were found. conclusion: hypertensive patients were characterized by increased il- adipose tissue is now recognized as a complex organ with a crucial role in energy metabolism and in the development of obesity and metabolic syndrome. modified response and metabolism of hormones has been observed in the visceral adiposity during obesity, specifically related to cortisone. the aim of this study was to assess the response to different concentrations of cortisone in adipocyte cell line t l . the expressions of β-hsd , enzyme responsible for the reduction of cortisone to cortisol, and aqp , involved in glycerol transport, were quantified after treating differentiated cells with cortisone at doses of , . , , and lmol/l during , , , , min, and h. total rna and cdna were obtained from the samples to develop a real time pcr using mnsod as housekeeping gene. results suggest time and dose dependent response of β-hsd and aqp ; increases in the expression were observed during the first min of treatment ( and fold, respectively), followed by expression decrease for both in a min period (p < . ). for the treatment with lmol/l cortisone, both proteins expressions showed quadratic tendencies, β-hsd tendency is described by the equation y = . + . x À . x while aqp tendency is described by y = . À . x + . x . it can be concluded that long term effects of cortisone over adipocyte metabolism may be modulated by the induction or repression of proteins like aqp and should be explored in obese individuals. objective: to present a series of cases of metabolic syndrome patients suffering sleep disorders in which the most relevant metabolic marker is serum tryglicerides levels. it has been considered that the key meatbolic alteration underlying metabolic syndrome is a resitance to insulin action. however, there could be other metabolic abnormalities that may lead to the devleopment of the clinical feautres of this diseasea. materials and methods: patients undergoing a medical check up at medica sur hospital were included. each patient was assesed in order to determine both matabolic syndrome and a current sleep disorder. anthropometric measures were taken, body rates were calculated and blood samples were taken for laboratory tests (serum glucose, tryglicerides and cholesterol levels determination). results were analysed with the spss software. results: fifteen patients meeting the world health organization metabolic syndrome were included, and who referred snoring, difficulties on getting asleep or frequent waking up while sleeping. anthropic measures, and lab results were. discussion: yet, the majority of these patients do not have serum glucose abnormalities, but mainly their weights correspond to overweight and to a phenotype of central adipose tissue distribution. the most significant metabolic alteration, in this set of patients, was hypertigliceridemia. this results suggests that there may be other metabolic pathways leading to the development of this disease. introduction: prediabetes, a condition leading to diabetes and cardiovascular diseases (cvd). in cameroon, few studies have been done about this health indicator. aims: to determine the prevalence of prediabetes and diabetes in cameroon cohort, and to compare metabolic risk factors between normoglyceamia and prediabetes individuals. patients and methods: a sample of cameroonian men and women ( - years) participated in a health survey. statistical analysis of data compared risk factors between three subgroups: normoglyceamia (ng), prediabetes (pd) and diabetes (dt). prediabetes was defined as a glyceamia of - mg/dl. metabolic syndrome (mets) was diagnosed using the national cholesterol education program (ncep) definition. results: the distribution of ng, pd and dt prevalence in the overall sample was . %, . % and . % respectively. the prevalence of mets in those with pd ( . %) was significantly higher than in those with ng ( %). many significant differences between ng and pd subjects were also noticed. conclusion: in this study, approximately % of the population who were found to be diabetic and prediabetic is at risk of cardiovascular diseases. our findings also show that prediabetes individuals are different from those with normal glycaemia in a great number of metabolic abnormalities including a higher prevalence of mets. prevention and control measures should be set urgently. research design and methods: prospective study of the thai comprehensive cirs was further evaluated by multiple logistic regressions. in determine the ability of the thai comprehensive cirs scores in predicting each outcome, the adjusted odds ratio was calculated, and backward stepwise selection was used in the statistical modeling. results: there were also prospective correlations between the baseline thai comprehensive cirs instrument and -month outcomes). total score at baseline emerged as significant predictors of -month qol (r = . - . , p < . ). every subscale of the thai comprehensive cirs was significantly related to patient satisfaction (r = . - . ), with only the neighborhood subscale as a significant predictor for adl (r = . ). the other outcomes (self management behavior, cost of care, and dbp) were not significant concurrent baseline predictors. method: we collected laboratory results of body mass index (bmi), blood pressure, fasting glucose, lipid profiles (total cholesterol, triglycerides, ldl-and hdl-cholesterol level) and visceral fat amount of cancer survivors who visited health promotion center at seoul national university hospital. an age and sex-matched control was selected randomly for each cancer survivor from visitors of this center. we compared blood pressure, fasting glucose, lipid profiles and visceral fat amount between cancer survivors and controls using multiple regression analysis after adjustment for bmi. results: one hundred fifty five cancer survivors and controls were included in statistical analyses. cancer survivors tended to have lower bmi compared to controls ( . ae . kg/m vs. . ae . kg/ m , p = . ) after adjustment for bmi, cancer survivors showed lower fasting glucose level ( . ae . mg/dl vs. . ae . mg/ dl, p = . ). however there were no significant differences of blood pressure, lipid profiles or visceral fat amount. background: both insulin deficiency and resistance are reported in patients with β-thalassemia major (btm). we assessed the ogtt and -h continuous glucose concentration by the continuous glucose monitoring system (cgms) and calculated homeostatic model assessment (homa), and quicki in adolescents with btm on regular blood transfusions and iron-chelation therapy. results: in adolescents with btm (age: . ae years), ogtt, ( %) showed impaired fasting blood (plasma) glucose concentration (bg) (> . mmol/l). two-hour after the glucose load, one of them had bg = . mmol/l (diabetic) and two had igt (bg > . and < . mmol/l). monitoring the maximum (postprandial) bg using cgms, adolescents had diabetes ( %) (bg > . mmol/l) and nine had igt ( %). homa and quicki revealed levels < . ( . ae . ) and > . ( . ae . ), respectively, ruling out significant insulin resistance in these adolescents. neither fasting serum insulin nor c-peptide concentrations were correlated with fasting bg or ferritin levels. the average and maximum blood glucose levels during cgm were significantly correlated with the fasting bg (r = . and . , respectively, with p < . ) and with the bg at -h after oral glucose intake (r = . and . respectively, with p < . ). ferritin concentrations were correlated with the fasting bg and the h blood glucose levels in the ogtt (r = . , and r = . , respectively, p < . ) as well as with the average bg recorded by cgm (r = . , p < . ). conclusion: cgm has proven to be superior to ogtt for the diagnosis of glycemic abnormalities in adolescents with btm. background: in obese children pancreatic beta-cells may not be able to cope with insulin resistance leading to hyperglycemia and type diabetes (t dm). objectives: to assess oral glucose tolerance, -h continuous blood glucose concentrations (cgm) and calculate homeostatic model assessment (homa), and the quantitative insulin sensitivity check index (quicki) in children and adolescents with simple obesity (bmisds = ae . ). results: ogtt performed in obese adolescents ( . ae years) revealed three cases ( %) with ifg (> . mmol/l), four cases ( %) with igt (> . < . mmol/l), and none with diabetes. using the cgms, ift was detected in four cases, the maximum bg ( h or more after meal) was > . and < . mmol/l (igt) in nine children ( %) and > . mmol/l (diabetes) in one case ( . %). five cases had a minimum bg recorded of < . mmol/l (hypoglycemia). no glycemic abnormality was detected using hba c ( . ae . %). / patients had homa values > . and quicki values < . denoting insulin resistance. beta cell mass percent (b %) = ae . % and insulin sensitivity (is) = . ae . % denoting insulin resistance with hyperinsulinaemia and preserved beta cell mass. in obese children and adolescents; cgms is superior to ogtt and hba c in detection of the glycemic abnormalities, which appears to be secondary to insulin resistance. introduction: the aim of this study is to evaluate the effect of vitamin e supplementation on glycemic control, lipid profile, inflammation markers and malondialdehyde level of type diabetic patients. material and method: thirty type diabetic patients were participated in this randomized single blind placebo controlled clinical trial study. fasting blood glucose, serum triglyceride, total cholesterol, ldl, and hdl-cholesterol concentration, malondialdehyde (mda), hs-crp, il- , and insulin level were measured. each subject then given a breakfast that was contained g fat. subjects' post-prandial biochemical measurement was measured as well. patients' then randomly divided in two groups. treatment group received vitamin e ( iu/per day) and control group received placebo for weeks. at the end of weeks baseline procedure was repeated and fasting, and -h postprandial biochemical markers were measured. statistical analysis: data analyzed using mann-whitney u test to compare the mean differences between both groups. basic data expressed as mean ae standard deviation, fasting and postprandial biochemical parameters before and after intervention expressed as median. results: no significant differences were found in fasting and postprandial lipid profile, glucose, insulin and homa-ir after weeks of intervention between two groups. significant decreases in fasting and postprandial serum mda levels in treatment group were recorded. no significant differences were shown in fasting and postprandial inflammatory markers except fasting il- . the result of this study shows that short term supplementation of vitamin e is safe and effective in decrease oxidative stress in type diabetic patients. objective: there is evidence that patients with normal weight and central adiposity (elevated waist circumference and waist-hip index) present a higher cardiovascular and metabolic risk. it has been proven that central adiposity is a risk factor for elevated systolic and diastolic pressure amounts, low hdl cholesterol and altered glucose while fasting. materials and methods: patients treated at the integral diagnosis and treament center of medica sur hosptial were inclued. anthropometric measurments were taken and metabolic (glucose and profile of lipids with ultrasensitive reactive c protein) parameters were analyzed. results: nine hundred and forty patients were included. women with a normal body mass index but with a waist > cm, had metabolic alterations on serum lipids which have a statistical significance when compared with those women with a waist circumference lesser ran cm. an elevated waist circumference diameter, regardless of the bmi, increases the metabolic risk. the measurement of the circumference of the waist and the hip must take place by routine in any medical evaluation. aim of the study: to study the prevalence of prediabetes in elderly age group ( years and above) and to study cardiovascular risk factors in prediabetic group. methodology: study was conducted on patients of age years and above. they were screened for prediabetes as per ada guidelines . such prediabetic study group ( cases) was investigated for cardiovascular risk factors (obesity, hypertension, microalbuminuria, crp, retinopathy, dyslipidemia) along with age matched controls. standard statistical tests were applied for analyzing data. hypertension and retinopathy with the prediabetic state. risk factors are more associated with igt as compared to ifg. conclusion: prediabetes is widely prevalent in the elderly population. it has strong association with metabolic syndrome. prevalence of igt is higher as compared to ifg. similarly, cardiovascular risk factors are widely prevalent in the prediabetic population. dyslipidemia, obesity, microalbuminuria, hypertension and retinopathy share the significant association as risk factors. early identification, of prediabetic state followed by primordial and primary prevention of cardiovascular disease should be the focus of intervention. background: despite commonly using body mass index (bmi) in diagnosing obesity, the accuracy of bmi in detecting adiposity is unknown in korean. we assessed accuracy of bmi in detecting body fat percentage (bf%) defined obesity. methods: this study is a cross-sectional design of subjects (age - . years, men . %) who conducted korean national health and nutrition examination survey (knhanes iv- ) in korea from january to december . we assessed the diagnostic performance of bmi using the who reference standard for obesity of bf% ! % in men and ! % in women, which were measured by dual energy x-ray absorptiometry. we tested the correlation between bmi and bf% by sex and age groups. we defined the bmi cutoff for bf%-defined obesity using roc analysis. results: bmi-defined obesity was present in . % of men and . % of women. according to age and sex, a sensitivity and a specificity of bmi ( ! kg/m²) showed difference. the bmi cutoff value for bf %-defined obesity is . kg/m² (sensitivity %, specificity %). difference between bmi cutoff value of korean and that of american to detecting bf% is about À . kg/m². in korean, bmi showed a limited accuracy to detecting adiposity by age and sex. the difference between bmi cutoff-value of korean and that of american to detecting bf% obesity is smaller than the difference of bmi cutoff-value between the asia-pacific and who criteria. background: the healthkick intervention was developed as part of a study that aimed to address diabetes risk factors in primary schools within low-resource settings in the western cape, south africa. the intervention focused on grade - learners, their parents and the educators. aim: to ascertain the risk of developing diabetes and other noncommunicable diseases among educators. method: educators (n = ) from urban and rural schools, participated in a health check in . measurements included random blood glucose and cholesterol testing, and height, weight, waist circumference and blood pressure (bp) measurements. cut-off values for bp levels in adults years and older of the nhlbi were used for categorising hypertension. results: educators participating in this study were mainly females, with most of them ( %) falling in the age range between and years, and % being older than years. only % of educators had bps in the normal range. half of those on treatment for hypertension had levels above / mmhg, while % with bps above these levels were not on medication. about % of those who said they had diabetes (n = ) knew what treatment they were on. cholesterol levels above mmol/l were seen in %. only % said they smoked cigarettes, whereas % were previous smokers. preliminary results show that most participants had a body mass index > kg/m . conclusions: many of the educators who participated in the healthkick study are possibly at risk for developing cardiovascular and other related non-communicable diseases, such as diabetes. s.k. kota , s. ugale , n. gupta , k.d. modi endocrinology, medwin hospital, laparoscopic surgery, kirolskar hospital, hyderabad, india objective: the objective of the present study was to prospectively evaluate the results of laparoscopic ileal interposition (ii) with diverted sleeve gastrectomy (dsg) for control of type diabetes mellitus (t dm) and related metabolic abnormalities. methods: all patients underwent ii +dsg. they had t dm ! years with poor glycemic control despite adequate dosage of oral hypoglycemic agents (ohas) ae insulin. the primary outcome was remission of diabetes (hba c < . % without ohas/insulin) and secondary outcomes were reduction in antidiabetic agent requirement and components of metabolic syndrome. we report the preliminary postoperative follow-up data of . ae . months (range: - months). there were patients (m: f = : ) with mean age of . ae . (range: - years), duration of diabetes of . ae . years (range: - years), and preoperative body mass index of . ae . kg/m (range: . - . kg/m ). sixteen patients ( %) had hypertension, while dyslipidemia and microalbuminuria was present in patients ( %) each. twenty two patients ( . %) had diabetes remission. fifteen/sixteen ( %) patients had remission in hypertension. all participants had weight loss ranging between % and %. postoperatively statistically significant decline was observed in the glycemic and lipid parameters, microalbuminuria at all intervals (p < . ). patients with postoperative duration > months had better improvement in terms of reduction in glycemic, lipid parameters and microalbuminuria. three patients had vitamin b deficiency year after surgery. conclusion: ileal interposition combined with dsg addresses both foregut and hindgut theories and brings about remissions in t dm patients. background and objective: the objective of this study was to evaluate the screening potential of various anthropometric indices, namely body mass index (bmi), waist circumference (wc), waist-to-hip ratio (whr) and waist-to-height ratio (whtr) in the early detection of dysglycemia among the omani adult population. methods: our study included omani adults ( males and females) who participated in a cross-sectional, community-based study. we defined glycemic status based on american diabetes association (ada) thresholds: < . mmol/l as normal, . - . mmol/l as impaired fasting glucose (ifg) and ! . mmol/l as diabetes mellitus (dm). the cut-off values for the anthropometric indices namely, bmi, wc, whr and whtr were based on the standard definitions. the age adjusted analysis showed that out of the four anthropometric indices, among the males the whtr at the cut-point of . gave relatively higher value of odds ratio with or = . ( % ci: . , . ) and among the females whr at the cut-point of . showed maximum odds ratio with or = . ( % ci: . . . ). the areas under the roc curves, at the cut-point of ifg ! . mmol/l, was more for whtr in case of males and whr in case of females. conclusion: this study shows that out of the four anthropometric indices, there are differences in the predictive values of dysglycemia among the omani males and females. in case of males, the whtr ! . appears to be a better indicator for detecting dysglycemia whereas among the females the whr ( ! . ) is a better indicator. introduction: increased serum ferritin and iron stores are involved in the pathogenesis of insulin-resistance. polycystic ovary syndrome (pcos) is diagnosed by oligomenorrhea and hyperandrogenism. pcos and obesity were associated with elevated serum ferritin levels. the link between obesity and altered iron metabolism was proposed. object: to evaluate the association between serum ferritin levels and insulin resistance and metabolic syndrome in obese and non-obese women. methods: retrospective study. five hundred thirty-nine women, of whom had pcos and of whom did not have pcos, were included in the study. results: serum ferritin correlated with menstrual cycle length, sex hormone-binding globulin, total testosterone, androstenedione, triglyceride, and total cholesterol both in obese and non-obese women. obese women (bmi > ) with high ferritin (ferritin ! . ng/ml, n = ) levels had higher insulin resistance, impaired glucose tolerance, and liver enzymes than obese women with low ferritin levels (ferritin < . ng/ml, n = ). however, among non-obese women, insulin resistance and metabolic disturbances were not significantly different between high and low ferritin groups. women with high ferritin levels had a greater risk of pcos and hyperandrogenism than women with low ferritin levels. independent of obesity, hypertriglyceridemia was the major metabolic disturbance in women with elevated serum ferritin levels. conclusions: the pathogenesis of increased iron stores correlated with insulin resistance and metabolic syndrome among obese and nonobese premenopausal women was different. the hypertriglyceridemia in women with pcos might be associated with iron metabolism. nutrition rehabilitation, unite de dietetique, pegomas, france and yogic counseling for stress management. all subjects underwent a residential program for weeks followed by therapy at home for weeks. results were analyzed using paired 't' test. conclusion: in remote areas organization of screening on base of diabetes bus helps to detect t d and early glucose metabolism disorders in more than % of people with increased risk. findrisk scale is useful screening tool to detect these people. however, in older age groups, percentage of screen-detected t d decreases, which may indicate lower efficiency of findrisk questionnaire at age ! . background and aims: changes in the cellular oxidative status are involved in the pathogenesis of obesity-associated hepatic steatosis. the possibility of gender difference in this process was examined in an experimental model of obesity induced by a western high-fat and highcarbohydrate cafeteria diet. methods: four groups of six swiss cd mice ( day old) received either cafeteria diet (male and female) or balanced diet (male and female) for weeks. hepatic hydrogen peroxide (h o ), thiobarbituric acid reactive substances (tbars), reduced glutathione (gsh) and the activity and/or gene expression of catalase (cat), glutathione peroxidase (gpx), superoxide dismutase (sod), hypoxia inducible factor (hif- -alfa) and nuclear factor (erythroid-derived )like (nrf ) were measured. results: higher levels of tbars and mitochondrial h o were found in livers from cafeteria-fed animals of both genders, with higher levels in females. the level of gsh was lower in cafeteria-fed mice of both gender; females showed higher levels than males (cafeteria or balanced diet). cat and gpx activities were reduced in cafeteria-fed mice of both sexes; the activities in females being lower than those of males. sod activity and the gene expression of cat, gpx and sod were not significantly altered when compared by gender or dietary treatment, but the expression of hif- -alfa and nrf was increased in female cafeteria-fed mice. the female animals exhibited a higher susceptibility to cellular oxidative stress in cafeteria diet-induced obesity in comparison to males. the molecular mechanisms seem to be, in part at least, posttranscriptional. acknowledgements: capes, cnpq, fundac ßa˜o arauc aria. objectives: to investigate the relationship between body fat percentage and body mass index (bmi) among young adults aged - years. methods: young adults aged - years were recruited for study when they took health examination in september in taiwan. all subjects underwent bioelectrical impedance analysis (tanita bc- ) to estimate their body fat percentage. basic demographic data, height, and weight were collected, and bmi was calculated from height and weight. overweight and obesity were identified according to bmi. the correlation between body fat percentage and bmi was analyzed using sas software . . results: a total of male and female participants were enrolled. the mean age was . ae . years old. the mean body mass index was . ae . for men and . ae . for women. the mean body fat percentage was . ae . for men and . ae . for women. categorized by bmi, the mean body fat percentage was . ae . for men and . ae . for women in bmi < . group, . ae . for men and . ae . for women in bmi . - group, and . ae . for men and . ae . for women in bmi - group and . ae . for men and . ae . for women in bmi > group (p < . ). the prevalence of too high or obese body fat percentage among young adults aged - years in taiwan was . % in male and . % in female according to the who and nih recommendations. the cutoff values of healthy body fat percentage for young adults in chinese population ought to be modified. it is estimated that - % of women of reproductive age have polycystic ovarian syndrome (pcos). this article summarizes the recent development and findings in the cardiometabolic abnormalities in patients with pcos. patients with pcos have the clinical features of oligomenorrhoea, hirsutism and infertility; however, they also exhibit hyperinsulinemia, obesity, hypertension, dyslipidemia, and an increased pro-thrombotic state. they have an increased risk of type diabetes and impaired glucose tolerance, and sleep apnea is also found more commonly in this population. however, despite the presence of cardiovascular risk factors and increased surrogate markers of cardiovascular disease it is unclear if they have accelerated atherosclerosis. end point studies are currently lacking and the available evidence are conflicting. this article will address the current evidence for the adverse cardiovascular risk in pcos and the other factors that may be implicated. finally the therapeutic options for treatment will be discussed. conclusion: results suggest that in the fasted condition, when fatty acids levels are elevated, the gluconeogenic flux is higher in cafeteriafed rats, a finding consistent with the higher glycogen levels. the lower production of co indicates a deviation of the citric acid cycle intermediates into the cytosol, a change which may favour the synthesis of fatty acids and triacylglycerols. these liver metabolic disturbances probably contribute to fatty liver diseases, hyperglycemia and dyslipidemia in cafeteria diet-induced obesity. certain cancers. this study aims to evaluate the association between obesity and colorectal cancer risk and also if the association varies with the blood type, age of obesity or cancer subsites. the study was carried out on hospital patients, different ages, diagnosed with colorectal cancer. we determined the blood type, cancer subsites and age of symptoms. we evaluated their family history and their lifestyle in terms of physical activity, smoking and alcohol consumption. results: out of the patients, % had the bmi ! kg/m and all of them showed abdominal obesity. the age of obesity was up to years to % of the subjects and over years for % of them. symptoms were detected over months before diagnosis for % of the individuals and between and months for % of them. in what respects the cancer subsites, % of the cases were located on the descending colon, rectum and sigma. % of the patients had a family history of different types of cancer (colorectal, pulmonary, gastric or breast neoplasia). sixty-five percent of them were smokers, % were alcohol consumers and % carry light or no physical activity. forty-nine percent were blood group a individuals. the study shows that obesity is a statistically significant risk factor for colorectal cancer and the association is stronger for the patients with a higher age of obesity, descending colon and rectum localisation of the neoplasia and blood group a individuals. technical university munich, munich, ikfe institute, mainz, germany purpose: the angiotensin ii receptor antagonist telmisartan (t) has demonstrated bifunctional effects on the hemodynamic, vascular and metabolic features of patients with metabolic syndrome (ms). accordingly, we tested the hypothesis, that antihypertensive therapy with t vs. amlodipine (a) improves diastolic myocardial function, vascular function and metabolic characteristics in ms. methods: this randomised cross-over study investigated ms patients (bmi ae kg/m ) with mild-moderate hypertension before and after months therapy with t vs. a. laboratory and ultrasound data were taken in the fasting state and h after a test meal ( g carbohydrates). cardiac function was assessed by tissue doppler as systolic (s') and diastolic myocardial velocity (e') and vascular function at the common carotid artery as elasticity modulus and pulse wave velocity. results: after months with t, fasting systolic blood pressure was reduced by ae mmhg (p < . ) and postmeal by ae mmhg (p < . ) vs. a ( ae mmhg (p < . ) fasting and insignificant ae mmhg (p < . vs. t) postmeal). with t but not with a, diastolic pressure dropped by ae (p < . ) fasting and postmeal (p < . ). with t but not a, e' increased fasting and postprandially by . ae . (p = . ) and . ae . cm/s (p = . ) and so did s' (p < . and . ), whereas vascular function improved postprandially alone (p < . and p < . ). conclusion: in ms patients, mild to moderate hypertension and without cardiac disease, monotherapy with telmisartan improved diastolic and systolic cardiac function in particular postprandially whereas amlodipine did not. introduction: the metabolic disorders at the tunisian military pilots are more and more frequent affecting more and more young subjects. the expert doctor is in front of a big problem to know the evaluation as well as the control of the evolutionary genius of these disorders to be able to minimize their complications materials and methods: it is about a retrospective study which was interested in the files of the tunisian military pilots followed regularly in the center of expertise of aeronautical medicine since . on these files, we found the various types of metabolic anomalies by referring to the age and the anthropometric characters during their appearance, as well as the evolutionary follow-up of these anomalies with or without treatment results: the metabolic disorders were found at % of the military pilots. these disorders are represented in the order by dyslipide´mies, then disorders of the hepatic metabolism, the hyper urice´mie and finally the not insulin-dependent diabetes. the therapeutic care ways begins with the hygie´no-dietary rules before the passage in the medicinal treatment. the metabolic disorders make the bed of the cardiovascular diseases; their complications particularly at the military navigators are very grave. the correction of these anomalies is imperative to avoid the vascular accidents which can be responsible for a sudden incapacity during flight. comparison to wt controls, and the epididymal fat weighs significantly less in the ko (p = . ; normalized to body weight). the irx ko mice showed increased feed and water intake relative to their body weight compared to wt littermates. moreover, qpcr and western blot analysis indicates differential expression of irx during adipogenesis in t -l cells. our data suggest that irx plays a role in the development of adipose tissue. method: forty-six obese participants (both sexes, age range from to years) group mean ae sd, . ae . years were selected for the study based on a bmi ! kg/m *. the participants were randomized as two groups. all participants were assessed for bmi and lipid profile at the beginning and end of days of the intervention. twenty six participants ( from each group) were assessed for leptin and adiponectin. the yoga group practiced yoga for min two times in a day for days. at the same time of the day the walking group practiced min of walking for two times in day. each day participants were given non calorie restricted diet regulated as kcal/day. data recorded at the beginning and at the end of the intervention were compared by repeated measures analysis of variance using spss version . , followed by post-hoc analysis. results: both groups showed a significant decrease in bmi (p < . ) and in total cholesterol (p < . ). only yoga group showed significant reduction in ldl cholesterol (p < . ) and significant increase in leptin (p < . ). the walking group alone showed a significant reduction in triglycerides (p < . ) and in adiponectin (p < . ). objective: human urotensin ii is the most potent vasoconstrictor identified to data. however, association between urotensin ii and hypertension and whether the association is independent of endothelial function has been controversial. here, we studied the association under adjustment for serum nitric oxide in a case-control study. methods: hundred and ninety-seven hypertensives and age-and sex-matched normotensive controls were studied. plasma urotensin ii, serum nitric oxide and other traditional biomarkers were examined. association between urotensin ii and hypertension was evaluated by multivariate conditional logistic regression analysis. results: hypertensives had higher levels of urotensin ii [median (interquartile rang): . ( . - . ) ng/ml vs. . ( . - . ) ng/ ml] and lower nitric oxide [ . ( . - . ) lmol/l vs. . ( . - . ) lmol/l] than normotensive controls. urotensin ii positively correlated with sbp (r = . , p < . ), dbp (r = . , p = . ) but negatively correlated with nitric oxide (r = À . , p = . ). in multivariate regression analysis, subjects in the highest th percentile of urotensin ii concentration ( ! . ng/ ml) had . times the risk of hypertension than did individuals in the lowest quartile (< . ng/ml) (p = . ). both univariate and multivariate analysis in pairs of serum nitric oxide level-matched cases and controls showed that risk of hypertension significantly and positively increased with levels of urotensin ii (all p < . ). conclusions: urotensin ii was markedly associated with hypertension and the association was independent of endothelial function. this study suggested that urotensin ii may have an etiological role in hypertension. objective: dilated cardiomyopathy (dcm) is the third most common cause of hf. the implication of transcription factors (tfs) in molecular pathways that guide heart development and cardio-specific gene expression has recently been established. however, the role of cardiac specific tfs; myocardin and tbx in the failing heart is unknown. the present study was designed with the aim to determine the expression profile and regulation of these tfs in failing hearts. methods: myocardin and tbx mrna levels were estimated by quantitative rt-pcr (qrt-pcr) in human ventricular biopsies and pbmcs of dcm patients (n = ) and controls (subjects with ventricular septal defect) (n = ). copy number variations in myocardin and tbx were determined by qrt-pcr in dcm patients (n = ) and control (n = ). myocardin and tbx promoter methylation patterns were studied in pbmcs of dcm patients (n = ) and controls (n = ) by methylation specific pcr (msp). results: myocardin and tbx mrna levels were found to be significantly six fold (p . ) and seven fold (p . ) increased in the failing human myocardium as compared to control samples respectively. promoter hypermethylation of myocardin was observed only in patients and none of controls were found to carry methylated alleles for myocardin. we did not observe any significant difference in promoter methylation status of tbx . there was no significant difference observed in the copy number of both the transcription factors; myocardin and tbx between patients and controls. conclusion: our results suggest that epigenetically regulated expression of cardiac specific tfs; myocardin and tbx may contribute to pathophysiology of dcm. introduction: mir- is among the most abundantly expressed and consistently dysregulated mirnas in heart failure and has been implicated in cardiac fibrosis. however, its role in diabetic cardiomyopathy is not known. abstracts of the th international congress on prediabetes and metabolic syndrome normalisation of the majority of indicators of lipid and carbohydrate metabolism. a.g. kistauri , g. devidze , m. jibladze , a.a. kistauri internal medicine, tbilisi state medical university, tbilisi, surgery, kutaisi ortodox christian hospital, kutaisi, georgia, lund university, lund, sweden aims: diabetic foot syndrome is a complex of purulent-necrotic and/ or ostheoarthropatic changes of the foot. in case of purulent-necrotic complications, lethality reaches - %. objectives: optimisation of infected diabetic foot treatment. methods: eight-four patients, suffering from infected diabetic foot. following was used as a material for antibioticogram: soft tissue scraping from the bottom of the injury, purulent discharge, bone biopsy. results: degree of bacterial contamination was high: between and - : anaerobic flora - . %, aerobic flora À . %. bacterial flora in purulent zone (decreased- . % to . %): staphylococcus aureus, saprophyticus, epidermidis, ps. aeruginosa, enterococcus, e. coli. the highest sensibility was shown to the following drugs (decreased- . % to . %): tienam, meronem, amoxiklav, vankomicin, cefepim, ceftriaxon, ciprofloxacin, likacin, klindamicin. less sensitivity was detected to the following drugs ( . - . %): ampicilin, doxaciclin, cefazolin, erythromycin. based on the above, the most appropriate combinations are: ftorchinolines + i-iii generation aminoglycozides (combination i) and/or iii generation cefalosporines + lincosynamides (combination ii). using the first drug combination, infection was stopped in . % and in . % of cases using the second. high amputations were performed in two cases, six more than half of foot. in cases process was stopped and amputation was avoided. conclusions: cause of tissue necrosis during neuropathic form of diabetic foot is infection, during neuroischemiccritical ischemy and infection. neuroischemic infected injury is characterised with much faster course than infected neuropathic ulcer. the most appropriate treatment combination of diabetic foot is fluorcholines + i-iii generation aminoglycozyed and iii generation cefalosporines + lincosomydes. background: continuous glucose-monitoring system (cgms) is a tool for assessment of glycemic excursions. glucose variability is a risk factor independent of glycosylated hemoglobin (hba c) for diabetic complications. aim: to evaluate the prevalence and extent of glycemic excursions & unrecognized hypoglycemia in type diabetic patients. setting and design: the study was carried out in type diabetes patients on oral agents. material and methods: patients underwent continuous glucosemonitoring by cgms for days. number and duration of glycemic excursions, unrecognized hypoglycemia, correlation coefficient (%) between cgms and self-monitoring blood glucose (smbg), mean absolute difference (%mad were analyzed. results: the mean age of patients was . ae . years. the mean hba c was . ae . %. the mean number of glycemic readings was . ae . times. the correlation coefficient was . and the mad was . ae . %, which were considerable. twenty three ( %) patients experienced hypoglycemic events. twenty seven ( %) patients had hyperglycemic events. the hypoglycemic events were found to have significant correlation with the duration of diabetes and inverse correlation with hba c, whereas age was significantly correlated with females diabetics (p < . ). conclusion: this study demonstrated that type diabetic patients have a considerable number of hypoglycemic and hyperglycemia events that may be missed by smbg. internal medicine department, zagazig university, faculty of medicine, university hospital, medical biochemistry, zagazig university, faculty of medicine, zagazig, egypt impaired fibrinolysis increase the risk of cvd in diabetics, it has been found also in igt associating metabolic syndrome but there is no data concerning fibrinolysis in subjects with normal gt that may convert to diabetes. therefore, the aim of work was to study the fibrinolytic activity, as measured by tpa activity and t-pai- antigen as markers of endothelial dysfunction in normal and igt offspring of type diabetes compared to subjects without family history of diabetes. we measured fibrinolytic activity (tpa activity and tpai- antigen) in subjects, healthy volunteers and offspring of type ( normal gt and igt), we measured fasting plasma insulin, lipid profile and insulin resistance. we found that tpa activity was significantly reduced and tpai- was significantly raised in igt group as compared to normal gt. surprisingly tpa activity was also significantly reduced and tpai- was significantly raised in normal gt. also, we found that igt increases the (tpai- antigen and decrease tpa activity in igt by . fold and . respectively than normal gt offspring. we can concluded hypofibrinolysis may aggravate insulin resistance and promote progression of atherosclerosis in those offspring in the future. this may explain the increased prevalence of cardiovascular diseases in early discovered diabetics. moreover, changes of these parameters can be used as a predictor for early detection of prediabetic state even before occurrence of glucose intolerance and the proper correction of this hypofibrinolysis may delay the development of atherosclerosis in diabetic stage. introduction: type diabetes in children is the most common juvenile endocrinopathy. decreased bone mass has been shown to be a common complication of type diabetes. the aim of our study was to evaluate the characteristics of bone mineral density (bmd) in diabetic children and their relationship with the age of diabetes, glycemic control and the biological markers of bone remodeling. with an assay of biological markers of bone turnover were performed for each child. results: sex ratio was . in the diabetic group and . in the control group. the average age of diabetics was . years and that of controls was . years. the two groups were comparable concerning the age, sex, anthropometric parameters and pubertal stage. the only difference found between the two groups concerning calcium intake that was lower in the controls. bone mineral density did not differ significantly between the two study groups. a significant difference was found comparing averages of bone markers (osteocalcin and ctx). the seniority of diabetes was correlated to the bone mineral density only in the diabetic daughter. the glycemic control represented by hba c was inversely correlated to the bone mineral density. conclusion: the prevention of bone damage in the diabetic child must go through adequate calcium intake, a proper sports activity and especially a good control of the disease. background and aims: the aim of the present study was to investigate all-cause mortality in relation to physical inactivity and diabetic status among patients surviving an acute myocardial infarction (ami). we hypothesised that physically inactive patients had a higher mortality risk compared to those who were physically active, regardless of diabetic status. methods: we enrolled n = patients with ami admitted to the coronary care unit of the central hospital in va¨stera˚s, sweden between november and may . all-cause mortality was followed-up until may . the relation between self-reported leisure time physical inactivity during the last year, diabetic status and allcause mortality was analysed univariately using kaplan-meier curves and multivariately using cox regression adjusted for the confounders bmi, prior angina pectoris, prior stroke, smoking, age, sex, education level and immigration status. p-values< . were considered statistically significant. results: a total of n = ( . %) of the ami patients had valid values for diabetics status and leisure time physical inactivity. of these, n = ( . %) died during follow-up. the mortality was significantly different (log-rank test p < . ) between physically active and inactive patients with or without known diabetes (see figure) . notably, physically inactive patients had a higher mortality regardless of diabetic status. after adjusting for confounders, the hazard rate was . (p = . ) for having diabetes and . (p < . ) for being physically inactive. conclusions: physically inactive patients had a higher mortality risk compared to those who were physically active, regardless of diabetic status. medical pharmacology, akdeniz university, antalya, turkey aims: we investigated functional effects of glp- ( - ), glp- ( - ), exendin- ( - ), exendin ( - ) and role (s) of reactive oxygen species (ros) and endothelium-derived hyperpolarizing factor (edhf) in the effects of these agents in small resistance arteries from control and diabetic rats. methods: mesenteric arterial rings were suspended in wire myograph and responses to glp- ( - ) and its analogues were recorded in the absence and presence of ros scavengers; superoxide dismutase (sod, u/ml) and catalase (cat, u/ml). role of edhf in glp- induced responses was investigated in kcl ( mmol/l)-contracted rings following incubation with no synthase inhibitor l-name ( À mol/l) and cyclooxygenase inhibitor indomethacin ( À mol/l). results: glp- ( - ) and glp- ( - ), but not exendin- ( - ) or exendin ( - ) produced concentration-dependent relaxations in mesenteric arteries from control and diabetic rats that were significantly higher in control compared to diabetic rats and in endothelium-intact compared to denuded preparations. incubation of control and diabetic rat mesenteric arteries with cat did not affect responses to glp- ( - ) and glp- ( - ) while, sod caused a significant increase in relaxant responses only in diabetic rats. glp- ( - ) and glp- ( - ) induced relaxations were significantly and similarly blunted by l-name plus indomethacin in control and diabetic rats. we provided evidence about relaxant effect of glp- ( - ) and glp- ( - ) in rat resistance arteries and about the reduced vasorelaxant effect of glp- in diabetic rats. our findings suggested that edhf played a role in glp- -induced relaxations and that increment in certain ros and/or reduction in sod function might play a role in reduced vazorelaxant responses to glp- in diabetic rats. results: significant differences for systolic blood pressure, lipids levels and kidney function between the groups are depicted in table . homa-ir was elevated in both groups, but significantly higher in the diabetic group ( . ae . vs. . ae . ; p < . ). diastolic blood pressure, crp and total cholesterol were not significantly different between the two groups. in the longitudinal group hba c levels decreased dramatically in the diabetes group ( . ae . % vs. . ae . %; p < . ), but less in the normal glucose tolerance test group ( . ae . % vs. . ae . %; p < . ). conclusion: diabetic patients with morbid obesity have a much higher cv risk profile compared with nondiabetic subjects despite presenting with the same bmi and should therefore be the preferred candidates for metabolic surgery since capacities are very limited. objective: morbid obesity (mo) has been shown to be associated with hypothyroid disorders in some patients. we therefore investigated the relationship between thyroid function parameters, bmi and insulin resistance in patients with morbid obesity before and after bariatric surgery. in patients ( . % women) with mo ( ae years; bmi . ae . kg/m ), parameters of thyroid function (tsh, ft , ft ) and homa-ir were determined before and years after bariatric surgery (weight loss À . ae . kg; p < . ). due to the lack of normal distribution, thyroid function parameters were logarithmized for statistical evaluation. results: of the patients, presented with hypothyroidism (tshrange: . - . lu/ml) before surgery, six of them with overt hypotheroidism (ft -range: . - . ng/dl). in the euthyroid patients, tsh decreased from . ae . to . ae . lu/ml (logtsh . ae . vs. . ae . ; p < . ). in the hypothyroid patients, tsh declined from . ae . to . ae . liu/ml (logtsh . ae . vs. . ae . ; p < . ). in the latter, the decline in tsh was more pronounced than in euthyroid patients (p < . ). concordantly, ft concentrations increased by . % (p = . ) and by . % (p < . ) in euthyroid and hypothyroid patients. homa-ir declined from . ae . to . ae . (p < . ) in euthyroid patients and from . ae . to . ae . in hypothyroid patients (p < . ), but did not correlate with the decline in tsh. the improvement of thyroid function after bariatric surgery is not associated with the reduction in insulin resistance. therefore the improvement of thyroid function could independently contribute to the positive long-term effects of this intervention. introduction: some years ago chronic diseases were considered to be a problem of the rich and elderly population. today we know that within high-income countries, poor as well as young and middle-aged people are affected by chronic conditions. for chronic disease, there are a small number of risk factors common to many diseases. the major biological risk factors identified in the world health report are: overweight and obesity, raised blood pressure, raised blood glucose and abnormal blood lipids and its subset raised total cholesterol. objective: was to carry out an epidemiological survey on prevalence of raised fasting blood glucose in kosova. material and methods: according to the who steps methodology the fasting blood glucose in blood sample from finger was measure with accutrend plus on sample of randomly selected participants aged - years. results: according who criteria raised fasting blood glucose is if capillary glucose is more than . mmol/l or more than mg/dl. in kosova, females are in higher risk for diabetes than males (females . % vs. males . %), total . %. prevalence of raised fasting glucose was increased with age. at the age - year the prevalence of raised fasting blood glucose was . %, at age - year . %, at age group - year %, at age group - year was . % and at the age group - year was . %. conclusion: effective preventive interventions are needed, and health systems should prepare to detect and manage diabetes and its sequel. objectives: hypertension and hyperglycemia are features of the metabolic syndrome and diabetes. methylglyoxal (mg), a reactive glucose metabolite, is elevated in diabetic patients. we investigated whether mg induces hypertension and its molecular mechanisms. methods: male week old sprague-dawley rats were treated with mg ( mg/day by continuous infusion with a minipump) for weeks. aortic rings were used for vascular contractility, and other tissues alongwith cultured vascular smooth muscle cells (vsmcs) for molecular studies. hplc, western blotting and q-pcr were used to measure mg, proteins and mrna, respectively. sirna for angiotensinogen and the receptor for advanced glycation endproducts (rage) were used to study mechanisms. results: mg treated rats developed a significant increase in blood pressure, plasma aldosterone, renin, angiotensin (includes precursor and products), norepinephrine, epinephrine and dopamine levels. the aorta showed increased contractility to the a agonist phenylephrine. mg level and protein and mrna for angiotensin, at receptor, a d receptor and renin were significantly increased in the aorta and/or kidney of mg treated rats. treatment of cultured vsmcs with mg or high glucose ( mmol/l) significantly increased cellular mg, and protein and mrna for nf-jb, angiotensin, at and a d receptors, which were prevented by inhibition of nf-jb. silencing of mrna for rage prevented the increase in nf-kb induced by mg. silencing of mrna for angiotensinogen prevented the increase in protein for nf-jb, angiotensin, at and a d receptors. conclusions: mg activates nf-jb through rage and thereby increases activity of the renin angiotensin aldosterone system to cause increased vascular contractility and hypertension. background: guidelines state obesity as an indication for diabetes screening. abdominal obesity is valuable to manifest metabolic risk as much as and may be even more than body mass index (bmi). in this study the answer to "which is a better indicator for diabetes screening; bmi or waist circumference?" has been questioned. method: three hundred people attended to the invitation of diabetes screening in istanbul medeniyet university goztepe research and training hospital outpatient clinics. their demographic characteristics, bmi, waist circumference, fasting blood glucose (fbg), diabetes history and if diagnosed drug regimen were recorded. results: a total of individuals ( women, men) were enrolled. one hundred forty three of ( %) individuals had a bmi ! . among those people ( %) had fbg ! and < mg/dl and (% ) had fbg ! mg/dl (table ) . abdominal obesity was observed in individuals ( women, men). thirty % had known diabetes mellitus (dm). among patients with abdominal obesity and without dm diagnosis, % had dysglycemia (table ) . among obese individuals, % had a history of dm. dysglycemia rate among obese persons without a history of dm, was % (table ) conclusion: abdominal obesity is a strong predictor of diabetes as obesity and its presence should be considered as an indication for screening diabetes. internal medicine and cardiology, expertise centre of aviation medicine of tunis, mhiri, tunisia type diabetes is a rare disease compatible with aviation activity with restrictions and constraints of regular medical checks. this retrospective study was interested in drivers with type diabetes cemeda monitored since until . the aim of this work is to investigate the incidence of diabetes in the tunisian population of seafarers and show the difficulties of management of diabetic driver. sailors have diabetes type (or # %) and three student pilots (two civilians and military) had type diabetes resulting inability final flight. average blood glucose of diabetic patients was . g/l with a range of . and . g/l; glycosylated hemoglobin a c is an average of . % [range: . - . %]. the average age of diabetes is years and mean bmi of kg/m². a mild to moderate hypertension was found in % of diabetics; dyslipidemia was found in two-thirds of diabetics. the treatment of diabetic subjects: rules dietary guidelines were prescribed in only about % of cases. moreover, these measures were associated with treatment with oral antidiabetic (biguanide alone in % of cases; biguanide + pioglitazone in % of cases associated biguanide a sulphonylurea in approximately % of cases. conclusion: : the prevalence of niddm is significantly lower among sailors in the general population. the balance diabetic seafarers is the only guarantor of declining maturity of micro and macrovascular disease and strengthen the doctor′s attitude towards pn medical ethics and flight safety. methods: is a retrospective cohort study that included patients who attended a preventive evaluation unit between and , with at least three visits in that period. results: a total of patients were included, of whom ( %) had nafld at their first visit. the basal variables were similar between groups, with male predominance in the nafld group. high blood pressure and dyslipidemia predominate in the nafld group until visits and respectively. the other cardiovascular risk factors were similar until visit . the study showed a tendency to present high blood pressure, dyslipidemia and gallstones in the nafld group in a shorter period of time than the control group. levels of aspartate aminotransferase raised in a period of . vs. . years in the control group (p = . ). the study was not able to demonstrate a clear difference in the presentation of cardiovascular risk factors and liver function tests in patients with nafld and although there was a higher presentation of gallstones, it requires a larger sample and a longer follow up period to have significant results. objective: to determine the relationship between metabolic syndrome (ms) and exaggerated blood pressure response to exercise (ebp) in adolescents. methods: this cross sectional study was conducted in adolescents ( males, females), randomly selected of high schools, in maracaibo, venezuela. they underwent an exercise treadmill testing. the ms was defined according to the definition of the national cholesterol education program, adult treatment panel iii modified for adolescents. the bp was measured at rest and during the treadmill test (bruce protocol), and it was registered the systolic bp (sbp) in maximal exercise to define adolescents with ebp ( ! mmhg). statistical analysis: chi square test was used to establish associations between ms and ebp. results: the ms prevalence was . % (n = ) in all subjects, . % (n = ) in males and . % (n = ) in females (p: . ). the sbp in maximal exercise values were: . ae in adolescents with ms and . ae in adolescents without ms (p: . ). the prevalence of the ebp was . % (n = ) in all, . % (n = ) and % (n = ) in subjects with ms and without ms, respectively (p: . ). the ms is closely linked to the sbp response to exercise in adolescents. those adolescents with ms are more likely to have exaggerated sbp during exercise, indicating an important information about their cardiovascular risk. background: metabolic syndrome (mets) is a cluster of risk factors that carries a great risk for atherothrombotic events leading to significant morbidity and mortality. few studies evaluated the association between mets and acute stroke. the aim of this work was to study the prevalence of mets and its effect on icu mortality in acute non embolic ischemic stroke patients. patients and methods: we studied patients presented with acute ischemic stroke diagnosed by ct brain in the medical icu, zagazig university hospital for the presence of mets and its relation to age and sex as well as the number of components of mets. we studied also the relative risk of mets with its different components as well as age, sex, glasgow coma scale (gcs) and apache ii score on the mortality in those patients. results: mets was found in . % of patients. it was more prevalent in males ( . %). this prevalence increase progressively in males aged - years then decrease progressively while in females, prevalence increase progressively with age. . % of patients have three components of mets compared to . % with more than three components. the relative risk of mortality was found to be increased with increasing age, male gender, obesity, hyperglycemia, low hdl-c, increased serum triglycerides, lower gcs, increased map, mets per se and higher apache ii score. mets and apache ii score were good predictors of mortality. contrary to the usual approach, we could leave the future open to a bi-therapy associating glp- mimetics and dpp- inhibitors (before the supplementation in metformin and sulfamids or glitazones). case report: diabetes type in balance for years after being treated first with metformin only then added glitazone, to end by glp- mimetics at maximum doses and metformin but still not under control. it was decided to associate glp- mimetics and dpp inhibitor, ending up to a glycemia and insulin . and hba c: . . after stopping the treatment for days we observe: fast glucose , postprandial (on a diabetic diet), relative hypoglycemia generating a multi metabolic syndrome spiral. the increase of the fast glucose being explainable by the non-control of the glucagon produced during the night. pattern proposed: glucagon would not work on demand but time continuously. it has to be inhibited thanks to the glp as soon as the glycemia increases and this would be irrespective of food intake. therefore, there is no reason to use the dpp inhibitors only in case of resistance to endogen glp and let the glp -mimetics being destroyed by the dpp . this would lead to a therapeutic failure or usage of very high doses. we could treat upstream the sequence of energetic metabolism. first of all: glp -mimetics or dpp inhibitors. secondly: glp -mimetics and dpp inhibitors. those steps could be part of tomorrow′s decisional algorithm of type diabetes. abstracts of the th international congress on prediabetes and metabolic syndrome aim: to evaluate the prevalence tipe diabetes mellitus (dm ) and ischemic heart disease (ihd), and diabetogenic/atherogenic factors in patients with newly diagnosed long-term gout material: seventy males - -years (mean ) with untreated tophaceous primary gout - years (mean- ) duration (without renal insufficiency) were studied. uric acid level was fasting serum glucose, insulin (control- - , mean pmol/l), total and hdl cholesterol, triglyceride, bp and ecg monitoring mmol/l, insulin and pmol/l. one more patient, years, with ihd and triglyceride . , cholesterol . mmol/l, insulin pmol/l levels. thus, diabetes was in one and ihd in three patients two patients ( - years) with and years of gout and hyperinsulinemia thus, long-term gout (hyperuricemia) even with concomitant high bmi, insulin, cholesterol and triglyceride levels is not an evident risk factor for diabetes and ihd development. probably, antioxidative effects of uric acid play a role montes claros, brazil background: the leptin receptor is an important regulator of leptin activity and a potential mechanism for the obesity. the polymorphism leprgln arg could be associated with high body fat percentage (bf%) and body mass index (bmi) objective: to investigate the association leprgln arg with obesity indexes we obtained oral swab and anthropometric measures including waist circumference (wc), bmi and bf% for subjects aged ! years. the genotypes were determined by pcr-rflp method. the statistic analyze were carriedout in stata software. results: there were no differences of age average between sex (female . ae . ; male . ae . ). the prevalence of the overweight (bmi > kg/m ) was . %( ), normal, . % ( ) and obesity (bmi > kg/m ) . % ( ). the prevalence of high wc (> cm for women or > cm for men) was . % ( ) and . % ( ) in women and men, respectively (p = . ) and of the high bf% (> % for women and > % for men) was adiposity was not associated with genotypes. the frequencies of overweight were . %, . % and . % and of the obesity were . %, . % and . % in the genotypes aa, ag and gg, respectively. there was not also association for high wc conclusions: these findings suggest that the leprgln arg is not associated with high bf%, bmi or wc in this population hydrogen breath test (bth ), based on lack of source for hydrogen gas in humans other than bacterial metabolism of carbohydrates, is use to detect carbohydrates malabsorption aims: to evaluate the utility of bth in detect carbohydrates malabsorption in overweight-obese subjects. patients and methods: hundred and six consecutive subjects ( overweight, obese; males/ females leptin injection did not suppress ei. importantly, ts treatment reinstalled leptin sensitivity as seeing a significant decrease in ei for h (À %, p = . ) and increase of pstat level (À %, p < . ) in the hypothalamus after i acknowledgements: this work was supported by a grant of the romanian national authority for scientific research, cncs-uefiscdi, project number pn-ii-id-pce- - - ". dr. lixandru, was supported by the postdoctoral program posdru/ / . /s/ , from european social fund. this cluster-randomized controlled trial study aimed to assess the effectiveness of the interactive multi-modality technology (imm) as an intervention to increase self-management among type diabetic patients in a -month period. the imm intervention contained email, short message system (sms), and website with four main functions (i.e., selfregulation, self-monitoring and assessment, social support, and reminder system -linked to email and sms). in this trial, four public offices in bangkok metropolis were recruited and randomly assigned into either the intervention or the control group. one hundred and twenty four thai patients who had met inclusion criteria (hemoglobin a c or a c > . %, no serious illness, and internet and mobile phone accessibility) were subsequently assigned to the intervention (n = ) and the control (n = ) group. patients in the intervention group received the imm intervention. those in the control group received selfmanagement knowledge via email only. outcome measures, a c and behavioral questionnaires (diabetes quality of life, self-efficacy, and division of endocrinology and metabolism, national institute of nutrition, secundrabad, india introduction: we showed earlier that increased visceral adiposity in the offspring of magnesium deficient rats was associated with altered gene expression and increased stress.aim: to assess whether maternal magnesium deficiency modulates the gene expression of adipogenesis and insulin sensitivity in utero due to increased stress.methodology: female weanling wnin rats received for weeks, an ain g diet (control: mgc) or the same with % restriction of magnesium (mgr) and mated with control males. half the pregnant mgr dams were rehabilitated from conception (mgrc) while others continued on magnesium restriction. total rna was isolated from the mgc, mgr and mgrc embryos collected on day of gestation and expression of βhsd , pparc and adiponectin was quantified by real time pcr. body composition was determined in month old offspring by total body electrical conductivity (tobec).results: plasma magnesium levels in mgc and mgr dams before pregnancy; and month old mgc, mgr and mgrc offspring were on expected lines. mgr embryos had significantly higher expression of pparc and βhsd than mgc, whereas adiponectin expression was lower. on the other hand in mgrc th day embryos βhsd and pparc expression was restored to mgc, adiponectin expression introduction: khaya senegalensis is presently used for the treatment of diabetes in some west african countries.objectives: this study was conducted to investigate the anti-diabetic effects of the plant using in vitro and in vivo models.results: ethanolic extract of the root sample of the plant was subjected to solvent solvent fractionation which yielded a butanol fraction that possessed significantly higher (p < . ) anti-oxidative activity as well as a-glucosidase and a-amylase inhibitory activities than other (aqueous, ethyl acetate and dichloromethane) fractions. enzyme kinetic studies indicated that the butanol fraction is a non-competitive inhibitor for a-glucosidase with an inhibition binding constant (ki) of . lg/ml and a competitive inhibitor of a-amylase with a ki of . lg/ml. subsequently, the butanol fraction was subjected to in vivo studies in a type diabetes model of rats. after weeks of intervention, the fraction, at mg/kg bw, was found to improve the feed and fluid intake, body weight gain, blood glucose, glucose tolerance ability, serum insulin concentration and β cell function of diabetic animals. phytochemical analysis of the fraction through repeated column chromatography led to the isolation of bicyclo [ . . ] hexane- , , -triol. the structure of the compound was established through detailed spectroscopic methods including h nmr, c nmr and d nmr (cosy, hsqc and hmbc) experiments.conclusion: data from the study suggests that the butanol fraction of k. senegalensis contains bioactive agents that could be exploited in the management of type diabetes. objective: to determine the progression rate to impaired fasting glucose (ifg), impaired glucose tolerance (igt), and diabetes (dm ) in normal glucose tolerant (ngt) people during years follow up study using who and new criteria of ifg (ifg , -fasting glucose . - . mmol/l).research design and methods: this is an year prospective study in a randomly selected urban population aged ! years living in krakow, poland. persons had ngt. based on who criteria, ( . % of invited, men and women, aged mean . sd = . ) attended the follow-up assessment.. subjects underwent a physical and biochemical examination and questionnaire examination.results: the prevalence of dm , ifg and igt according to who criteria in examined population with baseline ngt was . %, . % and . % respectively. the prevalence of ifg , using new criteria, was . %, lowering cutoff point for ifg caused . % increase in the prevalence of ifg.among people with diagnosed diabetes % had newly diagnosed diabetes during the control study. the prevalence of dm and igt/ ifg was increasing with increasing age and bmi categories (p < . ). the lowest obesity prevalence both baseline and after follow up was found in those who remained ngt.conclusion: in the baseline ngt population high follow-up progression rate to impaired glucose metabolism was found. the implementation of new ifg diagnostic criteria increased the prevalence of ifg by . %. according to our results prevention of diabetes initiatives should focus on normal body weight preservation. results: sbp was found to be elevated in . % subjects whereas dbp was elevated among . % subjects. out of all the subjects, . % were overweight and . % obese. obese subjects were found to be more hypertensive than non-obese subjects (r = . ). sbp had strong correlation with age (r = . ), bmi (r = . ), whr (r = . ), fbs (r = . ), chol (r = . ) and ldl (r = . ) whereas dbp was found to be strongly correlated with same parameters and triglycerides (r = . ) also. no significant correlation was found with hba c levels and hdl-cholesterol. conclusion: hypertension was found to be more prevalent in males as compared to females in this diabetic population. there was an background: the medicine faculty, chiang mai university provided health screening to detect health problem and risk group for high school students who past entrance examination in this academic year . there is no official cutoff value of waist circumference (wc) measured at superior iliac crest level (wci) for overweight and obesity in thai young adolescence. we aimed to determine correlation between wci and to those measured at midpoint between lower costal margin and superior iliac crest (wcm) and to define appropriated wci and body mass index (bmi) cutoff levels for admission students in northern thailand.methods: the admission students had weight (kg), height (cm), wc, and blood pressure measurements.results: there were admission students. . % of them were female. the correlation between wci and wcm was . . for receiver operating characteristics analysis of having high bp (systolic ! mmhg or diastolic ! mmhg.) using wcm of cm in male and cm in female as standard (wcm ), area under curve ( . ) of wci of cm in male and cm in female (wci ) andabstracts of the th international congress on prediabetes and metabolic syndrome all patients were asked to follow a dietary plan for weeks before bth , day before the test, subjects were instructed to take a low fibre diet. bth was carried out both after overnight fasting (t ) and during oral glucose tolerance test (ogtt). hydrogen gas is detected in exhalate, cut-off value was settled at ppm.results: at t bth was positive in % of overweight and % of obese subjects.particularly, bth was positive in % of subjects with ms and in % of those without ms.during ogtt, % of bth results, negative at t , became positive.conclusions: obese subjects with ms had an bth altered value at t suggesting a intestinal dysbiosis.on the basis of our preliminary data, bth at t can be helpful to diagnose gastrointestinal disorders driving the idea of intestinal dysbiosis as a possible cause in pathogenesis of obesity, thus a probiotic supplementation is to be considered as baseline therapy in overweight-obesity. department of clinical physiology and pathology of locomotor apparatus, institute of gerontology ams ukraine, kyiv, ukraine aim of research: to determine uric acid level in blood serum and incidents of hyperuricemia among women and men of different age and their relation with some components of metabolic syndrome.object of research: age of examined patients was from to years old: women (n = ) and men (n = ). they were divided in following groups: i group (bmi = . - . ), ii -(bmi = . - . ), iii -(bmi = . - . ), iv -(bmi > ). average age of examined patients was . ae . years.methods: uric acid level in blood plasma was determined by uricaseperoxidase method. aim: we studied the prevalence and prognostic impact of the metabolic syndrome (ms) in acute myocardial infarction (ami) patients (pts) with normal (ngt) or abnormal glucose tolerance (agt).material and methods: a total of consecutive nondiabetic ami pts performed an oral glucose tolerance test at hospital discharge being categorized using idf/nhlbi/aha ms criteria into four groups (gr): gr. i -ngt no ms (n = ), gr. ii -ngt with ms (n = ), gr. iii -agt no ms (n = ), gr. iv -agt with ms (n = ). clinical characteristics and cv events during . years follow-up were studied.results: ms was diagnosed in % pts, with a higher prevalence in agt vs. ngt subjects (p < . ). ngtms and agtms subjects were more likely to be older (p < . ), women (p < . ), hypertensive (p < . ), have stroke history (p < . ) and hypertriglyceridemia (p < . ) compared to pts without ms. in hospital heart failure rates were higher in gr. ii, iv vs. gr. i, iii (p < . ). agtms subjects showed more often atrial fibrillation and a lower lvef% compared to ngtms (p < . ). cv events incidence during follow-up was similar among groups excepting significantly higher mortality in pts with ms, especially in agtms subjects (rr = . ( % ci . - . ) for ngtms; rr = . ( % ci . - . ) for agtms).conclusions: ms was present in % of nondiabetic ami patients and was associated with high long-term mortality; its incidence and the risk of death increased in the presence of agt. methods: a cross-sectional study was realized in government workers during his medical review, from april to september . the screening included height, weight, waist circumference, blood pressure measurements, plus a blood draw sample to determine glucose, triglycerides, and total cholesterol. body mass index (bmi) was used to diagnose overweight and obesity according to cut-offs proposed by the world health organization ( ). the mets was defined according with aha/nhlbi criteria ( ) . waist circumference (wc) and waist-to-height ratio (whr) were used as fat distribution indexes. all statistical analyses were performed using the spss v .results: in total, workers aged - years, of both sexes ( % males and % females), were included. the overall prevalence of mets was extremely high with % ( % in male, and % in female). abdominal obesity was present in . %, high triglycerides in . %, high-density lipoprotein cholesterol levels in . %, fasting hyperglycemia in . %, and hypertension in . % of the sample. % of the overweight or obese were diagnosed with metabolic syndrome. the prevalence of overweight and obese was extremely high too, according with gender: % in male, and % in female. mets was associated with cigarette smoking, absence of physical activity, a higher bmi and a greater proportion of obesity. the mets prevalence in this sector of mexican government workers is a very serious health problem. it is urgent to develop innovative programs that improve health situation. our rehabilitation department targets obesity and take care of patients a year, either in a outpatient (op, day hospital) or in patient (ip) programme.we focus on therapeutic education, and our approach is medical, nutritional, physical, psychological and social.the aim of our study is to compare the efficiency of the day hospital vs. in patient in the rehabilitation of obesity.two samples of patients who exited our unit months ago were compared.investigated criteria were: loss of weight during the programme, way of life after the programme (physical activities, diet), medical and psychological follow up.the results showed: . a weight loss between the patient admission and the trial date of . kg for in patients vs. . kg for day hospital patients. . the diet prescription is followed by . % of ip patients and by . % of op patients. . the prescription of physical activity was followed by % of ip patients and . % of op patients. . a psychological follow up is done by % of ip patients and % of op patients.the efficiency of the therapeutical education programme is proven in either ip or op patients.the day hospital allows a smooth return to normal life after a nutrition inpatient rehabilitation. research design and methods: a total of asymptomatic t dm subjects ( men and women; mean age: . ae . years) were enrolled. clinical and laboratory parameters, including hba c, glycoalbumin, lipid profile were evaluated and cardiovascular magnetic resonance (cmr) was performed. abnormal findings of cmr were defined as any one of the followings: . silent myocardial infarction. . inducible ischemia. . suspected cad.within days after taking cmr, invasive coronary angiography (ica) was performed in selective patients.results: among patients, a total of patients (silent myocardial infarction (n = ), inducible ischemia (n = ), suspected cad (n = )) had at least one abnormal finding on cmr and ica was recommended. finally, patients underwent ica, and subjects had significant cad (a total of coronary territories assess) overall, in asymptomatic t dm patients, the positive predictive value (ppv) of sp-cmr, cmr-a, c-cmr are %. however, the ppv of each mri to detect signinficant stenosis are %, % and %, respectively. in asymptomatic t dm patients, stress perfusion cmr showed higher ppv than cmr-a. introduction: observational data suggests that low -hyroxyvitamin d is associated with metabolic syndrome in diabetic and non diabetic patients. we examined the difference between components of metabolic syndrome before and after treatment with calcitriol in type diabetic patients with vitamin d deficiency.method and material: a total type diabetic patients were selected. patients had vitamin d deficiency that underwent calcitriol treatment with . lg per day for weeks. in all cases, clinical parameters including weight, systolic and diastolic blood pressure and laboratory parameters including levels of fasting blood glucose, insulin, lipid profile, calcium, phosphorous, hba c and insulin resistance were measured, before and after the treatment period. the two sets of results were then compared with one another.results: following treatment with calcitriol hba c, total cholesterol, ldl, hdl and diastolic blood pressure decreased significantly. (p = . , . , . , . and . respectively). but the changes in other parameters were not significant. subjects and methods: the five components of mets following the criteria of the international diabetes federation (idf) were measured in men (mean age . ae year) and women (mean age . ae . year) participating in the pep family heart study. we determined percentage body fat using skinfold thickness. we defined high %bf > % for females and > % for males and elevated bmi as ! kg/m². spss version was used for the statistical analyses; multiple linear regression models were used. two-tailed p < . was considered significant.results: mean values of wc, blood pressure (bp), fasting plasma glucose (fpg), triglycerides (tg), hdl-cholesterol and bmi were significantly higher in men than in women who had higher %bf ( % vs. %). using multiple linear regression models, we found significant associations with wc, %bf and bmi. bmi had the strongest associations with tg (beta . ; ci % . - . ), hdl-c (À . ; À . to À . ), sbp ( . objective: patients with esrd have an increased risk for cardiovascular morbidity and mortality. metabolic syndrome (metsy) has been implicated in the progression of cardiovascular disease (cvd). this cross sectional study investigated the prevalence of metsy in maintenance hemodialysis (hd) patients using a joint definition for metsy.patients and methods: subjects had to meet at least three of the following five criteria for metsy: elevated waist circumference, elevated triglyceride levels, low hdl cholesterol, elevated blood pressure and elevated fasting serum glucose. demographics, medical history, anthropometric and laboratory data were collected from the medical records. serum chemistries were obtained mid-week and waist circumference was measured twice after a hd session and the mean value was calculated. the study cohort consisted of % male patients with the mean age of . ae . years. hypertension was the leading cause of esrd ( %) followed by diabetic nephropathy ( %). metsy was identified in % of the cohort, with %, % and % having , and risk factors, respectively. the prevalence of metsy was highest amongst patients on hd for > years ( %). for those patients on hd < months, - months and > to < years, metsy was identified in %, % and %, respectively. metabolic syndrome was not associated with gender and age.conclusion: metsy is highly prevalent in hemodialysis patients, which suggests an additional risk for cvd. early screening for metsy may have protective role on cvd morbidity and mortality. department of family medicine, kangwon national university hospital, chuncheon, republic of korea introduction: it was reported decreased relative muscle mass was related with insulin resistance and prediabetes in us. the aim of this study is to investigate the association of relative muscle mass with cardiovascular disease risk factor using the nationally representative sample of korean adults.methods: this is a cross-sectional study using the data of the subjects who participated in the korean national health and nutrition examination survey (knhanes) in - . multiple linear regression analysis for survey design was used to explore the association between relative muscle mass and the factors of metabolic syndrome and homa-ir with adjustment for confounding factors.we also conducted multiple logistic regression analysis for survey design to investigate the relationship of relative muscle mass with metabolic syndrome.results: in comparison with subjects in the first quintile of relative muscle mass, the odds ratio ( % confidence interval) for metabolic syndrome for subjects in the fifth quintile was . ( . , . ) in the age < group and . ( . , . ) in the age ! group respectively after adjusting for confounding variables. relative muscle mass was inversely associated with sbp, dbp, serum tgs, fbs and homa-ir in both age < and age ! group, showing significant liner trend.conclusions: decreased relative muscle mass was inversely associated with the prevalence of metabolic syndrome, and the factors of metabolic syndrome except hdl-c. the causal relationship is not exactly known and would be elucidated through further longitudinal study. endocrinology, moscow regional research clinical institute, moscow, russia background: there has been growth in registered prevalence of type diabetes (t d) in russia. real prevalence of t d is much more higher. new approaches for early detection of glucose metabolism disorders are important.aim: assess effectiveness of new approach to screening of glucose metabolism disorders based on using diabetes bus in remote areas of moscow county. objective: to study the frequency of metabolic syndrome according to the atpiii criteria among elderly people attending the family practice clinic at the jordan university hospital, and to investigate the pattern of antihypertensive medications used for patients with metabolic syndrome.design: a total of elderly people ( males and females) aged years or more attending family practice clinic at jordan university hospital.materials and methods: elderly patients included were studied regarding the frequency of metabolic syndrome and its individual components according to the atpiii criteria. antihypertensive medications used by elderly patients with metabolic syndrome were also investigated.results: the frequency of metabolic syndrome was found to be . %. hypertension was the most frequent risk factor among all patients including males and females ( % in the whole sample, . % in males and . % in females). all risk factors except hypertension were significantly more frequent among patient with metabolic syndrome compared to those with no metabolic syndrome. the most commonly used antihypertensive medications were the angiotensin converting enzyme inhibitors ( . %), followed by beta blockers ( . %), calcium channel blockers ( %), and finally angiotensin receptor blockers and thiazide diuretics (both . %).conclusion: the frequency of metabolic syndrome was relatively high, which highlights the need to take some action to combat the syndrome. hypertension in particular showed the highest frequency among all risk factors. optimum control of hypertension by following the guidelines is essential in this context to better achieve control without adversely affecting the metabolic syndrome out come. introduction: metabolic syndrome is associated with a significantly increased risk of morbidity and mortality.objective: to assess incidence of the metabolic syndrome in patients of the team in the family medicine centre in kalesija through the medical audit.patients and methods: we have analyzed the medical records of all the patients with team with years of age and over ( records).we have used the international diabetes federation and the american heart association (aha) criteria for the definition of metabolic syndrome diagnosis. the analysis is done separately by sex, age and body mass index (bmi). the results of this study shows that ( %) of adults meet the criteria for the metabolic syndrome. of these, ( %) were women and ( %) men. % of patients in age group of - years meets the criteria for the metabolic syndrome. % of patients - years old, and % of patients ages and older, meets the criteria for the metabolic syndrome. out of the total number of female patients who meet the criteria for the metabolic syndrome, % had increased and % had normal bmi. from the male patients who met the criteria for metabolic syndrome, % had increased, and % had normal bmi.conclusion: the incidence of the metabolic syndrome in family medicine is high. metabolic syndrome is prevalent and significantly increased with age and bmi. more effective interventions in primary care are needed in order to reduce cardiovascular morbidity and mortality. methods: after weeks of high-fat diet, dio mice (n = ) were divided into two groups received either intraperitoneal (ip) injection of ts ( mg/kg, daily) or saline for days. another group of mice were fed low-fat diet (lf) as control (n = ). then both dio mice and lf mice were given intracerebroventricular (i.c.v.) injection of leptin or saline. results: ts significantly decreased final body weight gain (À %, p < . ) and average ei (À %, p < . ) in dio mice. ts significantly decreased pro-inflammatory markers (tnf-a, il- , il- β, p-ikk and p-ijba) in epididymal fat, liver and hypothalamus of dio mice. in lf mice, i.c.v. injection of leptin significantly suppressed ei compared to saline injection (À %, p = . ). however, central leptin sensitivity was blunted in dio mice evidenced aim: non-alcoholic fatty liver disease (nafld), which is characterized by the accumulation of fat in the liver in the absence of alcohol intake, strongly linked to metabolic syndrome. recently, proinflammatory cytokines and oxidative stress mechanisms have been implicated in the pathogenesis of psychiatric disorders. in addition, patients with drug-free schizophrenia have significantly higher body mass index than in aged-matched healthy controls. the purpose of the study was to investigate the effects of metabolic syndrome on the apomorphine-induced stereotypy in a rat model of nafld.materials and methods: eighteen male sprague-dawley rats were included in the study. in order to develop nafld model, rats (n = ) were provided with drinking water containing with % fructose for weeks, while control group (n = ) received only tap water. after the verification of fatty liver by ultrasonography, apomorphine-induced stereotypy was investigated as described by kenneth and kenneth ( ) . then, all rats were sacrificed; homovanillic acid (hva), a dopamine metabolite, levels were measured in brain homogenates. prefrontal cortical il- immunoexpression was evaluated by immunohistochemistry and hepatocellular changes were determined histologically.results: histological evaluation of liver sections confirmed macrovesicular steatosis in nafld rats. moreover, the stereotyped behavior scores, brain hva levels and il- expression were found significantly higher in nafld group than in the control group (p < . ). our results suggest that metabolic syndrome and fatty liver significantly induce dopaminergic activity and stereotyped behavior in rats. the neuromodulatory effects of pro-inflammatory cytokines and imbalance between oxidative and anti-oxidative status may underlie these alterations. the classical thinking in type diabetes is that the plasma glucose levels are regulated by interplay between insulin, glucagon and other peripheral mechanisms. a combination of insulin resistance and relative insulin insufficiency is considered to be causal to hyperglycemia. this traditional wisdom is now being challenged and an alternative model is proposed where the central nervous system (cns) plays a vital role in plasma glucose regulation. the role of cns in glucose regulation is well known. for example it has been shown that intracerebroventricular injection of glucose results in a decrease in plasma glucose level in rats. however whether and to what extent the cns has an active role in diabetic hyperglycemia is not known. we make mathematical models of different versions of the peripheral and central mechanisms and make differential correlational predictions which can be tested on oral glucose tolerance test ( background and aims: high calorie diets leads to fat liver and changes in the metabolic pathways. therefore the gluconeogenic capacity of the livers in a condition of high levels of exogenous fatty acids was evaluated in cafeteria-fed rats.methods: two groups of weaned wistar rats received cafeteria or balanced diet during days. the fasted livers were perfused with mmol/l lactate plus . mmol/l pyruvate in absence or in presence of mmol/l stearate plus traces of [ - c]-stearate. measured parameters: glucose, ketone bodies, [ c]co , oxygen uptake, hepatic contents of lipids and glycogen.results: cafeteria-fed rats presented increase in: body and liver weight, fat in the tissues and hepatic glycogen. perfusion experiments revealed that in cafeteria-fed rats the gluconeogenic flux was lower than in the control, but the infusion of stearate, caused a higher stimulus on glucose production. the co and ketone bodies production was reduced during the active gluconeogenesis in cafeteriafed and control rats, being the former less sensitive, whereas no differences were found after stearate infusion. background: despite advances in option of treatement diabetes, optimal glycemic control is not often achieved. glucose homeostasis is dependent on a complex interplay of multiple hormones and glucagon like peptide- (glp- ) receptor agonists are a new class of drug for the treatment of type diabetes. they are not considered as initial therapy for the majority of patient with type diabetes and their clinical use, long-term benefits, risks and their role in combination with other diabetes medication are still under investigation.study: in the retrospective study in we enrolled patients with poorly controlled type diabetes on one or two oral agents, who received additional therapy with glp- receptor agonist: liraglutide or exenatide. we monitored hba c value and body weight before and after modification of therapy.results: fifty-one patients, men, were - years old (mean years). their mean body weight was . kg (sd ae . ) and mean hba c . % (sd ae ). after - months of combined therapy with metformin and/or sulfonylurea and glp- agonist their mean hba c dropped to . % (sd ae . ) and their body weight reduced to . kg (sd ae . ). in patients with type diabetes and suboptimal control on one or two oral agents adding glp- receptor agonist was effective in improving glycemic control and body weight reduction. despite lack of evidence on their clinical use, long-term benefits and side effects these agents have the potential to change the diabetes treatment by replacing traditional secretagogues because of superior control and association with weight loss. objective: the metabolic syndrome (ms) is a particular affection that has been associated with so many factors such as hypertention. both increase cardiovascular diseases. due to the higher prevalence of hypertension in our country, this study aim to determine the frequency of ms in newly diagnosed hypertensive patients in oder to improve the follow -up of these subjets.methodology: over a period of months, we conducted a crosssectional and descriptive study on patients recently diagnosed as hypertensive for < months. the selection of patients was done during external consultation in the cardiology unit at the university teaching hospital of yaounde. it was based on high blood pressure, anthropome´tric parameters such as weight, bmi, waist, abdominal circonference and biological values (lipid profile, blood glucose, uric acid). we identified patients aged between and years, with a mean age of years. people aged more than years were mostly affected. stage was the prominent stage of hypertension.the prevalence of metabolic syndrome was . % with a higher rate in female.the cardiovascular risk factors were obesity, alcoholism, sedentarity and hypo hdlc factors differenciating population with metabolic syndrom was obesity (p = . ), hyperglycemia (p = . ), hypo hdlc (p = . ) while the phenotypes most represented were hyperglycemia, abdominal obesity and hypo hdlc respectively. the metabolic syndrome is frequent in newly diagnosed hypertensive subjects; the females were most affected. metabolic syndrome should be investigated systematically in all hypetensive patients. background: although mainly inhibits osteoclastogenesis, osteoprotegerin is produced by vasculature too. serum opg (sopg) is elevated in both diabetics and patients with coronary artery disease (cad) but there are still insufficient data for its concentrations in impaired glucose tolerance (igt) subjects. aims: to determine sopg in males with igt and concomitant cad and to investigate its relationship with certain glucometabolic parameters.materials and methods: sopg was measured in males with performed percutaneous coronary interventions for cad- with igt and normoglycemic, and in age-and bmi-matched healthy normoglycemic controls. glucose abnormalities were screen-detected using a standard ogtt. mean intima-media thickness (imt) of common carotid arteries was measured by b-mode ultrasonography. opg was measured by elisa.results: sopg was significantly higher in igt patients compared to controls ( . ae . vs. . ae . pmol/l; p = . ) but did not differ between igt and normoglycemic cad patiens ( . ae . vs. . ae . pmol/l, p = . ). in all participants, sopg correlated positively with imt (p . ; pr . ). similarly, in igt males with cad, sopg correlated only with imt (p . ; pr . ). there were no associations with fasting and postchallange plasma glucose, hba c, fasting insulin, homa-ir, lipid parameters, blood pressure, bmi or waist circumference. we found higher sopg in males with igt and cad compared to the controls. opg did not correlate with glucose parameters but rather with markers of atherosclerosis. we speculate in cad patients with igt, the increased sopg might reflect the vascular damage and not glycemic status which requires further investigations. internal medicine, umf iuliu hatieganu cluj-napoca, cluj-napoca, umf 'victor babes' timisoara, timisoara, romania objective: the pro ala polymorphism in the pparg gene (c>g) is associated with less weight loss after treatment for obesity. this study aimed to investigate the association of rs polymorphism with weight loss year after bariatric surgery. the sample was composed of individuals with grade iii obesity undergoing roux-en y gastric bypass. anthropometric data were collected in the preoperative period and year after surgery. genotyping was performed by the method of allelic discrimination in real time pcr (polymerase chain reaction) using the taqman predesigned snp genotyping assays kits (applied biosystems, foster city, ca, usa). individuals with at least one variant allele were grouped and compared with those with the reference genotype.results: subjects ( . % females, mean age . ae . years) participated in the study. genotyping showed % (n = ) of individuals homozygous for the c allele (c/c) and % (n = ) heterozygous (c/g). there was no homozygous mutant (g/g). individuals with the c/c and c/g genotypes respectively showed a loss of . ae . and ae . kg; . ae and . ae . % of initial weight and . ae and . ae . % of excess body weight. there was no difference in weight loss between groups.conclusion: the pparg pro ala genotype seems to have no association with weight loss year after bariatric surgery. objective: evaluated determine the prevalence of ir, ms and associated factors among banking workers in southeastern brazil.methods: out of males and females banking employees, years old were evaluated by cross-sectional study including demographic, biochemical, anthropometric and hemodynamic. the ms was determinate by ncep and idf. the ir was determined by homa-ir, with the cut off > . .results: ( . % % ci . - . ) and ( . % % ci . - . ) of employees with ms, according to the ncep and idf, respectively and ( . %) with ri. the likelihood of developing the syndrome is greater in individuals with high level of education (or . ( % ci . - . ) and among those with overweight and obesity, the possibility of having ms is , ( % ci . - . , p = . ) and . ( % ci . - . , p = . ) times over, respectively. persons who are overweight are at risk of . ( % ci . - . ) times more likely to have elevated homa, and among those who are obese, the risk rises to . ( % ci . - . ).conclusion: this study showed the higher number of employees who have similar characteristics of the total active working, that despite high education, also have ms and ir, and the consequent risk of developing cardiovascular disease. prediabetes is considered as a strong risk factor for type diabetes (dm ). tcf l is a gen involved in dm susceptibility related with glp-l. objective: study the relationship of rs and rs variants of the tcf l gene with insulin levels, c-peptide and glp- in normoglycemia and prediabetes subjects. we included pre-diabetic and normoglycemic subjects. we measure fasting glucose, lipids, insulin, c-peptide and glp- ). insulin resistance and beta-cell function were calculated with the homa model. tcf l polymorphisms rs c/t and rs g/t were determined by pcr-rflp. for analyses two groups were compared: wild-type and carriers of two allele risk. we included a total of subjects aged ae years. weight, bmi, systolic and diastolic blood pressure and triglycerides were significantly lower in the group of healthy subjects. glp- was higher in normoglycemic subjects. the frequency of rs t allele was higher in pre-diabetic subjects, while the allele frequency of rs t was not significantly different between the groups. in carriers of rs t, serum insulin and homa-beta were significantly higher. plasma levels of glp- were lower in prediabetic subjects with and without the risk allele variant. in prediabetic subjects carriers of the rs g/t or tt had also lower levels of serum insulin, homa-ir and homa-beta. the glp- concentrations were lower in both groups.conclusions: in this work the rs polymorphism tcf l gene was associated with prediabetes. the frequency of the rs t allele tcf l gene was not different between groups. objective: determine hba c, igfbp , fgf and other metabolic markers in non-diabetic, prediabetic, type diabetics (t dm) of recent diagnosis. material and methods: a cross-sectional population based study was carried in - years old subjects classified with fasting glucose (fg) and after h g oral glucose load (gt), as normal with impaired fg (ifg), impaired gt (igt), with both alterations (ifg/igt) and dm . after - weeks subjects were re-classified and registration of anthropometric data, food intake and determination of a c, lipids, insulin, fgf and igfbp .results: we found . % for prediabetes and . % for dm (n = ). in the re-classification we classified: normal, ifg, igt, ifg/igt, dm . with anova analysis we found that hba c in dm patients was different from normal, ifg, ifg/igt subjects (p < . , p < . and p < . respectively). fgf levels was different among all groups (p < . ). normoglycemic subjects were better educated and had higher income than the prediabetic and dm subjects. dm subjects reported more screen time. prediabetic subjects had higher hdl-cholesterol. with multiple regression analysis we found igfbp positively correlated with daily caloric intake and triglycerides and negatively with bmi. the fgf correlated positively with insulin. the prevalence of pre-diabetes is more than twice of that of undiagnosed diabetes. we find fgf and insulin related with the metabolic status. igfbp was negatively correlation with bmi finding compatible with an association with insulin resistance. we have previously found that the expressions of several homeobox transcription factors, including irx , were reduced in subcutaneous fat in human obesity. a knock-out (ko) mouse line was acquired for the purpose of investigating the in vivo effects of irx deficiency with the main perspective on how these mice would handle a high-energy dietary intake. though initially undersized, male irx ko mice fed a high-fat ( %) diet approached similar weight and size as their wildtype (wt) littermates. yet, mri show that the irx ko mice have smaller adipose tissue depots and store less fat around organs in aim: to examine the role of mir- in the pathogenesis of diabetic cardiomyopathy.objectives: to study the cardiac expression of mir- and its effect on regulation of genes involved in akt-pkb signalling pathway in animal model of diabetic cardiomyopathy (dcm).methods: type diabetes was induced in adult wistar rats by high fat diet and i.p streptozotocin injections. the animals were sacrificed at weeks and development of cardiomyopathy was confirmed by heart/body weight ratio, histopathological examination, myocardial fibrotic and hypertrophic genes. cardiac tissues were examined for expression of mir- , its target genes by real time pcr.results: myocardial expression of mir- was significantly increased and showed a positive correlation with myocardial mrna levels of fibrotic genes (ctgf, fgf-b & tgf-b) in diabetic rats. myocardial mrna levels of potential targets of mir- , phosphatase and tensin homolog deleted on chromosome (pten) and programmed cell death protein (pdcd- ), were increased and their protein expression was decreased in dcm group and in fibroblasts exposed to high glucose (p < . ). increasing mir- levels promoted, whereas knocking down mir- attenuated, pten, pcdc- activity in cardiac fibroblasts. our results suggest that mir- contributes to cardiac fibrosis in dcm by modulating activity of akt/pkb pathway through pten and pcdc- . objectives: many studies have revealed that prevalence of metabolic syndrome may be related to lifestyle components. the aim of this study was to investigate the influence of dietary patterns on prevalence of metabolic syndrome (mets). the data was based on health and nutrition survey for japanese men and women aged - year. factor analysis was used to obtain dietary patterns applying to intake of food groups. the definition of mets was followed by the modified version of the criteria of idf that is applied to japanese population. values of waist circumference, hdl-cholesterol, blood pressures, and hba c were used to identify mets. logistic regression analysis was used to examine the association between dietary patterns and prevalence of mets.results: three dietary patterns of "fruits", "rice", and "meat" were identified. in males, greater values of "fruits" pattern was associated with a significantly lower prevalence of mets after adjustment for age, physical activity level, smoking and drinking status and other confounding variables (or = . , % ci . - . ).conclusions: fruits consumption was inversely associated with mets and this association may be explained by much intake of mandarin orange specific to this surveyed population. this finding necessitates further investigation on the mechanisms of fruits consumption on health benefits. introduction: the impaired glucose regulation shows a double risk of cardiovascular morbimortality and development of type diabetes, especially in patients with high cardiovascular risk.objective: identify the carbohydrate abnormalities in unknown diabetic patients with high cardiovascular risk.patients and methods: hundred and forty-eight non-diabetic patients were involved in this single-center study, with at least three known vascular risk factors, metabolic syndrome or with known cardiovascular event over months.all had a test load of g oral glucose (ogtt) followed by h after dosing plasma glucose, serum glycated hemoglobin (hba c) and lipid abnormalities exploration. cardiovascular exploration also concerned all patients.results: among these patients, were in primary prevention and in secondary prevention. cardiovascular events were reported to be dominated by myocardial infarction ( . %) and stroke ( . %).dysglucoregulation concerned patients ( %); the sex ratio was . and the average age was , . unknown diabetes, ifg and igt were diagnosed.these glucose abnormalities were found equally in both primary and secondary prevention.in the family, diabetes was concerned with % and cardiovascular events mainly expressed by early myocardial infarction and stroke were observed in %.the vascular risk factors were more present in igt group.hypertension was found in %, followed by dyslipidemia in %; % met metabolic syndrom's criteria (idf ) .conclusion: in primary prevention context, ogtt not only detects unknown diabetics but identifies igt patients who dysplay a high risk of cardiovascular events. the aim was to study some indicators of inflammatory process and oxidative metabolism in the patients arriving for surgical treatment of pathological obesity. laboratory tests have been carried out by conventional methods in patients with pathological obesity of abdominal type with a body mass index > kg/m before and after biliopancreatic shunting operation.rise of blood glucose level up to . % (p < . ), uric acid level up to . % (p < . ), as well as dyslipidemia were determined in patients. the content of malondialdehyde (mda) increased . times, the general antioxidant activity (aoa) decreased . times. concentration of c-reactive protein (crp) exceeded . times the control value. the long-term results in these patients within - months have shown normalisation of level of blood glucose, uric acid, high and very low density lipoprotein cholesterol, a tendency of decrease in the general cholesterol concentration. triglycerides decreased by %, still remaining at sufficiently high level. mda concentration decreased by . %, aoa increased by . %. crp level which was considerably raised before operation decreased within the next months but in months its average value increased five times in relation to normal rate.the obtained results are evidence of the interrelation of inflammation process and oxidative stress in patients with pathological obesity and metabolic syndrome. efficiency of surgical treatment was shown in the insulin resistance syndrome includes well-recognized cardiovascular risk factors such as low hdl levels, hypertension, hypertriglyceridemia, which is highly correlated with small dense ldl and increased lp(a) levels, which is cardiovascular risk factor. we aimed to study dyslipidemia, especially lp(a) level in addition to carotid intima media thickness (ca-imt) as a marker of atherosclerosis in normal and impaired glucose tolerance offspring of type dm. subjects were included and divided into two main groups; group(i) apparently healthy subjects with no family history of diabetes mellitus, as control group, group(iia) non diabetic offspring of type dm with normal glucose tolerance and group(iib) non diabetic offspring of type dm with impaired glucose tolerance. a statistically significant increase in mean ae sd of serum level of lp(a) and ca-imt in non diabetic impaired glucose tolerant offspring of type diabetes as compared to non diabetic normal glucose tolerant group, significant positive correlation between lp(a) and ca-imt vs. each of ldl-ch, triglycerides and cholesterol. also, a significant positive correlation between lp(a) and ca-imt and hdl-ch. in non diabetic impaired glucose tolerant offspring of type diabetes as compared to non diabetic normal glucose tolerant group. in conclusion the increase in serum level of lp(a) and increase of ca-imt in non diabetic offspring of type dm were associated with increasing severity of insulin resistance and increasing the degree of atherosclerosis explaining the high prevalence of cardiovascular diseases in subjects who are genetically prone to the development of diabetes. a. kostrzewa-tarnowska, m. człapka-matyasik, m. fejfer, j. jeszka weight loss can be achieved by any means of energy restriction, but the challenge is to achieve sustainable weight loss and prevent from weight gain without increasing the risk of chronic diseases. conventional high carbohydrate diets, even when based on wholegrain foods, increase insulinemia and may compromise weight control via mechanisms related to appetite stimulation and metabolic rate. the success of low fat diets has given a push for researches on alternative dietary strategies, including high content of bioactive compounds and low glycemic index (gi) diets.the aim of this study was to determine if high content of bioactive compounds using capillary blood sampling lead to any significant difference between the gis of the products mentioned. investigated group consisted of healthy people with normal weight, aged ae years (bmi . ae . kg/m ).foods with a low gi produce a lower peak in postprandial glucose and a less overall blood glucose increase during the first h after consumption compared with foods with a high gi. studies have shown that bioactive products lead to increased satiety, delayed return of hunger, and decreased food intake after ingestion of low-gi compared with high-gi foods.low-gi products may also play an extensive role in weight loss. this strategy can be associated with reducing total energy intake, modifying the macronutrient composition of the diet and lower postprandial glycaemia.research funded within the framework of the project po ig . . . - / . physiology, school of medicine, national university of ireland, galway, ireland introduction: current diagnostic criteria for type diabetes mellitus rely on increased blood glucose concentration following an oral glucose tolerance test (ogtt) or increased glycated haemoglobin. changes in these parameters occur long after insulin resistance manifests as plasma glucose concentration is homeostatically defended. in contrast, glucose oxidation measured by the c-glucose breath test ( c-gbt) is reduced as a direct consequence of insulin resistance. it is important to establish normative data and define the reliability of any diagnostic or scientific test therefore the aim of this study was to determine the reliability of the c-gbt as a diagnostic tool for type diabetes.methods: sixteen apparently-healthy controls { . ( . ) yrs, . ( . ) kg, . ( . ) cm, all data mean (sd)} underwent simultaneous ogtt and c-gbt on two separate occasions following a h overnight fast. mixed capillary blood and breath samples were collected at baseline and every min for h following ingestion of a . g glucose solution (shamrock, ireland) labelled with . g - c glucose.results: mean baseline co was . ae . delta viennapeedeebelemnite (d-vpdb) and peak co was À . ae . d-vpdb. fasting and h mixed capillary glucose concentrations were . ae . mmol/l and . ae . mmol/l respectively. per cent dose recovered c had a cronbach's alpha of . , while fasting and h glucose concentration were . and . respectively. we established normative data for the c-gbt. the c-gbt is a reliable test of whole body glucose oxidation which has the potential to be developed as a diabetes diagnostic test. introduction: outcome studies in morbidly obese patients (mo) have shown that diabetic patients have the highest benefit from bariatric surgery interventions. therefore it was of interest to study a variety of cardiovascular risk factors in a very large group of patients with mo (n = ), who were investigated in our center. we included patients with mo, of whom . % (n = ; mean hba c . ae . %) were diabetic. in a subset (n = ), patients were followed up years after bariatric surgery of whom . % (n = ) were diabetic. all patients without manifest type diabetes underwent a g oral glucose tolerance test, insulin levels were assessed, homa-insulin resistance (ir) was calculated. diabetes was diagnosed after ada criteria. apart from that demographic, cardiovascular risk-markers (blood pressure, lipids) renal and inflammation parameters were assessed. background: obex â is a dietary supplement to help lose weight. in addition, this supplement is specifically made with natural antioxidants molecularly activated to enhance their biological properties without altering their molecular structure.objectives: the purpose of this study was to evaluate the effect of obex â on anthropometric measurements and metabolic disorders in overweight and obese subjects. this was an open label pilot study conducted with overweight and obese adults (bmi > kg/m and < kg/m ), aged between and , who took obex â (without changes in lifestyle), at a dose of two sachets before the two main meals of each day for months. in addition to anthropometric measures and blood pressure, fasting plasma glucose, lipid profile, insulin, creatinine and uric acid were determined. insulin resistance by homa-ir and betacell function by homa-b were assessed. three indirect indexes were used to calculate insulin sensitivity.results: compared to baseline, obex â significantly reduced body weight (p = . ), body mass index, waist circumference, waist/hip ratio, waist/height ratio (p < . , respectively) and conicity index (p = . ). there was also a reduction in fasting glucose levels. compared to baseline, the use of obex â improved insulin secretion (homa-b) and hdl-c concentration (p < . ). no adverse effects were seen in any of the participants during the pilot study.conclusion: short-term treatment with obex â improved visceral and abdominal obesity, as well as ameliorating levels of select markers of metabolic disease risk in overweight and obese adults, indicating that further studies are warranted. methodology: a descriptive cross sectional study was conducted with families. the sample was family members (partner, offspring, blood family members and not family related individuals-all living in the same house). body mass index (bmi), lipid profile and glucose measured. also, the family functionality (ff) and perceived health status (phs). results: age mean was . years (sd, . ); female ( . %) and males ( . %). the rf were analyzed by the role in the family. seventy-five percent of the housewives were overweight, with high levels of glucose ( . %), cholesterol ( . %), triglyceride ( . %) and low hdl ( . %). husbands had overweight ( %), with high levels of glucose ( . %), cholesterol ( . %), and triglyceride ( . %). the children aged between and years, had glucose and cholesterol normal, but were overweight ( . %), and had high level of triglyceride ( . %) as well as low hdl ( . %). additionally, children and parents had only - portions of vegetables intake in - days in week; similarly . , had - portions of fruits or juice, but only - days by month. family functionality was reported with a mean of . (sd, . )- - scale and . (sd, . ) in phs. the family members in the ua are at high risk for developing dt . among them are underscored obesity, high levels of lipids, low consumption of vegetables and fresh fruits. ff and phs are also risk factors in these families. this study designed to compare the effect of three dietary oils: canola, rice bran and grape seed on lipid profile and paraoxanase activity of hyperlipidermic rats. method: hyperlipidemia was induced in wistar male rats by atherogenic diet. once hyperlipidemia was reached, the rats were randomly divided in four groups of animals according to the treatment received. treatment groups were fed canola, rice bran and grape seed oil for weeks. control rats fed regular rat chow diet which contains corn oil. baseline fasting blood lipid profile and paraxonase activity of experimental and control rats were compared at the beginning and at the end of the experiment.result: after -weeks of treatment, a significant decrease was found in serum triglyceride, total cholesterol and ldl-c concentration of rice bran and grape seed oil fed rats (p < . ), serum hdl-c concentration also increased significantly (p < . ). canola oil fed rats showed a significant decrease in total cholesterol, and triglyceride level and an increase in paraoxanase activity (p < . ), however, no significant differences were found in ldl-c and hdl-c concentration. the present study suggest that consumption grape seed, canola and rice bran oil may have beneficial effect on serum lipid profile, but in comparison of the tree dietary oils grape seed oil showed more beneficial effect in reducing hyperlipidemia. key: cord- - s gnxs authors: tee, augustine k.h.; oh, helen m.l.; hui, k.p.; lien, christopher t.c.; narendran, k.; heng, b.h.; ling, a.e. title: atypical sars in geriatric patient date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: s gnxs we describe an atypical presentation of severe acute respiratory syndrome (sars) in a geriatric patient with multiple coexisting conditions. interpretation of radiographic changes was confounded by cardiac failure, with resolution of fever causing delayed diagnosis and a cluster of cases. sars should be considered even if a contact history is unavailable, during an ongoing outbreak. the patient was a -year-old singaporean chinese woman who was a resident of a nursing home. she had a past history of vascular dementia with dysphagia and behavioral abnormalities, ischemic heart disease with atri-al fibrillation, and congestive cardiac failure. in addition, she also suffered from type diabetes mellitus, hypertension, osteoporosis, bilateral osteoarthritis of the knees, and an old traumatic fracture of the left humeral neck. as such, she was fully dependent in her daily activities. she was admitted to the geriatric department of tan tock seng hospital ( ) on march , , for pneumonia and urinary tract infection. these infections responded to a course of intravenous antimicrobial drugs. she also was assessed to have mild dysphagia, which required thickened fluids and blended diet without nasogastric feeding. her chest radiograph before discharge showed persistent bilateral lower zone consolidation (figure ), consistent with bilateral crepitations on auscultation. however, the patient was afebrile and improved functionally to being ambulant with assistance. she was discharged to the nursing home on march . within the next two days, the patient progressively became breathless, with nausea and vomiting. there was no associated cough or diarrhea. she was eventually admitted to the medical department of changi general hospital, a designated non-sars hospital, on march . on admission to the isolation room, she had a maximal tympanic temperature of . °c, with defervescence the next day. she remained afebrile during the remainder of her stay. her blood pressure was / mm hg, pulse rate of beats per minute, and respiratory rate of breaths per minute. her pulse oximetry was % while on l per minute of intranasal oxygen. the jugular venous pressure was not elevated. bilateral basal crepitations were heard on examination. all healthcare workers attending to the patient wore the recommended personal protective equipment, including gown, gloves, and n respirators, each time they entered the isolation room. investigations on admission showed that the patient's hemoglobin was . g/dl, leukocyte count was , /mm ( . % polymorphs, . % lymphocytes), and platelet count was , /mm . the serum urea was . mmol/l; serum potassium, . mmol/l; serum sodium, mmol/l; and creatinine, µmol/l. the liver function tests showed a total bilirubin, . µmol/l; serum albumin, g/l, serum alkaline phosphatase, µ/l; serum alanine transaminase, µ/l; serum aspartate transaminase, µ/l. her creatine kinase was µ/l, and c-reactive protein was elevated at . mg/l. she was diagnosed to have aspiration pneumonia, and intravenous ceftriaxone and metronidazole were prescribed. her chest radiograph showed infiltrates in the right lower zone. her urine, sputum, and blood cultures did not yield any bacterial growth. serologic testing for mycoplasma, legionella, and chlamydia and nasopharyngeal aspirate for common viral antigens were not performed, as clinical suspicion was low. she was subsequently transferred to the geriatric unit. her condition improved, and she was placed in the general ward on march . no protective equipment was used by staff attending her in the general ward. it was ascertained that she was previously admitted to a non-sars ward in tan tock seng hospital. however, on march , the patient became restless and more breathless. a repeat chest radiograph ( figure ) confirmed congestive cardiac failure. her repeat leukocyte count was , /mm ( . % polymorphs, . % lymphocytes), and the platelet count was , /mm . there was mild hyponatremia ( µmol/l) and worsening c-reactive protein levels ( . µg/l) but a stable creatine kinase ( µ/l). intravenous diuretic therapy was instituted, but in view of her poor premorbid functional status, the patient was not intubated or moved to in an intensive care unit. she went into respiratory failure and died on march . death was certified as being caused by pneumonia, with a contributing factor of ischemic heart disease. no autopsy or postmortem specimens were taken. in the week after the patient's death, a cluster of cases of atypical pneumonia surfaced, all of which could be traced to this patient. pneumonia developed in the patient's daughter-in-law, who had visited her in the hospital, and two grandsons living in the same household as the daugh-ter-in-law. another son-in-law, who met this daughter-inlaw during the funeral, also contracted a respiratory illness. a healthcare worker, who was unprotected while caring for the patient, was also admitted to changi general hospital for severe pneumonia. he was later transferred to tan tock seng hospital where he was diagnosed with sars. he required prolonged mechanical ventilation and eventually died of the illness. a female hospital cleaner in changi general hospital, who cleaned the room and tidied the patient's bed in the general ward, became symptomatic days after the patient died. she was admitted to changi general hospital days later and was transferred to tan tock seng hospital the next day. her husband was subsequently admitted to tan tock seng hospital with sars. all cases in the cluster had fever as a presenting complaint. on the basis of epidemiologic data (contact tracing linking her to one of the three original index cases in singapore) ( ) , the index patient's cause of death was determined to be sars (figure ). serologic testing for sars-cov by using enzyme-linked immunosorbent assay (elisa) techniques on various specimens during admission for febrile illness were positive at titers of to , for all patients within the cluster except the patient's daughter-in-law and the healthcare worker from the nursing home. since the issue of a global alert on atypical pneumonia by the world health organization on march , reported cases of sars increased daily and appeared in other countries, including canada, the united states, europe, and africa. the first three cases in singapore were reported on march . these cases were traced to a doctor from guangdong who infected guests at a hong kong hotel ( ) . the clinical features of sars are fairly nonspecific with a body temperature of > °c, occurring in % of patients, being the most sensitive feature in all the case series published thus far, ( ) ( ) ( ) . other symptoms described thus far have included nonproductive cough, dyspnea, malaise, diarrhea, chest pain, headache, myalgia, and vomiting. we describe here a fairly complicated atypical signs and symptoms of sars in an elderly patient. the patient had a fever, which responded to a course of broad-spectrum antimicrobial drugs, thus behaving in a manner not much different from a typical community-acquired pneumonia. the absence of fever during the final course of the patient's hospitalization could have been caused by an altered immune response in the geriatric age group, with a resulting normal leukocyte count. furthermore, prior usage of antimicrobial drugs and possible aspiration from dysphagia may further complicate detection of the disease. the suspicion of sars in this case was thus low before eventual epidemiologic links were established retrospectively. dyspnea is a common symptom reported previously, ranging from % to % of patients. cough has also been noted in % to % of cases in previous studies ( , ) . however the absence of cough, especially in the elderly, could be due to an underlying weak cough reflex. vomiting, though present in our patient, was only accounted for in % of cases in the canadian series ( ) . in a frail older person, this could also be caused by a number of circumstances. our patient had characteristic lymphopenia, which was seen in about % of reported cases. in addition, she also had mild hyponatremia and elevated c-reactive protein. however, thrombocytopenia, elevated transaminases, or raised creatine kinase levels were absent. serial chest radiograph progressed from a predominantly right lower lobe patchy consolidation to a radiographic picture of congestive cardiac failure. reports from sars cases have described mainly basal lung opacities, without any pleural effusion. an underlying poor cardiac function may masquerade the true picture of the air space disease characteristic of sars, especially if the stress of infection decompensates left ventricular ejection fraction. this radi-ologic interpretation could potentially mislead clinicians and lead to more patients, family members, and healthcare workers becoming infected. in addition, a bimodal pattern of time to deterioration of clinical symptoms has been previously reported ( ) . the information currently available on transmission of sars has been attributed to respiratory droplets from close contact which has been defined by who to be having cared for, having lived with, or having direct contact with respiratory secretions or body fluids of a patient known to be a suspected sars case. as the patient lived in a nursing home, the brief social contact during visits by family and friends, may prove sufficient for transmitting the virus. furthermore, the issue of possible coinfection and the influence of coexisting conditions have not been thoroughly investigated, which may change the clinical picture of sars so as to conceal detection. uncharacteristic clinical signs and symptoms, without any travel or contact history, are difficult to recognize. our case serves to highlight atypical signs and symptoms of sars, especially the resolving fever, delay in establishing a positive contact history, and the nonspecific chest radiographic appearance that could be affected by concurrent coexisting conditions, such as cardiac failure. we wish to draw attention to clinicians, so that a high level of suspicion is present as the sars-cov is highly contagious and can cause severe disease. we observed that despite being cared for in the general ward by staff without full personal protective equipment, only one healthcare worker in changi general hospital was infected. this observation supports the hypothesis that the virus may not transmit effectively under certain conditions. nevertheless, late diagnosis may lead to large clusters, as delayed isolation of suspect cases increases the risk of onward transmission in the community ( ) . a positive contact history may not be obvious, particularly in patients with cognitive impairment, until retrospective analysis is done. there is thus a need for continued surveillance of fever and clusters of pneumonia cases to improve the chances of early detection. nonetheless, with the imminent availability of accurate and rapid diagnostic tests, there is hope that the diagnosis of sars can be made with more certainty. this could be further enhanced by a revised case definition. coronavirus as a possible cause of severe acute respiratory syndrome a novel coronavirus associated with severe acute respiratory syndrome identification of a novel coronavirus in patients with severe acute respiratory syndrome who multicentre collaborative network for sars diagnosis. a multicentre collaboration to investigate the cause of severe acute respiratory syndrome case definitions for surveillance of severe acute respiratory syndrome world health organization a cluster of cases of severe acute respiratory syndrome in hong kong a major outbreak of severe acute respiratory syndrome in hong kong identification of severe acute respiratory syndrome in canada evaluation of who criteria for identifying patients with severe acute respiratory syndrome out of hospital: prospective observational study preventing local transmission of sars: lessons from singapore severe acute respiratory syndrome-singapore severe acute respiratory syndrome (sars) in singapore: clinical features of index patient and initial contacts update: outbreak of severe acute respiratory syndrome-worldwide clinical progression and viral load in a community outbreak of coronavirus-associated sars pneumonia: a prospective study epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in hong kong we thank leo yee sin and mark chen for their input on the case and t. ksiazek for providing the antigen for enzyme-linked immunosorbent assays, according to their method ( ).dr. augustine tee is a member of the royal college of physicians (united kingdom). he is currently working as a registrar in respiratory and critical care medicine at changi general hospital, singapore. key: cord- -ohw chbg authors: ma, hui; zhu, jiangong; liu, jianfei; zhang, xin; liu, yunxi; song, hongbin title: hospital biosecurity capacitation: analysis and recommendations from the prevention and control of covid- date: - - journal: j biosaf biosecur doi: . /j.jobb. . . sha: doc_id: cord_uid: ohw chbg the outbreak of covid- epidemic in december has highlighted issues with hospital biosafety capacitation in the people’s republic of china, although the epidemic has been controlled now. this study examined the primary issues, including an absence of hospital emergency system, inadequate management and control of nosocomial infection, limited hospital laboratory capacity, and poor hospital admission capacity. accordingly, the study put forward the following countermeasures and suggestions for hospitals to deal with future biosecurity events, such as a major epidemic: first, there is a need to build biosecurity management systems and emergency response mechanisms in hospitals; second, the investment and guarantee mechanisms for hospital biosecurity construction should be improved; third, the capacity building of biosecurity incident treatment needs attention in general hospitals; and fourth, comprehensive plans need to be developed for the integrated construction of medical treatment and prevention facilities through disease-control systems. in december , the coronavirus disease was detected in wuhan city, hubei province, people's republic of china, and rapidly spread to many provinces and cities across the country. at : on april , , the national health commission reported a total of cumulative , confirmed cases of covid- , including , deaths, and , cured cases, from provinces (autonomous regions and municipalities); in the hubei province, there were , confirmed cases, , deaths, and , cured cases [ ] . in contrast to the severe acute respiratory syndrome (sars) and influenza a virus, subtype h n (h n ), infections that respectively occurred in and in the people's republic of china, the severe acute respiratory syndrome coronavirus (sars-cov- ) that causes covid- is a new pathogen characterized by the following features: unknown animal origin, strong transmissibility, high susceptibility of the general population, and uncertain mortality rates in high-risk populations. the lack of an effective treatment for severe covid- has contributed to the considerable destructive power of the disease with regard to its effects on the society and economy [ , , ] . moreover, the epidemic has exposed inadequacies of biosecurity governance. a greater concern is that the slow early warning of the epidemic has seriously undermined the effectiveness of prevention and control measures as well as treatment in the later stages of the infection. thus, from the perspectives of ensuring the people's health, safeguarding national security, and maintaining the long-term national stability, it is essential to incorporate biosecurity into the national security system, systematically plan the construction of a national biosecurity risk-control and governance system, and comprehensively improve the national biosecurity governance capacity [ ] . after the outbreak of the covid- epidemic, the people's republic of china set up a leading group for a timely response to the epidemic. the state, the army, and local governments at all levels responded forcefully, and the military-civilian joint prevention and control mechanism was rapidly established to undertake decisive measures to prevent the import, spread, and transmission of the epidemic and thus block the nationwide transmission of the sars-cov- [ ] [ ] [ ] . the majority of military and civilian medical workers have fought hard at the frontline to reach the phased goals of "double increases" (increased treatment rate and cure rate) and "double decreases" (decreased infection rate and mortality rate), to achieve remarkable results in epidemic prevention and control [ ] . however, in the fight against the covid- epidemic, we found many issues that emerged in local hospitals in the response to a major epidemic. these issues indirectly reflected that hospitals have many shortcomings and weaknesses in the prevention and treatment of infectious diseases as well as with regard to hospital biosecurity construction [ ] . therefore, we aimed to evaluate those issues and develop suitable countermeasures. after the outbreak of the covid- epidemic, all provinces (autonomous regions and municipalities) across the country initiated first-level responses to public health emergencies to ensure the momentum of the epidemic was effectively contained. nevertheless, medical institutions at all levels, especially hospitals, demonstrated a weak response to the epidemic in the early stages, which was attributable to the following four reasons. first, the emergency response force for biosecurity was insufficient. although hospitals set up infection control or disease prevention department, due to the shortage of personnel skilled in biosecurity and lack of professional knowledge and skills, such as surveillance and early warning, sample collection, disinfection and quarantine, and protection training, the clinicians who had a poor understanding of the disease implemented inappropriate measures in the early stage, and thereby missed the best timepoint for disease control [ ] . second, the interactive emergency response mechanism did not function smoothly. with the large number of patients visiting hospitals, the poor information exchange among medical institutions, disease control institutions, and scientific research institutions caused doctors to have scant knowledge of the epidemiological characteristics, transmission patterns, and human-to-human transmission of sars-cov- infection, with the consequence of disappointing treatment results [ ] . third, the emergency reserves were inadequate. owing to the defective emergency reserve system and the large number of people quarantined for prevention and protection purposes, there was a nationwide shortage of masks, goggles, protective clothing, and quarantine clothing in hospitals [ ] . fourth, the hospital infectious disease monitoring network system does not play an early warning role in the early stage. since , the people's republic of china has successively established direct epidemic reporting system, pathogen surveillance system, unknown pneumonia case surveillance system, and symptom surveillance system, in order to facilitate early detection of new emerging infectious diseases. however, judging from the response to the epidemic, many of these systems did not play an adequate role in early warning [ ] . covid- is transmitted from the carrier to the infected mainly through droplets and close unprotected contact, and there is a possibility of airborne transmission due to aerosols produced during medical procedures [ ] . thus, covid- can be detected in ambient air of medical institutions [ ] , which everyone is generally susceptible to [ ] . it has been confirmed that there is human-to-human transmission and medical staff infection [ , , , ] . by february , , a total of , medical staff in hospitals were reported to have contracted the sars-cov- infection [ ] , and most ( %) were from the hubei province and diagnosed in the early stage of the outbreak in wuhan. therefore, the biosecurity protection of medical staff is of particular significance. because patients in the incubation period could not be detected in time at the outset of the epidemic, the medical staff failed to implement graded protection and standard prevention protocols [ ] , which resulted in nosocomial infections. after identifying the confirmed cases, the shortage of protective materials or gear and the lax implementation of hospital rules and regulations on nosocomial infections further exposed medical staff to the risk of nosocomial infection. in addition, nosocomial cross-infection among ordinary patients was not given due importance. cross-infection among patients or between doctors and patients is caused by poor conditions at the fever clinic or inadequate management of nosocomial infection. in particular, in the treatment of covid- , the vast majority of non-infectious and respiratory professionals had limited knowledge of the disease and its prevention and control, which contributed to the growth of the nosocomial infection rate, accounting for a large proportion of covid- cases. one example of this is the earliest nosocomial event at the department of neurology in wuhan union hospital [ ] . one of the gold standards for confirming the diagnosis of patients with sars-cov- infection is the etiological evidence, namely nucleic acid testing through real-time fluorescent polymerase chain reaction [ ] . however, the covid- epidemic has exposed several problems with regard to laboratory conditions and capabilities. first, there is a lack of bio-secure laboratories in hospitals. the covid- test needs to be carried out in secondary biosecurity laboratories [ , , ] , which are unavailable at many hospitals; moreover, hospitals that have these laboratories may be unable to obtain the testing qualification from relevant state departments in time, with a resultant failure to in timely detection and delay in the diagnosis and treatment of the disease. second, there is a lack of hospital testing materials. due to improper sampling, non-standard protocols, and issues with the stability and reliability of many hastily developed new kit products at some hospitals, the rate of positive detection was low. in addition, some patients had residual viral loads detected in stool samples after discharge from the hospital, which resulted in "re-positivity" [ ] and a risk of infection re-spread. during the epidemic, several hospitals faced difficulties with expanding capacities for quarantine and admission purposes in a short period. as of february , , patients received treatment across the country, and hospitals strived to expand hospital bed capacity [ ] . the first difficulty was the limited capacity for housing patients with infectious diseases. for instance, weeks after the outbreak, although there were designated hospitals in wuhan, a large number of patients were waiting for beds. two hospitals were temporarily built, and square cabin hospitals were quickly set up; therefore, the bed capacity increased sharply, which greatly relieved the pressure with regard to hospitalization of patients. the second challenge was the limited emergency treatment capacity. during the epidemic, many general hospitals undertook the tasks of emergency admission and treatment of patients with covid- and quarantine of suspected patients. however, most hospitals were apparently inexperienced at reforming medical institutions for segregated diagnosis and treatment, complete quarantine of confirmed and suspected cases, effective interruption of the route of transmission, and diagnosis and treatment of the disease [ , ] . moreover, the lack of treatment capacity delayed the treatment of other patients with tumors or traumatic infection. the third challenge was poor conditions at fever clinics. during the sars outbreak of , many hospitals set up fever clinics,, but some were put on hold for a long time, and their infrastructure could not fulfil the biosecurity requirements for sars-cov- . the covid- epidemic necessitated resumption or construction of temporary fever clinics and improvement of the facilities and conditions. moreover, these fever clinics strictly followed the observation and diagnostic protocols during quarantine, which subsequently increased the time to detection and hospitalization admission, thereby contributing to long wait times. at the core of the national medical treatment system, hospitals play a major role in biosecurity defense. in recent years, hospitals have gained remarkable achievements in responding to new outbreaks of infectious diseases such as sars, h n , ebola, and covid- [ , ] . therefore, it is of immense importance to clarify the status and role of hospitals in the national biosecurity system. first, it is recommended that future biosecurity laws or implementation regulations should clearly define the functions and roles of hospitals at all levels, from the national level onward, to legally define and safeguard the responsibilities of hospitals. second, it is necessary to call on hospitals at all levels to establish leading groups for biosecurity management and define their responsibilities and tasksnamely, undertaking emergency response to biosecurity emergencies in wartime and enhancing leadership and supervision over biosecurity work in hospitals in peacetime. third, it is essential to refine and improve emergency plans for different types of biosecurity emergencies [ ] . special attention should be paid to the following aspects: the establishment of a regional joint prevention and management mechanism; the overall planning of biothreat assessment, surveillance and early warning, emergency treatment, and disease treatment; the whole-chain link and process of restoration and reconstruction; and the coordination of the organization and command; talent; disease treatment; information platform; and material and equipment systems [ , ] . particularly, it is imperative to strengthen the setting up of symptom surveillance sentinel points, such as fever clinic and intestinal clinic, in hospitals; integrate the symptom surveillance and pathogen surveillance systems; enhance the ability to identify unknown pathogens; and improve the early identification and early warning capabilities of biothreat hospital outposts [ ] . as the epidemic swept through the country, all levels and types of hospitals across the country participated in covid- treatment, and nosocomial infections occurred in some hospitals for non-communicable diseases in wuhan and beijing. this suggests that general hospitals for non-communicable diseases can encounter biosecurity incidents and face serious risks similarly as hospitals for infectious diseases. therefore, it is suggested that, under the unified planning and guidance of the competent authorities, a biothreat treatment system should be developed at the national level, and funding support and specialist training should be reinforced. first, it is essential to increase investment in specialized hospitals such as those for infectious diseases. according to the proportion of the resident urban population, it is necessary to increase the number of hospitals that specialize in infectious diseases and set up biosecurity laboratories to meet the need for medium-scale treatment of infectious diseases. second, it is important to increase investment in public health and epidemic prevention in general hospitals. sufficient number of infectious diseases specialty and standardized fever clinics should be established in accordance with the construction requirements. the negative pressure isolation wards should be increased or modified to fulfil the requirements for accepting and treating patients with respiratory infectious diseases, which are normally used for the general hospitalization of patients in "peacetime" and for quarantine and emergency treatment in "wartime" [ , ] . drawing on effective practices in the united states, bio-control training and treatment wards should be set up in hospitals for ready-to-use purposes. third, it is necessary to improve the guarantee mechanism for emergency materials. it includes improving the national emergency materials reserve system, optimizing the production capacity guarantee and regional layout of important emergency materials, and unblocking the emergency procurement and supply channels [ , ] , in order to ensure the supply of emergency materials and outfit, such as medicines, vaccines, antibodies, masks, protective clothing, disinfectants, and goggles, for ready-to-use availability in critical conditions. the emergency treatment capacity of biosecurity incidents is related to the effectiveness of the treatment of biosecurity incidents, the health of the people, and national security and stability. first, it is necessary to establish and improve the biosecurity incident treatment system. relying on the medical treatment alliance and graded diagnosis and treatment, we should establish and improve the classification, stratification, and diversion of biosecurity incident treatment mechanism, unblock the conversion mechanism in peacetime and wartime, and urgently authorize non-public medical institutions and laboratories to rapidly expand their detection and treatment capabilities in "wartime." the application of g and artificial intelligence image-assisted technologies can help to carry out remote consultation on major infectious diseases and other biological events. it is vital to better the construction of medical personnel, encourage all medical staff to acquire the knowledge and basic skills of infectious diseases and biosecurity protection, and lay stress on the training on protection knowledge and skills of infectious diseases and biosecurity among non-infectious medical staff and grass-roots medical staff with low seniority and professional titles [ , ] . second, the technical standards and quality management standards of diagnosis and treatment need to be improved [ ] . the intervention measures for the prevention and control of infectious diseases should be strictly implemented, and the strategic pass should be moved up to achieve the "four early" (early detection, early reporting, early quarantine, and early treatment). in particular, priorities should be given to the medical treatment of mild patients to reduce the transition from mild cases to severe ones, as well as to the treatment of severe cases to reduce the mortality rate. third, scientific and technological researches, such as developing robot delivery systems and uav sterilization devices, upgrading medical emergency vehicles, negative-pressure quarantine stretchers, and negative-pressure first aid devices, and accelerating the research and application of novel technologies and treatments, including convalescent plasma treatment and blood purification treatment need to be carried out. it is vital to advance laboratory detection and diagnosis and establish on-site rapid detection technologies such as isothermal amplification, mass spectrometry, to improve the ability of rapid detection of pathogens [ ] . disease-control systems and medical institutions are crucial components of national biosecurity construction. through a dynamic integration of and cooperation between these two components, it is possible to ensure population health and construct better biosecurity systems. however, the problems of "attaching importance to treatment but neglecting prevention" and "separating treatment from prevention" are ubiquitous in the country. the lessons learned from the epidemic are extremely profound. therefore, greater effort should be invested to integrate medical and preventive forces and form a pattern of integrated construction of treatment and prevention facilities. first, it is necessary to further promote reforms of the disease-control system [ ] . the tripartite forces of disease-control institutions; general and specialized hospitals; and grassroots medical and health units should be coordinated to establish an interdependent "trinity" of disease-control systems characterized by division of labor, cooperation, and interdependence on each other's strengths [ ] . this would further intensify the role and function of hospital disease-control departments. in key and sensitive departments such as the emergency department, disease-control experts should be assigned and conferred adequate governance authority in terms of rights and responsibilities to enhance the ability of hospitals to deal with biosecurity incidents represented by public health emergencies. second, it is vital to improve the emergency response mechanism for integrated treatment and prevention. we recommend improvement of the effective interaction of mechanisms for scientific research, disease control, and clinical treatment, as well as 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community engagement (rcce) readiness and response to the covid- ( -ncov) interim guidance v regional joint prevention and control of major diseases not applicable data sharing not applicable to this article as no datasets were generated or analyzed during the current study. the authors have no competing interests to declare. this article is distributed under the terms of the creative commons attribution . international license (http://creativecommons.org/licenses/by/ . /), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/ . /) applies to the data made available in this article, unless otherwise stated. data sharing not applicable to this article as no datasets were generated or analyzed during the current study. this work was supported by medical innovation project ( cxz ), logistics scientific research project (alb j ) and national social science foundation ( gj - ). none. mh and shb conceived and wrote the manuscript.zjg, ljf,zx and lyx critically reviewed and revised the manuscript. all authors have read and approved the final manuscript. key: cord- -f ciho o authors: nan title: tuesday plenary session tuesday: posters date: - - journal: vox sang doi: . /j. - . . .x sha: doc_id: cord_uid: f ciho o nan from the perspective of causal inference, there is a hierarchy of evidence, ranging from case-series to large randomized controlled trials (rcts). in addressing a particular clinical or policy problem, clinicians or policy-makers can base their decisions on the types of clinical reports that have been published, along with an assessment of the strengths and weaknesses of each study. rcts are controlled clinical experiments in which patients are randomly allocated by the investigators to receive a treatment under study. if randomization is used, all participants are equally likely to be allocated to either the treatment or the control arm of the study. rcts should be distinguished from observational studies in which investigators passively observe patients who happen to receive a treatment under study. because the allocation of subjects to the treatment and control arms of an rct is random, the play of chance should distribute all confounding factors equally between these two arms. thus, the treatment and control arms of an rct should be equivalent with respect to all confounding factors except for the treatment under study. randomization removes selection bias, because neither the investigator nor the participant knows what the treatment allocation will be before a patient enters a study. moreover, if an rct is double-blind, observation bias is also removed, because preconceived notions about benefit from the treatment cannot color the reporting of symptoms by a patient or the assessment of disease activity by an investigator. when the undertaking of rcts is deemed unlikely, meta-analyses of individual patient data, that is, of the data recorded previously on subjects enrolled in published, small rcts may allow investigators to address issues of possible biases ed- - standardizing blood components would allow better monitoring of the effectiveness of transfusion d davenport university of michigan, ann arbor, mi, usa in routine transfusion of red blood cells (rbc) or platelet concentrates (pc), we have only a very rough idea of the dose we administer. the minimum expected hemoglobin content of rbc should be g (fda criteria). however, actual measurements have found a mean hemoglobin content of . ± . g per unit, with variability between manufacturers. percent of units may contain less than . g of hemoglobin while percent may contain more than . g. the effect of storage senescence can magnify these differences. the resulting hematocrit increase, depending on size of recipient and age of a unit, may be . to percent. apheresis collection of rbc can help standardized unit contents, but this technology is relatively expensive and time consuming. knowledge of actual hemoglobin content can be used to optimize red cell transfusion. one trial, using a simple formula incorporating the desired hemoglobin and estimated blood volume, showed that nearly percent of transfusion orders could be met with one unit while achieving a mean target hemoglobin of . g/dl. for pc transfusion, about percent of transfusions achieve the targeted dose of - ¥ platelets in actual practice, with considerable variability between institutions. without knowledge of the actual content of pc, determination of refractoriness and response to matched pc is problematic. standardization and labeling of rbc and pc units for content will permit accurate dosage and quantification of transfusion practice. are transfusion guidelines evidence-based? jp aubuchon dartmouth-hitchcock medical center, lebanon, nh, usa application of the results of randomized, controlled clinical trials to similar clinical situations should increase the predictability of the outcomes of transfusions. unfortunately, too few such trials have been conducted to investigate all the potential situations where transfusion might be applied. however, the ones that have been reported indicate that, in general, transfusion is unlikely to provide substantial benefit in many of the situations where it is routinely used. in the intensive care setting, transfusing red cells at a trigger point of g/dl rather than g/dl not only did not lead to increased anemic morbidity but was actually associated with a reduction in overall mortality. subgroup analyses indicated transfusion at the higher trigger point did not decrease morbidity in patients with cardiac disease nor decrease the time until weaning from a ventilator. following cardiac surgery, a transfusion trigger of a hematocrit of % yielded the same outcomes as one of %. an observational study suggested that patients with peripheral vascular disease and a post-operative hematocrit below % were more likely to suffer a morbid cardiac event, but this group of patients had more evidence of anemia and cardiac ischemia preoperatively, illustrating the pitfalls of observational studies. most would agree that transfusion is necessary below a hb of g/dl and unlikely to be necessary at a hb above g/dl, but most patients fall between these limits, and there are insufficient data in the and residual confounding factors, and may permit them to make a judgment of a causal relationship. sackett proposed that the evidence generated from meta-analyses of individual patient data be regarded as being equivalent in strength to that generated from rcts. meta-analysis is the structured and systematic integration of information from different studies of a given problem. when the results of individual studies are discrepant, the purpose of an overview is to investigate reasons for disagreements among studies. when the results are concordant, the goal of meta-analysis is to derive, through application of a number of quantitative techniques, a measure of the effect of the intervention across combined investigations. this measure is referred to as the 'summary' effect of the treatment under study. meta-analysis differs from the traditional, narrative reviews of the literature, in that: ( ) all completed investigations of the efficacy of an intervention that meet specific, eligibility criteria are retrieved and included in the overview; ( ) the quality of retrieved studies is assessed systematically; ( ) the degree of agreement among studies is evaluated, both conceptually and based on statistical criteria, and the synthesis of the findings proceeds only if the variation in reported results is sufficiently modest to be attributed to chance; and ( ) quantitative methods are used to calculate the summary effect of the intervention and to test that effect for statistical significance. ed- - biology of stem cell mobilization th papayannopoulou university of washington, seattle, wa, usa at baseline hematopoiesis, the majority of developing hematopoietic cells (precursors, progenitors and stem cells) is actively retained in bone marrow (bm), whereas fully mature cells emigrate to peripheral circulation. a small number of stem/progenitor cells are also present in blood, serving presumed physiologic roles for the repopulation of remote damaged areas. however, in several hematopoietic perturbations, i.e. post irradiation, post chemotherapy or by using empiric treatments, a heightened emigration (mobilization) of progenitor/stem cells was noted over years ago. the introduction of g-csf as an efficient mobilizing agent not only had a major clinical impact, but has triggered a flurry of studies exploring the mechanisms of mobilization. from these studies, significant insight has been gained about the molecular pathways leading to mobilization, especially by studying the altered environment within bm post mobilization, and less so by studying cells mobilized in blood. several attractive scenarios have been proposed and their importance was further bolstered by studying genetic mouse models. a prominent role of the sdf- /cxcr pathway has been emphasized, either by down regulation of cxcr , changes in sdf- gradients, or by disruption of sdf- /cxcr signaling. whether this pathway is disrupted by a proteolytic mechanism prevailing within bm post g-csf or by other protease-independent mechanisms has not yet been settled. in addition to sdf- /cxcr , disruption of other pathways responsible for the retention of primitive cells in bm can lead to mobilization. for example, disengagement of the vla /vcam- pathway by anti-functional antibodies or its genetic deficiency in mice results in egress of stem/progenitor cells. mobilization is also seen following the use of other cytokines (i.e. kit-l, flt- l, il- ) or chemokines (i.e. il- , gro?), complement activation, etc., but the detailed mechanisms or the interdependence of these other pathways with the ones already proposed have not been worked out. finally, efforts to improve mobilization efficiency in man has led to the use of combination treatments with g-csf, either by adding another cytokine (i.e. growth hormone), agonistic sdf- molecules (i.e. ctce ), or cxcr antagonists (i.e. amd ) which have yielded synergistic increments, and these will be discussed. a full understanding of the principles of mobilization, as well as the bm homing characteristics of mobilized cells after their i.v. infusion in transplantation, should lead to targeted, more efficient experimental protocols in the future. the possibility of deriving all kinds of mature cell types from embryonic stem (es) cells for the purpose of cell replacement therapies will probably face a major obstacle; a limited supply of available hla types for an ever growing population in demand. one possible solution is to use adult sources of stem cells such as the haematopoietic stem cells (hsc) that can repopulate the entire haematopoietic system after transplantation in a myeloablated host. however cells with the repopulating ability of hscs are still elusive for tissues such as muscle, heart, cns and pancreas. it was therefore exciting news when it was shown that hscs could repopulate other non-haematopoietic tissues arguing for a general role of bmderived cells in tissue regeneration. the term plasticity was thus coined to describe the phenomenon whereby cells of one lineage could trans-differentiate into cells of another tissue. this in turn implied that a certain degree of developmental plasticity was still available in the adult hsc, or their derived progeny, that allowed them to present with novel phenotypes. how exactly this was accomplished was a matter of speculation. in order to address the mechanism we used an animal model of liver failure where bmt with normal (wild type, wt) hsc was shown to rescue the liver failure; the repopulating hepatocytes apparently differentiated from the sole source of wt cells, the bm compartment. by studying the genetic composition of the regenerating liver nodules we observed that both wt and mutant dna was present in the nodules, a finding that was consistent with bm-derived cells fusing with host hepatocytes. the mechanism of plasticity was therefore directly related to the exposure of the donor bm-derived wt nucleus to the transcriptional environment of the hepatocyte and the expression of hepatocyte-specific genes. this fusion mechanism was also shown to underlie perceived cases of haematopoietic cell transdifferentiation to purkinje cells in the cerebellum and to cardiomyocytes. however, there are carefully executed studies that strongly support the alternative transdifferentiation mechanism in tissues such as epithelia or the epidermis. what these observations may imply is that in tissues with high rates of cell turnover, there may be a potent stem cell niche that can reprogram incoming cells to follow relevant cell lineages. if this hypothesis is correct, then the major research effort should focus on what makes the niche and whether it can be recreated faithfully in vitro so as to educate hscs to diverse lineages opening the way for realistic cell replacement therapies. collection and distribution of blood and its products to meet the medical needs of industrialized countries are typically managed through large-scale national or nationally-supported blood programs. the development, maintenance, and ultimate success of such programs are all components of a process that involves the delicate balance of continuously competing pressures, e.g. social, economic, ethical, political, regulatory/legislative. as with all endeavors that directly affect human life, safety is a central, unifying theme of this process. because transactions of blood inherently involve risks at both donation and reception/transfusion ends, efforts to enhance and maintain an acceptable level of safety generally rely on a focused program of risk management (rm). rm involves three equally important elements: identification/evaluation of risk factors in a process, control of exposure to them, and continuous monitoring to assess the effectiveness of countermeasures and the emergence of new risk factors. specific approaches to rm and quality assurance in transfusion medicine will be presented. examples from blood programs currently in effect in selected countries will be discussed. rm efforts within the corresponding blood program in greece will then be examined. the lack of data to adequately assess the status of this program suggests that at least one of the elements of rm -monitoring -can still be improved. a preliminary research effort aims to survey blood donors, transfusion recipients, and physicians in order to build an understanding of the specific factors that drive the perception of risk in the greek population. the findings form important stepping points upon which specific recommendations can be made for the development and maintenance of a comprehensive, effective rm program in greece. ed- - the use of haemovigilance data to increase safety in transfusion medicine haemovigilance is a surveillance of all the procedures in the transfusion chain. the intension is to collect and assess information on unexpected or undesirable effects in bleeding of donors and transfusion of blood components. in europe haemovigilance was introduced as a concept in the middle of the nineties. the first national reports on haemovigilance appeared in the late nineties, and were only dealing with complications related to transfusion. later on other kind of events like 'near miss' events were added. nowadays national reports are dealing with all steps in the transfusion line, and to some extend also with complications in blood donors. the state of the art is haemovigilance with retrospective registration of unwanted events that has happened, but also a more active prospective part with an early warning in a rapid alert system about new threats in the transfusion world. the aim of the different national haemovigilance systems has been to improve safety in the transfusion line. after the first years with haemovigilance in the european countries, what has been the outcome of this big effort? data from national reports do not signify major improvements, but safety is suggested to have improved due to many minor changes of procedures and awareness of dangerous situations. however, in most countries nothing really effective has been done to avoid failures, the most important cause of serious complications in transfusion of patients. systems which can prevent most of the failures are on the market. the cost of these equals the cost of nat screening for virus introduced in the same period of time. the common perception of transfusion risks is still much more focused on the hypothetical risk of virus transmission than to the demonstrated magnitude of severe complications related to bleeding of donors and transfusion of patients. therefore, to increase safety in transfusion medicine the nature and occurrence of the risks should be revealed by haemovigilance and not less important the results should be published with the aim to get a realistic common perception of the transfusion risks. the role of diagnostic testing to identify congenital vs acquired disorders of hemostasis and to optimize the management of perioperative bleeding g despotis washington university school of medicine, st louis, mo, usa excessive bleeding with trauma or after surgery can result in hypoperfusion and anemia related end-organ dysfunction and mortality as well as transfusion-related complications. several large studies have demonstrated that if bleeding is excessive after cardiac surgery to the point that reexploration is required, that overall mortality increases by - fold. transfusion related complications include the following potentially lethal complications: disease transmission of pathogens, acute hemolytic reactions, allergic reactions, transfusion associated acute lung injury, allo-immunization related disease (e.g. post-transfusion purpura, platelet refractoriness, transfusion-associated graft-vs-host disease) and other potential complications (e.g. increased perioperative infection or multi-organ system failure) related to transfusion associated immune modulation. in addition, blood shortages related to increasing consumption (i.e. expanding geriatric population) and/or a shrinking supply (i.e. related to exclusion of donors related to donor exclusion criteria designed to prevent disease transmission) may limit our ability to adequately manage our anemic and bleeding patients. this highlights the relative importance of accurate diagnosis and optimal management of excessive bleeding to minimize bleeding related complications and conserve our blood supply. patients at risk for excessive bleeding include those with an established hereditary disorder (e.g. vwd, hemophilia, connective tissue disorders), end-stage hepatic or renal disease as well as patients with acquired defects of the hemostatic system. in specific, patients with platelet (i.e. platelet refractoriness) or coagulation factor inhibitors at increased risk, extracorporeal circulation related defects or as related to certain pharmacologic agents). patients who require longer periods of extracorporeal circulation for cardiac surgical procedures (e.g. repeat, combined procedures or use of deep hypothermic circulatory arrest) are at a greater risk of developing excessive bleeding (e.g. cpb-related abnormalities). in addition, patients receiving one or more longacting anti-thrombotic medications in the immediate preoperative period (e.g. plavix, reopro, low molecular weight heparin etc) are at increased risk for bleeding. clinicians in the past have resorted to empiric and 'shot gun' approaches when managing excessive bleeding due lack of immediate availability of results from laboratory-based coagulation tests. on this basis, the use of point-of-care (poc) tests of hemostatic function to facilitate the optimal management of excessive bleeding, help differentiate between microvascular vs surgical bleeding and reduce transfusion have been investigated. five of six recently published studies have demonstrated that implementation of a standardized approach to manage bleeding (e.g. algorithm) which when coupled with either point-ofcare or laboratory tests of hemostatic function can optimize the management of bleeding and reduce total donor exposures by %. ddavp has bee shown to be beneficial with uremia-induced platelet dysfunction and with type i von willbrand's disease. although previous studies have not been able to conclusively show that ddavp can reduce bleeding and transfusion when administered prophylactically, more recent evidence indicates that this agent may be useful in preventing excessive bleeding when a test (point-of-care) reveals platelet dysfunction. recombinant activated factor vii (rfviia) is licensed for use in bleeding episodes in hemophiliac patients with inhibitors. although, only anecdotal reports and results from small clinical studies have shown that this agent can reverse life-threatening bleeding after major surgery, other reports indicate that there is variability in the effectiveness of rfviia as well as highlight lifethreatening thrombotic complications in a subset of high risk patients (i.e. patients with congenital or acquired thrombotic disorders or systemic activation of the hemostatic system such as with dic or after cardiac surgery). therefore, large clinical trials evaluating the efficacy and safety of rfviia are needed before any widespread use can be recommended. in recent years, molecular methods of blood grouping have become routine diagnostic procedures in many laboratories throughout the world. they have proved especially valuable for the determination of fetal blood groups. the ability to detect rhd in pregnancies where the fetus is at risk from haemolytic disease of the newborn represents a significant advance in obstetric care. furthermore, the occurrence of fetal dna in the mothers' peripheral blood has allowed this diagnostic procedure to be carried out without the risks that accompany amniocentesis (lo ymd. ( ) ann med : - ). determination of the coding sequence of all the genes giving rise to antigens within the blood group systems currently recognised is virtually complete. by correlating the coding sequence of these genes with the phenotype of red cells from individuals with different blood groups it has been possible to infer the molecular bases of most of the antigens comprising each blood group system (daniels gl ( ) human blood groups, nd ed. blackwell science). the polymorphic antigens of most systems other than abo and rh, are defined by single nucleotide substitutions (snps) which effect a single amino acid sequence change in the gene product. numerous methods, both manual and automated, are available to determine snps and these have been applied to the determination of blood groups. useful applications of snps detection methods include, determination of the blood group phenotype of patients who have been transfused recently and still have donor blood in their circulation (rozman p, dove t, gassner c et al. ( ) transfusion : - ), and donor screening to find compatible units for patients with multiple blood group antibodies or for the management of patients with diseases like the haemoglobinopathies who are going to be transfusion-dependent over many years (castilho l, rios m, bianco c et al. ( ) transfusion : - ). other applications of molecular methods include zygosity determination for rhd, determination of the blood group phenotype of patients with a positive direct antiglobulin test, selection of donors with rare blood group phenotypes, and as aids to the solution of complex blood grouping problems in the reference laboratory. the molecular bases of abo and rh antigens are complex and cannot be determined reliably by a single snp. nevertheless, methodologies are available that allow the comprehensive sequence analysis of individual genes and could be applied to abo and rh typing. whether or not this will ever be a cost-effective procedure is a moot point. it is clear that molecular methods are a useful addition to the range of diagnostic procedures available to transfusion medicine practitioners but it is important to remember that methods based on dna analysis determine phenotype by inference and not by direct measurement. the results of molecular tests should be interpreted with this caveat in mind. ed- - the hla system g stavropoulos general hospital 'g. gennimatas', athens, greece since its discovery in the mouse in the major histocompatibility complex (mhc) has become one of the most important region in the vertebrate genome with respect to infection, autoimmunity and transplantation. mhc primary function is to provide protection against pathogens. this is achieved through sophisticated pathways in which mhc class i molecules present endogenous antiges to cd + t cells and class ii molecules present exogenous antigens to cd + t cells. an increasing number of other proteins are being found that support these two pathways; many of these proteins, together with the class iii complement proteins, also map to the mhc. the mhc molecules were originally studied for their ability to cxonfer tolerance (histocompatibility) following tissue grafts or later, organ transplants. nowadays, the success of unrelated hematopoetic cell transplantation is influenced by the degree of mhc compatibility between the donor and patient. thus, for patients who lack matched donors, the rules that govern permissibility of mhc mismatching still need to be identified. for patients with high risk disease who lack matched donors, use of donors with a single mhc mismatch may permit early treatment before disease progression. scientific evidence to fully answer the questions 'when are platelet components clinically effective' and 'what do we really know?' is limited. despite this limitation and the level of uncertainty it generates with regard to treatment options and policies, it is reassuring to note that current prophylactic platelet transfusion protocols -mostly derived from empirical observations collected during the 's and 's -protect oncology patients from clinically relevant bleeding in more than % of thrombocytopenic days spent in hospital or at home, even in aggressive conditions such as leukemia, lymphoma and other severe blood diseases. this evidence seems to justify the prevalent policy of transfusing platelets when the patient's platelet count falls below per microliter (or in 'unstable' patients). this policy is based on positive outcomes of prospective and retrospective studies performed during the 's including some hundred non-surgical patients and on the desire of balancing the will of reducing patient exposure to limited, expensive, potentially infectious and immunogenic blood products with the objective of preventing clinically relevant hemorrhage. several national and international organizations endorse the above policy. although the role of platelet support in surgery or in specific clinical situations requiring invasive procedures or in patients affected by multi-organ and system co-morbidity suffers from even more limited evidence, the latter has been carefully collected and summarized in the guidelines for platelet transfusion published in j clin oncol ; : - . additional data on lumbar puncture are reported in ann hematol ; : - . another important topic where there is room for improvement and need for further investigation is platelet refractoriness, a condition developed by a proportion of chronic platelet recipients, which causes high hemorrhage risk if compatible platelets are not provided and in which consensus on the diagnosis and treatment is lacking. with regard to the type of platelet product, it will be necessary to determine the clinical impact of buffy-coat derived platelets, consistently used in europe and current object of increased interest in canada, as compared to the platelet-rich plasma method traditionally used in the us, of viral inactivation procedures and of laboratory methods for detection of bacterial contamination of platelet concentrates. in addition, ongoing studies on the clinical impact of high versus low platelet doses will provide novel elements to determine the relative merits of apheresis versus whole-blood derived platelets. as far as the established procedure of white cell reduction by filtration, which shows high technical efficiency and has been implemented as a standard by a number of institutions, debate is still ongoing on its equivalence with serologic screening for the prevention of cmv transmission, whereas general consensus supports its pre-storage use to prevent febrile, non hemolytic transfusion reactions. finally, although the high cost of filters do not allow a generalized use of this technology in many settings, white cell reduced platelets have been unequivocally shown to reduce alloimmune refractoriness from about % to about % of patients. ed- - ffp: appraisal of the evidence for the clinical use of ffp although the indications for transfusion of plasma (fresh frozen plasma; ffp) are limited, the use of ffp continues to rise in the united kingdom and has risen by over % in the past few years. local uk audits continue to document that a significant proportion of ffp transfusions are not consistent with indications reported in guidelines. a systematic review of the evidence base for the effectiveness of ffp was therefore undertaken to identify, select and appraise all relevant randomised controlled trials, as the most robust form of study to assess effectiveness of ffp. in the systematic review of ffp, the criteria for inclusion of full-published studies were: there must have been at least two groups in the study; • allocation to the groups must have been either by formal randomisation or by a quasi random method e.g. alternation; • one of the arms of trial must include ffp or plasma as an intervention; results on the relevant clinical or laboratory outcome must be presented. the main analysis was qualitative, and differentiated between: . studies of interventions comparing ffp with no ffp; . studies of interventions comparing ffp with a non-blood product e.g. solutions of colloids and/or crystalloids; . studies of interventions comparing ffp with a different blood product; . studies comparing different formulations of ffp, e.g. solvent detergent and methodine blue treated. an evaluation of studies comparing ffp with no ffp would be expected to provide the clearest direct evidence for a positive effect of ffp. studies comparing ffp with colloids or crystalloids were separately appraised because these latter products may have variable effects on coagulation tests. studies comparing different formulations of ffp do not directly evaluate effectiveness of ffp but were included because there is now a uk national policy to use these products in younger patients and therefore these trials might identify negative outcomes. the search strategy identified a total publications. although it may appear that this number of randomised trials might provide a reasonable evidence base to help inform clinical policy and decision making, the review identified a number of important concerns about the published trials. few of the identified studies included details of the study methodology (method of randomisation, blinding of patients and study personnel). the sample size of many included studies was very small (range - patients per arm). few studies took adequate account of the extent to which adverse events might negate the clinical benefits of treatment with ffp. many of the identified trials in groups such as cardiac, neonatal, and other clinical conditions, evaluated a prophylactic transfusion strategy. however, when these trials evaluating prophylactic usage were assessed together as a single grouping in the review, it appeared there was no consistent support for a beneficial effect of prophylactic ffp, irrespective of clinical setting. there is a pressing need to develop new trials to determine the effectiveness of ffp, including for those clinical situations in which it has become an accepted part of current transfusion practice. a law decided upon by the riksdag (the swedish parliament) often sets the general standards as a framework and authorises the central government authority concerned to elaborate and decide upon the more detailed regulations. laws and regulations define the level of quality and safety that has to be reached and state what must be done, while establishments and their managers are kept responsible for fulfilling the requirements and how this is done. guidelines (non-binding) present detailed instructions on ways how to fulfil the requirements. making a law is complicated and time-consuming. the ministry draws up a legislative proposal, refers the proposal to relevant bodies for consideration and comments, and then drafts a bill which is referred to the council on legislation for consideration before it is submitted to the riksdag. a parliamentary committee deals with the bill before it is put to the chamber of the riksdag for approval. when adopted, the bill becomes law. regulations elaborated by central government authorities are handled in a principally similar way. however, regulations are more readily adjusted to scientific and technical progress, and when legislation need requirements for technical details, these are preferably presented in a regulation. the ministry of health and social affairs is responsible for elaborating the bill to be submitted to the riksdag on the blood safety law. two central government authorities, designated as competent authorities, are responsible for preparing the appropriate complimentary regulations as well as for inspecting and licensing the blood establishments: • the national board of health and welfare (nbhw), responsible for requirements related to blood components intended for transfusion, and • the medical product agency (mpa), responsible for requirements related to blood components intended for the manufacture of medicinal products. sweden became a member of the eu ten years ago. since then, experts in transfusion medicine have been appointed by the ministry, nbhw and mpa for advice on scientific and technical issues and for representing sweden at expert meetings arranged by the commission. some of these experts are also members of the handbook committee of the national society for transfusion medicine, preparing and revising the national guidelines. consequently, the requirements of the directives are readily implemented in the daily work of the blood establishments before (due to legal and technical reasons) the new blood safety law and the revised nbhw and mpa regulations can be promulgated. to a great extent, requirements of the blood directives are covered by existing swedish legislation. no major problems or obstacles seem to arise when implementing new requirements into law and regulations and into the blood establishments' daily service. a few detailed requirements have been found difficult to follow precisely in the routine work. these minor difficulties, however, will not compromise the high quality and safety of blood components prepared according to the standards set by the blood directives. the landscape for blood collection and distribution includes availability and safety. true international availability of blood has not been reached. the landscape of safety has been mountainous, if viewed by the degree of frustration among the transfusion specialists. the reasons for frustration have varied from serological problems to those of transmissible infections, to which no end is in sight. mistrust in the safety of blood taken by others is one reason for lack of international landscape in blood collection and distribution. increasing demands on safety, availability and economy force the health care providers to reorganise blood services. national systems are winning ground. this may make it easier to achieve international collaboration. the council of europe has pioneered in creation of international recommendations for blood collection and distribution. in a european agreement on the exchange of therapeutic substances of human origin, including human blood, was published. its purpose was to make blood available to other parties of the agreement in case of urgent need. many countries ratified the agreement rapidly, some did it first in the nineties. in practice little exchange of blood components has taken place. the council of europe recommendations lack legal power. the european union is different, and it has taken on its agenda activities aiming at improving confidence in the safety of the blood transfusion chain in the community (commission communication ) . the agenda is based on an agreement reached at a high level eu meeting in adare, ireland in . first in the commission agenda was a recommendation on donor selection criteria, given in . then came the european blood directive / /ec, the aim of which is to improve the safety of blood and blood components within the union so that enough mutual trust between member countries can be achieved to make the exchange of blood components possible. being a legally binding document the directive is undoubtedly helpful in reaching a harmonised standard in europe. hopefully the european commission has the resources to follow its implementation. there are concerns, however. the epidemiological differences among the eu member countries and frequent appearance of new infectious agents potentially transmitted by blood make it difficult to foresee that even effective viral inactivation of blood components could totally erase the national differences in donor approval. blood collection and preparation of components are already the same in eu member countries and the directive helps in their further standardisation. there has not been much distribution of blood components internationally, with the exception of export of red cell concentrates to the us from switzerland and the netherlands. the european legislation opens new horizons and widens the european landscape as its purpose is to simplify the crossing of borders between the member states, but before true movement of blood components is achieved more work is needed on the eu commission blood agenda. the eu directive implemented into the legal act for polish blood transfusion service blood transfusion service (bts) in poland is an integral part of the public polish health service. in the country of nearly million people, approximately one million units of blood and plasma are collected every year from voluntary, nonremunarated donors, which is statistically over donations per inhabitants. blood and plasma are collected in strictly appointed centers and no private collection sites are permitted. the legal basis for the activity of polish bts is polish blood transfusion act of nd august which came into force as of january st . this act was then updated in november according to eu directive / /ec and came into force as of january th . this act introduced the principles for organization, collection, processing, storage, transport and quality assurance in bts. it specified -among others -the system of accreditation, haemovigilence, as well as requirements for bts employees. according to this act the polish bts is obliged to monitor and supervise immunohematology testing and transfusion procedures in all hospitals where blood and blood products are transfused. polish bts consists of regional blood transfusion centers (rbtc), one military center and one ministry of internal affairs and administration center as well as the institute of hematology and blood transfusion (ihbt) which acts as supervisor. the rbtcs have a uniform organization structure, uniform quality assurance system and act according to uniform guidelines issued by ihbt. they have two financing sources -the central budget and hospital reimbursement for distributed blood and blood products. the polish blood transfusion act of nd august , in force since january st , has been supplemented by decrees: . procedures for external bts audits; . requirements for donor selection; . requirements and procedures for organization and safe management of blood transfusion in hospitals; . requirements for implementing of national and regional donor registers; . employment criteria for bts personnel; . training requirements for hospital personnel involved in blood and blood product administration; . national, uniform price list for blood and blood products; . organization requirements for setting up of a national committee for blood and blood transfusion. introduction: several technical aspects must be considered in pediatric apheresis due to the size of the patient. factors that must be evaluated are extracorporeal circuit volume, blood flow rates, type of anticoagulant and vascular access. adverse events are mainly related either to vascular access or to metabolic or hemodynamic changes. aim of the study: in this study we show our experience using fresenius hemocare com.tec for pbsc collection in children. methods: twelve pediatric patients (median age years, range - ; median weight kg, range . - . kg) with solid tumors at onset or on relapse underwent collections with the p y kit of the fresenius hemocare com.tec blood cell separator. our cd + cells target was ¥ e /kg. collections were started if a peak of at least . e /l cd + cells ( per microlitre) were reached in the peripheral blood. in all the patients, leukapheresis were performed through a central venous catheter and temporary peripheral venous access. acd ratio : - : was combined with heparin u/kg. in children with < kg the separator was initialized with a compatible filtered and irradiated red blood cell unit, suspended in % albumin, up to the patient's hematocrit, to avoid transient hypovolemia, due to the volume sequestered in the separator. results: twenty-five procedures were performed. a median blood volume of ml (range . - . ml) was processed in a separation time of min (range - min). the median product weight was g (range - g) and yield of cd + cells was . ¥ e /kg body weight (range . - . ¥ e /kg body weight). three poor mobilizing patients (peripheral blood cd + peak of - cells per microlitre) underwent more than two apheresis to collect the desired transplantation dose ( . and ). all collection procedures were well tolerated. children never required sedation to perform the leukapheresis. only mild hypocalcemia-related symptoms, promptly responding to small i.v. boluses of calcium gluconate, were reported. no circulatory side effects were observed. blood flow alarms occurred in every procedures but no collection had to be terminated due to insufficient flow. conclusion: in summary, leukapheresis in children can be safely and effectively performed with the fresenius hemocare com.tec separator with minimal technical difficulties even in patients under kg. m-pa- alternative methods for prevention of infection transmission (pathogen inactivation etc.), cost-benefit considerations of the procedure itself. however, one must also take the loss of plasma into consideration -and more difficult: calculate the effects of changes in product quality, as reduced content of factor viii, protein s and other labile proteins. for methods involving pooling, there are also concerns about the risks due to the pool sizes. the major benefit of the methods will be the potential reduction of infectious transmission, but also possible advantages as reduction of allergic transfusion reactions and trali must be evaluated. the study types involved in cost-benefit considerations are costeffectiveness analysis where the cost and effects of an intervention and an alternative are presented in a ratio of incremental cost to incremental effect and cost-utility analysis, where quality-adjusted life years (qaly) are used as the effectiveness endpoint. qualityadjusted life years is a method that assigns a preference weight to each health state and estimates life-expectancy as the sum of these products of each preference weight and time spent for each state. a complete glossary of terms is found at http://www.hsph.harvard.edu/cearegistry. in literature, there are several publications on cost-benefit considerations within the field of transfusion medicine. concerning plasma products, the costeffectiveness of solvent-detergent plasma has been the major focus. however, the conclusions of different authors have been conflicting. in , aubuchon and birkmeyer published a paper (jama ; ( ) : - ) where they concluded that the cost was usd per qaly, which is far above the 'acceptable limit' of usd . this estimate was adjusted to usd . mill. per qaly in a letter to jama (jackson, jama ). in , riedler et al. published (vox sang : - ) that the discounted cost/life year saved for sd-ffp use in the uk was gbp for neonates and gbp for patients aged . the main reason for the differences between the two papers (and others) was considered to be different calculation of non-infectious complications. the papers cited above underline the difficulties of the cost-benefit considerations. the age of the patient, the outcome of the treatment, the quality of life in an infected patient and the cost of side effects will differ. in addition, how much are we willing to pay for protection against emerging viruses? this paper will not provide the answers, but introduction: the photodynamic treatment of therapeutic plasma using methylene blue (mb) in combination with visible light is a well established procedure for the inactivation of blood borne viruses. aim of the study: evaluation of the quality and stability of mb/light-treated plasma (mb plasma) prepared under worst case conditions for routine processing. methods: single donor units (n = ) were treated using the macopharma theraflex mb-plasma system which includes plasma membrane filtration (plas ) and addition of mb prior to illumination followed by mb and photoproduct filtration (blueflex). samples were taken before treatment and from the final product. additionally mb-treated plasma was prepared from four different plasma pools and stored for up to months. treatment was done under worst case conditions for the preservation of coagulation factors: maximum mb concentration during illumination ( . mmol/l), maximum storage time of whole blood before separation ( °c, h), maximum storage time of mb plasma before freezing ( h). several plasma parameters and the concentration of mb and its photoproducts (azure a, azure b, azure c and thionine) were determined. results: mb/light treatment had a significant influence on thrombin time (+ . %), fibrinogen (clauss) (- . %), factor v (- . %), factor viii (- . %), factor xi (- . %) and protein c (- . %). no significant changes were detected for at iii, vwf : rco, vwf cleaving protease, plasmin inhibitor and alpha- -antitrypsin. the entire virus inactivation procedure including the filtration steps for leukocyte depletion and mb and photoproduct depletion had no significant effect on activation markers (prothrombin fragment + , thrombin-antithrombin-complex, d-dimers). no further essential loss of coagulation factor activity was observed during storage of the plasma at °c for months. mb and its photoproducts (azure a, azure b, azure c) were depleted to a final concentration of < . mmol/l. thionine was undetectable in all samples. conclusion: photodynamic treatment of fresh frozen plasma (ffp) using the theraflex mb-plasma system leads to only moderate decreases in the activities of different coagulation factors even under worst case conditions for routine production. mb and its photoproducts were effectively removed from the plasma by the blue-flex-filter integrated in the theraflex-system. the quality of mb plasma is well preserved during storage. pulmonary complications, particularly transfusion-related acute lung injury and circulatory overload, are the most common causes of transfusion-associated morbidity and mortality in the developed world. trali is a syndrome characterized by acute respiratory distress, hypoxemia, hypotension and pulmonary edema, occurring within hours (usually - hours) of transfusion of a plasmacontaining blood product. other signs, including hypertension, leucopenia and hypocomplementemia, are less frequent. all blood products, except for albumin and solvent/detergent plasma, have been associated with trali, but red blood cells, platelets and ffp are the most common. the incidence is unknown, but : plasma-containing transfusions is the most commonly cited figure. in % of patients, recovery is well underway within hours, and leads to complete resolution. death occurs in - %. the profile of the at-risk recipient has not been identified. recurrent cases have been infrequently described. there are two prevailing theories of pathogenesis: ( ) antibody-mediated and ( ) -hit hypothesis. evidence supports both concepts and neither is mutually exclusive. more than % of reported cases are associated with blood components containing either hla-specific (class i or ii) or hnaspecific antibodies. in % these antibodies correspond to at least one epitope in the recipient. most implicated components are donated by multiparous women. five percent of patients have hla or hna antibodies in their pre-transfusion serum. treatment requires prompt, assertive respiratory intervention, frequently necessitating mechanical ventilation. because trali has a much better prognosis than ards, it is an important diagnosis. some blood collectors are diverting plasma from multiparous donors away from ffp production or routinely screening for hla antibodies. the most effective method for identifying 'high risk' components has not been identified. introduction: trali is a life threatening adverse reaction of blood transfusion. it is characterized by noncardiogenic pulmonary edema developed soon after blood transfusion. in japan, we built hemovigilance system in and have been collecting the voluntary reports of severe adverse reactions of blood transfusion including trali cases since . since the diagnostic criteria of trali have not been established until recently and no specific diagnostic markers for trali have been discovered so far, it is very difficult to make proper diagnosis of trali in each reported case. we have been collecting the cases with respiratory distress and pulmonary edema developed after blood transfusion as suspected case of trali. we reevaluated each report whether it meet the recommended diagnostic criteria for trali published in transfusion journal in dec. . aim of the study: purpose of this study is to select trali cases which met internationally recognized criteria so that it will reveal the possible causes of trali with laboratory testing for anti-leukocyte antibodies in donors and recipients. methods: the cases with respiratory failure and pulmonary edema are selected for evaluation from the adverse reaction case reports voluntarily reported to japanese red cross. in order to make a proper diagnosis of trali, we have been utilizing the respiratory distress questionnaire which has recently revised. this helps us eliminate other adverse reactions such as circulatory overload, cardiac failure, anaphylaxis and bacterial contamination, which results in selecting out the internationally recognized trali cases properly. for laboratory testing, flowpra and labscreen for hla antibodies and gift-fcm for hna antibodies are performed. the cross-matching test is also performed if possible. results: during past years, cases of trali and cases of possible trali have been confirmed by critical review of each questionnaire. of cases of definite trali, donor specimens were obtained in cases. of cases, anti-leukocyte antibodies were detected in cases ( %) of donors' blood, which was significantly higher than the positive rate of anti-leukocyte antibodies in donors' blood of other adverse transfusion reactions (< %). of cases of antibody positive donors, anti hla antibodies were detected in cases, anti hna antibodies were detected in cases, and both were detected in cases. of cases of positive anti hla antibodies, class i antibodies were detected in cases, class ii antibodies were detected in cases, and both were detected in cases. on the other hand, the anti-leukocyte antibodies were detected in % of trali recipients, and this rate is almost the same with that of positive rate of other adverse reactions of blood transfusion ( %). these results indicate anti-leukocyte antibodies in the blood donors are one of the prerequisites for developing trali from the antibody-hypothesis-oriented point of view. other cases with no detectable antibodies should be investigated in more detail in the future. thus, reevaluating trali cases based on recommended trali criteria will allow us to reveal new information about trali. of adverse events analysed by the serious hazards of transfusion (shot) scheme ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , ( %) were haemolytic transfusion reactions (htrs). were due to incorrect blood component transfused (ibct): / were abo incompatible and / caused by other red cell antibodies. a further cases were reported as acute htrs (ahtrs; i.e. occurring within hours of transfusion) whilst were recognised more than hours after transfusion and reported as delayed htrs (dhtr). / ( %) patients died and suffered major morbidity. htrs associated with ibct result from clinical or laboratory errors and are all preventable. it has been assumed that other htrs are unavoidable. closer scrutiny reveals that this may not always be the case, though review is hampered by incomplete investigations. / ahtrs occurred in group a ( / ) or group b ( / ) patients given group o platelets. of the ahtrs related to red cell transfusion, were due to errors, were in patients with auto-antibodies, in only of whom alloantibodies had been adequately excluded/identified. at least / dhtrs were potentially avoidable; in cases the antibody was detectable retrospectively in the pre-transfusion sample; in cases the presence of a previous antibody was not communicated to the laboratory. two patient deaths related to dhtr might have been avoided by earlier diagnosis and clinical involvement. % htrs reported to shot would have been avoided by compliance with pretransfusion testing guidelines and provision of group a platelets for all group a recipients. htrs can be clinically overlooked and inadequately investigated. national guidelines are needed for the investigation and management of htr, with focus on the identification of underlying causes to guide the choice of future component therapy. reference laboratories can provide valuable support in elucidating complex serological problems. patients treated with high dose chemotherapy and autologous blood progenitor cell (bpc) support may get malignant cells reinfused together with stem cells. we analyzed bpc products collected from patients suffering from germ cell cancer measuring malignant contamination and followed these patients for up to months after transplantation also with the question if transplanted malignant cells influence survival. aliquots of stem cell apheresis products containing one million mononuclear cells were sedimented on glass slides and by immunocytochemistry quantitation of cytokeratin expressing cells was performed manually with light microscopy and by automated image analysis. in of patients ( %) cytokeratin expressing cells were detected in bpc apheresis products of patients treated for germ cell cancer. we followed the activity of the malignant disease of patients for more than eight years in median months after transplantation. no significant difference in survival was demonstrated for our two patient groups. background: the use of adequate number of peripheral blood stem cells (pbsc), collected by mnc apheresis is essential for effective treatment of hematological malignancies, solid tumors, and other disorders by transplantation. aims: the goals of this study were: (a) to obtain an effective apheretic protocol for mnc harvesting, and (b) to compare the hematopoietic reconstitution after hspc transplantations in different clinical settings. methods: in this study, pbsc transplantations - allogeneic from matched sibling healthy donors and autologous -were performed in the management of patients with severe aplastic anemia, leukemias (all, anll, cml), multiple myeloma, hodgkin's and non-hodgkin's lymphoma, breast and ovarial cancer, and extragonadal non-seminal germ cell tumor. pbsc mobilization was achieved with rhg-csf ( - g/kgbm/day). mnc-apheresis procedures (generally one and occasionally two) were performed using blood cell separator cobe-spectra. the first mnc-apheresis was accomplished when the leukocyte cont was - ¥ e /l (autologous setting) or on the th day - hour after the last rhg-csf administration (allogeneic setting). the processed blood volume during one mnc-apheresis was . - . l, and . l for one pbsc transplantation in average. results: using a minimal target dose of cd + cell count ( ¥ e /kgbm), performing one mnc-apheresis procedure for % recipients sufficient number of pbscs were obtained. the mnc yield was . ¥ e /kgbm in allogeneic and . ¥ e /kgbm in autologous setting in average. the mean cd + yields for allogeneic and autologous transplantations were . ¥ e /kgbm and . ¥ e /kgbm, respectively. hematopoietic reconstitution was achieved on the . th day for leukocytes and the . th day for platelets when pbsc transplantation was applied. summary/conclusion: improved mnc and cd + cell yield, as well as rapid hematopoietic reconstitution were observed when: (a) the intention of auditing any clinical practice is, ostensibly, to improve patient care. the term 'audit' implies comparison against a standard. although absolute indications for transfusion have not been defined by clinical trials applicable to most clinical situations, many institutions have established their own transfusion triggers based on their reading of the literature and common practice at that hospital. assuming these represent prudent guidelines, comparison of actual practice to them may allow physicians to re-assess their pattern of hemotherapy and bring it into conformance with the guideline. there are several common ways of performing transfusion audits. retrospective analysis of transfusions allows appreciation of the clinical situation (and its ultimate outcome) but reviews the event through a 'retrospectoscope' that assesses clinical information in a different manner than that available to the clinician making the decision to transfuse. furthermore, the time lapse between the decision to transfusion and feedback about that decision may render the feedback from the reviewing body (e.g., a transfusion committee or blood utilization review committee) of little practical import. to speed the provision of feedback and emphasize educational rather than any punitive outcomes of the audit, some facilities have abolished attempts at determining whether the decision to transfuse was supportable and have used electronic means to feed back to clinicians a non-judgmental informational message summarizing the literature regarding the indications for transfusion. this appears to be at least as effective as the traditional retrospective audit system. prospective review of requests for blood components have the potential to redirect practice in a manner that immediately helps patients. however, such interactions with clinicians may come at inopportune times, may require considerable (unscheduled) time, and are most likely to be fruitful if a knowledgeable transfusion medicine expert can serve as the intermediary. both approaches (or a combination) have been shown to be beneficial in altering practice, but efforts must be diligent and sustained. providing data comparing a physician's practice to colleagues in the same specialty may prompt additional introspection and practice change, particularly if physician leadership of the institution supports the effort as a quality improvement tool. extending the comparison to a group of physicians and contrasting their transfusion habits with benchmark data from other institutions may also be helpful, but one needs to be ready to counter arguments that differences in patient groups are the reason for the differences in practice (studies have shown that, in general, practice patterns are primarily related to training and habit rather than large differences in patient acuity). increased focus on the performance of hospitals as expressed in outcome data may soon extend to transfusion practices as well. the public or governmental institutions may ask to see data illustrating the transfusion practice of an institution and its improvement over time. carefully conducted, diligent, and ongoing transfusion audits are an integral part of an institution's quality improvement program. informed consent: the term informed consent, appeared for the first time in the late s but it was only in the s that it attracted attention with regard to health care. numerous discussions and publications have attempted to define the meaning and the justification of informed consent in recent years. initially it consisted in the obligation of the physician to disclose information to the patient, regarding the procedure he was to undergo, but more recently, ethicists have emphasized the need to ensure the patient's understanding and his autonomous decision to consent. current institutional rules of ethics demand that the physician must obtain the informed consent of a patient 'prior to any substantial intervention' . what is however the meaning of informed consent? is it a mutual decision making between physician and patient? in 'principles of biomedical ethics' beauchamp and childress claim that' it is critically important to distinguish informational exchanges through which patients elect medical interventions, from acts of approving and authorizing those interventions. the elements of consent include: disclosure, voluntariness, decision and authorization. when applying the concept of informed consent in transfusion medicine one can distinguish it into donors' and patients' consent. donor informed consent: information to blood donors constitutes a sensitive issue. it refers to their protection from side-effects of the donation, as well as to protection of the recipient. with regard to whole blood donors a detailed history and information as to side effects are necessary for first-time donors. for repeat donors one needs mainly an updated history. because of time-pressure, whole blood donors are usually given written information and are asked to answer written questions. donors however differ in literacy and even literate ones do not always understand medical terminilogy; so, during the interview one should probe the degree of understanding of each donor. with first time apheresis donors more time is needed in order to explain the procedure and potential side effects. since granulocyte and stem-cell donors require premedication with growth factors and or corticosteroids, the responsibility for detailed information is even greater. the fact that all donors sign the informed consent does not mean that they are all adequately informed! interviewers must be familiar with side effects, their frequency and sequelae and must pass on this information. misses and near-misses, (serious) adverse events and failures in medical practice seem to be not preventable. in medical interventions, preparing and prescribing of medication, assistance by doctors and nurses, medical treatment and follow-up, unwanted and unexpected events occur (http://www.mederrors.com.). these events happen also in transfusion medicine and focus on safety is not unique. haemovigilance which is defined in the eu blood directive as 'a set of organised surveillance procedures relating to serious adverse or unexpected events or reactions in donors or recipients, and the epidemiological follow-up of donors' (eu directive / /ec off. j. european union. . . :l / -l / ) is established to help in trying to identify and minimise the misses and (serious) adverse events in the chain from donor to recipient of blood components. the causes or reasons should be studied in order to prevent re-occurrence. adverse event reporting in blood transfusion and transfusion medicine is complex. it depends on the cooperation between blood establishments with clinicians and hospitals. it implies knowledge of blood banking, transfusion medicine and routine clinical care of all gender and ages, of potential hazards of transfusion, of immune-haematology, of microbiology, and of epidemiology. an adverse event may have its cause in every single part of the blood chain and reference may take place to a proven problem, a potential problem, or to a justified doubt. in almost all blood transfusion centres, a single donation will be processed into a number of different products, and these units might be divided or processed into more products. blood components are produced from whole blood or apheresis donations, and depending of the blood drawing and processing techniques, a high number of products with different specifications is prepared. the products' shelf life is not equal and therefore the moment in time of actual use of each unit prepared from the same donation may differ. in case the unit of platelets harms the recipient, a rapid alert can warn in order not to issue or to transfuse the unit of red cells or the unit of ffp prepared from the same donation because of the potential adverse reaction, which was detected during or after the transfusion of the first unit used. haemovigilance is not only important to blood establishments and to patients and prescribers, but it is also to clinical scientists, and to the public at large. it should provide a basis for minimising adverse reactions on blood components, and it should enable the therapeutic potential of new or established treatments with components to be maximised, since demonstrations of safety during widespread use may lead to extended usage, and wider availability. it is quite worrisome that underreporting is a general problem in medical care. it might be expected that in transfusion medicine the same rates of underreporting can be found, but also that the same mechanisms for improvement are applicable. although medical misses occur and do not seem to be preventable, the handling of these misses is often quite poor. many patients like to hear a detailed explanation, and the majority expects even apologies from the treating physician. it seems desirable to look for new routes in the prevention of unwanted events of transfusion medicine. for problem solving, analysis and improvement of working methods, where needed and possible, are often the most effective methods. attention should be focused on improvement and not on identification of the person who caused the problem ('bad apple'). lack of communication and insufficient insight in each other work are often the causes of problems and unwanted events. it should be recognised that advices given by the haemovigilance officer or the blood transfusion committee about prevention without the input and commitment of the direct responsible persons will lead in most cases to advices which are not effective or which will not be accepted. setting up a haemovigilance system or appointing of haemovigilance officers or installation of blood transfusion committees will not be sufficient. it will be necessary to develop ways of registration, data collection and analysis, but more importantly to support by giving advice and training to prevent reoccurrence of the adverse events or not optimal use of blood components. the confidentiality of the information should be guarded sufficiently. for a physician-patient relation, even after a medical failure, a 'blame-free culture' with a central role for openness and transparency is necessary. for blood establishments and hospitals, there is an important role in the right assistance and help of the physicians concerned both on a practical and on an emotional way. m-pa- years of shot data - : a view of transfusion safety in the uk and reactions. this will require investment in infrastructure, for which there must be a trade-off in improved transfusion safety. transfusion-transmitted infections and serious immunological reactions are rare; shot has highlighted the need for blood services to implement strategies to minimise bacterial contamination and transfusion related acute lung injury and will monitor their effectiveness. from the inception of shot it has been clear that the most frequent transfusion hazard is 'incorrect blood component transfused' i.e. a patient receiving a blood component intended for another person or not meeting appropriate requirements. only a minority of these events results in patient harm and is reportable under the terms of the directive. haemovigilance schemes such as shot, that analyse no-harm errors and near-misses, can reveal clues as to the root causes of 'wrong blood', which contributed to deaths and cases of major morbidity in the uk between and . analysis of such events shows that most errors occur in clinical areas, the most frequent being failure of the 'bedside check' . clinical audit data indicates that % of patients are transfused without a wristband or other form of identification, whilst anecdotal reports suggest that urgent clinical situations, massive transfusions and nocturnal transfusions are particularly error-prone. strategies aimed at reducing errors include structured education and competency testing, and methodologies, both high and low-tech, to ensure accurate patient identification in all circumstances. onethird of errors occurs in hospital laboratories; denominator data on laboratory workload shows that work done outside of 'core hours' accounts for % of all pre-transfusion testing but % of errors, suggesting that biomedical scientists 'on-call' or on shift work are working under pressure and beyond their competency. % of hospitals reported that they participated in shot in , but only % of eligible hospitals reported adverse events suggesting that transfusion hazards remain under-recognised and under-reported. however, benchmarking of 'wrong blood' incidents against transfusion activity shows that the number of observed incidents is roughly proportional to blood use. if haemovigilance data is to contribute to improved transfusion safety, clinicians must be encour-aged to report all events, thus contributing to an evidence base that can be used to effect change and facilitate learning. barriers to reporting include cumbersome systems, lack of time and resource, lack of feedback and fear of blame. transfusion practitioners have a vital role in the recognition and reporting of adverse events, education and clinical audit, but must be adequately resourced and supported by senior clinicians and managers through an active hospital transfusion committee. *provisional. m-pa- passing the borders: when, how and where d pirc-tiljak croatian institute of transfusion med., zagreb, croatia there may come that moment in professional life when you have to follow a strong professional and ethical need and confront your evidence-based statements with the leadership, passing the border of your own small society. in order to protect patient's health and respect human right to be informed about all possible consequences of irregular medical therapy, insisting on professional dignity and truth, you feel responsible and follow-up processing of your serious error report. once you pass the border, trying to warn authorities and find ethical resonance and critical confirmation of your professional fears, you are 'persona non grata' . methods/results: reality checking, personal experiences and observations studying the path of serious error report. although the qc system functions, yet omissions happen . . . the possible reasons could be: lack of knowledge, lack of experience, lack of independency, personal confront of interest, immature leadership, political influence, even corruption . . . how strict do the authorities manage a fault, bearing in mind the responsibility toward the patients under the risk. there is a need to create an available, effective international expert's board which will react and give professional counselling support-asylum for endangered professionals who found enough power to blow the whistle. who will hear it? transfusion transmitted infections (tti) are a major source of concern given the repercussions of hiv, hepatitis c, bacteria and vcjd transmission by blood components. large amounts of resource have been expended in making products safer and in maintaining public confidence in the blood supply. identifying emerging infections of concern is a major activity for many transfusion services. of the long list of emerging infections identified by disease control agencies around the world, identifying those responsible for tti requires, amongst other things, that: • the agent is identifiable. • it is present in blood • it causes a disease of concern. • it is transmitted by transfusion. • it is present at relatively low frequency. • if a test is available (nat, serology or immunoassay) what the infection window period is. once an agent has been identified various approaches are possible, including: • donor selection by testing, geography or lifestyle e.g. wnv; • product selection e.g. erythrovirus (b ) antibody or bacterial testing; • product treatment e.g. pathogen inactivation; • patient selection e.g. cmv matching, immune status. against this background where should our attentions focus? some agents of initial concern are now known to be ubiquitous and have minimal disease association (ttv, gbv) although transmitted by transfusion. for others (coronavirus -sars or the possible kawasaki disease agent, dengue, flavivirus encephalopathies, avian flu, etc.) this is less certain, with agents arising from species crossover being of particular concern (avian flu, vcjd, hiv). • enhancement of automation/computerisation; • process control to provide an 'error-free pathway'; • (national) surveillance and trend analysis of results, preferably based on national working standards; • significantly increased sensitivity, especially from development of antigen/antibody 'combi' assays (e.g. for hiv, and recently, for hcv); • awareness of hbsag vaccine-escape mutants and design of assays to cope with this; • extension of range of agents and markers tested for (varies in different countries); • increasing range of assays available for testing donors with a relevant history of exposure to malaria or chagas' disease infection (for retrieval of otherwise wasted blood); • european union's in vitro diagnostics directive: this has caused some problems and reduced flexibility. nucleic acid testing (nat): nat continues to increase in blood service usage world wide, although not (as yet) to replace serological methods. trends include: • reduction in sample pool size; • increased automation (and process control); • increased multiplexing to detect or more agents in the same assay; • increased number of agents being tested by nat (varies in different countries); • introduction of rapid and flexible nat to detect west nile virus, in north america. bacterial screening of platelet preparations: several countries have introduced (or will introduce) routine screening of platelet concentrates either with biomerieux, bactalert or pall ebds ( depletion assessment). other bacterial testing methods are under active assessment, some rapid enough for possible 'point of use' testing. m-pa- evaluation of in vivo red blood cell recovery after processing with a new filter designed to reduce prions e nelson*, h taylor † , p whitley † and t lieu* *pall medical, covina, ca, † american red cross and evms, norfolk, va, usa background: a filter, called the leukotrap affinity prion reduction filter (prf b filter, pall medical), has been developed to reduce the level of infectious prions, associated with several fatal neurodegenerative diseases including variant creuztfeldt-jakob disease (vcjd), from leukocyte-reduced red cell products. aim: the objective of this study was to evaluate the quality of leukocyte-reduced red cells (lr-rbc) processed through this filter and stored for days. red cell quality was determined by measuring the in vivo red blood cell recovery hours after re-infusion of the -day stored red cells. storage hemolysis and atp were also determined. methods: units of blood ( ml) were collected from normal volunteers into the leukotrap wb system containing cp d/as- anticoagulant/preservative solutions (pall medical). units were either processed to lr-rbc within hours at room temperature (rt units), or after hours at - °c (cold units). the prion filter set was sterilely connected to the units on day , and the units were filtered and stored for days. samples were taken pre-and post-prion filtration and post-storage for plasma hemoglobin and atp determinations. post-storage samples were taken for labeling with -cr radioisotope, re-infusion, and determination of the -hour in vivo rbc recovery. a donor sample was also labeled with m-tc to allow for red cell mass determination. thus, both single-and double-label -hour recovery values were calculated. results: twelve units were collected. in vitro testing was completed on all units. in vivo testing was completed on units. the mean single-label -hour recoveries were . % and . % for the rt and cold units, respectively. the mean double-label recoveries were . % and . % for the rt and cold units, respectively. the overall combined mean in vivo and in vitro results are shown in the table. conclusion: the -hour in vivo red cell recovery means are well above the fda and council of europe's requirement of achieving a mean post-transfusion survival of no less than % of the transfused red cells, and they are comparable to this center's previous results of red cells filtered using the licensed leukotrap rc system with cp d/as- (pall medical introduction: to reduce the risk of platelet transfusion-associated sepsis (tas), methods to routinely screen for bacterial contamination have been implemented. pathogen inactivation treatment of labile blood components provides an alternative means to prevent tas. the intercept blood system for platelets (baxter healthcare) has received the ce mark and has been introduced into clinical practice. aims: this study compared the efficacy of bacterial screening using a culture method (bact/alert system, biomerieux) with pathogen inactivation (intercept blood system) for prevention of transfusion of platelet components contaminated with bacteria. methods: seven strains of bacteria associated with tas, including gram-positive staphylococcus epidermidis, streptococcus agalactiae, and staphylococcus aureus, gram-negative escherichia coli, and klebsiella pneumoniae, and the anaerobes propionibacterium acnes and clostridium perfringens were studied. for each strain, three double-dose platelet concentrates (~ ¥ e platelets in ml of % plasma and % intersol) were collected using the amicus® cell separator. on day of collection, calibrated stocks of bacteria ( , , cfu) were added to the double units. each double unit was divided into two identical products containing , , or cfu of bacteria and stored overnight under conventional blood bank conditions. the control platelet concentrate was not treated. the test platelet concentrate was treated with the intercept process ( mm amotosalen + j/sq cm uva). both units were cultured using the bact/alert system at the time of bacterial inoculation and on days , and of storage. samples ( ml) were taken for both the aerobic and anaerobic cultures. a platelet sample was considered contaminated with bacteria if a positive signal was registered within hours of culture. results: for control platelet concentrates, cultures failed to detect low-dose inocula. the time to positive culture varied with the bacterial strain, contamination level, and time of sampling. at and cfu per product, strains (s. epidermidis, e. coli, c. perfringens, s. agalactiae) and strains (e. coli, c. perfringens) tested negative after days of platelet storage, respectively. k. pneumoniae tested positive after - hours of culture when sampled on day of platelet storage for both and cfu per product. at cfu per product, p. acnes tested negative in aerobic culture and c perfringens tested negative in anaerobic culture after days of platelet storage. the anaerobic cultures of p. acnes became positive after hours of culture when sampled on day of platelet storage. of the strains studied, only s. aureus consistently tested positive after - hours of culture. in contrast, all test platelet concentrates treated with intercept remained negative by bact/alert cultures throughout the entire -day observation period regardless of the strain and the contamination level. conclusions: bacterial detection using cultures may fail to detect low levels of bacteria typically associated with platelet contamination at time of collection and processing. failure to detect bacteria will result in the release of contaminated platelet products with 'test negative-to-date' status. in contrast, inactivation of bacteria is capable of preventing release of contaminated platelet components. background: since nat implementation for hiv- and hcv rna in france, the residual risk (rr) of transfusion-transmitted infections (tti) has dramatically decreased. the rr estimates, for a threeyear period from to showed a significant decrease from / and / before nat implementation to / and / after nat implementation for hiv and hcv respectively. as for hbv, the serological screening is only based on both hbsag and anti-hbc assays. for the same period, the rr estimate for hbv is / , five times higher than hiv one and times higher than hcv one. aims: as the overall rr of tti is mainly related to hbv, and given the availability of hbv nat assays, a study was conducted to determine whether hbv nat has the ability to further reduce the hbv rr and then should be implemented in blood donor screening in france. we have estimated the wp reduction by nat in comparison with one of the most sensitive hbsag screening assays, on commercial seroconversion panels (bioclinical partners, franklin, ma, usa). the nat test was the procleix ultrio assay (genprobe/chiron, san diego, usa). the hbs ag test was the prism hbsag (abbott, france). the comparison was performed on both neat samples and diluted samples / , / , and / , in order to simulate minipools of different sizes. then, we have calculated the yield of hbv-infected donations detected by nat relative to prism hbsag assay. results: on the basis of a window period (wp) of days, ultrio assay is projected to close the wp by an average of days on undiluted samples, days in minipools of samples, days in minipools of samples and only days in minipools of samples. the projected yield calculated on the basis of . million donations collected per year in france, would be . unit per year for minipool-nat and to units per year for individual donation nat. conclusion: introduction of minipool-nat will offer only a little added benefit to transfusion safety relative to current serological screening strategies based on both hbsag and anti-hbc assays. hbv minipool-nat is then unsuitable for hbv screening in french blood donors. single-sample nat or minipool-nat with smaller pool sizes and/or modified procedures (genome enrichment or test improvement) would be more relevant. automation when technologically and practically feasible is a prerequisite for single-donation nat. therefore, decision has been made not to implement hbv nat in the french transfusion network until fully automated systems will be available. however, as the prevalence of hbv infections is higher in the overseas territories than in continental france, and as nat is performed on individual donations in these sites, hbv-nat has been implemented since december in these territories. combined detection of hepatitis c virus core antigen and antibody as an alternative to nucleic acid testing in blood screening grating the capillary cytometer with a robotic workstation and a small footprint centrifuge. significantly, there was no decrement in system performance following automation: of clinical samples ( . %) typed identically with this system and cat, and of the discrepant results were eventually resolved in favor of the automated cytometry method. testing showed high-throughput capabilities (currently samples/day) and was inexpensive. to demonstrate the flexibility of this testing platform, we also developed a method to perform completely automated counting of residual wbcs (rwbc) following leukoreduction of blood components. there were no significant differences in accuracy and precision when rwbc in analytical controls and authentic clinical samples were quantitated by the automated capillary cytometry method or the leucocount method performed manually. given the flexibility of this system, it is very likely that additional blood bank assays could be modified for high performance automated testing on this platform. noninvasive prenatal genotyping on cell free fetal dna in maternal plasma ce van der schoot sanquin research, amsterdam, netherlands in lo et al. demonstrated that in the maternal circulation small amounts of cell free fetal dna are present, concentrations ranging from on average genome equivalents(geq)/ml early in pregnancy to about geq/ml at the end of pregnancy. most likely this dna is derived fom apoptotic syncitiorophoblasts. the human placenta is hemichorial, which means that the syncitiotrophoblast is in direct contact with the maternal blood flow, and apoptotic nuclei are directly released into the maternal circulation. the cell free dna is very rapidly cleared from the circulation, the t / being only minutes. in we have shown that this cell free fetal dna could be used for rhd genotyping. in the last years many groups have shown the successful application of different prenatal genotyping assays such as fetal sexing, thalassemia, achondroplasia, duchenne's disease, adrenogenital syndrome etc. on this source of dna. importantly, no false positive result have been described due to the presence of fetal dna from previous pregnancies, the main draw back of prenatal diagnostics on circulating fetal cells. at present prenatal rhd genotyping has been introduced in routine diagnostics in the united kingdom, france and the netherlands. in large scale high throughput studies it has been shown that the diagnostic accuracy of prenatal rhd genotyping is over %, and it is to be expected that in the netherlands this screening will soon be introduced to restrict the antenatal anti-d immunoprophylaxis to women carrying rhd-positive fetuses. in a large european project (safe, co-ordinator maj hulten, warwick uk) many researchers collaborate to further explore the possibilities of cell free fetal dna for future diagnostics. standard operating procedures for the isolation of plasma dna have been established. control pcrs for the presence of fetal dna have been developed. recent findings on differences in methylation status of placental genes in fetal dna opens new possibilities. the main technical problem that hampers wide application of prenatal genotyping is the impurity of the fetal dna, only - % of the cell free dna in plasma is from fetal origin. this makes diagnostic assays on numerical chromosomal abnormalities impossible. and also for many single nucleotide polymorphisms (snps) such as almost all blood group antigens, assays are hampered by aspecific amplification from maternal dna. our own preliminary results indicate that this latter problem can be solved by pna clamping. the addition of a pna probe specific for the k-allele partial d feature d antigen alteration, often identified as distinct 'partial' d epitope loss. the clinical impact of partial ds is due to the ability of their carriers to form anti-d antibodies upon confrontation with regular d after transfusion, or pregnancy. this leads to the -naively spoken -contradictory finding of an allo anti-d antibody in a d positive individual in connection with a negative autocontrol. the antibodies themselves include the same fatal clinical potential as anti-d antibodies of d negative individuals, but may be even more hazardous since unexpected in d positive individuals a priori. d categories (ii to vii) represent a nomenclatorily defined subgroup of partial ds. the molecular cause of partial d lies within single (caused by point mutation in the respective rhd gene sequence), or multiple amino acid exchanges (caused by gene conversion events leading to rhd-rhce-rhd hybrid genes) which determines a qualitative d antigen alteration, rendering them distinguishable from regular d by a partial d carriers immune system. nowadays, transfusion specialists and gynaecologists are more or less aware of these facts and are taking them into consideration in the clinical setting. most partial d exhibit decreased d antigen density, enabling principal recognition of them. however, routine serological methods may not properly recognise all partial ds and will identify their carriers after immunisation only, which represents a reactive diagnostic/therapeutic attitude second best to an actively prognostic one. this actively prognostic proceeding with respect to early detection of partial ds became widely feasible by rhd dna typing techniques. currently, routine rhd dna typing techniques offer an affordable, accurate and fast approach to an unambiguous identification of partial ds and their reliable discrimination from weak d types, not at risk for allo anti-d immunisation. a reasonable proactive proceeding could e.g. demand for (once in a lifetime) routine rhd dna typing of all weakly expressed ds as defined by serology, since most partial ds also meet this phenotype. rhd allele frequencies and their geographical and regional prevalence will certainly have an important impact on dna typing strategies and their (mandatory) specificities. fluorescence cytometry for completely automated immunohematology testing d roback*, b barclay † and d hillyer † *emory university school of medicine, atlanta, † transfusion & transplantation technologi, decatur, ga, usa we previously described a methodology for accurate immunohematology testing by fluorescence cytometry [roback, j.d. et al. ( ) transfusion ( ), ]. this system utilized low-speed centrifugation of -well filter plates for red cell staining, and a smallfootprint capillary cytometer for data acquisition. when authentic clinical samples from hospitalized patients were tested for abo group, the presence of d antigen, and red cell alloantibodies, the results were well-correlated with those obtained by commerciallyavailable column agglutination technology (cat). this system determined the correct abo group and d type for . % of samples, compared to . % for cat (p > . ). when samples were tested for unexpected alloantibodies, fc determined the correct result for . % of samples, as compared to . % for cat (p > . ). this novel method was better than cat at detecting weak anti-a (p < . ) and alloantibodies. based on these promising results, we sought to completely automate this method by inte-prevents the aspecific amplification of the k-allele, and makes it possible to detect the fetal k-allele in the presence of excess of maternal k-alleles. furthermore, it has been shown that fetal dna is in the plasma present in shorter fragments (< bp) than maternal dna. size separation of cell free fetal dna can therefore be used to increase the relative concentration of fetal dna, which will help the development of new genotyping assays. in conclusion, cell free fetal dna in maternal plasma is nowadays routinely used for prenatal rhd typing and fetal sexing. new technical developments will make it possible to extend these indications to other blood group antigens in the near future. more insight in the characteristics of fetal dna might finally lead to wider applications, including numerical chromosomal aberrations. furthermore, it might become possible to apply genomic dna microarrays for the screening on many different inherited diseases, including hemoglobinopathies. determination of the affinity of anti-d present in the serum of immunized subjects and in anti-d ig preparations by a method using unlabeled antibodies p lambin*, m debbia* and y brossard † *institut national de la transfusion, † chp hopital saint antoine, paris, france introduction: few data are available concerning the affinity of maternal anti-d responsible for the hemolytic disease of the fetus and the newborn (hdn), and the affinity of anti-d immunoglobulin used for the prophylaxis of that disease. we recently described a method to measure the affinity (ka) of untagged anti-d monoclonal antibodies. aims of the study: in this work, a similar method was applied to determine the affinity constant (ka) of polyclonal anti-d present in the serum from d-immunized mothers and donors and from anti-d ig preparations. methods: a constant amount of o r r rbcs was sensitized with increasing concentrations of anti-d present in the sera from immunized subjects, and in anti-d ig preparations. at equilibrium, the amount of anti-d bound to rbcs was measured by elisa. the scatchard equation (linear regression) and the langmuir equation (hyperbolic regression) were used to determine the ka of anti-d. the experimental data fitted well with the scatchard equation (mean r † = . ) but a better correlation was observed with the langmuir equation (mean r † = . ). in maternal sera, the mean ka of anti-d was . ¥ to the m- (from . to ¥ to the m- ). in the sera from immunized donors, the mean ka was . ¥ to the m- (from . to . ¥ to the m- ) and in lots of anti-d ig, the mean ka was . ¥ to the m- (from . to . ¥ to the m- ). the comparison of anti-d affinity measured in cases of hdn in which infants presented a fetal anemia and in cases of hdn in which infants presented only a postnatal anemia showed no significant difference. the mean value of ka in the cases of fetal anemia was . ¥ to the m- whereas in the cases of postnatal anemia the mean value of ka was . ¥ to the m- . conclusion: the method previously described for monoclonal anti-d was applied to polyclonal anti-d present in the serum of d-immunized subjects and in ig preparations. the experimental data fitted well with the langmuir equation, and the affinity of polyclonal of anti-d was measured with accuracy. in addition, no significant difference was observed (at least in the cases of this study) between the affinities of anti-d measured in the most severe cases of hdn (fetal anemia) and in the less severe cases of hdn (post-natal anemia). introduction: cryopreservation of platelets is widely used in platelet immunology to ensure the availability of well characterised panel cells for the detection of hpa antibodies. but recovered platelets do not express the hpa- alloantigens. aim of the study: here we describe a method for the successful preservation of platelets by lyophilization. we report the value of this new reagent for the detection of hpa alloantibodies and especially anti hpa- alloantibodies. methods: rehydrated lyophilised platelets (lyo p) were tested for their reactivity with monoclonal antibodies against gpiibiiia, gpibix, gpiaiia and cd by flow cytometry. the levels of reactivity were comparable with the ones obtained with fresh platelets. the rehydrated platelets were used in the maipa with a panel of hpa antibodies (anti-hpa- a, ; anti-hpa- b, ; anti-hpa- a, ; anti-hpa- a, ; anti-hpa- b, ; anti-hpa- a, and anti-hpa- b, ). results: all hpa antibodies showed the expected pattern of reactivity and in several cases absorbance reading were well above those obtained with fresh platelets. absorbance values produced by inert sera were comparable with those obtained with fresh platelets (ranges . - . ). interestingly, we used lyophilized platelet with a high expression of cd bearing the hpa- system and we have detected anti hpa antibodies among sera previously negative with fresh platelets. nineteen sera concerned patients suffering from hematological diseases and from pregnancy women. conclusion: lyophilized platelets are possibly an ideal reagent for the platelet immunologist to be used for the detection of hpa antibodies. moreover, this work bring new insights on the hpa- system in platelet transfusion. we are now pursuing more extensive validation studies with a larger number of samples representing all known hpa specificities and several diseases. the diagnosis and treatment of sick infants and children requires a broad knowledge of physiology, biochemistry, genetics and the application of sophisticated testing and treatment options. one of these options is transfusion of blood and blood products. transfusion of the infant, especially the premature infant, and sick child, especially those with major organ dysfunction, requires careful consideration of their unique metabolic, hepatic and renal clearance mechanisms. guidelines that direct the indications for transfusion differ from those in adults. non-invasive measures of oxygen delivery and oxygen offloading may assist in guidelines for red blood transfusion. metabolic complications from massive transfusion and/or the manipulation of blood products must also be considered. evidence from a high quality randomised controlled trial suggests that anaemia is also well tolerated by critically ill patients. a restrictive approach to rbc transfusion that maintained the hb concentration between and g/l was found to be as effective as and possibly superior to a more liberal strategy of maintaining the hb concentration between and g/l. there are concerns that some groups of critically ill patients, such as those with cardiovascular disease and patients who are difficult to wean from mechanical ventilation, may benefit from higher hb levels. rbcs also have a role in primary haemostasis and higher triggers may be appropriate in coagulopathic patients. it is important to realise that blood is not a uniform product and the clinical efficacy of rbc transfusion may vary. one factor that may have a considerable effect on the quality of the rbc product is the storage time. rbcs undergo marked changes during refrigerated storage. the implications of these changes on tissue oxygenation are not known but these concerns have led some clinicians to request 'fresh' blood for critically ill patients. there is insufficient evidence to support such practice. it is of great practical importance to determine if, or when, fresh rbcs could be superior to stored rbcs. background: with a decreasing blood donor base, fully tested, fresh unrefrigerated whole blood (fuwb) has been found to be a more efficient and effective use of a limited resource in place of, or as an adjunct to, traditional blood component therapy in surgical situations associated with massive blood loss. aims: to outline the use of fuwb in situations where there is potential for intractable bleeding associated with major surgery, and evaluate platelet function in fuwb versus platelet components. methods: outcomes of fuwb and traditional blood component use were examined for cases of cardiac bypass surgery. in addition, exclusive use of fuwb for burns debridement cases was analysed. an evaluation of platelet function in whole blood compared to platelet components was also performed by measuring platelet aggregation and activation parameters. results: there was a decreased requirement for blood components following administration of whole blood post cardiac surgery. whole blood usage for burns debridement surgery eliminated the requirement for additional blood components. platelet activation was markedly reduced in whole blood compared to component platelets, and this may be one reason for the increased efficacy of whole blood in these clinical settings. conclusion: fuwb appears to have a role in minimising blood product requirements and consequent donor exposure in situations associated with massive blood loss. m-pa- transfusion practice for coronary artery bypass surgery in greece s lakoumenta, m vassili, g hatzidimitriou, t asteri, p stratigi, s kanellas and g palatianos hellenic society of blood transfusion, athens, greece cardiac surgery is associated with a demand for allogenic blood and blood product availability as well as a considerable consumption. the impact of consensus guidelines for allogenic blood transfusion during coronary artery bypass graft surgery (cabg) in us attracted great attention . the present study is conducted in order to reveal the transfusion practice in greece on a similar population i.e. patients undergoing cabg operations. methods: five participating centers collected data concerning transfusion of allogenic blood and blood products in patients undergoing elective first time cabg procedures, as well as parameters that may influence blood loss, such as duration of the operation, cardiopulmonary bypass time (cpb) etc. the total estimated blood loss was calculated as the sum of red blood cell volume reduction [(body weight in kg ¥ ml/kg) ¥ (admission haematocrit-discharge haematocrit)]+(red blood cell volume transfused). results: results are shown in table : means, standard deviations, and p-values of the wilcoxon test comparisons between the hospitals. a preliminary analysis of data from centres ( patients) showed no difference in patient characteristics (age, body weight, male to female ratio). there is a statistically significant difference (p < . ) between the five centers in duration of the operation, cpb, estimated blood loss and volume of transfused plasma. red cell use showed also a variation which however did not reach statistical significance (p < . ). the center with the highest figure for blood loss has the lowest volume of allogeneic red cell transfusion because of the use of cell salvage. conclusions: although variations, as those observed in greek cardiac surgery centers, have been documented in other countries, the variation in the use of plasma is striking and we are in the process of trying to identify the reasons. our study is in progress and additional data are being collected and will be presented. introduction: premature infants and at term newborns have an higher circulating blood volume per kilogram than the adults ( ml/kg in premature; ml/kg in at term), for this reason, in case of neonatal thrombocytopenia, a specific hemocomponent, with a very high platelet concentration, needs for transfusion therapy. the laboratory criteria for platelet transfusion are the following: (a) a plt count < ¥ cells/l if bleeding is observed; (b) a plt count < ¥ cells/l without bleeding; (c) a plt count < ¥ cells/l in newborns showing critical clinical conditions. aim of this study: in this study, we have monitored the plt transfusion therapy in our neonatal intensive care unit (nicu) in the last four years. methods: effects of plt transfusions have been followed in children ( premature infants and at term newborns). the weight of premature infants ranged from - g and at term newborn from - g. gestation age of premature infants ranged from - weeks and of at term ones, of course, from - weeks. for every platelet transfusion in these newborns, the volume of platelet concentrate has been of - ml/kg, with a plt count < ¥ cells/l. results : in the study period, plt transfusions have been performed: children have been only transfused one time, while multiple plt transfusions (ranged - ) needed for children according to clinical conditions. the observed clinical indications for transfusions have been the sepsis with haemorrhagic syndrome ( cases) , haemorrhagic syndrome without sepsis ( cases) and neonatal alloimmune thrombocytopenia without haemorrhagic syndrome ( cases). after hours from transfusion therapy, the absolute plt count and the correct count increment have increased in all little patients. the highest increase in plt count was ¥ cells/l, while the lowest ¥ cells/l. no difference in the efficacy of therapy has been detected between premature group and at term group. % of children have been discharged from hospital in good general conditions without complications in following controls. in conclusion, we can affirm that plt transfusion in premature infants and in at term newborns is an efficient and safe treatment of severe haemorrhagic conditions. however a collaboration between nicu and transfusion center is necessary to choice the adequate platelet concentrate's volume for transfusion and the best plt donor for the newborn. developing transfusion strategies fusion society of turkey (bbtst) in with contribution of blood transfusion centers. according to these figures % of centers attended operates apheresis procedures. two centers informed us that apheresis in the hospital was carried out at blood bank. there was not enough information from one center, so it was excluded. of the blood banks performing apheresis, were university hospital blood banks. another blood banks were producing both productive and therapeutic, produce only productive and produce only therapeutic procedures. one center did not respond. all centers reported to prepare and separate erythrocyte and plasma. however only centers reported to prepare random platelets as well. each center had apheresis machines between - . a total of centers was carrying out around < procedures, around - , at centers about - , at a further centers around - procedures a year (one center was excluded). of the responders to the survey , all procedure were done at blood banks, whereas at of them all were carried out by the hematology clinics. at other centers, productive procedures were conducted by the blood bank, and therapeutics were performed by the hematology division. a total of blood banks stated that they have not kept the platelet suspensions produced and used them straightaway. productive apheresis center capacities were as shown: centers < , centers - , centers - and centers > units have donations a year. around % of all apheresis procedures were carried out by large well run blood banks. conclusion: as the use and production of random platelets increase, and settle of apheresis devices in big centers will eventually decrease the demand of apheresis procedures and keep the welltrained staff at big centers, decrease the cost thereafter. • planning of resources for the financing of the bts, adoption of a methodology for creating and adjusting the price list of products, adoption of the yearly plan of needs for blood/products and services of health institutions which use blood/products. • achieving recognition of real costs of products and services from the health insurance fund and ministry of health. • harmonization of low level of acclaimed costs and real costs of basic transfusion activities. results: acclaimed costs for activities in transfusion practice (collection, testing, processing, storage, distribution and transport) as a reflection on the price of the products are % lower than real costs. the prices of health services in the official price list are much lower than the proportion of costs of material resources needed for the realization of these services. this especially affects the management of independent blood establishments (bti's in serbia) with core blood transfusion activities as their basic field of work, in comparison with the hospital based transfusion services, which are financed within the budget of the whole hospital. the hospitals with hospital based transfusion services involved partly in core transfusion activities are completely financed by the health insurance fund, while independent blood establishments are financed through the price of products and services they provide. conclusion: in order to provide adequate quantities of safe blood/products for the end user -the patient, it is elementary to create stabile and equal financial management conditions for the whole blood transfusion service in serbia. this can be achieved only by continuous cooperation of the health insurance fund, ministry of health and independent blood establishments. sion centers (rbtc). the activities on promotion and organization of voluntary, nonremunerated blood donation, blood collection and patients' services are carried out in the rbtc and in departments of blood transfusion (dbt), part of the district hospitals. the collected units in dbt are transported by special cars to the ncht and the rbtc for processing, testing and control. the same transport is used for the requested by dbt blood components for storage and distribution to hospital departments. thus the issued components are with an equal quality and safety for all patients throughout the country. lbbdbt introduces hemovigilance as a mandatory system, covering the whole chain of the blood transfusion process. it includes as well the creation of registries at a national, regional and district level of blood donors, recipients of blood products and all activities of the blood transfusion service. . seventy hospitals are exclusively users of blood, blood products and services. the current organization of blood transfusion services faces the following problems: fragmented transfusion service, lack of a national blood policy, the blood program is not nationally coordinated, limited knowledge on quality management, inadequately distributed human resources, limited material resources, lack of it system, lack of planned, continuous skill upgrading. as a direct consequence we have: suboptimal blood collection activities, inadequate blood supplies significantly vary between seasons, high percentage of replacement donors, outdated methodologies, old, even obsolete equipment, the quality of blood products is not standard, there is a lack of traceability. aim of study: to reorganize blood collection activities in serbia to increase collection of safe blood up to % ( blood units). methods: division of responsibilities between blood establishments and hospital based transfusion services by: • optimizing organizational structure • implementing blood collection standards to enhance blood safety and donor care • gradually replacing family donors with a network of voluntary non-remunerated blood donors from low risk population groups • creating and implementing a training strategy. results: through the eu funded project support to a national blood transfusion service in serbia, we are in the effort of integrating the services and standardizing their work. the blood collection working group began by dividing serbia into blood collection regions: north, central, and south. each region is divided into sub regions covering approximately half a million population ( in the north, in the central and in the south region). each sub region will have one standard mobile blood collection team to collect blood units daily, i.e. annually. the blood units per teams provide the blood units ( %) to cover hospital needs in serbia. to this effect, the following has been achieved: • blood collection activities in serbia analyzed • performance analysis of bte and hbts mobile teams in place • two model standard mobile teams tested in the field • national blood collection sop's written • national donor questionnaire form prepared • national set of blood collection standards prepared • list of donor deferral criteria prepared • blood collection equipment renewed • regional reorganization plans in progress. the objectives and results can be achieved by the participation and mutual cooperation of all institutions involved in blood transfusion within an integrated, standardized system with clearly delegated responsibilities. p- years of the national blood transfusion institute in serbia n nedeljkovic national blood transfusion institute, belgrade, yugoslavia nbti was founded in . since and unpaid blood donation is mandatory, organized in cooperation with red cross. blood donation is regulated by the law in , / . codex of voluntary blood donation and health care staff has also been established; blood donors donates blood annually. in the past years, there was over million blood donations, performed in accordance with who regulations. over transfusion medicine specialists and technicians specially trained for the work in blood transfusion service (n = ), perform transfusion medicine doctrine of rational labile blood component and stable blood derivatives therapy, based on the selfsufficiency concept in fr yugoslavia with . million inhabitants in serbia, montenegro and kosovo. plastic blood containers and tests are imported or given as humanitarian aid gift and from . now, they have been regulated by tender. in , test to lues was introduced, to hbsag in , to a-hiv in and to a-hcv in . information system was introduced in . nbti includes: national haemovigilance coordinatoin center, center for medical care of haemophiliacs, tissue typing center, center for prenatal and perinatal protection of pregnant women and newborns. activities of nbti are organized through: center for planning, organization and development of blood transfusion service, center for blood collection, preparation and distribution, center for immunology and immunochemistry, plasma fractionation center for plasma in west balkan countries, center for diagnostics means, center for quality control of drugs and medical and diagnostic means, center for education and training and scientific research work. nbti is the third year of gmp, sop, yus iso implementation. in the current reform of transfusiology system we are aiming for percent of voluntary blood donation. nbti is the publisher of the national bulletin of transfusion medicine and it is included in the education system of the belgrade university medical faculty and the estm in belgarde . the problems of blood service in russia ea selivanov and t danilova russian inst. of hematol. & transfusiol., st. petersburg, russian federation background: the blood transfusion service (bts) development as a platform for providing the hospitals with blood and blood derivatives is an important national problem. aims: russian blood service assessment with international comparison. methods: a study was conducted on the base of the reports from all regions of russia followed by a computer statistical analysis. results: blood and blood components were collected in the russian federation in in stations of blood transfusion and in blood transfusion departments at big hospitals. amount of donors in was equal to , voluntary donors being . % of them. the average number of whole blood donations in relation to the general population is per inhabitants, and on average percent of the donor base consists of first time donors. the average number of blood collected in relation to the general population and health care system is . ml per inhabitant and ml per one bed. an average volume of one blood donation is ml. blood was collected into plastic bags containing domestic or foreign anticoagulants. about . % of collected blood is used for procurement of blood components and preparations, . % of banked blood is used for transfusions. amount of donors and the volume of whole blood have been significantly decreased for the last years. at present in russia all donations are tested for abo blood group, rh(d) type, anti-hiv- / , hbsag, anti-hcv and syphilis. the total percentage of blood discarded after testing for transfusion-transmissible infections is . %. % of plasma is obtained by plasmapheresis. blood components collected are as ffp, rbc, frozen rbc, eukocyte-and platelet-depleted rbc, rbc suspension, and preparations: % albumin, immunoglobulins, and cryoprecipitate. as to blood safety measures -implementation of blood components leucodepletion and ffp and rbc quarantine in process. the new national strategy of bts reorganization has been developed. it includes the following: increasing the visibility and resource commitment to blood issues at the national, regional and municipal levels; the national voluntary donor programme promoting; blood safety increasing; blood collection, testing and pro-cessing concentration in federal and regional bts establishments, appropriate blood and blood components usage. calculating the cost of blood in turkey n solaz, s kemahli and s cin ankara university, ankara, turkey background: like other fields of the medicine cost efficacy is gaining importance in blood banking and transfusion medicine since last few years. since last years even the most developed countries started to discuss about the cost of blood. in turkey ministry of health determines the cost of blood annually. aim: to establish a safe, cost effective and reliable prices for blood components. methods: turkish ministry of health (moh) started to determine the cost of blood components as 'all inclusive' principle. this means that cost of a unit of blood component will cover all conventional expenses such as; blood typing, infectious screening, labour, consumables, etc. this system has provided uniformity to blood component costs but if the system is not controlled and followed properly it will cause serious risks. there might be some blood banks which will not respect the safety regulations and may modify the test standards for decreasing the cost of tests. conclusion: current blood product pricing system looks generally reasonable and reliable but moh should establish close follow up systems for avoiding any abuse on the safety of blood. background: a positive direct antiglobulin test occasionally occurs in normal blood donors, and is often discovered when the donor's red cells are found incompatible in a compatibility test. the incidence of a positive dat was expected to increase since more sensitive techniques (gel test) were installed. the aim of our study was to examine whether dat positive otherwise healthy donors presented any clinical or laboratory abnormalities. methods: in the first . cross-matches last year (in months) were found incompatible due to dat positivity of blood donors' red cells ( . %). dat positive [( +)-( +)] samples were only igg positive in cases, only c d positive in and igm positive and c d positive in case. all blood donors were notified and thirty two of them responded to a request for a further sample. a complete blood count, a reticulocyte count, bilirubin (total, direct, indirect), transaminases, serologic immunological tests (ana, anti-dna, anti-ena, rf, anticardiolipin antibodies), quantitative assessment of immunoglobulins, aptt and lupus anticoagulant were performed, as well as serologic tests for markers of viral infections. dat and iat were performed by gel test (id-diamed) according to the manufacturer's instructions. dat were performed with polyvalent and monovalent reagents (anti-igg, -igm, -iga, -c c, -c d). the blood donors were also examined clinically. the donors who had positive immunological tests were referred to a rheumatologist for further investigation. results: among the thirty one blood donors eight had received medication the last hours before blood donation, two had been vaccinated for hepatitis b recently, four presented signs of a viral infection soon after blood donation, three had evidence of an allergic condition, five had positive tests for anticardiolipin antibodies and ana, two were positive for anticardiolipin antibodies only and two had a positive ana test only. in six blood donors we did not find any abnormality that might be interrelated to dat positivity. conclusions: all blood donors with positive dat should be requested to undergo further investigation. some of them are possibly candidates to long medical follow-up, especially those with other immunologic abnormalities such as positive ana and/ or anticardiolipin antibodies. the eligibility of such donors for future donation of whole blood, platelets or plasma needs to be elucidated. tions: usefulness, frequency and sincerity in answering questions. donors could choose one of the offered answers and elaborate in writing the answer they have chosen. results: of the donors that participated in the survey ( . %) answered the questionnaire, ( . %) men and ( . %) women. that the survey was useful thought % and % that it was not. opinions were elaborated by . %. that the questionnaire should be completed before each blood donation was the opinion of . %, % thought it should be filled out only the first time blood is donated and . % that the questionnaire should not be completed at all. the answers given were sincere in . % of blood donors, % were not and . % were given automaticallywithout comprehension. conclusion: most donors believe that completing the questionnaire before each blood donation is an effective way to increase safety by preventing potentially infected individuals from donating blood. they are also aware of the importance of answering questions truthfully because the end result is protecting the wellbeing of both blood donors and receivers. analysis of blood donor's deferral in national institute for transfusion medicine -skopje for the last five years ( ) ( ) ( ) ( ) ( ) p blagoevska*, i nikolovska † and r grubovik* *national institute for transfusion medic, skopje, † medical center, prilep, macedonia introduction: safety of blood and blood products depends on many different factors, starting with selection of blood donors. the aim of this study is to analyze the number of deferred blood donors and the reasons for their deferral, as well as the total number of blood donors in nitm and their correlation (voluntary/family donors). materials and methods: this is a retrospective, epidemiological study and data were taken from the blood donor's registry in nitm from . . till . . . statistical mass includes blood donors who came to nitm to donate blood in the mentioned period. results: there were total donors in nitm and ( . %) deferrals. . % of deferred ones are male, as well as in the group with donated blood (males are predominant). the most common reason for deferral is low hb level in ( . %) blood donors, use of drugs - ( . %), low blood pressure - ( . %), high blood pressure - ( . %), infections - ( . %), cardiovascular diseases - ( . %) and others. relation voluntary/family donors is almost equal ( . : . ). in the last two years the number of voluntary blood donors is increasing ( : ), which is good sign. conclusion: percentage of deferred blood donors in first three years is ~ %, which is result of insufficient data and it is increasing in the last two years (> %). reasons for deferral are predominantly from temporary character ( . %). permanent deferrals are only ( . %), which is probably due to good education of the population and self-deferral. we should establish the national registry for deferred donors, as well as for the donors with positive markers for tti. we should design a strategy for returning of temporary deferred donors. regruting blood donors in multiethnical environment p blagoevska*, r grubovik* and k elezi † *national institute for transfusion medic, skopje, † medical center, gostivar, macedonia introduction: population in r.macedonia consists of % macedonians, % albanians and % others (serbs, gypsies, turks). over % of blood donors are voluntary non-remunerated and ~ % are family donors. transfusion service and red cross should recognize the values and cultural differences of minors groups and recruiters should developed methods for reaching and motivating them to donate blood. the aim of the study is to present the ethnical structure of our donors and to develop strategy for their regrutation and retention. the study reviews the results from the blood donation actions among the high schools and university students in west part of the country (multiethnical environment) from till . results: there were blood donations for the mentioned period. predominant blood donors are employed and high school students in %. family blood donors are ~ %; between them % are from albanian population. the ratio between blood donors macedonians vs. albanians is : . woman blood donors are presented with %. first time blood donors are %, and regular donors arẽ %. conclusion: first step in planning the blood donation in multiethnic society is creation of special teams of important and devoted volunteers, such as religious leaders, teachers, doctors and businessman. for a successful campaign it is necessary to design special promotional material and address personally to the target population on their mother language. background: pursuit of pharmaceutical purity of the blood in the bag has led to a shrinking donor base and a significantly more expensive product. decisions regarding new infectious marker testing and donor deferrals have typically been made emphasizing decreasing one specific risk without considering the effect the intervention will have on the overall safety of blood transfusion. regulations have been formulated by governmental agencies with limited input from the medical community. the decision making process has lacked risk benefit analyses and has not had the robustness associated with spirited discussions. policies made in this manner may result in certain risks being decreased but can also have adverse unintended consequences. discussion: in the u.s., the fda's implementation of donor exclusions to prevent possible transfusion transmitted vcjd has reduced the donor base by more than %. given the demographics of the deferred donors, the impact on plateletpheresis donations has been even greater. to compensate for the loss of donors, blood services will have to persuade present donors to donate more frequently, to recruit new donors, or both. one study has indicated that two-thirds of donors have no intention of donating more frequently. new donors have higher rates of infectious disease markers with positivity for hiv and hcv twice as high as repeat donors. despite sensitive testing techniques, window periods still exist and not all potentially infectious donors will be excluded. another area of concern is the aggressive use of inducements to attract new donors. some blood services are offering lavish incentives such as enrolling donors into drawings to win automobiles. most donors entering the lottery will be low risk; however, it is reasonable to worry that such extreme tactics might also attract persons who should not be donat- conclusion: (a) blood donors who were patients' relatives were many more than volunteers as well as more were men than women. also people of young ages were more than those from older ages. (b) the frequency of the diseases for which the blood units were tested was found to be in low levels in the population of the area. specifically as concerns hcv, it seems that transmission frequency has been reduced after the obligatory testing of hcv in blood transfusion centres and stations. genotype b of hepatitis c virus is the most frequent in blood donors d, from a to f, from a to k, a and a. these are differently distributed in the world: types and are the most common in europe and in usa. aims: considering that, in our region, anti-hcv antibody positivity is variable from . to % of general population, aim of this study has been to evaluate the prevalence of hcv genotypes in blood donors. methods: in period from may to december , blood units were analyzed by nat for viral rna research. nat has been performed on single sample by tma technique. on rna-positive samples, the hcv genotype has been identified by reverse hybridisation with line probe assay. results: blood donors have resulted hcv-rna positive with identification of the following genotypes: a = cases ( . %); b = ( . %); a + b = ( . %); a/ c = ( . %); = ( . %); = ( . %); none was a or a. we have also analyzed the differences between the two sexes in hcv-genotypes distribution. hcv- a has showed a double prevalence in men ( cases, . %) respect in women ( cases, . %), while genotype b is more frequent in women ( cases, . %) than in men ( cases, . %), moreover genotypes and do not compare in women. although an accurate pre-donation selection, discharging all subjects with alt > iu, our results show that . : donors, apparently healthy and without risk factors, have resulted hcv-positive. analyzing our data, the genotype b has resulted the most frequent in blood donors' population, followed by type , while the others have showed a very low prevalence. the high frequency of genotype in blood donors is explained by the observation that hcv is usually associated with low alt levels, for this reason affected subjects may escape to donor's screening only based on dosage of alt. on the contrary subjects affected by other hcv types, associated with high alt levels, may be deferred increasing the hcv b relative prevalence. at the end, the different distribution of hcv genotypes between men and women and between age's classes probably reflects differences in the pathogenic characteristics of the virus, in the transmission way and in the risk factors. in fact, it has been demonstrated that genotype is principally linked to a not transfusion transmission way; genotype is linked to old age, to female sex and to post-transfusion transmission; genotypes and are associated to young age and to an history of drugs abuse, respectively with high and low viral load; genotypes and are still little known because extremely rare in europe. p- kell blood group system and rare blood donors v fakitsa*, p karyda*, s giannoulea † , c antoniou*, j flesiopoulou*, e haliou*, m papakonstantinou*, h dessilla † , e katsadorou*, g lyrakos* and k sofroniadou* *general hospital of nikea, pireas, † blood transfusion center, athens, greece background: the kell blood group system is a compound antigen system exclusively of red blood cells. some of the kell antigens are highly immunogenic. the commoner kell antibody is anti-kel . the kel (cellano) antigen is a high frequency antigen and the blood donors lacking this antigen are quite rare. the blood donors who have not factor cellano are classified in the rare blood donors. rare blood by its very nature is required rarely, but when needed that blood has to be ensured to specified patients. there are other blood donors in their family - ( . %) students, but the number of persons that donate blood from their neighborhood and close environment is much bigger - ( . %). motives for their donation are the following: their wish to help the ones that need blood - ( . %), concern that some day everyone can be a potential recipient of blood - ( . %), because of offered benefits - ( . %), for a friend or relative - ( . %), care for their health - ( . %), because of citizen duty - ( . %), because the others donate - ( . %), curiosity - ( . %). they want to be invited every months - (%) students, every months - ( . %), every months - ( . %) and ( the mean age of case group was / ± / and the mean weight of them was / ± / , / % was male and the mean number of blood donation was / ± / . the mean age of control group was / ± / and the mean weight of them was / ± / . / % of them was male and the mean number of blood donation was / ± / . the blood donors who were female, first time blood donor low wt the rate of vasovegal rx was higher in female, first time, low weight, younger blood donors (p < . ). the rate of vasovegal rx was higher in blood donor (p < . ) who were fatigue or first time blood donor, low wt blood donation, fatigue of them and starvation of them had higher absolute donation reaction than other donors. when each variable was adjusted for other variable by regression analysis. young age, first time blood donation, anxiety, fatigue, starvation were significant (p < . ) and the others were not. conclusion: donation -related vasovegal syncopal reactions are a multi factorial process. these reaction are more prevalent in blood donors who are young, first time donor, anxiety, fatigue, starvation. these reactions might be predicted vasovegal reaction and these some facth donors need more care. with better donation care, syncopal reaction may be decrease this would be improved donor safety, better donor retention, higher donor satisfaction, and reduce cost and increase regular blood donors. to avoid iron deficiency in blood donors, iron compensation is necessary in most females and males who donate more than - and - whole blood units per year, respectively. we present studies dealing with different dose and duration of iron compensation. in the first randomized placebo controlled study iron decreased continuously in males and females at donation intervals of two (males) and three months (females) without iron compensation. mg and mg daily combined with mg ascorbic acid over months (males) or months (females) compensated for iron loss or even overcompensated in females. in the second open study we reduced iron dose to mg daily over one month for both genders. this iron dose was sufficient for compensation of iron loss. a further reduction of iron dose to mg daily over half a month led to negative iron balance in the majority of donors. in all three studies donors with exhausted iron stores profit more from iron compensation, whereas donors with high ferritin values (> mg/ml) tend to loose storage iron. aim of the study: one of our campaign strategy how to increase blood donation among adolescents are periodical seminars and excursions for students of secondary schools (more than per year). the aim of this study is to analyze impact of our campaign educational system on adolescents in period - . methods: the donation of whole blood and aphaeresis platelets from donors of age from to (max. years for each class) were count for the period of five years ( ) ( ) ( ) ( ) ( ) . the percentage of the man´s donation was calculated for each target class ( ) ( ) ( ) ( ) ( ) . results please see tables and . in the tables there is shown observed data in relation to the total number of births in the czech republic in reviewed years. the study showed that number of donation from donors of age from to decreased during objected years. unfavourable state of total number of births in the czech republic ( birth in republic ( birth in , birth in ) and its decreasing tendency ( birth in !) is with high probability a major demographic factor affected number of young donors. despite energy invested in our campaign educational system our recruitment efforts should be intensified to decrease influence of demographic factors. we should find new ways and methods to attract new blood donors and keep the regular ones, too. the aim of the research was to investigate women's attitudes towards blood donation in cyprus. a statistical sample was selected using stratified sampling and consisted of women from the district of limassol (the second largest urban center of cyprus) between the ages of and . using linear logistic regression, the analysis of the data collected revealed that there is a greater probability for a woman to be a blood donor if she is of a higher educational level, a member of an organized group or association, or if she is acquainted with other blood donors. the percentage of female blood donors is higher in rural areas than in urban centers. % of women do not donate blood and attribute their reluctance to do so to health-related problems, while about % of those who have never donated blood claim to fear the blood donation procedure. in addition, more than half of the women who have stated they would never donate blood again have attributed their denial to healthrelated problems. the research revealed that there could be an increase of up to % of the percentage of female blood donors if they were given time off work for a few hours or one or two days afterwards. even though very few female blood donors expressed a preference for the blood donation to take place on a particular weekday, half of them prefer the donation to take place on the discussion: it is about small group of students. the impression is that the altruistic behaviour is present at most of the questioned students. the fact about free school days is not underestimated because it is one of the most important motives of blood donoring of the young population. families where the blood donoring is a tradition have a great influence for young children because the children in these families are better informed for blood donoring. conclusion: including the children in the process of education for young children is of particular importance because the altruistic behaviour as a higher feeling is from an early age of the child and it is under the influence of the environment (family and friends). active participation of the department for transfusion medicine in the educational process, especially in the education of young children, is a guarantee to achieve longlasted positive results. adverse reactions in blood donors taking betablocking antihypertensive medications l paesano*, m d'onofrio*, s misso † , g fratellanza* and e d'agostino* *university federico ii, naples, † hospital san sebastiano, caserta, italy one aim of blood donor's selection is to avoid an adverse reaction to phlebotomy (as vasovagal reaction, syncope and/or hypovolemic cardiac insufficiency). blood donation is surely contraindicated in various pharmacologic therapies, but not in all. in fact a certain degree of discretionarily exists about the assumption, or the period of suspension, relative to a numerous pharmaceutical products, as the antihypertensive agents. according to literature, the deferral of donors taking antihypertensive medication is not indicated when blood pressure is normal, symptoms are absent, and diuretics or similar agents are the only drugs used. on the contrary, it is a common opinion that an antihypertensive therapy by betablockers is not compatible with blood donation for its cardiac effects. nevertheless, in our daily activity, the observation of a blood donor taking beta-blocking drugs may occur for various causes. a possible error is a superficial pharmacological anamnesis, as it can occur in donations on autohemotheca, for a too fast medical visit (due to a large number of donors), or for the inexperience of the selector (often a not specialist of transfusion medicine young doctor). another possibility of observation is constitute by patients, undergoing to elective surgery, included in a program of autologous blood donation, suffering hypertension treated with betablockers. in fact, in this last case, the risk/benefit balance justify the blood letting procedure. in the last year we have just observed two severe post-donation reactions in donors suffering hypertension treated with atenolol. the reactions have been similar, in fact both donors showed lypotimia followed by convulsions about past half hour by the end of phlebotomy. no prodromic symptoms have been observer or referred. cardiac frequencies (cf) before donation were respectively and beat per minutes and blood pressures (bp) were both in the normal range ( / and / mmhg). after donation, during adverse reaction, cf showed no substantial variations, while bp have been decreased respectively to / and / mmhg. immediate treatment has consisted in putting the donors in the trendeleburg's position and in applying a dolorous stimulation. in the first case this treatment has been sufficient to report the bp to / mmhg (with disappearing of all symptoms) in only half hour time. in the second one, the marked hypotension showed a very slow remission, for this reason the subministration of a plasma expander needed, with the complete resolution of the symptoms after two hours. these two donors were not deferred from donation because they were periodic donors that had modified their antihypertensive therapy, without referring it neither in the questionnaire nor during anamnesis. our experience confirms that the blood donation don't must be permitted to subjects taking betablocking antihypertensive drugs. in fact these medications act on cardiac pump decreasing the cardiac rhythm and limiting the postdonation cardiac recover. this effect is very dangerous because it appears relatively in retard respect to the end of donation, when donor may have just leaved the transfusion center. introduction and aim of the study: in society under transition privatisation and marketisation probe all areas of life. transition to market economy is extremely important and sensitive issue in health and welfare services in general, and specifically in the case of blood transfusion service. the aim of the study was to analyze effects of confusing publicity which introduced possible ways of transforming blood transfusion service in serbia (ideas about privatization of some parts of national blood transfusion institute, buying blood from blood donors, selling blood from voluntary blood donors to private clinics, exporting blood from vbd, stories about tradition of paid blood donations in some european countries). publicity was restricted to a small number of sporadic outbreaks concerted in a limited period of time. table. conclusion: surveillance of adverse reactions and injuries or accidents during or after blood donation is essential for maintaining the well being of active blood donors, as well as for the safety and quality of the donated blood components. information on other activities and parameters affecting the quality of blood including materials, reagents and equipment should be collected and any serious deviations from standard operating procedures should be notified to the competent authority using haemovigilance infrastructures. skae has built up such procedures working along the lines of the european haemovigilance network. improvement of existing national haemovigilance systems is expected to follow from the implementation of the eu directive. although inevitable, blood donor deferrals lead to losses in donated blood supply and may affect donor-return rates and subsequent blood donations. to estimate the scope of blood donor deferrals and their causes, we analyzed the - data from regional blood centers using standardized criteria for temporary and permanent blood donor deferrals. within this period ( ) ( ) , . percent of persons who presented for donation were deferred; . % were temporary deferrals ( % due to laboratory test results, among others low hemoglobin, . % due to risk of acquiring a transfusiontransmissible infection) and . % were permanent ( % due to the infectious diseases markers, . % due to cardiovascular diseases). for regional blood centers the temporary deferral rates varied widely (see the table below ). in the case of individual regional centers, the differences as well as the most common causes were often difficult to explain. according to our analysis, some blood centers have a more restrictive approach to donor acceptance than others and this results in increased donated-blood loss. to some extent such losses could be avoided. further studies are recommended to elucidate the problem and eliminate unnecessary deferrals. caption : percentage of deferrals aims: from our experience in selecting blood donors, a certain number of issues have been noticed that remain obscure and need to clarification since those seem to 'haunt' the whole process of blood donation. methods: many first time blood donors and especially volunteers think that rejection reasons are permanent and they are completely incapable of donating blood their entire life. this is a 'tragic' misunderstanding since the doctor did not explain that the reason of the rejection is only temporary and in the future this man is capable of donating blood. those potential donors will never even approach again blood donation centre and when in the future they are asked why they do not donate blood, they repeat the cause of the past rejection. results: one of these rejection reasons is for example low blood pressure ( . % of total causes of rejection). as we all know blood pressure must be determined according to age, sex, weight and from other factors as sleep, emotional status, food and liquid intake. therefore blood pressure is very important but should be evaluated with all the above factors and must not be alone the only reason for rejection. even when one blood donor is rejected it should be made clear to him that this is only temporary and if in the future he is in better physical condition, he could donate blood. in fact - % of those donors rejected for hypotension are readmitted in blood donation after meeting the above mentioned criteria. another matter of equal importance is anemia ( . % of total causes of rejection), especially concerning young women. since most of those women tend to develop anemia due to depletion of iron stores, they should be advised to donate blood at longer periods than regular, to receive proper medication and diet according to their needs. the doctor must explain the donor the reasons for iron depletion, so blood donation should not be considered as the only cause for this situation from the donor. there are many factors contributing to anemia, menses, specific diets, overwhelming stress and exercise, not to mention other medical reasons. it is the duty of the doctor to correct those factors that resulted in iron depletion or anemia and readmits those donors in blood donation in the future ( - % of those rejected are readmitted in our centre). summary/conclusions: at our blood centre we have created a program of regular tests (blood tests-physical examination) for all our blood donors. our experienced and well taught personnel offers advice and provides useful information in every aspect of blood donation and more. we have created a friendly environment for all our volunteers with love, understanding and appreciation and believe that this is the only way to keep a constant 'flow' of blood in our region. introduction: an innovative perception for blood donation in a new and evolving environment must focus on specific matters and ideas and adopt in a certain level lifestyles and concerns of society. aims: the purpose of this study is to find methods and ideas that can help blood donation centers throughout our country to create new blood donors, give a motive and inspiration for blood donation by adopting new trends of society and finally accomplish national need. methods: by having a personal interview with many volunteers about their feelings for healthier life, their nutritional habits, daily physical activity, sports, vitamins, smoking, weight, cholesterol levels. we investigated whether they believe that blood donation has, if any role towards a more hygienic life. results: we divided blood donor volunteers according to their age, educational level, and number of blood donations per year. our results indicated that there is a tendency among young educated people to adopt a personal lifestyle that includes consuming healthier food, keeping their weight low close to the ideal, having some kind of personal activity, not smoking, watching cholesterol levels, following doctors advice and concerning seriously about their health. this dynamic group of blood donor volunteers considers blood donation as a contributing factor to well being and donates blood at specific intervals. besides the yearly run lab tests that are done by our blood centre they also seek advice and discuss any matter concerning their health with the blood centre doctor. it appears that they are extremely sensitive in those matters and they seem to appear well informed about issues concerning their health, they also believe that blood donation is part of the plan they have to keep fit and being well. in our blood centre we encourage this belief and we also provide information concerning this new trend towards healthier habits. summary/conclusions: this approach has already shown some positive results in our blood centre as many people especially young educated women have joined our blood donorship program and donate blood at scheduled intervals. in order to achieve our goal which is to raise the percentage of blood donors in the region we have to be flexible, innovative according to new habits and lifestyles. we have to move with society and modernize the way we attract various groups of people. blood donation against prejudice as saltamavros*, s dimitrakopoulos † , v zacharaki*, p giannaros*, s markou* and p tseliou* *st. andrews hospital patras greece, patras, † pyrgos general hospital, pyrgos, greece introduction: in order to achieve a greater population to be admitted in blood donation we have to provide information concerning any obscure issues that presents in selecting donors. to examine the accuracy of hb measurements obtained by the noninvasive clinical device, as compared to values detected by standard methods, (cell-dyn , abbott laboratories, usa), in a blood donor setting. methods: the nbm- device utilizes a finger base sensor using occlusion red/near-infrared spectroscopy (o-rnirs) to detect and analyze the hb/hct levels. the clinical trials were conducted at two blood donor centers (israel and usa). studies were carried out on a group of subjects ( females, males) aged - . subjects were healthy volunteers who had come to donate whole blood or aphaeresis components. after obtaining informed consent, hb/hct levels of all the study volunteer participants was tested non-invasively, using the nbm- device, followed by a venous blood sample. additionally, the usa center tested a capillary blood sample using the hematastat hct measurement device ( donors). hb levels were considered normal when readings were equal to or > . g/dl. results: venous hb measurements ranged from . - . g/dl. the mean nbm- hb level was . ± . g/dl, only . g/dl lower than the mean hb result obtained by venous sampling, which reached . ± . g/dl. the standard deviation of the difference between the invasive and noninvasive hb readings was found to be ± . g/dl. the mean absolute error (mae) of their difference was . g/dl. when checked against the cell-dyn in the usa center, where subjects had hb of . g/dl or lower, the nbm- and hematastat devices showed comparable sensitivity results. the nbm- using o-rnirs is a promising noninvasive technique for hb screening in blood donors. the device is easy to use and agreeable for both blood donors and personnel. the technique reduces the need for the invasive finger prick or venous blood sampling, thereby enhancing safety, reducing costs, and improving the experience of blood donation. the effect of short-term, temporary deferral on blood donor return rates and subsequent blood donations background: blood donors are deferred for numerous reasons. some deferrals like intravenous drug use, male homosexual contact or certain positive test results are permanent. the majority of donor deferrals, however, are short-term temporary deferrals (sttds) that are resolved in a matter of days, weeks or months, after which time the person is again an eligible blood donor. the effect of sttds on blood donor return rates and subsequent blood donations is studied. materials and methods: donors given sttds during the december to march were computer-matched with non deferred donors on the basis of age, sex, and donation date (case group: donors -control group: donors). computer records were evaluated during the next years ( march to march to determine donor return rates. significance for comparison between the two groups was based on chi-square analysis. results: the most common reasons sttds were elevated blood pressure ( %), deferred for medication ( %) and colds and/or sore throats ( . ). non deferred donors were a little more likely than donors with sttds to return over the next years ( . % vs. . % pv = . ) and non deferred donors donated more whole blood units. . according to ethnic structure, women -ethnic macedonians donate blood in largest numbers - ( %), while all other ethnic groups are present with only %. the most prevalent is the group of adults aged - ( - . %), with high school education - ( . %) and mostly those who donated blood - times ( - %). conclusion: having in mind that % of the population in macedonia is female, the obtained results reveal a significant, yet insufficient participation of women in blood donation with % in relation to the total number of blood donors surveyed in the period - . this is due to insufficient motivation and education of women from all ethnic groups especially those from the younger population and with elementary education. incorporating them in education and organization would contribute to their more extensive participating in blood donation. comparison of serum beta -microglobulin (b -mg) between hbsag positive donor and healthy control f tarabadi*, m shaeigan*, g babaee † , a talabiean* and m khadir* *iranian blood transfusion center, † tarbiat modarrs university, tehran, iran background: beta -microglobulin (b -mg) is a low molecular weight protein ( daltons) and found in all biological fluids it is light chain of histocompatibility class -human present on the most membranes of cells. in the hepatitis infection the viral antigen presentation on the hepatocyte in the presence of class -hla antigen plays a role in the elimination of the virus. method & samples: beta -micro globulin was measured in serum drawn from hbs ag positive blood donors include ( . %) female and ( . %) male in age between - years, and healthy ( %) female and ( %) male in the same age we detected serumic b -mg by enzyme immunoassay (ela). results: our studies showed b mg level increased in ( . %) hbs ag positive donor that was significant differences with healthy control (p = . ). conclusions: it seems that serum b mg is a good marker for hbs ag replication. the role of b mg in monitoring of response therapy needs to be more evaluated. and ( . %) were contributed by vd, rd and dd respectively. over the last / years, voluntary donations have shown a rising trend from . % to . %, where as rd ( . % to . %) and dd ( . % to . %) have shown a declining trend. the percentage of female donors was maximum in voluntary group as compared to rd and dd ( . % vs. . % vs. . %) respectively. the rates of all tti markers reactivity were significantly higher in rd as compared to others donors. the hbsag and anti hcv reactivity in vd and dd is comparable ( . % vs. . % and . % vs. . %). hiv antibodies was found more frequently in vd as compared to dd [ . % vs. . % (p < . )] whereas, vdrl reactivity was lower in formal as compared to latter [ . % vs. . % (p < . )]. conclusion: voluntary blood donation has shown a rising trend over a last few years, thus highlighting efficient donor motivational strategies. these strategies need to be strengthened to increase the female donor base. the safety of dd is equivalent to vd when the rates of tti are compared. thus, dd should be advised to donate blood regularly as voluntary blood donors. blood safety depends on a number of factors. the chain of safe blood starts with the donor. one of the procedures for obtaining safe blood for transfusion is the medical selection based on the completed questionnaire and the possibility of self-exclusion from the process of blood donation, the medical history of the potential donor and the medical examination. donor selection consists of two sets of information necessary for protection of the blood recipient as well as the donor himself. aim: to present the most frequent reasons for declining volunteer blood donors. material: the materials used for analysis were the questionnaires completed by all the potential blood donors at the transfusion department of the medical center in strumica as well as the record books of the blood donors which contain the results of the analysis we make for the potential donors. these donors donated blood in the period between and . results: during this period people volunteered to donate blood, out of which were allowed to donate blood, while were declined. out of the total number of blood donors were male and female donors. the reasons for declining potential donors were the following: . % had low levels of hb, . % were taking antibiotics, . % were ill, . % had low blood pressure, . % had high blood pressure, . % for other reasons. conclusion: donor selection and their care on one side and obtaining safe blood for transfusion on the other side entails obligatory organized medical control. the obligatory completion of questionnaires, the medical examination of the potential donor and their self-exclusion as a result of the feeling of personal responsibility as well as the obtained information are very important for the selection of quality blood donors and obtaining safe blood for transfusion. questionnaire on subjects-students, their knowledge and motivation on blood donation f vladareanu, a bugner and s sirian national institute of heamatology transf, bucharest, romania the research theme of this questionnaire is as follows: 'what is the level of knowledge and of motivation in the non-remunerated and voluntary blood donation at students?' we also tried to see the practical implications that this study will have and how it will influence the knowledge in this area. the purpose of this questionnaire was not dissimulated. the general theme of the knowledge and motivation on blood donation had been studied before through two big questionnaires applied in and , but the general population was their target. students had never been an investigated lot up to now. the hypothesis referring to this problem is as follows: students are not informed either on the act of donation, or on the crisis of blood. . the lack of information is a first cause of the indifference of the studied lot towards the idea of donation. . the lack of motivation of the studied lot is another cause. the questionnaire was applied on a lot of students from seven different cities: bucharest, iasi, constanta, cluj, sibiu, brasov, timisoara. the number of the questions was limited to , which we consider best for a questionnaire applied on the street or at college. as a conclusion, we can say that a passive-defensive attitude towards the blood donation was revealed after this questionnaire. not knowing the issue caused by their lack of information sometimes determines indifference at the statement of the subject. on a general dissolution environment of the responsibility of the youth, the donation problem is not in their aria of preoccupations, the general attitude being of non-involvement for the moment, at this idea which is not yet in every individual conscience and which is normally administrated at an institutional level. the donor data and the details of blood application of the north west transdanubian region of hungary k vÖrÖs*, c bercsÉnyi † , o petrÓ † , r jÁger † and e miskovits ‡ *hungarian national blood transfusion s., györ, † blood bank, tatabánya, ‡ headquarters hungarian n.b.s., budapest, hungary the ongoing fundamental reorganization of the blood service began on the . . in hungary. as the consequence of reorganization till . . , blood banks had been established instead of existing before, under direction of the hhnbts. the working profile of the regional blood centers and local blood banks will be changed step by step. virus screening, blood group serology and processing will be made in the regional centers. one of the regions is the 'north west transdanubian region' (nwtr, city györ as the center, with about inhabitants and hospital beds). local blood banks (tatabánya, sopron, and szombathely) are belonging to nwtr. the regional center and the local blood banks provide the labile blood products and high level clinical-transfusion service (cross-matching, antibody screening, outpatient immunhematology investigations, etc.) for the hospitals. annually donors donate blood in this region. this donation activity covers about the % of all inhabitants. the acceptance ratio of the donors is good ( - % of the donors were deferred). there are hospitals in our region. the regional demand on rbcc is - . u/year, on ffp is . - . u/year and on pc is - . u/year. the poster shows the donor data and the details of blood application of this region since . p- implementation of rbc collection using haemonetics mcs ® +: medical staff training, donor recruitment and acceptance g woimant, c fretz, d puydupin, e pÉlissier and jl beaumont efs ile de france, paris, france background: single donor rbc collection is an approved apheresis technique in france. aims: our goal was to evaluate the implementation of rbc collection in our center in terms of donor recruitment and acceptance, as well as medical staff training and adaptation. methods: donors were selected according to the french requirements for rbc collection (weight ≥ kg, height ≥ cm, hb ≥ . g/dl, ferritin ≥ ng/ml for repeat rbc donors). all personnel were trained on adequate communication with donors. eligible donors were contacted by mail, by phone or during pre-donation interview. among the recruited donors, all donors were male, % were regular whole blood donors, % were regular whole blood or apheresis donors and % were new donors. the medical staff was trained on rbc collection with the sdr protocol and disposable set ln pf on the mcs ® +. most of the medical staff was already used to autologous rbc donation with similar apheresis devices. blood samples were taken from donors pre-and post-donation, as well as to months later for those returning for a subsequent donation. donors were asked to fill out a post-donation survey for assessing donor comfort and information. results: donor profile and clinical follow-up are summarized in table . six percent of the donors had a ferritin level below ng/ml; these donors were regular whole blood donors. the collections were well tolerated and no changes in vital signs were noted. four reactions were reported: hematomas and citrate reactions. no reaction was observed post-donation and hemoglobin levels measured before next donation were back to normal. the technique was easily implemented by the medical staff and fitted well in the existing blood center processes. the medical staff as well as the donors found collection duration short (average of min). the results of the survey were very favorable as more than % of the donors considered their donation and the information they received as satisfying. most of them agreed to donate again and several actually donated twice during the evaluated period. conclusion: the implementation of rbc collection in our center, using haemonetics mcs ® +, was successful in terms of ease of use of the technique, as well as user and donor acceptance. we now plan to evaluate donor loyalty in the longer term. risk from first-time blood donors e zhiburt, s golosova and p reizman federal blood center, moscow, russian federation introduction: each third dose of whole blood in russia is donated by first-time blood donor. there are two reasons for attention to this kind of donors: ( ) possible risk of infectious disease in seronegative study; ( ) possible risk of donation for person with contraindication. aim of the study: we investigated role of regional deferred donors registry (rddr) in by first-time donor selection. methods: moscow rddr includes parts: hiv, viral hepatitis, syphilis, tuberculoses, malaria, drug users, psychiatry, days after blood donation. rddr was complete and our center began actively work with it since last year. each donor has to be registered in rddr and automatically checked for deferral reason. effectiveness of rddr was investigated. results: first-time donors donate less than % blood in our center. about a quarter of them are deferred before possible donation. part of donors deferred by rddr has been significantly increase in (c = . ; p < . ) at the expense of seropositive people. conclusion: rddr is effective for blood donor selection and decreases necessity in laboratory screening. first-time blood donors have to be examined before blood donation. if they have not contraindications, donation can be performed up to days before examination and screening. the double unite platelet production is important especially if the relatives of patient find the donors. we evaluated the effectiveness two apheresis machine for platelet collection. in our blood bank, one fenvall amicus and one cs + apparatus were used for platelet apheresis. apheresis were performed between / / and / / . including criteria of donors are that estimated process time is smaller than minute and estimated postapheresis platelet count is higher than ¥ /l. donors firstly was enrolled to amicus. if amicus was busy, then it was enrolled to cs. the properties of our donor populations were given in blood and plasma cell components are obtained either by traditional manual method from whole blood or by apheresis. modern medical treatment is based on transfusion of deficient components such as erythrocytes, leukocytes or plasma proteins. this involves new solutions to achieve higher yields and better quality of such components. the aim of our study was to estimate the efficacy of blood cell separator cobe trima in obtaining platelet concentrates (pcs) as compared to older-generation cobe spectra blood separator. apheresis procedures were performed on both these blood cell separators. the quality of platelet concentrates was tested during day storage period (see table below ). we have tested the effect of apheresis procedure on donors and estimated the operating comfort of both separators. the tolerance of both separators was satisfactory except for more frequent hypocalcemia when trima separator was used. most donors were more satisfied with trima procedure because of single venipuncture although it involved special donor selection (good vein access). in general we may say that trima is undoubtedly a more modern and more friendly separator. however, cobe spectra may continue to be used with success especially when a more versatile cell separator is necessary (leukocyte concentrates, peripheral blood stem cells or therapeutic apheresis). methods and results: tls ( procedures on patients) were used successfully in patients with acute or chronic leukemia with hyperleukocytosis (white cell count > ¥ e /l or blast count > ¥ e /l) when high cell count would promote leukostasis with vascular occlusion in the microcirculation. performed tl procedures were rapidly reduced both the white cell count and the whole blood viscosity. average fall in white cell count after treatment was . %. tp-treatments ( procedures on patients with symptomatic thrombocythemia and/or platelet count higher than ¥ e /l) were applied in order to prevent the development of 'thrombotic-hemorrhagic syndrome' . the tps performed resulted with rapid platelet counts reduction ( . % in average) and with clearly noted clinical improvements, subsequently. tes ( procedures on patients) were performed using manually technique in patients with 'cellular hyperviscosity syndrome' induced by high red blood cell count. it was shown that te procedures resulted to red blood cell number lowering and decreasing of blood hyperviscosity. average fall in hemoglobin and red blood cell concentrations after te treatments was from . % till . %. rbcx treatment ( procedures on five patients with malaria and two with severe aiha crysis) was performed on an urgent basis, particularly when clinical symptoms indicate life-threatening situations and resulted with rapid and significant reduction of concentration of unwanted pathogen affected rbcs and summary/conclusion: the effects of tcs depended on the nature and stage of the basic hds, of adequate selection of patients and of timely applied apheresis. rapid cytoreduction is obtained justly in patients with excessively high cell count, and this effect did not associated with bone marrow remission. thus, tc should be looked upon as adjunct to the standard treatment of different cithemias, but not as replacement therapy. the present study indicates that the best therapeutic effects were obtained by rbcx. were carried out with continuous flow blood cell separator cobe spectra and all patients underwent large volume leukapheresis (lvl). in all procedures, a blood warmer was connected to the return line and a continuous calcium infusion was administered preventively. six patients, who were under kg body weight, had the extracorporeal circuit primed with irradiated, filtered packed red cells diluted with % albumin solution. seven children had vital signs and ecg continuously monitored during the procedure. results: each patient underwent a median of collections (range - ). the inlet blood flow ranged between . and . ml/min (median . ml/min). the median blood volume processed was ml (range - ). leukapheresis lasted a median of min (range - ). the median total nucleated cell yield was . ¥ e /kg (range . - . ), mononuclear cell (mnc) yield was . ¥ e /kg (range . - . ) and cd + cell yield was . ¥ e /kg (range . - . ). the median of mnc collection efficiencies was . % (range . - . ). in ( . %) patients, in only one apheresis procedure more than ¥ e cd + cell/kg were collected. during ( . %) procedures patients had experienced apheresis-related side effects. the citrate-induced reactions were most commonly observed. the reactions were mild and cessation of collection was required only in one case, because of catheter related complication. mild sedation was required only in few very small children. post-donation platelet count was less than ¥ e /l in cases and these patients required platelet transfusion before subsequent procedure. our results show that lvl in pediatric patients is relatively safe procedure, well tolerated and with a very low risk of serious adverse events. close monitoring of blood counts, especially platelets, between pbsc collections is necessary. the cessation of procedure was required in only one case and no life threatening side effects occurred. neonatal alloimmune thrombocytopenia (natp) caused by fetomaternal mismatch for human platelet (plt) alloantigens (hpas) worsens approximately / pregnancies and can lead to a serious bleeding diathesis, intracranial hemorrhage (ich) and sometimes death of the fetus or newborns. we describe the successful management of a -year-old pregnant woman, alloimmunized to the hpa- a (p a , zwa) antigen, with a history of two previously children with severe thrombocytopenia and ich. the pregnant woman was at her terminal pregnancy and was suddenly admitted. to evaluate the risk of ich in the fetus, cordocente was performed to demonstrate fetal thrombocytopenia (plt . /mmc). to ensure a rapid provision of compatible negative-antigen platelets, we decide to collect platelets from the mother using apheresis. plateletapheresis was performed using com.tec separator, fresenius. blood processed was . ml in a short time procedure ( minutes). no significant adverse effects were observed in the mother and fetus, during and after the procedure. platelets collected ( . ¥ e ) were transferred to the preparation set and plasma was removed after centrifugation to resuspend the platelets in octaplas ab. then we separated the platelets into two units containing . ¥ e each. the day after the donation, the mother gave birth to a girl by caesarean section. after the transfusion, the plt account increased from . /mmc to . /mmc and after a week the child had plt . /mmc without hemorrhagic complication. according to the literature data and our observations of the patients, there are changes of the hemostasis system indexes in the most patients with the endogenous intoxication syndrome and immune disturbances. in the number of cases medicamentous therapy appears to be not enough to normalize the changes, but it is especially important for pregnant women and women in childbirth, because on the background of these disturbances different complications of pregnancy and postnatal period take place. the aim of our study was the substantiation of plasmapheresis using in complex therapy of purulent inflammatory complications in obstetrics and immunoincompatible pregnancy with hemostasiologic disturbances. patients with hemostasis system disturbances: one woman in childbirth with exacerbation of chronic pyelonephritis, who had in the first hours some signs of hypocoagulation on the background of permissible blood loss (prolonged coagulation time up to - minutes with episodes of its absence on the background of the normal indexes of general coagulogramm, quantity and function of thrombocytes and the dilute fibrin monomer complex level in times higher than the norm) and nine pregnant women with the perinatal losses in anamnesis severed by the pregnancy (threat of abortion, places of fetal egg detachment). these women were examined, the following was revealed: the high antibody titer to chorionic gonadotropin, parameters of partially activated thrombin time were higher than the norm ( - seconds), thrombin time ( - seconds), the dilute fibrin monomer complex ( - mg%), coagulation time ( - min). in all these cases the conservative methods of treatment (antibacterial, hemostatic, hormonal therapy) were effective for a short period of time and they didn't succeed to correct the given parameters of hemostasiogramm. the discrete centrifugation plasmapheresis was included in the complex of medical treatment. the woman in birth operations were done, in the programme of plasma replacement during the first two plasmapheresis procedures donor fresh-frozen plasma was included. six pregnant women on the given stage one course consisting of plasmapheresis procedures for plasma replacement with crystalloids was done, the volume of the removed plasma was - % of the circulating plasma volume. three pregnant women before delivery were required two courses of plasmapheresis more consisting of - procedures each. the system heparin was not used. in all patients already after the first procedure of plasmapheresis the normalization of hemostasis indexes was marked, that allowed to prolong pregnancy, to prevent the coagulopathy bleeding and the development of disseminated intravascular syndrome. four women are discharged from the hospital, the other patients are observed with progressive pregnancy. thus, the using of discrete centrifugation plasmapheresis is effective at the signs of hypocoagulation in patients with isoimmunisation with fetal antigens and infectious pathology, and is the reserve in prevention and treatment of obstetric complications. extracorporeal photochemotherapy: an alternative therapeutic approach to control graft versus host disease after allotransplant with reduced intensity conditioning regimen c del fante*, c perotti*, gl viarengo*, p bergamaschi*, p pedrazzoli † and l salvaneschi* *irccs policlinico s. matteo, pavia, † ospedale niguarda cà granda, milano, italy background: extracorporeal photochemotherapy (ecp) can be defined as an immunomodulatory therapy that demonstrated to be efficacious in treating patients affected with graft versus host disease (gvhd) after allotransplants for oncohematological diseases. reduced intensity conditioning regimen (ricr) for allotransplant is a relatively new practice in patients (pts) ineligible for a conventional myeloablative conditioning regimen. the use of immunosuppressive therapy (ist) to control gvhd is limited for the high risk of developing infections and disease relapse due to the strong reduction of graft versus tumor (gvt) effect. aims: to evaluate the effectiveness and safety of ecp in treating pts affected with gvhd post rcr and the possibility to taper, at the same time, the ist. methods: pts ( females, male), median age . years ( - ), affected with agvhd grade ii ( ) and extensive cgvhd ( ) gtx with median total granulocyte doses of ( - ) ¥ per gtx corresponding to . ¥ granulocytes/kg in children and . ¥ granulocytes/kg in adults. the wbc counts increased from baseline values of . ( - . ¥ ) g/l for both pediatric and adult patients to peak values of . ( . - . ) ¥ g/l (children) and . ( . - . ) ¥ g/l (adults) at one hour after gtx and to . ( . - . ) ¥ g/l (children) and . ( . - . ) ¥ g/l (adults) at hours after gtx. in out of patients ( %), the crp levels significantly declined ( ( - )%; p£ . ) during the granulocyte transfusion period; in almost all cases ( / ; %) after the initial or nd transfusion. thirty-eight patients ( %) were alive at day + after termination of neutropenia and gtx. patients without crp response to gtx ( / , %) and patients with severe viral infections / ( %) were not among the day + survivors. background: in recent years, the use of platelet concentrates obtained from single donors by automated apheresis has grown steadily. plateletpheresis donation is considered to be a safe procedure with modern instruments. so far, no studies have identified donor or procedure specific factors that may be associated with serious adverse events. aim: to evaluate the incidence of adverse events during plateletpheresis procedure, over a five-year period in our hospital. materials and methods: eight hundred single-needle plateletpheresis collections were performed by using two automated intermittent-flow cell separators: of them with mcs p and with mcsplus (haemonetics), according to automatic standard protocols a p and ldplp, respectively (with the collection of an additional plasma unit). acd-a was used as the anticoagulant in all apheresis procedures (acd-a: blood ratio was : ). most of the donors ( % men and % women) were patient´s relatives. half-hour before the initiation of the procedure, mg of calcium ( tablet cal-c-vita) were administered to each donor. the mean platelet yield was . e /unit. the overall rate of the donor related adverse events was . %. feeling faint was the most frequent event, which was occurred in . % of donations. hypotension and citrate related rates were . % and . %, respectively. all citrate related symptoms were only transient perioral paresthesias, which were relieved by slowing the i.v. rate, without additional administration of oral calcium. donor unconsciousness was the only observed severe event, the rate of which was . %. other adverse events were venipuncture related ( . %), machine related ( . %) and miscellaneous complications ( . %). ( ) plateletpheresis using the mcs p and the mcsplus automated cell separators is a safe procedure, with a low risk of serious adverse effects. ( ) with the used acd-a-to-blood ratio ( : ) satisfactory platelet concentrates were obtained with very low incidence of citrate-related events. ( ) the peros administration of calcium before the initiation of the procedure, probably lowers the rate and the severity of hypocalcemia symptoms. quality assessment of ffp collected as a byproduct of plateletpheresis . from the donors immediately with the initiation of the procedure (citrated whole blood) and . from the final platelet concentrates after one hour rest at room temperature without agitation. in vitro platelet response to the aggregation-inducing agonists adp, collagen, ristocetin and arachidonic acid was investigated by means of an aggregometer (pap- c, bio/data). results: there were no significant differences between the groups of donors with respect to age, sex, smoking habits, preapheresis wbc and plt counts and hemoglobin concentration, as well as in the harvesting time between the two cell separators. our findings are shown in the following table. mildly decreased response to all agonists was observed (mainly to adp and arachidonic acid) in the samples taken right after the initiation of the procedure, in both groups. platelets from the final component showed a further slight decrease in response to adp, which was more prominent in the mcs p device (p = . ). on the contrary, an increase in platelet response to the other three agonists was observed in both devices, which, however, was statistically significant upon collagen and ristocetin stimulation. conclusions: reduced response to aggregation stimuli is possibly caused immediately with the initiation of the apheresis process. literature reports regarding further platelet traumatisation due to the procedure, are rather conflicting. in our study, such traumatisation was observed only in the case of adp in the mcs p obtained collections and this could be correlated with the technological differences between the two devices. recovery of platelet aggregability, as it was expressed by the upregulation in platelet response in the other stimuli, could be attributed to the resting period and seems not to be affected by the timing of the leucodepletion procedure. background: lupus erythematosus often is accomplished with severe symptoms, such as polyarthritis, nephritis, pericarditis or dermal alterations. in pregnancy cytostatic therapy affects gestation. on the other hand the course of disease can be refractory to corticosteroid therapy. elimination of autoantibody and immuncomplexes by plasmapheresis could be an efficient way to amend the severity of symptoms. a year old pregnant woman in the th gestation week with systemic lupus erythematosus showed severe symptoms like polyarthritis, nephritis and pericarditis. treatment was initially mg/kg bw prednisolone for weeks and subsequently mg/kg bw for weeks. plasmapheresis was applied daily in the beginning and continued depending on the condition of the patient ( table ) . the eliminated plasma was substituted by fresh frozen plasma. the medium volume was . ml per apheresis. after day plasmapheresis treatment was suspended to avoid problems with coagulation and was followed by a cycle of immunoabsorptions to eliminate circulating immuncomplexes. results: prednisolone therapy alone brought no effect even after changing to high-dose treatment. a significant amelioration of all symptoms could be observed after the first plasmapheresis. good condition of the patient remained stable over the period of daily plasmapheresis for days. intermitting apheresis treatment for one day lead to a significant aggravation of symptoms. apheresis no. again lead to a recovery of the patient which held on until day . conclusions: treatment of systemic lupus erythematosus in pregnancy especially in combination with resistance to corticosteroid therapy, is an effective therapy to ease severe symptoms such as polyarthritis, pericarditis and nephritis. exposure to cytostatic drugs can be avoided and therefore the impairment of the fetus can be reduced. background: the collection of mnc represents the first step of photopheresis procedures and could be of critical importance in achieving a therapeutic goal. in this work we compare the cell yield of two collection programs on cobe spectra device: the mnc versus the autopbsc program using the ecp procedure modified by andreu. methods: procedures were carried out with mnc program and procedures with autopbsc on patients with cgvhd. both hemoglobin increased from . ± . to ± mg/tu, k+ from . ± . to . ± . mmol/l, level of glucose decreased from . ± . to . ± . to . ± . mmol/l, ldh from . ± . to . ± . ukat/, lactate from . ± . to . ± . mmol/l, ph from . ± . to . . . the volume of apheresis units was lower than wb-rbc, the leucocyte count was normal in all units. the rbc loss by filtration was . ± . ml/tu and was lower than at wb-rbc. in apheresis rbc there were the differences in hb and ht value between the day of storage and , in wb-rbc there were no differences. during the storage period we found no differences in k+ increasing value and no change in ph value between apheresis rbc and wb-rbc, the increasing of lactate was higher in wb -rbc, increasing of ldh correlated to hemolysis. the plasma hb value increase was higher at apheresis rbc in contradistinction to literature. hb and ht correlation in apheresis units according to predonate value in donors was lower than at wb -rbc. the method is a useful alternative to conventional whole blood donation, we get rbc units with high standard of quality and low correlation according to predonate hb and ht value in donors. acknowledgement: the study is supported by grant iga ministry of healthy cr n. nr/ - . background: in life-threatening exacerbations of sle a satisfying efficient therapy is lacking. despite intensive immunosuppressive therapy some patients are resistant or contraindicated to conventional treatment. in particular circulating antibodies and immune complexes play an important role in the pathogenesis of sle and mctd. an extracorporeal removal of these pathological substances may be effective in the treatment of active disease. methods: five patients with severe therapy-resistant sle/mctd underwent immunoadsorption onto protein a. blood was drawn from patients by using a jugular catheter or a peripheral intravenous catheter. anticoagulation was performed with acd-a and heparine or acd-a and r-hirudine. plasma was separated by centrifugation. the . to -fold total plasma volume was treated in every immunoadsorption. the columns were floated with a maximal plasma flow of ml/min. the procedure was carried out every second day. additionally supplementary intravenous immunglobulin therapy was given only once. results: remission of the disease was achieved in four patients. see table below . conclusion: pa-ia is highly effective regarding the elimination of autoantibodies and circulating immune complexes, might induce a remission in patients with sle/mctd. it is an acceptable alternative treatment option in patients when other therapies are ineffective or contraindicated. background: purification of bone marrow from erythrocytes is used to prevent early hemolysis in major abo incompatible allogeneic hemopoietic cell transplantations. erythrocyte depletion is strongly recommended to reduce product volume and stem cell purification before storing autologous and even allogeneic bone marrow in order to prevent early hemolysis and dmso toxicity that might develop after thawing. centrifugation, sedimentation with hes, and cell separating devices are methods for erythrocytes depletion. aim: in our center, we prefer to use cell separation device, since it is a reliable method and has a high-yield and risk of contamination with erythrocytes is low. success of the process is retrospectively analyzed for high and low volumes. method: erythrocytes depletion of bone marrow harvest was done in hemapharesis unit with cobe spectra device in the last five years in cases with bone marrow volume over ml, and cases with bone marrow volume under ml. fifteen of these cases were allogeneic, and were autologous procedures; a software uploaded with cobe pbsc coll vers . and (catalog no: - - ) set was used in the procedure, and at the same time, double bag system with intermediate connectors were used to prevent re-circulation (catalog no: - - ). results: the mean volume reduction was . % ( . - . ) for volumes over ml, and . % ( . - . ) for volumes less than ml. regarding the success of the procedure no statistically significant difference was found between procedures with high and low volumes. no complication developed related to the device or product, and waste bag never had to be re-used. in none of the patients early massive intravascular hemolysis was observed. conclusion: erythrocyte depletion and volume reducing with cell separation device is a reliable method. this process is successfully applied with high volumes (over ml); and in low volumes as well for reducing erythrocytes, and gain of mononuclear cells and cd + cells. platelet concentrates obtained by apheresis procedure-correlation between the initial count and the final concentration v srejic*, g bogdanovic*, z garic*, n vavic* and b balint † *national blood transfusion institute, † military medical academy, belgrade, serbia apheresis team of the national blood transfusion institute processed and classified data of donors who donated platelets by apheresis procedure from january till april . procedures were performed in accordance with the ldplp protocol, using haemonetics mcs+. initial donors' platelet count and the absolute platelet concentration in the final preparation were followed, as well as red blood cell and leukocyte contamination and the volume of the processed blood. donors' initial platelet count was not less than ¥ /l and the volume of the processed blood was not less than ml. according to histogram, the most frequent donors' initial platelet value ranged from ¥ /l to ¥ /l ( %). final concentration of the samples of tested donors ranged from . ¥ to . ¥ in the average volume of ml. regression analysis demonstrated that there was a correlation between the initial donors' platelet count and the obtained final concentrate. student's t test showed p < . . leukocyte contamination of the final concentrate prepared without the filter ranged from . ¥ /l to . ¥ /l. presence of red blood cells in the final concentrate ranged from . ¥ /l to . ¥ /l. p- therapeutic apheresis (ta) in croatian hospitalsadherence to respectable guidelines z zivkovic*, b jeren strujic*, s boras † , i bojanic † , b golubic cepulic † and z ivankovic † *clinical hospital dubrava, † clinical hospital center zagreb, zagreb, croatia introduction: besides considerable resources, ta requires high costs and risk for patients. therefore, indication for ta often considers interests of patient, hospital and requesting physician. the most respectable guidelines for the implementation of ta were defined by aabb and asfa, classifying total of diseases into categories (ctg), ranging from 'standard therapy' to 'lack of efficacy' . the objective of this study was to determine indications for ta performed in croatian hospitals in the period - , respecting aabb/asfa guidelines. results: during the observed period in croatia, ta was performed in patients suffering from various diseases. in ( %) patients ta was performed by membrane filtration, while in ( %) separation by centrifugation was used (table ) . according to the ctg, s of the aabb/asfa guidelines, ta was performed in ( %) diseases from ctg i, ( %) ctg ii, ( %) ctg iii, and ( %) ctg iv of patients. the most frequent indications included in ctg i were: myasthenia gravis ( %), collection of pbpcs ( %), sy. guillain-barré ( %), and plasmacytoma ( %). in ctg ii frequent indications were: poisonings ( %), systemic lupus erythematodes ( %), and rapidly progressing glomerulonephritis ( %), and in ctgs iii and iv: cytoreduction-polycythaemia ( %), thyroid storm ( %), gvhd ( %), and reumatoid arthritis ( %). ( ) the time spent for resolving h / , ( ) mtp / , ( ) discarded blood units / . iii group: wrong data input / , donor replacement / , marking errors / , error in determining blood group at the first blood taking / , errors in input medical consulting / and disregard of prohibitions / . the consequences are: ( ) the time spent for resolving h / , ( ) mtp . / . , ( ) discarded blood units / . conclusion: the analysis of errors has showed that the number of errors can be decreased by implementation of corrective/preventative action based on continual education of the staff, appropriate sop, effective organization, qmp for equipment. the conclusion of our study is that reducing the rate of work errors will decrease the waste of material and time, also that will decrease the number of discarded blood units. an iso standard for blood transfusion? background: in our search for an independent, objective assessment at western province blood transfusion service, we were unable to find one single model that met the specific requirements of blood transfusion. we therefore resorted to developing our own model but ask the question: why not have one international standard for blood transfusion? aims: our aim was to have a standardised system for the independent, objective assessment of our blood transfusion service with audits carried out by an internationally recognised body. we wanted a formalised, professional system of accreditation with inspection checklists, reports, certificates etc. methods: having moved away from accreditation by the american association of blood banks in mid 's, we evaluated various other options such as inspection by our government department of health or the world health organisation but neither organisation had trained inspectors or systems in place. we also investigated iso certification but, although this was acceptable on the quality management side, it did not cover the technical parameters relating to blood transfusion. results: we therefore developed our own model for accreditation that consists of three parts: • a quality management section incorporating iso principles; • a technical section incorporating specifications from the south african standards of practice (we also consulted the european, american, canadian and australian guides); • a laboratory section incorporating iso parameters (soon to be updated with iso ). we then chose to be accredited by the south african national accreditation system, sanas, an internationally recognised institution. once we had written a national accreditation checklist, sanas submitted this to two international accreditation bodies (iaf and ilac) for approval. the system has been in place for three years now during which time we have had four successful assessments. summary/conclusions: in developing our system, we reviewed what was being done elsewhere in the world and it became evident that, although there are great similarities between countries, there p- software for the management of the scansystem bacterial detection method the scansystem tm was developed for bacterial detection in blood products. to be implemented in blood banks, a specific software is now available in compliance with blood bank regulation in order to manage sample traceability and data file transfer. the software is divided in main levels: an administrator level to create an application configuration in compliance with customer needs (product bar code characteristics, frequency of the positive controls, manual or automatic data file transfer . . .), a technical level to manage the operators (password, id) and to validate some specific results, an operator level for routine testing. the software assess sample traceability when testing pools of samples from to more than . indeed, bacterial detection is performed for pools of to platelet samples and to red cell samples. each sample in the pool is traced through its barcode until the final result. the system is compatible with most of the barcode standard including isbt . in addition, the system checks each barcode protecting the sample against duplicate testing. the software assists and monitors the bacterial detection process from the sampling to the end of the test (final result), each step of the procedure is identified through its barcode and at each time, it is possible to know the test status for each sample. for a pool of samples, results can be obtained: 'negative' or 'on hold' for a positive result. for a 'negative' pool, each sample constituting the pool are determined as 'negative' . for an 'on hold' pool each sample constituting the pool must be tested as a single sample and the final result is 'negative' or 'positive' . data transfer may be manual or automatic. a final technical validation is necessary before the transfer through an active selection of results to download. final results are provided in a compliant format for an easy import into the blood bank database. all necessary information are displayed: 'machine id' 'product/sample barcode id' 'date' 'time of transfer' 'operator id' 'result' ('negative' or 'positive'). the main advantage of this software is a continuous check of each step reducing the risk of error in testing. it makes the scansystem tm test compatible with a routine use in blood banks according to the current regulations and quality assurance programs. is no overall consistency. we feel it would be of benefit to establish an international working group to investigate the feasibility of writing an iso standard for blood transfusion. the standard would harmonise quality management parameters based on iso principles and technical/laboratory parameters specific to blood transfusion. minimum technical specifications would need to be agreed upon based on the various standards and guidelines available around the world. this iso standard could then be used for the purposes of certification/accreditation or government inspections. this would ensure global standardisation of world-class best practices. first world countries would be able to achieve compliance and a subsequent step could be the establishment of an international forum to assist developing countries to work towards compliance in the longer term. residual leukocytes in leukoreduced cellular blood products -evaluation by flow cytometry web-based outcome review: do you know how productive your trima® can be? background: web-based outcome review is a new software tool developed by gambro bct for the management and the interpretation of data from the trima and trima accel tm automated blood collection systems. aim: does the interpretation of reports obtained through outcome review lead to an increase in the number of products per run and the overall productivity of the apheresis center? method: run data files (rdf) from trimaᮀ were collected and transferred onto the outcome review server. these rdf do not contain any donor related data that can lead to possible donor identification. the reports were generated on the outcome review website (gambro bct intranet), interpreted by a gambro bct employee and presented and discussed with the management of blood centers. results: a total of different reports can be generated on the website as a pdf file. for this study, reports were investigated. they are: doses per collection, doses per collection trend, platelet collection trend, platelet procedure performance, platelet procedure performance trend, product distribution, average procedure time, procedure time, machine productivity trend. the results obtained for a center can be compared to word-wide, national, regional or to other individual trima devices in the centre (benchmarks). this benchmarking allows the management of an apheresis center to compare the results, to draw the right conclusions and to develop and implement corrective actions. implementing successfully these corrective action plans will lead over time to productivity results that are more in line with the figures that are generally accepted to be the optimal production capabilities of trima. the reports also help to monitor the effects of the corrective action plan over time and to adjust this plan if the results are not in line with the expectations. reaching and maintaining the optimal production capabilities of trima will also increase the net revenue by procedure or decrease the cost by procedure for the blood centre. conclusion: web-based outcome review allows getting more products from the existing donor base by interpretation of the multiple reports and implementing the required corrective actions until optimal production capabilities of trima are reached and maintained. introduction: to examine the cell vitality of packed rbc's during storage several parameters like atp, free hb or , -dpg are used. less kits for the determination of atp are available and they need either a large sample volume and/or are time consuming. here we present the modification of a commercial testkit for a time-and cost saving detection of atp. methods: samples were analysed with (a) -phosphoglyceratekinase reaction according to bergmeyer, h. methods of enymatic analysis nd. edition. academic press, new york ; (b) detection via hplc and c) using a commercial testkit (r. greiner bio-chemica, germany). the atp-kit were minimized from ml to a total volume of ml and tests were performed in microtiterplates. results: samples were analysed in hplc and modificated commercial testkits, another samples have been examined in all tests. comparison of the results showed no discrepancies in the above mentioned methods. standard curves have been performed (range - mm atp) and statistical analysis demonstrated a given linearity (r = . ). variability has been calculated as . % (intraassay; n = ) and . % (inter-assay; n = ). the hand-on-time calculated for samples has been decreased from . hours to minutes. at least the costs of atp-determination have been reduced from € . to € . per sample. conclusion: performance of test kits in microtiter format is a fast and rapid method, reliable for high-throughput determination of atp in packed rbc's. background: in order to preserve both blood safety and availability it is mandatory that a minimal amount of blood units would be discarded due to defects in the materials and supplies used for blood collection, or to deviations in blood processing or storage. aims: ( ) to monitor the derangements of different materials and disposables used during blood collection and processing, and to study the suppliers' responses and corrective actions taken. ( ) to asses the relative contribution of different defective materials (dm) to the need to discard valuable blood components. materials and methods: about whole blood units were collected and processed by mda national blood services in [ ] [ ] [ ] . as part of the routine quality control activities, derangements of the dm used were recorded and analyzed. some different types of dm were defined. out of reports sent to the corresponding manufacturers for investigation, responses ( %) were received and analyzed. about % of dm were detected during blood collection. manufacturer defects of different materials were the reason for components discard in nearly % of cases. conclusion: defective materials are one of the major causes of the infringements of blood collection and blood component preparation processes. analysis and monitoring of the different defects and of the suppliers' responses and corrective actions are essential to improve products' safety and availability. establishment of a network for the exchange of information among international blood centers would enable the blood banking community to compare between different suppliers and to use the documented cases for training of personnel of both the blood services and the manufacturers. such a system may contribute to the improvement in quality of materials used and might lower the discard rate of valuable blood units. results: table analysis and characteristics of t ( ) comprehension of the blood bank's processes and the interaction between them and between the processes of the whole hospital. ( ) monitor, measure and analyze these processes, in order to improve their effectiveness continuously. ( ) implementation of internal and external quality controls for blood and blood products and implementation of appropriate statistical techniques for monitoring their results. ( ) identification of interested parties (doctors, donors, patients) satisfaction and taking up the necessary preventive or corrective actions to improve their satisfaction. the qms of our blood bank was certified by tuv rheinland in / / and the scope of the certification is: 'blood collection, testing of infections markers, production of blood components, compatibility screening for blood transfusion and other immunological tests and implementation of therapeutic schemes in thalassaemia patients' . the implementation of the qms based on iso : standards ensures the improvement of services provided by the blood bank and the increase in customer satisfaction, whether donors or patients are concerned. the former enjoy the respect and recognition of their social contribution, while the latter are assured of very high levels of service and health protection. finally, we shall not underestimate the positive impact of qms in the motivation of blood bank personnel. quality becomes integrated both in their professional and personal attitude and allows for achieving increased satisfaction from their work. equipment management in the national blood transfusion service in serbia introduction: new equipment was urgently needed in three blood transfusion establishments (bte) in serbia. equipment was mostly inadequate for core blood transfusion activities, placed in inappropriate facilities, very old without routine maintenance or calibration. also, technical documentation for most of the equipment did not exist, and procedures for equipment management and responsibilities were not defined. further more, coordination on equipment issues with the qa department was not recognized. service funded by the european agency for reconstruction, provided various equipment for the three blood transfusion establishments. the new equipment includes blood collection equipment, centrifuges, refrigerators, incubators, automated testing equipment, genetic analyzer and it equipment of . million euros value. before the new equipment is installed the bte's agreed to have the national procedures on installation, validation, calibration and preventative maintenance in place. this will ensure that the equipment can be properly installed and validated before use. the project has provided training on validation to the working group (wg) on quality. the wg has created national procedures related to the equipment, including quite new term validation. the same problems in implementation of procedures were present in all three bte's. significant efforts are made to explain to the staff how the equipment has an impact on quality, how to ensure that the equipment does what it is supposed to do, how to be confident that the results obtained are accurate and how important it is to generate records. qa managers played an important role in the preparation of facilities for equipment installation, making plans for equipment layouts, creating documents (master cards, instruction for use) and designing the validation protocols. the same procedures and records enable an exchange of results, comparability, sharing information on what works and what does not work between bte's. the qa managers also prepared an introduction of equipment requirements to the heads of departments, with special attention to the validation process so that they are able to fully understand what is required and why to validate their equipment. results: national standards in equipment management in serbia are set and are being implemented. qa managers carefully managed that the new, numerous equipment, delivered in the short period of months was correctly installed, validated, obtained with necessary documentation, followed by previously trained staff, so that equipment can be considered as controlled. the additional, positive effect is that validation is performed in one establishment for all bte in the country, allowing a more prompt response to problems and presenting of joint request to suppliers, as well as an easier way of monitoring equipment performance of the three bte's. organized equipment management has affect on every aspect of blood activities and finally to the quality of blood and blood components. background: the vista information system (vista tm ) is used in centers in europe as an apheresis management system. with vista tm it is possible to increase productivity, donor comfort and loyalty and therefore simultaneously improving the overall process in the center. aim: a calculation tool (microsoft excel) was developed to evaluate the added value of vista tm . three blood centers in different european countries completed a questionnaire using their local data. summarizing these figures gives us an idea about the impact of vista tm on the daily work and budget of a blood centre. method: the excel calculation tool that was used investigated major areas where vista tm could show added value: improvement of regulatory compliance, increase the efficiency in operations and improve productivity. results: regulatory compliance: the number of infringements decreased, causing a considerable direct financial gain because these events are very expensive to deal with. the time spent on regulatory reviews decreased with a mean value of %. operational efficiency: the number of reports is very site dependent: sometimes a report is made for every procedure together with the printout of a blood loss history form. because vista tm tracks all procedure related data, some sites decided to stop printing these types of reports and to go completely paperless. the percent time reduction in reporting is therefore very variable. however the % of errors related to these reports decreased considerably with a mean value of %. efficiency in operations was also obtained because of the number of reports that are available in vista tm . productivity, management and process reports allow verifying and correcting the daily operations of the blood center. increased productivity: depending on the center, also an increase in the number of platelet and plasma products collected was detected. the number of product discards caused by infiltration reduced with a mean value of %, mainly due to the possibility to have customized and more donor adapted trima settings. the percentage of whole blood donors targeted for conversion was very site dependent (min . %-max %). but because with vista any procedure brings between . and . products in general, the financial gain was considerable when donors could be converted from whole blood to apheresis. the use of vista allows the apheresis center to work with a reduced error rate and to increase the operational efficiency and the productivity. the financial impact of this has been estimated by the centers between € and € (mean value €) per procedure. establishment of national quality system in blood transfusion service in serbia introduction: the production of blood products is a semiautomated process in which the manual steps may be difficult to control and standardize. aim of the study: we introduced a specialised team for the blood production to test if this improved the control of the quality of the blood products. methods: the blood products tested for statistical process control were red cells in additive solution, buffy coat removed, and leukodepleted (ld) platelet pools prepared from buffy coats. the products were collected in t&b triple opti-pac from baxter and the platelet pools were ld using plx- filters from asahi and stored in platelet bags from baxter. using control charts, namely x-mrchart, exponentially weighted moving average ewma chart and for autocorrelated stationary data the ewmast chart, we examined if time series of quality control values were in statistical control. if not we examined if autocorrelation and/or differences between the technologists producing the blood products could explain the lack of control. data included approximately biweekly measurements of volume, haemoglobin (hb) concentration, hb/unit, haematocrit and log leukocyte count (wbc)/unit of units of red cells, measurements of volume, platelet concentration and platelet count/pool of ld platelet pools produced by a team of technologists and of ld platelet pools produced by a specially trained team of four technologists. results: log wbc/unit was out of statistical control due to systematic differences between technologists. apparent lack of control of volume, hb-concentration, hb/unit caused by autocorrelation disappeared when the ewmast chart was used. platelet concentration and volume of the platelet pools produced by the technologists were out of control. in that some technologists systematically produced low values. this could be explained by inappropriate handling of the platelet product between centrifugation and separation. systematic differences between the four specially trained technologists could not be demonstrated and they produced platelet pools with a significantly higher platelet count/pool. however, standard deviations of the four technologists differed significantly causing occasional outlying values. conclusion: training and routine in blood production or process automation, and also importantly, feed back to the technologists based on control chart quality control data, is recommended. background: one important principle of the use of blood and blood products is the ability to trace the units from donor to the recipient. this study set out to establish whether or not there was sufficient reporting on transfusions from the hospitals supplied by fort portal regional blood bank in western uganda as a means of establishing sound haemovigilance and look back systems. were reported with no unit number and could not be traced to the patients. there was sufficient reporting on the data requested by the blood bank. these results suggest that it is possible to establish effective 'look back' and haemovigilance systems. capture of data on outcomes and adverse effects will be necessary to fully establish the system. further efforts are required to educate those involved in transfusing blood about the need for adequate and accurate documentation. external quality assessment of blood grouping were misinterpreted as rhd-positive samples without the use of control reagent. rbc phenotyping was made correctly by . % of participants. the remaining . % of participants carried out the phenotyping incorrectly, while false-positive and false-negative results were derived in . % and . % of cases correspondingly. polyspecific human sera and monoclonal antibodies were used for abo, rh and antigens typing. the reason of errors in antigen detection was low quality of reagents. antibodies identification was carried out in six distributed exercises. % of participants detected anti-d-k-c alloantibody correctly. the rest of participants did not found alloantibodies or detected their specificity incorrectly. results of testing depended on quality of screening cells. thus, the participants using homemade pooled screening cells had a significant lower detection rate of antibodies comparing with those using diamed ag cell panel. consequently, the results of the first federal external quality assessment scheme show the necessity of improving the quality of red cell reagents produced in russia. in addition, the more appropriate training of staff is required. the importance of iso -quality system in increasing safety of blood transfusion introduction: hadassah hospital transfusion medicine department received on / iso -quality system accreditation. an essential element of this standard is the development of a reliable system to identify, document, analyze and correct actual and near miss events and assess the effectiveness of corrective and preventive actions. aim of the study: assessment of events and corrective actions following implementation of iso quality system. methods: events in the blood bank were identified by the staff, by internal or external audits and by complaints from the wards. all events were recorded and classified into two categories; quality system and technical. the latter were further classified into preanalytical (sample receipt), analytical (abo rh typing, antibody screen and identification, cross matching and phenotyping) and post-analytical (issue of components to wards). all events were graded into levels; -most severe, potentially harmful to patient. -severe, damage to process and result. -moderatly severe, damage to process only. -benign, no harm. events were corrected and effectiveness of corrective actions was assessed by monitoring recurrence of the event. results: during the years - , events were detected and recorded in the blood bank, they comprised . % of all tests performed ( ). most of the events were technical. all events were detected before causing harm to the patients. results are summarized in the table. *the percent analytical value is a summary of rates of events per test types included in this category. events detected in the quality system were mainly of severity level & , whereas technical events were mainly of severity levels & . analysis of event recurrence in the quality system revealed that % of events were resolved, whereas only %- % of technical problems were completely solved. the main source of event identification and documentation, in the quality system were audits whereas in the technical system, staff members revealed most events. the implementation of iso quality system provided a powerful means for recognition, analysis and study of patterns of near misses and actual events. understanding the root causes of events enables to choose the most effective corrective and preventive action to control event recurrence. evaluation of the frequency of events confined to the blood bank revealed a very low rate of . %. these results are in agreement with data in the literature. creating a non-punitive, non-stressing open environment, motivates personnel to identify and document events, which are regarded as opportunities for improvement and serve as important tools for upgrading transfusion safety. the explosive use of information technology and the speed with which it has spread into all life activities has created vulnerabilities for all organizations. those vulnerabilities are compounded by the complexity of information technology, limited time to market, development constraints, and constantly changing relationships between organizations and suppliers. growth in the sophistication of security threats makes it imperative that organizations remain equally competent in identifying vulnerabilities and mitigating security risks. aim: the goal of this document is to explain how isbt intends to provide guidance to the blood banking community on implementation of effective information security policy. when using information for critical activities, blood banks should consider information security as an important aspect of their management policies. evaluation of existing standards, such as iso and hipaa, allows us to establish a framework for information security without regard to the type of organization. it remains very difficult however, due to the complexities involved, to establish an information security policy without guidance. method: the isbt information task force was created to provide guidelines on information security for blood banking organizations of all sizes. the intent is to help them understand existing standards as well as provide tools for implementing information security policy. these guidelines are based on existing standards that are followed by most worldwide countries: iso and hipaa. results: information security can be defined as the 'protection of systems, information and services from accidental and deliberate threats to confidentiality, integrity and availability' . understanding existing information security standards was the first step for establishing a structure for the guidelines. the core is organized within an implementation framework and presented under the three following layers: . administrative for defining the it security organization, the information security policy, and information security awareness and training. . physical for providing solutions that relate to physical environment protection and access, equipment and it infrastructure security, and control for accessing computerized equipment. . technical for maintaining confidentiality of electronic information and ensuring that authorized access to information systems is maintained (technology relating to identification and authentication, logical access, operating system, network management, application access, etc.). strategy guidance is also included for senior managers in charge of establishing organization policy, including responsibilities and methods to successfully implement policy. further, the task force is addressing both risk analysis and management including identification of potential dangers to information systems (threat-source) and existing controls (risk description), as well as a plan to address identified vulnerabilities and mitigation of specific risks. conclusions: information security standards are prerequisite to understanding the issues involved when considering information vulnerability. international guidelines for information security, specifically directed to the blood banking community, are equally necessary if we are to identify, plan for, and mitigate risks associated with vulnerabilities to critical blood banking information. the isbt task force is committed to providing such guidelines. introduction: the important part of quality planning and quality assurance within production of blood components is measurement system analysis (msa). measurement system analysis was performed on microscopic counting of blood cells in our study. aim of the study: aim of this study is determination if microscopy counting of residual elements in whole blood plasma is suitable for quality control of blood components. methods: we practiced measurement system analysis in counting of residual elements (leukocytes and erythrocytes) in whole blood plasma. the counting performed two lab technicians in ten samples of plasma from whole blood. leukocytes and erythrocytes were measured in naggeotte counting chamber. we used the method of mean and range for the determination of reproducibility and repeatability (r&r) and analysis of variance for complex measurement system analysis. regulation diagrams were applied for the graphic statement. we determined the value of repeatability, reproducibility, coefficient r&r, variability among samples of plasma and total variability of measurement system. the important conclusion was to determinate if the microscopic counting of samples of blood components is sufficient with regard to quality parameters specified in guide to the preparation of blood components (erythrocytes: < . ¥ /l, leukocytes: < . ¥ /l). our results show that microscopy counting of residual elements in whole blood plasma is suitable for quality control of blood components. aim of the study: to provide transfusion services with a tool for proper qms implementation, an international collaborative study on qms applications, employing the 'process approach', has been undertaken by a group of transfusion services of varying sizes and structures with experience of qms, in collaboration with a university institute offering a master in qms implementation in health services, and an expert from a quality association. the 'process approach' serves as a tool to manage transfusion activities as a system based upon a network of processes and their interactions. guide-lines have been produced based upon this principle and will be published (volume and cd-rom) and distributed at no cost to all transfusion services of nations participating in the study. the main contents of the guide-lines' chapters are: through definition/analysis of single processes and the correlation network amongst these, the 'process approach' methodology renders the transfusion centre's functioning units completely interdependent, eliminates process interface barriers, provides personnel with a unified focus on the main transfusion objectives, and lays the basis for improvement of transfusion service quality, organization and performance through efficient control of processes' interactions. the blood screening system automated high-throughput nat system for simultaneous screening of hcv, hbv and hiv nucleic acids: full process surveillance e pfeifer*, b alessandri † , hr bachmann † , t barker † , y ohhashi*, c parkhouse*, j pinsl-ober ‡ , p wenzig ‡ and g ziegler ‡ *roche molecular systems, inc., pleasanton, usa, † roche instrument center ag, rotkreuz, switzerland, ‡ roche diagnostics gmbh, penzberg, germany introduction: the blood screening system combines on one deck both automation of dna/rna extraction from blood/plasma samples and multiplex pcr amplification and detection of nucleic acid targets. the system is designed for high-throughput single unit testing and pooled specimen processing. a data management system supervises and controls the complete process from initial sample pipetting through to result compilation and reporting. the objective of this project was to present the system assay and device built-in quality control measures that guarantee process safety and reliability. the study shows how internal control, external batch controls, pipetting sensors, validation & maintenance procedures, and a controlled development & manufacturing process yield an optimal test method and system stability. method: failure modes and effects criticality analysis (fmeca) was used to evaluate a mathematically derived safety metric for optimizing risk reduction. this method makes use of a system risk objective-function (srof), which provides a multivariate description of sample processing, amplification and detection steps. the method for analyzing system behaviour first employs product classification into risk domains, followed by ranking of process steps that are determined to be linked to known system hazards. this provides objective means for directing system design leading to risk minimization. the srof responses associated with redundant liquid sensing channels were shown to substantially reduce risk during sample or reagent transfer steps. the system liquid flow, airpressure-based (plld) and capacity-coupled liquid (clld) sensors detect aspiration and dispensing inaccuracies. sensor signal tolerance band widths studied for fluid classes representative of system reagents and for plasma samples from lipemic, icteric, and hemolized sample sources were shown to correlate with srof multivariate modelling. the impact of surveillance design elements on the srof response demonstrates that risk is functionally dependent on design elements. additional surveillance examples are presented that describes temperature sensing, robotic positioning and motion control. treatment of residual risk is addressed by introducing external controls that are configurable to specific workflow scenarios. the negative external control (nc) is used to check for contamination of reagents. five low concentration armored external controls, i.e. hiv- group m arna, hiv- group o arna, hiv- arna, hcv arna, and protected hbv dna are run at the beginning of a batch as a run-control measure. in addition to these roche controls the system supports running of user-defined external controls for co-validating the batch. the internal control (ic) is based on armored hiv- group m rna that is co-extracted and co-amplified with the external controls and the target nucleic acids potentially present in the sample. lastly, the system resource management monitors the status of samples, ready-to-use reagents and disposables via rack sensors and bar-coded bottles and tubes. the fmeca methodology provides a risk-minimized, comprehensive system design. redundant sensors with internal and external controls are evaluated through comparison of modelled versus actual run results. the system brings a new level of surveillance and throughput for automated pcr testing, and emphasizes roche's commitment to increasing the safety of the global blood supply. technical standards for safe storage and transport of blood components and blood samples objective: to implement standardization of technical specifications for safe storage, transport and distribution of blood samples and blood components intended for transfusion, as part of a quality system in blood transfusion medicine. methods: in the course of implementing a quality system in our blood establishment (distributing % of the national blood supply), we have developed standard operating procedures (sops) for temperature and hygienic conditions to maintain and control storage of blood components during their shelf life and to ensure their safe distribution to other blood services in the country and abroad, in compliance with eu directives / /ec and / /ec and the recommendations of the council of europe and who. procedures are validated and relevant records are kept. a statistical process control is also in place to monitor deviations from specified temperature and time range throughout the period of transportation. blood components collected and prepared for specific purposes (e.g. directed donations, irradiated units, hla-typed units, anti-cmv negative blood components and blood for neonates) are stored separately, and alarms and warning systems are in place. packing and transport conditions of red cells, platelets and ffp are submitted to the tests and criteria of adr (european agreement concerning the international carriage of dangerous goods by road). in greece, the adr legal framework has applied since . blood samples are classified according to adr in division . under un as diagnostic specimens, and the criteria for safe carriage include packaging, specific labelling and vehicle requirements as well as carrier obligations and personnel training. our blood establishment has a contract with biotrans, a private company accredited for packaging, storing and transporting blood, organs, tissues and cells as well as potentially infectious biologic substances and blood samples for diagnostic purposes. assurance system). the approach is specified in the form of requirements of art. . of the standard: the organization shall: (a) identify the process needed for the quality management system and their application throughout the organization, (b) determine the sequence and interactions of these processes, (c) determine criteria and methods needed to ensure that both the operation and control of these processes are effective. regional centre for transfusion medicine in biaĺystok was the first transfusion service in poland which was certified according to iso : standard. our expected profits from the implementation qms were: possibility to overview organization's pathways of operation and to inspire corrective and improvement actions, emphasis on the role of staff in the system, focus on self-control and responsibility for one's own work as a factor of staff's mentality creation/modification. our one year of experience with iso : standard proved the system to be handy tool of management for the organization collecting, processing, testing blood and releasing of blood products for the hospitals and to be well accepted by the staff. the implementation and certification of the internationally nor-malized quality management system simplify and shorten all accreditation and registration procedures required for legal activities of transfusion service as well as for any supplemental medical activities which may be performed by the centre. the implementation of qms facilitates the implementation of other quality systems and simplifies procedures required for the ce certification for the products. red blood cells stored in blood banks, normally undergo a series of chemical alterations, or storage lesions. the ultimate consequence of these lesions is a decrease in the viability of the red cells following transfusion. the chemical alterations are mainly changes in levels of na+, k+, cl-concentrations, ph and , dpg levels and they affect the electrical impedance of blood. the electrical impedance, cole-cole parameters, is determined mainly by the resistance of the red cell extracellular fluid (re), the resistance of the intracellular fluid (ri) and the capacitance of the cell membranes (cm). in this study we aimed to investigate the relation between blood parameters and electrical impedance changes, and their further clinical implication. all parameters were measured on erythrocyte suspension (es) samples during days of storage at oc on days , , , and . for whole blood (wb) samples during days of storage, same parameters were measured on days , , and . the measurement of the complex impedance of blood samples were performed in the frequency range from khz to mhz. by using the a hp lcr meter, the impedance z, and the phase angle a for each sample were read. these values were corrected according to the gain and phase characteristics of the amplifier; and the resistance r and the reactance x were calculated. each data was first fit to the cole-cole model; hence the cole-cole parameters, intracellular resistance ri, extracellular resistance re, characteristic frequency fc and phase angle a were obtained by using lms software. afterwards, cm was calculated by using ri, re, a and fc. whereas ri and cm decreased progressively with time on both wb and es, re changes showed some differences. the electrical impedance alterations were explained by measurements of na+, k+, clconcentrations, ph and , dpg by indicating days. storage of red cells resulted in a rise in extracellular k+ and a fall in extracellular na+, cl-, ph and , dpg. anova was used to evaluate differences in blood measures in relation to storage time. the results were presented as the mean ± sd. according to the regression analysis in spss, the intracellular resistance (ri) on both es and wb was affected more efficiently from all blood parameters among all other electrical parameters. although ri and re were correlated with na+, k+, cl-, ph and , dpg more significantly, cm measurements were failed to show correlations with blood parameters because of the intervening parameters, a and fc. the best relationship between the parameters mentioned above on both es and wb was ri and k+. ph changes were the same for ri and re both for es and wb. the correlation between parameters on es was better than those on wb, because whole blood consists of several particles that may affect our measurements. our study showed that , dpg has an effect on ri and re as efficiently as other blood parameters and therefore electrical impedance measurements may serve future implications. background: issue of quality blood products and donor safety are the main aims of blood transfusion services. a comprehensive quality system should be in place to fulfill these aims, which can be attained through strict adherence to the established standard operating procedures (sops). the drugs and cosmetics act of india, which controls the licensing of blood transfusion services, does not provide clear guidelines regarding plateletpheresis procedure. aim: we therefore established our own sop and operational flow chart for plateletpheresis that can be easily followed by other centers in india. methods: a total of plateletpheresis procedures performed using two cell separators (cs baxter, usa, mcs p, hemonetics, usa) were evaluated following our established sop. the mean platelet yield in cs was . ± . ¥ and in mcs p, it was . ± . ¥ per unit, however, only - % of sdps showed wbc levels < ¥ . six of donors complained of hypocalcemic symptoms. the operational flow chart designed in this study was found to be simple and easy to adapt by blood transfusion services in this country. the first advanced quality management training course for blood transfusion services in the western pacific region mk tan*, jp yu † and d teo* *health sciences authority, singapore, † who regional office for wpr, manila, singapore background: blood transfusion is a key part of modern medicine. a well-organised blood transfusion service (bts) is a prerequisite for the safe and effective use of blood and blood products. in , the world health organization (who) introduced a new initiative of quality management project (qmp) to achieve the goal of safe and adequate global supply of blood. through qmp, regional training centers were identified and quality management training (qmt) courses were established. in , centre for transfusion medicine (ctm) of health sciences authority singapore was appointed as a collaborating center for qmt in the western pacific region (wpr background: spectrophotometric method according to harboe was traditionally used at our institute for determination of free haemoglobin in supernatants of rbc blood components at the end of storage time. in the year hemocue plasma low hb system (hemocue, sweden) was introduced as a replacement method. aim: the aim of the study was to examine reliability and suitability of the hemocue method for measurement of free haemoglobin in supernatants of rccs. methods: hemocue plasma low hb method was validated and compared with harboe method. supernatants of rbc products were tested by two methods and results compared using regression analysis. additional testing was performed to investigate precision of hemocue method (within-run and between-day variation), trueness using reference material and to define optimal sample handling. results: regression analysis showed high correlation between two methods (r = . ), with higher values obtained with hemocue method. immediately after centrifugation one supernatant was measured times in order to determine within-run imprecision. coefficient of variation (cv) calculated from consecutive measurements was . %. to investigate between-day imprecision of the hemocue method one sample was divided in aliquots and frozen. one sample was thawed each day and measured. cv of five measurements was . %. during the period of validation measurements of reference material (low, medium and high) were performed. cv calculated for these measurements were . % (low), . % (medium) and . % (high). in order to investigate possibility of batch testing, supernatants of different rbc products were divided in aliquots and measured periodically during -month period. cvs calculated from measurements of each sample were in range . - . %. conclusion: hemocue plasma low hb method appears to be an excellent replacement for the harboe method. it is consistent, easy to use, measurements are performed in short time, and errors are minimized by eliminating dilutions and manual calculations. background: determination of haemolysis in red cell concentrates (rccs) at the end of storage time is routine method in quality control of blood components at our institute. for this purpose, haemoglobin concentration in supernatant of rccs is measured using hemocue plasma/low hb system (hemocue, sweden). according to manufacturer recommendation, visually turbid samples should be filtered before analysis with a . mm filter. because visual estimation of turbidity is highly subjective and unreliable, filtration of all supernatants before analysis using appropriate filters is possible solution for standardisation of the method. aim: the aim of the study was to investigate the effect of filtration of visually non-turbid samples on results of free haemoglobin measurement. methods: haemoglobin concentrations were measured in visually non-turbid supernatants before and after filtration using hemocue plasma/low hb photometer ( wb negative controls were used for each blood component. in all blood components tested bacterial contamination was detected using both types of bottles. in comparison with sa/sn bottles, nearly all enrolled microorganisms were detected faster in bpa/bpn bottles (see table ). all negative controls were negative (no false positive). the results of the study performed support the use of bact/alert bpa and bpn plastic bottles in quality control testing of different blood components. objective: management of returned blood products is important part of quality assurance activities in transfusion medicine. blood products are returned most frequently because of routine rotation of stock and because of nonconformities discovered after the product has been received. methods: qa data about returned blood products were retrospectively analysed for the -year period ( - ) . only blood products returned because of nonconformities were taken into consideration. data about the reasons for returns are presented and discussed. the top reasons for returns were positive dat, labelling errors, blood bag defects and visual appearance of blood units (see table ). in all cases positive dat was confirmed in our institute, and blood donors managed accordingly. nonconformities related to visual appearance of blood component and other nonconformities related to the quality of blood products were investigated and corrective actions conducted. in case of blood components returned because of damaged bag, significant problem is to investigate the cause of nonconformity (usually inappropriate transport conditions). conclusion: management of returned blood products is important tool in improving the quality of blood products. introduction: hemovigilance is the systematic monitoring of the blood transfusion chain for side effects and adverse incidents from the moment of blood collection until after administration of the unit to the recipient, and comprises all activities that can lead to a safer and more effective use of blood components. attempts to achieve a more safe and effective use of blood components constitute a huge task given the number of interventions and array of medical and not-medical personnel involved in the transfusion process. registration of the impact of all participants is a tremendous job as such. information management may enhance the chances for a successful hemovigilance. aim: the aim is, to establish a basis for all the information related to the chain, such as standard operating procedures, (inter)national guidelines, local transfusion protocols and forms, and procedures to direct the process. additional factors that contribute to the final results are the profile and role of employees, incidents, points of care, product information, prices, budget, contracts, etc. by clarifying and explaining the basis to all participants by means of an existing infra structure, everyone will gain access to identical, consistent and up-to-date information at all times. the primary activity is to create the basis by an outline of every individual link in the transfusion chain from donor to recipient. secondly, the resources, responsibilities, actions, and internal controls (what task, who is performing, why, which help, where, when) are documented. by creating distinct databases for these 'w's' in combination with a separate database for the hemovigilance process itself, it is possible to establish relations, hyperlinks, between the different databases. all the information collected in the foundation, complete with all the resources, responsibilities, actions, and internal controls is made available to target groups by means of the intranet in our hospital as well as in a printed handbook format. collecting and displaying the information on hemovigilance this way, creates a transparent and more easy-to-manage process. it establishes a basis, which incorporates all resources, responsibilities, actions, and internal controls to all participants and enables the organisation to operate both efficiently and effectively. it allows us to show auditors (both internal and external) which processes are related to which guidelines as well as the results in daily. in addition, it reveals which factors determine the genuine application of the guidelines in clinical practice. conclusion: by outlining the process, followed by defining, analysing, securing, on the 'w ' method, the hemovigilance process offers a stable basis and framework for all participants and may stimulate a more safe and effective use of blood components. background: transfusion medicine is a basic post-graduate specialty for medical doctors with a specific national curriculum in bulgaria. in order to improve the post-graduate training of medical doctors in transfusion medicine, a new curriculum was elaborated in . purpose of the new program: independent work of transfusion medicine specialists on all levels of the blood transfusion service (bts) -organization of bts, promotion of voluntary, nonremunerated blood donation, collection, processing, testing, storage and transport of blood and blood components, immunohematologic testing of patients, laboratory hematology, clinical experience, assistance and advice on diagnostic and therapeutic problems of patients, requiring treatment with blood products, teaching transfusion medicine to bts and clinical personnel. admittance and duration to training -medical doctors are admitted to post graduate specialization after a successful state examination. the overall duration of training is years, of which at least are obligatory for training in the national or regional blood transfusion centers. main sections of the curriculum: . organization of blood donation and blood transfusion, including promotion of voluntary, nonremunerated blood donation; organization, planning and information systems; organization of blood transfusion; quality management. . collection, processing, storage and transport of blood and blood components . laboratory hematology and specialized methods (general laboratory methods, immunology, immunohematology, transmissible infections, hemostaseology, nat techniques, flowcytometry) . clinical use of blood components and plasma products (treatment with blood products, adverse events and reactions, alternatives to blood transfusion). the new curriculum of transfusion medicine guarantees a better training of medical doctors, thus leading to safe and effective blood products their proper clinical use. introduction: transfusion medicine is integrated medical discipline based on clinical and laboratory practice. it is closely connected with molecular biology, genetics, as well as with apheresis, automatically techniques and transplantation. the aim of studies in transfusion medicine is proper education, skills, attitudes and knowledge of students at the medical faculty and of doctors on residency in transfusion medicine and other specialties about blood and its usage. material and methods: there will be presented how transfusion medicine is implemented in educational and health sector in r. results: there is -year specialization in transfusion medicine, established years ago (over specialists finished this specialization till now). we have postgraduate studies in tm started years ago. transfusiology, as subject at the medical faculty, is now included in new curricula of medical student, consists of theoretical and practical lectures. also, medical doctors on specialization in surgery, anesthesiology, obstetrics and gynecology, pediatrics, internal medicine, maxillo-facial surgery and others have obligatory -month education in tm. transfusion medicine is integral part in education of nurses and laboratory technicians; all personnel that work in transfusion field in our country finished -mounths course in tm and get certificate. conclusion: although we have already done so much in educational field, we will continue with our efforts to improve our collaboration with clinicians and to involve ourselves more in clinical disciplines. introduction: in hospitals of saint petersburg donor blood, its components and preparations, autoblood and its components, hemocorrectors are applied with the medical purpose at - % of hospital patients. the service of blood and the existing organization transfusion therapy in hospitals should provide maximal immunological and infectious safety and also its high medical efficiency. it demands special preparation for all doctors: general physicians on clinical transfusiology and doctors of blood service on all sections of the general, industrial and clinical transfusiology. clinical gemostasiology, pharmacology of hemotransfusion means and hemocorrectors, the organization of the blood service, the donor service; the organization, technique and technics of preparation of blood, its components and preparations, quality assurance, transfusion therapy programs, technique and technics of transfusion medicine, a problem of maintenance of immunological and infectious safety, preventive maintenance, diagnostics and treatment of posttransfusion complications, feature transfusion therapy in pediatrics and medicine of accidents). clinical physicians master all basic questions of clinical transfusiology, thus the special attention is given questions of clinical immunohematology and clinical gemostasiology, programs and a technique of transfusion therapy, the prevention of posttransfusion complications. employment are carried out in departments of city blood bank, hospitals blood departments. final examination under the test program and at interview shows sufficient mastering a theoretical and practical material (right answers of - %). the described system of postgraduate studies provides an opportunity of successful independent work of doctors on the workplaces both regular increase and qualifications not less often than time in - years. conclusion: the existing system of postgraduate education for doctors on transfusiology provides the blood services and hospital by the qualified staff. introduction: nowadays in hospitals of saint-petersburg more and more it is frequently applied the extracorporal hemacorrection (haemapheresis, haemasorbtion, plasmasorbtion, krhyoplasmasorbtion, ultrafiltration etc.) and photohemotherapy (optical radiation influence on blood) at various diseases and traumas. they are used at treatment almost % from the general number of patients of hospitals with positive results at % from them. for this purpose in hospitals there are specialized branches or cabinets with staff of the doctors -transfusiologists. therefore an actual problem is organization of postgraduate special education for them. because there is no specific blood banking and transfusion medicine training in either under or post graduate medical education those general practitioners have limited knowledge about this field. aim: to give basic knowledge and practice to those general practitioners moh has established a special training programme with the collaboration of medical schools for years. methods: this is a months programme which has basic components; theoretical education, laboratory and blood banking practice. the trainees are evaluated by a final examination. each group has limited cadets and the training is provided in selected blood banks with the collaboration of universities and moh training hospitals. conclusion: almost general practitioners are trained by this programme in the last years and those doctors helped to increase the quality of blood banking and transfusion service at their hospitals. background: even the history of public blood banking in turkey has dates back to , whole blood was comprising the majority of transfused units (more then %) in turkey until the last few years. aim: the main target was to decrease the whole blood use in a short time and establish countrywide effective blood transfusion practice. methods: there were no specific blood banking and transfusion education either at undergraduate and postgraduate medical education in turkey until the last few years. blood banks and transfusion society of turkey (bbtst) was established at with the main aim of education of the related people about blood banking and transfusion medicine. bbts has organized symposiums, national courses, national and international congresses since . due to increased knowledge about the blood components and improved infrastructure of blood banks whole blood consumption has decreased to national average to %. in most of the university hospitals and training hospitals this is around %. conclusion: like most of the public based behaviours dedicated efforts of civil initiative has changed the traditional habit of blood consumption in turkey by the direct affect of well organized educational activities. training of general practitioners in blood banking and transfusion medicine n solaz*, b keskinkilic † and c oruc † *ankara university, ankara, † ministry of health, ankara, turkey background: turkish ministry of health runs majority of the hospital blood banks in turkey. most of the moh hospital blood banks give service under the medical supervision of general practitioners. because there is no specific blood banking and transfusion medicine training in either under or post graduate medical education those general practitioners have limited knowledge about this field. aim: to give basic knowledge and practice to those general practitioners moh has established a special training programme with the collaboration of medical schools for years. methods: this is a months programme which has basic components; theoretical education, laboratory and blood banking practice. the trainees are evaluated by a final examination. each group has limited cadets and the training is provided in selected blood banks with the collaboration of universities and moh training hospitals. conclusion: almost general practitioners are trained by this programme in the last years and those doctors helped to increase the quality of blood banking and transfusion service at their hospitals. background: it has been accepted that during cardiac surgery the complement-system is activated which enhances ischemia-reperfusion injury, leading to postoperative complications as infections and organ failure. the lectin pathway is one of the mechanisms that can activate the complement-system, this pathway can be mediated by mannose-binding-lectin (mbl). the level of mbl in serum shows a wide variation. a low level of mbl can lead to more infections in some conditions and a high level to tissue damage after ischemiareperfusion injury. the effect of transfusions of erythrocyteconcentrates and plasma on the mbl levels and thereby on complications after cardiac surgery are not known. aim of the study: the role of pre-and postoperative mbl levels and the effect of transfusions on postoperative complications after cardiac surgery. in a randomized controlled trial cardiac surgery patients were included and blood samples were taken pre-and postoperatively. mbl measurements were performed by elisa assays. the data were linked with postoperative complications as mortality, infections and multiple-organ-dysfunction-syndrome-mods and with peri-operative erythrocyte and plasma transfusions. results: the mean pre-operative mbl-level was ± and postoperative ± mg/ml. there were no differences in preand post-operative mbl levels between patients with infections or mods compared with non-infected and non-mods patients. the difference in pre-operative mbl between non-survived ( ± ) and survived patients ( ± ) was not significant (p = . ). postoperative mbl levels between survived and non-survived patients was smaller. conclusions: pre-and postoperative mbl levels in cardiac surgery are not related to postoperative infections, mods and hospitalmortality. whether large amount of blood transfusions are affecting the mbl-levels and thereby the patients outcome is not known. introduction: patients undergoing cardiac surgery are receiving high amount of blood transfusions and are at risk for the development of infections and multiple-organ-dysfunction-syndrome (mods), these complications are influencing the survival of the patients. during cardiac surgery pro-and anti-inflammatory cytokines are released by different mechanisms. we found in a randomized trial in cardiac surgery a significant reduction in infections and mortality due to mods by transfusion of leukocytedepleted erythrocyte concentrates (ld) compared to leukocyte-containing, buffy-coat depleted erythrocytes (pc). aim of the study: the effect of ld on the concentration of proinflammatory cytokine il- and anti-inflammatory cytokine il- in relation to clinical outcome and complications after cardiac surgery. methods: in participating patients blood samples were taken before and after surgery. using elisa il- and il- were measured in these samples. the results were linked with the endpoints of the randomized trial: postoperative infections, mods and in-hospital mortality. results: all pre-operative concentrations of il- and il- were low. mean postoperative level for il- was ± and for il- ± . compared with patients without mods and without infections and survived patients only the il- was significant higher in patients who died and in patients with mods. there were no differences in mean levels related to ld and pc. the levels of il- were higher in patients receiving more then units blood transfusions compared to transfusions. conclusion: there is an association between mods and mortality and il- , not with il- . ld has no influence on mean levels of il- and il- . there is a correlation between transfusion of more then units and il- , not with il- . these cytokine-profiles are not associated with the beneficial effect of ld on the postoperative outcome in cardiac surgery patients. anemia and blood transfusion practice in critically ill patients e grouzi*, e tsigou*, p evagelopoulou † , g baltopoulos † and i spiliotopoulou* *kat general hospital, transfusion service, athens, † athens university school of nursing icu, athens, greece background: anemia is a common problem in critically ill patients admitted to intensive care unit (icu), but the consequences of anemia on mortality and morbidity in the critically ill is poorly defined. aim: to define the incidence of anemia and red blood cell (rbc) transfusion practice in critically ill patients in the icu) of our hospital, and to examine the relationship of anemia and rbc transfusion to clinical outcome. patients and methods: the period study was from july to december . patients were enrolled within h of icu admission. follow-up time was days, hospital discharge or death, whichever occurred first. results: a total of patients ( male, female, mean age . ± . years, range - ) were included in the study. the mean hemoglobin (hb) level at baseline was . ± . , which level was descending during the study. overall . % ( / ) of the patients received one or more rbc units while in the icu stay (mean . ± . units per patients). the mean pretransfusion hb was . ± . g/dl and the mean time to first icu transfusion was . ± . days. more rbc transfusions were given in the first week of the icu stay ( units vs , , units in the second, third and forth week respectively). the number of rbc units which a patient received during the study was positive associated with longer icu length of stay and an increase in mortality (r = . , p < . and r = . , p < . respectively). baseline hb level was significantly related to the number of rbc transfusion (r = . , p < . ), but was not an independent predictor risk factor of length of stay or mortality (r = . , p > . and r = . , p > . respectively). the mean baseline apache ii and saps scores were . ± . and . ± . respectively. furthermore both baseline apache ii and saps scores were significantly higher for patients with a baseline hb level of < g/dl ( . ± . vs . ± . and . ± . vs . ± . respectively), while the apache ii values were positive associated with a significantly increased likelihood of rbc transfusion (pearson correlation p < . ). conclusions: anemia is common in the critically ill patients, it appears early in the icu course and persists throughout the duration of the icu stay. rbc transfusion seems to be associated with worse clinical outcome. despite the intensive research for the transfusion practice, which taken place worldwide during recent years, data from our country is limited. the results of our study suggest that approaches to reduce rbc transfusion would be desirable. however, further well designed prospective studies with large number of patients are required to efficiently explore the risk of anemia, optimal transfusion hb threshold and the risk and benefit of rbc transfusion in the critically ill. consumption of blood products in a large, general hospital he heier*, j pillgram-larsen † , m hestnes ‡ , b gran*, a krog* and no skaga ‡ *ullevaal university hospital, oslo, † ullevaal university hospital, dept. of thoracic surgery, oslo, ‡ ullevaal university hospital, dept. of anestesiology, oslo, norway uuh is the largest general hospital in norway, and trauma referral centre for half of the norwegian population ( . mill) the trauma team performed initial assessment and resuscitation of patients, % males, during the first six months of . the aim of our study was to analyze transfusion practice at uuh with specific focus on trauma. materials and methods: blood consumption during this period was recorded. clinical data of trauma patients were collected from our trauma registry and anonymized before analysis. results: units of erythrocytes (er), of thrombocytes (thr) (buffy coat preparations from donors) and of s/d-treated whole plasma (op) (octaplasÒ) were transfused in uuh during this period. . % of er were given to surgical, . % to medical and . % to gynaecological and obstetric patients. % of er were given to patients above years. er units were given to patients (mean . units/patient; range - ). mean age of trauma patients was ± , median , range - years. for transfusion of this group local guidelines state that haemodynamically unstable patients should receive er if hgb < g/dl, irrespective of age and sex. eighty-eight patients ( . %) received er, of them as massive transfusion ( er units in < hours) ( . %), of these died ( %). altogether trauma patients received units of er ( . % of total uuh consumption), . thr ( . % of total) and units of op ( . % of total). massive transfusion consumed er ( %), . thr ( . %) and op ( . %) units. fourteen adult trauma patients ( . % of those transfused) received or er units only. lowest pre-transfusion hgb was . - . g/dl, median . , mean . ± ; highest post-transfusion hgb . - . g/dl, median . , mean . ± . five patients received er transfusion at higher pretransfusion hgb level than g/dl, but in er were given because of a hyperacute clinical situation. fifty-five% of issued er units had been stored for > days, while only % were issued before days of storage. discussion: life-saving effect of transfusion would seem evident in the massively transfused survivors, while in the other transfused patients documentation of clinical effect is inadequate. transfusion practice in trauma at uuh seems fairly well in accordance with internationally accepted guidelines. the trauma unit consumed a surprisingly small part of total uuh transfusion resources. trauma patients deviate from the general uuh patient population by sex and age; transfusion is otherwise mainly given to more elderly patients. further analysis is needed on transfusion indications and results to optimize the total use of blood products in uuh. special focus should be on transfusion to non-bleeding patients without haematological disease. it seems that only a small part of transfusion efforts results in the saving of life. in croatia national guidelines for the use of rhd gamma globulin were laid down in the year . in accordance with the guidelines, rhd gamma globulin is administered intramuscularly in doses of - mg and should be given to rhd negative women after delivery of rh positive children, after abortions, in week of their first pregnancy, as well as in cases pregnancies with an increased risk of fetomaternal hemorrhage. as to the latter, detection and measurement of fetomaternal hemorrhage are recommended. three years after the issuance of the guidelines a survey was conducted regarding the use of rhd gamma globulin that involved health institutions across the country. as many as deliveries and abortions were reported in . the institutions reported the usage of doses of mg rhd gamma globulin or doses/ deliveries + abortions. we compared our data with those obtained from similar surveys conducted in , i.e. before the issuance of the guidelines. in that year deliveries and abortions were reported, and doses of rhd gamma globulin or doses/ deliveries + abortions were administered. institutions were then divided into four categories: clinical hospitals, general hospitals with the capacity of - beds, general hospitals with the capacity of - beds, and institutions of rather limited capacity with gynaecology department. the range of the consumption of rhd gamma globulin/ deliveries + abortions in the first category was - with the median being ; in the second category there were - doses with the median being , in the third category - doses with the median being , while in the fourth category the range was - doses with the median of doses. the number of pregnancies which should have been protected with rhd immunization in year was obtained by the following formula: (frequency of rhd negative subjects) ¥ (frequency of the r gene) = . ¥ . = . . if a complete antenatal and postnatal preventive measures involving rhd immunization had been taken in , doses of rhd gamma globulin or mg/ deliveries + abortions should have been given. our research has shown that, despite of the national guidelines adopted in , the prevention of the rhd immunization in pregnant women is still not adequate in croatia. in fact, it has not improved since a year prior to the adoption of the guidelines. it has also been established that the category of the institution is a factor influencing the implementation of the protective measures. we consider that much more should be done on informing both women and gynaecologists about the importance of prophylaxis of the rhd immunization. consumption of plasma derivates in croatia g jaklin*, b golubic-cepulic † and m dondur* *general hospital, varazdin, † clinical hospital center zagreb, zagreb, croatia a increasing consumption of plasma derivates, their limited supply and insufficient national reserves are problems that croatia is faced with nowadays, as well as many other countries. in a study was carried out regarding the usage of plasma derivates. as many as health institutions took part having the capacity of acute beds out of a total of . the data regarding the use of plasma derivates were collected as follows: albumin, i.v. gamma globulin, and concentrate of coagulation factor viii in two periods of time. we divided institutions into three categories: clinical hospitals, general hospitals with the capacity of - beds and general hospitals with the capacity of - beds. institutional practice patterns regarding the use plasma derivates were compared among them. the parameters considered were the total consumption of plasma derivates, consumption per bed and consumption per inhabitant. data on the use of plasma derivates was obtained from hospital transfusion departments and pharmacies across the country. we compared our data with similar study carried out in . the consumption of albumin was . kg or kg/million inhabitants in and consumption per bed for the first category institutions was in range . - . kg with the median being . , for the second category the range was . - . kg with the median being . , while for the third category the range was . - . kg with the median being . . in in croatia the consumption of albumin was . kg or kg/million inhabitants. the consumption of i.v. gamma globulin was . kg or . kg/million inhabitants in and the consumption per bed for the first category institutions was in range . g- . g. with the median being . , for the second category was in range . - . g. with the median of . and for the third category was in range . - . with the median . g. in in croatia the consumption of i.v. gamma globulin was . kg or . /million inhabitants. the consumption of the concentrate of factor viii was . iu or . iu per inhabitant in . . iu, i.e. . %, was a recombinant factor viii. in the consumption of factor viii was . iu or . iu per inhabitant. discussion: the use of albumin showed stagnation. however, the use of i.v. gamma globulin increased . times and the use of the concentrate of factor viii increased . times if compared with the results in . self-sufficiency has not been reached in plasma derivates in croatia we needed l plasma for gamma globulin and l plasma for concentrate of factor viii for the level of usage of these plasma derivates in . significant differences in the level of usage among hospitals have been observed. these reflected a considerable difference in hospital policy regarding the use of these products in defined clinical settings. therefore, we would recommend that the national society sets out guidelines for the use of the products. background: blood bank good practice requires avoidance of rh alloimmunization. several studies report a probability of immunization of more than % following transfusion with rhd+ rbc's and as many as % in the case of platelets. aims: the purpose of this study was to investigate the development of anti-d and the causes of alloimmunization in a university hospital ( beds), reviewing our practice on the use of rhd+ blood components in rhd-recipients. method: a retrospective study was performed whereby . rhd-patients, from to , were evaluated for the development of anti-d analysing the data on the blood bank information system. results: from the . rhd-patients we found out identified anti-d, % ( ) detected before any transfusion in our hospital. of the left, nine were excluded because no information was available during some years. had history of pregnancy related to the immunization. patients were exposed to rhd+ blood components: were transfused only with rhd+ platelets (including two women of childbearing age); with rhd + rbc's. the remaining had been exposed exclusively to rhd -rbc's suggesting that some units could be mistyped. this idea was corroborated in three patients where there was a common donor (he was called for investigation). conclusions: transfusion services avoid as far as possible administration of rhd+ blood components to rhd-patients, although there are situations in which such transfusions are necessary. the retrospective review of records revealed the need for specific recommendations regarding the use of rh immunoglobulin to prevent anti-d immunization. the possibility of mistyping blood components also appeared in this review, emphasizing the role of these studies in the evaluation of methodologies used at blood banks. the purpose of the work: to present the usage of whole blood (wb) and blood products (bp) in the treatment of patients who are hospitalized in the internal disease department in gevgelija. material and methods: retrospective analysis is done according the data which were analysed in five years period ( ) ( ) ( ) ( ) ( ) . statistical methods which were taken from the history of the hospitalized patients in the internal department were used for analysis and the data of transfused wb units and units of bp were taken from the department of transfusion medicine. results: from the total hospitalized patients who have been analyzed, ( . %) received wb and bp, and there have been transfused units wb and bp. every patient, on an average, has been transfused with . units wb and bp. at the same time ( . %) units have been transfused as a wb, ( . %) have been transfused as red blood cells (rbcs) and ( . %) units have been transfused as a fresh frozen plasma (ffp). the data for every year particularly will be presented in our paper to the congress. the collaboration between doctors of transfusion medicine and health workers from the other medical branches is the most important thing in the medical practice. our aim is to raise the awareness among the health workers for the importance of blood safety and their role though adequate clinical usage of wb and rbcs, minimizing the non-useful transfusions, evaluation of reflexive information from undesirable reactions in the usage of blood and blood products, use the alternatives etc. the necessity of direct involvement of the doctors in transfusion medicine in the process of healthy workers' education from the other branches for regularly transfusion therapy via meetings and lectures is an imperative for regular function of the department of transfusion medicine. femoral neck fracture repair is one of the commonest orthopedic procedures. it mainly concerns intracapsular or intratrochanteric fractures and it may be considerably hemorrhagic, requiring blood transfusion perioperatively. the aim of our study was to investigate blood transfusion requirement in patients with femoral neck fractures repair at katerini general hospital during - and to compare them with other studies. one hundred sixty five ( ) unselected patients of whom ( %) were women and ( %) were men with a mean age of years (range - years) were studied retrospectively. seventy six ( %) patients had intracapsular fracture and ( %) intratrochanteric fracture. the mean hb concentration on admission was . g/dl (range . - g/dl) and the mean hb concentration at discharge was . g/dl (range . - . g/dl). a total of units of rbc were transfused (a mean of . units per patient). blood transfusion occurred in patients ( . %), ( - % in other studies) with a mean of . units per patient (range - units), ( . - . in other studies). patients with preoperative hb values < g/dl were transfused more often than those with hb values > g/dl ( % versus %) p: . . women were transfused more often men ( . % versus . %) p: . . patients aged > years were transfused more often than those aged < years ( % versus %) p: . . finally patients with intratrochanteric fractures were transfused more often than those with intracapsular fractures ( . % versus %) p: . . conclusions: in our study blood transfusion requirement for femoral neck fracture repair are similar with these reported in other studies. blood transfusion frequency is greater in patients with hb < g/dl, in patients older than years, in women and in intratrochanteric fractures repair. fresh frozen plasma guidelines and practices as saltamavros*, g talampouka*, c koumoundourou*, s dimitrakopoulos † and p tseliou* *st. andrews hospital patras greece, patras, † pyrgos general hospital, pyrgos, greece introduction: fresh frozen plasma transfusions should be done according to specific standards and guidelines. aims: we have reviewed the ffp transfusion practices followed in our hospital in an attempt to provide a set of guidelines and principles that will assist physicians and health care workers to make the right decisions for appropriate use of ffp transfusions. methods: retrospective review of ffp transfusions practices during the entire year of . we classified transfusion practices according to the diagnosis of the patient and also of the clinical depart-ment that demanded transfusion. then we analyzed our results by comparing the requests with the internationally approved guidelines for ffp transfusion and counted the percentage of ffp to rbc units. finally we discussed with our fellow physicians the proper use of ffp and informed them about the accepted guidelines. as we can see from the underneath table, diagnoses and departments with high consumption were: internal medicine %, plasmapheresis to patients suffering from guillain barre and ttp (thrombotic thrombopenic purpura) . % and trauma/surgery . %, cancer . %. summary/conclusions: the use of ffp corresponds to . % of the rbc units transfused in our hospital. plasma units should be used properly and according to internationally accepted standards. plasma use should be justified by the physician, in order to avoid unnecessary risks on behalf of the patient for effective treatment and care. to show gradual discontinuation of using whole blood and increased use of red blood cells (rbc) in the management of patients in the transfusion department of the clinical hospital 'zvezdara' . methods: data of wb and rbc use from to in our hospital. results: our data are presented in table . conclusion: after , wb usage rates systematically decreased from % to . %. however, in the period of - , the wb usage rates increased slightly, and we arrived at a generally very low rate of wb use, namely only in about % of the cases. education about transfusion medicine and rational use of blood in the medical curriculum was generally insufficient and very poor. therefore, we started an education program and we established a hospital transfusion committee (htc) with the task of medical control and monitoring the quality of clinical transfusion practice in our hospital. members of the htc are a specialist in transfusion medicine, an internal medicine specialist, an anesthesiologist, surgeon and gynecologist. we have been organizing courses for the medical staff, doctors and medical technicians since . background: platelet transfusions are given mainly to thrombocytopenic patients with malignant haematological diseases. currently the decision to give a prophylactic platelet transfusion is based almost exclusively on the number of circulating platelets in the patient although it is known that various clinical factors might influence the bleeding tendency. by free oscillating rheometry (for), using a reorox® instrument, it is possible to monitor the coagulation over time in whole blood and obtain information about clotting time and coagulum elasticity. aim of the study: the aim of this study was to find out if for using the reorox® instrument could be used to evaluate the hemostatic status of thrombocytopenic patients. methods: the change in elasticity over time in non-anticoagulated whole blood from leukaemia/lymphoma patients with thrombocytopenia was measured in the reorox® pre and post a platelet transfusion (n = ) and was compared with healthy controls (n = ). the effect of platelet concentration on coagulation was studied by diluting platelet rich plasma from healthy subjects with autologous plasma to various platelet counts whereafter the coagulation was monitored with for (n = ). the change in elasticity per minute (g'max slope) and maximum elasticity (g'max) were evaluated from the elasticity curves. results: the g'max, g'max slope and platelet count increased after transfusion for all patients. the thrombocytopenic patients had significantly lower g'max and g'max slope values both pre and post transfusion compared with healthy control subjects (p < . ). the measurement in platelet rich plasma showed that g'max and g'max slope increased with increasing platelet concentration. however patients with similar platelet count developed different clot elasticity. the reorox ® instrument responds to changes in haemostatic function in form of the clot elasticity. the fact that patients with similar platelet concentration developed different elasticity shows that clot elasticity is a function of not only platelet concentration but also of functional properties. the for method seems promising to evaluate platelet function. quality control of pre-storage leukodepleted red cell concentrates vu urlep salinovic, k perbil lazic and l lokar teaching hospital maribor, maribor, slovenia background: the system of quality assurance including quality control (qc) in transfusion medicine is most important for safe blood supply. the safety and quality of blood components are increased by pre-storage leukodepletion of whole blood (wb). aim: the qc of leukodepleted red cell concentrates (rcc), prepared from pre-storage filtration of wb (quadruple blood bag systems imuflex wb-rp terumo) is performed with the aim to be sure that the quality of leukodepleted rcc is in accordance with the guidelines of council of europe. in three years ( ) ( ) ( ) , units of wb were collected, among them ( . %) units were collected for pre-storage filtration and in ( . %) of these qc was done. within hours after collection, wb was filtered at room temperature. filtered wb was centrifuged at g for minutes and separated in rcc and plasma. the samples for qc were collected before and after filtration. for each unit, volume, hemoglobin, hematocrit, % of hemolysis and residual white blood cells (wbc) count were measured. the number of residual wbc after filtration was determined in the nageotte chambre. for all parameters the mean value and standard deviation were calculated. the results of qc for the following parameters were: volume ± . ml ( % corresponds with the guidelines of council of europe), hematocrit . ± . ( %), hemoglobin . ± . g/unit ( %), number of residual leukocytes . ± . ¥ ( %), hemolysis . ± . % ( %), the test of sterility was % negative. during filtration of wb, wbc were removed in approximately . %, the duration of filtration was ± minutes and the loss of hemoglobin was . ± . %. the pre-storage filtration of wb is highly efficient, . % of wbc were removed and the loss of hemoglobin was small. background: the patients of cardiosurgery use big amount of blood components. there is no uniform approach by treatment with blood components in these patients. the safest and the most rational use of blood is based on the individual treatment of a patient and the evaluation of the most clinical and laboratory factors. aim: the aim of our study is to analyse the use of blood components from , when the cardiosurgery department was founded in our hospital, to . the data about use of red cell concentrates (rcc), platelet concentrates (pc) and fresh frozen plasma (ffp) in the period from to were collected from information system datec. the average use of all three blood components per patient is presented. we were interested, if the average use per patient was diminished in the analysed period. results: the use of three blood components and average use of all blood components are presented in the table. the data from the table shows, that the number of patients increased more than three times, but the average use of blood components per patient was not essentially diminished. conclusion: during seven years period the use of blood components per patient in cardiosurgery was not diminished. for more rational use it is necessary to apply all methods of autologous blood transfusion because of the increasing number of cardiac operations and decreased number of voluntary blood donors. background: the presence of leucocytes in blood components is cause for appearance of various adverse posttransfusion reactions such as nhfptrs, urticary, anaphylactic shock, alloimunization and platelet refractorines, infection with bacteria and leucothropyc viruses (cmv, htlv). the removal of leucocytes from blood components through filtration is especially important in the treatment of patients with malignant diseases who need frequent transfusions of blood and blood components. this is because of their lowered immunologic status which is a result of the disease and received immunosuppressive chemotherapy and radiotherapy. aim: to show the prevention of posttransfusion reactions and the positive effect from transfusion of leucoreduced er. concentrates, produced with filtration in therapy of anaemia in patients with malignant diseases, treated in our daily transfusion hospital at medical center -stip. methods: patients with malignant diseases have been treated in our daily transfusion hospital in the last four years. most of these patients suffer from ca pulmonum, ca collonis, ca uteri, ca mammae. also, because of the secondary anaemia, the same patients were transfunded with at least two doses of leucoreduced er. concentrates. the blood donored by voluntary repeated blood donors was filtrated the same day after the donation, separation and the control of the same one. the blood was collected in baxter and terumo bags, and it was filtrated with baxter -sepacell rs - and pall -purecell rn filters. the analyses of leucoreduction were made for every filtrated and transfunded unit before and after filtration. the analyses samples were taken from the tubing system before and after the filter. haemathologic parameters were automatically made in the central clinic laboratory. results: er. concentrates poor with the leucocytes for about - . % were produced with the use od these filters, and platelets from - % with which side effects from frequent transfusions at these patients were prevented. with the routine monitoring of all patients none posttransfusion reactions were registered. the therapeutic effect is also important because of the fact that the number of er and the level of hg and hct remain almost unchanged. the aim of the blood banks is to help and to increase the safety of the blood components. the leucoreduction through of er. concentrates poor with leucocytes is a regular procedure in the therapy of malignant patients with remarkable clinical picture of anaemic syndrome and prevention the cancer recurrence end infection. the time of filtration is also very important which has to be shorter after collection of blood, because the leucocytes should be removed before they become disintegrated and relapse potentially dangerous substances end metabolites in the blood components. we have been applying so called ' prestorage filtration' because it has been proved that it is more efficient that bed -side filtration. background: the effect of leukocyte reduction of rbcs by filtration has been the topic of several rcts. these rcts investigated the effect of leukocyte reduction on mortality; post-operative infections and hospital stay in different patient populations. some rcts came up with answers that conflicted with the results of other rcts. aim of the study: with including the individual patient datasets of several rcts in one database, combined analyses are possible that may explain the differences in the reported results. using this technique, we may come up with answers (or questions) that cannot be obtained by performing standard meta-analyses of these rcts. methods: we coordinated several rcts comparing the perioperative use of buffy-coat depleted rbcs with the use of filtered rbcs. cardiac surgery patients were included in three rcts ( ¥ cabg and/or valve; ¥ re-cabg and/or valve; ¥ valve with or without cabg). oncologic surgery patients were also included in three rcts ( ¥ colorectal cancer; ¥ gi-oncology or vascular surgery; ¥ gi-oncology, vascular surgery or orthopedic surgery). the electronic data files of these rcts were uniformly recoded and entered in a single database. as different primary endpoints were investigated in the rcts, we focused on common endpoints, recorded in or more of the rcts. multivariate analyses were performed on: in-hospital mortality, -day mortality, hospital stay, stay on icu, postoperative infections, and mods. results: in the rcts, individual datasets from surgery patients were collected ( onco; cardiac; vascular; orthopedic, other). in the multivariate analyses, patients in the buffycoat depleted trial arm showed a higher mortality rate both in-hospital (p = . ) and at days post-surgery (p = . ). no association between randomization and stay in hospital (p = . ) or stay on icu (p = . ) was seen in the combined study population. also, no association of randomization with the incidence or duration of mods was seen. the analyses of post-operative infections in the total population showed the trial arm to be associated (p = . ), and 'hospital' to be far stronger associated (p < . ). however, when the oldest rct, that had not yet used our standard definition list for scoring post-operative infections, was excluded, the association with the hospital was lost (p = . ) and the trial arm became more strongly associated with infections (p = . ). in the analyses of surgery patients, the use of filtered rbcs, compared to the use of buffy-coat depleted rbcs, resulted in reduced mortality (both in-hospital and at days postsurgery) and a reduction in post-operative infections. the association of the variable 'hospital' with post-operative infections, as is frequently reported in literature, was initially confirmed in our analyses. however, when a standard definition for post-operative infections was used (excluding the datasets from one of six studies), this association was lost. background/aims: uk neqas for blood transfusion laboratory practice (btlp) operates an eqa service for uk laboratories (including eire) and participants throughout europe, including major groups in denmark (n = ) and portugal (n = ). in november a questionnaire was distributed to determine the criteria used for selecting phenotyped blood for different patient groups, including pre-menopausal women (pmfs). results were analysed by country to establish any variation in practice relating to the selection of k negative (k-) and rhc negative (c-) blood, since antibodies to these antigens are now the major cause of hdn. results: overall return rate was % (uk) and % (non-uk), although only centres treating pmfs were included in this analysis. k-blood was selected for pmfs by % in wales (n = ) and % in england (n = ), but only % in scotland (n = ), % in northern ireland (n = ) and % in eire (n = ). in mainland europe, variation was also observed: % in denmark (n = ), % in portugal (n = ) and % in other countries (n = from countries). fewer laboratories selected c-blood for pmfs: % in england and northern ireland, % in scotland and eire, rising to % in wales. mainland europe showed similar variation: % in denmark, % in portugal (all ccee matched) and % in other countries. there are no guidelines requiring selection of k-and c-blood for pmfs, but in the uk d negative blood is required for d negative females aged < years. trend analysis of questionnaire data in the uk, using theoretical clinical scenarios, shows a decrease in the number of laboratories that would select k + blood for a year old female (with pre-existing antibodies other than anti-k), from % ( ), % ( ) to % in . in this survey, k + blood was selected for a female aged (no antibodies) by %, whilst % selected a k + unit for a female aged (no antibodies), despite this patient being treated as a pmf for provision of d negative blood. a similar distinction was made between the and year old females in portugal and mainland europe. conclusions: variation in practice may at least in part be due to the availability of blood routinely labelled for rh and k. in the uk all donations are labelled, except for those from new donors, as are most units in portugal. uk questionnaire data ( ) suggested that > % laboratories would change to selecting k-blood for pmfs if all units were labelled. however, labelling alone does not account for the differences seen within the uk, and perhaps the trend towards providing k-(and to a lesser extent c-) blood for pmfs is influenced by advice from transfusion services. it would be of great interest to monitor and compare the incidence of hdn due to anti-k and anti-c in different countries to measure the outcome of differing practices for provision of blood to pmfs and to thereby inform future policy. there is no ultimate in ex-vivo assay described, which can predict the outcome of plt transfusion in vivo. current in ex-vivo assays and animal studies are rather very complicated to carry out, cost effective and time consuming. objective: we hypothesized that the quantitative measurement of gpib expression by facs can be used to predict the outcome of platelet survival post transfusion. in our previous studies we demonstrated that our phagocytosis assay can predict the plt survival sensitively (blood dec- ) . we isolated human washed plts by centrifugation and labelled with mepacrine and then incubated with pma-matured thp- cells ( °c). binding was measured by facs analysis of cd b/cd positive particles, and phagocytosis by counting mepacrine/cd positive particles. we measured gpib expression before and after plt-macrophages interaction by facs flowcytometry. results: gpib expression at surface of c fresh showed ± and after hours storage ± % expression. the gpib expression at surface of plt decreased and showed three populations with different densities high (gpib- ), low (gpib- ) and in-between (gpib- ). the binding and phagocytosis of plt showed an increase of ± % which implicates an indirect and negative relation to gpib- , and direct relation to gpib- expression. anti-human pselectin (cd p) delayed ± % the binding and annexing v ± % the phagocytosis of stored plts, after -hour storage. these results show that gpib expression is rather easy, reproducible test which can be standardised and be used as a very sensitive in vitroassay to predict platelet survival posttransfusion. transfusion and lung injury jd dodig*, d sovic † , m tomicic † and h sager* *university hospital 'sestre milosrdnice', zagreb, † institute for transfusion med, zagreb, croatia background: the respiratory tree has been viewed as an infrequent site of injury arising as serious complication of transfusion. in recent years, this view has changed as investigators have shown that two complications-circulatory overload and transfusion related acute lung injury-are relatively frequent events. case report: a -year-old men was admitted due to chronic macrohematuria. he had no history or current evidence of cardiac failure. the hb level was measured g/l. he received ml . % nacl and ml ringer solutions. after that, he was transfused with units of rbcs. during transfusion second unit he developed following symptoms: tachycardia, dyspnea, hypertension. massive pulmonary edema was noted. he was treated with mechanical ventilation, oxygen, diuretics, aminophillin, antihistaminic and corticosteroides. the patient recovered after being on ventilation for hours. two days after the patient was operated. after surgery he was transfused with units of rbcs. all transfusions were regularly performed. results: chest x-ray confirmed bilaterally pulmonary edema. the samples (patient and donors of first two units rbcs) tested were negative for the presence of hla specific and granulocyte antibodies. granulocyte agglutination and lymphocytotoxicity test were negative. tnf-a in recipient serum was slightly increased. conclusion: our patient is the first reported case suspected of trali, but all of the investigations didn't give us the answer. against neutrophils using flowcytometric detection of cell surface cd b expression and l-selectin shedding. methods: a hundred microl of volunteers' heparinized whole blood were incubated for minutes at °c with fmlp, lps or pma. monoclonal antibodies against hna a and hla-i, or patient serum were incubated with whole blood for min. surface cd b and l-selectin were detected using facscalibur. results: neutrophil activation was detected after fmlp, lps or pma stimulation. p map kinase inhibitor reduced activation induced by fmlp and lps. anti-hna a monoclonal antibodies induced neutrophil activation, which were also inhibited by p map kinase inhibitor. ten serum samples obtained from patients or donors who caused transfusion reactions were evaluated. five sera out of samples having anti-neutriphil and/or hla antibodies exhibited neutrophil activation, while two samples without leukocyte antibodies had no effect on any activation. conclusion: these findings indicate that neutrophils activation is regulated through mak kinase and detection of neutrophil activation may be useful to predict transfusion-related reactions. results: out of transfusion reactions were febrile, were anaphylactic, were due to circulatory overload, out of transfusion reactions concerned the transfusion of incorrect blood component. out of transfusion reactions concerned acute haemolytic reaction. post transfusion purpura or suspected trali was not seen. fatal complication was not seen. the reactions to plasma were predominately anaphylactic. we detected no case of bacterial contamination among the cultures of transfusion bags. conclusions: the incidence of reactions among patients malignancy was high, while among surgical patients was lower. the incidence of transfusion reactions during the months had no statistically significant difference. we suggest that the improvement in prevention of transfusion reactions require a continual vigilance system for rapid recognition and information regarding these complications. measurements of ige immunoglobulin in thalassemic patients, before and after blood transfusion background: many studies have reported the implications of proinflammatory cytokines including interleukin (il)- beta, il- and tumor necrosis factor alpha (tnf-alpha) in febrile nonhemolytic transfusion reactions. il- has been shown to accumulate in packed rbcs even after the procedure of filtration, which is explained by the release of il- from rbc receptors into the packed rbc super-natant. stress induced elevation in tnf-alpha levels was demonstrated in healthy individuals. aim: to assess the level of proinflammatory cytokines in peripheral blood of blood donors. material and methods: immediately upon blood collection, plasma was separated from postdonation blood samples obtained from blood donors and frozen at - °c. upon thawing, the level of the il- beta, il- and tnf-alpha cytokines was determined in plasma samples by elisa method using commercial kits for cytokine determination (roche molecular biochemicals). the level of il- beta was at the test detection limit in all donor plasma samples. in ( . %) bd, the level of il- was . pg/ml, exceeding the test sensitivity limit of . pg/ml. in ( . %) bd, the level of tnf-alpha was within the range of - pg/ml, with a test sensitivity limit of pg/ml. tnf-alpha levels > pg/ml were measured in plasma samples of ( . %) blood donors. the increased activity of blood donor's immune cells, indicated by elevated levels of the proinflammatory cytokines il- and tnf-alpha in peripheral circulation some blood donors, may lead to the occurrence of febrile nonhemolytic transfusion reactions in the recipients of the blood products manufactured from the blood of these blood donors. this hypothesis will be thoroughly investigated in our future studies. background: transfusion-related acute lung injury (trali) is a life-threatening complication of transfusion, under-recognized and underreported possibly lacking a consensus definition. aim: we report here a 'probable' case of trali syndrome in an elderly female patient. case presentation: an eighty-two year old female patient was transferred to the intensive care unit on the third postoperative day (pod) following the abrupt onset of acute pulmonary insufficiency (pao = mmhg, o saturation = %), hypotension (bp = / mmhg) and fever ( °c). this occurred ten minutes after initiation of an infusion of a unit of packed red blood cells (prc). the patient had no history of any cardiac or pulmonary disease. she was intubated and placed on mechanical respiration and supported hemodynamically. the cvp ( cm h o) ruled out fluid overload. the chest x-ray revealed bilateral pulmonary oedema, the echo cardiogram and blood cultures ruled out cardiac and infectious aetiology of the episode. after treatment for hours the patient improved significantly, was extubated and returned to the surgical unit on the th pod. reviewing the transfusion history we discovered that the patient did not receive any blood or blood component prior or during the correction of her ileum, but she was transfused a unit of ffp (fresh frozen plasma) five hours prior to the incident. the donor review revealed that the unit of ffp was from a -year old female with a history of multiple abortions whereas the prc unit was from a -year old male, a volunteer of several years who had no history of transfusions. there are some prerequisites for the implementation of a haemovigilance network and some of them have been met, so we can present the first results. methods: traceability of blood components is possible because there is unique information system in place in the whole country, identifying the donor, donation, each single blood component and identification of the recipient, but feed back information of the performed transfusion is still missing. cooperation between blood transfusion service and hospitals was established by introduction of hospital transfusion committees; the intensity and quality of their work is very different. homogeneity of reporting is achieved by the introduction of unique reporting form. a reporting route was defined: patients physician sends notification of atr to the local blood transfusion service. atr reporting form is prepared there and sent to the national blood transfusion service, where the data is collected for the centre for haemovigilance, which is going to be established very soon. data analysis will be responsibility of the centre for haemovigilance at the governmental level. type of adverse transfusion reactions and events is defined. education and information was passed to the health personnel by inclusion of haemovigilance in under and postgraduate programmes as well as seminars, scientific meetings and some publications. results: in the years - there were . blood components issued in slovenia and atrs were reported ( in blood components issued), in of them the severity grade was ( in . blood components issued). in the year there were considerable differences between the number of atr reports compared to the number of blood components issued among slovenian hospitals, ranging from in to atr in blood components issued. . % of all atr were not classified. conclusions: although the number of reported atrs was increased by % and % a year in and respectively, it can be assumed that the collected data is not complete. feed back reports, much more information and cooperation is needed, especially in some hospitals, which should contribute to a better registration of atrs and events in the future. the slovenian haemovigilance system still needs upgrading, but despite this, some important work has been done in building a national haemovigilance system. . considering the multiplicity groups in cattle and since there was no research on repeated blood transfusions reactions in iran's native cattle, we decided to consider crossmatching in different processes of repeated blood transfusion from a head of blood donor to five recipients and observe the clinical and hematological alterations. six healthy iran's native cow, . years old, with average weight of kg were used. the animals were dewormed by albendazole ( my/kg bw) and were kept for two weeks under uniform managemental condition. three days prior to blood transfusion, vital signs registration (temperature, heart rate and respiratory rate) blood collection via jugular vein was done to indicate the baseline of research parameters. after that, blood transfusions were performed from one donor cow to five recipients three times at one-week intervals. cross matching was done at each transfusion. after each transfusion the research parameters do determined. results indicated that one of the recipients cows experienced anaphylactic shock, in the first step of blood transfusion and another cows in the second step and finally in the third steps two other cows showed the serious shock. this is in the contrary of this opinion that the first transfusion can be given safely without crossmatching in cattle practice ( van der valt, et al. ( ) background and objectives: blood transfusion may lead to the manifestation of anti-hla and platelet-specific antibodies that may in turn bring about different problems like platelet refractoriness. it appears that the study of antibodies against hla-class i and platelet-specific antigens are useful for the selection and success of the appropriate treatment protocol. the aim of this study was to detect anti-hla and anti-platelet-specific antibodies by flowcytometry in patients with hematologic disorders (including acute leukemia, aplastic anemia) and patients with itp. in this descriptive study, anti-hla and platelet-specific antibodies were detected by flowcytometric technique, using sera drawn from patients with different haematological disorders who showed a poor response to platelet transfusion and from patients with itp. the results of anti-hla antibodies were then compared by panel reactive antibodies (pra). results: our results showed ( . %) out of ( . %) patients had anti-hla class-i antibodies in their sera. the frequency of each antibody isotype was found to be as follows: igm ( . %), igg ( . %) and iga ( . %). ( . %) out of patients had platelet specific antibodies and the frequency of each antibody isotype was found to be as follows: igm ( . %), igg ( . %) and iga ( . %). ( . %) out of patients had both antibodies. no difference was found between the two groups in platelet specific antibodies. despite significant correlation between flowcytometry and pra methods, pra can only detect antibodies which react with complement. conclusions: with increase in the number of platelet transfusion, immunization to hla antigens occurs; moreover, immunization against platelet specific antigens may also occur during autoimmunity. the presence of these antibodies may be one of the reasons of poor response to platelet transfusion and platelet refractoriness in patients under study. conducting similar studies with higher number of samples, platelet cross-match, and the use of hlamatched platelets for these patients are recommended. post transfusion purpura (ptp) is a rare, severe thrombocytopenia that results from alloimunization to platelet specific alloantigens, following blood transfusion. in this condition, the patient's own platelets are destroyed by the alloantibody even though they are not supposed to carry the 'guilty ' antigen. the disease is rare occurring mainly in multiparous women. the majority of reported cases involved antibodies against the platelet specific alloantigen hpa- a in a homozygous hpa- b patient. in a minority of cases the offending antibodies were directed against hpa- b, - a, - b, a, - a, - b. although self-limiting, the syndrome is characterized by severe bleeding with high morbidity and mortality; therefore prompt diagnosis and appropriate therapy is crucially important. ptp is a challenging diagnosis, because the patients are often critically ill or post-surgery, and have alternative explanations for thrombocytopenia such as infections or drugs. we present three patients with severe thrombocytopenia initially misdiagnosed. the first patient, a -year old women, had a past history of systemic lupus erythematosus and coombs positive autoimmune hemolytic anemia. at the present hospitalization, after antibiotic therapy for endocarditis, a severe hemolytic episode occurred and she need blood transfusion. when severe thrombocytopenia appeared, she was wrongly diagnosed as evans syndrome. the second patient, a -year old man, suffered from sepsis after vascular surgery and revealed clinical and laboratory picture of dic. the third patient, a -year old women, had end-stage renal failure and received heparin during hemodialysis, thus heparin-induced thrombocytopenia was first suspected. history of recent blood transfusion rose the suspicion of ptp in all this cases, and appropriate therapy with high dose iv immunoglobulin was started. adequate laboratory work-up confirmed the diagnosis. three different anti hpa-antibodies were identified: anti hpa- a, anti hpa- b and anti hpa- b, respectively. the platelets genotype of the first patient was hpa- b/ b, of the second hpa- a/ a and of the third patient, hpa- a/ a. the reported cases emphasized the importance of keeping in mind the possibility of ptp. incorrect diagnosis may lead to wrong treatment and fatal outcome. health sciences authority, singapore, singapore introduction: the haemovigilance programme in singapore was started by the centre for transfusion medicine (ctm) in . the system covers registration of collected, produced and transfused blood components, and monitors adverse transfusion reactions (atr). the programme runs on a voluntary, non-punitive and confidential basis. aims of the study: ( ) to gather and analyse reports of all adverse and untoward events occurring during transfusion of blood and components. ( ) to use the information acquired to determine the morbidity of transfusion. ( ) to provide guidance on corrective measures to prevent the recurrence of some accidents, and to improve transfusion safety. ( ) to improve public confidence by demonstrating to public, patients and professionals the safety of the existing transfusion system. methods: ( ) a common report form is used and made available to all participating hospitals. within the reporting system, the identification of the patient and staff involved are not required, to ensure confidentiality and protection of information belonging to the hospital. ( ) reportable events include immediate reactions during transfusion (haemolysis, non-haemolytic febrile transfusion reaction, urticaria, anaphylactic shock, bacterial contamination, trali), delayed untoward effects after transfusion (haemolysis, post-transfusion purpura, acute gvhd), transfusion-transmitted infections, incorrect components transfused, and near misses. ( ) within the hospitals, a responsible person ensures that all adverse events and untoward effects of transfusion are reported on the haemovigilance forms and provided to ctm for collation. within the ctm, the haemovigilance coordinator is designated to assist hospitals in investigating serious adverse events and advise on the reporting formats. results: ( ) the total number of reported cases has steadily increased since the introduction of the programme. ( ) the number of participating healthcare institutions has also increased to % (n = ). please refer to table entitled 'summary of the haemovigilance report - ' . ( ) the implementation of the haemovigilance programme in singapore is feasible with respect to the asian setting, and can significantly contribute to blood safety. ( ) there has been very good participation from the participating healthcare institutions, signifying greater awareness and willingness to partake in the programme. ( ) the results obtained from the programme have given rise to initiatives and recommendations aimed at reducing ( %) were rated for seriousness. of these, ( . %) were rated as grade (moderate to serious morbidity) or worse. ( . %) were rated for imputability to the blood transfusion. of these, a relationship to the transfusion was graded as 'certain' or 'probable' in ( . %) and as 'possible' in ( . %). overall relatively few errors were reported in comparison to other systems. a small number of reports concern (possibly) infected blood components, and imputability was deemed probable or certain only in a minority of these reports. autologous blood components gave rise to five reports (errors as well as mild transfusion reactions) which shows a relatively high risk associated with their use ( . per the rate of post transfusion hepatitis (pth) in israel in unknown. this information is important in order to learn about the residual infection risk in blood recipients. aim: to summarize the data on reported cases of pth. methods: suspected cases of pth are reported to mda blood services. the investigation procedure includes follow up testing of implicated donors and retesting of an archive sample of the transfused unit, if available. donors involved in suspected pth-b are tested for hbsag and anti-hbc. anti-hbc+ donors are tested for anti-hbs. hbv-dna testing is done if anti-hbs is less than miu/ml. donors involved in suspected pth-c, are tested for anti-hcv and alt. since hcv-ag or hcv-rna are performed, when appropriate. investigation is considered complete if all the involved donors are retested > months following the implicated unit. results: between between - suspected pth cases were reported: ( %) were pth-b, were pth-c ( %) and in patient both hbv and hcv infections were reported. investigation was completed in / ( %) cases, with % of the involved donors ( / ) being retested > months after the implicated donation. hbsag was not detected in any of the retested donors. anti-hbc was detected in donors involved in pth-b cases of which were also positive for anti-hbs. pcr for the detection of hbv-dna was performed on the 'anti-hbc+ only' donors, and none was found positive. only in / donors suspected to be involved in pt-hcv, anti-hcv antibodies were subsequently detected. this donation was collected and transfused before the introduction of anti-hcv testing in israel, which was implemented in . in another pth-c case, the implicated donor is still negative for anti-hcv, in follow up samples of up to months, but was found positive for hcv-ag and hcv-rna. pth investigation of all the donors involved was completed in % ( / ) of the cases where the patient received up to blood components. conclusion: in the past years an average of cases/year of suspected pth were reported to the israeli national blood services. investigation was completed in % of the reported cases. so far, there was no clear evidence of hbv transmission. in cases (out of . million blood units collected nationwide during - ) hcv seemed to be associated with blood transfusion: one caseprior to the implementation of anti-hcv testing and the otherprior to the implementation of hcv-ag testing in a donor that did not develop anti-hcv antibodies. these findings suggest that other modes of hbv and hcv transmission should be sought in blood recipients in israel. - . , p < . ). the seroprevalence for a-hiv in the bd population was . % (se: . ; ci: . - . ; p < . ) whereas in the a-hbc positive bd was . % (p < . ) and in the a-hbc negative bd was . %. from a-hiv positive donations, were also positive for a-hbc, that means that the sensitivity of the a-hbc in the detection of a donation a-hiv positive was . %. the relative prevalence (percentaje of positive donations for a-hiv in the a-hbc positive population divided the percentage of this marker in the donations a-hbc negative: rp) was . , which indicates that the number of bd a-hiv positive is . times higher in the a-hbc positive that in the a-hbc negative population of bd. as regards a-htlv, the seroprevalence in the bd population was . % (se: . ; ci: . - . , p < . ), in the a-hbc positive bd was . % (p < . ) and in the a-hbc negative bd was . %. from a-htlv positive donations, were also positive for a-hbc, that means that the sensitivity of the a-hbc in the detection of a donation a-htlv positive was . %. the rp for a-hbc as regards a-htlv was . , which indicates that the number of bd a-htlv positive is . times higher in the a-hbc positive that in the a-hbc negative population of bd. our results suggest that, in our bd population the screening with a-hbc would be useful to prevent other infections transmissible by blood transfusion, like retroviruses, because of the high sensitivity and the relative prevalence. . despite the high specificity of currently available elisas, the positive predictive value is lower in blood donors. therefore, immunoblot tests and polymerase chain reaction (pcr) have been adopted for routine testing in elisa +ve blood donors, by our service. . our data show that the real anti-hcv prevalence of our donor population is very low ( . %). . the selection and evaluation of appropriate assays of all donated blood for hcv infection ensure good laboratory practice and accurate post-notification counselling of infected donors. . given that donors who are elisa positive but persistently negative or indeterminate probably do not represent a risk for transmission, their deferral from donation increases the problem of availability of blood supply. . donor re-entry in the pool of donors is an issue for further discussion. . the introduction of nat technology may elicit more accurate responses and improve the screening process. background: the introduction of hcv antibody screening of all donor blood in represented a major step in the prevention of transfusion-associated hcv hepatitis and in identification of infected donors. the study of infected individuals provides a unique opportunity to define behavioral factors associated with infection. evaluating risk factors in hcv infected blood donors is essential for monitoring blood supply safety, donor screening effectiveness and developing appropriate prevention programs objectives: . to recognize the epidemiology of hepatitis c and how it differs geographically; . to investigate the risk factors for presence of anti-hcv antibody in blood donors; . to evaluate the effectiveness of our donor selection program in local level. methods: serological testing for hcv was performed according to standard procedures. initial screening was performed using secondgeneration eia and, after january , using third-generation eia. our study included a confirmation test (riba) a questionnaire was used to collect data concerning demographic, social and sexual behaviors, and number and type of donations of blood donors. the study also included testing of sexual partners and family members. changes in rates of hcv infections were evaluated by comparing yearly prevalence estimates. the overall prevalence of anti-hcv (eia) was . % out of blood donations. the average prevalence of hcv infection by riba was . %, which reaffirms the very low risk of transfusion-transmitted disease. the cumulative number of hcv infected donors was , with cases in males and cases in females. most infections were found among older persons ( % were aged - , and % aged - ). the seropositivity was higher in family/replacement donors ( %) than in volunteers ( %). the annual prevalence decreased throughout years. the relative importance of risk factors for hepatitis c was: transfusion %, hospitalization %, immigrants %, occupational %, sexual transmission %, injection drug use %, household contacts %, other %, tattooing %, unknown %. according to the criteria for blood donation, certain donors should have been excluded in the predonation interview but these donors had denied risky behaviour when questioned. the importance of sexual activity in the transmission of hcv has not been well-established as we tested sexual partners and family members and none of them was found positive. conclusions: our results suggest that major improvement in the safety and quality of our blood supply has been made in our area. introduction: apart from immuno-haematological complications, blood transfusion recipients are exposed to the risk of viral and bacterial contamination of donor blood. the latter infectious risks are generally associated with the number of donations that are needed in the production of blood products: the pooling effect. one measure recently being discussed is the generalisation of the use of trombocytapheresis for the production of trombocyte concentrates. normally, the trombocyte product is a concentration of trombocyte extractions from a pool of buffy coats: pooled platelet concentrates (ppc). in case of trombocytapheresis sufficient trombocytes for one transfusion can be collected from one single donor. aim of the study: in this presentation the effect of using % trombocytapheresis for the production of single donor platelets (sdp) instead of pooled platelet concentrates (ppc) on contamination risks will be assessed. these risks can be divided in ) the risk of bacterial contamination, ) the risk of viral contamination (e.g. hcv, hbv, hiv) resulting from window period donations, and ) the risk of contamination with tse or emerging infections for which no screening test exists. the contamination probability of sdp versus ppc is assessed on the basis of the production characteristics of both products, e.g. the presumption that the contamination risk per trombocyte product will be reduced by a factor equal to the number of pooled donations (five in our case). reduction of the bacterial contamination risk was estimated using the results of the bacterial testing of pooled and apheresis platelet products. as patients are likely to obtain multiple blood products during treatment, the contamination risk reduction through sdp is not only dependent on the reduction of risk in trombocyte products, but also will also dependent on the total number of blood products transfused and their associated contamination risks. the platelet recipient risk reduction was calculated on basis of the distribution of blood products received by the patient population of the university medical center utrecht (umcu) in the year . results: in the attached table the estimated risk reduction through % trombocytapheresis is shown for the general blood recipient patient and for the trombocyte recipient patients only. our analysis indicate that in platelet recipients, general application of sdp instead of ppc will reduce the risk for transfusion acquired tse infections by %, the risk of known viral infections by %, and transfusion acquired bacterial infections by %. the confidence intervals surrounding the results were obtained by bootstrapping. the large confidence intervals surrounding the reduction of bacterial infection risk is caused by the fact that only a limited set of apheresis trombocyte products were tested. conclusion: our analysis indicates that general application of sdp instead of ppc will not reduce the risk of transmitting infections to platelet recipients as linearly ( : ) as expected. whether it is a costeffective precautionary measure will have to be evaluated by a costbenefit analyses consideration clinical benefits and additional costs and risks of apheresis donations. introduction: hepatitis b is serious health problem world wide. its prevention, particularly in the population of blood donors is essential for providing good health care and protection. aim: the aim of this study is to present the distribution of hbsag(+) and hbsag(-) blood donors according to their profession. methods: specially designed questionnaires are used for interviewing the blood donors who has previously given signed consent for participation in this study. results: table shows the distribution of the blood donors in different professions. administrative clerks with ( . %) and the workers with ( . %) registered in the group of hbsag(+) blood donors, as well as workers with ( %) and administrative clerks with ( %) from the hbsag(-) group of blood donors are dominantly more frequent than the other categories of professions. health care professionals, housewives and farmers in both groups of blood donors are least frequent. taking in consideration the distribution of blood donors by the given professions in both groups, for u = and p > . there is no significant difference found. the analysis of the differences among the different frequencies, in distribution of blood donors according the profession, for d = . and p < . shows a significant difference, where the workers with ( . %) are the most dominantly represented. in relation to the issue of whether the type of profession of the blood donors is production or non production the results are presented on table . in the group of hbsag(+) blood donors the number of those who work in production profession- ( . %), is dominant over the number of those that has non-production profession- ( . %). in the group of hbsag(-) blood donors there is no significant difference between the types of professions. conclusion: having in consideration the professions of blood donors in both groups, for c = . and p < . there is a significant difference in the presented distribution. according to our study, which shows the horizontal transmission of hbv infection in the family in which there is an index case, the biggest number of participants in the study is workers, and the least number of participants are the farmers. introduction: blood donors, as part of the healthy population are tested for hbsag with each blood unit they give. therefore, they can be an epidemiological model for exploring the appearance of hbv infection in general population. aim: this study aims to show the distribution of hbv infection in blood donors in relation with their living conditions, space and facilities. the material needed for the study consists of the data obtained from confirmed hbsag(+) blood donors and confirmed hbsag(-) blood donors as control group. results: the table shows almost equal number of hbsag(+) blood donors that live in houses or flats. in the hbsag(-) group ( %) donors that live in a flat dominate compared to ( %) of those that live in a house. having in consideration the presented distribution (table ) for c = . and p < . there is a significant difference, that comes from the bigger number of blood donors ( ) that live in flat. as for the distribution of blood donors according the living space they use by member of the family (table ) , we can show that ( . %) of the hbsag(+) donors have less than m living space, in compared to ( %) from the hbsag(-) group. the bigger number of hbsag(+) blood donors with small living space gives bigger possibility for transmission of hbv infection in the family. the differences in the two groups for donors that have between and m , and between and m of living space per person, obviously are not very big. for u = and p > . there is no significant difference in the number of the donors in the two groups, when the available living space in m is discussed. introduction: when one of the sexual partners has hbv infection the other is also infected in from cases. aim: the aim of this study is to outline that the risk from transmission of hbv infection between sexual partners is smaller if they use condom as protection. methods: two groups of blood donors-hbsag(+) and hbsag(-) have been interviewed whether they are using condoms as protection, or not. results: table shows the distribution of blood donors concerning the use of condoms. table : in the group of hbsag(+) blood donors those who have not used condoms dominate with number of ( . %), in compared to those ( . %) who used condoms. these data are in favor of eventually possible sexual transmission of hbv infection in hbsag(+) blood donors. in the group of hbsag(-) blood donors dominate those who have used condom- ( %), compared to ( %) who have not. the given distribution of blood donors concerning the use of condoms for c = . and p < . , shows significant difference, which is due to the prevailing of the number of blood donors ( ), who have not used condom. of er -concentrates are leukodepleted. the choice of bacteriological control of empty bags for blood, bags with er -concentrates in additive solution, universal and iso group plasma, as well as the systems for taking of blood are taken on free choice. the control of the erytrocyte concentrates is performed on the first day after the preservation and dekanting, and again between the th- st day and th- th day after the preservation. the pulled plasma is controlled on the day of pouring (spreading), and the control of the iso group plasma on the day of deplasming. three months later the iso group and the universal plasma kept on the temperature of - °c is bacteriologically controlled again. bacteriological control is performed with standard procedures in the institute for health protection in stip. the transfusion transmitted infections are potentially dangerous complications of transfusion therapy in immunocompromised patients. the aim of this study was to determine the prevalence of transmissible infections in blood donor population in kashan, iran. a total of consecutive sera were tested for cmv-igm antibody, hbsag, hepatitis b core (hbc) antibody, hepatitis c (hcv) antibody, and hiv antibody with standard methods. of the sera tested, specimens ( . %) were cmv-igm positive. the frequency of seropositive revealed no significant differences between male and female donors. the frequency rates of cmv-igm seropositive tests tend to decline with increasing the age. there was no relation between the frequency rates of cmv-igm seropositive with the educational level, socioeconomic status, marital status, urban dweller and rural resident patients. the prevalence of hbv, hcv, and hiv antibody were . %, . %, and %, respectively. these findings implied important clinical applications because detection of cmv positive sera may reduce the risk for transmission of cmv in blood transfusion and thereby decrease the risk on cmv-induced complications. introduction: the worlds problem, aids, steel can't be said that is a problem in these three centers in r. macedonia, in which blood is collected, controlled, and distributed. found negative and of them were found positive for one of the three viruses (hiv- , hcv, hbv). with the elisa/axsym assay of the blood units which were negative by the procleix ultrio assay were positive for anti-hbcag and negative for anti-hbsag and hbsag. from those blood units units were given for transfusion following our blood centre protocol and the remaining units were discarded. the protocol consists of a good medical history, liver enzymes (ast, alt, ggt). we must take into consideration that from those that were found positive by the procleix ultrio assay was positive for anti-hcv and were positive for anti-hbsag. summary/conclusions: despite the fact of the short period of time we perform this method, the ability of the nat technique for rapid use, reliability and sensitivity in detecting three viruses simultaneously, indicates the need for immediate use in blood donation as a screening method. in spite of the high cost of the method, it is clear that this assay is a valuable tool in our blood centre to provide fast and safer blood. bacterial contamination of blood products is a persistent, but often overlooked, problem in transfusion medicine. in greece it is recommended that platelets (plt) must be used or discarded within five days post-collection. recent reports from europe have advocated the use of bacterial culturing of platelets on day or and, in case of negative result, prolongation of their storage time to days. aim of the study: to assess the prevalence of bacterial contamination of standard platelet units from whole blood, and to provide evidence that with the use of bacterial culturing it is feasible to extend the self life of platelets to days. materials and methods: eligible blood donors were bled according to standard operating procedures used in greece. plt were prepared from whole blood, solely for the purpose of the present study, by the platelet-rich plasma method. plts were stored for up to days at to °c with end-over-end agitation. other plts prepared from blood collected in triple-pack container system also provided with a predonation sampling device were also tested. plts were sampled in the bacteriology laboratory. plts were sampled on day , and . both aerobic and anaerobic culture bottles were inoculated with a -ml platelet sample. culture bottles were incubated at °c in an automated microbe -detection system (bact/alert system) until a positive reaction was detected or for days. all samples that were reactive were confirmed by routine culture. each reactive sample with bacteria growth on the routine culture was sub cultured for identification of the bacteria. results: a total of plt concentrates were cultured and bacterial contamination was assessed in each unit at day , and after collection. on of storage day two out of ( . %) plt units were found to be positive for bacterial growth. cases of unconfirmed positive results were noted at the beginning of the study. out of the other units which were negative on day and continued to be cultured for the next days, the assessment at day found no other positive. after further storage, at day , defined as the end of the prolonged incubation period, out of the plt concentrates ( . %) grew bacteria although testing of the same units on day and gave no signal. from the platelets units that were prepared from blood collected with a predonation sampling device, none of the plt concentrates gave a positive signal although pouches were found to be positive, and subculture showed bacterial growth of coagulase -negative staphylococcus. despite the relative small number of tested platelet concentrate units, our findings discourage specialists in attempting platelet storage time prolongation to days. bacterial contamination testing on day and a storage time of maximum days seems to be still the safest practice. bacterial screening of platelet concentrates using bact background: bacterial screening of blood components is a routine measure in the evaluation of blood product quality. at our institute bacterial screening is performed using bact/alert system. sampling and culturing of blood products is performed according to paul-erlich institute recommendations. methods: quality control data on the bacterial screening of platelet concentrates performed from - were retrospectively analysed. an initially positive (ip) and true positive (cp) rate, organisms isolated and time of detection are presented. results: a total of platelet products were tested during the year period. thirty ( . %) were found initially positive by bact/alert. the cultures screening positive were subjected to bac-terial identification to distinguish false positive from real positive signals. bacterial contamination was confirmed in ( . %) plt concentrates. positive cultures were confirmed and identified in an independent laboratory ( hbsag, anti-core, anti-hbs, anti-hcv, anti-hiv i/ii, anti-htlv i/ii, rpr. these patients were transfused with - units of concentrated red cells, depending on their problem. a total units were delivered from the beginning of their problem until december . the control were done using last generation enzyme-linked immunoassay (dade behring, ortho, biomeurieux), as also using automated enzyme-linked immunoassay (axgym). the same patients were checked by their physicians before the initiation of transfusions for the same diseases. results: we found: patients anti-hbc (+) and anti-hbs (+). patients anti-hbc (-) and Ánti-hbs (-) patients anti-hbc (-) and anti-hbs (+) patient anti-hbc (+) and anti-hbs (-) patient hbsag (+), anti-hbc (+) and anti-hbs (-). all patients were negative for hcv, hiv, htlv, and rpr. the same results were found also from patients' physicians. conclusions: we conclude that the blood supply for blood transfusion-transmitted diseases is % safe in our centre. these results are in accordance with current international literature. this is due to careful selection of blood donors, to high quality of corporation between departments as also to internal and external quality control. all these factors contribute to safety of transfusions, the quality of life of the patients and the protection of patient's environment. neither in the pipetor nor in the extractor runs was found contamination. no false positive were detected and all the positive samples confirmed. (see tables and ) . for hiv and hcv the specificity was . %. the validation criterion were met, so the system was implemented routinely in our laboratory. the purpose of our study was to analyse the applicability of the pall enhanced bacterial detection system (ebds) in the routine of our transfusion unit which is totally focused on apheresis platelet collection. methods: apheresis pcs, obtained by trima (cobe) and amicus (baxter) separators and re-suspended in % plasma and % ssp solution (macopharma), were submitted to microbiologic control using pall ebds system which uses oxygen percentage decrease as a surrogate marker of bacterial growth. the working steps were the following: - hour after donation, about ml of pc were sampled into the ebds collection pouch and then incubated at °c under continuous agitation (incubator helmer ) for hours. after this period, oxygen percentage was measured using an oxygen analyser (pall bdso ). the test is based on the 'pass/fail' principle. in case of 'fail' result the microbiology department has drawn up the procedure to follow in order to confirm the data and to allow the micro-organism to be identified. the incidence of post transfusion hepatitis has been reduced by blood donor screening for hbsag, but the hbv infection is still responsible for a certain cases of post-transfusion hepatitis in world-wide. in this study the hbsag negative blood units were evaluated for anti-hbc and hbv dna by pcr method. an extra sample was collected from hbsag, anti-hcv, anti-hiv and rpr-negative blood donors. all of samples were examined by approved anti-hbc assay. all of anti-hbc positive samples were tested by hbsab assay and evaluated for hbv dna (pcr). the sensitivity of the hbv dna (pcr) assay was estimated geq/ml according to vqc proficiency and run control panels. ( . %) out of samples were positive for anti-hbc. ( . %) out of anti-hbc positive samples were hbsab positive, and ( . %) were hbsab negative. all of samples were assayed for hbv dna (pcr) single and all of them were negative for hbv dna (pcr). further study for evaluation of anti-hbc test as a screening assay for blood unites in high hbv infection prevalence area strongly recommended. early detection of hepatitis b surface antigen: a comparison of ten assays hbsag detection is the corner stone of detection of hepatitis b virus infection in blood donors and patients with hbv infection. one of the most challenges is sensitivity of the technique and kit. in this study ten different assays evaluated by seroconversion and performance panels. some of them can not be used as screening assay due to low sensitivity. the sensitivity of ten hbsag assays from biorad, dade behring, biomeriux, diasorn, radim, diesse, thermo. biokit, gb and shanghai companies were evaluated by two or three seroconversion and two performance panels from boston biomedica ink. seroconversion panel is a series of samples that collected over a period of time from individual developing antibodies due to a primary infection. for evaluation of the assay sensitivity who and other notified body in the world-wide recommended the seroconversion and performance panels. the hbsag assays are two groups. group one with high sensitivity included six assays. they can detect ad and ay subtypes from . ng/ml bbi to . - . ng/ml bbi respectively. low sensitivity group included four assays and they can detect ad and ay subtypes more than . and . ng/ml bbi respectively. for blood safety, the high sensitivity hbsag assays recommended for blood screening and all assays should be evaluated by seroconversion and performance panels. diagnosis of chronic hdv infection is usually by antibody testing and hbv dna detected by pcr method. it is rare to find patients with two replicating hepatotropic viruses and if the accompanying hbv is replicating, prognosis will be very poor. to clarify the correlation between hepatitis delta virus infection and hepatitis b virus dna positivity, sensitive hbv dna (pcr) assay was used. the presence of hbv dna was investigated in patients referred during the aug. to dec. . all of them were hbsag positive. all samples were evaluated for hbv dna (pcr). the sensitivity of the hbv dna (pcr) assay was estimated geq/ml according to vqc proficiency panel and run control. anti-hdv was tested by commercial available enzyme immunosorbent assay. ( . %) were hbv dna positive and ( . %) were negative. ( . %) out of patients had evidence of delta infection and ( . %) samples of hbv dna (pcr) negative patients were positive for delta agent. the serum alanine aminotransferase (alt) levels in out of hbv dna (pcr) and anti-hdv positive patients were higher than reference interval, but only in out of hbv dna (pcr) negative and anti-hdv positive samples were higher than reference interval. the present data indicate that . % of patients with chronic hepatitis b have hepatitisdelta infection. patients with hbv dna (pcr) negativity had a significantly higher prevalence of delta marker ( . %) than those with hbv dna (pcr) positivity ( . %). delta rna testing in positive hbv dna and anti-hdv patients is recommended. introduction: reduction of the window period of hepatitis c virus (hcv) infection represents an important goal in the transfusional and diagnostic setting and nucleic acid technology-based tests have been introduced in some developed countries to reduce the potential risk of transfusion-associated infection. a prototype assay designed to simultaneously detect circulating hcv antigen and anti-hcv has been developed by biorad (biorad laboratories limited, marnes la coquette, france). aim of the present study: to define the cut-off (co) value of the assay and to evaluate the specificity and sensitivity of this new assay in the detection both of antibody and antigen comparing its efficacy with commercial assays. methods: in order to establish the co value and to evaluate the specificity of the assay, we tested sera samples from the general population and 'difficult' sera from haemodialysis patients (n conclusion: the new assay shows high sensitivity and specificity and could be a useful tool not only in the diagnostic setting, where procedures to reduce the window period, such as antigen or hcv-rna detection, are not currently recommended, but also in the screening of blood donations, when nucleic acid technologies is not feasible due to costs, organization, emergency and/or logistic difficulties. introduction: in recent years the concern with the blood safety regarding the transmission of blood-borne viruses has been improved. this safety has been achieved with the combining of different strategies, such as a careful selection of donors, the screening for relevant virological markers and the viral inactivation/ removal methods. more recently, the implementation of the nucleic acid amplification technologies for the detection of hiv- , hcv and hbv, has increase this aim by reducing the 'window period' of the infections. other viruses, such as parvovirus b (pb ) and hepatitis a virus (hav), can raise problems to the blood safety. these infections could provoke serious complications in some risk groups, like pregnant women, patients with haematological problems, children and patients with immunodeficiency. material and methods: an observational study was performed to determine the prevalence of pb and hav in portuguese blood donors. we gather, during four months, plasma donations and joined them into pools, with no more than donations each. [ ] [ ] [ ] [ ] [ ] in voluntary donors the anti-hcv prevalence ranged from . % to . %, in family replacement donors from . % to . %, autologous donors from % to . %. we observed that the anti-hcv prevalence has a decline tendency during years in blood donors. according to sex the anti-hcv prevalence in men is . % and women . % (p = . ). over the year periods the prevalence in men has a decline tendency ( . % to . %; p = . ) and increasing tendency in women ( . % to . %; p = . ). according to age group the anti-hcv is . % in - age group, . % in - age group, . % in - age group, . % in - age group (p = . ). the prevalence of anti-hcv is higher in fds than vds, but not statistical significant. [ ] [ ] [ ] [ ] [ ] . a total ftd and ad have been tested for hbsag. a sample was considered as hbsag positive when found repeatedly reactive by rd generation. immunoassay method (elisa). the chi-square test was used for statistical analysis. results: the -year overall hbsag prevalence among first time blood donors was . %. and ad . %. among autologous blood donors was observed a decreasing hbv prevalence from . % to . % in . according to age the prevalence was higher in - year group . %, while according to sex was higher in man ( . %) than female . % (p < . ). among ad, a decreased hbsag prevalence according to age was observed in men and women. the same trends by sex and age were observed in ftd. the prevalence of hbsag in ad was lower than in ftd. however, from - hbsag prevalence has decreased in the same proportion in both population. this decreased can explain by to main factor: the improvement hbsag screening method in blood donors and decreased the hbsag prevalence in general population. ( : ) . the hbv dna-emia in hbsag negative samples was . ¥ - . ¥ copies/ml. in two donors anti-hbc total was positive and in one anti-hbe was also detected. in one donor the glycin alanin mutation in the s region was identified. the frequency of hbv dna pos/hbsag neg donors in poland is high ( . %) therefore the decision to introduce routine hbv nat screening is justified. ( / ) with stored apheresis and whole blood derived platelet concentrates. of these failed results there were confirmed positives (presence of bacteria in both the ebds pouch and the platelet mother bag by culture) representing / . the bacteria detected were staphylococcus or streptococcus sp. of the fail results were false positives (no presence of bacteria in the ebds pouch and the platelet mother bag by culture) representing . % or / , and were not confirmed initial positives (no bacteria in the mother bag by culture, ebds pouch not tested) representing / . there was one reported case of a missed detection with confirmed presence of bacteria (staphylococcus epidermidis) in the mother bag by culture. subsequently, the bacteria strain was isolated and inoculated into platelet units in our laboratory at levels as low as cfu/ml. in all cases the pall ebds was able to detect. this supports the hypothesis that this missed detection was the result of a statistical sampling error rather than a system failure. the results from blood centers routinely using pall ebds demonstrated effective detection of bacteria in platelet products stored under routine conditions with a true positive rate of / , and with a low false positive rate (< . %). this is comparable to a recent survey result with other culture based systems. summary/conclusions: the minority group of pregnant women who come to labor without prenatal testing of hepatitis b and c revealed essentially similar prevalence of anti-hcv with healthy bd even if definitive confirmation is probably increased in this minority group. there is however markedly higher prevalence of hbv infection in the pw so that screening for hbv is essential for the prevention of vertical transmission. the systematic screening of bd with anti-hbc serves as further assurance for the prevention posttransfusion hepatitis eliminating only . % of the possibly infectious, a percentage which can be restored to the blood pool after proving their immunity. methods: blood samples were screened for the presence of hbsag, hcv and hiv antibodies using enzyme immune assay and for syphilis using the tpha test. the results were analysed retrospectively. all samples with results at or above the minimum positive value were considered reactive. the tests for hbsag, anti-hiv and anti-hcv were repeated in duplicate in all reactive donations. blood units that were reactive in the primary or secondary assays were discarded. hiv positivity was confirmed by western blot analysis using hiv blot . (genelab diagnostics) results: results from a total of screened donors were analysed. hepatitis b surface antigen rates was . %; anti-hcv seropositivity was . %; anti-hiv seropositivity was . % and tpha seropositivity was . %. one study calculated this risk to be one in for hbv, one in for hiv and one in for hcv. it is therefore important to take a careful history from blood donors to eliminate those at high risk of infection. in view of the high infectivity of hiv positive blood, it is important not only to screen donated blood but also to exclude donations from high-risk individuals, such as males who have engaged in homosexual activity and intravenous drug users. a careful history should identify those who should not give blood. in turkey, among blood donors the average hbsag prevalence in - was . %. but it had decreased to approximately . % in . anti-hcv positivity has been reported to be . % between and . but it was approximately . % in . rpr positivity in blood donors in turkey was reported to be < . % in and . % in . in , the rpr rates was . %. in our study these rates are . %, . %, . % and . % respectively. anti-hiv seropositivity was found around . introduction: the serological detection of specific antibodies to treponema pallidum (tp) is an effective means of diagnosing syphilis, and an automated chemiluminescent assay is ideally suited to testing large numbers of specimens for the laboratory diagnosis of the disease. aims of the study: to develop a qualitative syphilis assay for the detection of tp immunoglobulin m (igm) and g (igg) antibodies. the assay will be used for the serological diagnosis of syphilis using the architect platform, which has the capacity to test specimens/hour. the two-step assay is based on paramagnetic microparticle chemiluminescent technology, utilising microparticles coated with three recombinant tp antigens (tpn , tpn and tpn ) and acridinium labelled anti-human igg and igm monoclonal antibodies as conjugates. in the first step, specimens, microparticles and diluent are incubated together, prior to a wash step; in the second step, acridinium labelled antibodies are added and after washing, pre-trigger and trigger are added to produce chemiluminescence, which is measured as relative light units (rlu). specimens yielding rlus less than the cut-off are considered negative, while those yielding rlus greater than the cut-off are considered positive. the sensitivity of architect syphilis tp was determined to be %, after testing specimens that were previously screened as syphilis positive in fujirebio tppa; no prozoning was observed with high positive specimens (over titer by tppa). the specificity generated from testing hospitalised patients previously screened as tppa negative, was . %. testing a mixture of sera and plasma from random donor specimens, generated donor specificity figures of . %. the precision (cv%) with a positive control was . % ( % confidence interval: . - . %) by the standard -day nccls analysis (ep a ). in a study conducted at asahikawa medical college hospital, in which, positive and negative specimens were tested, concordance with fujirebio tppa was determined to be %. no significant interference to the assay was observed from bilirubin (conjugated type and free type), haemoglobin or lipid. the architect syphilis tp assay is an automated, specific and sensitive test for the detection of antibodies to t. pallidum. background: hcv exposure of blood donors is serologically determined by the detection of anti-hcv antibodies in serum or plasma. however a 'window' period of - days after exposure exists during which specific antibodies to hcv antigens cannot be detected. hcv rna detection and/or hcv core protein testing result in dramatic reductions in the preseroconversion window period. the new bio-rad test, based on the simultaneous detection of hcv core antigen and anti-hcv (core, ns , ns ) antibodies, improves the detection of hcv infection in the early phase. aims: the aim of this study is to assess the performance characteristics of this new screening microplate immunoassay, monolisa hcv ag-ab ultra, by using the bio-rad evolis automated microplate processor system. methods: this two-step elisa assay is based on the combination of an indirect test for the detection of antibodies (core, ns , ns ) and a sandwich test for core antigen detection. results are available within . hours, with sample addition monitoring and color coded reagents. no specimen pretreatment is required. evolis is a self-contained microplate processor designed for full automation of microplate-based eia techniques. the walkaway system can process four microplates at a time with continuous loading of samples and reagents. positive identification of samples, reagents and microplates, usage of disposable tips with clot detection, integrated quality control and complete traceability provide a high level of safety management. the monolisa hcv ag-ab ultra/evolis system performance is evaluated for clinical sensitivity on commercially available and well-documented seroconversion panels. the results are compared to viral rna detection and conventional hcv ab screening assays. specificity is evaluated by using random blood donor samples. results: among the seroconversion panels that begining with samples negative for hcv rna and anti-hcv antibodies, the monolisa hcv ag-ab ultra assay detects exposure to hcv an average of days earlier than the monolisa hcv plus v test. the mean delay of the monolisa hcv ag-ab assay in detecting hcv infection compared to hcv rna testing is around . days. the monolisa hcv ag-ab ultra/evolis system allows simultaneous detection of hcv core antigen and anti-hcv (core, ns , ns ) antibodies, thus significantly reducing the time gap between the initial detection of hcv rna and the first appearance of detectable anti-hcv antibodies. the fully automated system combines high degree of assay performance with optimization of laboratory workflow and safety management. operational evaluation of pall ebds bacterial detection system l larrea gonzalez, ma soler and rj roig centro de transfusion, valencia, spain introduction: regulatory bodies are increasingly mandating the use of bacterial detection systems for platelet products ( ed standards for blood banks and transfusion services). one system currently available is the pall ebds bacterial detection system which utilises percentage oxygen as a surrogate marker for bacterial growth. aims: to evaluate the pall ebds in routine use in our blood centre. in particular, to assess feasibility and adaptability to daily labour routines. the orbisac (gambro bct) system was used to produce leucocyte depleted buffy coat (bc) platelet pools ( bc/pool) stored in platelet additive solution (ssp macopharma). mean platelet count was . ¥ e /pool with mean leucocyte count . ¥ e /pool. ebds installation and training occurred over a day period. platelet pools were tested for bacterial contamination over the subsequent weeks. ebds pouches were sterile connected onto platelet pools hours after blood donation. platelet samples were taken into the pouches and then the pouches were incubated for hours on a shaking agitator at °c. after this time, percentage oxygen was measured. no positive results were found in this study. this was as expected due to the relatively low number of platelet pools tested and it also highlights the absence of false positive results. minimal training was required to use the ebds. the system was easy to use and did not require the use of a laminar flow cabinet to take samples. it was quick and simple to take samples and perform oxygen measurement. after pouch incubation, technician was able to make oxygen measurements in less than minutes. the data management system allowed full traceability of product and work flow. results were very easy to interpret. conclusion: the pall ebds was found to adapt perfectly to a routine blood centre environment. ( ) was . the percentage collected from volunteer blood donors was % (n = ) and the rest % (n = ) was given from patient-related donors. the age of donors ranged from to years old. the assay used for the detection of hbsag, hbeag, anti-hbc igg/total, anti-hbc igm, anti-hbe and anti-hbs was the automated microparticle enzyme immunoassay (axsym) of the abbot company. all the units were tested for hbsag, and anti-hbc igg. if the anti-hbc igg was detected, the specimens were automatically tested for anti-hbs. the units were wasted if the anti-hbs was negative, and the specimens were manually programmed for the testing of the anti-hbc igm, hbeag, and anti-hbe. from the total of tested units, of them were found to be positive to at least one marker of hbv infection, that means the . % of the health adult population was infected in the past by the hbv. the . % (n = ) was previously infected and now immunized with hbsag(-) and anti-core igg(+) and . % (n = ) were chronic carriers of the hbv with hbsag(+). the . % (n = ) of the positive donors were patient related donors and . % (n = ) were volunteer donors. in other words, of the not volunteers ( . %) and of the volunteers ( . %) were detected to be infectious. the combinations of the serologic markers for hbv are illustrated in the table attached. these results indicate that the incidence of hbv infection in the northeastern department of greece is equivalent to the incidence of hbv in other greek regions ( . %) as it is referred to the national haemovigilance data and moreover, the percentage of infectious donors is bigger among replacement donors, . % compared with the . % of voluntary donors. as a consequence, the best source for safe blood collection is the population of volunteers. earlier detection of human immunodeficiency type , hepatitis c and hepatitis b viruses using the procleix® ultrio tm assay on the procleix® system and the study objective was to assess the ability of the ultrio assay and associated discriminatory assays to reduce the detection windows for hiv- , hcv, and hbv. commercially available seroconversion panels were used for testing. methods: hiv- (n = ), hcv (n = ), and hbv (n = ) seroconversion panels were tested neat and diluted ( : and : ) in the ultrio assay. panels were tested neat in the appropriate discriminatory assay. times to detection of hiv- , hcv, and hbv nucleic acids in seroconversion panels were compared to the vendor's historical data on time to detection of antibody and/or antigen using licensed or validated serologic tests. p- effectiveness and limitations of methods for platelet bacteria screening -how to apply which screening method? the successful concept of virus safety in transfusion medicine is not suitable in bacterial contamination. bacteria can grow up in blood components to enormous amounts, whereas the initial number of contaminating bacteria is typically very low. therefore, sample drawing for bacteria screening must not be done immediately after blood donation. the established concept of relevance of clinical microbiology (pathogenic, non-pathogenic, facultative pathogenic species) is not valid for bacteria contaminating blood. here, the currently discussed criterion of clinical relevance is the ability of bacteria strains (not species!) to grow up in blood components. the paul ehrlich institute (pei) developed pei bacteria standards, which are characterized concerning their behavior in blood components. they contain a defined number of living bacteria, they are deep frozen, ready to use and shippable. there are two strategies to improve bacteria safety of blood: screening and pathogen reduction. neither of them is perfect, but screening methods are successfully established since several years in routine (belgium, the netherlands), and represent the current state of the art. further development and collecting of experience will produce the basis for assessments in the future. it is of high importance to apply the screening methods in dependence on their properties. methods implying an incubation/cultivation step ('early methods') have to be distinguished carefully from 'rapid methods' . for example, it is unreasonable to compare (or to advertise with) different sensitivities of methods not considering their detection principle or their informative value. both principles, cultivation methods as well as rapid methods, show advantages and disadvantages. selection of the method has to consider the respective conditions of the given blood service (including logistics up to time frame between issue and transfusion). results from the procleix hiv- /hcv and hiv- /hcv/hbv (procleix ultrio) assays for the detection of hiv- rna, hcv rna and hbv dna in blood donors of two blood transfusion centers of sw greece in discriminatory assay testing, out of ( % of the positive, . % of total) were reactive for hcv rna only and out of ( % of the positive, . % of total) were reactive for hiv- rna only. none were positive for both hiv- and hcv. the standard serological assays gave the same results for the above positive samples. two samples that tested positive by the standard serological assays tested negative in the procleix hiv- /hcv assay. of the samples tested by the ultrio assay, ( . %) tested reactive for hiv- /hcv/hbv. in discriminatory assay testing, out of ( . % of the positive, . % of total) was reactive for hiv- rna, out of ( % of the positive, . % of total) were reactive for hcv rna, and out of ( . % of the positive, . % of the total) were reactive for hbv dna. all were single positive i.e. none tested positive for more than virus. three out of positive samples for hbv dna tested negative by the standard serological tests. the opposite was not observed. the procleix ultrio assay is a definite improvement over the procleix assay in a region with a high incidence of hbv carriers. up until its use, it is obvious that hbv positive blood with very low antibody titers was transfused into patients. more results will show whether procleix ultrio can eventually replace the standard serological tests. the introduction: patients with hemophilia represent a high-risk group for post-transfusion hepatitis whose frequency is closely linked with the number and quantity of blood products used. in albania, the frequency of hepatitis is also linked with hbsag testing with elisa (introduced in ), and hcv testing (introduced in ). aim of the study: evaluation of the prevalence of the markers of hepatitis b, c, and d in patients with hemophilia. methods: our study included patients with hemophilia treated with cryoprecipitate and commercial clotting factors. blood testing for anti-hcv, anti-hdv, and hbsag was performed with elisa -gen. iii. results: of patients tested, cases ( %) were hbsag positive, cases ( %) were anti-hcv positive, and cases ( %) were anti-hdv positive. co-infection of hbsag and hcv was found in cases ( %), whereas co-infection of hcv, hdv, and hbv was found in persons ( %). the highest rates of infections and coinfections were found in patients above years of age. conclusion: mandatory blood testing has decreased the levels of post-transfusion hepatitis. in albania, hemophilia is also still treated with cryo-precipitation, thus patients are at a particularly high risk during the 'window period' . results: / ( . %) samples from rbd were anti hiv + nonreactive and rr for p ag both being nonreactive in the neutralization test, they were interpreted as false positives. / ( . %) sample from fbd was rr for p ag/anti hiv + nonreactive and it was confirmed positive by neutralization. this bd had been autoexcluded himself after blood donation. he showed seroconvertion days later: p ag nonreactive, anti hiv + reactive and western blot positive. the only bd p ag positive/anti hiv + nonreactive during the analized period, was an first time donor and the post donation autoexclusion was effective en this case. although a larger populations of bd is necessary to be studied and in spite of the low prevalence we have found, we consider p ag screening is an alternative up to implementation of nucleic acid testing and simultaneously we should increase the quantity of altruist repeat blood donors, undoubtedly, the best population to give blood. owing to the rather short interval between successive donations (~ days), this suggests that some - infectious units escape the screening annually. to these, one has to add the (now unknown) proportion of potentially hbsag negative + hbv dna positive ftbds. hcv: since the introduction of the screening in , the general incidence in rbd has dropped from . ‰ to . ‰, suggestive of a : escape rate. the prevalence in ftbd has stabilized at ± ‰. based on reasons similar to these employed for hbv, the residual incidence in rbd suggests that potentially infectious donation in rbd escapes the screening (= to a total of aprox. , annually). a limited investigation using hcv-antigen eia evidenced a ‰ escape rate in ftbds (= to a total of aprox. , annually table and are concerned to the fist two months of the implementation, where we had to adjust the volume of the eluate. conclusion: these system adjusts to the laboratory daily routine in the blood bank, with the pools released after first analysis in less than hours. background: the hbsag, anti-hcv, anti-hiv / , p antigen, alt and syphilis tests are performed for blood donations in czech republic. no nat tests are mandatory in czech republic. the aim of this pilot study was: . hcv rna pcr testing in anti-hcv negative blood donations; . correlation between hcv nat and anti-hcv testing results. methods: blood samples (anti-hcv serologically negative, alt not elevated) were pooled using the guardian plus spii into pools of samples. pools of ml were tested using the cobas ampliscreen hcv test v. . (roche). results: pools of samples from a-hcv serologically negative donations were tested from october to july . no one pool was initially reactive. invalid tests: ( . %) run failures were observed, due to: invalid internal controls ( . %) and invalid positive controls ( . %). invalid tests were repeated. in none of pools a positive hcv nat result was observed. conclusions: no discrepancy between hcv nat and a-hcv results was observed in our study. all of the nat tested donors in our study were regular voluntary whole blood or plasma donors who were repeatedly a-hcv serologically negative. the hcv incidence in the czech republic blood donor population is low but it is slightly growing up in general population. hcv nat testing could improve the safety of blood supply by reducing the window period for hcv. introduction: parvovirus b is the only parvovirus known to be a human pathogen. most commonly, it causes a mild childhood rash, erythema infectiosum, but in some cases more serious symptoms can be linked to b , such as acute or persistent arthropathies, critical failures of red cell production, hydrops fetalis, fetal loss, myocarditis or hepatitis. inactivation of the non-enveloped virus has proven difficult. as a consequence, manufacturers of blood products have implemented screening measures to reduce the load of parvovirus b in manufacturing plasma pools by the use of nucleic acid amplification techniques (nat). in our institute all blood donations were screened for human parvovirus b by nat since april . methods: over the last years . million donations were screened for b by nat. samples with a virus load over iu/ml were defined as positive, whereas samples with a virus load between the detection limit ( iu/ml) and iu/ml were defined as weak positive. weak positive products were released, whereas positive products were discarded. in addition infection markers of b positive donors (case group) were determined over a time period of one year. virus load and b antibody status was compared with b negative donors (randomised control group). b antibodies (igg vp , igm vp , ns ) were analysed by two commercial antibody tests. results: overall b nat-positive donors were identified with a virus load over iu/ml out of . million tested. there was a seasonal accumulation during spring and summer, whereas a large epidemic occurred throughout the last year. vp igg was detected in . % and % of the case and control group, respectively (p = . ). these data demonstrated statistically significance (p = . ). all donor samples which were b nat positive for more than three months developed neutralizing vp antibodies. in contrast, ns antibodies were observed in % of the case group and in % of the control group (p < . ). ns antibodies were detected more frequently in samples, which were b nat positive for more than six months. conclusion: b nat could be implemented in blood donor screening as release criterion without causing a shortage in blood supply. all b positive donors of the case group developed neutralizing antibodies within three months and virus load was dropped rapidly below iu/ml. these data support our testing algorithm all components of high positive donations (virus load over iu/ml) were discarded. donors with ns antibodies showed more often signs of a chronic disease with detectable levels of parvovirus b longer than six months. background: on recent years, the syphilis screening of blood donors has become increasingly important not only because of the transmission risk of this infection but also due to the risk behavior that this implies. on account of the importance of this screening the tests used are becoming more and more sensitive. aims: to evaluate an elisa screening test (the tmpa test recombinant is based on the sandwich principle, an immunoenzymatic technology in solid phase, for the measure of anti-treponema pallidum in serum or plasma). methods: in this study samples from blood donors were tested by the rotine 'cardiolipidic reagent for syphilis screening on microplates' -diagast laboratories as well as with 'hdtmpa recombinant' -hoslab diagnostics. positive samples were then confirmed with fta abs/tpha. results: using the mentioned tests we obtained the following results: . ( . %)cases turned out negative with both technologies; . ( . %) cases were positive in both methods; . cases were positive only using tmpa recombinant [of which ( . %) were confirmed positive by tpha/fta abs. as seen we found samples ( . %) that were only positives by tmpa recombinant test and that were confirmed by tpha/fta abs. we concluded that tmpa recombinant seems to be a suitable test for a quick and automated syphilis screening of blood donors and provides maximum safety for the recipients. background: in recent years, there has been substantial evidence indicating that typing and subtyping for hcv is clinically important in understanding hcv disease and its therapeutycal options. 'naive' viral load also seems to influence disease severity and responsiveness to therapy. therefore, viremia and genotype identification have been done routinely in molecular biology laboratory units. aims: the university hospital of coimbra studies and tests his own patients and patients from other hospitals in the central portugal. we also collect and test blood donor candidates from this region. we proposed to analyse the distribution of hcv genotypes in this region, among patients with cronic hcv infection. we have simultaneously analysed the viremia and correlated it with age and severity of liver disease. methods: nucleic acid extraction was done using the semiautomatic 'xstractor' from biomerieux laboratories (boom method). the genotyping used reverse hybridization and was performed using probes from the ¢ non-coding region (innulipa introduction: bacterial contamination of blood products remains a persistent problem. various techniques for the detection of bacteria in blood products exist but none of them has been widely accepted. bacterial detection systems could be divided into culture systems and rapid technologies. hemosystem has developed a rapid and sensitive technology for bacteria detection named scansystem tm . bacterial contamination of platelet concentrates is a rare event with an incidence between : to : per donation. therefore hemosystem developed a positive control in order to validate the scansystem tm platelet kit before use. aim of the study: the current study was designed to evaluate the performance of the scansystem tm positive control. the scansystem tm positive control is a capsule containing lyophilised lactobacillus casei subsp rhamnosus. the bacteria concentration per capsule is at least ¥ cfu. the positive control has to be stored at room temperature and is stable for years. after dilution in pbs, the preparation has to be used within hour. two capsules were tested for ten consecutive days with scansystem tm platelet kit as well as with optimised scansystem tm platelet kit. in an independent experiment three capsules were diluted in platelets stored in additive solution and were tested each with scansystem tm platelet kit and optimised scansystem tm platelet kit. results: microscopic fields were analysed for bacteria specific fluorescence for each sample. the ratio between bacteria specific fluorescence signals and analysed signals was . in all samples for both scansystem tm platelet kit and optimized scansystem tm platelet kit. therefore by definition all tested capsules were positive. the lyophilized positive control capsules enable the user to validate the scansystem tm platelet kit before use. because bacterial contamination of platelet products occurs rarely, the routine use of positive controls improves safety of the screening method. scansystem tm is currently the only method that provides this safety measure. introduction: whereas implementation of nat for blood donor screening reduced the risk for transfusion transmitted hiv and hcv infections currently below one per million transfusions, the risk for bacterial infections is estimated to be : to : . especially platelet products, which are stored at room temperature, are prone to bacterial contamination. aim of the study: several methods are currently developed to prevent the transfusion of bacterial contaminated platelet concentrates. the study investigates a new rapid bacterial detection method. material/methods: pool platelet concentrates were spiked with seven transfusion relevant bacteria strains under sterile conditions at concentrations of cfu/ml to cfu/ml. bacterial concentration was verified on blood agar plates immediately after spiking. five millilitres of spiked platelet concentrates were centrifuged, stained with thiazole orange dye and analysed directly by facs within five minutes after staining. aliquots of pool platelets spiked with concentration of cfu/ml and cfu/ml of each bacteria strain were incubated for two to eight hours in special bouillon at °c and were analysed by facs immediately after incubation. results: sensitivity of facs analysis differed between cfu/ml for e. coli and cfu/ml for klebsiella pneumoniae without preincubation and was enhanced to cfu/ml when a pre-incubation step of two to four hours was included. conclusion: bacteria detection by facs analysis combined with a short pre-incubation ( - h) at °c is a quick and simple method with sensitivity comparable to other commercially available detection systems. the advantage of this new method is the rapid analysis, easy handling, high sensitivity and less expensive price. introduction: detection of bacterial contamination of platelet concentrates represents a major challenge in transfusion medicine. for blood transfusion services the method must have a high sensitivity, an easy performance and a low price. aim of the study: in this spiking study we evaluated the new optimised scansystem tm platelet kit detection method for use in apheresis platelets. methods: apheresis platelet concentrates (apcs) were spiked with strains of ten different bacteria species. after different incubation periods, apcs spiked with cfu/ml were analysed by the optimised scansystem tm platelet kit. the number of bacteria was monitored by plating on blood agar. results: all bacteria strains were detected with the optimised scansystem tm platelet kit when the sample was collected h after spiking. identity of the spiked bacteria was confirmed by gram staining and dna fingerprints. conclusion: in summary, the optimised scansystem tm platelet kit was able to reliably detect ten transfusion relevant bacteria species in apheresis platelet concentrates within minutes when the sample was taken hours after spiking. background: since year our laboratory started routine screening of hcv-rna in plasma minipools for all plasma intended for fractionation. although nat testing is not yet mandatory all blood products are released depending upon nat results. aim: to test and compare two different methods of rna extraction in order to make all the necessary adjustments to the test procedures while preserving the availability of blood products. methods: plasma minipools of donations are prepared either on a tecan genesis robot or on a hamilton at plus. hcv-rna is isolated from ml plasma by using either the qiagen biorobot and qiamp virus biorobot kit or the manual extraction with cobas ampliscreen hcv pcr kit v . . results: between march and december a total of seronegative donations ( pools) were tested for the presence of hcv-rna. four pools were found to be positive for hcv-rna. of the four nat-positive pools with no eia-positive donor, four were confirmed as true positive by donor follow-up testing and/or testing of an independent sample from the index donation. all the positive donations were detected independently of the extraction method used (manual or automated). our experience shows that although the automated extraction method is 'off label' and it has to be validated, the use of biorobot does not pose a detectable contamination risk and it is possible to achieve a detection level for hcv less than iu/ml. the advantage of the manual method is that it has better recovery of nucleic acids than the qiagen extraction. concerning the time needed for the extraction process the automated method runs samples in hours where the manual method needs hours for samples, needing, prior to extraction, an extra centrifugation step for one hour. the automated extraction method results in an assay with a high sample throughput, fast time, sufficiently sensitive, that can be successfully introduced into routine use in laboratories which have more than samples/day while preserving the availability of blood products. anti-hcv similarly was high till ( . - . %), but in trend to decrease afterwards ( . %). anti-hiv reflected the low endemicity of the disease in public setting and was % through the mentioned years. rpr test for syphilis was around . %. directed donors were % of all and volunteer donors consisted nearly %. donors in our blood center are being informed about donation prior to giving their blood and donor questionnaire forms (dqf) are filled out by the donor candidates. using dqfs have been mandatory at all blood banks in turkey by law since . from that time infectious disease marker rates were dramatically reduced at all centers. donor information about the risks of transfusion and the importance of safe blood supply were detailed by the donation staff and physicians, consequently self-exclusion by the donor candidates who have risky behaviors was encouraged at our center. the interviewing staff was trained specifically for this topic. this steps were particularly emphasized in the last three years and the infectious screening results were displayed the outcome of this efforts. conclusion: education of the prospective donors, and recruit the voluntary, non-remunerated and regular donors will be the utmost goal of all blood banks. rigorous donor selection will contribute this ultimate success. we should spend more efforts to maximize enrolling voluntary donors to lower the serological marker results, consequently achieve safe blood. background: human t cell lymphotropic virus type i is endemic in japan, the caribbean, southeastern united states and parts of south america and africa. in non-endemic areas such as europe, htlv-i is less common and most infections are identified in immigrants. the epidemiology of htlv-ii is different, being predominantly found among indigenous american-indian populations and among ivdus, but the routes of transmission are the same. aim: our study's aim was to ascertain the prevalence of htlv i/ii in blood donors in order to understand the epidemiology of htlv in greece and initiate discussions of an acceptable level of risk and appropriate level of screening for rare transfusion-transmitted diseases. overall, anti-htlv seroprevalence levels among blood donors, are low. although the number of annual donations in this study is relatively small, the data for htlv indicate that rates of this infection are low and that infected donors will be seen infrequently. as all blood donations are screened for htlv i/ii during the last six years, a national survey is necessary in order to define the epidemiology of htlv in greece. introduction: toxoplasma gondii is the causative organism of toxoplasmosis. the disease transmitted by ingestion of either oocysts (in the feces of cats) or bradyzoites (in raw or undercooked meat). the parasite can also be acquired transplacentally by organ transplantation or from blood transfusion. the purpose of this study was survey of toxoplasma antibodies in some iranian blood donors at tehran blood center. blood samples were randomly collected for detecting of igg and igm antibodies (by elisa technique).the total numbers of donors was of (% ) were female and (% ) male in age ranged from to years. results: sera tested, ( %) were found to be positive for toxoplasma igg antibodies and ( . %) were igm antibodies positive and of them ( . %) were borderline for igm antibodies. among males the frequency of positivity was higher than woman but this different was not significant. the most frequency of seropositivity was found in age group to years. conclusions: diagnosis of toxoplasmosis can be aided by serologic or histocytologic examination. the acute infection in healthy individuals is generally asymptomatic and not associated with any morbidity but in an immunocompromised host, toxoplasmosis be a very serious disease, and this can occur if a person is infection with toxoplasmosis before or after his/her immunosystem is compromised. in spite of the progress in the development of diagnostic, therapeutic and prophylactic methods, virus hepatitis still presents a serious global health problem. the possibility of transmission of these infections through transfusion of blood and blood derivates implies obligatory control of the donated blood. post-transfusion hepatitis is an important health problem in everyday practice, especially in patients who have to receive transfusion of erythrocyte concentrates as the only possible treatment for many years. objective: to show the prevalence of hepatitis b (hbsag) and hepatitis c (anti hcv antibodies) in multitransfused thalassemic patients. in our region there are patients suffering from thalassemia major who are aged between and , and who have been receiving erythrocytic transfusion - times a month since the age of one or two. they receive washed red blood cells, and in certain periods filtered red blood cells, controlled for viral markers and they mostly receive blood from voluntary, periodic and regular donors. the patients are tested periodically for the presence of viral markers (hbsag, anti hcv antibodies), using tests for hbsag (abbott auxyme monoclonal eia) and for anti hcv (abbott hcv eia . ). the presence of markers for hepatitis b and hepatitis c has not been detected in any of these multitransfused thalassemic patients who receive at least transfusions a year. the tests in all patients were negative. the blood used for transfusion must be tested for viral markers, and for the patients who have to receive blood for their whole life, the blood should be from voluntary, regular and periodic donors who donate blood at least three times a year, because then the risk of transfusion transmissible infections is very small. introduction: we observe yearly the prevalence of transfusion transmitted diseases following instructions of skae (national coordination haemovigilance centre). aims: to investigate the prevalence of the most important blood borne infections in our blood transfusion centre in the state achaia during the last five years ( ) ( ) ( ) ( ) ( ) . materials and methods: the detection of hbsag, anti-hcv, anti-hiv / was made by automated microparticle enzyme immunoassay (axsym, abbott) and by enzyme-linked immunoassay methods (dade behring, ortho, biomerieux) syphilis tests were made by using rpr kits. confirmation for anti-hcv positive samples was made riba or inno-lia, while the confirmation of anti-hiv / positive samples was made by 'st. andrews' general hospital of patras reference centre. results: all the seropositive donors were first time donors. conclusion: ( ) we observe that there is a decrease in all four infections. ( ) the absence of anti-hiv seropositive donors is due to the high percentage of volunteer blood donation which approaches % in our centre during the last four years. methods: a prospective, one-year study has been set up in order to enrol at least out of the estimate of first-time donors, involving blood transfusion centres from of the italian regions. each centre was required to enrol all first-time donors born before december st, , and thus not included in the hbv mass vaccination campaign. the selected donors were tested for hbsag (mandatory by law) and for anti-hbc by commercial assays. all hbsag and/or anti-hbc positive specimens were stored frozen and sent to a reference laboratory for additional serological testing (anti-hbs, anti-hbe, anti-hbc/igm and anti-hbc avidity index by an experimental procedure) and for the determination of hbv-dna (both qualitative and quantitative) by real-time pcr. results: in the first months of the study the sites saw almost first-time donors, of whom . % belonged to the required age groups. among eligible donors, . % were both hbsag and anti-hbc positive, and . % were hbsag negative/anti-hbc positive. hbv positivity rates were higher in southern than in northern regions, although a high variability in hbv prevalence was observed between neighbouring areas in the north. hbsag positives were mostly males, % were positive for anti-hbe, % had raised alt and % were concurrently positive for anti-hbs. among hbsag negative/anti-hbc positive donors, % were negative and % were positive for anti-hbs. among anti-hbs positives, % showed values < miu/ml and % > miu/ml. the avidity index results suggested that approximately % of anti-hbc positive individuals were recently infected. conclusions: our preliminary data indicate that approximately % of the italian first-time donors are older than years of age and thus not belonging to the age groups who underwent to the mandatory vaccination against hbv, and that . % of them have serological markers of ongoing or past hbv infection. anti-hbc alone was detected in nearly % of the study population. hbv-dna testing is underway at the time of this writing. in our country mandatory tests for each blood donations are: hbsag, anti-hcv, anti-hiv / and tp ab. to c + ns + ns , ( . %) to c + ns , ( . %) to c + ns + ns , ( %) to ns + ns + ns , ( %) to c + ns + ns , ( %) to ns + ns . the use of the hcv core ag elisa test system may provide substantially earlier identification of hcv infection than it is possible with current serological assays. although all of six anti-hcv assays are very sensitive and specific screening assays, they didn't detect hcv infection in one patient. majority of anti-hcv positive patients ( . %) had anti-hcv ab for or more different epitopes of hcv. international comparison of performance of abbott prism assays used for blood donor screening background: the national serology reference laboratory, australia (nrl), coordinates a quality control (qc) programme for laboratories that screen for anti-hiv & , anti-hcv, hbsag and anti-htlv i/ii using the abbott prism assays. nineteen laboratories from australia, belgium, canada, ireland, israel, the netherlands, new zealand, norway, singapore, south africa and thailand have submitted data for this programme. aims: to determine the accuracy and precision of results from laboratories, individual prism instruments and different reagent lots by analysing data accumulated between october and january . the multi-marker qc sample 'pelispy s type ' (s ), produced by viral quality control (now acrometrix-viral quality control), was provided to participants. laboratories tested s in each calibration run, in addition to the manufacturer's controls, on each sub-channel of the instrument. pelispy was used as a 'go/nogo control' and results were required to be reactive (s/co > ) for a test run to be deemed valid. data were collected and analysed using the nrl's internet-based application edcnet (https://www.nrlqa.net). after submission, laboratories were able to compare their results with those submitted by other laboratories and investigate differences in results from reagent lots and instruments. data for five different s lots were exported from edcnet and analysed. results: nearly results were submitted: all results were reactive (s/co > ). fifty of these results ( . %) were excluded from analyses because they were reported from invalid test runs [due to pipetting, aspiration or sampling error (n = ) or due to unacceptable results (n = )]. a further results were excluded because data provided by laboratories were inconsistent or incorrect. a total of results, reported using different prism reagent lots ( for anti-hiv, for anti-hcv, for anti-htlv and for hbsag), were analysed. results from prism hbsag and anti-hiv showed the least variation with coefficient of variations (cv) of < % for all s lots. results from prism anti-hcv and anti-htlv produced cvs between . % and . % for all s lots. data reported for s lot ps (n = , range for anti-htlv to for hbsag) were analysed further to review performance of prism reagent lots. hbsag showed the least variability between prism reagent lots with < % bias for the prism hbsag reagent lots used (bias: the difference between the mean ratio for the reagent lot and the weighted mean ratio for all reagent lots, expressed as a percentage of the weighted mean ratio for all reagent lots). prism anti-htlv showed greater variability between reagent lots with a single reagent lot generating a + % bias. prism anti-hcv showed the greatest variability within reagent lot with results from of reagent lots showing a cv between % and %. conclusion: in results in a qc sample distributed to laboratories the abbott prism performance was found to be consistent over four assays. edcnet was robust in supporting laboratories' abilities to follow precision and accuracy of the assays in real time. introduction: since hcv rna testing of all blood donors started in finland in , the nat screening process has continuously been improved. investments in process automation have made the work more efficient and blood safety has further increased since hiv- rna screening of all blood donors started late . aim of the study: to implement hiv- rna testing in the nat screening program cost effectively, without increasing the throughput time of the samples and delay in the result reporting. to study if the sensitivity for both hiv- rna and hcv-rna will be sufficient when a single extraction is used and when the pool size of donations and the sample volume are kept unchanged. methods: the nucleic acids were isolated from plasma samples of ml with the magna pure lc instrument using the magna pure lc total nucleic acid isolation large volume kit. the internal controls from the cobas ampliscreen multiprep specimen preparation and control kit and the cobas amplicor hcv specimen preparation kit were added to the lysis/binding buffer ( ml/ml of each). from the final volume of the nucleic acid eluate ( ml) ml was used for the detection of hiv- rna (roche cobas ampliscreen) and ml for the detection of hcv rna (roche cobas amplicor). a run control containing both hiv- rna ( iu/ml) and hcv rna ( iu/ml) was included in all extraction runs. sensitivity of the both assays was assessed by testing dilution series of the who standards for hiv- rna and hcv rna. specificity was evaluated by testing fractionation plasmapool samples (n = ) and minipool samples (n = ). results: detection limits of the hiv- and hcv assays ( % hit rate) were calculated to be . iu/ml and . iu/ml respectively. specificity for both assays was % and during the validation phase also the robustness was good. the sensitivity of both assays with a pool size of was below the recommendations by the council of europe for blood donor screening (for hiv- rna iu/ml and for hcv iu/ml per individual donation). specificity of the assays was excellent, false reactive results were not observed. implementation of the hiv- nat assay in the screening program did not increase the throughput time of the donor samples when the pool size of donations, ml sample volume and a single extraction for two assays were used. the the very substantial increase in the number of industry-sponsored clinical trials has created challenges for medical schools, academic hospitals, faculty members of these institutions, and the journals that publish the results of these trials. in many cases, authors of reports of industry-sponsored clinical trials are paid consultants to the sponsor, have been paid by the sponsor to lecture on behalf of its products, or have equity in the sponsoring company. these ties to industry create a tension that actually is or can be perceived as • work internationally; • send young volunteers to international youth forums; • employ young people in your organisation; why use volunteers in blood donor recruitment? • they have networks to scout-groups, sports-organizations, tradeunions, rotary, staff of large companies etc. • they bring in fellow volunteers -with different prospects of society; • often paid recruiters are underpaid (!) and tend not to remain • you can not recruit by telephone! • out of donors are recruited by personal contact! • so you need direct personal contact = need many people (e.g. young ambassadors); • a large number of volunteer recruiters is a gift from heaven! paid donation gives the act of blood donation low status. the act of blood donation should be respected, and praised by role models, queens and presidents. efficient work and close cooperation of blood bank staff and volunteer organisations is the key to success in blood donor recruitment and retention! with such a prospect, it was important to evaluate the practices of blood donor selection in the eu. material and methods: a questionnaire was designed and sent in to the relevant institutions of the eu countries plus switzerland. the questionnaire included questions on the interviewing practices before homologous blood donations, regarding non-specific risks to donors and recipients, identified risks to donors, infectious, bacterial, viral, parasitic and prionic risks to recipients and non-infectious risks to recipients. the questionnaire also inquired about each country's exclusion period for each contraindication (ci) to donation. results: predonation interviews were prepared, in all countries, by circulating informative documents to blood donors. they were supported by written questionnaires in nearly all countries. in half of the countries, those interviews had to be led by physicians (nurses or technologists in the others). the - age limits for blood donation ( - for a first donation) were the rule in countries. in other countries the age limit could be brought forward to and extended to years old. the time interval between donations was identical for men and women in countries, and varied from to weeks according to country. the questions of the questionnaires were very similar as regards the identification of risks to donors and recipients, and very close to the requirements that appeared later in the / /ec directive. this particularly concerned how to meet the expectations of european donors, so that they come back to your blood center! know your donors: make regular donor surveys. age, gender, number of donations, number of first time donors, media consumption, education, job situation, income brackets. use local donor organisations let volunteers help! they work for free, but donor recruitment and -retention costs money. each blood center should have a local donor organisation, run by volunteers. the donor organisation should receive a payment for each bag collected. the reputation of the blood system tell the donors, what the blood is used for. that all blood is tested. and that blood provides safe medical treatment safety of the donor. insurance is a must good quality and efficiency in blood services decentralized blood collection no waste, and minimal outdating efficient service: • a friendly environment, • donor friendly opening hours, • pleasant rooms, beds and well equipped waiting rooms, • parking-spaces, transport, • beverages and food, • letters with correct data etc. donors expect to be serviced by trained, medical professionals and that the medical check-up is taken seriously. donors should be recognized continuously. use directed press-coverage to higher the self-esteem of the donors. donors should be well informed: • leaflets, posters and questionnaires should be % correct; • use e-mail and web-sites for quick up-date of donor information. be visible! • have an offensive and comprehensive media approach; • have a yearly national campaign june up to world blood donor day; • have an attractive home-page, constantly updated; • streamline your lay-out; • mail a donor magazine to all regular donors: • send newsletters regularly to volunteers and the press. • use recruitment cards. • easy phone-and fax numbers, e-mail addresses. directed campaign towards young people: • young ambassadors group; • special training sessions for young volunteers; • advertisements in media catering to young people; • poster competitions; • book and leaflets on blood addressed directly to young people; minimum bodyweight, blood pressure, pulse limits, questions involving viral risks, either sexually transmitted or linked to drug abuse, questions investigating risks of malaria transmission, questions aimed at identifying risk of prionic disease transmission. analyzing ineligibility times, on the other hand, revealed wide differences. for example, ineligibility for current multiple sexual partners, sexual relations with risk individuals, tattooing or body piercing, endoscopy, general anesthesia or invasive surgery, could vary from to months. previous transfusion history could not be a ci or could be one varying from months to indefinite ci (this point recently changed in several countries). the results of that survey have revealed some differences between countries in the questions asked and especially in the ineligibility times. however, the conditions under which donor selection interviews are conducted were similar in all countries. the enquiry tool used in this study proved to be well adapted to evaluate the donor selection practices throughout eu. a next step will be to use it to appreciate their evolutions and especially the impact of the /ec/ directive on these practices in the eu countries and furthermore to evaluate the results of this selection (rates and motives of deferral) which is a major factor of patients' transfusional safety. background: in europe on average whole-blood donations are performed per inhabitants and year. whole-blood donation comprises a puncture of a venous vessel and letting of blood (usually ml), which may be repeated several times a year. like other invasive procedures, blood donation has a range of effects on the individual who is subjected to it. aim: the aim of this paper is to review some aspects of the present state of knowledge on effects and complications of whole-blood donations. results: most studies of the effects of whole-blood donations on the donor have focused on negative or unpleasant events and on time in rather close association to the donation. complications related to percutaneous needle insertion (bruise assessed by inspection . % -bruise assessed using post-donation interview . %, sore arm - . %, nerve irritation . %, arterial puncture/pseudoaneurysm/arteriovenous fistula . - . % etc) are most commonly reported, while negative systemic reactions (vasovagal reactions . - . %, syncope . - . %) occurring in connection to blood donation are less frequent (newman bh: blood donor complications after whole-blood donation. curr opin hematol ; : - .) serious complications requiring hospitalization (myocardial infarction, stroke) are extremely rare ( . %). fatigue ( . %- . %) and diminished physical working capacity ( . %) are reported to occur during days after the donation. a recent study of a consecutive sample of swedish blood donors (nilsson sojka b, sojka p: the blood-donation experience: perceived physical, psychological and social impact of blood donation on the donor. vox sang ; : - .) (with a selfadministered questionnaire with an open-ended question: how does blood donation affect you? physically-bodily/psychologicallyspiritually/ethically-morally/socially during or after blood donation?) revealed that perceived negative effects (fatigue, diminished physical working capacity, vertigo/dizziness, susceptibility to infections etc) were less common ( % of the donors) than positive effects (feeling of satisfaction, being more alert, feeling generally better, less migraine, higher physical working capacity, respect from environment, feeling of relaxation etc; % of the donors). the duration of positive effects was regularly reported to be weeks, while negative effects lasted only days. investigations on the long-term effects of blood donation are scarce. yet, they may indicate that the donation of blood is associated with e.g. lower blood pressure and a reduced risk of myocardial infarction (nilsson sojka b, sojka p: the blood-donation experience: perceived physical, psychological and social impact of blood donation on the donor. vox sang ; : - ). conclusion: both the panorama and the frequency of occurrence of the different effects and complications of whole-blood donations vary as a function of how the information was gathered (openended questions, observations, interviews etc). serious reactions to whole-blood donations are extremely rare. more studies are needed in particular with respect to the long-term effects of regular wholeblood donations. t-pa- establishing a national adverse event reporting system for blood donors -a prospective study of . there was no national system and significant regional variation showed that the data was scientifically unsound. a coincidental initiative to remove the mandatory post donation rest period for regular donors further emphasised the lack of reliable, retrospective data to monitor and compare the impact of this new policy. aims: . to develop and implement a high quality, reliable national donor adverse events reporting (daer) system; . to define and categorise adverse events; . to record data systematically and prospectively using the existing computerised donor database. methods: from summer , a small project team of senior clinical and operational staff took months to agree a detailed policy for capturing and recording all donor adverse events, including precise definitions for grades of vasovagal reactions and bruising. detailed training material was written in may and the new protocol was validated in one region. from july to december a formal one day training programme was delivered to over staff working on mobile collection teams, static sites and blood centres. daer was fully implemented by january . adverse events are assessed by health care professionals on session and the relevant code entered onto the donor's computer record by clerical staff. information received after the session is entered by centre based doctors using the same system. the database is interrogated monthly for statistics. results: in the first months . million donors attended sessions throughout england and north wales. results were very consistent month on month. donors ( : ) had vasovagal symptoms but only % of these suffered syncope. % of all vasovagal reactions occurred in women. % occurred in donors aged - and a further % in donors aged - . (donors aged - represent only % of the total donor base.) donors ( : ) reported a delayed reaction, % of whom did lose consciousness. nerve injury, unrelated to haematoma, occurred in donors ( : ) and, more rarely, arterial puncture was diagnosed in donors ( : ). bruising was reported after the session by : donors. summary: a robust system has been developed and successfully implemented across a large, national blood service. based on the data already accumulated our next phase is to develop strategies to minimise adverse events, confident that any intervention will be effectively monitored. the community role in enhancement of voluntary, non-remunerated blood donation in the new millennium introduction: in the developing countries, about % of the blood supply comes from paid or replacement donors, where a high number of infected persons are in the donors population. only % of the global blood supply is donated as voluntary nonremunerated blood donors in countries with low and medium human development indices. and around % of the global blood population has access to only % of a safe blood supply. conclusion: blood is a national resource, it is the responsibility of governments through it's communities to ensure that the blood supply is safe and adequate to meet the needs of patients population and available to all who needs it. background: in response to a documented increase in the average age of donors, a survey was conducted to explore if young people had more unfavourable attitudes towards becoming blood donors. aim: to identify if the increasing difficulty in recruitment and retention of young people as donors, is linked to a low level of motivation for donating blood in this age group. methods: a national telephone-survey was conducted among a cross-sectional sample of the adult norwegian population ( participants). the survey was performed in november . results: five percent reported being active donors (had donated during the last months), % were passive donors (had not donated during the last months), % were non-donors with a positive attitude towards becoming donors, and % non-donors with no intentions ever to donate blood. in the youngest age group (age - ), % reported being active donors and % were passive donors. however, % of the young non-donors reported having intentions of becoming a blood donor. fifty-five percent of young non-donors had a negative attitude towards ever donating blood. all non-donors were asked why they did not donate. thirty-six percent of all non-donors reported health related reasons for not donating blood. thirty-one percent of all non-donors claimed that they did not donate because no one had requested them to do so personally, and % reported they did not care about blood donation. in comparison only % of young non-donors reported medical reasons for not donating. thirty-eight percent claimed lack of personal request, and % reported of lack of interest as the main reason for not donating. summary/conclusion: although the youngest age group was under-represented among active donors, we found that a great proportion ( %) of young non-donors had a positive attitude towards becoming blood donors. the most important reason why young people do not donate was the lack of a personal request. indifference regarding donation was not very widespread. a relatively high proportion of young people considered themselves as not medically disqualified to donate. in light of these findings, efforts to recruit young people as blood donors are strongly recommended. background: the ever-increasing demand for blood, coupled with emerging new threats to blood safety, motivate the strengthening of the blood banking infrastructure. aim: employing new technology as an instrument for building relationships of trust between blood bank and blood donors. material: . a new software module supporting the management of magnetic cards was added to e-aima blood bank management application. the magnetic card supports the following information: • front-side: donor's photograph, surname, name and blood group (including rhesus phenotype & kell) and sign of blood collection centre. • magnetic stripe where data concerning donor's serial number, medical history (risk factors), test results for infections and the number of donations is stored. . specific hardware allowing reading from and writing to magnetic cards is integrated to the software module: • magnetic card scanners were added to pcs serving to donation collection, including laptop for mobile team collection. • web cameras to capture the photograph of the donor to be printed on the card. • card printer was deemed necessary to produce magnetic cards for donors on a need basis. . consumables: blank plastic magnetic cards, ink cartridges for printer. methods: in order to evaluate the performance of magnetic cards compared to the paper-based system, a questionnaire was distributed to first-time and repeat blood donors, in order to be used as an indicant of donor's satisfaction. . first-time donors increased . % in the months of application. among them, . % were donors 'for relatives or friends' turned into volunteer donors and . % were first-time volunteer donors. the questionnaire analysis further revealed: • % were motivated by the use of magnetic card. • % appreciated the presence of their photo on the card and they confessed that they had used it as a spill for recruiting their friends as donors. • % were persuaded that employing new technology would result in safer and more trustworthy procedures combined with reduced waiting time. • % considered magnetic cards more practical compared to paper cards because of their compact size and improved durability. . the turnover of repeat donors also increased . % after replacing their plain old paper cards with new ones. further analysis revealed that: • % appreciated the quick cross-checking of donor's identity. • % were satisfied with the effectiveness and efficiency of magnetic cards in managing donor's data. conclusions: in , greek health policy provided the legal basis for establishing the electronic national health card. the introduction of the national donor's magnetic card is another step towards this direction, being aligned with the modern national health strategy. apart from the positive impact on the number of both firsttime and repeat blood donors, it should be also pointed out that the use of a unique donor serial number on country level results in less error-prone procedures due to the reduction of administrative process overhead and facilitates interoperability between national blood banks using compatible technological infrastructure. t-pa- emerging technologies in transfusion. dna based assays until the late s, mandatory blood screening for transmissible infectious agents depended entirely on antigen/antibody-based detection assays. recent emergence of nucleic acid technologies (nat) has revolutionized viral diagnosis by not only increasing the sensitivity level but also facilitating the detection of several viruses in parallel, by multiplexing specific primers. however, in more complex biological situations when a broad spectrum of pathogens must be screened, the limitations of these first generation technologies became apparent. high throughput systems such as dna arrays permit a conceptually new approach. these miniaturized microsystems allow the detection of hundreds of different targets simultaneously, inducing a dramatic decrease in reagent consumption, in additional confirmation tests and simplify data interpretation. however, the microsystems actually available require additional instrumentation and reagents for sample preparation and target-amplification prior to detection on the dna array. future technologies such as 'lab-on-a-chip' include channels, fluidics and thermal zones allowing extraction, amplification and detection. another major challenge in the area of dna detection is the development of methods that do not rely on target-amplification systems. almost all blood group antigens are bi-allelic and encoded by single nucleotide polymorphisms (snps). to facilitate the direct availability of typed red cells and platelets, we develop a high-throughput technique to genotype by dna microarray the whole donor cohort for all clinically relevant red cell and platelet antigens. methods: a multiplex pcr was developed to both amplify and fluorescently label gene fragments of red cell and platelet antigens in one reaction. each array contains spots of short ( - nt) allelespecific oligonucleotides to discriminate between the two alleles of an antigen system. results: two blinded panels encompassing donors were genotyped for hpa- through - and ; no discrepancies were found. currently, arrays are prepared for the red cell systems. the fya/fyb, fy-gata mutation, jka/jkb, k/k, kpa/kpb, m/n, rhc/c, rhe/e, rhdpseudogen, rhdvi negative, rs, doa/dob, genotypes can be determined. the set up of genotyping assays for rare genotypes is difficult because of lack or insufficient amount of dna. the latter can be overcome by phi dna polymerase-mediated isothermal genomic dna amplification, from minute amounts of dna present in stored red cell fractions or antiserum. the results show that the blood group typing dna microarray will provide a reliable and fast genotyping procedure. the method can be further improved to obtain the necessary automated throughput for typing of large donor cohorts. and , all other weak d types should be regarded as potential anti-d immunizers. for correct determination of weak d both serological typing (polyclonal and monoclonal), as rhd dna typing are mandatory. when serology indicates weak d, more anti-d antibodies are tested ( epitope model) to distinguish partial d from weak d. in addition, an rhd mpx pcr is performed to detect the presence of rhd exons , , , , and . in all known weak d types, all six rhd specific exons are amplified (except for weak d type which lacks rhd exons and ), whereas partial d phenotypes usually show aberrant patterns. aim: the aim of this study was to evaluate the diagnostic scheme for weak d typing. methods: between and , samples were investigated for weak d characteristics. four pcr-ssp assays were developed for identification of weak d types ( t > g), ( g > c), ( c > g) and ( c > a). weak d type was identified by the combination of serology and absence of exons and by rhd mpx pcr. rhd-specific exon sequencing was performed when serology and molecular typing were inconsistent. results: all samples were subjected to the rhd mpx pcr and sample showed absence of rhd exons and , indicative of a weak d type when combined with serology. the remaining samples were analyzed by the weak d pcr-ssps, resulting in weak d type samples, weak d type samples, weak d type samples and weak d type sample. two samples remained undetermined and were sequenced for all rhd exons and the rhd promotor region. one sample showed the mutations corresponding to the dau partial d phenotype ( g>a, g>a and c>t). the other sample had only one, not previously known mutation ( a>t), which is located intracellularly at the coohtail. extensive serology using the epitope model showed a pattern matching weak d. this new weak d variant was registered as weak d type . conclusions: based on these results it may be concluded that weak d phenotypes should be confirmed on molecular level to avoid misinterpretation of partial d that cannot be detected by rhd mpx pcr analyses. patients with weak d phenotypes, except for types , and should be regarded as being at risk for anti-d immunization after transfusion of rhd-positive blood products and should therefore be treated with rhd-negative bloodproducts. in this evaluation, out of patients carried such alleles. introduction: although kell antigens are expressed very early during erythropoiesis and a . % incidence of anti-kel is found in obstetric patients, this is a relatively rare cause of hdn. anemia is produced by immune destruction of fetal rbcs and suppression of erythropoiesis. maternal antibody titers or amniotic/cord blood bilirubin levels are not relevant indicators of the severity of the disease, and the measurement of the fetal haemoglobin by cordocentesis is a procedure with risks of miscarriage and sensitization. pcr techniques for the determination of blood groups using fetal dna isolated from maternal plasma, allows the application of noninvasive methods. clinical cases: we describe two cases of pregnancies in women with anti-kel acquired by transfusion/previous pregnancies: st case: in july , a -year-old woman (gravida , para ), rhdnegative, kel -negative was referred at weeks gestation. the father's phenotype was rhd-positive, kel -positive. a maternal antibody screen revealed d and kel alloantibodies. dna was extracted from amniotic liquid. the kel genotype was determined by pcr-rflp using the bsm i. pcr-ssp was used to studied intron and exon of the rhd gene. the results showed that the fetus was positive for rhd sequences and showed kel homozygosity; nd case: in august , a -year-old woman (gravida , para ) was referred at weeks gestation. she had a history of transfusion with rbcs units in -one of the donors was kel positive. the woman typed rhd-negative and her husband typed rhd-positive. rbcs from both were kel -negative. the maternal antibody screen revealed anti-kel . doubts existed about the putative father of this child. dna was extracted from maternal plasma using the magna pure lc (roche). real-time pcr was applied to analyse: sequences of intron , exons , , and pseudogene of the rhd gene and the sry gene by sybr green; and the alleles kel /kel by hybridization probes. all rhd sequences were detected (with the exception of the pseudogene) and the kel genotype gave a kel /kel result. in both cases the doctors choose not to use any invasive method to monitoring the fetuses regarding a hdn due to anti-kell antibodies, and the results of the molecular analysis were confirmed by testing the cord rbcs after birth. discussion: these cases illustrate the reliability of the molecular biology results, based on the collection of simple peripheral blood samples. a determination that the fetus lacks the relevant antigen obviates the need for expensive and invasive monitoring throughout the pregnancy. evidence-based medicine (ebm) is defined as: 'the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. the practice of ebm requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research and our patient's unique values and circumstances. ' otherwise healthy individuals without cardiopulmonary dysfunction (cdf) tolerate acute reduction of haemoglobin concentration to about g/dl, provided that blood volume is kept normal by a volume expander. however, individuals experience physical fatigue, and there is faint reduction of perception as measured by neurophysiological tests. symptoms are reversed upon retransfusion of fresh, autologous erythrocytes. acute, normovolemic anemia seems to be progressively less tolerated with increasing age and cdf. controversy has existed on whether or not to correct hypoalbuminemia in asb or icp by infusion of albumin. recently a large trial showed no outcome differences between icp patients treated with albumin or saline. thus in general there is no indication for albumin in asb or icp. however, albumin may yet be advantageous in e.g. patients with head injuries. furthermore, fractionated albumin is not equivalent to native albumin, since fractionation stabilizers remain bound to the albumin molecule. thus more refined albumin preparations may carry advantages still to be investigated. erythrocytes are given to increase the total oxygen transportation capacity of the organism. the effect of blood bank stored erythrocytes may differ from that of fresh, autologous erythrocytes, since changes of presumably important erythrocyte properties occur during storage. in the only large trial available, a transfusion trigger of . g/dl was found to be favourable to one of g/dl in icp, except possibly in icp with unstable angina pectoris or heart infarction. however, the erythrocyte concentrates given were not leukocyte filtered, and side effects of infused leukocytes may have hampered the conclusion. on the other hand, a metanalysis showed transfusion as an independent indicator of unfavourable outcome in coronary bypass patients, but again, leukocyte filtered erythrocyte preparations were not applied. the effect on morbidity and mortality of 'top up' transfusions given e.g. to mobilize patients postoperatively has not been studied by trials, although this effect seems evident to many clinicians. grave anemia may reduce the haemostatic effect of thrombocytes because changes of blood rheology reduces the pressure forcing thrombocytes against the walls of small vessels. the transfusion trigger for thrombocytes in asb or icp remains to be established by clinical trials, however. the same applies for fresh frozen plasma, which is infused as a source of coagulation factors. on the other hand, the haemostatic effect of various fibrinolysis inhibitors is well established in asb and icp, but many clinicians appear hesitant to use them. another interesting haemostatic agent is recombinant fviia, the use of which to control asb in blunt trauma is supported by one well controlled clinical trial. evidence by systematic research is insufficient to decide what is optimal transfusion practice. the procurement of such evidence is one of the greatest current challenges to transfusion medicine research. . concerns about the transfusion-related complications, such as infections, tumour behaviour and immuno-modulatory effects, and the costs, necessitated a re-evaluation of the transfusion practice. aims: the goal of this study is to evaluate if a restrictive transfusion policy (hb transfusion trigger < . mmol/l) reduces the amount of red cell transfusion compared to a liberal transfusion trigger (hb < . mmol/l) without a decrease in hrqol. because of concerns about the feasibility of this study early results were analysed and are presented in this abstract. material and methods: after a run in period of months (hb transfusion trigger of hb < . mmol/l) patients are randomised for the restrictive or the liberal transfusion policy. patients are followed then months. hrqol is measured after inclusion, after randomisation, weeks, , , , and months after randomisation. also anaemia related complications and red cell antibodies are scored. hb values were blinded for the patients during the study period. results: from july till june patients were included ( ra, rars, rcmd, raeb, cmmol) in general hospitals and university hospital. two patients died in the run in period. eight patients were randomised for the restrictive transfusion policy and patients for the liberal transfusion policy. the mean follow up period in the liberal group was . months (inclusive run in period) and . months for the restrictive group. two patients in the liberal group died after randomisation. one patient received growth factors. in the restrictive group patients finished the study, received growth factors and patient withdrew informed consent. the mean hb level was lower in the restrictive group and after randomisation about % reduction in amount of transfused red cells was found ( . units per pt per month in the liberal group vs . in the restrictive group). no anaemia related complications were found, e.g. cardiac failure and cerebro vascular ischemia nor a decrease in activity performance. conclusion: there were some concerns after introduction of the restrictive transfusion policy. this preliminary results show, however, that a restrictive transfusion policy leads to a diminished use of red cell transfusion without an increase of cardiac complications or a decrease in activity performance. this study will be continued to compare hrqol scores in both groups. introduction: strong evidence supports the efficacy of blood conservation strategies such as autologous blood donation (abd) and erythropoietin (epo) for reducing exposure to allogeneic blood. however, use of these interventions is highly variable among institutions and frequently sub-optimal. the program to reduce orthopedic blood exposure (probe) evaluated a blood conservation program in patients undergoing total hip joint arthroplasty (thja) at ontario hospitals. aim of the study: the objective of probe was to determine whether a comprehensive blood conservation algorithm (bca) was more effective than usual care (uc) for reducing exposure to allogeneic blood in patients undergoing thja. methods: we randomized hospitals that perform high volume elective primary thja to implement either a bca or to continue with uc. the bca consisted of three components: physician and patient education, blood conservation interventions (use of abd or epo), and transfusion guidelines. t-pa- table) . mortality for non-transfused patients was significantly lower than for patients receiving either lr-or s-prbc at all time points (p < . ). t-pa- thalassaemia: the impact on blood transfusion services thalassaemia major is a genetically determined disease that causes severe chronic anaemia and further complications. it can be managed successfully in the vast majority of cases, so long as public health and other scientific and organizational infrastructures are adequate. although the progress achieved in the field of bone marrow transplantation and other disciplines promises cure of the genetic defect, regular blood transfusion from early childhood remains the cornerstone of treatment of patients with thalassaemia major. this presents national health authorities with the formidable task of assuring an adequate blood supply of high quality and safety for these patients and ensuring that it is transfused in the appropriate way. the basic principle in the modern management of thalassaemia patients is that of a global approach to care. within this approach, a standardized protocol for regular blood transfusions is a prerequisite for the patient's long survival and quality of life. if thalassaemia patients are not transfused effectively, the severe anaemia and over-expansion of bone marrow due to ineffective erythropoesis can lead to poor growth, bone deformities, organomegaly and impairment of normal physical activities. in countries or regions with large numbers of thalassaemic patients, the organizational and technical aspects of meeting their blood requirements represents a heavy additional workload for the blood transfusion services responsible for providing blood for this group of multi-transfused patients. the acquisition and preparation of blood, genotyping the patients' blood group (including at least rh, kell, kidd and duffy systems) preventing the transmission of infectious diseases and other transfusion associated complications, and assessing the patients' blood transfusion indices all have a tremendous impact on blood transfusion and treatment units. blood transfusion services are thus confronted with major challenges that can only be met if appropriate national transfusion policies are in place, both in the laboratory and the clinical setting of blood transfusion. the availability of safe blood is related to the effectiveness of donation programmes aimed at recruiting and retaining voluntary unpaid blood donors who are at low risk for the transmission of infectious diseases. sufficiency is further related to resources, organization and management of the blood transfusion service and continuous education of its staff. high technical standards for the transfused product and quality management systems are required to ensure that the product meets these requirements, as well as pre-transfusion, transfusion and haemovigilance systems and other more stringent quality measures in the whole chain of blood donation and transfusion. additional measures and continuous care are specifically required for the optimal transfusion therapy of the thalassaemic patient. the patients should be transfused with red cell concentrates, (rccs) preferably not more than one week's old and leucodepleted. other processes i.e washing of rccs, use of nutrient additive solutions, irradiation etc may be used to improve the quality and the safety of the transfused product, while other advances in red cell transfusion are expected to improve blood safety by preventing adverse reactions and reducing exposure of the patient to donor blood. should patients with thalassemia intermedia be regularly transfused? thalassemia major (tm) and thalassemia intermedia (ti) share mostly a common basic molecular mechanism, that is the reduced synthesis of the * globin chains. the consequences of the resulting chronic hemolytic anemia are also common and include growth retardation, bone marrow expansion, extramedular hematopoiesis, splenomegaly, increased intestinal iron absorption, susceptibility to infections and hypercoagulability. what differentiates the two forms of the disease is the severity of the clinical phenotype, which in turn depends on a particularly heterogeneous molecular background and imposes diverse therapeutic strategies. the consequences of the genetic defect as well as the effect of the applied therapy seem to be mainly responsible for the clinical course of the disease. in untreated tm cases, the aforementioned consequences occur fast and patients die early in life mainly due to high output heart failure. over the past decades, the gradual adoption of the current transfusion and iron chelation strategies and the patients' compliance with this therapy have resulted in a significant improvement of survival, that according to recent statistics reaches % at age . this rate is even better in well-treated patients, almost % of whom survive at age . regular therapy extends survival mainly by preventing early development of cardiac complications. in addition, a multi-organ improvement is accomplished while patients' physical appearance is almost indistinguishable from that of the general population, hence permitting a normal social behavior with a high overall quality of life. bone marrow expansion and extramedular hematopoiesis are prevented; hepatosplenomegaly is substantially restricted and usually there is no need for splenectomy, while thromboembolic complications are rare and pulmonary hypertension is practically absent. patients with ti remain as a rule without regular therapy until a number of severe complications arise. the consequences of chronic anemia develop slowly compared to untreated tm cases and dominate patients' clinical picture usually by the third decade of life. at this time, all patients have developed hepatosplenomegaly and most of them have been splenectomized. bone marrow expansion results to bone deformities and fractures often occur. extramedular hemaotpoietic masses and bone deformities may lead to various complications depending on their bulk and location, such as neurological symptoms from masses arising in the paraspinal area or dyspnea from lung restriction. hypercoagulability, resulting from defects of native erythrocyte membrane phospholipids, together with the coexistent thrombocytosis in splenectomized patients lead to a wide spectrum of thromboembolic events. pulmonary involvement with respiratory dysfunction and hypoxemia as well as pulmonary hypertension leading to congestive heart failure are well documented in ti patients. nowadays, the beneficial effects of regular transfusion and chelation therapy in tm are beyond any doubt. the occasional application of transfusions in ti has a transient effect and does not seem to inhibit the consequences of chronic hypoxia. intensive and regular transfusion and chelation therapy in ti has proved effective in ameliorating the established complications such as spinal cord compression, hypercoagulability and pulmonary hypertension, without however reversing them. given the -year experience on intensive therapy in tm and the first encouraging data in ti, the earlier application of such treatment seems to be crucial in ti. the timing however of therapeutic intervention in ti in order to prevent anemia-related complications still remains an open issue that needs to be properly addressed. the impact of prestorage leucodepletion on the immediate transfusion adverse events of patients with thalassaemia major backround: regular blood transfusion therapy in patients with bthalassaemia major decreases the complications of anemia but it is associated to many immediate and delayed side effects. febrile non haemolytic transfusion reactions (fnhtr) are common complications due to alloimmunization of recipients against hla and/or specific antigens on donor's wbcs or to the accumulation during storage of biologic response modifiers (bmrs) that are directly pyrogenic or indirectly by stimulating recipients' white cells to produce pyrogenic mediators. post storage leucoreduction (lr) has reduced the fnhtr in these patients from % to . % per unit. it is unknown whether introduction of prestorage leucodepletion (ld) has reduced the incidence of nhftr further. we analyzed the immediate transfusion reactions of adult patients with b-thalassaemia major transfused with a total of . rbc units from january to december . all units were fresh, stored less than days. . units were lr-rbc, . units were ld-rbc and . were washed lr-rbc. results: the incidence of fnhtr and allergic reactions in patients receiving lr-rbc was . % and . %/per unit respectively, in those receiving ld-rbc was . % and . %/per unit respectively, while in those receiving washed lr-rbcs was . % and . %/per unit respectively. the relative risk (rr) of fnhrt and allergic reactions following transfusion of ld-rbc and washed lr-rbc compared to lr-rbc is shown in table. conclusion: prestorage leucodepletion and washing of rbcs reduced the risk of fnhrt in regularly transfused b-thalassaemia patients . times compared to poststorage filtration. these findings show that fnhtr after rbc transfusions are due not only to alloimmunization but also to accumulation of bmrs even in patients transfused with fresh rbcs. washing is as effective as prestorage leucodepletion in reducing fnhtr. prestorage leucodepletion has no effect on allergic reactions or other immediate adverse events in these patients. t-pa- viral inactivation/elimination of plasma derived medicinal products the safety of medicinal plasma products (mpps) relies on a whole range of measures from the quality of the source material to the release of the products after manufacturing under cgmp conditions. viral safety relies on careful donor selection, viral testing of the source material and viral inactivation and/or elimination during the manufacturing process. mpp manufacturing processes must include viral safety steps capable of inactivating, and/or eliminating, a large range of viruses covering the known blood borne viruses as well as anticipating possible future pathogens. it is recognized that one single step is often not sufficient to satisfy this requirement and manufacturing processes very often include two or even three complementary viral safety steps. very efficient methods have been implemented by manufacturers, for two decades, for the inactivation of major blood borne enveloped viruses (hiv, hcv and hbv). additional safety steps have also been introduced to provide a second step for enveloped viruses and to extend the efficacy to nonenveloped viruses (hav and parvovirus b ). pasteurisation (liquid heat treatment at °c) which has been historically used for viral inactivation of albumin solutions has been applied to some other plasma products. solvent-detergent (sd) treatment which is specific to enveloped viruses is used primarily for coagulation factors. since the introduction of sd-treated products, no hiv, hcv or hbv transmission has been reported. viral inactivation of coagulation factors can also be achieved using various conditions of dry-heating. acidic treatment is also an efficient means of inactivating viruses in igg products. nanofiltration using filters of less than nm pore size was introduced in the early s. this technique for viral elimination is based on the size of the agent and is independent of their resistance to other treatments. this property could be helpful in cases of new emerging pathogenic agents. new inactivation tech-niques are currently under development such as uv treatment or gamma irradiation with efficacy reported on enveloped as well as non-enveloped viruses. these new techniques can complement existing methods after careful validation that they do not have harmful effects on proteins in the product. the efficacy of existing techniques is well documented in controlled clinical studies and pharmacovigilance records. their application to each product is extensively validated at laboratory scale, according to international regulations and then carefully evaluated by health authorities. in this context, a recent european guideline established a viral risk assessment model to quantitatively estimate the theoretical safety margins of mpps, by taking into account the different safety measures, such as viral testing of plasma and the efficacy of viral inactivation/elimination steps. whilst technical limitations and some lack of scientific data lead to very conservative estimates, this model gives an overall assessment of the efficacy of the measures in the manufacture of a given product. developments in viral inactivation/elimination methods, in plasma testing as well as in evaluation procedures have together given mpps an excellent level of safety never previously achieved. to date the important safety measures needed to ensure a high safety margin to pooled plasma products are well understood by the plasma fractionation industry. safety nets rely on carefully done: donor selection to exclude high-risk donors, serological and nat viral testing of single donations and, pooled plasma testing using sensitive validated methods, and most particularly, efficient viral reduction treatments that must be validated and implemented at a large-scale following good manufacturing practices. over the last years, successive key breakthrough in plasma product viral safety have included the use of solvent-detergent treatment to inactivate lipid-enveloped viruses, and nat testing of starting plasma pools and viral nanofiltration of products to reduce the risks associated to small non-enveloped viruses. the excellence of the system currently in place is illustrated by the demonstration that these safety barriers have virtually stopped the transmission of known viruses and avoided that of 'emerging' agents, such as west nile virus (wnv). however, multiple viral reduction treatments have generally decreased product recovery. in addition, although the implementation of viral reduction treatments have forced fractionators to introduce significant changes to product manufacturing methods, this period has been understandably followed by a period of relative conservatism of the plasma fractionation industry against further process changes. as time evolves and market dynamics changes struggle for improved economic balance of the plasma product industry is putting product recovery and diversified product portfolio at the forefront of r&d objectives. these developments in the plasma fractionation scene of the western world have been taking place in a context where many patients in the developing world are still treated with sub-standard, non-virally inactivated crude plasma fractions. in this specific area, one can expect that the developing world will bring innovative thoughts and take actions to find ways to improve the quality and safety of their own local plasma product supply. safety strategies adapted to the infrastructure and economy of less solvable countries may have to be considered. the intercept blood system for plasma uses a synthetic psoralen, amotosalen hcl, and long-wavelength ultraviolet light to photochemically inactivate a broad spectrum of bloodborne pathogens in plasma intended for transfusion (intercept plasma, i-ffp). phase clinical trials have shown that i-ffp retains proteins necessary for hemostasis in the treatment of acquired and inherited coagulopathies, and in support of therapeutic plasma exchange for ttp. a prototype plasma processing set was used for the clinical trials. for commercialization, a new processing set has been developed to improve productivity. the prototype set accommodated approximately ml of plasma, whereas the improved set accommodates up to ml of plasma, resulting in up to three i-ffp doses per treatment. aims: this study was designed to characterize pro-and anti-thrombotic proteins in i-ffp prepared using the improved processing set. proteins of interest included components of the intrinsic and extrinsic coagulation cascade, the fibrinolytic pathway, the contact factor pathway, and the complement system, the vonwillebrand complex, endogenous inhibitors, and markers of thrombin generation. methods: six fresh jumbo ( ml) apheresis plasma units, collected using the haemonetics pcs device (gambro), were photochemically treated. sodium citrate was used as the anticoagulant. plasma samples for analysis were collected before and after photochemical treatment, and were frozen below - °c until batch analysis. standardized clinical assays were used for all analyses. results: (results in the table below are expressed as the percent activity in i-ffp in proportion to the activity in plasma before treatment [mean ± sd]). retention of procoagulant factors in i-ffp plasma ranged from % to %. factor viii and vonwillebrand factor activity, antigen, cleaving protease activity (vwf : cp, adamts- ), and multimeric composition remained within normal ranges after treatment. endogenous inhibitors of coagulation were retained % to %. plasminogen and alpha -antiplasmin were retained % and %, respectively. retention of contact factors was variable; some factors were below the reference range prior to pct. with the exception of tat, all markers of coagulation activation were well within normal ranges. the tat level in one i-ffp unit was slightly above the normal range; all other units had tat levels that were well within the normal range. the significance of this is unclear. cept plasma is similar to conventional plasma. the improved processing set, intended for commercialization, allows up to doses of i-ffp to be produced from a single photochemical treatment. background: guidelines of the european directive / /ec require that fresh plasma prior to freezing contains < residual rbcs per litre. this rbcs content is below the sensitivity limit of the automated cell counters used in routine laboratories. aim of the study: it was therefore essential to make available an alternative method to detect and quantify rbcs in plasma. we implemented a method by flow cytometry using a pe conjugated anti-glycophorin a (gpa) monoclonal antibody that recognises rbcs and erythroid precursors. to quantify residual rbcs in fresh plasma, the method uses the same trucount test tubes (becton dickinson) as those used to quantify wbcs and that contain a known number of fluorescent beads. after addition of plasma and pe-gpa antibody, cell counting is performed on flow cytometer (bd facscalibur). validation of the method: assessment of accuracy, linearity, and reproducibility with different pe-gpa antibodies (immunotech and pharmingen) application of the method: quantification of rbcs in fresh plasmas divided into groups: group : plasmas from leucoreduced whole blood, group : plasmas from packed cells after removal of buffy coat and specific filtration, group : : apheresis plasmas. results: validation of the method: for both anti gpa antibodies, detection threshold is . ¥ residual rbcs/l; linearity study with concentrations of . , . , . , . , . , . , and . ¥ rbcs/l showed excellent correlation between observed and expected values (r > . ); reproducibility study showed c.v of respectively . % and %. for values > ¥ rbcs/l, it appeared necessary to introduce a correction factor of . for the anti gpa pharmingen. quantification of rbcs in plasma: group (plasma from leucoreduced whole blood): . ± . rbcs/l; group (plasma from packed cells after removal of buffy coat and filtration): < . °¥ rbcs/l in all the cases; group (apheresis plasma): < . °¥ rbcs/l in all the cases. conclusion: quantification of rbcs in plasma by flow cytometry is a precise, quick and reproducible test. in addition this study shows that even if there are differences in residual rbcs counts according to the origin of plasma, the obtained values are much lower than regulatory requirements. . improving basic transfusion knowledge amongst health workers; . improving pre-operative preparation for surgery . strategies such as cell salvage autotransfusion combined with a conservative transfusion strategy for the use of allogeneic blood. my presentation will outline the approach adopted to ensure that the use of cell salvage autotransfusion both improves the use of allogeneic blood and preserves allogeneic stores. well-organised training can both minimise the risk of using such advanced techniques and decrease the overall risk involved in undergoing surgery where blood loss may be a significant factor in increasing morbidity and mortality. the various training methods employed to improve knowledge in this area will be described. the increasing current perception that the safety of allogeneic blood transfusion has dramatically been improved during the last decade is challenging autologous haemotherapy methods. in addition, growing concern about the unfavourable cost-effectiveness of most autologous haemotherapy methods requires a refinement of the application of these measures to well defined circumstances. in contrast, newly emerging transfusion-transmissible infections or periods of blood shortage might revive interest in these blood sparing techniques. the first two cases of transfusion transmitted vcjd provide a paradigm for this scenario; not so much with respect to a public fear of infection but rather a waning donor population due to more rigorous recruitment criteria. preoperative autologous blood donation (pabd) still plays a significant role in settings with high individual benefit for the patient, high transfusion probabilities and when all opportunities of cost minimization can be applied. adjustment to the individual situation of the patient is the main aim of a medically reasonable and economic use of autologous haemotherapy. this implies consideration of the patient's haematocrit, blood volume, tolerable blood loss, expected blood loss, etc. in order to choose the optimal method in the individual case. in this respect, double red cell apheresis may play a significant role. with this approach, donation schedules assumed to enhance erythropoiesis can be adopted. moreover, inconveniencies caused by long distances between patient home and donation service can be facilitated by withdrawing two red cell units during one session in selected patients. in conclusion, red cell apheresis can be used to promote the proposed approach towards individualized autologous haemotherapy preoperative plasmapheresis is considered to be a sensible adjunct if intraoperative retransfusion of salvaged and washed red cells is planned. acute normovolaemic haemodilution is valuable when the patient's tolerability of the haemodilution and the expected blood loss are carefully examined beforehand. intraor postoperative salvage of wound blood can also be regarded as useful measures to prevent allogeneic transfusions as long as the specific advantages and disadvantages of the different methods are taken into account. finally, alternative and supplemental measures such as iron or erythropoietin administration should always be considered in order to optimize the efficacy and effectiveness of autologous haemotherapy methods. the goal of a 'bloodless medicine' might not be reached but is supposed to be approached closely with an integrated concept exploiting all measures available. however, in times of restricted health care resources, regular sound costeffectiveness analyses, taking the availability and the cur-rent safety profile of allogeneic blood products into account, are always warranted and needed. compensatory fluid replacement of surgical blood losses: the transfusion of allogeneic blood is expensive and -although safer than ever before -still associated with potential complications. to reduce both, costs and immanent risks, allogeneic transfusion should either be completely avoided or at least minimized during surgical procedures. as a consequence an intraoperative blood loss is initially not replaced by red blood cells, but by erythrocyte-free, i.e. cristalloidal or colloidal solutions. when normovolemia is maintained the resulting dilutional anemia is compensated by an increase of cardiac output and enhanced arterial o extraction. however, once the hb has dropped to values recommended as the lower intraoperative limit, or once compensatory mechanisms of acute anemia become exhausted, as a rule transfusion of red blood cells (rbc) is initiated to increase arterial oxygen content (cao ) and to preserve a margin of safety for tissue oxygenation and organ function. as an alternative to immediate rbc transfusion, ventilation with pure o (hyperoxic ventilation) can be employed to rapidly raise cao by increasing the amount of physically dissolved o in plasma (hyperoxia). however, molecular o causes vasoconstriction, mediated by products of the arachidonic acid metabolic pathway. as a consequence hyperoxia has been shown to increase systemic vascular resistance and to decrease cardiac output and o consumption in subjects with normal hemoglobin concentration ( properly scheduled, three women who did not reach the necessary hct level after the first donation and consequently they got out of the protocol, and one woman who had unexpected intraoperative bleeding and received homologous units in addition. the patients undergoing tkr and the patients undergoing removal of implants predeposited and units respectively, but finally and of them have been used. according to our patients data, the . % of unused autologous blood units belongs to patients with tkr and implant removal. therefore a better schedule is needed for these type of surgery. all the autologous donors were supported by oral iron supplementation throughout the predonation and month past surgery. fourteen of our cases were supported by erythropoietin s.c. in a dose of iu/kg every other day. the majority of these patients was female, only one was male with multiple alloantibodies and was scheduled to predonate autologous units. all of them underwent thr except one woman who also had a tkr months later. the autologous blood donation was well tolerated by all patients and only one woman had a reaction during predonation. furthermore a group of patients matched for age, sex and type of surgery, who did not predeposit blood, received a mean of . homologous units per patient, that is more than the patients on pabd program. our results show that autologous transfusion can be used in scheduled orthopedic surgical procedures and can reduce the need for homologous blood. however, every effort should be made to render the practice of pabd more efficient and to minimize its costs. colloid solutions and their establishment in clinical practice background: various situations like trauma, critical ill patients, sepsis, major surgical procedures and anaphylactic reactions are associated with disturbances in fluid homeostasis. this disturbance is related with reduced oxygen delivery, subsequent lactic acidosis and imbalance in oxidative status. the final result will most likely be an increased mortality and morbidity. aim: the important issue from clinical aspect is to define the optimal volume and type of fluid therapy. the debate for the ideal resuscitation solution lasts a couple of decades due to inconclusive and conflicting results. method: we searched the literature for clinical trials and major met analyses concerning patients undergoing scheduled surgical procedures, trauma patients and critical ill who received resuscitation fluids. results: dextrans reduce blood viscosity and von willebrand factor levels more, for the same degree of hemodilution, compared to other plasma expanders. in clinical setting they are effective in reducing the incidence of deep vein thrombosis and pulmonary embolism. after the initiation of dextran for prophylaxis against anaphylactic reactions, they are considered the safest plasma substitutes, except maybe during pregnancy. dextran % is the most like to cause the 'hyperoncotic acute renal failure' syndrome. gelatins also cause a decrease in circulating levels of vwf : ag, vwf r : co, thrombin-antithrombin complexes and f + . in clinical aspect however, there are contradicted results about the effect of gelatins in bleeding diathesis, although they appear to exert a greater effect on rbcs protection from mechanical stress. in respect to anaphylactoid reactions, they have the greatest relative risk. hes has the same effectiveness in volume expansion with albumin and has the advantage of remaining intravascular even if there is an increased capillary permeability. in addition, it may improve splanchnic blood flow and tissue oxygenation. hes / . subsides the inflammatory response in patients undergoing major surgery, compared to a crystalloid-based volume therapy, but has conflicting results about it's effects on neutrophil respiration burst. clinical trials have so far failed to have a unanimous conclusion about the bleeding diathesis after hes administration, especially. caution must be held when administering hes during renal transplantation. albumin became the scapegoat of transfusion strategy during the past years. resent met analysis have contradicted results about the safety of albumin infusion in variouw settings. a positive effect seems to have the early administration of hypertonic solutions in trauma patients, especially in combination with dextrans. conclusions: although some minor conclusions can be extracted, there is still a great lack of large scale multicentre randomized prospective clinical trials for extracting evidence based criteria. instead, we try to extract conclusions through met analysis. results show no evidence that resuscitation with colloids reduces the risk of death compared with crystalloids in patients with trauma, burns, major surgery or sepsis. also, there is lack of evidence that one colloid solution is safer -in clinical aspect -than any other. recombinant human erythropoietin therapy in critically ill patients -a dose response study* objective: the aim of our study was to assess the efficacy of two dosing schedules of recombinant human erythropoietin (rhuepo) in increasing hemoglobin (hb) level and reducing the exposure to red blood cells (rbc) transfusion in critically ill patients. design: a prospective, randomized, multicenter trial. patients: a total of patients who met eligibility criteria were enrolled. intervention: patients were randomly assigned to receive intravenous (i.v.) iron saccharate alone (control group), i.v. iron saccharate and subcutaneous rhuepo units once per week (group a) and i.v. iron saccharate and subcutaneous rhuepo units three times per week (group b). rhuepo was given for a minimum of weeks or until icu discharge or death. the maximum duration of therapy was weeks. the requirement for rbc transfusions was significantly higher in control group than that in group a and b. no significant difference was observed between group a and b. the mean increase in hematocrit (dhct) and hb (dhb) from baseline to final measurement were significantly higher in group b than these in control group. dhct was significantly higher in group b than that in group a. dhct in group a was significantly higher than that in controls, whereas dhb did not differ significantly between control and group a. conclusion: administration of rhuepo in critically ill patients significantly reduced the need for rbc transfusions. the magnitude of the reduction did not differ between the low and high dose of rhuepo, whereas there was a dose response of hct and hb to rhuepo in these patients. in transfusion medicine, antibodies to antigens in the platelet membrane have traditionally been regarded as less significant compared with antibodies towards red cell antigens. there is an increasing awareness of antibodies towards platelet antigens. detection of autoantibodies to platelets can be a diagnostic challenge, but is seldom a problem in transfusion medicine because patients with such antibodies rarely are candidates for platelet transfusions. also, severe foetal thrombocytopenia is seldom present in pregnancies with autoantibodies to platelet antigens. the real challenge in transfusion medicine is related to patients with severe thrombocytopenia who are refractory to platelet transfusion due to alloantibodies towards platelet antigens. in our department, flow cytometry is used for compatibility testing and the choice of compatible blood donor is done without knowledge of antibody specificity. if crossmatch negative random donors cannot be identified, antibody specificity testing is performed and donors are chosen based on the specificity of the antibodies determined by a modified maipa procedure and with hla class i beads (flowpra from one lambda, usa) in flow cytometry. in some cases both hla class i and human platelet antigen (hpa) specific antibodies are detected and hla class i, hpa matched donors are chosen for crossmatch. if the crossmatch is negative, there is > % chance of successful transfusions. in some cases drug induced anti-platelet antibodies are suspected and flow cytometry based antibody tests are performed in the presence and absence of the drug. in the case of suspected heparin induced antibodies, a beads assay is performed (diamed, switzerland). two percent of caucasian women have the platelet type hpa bb. ten percent of these women make anti-hpa a antibodies in their first hpa a incompatible pregnancy. in - new-born has thrombocytopenia due to maternal alloantibodies which have crossed the placenta (neonatal alloimmune thrombocytopenia, naitp). results from a screening study covering the outcome of pregnancies show that only babies were born with intracranial haemorrhage (ich) and there was no still-born babies in the study. pregnant women with a-hpa a antibodies were diagnosed, received careful clinical follow-up and the delivery was performed by caesarean section in week of the pregnancy with immediate transfusion of hpa compatible platelets if the new-born had platelet count < ¥ e /l. in previous studies, it is reported the ich appears in - % of the pregnancies where antibodies are present and that % of the babies with ich, die. our results are different from what is reported from other studies and this may reflect the prospective approach and the clinical interventions. naitp represent a challenge in transfusion medicine both diagnostically, but also related to compatible blood products for the thrombocytopenic new-born and the mother who may have high level of antibodies towards platelet antigens. methods: apheresis platelets ( ¥ e mean) from donors with same blood group were pooled and divided equally into two bags, po- and control (pl , baxter), which have and ml/m *day*atm of oxygen permeability, respectively. on days , , , , , and of storage, swirling, mean platelet volume, po , pco , ph, glucose, lactate, aggregation, and p-selectin expression were evaluated. six experiments were performed. results: the swirling pattern was preserved better for up to days in po- ( / ) than in control ( / ) bags. dropped ph less than . on day was observed / in po- whereas / in the control. aggressive drop of glucose ( mmol/l) with prominent lactate accumulation ( mg/l) was also observed on day in of control bags. the po level in the control dropped more significantly by % ( . mmhg) on day than in po- ( . mmhg) compared with the initial level ( . mmhg) (p < . ). these results suggest that aerobic metabolism of higher concentration platelets was maintained better in a container with higher oxygen permeability. and less lactate generation with slower glucose consumption is also suggested in po- bags than in control bags. the %hsr and aggregation decreased gradually in a similar manner in both bags until day , and became a detrimental defect in of control bags on day . p-selectin expression was higher in control bags than in po- on days and with no statistical difference. in two control bags p-selectin expression reached > % and was accompanied by a loss of swirling. these functional and biochemical characteristics of platelets at a higher concentration were kept better for - days when stored in a container with higher oxygen permeability than in the best of marketed containers. t-pa- background: maintenance of a neutral ph in the range of . - . is essential for preservation of platelet function and viability during storage. furthermore, studies have also indicated that the presence of glucose in the platelet suspending medium is important for maintenance of platelet quality. however, a platelet additive solution (pas) containing glucose having a ph of . - . cannot be manufactured by steam sterilization due to caramelization of glucose. in order to have optimal ph, the currently available pas such as t-sol does not contain any glucose. this study describes a novel twostep approach to provide a glucose containing additive solution (pas-g) by using an acid, glucose containing electrolyte solution (ph . ) for resuspension and processing of the pooled buffy coats (bc), followed by transfer of the processed platelet concentrate (pc) into a storage bag containing bicarbonate for ph neutralization and maintenance during extended storage. aim: compare the platelet quality of pooled bc pc stored in pas-g with pooled bc pc stored in t-sol. methods: a paired study design was used, where a pool of bcs obtained from standard day -old cpd-wb units, was divided into two equal parts: one part was resuspended and processed with a pall leukoreduction system (atsbc) using t-sol, the other part was processed in a similar manner with the acid part of pas-g. percentage plasma carryover ranged from - %. both processed pc products were transferred and stored in elx tm bags with the pas-g pc elx bag containing a bicarbonate tablet. ten replicate studies were performed. results: the yields ( . ± . vs. . ± . °¥ e ) were similar (pags vs t-sol). statistically significant (p < . with paired ttest) improved platelet quality at days , , and of storage was observed with platelets stored in pas-g as compared to t-sol. the table below shows results at and days of storage for ph, extent of shape change (esc) and hypotonic shock response (hsr). the results for t-sol stored platelets correlated highly with initial glucose (% plasma carry over) level (r = . for esc, and r = . for hsr at days storage), while no significant correlations were found for pas-g stored platelets. conclusion: this study demonstrated the practicality of using a two step procedure to store bc pc in a glucose containing additive solution with neutral ph during storage, and confirmed the importance of glucose in the storage medium as nutrient for optimal platelet storage quality. the effect of irradiation on white cell reduced platelet concentrates, stored for days background: the storage of white cell (wbc)-reduced platelet concentrates (pcs) can be extended from to days provided the quality has been validated and bacterial screening is performed. irradiation up to gray (gy) does not affect platelet quality, but the effect of pre storage irradiation with subsequent storage up to days is not known. method: two wbc reduced pcs, each made from buffy coats and a unit of plasma, were pooled and divided into control group 'a' and study group 'b' . pcs in group 'b' were irradiated immediately after preparation with gy. pcs in both groups 'a' and 'b' were then stored on a continuous flat bed shaker at - °c. swirl, ph and cd p expression were determined on day , and . twelve experiments were performed and compared with a paired t-test, p < . was considered significant. results: see table (day values; mean ± sd; n = ). pooling and dividing of the pcs was successful with respect to volume and platelet number. on day , the ph in group 'b' was slightly lower than in group 'a', but the difference is not significant. in group 'a', ph on day was < . in / pcs, versus / in group 'b' (not significant). the cd p expression in irradiated pcs is not significantly higher than in non-irradiated pcs. conclusion: irradiation had no significant effect on platelet quality when stored for up to days after blood collection. - b, - a, - b, pra %, donors. in patient -three transfu-sions were effective (two crossmatches neg by lct and pift, one pos lct, neg pift) but later on, when the patient was in severe clinical status (shortly before his death) two transfusions were ineffective in spite of neg crossmatches. it is very likely that for the same reason patient and were refractory to two and one hpa compatible platelet units respectively. in patient and compatible platelets were not transfused because they died before the whole procedure (diagnosis and finding a proper donor) was completed. conclusions: . the frequency of occurrence of anti-hpa antibodies in transfused patients was: - b, - b, - b, - a, - a; in three patients they were monospecific, in four polyspecific. . in patients who developed anti-hpa alone, transfusions of platelets without relevant hpa antigens were successful. .the effectiveness of compatible platelets in patients with both anti-hpa and -hla was more difficult to assess because of their severe clinical status, which might have been responsible for transfusion failure. in one of these patients, however, the transfusions of compatible platelets were successful when he was in relatively good clinical status, but shortly before death transfusions were ineffective. t-pa- the successful implementation of nucleic acid testing (nat) for hiv, hbv, hcv and further viruses as well as improved donor selection led to a dramatic risk reduction for viral transmission via blood transfusion over the last years. today, other risks get into the focus of haemovigilance. bacterial contamination of blood products can occur via the donor, suffering from a (clinically unapparent) bacterial infection, or via the donation process itself, storage and handling of the blood product. particularly platelet concentrates (pc) are vulnerable to bacterial growth due to their storage conditions. patients receiving such products have a potential risk of severe complications or even death. modern hygiene regimes, e.g. improved disinfection of the donors´ skin or preparation of blood products in fully closed systems as well as diversion, led to a significant reduction of bacterial contamination risk in the past. however, a small risk remains. therefore, two possible ways of further reducing the risk of bacterial contamination of blood products are feasible: (a) testing and/or (b) inactivation. testing for bacterial contamination is possible by different methods: direct detection methods for bacteria (microscopy, flow cytometry) have disadvantages regarding sample size and detection limit. bacteria might rapidly grow in a contaminated pc, so testing should be performed as close as possible to transfusion to the recipient. biochemical methods like oxygen consumption might not detect anaerobic germs. automated culture methods are still the most sensitive technique, but they have their downsides as well (e.g. time and size of aliquot drawn). novel molecular genetic test methods for detection of bacterial nucleic acid are in different states of development, but still have to proof their suitability for routine use. three different principles of pathogen inactivation can be distinguished: photodynamic reactions produce oxygen radicals which in turn inactivate bacterial structures by oxidation processes. examples for these chemicals are phenothiazines like methylene blue and thionin as well as vitamins like riboflavin (vitamin b ). photochemical reactants penetrate cell boundaries and irreversibly inhibit nucleic acid, thus blocking replication and proliferation of pathogens. chemicals of this group are psoralens like amotosalen as well as pen- or s- . the third method, the solvent detergent (sd) method, is used for pooled plasma only and consists of the combination of both solvents and detergents, which interact with membranes and destroy bacteria. methods for inactivation of bacterial contaminants have to proof, that they effectively inhibit bacterial growth while maintaining full functionality of the blood product at the same time. these two qualities have to be fulfilled up to the end of the storage period. toxic or mutagenic compounds must not remain in the final product. the technology must be easily integrated into the existing work cycle of a blood bank. finally, costs per product must be acceptable. in summary, both testing and inactivation have their advantages and disadvantages, which have to be weighed up against costs and benefits of both procedures. pros and cons of introduction of inactivation methods in a blood donor service producing blood components per year will be discussed. bacterial contamination of blood components, particularly platelets, is now recognized as a serious adverse reaction that is preventable. there are many studies that have documented that these reactions occur from platelets stored at room temperature, most commonly arising from a skin contaminant, but originating from donors with asymptomatic bacteremia in about / of cases. the problem is intensified for patients receiving pools of platelets compared to single donor platelets collected by apheresis. reactions are more commonly noted and more severe with platelets stored for greater lengths of time. previous studies at johns hopkins described a series of reactions in years with reactions more common in platelet pools ( : transfusions) than with single donor platelets ( : transfusions). these reactions caused fatalities in of cases. although our data suggests that these reactions are more common than other studies using hemovigilance systems, our case definition requiring culture of all transfusion reactions to platelets led to a more reliable estimate of the incidence of sepsis from platelets, many potential solutions have been proposed to prevent these reactions. improved skin antisepsis should always be sought but will never eliminate the / of reactions due to asymptomatic bacteremia. the same limitation applies to methods that divert potential skin plugs from the collection bag. antibiotics in the bag would lead to manufacturing concerns or problems for patients with drug allergies. although cold storage of platelets is currently being revisited, it is not yet a practical solution. pathogen eradication systems have been developed but they remain unapproved in most of the world and have led to concerns about toxicity of additives, damage to treated cells, and cost. as a result of increasing recognition of the problem, there has been increased interest in bacterial screening to prevent sepsis from platelets. in march , the aabb standards required testing of platelets for bacterial contamination. testing programs have been implemented in the us widely as a result of the aabb action. licensed systems based upon bacterial culture or growth characteristics are available for single donor platelets and have been commonly employed. although these systems have some difficulty with false positive reactions, the evolving national data suggest an incidence of : true positive reactions. these data suggest that a number of serious reactions have been averted, although some cases have persisted due to incomplete adoption, problems with slow growing bacteria, or the use of inferior testing methods with inadequate sensitivity. whole blood derived platelets have become a more difficult issue, since the approved testing methods are limited. the use of ph monitoring, gram stain, glucose measurements, and inspection for swirling have all been attempted. these methods are not sufficiently sensitive or specific to interdict many contaminated units, so that screening for bacteria in pooled platelets is less effective. it is anticipated that new methods may become available to make screening of whole blood derived platelets easier to perform in a reliable manner. it is also hoped that bacterial screening of platelets may form the basis to permit seven day storage and prestorage pooling in the us. results: twenty four hcv rna (+)/anti-hcv(-) repeat donors were previously tested in routine hcv rna in mini-pools and were negative. twenty available look back samples were individually tested for hcv rna and in one the virus was detected. to make sure that the failure of hcv rna detection in routine nat was not due to the pooling procedure, the hcv rna was tested in undiluted look back sample and dilutions of this sample by hcv negative plasma: / repeats of x dilution and / repeats of x dilution were hcv rna negative, whereas / repeat of x dilution and / repeats of undiluted sample were positive. the results of cobas amplicor monitor (sensitivity iu/ml) were negative, which means that viremia in hcv rna mini-pool negative donation was below iu/ml. in the recipient of red blood cell concentrate from this donation hepatitis c was diagnosed. however, the possibility of pretransfusion hcv infection cannot be excluded as no hcv marker tests were performed before transfusion. the patient and the donor were infected with genotype a. the low hcv viremia (below iu/ml) in the preseroconversion window period was responsible for no hcv rna detection in routine mini-pool hcv rna testing. introduction and aim of the study: bacterial contamination is a life threatening risk of blood transfusion, especially with platelet transfusions. bacterial culturing (bc) of platelets as well as pathogen reduction (pr) reduce the likelihood of such contamination. where the costs of bacterial contamination are far less than the costs of pathogen reduction, the latter will reduce not only the risk of bacterial contamination but also risks of other pathogens. therefore, the question arises whether this additional expenditure can be justified in the light of the additional effect achieved. this question we will answer by cost-effectiveness and sensitivity analyses. methods: the balance between costs and effects of preventing adverse events due to platelet transfusion is assessed using a mathematical model and assuming optimal effectiveness of pr. model parameters and valuations of health states were obtained from literature and information from dutch sanquin blood banks. . while the estimates in comparison to the situation without bc or pr are surrounded with large uncertainties, the conclusion that pr is not cost-effective in comparison to bc is very robust. the cost-effectiveness of bc and pr are very sensitive to the estimates concerning sepsis probability and associated complication rate, the cost-effectiveness of pr relative to bc is not. this conclusion is also insensitive to a wide range of assumptions regarding residual risks and costs associated with hiv, hcv and hbv. the estimates indicate that culturing in the netherlands is cost-effective, even with the deviation bag in place. the estimates however appear to be very sensitivity to the probability of sepsis. a decision to use pr will, after the introduction of bc and the use of a deviation bag, never meet cost-effectiveness criteria. even when assuming perfect protection, the conclusion that it is not cost-effective in comparison to bc is very robust and does not alter when varying underlying parameters within their margins of uncertainty. table) . of cb collection. two collections have been transplanted to date and this represents a . % take-up rate ( . % where a sibling is alive). this compares favourably with the numbers transplanted from unrelated cb banks. dcb collection is therefore at least as efficient a method as unrelated cb collection for transplantation albeit in the limited number of cases where a dcb collection is possible. dcb collection has the benefit of a possible immediate transplant combined with the availability of a sibling donor for future donation of both stem cells and lymphocytes. it is therefore a useful service to provide and complements the work of unrelated cord blood banks. increased yield of mature platelets in cultures of cd -enriched cord blood cells maintained at °c introduction: the future use in transplantation of ex vivo expanded hematopoietic stem (hsc) and progenitors cells will facilitate the transplantation of adult patients and speed up hematologic recovery. also ex vivo cultures of hscs may eventually permit to produce donor-free blood components such as platelets for transfusion. culture of animal cells is routinely done at °c. however there is previous clinical evidence suggesting that hematopoiesis may be more active in hyperthermic patients. we have therefore compared the effect of hyperthermia on the ex vivo expansion and differentiation of cord bloodderived hsc in megakaryocytes (mk) and mature platelets. the cord blood-derived cd cells were cultured continuously at °c or °c for days in cytokine conditions optimized for mk development and maturation. the cultures were regularly monitored for various parameters. results: compared to °c, the cultures maintained at °c produced significantly more total cells ( . fold) and total mks ( fold), and showed accelerated and enhanced mk maturation with increased yield of proplatelets and mature platelets ( . fold). accordingly, the cells cultured at °c contained an increased frequency of cfc-mk ( fold) at day . cultures done at °c and °c were also more efficient than at °c but less than at °c. platelets produced in °c cultures could be normally activated by thrombin. as expected, the cells cultured at °c contained an increased amount of the heat shock protein hsp . control experiments showed that the culture of several cell lines was inhibited or unaffected by the °c temperature. the unexpected resistance of hematopoietic cells to the deleterious effects of heat and the stimulatory effect of > °c temperatures on hsc proliferation and differentiation indicate that the routine culture of normal human cells at °c is a paradigm that needs to be revised. the responsible molecular mechanisms remain to be identified but the observation will facilitate the ex vivo expansion of the progenitors of the mk and possibly other lineages. the synchronous generation of a significant number of mature platelets in vitro will facilitate the study of the mechanisms of platelet formation and ageing and could eventually have important applications in transfusion medicine. it remains to be seen if the stimulatory effects of higher than °c temperatures represent a protective response against sustained body fever that is specific to the hematopoietic system. several countries have, in the past few years, included human tissue banking within a regulatory framework similar to that of blood. indeed, tissue safety has come to the forefront of the preoccupations of regulatory agencies after several well publicised morbidity and mortality cases have been reported in the press. tissue safety has many features similar if not identical to blood safety and a review of those common elements will be reported. as well, arguments in favor of integrating tissue banking within a blood system will be discussed, one of the more important aspect of which being the expertise of the blood centre staff with cgmps. the experience of a blood establishment (héma-québec) with the integration of tissue banking such as bone, skin, heart valves within its operations will be reported, emphasizing the medical as well as the management aspects of such an integration. finally, tissue banking is an activity which brings more expertise to a blood centre, expands its knowledge of its customers and gives more opportunities to its personnel. umbilical cord blood (cb) is an important source of stem cells for clinical transplantation and may cause less gvh disease than non-t-depleted bone marrow (bm). the relatively low numerical cell dose available from cb has usually restricted its use for transplantation in adults. only - % of patients have an hla matched sibling and for others an unrelated bm or a stored unrelated cb donation may also not be available. for some children the collection of cb following the birth of a sibling may be the only opportunity for a transplant. directed cb (dcb) donations from matched siblings have been shown to give better long-term overall results than matched unrelated cb or bm. dcb collection is however not as easy to control as cb for banking where dedicated hospitals and trained staff are used. here we review dcb banking in oxford over a . -year period. requests were received for deliveries from mothers and of these, collections were successful including pairs of twins. failed collection was most often due to a damaged cord at delivery. collections were made for siblings possibly requiring transplant (median age ) with for leukaemia, for erythroid disorders, for immune deficiency, for enzyme deficiency and others. the remaining collections were mostly requested where there was a family history of an inherited disorder (majority scid). three collections tested positive for anti-hcv antibody but negative for hcv by pcr. collections were not excluded on the basis of volume or cell number. mean volume was ml (range - , % exceeded mls) and mean tnc count was . ¥ (range . - . , % exceeded . ¥ ^ ). the mean cd +ve count was . ¥ (range . - . ). all collections were cryopreserved within hours using dmso/dextran/saline without volume reduction. the mean tnc viability prior to freezing was % (range - %) and the mean cd +ve viability post freezing was % (range - %). the reliance on the goodwill of midwives and the logistical difficulties that arise when organising collections from many different hospitals do not appear to reduce the success . rhd and rhce typing was performed by multiplex-pcr with fluorescent primer pairs. positive results were obtained for rhd-exons - , , and polymorphisms associated with antigens c, c, cw, e and e. sequencing of rhce-sequences, including exons to and intron/exon borders, were done by direct taq cyclesequencing using bigdye-terminators v. . in an abi (applied biosystems). background: a number of adverse immune reactions associated with blood transfusion result from contamination of blood products by donor white blood cells. among these reactions, transfusionassociated graft-versus-host disease (ta-gvhd) has a mortality of greater than %. mirasol ® pathogen reduction technology (prt) has been developed for the reduction of viruses, bacteria, parasites and white blood cells loads in blood products. the technology is based on light and riboflavin photochemistry. this study was performed in order to evaluate the effectiveness of the mirasol ® prt process for inactivation of human pbmncs. methods: human pbmncs were collected from trima platelet apheresis disposable sets, purified by ficoll-hypaque discontinuous gradient centrifugation and divided into test and control samples. the test cells were treated with mirasol ® prt in autologous plasma on day . both test and control samples (n = ) were tested on day for cellular immunophenotype, t-cell activation using flow cytometry, proliferation in response to mitogen or allogeneic stimulator cells, ability to stimulate the proliferation of allogeneic responder cells and cytokine synthesis in response to lps stimulation was measured using a cba assay kit. results: although mirasol ® prt treatment did not significantly change the distribution of cd +, cd +cd +, cd +cd +, cd + and cd +cd + human lymphocyte subpopulations there were significant functional change. the expression of the activation marker, cd , was observed in . % (sd = . %) of control t cells upon activation with pma, while only a . % (sd = . %) of the test t cells increased cd expression. proliferation assays showed that h-thymidine incorporation did not increase in the test cells in response to either pha or allogeneic stimulator pbmnc compared to the significant increase in thymidine incorporation levels observed with control cells. the test cells, when compared to the controls cells, demonstrated an inability to stimulate allogeneic responder pbmnc proliferation. the release of il- , il- , il- b and il- cytokines after -h incubation in culture media increased significantly to pg/ml (sd = ), > pg/ml, pg/ml (sd = ) and > pg/ml for control cells, respectively. under the same conditions, these cytokines in test samples remained at background levels of . pg/ml (sd = . ) for il- , . pg/ml (sd = . ) for il- , pg/ml (sd = ) for il- b and pg/ml (sd = ) for il- . addition of lps further stimulated the release of tnf-a, il- , il- , il- b and il- in the control samples, but not in the test cell samples. in vitro studies demonstrate that mirasol ® prt treatment does not change lymphocyte immunophenotype, inhibits tcell activation by pma, abolishes pbmnc proliferative activity, eliminates pbmnc stimulatory activity for responder cell proliferation and suppresses the production of cytokines by pbmnc in both the absence or presence of lps. introduction: it has been discovered that vaccination of dendritic cells (dcs) with tumor antigens is a potential strategy to induce tumor-specific immunity in tumor-bearing patients. aim of the study: the purpose of the study was to investigate whether human monocyte-derived dendritic cells (dcs) were able to present p bcr-abl protein and induce antigen-specific ctl responses in vitro after transfected with total rna of k cells (k -rna). methods: dcs were derived from human pbmncs, which were incubated for days in the presence of gm-csf and il- , and then were transfected with k -rna using electroporation or dotap lipofection. to verify the successful transfection of dcs with k -rna, bcr-abl fusion genes expression of dcs was detected by rt-pcr and western blot. the immune phenotypes of the dcs were analyzed by flow cytometry. the cytotoxicity of ctl was assayed by propidium iodide (pi) staining and flow cytometry. results: it was shown that the bcr-abl fusion gene was detected in the dcs immediately after the transfection, but disappeared hours later, while the cells were expressing p bcr-abl protein and expressing increased cd , cd , cd , hla-dr. moreover, the transfected dcs could significantly promote the t lymphocytes to kill the target k cells. conclusion: human dendritic cells transfected with total rna of k cells in vitro could induce effective p bcr-abl proteinspecific immune responses and be used to induce tumor-specific immunity, which implies potential application of immunotherapy to tumors. appear to be relevant to the clinical response. ivig has a remarkably good safety record for long term administration, however the following side effects have been observed: mild, infusion-rate related reactions such as headaches, myalgia or fever; moderate but inconsequential events, such as aseptic meningitis and skin rash; and severe, but rare, complications such as thromboembolic events and renal tubular necrosis. judicial use of ivig based on results from controlled studies is recommended. t-pl - donor-lymphocyte infusion: transfusion immunotherapy following allogeneic hematopoietic transplantation the notion that bone marrow containing immunocompetent cells is capable of mediating an antitumor effect was determined experimentally almost years ago. subsequently, pooled leukocytes from patients with cml were found to effect responses in patients with advanced leukemia. response correlated with cell dose and with severity of gvhd. in the 's, the graft-versus-leukemia (gvl) effect was defined in the transplant setting using a lethallyirradiated mouse model and splenocyte infusions. such studies suggested that gvl could be enhanced without causing severe gvhd. the era of adoptive immunotherapy in the transplant setting began in the 's with reports of donor lymphocyte infusions (dli) for relapsed acute and chronic leukemias after bone marrow transplant. it is now clear that chronic myelocytic leukemia (cml) in chronic phase is highly susceptible to gvl effects mediated by dli which induce durable remission in - % of relapsed patients. the success rate is % or less in patients with accelerated phase or blast crisis. since dli cell dose appears to be important in this setting, strategies of escalating dose infusions have been investigated to enhance gvl without exacerbating gvhd. unfortunately, the response to dli in relapsed acute leukemia and myeloma is less favorable (< %) and less durable. dli have been used successfully to treat viral infections and virus-associated malignancies following transplant. both unfractionated dli and ex vivo-generated tcell clones have suppressed reactivated cytomegalovirus and eradicated epstein-barr virus-induced lymphoproliferative disease, a polyclonal proliferation of donor-origin b cells that occurs after transplant. where tumor-specific antigens have been defined, efforts to target dli have been undertaken and donor and patient immunization has been investigated. acute or chronic gvhd develops in approximately % of patients receiving dli for relapsed hematologic malignancies and for related, but not unrelated transplants, correlates with the donor t-cell dose. dli-induced pancytopenia occurs in approximately % to % of patients, is generally mild, and transient, but in < % of patients, aplasia is severe and prolonged. complications of aplasia include infection, bleeding, increased transfusion requirements. efforts to limit the adverse effects of dli while retaining the therapeutic effects include insertion of 'suicide genes, ' selection of lymphocyte subpopulations, and targetting lineage-specific minor histocompatibility antigens. available clinical and experimental evidence suggests, that in addition to primary and secondary immune deficiencies, a wide spectrum of immune-mediated conditions could benefit from intravenous immunoglobulin (ivig), including acute and chronic/relapsing diseases, autoimmune diseases mediated by pathogenic autoantibodies or by autoaggressive t cells and inflammatory disorders e.g. an imbalance in cytokine networks. trimar-collected apheresis platelet concentrates (pcs) were exposed to . j/ml uv light in the presence of um riboflavin, followed by storage under blood bank conditions with various concentrations of -deoxyglucose from to mm for days. the control platelets were not stressed by uv light exposure and were stored under the same conditions without -dog presence. all test and control platelets were measured for in vitro cell quality including rates of glycolysis, morphology score and activation levels at days , , and . results: lactate production and glucose consumption increased from . mmol/ cells/h (sd = . ) and . mmol/ cells/h (sd = . ) for control samples to . (sd = . ) and . (sd = . ) for uv-treated platelets, respectively. uv treatment also caused a decrease in ph from . (sd = . ) for controls to . (sd = . ) for treated platelets at day , hsr from % (sd = . ) to % (sd = . ), esc from . % (sd = . ) to . % (sd = . ), swirl from . (sd = . ) to . (sd = . ), and increased p-selectin expression from . % (sd = . ) to . % (sd = . ). addition of -dog up to mm significantly reduced lactate production rate to . mmol/ cells/h (sd = . ) and glucose consumption rate to . mmol/ cells/h (sd = . ), and maintained ph above . (sd = . ) for days of storage. the effect of -dog exhibited a dose-dependent response. however, the addition of -dog had no effects on hsr ( . + . % at day ), esc ( . + . % at day ), swirl ( . + . at day ) and p-selectin expression ( . + . % at day ) during platelet storage. atp contents in both treated and control groups were maintained at a relatively constant level above % of the value seen in fresh platelets. furthermore, an exaggeration of uv-stressed platelet aggregation by addition of -dog was also observed. conclusions: increased glycolytic flux is not a direct cause for platelet morphology changes and spontaneous activation incurred during the development of the storage lesion. the results also suggest that a reduction in glucose utilization may foster an increase in platelet loss during storage. aim of the study: was to evaluate analytical sensitivity, sensitivity and inclusivity for subtypes and genotypes of hiv, hcv and hbv, the assay's effectiveness in closing the pre-seroconversion window period, clinical specificity as well as the effect of endogenous substances and microorganisms on the sensitivity and specificity of the assay. methods: secondary standard traceable to who international standard for hiv- ( / ), international standards for hcv ( / ) and hbv ( / ) were used to determine the analytical sensitivity. sensitivity and inclusivity for hiv- subtypes other than hiv- b, for hiv- and for hepatitis b and c genotypes as well as specificity was evaluated with > specimens. results: results from this study indicate that high analytical sensitivities ( iu/ml hiv- m, cp/ml hiv- o and . cp/ml hiv- , iu/ml hcv and iu/ml hbv) and a specificity of > . % are accomplishable for the mpx test. the % detection rate for hiv- m subtype isolates (a through h) was between to iu/ml, for hcv genotype isolates ( a through ) between to iu/ml and for hbv genotype isolates (a through g and precore mutant) between to iu/ml. investigating seroconversion panels, hiv- rna was detected an average of and days earlier than hiv- antigen with abbott hivag- monoclonal and coulter p antigen tests, respectively, hcv rna an average of or days earlier than hcv antibody with the abbott hcv eia . or ortho eia . tests, hbv dna an average of days earlier than hbsag with the abbott hbsag eia imx test. for all targets, no interference was detected with microorganisms tested as well as elevated levels of triglycerides, albumin, hemoglobin, human dna or bilirubin. conclusion: automated pooling, sample preparation, and real time pcr using the blood screening system taqscreen mpx test is an efficient and sensitive method to simultaneously screen for five important viruses in human plasma. the mpx test is another evolution step in the development of pcr automation by roche molecular diagnostics, and further represents roche's commitment to increasing the safety of the global blood supply. aim of the study: a prospective hemovigilance plan was set up in order to establish a registry for future reference, and to detect any unexpected side effect of ip that may occur with significant frequency in populations and indications that were not studied before and outside of a formal trial environment. methods: this plan is proposed to blood establishments and transfusion prescribers who have already decided to implement ip. this is an observational, non randomized, non controlled plan. no patient selection, inclusion or exclusion criteria are required. all ip transfusions are documented using an internet form, whether or not a reaction is observed. patient population data are collected anonymously, for epidemiological purposes. results: between october and september , apheresis ip units have been transfused in sites and registered in the database. ip platelets were considered leucocyte inactivated and were not irradiated, but were antigen matched as indicated ( . %). the population of patients receiving at least one transfusion (n = ) included . % of males, . % of females, the median age was (range - ). the most frequent broad diagnostic categories were hematology-oncology ( . %) and cardiovascular surgery ( . %). the patients received their transfusions either in regular hospital wards ( . %), intensive care units ( . %) or as outpatients ( . %). the number of transfusions by patient ranged from to (mean . ± . , median ). half of the patients ( . %) had previous transfusion experience and . % had previous history of transfusion reaction. transfusion reactions, defined as any deterioration of the patient's state of health observed following transfusion, were observed in . % (n = ) of the transfusions ( % ci . - . ), and . % of patients. only ( . %) were considered serious. after further causality analysis including biological and clinical investigations by the transfusion physician, . % ( % ci . - . ) of the transfusions were confirmed as having caused reactions in . % of patients, none of them serious. the most often reported symptoms were chills ( . %) and fever ( . %). itching, skin rash or urticaria was observed in . % of transfusions. of the serious reactions, one was hypotensive shock in a patient with liver cirrhosis and haemorrhage, and one was septic shock, in which the platelet unit bacterial culture was negative. none of the reactions occurred in cardiovascular surgery patients. patients were more likely to experience reactions if they had previous transfusion history (odd ratio . , p = . ). the active hemovigilance plan is a valid and feasible method to collect epidemiological data on transfusion safety. the risk profile of ip transfusions appears favorable. quality of theraflex mb-plasma during storage and treatment s reichenberg* and n mÜller † *maco pharma international gmbh, langen, † inst. for transfusion medicine, essen, germany background: although in the last decades thanks to the implementation of several methods like donor selection and testing procedures the risk of virus transmission from plasma has decreased, infection of patients still exists. additionally new viruses like west nile virus enter the transfusion chain. therefore, the treatment of therapeutic plasma with methylene blue (mb) is a technique used in several european countries for pathogen inactivation. macopharma has developed the proprietary theraflex mb-plasma bag system including a mb pill and a final mb filtration step. aims: aim of the study is to show the quality of the mb plasma during the preparation procedure and during storage using the theraflex system. methods: for the preparation process every single step was evaluated using single donor plasma units. for the evaluation of the plasma factors ml were drawn at different stages (before treatment, after plasma filtration with plas , after dissolution of the mb pill, after illumination, after treatment). because the sample volume for single sample measurements would be too low the samples were pooled after drawing and measured for the specified factors. six samples of each stage were pooled at three days. a whole panel of plasma factors was measured for the resulting three pools. global tests: quick, inr, aptt, thrombin time coagulation factors: fibrinogen, factor ii, factor v, factor viii:c, factor ix, factor x, factor xi inhibitors: at iii, protein c, protein s fibrinolysis: plasmin inhibitor, alpha -antitrypsin complement: ch activation: tat, factor xiia, d-dimer stability data were generated using three plasma pools. six plasmas were pooled and afterwards divided into six aliquots. each was treated as single unit and then each was divided into six storage samples. the same plasma factors as for the manufacturing process were evaluated. results: a moderate reduction for some coagulation factors during the preparation was found in the illumination step but not in the other preparation stages. this was mainly fibrinogen ( . %), factor viii ( . %), and factor x ( . %). despite this reduction the values were within the ranges found in non-treated plasma. all investigated plasma factors remained stable during the investigated storage time. summary/conclusions: the investigation showed that plasma treated with the theraflex procedure showed slight reduction during treatment and no reduction during storage. all plasma factors remained within the threshold values. the treatment of therapeutic plasma with mb is a valid technique of pathogen inactivation. validation of intercept treatment of pooled platelets g santos, c silva, f pereira and g sousa lisbon regional blood centre, lisbon, portugal background: intercept blood system for platelets uses amotosalen hcl and uva light to inactivate viruses, bacteria, protozoa and leucocytes that may contaminate platelet products. aims: the purpose of the study was to assess the feasibility of introducing this technology in the routine of lisbon regional blood center (crsl) and validate the procedure in our center. material and methods: whole blood units of ml were collected from volunteer blood donors in quadruple top and bottom blood bags (optipure rc soft t& b baxter), kept in n-butanodiol plates; buffy coats with a volume of ml were obtained in the opipress ii and kept overnight at room temperature before pooling. five buffy coats were pooled with ml intersol using the octopus system intercept buffy coat pooling set with an integrated filter. the pools were treated using the intercept. samples were taken before treatment, after cad remotion, on days , and . the following tests were performed: platelet count, mean platelet volume, ph, swirling. results: all pools met the intercept guardbands. platelet yield pre inactivation was . ¥ ( . - . ¥ ; sd- . ). platelet pool volume was . ml (sd- . ). plasma % was within . % and . %. all pools had leucocytes within council of europe specifications. after photoinactivation the platelet concentrates had . ¥ (± . ). the average platelet loss was . ¥ . the ph was within specifications during all the storage period. conclusions: intercept treatment of pooled buffy coat platelets is feasible in the routine of crsl and in vitro parameters do not show significant changes, allowing us to proceed to clinical use. shown ip and conventional platelets (cp), stored for up to days, exhibit comparable hemostatic efficacy and safety. extension of platelet storage duration to days has the potential to improve platelet availability and reduce outdating and inventory shortages. clinical efficacy and safety of ip stored for days were investigated. methods: a randomized, controlled, single-center, crossover, noninferiority design (pilot) study evaluated efficacy and safety of buffy coat ip vs buffy coat cp, each stored for days. patients were randomized to receive one -day ip transfusion and one -day cp transfusion in random order. after each study transfusion, the hour platelet count, ci, and cci; time to next transfusion; bleeding response; transfusion reactions; and serious adverse events (saes) were assessed. the primary endpoint, -hour cci, was analyzed by a one-sided non-inferiority test for the per protocol population (patients with both transfusions and no major protocol deviations interfering with efficacy evaluation). the per protocol population included patients, randomized to the ip-cp sequence and to the cp-ip sequence. more patients received allogeneic stem cell transplant in the cp-ip sequence than the ip-cp sequence ( % vs %; p = . ). mean platelet dose (¥ e ) was . for ip and . for cp (p = . ). there was a significant period by treatment interaction (p = . ) at the . significance level; therefore, the first period only was also analyzed for the primary endpoint. including both treatment periods, mean (±sd) -hour cci (¥ e ) was . ± . for ip vs . ± . for cp. the mean paired difference for both sequences was . ¥ e (p = . by non-inferiority test; upper bound of the % confidence interval = . ). for the first period only, mean -hour cci (¥ e ) was . ± . for ip vs . ± . for cp) the mean paired difference for the first period sequences was . ¥ e (p = . by non-inferiority test; upper bound of the % confidence interval = . ). the non-inferiority margin for the study was . ¥ e for mean treatment difference in cci (cp-ip). median time to next transfusion was h for ip vs h for cp following the first transfusion (p = . log-rank test; data censored at days after transfusion) and h ip vs h cp after the second transfusion (p = . ). bleeding pre-or post-transfusion was uncommon, usually mucocutaneous, and grade or lower, and responded similarly to ip and cp. no significant transfusion reactions or saes were reported. in this double-blinded, two-treatment crossover study the primary endpoint regarding -hour cci was not met. however, transfusion with -day-old platelets treated by the intercept blood system showed only a marginally and probably clinically insignificantly lower -hour cci compared to -day-old conventional platelets. methods: new zealand white rabbits were transfused with syngeneic blood ( ml/kg), across a major antigen (hgd) mismatch. high anti-s- ab titers (≥ : ) were induced after repeated immunization (days , , , , ) with klh-(s- ) hapten (klhhapten) in complete freund's adjuvant. ab titers against srbc were determined by gel card agglutination, or by facscan with fitc-goat_anti-rabbit_igg. survival of infused rbc ( ml/kg) treated with different methods was assessed by rbc biotinylation. blood samples were taken , , , , and days after transfusion, analyzed using streptavidin_pe and facscan to determine the proportion of circulating biotinylated rbc. results: groups (g) of rabbits were transfused with control rabbit rbc (crbc; n = , g ), or o-srbc (n = , g ). no ab against o-srbc developed after biweekly transfusions over weeks in g rabbits. high ab titers to o-srbc could however be induced by klh-hapten immunization in a different group of animals (n = ; g ). transfused rabbits (g & g ) exhibited no change in hematocrit or body weight and maintained good vital signs. high titer anti-s- abs were then induced by klh-hapten immunization in rabbits from g (n = ) and g (n = ), and in a group (n = , g ) of naïve rabbits. non-immunized rabbits (g , n = ), and (g , n = ) were maintained on the biweekly transfusion schedule of crbc and o-srbc, respectively. all rabbits treated with klh-hapten developed comparably high ab titers. klh-hapten immunization did not affect the viability of crbc in g rabbits. transfusion of o-srbc demonstrated reduced viability in hyper-immune g rabbits, but not any of the g rabbits. g rabbits exposed to o-srbc transfusions prior to hyper-immunization with klh-hapten, had viability of o-srbc comparable to crbc, suggesting induction of immune tolerance by repeated exposure to o-srbc. after depletion of labeled o-srbc from circulation, g and g were transfused with m-srbc. viability of m-srbc in all g rabbits (hyper-immune or not) and the hyperimmune g rabbits was equivalent to crbc circulation in g rabbits. in pre-immunized rabbits with high titer anti-s- ab, o-srbc are cleared faster than control. in contrast, m-srbc survive normally in rabbits with high anti-s- ab titers. repeated transfusion of o-srbc does not result in alloimmunization of naive rabbits. the modified s- rbc process offers the potential for pathogen inactivation with elimination of immunoreactivity and retention of rbc viability. introduction: the bombay phenotype is extremely rare and characterized by complete absence of abh activity both on erythrocytes and in secretions. those individuals can produce anti-h, which is active over a wide thermal range. method: using liss indirect antiglobulin technique, the patient's serum showed + reaction by panel of eleven cells at room temperature phase as well as indirect phase while the auto reaction is negative. a cold adsorption using rabbit erythrocyte stroma was done to remove the cold antibodies from the serum; + reaction of an antibody was detected in the patient serum after five folds of rabbit erythrocyte stroma adsorption. introduction: immunohematology reference laboratory in kuwait central blood bank receives samples from all hospitals in kuwait both governmental and private sector. the laboratory performs the tests according to international standards and it is monitored by internal and external quality assessments on periodic basis. material and method: a tube and gel cards are two methods in the reference laboratory for antibody identification. the laboratory can identify the most commonly encountered clinically significant antibodies and investigates causes of positive direct antiglobulin test that occur mostly in autoimmune hemolytic anemia. there are facilities to phenotype most of rare red blood cell antigens. results: records of all patients investigated in the laboratory since the year are kept in computerized system that has patient's records. central blood bank has the potential to identify rare phenotypes such as kpb-, jsb-, lan-, bombay, rzr , rzr , r¢r¢, r¢r≤, r≤r≤, ge- , , and rare red blood cell antibodies such as high frequency antibodies anti-k, anti-ge , anti-h, anti-lan, anti-kpb, anti-jsb, anti-wrb, anti-ena, anti-csa and low frequency antibodies anti-kpa-, anti-jsa-, anti-dia, anti-lua, anti-cob as well as hightiter-low-avidity antibodies such as anti-chido. samples of rare red blood cells and rare serums are kept frozen either by glycerol or liquid nitrogen technique to be used for pre-transfusion compatibility testing and continuing educational program. purpose of the work: to present the substitution of the blood groups o, a, b, ab in abo blood group system and rh (d) blood group in rh (d) blood group system in the population in the gevgelija-valandovo region. material and methods: a retrospective analysis was done on the data of following the blood groups o, a, b, ab and d in the blood group system abo and rh in the gevgelija-valandovo region. the asked population are voluntary blood donors, candidates for drivers, patients, pregnant women and newborn children. the period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) was analysed. the examinations were done with two standard methods (on the plate and in tube), to define blood groups from the most represented blood group systems abo and rh in the population. tests were done with different series of commercial anti serum tests from domestic and foreign origin. results: totally . examinees were typified. with o blood group were . ( . %); with blood group a were . ( . %); b blood group . ( . %) and ab blood group were . ( . %) examinees. totally . ( . %) were d positive and . ( . %) were d negative. discussion: the given results from our examinations for the frequency of o, a, b, ab and rh (d) blood groups from abo and rh (d) blood group systems in the region gevgelija-valandovo show that the most present is the blood group a from abo blood group system . ( . %) and d blood group in rh system with . ( . ) form examined population. the results are in correlation with data from the literature for other european nations. introduction: the policy of our center is to transfuse all heamatologic multitransfused patients with their own rhesus and kell phenotype. in addition, thalassemic and young leukemic patients are being transfused with compatible phenotype of the most clinical important duffy and kidd systems while all the other patients receive blood compatible only with abo and rhesus system. nevertheless, it is observed a significant positivity of the indirect antiglobulin test, due to alloimmunization. aim of the study: in this study we tried to evaluate the prevalence of alloimmunization in patients of our region. the most frequent detectable alloantibody remains the anti-d, with high prevalence . % of anti-d in females versus . % in males, due to alloimmunization during the pregnancy. as a consequence, the high incidence of anti-d is not transfusion related and anti-e is evidenced to be the most frequent transfusion related alloantibody, followed by anti-kell. care must be taken in order to transfuse as more patients as possible with their own phenotype regarding, at least the most immunogenic antigens, like anti-e and anti-kell. severe hemolytic reaction due to anti-j k background: red blood cell alloantibodies directed against antigens of the kidd system are notorious for causing delayed hemolytic transfusion reactions. the antibodies are formed because of pregnancy or transfusion. blood donors with the red blood cell (rbc) phenotype jk(a-b-) are extremely rare in the white population and exhibit a frequency of less than . %. however, the rare phenotype jk(a-b-) is more common in polynesians ( . %). individuals with jk(a-b-) phenotypes typically form anti-jk with inseparable anti-jka and anti-jkb activity. some jk(a-b-) patients' sera may show an additional distinct anti-jka or anti-jkb component when examined with adsorption studies. case report: a years-old caucasian female with a negative antibody screen, no prior history of transfusion, presented with gastrorrhagia. it is reported four pregnancies with no history of haemolytic disease of the newborn (hdn). on admission, her haemoglobin was . g/dl. she was given units of crossmatchcompatible rbc. on day her haemoglobin was . g/dl, with a total bilirubin of . mg/dl and lactate dehydrogenase of u/l. on th day an unexpected fall in hb ( . g/dl) occurred with an increase of bilirubin to . mg/dl and of lactate dehydrogenase to u/l. a new blood sample obtained for antibody screening and additional crossmatches showed a pan-agglutination and incompatible crossmatch. anti-jk antibody high titer was detected in the plasma by gel-test using liss/coombs cards (id-diamed). the dat was negative and the antibody reacted equally with jk(a-b+), and jk(a-b+) panel cells (jka: / and jkb: / ). other alloantibodies could not excluded, because jk(a-b-) cells are not available. she was started with erythropoietin-a (epo), folic acid, fe iv and high dose intravenous immunoglobulin (ivig). the epo was discontinued after four week of therapy when the haemoglobin was g/dl. two months later her haemoglobin was . g/dl and anti-jk was present in the same titer. a year later her blood cell count was normal and the anti-jk was detected in a lessened titer ( / ). no additional distinct anti-jka or anti-jkb component was shown after two adsorptions at °c using carefully selected phenotyped red cell compatible with patient's rh, fy, mnss, lu, le system and jka(+) and jkb(-), but two additional alloantibodies anti-c and anti-e of low titer ( / ) were revealed. the rare anti-jk alloantibody found in this case displayed the erratic nature of many kidd system antibodies. although anti-jk may cause mild hemolytic disease of newborn, she did not have a history of hdn. our patient was sensitized to a kidd antigen during pregnancy, but showed no serologically detectable antibody until challenged with a massive transfusion following a gastrorrhagia. the use of epo and high dose intravenous immunoglobulin succeeded to avoid transfusion with incompatible rbc unit. background: differential warm adsorption is used in the investigation of patients with red cell autoantibodies for searching of underlying alloantibodies, but it is also useful in the detection of clinically significant alloantibodies in patients with alloantibodies to high frequency antigens such as k, kpb, lub and inb. this technique is especially useful in cases when patients when patient's phenotype cannot be identified due to recent transfusion. purpose: differential warm adsorption is performing on cases presented with an antibody reacting with all red cells of the panel and having a negative auto control test. in these cases, even rare cells panels, which allow the identification of a pan antibody, are available, other more common clinical significant antibodies cannot be excluded. methods and result: case . a years-old caucasian female with preexisting myeloproliferative disorder (polycythemia) presented with pancytopenia. anti-k was detected in the plasma. it is reported two pregnancies and no history of transfusion. the dat was negative and the plasma did not react with one k-cell present on the red cell panel in use. the anti-k specificity was confirmed using additional k-cells. the patient's red cell were group a, d+, k+, k-, c-, e-, fy(a-), s-, le(a-), kp(a-), cw-. she was transfused with two units rbc k-. ten days after the first transfusion the dat became positive and the one k-cell present on the red cell panel reacted with her plasma. two adsorptions were carried out at °c using carefully selected phenotyped red cell (compatible with patient's rh, fy, jk, mnss, lu, le system and k positive). an anti-fya was identified in the presence of ant-k. . an antik (titer / ) was suspected. because k-red cell was not present in the panel in use, adsorptions were carried out at °c using carefully selected phenotyped red cell (compatible with patient's rh, fy, jk, mnss, lu, le system and k positive). after the anti-k antibody was totally removed, no additional alloantibodies were revealed. conclusion: differential adsorption in cases with alloantibodies to high frequency antigens represents a useful application of the technique and helps in the identification of clinical significant antibodies present, allowing a more accurate decision for transfusion. evaluation of validity of the expired enzymetreated . % red cells in antibody identification gel tests using nacl cards p chalkia, s intzepeli, v avgoloupi, a tsoukala, e ntinopoulou and p didoudi ahepa hospital, thssaloniki, greece background: expired red blood cells of required phenotypic profile is often used to identify antibody specificities in patients with multiple anti-erythrocytes antibodies. accurate results depend on the integrity of the antigens. purpose: to validate the expired enzyme-treated . % red cells for use in antibody identification gel tests using nacl cards. the serum of nineteen patients with common specificities antibodies in rhesus, kell, duffy, kidd, and mnss systems tested with commercially prepared . % enzyme treated cells rbc panel (id-diamed). gel tests were performed according to the manufacturer's instructions on in-date rbc and simultaneously on rbc month to months past expiration. reactivity of the expired antigen positive and antigen cells was compared to in-date cells. results: twenty antibodies detected with enzyme treated red cells in neutral gel cards [d( ), c( ), e( ), k( ), cw( )] and were tested with enzyme treated red cells in use and rbc to months post expiration. seventeen antibodies tested with enzyme treated cells gave acceptable results with antigen positive cells to months post-expiration, except anti-k antibodies (negative with k positive cells - months post expiration). conclusion: most rbc antigens studied were detectable months after rbcs expiration date. tests with . % cells were valid in gel test (nacl/enzyme) for at least months after manufacturer assigned expiration date and may be helpful for complex identification studies. studies for more antigens specificities are needed to testify the validity of the expired enzyme-treated . % red cells. background: wr(a) is a low-incidence blood group antigen ( : ) in the caucasian population. despite that anti-wr(a) is a common antibody type, it may cause severe transfusion reactions, haemolytic disease of the new-born. anti-wr(a) may occur as an autoantibody or arise without immune stimulus. we report a case of a naturally occurring anti-wr(a) antibody. case report, methods and results: -year-old non-transfused male patient with acute pancreatitis and severe anaemia had been transferred to surgery from a county hospital. the serological status identified by their blood bank was: b rhd positive, with anti-wr(a) antibody in the serum (cellbind card method). our results: the patient's cells were group b rhd positive (microplate method), dat negative (tube and gel test method). the antibody identification showed positive antibody reaction with all enzyme treated test cells but negative reactions in liss iat (tube test) and gel iat (scangel and diamed). discussion: our routine tests for antibody detection didn't detect any specific antibody in patient's serum. he was transfused several units of blood, that was wr(a) negative and showed negative crossmatch reactions. the patient had no transfusion reactions. days after the transfusion anti-wr(a) specificity was confirmed in the serum with cellbind test. only few test cell panels contain wr (a) positive cells, which are usually not present in commercial screening cells. in our case the cross-match was only performed for this patient because of the detected nonspecific antibody reaction in enzyme. the risk of transfusion reactions caused by rare antigens are particularly high in the type and screen cases. background: according to requirements of the french committee for accreditation (comité français pour l'accréditation cofrac, iso standards), it is essential to use validated and standardised methods in immunohematology. this imposes, among various requirements, the knowledge of metrological tolerances for all the techniques. aim: a multicentre study was carried out to define the maximal acceptable deviations concerning incubation temperature and time, volumes of patient plasma and of tests cells for antibody screening using indirect antiglobulin test (iat) in filtration technique. the antibody screenings were performed manually in blood centres using different filtration systems: id diamed, biovue ortho and scangel biorad, the same tests cells, a standard ng/ml anti rh (provided by cnrgs), a positive control anti kel and a negative control. all equipment used (oven, chronometer, pipettes) were calibrated according to cofrac standards. each antibody sample was tested under the following combined conditions ( tests/sample): results: all the tests of antibody screenings from the multiples combinations of the above parameters gave the same results with a + intensity agglutination for positive samples and the absence of agglutination for the negative control. conclusion: this study allowed us to define a range of tolerance for critical physical parameters involved in the antibody screening in iat using commercial filtration systems maryvonne. the authors present a retrospective study involving blood donors from the university hospital of coimbra during the year . the incidence of weak d and rh (d) phenotype was determined in individuals who were rh (d) negative. the ab and rh(d) blood grouping was performed using a column gel agglutination card (diamed). the rh (d) typing was done using a anti-d polyclonal and a anti-d monoclonal antibodies. all donors that gave negative or poor agglutination results were tested for weak d with an indirect antiglobulin test, with anti-igg (gel matrix card) plus anti-d serum (diamed). within our target group of blood donors the rh (d) negative represented . % of the total sample. we also describe ab , rh(d) phenotype (c, c, d, e, e) group frequencies and establish reliable estimates frequency for weak d and rhesus haplotypes. the background: in s and s several authors tried to assess the relationship between the number od igg molecules per rbc and in vivo haemolysis, but determinations usually concerned small groups of tested patients. some of the investigators suggested that the number of igg autoantibody molecules per rbc was a major determinant of the severity of the haemolysis, whereas others found aiha patients with severe haemolysis and undetectable autoantibodies. aim: presentation of our experience with the quantitative elat performed on a large group of aiha patients during long-term observation. material and methods: six hundred fifty eight blood samples from warm-type aiha patients were randomly tested for the number of igg molecules per rbc. eighty six of the patients were tested periodically from to times at one-month intervals. autoantibodies on rbcs were detected by the direct antiglobulin test (microcolumn technology) and measured by the enzyme-linked antiglobulin test (elat). results: in about / of tested samples the number of igg molecules per rbc was small (< ) and the laboratory signs of haemolysis were present in . % of them as well as in . % samples with moderately coated red cells ( - igg/rbc). the large number of igg molecules per rbc (> ) was significantly associated with high frequency ( . %) of severe haemolysis and it was also associated with presence of multiple igg subclasses on rbcs and c d. in % of patients tested periodically, the number of igg molecules per rbc decreased and it significantly correlated with improvement of haemolysis parameters. in % of aiha patients the number of igg fluctuated and it was a poor prognostic factor. conclusion: in aiha patients the dynamics of the changing number of igg autoantibody molecules per rbc is a more helpful diagnostic and prognostic parameter than the number of igg molecules per rbc evaluated in one test. -b+) , -h-negative (using the anti-h lectin). antibody work-up showed a positive antibody screen (liss and peg-tube methods) reacting + with o rbcs at all phases and + with a rbcs. the direct antiglobulin test (dat) was positive with polyspecific ahg as well as anti-c b,-c d (table ) . prewarming of test system did not change the reactivity ( + at antiglobulin phase). a treatment with dithiothreitol (dtt) was performed and abolished all reactivity of the serum ( table ). autoabsorption of the patient's plasma was performed. the absorbed plasma showed a decrease in reactivity from + to + when tested with o red cells, as well as a significant reduction in antibody titer from : to : tested at immediate spin (table ). the patient remained crossmatch incompatible with o and a rbcs, but was compatible with oh rbcs. summary: we report an unusually strong igm anti-h antibody in this patient, who may require oh phenotype units. the patient is not a para-bombay since her red cells type strongly as group a. the cause for the auto-anti-h remains unknown at this time. if a thermal amplitude test shows that the antibody appears to be clinically significant the patient should receive h-units if transfusion is required. introduction: fetomaternal haemorrhage may determine an alloimmunization, in fact the transplacental passage of antibodies may cause the haemolytic disease of newborn. for this reason, in pregnant women, a screening for irregular antibodies research is routinely performed. however the indirect antiglobulin test (iat) may result falsely positive or negative for various causes, as operative mistakes or low specificity/sensitivity of the used techniques. aim of the study. in this study we have retrospectively evaluated the real incidence of alloimmunizations occurred in women screened by private laboratories. methods: we have studied . women, - years old, resulted iat positive at the first screening and successively assisted by our two hospitals. all women were re-tested, using gel-agglutination technique, for both direct antiglobulin test and iat. results: a positive iat was confirmed only in cases; moreover a rbc autoimmunization was found in women. anti-d ( cases), e ( ), c ( ), k ( ), c ( ), s ( ), d + jka ( ), d + s + e ( ), d + c + k ( ), m ( ), c + e ( ), d + c + g ( ) were the identified alloantibody specificities. anti-s, -e, -k, -c and -jka were the specificities in autoimmunized women. conclusion: in conclusion, a real alloimmunization is occurred only in . % of screened women, while in the remaining cases iat resulted falsely positive: this observation forces us to affirm that, in order to minimize errors and alarmisms, the screening for antibody research in pregnant women must be performed only by immunohematology qualified center. background: one of the problems of the rbc transfusion is the alloimmunisation and the delayed haemolytic reactions (dhtr). besides rhesus and kell systems the antibodies against kidd antigens cause both dhtr and difficulties in their detection. aim and methods: the exact recording of all blood units according to abo rhesus kell and kidd systems. the abo-rh-kell systems are identified through automated microcolumn method (autovue, ortho), while kidd antigens are identified manually using microcolumn gel (diamed). results: the percentage of jka+ and jkb+ found in our department ( . %) and ( %) respectively is similar to that of the caucasian population. conclusions: given the fact that there is lack of available freezing rbc system in greece, detailed recording of all units to the above antigenic systems can be proved extremely useful under circumstances of incompatibility. in the latter case suitable donors can be called and cover the shortage. the identification of all antigentic systems of the donated rbc units is underway. background: in many countries transfusion recipients are currently typed and transfused d-positive, if their red cells are agglutinated by igm monoclonal anti-d that do not react with dvi. the transfusion strategy in weak d patients is not clear defined and it depends on the chosen monoclonal reagents and methods. patients who are carrying dw types , and were prone to develop anti-d. aim: the aim of this pilot study was to estimate capability of commercially available monoclonal anti-d reagents to recognize this weak d types as rhd positive. material and methods: edta anticoagulant blood samples were collected from blood donors, previously typed as weak d positive by indirect antiglobulin test. molecular genotyping of rhd gene and weak d alleles by cde-ssp and d weak-ssp kits (inno-train, germany) were performed. direct agglutination was tested in a tubes and microplates using the following antibodies: rum- , th- , ms- (bioscot/serologicals) and d e / - (immucor). results: out of samples molecular typing results were as follows: in samples dw were not determined, in samples, weak d type ; weak d type ; weak d type , weak d type ; weak d type and weak d type were determined. by all monoclonal reagents % weak d type , % weak d type , % weak d type and % weak d type negative results were given. by all monoclonal reagents weak d type and weak d type positive results were given. conclusion: according to weak d types, which were known to be at risk for anti-d immunization further advances may be brought by improved patient's monoclonal typing reagents with a low and donor's monoclonal typing reagents with high affinity for weak d type , type and type . such improved typing strategies with novel reagents would enhance the transfusion safety. background: vel is a high-incidence antigen found in > % of the population. anti-vel can be igm or igg and reacts optimally at iat, although it can also react at immediate spin and c. anti-vel may or may not cause severe hemolytic transfusion reactions and mild to severe hdn. autoanti-vel has also been reported. the aabb technical manual th edition states that the vel antigen is unaffected by protease and sulfhydryl treatment. we have reason to believe that sulfhydryl treatment may have an effect on the vel antigen as evidenced by a recently referred case. case report: a year-old caucasian female presented with symptoms of anemia and renal vascular hypotension. transfusion history indicated multiple red cell transfusions in . according to the patient, previous attempts to locate compatible units were unsuccessful. the case was referred to our laboratory. the patient's red cells (rbcs) typed as group o, d+ with a negative dat. the serological picture revealed an antibody reacting + - + s at c/liss, as well as at the antiglobulin phase. the antibody reacted with all rbcs tested and the autocontrol was negative. further characterization of the antibody showed similar reactivity using enzyme-treated rbcs ( . % ficin) and no reactivity using . m dithiothreitol-(dtt)treated rbcs. a high incidence negative red cell panel (untreated) was selected that lacked antigens reported to be destroyed by dtt. the antibody reacted with all rbcs tested. additional rbcs were tested that lacked high-incidence antigens, including vel. the antibody did not react with four vel-rbcs tested using liss and peg methods. the patient's rbcs typed as vel-negative. all other clinically significant antibodies were ruled out using vel-or dtt-treated rbcs. based on the unusual reactivity demonstrated by the anti-vel, we tested different examples of anti-vel (frozen in our rare sera inventory) against two sets of known vel+ and vel-rbcs. one rbc set was dtt-treated; the other set was tested neat. liss enhancement was used to test both sets. one of the antisera failed to react with the positive control and one reacted with the negative control. both were disqualified from the study. four of ten remaining antisera demonstrated a decrease in reactivity > grade, between the neat and the dtt-treated rbcs. the remaining six antisera showed no change in reactivity. conclusion: contrary to the statement in the aabb technical manual, we discovered that sulfhydryl treatment ( . m dtttreatment) can have an effect on the vel antigen. our experience has demonstrated that in some cases anti-vel may not react or may show reduced reactivity when tested with dtt-treated rbcs. therefore, the presence of anti-vel should not be ruled out if negative reactivity with dtt-treated rbcs is encountered. additionally, dtt treatment may be a useful tool obtaining rule-outs of other clinically significant antibodies in the presence of anti-vel. additional data is needed to confirm these findings. but with no identified specific antibodies were investigated by repeated screening/crossmatch, papainized panel identification, hla antibody screening by lymphocytotoxicity test (lct) and elisa in some cases. patients' age, sex, department, diagnosis, previous transfusions/pregnancies, techniques, reactions' strength, number of positive cells, urgency, subsequent antibody tests, identification and lct were noted. antibody tests were performed: at pretransfusion testing (pt) by liss-coombs (diamed) and at blood grouping (bg) by biovue polyspecific (ortho) microcolumns -manually in urgency and routinely by sampler iif (diamed) and mitis (ortho) systems. results: investigated reactivity was recorded in samples from patients; ( . %) patients had > episode. these findings comprised . % of unexpected results found at pt and bg. incidences were . % at routine and . % at urgent bg ( and bgs, respectively), and . % both at routine and urgent pt ( and pts, respectively). . % patients were female, . % over , but . % < years, coming mostly from surgery ( . %), internal medicine ( . %), hematology ( . %), ginecology ( . %), cardiac diseases ( . %) and cardiac surgery ( . % patients). frequent diagnosis were solid tumors ( . %), cardiac diseases ( . %), hematologic malignancies ( . %), uraemia ( . %), orthopedic surgery ( . %) and hepatic diseases ( . % patients). . % patients were previously transfused, with only . % patients proved as not transfused or pregnant. subsequently positive antibody test during the study had . % tested patients. at pt positive crossmatch was found in . %, antibody screening in . % and both tests in . % cases. majority of reactions were ' +' ( % at pt and . % at bg); reactions ' +' or ' +' were found in only . % cases at pt, compared to % at bg. one crossmatch only was positive in . % positive crossmatches, with / patients having > crossmatched unit. ahg identification was positive in . % tested patients; in % of them papainized panel was also positive. lymphocytotoxic antibodies were found in . % tested patients; . % ( %- %) of lymphocytes were reactive. finally, the cause of reactivity in antibody tests was determined as 'laboratory mistake' in . %, hla lymphocytotoxic antibodies in . %, 'igg antibodies of unknown specificity' in . % (hla noncytotoxic antibodies in / elisa tested samples!), contaminated sample in . %, anti-bga in . %, non-specific cold antibodies in . %, subsequently recognized specific antibodies in . % ( lua, m, kpa, yka), non-specific autoantibodies in . %, carry-over of dat-positive cells and antibody to reagent in . % cases each, while in . % cases antibody screening and in . % cases crossmatch was repeatedly positive without confirmation in panels. discussion: after introducing of sensitive microcolumns, positive antibody tests without detectable specific antibodies require significant laboratory activities, particularly in older patients with malignancies or surgery. such reactivity was frequently caused by laboratory mistake, but often hla and sometimes specific antibodies were later recognized, or reactivity continued without confirmation in panels. relationships that may be helpful are further discussed in abstract part ii. results: significant differences (p < . ) and relationships of interest were noted. sex. in female vs male patients frequent features were: crossmatch as only reactivity at pt ( . % vs . %), positive lct ( . % vs . %), lymphocytotoxic hla antibodies (lytxab) ( . % vs . %) and reactivity 'positive screening, negative panels' ( . % vs . %); in males non-specific cold antibodies ( . % vs . %) and antibodies to reagents ( . % vs ) were noted. age. in patients > vs < reactivity was often found at pt ( . % vs . %), caused by lytxab ( . % vs . %), anti-bga ( . % vs . %) or 'positive crossmatch, negative panels' ( . % vs ), but rarely by laboratory mistake ( . % vs . %) or later recognized antibody ( of patients). subsequent antibody tests: tests were subsequently positive more often if reactivity was found at pt ( . % vs . % at bg), as positive antibody screening ( . % vs . % if positive crossmatch), with positive panels ( . % vs . % if negative). subsequent tests were positive in only . % patients with lytxab, % with anti-bga, of with antibodies to reagent and in no case with 'positive crossmatch, negative panels' . techniques. lct was positive in % and . % tested samples found at urgent and routine pt (diamed), vs at bg. all cases due to lytxab, of anti-bga and of 'positive antibody screening, negative panels' were found by diamed. at bg (ortho) . % cold antibodies and . % laboratory mistakes were found. positive antibody test: identification was negative in . % screening-only cases; % of them were caused by laboratory mistake. lytxab were found in . % crossmatch-only cases; . % reactivities caused by lytxab were crossmatch-only. identification. ahg panel was positive in % cases with lytxab (in with papainized panel) and often due to 'igg antibodies of unknown specificity' ( . %), anti-bga ( . %), contaminated sample ( . %), but also to later recognized specific antibody ( . % cases). strength of reaction: laboratory mistake was noted in . % of 'w', . % of ' +', . % of ' +' and . % of ' + and +' antibody screenings (ns). diagnosis. in patients with solid and hematologic malignancy reactivity was often found at pt ( % and . % of patients, respectively), due to positive crossmatch ( % and %; and . % patients with liver and cardiac diseases) and caused by lytxab ( . % and . %) or 'crossmatch/screening positive, panels negative' ( . % patients with solid tumors). in patients with liver and cardiac diseases reactivity was often found at bg ( . % and . % of patients), due to laboratory mistake ( % and %) or cold antibodies ( . % and %), respectively. discussion: features of non-specific reactivity depended on sex, age, positive antibody test, diagnosis and, moreover, used techniques, sometimes in very distinctive manner. this analysis might be of considerable help in planning of laboratory tests, but also in quick analysis of unexpected results and choice of further testing, particularly in urgent situations. background: worldwide screen and type is a very usual method for pre-transfusional testing. the ultimate objective is to prevent not only the clinically expressed delayed hemolytic transfusion reactions but also the serologically revealed ones. aim: the aim of this study was to determine the frequency of red blood cell (rbc) alloantibodies in patients undergoing cardiac surgery or cardiac procedure, during the pre-transfusion screening. materials and methods: blood samples of patients ( male and female) were evaluated. the mean age of the patients was years. pre-transfusion samples were examined for clinically significant alloantibodies, using antibody screening with gel test (liss -enzyme). in case of a positive result, identification was performed (panel with autologous control). in addition, the serological testing included cold agglutinins´ detection (tube test), as well as titration (tube test) and identification (gel test) in case of a positive result. when the result was marginal ( / ) a new test was carried out after a seven days period. in the presence of a positive autologous control or an autoantibody, samples were examined with direct antiglobulin test (dat). results: alloantibodies were detected in patients with the incidence of . %. antibodies were registered more frequently in females ( / , . %) than in males ( / , . %). patients ( . %) developed single antibody with anti-kell being the most frequent. the incidence and the specificity of the detected antibodies are summarized in the following table (table ). in patients ( . %) multiple antibodies were detected, with most frequent the anti-d and anti-c combination. patients ( . %) were dat positive. autoantibodies were found in patients ( . %), all of which had specificity to rhesus system. cold agglutinins were positive in patients ( . %). no specificity could be assigned in patients ( . %), while in patients ( . %) non specific reactions in enzyme treated rbcs, were observed. one patient developed delayed haemolytic reaction days post-transfusion, due to anti-jka. the antibody, however, was not detected in the pretransfusion sample re-testing. the frequency of the pre-transfusion detection of red blood cell alloantibodies in our center, was . %. the most frequently identified were the anti-kell and anti-rh. the high rates of unidentifiable antibodies and non specific reactions in enzyme treated rbcs are probably attributed to the kind of medication that most of these patients receive, as well as to the degree of inflammatory process which usually accompanies such diseases. the high frequency of unidentifiable antibodies indicates that a larger and more complex erythrocyte panel would be useful for routine testing. the routine pre-transfusion screening for alloantibodies probably assures the prevention of dhtrs and provides sufficient time for blood selection for transfusion. introduction: in the united kingdom, about % of women form red cell allo-antibodies in pregnancy and . % of all pregnant women produce anti-c. before the introduction of prophylactic anti-d, it was reported that % of the total haemolytic disease of the newborn (hdn) cases were due to anti-c. currently, cases of hdn due to anti-c are half as frequent as anti-d and % of the uk population are rhc negative. we present two unusual cases of pregnant women who are d and c negative and have anti-c and anti-d detected in their serum. case studies and results: case : a -year-old asian woman had three previous uneventful pregnancies. in her th pregnancy she presented with miscarriage at weeks gestation. she was group b, d and c negative. her serum contained anti-c and anti-d. anti-d was detected by liss tube iat and anti-c was only detected by manual polybrene technique ( . iu/ml by quantification using r r cells). in a th pregnancy, no antibodies were detected until weeks gestation when this patient presented in early labour. anti-c was then detected by two-stage papain technique only as well as anti-d. case : a -year-old asian woman had a positive antibody screen post caesarean section in jan . no antibody had been detected during the pregnancy. standard prophylactic anti-d was given at and weeks gestation as this patient was d neg. anti-c and anti-d were confirmed in her serum. the anti-c level was . iu/ml using rr cells and the anti-d level was < . iu/ml using r r cells (prophylactic anti-d ig). she was phenotyped as o r¢r¢. at delivery the baby was found to have a negative dat and was phenotyped as r¢r. discussion: cde/cde (r¢r¢) is an uncommon phenotype in the uk population with a frequency of / . in routine antenatal testing, abo/d grouping is only performed for pregnant women at booking and weeks gestation according to bcsh guidelines. full rh phenotyping is not carried out unless the pregnant women has a positive antibody screen. in routine testing of the above cases, this extremely rare phenotype is missed. prophylactic anti-d was given to both patients and immunisation due to anti-d was prevented. there is currently no prophylactic regime developed to prevent anti-c allo-immunisation by the fetus in pregnancy. antenatal management of patients with anti-c and anti-d during pregnancy can be problematic: (i), problem in antibody identification; (ii) monitoring of antibody level (i.e. quantitation by auto analyser for anti-c and anti-d) with two different cells and ( ) provision of blood during pregnancy, at labour and post delivery for both mother and newborn. study on the frequency of red cell phenotypes (e.g. duffy, kidd and mns blood group system) in our local population l leou, yf wong, mbc koh and d teo health sciences authority, singapore, singapore background: the frequency of various red cell antigens in the caucasian population has been well studied. to date, the frequency of these antigens in the local population composed of a multi-racial mixture of chinese, malay, indian and others is still unclear, especially in the malays with paucity of data in the literature. aims: to investigate the frequency of clinically significant red cell antigens duffy, kidd and mns across the local ethnic groups. to investigate the occurrence of rare phenotypes. to be aware of these rare phenotypes so as to facilitate planning of blood inventories and supplies. typing for the duffy, kidd and ss antigen on blood donors was performed using monoclonal as well as polyclonal anti-sera by manual tube method. a total of blood donor samples were tested using specific anti-sera that will agglutinate red blood cells that have the corresponding antigen. agglutination is demonstrated by the indirect antiglobulin technique. result and discussion: table -a higher frequency of the fy(a+b-) phenotype is seen in chinese, malay and others in contrast to the indian and caucasian population. the clinically significant allo-antibody anti-fya is rarer in our local population. it occurs predominantly in malays and indians and usually in combination with other antibodies. it means that provision of antigen negative blood may be difficult. table -all groups show similarity of distribution of the kidd phenotype with the caucasians and distinct from the american blacks. the jk(a+b-) and jk(a+b+) phenotypes are relatively equal in frequency and there should be no problem looking for such a phenotype in the local population. table -the s-s+ phenotype is most common amongst all races. the indians are more similar to the caucasians with a relatively high frequency of s+s+ phenotype. the chinese and malay distribution are unique with > % being s+. conclusion: there is a unique distribution of red cell antigen groups in the races and the data on malays is especially useful. this data will allow the national blood service in its inventory planning and the potential difficulties of providing antigen negative products due to clinically significant allo-antibodies. miltenberger phenotypes among taiwanese table . conjointly, in order to obtain the frequency of mi.v phenotype, we screened samples among with anti-hil and four additional cases of mi.v were found. conclusion: in this study significant miltenberger polymorphism was seen among the taiwanese population. besides previously described mi.iii phenotype ( . %), there were also mi.i/ii phenotype ( . %), mi.v phenotype ( . %), mi.vi phenotype ( . %), mi.x phenotype ( . %), and most interestingly two miltenberger related not yet classified variants ( %). related variant a ( . %) was phenotypes as mia+, anek+ and hil+. related variant b ( . %) was phenotyped as mia+, anek+. interestingly, both variants were mur-(negative). the total estimated frequency of miltenberger variants in taiwanese population (including related variants a and b) is therefore . % (table ). the discovery of unclassified variants (most likely not yet described in the literature) is of great interest in the field of immunohaematology and warrant further molecular genetic study. introduction: the use of column technologies for the detection of rbc antibodies improved significantly the screen test sensitivity. each column-based method has its advantages and disadvantages. aim: to compare antibody detection by two column agglutination tests; the fully automated ortho auto vue tm method and the manual diamedᮀ id-micro typing system. material and methods: during the study period patient samples were screened, of the positive results were evaluated. blood samples with positive screen tests by the ortho auto vue tm method (av) performed with % cell suspension, and patient samples with antibodies identified by the diamedᮀ system (dm), were reciprocally re-screened, respectively. positive samples were tested by diamed panels for antibody identification. sera samples were divided into categories according to antibody specificity; . rh system antibodies (n = ), . clinically significant non rh system antibodies (n = ), . clinically non significant antibodies (n = ), . auto antibodies (n = ), . not identified (ni) antibodies (n = ), . negative screening results by the diamed technique (n = ). the categories were divided, according to the intensity of agglutination in the screen test, into those exhibiting stronger reactions by the auto vue (av > dm), those exhibiting equal strength reactions (av = dm) and those with weaker reactions by the auto vue (av < dm). statistical analysis was carried out using the wilcoxon signed ranks matched-pairs test. results: a total of samples were compared, . % of them gave stronger reactions by av, . % gave equal reaction strength and . % of them gave weaker reactions by av. positive screen tests by av only were detected in samples, no specific antibodies were identified. in contrast to that, positive screen tests by dm only were detected in samples, were rh system related, kell system related and not identified, results are summarized in the table. discussion and summary: the antibodies detected by dm only, are anti-d and antibodies directed to low frequency antigens. the failure of av to detect rh system antibodies is further sustained by the fact that statistically significant weaker reactions for this antibody system were obtained by av technique. recently ortho-clinical diagnostics modified the screening reagent red blood cells to . % suspension, in order to improve the sensitivity of the method (unpublished data). the possible explanation for the failure to detect low frequency antibodies is that ortho screen cells do not consistently carry the low frequency antigens cw and kpa. positive screen tests detected by av only, can be explained either by the fact that antibody identification was carried out on dm panels, or these are false positive reactions. in order to clarify this question we recently repeated these av only positive samples by the manual ortho bio vue technique. preliminary results indicate that no specific antibodies were detected. it can be assumed that these results are false positive. further study of this issue is required. aim of the study: we have detected blood donor with rohar variant which was mistaken as d-and his donations used for d-recipients. we tested these patients in order to evaluate possible anti-d or anti-lfa immunization. methods: rohar variant was tested serologically (commercial and workshop moabs) and on dna level (pcr-ssp). involved recipients were tested by diamed column agglutination (gliat with normal and enzyme treated rbcs) with commercial rbcs and with rh and rh rbcs. results: rohar variant was confirmed on phenotype and genotype levels. in four d-and two d+ recipients of rohar positive units no anti-d not anti-rh or -rh antibodies were detected. in one case anti-le(a) antibody was found. conclusion: in our cases massive exposition of recipients (whole transfusion unit) by rohar red cells did not lead to production of detectable anti-d or anti-lfa. the immunogenic potential of this variant seems to be low. unusual ab grouping discrepancy -inhibition of anti-b reagent by isolated increase of plasmatic b substance in a patient with group ab and pancreatic cancer m pisacka*, k petrtylova † , m kralova* and h flidrova* *uhkt, prague , † blood bank, faculty hospital m, prague , czech republic introduction: in rare pathological conditions excess amount of blood-group specific substances can be observed and can cause neutralization of grouping reagents. changes in abh and related histo-blood group antigens in malignant tissues were described but there are few information about similar changes in secreted bloodgroup specific substances. aim of the study: we describe a case of isolated increase of b group substance in plasma of a group ab patient with pancreatic cancer. methods: ab grouping was performed with registered immucor reagents (immuclone: anti-a birma , anti-b lb ) by slide and tube tests. neutralizing effect was quantified by (i) inhibition od anti-b reaction by titrated patient's serum; and (ii) inhibition of titrated anti-a and anti-b reagents by patient's serum, compared to ab serum of a healthy donor. results: slide test: unwashed rbcs: group a, washed rbcs: ab. tube test (washed rbcs): ab. titrated patient's serum when added in aliquot to anti-b reagent inhibited agglutination up to titre . titration of reagents /+ aliquot of serum added/: anti-a: titre (both patient's serum and control); anti-b + patient's serum: titre , anti-b + control: titre . conclusion: pancreas is known as rich source of blood group specific substances. malignant transformation is known to be associated with either loss or re-expression of cell-bound abh antigens. reported excessive increase of b substance in group ab patient could be either due to loss of a-transferase activity in malignant pancreas cells or isolated increase of b-transferase activity. further studies on larger groups of pancreatic cancer patients will help to understand this observation. weakened abh reactions of unwashed rbcs could be of diagnostic importance, because in other case this observation preceded several years the pancreatic cancer clinical manifestation. implementation of the autovue innova, an upgraded column agglutination technology (cat) for pre-transfusion testing in a large blood establishment c politis, k armyros, a antypas, v malamou and p katsea g. gennimatas general hospital, athens, greece objective: automated cat testing in a blood transfusion laboratory aims at standardization and savings in labour as well as reagents. a new technology is evaluated in comparison to standard methods. materials and methods: we used column agglutination technology with the innova autovue system, ortho, ratrian n.j. according to the manufacturers this system provides priority to the management of the stat samples while the random access feature of the system enhances the system throughput. it provides an extended test menu as well as automated antibody identification with the red cells panels. the autovue innova system supports the bi-directional communication with the lis interface for all the tests including the crossmatches and it provides a continuous traceability and notifying of the instrument's status concerning either the required and available resources or the proper function of the system's submodules. in this study we performed tests including forward and reverse abo group, rh type and phenotype and kell in randomly selected blood donors, as well tests in haematological patients for antibody screening using an untreated three-cell panel and autocontrol in the indirect antiglobulin test (iat). the results and the time performance (specimen handing, operation of testing and recording of results) were compared with those obtained by the semiautomatic id-diamed gel agglutination microtyping system and by standard manual methods. results: test results showed % agreement between all three methods. samples were tested per min with the autovue innova, compared to min required for the same number of tests performed with manual testing and min with the semi-automated method. the technical execution was easy with the autovue innova procedure and it appears that the consumption of testing reagents is smaller with the automated system comparing with the other methods. computerization of the test results with the autovue innova provides an important advantage in record keeping in the blood establishment. conclusion: standardization of sample collection and tests performance in pre-transfusion testing, as well as computerized records and time saving are advantages offered by the autovue innova, a new automated column agglutination technology, comparing with a semi-automated and the classical manual methods. a heavy workload is expected to significantly decrease time performance. clearance of senescent erythrocytes in young and old individuals al racca, a ensinck, c cotorruelo, s garcÍa borrÁs, l racca and cs biondi universidad nacional de rosario, rosario, argentina introduction: after a lifespan of days, human red blood cells (rbc) are captured and phagocytized by monocytes/macrophages. the accumulation of autologous igg on rbc membrane provides a direct mechanism for the removal of senescent (se) rbc. an alternative pathway, immunoglobulin-independent, with participation of sialic acid, has been proposed. the physiological elimination of serbc might be modified by individual's age. aim of the study: to investigate in young and old individuals, the interaction between monocytes and different erythrocytes suspensions: serbc, rbc stored with or without serum and desialinized rbc. methods: healthy individuals blood samples ( - years old, n = and > years old, n = ) were studied. different suspensions from each sample were obtained: (i) se and young (y) rbc by differential centrifugation; (ii) rbc stored with its own serum (rbcs) and without serum (rbcws); and (iii) rbc desialinized with neuraminidase (ne) and tripsine (t). the suspensions were subjected to the erythrophagocytosis assay: peripheral blood monocytes were incubated with the different erythrocyte suspensions for h at °c. two hundred cells were analyzed to determine the percentage of active monocytes (am) with phagocytosed and adherent red cells. non sensitized rbc (nrbc) and ex vivo sensitized rbc (srbc) were used as negative and positive controls respectively. results: the% of am obtained with old individuals were: serbc: . + . , yrbc: . + . , rbcs: . + . , rbcws: . + . , nerbc: . + . , trbc: . + . , nrbc: . + . ; srbc: . + . . the values of am obtained with young individuals were: serbc: . + . , yrbc: . + . , rbcs: . + . , rbcws: . + . , nerbc: . + . , trbc: . + . . nrbc: . + . ; srbc: . + . . conclusions: no differences in the% of am were found when compared to positive and negative controls, indicating that this assay would not detect variations in the phagocytic activity of monocytes from young and old donors. the values of am with serbc were higher (p < . ) than those obtained with yrbc in both populations analysed. the rate of erythrophagocytosis with serbc in old individuals was significantly higher (p < . ) than that obtained in young donors. the increase observed may be due to agedependent changes of rbc that occur with human ageing. the% of am with rbcs were higher (p < . ) in old individuals. no modifications were observed with rbcws. the significant increase in the rate of erythrophagocytosis with serbc and rbcs show the involvement of autologous igg in the selective removal of erythrocytes. these values were higher in old individuals indicating that this process would increase in aged donors. the tripsine activity was not enough to modify the% am. the values of am obtained with neuraminidase treated rbc were higher than those observed with yrbc (p < . ). however these values were similar between young and old individuals, suggesting that the desialylation would not participate in the increased removal of erythrocytes observed in old donors. cell-cell adhesion is a crucial phenomenon for the relationship between the cell and its environment. therefore, the development of experimental methods to obtain quantitative parameters of cellular adhesion is important. erythrocytes are widely available and their membrane properties are well known, so these cells are used as an ideal model for studying the cellular interaction mechanisms. the study of the formation and break-up of receptor-ligand bonds in sheared erythrocyte suspensions is a subject of considerable importance in the blood circulation, where formation and break-up of blood cell aggregates occur in a variety of physiological and pathological conditions. the main two objectives of this work were to study the cellular adhesion phenomenon using erythrocyte adhesion mediated by monoclonal anti-a antibody as a model and to achieve quantitative values of the parameters involved in the intercellular binding and its possible relationship with cellular deformability parameters. agglutinates of two a erythrocytes (doublets) induced by specific monoclonal antibodies anti-a were used. adhesion energy was indirectly quantified by the study of doublet dissociation under the effect of a given shear stress using a controlled flow chamber system. the chamber was installed on the stage of an optical inverted microscope (union optical, magnification ¥) in such a way that the cover glass was the floor of the microchannel. a ccd (charge coupled device) camera was placed in the ocular tube of the microscope and connected to a digital image processor (ipplus system) to digitize, record and analyze microscopic images. the doublets were initially immobilized inside the chamber, and then put under different shear stress values by a controlled laminar flow during a definite time. in this way, a shear stress parallel to the contact surface between both cells was applied, observing that the upper cell detached progressively with time and also with a gradual rise of the shear stress. the sequential microscopical images were registered and digitally processed, measuring the geometrical dimensions that the cells acquire during the deformation process, and the dissociation of the antigen-antibody bond. digital image processing allows the analysis and the quantification of the red blood cells doublets dissociation phenomenon. these results show that, while the shear stress applied is raised, the contact area between both cells diminishes. the obtained parameters give important information that lead to the estimation of the value of adhesion energy between two red blood cells agglutinated by monoclonal antibodies. as consequence, they will allow the characterization of the antibodies used, since it would evaluate their association capacity with cellular antigens. glycophorins (gp) a, b and c are abundant transmembrane integral proteins in red blood cell (rbc). their highly glycosylated nature and high sialic acid content account for the net negative charge of mature rbc membrane, which is physiologically important because it impedes any tendency to stick together in the circulation. in this study, we have tested anti-gp specific mouse monoclonal antibodies (moab) as primary antibody to directly agglutinate rbc. fret technique has been developed to characterize the hemoagglutination based on the interaction of fluorophores (alexa tm, dio and dii) located in the rbc membrane or combined to secondary antibody directed against the primary agglutining moab. combined intensity (spectral) and lifetime (flim) imaging was used to discriminate the fret signal of molecules on their different lifetimes whereas their emission spectra overlap (alexa tm or dio/dii) as independent phenomena of the fluorophore concentration and photobleaching. furthermore, gp-cytoskeleton interactions were analyzed by d-fluorescence microscopy after lipid extraction with triton x- in red cell. all the antibody used was found to directly agglutinate the human rbc. in view of the fluorescence properties depicted in rbc for the pair of fluorophore alexa- tm (donor) and dii (acceptor), it may be expected that upon agglutination of rbc, effective fret should be observed. flim in dynamic-state provides a discrimination of molecules in their fluorescence lifetime, which allows to evaluate the underlying mechanism of energy transfer process in the agglutinated erythrocytes. the results demonstrate that's upon excitation at nm the flim-fret from alexa tm to dii for the anti-gpb moabs only with a lifetime distribution in the picosecond range. similarly, effective fret was not observed for the anti-gpa moabs. the contrast in measured lifetime image is a reliable indicator for spatial variations in donor-acceptor association. d-fluorescence microscopy images showed interactions between gpc or gpb and cytoskeleton and did not show interactions between gpa and cytoskeleton. all together, these results only revealed by fret-flim and d-fluorescence microscopy strongly support the importance of the specific reactivity with glycophorin a or b of agglutining moab. introduction: the frequency of alloimmunization to red blood cell antigens in transfused sickle cell patients can range from to %, but the development of autoantibodies is much less recognized and descried. aim of the study: in order to evaluate the autoantibody formation and observe the blood transfusion association, we analyzed the direct antiglobulin test (dat) as well as the antibody screening results in transfused sickle cell patients. methods: all the patients included in the study had received at least unit of red blood cell concentrate, on the majority of the cases matched for the c, c, e, e, k antigens. the transfusion range was - units. the dat performed was a polyspecific gel test. in cases of positive dat, was performed the monospecific gel test (igg, iga, igm, c c, c d) . in almost all of cases an acid glicin elution was performed and the eluate was tested against a red cell panel (liss/coombs and papain). an antibody screening by gel test (liss/coombs and papain) was performed in all the patients. the dat was positive in ( %) of the patients. in cases ( %), the dat was igg type, in case ( %) igg + c d and in case ( %) igg + c c + c d. the acid elution was performed in cases. the eluate was positive in cases ( %). in ( %), of the cases, autoantibodies were pointed out whose specificity were specificity public, anti-e (rh ), anti-c (rh ), anti-ce (rh ). in cases ( %) we found alloantibodies whose specificity were anti-e(rh ), anti-k(k ), anti-c (rh ) and anti-jka (jk ). in the cases ( %) no antibody was identified on the eluate and the cause of positive dat is unclear. we could correlate the positive dat with a presence of autoantibodies in ( . %) of the patients. of these, ( %) had a blood transfusion association. the global frequency of red cell alloimmunization in this set of patients was %. seventeen patients ( %) of the patient who had autoantibodies had also alloantibodies associated. conclusion: the mechanism by which erythrocyte antibodies form in association with blood transfusion are not well understood, but even though the medical literature indicates strong association with blood transfusion as well erythrocyte alloantibody formation, we could not find support for this association. the loss of splenic to sickle cell patients could be important because experimental studies suggest that the spleen is involved in the regulation of autoantibody formation. forward and reverse blood grouping with lateral flow based assays p schwind*, i aebischer*, k loester † and p monod* *medion diagnostics gmbh, duedingen, switzerland, † prisma diagnostika gmbh, berlin, germany background: recently, a lateral flow assay for simultaneous typing of abod, rhesus subgroups and kell with stable end-point and without a centrifugation step was presented (loester k, fleischhauer s, schwind p: lateral flow assay for simultaneous typing of of abo, rhesus subgroups and kell. vox sang , (suppl. ), ). in many countries, the determination of isoagglutinins in addition to the red cell antigens is mandatory for abo grouping. aims: to develop a lateral flow test for reverse grouping, supplementing the lateral flow typing assay. a lateral flow device was constructed with a separation membrane equipped in a cassette housing having distinct incubation wells, application zones and detection areas. microliters of % suspensions of reagent red cells for reverse grouping (reverse-cyte a , a , b, , medion diagnostics, switzerland) are mixed in each incubation well with microliters of plasma. the resulting suspensions are incubated for min, followed by the transfer of microliters each to the application zones, where migration starts immediately. results can be read after min in the detection areas. a positive result is recognized as a distinct red dot, a negative result is monitored by the absence of a dot. results: the plasmas of donors, previously determined for the respective blood groups and isoagglutinins by the tube technique, have been tested with this method. the results for both methods were in full agreement. conclusions: a simple, rapid and flexible lateral flow method for reverse grouping is presented, allowing now for the determination of forward and reverse typing in similar formats. both methods give results after min with stable end-points without the need of a centrifugation step and are easily applicable to non-laboratory environments. the performance of the autovuetm system for red cell antibody screening of blood donors during background: in israel every donation is tested for the presence of red cell antibodies (rbc abs). screening is performed on the autovuetm system, using ortho screening rbc since the year . aim: (i) to summarize the performance of the autovuetm system for rbc abs, during years ( ) ( ) ( ) ( ) ( ) . (ii) to evaluate if an initial low positive result, with two negative repeats, could be considered a negative result. methods and results: rbc abs screening was performed using igg cassettes. positive results were confirmed by diamed gel cards, with screening rbc, followed by diamed panels for abs identification. results: summary of the results is presented in the table. (i) in . % of , blood donations that were screened, during - , using the autovuetm system, a positive initial result for rbc abs was detected, which was confirmed in . % ( . % of the donations). an increased percentage of confirmed tests is noted, since , probably due to an improvement in the manufacturing of the cassettes by ortho. (ii) during the validation, samples with low positive results (agglutination degree of . ) were retested twice on the autovuetm. / ( %) gave negative results in both repeats. only / was confirmed positive and anti-m was identified by diamed gel test. the remaining samples had at least one positive repeat. / ( . %) of those samples were confirmed positive. summary: autovuetm can be used as a competent method for rbc abs screening, in blood services which require high thoughput automated systems. samples with a low positive agglutination, which were negative in two repeats, can be considered negative. retesting these samples on the autovuetm, can reduce the number of tests sent for confirmation and allow early release of blood components. rk tagi-zadeh*, aa karimov*, ar hasanov † , ly novruzova* and si donskov ‡ *hematology and transfusiology, baku, † blood transfusion centre, ganja, azerbaijan, † centre for hematology, moscow, russian federation background: the main method of treatment of severe homozygous thalassemia forms at the moment is still an anemia control with regular rbc transfusions. the use of adequate transfusion regime for these patients not only prolongs their lives but also promotes normal physical development of the children and improves the quality of their lives. however, necessity to do multiple transfusions increases a risk of post-transfusion reactions and complications due to alloimmunization to rbc antigens. in order to prevent posttransfusion reactions it is essential to know the frequency of blood group distribution in the region and then implement organizational procedures to enhance the transfusion services for these patients. objective: examine the distribution of rbc antigens among thalassemic patients and blood donors. methods: blood samples of homozygous betta-thalassemia patients (who stayed at the daytime inpatient wards of scientific research institute of hematology and transfusiology baku, azerbaijan) and blood donors of azeri nationality were examined. patients' blood samples were typed on rbc rh (c, c, d, e, e) and kell (k, k) antigens. gel test bio-rad (france) was used to detect rbc antigens. results: phenotyping of the patients' rbc rh antigens (d, c, c, e, e, cw) revealed that frequency of occurrence of the antigens in general was higher than in the donors. studying of rh phenotype distribution showed that the patients' ccdee ( . %) •• ccdee ( . %) phenotypes were twice as much higher than the occurrence of those in the donors ( % and . % respectively). phenotype ccdee occurs more frequently in the donors ( %), whereas it is significantly rare in the patients ( . %). the similar picture was observed in relation to ccdee and ccdee phenotypes, which occurred more frequently among donors ( . % and . %) than in thalassemic patients ( . % and . %). additionally, the results demonstrated that k antigen of the kell system was not detected in the thalassemic patients whereas k antigen was detected in all the patients. the same picture was observed with two other antigens of this system. thus among the patients typed on rbc antigens kpa antigen was detected in just one case whereas kpb was detected in the rest the patients. the results of the analysis showed that for thalassemic patients with phenotypes ccdee and ccdee it is easier to find compatible blood than for patients with phenotypes ccdee, ccdee and ccdee. furthermore, it is known, that some congenital diseases are genetically connected with the specific group systems, for example, the mcleod syndrome is genetically associated with the sharp suppression of the kell alloantigen expression (absence of gene kx). the fact of the discovered absence of antigen k in homozygous bthalassemic patients makes it possible to assume, that this group of patients suffer from scarcity along the kell system, like the scarcity in mcleod syndrome. all the mentioned above make it possible for us to conclude, that prior to blood transfusion to thalassemic patients phenotyping of rbc rh and kell antigens must be carried out. hyperhaemolysis in sickle cell disease due to complement activation. tessa thorp rci national blood service manchester uk tm thorp national blood service, manchester, uk introduction: sickle haemoglobin is caused by a genetic mutation in codon of the beta globin gene, resulting in the conversion of glutamic acid to valine. when critical amounts of polymer accumulate within the sickled erythrocyte cellular injury results. clinically sickle cell disease is characterised by chronic haemolysis and intermittent vaso-occlusion. mold et al. demonstrated that deoxygenation and sickling of erythrocytes is related to membrane phospholipid changes and these changes result in the activation of the alternative complement pathway. aim: the objective of this study was to measure the amount of c c and c d bound in vivo to red cells of homozygous and heterozygous sickle cell patients. these levels were then compared to 'normal' sickle negative blood donors. haemoglobin levels and red cell morphology were also examined for signs of active haemolysis. the hypothesis was that an increase in red cell bound complement in vivo could provide an indication of hyperhaemolysis syndrome is sickle patients. method: flow cytometric analysis using rabbit anti-c c or anti-c d and fitc labelled goat anti-rabbit was developed using a beckman epics xlmcl flow cytometer. control samples were prepared using a fruitstone buffer technique of complement coating. results: a total of heterozygous sickle patients and homozygous patients were analysed. of the homozygous patients analysed only one was undergoing a sickle crisis. a positive result was indicated if the mean trait or homozygous sample was coated with complement to a greater degree that the mean normal donor plus two standard deviations. the results obtained in this research project indicate an increase in c c levels bound to red cells of homozygous sickle patients in vivo. statistical analysis of results obtained suggest that there was no increase in c d levels in either sickle trait or homozygous sickle patients. conclusion: these findings support research carried out by mold et al. ( ) and are present in more than % of caucasian population. it has been reported that anti-chido and anti-rogers don't cause hemolitic reaction but may be responsible for life-threatening anaphylactic reaction during transfusion of plasma proteins. case report: positive iat and dat were detected in a years old swedish woman, a rh negative, at th week of pregnancy. previous iat and dat determinations were negative. at time of detection dat wsa weakly positive and igg subclasses identified. antibody identification revealed the presence of high titre ( : ) anti-chido and anti-rogers antibodies. a slight decrease in platelet count (from . /ul to . /ul) was observed. this pattern showed no variation until the end of the pregnancy. at th week a healthy baby was delivered, dat negative. the mother dat and iat remained positive for four months after delivery. the platelets count raised again to . /ul. the same laboratory findings were detected in a previuos pregnancy in sweden. the patient reported the presence of antibodies at th week that disappeared few months after delivery. a healthy baby, dat negative was delivered in this case too. conclusions: this is the first report of the presence of chido and rogers as autoantibodies during the last months of pregnancy. the association with decrease in platelets count and the lack of evident clinical symptoms need further investigation. p- rbc alloantibody frequency and their prevalence within chinese, malay and indian community in singapore e widjaja, mbc koh and d teo health science authority, singapore, singapore background and aim: there is a recognised existence of different alloantibodies in different ethnic groups. while this has been studied in the caucasian population, their frequencies remain less well documented in the asian population. the frequency of different alloantibodies and their distribution in terms of age, sex in singapore population is studied, as were their prevalence within the chinese, malay and indian races in singapore. design and method: we conducted a retrospective study for the frequency of alloantibodies on blood samples over . these blood samples were largely sent by hospitals where preliminary antibody screening had been done and positive result obtained. they were sent to the centre for transfusion medicine for antibody identification. small number of these samples came from hospitals where preliminary antibody testing was not done. the antibody distribution across different ethnic groups (chinese, malays, indians) age and sex were studied. results: the most frequent alloantibodies in the population is mia ( . %), e ( %), le a ( . %), le b ( . %), p ( . %), m ( . %), d ( . %), c ( . %), jka ( . %) and c ( . %). within the chinese community, the most frequent alloantibodies were similar: mia ( . %), e ( . %), le a ( %), le b ( . %) and p ( . %). in the malays, the most frequent alloantibodies were le a ( %), le b ( . %), mia ( . %), e( . %) and p ( . %); while in the indians, these were mia ( . %), le b ( . %), le a ( . %), d ( . %), and e ( . %), with the anti-d reflecting the higher incidence of rh d negativity in the indians race. for the lower incidence antibodies, anti-c was more common in the malays and indians ( %) compared to chinese ( . %). anti jka tended to occur mainly in the malay race and anti-c was rare in all (< %) reflecting the high prevalence of c in the singapore population (r r phenotype). the ratio of alloimmunised male to female (m : f) is : . most alloantibodies demonstrated significant skewing towards to the female, although relatively less so for mia where m : f ratio is almost equal at : . . alloimmunisation increased with age for mia, e, k, p , jka and fyb while the frequency of alloimmunisation to lea, leb, d, m and c decresed with age. the prevalence of patients with multiple alloantibodies ( or more) within the alloimmunised subjects is . %. conclusion: anti mia is very common within the asian population especially in the chinese. anti d is common in the indians. most antibodies show increased frequency with age except for anti lea + b, d and m. the majority of alloimmunised patients are females. study aim: to identify the present antibodies in newborns, after a positive direct antiglobulin test (dat). material and method: during a years period, from / / - / / , we studied newborns and their mothers. each newborn was examined for abo group, rhesus with phenotype, kell and dat. each mother was also tested for abo group, rhesus with phenotype, kell and indirect antiglobulin test (iat). after each positive dat, the study was continued with the elution test, in order to identify the present antibody. dat test was performed with dc screening i-diamed sa, switzerland. for the laboratorial analysis of newborns the sample used was cord blood and in certain cases venous blood. results: the dat test was positive in ( %) of newborns and the antibodies found were igg type immunoglobulin. anti-a antibody was detected in ( . %) (newborns of group a with mothers of group o), anti-b antibody in ( %) (newborns of group b with mothers of group o), anti-d antibody in ( . %) (newborns d+ from d-mothers), anti-e in one case and anti-jka in another one. the eluate test was found negative in newborns and in the rest , no special antibody could be identified. the results are presented in the following table. conclusion: the majority of antibodies in newborns with a positive dat test, is due to abo incompatibility (the mother belongs to group o and the newborn to group a or b). anti-d ( ), anti-e ( ), anti-k ( ), anti-fya ( ), anti-s ( ), anti-jkb ( ), anti-n ( ), anti-kpb ( ). in two patients antibodies were identified, while in / ( . %) no antibody was identified (unspecific). it is remarkable that only in out of patients with both dat and iat positive, an irregular antibody was identified, while the rest patients had unspecific antibodies. in patients with only iat positive, had an irregular antibody and had unspecific antibodies. in out of patients with both dat and iat negative the cause of incompatibility was the positive dat in the corresponding sample of the blood donor, while in the rest patients the reasons were technical problems that include the inappropriate blood sample of the patient, patients under medication and errors during the crossmatching procedure. the results show that the incidence of red cell incompatibility in our hospital is . % and the most common antibodies are anti-k, anti-e, anti-fya, while anti-d is important for d negative patients. . % of the detected antibodies were unspecific and this is still a problem that possibly was due to the lack of additional panels of reagent red cells or antibodies to low-incidence antigens. finally, in some cases the reasons for incompatibility are due to factors affecting the blood donor or to technical problems in the crossmatching procedure. multiple isoforms excluding normal rhd mrna detected in rh blood group del phenotype with rhd a allele introduction: del phenotype is very common in rh-negative chinese. the rates in hans (more than % in china) were reported from % to %. moreover all del individuals in this population were found mainly carrying a same allele, rhd a, through genomic dna analysis. those individuals always possess one or two of this allele with ccee or ccee phenotypes. aim and the study: we focused on the mrna investigations of del individuals carrying rhd a alleles, in chinese, to expect it could be explained that why a silent mutation is associated with del phenotype. the full-length rhd mrna was analyzed in rh-positive donors with cde/cde and cde/cde genotypes, respectively, and del phenotype individuals carrying rhd a allele with cde/cde, cde/cde, cde/cde and cde/cde genotypes, respectively, through reversed-trancriptase pcrs and cdna direct or cloning sequencing. results: five transcripts and isoforms were detected in rh-positive and del, respectively. among them, isoforms have identical sequences, which are transcripts with exon , exons and , exons and , and exons to spliced out. the normal rhd mrna was only observed in rh-positive, but not in del individuals. in stead, two additional transcripts were found in del individuals. its exon or exons - were spliced out, but both possess a bp segment of sequence from intron of rhd. through additional reversedtrancriptase pcrs, which amplified exon to ¢-region and exon to ¢-region, the results showed that exon did not exist in del anyway. conclusion: (i) a normal rhd protein does not exist in a del individual with rhd a allele since the exon was always spliced out in all isoforms. all transcripts in del maintain a normal open reading frame and encode proteins with different numbers of amino acid residues and different c-terminals (genbank ay , ay , ay , ay , ay , ay ). among them, the sequence of del (isoform with exon spliced) transcript was the most similar as normal rhd mrna. this isoform was first described by chang et al. in taiwan in . it encodes amino acid residues and has amino acids more than normal rhd. it is different from rhd after codon . in normal rhd protein, the amino acids after ( residues) are mainly the trans-membrane and intracellular regions. therefore a further study on if a del red cell possesses all epitopes of normal d antigen may be significative. (ii) a normal rh-positive individual has also the transcript of del that was found in del. (iii) there is only one polymorphism in the region of bp segment between rhd intron and of the del transcripts, which indicated that other polymorphisms may exist in intron of rhd a allele compared rhd to explain that this situation was not happened in normal rh-positive individuals. total wbc were enumerated by flow cytometry and cell counting. wbc subsets were analyzed by flow cytometry with three-color fluorescence. in this study, the third generation bags and filters are used. results: before filtration, the total number of wbc, was significantly higher in fresh units compared with stored units, whereas in postfiltration samples the number of white cells was significantly lower in the fresh compared with the stored units. although absolute numbers were significantly reduced, filtration also induced significant changes in the proportions of subsets in hoth fresh and storod units, the percentage of t cells was decreased, whereas the percentage of b cells and monocytes was increased after filtration. in conclusion, both pre and post storage wbc filtration affect the proportions of wbc in the final product but pre storage wbc filtration of platelet concentrates is superior than post storage wbc filtration. the effect of pre-and post-storage filtration on platelet rich plasma: derived platelet concentrations background and objective: the white blood cells (wbc) within transfusion products are a major stimulus for a number of detrirmental biological reactions, including febrile nonhemolytic transfusion reactions, alloimmunization against hla antigens and cytomegalovirus transmission. in this work, our objective was to study the effect of storage time on the filtration of platelet concentrates (pcs). the total number of white blood cells as well as the distribution of wbc subsets, in units filtered before and after storage were compared. materials and methods: platelet rich plasma -derived pcs were filtered either fresh ( pooled we reported earlier that metabolic arrest followed by incubation at °c reduces the platelet storage lesion (badlou et al. transfusion ) . here we report that this treatment also reduces binding and phagocytosis by macrophages. metabolic suppressed platelets (msp) were prepared by incubation in glucose-free, antimycin a containing medium ( min, °c) followed by storage ( h, °c) and recovery with glucose ( h, °c). controls were (i) platelets in glucose-rich medium stored for h at °c and recovery with glucose (c ) and (ii) platelets stored for h at °c (c ) with rewarming. platelets were labelled with mepacrine and incubated with pma-matured thp- cells ( °c). binding was measured by facs analysis of cd b/cd positive particles, and phagocytosis by counting mepacrine/cd positive particles. binding of msp, c , c was ± , ± , ± % of total platelets. phagocytosis of msp, c and c was ± , ± , ± % of total macrophages (means ± sem, n = ). before recovery of msp, binding/phagocytosis was % higher than thereafter, revealing energy-dependent control of the mechanisms that trigger plateletmacrophage interaction. these data show that metabolic suppression prior to cold storage attenuates binding and phagocytosis by phagocytes and may help to develop means to improve platelet survival post-transfusion. platelet compatibility testing and alloimunization in multiply transfused hematologic patients purpose: multiply transfused patients with heamotological malignancy often become refractory to platelets due to alloimmunization. refractoriness is usually defined as an insufficient platelet increment after consecutive platelet transfusions. two major causes of a decreased platelet increment can be distinguished, immune and nonimmune factors. alloimmunization occurs most frequently against the hla, and rarely against the hpa system. nonimmune factors been identified are splenomegaly, fever, sepsis, and disseminated intravascular coagulation as well as the quality of the transfused platelet concentrates. we performed this study in order to investigate platelet crossmatching, compatibility, and antibody determination among thrombocytopenic patients multiply transfused. we performed crossmatchingcompatibility tests of single donor leucodepleted, abo compatible, platelet concentrates been transfused in patients with leukemia and lymphoma, males and females with mean age ± years old. we also obtained samples from the patients for platelet antibody detection. we evaluated the cci (corrected count increment) h after the transfusion. the solid phase rbc adherence assay (modified capture p system/immucor) was used for platelet compatibility and antibody detection. a total of compatibility tests were performed, of which were compatible. twenty five compatible platelet concentrates out of were clinically evaluated. twenty from compatible crossmatches ( %) were resulted in successful transfusion while only from ( %) in unsuccessful. the incompatible platelets been transfused was resulted in unsuccessful transfusion. we found statistically significant difference among patients successfully transfused with compatible and incompatible platelets (p~ . ). additionally patients out of ( . %) had been alloimmunized against multiple hla antibodies. three patients transfused with compatible platelets, during the study, developed alloantibodies. we found a large number of incompatible platelet concentrates that result in unsuccessful transfusion and clinical response. the platelet compatibility testing as well as alloantibody determination of multiply transfused patients is necessary for the identification and selection of compatible, with the patients, donors in order to result in succesful transfusion and clinical outcome. furthermore compatible platelet concentrates provide optimal support for refractory patients and it is known that they are acceptable as an alternative component. naitp is a rare clinical syndrome characterized by marked thrombocytopenia shortly after birth. it is caused by maternal immunization against paternally inherited antigens present on foetal platelets. screening and identification of antibodies in the maternal blood sample is the main support in the diagnosis and management of naitp. we have evaluated the frequency of maternal alloimmunization, the role of the antibodies involved (hpa and/or hla systems) and the pertinent risk of naitp in neonates using a fully automated system with a solid phase red cell adherence methodology (sprc-capture p) and paternal or random donors (indirect test). screening started in june and is still in course: in january , blood samples were examined. identification of antibodies in maternal serum was carried out using elisa methodologies: maipa and commercial kits (pak-plus and quick screen-gti). of the blood samples analysed, were reactive and the specificity of the antibodies were: anti hpa a: , anti hpa b: , anti hpa a + hla: , anti hpa b. , anti hla: , auto hpa- b: . specificity of hpa antibodies was confirmed by determination of parents' hpa genotype (hpa- , , , , , ) using pcr-ssp or pcr-rflp. the infants with hpa immunization suffered from severe (plt count - /ml) and symptomatic naitp (bleeding and petechiae were present), therefore they were treated with platelet transfusion and administration of high doses of intravenous immunoglobulin. we confirm that naitp due to hpa- and hla immunization is clinically less severe: all neonates had mild and self limiting thrombocytopenia at birth; no therapy was administered. it would be advisable to carry out pre-natal screening, at reasonable cost, using maternal serum versus paternal platelets and to proceed to the identification of antibodies only in presence of positive results. background: fetal or neonatal alloimmune thrombocytopenia (fmait) results from a maternal alloimmunization against fetal platelet antigens. it is the commonest cause of severe thrombocytopenia in the neonatal period. the diagnosis of fmait is made initially on clinical grounds, depending on exclusion of other causes of neonatal thrombocytopenia. in caucasians, hpa- a is the most frequently implicated antigen. other antigens such as hpa- a, or hpa- a are less often implicated. during the past few years fmait has been reported associated with rare or private antigens. the diagnosis is straightforward when a maternal alloantibody with a corresponding parental antigen incompatibility is present. however it could be equivocal in the absence of such an antibody or difficult when a private antigen is implicated. if the father is heterozygous for the considered antigen, the infant's platelet typing should be performed to confirm the diagnosis. due to the risk of hemorrhage, particularly intracranial hemorrhage (ich), during the course of severe thrombocytopenia, specific therapy is mandatory. because subsequent siblings may be more severely affected, accurate diagnosis will allow better management of subsequent pregnancies. study design and methods: since the first documented case of feto-maternal alloimmune thrombocytopenia (fmait) due to anti hpa- bw (maxa+), no additional cases have been reported. we present here a retrospective analysis of the cases referred to our laboratories in recent years. since we have screened for rare or private antigens in suspected cases of fmait when there is no incompatibility for the most frequently implicated antigens. the diagnosis was performed by genotyping and identification of the maternal alloantibody by the maipa technique. results: parental genotyping showed hpa- bw (maxa+) mismatch as the sole antigenic incompatibility in out of families. in the last one, incompatibility was found for hpa- without anti hpa- b maternal alloantibody. as the father was found to be hpa- bw (maxa+) heterozygous in all the cases, the infant or fetus was genotyped to ascertain the diagnosis. the maternal alloantibody was identified in the maipa technique. however, our data strongly suggest that recognition of the hpa- bw (maxa+) epitope is not uniform. the neonatal thrombocytopenia was severe in most cases with bleeding. the outcome was good in all the cases but one. conclusion: this analysis confirms that anti hpa- bw (maxa+) fmait is not uncommon and was found to be around % of our confirmed fmait cases with parental incompatibilities and presence of maternal alloantibodies. it is a clinically severe syndrome which requires prompt diagnosis, albeit difficult, and maternal platelet transfusion therapy. laboratory investigation of a suspected fmait case should be carried out in a specialist laboratory wellexperienced in optimal testing. therapy requires strict collaboration between clinicians and blood bank services. appropriate management and antenatal therapy should be considered for successive pregnancies to prevent fetal bleeding. introduction: the human platelet (plt) antigen (hpa) system is independent of the hla system. therefore, host-or donor derived alloimmune thrombocytopenia can develop after allogeneic haematopoietic stem cell transplantation (hsct) even in hlamatched donor-recipient pairs. we report the first case on a stem cell recipient developing thrombocytopenia due to host-derived hpa- a antibodies after non-myeloablative allogeneic hsct. a year-old male patient was diagnosed with multiple myeloma in / . treatment consisted of cycles vincristin, adriamycin and dexamethason followed by tandem autologous stem cell transplantation. because of progressive disease he received cycles of bortezomib, and after complete remission a stem cell allograft ( . ¥ /kgbw cd + cells) from his histocompatible (hla a,b,c,dr identical) brother after reduced intensity conditioning regimen with fludarabine ( ¥ mg/m ) and alkeran ( mg/m ). he had received only twice packed red blood cell concentrates and one plt concentrate before allogeneic hsct. stable bilinear engraftment occurred around d but was accompanied with a continuous decrease of plt counts. between d and d the patient received seven plt transfusions, containing a median of . ¥ plt/unit (range , - , ¥ plt/unit) from random donors. the corrected plt count increments at to h after these transfusions were < /ml. therefore, and because of even a further decline of platelet counts to /ml on d we investigated the presence of plt antibodies. methods: the patient's serum was tested by antigen capture elisa assays (pakplus® and pak ®, gti) and a solid phase assay (capture-p®, immucor). the maipa assay was used to confirm the results obtained by the above mentioned assays. in addition, we tested the patient's serum by the maspat kit (clb) against plt from the donor and against homozygous hpa- a plt obtained from our donor pool. stored recipient's dna from the time before hsct was used for genotyping. genotyping for hpa- , - , - and - of the donor and the recipient was performed by pcr-ssp (hpa, protrans). the patient's serum obtained on d after hsct reacted strongly with the donor's plt due to anti-hpa- a antibodies and antibodies against hla class i antigens. the patient's genotype before transplantation was hpa- bb, - aa, - ab, and - aa; the donor was hpa- ab, - aa, - aa, and - aa. thus, the antibodies were host derived and directed against the donor's plt. serum samples obtained on d , d and d after hsct contained antibodies against hla class i antigens but hpa- a antibodies were not anymore detectable. no hla antibodies were detectable on d after hsct. the severe thrombocytopenia was caused by hostderived hpa- a antibodies. fortunately, plt counts started to increase on d spontaneously and the patient could be discharged at d (plt . /ml) with a complete donor chimerism. the decrease of the serum antibodies parallel to the increase of the plt count strongly suggests a progressive elimination of residual host cells. we conclude that the hpa mismatch between recipient and host affected thrombopoietic engraftment and the success of plt transfusions. severe neonatal alloimmune thrombocytopenia with anti-hpa- b antibodies: case report p moncharmont, m vignal, y mÉrieux and d rigal efs rhone alpes site de lyon, lyon cedex , france usually, in case of feto-maternal incompatibility, the platelet (plt) specific anti-hpa- b antibodies (ab) induce only sometimes a mild neonatal alloimmune thrombocytopenia (nait). contrary to this observation here is reported the case of a severe nait. a -year old mother, gestation /partum , gave birth to a male neonate by caesarean section at weeks of gestation because of intra-uterine growth retardation (iugr) and anamniotic fetus. five years before, she had had a first pregnancy with iugr of the fetus but no nait. the second neonate weighted . g, was . cm tall and had a head circumference of . cm. the apgar score was , , , at , , and min respectively after birth. no bleeding, hepatomegaly, splenomegaly or infectious signs were noted. five hours after birth, a respiratory distress syndrome appeared and an oxygenotherapy was performed during h. the plt count which was . , . and . giga/l at day (d) , d and d respectively dropped dramatically at . giga/l at d . simultaneously, an intracranial hemorrhage grade ii was diagnosed on ultrasound scan. because of the clinical signs and of the decreasing plt count the mother's serum was tested for plt-specific ab by immunocapture and the ab identified by the monoclonal ab-specific immobilization of plt antigen (maipa) assay. a plt genotyping was performed in the neonate and his parents by sequence-specific primers polymerase chain reaction. the mother was hpa- a/a and anti-hpa- b ab were detected in her serum. the baby was heterozygous, hpa- a/b. plt were transfused to the baby and the plt count rose to . , . and . giga/l at d , and respectively. no further transfusion was needed and the development of the baby was satisfactory with a normal electroencephalogram. in conclusion, when a mild thrombocytopenia with iugr and hypoxia but without bleeding signs is present in a neonate immediately after birth, a maternal plt specific ab screening must be performed in case the thrombocytopenia became severe during the newborn monitoring. anti-hpa- b ab can be detected. partial results of the incidence of heparin induced thrombocytopenia type ii osc oliveira*, ra rached*, c cavalheiro-filho*, jc nicolau*, shgl pasqualucci*, daf chamone † and sp bydlowski † *heart institute, university of são paulo, † university of são paulo, são paulo, brazil heparin induced thrombocytopenia type ii (hit) is a severe side effect of heparin, associated with heparin-platelet factor antibodies. hit type ii occurs in up to % of patients who are exposed to unfractionated heparin (ufh). in our institution patients that are under heparin treatment are mostly cardiac patients. the purpose of this study is to determine the incidence of hit type ii in these patients. material and methods: patients from the intensive care unit and cardiac care unit treated with ufh or low molecular weight heparin (lmwh) for or more days were studied. known causes of thrombocytopenia were excluded. platelet count was monitored pre and post heparin therapy. all selected patients were tested for detection of anti heparin/pf antibody test (diamed id-card). results: from the studied patients, ( . %) developed thrombocytopenia (determined by a decrease in the platelet count below %, after the introduction of heparin therapy); ( . %) did not show decrease in the platelet count. six ( . %) out of thrombocytopenic patients were positive for anti-heparin/pf antibody. three ( . %) out of non thrombocytopenic patients were positive for anti-heparin/pf antibody. the results demonstrate that ( . %) patients were positive for anti-heparin/pf antibody and they were no different from those described in the literature regarding the frequency of heparin induced thrombocytopenia. moreover, a higher frequency of patients with heparin/pf antibody was noted without the presence of thrombocytopenia, indicating that other factors should be considered. introduction: neonatal alloimmune thrombocytopenia (natp) due to maternal immunization against fetal platelet antigens affects . - in live births. although it is usually a self-limiting condition, a major complication in cases of severe thrombocytopenia is the occurrence of intracranial haemorrhage leading to death (in up to % of reported cases). the commonest antibodies are anti-hpa- a. treatment consists of ivig, compatible donor platelet concentrates or washed maternal platelets. the administration of random donor platelet transfusions is controversial but has been used successfully in some urgent cases when compatible platelets were not available. case report: a baby born in week of gestation to a healthy mother after first uneventful pregnancy; birth weight g, apgar score . immediately after birth, severe thrombocytopenia ( ¥ /l) and signs of haemorrhagic diathesis (generalized petechiae and ich gr. ii-iii) were observed. coagulation tests were abnormal and k-vitamin, fresh frozen plasma and random donor platelet concentrate (retrospectively genotyped as hpa- a/a) were given. twenty-four hours later platelet count rose to ¥ /l and no new petechiae were observed. on third day of life the blood platelet count was ¥ /l and the newborn received ivig g/kg and corticosteroides. twenty-four hours later the platelet count rose to ¥ /l and further clinical course was uneventful. natp due to hpa- a was serologically confirmed. conclusion: optimal therapy for an infant with severe thrombocytopenia during the first h of life is the transfusion of platelets that will not be destroyed by the maternal alloantibody in the infant circulation. random donor platelet concentrates are controversial in a setting where optimal treatment is not available, however, in this case they led to a significant platelet count improvement in spite of hpa- a incompatibility. accordingly, random donor platelets may be considered appropriate in emergency situations. background: rhd is the most immunogenic blood group antigen, and its correct identification is essential in the blood bank and in the prevention of the haemolytic disease of the newborn. the weak d phenotype is the most common d variant, with a frequency of . % to % in caucasian individuals. there are several weak d types, with different frequencies in european countries, which may pose serologic problems and have the potential for alloimmunization. the objective of the study was to determine the frequency of the principal weak d types in portugal. study design and methods: lisbon regional centre of the portuguese blood institute and oporto são joão university hospital selected samples from blood donors and patients. rhd was tested by two (oporto) or three (lisbon) distinct anti-sera, in direct agglutination tests, at room temperature. when discrepant results were observed, the samples were tested with panels of monoclonal anti-d by liss-iat. samples that reacted weakly with igm anti-d but positive with igg anti-d were sent to the molecular biology centre. pcr with sequence-specific primers was performed using two commercially available kits (inno-train and bagene). real-time pcr, carried out on a light cycler, was applied when the interpretation was dubious. results: samples were referred after being characterized as weak d. in cases we obtained a positive result, with a preponderance of weak d type ( . %) over type ( . %), ( . %) and ( . %). two samples were not categorized. the high incidence of weak d type in our population is in marked contrast to studies performed in other european populations where weak d type was the most frequent. this might be due to our sample selection criteria or ethnic variation in the causes of weak d. there are advantages in genotyping serologically depressed d samples: to avoid the waste of d-negative rbc units and the use of immunoglobulin in pregnant women, who have no risk of alloimmunization. analysis of rhd zygosity in different rh phenotypes cal except for a -bp t insertion. the deletion of the rhd gene, found in most rhd-negative caucasians, was theoretically due to recombination of the upstream and downstream rhesus boxes resulting in the formation of a hybrid rhesus box. thus, the detection of a hybrid rhesus box in an rhd-positive individual denotes an rhd heterozygous status. aim of the study: to determine the rhd zygosity in different rh phenotypes. methods: blood samples from white trios (father, mother and child) were studied. the rh phenotype was performed by hemmaglutination and the rhd zygosity was inferred in each member of the family groups. the rhd deleted allele was determined by a pcr strategy using a forward primer complementary to ¢ end of the identity region of the upstream and hybrid rhesus boxes and a reverse primer complementary to the ¢ end of identity region of the downstream and hybrid rhesus boxes. these primers selectively amplify a -bp segment of the hybrid rhesus box in rhdnegative and rhd-positive heterozygous samples. serological and pcr inconsistencies were studied by a pcr-rflp method to detect another polymorphic site of the hybrid rhesus box. frequencies were obtained analysing only unrelated individuals (fathers and mothers, n = ). results: ( . %) rhd-positive and ( . %) rhd-negative samples were phenotyped. of the rhd-positive donors, ( . %) were rhd homozygous and ( . %) were rhd heterozygous according to pcr. pcr-rflp analysis confirmed the results of pcr in serological and molecular discrepancies. these results were coherent within each family group and did not differ from those published in the literature for caucasians based on the most probable genotype method. however, the homozygosity indexes were significantly higher in the dccee ( . % vs . %) and dccee ( . % vs . %) phenotypes due to an increase of the dce haplotype. in all samples with the dce haplotype the rhces allele, frequent in individuals of african descent, was investigated by pcr-ssp. this allele was found in . % of the dce haplotypes. . rhd and rhce typing was performed by multiplex-pcr with fluorescent primer pairs. positive results were obtained for rhd-exons - , , and polymorphisms associated with antigens c, c, cw, e and e. sequencing of rhce-sequences, including exons to and intron/exon borders, were done by direct taq cycle-sequencing using bigdye-terminators v. . in an abi (applied biosystems). results: see table . the substitutions of rhce-specific nucleotides in exons , and with their rhd-specific counterparts lead to different new rhc-antigens with weakened expression. since one amino acid change in allele lie in extracellular loop of the antigen suggested that this antigen may be involved in allo-immunization. inheritance of a rhd cat vi type ii in a twin pregnancy: a case report introduction: determination of hdn-relevant fetal blood groups in amniocentic fluid with pcr is a routinely used method. misinterpretation of test results -e.g. overlooking rhd category -decreases depending on the number of examinated rhd-specific exons. case report: a -year old mother (w.o.g. ) pregnant with twins was regularly tested for irregular antibodies and was shown to have an anti-d. after amniocentesis of both foetuses tests for the occurrence of rhd intron , exons and were performed in the hospital's lab. the sample of fetus i showed pcr-products for intron , exon and exon while sample of fetus ii lacked rhd-specific intron . therefore we investigated blood samples from the parents as well as amniocentic fluid of both foetuses. methods: total dna was amplified in a multiplex pcr with fluorogenic primers for rhd exons - , & ; polymorphisms for dweak type - , d-vii, d-hmi and rhce polymorphisms for c, c, cw, e, e. capillary electrophoresis for size fractionation and fluorigeneic analysis was done in an abi . rhd zygosity was determined by quantitative real-time pcr with co-amplification of rhdand rhce-specific exon and subsequent calculation of d ct value (ct rhce minus ct rhd). results: while maternal dna sample has been genotyped as rhdnegative, amplification of paternal dna for rhd-specific exons , , , and were possible and failed only in exon - . determination of rhd-zygosity revealed a homozygous constellation of the rhd-gen. investigation of amniocentic fluid from both foetuses resulted in a rhd-wildtyp for fetus i and a rhd cat. vi type ii for fetus ii which was the reason for missing amplification in rhd intron pcr. results: weak d type was not identified in our research population. weak d type was identified in cn, weak d type was identified in cn and weak d type was found in cn, bsa, be, bc and saa. conclusions: although weak d types to represent the majority of all weak d phenotypes in caucasian populations, none of these weak d alleles were found in black populations. since none of the frequent weak d types were identified in non-caucasians one might not expected to find type in all populations. however, regarding rhd phylogeny, the weak d type mutations ( c > g and t > g) form the basis of a cluster of aberrant alleles that are predominantly observed in blacks. therefore, it is not surprising that weak d type was identified in non-caucasians. based on these results it may be concluded that weak d phenotypes have evolved relatively recently since they are present in caucasian and asian methods: dna was extracted from a, b, ab subgroups, and provisional cis-ab after serological abo typing. allelespecific pcr, rflp, direct sequencing of exon and , and allele separation were performed on these samples. results: abo*a allele was observed in an aint subgroup. two new a alleles that showed g > a base change and c > t of intron and a polymorphism of c > t in a(pro) intron were discovered. o and o alleles were also observed. in b subgroups, a silent substitution c > t (leu leu) was observed as a new b allele. another new b allele which showed g > a was also found in b subgroups. conclusion: we discovered new abo alleles and polymorphisms in korean populations. many other polymorphisms and alleles already reported in japanese were also observed in koreans. evaluation of a multiplex snapshot-pcr method for red blood cell marker genotyping c jungbauer*, c hobel*, em dauber † , pk rabitsch*, dwm schwartz* and wr mayr* *austrian red cross, † medical university vienna, vienna, austria once conventional reagents for identification of rare red blood cell phenotypes are scarce, methods using current nucleic acid testing techniques to identify the patient's genotype and possibly to screen for donors would be desirable. the approach of multiplexgenotyping using pcr-ssp has apparently technical constraints so we are currently analyzing whether a modification using snapshot pcr-technique could provide a routine application for such purposes. compared to ssp-technique, the snapshot pcr only requires one single primer (labeling reaction) for the detection of two (or more) alleles instead of one pair of primers for every single allele. briefly, we perform snapshot pcr as follows: in a first step, dna segments covering the essential polymorphic regions for the abo, rhd, kel, jk and fy genes are amplified using a standard pcr step. after purification treatment of the pcr products (roche high pure pcr product purification kit or shrimp alkaline phosphatase (sap)/exo treatment according to the abi prism snapshot multiplex kit protocol) the labeling reaction is performed using the abi prism snapshot multiplex kit. after a second purification step the products are analyzed on a abi prism genetic analyser in fragment analysis mode. our preliminary results show the feasibility of this approach as reliable typing results can be obtained for all tested single nucleotide polymorphisms corresponding to alleles. generally a better signal quality from controls and samples is obtained compared to the ssp-technique with consecutive gel electrophoresis. we also consider the possibility of the automated interpretation of the results as an important improvement, especially when aiming for an application for a large number of samples (donors) or markers (patients). in contrast, the method involves more manual steps and higher costs. we may conclude that the implementation of snapshot-pcr techniques for red cell marker genotyping is a promising alternative to pcr-ssp. the obvious quality improvements compared to pcr-ssp might be critical for a routine application in blood banks (donor screening) or complex questions in clinical laboratories. quantification and quality control of monoclonal antibody using an optical sensor based on the laser reflectometry technique the monoclonal antibodies (moab) are biological reagents of homogeneous activity. they are generally used in the recognition and quantification of very small amounts of biological substances (hormones, enzymes) present in a solution, ag identification, blood group determination, oncology, organs transplant, etc. moab can be characterized by its specificity and affinity. affinity may be expressed as the equilibrium association constant (k). several techniques are available to determine the equilibrium constant of the ag-ab interaction. in this work, is shown an optical sensor for monoclonal antibody quantification by reflectometry technique. the laser reflectometry technique (null ellipsometry technique) can give information about the kinetic of the interactions, stoichiometry of molecular binding and the concentration of molecules in a solution, and also offers detailed and accurate determinations of real-time adsorption kinetics of protein without labeling. a silicon wafer was chosen as reflectant surface. once fixed the principal angle of incidence, an amount of anti-ab is added to the sample. the reflected laser intensity is registered in real time as the protein is being adsorbed onto the wafer. the mathematical analysis of the results verifies that the antibodies adsorption follows langmuir's kinetics. from the curve analysis, the parameters related to the anti-ab concentration are extracted. from them, the calibration curve is constructed. this curve allows the desired commercial monoclonal antibody quantification. the developed technique shows to be sensible and precise. the obtained graphics are very well approximated (r > . ) verifying that the monoclonal anti-ab associa- study aim: to prevent the sensitization to rh (d), to a d-patient who was transfused with d+ blood. material and method: on september , ( / / ), we admitted to our hospital through air-carriage, a female of years old, badly injured after a car-accident. the patient was on an olighemic shock (ht: %) due to retroperitoneal, paracolic and procystic hematomas, had multiple fractures on the left feet, the main important of which was an acetabulum one. she had a blood group: o, d-and her phenotype was ccdee with du-. after her arrival she was urgently admitted to the surgery room and our blood bank was asked for condensed red cells. initially she was transfused with blood of the same group (o, d-) but when we were short out of dblood, we were asked for more units. the necessity of blood was imperative, the patient was on a critical condition and the mechanism of blood transport, from another blood bank would take some time to be put in motion, and so it was decided that the patient would be provided with d+ blood. the indirect antiglobulin test (iat) and papaine were negative, so there would be no problem with the transfusion with d+ blood. the patient received finally units ( ml) of d+ condensed red cells, out of that were initially asked. before the h from the surgery had passed, it was decided that human anti-d immunoglobulin (rhesogamma p) should be provided, in order to prevent the sensitization of the patient to rh (d). the indicted dose was - iu/ ml of the transfused blood, provided piecemeal during a several days period. analyzed by real-time pcr amplification. based on a published report, we selected primer pairs targeting insertion/deletion polymorphisms which are located on different chromosomes, unrelated to each other and not associated with immunocompatibility. we optimized the amplification conditions for all primer pairs using our sybr green real-time quantitative pcr protocols, and investigated analytical sensitivity for each primer pair by performing spiking studies, in which a single copy of positive dna was added into copies of negative dna followed by allele-specific pcr amplification. we also created a theoretical panel of donor-recipient pairs (n = ) to evaluate the clinical sensitivity for detection of ta-mc using both hla-dr and indel panels. results: for the short-term samples, additional mc cases was identified in non-lr group using indel panel; and one additional mc case was detected in lr group (table ) . for the long-term follow-up samples, additional mc cases were found. when evaluating analytical sensitivity, we were able to detect a single copy of positive dna mixed with copies of negative dna in a single amplification tube for all primer pairs. we were also able to calculated the clinical sensitivity that using donor-recipient pairs. . % of donor-recipient had at least one informative allele for detection of ta-mc if we consider both hla-dr and indel panels. conclusion: using our new indel panel, we were able to detect more instances of mc in this cohort of patients. we conclude that the dr assay underestimates the presence of mc. moreover, the tandem use of both panels provides a powerful tool for the detection of mc with . % of recipients having at least one informative allele. background: we reported severe immunesuppression and longterm transfusion-associated microchimerism (ta-mc) in transfused trauma patients. we have also reported, in a murine transfusion model, that sensitivity to -chloro- - dinitrobenzene could be transferred, albeit transiently, by transfusion of fresh blood from a sensitized donor to a naïve immunecompetent recipient. in order to mimic the immunecompromised status of trauma patients and further investigate the mechanism underlying ta-mc, we established an animal model using immunedeficient knock-out mice. aim: our objective was to test virus-specific immune functionality of the chimeric donor leukocytes in a murine ta-mc model. material and methods: female rag- /common gamma double knock-out mice were transfused with fresh blood collected from male balb/c mice, which were either not infected (non-primed, np) or infected twice (primed, p) with million viral particles of murine cmv (mcmv). at different post-transfusion time-points ( h, weeks, weeks, weeks, weeks), different female recipients plus non-transfused female knock-out controls were challenged with million viral particles of mcmv intra-peritoneally, and then monitored weekly for the concentrations of male donor cells as well as mcmv viral load in recipient's circulation. each female knock-out received only one challenge of mcmv. if the subject died, we quantitated mcmv viral load in the brain, spleen, lung and liver. we used real-time quantitative pcr targeting murine y-chromosome, h k and mcmv to quantitate male donor cells, transfused recipient cell dna input, and mcmv vrial load, respectively. the number of recipient cell dna input served as a denominator to calculate the concentration of male donor cells and the mcmv viral load. results: results of overall mortality are summarized in the table. all female knock-out recipients transfused with primed donor blood, except for the post-transfusion weeks, are able to survive mcmv infection. all non-transfused control and recipients transfused with non-primed donor blood died after mcmv infection; these two groups also had higher mcmv viral load in blood than the recipients transfused with primed donor blood. when the subject died, we were able to detect mcmv in all four organs we analyzed, with liver having the highest mcmv viral load. there was no significant difference for the concentration of donor cells in recipients' blood between recipients transfused with non-primed donor blood and recipients with primed donor blood. the preliminary data of our study showed that chimeric primed donor cells, but not non-primed donor cells, are able to protect immune compromised knock-out recipients from murine cmv infection. the time-point of 'post-transfusion weeks' might represent a weak window for the functionality of chimeric donor cells, which requires further investigation and confirmation. aims: to compare the effectiveness and the cost of epoetin-a and darbepoetin in patients undergoing pabd. methods: seven adult patients scheduled for operations were administered aranesp ( mg sc once or q weeks if needed) for pabd (aranesp group) and they were compared with a historical epoetin-a group of seven age-matched adults (eprex iu/kg biweekly). the two groups were matched according to the ht, ferritin levels, number of the predonated units and type of the operation performed. cbc count and reticulocytes were measured weekly during the donation period, the day before, day and day after surgery while ferritin and biochemical indices were measured during the first visit. erythropoiesis-stimulating factor was administered when ht £ % during blood donations and blood donation was not performed if ht < %. results: there was no statistical significant difference in hematological parameters during the donation period, the pre-operation day and after surgery between the two groups. five of seven patients from both groups received one or two autologous blood units. both factors were well tolerated without any side effects. the cost per patient was . € in the aranesp group and . € in the epoetin group. conclusion: despite the small number of patients and the limitations of this preliminary retrospective trial we believe that subcutaneous darbepoetin-a is equally effective with epoetin-a in patients undergoing pabd. darbepoetin has the advantage of less frequent administration and it is possibly superior that epoetin-a in terms of patient compliance. however smaller doses should be examined in order to reduce the cost. larger prospective randomized trials are needed to estimate the cost-effectiveness of the use of darbepoetin-a in pabd. background: incompatibility with many blood units is a major problem in transfusion therapy. in selective operations, preoperative autologous blood donation could solve many problems, when of course the patient's condition and his haemoglobin levels are appropriate. we present here the experience of our blood transfusion centre from operations in patients with anti-erythroid antibodies. materials: three patients ( male and females), aged between - years old, had to undergo selective operations, total hip replacement surgery and aortic aneurysm. introduction: because of improvements in surgical techniques, preoperative autologous blood donation (pabd) in patients undergoing radical retropubic prostatectomy (rp) is contested. aim of the study: we wanted to develop and validate an algorithm to determine the patients who probably do not benefit from pabd. methods: we calculated the perioperative hb-loss of consecutive patients (group ) who donated two red cell units (rbc) of autologous blood and weeks before undergoing rp: hb-loss (g) = preop-hb ¥ bv + (n rbc ¥ ) -(postop-hb ¥ bv) (bv = blood volume (l) = body weight (kg) ¥ . ; postop-hb = hb ( - h after rp); n rbc = number of transfused autologous and allogeneic rbc). hb of rbc was taken as g. rbc requirement is probably if initial-hb -(hb-loss: bv) -trigger-hb (taken as g/l) < (initial-hb = hb at the first contact with the pabd-unit). this assumption was validated by the next patients who were also assigned for pabd (group ). pabd was refused if the probability of rbc requirement (prr) was < %. between - % one rbc was taken after considering the patient's individual risk of pabd. if prr exceeded % two donations were planned. results: both groups did not significantly differ in age or initial hb. preop-and postop-hb were significantly lower in group ( vs and vs g/l). % of autologous blood of group were discarded, / patients needed additional allogeneic rbc. hb-loss caused by rp was ± g. mean prr in group was . %. / patients donated one rbc, which was later discarded, and no patients donated two rbc. / of group needed allogeneic rbc. mean prr of these patients was % (range . - . ). conclusion: postop-hb were lower in rp-patients with pabd because of the lower preop-hb and the restrictive indication for transfusion of autologous blood. the individual calculation of prr, for which only body-weight and initial-hb of the patient are necessary, shows that pabd in patients undergoing rp is indicated only in rare cases. the algorithm also may be used in other major operations, if hb-loss is known. use of darbepoetin-alpha in preoperative autologous blood donation: preliminary results background: preoperative autologous blood donation (pabd) is an alternative practice to eliminate complications of allogeneic blood transfusion although its cost-effectiveness has been questioned. darbepoetin-a (aranesp, genesis pharma sa) is a novel erythropoiesis-stimulating factor that it has been shown to be equivalent to epoetin-a (eprex, janssen-cilag) in patients with chronic renal failure and cancer. darbepoetin-a has a longer serum half-life and higher relative potency than epoetin-a. this property leads to less frequent administration and may reduce drug cost. so far, no clinical trials with darbepoetin have been published in patients with surgical anemia. other ( . %) patients who required autologous and homologous blood, had average predonation hb level of (sd ± . ) g/l. we found a significant relationship between the need for postoperative transfusion and the predonation hb level (p = . ), predonation htc values (p = . ), weight (p = . ) and gender (p = . ): female patients and patients with lower predonation hb and htc, as well as patients with lower body weight more often needed additional homologous blood transfusion. no relationship was found between age of patients and the need for transfusion (p = . ). ( . %) patients with ptka were transfused with autologous blood only, and had average predonation hb level of (sd ± . ) g/l. other ( . %) patients transfused with autologous and homologous blood had average predonation hb level of (sd ± . ) g/l. the significant relationship was found between the need for postoperative transfusion and weight (p = . ): patients with lower body weight more often needed additional homologous blood transfusion. no relationships were found between predonation hb level (p = . ) predonation htc values (p = . ), gender (p = . ) and age (p = . ) of patients and the need for postoperative transfusion. conclusions: our results show that over % of patients needed only autologous blood. in our patients with ptha predonation hb was significant predictive factor for additional transfusion therapy, while in ptka it was not observed. in both groups of patients body weight was significant predictive factor, thus this feature seems important for planning of transfusion therapy in patients with ptha and ptka. aim: prevention results of loosen anastomoses on colon, with fibrin sealent (fs) application and influence on colagen production. materials and methods: investigations were done on rats, weight - g. in control group, after partial resection of left half of colons termino-terminal anastomosis was derivated. fs was applied in examined group. concentration of colagen was done indirectly, with quantitative l-hydroxyproline determination. place of anastomosis, cm proximal and cm distal of anastomosis, was analyzed iii, v, vii and xiii day postoperatively. results: analysis of hydroxyproline on the place of anastomosis showed higher hydroxyproline value in group with fs application. the highest approximate value of hydroxyproline was registered v day postoperatively. distal, cm of anastomosis, the quantity of hydroxyproline is higher iii day postoperatively in control group but v postoperative day value is intensively growing in group with fs application. electronic microscopical was done v postoperative day in control group at the place of anastomosis detected a defect with detritus and absence of larger colagen fibres. in group with fs application on the place on anastomosis, in the shape of bundle, colagen fibres were grouped and completely fills the place of anastomosis. conclusion: fs application accomplish higher concentration of colagen in all segments of isolated colon, that enables better healing of anastomosis. the study of the use of the safest blood (autologous blood transfusion) through preoperative blood donation (pbd) in surgery patients introduction: the use of the autologous blood is already under consideration in developed countries. thus, it is probable that autologous blood donation would be effective in one way or the other in reducing blood transfusion complications. in this study, pbd as the easiest method to use and the most cost-effective one was selected. aim of the study: it aims at improving blood safety and raising blood inventory. methods: in this study, patients, including males and females, intended to undergo elective surgery were selected as subjects to donate their autologous blood. the subjects with hematocrite level of about - percent as ordered by their physician donated their blood by this method. blood collection procedure was followed at - day intervals. the blood volume taken from patients in every collection differed from - ml according to their weight. results: this study showed that in all patients undergoing plastic, gynaecological, jaw, and ent surgeries autologous blood transfusion was used with no need for allogenic transfusion. in other surgeries, including orthopaedics, the need for allogenic transfusion was estimated to be at about percent of cases. to avoid the complications of allogenic blood transfusion, the safest way is the use of autologous blood which involves low cost and is easy to perform. the introduction: the purpose of this study is to describe a technique to perform labelling of autologous platelet-gel with in-oxine and to evaluate its usefulness, after in vivo graft implant, as a marker of bone osteoinduction by means of scintigraphy, in patients with jaws bone defects following the enucleation of cystic lesions and cystic lesion derived from extraction of deeply impacted lower third molar. methods: agp made. consent was obtained by patient to conduct hiv and hbv testing. briefly, cc to cc of blood is withdrawn from the patient. the blood was separated, by means of successive step of centrifugation, in to platelet-rich plasma (prp) , platelet-poor plasma (ppp), and red blood cells (rbc). the red blood cells were discarded. the prp [comprises of approximately % of the total blood volume withdrawn] had platelet counts of - /mm . the procedures of agp labelling were performed in laminar flow chamber. to seconds the solution will assume a gel-like consistency forming platelet gel. imaging: the scintigraphy was performed h after application of labelled agp (early scan) and at , , , h (delayed scan) by means of a gamma camera equipped with medium energy collimator. a later scan was performed at days after graft. the platelet uptake index (pui) was then calculated by dividing the cpm/pixel in the graft roi (recognized in and planar and trans-axial slice) for cpm/pixel in a mirror background roi. in vitro sampling: the radioactivity of the plasma samples collected at , h and at lapse time = h for days, were used for the plasma clearance determinations and for in vitro studies of the platelet loss from the gel. results: all patients presented early high concentration of in oxine agp, at site of the graft, that was easy recognized at scintigraphy performed as in anteroposterior and lateral planar projection of the jaw as in spet slices reconstructions. all labelled agp was well confined within area of original implant and no activity was seen in the surrounding tissues or in the distant organ. conclusion: all patients studied well tolerate the implant of agp; no adverse reactions were observed and follow up -performed months later -showed bone remodelling activity in the site of the graft. serial blood donations in a ko pregnant woman with the use of recombinant erythropoietin for intrauterine transfusions of severe hemolytic disease of the newborn due to anti-ku biweekly) were administered to the mother to ensure an adequate supply of compatible rbcs for intrauterine transfusions and possible perinatal haemorrhage as well. results: intrauterine transfusions were repeated every - weeks. by the th week of gestation the patient had donated four units of blood, her hematocrit was %, anti-ku titre was / and four intrauterine transfusions had been performed. cesarian section was decided and the apgar of the newborn were and at and min. the newborn was treated with phototherapy but without exchange transfusions and two weeks later he was discharged. by the th day of life rh-epo was administrated to him due to anemia. the maternal red cells completely disappeared from the child's blood by the day . the experience of the use of erythropoietin in pregnancy is minimal. as illustrated by this case treatment with rh-epo and iv fe has effectively increased mother's capacity to donate rbcs' for autologous use and intrauterine transfusions as well, with no adverse effects to the mother or the child. however, further research is necessary to evaluate if rh-epo crosses the placenta. introduction: blood components should be transported by a system which has been validated. the containers used for transport should be well insulated, some form of temperature indicator should be used to monitor the in-transit temperature. whole blood should be stored at different temperatures above °c. aim of the study: bags with whole blood collected in a collection site are transported in containers without active cooling. we tested temperature of blood in containers put into the extreme weather conditions (+ °c, - °c) during loading test for transport. methods: the container without active cooling was filled with the exact number of bags with blood and the exact number of passive cooling elements (frozen water cubes in plastic) placed in the exact positions without close contact with the blood bags. the bags with blood of the temperature + °c, + °c and + °c were used. temperature indicators were situated in the bottom, centre and top of the container. filled container was placed into thermostat (+ °c) or freezer (- °c). the temperature was observed in min intervals for three hours, first measurement was min after putting into freezer or termostat. results: (see table ) nt, non tested; tmp, temperature. in the table there are shown minimum and maximum temperature parametres observed during tested time including increasing or decreasing trend. conclusion: loading test for transport of the bags with collected whole blood helps us to optimize transporting system, especially number of cooling elements in relation to the season and its place in the container. in the light of presented data we corrected transporting system to maintain the recommended temperature during transport. background: since , we have produced pooled and filtered platelet concentrates out of four buffy coats in tsol platelet additive solution and have stored them in pall autostop clx bags made out of pvc/totm. the residual plasma content is between - %, the mean volume about ml and the mean platelet-content is . ¥ per unit. for pathogen inactivation or bacterial screening it is necessary to extent the storage time from to days. new foliage like polyolefin is supposed to maintain a good quality environment for prolonged storage of platelets. aims: storage bags made out of polyolefin (pall autostop elx) were tested to prove their suitability for prolonged storage of platelets. methods: twins made out of pools from buffy coats were produced with the standard method, one twin was stored in the conventional bag (cb) the other in the new foliage bag (nfb). the platelet pools were stored on flatbed shakers at °c, and sampled at day , day and day . ph, glucose, lactate, hypotonic shock response (hsr) and p-selectin expression were measured by standard in-house methods. results: mean ph on day with cb was . , with nfb . ; glucose with cb . mmol/l, with nfb . mmol/l; lactate with cb . mmol/l, and with nfb . mmol/l, hsr with cb %, with nfb %; p-selectin with cb % and with nfb %. the new platelet storage bag showed better results of in vitro quality markers, especially after day of storage. prolonging storage time will make it easier to introduce bacterial screening or pathogen inactivation techniques into platelet transfusion. the possibility to filter rbc either at °c or rt simplifies the preparation process. filtration at + °c enables to achieve a better leukoreduction performance. the nbs has successfully implemented this project which has the potential for improvement in patient safety and is predicated upon practical application and risk reduction rather than elimination. the impact of this work on the incidence of trali will require detailed, long term analysis of hemovigilance data using existing mechanisms. active communication, a team approach, perceived value of the initiative and the hard work of all staff involved were key success factors. quality assessment of buffy coat-derived platelets prepared from leucoreduced whole blood background: whole blood can be separated into; plasma, buffy coat and red-cell conc (rcc) by differential centrifugation and separation on a separation device. because of the high hematocrit of the rcc, % of the process time is needed for expression of the rcc. by increasing the internal diameter of the tubing at the bottom of a t&b system by . mm. a decrease of the process time is expected. methods: units of whole blood were collected with the new t 'wide boring' blood pack and separated on a routine base. quality control parameters were checked and the whole process time was monitored. free hemoglobine was measured up to days. results: process time of a 'wide boring' bag is significant shorter compared to a standard blood bag. average decrease: s. slightly increase in free hemoglobine is measured probably due to the increased express rate of the red cells. bloodproducts produced with the new t meet european guidelines. no significant increase of free hemoglobine due to the faster expression is measured. an significant decrease in process time is measured with the wide boring bloodpack. the new fresenius hemocare rcc in-line system: t can be used for routine production which will speed up the production process considerably. introduction: leukoreduction of blood components is required to prevent several transfusion-associated complications. aim: the aim of this study was the full process validation of the pall leukotrap wb system for the preparation of leukoreduced blood components. we collected whole blood units from donors suitable for donation using a quadruple blood-bag, which includes an wbf in-line filter (pall) for the removal of leukocytes and platelets. mixer balances (baxter) were used and donation occurred within min in all cases. after donation whole blood units were stored at room temperature for h. subsequently, whole blood filtration was performed by gravity at a standard height of cm using a blood leukoreduction cart (baby leuko cart, itl-corporation). filtered units were centrifuged at g ¥ min by an heraeus cryofuge i. an automatic extractor (bag press plus-bioelettronica) was used to prepare red cell concentrates in sag-m solution and fresh plasma units. air in the system was automatically expelled by the extractor. complete cell counts and hemoglobin concentration were evaluated in pre-filtration samples and at the end of the blood components preparation using an automated cell counter (pentra dx -abx). we enumerated residual leukocytes in red cell units by flow cytometry (becton dickinson-leucocount kit). results: pre-filtration data of whole blood and end-of-process data of red cell and plasma filtered units, are summarized in table . results are given as mean and standard deviation. whole blood filtration was completed within min in all cases. red cell units were transfused after a mean of days to patients affected from transfusion dependent ( %), post-surgery ( %), and post chemotherapy anemias ( %). no cases of transfusion reaction were observed. the pall leukotrap wb system was easily introduced in our setting. all blood components prepared by the system fulfilled the council of europe requirements with regards to hemoglobin content in red cell units and post-filtration residual leukocytes. future studies are needed to evaluate its cost-effectiveness in the setting of routine blood component preparation. background: during an evaluation of the compodock (fresenius hemocare) sterile connection device (scd), we observed irregularities on the inside of the tubing at the site of the weld. it was our aim to investigate the effect of these observations on the quality of blood products. methods: three leukoreduced red cell concentrates (rccs) were pooled and divided over bag systems: one without weld in the connecting tubing, one with a compodock-weld, and one with a weld made with the terumo scd. the rcc was transferred times over this tubing to have maximum result if the weld had deleterious effects. the rccs were stored in pvc containers, and sampled on day , , and , and free hemoglobin (hb) was measured. the same procedure was also performed using platelet concentrates (pcs), but these were stored in polyolefin containers, sampled on day , and , and cd expression was measured. ten experiments were performed per blood component. according to who standards processing of blood into labile components are considered an expression of quality of transfusion service. in our practice, modern transfusion principles are successfully applied. they cover blood collection, serological processing of blood units, technological preparation of blood products (gmp, sop) and rational utilization of blood components and blood derivatives. in the past four years ( , .) aberrations from these principles have taken place (self-sufficiency). nbti collected x = ( ) blood units into blood bags. in serbia x = ( ) blood units. retrospective analysis: ldpc-bc was administered x = % with the satisfactory haemostatic effect. increase of the cyta and plasmapheresis-manual procedures was also noted ( %). increase of the use of leukocyte poor red blood cells was also registered ( % introduction: according to the relevant recommendations of the council of europe, whole blood is a source material used for the preparation of blood components and blood products. basic concept of the therapeutic use of blood components is the compensation of the lacking or deficient blood component. in that way, a possibility of the infusion of unrequired or deleterious components of whole blood is eliminated. objective of this presentation is to analyze the reasons of non-utilization of certain blood units, the actual quantity and ratio. aim of the study: the purpose of our in vitro study is to compare storage of platelet concentrates at °c with platelets stored at °c, and to determine the in vitro-effects of pre-incubation at °c for h prior to analysis on the basis of the maintenance of platelet metabolic and cellular integrity. methods: platelets concentrates (pcs) were prepared from pooled buffy coats (bc) for paired studies to be stored into different conditions. (i) at - degree on a flat bed agitator; (ii) at - degree on a flat bed agitator and pre-incubated for h prior to analysis; (iii) at °c; and (iv) at °c and pre-incubated for h prior to analysis. this paired in vitro study (n = ) over days include volume, platelet counts, mpv, volume, ph, po , pco , bicarbonate, glucose, lactate, swirling, leucocytecount, hsr, esc, atp, ldh and release of a-granule content (rantes, ß-thromboglobulin and pf ). results: platelet count (day and ; p < . ), mpv (day ; p < . ), ph (day and ; p < . ), pco (day and ; p < . ), bicarbonate (day ; p < . ), glucose (day , , , and ; p < . ), atp (day and ; p < . ) was significantly higher in platelets stored at °c and platelets stored at °c with preincubation. ldh (day ; p < . ), bicarbonate (day and ; p < . ), lactate (day , , , and ; p < . ), ph (day and ; p < . ), esc (day , , , and ; p < . ), hsr (day , and ; p < . ) was significantly lower in platelets stored at °c and platelets stored at °c with pre-incubation. the concentration of rantes, ß-thromboglobulin and pf was significantly higher in platelets stored at °c than in platelets stored at °c (day , , , and ; p < . ). hsr (day and ; p < . ) and esc (day , , and ; p < . ) was significantly higher in preincubated platelets stored at °c compared with platelets stored at °c. conclusion: platelets stored at °c maintain metabolic and cellular characteristics to a great extent during days of storage. we confirm the loss of platelet discoid shape and have shown that loss of discoid shape in platelets stored at °c is associated with decreased metabolic rate and decreased release of a-granule content. aim: as reference centre of the swiss blood transfusion service for new materials and blood products we evaluated that system for routine use and official registration in switzerland. method: whole blood donations were collected in a whole blood filtration set with cpda- and stored at room temperature for h before filtration at room temperature. the leucodepleted whole blood was stored for days. following parameters were analysed on day , , : free haemoglobin in%, k. in addition leucocyte count was performed on day and a blood culture on day (see table) . blood cultures on day remained negative and all counts of residual leucocytes were below ¥ (exponential) /unit. summary and conclusion: as expected there was a clear increase in k and free haemoglobin after day . however the results were within the required specifications from the european and swiss guidelines up to day . we conclude that autologous leucodepleted whole blood can be stored in cpda- -for days without loss of stability of the red cells. we will introduce the system to the offi-cial material list of the swiss blood transfusion service and then implement the procedure to our daily routine. results of ffp production from whole blood, and of ffp and pc produced by use of cell separator over a -month period before and after the introduction of measures for trali prevention are presented. the following measures were undertaken: ( ) blood of female donors was not used for ffp production, and plasma was only used for fractionation ( ) plasma of female donors was not used for kt-bc pools ( ) platelets and plasma were produced on a cell separator only from the female donors without a history of pregnancy. female donors of whole blood: %*; %** ffp produced by plasmapheresis: %*; . %** female donor units on cell separator: . %*; . %** ffp from total plasma units: %*; %** plasma units used for bc-pc pools: %*; %** *period before and **after the introduction of measures for trali prevention the exclusion of female donors had no major impact on the production of ffp and bc-pc pools from whole blood because of the very low rate of female subjects in the croatian blood donor population. the amount of plasma and pc collected from female donors by use of cell separator was significantly lower (~ %), however, without any major impact on total ffp store because of the small rate of plasma and platelets obtained by apheresis. background: platelet concentrates (pcs) are currently stored for a maximum of days. extended storage to days would increase the supply and reduce the waste of pcs. transfusion-associated graftversus-host-disease (ta-gvhd) is a severe transfusion reaction caused by t-lymphocytes in the transfusion product. the risk of developing ta-gvhd can be prevented by gamma irradiation of the pcs. various in vitro tests can be used to study the quality of pcs such as inspection of the swirling phenomenon, hypotonic shock response (hsr), detection of platelet surface markers (e.g. cd p and cd b), metabolic parameters and blood gases. free oscillation rheometry (for) using the instrument reorox® can be used to monitor the coagulation over time in whole blood, pcs and plasma samples, and to obtain information about clotting time and coagulum elasticity. aim of the study: the purpose of this study was to evaluate the quality of pcs obtained by apheresis technique during storage for days and to study the effect of gamma irradiation by using several in vitro methods including for. methods: platelets were collected from healthy donors (n = ) using apheresis technique. the pc from each donor was divided in units, one served as control and the other was gamma irradiated with gy. the pcs were stored on a flatbed agitator at °c for days. samples were taken on day (= day of collection) for analysis of blood gases, metabolic parameters (glucose and lactate), platelet count and swirling. samples taken on day , and were also analysed for hrs, cd p (p-selectin) and cd b (gpib) expression utilising flow cytometry. evaluation of coagulation by for was performed on day , and . the maximum elasticity (g'max) and the time to g' were evaluated from the for elasticity curves. results: there was no difference between irradiated and nonirradiated pcs regarding any of the tested parameters during the storage period. swirling, hsr, platelet count and percentage of cd b expressing cells were well maintained for days of storage. glucose decreased and lactate increased significantly during the storage period, from . mmol/l to . mmol/l for lactate and from . mmol/l to . mmol/l for glucose. the percent cd p expressing cells increased significantly during storage from % on day to % on day . po was well maintained but ph increased and pco decreased significantly between day and whereafter ph decreased and pco continued to decrease. the for parameters g'max and time to g'max increased significantly between day and and the time to g'max continued to increase significantly between day and . the results indicate a well preserved platelet quality after storage for days. gamma irradiation did not affect the platelet quality. cytokine release during storage of buffy coat platelet concentrates produced manually and automatically background: transfusion reactions following platelet transfusion are still a problem even when leukoreduction is included in the production process. platelet derived cytokines released during storage upon activation or lysis, accumulate in the platelet products and have been suggested to be involved in transfusion reactions. rantes (regulated upon activation, normal t cell expressed and presumably secreted) is a chemokine playing an important role in the inflammatory immune response and causes degranulation of eosinophiles and release of histamines from basophiles, which again can cause allergic reactions. tgf-b (transforming growth factor b ) has been shown to be immunosuppressive, inhibits the proliferation of t-and b-lymphocytes and decreases the secretion of igg and igm from b-lymphocytes. aims: as part of our quality control program, we aimed to quantify the amounts of rantes and tgf-b released during storage in platelet concentrates produced from pooled buffy coats by our manual routine method (m-pcs) and by an automated method using the orbisac system (gambro) (a-pcs). methods: pcs were produced from buffy coats. following overnight storage at - °c, buffy coats were pooled with ml t-sol (baxter). forty-two pcs were produced either manually (n = ) using the imugard iii s-pl set (terumo) with integrated soft leuko-reduction filter or by the automated procedure (n = ) using the orbisac validation bc set (gambro) equipped with the lrp leuko-reduction filter (pall). swirling was scored visually, platelet count and mpv were measured on a cell counter (cobas argos, roche), and blood gas analyses, glucose as well as lactate were measured on an abl series analyser (radiometer). samples for testing of cytokines were centrifuged for min at g, °c; supernatants were harvested and frozen at - °c until analysis. cytokines were quantified using quantikine human rantes immunoassay (r&d systems) and human tgf-b elisa immunosorbent assay (bender medsystems gmbh). all analyses were performed on days , and . results: platelet concentrate volume (mean): m-pcs: ml, a-pcs: ml. platelet yield was found to be . ¥ for m-pcs and . ¥ for a-pcs (p < . ). in all pcs ph levels were between . - . . glucose consumption and lactate production from days - and days - did not differ significantly. rantes levels (pg pr plts) were significantly higher in a-pcs than in m-pcs (p = . , repeated measures analysis of variance), but no significant difference was found in tgf-b levels (pg pr plts). summary and conclusions: preparation of buffy coat platelet concentrates by the automated orbisac system improves platelet yield compared to our manual processing procedure, but the levels of the chemokine rantes were significantly highest in the automatically produced products. the clinical importance of these findings is still unclear, but may be related to the shear stress the platelets are subjected to during the automated production process. the quality of cryopreserved vs liquid stored platelets: a comparative study table . the mismatches can be divided into the two categories. the first of them is characterized by differences in allelic groups, i.e. at low-resolution level. allelic group differences were detected in the group with one mismatch, most of them in hla-c locus (this locus was not concluded in primary donor search). in the other category there are differences in alleles within the same group, i.e. at high-resolution level only. differences within the same group in all tested loci were detected in the group with one mismatch. the mismatches described above were heterogeneous and a correlation of specific mismatch with transplantation outcome was not possible in this group. conclusion: the use of high-resolution dna methods makes the identification of hla match/mismatch more accurate and can affect the outcome of unrelated hsct. this work was supported by the grant iga mz, no. nr/ - . pre-freezing and post-thawing quality controls in umbilical cord blood assigned for transplantation p bergamaschi, c perotti, g viarengo, c del fante, c parisi, a marchesi, l bellotti and l salvaneschi irccs policlinico 'san matteo', pavia, italy background and aims: nowadays umbilical cord blood (ucb) represents a well established source of haematopoietic stem cells for unrelated transplantation in children affected with haematological and inherited diseases. thanks to the large-scale banking of unrelated units and the preliminary encouraging results, ucb employ in adults is quickly growing up. in this context, total nucleated cells (tnc) count of the graft is considered the main predictor for clinical outcome; however, other indicators of the haematopoietic potential, such as cd + cell content and short-term culture clonogenic assay, are recommended in accordance to netcord-fact stan-dards. in order to guarantee the safety and the prompt availability of a ucb unit assigned to a matched recipient, a pattern of rigorous quality controls should be carried out not only at the time of cryopreservation but also before the release for transplant. we report the results of the quality controls performed on thawed cryovials referring to the units delivered by our ucb bank compared to the pre-freezing values. methods: every ucb unit stored in our bank is accompanied by satellite cryovials available for subsequent controls. for each unit issued for transplantation, one cryotube was thawed in °c water bath with gentle agitation without washing out dmso. tnc and mononucleated cells (mnc) were estimated by an automated cell counter; viability and cd + cell count were evaluated by flow cytometry with a no-wash, single-platform technique and aminoactinomycin d. cfu assay was performed using commercial reagents (methocult gf h , stemcell technologies) and colonies were counted after days. the same tests were performed before cryopreservation, taking a sample from each fresh unit. moreover, before the delivery for transplant, a second cryotube was thawed to investigate the bacterial contamination by direct microbial culture, whereas the sterility test before freezing was performed by inoculum into ml media (bact/alert®fa/fn, biomérieux inc). results: the ucb characteristics before freezing and after thawing are detailed in the tables , and . post-thawing tnc and mnc, as well as cd + cells, showed no significant difference in comparison to the pre-freezing values. despite of the expected decrease of the overall viability after thawing, we observed a highly satisfactory viability referred to the cd + cells. the colony forming units (cfu) growth after thawing was documented and was always lower as respect to the pre-freezing assay. finally, the results of microbial cultures were negative for all the units on both fresh and thawed specimens. conclusions: in our experience, well standardized evaluation of ucb content could be obtained with regard to tnc, mnc and cd + cell. concerning the results of short-term cultures, the presence of dmso as inhibiting factor may be advocated to explain the discrepancies between fresh and thawed samples. finally, rigorous quality controls documented that the procedures of manipulation and cryopreservation did not affect the quality of ucb to be infused for transplant and provided to the physician all the parameters necessary for a safe transplant in a close and appropriate time. bone marrow transplantation or bmt transplantation of progenitor blood cells to regenerate blood normal cells in patients with blood disorders. bone marrow has an organized and structured architecture in which close relationships exist between a regulatory microenvironment and primitive hematopoietic cells. in fact, normal hematopoietic cells depends on critical interactions that occur between stem cells and their microenvironment. this microenvironment is a complex meshwork composed of growth factors, stromal cells, and extracellular matrix. marrow injury can occur as a consequence of a variety of diseases. some diseases could be due to a microenvironment that fails to support hematopoiesis. a possibility is that aplasia and leukemia share a common etiology such as drug, chemical, radiation, virus or other environmental hazards. we can say that microenvironmental abnormalities in interactions between stromal cells and hematopoietic progenitors may be important in the pathogenesis and clinical expression of hematopoietic malignancies in humans. background: intrauterine growth retardation, with associated low birth weight, represents one of the most important cause of baby mortality and morbidity. understanding the genetic bases of this adverse event is still an open goal. there is evidence that motherchild hla compatibility and hla-drb foetal genotype are associated with a reduced placental growth and a low birth weight. the recent institution of cord blood banks, with their huge amount of hla types, offers an unique opportunity to look inside the molecular bases of normal birth weight. aims: we investigated whether the baby-linked immunogenetic profile, i.e. hla gene frequencies and homozygosity rate, affects the physiological variance of the size at birth. methods: cord blood units ( from males and from females) were hla typed with pcr-ssp and/or reverse pcr-sso techniques and recorded in the cord blood bank database of pavia-italy. all were defined at low resolution level for hla-a and b genes and at high resolution for hla-drb . blood units were also randomly typed for hla-dqa and dqb at high resolution. results: mean birth weight was g and mean relative birth weight (i.e. corrected for gestational age according to the gender) was . g. babies were < th centile ( g) and were > th centile ( g). comparing the hla allele distribution in these extreme bands we found that hla drb * was significantly associated with high relative birth weight: . % in th centile vs . % in th centile, p = . . on the contrary, hla-drb * and dqb * were associated with low relative birth weight: . % and . % respectively in th centile vs . % and . % in th centile p = . and p = . . all infants were analysed as to the effect of the above mentioned alleles. we confirmed the positive association of hla-drb * and higher relative birth weight (mean . vs . ; p = . ) as well as the association of hla-drb * with lower relative birth weight (mean . vs . , p = . ). no significant association was found as far as hla homozygosity was concerned. conclusions: the present findings confirm the role of foetal hla-drb gene in the intrauterine growth. about the specific involved alleles, one possible explanation comes from the studies of crystallography and amino acid sequencing of hla-dr binding groove. it has been demonstrated that hla-drb * and hla-drb * genes encode for different amino acid sequences in the pocket of the molecule (aa , , ). this implies distinct functional restriction patterns. the sequence motif of hla-dr is characteristic of some autoimmune conditions, such as hashimoto's thyroiditis, and preeclampsia which is associated with intrauterine growth retarda- which provides a high yield and excellent purity without lymphocyte and erythrocyte contamination. in a month period, we studied blood samples from bone marrow transplant patients and from normal subjects. the extraction of leukocyte polymorphonuclear was obtained with a %- % dextran solution in . % saline. after incubation at room temperature with lymphopre solution, the mixture was centrifuged. two clear and separate rings of mononuclear and pmn leukocytes were obtained. to eliminate any red blood cells, pmnl ring was separated and washed three times with cold ammonium chloride. after a short period of incubation °c, mixture was centrifuged and the pmnls were isolated. the purity and viability of total leukocyte population was counted and the percentage of pmnl obtained was established. the total blood samples studied were divided in two groups, i.e., bone marrow transplant patients and normal subjects. in both cases the pmns isolated were of high purity and viability. the overall percentage of pmnls obtained from both groups under study was % to % when stained with gimsa or wright staining method. the viability of isolated pmnls was also % too, which is excellent for numerous immunological or molecular studies. the pmnls isolated by this method were highly pure and viable in comparison with standard methods used to isolate human pmnls. generation a high amount of pmnls is another advantage of the suggested method. this method to separate pmnls is recommended for in vitro studies of different subjects. et al. .) the object of exchange transfusion (et) is to remove bilirubin already present in the plasma or remove alloantibody which can cause hemolytic disease (in order anti-d, anti-c and anti-k are easily the most important) or remove anti-d positive red cells. we have studied exchange transfusion in our hospital in neonatal intensive care unit, during to . at delivery cord samples were taken for determination blood group, rhesus, hb and ht have been counted. also direct antiglobulin test (dat) has been performed. in cases of positive dat, hb and bilirubin levels were monitored. newborn body-weight were weighted (ranged g to g). the blood for et was of group o, d negative and kell negative and was compatible with the serum of mothers; it was less than days old. the blood was screened for hbs and for anti-cmv as well as being submitted to all usual tests. the method has been determined by using the umbilical vein; the multi-way tap makes it possible to draw blood from the infant into the syringe, to discard the blood into a sterile empty vessel, then to draw blood from a donor unit into the syringe and inject this into the infant. results: exchange transfusions were carried out. four out of et due to abo incompatibility mother-newborn. five out of due to rhesus incompatibility mother-newborn and eight out of due to jaundice undetermined origin and immaturity. the last two years only three et were carried out due to immaturity. conclusions: phototherapy, when applied early enough and with sufficient intensity, can avoid the need for exchange transfusion in many infants. phototherapy alone or phototherapy plus high dose igg therapy has been used to minimize exchange transfusions in this population. detection abo blood group system antibodies of neonatal using fully automated column agglutination technology (auto-vue) background: the abo blood group system remains the most important in transfusion practice. this is because of the regular occurrence of the antibodies anti-a, anti-b and anti-a, b reactive at °c, in persons whose red cells lack the corresponding antigens. the regular presence of anti-a and anti-b is used in the routine determination of abo blood groups; in addition to testing red cells for a and b antigens, the group is checked, in serum or reverse grouping, by testing the serum against red cells of known abo groups. methods: samples were taken from newborns at first h of life for abo blood group typing during - . simultaneously the presence of anti-a and anti-b antibodies has been studied using fully automated column agglutination technology (auto vue ortho diagnostic systems) with bio-vue cassettes aborh/reverse. the column agglutination technology is based upon the ability of glass beads to form a physical barrier between agglutinated and unagglutinated red cells. to determine the abo serum group, test serum and abo reagent red cells were added to the top of column containing diluents. the abo grouping columns were centrifuged and examined for agglutination. the presence or absence of agglutination has been recorded. results: in out of newborns were found detected antibodies anti-a, anti-b. in out of newborns no antibodies were found. in out of were found antibodies maternal origin. the automated reader detected all positive reactions. positive results were recorded on a scale from + . to + . conclusions: the technical performance of device allows objectivity and precision to detect abo blood group antibodies of newborn. the origin and the type of antibodies and also factors that influence their presence are to be studied. introduction: diagnosis, management and prevention of red blood cell immunization have improved, so hemolytic disease of the newborn (hdn) has changed from a common to a rare pathology. aim of the study. in this study we have retrospectively evaluated the benefits of the immunohematological screening for the management of pregnancies with alloimmunization. methods: in the last years, we have performed an immunohematological screening on all pregnant women assisted by our hospitals. ab and rh typing, antibody screening and, eventually, identification and titration were performed on maternal specimens by microcolumn technique. results: not considering ab incompatibilities, we have discovered alloimmunized women with the following specificities: anti-d, anti-c, anti-c, anti-e, anti-jka, anti-d + anti-jka, anti-d + anti-s, anti-d + anti-c, anti-d + anti-c + anti-k, anti-s, anti-k, anti-m, anti-c + anti-e and anti-d + anti-c + anti-g. the most severe hdn were the d + c + g, the c + e and out of c newborns, with mean hemoglobin between and g/l, bilirubin = . g/l, reticulocyte count = %. in these exchange transfusion needed at the delivery. other newborns were only treated with phototherapy. conclusion. thanks to the immunohematological monitoring, the diagnosis of alloimmunization, the correct management of pregnancy and the adequate neonatal therapy were possible. in fact all newborns survived and showed no neurological lesions in the following controls. conclusion: in order to provide a highly specialized perinatal care, immunohematologist, obstetric and pediatric should provide a good antenatal and perinatal screening. this is an interesting case of rhd immunisation in rhd negative woman despite the application of rhd immunoprophylaxis. case report: a blood sample of pregnant woman, years of age, in th gestation week, was sent to our laboratory for serological analysis. her blood group was o, ccddee and she had an anti-d antibody reactive only with enzyme treated panel of test erythrocytes. her husband was a, ccdee, and two children were both a, ccddee. on the next visit, she gave the data of one arteficial and one missed abortion before the th gestation week covered with mg of rhd immunoprophylaxis, but without the measurement of fetomaternal haemorrhage (fmh). both of abortions were after the deliveries. until the end of the pregnancy, detailed serological analysis showed anti-d specificity of antibody in her sera which remained reactive only with enzyme treated red blood cells. the fetus was under permanent ultrasound control. she delivered a mature, rhd positive, ccdee male child, without any sign of haemolytic disease. the proper personal history, measurement of the size of fmh, distinguishing the anti-d and anti-g specificity of the antibody, administration of rhd immunoprophylaxis and cooperation between transfusion medicine specialists, gyneacologists and neonatologists still remain major principles of prenatal and perinatal care concerning haemolytic deisease of the fetus and newborn caused by anti-d antibody. anti d antibody, reactive only with enzyme treated red blood cells is usually harmless for fetus and the newborn. introduction: red blood cell (rbc) transfusion is widely used in neonatal intensive care units for acute or chronic pathological conditions. clinical indications for rbc transfusion are shock, sepsis and/or anemia with the following laboratory criteria: a) hematocrit (hct) < % or hemoglobin (hb) < g/dl and reticulocytes < %; b) hct < % or hb < g/dl in these conditions: o required < %, recurrent apnoea and bradicardia, cardiac rate > bpm and respiratory rate > bpm for more h; c) hct < % or hb < g/dl with severe respiratory distress. aim of the study. aim of this study has been to evaluate the effectiveness of rbc transfusion therapy in premature and at term newborns independently of initial pathological conditions. methods: our therapeutic objective has been to achieve an hct of % after the whole cycle of transfusion therapy. for each little patient, the volume of transfused rbc unit has been calculated, according to international guide lines, using the following criteria: weight (kg) ¥ blood volume ( ml per kg if premature or ml per kg if at term newborn) ¥ (hct desired -hct observed)/hct of unit transfused. particularly we have considered that premature infants (with a gestation age of - weeks) show a range of weight from to . g, while at term newborns from . to . g. in order to avoid a circulatory overload, the indicated hemocomponent has been always packed rbc with higher possible hematocrit. for the same reason, the rate of infusion has been always - ml/kg/hour. methods: this is a descriptive study. the name of the neonates who received transfusion was obtained from the blood bank of beheshti hospital. information concerning the type of blood product, frequency and indication of transfusion, sex, gestational age and weight of infants was recorded in questionnaire and analyzed. results: out of neonates admitted during one year, ( male, female) received blood components. fifty four percent received one, % two and % received three types of blood components. the frequency of transfusions were times. the most common used blood products were fresh frozen plasma ( %), red blood cell ( %), whole blood ( %) and platelets ( %). all the blood products except whole blood were used more common in premature and low birth weight infants. appropriateness of transfusion of red cells, fresh frozen plasma, platelets and whole blood were %, %, % and % respectively. (hdn) . in accordance to current regulations, this study is carried out in all pregnant women attending in our service. according to our protocol, when an alloantibody of any specificity is detected through the liss-coombs gel technique, the same determination is made using papain-treated screen cells to detect any association with other antibodies which could be of clinical relevance for a hdn. there are scientific evidences that the use of enzymatic techniques increase the test's sensitivity, though clinical relevance of 'enzyme only antibodies' may be questioned. aims: demonstrate the importance of a routine identification of irregular antibodies in pregnant by two methods (liss-coombs -enzymatic) and the prevalence of anti-d associated antibodies, only detected by using enzymatic technique. analyze the need to carry out a follow up of sensitized patients to determine if the associated antibodies only detected with in an enzymatic medium can be detected with a liss-coombs medium during pregnancy, thus acquiring clinical significance for hdn. materials and methods: between january and december we studied d-negative pregnant women. the studies performed were: abo grouping, d and weak d, rh phenotype, direct antiglobulin test and irregular antibody detection (iad) against commercial screen cells with liss-coombs (diamed) ® gel-medium technique, according to the manufacturer's specifications. when iad were positive, an antibody identification using two commercial cell panels with gel techniques (liss-coombs-enzymatic) was performed. along the pregnancy, periodic controls were carried out to determine the exact moment when antibodies, previously only identified in an enzymatic medium, could be detected in a liss-coombs medium (clinically significant antibodies). results: out of d-negative studied samples, ( . %) had a positive dai and it was only showed anti-d specificity in a liss-coombs medium. after analyzing this specificity against enzymetreated erythrocytes, it was possible to determine that patients ( . %) had in their serum other anti-d associated alloantibodies: anti-k ( . %), anti-c ( . %), anti-e ( . %) and anti-c + e ( . %). during the immunohematologic follow up, it was determined that in / patients some of the antibodies which were previously only detected in an enzymatic medium, could be identified in a liss-coombs medium and later they were identified in the red cell elution of the newborn. conclusions: these results confirm the relevance of a screening for irregular antibodies of clinical importance by means of a conven-tional technique and one of increased sensitivity in all pregnant women. the detection of an association of antibodies provides information for the undertaking of diagnostic and therapeutic measures, both by the obstetrician, as for any eventual transfusional requirements for hdn. it was also concluded that, although antibodies detected in an enzymatic medium are considered of low clinical significance, its investigation and follow up is suggested in pregnant women to determine the moment in which they can be detected in an antiglobulinic medium, thus revealing their clinical significance. background: fibrin glue is one of the most complex human plasma derivatives both in terms of composition and clinical applications. this product mimics the last step of coagulation cascade through activation of fibrinogen by thrombin, leading to the formation of a fibrin clot in the presence of factor xiii. in contrast to synthetic adhesives, the significant advantage of this plasma-derived sealant is its biocompatibility and biodegradability as well as the fact that it does not induce inflammation, foreign body reaction or extensive fibrosis. readsorption of the fibrin clot is achieved during wound healing within days/weeks following application, depending upon the type of surgery, the amount and type of product used or the proteolytic activity of the treated site. the risk of virus transmission by commercial fibrin glue products is still debated and investigators are looking for alternative fibrinogen sources. many of these studies rely on autologous on single donor cryoprecipitate as source of fibrinogen. aims: the aim of this study was to compare single and double methods of cryoprecipitation of fibrin glue. the influence of different plasma preparation methods and plasma storage temperatures (- °c and - °c) on the quality of fibrinogen concentrate was examined. methods: whole blood was collected by standard phlebotomy technique and centrifuged at ¥ g for min within h of collection. plasma was removed. four units of plasma were pooled into a ml bag, mixed, divided into parts (aprox. . ml) and immediately frozen. two of these units were stored at - °c and units of ffp at - °c. after one month the plasma was thawed at °c during - h. the fibrinogen concentrates ( - ml) were received by single and double cryoprecypitation. to compare single and double methods of cryoprecipitation, the levels of fibrinogen, fibronectin, plasminogen and factor xiii were determined. results and conclusion: the levels of fibrynogen were significantly higher in fibrynogen concentration obtained by double cryoprecypitation from plasma stored at - °c. there were no significant differences in the level of plasminogen in both tested groups. double cryoprecipitation of a single unit of plasma (stored - °c) is an efficient, simple and safe method of obtaining fibrin glue. background: talking about professional risk we generally consider the risk of acquiring some kind of infective disease through accidental injury. in this article i would like to point out another side of the problem-the risk of making preventable medical error. with all its consequences. aim: how blood transfusion errors are among the most serious types of medical errors, the final goal is to initiate nationwide, regular, mandatory error reporting. information obtained, distributed and openly discussed at professional meetings will contribute to improving the patient safety. at the same time it would contribute to avoidance of blaming and shaming of many health care providers. prevent what preventable could be! method: retrospective analyze was conducted at the middle size blood transfusion center ( donations per year and utilization of approximately of components). results: after clearly distinguishing adverse events due to underlying patient condition from preventable medical error we fined out that: -great majority of adverse events resulted from medical error -every part of blood transfusion center, from blood donation ward, through laboratory testing to component issuing has it' weak points' or vulnerable places -any educational level is equally liable to error there is no significant difference about occurrence time: -working day/holiday -emergency/routine request -routine h/out of routine h -main error cause were as follows: -donor sample misidentification -rhd typing error -abo typing error -incorrectly performed cross match -recipient misidentification -wrong component prepared -sample confusion during freezing preparation conclusion: the truth incidence of transfusion medical errors is underestimated. mandatory report of fatal or 'only' harmful errors to the referent institution and its periodical announcement is the step ahead in preventing errors. those reports should be discussed at professional meetings (not at the 'yellow pages') and served as educational tool. but, as the most of the errors are system related, the key to reduce them is to focus on improvement of the system and nil for plasma. wastage rate was highest for plasma components. the influence of local practices on such discarding and whether avoidable shall be discussed. audit for blood discarding and corrective actions to minimize discarding is essential for all transfusion services and blood centers. designed technical and economic support. options include importing finished products and/or procuring products made from locally collected plasma. one approach is to consider local fractionation of plasma by building and operating a plasma fractionation facility, which may produce, finished products, or may produce intermediate products that are further manufactured in another facility. an alternative approach is the implementation of a plasma fractionation program where local plasma is sent to an established fractionator, and the plasma is fractionated following preagreed terms. the end products are returned to the country of the plasma supplier. in the national center for the production of blood products was established, under the direction of elias politis and years later in begun the production of dried plasma from greek donors. by the year the center started the production of fibrinogen and by the year the production of antihaemophilc factor. in all the activities of the center settled down due to administrative aspects. at the beginning of s a contract fractionation program was instituted (under the direction of k. sofroniadou) concerning the fractionation of liquid plasma and production of albumin, which by the end of year stopped and was replaced with a new contract for the fractionation of source plasma and the production of albumin. the challenge of adapting to the new and more stringent regulations governing the manufacture of blood products was great and brought a lot of changes in the structure of our center. a new bar-coding system ensuring the traceability of blood donations was instituted together with complex software for packaging and preparation of plasma shipments to the fractionation center together with all necessary paper work. a close collaboration with the medicines regulatory authority in order to be able to fulfill all the requirements that regulate issues associated to the quality and safety of human derived medicinal products. collaboration with blood collection establishments was promoted in order to increase the amount of plasma produced. there is a continuous effort from all the implicated parts in order to follow defined quality assurance procedures as highlighted by international guidelines for the blood donor selection, collection procedures, testing methods, donation handling, storage and transportation of plasma. the plasma contract fractionation program may serve, as an initial step prior to switching production to a locally built facility. this lapse of time may be used to expand the plasma collection potential, and to permit appropriate design, qualification and validation of the facility as well as training of local personnel. background: fibrin glue became a reality in the early s, when techniques for the isolation and concentration of clotting factors were improved. in , matras et al. described successful application of fibrin glue for peripheral nerve repair. this encouraging report prompted the use of fibrin glue in wound closure, skin grafting and bone union of osteotomies. the fibrinogen component of fibrin glue is produced from single unit donations of fresh frozen plasma. such procedure helps to reduce the risk of transfusion transmitted infections encountered by exposure to pools from large numbers of donors or by use of fibrinogen prepared from autologous blood prior to surgery. the second component, a mixture of thrombin and cacl , is commercially available. thrombin is applied to the operation site simultaneously and in equal volume to the fibrinogen but from a separate syringe. there are many methods of fibrinogen concentrate preparation but none of them has been described in detail. aims: the aim of this study was to choose/select the most effective, simple and safe method of obtaining fibrinogen concentrate (basic component of fibrinogen glue) which would also be easy to prepare in blood transfusion centers. methods of precipitation of fibrinogen by polyethylene glycol (peg), ammonium sulphate, ethanol or cryoprecipitation were compared. methods: plasma was obtained after centrifugation ( ¥ g for min) of whole blood. four units of plasma were pooled into a ml bag, mixed, divided into parts and immediately frozen. one of them was stored at - °c and after one month the plasma was thawed at °c during - h. fibrinogen was obtained by cryprecipitation and each of the three remaining units was precipitated with ethanol, peg and ammonium sulphate. the levels of fibrinogen, fibronectin, plasminogen and factor xiii were determined in each fibrinogen concentrate. results and conclusion: the level of fibrynogen ratio in fibrinogen concentration, obtained by peg and ammonium sulphate was significantly higher. cryoprecipitation is a simple, economic and reproducible procedure with the advantage of being performed in a closed system. plasma fractionation program in greece: an unknown history the provision of safe and sufficient plasma derivatives to meet the needs of local population requires special consideration and a well- (light cycler, roche diagnostic systems, nj) was used for the identification of the c y, h d and the s c point mutations of the hemochromatosis gene, and were based on protocols developed, for c y by the unidad de medicina molecular (ingo, santiago de compostela, espanha), and for the other two mutations by bolhalder m et al. the primers and probes were designed by tib molbiol (berlin, germany). results: the analysis of the percentages of genotypes and allele frequencies of the hemochromatosis gene mutations are described in the table. no differences were found between the patients and the controls. when we compared subgroups of patients based on their hepatitis c genotypes, a higher value for the c y allele was obtained ( . %) in individuals with genotype , however without statistical significance. discussion: hereditary hemochromatosis is a common disorder and is associated, in some studies, with a worst prognosis in patients with viral hepatitis. follow-up studies are necessary in order to evaluate if the presence of these mutations can cause a more severe course of the illness (greater risk to develop fibrosis or cirrhosis) and a different outcome when treated with antiviral drugs. also, it will be important to evaluate if aggressive phlebotomies will modify their clinical evolution. introduction: portugal has a higher prevalence of viral hepatitis, with probably more than . patients chronic infected with hepatitis b and/or c. hereditary hemochromatosis (hfe) is one of the most common causes of known hereditary illnesses with hepatic repercussion. hfe mutations are also found in linkage desiquilibrium with particular hla haplotypes, conferring, eventually, a different response to viral agents and antiviral drugs. in this study we evaluated the prevalence of the main mutations c y, h d and s c for the hfe in a population with chronic hepatitis b and/or c and in a cohort control. background: haemolytic disease of the newborn (hdn) is the destruction of the red blood cells of the fetus and neonate by antibodies produced by the mother. although postpartum rhig prophylaxis reduced the incidence of alloimmunization from pregnancy from % to - %, the doubt subsists if it is appropriate to use it as routine antenatal prophylaxis. material and methods: a total of samples ( mothers and newborns), from / / and / / , were studied. all abo, rh typing, antibody tests and dat were carried out in column agglutination tests. results: from the cases studied it was found cases without incompatibility ( %). from the incompatibilities, . % were abo, . % were rhd, . % were other rh incompatibilities, and . % were due to auto-antibodies. % of the mothers were rhd+ and % rhd-. conclusion: of the pregnant women studied, only were rhd-. from this group ( %) delivered rhd-newborns, what revealed that the antenatal prophylaxis they were submitted was unnecessary. from the pregnant women rhd-, % had incompatibility abo, which decreases to near % the risk of development of rhd immunization. being anti-d immunoglobulin a product that has the potential risk of infection transmission, is it appropriate to use indiscriminately as a routine antenatal prophylaxis? the introduction of molecular methods to determine the fetal rhd genotype could rationalize the use of antenatal anti-d immunoglobulin prophylaxis. introduction: the frequency of hla a haplotype expression has been found about - % in caucasian and in greek population particularly, . %. because of the high frequency, it is used widely in anticancer immunization. the immune system plays an important role in the defense against neoplastic disease and immune response show temporal chances related to circadian variation of antibodies and total lymphocytes in the peripheral blood. aim: the probable difference in the frequency of hla a expression and their lymphocyte phenotype into a group of cancer patients and a group of healthy donors, during screening of immunization with hla-combined peptides. materials and methods: healthy donors who proceeded in the department of transfusion medicine, university hospital of heraklion crete were tested for the hla a expression. in of these donors the expression of cd , cd , cd , cd , cd , cd , hla dr, cd +cd +, cd +cd +, cd -cd +, cd +cd -cd +, cd -cd -cd +, cd -cd -cd + was examined. meanwhile, patients with metastatic cancer who were hospitalized in the department of medical oncology, university hospital of heraklion crete, were tested for their hla a expression, while in of them for their lymphocyte phenotype. the antigens expression was examined in flow cytometry. the hla a expression in healthy donors was . % and in cancer patients % (p > . ). in table the mean, standard error, t-test and p of the two groups are included. (see table ). the two groups (healthy donors and cancer patients) revealed no statistical significant difference on lymphocyte phenotype, except of the cd expression, which was higher in cancer patients. summary and conclusion: the expression of hla a in cancer patients and in healthy donors was comparable. also, the lymphocyte phenotype among the two groups has not statistical significant difference, except of the cd (total b-cells). the significance of this result has to be investigated. in the course of original documents research i found out that dr. kalic, head of the first organized blood transfusion institution in the balkan region (at beograd, serbia, in ), set himself a professional goal: blood should be awaiting all patients and transfusion should not be a privilege of large city inhabitants only. dr. kalic's idea was that blood transfusion should be administered according to clearly given instructions and using simple blood sets. encouraged by the conclusions of the congress held in paris in , dr. kalic started preparations for the transport of blood to the inland. he concluded bravely that citrated blood could be sent by regular mail, as an ordinary parcel, without particular protection from the outside temperature. he advised his colleagues to use blood as an intravenous injection. blood was taken from voluntary female donor in belgrade (capital), march . after keeping it for days at storage, blood was forwarded on a two-day journey to a small town, kilometres away from belgrade. there it was kept on a room temperature before its final use for a treatment of a patient suffering from secondary anaemia. the patient underwent the procedure without side effects and responded to the transfusion with blood sent in this manner much better in comparison to earlier methods of direct blood transfused. reminding ourselves of the courage of our ancestors to implement their professional knowledge and personal original ideas in a new way with the desire to help the patient as successfully as possible, we pay them the deserved respect and gratitude for inspiring and encouraging us in this way to try the same. conclusions: automation leads to increased standardization, faster specimen processing and reporting, elimination of manual specimen identification, uniform interpretation of serological reaction patterns and objective reading of haemagglutination endpoints. using auto-vue allowed the staff uninterrupted time to perform quality assurance duties, extended antibody identifications, preventative maintenance, inventory control. the instrument allowed us to leverage current staff to a more productive, less stressful level. introduction: exosomes are - nm secreted vesicles produced by antigen-presenting cells (apcs). the finding that exosomes from dc pulsed with tumor-derived peptides elicited potent antitumor tcell responses and tumor regression in mice has led to the proposal that human exosomes could be effective vectors for antigen delivery in the context of cancer immunotherapy. aim of the study: to establish the method of producing a new kind of tumor vaccine -exosomes secreted by dc, pulsed with tumor peptides. methods: exosomes used in this study were generated from monocyte-derived dc pulsed with peptides from k tumor cell lines. exosomes were purified by the methods of ultrafiltration and ultracentrifugation. the methods of dynal magnetic beads, flow cytometry and western-blotting were used to determine the surface molecules of the exosomes. the function of the exosomes was deter- objective: to develop an immunoheatological technique for the study of erythrocyte hyaluronic acid sodium salt (cd ) receptor expression in red blood cells (rbcs) from adults and newborns. materials and methods: samples of anticoagulated blood from adults (n = ) and umbilical cordon (n = ) were used. several dilutions oh hailuronic acid sodium salt solution % (sigma l- h ) were confronted with % erythrocyte suspension in phosphate saline buffer (pbs) ph . . the rbcs were previously treated with an enzymatic solution of % bromeline in pbs ph . (sigma l h ). agglutination readings' were been by slow sharking after of h incubation at °c. the results were expressed through the sensibility parameter which involves titer and score. this is defined by a mathematical expression a = à si. di- . - (i = , , . . .) where si represent the score and di- is dilution inverse. the adult' rbcs showed a = ± , while en the newborn the parameter was a = ± . our results showed significant differences between both groups. conclusions: in this work, we present a simple immunohematological technique for the hyaluronic acid sodium salt (cd ) receptor expression in red blood cells, which could be a useful tool to evaluate the alterations of the receptor's expression in rbc. a new technology for crossmatching tests adapted to a fully automated system l gaillard, v desvigne, a boulet, l fauconnier and jm pelosin diagast, loos, france we have developed a new automated technology for crossmatching (compatibility) test suitable for automation and high throughput. the method does not require centrifugation steps thanks to the use of magnetised red blood cells (rbc). all the steps described are performed on the fully automated qwalys system. this methodology requires washing steps under magnetic field and is based on the fixation of sensitised rbc on the surface of a well coated with monoclonal anti-human globulins. in a first step, the red blood cells from target blood bags were magnetised during min. then the patient plasma is distributed on a microplate and incubated with the previously magnetised rbc during min at °c. excess of unbound immunoglobulins is removed by washing steps. in a third step, sensitised magnetised rbc were transferred in the antiglobulins coated plate and placed min on a magnet plate. wells in which antigen-antibody interactions have occurred display a confluent layer of rbc (positive reaction). the negative reaction appeared as a pellet in the middle of the well. the test can be read by an automatic reader or by naked eye. the patterns in the well are stable for at least h at room temperature. the plasma samples are provided by the laboratory of haematology of the chru of lille. the red blood cells are collected from segment of tubing of blood bags coming from the laboratory of blood donors of the efs (french blood services) nord de france-lille. the results are obtained in min. comparative studies showed that our new technology, without any centrifugation steps, is reliable and sufficiently sensitive and specific enough to perform cross matching tests using a high throughput automated system. the mechanisms of p -dependent apoptosis involve a set of genes that possess the ability to modulate oxidative stress. one of them pig , is induced by p through a microsatellite in its promoter region. this microsatellite has been proposed to represent an evolutionary adaptation of tumor suppressor mechanisms. microsatellite instability and genetic constitution, comprising the presence of the low repetition allele ( tgycc repeats), at this locus have been hypothesized to provide an increased risk for cancer development. aim: in the present analysis we examined this polymorphism in blood samples from voluntary health donors and compared it with human lung cancer samples, employing two different ethnic groups, greek and british. results: analysis of this locus in both types of samples showed: (i) the homozygous presence of the repeats allele only in the samples from healthy blood donors; (ii) a very low frequency of microsatellite instability (< %) and no loss of heterozygosity in matched normal-tumor tissues; and (iii) a non-significant increase of the most frequent allele ( repeats) in the cancer groups as compared to samples from healthy blood donors. the last two observations were found in both greek and british populations. conclusion: taken together, these data do not support the notion that this pig polymorphism is associated with an increased risk for cancer susceptibility. background: blood group determinations are routinely performed by the sensitive technique 'gel test' for the last few years. many weak d and partial d phenotypes which react as d negative or weak d by slide test, are assigned the rh d + status by gel test. this is most desirable in the case of blood donors but creates concern in case of patients and antenatal women with a partial d phenotype. case report: we report a female patient (blood group o, c+, c+, e-, e+) whose red blood cells gave a positive reaction of different strength and speed with different anti-d antibodies in slide tests. we were asked to type the patient and provide the appropriate blood units. the patient's cells gave a +/ + reaction in the standard screening procedure for the rh d in gel test micro-typing system that contains a polyclonal reagent of human origin (which allows a direct detection of most weak ds), a + reaction in a test with monoclonal anti-d and a +/ + reaction in the gel test micro-typing system destined to detect du and which contains polyclonal anti-d of human origin. however, since the slide test gave a rather slow onset of agglutination with one commercial reagent (made up of a blend of polyclonal and monoclonal anti-d) we tested the patient's red cells against anti-d reagents in the id-partial d typing system. one of these (number ) gave negative reactions and the remaining five gave positive reactions (ranging from +/ + to +), indicative of a partial d category vii phenotype. the patient's red cells were also tested in the id-card 'diaclon abo/d' . this card provides the complete profile for abo/rh d in one single procedure step, including the confirmation of rh d. it contains two different anti-d reagents within the gel matrix in two consecutive microtubes. the first anti-d (polyclonal human) is expected to give a positive result with d+ red cells and partial d category vi, while the second (monoclonal rabbit) is expected to give a negative result with dvi+ red cells. our patient's cells gave a negative reaction with the first and a +/ + reaction with the second anti-d in this system, indicating a d variant other than dvi. finally the patient was assigned the partial d category vii phenotype (according to the pattern of the reactions obtained with the id-partial d typing set) and rhesus d negative blood units were issued. this case illustrates the diversity of reagents used for rhesus typing in different laboratories. failure to disclose some d variants is a disadvantage when typing patients. a combination of techniques is often needed to reveal the real rh d phenotype. the only single system that could have revealed a d variant in our patient from the beginning, is the id-card 'diaclon abo/d' with two different anti-d reagents in two consecutive microtubes as described above. a cost-benefit analysis should be undertaken to show whether it should replace other screening tests for abo and rh d when typing patients. who cares about the quality of life of the chronic patients treated with blood products? d ilcenco*, e hanganu-turtureanu † , c burcoveanu † , c vartolomei ‡ and d azoicai § *blood transfusion center, † hospital 'sfantul spiridon', ‡ institute of hygiene, § university of medicine, iasi, romania quality of life is one of the methods used to appreciate the quality of the health system. romania is going to join soon the european union, so there must be a concern regarding the improvement of the national health system. blood receiver's life quality never been researched before in romania. we have been chosen a batch of chronic ill patients who have been received blood transfusion with blood or blood components, and asked them to complete two types of questionnaires regarding their life. we used nottingham health profile and beck's depresion index. results shows that this kind of patients need special care, because they all (with one single exception) feel frustrated and feel like a burden to the other normal persons. evolution of the pain index, mobility index, energy index, emotions index, sleep index and social isolation index was in concordance with the depression index. in conclusion, this type of patients needs special attention and medical authorities should make more efforts to assure their life quality support. transfusion medicine practice in surgically treated urology patients: our experience il ilincic*, bm bozovic* and ts tadic † *clinical center dr dragisa misovic, † natio. blood transfusion inst., belgrade, serbia objective: multiple studies demonstrate that the use of blood/blood products in patients undergoing elective urology surgeries, as well as the actual needs assessment, present the issue of numerous debates. method: using the retrospective method, utilization of blood/blood products was analyzed, as well as the ratio of prepared/used blood units in urology patients in the surgical ward, in the intensive care unit (icu) and at the urology center within the cc dr dragisa conclusion: due to a rather liberal use of primarily ffp in certain cases (cystectomiae in the first place), and a discrepancy between the prepared and actually used blood units, hospital transfusion committees should be an imperative in order to solve current dilemmas regarding justified use and proper administration of blood and blood products. background: the safe collection, production, distribution and application of blood and blood products in a high quality needs logistic on a high level. since the seventies computers, special software and barcode are used in transfusion medicine and improved the safety of processing data. in the last years a new technology was developed for industrial use, the radio frequency identification (rfid). aim: the aim of our studies was to check whether rfid can use reasonable in transfusion medicine. methods: at first we developed a flow chart, where we can use the technology and where are the problems by introduction. so we tested in the red cross donation centre in saxony about passive rfid smart label under real conditions. in cooperation between the akh vienna and novatech research a new handheld pc software 'labelview' for all steps around the transfusion was developed, including the identification of the patient and the processing of the haemovigilance data, and tested in first time. results: passive and semiactive (with temperature control) rfid labels survives all hard steps during the working up of the whole blood (e.g. centrifugation by g, separation, etc.). as a result of the contactless identification they are help to make easier the documentation of all processing steps according good manufacturing practice. in clinical practice they are a good supplement to bed side transfusion software. conclusion: for all lot of problems by the logistic and the safe identification around the transfusion existing various single point solutions such as patient-wristband, bed-side test, double check of blood group typing and donor -donation registry in software, etc. the lecture will deal with new developments in logistics and data management, which can help to reduce the problems associated with documentation, safe identification and reporting of haemovigilance data. our experiences with the immunohaematological analyser olympus pk applied conventional and no conventional (hemolytic medium time) techniques in sera of patients with ascariasis. results: the ai and hk tests showed: b epithopes in ae from b patients and in ae from ab patients; a epithopes in ae from ab patient and in ae from a patients; p and p epithopes in ae and only p epithopes in ae. these patients had both epithopes in their erythrocytes. the hemolytic techniques showed: anti b immune antibodies in sera and anti a immune antibodies in sera. the presence of abo and p epithopes in ae and immune antibodies in patients with ascariasis show a relation about blood groups and ascariasis. the fact of to find the same abo and p antigens in a. umbricoides and in its hosts suggests that the parasite might absorb them during its life cycle. these epithopes would be involved in the molecular mimicry. the use of filters for leucocyte depletion in anemic patients on maintenance hemodialysis g poposki*, s kovaceski*, b krstanoski*, s mena* and n solaz † *institute of nephrology, struga, macedonia, † ankara university, faculty of medicine, ankara, turkey introduction: renal anemia is one of the major chronic complications in end stage renal disease. it is caused by reduced production of erythropoietin (epo) due to uremic toxin effects, reduced halflife of rbc, iron deficiency, aluminum intoxication, blood loss during hemodialysis, gastrointestinal hemorrhage, epistaxis, infections etc. allogenic blood transfusion is transplantation of certain or all cell types. however, allogenic blood transfusion can contribute to many immune system disturbances with clinical side effects. besides erythrocytes, mononuclear, t and b-lymphocytes, are also transfused, which cause immunomodulatory disturbances in immune system of recipient. leukocytes are responsible for frequent febrile non-hemolytic transfusion reactions, alloimmunization toward leukocytes and hla antigen and transmission of cmv. anti-le antibodies, forming of immune-complexes, complement activation with pirogenic c a and c a immunoinflamatoric citokines cause febrile reactions. commercial use of filters for leukocyte depletion with removal of leukocytes and degraded products of microagregates and cytokines, cause minimum harmful immunomodulatory effects and prevent transmission of cmv. aim: the aim of the study was to present the effects of transfusion of erythrocytes with residual number of leukocytes in anemic patients on chronic hemodialysis at institute of nephrology in struga. matherial and methods: during - period all anemic patients on hemodialysis were divided in groups. the first group pts with febrile non-hemolitic transfusion reaction. the second group- pts immunized toward leukocyte and hla antigen. the third group young candidates for kidney transplantation for prevention of hla immunization. the fourth group pts with sle (for immune-complexes and autoantibodies). total patients ( males and females) received units of rbc with residual number of leukocytes. commercial filters of baxterÔ (lekostop lds) and terumoÔ (imugard iii rc) of second and third generation with microagregate filter and synthetic polyurethane fibers, with - microns pores that remove leukocytes, platelets, microagregates and fibrin were used. erythrocyte concentrates are filtered until days of collection. result: aabb permits maximum < ¥ wbcs/unit for prevention of febrile non-hemolytic reaction. the filters we used reach residual leukocyte number of ¥ the le reduction of - . %. the number of rbc after filtration is minimum % - g hb per unit. in none of the patients who have received the leuco-filtered blood, no adverse post transfusion reactions were noticed. conclusion: the used filters for leucocyte depletion are characterized with superior biocompatibility, excellent elimination of all types of leucocytes and high 'recovery' of erythrocytes. the use of filters for le depletion reduces and minimizes the side effects of allogenic blood transfusion in patients on chronic hemodialysis who are alloimmunized, in patients with sle, and particularly in young patients candidates for kidney transplantation. background: fv leiden, prothrombin g a, mthfr c t are three most common and important prothrombotic inherited mutations. aims: the aim of the case-control study was to assess the prevalence of mutations and their single or combined effects as risk factors for thrombosis. methods: the study included thrombotic patients (venous thromboembolism, chronical venous diseases, different etiology) and asymptomatic healthy individuals as control group. extraction of genomic dna was followed with genotyping of fvl by pcr-ssp, prothrombin and mthfr mutation by pcr-rflp. results: a statistically significantly higher prevalence of fvl mutation was found in thrombotic patients ( . % heterozygous, . % homozygous) compared to controls ( . % heterozygous), p < . . the or for heterozygous carriers was . ( % ci . - . ), confirming the association of fvl mutation with the risk of thrombosis. there was no statistically significant difference in the prevalence of the prothrombin mutation in patients ( . %) and controls ( . %), or . ( % ci . - . ), p = . . although the group of thrombotic patients showed a higher prevalence of homozygous carriers of c t mthfr than the control group ( . % vs . %), or was not significant ( . , % ci . - . ), p = . . analysis of combined effects of mutations showed an additional thrombotic risk for carriers of fvl mutation and both mutated alleles of c t mthfr gene (tt and ct) (or . , % ci . - . ), p < . . conclusions: fv leiden mutation was detected as significant single risk factor for thrombosis in studied patients group. additional prothrombotic risk have carriers of fvl mutation and c t mthfr gene mutation. a female patient in a high fever due to urinary tract infection does not respond being given antibiotics. on the contrary, leukocytes rose (to ¥ /l), anaemia became even deeper, as well as thrombocytopenia. hemocultures were negative. hematologist decided to search for hematological disease. the first citology results of bone marrow aspirate suggested lymphoproliferative disease ( % atipical plasma cells). to treat heavy anaemia (hgb g/l) hematologist asked for red blood cell concentrate. pretransfusion testing revealed warm autoantibodies in the patient serum and on red blood cells. antibodies had no apparent specificity. biochemical parameters (bilirubin, ldh, haptoglobin) suggested mild hemolitic process. electroforesis revealed polyclonal hypergamaglobulinaemia. the th day of hospital treatment, the therapy with corticosteroids was introduced (solu-medrol mg per day). coagulation parameters were tested: pt . inr, aptt s, fibrinogen . g/l, trb ¥ /l, d-dimer mg/l, atiii %. dic was suspected. liver enzymes showed mild liver dysfunction (normal ast, alt, elevated ggt, low che). substitution therapy started with dose of cryoprecipitate, dose of fresh frozen plasma, iu atiii, doses of red blood cells and vitamin k mg. two days after the substitution therapy we saw pt . inr, aptt s, fibrinogen < . g/l, trb ¥ /l, atiii %. during the next few days erythrocytes and thrombocytes rose, but due only to corticosteroid therapy and not to substitution therapy. the patient had neither signs of con-sumptive coagulopathy, nor hypoproduction of coagulation factors, except for fibrinogen. till th day of therapy, fibrinogen was below . g/l. there was no hemorrhagic diathesis. after that, fibrinogen rose, and on the st day the patient was recovered, in both clinical and laboratory terms. the results of immunological tests, collected later, confirm the diagnosis of systemic lupus erythematosus. we did not have any specific test to confirm antibody mediated hypofibrinogenaemia, but in the setting of sle, without any specific treatment except corticosteroids, fibrinogen recovered. we assume it is quite enough for highly suspected immunological hypofibrinogenaemia. results: twenty-four-year-old male patient with severe hemophilia type a suffering from low incoercible digestive bleeding secondary to ischemic colitis caused by autoimmunity (vasculitis) without response to current management. treatment was initiated with mg/kg/dose of rfviia (*) for days, after which there was clinical and endoscopic recovery, and an inh decrease to . ub/ml (fviii dosage %) . he began to take meprednisone ( mg/kg/day) for days, after which the inh titre was . ub/ml. (table a ,b) the patient underwent surgery the following year (correction of equinus foot). he entered the operating room with an inh of . ub/ml and was treated with mg/kg/dose of rfviia (*) for days, obtaining an excellent hemostatic response. he had two autologous blood units, but it was not necessary to be administered. the inh titre decreased again (down to . ub/ml) during the intratreatment stage. thirty-five days after rfviia, the inh titre was . ub/ml. (table a ,b) the presence of high titre inh against fviii is a critical problem in cases of bleeding or surgery need due to the inefficacy of the available therapeutic options and the severity of the events. in this case, we have observed that, apart from inducing hemostasia through the activation of the coagulation extrinsic path, rfviia could reduce the inh titre in sequential dosages. we have introduced the case of a -year-old patient with hemophilia complicated by a high titre inh against fviii. in this case, we have observed that, apart from inducing an effective hemostasia through the activation of the coagulation extrinsic path, rfviia could reduce the inh titre in sequential dosages. there was also a decrease in the inh titre concomitantly with an increase of the plasma fviii level during its use. this phenomenon suggests that rfviia could produce a modulation in the immune response. evaluation of an automated blood collection system with standard ratio of anti-coagulation and integrated filter for whole blood leucodepletion l dadiotis, a kolokytha, m dimou, a perdiou, c alepi, p spyropoulou, e igoumenides, c velidou, v panagopoulou and s matsagos tzaneion general hospital, pireas, greece automated blood collection system (abc) is a device manufactured by macopharma which collects by gravity a preset volume of blood and mixes it with anticoagulant (ac) in standard ratio ( : ). this is managed by passing the ac, which is stored in a special bag, anti-erythrocyte antibodies are immunoglobulins that belong to the igg, igm and iga classes. their common characteristic is a specific reaction with antigens that are located on the erythrocyte surface. they can emerge as auto antibodies and alloantibodies. the blood transfusion in patients may induce a post-transfusion hemolytic reaction (pthr). in order to avoid or reduce the danger of the pthr it is necessary to examine whether there are irregular anti-erythrocyte antibodies in the patient's serum as well as in the serum of the voluntary blood donors. all the irregular anti-erythrocyte antibodies are not clinically relevant. the experience shows that the clinically significant antibodies most often belong to abo, rh, kell, kidd, duffy and ssu blood groups. in the period from april, to november, , we monitored and examined, at the institute for blood transfusion, clinically significant antibodies in the serum of the patients who are treated with blood transfusions as well as in the serum of the voluntary blood donors. we used the following tests for detecting irregular anti-erythrocyte antibodies: enzyme test, indirect coombs test, screening test by the commercial test erythrocytes and gel filtration method. the detected irregular antierythrocyte antibodies are identified by means of the commercial test erythrocytes for identification. our results are the following: voluntary blood donors: anti d, anti c + d and anti-leb antibodies. patients: anti-d, anti-k, anti-fya, anti-c and anti-e antibodies. in nine patients, anti-erythrocyte antibodies were discovered, namely, those that react at the temperature higher than °b ut whose specificity we could not discover with the existing techniques. improved predictive factors of response for myelodysplastic syndrome patients treated by the combination of erythropoietin and g-csf s park*, c kelaidi † , s grabar ‡ , v bardet ‡ , d vassilieff ‡ , f picard ‡ , m guesnu ‡ , mc quarre ‡ , p fenaux § and f dreyfus ‡ *service hématologie, hopital cochin, † hématologie, hopital avicenne, ‡ service hématologie, hopital cochin, § hématologie, hopital avicenne, paris, france it has previously been shown that serum epo level and number of previous red blood cell transfusions are predictive factors of response to epo + g-csf treatment of myelodysplastic syndromes (mds). in a subgroup of patients with mds having sepo < ui/l, known to be good responders to epo + g-cscf, the gfm group wanted to refine the model predicting the response to epo + g-csf, especially with cytology (who classification with dysplasia and percentage of erythroblasts and blasts). in a population of patients (ra, rars and raeb < % blasts) receiving epo ± gcsf between and and having serum epo < ui/l, the response rate at week (iwg criteria) was %. six variables were associated with response to epo ± g-csf for mds: age > years (p = . ), number of prior red blood cell transfusions < packs/months (p = . ), serum epo level < ui/l (p = . ), percentage of blasts < % (p = . ), percentage of erythroblasts > % (p = . ) and low ipss score (p = . ). we did not found any influence of dysplasia, type of rhepo (darbopoietin alfa or epoietin alfa) and karyotype on response rate. in multivariate analysis, age through a rotating pump. the abc can be used with all types of p- pan-european blood safety alliance the pan-european blood safety alliance is a unique alliance of patient organizations, formed to promote the highest level of blood safety for all in europe. it was formerly established on february , during the course of the first general meeting of the pbsa, which comprised of founding patient organizations. the objectives of the pbsa are: . to promote the fundamental right and duty to safety of all patients in need of blood transfusions and blood products. . to ensure the availability of sufficient amounts of safe blood, to meet all treatment need through: -the education of all staff handling blood components, to reduce human error. -the implementation of and access to, proactive blood safety technologies, for each patient across europe. -haemovigilance -the adequate access to blood transfusion services, which should be provided free of charge to the patient. other objectives are to raise awareness on a local and european level regarding blood safety, to promote eu legislation that improves safety standards of blood transfusion services, including stem cell preparation and storage across europe and to lobby for increased patient influence on eu health policy makers. very importantly, the alliance aims at providing a forum for patients, healthcare professionals, health policy makers and relevant industry, as well as acting as a point of reference to the national health authorities, the european commission and other european institutions, when seeking the opinions of patients on blood safety. cerns of insertional mutagenesis and the safety of some viral vectors that randomly insert genes through the genome have been recently resurfaced following the development of a haematological malignancy in a child treated with a retroviral vector. particularly questions also remain as to, whether gene therapy and the production of ectopic factor viii and ix will be a risk for inhibitor development or indeed whether it might promote tolerance in those patients with inhibitors. w-pl - gene therapy for thalassemia: will it become reality? university of washington, seattle, wa, usa experiments aimed to develop gene therapy approaches for the beta chain hemoglobinopathies, sickle cell disease and beta thalassemia started about years ago. in the beginning results were dismal because of the extremely low and variable expression of globin genes contained in the therapeutic vectors. a major development occurred in with the discovery of powerful regulatory elements that could guarantee high level of globin gene expression. these elements when incorporated into viral vectors allow expression of therapeutic levels of the transferred globin genes. a second major progress was achieved with the development of safe lentiviral vectors that can efficiently infect the human pluripotent repopulating hemopoietic stem cells. as a result of this progress, today beta thalassemia and sickle cell disease can be cured in murine models of these disorders. considerable effort is already being devoted into further improvement of lenti viral vectors with emphasis on incorporating elements which will decrease the probability of insertional mutagenesis and leukemogenesis. the major challenge for the clinical application of stem cell gene therapy of thalassemia is the need for genetic correction of large numbers of mutant stem cells. in vivo selection of corrected stem cells is being investigated but there are questions about its safety because of the possibilities of clonal expansion of stem cell lines carrying undesirable integrants. other major challenges have to do with logistics: production of therapeutic vectors, infrastructure required for stem cell gene therapy delivery, and sponsoring and funding of the clinical trials. gene therapy trials on limited number of patients are expected to be initiated relatively soon. if these trials are successful and cures of beta thalassemia ensue, the major challenge will be the delivery of this molecular therapy in the context of medical practice. w-pl - gene therapy for haemophilia haemophilia is an ideal target for gene therapy because only a small rise in factor levels to - u/dl would achieve the goals of prophylaxis without regular infusions of concentrate and deliver a substantial improvement in lifestyle for patients with severe haemophilia. gene therapy for haemophilia today relies upon addition of normal factor viii or ix genes. with present technology gene therapy can offer the prospect of a true 'cure' for haemophilia in animal models, although this may not be currently realizable in man. more than patients with haemophilia have now been treated in phase gene therapy protocols. all studies have failed to conclusively show that therapeutic levels of factor viii and ix can be reliably obtained. the first trial reported used im injection of a factor ix containing recombinant adeno associated virus (raav) in adult patients with severe haemophilia b. only very modest increases in factor ix level, < u/dl rise, in / patients enrolled were observed, although less factor ix concentrate was needed in / subjects. a similar study using the same raav vector via intrahepatic artery infusion has been conducted. this has been complicated by the observation of aav vector in the semen of subjects. in six patients enrolled, no durable levels of ix above u/dl were seen. further development of this raav vector is suspended. for haemophilia a, three systems are have been tried. the first study was an ex vivo addition of factor viii gene to autologous fibroblasts and then laparoscopic reimplantation. preclinical assessments demonstrated durable expression of factor viii (> % of normal) for > year in mice following a single treatment. in / patients treated repeated factor viii rises ( . - . u/dl) were seen, but no improvements lasted beyond months. the second protocol used a murine leukemia retrovirus containing factor viii, injected intravenouslya development of preclinical data in rabbits and haemophilic dogs. / patients enrolled sustained levels of factor viii > u/dl. the third study, using a modified, 'gutless', adenovirus containing factor viii gene has recruited one patient. this patient demonstrated transient liver toxicity and thrombocytopenia at doses lower than those that cause toxicity in primates. sustained levels of factor viii of ~ u/dl have been observed over a number of months. accrual to the study has been poor. haemophilia remains a prime target for gene therapy. however, haemophilia is no longer a life threatening disease with current therapy that is both safe and efficacious. a balance between the benefits and theoretical risks must be borne in mind when considering gene-based approaches to therapy. con- reference: petz ld, garratty g. immune hemolytic anemias. nd ed. philadelphia: churchill livingstone, , pp - . w-pa- autoimmune neutropenia introduction: autoimmune neutropenia (ain), a granulocytic disorder due to the presence of anti-neutrophil antibodies, may present as neutropenia of varying degree with or without recurrent infections un previously healthy individuals (primary or idiopathic ain) or in patients with a known underlying disease such as lupus erythematosus, lymphoid malignancies, etc (secondary ain). the condition affects more frequently infants of small ages while it is rare in adults [ ] [ ] [ ] [ ] [ ] [ ] [ ] . in some patients, diagnosis is established in occasion of a respiratory, urinary or cutaneous infection, but in many cases is simply a finding of cell blood counting performed for unrelated reasons [ ] . clinical and laboratory findings: in general, physical examination is negative. laboratory investigation reveals the existence of isolated neutropenia. association of the disorder with autoimmune hemolytic anemia or autoimmune thrombocytopenia is rarely seen [ ] . blood biochemistry is normal while serologic tests for bacterial, viral or other pathogens may be positive depending on the underlying infection. bone marrow is hypercellular without maturation arrest of granulocytic series. hemopoietic stem cell reserves and function are normal or increased, and stromal cell function is within the range of the normality [ ]. methods for the detection of granulocyte-specific antibodies: serology for the detection of granulocyte-specific antibodies has been marred, compared to erythrocyte serology, because the target cell here, the granulocyte, is short-lived, fragile and becomes easily activated. the former two of these difficulties require absolutely freshly (< h old) isolated neutrophils from a panel of donors to be used every day to run the tests with sera from patients, while the third difficulty is more important since spontaneous cell clumping in vitro is very common and nay mimic the specific aggregation caused by cross-linkage of surface bound antibodies in the granulocyte agglutination test (gat). in order to overcome these problems, the second international granulocyte serology workshop [ ] recommended a combination of two tests as the best screening procedure for the detection of granulocyte autoantibodies in patient sera, gat and granulocyte immunofluorescence test (gift). gat is mainly mediated by igm antibodies and is positive in about % of cases. gift detects igg antibodies and is positive in about % of cases. it is to be noted that flow-cytometry fluorescence may arise not only from the surface but also from the cytoplasm of neutrophils, necessitating assessment of membrane fuorescence by microscopy. a good direct anti-granulocyte test is not available today. this is due to the fact that too few neutrophils can be obtained from the blood of neutropenic patients, and also to the observation that neutrophils are often activated in vivo because if an underlying infection or other inflammatory process, thus expressing fcgrii and fcgriiib to which nonspecific binding of w-pa- practical approach to transfusion in autoimmune hemolytic anemia (aiha) g garratty american red cross blood services, pomona, ca, usa a major problem when transfusing patients with aiha is that often all units are incompatible. this may be due to autoantibodies (autoab) and/or alloantibodies (allo-ab). if the incompatibility is due to only auto-ab, then transfusion of incompatible blood will not usually result in a clinically significant reaction, but if due to alloab, the result may be similar to that seen in any other patient (i.e. a hemolytic transfusion reaction ranging from mild to severe). thus, it is essential (as in any other patient) to exclude the presence of allo-ab. it is wise to phenotype all patients, for as many antigens as possible, before the patient receives transfusion. there are two popular approaches to determine if allo-abs are present but being masked by 'warm' auto-ab activity. the preferred method is to remove the auto-ab by adsorbing the patient's serum with autologous rbcs treated with enzymes, or preferably, with zzap reagent. the latter reagent contains an enzyme leading to optimal adsorption of auto-ab, and dtt. these two chemicals will destroy significant antigens other than rh and kidd (e.g. mns, duffy, kell, lutheran, dombrock, cromer, lw, some yta and ge, inb, jmh, ch, rg, pr antigens), thus will not adsorb alloantibodies to these antigens. if autoadsorption is not possible (e.g. patient has been transfused recently or there are too few rbcs), one has to perform adsorption with enzymes or zzap-treated allogeneic rbcs. one does not have to be concerned with covering any antigens destroyed by zzap (e.g. kell and duffy systems). we use a rough guide relating the strength of the indirect antiglobulin test to the number of adsorptions needed to remove auto-ab ( + = adsorption; + = adsorptions; + = adsorptions; + = or more adsorptions). if there is no activity left after the adsorptions, then one can suspect that the incompatibility was due to auto-ab, but on rare occasions one can be wrong and an allo-ab to a high-frequency antigen has been removed. this is a major disadvantage of using allogeneic adsorptions, and is why adsorptions with autologous rbcs are preferred. if time ( - h) does not allow for adsorptions, one can dilute the patient's serum (e.g. in , or in ) and test the dilution against a panel to see if any alloantibody specificity becomes obvious. another approach is to select units matching the patient's phenotype as closely as possible. when dealing with cold agglutinin syndrome one can usually exclude allo-ab activity by testing strictly at c. this can be helped by performing adsorptions with enzyme-treated autologous rbcs at c, but it is difficult to adsorb all of the powerful cold autoagglutinin activity. it is reported that - % of aiha have allo-abs; the incidence is even higher in patients who have received multiple transfusions. thus, we feel that procedures such as those discussed above must be performed before transfusing incompatible blood if time allows. one should always negotiate with the attending physician regarding the time it will take to perform adsorptions. a decision may be made not to perform adsorptions if the patient has life-threatening hemolysis, and especially if the patient has never been transfused, or pregnant. serum igg may occur (naig). the presence of immune-comlexes in the serum, such as in patients with felty's syndrome, lupus erythematosus and other diseases, as well as the presence of immune aggregates formed in sera stored frozen for long time, may give false-positive tests given that they may bind to fcgriiib molecules expressed on the surface of neutrophils. elimination of immunecomplexes and immune aggregates can be easily obtained by ultracentrifugation [ ] . another cause of false-positive results may be the presence of anti-hla antibodies because of allo-immunization. these allo-antibodies react with hla molecules found not only on neutrophils but also on the surface of many other cells including lymphocytes. these allo-antibodies can be eliminated by platelet absorption. it seems that the best method in the search of true antigranulocyte antibodies is the monoclonal antibody-specific immobilization of granulocyte antigens (maiga) [ ] . with this method one can specify anti-granulocyte antibodies using a panel of known granulocyte antigenic specificity. finally, it is notable that the levels of serum antibodies to neutrophils may vary considerably over the time. one negative test does not exclude ain. usually, two to three tests have to be run over a period of months [ ] . antigenic specificity: human neutrophil antigens (hna) are classified according to an international granulocyte antigen working party [ ] . three glycoproteins have been found to be involved in the determination of antigenic specificity, fcgriiib, gpnb (cd ) and gp - . the respective antigens, frequencies and alleles are illustrated in table . antigenic specificity can also be studied by using methods applied in molecular biology. a promising approach is transfection of mammalian cells by cdna derived from granulocyte antigen specific mrna. cell lines have been established with cells expressing the respective human granulocyte antigen, making the detection of anti-granulocyte antibodies more easier. genotyping of hna antigens can also be stydied with the pcr technique [ ] . references are available from the author upon request. w-pa- a rare case of 'coombs negative' autoimmune haemolytic anaemia due to red cell autoantibodies of iga class warm autoimmune haemolytic anaemia (waiha) is usually associated with red cell auto-antibodies of the igg class, which can be detected by polyspecific direct antiglobulin test (dat). routine polyspecific direct antiglobulin tests contain anti-igg and anti-c d components, and are not standardized to react with iga-or igmsensitized red blood cells. haemolytic anaemia caused by warmreacting auto-antibodies solely of the iga class is exceedingly rare. those cases of autoimmune haemolytic anaemia can be difficult to diagnose because of the negative polyspecific coombs' test, which is a standard in investigation of possible causes of haemolysis. we present a case of severe warm autoimmune haemolytic anaemia caused by iga class autoantibodies. a -yr old male patient was admitted with anaemia, haemoglobinuria, and other signs of severe haemolytic disease. he received multiple transfusions but haemoglobin level did not rise above g/dl. the initial polyspecific direct antiglobulin test, containing an anti-igg and anti-c d antiserum, was negative. tests for cold agglutinins and other possible causes of haemolysis were negative. only by using a monospecific, anti-iga antiserum could we show that the warm iga auto-antibodies against red blood cells were present on patient's erythrocytes. we have not detected signs of complement activation by iga autoantibodies in this patient. the patient received corticosteroids with good initial effect. his haemoglobin level stabilized and he did not require more transfusions. anti-iga direct antiglobulin test became negative about to weeks after the therapy was initiated. however, in spite for the initial effect of steroid therapy haemolysis continued, and splenectomy was performed months after diagnosis was made. it has been shown that human lymphocytes, granulocytes and monocytes contain specific fc receptors for iga, and both monocyte-mediated phagocytosis and antibody-dependent cellular cytotoxicity due to iga auto-antibodies has been demonstrated. there is also increasing evidence that iga auto-antibodies can activate complement, both via the classical and the alternative pathway. a phenomenon of 'reactive haemolysis', which involves c -independent binding of c b complexes to 'bystander' red blood cells, has also been described. we emphasize the importance of performing additional testing in cases of apparent 'coombs' negative' haemolytic anaemia due to iga, igm or 'low affinity' igg autoantibodies, and serological aids that are available for that purpose. described. both siblings were born on term, in good general clinical status, free from any signs of infection, and with isolated severe neutropenia ( and neutrophils/ml). the diagnosis of annanti hna- a was made upon exclusion of other possible causes of neonatal neutropenia, and confirmed by serological testing of granulocyte antigens and antigranulocyte antibodies. in both cases, the course of the disease was mild, with bacterial omphalitis on day and , respectively. omphalitis was successfully treated with -day antibiotic therapy according to antibiotic sensitivity report. the first neonate received standard dosage of intravenous gammaglobulins for days without success. this was followed by an attempt at neutrophil count increase with -week corticosteroid therapy, also without response. the second neonate received no specific therapy for neutrophil count increase. the children were discharged for home care with clinical and laboratory control examinations at -week intervals. in spite of prolonged neutropenia ( and months, respectively), no other infections were recorded. discussion and conclusion: in our patients, the therapeutic approach to ann was individualized, based on standard antibiotic therapy, intravenous gammaglobulins, corticosteroids, available literature data, and our own clinical experience. although in the last few years rh-gcsf is successfully used in patients with neutropenia, we decided to postpone its use in case the neonatal sepsis developed. the reasons for such decision were: ( ) the fact that both neonates were in good general clinical status, with a mild course of the disease with only short-term umbilical infection successfully managed with antibiotic therapy; ( ) literature reports suggesting the unexpected failure to respond to rh-gcsf therapy in patients with neutropenia induced by anti hna- a immunization, and ( ) the unknown effect of rh-gcsf on developing tissues of the neonate. the choice and efficacy of specific therapy for neutrophil count increase in the management of alloimmune neonatal neutropenia have not yet been fully defined and require additional evaluation in the majority of cases. male donors for the production of fresh frozen plasma: a special issue for trali patients trali is a significant cause of transfusion associated morbidity and mortality, and has been reported as the third most common cause of fatal transfusion reactions. there is no good evidence on which to base transfusion support policy for patients who have experienced trali. the hypothesis that there may be patient associated factors that contribute to the risk of trali is generally accepted. for this reason it seems reasonable to try to avoid further transfusion during the period of illness. if this is unavoidable the next best solution to reduce the risk of recurrence seems to be the avoidance of using plasma containing blood components (especially ffp) as there is a high chance of positivity for leucocyte antibodies especially for those coming from female donors. as fresh frozen plasma transfusion accounts for up to half of all trali cases and as our center is the only in greece responsible for the testing and processing of blood from blood donors representing military recruits, the last two years we tried to set up a project in order to provide components from male donors on request. our donor base consists predominantly from males donors ( . %), aged between and years old, with a small chance of having a positive history for transfusion the difficulty of the project consisted on the fact that these donors are assigned to military camps throughout greece, which makes difficult the on time arrival of the units to our establishment in order to be processed for the production of ffp conform the european council quality requirements. this was the main reason why, till now, all plasma produced from these donations was regarded as plasma for fractionation. the first step for implementing the new project was to evaluate the number of donations that, by minor changes on the time of arrival, could be processed for ffp production. the next step was to re-schedule the shifts of the personnel for the on time production of ffp. during , % of donations were fulfilling the specifications for the production of ffp and with the flexibility of the schedule the % of them were successfully processed to ffp. during , % of the donations were fulfilling the specifications and . % of them were processed to ffp. so it is feasible to increase the proportion of male ffp by organizing better the transportation of blood from the donation sites to the blood establishment and by retaining available specialized personnel to cover the extra shifts. maximising the blood supply chain in times of shortage shortages in the blood supply chain may occur for a variety of reasons. they may be temporary e.g. due to a flu epidemic or prolonged e.g. due to the exclusion of a high proportion of donors due to new pre-donation tests or because of a lack of volunteer donors. increasing awareness of the possibility of blood shortages mainly related to increased precautions associated with the possible transmission of vcjd by transfusion has been the driver for the development of blood shortage contingency plans in the uk. in england and north wales, hospitals and the national blood service (nbs) have worked together to develop an integrated blood shortage plan (ibsp) designed to ensure that hospitals and the nbs work together within a consistent, integrated framework giving patients equal access to available blood on the basis of need. an essential element of the plan is the principle that shortages can, in most cases be avoided by reducing the current usage of blood through appropriate use programmes. the impetus for hospitals to implement these programmes was a government circular (hsc / ). hospitals have embraced the circular and have recruited specialist hospital transfusion practitioners, introduced lower hb triggers, cell salvage and hospital transfusion teams and are participating in the blood stocks management scheme (bsms). audits of compliance with the circular have taken place, and a web based tool kit is available. the demand for blood has declined for the last three years, with a decrease of about % during - , suggesting that the drive for improvement has been successful. the shortage plan introduced in england and north wales has two key aims: that the national pool of blood is available for all essential transfusions for all patients and that overall usage is reduced to ensure the most urgent cases receive blood. the plan is structured to provide actions for the nbs and hospitals in three phases, 'normal' circumstances, reduced availability and severe prolonged shortage. hospitals should have documented emergency blood management arrangements for each of the phases. the national plan is activated when the nbs red cell stock level falls to pre-defined levels, hospitals are informed by fax that they should reduce their normal stock holding levels according to guidance in the ibsp and comply with the daily hospital usage budget. the bsms has used its knowledge of hospital inventory levels and demand to provide guidance on appropriate inventory levels for normal and reduced status, it also provides the daily hospital budget. to monitor progress against the recommendations in hsc / hospitals will be benchmarked against a number of performance indicators. these include the presence of emergency blood management arrangements, median red cell usage for a number of surgical procedures and percentage wastage of blood. there have been no shortages within the nbs for more than six years, it is hoped that the implementation of the ibsp will help to ensure that in the unlikely event of reduced availability blood will be available to the maximum number of patients requiring a blood transfusion. w-pa- transfusion during disaster g klein nih, bethesda, md, usa publicity given to blood donation during wartime has created a powerful association between the need for blood and occurrence of a disaster. blood is rarely needed in excessive quantities at the moment a disaster occurs. the outpouring of blood donors, especially at the site of a disaster, often proves counterproductive. the terrorist attacks on the world trade center on september , , with almost deaths and more than injuries, provides an instructive model. more than a million potential donors contacted blood-collection centers. hundreds of thousands of prospective blood donors crowded collection facilities and many waited for hours, often to be turned away. qualified staff were in short supply and screening errors occurred as minimally qualified staff were recruited and as collection personnel fatigued. supplies and storage capabilities were pushed to their limit. some blood was inadequately processed and stored. resources were diverted from needed apheresis collections and component preparation to whole blood collection. in the aftermath of the disaster, blood outdated and volunteer donors became disillusioned as their 'gift of life' was refused or unused. similar responses have occurred numerous times over the -year period since blood-donor programs were introduced. in virtually every civilian disaster in the u.s. during the past century, all the blood that was needed was immediately available from blood inventory. in only four cases were more than units of blood used in the first to h. in in new york, the five hospitals closest to the disaster site admitted only disaster victims. the new york blood center, which supplies percent of blood for the city's hospitals, added units to routine inventory at hospitals. the center received telephone calls and collected more than units of blood in the first h. in the area of the pentagon, the chesapeake and potomac red cross blood center supplemented hospital blood inventories within h of the disaster. meanwhile, spurred by well-meaning media and federal officials, lines of blood donors were being processed at local hospitals, makeshift collection centers, the small research hospital at nih, and at a building next to the white house. in the week after september , america's blood centers collected more units of blood, and the american national red cross collected more units than in the same period the previous year. more than units were collected for the disaster victims, but only units were used. u.s. blood collectors and federal agencies have created a disaster plan that acknowledges the need for altruistic people to volunteer for blood donation in the time of disaster and speaks with a single voice to avoid needless collection activity while harnessing the good will of well-intentioned people to supplement the ongoing need for volunteer blood donation. rehabilitation of blood transfusion service in azerbaijan cd asadov, ga huseynov and ab hagiyev institute of hematology and transfusiolo, baku, azerbaijan at the end of th years of the last century in azerbaijan as well as in other republics of the former ussr began process of progressive deterioration of blood service parameters. in result there was an essential reduction of prepared blood and blood components quantity, manufacture of preparations from blood's plasma has completely stopped. it is connected by that our republic experiences a heavy transition period from scheduled to market economy. after reception by azerbaijan of the sovereignty on development of a national policy the big work has been lead to areas blood transfusion and development of national rules and the standards regulating functioning of establishments of blood service. in the law about ' the donorship of blood and its components in the azerbaijan republic' has been accepted, instructions on physical examination of donors and preparations of blood and its components are authorized, and also the new speciality transfusiology has been entered into the nomenclature of medical specialities. now the national program of blood service development is developed. at drawing up of the program social and economic conditions of the country, ethnic both cultural traditions and a mental potential of the nation are considered. within the framework of this program is planned to refuse gradually a paid blood donation during the certain period of time to reach %s' voluntary unpaid blood donorship. however in connection with limitation of resources, the state is not capable to allocate enough of means for its realization. the big work on attraction of the international organizations has been carried out. now the project of the united nations development program (undp) 'rehabilitation of blood transfusion service in azerbaijan' is carried out at sponsor's support of the norwegian government. realization of this project will lead to reorganization of blood transfusion service in our country according to practice of the european countries. within the framework of project realization it is planned to make changes and additions to a existing law about a blood and its components donorship to bring it into accord with recommendations of the europe council. updating of the russian law 'concerning the donation of blood and blood components' on june , , a law, 'concerning the donation of blood and blood components, ' was signed by the first russian president, boris eltsin. now, after more than ten years of market economy and democratic evolution in russia, this law was significantly changed on august , , as shown in the following sections: . the development of a voluntary blood donor system. . removal of the upper age limit for blood donors. . funding for blood donations. from january , , each level of the state power budgets for a blood donor service to supply blood products for federal, regional, or municipal hospitals. costs of these drugs and the need of prolonged growth factor treatment in these disorders. w-pa- can iron administration reduce peripartum blood transfusion c breymann university of zurich, zurich, switzerland the prevalence of iron-deficiency anemia in different regions of the world ranges from to %. the increased iron requirement in pregnancy and the puerperium carry with it an increased susceptibility to iron deficiency and iron-deficiency anemia and perioperative or peripartal blood transfusion. however, if ever possible administration of blood transfusion should be avoided for several reasons which will be pointed out in the talk. infections: it is well known that various pathogens such as bacteria and virus can be transmitted by administration of blood. around . % of are contaminated by bacteria such as yersinia or pseudomonas species but are not screened routinely for bacteria. in addition there is no donor screening for hepatitis a, herpes species (cmv, ebv, hhv , hhv ), parvovirus b , hepatitis g ( . %) and tt (transfusion transmitted) virus ( . %). numbers for positive testings for 'classic' virus such as hiv, hep. b and hep. c vary from country to country and lie around : to : depending on quality of donor screening programs, pcr sensitivity etc. recently there is increasing evidence that even prions which cause the jakob creutzfeld disease variation ('mad cow disease') might be transmitted by transfusions. therefore the fda has determined that blood donors from countries with high prevalence of prion positive persons are not permitted to give blood in the us (e.g. donors from uk). beside infections, other well known effects of transfusion are problems due to incorrect blood or components transfused, post transfusion purpura, acute and delayed lung injury, graft versus host disease and other acute and delayed allergic reactions. beside these negative effects it was also shown that patients who receive blood transfusion liberally after operations or in icu show higher morbidity and mortality compared to patients with restrictive transfusion policy. this might be due to negative effects on immune functions and inflammatory reactions and lack of stored blood to efficiently improve organ oxygenation. for example it is known that stored blood has worse capillary perfusion and worse viscosity properties compared to fresh blood. taken together there is increasing scientific evidence that blood transfusion is not the gold standard for anaemia management and alternatives such as endogenous blood pooling and efficient treatment of any anaemia must be enforced in the clinical settings. prevention and correction presuppose reliable laboratory parameters and a thorough understanding of the mechanisms of iron therapy. in order to correctly diagnose the type and degree of anaemia, a prerequisite for selection of the proper therapy, one must first of all correctly differentiate between the relative, i.e. the physiological anaemia of pregnancy due to the normal plasma volume increase during pregnancy, and 'real anaemias' with various different pathophysiological causes. when defining the hb cutoff value for anaemia in pregnancy, the extent of the plasma volume changes with respect to the gestational age must be taken into consideration. it has been found that haemoglobin values < . g/dl in the first and third trimesters, and < . g/dl in the second trimester may point to an anaemic situation which should be further clarified. the first important steps for diagnosing anaemia in a pregnant patient include a thorough check of her medical w-pa- impact of epo treatment on transfusion requirements in myelodysplasia c gardin and p fenaux hopital avicenne, aphp, university of paris , bobigny, france myelodysplastic syndromes (mds) are clonal disorders of hematopoeisis, associated with bone marrow failure and an increased risk of evolution to acute myeloid leukemia (aml). despite an normal or increased bone marrow cellularity in most cases, cytopenias worsen with time due to increased apoptosis and defective differentiation of blood lineage precursors. incidence of mds increases with age and reach / above years of age. bone marrow cytogenetics number of cytopenia and percentage of bone marrow blasts are strong predictors of survival and evolution to aml. a composite international prognosis scoring system (ipss) is used in everyday practice to guide the management of these diseases. these disorders are heterogeneous and include 'low risk' patients (less than % bone marrow blasts) with a prolonged evolution marked by chronic anemia, and 'high-risk' patients (excess of bone marrow blasts > %) evolving in a short timespan with severe cytopenias, and to aml in approximately % of cases. at diagnosis, % of mds patients are anemic, with an hemoglobin level less than g/l, and % of them will require chronic blood components transfusion, during the evolution of their disease. chronic anemia and multiple blood products transfusions are associated with an altered quality of life, clinical iron overload, and important health care costs. although transfusion practices and patient's transfusion need are variable, elderly mds patients require a mean of - units/year of follow-up, in recent surveys. therapies able to diminish or abolish the need for rbc transfusion have therefore a major role in the management of mds, as allogeneic bone marrow transplantation, the only curative therapy of these diseases, is limited to a small subset of mds patients. high-doses of recombinant erythropoetin (epo) ( - u/kg tiw, or a - u as single weekly dose) are typically used in low-risk mds. the response rate to epo is - %, including major responses (suppression of rbc dependency or rise of hemoglobin level of more than g/l). absent or low rbc transfusion needs and a serum epo level less than u/l are strongly predictive of response to epo, in patients with low-risk mds. the duration of response is variable ( - months) in most studies, with some long-term responders. the use of higher doses of epo or its prolonged administration may be associated with higher response rates, although no randomized studies are available combination of epo and low-dose granulocyte-colony stimulating factor (g-csf) increases the response rate to - %, including in patients not responding to several weeks of treatment with epo alone. two randomized trials published in , compared g-csf-epo to rbc transfusions and confirmed the efficacy of this combination, and a longer survival of epo-g-csf responding patients. studies are ongoing in mds, including with darbepoetin, a modified erythropoetin with longer half-life, administered once a week. two such studies have been recently reported, (darbepoetin or ug/week) with response rates varying from % to % in low-risk mds. in both studies, a response to darbepoetin was observed in some patients, who failed to respond to previous treatments with alpha or beta epoetin. further assessment of the optimal dosage, administration schedule of these drugs, and validation of their likely impact on qol are required, in order to epo and its derivatives to gain acceptance in mds, due the high history and a medical examination. this procedure often lays the basis for a correct diagnosis. the current gold standard to detect iron deficiency remains the serum ferritin value. to be reliable, this requires the ruling out of an infection (chronic or acute) as a cause of the anaemia. we recommend a complete laboratory test for the exact haematological status as well as the assessment of specific chemical laboratory parameters. these should the hb level alone is insufficient to guide management. a complete work-up (ferritin, transferrin saturation) is essential, preferably with haematological indices such as hypochromic and microcytic red cells and reticulocytes, classified by degree of maturity, in particular, before parenteral therapy is given. since ferritin acts as both an iron-storage and acute-phase protein, it cannot be used to evaluate iron status in the presence of inflammation. a high ferritin level thus requires the presence of an inflammatory process to be eliminated before it can be taken at face value. if the c-reactive protein level is also raised, the soluble tfr concentration can be used, since it is unaffected by inflammation. inadequate understanding of the complex chemistry of parenteral iron administration was previously responsible for serious side effects, such as toxic and allergic reactions, and even anaphylactic shock, in particular with dextran preparations. however, the current type ii iron complexes that release iron to the endogenous iron-binding proteins with a half-life of about h are not only effective but carry a minimal risk of allergic accident and overload, especially after a comprehensive pretreatment work-up. after correct diagnosis, major emphasis should be put on safe and effective treatment of anemia which again depends on severity of anemia, time for restoration and patients characteristics. today effective alternatives to oral iron only or blood transfusion such as parenteral iron sucrose complex and in selected cases also recombinant erythropoietin have been investigated and show promising results concerning effective treatment of anemia during pregnancy and postpartum. our departmental data collected over years and backed by postmarketing experience in countries indicate that iron sucrose complex therapy is a valid first-line option for the safe and rapid reversal of iron-deficiency anemia. w-pa- iron therapy in orthopaedic surgery surgery of the vertebral column, hip or knee is considered a bloody procedure (blood loss > l) and as a consequence represents the main indication for red blood cell transfusion in orthopaedics. because of the non-negligible residual risk of transmission of infectious agents by transfusion, but mainly because of immunologic complications induced by the administration of foreign proteins and cells, an alternative solution has been actively sought. studies have clearly shown that in patients undergoing such surgery, transfusion risk correlates inversely with pre-operative hemoglobin level. correction of even slight preoperative anemia is thus mandatory. in the elderly, iron and vitamin deficiency (b and/or folic acid) should be looked for as a matter of routine. we recommend the use of iron + epo whenever a rapid correction (< weeks) of the anemia is desirable in cases with transferrin saturation < % and ferritin levels < mg/l. with this regime it is possible to collect up to autologous blood units in cases of increased perioperative blood loss (e.g. double hip replacement). in the post-operative period, anemia worsens because of the existing inflammatory state. this inhibits iron absorption from the intestine and iron release from the macrophages while it affects epo function and production. there is increasing evidence that i.v. iron combined with epo induces a rapid correction of post-operative anemia. it is thus recommended to stimulate erythropoiesis by i.v. iron and epo starting on the first post-operative day and to avoid transfusions in asymptomatic patients even in cases with hb as low as g/l. background: hereditary hemochromatosis is one of the most common inherited disorders in which an excessive amount of iron is absorbed from the diet and then deposited in organs. the effective treatment is the regular whole blood removal which causes erythropoesis activation and leads to decrease of iron stores. red cell apheresis is an optional method for removing of higher amount of erytrocytes in one session. we performed red cell apheresis in patients with diagnosis of hereditary hemochromatosis ( ¥ c y homozygotes, ¥ c y + h d heterozygote) using haemonetics mcs p cell separator (protocol tae) in which red cells are removed from patients in - cycles; plasma and buffy-coat are reinfused. collection time, donor convenience, side effects and red cell yield were recorded and analysed. samples for hematology and iron studies in patients were drawn, analyzed and compared to baseline levels. background: the collection of units of red blood cells by apheresis (drbc) has been reported to be safe and effective in increasing the yield of rbc units from a donor population. however several reports demonstrated the risk of inducing iron depletion when the interval between a drbc donation and a subsequent rbc donation is shorter than days. aims: to evaluate the recovery from anaemisation and iron stores depletion after drbc donation. methods: donors who underwent drbc donation between december , and february , have been enrolled in a follow up program to monitor haemoglobin (hb), htc, serum iron and ferritin values. these parameters have been assessed on the day of donation and, thereafter and days after drbc procedure. donors suitable to drbc apheresis had to have: age between and years, weight > kg, hb > . g/dl and serum ferritin between and ng/ml. a written informed consent about the collection procedure and the follow-up program has been obtained from all the enrolled donors. drbc collection procedures have been performed by using a mcs + (haemonetics) cell separators. results: out of donors who donated drbc during the study period, only males completed the follow up program and have been analysed. baseline haematological values and iron metabolism parameters were: mean hb . ± . g/dl, ferritin ± ng/ml, serum iron ± microg/dl. on day mean hb was . ± . g/dl (p < . ). on day mean hb was . ± . g/dl (p < . ), ferritin ± ng/ml (p < . ), serum iron ± (p ns). only out of donors ( %) had a ferritin value > ng/ml. in the studied donors the collection of units of rbcs induced an expected reduction of about grams of hb, however only % of this reduction was recovered after days (p < . ). similarly, also iron stores have not been restored after months from donation, as shown by a % reduction in mean serum ferritin value. according to these data it appear that the amount of iron 'lost' with the donation of units of rbcs (approximately - mg of elemental iron) could not be completely compensated by iron absorption from the diet intake. further data are necessary to define the risk of iron depletion after the donation of a drbc, however, at least in areas where iron intake by diet is not very high, the opportunity to prolong the interval between a drbc and a subsequent rbcs donation beyond six months or to provide adequate iron supplementation therapy should be carefully considered. background: increased transferrin saturation and/or serum ferritin have been observed in italy in approximatively % of subjects at first blood donation and, in these subjects, hfe mutations prevalence was . for c y and . for h d (velati et al., ) . aims: the role of the c y mutation is well known in the patho-genesis of iron overload, whereas the role of the h d mutation remains uncertain. the aims of the present study were first to study the main hfe mutations prevalence in a random group of repeat blood donors and second to evaluate iron parameters and iron depletion in repeat blood donors heterozygous for the h d mutation in comparison to a population of blood donors wt/wt for the h d mutation. methods: a total of repeat blood donors were examined in italian transfusion centers ( in northern italy and in southern) for c y and h d mutations. out of those, blood donors heterozygous for the h d mutation and wt/wt for the same hfe mutation, both groups wt/wt for the c y, were enrolled to evaluate iron parameters and iron depletion. these two groups were similar for number of blood donations (expressed as iron loss) and for sex distribution. serum ferritin (sf) was the iron index recorded at first and second observation. results: table summarizes the allelic frequencies in the blood donors. table reports the haematological evaluation in the subjects heterozigous for h d mutation and the wt/wt for the same mutation. conclusions: these data suggest that subjects with h d mutation of the hfe gene have, at first observation, a higher ferritin levels than subjects wt/wt. this seems to be more evident in blood donors of southern italy than in northern. blood donation induces significant reduction of the iron stores both in h d heterozygous and in wt/wt subjects. although our observation is preliminary and restricted to a limited number of subjects, it seems worthwhile to extend the follow-up of blood donors h d heteroxygotes or even homozygotes when available, in order to get further insights on the h d role in iron metabolism. background: cd is a sialylated glycoprotein expressed on the surface of most hematopoietic cells and has been implicated in cell adhesion and signaling. consequently the levels of soluble cd as well as the expression on the cell surface is a marker of cell activation. furthermore, downregulation of this molecule has been correlated with increased susceptibility to infections. the myelodysplastic syndromes (mds) are a group of stem cell disorders characterized by ineffective hematopoiesis, refractory cytopenias and an increased risk of leukemic transformation. the mds patients are often introduced to transfusions for anemia improvement and present increased susceptibility to infections. aims: we studied cd expression in transfusion-dependent and non-transfused mds patient in an effort to investigate mechanisms of regulation of this molecule. we also studied other activationassociated antigens in the absence of manifest infection. material and methods: forty-two patients were included in the study suffering from refractory anaemia (ra). thirty-one were males and females aged to (median ). twenty of them had never been transfused (group a) and were regularly transfused (group b). nineteen age matched healthy individuals were used as controls (group c). cell surface antigens were detected by direct immuno-fluorescence evaluated by flow cytometer. the following mouse monoclonal antibodies were tested: anti-cd b, anti-cd , anti-cd , and anti-cd . leukocytes were gated according to cd . we used a sensitive sandwich enzyme linked immunoassay to measure the level of soluble vascular adhesion molecule as an indicator of endothelial cell activation. the r&d elisa kit was used according to the manufacturer's instructions. results: the cd was found down-regulated in the transfusiondependent mds patients compared with the non-transfused ones (p < . ) and controls (p = . ). this downregulation concerned the proportion of cd + cells, that was lower in the transfused patients than the non-transfused (p < . ) and controls (p = . ), and the rfi (relative fluorescence intensity) value that was also lower in the group a compared to the group b (p < . ) and group c (p = . ). negative correlation was observed between the cd expression and cd b (p = . ) and cd (p = . ). cd b was found up-regulated in the transfused patients. the rfi value was significantly elevated in the transfused patient compared with the non-transfused and controls (p = . and . respectively) while the percentage of cd b cells did not differ significantly between the various groups. increased expression of cd was also found in the group a compared to group b (p < . ) and c (p = . ). the proportion of cd + cells did not differ between the various groups. the levels of immuno-reactive svcam- as determined by elisa were found . + . in group a, . + in group b and . + . in the control group. conclusions: activated hemopoietic and endothelial cells are found in mds that may be associated to the vascular disorders found in these patients. cd downregulation may also be associated to increased susceptibility to infections in these patients. despite improved safety of the blood supply, allogeneic blood transfusion continues to be associated with risks that can be eliminated or reduced by autologous transfusion. preoperative autologous blood donation (pad) prevents transfusion-transmitted viral infection, red cell alloimmunization, and some adverse transfusions reactions. it may decrease the risk of postoperative wound infection because immunosuppression as a result of allogeneic blood transfusion is avoided. pad also supplements the blood supply, provides compatible blood for patients with alloantibodies and rare red cell phenotypes, accelerates erythropoiesis, and provides peace of mind to patients. as any medical intervention, pad has both advantages and disadvantages. with proper patient selection and dedicated attention to process control and quality assurance, the advantages outweigh. background: prestorage pooling of whole blood derived (wbd-pc's) buffy coat platelet concentrates (pc) is common practice in europe event-free survival was significantly better in patients who responded to epo + g-csf. we have reviewed data in centers and the gfm has the intention to extend the study to a larger population in at least centers in france blood components and preparations. the new law prohibits the mixing of different blood products, i.e. blood components and blood fractions. different methods are necessary for the quality control of blood components and blood preparations privileges for blood donors include: -a paid day off work on the day of blood donation and medical examination for blood donation additional paid day off work after blood donation an extra paid day off work if blood is given during vacation or on a holiday this award will be given to non-remunerated donors after blood donations or plasma donations. before , each 'honoured donor of russia' or 'honoured donor of the ussr' had three privileges: free use of public transportation, receipt of certain pharmaceuticals free of charge, and a discount on apartment utilities previously, municipalities also could have their own blood establishments. this resulted in more than blood establishments in the russian federation. from both administrative and financial points of view, many of these are too small to be costeffective, and should be discontinued. services, and wider implementation of modern technology for blood collection, testing, processing, storage, and distribution acknowledgements: we thank ksw microtec ag, dresden/ germany for sponsoring the rfid-labels and novatech research gmbh, vienna/austria for developing the clinic-software. background: the national preparation human immunoglobulin g % for intravenous use (ivig) that is produced at the serbian institute for blood transfusion is used in therapy of neurological, heartand haemolytic diseases and on patients that have undergone surgery. aims: it is our aim to prove the impact of this national medical preparation human immunoglobulin g % for intravenous use on patients that have been infected with sepsis as a consequence of surgery. material and methods: human immunoglobulin g % for intravenous use (ivig) has been used in the study. the preparation is liquid, % stabilised with glucose of a ph value of . ± . . it is used in those cases where sepsis developed after surgery. both an ivig group (n = ) and a control group (n = ) were viewed; the control group not being treated with ivig. the number of specimens with the ivig therapy cholecystitis is (n = ), and the control group (n = ); pancreatitis (n = ) control group (n = ); intestinal obstruction (n = ) control group (n = ); abdominal organ perforation (n = ) control group (n = ); abdominal perforate injuries (n = ) control group (n = ); serious abdominal interventions (n = ) control group (n = ). the period of hospitalisation of the patients in the ivig group was ± days while the period of hospitalisation in the control group was ± days. the mortality rate in the ivig group was % counter . % in the control group. summary: toxic gram -negative bacteria caused synergistic damage of human tissues and generalized inflammatory responsesepsis. by using human immunoglobulin g % for intravenous use, in cases of severe disease, the mortality rate is significantly lowered, depending of course on the anamnesis of the patient prior to surgery and the presence of other diseases such as diabetes mellitus, neoplasma, cardiac diseases etc. background: manual production pc from buffy coats (bc) is a procedure with some consecutive manipulations. the orbisac system (gambro bct) automates the steps and we assessed its performance. material and methods: pc were produced by this device and some parameters were studied. for the preparation of pc, bc were pooled using the orbisac set, with an integrated filter (pall lrp ). bc pool was resuspended in the additive solution t-sol in order to obtain a final ratio plasma/t-sol / . the pc was stored in a gambro elp bag. results: the average platelet count per unit was . ¥ e . the platelet recovery from pooled bc was . % (range . %- . %). all products of the tested pc containing < ¥ e wbc (by flow cytometry). the values of ph on day and of storage were . and . . the swirling phenomenon was good until day °. the average loss of haemoglobin per bc was . g.conclusions:the orbisac system is very suitable for routine pc preparation and it allows increased productivity and better standardization method for pc preparation. platelet concentrates met the requirements for leucodepleted product. increased production of plasma components from male donors background: we routinely separate whole blood (wb) after hard centrifugation into a red cell concentrate (rcc), a buffy coat (bc) and plasma (pl) by an automated expresser (compomat, fresenius). the bcs are subsequently processed into platelet concentrates (pcs) by soft centrifugation and an additional (manual) expression step. the atreus c system (gambro bct) eliminates several of those hand-on steps by combining them into one integrated process. a processing 'circular' bag is placed in the device and filled with the wb. while the bag is centrifuged, the system expresses pl, pc and rcc into separate containers. the rccs are subsequently leukoreduced (manually) with a filter (lr-rccs). this study was designed to evaluate the storage characteristics of the rccs obtained with a prototype of the atreus system in comparison to rccs obtained by routine procedure. methods: whole blood ( ml) was collected in top-and-bottom bags, and randomly selected to be processed by either ( ) current routine or ( ) atreus c. rccs were leukoreduced with the integrated inline filter: fresenius (routine group) or pall rc d (atreus). lr-rccs were stored at °c and sampled until day . various in vitro measurements were performed (n = per group).results: see table (mean ± sd). the lr-rccs contained significantly more leukocytes in the atreus group. despite the rbc loss in the bc, hemoglobin (hb) content was % lower in the atreus group, but met the requirements. in vitro storage characteristics for the rccs were similar in both groups. the atreus pcs contained ± ¥ platelets in ± ml. although plasma volume was higher in the routine group, subsequent preparation of pcs would have resulted in an additional loss of ml per unit in the control group. atreus plasma had extremely low levels of residual wbc and rbc. . ± . . ± . < < . aims: the aim of this study was to examine platelet quality of prestorage pooled prp-derived pc's for up to days storage. methods: pc's were manufactured from wbd-pc's using in-line filtration of prp on day . on day , either , , , or pc's were pooled into an elx® container using a sterile connecting device. studies were performed on days , and for the following measure of platelet quality. ph, morphology score (ms), extent of shape change (esc), hypotonic shock response (hsr), percent in surface expression of p-selectin (p-sel), phosphatidyl serine (ps), glycoprotein b (gp b) and by thromboelastography of the prp (maximum aplitude, ma). results: a total of pools were studied, each of , , and pc's. the mean platelet yield was . ¥ e with a range of . - . ¥ e . the five pc's had a mean yield of . ¥ e and all maintained a ph > . on day . all products had less than ¥ e residual wbc. platelet quality data is presented in the table. data are the mean ± sd, n = . conclusion: platelet pools manufactured from pc's produced by inline filtered prp and stored in elx® containers show good quality preservation to day over a range of platelet yields. introduction: the big progress in treatment of critically ill children significantly increases the need for blood and blood products. loss of blood (lowering of the total erythrocyte mass), as well as decreasing of oxygen capacity of blood that can influence cardiovascular function, is main indication for the erythrocyte transfusion. aim of the study: to present the number of erythrocyte concentrates (ek) that were issued to the pediatric clinic in skopje, as well as to point out how they were distributed. material and method: this is a retrospective study performed in nitm-skopje from january till may . the following criteria were followed: hemoglobin (hb), hematocrit (htc), as well the clinical evaluation, and then final decision for transfusion was made.results: there were blood units (ek) issued for the mentioned period to pediatric clinic for pediatric patients (~ , % units/per child). the biggest consumers are children at intensive care unit and at the hematology-oncology unit. one unit of leukodepleted erythrocytes (er) was split equally to - bags. for small and prematurely born children and for some other selected patients er unit was filtered and irradiated. the dosage was - ml er (depends on age and body weigh). ek was issued as washed concentrates, ek were filtered and ek were resuspended in ab plasma. distribution among abo system was the following: conclusion: gynecologic patients consumed rbc more than times than obstetric ones ( vs ) and the number of given transfusions is high. the a blood group is the most needed one. we should insist on using the who guidelines for the proper clinical use of blood and try to minimize the percentage of given transfusion. and z. cermakova university hospital, ostrava, czech republic background: fully automated system olympus pk is an immunohaematological analyser for detection of red blood cells antigens of ab , rh (d, c, c, e, e) and kell systems without centrifugation by mam (microplate agglutination method) on unique terraced microplate olympus. in the czech republic analyser pk is used only in blood center ostrava. aim: to evaluate the validity of results, sensitivity of microplate agglutinaton method, cause of abortive tests, requirements for analyst, capacity and reliability. methods: blood samples of donors were tested between july and january . all samples were analysed for ab blood group. samples were tested for rhd antigen and ones for rh (c, c, e, e) and k antigen. the validity of the results was evaluated for ab with parallel testing antigens and antibodies, while for rh (d, c, c, e, e) and k using two diagnostic serums. sensitivity of mam i.e. occurrence false negative or positive results were found out when results were confronted with previous ones in our data bank acquired testing classical manual tube or microplate methods. requirements for analyst were evaluated in according to demands for needful knowledge for new analyst, necessity of control pk during testing and maintenance. capacity were evaluated as a number of samples tested per day. reliability determine by occurrence disorders. results: ab , rh (d, c, c, e, e) and k were investigated truly by first testing at . % samples. two diagnostic serums anti-d olymp igm and totem differentiate directly rhd negative and rhd positive donors. false negative or positive results were not founded out due to mam or quality of diagnostic serums. about . % samples with abortive tests were analysed next time the same testing or manual technique. causes of abortive tests were microagglutination several samples except for anticoagulative edta, weak solution of red blood cells prepared by analyser, damage of microplate, hemolysis due to impurity of microplate. in one case analyser evaluated false ab blood group due to hemolysis. analyser has friendly software, simple maintenance and sound control during testing, capacity about samples per day and minimal occurrence of weighty disorders. conclusion: analyser olympus pk is an effective alternative full automation for medium serological laboratory and together with mam easy and truly proves blood groups of majority samples with minimal necessity repetition due to abortive tests. introduction and aim of the study: the purpose of this study is to establish nested-pcr for the detection of hepatitis b virus (hbv) in blood and blood products. methods: the primer pair set was designed to amplify bp in sregion of hbv genome in the first pcr and bp of first pcr amplicon with rubisco (internal control) in the second pcr. to assess the specificity of pcr results, all the samples were tested cross-reactivity or interference in the assay. results: in case of hbv spiked blood products such as immunoglobulin and coagulation factors, this method could detect hbv dna up to . iu/ml. nested-pcr was compared with pcr-elisa and hybrid capture ii (hc-ii), the pcr-elisa showed a sensitivity of % (hc-ii; %) and a specificity of % (hc-ii; %) (p < . ). the results of the study show that nested-pcr and pcr-elisa could be used equally in the management for hbv detection in blood and blood products. p- blood component therapy: slow improvement a mrdja health center subotica, subotica, serbia background: transfusion department at general hospital was founded in . since that time till now it has answered to all demands in blood and blood components. aim: the aim is to present development of the transfusiology department in the last years, so that we could see how much of scientific knowledge we have adopted and in which direction our department goes at the moment. method: retrospective analysis of blood/component utilization in period from . january to . december . results: in whole blood participated in the consumption with . %, packed red blood cells with (rbc) only . %, washed rbc were used in . % of the cases. in whole blood participated in the consumption with . %, packed rbc with . %, washed rbc with . % and rbc in additive solution with . %. as far as plasma preparations are concerned, there has been, since , a great consumption of plasma -witch was separated from whole blood in period up to five day in . % cases, and small consumption of fresh frozen plasma (ffp) only . %. since , there has completely been cancelled the production of five day old plasma, only ffp is being used. from to for the patients who needed platelets, platelet rich plasma (prp) was prepared and applied right after preparation. the consumption rate was from units to units per year. in , after the purchase of platelet shaker, began the production of platelet concentrates (pc) and consumption suddenly rose from units in to units in . conclusions: it is obvious from the analysis that irrational consumption of whole blood was reduced to more acceptable values and therefore the use of component therapy got increased. variation in blood consumption and its slight increase is obvious though application red blood cells was conducted according to strict indications. in the production of plasma old up to five days was cancelled and instead we produced only ffp. pc we prepared for patients only in agreement of treating physician. although very slow progress in development of transfusion therapy in our department can be seen in accepting scientific knowledge. transfusion specialist are active participants in patient treatment and by accepting scientific achievement are able to set standards and help our colleagues, clinics, in successful hemotherapy. introduction: blood groups may act as receptors of parasites, bacteria and viruses. there is evidence that they perform a function and play a biological role. objective: the aim was to detect abo and p epithopes in ascaris lumbricoides extracts (ae) and to study the presence of immune antibodies in patients with ascariasis. materials and methods: ae were prepared by refrigerated mechanical rupture of adult specimens. agglutination inhibition (ai) and haemogglutination kinetics (hk) tests were made with the ae. the patients´ abo and p blood groups were determined. we total febrile non haemolitic male transfusion reaction f e m a l e alloimunisation on le/hla male antigens f e m a l e kandidates of renal male transplantation female lupus nephritis male f e m a l e total female male introduction: irradiation of blood product has been in routine use to prevent graft-versus-host disease (gvhd) in certain recipients for many yeas. gamma irradiation can abrogate the ability of lymphocytes to proliferate in vitro, cgy of gamma radiation reduce lymphocyte response to mitogens by %.the aim of the study: . to estimate potassium level increment in stored irradiation blood units. . to compare the increment in potassium level between leucodepleted and non leucodepleted, irradiated stored blood units. . to evaluate the expiratory date of blood units post irradiation. the study included units of blood collected in cpd-adsol (as- ). in twenty units the blood collection bag was with inline leucodepletion, while the other units were non leucodepleted. all the units were irradiated using caesium as a source of irradiation, with a dose of - cgy. baseline samples from the bags were obtained for measuring of extra cellular potassium (k+). control samples included. results: there is statistically significant increment in potassium level in the irradiated samples compared to the non irradiated samples starting from st day post irradiation and continues to day post irradiation. comparing the group of irradiated leucodepleted, with irradiated non leuconondepleted, for potassium level estimation during the days of storage post irradiation. there is no statistically significant difference between the two groups during all the days of storage, starting from base line samples and other samples post irradiation until day , p value of more than . . . gamma irradiation of bloods units can cause cell damage that the use of such components needs to be modified. . there is a significant increment in the extra cellular potassium level in irradiated blood units that shows doubling value within h post irradiation. . there is no significant difference in extra cellular potassium level increment post irradiation when prestorage leucodepleted units are compared with non leucodepleted units. . an out date of days post collection (unless they expired before) for irradiated red blood units seems reasonable to ensure transfusion of irradiated units without serious complications, except in neonates and massive transfusion cases where irradiated blood units should be fresh and used within - h post irradiation. . the percentage of irradiated blood units requested by our physicians ( . %) is very less that reflects the needs of physicians awareness of the indications for requesting irradiated components that can prevent serious post transfusion complications. the use of whole blood and blood components in treatment of surgical patients in ten years period was analyzed in iran. in accordance with world trend of using blood component therapy, in medical centers throughout the country in ten years period, there are decreasing trend of using whole blood from % ( ) to . % ( ) and increasing trend of using packed red cells component therapy from . % ( ) to . % ( ) . there is also increasing trend of using fresh frozen plasma (ffp) from . % ( ) to . % ( ) . comparing and year, in use of blood therapy related to hospitalized patients at surgical department who received blood and patients who did not received blood; it appears that there is statistically significant difference between these two years. results: during year period, a total of units of blood and units of f.f.p were used. more specifically, the results can be shown in the following table . a high rate of f.f.p usage is observed both in surgery and pathology clinics. the main causes of its usage are: haemodynamic disorders -volume depletion, and coagulation disorders and low blood protein, for the two clinics respectively. conclusion: the only way for rational usage of f.f.p is the regular reminding of plasma transfusion indications to the clinical doctors, so that undesirable side-effects caused by plasma transfusion will be reduced and the percentage of plasma used for fractionation will increase. acquired factor v inhibitor is extremely rare and is associated with diverse clinical symptomatology that varies from asymptomatic forms of the disease to very severe hemorrhagic episodes with a potentially lethal outcome. it may occur spontaneously or as a result of various clinical conditions. a -year-old man was admitted to our hospital with a diagnosis of left-sided periscrotal abscess and scheduled for an incision procedure. during the routine preoperative procedure screening coagulation tests showed pathologic values: aptt s, pt %, fibrinogen . g/l, fv % (other factors were in normal range), platelet count ¥ /l. factor v inhibitor was detected by a modified bethesda assay. the assay showed a low level of inhibitor of about . bethesda units (bu). the patient's medical history showed no major morbidity except appendectomy performed years ago. the patient was prepared for operative procedure, with preventive preoperative administration of fresh frozen plasma (ffp) in a dose of mg/kg (~ ml). upon ffp transfusion, repeated determination of the factor v plasma was unchanged from the initial finding ( %), indicating a failure of therapeutic response. as the measured level of factor v activity was at the borderline hemostatic level, and the operative procedure was not associated with a high risk of hemorrhage, the patient underwent abscess incision. the procedure and postoperative course were uneventful and without major hemorrhage. laboratory testing for the possible systemic autoimmune disorder produced normal findings. control examination performed two years later revealed no major clinical or laboratory variation, while a low factor v level persisted ( %) along with the presence of factor v inhibitor at a level of . bu. we have evaluated two groups of rcc's, one we routinely use (quadruple leucoflex lcr t/t cpd/sagm) (macopharma) and one using an automated collection device which gives the ability to collect whole blood in cpd with a rate of : respectively during the whole donation. the mentioned system has been evaluated using the suitable, quadruple leu-coflex lcr t/t cpd/sagm (macopharma). whole blood ml in cpd was collected from random donors. in both groups the whole system was stored at scaled r.t. ± °c for to h. after component separation (beckman coulter j mi-optipress i-baxter), the red cell concentrates were filtered immediately at r.t. ± °c. sampling was done after filtration and wbc measurements were determinated using nageotte champer (bright line-detection limit . wbc/ml) with leucoplate solution (sobioda). the other parameters were measured with (celldyne abbott). conclusion: all products met the accordance of national and european norms for blood components quality. leucodepletion with leucoflex lcr and abc leucoflex lcr ( . and . ) is highly efficient. the use of abc leucoflex lcr showed better scaled donation in terms of collection (statistical analysis mann-whitney, minitab p-value = . < . ). additionally less hb-loss occurred, due to the filtration process, most probably due to the total absence of clots (analysis man-whitney, minitab, p-value = . < . ). this new generation of collection gives the ability in blood services to collect well calibrated donations, indoors or outdoors. smaller quantities of donations theoretically can be valid because of the stable : , rate of donation. the abc system gives the ability of fully traceability during donation. macopharma's blood collection bags, with or without integrated filters, provided they have this modified system of storing the ac. the device can keep records for many parameters and can transfer them to the data base server of the blood center. to evaluate the performance of the abc, we conducted a comparative study between abc leucoflex lst system and leucoflex lst system we currently use. the later is a well known macopharma's system for collection of whole blood with integrated whole blood filter and the final production of one unit of leucodepleted crcs and one unit of leucodepleted plasma. the abc was handled with the same system modified with the storage bag for the ac. issues of comparison were the accuracy in donation volume, the duration of filtration, the loss of blood in the filter and the residual wb cells after filtration. we performed donations with the lst system and donations with the abc lst system. all the donors were random male volunteers and they were meant to donate mls of whole blood. our results analysed by mann-whitney, minitab statistical analysis have as follows: . no significant difference was found between the two systems concerning the whole blood volume, but there was broader distribution of the values in the lst system compared to the abc lst system. . the duration of filtration has been found without statistically significant differences between the two systems. . the loss of volume in the filter of lst is higher than in the abc lst (p = . < . , which is statistically significant). . there was very good leucodepletion with the lst systems (median reduction of the wb cells . log) but there was a superiority of the abc lst over the lst concerning the leucodepletion per litter and per unit (p: . and p: . respectively). . the personnel after a very short period of training accepted fully the abc procedure.in conclusion abc is an easy to handle device which provides with high quality blood products in combination with leucoflex lst . evaluation of a post-storage filter for wbcs with an incorporated waste bag for washing rccs leucolab lcg is a system manufactured by macopharma for poststorage filtration of a rcc unit (with or without an incorporated waste bag for further washing of the filtered product). to evaluate the efficiency and reliability of the above system we conducted a study with twenty three random units of rccs stored in cpd/sag-m, aged - days, filtered and consecutively washed with ml of normal saline, span down in the regular way and the supernatant extracted in the waste bag. issues for evaluation were: . the duration of priming and filtering the rccs. . the loss of volume in the filter. . the efficiency of the filtration. . the acceptance of the personnel of a new (to them) filtration system.our results have as follows: . we counted the duration of priming and filtration. median time of priming was s (range - ) and of filtration was min (range - ). . the median volume lost in the filter (as calculated) was . ml (ranging from . to . ). this narrow range is apparently due to the non-flexible cell of the filter. . the efficiency of the leucodepletion was counted by flow cytometry. the median wbc counted per lt was . ¥ (range . - . ¥ ) and per unit was . ¥ (range . - . ¥ ). the median reduction of the wbc count was . log (range . - . ). . the personnel involved in the procedure found the system easy to handle, even without specific training. in conclusion the lcg is a reliable and easy to handle system, for leucodepleting (and washing) rccs, very efficient in removing wbcs with negligible loss of volume. objective: standardization of blood banks and establishing quality assurance are important landmarks in the new era of transfusion medicine. as the number of blood banks grows and the capacities of them changes, centralization need arises and trends to nationally coordinated blood services eventually appear. aim: to investigate the types and capacities of blood bank in the country and evaluate the statistics of them. material and method: blood banks and transfusion society of turkey conducted a nation-wide survey of a comprehensive questionnaire. this is a preliminary report of this investigation and illustrates the capacities of the most blood banks in turkey. it also guides the nationally planned renewing structure of blood banks. results: there are nearly blood banks and blood stations in whole country. the overall blood collected at those centers is about . . units. nearly one in third is being collected at government hospitals ( . %), nearly the same is collected at university hospital blood banks ( . %). the third major group is the red crescent society blood centers-rcsbc ( . %), followed by the social security hospitals ( . %). blood collecting capacities are not appearing in the same order. the major blood banks belong to the rcsbcs, whereas the small ones are mostly government hospitals. the only donor recruitment organization is run by the rcsbcs. yearly blood collecting capacity blood banks (%) > . . . - . . . - . . . - . . < . . conclusion: there are many steps for improving blood safety in a country, and the prior ones are structuring the blood transfusion system and donor organization on a national basis, and then establishing good manufacturing practices. these are only possible after centralization of all existing blood banks. in our country, we should first arrange all small capacity blood banks and standardize them. controversial clinical questions considered in a medical opinion forum by physicians for the advancement of transfusion medicine (patm) patm is a newly formed group of close to physicians drawn from pathology and hematology, transfusion services, hospital blood banks and blood centers. its mission is to address the concern that patient oriented medical opinion and influence has been diminished in transfusion medicine (tm). they believe that a patient oriented voice should be distinct from institutional, commercial or regulatory weight and have a common focus on patients and the therapeutics of transfusion and related therapies. therefore, their first objective is to create a new medical, patient oriented voice that weighs in on national policy pertaining to treatments related to tm. as such, patm held its first medical opinion forum where members of the group debated important questions pertaining to tm clinical practice. the forum was held just prior to the aabb annual meeting and attracted physicians. the questions debated were preselected by patm membership via an email survey. respondents were asked to select their top four preferences from among topics in five broad categories. the top two topics were selected for the forum from the completed surveys. the subjects selected and debated were (i) what are the medical considerations for reducing the rate of mistransfusion? and (ii) what are the medical considerations for managing a limited blood inventory? the participants were divided into four groups, with each topic assigned to two groups. all the groups were given two h to debate and arrive at consensus on their topic. each group then presented a summary of their discussions along with specific recommendations for addressing these clinical practice issues. there was remarkable consensus between the groups debating the same issue. the conclusions and recommendations on these two topics will be presented in detail. patm is a new organization that will add an important medical voice and opinion on current topics in tm. at its first meeting, two topics were successfully discussed and debated with broad consensus achieved on current issues confronting the field. key: cord- -fr uod authors: nan title: saem abstracts, plenary session date: - - journal: acad emerg med doi: . /j. - . . .x sha: doc_id: cord_uid: fr uod nan objectives: we sought to determine if the ocp policy resulted in a meaningful and sustained improvement in ed throughput and output metrics. methods: a prospective pre-post experimental study was conducted using administrative data from community and tertiary centers across the province. the study phases consisted of the months from february to september compared against the same months in . operational data for all centres were collected through the edis tracking systems used in the province. the ocp included main triggers: ed bed occupancy > %, at least % of ed stretchers blocked by patients awaiting inpatient bed or disposition decision, and no stretcher available for high acuity patients. when all criteria were met, selected boarded patients were moved to an inpatient unit (non-traditional care space if no bed available). the primary outcome was ed length of stay (los) for admitted patients. the ed load of boarded patients from - am was reported the editors of academic emergency medicine (aem) are honored to present these abstracts accepted for presentation at the annual meeting of the society for academic emergency medicine (saem), may to in chicago, illinois. these abstracts represent countless hours of labor, exciting intellectual discovery, and unending dedication by our specialty's academicians. we are grateful for their consistent enthusiasm, and are privileged to publish these brief summaries of their research. this year, saem received abstracts for consideration, and accepted . each abstract was independently reviewed by up to six dedicated topic experts blinded to the identity of the authors. final determinations for scientific presentation were made by the saem program scientific subcommittee co-chaired by ali s. raja, md, mba, mph and steven b. bird, md, and the saem program committee, chaired by michael l. hochberg, md. their decisions were based on the final review scores and the time and space available at the annual meeting for oral and poster presentations. there were also innovation in emergency medicine education (ieme) abstracts submitted, of which were accepted. the ieme subcommittee was co-chaired by joanna leuck, md and laurie thibodeau, md. we present these abstracts as they were received, with minimal proofreading and copy editing. any questions related to the content of the abstracts should be directed to the authors. presentation numbers precede the abstract titles; these match the listings for the various oral and poster sessions at the annual meeting in chicago, as well as the abstract numbers (not page numbers) shown in the key word and author indexes at the end of this supplement. all authors attested to institutional review board or animal care and use committee approval at the time of abstract submission, when relevant. abstracts marked as ''late-breakers'' are prospective research projects that were still in the process of data collection at the time of the december abstract deadline, but were deemed by the scientific subcommittee to be of exceptional interest. these projects will be completed by the time of the annual meeting; data shown here may be preliminary or interim. on behalf of the editors of aem, the membership of saem, and the leadership of our specialty, we sincerely thank our research colleagues for these contributions, and their continuing efforts to expand our knowledge base and allow us to better treat our patients. david background: two to ten percent of patients evaluated in the emergency departments (ed) present with altered mental status (ams). the prevalence of non-convulsive seizure (ncs) and other electroencephalographic (eeg) abnormalities in this population is not known. this information is needed to make recommendations regarding the routine use of emergent eeg in ams patients. objectives: to identify the prevalence of ncs and other eeg abnormalities in ed patients with ams. methods: an ongoing prospective study at two academic urban ed. inclusion: patients ‡ years old with ams. exclusion: an easily correctable cause of ams (e.g. hypoglycemia, opioid overdose). a -minute eeg with the standard electrodes was performed on each subject as soon as possible after presentation (usually within hour). outcome: the rate of eeg abnormalities based on blinded review of all eegs by two boardcertified epileptologists. descriptive statistics are used to report eeg findings. frequencies are reported as percentages with % confidence intervals (ci), and inter-rater variability is reported with kappa. results: the interim analysis was performed on consecutive patients (target sample size: ) enrolled from may to october (median age: , range - , % male). eegs for patients were reported uninterpretable by at least one rater ( by both raters). of the remaining , only ( %, %ci - %) were normal according to either rater (n = by both). the most common abnormality was background slowing (n = , %, %ci - %) by either rater (n = by both), indicating underlying encephalopathy. ncs was diagnosed in patients ( %, %ci, - %) by at least one rater (n = by both), including ( %, %ci - %) patients in non-convulsive status epilepticus (ncse). patients ( %, %ci - %) had interictal epileptiform discharges read by at least one rater (n = by both) indicating cortical irritability and an increased risk of spontaneous seizure. inter-rater reliability for eeg interpretations was modest (kappa: . , %ci . - . ). objectives: to define diagnostic sbi and non-bacterial (non-sbi) biosignatures using rna microarrays in febrile infants presenting to emergency departments (eds). methods: we prospectively collected blood for rna microarray analysis in addition to routine screening tests including white blood cell (wbc) counts, urinalyses, cultures of blood, urine, and cerebrospinal fluid, and viral studies in febrile infants days of age in eds . we defined sbi as bacteremia, urinary tract infection (uti), or bacterial meningitis. we used class comparisons (mann-whitney p < . , benjamini for mtc and . fold change filter), modular gene analysis, and k-nn algorithms to define and validate sbi and non-sbi biosignatures in a subset of samples. results: % ( / ) of febrile infants were evaluated for sbi. . % ( / ) had sbi ( ( . %) bac-teremia, ( . %) utis, and ( . %) bacterial meningitis). infants with sbis had higher mean temperatures, and higher wbc, neutrophil, and band counts. we analyzed rna biosignatures on febrile infants: sbis ( meningitis, bacteremia, uti), non-sbis ( influenza, enterovirus, undefined viral infections), and healthy controls. class comparisons identified , differentially expressed genes between sbis and non-sbis. modular analysis revealed overexpression of interferon related genes in non-sbis and inflammation related genes in sbis. genes were differently expressed (p < . ) in each of the three non-sbi groups vs sbi group. unsupervised cluster analysis of these genes correctly clustered % ( / ) of non-sbis and sbis. k-nn algorithm identified discriminatory genes in training set ( non-sbis vs sbis) which classified an independent test ( non-sbis vs sbis) with % accuracy. four misclassified sbis had over-expression of interferon-related genes, suggesting viral-bacterial co-infections, which was confirmed in one patient. background: improving maternal, newborn, and child health (mnch) is a leading priority worldwide. however, limited frontline health care capacity is a major barrier to improving mnch in developing countries. objectives: we sought to develop, implement, and evaluate an evidence-based maternal, newborn, and child survival (mncs) package for frontline health workers (fhws). we hypothesized that fhws could be trained and equipped to manage and refer the leading mnch emergencies. methods: setting -south sudan, which suffers from some of the world's worst mnch indices. assessment/intervention -a multi-modal needs assessment was conducted to develop a best-evidence package comprised of targeted trainings, pictorial checklists, and reusable equipment and commodities ( figure ). program implementation utilized a trainingof-trainers model. evalution - ) pre/post knowledge assessments, ) pre/post objective structured clinical examinations (osces), ) focus group discussions, and ) closed-response questionnaires. results: between nov to oct , local trainers and fhws were trained in of the states in south sudan. knowledge assessments among trainers (n = ) improved significantly from . % (sd . ) to . % (sd . ) (p < . ). mean scores a maternal osce and a newborn osce pre-training, immediately post-training, and upon - month follow-up are shown in the table. closed-response questionnaires with fhws revealed high levels of satisfaction, use, and confidence with mncs materials. participants reported an average of . referrals (range - ) to a higher level of care in the - months since training. furthermore, . % of fhws were more likely to refer patients as a result of the training program. during seven focus group discussions with trained fhws, respondents (n = ) reported high satisfaction with mncs trainings, commodities, and checklists, with few barriers to implementation or use. conclusion: these findings suggest mncs has led to improvements in south sudanese fhws' knowledge, skills, and referral practices with respect to appropriate management of mnch emergencies. no study has compared various lactate measurements to determine the optimal parameter to target. objectives: to compare the association of blood lactate kinetics with survival in patients with septic shock undergoing early quantitative resuscitation. methods: preplanned analysis of a multicenter edbased rct of early sepsis resuscitation targeting three physiological variables: cvp, map, and either central venous oxygen saturation or lactate clearance. inclusion criteria: suspected infection, two or more sirs criteria, and either sbp < mmhg after a fluid bolus or lactate > mmol/l. all patients had an initial lactate measured with repeat at two hours. normalization of lactate was defined a lactate decline to < . mmol/l in a patient with an intial lactate ‡ . . absolute lactate clearance (initial -delayed value), and relative ((absolute clearance)/(initial value)* ) were calculated if the initial lactate was ‡ . . the outcome was in-hospital survival. receiver operating characteristic curves were constructed and areas under the curve (auc) were calculated. difference in proportions of survival between the two groups at different lactate cutoffs were analyzed using % ci and fisher exact tests. results: of included patients, the median initial lactate was . mmol/l (iqr . , . ), and the median absolute and relative lactate clearance were mmol/l (iqr . , . ) and % (iqr , ). an initial lactate > . mmol/l was seen in / ( %), and / ( %) patients normalized their lactate. overall sutures on trunk and extremity lacerations that present in the ed. the use of absorbable sutures in the ed setting confers several advantages: patients do not need to return for suture removal which results in a reduction in ed crowding, ed wait times, missed work or school days, and stressful procedures (suture removal) for children. objectives: the primary objective of this study is to compare the cosmetic outcome of trunk and extremity lacerations repaired using absorbable versus nonabsorbable sutures in children and adults. a secondary objective is to compare complication rates between the two groups. methods: eligible patients with lacerations were randomly allocated to have their wounds repaired with vicryl rapide (absorbable) or prolene (nonabsorbable) sutures. at a day follow-up visit the wounds were evaluated for infection and dehiscence. after months, patients were asked to return to have a photograph of the wound taken. two blinded plastic surgeons using a previously validated mm visual analogue scale (vas) rated the cosmetic outcome of each wound. a vas score of mm or greater was considered to be a clinically significant difference. results: of the patients enrolled, have currently completed the study including in the vicryl rapide group and in the prolene group. there were no significant differences in the age, race, sex, length of wound, number of sutures, or layers of repair in the two groups. the observer's mean vas for the vicryl rapide group was . mm ) and that for the prolene group was . mm ( %ci . - . ), resulting in a mean difference of . mm ( %ci- . to . , p = . ). there were no significant differences in the rates of infection, dehiscence, or keloid formation between the two groups. conclusion: the use of vicryl rapide instead of nonabsorbable sutures for the repair of lacerations on the trunk and extremities should be considered by emergency physicians as it is an alternative that provides a similar cosmetic outcome. objectives: to determine the relationship between infection and time from injury to closure, and the characteristics of lacerations closed before and after hours of injury. methods: over an month period, a prospective multi-center cohort study was conducted at a teaching hospital, trauma center and community hospital. emergency physicians completed a structured data form when treating patients with lacerations. patients were followed to determine whether they had suffered a wound infection requiring treatment and to determine a cosmetic outcome rating. we compared infection rates and clinical characteristics of lacerations with chisquare and t-tests as appropriate. results: there were patients with lacerations; had documented times from injury to closure. the mean times from injury to repair for infected and noninfected wounds were . vs. . hrs (p = . ) with % of lacerations treated within hours and % ( ) treated hours after injury. there were no differences in the infection rates for lacerations closed before ( . %, %ci . - . ) or after ( . %, %ci . - . ) hours and before ( . %, % ci . %- . %) or after ( . %, % ci . %- . %) hours. the patients treated hours after injury tended to be older ( vs. yrs p = . ) and fewer were treated with primary closure ( % vs. % p < . ). comparing wounds or more hours after injury with more recent wounds, there was no effect of location on decision to close. wounds closed after hours did not differ from wounds closed before hours with respect to use of prophylactic antibiotics, type of repair, length of laceration, or cosmetic outcome. conclusion: closing older lacerations, even those greater than hours after injury, does not appear to be associated with any increased risk of infection or adverse outcomes. excellent irrigation and decontamination over the last years may have led to this change in outcome. background: deep burns may result in significant scarring leading to aesthetic disfigurement and functional disability. tgf-b is a growth factor that plays a significant role in wound healing and scar formation. objectives: the current study was designed to test the hypothesis that a novel tgf-b antagonist would reduce scar contracture compared with its vehicle in a porcine partial thickness burn model. methods: ninety-six mid-dermal contact burns were created on the backs and flanks of four anesthetized young swine using a gm aluminum bar preheated to °celsius for seconds. the burns were randomized to treatment with topical tgf-b antagonist at one of three concentrations ( , , and ll) in replicates of in each pig. dressing changes and reapplication of the topical therapy were performed every days for weeks then twice weekly for an additional weeks. burns were photographed and full thickness biopsies were obtained at , , , , and days to determine reepithelialization and scar formation grossly and microscopically. a sample of burns in each group had % power to detect a % difference in percentage scar contracture. results: a total of burns were created in each of the three study groups. burns treated with the high dose tgf-b antagonist healed with less scar contracture than those treated with the low dose and control ( ± %, ± %, and ± %; anova p = . ). additionally, burns treated with the higher, but not the lower dose of tgf-b antagonist healed with significantly fewer full thickness scars than controls ( . % vs. % vs. . % respectively; p < . ). there were no infections and no differences in the percentage wound reepithelialization among all study groups at any of the time points. conclusion: treatment of mid-dermal porcine contact burns with the higher dose tgf-b antagonist reduced scar contracture and rate of deep scars compared with the low dose and controls. background: diabetic ketoacidosis (dka) is a common and lethal complication of diabetes. the american diabetes association recommends treating adult patients with a bolus dose of regular insulin followed by a continuous insulin infusion. the ada also suggests a glucose correction rate of - mg/dl/hr to minimize complications. objectives: compare the effect of bolus dose insulin therapy with insulin infusion to insulin infusion alone on serum glucose, bicarbonate, and ph in the initial treatment of dka. methods: consecutive dka patients were screened in the ed between march ' and june ' . inclusion criteria were: age > years, glucose > mg/dl, serum bicarbonate or ketonemia or ketonuria. exclusion criteria were: congestive heart failure, current hemodialysis, pregnancy, or inability to consent. no patient was enrolled more than once. patients were randomized to receive either regular insulin . units/kg or the same volume of normal saline. patients, medical and research staff were blinded. baseline glucose, electrolytes, and venous blood gases were collected on arrival. bolus insulin or placebo was then administered and all enrolled patients received regular insulin at rate of . unit/kg/hr, as well as fluid and potassium repletion per the research protocol. glucose, electrolytes, and venous blood gases were drawn hourly for hours. data between two groups were compared using unpaired t-test. results: patients were enrolled, with being excluded. patients received bolus insulin; received placebo. no significant differences were noted in initial glucose, ph, bicarbonate, age, or weight between the two groups. after the first hour, glucose levels in the insulin group decreased by mg/dl compared to mg/dl in the placebo group (p = . , % ci . to . ). changes in mean glucose levels, ph, bicarbonate level, and ag were not statistically different between the two groups for the remainder of the hour study period. there was no difference in the incidence of hypoglycemia in the two groups. conclusion: administering a bolus dose of regular insulin decreased mean glucose levels more than placebo, although only for the first hour. there was no difference in the change in ph, serum bicarbonate or anion gap at any interval. this suggests that bolus dose insulin may not add significant benefit in the emergency management of dka. ihca; . return of spontaneous circulation (rsoc). traumatic cardiac arrests were excluded. we recorded baseline demographics, arrest event characteristics, follow-up vitals and laboratory data, and in-hospital mortality. apache ii scores were calculated at the time of rosc, and at hrs, hrs, and hrs. we used simple descriptive statistics to describe the study population. univariate logistic regression was used to predict mortality with apache ii as a continuous predictor variable. discrimination of apache ii scores was assessed using the area under the curve (auc) of the receiver operator characteristic (roc) curve. results: a total of patients were analyzed. the median age was years (iqr: - ) and % were female. apache ii score was a significant predictor of mortality for both ohca and ihca at baseline and at all follow-up time points (all p < . ). discrimination of the score increased over time and achieved very good discrimination after hrs (table, figure) . conclusion: the ability of apache ii score to predict mortality improves over time in the hours following cardiac arrest. these data suggest that after hours, apache ii scoring is a useful severity of illness score in all post-cardiac arrest patients. background: admission hyperglycemia has been described as a mortality risk factor for septic non-diabetics, but the known association of hyperglycemia with hyperlactatemia (a validated mortality risk factor in sepsis) has not previously been accounted for. objectives: to determine whether the association of hyperglycemia with mortality remains significant when adjusted for concurrent hyperlactatemia. methods: this was a post-hoc, nested analysis of a single-center cohort study. providers identified study subjects during their ed encounters; all data were collected from the electronic medical record. patients: nondiabetic adult ed patients with a provider-suspected infection, two or more systemic inflammatory response syndrome criteria, and concurrent lactate and glucose testing in the ed. setting: the ed of an urban teaching hospital; to . analysis: to evaluate the association of hyperglycemia (glucose > mg/dl) with hyperlactatemia (lactate ‡ . mmol/l), a logistic regression model was created; outcome-hyperlactatemia; primary variable of interest-hyperglycemia. a second model was created to determine if concurrent hyperlactatemia affects hyperglycemia's association with mortality; outcome- -day mortality; primary risk variablehyperglycemia with an interaction term for concurrent hyperlactatemia. both models were adjusted for demographics, comorbidities, presenting infectious syndrome, and objective evidence of renal, respiratory, hematologic, or cardiovascular dysfunction. results: ed patients were included; mean age ± years. ( %) subjects were hyperglycemic, ( %) hyperlactatemic, and ( %) died within days of the initial ed visit. after adjustment, hyperglycemia was significantly associated with simultaneous hyperlactatemia (or . , %ci . , . ). hyperglycemia with concurrent hyperlactatemia was associated with increased mortality risk (or . , %ci . , . ) , but hyperglycemia in the absence of simultaneous hyperlactatemia was not (or . , %ci . , . ) . conclusion: in this cohort of septic adult non-diabetic patients, mortality risk did not increase with hyperglycemia unless associated with simultaneous hyperlactatemia. the previously reported association of hyperglycemia with mortality in this population may be due to the association of hyperglycemia with hyperlactatemia. the background: near infrared spectroscopy (sto ) represents a measure of perfusion that provides the treating physician with an assessment of a patient's shock state and response to therapy. it has been shown to correlate with lactate and acid/base status. it is not known if using information from this monitor to guide resuscitation will result in improved patient outcomes. objectives: to compare the resuscitation of patients in shock when the sto monitor is or is not being used to guide resuscitation. methods: this was a prospective study of patients undergoing resuscitation in the ed for shock from any cause. during alternating day periods, physicians were blinded to the data from the monitor followed by days in which physicians were able to see the information from the sto monitor and were instructed to resuscitate patients to a target sto value of . adult patients (age> ) with a shock index (si) of > . (si = heart rate/systolic blood pressure) or a blood pressure < mmhg systolic who underwent resuscitation were enrolled. patients had a sto monitor placed on the thenar eminence of their least-injured hand. data from the sto monitor were recorded continuously and noted every minute along with blood pressure, heart rate, and oxygen saturation. all treatments were recorded. patients' charts were reviewed to determine the diagnosis, icu-free days in the days after enrollment, inpatient los, and -day mortality. data were compared using wilcoxon rank sum and chi-square tests. results: patients were enrolled, during blinded periods and during unblinded periods. the median presenting shock index was . (range . to . ) for the blinded group and . ( . - . ) for the unblinded group (p = . ). the median time in department was minutes (range - ) for the blinded and minutes (range - ) for the unblinded groups (p = . ). the median hospital los was day (range - ) for the blinded group, and days (range - ) in the unblinded group (p = . ). the mean icu-free days was ± for the blinded group and ± for the unblinded group (p = . ). among patients where the physician indicated using the sto monitor data to guide patient care, the icu-free days were . ± for the blinded group and . ± for the blinded group (p = . ). background: inducing therapeutic hypothermia (th) using °c iv fluids in resuscitated cardiac arrest patients has been shown to be feasible and effective. limited research exists assessing the efficiency of this cooling method. objectives: the objective was to determine an efficient infusion method for keeping fluid close to °c upon exiting an iv. it was hypothesized that colder temperatures would be associated with both higher flow rate and insulation of the fluid bag. methods: efficiency was studied by assessing change in fluid temperature ( c) during the infusion, under three laboratory conditions. each condition was performed four times using liter bags of normal saline. fluid was infused into a ml beaker through gtts tubing. flow rate was controlled using a tubing clamp and in-line transducer with a flowmeter, while temperature was continuously monitored in a side port at the terminal end of the iv tubing using a digital thermometer. the three conditions included infusing chilled fluid at a rate of ml/min, which is equivalent to ml/kg/hr for an kg patient, ml/min, and ml/min using a chilled and insulated pressure bag. descriptive statistics and analysis of variance was performed to assess changes in fluid temperature. results: the average fluid temperatures at time were . ( % ci . - . ) ( ml/min), . ( % ci . - . ) ( ml/min), and . ( % ci . - . ) ( ml/min + insulation). there was no significant difference in starting temperature between groups (p = . ). the average fluid temperatures after ml had been infused were . ( % ci . - . ) ( ml/min), . ( % ci . - . ) ( ml/min), and . ( % ci . - . ) ( ml/min + insulation). the higher flow rate groups had significantly lower temperature than the lower flow rate after ml of fluid had been infused (p < . ). the average fluid temperatures after ml had been infused were . ( % ci . - . ) ( ml/min), . ( % ci . - . ) ( ml/min), and . ( % ci . - . ) ( ml/min + insulation). there was a significant difference in temperature between all three groups after ml of fluid had been infused (p < . ). conclusion: in a laboratory setting, the most efficient method of infusing cold fluid appears to be a method that both keeps the bag of fluid insulated and is infused at a faster rate. fluid bolus. patients were categorized by presence of vasoplegic or tissue dysoxic shock. demographics and sequential organ failure assessment (sofa) scores were evaluated between the groups. the primary outcome was in-hospital mortality. data were analyzed using t-tests, chi-squared test, and proportion differences with % confidence intervals as appropriate. results: a total of patients were included: patients with vasoplegic shock and with tissue dysoxic shock. there were no significant differences in age ( vs. years), caucasian race ( % vs. %), or male sex ( % vs. %) between the dysoxic shock and vasoplegic shock groups, respectively. the group with vasoplegic shock had a lower initial sofa score than did the group with tissue dysoxic shock ( . vs. . points, p = . ). the primary outcome of in-hospital mortality occurred in / ( %) of patients with vasoplegic shock compared to / ( %) in the group with tissue dysoxic shock (proportion difference %, % ci - %, p < . ). conclusion: in this analysis of patients with septic shock, we found a significant difference in in-hospital mortality between patients with vasoplegic versus tissue dysoxic septic shock. these findings suggest a need to consider these differences when designing future studies of septic shock therapies. background: the pre-shock population, ed sepsis patients with tissue hypoperfusion (lactate of . - . mm), commonly deteriorates after admission and requires transfer to critical care. objectives: to determine the physiologic parameters and disease severity indices in the ed pre-shock sepsis population that predict clinical deterioration. we hypothesized that neither initial physiologic parameters nor organ function scores will be predictive. methods: design: retrospective analysis of a prospectively maintained registry of sepsis patients with lactate measurements. setting: an urban, academic medical center. participants: the pre-shock population, defined as adult ed sepsis patients with either elevated lactate ( . - . mm) or transient hypotension (any sbp < mmhg) receiving iv antibiotics and admitted to a medical floor. consecutive patients meeting pre-shock criteria were enrolled over a -year period. patients with overt shock in the ed, pregnancy, or acute trauma were excluded. outcome: primary patientcentered outcome of increased organ failure (sequential organ failure assessment [sofa] score increase > point, mechanical ventilation, or vasopressor utilization) within hours of admission or in-hospital mortality. results: we identified pre-shock patients from screened. the primary outcome was met in % of the cohort and % were transferred to the icu from a medical floor. patients meeting the outcome of increased organ failure had a greater shock index ( . vs . , p = . ) and heart rate ( vs , p < . ) with no difference in initial lactate, age, map, or exposure to hypotension (sbp < mmhg). there was no difference in the predisposition, infection, response, and organ dysfunction (piro) score between groups ( . vs . , p = . ). outcome patients had similar initial levels of organ dysfunction but had higher sofa scores at , , and hours, a higher icu transfer rate ( vs %, p < . ), and increased icu and hospital lengths of stay. conclusion: the pre-shock sepsis population has a high incidence of clinical deterioration, progressive organ failure, and icu transfer. physiologic data in the ed were unable to differentiate the pre-shock sepsis patients who developed increased organ failure. this study supports the need for an objective organ failure assessment in the emergency department to supplement clinical decision-making. background: lipopolysaccharide (lps) has long been recognized to initiate the host inflammatory response to infection with gram negative bacteria (gnb). large clinical trials of potentially very expensive therapies continue to have the objective of reducing circulating lps. previous studies have found varying prevalence of lps in blood of patients with severe sepsis. compared with sepsis trials conducted years ago, the frequency of gnb in culture specimens from emergency department (ed) patients enrolled in clinical trials of severe sepsis has decreased. objectives: test the hypothesis that prior to antibiotic administration, circulating lps can be detected in the plasma of fewer than % of ed patients with severe sepsis. methods: secondary analysis of a prospective edbased rct of early quantitative resuscitation for severe sepsis. blood specimens were drawn at the time severe sepsis was recognized, defined as two or more systemic inflammatory criteria and a serum lactate > mm or spb< mmhg after fluid challenge. blood was drawn in edta prior to antibiotic administration or within the first several hours, immediately centrifuged, and plasma frozen at ) °c. plasma lps was quantified using the limulus amebocyte lysate assay (lal) by a technician blinded to all clinical data. results: patients were enrolled with plasma samples available for testing. median age was ± years, % female, with overall mortality of %. forty of patients ( %) had any culture specimen positive for gnb including ( %) with blood cultures positive. only five specimens had detectable lps, including two with a gnb-positive culture specimen, and three were lps-positive without gnb in any culture. prevalence of detectable lps was . % (ci: . %- . %). the frequency of detectable lps in antibiotic-naive plasma is too low to serve as a useful diagnostic test or therapeutic target in ed patients with severe sepsis. the data raise the question of whether post-antibiotic plasma may have a higher frequency of detectable lps. background: egdt is known to reduce mortality in septic patients. there is no evidence to date that delineates the role of using a risk stratification tool, such as the mortality in emergency department sepsis (meds) score, to determine which subgroups of patients may have a greater benefit with egdt. objectives: our objective was to determine if our egdt protocol differentially affects mortality based on the severity of illness using meds score. methods: this study is a retrospective chart review of patients, conducted at an urban tertiary care center, after implementing an egdt protocol on july , (figure) . this study compares in-hospital mortality, length of stay (los) in icu, and los in ed between the control group ( patients from / / - / / ) and the postimplementation group ( patients from / / - / / ), using meds score as a risk stratification tool. inclusion criteria: patients who presented to our ed with a suspected infection, and two or more sirs criteria, a map< mmhg, a sbp< mmol/l. exclusion criteria: age< , death on arrival to ed, dnr or dni, emergent surgical intervention, or those with an acute myocardial infarction or chf exacerbation. a two-sample t-test was used to show that the mean age and number of comorbidities was similar between the control and study groups (p = . and . respectively). mortality was compared and adjusted for meds score using logistic regression. the odds ratios and predicted probabilities of death are generated using the fitted logistic regression model. ed and icu los were compared using mood's median test. results: when controlling for illness severity using meds score, the relative risk (rr) of death with egdt is about half that of the control group (rr = . , % ci [ . - . ], p= . ). also, by applying meds score to risk stratify patients into various groups of illness severity, we found no specific groups where egdt is more efficacious at reducing the predicted probability of death (table ) . without controlling for meds score, there is a trend in reduction of absolute mortality by . % when egdt is used (control = . %, study = . %, p = . ). egdt leads to a . % reduction in the median los in icu (control = hours, study = hours, p = . ), without increasing los in ed (control = hours, study = hours, p = . ). conclusion: egdt is beneficial in patients with severe sepsis or septic shock, regardless of their meds score. background: in patients experiencing acute coronary syndrome (acs), prompt diagnosis is critical in achieving the best health outcome. while ecg analysis is usually sufficient to diagnose acs in cases of st elevation, acs without st elevation is reliably diagnosed through serial testing of cardiac troponin i (ctni). pointof-care testing (poct) for ctni by venipuncture has been proven a more rapid means to diagnosis than central laboratory testing. implementing fingerstick testing for ctni in place of standard venipuncture methods would allow for faster and easier procurement of patients' ctni levels, as well as increase the likelihood of starting a rapid test for ctni in the prehospital setting, which could allow for even earlier diagnosis of acs. objectives: to determine if fingerstick blood samples yield accurate and reliable troponin measurements compared to conventional venous blood draws using the i-stat poc device. methods: this experimental study was performed in the ed of a quaternary care suburban medical center between june-august . fingerstick blood samples were obtained from adult ed patients for whom standard (venipuncture) poc troponin testing was ordered. the time between fingerstick and standard draws was kept as narrow as possible. ctni assays were performed at the bedside using the i-stat (abbott point of care). results: samples from patients were analyzed by both fingerstick and standard ed poct methods (see table) . four resulted in cartridge error. compared to ''gold standard'' ed poct, fingerstick testing has a positive predictive value of %, negative predictive value of %, sensitivity of %, and specificity of %. no significant difference in ctni level was found between the two methods, with a nonparametric intraclass correlation coefficient of . ( % ci . - . , p-value < . ). conclusion: whole blood fingerstick ctni testing using the i-stat device is suitable for rapid evaluation of ctni level in prehospital and ed settings. however, results must be interpreted with caution if they are within a narrow territory of the cutoff for normal vs. elevated levels. additional testing on a larger sample would be beneficial. the practicality and clinical benefit of using fingerstick ctni testing in the ems setting must still be assessed. background: adjudication of diagnosis of acute myocardial infarction (ami) in clinical studies typically occurs at each site of subject enrollment (local) or by experts at an independent site (central). from from - , the troponin (ctn) element of the diagnosis was predicated on the local laboratories, using a mix of the th percentile reference ctn and roc-determined cutpoints. in , the universal definition of ami (ud-ami) defined it by the th percentile reference alone. objectives: to compare the diagnosis rates of ami as determined by local adjudication vs. central adjudication using udami criteria. methods: retrospective analysis of data from the myeloperoxidase in the diagnosis of acute coronary syndromes (acs) study (midas), an -center prospective study with enrollment from / / to / / of patients with suspected acs presenting to the ed < hours after symptom onset and in whom serial ctn and objective cardiac perfusion testing was planned. adjudication of acs was done by single local principal investigators using clinical data and local ctn cutpoints from different ctn assays, and applying the definition. central adjudication was done after completion of the midas primary analysis using the same data and local ctn assay, but by experts at three different institutions, using the udami and the manufacturer's th percentile ctn cutpoint, and not blinded to local adjudications. discrepant dignoses were resolved by consensus. local vs. central ctn cutpoints differed for six assays, with central cutpoints lower in all. statistics were by chi-square and kappa. results: excluding cases deemed indeterminate by central adjudication, cases were successfully adjudicated. local adjudication resulted in ami ( . % of total) and non-ami; central adjudication resulted in ( . %) ami and non-ami. overall, local diagnoses ( %) were either changed from non-ami to ami or ami to non-ami (p < . ). interrater reliability across both methods was found to be kappa = . (p < . ). for acs diagnosis, local adjudication identified acs cases ( %) and non-acs, while central adjudication identified acs ( %) and non-acs. overall, local diagnoses ( %) were either changed from non-acs to acs or acs to non-acs (p < . ). interrater reliability found kappa = . (p < . ). conclusion: central and local adjudication resulted in significantly different rates of ami and acs diagnosis. however, overall agreement of the two methods across these two diagnoses was acceptable. occur four times more often in cocaine users. biomarkers myeloperoxidase (mpo) and c-reactive protein (crp) have potential in the diagnosis of acs. objectives: to evaluate the utility of mpo and crp in the diagnosis of acs in patients presenting to the ed with cocaine-associated chest pain and compare the predictive value to nonusers. we hypothesized that these markers may be more sensitive for acs in nonusers given the underlying pathophysiology of enhanced plaque inflammation. methods: a secondary analysis of a cohort study of enrolled ed patients who received evaluation for acs at an urban, tertiary care hospital. structured data collection at presentation included demographics, chest pain history, lab, and ecg data. subjects included those with self-reported or lab-confirmed cocaine use and chest pain. they were matched to controls based on age, sex, and race. our main outcome was diagnosis of acs at index visit. we determined median mpo and crp values, calculated maximal auc for roc curves, and found cut-points to maximize sensitivity and specificity. data are presented with % ci. results: overall, patients in the cocaine positivegroup and patients in the nonusers group had mpo and crp levels measured. patients had a median age of (iqr, ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , % black or african american, and % male (p > . between groups). fifteen patients were diagnosed with acs: patients in the cocaine group and in the nonusers group. comparing cocaine users to nonusers, there was no difference in mpo (median [iqr, ] v ng/ml; p = . ) or crp ( [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] v [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] mg/l; p = . ). the auc for mpo was . ( % ci . - . ) v . ( % ci . - . ). the optimal cut-point to maximize sensitivity and specificity was ng/ml which gave a sensitivity of . and specificity of . . using this cutpoint, % v % of acs in cocaine users vs the nonusers would be identified. the auc for crp was . ( % ci . - . ) in cocaine users vs . ( % ci . - . ) in nonusers. the optimal cut point was . mg/l with a sensitivity of . and specificity of . . using this cutpoint, % v % of acs in cocaine users and nonusers would have been identified. conclusion: the diagnostic accuracy of mpo and crp is not different in cocaine users than nonusers and does not appear to have sufficient discriminatory ability in either cohort. results: hrs of moderate pe caused a significant decrease in rv heart function in rats treated with the solvent for bay - : peak systolic pressure (psp) decreased from ± . mmhg, control to ± . , pe, +dp/dt decreased from ± mmhg/sec to ± , -dp/dt decreased from ) ± mmhg/sec to ) ± . treatment of rats with bay - significantly improved all three indices of rv heart function (psp ± . , +dp/dt ± , -dp/dt ) ± ). hrs of severe pe also caused significant rv dysfunction (psp ± , -dp/dt ) ± ) and treatment with bay - produced protection of rv heart function (psp ± , -dp/dt ) ± ) similar to the hr moderate pe model. conclusion: experimental pe produced significant rv dysfunction, which was ameliorated by treatment of the animals with the soluble guanylate cyclase stimulator, bay - . hospital of the university of pennsylvania, philadelphia, pa; cooper university hospital, camden, nj background: patients who present to the ed with symptoms of potential acute coronary syndrome (acs) can be safely discharged home after a negative coronary computerized tomographic angiography (cta). however, the duration of time for which a negative coronary cta can be used to inform decision making when patients have recurrent symptoms is unknown. objectives: we examined patients who received more than one coronary cta for evaluation of acs to determine whether they had disease progression, as defined by crossing the threshold from noncritical (< % maximal stenosis) to potentially critical disease. methods: we performed a structured comprehensive record search of all coronary ctas performed from to at a tertiary care health system. low-tointermediate risk ed patients who received two or more coronary ctas, at least one from an ed evaluation for potential acs, were identified. patients who were revascularized between scans were excluded. we collected demographic data, clinical course, time between scans, and number of ed visits between scans. record review was structured and done by trained abstractors. our main outcome was progression of coronary stenosis between scans, specifically crossing the threshold from noncritical to potentially critical disease. results: overall, patients met study criteria (median age , interquartile range [iqr] ( . - ); % female; % black). the median time between studies was . months (iqr, . patients did not have stenosis in any vessel on either coronary cta, two studies showed increasing stenosis of < %, and the rest showed ''improvement,'' most due to better imaging quality. no patient initially below the % threshold subsequently exceeded it ( %; % ci, - . %). patients also had varying numbers of ed visits (median number of visits , range - ), and numbers of ed visits for potentially cardiac complaints (median , range - ); were re-admitted for potentially cardiac complaints (for example, chest pain or shortness of breath), and received further provocative cardiac testing, all of which had negative results. conclusion: we did not find clinically significant disease progression within a year time frame in patients who had a negative coronary cta, despite a high number of repeat visits. this suggests that prior negative coronary cta may be able to be used to inform decision making within this time period. . - . ) compared to non tro ct patients. there was no significant difference in image quality between tro ct images and those of dedicated ct scans in any studies performing this comparison. similarly, there was no significant difference between tro ct and other diagnostic modalities in regards to length of stay or admission rate. when compared to conventional coronary angiography as the gold standard for evaluation of cad, tro ct had the following pooled diagnostic accuracy estimates: sensitivity . conclusion: tro chest ct is comparable to dedicated pe, coronary, or ad ct in regard to image quality, length of stay, and admission rate and is highly accurate for detecting cad. the utility of tro ct depends on the relative pre-test probabilities of the conditions being assessed and its role is yet to be clearly defined. tro ct, however, involves increased radiation exposure and contrast volume and for this reason clinicians should be selective in its use. background: coronary computed tomographic angiography (ccta) has high sensitivity, specificity, accuracy, and prognostic value for coronary artery disease (cad) and acs. however, how a ccta informs subsequent use of prescription medication is unclear. objectives: to determine if detection of critical or noncritical cad on ccta is associated with initiation of aspirin and statins for patients who presented to the ed with chest pain. we hypothesized that aspirin and statins would be more likely to be prescribed to patients with noncritical disease relative to those without any cad. methods: prospective cohort study of patients who received ccta as part of evaluation of chest pain in the ed or observation unit. patients were contacted and medical records were reviewed to obtain clinical follow-up for up to the year after ccta. the main outcome was new prescription of aspirin or statin. cad severity on ccta was graded as absent, mild ( % to %), moderate ( % to %), or severe ( ‡ %) stenosis. logistic regression was used to assess the association of stenosis severity to new medication prescription; covariates were determined a priori. results: patients who had ccta performed consented to participate in this study or met waiver of consent for record review only (median age, , % female, % black). median follow-up time was days, iqr - days. at baseline, % of the total cohort was already prescribed aspirin and % on statin medication. two hundred seventy nine ( %) patients were found to have stenosis in at least one vessel. in patients with absent, mild, moderate, and severe cad on ccta, aspirin was initiated in %, %, %, and %; statins were initiated in %, %, %, and % of patients. after adjustment for age, race, sex, hypertension, diabetes, cholesterol, tobacco use, and admission to the hospital after ccta, higher grades of cad severity were independently associated with greater post-ccta use of aspirin (or . per grade, % ci . - . , p < . ) and statins (or . , % ci . - . , p < . ). conclusion: greater cad severity on ccta is associated with increased medication prescription for cad. patients with noncritical disease are more likely than patients without any disease to receive aspirin and statins. future studies should examine whether these changes lead to decreased hospitalizations and improved cardiovascular health. background: hess et al. developed a clinical decision rule for patients with acute chest pain consisting of the absence of five predictors: ischemic ecg changes not known to be old, elevated initial or -hour troponin level, known coronary disease, ''typical'' pain, and age over . patients less than required only a single troponin evaluation. objectives: to test the hypothesis that patients less than years old without these criteria are at < % risk for major adverse cardiovascular events (mace) including death, ami, pci, and cabg. methods: we performed a secondary analysis of several combined prospective cohort studies that enrolled ed patients who received an evaluation for acs in an urban ed from to . cocaine users and stemi patients were excluded. structured data collection at presentation included demographics, pain description, history, lab, and ecg data for all studies. hospital course was followed daily. thirty-day follow up was done by telephone. our main outcome was -day mace using objective criteria. the secondary outcome was potential change in ed disposition due to application of the rule. descriptive statistics and % cis were used. results: of visits for potential acs, patients had a mean age of . ± . yrs; % were black and % female. there were patients ( . %) with -day cv events ( dead, ami, pci). sequential removal of patients in order to meet the final rule for patients less than excluded patients based upon: ischemic ecg changes not old (n = , % mace rate), elevated initial troponin level (n = , % mace), known coronary disease (n = , % mace), ''typical'' pain (n = , % mace), and age over (n = , . % mace) leaving patients less than with . % mace [ % ci, . - . %]. of this cohort, % were discharged home from the ed by the treating physician without application of this rule. adding a second negative troponin in patients - years old identified a group of patients with a . % rate of mace [ . - . ] and a % discharge rate. the hess rule appears to identify a cohort of patients at approximately % risk of -day mace, and may enhance discharge of young patients. however, even without application of this rule, the % of young patients at low risk are already being discharged home based upon clinical judgment. background: a clinical decision support system (cdss) incorporates evidence-based medicine into clinical practice, but this technology is underutilized in the ed. a cdss can be integrated directly into an electronic medical record (emr) to improve physician efficiency and ease of use. the christopher study investigators validated a clinical decision rule for patients with suspected pulmonary embolism (pe). the rule stratifies patients using wells' criteria to undergo either d-dimer testing or a ct angiogram (ct). the effect of this decision rule, integrated as a cdss into the emr, on ordering cts has not been studied. objectives: to assess the effect of a mandatory cdss on the ordering of d-dimers and cts for patients with suspected pe. methods: we assessed the number of cts ordered for patients with suspected pe before and after integrating a mandatory cdss in an urban community ed. physicians were educated regarding cdss use prior to implementation. the cdss advised physicians as to whether a negative d-dimer alone excluded pe or if a ct was required based on wells' criteria. the emr required physicians to complete the cdss prior to ordering the ct. however, physicians maintained the ability to order a ct regardless of the cdss recommendation. patients ‡ years of age presenting to the ed with a chief complaint of chest pain, dyspnea, syncope, or palpitations were included in the data analysis. we compared the proportion of d-dimers and cts ordered during the -month periods immediately before and after implementing the cdss. all physicians who worked in the ed during both time periods were included in the analysis. patients with an allergy to intravenous contrast agents, renal insufficiency, or pregnancy were excluded. results were analyzed using a chi-square test. results: a total of , patients were included in the data analysis ( pre-and post-implementation). cts were ordered for patients ( . %) in the pre-implementation group and patients ( . %) in the post-implementation group; p = . . a d-dimer was ordered for patients ( . %) in the pre-implementation group and patients ( . %) in the post-implementation group; p = . . in this single-center study, emr integration of a mandatory cdss for evaluation of pe did not significantly alter ordering patterns of cts and d-dimers. identification of patients with low-risk pulmonary emboli suitable for discharge from the emergency department mike zimmer, keith e. kocher university of michigan, ann arbor, mi background: recent data, including a large, multicenter randomized controlled trial, suggest that a low-risk cohort of patients diagnosed with pulmonary embolism (pe) exists who can be safely discharged from the ed for outpatient treatment. objectives: to determine if there is a similar cohort at our institution who have a low rate of complications from pe suitable for outpatient treatment. methods: this was a retrospective chart review at a single academic tertiary referral center with an annual ed volume of , patients. all adult ed patients who were diagnosed with pe during a -month period from / / through / / were identified. the pulmonary embolism severity index (pesi) score, a previously validated clinical decision rule to risk stratify patients with pe, was calculated. patients with high pesi (> ) were excluded. additional exclusion criteria included patients who were at high risk of complications from initiation of therapeutic anticoagulation and those patients with other clear indications for admission to the hospital. the remaining cohort of patients with low risk pe (pesi £ ) was included in the final analysis. outcomes were measured at and days after pe diagnosis and included death, major bleeding, and objectively confirmed recurrent venous thromboembolism (vte). results: during the study period, total patients were diagnosed with pe. there were ( %) patients categorized as ''low risk'' (pesi £ ), with removed because of various pre-defined exclusion criteria. of the remaining ( %) patients suitable for outpatient treatment, patients ( . %; % ci, . % - . %) had one or more negative outcomes by days. this included ( . %; % ci, % - . %) major bleeding events, ( . %; % ci, % - . %) recurrent vte, and ( . %; % ci, % - . %) deaths. none of the deaths were attributable to pe or anticoagulation. one patient suffered both a recurrent vte and died within days. both patients who died within days were transitioned to hospice care because of worsening metastatic burden. at days, there was bleeding event ( . %; % ci, % - . %), no recurrent vte, and no deaths. the average hospital length of stay for these patients was . days (sd ± . ). conclusion: over % of our patients diagnosed with pe in the ed may have been suitable for outpatient treatment, with % suffering a negative outcome within days and . % suffering a negative outcome within days. in addition, the average hospital length of stay for these patients was . days, which may represent a potential cost savings if these patients had been managed as outpatients. our experience supports previous studies that suggest the safety of outpatient treatment of patients diagnosed with pe in the ed. given the potential savings related to a decreased need for hospitalization, these results have health policy implications and support the feasibility of creating protocols to facilitate this clinical practice change. background: chest x-rays (cxrs) are commonly obtained on ed chest pain patients presenting with suspected acute coronary syndrome (acs). a recently derived clinical decision rule (cdr) determined that patients who have no history of congestive heart failure, have never smoked, and have a normal lung examination do not require a cxr in the ed. objectives: to validate the diagnostic accuracy of the hess cxr cdr for ed chest pain patients with suspected acs. methods: this was a prospective observational study of a convenience sample of chest pain patients over years old with suspected acs who presented to a single urban academic ed. the primary outcome was the ability of the cdr to identify patients with abnormalities on cxr requiring acute ed intervention. data were collected by research associates using the chart and physician interviews. abnormalities on cxr and specific interventions were predetermined, with a positive cxr defined as one with abnormality requiring ed intervention, and a negative cxr defined as either normal or abnormal but not requiring ed intervention. the final radiologist report was used as a reference standard for cxr interpretation. a second radiologist, blinded to the initial radiologist's report, reviewed the cxrs of patients meeting the cdr criteria to calculate inter-observer agreement. patients were followed up by chart review and telephone interview days after presentation. results: between january and august , patients were enrolled, of whom ( %) were excluded and ( . %) did not receive cxrs in the ed. of the remaining patients, ( %) met the cdr. the cdr identified all patients with a positive cxr (sensitivity = %, %ci - %). the cdr identified of the patients with a negative cxr (specificity = %, %ci - %). the positive likelihood ratio was . ( %ci . - . ). inter-observer agreement between radiologists was substantial (kappa = . , %ci . - . ). telephone contact was made with % of patients and all patient charts were reviewed at days. none had any adverse events related to a background: increasing the threshold to define a positive d-dimer in low-risk patients could reduce unnecessary computed tomographic pulmonary angiography (ctpa) for suspected pe. this strategy might increase rates of missed pe and missed pneumonia, the most common non-thromboembolic finding on ctpa that might not otherwise be diagnosed. objectives: measure the effect of doubling the standard d-dimer threshold for ' 'pe unlikely'' revised geneva (rgs) or wells' scores on the exclusion rate, frequency, and size of missed pe and missed pneumonia. methods: prospective enrollment at four academic us hospitals. inclusion criteria required patients to have at least one symptom or sign and one risk factor for pe, and have -channel ctpa completed. pretest probability data were collected in real time and the d-dimer was measured in a central laboratory. criterion standard for pe or pneumonia consisted of cpta interpretation by two independent radiologists combined with necessary treatment plan. subsegmental pe was defined as total vascular obstruction < %. patients were followed for outcome at days. proportions were compared with % cis. results: of patients enrolled, ( %) were pe+ and ( %) had pneumonia. with rgs£ and standard threshold (< ng/ml), d-dimer was negative in / ( %, % ci: - %), and / were pe+ (posterior probability . %, % ci: - . %). with rgs£ and a threshold < ng/ml, d-dimer was negative in / ( %, - %) and / ( . %, . - . %) were pe+, but / missed pes were subsegmental, and none had concomitant dvt. the posterior probability for pneumonia among patients with rgs&# ; and d-dimer< was / ( . %, - %) which compares favorably to the posterior probability of / ( . %, - %) observed with rgs& # ; and d-dimer< ng/ml. of the ( %) patients who also had plain film cxr, radiologists found an infiltrate in only . use of wells£ produced similar results as the rgs&# ; for exclusion rate and posterior probability of both pe and pneumonia. conclusion: doubling the threshold for a positive d-dimer with a pe unlikely pretest probability can significantly reduce ctpa scanning with a slightly increased risk of missed isolated subsegmental pe, and no increase in rate of missed pneumonia. background: the limitations of developing world medical infrastructure require that patients are transferred from health clinics only when the patient care needs exceed the level of care at the clinic and the receiving hospital can provide definitive therapy. to determine what type of definitive care service was sought when patients were transferred from a general outpatient clinic operating monday through friday from : am to : pm in rural haiti to urban hospitals in port-au-prince. methods: design -prospective observational review of all patients for whom transfer to a hospital was requested or for whom a clinic ambulance was requested to an off-site location to assist with patient care. setting -weekday, daytime only clinic in titanyen, haiti. participants/subjects -consecutive series of all patients for whom transfer to another health care facility or for whom an ambulance was requested during the time period of / / - / / and / / - / / . results: between / / - / / and / / - / / patients were identified who needed to be transferred to a higher level of care. sixteen patients ( . %) presented with medical complaints, ( . %) were trauma patients, ( . %) were surgical, and ( . %) were in the obstetric category. within these categories, patients were pediatric and non-trauma patients required blood transfusion. conclusion: while trauma services are often focused on in rural developing world medicine, the need for obstetric care and blood transfusion constituted six ( . %) cases in our sample. these patients raise important public health, planning, and policy questions relating to access to prenatal care and the need to better understand transfusion medicine utilization among rural haitian patients with non-trauma related transfusion needs. the data set is limited by sample size and single location of collection. another limitation of understanding the needs is that many patients may not present to the clinic for their health care needs in certain situations if they have knowledge that the resources to provide definitive care are unavailable. background: the practice of emergency medicine in japan has been unique in that emergency physicians are mostly engaged in critical care and trauma with a multi-specialty model. for the last decade with progress in medicine, an aging population with complicated problems, and institution of postgraduate general clinical training, the us model emergency medicine with single-specialty model has been emerging throughout japan. however, the current status is unknown. objectives: the objective of this study was to investigate the current status of implementation of the us model emergency medicine at emergency medicine training institutions accredited by the japanese association for acute medicine (jaam). methods: the er committee of the jaam, the most prestigious professional organization in japanese emergency medicine, conducted the survey by sending questionnaires to accredited emergency medicine training institutions. results: valid responses obtained from facilities were analyzed. us model em was provided in facilities ( % of facilities), either in full time ( hours a day, seven days a week; facilities) or in part time (less than hours a day; facilities). among these us model facilities, % have a number of beds between - . the annual number of ed visits was less than , in %, and % have ambulance transfers between , - , per year. the number of emergency physicians was less than in % of the facilities. postgraduate general clinical training was offered at us model ed in facilities, and ninety hospitals adopted us model em after , when a -year period of postgraduate general clinical training became mandatory for all medical graduates. sixty-four facilities provided a residency program to be a us model emergency physician, and another institutions were planning to establish it. conclusion: us model em has emerged and become commonplace in japan. the background including advance in medicine, aging population, and mandatory postgraduate general clinical training system are considered to be contributing factors. erkan gunay, ersin aksay, ozge duman atilla, nilay zorbalar, savas sezik tepecik research and training hospital, izmir, turkey background: workplace safety and occupational health problems are increasing issues especially in developing countries as a result of the industrial automatisation and technologic improvements. occupational injuries are preventable but they can occasionally cause morbidity and mortality resulting in work day loss and financial problems. hand injuries are one-third of all traumatic injuries and are the most injured parts after occupational accidents. objectives: we aim to evaluate patients with occupational upper extremity injuries for demographic characteristics, injury types, and work day loss. methods: trauma patients over years old admitted to our emergency department with an occupational upper extremity injury were prospectively evaluated from . . to . . . patients with one or more of digit, hand, forearm, elbow, humerus, and shoulder injuries were included. exclusion criteria were multitrauma, patient refusal to participate, and insufficient data. patients were followed up from the hospital information system and by phone for work day loss and final diagnosis. results: during the study period there were patients with an occupational upper extremity injury. total of ( . %) patients were included. patients were . % male, . % between the age to , and mean age was calculated . ± . years. . % of the patients were from the metal and machinery sector, and primary education was the highest education level for the . % of the patients. most injured parts were fingers with the highest rate for index finger and thumb. crush injury was the most common injury type. . % (n = ) of the patients were discharged after treatment in the emergency department. tendon injuries, open fractures, and high degree burns were the reasons for admission to clinics. mean work day loss was . ± . days and this increases for the patients with laboratory or radiologic studies, consultant evaluation, or admission. the - age group had a significantly lower work day loss average. conclusion: evaluating occupational injury characteristics and risks is essential for identifying preventive measures and actions. with the guidance of this study preventive actions focusing on high-risk sectors and patients may be the key factor for avoiding occupational injuries and creating safer workplace environments in order to reduce financial and public health problems. background: as emergency medicine (em) gains increased recognition and interest in the international arena, a growing number of training programs for emergency health care workers have been implemented in the developing world through international partnerships. objectives: to evaluate the quality and appropriateness of an internationally implemented emergency physician training program in india. methods: physicians participating in an internationally implemented em training program in india were recruited to participate in a program evaluation. a mixed methods design was used including an online anonymous survey and semi-structured focus groups. the survey assessed the research, clinical, and didactic training provided by the program. demographics and information on past and future career paths were also collected. the focus group discussions centered around program successes and challenges. results: fifty of eligible trainees ( %) participated in the survey. of the respondents, the vast majority were indian; % were female, and all were between the ages of and years (mean age years). all but two trainees ( %) intend to practice em as a career. one-third listed a high-income country first for preferred practice location and half listed india first. respondents directly endorsed the program structure and content, and they demonstrated gains in self-rated knowledge and clinical confidence over their years of training. active challenges identified include: ( ) insufficient quantity and inconsistent quality of indian faculty, ( ) administrative barriers to academic priorities, and ( ) persistent threat of brain drain if local opportunities are inadequate. conclusion: implementing an international emergency physician training program with limited existing local capacity is a challenging endeavor. overall, this evaluation supports the appropriateness and quality of this partnership model for em training. one critical challenge is achieving a robust local faculty. early negotiations are recommended to set educational priorities, which includes assuring access to em journals. attrition of graduated trainees to high-income countries due to better compensation or limited in-country opportunities continues to be a threat to long-term local capacity building. background: with an increasing frequency and intensity of manmade and natural disasters, and a corresponding surge in interest in international emergency medicine (iem) and global health (gh), the number of iem and gh fellowships is constantly growing. there are currently iem and gh fellowships, each with a different curriculum. several articles have proposed the establishment of core curriculum elements for fellowship training. to the best of our knowledge, no study has examined whether iem and gh fellows are actually fulfilling these criteria. objectives: this study sought to examine whether current iem and gh fellowships are consistently meeting these core curricula. methods: an electronic survey was administered to current iem and gh fellowship directors, current fellows, and recent graduates of a total of programs. survey respondents stated their amount of exposure to previously published core curriculum components: em system development, humanitarian assistance, disaster response, and public health. a pooled analysis comparing overall responses of fellows to those of program directors was performed using two-sampled t-test. results: response rates were % (n = ) for program directors and % (n = ) for current and recent fellows. programs varied significantly in terms of their emphasis on and exposure to six proposed core curriculum areas: em system development, em education development, humanitarian aid, public health, ems, and disaster management. only % of programs reported having exposure to all four core areas. as many as % of fellows reported knowing their curriculum only somewhat or not at all prior to starting the program. conclusion: many fellows enter iem and gh fellowships without a clear sense of what they will get from their training. as each fellowship program has different areas of curriculum emphasis, we propose not to enforce any single core curriculum. rather, we suggest the development of a mechanism to allow each fellowship program to present its curriculum in a more transparent manner. this will allow prospective applicants to have a better understanding of the various programs' curricula and areas of emphasis. background: advance warning of probable intensive care unit (icu) admissions could allow the bed placement process to start earlier, decreasing ed length of stay and relieving overcrowding conditions. however, physicians and nurses poorly predict a patient's ultimate disposition from the emergency department at triage. a computerized algorithm can use commonly collected data at triage to accurately identify those who likely will need icu admission. objectives: to evaluate an automated computer algorithm at triage to predict icu admission and -day in-hospital mortality. methods: retrospective cohort study at a , visit/ year level i trauma center/tertiary academic teaching hospital. all patients presenting to the ed between / / and / / were included in the study. the primary outcome measure was icu admission from the emergency department. the secondary outcome measure was -day all-cause in-hospital mortality. patients discharged or transferred before days were considered to be alive at days. triage data includes age, sex, acuity (emergency severity index), blood pressure, heart rate, pain scale, respiratory rate, oxygen saturation, temperature, and a nurse's free text assessment. a latent dirichlet allocation algorithm was used to cluster words in triage nurses' free text assessments into topics. the triage assessment for each patient is then represented as a probability distribution over these topics. logistic regression was then used to determine the prediction function. results: a total of , patients were included in the study. . % were admitted to the icu and . % died within days. these patients were then randomly allocated to train (n = , ; %) and test (n = , ; %) data sets. the area under the receiver operating characteristic curve (auc) when predicting icu background: at the saem annual meeting, we presented the derivation of two hospital admission prediction models adding coded chief complaint (ccc) data from a published algorithm (thompson et al. acad emerg med ; : - ) to demographic, ed operational, and acuity (emergency severity index (esi)) data. objectives: we hypothesized that these models would be validated when applied to a separate retrospective cohort, justifying prospective evaluation. methods: we conducted a retrospective, observational validation cohort study of all adult ed visits to a single tertiary care center (census: , /yr) ( / / - / / ). we downloaded from the center's clinical tracking system demographic (age, sex, race), ed operational (time and day of arrival), esi, and chief complaint data on each visit. we applied the derived ccc hospital admission prediction models (all identified ccc categories and ccc categories with significant odds of admission from multivariable logistic regression in the derivation cohort) to the validation cohort to predict odds of admission and compared to prediction models that consisted of demographic, ed operational, and esi data, adding each category to subsequent models in a stepwise manner. model performance is reported by areaunder-the-curve (auc) data and %ci. signs, pain level, triage level, -hour return, number of past visits in the previous year, injury, and one of chief complaint codes (representing % of all visits in the database). outputs for training included ordering of a complete blood count, basic chemistry (electrolytes, blood urea nitrogen, creatinine), cardiac enzymes, liver function panel, urinalysis, electrocardiogram, x-ray, computed tomography, or ultrasound. once trained, it was used on the nhamcs-ed database, and predictions were generated. predictions were compared with documented physician orders. outcomes included the percent of total patients who were correctly pre-ordered, sensitivity (the percent of patients who had an order that were correctly predicted), and the percent over-ordered. waiting time for correctly pre-ordered patients was highlighted, to represent a potential reduction in length of stay achieved by preordering. los for patients overordered was highlighted to see if over-ordering may cause an increase in los for those patients. unit cost of the test was also highlighted, as taken from the medicare fee schedule. physician times. however, during peak ed census times, many patients with completed tests and treatment initiated by triage await discharge by the next assigned physician. objectives: determine if a physician-led discharge disposition (dd) team can reduce the ed length of stay (los) for patients of similar acuity who are ultimately discharged compared to standard physician team assignment. methods: this prospective observational study was performed from / to / at an urban tertiary referral academic hospital with an annual ed volume of , visits. only emergency severity index level patients were evaluated. the dd team was scheduled weekdays from : until : . several ed beds were allocated to this team. the team was comprised of one attending physician and either one nurse and a tech or two nurses. comparisons were made between los for discharged patients originally triaged to the main ed side who were seen by the dd team versus the main side teams. time from triage physician to team physician, team physician to discharge decision time, and patient age were compared by unpaired t-test. differences were studied for number of patients receiving x-rays, ct scan, labs, and medications. results: dd team mean los in hours for discharged patients was shorter at . ( % ci: . - . , n = ) compared to . ( % ci: . - . , n = ) on the main side, p < . . the mean time from triage physician to dd team physician was . hours ( % ci: . - . , n = ) versus to . hours ( % ci: . - . , n = ) to main side physician, p < . . the dd team physician mean time to discharge decision was . hour ( % ci: . - . , n = ) compared to . hours ( % ci: . - . , n = ) for main side physician, p < . . the dd team patients' mean age was . years ( % ci: . - . , n = ) compared to main side patients' mean age of . years ( % ci: . - . , n = .) the dd team patients (n = ) received fewer x-rays ( % vs. %), ct scans ( % vs. %), labs ( % vs. %), and medications ( % vs. %) than main side patients (n = ), p < . for all compared. conclusion: the dd team complements the advanced triage process to further reduce los for patients who do not require extended ed treatment or observation. the dd team was able to work more efficiently because its patients tended to be younger and had fewer lab and imaging tests ordered by the triage physician compared to patients who were later seen on the ed main side. ed objectives: to evaluate the association between ed boarding time and the risk of developing hapu. methods: we conducted a retrospective cohort study using administrative data from an academic medical center with an adult ed with , annual patient visits. all patients admitted into the hospital through the ed / / - / / were included. development of hapu was determined using the standardized, national protocol for cms reporting of hapu. ed boarding time was defined as the time between an order for inpatient admission and transport of the patient out of the ed to an in-patient unit. we used a multivariate logistic regression model with development of a hapu as the outcome variable, ed boarding time as the exposure variable, and the following variables as covariates: age, sex, initial braden score, and admission to an intensive care unit (icu) from the ed. the braden score is a scale used to determine a patient's risk for developing a hapu based on known risk factors. a braden score is calculated for each hospitalized patient at the time of admission. we included braden score as a covariate in our model to determine if ed boarding time was a predictor of hapu independent of braden score. results: of , patients admitted to the hospital through the ed during the study period, developed a hapu during their hospitalization. clinical characteristics are presented in the table. per hour of ed boarding time, the adjusted or of developing a hapu was . ( % ci . - . , p = . ). a median of patients per day were admitted through the ed, accumulating hours of ed boarding time per day, with each hour of boarding time increasing the risk of developing a hapu by %. conclusion: in this single-center, retrospective study, longer ed boarding time was associated with increased risk of developing a hapu. queried ed and inpatient nurses and compared their opinions toward inpatient boarding. it also assessed their preferred boarding location if they were patients. objectives: this study queried ed and inpatient nurses and compared their opinions toward inpatient boarding. methods: a survey was administered to a convenience sample of ed and ward nurses. it was performed in a -bed academic medical center ( , admissions/yr) with a -bed ed ( , visits/yr). nurses were identified as ed or ward and whether they had previously worked in the ed. the nurses were asked if there were any circumstances where admitted patients should be boarded in the ed or inpatient hallways. they were also asked their preferred location if they were admitted as a patient. six clinical scenarios were then presented and their opinions on boarding queried. results: ninety nurses completed the survey; ( %) were current ed nurses (ced), ( %) had previously worked in the ed (ped). for the entire group ( %) believed admitted patients should board in the ed. overall, ( %) were opposed to inpatient boarding, with % of ced versus % of current ward (cw) nurses (p < . ) and % of ped versus % of nurses never having worked in the ed (ned) opposed (p < . ). if admitted as patients themselves, overall ( %) preferred inpatient boarding, with % of ced versus % of cw nurses (p < . ) and % of ped versus % ned nurses (p = . ) preferring inpatient boarding. for the six clinical scenarios, significant differences in opinion regarding inpatient boarding existed in all but two cases: a patient with stable copd but requiring oxygen and an intubated, unstable sepsis patient. conclusion: ward nurses and those who have never worked in the ed are more opposed to inpatient boarding than ed nurses and nurses who have worked previously in the ed. nurses admitted as patients seemed to prefer not being boarded where they work. ed and ward nurses seemed to agree that unstable or potentially unstable patients should remain in the ed. weeks. staff satisfaction was evaluated through pre/ post-shift and study surveys; administrative data (physician initial assessment (pia), length of stay (los), patients leaving without being seen (lwbs) and against medical advice [lama] ) were collected from an electronic, real-time ed information system. data are presented as proportions and medians with interquartile ranges (iqr); bivariable analyses were performed. results: ed physicians and nurses expected the intervention to reduce the los of discharged patients only. pia decreased during the intervention period ( vs minutes; p < . ). no statistically/clinically significant differences were observed in the los; however, there was a significant reduction in the lwbs ( . % to . % p = . ) and lama ( . % to . % p = . ) rates. while there was a reduction of approximately patients seen per physician in the affected ed area, the total number of patients seen on that unit increased by approximately patients/day. overall, compared to days when there was no extra shift, % of emergency physicians stated their workload decreased and % felt their stress level at work decreased. conclusion: while this study didn't demonstrate a reduction in the overall los, it did reduce pia times and the proportion of lwbs/lama patients. while physicians saw fewer patients during the intervention study period, the overall patient volume increased and satisfaction among ed physicians was rated higher. provider-and hospital-level variation in admission rates and -hour return admission rates jameel abualenain , william frohna , robert shesser , ru ding , mark smith , jesse m. pines the george washington university, washington, dc; washington hospital center, washington, dc background: decisions for inpatient versus outpatient management of ed patients are the most important and costliest decision made by emergency physicians, but there is little published on the variation in the decision to admit among providers or whether there is a relationship between a provider's admission rate and the proportion of their patients who return within hours of the initial visit and are subsequently admitted ( h-ra). objectives: we explored the variation in provider-level admission rates and h-ra rates, and the relationship between the two. methods: a retrospective study using data from three eds with the same information system over varying time periods: washington hospital center (whc) ( - ), franklin square hospital center (fshc) , and union memorial hospital (umh) . patients were excluded if left without being seen, left against medical advice, fast-track, psychiatric patients, and aged < years. physicians with < ed encounters or an admission rate < % were excluded. logistic regression was used to assess the relationship between physician-level h-ra and admission rates, adjusting for patient age, sex, race, and hospital. results: , ed encounters were treated by physicians. mean patient age was years sd , % male, and % black. admission rates differed between hospitals (whc = %, umh = %, and fshc = %), as did the h-ra (whc = . %, umh = . %, and fshc = . %). across all hospitals, there was great variation in individual physician admission rates ( . %- . %). the h-ra rates were quite low, but demonstrated a similar magnitude of individual variation ( . %- . %). physicians with the highest admission rate quintile had lower odds of h-ra (or . % ci . - . ) compared to the lowest admission rate quintile, after adjusting for other factors. no intermediate admission rate quintiles ( nd, rd, or th) were significantly different from the lowest admission rate quintile with regard to h-ra. conclusion: there is more than three-fold variation in individual physician admission rates indicating great variation among physicians in hospital admission rates and h-ra. the highest admitters have the lowest h-ra; however, evaluating the causes and consequences of such significant variation needs further exploration, particularly in the context of health reform efforts aimed at reducing costs. background: ed scribes have become an effective means to assist emergency physicians (eps) with clinical documentation and improve physician productivity. scribes have been most often utilized in busy community eds and their utility and functional integration into an academic medical center with resident physicians is unknown. objectives: to evaluate resident perceptions of attending physician teaching and interaction after introduction of scribes at an em residency training program, measured through an online survey. residents in this study were not working with the scribes directly, but were interacting indirectly through attending physician use of scribes during ed shifts. methods: an online ten question survey was administered to residents of a midwest academic emergency medicine residency program (pgy -pgy program, annual residents), months after the introduction of scribes into the ed. scribes were introduced as emr documentation support (epic , epic systems inc.) for attending eps while evaluating primary patients and supervising resident physicians. questions investigated em resident demographics and perceptions of scribes (attending physician interaction and teaching, effect on resident learning, willingness to use scribes in the future), using likert scale responses ( minimal, maximum) and a graduated percentage scale used to quantify relative values, where applicable. data were analyzed using kruskal-wallis and mann-whitney u tests. results: twenty-one of em residents ( %) completed the survey ( % male; % pgy , % pgy , % pgy ). four residents had prior experience with scribes. scribes were felt to have no effect on attending eps direct resident interaction time (mean score . , sd . ), time spent bedside teaching ( . , sd . ), or quality of teaching ( . , sd . ), as well as no effect on residents' overall learning process ( . , sd . ). however, residents felt positive about utilizing scribes at their future occupation site ( . , sd . ). no response differences were noted for prior experience, training level, or sex. conclusion: when scribes are introduced at an em residency training site, residents of all training levels perceive it as a neutral interaction, when measured in terms of perceived time with attending eps and quality of the teaching when scribes are present. the effect of introduction of an electronic medical record on resident productivity in an academic emergency department shawn london, christopher sala university of connecticut school of medicine, farmington, ct background: there are little available data which describe the effect of implementation of an electronic medical record (emr) on provider productivity in the emergency department, and no studies which, to our knowledge, address this issue pertaining to housestaff in particular. objectives: we seek to quantify the changes in provider productivity pre-and post-emr implementation to support our hypothesis that resident clinical productivity based on patients seen per hour will be negatively affected by emr implementation. methods: the academic emergency department at hartford hospital, the principle clinical site in the university of connecticut emergency medicine residency, sees over , patients on an annual basis. this environment is unique in that pre-emr, patient tracking and orders were performed electronically using the sunrise system (eclipsys corp) for over years prior to conversion to the allscripts ed emr in october, for all aspects of ed care. the investigators completed a random sample of days/evening/night/weekend shift productivity to obtain monthly aggregate productivity data (patients seen per hour) by year of training. results: there was an initial . % decrease of in productivity for pgy- residents on average from . patients per hour on average in the three blocks preceding activation of the emr to . patients seen per hour compared in the subsequent three prior blocks. pgy performance returned to baseline in the subsequent three months to . patients per hour. there was no change noted in patients seen per hour of pgy- and pgy- residents. conclusion: while many physicians tend to assume that emrs pose a significant barrier to productivity in the ed, in our academic emergency department, there was no lasting change on resident productivity based on the patients seen per hour metric. the minor decrease which did occur in pgy- residents was transient and was not apparent months after the emr was implemented. our experience suggests that decrease in the rate of patients seen per hour in the resident population should not be considered justification to delay or avoid implementation of an emr in the emergency department. emory university, atlanta, ga; children's healthcare of atlanta, atlanta, ga background: variation in physician practice is widely prevalent and highlights an opportunity for quality improvement and cost containment. monitoring resources used in the management of common pediatric emergency department (ed) conditions has been suggested as an ed quality metric. objectives: to determine if providing ed physicians with severity-adjusted data on resource use and outcomes, relative to their peers, can influence practice patterns. methods: data on resource use by physicians were extracted from electronic medical records at a tertiary pediatric ed for four common conditions in mid-acuity (emergency severity index level ): fever, head injury, respiratory illness, and gastroenteritis. condition-relevant resource use was tracked for lab tests (blood count, chemistry, crp), imaging (chest x-ray, abdominal x-ray, head ct scan, abdominal ct scan), intravenous fluids, parenteral antibiotics, and intravenous ondansetron. outcome measures included admission to hospital and ed length of stay (los); -hr return to ed (rr) was used as a balancing measure. scorecards were constructed using box plots to show physicians their practice patterns relative to peers (the figure shows an example of the scorecard for gatroenteritis for one physician, showing resources use rates for iv fluids and labs). blinded scorecards were distributed quarterly for five quarters using rolling-year averages. a pre/post-intervention analysis was performed with sep , as the intervention date. fisher's exact and wilcoxon rank sum tests were used for analysis. results: we analyzed , patient visits across two hospitals ( , pre-and , post-intervention), comprising . % of the total ed volume during the study period. patients were seen by physicians (mean patients/physician). the table shows overall physician practice in the pre-and post-intervention periods. significant reduction in resource use was seen for abdominal/pelvic ct scans, head ct scan, chest x-rays, iv ondansetron, and admission to hospital. ed los decreased from min to min (p = . ). there was no significant change in -hr return rate during the study period ( . % pre-, . % post-intervention). conclusion: feedback on comprehensive practice patterns including resource use and quality metrics can influence physician practice on commonly used resources in the ed. billboards, via iphone application, twitter, and text messaging. there is a paucity of data describing the accuracy of publically posted ed wait times. objectives: to examine the accuracy of publicly posted wait times of four emergency departments within one hospital system. methods: a prospective analysis of four ed-posted wait times in comparison to the wait times for actual patients. the main hospital system calculated and posted ed wait times every twenty minutes for all four system eds. a consecutive sample of all patients who arrived / over a -week period during july and august was included. an electronic tracking system identified patient arrival date and the actual incurred wait time. data consisted of the arrival time, actual wait time, hospital census, budgeted hospital census, and the posted ed wait time. for each ed the difference was calculated between the publicly posted ed wait time at the time of patient's arrival and the patient's actual ed wait time. the average wait times and average wait time error between the ed sites were compared using a two-tailed student's t-test. the correlation coefficient between the differences in predicted/ actual wait times was also calculated for each ed. results: there were wait times within the four eds included in the analysis. the average wait time (in minutes) at each facility was: . (± . ) for the main ed, . (± . ) for freestanding ed (fed) # , . (± . ) for fed # , and . (± . ) for the small community ed. the average wait time error (in minutes) for each facility was (± . ) for the main ed, (± . ) for fed # , (± . ) for fed # , and (± . ) for the community hospital ed. the results from each ed were statistically significant for both average wait time and average wait time error (p < . ). there was a positive correlation between the average wait time and average wait time error, with r-values of . , . , . , and . for the main ed, fed # , fed # , and the small community hospital ed, respectively. each correlation was statistically significant; however, no correlation was found between the number of beds available (budgeted-actual census) and average wait times. conclusion: publically posted ed wait times are accurate for facilities with less than ed visits per month. they are not accurate for eds with greater than visits per month. reduction of pre-analytic laboratory errors in the emergency department using an incentive-based system benjamin katz, daniel pauze, karen moldveen albany medical center, albany, ny background: over the last decade, there has been an increased effort to reduce medical errors of all kinds. laboratory errors have a significant effect on patient care, yet they are usually avoidable. several studies suggest that up to % of laboratory errors occur during the pre-or post-analytic phase. in other words, errors occur during specimen collection and transport or reporting of results, rather than during laboratory analysis itself. objectives: in an effort to reduce pre-analytic laboratory errors, the ed instituted an incentive-based program for the clerical staff to recognize and prevent specimen labeling errors from reaching the patient. this study sought to demonstrate the benefit of this incentive-based program. methods: this study examined a prospective cohort of ed patients over a three year period in a tertiary care academic ed with annual census of , . as part of a continuing quality improvement process, laboratory specimen labeling errors are screened by clerical staff by reconciling laboratory specimen label with laboratory requisition labels. the number of ''near-misses'' or mismatched specimens captured by each clerk was then blinded to all patient identifiers and was collated by monthly intervals. due to poor performance in , an incentive program was introduced in early by which the clerk who captured the most mismatched specimens would be awarded a $ gift card on a quarterly basis. the total number of missed laboratory errors was then recorded on a monthly basis. investigational data were analyzed using bivariate statistics. background: most studies on operational research have been focused in academic medical centers, which typically have larger volumes of patients and are located in urban metropolitan areas. as cms core measures in begin to compare emergency departments (eds) on treatment time intervals, especially length of stay (los), it is important to explore if any differences exist inherent to patient volume. objectives: the objective of this study is to look at differences in operational metrics based on annual patient census. the hypothesis is that treatment time intervals and operational metrics differ amongst these different categories. methods: the ed benchmarking alliance has collected yearly operational metrics since . as of , there are eds providing data across the united states. eds are stratified by annual volume for comparison in the following categories: < k, - k, - k, and over k. in this study, metrics for eds with < k visits per year were compared to those of different volumes, averaged from - . mean values were compared to < k visits as a reference point for statistical difference using t-tests to compare means with a p-value < . considered significant. results: as seen in the table, a greater percentage of high acuity of patients was seen in higher volume eds than in < k eds. the percentage of patients transferred to another hospital was higher in < k eds. a higher percentage arrived by ems and a higher percentage were admitted in higher volume eds when compared to < k visits. in addition, the median los for both discharged and admitted patients and percentage who left before treatment was complete (lbtc) were higher in the higher volume eds. conclusion: lower volume eds have lower acuity when compared to higher volume eds. lower volume eds have shorter median los and left before treatment complete percentages. as cms core measures require hospitals to report these metrics, it will be important to compare them based on volume and not in aggregate. does the addition of a hands-free communication device improve ed interruption times? amy ernst, steven j. weiss, jeffrey a. reitsema university of new mexico, albuquerque, nm background: ed interruptions occur frequently. recently a hands-free communication device (vocera) was added to a cell phone and a pager in our ed. objectives: the purpose of the present study was to determine whether this addition improved interruption times. our hypothesis was that the device would significantly decrease length of time of interruptions. methods: this study was a prospective cohort study of attending ed physician calls and interruptions in a level i trauma center with em residency. interruptions included phone calls, ekg interpretations, pages to resuscitation, and other miscellaneous interruptions (including nursing issues, laboratory, ems, and radiology). we studied a convenience sampling intended to include mostly evening shifts, the busiest ed times. length of time the interruption lasted was recorded. data were collected for a comparison group pre-vocera. three investigators collected data including seven different addendings' interruptions. data were collected on a form, then entered into an excel file. data collectors' agreement was determined during two additional four hour shifts to calculate a kappa statistic. spss was used for data entry and statistical analysis. descriptive statistics were used for univariate data. chi-square and mann whitney u nonparametric test were used for comparisons. results: of the total interruptions, % were phone calls, % were ekgs to be read, % were pages to resuscitation, and % miscellaneous. there were no significant differences in types of interruptions pre-vs. post-vocera. pre-vocera we collected hours of data with interruptions with a mean . per hour. post-vocera, hours of data were collected with interruptions with a mean . per hour. there was a significant difference in length of time of interruptions with an average of minutes pre-vocera vs. minutes post-vocera (p = . , diff . , % ci . - . ). vocera calls were significantly shorter than non-vocera calls ( vs minutes, p < . ). comparing data collectors for type of interruption during the same -hour shift resulted in a kappa (agreement) of . . conclusion: the addition of a hands-free communication device may improve interruptions by shortening call length. '' talk background: analyses of patient flow through the ed typically focus on metrics such as wait time, total length of stay (los), or boarding time. however, little is known about how much interaction a patient has with clinicians after being placed in a room, or what proportion of the in-room visit is also spent ''waiting,'' rather than directly interacting with care providers. objectives: the objective was to assess the proportion of time, relative to the time in a patient care area, that a patient spends actively interacting with providers during an ed visit. methods: a secondary analysis of audiotaped encounters of patients with one of four diagnoses (ankle sprain, back pain, head injury, laceration) was performed. the setting was an urban, academic ed. ed visits of adult patients were recorded from the time of room placement to discharge. audiotapes were edited to remove all downtime and non-patient-provider conversations. los and door-to-doctor times were abstracted from the medical record. the proportion of time the patient spent in direct conversation with providers (''talk-time'') was calculated as the ratio of the edited audio recording time to the time spent in a patient care area (talk-time = [edited audio time/(los -door-to-doctor)]). multiple linear regression controlling for time spent in patient care area, age, and sex was performed. results: the sample was % male with a mean age of years. median los: minutes (iqr: - ), median door-to-doctor: minutes (iqr: - ), median time spent in patient care area: minutes (iqr: - ). median time spent in direct conversation with providers was minutes (iqr: - ), corresponding to a talk-time percentage of . % (iqr: . - . %). there were no significant differences based on diagnosis. regression analysis showed that those spending a longer time in a patient care area had a lower percentage of talk time (b = ) . , p = . ). conclusion: although limited by sample size, these results indicate that approximately % of a patients' time in a care area is spent not interacting with providers. while some of the time spent waiting is out of the providers' control (e.g. awaiting imaging studies), this significant ''downtime'' represents an opportunity for both process improvement efforts to decrease downtime as well as the development of innovative patient education efforts to make the best use of the remaining downtime. degradation of emergency department operational data quality during electronic health record implementation michael j. ward, craig froehle, christopher j. lindsell university of cincinnati, cincinnati, oh background: process improvement initiatives targeted at operational efficiency frequently use electronic timestamps to estimate task and process durations. errors in timestamps hamper the use of electronic data to improve a system and may result in inappropriate conclusions about performance. despite the fact that the number of electronic health record (ehr) implementations is expected to increase in the u.s., the magnitude of this ehr-induced error is not well established. objectives: to estimate the change in the magnitude of error in ed electronic timestamps before and after a hospital-wide ehr implementation. methods: time-and-motion observations were conducted in a suburban ed, annual census , , after receiving irb approval. observation was conducted weeks pre-and weeks post-ehr implementation. patients were identified on entering the ed and tracked until exiting. times were recorded to the nearest second using a calibrated stopwatch, and are reported in minutes. electronic data were extracted from the patient-tracking system in use pre-implementation, and from the ehr post-implementation. for comparison of means, independent t-tests were used. chi-square and fisher's t-tests were used for proportions, as appropriate. results: there were observations; before and after implementation. the differences between observed times and timestamps were computed and found to be normally distributed. post-implementation, mean physician seen times along with arrival to bed, bed to physician, and physician to disposition intervals occurred before observation. physician seen timestamps were frequently incorrect and did not improve postimplementation. significant discrepancies (ten minutes or greater) from observed values were identified in timestamps involving disposition decision and exit from the ed. calculating service time intervals resulted in every service interval (except arrival to bed) having at least % of the times with significant discrepancies. it is notable that missing values were more frequent post-ehr implementation. conclusion: ehr implementation results in reduced variability of timestamps but reduced accuracy and an increase in missing timestamps. using electronic timestamps for operational efficiency assessment should recognize the magnitude of error, and the compounding of error, when computing service times. background: procedural sedation and analgesia is used in the ed in order to efficiently and humanely perform necessary painful procedures. the opposing physiological effects of ketamine and propofol suggest the potential for synergy, and this has led to interest in their combined use, commonly termed ''ketofol'', to facilitate ed procedural sedation. objectives: to determine if a : mixture of ketamine and propofol (ketofol) for ed procedural sedation results in a % or more absolute reduction in adverse respiratory events compared to propofol alone. methods: participants were randomized to receive either ketofol or propofol in a double-blind fashion according to a weight-based dosing protocol. inclusion criteria were age years or greater, and asa class - status. the primary outcome was the number and proportion of patients experiencing an adverse respiratory event according to pre-defined criteria (the ''quebec criteria''). secondary outcomes were sedation consistency, sedation efficacy, induction time, sedation time, procedure time, and adverse events. results: a total of patients were enrolled, per group. forty-three ( %) patients experienced an adverse respiratory event in the ketofol group compared to ( %) in the propofol group (difference %; % ci ) % to %; p = . ). thirty-eight ( %) patients receiving ketofol and ( %) receiving propofol developed hypoxia, of whom three ( %) ketofol patients and ( %) propofol patient received bag-valve-mask ventilation. sixty-five ( %) patients receiving ketofol and ( %) receiving propofol required repeat medication dosing or lightened to a ramsay sedation score of or less during their procedure (difference %; % ci % to %; p = . ). procedural agitation occurred in patients ( . %) receiving ketofol compared to ( %) receiving propofol (difference . %, % ci % to %). recovery agitation requiring treatment occurred in six patients ( %, % ci . % to . %) receiving ketofol. other secondary outcomes were similar between the groups. patients and staff were highly satisfied with both agents. conclusion: ketofol for ed procedural sedation does not result in a reduced incidence of adverse respiratory events compared to propofol alone. induction time, efficacy, and sedation time were similar; however, sedation depth appeared to be more consistent with ketofol. with propofol and its safety is well established. however, in cms enacted guidelines defining propofol as deep sedation and requiring administration by a physician. common edps practice had been one physician performing both the sedation and procedure. edps has proven safe under this one-physician practice. however, the guidelines mandated separate physicians perform each. objectives: the study hypothesis was that one-physician propofol sedation complication rates are similar to two-physician. methods: before and after, observational study of patients > years of age consenting to edps with propofol. edps completed with one physician were compared to those completed with two (separate physicians performing the sedation and the procedure). all data were prospectively collected. the study was completed at an urban level i trauma center. standard monitoring and procedures for edps were followed with physicians blinded to the objectives of this research. the frequency and incremental dosing of medication was left to the discretion of the treating physicians. the study protocol required an ed nurse trained in data collection to be present to record vital signs and assess for any prospectively defined complications. we used chi-square tests to compare the binary outcomes and asa scores across the time periods, and two-sample t-tests to test for differences in age between the two time periods. results: during the -year study period we enrolled patients: one-physician edps sedations and (- to ) also received bag-valve-mask ( ) [ . to ) ( ) [ . to ] (- to ) two-physician. all patients meeting inclusion criteria were included in the study. total adverse event rates were . % and . %, respectively (p = . ). the most common complications were hypotension and oxygen desaturation, and they respectively showed one-physcian rates of . % and . % and two-physician rates of . % and . % (p = . and . .) the unsuccessful procedure rates were . % vs . % (p = . ). conclusion: this study demonstrated no significant difference in complication rates for propofol edps completed by one physician as compared to two. background: overdose patients are often monitored using pulse oximetry, which may not detect changes in patients on high-flow oxygen. objectives: to determine whether changes in end-tidal carbon dioxide (etco ) detected by capnographic monitoring are associated with clinical interventions due to respiratory depression (crd) in patients undergoing evaluation for a decreased level of consciousness after a presumed drug overdose. methods: this was a prospective, observational study of adult patients undergoing evaluation for a drug overdose in an urban county ed. all patients received supplemental oxygen. patients were continuously monitored by trained research associates. the level of consciousness was recorded using the observer's assessment of alertness/sedation scale (oaa/s). vital signs, pulse oximetry, and oaa/s were monitored and recorded every minutes and at the time of occurrence of any crd. respiratory rate and etco were measured at five second intervals using a capno-stream monitor. crd included an increase in supplemental oxygen, the use of bag-valve-mask ventilations, repositioning to improve ventilation, and physical or verbal stimulus to induce respiration, and were performed at the discretion of the treating physicians and nurses. changes from baseline in etco values and waveforms among patients who did or did have a clinical intervention were compared using wilcoxon rank sum tests. results: patients were enrolled in the study (age , range to , % male, median oaas , range to ). suspected overdoses were due to opioids in , benzodiazepines in , an antipsychotic in , and others in . the median time of evaluation was minutes (range to ). crd occurred in % of patients, including an increase in o in %, repositioning in %, and stimulation to induce respiration in %. % had an o saturation of < % (median , range to ) and % had a loss of etco waveform at some time, all of whom had a crd. the median change in etco from baseline was mmhg, range to . among patients with crd it was mmhg, range to , and among patients with no crd it was mmhg, range to (p = . ). conclusion: the change in etco from baseline was larger in patients who required clinical interventions than in those who did not. in patients on high-flow oxygen, capnographic monitoring may be sensitive to the need for airway support. how reliable are health care providers in reporting changes in etco waveform anas sawas , scott youngquist , troy madsen , matthew ahern , camille broadwater-hollifield , andrew syndergaard , jared phelps , bryson garbett , virgil davis university of utah, salt lake city, ut; midwestern university, glendale, az background: etco changes have been used in procedural sedation analgesia (psa) research to evaluate subclinical respiratory depression associated with sedation regiments. objectives: to evaluate the accuracy of bedside clinician reporting of changes in etco . methods: this was a prospective, randomized, singleblind study conducted in ed setting from june until the present time. this study took place at an academic adult ed of a -bed ( in the ed) and a level i trauma center. subjects were randomized to receive either ketamine-propofol or propofol according to a standardized protocol. loss of etco waveforms for ‡ sec were recorded. following sedation, questionnaires were completed by the sedating physicians. digitally recorded etco waveforms were also reviewed by an independent physician and a trained research assistant (ra). to ensure the reliability of trained research assistants, we compared their analyses with the analyses of an independent physician for the first recordings. the target enrollment was patients in each group (n = total). statistics were calculated using sas statistical software. results: patients were enrolled; ( . %) are males and ( . %) are females. mean age was . ± . years. most participants did not have major risk factors for apnea or for further complications ( . % were asa class or ). etco waveforms were reviewed by ( . %) sedating physicians and ( . %) nurses at the bedside. there were ( . %) etco waveforms recordings, ( . %) were reviewed by an independent physician and ( %) were reviewed by an ra. a kappa test for agreement between independent physicians and ras was conducted on recordings and there were no discordant pairs (kappa = ). compared to sedating physicians, the independent physician was more likely to report etco wave losses (or . , % ci . - . ). compared to sedating physicians, ras were more likely to report etco wave losses (or . , % ci . - . ). conclusion: compared to sedating physicians at the bedside, independent physicians and ras were more likely to note etco waveform losses. an independent review of recorded etco waveform changes will be more reliable for future sedation research. background: comprehensive studies evaluating current practices of ed airway management in japan are lacking. many emergency physicians in japan still experience resistance regarding rapid sequence intubation (rsi). objectives: we sought to describe the success and complication rate of rsi with non-rsi. methods: design and setting: we conducted a multicenter prospective observational study using the jean registry of eds at academic and community hospitals in japan during between and . data fields include ed characteristics, patient and operator demographics, method of airway management, number of attempts, and adverse events. we defined non-rsi as intubation with sedation only, neuromuscular blockade only, and without medication. participants: all patients undergoing emergency intubation in ed were eligible for inclusion. cardiac arrest encounters were excluded from the analysis. primary analysis: we described rsi with non-rsi in terms of success rate on first attempt, within three attempts, and complication rate. we present descriptive data as proportions with % confidence intervals (cis). we report odds ratios (or) with % ci via chi-square testing. results: the database recorded intubations (capture rate %) and met the inclusion criteria. rsi was the initial method chosen in ( %) and non-rsi in ( %). use of rsi varied among institutes from % to %. success cases of rsi on first and within three attempts are intubations ( %, %ci %- %) and intubations ( %, %ci %- %), respectively. the success cases of non-rsi on first and within three attempts are intubations ( %, %ci %- %) and intubations ( %, %ci %- %). success rates of rsi on first and within three attempts are higher than non-rsi (or . , %ci . - . and or . , % ci . - . , respectively). we recorded complications in rsi ( %) and in non-rsi ( %). there is no significant difference of complication rate between rsi and non-rsi (or . , % ci . - . ). conclusion: in this multi-center prospective study in japan, we demonstrated a high degree of variation in use of rsi for ed intubation. additionally we found that success rate of rsi on first and within three attempts were both higher than non-rsi. this study has the limitation of reporting bias and confounding by indication. (originally submitted as a ''late-breaker.'') methods: this was a prospective, randomized, singleblind study conducted in the ed setting from june until the present time. this study took place at an academic adult ed of a -bed ( in the ed) and a level i trauma center. subjects were randomized to receive either ketamine-propofol or propofol according to a standardized protocol. etco waveforms were digitally recorded. etco changes were evaluated by the sedating physicians at the bedside. recorded waveforms were reviewed by an independent physician and a trained research assistant (ra). to ensure the reliability of trained ras, we computed a kappa test for agreement between the analysis of independent physicians and ras for the first recordings. a post-hoc analysis of the association between any loss, the number of losses, and total duration of loss of etco waveform and crp was performed. on review we recorded the absence or presence of loss of etco and the total duration in seconds of all lost etco episodes ‡ seconds. ors were calculated using sas statistical software. results: patients were enrolled; ( . %) are males and are ( . %) females. . % participants were asa class or . waveforms were reviewed by ( . %) sedating physicians. there were ( . %) waveforms recordings, ( . %) were reviewed by an independent physician and ( %) were reviewed by ras, where there were no discordant pairs (kappa = ). there were ( . %) crp events. any loss of etco was associated with a non-significant or of . ( % ci . - . ) for crp. however, the duration of etco loss was significantly associated with crp with an or of . ( % ci . - . ) for each second interval of lost etco . the number of losses was significantly associated with the outcome (or . , % ci . - . ). conclusion: defining subclinical respiratory depression as present or absent may be less useful than quantitative measurements. this suggests that risk is cumulative over periods of loss of etco , and the duration of loss may be a better marker of sedation depth and risk of complications than classification of any loss. background: ed visits present an opportunity to deliver brief interventions (bis) to reduce violence and alcohol misuse among urban adolescents at risk for future injury. previous analyses demonstrated that a brief intervention resulted in reductions in violence and alcohol consequences up to months. objectives: this paper describes findings examining the efficacy of bis on peer violence and alcohol misuse at months. methods: patients ( - yrs) at an ed reporting past year alcohol use and aggression were enrolled in the rct, which included computerized assessment, and randomization to control group or bi delivered by a computer (cbi) or therapist assisted by a computer (tbi). baseline and months included violence (peer aggression, peer victimization, violence related consequences) and alcohol (alcohol misuse, binge drinking, alcohol-related consequences). results: adolescents were screened ( % participation). of those, screened positive for violence and alcohol use and were randomized; % completed -month follow-up. as compared to the control group, the tbi group showed significant reductions in peer aggression (p < . ) and peer victimization (p < . ) at months. bi and control groups did not differ on alcohol-related variables at months. conclusion: evaluation of the saferteens intervention one year following an ed visit provides support for the efficacy of computer-assisted therapist brief intervention for reducing peer violence. violence against ed health care workers: a -month experience terry kowalenko , donna gates , gordon gillespie , paul succop university of michigan, ann arbor, mi; university of cincinnati, cincinnati, oh background: health care (hc) support occupations have an injury rate nearly times that of the general sector due to assaults, with doctors and nurses nearly times greater. studies have shown that the ed is at greatest risk of such events compared to other hc settings. objectives: to describe the incidence of violence in ed hc workers over months. specific aims were to ) identify demographic, occupational, and perpetrator factors related to violent events; ) identify the predictors of acute stress response in victims; and ) identify predictors of loss of productivity after the event. methods: longitudinal, repeated methods design was used to collect monthly survey data from ed hc workers (w) at six hospitals in two states. surveys assessed the number and type of violent events, and feelings of safety and confidence. victims also completed specific violent event surveys. descriptive statistics and a repeated measure linear regression model were used. results: ed hcws completed monthly surveys, and violent events were reported. the average per person violent event rate per months was . . events were physical threats ( . per person in months). events were assaults ( . per person in months). violent event surveys were completed, describing physical threats and assaults with % resulting in injuries. % of the physical threats and % of the assaults were perpetrated by men. comparing occupational groups revealed significant differences between nurses and physicians for all reported events (p = . ), with the greatest difference in physical threats (p = . ). nurses felt less safe than physicians (p = . ). physicians felt more confident than nurses in dealing with the violent patient (p = . ). nurses were more likely to experience acute stress than physicians (p < . ). acute stress significantly reduced productivity in general (p < . ), with a significant negative effect on ''ability to handle/ manage workload'' (p < . ) and ''ability to handle/ manage cognitive demands'' (p < . ). conclusion: ed hcws are frequent victims of violence perpetrated by visitors and patients. this violence results in injuries, acute stress, and loss of productivity. acute stress has negative consequences on the workers' ability to perform their duties. this has serious potential consequences to the victim as well as the care they provide to their patients. a randomized controlled feasibility trial of vacant lot greening to reduce crime and increase perceptions of safety eugenia c. garvin, charles c. branas perelman school of medicine at the university of pennsylvania, philadelphia, pa background: vacant lots, often filled with trash and overgrown vegetation, have been associated with intentional injuries. a recent quasi-experimental study found a significant decrease in gun crimes around vacant lots that had been greened compared with control lots. objectives: to determine the feasibility of a randomized vacant lot greening intervention, and its effect on police-reported crime and perceptions of safety. methods: for this randomized controlled feasibility trial of vacant lot greening, we partnered with the pennsylvania horticulture society (phs) to perform the greening intervention (cleaning the lots, planting grass and trees, and building a wooden fence around the perimeter). we analyzed police crime data and interviewed people living around the study vacant lots (greened and control) about perceptions of safety before and after greening. results: a total of sq ft of randomly selected vacant lot space was successfully greened. we used a master database of , vacant lots to randomly select vacant lot clusters. we viewed each cluster with the phs to determine which were appropriate to send to the city of philadelphia for greening approval. the vacant lot cluster highest on the random list to be approved by the city of philadelphia was designated the intervention site, and the next highest was designated the control site. overall, participants completed baseline interviews, and completed follow-up interviews after months. % of participants were male, % were black or african american, and % had a household income less than $ , . unadjusted difference-in-differences estimates showed a decrease in gun assaults around greened vacant lots compared to control. regression-adjusted estimates showed that people living around greened vacant lots reported feeling safer after greening compared to those who lived around control vacant lots (p < . ). conclusion: conducting a randomized controlled trial of vacant lot greening is feasible. greening may reduce certain gun crimes and make people feel safer. however, larger prospective trials are needed to further investigate this link. screening for violence identifies young adults at risk for return ed visits for injury abigail hankin-wei, brittany meagley, debra houry emory university, atlanta, ga background: homicide is the second leading cause of death among youth ages - . prior studies, in nonhealth care settings, have shown associations between violent injury and risk factors including exposure to community violence, peer behavior, and delinquency. objectives: to assess whether self-reported exposure to violence risk factors can be used to predict future ed visits for injuries. methods: we conducted a prospective cohort study in the ed of a southeastern us level i trauma center. patients aged - presenting for any chief complaint were included unless they were critically ill, incarcerated, or could not read english. recruitment took place over six months, by a trained research assistant (ra). the ra was present in the ed for - days per week, with shifts scheduled such that they included weekends and weekdays, over the hours from am- pm. patients were offered a $ gift card for participation. at the time of initial contact in the ed, patients completed a written questionnaire which included validated measures of the following risk factors: a) aggression, b) perceived likelihood of violence, c) recent violent behavior, d) peer behavior, e) community exposure to violence, and f) positive future outlook. at months following the initial ed visit, the participants' medical records were reviewed to identify any subsequent ed visits for injury-related complaints. data were analyzed with chi-square and logistic regression analyses. results: patients were approached, of whom patients consented. participants' average age was . years, with % female, and % african american. return visits for injuries were significantly associated with hostile/aggressive feelings (rr . , ci . , ) , self-reported perceived likelihood of violence (rr . , ci . , . ) , recent violent behavior (rr . , ci . , . ) , and peer group violence (rr . , ci . , . ) . these findings remained significant when controlling for participant sex. conclusion: a brief survey of risk factors for violence is predictive of return visit to the ed for injury. these findings identify a potentially important tool for primary prevention of violent injuries among young adults visiting the ed for both injury and non-injury complaints. background: sepsis is a commonly encountered disease in ed, with high mortality. while several clinical prediction rules (cpr) including meds, sirs, and curb- exist to facilitate clinicians in early recognition of risk of mortality for sepsis, most are of suboptimal performance. objectives: to derive a novel cpr for mortality of sepsis utilizing clinically available and objective predictors in ed. methods: we retrospectively reviewed all adult septic patients who visited the ed at a tertiary hospital during the year with two sets of blood cultures ordered by physicians. basic demographics, ed vital signs, symptoms and signs, underlying illnesses, laboratory findings, microbiological results, and discharge status were collected. multivariate logistic regressions were used to obtain a novel cpr using predictors with < . p-value tested in univariate analyses. the existing cprs were compared with this novel cpr using auc. results: of included patients, . % died in hospital, % had diabetes, % were older than years of age, % had malignancy, and % had positive blood bacterial culture tests. predisposing factors including history of malignancy, liver disease, immunosuppressed status, chronic kidney disease, congestive heart failure, and older than years of age were found to be associated with mortality (all p < . ). patients who developed mortality tended to have lower body temperature, narrower pulse pressure, higher percentage of red cell distribution width (rdw) and bandemia, higher blood urea nitrogen (bun), ammonia, and c-reactive protein level, and longer prothrombin time and activated partial thromboplastin time (aptt) (all p < . ). the most parsimonious cpr incorporating history of malignancy (or . , % ci . - . ), prolonged aptt ( . , . - . ), presence of bandemia ( . , . - . results: there was poor agreement between the physician's unstructured assessment used in clinical practice and the guidelines put forth by the aha/acc/acep task force. ed physicians were more likely to assess a patient as low risk ( %), while aha guidelines were more likely to classify patients as intermediate ( %) or high ( %) risk. however, when comparing the patient's final acs diagnosis and the relation to the risk assessment value, ed physicians proved better predictors of high-risk patients who in fact had acs, while the aha/acc/acep guidelines proved better at correctly identifying low-risk patients who did not have acs. conclusion: in the ed, physicians are far more efficient at correctly placing patients with underlying acs into a high-risk category, while established criteria may be overly conservative when applied to an acute care population. further research is indicated to look at ed physicians' risk stratification and ensuing patient care to assess for appropriate decision making and ultimate outcomes. compartative conclusion: the amuse score was more specific, but the wells score was more sensitive for acute lower limb dvt in this cohort. there is no significant advantage in using the amuse over the wells score in ed patient with suspected dvt. background: the direct cost of medical care is not accurately reflected in charges or reimbursement. the cost of boarding admitted patients in the ed has been studied in terms of opportunity costs, which are indirect. the actual direct effect on hospital expenses has not been well defined. objectives: we calculate the difference to the hospital in the cost of caring for an admitted patient in the ed and in a non-critical care in-patient unit. methods: time-directed activity-based costing (tdabc) has recently been proposed as a method of determining the actual cost of providing medical services. tdabc was used to calculate the cost per patient bed-hour both in the ed and for an in-patient unit. the costs include nursing, nursing assistants, clerks, attending and resident physicians, supervisory salaries, and equipment maintenance. boarding hours were determined from placement of admission order to transfer to in-patient unit. a convenience sample of consecutive non-critical care admissions was assessed to find the degree of ed physician involvement with boarded patients. results: the overhead cost per patient bed-hour in the ed was $ . . the equivalent cost per bed-hour inpatient was $ . , a differential of $ . . there were , boarding hours for medical-surgical patients in , a differential of $ , , . for the year. for the short-stay unit (no residents), the cost per patient hour was $ . and the boarding hours were , . this resulted in a differential cost of $ , . , a total direct cost to the hospital of $ , , . . review of consecutive admissions showed no orders placed by the ed physician after decision-toadmit. conclusion: concentration of resources in the ed means considerably higher cost per unit of care as compared to an in-patient unit. keeping admitted patients boarding in the ed results in expensive underutilization. this is exclusive of significant opportunity costs of lost revenue from walk-out and diverted patients. this study includes the cost of teaching attendings and residents (ed and in-patient) . in a non-teaching setting, the differential would be less and the cost of boarding would be shared by a fee-for-service ed physician group as well as the hospital. improving identification of frequent emergency department users using a regional health information background: frequent ed users consume a disproportionate amount of health care resources. interventions are being designed to identify such patients and direct them to more appropriate treatment settings. because some frequent users visit more than one ed, a health information exchange (hie) may improve the ability to identify frequent ed users across sites of care. objectives: to demonstrate the extent to which a hie can identify the marginal increase in frequent ed users beyond that which can be detected with data from a single hospital. methods: data from / / to / / from the new york clinical information exchange (nyclix), a hie in new york city that includes ten hospitals, were analyzed to calculate the number of frequent ed users ( ‡ visits in days) at each site and across the hie. results: there were , ( % of total patients) frequent ed users, with , ( %) of frequent users having all their visits at a single ed, while , ( %) frequent users were identified only after counting visits to multiple eds (table ) . site-specific increases varied from % to % (sd . ). frequent ed users accounted for % of patients, but for % of visits, averaging . visits per year, versus . visits per year for all other patients. . % of frequent users visited two or more eds during the study period, compared to . % of all other patients. conclusion: frequent ed users commonly visited multiple nyclix eds during the study period. the use of a hie helped identify many additional frequent users, though the benefits were lower for hospitals not located in the relative vicinity of another nyclix hospital. measures that take a community, rather than a single institution, into account may be more reflective of the care that the patient experiences. indocyanine background: due to their complex nature and high associated morbidity, burn injuries must be handled quickly and efficiently. partial thickness burns are currently treated based upon visual judgment of burn depth by the clinician. however, such judgment is only % accurate and not expeditious. laser doppler imaging (ldi) is far more accurate -nearly % after days. however, it is too cumbersome for routine clinical use. laser assisted indocyanine green angiography (laicga) has been indicated as an alternative for diagnosing the depth of burn injuries, and possesses greater utility for clinical translation. as the preferred outcome of burn healing is aesthetic, it is of interest to determine if wound contracture can be predicted early in the course of a burn by laic-ga. objectives: determine the utility of early burn analysis using laicga in the prediction of -day wound contracture. methods: a prospective animal experiment was performed using six anesthetized pigs, each with standardized wounds. differences in burn depth were created by using a . · . cm aluminum bar at three exposure times and temperatures: degrees c for seconds, degrees c for seconds, and degrees c for seconds. we have shown in prior validation experiments that these burn temperatures and times create distinct burn depths. laicga scanning, using lifecell spy elite, took place at hour, hours, hours, hours, and week post burn. imaging was read by a blinded investigator, and perfusion trends were compared with day post-burn contraction outcomes measured using imagej software. biopsies were taken on day to measure scar tissue depth. results: deep burns were characterized by a blue center indicating poor perfusion while more superficial burns were characterized by a yellow-red center indicating perfusion that was close to that of the normal uninjured adjacent skin (see figure) . a linear relationship between contraction outcome and burn perfusion could be discerned as early as hour post burn, peaking in strength at - hours post-burn. burn intensity could be effectively identified at hours post-burn, although there was no relationship with scar tissue depth. conclusion: pilot data indicate that laicga using lifecell spy has the ability to determine the depth of injury and predict the degree of contraction of deep dermal burns within - days of injury with greater accuracy than clinical scoring. the objectives: we hypothesize that real-time monitoring of an integrated electronic medical records system and the subsequent firing of a ''sepsis alert'' icon on the electronic ed tracking board results in improved mortality for patients who present to the ed with severe sepsis or septic shock. methods: we retrospectively reviewed our hospital's sepsis registry and included all patients diagnosed with severe sepsis or septic shock presenting to an academic community ed with an annual census of , visits and who were admitted to a medical icu or stepdown icu bed between june and october . in may an algorithm was added to our integrated medical records system that identifies patients with two sirs criteria and evidence of endorgan damage or shock on lab data. when these criteria are met, a ''sepsis alert'' icon (prompt) appears next to that patient's name on the ed tracking board. the system also pages an in-house, specially trained icu nurse who can respond on a prn basis and assist in the patient's management. months of intervention data are compared with months of baseline data. statistical analysis was via z-test for proportions. results: for ed patients with severe sepsis, the preand post-alert mortality was of ( %) and of ( %), respectively (p = . ; n = ). in the septic shock group, the pre-and post-alert mortality was of ( %) and of ( %), respectively (p = . ). with ed and inpatient sepsis alerts combined, the severe sepsis subgroup mortality was reduced from % to % (p = . ; n = ). conclusion: real-time ed ehr screening for severe sepsis and septic shock patients did not improve mortality. a positive trend in the severe sepsis subgroup was noted, and the combined inpatient plus ed data suggests statistical significance may be reached as more patients enter the registry. limitations: retrospective study, potential increased data capture post intervention, and no ''gold standard'' to test the sepsis alert sensitivity and specificity. ) . descriptive statistics were calculated. principal component analysis was used to determine questions with continuous response formats that could be aggregated. aggregated outcomes were regressed onto predictor demographic variables using multiple linear regression. results: / physicians completed the survey. physicians had a mean of . ± . years experience in the ed. . % were female. eight physicians ( %) reported never having used the tool, while . % of users estimated having used it more than five times. % of users cited the ''p'' alert on the etb as the most common notification method. most felt the ''p'' alert did not help them identify patients with pneumonia earlier (mean = . ± . ), but found it moderately useful in reminding them to use the tool ( . ± . ). physicians found the tool helpful in making decisions regarding triage, diagnostic studies, and antibiotic selection for outpatients and inpatients ( . ± . , . ± . , . ± . , and . ± . , respectively). they did not feel it negatively affected their ability to perform other tasks ( . ± . ). using multiple linear regression, neither age, sex, years experience, nor tool use frequency significantly predicted responses to questions about triage and antibiotic selection, technical difficulties, or diagnostic ordering. conclusion: ed physicians perceived the tool to be helpful in managing patients with pneumonia without negatively affecting workflow. perceptions appear consistent across demographic variables and experience. objectives: we seek to examine whether use of the salt device can provide reliable tracheal intubation during ongoing cpr. the dynamic model tested the device with human powered cpr (manual) and with an automated chest compression device (physio control lucas ). the hypothesis is that the predictable movement of an automated chest compression device will make tracheal intubation easier than the random movement from manual cpr. methods: the project was an experimental controlled trial and took place in the ed at a tertiary referral center in peoria, illinois. this project was an expansion arm of a similarly structured study using traditional laryngoscopy. emergency medicine residents, attending physicians, paramedics, and other acls-trained staff were eligible for participation. in randomized order, each participant attempted intubation on a mannequin using the salt device with no cpr ongoing, during cpr with a manual compression, and during cpr with an automatic chest compression. participants were timed in their attempt and success was determined after each attempt. results: there were participants in the trial. the success rates in the control group and the automated cpr group were both % ( / ) and the success rate in the manual cpr group was % ( / objectives: our primary hypothesis was that in fasting, asymptomatic subjects, larger fluid boluses would lead to proportional aortic velocity changes. our secondary endpoints were to determine inter-and intra-subject variation in aortic velocity measurements. methods: the authors performed a prospective randomized double-blinded trial using healthy volunteers. we measured the velocity time integral (vti) and maximal velocity (vmax) with an estimated - °pulsed wave doppler interrogation of the left ventricular outflow in the apical- cardiac window. three physicians reviewed optimal sampling gate position, doppler angle and verified the presence of an aortic closure spike. angle correction technology was not used. subjects with no history of cardiac disease or hypertension fasted for hours and were then randomly assigned to receive a normal saline bolus of ml/kg, ml/kg or ml/kg over minutes. aortic velocity profiles were measured before and after each fluid bolus. results: forty-two subjects were enrolled. mean age was ± (range to ) and mean body mass index . ± . (range . to ). mean volume (in ml) for groups receiving ml/kg, ml/kg, and ml/kg were , , and , respectively. mean baseline vmax (in cm/s) of the subjects was . ± . (range to ). mean baseline vti (in cm) was . ± . (range . to . ). pre-and post-fluid mean differences for vmax were ) . (± . ) and for vti . (± . ). aortic velocity changes in groups receiving ml/kg, ml/kg, and ml/kg were not statistically significant (see table) . heart rate changes were not significant. background: clinicians recognize that septic shock is a highly prevalent, high mortality disease state. evidence supports early ed resuscitation, yet care delivery is often inconsistent and incomplete. the objective of this study was to discover latent critical barriers to successful ed resuscitation of septic shock. objectives: clinicians recognize that septic shock is a highly prevalent, high mortality disease state. evidence supports early ed resuscitation, yet care delivery is often inconsistent and incomplete. the objective of this study was to discover latent critical barriers to successful ed resuscitation of septic shock. methods: we conducted five -minute risk-informed in-situ simulations. ed physicians and nurses working in the real clinical environment cared for a standardized patient, introduced into their existing patient workload, with signs and symptoms of septic shock. immediately after case completion clinicians participated in a minute debriefing session. transcripts of these sessions were analyzed using grounded theory, a method of qualitative analysis, to identify critical barrier themes. results: fifteen clinicians participated in the debriefing sessions: four attending physicians, five residents, five nurses, and one nurse practitioner. the most prevalent critical barrier themes were: anchoring bias and difficulty with cognitive framework adaptation as the patient progressed to septic shock (n = ), difficult interactions between the ed and ancillary departments (n = ), difficulties with physician-nurse commu-nication and teamwork (n = ), and delays in placing the central venous catheter due to perceptions surrounding equipment availability and the desire to attend to other competing interests in the ed prior to initiation of the procedure (n = and ). each theme was represented in at least four of the five debriefing sessions. participants reported the in-situ simulations to be a realistic representation of ed sepsis care. conclusion: in-situ simulation and subsequent debriefing provides a method of identifying latent critical areas for improvement in a care process. improvement strategies for ed-based septic shock resuscitation will need to address the difficulties in shock recognition and cognitive framework adaptation, physician and nurse teamwork, and prioritization of team effort. the background: the association between blood glucose level and mortality in critically ill patients is highly debated. several studies have investigated the association between history of diabetes, blood sugar level, and mortality of septic patients; however, no consistent conclusion could be drawn so far. objectives: to investigate the association between diabetes and initial glucose level and in-hospital mortality in patients with suspected sepsis from the ed. methods: we conducted a retrospective cohort study that consisted of all adult septic patients who visited the ed at a tertiary hospital during the year with two sets of blood cultures ordered by physicians. basic demographics, ed vital signs, symptoms and signs, underlying illnesses, laboratory findings, microbiological results, and discharge status were collected. logistic regressions were used to evaluate the association between risk factors, initial blood sugar level, and history of diabetes and mortality, as well as the effect modification between initial blood sugar level and history of diabetes. results: a total of patients with available blood sugar levels were included, of whom % had diabetes, % were older than years of age, and % were male. the mortality was % ( % ci . - . %). patients with a history of diabetes tended to be older, female, and more likely to have chronic kidney disease, lower sepsis severity (meds score), and positive blood culture test results (all p < . ). patients with a history of diabetes tended to have lower in-hospital mortality after ed visits with sepsis, controlling for initial blood sugar level (aor . , % ci . - . , p = . ). initial normal blood sugar seemed to be beneficial compared to lower blood sugar level for in-hospital mortality, controlled history of diabetes, sex, severity of sepsis, and age (aor . , % ci . - . , p = . ). the effect modification of diabetes on blood sugar level and mortality, however, was found to be not statistically significant (p = . ). conclusion: normal initial blood sugar level in ed and history of diabetes might be protective for mortality of septic patients who visited the ed. further investigation is warranted to determine the mechanism for these effects. methods: this irb-approved retrospective chart review included all patients treated with therapeutic hypothermia after cardiac arrest during at an urban, academic teaching hospital. every patient undergoing therapeutic hypothermia is treated by neurocritical care specialists. patients were identified by review of neurocritical care consultation logs. clinical data were dually abstracted by trained clinical study assistants using a standardized data dictionary and case report form. medications reviewed during hypothermia were midazolam, lorazepam, propofol, fentanyl, cisatracurium, and vecuronium. results: there were patients in the cohort. median age was (range - years), % were white, % were male, and % had a history of coronary artery disease. seizures were documented by continuous eeg in / ( %), and / ( %) died during hospitalization. most, / ( %), received fentanyl, / ( %) received benzodiazepine pharmacotherapy, and / ( %) received propofol. paralytics were administered to / ( %) patients, / ( %) with cisatracurium and / ( %) with vecuronium. of note, one patient required pentobarbital for seizure management. conclusion: sedation and neuromuscular blockade are common during management of patients undergoing therapeutic hypothermia after cardiac arrest. patients in this cohort often received analgesia with fentanyl, and sedation with a benzodiazepine or propofol. given the frequent use of sedatives and paralytics in survivors of cardiac arrest undergoing hypothermia, future studies should investigate the potential effect of these drugs on prognostication and survival after cardiac arrest. background: the use of therapeutic hypothermia (th) is a burgeoning treatment modality for post-cardiac arrest patients. objectives: we performed a retrospective chart review of patients who underwent post cardiac arrest th at eight different institutions across the united states. our objective was to assess how th is currently being implemented in emergency departments and assess the feasibility of conducting more extensive th research using multi-institution retrospective data. methods: a total of charts with dates from - were sent for review by participating institutions of the peri-resuscitation consortium. of those reviewed, eight charts were excluded for missing data. two independent reviewers performed the review and the results were subsequently compared and discrepancies resolved by a third reviewer. we assessed patient demographics, initial presenting rhythm, time until th initiation, duration of th, cooling methods and temperature reached, survival to hospital discharge, and neurological status on discharge. results: the majority of cases of th had initial cardiac rhythms of asystole or pulseless electrical activity ( . %), followed by ventricular tachycardia or fibrillation ( . %), and in . % the inciting cardiac rhythm was unknown. time to initiation of th ranged from - minutes with a mean time of min (sd . ). length of th ranged from - minutes with a mean time of minutes (sd ). average minimum temperature achieved was . °c, with a range from . - . °c (sd . °c). of the charts reviewed, ( . %) of the patients survived to hospital discharge and ( . %) were discharged relatively neurologically intact. conclusion: research surrounding cardiac arrest has always been difficult given the time and location span from pre-hospital care to emergency department to intensive care unit. also, as witnessed cardiac arrest events are relatively rare with poor survival outcomes, very large sample sizes are needed to make any meaningful conclusions about th. our varied and inconsistent results show that a multi-center retrospective review is also unlikely to provide useful information. a prospective multi-center trial with a uniform th protocol is needed if we are ever to make any evidence-based conclusions on the utility of th for post-cardiac arrest patients. serum results: mean la was . , sd = . . mean age was . years old, sd = . . a statistically significant positive correlation was found between la and pulse, respiratory rate (rr), wbc, platelets, and los, while a significant negative correlation was seen with temperature and hco -. when two subjects were dropped as possible outliers with la > , it resulted in non-significant temperature correlation, but a significant negative correlation with age and bun was revealed. patients in the higher la group were more likely to be admitted (p = . ) and have longer los. of the discharged patients, there was no difference in mean la level between those who returned (n = , mean la of . , sd = . ) and those who did not (n = , mean la of . , sd = . ), p = . . furthermore, mean la levels for those with sepsis (n = , mean la of . , sd = . ) did not differ from those without sepsis (n = , mean la of . , sd = . ), p = . . conclusion: higher la in pediatric patients presenting to the ed with suspected infection correlated with increased pulse, rr, wbc, platelets, and decreased bun, hco -, and age. la may be predictive of hospitalization, but not of -day return rates or pediatric sepsis screening in the ed. background: mandibular fractures are one of the most frequently seen injuries in the trauma setting. in terms of facial trauma, madibular fractures account for - % of all facial bone fractures. prior studies have demonstrated that the use of a tongue blade to screen these patients to determine whether a mandibular fracture is present may be as sensitive as x-ray. one study showed the sensitivity and specificity of the test to be . % and . %, respectively. in the last ten years, high-resolution computed tomography (hct) has replaced panoramic tomography (pt) as the gold standard for imaging of patients with suspected mandibular fractures. this study determines if the tongue blade test (tbt) remains as sensitive a screening tool when compared to the new gold standard of ct. objectives: the purpose of the study was to determine the sensitivity and specificity of the tbt as compared to the new gold standard of radiologic imaging, hct. the question being asked: is the tbt still useful as a screening tool for patients with suspected mandibular fractures when compared to the new gold standard of hct? methods: design: prospective cohort study. setting: an urban tertiary care level i trauma center. subjects: this study took place from / / to / / in which any person suffering from facial trauma presented. intervention: a tbt was performed by the resident physician and confirmed by the supervising attending physician. ct facial bones were then obtained for the ultimate diagnosis. inter-rater reliability (kappa) was calculated, along with sensitivity, specificity, accuracy, ppv, npv, likelihood ratio (lr) (+), and likelihood ratio (lr) (-) based on a · contingency tables generated. results: over the study period patients were enrolled. inter-rater reliability was kappa = . (se + . ). the table demonstrates the outcomes of both the tbt and ct facial bones for mandibular fracture. the following parameters were then calculated based on the contingency table: sensitivity . (ci . - . ), specificity . (ci . - . ), ppv . (ci . - . ), npv . (ci . - . ), accuracy . , lr(+) . ), lr (-) . (ci . - . ). conclusion: the tbt is still a useful screening tool to rule out mandibular fractures in patients with facial trauma as compared to the current gold standard of hct. background: appendicitis is the most common surgical emergency occurring in children. the diagnosis of pediatric appendicitis is often difficult and computerized tomography (ct) scanning is utilized frequently. ct, although accurate, is expensive, time-consuming, and exposes children to ionizing radiation. radiologists utilize ultrasound for the diagnosis of appendicitis, but it may be less accurate than ct, and may not incorporate emergency physician (ep) clinical impression regarding degree of risk. objectives: the current study compared ep clinical diagnosis of pediatric appendicitis pre-and post-bedside ultrasonography (bus). methods: children - years of age were enrolled if their clinical attending physician planned to obtain a consultative ultrasound, ct scan, or surgical consult specific for appendicitis. most children in the study received narcotic analgesia to facilitate bus. subjects were initially graded for likelihood of appendicitis based on research physician-obtained history and physical using a visual analogue scale (vas). immediately subsequent to initial grading, research physicians performed a bus and recorded a second vas impression of appendicitis likelihood. two outcome measures were combined as the gold standard for statistical analysis. the post-operative pathology report served as the gold standard for subjects who underwent appendectomy, while post -week telephone follow-up was used for subjects who did not undergo surgery. various specific ultrasound measures used for the diagnosis of appendicitis were assessed as well. results: / subjects had pathology-proven appendicitis. one subject was pathology-negative post-appendectomy. of the subjects who did not undergo surgery, none had developed appendicitis at the post -week telephone follow-up. pre-bus sensitivity was % ( - %) while post-bus sensitivity was % ( - %). both pre-and post-bus specificity was % ( - %). pre-bus lr+ was ( - ), while post-bus lr+ was ( - ). pre-and post-bus lr-were . and . , respectively. bus changed the diagnosis for % of subjects ( - %). background: there are very little data on the normal distance between the glenoid rim and the posterior aspect of the humeral head in normal and dislocated shoulders. while shoulder x-rays are commonly used to detect shoulder dislocations, they may be inadequate, exacerbate pain in the acquisition of some views, and lead to delay in treatment, compared to bedside ultrasound evaluation. objectives: our objective was to compare the glenoid rim to humeral head distance in normal shoulders and in anteriorly dislocated shoulders. this is the first study proposing to set normal and abnormal limits. methods: subjects were enrolled in this prospective observation study if they had a chief complaint of shoulder pain or injury, and received a shoulder ultrasound as well as a shoulder x-ray. the sonographers were undergraduate students given ten hours of training to perform the shoulder ultrasound. they were blinded to the x-ray interpretation, which was used as the gold standard. we used a posterior-lateral approach, capturing an image with the glenoid rim, the humeral head, as well as the infraspinatus muscle. two parallel lines were applied to the most posterior aspect of the humeral head and the most posterior aspect of the glenoid rim. a line perpendicular to these lines was applied, and the distance measured. in anterior dislocations, a negative measurement was used to denote the fact that the glenoid rim is now posterior to the most posterior aspect of the humeral head. descriptive analysis was applied to estimate the mean and th to th interquartile range of normal and anteriorly dislocated shoulders. results: eighty subjects were enrolled in this study. there were six shoulder dislocations, however only four were anterior dislocations. the average distance between the posterior glenoid rim and the posterior humeral head in normal shoulders was . mm, with a th to th inter-quartile range of . mm to . mm. the distance in our four cases of anterior dislocation was ) mm, with a th to th interquartile range of ) mm to ) mm. conclusion: the distance between the posterior humeral head to posterior glenoid rim may be mm to mm in patients presenting to the ed with shoulder pain but no dislocation. in contrast, this distance in anterior dislocations was greater than ) mm. shoulder ultrasound may be a useful adjunct to x-ray for diagnosing anterior shoulder dislocations. conclusion: in this retrospective study, the presence of rv strain on focus significantly increases the likelihood of an adverse short term event from pulmonary embolism and its combination with hypotension performs similarly to other prognostic rules. background: burns are expensive and debilitating injuries, compromising both the structural integrity and vascular supply to skin. they exhibit a substantial potential to deteriorate if left untreated. jackson defined three ''zones'' to a burn. while the innermost coagulation zone and the outermost zone of hyperemia display generally predictable healing outcomes, the zone of stasis has been shown to be salvageable via clinical intervention. it has therefore been the focus of most acute therapies for burn injuries. while laser doppler imaging (ldi) -the current gold standard for burn analysis -has been % effective at predicting the need for second degree burn excision, its clinical translation is problematic, and there is little information regarding its ability to analyze the salvage of the stasis zone in acute injury. laser assisted indocyanine green dye angiography (laicga) also shows potential to predict such outcomes with greater clinical utility. objectives: to test the ability of ldi and laicga to predict interspace (zone of stasis) survival in a horizontal burn comb model. methods: a prospective animal experiment was performed using four pigs. each pig had a set of six dorsal burns created using a brass ''comb'' -creating four rectangular · mm full thickness burns separated by · mm interspaces. laicga and ldi scanning took place at hour, hours, hours, and week post burn using novadaq spy and moor ldi respectively. imaging was read by a blinded investigator, and perfusion trends were compared with interspace viability and contraction. burn outcomes were read clinically, evaluated via histopathology, and interspace contraction was measured using image j software. results: laicga data showed significant predictive potential for interspace survival. it was . % predictive at hours post burn, % predictive hours post burn, and % predictive days post burn using a standardized perfusion threshold. ldi imaging failed to predict outcome or contraction trends with any degree of reliability. the pattern of perfusion also appears to be correlated with the presence of significant interspace contraction at days, with an % adherence to a power trendline. ventions, isolation, testing, treatment, and ''other'' category intervention were identified. one intervention involving school closures was associated with a % decrease in pediatric ed visits for respiratory illness. conclusion: most interventions were not tested in isolation, so the effect of individual interventions was difficult to differentiate. interventions associated with statistically significant decreases in ed crowding were school closures, as well as interventions in all categories studied. further study and standardization of intervention input, process, and outcome measures may assist in identifying the most effective methods of mitigating ed crowding and improving surge capacity during an influenza or other respiratory disease outbreak. communication background: the link between extended shift lengths, sleepiness, and occupational injury or illness has been shown, in other health care populations, to be an important and preventable public health concern but heretofore has not been fully described in emergency medical services (ems objectives: to assess the effect of an ed-based computer screening and referral intervention for ipv victims and to determine what characteristics resulted in a positive change in their safety. we hypothesized that women who were experiencing severe ipv and/or were in contemplation or action stages would be more likely to endorse safety behaviors. methods: we conducted the intervention for female ipv victims at three urban eds using a computer kiosk to deliver targeted education about ipv and violence prevention as well as referrals to local resources. all adult english-speaking non-critically ill women triaged to the ed waiting room were eligible to participate. the validated universal violence prevention screening protocol was used for ipv screening. any who disclosed ipv further responded to validated questionnaires for alcohol and drug abuse, depression, and ipv severity. the women were assigned a baseline stage of change (precontemplation, contemplation, action, or maintenance) based on the urica scale for readiness to change behavior surrounding ipv. participants were contacted at week and months to assess a variety of pre-determined actions such as moving out, to prevent ipv during that period. statistical analysis (chi-square testing) was performed to compare participant characteristics to the stage of change and whether or not they took protective action. results: a total of , people were screened and disclosed ipv and participated in the full survey. . % of the ipv victims were in the precontemplative stage of change, and . % were in the contemplation stage. women returned at week of follow-up ( . %), and ( . %) women returned at months of followup. . % of those who returned at week, and % of those who returned at months took protective action against further ipv. there was no association between the various demographic characteristics and whether or not a woman took protective action. conclusion: ed-based kiosk screening and health information delivery is both a feasible and effective method of health information dissemination for women experiencing ipv. stage of change was not associated with actual ipv protective measures. objectives: we present a pilot, head-to-head comparison of x and x effectiveness in stopping a motivated person. the objective is to determine comparative injury prevention effectiveness of the newer cew. methods: four humans had metal cew probe pairs placed. each volunteer had two probe pairs placed (one pair each on the right and left of the abdomen/inguinal region). superior probes were at the costal margin, inches lateral of midline. inferior probes were vertically inferior at predetermined distances of , , , and inches apart. each volunteer was given the goal of slashing a target feet away with a rubber knife during cew exposure. as a means of motivation, they believed the exposure would continue until they reached the goal (in reality, the exposure was terminated once no further progress was made). each volunteer received one exposure from a x and a x cew. the exposure order was randomized with a -minute rest between them. exposures were recorded on a hi-speed, hi-resolution video. videos were reviewed and scored by six physician, kinesiology, and law officer experts using standardized criteria for effectiveness including degree of upper and lower extremity, and total body incapacitation, and degree of goal achievement. reviews were descriptively compared independently for probe spread distances and between devices. results: there were exposures ( pairs) for evaluation and no discernible, descriptive reviewer differences in effectiveness between the x and the x cews when compared. background: the trend towards higher gasoline prices over the past decade in the u.s. has been associated with higher rates of bicycle use for utilitarian trips. this shift towards non-motorized transportation should be encouraged from a physical activity promotion and sustainability perspective. however, gas price induced changes in travel behavior may be associated with higher rates of bicycle-related injury. increased consideration of injury prevention will be a critical component of developing healthy communities that help safely support more active lifestyles. objectives: the purpose of this analysis was to a) describe bicycle-related injuries treated in u.s. emergency departments between and and b) investigate the association between gas prices and both the incidence and severity of adult bicycle injuries. we hypothesized that as gas prices increase, adults are more likely to shift away from driving for utilitarian travel toward more economical non-motorized modes of transportation, resulting in increased risk exposure for bicycle injuries. methods: bicycle injury data for adults ( - years) were obtained from the national electronic injury surveillance system (neiss) database for emergency department visits between - . the relationship between national seasonally adjusted monthly rates of bicycle injuries, obtained by a seasonal decomposition of time series, and average national gasoline prices, reported by the energy information administration, was examined using a linear regression analysis. results: monthly rates of bicycle injuries requiring emergency care among adults increase significantly as gas prices rise (p < . , see figure) . an additional , adult injuries ( % ci - , ) can be predicted to occur each month in the u.s. (> , injuries annually) for each $ rise in average gasoline price. injury severity also increases during periods of high gas prices, with a higher percentage of injuries requiring admission. conclusion: increases in adult bicycle use in response to higher gas prices are accompanied by higher rates of significant bicycle-related injuries. supporting the use of non-motorized transportation will be imperative to address public health concerns such as obesity and climate change; however, resources must also be dedicated to improve bicycle-related injury care and prevention. background: this is a secondary analysis of data collected for a randomized trial of oral steroids in emergency department (ed) musculoskeletal back pain patients. we hypothesized that higher pain scores in the ed would be associated with more days out of work. objectives: to determine the degree to which days out of work for ed back pain patients are correlated with ed pain scores. methods: design: prospective cohort. setting: suburban ed with , annual visits. participants: patients aged - years with moderately severe musculoskeletal back pain from a bending or twisting injury £ days before presentation. exclusion criteria included nonmusculoskeletal etiology, direct trauma, motor deficits, and employer-initiated visits. observations: we captured initial and discharge ed visual analog pain scores (vas) on a - scale. patients were contacted approximately days after discharge and queried about the days out of work. we plotted days out of work versus initial vas, discharge vas, and change in vas and calculated correlation coefficients. using the bonferroni correction because of multiple comparisons, alpha was set at . . results: we analyzed patients for whom complete data were available. the mean age was ± years and % were female. the average initial and discharge ed pain scales were . ± . and . ± . , respectively. on follow-up, % of patients were back to work and % did not lose any days of work. for the plots of the days out of work versus the initial and discharge vas and the change in the vas, the correlation coefficients (r ) were . (p = . ), . (p = . ), and . (p = . ), respectively. conclusion: for ed patients with musculoskeletal back pain, we found no statistically significant correlation between days out of work and ed pain scores. background: conducted electrical weapons (cews) are common law enforcement tools used to subdue and repel violent subjects and, therefore, prevent further injury or violence from occurring in certain situations. the taser x is a new generation of cew that has the capability of firing two cartridges in a ''semi-automatic'' mode, and has a different electrical waveform and different output characteristics than older generation technology. there have been no data presented on the human physiologic effects of this new generation cew. objectives: the objective of this study was to evaluate the human physiologic effects of this new cew. methods: this was a prospective, observational study of human subjects. an instructor shot subjects in the abdomen and upper thigh with one cartridge, and subjects received a -second exposure from the device. measured variables included: vital signs, continuous spirometry, pre-and post-exposure ecg, intra-exposure echocardiography, venous ph, lactate, potassium, ck, and troponin. results: ten subjects completed the study (median age . , median bmi . , % male). there were no important changes in vital signs or in potassium. the median increase in lactate during the exposure was . , range . to . . the median change in ph was ) . , range ) . to . . no subject had a clinically relevant ecg change, evidence of cardiac capture, or positive troponin up to hours after exposure. the median change in creatine kinase (ck) at hours was , range ) to . there was no evidence of impairment of breathing by spirometry. baseline median minute ventilation was . , which increased to . during the exposure (p = . ), and remained elevated at . post-exposure (p = . ). conclusion: we detected a small increase in lactate and decrease in ph during the exposure, and an increase in ck hours after the exposure. the physiologic effects of the x device appear similar to previous reports for ecd devices. use background: public bicycle sharing (bikeshare) programs are becoming increasingly common in the us and around the world. these programs make bicycles easily accessible for hourly rental to the public. there are currently active bikeshare programs in cities in the us, and more than programs are being developed in cities including new york and chicago. despite the importance of helmet use, bikeshare programs do not provide the opportunity to purchase or rent helmets. while the programs encourage helmet use, no helmets are provided at the rental kiosks. objectives: we sought to describe the prevalence of helmet use among adult users of bikeshare programs and users of personal bicycles in two cities with recently introduced bicycle sharing programs (boston, ma and washington, dc). methods: we performed a prospective observational study of bicyclists in boston, ma and washington, dc. trained observers collected data during various times of the day and days of the week. observers recorded the sex of the bicycle operator, type of bicycle, and helmet use. all bicycles that passed a single stationary location in any direction for a period of between and minutes were recorded. data are presented as frequencies of helmet use by sex, type of bicycle (bikeshare or personal), time of the week (weekday or weekend), and city. logistic regression was used to estimate the odds ratio for helmet use controlling for type of bicycle, sex, day of week, and city. results: there were observation periods in two cities at locations. , bicyclists were observed. there were ( . %) bicylists riding bikeshare bicycles. overall helmet use was . %, although helmet use varied significantly with sex, day of use, and type of bicycle (see figure) . bikeshare users were helmeted at a lower rate compared to users of personal bicycles ( . % vs . %). logistic regression, controlling for type of bicycle, sex, day of week, and city demonstrate that bikeshare users had higher odds of riding unhelmeted (or . , % ci . - . ). women had lower odds of riding unhelmeted (or . , . - . ), while weekend riders were more likely to ride unhelmeted (or . , . - . ). conclusion: use of bicycle helmets by users of public bikeshare programs is low. as these programs become more popular and prevalent, efforts to increase helmet use among users should increase. background: abusive head trauma (aht) represents one of the most severe forms of traumatic brain injury (tbi) among abused infants with % mortality. young adult males account for % of the perpetrators. most aht prevention programs are hospital-based and reach a predominantly female audience. there are no published reports of school-based aht prevention programs to date. objectives: . to determine whether a high schoolbased aht educational program will improve students' knowledge of aht and parenting skills. . to evaluate the feasibility and acceptability of a school-based aht prevention program. methods: this program was based on an inexpensive commercially available program developed by the national center on shaken baby syndrome. the program was modified to include a -minute interactive presentation that teaches teenagers about aht, parenting skills, and caring for inconsolable crying infants. the program was administered in three high schools in flint, michigan during spring . student's knowledge was evaluated with a -item written test administered pre-intervention, post-intervention, and two months after program completion. program feasibility and acceptability were evaluated through interviews and surveys with flint area school social workers, parent educators, teachers, and administrators. results: in all, high school students ( % male) participated. of these, ( . %) completed the pretest and post-test with ( %) completing the twomonth follow-up test. the mean pre-intervention, postintervention, and two-month follow-up scores were %, %, and % respectively. from pre-test to posttest, mean score improved %, p < . . this improvement was even more profound in young males, whose mean post-test score improved by %, p < . . of the participating social workers, parent educators, teachers, and administrators, % ranked the program as feasible and acceptable. conclusion: students participating in our program showed an improvement in knowledge of aht and parenting skills which was retained after two months. teachers, social workers, parent educators, and school administrators supported the program. this local pilot program has the potential to be implemented on a larger scale in michigan with the ultimate goal of reducing aht amongst infants. will background: fear of litigation has been shown to affect physician practice patterns, and subsequently influence patient care. the likelihood of medical malpractice litigation has previously been linked with patient and provider characteristics. one common concern is that a patient may exaggerate symptoms in order to obtain monetary payouts; however, this has never been studied. objectives: we hypothesize that patients are willing to exaggerate injuries for cash settlements and that there are predictive patient characteristics including age, sex, income, education level, and previous litigation. methods: this prospective cross-sectional study spanned june to december , in a philadelphian urban tertiary care center. any patient medically stable enough to fill out a survey during study investigator availability was included. two closed-ended paper surveys were administered over the research period. standard descriptive statistics were utilized to report incidence of: patients who desired to file a lawsuit, patients previously having filed lawsuits, and patients willing to exaggerate the truth in a lawsuit for a cash settlement. chi-square analysis was performed to determine the relationship between patient characteristics and willingness to exaggerate injuries for a cash settlement. results: of surveys, were excluded due to incomplete data, leaving for analysis. the mean age was with a standard deviation of , and % were male. the incidence of patients who had the desire to sue at the time of treatment was %. the incidence of patients who had filed a lawsuit in the past was %. of those patients, % had filed multiple lawsuits. fifteen percent [ % ci - %] of all patients were willing to exaggerate injuries for cash settlement. sex and income were found to be statistically significant predictors of willingness to exaggerate symptoms: % of females vs. % of males were willing to exaggerate (p = . ), and % of people with income less than $ , /yr vs. % of those with income over $ , / yr were willing to exaggerate (p = . ). conclusion: patients at a philadelphian urban tertiary center admit to willingness to exaggerate symptoms for a cash settlement. willingness to exaggerate symptoms is associated with female sex and lower income. background: current data suggest that as many as % of patients presenting to the ed with syncope leave the hospital without a defined etiology. prior studies have suggested a prevalence of psychiatric disease as high as % in patients with syncope of unknown etiology. objectives: to determine whether psychiatric disease and substance abuse are associated with an increased incidence of syncope of unknown etiology. methods: prospective, observational, cohort study of consecutive ed patients ‡ presenting with syncope was conducted between / and / . patients were queried in the ed and charts reviewed about a history of psychiatric disease, use of psychiatric medication, substance abuse, and duration. data were analyzed using sas with chi-square and fisher's exact tests. results: we enrolled patients who presented to the ed after syncope, of whom did not have an identifiable etiology for their syncopal event. . % of those without an identifiable etiology were male. ( %) patients had a history of or current psychiatric disease ( % male), and patients ( %) had a history of or current substance abuse ( % male). among males with psychiatric disease, % had an unknown etiology of their syncopal event, compared to % of males without psychiatric disease (p = . ). similarly, among all males with a history of substance abuse, % had an unknown etiology, as compared to % of males without a history of substance abuse (p = . ). a similar trend was not identified in elderly females with psychiatric disease (p = . ) or substance abuse (p = . ). however, syncope of unknown etiology was more common among both men and women under age with a history of substance abuse ( %) compared to those without a history of substance abuse ( %; p = . ). conclusion: our results suggest that psychiatric disease and substance abuse are associated with increased incidence of syncope of unknown etiology. patients evaluated in the ed or even hospitalized with syncope of unknown etiology may benefit from psychiatric screening and possibly detoxification referral. this is particularly true in men. (originally submitted as a ''late-breaker.'') scope background: after discharge from an emergency department (ed), pain management often challenges parents, who significantly under-treat their children's pain. rapid patient turnover and anxiety make education about home pain treatment difficult in the ed. video education standardizes information and circumvents insufficient time and literacy. objectives: to evaluate the effectiveness of a -minute instructional video for parents that targets common misconceptions about home pain management. methods: we conducted a randomized, double-blinded clinical trial of parents of children ages - years who presented with a painful condition, were evaluated, and discharged home in june and july . parents were randomized to a pain management video or an injury prevention control video. primary outcome was the proportion of parents who gave pain medication at home. these data were recorded in a home pain diary and analyzed using a chi-square test. parents' knowledge about pain treatment was tested before, immediately following, and days after intervention. mcnemar's test statistic determined odds that knowledge correlated with the intervention group. results: parents were enrolled: watched the pain education video, and the control video. . % completed follow up, providing information about home pain education use. significantly more parents provided at least one dose of pain medication to their children after watching the educational video: % vs. % (difference %, % ci . %, . %). the odds the parent had correct knowledge about pain treatment significantly improved immediately following the educational video for knowledge about pain scores (p = . ), the effect of pain on function (p < . ), and pain medication misconceptions (p < . ). these significant differences in knowledge remained days after the video intervention. the educational video about home pain treatment viewed by parents significantly increased the proportion of children receiving pain medication at home and significantly improved knowledge about at-home pain management. videos are an efficient tool to provide medical advice to parents that improves outcomes for children. methods: this was a prospective, observational study of consecutive admitted cpu patients in a large-volume academic urban ed. cardiology attendings round on all patients and stress test utilization is driven by their recommendation. eligibility criteria include: age> , aha low/intermediate risk, nondynamic ecgs, and normal initial troponin i. patients > and with a history of cad or co-existing active medical problem were excluded. based on prior studies and our estimated cpu census and demographic distribution, we estimated a sample size of , patients in order to detect a difference in stress utilization of % ( -tailed, a = . , b = . ). we calculated a timi risk prediction score and a diamond & forrester (d&f) cad likelihood score on each patient. t-tests were used for univariate comparisons of demographics, cardiac comorbidities, and risk scores. logistic regression was used to estimate odds ratios (ors) for receiving testing based on race, controlling for insurance and either timi or d&f score. results: over months, , patients were enrolled. mean age was ± , and % ( % ci - ) were female. sixty percent ( % ci - ) were caucasian, % ( % ci - ) african american, and % ( % ci - ) hispanic. mean timi and d&f scores were . ( % ci . - . ) and % ( % ci - ). the overall stress testing rate was % ( % ci - ). after controlling for insurance status and timi or d&f scores, african american patients had significantly decreased odds of stress testing (or timi . ( % ci . - . ), or d&f . ( % ci . - . )). hispanics had significantly decreased odds of stress testing in the model controlling for d&f (or d&f . ( % ci . - . )). conclusion: this study confirms that disparities in the workup of african american patients in the cpu are similar to those found in the general ed and the outpatient setting. further investigation into the specific provider or patient level factors contributing to this bias is necessary. the outcomes for hf and copd were sae . %, . %; death . %, . %. we found univariate associations with sae for these walk test components: too ill to walk (both hf, copd p < . ); highest heart rate ‡ (hf p = . , copd p = . ); lowest sao < % (hf p = . , copd p = . ); borg score ‡ (hf p = . , copd p = . ); walk test duration £ minute (hf p = . . copd p = . ). after adjustment for multiple clinical covariates with logistic regression analyses, we found ''walk test heart rate ‡ '' had an odds ratio of . for hf patients and ''too ill to start the walk test'' had an odds ratio of . for copd patients. conclusion: we found the -minute walk test to be easy to administer in the ed and that maximum heart rate and inability to start the test were highly associated with adverse events in patients with exacerbations of hf and copd, respectively. we suggest that the -minute walk test be routinely incorporated into the assessment of hf and copd patients in order to estimate risk of poor outcomes. the objectives: the objective of this study was to investigate differences in consent rates between patients of different demographic groups who were invited to participate in minimal-risk clinical trials conducted in an academic emergency department. methods: this descriptive study analyzed prospectively collected data of all adult patients who were identified as qualified participants in ongoing minimal risk clinical trials. these trials were selected for this review because they presented minimal factors known to be associated background: increasing rates of patient exposure to computerized tomography (ct) raise questions about appropriateness of utilization, as well as patient awareness of radiation exposure. despite rapid increases in ct utilization and published risks, there is no national standard to employ informed consent prior to radiation exposure from diagnostic ct. use of written informed consent for ct (icct) in our ed has increased patient understanding of the risks, benefits, and alternatives to ct imaging. our team has developed an adjunct video educational module (vem) to further educate ed patients about the ct procedure. objectives: to assess patient knowledge and preferences regarding diagnostic radiation before and after viewing vem. methods: the vem was based on icct currently utilized at our tertiary care ed (census , patients/ year). icct is written at an th grade reading level. this fall, vem/icct materials were presented to a convenience sample of patients in the ed waiting room am- pm, monday-sunday. patients who were < years of age, critically ill, or with language barrier were excluded. to quantify the educational value of the vem, a six-question pretest was administered to assess baseline understanding of ct imaging. the patients then watched the vem via ipad (macintosh) and reviewed the consent form. an eight-question post-test was then completed by each subject. no phi were collected. pre-and post-test results were analyzed using mcnemar's test for individual questions and a paired t-test for the summed score (sas version . ). results: patients consented and completed the survey. the average pre-test score for subjects was poor, % correct. review of vem/icct materials increased patient understanding of medical radiation as evidenced by improved post-test score to %. mean improvement between tests was % (p < . ). % of subjects responded that they found the materials helpful, and that they would like to receive icct. conclusion: the addition of a video educational module improved patient knowledge regarding ct imaging and medical radiation as quantified by pre-and posttesting. patients in our study sample reported that they prefer to receive icct. by educating patients about the risks associated with ct imaging, we increase informed, shared decision making -an essential component of patient-centered care. does objectives: we sought to determine the relationship between patients' pain scores and their rate of consent to ed research. we hypothesized that patients with higher pain scores would be less likely to consent to ed research. methods: retrospective observational cohort study of potential research subjects in an urban academic hospital ed with an average annual census of approximately , visits. subjects were adults older than years with chief complaint of chest pain within the last hours, making them eligible for one of two cardiac biomarker research studies. the studies required only blood draws and did not offer compensation. two reviewers extracted data from research screening logs. patients were grouped according to pain score at triage, pain score at the time of approach, and improvement in pain score (triage score -approach score). the main outcome was consent to research. simple proportions for consent rates by pain score tertiles were calculated. two multivariate logistic regression analyses were performed with consent as outcome and age, race, sex, and triage or approach pain score as predictors. results: overall, potential subjects were approached for consent. patients were % caucasian, % female, and with an average age of years. six patients did not have pain scores recorded at all and did not have scores documented within hours of approach and were excluded from relevant analyses. overall, . % of patients consented. consent rates by tertiles at triage, at time of approach, and by pain score improvement are shown in tables and . after adjusting for age, race, and sex, neither triage (p = . ) nor approach (p = . ) pain scores predicted consent. conclusion: research enrollment is feasible even in ed patients reporting high levels of pain. patients with modest improvements in pain levels may be more likely to consent. future research should investigate which factors influence patients' decisions to participate in ed research. conclusion: in this multicenter study of children hospitalized with bronchiolitis neither specific viruses nor their viral load predicted the need for cpap or intubation, but young age, low birth weight, presence of apnea, severe retractions, and oxygen saturation < % did. we also identified that children requiring cpap or intubation were more likely to have mothers who smoked during pregnancy and a rapid respiratory worsening. mechanistic research in these high-risk children may yield important insights for the management of severe bronchiolitis. brigham & women's hospital, boston, ma background: siblings and children who share a home with a physically abused child are thought to be at high risk for abuse. however, rates of injury in these children are unknown. disagreements between medical and child protective services professionals are common and screening is highly variable. objectives: our objective was to measure the rates of occult abusive injuries detected in contacts of abused children using a common screening protocol. methods: this was a multi-center, observational cohort study of child abuse teams who shared a common screening protocol. data were collected between jan , and april , for all children < years undergoing evaluation for physical abuse and their contacts. for contacts of abused children, the protocol recommended physical examination for all children < years, skeletal survey and physical exam for children < months, and physical exam, skeletal survey, and neuroimaging for children < months old. results: among , children evaluated for abuse, met criteria as ''physically abused'' and these had contacts. for each screening modality, screening was completed as recommended by the protocol in approximately % of cases. of contacts who met criteria for skeletal survey, new injuries were identified in ( . %). none of these fractures had associated findings on physical examination. physical examination identified new injuries in . % of eligible contacts. neuroimaging failed to identify new injuries among eligible contacts less than months old. twins were at significantly increased risk of fracture relative to other nontwin contacts (or . ). conclusion: these results support routine skeletal survey for contacts of physically abused children < months old, regardless of physical examination findings. even for children where no injuries are identified, these results demonstrate that abuse is common among children who share a home with an abused child, and support including contacts in interventions (foster care, safety planning, social support) designed to protect physically abused children. methods: this was a retrospective study evaluating all children presenting to eight paediatric, universityaffiliated eds during one year in - . in each setting, information regarding triage and disposition were prospectively registered by clerks in the ed database. anonymized data were retrieved from the ed computerized database of each participating centre. in the absence of a gold standard for triage, hospitalisation, admission to intensive care unit (icu), length of stay in the ed, and proportion of patients who left without being seen by a physician (lwbs) were used as surrogate markers of severity. the primary outcome measure was the association between triage level (from to ) and hospitalisation. the association between triage level and dichotomous outcomes was evaluated by a chi-square test, while a student's t-test was used to evaluate the association between triage level and length of stay. it was estimated that the evaluation of all children visiting these eds for a one year period would provide a minimum of , patients in each triage level and at least events for outcomes having a proportion of % or more. results: a total of , children visited the eight eds during the study period. pooled data demonstrated hospitalisation proportions of %, %, %, %, and . % for patients triaged at level , , , , and respectively (p < . ). there was also a strong association between triage levels and admission to icu (p < . ), the proportion of children who lwbs (p < . ), and length of stay (p < . ). background: parents frequently leave the emergency department (ed) with incomplete understanding of the diagnosis and plan, but the relationship between comprehension and post-care outcomes has not been well described. objectives: to explore the relationship between comprehension and post-discharge medication safety. methods: we completed a planned secondary analysis of a prospective observational study of the ed discharge process for children aged - months. after discharge, parents completed a structured interview to assess comprehension of the child's condition, the medical team's advice, and the risk of medication error. limited understanding was defined as a score of - from (excellent) to (poor). risk of medication error was defined as a plan to use over-the-counter cough/cold medication and/or an incorrect dose of acetaminophen (measured by direct observation at discharge or reported dose at follow-up call). parents identified as at risk received further instructions from their provider. the primary outcome was persistent risk of medication error assessed at phone interview - days post-discharge. a major barrier to administering analgesics to children is the perceived discomfort of intravenous access. the delivery of intranasal analgesia may be a novel solution to this problem. objectives: we investigated whether the addition of the mucosal atomizer device (mad) as an alternative for fentanyl delivery would improve overall fentanyl administration rates in pediatric patients transported by a large urban ems system. we performed a historical control trial comparing the rate of pediatric fentanyl administration months before and months after the introduction of the mad. study subjects were pediatric trauma patients (age < years) transported by a large urban ems agency. the control group was composed of patients treated in the months before introduction of the mad. the experimental group included patients treated in the months after the addition of the mad. two physicians reviewed each chart and determined whether the patient met predetermined criteria for the administration of pain medication. a third reviewer resolved any discrepancies. fentanyl administration rates were measured and compared between the two groups. we used two-sample t-tests and chi-square tests to analyze our data. results: patients were included in the study: patients in the pre-mad group and in the post-mad group. there were no significant differences in the demographic and clinical characteristics of the two groups. ( . %) patients in the control arm received fentanyl. ( . %) of patients in the experimental arm received fentanyl with % of the patients receiving fentanyl via the intranasal route. the addition of the mad was not associated with a statistically significant increase in analgesic administration. age and mechanism of injury were statistically more predictive of analgesia administration. conclusion: while the addition of the mucosal atomizer device as an alternative delivery method for fentanyl shows a trend towards increased analgesic administration in a prehospital pediatric population, age and mechanism of injury are more predictive in who receives analgesia. further research is necessary to investigate the effect of the mad on pediatric analgesic delivery. methods: this was a prospective study evaluating php-se before (pre) and after (post) a ppp introduction and months later ( -mo). php groups received either ppp review and education or ppp review alone. the ppp included a pain assessment tool. the se tool, developed and piloted by pediatric ems experts, uses a ranked ordinal scale ranging from 'certain i cannot do it' ( ) to 'completely certain i can do it' ( ) for items: pain assessment ( items), medication administration ( ) and dosing ( ) , and reassessment ( ). all items and an averaged composite were evaluated for three age groups (adult, child, toddler). paired sample t-tests compared post-and -mo scores to pre-ppp scores. results: of phps who completed initial surveys, phps completed -mo surveys. ( %) received education and ppp review and ( %) review only. ppp education did not affect php-se (adult p = . , child p = . , toddler p = . ). the largest se increase was in pain assessment. this increase persisted for child and toddler groups at months. the immediate increase in composite se scores for all age groups persisted for the toddler group at months. conclusion: increases in composite and pain assessment php-se occur for all age groups immediately after ppp introduction. the increase in pain assessment se persisted at months for pediatric age groups. composite se increase persisted for the toddler age group alone. background: pediatric medications administered in the prehospital setting are given infrequently and dosage may be prone to error. calculation of dose based on known weight or with use of length-based tapes occurs even less frequently and may present a challenge in terms of proper dosing. objectives: to characterize dosing errors based on weight-based calculations in pediatric patients in two similar emergency medical service (ems) systems. methods: we studied the five most commonly administered medications given to pediatric patients weighing kg or less. drugs studied were morphine, midazolam, epinephrine : , , epinephrine : , and diphenhydramine. cases from the electronic record were studied for a total of months, from january to july . each drug was administered via intravenous, intramuscular, or intranasal routes. drugs that were permitted to be titrated were excluded. an error was defined as greater than % above or below the recommended mg/kg dosage. results: out of , total patients, , were pediatric patients. had documented weights of < kg and patients were given these medications. we excluded patients for weight above the %ile or below the %ile, or if the weight documentation was missing. of the patients and doses, errors were noted in ( %; % ci %, %). midazolam was the most common drug in errors ( of doses or %; % ci %, %), followed by diphenhydramine ( / or %; % ci %, %), epinephrine ( / or %; % ci %, %), and morphine sulfate ( / or %; % ci, %, %). underdosing was noted in of ( %; % ci %, %) of errors, while excessive dosing was noted in of ( %; % ci %, %). conclusion: weight-based dosing errors in pediatric patients are common. while the clinical consequences of drug dosing errors in these patients are unknown, a considerable amount of inaccuracy occurs. strategies beyond provision of reference materials are needed to prevent pediatric medication errors and reduce the potential for adverse outcomes. drivers background: homelessness affects up to . million people a year. the homeless present more frequently to eds, their ed visits are four times more likely to occur within days of a prior ed evaluation, and they are admitted up to five times more frequently than others. we evaluated the effect of a street outreach rapid response team (sorrt) on the health care utilization of a homeless population. a nonmedical outreach staff responds to the ed and intensely case manages the patient: arranges primary care follow-up, social services, temporary housing opportunities, and drug/ alcohol rehabilitation services. objectives: we hypothesized that this program would decrease the ed visits and hospital admissions of this cohort of patients. methods: before and after study at an urban teaching hospital from june, -december, in indianapolis, indiana. upon identification of homeless status, sorrt was immediately notified. eligibility for sorrt enrollment is determined by housing and urban development homeless criteria and the outreach staff attempted to enter all such identified patients into the program. the patients' health care utilization was evaluated in the months prior to program entry as compared to the months after enrollment by prospectively collecting data and a retrospective medical record query for any unreported visits. since the data were highly skewed, we used the nonparametric signed rank test to test for paired differences between periods. results: patients met criteria but two refused participation. the -patient cohort had total ed visits ( pre and post) with a mean of . (sd . ) and median of . (range - ) ed visits in months pre-sorrt as compared to a mean of . (sd . ) and median of . ( - ) in months post-sorrt (p = . ). there were total inpatient admissions pre-intervention and post-intervention, with a mean of . (sd . ) and median of . ( . ) per patient in the pre-intervention period as compared to . (sd . ) and . ( - ) in the post-intervention period (p = . ). in the pre-sorrt period . % had at least one inpatient admission as compared to . % post-sorrt (p = . ). there were no differences in icu days or overall length of stay between the two periods. conclusion: an aggressive case management program beginning immediately with homeless status recognition in the ed has not demonstrated success in decreasing utilization in our population. methods: this was a secondary analysis of a prospective randomized trial that included consenting patients discharged with outpatient antibiotics from an urban county ed with an annual census of , . patients unable to receive text messages or voice-mails were excluded. health literacy was assessed using a validated health literacy assessment, the newest vital sign (nvs). patients were randomized to a discharge instruction modality: ) standard care, typed and verbal medication and case-specific instructions; ) standard care plus text-messaged instructions sent to the patient's cell phone; or ) standard care plus voice-mailed instructions sent to the patient's cell. patients were called at days to determine preference for instruction delivery modality. preference for discharge instruction modality was analyzed using z-tests for proportions. results: patients were included ( % female, median age , range months to years); were excluded. % had an nvs score of - , % - , and % - . among the . % of participants reached at days, % preferred a modality other than written. there was a difference in the proportion of patients who preferred discharge instructions in written plus another modality (see table) . with the exception of written plus another modality, patient preference was similar across all nvs score groups. conclusion: in this sample of urban ed patients, more than one in four patients prefer non-traditional (text message, voice-mail) modalities of discharge instruction delivery to standard care (written) modality alone. additional research is needed to evaluate the effect of instructional modality on accessibility and patient compliance. figure) . conclusion: cumulative saps ii scoring fails to predict mortality in ohca. the risk scores assigned to age, gcs, and hco independently predict mortality and combined are good mortality predictors. these findings suggest that an alternative severity of illness score should be used in post-cardiac arrest patients. future studies should determine optimal risk scores of saps ii variables in a larger cohort of ohca. objectives: to determine the extent to which cpp recovers to pre-pause levels with seconds of cpr after a -second interruption in chest compressions for ecg rhythm analysis. methods: this was a secondary analysis of prospectively collected data from an iacuc-approved protocol. fortytwo yorkshire swine (weighing - kg) were instrumented under anesthesia. vf was electrically induced. after minutes of untreated vf, cpr was initiated and a standard dose of epinephrine (sde) ( . mg/kg) was given. after . minutes of cpr to circulate the vasopressor, compressions were interrupted for seconds to analyze the ecg rhythm. this was immediately followed by seconds of cpr to restore cpp before the first rs was delivered. if the rs failed, cpr resumed and additional vasopressors (sde, and vasopressin . mg/kg) were given and the sequence repeated. the cpp was defined as aortic diastolic pressure minus right atrial diastolic pressure. the cpp values were extracted at three time points: immediately after the . minutes of cpr, following the -second pause, and immediately before defibrillation for the first two rs attempts in each animal. eighty-three sets of measurements were logged from animals. descriptive statistics were used to analyze the data. in most cities, the proportion of patients who achieve prehospital return of spontaneous circulation (rosc) is less than %. the association between time of day and ohca outcomes in the prehospital setting is unknown. objectives: we sought to determine whether rates of prehospital rosc varied by time of day. we hypothesized that night ohcas would exhibit lower rates of rosc. methods: we performed a retrospective review of cardiac arrest data from a large, urban ems system. included were all ohcas occurring in individuals > years of age from / / to / / . excluded were traumatic arrests and cases where resuscitation measures were not performed. day was defined as : am- : pm, while night was : pm- : am. we examined the association between time of day and paramedic-perceived prehospital rosc in unadjusted and adjusted analyses. variables included age, sex, race, presenting rhythm, aed application by a bystander or first responder, defibrillation, and bystander cpr performance. analyses were performed using chisquare tests and logistic regression. objectives: determine whether a smei helps to improve physician compliance with ihi bundle and reduce patient mortality in ed patients with s&s. methods: we conducted a pre-smei retrospective review of four months of ed patients with s&s to determine baseline pre-smei physician compliance and patient mortality. we designed and completed a smei attended by of ed attending physicians and of ed resuscitation residents. finally, we conducted a twenty-month post-smei prospective study of ongoing physician compliance and patient mortality in ed patients with s&s. results: in the four month pre-smei retrospective review, we identified patients with s&s, with a % physician overall compliance and mortality rate of %. the average ed physician smei multiple-choice pre-test score was %, and showed a significant improvement in the post-test score of % (p = . ). additionally, % of ed physicians were able to describe three new clinical pearls learned and % agreed that the smei would improve compliance. in the twenty months of the post-smei prospective study, we identified patients with s&s, with a % physician overall compliance, and mortality rate of %. relative physician compliance improved % (p = . ) and relative patient mortality was reduced by % (p < . ) when comparing pre-and post-smei data. conclusion: our data suggest that a smei improves overall physician compliance with the six hour goals of the ihi bundle and reduces patient mortality in ed patients with s&s. conclusion: using a population-level, longitudinal, and multi-state analysis, the rate of return visits within days is higher than previously reported, with nearly in returning back to the ed. we also provide the first estimation of health care costs for ed revisits. background: the ability of patients to accurately determine their level of urgency is important in planning strategies that divert away from eds. in fact, an understanding of patient self-triage abilities is needed to inform health policies targeting how and where patients access acute care services within the health care system. objectives: to determine the accuracy of a patient's self-assessment of urgency compared against triage nurses. methods: setting: ed patients are assigned a score by trained nurses according to the canadian emergency department triage and acuity scale (ctas). we present a cross-sectional survey of a random patient sample from urban/regional eds conducted during the winters of and . this previously validated questionnaire, based on the british healthcare commission survey, was distributed according to a modified dillman protocol. exclusion criteria consisted of: age - years, left prior to being seen/treated, died during ed visit, no contact information, presented with a privacy-sensitive case. alberta health services provided linked non-survey administrative data. results: , surveys distributed with a response rate of %. patients rated health problems as life-threatening ( %), possibly life-threatening ( %), urgent ( %), somewhat urgent ( %), or not urgent ( %). triage nurses assigned the same patients ctas scores of i (< %), ii ( %), iii ( %), iv ( %) or v ( %). patients self-rated their condition as or points less urgent than the assigned ctas score (< % of the time), points less urgent ( %), point less urgent ( %), exactly as urgent ( %), point more urgent ( %), points more urgent ( %), or or points more urgent ( %, respectively). among ctas i or ii patients, % described their problem as life-threatening/possibly life-threatening, % as urgent (risk of permanent damage), % as urgent (needed to be seen that day), and % as not urgent (wanted to be but did not need to be seen that day). conclusion: the majority of ed patients are generally able to accurately assess the acuity of their problem. encouraging patients with low-urgency conditions to self-triage to lower-acuity sources of care may relieve stress on eds. however, physicians and patients must be aware that a small minority of patients are unable to self-triage safely. when the tourniquet was released, blood spurted from the injured artery as hydrostatic pressure decayed. pressure and flow were recorded in three animals (see table) . the concept was proof-tested in a single fresh frozen human cadaver with perfusion through the femoral artery and hemorrhage from the popliteal artery. the results were qualitatively and quantitatively similar to the swine carcass model. conclusion: a perfused swine carcass can simulate exsanguinating hemorrhage for training purposes and serves as a prototype for a fresh-frozen human cadaver model. additional research and development are required before the model can be widely applied. background: in the pediatric emergency department (ped), clinicians must work together to provide safe and effective care. crisis resource management (crm) principles have been used to improve team performance in high-risk clinical settings, while simulation allows practice and feedback of these behaviors. objectives: to develop a multidisciplinary educational program in a ped using simulation-enhanced teamwork training to standardize communication and behaviors and identify latent safety threats. methods: over months a workgroup of physicians and nurses with experience in team training and simulation developed an educational program for clinical staff of a tertiary ped. goals included: create a didactic curriculum to teach the principles of crm, incorporate principles of crm into simulation-enhanced team training in-situ and center-based exercises, and utilize assessment instruments to evaluate for teamwork, completion of critical actions, and presence of latent safety threats during in-situ sim resuscitations. results: during phase i, clinicians, divided into teams, participated in -minute pre-training assessments of pals-based in-situ simulations. in phase ii, staff participated in a -hour curriculum reviewing key crm concepts, including team training exercises utilizing simulation and expert debriefing. in phase iii, staff participated in post-training minute teamwork and clinical skills assessments in the ped. in all phases, critical action checklists (cac) were tabulated by simulation educators. in-situ simulations were recorded for later review using the assessment tools. after each simulation, educators facilitated discussion of perceptions of teamwork and identification of systems issues and latent hazards. overall, in-situ simulations were conducted capturing % of the physicians and % of the nurses. cac data were collected by an observer and compared to video recordings. over significant systems issues, latent hazards, and knowledge deficits were identified. all components of the program were rated highly by % of the staff. conclusion: a workgroup of pem, simulation, and team training experts developed a multidisciplinary team training program that used in-situ and centerbased simulation and a refined crm curriculum. unique features of this program include its multidisciplinary focus, the development of a variety of assessment tools, and use of in-situ simulation for evaluation of systems issues and latent hazards. this program was tested in a ped and findings will be used to refine care and develop a sustainment program while addressing issues identified. objectives: our hypothesis is that participants trained on high-fidelity mannequins will perform better than participants trained on low-fidelity mannequins on both the acls written exam and in performance of critical actions during megacode testing. the study was performed in the context of an acls initial provider course for new pgy residents at the penn medicine clinical simulation center and involved three training arms: ) low fidelity (low-fi): torso-rhythm generator; ) mid-fidelity (mid-fi): laerdal simmanÒ turned off; and ) high-fidelity (high-fi): laerdal simmanÒ turned on. training in each arm of the study followed standard aha protocol. educational outcomes were evaluated by written scores on the acls written examination and expert rater reviews of acls megacode videos performed by trainees during the course. a sample of subjects were randomized to one of the three training arms: low-fi (n = ), mid-fi (n = ), or high-fi (n = ). results: statistical significance across the groups was determined using analysis-of-variance (anova). the three groups had similar written pre-test scores [low-fi . ( . ), mid-fi . ( . ), and high-fi . ( . )] and written post-test scores [low-fi . ( . ), mid-fi . ( . ), and high-fi . ( . )]. similarly, test improvement was not significantly different. after completion of the course, high-fi subjects were more likely to report they felt comfortable in their simulator environment (p = . ). low-fi subjects were less likely to perceive a benefit in acls training from high-fi technology (p < . ). acls instructors were not rated significantly different by the subjects using the debriefing assessment for simulation in healthcareª (dash) student version except for element , where the high-fi group subjects reported lower scores ( . vs . and . in the other groups, p = . ). objectives: we sought to determine if stress associated with the performance of a complex procedural task can be affected by level of medical training. heart rate variability (hrv) is used as a measure of autonomic balance, and therefore an indicator of the level of stress. methods: twenty-one medical students and emergency medicine residents were enrolled. participants performed airway procedures on an airway management trainer. hrv data were collected using a continuous heart rate variability monitoring system. participant hrv was monitored at baseline, during the unassisted first attempt at endotracheal intubation, during supervised practice, and then during a simulated respiratory failure clinical scenario. standard deviation of beat to beat variability (sdnn), very low frequency (vlf), total power (tp), and low frequency (lf) was analyzed to determine the effect of practice and level of training on the level of stress. a cohen's d test was used to determine differences between study groups. results: sdnn data showed that second-year residents were less stressed during all stages than were fourthyear medical students (avg d = . ). vlf data showed third-year residents exhibited less sympathetic activity than did first-year residents (avg d = ) . ). the opportunity to practice resulted in less stress for all participants. tp data showed that residents had a greater degree of control over their autonomic nervous system (ans) than did medical students (avg d = . ). lf data showed that subjects were more engaged in the task at hand as the level of training increased indicating autonomic balance (avg d = . ). conclusion: our hrv data show that stress associated with the performance of a complex procedural task is reduced by increased training. hrv may provide a quantitative measure of physiologic stress during the learning process and thus serve as a marker of when a subject is adequately trained to perform a particular task. objectives: we seek to examine whether intubation during cpr can be done as efficiently as intubation without ongoing cpr. the hypothesis is that the predictable movement of an automated chest compression device will make intubation easier than the random movement from manual cpr. methods: the project was an experimental controlled trial and took place in the emergency department at a tertiary referral center in peoria, illinois. emergency medicine residents, attendings, paramedics, and other acls trained staff were eligible for participation. in randomized order, each participant attempted intubation on a mannequin with no cpr ongoing, during cpr with a human compressor, and during cpr with an automatic chest compression device (physio control lucas ). participants could use whichever style laryngoscope they felt most comfortable with and they were timed during the three attempts. success was determined after each attempt. results: there were participants in the trial. the success rate in the control group and the automated cpr group were both % ( / ) and the success rate in the manual cpr group was % ( / ). the differences in success rates were not statistically significant (p = . and p = . ). the automated cpr group had the fastest average time ( . sec; p = . ). the mean times for intubation with manual cpr and no cpr were not statistically different ( . sec, . sec; p = . ). conclusion: the success rate of tracheal intubation with ongoing chest compression was the same as the success rate of intubation without cpr. although intubation with automatic chest compression was faster than during other scenarios, all methods were close to the second timeframe recommended by acls. based on these findings, it may not always be necessary to hold cpr to place a definitive airway; however, further studies will be needed. background: after acute myocardial infarction, vascular remodeling in the peri-infarct area is essential to provide adequate perfusion, prevent additional myocyte loss, and aid in the repair process. we have previously shown that endogenous fibroblast growth factor (fgf ) is essential to the recovery of contractile function and limitation of infarct size after cardiac ischemia-reperfusion (ir) injury. the role of fgf in vascular remodeling in this setting is currently unknown. objectives: determine the role of endogenous fgf in vascular remodeling in a clinically relevant, closed-chest model of acute myocardial infarction. methods: mice with a targeted ablation of the fgf gene (fgf knockout) and wild type controls were subjected to a closed-chest model of regional cardiac ir injury. in this model, mice were subjected to minutes of occlusion of the left anterior descending artery followed by reperfusion for either or days. immunofluorescence was performed on multiple histological sections from these hearts to visualize capillaries (endothelium, anti-cd antibody), larger vessels (venules and arterioles, antismooth muscle actin antibody), and nuclei (dapi). digital images were captured, and multiple images from each heart were measured for vessel density and vessel size. results: sham-treated fgf knockout and wild type mice show no differences in capillary or vessel density suggesting no defect in vessel formation in the absence of endogenous fgf . when subjected to closed-chest regional cardiac ir injury, fgf knockout hearts had normal capillary and vessel number and size in the peri-infarct area after day of reperfusion compared to wild type controls. however, after days, fgf knockout hearts showed significantly decreased capillary and vessel number and increased vessel size compared to wild type controls (p < . ). conclusion: these data show the necessity of endogenous fgf in vascular remodeling in the peri-infarct zone in a clinically relevant animal model of acute myocardial infarction. these findings may suggest a potential role for modulation of fgf signaling as a therapeutic intervention to optimize vascular remodeling in the repair process after myocardial infarction. the diagnosis of aortic dissections by ed physicians is rare scott m. alter, barnet eskin, john r. allegra morristown medical center, morristown, nj background: aortic dissection is a rare event. the most common symptom of dissection is chest pain, but chest pain is a frequent emergency department (ed) chief complaint and other diseases that cause chest pain, such as acute coronary syndrome and pulmonary embolism, occur much more frequently. furthermore, % of dissections are without chest pain and % are painless. for all these reasons, diagnosing dissection can be difficult for the ed physician. we wished to quantify the magnitude of this problem in a large ed database. objectives: our goal was to determine the number of patients diagnosed by ed physicians with aortic dissections compared to total ed patients and to the total number of patients with a chest pain diagnosis. methods: design: retrospective cohort. setting: suburban, urban, and rural new york and new jersey eds with annual visits between , and , . participants: consecutive patients seen by ed physicians from january , through december , . observations: we identified aortic dissections using icd- codes and chest pain diagnoses by examining all icd- codes used over the period of the study and selecting those with a non-traumatic chest pain diagnosis. we then calculated the number of total ed patients and chest pain patients for every aortic dissection diagnosed by emergency physicians. we determined % confidence intervals (cis). results: from a database of . million ed visits, we identified ( . %) aortic dissections, or one for every , ( % ci , to , ) visits. the mean age of aortic dissection patients was ± years and % were female. of the total visits there were , ( %) with a chest pain diagnosis. thus there is one aortic dissection diagnosis for every ( % ci to , ) chest pain diagnoses. conclusion: the diagnosis of aortic dissections by ed physicians is rare. an ed physician seeing , to , patients a year would diagnose an aortic dissection approximately once every to years. an aortic dissection would be diagnosed once for approximately every , ed chest pain patients. patients were excluded if they suffered a cardiac arrest, were transferred from another hospital, or if the ccl was activated for an inpatient or from ems in the field. fp ccl activation was defined as ) a patient for whom activation was cancelled in the ed and ruled out for mi or ) a patient who went to catheterization but no culprit vessel was identified and mi was excluded. ecgs for fp patients were classified using standard criteria. demographic data, cardiac biomarkers, and all relevant time intervals were collected according to an on-going quality assurance protocol. results: a total of ccl activations were reviewed, with % male, average age , and % black. there were ( %) true stemis and ( %) fp activations. there were no significant differences between the fp patients who did and did not have catheterization. for those fp patients who had a catheterization ( %), ''door to page'' and ''door to lab'' times were significantly longer than the stemi patients (see table) , but there was substantial overlap. there was no difference in sex or age, but fp patients were more likely to be black (p = . ). a total of fp patients had ecgs available for review; findings included anterior elevation with convex ( %) or concave ( %) elevation, st elevation from prior anterior ( %) or inferior ( %) mi, pericarditis ( %), presumed new lbbb ( %), early repolarization ( %), and other ( %). conclusion: false ccl activation occurred in a minority of patients, most of whom had ecg findings warranting emergent catheterization. the rate of false ccl activation appears acceptable. background: atrial fibrillation (af) is the most common cardiac arrhythmia treated in the ed, leading to high rates of hospitalization and resource utilization. dedicated atrial fibrillation clinics offer the possibility of reducing the admission burden for af patients presenting to the ed. while the referral base for these af clinics is growing, it is unclear to what extent these clinics contribute to reducing the number of ed visits and hospitalizations related to af. objectives: to compare the number of ed visits and hospitalizations among discharged ed patients with a primary diagnosis of af who followed up with an af clinic and those who did not. methods: a retrospective cohort study and medical records review including three major tertiary centres in calgary, canada. a sample of patients was taken representing patients referred to the af clinic from the calgary zone eds and compared to matched control ed patients who were referred to other providers for follow-up. the controls were matched for age and sex. inclusion criteria included patients over years of age, discharged during the index visit, and seen by the af clinic between january , and october , . exclusion criteria included non-residents and patients hospitalized during the index visit. the number of cardiovascular-related ed visits and hospitalizations was measured. all data are categorical, and were compared using chi-square tests. results: patients in the control and af clinic cohorts were similar for all baseline characteristics except for a higher proportion of first episode patients in the intervention arm. in the six months following the index ed visit, study group patients ( . %) visited an ed on occasions, and ( %) were hospitalized on occasions. of the control group, patients ( . %) visited an ed on occasions, and ( %) were hospitalized on occasions. using a chi-square test we found no significant difference in ed visits (p = . ) or hospitalizations (p = . ) between the control and af clinic cohorts. conclusion: based on our results, referral from the ed to an af clinic is not associated with a significant reduction in subsequent cardiovascular related ed visits and hospitalizations. due to the possibility of residual confounding, randomized trials should be performed to evaluate the efficacy of af clinics. reported an income of less than $ , . there were no significant associations between sex, race, marital status, education level, income, insurance status, and subsequent -and- day readmission rates. hla score was not found to be significantly related to readmission rates. the mean hla score was . (sd = . ), equivalent to less than th grade literacy, meaning these patients may not be able to read prescription labels. for each unit increase in hfkt score, the odds of being readmitted within days decreased by . (p < . ) and for - days decreased by . (p < . ). for each unit increase in scbs score, the odds of being readmitted within days decreased by . (p = . ). conclusion: health care literacy in our patient population is not associated with readmission, likely related to the low literacy rate of our study population. better hf knowledge and self-care behaviors are associated with lower readmission rates. greater emphasis should be placed on patient education and self-care behaviors regarding hf as a mechanism to decrease readmission rates. comparison of door to balloon times in patients presenting directly or transferred to a regional heart center with stemi jennifer ehlers, adam v. wurstle, luis gruberg, adam j. singer stony brook university, stony brook, ny background: based on the evidence, a door-to-balloon-time (dtbt) of less than minutes is recommended by the aha/acc for patients with stemi. in many regions, patients with stemi are transferred to a regional heart center for percutaneous coronary intervention (pci). objectives: we compared dtbt for patients presenting directly to a regional heart center with those for patients transferred from other regional hospitals. we hypothesized that dtbt would be significantly longer for transferred patients. methods: study design-retrospective medical record review. setting-academic ed at a regional heart center with an annual census of , that includes a catchment area of hospitals up to miles away. patients-patients with acute stemi identified on ed -lead ecg. measures-demographic and clinical data including time from triage to ecg, from ecg to activation of regional catheterization lab, and from initial triage to pci (dtbt , and door to intravascular balloon deployment (d b). methods: the study was performed in an inner-city academic ed between / / and / / . every patient for whom ed activation of our stemi system occurred was included. all times data from a pre-existing quality assurance database were collected prospectively. patient language was determined retrospectively by chart review. results: there were patients between / / and / / . patients ( %) were deemed too sick or unable to provide history and were excluded, leaving patients for analysis. ( %) spoke english and ( %) did not. in the non-english group, chinese was the most common language, in ( %) background: syncope is a common, potentially highrisk ed presentation. hospitalization for syncope, although common, is rarely of benefit. no populationbased study has examined disparities in regional admission practices for syncope care in the ed. moreover, there are no population-based studies reporting prognostic factors for -and -day readmission of syncope. objectives: ) to identify factors associated with admission as well as prognostic factors for -and -day readmission to these hospitals; ) to evaluate variability in syncope admission practices across different sizes and types of hospitals. methods: design -multi-center retrospective cohort study using ed administrative data from albertan eds. participants/subjects -patients > years of age with syncope (icd : r ) as a primary or secondary diagnosis from to june . readmission was defined as return visits to the ed or admission < days or - days after the index visit (including against medical advice and left without being seen during the index visit). outcomes -factors associated with hospital admission at index presentation, and readmission following ed discharge, adjusted using multivariable logistic regression. results: overall, syncope visits occurred over years. increased age, increased length of stay (los), performance of cxr, transport by ground ambulance, and treatment at a low-volume hospital (non-teaching or non-large urban) were independently associated with index hospitalization. these same factors, as well as hospital admission itself, were associated with -day readmission. additionally, increased age, increased los, performance of a head ct, treatment at a low-volume hospital, hospital admission, and female sex were independently associated with - day readmission. arrival by ground ambulance was associated with a decreased likelihood of both -and - day readmission. conclusion: our data identify variations in practice as well as factors associated with hospitalization and readmission for syncope. the disparity in admission and readmission rates between centers may highlight a gap in quality of care or reflect inappropriate use of resources. further research to compare patient out-comes and quality of patient care among urban and non-urban centers is needed. background: change in dyspnea severity (ds) is a frequently used outcome measure in trials of acute heart failure (ahf). however, there is limited information concerning its validity. objectives: to assess the predictive validity of change in dyspnea severity. methods: this was a secondary analysis of a prospective observational study of a convenience sample of ahf patients presenting with dyspnea to the ed of an academic tertiary referral center with a mixed urban/ suburban catchment area. patients were enrolled weekdays, june through december . patients assessed their ds using a -cm visual analog scale at three times: the start of ed treatment (baseline) as well as at and hours after starting ed treatment. the difference between baseline and hour was the -hour ds change. the difference between baseline and hours was the -hour ds change. two clinical outcome measures were obtained: ) the number of days hospitalized or dead within days of the index visit ( -day outcome), and ) the number of days hospitalized or dead within days of the index visit ( -day outcome). results: data on patients were analyzed. the median -day outcome variable was days with an interquartile range (iqr) of to . the median -day outcome variable was days (iqr to . ). the median -hour ds change was . cm (iqr . to . ). the median -hour ds change was . cm (iqr . to . ). the -day and -day mortality rates were % and % respectively. the spearman rank correlations and % confidence intervals are presented in the table below. conclusion: while the point estimates for the correlations were below . , the % ci for two of the correlations extended above . . these pilot data support change in ds as a valid outcome measure for ahf when measured over hours. a larger prospective study is needed to obtain a more accurate point estimate of the correlations. background: the majority of volume-quality research has focused on surgical outcomes in the inpatient setting; very few studies have examined the effect of emergency department (ed) case volume on patient outcomes. objectives: to determine whether ed case volume of acute heart failure (ahf) is associated with short-term patient outcomes. methods: we analyzed the nationwide emergency department sample (neds) and nationwide inpatient sample (nis), the largest, all-payer, ed and inpatient databases in the us. ed visits for ahf were identified with a principal diagnosis of icd- -cm code .xx. eds were categorized into quartiles by ed case volume of ahf. the outcome measures were early inpatient mortality (within the first days of admission), overall inpatient mortality, and hospital length of stay (los). results: there were an estimated , visits for ahf from approximately , eds in ; % were hospitalized. of these, the overall inpatient mortality rate was . %, and the median hospital los was days. early inpatient mortality was lower in the highest-volume eds, compared with the lowest-volume eds ( . % vs. . %; p < . ). similar patterns were observed for overall inpatient mortality ( . % vs. . %; p < . ). in a multivariable analysis adjusting for patient and hospital characteristics, early inpatient mortality remained lower in patients admitted through the highest-volume eds (adjusted odds ratios [or], . ; % confidence interval [ci], . - . ), as compared with the lowest-volume eds. there was a trend towards lower overall inpatient mortality in the highest-volume eds; however, this was not statistically significant (adjusted or, . ; %ci, . - . ). by contrast, using the nis data including various sources of admissions, a higher case volume of inpatient ahf patients predicted lower overall inpatient mortality (adjusted or, . ; %ci, . - . ). the hospital los in patients admitted through the highest-volume eds was slightly longer (adjusted difference, . day; %ci, . - . ), compared with the lowest-volume eds. conclusion: ed patients who are hospitalized for ahf have an approximately % reduced early inpatient mortality if they were admitted from an ed that handles a large volume of ahf cases. the ''practice-makesperfect'' concept may hold in emergency management of ahf. emergency department disposition and charges for heart failure: regional variability alan b. storrow, cathy a. jenkins, sean p. collins, karen p. miller, candace mcnaughton, naftilan allen, benjamin s. heavrin vanderbilt university, nashville, tn background: high inpatient admission rates for ed patients with acute heart failure are felt partially responsible for the large economic burden of this most costly cardiovascular problem. objectives: we examined regional variability in ed disposition decisions and regional variability in total dollars spent on ed services for admitted patients with primary heart failure. methods: the nationwide emergency department sample (neds) was used to perform a retrospective, cohort analysis of patients with heart failure (icd- code of .x) listed as the primary ed diagnosis. demographics and disposition percentages (with se) were calculated for the overall sample and by region: northeast, south, midwest, and west. to account for the sample design and to obtain national and regional estimates, a weighted analysis was conducted. results: there were , weighted ed visits with heart failure listed as the primary diagnosis. overall, over eighty percent were admitted (see table) . fifty-two percent of these patients were female; mean age was . years (se . ). hospitalization rates were higher in the northeast ( . %) and south ( . %) than in the midwest ( . %) and west ( . %). total monies spent on ed services were highest in the south ($ , , ) followed by the northeast ($ , , ), west ($ , , ) and midwest ($ , , ) . conclusion: this large retrospective ed cohort suggests a very high national admission rate with significant regional variation in both disposition decisions as well as total monies spent on ed services for patients with a primary diagnosis of heart failure. examining these estimates and variations further may provide strategies to reduce the economic burden of heart failure. background: workplace violence in health care settings is a frequent occurrence. gunfire in hospitals is of particular concern. however, information regarding such workplace violence is limited. accordingly, we characterized u.s. hospital-based shootings from - . objectives: to determine extent of hospital-based shootings in the u.s. and involvement of emergency departments. methods: using lexisnexis, google, netscape, pub-med, and sciencedirect, we searched reports for acute care hospital shooting events from january through december , and those with at least one injured victim were analyzed. results: we identified hospital-related shootings ( inside the hospital, on hospital grounds), in states, with victims, of whom were perpetrators. in comparison to external shootings, shootings within the hospital have not increased over time (see figure) . perpetrators were from all age groups, including the elderly. most of the events involved a determined shooter: grudge ( %), suicide ( %), ''euthanizing'' an ill relative ( %), and prisoner escape ( %). ambient societal violence ( %) and mentally unstable patients ( %) were comparatively infrequent. the most common injured was the perpetrator ( %). hospital employees comprised only % of victims; physician ( %) and nurse ( %) victims were relatively infrequent. the emergency department was the most common site ( %), followed by patient rooms ( %) and the parking lot ( %). in % of shootings within hospitals, the weapon was a security officer's gun grabbed by the perpetrator. ''grudge'' motive was the only factor determinative of hospital staff victims (or = . , % ci . - . ). conclusion: although hospital-based shootings are relatively rare, emergency departments are the most likely site. the unpredictable nature of this type of event represents a significant challenge to hospital security and deterrence practices, as most perpetrators proved determined, and many hospital shootings occur outside the building. impact of emergency physician board certification on patient perceptions of ed care quality albert g. sledge iv , carl a. germann , tania d. strout , john southall maine medical center, portland, me; mercy hospital, portland, me background: the hospital value-based purchasing program mandated by the affordable care act is the latest example of how patients' perceptions of care will affect the future practice environment of all physicians. the type of training of medical providers in the emergency department (ed) is one possible factor affecting patient perceptions of care. a unique situation in a maine community ed led to the rapid transition from non-emergency medicine (em) residency trained physicians to all em residency trained and american board of emergency medicine (abem) certified providers. objectives: the purpose of this study was to evaluate the effect of the implementation of an all em-trained, abem-certified physician staff on patient perceptions of the quality of care they received in the ed. methods: we retrospectively evaluated press ganey data from surveys returned by patients receiving treatment in a single, rural ed. survey items addressed patient's perceptions of physician courtesy, time spent listening, concern for patient comfort, and informativeness. additional items evaluated overall perceptions of care and the likelihood that the respondent would recommend the ed to another. data were compared for the three years prior to and following implementation of the all trained, certified staff. we used the independent samples t-test to compare mean responses during the two time periods. bonferroni's correction was applied to adjust for multiple comparisons. results: during the study period, , patients provided surveys for analysis: , during the pre-certification phase and , during the post-certification phase. across all six survey items, mean responses increased following transition to the board-certified staff. these improvements were noted to be statistically significant in each case: courtesy p < . , time listening p < . , concern for comfort p < . , informativeness p < . , overall perception of care p < . , and likelihood to recommend p < . . conclusion: data from this community ed suggest that transition from a non-residency trained, abem certified staff to a fully trained and certified model has important implications for patient's perceptions of the care they receive. we observed significant improvement in rating scores provided by patients across all physicianoriented and general ed measures. background: transfer of care from the ed to the inpatient floor is a critical transition when miscommunication places patients at risk. the optimal form and content of handoff between providers has not been defined. in july , ed-to-floor signout for all admissions to the medicine and cardiology floors was changed at our urban, academic, tertiary care hospital. previously, signout was via an unstructured telephone conversation between ed resident and admitting housestaff. the new signout utilizes a web-based ed patient tracking system and includes: ) a templated description of ed course is completed by the ed resident; ) when a bed is assigned, an automated page is sent to the admitting housestaff; ) ed clinical information, including imaging, labs, medications, and nursing interventions (figure) is reviewed by admitting housestaff; ) if housestaff has specific questions about ed care, a telephone conversation between the ed resident and housestaff occurs; ) if there are no specific questions, it is indicated electronically and the patient is transferred to the floor. objectives: to describe the effects on patient safety (floor-to-icu transfer in hours) and ed throughput (ed length of stay (los) and time from bed assignment to ed departure) resulting from a change to an electronic, discussion-optional handoff system. conclusion: transition to a system in which signout of admitted patients is accomplished by accepting housestaff review of ed clinical information supplemented by verbal discussion when needed resulted in no significant change in rate of floor-to-icu transfer or ed los and reduced time from bed assignment to ed departure. background: emergency physicians may be biased against patients presenting with nonspecific complaints or those requiring more extensive work-ups. this may result in patients being seen less quickly than those with more straightforward presentations, despite equal triage scores or potential for more dangerous conditions. objectives: the goal of our study was to ascertain which patients, if any, were seen more quickly in the ed based on chief complaint. methods: a retrospective report was generated from the emr for all moderate acuity (esi ) adult patients who visited the ed from january through december at a large urban teaching hospital. the most common complaints were: abdominal pain, alcohol intoxication, back pain, chest pain, cough, dyspnea, dizziness, fall, fever, flank pain, headache, infection, pain (nonspecific), psychiatric evaluation, ''sent by md,'' vaginal bleeding, vomiting, and weakness. non-parametric independent sample tests assessed median time to be seen (ttbs) by a physician for each complaint. differences in the ttbs between genders and based on age were also calculated. chi-square testing compared percentages of patients in the ed per hour to assess for differences in the distribution of arrival times. results: we obtained data from , patients. patients with a chief complaint of weakness and dizziness waited the longest with a median time of minutes and patients with flank pain waited the shortest with minutes (p < . ) ( figure ). overall, males waited minutes and females waited minutes (p < . ). stratifying by gender and age, younger females between the ages of - waited significantly longer times when presenting with a chief complaint of abdominal pain (p < . ), chest pain (p < . ), or flank pain (p < . ) as compared to males in the same age group ( figure ). there was no difference in the distribution of arrival times for these complaints. conclusion: while the absolute time differences are not large, there is a significant bias toward seeing young male patients more quickly than women or older males despite the lower likelihood of dangerous conditions. triage systems should perhaps take age and gender better into account. patients might benefit from efforts to educate em physicians on the delays and potential quality issues associated with this bias in an attempt to move toward more egalitarian patient selection. background: detailed analysis of emergency department (ed) event data identified the time from completion of emergency physician evaluation (doc done) to the time patients leave the ed as a significant contributor to ed length of stay (los) and boarding at our institution. process flow mapping identified the time from doc done to the time inpatient beds were ordered (bo) as an interval amendable to specific process improvements. objectives: the purpose of this study was to evaluate the effect of ed holding orders for stable adult . ( . - . ) . ( . - . ) . ( . - . ) . ( . - . ) . ( . - . ) . ( . - . ) inpatient medicine (aim) patients on: a) the time to bo and b) ed los. methods: a prospective, observational design was used to evaluate the study questions. data regarding the time to bo and los outcomes were collected before and after implementation of the ed holding orders program. the intervention targeted stable aim patients being admitted to hospitalist, internal medicine, and family medicine services. ed holding orders were placed following the admission discussion with the accepting service and special attention was paid to proper bed type, completion of the emergent work-up and the expected immediate course of the patient's hospital stay. holding orders were of limited duration and expired hours after arrival to the inpatient unit. results: during the -month study period, patients were eligible for the ed holding orders intervention; ( . %) were cared for using the standard adult medicine order set and ( . %) received the intervention. the median time from doc done to bo was significantly shorter for patients in the ed holding orders group, min (iqr , ) vs. min (iqr , ) for the standard adult medicine group, p < . . similarly, the median ed los was significantly shorter for those in the ed holding orders group, min (iqr , ) vs. min (iqr , ) for the standard adult medicine group, p < . . no lapses in patient care were reported in the intervention group. conclusion: in this cohort of ed patients being admitted to an aim service, placing ed holding orders rather than waiting for a traditional inpatient team evaluation and set of admission orders significantly reduced the time from the completion of the ed workup to placement of a bo. as a result, ed los was also significantly shortened. while overall utilization of the intervention was low, it improved with each month. emergency department interruptions in the age of electronic health records matthew albrecht, john shabosky, jonathan de la cruz southern illinois university school of medicine, springfield, il background: interruptions of clinical care in the emergency department (ed) have been correlated with increased medical errors and decreased patient satisfaction. studies have also shown that most interruptions happen during physician documentation. with the advent of the electronic health record and computerized documentation, ed physicians now spend much of their clinical time in front of computers and are more susceptible to interruptions. voice recognition dictation adjuncts to computerized charting boast increased provider efficiency; however, little is known about how data input of computerized documentation affects physician interruptions. objectives: we present here observational interruptions data comparing two separate ed sites, one that uses computerized charting by conventional techniques and one assisted by voice recognition dictation technology. methods: a prospective observational quality initiative was conducted at two teaching hospital eds located less than mile from each other. one site primarily uses conventional computerized charting while the other uses voice recognition dictation computerized charting. four trained observers followed ed physicians for minutes during shifts. the tasks each ed physician performed were noted and logged in second intervals. tasks listed were selected from a predetermined standardized list presented at observer training. tasks were also noted as either completed or placed in queue after a change in task occurred. a total of minutes were logged. interruptions were noted when a change in task occurred with the previous task being placed in queue. data were then compared between sites. results: ed physicians averaged . interruptions/ hour with conventional computerized charting compared to . interruptions/hour with assisted voice recognition dictation (p = . ). conclusion: computerized charting assisted with voice recognition dictation significantly decreased total per hour interruptions when compared to conventional techniques. charting with voice recognition dictation has the potential to decrease interruptions in the ed allowing for more efficient workflow and improved patient care. background: using robot assistants in health care is an emerging strategy to improve efficiency and quality of care while optimizing the use of human work hours. robot prototypes capable of performing vital signs and assisting with ed triage are under development. however, ed users' attitudes toward robot assistants are not well studied. understanding of these attitudes is essential to design user-friendly robots and to prepare eds for the implementation of robot assistants. objectives: to evaluate the attitudes of ed patients and their accompanying family and friends toward the potential use of robot assistants in the ed. methods: we surveyed a convenience sample of adult ed patients and their accompanying adult family members and friends at a single, university-affiliated ed, / / - / / . the survey consisted of eight items from the negative attitudes towards robots scale (normura et al.) modified to address robot use in the ed. response options included a -point likert scale. a summary score was calculated by summing the responses for all items, with a potential range of (completely negative attitude) to (completely positive attitude). research assistants gave the written surveys to subjects during their ed visit. internal consistency was assessed using cronbach's alpha. bivariate analyses were performed to evaluate the association between the summary score and the following variables: participant type (patient or visitor), sex, race, time of day, and day of week. results: of potential subjects approached, ( %) completed the survey. participants were % patients, % family members or friends, % women, % white, and had a median age of . years (iqr - ). cronbach's alpha was . . the mean summary score was . (sd = . ), indicating subjects were between ''occasionally'' and ''sometimes'' comfortable with the idea of ed robot assistants (see table) . men were more positive toward robot use than women (summary score: . vs . ; p = . ). no differences in the summary score were detected based on participant type, race, time of day, or day of week. conclusion: ed users reported significant apprehension about the potential use of robot assistants in the ed. future research is needed to explore how robot designs and strategies to implement ed robots can help alleviate this apprehension. background: emergency department cardioversion (edc) of recent-onset atrial fibrillation or flutter (af) patients is an increasingly common management approach to this arrhythmia. patients who qualify for edc generally have few co-morbidities and are often discharged directly from the ed. this results in a shift towards a sicker population of patients admitted to the hospital with this diagnosis. objectives: to determine whether hospital charges and length of stay (los) profiles are affected by emergency department discharge of af patients. methods: patients receiving treatment at an urban teaching community hospital with a primary diagnosis of atrial fibrillation or flutter were identified through the hospital's billing data base. information collected on each patient included date of service, patient status, length of stay, and total charges. patient status was categorized as inpatient (admitted to the hospital), observation (transferred from the ed to an inpatient bed but placed in an observation status), or ed (discharged directly from the ed). the hospital billing system automatically defaults to a length of stay of for observation patients. ed patients were assigned a length of stay of . total hospital charges and mean los were determined for two different models: a standard model (sm) in which patients discharged from the ed were excluded from hospital statistics, and an inclusive model (im) in which discharged ed patients were included in the hospital statistics. statistical analysis was through anova. results: a total of patients were evaluated for af over an -month period. of these, ( %) were admitted, ( %) were placed in observation status, and ( %) were discharged from the ed. hospital charges and los in days are summarized in the table. all differences were statistically significant at (p < . ). conclusion: emergency department management can lead to a population of af patients discharged directly from the ed. exclusion of these patients from hospital statistics skews performance profiles effectively punishing institutions for progressive care. background: recent health care reform has placed an emphasis on the electronic health record (ehr). with the advent of the ehr it is common to see ed providers spending more time in front of computers documenting and away from patients. finding strategies to decrease provider interaction with computers and increase time with patients may lead to improved patient outcomes and satisfaction. computerized charting adjuncts, such as voice recognition software, have been marketed as ways to improve provider efficiency and patient contact. objectives: we present here observational data comparing two separate ed sites, one where computerized charting is done by conventional techniques and one that is assisted with voice recognition dictation, and their effects on physican charting and patient contact. methods: a prospective observational quality initiative was conducted at two teaching hospitals located less than mile from each other. one site primarily uses conventional computerized charting while the other uses voice recognition dictation. four trained quality assistants observed ed physicians for minutes during shifts. the tasks each physician performed were noted and logged in second intervals. tasks listed were identified from a predetermined standardized list presented at observer training. a total of minutes were logged. time allocated to charting and that allocated to direct patient care were then compared between sites. results: ed physicians spent . % of their time charting using conventional techniques vs . % using voice recognition dictation (p = . ). time allocated to direct patient care was found to be . % with conventional charting vs . % using dictation (p = ). in total, ed physicians using conventional charting techniques spent / minutes charting. ed physicians using voice recognition dictation spent / minutes dictating and an additional . / minutes reviewing or correcting their dictations. the use of voice recognition assisted dictation rather than conventional techniques did not significantly change the amount of time physicians spent charting or with direct patient care. although voice recognition dictation decreased initial input time of documenting data, a considerable amount of time was required to review and correct these dictations. objectives: for our primary objective, we studied whether emergency department triage temperatures detected fever adequately when compared to a rectal temperature. as secondary objectives, we examined the temperature differences when a rectal temperature was taken within an hour of non-invasive temperature, temperature site (oral, axillary, temporal), and also examined the patients that were initially afebrile but were found to be febrile by rectal temperature. methods: we performed an electronic chart review at our inner city, academic emergency department with an annual census of , patients. we identified all patients over the age of who received a non-invasive triage temperature and a subsequent rectal temperature while in the ed from january through february . specific data elements included many aspects of the patient's medical record (e.g. subject demographics, temperature, and source). we analyzed our data with standard descriptive statistics, t-tests for continuous variables, and pearson chi-square tests for proportions. results: a total of , patients met our inclusion criteria. the mean difference in temperatures between the initial temperature and the rectal temperature was . °f, with . % having higher rectal temperatures ‡ °f, and . % having higher rectal temperatures ‡ °f. the mean temperature difference among the , patients who an initial noninvasive temperature and a rectal temperature within one hour was . °f. the mean difference among patients that received oral, axillary, and temporal temperatures was . °f, . °f, and . °f respectively. approximately one in five patients ( . %) were initially afebrile and found to be febrile by rectal temperature, with an average temperature difference of . °f. these patients had a higher rate of admission, and were more likely to be admitted to the intensive care unit. conclusion: there are significant differences between rectal temperatures and non-invasive triage temperatures in this emergency department cohort. in almost one in five patients, fever was missed by triage temperature. background: pediatric emergency department (ped) overcrowding has become a national crisis, and has resulted in delays in treatment, and patients leaving without being seen. increased wait times have also been associated with decreased patient satisfaction. optimizing ped throughput is one means by which to handle the increased demands for services. various strategies have been proposed to increase efficiency and reduce length of stay (los). objectives: to measure the effect of direct bedding, bedside registration, and patient pooling on ped wait times, length of stay, and patient satisfaction. methods: data were extracted from a computerized ed tracking system in an urban tertiary care ped. comparisons were made between metrics for ( , patients) and the months following process change ( , patients). during , patients were triaged by one or two nurses, registered, and then sent either to a -bed ped or a physically separate -bed fast-track unit, where they were seen by a physician. following process change, patients were brought directly to a bed in the -bed ped, triaged and registered, then seen by a physician. the fast-track unit was only utilized to accommodate patient surges. results: anticipating improved efficiencies, attending physician coverage was decreased by %. after instituting process changes, improvements were noted immediately. although daily patient volume increased by %, median time to be seen by a physician decreased by %. additionally, median los for discharged patients decreased by %, and median time until the decisionto-admit decreased by %. press-ganey satisfaction scores during this time increased by greater than mean score points, which was reported to be a statistically significant increase. conclusion: direct bedding, bedside registration, and patient pooling were simple to implement process changes. these changes resulted in more efficient ped throughput, as evidenced by decreased times to be seen by a physician, los for discharged patients, and time until decision-to-admit. additionally, patient satisfaction scores improved, despite decreased attending physician coverage and a % decrease in room utilization. ) . during period , the ou was managed by the internal medicine department and staffed by primary care physicians and physician assistants. during periods and , the ou was managed and staffed by em physicians. data collected included ou patient volume, length of stay (los) for discharged and admitted patients, admission rates, and -day readmission rates for discharged patients. cost data collected included direct, indirect, and total cost per patient encounter. data were compared using chi-square and anova analysis followed by multiple pairwise comparisons using the bonferroni method of p-value adjustment. results: see table. the ou patient volume and percent of ed volume was greater in period compared to periods and . length of stay, admission rates, -day readmission rates, and costs were greater in period compared to periods and . conclusion: em physicians provide more cost-effective care for patients in this large ou compared to non-em physicians, resulting in shorter los for admitted and discharged patients, greater rates of patients discharged, and less -day readmission rates for discharged patients. this is not affected by an increase in ou volume and shows a trend towards improvement. background: emergency department (ed) crowding continues to be a problem, and new intake models may represent part of the solution. however, little data exist on the sustainability and long-term effects of physician triage and screening on standard ed performance metrics, as most studies are short-term. objectives: we examined the hypothesis that a physician screening program (start) sustainably improves standard ed performance metrics including patient length of stay (los) and patients who left without completing assessment (lwca). we also investigated the number of patients treated and dispositioned by start without using a monitored bed and the median patient door-to-room time. methods: design and setting: this study is a retrospective before-and-after analysis of start in a level i tertiary care urban academic medical center with approximately , annual patient visits. all adult patients from december until november are included, though only a subset was seen in start. start began at our institution in december . observations: our outcome measures were length of stay for ed patients, lwca rates, patients treated and dispositioned by start without using a monitored bed, and door-to-room time. statistics: simple descriptive statistics were used. p-values for los were calculated with wilcoxon test and p-value for lwca was calculated with chi-square. results: table shows median length of stay for ed patients was reduced by minutes/patient (p-value < . ) when comparing the most recent year to the year before start. patients who lwca were reduced from . % to . % (p-value < . ) during the same time period. we also found that in the first half-year of start, % of patients screened in the ed were treated and dispositioned without using a monitored bed and by the end of year , this number had grown to %. median door-to-room time decreased from . minutes to . minutes over the same period of time. conclusion: a start system can provide sustained improvements in ed performance metrics, including a significant reduction in ed los, lwca rate, and doorto-room time. additionally, start can decrease the need for monitored ed beds and thus increase ed capacity. . labs were obtained in %, ct in %, us in %, and consultation in %. % of the cohort was admitted to the hospital. the most commonly utilized source of translation was a layman ( %). a professional translator was used in % and translation service (language line, marty) in %. the examiner was fluent in the patient's language in %. both the patient and examiner were able to maintain basic communication in %. there were patients in the professional/ fluent translation group and patients in the lay translation group. there was no difference in ed los between groups vs min; p = . . there was no difference in the frequency of lab tests, computerized tomography, ultrasound, consultations, or hospital admission. frequencies did not differ by sex or age. conclusion: translation method was not associated with a difference in overall ed los, ancillary test use, or specialist consultation in spanish-speaking patients presenting to the ed for abdominal pain. emergency department patients on warfarin -how often is the visit due to the medication? jim killeen, edward castillo, theodore chan, gary vilke ucsd medical center, san diego, ca background: warfarin has important therapeutic value for many patients, but has been associated with signi-ficant bleeding complications, hypersensitivity reactions, and drug-drug interactions, which can result in patients seeking care in the emergency department (ed). objectives: to determine how often ed patients on warfarin present for care as a result of the medication itself. methods: a multi-center prospective survey study in two academic eds over months. patients who presented to the ed taking warfarin were identified, and ed providers were prospectively queried at the time of disposition regarding whether the visit was the result of a complication or side effect associated with warfarin. data were also collected on patient demographics, chief complaint, triage acuity, vital signs, disposition, ed evaluation time, and length of stay (los). patients identified with a warfarin-related cause for their ed visit were compared with those who were not. statistical analysis was performed using descriptive statistics. results: during the study period, , patients were cared for by ed staff, of whom were identified as taking warfarin as part of their medication regimen. of these, providers identified . % ( patients) who presented with a warfarin-related complication as their primary reason for the ed visit. . % ( ) each hours of daily boarding is associated with a drop of . raw score points in both pg metrics. these seemingly small drops in raw scores translate into major changes in rankings on press ganey national percentile scales (a difference of as much as percentile points). our institution commonly has hundreds of hours of daily boarding. it is possible that patient-level measurements of boarding impact would show stronger correlation with individual satisfaction scores, as opposed to the daily aggregate measures we describe here. our research suggests that reducing the burden of boarding on eds will improve patient satisfaction. background: prolonged emergency department (ed) boarding is a key contributor to ed crowding. the effect of output interventions (moving boarders out of the ed into an intermediate area prior to admission or adding additional capacity to an observation unit) has not been well studied. objectives: we studied the effect of a combined observation-transition (ot) unit, consisting of observation beds and an interim holding area for boarding ed patients, on the length of stay (los) for admitted patients, as well as secondary outcomes such as los for discharged patients, and left without being seen rates. methods: we conducted a retrospective review ( months pre-, months post-design) of an ot unit at an urban teaching ed with , annual visits (study ed). we compared outcomes to a nearby communitybased ed with , annual visits in the same health system (control ed) where no capacity interventions were performed. the ot had beds, full monitoring capacity, and was staffed hours per day. the number of beds allocated to transition and observation patients fluctuated throughout the course of the intervention, based on patient demands. all analyses were conducted at the level of the ed-day. wilcoxon rank-sum and analysis of covariance tests were used for comparisons; continuous variables were summarized with medians. results: in unadjusted analyses, median daily los of admitted patients at the study ed was minutes lower in the months after the ot opened, . to . hours (p < . ). control site daily los for admitted patients increased minutes from . to . hours (p < . ). results were similar after adjusting for other covariates (day of week, ed volume, and triage level). los of discharged patients at study ed decreased by minutes, from . hours to . hours (p < . ), while the control ed saw no significant changes in discharged patient los ( . hours to . hours, p = . ). left without being seen rates did not decrease at either site. conclusion: opening an ot unit was associated with a -minute reduction in average daily ed los for admitted patients and discharged patients in the study ed. given the large expense of opening an ot, future studies should compare capacity-dependent (e.g., ot) vs. capacity-independent (e.g, organizational) interventions to reduce ed crowding. fran balamuth, katie hayes, cynthia mollen, monika goyal children's hospital of philadelphia, philadelphia, pa background: lower abdominal pain and genitourinary problems are common chief complaints in adolescent females presenting to emergency departments. pelvic inflammatory disease (pid) is a potentially severe complication of lower genital tract infections, which involves inflammation of the female upper genital tract secondary to ascending stis. pid has been associated with severe sequelae including infertility, ectopic pregnancy, and chronic pelvic pain. we describe the prevalence and microbial patterns of pid in a cohort of adolescent females presenting to an urban emergency department with abdominal or genitourinary complaints. objectives: to describe the prevalence and microbial patterns of pid in a cohort of adolescent patients presenting to an ed with lower abdominal or genitourinary complaints. methods: this is a secondary analysis of a prospective study of females ages - years presenting to a pediatric ed with lower abdominal or genitourinary complaints. diagnosis of pid was per cdc guidelines. patients underwent chlamydia trachomatis (ct) and neisseria gonorrhea (gc) testing via urine aptima combo assay and trichomonas vaginalis (tv) testing using the vaginal osom trichomonas rapid test. descriptive statistics were performed using stata . . results: the prevalence of pid in this cohort of patients was . % ( % ci . %, . %), . % ( % ci . %, . %) of whom had positive sexually transmitted infection (sti) testing: % ( % ci . %, . %) with ct, . % ( % ci . , . %) with gc, and . % ( % ci . %, . %) with tv. . % ( % ci . , . %) of patients diagnosed with pid received antibiotics consistent with cdc recommendations. patients with lower abdominal pain as their chief complaint were more likely to have pid than patients with genitourinary complaints (or . , % ci . , . ). conclusion: a substantial number of adolescent females presenting to the emergency department with lower abdominal pain were diagnosed with pid, with microbial patterns similar to those previously reported in largely adult, outpatient samples. furthermore, appropriate treatment for pid was observed in the majority of patients diagnosed with pid. impact background: in resource-poor settings, maternal health care facilities are often underutilized, contributing to high maternal mortality. the effect of ultrasound in these settings on patients, health care providers, and communities is poorly understood. objectives: the purpose of this study was to assess the effect of the introduction of maternal ultrasound in a population not previously exposed to this intervention. methods: an ngo-led program trained nurses at four remote clinics outside koutiala, mali, who performed , maternal ultrasound scans over three years. our researchers conducted an independent assessment of this program, which involved log book review, sonographer skill assessment, referral follow-up, semi-structured interviews of clinic staff and patients, and focus groups of community members in surrounding villages. analyses included the effect of ultrasound on clinic function, job satisfaction, community utilization of prenatal care and maternity services, alterations in clinical decision making, sonographer skill, and referral frequency. we used qrs nvivo to organize qualitative findings, code data, and identify emergent themes, and graphpad software (la jolla, ca) and microsoft excel to tabulate quantitative findings results: -findings that triggered changes in clinical practice were noted in . % of ultrasounds, with a . % referral rate to comprehensive maternity care facilities. -skill retention and job satisfaction for ultrasound providers was high. -the number of patients coming for antenatal care increased, after introduction of ultrasound, in an area where the birth rate has been decreasing. -over time, women traveled from farther distances to access ultrasound and participate in antenatal care. -very high acceptance among staff, patients and community members. -ultrasound was perceived as most useful for finding fetal position, sex, due date, and well-being. -improved confidence in diagnosis and treatment plan for all cohorts. -improved compliance with referral recommendations. -no evidence of gender selection motivation for ultrasound use. conclusion: use of maternal ultrasound in rural and resource-limited settings draws women to an initial antenatal care visit, increases referral, and improves job satisfaction among health care workers. methods: a retrospective database analysis was conducted using the electronic medical record from a single, large academic hospital. ed patients who received a billing diagnosis of ''nausea and vomiting of pregnancy'' or ''hyperemesis gravidarum'' between / / and / / were selected. a manual chart review was conducted with demographic and treatment variables collected. statistical significance was determined using multiple regression analysis for a primary outcome of return visit to the emergency department for nausea and vomiting of pregnancy. results: patients were identified. the mean age was . years (sd± . ), mean gravidity . (sd± . ), and mean gestational age . weeks (sd± . ). the average length of ed evaluation was min (sd± ). of the patients, ( . %) had a return ed visit for nausea and vomiting of pregnancy, ( %) were admitted to the hospital, and ( %) were admitted to the ed observation protocol. multiple regression analysis showed that the presence of medical co-morbidity (p = . ), patient gravditity (p = . ), gestational age (p = . ), and admission to the hospital (p = . ) had small but significant effects on the primary outcome (return visits to the emergency department). no other variables were found to be predictive of return visits to the ed including admission to the ed observation unit or factors classically thought to be associated with severe forms of nausea and vomiting in pregnancy including ketonuria, electrolyte abnormalities, or vital sign abnormalities. conclusion: nausea and vomiting in pregnancy has a high rate of return ed visits that can be predicted by young patient age, low patient gravidity, early gestational age, and the presence of other comorbidities. these patients may benefit from obstetric consultation and/or optimization of symptom management after discharge in order to prevent recurrent utilization of the ed. prevalence conclusion: there is a high prevalence of ht in adult sa victims. although our study design and data do not allow us to make any inferences regarding causation, this first report of ht ed prevalence suggests the opportunity to clarify this relationship and the potential opportunity to intervene. background: sexually transmitted infections (sti) are a significant public health problem. because of the risks associated with stis including pid, ectopic pregnancy, and infertility the cdc recommends aggressive treatment with antibiotics in any patient with a suspected sti. objectives: to determine the rates of positive gonorrhea and chlamydia (g/c) screening and rates of empiric antibiotic use among patients of an urban academic ed with > , visits in boston, ma. methods: a retrospective study of all patients who had g/c cultures in the ed over months. chi-square was used in data analysis. sensitivity and specificity were also calculated. results: a positive rate of / ( . %) was seen for gonorrhea and / ( . %) for chlamydia. females had positive rates of / ( . %) and / ( . %) respectively. males had higher rates of / ( . %) (p =< . ) and / ( . %) (p = . ). patients with g/c sent received an alternative diagnosis, the most common being uti ( ), ovarian pathology ( ), vaginal bleeding ( ), and vaginal candidiasis ( ); were excluded. this left without definitive diagnosis. of these, . % ( / ) of females were treated empirically with antibiotics for g/c, and a greater percentage of males ( %, / ) were treated empirically (p < . ). of those empirically treated, / ( . %) had negative cultures. meanwhile / ( . %) who ultimately had positive cultures were not treated with antibiotics during their ed stay. sensitivity of the provider to predict presence of disease based on decision to give empiric antibiotics was . (ci . - . ). specificity was . (ci . - . ). conclusion: most patients screened in our ed for g/c did not have positive cultures and . % of those treated empirically were found not to have g/c. while early treatment is important to prevent complications, there are risks associated with antibiotic use such as allergic reaction, c difficile infection, and development of antibiotic resistance. our results suggest that at our institution we may be over-treating for g/c. furthermore, despite high rates of treatment, % of patients who ultimately had positive cultures did not receive antibiotics during their ed stay. further research into predictive factors or development of a clinical decision rule may be useful to help determine which patients are best treated empirically with antibiotics for presumed g/c. background: air travel may be associated with unmeasured neurophysiological changes in an injured brain that may affect post-concussion recovery. no study has compared the effect of commercial airtravel on concussion injuries despite rather obvious decreased oxygen tension and increased dehydration effect on acute mtbi. objectives: to determine if air travel within - hours of concussion is associated with increased recovery time in professional football and hockey players. methods: prospective cohort study of all active-roster national football league and national hockey league players during the - seasons. internet website review of league sties for injury identification of concussive injury and when player returned to play solely for mtbi. team schedules and flight times were also confirmed to include only players who flew immediately following game (within - hr). multiple injuries were excluded as were players who had injury around all-star break for nhl and scheduled off week in nfl. results: during the - nfl and nhl seasons, ( . %) and ( . %) players experienced a concussion (percent of total players), in the respective leagues. of these, nfl players ( %) and nhl players ( %) flew within hours of the incident injury. the mean distance flown was shorter for nfl ( miles, sd vs. nhl , sd ) miles and all were in a pressurized cabin. the mean number of games missed for nfl and nhl players who traveled by air immediately after concussion was increased by % and % (respectively) than for those who did not travel by air nfl: . (sd . ) vs. . games (sd . ) and nhl: . games (sd . ) vs. . (sd . ); p < . . conclusion: this is an initial report of an increased rate of recovery in terms of more games missed, for professional athletes flying commercial airlines post-mtbi compared to those that do not subject their recently injured brains to pressurized airflight. the obvious changes of decreased oxygen tension with altitude equivalent of , feet, decreased humidity with increased dehydration, and duress of travel accompanying pressurized airline cabins all likely increase the concussion penumbra in acute mtbi. early air travel post concussion should be further evaluated and likely postponed - hr. until initial symptoms subside. background: previous studies have shown better in-hospital stroke time targets for those who arrive by ambulance compared to other modes of transport. however, regional studies report that less than half of stroke patients arrive by ambulance. objectives: our objectives were to describe the proportion of stroke patients who arrive by ambulance nationwide, and to examine regional differences and factors associated with the mode of transport to the emergency department (ed). methods: this is a cross-sectional study of all patients with a primary discharge diagnosis of stroke based on previously validated icd- codes abstracted from the national hospital ambulatory medical care survey for - . we excluded subjects < years of age and those with missing data. the study related survey variables included patient demographics, community characteristics, mode of transport to the hospital, and hospital characteristics. results: patients met inclusion criteria, representing , , patient records nationally. of these, . % arrived by ambulance. after adjustment for potential confounders, patients residing in the west and south had lower odds of arriving by ambulance for stroke when compared to northeast (southern region, or . , % ci . - . , western region, or . , % ci . - . , midwest region, or . , % ci . - . ). compared to the medicare population, privately insured and self insured had lower odds of arriving by ambulance (or for private insurance . , % ci . - . and or for self payers . , % ci . - . ). age, sex, race, urban or rural location of ed, or safety net status were not independently associated with ambulance use. conclusion: patients with stroke arrive by ambulance more frequently in the northeast than in other regions of the us. identifying reasons for this regional difference may be useful in improving ambulance utilization and overall stroke care nationwide. objectives: we sought to determine whether there was a difference in type of stroke presentation based upon race. we further sought to determine whether there is an increase in hemorrhagic strokes among asian patients with limited english proficiency. methods: we performed a retrospective chart review of all stroke patients age and older for year of patients that were diagnosed with cerebral vascular accident (cva) or intracranial hemorrhage (ich). we collected data on patient demographics, and past medical history. we then stratified patients according to race (white, black, latino, asian, and other). we classified strokes as ischemic, intracranial hemorrhage (ich), subarachnoid hemorrhage (sah), subdural hemorrhage (sdh), and other (e.g., bleeding into metatstatic lesions). we used only the index visit. we present the data percentages, medians and interquartile ranges (iqr). we tested the association of the outcome of intracranial hemorrhage against demographic and clinical variables using chi-square and kruskal-wallis tests. we performed a logistic regression model to determine factors related to presentation with an intracranial hemorrhage (ich background: the practice of obtaining laboratory studies and routine ct scan of the brain on every child with a seizure has been called into question in the patient who is alert, interactive, and back to functional baseline. there is still no standard practice for the management of non-febrile seizure patients in the pediatric emergency department (ped). objectives: we sought to determine the proportion of patients in whom clinically significant laboratory studies and ct scans of the brain were obtained in children who presented to the ped with a first or recurrent non-febrile seizure. we hypothesize that the majority of these children do not have clinically significant laboratory or imaging studies. if clinically significant values were found, the history given would warrant further laboratory and imaging assessment despite seizure alone. methods: we performed a retrospective chart review of patients with first-time or recurrent non-febrile seizures at an urban, academic ped between july to june . exclusion criteria included children who presented to the ped with a fever and age less than months. we looked at specific values that included a complete blood count, basic metabolic panel, and liver function tests, and if the child was on antiepileptics along with a level for a known seizure disorder, and ct scan. abnormal laboratory and ct scan findings were classified as clinically significant or not. results: the median age of our study population is years with male to female ratio of . . % of patients had a generalized tonic-clonic seizure. laboratory studies and ct scans were obtained in % and % of patients, respectively. five patients had clinically significant abnormal labs; however, one had esrd, one developed urosepsis, one had eclampsia, and two others had hyponatremia, which was secondary to diluted formula and trileptal toxicity. three children had an abnormal head ct: two had a vp shunt and one had a chromosomal abnormality with developmental delay. conclusion: the majority of the children analyzed did not have clinically significant laboratory or imaging studies in the setting of a first or recurrent non-febrile seizure. of those with clinically significant results, the patient's history suggested a possible etiology for their seizure presentation and further workup was indicated. background: in patients with a negative ct scan for suspected subarachnoid hemorrhage (sah), ct angiography (cta) has emerged as a controversial alternative diagnostic strategy in place of lumbar puncture (lp). objectives: to determine the diagnostic accuracy for sah and aneurysm of lp alone, cta alone, and lp followed by cta if the lp is positive. methods: we developed a decision and bayesian analysis to evaluate ) lp, ) cta, and ) lp followed by cta if the lp is positive. data were obtained from the literature. the model considers probability of sah ( %), aneurysm ( % if sah), sensitivity and specificity of ct ( . % and % overall), of lp (based on rbc and xanthochromia), and of cta, traumatic tap and its influence on sah detection. analyses considered all patients and those presenting at less than hours or greater than hours from symptom onset by varying the sensitivity and specificity of ct and cta. results: using the reported ranges of ct scan sensitivity and the specificity, the revised likelihood of sah following a negative ct ranged from . - . %, and the likelihood of aneurysm ranged from . - . %. following any of the diagnostic strategies, the likelihood of missing sah ranged from - . %. either lp strategy diagnosed . % of sahs versus - % with cta alone because cta only detected sah in the presence of an aneurysm. false positive sah with lp ranged from . - . % due to traumatic taps and with cta ranged from . - . % due to aneurysms without sah. the positive predictive value for sah ranged from . - % with lp and from . - % with cta. for patients presenting within hours of symptom onset, the revised likelihood of sah following a negative ct became . %, and the likelihood of aneurysm ranged from . - . %. following any of the diagnostic strategies, the likelihood of missing sah ranged from . - . %. either lp strategy diagnosed . % of sah versus - % with cta alone. false positive sah with lp was . % and with cta ranged from . - . %. the positive predictive value for sah was . % with lp and from . - % with cta. cta following a positive lp diagnosed . - % of aneurysms. conclusion: lp strategies are more sensitive for detecting sah but less specific than cta because of traumatic taps, leading to lower predictive value positives for sah with lp than with cta. either diagnostic strategy results in a low likelihood of missing sah, particularly within hours of symptom onset. background: recent studies support perfusion imaging as a prognostic tool in ischemic stroke, but little data exist regarding its utility in transient ischemic attack (tia). ct perfusion (ctp), which is more available and less costly to perform than mri, has not been well studied. objectives: to characterize ctp findings in tia patients, and identify imaging predictors of outcome. methods: this retrospective cohort study evaluated tia patients at a single ed over months, who had ctp at initial evaluation. a neurologist blinded to ctp findings collected demographic and clinical data. ctp images were analyzed by a neuroradiologist blinded to clinical information. ctp maps were described as qualitatively normal, increased, or decreased in mean transit time (mtt), cerebral blood volume (cbv), and cerebral blood flow (cbf). quantitative analysis involved measurements of average mtt (seconds), cbv (cc/ g) and cbf (cc/[ g x min]) in standardized regions of interest within each vascular distribution. these were compared with values in the other hemisphere for relative measures of mtt difference, cbv ratio, and cbffratio. mtt difference of ‡ seconds, rcbv as £ . , and rcbf as £ . were defined as abnormal based on prior studies. clinical outcomes including stroke, tia, or hospitalization during follow-up were determined up to one year following the index event. dichotomous variables were compared using fisher's exact test. logistic regression was used to evaluate the association of ctp abnormalities with outcome in tia patients. results: of patients with validated tia, had ctp done. mean age was ± years, % were women, and % were caucasian. mean abcd score was . ± . , and % had an abcd ‡ . prolonged mtt was the most common abnormality ( , %), and ( . %) had decreased cbv in the same distribution. on quantitative analysis, ( %) had a significant abnormality. four patients ( . %) had prolonged mtt and decreased cbv in the same territory, while ( %) had mismatched abnormalities. when tested in a multivariate model, no significant associations between mismatch abnormalities on ctp and new stroke, tia, or hospitalizations were observed. conclusion: ctp abnormalities are common in tia patients. although no association between these abnormalities and clinical outcomes was observed in this small study, this needs to be studied further. objectives: we hypothesized that pre-thrombolytic anti-hypertensive treatment (aht) may prolong door to treatment time (dtt). methods: secondary data analysis of consecutive tpatreated patients at randomly selected michigan community hospitals in the instinct trial. dtt among stroke patients who received pre-thrombolytic aht were compared to those who did not receive pre-thrombolytic aht. we then calculated a propensity score for the probability of receiving pre-thrombolytic aht using a logistic regression model with covariates including demographics, stroke risk factors, antiplatelet or beta blocker as home medication, stroke severity (nihss), onset to door time, admission glucose, pretreatment systolic and diastolic blood pressure, ems usage, and location at time of stroke. a paired t-test was then performed to compare the dtt between the propensity-matched groups. a separate generalized estimating equations (gee) approach was also used to estimate the differences between patients receiving pre-thrombolytic aht and those who did not while accounting for within-hospital clustering. results: a total of patients were included in instinct; however, onset, arrival, or treatment times were not able to be determined in , leaving patients for this analysis. the unmatched cohort consisted of stroke patients who received pre-thrombolytic aht and stroke patients who did not receive aht from - (table) . in the unmatched cohort, patients who received pre-thrombolytic aht had a longer dtt (mean increase minutes; % confidence interval (ci) - minutes) than patients who did not receive pre-thrombolytic aht. after propensity matching (table) , patients who received pre-thrombolytic aht had a longer dtt (mean increase . minutes, % ci . - . ) than patients who did not receive pre-thrombolytic aht. this effect persisted and its magnitude was not altered by accounting for clustering within hospitals. conclusion: pre-thrombolytic aht is associated with modest delays in dtt. this represents a feasible target for physician educational interventions and quality improvement initiatives. further research evaluating optimum hypertension management pre-thrombolytic treatment is warranted. post-pds, % had only pre-pds, and % had both. the most common pds included failure to treat post-treatment hypertension ( , %), antiplatelet agent within hours of treatment ( , %), pre-treatment blood pressure over / ( , %), anticoagulant agent within hours of treatment ( , %), and treatment outside the time window ( , %). symptomatic intracranial hemorrhage (sich) was observed in . % of patients with pds and . % of patients without any pd. in-hospital case fatality was % with and % without a pd. in the fully adjusted model, older age was significantly associated with pre-pds (table) . when post-pds were evaluated with adjustment for pre-pds, age was not associated with pds; however, pre-pds were associated with post-pds. conclusion: older age was associated with increased odds of pre-pds in michigan community hospitals. pre-pds were associated with post-pds. sich and in-hospital case fatality were not associated with pds; however, the low number of such events limited our ability to detect a difference. ct background: mri has become the gold standard for the detection of cerebral ischemia and is a component of multiple imaging enhanced clinical risk prediction rules for the short-term risk of stroke in patients with transient ischemic attack (tia). however, it is not always available in the emergency department (ed) and is often contraindicated. leukoaraiosis (la) is a radiographic term for white matter ischemic changes, and has recently been shown to be independently predictive of disabling stroke. although it is easily detected by both ct and mri, their comparative ability is unknown. objectives: we sought to determine whether leukoaraiosis, when combined with evidence of acute or old infarction as detected by ct, achieved similar sensitivity to mri in patients presenting to the ed with tia. methods: we conducted a retrospective review of consecutive patients diagnosed with tia between june and july that underwent both ct and mri as part of routine care within calendar day of presentation to a single, academic ed. ct and mr images were reviewed by a single emergency physician who was blinded to the mr images at the time of ct interpretation. la was graded using the van sweiten scale (vss), a validated grading scale applicable to both ct and mri. anterior and posterior regions were graded independently from to . results: patients were diagnosed with tia during the study period. of these, had both ct and mri background: helping others is often a rewarding experience but can also come with a ''cost of caring'' also known as compassion fatigue (cf). cf can be defined as the emotional and physical toll suffered by those helping others in distress. it is affected by three major components: compassion satisfaction (cs), burnout (bo), and traumatic experiences (te). previous literature has recognized an increase in bo related to work hours and stress among resident physicians. objectives: to assess the state of cf among residents with regard to differences in specialty training, hours worked, number of overnights, and demands of child care. we aim to measure associations with the three components of cf (cs, bo, and te). methods: we used the previously validated survey, proqol . the survey was sent to the residents after approval from the irb and the program directors. results: a total of responses were received ( % of the surveyed). five were excluded due to incomplete questionnaires. we found that residents who worked more hours per week had significantly higher bo levels (median vs , p = . ) and higher te ( vs , p = . ) than those working less hours. there was no difference in cs ( vs , p = . ). eighteen percent of the residents worked a majority of the night shifts. these residents had higher levels of bo background: emergency department (ed) billing includes both facility and professional fees. an algorithm derived from the medical provider's chart generates the latter fee. many private hospitals encourage appropriate documentation by financially incentivizing providers. academic hospitals sometimes lag in this initiative, possibly resulting in less than optimal charting. past attempts to teach proper documentation using our electronic medical record (emr) were difficult in our urban, academic ed of providers (approximately attending physicians, residents, and physician assistants). objectives: we created a tutorial to teach documentation of ed charts, modified the emr to encourage appropriate documentation, and provided feedback from the coding department. this was combined with an incentive structure shared equally amongst all attendings based on increased collections. we hypothesized this instructional intervention would lead to more appropriate billing, improve chart content, decrease medical liability, and increase educational value of charting process. methods: documentation recommendations, divided into two-month phases of - proposals, were administered to all ed providers by e-mails, lectures, and reminders during sign-out rounds. charts were reviewed by coders who provided individual feedback if specific phase recommendations were not followed. our endpoints included change in total rvu, rvus/ patient, e/m level distribution, and subjective quality of chart improvement. we did not examine effects on procedure codes or facility fees. results: our base average rvu/patient in our ed from / / - / / was . with monthly variability of approximately %. implementation of phase one increased average rvu/patient within two weeks to . ( . % increase from baseline, p < . ). the second aggregate phase implemented weeks later increased average rvu/patient to . ( . % increase from baseline, p < . ). conclusion: using our teaching methods, chart reviews focused on - recommendations at a time, and emr adjustments, we were able to better reflect the complexity of care that we deliver every day in our medical charts. future phases will focus on appropriate documentation for procedures, critical care, fast track, and pediatric patients, as well as examining correlations between increase in rvus with charge capture. identifying mentoring ''best practices'' for medical school faculty julie l. welch, teresita bellido, cherri d. hobgood background: mentoring has been identified as an essential component for career success and satisfaction in academic medicine. many institutions and departments struggle with providing both basic and transformative mentoring for their faculty. objectives: we sought to identify and understand the essential practices of successful mentoring programs. methods: multidisciplinary institutional stakeholders in the school of medicine including tenured professors, deans, and faculty acknowledged as successful mentors were identified and participated in focused interviews between mar-nov . the major area of inquiry involved their experiences with mentoring relationships, practices, and structure within the school, department, or division. focused interview data were transcribed and grounded theory analysis was performed. additional data collected by a institutional mentoring taskforce were examined. key elements and themes were identified and organized for final review. results: results identified the mentoring practices for three categories: ) general themes for all faculty, ) specific practices for faculty groups: basic science researchers, clinician researchers, clinician educators, and ) national examples. additional mentoring strategies that failed were identified. the general themes were quite universal among faculty groups. these included: clarify the best type of mentoring for the mentee, allow the mentee to choose the mentor, establish a panel of mentors with complementary skills, schedule regular meetings, establish a clear mentoring plan with expectations and goals, offer training and resources for both the mentor and mentee at institutional and departmental levels, ensure ongoing mentoring evaluation, create a mechanism to identify and reward mentoring. national practice examples offered critical recommendations to address multi-generational attitudes and faculty diversity in terms of gender, race, and culture. conclusion: mentoring strategies can be identified to serve a diverse faculty in academic medicine. interventions to improve mentoring practices should be targeted at the level of the institution, department, and individual faculty members. it is imperative to adopt results such as these to design effective mentoring programs to enhance the success of emergency medicine faculty seeking robust academic careers. background: women comprise half of the talent pool from which the specialty of emergency medicine draws future leaders, researchers, and educators and yet only % of full professors in us emergency medicine are female. both research and interventions are aimed at reducing the gender gap, however, it will take decades for the benefits to be realized which creates a methodological challenge in assessing system's change. current techniques to measure disparities are insensitive to systems change as they are limited to percentages and trends over time. objectives: to determine if the use of relative rate index (rri) better predicts which stage in the system women are not advancing in the academic pipeline than traditional metrics. methods: rri is a method of analysis that assesses the percent of sub-populations in each stage relative to their representation in the stage directly prior. thus, there is a better notion of the advancement given the availability to advance. rri also standardizes data for ease of interpretation. this study was conducted on the total population of academic professors in all departments at yale school of medicine during the academic year of - . data were obtained from the yale university provost's office. results: n = . there were a total of full, associate, and assistant professors. males comprised %, %, and % respectively. rri for the department of emergency medicine (dem) is . , . , and . , for full, associate, and assistant professors, respectively while the percentages were %, %, and % respectively. conclusion: relying solely on percentages masks improvements to the system. women are most represented at the associate professor level in dem, highlighting the importance of systems change evidence. specifically, twice as many women are promoted to associate professor rank given the number who exists as assistant professors. within years, the dem should have an equal system as the numbers of associate professors have dramatically increased and will be eligible to promote to full professor. additionally, dem has a better record of retaining and promoting women than other yale departments of medicine at both associate and full professor ranks. objectives: we examine the payer mixes of community non-rehabilitation eds in metropolitan areas by region to identify the proportion of academic and nonacademic eds that could be considered safety net eds. we hypothesize that the proportion of safety net academic eds is greater than that for non-academic eds and is increasing over time. methods: this is an ecological study examining us ed visits from through . data were obtained from the nationwide emergency department sample (neds). we grouped each ed visit according to the unique hospital-based ed identifier, thus creating a payer mix for each ed. we define a ''safety net ed'' as any ed where the payer mix satisfied any one of the following three conditions: ) > % of all ed visits are medicaid patients; ) > % of all ed visits are self-pay patients; or ) > % of all ed visits are either medicaid or self-pay patients. neds tags each ed with a hospital-based variable to delineate metropolitan/non-metropolitan locations and academic affiliation. we chose to examine a subpopulation of eds tagged as either academic metropolitan or non-academic metropolitan, because the teaching status of non-metropolitan hospitals was not provided. we then measured the proportion of eds that met safety net criteria by academic status and region. results: we examined , , , , and , weighted metro eds in years - , respectively. table presents safety net proportions. the proportions of academic safety net eds increased across the study period. widespread regional variability in safety net proportions existed across all years. the proportions of safety net eds were highest in the south and lowest in the northeast and midwest. table describes these findings for . conclusion: these data suggest that the proportion of safety-net academic eds may be greater than that of non-academic eds, is increasing over time, and is objectives: to examine the effect of ma health reform implementation on ed and hospital utilization before and after health reform, using an approach that relies on differential changes in insurance rates across different areas of the state in order to make causal inferences as to the effect of health reform on ed visits and hospitalizations. our hypothesis was that health care reform (i.e. reducing rates of uninsurance) would result in increased rates of ed use and hospitalizations. methods: we used a novel difference-in-differences approach, with geographic variation (at the zip code level) in the percentage uninsured as our method of identifying changes resulting from health reform, to determine the specific effect of massachusetts' health care reform on ed utilization and hospitalizations. using administrative data available from the massachusetts division of health care finance and policy acute hospital case mix databases, we compared a one-year period before health reform with an identical period after reform. we fit linear regression models at the area-quarter level to estimate the effect of health reform and the changing uninsurance rate (defined as self-pay only) on ed visits and hospitalizations. results: there were , , ed visits and , hospitalizations pre-reform and , , ed visits and , hospitalizations post-reform. the rate of uninsurance decreased from . % to . % in the ed group and from . % to . % in the hospitalization group. a reduction in the rate of the uninsured was associated with a small but statistically significant increase in ed utilization (p = . ) and no change in hospitalizations (p = . ). conclusion: we find that increasing levels of insurance coverage in massachusetts were associated with small but statistically significant increases in ed visits, but no differences in rates of hospitalizations. these results should aid in planning for anticipated changes that might result from the implementation of health reform nationally. with high levels of co-morbidity when untreated in adolescents. despite broad cdc screening recommendations, many youth do not receive testing when indicated. the pediatric emergency department (ped) is a venue with a high volume of patients potentially in need of sti testing, but assessing risk in the ped is difficult given constraints on time and privacy. we hypothesized that patients visiting a ped would find an audio-enhanced computer-assisted self-interview (acasi) program to establish sti risk easy to use, and would report a preference for the acasi over other methods of disclosing this information. objectives: to assess acceptability, ease of use, and comfort level of an acasi designed to assess adolescents' risk for stis in the ped. methods: we developed a branch-logic questionnaire and acasi system to determine whether patients aged - visiting the ped need sti testing, regardless of chief complaint. we obtained consent from participants and guardians. patients completed the acasi in private on a laptop. they read a one-page computer introduction describing study details and completed the acasi. patients rated use of the acasi upon completion using five-point likert scales. results: eligible patients visited the ped during the study period. we approached ( %) and enrolled and analyzed data for / ( %). the median time to read the introduction and complete the acasi was . minutes (interquartile range . - . minutes). . % of patients rated the acasi ''very easy'' or ''easy'' to use, . % rated the wording as ''very easy'' or ''easy'' to understand, % rated the acasi ''very short'' or ''short'', . % rated the audio as ''very helpful'' or ''helpful,'' . % were ''very comfortable'' or ''comfortable'' with the system confidentiality, and . % said they would prefer a computer interface over in-person interviews or written surveys for collection of this type of information. conclusion: patients rated the computer interface of the acasi as easy and comfortable to use. a median of . minutes was needed to obtain meaningful clinical information. the acasi is a promising approach to enhance the collection of sensitive information in the ped. the participants were randomized to one of three conditions, bi delivered by a computer (cbi), bi delivered by a therapist assisted by a computer (tbi), or control, and completed , , and month follow-up. in addition to content on alcohol misuse and peer violence, adolescents reporting dating violence received a tailored module on dating violence. the main outcome for this analysis was frequency of moderate and severe dating victimization and aggression at the baseline assessment and , , and months post ed visit. results: among eligible adolescents, % (n = ) reported dating violence and were included in these analyses. compared to controls, after controlling for baseline dating victimization, participants in the cbi showed reductions in moderate dating victimization at months (or . ; ci . - . ; p < . , effect size . ) and months (or . ; ci . - . ; p < . , effect size . ); models examining interaction effects were significant for the cbi on moderate dating victimization at and months. significant interaction effects were found for the tbi on moderate dating victimization at and months and severe dating victimization at months. the computer-based intervention shows promise for delivering content that decreases moderate dating victimization over months. the therapist bi is promising for decreasing moderate dating victimization over months and severe dating victimization over months. ed-based bis delivered on a computer addressing multiple risk behaviors could have important public health effects. figure . the -only ordinance was associated with a significant reduction of ar visits. this ordinance was also associated with reduction in underage ar visits, ui student visits, and public intoxication bookings. these data suggest that other cities should consider similar ordinances to prevent unwanted consequences of alcohol. background: prehospital providers perform tracheal intubation in the prehospital environment, and failed attempts are of concern due to the danger of hypoxia and hypotension. some question the appropriateness of intubation in this setting due to the morbidity risk associated with intubation in the field. thus it is important to gain an understanding of the factors that predict the success of prehospital intubation attempts to inform this discussion. objectives: to determine the factors that affect success rates on first attempt of paramedic intubations in a rapid sequence intubation (rsi) capable critical care transport service. methods: we conducted a multivariate logistic analysis on a prospectively collected database of airway management from an air and land critical care transport service that provides scene responses and interfacility transport in the province of ontario. background: motor vehicle collisions (mvcs) are one of the most common types of trauma for which people seek ed care. the vast majority of these patients are discharged home after evaluation. acute psychological distress after trauma causes great suffering and is a known predictor of posttraumatic stress disorder (ptsd) development. however, the incidence and predictors of psychological distress among patients discharged to home from the ed after mvcs have not been reported. objectives: to examine the incidence and predictors of acute psychological distress among individuals seen in the ed after mvcs and discharged to home. methods: we analyzed data from a prospective observational study of adults - years of age presenting to one of eight ed study sites after mvc between / and / . english-speaking patients who were alert and oriented, stable, and without injuries requiring hospital admission were enrolled. patient interview included assessment of patient sociodemographic and psychological characteristics and mvc characteristics. level of psychological distress in the ed was assessed using the -item peritraumatic distress inventory (pdi). pdi scores > are associated with increased risk of ptsd and were used to define substantial psychological distress. descriptive statistics and logistic regression were performed using stata ic . (statacorp lp, college station, texas). results: mvc patients were screened, were eligible, and were enrolled. / ( %) participants had substantial psychological distress. after adjusting for crash severity (severity of vehicle damage, vehicle speed), substantial patient distress was predicted by sociodemographic factors, pre-mvc depressive symptoms, and arriving to the ed on a backboard (table) . conclusion: substantial psychological distress is common among individuals discharged from the ed after mvcs and is predicted by patient characteristics separate from mvc severity. a better under standing of the frequency and predictors of substantial psychological distress is an important first step in identifying these patients and developing effective interventions to reduce severe distress in the aftermath of trauma. such interventions have the potential to reduce both immediate patient suffering and the development of persistent psychological sequelae. figure) the predictive characteristics of pets, pesi, and spesi for -day mortality in emperor, including auc, negative predictive value, sensitivity, and specificity were calculated. results: the of patients ( . %; % ci . %- . %) classified as pets low had -day mortality of . % ( % ci . - . %), versus . % ( % ci . %- . %) in the pets high group, statistically similar to pesi and spesi. pets is significantly more specific for mortality than the spesi ( . % v . %; p < . ), classifying far more patients as low-risk while maintaining a sensitivity of % ( % ci . %- . %), not significantly different from spesi or pesi (p > . ). conclusion: with four variables, pets in this derivation cohort is as sensitive for -day mortality as the more complicated pesi and spesi, with significantly greater specificity than the spesi for mortality, placing % more patients in the low-risk group. external validation is necessary. nicole seleno, jody vogel, michael liao, emily hopkins, richard byyny, ernest moore, craig gravitz, jason haukoos denver health medical center, denver, co background: the sequential organ failure assessment (sofa) score, base excess, and lactate have been shown to be associated with mortality in critically ill trauma patients. the denver emergency department (ed) trauma organ failure (tof) score was recently derived and internally validated to predict multiple organ failure in trauma patients. the relationship between the denver tof score and mortality has not been assessed or compared to other conventional measures of mortality in trauma. objectives: to compare the prognostic accuracies of the denver ed tof score, ed sofa score, and ed base excess and lactate for mortality in a large heterogeneous trauma population. methods: a secondary analysis of data from the denver health trauma registry, a prospectively collected database. consecutive adult trauma patients from through were included in the study. data collected included demographics, injury characteristics, prehospital care characteristics, response to injury characteristics, ed diagnostic evaluation and interventions, and in-hospital mortality. the values of the four clinically relevant measures (denver ed tof score, ed sofa score, ed base excess, and ed lactate) were determined within four hours of patient arrival, and prognostic accuracies for in-hospital mortality for the four measures were evaluated with receiver operating characteristic (roc) curves. multiple imputation was used for missing values. results: of the , patients, the median age was (iqr - ) years, median injury severity score was (iqr - ), and % had blunt mechanisms. thirty-eight percent ( , patients) were admitted to the icu with a median icu length of stay of . (iqr - ) days, and % ( patients) died. in the non-survivors, the median values for the four measures were ed sofa . (iqr . - . ); denver ed tof . (iqr . - . ); ed base excess . (iqr . - . ) meq/l; and ed lactate . (iqr . - . ) mmol/l. the areas under the roc curves for these measures are demonstrated in the figure. conclusion: the denver ed tof score more accurately predicts in-hospital mortality in trauma patients as compared to the ed sofa score, ed base excess, or ed lactate. the denver ed tof score may help identify patients early who are at risk for mortality, allowing for targeted resuscitation and secondary triage to improve outcomes in these critically ill patients. the background: both animal and human studies suggest that early initiation of therapeutic hypothermia (th) and rapid cooling improve outcomes after cardiac arrest. objectives: the objective was to determine if administration of cold iv fluids in a prehospital setting decreased time-to-target-temperature (tt) with secondary analysis of effects on mortality and neurological outcome. methods: patients resuscitated after out-of-hospital cardiac arrest (oohca) who received an in-hospital post cardiac arrest bundle including th were prospectively enrolled into a quality assurance database from november to november . on april , a protocol for intra-arrest prehospital cooling with °c normal saline on patients experiencing oohca was initiated. we retrospectively compared tt for those receiving prehospital cold fluids and those not receiving cold fluids. tt was defined as °c measured via foley thermistor. secondary outcomes included mortality, good neurological outcome defined as cerebral performance category (cpc) score of or at discharge, and effects of pre-rosc cooling. results: there were patients who were included in this analysis with patients receiving prehospital cold iv fluids and who did not. initially, % of patients were in vf/vt and % asystole/pea. patients receiving prehospital cooling did not have a significant improvement in tt ( minutes vs minutes, p = . ). survival to discharge and good neurologic outcome were not associated with prehospital cooling ( % vs %, p = . ) and cpc of or in % vs %, (p = . ). initiating cold fluids prior to rosc showed both a nonsignificant decrease in survival ( % vs %, p = . ) and increase in poor neurologic outcomes ( % vs %, p = . ). % of patients received £ l of cooled ivf prior to hospital arrival. patients receiving prehospital cold ivf had a longer time from arrest to hospital arrival ( vs min, p =< . ) in addition to a prolonged rosc to hospital time ( vs min, p = . ). conclusion: at our urban hospital, patients achieving rosc following oohca did not demonstrate faster tt or outcome improvement with prehospital cooling compared to cooling initiated immediately upon ed arrival. further research is needed to assess the utility of prehospital cooling. assessment background: an estimated % of emergency department (ed) patients years of age and older have delirium, which is associated with short-and long-term risk of morbidity and mortality. early recognition could result in improved outcomes, but the reliability of delirium recognition in the continuum of emergency care is unknown. objectives: we tested whether delirium can be reliably detected during emergency care of elderly patients by measuring the agreement between prehospital providers, ed physicians, and trained research assistants using the confusion assessment method for the icu (cam-icu) to identify the presence of delirium. our hypothesis was that both ed physicians and prehospital providers would have poor ability to detect elements of delirium in an unstructured setting. methods: prehospital providers and ed physicians completed identical questionnaires regarding their clinical encounter with a convenience sample of elderly (age > years) patients who presented via ambulance to two urban, teaching eds over a three-month period. respondents noted the presence or absence of ( ) an acute change in mental status, ( ) inattention, ( ) disorganized thinking, and ( ) altered level of consciousness (using the richmond agitation sedation scale). these four components comprise the operational definition of delirium. a research assistant trained in the cam-icu rated each component for the same patients using a standard procedure. we calculated inter-rater reliability (kappa) between prehospital providers, ed physicians, and research assistants for each component. objectives: this study aimed to assess the association between age and ems use while controlling for potential confounders. we hypothesized that this association use would persist after controlling for confounders. methods: a cross-sectional survey study was conducted at an academic medical center's ed. an interview-based survey was administered and included questions regarding demographic and clinical characteristics, mode of ed arrival, health care use, and the perceived illness severity. age was modeled as an ordinal variable (< , - , and ‡ years). bivariate analyses were used to identify potential confounders and effect measure modifiers and a multivariable logistic regression model was constructed. odds ratios were calculated as measures of effect. results: a total of subjects were enrolled and had usable data for all covariates, ( %) of whom arrived via ems. the median age of the sample was years and % were female. there was a statistically significant linear trend in the proportion of subjects who arrived via ems by age (p < . ). compared to adults aged less than years, the unadjusted odds ratio associating age and ems use was . ( % ci: background: we previously derived a clinical decision rule (cdr) for chest radiography (cxr) in patients with chest pain and possible acute coronary syndrome (acs) consisting of the absence of three predictors: history of congestive heart failure, history of smoking, and abnormalities on lung auscultation. objectives: to prospectively validate and refine a cdr for cxr in an independent patient population. methods: we prospectively enrolled patients over years of age with a primary complaint of chest pain and possible acs from september to january at a tertiary care ed with , annual patient visits. physicians completed standardized data collection forms before ordering chest radiographs and were thus blinded to cxr findings at the time of data collection. two investigators, blinded to the predictor variables, independently classified cxrs as ''normal,'' ''abnormal not requiring intervention,'' and ''abnormal requiring intervention'' (e.g, heart failure, infiltrates) based on review of the radiology report and the medical record. analyses included descriptive statistics, inter-rater reliability assessment (kappa), and recursive partitioning. results: of visits for possible acs, mean age (sd) was . ( . ) and % were female. twenty-four percent had a history of acute myocardial infarction, % congestive heart failure, and % atrial fibrillation. seventy-one ( . %, % ci . - . ) patients had a radiographic abnormality requiring intervention. ing the likelihood of coronary artery disease (cad) could reduce the need for stress testing or coronary imaging. acyl-coa:cholesterol acyltransferase- (acat ) activity has been shown in monkey and murine models to correlate with atherosclerosis. objectives: to determine if a novel cardiac biomarker consisting of plasma cholesteryl ester levels (ce) typically derived from the activity of acat is predictive of cad in a clinical model. methods: a single center prospective observational cohort design enrolled a convenience sample of subjects from a tertiary care center with symptoms of acute coronary syndrome undergoing coronary ct angiography or invasive angiography. plasma samples were analyzed for ce composition with mass spectrometry. the primary endpoint was any cad determined at angiography. multivariable logistic regression analyses were used to estimate the relationship between the sum of the plasma concentrations from cholesteryl palmitoleate ( : ) and cholesteryl oleate ( : ) (defined as acat -ce) and the presence of cad. the added value of acat -ce to the model was analyzed comparing the c-statistics and integrated discrimination improvement (idi). results: the study cohort was comprised of participants enrolled over months with a mean age (± . ) years, % with cad at angiography. the median plasma concentration of acat -ce was lm ( , ) in patients with cad and lm ( , ) in patients without cad (p = . ) (figure) . when considered with age, sex, and the number of conventional cad risk factors, acat -ce were associated with a . % increased odds of having cad per lm increase in concentration. the addition of acat -ce significantly improved the c-statistic ( . vs . , p = . ) and idi ( . , p < . ) compared to the reduced model. in the subgroup of low-risk observation unit patients, the ce model had superior discrimination compared to the diamond forrester classification (idi . , p < . ). conclusion: plasma levels of acat -ce, considered in a clinical model, have strong potential to predict a patient's likelihood of having cad. in turn, this could reduce the need for cardiac imaging after the exclusion of mi. further study of acat -ce as biomarkers in patients with suspected acs is needed. background: outpatient studies have demonstrated a correlation between carotid intima-media thickness (cimt) on ultrasound and coronary artery disease (cad). there are no known published studies that investigate the role of cimt in the ed using cardiac ct or percutaneous cardiac intervention (pci) as a gold standard. objectives: we hypothesized that cimt can predict cardiovascular events and serve as a noninvasive tool in the ed. methods: this was a prospective study of adult patients who presented to the ed and required evaluation for chest pain. the study location was an urban ed with a census of , annual visits and -hour cardiac catheterization. patients who did not have ct or pci or had carotid surgery were excluded from the study. ultrasound cimt measurements of right and left common carotid arteries were taken with a mhz linear transducer (zonare, mountain view, ca). anterior, medial, and posterior views of the near and far wall were obtained ( cimt scores total). images were analyzed by carotid analyzer (mailing imaging application llc, coralville, iowa). patients were classified into two groups based on the results from ct or pci. a subject was classified as having significant cad if there was over % occlusion or multi-vessel disease. results: ninety of patients were included in the study; . % were males. mean age was . ± years. there were ( . %) subjects with significant cad and ( . %) with non-significant cad. the mean of all cimt measurements was significantly higher in the cad group than in the non-cad group ( . ± . vs. . ± . ; p < . ). a logistic regression analysis was carried out with significant cad as the event of interest and the following explanatory variables in the model: objectives: to determine the diagnostic yield of routine testing in-hospital or following ed discharge among patients presenting to an ed following syncope. methods: a prospective, observational, cohort study of consecutive ed patients ‡ years old presenting with syncope was conducted. the four most commonly utilized tests (echocardiography, telemetry, ambulatory electrocardiography monitoring, and cardiac markers) were studied. interobserver agreement as to whether tests results determined the etiology of the syncope was measured using kappa (k) values. results: of patients with syncope, ( %) had echocardiography with ( %) demonstrating a likely etiology of the syncopal event such as critical valvular disease or significantly depressed left ventricular function (k = . ). on hospitalization, ( %) patients were placed on telemetry, ( %) of these had worrisome dysrhythmias (k = . ). ( %) patients had troponin levels drawn of whom ( %) had positive results (k = ); ( %) patients were discharged with monitoring with significant findings in only ( . %) patients (k = . ). overall, ( %, % ci - %) studies were diagnostic. conclusion: although routine testing is prevalent in ed patients with syncope, the diagnostic yield is relatively low. nevertheless, some testing, particularly echocardiography, may yield critical findings in some cases. current efforts to reduce the cost of medical care by eliminating non-diagnostic medical testing and increasing emphasis on practicing evidence-based medicine argue for more discriminate testing when evaluating syncope. (originally submitted as a ''late-breaker.'') unusual fatigue was reported by . % (severe . %) and insomnia by . % (severe . %). these findings have led to risk management recommendations to consider these symptoms as predictive of acute coronary syndromes (acs) among women visiting the ed. objectives: to document the prevalence of these symptoms among all women visiting an ed. to analyze the potential effect of using these symptoms in the ed diagnostic process for acs. methods: a survey on fatigue and insomnia symptoms was administered to a convenience sample of all adult women visiting an urban academic ed (all arrival modes, acuity levels, all complaints). a sensitivity analysis was performed using published data and expert opinion for inputs. results: we approached women, with enrollments. see table. the top box shows prevalences of prodromal symptoms among all adult female ed patients. the bottom box shows outputs from sensitivity analysis on the diagnostic effect of initiating an acs workup for all female ed patients reporting prodromal symptoms. conclusion: prodromal symptoms of acs are highly prevalent among all adult women visiting the ed in this study. this likely limits their utility in ed settings. while screening or admitting women with prodromal symptoms in the ed would probably increase sensitivity, that increase would be accompanied by a dramatic reduction in specificity. such a reduction in specificity would translate to admitting, observing, or working up somewhere between % and % of all women visiting the ed, which is prohibitive in terms of personal costs, risks of hospitalization, and financial costs. while these symptoms may or may not have utility in other settings such as primary care, their prevalence, and the implied lack of specificity for acs suggest they will not be clinically useful in the ed. length methods: we examined a cohort of low-risk chest pain patients evaluated in an ed-based ou using prospective and retrospective ou registry data elements. cox proportional hazard modeling was performed to assess the effect of testing modality (stress testing vs. ccta) on the los in the cdu. as ccta is not available on weekends, only subjects presenting on weekdays were included. cox models were stratified on time of patient presentation to the ed, based on four hour blocks beginning at midnight. the primary independent variable was first test modality, either stress imaging (exercise echo, dobutamine echo, stress mri) or ccta. age, sex, and race were included as covariates. the proportional hazards assumption was tested using scaled schoenfield residuals, and the models were graphically examined for outliers and overly influential covariate patterns. test selection was a time varying covariate in the am strata, and therefore the interaction with ln (los) was included as a correction term. after correction for multiple comparisons, an alpha of . was held to be significant. results: over the study period, subjects (of , in the registry) presented on non-weekend days. the median los was . hours (iqr . - . hours), % were white, and % were female. the table shows the number of subjects in each time strata, the number tested, and the number undergoing stress testing vs. ccta. after adjusting all models for age, race, and sex, the hazard ratio (hr) for los is as shown. only those patients presenting between am and noon noted a significant improvement in los with ccta use (p < . ). objectives: determine the validity of a managementfocused em osce as a measure of clinical skills by determining the correlation between osce scores and faculty assessment of student performance in the ed. methods: medical students in a fourth year em clerkship were enrolled in the study. on the final day of the clerkship students participated in a five-station em osce. student performance on the osce was evaluated using a task-based evaluation system with - critical management tasks per case. task performance was evaluated using a three-point system: performed correctly/timely ( ), performed incorrectly/late ( ), or not performed ( ). descriptive anchors were used for performance criteria. communication skills were also graded on a three-point scale. student performance in the ed was based on traditional faculty assessment using our core-competency evaluation instrument. a pearson correlation coefficient was calculated for the relationship between osce score and ed performance score. case item analysis included determination of difficulty and discrimination. the acgme also requires that trainees are evaluated on these ccs during their residency. trainee evaluation in the ccs are frequently on a subjective rating scale. one of the recognized problems with a subjective scale is the rating stringency of the rater, commonly known as the hawk-dove effect. this has been seen in standardized clinical exam scoring. recent data have shown that score variance can be related to evaluator performance with a negative correlation. higher-scoring physicians were more likely to be a stringent or hawk type rater on the same evaluation. it is unclear if this pattern also occurs in the subjective ratings that are commonly used in assessments of the ccs. objectives: comparison of attending physician scores on the acgme ccs with attending ratings of residents for a negative correlation or hawk-dove effect. methods: residents are routinely evaluated on the ccs with a - numerical rating scale as part of their training. the evaluation database was retrospectively reviewed. residents anonymously scored attending physicians on the ccs with a cross-sectional survey that utilized the same rating scale, anchors, and prompts as the resident evaluations. average scores for and by each attending were calculated and a pearson correlation calculated by core competency and overall. results: in this irb-approved study, a total of attending physicians were scored on the ccs with evaluations by residents. attendings evaluated residents with a total of , evaluations completed over a -year period. attending mode score was ranging from to ; resident scores had a mode of with a range of to . there was no correlation between the rated performance of the attendings overall or in each ccs and the scores they gave (p = . - . ). conclusion: hawk-dove effects can be seen in some scoring systems and has the potential to affect trainee evaluation on the acgme core competencies. however, a negative correlation to support a hawk-dove scoring pattern was not found in em resident evaluations by attending physicians. this study is limited by being a single center study and utilizing grouped data to preserve resident anonymity. background: all acgme-accredited residency programs are required to provide competency-based education and evaluation. graduating residents must demonstrate competency in six key areas. multiple studies have outlined strategies for evaluating competency, but data regarding residents' self-assessments of these competencies as they progress through training and beyond is scarce. objectives: using data from longitudinal surveys by the american board of emergency medicine, the primary objective of this study was to evaluate if resident self-assessments of performance in required competencies improve over the course of graduate medical training and in the years following. additionally, resident self-assessment of competency in academic medicine was also analyzed. methods: this is a secondary data analysis of data gathered from two rounds of the abem longitudinal study of emergency medicine residents ( - and - ) and three rounds of the abem longitudinal study of emergency physicians ( , , ). in both surveys, physicians were asked to rate a list of items in response to the question, ''what is your current level of competence in each of the following aspects of work in em?'' the rated items were grouped according to the acgme required competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, and system-based practice. an additional category for academic medicine was also added. results: rankings improved in all categories during residency training. rankings in three of the six categories improved from the weak end of the scale to the strong end of the scale. there is a consistent decline in rankings one year after graduation from residency. the greatest drop is in medical knowledge. mean self-ranking in academic medicine competency is uniformly the lowest ranked category for each year. conclusion: while self-assessment is of uncertain value as an objective assessment, these increasing rankings suggest that emergency medicine residency programs are successful at improving residents' confidence in the required areas. residents do not feel as confident about academic medicine as they do about the acgme required competencies. the uniform decline in rankings the first year after residency is an area worthy of further inquiry. screening medical student rotators from outside institutions improves overall rotation performance shaneen doctor, troy madsen, susan stroud, megan l. fix university of utah, salt lake city, ut background: emergency medicine is a rapidly growing field. many student rotations are limited in their ability to accommodate all students and must limit the number of students they allow per rotation. we hypothesize that pre-screening visiting student rotators will improve overall student performance. objectives: to assess the effect of applicant screening on overall rotation grade and mean end of shift card scores. methods: we initiated a medical student screening process for all visiting students applying to our -week elective em rotation starting in . this consisted of reviewing board scores and requiring a letter of intent. students from our home institution were not screened. all end-of-shift evaluation cards and final rotation grades (honors, high pass, pass, fail) from to were analyzed. we identified two cohorts: home students (control) and visiting students. we compared pre-intervention ( ) ( ) ( ) ( ) ( ) and postintervention ( - ) scores and grades. end of shift performance scores are recorded using a fivepoint scale that assesses indicators such as fund of knowledge, judgment, and follow-through to disposition. mean ranks were compared and p-values were calculated using the armitage test of trend and confirmed using t-tests. results: we identified visiting students ( pre, post) and home students ( pre, post). ( . %) visiting students achieved honors pre-intervention while ( . %) achieved honors post-intervention (p = . ). no significant difference was seen in home student grades: ( . %) received honors pre- and ( . %) received honors post- conclusion: we found that implementation of a screening process for visiting medical students improved overall rotation scores and grades as compared to home students who did not receive screening. screening rotating students may improve the overall quality of applicants and thereby the residency program. background: there are many descriptions in the literature of computer-assisted instruction in medical education, but few studies that compare them to traditional teaching methods. objectives: we sought to compare the suturing skills and confidence of students receiving video preparation before a suturing workshop versus a traditional instructional lecture. methods: first and second year medical students were randomized into two groups. the control group was given a lecture followed by minutes of suturing time. the video group was provided with an online suturing video at home, no lecture, and given minutes of suturing time during the workshop. both groups were asked to rate their confidence before and after the workshop, and their belief in the workshop's effectiveness. each student was also videotaped suturing a pig's foot after the workshop and graded on a previously validated -point suturing checklist. videos were scored. results: there was no significant difference between the test scores of the lecture group (m = . , sd = . , n = ) and the video group (m = . , sd = . , n = ) using the two-sample independent ttest for equal variances (t( ) = ) . , p = . ). there was a statistically significant difference in the proportion of students scoring correctly for only one point: ''curvature of needle followed'': / in the lecture group and / in the video group (chi = . , df = , p = . ). students in the video group were found to be . times more likely to have a neutral or favorable feeling of suturing confidence before the workshop (p = . , ci . - . ) using a proportional odds model. no association was detected between group assignment and level of suturing confidence after the workshop (p = . ). there was also no association detected between group assignment and opinion of the suturing workshop (p = . ) using a logistic regression odds model. among those students who indicated a lack of confidence before training, there was no detected association (p = . ) between group assignment and having an improved confidence using a logistic regression odds model. conclusion: students in the video group and students in the control group achieved similar levels of suturing skill and confidence, and equal belief in the workshop's effectiveness. this study suggests that video instruction could be a reasonable substitute for lectures in procedural education. background: accurate interpretation of the ecg in the emergency department is not only clinically important but also critical to assess medical knowledge competency. with limitations to expansion of formal didactics, educational technology offers an innovative approach to improve the quality of medical education. objectives: the aim of this study was to assess an online multimedia-based ecg training module evaluating st elevation myocardial infarction (stemi) identification among medical students. methods: a convenience sample of fifty-two medical students on their em rotations at an academic medical center with an em residency program was evaluated in a before-after fashion during a -month period. one cardiologist and two ed attending physicians independently validated a standardized exam of ten ecgs: four were normal ecgs, three were classic stemis, and three were subtle stemis. the gold standard for diagnosis was confirmed acute coronary thrombus during cardiac catheterization. after evaluating the ecgs, students completed a pre-intervention test wherein they were asked to identify patients who required emergent cardiac catheterization based on the presence or absence of st segment elevation on ecg. students then completed an online interactive multimedia module containing minutes of stemi training based on american heart association/american college of cardiology guidelines on stemi. medical students were asked to complete a post-test of the ecgs after watching online multimedia. objectives: our objective was to quantify the number of pre-verbal pediatric head cts performed at our community hospital that could have been avoided by utilizing the pecarn criteria. methods: we conducted a standardized chart review of all children under the age of who presented to our community hospital and received a head ct between jan st, and dec st, . following recommended guidelines for conducting a chart review, we: ) utilized four blinded chart reviewers, ) provided specific training, ) created a standardized data extraction tool, and ) held periodic meetings to evaluate coding discrepancies. our primary outcome measure was the number of patients who were pecarn negative and received a head ct at our institution. our secondary outcome was to reevaluate the sensitivity and specificity of the pecarn criteria to detect citbi in our cohort. data were analyzed using descriptive statistics and % confidence intervals were calculated around proportions using the modified wald method. results: a total of patients under the age of received a head ct at our institution during the study period. patients were excluded from the final analysis because their head cts were not for trauma. the prevalence of a citbi in our cohort was . % ( % ci . %- . %) ( (dti) measures disruption of axonal integrity on the basis of anisotropic diffusion properties. findings on dti may relate to the injury, as well as the severity of postconcussion syndrome (pcs) following mtbi. objectives: to examine acute anisotropic diffusion properties based on dti in youth with mtbi relative to orthopedic controls and to examine associations between white matter (wm) integrity and pcs symptoms. methods: interim analysis of a prospective casecontrol cohort involving youth ages - years with mtbi and orthopedic controls requiring extremity radiographs. data collected in ed included demographics, clinical information, and pcs symptoms measured by the postconcussion symptom scale. within hours of injury, symptoms were re-assessed and a -direction, diffusion weighted, spin-echo imaging scan was performed on a t philips scanner. dti images were analyzed using tract-based spatial statistics. fractional anisotropy (fa), mean diffusivity (md), axial diffusivity (ad), and radial diffusivity were measured. results: there were no group demographic differences between mtbi cases and controls. presenting symptoms within the mtbi group included gcs = %, loss of consciousness %, amnesia %, post-traumatic seizure %, headache %, vomiting %, dizziness %, and confusion %. pcs symptoms were greater in mtbi cases than in the controls at ed visit ( . ± . vs. . ± . , p < . ) and at the time of scan ( . ± . vs. . ± . , p < . ). the mtbi group displayed decreased fa in cerebellum and increased md and ad in the cerebral wm relative to controls (uncorrected p < . ). increased fa in cerebral wm was also observed in mtbi patients but the group difference was not significant. pcs symptoms at the time of the scan were positively correlated with fa and inversely correlated with rd in extensive cerebral wm areas (p < . , uncorrected). in addition, pcs symptoms in mtbi patients were also found to be inversely correlated with md, ad, and rd in cerebellum (p < . ). conclusion: dti detected axonal damage in youth with mtbi which correlated with pcs symptoms. dti performed acutely after injury may augment detection of injury and help prediction of those with worse outcomes. background: sports-related concussion among professional, collegiate, and more recently high school athletes has received much attention from the media and medical community. to our knowledge, there is a paucity of research in regard to sports-related concussion in younger athletes. objectives: the aim of this study was to evaluate parental knowledge of concussion in young children who participate in recreational tackle football. methods: parents/legal guardians of children aged - years enrolled in recreational tackle football were asked to complete an anonymous questionnaire based on the cdc's heads up: concussion in youth sports quiz. parents were asked about their level of agreement in regard to statements that represent definition, symptoms, and treatment of concussion. results: a total of out of parents voluntarily completed the questionnaire ( % response rate). parent and child demographics are listed in table . ninety four percent of parents believed their child had never suffered a concussion. however, when asked to agree or disagree with statements addressing various aspects of concussion, only % (n = ) could correctly identify all seven statements. most did not identify that a concussion is considered a mild traumatic brain injury and can be achieved from something other than a direct blow to the head. race, sex, and zip code had no significant association with correctly answering statements. education ( . ; p < . ) and number of years the child played ( . ; p < . ) had a small effect. fifty-three percent of parents reported someone had discussed the definition of concussion with them and % the symptoms of concussion. see table for source of information to parents. no parent was able to classify all symptoms listed as correctly related or not related to concussion. however, identification of correct concussion definitions correlated with identification of correct symptoms ( . ; p < . ). conclusion: while most parents had received some education regarding concussion from a health care provider, important misconceptions remain among parents of young athletes regarding the definition, symptoms, and treatment of concussion. this study highlights the need for health care providers to increase educational efforts among parents of young athletes in regard to concussion. figure ). / ( %) of patients with baseline liver dysfunction were (oh)d deficient and / ( %) of deaths were patients who had insufficient levels of (oh)d. there was an inverse association between (oh)d level and tnf-a (p = . ; figure ) and il- (p = . ). background: fever is common in the emergency department (ed), and % of those diagnosed with severe sepsis present with fever. despite data suggesting that fever plays an important role in immunity, human data conflict on the effect of antipyretics on clinical outcomes in critically ill adults. objectives: to determine the effect of ed antipyretic administration on -day in-hospital mortality in patients with severe sepsis. methods: single-center, retrospective observational cohort study of febrile severe sepsis patients presenting to an urban academic , -visit ed between june and june . all ed patients meeting the following criteria were included: age ‡ , temperature ‡ . °c, suspected infection, and either systolic blood pressure £ mmhg after a ml/kg fluid bolus or lactate of ‡ . patients were excluded for a history of cirrhosis or acetaminophen allergy. antipyretics were defined as acetaminophen, ibuprofen, or ketorolac. results: one hundred-thirty five ( . %) patients were treated with an antipyretic medication ( . % acetaminophen). intubated patients were less likely to receive antipyretic therapy ( . % vs. . %, p < . ), but the groups were otherwise well matched. patients requiring ed intubation (n = ) had much higher in-hospital mortality ( . % vs. . %, p < . ). patients given an antipyretic in the ed had lower mortality ( . % vs. . %, p < . ). when multivariable logistic regression was used to account for apache-ii, intubation status, and fever magnitude, antipyretic therapy was not associated with mortality (adjusted or . , . - . , p = . ). conclusion: although patients treated with antipyretic therapy had lower -day in-hospital mortality, antipyretic therapy was not independently associated with mortality in multivariable regression analysis. these findings are hypothesis-generating for future clinical trials, as the role of fever control has been largely unexplored in severe sepsis (grant ul rr , nih-ncrr). , and caval index ) . ± . (ci ) . , ) . ) and all were statistically significant. the groups receiving ml/kg and ml/kg had statistically significant changes in caval index; however the ml/kg group had no significant change in mean ivc diameter. one-way anova differences between the means of all groups were not statistically different. conclusion: overall, there were statistically significant differences in mean ivc-us measurements before and after fluid loading, but not between groups. fasting asymptomatic subjects had a wide inter-subject variation in both baseline ivc-us measurements and fluid-related changes. the wide differences within our ml/kg group may limit conclusions regarding proportionality. there were significant differences in performance on ed measures by ownership (p < . ) and region (p = . ). scores on ed process measures were highest at for-profit hospitals ( % above average) and hospitals in the south ( % above average), and lowest at public hospitals ( % below average) and hospitals in the northeast ( % below average). conclusion: there was considerable variation in performance on the ed measures included in the vbp program by hospital ownership and region. ed directors may come under increasing pressure to improve scores in order to reduce potential financial losses under the program. our data provide early information on the types of hospitals with the greatest opportunity for improvement. methods: design/setting -an independent agency mandated by the government collected and analyzed ed patient experience data using a comprehensive, validated multidimensional instrument and a random periodic sampling methodology of all ed patients. a prospective pre-post experimental study design was employed in the eight community and tertiary care hospitals most affected by crowding. two . month study periods were evaluated (pre: / - / / ; post: / / - / / ). outcomes -the primary outcome was patient perception of wait times and crowding reported as a composite mean score ( - ) from six survey items with higher scores representing better ratings. the overall rating of care by ed patients (composite score) and other dimensions of care were collected as secondary outcomes. all outcomes were compared using chi-square and two-tailed student's t-tests. results: a total of surveys were completed in both the pre-ocp and post-ocp study periods representing a response rate of %. we compared in-patient mortality from ami for patients who lived in a community with either . miles or miles of a closure but did not need to travel farther to the nearest ed with those who did not. we used patient-level data from the california office of statewide health and planning development (oshpd) database patient discharge data, and locations of patient residence and hospitals were geo-coded to determine any changes in distance to the nearest ed. we applied a generalized linear mixed effects model framework to estimate a patient's likelihood to die in the hospital of ami as a function of being affected by a neighborhood closure event. results background: fragmentation of care has been recognized as a problem in the us health care system. however, little is known about ed utilization after hospitalization, a potential marker of poor outpatient care coordination after discharge, particularly for common inpatient-based procedures. objectives: to determine the frequency and variability in ed visits after common inpatient procedures, how often they result in readmission, and related payments. methods: using national medicare data for - , we examined ed visits within days of hospital discharge after six common inpatient procedures: percutaneous coronary intervention, coronary artery bypass grafting (cabg), elective abdominal aortic aneurysm repair, back surgery, hip fracture repair, and colectomy. we categorized hospitals into risk-adjusted quintiles based on the frequency of ed visits after the index hospitalization. we report visits by primary diagnosis icd- codes and rates of readmission. we also assessed payments related to these ed visits. results: overall, the highest quintile of hospitals had -day ed visit rates that ranged from a low of . % with an associated . % readmission rate (back surgery) to a high of . % with an associated . % readmission rate (cabg). the most variability was more than -fold and found among patients undergoing colectomy in which the worst-performing hospitals saw . % of their patients experienced an ed visit within days while the best-performing hospitals saw . %. average total payments for the -day window from initial discharge across all surgical cohorts varied from $ , for patients discharged without subsequent ed visit; $ , for those experiencing an ed visit(s); $ , for those readmitted through the ed; and $ , for those readmitted from another source. if all patients who did not require readmission also did not incur an ed visit within the -day window, this would represent a potential cost savings of $ million. conclusion: among elderly medicare recipients there was significant variability between hospitals for -day ed visits after six common inpatient procedures. the ed visit may be a marker of poor care coordination in the immediate discharge period. this presents an opportunity to improve post-procedure outpatient care coordination which may save costs related to preventable ed visits and subsequent readmissions. objectives: we sought to assess the effect of pharmacist medication review on ed patient care, in particular time from physician order to medication administration for the patient (order-to-med time). methods: we conducted a multi-center, before-after study in two eds (urban academic teaching hospital and suburban community hospital, combined census of , ) after implementation of the electronic prospective pharmacy review system (prs). the system allowed a pharmacist to review all ed medication orders electronically at the time of physician order and either approve or alter the order. we studied a -month time period before implementation of the system (pre-prs, / / - / / ) and after implementation (post-prs, / / - / / ). we collected data on all ed medication orders including dose, route, class, pharmacist review action, time of physician order, and time of medication administration. differences in order-to-medication between the pre-and post-prs study periods were compared using a results: ed metrics that were significantly associated with lbtcs varied across ed patient-volume categories (table) . for eds seeing less than k patients annually, the percentage of ems arrivals admitted to the hospital and ed square footage were both weakly associated with lbtcs (p = . ). for eds seeing at least k- k patients, median ed length of stay (los), percent of patients admitted to hospital through the ed, percent of ems arrivals admitted to hospital, and percent of pediatric patients were all positively associated, while percent of patients admitted to the hospital was negatively associated with lbtcs. for eds seeing k- k, median los and percent of x-rays performed were positively associated, while percent of ekgs performed was negatively associated with lbtcs. for eds seeing k- k, percent of patients admitted to the hospital through the ed was negatively associated and percent of ekgs performed was positively associated with lbtcs. for eds with volume greater than k, none of the selected variables were associated with lbtc. conclusion: ed factors that help explain high lbtc rates differ depending on the size of an ed. interventions attempting to improve lbtc rates by modifying ed structure or process will need to consider baseline ed volume as a potential moderating influence. objectives: our study sought to compare bacterial growth of samples taken from surfaces after use of a common approved quat compound and a virtually non-toxic, commercially available solution containing elemental silver ( . %), hydrogen peroxide ( %), and peroxyacetic acid ( %) (shp) in a working ed. we hypothesized that, based on controlled laboratory data available, shp compound would be more effective on surfaces in an active urban ed. methods: we cleaned and then sampled three types of surfaces in the ed (suture cart, wooden railing, and the floor) during midday hours one minute after application of tap water, quat, and shp and then again at hours without additional cleaning. conventional environmental surface surveillance rodac media plates were used for growth assessment. images of bacterial growth were quantified at and hours. standard cleaning procedures by hospital staff were maintained per usual. results: shp was superior to control and quat one minute after application on all three surfaces. quat and water had x and x more bacterial growth than the surface cleaned with shp, respectively. hours later, the shp area produced fewer colonies sampled from the wooden railing: x more bacteria for quat, and x for water when compared to shp. h cultures from the cart and floor had confluent growth and could not be quantified. conclusion: shp outperforms quat in sterilizing surfaces after one minute application. shp may be a superior agent as a non-toxic, non-corrosive, and effective agent for surfaces in the demanding ed setting. further studies should examine sporidical and virucidal properties in a similar environment. objectives: evaluate the effect on patient satisfaction of increasing waiting room times and physician evaluation times. methods: emergency department flow metrics were collected on a daily basis as well as average daily patient satisfaction scores. the data were from july through february , in a , census urban hospital. the data were divided into equal intervals. the arrival to room time was divided by minute intervals up to minutes with the last group being greater than minutes. the physician evaluation times were divided into minute intervals, up to , the last group greater than with days in the group. data were analyzed using means and standard deviations, and well as anova for comparison between groups. results: the overall satisfaction score for the outpatient emergency visit was higher when the patient was in a room within minutes of arrival ( . , std deviation . ), analysis of variation between the groups had a p = . , for the means of each interval (see table ). the total satisfaction with the visit as well as satisfaction with the provider dropped when the evaluation extended over minutes, but was not statistically significant on anova analysis (see table for means). conclusion: once a patient's time in the waiting room extends beyond minutes, you have lost a significant opportunity for patient satisfaction; once they have been in the waiting room for over minutes, you are also much more likely to receive a poor score. physician evaluation time scores are much more consistent but as longer evaluation times occurred beyond total of minutes we started to see a trend downward in the satisfaction score. results: in all three eds, pain medication rates (both in ed and rx) varied significantly by clinical factors including location of pain, discharge diagnosis, pain level, and acuity. we observed little to no variation in pain medication rates by patient factors such as age, sex, race, insurance, or prior ed visits. the table displays key pain management practices by site and provider. after adjusting for patient and clinical characteristics, significant differences in pain medication rates remained by provider and site (see figure) . conclusion: within this health system, the approach to pain management by both providers and sites is not standardized. investigation of the potential effect of this variability on patient outcomes is warranted. results: all measures showed significant differences, p < . . average pts/h decreased post-cpoe and did not recover post transitional period, . ± . vs . ± . , p < . . rvu/h also decreased post-cpoe and did not recover post transitional period, . ± . vs . ± . and . ± . , p < . . charges/h also decreased after cpoe implementation and did not recover after system optimization. there was a sustained significant decrease in charges/h of . % ± . % post cpoe and . % ± . % post optimization, p < . . sub-group analysis for each provider group was also evaluated and showed variability for different providers. conclusion: there was a significant decrease in all productivity metrics four months after the implementation of cpoe. the system did undergo optimization initiated by providers with customization for ease and speed of use. however, productivity measurements did not recover after these changes were implemented. these data show that with the implementation of a cpoe system there is a decrease in productivity that continues even after a transition period and system customization. background: procedural competency is a key component of emergency medicine residency training. residents are required to log procedures to document quantity of procedures and identify potential weaknesses in their training. as emergency medicine evolves, it is likely that the type and number of procedures change over time. also, exposure to certain rare procedures in residency is not guaranteed. objectives: we seek to delineate trends in type and volume of core em procedures over a decade of emergency medicine residents graduating from an accredited four-year training program. methods: deidentified procedure logs from - were analyzed to assess trends in type and quantity of procedures. procedure logs were self-reported by individual residents on a continuous basis during training onto a computer program. average numbers of procedures per resident in each graduating class were noted. statistical analysis was performed using spss and includes a simple linear regression to evaluate for significant changes in number of procedures over time and an independent samples two-tailed t-test of procedures performed before and after the required resident duty hours change. results: a total of procedure logs were analyzed and the frequency of different procedures was evaluated. a significant increase was seen in one procedure, the venous cutdown. significant decreases were seen in procedures including key procedures such as central venous catheters, tube thoracostomy, and procedural sedation. the frequency of five high-stakes/ resuscitative procedures, including thoracotomy and cricothyroidotomy, remained steady but very low (< per resident over years). of the remaining procedures, showed a trend toward decreased frequency, while only increased. conclusion: over the past years, em residents in our program have recorded significantly fewer opportunities to perform most procedures. certain procedures in our emergency medicine training program have remained stable but uncommon over the course of nearly a decade. to ensure competency in uncommon procedures, innovative ways to expose residents to these potentially life saving skills must be considered. these may include practice on high-fidelity simulators, increased exposure to procedures on patients during residency (possibly on off-service rotations), or practice in cadaver and animal labs. objectives: to study the effectiveness of a unique educational intervention using didactic and hands-on training in usgpiv. we hypothesized that senior medical students would improve performance and confidence with usgpiv after the simulation training. methods: fourth year medical students were enrolled in an experimental, prospective, before and after study conducted at a university medical school simulation center. baseline skills in participant's usgpiv on simulation vascular phantoms were graded by ultrasound expert faculty using standardized checklists. the primary outcome was time to cannulation, and secondary outcomes were ability to successfully cannulate, number of needle attempts, and needle-tip visualization. subjects then observed a -minute presentation on correct performance of usgpiv followed by a -minute hands-on practical session using the vascular simulators with a : to : ultrasound instructor to student ratio. an expert blinded to the participant's initial performance graded post-educational intervention usgpiv ability. pre-and post-intervention surveys were obtained to evaluate usgpiv confidence, previous experience with ultrasound, peripheral iv access, usg-piv, and satisfaction with the educational format. objectives: this study examines the grade distribution of resident evaluations when the identity of the evaluator was anonymous as compared to when the identity of the evaluator was known to the resident. we hypothesize that there will be no change in the grades assigned to residents. methods: we retrospectively reviewed all faculty evaluations of residents and grades assigned from july , through november , . prior to july , the identity of the faculty evaluators was anonymous, while after this date, the identity of the faculty evaluators was made known to the residents. throughout this time period, residents were graded on a five-point scale. each resident evaluation included grades in the six acgme core competencies as well as in select other abilities. specific abilities evaluated varied over the dates analyzed. evaluations of residents were assigned to two groups, based on whether the evaluator was anonymous or made known to the resident. grades were compared between the two groups. results: a total of , grades were assigned in the anonymous group, with an average grade of . ( ci . , . ). a total of , grades were assigned in the known group with an average grade of . ( ci . , . ). specific attention was paid to assignment of unsatisfactory grades ( or on the five-point scale). the anonymous group assigned grades in this category, comprising . % of all grades assigned. the known group assigned grades in this category, comprising . % of all grades assigned. unsatisfactory grades were assigned by the anonymous group . % ( ci . , . ) more often. additionally, . % ( ci . , . ) fewer exceptional grades ( or on the five-point scale) were assigned by the anonymous group. conclusion: the average grade assigned was closer to average ( on a five-point scale) when the identity of the evaluator was made known to the residents. additionally, fewer unsatisfactory and exceptional grades were assigned in this group. this decrease of both unsatisfactory and exceptional grades may make it more difficult for program directors to effectively identify struggling and strong residents respectively. testing to improve knowledge retention from traditional didactic presentations: a pilot study david saloum, amish aghera, brian gillett maimonides medical center, brooklyn, ny background: the acgme requires an average of at least hours of planned educational experiences each week for em residents, which traditionally consists of formal lecture based instruction. however, retention by adult learners is limited when presented material in a lecture format. more effective methods such as small group sessions, simulation, and other active learning modalities are time-and resource-intensive and therefore not practical as a primary method of instruction. thus, the traditional lecture format remains heavily relied upon. efficient strategies to improve the effectiveness of lectures are needed. testing utilized as a learning tool to force immediate recall of lecture material is an example of such a strategy. objectives: to evaluate the effect of immediate postlecture short answer quizzes on em residents' retention of lecture content. methods: in this prospective randomized controlled study, em residents from a community based -year training program were randomized into two groups. block randomization provided a similar distribution of postgraduate year training levels and performance on both us-mle and in-training examinations between the two groups. each group received two identical -minute lectures on ecg interpretation and aortic disease. one group of residents completed a five-question short answer quiz immediately following each lecture (n = ), while the other group received the lectures without subsequent quizzes (n = ). the quizzes were not scored or reviewed with the residents. two weeks later, retention was assessed by testing both groups with a -question multiple choice test (mct) derived in equal part from each lecture. mean and median test results were then compared between groups. statistical significance was determined using a paired t-test of median test scores from each group. results: residents who received immediate post-lecture quizzes demonstrated significantly higher mct scores (mean = %, median %, n = ) compared to those receiving lectures alone (mean = %, median = %, n = ); p = . . conclusion: short answer testing immediately after a traditional didactic lecture improves knowledge retention at a -week interval. limitations of the study are that it is a single center study and long term retention was not assessed. background: the task of educating the next generation of physicians is steadily becoming more difficult with the inherent obstacles that exist for faculty educators and the work hour restrictions that students must adhere to. the obstacles make developing curricula that not only cover important topics but also do so in a fashion that helps support and reinforce the clinical experiences very difficult. several areas of medical education are using more asynchronous techniques and self-directed online educational modules to overcome these obstacles. objectives: the aim of this study was to demonstrate that educational information pertaining to core pediatric emergency medicine topics could be as effectively disseminated to medical students via self-directed online educational modules as it could through traditional didactic lectures. methods: this was a prospective study conducted from august , through december , . students participating in the emergency medicine rotation at carolinas medical center were enrolled and received education in a total of eight core concepts. the students were divided into two groups which changed on a monthly basis. group was taught four concepts via self-directed online modules and four traditional didactic lectures. group was taught the same core concepts, but in opposite fashion to group . each student was given a pre-test, post-test, and survey at the conclusion of the rotation. results: a total of students participated in the study. students, regardless of which group assigned, performed similarly on the pre-test, with no statistical difference among scores. when looking at the summative total scores between online and traditional didactic lectures, there was a trend towards significance for more improvement among those taught online. the student's assessment of the online modules showed that the majority either felt neutral or preferred the online method. the majority thought the depth and length of the modules were perfect. most students thought having access to the online modules was valuable and all but one stated that they would use them again. conclusion: this study demonstrates that self-directed, online educational modules are able to convey important concepts in emergency medicine similar to traditional didactics. it is an effective learning technique that offers several advantages to both the educator and student. background: critical access hospitals (cah) provide crucial emergency care to rural populations that would otherwise be without ready access to health care. data show that many cah do not meet standard adult quality metrics. adults treated at cah often have inferior outcomes to comparable patients cared for at other community-based emergency departments (eds). similar data do not exist for pediatric patients. objectives: as part of a pilot project to improve pediatric emergency care at cah, we sought to determine whether these institutions stock the equipment and medications necessary to treat any ill or injured child who presents to the ed. methods: five north carolina cah volunteered to participate in an intensive educational program targeting pediatric emergency care. at the initial site visit to each hospital, an investigator, in conjunction with the ed nurse manager, completed a -item checklist of commonly required ed equipment and medications based on the acep ''guidelines for care of children in the emergency department''. the list was categorized into monitoring and respiratory equipment, vascular access supplies, fracture and trauma management devices, and specialized kits. if available, adult and pediatric sizes were listed. only hospitals stocking appropriate pediatric sizes of an item were counted as having that item. the pharmaceutical supply list included antibiotics, antidotes, antiemetics, antiepileptics, intubation and respiratory medications, iv fluids, and miscellaneous drugs not otherwise categorized. results: overall, the hospitals reported having % of the items listed (range - %). the two greatest deficiencies were fracture devices (range - %), with no hospital stocking infant-sized cervical collars, and antidotes, with no hospital stocking pralidoxime, / hospitals stocking fomepizole, and / hospitals stocking pyridoxine and methylene blue. only one of the five institutions had access to prostaglandin e. the hospitals stated cost and rarity of use as the reason for not stocking these medications. conclusion: the ability of cah to care for pediatric patients does not appear to be hampered by a lack of equipment. ready access to infrequently used, but potentially lifesaving, medications is a concern. tertiary care centers preparing to accept these patients should be aware of these potential limitations as transport decisions are made. background: while incision and drainage (i&d) alone has been the mainstay of management of uncomplicated abscesses for decades, some advocate for adjunct antibiotic use, arguing that available trials are underpowered and that antibiotics reduce treatment failures and recurrence. objectives: to investigate the role of antibiotics in addition to i&d in reducing treatment failure as compared to management with i&d alone. methods: we performed a search using medline, embase, web of knowledge, and google scholar databases (with a medical librarian) to include trials and observational studies analyzing the effect of antibiotics in human subjects with skin and soft-tissue abscesses. two investigators independently reviewed all the records. we performed three overlapping meta-analy-ses: . only randomized trials comparing antibiotics to placebo on improvement of the abscess during standard follow-up. . trials and observational studies comparing appropriate antibiotics to placebo, no antibiotics, or inappropriate antibiotics (as gauged by wound culture) on improvement during standard follow-up. . only trials, but broadened outcome to include recurrence or new lesions during a longer follow-up period as treatment failure. we report pooled risk ratios (rr) using a fixed-effects model for our point estimates with shore-adjusted % confidence intervals (ci). results: we screened , records, of which studies fit inclusion criteria, of which were meta-analyzed ( trials, observational studies) because they reported results that could be pooled. of the studies, enrolled subjects from the ed, from a soft-tissue infection clinic, and from a general hospital without definition of enrollment site. five studies enrolled primarily adults, pediatrics, and without specification of ages. after pooling results for all randomized trials only, the rr = . ( % ci: . - . ). exposure being ''appropriate'' antibiotics (using trials and observational studies) resulted in a pooled rr = . ( % ci: . - . ). when we broadened our treatment failure criteria to include recurrence or new lesions at longer lengths of follow-up (trials only), we noted a rr = . ( % ci: . - . ). conclusion: based on available literature pooled for this analysis, there is no evidence to suggest any benefit from antibiotics in addition to i&d in the treatment of skin and soft tissue abscesses. (originally submitted as a ''late-breaker.'') primary objectives: to compare wound healing and recurrence rates after primary vs. secondary closure of drained abscesses. we hypothesized the percentage of drained ed abscesses that would be completely healed at days would be higher after primary closure. methods: this randomized clinical trial was undertaken in two academic emergency departments. immunocompetent adult patients with simple, localized cutaneous abscesses were randomly assigned to i & d followed by primary or secondary closure. randomization was balanced by center, with an allocation sequence based on a block size of four, generated by a computer random number generator. the primary outcome was percentage of healed wounds seven days after drainage. a sample of patients had % power to detect an absolute difference of % in healing rates assuming a baseline rate of %. all analyses were by intention to treat. results: twenty-seven patients were allocated to primary and to secondary closure, of whom and , respectively, were followed to study completion. healing rates at seven days were similar between the primary and secondary closure groups ( we compared consecutive patients each scanned on the or slice ccta in - . measures and outcomes-data were prospectively collected using standardized data collection forms required prior to performing ccta. the main outcomes were cumulative radiation doses and volumes of intravenous contrast. data analysis-groups compared with t-, mann whitney u, and chi-square tests. results: the mean age of patients imaged with the and scanners were (sd ) vs. ( ) (p = . ). male:female ratios were also similar ( : vs. : respectively, p = . ). both mean (p < . ) and median (p = . ) effective radiation dose were significantly lower with the ( . and msv) vs. the -slice scanner ( . and msv) respectively. prospective gating was successful in % of the scans and only in % of the scans (p < . ). mean iv contrast volumes were also lower for the vs. the -slice scanner ( ± vs. ± ml; p < . ). the % non-diagnostic scans was similarly low in both scanners ( % each). there were no differences in use of beta-blockers or nitrates. conclusion: when compared with the -slice scanner, the -slice scanner reduces the effective radiation doses and iv contrast volumes in ed patients with cp undergoing ccta. need for beta-blockers and nitrates was similar and both scanners achieved excellent diagnostic image quality. background: a few studies have demonstrated that bedside ultrasound measurement of inferior vena cava to aorta (ivc-to-ao) ratio is associated with the level of dehydration in pediatric patients and a proposed cutoff of . has been suggested, below which a patient is considered dehydrated. objectives: we sought to externally validate the ability of ivc-to-ao ratio to discriminate dehydration and the proposed cutoff of . in an urban pediatric emergency department (ed). methods: this was a prospective observational study at an urban pediatric ed. we included patients aged to months with clinical suspicion of dehydration by the ed physician and an equal number of control patients with no clinical suspicion of dehydration. we excluded children who were hemodynamically unstable, had chronic malnutrition or failure to thrive, open abdominal wounds, or were unable to provide patient or parental consent. a validated clinical dehydration score (cds) (range to ) was used to measure initial dehydration status. an experienced sonographer blinded to the cds and not involved in the patient's care measured the ivc-to-ao ratio on the patient prior to any hydration. cds was collapsed into a binary outcome of no dehydration or any level of dehydration ( or higher). the ability of ivc-to-ao ratio to discriminate dehydration was assessed using area under the receiver operating characteristic curve (auc) and the sensitivity and specificity of ivc-to-ao ratio was calculated for three cutoffs ( . , . , . ). calculation of auc was repeated after adjusting for age and sex. results: patients were enrolled, ( %) of whom had a cds of or higher. median age was (interquartile range - ) months, and ( %) were female. the ivcto-ao ratio showed an unadjusted auc of . ( % ci . - . ) and adjusted auc of . ( % ci . - . ). for a cutoff of . sensitivity was % ( % ci %- %) and specificity % ( % ci %- %); for a cutoff of . sensitivity was % ( % ci %- %) and specificity % ( % ci %- %); for a cutoff of . sensitivity was % ( % ci %- %) and specificity % ( % ci %- %). conclusion: the ability of the ivc-to-ao ratio to discriminate dehydration in young pediatric ed patients was modest and the cutoff of . was neither sensitive nor specific. background: while early cardiac computed tomographic angiography (ccta) could be more effective to manage emergency department (ed) patients with acute chest pain and intermediate (> %) risk of acute coronary syndrome (acs) than current management strategies, it also could result in increased testing, cost, and radiation exposure. objectives: the purpose of the study was to determine whether incorporation of ccta early in the ed evaluation process leads to more efficient management and earlier discharge than usual care in patients with acute chest pain at intermediate risk for acs. methods: randomized comparative effectiveness trial enrolling patients between - years of age without known cad, presenting to the ed with chest pain but without ischemic ecg changes or elevated initial troponin and require further risk stratification for decision making, at nine us sites. patients are being randomized to either ccta as the first diagnostic test or to usual care, which could include no testing or functional testing such as exercise ecg, stress spect, and stress echo following serial biomarkers. test results were provided to physicians but management in neither arm was driven by a study protocol. data on time, diagnostic testing, and cost of index hospitalization, and the following days are being collected. the primary endpoint is length of hospital stay (los). the trial is powered to allow for detection of a difference in los of . hours between competing strategies with % power assuming that % of projected los values are true. secondary endpoints are cumulative radiation exposure, and cost of competing strategies. tertiary endpoints are institutional, caregiver, and patient characteristics associated with primary and secondary outcomes. rate of missed acs within days is the safety endpoint. results: as of november st, , of patients have been enrolled (mean age: ± , . % female, acs rate . %). the anticipated completion of the last patient visit is / / and the database will be locked in early march . we will present the results of the primary, secondary, and some tertiary endpoints for the entire cohort. conclusion: romicat ii will provide rigorous data on whether incorporation of ccta early in the ed evaluation process leads to more efficient management and triage than usual care in patients with acute chest pain at intermediate risk for acs. (originally submitted as a ''late-breaker.'') meta background: many studies have documented higher rates of advanced radiography utilization across u.s. emergency departments (eds) in recent years, with an associated decrease in diagnostic yield (positive tests / total tests). provider-to-provider variability in diagnostic yield has not been well studied, nor have the factors that may explain these differences in clinical practice. objectives: we assessed the physician-level predictors of diagnostic yield using advanced radiography to diagnose pulmonary embolus (pe) in the ed, including demographics and d-dimer ordering rates. methods: we conducted a retrospective chart review of all ed patients who had a ct chest or v/q scan ordered to rule out pe from / to / in four hospitals in the medstar health system. attending physicians were included in the study if they had ordered or more scans over the study period. the result of each ct and vq scan was recorded as positive, negative, or indeterminate, and the identity of the ordering physician was also recorded. data on provider sex, residency type (em or other), and year of residency completion were collected. each provider's positive diagnostic yield was calculated, and logistic regression analysis was done to assess correlation between positive scans and provider characteristics. results: during the study period, , scans ( , cts and , v/qs) were ordered by providers. the physicians were an average of . years from residency, % were female, and % were em-trained. diagnostic yield varied significantly among physicians (p < . ), and ranged from % to %. the median diagnostic yield was . % (iqr . %- . %). the use of d-dimer by provider also varied significantly from % to % (p < . ). the odds of a positive test were significantly lower among providers less than years out of residency graduation (or . , ci . - . ) after controlling for provider sex, type of residency training, d-dimer use, and total number of scans ordered. conclusion: we found significant provider variability in diagnostic yield for pe and use of d-dimer in this study population, with % of providers having diagnostic yield less than or equal to . %. providers who were more recently graduated from residency appear to have a lower diagnostic yield, suggesting a more conservative approach in this group. background: the literature reports that anticoagulation increases the risk of mortality in patients presenting to emergency departments (ed) with head trauma (ht). it has been suggested that such patients should be treated in a protocolized fashion, including ct within minutes, and anticipatory preparation of ffp before ct results are available. there are significant logistical and financial implications associated with implementation of such a protocol. objectives: our primary objective was to determine the effect of anticoagulant therapy on the risk of intracranial hemorrhage (ich) in elderly patients presenting to our urban community hospital following bunt head injury. methods: this was a retrospective chart review study of ht patients > years of age presenting to our ed over a -month period. charts reviewed were identified using our electronic medical record via chief complaints and icd- codes and cross referencing with written ct logs. research assistants underwent review of at least % of their contributing data to validate reliability. we collected information regarding use of warfarin, clopidogrel, and aspirin and ct findings of ich. using univariate logistic regression, we calculated odds ratios (or) for ich with % ci. results: we identified elderly ht patients. the mean age of our population was , ( . %) admitted to using anticoagulant therapy, and % were on antiplatelet drugs. ( . %) of the cohort had icb, patients required neurosurgical intervention, and had transfusion of blood products. of the non-anticoagulated patients, ( . %) were found to have ich, half of those ( ) , and mir- ) were measured using real-time quantitative pcr from serum drawn at enrollment. il- , il- , and tnf-a were measured using a bio-plex suspension system. baseline characteristics, il- , il- , tnf-a and micrornas were compared using one way anova or fisher exact test, as appropriate. correlations between mirnas and sofa scores, il- , il- , and tnf-a were determined using spearman's rank. a logistic regression model was constructed using in-hospital mortality as the dependent variable and mirnas as the independent variables of interest. bonferroni adjustments were made for multiple comparisons. results: of patients, were controls, had sepsis, and had septic shock. we found no difference in serum mir- a or mir- between cohorts, and found no association between these micrornas and either inflammatory markers or sofa score. mir- demonstrated a significant correlation with sofa score (q = . , p = . ), il- (q = . , p = . ), but not il- or tnf-a (p = . , p = . ). logistic regression demonstrated mir- to be associated with mortality, even after adjusting for sofa score (p = . ). conclusion: mir- a or mir- failed to demonstrate any diagnostic or prognostic ability in this cohort. mir- was associated with inflammation, increasing severity of illness, and mortality, and may represent a novel prognostic marker for diagnosis and prognosis of sepsis. objectives: to examine the association between emergency physician recognition of sirs and sepsis and subsequent treatment of septic patients. methods: a retrospective cohort study of all-age patient medical records with positive blood cultures drawn in the emergency department from / - / at a level i trauma center. patient parameters were reviewed including vital signs, mental status, imaging, and laboratory data. criteria for sirs, sepsis, severe sepsis, and septic shock were applied according to established guidelines for pediatrics and adults. these data were compared to physician differential diagnosis documentation. the mann-whitney test was used to compare time to antibiotic administration and total volume of fluid resuscitation between two groups of patients: those with recognized sepsis and those with unrecognized sepsis. results: sirs criteria were present in / reviewed cases. sepsis criteria were identified in / cases and considered in the differential diagnosis in / septic patients. severe sepsis was present in / cases and septic shock was present in / cases. the sepsis -hour resuscitation bundle was completed in the emergency department in cases of severe sepsis or septic shock. patients who met sepsis criteria and were recognized by the ed physician had a median time to antibiotics of minutes (iqr: - ) and a median ivf of ml (iqr: - ). the patients who met sepsis criteria but went unrecognized in the documentation had a median time to antibiotics of minutes (iqr: - ) and median volume of fluid resuscitation of ml (iqr: . median time to antibiotics and median volume of fluid resuscitation differed significantly between recognized and unrecognized septic patients (p = . and p = . , respectively). conclusion: emergency physicians correctly identify and treat infection in most cases, but frequently do not document sirs and sepsis. lack of documentation of sepsis in the differential diagnosis is associated with increased time to antibiotic delivery and a smaller total volume of fluid administration, which may explain poor sepsis bundle compliance in the emergency department. background: severe sepsis is a common clinical syndrome with substantial human and financial impact. in the first consensus definition of sepsis was published. subsequent epidemiologic estimates were collected using administrative data, but ongoing discrepancies in the definition of severe sepsis led to large differences in estimates. objectives: we seek to describe the variations in incidence and mortality of severe sepsis in the us using four methods of database abstraction. methods: using a nationally representative sample, four previously published methods (angus, martin, dombrovskiy, wang) were used to gather cases of severe sepsis over a -year period ( ) ( ) ( ) ( ) ( ) ( ) . in addition, the use of new icd- sepsis codes was compared to previous methods. our main outcome measure was annual national incidence and in-hospital mortality of severe sepsis. results: the average annual incidence varied by as much as . fold depending on method used and ranged from , ( / , population) to , , ( , / , ) using the methods of dombrovskiy and wang, respectively. average annual increase in the incidence of severe sepsis was similar ( . - . %) across all methods. total mortality mirrored the increase in incidence over the -year period ( background: radiation exposure from medical imaging has been the subject of many major journal articles, as well as the topic of mainstream media. some estimate that one-third of all ct scans are not medically justified. it is important for practitioners ordering these scans to be knowledgeable of currently discussed risks. objectives: to compare the knowledge, opinions, and practice patterns of three groups of providers in regards to cts in the ed. methods: an anonymous electronic survey was sent to all residents, physician assistants, and attending physicians in emergency medicine (em), surgery, and internal medicine (im) at a single academic tertiary care referral level i trauma center with an annual ed volume of over , visits. the survey was pilot tested and validated. all data were analyzed using the pearson's chi-square test. results: there was a response rate of % ( / ). data from surgery respondents were excluded due to a low response rate. in comparison to im, em respondents correctly equated one abdominal ct to between and chest x-rays, reported receiving formal training regarding the risks of radiation from cts, believe that excessive medical imaging is associated with an increased lifetime risk of cancer, and routinely discuss the risks of ct imaging with stable patients more often (see table ). particular patient factors influence whether radiation risks are discussed with patients by % in each specialty (see table ). before ordering an abdominal ct in a stable patient, im providers routinely review the patient's medical imaging history less often than em providers surveyed. overall, % of respondents felt that ordering an abdominal ct in a stable ed patient is a clinical decision that should be discussed with the patient, but should not require consent. conclusion: compared with im, em practitioners report greater awareness of the risks of radiation from cts and discuss risks with patients more often. they also review patients' imaging history more often and take this, as well as patients' age, into account when ordering cts. these results indicate a need for improved education for both em and im providers in regards to the risks of radiation from ct imaging. background: in nebraska, % of emergency departments have annual visits less than , , and the predominance are in rural settings. general practitioners working in rural emergency departments have reported low confidence in several emergency medicine skills. current staffing patterns include using midlevels as the primary provider with non-emergency medicine trained physicians as back-up. lightly-embalmed cadaver labs are used for resident's procedural training. objectives: to describe the effect of a lightlyembalmed cadaver workshop on physician assistants' (pa) reported level of confidence in selected emergency medicine procedures. methods: an emergency medicine procedure lab was offered at the nebraska association of physician assistants annual conference. each lab consisted of a -hour hands-on session teaching endotracheal intubation techniques, tube thoracostomy, intraosseous access, and arthrocentesis of the knee, shoulder, ankle, and wrist to pas. irb-approved surveys were distributed pre-lab and a post-lab survey was distributed after lab completion. baseline demographic experience was collected. pre-and post-lab procedural confidence was rated on a six-point likert scale ( - ) with representing no confidence. the wilcoxon signed-rank test was use to calculate p values. results: pas participated in the course. all completed a pre-and post-lab assessment. no pa had done any one procedure more than times in their career. pre-lab modes of confidence level were £ for each procedure. post-lab modes were > for each procedure except arthrocentesis of the ankle and wrist. however, post lab assessments of procedural confidence significantly improved for all procedures with p values < . . conclusion: midlevel providers' level of confidence improved for emergent procedures after completion of a procedure lab using lightly-embalmed cadavers. a mobile cadaver lab would be beneficial to train rural providers with minimal experience. background: use of automated external defibrillators (aed) improves survival in out-of-hospital cardiopulmonary arrest (ohca). since , the american heart association has recommended that individuals one year of age or older who sustain ohca have an aed applied. little is known about how often this occurs and what factors are associated with aed use in the pediatric population. objectives: our objective was to describe aed use in the pediatric population and to assess predictors of aed use when compared to adult patients. methods: we conducted a secondary analysis of prospectively collected data from u.s. cities that participate in the cardiac arrest registry to enhance survival (cares). patients were included if they had a documented resuscitation attempt from october , through december , and were ‡ year old. patients were considered pediatric if they were less than years old. aed use included application by laypersons and first responders. hierarchical multivariable logistic regression analysis was used to estimate the associations between age and aed use. results: there were , ohcas included in this analysis, of which ( . %) occurred in pediatric patients. overall aed use in the final sample was , , with , ( . %) total survivors. aeds were applied less often in pediatric patients ( . %, % ci: . %- . % vs . %, % ci: . %- . %). within the pediatric population, only . % of patients with a shockable rhythm had an aed used. in all pediatric patients, regardless of presenting rhythm, aed use demonstrated a statistically significant increase in return of spontaneous circulation (aed used . %, % ci: . - . vs aed not used . %, % ci: . - . , p < . ), although there was no significant increase in survival to hospital discharge (aed used . %; aed not used . %; p = . ). in the adjusted model, pediatric age was independently associated with failure to use an aed (or . , % ci: . - . ) as was female sex (or . , % ci: . - . ). patients who had a public arrest (or . , % ci: . - . ) or one that was witnessed by a bystander (or . . %: ci . - . ) were also predictive of aed use. conclusion: pediatric patients who experience ohca are less likely to have an aed used. continued education of first responders and the lay public to increase aed use in this population is necessary. does implementation of a therapeutic hypothermia protocol improve survival and neurologic outcomes in all comatose survivors of sudden cardiac arrest? ken will, michael nelson, abishek vedavalli, renaud gueret, john bailitz cook county (stroger), chicago, il background: the american heart association (aha) currently recommends therapeutic hypothermia (th) for out of hospital comatose survivors of sudden cardiac arrest (cssca) with an initial rhythm of ventricular fibrillation (vf). based on currently limited data, the aha further recommends that physicians consider th for cssca, from both the out and inpatient settings, with an initial non-vf rhythm. objectives: investigate whether a th protocol improves both survival and neurologic outcomes for cssca, for out and inpatients, with any initial rhythm, in comparison to outcomes previously reported in literature prior to th. methods: we conducted a prospective observational study of cssca between august and may whose care included th. the study enrolled eligible consecutive cssca survivors, from both out and inpatient settings with any initial arrest rhythm. primary endpoints included survival to hospital discharge and neurologic outcomes, stratified by sca location, and by initial arrest rhythm. results: overall, of eligible patients, ( %, % ci - %) survived to discharge, ( %, % ci - %) with at least a good neurologic outcome. twelve were out and were inpatients. among the outpatients, ( %, % ci - %) survived to discharge, ( %, % ci - %) with at least a good neurologic outcome. among the inpatients, ( %, % ci - ) survived to discharge, ( %, % ci - %) with at least a good neurologic outcome. by initial rhythm, patients had an initial rhythm of vf/t and non-vf/t. among the patients with an initial rhythm of vf/t, ( %, ci - %) survived to discharge, all with at least a good outcome, including out and inpatients. among the patients with an initial rhythm of non-vf/t, ( %, ci - %) survived to discharge, ( %, ci - %) with at least a good neurologic outcome, including out and inpatients. conclusion: our preliminary data initially suggest that local implementation of a th protocol improves survival and neurologic outcomes for cssca, for out and inpatients, with any initial rhythm, in comparison to outcomes previously reported in literature prior to th. subsequent research will include comparison to local historical controls, additional data from other regional th centers, as well as comparison of different cooling methods. protocolized background: therapeutic hypothermia (th) has been shown to improve the neurologic recovery of cardiac arrest patients who experience return of spontaneous circulation (rosc). it remains unclear as to how earlier cooling and treatment optimization influence outcomes. objectives: to evaluate the effects of a protocolized use of early sedation and paralysis on cooling optimization and clinical outcomes in survivors of cardiac arrest. methods: a -year ( - ), pre-post intervention study of patients with rosc after cardiac arrest treated with th was performed. those patients treated with a standardized order set which lacked a uniform sedation and paralytic order were included in the pre-intervention group, and those with a standardized order set which included a uniform sedation and paralytic order were included in the post-intervention group. patient demographics, initial and discharge glasgow coma scale (gcs) scores, resuscitation details, cooling time variables, severity of illness as measured by the apache ii score, discharge disposition, functional status, and days to death were collected and analyzed using student's t-tests, man-whitney u tests, and the log-rank test. results: patients treated with th after rosc were included, with patients in the pre-intervention group and in the post-intervention group. the average time to goal temperature ( °c) was minutes (pre-intervention) and minutes (post-intervention) (p = . ). a -hour time target was achieved in . % of the patients (post-intervention) compared to . % in the pre-group (p = . ). twenty-eight day mortality was similar between groups ( . % and . %) though hospital length of stay ( days pre-and days post-intervention) and discharge gcs ( preand -post-intervention) differed between cohorts. more post-intervention patients were discharged to home ( . %) compared to . % in the pre-intervention group. conclusion: protocolized use of sedation and paralysis improved time to goal temperature achievement. these improved th time targets were associated with improved neuroprotection, gcs recovery, and disposition outcome. standardized sedation and paralysis appears to be a useful adjunct in induced th. background: ct is increasingly used to assess children with signs and symptoms of acute appendicitis (aa) though concerns regarding long-term risk of exposure to ionizing radiation have generated interest in methods to identify children at low risk. objectives: we sought to derive a clinical decision rule (cdr) of a minimum set of commonly used signs and symptoms from prior studies to predict which children with acute abdominal pain have a low likelihood of aa and compared it to physician clinical impression (pci). methods: we prospectively analyzed subjects aged to years in u.s. emergency departments with abdominal pain plus signs and symptoms suspicious for aa within the prior hours. subjects were assessed by study staff unaware of their diagnosis for clinical attributes drawn from published appendicitis scoring systems and physicians responsible for physical examination estimated the probability of aa based on pci prior to their medical disposition. based on medical record entry rate, frequently used cdr attributes were evaluated using recursive partitioning and logistic regression to select the best minimum set capable of discriminating subjects with and without aa. subjects were followed to determine whether imaging was used and use was tabulated by both pci and the cdr to assess their ability to identify patients who did or did not benefit based on diagnosis. results: this cohort had a . % prevalence ( / subjects) of aa. we derived a cdr based on the absence of two out of three of the following attributes: abdominal tenderness, pain migration, and rigidity/ guarding had a sensitivity of . % ( % ci: . - . ), specificity of . % ( % ci: . - . ), npv of . % ( % ci: . - . ), and negative likelihood ratio of . ( % ci: . - . ). the pci set at aa < % pre-test probability had a sensitivity of . % ( % ci: . - . ), specificity of . % ( % ci: . - . ), npv of . % ( % ci: . - . ), and negative likelihood ratio of . ( % ci: . - . ). the methods each classified % of the patients as low risk for aa. our cdr identified . % ( / ) of low risk subjects who received ct but being aa (-), could have been spared ct, while the pci identified . % ( / ). conclusion: compared to physician clinical impression, our clinical decision rule can identify more children at low risk for appendicitis who could be managed more conservatively with careful observation and avoidance of ct. negative background: abdominal pain is the most common complaint in the ed and appendicitis is the most common indication for emergency surgery. a clinical decision rule (cdr) identifying abdominal pain patients at a low risk for appendicitis could lead to a significant reduction in ct scans and could have a significant public health impact. the alvarado score is one of the most widely applied cdrs for suspected appendicitis, and a low modified alvarado score (less than ) is sometimes used to rule out acute appendicitis. the modified alvarado score has not been prospectively validated in ed patients with suspected appendicitis. objectives: we sought to prospectively evaluate the negative predictive value of a low modified alvarado score (mas) in ed patients with suspected appendicitis. we hypothesized that a low mas (less than ) would have a sufficiently high npv (> %) to rule out acute appendicitis. methods: we enrolled patients greater than or equal to years old who were suspected of having appendicitis (listed as one of the top three diagnosis by the treating physician before ancillary testing) as part of a prospective cohort study in two urban academic eds from august to april . elements of the mas and the final diagnosis were recorded on a standard data form for each subject. the sensitivity, specificity, negative predictive value (npv), and positive predictive value (ppv) were calculated with % ci for a low mas and final diagnosis of appendicitis. background: evaluating children for appendicitis is difficult and strategies have been sought to improve the precision of the diagnosis. computed tomography is now widely used but remains controversial due to the large dose of ionizing radiation and risk of subsequent radiation-induced malignancy. objectives: we sought to identify a biomarker panel for use in ruling out pediatric acute appendicitis as a means of reducing exposure to ionizing radiation. methods: we prospectively enrolled subjects aged to years presenting in u.s. emergency departments with abdominal pain and other signs and symptoms suspicious for acute appendicitis within the prior hours. subjects were assessed by study staff unaware of their diagnosis for clinical attributes drawn from appendicitis scoring systems and blood samples were analyzed for cbc differential and candidate proteins. based on discharge diagnosis or post-surgical pathology, the cohort exhibited a . % prevalence ( / subjects) of appendicitis. clinical attributes and biomarker values were evaluated using principal component, recursive partitioning, and logistic regression to select the combination that best discriminated between those subjects with and without disease. mathematical combination of three inflammation-related markers in a panel comprised of myeloid-related protein / complex (mrp), c-reactive protein (crp), and white blood cell count (wbc) provided optimal discrimination. results: this panel exhibited a sensitivity of % ( % ci, - %), a specificity of % ( % ci, - %), and a negative predictive value of % ( % ci, - %) in this cohort. the observed performance was then verified by testing the panel against a pediatric subset drawn from an independent cohort of all ages enrolled in an earlier study. in this cohort, the panel exhibited a sensitivity of % ( % ci, - %), a specificity of % ( % ci, - %), and a negative predictive value of % ( % ci, - %). conclusion: appyscore is highly predictive of the absence of acute appendicitis in these two cohorts. if these results are confirmed by a prospective evaluation currently underway, the appyscore panel may be useful to classify pediatric patients presenting to the emergency department with signs and symptoms suggestive of, or consistent with, acute appendicitis and thereby sparing many patients ionizing radiation. background: there are no current studies on the tracking of emergency department (ed) patient dispersal when a major ed closes. this study demonstrates a novel way to track where patients sought emergency care following the closure of saint vincent's catholic medical center (svcmc) in manhattan by using de-identified data from a health information exchange, the new york clinical information exchange (nyclix). nyclix matches patients who have visited multiple sites using their demographic information. on april , , svcmc officially stopped providing emergency and outpatient services. we report the patterns in which patients from svcmc visited other sites within nyclix. objectives: we hypothesize that patients often seek emergency care based on geography when a hospital closes. methods: a retrospective pre-and post-closure analysis was performed of svcmc patients visiting other hospital sites. the pre-closure study dates were january , -march , . the post closure study dates were may , -july , . a svcmc patient was defined as a patient with any svcmc encounter prior to its closure. using de-identified aggregate count data, we calculated the average number of visits per week by svcmc patients at each site (hospital a-h). we ran a paired t-test to compare the pre-and post-closure averages by site. the following specifications were used to write the database queries: of patients who had one or more prior visits to svcmc for each day within the study return the following: a. eid: a unique and meaningless proprietary id generated within the nyclix master patient index (mpi). b. age: thru the age of . persons over were listed as '' + '' c. ethnicity/race d. type of visit: emergency e. location of visit: specific nyclix site. results: nearby hospitals within miles saw the highest number of increased ed visits after svcmc closed. this increase was seen until about miles. hospitals > miles away did not see any significant changes in ed visits. see table. conclusion: when a hospital and its ed close down, patients seem to seek emergency care at the nearest hospital based on geography. other factors may include the patient's primary doctor, availabilities of outpatient specialty clinics, insurance contracts, or preference of ambulance transports. this study is limited by the inclusion of data from only the eight hospitals participating in nyclix at the time of the svcmc closure. upstream methods: data were collected on all ed ems arrivals from the metro calgary (population . million) area to its three urban adult hospitals. the study phases consisted of the months from february to october (pre-ocp) compared against the same months in (post-ocp). data from the ems operational database and the regional emergency department information system (redis) database were linked. the primary analysis examined the change in ems offload delay defined as the time from ems triage arrival until patient transfer to an ed bed. a secondary analysis evaluated variability in ems offload delay between receiving eds. conclusion: implementation of a regional overcapacity protocol to reduce ed crowding was associated with an important reduction in ems offload delay, suggesting that policies that target hospital processes have bearing on ems operations. variability in offload delay improvements is likely due to site-specific issues, and the gains in efficiency correlate inversely with acuity. methods: a pre-post intervention study was conducted in the ed of an adult university teaching hospital in montreal (annual visits = ). the raz unit (intervention), created to offload the acu of the main ed, started operating in january, . using a split flow management strategy, patients were directed to the raz unit based on patient acuity level (ctas code and certain code ), likelihood to be discharged within hours, and not requiring an ed bed for continued care. data were collected weekdays from : to : for months (september -december ) (pre-raz) and for . months (february -march ) (post-raz). in the acu of the main ed, research assistants observed and recorded cubicle access time, and nurse and physician assessment times. databases were used to extract socio-demographics, ambulance arrival, triage code, chief complaint, triage and registration time, length of stay, and ed occupancy. background: telephone follow-up after discharge from the ed is useful for treatment and quality assurance purposes. ed follow-up studies frequently do not achieve high (i.e. ‡ %) completion rates. objectives: to determine the influence of different factors on the telephone follow-up rate of ed patients. we hypothesized that with a rigorous follow-up system we could achieve a high follow-up rate in a socioeconomically diverse study population. methods: research assistants (ras) prospectively enrolled adult ed patients discharged with a medication prescription between november , and september , from one of three eds affiliated with one health care system: (a) academic level i trauma center, (b) community teaching affiliate, and (c) community hospital. patients unable to provide informed consent, non-english speaking, or previously enrolled were excluded. ras interviewed subjects prior to ed discharge and conducted a telephone follow-up interview week later. follow-up procedures were standardized (e.g. number of calls per day, times to place calls, obtaining alternative numbers) and each subject's follow-up status was monitored and updated daily through a shared, web-based data system. subjects who completed follow-up were mailed a $ gift card. we examined the influence of patient (age, sex, race, insurance, income, marital status, usual major activity, education, literacy level, health status), clinical (acuity, discharge diagnosis, ed length of stay, site), and procedural factors (number and type of phone numbers received from subjects, offering two gift cards for difficult to reach subjects) on the odds of successful followup using multivariate logistic regression. results: of the , enrolled, % were white, % were covered by medicaid or uninsured, and % reported an annual household income of <$ , . % completed telephone follow-up with % completing on the first attempt. the table displays the factors associated with successful follow-up. in addition to patient demographics and lower acuity, obtaining a cell phone or multiple phone numbers as well as offering two gift cards to a small number of subjects increased the odds of successful follow-up. conclusion: with a rigorous follow-up system and a small monetary incentive, a high telephone follow-up rate is achievable one week after an ed visit. methods: an interrupted time-series design was used to evaluate the study question. data regarding adherence with the following pneumonia core measures were collected pre-and post-implementation of the enhanced decision-support tool: blood cultures prior to antibiotic, antibiotic within hours of arrival, appropriate antibiotic selection, and mean time to antibiotic administration. prescribing clinicians were educated on the use of the decision-support tool at departmental meetings and via direct feedback on their cases. results: during the -month study period, complete data were collected for patients diagnosed with cap: in the pre-implementation phase and post-implementation. the mean time to antibiotic administration decreased by approximately one minute from the pre-to post-implementation phase, a change that was not statistically significant (p = . ). the proportion of patients receiving blood cultures prior to antibiotics improved significantly (p < . ) as did the proportion of patients receiving antibiotics within hours of ed arrival (p = . ). a significant improvement in appropriate antibiotic selection was noted with % of patients experiencing appropriate selection in the post-phase, p = . . use of the available support tool increased throughout the study period, v = . , df = , p < . . all improvements were maintained months following the study intervention. conclusion: in this academic ed, introduction of an enhanced electronic clinical decision support tool significantly improved adherence to cms pneumonia core measures. the proportion of patients receiving blood cultures prior to antibiotics, antibiotics within hours, and appropriate antibiotics all improved significantly after the introduction of an enhanced electronic clinical decision support tool. background: emergency medicine (em) residency graduates need to pass both the written qualifying exam and oral certification exam as the final benchmark to achieve board certification. the purpose of this project is to obtain information about the exam preparation habits of recent em graduates to allow current residents to make informed decisions about their individual preparation for the abem written qualifying and oral certification exams. objectives: the study sought to determine the amount of residency and individual preparation, to determine the extent of the use of various board review products, and to elicit evaluations of the various board review products used for the abem qualifying and certification exams. methods: design: an online survey instrument was used to ask respondents questions about residency preparation and individual preparation habits, as well as the types of board review products used in preparing for the em boards. participants: as greater than % of all em graduates are emra members, an online survey was sent to all emra members who have graduated for the past three years. observations: descriptive statistics of types of preparation, types of resources, time, and quantitative and qualitative ratings for the various board preparation products were obtained from respondents. results: a total of respondents spent an average of . weeks and hours per week preparing for the written qualifying exam and spent an average of weeks and . hours per week preparing for the oral certification exam. in preparing for the written qualification exam, % used a preparation textbook with % using more than one textbook and % using a board preparation course. in preparing for the oral qualifying exam, % used a preparation textbook while % used a preparation course. sixty-seven percent of respondents reported that their residency programs had a formalized written qualifying exam preparation curriculum of which % was centered on the annual in-training exam. eight-five percent of residency programs had a formalized oral certification exam preparation. respondents reported spending on average $ preparing for the qualifying exam and $ for the certification exam. conclusion: em residents spend significant amounts of time and money and make use of a wide range of residency and commercially available resources in preparing for the abem qualifying and certification exams. background: communication and professionalism skills are essential for em residents but are not wellmeasured by selection processes. the multiple mini-interview (mmi) uses multiple, short structured contacts to measure these skills. it predicts medical school success better than the interview and application. its acceptability and utility in em residency selection is unknown. objectives: we theorized that the mmi would provide novel information and be acceptable to participants. methods: interns from three programs in the first month of training completed an eight-station mmi developed to focus on em topics. pre-and post-surveys assessed reactions using five-point scales. mmi scores were compared to application data. results: em grades correlated with mmi performance (f( . ) = : , p < . ) with honors students having higher mmi summary scores. higher third year clerkship grades trended to higher mmi performance means, although not significantly. mmi performance did not correlate with a match desirability rating and did not predict other individual components of the application including usmle step or usmle step . participants preferred a traditional interview (mean difference = . , p < . ). a mixed format was preferred over a pure mmi (mean difference = . , p < . ). preference for a mixed format was similar to a traditional interview. mmi performance did not significantly correlate with preference for the mmi; however, there was a trend for higher performance to associate with higher preference (r = . , t( ) = . , n.s.) performance was not associated with preference for a mix of interview methods (r = . , t( ) = . , n.s.). conclusion: while the mmi alone was viewed less favorably than a traditional interview, participants were receptive to a mixed methods interview. the mmi appears to measure skills important in successful completion of an em clerkship and thus likely em residency. future work will determine whether mmi performance correlates with clinical performance during residency. background: the annual american board of emergency medicine (abem) in-training exam is a tool to assess resident progress and knowledge. when the new york-presbyterian (nyp) em residency program started in , the exam was not emphasized and resident performance was lower than expected. a course was implemented to improve residency-wide scores despite previous em literature failing to exhibit improvements with residency-sponsored in-training exam interventions. objectives: to evaluate the effect of a comprehensive, multi-faceted course on residency-wide in-training exam performance. methods: the nyp em residency program, associated with cornell and columbia medical schools, has a year format with - residents per year. an intensive -week in-training exam preparation program was instituted outside of the required weekly residency conferences. the program included lectures, pre-tests, high-yield study sheets, and remediation programs. lectures were interactive, utilizing an audience response system, and consisted of core lectures ( - . hours) and three review sessions. residents with previous in-training exam difficulty were counseled on designing their own study programs. the effect on intraining exam scores was measured by comparing each resident's score to the national mean for their postgraduate year (pgy). scores before and after course implementation were evaluated by repeat measures regression modeling. overall residency performance was evaluated by comparing residency average to the national average each year and by tracking abem national written examination pass rates. results: resident performance improved following course implementation. following the course's introduction, the odds of a resident beating the national mean increased by . ( % ci . - . ) and the percentage of residents exceeding the national mean for their pgy year increased by % ( % ci %- %). following course introduction, the overall residency mean score has outperformed the national exam mean annually and the first-time abem written exam board pass rate has been %. conclusion: a multi-faceted in-training exam program centered around a -week course markedly improved overall residency performance on the in-training exam. limitations: this was a before and after evaluation as randomizing residents to receive the course was not logistically or ethically feasible. . years of practice. among the nonresidency trained, non-boarded em physicians, the percentage of individuals with board actions against them was significantly higher ( . % vs. . %, % ci for difference of . % = . to . %), but the incidence of actions was not significant ( . vs. . events/ years of practice, % ci for difference of . / = ) / to + / ), but the power to detect a difference was %. conclusion: in this study population, em-trained physicians had significantly fewer total state medical board disciplinary actions against them than non-em trained physicians, but when adjusted for years of practice (incidence), the difference was not significantly different at the % confidence level. the study was limited by low power to detect a difference in incidence. objectives: we chose pain documentation as a long term project for quality improvement in our ems system. our objectives were to enhance the quality of pain assessment, to reduce patient suffering and pain through improved pain management, to improve pain assessment documentation, to improve capture of initial and repeat pain scales, and to improve the rate of pain medication. this study addressed the aim of improving pain assessment documentation. methods: this was a quasi-experiment looking at paramedic documentation of the pqrst mnemonic and pain scales. our intervention consisted of mandatory training on the importance and necessity of pain assessment and treatment. in addition to classroom training, we used rapid cycle individual feedback and public posting of pain documentation rates (with unique ids) for individual feedback. the categories of chief complaint studied were abdominal pain, blunt injury, burn, chest pain, headache, non-traumatic body pain, and penetrating injury. we compared the pain documentation rates in the months prior to intervention, the months of intervention, and months post intervention. using repeated-measures anova, we compared rates of paramedic documentation over time. results: our ems system transported patients during the study period, of whom were for painful conditions in the defined chief complaint categories. there were paramedics studied, of whom had complete data. documentation increased from of painful cases ( . %) in qtr to of painful cases ( . %) in qtr . the trend toward increased rates of pain documentation over the three quarters was strongly significant (p < . ). paramedics were significantly more likely to document pain scales and pqrst assessments over the course of the study with the highest rates of documentation compliance in the final -month period. conclusion: a focused intervention of education and individual feedback through classroom training, one on one training, and public posting improves paramedic documentation rates of perceived patient pain. background: emergency medical services (ems) systems are vital in the identification, assessment, and treatment of trauma, stroke, myocardial infarction, and sepsis and improving early recognition, resuscitation, and transport to adequate medical facilities. ems personnel provide similar first-line care for patients with syncope, performing critical actions such as initial assessment and treatment as well as gathering key details of the event. objectives: to characterize emergency department patients with syncope receiving initial care by ems and their role as initial providers. methods: we prospectively enrolled patients over years of age who presented with syncope or near syncope to a tertiary care ed with , annual patient visits from june to june . we compared patient age, sex, comorbidities, and -day cardiopulmonary adverse outcomes (defined as myocardial infarction, pulmonary embolism, significant cardiac arrhythmia, and major cardiovascular procedure) between ems and non-ems patients. descriptive statistics, two-sided ttests, and chi-square testing were used as appropriate. results: of the patients enrolled, ( . %) arrived by ambulance. the most common complaint in patients transported by ems was fainting ( . %) or dizziness ( . %); syncope was reported in ( . %). compared to non-ems patients, those who arrived by ambulance were older (mean age (sd) . ( . ), vs. . ( . ) years, p = . ). there were no differences in the proportion of patients with hypertension ( . % vs . %, p = . ), coronary artery disease ( . % vs . %, p = . ), diabetes mellitus ( . % vs . %, p = . ), or congestive heart failure ( . % vs . %, p = . ). sixtynine ( . %) patients experienced a cardiopulmonary event within days. twenty-eight ( . %) patients who arrived by ambulance and ( . %) non-ems patients had a subsequent cardiopulmonary adverse event (rr . , %ci . - . ) within days. the table tabulates interventions provided by ems prior to ed arrival. conclusion: ems providers care for more than one third of ed syncope patients and often perform key interventions. ems systems offer opportunities for advancing diagnosis, treatment, and risk stratification in syncope patients. background: abdominal pain is the most common reason for visiting an emergency department (ed), and abdominopelvic computed tomography (apct) use has increased dramatically over the past decade. despite this, there has been no significant change in rates of admission or diagnosis of surgical conditions. objectives: to assess whether an electronic accountability tool affects apct ordering in ed patients with abdominal or flank pain. we hypothesized that implementation of an accountability tool would decrease apct ordering in these patients. methods: before and after study design using an electronic medical record at an urban academic ed from jul-nov , with the electronic accountability tool implemented in oct for any apct order. inclusion criteria: age >= years, non-pregnant, and chief complaint or triage pain location of abdominal or flank pain. starting oct th , , resident attempts to order apct triggered an electronic accountability tool which only allowed the order to proceed if approved by the ed attending physician. the attending was prompted to enter the primary and secondary diagnoses indicating apct, agreement with need for ct and, if no agreement, who was requesting this ct (admitting or consulting physician), and their pretest probability ( - ) of the primary diagnosis. patients were placed into two groups: those who presented prior to (pre) and after (post) the deployment of the accountability tool. background: there has been a paradigm shift in the diagnostic work-up for suspected appendicitis. edbased staged protocols call for the use of ultrasound prior to ct scanning because of its lack of radiation, and the morbidity related to contrast. a barrier to implementation is the lack of / availability of ultrasound. objectives: to evaluate the impact of the implementation of ed performed appendix ultrasounds (apus) on ct utilization in the staged workup for appendicitis in the emergency department. methods: we performed a quasi-experimental, before/ after study. we compared data from the first months of , before the availability of ed performed apus, with the same interval in after introduction of ed apus. we excluded patients who had appendectomies for reasons other than appendicitis or had been diagnosed prior to arrival. no patient identifiers were included in the analysis and the study was approved by the hospital irb. we report the following descriptive statistics (percentages, sensitivities, and absolute utilization changes conclusion: implementation of an ed apus in the staging work up of appendicitis was associated with a significant reduction in overall ct utilization in the ed. objectives: this study aims to evaluate ed patients' knowledge of radiation exposure from ct and mri scans as well as the long-term risk of developing cancer. we hypothesize that ed patients will have a poor understanding of the risks, and will not know the difference between ct and mri. methods: design -this was a cross-sectional survey study of adult, english-speaking patients at two eds from / / - / / . setting -one location was a tertiary care center with an annual ed census of , patient visits and the other was a community hospital with annual ed census of , patient visits. obser-vations -the survey consisted of six questions evaluating patients' understanding of radiation exposure from ct and mri as well as long-term consequences of radiation exposure. patients were then asked their age, sex, race, highest level of education, annual household income, and whether they considered themselves health care professionals. results: there were participants in this study, (of , total) from the academic center and (of , total) from the community hospital during the study period. overall, only % ( % ci - %) of participants understood the radiation risks associated with ct scanning. % ( % ci - %) of patients believed that an abdominal ct had the same or less radiation as a chest x-ray. % ( % ci - %) believed that there was an increased risk of developing cancer from repeated abdominal cts. only % ( % ci - %) of patients knew that mri scans had less radiation than ct. % ( % ci - %) either didn't know or believed that repeated mris were associated with an increased risk of developing cancer. higher educational level, household income, and identification as a health care professional all were associated with correct responses, but even within these groups, a majority gave incorrect responses. conclusion: in general, ed patients do not understand the radiation risks associated with advanced imaging modalities. we need to educate these patients so that they can make informed decisions about their own health care. background: homelessness has been associated with many poor health outcomes and frequent ed utilization. it has been shown that frequent use of the ed in any given year is not a strong predictor of subsequent use. identifying a group of patients who are chronic high users of the ed could help guide intervention. objectives: the purpose of this study is to identify if homelessness is associated with chronic ed utilization. methods: a retrospective chart review was accomplished looking at the records of the most frequently seen patients in the ed for each year from - at a large, urban academic hospital with an annual volume of , . patients' visit dates, chief complaints, dispositions, and housing status were reviewed. homelessness was defined by self-report at registration. patients were categorized according to their ed utilization with those seen > times in at least three of the five years of the study identified as chronic high utilizers; and those who visited the ed > times in at least three of the five years of the study were identified as chronic ultra-high utilizers. descriptive statistics with confidence intervals were calculated, and comparisons were made using non-parametric tests. results: during the -year study period, , unique patients were seen, of whom . % patients were homeless. patients were identified as frequent users. there were patients who presented on the top utilizer lists from multiple years. ( %, %ci - ) patients were identified as homeless. patients were seen > times in at least three of the years and ( %, - ) were homeless. patients were seen > times in at least three of the years and ( %, - ) were homeless. our facility has a % admission rate; however, non homeless chronic ultra-high utilizers had admission rates of % and homeless chronic ultra-high utilizers were admitted %. conclusion: chronic ultra-high utilizers of our ed are disproportionately homeless and present with lower severity of illness. these patients may prove to be a cost-effective group to house or otherwise involve with aggressive case management. the debate over homeless housing programs and case management solutions can be sharpened by better defining the groups who would most benefit and who represent the greatest potential saving for the health system. background: the prevalence of obese patients presenting to our emergency department (ed) is %: obese patients present in disproportionate number compared to the general population (us rate = %). in spite of this, there is a disconnect in patients' perceptions of weight and health: many patients underestimate their weight and report a key barrier to weight loss is patient-provider communications; such discussions have proven to be highly effective in smoking, drug, and alcohol cessation, an important initial step toward promoting wellness. information about patient provider communication is essential for designing and implementing emergency department (ed) based interventions to help increase patient awareness about weightrelated medical issues and provide counseling for weight reduction. objectives: we assessed patients' perceptions about obesity as disease and patient communication with their providers through two questions: do you believe your present weight is damaging to your health? has a doctor or other health professional every told you that you are overweight? methods: a descriptive cross-sectional study was performed in an academic tertiary care ed. a randomized sample of patients (every fifth) presenting to the ed (n = ) was enrolled. pregnant patients, patients who were medically unstable, cognitively impaired, or who were unable or unwilling to provide informed consent were excluded. percentages of ''yes'' and ''no'' are reported for each question based on patient bmi, ethnicity, sex, and the number of comorbid conditions. regression analysis was used to determine differences in responses between subgroups. results: among overweight/obese, white/black patients, . % do not feel their weight is damaging to their health and . % reported they have not been told by a doctor they are overweight. of individuals who have been told by a doctor they were overweight, . % still believe their present weight is not damaging to their health. of individuals who have not been told by a doctor they were overweight, . % believe their present weight is damaging to their health. differences in race and age were not found. p values < . for all results. conclusion: our data point toward a disconnect regarding patients' perceptions of health and weight. timely education about the burden of obesity may lead to a decrease in its overall prevalence. (originally submitted as a ''late-breaker.'') objectives: to examine the attitudes and expectations of patients admitted for inpatient care following an emergency department visit. methods: a descriptive study was done by surveying a voluntary sample of adult patients (n = ) admitted to the hospital from the emergency department in one urban teaching hospital in the midwest. a short, ninequestion survey was developed to assess patient attitudes and expectations towards hiv testing, consent, and requirements. analyses consisted of descriptive statistics, correlations, and chi-square analyses. results: the majority of patients report that hiv testing should be a routine part of health care screening ( . %) and that the hospital should routinely test admitted patients for hiv ( . %). despite these overall positive attitudes towards hiv testing, the data also suggest that patients have strong attitudes towards consent requirements with % acknowledging that hiv testing requires special consent and % reporting that separate consent should be required. the data also showed a statistically significant difference in the proportion of patients who believed that hiv testing is a part of routine health care screening by race (v = . , df = , p = . ). conclusion: patients attitudes and expectations towards routine hiv testing are consistent with the cdc recommendations. emergency departments are an ideal setting to initiate hiv testing and the findings suggest that patients expect hospital policies outline procedures for obtaining consent and screening all patients who are admitted to the hospital from the ed. results: the analysis revealed a ''hot spot'', a cluster of counties ( . %) with high ca rates adjacent to counties with high ca rates, located across the southeastern us (p < . ). within these counties, the average ca rate was % higher than the national average. a ''cool spot'', a cluster of counties ( . %) with low rates, was located across the midwest (p < . ). in this cool spot the average ca rate was % lower than the national average. figures and show us adjusted rates and spatial autocorrelation of ca deaths, respectively. conclusion: we identify geographic disparities in ca mortality and describe the cardiac arrest belt in the southeastern us. a limitation of this analysis was the use of icd- codes to identify cardiac arrest deaths; however, no other national data exist. an improved understanding of the drivers of this variability is essential to targeted prevention and treatment strategies, especially given the recent emphasis on development of cardiac resuscitation centers and cardiac arrest systems of care. an understanding of the relation between population density, cardiac arrest count, and cardiac arrest rate will be essential to the design of an optimized cardiac arrest system. we defined ed utilization during the past months as non-users ( visits), infrequent users ( - visits), frequent users ( - visits), and super-frequent users ( ‡ visits). we compared demographic data, socioeconomic status, health conditions, and access to care between these ed utilization groups. results: overall, super-frequent use was reported by . % of u.s. adults, frequent use by %, and infrequent ed use by %. higher ed utilization was associated with increased self-reported fair to poor health ( % for super-frequent, % for frequent, % for infrequent, % for non-ed users). frequent ed users were also more likely to be impoverished, with % of superfrequent, % of frequent, % of infrequent, and % of non-ed users reporting a poverty-income ratio < . adults with higher ed utilization were more likely to report the ed as the place they usually go when sick ( % for super-frequent, % for frequent, % for infrequent, . % for non-ed users). they also reported greater outpatient resource utilization, with % of super-frequent, % of frequent, % of infrequent, and % of non-ed users reporting ‡ outpatient visits/year. frequent ed users were also more likely than non-ed users to be covered by medicaid ( % for super-frequent, % for frequent, % for infrequent, % for non-ed users). conclusion: frequent ed users were a vulnerable population with lower socioeconomic status, poor overall health, and high outpatient resource utilization. interventions designed to divert frequent users from the ed should also focus on chronic disease management and access to outpatient services, rather than focusing solely on limiting ed utilization. objectives: we explored factors associated with specialty provider willingness to provide urgent appointments to children insured by medicaid/chip. methods: as part of a mixed method study of child access to specialty care by insurance status, we conducted semi-structured qualitative interviews with a purposive sample of specialists and primary care physicians (pcps) in cook county, il. interviews were conducted from april to september , until theme saturation was reached. resultant transcripts and notes were entered into atlas.ti and analyzed using an iterative coding process to identify patterns of responses in the data, ensure reliability, examine discrepancies, and achieve consensus through content analysis. results: themes that emerged indicate that pcps face considerable barriers getting publicly insured patients into specialty care and use the ed to facilitate this process. ''if i send them to the emergency room, i'm bypassing a number of problems. i'm fully aware that i'm crowding the emergency room.'' specialty physicians reported that decisions to refuse or limit the number of patients with medicaid/chip are due to economic strain or direct pressure from their institutions ''in the last budget revision, we were [told], 'you are losing money, so you need to improve your patient mix'''. in specialty practices with limited medicaid/chip appointment slots, factors associated with appointment success included: high acuity or complexity, personal request from or an informal economic relationship with the pcp, geography, and patient hardship. ''if it's a really desperate situation and they can't find anybody else, i will make an exception''. specialists also acknowledged that ''patients who can't get an appointment go to the er and then i am obligated to see them if they're in the system.'' conclusion: these exploratory findings suggest that a critical linkage exists between hospital eds and affiliated specialty clinics. as health systems restructure, there is an opportunity for eds to play a more explicit role in improving care coordination and access to specialty care. albert amini, erynne a. faucett, john m. watt, richard amini, john c. sakles, asad e. patanwala university of arizona, tucson, az background: trauma patients commonly receive etomidate and rocuronium for rapid sequence intubation (rsi) in the ed. due to the long duration of action of rocuronium and short duration of action of etomidate, these patients require prompt initiation of sedatives after rsi. this prevents the potential of patient awareness under pharmacological paralysis, which could be a terrifying experience. objectives: the purpose of this study was to evaluate the effect of the presence of a pharmacist during traumatic resuscitations in the ed on the initiation of sedatives and analgesics after rsi. we hypothesized that pharmacists would decrease the time to provision of sedation and analgesia. methods: this was an observational, retrospective cohort study conducted in a tertiary, academic ed that is a level i trauma center. consecutive adult trauma patients who received rocuronium in the ed for rsi were included during two time periods: / / to / / (pre-phase -no pharmacy services in the ed) and / / to / / (post-phase -pharmacy services in the ed). since the pharmacist could not respond to all traumas in the post-phase, this was further categorized based on whether the pharmacist was present or absent at the trauma resuscitation. data collected included patient demographics, baseline injury data, and medications used. the median time from rsi to initiation of sedatives and analgesics was compared between the pre-phase group (group ), post-phase pharmacist absent group (group ), and post-phase pharmacist present group (group ) using the kruskal-wallis test. results: a total of patients were included in the study (group = , group = , and group = ). median age was , . , and . years in groups , , and , respectively (p = . ). there were no other differences between groups with regard to demographics, mechanism of injury, presence of traumatic brain injury, glasgow coma scale score, vital signs, ed length of stay, or mortality. median time between rsi and post-intubation sedative use was , , and minutes in groups , and , respectively (p < . ). median time between rsi and post-intubation analgesia use was , , and minutes in groups , , and , respectively (p < . ). the presence of a pharmacist during trauma resuscitations decreases time to provision of sedation and analgesia after rsi. background: outpatient antibiotics are frequently prescribed from the ed, and limited health literacy may affect compliance with recommended treatments. objectives: among patients stratified by health literacy level, multimodality discharge instructions will improve compliance with outpatient antibiotic therapy and follow-up recommendations. methods: this was a prospective randomized trial that included consenting patients discharged with outpatient antibiotics from an urban county ed with an annual census of , . patients unable to receive text messages or voicemails were excluded. health literacy was assessed using a validated health literacy assessment, the newest vital sign (nvs). patients were randomized to a discharge instruction modality: ) usual care, typed and verbal medication and case-specific instructions; ) usual care plus text messaged instructions sent to the patient's cell phone; or ) usual care plus voicemailed instructions sent to the patient's cell phone. antibiotic pick-up was verified with the patient's pharmacy at hours. patients were called at days to determine antibiotic compliance. z-tests were used to compare -hour antibiotic pickup and patient-reported compliance across instructional modality and nvs score groups. results: patients were included ( % female, median age , range months to years); were excluded. % had an nvs score of - , % - , and % - . the proportion of prescriptions filled at hours varied significantly across nvs score groups; self-reported medication compliance at days revealed no difference across different instructional modalities nor nvs scores (table ) . conclusion: in this sample of urban ed patients, hour prescription pickup varied significantly by validated health literacy score, but not by instruction delivery modality. in this sample, patients with lower health literacy are at risk of not filling their outpatient antibiotics in a timely fashion. has been developed, validated, and utilized to study the processes of care involved in successful care transitions from inpatient to outpatient settings, but has not been utilized in the ed. objectives: we hypothesized that the ctm- could be successfully implemented in the ed without differential item difficulty by age, sex, education, or race; and would be associated with measures of quality of care and likelihood of following physician recommendations. methods: a descriptive study design based on exit surveys was used to measure ctm- scores and likelihood of following treatment recommendations. surveys were administered to a daily cross-sectional sample of all patients leaving the ed between a- a by research assistants in an urban academic ed setting for weeks in november . we report means and standard deviations, and analysis of variance to identify differences in ctm- scores for those who planned and did not plan to follow ed recommendations. results: surveys were completed; patients were ± years old, % black, % female, % with at least some college education, and % were admitted. average ctm- score was . ± . (range - ). scores were not associated with sex (p = . ), race (p = . ), or education level (p = . ). lower ctm scores were associated with increasing age (p = . ), patient perceptions that the ed team was less likely to use words that they understood, listen carefully to them, inspire their confidence and trust, or encourage them to ask questions (all p < . ). those who reported they were ''very likely'' to follow ed treatment had an average score of ± , while those who were ''unlikely'' or ''very unlikely'' to follow ed treatment plans had an average score ± (p = . ). conclusion: the ctm- performs well in the ed and exhibited only differential item difficulty by age; there was no significant difference by race, sex, or education level. furthermore, it is highly associated with likelihood of following physician recommendations. future studies will focus on ctm- scores ability to discriminate between patients who did or did not experience a subsequent ed visit or rehospitalization. age and race were found to be significant predictors of the race pathway. regression of the data by race revealed blacks (or . : ci . - . ; p < . ), hispanics (or . : ci . - . ; p = . ), and asians (or . : ci . - . ; p = . ), were more likely to enter the race cohort than were whites; however, much of this discrepancy is accounted for by age. the mean age of minority patients was years, while white patients were older at years (p = . ). conclusion: in a diverse demographic population we found that racial minorities were presenting at younger ages for chest pain and were more likely to receive cardiac testing at bedside than their white counterparts; and hence, were selected to a lower level of care (nonmonitored unit background: expanding insurance coverage is designed to improve access to primary care and reduce use of emergency services. whether expanding coverage achieves this is of paramount importance as the united states prepares for the affordable care act. objectives: we examined ed and outpatient department use after the state children's health insurance program (schip) coverage expansion, focusing on adolescents (a major target group for schip) versus young adults (not targeted). we hypothesized that coverage would increase use of outpatient services and emergency department services would decrease. methods: using the national ambulatory medical care survey and the national hospital ambulatory medical care survey, we analyzed years - as baseline and then compared use patterns in - after schip launch. primary outcomes were populationadjusted annual visits to ed versus non-emergency outpatient settings. interrupted time-series were performed on use rates to ed and outpatient departments between adolescents ( - years old) and young adults ( - years old) in the pre-schip and schip periods. outpatient-to-ed ratios were calculated and compared across time periods. results: the mean number of outpatient adolescent visits increased by visits per persons ( % ci, - ), while there was no statistically significant increase in young adult outpatient visits across time periods. there was no statistically significant change in the mean number of adolescent ed visits across time periods, while young adult ed use increased by visits per persons ( % ci, - ). the adolescent outpatient-to-ed ratio increased by . ( % ci, . - . ), while the young adults ratio decreased by . across time periods ( % ci, ) . to ) . ). conclusion: since schip, adolescent non-ed outpatient visits increased while ed visits remained unchanged. in comparison to young adults, expanding insurance coverage to adolescents improved access to health care services and suggests a shift to non-ed settings. as an observational study we are unable to control for secular trends during this time period. also as an ecological study we are unable to examine individual variation. expanding insurance through the affordable care act of will likely increase use of outpatient services but may not decrease emergency department volumes. background: cancer patients are receiving a greater proportion of their care on an outpatient basis. the effect of this change in oncology care patterns on ed utilization is poorly understood. objectives: to examine the characteristics of ed utilization by adult cancer patients. methods: between july and march , all new adult cancer patients referred to a tertiary care cancer centre were recruited into a study examining psychological distress. these patients were followed prospectively until september . the collected data were linked to administrative data from three tertiary care eds. variables evaluated in this study included basic we have previously shown that reducing non-value-added activities through the application of the lean process improvement methodology improves patient satisfaction, physician productivity and emergency department length of stay. objectives: in this investigation, we tested the hypothesis that non-value-added activities reduce physician job satisfaction. methods: to test this hypothesis, we conducted timemotion studies on attending emergency physicians working in an academic setting and categorized their activities into value-added (time in room with patient, time discussing cases and educating medical learners, time in room with patient and learner), necessary non-valueadded activities (charting, sign out, looking up labs), and unnecessary non-value-added activities (looking for things, looking for people, on the phone). the physicians were then surveyed using a -point likert scale to determine their relative satisfaction with each of the individual tasks ( worst part of day, best part of day). results: physicians spent % of their shift performing value-added work, % of their shift performing necessary non-value-added activities, and % of their shift performing unnecessary non-value-added activities (waste). weighted physician satisfaction (satisfaction x [percent time spent performing the activity / percent time engaged in activity category]) was highest when the physician was performing value-added work ( . ) compared to performing either necessary non-valueadded work ( . ) or waste ( . ). conclusion: the attending physicians we studied spent the majority of their time performing non-value-added activities, which were associated with lower satisfaction. application of process improvement techniques such as lean, which focus on reducing non-value-added work, may improve emergency physician job satisfaction. background: rocuronium and succinylcholine are the most commonly used paralytics for rapid sequence intubation (rsi) in the ed. after rsi, patients need sustained sedation while they are mechanically ventilated. however, the longer duration of action of rocuronium may influence subsequent sedation dosing, while the patient is therapeutically paralyzed. objectives: we hypothesized that patients who receive rocuronium would be more likely to receive lower doses of post-rsi sedation compared to patients who receive succinylcholine. methods: this was an observational, retrospective cohort study conducted in a tertiary, academic ed. consecutive adult patients, who received rsi using etomidate for induction of sedation between / / to / / , were included. patients were then categorized based on whether they received rocuronium or succinylcholine for paralysis. the dosing of post-rsi sedative infusions was compared at , , , and minutes after initiation between the two groups using the wilcoxon rank-sum test. results: a total of patients were included in the final analysis (rocuronium = , succinylcholine = ). mean age was and years in the rocuronium and succinylcholine groups, respectively (p = . ). there were no other baseline differences between groups with regard to demographics, reason for intubation, stroke, traumatic brain injury, glasgow coma scale score, pain scores, or vital signs. in the overall cohort, . % (n = ) of patients were given a sedative infusion or bolus in the ed. most patients were initiated on propofol (n = ) or midazolam (n = ) infusions. median propofol infusion rates at , , , and minutes were , , . , and mcg/kg/min in the rocuronium group and , , , and mcg/kg/ min in succinylcholine group, respectively. the difference was statistically significant at (p < . ) and (p = . ) minutes. median midazolam infusion rates at , , , and minutes were , , , and mg/hour in the rocuronium group and , , , and . mg/hour in succinylcholine group, respectively. the difference was statistically significant at (p = . ) and (p = . ) minutes. conclusion: patients who receive rocuronium are more likely to receive lower doses of sedative infusions post-rsi due to sustained therapeutic paralysis. this may put them at risk for being awake under paralysis. what is the impact of the implementation of an there was a difference in presenting pain (p < . ), stress (p < . ), and anxiety (p < . ) among patients that received an opioid in the ed. there was a difference in presenting pain (p < . ) for patients discharged with an opioid prescription, but not for stress (p = . ) or anxiety (p = . ). conclusion: patient-reported pain, stress, and anxiety are higher among patients who received an opiate in the ed than in those who did not, but only pain is higher among patients who received a discharge prescription for an opioid. methods: this was a prospective, randomized crossover study on the use of gvl and dl by incoming pediatric interns prior to advanced life support training. at the start of the study, the interns received a didactic session and expert modeling of the use of both devices for intubation. two scenarios were used: ( ) normal intubation with a standard airway and ( ) difficult intubation with tongue edema and pharyngeal swelling. interns then intubated laerdal simbaby in each scenario with both gvl and dl for a total of four randomized intubation scenarios. primary outcomes included time to successful intubation and the rate of successful intubation. the interns also rated their satisfaction with the devices using a visual analog scale ( - ) and chose their preferred device for their next intubation. results: interns were included in this study. in the normal airway scenario, there were no differences in the mean time for intubation with gvl or dl ( . ± . vs . ± . seconds, p = ns) or the number of interns who performed successful intubation ( vs , p = ns). in the difficult airway scenario, the interns took longer to intubate with gvl than dl ( . ± . vs . ± . seconds, p = . ), but there were no differences in the number of successful intubations ( vs , p = ns). interns rated their satisfaction higher for gvl than dl ( . ± . vs . ± . , p = . ) and gvl was chosen as the preferred device for their next intubation by a majority of the interns ( / , %). conclusion: for novice clinicians, gvl does not improve the time to intubation or intubation success objectives: to determine the time to intubation, the number of attempts, and the occurrence of hypoxia, in patients intubated with a c-mac device versus those intubated using a standard laryngoscope. methods: randomized controlled trial using exception from informed consent that included patients undergoing endotracheal intubation with a standard laryngoscope at an urban level i trauma center. eligible patients were randomized to undergo intubation using the c-mac or standard laryngoscopy. standard laryngoscopy was performed using a c-mac device laryngoscope with the video output obstructed to ensure equivalent laryngoscope blades in the two groups. data were collected by a trained research assistant at the patient's bedside and video review by the investigators. the number of attempts made, the initial and lowest oxygen saturation (spo ), and the total time until the intubation was successful was recorded. hypoxia was defined as an oxygen saturation < %. data were compared with wilcoxon rank sum and chi-square tests. results: thirty-eight patients were enrolled, ( % male, median age , range to , median spo %, range to ) in the standard laryngoscopy group and ( % male, median age , range to , median spo . %, range to ) in the c-mac group. the median number of attempts for standard laryngoscopy was , range to , and for c-mac was , range to (p = . ). the median time to intubation for the standard laryngoscopy group was seconds (range to ) and for the c-mac group was seconds (range to )(p = . ). hypoxia was detected in / ( %) in the standard laryngoscopy group and / ( %) in the c-mac group (p = . ). the median decrease in oxygen saturation during the attempt was . % (range % to %) for the standard laryngoscopy group and . % (range % to %) for the c-mac group. conclusion: we did not detect a difference in number of attempts, the occurrence of hypoxia, or the diagnosis of aspiration pneumonia between standard laryngoscopy and the c-mac. the time to successful intubation was shorter for patients intubated with the c-mac. the c-mac device appears to be superior to standard laryngoscopy for emergent endotracheal intubation. (originally submitted as a ''late-breaker.'') the background: aspiration pneumonia is a complication of endotracheal intubation that may be related to the difficulty of the airway procedure. objectives: to determine the association of the device used, the time to intubation, the number of attempts to intubate, and the occurrence of hypoxia with the subsequent development of aspiration pneumonia. methods: this was a prospective observational study of patients undergoing endotracheal intubation by emergency physicians at an urban level i trauma center conducted from / / until / / . the device used on the initial attempt to intubate was at the discretion of the treating physician. data were collected by a trained research assistant at the patient's bedside. the device used, the number of attempts made to intubate, the lowest oxygen saturation during the attempt, and the total time until intubation was successfully accomplished were recorded. patient's medical records were reviewed for the subsequent diagnosis of aspiration pneumonia. hypoxia was defined as an oxygen saturation < %. data were analyzed using multinomial logistic regression and odds ratios (or). results: patients were enrolled; ( %) subsequently developed aspiration pneumonia. were intubated with a standard laryngoscope (sl), using the c-mac, with an intubating laryngeal mask, and with nasotracheal intubation (ni) (or . , % ci = . - . ). comparison of individual devices versus sl did not show an association by device type. the median number of attempts for patients with aspiration pneumonia was , range to , and for those without was , range to (or . , %ci = . - . ). the median time to intubation for patients who developed aspiration pneumonia was seconds (range to ) and for those who did not was seconds (range to )(or . , %ci = . - . ). hypoxia during intubation was detected in / ( %) in the aspiration pneumonia group and / ( %) in the no aspiration pneumonia group (or . , % ci = . - . ). conclusion: there was not an association between the device used, the number of attempts, the time to intubation, or the occurrence of hypoxia during the intubation, and the subsequent occurrence of aspiration pneumonia. background: japanese census data estimate that million, or nearly % of the overall population, will be over age by the year . similar trends are apparent throughout the developed world. although increased patient age affects airway management, comprehensive information in emergency airway management for the elderly is lacking. objectives: we sought to characterize emergency department (ed) airway management for the elderly in japan including success rate, and major adverse events using a large multi-center registry. methods: design and setting: we conducted a multicenter prospective observational study using the japanese emergency airway network (jean) registry of eds at academic and community hospitals in japan between and inclusive. data fields included ed characteristics, patient and operator demographics, methods of airway management, number of attempts, success rate, and adverse events. participants: patient inclusion criteria were all adult patients who underwent emergent tracheal intubation in the ed. primary analysis: patients were divided to into two groups defined as follows: to years old and over years old. we describe primary success rates and major adverse events using simple descriptive statistics. categorical data are reported as proportions and % confidence intervals (cis). results: the database recorded patients (capture rate %) and met the inclusion criteria. of patients, patients were to years old ( %) and were over years old ( %). the older group had a significantly higher success rate at first attempt intubation ( / ; . %, % ci . - . %) compared with the younger group ( / ; . %, % ci . - . %). the older group had similar major adverse event rates ( / ; . %, % ci . - . %) compared with the younger group ( / ; . %, % ci . - . %). (see table ) background: the degree to which a patient's report of pain is associated with changes in blood pressure, heart rate, and respiratory rate is not known. objectives: to determine to what degree a standardized painful stimulus effects a change in systolic blood pressure (sbp), diastolic blood pressure (dbp), heart rate (hr), or respiratory rate (rr), and compare changes in vital signs between patients based on pain severity. methods: prospective observational study of healthy human volunteers. subjects had their sbp, dbp, hr, and rr measured prior to pain exposure, immediately after, and minutes after. pain exposure consisted of subjects placing their hand in a bath of degree water for seconds. the bath was divided into two sections; the larger half was the reservoir of cooled water monitored to be degrees, the other half filled from constant overflow over the divider. water drained from this section into the cooling unit and was then pumped up into the base of the reservoir through a diffusion grid. subjects completed a mm visual analog scale (vas) representing their perceived pain during the exposure and graded their pain as minimal, moderate or severe. data were compared using % confidence intervals. results: subjects were enrolled, mean pain vas mm, range to , reported mild pain, moderate pain, and severe pain. the percent change from baseline in vital signs during the exposure and minutes after are presented in the table. conclusion: there was a wide variety in reported pain among subjects exposed to a standard painful stimulus. there was a larger change in heart rate during the exposure among subjects who described a standardized painful exposure as moderate than in those who described it as severe. the small observed changes in blood pressure and respiratory rate seen during the exposure did not differ by pain report or persist after minutes. background: vital signs are often used to validate intensity of pain. however, few studies have looked at the capacity of vital signs to estimate pain intensity, particularly in patients with a diagnosis that a majority of physicians would agree produce significant pain in the ed. objectives: to determine the association between pain intensity and vital signs in consecutive ed patients and in a sub-group of patients with diagnosis known to cause significant pain. methods: we performed a post-hoc analysis of prospectively acquired data in a cohort study done in an urban teaching hospital with computerized triage and nurses records. we included all consecutive ed adult patients ( ‡ years old), who had any level of pain intensity measured during triage, from march to november . the primary outcome was the mean heart rate, systolic and diastolic blood pressure for every pain intensity level from to on a verbal numerical scale. our secondary outcomes where the same but limited to patients with the following diagnosis: fracture, dislocation, and renal colic. we performed descriptive statistics, one-way and two-way anovas when appropriate. results: during our study period, , patients ‡ years old where triaged with a pain intensity of at least / and had a diagnosis known to cause significant pain. . % of patients were female, with a mean pain intensity of . / , mean age of . years (± . ), and . % were ‡ years old. there was a statistically significant difference (p < . ) in mean heart rate, systolic and diastolic blood pressure for each level of pain intensity, ex: difference between / and / for mean heart rate was . beats per minutes, for systolic pressure was . mmhg and for diastolic . mmhg. results are similar for painful diagnosis: difference for mean heart rate was . beats per minutes, for systolic pressure was . mmhg and diastolic . mmhg. however, these differences are not clinically significant. conclusion: although our study is a post hoc analysis, pain intensity, heart rate, systolic and diastolic pressures during triage are usually reliable data and a prospective study would likely produce the same result. these vital signs cannot be used to estimate or validate pain intensity in the emergency department. % had a positive urine drug screen. logistic multivariate regressions analyses revealed the following factors to be significantly associated with the risk of having an abnormal head ct: association with seizure (p = . ); length of time of loss of consciousness, ranging from none to - min to > min (p = . ); alteration of consciousness (p = . ); post-traumatic amnesia (p = . ); alcohol intake prior to injury (p = , ); and initial ed gcs (p = . ). conclusion: in an emergency department cohort of patients with traumatic brain injury, symptoms including loss of or alteration in consciousness, seizure, post traumatic amnesia, and alcohol intake appear to be significantly associated with abnormal findings on head ct. these clinical findings on presentation may be useful in helping triage head injury patients in a busy emergency department, and can further define the need for urgent or emergent imaging in patients without clearly apparent injuries. background: the etiology of neurogenic shock is classically attributed to diminished peripheral vascular resistance (pvr) secondary to loss of sympathetic outflow to the peripheral vasculature. however, the sympathetic nervous system also controls other key elements of the cardiovascular system such as the heart and capacitance vessels and disruptions in their function could complicate the hemodynamic presentation. objectives: we sought to systematically examine the hemodynamic profiles of a series of trauma patients with neurogenic shock. methods: consecutive trauma patients with documented spinal cord injury complicated by clinical shock were enrolled. hemodynamic data including systolic and diastolic blood pressure, heart rate (hr), impedance-derived cardiac output, pre-ejection period (pep), left ventricular ejection time (lvet), and calculated systemic pvr were collected in the ed. data were normalized for body surface area and a validated integrated computer model of human physiology (guyton model) was used to analyze and categorize the hemodynamic profiles based on etiology of the hypotension using a systems analysis. correlation between markers of sympathetic outflow (hr, pep, lvet) and shock etiology category was examined. results: of patients with traumatic neurogenic shock, the etiology of shock was decrease in pvr in ( %; % ci to %), loss of vascular capacitance in ( %; to %), and mixed peripheral resistance and capacitance responsible in ( %; to %). the markers of sympathetic outflow had no correlation to any of the elements in the patients' hemodynamic profiles. conclusion: neurogenic shock is often considered to have a specific well-characterized pathophysiology. results from this study suggest that neurogenic shock can have multiple mechanistic etiologies and represents a spectrum of hemodynamic profiles. this understanding is important for the treatment decisions made in the management of these patients. -year ( - ) , pre-post intervention study of trauma patients requiring massive blood transfusion was performed. we divided the population into two cohorts: a pre-protocol group (pre) which included trauma patients receiving mbt not aided by a protocol, and a post-protocol group (post) who underwent mbt via the mbtp. patient demographics, hour blood component totals, timing of blood component delivery, trauma injury severity score (iss), initial glasgow coma scale (gcs) score, trauma mechanism, and patient mortality data were collected and analyzed using fisher's exact tests, student's t-tests, and mann-whitney u tests. results: fifty-two patients were included for study. median times to delivery of first products were reduced for prbcs ( minutes), ffp ( minutes), and platelets ( minutes) between the pre and post cohorts. median time to delivery of any subsequent blood product was significantly reduced ( minutes) in the post cohort (p = . ). the median number of blood products delivered was increased by . units for prbcs, units for ffp, . units for platelets, and unit for cryoprecipitate after implementation of mbtp. the percentage of patients receiving higher blood product ratios (> : ) was reduced between the pre and post cohorts for prbc to ffp ( % reduction) and prbc to platelet ratio groups ( % reduction). despite improved transfusion timing and ratios, we found no significant difference in mortality (p = . ) between pre and post cohorts when we adjusted for injury severity. conclusion: protocolized delivery of massive blood transfusion might reduce time to product availability and delivery, though it is unclear how this affects patient mortality in all us trauma centers. background: burns are common injuries that can result in significant scarring leading to poor function and disfigurement. unlike mechanical injuries, burns often progress both in depth and size over the first few days after injury, possibly due to inflammation and oxidative stress. a major gap in the field of burns is the lack of an effective therapy that reduces burn injury progression. objectives: since mesenchymal stem cells (msc) have been shown to improve healing in several injury models, we hypothesized that species-specific msc would reduce injury progression in a rat comb burn model. methods: using a gm brass comb preheated to degrees celsius, we created four rectangular burns, separated by three unburned interspaces on both sides of the backs of male sprague-dawley rats ( g). the interspaces represented the ischemic zones surround-ing the central necrotic core. left untreated, most of these interspaces become necrotic. in an attempt to reduce burn injury progression, rats were randomized to tail vein injections of ml rat-specific msc cells/ml (n = ) or normal saline (n = ) minutes after injury. tracking of the stem cells was attempted by injecting several rats with quantum dot-labeled msc. results: by four days post-injury, all of the interspaces in the control rats ( / , %) became necrotic while in the experimental group, / ( %) of the interspaces became necrotic (fisher's exact test; p < . ). at days, the percentage of the unburned interspaces that became necrotic in the msc treated group was significantly less than in the control group ( % vs. %, p < . ). we were unable to identify any quantum dot labeled msc in the injured skin. no adverse reactions or wound infections were noted in rats injected with msc. conclusion: intravenous injection of rat msc reduced burn injury progression in a rat comb burn model. although basic demographics of bicyclists in accidents have been described, there is a paucity of data describing the street surface involved in accidents, and whether designated bicycle roadways offer protection. this lack of information limits informed attempts to change infrastructure in a way that will decrease morbidity and/or mortality of cyclists. objectives: to identify road surface types involved in pedal cyclist injuries and determine the relationship between injury severity and the use of designated bicycle roadways (dbr) versus non-designated roadways (ndr). we hypothesized that more severe injuries would happen at intersections regardless of dbr versus ndr. methods: this retrospective cohort study reviewed the trauma database from a level i trauma center in tucson, az. we identified all bicyclists in the database injured in accidents involving a motor vehicle from january , , through december , . the patients were then linked to a local government database that documents location (latitude/longitude) and direction of travel of the cyclist. seventy-eight total incidents were identified and categorized as occurring on a dbr versus ndr and occurring at an intersection versus not at an intersection. results: only one patient who arrived at the trauma center died. fifty-one of the accidents ( %) occurred on dbrs; % of accidents occurring on dbrs took place in intersections. conversely, % of accidents on ndrs occurred outside of intersections. the odds of an injury occurring at an intersection versus not at an intersection were . times higher ( % ci: . - . ) for dbrs compared to ndrs. the odds of a trauma being severe (admitted) versus not severe (discharged home) were . times higher ( % ci: . - . ) when a collision occurred not at an intersection versus at an intersection. conclusion: contrary to our hypothesis, in this study group severe injuries were more likely outside of an intersection. however, intersections on dbrs were identified as problematic as cyclists on a dbr were more likely to be injured in an intersection. future city planning could target improved cyclist safety in intersections. background: minor thoracic injury (mti) is frequent and a significant proportion will still have moderate to severe pain at days. there is a lack of risk factors to orient specific treatment at ed discharge. objectives: to determine risk factors of having pain ( ‡ / , on a numerical intensity pain score from to ) at days in a population of minor thoracic injury patients discharged from the ed. methods: a prospective multi-center cohort study was conducted in four canadian eds, from november to january . all consecutive patients, years and older, with mti (with or without rib fracture), a normal chest x-ray, and discharged from the ed were eligible. a standardized clinical and radiological evaluation was done at and weeks. standardized phone interviews were done at and days. pain evaluation occurred at five time points (ed visit, and weeks, and days). using a pain trajectory model (sas), we planned to identify groups with different pain evolution at days. the final model was based on the importance of difference in pain evolution, confidence intervals, and number of patients in each group. to judge the adequacy of the final model, we examined whether the posteriori probabilities (i.e., a participant's probability of belonging to a certain trajectory group) averaged at least % for each trajectory group. then using logistic multinomial regression and the low risk group of having pain as the control group, we identified significant predictors of patients in the moderate and high risk groups having pain at days. results: in our cohort of , patients, , had an evaluation at days. we identified three groups at low ( %), moderate ( . %), and high risk ( . %) of having pain ‡ / at days. using risk factor identified by univariate analysis, we created a model to identify patients at risk containing the following predictors: age ‡ years old, women, current smoker, two or more rib fractures, complaint of dyspnea, and saturation < % at initial visit. posteriori probabilities for low, moderate, and high risk were %, %, and %. conclusion: to our knowledge, this is the first study to identify potential risk factor for having pain at days after minor thoracic injury. these risk factors should be validated in a prospective study to guide specific treatment plan. the use of ultrasound to evaluate traumatic optic neuropathy benjamin burt, lisa montgomery, cynthia garza meissner, sanja plavsic-kupesic, nadah zafar ttuhsc -paul l foster school of medicine, el paso, tx background: whenever head trauma occurs, there is the possibility for a patient to have an optic nerve injury. the current method to evaluate optical nerve swelling is to look for proptosis. however, by the time proptosis presents, significant damage has already occurred. therefore, there is a need to establish a method to evaluate nerve injury prior to the development of proptosis. objectives: fundamental to understanding the pathophysiology of optic nerve injury and repair is an understanding of the optic nerve's temporal response to trauma including blood flow changes and vascular reactivity. the aim of our study was to assess the dependability and reproducibility of ultrasound techniques to sequence optic nerve healing and monitor the vascular response of the ophthalmic artery following an optic nerve crush. methods: the rat's orbit was imaged prior to and following a direct injury to the optic nerve, at hours and at days. d, d, and color doppler techniques were used to detect blood flow and the course of the ophthalmic artery and vein, to evaluate the course and diameter of the optic nerve, and to assess the extent of optic nerve trauma and swelling. the parameters used to evaluate healing over time were pulsatility and resistance indices of the ophthalmic artery. results: we have established baseline ultrasound measurements of the optic nerve diameter, normal resistance and pulsatility indices of the ophthalmic artery, and morphological assessment of the optic nerve in a rat model. longitudinal assessment of d and d ultrasound parameters were used to evaluate vascular response of the ophthalmic artery to optic nerve crush injury. we have developed a rat model system to study traumatic optic nerve injury. the main advantages of ultrasound are low cost, non-invasiveness, lack of ionizing radiation, and the potential to perform longitudinal studies. our preliminary data indicate that d and d color doppler ultrasound may be used for the evaluation of ophthalmic artery and total orbital perfusion following trauma. once baseline ultrasound and doppler measurements are defined there is the opportunity to translate the rat model to evaluate patients with head trauma who are at risk for optic nerve swelling and to assess the usefulness of treatment interventions. background: alcoholism is a chronic disease that affects an estimated . million american adults. a common presentation to the emergency department (ed) is a trauma patient with altered sensorium who is presumed to be alcohol intoxicated by the physicians based on their olfactory sense. often ed physicians may leave patients suspected of alcohol intoxication aside until the effects wear off, potentially missing major trauma as the source of confusion or disorientation. this practice often results in delays in diagnosing acute potentially life-threatening injuries in the patients with presumed alcohol intoxication. objectives: this study will determine the accuracy of physicians' olfactory sense for diagnosing alcohol intoxication. methods: patients suspected of major trauma in the ed underwent an evaluation by the examining physician for the odor of alcohol as well as other signs of intoxication. each patient had determination of blood alcohol level. alcohol intoxication was defined as a serum ethanol level ‡ mg/dl. data were reported as means with % confidence intervals ( % ci) or proportions with inter-quartile ranges (iqr %- %). results: one hundred and fifty one patients ( % males) were enrolled in the study, median age years (iqr - ). the median score for glasgow coma scale was . the level of training of examining physician was a median of pgy (iqr pgy -attending). prevalence of alcohol intoxication was % ( % ci: % to %). operating characteristics: physician assessment of alcohol intoxication, sensitivity % ( % ci: % to %), specificity % ( % ci: % to %), positive likelihood ratio . ( % ci: . to . ), negative likelihood ratio . ( % ci: . to . ), and accuracy % ( % ci: % to %). patients who were falsely suspected of being intoxicated were . % ( % ci: % to %). conclusion: although the physicians had a high degree of accuracy in identifying patients with alcohol intoxication based on their olfactory sense, they still falsely overestimated intoxication in a significant number of non-intoxicated trauma patients. the background: optimal methods for education and assessment in emergency and critical care ultrasound training for residents are not known. methods of assessment often rely on surrogate endpoints which do not assess the ability of the learner to perform the imaging and integrate the imaging into diagnostic and therapeutic decisions. we designed an educational strategy that combines asynchronous learning to teach imaging skills and interpretation with a standardized assessment tool using a novel ultrasound simulator to assess the learner's ability to acquire and interpret images in the setting of a standardized patient scenario. objectives: to assess the ability of emergency medicine and surgical residents to integrate and apply information and skills acquired in an asynchronous learning environment in order to identify pathology and prioritize relevant diagnoses using an advanced cardiac ultrasound simulator. methods: em r residents and r surgical residents completed an online focused training program in cardiac ultrasonography (iccu elearning, https:// www.caeiccu.com/lms). this consisted of approximately hours of intensive training in cardiac ultrasound. residents were then given cases with a patient scenario that lacked significant details that would suggest a specific diagnosis. the resident was then given a list of possible diagnoses and asked to rank the top five diagnoses in order of most likely to least likely. each resident (blinded to the pathology displayed by the simulator) then imaged using an ultrasound simulator. after imaging, the residents were given the same list of potential diagnoses, and asked to rank them again from - . results: overall, residents ranked the correct diagnosis in the top five significantly more times post-ultrasound than pre-ultrasound. additionally, the residents made the correct diagnosis significantly more times postultrasound than pre-ultrasound. similar patterns occur for congestive heart failure, pericardial effusion with tamponade, and pleural effusion. there was no significant difference pre-and post-ultrasound for pulmonary embolism and anterior infarction. conclusion: an asynchronous online learning program significantly improves the ability of emergency medicine and surgical residents to correctly prioritize the correct diagnosis after imaging with a standardized pathology imaging simulator. mark favot, jacob manteuffel, david amponsah henry ford hospital, detroit, mi background: em clerkships are often the only opportunity medical students have to spend a significant amount of time caring for patients in the ed. it is imperative that students gain exposure to as many of the various fields within em as possible during this time. if the exposure of medical students to ultrasound is left to the discretion of the supervising physicians, we feel that many students would complete an em clerkship with limited skills and knowledge in ultrasound. the majority of medical students receive no formal training in ultrasound during medical school and we believe that the em clerkship is an excellent opportunity to fill this educational gap. objectives: evaluate the usefulness and effectiveness of a focused ultrasound curriculum for medical students in an em clerkship at a large, urban, academic medical center. methods: prospective cohort study of fourth year medical students doing an em clerkship. as part of the clerkship requirements, the students have a portion of the curriculum dedicated to the fast exam and ultrasound-guided vascular access. at the end of the month they take a written test, and month later they are given a survey via e-mail regarding their ultrasound experience. em residents also completed the test to serve as a comparison group. all data analysis was done using sas . . scores were integers ranging between and . descriptive statistics are given as count, mean, standard deviation, median, minimum, and maximum for each group. due to non-gaussian nature of the data and small group sizes, a wilcoxon two-sample test was used to compare the distributions of scores between the groups. results: in the table, the distribution of scores was compared between the residents (controls) and the students (subjects). the mean and median scores of the student group were higher than those of the resident group. the difference in scores between the two groups was statistically significant (p = . ). conclusion: our data reveal that after completing an em clerkship with time devoted to learning ultrasound for the fast exam and vascular access, fourth year medical students are able to perform better than em residents on a written test. what remains to be determined is if their skills in image acquisition and in performance of ultrasound-guided vascular access procedures also exceed those of em residents. results: there were respondents (total response rate . %). compared to non-em students, students pursuing em ( students, . %) were more drawn to their specialty for work hour control (p < . ) and shorter residency length (p < . ). em students were less likely than non-em students to be drawn to their chosen specialty for future academic opportunities (p < . ). em students formed their mentorships by referral significantly more than non-em students (p < . ), though there was no statistical difference in quality of existing mentorships amongst students. of the students not currently and never formerly interested in em, the most common response ( . %) for why they did not choose em was the lack of a strong mentor in the field. conclusion: the results confirmed previous findings of lifestyle factors drawing students to em. future academic opportunities were less likely to draw students to em than students pursuing other specialties. lack of mentorship in the field was the most common reason given for why students did not consider em. given the lack of direct em exposure until late in the curriculum of most medical schools, mentorship may be particularly important for em and future study should focus on this area. background: misdiagnosis is a major public health problem. dizziness leads to million visits annually in the us, including . million to the emergency department (ed). despite extensive ed workups, diagnostic accuracy remains poor, with at least % of strokes missed in those presenting with dizziness. ed physicians need and want support, particularly in the best method for diagnosis. strong evidence now indicates the bedside oculomotor exam is the best method of differentiating central from peripheral causes of dizziness. objectives: after a vertigo day that includes instruction in head impulse testing, emergency medicine residents will feel comfortable discharging a patient with signs of vestibular neuritis and a positive head impulse test without ordering a ct scan. methods: post graduate year - emergency medicine residents participated in a four hour vertigo day. we developed a mixed cognitive and systems intervention with three components: an online game that began and ended the day, a didactic taught by dr. newman-toker, and a series of small group exercises. the small group sessions included the following: a question and answer session with the lecturer; vertigo special tests (cerebellar assessment, dix hall-pike, epley maneuver); a head impulse hands-on tutorial using a mannequin; and a video lecture on other tests useful in vertigo evaluation (nystagmus, test of skew, vestibulocular reflex, ataxia). results: thirty emergency medicine residents were studied. before and after the intervention the residents were given a survey in which one question asked ''in a patient with acute vestibular syndrome and a history and exam compatible with vestibular neuritis, i would be willing to discharge the patient without neuroimaging based on an abnormal head impulse test result that i elicited''. resident answers were based on a sevenpoint likert scale from strongly agree to strongly disagree. twenty-five residents completed both surveys. of the seven residents who changed their responses pre to post,a significant proportion ( %) changed their answer from disagree/neutral to agree after a hour vertigo day (mcnemar's test, p value = . ). conclusion: in this single-center study, teaching headimpulse testing as part of a vertigo day increases resident comfort with discharging a patient with vestibular neuritis without a ct scan. background: previous studies have been inconsistent in determining the effect of increased ed census on resident workload and productivity. we examined resident workload and productivity after the closure of a large urban ed near our facility, which resulted in a rapid % increase in our census. objectives: we hypothesized that the closure of a nearby hospital closure with a resulting influx of ed patients to our facility would not change resident productivity. methods: this computer-assisted retrospective study compared new patient workups per hour and patient load before and after the closure of a large nearby hospital. specifically, new patient workups per hour and the pm patient census per resident were examined for a one-year period in the calendar year prior to the closing and also for one year after the closing. we did not include the four month period surrounding the closure in order to determine the long-term overall effect. background: emergency medicine residents use simulation for training due to multiple factors including the acuity of certain situations they are faced with, and the rarity of others. current training on highfidelity mannequin simulators is often critiqued by residents over the physical exam findings present, specifically the auscultatory findings. this detracts from the realism of the training, and may also lead a resident down a different diagnostic or therapeutic pathway. wireless remote programmed stethoscopes represent a new tool for simulation education which allows any sound to be wirelessly transmitted to a stethoscope receiver. objectives: our goal was to determine if a wireless remote programmed stethoscope was a useful adjunct in simulation-based cases using a high-fidelity mannequin. our hypothesis was that this would represent a useful adjunct in simulation education of emergency medicine residents. methods: starting june , pgy - emergency medicine residents were assessed in two simulation-based cases using pre-determined scoring anchors. an experimental randomized crossover design was used in which each resident performed a simulation case with and without a remote programmed stethoscope on a highfidelity mannequin. scoring anchors and surveys were used to collect data with differences of means calculated. results: fourteen residents participated in the study. residents noted most realistic physical exam findings associated with the case with the adjunct in / ( %) and that their preference was for the use of the adjunct in / ( %). based off of a five-point likert scale, with being the most realistic, the adjunct-associated case averaged . as compared to . without (difference of means . , p = . ). average scores of residents with the adjunct were . / with the use of the adjunct and . / without (difference of means . , p = . ). average total times were : with the adjunct as compared to : without. conclusion: a wireless remote programmed stethoscope is a useful adjunct in simulation training of emergency medicine residents. residents noted physical exam findings to be more realistic, preferred its use, and had approached significant improvement of scores when using the adjunct. background: prior studies predict an ongoing shortage of emergency physicians to staff the nation's eds, especially in rural areas. to address this, em organizations have discussed broadening access to acgme or aoa accredited em residency programs to physicians who previously trained in another specialty and focusing on physicians already practicing in rural areas. objectives: to investigate whether em program directors (pds) from allopathic and osteopathic residency programs would be willing to accept applicants previously trained in other specialties and whether this willingness is modified by applicants' current practice in rural areas. methods: a five-question web-based survey was sent to u.s. em pds asking questions about their policies on accepting residents with past training and from rural practices. questions included whether a pd would accept a resident with prior training in other specialties, how many years from this training would the applicant be still a competitive candidate and if a physician was practicing in a rural region would the likelihood of acceptance to the program be improved. different characteristics of the residency programs were recorded including length of program, years in existence, size, type, and location of program. we compared responses by program characteristics using chi-square test. results: of the ( %) pds responding to date, a large majority ( %) reported they do accept applicants with previous residency training, although directors of osteopathic programs were less likely to accept these applicants ( % vs % for allopathic; p < . ). overall, % of pds reported no limit on the length of time from prior training to when they are accepted at an em program. % reported it is very or possibly realistic they would accept a candidate who had completed training and was board certified in another specialty. a majority of all respondents ( %) felt a physician practicing in a rural setting might be viewed as a more favorable candidate, even if the resident would only be in the program for years after receiving training credit. directors of newer programs (< years of existence) were more likely to view these candidates favorably than older programs ( % vs %; p = . ). conclusion: there appear to be many em residency programs that would at least review the application and consider accepting a candidate who trained in another specialty. a qualitative assessment of emergency medicine self-reported strengths todd guth university of colorado, aurora, co background: self-reflection has been touted as a useful way to assess the acgme core competencies. objectives: the purpose of this study is to gain insight into resident physician professional development through analysis of self-perceived strengths. a secondary purpose is to discover potential topics for selfreflective narrative essays relating to the acgme core competencies. methods: design: a small qualitative study was performed to explore the self-reported strengths of emergency medicine (em) residents in a single four-year residency. participants: all residents regardless of year of training were also asked to report their selfperceived strengths. observations: residents were asked: ''what do you feel are your greatest strengths as a resident? provide a quick description.'' the author and another reviewer identified themes from within each year of residency with abraham maslow's conscious competence conceptual framework in mind. occurrences of each theme were counted by the reviewers and organized according to frequency. once the top ten themes for each year of residency were identified and exemplar quotes identified, the two reviewers identified trends. inter-rater agreements were calculated. results: representing unconscious incompetency, the first trend was the reported presence of ''enthusiasm and a positive attitude'' from residents early in their training that decreases further along in training. additionally, a ''willingness and motivation to improve and learn'' was reported as a strength throughout all the years of training but most frequently reported in the first two years of residency. entering into conscious incompetence, the second trend identified was ''recognition of limitations and openness to constructive feedback'' that was mentioned frequently in the second and third years of residency. demonstrating conscious competence, the third trend identified was the increase in identification of the strengths of ''educational leadership, teamwork skills and communication, and departmental patient flow and efficiency'' in the later years of residency. conclusion: self-reported strengths has helped to identify both themes within each year of residency and trends among the years of residency that can serve as areas to explore in self-reflective narratives relating to the acgme core competencies. training. pofu can also be used to assess the acgme core competency of practice-based learning. the exact form or frequency of pofu assessment among various em residencies, however, is not currently known. objectives: we aimed to survey em residencies across the country to determine how they fulfill the pofu requirement and whether certain program structure variables were associated with different pofu systems. we hypothesized that implementation of pofu systems among em residencies would be highly variable. methods: in this irb-approved study, all program directors of acgme allopathic em residencies were invited to complete a -question survey on their current approaches to pofu. respondents were asked to describe their current pofu system's characteristics and rate its ease of use, effectiveness, and efficiency. data were collected using surveymonkey(tm) and reported using descriptive statistics. results: of residencies surveyed, ( %) submitted complete data. . % were completed by program directors and over three-fourths ( . %) of em residencies require monthly completion of pofus. the mean total pofus required per year was ( % ci - ), with a median of and a range of - . almost / ( %) of residencies use an electronic pofu system. most ( %) -year em residencies use an electronic pofu system, compared with half ( %) of -year residencies (difference %, p = . , % ci . %- . %). seven commercially available electronic programs are used by % of the residencies, while % use a customized product. most respondents ( %) rated their pofu system as easy to use, but less than half ( %) felt it was an effective learning tool or an efficient one ( %). onethird ( %) would use a different pofu system if available, and almost half ( %) would be interested in using a multi-residency pofu system. conclusion: em residency programs use many different strategies to fulfill the rrc requirement for pofu. the number of required pofus and the method of documentation vary considerably. about two-thirds of respondents use an electronic pofu system. less than half feel that pofu logs are an effective or efficient learning tool. background: certification of procedural competency is requisite to graduate medical education. however, little is known regarding which platforms are best suited for competency assessment. simulators offer several advantages as an assessment modality, but evidence is lacking regarding their use in this domain. furthermore, perception of an assessment environment has important influence on the quality of learning outcomes, and procedural skill assessment is ideally conducted on a platform accepted by the learner. objectives: to ascertain if a simulator performs as well as an unembalmed cadaver with regard to residents' perception of their ability to demonstrate procedural competency during ultrasound (us) guided internal jugular vein (ij) catheterization. methods: in this cross-sectional study at an urban community hospital during july of , residents in their second or third year of training from a -year em residency program performed us guided catheterizations of the ij on both an unembalmed cadaver and a simulator manufactured by blue phantom. after the procedure, residents completed an anonymous survey ascertaining how adequately each platform permitted their demonstration of proficiency on predefined procedural steps. answers were provided on a likert scale of to , with being poor and being excellent. p values < . were considered educationally significant. results: the median overall rating of the simulator (s) to serve as an assessment platform was similar to that of the cadaver (c) with scores of . and . respectively, p = . . median ratings for permitting the demonstration of specific procedural steps were as follows: conclusion: senior em residents positively rate the blue phantom simulator as an assessment platform and similarly to that of a cadaver with regard to permitting their demonstration of procedural competency for us guided ij catheterization, but did prefer the cadaver to a greater degree when identifying and guiding the needle into the ij. methods: in fall , wcmc and wcmc-q students taking the course completed a question pre-and post-test. wcmc-q students also completed a postcourse single-station objective structured clinical examination (osce) that evaluated their ability to identify and perform eight actions critical for a first responder in an emergency situation (table ) . results: on both campuses, mean post-test scores were significantly higher than mean pre-test scores (p £ . ). on the pre-test, mean wcmc student scores were significantly higher than for wcmc-q students (p = . ); however, no difference was found in mean post-test scores (p = . ). there was no association between the scores on the osce (mean = . , sd = . ) and the post-test (p = . ) even after adjusting for a possible evaluators' effect (table ) . clinical skills course was effective in enhancing student knowledge in both qatar and new york as evidenced by the significant improvement in scores from the pre-to post-tests. the course was able to bring wcmc-q student scores and presumably knowledge up to the same level as wcmc students. students performed well on the osce, suggesting that the course was able to teach them the critical actions required of a first responder. the lack of association between the post-test and osce scores suggests that student knowledge does not independently predict ability to learn and demonstrate critical actions required of a first responder. future studies will evaluate whether the course affects the students' clinical practice. assess breathing assess circulation call ems call ems and assess abcs prior to other interventions immobilize localize and control bleeding splint fractured extremity and skills specific to wilderness medicine by incorporating simulated medical scenarios into a day-long adventure race. this event has gained acceptance nationally in wilderness medical circles as an excellent way to appreciate the challenges of wilderness medicine, however its effectiveness as a teaching tool has not yet been verified. objectives: the objective of this study was to determine if improvement in simulated clinical and didactic performance can be demonstrated by teams participating in a typical medwar event. methods: we developed a complex clinical scenario and written exam to test the basic tenets that are reinforced through the medwar curriculum. teams were administered the test and scored on a standardized scenario immediately before and after the midwest medwar race. teams were not given feedback on their pre-race performance. scenario performance was based on the number of critical actions correctly performed in the appropriate time frame. data from the scenario and written exams were analyzed using a standard paired difference t-test. results: a total of teams participated in both the pre-and post-event scenarios. the teams' pre-race scenario performance was . % (sd = . , n = ) of critical actions met compared to a post-race performance of . % (sd = . , n = ). the mean improvement was . % (sd = . , n = , % ci . , . ) with a significant paired two-tailed t-test (p £ . ). a total of individual subjects took the written pre-and posttests. the written scores averaged pre-race . % (sd = . , n = ) and post-race . % (sd = . , n = ). the mean improvement was . % (sd = . , n = , ci ) . , . ), with a significant paired twotailed t-test (p £ . ). conclusion: medwar participants demonstrated a significant improvement in both written exam scores and the management of a simulated complex wilderness medical scenario. this strongly suggests that medwar is an effective teaching platform for both wilderness medicine knowledge and skills. palliative methods: ed residents and faculty of an urban, tertiary care, level i trauma center were asked to complete an anonymous survey ( / - / ). participants ranked statements on a five-point likert scale ( = strongly disagree- = strongly agree). statements covered four main domains of barriers related to: ) education/training, ) communication, ) ed environment; ) personal beliefs. respondents were also asked if they would call pc consult for ed clinical scenarios (based on established triggers). results: / ( %) eligible participants completed the survey ( residents, faculty), average age was years, % ( / ) male, and % ( / ) caucasian. respondents identified two major barriers to ed-pc provision: lack of hour availability of pc team (mean score . ) and lack of access to complete medical records ( . ). listed domain barriers included: communication-related issues (mean . ) like access to family or primary providers, ed environment ( . ) for example chaotic setting with time-constraints, education/training ( . ) related to pain/pc, and personal beliefs regarding end-of-life ( . ). all respondents agreed that they would call pc consult for a 'hospice patient in respiratory distress', and a majority ( %) would consult pc for 'massive intracranial hemorrhage, traumatic arrest, and metastatic cancer'. however, traditional in-patient triggers like frequent re-admits for organ failure issues (dementia, congestive heart failure, and obstructive pulmonary disease exacerbations) were infrequently ( %) chosen for pc consult. conclusion: to enhance pc provision in the ed setting, two main ed physician perceived barriers will likely need to be addressed: lack of access to medical records and lack of - availability of pc team. ed physicians may not use the same criteria to initiate pc consults as compared to the traditionally established inpatient pc consult trigger models. percent of charts with an mse by ait prior to resident evaluation (a measure of reduced diagnostic uncertainty and decision-making), ( ) ed volume. results: there were no educationally significant differences in productivity or acuity between the pre-ait and post-ait groups. mse was recorded in the chart prior to resident evaluation in . % of cases. ed volume rose by . % between periods. conclusion: ait did not affect productivity or acuity of patients seen by em s. while some volume was directed away from residents by ait (patients treated-andreleased by ait only), overall volume increased and made up the difference. this is similar to previously reported rankings that program directors gave to the same criteria. although medical students agreed with program directors on the importance of most aspects of the nrmp application areas of discordance included higher medical student ranking for extracurricular activities and a lower relative ranking for aoa status than program directors. this can have implications for medical student mentoring and advising in the future. background: emergency care of older adults requires specialized knowledge of their unique physiology, atypical presentations, and care transitions. older adults often require distinctive assessment, treatment and disposition. emergency medicine (em) residents should develop expertise and efficiency in geriatric care. older adults represent over % of most emergency department (ed) volumes. yet many em residencies lack curricula or assessment tools for competent geriatric care. the geriatric emergency medicine competencies (gemc) are high-impact geriatric topics developed to help residencies meet this demand. objectives: to examine the effect of a brief gemc educational intervention on em resident knowledge. methods: a validated -question didactic test was administered at six em residencies before and after a gemc focused lecture delivered summer and fall of . scores were analyzed as individual questions and in defined topic domains using a paired student's t-test. results: a total of exams were included. the testing of didactic knowledge before and after the gemc educational intervention had high internal reliability ( . %). the intervention significantly improved scores in all domains (table ) . graded increase in geriatric knowledge occurred by pgy year with the greatest improvement seen at the pgy level (table ) . conclusion: even a brief gemc intervention had a significant effect on em resident knowledge of critical geriatric topics. a formal gemc curriculum should be considered in training em residents for the demands of an ageing population. the overall procedure experience of this incoming class was limited. most r s had never received formal education in time management, conflict of interest management, or safe patient trade-off. the majority lacked confidence in their acute and chronic pain management skills. these entry level residents lacked foundational skill levels in many knowledge areas and procedures important to the practice of em. ideally medical school curricular offerings should address these gaps; in the interim, residency curricula should incorporate some or all of these components essential to physician practice and patient safety. background: the american heart association and international liaison committee on resuscitation recommend patients with return of spontaneous circulation following cardiac arrest undergo post-resuscitation therapeutic hypothermia. in post-cardiac arrest patients presenting with a rhythm of vf/vt, therapeutic hypothermia has been shown to reduce neurologic sequelae and decrease overall mortality. objectives: to explore clinical practice regarding the use of therapeutic hypothermia and compare survival outcomes in post-cardiac arrest patients. a secondary outcome was to assess whether the initial presenting cardiac arrest rhythm (ventricular fibrillation/ventricular tachycardia (vf/vt) versus pulseless electrical activity (pea) or asystole) was associated with differences in outcomes. methods: a retrospective medical record review was conducted for all adult ( ‡ years) post-cardiac arrest patients admitted to the icu of an academic tertiary care centre (annual ed census , ) from - . data were extracted using a standardized data collection tool by trained research personnel. results: patients were enrolled. mean (sd) age was ( ) and . % were male. of ( . %) patients treated with hypothermia, ( . %) presented with an initial rhythm of vf/vt and ( . %) presented with pea or asystole. nine ( . %) patients with vf/vt were treated with therapeutic hypothermia and discharged from hospital compared to ( . %) patients with pea or asystole (d . %; % ci: . %, . %). of patients not treated with hypothermia, ( . %) presented with vf/vt, ( . %) presented with pea or asystole, and ( . %) initial rhythms were unknown. fifteen ( . %) patients with vf/vt, not treated with hypothermia, were discharged from hospital compared to ( . %) patients with pea or asystole (d . %; % ci: . %, . %). regardless of initial presenting rhythm or initiation of therapeutic hypothermia, ( . %) discharged patients had good neurological function as assessed by the cerebral performance category (cpc score - ). conclusion: although recommended, post-cardiac arrest therapeutic hypothermia was not routinely used. patients with vf/vt and treated with hypothermia had better outcomes than those with pea or asystole. further research is needed to assess whether cooling patients with presenting rhtyhms of pea or asystole is warranted. racial background: chronic obstructive pulmonary disease (copd) is a major public health problem in many countries.the course of the disease is characterised by episodes, known as acute exacerbations (ae), when symptoms of cough, sputum production, and breathlessness become much worse. the standard prehospital management of patients suffering from an aecopd includes oxygen therapy, nebulised bronchodilators, and corticosteroids. high flow oxygen is used routinely in prehospital areas for breathless patients with copd. there is little high quality evidence on the benefits or potential dangers in this setting but audits have shown increased mortality, acidosis, and hypercarbia in patients with aecopd treated with high flow oxygen. objectives: to compare standard high flow oxygen treatment with titrated oxygen treatment for patients with an aecopd in the prehospital setting. methods: cluster randomized controlled parallel group trial comparing high flow oxygen treatment with titrated oxygen treatment in the prehospital setting. in an intention to treat analysis (n = ), the risk of death was significantly lower in the titrated oxygen arm compared with the high flow oxygen arm for all patients and for the subgroup of patients with confirmed copd (n = ). overall mortality was % ( deaths) in the high flow oxygen arm compared with % ( deaths) in the titrated oxygen arm; mortality in the subgroup with confirmed copd was % ( deaths) in the high flow arm compared with % ( deaths) in the titrated oxygen arm. titrated oxygen treatment reduced mortality compared with high flow oxygen by % for all patients (p = . ) and by % for the patients with confirmed chronic obstructive pulmonary disease (p = . ). patients with copd who received titrated oxygen according to the protocol were significantly less likely to have respiratory acidosis or hypercapnia than were patients who received high flow oxygen. conclusion: titrated oxygen treatment significantly reduced mortality, hypercapnia, and respiratory acidosis compared with high flow oxygen in aecopd. these results provide strong evidence to recommend the routine use of titrated oxygen treatment in patients with breathlessness and a history or clinical likelihood of copd in the prehospital setting. (originally submitted as a ''late-breaker.'') trial registration australian new zealand clinical trials register actrn . background: toxic particulates and gases found in ambulance exhaust are associated with acute and chronic health risks. the presence of such materials in areas proximate to ed ambulance parking bays, where emergency services' vehicles are often left running, is potentially of significant concern to ed patients and staff. objectives: investigators aimed to determine whether the presence of ambulances correlated with ambient particulate matter concentrations and toxic gas levels at the study site ed. methods: the ambulance exhaust toxicity in healthcare-related exposure and risk [aether] program conducted a prospective observational study at an academic urban ed / level i trauma center. environmental ambient gas was sampled over a continuous five-week period from september to october . two sampling locations in the public triage area (public patient dropoff area without ambulances) and three sampling locations in the ambulance triage area were randomized for -hour monitoring windows with a temporal resolution of minutes to obtain days of non-contiguous data for each location. concentrations of particulate matter less than . microns in aerodynamic size (pm . ), oxygen, hydrogen sulfide (h s), and carbon monoxide (co) as well as lower explosive limit for methane (lel) were monitored with professionally calibrated devices. ambulance traffic was recorded through offline review of / security video footage of the site's ambulance bays. results: , measurements at the public triage nurse desk space revealed pm . concentrations with a mean of . ± . lg/m (median . lg/m ; maximum , . lg/m ). , ambulance triage nurse desk space pm . concentrations recorded a mean of . ± . lg/m (p < . , unpaired t test; median . lg/m ; maximum . lg/m ). oxygen levels remained steady throughout the study period; co, h s, and lel were not detected. ambulance activity levels had the highest correlations with pm . concentrations at the ambulance triage foyer (r = . ) and desk area (r = . ) where patients wait and ed staff work - hr shifts. conclusion: ed spaces proximate to ambulance parking bays had higher levels of pm . than areas without ambulance traffic. concentrations of ambient particulate matter in acute care environments may pose a significant health threat to patients and staff. an ems ''pit crew'' model improves ekg and stemi recognition times in simulated prehospital chest pain patients sara y. baker , salvatore silvestri , christopher d. vu , george a. ralls , christopher l. hunter , zack weagraff , linda papa orlando regional medical center, orlando, fl; florida state university college of medicine, orlando, fl background: prehospital teams must minimize time to ekg acquisition and stemi recognition to reduce overall time from first medical contact to reperfusion. auto-racing ''pit crews'' model rapid task completion by pre-assigning roles to team members. objectives: we compared time-to-completion of key tasks during chest pain evaluation in ems teams with and without pre-assigned roles. we hypothesized that ems teams using the ''pit crew'' model would improve time to recognition and treatment of stemi patients. methods: a randomized, controlled trial of paramedic students was conducted over months at orlando medical institute, a state-approved paramedic training center. we compared a standard ems chest pain management algorithm (control) with a pre-assigned tasks (''pit crew'') algorithm (intervention) in the evaluation of simulated chest pain patients. students were randomized into groups of three; intervention and control groups did not interact after randomization. all students reviewed basic prehospital chest pain management and either the standard or pre-assigned tasks algorithm. groups encountered three simulated patients. laerdal simmanÒ software was used track completion of tasks: taking vital signs, iv access, ekg acquisition and interpretation, asa administration, hospital stemi notification, and total time on scene. results: we conducted simulated-patient encounters ( control / intervention encounters). mean time-to-completion of each task was compared in the control and intervention groups respectively. time to obtain vital signs was : vs. : min (p = . ); time to asa administration was : vs : min (p < . ); time to ekg acquisition was : vs : min (p < . ); time to ekg interpretation was : vs : min (p < . ); time to iv access was : vs : min (p = . ); time to stemi notification was : vs : min (p < . ); and time to scene completion was : vs : min (p < . ). conclusion: paramedic student teams with pre-assigned roles (the ''pit crew'' model) were faster to obtain vital signs, administer asa, acquire and interpret the ekg, stemi notification, and overall time on scene during simulated patient encounters. further study with experienced ems teams in actual patient encounters is necessary to confirm the relevance of these findings. background: use of automated external defibrillators (aed) has remained low in the u.s. understanding the effect of neighborhoods on the probability of having an aed used in the setting of a public arrest may provide important insights for future placement of aeds. objectives: to determine associations between the racial and income composition of neighborhoods (as defined by u.s. census tracts), individual arrest characteristics, and whether bystanders or first responders initiate aed use. methods: cohort study using surveillance data prospectively submitted by emergency medical services systems and hospitals from u.s. sites to the cardiac arrest registry to enhance survival between october , and december , . neighborhoods were defined as high-income vs. low-income based on the median household income being above or below $ , and as white or black if > % of the census tract was of one race. neighborhoods without a predominant racial composition were defined as integrated. arrests that occurred within a public location (excluding medical facilities and airports) were eligible for inclusion. hierarchical multi-level modeling, using stata v . , was used to determine the association between individual and census tract characteristics on whether an aed was used. results: of , eligible cases, an aed was used in arrests ( . %) by a first responder (n = , , . %) or bystander (n = , . %). patients whose arrest was witnessed (odds ratio [or] . ; % confidence interval [ci] . - . ) were more likely to have an aed used (table) . when compared to high-income white neighborhoods, arrest victims in low-income black neighborhoods were least likely to have an aed used (or . ; % ci . - . ). arrest victims in lowincome white (or . ; % ci . - . ) and lowincome integrated (or . ; % ci . - . ) were also less likely to have an aed used. conclusion: arrest victims in black and low-income neighborhoods are least likely to have an aed used by a layperson or first responder. future research is needed to better understand the reasons for low rates of aed use for cardiac arrests in these neighborhoods. the impact of an educational intervention on the pre-shock pause interval among patients experiencing an out-of-hospital cardiac arrest jonathan studnek , eric hawkins , steven vandeventer carolinas medical center, charlotte, nc; mecklenburg ems agency, charlotte, nc background: pre-shock pause duration has been associated with survival to hospital discharge (std) among patients experiencing out-of-hospital cardiac arrest (oohca) resuscitation. recent research has demonstrated that for every -second increase in this interval there is an % decrease in std. objectives: determine if a decrease in the pre-shock pause interval for patients experiencing oohca could be realized after implementation of an educational intervention. methods: this was a retrospective analysis of data obtained from a single als urban ems system from / / to / / and / / to / / . in august , an educational intervention was designed and delivered to approximately paramedics emphasizing the importance of reducing the time off chest during cpr. specifically, the time period just prior to defibrillation was emphasized by having rescuers count every th compression and pre-charge the defibrillator on the th compression. in order to determine if this change resulted in process improvement, months of data were assessed before and months after the educational intervention. pre-shock pause was the outcome variable and was defined as the time period after compressions ceased until a shock was delivered. this interval was measured by a cpr feedback device connected to the defibrillator. inclusion criteria were adult patients who required at least one defibrillation and had the cpr feedback device connected during the defibrillation attempt. analysis was descriptive utilizing means and % ci as well as wilcoxon rank sum test to assess difference between the two time periods. results: in the pre-intervention period there were patients who received defibrillations compared to patients receiving defibrillations in the post-intervention phase. the mean duration of the pre-shock pause pre-intervention was seconds ( % ci - ) while the post-intervention duration was seconds ( % ci - ). the difference in pre-shock pause duration was statistically significant with p < . . conclusion: these data indicate that after a simple educational intervention emphasizing decreasing time off chest prior to defibrillation the pre-shock pause duration decreased. future research must describe the sustainability of this intervention as well as the effects this process measure may have on outcomes such as survival to hospital discharge. background: the broselow tape (bt) has been used as a tool for estimating medication dosing in the emergency setting. the obesity trend has demonstrated a tendency towards insufficient pediatric weight estimations from the bt, and thus potential under-dosing of resuscitation medications. objectives: this study compared drug dosing based on the bt with dosing from a novel electronic tool (et) that accounts for provider estimation of body habitus. methods: data were obtained from a prospective convenience sample of children ages to years arriving to a pediatric emergency department. a clinician performed an assessment of body habitus (average/underweight, overweight, or obese), blinded to the patient's actual weight and parental weight estimate. parental estimate of weight and measured length and weight were collected. epinephrine dosing was calculated from the measured weight, the bt measurement, as well as from a smart-phone tool based on the measured length and clinician's estimate of body habitus, and a modified tool (mt) incorporating the parent estimate of habitus. the wilcoxson rank-sum test was used to compare median percent differences in dosing. results: one hundred children (mean age years) were analyzed; % were overweight or obese. clinicians correctly identified children as overweight/obese % of time (ci . - . ). adding parent estimate of weight improved this to a sensitivity of % (ci . - . ). the median difference between the weight-based epinephrine dose and bt dose was %. for the et the median difference from the weight-based dose was % (p = . compared to the bt), and for the mt was . % (p < . compared to the bt). when a clinically significant difference was defined as ± % of the actual dose, bt was within that range % of the time, et was within range % of the time (p = . ), and mt was within range % of the time ( background: in most out-of-hospital cardiac arrest (ohca) events, a call to - - is the first action by bystanders. accurate diagnosis of cardiac arrest by the call taker depends on the caller's verbal description. if cardiac arrest is not suspected, then no telephone cpr instructions will be given. objectives: we measured the effect of a change in the ems call taker question sequence on the accuracy of diagnosis of cardiac arrest by - - call takers. methods: we retrospectively reviewed the cardiac arrest registry to enhance survival (cares) dataset for january , through june , from a city, population , , with a longstanding telephone cpr program (apco). we included ohca cases of any age who were in arrest prior to the arrival of ems and for whom resuscitation was attempted. in early , - - call takers were taught to follow a revised telephone script that emphasized focused questions, assertive control of the caller, and provision of hands-only cpr instructions. the medical director personally explained the reasons for the changes, emphasizing the importance of assertive control of the caller and the comparative safety of chest compressions in patients not in cardiac arrest. beginning in , call recordings were reviewed regularly with feedback to the call taker by the - - center leadership. the main outcome measure was sensitivity of the - - call taker in diagnosing cardiac arrest. bystander cpr was reported by ems crews attending the event. we compared with and using the v test and odds ratios (or). results: there were ohca cases in , cases in , and in the first half of ( / , population). the mean age was ± years, and % of the events were witnessed. before the revision, % of ohca cases were identified by - - dispatchers; and after the revised questioning sequence, % were identified (or . , % ci . - . ). the false positive rate changed little (from /month to /month). the mean time to question callers was unchanged ( vs seconds). bystander cpr was performed in . % of events in , . % in , and . % of events in (p < . ). conclusion: emphasis on scripted assessment improved sensitivity without loss of specificity in identifying ohca. with repeated feedback, it translated to an increase in victims receiving bystander cpr. in an out-of hospital cardiac arrest population confirmed by autopsy salvatore silvestri, christopher hunter, george ralls, linda papa orlando regional medical center, orlando, fl background: quantitative end-tidal carbon dioxide (etco ) measurements (capnography) have consistently been shown to be more sensitive than qualitative (colorimetric) ones, and the reliability of capnography for assessing airway placement in low perfusion states has sometimes been questioned in the literature. objectives: this study examined the rate of capnographic waveform presence of an intubated out-of-hospital cardiac arrest cohort and its correlation to endotracheal tube location confirmed by autopsy. our hypothesis is that capnography is % accurate in determining endotracheal tube location, even in low perfusion states. methods: this cross-sectional study reviewed a detailed prehospital cardiac arrest database that regularly records information using the utstein style. in addition, the ems department quality manager routinely logs the presence of an alveolar (four-phase) capnographic waveform in this database. the study population included all cardiac arrest patients from january , through december , managed by a single ems agency in orange county, florida. patients were included if they had endotracheal intubation performed, had capnographic measurement obtained, failed to regain return of spontaneous circulation (rosc), and had an autopsy performed. the main outcome was the correlation of the presence of an alveolar waveform and the location of the ett at autopsy. results: during the study period, cardiac arrests were recorded. of these, had an advanced airway placed (ett or laryngeal tube airway), and no rosc. of the advanced airway cases, were managed with an ett. autopsies were performed on of these patients and resulted in our study cohort. the location of the ett at autopsy was recorded on all of these cases. capnographic waveforms were recorded in the field in all of these study patients, and % of the tubes were located within the trachea at autopsy. the sensitivity of capnography in determining proper endotracheal tube location was % in this study. conclusion: in our study, the presence of a capnographic waveform was % reliable in confirming proper placement of endotracheal tubes placed in outof-hospital patients with poor perfusion states. results: over variables were presented to the ems medical directors responding ( % survey population captured). among the myriad of responses, ( %) initiate cardiopulmonary resuscitation (cpr) at compressions to ventilations consistent with il-cor/aha guidelines. seven ( %) initiate continuous chest compressions from the start of cpr with no pause and interposed ventilations. nine ( %) begin chest compressions only during the first - minutes, with either passive oxygenation by oxygen mask (six; %) or no oxygen (three; %). airway management following non-invasive oxygenation and ventilation by primary endotracheal intubation occurs in systems ( %), while six ( %) use supraglottic devices. fourteen ( %) allow paramedics to decide between endotracheal and supraglottic device placement. thirty systems ( %) utilize continuous waveform capnography. the initial approach to non-ems witnessed ventricular fibrillation is chest compression prior to first defibrillation in systems ( %). eighteen systems ( %) escalate defibrillation energy settings, with four systems ( %) utilizing dual sequential defibrillation. twenty ( %) initiate therapeutic hypothermia in the field. conclusion: wide variability in ca care standards exists in america's largest urban ems systems in mid- , with many current practices promoting more continuity in chest compressions than specified in the ilcor/aha guidelines. endotracheal intubation, a past mainstay of ca airway management, is deemphasized in many systems. immediate defibrillation of non-ems witnessed ventricular fibrillation is uncommon. objectives: determine the out-of-hospital cardiac arrest survival in this area of puerto rico using the utstein method. methods: prospective observational cohort study of adult patients presenting with an out-of-hospital cardiac arrest to the upr hospital ed. study endpoints will be survival and neurologically intact survival at hospital discharge, months, and months. results: a total of consecutive cardiac arrest events were analyzed for a period of years. one-hundred fifteen events met criteria for primary cardiac etiology ( . %). the average age for this group was . years. there were female ( . %) and male ( . %) participants. the average time to start cpr was . minutes. transportation to the ed was . % by ems and . % by private vehicle. a total of events were witnessed ( . %). the survival rate to hospital admission was . %. the overall cardiac arrest survival was . % and overall neurologically intact survival was . %. neurologically intact survival at and months was . %. the rate of bystander cpr in our population was . % with a survival rate of . %. conclusion: survival from out-of-hospital cardiac arrest in the area served by the upr hospital is low but comparable to other cities in the us as reported by the cdc cardiac arrest registry to enhance survival (cares). this low survival rate might be due to low bystander cpr rate and prolonged time to start cpr. background: hyperventilation has been directly correlated with increased mortality for out-of-hospital cpr. ems providers may hyperventilate patients at levels above national bls guidelines. real-time feedback devices, such as ventilation timers, have been shown to improve cpr ventilation rates towards bls standards. it remains unclear if the combination of a ventilation timer and pre-simulation instruction would influence overall ventilation rates and potentially reduce undesired hyperventilation. objectives: this study measured ventilation rates of standard cpr (and pre-instruction on effects of hyperventilation) compared to cpr with the use of a commercial ventilation timer (and pre-instruction on effects of hyperventilation). we propose that use of a ventilation timer, measuring and displaying to ems providers real-time ventilations delivered, will have no difference in ventilation rates when comparing these groups. methods: this prospective study placed ems providers into four groups: two controls measuring ventilation rates before ( a) and after instruction ( b) on the deleterious effects of hyperventilation, and a concurrent intervention pair with before ( a) and after instruction ( b), with the second pair measuring ventilation rates with a ventilation timer that provides immediate feedback on respirations given. ventilation rates were measured for a -second period after one minute of simulated cpr using mannequins. the control set without instruction ( a, n = ) averaged . breaths ( % ci = . - . ) and with instruction ( b, n = ) averaged . breaths ( % ci = . - . ). the intervention set without instruction ( a, n = ) averaged . breaths ( % ci = . - . ) and with instruction ( b, n = ) averaged . breaths ( % ci = . - . ). there was a significant improvement (p = . ) in ventilation rates with use of a ventilation timer (control group versus intervention group regardless of pre-instruction). there was no statistically significant difference between groups with respect to instruction alone (p = . ). conclusion: the use of a ventilation timer significantly reduced overall ventilation rates, providing care closer to bls guidelines. the addition of pre-simulation instruction added no significant benefit to reducing hyperventilation. background: in , the american heart association (aha) recommended a compression rate of (roc) / min and a depth of compressions (doc) at least inches for effective cpr. as an educational tool for lay rescuers, the aha as adopted the catch phrase ''push hard, push fast''. objectives: in this irb-exempt study, we sought to determine if persons without formal cpr training could perform non-ventilated cpr as well as those who have been trained in the past or those currently certified. methods: a convenience sample of patrons of the new york state fair was asked to perform minutes of hands-only cpr on a prestan pp-am- m adult cpr manikin. these devices provide visual indicators of acceptable rate and depth of compressions. each subject was video recorded on a dell latitude laptop computer with a logitech quick cam using logitech quick cam . . for windows software. results: a total of volunteers ( male, female) aged - years participated: were never certified (nc) in cpr, were previously certified (pc), and were currently certified (cc). there was no difference in age across the groups. the cc group had a higher proportion of females (chi-square = . , p < . ). cc volunteers sustained roc and doc for an average of . seconds as compared to an average of . seconds (pc) and . seconds (nc) respectively. (f = . , p < . ). the cc maintained roc of closer to / min (mean . /min) when compared to the pc (mean . /min) and nc (mean . /min) groups (f = . , p < . ). a higher proportion of volunteers of the cc group were able to perform adequate doc (chi-square = . , p < . ), and hand placement (chisquare = . , p < . ) when compared to the other two groups. conclusion: compared to the target roc and doc, none of the groups did well and only subjects met target roc/doc. increased out-of-hospital cardiac arrest survivability due to lay rescuer intervention is only assured if cpr is effectively administered. the effect and benefit of maintaining formal cpr training and certification is clear. background: more than , out-of-hospital cardiac arrests (ohcas) occur annually in the united states (us). automated external defibrillators (aeds) are life-saving devices in public locations that can significantly improve survival. an estimated million aeds have been sold in the us; however, little is known about whether locations of aeds match oh-cas. these data could help determine optimal placement of future aeds and targeted cpr/aed training to improve survival. objectives: we hypothesized that the majority (> %) of aeds are not located in close proximity ( feet) to the occurrence of cardiac arrests in a major metropolitan city. methods: this was a retrospective review of prospectively collected cardiac arrest data from philadelphia ems from january , until december , . included were ohcas of presumed cardiac etiology in individuals years of age or older. excluded were oh-cas of presumed traumatic etiology, cases where resuscitation was terminated at the scene, and those dead on arrival. aed locations in philadelphia were obtained from myheartmap, a database of installed and wallmounted aeds in pennsylvania. we used gis mapping software to visualize where ohcas occurred relative to where aeds were located and to determine the radius of ohcas to aeds. arrests within a , , and foot radius of aeds were identified using the attribute location selection option in arcgis. the lengths of radii were estimated based on the average time it would take for a person to walk to and from an aed ( feet minutes; feet minutes; feet minutes). results: we mapped , ohcas and , aeds in philadelphia county. ohcas occurred in males ( %; / ) and the mean age was . years. ventricular fibrillation occurred in % ( / ). aeds were primarily located in schools/universities ( %), office buildings ( %), and residential buildings ( %). aeds were not identified within feet in % ( , ) of ohcas, within feet of % ( , ) of ohcas, and within feet in % ( , ) of ohcas. the figure (large black circles) illustrates aed/ohca within feet on the left and feet on the right. conclusion: aeds were rarely close to the locations of ohcas, which may be a contributor to low cardiac arrest survival rates. innovative models to match aed availability with ohcas should be explored. (originally submitted as a ''late-breaker.'') potential background: early and frequent epinephrine administration is advocated by acls; however, epinephrine research has been conducted primarily with standard cpr (std). active compression-decompression cpr with an impedance threshold device (acd-cpr + itd) has become the standard of care for out of hospital cardiac arrest in our area. the hemodynamic effects of iv epinephrine under this technique are not known. objectives: to determine the hemodynamic effects of iv epinephrine in a swine model undergoing acd-cpr+itd. methods: six female swine ( ± kg) were anesthetized, intubated, and mechanically ventilated. intracranial, thoracic aorta, and right atrial pressures were recorded via indwelling catheters. carotid blood flow (cbf) was recorded via doppler. etc , sp , and ekg were monitored. ventricular fibrillation was induced and went untreated for minutes. three minutes each of standard cpr (std), std-cpr+itd, and acd-cpr+itd was preformed. at minute of the resuscitation, lg/kg of iv epinephrine was administered and acd-cpr+itd was continued for minute. statistical analysis was performed with a paired t-test. results: aortic pressure and calculated cerebral and carotid perfusion pressures increased from std < std+itd < acd-cpr+itd (p £ . ). epinepherine administered during acd-cpr+itd signficantly increased mean aortic ( ± vs ± , p = . ), cerebral ( ± vs ± , p = . ), and coronary perfusion pressures ( ± vs ± , p = . ); however, mean cbf and etco decreased (respectively ± vs ± . , p = . ; ± vs ± , p = . ). conclusion: the administration of epinepherine during acd-cpr+itd signficantly increased markers of macrocirculation, while significantly decreasing etco , a proxy for organ perfusion. while the calculated cerebral perfusion pressures increased, the directly measured cbf decreased. this calls into question the ability of calculated perfusion pressures to accurately reflect blood flow and oxygen delivery to end organs. hypoxia background: during cardiac arrest most patients are placed on % oxygen with assisted ventilations. after return of spontaneous circulation (rosc), % oxygen is typically continued for an extended time. animal data suggest that immediate post-arrest titration of oxygen by pulse oximetry produces better neurocognitive/ histologic outcomes. recent human data suggest that arterial hyperoxia is associated with worse outcomes. objectives: to assess the relationship between hypoxia, normoxia, and hyperoxia post-arrest and outcomes in post-cardiac arrest patients treated with therapeutic hypothermia. methods: we conducted a retrospective chart review of post-arrest patients admitted to an academic medical center between january, and december, who had arterial blood gases (abg) drawn after rosc. demographic variables were analyzed using anova and chi-square tests as appropriate. unadjusted logistic regression analyses were performed to assess the relationship between hypoxia (pao < mmhg), normoxia ( - mmhg), hyperoxia (> mmhg), and mortality. results: on first abg ( patients), ( . %) were hypoxic, ( . %) normoxic, and ( . %) hyperoxic. the average age of the cohort was . years (no difference for hypoxic, normoxic, and hyperoxic patients). overall mortality was . % ( / ). there were no significant differences between initial heart rate, systolic blood pressure, sex, race, or pre-arrest functional status. in-hospital mortality was significantly higher when the first abg demonstrated hypoxia ( . %; / ) than for normoxia ( . %; / ) or hyperoxia ( %; / ). in unadjusted logistic regression analysis of first pao values, hyperoxia was not associated with increased mortality (or . ; % ci . - . ) but hypoxia was associated with increased mortality (or . ; % ci . - . ). conclusion: hypoxia but not hyperoxia on first abg was associated with mortality in a cohort of post-arrest patients. background: there are over , deaths due to cardiac arrest per year in the us. the aha recommends monitoring the quality of cpr primarily through the use of end tidal co (etco ). the level of etco is significantly dependant on minute ventilation and altered by pressor and bicarbonate use. cerebral oximetry (cereox) uses near infrared spectroscopy to non-invasively measure oxygen saturation of the frontal lobes of the brain. cereox has been correlated with cerebral blood flow and jugular vein bulb saturations. objectives: the objective of this study is to compare the simultaneous measurement of etco and cereox to investigate which monitoring method provides the best measure of cpr quality as defined by return of spontaneous circulation (rosc). methods: a prospective cohort of a convenient sample of patients using out-of-hospital and ed cardiac arrest from two large eds. patients were monitored simultaneously by etco and cereox during cpr. patient demographics and arrest data were collected using the utstein criteria. all patients were monitored throughout the resuscitation efforts. rosc was defined as a palpable pulse and a measurable blood pressure for a minimum of thirty minutes. results: twenty two patients were enrolled with complete data sets; % of the subjects had rosc. average down time of rosc subjects was minutes (sd ± . ) and minutes (sd ± . ) for subjects without rosc. the inability to obtain a value of either for etco or cereox was % and % specific with an % and % npv respectively for predicting lack of rosc. obtaining a value of either for etco or cereox was % and % sensitive, respectively in identifying rosc. subjects with rosc had sustained values above for . mins on cereox and . mins on etco prior to rosc. the increase in values over a three minute period prior to rosc was . on cereox and . on etco . conclusion: the inability to obtain a value of on either the etco or cereox strongly predicted lack of rosc. cereox provides a larger magnitude and closer temporal increase prior to rosc than etco . attaining a value of on cereox was more predictive of rosc than etco . an discrepancies due to communicating information to multiple listeners in a short amount of time. this creates a communication barrier not always apparent to practitioners. we examine the perceptions of ems and ed personnel on the transfer of care and its correlation to missing patient data. objectives: evaluate provider perception of information transfer by ems and ed personnel and compare this to an external observer's objective assessment. methods: this is a retrospective quality improvement program at an academic level i trauma center. transfers of medical and trauma patients from ems to ed personnel were attended by trained external observers, research associates (ra). ra recorded the data communicated: name, age, past medical history (pmh), allergies, medications, events, active problems, vital signs (vs), level of consciousness (loc), iv access, and treatments given. then, ems and ed staff rated their perception of transfer on a - rating scale. results: ra evaluated patient transfers ( medical and trauma). transfer time did not differ, . minutes for medical ( % ci: . - . ), . minutes for trauma patients ( % ci: . - . )(p = . ). missing data between the two groups also did not differ, except loc and treatment were missed more in medical transfers, while pmh was missed more in the trauma transfers. comparing the transfers with all vs present ( %, / ) and all vs missing ( %, / ), with all vs missing, there was no difference in perception of transfer for ems ( . / vs present vs . / vs absent) or ed staff ( . / vs present, . / vs absent). when all vital signs were missing, ra rated . % of transfers as poor, whereas when all vs were present . % of transfers were considered good. conclusion: ems and ed staff felt transfers of care were professional, teams were attentive, and had similar amounts of interruptions for both medical and trauma cases. their perception of transfer of care was similar even when key information was missing, although external observers rated a significant amount of transfers poorly. thus, ems and ed staffs were not able to evaluate their own performance in a transfer of care and external observers were found to be better evaluators of transfers of care. swati singh, john brown, prasanthi ramanujam ucsf, san francisco, ca background: ems transports a large number of psychiatric emergencies to emergency departments (ed) across the us. research on paramedic education related to behavioral emergencies is sparse, but based on expert opinion we know that gaps in paramedic knowledge and training exist. in our system, paramedics triage patients to medical, detoxification, and purely psychiatric destinations, so a paramedic's understanding of these emergencies directly affects the flow of patients in our eds. objectives: our objectives were to understand the gaps in current training and develop a targeted curriculum for field providers with a long term goal of appropriately recognizing and triaging subjects to the ed. methods: data were collected using a survey that was distributed during a paramedic association meeting in october . subjects were excluded if they did not complete the survey. survey questions addressed demographics of paramedics, frequency of various psychiatric emergencies and their confidence in managing these emergencies. data were collated, analyzed, and presented as descriptive statistics. results: forty-nine surveys were distributed with a response rate of % (n = / ). of the respondents, % (n = ) were male and % (n = ) had at least five years experience. mood, thought, and cognitive disorders were the most frequently encountered presentations and % (n = ) of respondents came across psychiatric emergencies multiple times a week. many respondents did not feel confident managing agitated delirium (n = , %), acute psychosis (n = , %), and intimate partner or elder abuse (n = , %). a third to a half of the respondents felt they have little or no training in chemical sedation (n = , %), verbal de-escalation (n = , %), and triaging patients (n = , %). conclusion: we identified a need for a revised curriculum on management of psychiatric emergencies. future steps will focus on development of a curriculum and change in knowledge after implementation of this curriculum. background: prehospital endotracheal intubation has long been a cornerstone of resuscitative efforts for critically ill or injured patients. paramedic airway management training will need to be modified due to the acc/aha guidelines to ensure maintenance of competency in overall management of airway emergencies. how best to modify the training of paramedics requires an understanding of current experience. objectives: the purpose of this report is to characterize the airway management expertise of experienced and non-experienced paramedics in a single ems system. methods: we retrospectively reviewed all prehospital intubations from an urban/suburban ambulance service (professional ambulance, inc.) over a five-year period (january , to december , ). characteristics of airway management by paramedics with - years of experience (group ) were compared to those with greater than years of experience (group ). airway management was guided by massachusetts statewide treatment protocols governing direct laryngoscopy and all adjunctive approaches. attempts are characterized by laryngoscope blade passing the lips. difficult and failed airways were managed with extraglottic devices (egd) or needle cricothyroidotomy. we reviewed patient characteristics, intubation methods, rescue techniques, and adverse events. results: patients required airway management: ( %) were performed by group and ( %) were performed by group . group was both faster to intubate ( . vs . attempts, p = . ) and less likely to use a rescue device ( . % vs . %, p = . ). both are equally likely to go directly to a rescue device ( % vs %, p = . ). all patients were successfully oxygenated and ventilated with either an endotracheal tube or egd. no surgical airways were performed and no patients died as a result of a failed airway. conclusion: while intubation success rates of paramedics with less than and greater than five years of experience are similar, less experienced paramedics use fewer attempts and are less likely to use a rescue device. both recognize difficult airways and go directly to rescue devices equally. this highlights difficulties faced maintaining competence. education requirements must be evaluated and redesigned to allow paramedics to maintain competence and emphasize airway management according to the latest resuscitation guidelines. how well do ems - - protocols predict ed utilization for pediatric patients? stephanie j. fessler , harold k. simon , daniel a. hirsh , michael colman emory university, atlanta, ga; grady health systems, atlanta, ga background: the use of emergency medical services (ems) for low-acuity pediatric problems has been well documented. however, it is unclear how accurately general ems dispatch protocols predict the subsequent ed utilization for these patients. objectives: to determine the ed resource utilization rate of pediatric patients categorized as low acuity by - - dispatch protocols and then subsequently transferred to a children's hospital. methods: all transports for pediatric patients from the scene by a large urban general ems provider that were prioritized as low acuity by initial - - dispatch protocols were identified. protocols were based on the national academy of medical priority dispatch system, v . starting on jan , , consecutive cases of patients transported to three pediatric emergency departments (ped) of a large tertiary care pediatric health care system were reviewed. demographics, ped visit characteristics, resource utilization, and disposition were recorded. those patients who received meds other than po antipyretics, had labs other than a strep test, a radiology study, a procedure, or were not discharged home were categorized into the significant ed resource utilization group. results: % of the patients were african american and either had public insurance or self-pay ( %, % respectively). the median age was months ( d- yr). % were female. none of these low-acuity patients were upgraded by ems operators en route. upon arrival to the ped, % of transported patients were classified into the significant utilization group. six of the total patients were admitted, including a y/o requiring emergent intubation, an m/o old with a broken cvl, a y/o with sickle cell pain crisis, and a y/o with altered mental status. the remainder of the significant resource utilization group consisted of children needing procedures, anti-emetics, narcotic pain control, labs, and xrays. conclusion: in this general ems - - system, dispatch protocols for pediatric patients classified as low priority did poorly in predicting subsequent ed utilization with % requiring significant resources. further, ems operators did not recognize a critical child who needed emergent intervention. opportunity exists to refine general ems - - protocols for children in order to more accurately define an ems priority status that better correlates with ultimate needs and resource utilization. the objectives: determine if there is an association between a patient's impression of the overall quality of care and his or her satisfaction with provided pain management. it was hypothesized that satisfaction with pain management would be significantly associated with a patient's impression of the overall quality of care. methods: this was a retrospective review of patient satisfaction survey data initially collected by an urban als ems agency from / / to / / . participants were randomly selected from all patients transported proportional to their paramedic defined acuity; categorized as low, medium, or high with a goal of interviews per month. the proportions of patients sampled from each acuity level were % low, % medium, and % high. patients were excluded if there was no telephone number recorded in the prehospital patient record or they were pronounced dead on scene. all satisfaction questions used a five-point likert scale with ratings from excellent to poor that were dichotomized for analysis as excellent or other. the outcome variable of interest was the patient's perception of the overall quality of care. the main independent variable had patients rate the staff who treated them at the scene on their helping to control or reduce their pain. demographic variables were assessed for potential confounding. results: there were , patients with complete data for the outcome and main independent variable with . % male respondents and an average age of . (sd = . ). overall quality of care was rated excellent by . % of patients while . % rated their pain management as excellent. of patients who rated their pain management as excellent, . % rated overall quality of care as excellent while only . % of patients rated overall quality excellent if pain management was not excellent. when controlling for potential confounding variables, those patients who perceived their pain management to be excellent were . ( % ci . - . ) times more likely to rate their overall quality of care as excellent compared to those with non-excellent perceived pain management. conclusion: patients' perceptions of the overall quality of care were significantly associated with their perceptions of pain management. objectives: the purpose of this study is to determine whether ground-based paramedics could be taught and retain the skills necessary to successfully perform a cricothyrotomy. methods: this retrospective study was performed in a suburban county with a population of , and , ems calls per year. participants were groundbased paramedics in a local ems system who were taught wire-guided cricothyrotomy as part of a standardized paramedic educational update program. as part of the educational program, paramedics were taught wire-guided cricothyrotomy on a simulation model previously developed to train emergency medicine residents. after viewing an instructional video, the participants were allowed to practice using a step checklist. not all of these steps were automatic failures. each paramedic was individually supervised performing a cricothyrotomy on the simulator until successful; a minimum of five simulations was required. retention was assessed using the same -step checklist during annual skills testing, after a minimum of weeks to a maximum of months posttraining. results: a total of paramedics completed both the initial training and reassessment during the time period studied. during the initial training phase, % ( of ) of the paramedics were successful in performing all steps of the wire-guided cricothyrotomy. during the retention phase . % ( of ) retained the skills necessary to successfully perform the wire-guided cricothyrotomy. of the -step checklist, most steps were performed successfully by all the paramedics or missed by only of the paramedics. step # , which involved removing the needle prior to advancing the airway device over the guidewire, was missed by . % ( of ) of the participants. step # was not an automatic failure since most participants immediately self-corrected and completed the procedure successfully. conclusion: paramedics can be taught and can retain the skills necessary to successfully perform a wireguided cricothyrotomy on a simulator. future research is necessary to determine if paramedics can successfully transfer these skills to real patients. helicopter emergency medical services in background: netcare is one of the largest private providers of emergency air medical care in south africa. each hems (helicopter emergency medical service) crew is manned by a physician-paramedic team and is dispatched based on specific medical criteria, time to definitive care, and need for physician expertise. objectives: to describe the characteristics of net-care air medical evacuations in gauteng province and to analyze the role of physicians in patient care and effect on call times. methods: all patients transported by a netcare helicopter over a one year period from january -december were enrolled in the study. injury classifications, demographics, procedures, scene and flight times were collected retrospectively from run sheets. data were described by medians and interquartile intervals. results: a total of patients were transported on flights originating from the netcare gauteng helicopter base. ninety-two percent were traumarelated, with % resulting from motor vehicle accidents. physician expertise was listed % of the time as the indication for air medical response. a total of advanced procedures were performed by physicians on patients, including paralytic-assisted intubations, chest tube placement, and cardiac pacing. the median total call time was minutes with minutes spent on scene, compared with and minutes when advanced procedures were performed by hems (p < . ). conclusion: trauma accounts for an overwhelming majority of patients requiring emergency air medical transportation. advanced medical procedures were performed by physicians in nearly a quarter of the patients. there were significant differences in call times when advanced procedures were performed by hems. objectives: we sought to evaluate the level of awareness and adoption of the off-line protocol guidelines by utah ems agencies. methods: we surveyed all ems agencies in utah months after protocol guideline release. medical directors, ems captains, or training coordinators completed a short phone survey regarding their knowledge of the emsc protocol guidelines, and whether their agency had adopted them. in particular, participants were asked about the pain protocol guideline and their management of pediatric pain. results: of the agencies, participated in the survey ( %). of those participating, agencies ( %) were excluded from the analysis: ( %) who only treat adults and ( %) who do not participate in electronic data entry. of the remaining agencies ( %), ( %) were familiar with the utah emsc protocol guidelines; agencies ( %) have either partially or fully adopted the protocol guidelines. agencies ( %) were familiar with the pain treatment protocol guideline; ( %) had adopted it; ( %) planned to either partially or fully adopt the protocol. overall, agencies ( %) had offline protocols allowing the administration of narcotics to children. of those, ( %) had intranasal fentanyl as an available medication and delivery route. of the agencies with offline protocols for pain, ( %) reported familiarity with the emsc pain protocol guideline. conclusion: the creation and dissemination of statewide emsc protocol guidelines results in widespread awareness ( %) and to date % of agencies have adopted them. future investigation into factors associated with protocol adoption should be explored. background: intranasal (in) naloxone is safe and effective for the treatment of opioid overdose. while it has been extensively studied in the out-of-hospital environment in the hands of paramedics and lay people, we are unaware of any studies evaluating the safety and efficacy of in naloxone administration by bls providers. in recent years in naloxone has been added to the bls armamentarium; however, most services/states require an als unit be dispatched and attempt an intercept if in naloxone is administered by the bls providers. objectives: the purpose of this study is to evaluate the safety and effectiveness of bls-administered in naloxone in an urban environment. methods: retrospective cohort review as part of the ongoing qa process of all patients who had in naloxone administration by bls providers. the study was part of a special projects waiver by massachusetts oems from february through november in a busy urban tiered ems system in the metro-boston area. exclusion criteria: cardiac arrest. demographic information was collected, as well as vital signs, number of naloxone doses by bls, patient response to bls naloxone administration (clinical improvement in mental status and/or respiratory status), als intercept. descriptive statistics and confidence intervals are reported using microsoft excel and spss . . results: fifty-six cases of bls-administered in naloxone were identified, and were excluded as cardiac arrests. the included cases had a mean age of . years ± . (range - ), and % (ci - ) were male. of the included cases, % (ci - ) of patients responded to bls administration of naloxone. of the responders, % (ci - ) required two doses. there were protocol violations representing % (ci . - . ) of the total administrations, however in % of these protocol violations the patients had a positive response to the administration of in naloxone. seven of the protocol violations were patients who required a second mg dose of naloxone. eleven cases did not have an als intercept; only of these patients did not respond to bls administration of naloxone. there were no identified adverse events. conclusion: bls providers safely and successfuly administered in naloxone achieving a response rate consistent with studies of als providers' administration of in naloxone. given the success rate of bls providers, it may be feasible for bls to manage responders without the aid of an als intercept. background: an estimated % of patients arriving by ambulance to the ed are in moderate to severe pain. however, the management of pain in the prehospital setting has been shown to be inadequate, and untreated pain may have negative consequences for patients. objectives: to determine if focused education on pediatric pain management and implementation of a pain management protocol improved the prehospital assessment and treatment of pain in adult patients. specifically, this study aimed to determine if documentation of pain scores and administration of morphine by ems personnel improved. methods: this was a retrospective before and after study conducted by reviewing a county-wide prehospital patient care database. the study population included all adult patients transported by ems between february and february with a working assessment of trauma or burn. ems patient care records were searched for documentation of pain scores and morphine administration years before and years after an intensive pediatric focused pain management education program and implementation of a pain management protocol. frequencies and % cis were determined for all patients meeting the inclusion criteria in the before and after time period and chisquare was used to compare frequencies between time periods. a secondary analysis was conducted using only subjects documented as meeting the protocol's treatment guidelines. results: , ( %) of , adult patients transported by ems during the study period met the inclusion criteria: , in the before and , in the after period. subject demographics were similar between the two periods. documentation of pain score did not change between the time periods ( background: there is a presumption that ambulance response times affect patient outcome. we sought to determine if shorter response times really make a difference in hospital outcomes. objectives: to determine if ambulance response time makes a difference in the outcomes of patients transported for two major trauma (motor vehicle crash injuries, penetrating trauma) and two major medical (difficulty breathing and chest pain complaints) emergencies. methods: this study was conducted in a metropolitan ems system serving a population total of , including urban and rural areas. cases were included if the private ems service was the first medical provider on scene, the case was priority , and the patient was years and older. a -month time period was used for the data evaluation. four diagnoses were examined: motor vehicle crash injuries, penetrating trauma, difficulty breathing, and chest pain complaints. ambulance response times were assessed for each of the four different complaints. the patients' initial vital signs were assessed and the number of vital signs out of range was recorded. a sampling of all cases which went to the single major trauma center was selected for evaluation of hospital outcome. using this hospital sample, number of vital signs out of range were assessed as a surrogate marker indicating severity of hospital outcome. correlation coefficients were used to evaluate interactions between independent and outcome variables. results: of the cases we reviewed over the month period, we found that the ems service responded significantly faster to trauma complaints at . minutes (n = ) than medical complaints at . minutes (n = ) . in the hospital sample of cases, number of vital signs out of range were positively correlated with hospital days (r = . ), admits (r = . ), icu admits (r = . ), and deaths (r = . ), but not response times (r = (-) . ). in the entire sample, there was no correlation between vital signs out of range and response times for any diagnosis (see figure) . conclusion: conclusions: based on our hospital sample which showed that number of vital signs out of range was a surrogate marker of worse hospital outcomes, we find that hospital outcomes are not related to initial response times. adverse effects following prehospital use of ketamine by paramedics eric ardeel baylor college of medicine, houston, tx background: ketamine is widely used across specialties as a dissociative agent to achieve sedation and analgesia. emergency medical services (ems) use ketamine to facilitate intubation and pain control, as well as to sedate acutely agitated patients. published studies of ems ketamine practice and effects are scarce. objectives: describe the incidence of adverse effects occurring after ketamine administration by paramedics treating under a single prehospital protocol. methods: a retrospective analysis was conducted of consecutive patients receiving prehospital ketamine from paramedics in the suburban/rural ems system of montgomery county hospital district, texas between august , and october , . ketamine administration indications were: need for rapid control of violent/agitated patients requiring treatment and transport; sedation and analgesia after trauma; facilitation of intubation and mechanical ventilation. ketamine administration contraindications were: equivalent ends achieved by less invasive means; hypertensive crisis; angina; signs of significantly elevated intracranial pressure; anticipated inability to support or control airway. all patients were included, regardless of indication for ketamine administration. data were abstracted from electronic patient care records and available continuous physiologic monitoring data, and analyzed for the presence of adverse effects as defined a priori in ''clinical practice guidelines for emergency department ketamine dissociative sedation: update.'' results: no patients were identified as experiencing adverse effects as defined by the referenced literature. ketamine was utilized most often for patients with the following nemsis provider's primary impression: ( %) altered level of consciousness, ( %) behavioral/psychiatric, ( %) traumatic injury. overall, combativeness was associated with ( %) patients. the mean age was years (range - years) and ( %) were male. the mean ketamine dose was mg (range - mg) and twenty-four ( %) patients received multiple administrations. conclusion: in this patient population, our data indicate that prehospital ketamine use by ems paramedics, across all indications for administration, was safe. further study of ketamine's utility in ems is warranted. an background: rigorous evaluation of the effect of implementing nationally vetted evidence-based guidelines (ebgs) has been notoriously difficult in ems. specifically, human subjects issues and the health insurance portability and accountability act (hipaa) present major challenges to linking ems data with distal outcomes. objectives: to develop a model that addresses the human subjects and hipaa issues involved with evaluating the effect of implementing the traumatic brain injury (tbi) ebgs in a statewide ems system. methods: the excellence in prehospital injury care (epic) project is an nih-funded evaluation of the effect of implementing the ems tbi guidelines throughout arizona (ninds- r ns - a ). to accomplish this, a partnership was developed between the arizona department of health services (adhs), the university of arizona, and more than ems agencies that serve approximately % of the state's population. results: ebg implementation: implementation follows all routine regulatory processes for making changes in ems protocols. in arizona, the entire project must be carried out under the authority of the adhs director. evaluation: a before-after system design is used (randomization is not acceptable). hipaa: as an adhsapproved public health initiative, epic is exempt from hipaa, allowing sharing of protected health information between participating entities. for epic, the state attorney general provided official verification of hi-paa exemption, thus allowing direct linkage of ems and hospital data. irb: once epic was officially deemed a public health initiative, the university irb process was engaged. as an officially sanctioned public health project, epic was determined to not be human subjects research. this allows the project to implement and evaluate the effect of this initiative without requiring individual informed consent. conclusion: by utilizing an ems-public health-university partnership, the ethical and regulatory challenges related to evaluating implementation of new ebgs can be successfully overcome. the integration of the department of health, the attorney general, and the university irb can properly protect citizens while permitting efficient implementation and rigorous evaluation of the effect of ebgs. this novel approach may be useful as a model for evaluation of implementing ems ebgs in other states and large counties. ( . %- . % by age) were transported to non-trauma centers. the most common reasons cited by ems for hospital selection were: patient preference ( . %), closest facility ( . %), and specialty center ( . %). patient preference increased with age (p for trend . ) and paralleled under-triage ( figure ). iss ‡ patients transported to non-trauma hospitals by patient request had lower unadjusted mortality ( . %, %ci . - . ) than similar patients transported to trauma centers ( . %, %ci . - . ) or transported for other reasons ( . %, %ci . - . ) (figure ) . under-triage appears to be influenced by patient preference and age. self-selection for transport to non-trauma centers may result in under-triaged patients with inherently better prognosis than triagepositive patients. background: only % of all out-of-hospital cardiac arrest (ohca) patients receive bystander cpr (cardiopulmonary resuscitation). the neighborhood in which an ohca occurs has significant influence on the likelihood of receiving bystander cpr. objectives: to utilize geographic information systems to identify ''high-risk'' neighborhoods, defined as census tracts with high incidence of ohca and low cpr prevalence. methods: design: secondary analysis of the cardiac arrest registry to enhance survival (cares) dataset for denver county, colorado. population: all consecutive adults (> years old) with ohca due to cardiac etiology from january , through december , . data analysis: analyses were conducted in arc-gis. three spatial statistical methods were used: local morans i (lmi), getis-ord gi*(gi*), and spatial empirical bayes (seb) adjusted rates. census tracts with high incidence of ohca, as identified by all three spatial statistical methods, were then overlain with low bystander cpr census tracts, which were identified in at least two out of three statistical methods (lmi, gi*, or the lowest quartile of bystander cpr prevalence). overlapping census tracts identified with both high ohca incidence and low cpr prevalence were designated as ''highrisk''. results: a total of arrests in census tracts occurred during the study period, with arrests included in final sample. events were excluded if they were unable to be geocoded (n = ), outside denver county (n = ), or occurred in a jail (n = ), hospital/ physician's office (n = ), or nursing home (n = ). for high ohca incidence: lmi identified census tracts, gi* identified census tracts, and the seb method identified census tracts. twenty-five census tracts were identified by all three methods. for low bystander cpr prevalence: lmi identified census tracts, gi* identified census tracts, and census tracts were identified as being in the lowest quartile of cpr prevalence. twenty-four census tracts were identified by two of the three methods. two census tracts were identified as high-risk having both high ohca incidence and low cpr prevalence (figure) . high-risk census tract demographics as compared to denver county are shown in the table. conclusion: the two high-risk census tracts, comprised of minority and low-income populations, appear to be possible sites for targeted community-based cpr interventions. objectives: we sought to assess the accuracy and correlation of geographic information system (gis) derived transport time compared to actual ems transport time in ohca patients. methods: prospective, observational cohort analysis of ohca patients in vancouver, b.c., one of the sites of the resuscitation outcomes consortium (roc). a random sample from all of the ohca cases from / through / was selected for analysis from one site of the roc epistry. using gis, ems transport time was derived from reported latitude/longitude coordinates of the ohca event to the actual receiving hospital. this was calculated via the actual network distance using arcgis. this gis-derived time was then compared to the actual ems transport time (in minutes) using the wilcoxon signed rank test. scatter plot analysis of actual vs. gis times were created to evaluate the relationship between actual and calculated time. a linear regression model predicting actual ems transport time from the derived gis-time was also developed in order to examine the potential relationship between the two variables. differences in the relationship were also investigated based on time of the day to reflect varying traffic conditions. results: cases were randomly selected for analysis. the median actual transport time was significantly longer than the median gis derived transport time ( . minutes vs. . minutes). scatter plot analysis did not reveal any significant correlation between actual and gis-based time. additionally, there was poor approximation of gis-based time and actual ems time (r = . ) with no evidence of a significant linear relationship between the two. the poorest correlation of time was observed during the morning hours ( : - : ; r = . ) while the strongest correlation was during the overnight hours ( : - : ; r = . ). conclusion: gis derived time does not appear to correlate well with actual ems transport time of ohca patients. efforts should be made to accurately obtain actual ems transport times for ohca patients. objectives: we first sought to describe the incidence of ohca presenting to the ed. we then sought to determine the association between hospital characteristics and survival to hospital admission. methods: we identified patients with diagnoses of cardiac arrest or ventricular fibrillation (icd- . or . ) in the nationwide emergency department sample, a nationally representative estimate of all ed admissions in the us. eds reporting ‡ patient with ohca were included. our primary outcome was survival to hospital admission. we examined variability in hospital survival rate and also classified hospitals into high or low performers based on median survival rate. we used this dichotomous hospital level outcome to examine factors associated with survival to admission including hospital and patient demographics, ed volume, cardiac arrest volume, and cardiac catheterization availability. all unadjusted and adjusted analyses were performed using weighted statistics and logistic regressions. results: of the hospitals, ( . %) were included. in total, , cases of cardiac arrest were identified, representing an estimated , cases nationally. overall ed ohca survival to hospital admission was . % (iqr . %, . %) in adjusted analyses, increased survival to admission was seen in hospitals with teaching status (or . , % ci . - . , p < . ), annual ed visits ‡ , (or . , % ci . - . , p < . ), and pci capability (or . , % ci . - . , p = . ). in separate adjusted analyses including teaching status and pci capabilities, hospitals with > annual cardiac arrest cases (or . , % ci . - . , p < . ) were also shown to have improved survival (figure) . conclusion: ed volume, cardiac arrest volume, and pci capability were associated with improved survival to hospital admission in patients presenting to the ed after ohca. an improved understanding of the contribution of ed care to ohca survival may be useful in guiding the regionalization of cardiac arrest care. background: prior investigations have demonstrated regional differences in out-of-hospital cardiac arrest (ohca) outcomes, but none have evaluated survival variability by hospital within a single major us city. objectives: we hypothesized that -day survival from ohca would vary considerably among one city's receiving hospitals. methods: we performed a retrospective review of prospectively collected cardiac arrest data from a large, urban ems system. our population included all ohcas with a recorded social security number (which we used to determine -day survival through the social security death index) that were transported to a hospital between / / and / / . we excluded traumatic arrests, pediatric arrests, and hospitals receiving less than ohcas with social security numbers over the three-year study period. we examined the associa-tion between receiving hospital and -day survival. additional variables examined included: level i trauma center status, teaching hospital status, ohca volume, and whether post-arrest therapeutic hypothermia (th) protocols were in place in . statistics were performed using chi-square tests and logistic regression. results: our study population comprised arrest cases delivered to unique hospitals with an overall -day survival of . %. mean age was . (sd . ) years. males comprised . % of the cohort; . % of victims were black. thirty-day survival varied significantly among the hospitals, ranging from . % to . % (chi-square . , p = . ). ohcas delivered to level i trauma centers were significantly more likely to survive ( . % vs. . %, p = . ), as were those delivered to hospitals known to offer post-arrest th ( . % vs. . %, p = . ). hospital teaching status and ohca volume were not associated with survival. conclusion: there was significant variability in ohca survival by hospital. patients were significantly more likely to survive if transported to a level i trauma center or hospital with post-arrest th protocols, suggesting a potential role for regionalization of ohca care. limiting our population to ohcas with recorded social security numbers reduced our power and may have introduced selection bias. further work will include survival data on the complete set of ohcas transported to hospitals during the three-year study period. background: traumatic brain injury is a leading cause of death and disability. previous studies suggest that prehospital intubation in patients with tbi may be associated with mortality. limited data exist comparing prehospital (ph) nasotracheal (nt), prehospital orotracheal (ot), and ed ot intubation and mortality following tbi. objectives: to estimate the associations between ph nt, ph ot, and ed ot intubation and in-hospital mortality in patients with moderate to severe tbi, with hypotheses that ph nt and ph ot intubation would be associated with increased mortality when compared to ed ot or no intubation. methods: an analysis using the denver health trauma registry, a prospectively collected database. consecutive adult trauma patients from - with moderate to severe tbi defined as head abbreviated injury scale (ais) scores of - . structured chart abstraction by blinded physicians was used to collect demographics, injury and prehospital care characteristics, intubation status and timing, in-hospital mortality and survival time, and neurologic function at discharge. poor neurologic function was defined as cerebral performance category score of - . multivariable logistic regression and survival analyses were performed, using multiple imputation for missing data. results: of the , patients, the median age was (iqr - ) years. the median ph gcs was (iqr - ), median injury severity score was (iqr - ), and median head ais was (iqr - ). ph nt occurred in . %, ph ot in . %, and ed ot in . %, while mortality occurred in . %. the -, -, and -hour survival analyses are outlined in the table. survival curves for ph nt, ph ot, and ed ot are demonstrated in the figure (p < . ) . conclusion: prehospital intubation in patients with moderate to severe tbi is associated with increased mortality. contrary to our initial hypothesis, there was also a significant association between ed intubation and mortality. these associations persisted despite survival time, and while adjusting for injury severity. background: sbdp is a breakdown product of the cytoskeletal protein alpha-ii-spectrin found in neurons and has been detected in severe tbi. objectives: this study examined whether early serum levels of sbdp could distinguish: ) mild tbi from three control groups; ) those with and without traumatic intracranial lesions on ct (+ct vs -ct); and ) those having a neurosurgical intervention (+nsg vs -nsg) in mild and moderate tbi (mmtbi). methods: this prospective cohort study enrolled adult patients presenting to two level i trauma centers following mmtbi with blunt head trauma with loss of consciousness, amnesia, or disorientation and a gcs - . control groups included uninjured controls and trauma controls presenting to the ed with orthopedic injuries or an mvc without tbi. mild tbi was defined as gcs and moderate tbi as having a gcs < . blood samples were obtained in all patients within hours of injury and measured by elisa for sbdp (ng/ml). the main outcomes were: ) the ability of sbdp to distinguish mild tbi from three control groups; ) to distinguish +ct from -ct and; ) to distinguish +nsg from -nsg. data were expressed as means with %ci, and performance was tested by roc curves (auc and %ci). results: there were patients enrolled: tbi patients ( gcs , gcs - ), trauma controls ( mvc controls and orthopedic controls), and uninjured controls. the mean age of tbi patients was years (range - ) with % males. fourteen ( %) had a +ct and % had +nsg. mean serum sbdp levels were . ( %ci . - . ) in normal controls, . ( . - . ) in orthopedic controls, . ( . - . ) in mvc controls, . ( . - . ) in mild tbi with gcs , and . ( . - . ) in tbi with gcs - (p < . ). the auc for distinguishing mild tbi from both controls was . ( %ci . - . ). mean sbdp levels in patients with -ct versus +ct were . ( . - . ) and . ( . - . ) respectively (p < . ) with auc = . ( %ci . - . ). mean sbdp levels in patients with -nsg versus +nsg were . ( . - . ) and . ( . - . ) respectively (p < . ) with auc = . ( %ci . - . ). conclusion: serum sbdp levels were detectable in serum acutely after injury and were associated with measures of injury severity including ct lesions and neurosurgical intervention. further study is required to validate these findings before clinical application. utility of platelet background: pre-injury use of anti-platelet agents (e.g., clopidogrel and aspirin) is a risk factor for increased morbidity and mortality in patients with traumatic intracranial hemorrhage (tich). some investigators have recommended platelet transfusion to reverse the anti-platelet effects in tich. objectives: this evidence-based medicine review examines the evidence regarding the effect of platelet transfusion in emergency department (ed) patients with pre-injury anti-platelet use and tich on patientoriented outcomes. methods: the medline, embase, cochrane library, and other databases were searched. studies were selected for inclusion if they compared platelet transfusion to no platelet transfusion in the treatment of adult ed patients with pre-injury anti-platelet use and tich, and reported rates of mortality, neurocognitive function, or adverse effects as outcomes. we assessed the quality of the included studies using ''grading of recommendations assessment, development and evaluation'' (grade) criteria. categorical data are presented as percentages with % confidence interval (ci). relative risks (rr) are reported when clinically significant. results: five retrospective, registry-based studies were identified, which enrolled patients cumulatively. based on standard criteria, three studies were of ''low'' quality evidence and two studies had ''very low'' qualities. one study reported higher in-hospital mortality in patients with platelet transfusion (ohm et al), another showed a lower mortality rate in patients receiving platelet transfusion (wong et al). three studies did not show any statistical difference in comparing mortality rates between the groups (table) . no studies reported intermediate-or long-term neurocognitive outcomes or adverse events. conclusion: five retrospective registry studies with suboptimal methodologies provide inadequate evidence to support the routine use of platelet transfusion in adult ed patients with pre-injury anti-platelet use and tich. abnormal levels of end-tidal carbon dioxide (etco ) are associated with severity of injury in mild and moderate traumatic brain injury (mmtbi) linda papa , artur pawlowicz , carolina braga , suzanne peterson , salvatore silvestri orlando regional medical center, orlando, fl; university of central florida, orlando, fl background: capnography is a fast, non-invasive technique that is easily administered and accurately measures exhaled etco concentration. etco levels respond to changes in ventilation, perfusion, and metabolic state, all of which may be altered following tbi. objectives: this study examined the relationship between etco levels and severity of tbi as measured by clinical indicators including glasgow coma scale (gcs) score, computerized tomography (ct) findings, requirement of neurosurgical intervention, and levels of a serum biomarkers of glial damage. methods: this prospective cohort study enrolled adult patients presenting to a level i trauma center following a mmtbi defined by blunt head trauma followed by loss of consciousness, amnesia, or disorientation and a gcs - . etco measurements were recorded from the prehospital and emergency department records and compared to indicators of tbi severity. results: of the patients enrolled, ( %) had a normal etco level and ( %) had an abnormal etco level. the mean age of enrolled patients was (range - ) and ( %) were male. mechanisms of injury included motor vehicle collision in ( %), motor cycle collision in ( %), fall in ( %), bicycle/ pedestrian struck in ( %), and other in ( %). eight ( %) patients had a gcs - and ( %) had a gcs - . of the ( %) patients with intracranial lesions on ct, ( %) had an abnormal etco level (p = . ). of the ( %) patients who required a neurosurgical intervention, % had an abnormal etco level (p = . ). levels of a biomarker indicative of astrogliosis were significantly higher in those with abnormal etco compared to those with a normal etco (p = . ). conclusion: abnormal levels of etco were significantly associated with clinical measures of brain injury severity. further research with a larger sample of mmtbi patients will be required to better understand and validate these findings. background: acetaminophen (apap) poisoning is the most frequent cause of acute hepatic failure in the us. toxicity requires bioactivation of apap to toxic metabolites, primarily via cyp e . children are less susceptible to apap toxicity; one current theory is that children's conjugative pathway (sulfonation) is more active. liquid apap preparations contain propylene glycol (pg), a common excipient that inhibits apap bioactivation and reduces hepatocellular injury in vitro and in rodents. cyp e inhibition may decrease toxicity in children, who tend to ingest liquid apap preparations, and suggests a potential novel therapy. objectives: to compare phase i (toxic) and phase ii (conjugative) metabolism of liquid versus solid prepara-tions of apap. we hypothesize that ingestion of a liquid apap preparation results in decreased production of toxic metabolites relative to a solid preparation, likely due to the presence of pg in the liquid preparations. methods: design-pharmacokinetic cross-over study. setting-university hospital clinical research center. subjects-adults ages - taking no chronic medications. interventions-subjects were randomized to receive a mg/kg dose of a commercially available solid or liquid apap preparation. after a washout period of greater than week, subjects received the same dose of apap in the alternate preparation. apap, apap-glucuronide and apap-sulfate (phase metabolites), apap-cysteinate and apap-mercapturate (phase metabolites) were analyzed via lc/ms in plasma over hours. peak concentrations and measured auc were compared using paired-sample t-tests. plasma pg levels were measured. results: fifteen subjects completed the protocol. peak concentrations and aucs of the cyp e derived toxic metabolites were significantly lower following ingestion of the liquid preparation (table, figure) . the glucuronide and sulfate metabolites were not different. pg was present following ingestion of liquid but not solid preparations. conclusion: ingestion of liquid relative to solid preparations in therapeutic doses results in decreased plasma levels of toxic apap metabolites. this may be due to inhibition of cyp e by pg, and may explain the decreased susceptibility in children. a less hepatotoxic formulation of apap can potentially be developed if co-formulated with a cyp e inhibitor. background: pressure immobilization bandages have been shown to delay mortality for up to hours after coral snake envenomation, providing an inexpensive and effective treatment when antivenin is not readily available. however, long-term efficacy has not been established. objectives: determine if pressure immobilization bandages, consisting of an ace wrap and splint, can delay morbidity and mortality from coral snake envenomation, even in the absence of antivenin therapy. methods: institutional animal care and use committee approval was obtained. this was a randomized, observational pilot study using a porcine model. ten pigs ( . kg to . kg) were sedated and intubated for hours. pigs were injected subcutaneously in the left distal foreleg with mg of lyophilized m. fulvius venom resuspended in water, to a depth of mm. pigs were randomly assigned to either a control group (no compression bandage and splint) or a treatment group (compression bandage and splint) approximately minute after envenomation. pigs were monitored daily for days for signs of respiratory depression, decreased oxygen saturations, and paresis/paralysis. in case of respiratory depression, pigs were euthanized and time to death recorded. chi-square was used to compare rates of survival up to days and a kaplan-meier survival curve constructed. results: average survival time of control animals was ± minutes compared to , ± , minutes for treated animals. significantly more pigs in the treatment group survived to hours than in the control group (p = . ). two of the treatment pigs survived to the endpoint of days, but showed necrosis of the distal lower extremity. conclusion: long-term survival after coral snake envenomation is possible in the absence of antivenin with the use of pressure immobilization bandages. the applied pressure of the bandage is critical to allowing survival without secondary consequences (i.e. necrosis) of envenomation. future studies should be designed to accurately monitor the pressures applied. background: patients exposed to organophosphate (op) compounds demonstrate a central apnea. the kölliker-fuse nuclei (kf) are cholinergic nuclei in the brainstem involved in central respiratory control. objectives: we hypothesize that exposure of the kf is both necessary and sufficient for op-induced central apnea. methods: anesthetized and spontaneously breathing wistar rats (n = ) were exposed to a lethal dose of dichlorvos using three experimental models. experiment (n = ) involved systemic op poisoning using subcutaneous (sq) dichlorvos ( mg/kg or x ld ). experiment (n = ) involved isolated poisoning of the kf using stereotactic microinjections of dichlorvos ( micrograms in microliters) into the kf. experiment (n = ) involved systemic op poisoning with isolated protection of the kf using sq dichlorvos ( mg/kg) and stereotactic microinjections of organophosphatase a (opda), an enzyme that degrades dichlorvos. respiratory and cardiovascular parameters were recorded continuously. histological verification of injection site was performed using kmno injections. animals were followed post-poisoning for hour or death. betweengroup comparisons were performed using a repeated measured anova or student's t-test where appropriate. results: animals poisoned with sq dichlorvos demonstrated respiratory depression starting . min post exposure, progressing to apnea . min post exposure. there was no difference in respiratory depression between animals with sq dichlorvos and those with dichlorvos microinjected into the kf. despite differences in amount of dichlorvos ( mg/kg vs . mg/kg) and method of exposure (sq vs cns microinjection), min following dichlorvos both groups (sq vs microinjection respectively) demonstrated a similar percent decrease in respiratory rate ( . vs . , p = . ), minute ventilation ( background: patients sustaining rattlesnake envenomation often develop thrombocytopenia, the etiology of which is not clear. laboratory studies have demonstrated that venom from several species, including the mojave rattlesnake (crotalus scutulatus scutulatus), can inhibit platelet aggregation. in humans, administration of crotaline fab antivenom (av) has been shown to result in transient improvement of platelet levels; however, it is not known whether platelet aggregation also improves after av administration. objectives: to determine the effect of c. scutulatus venom on platelet aggregation in vitro in the presence and absence of crotaline fab antivenom. methods: blood was obtained from four healthy male adult volunteers not currently using aspirin, nsaids, or other platelet-inhibiting agents. c. scutulatus venom from a single snake with known type b (hemorrhagic) activity was obtained from the national natural toxins research center. measurement of platelet aggregation by an aggregometer was performed using five standard concentrations of epinephrine (a known platelet aggregator) on platelet-rich plasma over time, and a mean area under the curve (auc) was calculated. five different sample groups were measured: ) blood alone; ) blood + c. scutulatus venom ( . mg/ml); ) blood + crotaline fab av ( mg/ml); ) blood + venom + av ( mg/ ml); ) blood + venom + av ( mg/ml). standard errors of the mean (sem) were calculated for each group. results: antivenom administration by itself did not significantly affect platelet aggregation compared to baseline ( . ± . %, p = . ). administration of venom decreased platelet aggregation ( . ± . %, p < . ). concentrated av administration in the presence of venom normalized platelet aggregation ( . ± . %) and in the presence of diluted av significantly increased aggregation ( . ± . %); p < . for both groups when compared to the venom-only group. to control for the effects of the venom and av, each was run independently in platelet-rich plasma without epinephrine; neither was found to significantly alter platelet aggregation. conclusion: crotaline fab av improved platelet aggregation in an in vitro model of platelet dysfunction induced by venom from c. scutulatus. the mechanism of action remains unclear but may involve inhibition of venom binding to platelets or a direct action of the antivenom on platelets. background: routine use of both breathalyzers and hand sanitizers is common across emergency depart-ments. the most common hand sanitizer on the market, purell, contains % ethyl alcohol and a lesser amount of isopropyl alcohol. previous investigations have documented that risk is low to the health care worker who applies frequent hand sanitizers to themselves. however, it is unknown whether this alcohol mixture causes false readings on a breathalyzer machine being used to determine alcohol levels on others. objectives: to determine the effect on the measurement of breathalyzer readings in individuals who have not consumed alcohol after hand sanitizer is applied to the experimenter holding a breathalyzer machine. methods: after obtaining informed consent, a breathalyzer reading was obtained in participants who had not consumed any alcohol in the last hours. three different experiments were performed with different participants in each. in experiment , two pumps of hand sanitizer were applied to the experimenter. without allowing the sanitizer to dry, the experimenter then measured the breathalyzer reading of the participant. in experiment , one pump of sanitizer was applied to the experimenter. measurements of the participant were taken without allowing the sanitizer to dry. in experiment , one pump of sanitizer was placed on the experimenter and rubbed until dry according to the manufacturer's recommendations. readings were recorded and analyzed using paired t-tests. results: the initial breathalyzer reading for all participants was . after two pumps of hand sanitizer were applied without drying (experiment ), breathalyzers ranged from . to . , with a mean above the legalintoxication limit of . (t( ) = ) . , p < . ). after one pump of hand sanitizer was applied without drying (experiment ), breathalyzers ranged from . to . , with a mean of . (t( ) = ) . , p < . ). after one pump of hand sanitizer was applied according to manufacturer's directions (experiment ), breathalyzers ranged from . to . with a mean of . (t( ) = ) . , p < . ). conclusion: use of hand sanitizer according to the manufacturer's recommendations results in a small but significant increase in breathalyzer readings. however, the improper and overuse of common hand sanitizer elevates routine breathalyzer readings, and can mimic intoxication in individuals who have not consumed alcohol. stephanie carreiro, jared blum, francesca beaudoin, gregory jay, jason hack objectives: the primary aim of this study is to determine if pretreatment with ile affects the hemodynamic response to epinephrine in a rat model. hemodynamic response was measured by a change in heart rate (hr) and mean arterial pressure (map). we hypothesized that ile would limit the rise in map and hr that typically follow epinephrine administration. methods: twenty male sprague dawley rats (approximately - weeks of age) were sedated with isoflurane and pretreated with a ml/kg bolus of ile or normal saline, followed by a mcg/kg dose of epinephrine intravenously. intra-arterial blood pressure and hr were monitored continuously until both returned to baseline (biopaq). a multifactorial analysis of variance (manova) was performed to assess the difference in map and hr between the two groups. standardized t-tests were then used to compare the peak change in map, time to peak map, and time to return to baseline map in the two groups. results: overall, a significant difference was found between the two groups in map (p = . ) but not in hr (p = . ). there was a significant difference (p = . ) in time to peak map in the ile group ( sec, % ci - ) versus the saline group ( sec, % ci - ) and a significant difference (p = . ) in time to return to baseline map in ile group ( sec, % ci - ) versus the saline group ( sec, % ci - ). there was no significant difference (p = . ) in the peak change in map of the ile group ( . , mmhg, % ci - ) versus the saline group ( . mmhg, % ci - ). conclusion: our data show that in this rat model ile pretreatment leads to a significant difference in map response to epinephrine, but no difference in hr response. ile delayed the peak effect and prolonged the duration of effect on map but did not alter the peak increase in map. this suggests that the use of ile may delay the time to peak effect of epinephrine if the drugs are administered concomitantly to the same patient. further research is needed to explore the mechanism of this interaction. rasch analysis of the agitation severity scale when used with emergency department acute psychiatry patients tania d. strout, michael r. baumann maine medical center, portland, me background: agitation is a frequently observed and problematic phenomenon in mental health patients being treated in the emergency setting. the agitation severity scale (agss), a reliable and valid instrument, was developed using classical test theory to measure agitation in acute psychiatry patients. objectives: the aim of this study was to analyze the agss according to the rasch measurement model and use the results to determine whether improvements to the instrument could be made. methods: this prospective, observational study was irb-approved. adult ed patients with psychiatric chief complaints and dsm-iv-tr diagnoses were observed using the agss. the rasch rating scale model was employed to evaluate the items comprising the agss using winsteps statistical software. unidimensionality, item fit, response category performance, person and item separation reliability, and hierarchical ordering of items were all examined. a principle components analysis (pca) of the rasch residuals was also performed. results: variable maps revealed that all of the agss items were used to some degree and that the items were ordered in a way that makes clinical sense. several duplicative items, indicating the same degree of agitation, were identified. item ( . ) and person ( . ) separation statistics were adequate, indicating appropriate spread of items and subjects along the agitation continuum and providing support for the instrument's reliability. keymaps indicated that the agss items are functioning as intended. analysis of fit demonstrated no extreme misfitting items. pca of the rasch residuals revealed a small amount of residual variance, but provided support for the agss as being unidimensional, measuring the single construct of agitation. the results of this rasch analysis support the agss as a psychometrically robust instrument for use with acute psychiatry patients in the emergency setting. several duplicative items were identified that may be eliminated and re-evaluated in future research; this would result in a shorter, more clinically useful scale. in addition, a gap in items for patients with lower levels of agitation was identified. generation of additional items intended to measure low levels of agitation could improve clinician's ability to differentiate between these patients. background: attempted suicide is one of the strongest clinical predictors of subsequent suicide and occurs up to times more frequently than completed suicide. as a result, suicide prevention has become a central focus of mental health policy. in order to improve current treatment and intervention strategies for those presenting with suicide attempt and self-injury in the emergency department (ed), it is necessary to have a better understanding of the types of patients who present to the ed with these complaints. objectives: to describe the epidemiology of ed visits for attempted suicide and self-inflicted injury over a year period. methods: data were obtained from the national hospital ambulatory medical care survey (nhamcs). all visits for attempted suicide and self-inflicted injury (e -e ) during - were included. trend analyses were conducted using stata's nptrend (a nonparametric test for trends that is an extension of the wilcoxon rank-sum test) and regression analyses. a two-tailed p < . was considered statistically significant. results: over the -year period, there were an average of , annual ed visits for attempted suicide and self-inflicted injury ( . [ % confidence interval (ci) . - . ] visits per , us population). the overall mean patient age was years, with visits most common among ages - ( . ; %ci . - . ). the average annual number of ed visits for suicide attempt and self-inflicted injury more than doubled from , in - to , in - . during the same timeframe, ed visits for these injuries per , us population almost doubled for males ( . to . ), females ( . to . ), whites ( . to . ), and blacks ( . to . ). no temporal differences were found for method of injury or ed disposition; there was, however, a significant decrease in visits determined by the physician to be urgent/emergent from % in to % in . conclusion: ed visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. in addition, this information may be used to inform current suicide and self-injury related ed interventions and treatment programs. benjamin l. bregman, janice c. blanchard, alyssa levin-scherz george washington university, washington, dc background: the emergency department (ed) has increasingly become a health care access point for individuals with mental health needs. recent studies have found that rates of major depression disorder (mdd) diagnosed in eds are far above the national average. we conducted a study assessing whether individuals with frequent ed visits had higher rates of mdd than those with fewer ed visits in order to help guide screening and treatment of depressed individuals encountered in the ed. objectives: this study evaluated potential risk factors associated with mdd. we hypothesized that patients who are frequent ed visitors will have higher rates of mdd. methods: this was a single center, prospective, crosssectional study. we used a convenience sample of noncritically ill, english speaking adult patients presenting with non-psychiatric complaints to an urban academic ed over months in . we oversampled patients presenting with ‡ visits over the previous days. subjects were surveyed about their demographic and other health and health care characteristics and were screened with the phq , a nine-item questionnaire that is a validated, reliable predictor of mdd. we conducted bivariate (chi-square) and multivariate analysis controlling for demographic characteristics using sta-ta v. . . our principal dependent variable of interest was a positive depression screen (phq score ‡ ). our principal independent variable of interest was ‡ visits over the previous days. results: our response rate was . % with a final sample size of . of our total sample, ( . %) had three or greater visits within the prior days. one hundred ( %) frequent visitors had a positive phq mdd screen as compared to ( . %) of subjects with fewer than three visits (p < . ). in our multivariate analysis, the odds for having three or more visits for subjects who had a positive depression screen was . ( . , . ). of subjects with three or more visits with a positive depression screen, only ( %) were actively being treated for mdd at the time of their visit. conclusion: our study found a high prevalence of untreated depression among frequent users of the ed. eds should consider routinely screening patients who are frequent consumers for mdd. in addition, further studies should evaluate the effect of early treatment and follow up for mdd on overall utilization of ed services. access to psychiatric care among patients with depression presenting to the emergency department janice c. blanchard, benjamin l. bregman, dana rosenfarb, qasem al jabr, eun kim george washington university, washington, dc background: literature suggests that there is a high rate of major depressive disorder (mdd) in emergency department (ed) users. however, access to outpatient mental health services is often limited due to lack of providers. as a result, many persons with mdd who are not in active treatment may be more likely to utilize the ed as compared to those who are currently undergoing outpatient treatment. objectives: our study evaluated utilization rates and demographic characteristics associated with patients with a prior diagnosis of mdd not in active treatment. we hypothesized that patients who present to the ed with untreated mdd will have more frequent ed visits. methods: this was a single center, prospective, crosssectional study. we used a convenience sample of noncritically ill, english speaking adult patients presenting with non-psychiatric complaints to an urban academic ed over months in . subjects were surveyed about their demographic and other health and health care characteristics and were screened with the phq , a nine-item questionnaire that is a validated, reliable predictor of mdd. we conducted bivariate (chi-square) and multivariate analysis controlling for demographic characteristics using stata v. . . our principal dependent variable of interest was a positive depression screen (phq ‡ ). our analysis focused on the subset of patients with a prior diagnosis of mdd with a positive screen for mdd during their ed visit. results: our response rate was . % with a final sample size of . ( . %) patients screened positive for mdd with a phq score ‡ . of the patients with a positive depression screen, . % reported a prior history of treatment for mdd (n = ). of these patients, only . % were currently actively receiving treatment. hispanics who screened positive for depression with a history of mdd were less likely to actively be undergoing treatment as compared to non-hispanics ( . % versus . %, p = . ). patients with incomes less than $ , were more likely to actively be receiving treatment as opposed to higher incomes ( . % versus . % p = . ). conclusion: patients presenting to our ed with untreated mdd are more likely to be hispanic and less likely to be low income. the emergency department may offer opportunities to provide antidepressant treatment for patients who screen positive for depression but who are not currently receiving treatment. evaluation of a two-question screening tool (phq- ) for detecting depression in emergency department patients jeffrey p. smith, benjamin bregman, janice blanchard, nasser hashim, mary pat mckay george washington university, washington, dc background: the literature suggests there is a high rate of undiagnosed depression in ed patients and that early intervention can reduce overall morbidity and health care costs. there are several well validated screening tools for depression including the nine-item patient health questionnaire (phq- ). a tool using a two-question subset, the phq- , has been shown to be an easily administered, reasonably sensitive screening tool for depression in primary care settings. objectives: to determine the sensitivity and specificity of the phq- in detecting major depressive disorders (mdd) among adult ed patients presenting to an urban teaching hospital. we hypothesize that the phq- is a rapid, effective screening tool for depression in a general ed population. methods: cross sectional survey of a convenience sample of adult, non-critically ill, english speaking patients with medical and not psychiatric complaints presenting to the ed between am and pm weekdays. patients were screened for mdd with the phq- . we used spss v . to analyze the specificity, sensitivity, positive predictive value (ppv), negative predictive value (npv), and kappa of phq- scores of and (out of possible total score of ) compared to a validated cut-off score of or higher of points on the phq- . the two questions on the phq- are: ''over the last two weeks, how often have you had little interest in doing things? how often have you felt down, depressed or hopeless?'' responses are scored from - based on ''never'',''several days'', ''more than half'', ''nearly every day''. results: subjects of approached agreed to participate ( . % response rate), and ( . %) completed the phq- . the phq- identified ( . %) subjects with mdd. table outlines the percent of subjects who were positive and the sensitivity, specificity, positive, and negative predictive values and kappa for each cut-off on the phq- . conclusion: the phq- is a sensitive and specific screening tool for mdd in the ed setting. moreover, the phq- is closely correlated with the phq- , especially if a score of or greater is used. given the simplicity and ease of using a two-item questionnaire and the high rates of undiagnosed depression in the ed, including this brief, self-administered screening tool to ed patients may allow for early awareness of possible mdd and appropriate evaluation and referral. patients. however, much of this self-harm behavior is not discovered clinically and very little is known about the prevalence and predictors of current ed screening practices. attention to this issue is increasing due to the joint commission's patient safety goal , which focuses on identification of suicide risk in patients. objectives: to describe the prevalence and predictors of screening for self-harm and of presence of current self-harm in eds. methods: data were obtained from the nimh-funded emergency department safety assessment and followup evaluation (ed-safe). eight u.s. eds reviewed charts in real time for - hours a week between / and / . all patients presenting during enrollment shifts were characterized as to whether a selfharm screening had been performed by ed clinicians. a subset of patients with a positive screening was asked about the presence of self-harm ideation, attempts, or both by trained research staff. we used multivariable logistic regression to identify predictors of screening and of current self-harm. data were clustered by site. in each model we examined day and time of presentation, age < years, sex, race, and ethnicity. results: of the , patients presenting during research shift, , ( %) were screened for self-harm. screening rates varied among sites and ranged from % to %, with one outlier at %. of those screened, , ( %) had current self-harm. among those with selfharm approached by study personnel (n = , ), ( %) had thoughts of self-harm (suicidal or non-suicidal), ( %) had thoughts of suicide, ( %) had self-harm behavior, and ( %) had suicide attempt(s) over the preceding week. predictors of being screened were: age < years, male sex, weekend presentation, and night shift presentation (table) . among those screened, predictors of current self-harm were: age < years, white race, and night shift presentation. conclusion: screening for self-harm is uncommon in ed settings, though practices vary dramatically by site. patients presenting at night and on weekends are more likely to be screened, as are those under age and males. current self-harm is more common among those presenting on night shift, those under age , and whites. results: there were out-of-hospital records reviewed, and hospital discharge data were available in non-cardiac arrest patients. of the patients, ( . %) patients survived to hospital discharge and ( . %) died during hospitalization. the mean age of those transported was years (sd ), ( %) were male, ( %) were trauma-related, and ( %) were admitted to the icu. average systolic blood pressure (sbp), pulse (p), respiratory rate (rr), oxygen saturation (o sat), and end-tidal carbon dioxide (etco ) were sbp = (sd ), p = (sd ), rr = (sd ), o sat = % (sd ), and etco = (sd conclusion: of all the initial vital signs recorded in the out-of-hospital setting, etco was the most predictive of mortality. these findings suggest that pre-hospital etco is a useful clinical tool for determining severity of illness and appropriate triage. background: the prehospital use of continuous positive airway pressure (cpap) ventilation is a relatively new management for acute cardiogenic pulmonary edema (acpe) and there is little high quality evidence on the benefits or potential dangers in this setting. objectives: the aim of this study was to determine whether patients in severe respiratory distress treated with cpap in the prehospital setting have a lower mortality than those treated with usual care. methods: randomized, controlled trial comparing usual care versus cpap (whisperflowÒ) in a prehospital setting, for adults experiencing severe respiratory distress, with falling respiratory efforts, due to a presumed acpe. patients were randomised to receive either usual care, including conventional medications (nitrates, furosemide, and oxygen) plus bag-valve-mask ventilation, versus conventional medications plus cpap. the primary outcome was prehospital or in-hospital mortality. secondary outcomes were need for tracheal intubation, length of hospital stay, change in vital signs, and arterial blood gas results. we calculated relative risk with % cis. results: fifty patients were enrolled with mean age ae (sd ae ), male ae %, mortality ae %. the risk of death was significantly reduced in the cpap arm with mortality ae % ( deaths) in the usual care arm compared to ae % ( death) in the cpap arm (rr, ae ; % ci ae to ae ; p = ae ). patients who received cpap were significantly less likely to have respiratory acidosis (mean difference in ph ae ; % ci ae to ae ; p = ae ; n = ) than patients receiving usual care. the length of hospital stay was significantly less in the patients who received cpap (mean difference ae days; % ci ) ae to ae , p = ae ). conclusion: we found that cpap significantly reduced mortality, respiratory acidosis, and length of hospital stay for patients in severe respiratory distress caused by acpe. this study shows the use of cpap for acpe improves patient outcomes in the prehospital setting. (originally submitted as a ''late-breaker.'') trial reg. anzctr actrn ; funding fisher and paykal suppliers of the whisperflowÒ cpap device. background: because emergency service utilization continues to climb, validated methods to safely identify and triage low-acuity patients to either alternate care destinations or a complaint-appropriate level of ems response is of keen interest to ems systems and potentially payers. though the literature generally supports the medical priority dispatch system (mpds) as a tool to predict low-acuity patients by various standards, correlation with initial patient physiologic data and patient age is novel. objectives: to determine whether the six mpds priority determinants for protocol (sick person) can be used to predict initial ems patient acuity assessment or severity of an aggregate physiologic score. our longterm goal is to determine whether mpds priority can be used to predict patient acuity and potentially send only a first responder to do an in-person assessment to confirm this acuity, while reserving als transport resources for higher acuity patients. methods: calls dispatched through the wichita-sedgwick county - - center between july , and october , using mpds protocol (sick person) were linked to the ems patient care record for all patients and older. the six mpds priority determinants were evaluated for correlation with initial ems acuity code, initial vital signs, rapid acute physiology score (raps), or patient age. the ems acuity code scores patients from low to severe acuity, based on initial ems assessment. results: there were calls dispatched using protocol for those years of age and older during the period, representing approximately % of all ems calls. there is a significant difference in the first encounter vital signs among different mpds priority levels. based on the logistic regression model, the mpds priority code alone had a sensitivity of % and specificity of % for identifying low-acuity patients with ems acuity score as the standard. the area under the curve (auc) for roc is . for mpds priority codes alone, while addition of age increases this value to . . if we use the raps score as the standard to the mpds priority code, auc is . . if we include both mpds and age in the model, the auc is . . conclusion: in our system, mpds priority codes on protocol (sick person) alone, or with age or raps score, are not useful either as predictors of patient acuity on ems arrival or to reconfigure system response or patient destination protocols. alternate ambulance destination program c. nee-kofi mould-millman , tim mcmahan , michael colman , leon h. haley , arthur h. yancey emory university, atlanta, ga; grady ems, atlanta, ga background: low-acuity patients calling - - are known to utilize a large proportion of ems and ed resources. the national association of ems physicians and acep jointly support ems alternate destination programs (adps) in which low-acuity patients are allocated alternative resources non-emergently. analysis of one year's adp data from our ems system revealed that only . % of eligible patients were transported to alternate destinations (ambulatory clinics). reasons for this low success rate need investigation. objectives: to survey emts and discover the most frequent reasons given by them for transportation of eligible patients to eds instead of to clinics. methods: this study was conducted within a large, urban, hospital-based ems system. upon conducting an adp for months, a paper-based survey was created and pre-tested. all medics with any adp-eligible patient contact were included. emts were asked about personal, patient, and system related factors contributing to ed transport during the last months of the adp. qualitative data were coded, collated, and descriptively reported. results: sixty-three respondents ( emt-intermediates and emt-paramedics) completed the survey, representing % of eligible emts. thirty-one emts ( %) responded that they did not attempt to recruit eligible patients into the adp in the last program months. of those emts, ( %) attributed their motive to multiple, prior, failed recruitment attempts. the emts who actively recruited adp patients were asked reasons given by patients for clinic transport refusals: ( %) cited that patients reported no prior experience of care at the participating clinics, and ( %) reported patients had a strong preference for care in an ed. regarding system-related factors contributing to non-clinic transport, of the emts ( %) reported that clinic-consenting patients were denied clinic visits, mostly because of non-availability of same-day clinic appointments. conclusion: respondents indicated that poor emt enrollment of eligible patients, lack of available clinic time slots, and patient preference for ed care were among the most frequent reasons contributing to the low success rate of the adp. this information can be used to enhance the success of this, and potentially other adp programs, through modifications to adp operations and improved patient education. the effect of a standardized offline pain treatment protocol in the prehospital setting on pediatric pain treatment brent kaziny , maija holsti , nanette dudley , peter taillac , hsin-yi weng , kathleen adelgais university of utah, school of medicine, salt lake city, ut; university of colorado, school of medicine, aurora, co background: pain is often under treated in children. barriers include need for iv access, fear of delayed transport, and possible complications. protocols to treat pain in the prehospital setting improve rates of pain treatment in adults. the utah ems for children (emsc) program developed offline pediatric protocol guidelines for ems providers, including one protocol that allows intranasal analgesia delivery to children in the prehospital setting. objectives: to compare the proportion of pediatric patients receiving analgesia for orthopedic injury by prehospital providers before and after implementation of an offline pediatric pain treatment protocol. methods: we conducted a retrospective study of patients entered into the utah prehospital on-line active reporting information system (polaris, a database of statewide ems cases) both before and after initiation of the pain protocol. patients were included if they were age - years, with a gcs of - , an isolated extremity injury, and were transported by an ems agency that had adopted the protocol. pain treatment was compared for years before and months after protocol implementation with a wash-out period of months for agency training. the difference in treatment proportions between the two groups was analyzed and % cis were calculated. results: during the two study periods, patients met inclusion criteria. patient demographics are outlined in the table. / ( . %) patients were treated for pain before compared to / ( . %) patients treated after the pain protocol was implemented; a difference of . % ( % ci: . %- . %). patients were more likely to receive pain medication if they had a pain score documented (or: . ; % ci: . - . ) and if they were treated after the implementation of a pain protocol (or: . ; % ci: . - . ). factors not associated with the treatment of pain include age, sex, and mechanism of injury. conclusion: the creation and adoption of statewide emsc pediatric offline protocol guideline for pain management is associated with a significant increase in use of analgesia for pediatric patients in the prehospital setting. background: evidence-based guidelines are needed to determine the appropriate use of air medical transport, as few criteria currently used predict the need for air transport to a trauma center. we previously developed a clinical decision rule (cdr) to predict mortality in injured, helicopter-transported patients. objectives: this study is a prospective validation of the cdr in a new population. methods: a prospective, observational cohort analysis of injured patients ( ‡ y.o.) transported by helicopter from the scene to one of two level i trauma centers. variables analyzed included patient demographics, diagnoses, and clinical outcomes (in-hospital mortality, emergent surgery w/in hrs, blood transfusion w/in hrs, icu admit greater than hrs, combined outcome of all). prehospital variables were prospectively obtained from air medical providers at the time of transport and included past medical history, mechanism of injury, and clinical factors. descriptive statistics compared those with and without the outcomes of interest. the previous cdr (age ‡ , gcs £ , sbp < , flail chest) was prospectively applied to the new population to determine its accuracy and discriminatory ability. results: patients were transported from october -august . the majority of patients were male ( %), white ( %), with an injury occurring in a rural location ( %). most injuries were blunt ( %) with a median iss of . overall mortality was %. the most common reasons for air transport were: mvc with high risk mechanism ( %), gcs £ ( %), loc > minutes ( %), and mvc > mph ( %). of these, only gcs £ was significantly associated with any of the clinical outcomes. when applying the cdr, the model had a sensitivity of % ( . %- %), a specificity of . % ( . %- . %), a npv of % ( . %- %), and a ppv of . % ( . %- . %) for mortality. the area under the curve for this model was . , suggesting excellent discriminatory ability. conclusion: the air transport decision rule in this study performed with high sensitivity and acceptable specificity in this validation cohort. further external validation in other systems and with ground transported patients are needed in order to improve decision making for the use of helicopter transport of injured patients. background: acute non-variceal upper gastrointestinal (gi) bleeding is a common indication for hospital admission. to appropriately risk-stratify such patients, endoscopy is recommended within hours. given the possibility to safely manage patients as outpatients after endoscopy, risk stratification as part of an emergency department (ed) observation unit (ou) protocol is proposed. objectives: our objective was to determine the ability of an ou upper gi bleeding protocol to identify a lowrisk population, and to expeditiously obtain endoscopy and disposition patients. we also identified rates of outcomes including changes in hemoglobin, abnormal endoscopy findings, admission, and revisits. background: acute uncomplicated pyelonephritis (pyelo) requires no imaging but a ct flank pain protocol (ctfpp) may be ordered to determine if patients with pyelo and flank pain also have an obstructing stone. the prevalence of kidney stone and the characteristics predictive of kidney stone in pyelo patients is unknown. objectives: to determine elements on presentation that predict ureteral stone, as well as prevalence of stone and interventions in patients undergoing ct for pyelo. methods: retrospective study of patients at an academic ed who received a ctfpp scan between / and / . ctfpps were identified and randomly selected for review. pyelo was defined as: positive urine dip for infection and > wbc/hpf on formal urinalysis in addition to flank pain/cva tenderness, chills, fever, nausea, or vomiting. patients were excluded for age < y.o., renal disease, pregnancy, urological anomaly, or recent trauma. clinical data ( elements) were gathered blinded to ct findings; ct results were abstracted separately and blinded to clinical elements. ct findings of hydronephrosis and hyrdroureter (hydro) were used as a proxy for hydro that could be determined by ultrasound prior to ct. patients were categorized into three groups: ureteral stone, no significant findings, and intervention or follow-up required. classification and regression tree analysis was used to determine which variables could identify ureteral stone in this population of pyelo patients. results: out of the patients, ( . %) met criteria for pyelo; subjects had a mean age of ± . and % (n = ) were female. ct revealed ( %, % ci = . - . ) symptomatic stones, and ( %, % ci = . - . ) exams with no significant findings. two patients needed intervention/ follow-up ( %, % ci = . - . ), one for perinephric hemorrhage and the other for pancreatitis. hydro was predictive for ureteral stone with an or = . ( % ci = . - , p < . ). eleven ( %) ureteral stone patients were admitted and ( %) of them had procedures. of these patients, % had ct signs of obstruction, ( %) had hydronephrosis, and ( %) had hydroureter. conclusion: hydronephrosis was predictive of ureteral stone and in-house procedures. prospective study is needed to determine whether ct scan is warranted in patients with pyelonephritis but without hydronephrosis or hydroureter. curative objectives: the specific aim of this analysis was to describe characteristics of patients presenting to the emergency department (ed) at their index diagnosis, and to determine whether emergency presentation precludes treatment with curative intent. methods: we performed a retrospective cohort analysis on a prospectively maintained institutional tumor registry to identify patients diagnosed with crc from - . emrs were reviewed to identify which patients presented to the ed with acute symptoms of crc as the initial sign of their illness. the primary outcome variable was treatment plan (curative vs. palliative). secondary outcome variables included demographics, tumor type and location. descriptive statistics were conducted for major variables. chi-squre and fisher's exact tests were used to detect the association between categorical variables. two-sample t-test was used to identify the association between continuous and categorical variables. results: between jan and dec , patients were identified at our institution with crc. ( %) were male and ( %) were female, with mean age . ; sd: . . thirty-three patients ( . %) initially presented to the ed, of whom ( . %) received palliation. of patients who initially presented elsewhere, ( . %) received palliation. acute ed presentation with crc symptoms did not preclude treatment with curative intent (p = . ). patients who presented emergently were more likely to be female ( % vs male %; p = . ) and older ( vs. ; p = . ). there was no statistically significant relationship between age, sex, tumor location, or type and treatment approach. conclusion: patients with crc may present to the ed with acute symptoms, which ultimately leads to the diagnosis. emergent presentation of crc does not preclude patients from receiving therapy with curative intent. cannabinoid (or . , , and white blood cell (wbc) count ‡ , /mm (or . , % ci . - . ). conclusion: age ‡ years is not associated with need for admission from an ed observation unit. older adults can successfully be cared for in these units. initial temperature, respiratory rate, and pulse were not predictive of admission, but extremely elevated blood pressure was predictive. other relevant predictor variables included comorbidities and elevated wbc count. advanced age should not be a disqualifying criterion for disposition to an ed observation unit. older adult fallers in the emergency department luna ragsdale, cathleen colon-emeric duke university, durham, nc background: approximately / of community-dwelling older adults experience a fall each year, and . million are treated in u.s. emergency departments (ed) annually. the ed offers a potential location for identification of high-risk individuals and initiation of fall-prevention services that may decrease both fall rates and resource utilization. objectives: the goal of this study was to: ) validate an approach to identifying older adults presenting with falls to the ed using administrative data; and ) characterize the older adult who falls and presents to the ed and determine the rate of repeat ed visits, both fall-related and all visits, after an index fall-related visit. methods: we identified all older adults presenting to either of the two hospitals serving durham county residents during a six month period. manual chart review was completed for all encounters with icd codes that may be fall-related. charts were reviewed months prior and months post index visit. descriptive statistics were used to describe the cohort. results: a total of older adults were evaluated in the ed during this time period; ( . %) had an icd code for a potentially fall-related injury. of these, record review identified ( %) with a fall from standing height or less. of the fallers, . % of the patients were discharged, % were admitted, and % were admitted under observation. of those who fell, . % had an ed visit within the previous year. approximately / ( . %) of these were fall related. over half ( . %) of the patients who fell returned to the ed within one year of their index visit. a large proportion ( . %) of the return visits was fall-related. follow-up with a primary care provider or specialist was recommended in % of the patients who were discharged. overall mortality rate for fallers over the year following the index visit was %. conclusion: greater than fifty percent of fallers will return to the ed after an index fall, with a large proportion of the visits related to a fall. a large number of these fallers are discharged home with less than fifty percent having recommended follow-up. the ed represents an important location to identify high-risk older adults to prevent subsequent injuries and resource utilization. objectives: we studied whether falls from a standing position resulted in an increased risk for intracranial or cervical injury verses falling from a seated or lying position. methods: this is a prospective observational study of patients over the age of who presented with a chief complaint of fall to a tertiary care teaching facility. patients were eligible for the study if they were over age , were considered to be at baseline mental status, and were not triaged to the trauma bay. at presentation, a questionnaire was filled out by the treating physician regarding mechanism and position of fall, with responses chosen from a closed list of possibilities. radiographic imaging was obtained at the discretion of the treating physician. charts of enrolled patients were subsequently reviewed to determine imaging results, repeat studies done, or recurrent visits. all patients were called in follow-up at days to assess for delayed complications related to the fall. data were entered into a standardized collection sheet by trained abstractors. data were analyzed with fisher's exact test and descriptive statistics. this study was reviewed and approved by the institutional review board. results: two-hundred sixty two patients were enrolled during the study period. one-hundred ninety eight of these had fallen from standing and fell from either sitting or lying positions. the mean age for patients was (sd . ) for those who fell from standing and (sd . ) for those who fell from sitting or lying. there were patients with injuries who fell from standing: three with subdural hematomas, one with a cerebral contusion, one with an osteophyte fracture at c , and one with an occipital condyle fracture with a chip fracture of c . there were patients with injuries who fell from a seated or lying position: one with a traumatic subarachnoid hemorrhage and one with a type ii dens fracture. the overall rate of traumatic intracranial or cervical injury in elders who fell was %. no patients required surgical intervention. there was no difference in rate of injury between elders who fell from standing versus those who fell from sitting or lying (p = ). (table) . conclusion: both instruments identify the majority of patients as high-risk which will not be helpful in allocating scarce resources. neither the isar nor the trst can distinguish geriatric ed patients at high or low risk for or -month adverse outcomes. these prognostic instruments are not more accurate in dementia or lower literacy subsets. future instruments will need to incorporate different domains related to short-term adverse outcomes. background: for older adults, both inpatient and outpatient care involves not only the patient and physician, but often a family member or informal caregiver. they can assist in medical decision making and in performing the patient's activities of daily living. to date, multiple outpatient studies have examined the positive roles family members play during the physician visit. however, there is very limited information on the involvement of the caregiver in the ed and their relationship with the health outcomes of the patient. objectives: to assess whether the presence of a caregiver influences the overall satisfaction, disposition, and outpatient follow-up of elderly patients. we performed a three-step inquiry of patients over years old who arrived to the upenn ed. patients and care partners were initially given a questionnaire to understand basic demographic data. at the end of the ed stay, patients were given a satisfaction survey and followed through days to assess time to disposition, whether the patient was admitted or discharged, outpatient follow-up, and ed revisit rates. chi-square and t-tests were used to examine the strength of differences in the elderly patients' sociodemographics, self-rated health, receiving aid with their instrumental activities of daily living, and number of health problems by accompaniment status. multivariate regression models were constructed to examine whether the presence or absence of caregivers affected satisfaction, disposition, and follow-up. results: overall satisfaction was higher among patients who had caregivers ( . points), among patients who felt they were respected by their physician ( . points), and had lower lengths of stay ( hours). patients with caregivers were also more likely to be discharged home (or . ) and to follow-up with their regular physician (or . ). there was no evidence to suggest caregivers affected the overall rates of revisits back to an ed. conclusion: for older adults, medical care involves not only the patient and physician, but often a family member or an informal care companion. these results demonstrate the positive influence of caregivers on the patients they accompany, and emergency physicians should define ways to engage these caregivers during their ed stay. this will also allow caregivers to participate when needed and can help to facilitate transitions across care settings. background: shared decision making has been shown to improve patient satisfaction and clinical outcomes for chronic disease management. given the presence of individual variations in the effectiveness and side effects of commonly used analgesics in older adults, shared decision making might also improve clinical outcomes in this setting. objectives: we sought to characterize shared decision making regarding the selection of an outpatient analgesic for older ed patients with acute musculoskeletal pain and to examine associations with outcomes. methods: we conducted a prospective observational study with consecutive enrollment of patients age or older discharged from the ed following evaluation for moderate or severe musculoskeletal pain. two essential components of shared decision making, ) information provided to the patient and ) patient participation in the decision, were assessed via patient interview at one week using four-level likert scales. results: of eligible patients, were reached by phone and completed the survey. only % ( / ) of patients reported receiving 'a lot' of information about the analgesic, and only % ( / ) reported participating 'a lot' in the selection of the analgesic. there were trends towards white patients (p = . ) and patients with higher educational attainment (p = . ) reporting more participation in the decision. after adjusting for sex, race, education, and initial pain severity, patients who reported receiving 'a lot' of information were more likely to report optimal satisfaction with the analgesic than those receiving less information ( % vs. %, p < . ). after the same adjustments, patients who reported participating 'a lot' in the decision were also more likely to report optimal satisfaction with the analgesic ( % vs. %, p < . ) and greater reductions in pain scores (mean reduction in pain . vs. . , p < . ) at one week than those who participated less. background: quality of life (qol) measurements have become increasingly important in outcomes-based research and cost-utility analyses. dementia is a prevalent, often unrecognized, geriatric syndrome that may limit the accuracy of patient self-report in a subset of patients. the relationship between caregiver and geriatric patient qol in the emergency department (ed) is not well understood. objectives: to qualify the relationship between caregiver and geriatric patient qol ratings in ed patients with and without cognitive dysfunction. methods: this was a prospective, consecutive patient, cross-sectional study over two months at one urban academic medical center. trained research assistants screened for cognitive dysfunction using the short blessed test and evaluated health impairment using the quality of life-alzheimer's disease (qol-ad) test. when available in the ed, caregivers were asked to independently complete the qol-ad. consenting subjects were non-critically ill, english-speaking, community-dwelling adults over years of age. responses were compared using wilcoxon signed ranks test to assess the relationships between patient and caregiver scores from the qol-ad stratified by normal or abnormal cognitive screening results. significance was defined by p < . . results: patient qol ratings were obtained from patient-caregiver pairs. patients were % female, % african-american, with a mean age of -years, and % had abnormal cognitive screening tests. compared with caregivers, cognitively normal patients had no significant qol assessment differences except for questions of energy level and overall mood. on the other hand, cognitively impaired patients differed significantly on questions of energy level and ability to perform household chores with a trend towards significant differences for living setting (p = . ) and financial situation (p = . ). in each category, the differences reflected a caregiver underestimation of quality compared with the patient's self-rating. conclusion: discrepancies between qol domains and total scores for patients with cognitive dysfunction and their caregivers highlights the importance of identifying cognitive dysfunction in ed-based outcomes research and cost-utility analyses. further research is needed to quantify the clinical importance of the patient-and caregiver-assessed quality of life. background: age is often a predictor for increased morbidity and mortality. however, it is unclear whether old age is a predictor of adverse outcome in syncope. objectives: to determine whether old age is an independent predictor of adverse outcome in patients presenting to the emergency department following a syncopal episode. methods: a prospective observational study was conducted from june to july enrolling consecutive adult ed patients (> years) presenting with syncope. syncope was defined as an episode of transient loss of consciousness. adverse outcome or critical intervention were defined as gastrointestinal bleeding or other hemorrhage, myocardial infarction/percutaneous coronary intervention, dysrhythmia, alteration in antidysrhythmics, pacemaker/defibrillator placement, sepsis, stroke, death, pulmonary embolus, or carotid stenosis. outcomes were identified by chart review and -day follow-up phone calls. results: of patients who met inclusion criteria, an adverse event occurred in % of patients. overall, % of patients with risk factors had adverse outcomes compared to . % of patients with no risk factors. in particular, / ( %; % ci - %) of patients < with risk factors had adverse outcomes, while / ( %; % ci - %) of the elderly with risk factors had adverse outcomes. in contrast, among young people / ( %; % ci . - . %) of patients without risk factors had adverse outcomes while / ( . %; % ci . - %) of patients ‡ without risk factors had adverse outcomes. conclusion: although the elderly are at greater risk for adverse outcomes in syncope, age ‡ or older alone does not appear to be a predictor of adverse outcome following a syncopal event. based on these data, it should be safe to discharge home from the ed patients with syncope, but without risk factors, regardless of age. (originally submitted as a ''late-breaker.'') antibiotics background: adherence to national guidelines for hiv and syphilis screening in eds is not routine. in our ed, hiv and syphilis screening rates among patients tested for gonorrhea and chlamydia (gc/ct) have been reported to be % and %, respectively. objectives: to determine the effect of a sexually transmitted infection (sti) laboratory order set on hiv and syphilis screening among ed patients tested for gc/ct. we hypothesized that a sti order set would increase screening rates by at least %. methods: a -month, quasi-experimental study in an urban ed comparing hiv and syphilis screening rates of gc/ct-tested patients before (control phase) and after the implementation of a sti laboratory order set (intervention phase). the order set linked blood-based rapid hiv and syphilis screening with gc/ct testing. consecutive patients completing gc/ct testing were included. the primary outcome was the absolute difference in hiv and syphilis screening rates among gc/ ct-tested patients between phases. we estimated that subjects per phase were needed to provide % power (p-value of £ . ) to detect an absolute difference in screening rates of %, assuming a baseline hiv screening rate of %. results: the ed census was , . characteristics of patients tested for gc/ct were similar between phases: the mean age was years (sd = ) and most were female ( %), black ( %), hispanic ( %), and unmarried ( % services have recommended the use of immunization programs against influenza disease within hospitals since the s. the emergency department (ed) being the ''safety net'' for most non-insured people is an ideal setting to intervene and provide primary prevention from influenza. objectives: the purpose of this study is to assess whether a pharmacist-based influenza immunization program is feasible in the ed, and successful in increasing the percentage of adult patients receiving the influenza vaccine. methods: implementation of pharmacist-based immunization program was developed in coordination with ed physicians and nursing staff in . the nursing staff, using an embedded electronic questionnaire within their triage activity, screened patients for eligibility for the influenza vaccine. the pharmacist using an electronic alert system within the electronic medical record identified patients who we deemed eligible and if agreed the pharmacist vaccinated the patient. patients who refused to be vaccinated were surveyed to ascertain their perception concerning immunization offered by a pharmacist in the ed. feasibility and safety data for vaccinating patient in the ed were recorded. results: patients were approached and enrolled into the study. of the , % agreed to receive the influenza vaccine from a pharmacist in the ed. the median screening time was minutes and median vaccination time was minutes for a total of minutes from screening time to vaccination time. % were willing to receive the influenza vaccine from a pharmacist, and % were willing to receive the vaccine in the ed. the main reason given for refusing to receive the influenza vaccine was ''patient does not feel at risk of getting the disease''; only . % stated they were vaccinated recently. conclusion: a pharmacist-based influenza immunization program is feasible in the ed, and has the potential to successfully increase the percentage of adult patients receiving the vaccine. . ± . , p < . ). ed visits by hiv-infected patients also had longer lengths of ed stay ( ± . minutes vs. . ± . minutes, p < . ) and were more likely to be admitted ( % vs. %, p < . ), than their non-hiv infected counterparts. conclusion: although ed visits by hiv-infected individuals in the u.s. are relatively infrequent, they occur at rates higher than the general population, and consume significantly more ed resources than the general population. the background: the influence of wound age on the risk of infection in simple lacerations repaired in the emergency department (ed) has not been well studied. it has traditionally been taught that there is a ''golden period'' beyond which lacerations are at higher risk of infection and therefore should not be closed primarily. the proposed cutoff for this golden period has been highly variable ( - hours in surgical textbooks). objectives: to answer the following research question: are wounds closed via primary repair after the golden period at increased risk for infection? methods: we searched medline, embase, and other databases as well as bibliographies of relevant articles. we included studies that enrolled ed patients with lacerations repaired by primary closure. exclusion: . intentional delayed primary repair or secondary closure, . wounds requiring intra-operative repair, skin graft, drains, or extensive debridement, and . grossly contaminated or infected at presentation. we compared the outcome of wound infection in two groups of early versus delayed presentations (based on the cut-offs selected by the original articles). we used ''grading of recommendations assessment, development and evaluation'' (grade) criteria to assess the quality of the included trials. frequencies are presented as percentages with % confidence intervals. relative risk (rr) of infection is reported when clinically significant. results: studies were identified. four trials enrolling patients in aggregate met our inclusion/exclusion criteria. two studies used a -hour cut-off and the other two used a -hour cut-off for defining delayed wounds. the overall quality of evidence was low. the infection rate in the wounds that presented with delay ranged from . % to %. one study with the smallest sample size (morgan et al), which only enrolled lacerations to the hand and forearm, showed higher rates of infection in patients with delayed wounds (table). the infection rates in delayed wound groups in the remaining three studies were not significantly different from the early wounds. conclusion: the evidence does not support the existence of a golden period, nor does it support the role of wound age on infection rate in simple lacerations. background: although clinical studies in children have shown that temperature elevation is an independent and significant predictor of bacteremia in children, the relationship in adults is largely unknown or equivocal. objectives: review the incidence of positive blood cultures on critically ill adult septic patients presenting to an emergency department (ed) and determine the association of initial temperature with bacteremia. methods: july to july retrospective chart review on all patients admitted from the ed to an urban community hospital with sepsis and subsequently expiring within days of admission. fever was defined as a temperature ‡ °c. sirs criteria were defined as: ) temperature ‡ °c or £ °c, ) heart rate ‡ beats/ minute, ) respiratory rate ‡ or mechanical ventilation, ) wbc ‡ , /mm or < , or bands ‡ %. objectives: we examined the utility of limited genetic sequencing of bacterial isolates using multilocus sequence typing (mlst) to discriminate between known pathogenic blood culture isolates of s. epidermidis and isolates recovered from skin. methods: ten blood culture isolates from patients meeting the centers for disease control and prevention (cdc) criteria for clinically significant s. epidermidis bacteremia and ten isolates from the skin of healthy volunteers were studied. mlst was performed by sequencing bp regions of seven genes (arc, aroe, gtr, muts, pyr, tpia, and yqil) . genetic variability at these sites was compared to an international database (www.sepidermidis.mlst.net) and each strain was then categorized into a genotype on the basis of known genetic variation. the ability of the gene sequences to correctly classify strains was quantified using the support vector machine function in the statistical package r. , bootstrap resamples were performed to generate confidence bounds around the accuracy estimates. results: between-strain variability was considerable, with yqil being most variable ( alleles) and tpia being least ( allele). the muts gene, responsible for dna repair in s. epidermidis, showed almost complete separation between pathogenic and commensal strains. when the seven genes were used in a joint model, they correctly predicted bacterial strain type with % accuracy (iqr , %). conclusion: multilocus sequence typing shows excellent early promise as a means of distinguishing contaminant versus truly pathogenic isolates of s. epidermidis from clinical samples. near-term future goals will involve developing more rapid means of sequencing and enrolling a larger cohort to verify assay performance. conference are presented by influenza scenario in table and background: antiviral medications are recommended for patients with influenza who are hospitalized or at high risk for complications. however, timely diagnosis of influenza in the ed remains challenging. influenza rapid antigen tests have short turn-around times, making them potentially useful in the ed setting, but their sensitivities may be too low to assist with treatment decisions. objectives: to evaluate the test characteristics of the binaxnow influenza a&b rapid antigen test (rat) in ed patients. methods: we prospectively enrolled a systematic sample of patients of all ages presenting to two eds with acute respiratory symptoms or fever during three consecutive influenza seasons ( ) ( ) ( ) ( ) . research personnel collected nasal and throat swabs, which were combined and tested for influenza with rt-pcr using cdc-provided primers and probes. ed clinicians independently decided whether to obtain a rat during clinical care. rats were performed in the clinical laboratory using the binaxnow influenza a&b test on nasal swabs collected by ed staff. the study cohort included subjects who underwent both a research pcr and clinical rat. rat test characteristics were evaluated using pcr as the criterion standard with stratified sub-analyses for age group and influenza subtype (pandemic h n (ph n ), non-pandemic influenza a, influenza b). results: subjects were enrolled; subjects were pcr positive for influenza ( ph n , non-pandemic influenza a, and influenza b). for all age groups, rat sensitivities were low and specificities were high ( hiv infection with cd < ; and among nursing home residents, inability to independently perform activities of daily living. sources for bacterial cultures included blood, sputum (adults only), bronchoalveolar lavage (bal), tracheal aspirate, and pleural fluid. only sputum specimens with a bartlett score ‡ + were considered adequate for culturing. results: among children enrolled, ( %) had s. aureus cultured from ‡ specimen, including with methicillin-resistant s. aureus (mrsa) and with methicillin-susceptible s. aureus (mssa). specimens positive for s. aureus included pleural fluid, blood, tracheal aspirates, and bal. two children with s. aureus had evidence of co-infection: influenza a, and streptococcus pneumoniae. among adults enrolled, ( %) grew s. aureus from ‡ specimen, including with mrsa and with mssa. specimens positive for s. aureus included blood, sputum, and bal. five adults with s. aureus had evidence of co-infections: coronavirus, respiratory syncytial virus, s. pneumoniae, and pseudomonas aeruginosa. presenting clinical characteristics and outcomes of subjects with staphylococcal cap are summarized in tables - . conclusion: these preliminary findings suggest s. aureus is an uncommon cause of cap. although the small number of staphylococcal cases limits conclusions that can be drawn, in our analysis staphylococcal cap appears to be associated with co-infections, pleural effusions, and severe disease. future work will focus on continued enrollment and developing clinical prediction models to aid in diagnosing staphylococcal cap in the ed. background: emergency care has been a neglected public health challenge in sub-saharan africa. the goal of global emergency care collaborative (gecc) is to develop a sustainable model for emergency care delivery in low-resource settings. gecc is developing a training program for emergency care practitioners (ecps). objectives: to analyze the first patient visits at karoli lwanga ''nyakibale'' hospital ed in rural uganda to determine the knowledge and skills needed in training ecps. methods: a descriptive cross-sectional analysis of the first consecutive patient visits in the ed's patient care log was reviewed by an unblinded abstractor. data on demographics, procedures, laboratory testing, bedside ultrasounds (us) performed, radiographs (xrs) ordered, and diagnoses were collated. all authors discussed uncertainties and formed a consensus. descriptive statistics were performed. results: of the first patient visits, procedures were performed in ( . %) patients, including ( . %) who had ivs placed, ( . %) who received wound care, and ( . %) who received sutures. complex procedures, such as procedural sedations, lumbar punctures, orthopedic reductions, nerve blocks, and tube thoracostomies, occurred in ( . %) patients. laboratory testing, xrs, and uss were performed in ,( . %), ( . %), and ( %) patients, respectively. infectious diseases were diagnosed in ( . %) patients; ( . %) with malaria and ( . %) with pneumonia. traumatic injuries were present in ( %) patients; ( . %) needing wound care and ( . %) with fractures. gastrointestinal and neurological diagnoses affected ( . %) and ( . %) patients, respectively. conclusion: ecps providing emergency care in sub-saharan africa will be required to treat a wide variety of patient complaints and effectively use laboratory testing, xrs, and uss. this demands training in a broad range of clinical, diagnostic, and procedural skills, specifically in infectious disease and trauma, the two most prevalent conditions seen in this rural sub-saharan africa ed. assessment of point-of-care ultrasound in tanzania background: current chinese ems is faced with many challenges due to a lack of systematic planning, national standards in training, and standardized protocols for prehospital patient evaluation and management. objectives: to estimate the frequency with which prehospital care providers perform critical actions for selected chief complaints in a county-level ems system in hunan province, china. methods: in collaboration with xiangya hospital (xyh), central south university in hunan, china, we collected data pertaining to prehospital evaluation of patients on ems dispatches from a '' - - '' call center over a -month period. this call center services an area of just under km with a total population of . million. each ems team consists of a driver, a nurse, and a physician. this was a cross-sectional study where a single trained observer accompanied ems teams on transports of patients with a chief complaint of chest pain, dyspnea, trauma, or altered mental status. in this convenience sample, data were collected daily between am and pm. critical actions were pre-determined by a panel of emergency medicine faculty from xyh and the university of maryland school of medicine. simple statistical analysis was performed to determine the frequency of critical actions performed by ems providers. results: during the study period, patients were transported, of whom met the inclusion criteria. ( . %) evaluations were observed directly for critical actions. the table shows the frequency of critical actions performed by chief complaint. none of the patients with chest pain received an ecg even though the equipment was available. rapid glucose was checked in only . % of patients presenting with altered mental status. a lung exam was performed in . % of patients with dyspnea, and the respiratory rate was measured in . %. among patients transported for trauma, blood pressure, and heart rate were only measured in % and . %, respectively. conclusion: in this observation study of prehospital patient assessments in a county-level ems system, critical actions were performed infrequently for the chief complaints of interest. performance frequencies for critical actions ranged from to . %, depending on the chief complaint. standardized prehospital patient care protocols should be established in china and further training is needed to optimize patient assessment. trends little is known about the comparative effectiveness of noninvasive ventilation (niv) versus invasive mechanical ventilation (imv) in chronic obstructive pulmonary disease (copd) patients with acute respiratory failure. objectives: to characterize the use of niv and imv in copd patients presenting to the emergency department (ed) with acute respiratory failure and to compare the effectiveness of niv vs. imv. methods: we analyzed the - nationwide emergency department sample (neds), the largest, all-payer, us ed and inpatient database. ed visits for copd with acute respiratory failure were identified with a combination of copd exacerbation and respiratory failure icd- -cm codes. patients were divided into three treatment groups: niv use, imv use, and combined use of niv and imv. the outcome measures were inpatient mortality, hospital length of stay (los), hospital charges, and complications. propensity score analysis was performed using patient and hospital characteristics and selected interaction terms. results: there were an estimated , visits annually for copd exacerbation and respiratory failure from approximately , eds. ninety-six percent were admitted to the hospital. of these, niv use increased slightly from % in to % in (p = . ), while imv use decreased from % in to % in (p < . ); the combined use remained stable ( %). inpatient mortality decreased from % in to % in (p < . ). niv use varied widely between hospitals, ranging from % to % with median of %. in a propensity score analysis, niv use (compared to imv) significantly reduced inpatient mortality (risk ratio . ; % confidence interval [ci] . - . ), shortened hospital los (difference ) days; %ci ) to ) ), and reduced hospital charges ; ) . niv use was associated with a lower rate of iatrogenic pneumothorax compared with imv use ( . % vs. . %, p < . ). an instrumental analysis confirmed the benefits of niv use, with a % reduction in inpatient mortality in the niv-preferring hospitals. conclusion: niv use is increasing in us hospitals for copd with acute respiratory failure; however, its adoption remains low and varies widely between hospitals. niv appears to be more effective and safer than imv in the real-world setting. background: dyspnea is a common ed complaint with a broad differential diagnosis and disease-specific treatment. bronchospasm alters capnographic waveforms, but the effect of other causes of dyspnea on waveform morphology is unclear. objectives: we evaluated the utility of capnographic waveforms in distinguishing dyspnea caused by reactive airway disease (rad) from non-rad in adult ed patients. methods: this was a prospective, observational, pilot study of a convenience sample of adult patients presenting to the ed with dyspnea. waveforms, demographics, past medical history, and visit data were collected. waveforms were independently interpreted by two blinded reviewers. when the interpreters disagreed, the waveform was re-reviewed by both reviewers and an agreement was reached. treating physician diagnosis was considered the criterion standard. descriptive statistics were used to characterize the study population. diagnostic test characteristics and inter-rater reliability are given. results: fifty subjects were enrolled. median age was years (range - ), % were female, % were caucasian. / ( %) had a history of asthma or chronic obstructive pulmonary disease. rad was diagnosed by the treating physician in / ( %) and / ( %) had received treatment for dyspnea prior to waveform acquisition. the interpreters agreed on waveform analysis in / ( %) cases (kappa = . ). test characteristics for presence of acute rad, including %ci, were: overall accuracy % ( . %- . %), sensitivity % ( . %- . %), specificity % ( . %- . %), positive predictive value % ( . %- . %), negative predictive value % ( . %- . %), positive likelihood ratio . ( . - . ) , negative likelihood ratio . ( . - . ). conclusion: inter-rater agreement is high for capnographic waveform interpretation, and shows promise for helping to distinguish between dyspnea caused by rad and dyspnea from other causes in the ed. treatments received prior to waveform acquisition may affect agreement between waveform interpretation and physician diagnosis, affecting the observed test characteristics. asthma background: asthma and chronic obstructive pulmonary disease (copd) patients who present to the emergency department (ed) usually lack adequate ambulatory disease control. while evidence-based care in the ed is now well defined, there is limited inform-ation regarding the pharmacologic or non-pharmacologic needs of these patients at discharge. objectives: this study evaluated patients' needs with regard to the ambulatory management of their respiratory conditions after ed treatment and discharge. methods: over months, adult patients with acute asthma or copd, presenting to a tertiary care alberta hospital ed and discharged after being treated for exacerbations, were enrolled. using results from standardized in-person questionnaires, charts were reviewed by respiratory researchers to identify care gaps. results: overall, asthmatic and copd patients were enrolled. more patients with asthma required education on spacer devices ( % vs %). few asthma ( %) and no copd patients had written action plans; asthma patients were more likely to need adherence counseling ( % vs %) for preventer medications. more patients with asthma required influenza vaccination ( % vs %; p = . ); pneumococcal immunization was low ( %) in copd patients. only % of asthmatics reported ever being referred to an asthma education program and % of the copd patients reported ever being referred to pulmonary rehabilitation. at ed presentation, % of the asthmatics required the addition of inhaled corticosteroids (ics) and % required the addition of ics/long acting beta-agonist (ics/laba) combination agents. on the other hand, % of copd patients required the addition of long-acting anticholinergics while most ( %) were receiving preventer medications. finally, % of copd and % of asthma patients who smoked required smoking cessation counseling. conclusion: overall, we identified various care gaps for patients presenting to the ed with asthma and copd. there is an urgent need for high-quality research on interventions to reduce these gaps. methods: this is an interim, sub-analysis of an interventional, double-blinded study performed in an academic urban-based adult ed. subjects with acute exacerbation of asthma with fev < % predicted within minutes following initiation of ''standard care'' (including a minimum of mg nebulized albuterol, . mg nebulized ipratropium, and mg corticosteroid) who consented to be in a trial were included. all treatment was administered by emergency physicians unaware of the study objectives. patients were randomly assigned to treatment with placebo or an intravenous beta agonist. all subjects had fev and ds obtained at baseline, , , and hours after treatment. fev was measured using a bedside nspire spirometer, and ds was calculated using a modified borg dyspnea score. results: thirty-eight patients were included for analysis. spearman's rho test (rho) was used to measure correlations between fev and ds at , , and hours post study entry and subsequent hospitalization. rho is negative for fev (higher fev correlates to lower rate of hospitalization) and positive for ds (higher ds correlates to higher rate of hospitalization). at each time point, ds were more highly correlated to hospitalization than were fev (see table) . conclusion: dyspnea score at , , and hours were significantly correlated with hospital admission, whereas fev was not. in this set of subjects with moderate to severe asthma exacerbations, a standardized subjective tool was superior to fev for predicting subsequent hospitalization. methods: this is an interim, subgroup analysis of a prospective, interventional, double-blind study performed in an academic urban ed. subjects who were consented for this trial presented with acute asthma exacerbations with fev £ % predicted within minutes following initiation of ''standard care'' (includes a minimum of . mg nebulized albuterol, . mg nebulized ipratropium, and mg of a corticosteroid). ed physicians who were unaware of the study objectives administered all treatments. subjects were randomized in a : ratio to either placebo or investigational intravenous beta agonist arms. blood was obtained at and . hours after the start of the hour long infusion. blood was centrifuged and serum stored at ) °c, and then shipped on dry ice for albuterol and lactate measurements at a central lab. the treatment lactate and d lactate were correlated with hr serum albuterol concentrations and hospital admission using partial pearson correlations to adjust for ds. results: subjects were enrolled to date, with complete data. the mean baseline serum lactate level was . mg/dl (sd ± . ). this increased to . mg/ dl (sd ± . ) at . hrs. the mean hr ds was . (sd ± . ). the correlations between treatment lactate, d lactate, hr serum albuterol concentrations (r, s and total) and admission to hospital are shown (see table) . both treatment and d lactate were highly conrrelated with total serum albuterol, r albuterol, and s albuterol. there was no correlation between treatment lactate or d lactate and hospital admission. conclusion: lactate and d lactate concentrations correlate with albuterol concentrations in patients presenting had asthma. fifty one percent were < years old and % were female. we found a decline of % ( % ci: %- %, p < . ; r = . , p < . ) in the overall yearly asthma visits to total ed visits from to . when we analyzed sex and age groups separately, we found no statistically significant changes for females or for males < years old (r £ . , p ‡ . ). for females and males > years old, yearly asthma visits to total ed visits from to decreased % ( % ci: %- %, p < . ; r = . , p < . ) and % ( % ci: %- %, p < . ; r = . , p < . ), respectively. conclusion: we found an overall decrease in yearly asthma visits to total ed visits from to . we speculate that this decrease is due to greater corticosteroid use despite the increasing prevalence of asthma. it is unclear why this decrease was seen in adults and not in children and why it was greater for adult females than males. objectives: our objectives were to describe the use of a unique data collection system that leveraged emr technology and to compare its data entry error rate to traditional paper data collection. methods: this is a retrospective review of data collection methods during the first months of a multicenter study of ed, anti-coagulated, head injury patients. on-shift ed physicians at five centers enrolled eligible patients and prospectively completed a data form. enrolling ed physicians had the option of completing a one-page paper data form or an electronic ''dotphrase'' (dp) data form. our hospital system uses an epicÒbased emr. a feature of this system is the ability to use dps to assist in medical information entry. a dp is a preset template that may be inserted into the emr when the physician types a period followed by a code phrase (in this case ''.ichstudy''). once the study dp was inserted at the bottom of the electronic ed note, it prompted enrolling physicians to answer study questions. investigators then extracted data directly from the emr. our primary outcomes of interest were the prevalence of dp data form use and rates of data entry errors. results: from / through / , patients were enrolled. dp data forms were used in ( . %; % ci . , . %) cases and paper data forms in ( . %; % ci . , . %). the prevalence of dp data form use at the respective study centers was %, %, %, %, and %. sixty-six ( . %; % ci . , . %) of physicians enrolling patients used dp data entry at least once. using multivariate analysis, we found no significant association between physician age, sex, or tenure and dp use. data entry errors were more likely on paper forms ( / , . %; % ci . , . %) than dp data forms ( / , . %; % ci . , . %), difference in error rates . % ( % ci . , . %, p < . ). conclusion: dp data collection is a feasible means of study data collection. dp data forms maintain all study data within the secure emr environment obviating the need to maintain and collect paper data forms. this innovation was embraced by many of our emergency physicians. we found lower data entry error rates with dp data forms compared to paper forms. background: inadequate randomization, allocation concealment, and blinding can inflate effect sizes in both human and animal studies. these methodological limitations might in part explain some of the discrepancy between promising results in animal models and non-significant results in human trials. whereas blinding is not always possible, in clinical or animal studies, true randomization with allocation concealment is always possible, and may be as important in minimizing bias. objectives: to determine the frequency with which published emergency medicine (em) animal research studies report randomization, specific randomization methods, allocation concealment, and blinding of interventions and measurements, and to estimate whether these have changed over time. methods: all em animal research publications from / through / in ann emerg med and acad emerg med were reviewed by two trained investigators for a statement regarding randomization, and specific descriptions of randomization methods, allocation concealment, blinding of intervention, and blinding of measurements, when possible. raw initial agreement was calculated and differences were settled by consensus. the first (period = - ) and second (period = - ) -year periods were compared with % confidence intervals. results: of em animal research studies, were appropriate for review because they involved intervention in at least two groups. blinding of interventions and measurements were not considered possible in % and %, respectively. significant differences between period and were absent, although there was a trend towards less blinding of interventions and more blinding of measurements. raw agreement was %. conclusion: although randomization is mentioned in the majority of studies, allocation concealment and blinding remain underutilized in em animal research. we did not compare outcomes between blinded and non-blinded, randomized and non-randomized studies, because of small sample size. this review fails to demonstrate significant improvement over time in these methodological limitations in em animal research publications. journals might consider requiring authors to explicitly describe their randomization, allocation, and blinding methods. background: cluster randomized trials (crts) are increasingly utilized to evaluate quality improvement interventions aimed at health care providers. in trials testing ed interventions, migration of eps between hospitals is an important concern, as contamination may affect both internal and external validity. objectives: we hypothesized geographically isolating emergency departments would prevent migratory contamination in a crt designed to increase ed delivery of tpa in stroke (the instinct trial). methods: instinct was a prospective, cluster-randomized, controlled trial. twenty-four michigan community hospitals were randomly selected in matched pairs for study. following selection of a single hospital, all hospitals within miles were excluded from the sample pool. individual emergency physicians staffing each site were identified at baseline ( ) and months later. contamination was defined at the cluster level, with substantial contamination defined a priori as > % of eps affected. non-adherence, total crossover (contamination + non-adherence), migration distance and characteristics were determined. results: emergency physicians were identified at all sites. overall, ( . %) changed study sites. one moved between control sites, leaving ( . %) total crossovers. of these, ( . %) moved from intervention to control (contamination) and ( . %) moved from control to intervention (non-adherence). contamination was observed in of sites, with % and % contamination of the total site ep workforce at follow-up, respectively. two of crossovers occurred between hospitals within the same health system. average migration distance was miles for all eps in the study and miles for eps moving from intervention to control sites. conclusion: the mobile nature of emergency physicians should be considered in the design of quality improvement crts. use of a -mile exclusion zone in hospital selection for this crt was associated with very low levels of substantial cluster contamination ( of ) and total crossover. assignment of hospitals from a single health system to a single study group and/or an exclusion zone of miles would have further reduced crossovers. increased reporting of contamination in cluster randomized controlled trials is encouraged to clarify thresholds and facilitate crt design. objectives: an extension of the lr, the average absolute likelihood ratio (aalr), was developed to assess the average change in the odds of disease that can be expected from a test, or series of tests, and an example of its use to diagnose wide qrs complex tachycardia (wct) is provided. methods: results from two retrospective multicenter case series were used to assess the utility of qrs duration and axis to assess for ventricular tachycardia (vt) in patients with undifferentiated regular sustained wct. serial patients with heart rate (hr) > beats per minute and qrs duration > milliseconds (msec) were included. the final tachydysrhythmia diagnosis was determined by a number of methods independent of the ecg. the aalr is defined as: aalr = /n total [r (n i *lr i ) (for lr > ) + r (n k /lr k ) (for lr < )], where lr i and lr k are the interval lrs, and n i and n k are the number of patients with test results within the corresponding intervals. roc curves were constructed, and interval lrs and aalrs were calculated for the qrs duration and axis tests individually, and when applied together. confidence intervals were bootstrapped with , replications using the r boot package. results: patients were included: with supraventricular tachycardia (svt) and with vt. optimal qrs intervals (msec) for distinguishing vt from svt were: qrs £ , < qrs < , and qrs ‡ . qrs axis results were dichotomized to upward right axis ( - degrees) or not () to degrees). results are listed in the table. conclusion: application of the qrs interval and axis tests together for patients with wide qrs complex tachycardia changes the odds of ventricular tachycardia, on average, by a factor of . ( % ci . to . ), and this is mildly improved over the qrs duration test alone. both a strength and weakness of the aalr is its dependence on the pretest probability of disease. the aalr may be helpful for clinicians and researchers to evaluate and compare diagnostic testing approaches, particularly when strategies with serial non-independent tests are considered. consultation for adults with metastatic solid tumors at an urban, academic ed located within a tertiary care referral center. field notes were grouped into barrier categories and then quantified when possible. patient demographics for those who did and did not enroll were extracted from the medical record and quantified. patients who did not meet inclusion criteria for the study (e.g., cognitive impairment) were excluded from the analysis. results: attempts were made to enroll eligible patients in the study, and were successfully enrolled ( % enrollment rate). barriers to enrollment were deduced from the field notes and placed into the following categories from most to least common: patient refusal ( ); diagnostic uncertainty regarding cancer stage ( ); severity of symptoms preclude participation ( ); patient unaware of illness or stage ( ); and family refusal ( ). conclusion: patients, families, and diagnostic uncertainty are barriers to enrolling ed patients with advanced illness in clinical trials. it is unclear whether these barriers are generalizable to other study sites and disease processes other than cancer. objectives: the purpose of this study was to evaluate the use of a high-fidelity mannequin bedside simulation scenario followed by a debriefing session as a tool to improve medical student knowledge of palliative care techniques. methods: third year medical students participating in a -week simulation curriculum during a surgery/ emergency medicine/anesthesia clerkship were eligible for the study. all students were administered a pretest to evaluate their baseline knowledge of palliative care and randomized to a control or intervention group. during week or , students in the intervention group participated in and observed two end-of-life scenarios. following the scenarios, a faculty debriefer trained in palliative care addressed critical actions in each scenario. during week , all students received a posttest to evaluate for improvement in knowledge. the pre-test and post-test consisted of questions addressing prognostication, symptom control, and the medicare hospice benefit. students were de-identified and pre-and post-tests were graded by a blinded scorer. results: from jan-dec , students were included in the study and were excluded due to incomplete data. the mean score on the pre-test for the intervention group was . , and for the control group was . (p = . the results indicate that educators identify the most important scenarios as protocol-based simulations. respondents also suggested that scenarios of very common emergency department presentations bear a great deal of importance. emergency medicine educators assign priority to simulations involving professionalism and communication. finally, many respondents noted that they use simulation to teach the presentation and management of rare or less frequent, but important disease processes. the identification of these scenarios would suggest that educators find simulation useful for filling in ''gaps'' in resident education. background: prescription drug misuse is a growing problem among adolescent and young adult populations. objectives: to determine factors associated with past year prescription drug misuse defined as using prescription sedatives, stimulants, or opioids to get high, taking them when they were prescribed to someone else or taking more than was prescribed among patients seeking care in an academic ed. methods: adolescents and young adults ( - ) presenting for ed care at a large, academic teaching hospital were approached to complete a computerized screening questionnaire regarding demographics, prescription drug misuse, illicit drug use, alcohol use, and violence in the past months. logistic regression was used to predict past year prescription drug misuse. results: over the study time period, there were participants ( % response rate) of whom ( . %) endorsed past year prescription drug misuse. specifically, rates of past year misuse for opioids was . %, sedatives was . %, and stimulants was . %. significant overlap exists among classes with over % misusing more than one class of medications. in the multivariate analysis significant predictors of past year prescription drug misuse included female gender (or conclusion: approximately one in seven adolescents or young adults seeking ed care have misused prescription drugs in the past year. while opioids are the most common drug misused, significant overlap exists among this population. given the correlation of prescription drug misuse with the use and misuse of other substances (i.e. alcohol, cough medicine, marijuana) more research is needed to further understand these relationships and inform interventions. additionally, future research should focus on understanding the differences in demographics and risk factors associated with misuse of each separate class of prescription drugs. prospective objectives: this study aims to examine the association of depression with high ed utilization in patients with non-specific abdominal pain. methods: this single-center, prospective, cross-sectional study was conducted in an urban academic ed located in washington, dc as part of a larger study to evaluate the interaction between depression and frequency of ed visits and chronic pain. as part of this study, we screened patients using the phq- , a nineitem questionnaire that is a validated, reliable predictor of major depressive disorder. we analyzed the subset of respondents with a non-specific abdominal pain diagnosis (icd- code of .xx). our principal outcome of interest was the rate of a positive depression screen in patients with non-specific abdominal pain. we analyzed the prevalence of a positive depression screen among this group and also conducted a chi-square analysis to compare high ed use among abdominal pain patients with a positive depression screen versus those without a positive depression screen. we defined high ed utilization as > visits in a -day period prior to the enrollment visit. background: numerous studies have found high rates of co-morbid mental illness and chronic pain in emergent care settings. one psychiatric diagnosis frequently associated with chronic pain is major depressive disorder (mdd). objectives: we conducted a study to characterize the relationship between mdd and chronic pain in the emergency department (ed) population. we hypothesized that patients who present to the ed with selfreported chronic pain will have higher rates of mdd. methods: this was a single-center, prospective, crosssectional study. we used a convenience sample of noncritically ill, english speaking adult patients presenting with non-psychiatric complaints to an urban academic ed over months in . we oversampled patients presenting with pain-related complaints (musculoskeletal pain or headache). subjects were surveyed about their demographic and other health and health care characteristics and were screened with the phq , a nine-item questionnaire that is a validated, reliable predictor of mdd. we conducted bivariate (chi-square) and multivariate analysis controlling for demographic characteristics (race, income, sex, age) using stata v. . . our principal dependent variable of interest was a positive depression screen (phq score ‡ ). our principal independent variable of interest was the presence of self-reported chronic pain (greater than months). results: of patients enrolled, did not meet all inclusion criteria. had two or more assessments for comparison. their average age was (range - ), % were male, and % were in police custody. % used methadone alone; % heroin alone; % oxycodone alone; and the rest used multiple opioids. the average dose of im methadone was . mg (range - mg); all but patients received mg. the mean cows score before receiving im methadone was . (range - ), compared to . (range - ) minutes after methadone (p < . ; mean difference = ) . ; % ci = ) . to ) . ). the mean wss before and after methadone was ) . (range ) to ) ) and ) . (range ) to ), respectively (p < . ; % ci = ) . to ) . ). the mean physician-assessed wss was significantly lower than the patient's own assessment by . (p < . ). adverse events included an asthmatic patient with bronchospasm whose oxygen saturation decreased from % to % after receiving methadone, a patient whose oxygen saturation decreased from % to %, and two patients whose amss decreased from ) to ) (indicating moderate sedation). background: as the us population ages, the coexistence of copd and acute coronary syndrome (acs) is expected to be more frequent. very few studies have examined the effect of copd on outcomes in acs patients, and, to our knowledge, there has been no report on biomarkers that possibly mediate between copd and long-term acs patient outcomes. objectives: to determine the effect of copd on longterm outcomes in patients presenting to the emergency department (ed) with acs and to identify prognostic inflammatory biomarkers. methods: we performed a prospective cohort study enrolling acs patients from a single large tertiary center. hospitalized patients aged years or older with acs were interviewed and their blood samples were obtained. seven inflammatory biomarkers were measured, including interleukin- (il- ), c-reactive protein (crp), tumor necrosis factor-alpha (tnf-alpha), vascular cell adhesion molecule (vcam), e-selectin, lipoprotein-a (lp-a), and monocyte chemoattractant protein- (mcp- ). the diagnoses of acs and copd were verified by medical record review. annual telephone follow-up was conducted to assess health status and major adverse cardiovascular events (mace) outcomes, a composite endpoint including myocardial infarction, revascularization procedure, stroke, and death. background: aortic dissection (ad) is an uncommon life-threatening condition requiring prompt diagnosis and management. thirty-eight percent of cases are missed upon initial evaluation. the cornerstone of accurate diagnosis hinges on maintaining a high index of clinical suspicion for the various patterns of presentation. quality documentation that reflects consideration for ad in the history, exam, and radiographic interpretation is essential for both securing the diagnosis and for protecting the clinician in missed cases. objectives: we sought to evaluate the quality of documentation in patients presenting to the emergency department with subsequently diagnosed acute ad. methods: irb-approved, structured, retrospective review of consecutive patients with newly diagnosed non-traumatic ad from to . inclusion criteria: new ad diagnosis via ed. exclusion criteria: ad diagnosed at another facility; chronic, traumatic, or iatrogenic ad. trained/monitored abstractors used a standardized data tool to review ed and hospital medical records. descriptive statistics were calculated as appropriate. inter-rater reliability was measured. our primary performance measure was the prevalence of a composite of all three key historical elements ( . any back pain, . neurologic symptoms including syncope, and . sudden onset of pain.) in the attending emergency physician's documentation. secondary outcomes included documentation of: ad risk factors, pain quality, back pain at multiple locations, presence/absence of pulse symmetry, mediastinal widening on chest radiograph, and migratory nature of the pain. results: / met our inclusion/exclusion criteria. the mean age was . years; % were male, ( . %) were stanford a. ( %) presented with a chief complaint of chest pain. primary outcome measure: / ( . %; %ci = . , . ) documented the presence/ absence of all three key historical elements. [back pain = / ; . % ( . , . ); neuro symptoms = / ; % ( . , . ); sudden onset = / ; . % ( . , . ).] limitations: small number of confirmed ad cases. conclusion: in our cohort, emergency physician documentation of key historical, physical exam, and radiographic clues of ad is suboptimal. although our ed miss rate is lower than that which has been reported by previous authors, there is an opportunity to improve documentation of these pivotal elements at our institution. objectives: this study assessed the opinions of iem and gh fellowship program directors, in addition to recent and current fellows regarding streamlining the application process and timeline in an attempt to implement change and improve this process for program directors and fellows alike. methods: a total of current iem and gh fellowship programs were found through an internet search. an electronic survey was administered to current iem and gh fellowship directors, current fellows, and recent graduates of these programs. results: response rates were % (n = ) for program directors and % (n = ) for current and recent fellows. the great majority of current and recent fellows ( %) and program directors ( %) support transitioning to a common application service. similarly, % of current and recent fellows and % of program directors support instituting a uniform deadline date for applications. however, only % of recent/current fellows and % of program directors would support a formalized match process like nrmp. conclusion: the majority of fellows and program directors support streamlining the application for all iem and gh fellowship programs. this could improve the application process for both fellows and program directors, and ensure the best fit for the candidates and for the fellowship programs. in order to establish effective emergency care in rural sub-saharan africa, the unique practice demographics and patient dispositions must be understood. objectives: the objectives of this study are to determine the demographics of the first patients seen at nyakibale hospital's ed and assess the feasibility of treating patients in a rural district hospital ed in sub-saharan africa. methods: a descriptive cross-sectional analysis of the first consecutive patient visits in the ed's patient care log was reviewed by an unblinded abstractor. data collected included age, sex, condition upon discharge, and disposition. all authors discussed uncertainties and formed a consensus. descriptive statistics were performed. results: of the first patient visits, ( . %) occurred when the outpatient clinic was open. there were ( %) male visits. the average age was . years (sd ± . ). pediatric visits accounted for ( . %) patients, and ( . %) visits were for children under five years old. only one patient expired in the ed, and ( . %) were in good condition after treatment, as subjectively defined by the ed physicians. one person was transferred to another hospital. after treatment, ( %) patients were discharged home. of those admitted to an inpatient ward, ( . %) patients were admitted to medical wards, ( . %) to pediatrics, and ( %) to surgical. only six ( . %) patients went directly to the operating theatre. conclusion: this consecutive sample of patient visits from a novel rural district hospital ed in sub-saharan africa included a broad demographic range. after treatment, most patients were judged to be in ''good condition'', and over one third of patients could be discharged after ed management. this sample suggests that it is possible to treat patients in an ed in rural sub-saharan africa, even in cases where surgical backup and transfers to higher level of care are limited or unavailable. background: communication failures in clinical handoffs have been identified as a major preventable cause of patient harm. in italy, advanced prehospital care is provided predominantly by physicians who work on ambulances in teams with either nurses or basic rescuers. the hand-offs from prehospital physicians to hospital emergency physicians (eps) is especially susceptible to error with serious consequences. there are no studies in italy evaluating the communication at this transition in patient care. studying this, however, requires a tool that measures the quality of this communication. objectives: the purpose of this study is to develop and validate a tool for the evaluation of communication during the clinical handoff from prehospital to emergency physicians in critically ill patients. methods: several previously validated tools for evaluating communication in hand-offs were identified through a literature search. these were reviewed by a focus group consisting of eps, nurses, and rescuers, who then adapted and translated the australian isbar (identification, situation, background, assessment, recommendation), the tool most relevant to local practice. the italian isbar tool consists of the following elements: patient and provider identification; patient's chief complaint; patient's past medical history, medications, and allergies; prehospital clinical assessment (primary survey, illness severity, vital signs, diagnosis); treatment initiated and anticipated treatment plan. we conducted and video-taped the hand-offs of care from the prehospital physicians to the eps in pediatric critical care simulations. four physician raters were trained in the italian isbar tool and used it to independently assess communication in each simulation. to assess agreement we calculated the proportion of agreement among raters for each isbar question, fleiss' kappas for each simulation, as well as mean agreement and mean kappas with standard deviations. results: there was % agreement among the four physicians on % of the items. the mean level of agreement was % (sd . ). the overall mean kappa was . (sd . ). conclusion: the standardized tool resulted in good agreement by physician raters. this validated tool may be helpful in studying and improving hand-offs in the prehospital to emergency department setting. objectives: we hypothesized that residents who were provided with vps prior to hfs would perform more thoroughly and efficiently than residents who had not been exposed to the online simulation. methods: we randomized a group of residents from an academic, pgy - emergency medicine program to complete an online vps case, either prior to (vps group, n = residents) or after (n = ) their hfs case. the vps group had access to the online case (which reviewed asthma management) days prior to the hfs session. all residents individually participated in their regularly scheduled hfs and were blinded to the content of the case -a patient in moderate asthma exacerbation. the authors developed a dichotomous checklist consisting of items recorded as done/not done along with time completed. a two sample proportion test was used to evaluate differences in the individual items completed between groups. a wilcoxon rank sum test was used to determine the differences in overall and subcategory performance between the two groups. median time to completion was analyzed using the log-rank test. results: the vps group had better overall checklist performance than the control group (p-value . ). in addition, the vps group was more thorough in obtaining an hpi (p-value . ). specific actions (related to asthma management) were performed better by the vps group: inquiring about last/prior ed visits ( . ), total number of hospitalizations in the prior year ( . ), prior intubations ( . ), and obtaining peak flow measurements ( . ). overall there was no difference in time to event completion between the two groups. conclusion: we found that when hfs is primed with educational modalities such as vps there was an improvement in performance by trainees. however, the improved completeness of the vps group may have served as a barrier to efficiency, inhibiting our ability to identify a statistical significant efficiency overall. vps may aid in priming the learners and maximize the efficiency of training using high-fidelity simulations. training using an animal model helped develop residents' skills and confidence in performing ptv. retention was found to be good at months post-training. this study underscores the need for hands-on training in rare but critical procedures in emergency medicine. methods: in this cross-sectional study at an urban community hospital, residents in their second or third year of training from a -year em residency program performed us-guided catheterizations of the ij on a simulator manufactured by blue phantom. two board-certified em physicians observed for the completion of pre-defined procedural steps using a checklist and rated the residents' overall performance of the procedure. overall performance ratings were provided on a likert scale of to , with being poor and being excellent. residents were given credit for performing a procedural step if at least one rater marked its completion. agreement between raters was calculated using intraclass correlation coefficients for domain and summary scores. the same protocol was then repeated on an unembalmed cadaver using two different board-certified em physician raters. criterion validity of the residents' proficiency on the simulator was evaluated by comparing their median overall performance rating on the simulator to that on the cadaver and by comparing the proportion of residents completing each procedural step between modalities with descriptive statistics. results: em residents' overall performance rating on the simulator was . ( % ci: . to . ) and on the cadaver was . ( % ci: . to . ). the results for each procedural step are summarized in the attached figure. inter-rater agreement was high for assessments on both the simulator and cadaver with overall kappa scores of . and . respectively. background: the environment in the emergency department (ed) is chaotic. physicians must learn how to multi-task effectively and manage interruptions. noise becomes an inherent byproduct of this environment. previous studies in the surgical and anesthesiology literature examined the effect of noise levels and cognitive interruptions on resident performance during simulated procedures; however, the effect of noise distraction on resident performance during an ed procedure has not yet been studied. objectives: our aim was to prospectively determine the effects of various levels of noise distraction on the time to successful intubation of a high-fidelity simulator. methods: a total of emergency medicine, emergency medicine/internal medicine, and emergency medicine/family medicine residents were studied in a background noise environments of less than decibels (noise level ), - decibels (noise level ), and of greater than decibels (noise level ). noise levels were standardized by a dosimeter (ex tech instruments, heavy duty ). each resident was randomized to the order in which he or she was exposed to the various noise levels and had a total of minutes to complete each of the intubation attempts, which were performed in succession. time, in seconds, to successful intubation was measured in each of these scenarios with the start time defined as the time the resident picked up the storz c-mac video laryngoscope blade and the finish time defined as the time the tube passed through the vocal cords as visualized by an observer on the storz c-mac video screen. analytic methods included analysis of variance, student's t-test, and pearson's chi-square. results: no significant differences were found between time to intubation and noise level nor did the order of noise level exposure affect the time to intubation (see table) . there were no significant differences in success rate between the three noise levels (p = . ). a significant difference in time to intubation was found between the residents' second and third intubation attempts with decreased time to intubation for the third attempt (p = . ). conclusion: noise level did not have an effect on time to intubation or intubation success rate. time to intubation decreased between the second and third intubations regardless of noise level. background: growing use of the emergency department (ed) is cited as a cause of rising health care costs and a target of health care reform. eds provide approximately one quarter of all acute care outpatient visits in the us. eds are a diagnostic center and a portal for rapid inpatient admission. the changing role of eds in hospital admissions has not been described. objectives: to compare if admission through the ed has increased compared to direct hospital admission. we hypothesized that the use of the ed as the admitting portal increased for all frequently admitted conditions. methods: we analyzed the nationwide inpatient sample (nis), the largest us all-payer inpatient care database, from - . nis contains data from approximately million hospital stays each year, and is weighted to produce national estimates. we used an interactive, webbased data tool (hcupnet) to query the nis. clinical classification software (ccs) was used to group discharge diagnoses into clinically meaningful categories. we calculated the number of annual admissions and proportion admitted from the ed for the most frequently admitted conditions. we excluded ccs codes that are rarely admitted through the ed (< %) as well as obstet- background: the optimal dose of opioids for patients in acute pain is not well defined, although . mg/kg of iv morphine is commonly recommended. patient-controlled analgesia (pca) provides an opportunity to assess the adequacy of this recommendation as use of the pca pump is a behavioral indication of insufficient analgesia. objectives: to assess the need for additional analgesia following a . mg/kg dose of iv morphine by measuring additional self-dosing via a pca pump. methods: a three-arm randomized controlled trial was performed in an urban ed with , annual adult visits. a convenience sample of ed patients ages to with abdominal pain of < days duration requiring iv opioids was enrolled between / and / . all patients received an initial dose of . mg/kg iv morphine. patients in the pca arms could request additional doses of mg or . mg iv morphine by pressing a button attached to the pump with a -minute lock-out period. for this analysis, data from both pca arms were combined. software on the pump recorded times when the patient pressed the button (activation) and when he/she received a dose of morphine (successful activation). results: patients were enrolled in the pca arms. median baseline nrs pain score was . mean amount of supplementary morphine self-administered over the hour study period subsequent to the loading dose was . mg and . mg for the and . mg pca groups respectively. patients activated the pump at least once ( %, % ci: to %). figure shows the frequency distribution of the number of times the pump was activated. of those who activated the pump, the median number of activations per person was (iqr: to ). there were activations of the pump. % of activations were successful (followed by administration of morphine), while % were unsuccessful as they occurred during the -minute lock-out periods. % of the activations occurred in the first minutes, % in the second minutes, % in the third minutes, and % in the last minutes after the initial loading dose. conclusion: almost all patients requested supplementary doses of pca morphine, half of whom activated the pump five times or more over a course of hours. this frequency of pca activations suggests that the commonly recommended dose of . mg/kg morphine may constitute initial oligoanalgesia in most patients. marie-pier desjardins, benoit bailey, fanny alie-cusson, serge gouin, jocelyn gravel chu sainte-justine, montreal, qc, canada background: administration of corticosteroid at triage has been suggested to decrease the time to corticosteroid administration in the ed. objectives: to compare the time between arrival and corticosteroid administration in patients treated with an asthma pathway (ap) or with standard management (sm) in a pediatric ed. methods: chart review of children aged to years diagnosed with asthma, bronchospasm, or reactive airways disease seen in the ed of a tertiary care pediatric hospital. for a one year period, % of all visits were randomly selected for review. from these, we reviewed patients who were eligible to be treated with the ap ( ‡ months with previous history of asthma and no other pulmonary condition) and who had received at least one inhaled bronchodilator treatment. charts were evaluated by a data abstractor blinded to the study hypothesis using a standardized datasheet. various variables were evaluated such as age, respiratory rate and saturation at triage, type of physician who saw patient first, treatment prior to visit, in ed, and at discharge, time between arrival and corticosteroid administration, and length of stay (los background: return visits comprise . % of pediatric emergency department (ped) visits, at a cost of >$ million/year nationally. these visits are typically triaged with higher acuity and admission rates and raise concern for lapses in quality of care and patient education during the first visit. objectives: the aim of this qualitative study was to describe parents' reasons for return visits to the ped. methods: we prospectively recruited a convenience sample of parents of patients under the age of years who returned to the ped within hours of their previous visit. we excluded patients who were instructed to return, had previously left without being seen, arrived without a parent, were wards of the state, or did not speak english. after obtaining consent, the principal investigator (ce) conducted confidential, in-person, tape-recorded interviews with parents during ped return visits. parents answered open-ended questions and closed-ended questions using a five-point likert scale. responses to open-ended questions were analyzed using thematic analysis techniques. the scaled responses were grouped into three categories of agree, disagree, or neutral. results: from the closed-ended responses, % of parents agreed that their children were getting sicker, and % agreed that their children were not getting better. % agreed that they were unsure how to treat the illness, however only % agreed they did not feel figure : frequency distribution of number of pca activations comfortable taking care of the illness. only % agreed that the medical condition and/or the instructions were not clearly explained in the first visit. some common themes from the open-ended questions included worsening or lack of improvement of symptoms. many parents reported having unanswered questions about the cause of the illness and hoped to find out the cause during the return visit. conclusion: most parents brought their children back to the ped because they believed the symptoms had worsened or were not improving. although a large proportion of parents believed that the medical condition was clearly explained at the first visit, many parents still had unanswered questions about the cause of their child's illness. while worsening symptoms seemed to drive most return visits, it is possible that some visits related to failure to improve might be prevented during the first ped visit through a more detailed discussion of disease prognosis and expected time to recover. pediatric background: experience indicates that it is difficult to effectively quell many parents' anxiety toward pediatric fevers, making this a common emergency department (ed) complaint. the question remains as to whether athome treatment has any effect on the course of emergency department treatment or length of stay in this population. objectives: to determine whether anti-pyretic treatment prior to arrival in the emergency department affects the evaluation or emergency department length of stay of febrile pediatric patients. methods: a convenience sample of children, ages - years, who presented to a tertiary care ed with chief complaint of fever were enrolled. parents were asked to participate in an eight-question survey. questions related to demographic information, pre-treatment of the fever, contact with primary care providers prior to ed arrival, and immunization status. upon admission or discharge, investigators recorded information regarding length of stay, laboratory tests and imaging ordered, and medications given. results: eighty-one patients were enrolled in the study. seventy-six percent of the patients were pre-treated with some form of anti-pyretic by the caregiver prior to ed arrival. there was no significant effect of pre-treatment on whether laboratory tests or medications were ordered in the ed or whether the patient was admitted or discharged. the length of ed stay was found to be significantly shorter among those who received anti-pyretics prior to arrival ( ± vs. ± minutes; p = . ). conclusion: among febrile children, those who receive anti-pyretics prior to their ed visit had statistically significant shorter length of stays. this also supports implementation of triage or nursing protocols to administer an anti-pyretic as soon as possible in the hope of decreasing ed throughput times. background: during the past two decades, the prevalence of overweight (bmi percentile > ) in children has more than doubled, reaching epidemic proportions both nationally and globally. the public health burden is enormous given the increased risk of adult obesity as well as the adverse consequences on cardiovascular, metabolic, and psychological health. despite the overwhelming prevalence, the effect of obesity on emergency care has received little attention. objectives: the goal of this study is to determine the relation of weight on reported emergency department visits in children from a nationally representative sample. methods: weight (as reported by parents) and height along with frequency of and reason for emergency department (ed) use in the last months were obtained from children aged - y (n = , ) in the cross-sectional, telephone-administered, national survey of children's health (nsch). bmi percentiles were calculated using sex-specific bmi for age growth charts from the cdc ( ). children were categorized as: underweight (bmi percentile£ ), normal weight (> to < ), at-risk for overweight ( to < ), and overweight ( ‡ ). prevalence of ed use was estimated and compared across bmi percentile categories using chisquare analysis and multivariable logistic regression. taylor-series expansion was used for variance estimation of the complex survey design. results: the prevalence of at least one ed use in the past months increased with increasing bmi percentiles (figure , p < . ). additionally, overweight children were more likely to have more than one visit. overweight children were also less likely to report an injury, poisoning, or accident as the reason for ed visit compared to other bmi categories ( , , , % in overweight, at-risk, normal, and underweight respectively, p < . ). conclusion: as rates of childhood obesity continue to grow in the u.s., we can expect greater demands on the ed. this will likely translate into an increased emphasis on the care of chronic conditions rather than injuries and accidents in the pediatric ed setting. results: mean pediatric satisfaction score was . (sd . ) compared with . ( . ) for adult patients (p < . ); monthly sample sizes ranged from - and from - for the two populations, respectively. both populations showed an increase in satisfaction after opening of the ped-ed. for both populations there was no significant trend in patient satisfaction from the beginning of the study period to the opening of the ped-ed, but after the opening the models of the populations differed. the pediatric satisfaction model was an interrupted two-slope model, with an immediate jump of . points in november and an increase of . points per month thereafter. in contrast, adult satisfaction scores did not show a jump but increased linearly (two slope model) after / at a rate of . per month. prior to the opening of the ped-ed, mean monthly pediatric and adult satisfaction scores were . ( . ) and . ( . ), respectively (difference . % ci . - . , p = . ). after the opening the mean scores were . ( . ) and . ( . ), respectively (difference . , % ci . - . , p < . ). conclusion: opening of a dedicated ped-ed was associated with a significant increase in patient satisfaction scores both for children and adults. patient satisfaction for children, as compared to adults, was higher before and after opening a ped-ed. the background: there are racial disparities in outcomes among injured children. in particular, black race appears to be an independent predictor of mortality. objectives: to evaluate disparities among ed visits for unintentional injuries among children ages - . methods: five years of data ( ) ( ) ( ) ( ) ( ) from the national hospital ambulatory cares survey were combined. inclusion criteria were defined as unintentional injury visits (e-code . to . or . to . ) and age - years. visit rates per population (defined by the us census) were calculated by race and age group. weighted multivariate logistic regression analysis was performed to describe associations between race and specific outcome variables and related covariates. primary statistical analyses were performed using sas version . . . results: , , of , , weighted ed visits met our inclusion criteria ( . %). per persons, black children had . times as many ed visits for unintentional injuries as whites (table) . there were no racial differences in the sex ratio ( . boy visits: girl), proportion of visits by age, ed disposition, immediacy with which they needed to be seen, whether or not they were evaluated by an attending physician, metropolitan vs. rural hospital, admission length of stay, mode of transportation for ed arrival, number of procedures, diagnostic services, or ed medications. background: sudden cardiac arrests in schools are infrequent, but emotionally charged events. little data exist that describes aed use in these events. objectives: the purpose of our study was to ) describe characteristics and outcomes of school cardiac arrests (ca), and ) assess the feasibility of conducting bystander interviews to describe the events surrounding school ca. methods: we performed a telephone survey of bystanders to ca occurring in k- schools in communities participating in the cardiac arrest registry to enhance survival (cares) database. the study period was from / - / and continued in one community through . utstein style data and outcomes were collected from the cares database. a structured telephone interview of a bystander or administrative personnel was conducted for each ca. a descriptive summary was used to assess for the presence of an aed, provision of bystander cpr (bcpr), and information regarding aed deployment, training, and use and perceived barriers to aed use. descriptive data are reported. results: during the study period there were , ca identified at cares communities, of which were identified as educational institutions. of these, ( . %) events were at k- schools with ( . %) being high schools. of the arrests, a minority were children ( ( . %) < age ), most ( , . %) were witnessed, a majority ( , . %) received bcpr, and ( . %) were initially in ventricular fibrillation (vf). most arrests / ( %) occurred during the school day ( a- p). overall, ( . %) survived to hospital discharge. interviews were completed for of ( . %) k- events. eighteen schools had an aed on site. most schools ( . %) with aeds reported that they had a training program and personnel identified for its use. an aed was applied in of patients, and of these were in vf and survived to hospital discharge. multiple reasons for aed non-use (n = ) were identified. conclusion: cardiac arrests in schools are rare events; most patients are adults and received bcpr. aed use was infrequent, even when available, but resulted in excellent ( / ) survival. further work is needed to understand aed non-use. post-event interviews are feasible and provide useful information regarding cardiac arrest care. physician background: gastroenteritis is a common childhood disease accounting for - million annual pediatric emergency visits. current literature supports the use of anti-emetics reporting improved oral re-hydration, cessation of vomiting, and reduced need for iv re-hydration. however, there remains concern that using these agents may mask alternative diagnoses. objectives: to assess outcomes associated with use of a discharge action plan using ed-dispensed ondansetron at home in the treatment of gastroenteritis. methods: a prospective, controlled, observational trial of patients presenting to an urban pediatric emergency department (census , ) over a -month period for acute gastroenteritis. fifty patients received ondansetron in the ed. twenty-nine patients were enrolled in the pediatric emergency department discharge action plan (ped-dap) where ondansetron for home use was dispensed by the treating clinician. twenty-one patients were controls. control patients did not receive home ondansetron. ped-dap patients were given instructions to administer the ondansetron for ongoing symptoms any time hours post ed discharge. all patients were followed by phone at - days to assess for the following: time of emesis resolution, alternative diagnoses, unscheduled visits, and adverse events. results: all patients were followed by phone. / ped-dap patients received home ondansetron. / patients had resolution of emesis in the ed. / had resolution of their emesis between time of discharge and hours. / of ped-dap patients reported emesis after hours from ed discharge. five patients reported an unscheduled visit. all five return visits returned to the ed ( / returned for emesis, / for diarrhea). / controls reported resolution of symptoms within the ed. / of controls had resolution between time of discharge and hours. / of the control patients had resolution with between and hours post discharge. / had an unscheduled appointment with the pmd at hours post-discharge for ongoing fever and nausea. in follow-up there were no alternative diagnoses identified. the effect of the ped-dap on resolution of emesis between discharge and hours appears to be statistically significant (p value < . ). conclusion: ondansetron given in schedule with a discharge action plan appears to provide a modest benefit in resolution of symptoms relative to a control population. objectives: to determine the repeatability coefficient of a mm vas in children aged to years in different circumstances: assessments done either at or minute interval, when asked to recall their score or to reproduce it. methods: a prospective cohort study was conducted using a convenience sample of patients aged to years presenting to a pediatric ed. patients were asked to indicate, on a mm paper vas, how much they liked a variety of food with four different sets of three questions: (set ) questions at minute interval with no specific instruction other than how to complete the vas and no access to previous scores, (set ) same format as set except for questions at minute interval, (set ) same as set except patients were asked to remember their answers, and (set ) same as set except patients were shown their previous answers. for each set, the repeatability coefficient of the vas was determined according to the bland-altman method for measuring agreement using repeated measures: . x Ö x s w where s w is the within-subject standard deviation by anova. the sample size required to estimate s w to % of the fraction value as recommended was patients if we obtained three measurements for each patient. results: a total of patients aged . ± . years were enrolled. the repeatability coefficient for the questions asked at minute intervals was mm, and mm when asked at minute interval. when asked to remember their previous answers or to reproduce them, the repeatability coefficient for the questions was mm and mm, respectively. conclusion: the condition of the assessments (variation in intervals or patients asked to remember or to reproduce their previous answers) influence the testretest reliability of the vas. depending on circumstances, the theoretical test-retest reliability in children aged to years varies from to mm on a mm paper vas. background: skull radiographs are a useful tool in the evaluation of pediatric head trauma patients. however, there is no consensus on the ideal number of views that should be obtained as part of a standard skull series in the evaluation of pediatric head trauma patients. objectives: to compare the sensitivity and specificity of a two-and four-film x-ray series in the diagnosis of skull fracture in children, when interpreted by pediatric emergency medicine physicians. methods: a prospective, crossover experimental study was performed in a tertiary care pediatric hospital. the skull radiographs of children were reviewed. these were composed of the most recent cases of skull fracture for which a four-film radiography series was available at the primary setting and controls, matched for age. two modules, containing a random sequence of two-and four-film series of each child, were constructed in order to have all children evaluated twice (once with two films and once with four films). board-certified or -eligible pediatric emergency physicians evaluated both modules two to four weeks apart. the interpretation of the four-film series by a radiologist, or when available, the findings on ct scan, served as the gold standard. accuracy of interpretation was evaluated for each patient. the sensitivity and specificity of the two-film versus the four-film skull xray series, in the identification of fracture, were compared. this was a non-inferiority cross-over study evaluating the null hypothesis that a series with two views would have a sensitivity (specificity) that is inferior by no more than . compared to a series with four views. a total of controls and cases were needed to establish non-inferiority of the two-film series versus the four-film series, with a power of % and a significance level of %. results: ten pediatric emergency physicians participated in the study. for each radiological series, the proportion of accurate interpretation varied between . to . . the four-film series was found to be more sensitive in the detection of skull fracture than a two-film series (difference: . , %ci . to . ). however, there was no difference in the specificity (difference: . , %ci ) . to . ). conclusion: for children sustaining a head trauma, a four-film skull radiography series is more sensitive than a two-film series, when interpreted by pediatric emergency physicians. the objectives: we developed a free online video-based instrument to identify knowledge and clinical reasoning deficits of medical students and residents for pediatric respiratory emergencies. we hypothesized that it would be a feasible and valid method of differentiating educational needs of different levels of learners. methods: this was an observational study of a free, web-based needs assessment instrument that was tested on third and fourth year medical students (ms - ) and pediatric and emergency medicine residents (r - ). the instrument uses youtube video triggers of children in respiratory distress. a series of cased-based questions then prompts learners to distinguish between upper and lower airway obstruction, classify disease severity, and manage uncomplicated croup and bronchiolitis. face validity of the instrument was established by piloting and revision among a group of experienced educators and small groups of targeted learners. final scores were compared across groups using t-tests to determine the ability of the instrument to differentiate between different levels of learners (concurrent validity). cronbach's alpha was calculated as a measure of internal consistency. results: response rates were % among medical students and % among residents. the instrument was able to differentiate between junior (ms , ms , and r ) and senior (r , r ) learners for both overall mean score ( % vs. %, p < . ) and mean video portion score ( vs. %, p = . ). table compares results of several management questions between junior and senior learners. cronbach's alpha for the test questions was . . conclusion: this free online video-based needs assessment instrument is feasible to implement and able to identify knowledge gaps in trainees' recognition and management of pediatric respiratory emergencies. it demonstrates a significant performance difference between the junior and senior learners, preliminary evidence of concurrent validity, and identifies target groups of trainees for educational interventions. future revisions will aim to improve internal consistency. results: the survey response rate was % ( / ). among responding programs, ( %) reside within a children's hospital (vs. general ed); ( %) are designated level i pediatric trauma centers. forty-three ( %) programs accept - pem fellows per year; ( %) provided at least some eus training to fellows, and ( %) offer a formal eus rotation. on average this training has existed for ± years and the mean duration of eus rotations is ± weeks. twenty-eight ( %) programs with eus rotations provide fellow training in both a general ed and a pediatric ed. there were no hospital or program level factors associated with having a structured training program for pem fellows. conclusion: as of , the majority of pem fellowship programs provide eus training to their fellows, with a structured rotation being offered by most of these programs. background: ed visits are an opportunity for clinicians to identify children with poor asthma control and intervene. children with asthma who use eds are more likely than other children to have poor control, not be using controller medications, and have less access to traditional sources of primary care. one significant barrier to ed-based interventions is recognizing which children have uncontrolled asthma. objectives: to determine whether the pacci, a item parent-administered questionnaire, can help ed clinicians better recognize patients with the most uncontrolled asthma and differentiate between intermittent and persistent asthma. methods: this was a randomized controlled trial performed at an urban pediatric ed. parents were asked to answer questions about their child's asthma including drug adherence and history of exacerbations, as well as answer demographic questions. using a convenience sample of children - years presenting with an asthma exacerbation, attending physicians in the study were asked to complete an assessment of asthma control. physicians were randomized to receive a completed pacci (intervention) or not (control group). using an intent-to-treat approach, clinicians' ability to accurately identify ) four categories of control used by the national heart, lung, and blood institute (nhlbi) asthma guidelines, ) intermittent vs. persistent level asthma, and ) controlled / mildly uncontrolled vs. moderate/severely uncontrolled asthma were compared for both groups using chi-square analysis. results: between january and august , patients were enrolled. there were no statistically significant differences between the intervention and control groups for child's sex, age, race and parents' education. conclusion: the pacci improves ed clinicians' ability to categorize children's asthma control according to nhlbi guidelines, and the ability to determine when a child's control has been worsening. ed clinicians may use the pacci to identify those children in greatest need for intervention, to guide prescription of controller medications, and communicate with primary care providers about those children failing to meet the goals of asthma therapy. figure) . fewer than half of physicians reported the parent of a -year-old being discharged from their ed following an mvc-related visit would receive either child passenger safety information or referrals (table) . conclusion: emergency physician report of child passenger safety resource availability is associated with trauma center designation. even when resources are available, referrals from the ed are infrequent. efforts to increase referrals to community child passenger safety resources must extend to the community ed settings where the majority of children receive injury care. background: pediatric subspecialists are often difficult to access following ed care especially for patients living far from providers. telemedicine (tm) can potentially eliminate barriers to access related to distance, and cost. objectives: to evaluate the overall resource savings and access that a tm program brings to patients and families. methods: this study took place at a large, tertiary care regional pediatric health care system. data were collected from / - / . metrics included travel distance saved (round trip between tm presenting sites and the location of the receiving sites), time savings, direct cost savings (based on $ . /mile) and potential work and school days saved. indirect costs were calculated as travel hrs saved/encounter (based on an average speed of miles/hr). demographics and services provided were included. results: tm consults were completed by separate pediatric subspecialty services. most patients were school aged ( % >/= yrs old objectives: to analyze test characteristics of the pathway and its effects on ed length of stay, imaging rates, and admission rate before versus after implementation. methods: children ages - presenting to one academic pediatric ed with suspicion for appendicitis from october -august were prospectively enrolled to a pathway using previously validated lowand high-risk scoring systems. the attending physician recorded his or her suspicion of appendicitis and then used one of two scoring systems incorporating history, physical exam, and cbc. low-risk patients were to be discharged or observed in the ed. high-risk patients were to be admitted to pediatric surgery. those meeting neither low-nor high-risk criteria were evaluated in the ed by pediatric surgery, with imaging at their discretion. chart review and telephone follow-up were conducted two weeks after the visit. charts of a random sample of patients with diagnoses of acute appendicitis or chief complaint of abdominal pain and undergoing a workup for appendicitis in the eight months before and after institution of the pathway were retrospectively reviewed by one or two trained abstractors. results: appendicitis was diagnosed in of patients prospectively enrolled to the pathway ( %). mean age was . years. of those with appendicitis, were not low-risk (sensitivity . %, specificity . %). the high-risk criteria had a sensitivity of . % and specificity of . %. a priori attending physician assessment of low risk had a sensitivity of % and specificity of . %. a priori assessment of high risk had a sensitivity of . % and specificity of . %. we reviewed visits prior to the pathway and after. mean ed length of stay was similar ( minutes before versus after). ct was used in . % of visits before and . % after (p = . ). use of ultrasound increased ( . % before versus . % after, p < . ). admission rates were not significantly different ( . % before versus . % after, p = . ). conclusion: the low-risk criteria had good sensitivity in ruling out appendicitis and can be used to guide physician judgment. institution of this pathway was not associated with significant changes in length of stay, utilization of ct, or admission rate in an academic pediatric ed. computer-delivered alcohol and driver safety behavior screening and intervention program initiated during an emergency department visit mary k. murphy , lucia l. smith , anton palma , david w. lounsbury , polly e. bijur , paul chambers yale university, new haven, ct; albert einstein college of medicine, bronx, ny background: alcohol use is involved in percent of all fatal motor vehicle crashes and recent estimates show that at least , people were injured due to distracted driving last year. patients who visit the emergency department (ed) are not routinely screened for driver safety behavior; however, large numbers of patients are treated in the ed every day creating an opportunity for screening and intervention on important public health behaviors. objectives: to evaluate patient acceptance and response to a computer-based traffic safety educational intervention during an ed visit and one month follow-up. methods: design. pre /post educational intervention. setting. large urban academic ed serving over , patients annually. participants. medically stable adult ed patients. intervention. patients completed a self-administered, computer-based program that queried patients on alcohol use and risky driving behaviors (texting, talking, and other forms of distracted driving). the computer provided patients with educational information on the dangers of these behaviors and collected data on patient satisfaction with the program. staff called patients one month post ed visit for a repeat query. results: patients participated; average age ( - ), % hispanic, % male. % of patients reported the program was easy to use and were comfortable receiving this education via computer during their ed visit. self-reported driver safety behaviors pre, post intervention (% change): driving while talking on the phone %, % () %, p = . ), aggressive driving %, % () %, p = . ), texting while driving %, % () %, p = . ), driving while drowsy %, % () %, p = . ), drinking in excess of nih safe drinking guidelines %,% () %, p = . ), drinking and driving %, % () %, p = . ). conclusion: we found a high prevalence of selfreported risky driving behaviors in our ed population. at month follow-up, patients reported a significant decrease in these behaviors. overall patients were very satisfied receiving educational information about these behaviors via computer during their ed visit. this study indicates that a low-intensity, computer-based educational intervention during an ed visit may be a useful approach to educate patients about safe driving behaviors and promote behavior change. prevalence of depression among emergency department visitors with chronic illness janice c. blanchard, benjamin l. bregman, jeffrey smith, mohammad salimian, qasem al jabr george washington university, washington, dc background: persons with chronic illnesses have been shown to have higher rates of depression than the general population. the effect of depression on frequent emergency department (ed) use among this population has not been studied. objectives: this study evaluated the prevalence of major depressive disorder (mdd) among persons presenting with depression to the george washington university ed. we hypothesized that patients with chronic illnesses would be more likely to have mdd than those without. methods: this was a single center, prospective, crosssectional study. we used a convenience sample of noncritically ill, english-speaking adult patients presenting with non-psychiatric complaints to an urban academic ed over months in . subjects were screened with the phq , a nine-item questionnaire that is a validated, reliable predictor of mdd. we also queried respondents about demographic characteristics as well as the presence of at least one chronic disease (heart disease, hypertension, asthma, diabetes, hiv, cancer, kidney disease, or cerebrovascular disease). we evaluated the association between mdd and chronic illnesses with both bivariate analysis and multivariate logistic regression controlling for demographic characteristics (age, race, sex, income, and insurance coverage). results: our response rate was . % with a final sample size of . of our total sample, ( . %) had at least one of the chronic illnesses defined above. of this group, ( . %) screened positive for mdd as compared to ( . %) of the group without chronic illnesses (p < . ). in multivariate analysis, persons with chronic illnesses had an odds ratio for a positive depression screen of . ( . , . ) as compared to persons without illness. among the subset of persons with chronic illnesses (n = ), . % had ‡ visits in the prior days as compared to . % of persons with chronic illnesses without mdd (p = . ). conclusion: our study found a high prevalence of untreated mdd among persons with chronic illnesses who present to the ed. depression is associated with more frequent emergency department use among this population. initial blood alcohol level aids ciwa in predicting admission for alcohol withdrawal craig hullett, douglas rappaport, mary teeple, daniel butler, arthur sanders university of arizona, tucson, az background: assessment of alcohol withdrawal symptoms is difficult in the emergency department. the clinical institute withdrawal assessment (ciwa) is commonly used, but other factors may also be important predictors of withdrawal symptom severity. objectives: the purpose of this study is to determine whether ciwa score at presentation to triage was predictive of later admission to the hospital. methods: a retrospective study of patients presenting to an acute alcohol and drug detoxification hospital was performed from july through january . patients were excluded if other drug withdrawal was present in addition to alcohol. initial assessment included age, sex, vital signs, and blood alcohol level (bal) in addition to hourly ciwa score. admission is indicated for a ciwa score of or higher. data were analyzed by selecting all patients not immediately admitted at initial presentation. logistic regression using wald's criteria for stepwise inclusion was used to determine the utility of the initially gathered ciwa, bal, longest sobriety, liver cirrhosis, and vital signs in predicting subsequent admission. results: there were patients who fit the inclusion criteria, with admitted for treatment at initial intake and another admitted during the following hours. logistic regression indicated that presenting bal was a strong predictor (p = . ) of admission for treatment after initial presentation, as was presenting ciwa (p = . ). thus, presenting bal provided a substantial addition above initial ciwa in predicting later admission. no other variables added significantly to the prediction of later admission. to determine the interaction between presenting bal and ciwa scores, we ran a repeated measures analysis of the first five ciwa scores (from presentation to hours later), using bal split into low (bal < . ) and high (bal > . ) groups (see figure) . their interaction was significant, f ( , ) = . , p < . , g = . . those presenting with higher initial bal had suppressed ciwa scores that rose precipitously as the alcohol cleared. those with low presenting bal showed a decline in ciwa over time conclusion: initial assessment using the common assessment tool ciwa is aided significantly by bal assessment. patients with higher presenting bal are at higher risk for progression to serious alcohol withdrawal symptom. objectives: to describe patient and visitor characteristics and perspectives on the role of visitors in the ed and determine the effect of visitors on ed and hospital outcome measures. methods: this cross-sectional study was done in an , -visit urban ed, and data were attempted to be collected from all patients over a consecutive -hour period from august to , . trained data collectors were assigned to the ed continuously for the study period. patients assigned to a rapid care section of the ed ( %) were excluded. a visitor was defined as a person other than a health care provider (hcp) or hospital staff present in a patient's room at any time. patient perspectives on visitors were assessed in the following domains: transportation, emotional support, physical care, communication, and advocating for the patient. ed and hospital outcome measures pertaining to ed length of stay (los) and charges, hospital admission rate, hospital los and charges were obtained from patient medical records and hospital billing. data analyses included frequencies, student's t-tests for continuous variables, and chi-square tests of association for categorical variables. all tests for significance were two-sided. objectives: to examine the effect of sunday alcohol availability on ethanol-related visits and alcohol withdrawal visits to the ed. methods: study design was a retrospective beforeafter study using electronically archived hospital data at an urban, safety net hospital. all adult non-prisoner ed visits from / / to / / were analyzed. an ethanol-related ed visit was defined by icd- codes related to alcohol ( .x, .x, . , . ). an alcohol withdrawal visit was defined by icd- codes of delirium tremens ( . ), alcohol psychosis with hallucination ( . ), and ethanol withdrawal ( . ). we generated a ratio of ethanol-related ed visits to total ed visits (ethanol/total) and ratio of alcohol withdrawal ed visits to total ed visits (withdrawal/total). a day was redefined as am to am. the ratios were averaged within the four seasons to account for seasonal variations. data from summer were dropped as it spanned the law change. we stratified data into sunday and non-sunday days prior to analysis to isolate the effects of the law change. we used multivariable linear regression to estimate the association of the ratio with the law change while adjusting for time and the seasons. each ratio was modeled separately. the interaction between time and the law change was assessed using p < . . results: during the study there were a total of , ed visits including , ( % of total) ethanol-related visits and , ( % of total) alcohol withdrawal visits. unadjusted ratios in seasonal blocks are plotted in the figure with associated % ci and best fit regression line for before and after law change, respectively. after adjusting for time and season in the multivariable linear regression, we found no significant association of either ethanol/total or withdrawal/total with the law change. this remained true for both sunday and non-sunday data. all interactions assessed were not significant. conclusion: the change in colorado law to allow the sale of full-strength alcoholic beverages on sundays did not significantly affect ethanol-related or alcohol withdrawal ed visits. background: olanzapine is a second-generation antipsychotic (sga) with actions at the serotonin/histamine receptors. post-marketing reports and a case report have documented dangerous lowering of blood pressure when this antipsychotic is paired with benzodiazepines, but a recent small study found no bigger decreases in blood pressure compared to another antipsychotic like haloperidol. decreases in oxygen saturations, however, were larger when olanzapine was combined with benzodiazepines in alcohol-intoxicated patients. it is unclear whether these vital sign changes are associated with the intramuscular (im) route only. objectives: the assessment of vital signs following administration of either oral (po) or im olanzapine, either with or without benzodiazepines (benzos) and with or without concurrent alcohol intoxication. methods: this is a structured retrospective chart review of all patients who received olanzapine in an academic medical center ed from - who had vital signs documented both before medication administration and within four hours afterwards. vital signs were calculated as pre-dose minus lowest post-dose vital sign within hours, and were analyzed in an anova with route (im/po), benzo use (+/)), and alcohol use (+/)) as factors. significance level was set to < . . results: there were patients who received olanzapine over the study period. a total of patients ( po, im) met inclusion criteria. systolic blood pressures decreased across all groups as patients reduced their agitation. neither the route of administration, concurrent use of benzos, nor the use of alcohol were associated with significant changes in systolic bp (p = ns for all comparisons; see figure ). decreases in oxygen saturations, however, were significantly larger for alcoholintoxicated patients who subsequently received im olanzapine + benzos compared to other groups (route: p < . ; alcohol: p < . ; route x alcohol: p < . ; route x benzos x alcohol: p < . ; see figure ). conclusion: alcohol and benzos are not associated with significant decreases in blood pressure after po olanzapine, but im olanzapine + benzos is associated with potentially significant oxygen desaturations in patients who are intoxicated. intoxicated patients may have differential effects with the use of im sgas such as olanzapine when combined with benzos, and should be studied separately in drug trials. patients with a psychiatric diagnosis rasha buhumaid, jessica riley, janice blanchard george washington university, washington, dc background: literature suggests that frequent emergency department (ed) use is common among persons with a mental health diagnosis. few studies have documented risk factors associated with increased utilization among this population. objectives: to understand demographic characteristics of frequent users of the emergency department and describe characteristics associated with their visits. it was hypothesized that frequent visitors would have a higher rate of medical comorbidities than infrequent visitors. methods: this was a retrospective study of patients presenting to an urban, academic emergency department in . a cohort of all patients with a mental health-related final icd- coded diagnosis (axis i or axis ii) was extracted from the electronic medical record. using a standard abstraction form, a medical chart review collected information about medical comorbidities, substance abuse, race, age, sex, and insurance coverage, as well as diagnosis, disposition, and time of each visit. results: our sample consisted of frequent users ( ‡ visits in a day period) and infrequent users (£ visits in a day period). frequent users were more likely to be male ( % vs. . % p = . ), black ( % vs. % p < . ), and had a higher average number of comorbid conditions ( . , %ci . , . ) as compared to infrequent users ( . , %ci . , . ). a higher percentage of visits in the infrequent user group occurred during the day ( % vs. . % p < . ) while a higher number of visits in the frequent users occurred after midnight ( . % vs. . % p = . ). visits in the frequent user group were less likely to be for a psychiatric complaint ( . % vs. . %) and less likely to result in a psychiatric admission ( . % versus . %) as compared to the infrequent user group (p < . ). conclusion: our data indicate that among patients with psychiatric diagnoses, those who make frequent ed visits have a higher rate of comorbid conditions than infrequent visitors. despite their increased use of the ed, frequent visitors have a significantly lower psychiatric admission rate. many of the visits by frequent users are for non-psychiatric complaints and may reflect poor access to outpatient medical and mental health services. emergency departments should consider interventions to help address social and medical issues among mental health patients who frequently use ed services. background: the world health organization estimates that one million people die annually by suicide. in the u.s., suicide is the fourth leading cause of death between the ages of and . many of these patients are seen in ed, while outpatient visits for depression are also high. no recent analysis has compared these groups in the recent years. objectives: to determine if there is a relationship between the incidence of suicidal and depressed patients presenting to emergency departments and the incidence of depressed patients presenting to outpatient clinics from - . the secondary objective is to analyze trends in suicidal patients in the ed. methods: we used nhamcs (national hospital ambulatory medical care survey) and namcs (national ambulatory medical care survey), national surveys completed by the centers for disease control, which provide a sampling of emergency department and outpatient visits respectively. for both groups, we used mental-health-related icd- -cm, e codes and reasons for visit. we compared suicidal and depressed patients who presented to the ed, to those who presented to outpatient clinics. our subgroup analyses included age, sex, race/ethnicity, method of payment, regional variation, and urban verses rural distribution. results: ed visits for depression ( . %) and suicide attempts ( . %) remained stable over the years, with no significant linear trend. however, office visits for depression significantly decreased from . % of visits in to . % of visits in . non-latino whites had a higher percentage of ed visits for depression ( . %) and suicide attempt ( . %) (p < . ), and a higher percentage of office visits for depression than all other groups. among patients age - years, ed visits for suicide attempt significantly increased from . % in to . % in . homeless patients had a higher percent of ed visits for depression ( . %) and suicide attempt ( background: for potentially high-risk ed patients with psychiatric complaints, efficient ed throughput is key to delivering high-quality care and minimizing time spent in an unsecured waiting room. objectives: we hypothesized that adding a physician in triage would improve ed throughput for psychiatric patients. we evaluated the relationship between the presence of an ed triage physician and waiting room (wr) time, time to first physician order, time to ed bed assignment, and time spent in an ed bed. methods: the study was conducted from / - / at an academic ed with annual visits and a dedicated on-site emergency psychiatric unit. we performed a pre/post retrospective observational cohort study using administrative data, including weekend visits from noon- pm, months pre and post addition of weekend triage physicians. after adjusting for patient age, sex, insurance status, emergency severity index score, mode of arrival, ed occupancy rate, wr count, boarding count, and average wr los, multiple linear regression evaluated the relationship between the presence of a triage physician and four ed throughput outcomes: time spent in the wr, time to first order, time spent in an ed bed, and the total ed los. results: visits met inclusion criteria, in the months before and in the months after physicians were assigned to triage on weekends. table reports demographic data; multivariate analysis results are found in table . the presence of a triage physician was associated with an ( % ci . - . ) minute increase in wr time and no associated change in time to first order, time spent in an ed bed, or in the overall ed los. conclusion: use of triage physicians has been reported to decrease the time patients spend in an ed bed and improve ed throughput. however, for patients with psychiatric complaints, our analysis revealed a slight increase in wr time without evident change in the time to first order, time spent in an ed bed, or total ed los. improvements in ed throughput for psychiatric patients will likely require system-level changes, such as reducing ed boarding and improving lab efficiency to speed the process of medical clearance and reduce time spent in the unsecured wr. these findings may not be generalizable to eds without a dedicated ed psychiatric unit with full-time social workers to assist with disposition. initial assessment included ciwa scoring, repeated hourly, as well as other variables (see table ). treatment and admission to the inpatient hospital was indicated for a ciwa score of or higher. statistical analysis was performed utilizing repeated measures general linear modeling for ciwa scores and anova for all other variables. results: there were patients who fit the inclusion criteria, with admitted for treatment at initial intake and another admitted during the following hours. the table below compares the three most prevalent ethnic populations seen at our hospital. native americans presented at a significantly younger age (p < . ) than the other two ethnicities. initial ciwa scores taken on admission were significantly lower in the native american group than the other two groups (p < . ) and at hour a difference existed but failed to reach significance. repeated measures analysis indicate that ciwa scores progressed in a u-shaped curvilinear fashion (see figure ) conclusion: initial assessment utilizing ciwa scores appears to be affected by ethnicity. care must be taken when assessing and making decisions on a single initial ciwa score. further research is needed in this area as our numbers are small and differences might be seen in subsequent scoring. in addition, our study consists of primarily male patients and does not include african-american patients. background: age is a risk factor for adverse outcomes in trauma, yet evidence supporting the use of specific age cut-points to identify seriously injured patients for field triage is limited. objectives: to evaluate under-triage by age, empirically examine the association between age and serious injury for field triage, and assess the potential effect of mandatory age criteria. methods: this was a retrospective cohort study of injured children and adults transported by ems agencies to hospitals in regions of the western u.s. from - . hospital records were probabilistically linked to ems records using trauma registries, emergency department data, and state discharge databases. serious injury was defined as an injury severity score (iss) ‡ (the primary outcome). we assessed under-triage (triage-negative patients with iss ‡ ) by age decile, different mandatory age criteria, and used multivariable logistic regression models to test the association (linear and non-linear) between age and iss ‡ , adjusted for important confounders. results: , injured patients were evaluated and transported by ems over the -year period. under-triage increased markedly for patients over years, reaching % for those over years ( figure ). mandatory age triage criteria decreased under-triage, while substantially increasing over-triage: one iss ‡ patient identified for every additional patients triaged to major trauma centers. among patients not identified by other criteria, age had a strong non-linear association with iss ‡ (p < . ); the probability of serious injury steadily increased after years, becoming more notable after years ( figure ). conclusion: under-triage in trauma increases in patients over years, which may be reduced with mandatory age criteria at the expense of system efficiency. among patients not identified by other criteria, serious injury steadily increased after years, though there was no age at which risk abruptly increased. background: although limited resuscitation with hemoglobin-based oxygen carriers (hbocs) improves survival in several polytrauma models, including those of traumatic brain injury (tbi) with uncontrolled hemorrhage (uh) via liver injury, their use remains controversial. objectives: we examine the effect of hboc resuscitation in a swine polytrauma model with uh by aortic tear +/) tbi. we hypothesize that limited resuscitation with hboc would offer no survival benefit and would have similar effects in a model of uh via aortic tear +/) tbi. methods: anesthetized swine subjected to uh inflicted via aortic tear +/) fluid percussion tbi underwent equivalent limited resuscitation with hboc, lr, or hboc+nitroglycerin (ntg) (vasoattenuated hboc) and were observed for hours. comparisons were between tbi and no-tbi groups with adjustment for resuscitation fluid type using two-way anova with interaction and tukey kramer adjustment for individual comparisons. results: there was no independent effect of tbi on survival time after adjustment for fluid type (anova, tbi term p = . ) and there was no interaction between tbi and resuscitation fluid type (anova interaction term p = . ). there was a significant independent effect of fluid type on survival time (anova p = . background: intracranial hemorrhage (ich) after a head trauma is a problem frequently encountered in the ed. an elevated inr is recognized as a risk of bleeding. however, in a patient with an inr in normal range, a level associated with a lower risk of ich is not known. objectives: the aim of this study was to identify an inr threshold that could predict a decreased risk of an ich after a head trauma in patients with a normal inr. it is hypothesized that there is a threshold at which the likelihood of bleeding decreases significantly. methods: we did a study using data from a registry of patients with mild to severe head trauma (n = ) evaluated in a level i trauma center in canada between march and february . all the patients with a documented scan interpreted by a radiologist and a normal inr, defined as a value less then . , were included. we determined the correlation between inr value binned by . and the proportion of patients with an ich. threshold was defined by consensus as an abrupt change of more than % in the percentage of patients with ich. univariate frequency distribution was tested with pearson's chisquare test. logistic regression analysis was then used to study the effects of inr on ich with the following confounding factors: age, sex, and intake of warfarin, clopidogrel, or aspirin. results are presented with % confidence intervals. results: patients met the inclusion criteria. the mean age was . years ± . and % were men. patients ( . %) had an ich on brain scan. we found a significantly lower risk of ich at a threshold of inr less than . (p < . , univariate or = . , %ci . - . ) and a strong correlation between the risk of bleeding for every increase of the inr (r = . ). in fact, after adjustment for confounding variables, every . inr increase was associated with an increased risk of having an ich (or . ; % ci . - . ). conclusion: we were able to demonstrate an inr threshold under which the probability of ich was significantly lower. we also found a strong association between the risk of bleeding and the increase in inr within a normal range, suggesting that clinicians should not be falsely reassured by a normal inr. our results are limited by the fact that this is a retrospective study and a small proportion of traumatic brain injured patients in our database had no scan or inr at their ed visit. a prospective cohort study would be needed to confirm our results. background: increasingly, patients with tbi are being seen and managed in the emergency neurology setting. knowing which early signs are associated with prognosis can be helpful in directing the acute management. objectives: to determine whether any factors early in the course of head trauma are associated with shortterm outcomes including inpatient admission, in-hospital mortality, and return to the hospital within days. methods: this irb-approved study is a retrospective review of patients head injury presenting to our tertiary care academic medical center during a -month period. the dataset was created using redcap, a data management solution hosted by our medical school's center for translational science institute. results: the median age of the cohort (n = ) was , iqr = - yrs, with % being male. % had a gcs of - (mild tbi), % - (moderate tbi), and % gcs < (severe tbi). % of patients were admitted to the hospital. the median length of hospital stay was days, with an iqr of - days. of those admitted, % had an icu stay as well. the median icu los was also days, with an iqr of - days. twenty nine ( %) patients died during their hospital stay. lower gcs was predictive of inpatient admission (p = . ) as well as icu days (p < . ). significant predictors of re-admission to the hospital within days included hypotension (p = . ) upon initial presentation. the prehospital and ed gcs scores were not statistically significant. significant predictors of in-hospital death in a model controlling for age included bradycardia (p = . ), hyperglycemia (p = . ), and lower gcs (p = . ). the incidence of bradycardia (hr < ) was . %. conclusion: early hypotension, hyperglycemia, and bradycardia along with lower initial gcs are associated with significantly higher likelihood of hospital admission, including icu admission, as well as intrahospital death and re-admission. background: over , people per day require treatment for ankle sprains, resulting in lost workdays and training for athletes. platelet rich plasma (prp) is an autologous concentration of platelets which, when injected into the site of injury, is thought to improve healing by promoting inflammation through growth factor and cytokine release. studies to date have shown mixed results, with few randomized or placebo-controlled trials. the lower extremity functional scale (lefs) is a previously validated objective measure of lower extremity function. objectives: is prp helpful in acute ankle sprains in the the emergency department? methods: prospective, randomized, double-blinded, placebo-controlled trial. patients with severe ankle sprains and negative x-rays were randomized to trial or placebo. severe was defined as marked swelling and ecchymosis and inability to bear weight. both groups had cc of blood drawn. trial group blood was centrifuged with a magellan autologous platelet separator (arteriocyte, cleveland) to yield - cc of prp. prp along with . cc of % lidocaine and . cc of . % bupivicaine was injected at the point of maximum tenderness by a blinded physician under ultrasound guidance. control group blood was discarded and participants were injected in a similar fashion substituting sterile . % saline for prp. both groups had visual analog scale (vas) pain scores and lefs on days , , , and . all participants had a posterior splint and were made non weight bearing for days after which they were reexamined, had their splint removed, and were asked to bear weight as tolerated. participants were instructed not to use nsaids during the trial. results: patients were screened and were enrolled. four withdrew before prp injection was complete. eighteen were randomized to prp and to placebo. see tables for results. vas and lefs are presented as means with sd in parentheses. demographics were not statistically different between groups. conclusion: in this small study, prp did not appear to offer benefit in either pain control or healing. both groups had improvement in their pain and functionality and did not differ significantly during the study period. limitations include small study size and large number of participant refusals. methods: a structured chart review of all icd- radius fracture coded charts spanning march , to july , was conducted. specific variable data were collected and categorized as follows: age, moi, body mass index, and fracture location. the charts were reviewed by two medical students, with % of the charts reviewed by both students to confirm inter-rater reliability. frequencies and inter-quartile ranges were determined. comparisons were made with fisher's exact test and multiple logistic regression. results: charts met inclusion criteria. charts were excluded due to one of the following reasons: no fracture or no x-ray ( ), isolated ulnar fracture ( ), or undocumented or penetrating moi ( ). of the analyzed patients (n = ), distal radius fractures were most common ( %), followed by proximal ( %) and midshaft ( %). chart reviewers were found to be reliable (j = ). age and moi were significantly associated with fracture location (see table) . ages - and bike accidents were more strongly associated with proximal radius fractures (odds ratio: [ - ] and [ - ], respectively). conclusion: patients presenting to our inner city ed with a radius fracture are more likely to have a distal fracture. adults - and bike accidents had a significantly higher incidence of proximal fractures than other ages or mois. background: trauma centers use guidelines to determine the need for a trauma surgeon in the ed on patient arrival. a decision rule from loma linda university that includes penetrating injury and tachycardia was developed to predict which pediatric trauma patients require emergent intervention, and thus are most likely to benefit from surgical presence in the ed. objectives: our goal was to validate the loma linda rule (llr) in a heterogeneous pediatric trauma population and to compare it to the american college of surgeons' major resuscitation criteria (mrc). we hypothesized that the llr would be more sensitive than the mrc for identifying the need for emergent operative or procedural intervention. methods: we performed a secondary analysis of prospectively collected trauma registry data from two urban level i pediatric trauma centers with a combined annual census of approximately , visits. consecutive patients < years old with blunt or penetrating trauma from through were included. patient demographics, injury severity scores (iss), times of ed arrival and surgical intervention, and all variables of both rules were obtained. the outcome (emergent operative intervention within hour of ed arrival or ed cricothyroidotomy or thoracotomy) was confirmed by trained, blinded abstractors. sensitivities, specificities, and % confidence intervals (cis) were calculated for both rules. results: , patients were included with a median age of . years and a median iss of . emergent intervention was required in patients ( . %). the llr had a sensitivity ranging from . %- . % ( % ci: . %- . %) and specificity ranging from . %- . % ( % ci: . %- . %) between both institutions. the mrc had a sensitivity ranging from . %- . % ( % ci: . %- . %) and specificity ranging from . %- . % ( % ci: . %- . %) between institutions. conclusion: emergent intervention is rare in pediatric trauma patients. the mrc was more sensitive for predicting the need for emergent intervention than the llr. neither set of criteria was sufficiently accurate to recommend their routine use for pediatric trauma patients. droperidol for sedation of acute behavioural disturbance leonie a. calver , colin page , michael downes , betty chan , geoffrey k. isbister calvary mater newcastle and university of newcastle, newcastle, australia; princess alexandra hospital, brisbane, australia; calvary mater newcastle, newcastle, australia; prince of wales hospital, sydney, australia background: acute behavioural disturbance (abd) is a common occurrence in the emergency department (ed) and is a risk to staff and patients. there remains little consensus on the most effective drug for sedation of violent and aggressive patients. prior to the food and drug administration's black box warning, droperidol was commonly used and was considered safe and effective. objectives: this study aimed to investigate the effectiveness of parenteral droperidol for sedation of abd. methods: as part of a prospective observational study, a standardised protocol using droperidol for the seda-acute and delayed behavioral deficits were demonstrated in this rat model of co toxicity, which parallels the neurocognitive deficit pattern observed in humans (see figure) . similar to prior studies, pathologic analysis of brain tissue demonstrated the highest percentage of necrotic cells in the cortex, pyramidal cells, and cerebellum. the collected data are summarized in the table. we have developed an animal model of severe co toxicity evidenced by behavioral deficits and neuronal necrosis. future efforts will compare neurologic outcomes in severely co poisoned rats treated with hypothermia and % inspired o versus hbo to normothermic controls treated with % inspired o . increasing in popularity, attracting more than , annual participants worldwide. prior studies have consistently documented renal function impairment, but only after race completion. the incidence of renal injury during these multi-day ultramarathons is currently unknown. this is the first prospective cohort study to evaluate the incidence of acute kidney injury (aki) in runners during a multi-day ultramarathon foot race. objectives: to assess the effect of inter-stage recovery versus cumulative damage on resulting renal function during a multi-day ultramarathon. methods: demographic and biochemical data gathered via phlebotomy and analyzed by istatÒ (abbott, nj) were collected at the start and finish of day ( miles), ( miles), and ( miles) during racing the planet'sÒ -mile, -day self-supported desert ultramarathons. pre-established rifle criteria using creatinine (cr) and glomerular filtration rate (gfr) defined aki as ''no injury'' (cr < . x normal, decrease of gfr < %), ''risk'' (cr . x normal, decrease of gfr by - %), and ''injury'' (cr x normal, decrease of gfr by - %). results: thirty racers ( % male) with a mean (+/) sd) age of + /- years were studied during the sahara (n = , . %), gobi (n = , %), and namibia (n = , . %) events. the average decrease in gfr from day start to day finish was + /- (p < . , % ci . - . ); day start to day finish was . + /- . (p < . , % ci . - . ); and day start to day finish was . ± . (p < . , % ci . - ). runners categorized as risk and injury for aki after stage was . % and %; after stage was % and %, and after stage was . % and . % conclusion: the majority of participants developed significant levels of renal impairment despite recovery intervals. given the changes in renal function, potentially harmful non-steroidal anti-inflammatory drugs should be minimized to prevent exacerbating acute kidney injury. background: more than % of the elderly abuse prescription drugs, and emergency medicine providers frequently struggle to identify features of opioid addiction in this population. the prescription drug use questionnaire (pduqp) is a validated, -item, patient-administered tool developed to help health care providers better identify problematic opioid use, or dependence, in patients who receive opioids for the treatment of chronic pain. objectives: to identify the prevalence of prescription drug misuse features in elderly ed patients. methods: this cross-sectional, observational study was conducted between / and / in the ed of an urban, university-affiliated community hospi-tal that serves a large geriatric population. all patients aged to inclusive were eligible, and were recruited on a convenience basis. exclusion criteria included known dementia, and critical illness. outcomes of interest included self-reported history of prior prescription opioid use, substance abuse history, aberrant medication-taking behaviors, and pduqp results. results: one hundred patients were approached for participation. two were excluded for inability to read english, three were receiving analgesia for metastatic cancer, had never taken a prescription opioid, and seven refused to participate beyond pre-screening. sixty patients completed the study (see table ). of those, . % reported four or more visits within months; chronic pain was reported by . %; debilitating pain by . %; prior pain management referral by . %; and storing opioids for future use by %. seventeen patients reported current prescription opioid use, and were administered the pduqp (see figure) . in this population, . % thought their pain was not adequately being treated; . % reported having to increase the amount of pain medication they were taking over the prior months; . % saved up future pain medication; . % had doctors refuse to give them pain medication for fear that the patient would abuse the prescription opioids; and . % reported having a previous drug or alcohol problem. conclusion: screening instruments, such as the pduqp, facilitate identification of geriatric patients with features of opioid misuse. a high proportion of patients in this study save opioids for further use. interventions for safe medication disposal may decrease access to opioids and subsequent morbidity. age extremes, male sex, and several chronic health conditions were associated with increased odds of heat stroke, hospital admission, and death in the ed by a factor of - . chronic hematologic disease (e.g. anemia) was associated with a - fold increase in adjusted odds of each of these outcomes. conclusion: hri imposes a substantial public health burden, and a wider range of chronic conditions confer susceptibility than previously thought. males, older adults, and patients with chronic conditions, particularly anemia, are likely to have more severe hri, be admitted, or die in the ed. background: carbon monoxide (co) poisoning is a remarkable cause of death worldwide. co, produced by the incomplete combustion of hydrocarbons, has many toxic effects on especially the heart and brain. co binds strongly to cytochrome oxidase, hemoglobin, and myoglobin causing hypoxia of organs and issues. co converts hemoglobin to carboxyhemoglobin and makes transport of oxygen through the body impossible and causes severe hypoxia. objectives: the aim of this study is to investigate the levels of s b and neuron specific enolase (nse) measured both during admittance and at the sixth hour of hyperbaric and normobaric oxygen therapy carried out on patients with a diagnosis of co poisoning. methods: the study is designed as a prospective observational laboratory study. forty patients were enrolled in the study: underwent normobaric oxygen therapy (nbot) and the other underwent hyperbaric oxygen therapy (hbot). levels of s b and nse were measured both during admittance and at the sixth hour of admittance of all patients. demographic data, clinical characteristics, and outcome measures were recorded. all data were statistically analyzed. results: in both treatment groups, mean levels of nse after therapy were significantly lower than admittance levels. although levels of nse measured before and hours after treatment in hbot group were high, the difference between groups was not statistically significant (p > . ). in both treatment groups, mean levels of s b after therapy were significantly lower than admittance levels; likewise nse. although levels of s b measured before and hours after treatment in hbot group were high, the difference between groups was not statistically significant (p > . ). additionally, while levels of s b measured after treatment in the hbot group were lower compared to the nbot group, the difference between groups was also not statistically significant (p > . ). conclusion: levels of s b and nse as evidence for brain injury elevation in case of co poisoining and decrease by therapy according to our study as well as previous studies. decrease in levels of s b is more significant. according to our results, s b and nse may be useful markers in case of co poisoning; however, we did not meet any data providing more value in determining hbot indications and determining levels of cohb in the management of patients with a diagnosis of co poisoining. neurons objectives: this study was conducted to determine if neurons in the dmh, and its neighbor the paraventricular hypothalamus (pvn), were likewise involved in mdma-mediated neuroendocrine responses, and if serotonin a receptors ( -ht a) play a role in this regional response. methods: in both experiments, male sprague dawley rats (n = - /group) were implanted with bilateral cannulas targeting specific regions of the brain, i.v. catheters for drug delivery, and i.a. catheters for blood withdrawal. experiments were conducted in raturn cages, which allow blood withdrawal and drug administration in free moving animals while recording their locomotion. in the first experiment, rats were microinjected into the dmh, the pvn, or a region between, with the gabaa agonist muscimol ( pmol/ nl/side) or pbs ( nl) and min later were injected with either mdma ( . mg/kg i.v.) or an equal volume of saline. blood was withdrawn prior to microinjections and minutes after mdma for ria measurement of plasma acth. locomotion was recorded throughout the experiment. in a separate experiment of identical design, either the -ht a antagonist way (way, nmol/ nl/side) or saline was microinjected followed by i.v. injection of mdma or saline. in both experiments, increases in acth and distance traveled were compared between groups using an anova analysis. results: when compared to controls, microinjections of muscimol into the dmh, pvn, or the area in between attenuated plasma increases in acth and locomotion evoked by mdma. when microinjected into the dmh or pvn, way had no effect on acth, but when injected into the region of the dmh it significantly increased locomotion. background: poor hand-offs between physicians when admitting patients have been shown to be a major source of medical errors. objectives: we propose that training in a standardized admissions protocol by emergency medicine (em) to internal medicine (im) residents would improve the quality of and quantity of communication of vital patient information. methods: em and im residents at a large academic center developed an evidence-based admission handover protocol termed the ' ps' (table ) . em and im residents received ' ps' protocol training. im residents recorded prospectively how well each of the seven ps were communicated during each admission pre-and post-intervention. im residents also assessed the overall quality of the handover using a likert scale. the primary outcome was the change in the number of 'ps' conveyed by the em resident to the accepting im resident. data were collected for six weeks before and then for six weeks starting two weeks after the educational intervention. results: there were observations recorded in the preintervention (control) group and observations in the post-intervention group. for each of the seven 'ps' the percentage of observation where all of the information was communicated is shown in table . the communication of 'ps' increased following the intervention. this rise was statistically significant for patient information and pending tests. in the control group the mean of total communicated ps was and in the intervention group, the mean increased to (p < . ). the quality of the handover communication had a mean rating of . in the control group and . in the intervention group (p < . ). conclusion: this educational intervention in a cohort of em and im residents improved the quality and quantity of vital information communicated during patient handovers. the intervention was statistically significant for patient information transfer and tests pending. the results are limited by study size. based on our preliminary data, an agreed-upon handover protocol with training improved the amount and quality of communication during patients' hospital admission on simple items that were likely had been taken for granted as routinely transmitted. we recruited a convenience sample of residents and students rotating in the pediatric emergency department. a two-sided form had the same seven clinical decisions on each side: whether to perform blood, urine, spinal fluid tests, imaging, iv fluids, antibiotics, or a consult. the rating choices were: definitely not, probably not, probably would, and definitely would. trainees rated each decision after seeing a patient, but before presenting to the preceptor, who, after evaluating the patient, rated the same seven decisions on the second side of the form. the preceptor also indicated the most relevant decision (mrd) for that patient. we examined the validity of the technique using hypothesis testing; we posited that residents would have a higher degree of concordance with the preceptor than would medical students. this was tested using dichotomized analyses (accuracy, kappa) and roc curves with the preceptor decision as the gold standard. results: thirty-one students completed forms (median forms; iqr , ) and residents completed ( ; iqr , ). preceptors included attending physicians and fellows ( ; iqr , ). students were concordant with preceptors in % (k = . ) of mrd while residents agreed in . % (p = . ), k = . . roc analysis revealed significant differences between students and residents in the auc for the mrd ( . vs . ; p = . ). conclusion: this measure of trainee-preceptor concordance requires further research but may eventually allow for assessment of trainee clinical decision-making. it also has the pedagogical advantage of promoting independent trainee decision-making. background: basic life support (bls) and advanced cardiac life support (acls) are integral parts of emergency cardiac care. this training is usually reserved in most institutions for residents and faculty. the argument can be made to introduce bls and acls training earlier in the medical student curriculum to enhance acquisition of these skills. objectives: the goal of the survey was to characterize the perceptions and needs of graduating medical students in regards to bls and acls training. methods: this was a survey-based study of graduating fourth year medical students at a u.s. medical school. the students were surveyed before voluntarily participating in a student-led acls course in march of their final year. the surveys were distributed before starting the training course. both bls and acls training, comfort levels, and perceptions were assessed in the survey. results: of the students in the graduating class, participated in the training class with ( %) completing the survey. % of students entered medical school without any prior training and % started clinics without training. . % of students reported witnessing an average of . in-hospital cardiac arrests during training (range of - ). overall, students rated their preparedness . (sd . ) for adult resuscitations on a - likert scale with being the unprepared. % and % of students believe that bls and acls should be included in the medical student curriculum respectively with a preference for teaching before starting clerkships. % of students avoided participating in resuscitations due to lack of training. of those, % said they would have participated had they been trained. conclusion: to our knowledge, this is one of the first studies to address the perceptions and needs for bls and acls training in u.s. medical schools. students feel that bls and acls training is needed in their curriculum and would possibly enhance perceived comfort levels and willingness to participate in resuscitations. background: professionalism is one of six core competency requirements of the acgme, yet defining and teaching its principles remains a challenge. the ''social contract'' between physician and community is clearly central to professionalism so determining the patient's understanding of the physician's role in the relationship is important. because specialization has created more narrowly focused and often quite different interactions in different medical environments, the patient concept of professionalism in different settings may vary as well. objectives: we hoped to determine if patients have different conceptions of professionalism when considering physicians in different clinical environments. methods: patients were surveyed in the waiting room of an emergency department, an outpatient internal medicine clinic, and a pre-operative/anesthesia clinic. the survey contained examples of attributes, derived from the american board of internal medicine's eight characteristics of professionalism. participants were asked to rate, on a -point scale, the importance that a physician possess each attribute. an anova analysis was used to compare the sites for each question. results: of who took the survey, were in the emergency department, were in the medicine clinic, and were in the pre-operative clinic. females comprised % of the study group and the average age was with a range from to . there was a significant difference on the attribute of ''providing a portion of work for those who cannot pay;'' this was rated higher in the emergency department (p = . ). there was near-significance (p = . ) on the attribute of ''being able to make difficult decisions under pressure,'' which was rated higher in the pre-op clinic. there was no difference for any of the other questions. the top four professional attributes at each clinical site were the same -''honesty,'' ''excellence in communication and listening,'' ''taking full responsibility for mistakes,'' and ''technical competence/ skill;'' the bottom two were ''being an active leader in the community'' and ''patient concerns should come before a doctor's family commitments.'' conclusion: very few differences between clinical sites were found when surveying patient perception of the important elements of medical professionalism. this may suggests a core set of values desired by patients for physicians across specialties. emergency medicine faculty knowledge of and confidence in giving feedback on the acgme core competencies todd guth, jeff druck, jason hoppe, britney anderson university of colorado, aurora, co background: the acgme mandates that residency programs assess residents based upon six core competencies. although the core competencies have been in place for a number of years, many faculty are not familiar with the intricacies of the competencies and have difficulty giving competency-specific feedback to residents. objectives: the purpose of the study is to determine the extent to which emergency medicine (em) faculty can identify the acgme core competencies correctly and to determine faculty confidence with giving general feedback and core competency focused feedback to em residents. methods: design and participants: at a single department of em, a survey of twenty-eight faculty members, their knowledge of the acgme core competencies, and their confidence in providing feedback to residents was conducted. confidence levels in giving feedback were scored on a likert scale from to . observations: descriptive statistics of faculty confidence in giving feedback, identification of professional areas of interest, and identification of the acgme core competencies were determined. mann-whitney u tests were used to make comparisons between groups of faculty given the small sample size of the respondents. results: there was a % response rate of the faculty members surveyed. eight faculty members identified themselves as primarily focused on education. although those faculty members identifying themselves as focused on education scored higher than non-education focused faculty for all type of feedback (general feedback, constructive feedback, negative feedback), there was only a statistical difference in confidence levels . versus . (p < . ) for acgme core competency specific feedback when compared to noneducation focused faculty. while education focused faculty correctly identified all six of acgme core competencies % of the time, not one of the non-education focused faculty identified all six of the core competencies correctly. non-education focused faculty only correctly identified three or more competencies % of the time. conclusion: if residency programs are to assess residents using the six acgme core competencies, additional faculty development specific to the core competencies will be needed to train all faculty on the core competencies and on how to give core competency specific feedback to em residents. there is no clear consensus as to the most effective tool to measure resident competency in emergency ultrasound. objectives: to determine the relationship between the number of scans and scores on image recognition, image acquisition, and cognitive skills as measured by an objective structured clinical exam (osce) and written exam. secondarily, to determine whether image acquisition, image recognition, and cognitive knowledge require separate evaluation methodologies. methods: this was a prospective observational study in an urban level i ed with a -year acgme-accredited residency program. all residents underwent an ultrasound introductory course and a one-month ultrasound rotation during their first and second years. each resident received a written exam and osce to assess psychomotor and cognitive skills. the osce had two components: ( ) recognition of images, and ( ) acquisition of images. a registered diagnostic medical sonographer (rdms)-certified physician observed each bedside examination. a pre-existing residency ultrasound database was used to collect data about number of scans. pearson correlation coefficients were calculated for number of scans, written exam score, image recognition, and image acquisition scores on the osce. results: twenty-nine residents were enrolled from march to february who performed an average of scans (range - ). there was no significant correlation between number of scans and written exam scores. an analysis of the number of scans and the ocse found a moderate correlation with image acquisition (r = . , p = . ) and image recognition (r = . , p = < . )). pearson correlation analysis between the image acquisition score and image recognition score found that there was no correlation (r = . , p = . ). there was a moderate correlation with image acquisition scores to written scores (r = . , p = . ) and image recognition scores to written scores (r = . , p = . ). conclusion: the number of scans does not correlate with written tests but has a moderate correlation with image acquisition and image recognition. this suggests that resident education should include cognitive instruction in addition to scan numbers. we conclude that multiple methods are necessary to examine resident ultrasound competency. background: although emergency physicians must often make rapid decisions that incorporate their interpretation of an ecg, there is no evidence-based description of ecg interpretation competencies for emergency medicine (em) trainees. the first step in defining these competencies is to develop a prioritized list of ecg findings relevant to em contexts. objectives: the purpose of this study was to categorize the importance of various ecg diagnoses and/or findings for the em trainee. methods: we developed an extensive list of potentially important ecg diagnoses identified through a detailed review of the cardiology and em literature. we then conducted a three-round delphi expert opinion-soliciting process where participants used a five-point likert scale to rate the importance of each diagnosis for em trainees. consensus was defined as a minimum of percent agreement on any particular diagnosis at the second round or later. in the absence of consensus, stability was defined as a shift of percent or less after successive rounds. results: twenty-two em experts participated in the delphi process, sixteen ( %) of whom completed the process. of those, fifteen were experts from eleven different em training programs across canada and one was a recognized expert in em electrocardiography. overall, diagnoses reached consensus, achieved stability, and one diagnosis achieved neither consensus nor stability. out of potentially important ecg diagnoses, ( %) were considered ''must know'' diagnoses, ( %) ''should know'' diagnoses, and ( %) ''nice to know'' diagnoses. conclusion: we have categorized ecg diagnoses within an em training context, knowledge of which may allow clinical em teachers to establish educational priorities. this categorization will also facilitate the development of an educational framework to establish em trainee competency in ecg interpretation. ''rolling refreshers background: cardiac arrest survival rates are low despite advances in cardiopulmonary resuscitation. high quality cpr has been shown to impart greater cardiac arrest survival; however, retention of basic cpr skills by health care providers has been shown to be poor. objectives: to evaluate practitioner acceptance of an in-service cpr skills refresher program, and to assess for operator response to real-time feedback during refreshers. methods: we prospectively evaluated a ''rolling refresher'' in-service program at an academic medical center. this program is a proctored cpr practice session using a mannequin and cpr-sensing defibrillator that provides real-time cpr quality feedback. subjects were basic life support-trained providers who were engaged in clinical care at the time of enrollment. subjects were asked to perform two minutes of chest compressions (ccs) using the feedback system. ccs could be terminated when the subject had completed approximately seconds of compressions with < corrective prompts. a survey was then completed by to obtain feedback regarding the perceived efficacy of this training model. cpr quality was then evaluated using custom analysis software to determine the percent of cc adequacy in -second intervals. results: enrollment included subjects from the emergency department and critical care units ( nurses, physicians, students and allied health professionals). all participants completed a survey and cpr performance data logs were obtained. positive impressions of the in-service program were registered by % ( / ) and % ( / ) reported a self-perceived improvement in skills confidence. eighty-three percent ( / ) of respondents felt comfortable performing this refresher during a clinical shift. thirtynine percent ( / ) of episodes exhibited adequate cc performance with approximately seconds of cc. of the remaining episodes, . ± . % of cc were adequate in the first seconds with . ± . % of cc adequate during the last second interval (p = . ). of these individuals, improved or had no change in their cpr skills, and individuals skills declined during cc performance (p = . ). conclusion: implementation of a bedside cpr skill refresher program is feasible and is well received by hospital staff. real time cpr feedback improved upon cpr skill performance during the in-service session. teaching emergency medicine skills: is a self-directed, independent, online curriculum the way of the future? tighe crombie, jason r. frank, stephen noseworthy, richard gerein, a. curtis lee university of ottawa, ottawa, on, canada background: procedural competence is critical to emergency medicine, but the ideal instructional method to acquire these skills is not clear. previous studies have demonstrated that online tutorials have the potential to be as effective as didactic sessions at teaching specific procedural skills. objectives: we studied whether a novel online curriculum teaching pediatric intraosseus (io) line insertion to novice learners is as effective as a traditional classroom curriculum in imparting procedural competence. methods: we conducted a randomized controlled educational trial of two methods of teaching io skills. preclinical medical students with no past io experience completed a written test and were randomized to either an online or classroom curriculum. the online group (og) were given password-protected access to a website and instructed to spend minutes with the material while the didactic group (dg) attended a lecture of similar duration. participants then attended a -minute unsupervised manikin practice session on a separate day without any further instruction. a videotaped objective structured clinical examination (osce) and post-course written test were completed immediately following this practice session. finally, participants were crossed over into the alternate curriculum and were asked to complete a satisfaction survey that compared the two curricula. results were compared with a paired t-test for written scores and an independent t-test for osce scores. results: sixteen students completed the study. pre-course test scores of the two groups were not significantly different prior to accessing their respective curricula (mean scores of % for og and % for dg, respectively; p > . ). post-course written scores were also not significantly different (both with means of %; p > . ); however, for the post-treatment osce scores, the og group scored significantly higher than the dg group (mean scores of . % and . %; t( ) = . , p < . .) conclusion: this novel online curriculum was superior to a traditional didactic approach to teaching pediatric io line insertion. novice learners assigned to a selfdirected online curriculum were able to perform an emergency procedural skill to a high level of performance. em educators should consider adopting online teaching of procedural skills. background: applicants to em residency programs obtain information largely from the internet. curricular information is available from a program's website (pw) or the saem residency directory (sd). we hypothesize that there is variation between these key sources. objectives: to identify discrepancies between each pw and sd. to describe components of pgy - em residency programs' curricula as advertised on the internet. methods: pgy - residencies were identified through the sd. data were abstracted from individual sd and pw pages identifying pre-determined elements of interest regarding rotations in icu, pediatrics, inpatient (medicine, pediatrics, general surgery), electives, orthopedics, toxicology, and anesthesia. agreement between the sd and pw was calculated using a cohen's unweighted kappa calculation. curricula posted on pws were considered the gold standard for the programs' current curricula. results: a total of pgy - programs were identified through the sd and confirmed on the pw. ninetyone of programs ( %) had complete curricular information on both sites. only these programs were included in the kappa analysis for sd and pw comparisons. of programs with complete listings, of programs ( %) had at least one discrepancy. the agreement of information between pw and sd revealed a kappa value of . ( % ci . - . ). analysis of pw revealed that pgy - programs have an average of . (range, - ), . (range, - ), . (range, - ), and . (range, - ) blocks of icu, pediatrics, elective, and inpatient, respectively. common but not rrc-mandated rotations in orthopedics, toxicology, and anesthesiology are present in , , and percent of programs, respectively. conclusion: publicly accessible curricular information through the sd and pw for pgy - em programs only has fair agreement (using commonly accepted kappa value guides). applicants may be confused by the variability of data and draw inaccurate conclusions about program curricula. from the gravid uterus and improves cardiac output; however, this theory has never been proven. objectives: we set out to determine the difference in inferior vena cava (ivc) filling when third trimester patients were placed in supine, llt, and right lateral tilt (rlt) positions using ivc ultrasound. methods: healthy pregnant women in their third trimester presenting to the labor and delivery suite were enrolled. patients were placed in three different positions (supine, rlt, and llt) and ivc maximum (max) and minimum (min) measurements were obtained using the intercostal window in short axis approximately two centimeters below the entry of the hepatic veins. ivc collapse index (ci) was calculated for each measurement using the formula (max-min)/max. in addition, blood pressure, heart rate, and fetal heart rate were monitored. patients stayed in each position for at least minutes prior to taking measurements. we compared ivc measurements using a one-way analysis of variance for repeated measures. results: twenty patients were enrolled. the average age was years (sd . ) with a mean estimated gestational age of . weeks (sd . ). there were no significant differences seen in ivc filling in each of the positions (see table ). in addition, there were no differences in hemodynamic parameters between positions.ten ( %) patients had the largest ivc measurement in the llt position, ( %) patients in the rlt position, and ( %) in the supine position. conclusion: there were no significant differences in ivc filling between patient positions. for some third trimester patients llt may not be the optimal position for ivc filling. background: although the acgme and rrc require competency assessment in ed bedside ultrasound (us), there are no standardized assessment tools for us training in em. objectives: using published us guidelines, we developed four observed structured competency evalua-tions (osce) for four common em us exams: fast, aortic, cardiac, and pelvic. inter-rater reliability was calculated for overall performance and for the individual components of each osce. methods: this prospective observational study derived four osces that evaluated overall study competency, image quality for each required view, technical factors (probe placement, orientation, angle, gain, and depth), and identification of key anatomic structures. em residents with varying levels of training completed an osce under direct observation of two em-trained us experts. each expert was blinded to the other's assessment. overall study competency and image quality of each required views were rated on a five-point scale ( poor, -fair, -adequate, -good, -excellent), with explicit definitions for each rating. each study had technical factors (correct/incorrect) and anatomic structures (identified/not identified) assessed as binary variables. data were analyzed using cohen's and weighted k, descriptive statistics, and % ci. results: a total of us exams were observed, including fast, cardiac, aorta, and pelvic. total assessments included ratings of overall study competency, ratings of required view image quality, ratings of technical factors, and ratings of anatomic structures. inter-rater assessment of overall study competency showed excellent agreement, raw agreement . ( . , . ), weighted k . ( . , . ). ratings of required view image quality showed excellent agreement: raw agreement . ( . , . ), weighted k . ( . , . ). inter-rater assessment of technical factors showed substantial agreement: raw agreement . ( . , . ), cohen's k . ( . , . ). ratings of identification of anatomic structures showed substantial agreement: raw agreement . ( . , . ), cohen's k . ( . , . ). conclusion: inter-rater reliability is substantial to excellent using the derived ultrasound osces to rate em resident competency in fast, aortic, cardiac, and pelvic ultrasound. validation of this tool is ongoing. a objectives: the objective of this study was to identify which transducer orientation, longitudinal or transverse, is the best method of imaging the axillary vein with ultrasound, as defined by successful placement in the vein with one needle stick, no redirections, and no complications. methods: emergency medicine resident and attending physicians at an academic medical center were asked to cannulate the axillary vein in a torso phantom model. the participants were randomized to start with either the longitudinal or transverse approach and completed both sequentially, after viewing a teaching presentation. participants completed pre-and post-attempt questionnaires. measurements of each attempt were taken regarding time to completion, success, skin punctures, needle redirections, and complications. we compared proportions using a normal binomial approximation and continuous data using the t-distribution, as appropriate. a sample size of was chosen based on the following assumptions: power, . ; significance, . ; effect size, % versus %. results: fifty-seven operators with a median experience of prior ultrasounds ( to iqr) participated. first-attempt success frequency was / ( . ) for the longitudinal method and / ( . ) for the transverse method (difference . , % ci . - . ); this difference was similar regardless of operator experience. the longitudinal method had fewer redirections (mean difference . , % ci . - . ) and skin punctures (mean difference . , % ci ) to . ). arterial puncture occurred in / longitudinal attempts and / transverse attempts, with no pleural punctures in either group. among successful attempts, the time spent was seconds less for longitudinal method ( % ci - ). though % of participants had more experience with the transverse method prior to the training session, % indicated after the session that they preferred the longitudinal method. methods: a prospective single-center study was conducted to assess the compressibility of the basilic vein with ultrasound. healthy study participants were recruited. the compressibility was assessed at baseline, and then further assessed with one proximal tourniquet, two tourniquets (one distal and one proximal), and a proximal blood pressure cuff inflated to mmhg. compressibility was defined as the vessel's resistance to collapse to external pressure and rated as completely compressible, moderately compressible, or mildly compressible after mild pressure was applied with the ultrasound probe. results: one-hundred patients were recruited into the study. ninety-eight subjects were found to have a completely compressible basilic vein at baseline. when one tourniquet and two tourniquets were applied and participants, respectively, continued to have completely compressible veins. a fisher's exact test comparing one versus two tourniquets revealed no difference between these two techniques (p = . ). only two participants continued to have completely compressible veins following application of the blood pressure cuff. the compressibility of this group was found to be statistically significant by fisher's exact test compared to both tourniquet groups (p < . ). furthermore, participants with the blood pressure cuff applied were found to have moderately compressible veins and participants were found to have mildly compressible veins. conclusion: tourniquets and blood pressure cuffs can both decrease the compressibility of peripheral veins. while there was no difference identified between using one and two tourniquets, utilization of a blood pressure cuff was significantly more effective to decrease compressibility. the findings of this study may be utilized in the emergency department when attempting to obtain peripheral venous access, specifically supporting the use of blood pressure cuffs to decrease compressibility. background: electroencephalography (eeg) is an underused test that can provide valuable information in the evaluation of emergency department (ed) patients with altered mental status (ams). in ams patients with nonconvulsive seizure (ncs), eeg is necessary to make the diagnosis and to initiate proper treatment. yet, most cases of ncs are diagnosed > h after ed presentation. obstacles to routine use of eeg in the ed include space limitations, absence of / availability of eeg technologists and interpreters, and the electrically hostile ed environment. a novel miniature portable wireless device (microeeg) is designed to overcome these obstacles. objectives: to examine the diagnostic utility of micro-eeg in identifying eeg abnormalities in ed patients with ams. methods: an ongoing prospective study conducted at two academic urban eds. inclusion: patients ‡ years old with ams. exclusion: an easily correctable cause of ams (e.g. hypoglycemia, opioid overdose). three -minute eegs were obtained in random order from each subject beginning within one hour of presentation: ) a standard eeg, ) a microeeg obtained simultaneously with conventional cup electrodes using a signal splitter, and ) a microeeg using an electrocap. outcome: operative characteristics of micro-eeg in identifying any eeg abnormality. all eegs were interpreted in a blinded fashion by two board-certified epileptologists. within each reader-patient pairing, the accuracy of eegs and were each assessed relative to eeg . sensitivity, specificity, and likelihood ratios (lr) are reported for microeeg by standard electrodes and electrocap (eegs and ). inter-rater variability for eeg interpretations is reported with kappa. results: the interim analysis was performed on consecutive patients (target sample size: ) enrolled from may to october (median age: , range: - , % male). overall, % ( % confidence interval [ci], - %) of interpretations were abnormal (based on eeg ). kappa values representing the agreement of neurologists in interpretation of eeg - were . ( . - . ), . ( . - . ), and . ( . - . ), respectively. conclusion: the diagnostic accuracy and concordance of microeeg are comparable to those of standard eeg but the unique ed-friendly characteristics of the device could help overcome the existing barriers for more frequent use of eeg in the ed. (originally submitted as a ''late-breaker.'') a background: patients who use an ed for acute migraine are characterized by higher migraine disability scores, lower socio-economic status, and are unlikely to have used a migraine-specific medication prior to ed presentation. objectives: to determine if a comprehensive migraine intervention, delivered just prior to ed discharge, could improve migraine impact scores one month after the ed visit. methods: this was a randomized controlled trial of a comprehensive migraine intervention versus typical care among patients who presented to an ed for management of acute migraine. at the time of discharge, for patients randomized to comprehensive care, we reinforced their diagnosis, shared a migraine education presentation from the national library of medicine, provided them with six tablets of sumatriptan mg and tablets of naproxen mg, and if they wished, provided them with an expedited free appointment to our institution's headache clinic. patients randomized to typical care received the care their attending emergency physician felt was appropriate. the primary outcome was a between-group comparison of the hit score, a validated headache assessment instrument, one month after ed discharge. secondary outcomes included an assessment of satisfaction with headache care and frequency of use of migraine-specific medication within that one month period. the outcome assessor was blinded to assignment. results: over a month period, migraine patients were enrolled. one month follow-up was successfully obtained in % of patients. baseline characteristics were comparable. one month hit scores in the two groups were nearly identical ( vs , %ci for difference of : ) , ), as was dissatisfaction with overall headache care ( % versus %, %ci for difference of %: ) , %). not surprisingly, patients randomized to the comprehensive intervention were more likely to be using triptans or migraine-preventive therapy ( % versus %, %ci for difference of %: , %) one month later. conclusion: a comprehensive migraine intervention, when compared to typical care, did not improve hit scores one month after ed discharge. future work is needed to define a migraine intervention that is practical and useful in an ed. background: lumbar puncture (lp) is the standard of care for excluding non-traumatic subarachnoid hemorrhage (sah), and is usually performed following head ct (hct). however, in the setting of a non-diagnostic hct, lp demonstrates a low overall diagnostic yield for sah (< % positive rate). objectives: to describe a series of ed patients diagnosed with sah by lp following a non-diagnostic hct, and, when compared to a set of matched controls, determine if clinical variables can reliably identify these ''ct-negative/lp-positive'' patients. methods: retrospective case-control chart review of ed patients in an integrated health system between the years - (estimated - million visits among eds). patients with a final diagnosis of non-traumatic sah were screened for case inclusion, defined as an initial hct without sah by final radiologist interpretation and a lp with > red blood cells/mm , along with either ) xanthochromic cerebrospinal fluid, ) angiographic evidence of cerebral aneurysm or arteriovenous malformation, or ) head imaging showing sah within hours following lp. control patients were randomly selected among ed patients diagnosed with headache following a negative sah evaluation with hct and lp. controls were matched to cases by year and presenting ed in a : ratio. stepwise logistic regression and classification and regression tree analysis (cart) were employed to identify predictive variables. inter-rater reliability (kappa) was determined by independent chart review. results: fifty-five cases were identified. all cases were hunt-hess grade or . demographics are shown in table . thirty-four cases ( %) had angiographic evidence of sah. five variables were identified that positively predicted sah following a normal hct with % sensitivity ( % ci, - %) and % specificity ( % ci, - %): age > years, neck pain or stiffness, onset of headache with exertion, vomiting with headache, or loss of consciousness at headache onset. kappa values for selected variables ranged from . - . ( % sample). the c-statistic (auc) and hosmer-lemeshow test p-value for the logistic regression model are . and . , respectively (table ) . conclusion: several clinical variables can help safely limit the amount of invasive testing for sah following a non-diagnostic hct. prospective validation of this model is needed prior to practice implementation. background: post-thrombolysis intracerebral hemorrhage (ich) is associated with poor outcomes. previous investigations have attempted to determine the relationship between pre-existing anti-platelet (ap) use and the safety of intravenous thrombolysis, but have been limited by low event rates thus decreasing the precision of estimates. objectives: our objective was to determine whether pre-existing ap therapy increases the risk of ich following thrombolysis. methods: consecutive cases of ed-treated thrombolysis patients were identified using multiple methods, including active and passive surveillance. retrospective data were collected from four hospitals from - , and distinct hospitals from - as part of a cluster randomized trial. the same chart abstraction tool was used during both time periods and data were subjected to numerous quality control checks. hemorrhages were classified using a pre-specified methodology: ich was defined as presence of hemorrhage in radiographic interpretations of follow up imaging (primary outcome). symptomatic ich (secondary outcome) was defined as radiographic ich with associated clinical worsening. a multivariable logistic regression model was constructed to adjust for clinical factors previously identified to be related to postthrombolysis ich. as there were fewer sich events, the multivariable model was constructed similarly, except that variables divided into quartiles in the primary analysis were dichotomized at the median. results: there were patients included, with % having documented pre-existing ap treatment. the mean age was years, the cohort was % male, and the median nihss was . the unadjusted proportion of patients with any ich was . % without ap and . % with ap (difference . %, % ci ) . % to . %); for sich this was . % without ap and % with ap (difference . %, %ci ) to . %). no significant association between pre-existing ap treatment with radiographic or symptomatic ich was observed (table) . conclusion: we did not find that ap treatment was associated with post-thrombolysis ich or sich in this cohort of community treated patients. pre-existing tobacco use, younger age, and lower severity were associated with lower odds of sich. an association between ap therapy and sich may still exist -further research with larger sample sizes is warranted in order to detect smaller effect sizes. background: post-cardiac arrest therapeutic hypothermia (th) improves survival and neurologic outcome after cardiac arrest, but the parameters required for optimal neuroprotection remain uncertain. our laboratory recently reported that -hour th was superior to -hour th in protecting hippocampal ca pyramidal neurons after asphyxial cardiac arrest in rats. cerebellar purkinje cells are also highly sensitive to ischemic injury caused by cardiac arrest, but the effect of th on this neuron population has not been previously studied. objectives: we examined the effect of post-cardiac arrest th onset time and duration on purkinje neuron survival in cerebella collected during our previous study. methods: adult male long evans rats were subjected to -minute asphyxial cardiac arrest followed by cpr. rats that achieved return of spontaneous circulation (rosc) were block randomized to normothermia ( . deg c) or th ( . deg c) initiated , , , or hours after rosc and maintained for or hours (n = per group). sham injured rats underwent anesthesia and instrumentation only. seven days post-cardiac arrest or sham injury, rats were euthanized and brain tissue was processed for histology. surviving purkinje cells with normal morphology were quantified in the primary fissure in nissl stained sagittal sections of the cerebellar vermis. purkinje cell density was calculated for each rat, and group means were compared by anova with bonferroni analysis. results: purkinje cell density averaged (+/) sd) . ( . ) cells/mm in sham-injured rats. neuronal survival in normothermic post-cardiac arrest rats was significantly reduced compared to sham ( . % ( . %)). overall, th resulted in significant neuroprotection compared to normothermia ( . % ( . %) of sham). purkinje cell density with -hour duration th was . % ( . %) of sham and -hour duration th was . % ( . %), both significantly improved from sham (p = . between durations). th initiated , , , and hours post-rosc provided similar benefit: . % ( . %), . % ( . %), . % ( . %), and . % ( . %) of sham, respectively. conclusion: overall, these results indicate that postcardiac arrest th protects cerebellar purkinje cells with a broad therapeutic window. our results underscore the importance of considering multiple brain regions when optimizing the neuroprotective effect of post-cardiac arrest th. the effect of compressor-administered defibrillation on peri-shock pauses in a simulated cardiac arrest scenario joshua glick, evan leibner, thomas terndrup penn state hershey medical center, hershey, pa background: longer pauses in chest compressions during cardiac arrest are associated with a decreased probability of successful defibrillation and patient survival. having multiple personnel share the tasks of performing chest compressions and shock delivery can lead to communication complications that may prolong time spent off the chest. objectives: the purpose of this study was to determine whether compressor-administered defibrillation led to a decrease in pre-shock and peri-shock pauses as compared to bystander-administered defibrillation in a simulated in-hospital cardiac arrest scenario. we hypothesized that combining the responsibilities of shock delivery and chest-compression performance may lower no-flow periods. methods: this was a randomized, controlled study measuring pauses in chest compressions for defibrillation in a simulated cardiac arrest. medical students and ed personnel with current cpr certification were surveyed for participation between july and october . participants were randomized to either a control (facilitator-administered shock) or variable (participantadministered shock) group. all participants completed one minute of chest compressions on a mannequin in a shockable rhythm prior to initiation of prompt and safe defibrillation. pauses for defibrillation were measured and compared in both study groups. results: out of total enrollments, the data from defibrillations were analyzed. subject-initiated defibrillation resulted in a significantly lower pre-shock handsoff time ( . s; % ci: . - . ) compared to facilitator-initiated defibrillation ( . s; % ci: . - . ). furthermore, subject-initiated defibrillation resulted in a significantly lower peri-shock hands-off time ( . s; % ci: . - . ) compared to facilitator-initiated defibrillation ( . s; % ci: . - . ). conclusion: assigning the responsibility for shock delivery to the provider performing compressions encourages continuous compressions throughout the charging period and decreases total time spent off the chest. this modification may also decrease the risk of accidental shock and improve patient survival. however, as this was a simulation-based study, clinical implementation is necessary to further evaluate these potential benefits. objectives: to determine the sensitivity and specificity of peripheral venous oxygen (po ) to predict abnormal central venous oxygen saturation in septic shock patients in the ed. methods: secondary analysis of an ed-based randomized controlled trial of early sepsis resuscitation targeting three physiological variables: cvp, map, and either scvo or lactate clearance. inclusion criteria: suspected infection, two or more sirs criteria, and either systolic blood pressure < mmhg after a fluid bolus or lactate > mm. peripheral venous po was measured prior to enrollment as part of routine care, and scvo was measured as part of the protocol. we analyzed for agreement between venous po and scvo using spearman's rank. sensitivity and specificity to predict an abnormal scvo (< %) were calculated for each incremental value of po . results: a total of were analyzed. median po was mmhg (iqr , ). median initial scvo was % (iqr , ). thirty-nine patients ( %) had an initial scvo < %. spearman's rank demonstrated fair correlation between initial po and scvo (q = . ). a cutoff of venous po < was % sensitive and % specific for detecting an initial scvo < %. twenty-seven patients ( %) demonstrated an initial po of > . conclusion: in ed septic shock patients, venous po demonstrated only fair correlation with scvo , though a cutoff value of was sensitive for predicting an abnormal scvo . twenty percent of patients demonstrated an initial value above the cutoff, potentially representing a group in whom scvo measurement could be avoided. future studies aiming to decrease central line utilization could consider the use of peripheral o measurements in these patients. sessions. ninety-two percent were rns, median clinical experience was - years, and % were from an intensive care unit. provider confidence increased significantly with a single session despite the highly experienced sample (figure ). there was a trend for further increased confidence with an additional session and the increased confidence was maintained for at least - months given the normal sensitivity analysis. conclusion: high fidelity simulation significantly increases provider confidence even among experienced providers. this study was limited by its small sample size and recent changes in acls guidelines. background: recent data suggest alarming delays and deviations in major components of pediatric resuscitation during simulated scenarios by pediatric housestaff. objectives: to identify the most common errors of pediatric residents during multiple simulated pediatric resuscitation scenarios. methods: a retrospective observational study conducted in an academic tertiary care hospital. pediatric residents (pgy and pgy ) were videotaped performing a series of five pediatric resuscitation scenarios using a high-fidelity simulator (simbaby, laerdal): pulseless non-shockable arrest, pulseless shockable arrest, dysrhythmia, respiratory arrest, and shock. the primary outcome was the presence of significant errors prospectively defined using a validated scoring instrument designed to assess sequence, timing, and quality of specific actions during resuscitations based on the aha pals guidelines. residents' clinical performances were measured by a single video reviewer. the primary analysis was the proportion of errors for each critical task for each scenario. we estimated that the evaluation of each resident would provide a confidence interval less than . for the proportion of errors. results: twenty-four of residents completed the study. across all scenarios, pulse check was delayed by more than seconds in % ( %ci: %- %). for non-shockable arrest, cpr was started more than seconds after recognizing arrest in % ( %ci - %) and inappropriate defibrillation was performed in % ( %ci - %). for shockable arrest, participants failed to identify the rhythm in % ( %ci - %), cpr was not performed in % ( %ci - %), while defibrillation was delayed by more than seconds in % ( %ci - %) and not performed in one case. for shock, participants failed to ask for a dextrose check in % ( %ci - %), and it was delayed by more than seconds for all others. conclusion: the most common error across all scenarios was delay in pulse check. delays in starting cpr and inappropriate defibrillation were common errors in non-shockable arrests, while failure to identify rhythm, cpr omission, and delaying defibrillation were noted for shockable arrests. for shock, omission of rapid dextrose check was the most common error, while delaying the test when ordered was also significant. future training in pediatric resuscitation should target these errors. background: many scoring instruments have been described to measure clinical performance during resuscitation; however, the validity of these tools has yet to be proven in pediatric resuscitation. objectives: to determine the external validity of published scoring instruments to evaluate clinical performance during simulated pediatric resuscitations using pals algorithms and to determine if inter-rater reliability could be assessed. methods: this was a prospective quasi-experimental design performed in a simulation lab of a pediatric tertiary care facility. participants were residents from a single pediatric program distinct from where the instrument was originally developed. a total of pgy s and pgy s were videotaped during five simulated pediatric resuscitation scenarios. pediatric emergency physicians rated resident performances before and after a pals course using standardized scoring. each video recording was viewed and scored by two raters blinded to one another. a priori, it was determined that, for the scoring instrument to be valid, participants should improve their scores after participating in the pals course. differences in means between pre-pals and post-pals and pgy and pgy were compared using an anova test. to investigate differences in the scores of the two groups over the five scenarios, a two-factor anova was used. reliability was assessed by calculating an interclass correlation coefficient for each scenario. results: following the pals course, scores improved by . % ( . to . ), . % ( . to . ), . % () . to . ), . % ( . to ), and . % () . to . ) for the pulseless non-shockable arrest, pulseless shockable arrest, dysrhythmia, respiratory, and shock scenarios respectively. there were no differences in scores between pgy s and pgy s before and after the pals course. there was an excellent reliability for each scoring instrument with iccs varying between . and . . conclusion: the scoring instrument was able to demonstrate significant improvements in scores following a pals course for pgy and pgy pediatric residents for the pulseless non-shockable arrest, pulseless shockable, and respiratory arrest scenarios only. however, it was unable to discriminate between pgy s and pgy s both before and after the pals course for any scenarios. the scoring instrument showed excellent inter-reliability for all scenarios. a background: medical simulation is a common and frequently studied component of emergency medicine (em) residency curricula. its utility in the context of em medical student clerkships is not well defined. objectives: the objective was to measure the effect of simulation instruction on medical students' em clerkship oral exam performance. we hypothesized that students randomized to the simulation group would score higher. we predicted that simulation instruction would promote better clinical reasoning skills and knowledge expression. methods: this was a randomized observational study conducted from / to / . participants were fourth year medical students in their em clerkship. students were randomly assigned on their first day to one of two groups. the study group received simulation instruction in place of one of the lectures, while the control group was assigned to the standard curriculum. the standard clerkship curriculum includes lectures, case studies, procedure labs, and clinical shifts without simulation. at the end of the clerkship, all students participated in written and oral exams. graders were not blinded to group allocation. grades were assigned based on a pre-defined set of criteria. the final course composite score was computed based on clinical evaluations and the results of both written and oral exams. oral exam scores between the groups were compared using a two-sample t-test. we used the spearman rank correlation to measure the association between group assignment and the overall course grade. the study was approved by our institutional irb. results: sixty-one students participated in the study and were randomly assigned to one of two groups. twenty-nine ( . %) were assigned to simulation and the remaining ( . %) students were assigned to the standard curriculum. students assigned to the simulation group scored . % ( % ci . - . %) higher on the oral exam than the non-simulation group. additionally, simulation was associated with a higher final course grade (p < . ). limitations of this pilot study include lack of blinding and interexaminer variability. conclusion: simulation training as part of an em clerkship is associated with higher oral exam scores and higher overall course grade compared to the standard curriculum. the results from this pilot study are encouraging and support a larger, more rigorous study. initial approaches to common complaints are taught using a standard curriculum of lecture and small group case-based discussion. we added a simulation exercise to the traditional altered mental status (ams) curriculum with the hypothesis that this would positively affect student knowledge, attitudes, and level of clinical confidence caring for patients with ams. methods: ams simulation sessions were conducted in june and ; student participation was voluntary. the simulation exercises included two ams cases using a full-body simulator and a faculty debriefing after each case. both students who did and did not participate in the simulations completed a written post-test and a survey related to confidence in their approach to ams. results: students completed the post-test and survey. ( %) attended the simulation session. ( %) attended all three sessions. ( %) participated in the lecture and small group. ( %) did not attend any session. post-test scores were higher in students who attended the simulations versus those who did not: (iqr, - ) vs. (iqr, - ); p < . . students who attended the simulations felt more confident about assessing an ams patient ( % vs. %; p = . ), articulating a differential diagnosis ( % vs. %; p = . ), and knowing initial diagnostic tests ( % vs. %; p = . ) and initial interventions ( % vs. %; p = . ) for an ams patient. students who attended the simulations were more likely to rate the overall ams curriculum as useful ( % vs. %; p < . ). conclusion: addition of a simulation session to a standard ams curriculum had a positive effect on student performance on a knowledge-based exam and increased confidence in clinical approach. the study's major limitations were that student participation in the simulation exercise was voluntary and that effect on applied skills was not measured. future research will determine whether simulation is effective for other chief complaints and if it improves actual clinical performance. background: the acgme has defined six core competencies for residents including ''professionalism'' and ''interpersonal and communication skills.'' integral to these two competencies is empathy. prior studies suggest that self-reported empathy declines during medical training; no reported study has yet integrated simulation into the evaluation of empathy in medical training. objectives: to determine if there is a relation between level of training and empathy in patient interactions as rated during simulation. methods: this is a prospective observational study at a tertiary care center comparing participants at four different levels of training: first (ms ) and third year (ms ) medical students, incoming em interns (pgy ), and em senior residents (pgy / ). trainees participated in two simulation scenarios (ectopic pregnancy and status asthmaticus) in which they were responsible for clinical management (cm) and patient interactions (pi). this was the first simulation exposure during an established simulation curriculum for ms , ms , and pgy . two independent raters reviewed videotaped simulation scenarios using checklists of critical actions for clinical management (cm: - points) and patient interactions (pi: - points). inter-rater reliability was assessed by intra-class correlation coefficients (iccs objectives: we explored attitudes and beliefs about the handoff, using qualitative methods, from a diverse group of stakeholders within the ems community. we also characterized perceptions of barriers to high-quality handoffs and identified strategies for optimizing this process. methods: we conducted seven focus groups at three separate gatherings of ems professionals (one local, two national) in / . snowball sampling was used to recruit participants with diverse professional, experiential, geographic, and demographic characteristics. focus groups, lasting - minutes, were moderated by investigators trained in qualitative methods, using an interview guide to elicit conversation. recordings of each group were transcribed. three reviewers analyzed the text in a multi-stage iterative process to code the data, describe the main categories, and identify unifying themes. results: participants included emts, paramedics, physicians, and nurses. clinical experience ranged from months to years. recurrent thematic domains when discussing attitudes and beliefs were: perceptions of respect and competence, professionalism, teamwork, value assigned to the process, and professional duty. modifiers of these domains were: hierarchy, skill/training level, severity/type of patient illness, and system/ regulatory factors. strategies to improving barriers to the handoff included: fostering familiarity and personal connections between ems and ed staff, encouraging two-way conversations, feedback, and direct interactions between ems providers and ed physicians, and optimizing ways for ems providers to share subjective impressions (beyond standardized data elements) with hospital-based care teams. conclusion: ems professionals assign high value to the ed handoff. variations in patient acuity, familiarity with other handoff participants, and perceptions of respect and professionalism appear to influence the perceived quality of this transition. regulatory strategies to standardize the contents of the handoff may not alone overcome barriers to this process. miology, public health) then developed an approach to assign ems records to one of symptom-based illness categories (gastrointestinal illness, respiratory, etc). ems encounter records were characterized into these illness categories using a novel text analytic program. event alerts were identified across the state and local regions in illness categories using either change detection from baseline with (cusum) analysis (three standard deviations) and a novel text-proportion (tap) analysis approach (sas institute, cary, nc). results: . million ems encounter records over a year period were analyzed. the initial analysis focused upon gastrointestinal illness (gi) given the potential relationship of gi distress to infectious outbreaks, food contamination and intentional poisonings (ricin). after accounting for seasonality, a significant gi event was detected in feb (see red circle on graph). this event coincided with a confirmed norovirus outbreak. the use of cusum approach (yellow circle on graph) detected the alert event on jan , . the novel tap approach on a regional basis detected the alert on dec , . conclusion: ems has the advantage of being an early point of contact with patients and providing information on the location of insult or injury. surveillance based on ems information system data can detect emergent outbreaks of illness of interest to public health. a novel text proportion analytic technique shows promise as an early event detection method. assessing chronic stress in the emergency medical services elizabeth a. donnelly , jill chonody university of windsor, windsor, on, canada; university of south australia, adelaide, australia background: attention has been paid to the effect of critical incident stress in the emergency medical services (ems); however, less attention has been given to the effect of chronic stress (e.g., conflict with administration or colleagues, risk of injury, fatigue, interference in non-work activities) in ems. a number of extant instruments assess for workplace stress; however, none address the idiosyncratic aspects of work in ems. objectives: the purpose of this study was to validate an instrument, adapted from mccreary and thompson ( ) , that assesses levels of both organizational and operational work-related chronic stress in ems personnel. methods: to validate this instrument, a cross-sectional, observational web-based survey was used. the instrument was distributed to a systematic probability sample of emts and paramedics (n = , ). the survey also included the perceived stress scale (cohen, ) to assess for convergent construct validity. results: the survey attained a . % usable response rate (n = ); respondent characteristics were consistent across demographic characteristics with other studies of emts and paramedics. the sample was split in order to allow for exploratory and confirmatory fac-tor analyses (n = /n = ). in the exploratory factor analysis, principal axis factoring with an oblique rotation revealed a two-factor, -item solution (kmo = . , v = . , df = , p £. ). confirmatory factor analysis suggested a more parsimonious, two-factor, -item solution (v = . , df = , p £ . , rmsea = . , cfi = . , tli = . , srmr = . ). the factors demonstrated good internal reliability (operational stress a = . , organizational stress a = . ). both factors were significantly correlated (p £ . ) with the hypothesized convergent validity measure. conclusion: theory and empirical research indicate that exposure to chronic workplace stress may play an important part in the development of psychological distress, including burnout, depression, and posttraumatic stress disorder (ptsd). workplace stress and stress reactions may potentially interfere with job performance. as no extant measure assesses for chronic workplace stress in ems, the validation of this chronic stress measure enhances the tools ems leaders and researchers have in assessing the health and well-being of ems providers. effect of naltrexone background: survivors of sarin and other organophosphate poisoning can develop delayed encephalopathy that is not prevented by standard antidotal therapy with atropine and pralidoxime. a rat model of poisoning with the sarin analogue diisoprophylfluorophosphate (dfp) demonstrated impairment of spatial memory despite antidotal therapy with atropine and pralidoxime. additional antidotes are needed after acute poisonings that will prevent the development of encephalopathy. objectives: to determine the efficacy of naltrexone in preventing delayed encephalopathy after poisoning with the sarin analogue dfp in a rat model. the hypothesis is that naltrexone would improve performance on spatial memory after acute dfp poisoning. the sarin analogue dfp was used because it has similar toxicity to sarin while being less dangerous to handle. methods: a randomized controlled experiment at a university animal research laboratory of the effects of naltrexone on spatial memory after dfp poisoning was conducted. long evans rats weighing - grams were randomized to dfp group (n = , rats received a single intraperitoneal (ip) injection of dfp mg/kg) or dfp+naltrexone group (n = , rats received a single ip injection of dfp ( mg/kg) followed by naltrexone mg/kg/day). after injection, rats were monitored for signs and symptoms of cholinesterase toxicity. if toxicity developed, antidotal therapy was initiated with atro-background: one of the primary goals of management of patients presenting with known or suspected acetaminophen (apap) ingestion is to identify the risk for apap-induced hepatotoxicity. current practice is to measure apap level at a minimum of hours post ingestion and plot this value on the rumack-matthew nomogram. one retrospective study of apap levels drawn less than hours post-ingestion found a level less than mcg/ml to be sufficient to exclude toxic ingestion. objectives: the aim of this study was to prospectively determine the negative predictive value (npv) for toxicity of an apap level of less than mcg/ml obtained less than hours post-ingestion. methods: this was a multicenter prospective cohort study of patients presenting to one of five tertiary care hospitals that are part of the toxicology investigator's consortium (toxic). eligible patients presented to the emergency department less than hours after known or suspected ingestion and had the initial apap level obtained at greater than but less than hours post ingestion. a second apap level was obtained at hours or more post-ingestion and plotted on the rumack-matthew nomogram to determine risk of toxicity. the outcome of interest was the npv of an initial apap level less than mcg/ml. a power analysis based on an alpha = . and power of . yielded the requirement of subjects. results: data were collected on patients over a month period from may to nov . patients excluded from npv analysis consisted of: initial apap level greater than mcg/ml ( ), negligible apap level on both the initial and confirmatory apap level ( ), initial apap level drawn less than one hour after ingestion ( ), or an unknown time of ingestion ( ). ninety-three patients met the eligibility criteria. two patients ( . %) with an initial apap level less than mcg/ml ( mcg/ml at min, mcg/ml at min) were determined to be at risk for toxicity based on oh s saem annual meeting abstracts implementation of an emergency department sign-out checklist improves patient hand-offs at change of shift nicole m ma computer-assisted self-interviews improve testing for chlamydia and gonorrhea in the pediatric emergency department is the australian triage system a better indicator of psychiatric patients' needs for intervention than the ena emergency severity index triage system? patients were given an initial dose of mg droperidol intramuscularly followed by an additional dose of mg after min if required. inclusion criteria were patients requiring physical restraint and parenteral sedation. the primary outcome was the time to sedation. secondary outcomes were the proportion of patients requiring additional sedation within the first hour, over-sedation measured as - on the sedation assessment tool, and respiratory compromise measured as oxygen saturation < %. results: droperidol was administered to patients and of these had sedation scores documented. presentations included % with alcohol intoxication. dose ranged from . mg to mg, median mg (interquartile range conclusion: droperidol is effective for rapid sedation for abd and rarely causes over-sedation serum creatinine (scr) is widely used to predict risk; however, gfr is a better assessment of kidney function. objectives: to compare the ability of gfr and scr to predict the development of cin among ed patients receiving cects. we hypothesized that gfr would be the best available predictor of cin. methods: this was a retrospective chart review of ed patients ‡ years old who had a chest or abdomen/pelvis cect between / / and / / . baseline and follow-up scr levels were recorded. patients with initial scr > . mg/dl were excluded, as per hospital radiology department protocol. cin was defined as a scr increase of either %, . mg/dl, or a gfr decrease of % within hours of contrast exposure. gfr was calculated using the ckd epi and mdrd formulae, and analyzed in original units and categorized form (< , ‡ ) with each additional unit decrease in ckd epi, subjects were % more likely to develop cin (or = . ) (p < . ). additionally, subjects with ckd epi < were . (or) times more likely to have cin than subjects with ckd epi ‡ in original units, ckd epi (p < . ) and mdrd (p < . ) both had a significantly higher auc than scr. conclusion: age, as an independent variable, is the best predictor of cin, when compared with scr and gfr. due to a small number of cases with cin, the confidence intervals associated with the odds ratios are wide. future research should focus on patient risk stratification and establishing ed interventions to prevent cin. a rat model of carbon monoxide induced neurotoxicity heather ellsworth non-traumatic subarachnoid hemorrhage diagnosed by lumbar puncture following non-diagnostic head ct: a retrospective case-control study and decision a dass score of > has been previously defined as an indicator of increased stress levels. multivariable logistic regression was utilized to identify demographic and work-life characteristics significantly associated with stress. results: . % of individuals responded to the survey ( , / , ) and prevalence of stress was estimated at . %. the following work-life characteristics were associated with stress: certification level, work experience, and service type. the odds of stress in paramedics was % higher when compared to emt-basics (or = . , % ci = . - . ). when compared to £ years of experience - . ) were more likely to be stressed. ems professionals working in county (or = ci = . - . ) and private services (or = ) were more likely than those working in fire-based services to be stressed. the following demographic characteristics were associated with stress: general health and smoking status finally, former smokers (or = . , % ci = . - . ) and current smokers (or = . , % ci = . - . ) were more likely to be stressed than non-smokers literature suggests this is within the range of stress among nurses, and lower than physicians. while the current study was able to identify demographic and work-life characteristics associated with stress, the long-term effects are largely unknown methods: design: prospective randomized controlled trial. subjects: female sus scrofa swine weighing - kg were infused with amitriptyline . mg/kg/minute until the map fell to % of baseline values. subjects were then randomized to experimental group (ife ml/kg followed by an infusion of . ml/kg/minute) or control group (sb meq/kg plus equal volume of normal saline). interventions: we measured continuous heart rate (hr), sbp, map, cardiac output (co), systemic vascular resistance (svr), and venous oxygen saturation (svo ). laboratory values monitored included ph, pco , bicarbonate, lactate, and amitriptyline levels. descriptive statistics including means, standard deviations, standard errors of measurement, and confidence limits were calculated. results: of swine, seven each were allocated to ife and sb groups. there was no difference at baseline for each group regarding hr, sbp, map, co, svr, or svo . ife and sb groups required similar mean amounts of tca to reach hypotension one ife and two sb pigs survived. conclusion: in this interim data analysis of amitriptyline-induced hypotensive swine, we found no difference in mitigating hypotension between ife and sb lipid rescue : a survey of poison center medical directors regarding intravenous fat emulsion therapy michael r. christian , erin m. pallasch cook county hospital (stroger), chicago, il reliability of non-toxic acetaminophen concentrations obtained less than hours after ingestion evaluating age in the field triage of injured background: hiv screening in eds is advocated to achieve the goal of comprehensive population screening. yet, hiv testing in the ed is sometimes thwarted by a patient's condition (e.g. intoxication) or environmental factors (e.g. other care activities). whether it is possible to test these patients at a later time is unknown. objectives: we aimed to determine if ed patients who were initially unable to receive an hiv testing offer might be tested in the ed at a later time. we hypothesized that factors preventing testing are transient and that there are subsequent opportunities to repeat testing offers. methods: we reviewed medical records for patients presenting to an urban, academic ed who were approached consecutively to offer hiv testing during randomly selected periods from january to january . patients for whom the initial attempted offer could not be completed were reviewed in detail with standardized abstraction forms, duplicate abstraction, and third-party discrepancy adjudication. primary outcomes included repeat hiv testing offers during that ed visit, and whether a testing offer might eventually have been possible either during the initial visit or at a later visit within months. outcomes are described as proportions with confidence intervals. results: of patients approached, initial testing offers could not be completed for ( %). these were % male, % white, and had a median age of ( - ). a repeat offer of testing during the initial visit would have been possible for / ( %), and / ( %) were actually offered testing on repeat approach. of the for whom a testing offer would not have been possible on the initial visit, ( %) had at least one additional visit within months, and / ( %) could have been offered testing on at least one visit. overall, a repeat testing offer would have been possible for / ( %, % ci - %). conclusion: factors preventing an initial offer of hiv testing in the ed are generally transient. opportunities for repeat approach during initial or later ed encounters suggest that, given sufficient resources, the ed could succeed in comprehensively screening the population presenting for care. ed screening personnel who are initially unable to offer testing should repeat their attempt. hiv adopt an ''opt-out'' rapid hiv screening model in order to identify hiv infected patients. previous studies nationwide have shown acceptance rates for hiv screening of - % in emergency departments. however, it is unknown how acceptance rates will vary in a culturally and ethnically diverse urban emergency department.objectives: to determine the characteristics of patients who accept or refuse ''opt-out'' hiv screening in an urban emergency department.methods: a self-administered, anonymous survey is administered to ed patients who are to years of age. the questionnaire is administered in english, russian, mandarin, and spanish. questions include demographic characteristics, hiv risk factors, perception of hiv risk, and acceptance of rapid hiv screening in the emergency department. results: to date patients responded to our survey. of the , ( . %) did not accept an hiv test (group ) in their current ed visit and ( . %) accepted an hiv test (group ). the major two reasons given for opting out (i.e., group ) was ''i do not feel that i am at risk'' ( . %) and ''i have been tested for hiv before'' ( . %). there was no difference between the groups in regards to sex (p = . ), age (p = . ), religious affiliation (p = . ), marital status (p = . ), language spoken at home (p = . ), and whether they had been hiv tested before ( . % in group and . % in group ; p = . ). however, there was a statistically significant difference with regards to educational level and income. more patients in group ( . %) and . % in group had less than a college level education (p < . ). similarly, more patients in group ( . %) and only . % in group had an annual household income of £$ , (p < . ). conclusion: in a culturally and ethnically diverse urban emergency department, patients with a lower socioeconomic status and educational level tend to opt out of hiv screening test offered in the ed. no significant difference in acceptance of ed hiv testing was found to date based on primary language spoken at home or religious affiliation background: antimicrobial resistance is a problem that affects all emergency departments. objectives: our goal was to examine all urinary pathogens and their resistance patterns from urine cultures collected in the emergency department (ed).methods: this study was performed at an urban/suburban community-teaching hospital with an annual volume of , visits. using electronic records, all cases of urine cultures received in were reviewed for data including type of bacteria, antibiotic resistance, and health care exposure (hcx). hcx was defined as no prior hospitalization within the previous six months, hospitalization within the previous three months, hospitalization within the previous six months, nursing home resident (nh), and presence of an indwelling urinary catheter (uc). an investigator abstracted all data with a second re-abstracting a random % for kappa statistics between . and . . group background: approximately - % of patients treated with epinephrine for anaphylaxis receive a second dose but the risk factors associated with repeat epinephrine use remain poorly defined. objectives: to determine whether obesity is a risk factor for requiring + epinephrine doses for patients who present to the emergency department (ed) with anaphylaxis due to food allergy or stinging insect hypersensitivity. methods: we performed a retrospective chart review at four tertiary care hospitals that care for adults and children in new england between the following time periods: massachusetts general hospital ( / / - / / ), brigham and women's hospital ( / / - / / ), children's hospital boston ( / / - / / ), hasbro children's hospital ( / / - / / ). we reviewed the medical records of all patients presenting to the ed for food allergy or stinging insect hypersensitivity using icd cm codes. we focused on anthropomorphic data and number of epinephrine treatments given before and during the ed visit. among children, calculated bmis were classified according to cdc growth indicators as underweight, healthy, overweight, or obese. all patients who presented on or after their th birthday were considered adults.background: transitions of care are ubiquitous in the emergency department (ed) and inevitably introduce the opportunity for errors. despite recommendations in the literature, few emergency medicine (em) residency programs provide formal training or standard process for patient hand-offs. checklists have been shown to be effective quality improvement measures in inpatient settings and may be a feasible method to improve ed hand-offs. objectives: to determine if the use of a sign-out checklist improves the accuracy and efficiency of resident sign-out in the ed as measured by reduced omission of key information, communication behaviors, and time to sign-out each patient. methods: a prospective study of first-and second-year em and non-em residents rotating in the ed at an urban academic medical center with an annual ed volume of , . trained clinical research assistants observed resident sign-out during shift change over a two-week period and completed a -point binary observable behavior data collection tool to indicate whether or not key components of sign-out occurred. time to sign out each patient was recorded. we then created and implemented a computerized sign-out checklist consisting of key elements that should be addressed during transitions of care, and instructed residents to use this during hand-offs. a two-week post-intervention observation phase was conducted using the same data collection tool. proportions, means, and non-parametric comparison tests were calculated using stata. results: one hundred fifteen sign-outs were observed prior to checklist implementation and after; one sign-out was excluded for incompleteness. significant improvements were seen in four of the measured signout components: inclusion of history of present illness increased by % (p < . ), likely diagnosis increased by % (p = . ), disposition status increased by % (p < . ), and patient/care team awareness of plan increased by % (p < . ). (figure ) time data for sign-outs pre-implementation and post-implementation were available. seven sign-outs were excluded for incompleteness or spurious values. mean length of sign out was s ( % ci to ) and . s ( % ci to ) per patient. conclusion: implementation of a checklist improved the transfer of information but did not affect the overall length of time for the sign-out. the objectives: to determine risk factors associated with adult patients presenting to the ed with cellulitis who fail initial antibiotic therapy and require a change of antibiotics or admission to hospital. methods: this was a prospective cohort study of patients ‡ years presenting with cellulitis to one of two tertiary care eds (combined annual census , ). patients were excluded if they had been treated with antibiotics for the cellulitis prior to presenting to the ed, if they were admitted to hospital, or had an abscess only. trained research personnel administered a questionnaire at the initial ed visit with telephone follow-up weeks later. patient characteristics were summarized using descriptive statistics and % confidence intervals (cis) were estimated using standard equations. backwards stepwise multivariable logistic regression models determined predictor variables independently associated with treatment failure (failed initial antibiotic therapy and required a change of antibiotics or admission to hospital). results: patients were enrolled, were excluded, and were lost to follow-up. the mean (sd) age was . ( . ) and . % were male. ( . %) patients were given antibiotics in the ed. ( . %) were given oral, ( . %) were given iv, and ( . %) patients were given both oral and iv antibiotics. ( . %) patients had a treatment failure. fever (temp > °c) at triage (or: . , % ci: . , . ), leg ulcers (or: . , % ci: . , . ), edema or lymphedema (or: . , % ci: . , . ), and prior cellulitis in the same area (or: . , % ci: . , . ) were independently associated with treatment failure. conclusion: this analysis found four risk factors associated with treatment failure in patients presenting to the ed with cellulitis. these risk factors should be considered when initiating empiric outpatient antibiotic therapy for patients with uncomplicated cellulitis. use background: children presenting for care to a pediatric emergency department (ped) commonly require intravenous catheter (iv) placement. prior studies report that the average number of sticks to successfully place an iv in children is . . successfully placing an iv requires identification of appropriate venous access targets. the veinviewer visionÒ (vvv) assists with iv placement by projecting a map of subcutaneous veins on the surface of the skin using near infrared light. objectives: to compare the effectiveness of the vvv versus standard approaches: sight (s) and sight plus palpation (s+p) for identifying peripheral veins for intravenous catheter placement in children treated in a ped. methods: experienced pediatric emergency nurses and physicians identified peripheral venous access targets appropriate for intravenous cannulation of a cross-sectional convenience sample of english speaking children aged - years presenting for treatment of sub-critical injury or illness whose parents provided consent. the clinicians marked the veins with different colored washable marker and counted them on the dorsum of the hand and in the antecubital fossa using the three approaches: s, s+p, and vvv. a trained research assistant photographed each site for independent counting after each marking and recorded demographics and bmi. counts were validated using independent photographic analyses. data were entered into sas . and analyzed using paired t-tests. results: patients completed the study. clinicians were able to identify significantly more veins on the dorsum of the hand using vvv than s alone or s+p, . (p < . , ci . - . ) and . (p < . , ci . - . ), respectively, as well as significantly more veins in the antecubital fossa using vvv than s alone or s+p, . (p < . , ci . - . ) and . (p < . , ci . - . ), respectively. the differences in numbers of veins identified remained significant at p < . level across all ages, races, and bmis of children and across clinicians and validating independent photographic analyses. conclusion: experienced emergency nurses and physicians were able to identify significantly more venous access targets appropriate for intravenous cannulation in the dorsum of the hand and antecubital fossa of children presenting for treatment in a ped using vvv than the standard approaches of sight or sight plus palpation. an background: mental health emergencies have increased over the past two decades, and contribute to the ongoing rise in u.s. ed visit volumes. although data are limited, there is a general perception that the availability of in-person psychiatric consultation in the ed and of inpatient psychiatric beds is inadequate. objectives: to examine the availability of in-person psychiatry consultation in a heterogeneous sample of u.s. eds, and typical delays in transfer of ed patients to an inpatient psychiatric bed. methods: during - , we mailed a survey to all ed directors in a convenience sample of nine us states (ar, co, ga, hi, ma, mn, or, vt, and wy). all sites were asked: ''are psychiatric consults available in-person to the ed?'' (yes/no), with affirmative respondents asked about the typical delay. sites also were asked about typical ed boarding time between a request for patient transfer and actual patient departure from the ed to an inpatient psychiatric bed. ed characteristics included rural/urban location, visit volume (visits/hour), admission rate, ed staffing, and the proportion of patients without insurance. data analysis used chi-square tests and multivariable logistic regression. results: surveys were collected from ( %) of the eds, with > % response rate in every state. overall, only % responded that psychiatric consults were available in-person to the ed. in multivariable logistic regression, ed characteristics independently associated with lack of in-person psychiatric consultation were: location within specific states (eg, ar, ga), rural location, lower visit volume, and lower admission rate. among the subset of eds with psychiatric consults available, % reported a typical wait time of at least hour. overall, % of eds reported that the typical time from request to actual patient transfer to an inpatient psychiatric bed was > hours, and % reported a maximum time in past year of > day (median days, iqr - ). in a multivariable model, location in ma and higher visit volume were associated with greater odds of a maximum wait time of > day. conclusion: among surveyed eds in nine states, only % have in-person psychiatric consultants available. moreover, approximately half of eds report boarding times of > h from request for transfer to actual departure to an inpatient psychiatric bed.background: many emergency departments (ed) in the united states use a five tiered triage protocol that has a limited evaluation of psychiatric patients. the australian triage scale (ats), a psychiatric triage system, has been used throughout australia and new zealand since the early s. objectives: the objective of the study is to compare the current triage system, emergency nurses association (ena) esi -tier, to the ats for the evaluation of the psychiatric patients presenting to the ed. methods: a convenience sample of patients, years of age and older, presenting with psychiatric complaints at triage were given the ena triage assessment by the triage nurse. a second triage assessment, performed by a research fellow, included all observed and reported elements using the ats protocol, a self-assessment survey and an agitation assessment using the richmond agitation sedation scale (rass). the study was performed at an inner city level i trauma center with , visits per year. the ed was a catchment facility for the police department for psychiatric patients in the area. patients were excluded if they were unstable, unable to communicate, or had a non-psychiatric complaint. results were analyzed in spss v . the analysis of data used frequencies, descriptive and anova. results: a total of patients were enrolled in the study: % were african american, % caucasian, % hispanic, % asian, and % indian; % of subjects enrolled were male. the patients' level of agitation using rass showed % were alert and calm, % were restless and anxious, % were agitated, and % combative, violent, or dangerous to self. the only significant correlation found was among the ats and several self assessment questions: ''i feel agitated on a to scale'' (p = . ) and ''i feel violent on a to scale'' (p = . ). there were no significant correlations found among the ena triage, rass scores, and throughput times. conclusion: the ats test was more sensitive to the patient declaring that he or she was agitated or felt violent. this shows that this system might be a more useful system in determining the severity of need of psychiatric patients presenting to the ed. variations background: hemoglobin-based oxygen carriers (hbocs) have been evaluated for small-volume resuscitation of hemorrhagic shock due to their oxygen carrying capability, but have found limited utility due to vasoactive side-effects from nitric oxide (no) scavenging. objectives: to define an optimal hboc dosing strategy and evaluate the effect of an added no donor, we use a prehospital swine polytrauma model to compare the effect of low-vs. moderate-volume hboc resuscitation with and without nitroglycerin (ntg) co-infusion as an no donor. we hypothesize that survival time will improve with moderate resuscitation and that an no donor will add additional benefit. methods: survival time was compared in groups (n = ) of anesthetized swine subjected to simultaneous traumatic brain injury and uncontrolled hemorrhagic shock by aortic tear. animals received one of three different resuscitation fluids: lactated ringers (lr), hboc, or vasoattenuated hboc with ntg co-infusion. for comparison, these fluids were given in a severely limited fashion (sl) as one bolus every minutes up to four total, or a moderately limited fashion (ml) as one bolus every minutes up to seven total, to maintain mean arterial pressure ‡ mmhg. comparison of resuscitation regimen and fluid type on survival time was made using two-way anova with interaction and tukey kramer adjustment for individual comparisons. results: there was a significant interaction between fluid regimen and resuscitation fluid type (anova, p = . ) indicating that the response to sl or ml resuscitation was fluid type-dependent. within the lr and hboc+ntg groups, survival time (mean, %ci) was longer for sl, . min ( injuries are common and result from many different mechanisms of injury (moi). knowing common fracture locations may help in diagnosis and treatment, especially in patients presenting with distracting injuries that may mask the pain of a radius fracture.objectives: we set out to determine the incidence of radius fracture locations among patients presenting to an urban emergency department (ed).background: carbon monoxide (co) is the leading cause of poisoning morbidity and mortality in the united states. standard treatment includes supplemental oxygen and supportive care. the utility of hyperbaric oxygen (hbo) therapy has been challenged by a recent cochrane review. hypothermia may mitigate delayed neurotoxic effects after co poisoning as it is effective in cardiac arrest patients with similar neuropathology. objectives: to develop a rat model of acute and delayed severe co toxicity as measured by behavioral deficits and cell necrosis in post-sacrifice brain tissue.methods: a total of rats were used for model development; variable concentrations of co and exposure times were compared to achieve severe toxicity. for the protocol, six senescent long evans rats were exposed to , ppm of co for minutes then , ppm for minutes, followed by three successive dives at , ppm with an endpoint of apnea or seizure; there was a brief interlude between dives for recovery. a modified katz assessment tool was used to assess behavior at baseline and hours, day, and , , , , , and weeks post-exposure. following this, the brains were transcardially fixed with formalin, and lm sagittal slices were embedded in paraffin and stained with hematoxylin and eosin. a pathologist quantified the percentage of necrotic cells in the cortex, hippocampus (pyramidal cells), caudoputamen, cerebellum (purkinje cells), dentate gyrus, and thalamus of each brain to the nearest % from randomly selected high power fields ( x background: there remains controversy about the cardiotoxic effects of droperidol, and in particular the risk of qt prolongation and torsades des pointes (tdp).objectives: this study aimed to investigate the cardiac and haemodynamic effects of high-dose parenteral droperidol for sedation of acute behavioural disturbance (abd) in the emergency department (ed). methods: a standardised intramuscular (im) protocol for the sedation of ed patients with abd was instituted as part of a prospective observational safety study in four regional and metropolitan eds. patients with abd were given an initial dose of mg droperidol followed by an additional dose of mg after min if required. inclusion criteria were patients requiring physical restraint and parenteral sedation. the primary outcome was the proportion of patients who have a prolonged qt interval on ecg. the qt interval was plotted against the heart rate (hr) on the qt nomogram to determine if the qt was abnormal. secondary outcomes were frequency of hypotension and cardiac arrhythmias. results: ecgs were available from of patients with abd given droperidol. the median dose was mg (iqr - mg; range: to mg). the median age was years (rnge: to ) and were males ( %). a total of four ( %) qt-hr pairs were above the ''at-risk'' line on the qt nomogram. transient hypotension occurred in ( %), and no arrhythmias were detected.conclusion: droperidol appears to be safe when used for rapid sedation in the dose range of to mg. it rarely causes hypotension or qt prolongation. blood background: soldiers and law enforcement agents are repeatedly exposed to blast events in the course of carrying out their duties during training and combat operations. little data exist on the effect of this exposure on the physiological function of the human body. both military and law enforcement dynamic entry personnel, ''breachers'', began expressing sensitivity to the risk of injury as a result of multiple blast exposures. breachers apply explosives as a means of gaining access to barricaded or hardened structures. these specialists can be exposed to as many as a dozen lead-encased charges per day during training exercises.objectives: this observational study was performed by the breacher injury consortium to determine the effect of short-term exposure to blasts by breachers on whole blood lead levels (blls) and zinc protoporphyrin levels (zppls). methods: two -week basic breaching training classes were conducted by the united states marine corps' weapons training battalion dynamic entry school. each class included students and up to three instructors, with six non-breaching marines serving as a control group. to evaluate for lead exposure, venous blood samples were acquired from study participants on the weekend prior and following training in the first training class, whereas the second training class had an additional level performed mid-training. blls and zppls were measured in a whole-blood sample using the furnace atomic absorption method and hematofuorimeter method, respectively. results: analysis of these blast injury data indicated students demonstrated significantly increased blls post-explosion (mean = mcg/dl, sd . , p < . ) compared to pre-training (mean = mcg/dl, sd . ) and control subjects (mean = mcg/dl, sd . , p < . ). instructors also demonstrated significantly increased blls post explosion (mean = mcg/dl, sd . , p < . ) compared to pre-training (mean = mcg/ dl, sd . ) and control subjects (mean = mcg/dl, sd . , p < . ). student and instructor zppls were not significantly different in post-training compared to pretraining or control groups. conclusion: the observation from this study that breachers are at risk of mild increases in blls support the need for further investigation into the role of lead following repeated blast exposure with munitions encased in lead. direct observation of the background: notification of a patient's death to family members represents a challenging and stressful task for emergency physicians. complex communication skills such as those required for breaking bad news (bbn) are conventionally taught with small-group and other interactive learning formats. we developed a de novo multi-media web-based learning (wbl) module of curriculum content for a standardized patient interaction (spi) for senior medical students during their emergency medicine rotation.objectives: we proposed that use of an asynchronous wbl module would result in students' skill acquisition for breaking bad news. methods: we tracked module utilization and performance on the spi to determine whether students accessed the materials and if they were able to demonstrate proficiency in its application. performance on the spi was assessed utilizing a bbn-specific content instrument developed from the griev_ing mnemonic as well as a previously validated instrument for assessing communication skills.results: three hundred seventy-two students were enrolled in the bbn curriculum. there was a % completion rate of the wbl module despite students being given the option to utilize review articles alone for preparation. students interacted with the activities within the module as evidenced by a mean number of mouse clicks of . (sd . ). overall spi scores were . %, (sd . ) with content checklist scores of . % (sd . ) and interpersonal communication scores . % (sd . ). five students had failing content scores (< %) on the spi and had a mean number of clicks of . (sd . ), which is not significantly lower than those passing (p = . ). students in the first year of wbl deployment completed self-confidence assessments which showed significant increases in confidence ( . tobackground: pelvis ultrasonography (us) is a useful bedside tool for the evaluation of women with suspected pelvic pathology. while pelvic us is often performed by the radiology department, it often lacks clinical correlation and takes more time than bedside us in the ed. this was a prospective observational study comparing the ed length of stay (los) of patients receiving ed us versus those receiving radiology us. objectives: the primary objective was to measure the difference in ed los. the secondary objectives were to ) assess the role of pregnancy status, ob/gyn consult in the ed, and disposition, in influencing the ed los; and ) to assess the safety of ed us by looking at patient return to the ed within weeks and whether that led to an alternative diagnosis.methods: subjects were women over years old presenting with a gi or gu complaint, and who received either an ed or radiology us. a t-test was used for the primary objective, and linear regression to test the secondary objective. odds ratios were performed to assess for interaction between these factors and type of ultrasound. subgroup analyses were performed if significant interaction was detected. results: forty-eight patients received an ed us and patients received a radiology us. subjects receiving an ed us spent minutes less in the ed (p < . ). in multivariate analysis, even when controlling for pregnancy status, ob/gyn consult, and disposition, patients who received an ed us had a los reduction of minutes (p < . ). in odds ratio analysis, patients who were pregnant were times more likely to have received an ed us (p < . ). patients who received an ob/gyn consult in the ed were five times more likely to receive a radiology us (p < . ). there was no association between type of us and disposition. in subgroup analyses, pregnant and non-pregnant patients who received an ed us still had a los reduction of minutes (p < . ) and minutes (p < . ), respectively. sample sizes were inadequate for subgroup analysis for subjects who had ob/gyn consults. in patients who did not receive an ob/gyn consult, those who received an ed us had a los reduction of minutes (p < . ). finally, % of subjects returned within two weeks, but none led to an alternative diagnosis. conclusion: even when controlling for disposition, ob/gyn consultation, and pregnancy status, patients who received an ed us had a statistically and clinically significant reduction in their ed los. in addition, ed us is safe and accurate. background: although early surface cooling of burns reduces pain and depth of injury, there are concerns that cooling of large burns may result in hypothermia and worse outcomes. in contrast, controlled mild hypothermia improves outcomes after cardiac arrest and traumatic burn injury. objectives: the authors hypothesized that controlled mild hypothermia would prolong survival in a fluidresuscitated rat model of large scald burns. methods: forty sprague-dawley rats ( - g) were anesthetized with mg/kg intramuscular ketamine and mg/kg xylazine, with supplemental inhalational isoflurane as needed. a single full-thickness scald burn covering % of the total body surface area was created per rat using a mason-walker template placed in boiling water ( deg c) for a period of seconds. the rats were randomized to hypothermia (n = ) and nonhypothermia (n = ). core body temperature was continuously monitored with a rectal temperature probe. hypothermia was induced through intraperitoneal injection of cooled ( deg c) saline. the core temperature was reduced by deg c and maintained for a period of hours, applying an ice or heat pack when necessary. the rats were then rewarmed back to baseline temperature. in the control group, room temperature saline was injected into the intraperitoneal cavity and core temperature was maintained using a heating pad as needed. the rats were monitored until death or for a period of days, whichever was greater. the primary outcome was death. the difference in survival was determined using a kaplan-meier analysis or log rank test. results: the mean core temperatures were . deg c for the hypothermic group and . deg c for the normothermic group. the mean survival times were hours for the hypothermic group ( % confidence interval [ci] = to ) and hours for the normothermic group ( % ci = to ). the seven-day survival rates in the hypothermic and non-hypothermic groups were % and %. these differences were not significant, p = . for both comparisons. conclusion: induction of brief mild hypothermia increases but does not significantly prolong survival in a resuscitated rat model of large scald burns. serum objectives: we sought to determine levels of serum mtdna in ed patients with sepsis compared to controls and the association between mtdna and both inflammation and severity of illness among patients with sepsis. methods: prospective observational study of patients presenting to one of three large, urban, tertiary care eds. inclusion criteria: ) septic shock: suspected infection, two or more systemic inflammatory response (sirs) criteria, and systolic blood pressure (sbp) < mmhg despite a fluid bolus; ) sepsis: suspected infection, two or more sirs criteria, and sbp > mmhg; and ) control: ed patients without suspected infection, no sirs criteria, and sbp > mmhg. three mtdnas (cox-iii, cytochrome b, and nadh) were measured using real-time quantitative pcr from serum drawn at enrollment. il- and il- were measured using a bio-plex suspension array system. baseline characteristics, il- , il- , and mtdnas were compared using one way anova or fisher exact test, as appropriate. correlations between mtdnas and il- /il- were determined using spearman's rank. linear regression models were constructed using sofa score as the dependent variable, and each mtdna as the variable of interest in an independent model. a bonferroni adjustment was made for multiple comparisons.results: of patients, were controls, had sepsis, and had septic shock. we found no significant difference in any serum mtdnas among the cohorts (p = . to . ). all mtdnas showed a small but significant negative correlation with il- and il- (q = ) . to ) . ). among patients with sepsis or septic shock (n = ), we found a small but significant negative association between mtdna and sofa score, most clearly with cytochrome b (p = . ). conclusion: we found no difference in serum mtdnas between patients with sepsis, septic shock, and controls. serum mtdnas were negatively associated with inflammation and severity of illness, suggesting that as opposed to trauma, serum mtdna does not significantly contribute to the pathophysiology of the sepsis syndromes. methods: we consecutively enrolled ed patients ‡ years of age who met anaphylaxis diagnostic criteria from april to july at a tertiary center with , annual visits. we collected data on antihypertensive medications, suspected causes, signs and symptoms, ed management, and disposition. markers of severe anaphylaxis were defined as ) intubation, ) hospitalization (icu or floor), and ) signs and symptoms involving ‡ organ systems. antihypertensive medications evaluated included beta-blockers, angiotensin converting enzyme (ace) inhibitors, and calcium channel blockers (ccb). we conducted univariate and multivariate analyses to measure the association between antihypertensive medications and markers of severe anaphylaxis. because previous studies demonstrated an association between age and the suspected cause of the reaction with anaphylaxis severity, we adjusted for these known confounders in multivariate analyses. we report associations as odds ratios (ors) and corresponding % cis with p-values. results: among patients with anaphylaxis, median age (iqr) was ( - ) and ( . %) were female. eight ( . %) patients were intubated, ( %) required hospitalization, and ( %) had ‡ system involvement. forty-nine ( %) were on beta-blockers, ( %) on ace inhibitors, and ( . %) on ccb. in univariate analysis, ace inhibitors were associated with intubation and ‡ system involvement and ccb were associated with hospital admission. in multivariate analysis, after adjusting for age and suspected cause, ace inhibitors remained associated with hospital admission and beta-blockers remained associated with both hospital admission and ‡ system involvement. conclusion: in ed patients, beta-blocker and ace inhibitor use may predict increased anaphylaxis severity independent of age and suspected cause of the anaphylactic reaction. background: advanced cardiac life support (acls) resuscitation requires rapid assessment and intervention. some skills like patient assessment, quality cpr, defibrillation, and medication administration require provider confidence to be performed quickly and correctly. it is unclear, however, whether high-fidelity simulation can improve confidence with a multidisciplinary group of providers with high levels of clinical experience. objectives: the purpose of the study was to test the hypothesis that providers undergoing high-fidelity simulation of cardiopulmonary arrest scenarios will express greater confidence. methods: this was a prospective cohort study conducted at an urban level i trauma center from january to october with a convenience sample of registered (rn) and license practical nurses, nurse practitioners, resident physicians, and physician assistants who agreed to participate in / high-fidelity simulation (laerdal g) sessions of cardiopulmonary arrest scenarios about months apart. demographics were recorded. providers completed a validated preand post-test five-point likert scale confidence measurement tool before and after each session that ranged from not at all confident ( ) to very confident ( ) in recognizing signs and symptoms of, appropriately intervening in, and evaluating intervention effectiveness in cardiac and respiratory arrests. descriptive statistics, paired t-tests, and anova were used for data analysis. sensitivity testing evaluated subjects who completed their second session at months rather than months. results: sixty-five subjects completed consent, completed one session, and completed at least two background: prehospital studies have focused on the effect of health care provider gender on patient satisfaction. we know of no study that has assessed patient satisfication with patient and prehospital provider gender. some studies have shown higher patient satisfaction rates when cared for by a female health care provider.objectives: to determine the effect of ems provider gender on patient satisfaction with prehospital care. methods: a convenience sampling of all adult patients brought in to our ed, an urban level i trauma center by ambulance. a trained research associate (ra) stationed at triage conducted a survey using press ganey ems patient satisfaction questions. there were thirteen questions evaluating prehospital provider skills such as driving, courtesy, listening, medical care, and communication. each skill was assigned a point value between one and five; the higher the value the better the skill was performed. the patient's ambulance care report was copied for additional data extraction.results: a total of surveys were done. average patient age was , and % were female. scores for all questions totaled (mean . ± . ). prehospital providers pairings were: male-male (n = ), male-female (n = ), and female-female (n = ). there were no statistically significant differences in scores between our pairings (mean scores for male:male . , male:female . , and female:female . ; p = . ). we found nonstatistical differences in satisfaction scores based on the gender of the emt in the back of the ambulance: males had a mean score of . and females had a mean score of . (p = . ). we examined gender concordance by comparing gender of the patient to the gender of the prehospital provider and found that male-male had a mean score of . , female-female . , and when the patient and prehospital provider gender did not match, . (p = . ). conclusion: we found no effect of gender difference on patient satisfaction with prehospital care. we also found that overall, patients are very satisfied with their prehospital care. objectives: we set out to determine the sensitivity and specificity of eps in determining the presence of recently ingested tablets or tablet fragments.methods: this was a prospective volunteer study at an academic emergency department. healthy volunteers were enrolled and kept npo for hours prior to tablet ingestion. over minutes subjects ingested ml of water and tablets. ultrasounds video clips were performed prior to any tablet ingestion, after drinking ml of water, after tablets, after tablets, after tablets, and minutes after the final tablet ingestion yielding six clips per volunteer. all video clips were randomized and shown to three eps who were fellowship-trained in emergency ultrasound. eps recorded the presence or absence of tablets.results: ten volunteers underwent the pill ingestion protocol and sixty clips were collected. results for all cases and each rater are reported in the table. overall there was moderate agreement between raters (kappa = . ). sub-group analysis of , , or pills did not show any significant improvement in sensitivity and specificity.conclusion: ultrasound has moderate specificity but poor sensitivity for identification of tablet ingestion. these results imply that point-of-care ultrasound has limited utility in diagnosing large tablet ingestion. background: intravenous fat emulsion (ife) therapy is a novel treatment that has been used to reverse the acute toxicity of some xenobiotics with varied success. us poison control centers (pcc) are recommending this therapy for clinical use, but data regarding these recommendations are lacking.objectives: to determine how us pcc have incorporated ife as a treatment strategy for poisoning. methods: a closed-format multiple-choice survey instrument was developed, piloted, revised, and then sent electronically to every medical director of an accredited us pcc using surveymonkey in march ; addresses were obtained from the aapcc listserv, participation was voluntary and remained anonymous; three reminder invitations were sent during the study period. data were analyzed using descriptive statistics.results: forty-five of ( %) pcc medical directors completed the survey. all respondents felt that ife therapy played a role in the acute overdose setting. thirty ( %) pcc have a protocol for ife therapy: ( %) recommend an initial bolus of . ml/kg of a % lipid emulsion, ( %) pcc recommend an infusion of lipids, and / pcc recommend an initial infusion rate of . ml/kg of a % lipid emulsion. thirty-three ( %) felt that ife had no clinically significant side effects at a bolus dose of . ml/kg ( % emulsion). forty-four directors ( %) felt that the ''lipid sink'' mechanism contributed to the clinical effects of ife therapy, but ( %) felt that there was a yet undiscovered mechanism that likely contributed as well. in a scenario with cardiac arrest due to a single xenobiotic, directors stated that their center would always or often recommend ife after overdose of bupivicaine ( ; %), verapamil ( ; %), amitriptyline ( ; %), or an unknown xenobiotic ( ; %). in a scenario with significant hemodynamic instability due to a single xenobiotic, directors stated that their pcc would always or often recommend ife after overdose of bupivicaine ( ; %), verapamil ( ; %), amitriptyline ( ; %), or an unknown xenobiotic ( ; %).conclusion: ife therapy is being recommended by us pcc. protocols and dosing regimens are nearly uniform. most directors feel that ife is safe but are more likely to recommend ife in patients with cardiac arrest than in patients with severe hemodynamic compromise. further research is warranted. levels drawn at hours or more ( mcg/ml at hours, mcg ⁄ ml at hours, respectively). npv for toxic ingestion of an initial apap level less than mcg/ml was . % ( % ci . - . %).conclusion: an apap level of less than mcg/ml drawn less than hours after ingestion had a high npv for excluding toxic ingestion. however, the authors would not recommend reliance on levels obtained under hours to exclude toxicity as the potential for up to . % false negative results is considered unacceptable. background: genetic variations in the mu-opioid receptor gene (oprm ) mediate individual differences in response to pain and addiction.objectives: to study whether the common a g (rs ) mu-opioid receptor single nucleotide polymorphism (snp) or the alternative splicing snp of oprm (rs ) was associated with overdose severity, we assessed allele frequencies of each including associations with clinical severity in patients presenting to the emergency department (ed) with acute drug overdose. methods: in an observational cohort study at an urban teaching hospital, we evaluated consecutive adult ed patients presenting with suspected acute drug overdose over a -month period for whom discarded blood samples were available for analysis. specimens were linked with clinical variables (demographics, urine toxicology screens, clinical outcomes) then de-identified prior to genetic snp analysis. in-hospital severe outcomes were defined as either respiratory arrest (ra, defined by mechanical ventilation) or cardiac arrest (ca, defined by loss of pulse). blinded taqman genotyping (applied biosystems) of the snps were performed after standard dna purification (qiagen) and whole genome amplification (qiagen repli-g). the plink . genetic association analysis program was used to verify snp data quality, test for departure from hardy-weinberg equilibrium, and test individual snps for statistical association. results: we evaluated patients ( % female, mean age . ) who overall suffered ras and cas (of whom died). urine toxicology was positive in %, of which there were positives for benzodiazepines, cocaine, opiates, methadone, and barbiturates. all genotypes examined conformed to hardy-weinberg equilibrium. the g allele was associated with . fold increased odds of ca/ra (or . , p < . ). the rs mutant allele was not associated with ca/ ra. conclusion: these data suggest that the g mutant allele of the oprm gene is associated with worse clinical severity in patients with acute drug overdose. the findings add to the growing body of evidence linking the a g snp with clinical outcome and raise the question as to whether the a g snp may be a potential target for personalized medical prescribing practices with regard to behavioral/physiologic overdose vulnerability. key: cord- - rqnu bu authors: nan title: th international symposium on intensive care and emergency medicine: brussels, belgium. - march date: - - journal: crit care doi: . /s - - - sha: doc_id: cord_uid: rqnu bu nan the relationship between systemic glycocalyx degradation markers and regional glycocalyx thickness in non-septic critically ill patients is unclear. conjunctival sidestream dark fieldimaging for the purpose of glycocalyx thickness estimation has never been performed. we aimed to investigate whether changes in glycocalyx thickness in conjunctival and sublingual mucosa are associated with global glycocalyx shedding markers. methods: in this single-centre prospective observational study, using techniques for direct in-vivo observation of the microcirculation, we performed a single measurement of glycocalyx thickness in both ocular conjunctiva and sublingual mucosa in mixed cardio surgical (n= ) and neurocritical patients (n= ) and compared these data with age-matched healthy controls (n= ). in addition we measured systemic syndecan- levels results: in the sublingual and conjunctival region we observed a significant increase of the perfused boundary region (pbr) in both neuro critical and cardiac surgical icu patients, compared to controls ( . ], p< , ). we detected a weak correlation between syndecan- and sublingual pbr(r= . , p= . ) but no correlations between global glycocalyx damage markers and conjuctival glycocalyx thickness. conclusions: conjunctival glycocalyx thickness evaluation using sdf videomicroscopy is suitable and is impaired in non-septic icu patients but only measurements in sublingual mucosa are correlating with systemic glycocalyx shedding markers. global glycocalyx damage is more severe in cardiac comparing to neuro critical patients. introduction: endothelial dysfunction plays a major role in the sepsis related organ dysfunction, and is featured by vascular leakage. amp-activated protein kinase (ampk) is known to regulate actin cytoskeleton organization and interendothelial junctions (iejs), contributing to endothelial barrier integrity. we have already demonstrated its role in defence against sepsis induced hyperpermeability [ ] , but the underlying mechanisms remain unknown. this project aims to identify molecular targets involved in the beneficial action of ampk against endothelial barrier dysfunction. methods: experiments have been performed in human microvascular dermal endothelial cells. α ampk activity has been modulated via the use of a specific sirna or treatment by two pharmacological ampk activators (aicar, ). we have investigated the effect of this modulation on the expression/phosphorylation of connexin (cx ) and heat shock protein (hsp ), two proteins playing a key role in maintenance of iejs and actin dynamics respectively. results: we show that α ampk is required to sustain the level of cx expression as it was drastically reduced in cells transfected with a sirna targeting specifically α ampk. regarding hsp , its expression level was not affected by α ampk deletion. however, both ampk activators increased its phosphorylation on ser , in a α ampkdependent manner, while they had no effect on cx . our results also reveal that hsp phosphorylation concurred with the appearance of actin stress fibers at the periphery of cells, suggesting a beneficial role for phsp as well as f-actin stress fibers in vascular barrier function through reinforcing the endothelial tethering. conclusions: our work identifies the regulation of cx expression and hsp phosphorylation as potential protective responses underlying the beneficial action of ampk against endothelial barrier dysfunction. ampk could consequently represent a new therapeutic target during sepsis. introduction: sepsis induced cardiomyopathy (sic) is a serious condition during sepsis with a mortality rate up to % ( ) . sic is clinically manifested with left ventricle impaired contractility ( ) . melusin is a muscle-specific protein involved in sustaining cardiomyocyte survival thorough the activation of akt signaling pathways ( ) . pi k-akt signaling pathway plays a pivotal role in regulating calcium channel activity ( ) . we hypothesized that melusin overexpression could exert a protective effect on cardiac function during septic injury. methods: animals were treated with an intraperitoneal injection of lipopolysaccharide (lps) at mg/kg. sv strain knockout mice (ko) for melusin gene and fvb strain with cardiac-specific overexpression (ov) of melusin were compared. each group was studied together with a control group (wt). hemocardiac parameters were studied at hour and hours through echocardiography. another cohort of animals was sacrificed hours after mg/kg lps treatment and cardiac tissues and blood sample were harvested for wb analysis to quantify the expression of akt, p-akt and cacna c and elisa analysis for troponin levels. results: sv wt, ko melusin and fvb wt mice groups, fractional shortening (fs) was significantly impaired after lps challenge and was associated with compensatory tachycardia (fig. ) . fvb ov mice group didn't show decrease in fs. consistent with the increased akt phosphorylation observed in ov mice, the expression of cacna c was also significantly higher both at basal levels and after lps treatment in ov mice compared to wt mice (fig. ) . troponin levels didn't differ between mice groups after lps treatment conclusion: melusin has protective role in lps induced cardiomyopathy, likely through akt phosphorylation controlling the cacna c protein density. introduction: liver dysfunction is frequent in sepsis, but its pathophysiology remains incompletely understood. since altered liver function has also been described in icu patients without sepsis [ , ] , the influence of sepsis may be overestimated. we hypothesized that sedation and prolonged mechanical ventilation after abdominal surgery is associated with impaired liver function independent of sepsis. methods: sedated and mechanically ventilated pigs underwent abdominal surgery for regional hemodynamic monitoring and were subsequently randomized to fecal peritonitis and controls, respectively (n= , each), followed by h observation. indocyanine green (icg) retention rate minutes after injection of . mg/kg icg (icg r ) was determined at baseline, and , and h after sepsis induction (si), and at the same time points in controls. concurrent with icg r , plasma volume, total hepatic perfusion (ultrasound transit time), and bilirubin and liver enzymes were measured. anova for non-parametric repeated measurements was performed in both groups separately. results: icg r increased over time without significant differences between groups (table ). there was a parallel increase in bilirubin in septic but not control animals. the other measured parameters were similar in both groups at the end of the experiment. conclusion: liver function was impaired under sedation and prolonged mechanical ventilation after abdominal surgery, even in animals without sepsis. the underlying reasons should be further explored. introduction: previous work has shown the cytoprotective properties of antithrombin-affinity depleted heparin (aadh), by neutralization of cytotoxic extracellular histones [ ] , major mediators of death in sepsis [ , ] . aadh was produced from clinical grade heparin, resulting in preparations that have lost > , % of their anticoagulant activity. to gain insight into the mechanisms and the basic pharmacological aspects of aadh protective properties, we performed a systematic analysis of how aadh is tolerated in mice and ascertained its effects in three different in vivo models of inflammation and infection. methods: dose ranging studies, short term and medium term, were performed in c bl/ mice. the effects of i.v. administration of extracellular histones in the presence or absence of aadh were assessed in mice. we further analysed the effect of aadh in models of concanavalin a-and mrsa-mediated lethality. in all studies we assessed clinical signs, lab parameters and histology. results: aadh was well tolerated in both short term and intermediate term (till days) experiments in mice, in the absence of any signs of tissue bleeding. aadh was able to revert the cytotoxic properties of i.v. administered histones. in a concanavalin a mediated model of sterile inflammation, we confirmed that aadh has protective properties that counteract the cytotoxic effects of extracellular histones. in an in vivo lethal mrsa model, for the first time, aadh was shown to induce a survivalbenefit. conclusions: we conclude that aadh contributes to the overall increased survival by means of neutralization of extracellular histones and represents a promising product for further development into a drug for the treatment of inflammatory diseases and sepsis. introduction: urokinase (uk) and tissue plasminogen activator (tpa) mediate thrombolytic actions by activating endogenous plasminogen. thrombomodulin (tm) complexes with thrombin to activate protein c and thrombin activatable fibrinolysis inhibitor (tafi). activated protein c (apc) modulates coagulation by digesting factors v and viii and activates fibrinolysis by decreasing pai- functionality. methods: the purpose of this study is to compare the effects of rtm and apc on urokinase and tpa mediated thrombolysis utilizing thromboelastography. results: native whole blood was activated using a diluted intrinsic activator (aptt reagent, triniclot). the modulation of thrombolysis by tpa and uk (abbott, chicago, usa) was studied by supplementing these agents to whole blood and monitoring teg profiles. apc (haematologic technologies, vt, usa) and rtm (asahi kasai pharma, tokyo, japan) were supplemented to the activated blood at . - . ug/ml. the modulation of tpa and uk induced thrombolysis by apc and rtm was studied in terms of thromboelastograph patterns. the effect of both apc and rtm on plasma based systems supplemented with tpa was also investigated. patients treated with antibiotic therapy were eligible for inclusion. the plausibility of infection (definite, probable, possible, none) was determined based on the centers for diseases control (cdc) criteria. patients with sepsis (definite/probable/possible infection and a sofa score increase of >= ) were screened for death within days and secondary infections h to days after icu admission, using the cdc criteria. hla-dra and cd mrna expressions were determined by reverse transcription quantitative pcr. results: among icu admissions, a blood sample for rna analysis was collected in cases. two hundred fifty-seven patients met the inclusion criteria and provided written informed consent. sepsis was noted in patients. the sepsis patients experienced death in cases ( %), secondary infection in cases ( %), and death and/or secondary infection in cases ( %). table shows the results of hla-dra and cd expression related to death and secondary infections. conclusions: the mrna expression of hla-dra on icu admission was significantly decreased in patients with sepsis who died or contracted secondary infections within days. cd expression was not significantly decreased in patients with negative outcome. introduction: acid-base disturbances are common in patients with infection admitted to the intensive care unit (icu). more attention is given to hyperlactatemia in this patient population as a prognostic factor, although other acid-base disturbances may also have an impact on patient outcomes. our objective is to describe the acid-base profile of this patient population and determine the association between different acid-base abnormalities and icu mortality. methods: retrospective cohort of patients admitted with infection to an intensive care unit. patients were stratified according to ph (< . ; . - . ; > . ) and, then, according to the standard base excess (sbe) (< - ; - -+ ; > + ). in each of these strata and the whole population, the proportions of acid-base disturbances were quantified during the first hours of icu admission. to assess the association between acid-base disturbances and outcome, a logistic regression model was fit, adjusting for age, sex and saps score. results: patients were analysed. ( %) patients were acidemic and ( %) presented with a normal ph. metabolic acidosis (as assessed by sbe) was observed in all subgroups, regardless of ph levels (ph < ). lactic acidosis was observed in % of the whole population; sig (strong ion gap) acidosis, in %; sid (hyperchloremic) acidosis, in %; metabolic alkalosis, in %; and respiratory acidosis, in % of the patients. introduction: sepsis-induced brain dysfunction has been neglected until recently due to the absence of specific clinical or biological markers. there is increasing evidence that sepsis may pose substantial risks for long term cognitive impairment. methods: to find out clinical and inflammatory factors associated with acute sepsis-induced brain dysfunction (sibd) serum levels of cytokines, complement breakdown products and neurodegeneration markers were measured by elisa in sera of sibd patients and healthy controls. association between these biological markers and cognitive test results was investigated. results: sibd patients showed significantly increased il- , il- , il- and c d levels and decreased tnf-α, il- , c a and ic b levels than healthy controls. no significant alteration was observed in neuronal loss and neurodegeneration marker (neuron specific enolase (nse), amyloid β, tau) levels. increased il- β, il- , il- , il- , tnf-α and decreased c d, c a and ic b levels were associated with septic shock, coma and mortality. transient mild cognitive impairment was observed in of patients who underwent neuropsychological assessment. cognitive dysfunction and neuronal loss were associated with increased duration of septic shock and delirium but not baseline serum levels of inflammation and neurodegeneration markers. conclusions: increased cytokine levels, decreased complement activity and increased neuronal loss are indicators of poor prognosis and adverse events in sibd. cognitive dysfunction and neuronal destruction in sibd do not seem to be associated with systemic inflammation factors and alzheimer disease-type neurodegeneration but rather with increased duration of neuronal dysfunction and enhanced exposure of the brain to sepsisinducing pathogens. introduction: high levels of some aromatic microbial metabolites (amm) in serum are related to the severity and mortality of critically ill patients [ ] . several studies have discussed the imbalance and loss of the diversity of gut microbiota but there are practically no data on the gut microbial metabolites in critical conditions, only a little -in healthy people [ , ] . the aim of this work is to analyze the connection between serum and fecal levels of amm in icu patients. methods: simultaneously serum and fecal samples (sfs) from icu patients with nosocomial pneumonia (group i), sfs from icu neurorehabilitation patients (group ii) and sfs from healthy people were taken for gc/ms analyses. the following amm were measured: phenylpropionic (phpa), phenyllactic (phla), p-hydroxybenzoic (p-hba), p-hydroxyphenyllactic (p-hphla), p-hydroxyphenylacetic (hphaa), p-hydroxyphenylpropionic (p-hphpa) and homovanillic (hva) acids. data were presented as medians with interquartile range (ir, - %) using statistica . results: the sum of the level of most relevant metabolites ( amm) -phla, p-hphla, p-hphaa, and hva -in serum samples from group i and group ii were equal to . ( . - . ) μ m and . ( . - . ) μ m, respectively, and were higher than in healthy people - . ( . - . ) μ m (p< . ). we suppose the presence of the correlation of amm profile in blood and intestine. particularly, sfs of healthy people are characterized by the prevalence of phpa; amm are not detected in feces of non-survivors but only hva dominates in their serum in the absence of other (fig. ) . conclusions: the amm profiles in gut and serum are interrelated; amm in serum probably reflect the violation and loss of biodiversity of the gut microbiota in critically ill patients. introduction: since nitrogen oxide (no) is an essential component of the immune system, the dynamics of plasma no concentration was studied in order to predict the development of sepsis [ , ] . methods: with the permission of the ethics committee included the full-term newborns with respiratory diseases on a ventilator, retrospectively divided into two groups (i, n= -sepsis - days; ii, n= without sepsis), at , - , days was studied by elisa the plasma concentration of no, nos- , nos- , adma (multilabel coulter victor- , finland). to select points "cut-off" used the method of roc-lines. results: the statistical power of the study was . % (α< . ). at admission in patients of groups i and ii decrease the concentration of no and increased adma in plasma (p< . ) relative to healthy newborns. after - days, relatively in patients of groups introduction: sepsis-associated disseminated intravascular coagulation (sac) is associated with decreased platelet counts and formation. the widespread activation of platelets contribute to vascular occlusions, fibrin deposition, multi-organ dysfunction, contributing to a two-fold increase in mortality. the purpose was to measure markers of platelet function in the plasma of patients with clinically established sac and to determine association to disease severity and outcome. methods: plasma samples from adult intensive care unit (icu) patients with sepsis and suspected sac were collected at baseline and on days and . dic scores were calculated using platelet count, d-dimer, inr, and fibrinogen. patients were categorized as having no dic, non-overt dic, or overt dic. plasma levels of cd l, von willebrand factor (vwf), platelet factor- (pf- ), and microparticles (mp) were quantified using commercially available elisa methods. results: markers of platelet activation were significantly elevated in patients with sepsis alone and with suspected dic compared to normal healthy individuals on icu day (p< . ). levels of platelet-associated biomarkers were compared between survivors and non-survivors. pf- was significantly decreased in non-survivors compared to survivors (p = . ). patients were stratified based on platelet count and levels of markers were compared between groups. cd l, vwf, pf , and mp showed significant variation based on platelet count, with all markers exhibiting stepwise elevation with increasing platelet count. conclusions: markers of platelet activation were significantly elevated in patients with sac compared to healthy individuals. pf levels showed significant difference based on dic score or mortality, and differentiated the non-survivors compared to survivors. cd l, vwf, pf , and mp showed significant association with platelet count, increasing in a stepwise manner with increases in platelet count (table ) . prognostic value of mean platelet volume in septic patients: a prospective study a chaari king hamad university hospital, bussaiteen, bahrain critical care , (suppl ):p introduction: mean platelet volume (mpv) has been reported as a valuable marker of inflammatory diseases. the aim of the current study is to assess the prognostic value of mpv in septic patients. methods: prospective study including all patients admitted to the intensive care unit (icu) with sepsis or septic shock. demographic, clinical and laboratory data were collected. the mpv was checked on admission and on day . two groups were compared: survivors and non-survivors. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] days in survivors and . [ . - ] days in non-survivors (p= . ). conclusions: the decrease of the platelet count but not the increase of the mpv was associated with increased mortality in critically-ill septic patients. endotoxin activity assay levels measured within hours after icu admission affected patients' severity assessments a kodaira , t ikeda , s ono , s suda , t nagura tokyo medical university, tokyo, japan, introduction: sepsis profoundly alters immune homeostasis by inducing first a systemic pro-inflammatory, then an anti-inflammatory state. we evaluate the prognostic value of ex vivo lipopolysaccharide (lps) stimulation of whole blood in septic patients, at day and after intensive care unit (icu) admission. methods: this prospective cohort study included patients with severe sepsis or septic shock admitted to a surgical icu of a university hospital. blood was drawn on day and day , and stimulated ex vivo with lps for hours. tumor necrosis factor alpha (tnf), interleukin (il) , il and il were measured. twenty-three healthy adults served as controls. outcomes were ventilator and icu-free days, sofa score at day and , and need for dialysis during the course of sepsis. results: forty-nine patients were included (mean age ± years). the blood of septic patients was less responsive to ex vivo stimulation with lps than that of healthy controls, as demonstrated by lower tnf, il , il and il release ( fig. ). at day , patients above the th percentile of il release had significantly fewer ventilator and icu-free days than those in the lower th percentile (fig. ) . in contrast, patients in whom il release increased between day and day had significantly lower sofa scores at day and and need for dialysis, and more icu-free days than patients in whom il release decreased (table ) . conclusions: greater lps-stimulated il release in septic patients at day was associated with poorer clinical outcomes and may reflect the severity of the forthcoming immunoparalysis. however, an increase in il release between day and day was associated with favorable outcomes, perhaps signaling immune restoration. introduction: hyperthermic intraperitoneal chemotherapy with cytoreductive surgery (hipec-crs) is a curative treatment modality for peritoneal carcinomatosis. extensive debulking surgery, peritoneal stripping and multiple visceral resections followed by intraperitoneal installation of heated high-dose chemotherapeutic agents, a process leads to a 'high-inflammatory' syndrome. serum procalcitonin (pct), a biomarker for bacterial sepsis, in the heightened inflammatory state after hipec-crs might be of limited utility. our aim is to determine the trends of pct in the early postoperative phase of hipec-crs and to identify trends in patients with and without bacterial sepsis methods: in a case-control design, we reviewed all patients undergoing hipec-crs over a -month period ( ) ( ) ( ) . patients were divided into groups based on whether they developed bacterial sepsis in the first days after surgery (infected v/s non-infected). summary data are expressed as medians and ranges. two-tailed nonparametric tests were performed and considered significant at p values of less than . results: patients' data was analyzed. infections developed in % ( patients) with escherichia coli as the predominant pathogen isolated ( % isolates). pct levels (ngm/ml) were elevated postoperatively in both infected and non-infected patients; day infected . (iqr . introduction: early outcome in cardiac surgery has been an area of growing interest where the given risks raise several predictive models for assessment of postoperative outcome [ ] . procacitonin (pct) emerges as a possible predictive tool in cardiothoracic intensive care unit (cticu).we aim at testing the predictive power of pct for early morbidity, prolonged ventilation, icu and hospital stay, in patients developing early fever after cardiac surgery methods: a retrospective descriptive study done in tertiary cardiac center, enrolling patients who stayed for more than hours post-operatively in the cticu risk stratification included additive euro score and pct immunoluminometricaly prior to surgery and every hours in response to onset of fever. results: we screened consecutive patients who underwent open heart cardiac, of which patients were enrolled in the study. patients were divided into two groups based on the level of pct, those with value > ng/ml (group ) and those with level < ng/ml (group ). patients in group as compared to group , over the postoperative course was associated with prolonged icu stay (p= . ), length of mechanical ventilation (p= . ), length of hospitalization (p= . ), acute kidney injury (p= . ) and culture positivity (p= . ). multivariate analysis showed that pct > ng/ml was was significantly associated with positive cultures. (p= . ) conclusions: a rise of serum pct carries the signals of early icu morbidity and lengths of ventilation, icu stay and hospital stay methods: patients aged ( - ) days ( - days) underwent cardiac surgery with cardiopulmonary bypass for severe congenital heart disease. in the dynamics levels of pct, mr-proadm, ct-proavp and mr-proanp were measured before surgery and on the , , and days after the operation with the kryptor compact plus analyzer. data are presented as medians with interquartile range. the mann-whitney u-test was used to compare the data. values of p < . were statistically significant. results: patients ( %) required alv for more than hours. in this group statistically significant higher levels of pct, mr-proadm and mr-proanp were found throughout the period ( table ). the level of ct-proavp had increased to statistical significance since the day after the operation. patients were in the icu for more than hours. in this group statistically significant higher levels of pct, mr-proadm were found throughout the whole period ( table ). the higher level of mr-proanp was statistically significant on the st and th days after surgery, mr-proanp had a tendency of increasing values on nd and rd days. ct-proavp increased to statistical significance since the nd day after the operation and persisted throughout the studied period. conclusions: pct, mr-proadm and mr-proanp can be used as predictors of prolonged alv for children of the first year of life after cardiac surgery with cardiopulmonary bypass. the level of ct-proavp can be considered since the day after surgery. pct and mr-proadm may be used to predict the los in the icu. mr-proanp and ct-proavp can be considered since the and days after surgery respectively. introduction: early prediction of the risk of death among patients admitted at the emergency department (ed) remains an unmet need. the prognostic performance of hbp that is secreted by neutrophils was prospectively validated in a series of sequential ed admissions. methods: hbp and elements of qsofa were analyzed prospectively in serial ed admissions (main reasons for admission: acute abdominal pain . %; fever . %; vomiting/diarrhea . %; dyspnea . %; neurologic signs . %; non-specific complaints . %; most patients admitted for more than one reasons). upon ed admission patients were scored as low-risk, intermediate-risk and high-risk at the discretion of the physician. hbp was measured in blood samples upon admission by an enzyme immunosorbent assay. results: hbp was significantly greater among patients who died very early (fig. ). in five out of six of patients dying early hbp was greater than ng/ml. we combined hbp more than ng/ml and the presence of one sign of qsofa into a new score; this had . % sensitivity to predict -day mortality. the respective sensitivity of two signs of qsofa was . % (p: . ). the use of this new score allowed better stratification of patients originally considered at the triage as low-risk into high-risk (fig. ) . conclusions: we propose hbp more than ng/ml and one qsofa sign as an early score for -day mortality at the ed. introduction: despite of our growing knowledge in pathophysiology of septic shock still remain one of the most important factors of hospital mortality. it is thought that early diagnosis and treatment at early stage of septic shock would decrease its mortality. there have been on-going studies in recent years which research the usability of heparin binding protein (hbp) in early diagnosis of sepsis [ ] . to seek the usability of c-reactive protein (c-rp), procalcitonin (pct) and hbp biomarker combination in early diagnosis of septic shock. methods: patients, who have the diagnosis of septic shock, that are expected to stay in intensive care unit more than hours, and aged between - are included in the study. data are collected from the patients' blood samples that are drawn on admission, on the th hour, and on the day of discharge or death. results: it has been found in our study that, best "cut-off" value ng/ml, specificity . and sensitivity . for hbp. compared with other biomarkers, hbp was the best predictor of progression to organ dysfunction (area under the receiver operating characteristic curve (auc) = . ). conclusions: although there have been many biomarkers for early diagnose of septic shock, c-rp and pct are the most common used markers in nowadays' clinical practice. the usability of hbp in early diagnosis of sepsis is still being researched. we concluded that pct, c-rp and hbp biomarker combination is usable to diagnose septic shock at the end of our study. introduction: reduced adamts- and increased von willebrand factor (vwf)/adamts- ratio have been observed in sepsis and are associated with the severity of the disease [ , ] . however, their change during the septic episode and in the event of a change in the clinical status of the septic patients has not been investigated. the aim of the study was to assess the variation of these hemostatic parameters in critically ill patients during the course of a septic episode. methods: we monitored septic patients admitted in the intensive care unit (icu). improved (group a) while deteriorated (group b). we assessed vwf, adamts- and the vwf/adamts- ratio on admission in icu (time point ) and at the time of a change in patients' clinical condition (remission or deterioration, time point ). results: in group a, adamts- and the vwf/adamts- ratio did not significantly change ( . ± . vs . ± . conclusions: hemostatic disorders, as assessed by vwf and adamts- levels were detected in septic patients, while their changes differed according to the evolution of the septic episode. adamts- changes may be associated with outcome. methods: adult patients with at least one sign of qsofa and infection or acute pancreatitis or after operation were prospectively followed-up. blood was sampled the first hours; those with hiv infection, neutropenia and multiple injuries were excluded. sepsis was diagnosed using the sepsis- criteria. soluble urokinase plasminogen activator receptor (supar) was measured by an enzyme immunoassay. results: sixty patients were classified with sepsis using the sepsis- definitions. presence of at least two signs of qsofa had . % sensitivity, . % specificity, . % positive predictive value and . % negative predictive value for the diagnosis of sepsis. the integration of qsofa signs and supar improved the diagnostic performance ( fig. ) . conclusions: conclusions two signs of qsofa have significant positive prognostic value for sepsis but low sensitivity. this is improved after integration with supar. the intelligence- study is supported by the european commission through the seventh framework programme (fp ) hemospec. introduction: sepsis is a frequent reason for admission in the emergency department (ed) and its prognostic mainly relies on early diagnosis. in addition, no validated prognostic tool is currently available. therefore, identification of patients at high risk of worsening in the ed is key. the triage objective was to assess the prognostic value of a blood marker panel to predict early clinical worsening of patients admitted in the ed with suspected sepsis. methods: triage was a prospective, multicenter ( sites in france and belgium) study on biological samples conducted in partnership with biomerieux s.a. patients admitted in the ed with suspected or confirmed community-acquired infection for less than h were included. exclusion criteria were: admission in the ed for more than hours, septic shock at admission, immunodepression, sepsis syndrome days prior to admission. the protocol included clinical and biological time points (h , h , h , h , d ). patients were classified in groups at admission (infection, sepsis, severe sepsis) and divided into evolution/prognosis groups depending on worsening or not from their initial condition to severe sepsis or septic shock and sofa score's evolution. the evolution criteria were centrally evaluated by an independent adjudication committee of sepsis experts including emergency physicians and intensivists. patients were followed up to day for mortality. results: the study duration was years with patients included ( excluded). the centralized analysis is in progress to select the combination of biomarkers with the best prognostic performance comparing both evolution/prognosis groups. currently, patients have been classified as worsening and some results will be available in . conclusions: triage is the largest prospective multicenter study assessing the prognostic value of a panel of blood markers in eds which could help identification of septic patient at risk of worsening at time of admission in the ed and develop specific management. introduction: immune status characterization in intensive care unit (icu) patients presents a major challenge due to the heterogeneity of response. in this study, the filmarray® system was used with customized gene assays to assess the immune profile of critically-ill icu patients compared to healthy volunteers; from within the realism cohort. methods: a customized filmarray® pouch containing assays was designed; target and reference genes. detection and semiquantification of assays from whole blood collected in paxgene tubes occurs in the device within hour. a total of subjects from the realism cohort were tested in duplicates: trauma, septic shock and surgery patients, along with healthy volunteers. the patients' selection was based on hla-dr expression on monocytes, and pha-(phytohaemagglutinin) stimulated t-cell proliferation assay, to have various immune profiles. results: quantification cycle values of the target genes were normalized by the geometrical mean of reference genes to account for the different cell counts among specimens. the number of the cd + cells and hla-dr, determined by flow cytometry, showed good correlation to cd d and cd gene expression, respectively. seven genes showed significant differences in expression levels between the healthy volunteers and patient groups: cd d, cd , ctla & cx cr were down-regulated, while il- , il rn and s a were up-regulated in the patient populations. the use of relative quantitative difference of some markers was able to distinguish and introduction: early, rapid diagnosis is integral to the efficient effective treatment of sepsis; however, there is no gold standard for diagnosis, and biochemical surrogates are of limited and controversial utility. the cytovale system measures biophysical properties of cells by imaging thousands of single cells per second as they are hydrodynamically stretched in a microfluidic channel. this platform has been shown to measure dozens of mechanical, morphological, and cell surface biomarkers of wbc activation simultaneously [ , ] . in this study, we show the performance of the cytovale system in measuring biophysical markers for sepsis detection in the emergency department (ed). methods: we conducted an irb-approved prospective cohort study of emergency department (ed) patients with + sirs criteria and evidence of organ dysfunction. patients were included for analysis. blood samples for the cytovale assay were collected in the ed, and the diagnosis of sepsis was adjudicated by blinded clinician review of the medical record. captured imaging data were analyzed using computer vision to quantify mechanical parameters per cell, and a logistic model was trained to discriminate patients who had sepsis from those who did not. results: we found substantial biophysical differences between cells from septic and non-septic patients as observed at both the single cell level (fig. ) and when looking at the overall leukocyte populations (fig. ) . a multiparameter classification algorithm to discriminate septic from non-septic patients based on biophysical markers currently yields a sensitivity of % with a negative predictive value of %. conclusions: in patients presenting to the ed with of sirs criteria and evidence of organ dysfunction, the cytovale system provides a potentially viable means for the early diagnosis of sepsis via the quantification of biophysical properties of leukocytes. oxidative stress and other biomarkers to predict the presence of sepsis in icu patients v tsolaki, m karapetsa, g ganeli, e zakynthinos icu, larissa, greece critical care , (suppl ):p introduction: early identification of sepsis adds a survival benefit in icu patients. several biomarkers have been evaluated, yet an optimal marker is still lacking [ ] . methods: we prospectively determined oxidative status in patients admitted in a general intensive care unit of the university hospital of larisa. oxidative status was determined measuring the novel static (sorp) and capacity (corp) oxidation-reduction potential markers. other biomarkers (bnp, presepsin, crp) were measured, and the discriminative properties for the detection of sepsis were evaluated. results: oxidative status was evaluated in a hundred and fifty two consecutive patients. patients with severe sepsis and septic shock had significantly higher sorp values than patients without sepsis ( introduction: c-reactive protein (crp), is reported to be an effective marker for the assessment of vascular inflammation activity and acute coronary events prediction [ ] .we hypothesized that preoperative crp elevation is related to the occurrence of postoperative adverse cardiovascular outcomes. methods: we prospectively included patients scheduled to undergo different vascular surgeries from december to september . we assessed demographic data, comorbidities, revised cardiac risk index (rcri) and biomarkers (crp, cardiac troponin high sensitive ths, creatinine and urea) in the preoperative period. we also noted type and duration of surgery, intraoperative blood loss, icu stay and mortality. we evaluated crp as a predictive marker of major cardiovascular events defined as chest pain, ths elevation, electrocardiogram changes, arrhythmia, pulmonary embolism, stroke occuring within postoperative months. results: during our study, patients were scheduled to undergo vascular surgeries. from the patients, % developed adverse cardiac events (table ) . we showed the predictive value of crp in major cardiovascular event in a roc analysis (fig. ) . the cuttoff value of cpr was giving % of sensitivity and % of specificity. conclusions: our study pointed out that crp preoperative elevation could have a very strong predictive value of post-operative cardiovascular events in vascular surgery, this is in line with results showed by previous studies [ ] . introduction: elderly are particularly susceptible to bacterial infections and sepsis, and they comprise an increasing proportion of intensive care unit (icu) admissions. our aim was to evaluate the impact of age on critically ill infected patients. methods: we performed a post-hoc analysis of all infected patients admitted to icu enrolled in a -year prospective, observational, multicenter study involving icus. patients aged < , - and >= years were compared (group a, b, and c). multidrug-resistance (mdr) was defined as acquired non-susceptibility to at least one agent within three or more antimicrobial categories. results: of the patients analyzed, ( . %) were infected on icu admission. of these, ( %) belonged to group a, ( %) to group b and ( %) to group c. group c were more dependent, had higher saps ii and charlson scores (p< . ). icu and hospital length of stay did not differ between groups. microorganism isolation and bacteremia were higher in group b ( % and %, respectively) than groups a ( % and %, respectively) and c ( % and %, respectively; p< . ). septic shock was present in % of patients and was more frequent in groups b ( %) and c ( %) than group a ( %). the most common sources of infections were respiratory and intra-abdominal. isolation of gram-negative bacteria was significantly increased in group b and c (p= . ). the most common isolated bacteria were escherichia coli ( %), staphylococcus aureus ( %) and pseudomonas aeruginosa ( %) for all groups. in total, isolates ( %) corresponded to mdr bacteria, of which % were staphylococcus aureus. age was not a risk factor for infection by mdr. all-cause mortality in icu and hospital was: % and %; % and %; % and % -respectively for groups a, b, and c (p < . ). conclusions: old patients ( - years) were more prone to present with bacteremia, which could account for the increased severity of sepsis and higher all-cause mortality. age was not a risk factor for mdr infection. introduction: the rapid identification of pathogens using patient samples is crucial. delays in this can potentially have serious implications for patients and infection prevention/control [ ] . the aim of this project was to identify the number of microbiology samples sent, the number rejected and reasons for rejection, with the intention to reduce such instances. methods: data was collected retrospectively on icu admissions from january-june to a university hospital in the uk. patients were identified and data collected using the intensive care national audit and research centre (icnarc) database and from electronic patient records. data collected included: demographics, length of stay, microbiology samples sent and details on the rejected samples. results: patients were identified with a total of (median: samples/patient) samples sent to microbiology. were rejected ( %). ( %) patients had at least sample rejected. the median number of samples rejected per patient was (range: - ). the fig. (abstract p ). the area under the curve for crp elevation is . most common samples rejected were urine ( %), blood ( %), faeces ( %) and sputum ( %). ( %) of the samples were resent for testing (median day; range - ). reasons for sample rejection are shown in table . most rejections occurred within -hours of admission ( fig. ) . conclusions: this study confirms a high number of samples are sent to microbiology. although a few are rejected, overall this represents a large number, with most occurring during the first days of admission. reasons for sample rejection are remedial through improved training and vigilance. a bespoke guide to sample collection for microbiology coupled with a training program for healthcare professionals has been introduced with the aim to reduce sample rejections from % to . %. introduction: careful hand hygiene of health-care workers (hcws) is recommended to reduce transmission of pathogenic microorganisms to patients [ ] . mobile phones are commonly used during work shifts and may act as vehicles of pathogens [ , ] . the purpose of this study was to assess the colonization rate of icu hcws' mobile phones before and after work shifts. methods: prospective observational study conducted in an academic, tertiary-level icu. hcws (including medical and nursing staff) had their mobile phones sampled for microbiology before and after work shifts on different days. samples were taken with eswab in a standardized modality and seeded on columbia agar plus % sheep blood. a semiquantitative growth evaluation was performed at and hours after incubation at °c. results: fifty hcws participated in the study ( % of department staff). one hundred swabs were taken from mobile phones. fortythree hcws ( %) reported a habitual use of their phones during the work shift, and of them ( . %) usually kept their mobiles in the uniform pocket. all phones ( %) were positive for bacteria. the most frequently isolated bacteria were coagulase negative staphylococcus, bacillus sp. and mrsa ( %, %, %, respectively). no patient admitted to the icu during the study period was positive for bacteria found of hcws' mobile phones. no difference in bacteria types and burden was found between the beginning and the end of work shifts. conclusions: hcws' mobile phones are always colonized mainly by flora resident on hcw's hands, even before the work shift and irrespective of the microbiological patients' flora. further studies are warranted to investigate the role of mobile phones' bacterial colonization in the icu setting and to determine whether routine cleaning of hcws' mobile phones may reduce the rate of infection transmission in critical patients. methods: sixty samples were collected from aicu (n= ), picu (n= ) and or (n= ) during august to september . samples were randomly selected and taken at the end of the hcws duty with a sterile swab covering all mp surfaces. the inoculation was made into blood sheep and eosyn methilene blue agar for culture. isolated bacteria were identified according to standard microbiological techniques. antibiotic sensitivity testing was performed using disc diffusion method. results: overall mp bacterial colonization rate was %. main results are detailed in table . most common non pathogenic bacteria was staphylococcus epidermidis n= ( %). isolated pathogenic bacteria conclusions: we found high rates of mp colonization with pathogenic bacteria. an educational program is necessary to reduce the contamination and transmission of these high risk microorganisms. introduction: the objective of this study was to evaluate the variability in the dynamics and levels of airborne contamination within a hospital intensive care unit in order to establish an improved understanding of the extent to which airborne bioburden contributes to cross-infection of patients. microorganisms from the respiratory tract or skin can become airborne by coughing, sneezing and periods of increased activity such as bed changes and staff rounds. current knowledge of the clinical microflora is limited however it is estimated that - % of nosocomial infections are transmitted via air. methods: environmental air monitoring was conducted in glasgow royal infirmary icu, in the open ward and in patient isolation rooms. a sieve impactor air sampler was used to collect l air samples every minutes over hour ( : - : h) and hour ( : - : h) periods. samples were collected, room activity logged and the bacterial contamination levels were recorded as cfu/m of air. results: a high degree of variability in levels of airborne contamination was observed over the course of a hour day and a period in a hospital icu. counts ranged from - cfu/m over hours in an isolation room occupied for days by a patient with c. difficile infection. contamination levels were found to be lowest during the night and in unoccupied rooms, with an average value of cfu/m . peaks in airborne contamination showed a direct relation to increased room activity. conclusions: this study demonstrates the degree of airborne contamination that can occur in an icu over a hour period. numerous factors were found to contribute to microbial air contamination and consideration should be given to potential improved infection control strategies and decontamination technologies which could be deployed within the clinical environment to reduce the airborne contamination levels, with the ultimate aim of reducing healthcareassociated infections from environmental sources. new practice of fixing the venous catheter of the jugular on the thorax and its impact on the infection f goldstein, c carius, a coscia quintad'or, rio de janeiro, brazil critical care , (suppl ):p introduction: central line-associated bloodstream infection (clabsi) is an important concern in the icu, mainly in those with a high density of use of central venous catheter. any measures that may have an impact on the reduction of clabsi are important in reducing morbidity and mortality of hospitalized patients. therefore we present a retrospective study comparing the fixation site (neck vs. thorax) of the catheters implanted in the jugular vein, guided by ultrasonography and evaluating its impact on the incidence of clabsi. the purpose of our study was to identify if there is any positive impact on the reduction of clabsi when the catheter is fixated on the thorax. methods: a retrospective unicentric study comparing the infection rates between the year of , when the traditional technique of catheter fixation on the neck was used, and , when % of the catheters were fixated on the thoracic region. the criteria for clabsi were defined by the infection commission of quintad`or hospital and the data on clabsi were provided by the same commission. during this period there were no changes in the team of our unit and the patient's profile was the same. no deep vein catheter impregnated with antibiotics were used in the patients included in the study. the comparison used fisheŕs test as a tool. all the patients hospitalized in the intensive care unit with indication of the central venous catheter of short permanence in the internal jugular vein were included. patients with the central venous catheter of short permanence in other topographies, patients with hemodialysis catheter or with picc were excluded. results: during the year of , internal jugular vein catheters were installed in our unit using the traditional technique, fixing the catheter on the neck. in this period, cases of clabsi were detected. on the other hand, in the year of , internal jugular vein catheters were installed in the same unit, all of them, using the thorax as the point of fixation. although the number of catheters installed this year was higher, there was no case of clabsi. it appears that this position, provides a better fixation of the catheter, avoiding that the bandage gets uncovered. conclusions: during the year of , though there were more patients using deep vein catheters of short permanence, we had less clabsi events on our unity compared to the year of . fisher's exact test identified a p-value of this association of . . fixation of the internal jugular vein catheter in the thorax seems to contribute to the prevention of clabsi. further prospective and randomized studies are required to evaluate the contribution of fixation of the jugular vein catheter in the thorax in the clabsi prevention. introduction: the oral cavity of a patient who has been hospitalized presents a different flora from normal healthy people. after h hours of hospital stay, the flora presents a bigger number of microorganisms that can be responsible for secondary infections, like pneumonia, because of their growth and proliferation. the objective of our study was to assess the dental plaque index on patients on admission to an intensive care unit, and reassess days later, to evaluate the efficacy of oral hygiene. methods: prospective, descriptive and observational study in an intensive care unit of the chp. demographic, admission motive, hospital length of stay, feeding protocol, respiratory support need and oral hygiene protocol data was collected. the greene & vermillion simplified oral hygiene index (iho-s) was used as the assessment tool on the first h and on th day. results: patients were evaluated, of which were excluded for not meeting the minimal dentition. patients had a mean age of , ± , years, , % were males and most of medical and surgical scope ( , % each). mean hospital length of stay was , ± , days. the majority of patients were sedated ( %), under ventilator support ( , %) and with enteric nutritional support, under nasogastric tube feeding. initial iho-s score was , ± , , rising to , ± , (p< , ) days later. conclusions: various studies have proven the importance of a good oral hygiene to avoid bacterial growth and reduce the risk for nosocomial infections. in this study, we've observed a significant worsening of oral hygiene one week after admission. although this could be unimportant for a one week staying patient, it could indicate an increased risk for nosocomial infections for longer staying patients, which could benefit from a more efficient oral hygiene protocol. positive pocket cultures and infection risk after cardiac electronic device implantation-a retrospective observational single-center cohort study p pekić methods: we performed a retrospective observational single-center cohort study on patients who received de novo implantation of pacemaker, cardioverter-defibrillator or cardiac resynchronization therapy device in a two-year period. each patient was implanted using standard aseptic procedure according to local protocol and antibiotic (cefazolin) prophylaxis before the procedure. pocket aspirate was taken after irrigating the wound with normal saline just before device placement. results: we analyzed patients ( . % male, . % female). the most often implanted device was a ddd pacemaker followed by a vvi pacemaker. mean length of hospital stay was . ± . days. there were ( . %) positive cultures with overall ( . %) clinically apparent infections which required prolonged iv antibiotics, removal of device and reimplantation after infection resolution. in regard to microbiology, s. epidermidis ( . %) and coagulase negative staphylococcus ( . %) were the most often finding which is in contrast to the cultures described in the literature. the only statistically significant risk factor for positive pocket culture was male sex and presence of a urinary catheter. invasive vascular devices, previous intrahospital infection, and diabetes were not found to increase the likelihood of positive pocket culture. conclusions: positive pocket cultures after cied implant are a frequent finding mostly due to contamination and colonisation. the risk factors for such a finding differ from the usual and expected clinical circumstances. our results are consistent with those in the literature. it turns out that the most important preventive measure in cied implantation is strict aseptic procedure. introduction: intensive care patients are in constant risk of contamination due to suppression of their immune system, use of invasive procedures and medical equipment and health associated infections (hai). chlorhexidine gluconate (chg) is an antiseptic and disinfectant product. in medical research it has been found that daily chg bathing is affective in reducing levels of skin and central line related infections (climo, ) . it is also referred to in the recommendations of the ministry of health "prevention of septicemia due to central lines" ( ). methods: unit guide lines for patient dry bathing were written in may and thereafter began the implementation and instruction of nursing staff. quality control was inspected by observation. there was a phase questioner that included several categories such as: preparation of the chg solution, staff protection actions, infusions and surgical wound dressings, bathing performance and documentation. results: a gradual rise of %was observed in theperformance ofdry bathing according to the unit guidelines conclusions: % of observed dry baths where performed according to the guide lines. points for improvement: correct care of infusions and surgical wound dressing and verify use of separate wipes for each body part. next we will examine the correlation between the use of dry baths and theextent of infections in the unit. dry baths are nowconsidered an integralpart of the daily nursing routine. they have no substantial costs, help prevent complications from infection and add to the patient's safety. introduction: despite reductions in mortality reported with sdd, concerns about bacterial resistance and alteration of microbiome limit use. a retrospective observational study was conducted into the effect of local sdd protocols on vap rates and resistance patterns. over a -year period, regimens were used dependent on drug availability and hospital antibiotic stewardship concerns. the study was designed to review practice and identify any risks of partial implementation. methods: patients ventilated on a general intensive care were identified via clinical information systems. three periods were reviewed for adherence to sdd protocols, pre sdd (jan -feb ), full (july -sept ) and partial (july -sept ). high-risk patients during both sdd periods also received iv antibiotics for hours. patients admitted with pneumonia or tuberculosis were excluded from vap analysis. remaining patients' records were reviewed and the clinical pulmonary infection score (cpis) calculated for each ventilated day to identify vap rates. positive respiratory microbiological results for all patients admitted to the icu during each time period were reviewed to assess for wider changes in local resistance patterns. results: protocol adherence was assessed in patients during the full sdd period and during the partial ( table ). the number of patients included for analysis of vap rates during each period was pre sdd, during full sdd and during partial sdd. there were no significant changes in resistance patterns or clostridium difficule rates (table ) . conclusions: compliance with the available enteral antibiotics was reasonable but with iv antibiotics was poor. it is accepted that alterations and non-adherence to protocols risk development of resistant bacterial strains. within our unit no decrease in vap rates was seen but reassuringly no increased rates of extended bacterial resistance were identified during the treatment periods. introduction: arterial catheters are commonly used in intensive care units (icu) and are among the most frequently manipulated vascular access devices. our aim was to evaluate the rate of arterial catheterrelated bloodstream infection and colonization. methods: this was a -month, prospective and monocentric cohort study, performed in a multipurpose icu. all arterial catheters, inserted in or presented to the icu, were cultured and assessed for colonization or catheter-related bloodstream infection (crbi). results: we enrolled patients ( . % males, average age ± years, saps ± ) of whom a total of arterial catheters were analyzed for a total of catheter-days. radial arterial catheters were inserted in . % (n= ), femoral arterial catheters in . % (n= ) and other arterial catheters in . % (n= ). signs of dysfunction were found in . % and . %, respectively. radial arterial catheters colonization (n= ) and crbi (n= ) occurred at a rate of . and . / catheter-days. femoral arterial catheters colonization (n= ) and crbi (n= ) occurred at a rate of . and . / catheter-days, respectively. mean catheter time insertion was significantly higher in colonized catheters/crbi ( ± days; % ci: - ) when compared to arterial catheters with negative cultures ( ± days; % ci: - ); p = . ). colonized lines showed acinetobacter baumannii (n= ), staphylococcus epidermidis (n= ), enterococcus spp (n= ) and pseudomonas aeruginosa (n= ). crbi were caused by staphylococcus epidermidis (n= ) and staphylococcus haemolyticus (n= ). conclusions: the incidence of radial arterial catheters colonization and crbi were lower than reported rates in literature. colonization and crbi rates were higher in femoral catheters. femoral catheters showed dysfunction more frequently. prolonged catheterization was associated with colonization and crbi. a multimodality approach to decreasing icu infections by hydrogen peroxide, silver cations and compartmentalization and applying acinetobacter as infection marker introduction: nosocomial infections at the intensive care unit (icu) represent a substantial health threat [ , ] . icu infections are mainly attributed to the extended hospital delay which results in high morbidities and mortalities. methods: a cross sectional study was conducted at the intensive care unit, aseer central hospital, saudi arabia over months period ( ) ( ) . the intervention program included the application of mist of hydrogen peroxide and silver cations, physical separation and compartmentalization of the intensive care unit. the glosair™ system was used to deliver a mist of hydrogen peroxide and silver cations. hydrogen peroxide is an oxidizing agent, which kills microorganisms. results: a total of strains of acinetobacter species were identified from the patients over the months period (fig. ) . the mean infection rates decreased from . in the first three months of the program to in the last three month after continuous. conclusions: the program using the three procedures offered a significant decrease in infections at the icu as measured by acinetobacter count, which is one of the most hazardous nosocomial pathogens. introduction: the efficacy of ß lactam antibiotics is related to the time above mic. continuous or extended infusions can be used to increase the time above mic, especially in patients with normal or increased drug clearance. administering antibiotics by continuous infusion is not a new concept. a review in looks at the outcomes of continuous infusions [ ] . more recently an improvement in mortality has been demonstrated [ ] . our perception was that uptake of this low cost intervention was not common, so we undertook a survey to determine how commonly continuous infusions are used in england. methods: a telephone survey of all intensive care units in england was undertaken. questions included: -are you using continuous or extended antibiotic infusions? -which antibiotics are you using for continuous or extended infusions? -if not currently using has it been considered? data was collected over a week in june . results: there was an % response rate. ( . %) of the units continuously infuse some antibiotics, however . % of those only infuse vancomycin and not ß lactams. only of the total responders ( . %) infuse antibiotics other than vancomycin (i.e. ß lactams). conclusions: the theoretical advantage of continuous infusion of ß lactam antibiotics has been described for over years. there is now evidence that this may improve survival. despite this, uptake in england has been slow. introduction: infections contribute to a significant proportion of morbidity and mortality worldwide. while many infections are successfully managed with antimicrobial therapy, rates of antimicrobial resistance (amr) are increasing. certain patient populations such as those admitted to intensive care units (icu) are at high risk. methods: we conducted a retrospective, observational study of all icu patients at a tertiary referral hospital in rwanda from january through december we collected data on diagnosis, icu length of stay, mortality and hospital length of stay, as well as microorganism, site of culture, amr and antibiotics prescribe. results: overall, patients were admitted to the icu. most patients were admitted from the main operating theater (n= , %).the most common admitting diagnoses were sepsis (n= , %), head trauma (n= , %). a total of samples were collected from patients. the samples were from blood (n= , %), tracheal aspirate (n= , %),. the most common organisms isolated were klebsiella (n= , %), acinetobacter (n= , %), e.coli (n= , %), proteus (n= , %), citrobacter (n= , %), s aureus (n= , %), pseudomonas (n= , %), and other (n= , %). of klebsiella isolates, % and % were resistant to ceftriaxone and cefotaxime, respectively. of e.coli isolates, % and % were resistant to ceftriaxone and cefotaxime, respectively. all acinetobacter isolates were resistant to ceftriaxone and cefotaxime. conclusions: there is an alarming rate of antimicrobial resistance to commonly used antibiotics in the icu. expanding antibiotic options and strengthening antimicrobial stewardship are critical for patient care. the last three days g latten , p stassen zuyderland mc, sittard-geleen, netherlands, introduction: this study provides an overview of the prehospital course of patients with a (suspected) infection in the emergency department (ed). most research on serious infections and sepsis has focused on the hospital environment, while potentially most delay, and therefore possibly the best opportunity to improve treatment, lies in the prehospital setting. methods: patients were included in this prospective observational study during a week period in . all patients aged years or older with a suspected or proven infection were included. prehospital, ed and outcomes were registered. results: in total, patients visited the ed during the study period, of whom ( . %) patients had a (suspected) infection. (fig. ) median duration of symptoms before ed visit was days (iqr - days), with . % of patients using antibiotics before arrival in the ed. most patients ( %) had been referred by a general practicioner (gp), while . % of patients had visited their gp previously during the current disease episode. twenty-two patients ( . %) experienced an adverse outcome (icu admission and/or -day all-cause mortality): these patients were less often referred by a general practicioner (gp) ( . vs. . %, p= . ) and were considered more urgent both by ems and in the ed. conclusions: the prehospital phase of patients with an infection provides a window of opportunity for improvement of care. patients become ill days before the ed visit and . % already visited their gp previously during the current disease episode, while . % is currently using antibiotics. future research should focus on quality improvement programs in the prehospital setting, targeting patients and/or primary care professionals. introduction: worldwide, the prevalence of tetanus has decreased.-however, even if progress has been made in the combat to eradicate tetanus it may be a cause of admission to intensive care.the objectives of our study are to determine epidemiological,clinical and prognostic characteristics for severe tetanus in our unit. methods: we conducted a retrospective study in the medical intensive care unit of ibn rushd hospital in casablanca in morocco from to .we studied the epidemiological,clinical and prognostic characteristics of the patients who were admitted for severe tetanus. results: the incidence of severe tetanus was . % affecting male in %. . % were aged between and years old. in . % there were a integumentary portal of entry. contractures were present in %of the cases. at intensive care unit admission, . % of the patients were sedated. the anti-tetanus vaccination was never updated. according to the dakar score . % of the patients were listed dakar , . % dakar and . % dakar . for the mollaret score, the crude form was found in . %, the acute generalized form was found in . % and the severe form in . % of the cases.mechanical ventilation was necessary in . %. diazepam and baclofen were used in . %, phenobarbital in . % and propofol in . %. a serotherapy was used for all the patients and a preliminary vaccination dose for . %. all the patients received antibiotics, penicillin g . % and metronidazole . %. the mortality was . %. the length of intensive care stay was significantly higher. the need for an intubation,its duration and the occurrence of autonomic dysfunction have significantly influenced the mortality. conclusions: to improve the prognosis in these serious forms of tetanus,it is highly important to identify the warning signs and refer patients in intensive care for early and appropriate management in intensive care. introduction: bloodstream infections (bsis) are associated with increased mortality in the icu. the aim of the study was to evaluate the epidemiology and resistance patterns during the period to . methods: bacteria and fungi isolated from the blood of patients hospitalized in a mixed icu during the study period were retrospectively analyzed. sensitivity testing was performed with disk diffusion (kirby-bauer) and microscan walkaway plus for minimal inhibitory concentrations. results: during the study period patients were hospitalized in the icu. bsis were diagnosed in cases ( . %). the isolated microorganisms were acinetobacter baumannii ( %), klebsiella pneumoniae ( %), other enterobacteriaceae ( %), pseudomonas aeruginosa ( %), stenotrophomonas maltophilia ( %), enterococci ( %), staphylococci ( %) and candida spp. ( %). of the a. baumannii isolates, % were resistant to carbapenems, . % to colistin, and % to tigecycline. of the k. pneumoniae isolates % were resistant to carbapenems, % to colistin, and . % to tigecycline. of the p. aeruginosa species % were resistant to carbapenems and they were all susceptible to colistin. the rate of resistance to vancomycin was % for the e. faecium isolates, . % for the e. faecalis, while the resistance to methicillin of the coagulase negative staphylococci was %. the most commonly isolate species of candida was c. albicans. conclusions: multi-drug resistant isolates, especially a. baumannii and enterobacteriaceae, are a serious problem in our icu. gram positive bacteria are less common, but the resistance of enterococci to vancomycin is significant. antibiotic stewardship and infection control measures should be applied in a more strict way. nosocomial sinusitis in intensive care unit patients i titov introduction: nosocomial sinusitis (ns) is a complication of critically ill patients which develops - h after admission and is mostly linked but not limited to such invasive procedures as nasotracheal intubation and nasogastric tube placement. ns is often overlooked as a source of pyrexia of unknown origin, meningeal manifestations, sepsis and ventilator associated pneumonia in icu patients. ct scanning and sinus puncture are used to confirm the inflammatory process and identify the pathogen behind it. methods: a retrospective case study of . icu patients for a period of - was performed. we have analysed data from the ct scans of paranasal sinuses and bacteriological findings of samples obtained from sinus puncture. results: ( . %) patients were suspected of ns on the - th day of stay in the icu. the ct scan confirmed pathological changes in patients ( . %). hemisinusitis was detected in patients ( . %) and pansinusitis in patients ( . %). there was also an isolated case of maxillary sinusitis in patient ( . %). the pathogenic culture was identified only in ( %) samples, . % of which revealed isolated bacteria and . % a polymicrobial association. gram positive bacteria were detected in . % of cases and gram negative in . %. most cases revealed multiple antibiotic resistance. conclusions: . ns has proved to be largely caused by gram negative bacteria and polymicrobial associations. the use of broad spectrum antibiotics in icu may justify the presence of sterile cultures. .early identification of risk patients in icu as well as the use of screening ct scan may benefit timely diagnosis and adequate treatment of patients. .preventive considerations include: patient's bed head elevation, the use of oral gastric tube in sedated and coma patients on ventilation, nasotracheal intubation only if indicated, removal of nasogastric tube at night, proper hygiene. conclusions: only of , tb patients ( %) required critical care intervention (table ) . those admitted to icu were older and more likely to have pulmonary, cns, miliary or abdominal tb (table ) . mortality was high despite critical care input in a unit familiar with managing tb, and hour access to infectious diseases advice within the trust, likely due to overwhelming organ dysfunction, patient frailty and advanced tb infection. rates of drug resistant tb were low and comparable to uk-wide rates over that period ( % mono-drug resistant, % mdr) thus less likely a contributory factor to the majority of deaths. short term antibiotics prevent early vap in patients treated with mild therapeutic hypothermia after cardiac arrest t daix , a cariou , f meziani , pf dequin , c guitton , n deye , g plantefève , jp quenot , a desachy , t kamel , s bedon-carte , jl diehl , n chudeau , e karam , f renon-carron , a hernandez padilla , p vignon , a le gouge introduction: patients treated with mild therapeutic hypothermia after cardiac arrests with shockable rhythm are at high risk of ventilator-associated pneumonia (vap) [ ] . despite retrospective trials suggesting a benefit of short-term ( h) antibiotics in this setting [ ] , it is not recommended. the primary objective was to demonstrate that systematic antibiotic prophylaxis can reduce incidence of early vap (< days). the impact on incidence of late vap and on day mortality was also assessed. methods: multicenter, placebo-controlled, double-blinded, randomized trial. icu patients > years, mechanically ventilated after out-of-hospital resuscitated cardiac arrest related to initial shockable rhythm and treated with mild therapeutic hypothermia were included. moribund patients and those requiring extracorporeal life supports, with ongoing antibiotic therapy, known chronic colonization with multiresistant bacteria or known allergy to beta-lactam antibiotics were excluded. either iv injection of amoxicillin-clavulanic acid ( g/ mg) or placebo was administered times a day for days. all pulmonary infections were recorded and blindly confirmed by an adjudication committee. results: in intention to treat analysis, patients were analyzed, (treatment group n= ; mean age . ± . years, sex ratio= , sofa score . ± . ). global characteristics of cardiac arrest were similar (no flow= . min vs . min, low-flow= . min vs . min). vap were confirmed incl. early vap, in treatment group vs in placebo group (hr= . ; ic %=[ . ; . ]) (fig. ) . occurrence of late vap ( % vs . %) and day mortality ( . % vs . %) was not affected by the study procedure. conclusions: short-term antibiotic prophylaxis significantly decreases incidence of early vap in patients treated with mild therapeutic hypothermia after out-of-hospital cardiac arrest related to shockable rhythm and should be recommended. introduction: antibiotics are the most commonly prescribed drugs in icu.in the era of antibiotic resistance it is difficult to choose antibiotics during septic episode.the choice antibiotics mainly depends on clinical diagnosis,culture sensitivity and local flora. whether severity of illness really maters is not well known. to study antibiotic prescription pattern and whether the choice of antibiotic varies according to hemodynamic stability in patients admitted in icu.to study of microbiological isolates and their variability according to hamodynamic stability in icu patients. methods: all icu patients of more than years age who received antibiotics and where cultures had been sent were included in the study.patients discharged against medical advice and where treatment had been withdrawn were excluded in this study. this prospective observational study was conducted between july to march .patients were divided into stable and unstable group according to hemodynamic parameter and usage of antibiotics and microbiological isolated were correlated. icu mortality and length of stay were correlated between hemodynamically stable and unstable group. results: sepsis episode were analysed. mean age was years, male predominant, and average apache iv score was (sd ). we had patients in unstable group of which % patients got discharged and % of patients got discharged in stable group. antibiotic combination therapy was used more in hemodynamically unstsble patients(p . ). blbli was used more in stable group. drug resistance in microbiological isolates did not reveal any statistically significant difference among stable or unstable group. conclusions: there is a tendency to administer combination antibiotics in sicker group of patients with hemodynamic instability. prevalence of microbial flora did not show any statistical difference. outcome is worse in hemodynamically unstable patients. the clinical significance of candida score in critically ill patients with candida infection h al-dorzi , r khan , t aldabbagh , a toledo , s al johani , a almutairi , s khalil , f siddiqui , y arabi king abdulaziz medical city, riyadh, saudi arabia, msd, riyadh, saudi arabia, king saud bin abdulaziz university for health sciences, riyadh, saudi arabia critical care , (suppl ):p introduction: candida score (cs) is used to identify patients with invasive candidiasis in the icu, but its clinical use has not become widespread. our objective was to evaluate the clinical significance of cs in a mixed population of icu patients. methods: this was a prospective observational study of critically ill patients who had candida species growth during their stay in any of six different icus of a tertiary-care center. two intensivists classified patients as having candida colonization or invasive candidiasis according to predefined criteria. cs was calculated for each patient on the day of candida species growth as follows: . see text for description point for parenteral nutrition + point for surgery + point for multifocal candida colonization + points for severe sepsis. the receiver operating characteristic (roc) curve was plotted to assess cs ability to discriminate between invasive candidiasis and candida colonization. results: cs was . ± . in patients with candida colonization (n= ) and . ± . in those with invasive candidiasis (n= ) (p< . ). however, only . % of invasive candidiasis cases had cs >= (compared with . % of candida colonization cases; p< . ). the roc curve (fig. ) showed that cs had fair ability to discriminate between invasive candidiasis and candida colonization (area under the curve . , % confidence interval . to . ; p< . ). in patients with invasive candidiasis, cs was similar in hospital survivors and nonsurvivors ( . ± . and . ± . , respectively; p= . ). cs did not discriminate between survivors and nonsurvivors (area under the roc curve . , % confidence interval . to . ; p< . ). conclusions: cs was higher in patients with invasive candidiasis than those with candida colonization. however, its ability to discriminate between these patients was only fair. cs was not associated with hospital mortality. poor reliability of creatinine clearance estimates in predicting fluconazole exposure in liver transplant patients m lugano, p cojutti, f pea asuiud, udine, italy critical care , (suppl ):p introduction: invasive candidiasis (ic) is a frequent complication in liver transplant (lt) recipients, especially during the first - months after lt. fluconazole is a triazole antifungal used for prophylaxis and treatment of ic. due to its renal elimination, dose adjustments are usually based on estimated creatinine clearance (ecrcl). however, the reliability of ecrcl in predicting fluconazole clearance has never been investigated in this population. the aim of this study was to conduct a population pharmacokinetic (poppk) analysis in a cohort of lt patients who underwent therapeutic drug monitoring (tdm) in order to find out which covariates may influence fluconazole pharmacokinetics (pks). methods: this retrospective study included lt patients who were admitted to the intensive care unit of our university hospital between december and may , and who were treated with intravenous fluconazole in the first months after lt. tdm of fluconazole was performed with the intent of attaining the efficacy pharmacodynamic target (auc h/mic > . ). the tested covariates were: age, gender, ckd-epi ecrcl, time from lt, serum albumin and transaminases, saps ii score. poppk was carried out with pmetrics software. results: nineteen patients (mean±sd age, weight and serum creatinine of ± . years, ± . kg, . ± . mg/dl, respectively) with a total of fluconazole trough plasma concentrations were included in the poppk analysis. mean±sd fluconazole distribution volume (vd) and clearance (cl) were . ± . l and . ± . l/h. age and time from lt were the only clinical covariates significantly correlated with fluconazole vd and cl, respectively. conversely, ckd-epi eclcr was unable to predict fluconazole cl. conclusions: ckd-epi eclcr is unreliable in predicting fluconazole exposure in lt recipients. consistently, in this population adaptation of fluconazole dose should be based on measured crcl, and tdm may be helpful in optimizing drug exposure. outcomes of a candidiasis screening protocol in a medical icu m boujelbèn , i fathallah , h kallel , d sakis , m tobich , s habacha , n ben salah , m bouchekoua , s trabelsi , s khaled , n kouraichi introduction: the aim is to determine the incidence, characteristics and risk factors of invasive candidiasis (ic) in critically ill patients by using a weekly screening protocol. methods: a months' prospective study was conducted in a -bed micu. the candidiasis screening consisted of the culture of plastic swabs (from different body sites), urine and respiratory tract samples.it was conducted upon admission and on weekly basis for all the patients. decision to treat was based on clinical and microbiological features. results: patients were included. the colonization rate with candida spp was . %(n= ). screening samples were collected with a positivity rate at . %(n= ). table describes the isolated candida species by site. antifungal resistance was tested in ( %) species. the resistance rate to fluconazole was . %(n= ). the antifungal resistance of candida albicans is detailed in table . ( . %) patients presented an ic with a mean age and mean saps ii at . ± years and ± . respectively. ( %) presented acute renal failure upon admission. . % (n= ) of the patients needed mechanical ventilation. the median length of stay was days [ . - . ] and the mortality rate was . %(n= ). the mean sofa score upon infection was . ± . . the candida score was >= . and the colonization index was >= . in fig. (abstract p ). roc curve for candida score discrimintaing between invasive candidiasis and candida colonization . %(n= ) and . %(n= ) of the patients respectively. only one patient had a positive blood culture. mannan antigen and anti-mannan antibodies were screened only in five patients with a positivity rate at %(n= ). the most isolated species was: candida albicans . %(n= ). multivariate analysis showed that prior use of imipinem more than days was a risk factor for ic (or= . , ci [ . ; . ], p= . ). conclusions: this study showed the ecology and epidemiology of candida species in our micu with an increased ic rate and high mortality. prior imipinem use was a risk factor for ic. introduction: icu-acquired infection is as high as . episodes per patient-days in lower-middle income countries like india (who). almost three times higher than in high-income countries [ ] . candida infection is the rd most commonly acquired nosocomial infection in india burdening the debilitated patient with longer icu stay [ ] . there are no definite guidelines on whether & when to start antifungal treatment, specific to india where ifi risk is high and diagnostic facilities are limited. currently, the intensivists across india are using antifungals, according to their clinical experience and selective application of international guidelines leading to non-uniformity of patient outcomes. in an endeavour to synchronize anti-fungal therapy and educate intensivists from small cities of india, intensivists and infectious disease specialist of international repute were approached to design a module on 'invasive fungal infections -when to start anti-fungals in icu [ fig. ]. the ifi in india was summarised into a compact hour session for dissemination of knowledge using idsa as a reference guideline. intensivists from across india were trained on the module by our faculty. the module was rolled out to intensivists and pulmonologists focussing particularly on the tier- & tier - cities where avenues for learning are limited [ fig. introduction: trichosporon species are fungi found in nature and human normal flora but they can be an opportunistic pathogen, introduction: this study assessed whether empiric combination antibiotic therapy directed against gram-negative bacteria is associated with lower intensive care unit (icu) mortality compared to single antibiotic therapy. methods: retrospective cohort study on prospectively collected data conducted in the icu of a tertiary care hospital in india between july to march . all consecutive infection episodes treated with empiric antibiotic therapy and with subsequent positive culture for gram-negative bacteria were included. primary and secondary outcomes were all cause icu mortality and icu length of stay (los). outcomes were compared between infection episodes treated with single vs.combination antibiotic therapy. results: of total episodes of gram-negative infections . % received combination-antibiotic therapy. baseline demographic and clinical characteristics between single vs. combination therapy groups were similar (mean age: p= . ; sex: p= . ; mean apache iv score: p= . ). overall icu mortality did not significantly differ between single and combination antibiotic groups ( . % vs. %; p= . ). in single antibiotic group, icu mortality was significantly higher for antibiotic-resistant compared to antibiotic-sensitive bacteria ( . % vs. . %, p= . ). in combination group, significantly lower icu mortality was noted if bacteria was sensitive to even one antibiotic compared to pan-resistant bacteria ( . % vs. . %, p= . ). icu los was similar between antibiotic-sensitive bacteria and antibiotic-resistant bacteria, both in single and combination therapy groups (single, antibiotic-sensitive vs. antibiotic-resistant: mean los±sd . ± . vs. . ± days; p= . ; combination, antibioticsensitive vs. antibiotic-resistant: . ± . vs. . days; p= . ). conclusions: irrespective of the number of antibiotics prescribed as empiric therapy, outcome of patients solely depends on the sensitivity pattern of the bacteria isolated. pharmacokinetics of trimethoprim and sulfametrole in critically ill patients on continuous haemofiltration r welte , j hotter , t gasperetti , r beyer , r introduction: the combination of trimethoprim and sulfametrole (tmp-smt, rokiprim®) is active against multi-drug resistant bacteria and pneumocystis jirovecii. in critically ill patients undergoing continuous veno-venous haemofiltration (cvvh), however, its use is limited because of lacking pharmacokinetic data. methods: pharmacokinetics of both drugs were determined after standard doses in patients on cvvh and in critically ill patients with approximately normal renal function. quantification of tmp and smt was done by high pressure liquid chromatography (hplc) and uv detection after pre-purification by solid phase extraction. the total clearance (cltot) was estimated from arterial plasma levels and the haemofilter clearance (clhf) from plasma and ultrafiltrate concentrations. results: six patients on cvvh ( after the first dose, at steady state) and nine patients off cvvh have been enrolled ( after first dose, at steady state). after a single dose, cltot of smt was . ( . - . , median [range]) and . ( . - . ) l/h on and off cvvh, respectively. at steady state, we observed a cltot of . ( . - . ) and . ( . - . ) l/h, respectively, on and off cvvh. steady state trough levels (cmin) of smt amounted to - mg/l in patients on cvvh and - in patients off cvvh. cltot of tmp was . ( . - . ) l/h on cvvh and . ( . - . ) l/h off cvvh after the first dose. at steady state, its cltot amounted to . ( . - . ) and . ( . - . ) l/h on and off cvvh, respectively. cmin was - mg/l on cvvh and - mg/l in patients off cvvh. clhf accounted for - % of cltot of smt and - % of cltot tmp. conclusions: exposure to both antimicrobial agents is highly variable, but comparable in patients on and off cvvh. as considerable amounts of smt and tmp are eliminated by cvvh, no excessive accumulation appears to take place during treatment with standard doses. the positive impact of meropenem stewardship intervention at a brazilian intensive care unit w freitas introduction: loss of colistin as a clinical option has profound public health implications. widespread use of colistin in agriculture and humans has seen the emergence of mcr- mediated resistance amongst south african patients [ ] . we sought to describe the trends of colistin minimum inhibitory concentrations (mic) over two years using data collected by smart. methods: smart monitors the in vitro susceptibility of clinical aerobic and facultative gram-negative bacterial isolates to selected antimicrobials of importance, enabling longitudinal analyses to determine changes over time. the dataset comprised bacterial isolates from four different south african private pathology laboratories and one public sector pathology laboratory from - . the methods used in the study have been described elsewhere [ ] . isolate proportions between years were compared using the chisquared test with yates' continuity correction. ( ) ( ) ( ) ( ) days]; patients underwent renal replacement therapy. the median treatment duration (iqr) was ( - ) days. in . % of cases, antibiotic-therapy therapy combination (phosphomycin and colistin) was chosen. all the patients experienced a clinical response by / hours from the ceftazidime/avibactam commencing. in / bacteraemic patients negativization of blood culture occurred by hours as well as of the rectal swab in / patients. a (b) recurred and a second treatment was given. / ( . %) patients survived, whereas death was caused by multi-organ failure. the susceptibility test of strains showed sensitivity to ceftazidime/avibactam, whereas % of resistance to carbapenems, quinolones and iii/iv generation cephalosporin, tigecycline and piperacillin/tazobactam; . % of susceptibility to fosfomycin and colistin; (v) less than % of suceptibility to aminoglicosides. conclusions: the strains of kp-cp were susceptible to ceftazidimeavibactam despite the high carbapenem-resistance recorded in our icu, because od rare identification of kp-cp vim/ndl +. the preliminary data seems to confirm the efficacy and clinical utility of this antibiotic for the critically ill patients. introduction: multidrug resistant bacteria (mdr) are an increasing problem on intensive care units. lung infections caused by acinetobacter baumannii are frequently difficult to treat. phages have regained attention as treatment option for bacterial infections due to their specificity and effectivity in lysis. the aim of this preclinical study was to determine efficacy and safety of a novel phage preparation in mice. methods: mice were transnasally infected with a mdr a. baumannii strain [ ] and hours later treated intratracheally with a specific phage or solvent. phage acibel [ ] was produced as suspension including efficient depletion of endotoxins. at defined time points, clinical parameters, bacterial burden in lung and bronchoalveolar lavage fluid (balf) and cell influx were determined. further, lung permeability and cytokine release were quantified and histopathological examination was performed. results: mice treated with phages recovered faster from infectionassociated hypothermia. hours after infection, phage treatment led to a reduction in bacterial loads in lungs and balf. in addition, lung permeability and cytokine production were reduced in phagetreated mice. histopathological examination of the lungs showed less spreading of bacteria to the periphery in phage-treated mice, whereas cellular recruitment into the lung was unaffected. no adverse effects were observed. conclusions: for the first time a highly purified phage against a. baumannii was successfully used in vivo. the current preclinical data support the concept of a phage-based therapy against pulmonary a. baumannii infections. introduction: vap is common in critically ill patients and associated with high morbidity and mortality, especially when caused by antibiotic resistant bacteria. recently, phage therapy has emerged as a promising non-antibiotic based treatment of antibiotic resistant bacterial infections. however, proof-of-concept experimental and clinical studies are missing before its wider use in clinical medicine. the goal of this experimental study was to compare the efficacy of phage therapy versus antibiotics for the treatment of mrsa in a rat model of vap. methods: four hours after intubation and protective ventilation, rats were inoculated via the endotracheal tube with - x cfu (ld ) of the mrsa clinical isolate aw . the animals were subsequently extubated. two hours after bacterial challenge, rats were randomised to receive intravenously either teicoplanin (n= ), a cocktail of lytic anti-s. aureus bacteriophages (n= ) or combination of both (n= ). animals served as control (no treatment). survival by hours was the primary outcome. secondary outcomes were bacterial count in lungs, spleen and blood. kaplan-meier estimates of survival were done and multiple comparisons of survival rates performed using the holm-sidak method. results: treatment with either phages, antibiotics or combination of both significantly increased survival ( %, %, % respectively, compared to % survival for controls, p< . ). there were no statistical differences in survival rates between either forms of treatment ( fig. ) . treatments hinder the systemic extension of the infection into the blood and spleen without impacting bacterial counts within the lungs, but the numbers are too small to perform statistical tests (table ) introduction: the aim of the study was comparative evaluation of the clinical and microbiological efficacy of combination of amikacin thru nebuliser aeroneb pro and standard antimicrobal therapy (amtcomb) with standard antimicrobal therapy (amtst) in treatment of ventilator-associated pneumonia (vap) and ventilator-associated tracheobronchitis (vat) caused by multi-drug resistant gram-negative bacteria. methods: in prospective two-center study with retrospective control included patients with vap and vat. in amtst group (retrospective, n= ) we used combination of meropenem g every h iv as continuous infusion, cefoperazon/sulbactam g every h iv as continuous infusion and amikacin g iv every h. in amtcomb group (prospective, n= ) we used combination of amtst and amikacin inhalation mg every h thru nebuliser aeroneb pro. results: in amtcomb clinical cure rate was %, while in amtst . % (p< . ), clinical pulmonary infection score (cpis) on day was ( - ) points in amtst and ( - ) points in amtcomb (p< . ). recurrence of vap/vat was . % in amtst and . % in amtcomb (p= . ). on day infectious agent titer in tracheal aspirate was ( - ) cfu/ml in amtst group, while (no growth- ) cfu/ml in amtcomb (p= . ). microbiological eradication observed in patients in amtcomb vs in patient in amtst and microbiological persistance observed in patients in amtcomb vs patients in amtst (p= . ). in amtcomb on rd day sputum was less purulent (p= . ). amikacin nebulisation didn't led to deterioration of organ dysfunction: on day there was no difference in platelet count, creatinine and bilirubin levels as compared to day (p= . ; p= . , p= . , respectively). conclusions: addition of amikacin inhalation mg every h thru aeroneb pro nebuliser in patients with vap and vat was more efficacious than intravenous standard antimicrobal treatment with comparable safety profile. introduction: the aim of the study was to assess the effectiveness of inhaled colistin (ic) as an adjunct to systemic antibiotics in the treatment of ventilator-associated pneumonia (vap). methods: icu patients with vap were enrolled in this observational study. resolution of vap was assessed as primary endpoint; eradication of pathogens in sputum, weaning time, duration of icu stay and mortality were assessed as secondary outcomes. patients were split into groups: gr. (n = ) -addition of ic to systemic antibiotics without changing the basic regimen; gr. (n = ) -change in systemic antibiotics according to sensitivity. groups were comparable. ic was administered in a dose of million iu tid (xselia pharmaceuticals aps, denmark). statistical analysis was performed using statistica . (m, σ, newman-keuls test; p < . ). results: vap resolution rate was % in gr. (vs. % in gr. , p = . ); eradication of pathogens from sputum by the th day. treatment was achieved in % of gr. and % in the gr. (n = ) (p> . ); in gr. weaning from ventilation was possible earlier than in gr. - . ± . days. in gr. vs. . ± . days. in gr. (p = . ); in gr. duration of icu stay was shorter than in gr. - . ± . days vs. . ± . days. in gr. (p = . ). no mortality differences were detected. conclusions: administration of inhaled colistin million iu tid is effective as an adjunct to systemic antibiotics in the treatment of vap. this modified treatment promotes a more rapid resolution of vap, earlier weaning from ventilator, reduction of the duration of icu stay, with no impact on mortality. the addition of ic to systemic antibiotics should be considered as second-line regimen in vap patients. factors associated with no de-escalation of empirical antimicrobial therapy in icu settings with high rate of multi-drug resistant bacteria c routsi introduction: de-escalation is recommended in the management of antimicrobial therapy in icu patients [ ] . however, this strategy has not been adequately evaluated in the presence of increased prevalence of multidrug-resistant (mdr) bacteria. the aim of this study was to identify factors associated with no de-escalation in icus with high rate of mdr bacteria [ ] . methods: prospective, multicenter study conducted in greek icus over a -year period. patients with laboratory confirmed infections were included. sofa score on admission, on septic episode and thereafter every h over days, infection site(s), culture results, antimicrobial therapy, and mortality were recorded. only the first septic episode was analyzed. in order to assess the factors associated with no de-escalation, a multivariate analysis was performed. results: a total of patients (admission sofa score ± ) were analyzed. % of those had septic episode on icu admission; % patients had an icu-acquired. de-escalation was applied to ( %) patients whereas it was not feasible in patients ( %) due to the recovery of mdr pathogens or it was not applied, although the microbiology results allowed it, in patients ( %). septic shock on the day of septic episode was present in % and % of patients with and without de-escalation, respectively, p= . ). compared to no de-escalation, de-escalation strategy was associated with a shorter duration of shock ( ± vs. ± days, p< . ) and all-cause mortality ( . % vs. . %, p< . ). multivariate analysis showed that the variables associated with no de-escalation were: a deteriorating clinical course as indicated by an increasing sofa score (or . , p< . ) and a lack of de-escalation possibility due to recovery of mdr pathogens (or . , p= . ). conclusions: deteriorating clinical course and mdr pathogens are independently associated with no de-escalation strategy in critically ill patients. conclusions: the qsofa scale in the prognosis of sepsis does not differ significantly from the sirs criteria, but in the prognosis of mortality is significantly better than sirs. qsofa significantly worse in the prognosis of sepsis and death than the sofa scale. the international task force of sepsis- introduced the quick sequential failure assessment (qsofa) score to supersede the systemic inflammatory response syndrome (sirs) score as the screen tool for sepsis. the objective of this study is to prospectively access the diagnostic value of qsofa and sirs among patients with infection in general wards. methods: a prospective cohort study conducted in ten general wards of a tertiary teaching hospital. for a half-year period, consecutive patients who were admitted with infection or developed infection during hospital stay were included. demographic data and all variables for qsofa, sirs and sofa scores were collected. we recorded daily qsofa, sirs and sofa scores until hospital discharge, death, or day , whichever occurred earlier. the primary outcome was sepsis at days. discrimination was assessed using the area under the receiver operating characteristic curve (auroc) and sensitivities or specificities with a conventional cutoff value of . results: of patients (median age, years [iqr, - ]; male, [ %]; most common diagnosis pneumonia, [ %]) who were identified with infection in general wards, ( %) developed sepsis at a median of (iqr, - ) day, patients ( %) and patients ( %) met qsofa and sirs criteria at a median of (iqr, - ) and (iqr, - ) day, respectively. the qsofa performed better than sirs in diagnosing sepsis, with an auroc of . ( % ci, . - . ) vs . ( % ci, . - . ). with a conventional cutoff value of , qsofa had lower sensitivity ( % [ % ci, %- %] vs. % [ % ci, %- %], p < . ) and higher specificity ( % [ % ci, %- %] vs. % [ % ci, %- %], p < . ) than sirs (table ) . conclusions: among patients with infection in general wards, the use of qsofa resulted in greater diagnostic accuracy for sepsis than sirs during hospitalization. qsofa and sirs scores can predict the occurrence of sepsis with high specificity and high sensitivity, respectively. prognostic accuracy of quick sequential organ failure assessment (qsofa) score for mortality: systematic review and meta-analysis introduction: the purpose of this study was to summarize the evidence assessing the qsofa [ ] , calculated in admission of the patient in emergency department (ed) or intensive care unit (icu), as a predictor of mortality. the hypothesis was that this tool had a good prediction performance. methods: systematic review and meta-analysis of studies assessing qsofa as prediction tool for mortality found on pubmed, ovid, embase, scopus and ebsco database from inception until november . the primary outcomes were mortality (icu mortality, inhospital mortality, and -day mortality). studies reporting sensitivity and specificity of the qsofa making it possible to create a x table were included. the diagnostic odds ratio (lndor) was summarized following the approach of dersimonian and laird using the software r ('mada' package). the summary roc curve was created using the reistma model (bivariate model). the revman software was used to organize the data. results: the search strategy yielded citations. of unique citations, met the inclusion criteria ( , patients). the sensitivity and specificity from each study are shown in fig. . the meta-analysis of the dor was . ( % confidence interval (ci): . - . ) and of the lndor was . ( % ic: . - . ) (fig. ) . the pooled area under the summary receiver operating characteristic (sroc) curve was . . the summary estimative of the sensitivity was . and the false positive rate was . , by bivariate diagnostic random-effects metaanalysis. the chi-square goodness of fit test rejects the assumption of homogeneity, and the fit of the model for heterogeneity was better (p-value = . ). conclusions: the qsofa has a poor performance to predict mortality in patients admitted to the ed or icu. introduction: sepsis and septic shock patients are the most common cause of death in intensive care units. [ ] the aim of this study is to quantify the relationship between hours sequential organ failure assessment (sofa) scores change and in-hospital mortality as a treatment outcome in sepsis and septic shock patients. introduction: an outreach team, akin to a rapid response team, is made up of healthcare professionals assembled together for quick and effective reviews in managing of rapidly deteriorating or gravely deteriorated patients [ ] . this study aimed to look at the variety of patient referrals in terms of their severity, patient dynamics, reasons for referral and their subsequent dispositions. methods: patient records were randomly reviewed retrospectively from july to october . data were collated in an excel spreadsheet for comparison and then sorted in accordance with the clinical questions and percentages calculated. results: from the referrals, the severity criteria was done by calculating the national early warning score (news). it was found that % patients had a score of - , % had a score of - , and % scored more or equal to . % of patients were in the age range - years old. % referrals came from the emergency department (ed) where a consultant was involved in the decision of the referral; of this, % were referred during office hours of am to pm where there was greater manpower to aid management. % referrals came from inpatients on the general wards; % were done during office hours. % of referrals were transferred to ic/hd upon review; % were not, from whom died and were later admitted after procedures ( %) or because they deteriorated further ( %). for reasons for referrals and disposition decisions, see fig. . conclusions: despite having no set criteria for outreach team referrals, the accuracy rate was nearly % admissions to ic/hd based on clinician concerns. there was only % re-admission rate having been re-reviewed when the patients had not been deemed suitable for ic/hd admission initially. therefore referrals were done accurately and safely with the protocol of clinician referral openness directly to ic consultants. introduction: prompt recognition of patient deterioration allows early initiation of medical intervention with reduction in morbidity and mortality. this digital era provides an opportunity to harness the power of machine learning algorithms to process and analyze big data, automatically acquired from the electronic medical records. the results can be implemented in real-time. intensix (netanya, israel) has developed a novel predictive model that detects early signs of patient deterioration and alerts physicians. in this study we prospectively validated the ability of the model to detect patient deterioration in real time. methods: the model was developed and validated using a retrospective cohort of consecutive patients admitted to the intensive care unit in the tel-aviv sourasky medical centera tertiary care facility in israel, between january and december . in this study, we tested model performance in real time, on a cohort of patients admitted to the same icu between june and august . significant events that lead to major interventions (e.g. intubation, initiation of treatment for sepsis or shock, etc.) were tagged upon medical case review by a senior intensivist, blinded to model alerts. these tags were then compared with model alerts. [ ] [ ] [ ] [ ] . reviews occurred despite 'low news' (fig. ) . rrt review led to cc admission in ( . %) cases; median [iqr] news [ ] [ ] [ ] [ ] [ ] [ ] . probability of admission increased with higher news (fig. ), however admissions had 'low news'. of these were excluded due to high news trigger in the preceding hrs or post-operative status. the remaining ( . %) represented genuine low news cases; age [ - ], % male, admission apache ii [ - ] and day sofa [ ] [ ] [ ] [ ] [ ] . admission source was emergency department %, medical %, surgical %. diagnoses are shown in table . no low news patients with sepsis were qsofa positive. cc length of stay was [ ] [ ] [ ] [ ] days and icu mortality was . %. conclusions: a high proportion of rrt activity occurs at low levels of abnormal physiology. despite an association between news and cc admission, news fails to trigger for approximately one in ten admitted cases. clinical concern remains an important component of the escalation of acutely ill patients. meanwhile, novel markers of deterioration should be sought and validated. introduction: although rapid response systems are known to reduce in-hospital cardiac arrest rate, their effect on mortality remains debated. the rapid response call (rrc) is a system designed to escalate care to a specialised team in response to the detection of patient deterioration. there are diurnal variations in hospital staffing levels that can influence the performance of rapid response systems and patient outcomes. the objective of this study was to examine the relationship between the time of rrc activations and patient outcome. methods: review of retrospectively collected, linked clinical and administrative datasets, at a private hospital during a -month period. all patients with medical emergency team activation were included. rapid response calls occurring between : - : were defined as 'out of hours'. results: between january and october there were rrc. the trigger for rrcs activation was nurse concern ( ; . %), modified early warning score ( ; . %) and cardiac arrest ( ; . %). rrcs were "out of hours" being the main activation trigger a modified warning score > . "out of hours" patients had higher icu admissions ( . % versus %) and were more likely to have an inhospital cardiopulmonary arrest (or= . , p< . ). conclusions: the diurnal timing of rrcs appears to have significant implications for patient outcomes. out of hours calls are associated to a poorer outcome. this finding has implications for staffing and resource allocation. and septic shock) and severe sepsis (incl. septic shock) using icd- codes coded as primary and secondary discharge diagnoses and procedural ops codes. we assessed incidences and discharge disposition incl. mortality. results: incidences, mortalities and discharge disposition comparing and and the mean annual increase in incidence rates are reported in tables and . conclusions: the annual increase in standardized sepsis incidence rates is greater than in infections, but similar to the increase in infectious disease patients with organ dysfunction, which are less prone to coding incentives than sepsis codes. an increasing number of patients is discharged to nursing homes and hospice. given the alarming increase in sepsis cases and deaths, this analysis confirms sepsis as a key priority for health care systems. introduction: patients with urgent admissions to the hospital on weekends may be subjected to a higher risk of worse outcomes, which may be due to differences in compliance to established processes. because delays to antibiotic administration is an important measure of sepsis protocol efficiency and has been associated to worse outcomes, we aimed to assess the association of the weekend effect (admissions on weekend) with timing to antibiotic administration. methods: patients included in the sepsis protocol in the emergency department (ed) of hospital sao rafael, from january to july were retrospectively evaluated. sepsis protocol is supposed to be activated to every patient with a suspected sepsis diagnosis in the ed. we evaluated the association of weekend (saturday or sunday) admission with timing to antibiotic administration. introduction: current sepsis guidelines emphasize resuscitation of hypotension to a mean arterial pressure (map) of at least mmhg [ ] . a map less than mmhg appears to be associated with poor outcomes in postoperative patients in the intensive care unit (icu) [ ] . however, extent of hypotension in critically ill septic patients during icu stay and its relationship with adverse outcomes is poorly defined. we determined the magnitude of hypotension in icu patients with a diagnosis of sepsis and its association with major complications. conclusions: reduced mortality may be supposed to be correlated to a quicker recovery of organ damage sepsis related. pcrts should be warranted in the future to corroborate these preliminary data. introduction: the pd- /pd-l immune checkpoint pathway is involved in sepsis-associated immunopathy. we assessed the safety of anti-pd-l (bms- , bristol-myers squibb) and its effect on immune biomarkers and exploratory clinical outcomes in participants with sepsis-associated immunopathy. methods: participants with sepsis/septic shock and absolute lymphocyte count <= cells/μ l received bms- i.v. ( - mg; n= ) or placebo (pbo; n= ) + standard of care and were followed for d. primary endpoints were death and adverse events (aes); secondary endpoints were monocyte (m)hla-dr levels and clinical outcomes. methods: this observational study was performed using a prospective, multi-center registry of septic shock. we compared the -day mortality between patients who were excluded from the new definition (defined as < mmol/l after volume resuscitation) and those who were not (lactate level >= mmol/l after volume resuscitation), from among a cohort of patients with refractory hypotension, and requiring the use of vasopressors. results: of patients with refractory hypotension, requiring the use of vasopressors, had elevated lactate levels, while did not have elevated lactate levels (neither initially nor after volume resuscitation), and ( . %) had elevated lactate levels initially, which normalized after fluid resuscitation (fig. ). thus, these patients were excluded by the new definition of septic shock. significantly lower -day mortality was observed in these patients than in those who had not been excluded ( . % vs . %, p= . ). conclusions: it seems reasonable for septic shock to be defined by the lactate levels after volume resuscitation, however due to small sample size further large scale study is needed. results: significant downregulation (p< . ) of about pro-and anti-inflammatory cytokines, including il- , ip- , tnf-a, mip- a, mip- ß, il- , was documented. ifn-g effect on macrophages and dendritic cells was inhibited at the level of phosphorylated stat . ifn-ginduced expression of cxcl and cxcl in macrophages was reduced. patients treated in vivo with higher dosages of apoptotic cells had lower cytokine/chemokine levels compared to those treated with lower levels, and in inverse correlation to agvhd staging. in vitro binding of apoptotic cells to lps was documented. conclusions: the cytokine storm is significantly modified towards homeostasis following apoptotic cell treatment. the mechanism is multifactorial and was shown to include tam receptor triggering, nfkb inhibition, and lps binding. these results together with previous studies showing significantly higher murine survival in sepsis models of lps and cecal ligation puncture suggest that apoptotic cells may be used to treat patients with sepsis. a multicenter clinical trial in septic patients is planned in . moreover, the urine output significantly increased in survival group. conclusions: the present study suggests that cytokine-oriented critical care using pmma-chdf might be effective the treatment of sepsis and ards, particularly,in the treatment of ards associated with aspiration pneumonia in elderly patients. the polymyxin b immobilized fiber column direct hemoperfusion has an effect for septic shock but has no effect on sepsis: a cohort study and propensity-matched analysis k hoshino introduction: overwhelming cytokine release often referred to as "cytokine storm" is a common feature of septic shock, resulting in multiple organ dysfunction and early death. attenuating this cytokine storm early by eliminating cytokines may have some pathophysiological rationale. our aim was to investigate the effects of extracorporeal cytokine removal (cytosorb) therapy on organ dysfunction and inflammatory response within the first hours from the onset of septic shock. methods: patients with: sepsis of medical origin, on mechanical ventilation, noradrenaline > mg/min, procalcitonin > ng/ml and no need for renal replacement therapy, were randomized into cytosorb and control groups. cytosorb therapy lasted for hours. in addition to detailed clinical data collection, blood samples were taken to determine il- , il- ra, il- , il- , il- , tnf-α, pct, crp levels. introduction: blind pericardiocentesis leading to low success rate and high complication rates such as ventricular wall or oesophageal perforations, pneumothorax or upper abdominal organ injury.real time needle visualisation is allowing us to avoid this major complication [ ] . methods: we presented cases of acute traumatic cardiac tamponade secondary to severe chest injury. both patients presented with haemodynamic instability and echocardiographic features of pericardial tamponade. pericardiocentesis under ultrasound guidance at left parasternal area with needle directed from medial to lateral technique were performed (fig. ) . real time needle tip visualisation done throughout the procedure (fig. a) . needle placement in pericardial space was confirmed with agitated saline and guidewire visualisation (fig. b) . pigtail catheter was inserted and blood was aspirated until the patient were haemodynamically improved. repeated ultrasound was done to confirm the absence of ultrasonographic features of tamponade and complications. results: we demonstrated a successful real time needle visualisation ultrasound guided pericardiocentesis in cases acute traumatic pericardial tamponade. procedural time (time from needle piercing the skin to time needle entering the pericardium) in both cases were less than minute. post procedural ultrasound confirmed no major complications. conclusions: the real time needle visualisation using ultrasound was important to reduce major complications during pericardiocentesis. the safety of the highly invasive procedure can be improved with real time needle visualisation. osman a et al. eur j emerg med (in press), introduction: diagnosis of cardiac tamponade post continuous-flow left ventricle assist devices (cf-lvads) is challenging due to missing pulsatility. recent case study of sublingually microcirculation with incident dark-field imaging (idf) provide a new improved imaging for clinical assessment of cardiac tamponade in a patient with cf-lvad. we sought to examine the changes in microvascular flow index (mfi) as a sign of cardiac tamponade following lvad implantation. methods: off-site quantitative analysis of sublingual microcirculation clips with automated vascular analyses software (ava; microvision medical©), and the velocity distributions followed during admission till discharge in patients with end-stage heart failure treated with cf-lvad complicated by cardiac tamponade. results: eleven out of thirty lvad implantations, males, mean age ± years, april to january , (( heart mate (hm ) and heartmate ii (hm ii) (thoratec corp., ca)), were complicated by rethoracotomy due to early postoperative cardiac tamponade within week. there sublingual microcirculation was examined by a novel incident dark-field imaging (idf) before and daily post-lvad implantation. pre-lvad microcirculation was typical for heart failure, characterized by slowly, sludging movement of red blood cells (rbcs), (fig. a arrows) . directly after implantation, a normal microcirculatory flow was seen with a high rbcs velocity (fig. b) . on the day of tamponade the patients were stable except for severe failure of microcirculation as reflected by drop in mfi (fig. c ) and congestion in venules (* in fig. c ). in out of patients there was a significant drop in mfi before tamponade was clinically recognized (p< . ). shortly after rethoracotomy a quick restoration of microcirculatory flow has been found. conclusions: sublingual microcirculation imaging is a simple and sensitive non-invasive tool in early detection of cardiac tamponade. survey on the use of cardiovascular drugs in shock (ucards) - results: a total of physicians responded. as detailed in table , the respondents think that dobutamine is first-line inotrope to increase cardiac pump function (n= , %) and should be started when signs of hypoperfusion or hyperlactatemia despite adequate use of fluids and vasopressors in the context of low left ventricular ejection fraction are present (n= , %). the most accepted target was an adequate cardiac output (n= , %). the combination of noradrenaline and dobutamine was preferred to single treatment with adrenaline mainly due to possibility to titrate individually (n= , %). the main reason for adding another inotrope was to use synergistic effects of two different mechanisms of action (n= , %). according to respondents, phosphodiesterase-inhibitors should be used in the treatment of predominant right heart failure because of prominent vasodilatory effect on the pulmonary circulation (n= , %). they also believe levosimendan is the only inotrope that does not increase myocardial oxygen demand (n= , %). vasodilators are used in cardiogenic shock to decrease left ventricular afterload (n= , %). there is no experience or no opinion about the use of ß-blockers in shock states (n= , %). conclusions: this web-based survey provided latest trends on inotrope use in shock states which showed considerable diversity among respondents in opinions about its use. introduction: recent literature data clearly indicated that in patients with shock the resuscitation of macro-circulation often does not match with microcirculation and tissue perfusion improvement. unfortunately, the bed-side assessment of regional perfusion remains difficult, particulary in critically ill patients. in the last years thermography has been used in different medical fields but no studies have been performed on the use of this technique in critically ill patients. the aim of this study was to evaluate whether thermography is feasible and may provide useful data during resuscitation of patients with septic shock. methods: in patients with septic shock we collected central systemic temperature and infrared images (flir-t digital camera) of limbs at , , and hours after shock occurrence. thermal pattern distribution of the limbs was obtained by a specific analysis of the images (thermacam™researcher p). a systemic to peripheral temperature gradient called "Δ systemic-limb temperature" was calculated for each single temperature data collected. results: macrocirculatory and perfusion parameters improved in all the patients throughout the study period: mean values of noradrenaline dose decreased from . to . γ/kg/min, mean map increased from to mmhg and mean blood lactate decreased from . to . mmol/l. the "Δ systemic-limb temperature" pattern showed an heterogenous time course in the patients with a mean overall increase at and hours (fig. ) . conclusions: as expected, the regional data obtained by thermography did not match with macrocirculatory and systemic perfusion parameters. the significance and the relationship between treatments and data observed will be investigated by appropriate studies. regional differences in the treatment of refractory septic shockan analysis of the athos- data introduction: vasodilatory shock is a common syndrome with high mortality. despite established care protocols, regional differences in treatment remain. we sought to characterize these differences using data from the recently published athos- study [ ] . methods: individual patient data were analyzed at baseline and at h for regional differences in demographics, clinical characteristics, and treatment patterns, and grouped according to four geographical areas: the united states (us), canada (ca), europe (eu) and australasia (au). p-values were calculated by kruskal-wallis tests for continuous data and chi-square tests for categorical data. subsequent temporal analysis compared changes in the treatment of shock, indexed by changes in patient acuity level. results: regional differences existed with respect to bmi (p= . ), albumin (p< . ), cvp (p= . ), meld score (p= . ), apache ii score (p= . ) and sofa score (p= . ). baseline norepinephrine (ne) and ne equivalent doses were significantly higher in eu (p< . and p= . , respectively), and utilization of vasopressin was correspondingly lower (p< . ). at baseline, stress dose steroids were utilized to a greater extent in the us and ca (p= . ). temporal analysis revealed differences in the utilization of vasopressin and steroids with changes in patient acuity: in eu, increasing acuity was associated with a lower utilization of vasopressin, and in ca, increased acuity was associated with a lower utilization of steroids. steroid utilization was higher with increased level of acuity in au and the us. conclusions: significant differences in the treatment of vasodilitory shock exist globally, with important implications: (a) there are introduction: levosimendan is a calcium sensitizer and katp-channel opener exerting sustained hemodynamic and symptomatic effects. in the past fifteen years, levosimendan has been used in clinical practice also to stabilize at-risk patients undergoing cardiac surgery. recently, the three randomized, placebo-controlled, multicenter studies licorn [ ] , cheetah [ ] and levo-cts [ ] have been testing the peri-operative use of levosimendan in patients with compromised cardiac ventricular function. over smaller trials conducted in the past [ ] suggested beneficial outcomes with levosimendan in peri-operative settings. in contrast, the latest three studies were neutral or inconclusive. we aim to understand the reasons for such dissimilarity. methods: we re-analyzed the results of the latest trials in the light of the previous literature to find sub-settings in which levosimendan can be demonstrated harmful or beneficious. results: none of the three latest studies raised any safety concern, which is consistent with the findings of the previous smaller studies. in levo-cts, mortality was significantly lower in the levosimendan arm than in the placebo arm in the subgroup of isolated cabg patients ( fig. ) [ ] . the trend towards both hemodynamic and long term mortality benefits is maintained in recent meta-analyses [ , ] including the three larger recent studies. conclusions: despite the fact that the null hypothesis could not be ruled out in the recent trials, we conclude that levosimendan can still results: patients were included in levosimendan group and in control group. in the whole population, weaning failure incidence and mortality was comparable between the groups (respectively % vs %, pr , and % vs %, pr= , ). higher assistance duration, longer stay under mechanical ventilation and longer duration of stay in critical care unit were observed in levosimendan group. in the post-cardiotomy sub-group (table ) , weaning failure was lower in levosimendan group ( % vs %, pr , ) and levosimendan was an independent protective factor from weaning failure (or , , pr , ). positive impact of levosimendan may be explained in part by his calcium sensitizer effect and by facilitating recovery of myocardial calcium homeostasis in postcardiotomy cardiac stunning. conclusions: levosimendan failed to reduce the incidence of ecmo weaning failure, except for post-cardiotomy population. renal outcomes of vasopressin and its analogues in distributive shock: a systematic review and meta-analysis of randomized trials introduction: venous return (vr) is driven by the difference between mean systemic filling pressure (msfp) and right atrial pressure (rap) and determines the maximum ecmo flow. msfp depends on stressed volume and vascular compliance. it can be modified by absolute blood volume changes and shifts between stressed and unstressed volume. norepinephrine (ne) may increase stressed volume by constriction of venous capacitance and at the same time increase the resistance to systemic flow. we therefore studied the effects of ne on msfp, maximum ecmo flow and the ecmo pressure head (map-rap). methods: msfp was measured with blood volume at euvolemia and ne to ( . , . and . μg/kg/h) in a closed-chest porcine va-ecmo model (n= , central cannulation with left atrial vent and avshunt) in ventricular fibrillation. the responses of rap and vr (measured as ecmo flow, qecmo) were studied at variable pump speeds including maximum possible speed without clinically apparent vessel collapse at constant airway pressure. results: the ecmo pump speed and qecmo showed a strictly linear relationship (r . to . , range over all conditions) despite increased pressure head, indicating that the maximum qecmo was determined by vr alone. ne led to both increases in msfp and qecmo in a dose dependent way, indicating a rightward shift in the vr plot ( fig. ) via recruitment of stressed from unstressed volume ( table , fig. ). this resulted in an increased msfp during ne despite decreased absolute blood volume ( . ± . l vs. . ± . l, p= . ). the reduced blood volume was associated with hemoconcentration suggesting plasma leakage. conclusions: ne shifts the vr curve to the right, allowing a higher maximum ecmo flow. the ne induced increase in msfp results from recruitment of unstressed volume to stressed volume, which may be modified by changes in vascular compliance. the effects on pump afterload were not limiting. introduction: to locate vessels for percutaneous central venous catheterizations, it may be helpful to apply not only real-time ultrasound (us) guidance but also us-assistance vein prelocation. the aim of this study was to evaluate the superiority of two us methods compared to surface landmark methods by reviewing randomized control trials (rcts). methods: as updating an earlier systematic review [ ] , we searched pubmed and central in november . we included rcts which compared the failure rates of internal jugular or femoral venous cannulations among ) real-time us guidance, ) us-assistance vein prelocation and ) surface landmark methods. a frequentist network meta-analysis was conducted using the netmeta package on r. results: out of citations, rcts ( patients) were eligible. the number of studies comparing outcomes between real-time us guidance vs. surface landmark methods, us-assistance vein prelocation vs surface landmark methods and real-time us guidance vs us-assistance vein prelocation was , and . regarding cannulation failure rate, network meta-analysis in a fix-effect model showed that a p-score was lower in the real-time us guidance than us-assistance vein prelocation ( . vs. . ), by reference to surface landmark methods, and also regarding arterial punctures, a p-score was lower in the real-time us guidance than us-assistance vein prelocation ( . vs. . ). conclusions: based on the present network meta-analysis of rcts, pscores of cannulation failure and arterial puncture were lower in the real-time us guidance, suggesting that the us-assistance vein prelocation is superior than the real-time us guidance, both of which achieve lower rates of failure and arterial puncture compared to the landmark methods. we speculates that the inferiority of real-time guidance is associated with difficulties in manipulating the needle together with an echo probe in targeting relatively smaller veins in children. introduction: we present a case report of 'shoshin beriberi' in a young female who was 'fussy with food' that developed an acutely progressive metabolic acidosis and multi-organ failure requiring intensive care support. methods: our patient was a -year-old british woman who presented to the emergency department (ed) with a ten-day history of diarrhea, vomiting and increasing fatigue. she had a past medical history of gastroparesis, polycystic ovary syndrome (on metformin), laparoscopic cholecystectomy and hysteropexy. she lived with her husband and two children who had viral gastroenteritis two weeks previously. results: the patient had a metabolic acidosis (ph . ) with raised lactate (> ) on initial blood gas in the ed. a . % sodium bicarbonate infusion and hemofiltration were commenced overnight. the patient's ph and lactate remained static with an increasing work of breathing over this period. by morning she developed flash pulmonary oedema and hypotension, the first signs of acute cardiac failure. an echocardiogram displayed severely impaired left ventricular function with ejection fraction of %. the patient was intubated and inotropic support was commenced. it was thought that a micronutrient deficiency may have caused a rapid onset cardiac failure. pabrinex (containing ml of thiamine hydrochloride) was commenced and within hours the patient's metabolic acidosis markedly improved ( fig. ). complete reversal of the cardiac failure occurred over hours. conclusions: shoshin is a rare clinical manifestation of thiamine deficiency [ ] . it is an important differential diagnosis to bear in mind after excluding more common aetiologies of heart failure. especially in this case as our patient had no obvious risk factors at the time of presentation. we suggest empiric use of thiamine should be considered in treatment algorithms for young patients presenting with acute cardiac failure. the pateint had provided informed consent for publication. introduction: takotsubo syndrome (ts) is known to be an acute transient cardiac condition accompanied with acute heart failure. ts is often triggered by critical illness but that has been rarely studied in icu practice.therefore, it is known, that the use of catecholamines can directly induce ts, worsen lvot obstruction, and delay spontaneous recovery in ts patients, it is nearly impossible to avoid their administration in critically ill [ ] . methods: we have analyzed medical records from patients with ts, that were revealed during year in our hospital. ts was defined due to mayo criteria, including transient regional wall motion abnormalities, mildly elevated troponin level and no signs of obstructive cad on coronary angiography. results: out of patients who developed ts in icu or iccu, hemodynamic instability occurred in acute phase of ts in ( %) cases. ( %) of patients were admitted to icu in due to septic shock ( patients), major bleeding ( ), cerebral mass lesion ( ) and ards ( ) and required treatment with catecholamines. general mortality rate in ts patients was ( %), and ( %) in critically ill ts patients. mean duration of noradrenalin infusion was , days, dobutamine infusion , days. patients with ts needed more icu resources and longer icu-stay. mortality rate was higher in ts patients ( %) vs the icu-population ( %), p = . . conclusions: ts seems to be an often cause of lv dysfunction and acute heart failure in critically ill. it seems that ts could be a predictor of worse prognosis in critically ill patients. although catecholamine administration may worsen the patient prognosis and induce further ahf in critically ill patients it rearely can be avoided. introduction: previous studies on readmission following lvad implantation have focused on hospital readmission after dismissal from the index hospitalization. since there are very little data existing, the purpose of this study was to examine intensive care unit (icu) readmission in patients during their initial hospitalization for lvad implantation to determine reasons for, factors associated with, and mortality following icu readmission. methods: this was a retrospective, single center, cohort study in an academic tertiary referral center. all patients at our institution undergoing first time lvad implantation from february to march were included. patients dismissed from the icu who then required icu readmission prior to hospital dismissal were compared to those not requiring icu readmission prior to hospital dismissal. results: among lvad patients, ( . %) required icu readmission. the most common reasons for admission were bleeding and respiratory failure (fig. ) . factors found to be significantly associated with icu readmission were preoperative hemoglobin level of less than g/dl, preoperative estimated glomerular filtration rate < ml/min/ . m , preoperative atrial fibrillation, preoperative dialysis, longer cardiopulmonary bypass times, and higher intraoperative allogeneic blood transfusion requirements. mortality at year was . % in patients requiring icu readmission vs. . % in those not requiring icu readmission (age-adjusted or= . , % ci . to . , p= . ). conclusions: icu readmission following lvad implantation occurred relatively frequently and was associated with significant one-year mortality. these data can be used to identify lvad patients at risk for icu readmission and implement practice changes to mitigate icu readmission. future larger and prospective studies are warranted. atrial fibrillation and infection among acute patients in the emergency department: a multicentre cohort study of prevalence and prognosis t graversgaard odense university hospital, odense, denmark critical care , (suppl ):p introduction: patients with infection presenting with atrial fibrillation (af) are frequent in emergency departments (ed). this combination is probably related to a poor prognosis compared to lone af or infection, but existing data are scarce. aim: to describe the prevalence and prognosis for af and infection individually and concomitantly in an ed setting. introduction: its afterload reducing effects make peep the treatment of choice for cardiogenic pulmonary edema. studies indicate that peep may lower coronary blood flow. its effects on left ventricular contractility is unclear. most of the surrogate measures for cardiac contractility are dependent on afterload and contractility assessment under peep may therefore be biased. we have investigated cardiac contractility under peep with the endsystolic pressure volume relationship (espvr) as a load-independent measure of contractility. methods: patients scheduled for coronary angiography were ventilated with cpap and a full face mask at three levels of peep ( , and cmh o) in random order. structural cardiac pathologies were excluded with echocardiography. at every peep level, left ventricular pressure volume loops (millar conductance catheter with inca system, leycom, netherlands) were obtained. the endsystolic elastance was derived from a pv-loop family under preload reduction with an amplatzer sizing balloon in the inferior caval vein. all participants gave written informed consent. the study was approved by the bernese ethics committee. results: women and men with an age ± years were studied. ejection fraction was ± % at baseline. mean espvr at peep levels of , and were . ± . , . ± . and . ± . mmhg/ml (p = . , repeated measurements anova). dp/dt and ejection fraction did not differ between the peep levels (p= . and . ). conclusions: moderate levels of peep did not influence endsystolic elastance. higher peep and patients in cardiogenic shock should be investigated. introduction: we sought to assess the feasibility of d volumetric analysis with transthoracic echocardiography in critically ill patients. we choose a cohort typical of icu where accurate volumetric analysis is important: hypoxic, mechanically ventilated patients. d analysis is enticing in simplicity and wealth of data available. it is accurate in cardiology patients [ ] but has not been assessed in the icu. methods: patients were imaged within hours of admission. inclusion criteria: adult, hypoxic (p:f < ), mechanically ventilated, doppler stroke volume (sv) assessment possible. echocardiography: seimens sc real-time volumetric analysis with standard b-mode and doppler assessment. images unacceptable if > segments unable to be seen in volumetric planes. d left ventricle (lv) and right ventricle (rv) analysis with tomtec imaging and seimens acuson respectively and compared to doppler derived sv. % limit of agreement considered clinically acceptable [ ] . imaging was optimised for volumetric analysis ( - vols/sec). results: patients, in sinus, in af. no significant difference seen between doppler vs d simpson's biplane, d lv or d rv sv estimation. feasibility, sv values and bias are reported in table and fig. . limit of agreement for corrected doppler vs lv d sv = - % to %; rv d sv = - . % to . %. conclusions: d lv and rv volumetric analysis is feasible in majority of patients requiring mechanical ventilation, however lacks agreement with doppler derived stroke volume assessment. although images may appear sufficient, the semi-automated software appears to underestimate stroke volume. further larger studies using thermodilution are warranted. introduction: body position changes such as leg raising are used to determine fluid responsiveness. we hypothesized that the trendelenburg position increases resistance to venous return. together with abolishment of the hepatic vascular waterfall, this may limit the increase in regional blood flow. methods: inferior vena cava (ivc), portal vein (pv), hepatic, superior mesenteric (sma) and carotid artery blood flows and arterial, right atrial (ra) and hepatic (hv) and portal venous blood pressures were measured in anesthetized and mechanically ventilated pigs in supine and °trendelenburg positions. all hemodynamic parameters were measured during end-expiration at cmh o peep, and at inspiratory hold with increasing airway pressures (awp) of , , and cmh o, respectively. paired t test was used to compare pressures and flows in different positions during end-expiration. repeated measures anova was performed to evaluate the effects of awp on hemodynamic parameters. results: trendelenburg position significantly increased ra, hv and pv blood pressures at end-expiration, while qpv and qsma remained unchanged, qha increased and qivc showed a trend to decrease (table ). in both positions, all blood flows decreased with increasing awp, and the difference between ppv and qsma became smaller, indicating splanchnic blood pooling ( table ). in the trendelenburg position, splanchnic blood pooling was less severe compared to supine position. conclusions: trendelenburg position tended to decrease venous return from inferior vena cava. further increases in rap by augmenting awp led to a decrease in all flows and signs of abolished hepatic vascular waterfall. passive manoeuvers to assess fluid responsiveness evoke complex hemodynamic reactions which are not fully understood. introduction: despite of preventive measures, the incidence of deep venous thrombosis (dvt) in icu patients is estimated to range from - %. while clinical diagnostics is unreliable, ultrasound compression test (uct) has proven to be a highly sensitive and specific modality for the recognition of lower extremity dvt [ ] . delegating this competence to icu nurses can increase uct availability and enable preventive dvt screening. therefore, we decided to conduct a clinical study to evaluate the sensitivity and specificity of uct performed by general icu nurse in icu patients compared to an investigation by icu physician certified in ultrasound. methods: prior to the study, each nurse participating in the study completed one-hour training in uct and examined patients under supervision. then, icu patients without known dvt underwent uct in the femoral and popliteal region of both lower extremities performed by trained general icu nurse. on the same day, the examination was repeated by an icu physician. the results of the examinations of each patient were blinded to each other for both investigators until both tests were performed. in case of a positive test, the nurse immediately reported the result to the icu physician. the sensitivity and specificity of the test performed by general nurse was calculated in comparison with the examination by a specialist. results: a total of patients were examined. both lower extremities were examined in all patients. the prevalence of dvt of , % has been found. the overall sensitivity of the examination performed by general nurse was . %, the specificity % with negative predictive value of . %, positive predictive value of % and accuracy of . %. the results of our study have shown that general icu nurses are able to perform bedside screening of dvt by compression ultrasound test with a high degree of reliability after a brief training. methods: a cytosorb® (cytosorbents, new jersey, usa) ha device was inserted within the cpb circuit in ten patients undergoing elective cardiac surgery. one hour after cpb onset, the activity of coagulation factors (antithrombin (at), von willebrand factor (vwf), factors ii, v, viii, ix, xi, and xii) were measured before and after the device. pre and post device measurements were compared using student ttest, a p value < . was considered statistically significant. results: patients' mean age was . ± . years, % were female, the mean euroscore ii was . ± . . procedures were: coronary artery bypass graft (cabg) ( / ), aortic root replacement ( / ) and cabg combined with aortic valve replacement ( / ). mean cpb duration was . ± . min. pre and post ha measurements of coagulation factors activity are presented in fig. . post-device at and fii activity was significantly lower (respectively from . to . , p= . and from . to . , p= . ) compared to predevice measurement. there was no statistically significant difference between pre-and post-ha measurements for all other coagulation parameters conclusions: pre and post ha cytosorb® measurements for coagulation factor activity were not different except for a small decrease in at and fii activity. this might be related with intra-device consumption or adsorption. further analyses accounting for cpb fluid balance, the entire study population and timepoints are pending. introduction: the aim of this study is to evaluate changes in hemodynamics and microvascular perfusion during extracorporeal blood purification with cytosorb in patients with septic shock requiring renal replacement therapy. methods: eight adult patients with septic shock requiring continuous renal replacement therapy for acute renal failure were enrolled and underwent a -hour treatment with the emodasorption cartridge cytosorb. measurements were taken at baseline before starting cytosorb, after h (t ) and h (t ) and included: blood gases, macrohemodynamic parameters (picco ), vasopressor and inotropic dose, plasma levels of cytokines (interleukin [il]- , il , il , il , tumor necrosis factor alpha) and parameters of microvascular density and perfusion (sublingual sidestream dark field videomicroscopy). procalcitonin was measured at baseline and after h of treatment. results: a non-significant decrease in plasma levels of cytokines was observed over time. hemodynamic parameters and vasopressor requirement remained stable. the microvascular flow index increased significantly at t , total vessel density and perfused vessel density increased at t and t ( introduction: objective renal replacement therapy (rrt) with the oxiris filter is used in sepsis septic shock with aki, but few clinical studies compare the adsorbing effect of oxiris filter on the inflammatory mediators to rrt. the aim of this study is -to confirm whether oxiris decreases cytokines and procalcitonin in sepsis septic shock. -this effect is superior to rrt. -this translates in a better cardio renal response. methods: a coohort study and a propensity-matched analysis included patients admitted to three intensive care (aurelia hospital, european hospital, tor vergata -rome) with a diagnosis of septic shock. patients were submitted to rrt with oxiris filter and patients to rrt.il , procalcitonin, the cardiorenal indices and sofa score were compared before (t ) and at the end of the treatments (t ). all data are expressed as mean±sd. anova one way was used to compare the changes of the variables in the time. p< . was considered statistically significant. results: of patients submitted to rrt with the oxiris filter could be matched to septic patients who received rrt. il and procalcitonin decreased in the oxiris group (p< . ) but not in the rrt group.-map increased (p< . ) and noradrenaline dosage decreased in oxiris group (p< . ), but non in rrt group. also pao /fio ratio, diuresis, sofa improved only in the in the oxiris group (p< . ). conclusions: in sepsis/septic shock patients with aki, il and procalcitonin decrease more in the oxirs group then in the rrt group.this is associated with an improvement of the cardio -renal function and the clinical condition.the study confirms that rrt with oxiris filter may be useful in sepsis/septic shock when other convective/diffusive techinques fail. introduction: advos (hepa wash gmbh, munich, germany) is a recently developed ce-certified albumin-based hemodialysis procedure for the treatment of critically ill patients. in addition to the removal of water-soluble and albumin-bound substances, acid-base imbalances can be corrected thanks to an automatically regulated dialysate ph ranging . to . . methods: patients treated with the advos procedure between in the department of intensive care medicine of the university medical center hamburg-eppendorf were retrospectively analyzed. overall treatments in critically ill patients (mean sofa score ) were evaluated. additionally, subgroup analysis for hyperbilirubinemia, respiratory acidosis and non-respiratory acidosis were conducted. results: severe hyperbilirubinemia (> mg/dl) was present in treatments, while and treatments were performed to treat respiratory (paco > mmhg) and non-respiratory (paco < mmhg) acidosis (ph< . ), respectively. mean treatment duration was h. advos procedure was able to correct acidosis and reduce bilirubin, bun and creatinine levels significantly. the subgroup analysis shows an average bilirubin reduction of % per advos multi treatment in the hyperbilirubinemia group ( . mg/dl vs . mg/dl, p< . ). moreover, ph ( . vs. . , p< . ) and paco ( . vs. . mmhg, p< . ) were corrected in the respiratory acidosis group, while in the non-respiratory acidosis group, an improvement in ph ( . vs. . , p< . ), hco ( . vs. . , p= . ) and base excess (- . vs. - . , p= . ) could be observed. there were no treatment-related adverse events during therapy. conclusions: advos is a safe and effective hemodialysis procedure, which is able to remove water soluble and protein bound markers and correct severe acidosis in critically ill patients. score for timely prescribing (stop) renal replacement therapy in intensive care unit -preliminary study of a mneumonic approach introduction: the moment of initiation of renal replacement therapy (rrt) in critically ill patients and a reason for debate, without having objective criteria that indicate it. the objective of this study was to propose a score to help identify the ideal time for the initiation of rrt, and if there is correlation between this score and intensive care unit length of stay and mortality. methods: patients admitted to the intensive care unit, > -yearsold, to whom rrt were indicated by the intensivist. the study protocol was approved by the hospital das forças armadas ethical committe, and written informed consent was obtained from all patients. the stop was assigned according to the presence or not of each of the items (fig. ). they were classified into groups a and b according to fig. , and the group change was recorded. results: patients admitted to icu in the period, excluded for limitation of therapeutic efforts. were admitted to the study, with the mean age of . years; , % males (n= ). distribution among the groups: a (n= , . %), a ( , . %), a ( , . %), b ( , . %), b ( , . %) e b (no patients). there were statistically significant correlation between group change and mortality (p . ), and between the stop and nephrologist agreement (p . ). there was no correlation between stop value and icu los (p , ) or stop and mortality (p . ). conclusions: the stop value is correlated with hemodialysis indication agreement between intensivists and nephrologists, and not correlated with icu los or mortality. the group change was correlated to increased mortality, in the study population. the significance of stop as a tool in determining the moment of initiation of renal replacement therapy remains a work in progress. introduction: liver transplant (lt) in patients with renal dysfunction presents intraoperative challenges and portends postoperative morbidity. continuous renal replacement therapy (crrt) is increasingly used for intraoperative support; however, there is a paucity of data to support this practice. methods: pilot randomized open-label controlled trial in adults receiving cadaveric lt with a modification of end-stage liver disease (meld) score >= and preoperative acute kidney injury (kdigo stage ) and/or estimated glomerular filtration rate < ml/min/ . m . patients were randomized to intraoperative crrt (icrrt) or standard of care. primary endpoints were feasibility and adverse events. secondary endpoints were changes in intraoperative fluid balance, complications, and hospital mortality. analysis was intention-to-treat. results: sixty patients were enrolled, ( %) were randomized ( to icrrt; to control). mean (sd) was age ( ) years, meld was ( ), % (n= ) had cirrhosis; % (n= ) received preoperative rrt; and % (n= ) were transplanted from icu. one patient allocated to icrrt did not receive lt. seven ( %) allocated to control crossed over intraoperatively icrrt ( ( ) min, with only interruptions (all due to access). icrrt fluid removal was . l (range - . ). fluid balance was . l ( . ) for icrrt vs. . l ( . ) for control (p= . ). postoperative crrt was similar ( % vs. %, p= . ). there were no differences in reexploration (p= . ), mechanical ventilation time (p= . ), reintubation (p= . ), sepsis (p= . ), or mortality (p= . ). conclusions: in this pilot trial of high acuity lt patients, icrrt was feasible and safe. these data will inform the design of a large trial to define the role of icrrt during lt. clinicaltrials.gov: nct . the uptake of citrate anticoagulation for continuous renal replacement therapy in intensive care units across the introduction: the purpose of this descriptive study is to report the trend of citrate anticoagulation uptake, used for continuous renal replacement therapy (crrt), in intensive care units (icus) across the united kingdom (uk). citrate anticoagulation has been used in the uk since , but its uptake since then is unknown [ ] . methods: a survey questionnaire targeted pharmacists working in uk adult icus providing crrt. invitations to participate were distributed utilising the united kingdom clinical pharmacy association online forum as a platform for access. survey administration was by self-completion and submissions were accessible over a total of six weeks. basic demographic data, icu specifications, the citrate system in use and implementation details were sought. a descriptive statistical analysis ensued. results: responses were received of which were analysed after duplication removal. trusts, encompassing a total units, in the uk confirmed use of citrate anticoagulation for crrt. units reported a mean of days to implement a citrate system (range to days). prismaflex® (baxter) and multifiltrate (fresenius) were reported as the most commonly used citrate systems; ( . %) and ( . %) units respectively. conclusions: there are icus in the uk [ ] . we conclude that a minimum of units ( %) use citrate anticoagulation for crrt in uk critical care centres. citrate systems of anticoagulation are becoming an increasing popular choice for regional anticoagulation, falling in line with international guidance [ ] . these guidelines were introduced in which corresponds to increase national uptake. introduction: patients requiring renal replacement therapy (rrt) whilst on significant doses of vasoactive medications have often been deemed unsuitable to undergo ultrafiltration (uf). however with better understanding of the pathophysiology of renal injury [ ] in intensive care patients we hypothesise that vasopressor/inotrope requirement will not significantly increase with uf or with a more negative fluid balance (fb). methods: data was retrospectively collected in a general icu/hdu of adult patients requiring acute rrt for acute kidney injury. patients on chronic dialysis were excluded. percentage change in vasopressor index and mean arterial pressure were combined to form the combined percentage change (cpc) which we used as an index of patient stability. results: patients were assessed undergoing a total of rrt sessions. the mean age was with females and males. mean fb for the hours from start of rrt was + mls (range - to + mls). using a model to correct for significant covariates and plotting hour fb against cpc we found no significant effect of fb on stability p= . (fig. ). mean uf volume was mls (range - mls). there was a non linear relationship between uf and stability with moderate volumes improving but larger volumes worsening stability (fig. ). this did not reach statistical significance (p= . ) so may be due to chance but is likely due to a lack of power. conclusions: fluid balance has no effect on cardiovascular stability during rrt in our cohort but there may be a varying effect of uf depending on volume. introduction: exposure of blood to a foreign surface such as a continuous renal replacement therapy (crrt) filter could lead to activation of platelets (plt) and fibrinogen (fib) trapping. thrombocytopenia has been reported in adults on crrt but data in pediatrics are scarce. our institution uses regional citrate anticoagulation (rca) as standard of care with prefilter hemodilution and hf filters (polysulfone, surface area (sa) . m ) regardless of patients' (pts) age and size. as filter sa is relatively larger in younger pts, we aimed to investigate the impact of crrt filter change on hemostasis parameters in infants on crrt in up to first three filter changes. methods: retrospective chart review results: patients < kg were included, age . ( . - ) months, weight . + . kg, with filters. metabolic disease was the most common principal diagnosis ( / , %), liver failure (lf) was the most common comorbidity ( / , %). all patients received prefilter continuous venovenous hemodiafiltration with minimum dose of ml/ . m /h. thrombocytopenia was common at crrt start ( / , %). plts decreased in % filter changes ( / ) by + % (pre vs post plt ( - ) vs ( - ), p< . ). fibrinogen also decreased from ( - ) to ( - ), p< . ; there was no change in ptt, pt, or inr values before and after filter changes. bleeding events were seen in / ( %) of pts ( / of lf pts vs / others, p= . ), but were not more common in pts who had decrease in plts or fib with filter changes ( % with drop in plts vs % without, p= . ; % with drop in fib vs % without, p= . ). conclusions: thrombocytopenia is common in infants on crrt. further decreases in plt and fibrinogen can be seen in with crrt filter changes if the filters are relatively large compared to patient size. bleeding events seems more related to underlying comorbidity, and less to changes in hemostatis parameters observed with filter change but would need to be confirmed with further studies. intensive monitoring of post filter ionized calcium concentrations during cvvhd with regional citrate anticoagulation: is it still required? introduction: the aim of the present study was to evaluate the role of postfilter calcium concentrations (pfca) in terms of safety and efficacy in large retrospective cohort of patients treated with cvvhd and regional citrate anticoagulation. methods: retrospective, observational study at a university hospital with icus. all patients treated with rca-crrt were included in the study. results: among patients treated with rca-cvvh pfca at the start of the cvvhd was available in pts. the pfca concentrations were in target range ( . - . mmol/l) in the majority of patients ( %), whereas % and % of patients had the pfca below or above the target range, respectively. in the further h of cvvhd treatment the propotion of patients with targeted pfca increased to % and remained stable. at the start of the rca-cvvhd there was a significant but weak correlation between the pfca and ionized systemic ca (ica) with a spearman rank-order correlation coefficient (rho) of . (p < . ). the coefficient of variation of pfca concentraions was significantly higher if compared to the coefficient of variation of ica concentration. using per protocol adaptations the incidence of a severe hypocalcemia (< . mmol/l) was low and present only at first hours of therapy: % and % of patients with pfca below the target range and . % and . % of patients with pfca in target range, at h and h respectively (p< . ). there was no correlation between pfca concentrations and filter lifetime. the results of the present study support the previous reports about higher measurements variation of pfca compared to systemic ica ( ). nevertheless due to the weak correlation of ica and pfca as well as a low number of patients with a severe metabolic complication, the results of our study question the necessity of intensive pfca monitoring during rca-crrt. present results need to be validated in further trials. introduction: in critically ill patients, occurrence of pain is frequent and usually correlates with worse outcomes, such as prolonged icu length of stay (los) and mechanical ventilation. in this regard, pain leads to sympathetic activation, inflammatory mediators and therefore, potentially to organic dysfunction. the aim of this study is to evaluate the relationship between acute pain in critically ill patients and their association with acute kidney injury (aki). methods: retrospective cohort with adults patients admitted between june and june , from the icu of hospital sírio libanês hospital in sao paulo (brazil). main exclusion criteria were: length of stay < h, coma and previous aki. the predictor pain was obtained through daily electronic records according to numerical verbal scale ( - ). the outcome was defined as serum creatinine elevation equal to or greater than . mg/dl and/or greater than % increase at any time after the first hours in the icu. the multivariate analysis was performed by binary logistic regression through distinct groups of early or late predictive factors in relation to aki. results: after the exclusion of patients, the incidence of pain with numerical verbal scale equal to or greater than points was . %. the outcome occurred in . % of the cohort. in the binary regression, using the more early predictive factors, sex and pain presented independent relation with the outcome -adjusted or . ( . - . ) and . ( . - . ), respectively (p < . ). in the analysis conclusions: poor management of icu pain is associated to worse outcomes, including increased risk to aki. the search for a better pain management strategy in the icu scenario should therefore be reinforced. introduction: acute kidney injury (aki) is a common complication in hospitalised patients, strongly associated with adverse outcomes [ ] . a lack of baseline incidence and outcome data limits our ability to assess local strategies aimed at improving aki care. methods: in an audit in three linked inner london hospitals we interrogated our electronic patient data warehouse (cerner millennium power insight electronic data warehouse) with a specially written query to identify cases of aki, defined by kdigo creatinine criteria, in patients aged over y admitted for > h during january to june . we excluded palliative care and obstetric patients. in the absence of premorbid baseline (median - d pre-admission) the admission creatinine value was used. end stage renal disease (esrd) and primary sepsis diagnosis was obtained from icd coding. results: of admissions, we excluded with pre-existing esrd (hospital mortality . %) and with fewer than one creatinine result who could not be assigned aki status (mortality . %). of the remaining there were with aki ( . %), with mortality increasing from no aki group ( . %), to aki stage ( . %), and a further increase to aki stages - ( . %) (p< . ) ( table ) . patients with aki were older (p< . ), more likely to be medical than surgical (p< . ), more likely to have a primary sepsis diagnosis (p< . ) and had higher baseline creatinine (median vs p< . ). no known baseline was found in . % of patients with aki, but their mortality did not significantly differ to those with a baseline ( . % vs . %, p= . ). conclusions: an electronic query identified the local burden of aki and it's associated hospital-mortality; such baseline data is essential to assess the effect of quality improvement interventions in aki prevention and care. introduction: acute kidney injury (aki) is a common condition in critically ill patients [ , ] . loop diuretics are generally used as first line treatment. however, controlled trials show controversial results. we ought to search systematically and realize a metaanalysis on the matter. methods: an electronic search of randomized clinical trials in adult patient treated with diuretics for aki compared with standard treatment or a control group was conducted. the primary objective of the analysis was to assess recovery of renal function. secondary endpoints included time to recovery of renal function, need for renal replacement therapy (rrt), mortality in the intensive care unit (icu) and complications. introduction: increased venous pressure is one of the mechanism leading to acute kidney injury (aki) after cardiac surgery. portal flow pulsatility and discontinuous intra-renal venous flow are potential ultrasound markers of the impact of venous hypertension on organs. the main objective of this study was to describe these signs after cardiac surgery and to determine if they are associated with aki. methods: this single center prospective cohort study (nct ) recruited adult patients able to give consent. ultrasound studies were performed before cardiac surgery and repeated on post-operative day (pod) , , and . abnormal portal and renal venous flow patterns are defined in fig. . the association between the studied markers and the risk of new onset of aki in the following hours period following an assessment was tested using logistic regression with a % confidence interval. clinical variables associated with the detection of the signs were tested using generalized estimating equation models. this study was approved by the local ethics committee. results: during the study period, patients were included. the presence of the studied ultrasound signs is presented in fig. . during the week following cardiac surgery, patients ( . %) developed aki, most often on pod ( . %). the detection of portal flow pulsatility and severe alterations in renal venous flow (pattern ) at icu admission (pod ) were associated with aki in the subsequent hours period and was independently associated with aki in multivariable models including euroscore ii and baseline creatinine ( table ). the variables associated with the detection of abnormal portal and renal patterns were associated with lower perfusion pressure, higher nt-pro-bnp and inferior vena cava measurements (table ) . conclusions: abnormal portal and intra-renal venous patterns are associated with early aki after cardiac surgery. these doppler features must be further studied as potential treatment targets to personalize management. introduction: acute kidney injury (aki) is very prevalent after cardiac surgery in children, and associated with poor outcomes [ ] . the present study is a preplanned sub-analysis of a prospective blinded observational study on the clinical value of the foresight nearinfrared spectroscopy (nirs) monitor [ ] . the purpose of this subanalysis was to develop a clinical prediction model for severe aki (saki) in the first week of picu stay. methods: saki was defined as serum creatinine (scr) >/= times the baseline, or urine output < . ml/kg/h for >/= h. predictive models were built using multivariable logistic regression. data collected during surgery, upon picu admission, as well as monitoring and lab data until h before saki onset, were used as predictors. relevant predictors with a univariate association with saki, were included in the models. accuracy of the models was tested using bootstraps, by auroc and decision curves. results: children were enrolled, admitted to the picu of the leuven university hospitals after cardiac surgery, between october and november . patients were excluded. children ( . %) developed saki in the first week of picu stay. a multivariate model with admission parameters (maximum lactate during surgery, duration of cpb, baseline scr, rachs and pim scores), and postoperative measurements (average heart rate, average blood pressure, hemoglobin, lactate), was most predictive for saki ( fig. ) . conclusions: the risk of saki in children after congenital cardiac surgery could be predicted with high accuracy. future models will also include medication data. these models will be compared against and combined with nirs oximetry data to investigate the independent and added predictive value of the foresight monitor. introduction: acute kidney injury (aki) occurs in over % of the patients in the intensive care unit (icu). the predominantly ethiology of aki is septic shock, the most common diagnosis in the icu. aki significantly increases the risk of both morbidity and mortality [ ] . methods: icu patients with septic shock was studied within hrs from admission. patients after cardiac surgery served as control group. all patients were sedated and mechanically ventilated. renal blood flow (rbf) and glomerular filtration rate (gfr) were obtained by the infusion clearance of paraaminohippuric acid (pah) and by extraction of cr-ethylenediamine ( cr-edta). n-acetyl-β -d-glucosaminidase (nag), was measured. results: rbf was % lower, renal vascular resistance % higher and the relation of rbf to cardiac index was % lower in patients with septic shock compared to the control group. gfr ( %, p= . ) and renal oxygen delivery (rdo ) ( %) where both significantly lower in the study group (table ) . there was no difference between the groups in renal oxygen consumption (rvo ) but renal oxygen delivery was almost % lower in septic shock patients. renal oxygen extraction was significantly higher in the study group than in the control group. in the study group, nag was . ± . units/mikromol creatinine more, i.e times the value in patients undergoing cardiac surgery [ ] . conclusions: sepsis related aki is caused by a renal afferent vasoconstriction resulting in a reduced rbf and lowered rdo in combination with an anchanged rvo , this results in a renal oxygen supply/ demand mismatch. introduction: the primary aim was to determine if the addition of daily creatine kinase (ck) measurement was usefully guiding decision making in intensive care units within greater glasgow and clyde. methods: after a change to the daily blood ordering schedule to include ck, a retrospective audit was carried out covering a -month period within intensive care units. all patients with ck > units/ litre were included. basic demographics, apache score and admitting diagnosis were recorded. utility of ck was assessed by determining the associated diagnosis and whether the diagnosis was first considered (diagnostic trigger) due to ck level, clinical suspicion or haematuria. additionally, it was determined if and what actions had been taken based on the raised ck and associated diagnoses. results: data was collected from / / to / / . patients were captured with ck > units/litre from an average combined admission rate of patients/month [ ] . total male patients ( . %) and female ( . %). age range to years (mean . ). apache score range to (mean . ) with estimated mean mortality of . %. patients ( . %) had associated diagnoses with elevated ck including: burns ( . %), compartment syndrome ( . %), myocardial infarction ( . %), myositis/myocarditis ( . %), neuroleptic malignant syndrome ( . %), rhabdomyolysis ( . %), serotonin syndrome ( . %), surgical procedure ( . %). as outlined in fig. the diagnostic trigger was the routine ck measurement in patients ( . %), prior clinical suspicion ( . %), haematuria ( . %) and unclear in ( . %). action was the correlation analysis showed the egfrs from every formula could all to some extent reflect the glomerular function or gfr accurately. the gfr (scys) formula was a quickly and accurate method for estimating gfr and may apply clinically in critically ill patients. perioperative chloride levels and acute kidney injury after liver transplantation: a retrospective observational study s choi introduction: the risk of developing acute kidney injury (aki) after liver transplantation in the immediate postoperative period ranges between to %. most studies in critically ill and surgical patients evaluated the link between chloride-rich resuscitation fluids, not serum chloride levels, and the incidence of aki. the association between preoperative chloride level or difference in perioperative chloride levels and the incidence of postoperative aki after liver transplantation were evaluated. methods: adult patients (>= years old) who underwent liver transplantation at seoul national university hospital between and were included in the retrospective analysis. the difference between preoperative serum chloride level and the immediate postoperative serum chloride level was defined as intraoperative chloride loading. postoperative aki within days of liver transplantation was diagnosed according to the rifle criteria. patients were divided into normochloremia group ( - meq/l), hypochloremia group (< meq/l), or hyperchloremia group (> meq/l) according to their preoperative chloride level. intraoperative chloride loading was defined as the difference between preoperative serum chloride level and immediate postoperative serum chloride level. . ) compared to patients with preoperative normochloremia. meld scores > and age > years were also associated with increased risk of aki. intraoperative chloride loading was not a significant risk factor for aki after liver transplantation. conclusions: preoperative hyperchloremia and hypochloremia were both associated with an increased risk of developing aki in the immediate postoperative period after liver transplantation. introduction: perioperative acute kidney injury (aki) is associated with significant morbidity and mortality [ ] . certain urinary biochemical parameters seem to have a standardized behavior during aki development and may act as surrogates of decreased glomerular filtration rate (gfr) aiding in early aki diagnosis [ ] . aim of this prospective observational study was the evaluation of urinary biochemical parameters as early indicators of aki in a cohort of major surgery patients. methods: patients were studied. aki was defined according to akin criteria within hrs after surgery [ ] . at pre-defined time points (preoperatively, recovery room [rr] and on postoperative days [pod] to ) simultaneous serum and urine samples were analyzed additional studies must confirm these findings and reevaluate these simple parameters as potential aki monitoring tools. urinary liver-type fatty acid-binding protein is the novel biomarker for diagnosis of acute kidney injury secondary to sepsis t komuro, t ota shonan kamakura general hospital, kamakura, kanagawa, japan critical care , (suppl ):p introduction: acute kidney injury (aki) is the predictor of poor prognosis for the patient with sepsis and septic shock. several diagnostic criteria for aki is used on clinical settings, but useful biomarker is not known yet. urinary liver-type fatty acid-binding protein(l-fabp) is associated with kidney function and aki [ ] , but that is not still discussed about aki secondary to sepsis. thus, we conducted the study of the association between urine l-fabp and aki with secondary to sepsis. (fig. ) . the cut-off line of l-fabp was . μg/g cr. conclusions: l-fabp can be the novel biomarker for diagnosis of aki. further investigation need for diagnostic value of l-fabp and usefulness of early intervention for aki used by l-fabp. introduction: biotransformation of -hydroxyvitamin d to active , (oh) d occurs primarily in the kidney. our aim was to explore whether this process was altered in patients with acute kidney injury (aki). methods: consecutive patients admitted to critical care at a tertiary hospital were recruited. the aki group comprised patients with kdigo stage ii or stage iii aki; the non-aki group were patients requiring cardiovascular or respiratory support, but with no aki. vitamin d metabolite concentrations were measured on days , and . statistical analysis included comparison between groups at each time point, and longitudinal profiles of vitamin d metabolites. results: interim analysis of participants ( % of the recruitment target) showed that , (oh) d concentrations were significantly lower in patients with aki at day and day . considering longitudinal changes, -hydroxyvitamin d profiles were not different between the groups ( fig. ) but there was a trend towards a longitudinal increase in , (oh) d in patients without aki, which was not seen in aki patients (fig. ) . conclusions: interim analysis indicates significant differences in concentrations of , (oh) d, but not (oh)d, in critically ill patients with aki. recruitment is ongoing and further results are awaited. introduction: acute renal failure affects from % to % of patients in the intensive care units (icus) and it is associated with excess mortality. hydratation is a useful preventive measure but it is often controindicated in critically ill patients who, on the contrary, often benefit by a strictly conservative strategy of fluid management. fenoldopam, a selective dopamine -receptor agonist, increases renal blood flow and glomerular filtration rate by vasodilating selectively the afferent arteriole of renal glomerulus. the aim of our study is to compare renal effects of fenoldopam and placebo in critically ill patients undergoing a restrictive fluid management. methods: we enrolled patients admitted to our icu. patients were assigned by randomization to study groups: fenoldopam (n= ) and placebo (n= ). fenoldopam was infused continuously at , mcg/kg/ min and equivalent volume for placebo during a period of seven days. creatinine, cystatin c and creatinine clearance were daily measured as markers of renal function. the incidence of aki according to rifle criteria (risk, injury, failure, loss, end stage kidney disease) was also calculated. results: patients with a negative fluid balance at the end of the week (~- ml, p= , ) were included in the analysis, in the placebo group and in the fenoldopam group. there were not significant differences in the trend of creatinine, creatinine clearance, cystatin c and in the incidence of aki between the groups during the week of infusion. conclusions: a continuous infusion of fenoldopam at , mcg/kg/ min does not improve renal function and does not prevent aki in critically ill patients undergoing a strictly conservative strategy of fluid management. introduction: this study aims to evaluate the efficacy of a protocol implemented for dysphagia risk factors [ ] in hospitalized patients in a cicu (coronary intensive care unit). methods: patients hospitalized in the cicu of a medium-sized hospital in presidente prudente, sp, brazil, were subjected to a survey that screened for dysphagia during the period from january of to september of . patients with at least one risk factor for dysphagia were evaluated by a phonoaudiologist and are the subject of this study. the information was statistically analyzed using epi info, version . . . software. considering significant p < . two-tailed, for logistic regressions multivariate estimated in the sample. results: for this study patients were selected, of which . % were male and the mean age was . ± . years. a higher incidence of dysphagia was observed among patients who had at least one of the following risk factors: stroke (odds ratio . p< . ); brain tumor (or . p= . ); chronic obstructive pulmonary disease (copd) (or . p= . ); degenerative diseases (or . p< . ); lower level of consciousness (or . p< . ); ataxic respiration (or . p< . ); aspiration pneumonia (or . p< . ); orotracheal intubation > h (or . p< . ); tracheostomy (or . p< . ); airway secretion (or . p< . ); nasoenteral tube (or . p< . ); gastrostomy (or . p= . ). there was no statistical significance for age > , traumatic brain injury, oropharyngeal surgery and unfavorable dentition. four factors appeared less than times and could not be analyzed (chagas disease, human immunodeficiency virus (hiv), orofacial burn and excess saliva). conclusions: we concluded that the dysphagia triage protocol insertion was effective to identify dysphagic patients and can be used as an additional tool in the intensive care risk management. physiological bases of this age old concept, more recently applied to endotracheal intubation, have never been confirmed by current methods. we therefore decided to study the effects of an apnea oxygenation period under hfnc oxygen therapy by means of a novel modelization of the respiratory system. methods: firstly, an airway model was built with anatomical, physical and physiological attributes similar to that of a healthy subject (fig. ) . this system reproduces the physiological evolution of intrapulmonary gases during apnea by progressively increasing co levels after having cut off previous o supplies (fio %). secondly, the effects of a hfnc apnea oxygenation of l/min with an fio of % were analyzed by collecting intrapulmonary gas samples at regular intervals (fig. ) . results: after minute of apnea oxygenation, intrapulmonary oxygen levels remain stable at %. after minutes, oxygen fraction reaches %, and increases up to % in minutes. regarding co levels, no significant modifications were observed. conclusions: a novel experimental and physiological model of the respiratory system has been developed and confirms the existence of an alveolar oxygen supply as well as the lack of a co washout during hfnc apnea oxygenation. however, these effects are only observed after a delay of about . to minutes. therefore, the clinical interests of this technique to reduce apnea-induced desaturation during intubation of a hypoxemic patient in the icu seem limited without adequate preoxygenation. combination of both preoxygenation and apnea oxygenation by hfnc can most likely explain positive results observed in other clinical studies. effect of % nebulized lignocaine versus % nebulized lignocaine for awake fibreoptic nasotracheal intubation in maxillofacial injuries in emergency department h abbas, l kumar king george's medical university,lucknow,india, lucknow, india critical care , (suppl ):p introduction: topical lignocaine is most commonly used pharmacological agent for anaesthetizing upper airway during fibreoptic bronchoscopy. we compare the effectiveness of two different concentrations, % lignocaine and % lignocaine, in nebulised form for airway anaesthesia during awake fibreoptic nasotracheal intubation in terms of patient's comfort and optimal intubating conditions, intubation time. methods: institutional ethics committee approved the study and written informed consent obtained; patients of either sex, between - years age with anticipated difficult airway planned for intubation were included for this study. patients were randomly allocated into two groups (a and b) based on sealed envelope method; patients and observers were blinded by using prefilled syringes of lignocaine.one group was nebulized with ml of % lignocaine(group a) and other with ml of % lignocaine(group b) in coded syringes via ultrasonic nebuliser for minutes followed by inj midazolam . mg/kg iv and inj fentanyl microgram/kg iv just before the procedure. the fibreoptic broncoscope was introduced via nostril and the other nostril was used for oxygen insufflation ( - l/min). the fibroscope was introduced through the glottic opening and visualising tracheal rings and carina.the endotracheal tube railroaded over the fiberscope and cuff inflated. results: the primary outcome measure was patient's comfort during awake fibreoptic nasotracheal intubation. the mean patient comfort puchner scale score of group a was . ± . and of group b was . ± . . the mean value of puchner scale of group b was significantly higher.the mean procedural time of group b was significantly higher ( . %) as compared to group a (p< . ). the no of intubations attempts did not differ between the two groups. conclusions: % nebulised lidocaine provided adequate airway anaesthesia and optimal intubating conditions, patient comfort, stable hemodynamics. introduction: this systematic review and meta-analysis aims to investigate whether video laryngoscopy (vl) improves the success of orotracheal intubation, when compared with direct laryngoscopy (dl). methods: a systematic search of pubmed, embase, and central databases was performed to identify studies comparing vl and dl for emergency orotracheal intubations outside the operating room. the primary outcome was rate of first pass intubation. subgroup analyses by location, device used, clinician experience, and clinical scenario were performed. the secondary outcome was rate of complications. results: the search identified studies with , emergency intubations. there was no overall difference in first-pass intubation with vl compared to dl. subgroup analysis showed first-pass intubations were increased with vl in the intensive care unit (icu) ( . ( . - . ); p< . ), but not in the emergency department or pre-hospital setting. rate of first-pass intubations were similar with glidescope® and dl, but improved with the cmac® ( . ( . - . ); p= . ). there was greater first-pass intubation with vl than dl among novice/trainee clinicians (or= . ( . - . ); p< . ), but not among experienced clinicians or paramedics/nurses. there was no difference in first-pass intubation with vl and dl during cardiopulmonary resuscitation or trauma. vl was associated with fewer oesophageal intubations than dl (or= . ( . - . ); p= . ), but more arterial hypotension (or= . ( . - . ); p= . ). conclusions: in summary, compared to dl, vl is associated with greater first-pass emergency intubation in the icu and among less experienced clinicians. vl is associated with reduced oesophageal intubations but a greater incidence of arterial hypotension. compared success rate between direct laryngoscope and video laryngoscope for emergency intubation, in emergency department: randomized control trial p sanguanwit, n laowattana ramathibodi hospital, bangkok, thailand critical care , (suppl ):p introduction: video laryngoscope was used as an alternative to intubate in the emergency room, designed for tracheal intubation more success [ , ] . methods: we performed a prospective randomized controlled trial study of patients who had sign of respiratory failure or met indication for intubation from july to june . patients were randomly by snose technique; assigned to video laryngoscope first or direct laryngoscope first. we collect the demographics, difficult intubation predictor, rapid sequence intubation, attempt, cormack-lehane view and immediate complication. primary outcome was first attempt success rate of intubation. results: first attempt success rate of video laryngoscope was . % trend to better than direct laryngoscope was . %, (p= . ), good glottic view (cormack-lehane view - ) of video laryngoscope was . % better than direct laryngoscope . %, and statistically significant (p= . ), no statistical significant in immediate serious complication between direct laryngoscope or video laryngoscope. conclusions: compared to the success rate between using video laryngoscope or direct laryngoscope for intubation, video laryngoscope trend to better success rate, and better glottic view. -year cohort of prehospital intubations and rescue airway techniques by helicopter emergency medical service physicians: a retrospective database study p de jong, c slagt, n hoogerwerf radboudumc, nijmegen, netherlands critical care , (suppl ):p introduction: in the netherlands the pre-hospital helicopter emergency medical service (hems) is physician based and an adjunct to ambulance services. all four hems stations together cover / specialist medical care in the netherlands. in many dispatches the added value is airway related [ ] . as part of our quality control cycle, all airway related procedures were analysed. high quality airway management is characterized by high overall and first pass endotracheal intubation (eti) success [ ] . methods: the hems database was analysed for all patients in whom prehospital advanced airway management was performed in the period - . balloon/mask ventilation, supraglottic airway (sga) devices, total intubation attempts, cormack & lehane (c&l) intubation grades, successful eti, primary and rescue surgical airway procedures and professional background were reviewed. results: in the -year period, there were dispatch calls. in total patients were treated in the prehospital setting by our hems. of those, required a secured airway. eti was successful in of ( . %). in the remaining patients ( fig. ) an alternative airway was needed. rescue surgical airway was performed in . %, . % received a rescue sga, rescue balloon/mask ventilation was applied in . % of cases, was allowed to regain spontaneous ventilation and in . % of patients all airway management failed. hems physicians, ambulance paramedics, hems paramedics and others (e.g. german emergency physicians) had eti first pass success rates of . %, . %, . % and . % respectively (fig. ) . difficult laryngoscopy (no epiglottis visible) was reported in . % of patients (table ) . conclusions: our data show that airway management performed by a physician based hems operation is safe and has a high overall eti success rate of . %. the total success rate is accompanied by a high first pass eti success rate. introduction: incidences associated with endotracheal tubes are frequent during mechanical ventilation (mv) of intensive care unit (icu) patients and can be associated with poor outcomes for patients and detrimental effects on health care facilities. here, we aimed to identify factors associated with event occurrence due to unsafe management of endotracheal tubes (e-umet). methods: a retrospective observational study was conducted in three icus: one surgical icu, one stroke icu, and one emergency department, at a tertiary hospital in japan from april to march . patients requiring mv and oral intubation during their icu stay were included. the primary finding was the incidence rate of e-umet (biting, unplanned extubations, and/or displacement of the endotracheal tube). the patients were divided into two groups: with or without e-umet. to investigate e-umet, potential factors possibly related to its occurrence were obtained from electronic medical records. we conducted univariable and multivariable analyses to investigate e-umet factors. results: of patients, e-umet occurred in ( . %). the mean and standard deviation for age and acute physiology and chronic health evaluation (apache) ii score were ( ) and ( ), respectively. according to a multivariate logistic-regression analysis, significant risk factors associated with e-umet included patients of neurosurgery (odds ratio (or) . ; % ci, . - . ; p= . ), sedative administration (or . ; % ci, . - . ; p< . ), and higher richmond agitation-sedation scale (rass) scores (or . ; % ci, . - . ; p< . ). the use of a restraint (or . ; % ci, . - . ; p= . ) was an independent factor associated with a lower probability of e-umet. conclusions: this study suggests that risk factors associated with e-umet include neurosurgery, higher rass scores, and the administration of sedatives. patients with these factors and longer oral intubation periods might require extra care. introduction: the use of nasal high flow (nhf) as a respiratory support therapy post-extubation has become increasingly more common. nhf has been shown to be non-inferior to niv and reduces escalation needs compared to conventional oxygen therapy. clinical outcomes using nhf in patients with type ii respiratory failure (rf) is less well understood. our aim was to determine if nhf can be used successfully when extubating type ii rf patients compared to type i rf. methods: we conducted a retrospective observational study on the use of nhf as an extubation respiratory support in (n= ) consecutive patients in icu over a -month period. primary outcome was the need for escalation in therapy (niv, intubation and palliation) post extubation. patients were categorised as high risk if they scored >= from: age>= years, bmi>= and >= medical comorbidity. results: analysis was conducted on all fifty-six (n= ) patients. type i rf group was composed of (n= ) patients with a mean age of . (±sd) years. type ii rf group had (n= ) patients with a mean age of . (±sd) years. in type i rf patients ( %) were successfully extubated with nhf compared to patients ( . %) in type ii. in type ii rf the outcomes were more variable with a greater requirement for niv. of these patients % required niv, . % required intubation and . % received nhf therapy for palliation. a higher average bmi ( . vs . kg/m ) was found in unsuccessfully vs successfully extubated patients in type ii rf. in type i rf escalation of therapy was equally distributed with % in each category. conclusions: the use of nhf for respiratory support post-extubation may become standard practice for type i rf in critical care settings. our data suggests that nhf can be used but with caution in type ii rf and clinicians should risk stratify patients to identify those at risk of re-intubation and post-extubation respiratory failure. introduction: pathogenesis of ventilator-associated pneumonia (vap) relies on colonization and microaspiration. oral topical decontamination reduced the vap incidence from to % [ ] . the persistence of antiseptic effect in the oral cavity is questionable; we hypothesize that continuous oral antiseptic infusion may offer a better decontamination. aim of the work: we developed endotracheal tube that allows continuous oral infusion of chlorhexidine (chx), and we want to test the technique versus the conventional on bacterial colonization. (provisional patent: ) methods: a two identical bio models for the upper airways were manufactured by ( dx diagnostics, usa) to adapt the modified and the ordinary endotracheal tubes (ett). the two techniques tested were using six hourly disinfection with chx (group a) versus disinfection through the hours infusion technique (group b). five microorganisms plus mixed bacteria were used and each was tested for five times. normal saline was used constantly to irrigate the biomodels and ten ml aliquot was collected by the procedure end. culturing of the aliquots from decanted broth pre and post disinfection was performed. the time to apply chx by practitioner was also compared. results: there was a trend towards lower bacterial growth in group a in experiments which reach statistical significance only with pseudomonas aeruginosa (p= . ). in one experiment the growth was lower in group b (fig. ) . additionally there was time saving advantage in group b ( ± . versus ± . min, p= . ). conclusions: the novel technique got at least non inferior results, plus time saving advantage. these results may warrant future clinical trial. monitoring airways non invasive online analysing different particle flow from the airways is never done before. in the present study we use a new technology for airway monitoring using mass spectrometric analysis of particle flow and their size distribution (pexa particles in expired air). the exhaled particles are collected onto a substrate and possible for subsequent chemical analysis for biomarkers. our hypothesis was that by analysing the particle flow online, we could optimise the mechanical ventilation. our hypothesis was that a small particle flow would probably be more gentle for the lung than a large particle flow when the lung is squeezed out and the majority of all small airways are open. methods: in the present study we analyse the particle flow from the airways in vivo, post mortem and during ex vivo lung perfusion using different ventilation modes; volume controlled ventilation (vcv) and pressure controlled ventilation (pcv) comparing small tidal volumes( ) versus big tidal volumes( ) at different peep (positive end-expiratory pressure) and after distribution of different drugs in six domestic pigs. results: we found that vcv resulted in a significant lower particle flow than pcv in vivo but in ex vivo settings the opposite was found (fig. ). in both in vivo and ex vivo settings we found that big tidal volume resulted in a larger particle flow than small tidal volumes.air. the opening and the closure of the small airways reflect the particle flow from the airways. we found that different ventilation modes resulted in different particle flow from the airways. we believe this technology will be useful for monitoring mechanical ventilated patients to optimise ventilation and preserve the lung quality and has a high potential to detect new biomarkers in exhaled air. introduction: malaria is a common problem in underdeveloped countries, with an estimated mortality of more than one million people per year. pulmonary involvement is one of the most serious manifestations of plasmodium falciparum malaria. non-invasive ventilation (niv) decreases muscular works and improves gas exchange by recruitment of hypoventilated alveolus. in this context, we analyze the impact of the use of non-invasive ventilation in malaria with pulmonary dysfunction. methods: it's a retrospective cohort study. we analyzed electronic records of patients who were diagnosed with malaria, with acute respiratory failure, who underwent respiratory therapy with niv between - within the intensive care unit (icu). the study variables were: icu mortality, length of hospital stay, niv time and outcome groups. statistical analysis was performed with the pearson correlation coefficient, with significance level of p < . . the statistics were performed using the bioestat . program. results: thirty-one patients were included in the study. four results were analyzed according to table and fig. . % of the patients were discharged from the hospital. pearson's correlation coefficient analysis showed statistical significance in the group (niv/discharge) in the analysis of patients hospitalized versus niv ( % ci = . to . <(p) = . ). conclusions: the use of niv was positive in patients using this resource as first-line treatment of malaria in the fight against respiratory decompensation, with improvement of symptoms. introduction: cpap is used to improve oxygenation in patient with arf. we aimed to determine non-inferiority (ni) of helmet cpap to facemask in arf based on physiological (heart rate (hr) and respiratory rate (rr)) and blood gas parameters (pao and paco ). we also compared patients' perception in dyspnea improvement after cpap using dyspnea scale (visual analogue scale (vas)) and likert score. methods: we randomized patients to helmet (n= ) and facemask (n= ) with . % of arf was due to acute pulmonary edema. cpap was applied for minutes. patients' physiological and blood gas parameters were recorded before and after intervention. patients then marked on dyspnea scale and likert score. ni of helmet would be declared if confidence interval (ci) of mean difference between groups (helmet's mean minus facemask's mean) in improving physiological, blood gas parameters and dyspnea scale was no worse than predetermined non-inferiority margin (nim). secondary outcome was to compare incidence of discomfort and mucosal dryness between groups. methods: this is a single center retrospective study performed in the icu of tel aviv medical center, israel, a tertiary academic referral hospital. using the electronic medical record system and intensix predictive critical care system for analysis, all patients admitted to the icu between . and . were assessed. respiratory deterioration in mv patients was defined as acute adjustment of fio increase > % or peep increase > cmh o that persisted for at least hours. the primary outcome was icu mortality. secondary outcome was length of icu stay (los). a chi square test for trends was used for the significance of mortality data and a one way anova test for los. results: mv patients were admitted to the icu with an overall mortality of . %. mortality and los were tripled in patients who experienced at least one respiratory deterioration when compared to no events ( . % vs. . %, p< . and . vs. . days, p< . respectively) (fig. ) . increased events of respiratory deteriorations showed significant trend of increased mortality (p< . ). conclusions: in mv patients, a single respiratory deterioration event carries a times higher mortality rate and length of stay (los). any additional event further increases both parameters. association of lung ultrasound score with mortality in mechanically ventilated patients j taculod, jt sahagun, y tan, v ong, k see national university hospital singapore, singapore, singapore critical care , (suppl ):p introduction: lung ultrasound is an important part of the evaluation of critically ill patients. it has been shown to predict recruitability in acute respiratory distress syndrome. however, little is known about the application of lung ultrasound in predicting mortality in mechanically ventilated patients. methods: observational study of mechanically ventilated patients admitted to the medical intensive care unit (icu) of a tertiary hospital (national university hospital, singapore) in and . only the first icu admissions of these patients were studied. lung ultrasound was done at six points per hemithorax and scored according to soummer (crit care med ): normal aeration = ; multiple, well-defined b lines = ; multiple coalescent b lines = ; lung consolidation = . the lung ultrasound (lus) score was calculated as the sum of points (score range - ). we analysed the association of lus score with icu/hospital mortality, using logistic regression, adjusted for age and acute physiology and chronic health evaluation (apache) ii score. results: patients were included (age . ± . years; female [ . %]; apache ii . ± . ; sepsis diagnosis [ . %]). icu and hospital mortality were . % and . % respectively. lus score was associated with increased icu (or . , % ci . - . , p= . ) and hospital (or . , % ci . - . , p= . ) mortality, adjusted for age and apache ii score. conclusions: lus score was associated with increased icu/hospital mortality and may be useful for risk stratification of mechanically ventilated patients admitted to icu. introduction: ventilator asynchrony results in morbidities and mortality. the aim of this study was to explore whether and how physicians used patient-ventilator interactions(pvi) to set mechanical ventilators(mv) in thailand. methods: thai physicians treating mv patients were asked to respond to questionnaires distributed in conferences and to e-mails sent. types of asynchronies encountered and frequency of mv adjustment guided by pvi were evaluated. in addition, correlations between physician's knowledge and )confidence to manage asynchronies and )their experience were analyzed. results: two hundred and eleven physicians answered the questionnaires. most of them were medical residents and icu specialists. % of them set and adjusted mv by asynchrony guidance and the majority used waveform analysis to more than a half of their patients. the most and the least common asynchronies encountered were double triggering and reverse triggering, respectively, while the most difficult-to-manage and the most easily managed asynchronies were periodic/?a b show $ #?>unstable breathing and flow starvation, respectively. lack of confidence and knowledge of pvi were the major reasons of physicians who did not perform asynchrony assessment. for knowledge evaluation, more than % of physicians incorrectly managed asynchrony. chest and icu fellows had the greatest skills in waveform interpretation and asynchrony management with the mean score of . from the total , compared with specialist( . ), medical residents( . ), internists( . ) and general practitioner( . ). there were poor correlations between years' experience in mv management and the skill in waveform interpretation (r = . , p= . ) and between physician's confidence in pvi management and the clinical skill (r = . , p< . ) conclusions: the majority of thai physicians realized the importance of pvi, but the skill in asynchrony management was moderate. intensive programs should be provided to improve their clinical performance. methods: six deeply anesthetized swine underwent tracheostomy, thoracostomy and experimental plef with ml/kg of radiopaque saline randomly instilled into either pleural space. animals were ventilated at vt= ml/kg, frequency= bpm, i/e= : , peep= cmh o, and fio = . . quantitative lung computed tomographic (ct) analysis of regional aeration and global frc measurements by nitrogen wash-in/wash-out technique were performed in each of these randomly applied positions: semi-fowler's (inclined °from horizontal in the sagittal plane); prone, supine, and lateral positions with dependent plef and non-dependent plef (fig. ) . results: no significant differences in frc were observed among the horizontal positions, either at baseline (p= . ) or with plef (p= . ) ( fig. a) . however, component sector total gas volume in each phase of the tidal cycle were different within all studied positions with and without plef (p=<. ). compared to other positions, prone and lateral position with non-dependent plef had a more homogenous vt distribution among quadrants (p=. , fig. b ). supine was associated with most dependent collapse (fig. c ) and greatest tendency for tidal recruitment ( % vs~ %, p= . , fig. d ). conclusions: changes in body position in the setting of effusioncaused chest asymmetry markedly affected the internal distributions of gas volume, collapse, ventilation, and tidal recruitment, even when commonly used global frc measurements provided little indication of these important positional changes. of the respondents, % were affiliated with multidisciplinary icus, % with thoracic and/or cardiac icus and % with neuro-icus. most respondents ( %) had completed their specialist training. overall, arterial oxygen tension (pao ) was the preferred parameter for the evaluation of oxygenation (fig. ). the proportions of doctors' preferences for increasing, decreasing or not changing an fio of . in two (out of six) patient categories at different pao levels are presented in table and table . conclusions: this is the largest survey of the preferred oxygenation targets among icu doctors. pao seems to be the preferred parameter for evaluating oxygenation. the characterisation of pao target levels in various clinical scenarios provide valuable information for future clinical trials on oxygenation targets in critically ill icu patients. introduction: sonographic assessment of diaphragmatic excursion and muscle thickening fraction have been suggested to evaluate diaphragm function during weaning trial [ ] . the purpose of this study is to compare these two parameters to predict extubation success. methods: this prospective study was carried out during months from march to november . we enrolled patients who were mechanically ventilated for more than h and met all criteria for extubation. the non inclusion criteria were: age < years, history of neuromuscular disease or severe chronic respiratory failure. we excluded subjects who needed reintubation for upper airway obstruction, neurological or hemodynamic alteration. the scenario involves a patient expected to receive mechanical ventilation for at least hours in the icu. all proportions are percentages of respondents with % confidence intervals. *p < . for comparisons of proportions of "no change" versus adjacent lower pao level (mcnemar's test) introduction: ventilator induced diaphragmatic dysfunction is known to be a contributor to weaning failure. some data suggest that assisted ventilation might protect from diaphragmatic thinning. aims of this study are to evaluate, by ultrasound (us), the change in diaphragm thickness and thickening in patients undergoing controlled and assisted mechanical ventilation (mv) and clinical factors associated with this change. methods: we enrolled patients who underwent either controlled mv (cmv) for cumulative hours or hours of pressure support (psv) if ventilation was expected to last for at least days. patients < years old, with neuromuscular diseases, phrenic nerve injury, abdominal vacuum dressing system and poor acoustic window were excluded. diaphragm thickness and thickening were measured with us as described by goligher and clinical data were collected every hours until icu discharge. results: we enrolled patients, were excluded because they had less than measurements and for low quality images, leaving patients for analysis. as expected, during cmv diaphragm thickening was almost absent and significantly lower than during psv (p< , ). diaphragm thickness did not reduce significantly during cmv (p= . ), but during psv significantly increased (p< . ) (fig. , where "day " represents the first day of psv). during cmv, in / patients diaphragm thickness showed a >= % reduction. they had a significantly higher fraction of days spent in cmv (p= . ) and longer neuromuscular blocking drugs (nbds) infusion (p= . ). during psv, / patients showed an increase in diaphragm thickness >= %. duration of hospital stay was significantly lower for these patients (p . ). differences between the two groups are reported in table . conclusions: longer time spent in cmv and with nbds infusion seems associated with a decrease in diaphragm thickness. assisted ventilation promotes an increase in diaphragm thickness, associated with a reduction in the length of hospitalization. prediction of intrinsic positive end-expiratory pressure using diaphragmatic electrical activity in neutrally-triggered and pneumatically-triggered pressure support f xia nanjing zhongda hospital, southeast university, nanjing, china critical care , (suppl ):p introduction: intrinsic positive end-expiratory pressure (peepi) may substantially increase the inspiratory effort during assisted mechanical ventilation. our purpose of the study was to assess whether electrical activity of the diaphragm (eadi) can be reliably used to estimate peepi in patients undergoing conventional pneumaticallycontrolled pressure support (psp) ventilation and neutrally-controlled introduction: atelectasis develops in critically ill obese patients submitted to mechanical ventilation. the pressure exerted by the abdominal weight on the diaphragm causes maldistribution of ventilation with increased pleural pressure and diminished response to peep. our objective was to analyze the effects of peep in the distribution of ventilation in obese and non-obese patients according to bmi (obese >= kg/m , or non-obese: to . kg/m ), using electrical impedance tomography (eit). methods: we assessed the regional distribution of ventilation of surgical and clinical patients submitted to a decremental peep itration monitored by eit. we calculated the percent ventilation to the nondependent (anterior) lung regions at the highest and lowest peep applied. the highest compliance of respiratory system was consistently observed at intermediate values of peep (between those extreme values), indicating that the highest peep caused pulmonary overdistension, whereas the lowest peep likely caused dependent lung collapse results: were enrolled patients, with non-obese patients ( , ± kg/m ) and obese patients ( . ± . kg/m ). all patients presented progressively decreased ventilation to dependent (posterior) lung regions when peep was lowered (p< . ). obese patients consistently presented higher ventilation to the anterior lung zones (when compared no nonobese), fig. introduction: lung protective ventilation is the mainstay of mechanical ventilation in critically ill patients [ ] . extracorporeal co removal (ecco r) can enhance such strategies [ ] and has been shown to be effective in low flow circuits based on renal replacement platforms [ , , ] . we show the results of a pilot study using a membrane lung in combination with a hemofilter based on a conventional renal replacement platform (prismalung™) in mechanically ventilated hypercapnic patients requiring renal replacement therapy (nct ). methods: the system incorporates a membrane lung ( . m ) in a conventional renal replacement circuit downstream of the hemofilter. mechanically ventilated patients requiring renal replacement therapy were included in the study. patients had to be hypercapnic at inclusion under protective ventilation. changes in blood gases were recorded after implementation of the extracorporeal circuit. thereafter ventilation was intended to be decreased per protocol until baseline paco was reestablished and changes in vt and pplat were recorded. data from patients were included in the final analysis. results: the system achieved an average co removal rate of . ± . ml/min which corresponded to a paco decrease from . ± . to . ± . mmhg (p< . ) and a ph increase from . ± . to . ± . (p< . ) [ fig. ]. after adaption of ventilator settings we recorded a decrease in vt from . ± . to . ± . ml/kg (p< . ) and a reduction of pplat from . ± . to . ± . cmh o (p< . ). these effects were even more pronounced in the "per protocol" analysis [ fig. ]. conclusions: low flow ecco r in combination with renal replacement therapy provides partial co removal at a rate of over ml/min can significantly reduce invasiveness of mechanical ventilation in hypercapnic patients. introduction: in ecco r-crrt, efficiency of co removal is higher positioning the oxygenator (oxy) up-stream than down-stream the haemofilter due to higher blood flow (bf) [ ] . we tested whether this effect was due to lower pre-filter pressure (pfp). methods: ecco r-crrt circuit was tested in-vitro (n= ) with the following settings: l bovine blood; bf ml/min; oxy . m (euroset); cvvh post mode; substitution flow ml/h; uf rate function off; . m haemofilter (diapact®, b.braun avitum); sweep air flow . l/min. pfp was evaluated at baseline, , and hours. co extraction was measured at bf of , and ml/min. sweep air flow/blood ratio was : . co was add to obtain paco of mmhg. co removal rate calculation ( ): co removal rate = (co ecco r inlet-co ecco r outlet)* blood flow (eq. ) co molar volume at °c [l/mol] = ; solubility of co at °c = . mmol/(l*mmhg); hco i = inlet hco concentration [mmol/l]; hco o = outlet hco concentration [mmol/l]; pi co = inlet co partial pressure [mmhg]; poco = outlet co partial pressure [mmhg] equation becomes: co removal rate= x ((hco i + . x pico ) -(hco o + . x poco )) x blood flow (eq. ) results: bf of ml/min was always reached with the up-stream configuration. bf was reduced to ml/min with the down-stream configuration due to high pfp alarm (table ). co removal increased to . ± . to . ± . , and . ± . ml/min, at bf of , and ml/ min (p< . ). conclusions: bf of ml/min can be reached only with the upstream configuration due to lower circuit pfps. bf directly correlates to co removal efficiency. we may speculate that simultaneous use of crrt and lf-ecco r and activation of the uf rate function with the down-stream setting may further increase pfp thus forcing to more enhanced reduction of bf and less effective co -removal. introduction: we describe the use of a novel low-flow ecco r-crrt device (prismalung-prismaflex, baxter healtcare gambro lundia-ab-lund, sweden) for simultaneous lung-renal support. methods: a retrospective review of patients submitted to prismalung-prismaflex due to aki associated to hypercapnic acidosis during the period may -august at prato hospital icu was performed. data collected were: demographic, physiologic, complications, outcome. data were presented as mean ± ds; anova test was used to compare changes of parameters over time; significance was set at p< , . results: we identified patients (mean age ± yr, mean sofa ± ). causes of hypercapnia were moderate ards (n= ) and ae-copd (n= ). in all patients a fr double lumen cannula was positioned and ml/min blood-flow with lt oxygen sweep-gas-flow was maintained; iv-heparin aiming to double aptt was used. haemo-diafiltration (effluent flow ml/kg/hour) was delivered. in all cases prismalung-prismaflex improved respiratory and metabolic parameters (figs. and ) without any complications. all patients survived to the treatment, nevertheless patients ( ae-copd; ards) died during icu stay due to irreversible cardiac complications. in ards cases: patients were successfully weaned from imv, mean duration of the treatment was ± hours, mean duration of imv after ecco r-crrt was ± days. in ae-copd cases: intubation was avoided in patients at risk of niv failure, patients were successfully weaning from imv, mean duration of the treatment was ± hours, mean duration of imv after ecco r-crrt was , ± , days. fig. (abstract p ) . minutes after implementation of the combined renal replacement and ecco r circuit a moderate decrease in paco (- . mmhg) corresponding to a slightly higher ph ( . ) was observed conclusions: the use of prismalung-prismaflex has been safe and effective: it may be argued that it could be due to the low-blood-flow used. the positive results of this preliminary study may constitute the rational for the design of a larger randomized control trial. systemic il- production and spontaneous breathing trial (sbt) outcome: the effect of sepsis introduction: spontaneous breathing trial (sbt), a routine procedure during ventilator weaning, entails cardiopulmonary distress, which is higher in patients failing the trial. an intense inflammatory response, expressed by increased levels of pro-inflammatory cytokines, is activated during sbt. sepsis, a common condition in icu patients, has been associated with increased levels of the pro-inflammatory cytokine il- . il- produced among others by skeletal muscles, has been associated with severe muscle wasting and maybe by icu acquired weakness. we hypothesised that il- increases during sbt, more evidently in sbt failures. we anticipate this response to be more pronounced in formerly septic patients fulfilling the criteria for sbt. methods: sbts of -min duration were performed and classified as sbt failure or success. blood samples were drawn before, at the end of the sbt and hours later. serum il- levels and other inflammatory mediators, commonly associated with distress, were determined and correlated with sbt outcome. subgroup analysis between septic and non-septic patients was performed. )kg/m ) were monitored for . ± . hours. apneas were identified ranging from - s (fig. a) . apneas were observed in % of patients, suggesting low predictability of respiratory insufficiency. the average mv was ± . %mvpred, as patients were often sleeping or mildly sedated. we assessed the effects of each apnea on the temporally associated mv (fig. b) . while apneas ranging in length from - s decrease mv by as much as %, their effect over min is < %. on a min time scale, even s apneas led to lowmv just % of the time (fig. c) . conclusions: while apneas were ubiquitous, they seldom led to lowmv over clinically relevant time scales. large compensatory breaths following an apnea generally restored mv to near pre-apnea levels. nonetheless, some apneas can become dangerous when ignored, as when subsequent sedation decreases compensatory breath size. rvm data provide a better metric of respiratory competence, driving better assessment of patient risk and individualization of care. introduction: diffuse alveolar hemorrhage (dah) is an acute lifethreatening event and recurrent episodes of dah may result in irreversible interstitial fibrosis. identifying the underlying cause is often challenging but is needed for optimal treatment. lung biopsy is often performed in the diagnostic evaluation of patients with suspected dah. however, the role of lung biopsy in this clinical context is unclear. hence, we sought to identify the spectrum of histopathologic findings and underlying causes in patients with dah who underwent lung biopsy, surgical or transbronchial. methods: we identified patients who underwent surgical lung biopsy (n = ) or bronchoscopic biopsy (n = ) in the evaluation of dah over a -year period from to . we extracted relevant clinical pathologic and laboratory data. results: the median age in our cohort was years with % females. serologic evaluation was positive in % of patients (n= ). most common histopathologic findings on surgical lung biopsy included alveolar hemorrhage (ah) with capillaritis in patients of whom six had necrotizing capillaritis, followed by ah without capillaritis in patients. the most common histopathologic finding on bronchoscopic lung biopsy was ah without vasculitis/capillaritis in patients, followed by ah with capillaritis in patients. there were no procedure related complications or mortality observed with either method of lung biopsy. the clinico-pathologic diagnoses in these patients are shown in tables and . conclusions: in patients with dah undergoing lung biopsy alveolar hemorrhage without capillaritis was found to be the most common histopathologic finding followed by pulmonary capillaritis. these histopathologic findings contributed to the final clinico-pathologic diagnoses of granulomatous polyangiitis and microscopic polyangiitis in a substantial portion of cases. future studies are needed to ascertain the benefits vs. risks of lung biopsy in patients with suspected dah. note that, an apnea of -sec will (by definition) drive mv over a -sec window down to , but will only decrease mv over a -sec window down to~ % mvpred and to less than % over a -min window. (c) likelihood of an apnea of specific length to decrease mv below the low mv cutoff over various time windows. note that a single -sec apnea has just a % chance to decrease mv below % in a -sec window and less than % chance to decrease mv below the cutoff over a -min window. even -sec apneas have just % chance of decreasing sustained mv over a -min window below the % mvpred cutoff ( ) granulomatosis polyangitis ( ) ah without capillaritis ( ) antiphospholipid syndrome ( ) microscopic polyangitis ( ) ah with diffuse alveolar damage( ) microscopic polyangitis ( ) ah with pulmonary vascular changes( ) pulmonary hypertension( ) introduction: assessing the sensitivity of the peripheral chemoreflex (spcr), we can predict the likelihood of developing respiratory and cardiovascular disorders. spcr is one of the markers of disease progression and good prognostic marker [ ] . disturbed respiratory mechanics can make it difficult to evaluate. breath-holding test may be helpful in such situation, the results of this test are inversely correlated with peripheral receptor sensitivity to carbon dioxide in healthy people [ ] .the aim of the study was to compare the breath-holding test to single-breath carbon dioxide test in the evaluation of the sensitivity of the peripheral chemoreflex in subjects with copd. methods: the study involved patients with copd with fev /fvc < % of predicted, all participants were divided into two groups depending of disease severity (gold classification, ). in group (mild-to-moderate copd, n= ) all patients had fev >= % and in group (severe-to-very severe copd, n= ) all patients had fev < %. breath-holding test was performed in the morning before breakfast: voluntary breath-holding duration was assessed three times, with min intervals [ ] . a mean value of the duration of the three samples was calculated. the single-breath carbon dioxide test [ ] was performed the next day. the study was approved by the local ethics committee. all subjects provided signed informed consent to both tests. and january . the data was collected from the hospital electronic and paper notes, and data collected was mortality rate, apa-che ii score, icnarc score, type of respiratory support received and whether there was documentation of advanced decisions in case of acute deterioration. results: there were patients admitted to the icu with acute respiratory failure as a complication of pulmonary fibrosis. the median apache ii score was and icnarc standardised mortality ratio was . . nine patients died on icu ( %) and hospital mortality was ten ( %). eight patients ( %) received high flow nasal oxygen, six ( %) received non-invasive ventilation, and two ( %) received invasive ventilation. the median time to death was . days. of patients for whom paper notes were available, no patient had any documented ceiling of care or end of life decisions. conclusions: our study confirmed a very high mortality in this cohort of patients, supporting national guidance that invasive respiratory support has limited value. we advise that frank discussion with patients and their families should happen early after diagnosis, such that end of life plans are already in place in the event of acute deteriorations. introduction: arf is common in critically ill patients. we compared diaphragm contractile activity in medical and surgical patients admitted to icu with a diagnosis of arf. methods: adult medical and major abdominal laparotomic surgical patients admitted to a general icu with a diagnosis of arf were enrolled. arf was defined as a pao /fio ratio<= mmhg/% and need for mechanical ventilation (mv) for at least hours. diaphragmatic ultrasound was realized bedside when the patient was stable and able to perform a trial of spontaneous breathing. a convex probe was placed in right midaxillary line ( th- th intercostal space) to evaluate right hemidiaphragm. diaphragmatic respiratory excursion and thickening were evaluated in m-mode on consecutive breaths and thickening fraction (tf) was calculated. antropometric, respiratory and hemodynamic parameters, saps , sofa score, duration of mv, need for tracheotomy and timing, septic state and site of infection, superinfections, icu and inhospital length of stay (los) and outcome were recorded. patients with trauma and neuromuscular disorders were excluded. p< . was considered significant. results: we enrolled patients: % medical and % surgical, without differences for age, sex, bmi, saps , sofa score, sepsis and superinfections. moderate arf was prevalent in both groups. during diaphragmatic examination, no differences were recorder for respiratory rate, hemodynamic state and fluid balance. surgical patients showed a lower but not significant diaphragm excursion ( . vs . cm), instead tf was significantly reduced ( vs %,p< . ). no differences emerged on duration of mv, but tracheotomy were higher in medical ones ( vs %,p< . ). icu and inhospital los do not differ between medical and surgical patients and mortality rate was respectively % and %. conclusions: in arf, surgical patients showed a lower diaphragm contractility compared to medical ones, maybe due to the combination of anesthetic and surgical effects, but with no influence on outcome. (fig. ) . the slope of the regression line for pes/paw plots was consistently higher for slow compressions ( . ± . ), as compared to fast ones ( . ± . ). a good agreement between Δ pes and Δ paw (fig. ) was found during slow maneuvers, but not during the fast ones. conclusions: slow chest compressions must be used when checking position/inflation of esophageal balloon. the fast maneuver produces hysteresis and underestimation of Δ pes (but not in direct Δ ppl). pes monitoring at high respiratory rates may be problematic. methods: consecutive comatose post cardiac arrest patients were ventilated with volume assist ventilation ( ml/kg ibw, peep cm h o) using elisa eit (lowenstein medical, ge). orogastric tube (nutrivent, sidam, it) was inserted, and eit vest (swisstom ag, ch) was applied in all patients. measurements were performed min after admission and after hrs (fig. ) . optimal peep was defined as lower inflection point using pv curve (pv), positive ptpeep (ptp) and optimal regional stretch/silent spaces (eit) results: methods to determine peep using pv, ptp and eit were comparable in non obese patients (p=ns introduction: the driving pressure of respiratory system (dp) reflects the extent of lung stretch during tidal breathing, and has been associated with mortality in ards patients during controlled mechanical ventilation [ ] . aim of this study was to examine dp during assisted ventilation, and examine if and when high dp occurs in patients in assisted ventilation with pav+. methods: critically ill patients hospitalized in the icu of the university hospital of heraklion, on mechanical ventilation in pav+ mode were studied. continuous recordings of all ventilator parameters were obtained for up to three days using a dedicated software. dp was calculated from the pav+ computed compliance (c) [ ] , and the measured exhaled tidal volume (vt, dp=vt/c). periods of sustained dp above cmh o were identified, and ventilation and clinical variables were evaluated. results: sixty-two patients and hrs of ventilation were analyzed. in half of the patients, dp was lower than cmh o in % of the recording period, while high-dp (> cmh o) more than % of the total time was observed in % of patients. icu non-survivors had more time with high dp than survivors (p= . ). periods of sustained high-dp (> cmh o for > h) were observed in patients. level of assist, minute ventilation, and respiratory rate were not different between the periods of high dp and the complete recordings, while vt was higher and c was lower during the high-dp period compared to the complete recording. the median compliance was below ml/ cmh o during the high-dp period, and above ml/cmh o during the complete recording. conclusions: high dp is not common, but does occur during assisted ventilation, predominantly when compliance is below ml/cmh o, and may be associated with adverse outcome. table summarizes the percent of monitored time with reported data for the two devices. figure depicts mv decrease following propofol and cannula dislodgement fol- fig. (abstract p ) . bland-altman analysis demonstrated that cvp-derived Δppl and Δpes were correlated significantly lowing a jaw thrust. table ) . negative (a-et) pco was strongly associated with good outcome and were significantly associated with overall survival (fig. ) conclusions: in conclusion, the negative arterial to end-tidal co pressure gradient may predict patient survival in some subgroups. introduction: ards may result from various diseases and is characterized by diffuse alveolar injury, lung edema formation, neutrophil-derived inflammation and surfactant dysfunction. various biomarkers have been studied in diagnostics and prognostication of ards. the purpose of the study was to measure the expression of proinflammatory mediators like il- and tnf, a cellular receptor with a role in innate immunity(tlr- ),and a biomarker of fibrogenesis (mmp- ) in different phases of ards patients. methods: we studied patients admitted to our icu with diagnosis of ards during the month of january . six ml of blood were prospectively collected at two times: during the acute phase and in a sub-acute phase before icu discharge. blood samples were centrifuged to obtain the platelet-rich plasma and plasmatic rna (crna) was isolated from platelets.il- , tnf, tlr- and mmp- expression in crna was determined by the droplet digital™ pcr as copies/ml. results: all patient showed a decrease in il- , tnf, tlr and mmp- levels after the acute phase of ards (fig. ) . patient and were affected by influenza a virus (h n ), patient was admitted for pneumococcal pneumonia and patient was affected by legionella. adequate ethiologic treatment was promptly started in patients with bacterial infection. mean duration of mechanical ventilation was . days. all patient survived icu stay and were discharged from hospital. conclusions: il- , tnf, tlr- and mmp- expression detected by extracted platelets rna, may be a novel tool useful for clinicians indicating persistent inflammation with resulting progressive alveolar fibrosis and impaired lung function. more data are necessary to understand the real clinical significance of this biomarkers and their role in fibroproliferation and progression of ards. introduction: although mesenchymal stem cells (mscs) transplantation has been shown to promote lung respiration in acute lung injury (ali) in vivo, its overall restorative capacity appears to be restricted mainly because of low engraftment in the injured lung. ang ii are upregulated in the injured lung. our previous study showed that ang ii increased mscs migration in an angiotensin ii type receptor (at r)dependent manner [ ] . the objective of our study was to determine whether overexpression of at r in mscs augments their cell migration and engraftment after systemic injection in ali mice. methods: a human at r expressing lentiviral vector was constructed and introduced into human bone marrow mscs. we also downregulated at r mrna expression using a lentivirus vector carrying at r shrna to transduce mscs. the effect of at r regulation on migration of mscs was examined in vitro. a mouse model of lipopolysaccharide (lps) induce ali was used to investigate the engraftment of at r-regulated mscs and the therapeutic potential in vivo. results: overexpression of at r dramatically increased ang ii-enhanced human bone marrow msc migration in vitro. moreover, msc-at r accumulated in the damaged lung tissue at significantly higher levels than control mscs h and h after systematic msc transplantation in ali mice. furthermore, msc-at r-injected ali mice exhibited a significant reduction of pulmonary vascular permeability and improved the lung histopathology and had additional anti-inflammatory effects. in contrast, there were less lung engraftment in msc-shat r-injected ali mice compared with msc-shcontrol after transplantation. thus, msc-shat r-injected group exhibited a significant increase of pulmonary vascular permeability and resulted in a deteriorative lung inflammation. conclusions: our results demonstrate that overexpression of at r enhance the migration and lung engraftment of mscs in ali mice and may provide a new therapeutic strategy for the injured lung. introduction: reorganization of endothelial barrier complex is critical for increased endothelial permeability implicated in the pathogenesis of acute respiratory distress syndrome. we have previously shown hepatocyte growth factor (hgf) reduced lipopolysaccharide (lps)-induced endothelial barrier dysfunction. however, the mechanism of hgf in endothelial barrier regulation remains to be unclear. methods: recombinant murine hgf with or without mtor inhibitor rapamycin were introduced on mouse pulmonary microvascular endothelial cells (pmvecs) barrier dysfunction stimulated by lps. then, endothelial permeability, adherent junction protein (occludin), endothelial injury factors (endothelin- and von willebrand factor), cell proliferation and mtor signaling associated proteins were tested. results: our study demonstrated that hgf decreased lps-induced endothelial permeability and endothelial cell injury factors, and attenuated occludin expression, cell proliferation and mtor pathway activation. conclusions: our findings highlight activation akt/mtor/stat- pathway provides novel mechanistic insights into hgf protective regulation of lps-induced endothelial permeability dysfunction. introduction: mechanical ventilation (mv) is a life-saving intervention for critically ill patients, but may also exacerbate pre-existing lung injury, a process termed ventilator-induced lung injury (vili). interestingly, we fig. (abstract p ) . fluorescein isothiocyanate-dextran or fluorescein isothiocyanate-bsa analysis of the effect of hgf on pmvecs permeability fig. (abstract p ) . western blot analysis of hgf on mtor signaling pathway discovered that the severity of vili is modulated by the circadian rhythm (cr). in this study, we are exploring the role of the myeloid bmal , a core clock component, in vili. methods: we employed mice lacking bmal in myeloid cells (lyzmcre-bmal -/-) and lyzmcre mice as controls. at circadian time (ct) or ct , mice were subjected to high tidal volume mv to induce vili. lung compliance, pulmonary permeability, neutrophil recruitment, and markers of pulmonary inflammation were analyzed to quantify vili. to assess neutrophil inflammatory responses in vitro, myeloid cells from bone marrow of wt and bmal -deficient animals were isolated at dawn zt (zeitgeber time ) and dusk (zt ), incubated with dcfh-da and stimulated for min with pma or pbs. neutrophil activation (ly g/cd b expression) and ros production (dcfh-da/ly g+ cells) were quantified. results: injurious ventilation of control mice at ct led to a significant worsening of oxygenation, decrease of pulmonary compliance, and increased mortality compared to ct . lyzmcre-bmal -/-mice did not exhibit any significant differences when subjected to mv at ct or ct . mortality in lyzmcre-bmal -/-mice after vili was significantly reduced compared to lyzmcre controls (ct ). neutrophils isolated from control mice at zt showed a significantly higher level of activation and increased ros production after pma-stimulation compared to zt . ros production of lyzmcre-bmal -/-neutrophils did not differ from zt to zt . conclusions: the lack of the clock gene bmal in myeloid cells leads to increased survival after injurious ventilation and to loss of circadian variations in neutrophil ros production. this suggests that the internal clock in myeloid cells is an important modulator of vili severity. introduction: hemodynamic resuscitation by means of fluids and norepinephrine (ne) is currently considered as a cornerstone of the initial treatment of septic shock. however, there is growing concern about the side effects of this treatment. the aim of this study was to assess the relationship between the hemodynamic resuscitation and the development of the ards. methods: new zealand rabbits. animals received placebo (sham= ) or lipopolysaccharide (lps) with or without (edx-r, n= ; edx-nr, n= ) hemodynamic resuscitation (fluids: ml/kg of ringer's lactate; and later ne infusion titrated up to achieve theirs initial arterial pressure). animals were monitored with an indwelling arterial catheter and an esophageal doppler. respiratory mechanics were continuously monitored from a sidestream spirometry. pulmonary edema was analyzed by the ratio between lung wet and lung dry weight (w/d), and the histopathological findings. results: sham group did not show any hemodynamic or respiratory changes. the administration of the lps aimed at increasing cardiac output and arterial hypotension. in the lps-nr group, animals remained hypotensive until the end of experiment. infusion of fluids in lps-r group increased cardiac output without changing arterial blood pressure, while the norepinephrine reversed arterial hypotension. compared to the lps-nr group, the lps-r group had more alveolar neutrophils and pneumocytes with atypical nuclei, thicker alveolar wall, non-aerated pulmonary areas and less lymphocyte infiltrating the interstitial tissue. in addition, the airway pressure increased more in the group lps-r, and the w/d, although slightly higher in the lps-r, did not show significant differences. conclusions: in this model of experimental septic shock resuscitation with fluid bolus and norepinephrine increased cardiac output and normalized blood pressure but worsened lung damage. obese patients have been excluded from most of the clinical trials testing the effects of peep in ards. we hypothesized that in morbidly obese patients the massive load of the abdomen/chest further increases lung collapse thus aggravating the severity of respiratory failure due to ards. methods: we performed a clinical crossover study to investigate the contribution of lung collapse to the severity of respiratory failure in ards obese patients and to determine the specific contribution of titrated peep levels and lung recruitment to changes in lung morphology, mechanics and gas exchange. patients were studied at the peep (peepicu) levels selected at our institution and at peep levels establishing a positive end-expiratory transpulmonary pressure (peepinc) and at peep levels determining the lowest lung elastance during a decremental peep (peepdec) trial following rm. results: thirteen patients were studied. at peepicu end-expiratory transpulmonary pressure was negative, lung elastance was increased and hypoxemia was present (table ) . regardless the titration technique there was no difference in the peep level obtained. at peepinc level endexpiratory lung volume increased, lung elastance decreased thus improving oxygenation. setting peep according to a peepdec trial after a rm further improved lung elastance and oxygenation. at peedec level after a rm lung collapse and overdistension were minimized (fig. ) . all patients maintained titrated peep levels up to hours without complications. conclusions: in severely obese patients with ards, setting peep according to a peepinc trial or peepdec trial following a rm identifies the same level of optimal peep. the improvement of lung mechanics, lung morphology and oxygenation at peepdec after a rm suggests that lungs of obese ards patients are highly recruitable and benefit from a rm and high peep strategy. introduction: lung protective ventilation (lpv) strategies, principally focused around the use of tidal volumes < ml/kg predicted body weight (pbw) remains an enduring standard of care for ventilated patients. however, implementation of and compliance with lpv is highly variable. we used 'nudge'-based interventions to assess if these can improve lpv. methods: ventilation data analysis over years ( hours in patients) showed patients had been ventilated with a median tidal volume of . ml/kg pbw with a significant proportion receiving over ml/kg pbw (fig. ) , an effect more pronounced in female patients and those with higher bmi. interventions: ) creation of a software tool to easily identify and monitor patients receiving tidal volumes that were too high for their pbw ) attached laminated reference guides to each ventilator to calculate pbw ) presentation, opportunistic education and verbal prompts to relevant clinical care staff regarding importance of lpv and use of pbw rather than actual body weight ) incorporating checking of tidal volumes on a daily ward rounds from junior clinical members results: we collected hourly ventilation data of the patients over a -week period ( hours in patients) following our interventions. there was, overall a statistically significant reduction tidal volume (p< . ). there was improvement in the ventilation of male patients (p< . ) but female patients endured higher tidal volumes. there was a mixed picture in different bmi grades. conclusions: reducing tidal volumes in mechanically ventilated patients can be done through a mix of behavioural and educational interventions, as well as using technological shortcuts. this helps to reduce the effort on the part of clinical staff to adhere to best practices, and ultimately improve patient outcomes. introduction: lung protective ventilation (lpv) using a tidal volume (vt) of - ml/kg ideal body weight (ibw) is recommended in the intensive care unit and theatres to reduce the incidence of pulmonary complications. the aim of this audit was to assess the extent to which lpv is used in theatres in a busy district general hospital and to implement measures to promote adherence to the recommendations. methods: anaesthetists completed questionnaires for all patients undergoing general anaesthesia at northwick park hospital over week. demographics, actual body weight (abw), height, american society of anesthesiologists (asa) score, and procedural information were recorded. ventilatory parameters included the ventilation mode, vt, and positive end expiratory pressure (peep (fig. ) . significantly more females ( %) received vt >= ml/kg than males ( %) (p< . ) (fig. ) . vt was independent of age, asa, bmi, ventilation mode, speciality, and patient position. conclusions: over half of the patients received vt >= ml/kg ibw. females were more likely to be over ventilated. a likely contributing factor is the disparity between abw and ibw in this cohort. we organised staff teaching and constructed ibw charts with the appropriate corresponding tidal volumes to be displayed in all theatres to promote the use of lpv. results: there were significant differences in ards incidence between groups: ards developed in . % of protective mv groups vs. . % of standard mv group (p= . , fisher's exact test). vap patients ventilated in a protective mode presented with lower duration of mv ( . ± . days) and icu stay( . ± . days) than patients with standard mv ( . ± . and . ± . days). there were significant differences in mortality rates between patient groups: . % in protective mv and . % in standard mv (p= . , fisher's exact test). conclusions: protective mv prevents the development of ards in vap septic patients. introduction: reduction of tidal volumes (tv) below ml/kg associated with low driving pressure (dp) might improve lung protection in patients with acute respiratory distress syndrome (ards). the current study tests the combination of coaxial double lumen endotracheal tube (to reduce instrumental dead-space) and moderately respiratory rate (rr) (< bpm) to maintain co at clinically acceptable levels while using ultraprotective tv. the objective is to considerably reduce dp, which has been preconized as an index more strongly associated with survival than tv, per se, methods: juvenile pigs were anesthetized, intubated and mechanically ventilated. severe lung injury (p/f< ) was induced using a double-hit model: repeated surfactant wash-out followed by injurious mechanical ventilation using low positive end-expiratory pressure and high dp (~ cmh o) for hours. then vts of , , and ml/kg were used in random sequence for min each, both using a standard and coaxial endotracheal tube. at each vt level, rr was adjusted to achieve paco = mmhg but not exceeding bpm. lung functional parameters and blood gas analysis were measured at each vt level. statistical analysis was performed using mixed linear model. results: coaxial endotracheal tube, but not the conventional tube, allowed decreasing vt to and ml/kg, while keeping paco at approximately mmhg and rr< bpm, reducing dp of . cmh o and . cmh o, respectively, compared to the conventional vt of ml/kg (fig. ) . conclusions: in this ards model, coaxial tube ventilation associated with moderately high rr allowed ultraprotective ventilation (vt= ml/kg) and reduced dp levels, maintaining paco at acceptable levels. this strategy might have a significant impact on mortality of severe ards patients. the table shows oxygenation and respiratory mechanics. figure : echocardiographically measured right heart function. conclusions: in morbidly obese mechanically ventilated patients with ards an increase in peep by cmh o (from . ± . cmh o to . ± . cmh o) did not impair right heart function, but improved respiratory mechanics and oxygenation. introduction: mechanical ventilation can, while being lifesaving, also cause injury to the lungs. the lung injury is caused by high pressures and mechanical forces but also by inflammatory processes which are not fully understood [ ] . heparin binding protein (hbp) released by activated granulocytes has been indicated as a possible mediator of increased vascular permeability in the lung injury associated with trauma and sepsis [ , ] . we wanted to investigate if hbp levels were increased in bronco alveolar lavage (bal) fluid or plasma in a pig model of ventilator induced lung injury. methods: anaesthetized pigs were surfactant depleted by saline lavage and randomized to receive ventilation with either tidal volumes of ml/kg with a peep of cm h o (controls, n= ) or ml/kg with a peep of cm h o (ventilator induced lung injury (vili) group, n= ). plasma and bal samples of hbp were taken at , , , and hours (fig. ) . results: characteristics of pigs by study group are shown in table . plasma levels of hbp did not differ significantly between pigs in the control and vili group at any time of sampling. hbp levels in bal fluid were significantly higher in the vili group after (p= . ), (p= . ), (p< . ) and (p= . ) hours of ventilation (fig. ) . conclusions: in a model of ventilator induced lung injury in pigs, levels of heparin binding protein in bal fluid increased significantly over time compared to controls. plasma levels however did not differ significantly between groups. (fig. ) . conclusions: this meta-analysis concluded that corticosteroid treatment in ards provided no benefit in decreasing mortality. in addition, this treatment was not associated with increasing risk of nosocomial infection. (fig. ) . the change in the pao /fio ratio was significant [rr( %ci)= . ( . - . ), p= . ] (fig. ) . finally, trial sequential analysis and grade indicated lack of firm evidence for a beneficial effect. conclusions: surfactant administration may improve oxygenation but has not been shown to improve mortality for adult ards patients. large rigorous randomized trials are needed to explore the effect of surfactant to adult ards patients. moderate to severe acute respiratory distress syndrome in a population of primarily non-sedated patients, an observational cohort study l bentsen, t strøm, p introduction: extracorporeal carbon-dioxide removal (ecco r) might allow ultraprotective mechanical ventilation with lower tidal volume (vt) (< ml/kg predicted body weight), plateau (pplat) (< cmh o) and driving pressures to limit ventilator-induced lung injury. this study was undertaken to assess the feasibility and safety of ecco r managed with a renal replacement therapy (rrt) platform to enable ultraprotective ventilation of patients with mild-to-moderate ards. methods: patients with mild (n= ) or moderate (n= ) ards were included. vt was gradually lowered from to , . and ml/kg, and peep adjusted to reach <=pplat<= cm h o. stand-alone ecco r (prismalung, no hemofilter associated with the rrt platform) was initiated when arterial paco increased by > % from its initial value. ventilation parameters (vt, rr, peep), respiratory system compliance, pplat and driving pressure, arterial blood gases, and ecco r-system characteristics were collected during at least hours of ultraprotective ventilation. complications, day- mortality, need for adjuvant therapies, and data on weaning off ecco r and mechanical ventilation were also recorded. results: while vt was reduced from to ml/kg and pplat kept < cmh o, peep was significantly increased from . ± . at baseline to . ± . cm h o, and the driving pressure was significantly reduced from . ± . to . ± . cm h o (both p< . ). the pao / fio ratio and respiratory-system compliance were not modified after vt reduction. mild respiratory acidosis occurred, with mean ph decreasing from . ± . to . ± . from baseline to -ml/kg vt. mean extracorporeal blood flow, sweep-gas flow and co removal were ± ml/min, ± . l/min and ± ml/min, respectively. mean treatment duration was ± hours. day- mortality was %. introduction: there is no consensus on the management of anticoagulation during extracorporeal membrane oxygenation (ecmo). ecmo is currently burdened by a high rate of hemostatic complications, possibly associated with inadequate monitoring of heparin anticoagulation. this study aims to assess the safety and feasibility of an anticoagulation protocol for patients undergoing ecmo based on thromboelastography (teg) as opposed to an activated partial thromboplastin time (aptt)-based protocol. methods: we performed a multicenter, randomized, controlled trial in two academic tertiary care centers. adult patients with acute respiratory failure treated with veno-venous ecmo were randomized to manage heparin anticoagulation using a teg-based protocol (target - minutes of the r parameter, teg group), or a standard of care aptt-based protocol (target . - of aptt ratio, aptt group). primary outcomes were safety and feasibility of the study protocol. results: forty-two patients were enrolled, were randomized to the teg group and to the aptt group. duration of ecmo was similar in the two groups ( ( - ) days in the teg group and ( - ) days in the aptt group, p= . ). heparin dosing was lower in the teg group compared to the aptt group ( . ( . - . ) iu/kg/h versus . ( . - . ) iu/kg/h respectively, p= . ). safety parameters, assessed as number of hemorrhagic or thrombotic events and transfusions given, were not different between the two study groups. as for the feasibility, the teg-based protocol triggered heparin infusion rate adjustments more frequently (p< . ) and results were less frequently in the target range compared to the aptt-based protocol (p< . ). number of prescribed teg or aptt controls (according to study groups) and protocol violations were not different between the study groups. conclusions: teg can be safely used to guide anticoagulation management during ecmo. its use was associated with the administration of lower heparin doses compared to a standard of care apttbased protocol. methods: single-center retrospective study of patients (n= ; ± . years; % males) undergoing vv-ecmo for severe ards. the acp-score ( - ) was calculated immediately before ecmo initiation and at ecmo-day , -day and -day , as follows: pneumonia as cause of ards - point; driving pressure >= cmh o - point; pao /fio ratio < mmhg - point; paco >= mmhg - point. results: longer duration of mechanical ventilation before vv-ecmo was associated with higher acp-scores. patients with higher acp-scores before vv-ecmo also presented longer total duration of mechanical ventilation and hospital stay. after vv-ecmo initiation, acp-scores significantly decreased from . ± . to . ± . , . ± . and . ± . at ecmo-day , -day and -day , respectively. at ecmo-day , patients with higher acp-scores ( - ) presented increased hospital mortality when compared with patients with lower acp-scores ( - ): . vs. . %, respectively (p= . ). at ecmo-day , high driving pressures and low pao /fio ratios were the acp-score determinants that significantly associated with increased hospital mortality. conclusions: in severe ards, vv-ecmo support allowed a significant and sustained acp-score reduction in most patients. this was achieved by artificial lung correction of low pao /fio , hypercapnia and elevated driving pressures. after an initial period of vv-ecmo support, patients with higher acp-scores present higher mortality rates. our results suggest that on-going adjustment of ecmo and ventilation parameters is necessary to maximize outcome. introduction: we sought to use mechanical power to describe "lung rest" in patients with acute respiratory distress syndrome (ards) supported with extracorporeal membrane oxygenation (ecmo). mechanical power describes work done by the ventilator on the patient's respiratory system over time. this concept unifies tidal volume, rate, and total pressure delivered during the ventilatory cycle into a discrete value that may be useful to guide ventilatory support. we hypothesized that initiation of ecmo led to decreased mechanical power delivered to the patient. methods: we reviewed the charts of the three medical intensive care unit patients at our institution supported with ecmo for severe ards. we collected data on plateau pressure, driving pressure, and mechanical power before initiating ecmo, then at < hours, hours, and hours after. we calculated the mechanical power delivered by the ventilator to the patient in joules per minute as . x respiratory rate x tidal volume x (peak pressure -½ x driving pressure) [ ] . results: all patients were alive at discharge and at days. mean pao /fio at ecmo initiation was ± , mean plateau pressure was ± cm water. all patients received neuromuscular blockade at initiation of ecmo. following ecmo initiation, mechanical power decreased by an average of %± % initially, by %± % at hours, and by %± % at hours (fig. ) . by comparison, driving pressure changed by an average value of - . ± . , - . ± . , and - . ± . cm water over those same intervals. average plateau pressure changed by - . ± . , - . ± . , and - . ± . cm water during the same time period (fig. ) . conclusions: in our limited case series, mechanical power decreased significantly following initiation of ecmo in patients with severe ards. we suggest mechanical power may be more useful than changes in driving pressure or plateau pressure when pursuing "lung rest" during ecmo. introduction: it is not clear whether acute respiratory distress syndrome (ards) is independently associated with mortality after controlling for underlying risk factor and baseline severity of illness. we attempted to assess the attributable mortality of ards by performing a systematic review and meta-analysis. methods: we systematically searched pubmed, embase, scopus and reference lists to identify observational studies reporting mortality rates of critically ill patients with and without ards. all included studies were matched for underlying risk factor. primary outcomes were all-cause in hospital-mortality and short-term mortality (combined day-mortality and intensive care unit-mortality). we calculated pooled risk ratios (rr) and % confidence intervals (ci) with a random-effects model. our meta-analysis was registered with prospero. results: of the initially retrieved articles, studies ( cohorts) involving patients were included. the underlying risk factor was sepsis, trauma and other in , and cohorts, respectively. in-hospital mortality was higher in patients with versus without ards ( cohorts; patients; rr . , % ci . - . ; p< . ). we saw a numerically stronger association between ards and inhospital mortality in trauma (rr . , % ci . - . ; p< . ) than sepsis (rr . , % ci . - . ; p= . ). short-term mortality was higher in patients with versus without ards ( cohorts; patients; rr . , % ci . - . ; p= . ). ards was independently associated with mortality in approximately half of the cohorts which controlled for baseline severity of illness using a multivariable analysis. conclusions: the accumulated evidence suggests that ards is independently associated with mortality after controlling for underlying risk factor; the association is stronger for trauma than septic patients. evidence is mixed as to whether ards is independently associated with mortality after controlling for baseline severity of illness. introduction: evidence is mixed as to whether acute respiratory distress syndrome (ards) is independently associated with mortality after controlling for baseline severity of illness, particularly in patients with sepsis. methods: this was an observational study comparing mortality rates of septic patients with and without ards. subjects for the present study were enrolled in ongoing prospective cohorts of critically ill patients hospitalized in medical intensive care unit (icu) in the united states or south korea. ards was defined using the berlin definition for cases after and the american-european consensus conference definition for cases before . sepsis was defined using the sepsis- definition. baseline severity of illness was assessed using a modified sequential organ failure assessment (sofa) after exclusion of the respiratory component. the primary outcome was inhospital mortality. results: of the critically ill patients enrolled in the cohorts, ( . %) had sepsis and comprised the population of the present study. of the septic patients, ( . %) had ards. patients with versus without ards had higher sofa score; both total (median vs ; p< . ) and modified ( vs ; p< . ). the unadjusted mortality of septic patients with ards was higher than septic patients without ards ( . % vs . %; p< . ). after controlling for baseline modified sofa score, both moderate and severe ards remained significant predictors for in-hospital mortality [odds ratio (or) . ; % confidence intervals (ci) . - . ; p< . and or . ; % ci . - . ; p< . , respectively]. in contrast, after controlling for baseline modified sofa score, mild ards was not associated with in-hospital mortality (or . ; % ci . - . ; p= . ). conclusions: among critically ill patients with sepsis, moderate and severe, but not mild, ards are associated with mortality after controlling for baseline severity of illness. a multicenter study on the inter-rater reliability of heart score among emergency physicians from three italian emergency departments introduction: previous studies suggested that the heart (based on history, ecg, age, risk factors, troponin) score could be a valid tool to manage the patients with chest pain at the emergency department (fig. ). our hypothesis was that there could be heterogeneity in the assignment, because of the history and ecg parameters. for this reason, our objective was to test the heart reliability. there are no published studies on this topic. methods: this is a multicenter retrospective study conducted in italian eds between march and october using clinical scenarios. twenty emergency physicians were included, provided that they had undergone a course on heart score. we used scenarios from a medical database with each scenario including demographic and clinical characteristics. each participant assigned scores to the scenarios using the heart. we tested the measure of interrater agreement using the kappa-statistic, the confidence intervals are bias corrected. a p-value of < . was used to define statistical significance. results: the participants' assignment is shown in fig. . the overall inter-rater reliability was good: kappa = . (ci %; . - . ); with a good agreement between the low and high class of risk but a moderate reliability in the medium class: kappa= . , . and . . we have not found differences of inter-rater reliability among the senior (more than yrs in ed) and junior physicians: kappa= . (ci %; . - . ) and . (ci %; . - - ).the heart score showed the worse value of inter-rater reliability in the history and ecg parameters : k inter = . (ci %; . - . ) and . (ci %; . - . ). conclusions: the heart showed a good inter-rater reliability but a fair agreement in the history parameter. the clinical experience doesn't influence the agreement in the assignment. the main limit of this study lies in using scenarios rather than real patients. introduction: the aim of the experiment was to study the efficacy of preconditioning, based on changes in inspiratory oxygen fraction on endothelial function in a model of myocardial ischemia/reperfusion injury in conditions of cardiopulmonary bypass (cpb). methods: the prospective study included rabbits divided into four equal groups: hypoxic preconditioning; hyperoxic preconditioning (hyperp); hypoxic-hyperoxic preconditioning (hhp); control group. animals were anesthetized and mechanically ventilated. we provided preconditioning, then started cpb, and then induced acute myocardial infarction by ligation of left anterior descending artery. after minutes of ischemia we performed minutes of reperfusion. we investigated endothelial function markers (endothelin- (et- ), asimmetric dimethylarginine (adma), nitric oxide metabolites) at stages before ischemia (after preconditioning in study groups), after ischemia and after reperfusion. results: the level of et- after the stage of ischemia increased in all groups, a significant difference was between hhp and control group (p= . ), then et- increased even more after the stage of reperfusion (p= . hhp vs control group). the concentration of nitrite decreased after the stages of ischemia and reperfusion in comparison with the baseline in all groups. however, the level of nitrite after all types of preconditioning was higher than in the control group (p= . ; . ; . ). the total concentration of nitric oxide metabolites in the study groups was higher than in the control group: before ischemia (after preconditioning) p= . ; after ischemia p= . ; after reperfusion, p= . . concentration of adma was lower in the hhp comparing with the control group at the stages after ischemia (p= . ) and after reperfusion (p= . ). conclusions: hyperp and hhp maintain endothelial function: the balance of nitric oxide metabolites and the reduction of et- hyperproduction in a model of myocardial ischemia/reperfusion injury in conditions of cpb. upscaling hemodynamic and brain monitoring during major cancer surgery: a before-after comparison study introduction: hemodynamic and brain monitoring are used in many high-risk surgical patients without well-defined indications and objectives. in order to rationalize both hemodynamic and anesthesia management, we implemented monitoring guidelines for patients undergoing major cancer surgery. methods: early , and for all eligible patients, we started to recommend (standard operating procedure, sop) cardiac output, central venous oxygen saturation, and depth of anesthesia monitoring with specific targets (map > mmhg, svv < %, ci > . l/min/ m , scvo > %, < bis < ). eligibility criteria were pelvic or abdominal cancer surgery expected to last > hours in adult patients. pre-, intra-, and post-operative data were collected from our electronic medical record (emr) database and compared before (from march to august ) and after (from march to august ) the sop implementation. results: a total of patients were studied, before and after the sop implementation. the two groups were comparable in terms of age, asa score, duration and type of surgery, the surgical possum score was higher after than before ( vs , p= . ). the use of cardiac output, scvo and bis monitoring increased from to %, to %, and to %, respectively (all p values < . ). intraoperative fluid volumes decreased ( . vs . ml/kg/h, p= . ), whereas the use of inotropes increased ( vs %, p= . ). the rate of postoperative delirium ( vs %, p= . ) and urinary track infection ( vs %, p= . ) decreased, as well as the median hospital length of stay ( . vs . days, p= . ). conclusions: in patients undergoing major surgery for cancer, despite an increase in surgical risk, the implementation of guidelines with predefined targets for hemodynamic and brain monitoring was associated with a significant improvement in postoperative outcome. introduction: tissue perfusion and oxygen delivery is low in patients with severe preeclampsia, which would explain multiple organ failure and death in these patients. the aim of this study was to determine the relationship between the base deficit and the risk of adverse maternal and perinatal outcomes. methods: retrospective multicenter cohort study included pregnant patients with severe preeclampsia admitted to six intensive care units at tertiary referral centers during a ten years period in colombia. clinical information was gathered from hospital medical records. the correlation of base deficit with adverse maternal outcomes was evaluated using logistic regression analysis. outcomes were maternal death, acute kidney injury, hellp syndrome, transfusion, eclampsia and extreme neonatal morbidity. results: patients were included in the study, we found a total of ( , %) maternal deaths, the median calculated base deficit obtained was - . meq/l. patients with base deficit greater than - . meq/l had significantly higher mortality rates or . (ci . - . ) p , . this group of patients was also associated with a higher probability of developing a class hellp syndrome or . (ci . - . ) p , . a more mild alteration in the base deficit (greater than - . meq/l) was related to the appearance of kidney injury or . (ci . - . ) p . y complete hellp or . (ci . - . ) p . . conclusions: base deficit is related to worse outcomes in patients with severe preeclampsia. according to our results, a cut-off point greater than - meq/l, there is a higher risk of death and worse outcomes such as class hellp syndrome. comparison of two different laser speckle contrast imaging devices to assess skin microcirculatory blood flow g guven, y ince, oi soliman, s akin, c ince erasmus mc, university medical center rotterdam, rotterdam, netherlands critical care , (suppl ):p introduction: laser speckle contrast imaging (lsci) is a common, non-contact and practical method used to assess blood flow of tissue surfaces. we have lack of knowledge about comparability of different lsci devices due to the arbitrary units (au) used to define blood flux. we sought to examine the linearity between skin blood flux, recorded using two different lsci devices. methods: we performed post-occlusive reactive hyperemia test (porh) on the arm and measured blood flux on the hand using two different lsci devices (moor instruments, devon, uk and perimed ab, järfälla, sweden). all volunteers were measured at baseline, during occlusion and after release of occlusion during the hyperemia phase. the third finger and fourth finger nail were selected for recording blood flux and au were used to express values. results: fifteen healthy, non-smoker male volunteers participated in this study. an excellent correlation was found between the two lsci devices (finger: r : . , p< . & finger nail: r : . , p< . ). data were also assessed in terms of the variability at different stages of the porh test (fig. a-d) . correlation of devices was still high at baseline, first minute of occlusion and in the post-occlusion hyperemia phase. however, in the period between minute after start of the occlusion and the beginning of the hyperemia, correlation was lower for the whole finger (r : . , p= . ) and correlation was lost for fingernail (r : . , p= . ) between the two devices. conclusions: skin blood flux measured with two different lsci devices are linearly correlated with each other. however care should be taken when assessing patients with low blood flux such as occurs during shock and ischemic organs. introduction: the aim of this study was to evaluate the effects of hyperoxia and mild hypoxia on microcirculatory perfusion in a rat model. methods: spontaneously breathing anesthetized (isoflurane) male wistar rats (n= ) were equipped with arterial (left carotid) and venous (right jugular) cannulae and tracheotomy. rats were randomized in groups: normoxiainspired oxygen fraction (fio ) of . ; hyperoxia -fio ; mild hypoxia -fio . . the following measurements were taken hourly for hours: blood gases, mean arterial pressure (map), stroke volume index (svi) and heart rate (echocardiography), skeletal muscle microvascular density (sidestream dark field videomicroscopy). results: at hour, arterial o tension was ± mmhg in normoxia, ± mmhg in hyperoxia, ± mmhg in mild hypoxia (p< . ). hyperoxia induced an increase in map (from ± to ± mmhg at h, p< . ) and a decrease in svi (from . ± . to . ± . ml/kg at h, p< . ), while in mild hypoxia map tended to decrease and svi tended to increase (p> . ). microvascular density decreased in hyperoxia and increased in mild hypoxia (fig. ) . conclusions: in anesthetized rats, microvascular density decreased with hyperoxia and increased with mild hypoxia. introduction: the imbalance between oxygen (o ) delivery and o requirement in patients with sepsis can be assessed by central venous oxygen saturation (scvo ). the low or high scvo may indicate cellular hypoxia or inability to utilize the o . this study aims to determine the relationship between high scvo and mortality in patients with sepsis. methods: a retrospective observational cohort study was done by collecting data (i.e., baseline characteristics, severity of infection and vasopressors) from medical records of >= -year-old patients with sepsis and st scvo measurement within hours of sepsis, who were admitted in a university hospital between and . the patients were stratified by st scvo level (< %, - %, > %) and apache-ii score (<= , > ). the primary outcome was inhospital mortality. results: among patients, those with high scvo ( . %) and low scvo ( . %) were associated with adjusted hazard ratios for death of . ( . - . , p= . ) and . ( . - . , p= . ), respectively, while those with normal scvo ( . %) as control. when the patients were stratified by scvo level and apache-ii score, using patients with normal scvo and low apache-ii score as control, those with high scvo and low apache-ii score, and those with low scvo and low apache-ii score had adjusted hazard ratios of . ( . - . , p= . ) and . ( . - . , p= . ). for those with normal, high and low scvo , and high apache-ii score had adjusted hazard ratios of . ( . - . , p= . ), . ( . - . , p= . ), and . ( . - . , p= . ), respectively. conclusions: the scvo > % with apache-ii score > , but not only scvo > %, is independently related to increased mortality in patients with sepsis. introduction: serum lactic acid levels and scvo are useful predictive parameters for patients with sepsis. however, little is known the differences in the impact of lactate levels and scvo on the prognosis of septic patients. in this study, we investigated these differences by analysing septic patients' characteristics and prognosis. methods: this study is a post hoc analysis of data obtained from a multicentre, prospective, randomized controlled trial, which compared two fluid management strategies for septic patients requiring mechanical ventilation. we categorised patients into the following four groups: scvo >= % and lactic acid levels < mmol/l (hh group); scvo >= % and lactic acid levels < mmol/l (hl group); scvo < % and lactic acid levels >= mmol/l (lh group) and scvo < % and lactic acid levels < mmol/l (ll group). sofa score, saps ii score, lactic acid levels, scvo and bnp were evaluated. primary outcome was -day mortality, whereas secondary outcomes were the duration of mechanical ventilation, administration of crrt, duration of catecholamine therapy and length of icu stay. results: in total, patients were included: hh group (n = ), hl group (n = ), lh group (n = ) and ll group (n = ). no significant differences were observed in terms of patient characteristics. further, -day mortality was % in the lh group, . % in the hh group, % in the ll group and % in the hl group, and there was no significant difference in terms of mortality among the groups. furthermore, there were no significant differences in terms of secondary outcomes. on multivariate analysis using the hl group as reference, the odds ratios for -day mortality in the lh, hh and ll groups were . ( %ci, . - . ), . ( %ci, . - . ) and . ( %ci, . - . ), respectively. conclusions: because -day mortality was higher in the hh group than in the ll group, serum lactic acid levels may have bigger impact on the prognosis of septic patients. introduction: in septic shock endothelial damage can lead to failure of microcirculation and low microcirculatory oxygen saturation. in the skin this is seen as mottling and can be quantified using hyper fig. (abstract p ) . changes in microvascular density spectral imaging. there is insufficient data about associations between skin oxygenation, severity of illness, biomarkers of endothelial damage and mortality in patients with septic shock. methods: this single centre observational study was performed in consecutive intensive care patients with septic shock. within hours of admission hyper spectral imaging of knee area skin was performed and blood was sampled for assay of biomarkers of endothelial cell damage (plasminogen activator inhibitor - (pai- ), soluble intercellular adhesion molecule (sicam- ), soluble vascular cell adhesion molecule (svcam- ), thrombomodulin, angiopoetin- ). nonlinear fitting of optical density spectra was used to calculate relative skin oxy/deoxy hemoglobin concentration and obtain oxygen saturation. the association between skin oxygen saturation, biomarkers, sepsis severity (apache ii, sofa) and -day mortality was analyzed. results: the median (iqr) age of patients was years ( to ), and % were males. the median sofa and apache ii scores were ( to ) and ( to ) and -day mortality rate was %. patients ( %) had mottling. there was a relationship between skin oxygenation, plasma biomarkers (thrombomodulin and svcam- ) and sepsis severity assessed by sofa and apache ii scores, p < . . using logistic regression analysis, skin oxygenation and biomarker concentrations were not associated with -day mortality rate. conclusions: in our cohort of patients with septic shock, skin oxygenation and biomarkers of endothelial injury were strongly associated with initial severity of sepsis but poorly predictive of -day mortality. comparison between ultrasound guided technique and digital palpation technique for radial artery cannulation in adult patients: a meta-analysis of randomized controlled trials s maitra, s bhattacharjee, d baidya all india institute of medical sciences, new delhi, new delhi, india critical care , (suppl ):p introduction: possible advantages and risks associated with ultrasound guided radial artery cannulation in-comparison to digital palpation guided method in adult patients are not fully known. previous meta-analyses included both adult and pediatric patients and long axis in-plane technique and short axis out of plane technique in the same analysis, which may have incurred biases [ , ] . methods: pubmed and cochrane central register of controlled trials (central) were searched (from to th november ) to identify prospective randomized controlled trials in adult patients where dimensional ultrasound guided radial artery catheterization has been compared with digital palpation guided technique. for continuous variables, a mean difference was computed at the study level, and a weighted standardized mean difference (smd) was computed in order to pool the results across all studies. for binary outcomes, the pooled odds ratio (or) with % confidence interval ( % ci) was calculated using the inverse variance method. results: data of patients from studies have been included in this meta-analysis. overall cannulation success rate was similar between short axis out of plane technique and digital palpation [p= . ; fig. ] and long axis in-plane technique with digital palpation. ultrasound guided long axis in-plane approach and short axis out of plane approach provides better first attempt success rate of radial artery cannulation in comparison to digital palpation [p= . and p= . respectively; fig. ]. no difference was seen in time to cannulate between long axis and short axis technique with palpation technique. conclusions: usg guided radial artery cannulation may increase the first attempt success rate but not the over all cannulation success when compared to digital palpation technique. introduction: ultrasound guidance may improve the success rate of vascular cannulation. there is lack of data regarding the utility of usg guided arterial cannulation in critically ill patients in shock. we aim to compare the impact of using real time ultrasound guidance versus palpation method in achieving arterial catheterization in critically ill patients in hypotension. methods: a single center, prospective, randomized trial was performed among critically ill patients aged > years, with hypotension (or requiring vasopressor infusion) and on not previous cannulated radial arteries. patients were randomized in a ratio of : to the ultrasound group or palpation group. under aseptic precautions, arterial puncture was performed using appropriate sized leader cath (vygon, ecquen, france), under real time usg guidance using short-axis out-of-plane view with bevel down. data were recorded and compared between two groups. the unpaired student's t-test or mann-whitney u test were used for continuous variables, and the uncorrected chi-squared or fisher's exact test were used for proportions. results: a total of patients with hypotensive shock requiring radial artery catheterization were randomized into palpation (n = ) and ultrasound (n = ) groups. first pass success rate was significantly higher in ultrasound group as compared to palpation group ( % vs %, p< . ). cannulation time was significantly shorter in ultrasound group ( . vs . ,p< . ). early complications were significantly higher in palpation group compared to ultrasound group ( . % vs . %, p< . ). conclusions: in critically ill patients with hypotension (or requiring vasopressors), ultrasound guidance improved first pass success rate, shortened the cannulation time and reduced the rate of early complications in radial artery catheterizations. relationship between inferior vena cava diameter and variability with mean arterial pressure and respiratory effort b kalin, k inci, g gursel gazi university school of medicine, ankara, turkey critical care , (suppl ):p introduction: there is no consensus on the use of vena cava inferior (ivc) diameter and variability in the assessment of fluid response (fr) in spontaneously breathing icu patients. influence from respiratory effort, experience requirement and measurement problems are reasons for not being preferred. the aim of the study is to investigate the relationship between ivc diameter, variability and spontaneous breathing effort and hypotension measured by ultrasonography in spontaneously breathing intensive care patients methods: the maximum and minimum diameters of the ivc were measured and the collapsibility index (ci) was calculated. measurements were made in d mode on cineloop recordings. diaphragm thickening ratio was used as a measure of respiratory effort. correlations between respiratory effort criteria with ivc minimum diameter and ci were calculated by pearson's correlation coefficient. ivc measurement criterias, such as inspiratory diameter of < cm, %, %, % of the ci were compared with chi square test in hypotensive and non-hypotensive patients. we took two mean arterial pressure threshold for hypotension as and mmhg for this calculation. results: patients were included in the study. for both hypotensive threshold values, there was no significant difference in the rates of hypotensive and non-hypotensive patients with and without a minimum ivc diameter of cm below. even there was no significant relationship between the ci higher than %, % and % and hypotension (p> . ). in spontaneously breathing patients, a significant correlation was found between respiratory effort and ivc ci and ivc diameter < cm conclusions: at the end of the study, there was a correlation between spontaneous breathing effort ivc diameter and ci in the intubed patients. additionally the result that ivc ci is not different even between hypotensive and non-hypotensive patients suggests that this method should be used with caution in predicting fr. introduction: fluid responsiveness in icu patients can be assessed using changes in pulse rate and blood pressure following administration of a fluid bolus, assisted if necessary by cardiac output (co) monitors such as the lidcoplus. this uses pulse contour analysis to estimate stroke volume (sv), with > % change in sv following a fluid challenge (fc) signifying overall benefit. there is no evidence that the use of co monitoring improves patient outcomes and it is unclear if it improves clinical decision making. methods: a lidcoplus monitor was set up with the screen covered. a ml fc was administered over minutes. the heart rate, systolic and mean arterial pressures were recorded before and after the fc. the clinician administering the fc was asked to decide if the patient was fluid responsive. following this decision, the sv change was revealed and the clinician asked again to assess fluid responsiveness. results: forty-five fluid challenges were studied. use of the lidco changed the decision made on occasions (fig. ) . in three patients ( %), this change in decision was appropriate and either corrected a misinterpretation of the haemodynamic data or represented a patient whose only marker of fluid responsiveness was a sv change. in four patients ( %), the lidco changed the decision inappropriately from a correct interpretation of the haemodynamic data. in six patients ( %) the sv change was ignored when it should have changed the initial decision. in the remaining patients ( %) the decision made with the haemodynamic data was in agreement with the sv change and unchanged by revealing the lidco data. conclusions: the use of lidco monitoring only appropriately changed the decision made with information from basic haemodynamic monitoring in % of patients. this augmentation of decision making was only seen in patients whose basic haemodynamic parameters did not respond to fluid. it changed a correct decision inappropriately in %. overall, no improvement in the assessment of fluid responsiveness was seen. introduction: there are accumulating evidences suggesting that intraoperative blood pressure affects postoperative outcome including myocardial injury, acute kidney injury, stroke, and mortality. in a patient undergoing laryngeal microsurgery (lms), blood pressure usually rises sharply due to the stimulation on the larynx. since pulse transit time (ptt) has been reported to reflect arterial blood pressure fairly well, it has possibility to be a marker for blood pressure which reflects beat-to-beat changes in blood pressure and is less invasive than arterial catheterization. methods: intraoperative noninvasive blood pressure (nibp), electrocardiogram (ecg), and photoplethysmogram (ppg) of patients undergoing lms were recorded simultaneously. ptt was defined as a time interval between the r-wave peak on ecg and the point which the maximal rising slope appears on the ppg. the mean ptt values for one minute before and after the increase in blood pressure due to the stimulation on larynx were compared. parameters of ppg such as width, height, maximal slope, minimal slope, and area were also compared. then, correlation between blood pressure and each variable was calculated. results: as the larynx was stimulated by lms, nibps have surged (systolic blood pressure, . p< . ) significantly in most of the patients. systolic blood pressure and ptt were inversely correlated (r = - . , p < . ). minimum slope of ppg also showed good negative correlation with systolic blood pressure (r = - . , p < . ). conclusions: ppt showed good correlation with systolic blood pressure and may have potential to be used as noninvasive continuous blood pressure monitor during a surgery in which blood pressure changes abruptly. introduction: aim of this prospective randomized pilot study was to investigate influence of intra operative restrictive volume approach and post operative lung ultrasound (lus)on prevention and early detection of postoperative interstitial syndrome development methods: cardiac patients who underwent non cardiac surgical procedure were randomly assigned for: group a-liberal volume approach or for group b-combination of restrictive intra operative volume approach and small dose of norepinephrine. all patients post operatively received <= . ml/kg/h fluids, mostly crystalloids. lus was performed before surgical procedure and hours after their admission in icu together with arterial blood gases measurements. the ultrasound characteristic of interstitial syndrome was development of b profile results: before surgery all patients had a profile. twenty for hours later in a group significantly higher number of patients / ( . %) vs / ( . %) in b group,had b profile (p< . ).at the same time there were no significant difference between the groups in amount of patients with pao /fio ratio <= ( patients with positive b lines from a group vs patients from group b).(p> . ) conclusions: intra operative fluid restriction is efficient in prevention of post operative cardiogenic pulmonary edema development. lus is a simple non invasive method for early detection of interstitial syndrome even before development of signs of respiratory deterioration. introduction: the peak rate of left ventricular (lv) pressure (dp/dtmax) has been classically used as a marker of lv systolic function. since measuring lv dp/dtmax requires lv catheterization, other surrogates have been proposed using the peripheral arterial waveform. the aim of this study was to test the performance of lv and arterial (aortic and femoral) dp/dtmax for assessing lv systolic function against the gold-standard (the slope of the end-systolic pressure-volume relationship, emax) during different cardiac loading and contractile conditions. methods: experimental study in pigs. lv pressure-volume data was obtained with a conductance catheter and peripheral pressures were measured via a fluid-filled catheter into the aortic, femoral, and radial arteries. emax was calculated during a transient occlusion of the inferior vena cava. the experimental protocol consisted in three consecutive stages with two opposite interventions each: changes in afterload (phenylephrine and nitroprusside), preload (bleeding and fluid bolus), and contractility (esmolol and dobutamine) (fig. ) . measurements were obtained before and after each hemodynamic intervention. results: emax variations and lv, aortic, femoral and radial dp/dtmax changes throughout the study are shown in fig. . all peripheral artery-derived dp/dtmax underestimated lv dp/dtmax. percentage changes in lv and femoral ddp/dtmax were tightly correlated (r = . ; p< . ). both lv and femoral dp/dtmax were affected by preload changes during fluid infusion. all peripheral dp/dtmax estimations allow to detect lv systolic function changes according to emax during isolated variations in contractility. conclusions: femoral and lv dp/dtmax accurately reflected emax changes, although both were affected by preload changes during fluid administration. fig. (abstract p ) . emax, lv dp/dtmax and aortic, femoral and radial dp/dtmax changes. (table , fig. ). concordance was < % and radial loa was ±< °for all devices; mean polar bias was < °for ft only (table , fig. ) . conclusions: cs, ft and pa are not interchangeable with tptd, because of inaccuracy [ ] . when considering limitations they may be used for trending. introduction: about years ago, the german physiologist pflüger stated that the cardio-respiratory system fulfils its physiological task by guaranteeing cellular oxygen supply and removing waste products of cellular metabolism. methods: the study was performed in early postoperative period after major abdominal surgery in patients. the physical condition of patients corresponded to class of asa. the median age was . ( . - . ) years. duration of the surgery was , ( , - , ) hours. surgery was performed under combined epidural anesthesia with mechanical ventilation. the study was conducted in the following stages: -admission from operating room; -in - hours; - - hours; - - hours; -after - hours after the surgery. results: depend on rate of oxygen extraction index (ero ) groups were revealed: group (n= )low ero (< %) followed by recovery to normal levels to stage - (ero = - %), group (n= )normal level ero ( %) in all the stages, group (n= )high levels ero (> %) with recovery to normal levels to stage , group (n= )high ero (> %) in all the stages. oxygen extraction index at admission to icu after surgery can be normal ( . % of patients), reduced ( . % of patients) or high ( . % of patients). when oxygen extraction ratio is reduced metabolic recovery occurs classically after - hours; when ero is elevated -after hours. core temperature improvement is connected with the restoration of oxygen homeostasis. so, under normal and reduced ero even mild central hypothermia after surgery were not observed, and at an elevated ero moderate hypothermia after surgery was observed with only to - hours post-surgery restoration. conclusions: maintaining an adequate tissue oxygenation is the cornerstone of metabolic response and postoperative recovery in patient after major abdominal surgery. (fig. ) . patients with cso < %time above %h had an odds ratio of hospital survival of . ( %ci . - . , p= . ) (fig. ) . conclusions: cerebral oxygen desaturation below % was significantly associated with outcome in patients undergoing vaecmo. in patients with cso < %time above h%, prognosis was especially poor. prospective trials are needed to evaluate if cso is a viable target for therapeutic interventions. introduction: during the second consensus meeting on microcirculatory analysis the exploration of novel parameters related to physiological function of the microcirculation was proposed. capillary hematocrit (chct) is a direct measure of capillary hemodilution, a potential mechanism of microcirculatory dysfunction in states of shock. our hypothesis was that by application of advanced computer vision (i) chct can be reliably measured in given capillaries, and (ii) change in chct reflects capillary hemodilution induced by cardiopulmonary bypass (cpb). methods: in patients undergoing coronary artery bypass surgery sublingual capillary microscopy videos were recorded before and during cpb primed with hes / . . per-capillary chct was estimated as the product of the number of red blood cells (rbc) and an assumed volume of nl, divided by the capillary volume including plasma gaps. rbc number was assessed by manual counting in the first frame of a given video clip, as well as using a novel advanced computer vision algorithm employing blob detection to calculate the mean per-capillary rbc number in all frames of a given video clip (fig. ) . results: capillaries were analyzed, within a total of and frames using manual and algorithmic analysis. a good correlation was found between both methods for chct (r= . , p< . , fig. ). cpb initiation resulted in an decrease in chct from (mean±sem) . ± . to . ± . , p< . and . ± . to . ± . , p= . in manual and algorithm. conclusions: accurate measurement of chct is possible using advanced computer vision, and it reflects hemodilution induced by initiation of cpb. chct further is a determinant of capillary delivery of oxygen. combined with the assessment of functional capillary volume, blood flow velocity, and capillary hemoglobin saturation, chct may enable direct optical quantification of capillary delivery of oxygen as an integrated functional parameter of the microcirculation. fig. (abstract p ) . prognosis of patients with cso < %time above %h was poor fig. (abstract p ) . detection of single erythrocytes using a novel advanced computer vision algorithm in a representative capillary ribbon extracted from a video frame of the sublingual microcirculation fig. (abstract p ) . the area under cso < % was significantly lower in survivors introduction: cardiac function is known to be impacted by sepsis. passive leg raise (plr) is an effective method to predict fluid responsiveness (fr) or cardiac response to preload expansion. preload functional status and trending cardiac output may identify patient phenotypes with varying cardiac reserve, dysfunction and outcome. methods: patient data were analyzed from a currently enrolling prospective randomized controlled study, evaluating the incidence of fr in critically ill patients with sepsis or septic shock (fresh study, nct ). patients randomized to plr guided resuscitation were classified as plr+ (fluid responsive/preload dependent) if stroke volume (sv) increased >= % when measured with a non-invasive bioreactance device (starling sv, cheetah medical). patients were categorized into different phenotypic cohorts based on changing physiology exhibited on plr and trending cardiac output over the initial hours of therapy. results: a total of plr assessments were performed in patients. overall, % ( / ) of assessments indicated a patient was plr+ after receiving initial resuscitation fluid of~ l. most patients ( %) demonstrated a dynamic physiology with changing plr status occurring > time over hours. there were no differences among the groups with respect to age, gender, or qsofa score (fig. ) . patients in group exhibited a significantly decreased icu stay ( . hours) compared to group ( . hours, p= . ) (fig. ) . patients in group exhibited significantly increased echo evidence of lv/rv cardiac dysfunction ( %), compared to group ( %, p= . ) ( table ) . patients in group exhibited % evidence of echo based lv/rv cardiac dysfunction. conclusions: physiological based resuscitation phenotypes identify significantly different patient groups. patients who are initially not plr+, but then become plr+ with no improved co are significantly more likely to have confirmed lv/rv dysfunction and a significantly longer icu stay. introduction: accurate measurement of a patient's intravascular volume status remains an unsolved clinical problem in the icu setting. in particular, septic and cardio-renal patients often receive volume challenges or diuresis, respectively, with little appreciation of baseline bv or the resulting response. this can lead to volume overload and/or depletion and associated increases in morbidity, mortality and hospital length of stay. methods: we tested the performance of a novel, rapid, minimally invasive technique capable of measuring pv, bv and glomerular filtration rate (mgfr) in human subjects. the method consists of a single iv injection of a large ( kda) carboxymethyl dextran conjugated to a rhodamine-derived dye and a small ( kda) carboxymethyl dextran conjugated to fluorescein. plasma and blood volumes were quantified minutes following the injection of the dye based on the indicatordilution principle. results: this phase b study included normal subjects, chronic kidney disease (ckd) stage iii and ckd stage iv subjects. pv and bv varied according to weight and body surface area, with pv ranging from to mls, and both were stable for greater than six hours with repeated measurements. there was excellent agreement ( fig. ) with nadler's formula for pv in normal subjects. a hour repeat dose measurement in healthy subjects showed pv variability of less than +/- %. following an intravenous bolus of ml % albumin solution the mean +/-(sd) measured increase in pv was . ml +/- . ml post infusion (fig. ) . conclusions: this novel bedside approach allowed for rapid and accurate determination of pv, bv, mgfr (data not shown) and dynamic monitoring following clinical maneuvers such as fluid administration, with a high level of safety, accuracy and reproducibility. this approach should assist the intensivist especially with volume administration and removal in septic and cardiorenal patients. introduction: accumulating evidence shows that fluid overload is independently associated with adverse outcome in children and adults with acute lung injury. fluid restriction initiated early in the disease process may prove beneficial, potentially by diminishing the formation of interstitial edema. the main goal of this study was to determine the short-term biophysical effects of intravenous (iv) fluid restriction during acute lung injury in relation to age. methods: infant ( - weeks) and adult ( - months) wistar rats were mechanically ventilated (mv) hours after intratracheal inoculation with lipopolysaccharide to model acute lung injury. both age groups were randomized to either a normal or restrictive iv fluid regimen during hours of mv. thereafter the rats were sacrificed and studied for markers of interstitial edema formation (wet-dry weight ratios), lung permeability (total protein and alpha- macroglobulin (a m) in bronchoalveolar lavage; bal) and local inflammation (cell counts and cytokines in bal). results: restrictive fluid therapy was not associated with worsening of hemodynamic indices during the period of mv in either infant or adult rats. however, as compared to the normal fluid regimen, restrictive fluid therapy led to lower wet-dry weight ratios of the lungs and kidneys in adult rats (p < . ), but not in infants (figs. and ). no difference was found in total protein and a m in bal between the two fluid regimens in both age groups. also, neutrophil influx in the lungs did not differ between fluid regimens in both age categories, nor did the influx of inflammatory cytokines il- and mip- in bal fluid. conclusions: there is an age-dependent effect of early fluid restriction on the formation of interstitial edema in local and distant organs in the disease process of acute lung injury. further investigation of the effects of fluid therapies in experimental models may help steering towards better treatment in critically ill patients. . ) . in a multivariate analysis fb was independently associated with: group c (p< . ), a history of diabetes (p= . ), the acute physiology and chronic health evaluation iii score (< . ) and the duration of aortic-cross clamp (p< . ). the main findings of this study substantiated the hypothesis that the introduction of continuous fb-tracking throughout the entire care process, is associated with a significant reduction in the administration of fluids in post-cardiac surgery patients, independent of differences in their baseline characteristics. demonstrating that certain organizational changes can influence medical behavior beyond the scope of teaching and instruction, and therefore serves to provide awareness to the current issue known as 'knowledge-to-care gap'. using a protocol for fluid resuscitation: how well is it followed? introduction: positive fluid balance in icu patients has been correlated with worse outcomes [ ] . consequently, we developed a protocol to guide fluid resuscitation. the protocol was introduced in and mandates that fluid responsiveness is assessed when administering fluid boluses. once a patient becomes fluid unresponsive, no further resuscitation fluid should be administered. to assess responsiveness, the protocol advises the use of haemodynamic data such as heart rate and blood pressure as well as the change in stroke volume (sv) measured by a lidcoplus monitor. after years of use and a rolling education program this protocol was felt to be well ingrained in our unit culture. we then assessed how well it was being followed. methods: staff performing fluid challenges were asked to fill out a form recording the haemodynamic and sv data measured before and after a fluid challenge. they were also asked to record their interpretation of just the haemodynamic data and then this data combined with the sv data. results: forty five forms were completed. the protocol was not followed on occasions ( %). four patients who should have been assessed as responsive were deemed to be unresponsive. six patients who should have been assessed as unresponsive were assessed as being responsive. the remaining deviations from the protocol represent misinterpretation of the haemodynamic data but correct use of the sv data to reach a correct final assessment. conclusions: despite being a longstanding ingrained practice in our icu, this review suggests that the protocol for fluid resuscitation is being followed incorrectly approximately a third of the time. this could result in inappropriate under or over administration of iv fluid. we plan to review the educational programme and raise awareness of the protocol to try and improve future compliance. introduction: understanding the effects of therapeutics on the left ventricular (lv) loading conditions is of utmost importance in critically ill patients. the effective arterial elastance (ea=esp/sv, where esp is aortic end-systolic pressure and sv stroke volume) is a lumped parameter of arterial load that has been proposed as an index of lv afterload. we aimed at comparing the effects of fluid administration on esp (i.e., the lv afterload in the pressure-volume phase-plane according to the classic "cardiocentric" framework) and on ea. methods: in mechanically ventilated patients, we recorded ea from the femoral peripheral systolic arterial pressure sap (ea=( . ×femoral sap)/sv) before and after the infusion of -ml of saline. patients in whom fluid administration induced an increase in cardiac index (picco- ) >= % were defined as "responders". introduction: the respiratory variations of the inferior vena cava (ivc) diameter in mechanically ventilated patients with preload responsiveness could be explain by a higher compliance of the ivc and/or higher respiratory variations of the ivc backward pressure, i.e., the central venous pressure (cvp).we aimed at determining the respective weight of these two phenomena. methods: in mechanically ventilated patients, haemodynamic, respiratory and the intra-abdominal pressure (iap) signals were continuously computerised. cvp, iap and the ivc diameter (transthoracic echocardiography) were recorded during end-inspiratory and endexpiratory occlusions, before and after the infusion of -ml of saline. patients in whom fluid administration induced an increase in cardiac index (picco- ) >= % were defined as "responders". the respiratory variations of the ivc diameter, cvp and iap were calculated as (end-inspiratory -end-expiratory values)/mean value. the compliance of the ivc was estimated by the ratio between (end-expiratoryend-inspiratory) values of ivc diameter and cvp. results: fluid administration increased cardiac index by more than % in patients. the respiratory variations of the ivc diameter predicted fluid responsiveness (area under the roc curve: . ( %ci: . - . ), p< . ). before fluid administration, the compliance of the ivc was not different between responders and non-responders ( . ± . vs. . ± . mm/mmhg, p= . ), whereas the respiratory variations of the cvp were higher in responders than in nonresponders ( ± vs. ± %, p= . ). the respiratory variations of the ivc diameter were associated with the respiratory variations of cvp (r= . , p= . ) but not of iap (r=- . , p= . ). conclusions: the respiratory variations of the ivc diameter rather depend on the respiratory variations of the cvp than on the ivc compliance. the iap seems to not be involved in the respiratory variations of the ivc diameter. hours and gedi measured at the same time was examined. since the dataset used in this study consists of repeated measurement data, the analysis used the general linear mixed effect model (glmm). the multivariate analysis adjusted with age, cr, and cardiac index was also conducted. results: of the patients with the total bnp measurements conducted for times and gedi measurements for times, the median of age and saps were (iqr - ) and (iqr - ), and the hospital mortality rate was %. the univariable analysis and the multivariable analysis using glmm respectively found statistically significant differences, with regression coefficient at . %ci . - . (p= . ), and . %ci . - . (p< . ). conclusions: while a positive correlation between gedi and bnp was statistically identified, its effect may be minor in clinical terms, and its significant clinical difference remains unclear. introduction: fluids are a cornerstone of the management of critically ill patients who are at risk of multiple organ dysfunction syndrome. however positive fluid balance (fb) is associated with worse morbidity and mortality in this population, so fluid administration needs to be carefully titrated and the nutritional support products must be taken in consideration. objective: evaluate the impact of nutritional support in the fluid balance in a intensive care unit methods: observational prospective study, conducted in eleven portuguese icus of nine general hospitals. patients with years of age or older were eligible if they were ventilated and had a length of stay (los) in icu greater than days. demographic data, fluid balance along type of nutritional support used in the first days and were collected from the selected patients. results: patients were enrolled, . % were male, the median age - ± ( - ), icu los - . ± . days, mortality rate of . % ( ). % of patients were admitted for medical reasons, . % had normal weight, the remaining patients were either overweight or obese. the average daily fb in the eight days was ± ml, being the maximum at day with + ml, slowly trending down reaching a neutral balance at day and reaching - ml at day . in the first days the majority of the intake is due to resuscitation driven fluids, however the nutritional support contribution rises as the days passes, reaching % at day and % at day ( fig. ) . regarding the administration route, the enteral route was responsible to , % of fluids at day compared to , % of parenteral route. the nutritional support is an factor to take into account regarding fluid balance in intensive care units. in this study after the th day the nutritional support, it was responsible for more than % of the total volume that was delivered to the patient and with an higher impact with the increase in los results: we included patients with mean age years, % male, apache ± , saps ii ± , sofa in admission ± , mechanical ventilation %, continuous renal replacement techniques %. the mean total volume administered during the first days was ± l with a mean dcb of ± l and a mean fluid accumulation of % ± . regarding fluid accumulation: % have < %, % between - % and . % > %. th-day mortality and icu mortality were % i % respectively. during the first week, the percentage of fluid accumulation was significantly higher in non-survivors than in survivors ( . ± . l vs. . ± . l, p . ) (fig. ) . cumulative survival was significantly lower (logrank = . , p= . ) in patients with > % of volume gain since the th day (fig. ) . > % volume gain in the th day is a independently associated variable to mortality after adjusting by age, apache and haemodialysis (or = . ; ci % . - . ; p = . ) ( table ) . conclusions: in septic shock patients, fluid overload more than % since -day of evolution is associated with a higher th-day mortality. its early detection may influence the prognosis and survival. introduction: sepsis is defined as a life-threatening organ dysfunction due to a deregulated host response to infection [ ] . fluid infusion is one of the cornerstones of sepsis resuscitation therapies. one of the major adverse effects reported is fluid overload (fo). the objective of this study was to assess influence of fo on sofa score changes from day to day . methods: this study is a retrospective, multicenter, epidemiologic data analysis. it was performed in three french icus. all adult patients admitted for septic shock, caused by peritonitis or pneumonia and mechanically ventilated, were enrolled. delta sofa score was defined as the sofa score measured on admission minus sofa score measured on day . results: patients met the inclusion criteria of the study. fo occurs in about % of the patients. cumulative fluid balance at day was greater in the fo group ( . versus . ml, p < . ) ( table ) . delta sofa score was higher in the no fo group than in the fo group ( . versus . , p = . ) (fig. ). there was a stepwise decrease of delta sofa score when duration of fluid overload was greater (p = . ) (fig. ) . in linear modelling, association between fo status and delta sofa score was confirmed with an adjusted rr of . [ . - . ] (p = . ) ( table ) . conclusions: ) fo patients had more prolonged multi-organ failure during septic shock; ) the longer the fo is the longer the more multi-organ failure last. , (t ) and (t ) minutes later. cardiovascular parameters were also measured at above time points. biomarker change from baseline (fold-change), indexed to hemoglobin, was compared between groups using mixed effects models (bonferroni-holm corrected p< . ). results: minor differences in measures of shock between groups after fluid administration resolved by t . cryst showed increased fold-change in hyaluronan compared to other groups at t (fwb p= . , hes p< . , gelo p< . ), t (fwb p< . ) and t (fwb p< . ) (fig. ) . gelo had increased fold-change in hyaluronan compared to other groups at t (hes p= . ), t (fwb p< . ) and t (fwb p< . , cryst p= . ), as did fwb at t (hes p= . ). cryst showed increased fold-change in il compared to other groups at t (hes p< . , gelo p= . ), t (hes p= . , gelo p= . ,), t (hes and gelo p< . ) and t (hes and gelo p< . ) (fig. ) , of il at t (gelo p= . ), and of kc at shock (fwb p= . , gelo p= . ), t (fwb p= . , gelo p= . ), and t (gelo p= . ). conclusions: rapid large-volume crystalloid given for hemorrhagic shock was associated with increased hyaluronan, a biomarker of endothelial glycocalyx damage, and inflammation, including increased il , il and kc. introduction: a bi-center randomized controlled trial has recently been published that investigates the impact of the type of fluid (crystalloid versus colloid) on patient outcome following major surgery [ ] . the study used a closed-loop fluid delivery system to eliminate the clinician bias when determining when to deliver fluids. the goal of the current analysis is to compare the immediate hemodynamic response to ml fluid boluses of either a crystalloid or a colloid solution. methods: patient consent was obtained prior to transferring the data from [ ] to edwards lifesciences for further post-hoc analysis. the percent change in stroke volume (dsv) following each ml bolus was tabulated and cross-referenced to the type of fluid. the responder rate and the dsv cumulative distribution function (cdf) were determined for each type of fluid administered. a responder was defined as a dsv >= % for a ml fluid challenge. the mean dsv was compared between the two groups using a student t-test. results: from the datasets reported in [ ] , were used in the analysis. descriptive statistics are summarized in table and the cdfs are plotted in fig. . more crystalloid boluses were administered. in both groups, the responder rate was around %. mean dsv was not significantly different between groups (p = . ). we observed similar responder rates and cdfs with the two fluid types, suggesting that the immediate hemodynamic response to ml fluid boluses is independent from the fluid type. we therefore hypothesized that it is the longer intra-vascular persistence of the colloid that explain the lower number of boluses required to achieve the hemodynamic endpoints targeted in the clinical study [ ] . fig. (abstract p ) . cumulative distribution functions of delta stroke volume for crystalloid and colloid fluid boluses the reduction projected to an average annual saving of , usd ( introduction: colloids are widely used for volume resuscitation. among synthetic colloids, hydroxyethyl starch (hes) is commonly administered. in cardiac surgery, priming of the cardiopulmonary bypass (cpb) circuit with colloids minimizes resuscitation volume and results in less pulmonary fluid accumulation. however, the use of hes has been associated with a higher incidence of renal damage and a higher occurrence of coagulopathy. the aim of this study was to investigate the effect of low dose ( - ml/kg) hes % ( / , ) in cpb pump priming on fluid balance, blood loss, transfusion requirement and occurrence of acute kidney injury. methods: in a pre-post design, data from patients undergoing cardiac surgery with cpb were analyzed. in patients, priming solution consisted of ml balanced crystalloids, ml mannitol %, tranexamic acid g and i.e. heparin. for the other patients, ml of the crystalloids were replaced with hes % ( / . ), the other components were the same. patients were matched : with propensity score method. the primary endpoint was intraoperative fluid balance. secondary endpoints were perioperative blood loss, transfusion requirement and the occurrence of acute kidney injury. results: in total, patients were analyzed. the hes group showed less positive fluid balance than the crystalloid group (p< . ). there was no difference in intraoperative blood loss (p= . ) and transfusion requirement (p= . ). the occurrence of acute kidney injury was not significantly different between the two groups (p= , ). conclusions: low-dose administration of - ml/kg hes % ( / . ) to cpb pump priming decreased intraoperative fluid accumulation without increasing perioperative blood loss and transfusion requirement. there was no effect on the incidence of acute kidney injury. priming cpb pumps with a low-dose of hes % ( / . ) is an important component for a restrictive volume strategy and might safely be used in patients with preexisting renal dysfunction. introduction: most crystalloid solutions used in critically ill patients have a greater chloride (cl) concentration than plasma, which may be detrimental. replacing some cl with bicarbonate (hc ) reduces cl, but may increase partial pressure of carbon dioxide (pc ) in blood. such an increase in pc may be harmful [ ] . the main objective was to determine if a hco balanced fluid resulted in increased paco compared to a conventional balanced fluid. methods: single center randomized controlled trial in an adult icu, comparing balanced fluid (sodium,na= mmol/l, chloride,cl= mmol/l, hco = mmol/l) vs conventional fluid (na= mmol/l, cl= mmol/l, hc <= mmol/l). university ethics committee approval:m . we used the absolute difference between the pco and mmhg as a comparison for the fluid groups. betweengroup comparisons of pc from d -d was done by repeated measures anova. a p value < . was considered significant. results: patients were allocated to the conventional group and to the balanced group. at baseline the groups were well matched (p> . ) for age, weight, gender, severity of illness and organ support. there were no significant differences in pc between the two fluid groups, overall or at d , d or d . the balanced group showed a significant improvement in egfr (scr), between d and d (p= . ) while the conventional group exhibited a significant decline (p= . ). there were no significant differences between the groups with respect to fluid requirements, number of positive blood cultures, icu renal replacement utilization, icu length of stay, icu mortality and day mortality. conclusions: the use of a balanced fluid did not result in an increase in pco and appears to be safe. a beneficial effect on renal function was observed. introduction: the effects of crystalloids and colloids on macro-and microcirculation is controversial. our aim was to compare their effects on microcirculation during free flap surgery when management was guided by detailed hemodynamic assessment. methods: patients undergoing maxillo-facial tumour resection and free flap reconstruction were randomized into a crystalloid (ringerfundin, rf, n= ) and a colloid ( % hydroxyethyl starch, hes, n= ) groups. cardiac index (ci), stroke volume (svi) and pulse pressure variation (ppv) were continuously monitored by a non-calibrated device (pulsioflex -pulsion, maquet). central venous oxygen saturation (scvo ), venous-to-arterial pco -gap (dco ), lactate levels and hourly urine output was also measured, and a multimodal, individualized approach based algorhithm was applied [ ] . microcirculation was assessed by laser doppler flowmetry (periflux ldpm, perimed jarfalla, sweden). measurements were performed at baseline and from the start of reperfusion hourly for hours. for statistical analysis, two-way rm anova was used. results: there was no difference between the groups regarding age, sex, length of surgery (whole population: ± min). patients in the rf-group required significantly more fluid in total (rf: ± , hes: ± ml, p= . ). both groups remained hemodynamically stable (ci, svi, ppv, scvo , dco , lactate and urine output) throughout the study. there was no difference between the rf-, and hes-groups in the laser doppler measurements neither on the control site nor in the flap (fig. ) . conclusions: we found that when hemodynamic management is guided by a multimodal assessment and stability is maintained, there was no difference between crystalloids and colloids in macrocirculation and microcirculatory perfusion. introduction: our aim is to evaluate the impact of crystalloid fluids on immune cells. intensive care unit (icu) patients' inflammatory status can switch from an early pro-inflammatory to a late anti-inflammatory phase, which favors infections. they can receive different crystalloids, either normal saline (ns), ringer's lactate (rl) or plasma-lyte (pl). high chloride concentration present in ns has been associated with various complications [ ] , whereas high doses of nacl have inflammatory effects on immune cells [ ] . however, the immune consequences of crystalloids in humans are ill-defined. methods: using our comprehensive immunemonitoring platform, we assessed the immunological phenotype of peripheral blood mononuclear cells (pbmc) in humans. healthy subjects received a liter of ns, rl and pl. blood samples were taken before and h later. pbmc phenotypes were assessed by flow cytometry and cytokine concentrations were measured by a multiplex assay. off-pump cardiac surgery patients were also randomized to receive either ns, rl or pl during surgery and their stay in the icu. blood samples were drawn at various time-points. all leucocytes were analyzed in a similar fashion. we are still recruiting. results: study of healthy subject's pbmc suggested that rl reduced classical monocytes, whereas ns increased lymphocyte activation and il- and mip- b levels. in cardiac surgery patients, our preliminary results suggested that rl and pl reduced classical monocytes and increased non-classical monocytes compared to ns. neutrophils were also affected differently by crystalloids, where ns seemed to activate them more. conclusions: our results suggest that crystalloids have different immune consequences. a better understanding of their immune modulation will lead to personalization of their use according to the inflammatory status of patients to restore their immune homeostasis. this randomised controlled open-label pilot study included patients presenting to an emergency department with suspected infection requiring a fluid bolus. patients received either a single bolus of ml/kg of . % nacl (isotonic group) or ml/kg of % nacl (hypertonic group). blood biomarker concentrations of glycocalyx shedding (syndecan- , hyaluronan), endothelial activation (sicam- , svcam- ) and inflammation (interleukin- , - , - , ngal, resistin) were measured at t (before fluid) and hour (t ), hours (t ) and - hours (t ) later. changes in biomarker concentrations were compared between study groups using mixed regression models, with fold-change from t reported. differences in fluid volumes were compared using the wilcoxon rank sum test. significance was set at p< . . results: syndecan- concentration in the isotonic group decreased from t to t (fold-change . , % ci . - . ), which was significantly different to the hypertonic group (fold-change . , % ci . - . )(p= . )( table ) . interleukin- concentration decreased in the isotonic group from t to t (fold-change . , % ci . - . ), which was significantly different to the hypertonic group (fold-change . , % ci . - . )(p= . ). otherwise, there were no significant differences in change over time between groups for measured biomarkers. total fluid volume administered between t and t was significantly higher in the isotonic group (p< . ) ( fig. ) but not different for subsequent time periods. conclusions: biomarkers of glycocalyx shedding, endothelial activation and inflammation were not different between patients receiving either . % or % saline. also, % nacl did not reduce administration of additional fluids. introduction: acute changes in pco are buffered by non-carbonic weak acids (atot), i.e., albumin, phosphates and hemoglobin. aim of the study was to describe acid-base variations induced by in-vitro pco changes in critically ill patients' blood and isolated plasma, compare them with healthy controls and quantify the contribution of different buffers. methods: blood samples were collected from patients admitted to the icu and controls. blood and isolated plasma were tonometered at and % of co in air. electrolytes, ph, blood gases, albumin, hemoglobin and phosphates were measured. the strong ion difference (sid) was calculated [ ] and non-carbonic buffer power was defined as β=-Δhco -/Δph [ ] . t-tests and linear regression were used for analysis. results: seven patients and controls were studied. hemoglobin, hematocrit and albumin were lower in patients (p< . ), while sid and phosphates were similar. pco changed from ± to ± mmhg, causing different blood ph variations in patients and controls ( . ± . vs. . ± . , p= . ). patients had lower blood and plasma β ( ± vs. ± , p< . and ± vs. ± , p= . , respectively). figure shows changes in [hco -] and sid induced in blood by pco variations. in both populations, ± % of [hco -] change was due to sid variations, while only ± % to changes in atot dissociation. a significant correlation between hematocrit and Δsid was observed in the whole study population (fig. ) . conclusions: the β of icu patients was lower, likely due to reduced albumin and hemoglobin concentrations. similar pco increases caused therefore greater ph variations in this population. electrolyte shifts, likely deriving from red blood cells [ ] , were the major buffer system in our in-vitro model of acute respiratory acidosis. introduction: there is an increasing trend in the incidence of aneurysmal subarachnoid haemorrhage in hong kong and the disease carries high morbidity and mortality rate. electrolyte disturbance is one of the known complications of sah and the outcomes associated with this are not fully understood. the objective of this retrospective local study is to evaluate the pattern of electrolyte disturbances in patients with sah and their impact on the prognostic functional outcome. methods: patients with spontaneous aneurysmal sah who were admitted to icu at pamela youde nethersole eastern hospital, hong kong between st january and st december were included into this retrospective local study. collected data include demographic details, comorbidities, serum electrolyte levels (sodium and potassium) from day to of admission into icu, radiographic intensity of haemorrhage using fisher scale and the clinical grading of sah using wfns. prognosis of these patients was estimated using the glasgow outcome scale at months after initial insult (fig. ) . results: a total of patients were included in this study. the mean age was , with the majority of patients being female ( . %). the most common aneurysm location was in anterior communicating artery, though poor outcomes were shown significant in patients with posterior circulation aneurysms. whilst early-onset hyponatremia was not correlated with poor outcome, late-onset hyponatremia was associated with better outcome. logistic regression analysis identified independent predictors of poor outcome (table ) . patients who underwent interventional radiological procedure treatment was shown to have better outcome. conclusions: hypernatremia after sah is associated with poor outcome. there does not appear to be significant evidence that hyponatremia has an effect on short-term mortality or certain outcome measures such as gos, and its longer-term effects are not well characterized. fig. note logarithmic transformation of los data). we found a statistically significant difference between the two groups when comparing the length of stay (p < . ). conclusions: dean et al demonstrated no significant difference in the mean length of stay using the same definitions of hypo and eunatraemia as in this study [ ] . even though our data appears to contradict their findings, regarding the statistical significance seen, we feel that this is not significant clinically, given the very similar median times for los between the two groups; the unbalanced design may contribute to the statistical significance. fig. (abstract p ) . length of stay between the two groups (note logarithmic scale for los) fig. (abstract p ). gos at months group consisted of patients with mean age . (sd . ) years and mean sodium . (sd . ) mmol/l with a median los of . (iqr . - . ) days. we found no statistically significant difference (p = . ) between the two groups when comparing the length of stay (fig. ) . conclusions: darmon et al demonstrated prognostic consequences of an admission sodium greater than , eliciting hypernatraemia as a factor independently associated with -day mortality [ ] . in contrast, our study suggests that hypernatraemia (as defined) is not associated with the length of stay, however this result is limited by the unbalanced design of this small study. introduction: our aim is to determine whether auscultation for bowel sounds helps in clinical decision making in icu patients with ileus. ileus can be the consequence of an operation, a side effect of drugs or the result of an obstruction requiring direct operative correction. although auscultation for bowel sounds is routinely performed in the icu and a well-established part of the physical examination in patients with suspected ileus, its clinical value remains largely unstudied. methods: a literature search of pubmed, embase and cochrane was performed to study the diagnostic value of auscultation for bowel sounds. results: auditory characteristics (tinkling, high pitched and rushes) were highly variable in postoperative ileus, mechanical ileus and healthy volunteers. the inter-observer variability for the assessment of the quantity, volume and pitch of bowel sounds was high, with a moderate interobserver agreement for discerning postoperative ileus, bowel obstruction and normal bowel sounds (kappa value . ). the intra-observer reliability of duplicated recordings for distinguishing between patients with normal bowels, obstructed bowels or postoperative ileus was % [ ] . no clear relation between bowel sounds and intestinal transit was found (table ) . sensitivity and positive predictive value were low: respectively % and % in healthy volunteers, % and % in obstructive ileus, and % and % in postoperative ileus ( table ) . conclusions: auscultation with the aim to differentiate normal from pathological bowel sounds is not useful in clinical practice. the low sensitivity and low positive predictive value together with a poor inter-and intra-observer agreement demonstrate the inaccuracy of utilizing bowel sounds for clinical decision-making. given the lack of evidence and standardization of auscultation, the critically ill patient is more likely to benefit from abdominal imaging. introduction: stress ulcer prophylaxis has become a standard of care in intensive care unit (icu). however, it has been proposed that enteral nutrition (en) could play preventive role for gastrointestinal bleeding and some studies revealed no added benefit of acid suppressive drugs to patients on en. based on these backgrounds, we use proton pump inhibitor (ppi) as stress ulcer prophylaxis during starvation period, and discontinue it within hours after commencing meals or en. the aim of this study is to evaluate the applicability of our protocol by reviewing the incidence of upper gastrointestinal bleeding (ugib) in our icu. methods: we conducted a retrospective observational study. all consecutive patients admitted to our icu between april and march were reviewed. patients who had ugib within hours after admission, had previous total gastrectomy, or underwent upper gastrointestinal surgery were excluded. the primary outcome was the incidence of overt or clinically important ugib, and the secondary outcome was protocol adherence. we presented descriptive data as number (percentage) and median (interquartile range). results: a total of patients were included. of those, ( . %) were male, median age was ( - ), and median sofa score was ( ) ( ) ( ) ( ) ( ) ( ) ( ) . of all patients, ( . %) had overt bleeding, and ( . %) had clinically important bleeding. both patients who introduction: patients requiring operative procedures admitted under non-surgical specialties typically experience delays in treatment and fail to meet peri-operative standards with regards to the timing of operative intervention. patients admitted from medicine requiring an emergency laparotomy have an increased mortality when compared to those patients admitted from surgery ( . % v . %) [ ] . methods: we undertook a retrospective case note review of patients requiring a non-elective laparotomy at our hospital during a sixmonth period in . patients were identified using the emergency theatre booking system. data were gathered on admission details, peri-operative care and post-operative stay. results: two main investigators reviewed patients to standardise data extraction. six patients presenting with inflammatory bowel disease were excluded from analysis. most patients ( . %) were admitted through the emergency department; ( . %) of whom were initially admitted under medicine, with only . % of these reviewed by a senior clinician prior to admission (table ). there was no statistically significant difference in mortality between the medicine and surgery groups. there was a trend to increased length of stay in icu and in hospital in the medical group (table ) . conclusions: lack of senior decision making may have a direct impact on patient care due to the inappropriate streaming of patients to medicine. the increased mean length of stay in those patients admitted to medicine may reflect a delay in surgical intervention and therefore a prolonged recovery period. we are introducing an acute abdominal pain screening and immediate action tool to improve identification of these high-risk patients and early involvement of senior decision makers. introduction: biomarkers reflecting the extent of surgical tissue trauma should be investigated in an effort to predict and prevent postoperative complications. the aim of the present study was to investigate blood concentrations of selected alarmins in patients after colorectal surgery in comparison to healthy individuals. the secondary aim was to analyze the relationship between alarmins and inflammatory biomarkers during early postoperative period. methods: the prospective, single-center, observational study consisted of non-surgical (ns) group (n= ) and surgical (s) group (n= ) undergoing colorectal surgery. serum levels of selected alarmins (s a and s a ) and inflammatory biomarkers (leukocytes; c-reactive protein, crp; interleukin- , il- ) were analyzed. results: proteins s a an s a had significantly higher serum values in the s-group during all three days after the surgery. the multidimensional model taking into account age, sex, weight, group and days revealed significant differences between study groups for both proteins s a and s a (p< . , p= . , respectively). biomarkers (leukocytes, crp, and il- ) showed significant differences between study subgroups (p< . , p< . , and p< . , respectively). in s-group, moderate positive correlations were found between s a and all biomarkers: leukocytes (r= . ), crp (r= . ), and il- (r= . ). s a had moderate positive correlation with leukocytes (r= . ). levels of s a also positively correlated with intensive care unit and hospital length of stay (r= . , r= . , respectively) conclusions: protein s a might be considered as early biomarker of first wave of immune activation elicited by surgical injury after colorectal surgery. the increase of the alarmins is reflected by the elevation of routine inflammatory biomarkers. introduction: critical illness-induced liver test abnormalities are associated with complications and death in adult icu patients, but remain poorly characterized in the pediatric icu (picu). in the pepanic rct, delaying initiation of parenteral nutrition to beyond day (late pn) was clinically superior to providing pn within h (early pn), but resulted in a higher rise in bilirubin. we aimed to document prevalence and prognostic value of abnormal liver tests and the impact of withholding early pn in the picu. methods: we performed a preplanned secondary analysis of of the pepanic patients aged days to years, as neonatal jaundice was considered a confounder. plasma concentrations of total bilirubin, alt, ast, γ gt, alp were measured systematically during picu stay. analyses were adjusted for baseline characteristics including severity of illness. results: during the first picu days, the prevalence of cholestasis (> mg/dl bilirubin) ranged between . %- . % and of hypoxic hepatitis (>= -fold uln for alt and ast) between . %- . %, both unaffected by the use of pn. throughout the first week in picu plasma bilirubin concentrations were higher in late pn patients (p< . ), but became comparable to early pn patients as soon as pn was started on day . plasma concentrations of γ gt, alp, alt and ast were unaffected by pn. high day plasma concentrations of γ gt, alt and ast (p<= . ), but not alp, were independent risk factors for picu mortality. day plasma bilirubin concentrations displayed a ushaped association with picu mortality, with higher mortality associated with bilirubin concentrations < . mg/dl and > . mg/dl (p<= . ). conclusions: in conclusion, overt cholestasis and hypoxic hepatitis were rare and unrelated to nutritional strategy. however, accepting a large macronutrient deficit during week increased plasma bilirubin. a mild elevation of bilirubin on the first picu-day was associated with lower risk of death and may represent an adaptive stress response rather than true cholestasis. positive fluid balance is an independent risk factor for intensive care unit mortality in patients with acute-on-chronic liver failure introduction: muscle wasting is a common consequence of disuse and inflammation during admission to intensive care with critical illness. limb muscles are known to decrease in size during critical illness, but less is known about muscles of the trunk. in this study, we tracked how psoas muscle area changes at multiple levels, in a group of patients with acute severe pancreatitis. methods: paired computed tomography (ct) scans were obtained from patients admitted to the royal liverpool university hospital's icu with acute severe pancreatitis. the first scan was within days of admission, and the second took place between to days later. for each scan, three slices were identified: the top and bottom plates of l , and the mid-point of l vertebral body. on each slice, the cross sectional area (csa) of the left and right psoas muscle was calculated using imagej. the difference and percentage change in csa between both scans was calculated. white cell counts and c-reactive protein results were obtained, with peak levels correlated against change in muscle size. results: combined csa of the left and right psoas muscle increased from top to bottom plates and was positively correlated with height (r= . , p< . mid l level)) and weight (r= . , p= . , mid l level) at all three levels. at all three levels, there were significant losses of csa between the two scans (see table ). crp was moderately correlated with percentage change in csa (r= - . , p= . ). increasing weight on admission was associated with greater percentage losses in csa (r= - . , p< . ). wcc did not correlate with change in size. in critically ill patients with acute severe pancreatitis, there are significant losses in both psoas muscles throughout the l level. further prospective studies are required to determine if inflammatory markers and cytokines have a role in these losses, and to determine the functional effects of these losses. introduction: the evidence for penta-therapy for hyperlipidemic severe acute pancreatitis (hl-sap) is anecdotal. the purpose of our study is to evaluate the efficacy of penta-therapy for hl-sap in a retrospective study. methods: retrospective study between january and december in a hospital intensive care unit.hl-sap patients were assigned to conventional treatment alone (the control group) or conventional treatment with the experimental protocol (the penta-therapy group) consists of blood purification, antihyperlipidemic agents, lowmolecular-weight heparin, insulin, covering the whole abdomen with pixiao (a traditional chinese medicine).serum triglyceride, serum calcium, apache ii score, sofa score, ranson score, ct severity index, and other serum biomarkers were evaluated. the hospital length of stay, local complications, systematic complications, rate of recurrence, overall mortality, and operation rate were considered clinical outcomes. results: hl-sap patients received conventional treatment alone (the control group) and patients underwent penta-therapy combined with conventional treatment (the penta-therapy group). serum amylase, serum triglyceride, white blood cell count, c -reactive protein, and blood sugar were significantly reduced, while serum calcium was significantly increased with penta-therapy. the changes in serum amylase, serum calcium were significantly different between the penta-therapy and control group on th day after the initiation of treatment. the reduction in serum triglyceride in the pentatherapy group on the second day and th day were greater than the control group. patients in the penta-therapy group had a significantly shorter length of hospital stay. conclusions: this study suggests that the addition of penta-therapy to conventional treatment for hl-sap may be superior to conventional treatment alone for improvement of serum biomarkers and clinical outcomes. average energy expenditure (ee) for all patients was ± kcal/kg (mean ± sd). there was no difference in the average ee between the patients who survived and those who died: ± and ± kcal/ kg (mean ± sd) respectively (p > . ). however, there was a negative correlation between ee and saps score in the non-survivors groupcorrelation coefficient - . , p < . . the energy deficit (computed by subtracting caloric intake from ee measurement) was similar among survivors and non-survivors, . ± vs . ± kcal/kg, respectively (mean ± sd) (p > . ). the patients who survived had received ± kcal/kg while those who died - ± kcal/kg (mean ± sd) (p > . ). the provision of protein was also similar for both groups: . ± . g/kg for survivors and ± . g/kg for nonsurvivors (mean ± sd) (p > . ). there was no statistically significant correlation between provision of calories and protein and outcomes such as length of hospital and icu stay or duration of mechanical ventilation. conclusions: average energy expenditure in critically ill patients with acute severe pancreatitis roughly equals to aspen estimation of kcal/kg and does not differ among survivors and non-survivors. outcomes such as survival, length of hospital and icu stay and duration of mechanical ventilation were unaffected by caloric nor protein provision in this sample. introduction: disturbances in gastrointestinal motility are common in critically ill patients receiving enteral nutrition. slow gastric emptying (ge) is the leading cause of enteral feeding intolerance (efi), which compromises nutritional status and is associated with increased morbidity and mortality. this phase a study evaluated the efficacy, safety and tolerability of acute tak- (previously td- ), a selective agonist of the hydroxytryptamine receptor ( ht ), compared with metoclopramide in critically ill patients with efi. methods: this was a double-blinded, double-dummy study conducted in mechanically ventilated patients with efi (> ml gastric residual volume) randomized to receive either intervention (tak- . mg over hour and . % saline ml injection qid) or control ( . % saline over hour and metoclopramide mg injection qid). within hour of the first dose, patients received a test meal of ml ensure® and ge was measured using scintigraphy. primary objectives were to evaluate the safety and tolerability of tak- and its effect on ge (% retention at mins) vs control. results: a total of patients (intervention, n = ; control, n = ) were studied. the median ages were and years in these groups, respectively. post-treatment, a -fold greater number of patients had normal gastric retention (< % at mins) in the intervention group vs the control group ( vs ; fig. ). in the intervention and control groups, (table ) . no aes led to treatment discontinuation. conclusions: a greater proportion of patients receiving tak- had normal gastric retention after a single dose compared with those receiving metoclopramide. treatment with tak- was not associated with an increase in aes. these results support further evaluation of tak- in critically ill patients with efi. method to assess gastric emptying in the fed state in enterally tube fed patients: comparison of the paracetamol absorption test to scintigraphy j james introduction: the paracetamol absorption test (pat) is the most common and practical approach for assessing gastric emptying (ge) in critically ill patients. however, current methods require that paracetamol be administered to an empty stomach, removing gastric contents and depriving patients of feeding for several hours. the objective of this study was to develop methods to assess gastric emptying in these patients without interrupting feeding. methods: gastric emptying was assessed in the fed state using pat and scintigraphy in healthy volunteers. paracetamol g in ml was ingested immediately before consumption of a test meal of ml ensure plus containing kcal, . g protein, and . g fat plus mbq of mtc-dpta as a scintigraphic agent. comparisons were made between paracetamol absorption and the time to % and % gastric emptying by scintigraphy at baseline and after administration of ulimorelin μg/ kg, a prokinetic agent known to enhance gastric emptying. blood samples for paracetamol were collected for up to h post administration. values for normal gastric emptying were based on the % confidence intervals for pk parameters. sensitivity and specificity were assessed by receiver operating characteristic (roc) analysis before and after treatment. results: the pat correlated with scintigraphy and pk parameters for normal emptying were determined. cmax and auc were the most sensitive and specific parameters for assessing ge with lowest variability and areas under the roc curve of . and . , respectively. a h sampling period appeared sufficient to distinguish normal from abnormal emptying. conclusions: the pat can be used to distinguish normal versus abnormal ge in the fed state. under the conditions used, patients can receive up to ml enteral feeding over a h test period ( ml/hr). this method can be used to distinguish normal from abnormal gastric emptying in enterally tube fed patients without interrupting feedings. introduction: for mechanically ventillated critically ill patients, the effect of full feeding on mortality is stil controversial. we aimed to investigate the relationship of energy intakes with -day mortality, and nutritional risk status influenced this relationship. methods: this prospective observational study was conducted among adult patients admitted to icu and required invasive mechanical ventilation (imv) for more than h. data on baseline characteristics and the modified nutritional risk in critically ill [mnutric] score was collected on day . energy intake and nutritional adequacy was recorded daily until death, discarge or until twelfth evaluable days. patients were divided into groups: a)received < % of prescribed energy b) received >= % of prescribed energy. results: patients ( % male, mean age . ± . years, mean body mass index . ± . kg/m , mean mnutricscore . ± . ) were included. in the univariate analysis, mnutrİc score was associated with -day mortality. in the multivariable logistic regregression analysis, mnutric score(odds ratio, or . , ci . - . , p < o.oo ) was associated with -day mortality. nutritional adequacy was assessed, median nutritional adequacy was . ( . - . ). in patients with high mnutrİc score ( - ), received >= % of prescribed energy was associated with a lower predicted -day mortality; this was not observed in patients with low mnutrİc score ( - ). conclusions: nearly % of imv required patients admitted to icu were at nutritional risk, mnutrİc score is associated with -day mortality. energy adequacy of >= % of prescribed amounts were associated with decreased mortality in patients with a high mnutrİc score. results: patients included in the study were asa iv. four patients died in the first few days after surgery ( ÷ days). mean length of stay in icu was . ± . days. univariate analysis showed a correlation between hypoalbuminemia and the onset of mof (p = . ); reduction of the lymphocyte count and risk of mof (p = . ). sofa score showed a significant correlation with occurrence of pneumonia (p = . ) and mof (p = . ). including the -day mortality among confounders, albumin and lymphocyte count were the strongest predictors of mof. length of stay in icu and ventilation days did not have statistical significance. bmi showed no predictive value of any outcome. conclusions: our sample was poor but results of our study seem to indicate malnutrition as an independent risk factor for elderly patients undergoing emergency surgery. early multidisciplinairy screening of dysphagia at admission to the emergency departmenta pilot study d melgaard, l sørensen, d sandager, a christensen, a jørgensen, m ludwig, p leutscher north denmark regional hospital, hjørring, denmark critical care , (suppl ):p introduction: dysphagia increase the risk of aspiration pneumonia, malnutrition, dehydration and death. this combined with the fact that patients with dysphagia have a longer stay in the hospital makes early prognosis and appropriate treatment important. knowledge about effect of early dysphagia screening is limited. the aim of this study is to examine the prevalence of dysphagia in the emergency department (ed) population. methods: this study included consecutively hospitalized patients in days from pm- pm at the ed of north denmark regional hospital. the screening took place within hours of admission. inclusion criteria were any of the following: age ≥ years, neurological disorders, alcoholism, copd, pneumonia, dyspnoea, diabetes or unexplained weight loss. a nurse screened patients with a water test and with signs of dysphagia tested by an occupational therapist with the v-vst and the meof-ii. results: of eligible patients ( % male, median age years) ( %) were screened. it was impossible to screen patients ( %) to limited time and patients ( %) due to poor health condition and patients ( %) declined participation. the prevalence of dysphagia in the study population was % ( patients). results from the water test were confirmed with v-vst and meof-ii. in patients with lung related diseases or circulatory diseases was the prevalence respectively % and %. patients, not screened due to poor health condition, were tested during hospitalisation and the prevalence of dysphagia was % in this group of patients. conclusions: the prevalence in ed patients was %. patients transferred to other departments due to poor health condition had a prevalence of %. it is possible to screen patients in the ed. the water test is a useful screening tool in an acute setting. introduction: to improve protein and energy delivery in a nutrition delivery bundle was introduced to a level icu. greater protein and energy intake is associated with improved outcomes in the critically ill [ ] [ ] [ ] [ ] , but only % of prescribed protein and energy is delivered in icus worldwide [ , ] . methods: percentage of target protein and energy delivery was measured via participation in the international nutrition survey (ins) before and after a "nutrition delivery bundle" was introduced by the icu dietitian. the nutrition delivery bundle involved all stakeholders in icu nutrition care (fig. ) and included the following quality improvement measures: increased icu dietetic staffing, update of icu enteral feeding protocol with staff education, use of higher protein formulations, earlier patient nutrition assessment, daily calculation of percentage nutrition delivery, increased nutrition communication through more regular discussion of patient care with medical team, expansion of choice of nasojejunal tube available, monthly reporting of key nutrition performance indicators, improved resources for cover dietitian(s) when icu dietitian on leave (fig. ) . results: prior to a nutrition delivery bundle being introduced the mater misericordiae university hospital (mmuh) icu achieved % of protein and % of energy targets over the first admission days of consecutive mechanically ventilated patients in icu > hrs enrolled in the international nutrition survey. this increased to % of protein and % of energy targets in (table ) . conclusions: a % improvement in protein and energy delivery to critically ill patients was seen after the introduction of a dietitian-led nutrition delivery bundle. introduction: the critically ill polytrauma patient with sepsis presents with variable energetic necessities characterized by a proinflammatory, pro-oxidative and hypermetabolic status. one of the challenges the icu doctor faces is adapting the nutritional therapy based on the individual needs of each patient. through this paper we wish to highlight the trend of energy needs in the case of critically ill polytrauma patients with sepsis by using non-invasive monitoring of respiratory gases based on indirect calorimetry (ge healthcare, helsinki, finland). methods: this is a prospective observational study carried out in the anesthesia and intensive care unit "casa austria", emergency county hospital "pius brinzeu", timisoara, romania. we monitored vo , vco , energy demand (ed), and specific clinical and paraclinical data. we measured energy demand values monitored by direct calorimetry with values calculated based on standard formulas. results: values have been recorded in the study. the mean vo was . ± . ml/min/kg, the mean vco was . ± . ml/min/kg. in regard with energy demand, the mean ed obtained through direct calorimetry was . ± . kcal/day, and those obtained by using mathematic formulas were . ± kcal/day (p < . ). moreover, statistically significant differences have been observed regarding the mean difference between energy demand determined using indirect calorimetry and that determined mathematically, respectively between the enteral and parenteral administered ed. conclusions: continuous monitoring of the energy demand in critically ill patients with sepsis can bring important benefits in regard with the clinical prognosis of these patients through the individualization and adaption of intensive therapy for each patient. introduction: cachexia is defined as a complex metabolic syndrome associated with underlying illness, characterized by loss of muscle with or without loss of fat. in cancer cachexia, reduction in muscle size has been demonstrated to be an independent risk factor for mortality. loss of muscle in icu patients is rapid and extensive and is also associated with mortality risk, but methods to measure muscle mass in these patients are lacking. surrogate methods (dexa, ct, ultrasound, total body water) do not measure muscle mass directly methods: the d -creatine (d -cr) dilution method takes advantage of the fact that % of cr is found in muscle and that muscle mass can be assessed by cr pool size. cr is transported into muscle against a concentration gradient and irreversibly converted to creatinine (crn), which is excreted in urine. a single oral dose of d -cr is transported to skeletal muscle, and measurement of d -crn enrichment in a spot urine sample provides an accurate estimate of skeletal muscle mass. results: the method has been validated in preclinical and clinical studies; in a large longitudinal observation study in older men, d -cr muscle mass was strongly associated with habitual walking speed, risk of falls, and incident mobility limitation; dexa failed to show these relationships. the d -cr method is being used in a nicu study to measure changes in muscle mass in neonates (gates foundation grant). further, this method has been incorporated into a trial assessing the treatment effects of a ghrelin agonist in icu patients with enteral feeding intolerance (nct ). in this trial, the d -cr dose is delivered intravenously and a spot urine sample is collected at baseline and postdose. conclusions: the d -cr method provides a non-invasive, accurate way to assess therapeutic agents that may mitigate the loss of skeletal muscle mass; it is of particular utility in clinical settings where changes in muscle mass are consequential, such as muscle loss during an icu admission. introduction: vitamin c, an enzyme cofactor and antioxidant, could hasten the resolution of inflammation, which affects most intensive care unit (icu) patients. while many observational studies have demonstrated that critical illness is associated with low levels of vitamin c, randomized controlled trials (rcts) of high-dose vitamin c, alone or in combination with other antioxidants, yielded contradicting results. the purpose of this systematic review and meta-analysis is to evaluate the clinical effects of vitamin c when administered to various populations of icu patients. methods: eligible trials: rcts comparing vitamin c, by enteral or parenteral routes, to placebo in icu patients. data collection and analysis: we searched medline, embase, and the cochrane central register of controlled trials. after assessing eligibility, data was abstracted in duplicate by two independent reviewers. overall mortality was the primary outcome; secondary outcomes were infections, icu length of stay (los), hospital los, and ventilator days. pre-specified subgroup analyses were conducted to identify more beneficial treatment effects. results: pooling rcts (n= ) reporting mortality, vitamin c was not associated with a lower risk of mortality (risk ratio [rr]: . , % confidence interval [ci]: . - . , p= . , i = %). in a subgroup analysis, trials of lower quality (n= ) were associated with a reduction in mortality (rr . , % ci . , . , p= . ), whereas high quality trials (n= ) were not. no statistical difference existed between subgroups (p= . ). in addition, no effect was found on infections, icu or hospital length of stay, and ventilator days. conclusions: current evidence does not support the hypothesis that vitamin c supplementation improves clinical outcomes of icu patients. introduction: the protein intake for patients who met adequacy for energy was assessed within our cardiothoracic intensive care. nutritional support should aim to provide at least % of calorie requirements to achieve nutritional adequacy with suggested protein requirements of . - g/kg/day [ ] . guidelines highlight the difficulty achieving the correct protein:energy ratio from nutritional support to meet this target especially in the obese population. methods: the audit was registered with clinical governance. data was collected prospectively from patients requiring tube feeding for three or more days from january -october (table ). data included type and volume of feed and calories from other sources. patients who met adequacy for energy (fig. ) introduction: patients admitted to the intensive care unit (icu) are usually at high risk of malnutrition [ , ] . the purpose of our study was to compare the accuracy of nutric score, nrs and sga in predicting los-icu, los-hosp and in-hospital mortality. methods: a total of consecutive patients admitted between march to june in a mixed (medical/surgical) icu were assessed on day of admission using the three screening tools to classify them into high-risk and low-risk of malnutrition. day apache scores and demographic data were recorded. los-icu, los-hosp inhospital mortality and secondary outcomes studied were need for supplemental nutritional support, need for ventilation and need for dialysis in high-risk and low-risk patients by each nutrition assessment tool. results: of the patients studied, ( . %) were males and ( . %) were females. . % males and . % females were found to be at a high risk of malnutrition by at least one of the scores. the mean apache score for patients at high risk (using any one screening tool) was . (sd . ) and . for the low risk group (sd . ; p < . ). the nrs and sga demonstrated statistically significant correlation(p= . ) for length of icu stay for both the high risk and low risk group whereas only the nrs correlated significantly for the length of hospital stay(p= . ). mortality was significantly higher in high risk patients identified using all scores. conclusions: there was a wide difference in the percent of patients identified as high-risk using each of the scores. introduction: nitrogen balance (nb) may be an important tool in the nutritional management of critically ill patients. cancer patients present a special challenge regarding nutrition, due to its peculiar characteristics related to neoplasia and adjuvant treatments. objectives: to evaluate nb in patients with solid cancer in the postoperative period in the icu, analyzing the correlation between nb and the mortality outcome in the icu. methods: retrospective cohort study. we evaluated adult patients (> years) admitted to the icus of two different hospitals, with diagnosis of current cancer in postoperative period (elective or emergency surgeries). patients were excluded if the diagnosis of cancer was not confirmed. nb (measured through analysis of dietary protein intake subtracted from -hour urinary urea plus an estimate of nonurinary losses) was calculated on the st, rd and th icu day. nb was measured only while the patient was in the icu. results: during the study period, patients were included (mean age . , mean apache . , . % male). admission apache ii and abdominal-site surgery were predictors of mortality. the nb of all patients was negative on the st icu day. in the patients who survived, nb of the rd and th day remained stable (negative), whereas in patients who died nb was more positive (fig. ) . there was no difference in the amount of protein ingested on the st day between survivors and deceased patients. conclusions: among adult patients with solid cancer in the postoperative period in the icu, nb was persistently negative in the survivors between st and th icu day, but among the patients who died nb tended to be more positive on the rd day. nb monitoring could allow a more adequate individualization of nutritional management in this group of patients. fig. (abstract p ) . nitrogen balance in st, rd and th icu day introduction: nutritional therapy plays an important role in the treatment of critically ill patients. caloric and protein goals are defined, and artificial nutrition tailored to the targets which are related to outcome [ ] . questions rise about the mean caloric and protein needs of patients, once discharged from icu, and the evolution of body weight, and nutritional adequacy. the aim is to know the ratios between caloric needs and intake of patients with a minimum stay at icu of days. methods: after evaluation of critically ill patients, patients were prospectively followed during their entire hospitalization. data concerning nutritional needs, prescriptions and delivery were collected from the electronic medical file. nutritional calculations of oral intake were done by nubel. ratios were made during the entire stay and body weight was followed up. results: in female and male patients, median age . years (range - year), estimated body weight of . ± kg and actual body weight of . ± kg, a mean caloric need of ± kcal/ day and an effective delivery of ± kcal/day was observed. body weight increased in two patients and decreased in ( %). in ten out of twelve patients, underfeeding was present. one patient with a caloric need of kcal/day received a mean caloric load of kcal/day ( . %). conclusions: the overall observed evolution in body weight was negative in most of the patients. nutritional adequacy was low after icu discharge and never reached target. introduction: severe burn injury can create a rapid-onset, sustained proinflammatory condition that can severely impair all major organs. this massive systemic response has been documented clinically by associated biomarker measurements including dramatic elevations in cytokines such as il- . the severity of multi-organ injury and subsequent development of other systemic complications in burn patients have been well-correlated with il- levels, including the increased risk of sepsis/multi-organ failure and associated morbidity and mortality. considering that estrogen is a powerful and easy to use anti-inflammatory agent, an experimental burn model was created to test the potential value of parenteral β-estradiol (e ) as a feasible and inexpensive early intervention to mitigate the the profound pro-inflammatory response associated with severe thermal injury. methods: male rats (n = ) were assigned randomly into three groups: ) controls/no burn (n = ); ) burn/placebo (n = ); and ) burn/e (n = ). burned rats received a % °tbsa dorsal burn, fluid resuscitation and one dose of e or placebo ( . mg/kg intra-peritoneal) minutes post-burn. eight animals from each of the two burn groups (burn/placebo and burn/e ) were sacrificed at minutes (sham group at days only), with four each of the two burn groups sacrificed at days. tissue samples from major organs and serum were obtained and analyzed by elisa for il- at each of these intervals. results: in the burned rats, β-estradiol decreased the organ levels of il- significantly as measured at both early ( min.) and late ( day) phases post-burn (figs. & . also, sham animal levels were comparable to the estradiol group, conclusions: experimentally, a single, early post-burn dose of estrogen significantly mitigates the associated detrimental inflammatory response in all major organs up to days. in turn, this may present a promising potential therapy to decrease the widespread multipleorgan dysfunction seen in severe burn injury patients. early, single-dose estrogen increases levels of brain-derived neurotrophic factor (bdnf), a neurotrophin for neuronal survival and neurogenesis following indirect brain inflammation caused by severe torso burns introduction: prior studies have found that patients with severe burns may suffer significant neurocognitive changes. while frequently attributed to psycho-social issues, we have found a substantial, rapid and sustained ( min - day) increase in rat brain inflammatory markers (for example, il- ) following remote torso burns that is blunted by a single post-burn dose of estrogen. brain-derived neurotrophic factor (bdnf), one of the most active neurotrophins, protects existing neurons and encourages the growth and differentiation of new neurons and synapses. as estrogens not only blunt inflammation but also exert an influence on cns growth factors, we hypothesized that β-estradiol (e ) might affect levels of bdnf in the post-burn rat brain. methods: male rats (n = ) were assigned randomly into three groups: controls/no burn (n = ); burn/placebo (n = ); and burn/e (n = ). burned rats received a % °tbsa dorsal burn, fluid resuscitation and one dose of e or placebo ( . mg/ kg intraperitoneally) minutes post-burn. eight animals from each of the two burn groups (burn/placebo and burn/e ) were sacrificed at hours and at days, respectively (sham group at days only), with four each of the two burn groups sacrificed at days. brain tissue samples were analyzed by elisa for bdnf. results: mean levels of bdnf were significantly elevated within hours and continued to increase up to days post-injury in burned animals receiving the β-estradiol (> pcg/mg) as compared with the placebo-treated burned animals (< pg/mg) and controls (< . pcg/mg). see fig. . conclusions: early, single-dose estrogen administration following remote severe burn injury significantly elevated levels of bdnf in brain tissue. this finding may represent an extremely novel and important pathway to enhance both neuroprotection and neuroregeneration in burn patients. the value of cortisol in patients with the infection and multiple organ dysfunction. s tachyla, a marochkov mogilev regional hospital, mogilev, belarus critical care , (suppl ):p introduction: hormones changes in patients with infection and multiple organ dysfunction is a topic that hasn't been adequately studied. goal of study: to establish the value of cortisol in patients with infection and multiple organ dysfunction. methods: after approval the ethics committee of the mogilev regional hospital a prospective observational study was performed. the study included patients aged to years. all patients were hospitalized in the intensive care unit with the infection and multiple organ dysfunction. patients with endocrine diseases and receiving glucocorticoids were excluded. cortisol levels were measured on admission and during the course of treatment by radioimmunoassay. in group l (n = ) patients had a low levels of cortisol, in the m group (n = ) -normal cortisol, in group h (n = ) -high cortisol. results: cortisol level was in l-group . ( . , . ) nmol/l, in mgroup . ( . ; . ) nmol/l, in h-group . ( , ; . ) nmol/l. it is found that the mortality was higher in the groups l - . % (p = . ) and h - . % (p = . ), than in the m-group - . %. the mgroup odds ratio equals . at % confidence interval . - . when compared with the h-group. in the m-group in survivors patients (n = ) showed a decrease cortisol with ( . , . ) nmol/l to . ( . , . ) nmol/l (p = . ). while the no survivors patients (n = ) showed increase cortisol with ( . , . ) nmol/l to . ( ; ) nmol/l (p = . ). thus itself cortisol level is not a marker of mortality. receiver operating curve analysis for cortisol was performed: area under the curve equals . at % confidence interval of . - . (p = . ), sensitivity . %, specificity . %. conclusions: in patients with infection and multiple organ dysfunction may be observed disorders in cortisol levels. these disorders require correction to prevent the increased mortality. introduction: the hypothalamic-pituitary-adrenal (hpa) axis is a key regulator of critical illness. cortisol and adreno-corticotrophic hormone (acth) are pulsatile, which emerges from the feed forwardfeedback of the two hormones [ ] . different genes are activated by continuous or pulsatile activation of the glucocorticoid receptor, even when the total amount is the same [ ] . we aimed to characterise the acth and cortisol profiles of patients who were critically ill after cardiac surgery and assess the impact of inflammatory mediators on serum cortisol concentrations. methods: patients with > organ system failure, > days after cardiac surgery were recruited. total cortisol was assayed every min, acth every hour and il , il , il , il , il , tnf-α every hours. cortisol binding globulin (cbg) was assayed at and hrs. the relationship between cortisol and the inflammatory mediators was quantified in individual patients using a mixed regression model. results: all profiles showed pulsatility of both cortisol and acth and there was concordance between the two hormones (see fig. ). one patient died after hours (see fig. ). this patient lost pulsatility and concordance of cortisol and acth. mean cbg was . μ g/ml at the start of sampling and . μ g/ml at the end. there was an association between il (p= . ), il (p< . ), il (p= . ) and serum cortisol levels. there was no association between the other mediators and cortisol. conclusions: cortisol and acth are both pulsatile in critical illness. because pulsatility emerges from the interaction between the two hormones[ ]the premise of a 'disconnect' between the pituitary and adrenal gland is refuted. il , il and il may have roles in the control of cortisol during critical illness. introduction: elevation in plasma cortisol is a vital response to sepsis and partially brought about by reduced cortisol breakdown in which bile acids (bas) may play a role. vice versa, cortisol can also upregulate bas. we hypothesized a central role for the hepatic glucocorticoid receptor (hgr) in cortisol and ba homeostasis and in survival from sepsis. methods: in a mouse model of sepsis, we documented hgr expression and investigated the impact of hepatocyte-specific shrnaknockdown of gr on markers of corticosterone (cort), ba and glucose homeostasis, inflammation and survival. we also compared hgr expression in human septic icu and elective surgery patients. results: in mice, sepsis reduced hgr expression with % (p= . ), elevated plasma cort, bas and glucose and suppressed a-ringreductases. also in human patients, sepsis reduced hgr expression (p< . ), further suppressed by treatment with steroids (p= . ). in septic mice, further and sustained hgr-inhibition increased mortality from % to % (p< . ). at h, hgr-inhibition prevented the rise in total plasma cort, but did not affect a-ring-reductases expression. however, it further reduced cort binding proteins, resulting in elevated free cort equal to septic mice without modified hgr. after days of hgr-inhibition in sepsis, total and free cort were comparable to septic mice without modified hgr, now explained by further reduced a-ring-reductase expression, possibly driven by higher hepatic ba content. hgr-inhibition blunted the hyperglycemic sepsis response without causing hypoglycemia, markedly increased hepatic and circulating inflammation markers and caused liver destruction (p< . ), the severity of which explained increased mortality. conclusions: in conclusion, sepsis partially suppressed hgr expression, which appears to upregulate free cort availability via lowered cort binding proteins and a-ring-reductases. however, further sustained hgr suppression evoked lethal excessive liver and systemic inflammation, independent of cort availability. introduction: cortisol levels have been found to be increased in sepsis patients, and high cortisol levels have been correlated with increased mortality. the purpose of this project is to assess the association of plasma cortisol levels with severity of coagulopathy in a population of patients with sepsis and clinically confirmed dic. methods: citrated, de-identified plasma samples were collected from adults with sepsis and suspected dic at the time of icu admission. platelet count was determined as part of standard clinical practice. pt/inr and fibrinogen were measured using standard techniques on the acl-elite coagulation analyzer. cortisol, d-dimer, pai- , cd l, nlrp , and microparticles were measured using commercially available elisa kits and were performed. dic score was calculated using isth scoring algorithm. results: cortisol showed significant variation based on dic status (kruskal-wallis anova, p < . ). patients with non-overt dic and overt dic exhibited significantly elevated cortisol levels compared to healthy controls (p < . for both groups). cortisol levels showed dic based variations. patients with sepsis and overt dic had elevated cortisol compared to patients with sepsis and no dic (p = . ) (fig. ) . correlations were evaluated between cortisol and hemostatic markers platelets, fibrinogen, inr, d-dimer, and pai- as well as with the inflammatory marker, nlrp and the platelet markers cd l and microparticles. cortisol conclusions: cortisol showed a significant association with hemostatic status in a population of patients with sepsis and welldefined coagulopathy. cortisol levels were significantly elevated in patients with overt or non-overt dic compared to healthy individuals and in patients with overt dic compared to those with sepsis without dic. introduction: in most cases presenting with hypoglycemia in emergency departments (eds), the etiology of the hypoglycemia is almost identified. however, about % of cases, the etiology of hypoglycemia cannot be determined. methods: this is a -year prospective observational study. a total of patients were transported to our ed with hypoglycemia. after the investigation, a rapid acth loading test (synthetic - acth μg iv.) was performed on patients with unexplained hypoglycemia; i.e., μg acth was administered intravenously and blood specimens were collected before loading, at min and min after acth administration. we adopted a peak serum cortisol level < μg/dl or a delta cortisol of < μ g/dl for the diagnosis of adrenal insufficiency. results: among the patients, of ( . %) were using antidiabetic drugs, ( . %) were using hypoglycemia-relevant drugs, ( . %) suffered from digestive absorption failure including malnutrition, ( . %) had been consuming alcohol, ( . %) suffered from malignancy, and ( . %) suffered from insulin autoimmune syndrome. initially, an etiology was unknown in of ( . %) patients. rapid acth test revealed the adrenal insufficiency in ( . %) among them. administration of hydrocortisone in adrenal insufficiency patients promptly improved hypoglycemia. in those patients, serum sodium level was lower (na; vs. meq/l, p< . ) and serum potassium level was higher (k; . vs. . meq/l, p< . ) than in the other hypoglycemic patients, respectively. there was no significant difference in baseline plasma glucose level on ed between the groups of patients ( vs. mg/dl, p= . ). conclusions: the probability of adrenal insufficiency was much greater than that of the better-known insulinoma as a cause of hypoglycemia. when protracted hypoglycemia of unknown etiology is recognized, we recommend that the patient is checked for adrenal function using the rapid acth loading test. introduction: sepsis caused have showed serious alternations of thyroid hormones releasing, causing a nonthyroidal illness syndrome. the aim of the study was to measure thyroid hormone levels in septic patients and analyse its relation with clinical state and outcome. methods: prospective study in a cohort of consecutive septic patients. we studied thyrotropin (tsh), free triiodothyronine fraction (ft ) and free thyroxin fraction (ft ) serum levels, apache ii and sofa score. statistical analysis was performed using spss . . results: we analysed episodes of sepsis ( %) and septic shock (ssh) ( %), the median age of the patients was (inter-quartile range, . - ) years; the main sources of infection were: respiratory tract ( %) and intra-abdomen ( %); . % had medical diseases. apache ii score was [ - ], sofa score was [ . - ] and day mortality was . %. our data shown . % with low levels of tsh (< . uui/ml), . % had low levels of ft (< . ng/dl) and . % low levels of ft (< pg/ml). the tsh ( . vs. . uui/ml) and ft ( . vs . pg/ml) concentration of ssh group were significantly lower than those of sepsis group, whereas ft ( . vs . ng/dl) it was not statistically significantly. correlation of ft to apa-che ii (r = − . , p = . ) and sofa score (r = − . , p = . ). the profile of death patients were men ( . %, n = ), with significantly older ( vs. years; p= , ), as well as clinical severity scores, apache ii ( . vs. . ; p< . ) and sofa ( . vs . ; p< , ). non-survivors had significantly lower tsh . vs. . uui/ ml; p= . , and ft . vs. . pg/ml, p= . , however ft did not show statistical significance . vs. . ng/dl, p=ns. conclusions: conclusions: most of our septic patients present an altered thyroid function. our data suggest that tsh and specially ft may be used as a marker of disease severity and a mortality predictor. observational study to evaluate short and long-term bone metabolism alteration in critical patients. introduction: reduction of bone mineral density and/or muscle mass can be short and long-term complications in critical patients admitted in intensive care unit (icu). the study aims to evaluate, during a -month period, the following parameters: ) the alterations of bone metabolism and quantitative and qualitative parameters of bone tissue, ) the proportion of subjects with bone fragility, and ) the identification of specific risk factors. methods: an observational-longitudinal monocentric study is being conducted in adult patients hospitalized in icu. the evaluations performed at baseline, and month visits include analysis of biochemical and instrumental exams. results: a specific clinical-care pathway was created between bone metabolic diseases unit and icu, in order to perform specific anamnestic collection, biochemical analysis of bone metabolism, and instrumental exams. patients were enrolled and evaluated at the baseline visit. biochemical exams, performed within hours of hospitalization, showed that % (n: ) of subjects had a deficit of ohvitamind < ng/dl, associated with normal corrected serum calcium levels and of these % (n: ) had high pth levels. bone alkaline phosphatase was increased in % (n: ) of patients. conclusions: critical patients are "fragile" subjects, which should be monitored with a short and long-term follow-up. the creation of a clinical pathway that includes specialists of bone metabolism may be a virtuous way to identify patients who report bone mass loss and increased fracture risk. this study will allow to implement the knowledge regarding specific risk factors of bone fragility and the most appropriate therapeutic choices as prevention and treatment. a retrospective analysis of predictors for length of intensive care stay for patients admitted with diabetic ketoacidosis a fung, tl samuels, ae myers, pg morgan east surrey hospital, redhill, uk critical care , (suppl ):p introduction: diabetic ketoacidosis (dka) is one of the most common metabolic causes of admission to the intensive care unit (icu). the incidence of dka is quoted as between . - episodes per patients with diabetes mellitus (dm) [ ] . we aim to establish the factors that affect length of stay (los) on icu. methods: we undertook an analysis of patients admitted to icu over the last years with a primary diagnosis of dka. we assessed whether there was an association between the following factors and an increased length of icu stay: age, gender, body mass index (bmi), systolic blood pressure, heart rate, sodium, potassium, haemoglobin and ph. these factors were assessed using multiple linear backward stepwise regression. results: overall, admissions were identified over the time period from the ward watcher database. the median los was . days (iqr . - . ). our analysis demonstrated that length of icu stay (alpha level < . ) was significantly associated with bmi, low systolic blood pressure, and the presence of hyponatraemia or hypernatraemia. conclusions: we found the variables that affect the los for patients presenting to our unit with dka are bmi, elow systolic bp, low sodium and high sodium. we intend to extend this work to include survival analysis with the same subgroup of patients. maximal glycemic gap is the best glycemic variability index correlated to icu mortality in medical critically ill patients t issarawattna, r bhurayanontachai prince of songkla university, songkla, thailand critical care , (suppl ):p introduction: several evidences shown a correlation of glycemic variability (gv) and icu mortality. however, there have been no report of the correlation between various parameters of gv and mortality in medical icu patients. the aim was to determine the correlation between various parameters of gv and medical icu mortality, as well as, to identify the best gv index to predict icu mortality. methods: a retrospective chart review was then conducted in medical icu at songklanagarind hospital. the patient characteristics, causes of admission, apache ii, blood glucose within the first hours of icu admission and icu mortality were recorded. glycemic variability parameters including maximal glycemic gap, standard deviation, coefficient of variation and j-index of blood glucose were calculated. the correlation of those gv index to icu mortality was determined. the roc and auroc of each gv index were then compare to identify the best gv index to predict icu mortality. results: of patients, patients ( . %) were survived ( table ). all gv indexes were significantly higher in non-survival group (p < . ) ( table ). maximal glycemic gap was independently correlated to icu mortality and give a highest auroc compared to others gv. (maximal glycemic gap auroc . ( %ci . - . vs. coefficient of variation auroc . ( %ci . - . ) vs standard deviation auroc . ( %ci . - . ) vs j-index auroc . ( %ci . - . ), (p< . ) (fig. ) . conclusions: maximal glycemic gap independently correlated to icu mortality and was the best gv to predict icu mortality in medical critically ill patients. reliability of capillary blood glucose measurement for diabetic patients in emergency department h ben turkia, s souissi, a souayeh, i chermiti, f riahi, r jebri, b chatbri, m chkir regional hospital of ben arous, ben arous, tunisia critical care , (suppl ):p introduction: acute glycemic disorders should be early diagnosed and treated in emergency department (ed), especially hypoglycemia. can capillary blood glucose (cg) replace plasmatic glucose (pg). the objective of this study was to compare capillary blood glucose with venous blood glucose methods: patients with type diabetes were included. we realize a capillary blood glucose with a glucose meter (acu-check active-roche) and a concomitant determination of venous blood glucose with laboratory machine (synchrony cx delta system beckman coulter). a correlation study (pearson correlation) between the two measurements was evaluated and linear fitting equation was established. the concordance was checked with bland and altman method. results: during the months of the study, patients were included. the average age was +/- years old, with a sex ratio = . majority of patients ( %,n= ) had type diabetes and % was treated with insulin. we found an excellent correlation between the two techniques with a pearson correlation coefficient r= . .topredict the pg from cg, we can use this equation: pg(g/l)= . cg(g/l)+ . (r = . ; p= . ). we noticed a good concordance between the two techniques especially in case of hypoglycemia and moderate hyperglycemia (fig. ) . however, releases were noted with a pg higher than g/l. conclusions: in ed, the measurement of capillary glucose can exempt from venous blood glucose especially in case of hypoglycemia and moderate hyperglycemia. is frequently found in critically ill patients in icu, especially patients who are treated for a long time. this study aims to analyse the comparison between length of stay and dvt incidents in critically ill patients. methods: a cross-sectional study was employed. we include all patients who were years or older and were treated in icu of dr soetomo public hospital for at least days. data were collected from june until june . the patients were examined with sonosite usg to look for any thrombosis in iliac, femoral, popliteal, and tibial veins and well's criteria were also taken. results: thirty patients were included in this study. this study shows that length of stay is not the only risk factor for dvt in patients treated in icu. in our data, we found out that the length of treatment did not significantly cause dvt. other risk factors such as age and comorbidities in patients who are risk factors may support the incidence of dvt events. the diagnosis of dvt is enforced using an ultrasound performed by an expert in the use of ultrasound to locate thrombus in a vein. conclusions: length of treatment is not a significant risk factor for dvt. several other factors still need to be investigated in order for dvt events to be detected early and prevented. [ ] was used to retrospectively study trends and outcomes of cancer patients admitted to the icu between and . logistic regression analysis was performed to assess predictors of -day and -year mortality. results: out of , icu admissions, , hemato-oncological, , oncological and patients with both a hematologic and solid malignancy were analyzed. hematologic patients had higher critical illness scores, while oncological patients had similar apache-iii and sofa-scores. in the univariate analysis, cancer was strongly associated with mortality (or . , table ). over the -year study period, -day mortality of cancer patients decreased by % (fig. ) . this trend persisted after adjustment for covariates, with cancer patients having significantly higher mortality (or= . , %ci: . , . ). between and , the adjusted -day mortality decreased by % every year. over the decade, -year mortality decreased by %. having cancer was the strongest individual predictor of -year mortality in the multivariate model (or= . , %ci: . , . ) (fig. ) . conclusions: between and , the number of cancer patients admitted to the icu increased steadily and significantly, while longitudinal clinical severity scores remained overall unchanged. although hematological and oncological patients had higher mortality rates than patients without cancer, both -day and -year mortality decreased significantly over the study period. introduction: sepsis was redefined in with the introduction of an increase in sequential organ failure assessment Δsofa) score of >= and the quicksofa (qsofa) as screening tools for sepsisrelated mortality. however, the implementation of these criteria into clinical practice has been controversial and the applicability for hematological patients is unclear. methods: we therefore studied the diagnostic accuracy of different sepsis criteria for sepsis and mortality according to definition criteria in a retrospective analysis of hematological patients in an academic tertiary care hospital. patient characteristics and variables were collected in icuand non-icu patients to determine the systemic inflammatory response syndrome (sirs), Δsofa and qsofa. by applying the definition of sepsis as "life-threatening organ dysfunction caused by a dysregulated host response to infection" [ ] as reference, the scores were evaluated. in patients with sepsis who died, / were sirs-negative, / Δsofa-negative and / qsofa-negative ( fig. and table ). conclusions: in conclusion, these findings suggest that criteria proposed in the sepsis- definition might have limitations as screening fig. (abstract p ) . results of the logistic regression analysis for (a) -day and (b) -year mortality. all covariates were statistically significant except for white race in the -year mortality model. ***p-value< - , **p-value< . , *p-value< . fig. (abstract p ) . longitudinal change in -day mortality for cancer patients (yes) compared with controls (no) over the -year study period. mortality in the cancer group decreased from % to % (- %), while mortality in the control group decreased from to % (- %). enoxaparin pharmacokinetics in patients with augmented renal clearance, preliminary results of a single center study introduction: augmented renal clearance (arc) has being described in some groups of critically ill patients. the aim was to investigate the impact of arc on the pharmacokinetics of enoxaparin. methods: this is a prospective study in a surgical and medical intensive care unit (icu) carried out from august to november . patients < years old, under prophylactic treatment with enoxaparin and normal plasma creatinine, were included. anti-xa activity was measured at second day under treatment. creatinine clearance was calculated from urine sample collected during -hours. arc was defined by a creatinine clearance >= ml/min/ . m . results: thirteen patients aged years old (± . ) were included. six patients developed arc and of them were in therapeutic range. seven patients did not develop arc and of them were in therapeutic range. there was no differences between the two groups in achieving therapeutic range (fisher test, p= . ). we did not observe thromboembolic events. conclusions: we found no relationship between arc and therapeutic failure in patients under prophylactic treatment with enoxaparin. introduction: this study reviewed argatroban use in patients in a tertiary hospital critical care unit. argatroban is a direct thrombin inhibitor approved for use in proven or suspected heparin-induced thrombocytopenia (hit) in patients with renal dysfunction. methods: this was a retrospective cohort study in a medical and surgical icu in a tertiary teaching hospital. data was collected for adult patients treated with argatroban for proven or suspected hit april-august , excluding patients requiring ecmo. we scored patients using the t score and compared this to an elisa immunoassay optical density score which quantifies the pf /h antibody level. also noted was use of continuous haemodialysis and organ failure using the sequential organ failure assessment (sofa), scoring >= defines failure. results: patients were treated with argatroban for proven or suspected hit. / patients had a positive elisa. there was no relationship between t score and elisa optical density (fig. ) . infusions were commenced at either the manufacturer recommended dose of μg/kg/min or a reduced dose of . μg/kg/min. patients receiving the reduced dose had a median of organs failing compared to in the standard regimen. the time taken to the first aptr in range was longer with the reduced dose regimen, however, the time to a stable aptr was less (table ). in patients the dose of argatroban never stabilised. died and was very sensitive to argatroban and required cessation of the infusion for interventions. in the reduced regimen group, there were episodes of bleeding, minor pr bleed in a patient with organs failure and upper gi bleed. conclusions: in this population of icu patients the t score did not correlate with the elisa optical density score, as found previously. patients with multi-organ failure mostly received the reduced starting dose. however, the bleeding events were still confined to this group. this correlates with previous studies that organ dysfunction necessitates a dose reduction for argatroban. results: the mean age in our study group was ± years. the effects of tpe on standard coagulation were increased aptt ( ± to ± s, p= . ) and decreased fibrinogen levels ( ± to ± mg/dl, p= . ). a non-significant decrease in platelet count was observed ( ± to ± /mm , p= . ). on rotem parameters tpe was associated with increased ct in extem ( ± to ± s, p= . ) and intem ( ± to ± s, p= . ) and increased maxvt on extem ( ± to ± s, p= . ) and intem ( ± to ± s, p= . ). all other rotem parameters changed non-significantly. the decrease observed in fibrinogen levels was not associated with a decrease in fibtem mcf ( ± to ± mm, p= . ). conclusions: our results demonstrate that tpe is associated with minimum changes in clot kinetics initiation that do not result in either pro-or anti-coagulant changes. therefore, tpe with fresh frozen plasma can be safely used in normal subjects. introduction: acutely ill patients are prone to critical illness anaemia, a multifactorial condition with potential contribution of iatrogenic anaemia defined as lowered hb due to large/frequent venepunctions. decline in hb is most pronounced in the first days of icu stay. it correlates with the need for rbc transfusion, but the impact on patient outcome is uncertain. the aim of this study was to determine impact of phlebotomy on change in hb (Δhb), and correlation of Δhb with need for transfusion, presence of central venous catheter (cvc) and patient outcome. conclusions: critical illness anaemia is an unexplained phenomenon. impact of phlebotomy is hard to unequivocally determine since there are many confounders. the change in hb levels during icu stay correlates with the need for transfusion that could cause immunomodulation and potentially adverse outcome. every effort should be made to maintain adequate hb levels and lower the risk of iatrogenic anemia. introduction: anemia is prevalent in critically ill traumatic brain injury (tbi) patients and red blood cell (rbc) transfusions are often required. over the years, restrictive transfusion strategies have been advocated in the general critically ill population. however, considerable uncertainty exists regarding optimal transfusion thresholds in critically ill tbi patients due to the susceptibility of the injured brain to hypoxemic damages. methods: we conducted an electronic self-administered survey targeting all intensivists and neurosurgeons from canada, australia and the united kingdom working caring for tbi patients. the questionnaire was developed using a structured process of domains/items generation and reduction with a panel of experts. it was validated for clinical sensibility, reliability and content validity. results: the response rate was . % ( / ). when presented with a scenario of a young patient with severe tbi, a wide range of transfusion practices was noted among respondents, with % favoring rbc transfusion at a hemoglobin level of g/dl or less in the acute phase of care, while % would use this trigger in the plateau phase. multiple trauma, neuromonitoring data, hemorrhagic shock and planned surgeries were the most important factors thought to influence the need for transfusion. the level of evidence was the main reason mentioned to explain the uncertainty regarding rbc transfusion strategies. conclusions: in critically ill tbi patients, transfusion practices and hemoglobin thresholds for transfusion are said to be influenced by patients' characteristics and the use of neuromonitoring in critical care physicians and neurosurgeons from canada, australia and the uk. equipoise regarding optimal transfusion strategy is manifest, mainly attributed to lack of clear evidences and clinical guidelines ( -year) . no significant associations were found between ffp:rbc ratio and mortality rates. patients with higher apache ii score received more platelet transfusions and mortality rates were higher in those who received platelets:rbc ratio > . on multivariate analysis, higher apa-che ii score was an independent predictor of increased mortality. conclusions: the compliance with the recommended : : ratio of blood products was poor. there was no association between transfusion ratios and mortality after adjusting for apache ii score. introduction: the lack of evidence-based medicine supporting the transfusion decision is illustrated by the wide range of blood product use during first-time coronary artery bypass grafting (cabg). use of red blood cells (rbc) ranges from to percent, while the use of platelets range from to [ ] . approximately percent of cabg patients suffer abnormal bleeding, with platelet dysfunction thought to be the most common culprit [ ] . methods: the objective of this study was to evaluate the use of allogeneic blood and blood products among patients undergoing first-time cabg over the past years. the first patients who underwent cabg (on-pump and off-pump) from st of march each year were included for analysis. the percentage of patients receiving rbc, fresh frozen plasma (ffp), platelet and cryoprecipitate during the first hours intra-and postoperatively were analysed. linear regression analysis was performed in each group. results: our analysis shows that the use of rbc decreased over the last years, in contrast to the use of the other investigated products. (see fig. ) the increase of platelets was the most pronounced with a direction coefficient of . and had the least variability (r = . ). (see fig. ) the decrease in rbc was less obvious than the rise in platelet use (direction coefficient of . ) and had a higher variability (r = . ). the consumption of ffp and cryoprecipitate stayed constant (direction coefficient of . and . respectively). the higher incidence of semi-urgent cabg in recent years, which involves continuation of anti-platelet therapy until the day before surgery, can be an explanation for our observed increased use of platelets. the observed decrease in rbc transfusion over the past years might be due to rising awareness of complications associated with red cell transfusion. introduction: red blood cells (rbc) transfusion is frequently required in cardiac surgery and is associated with increased morbidity and mortality rates. the aim of this study is to identify predictors of rbc transfusion for patients undergoing cardiac surgery, emphasizing the use of bioelectrical impedance analysis (bia). methods: this was a retrospective study of patients who underwent elective cardiac surgery between years and in a tertiary reference center. patients' demographic and clinical variables, preoperative bia measurements and postoperative data were analyzed. the univariate and multivariate logistic regression analyses were used to identify the predictors of postoperative rbc transfusion. all of the calculations were performed with ibm spss v. . introduction: red blood cells (rbc) transfusion is a common intervention in cardiac surgery and is associated with higher mortality rates and predisposes serious adverse events. the aim of this study was to determine whether red blood cells (rbc) transfusion is linked to long-term results after cardiac surgery. methods: this observational retrospective study included all of the patients who underwent any of the sts defined elective cardiac surgery types from to . we evaluated - year all-cause mortality rates and secondary postoperative outcomes defined by the sts risk prediction model. patients were categorized according to whether they received rbc transfusions postoperatively; long-term results were compared using cox-regression analysis and kaplan-meier method. introduction: transfusion of packed red cells (prcs) is an important treatment option for patients requiring intensive care but, like all treatments, it is not without risk. these patients, although may be more sensitive to anaemia, are also at increased risk of transfusionrelated complications. we conducted an audit of blood prescribing and administering practices in our intensive care unit. methods: audit proformas were placed in blood prescribing forms for a -month period. all transfusions of prcs were logged over this time, and transfusion triggers, post-transfusion haemoglobin (hb) and whether hb was checked between units was recorded, in addition to other supplementary information. results: over a -month period, transfusion events were recorded, with an average age of the transfused patients of years old (range - years). % of transfusion events were for low hb, % for bleeding and in % of cases the indication was not documented. for patients transfused for a low hb, the mean transfusion trigger was g/l (range: g/l - g/l). only % had a transfusion trigger of g/l or less, and a further % who were transfused for a low hb had a hb of g/l or more. % of transfusion events involved transfusing or more units and, in only % of these cases the hb was checked between units. excluding the two bleeding patients, the mean increase in hb following a single unit transfusion was . g/l (range g/l - g/l), whilst in patients transfused two units, the average increase in hb was g/l per unit transfused (range g/l - . g/l), suggesting single unit transfusions may have greater hb yields. conclusions: our audit demonstrated variability in transfusion triggers and progress needed with administering practices when transfusing multiple units of blood in the non-bleeding patient. we have since implemented measures to meet guidelines in both prescribing prcs with restrictive triggers and in the administration and assessment of hb between units, and will be re-auditing. introduction: there is a perceived increased risk of bleeding in cirrhosis patients undergoing invasive procedures. this lead to a high rate of empirical prophylactic transfusion, which has been associated to increased complications and cost. the best strategy to guide transfusion in these patients remains unclear. our aim was to compare three strategies to guide blood component transfusion prior to central venous catheterization (cvc) in critically ill cirrhosis patients. methods: single center, randomized, double-blinded, controlled clinical trial conducted in brazil [ ] . all cirrhosis patients admitted to the icu with indication for a cvc were eligible. participants were randomized : : to three transfusion strategies based on: ( ) standard coagulation tests (sct), ( ) rotational thromboelastometry (rotem) and ( ) restrictive. the primary outcome was proportion of transfusion of any blood component prior to cvc. secondary outcomes were incidence of major and minor bleeding, icu length of stay (los), and -day mortality. analysis was intention-to-treat. results: participants ( in each group) were enrolled between september and december . most were male ( . %) and listed for liver transplantation. the study ended after reaching efficacy in first interim analysis. there was no significant difference in baseline characteristics among groups. regarding primary endpoint, there was ( . %), ( . %), and ( . %) events in sct, rotem and restrictive groups, respectively (p < . ). there was no difference between sct and rotem groups (p > . ). overall -day mortality was . % and was similar between groups. icu los did not differ between groups. there was no major bleeding. overall minor bleeding occurred in . % with no difference between groups. conclusions: a restrictive strategy is safe and effective in reducing the need of blood component transfusion prior to cvc in critically ill cirrhosis patients. a rotem-based strategy was no different from transfusion guided by sct. introduction: desmopressin (ddavp) is a vasopressin analogue which improves platelet function. its general use as a haemostatic agent is still controversial. the aim of study was to evaluate the effect of prophylactic desmopressin in blood coagulation in patients undergoing heart valve surgery. methods: prospective, randomized, double-blind clinical trial performed at the heart institute of the university of são paulo. a total of adult patients undergoing heart valve surgery were enrolled from february to november . immediately after cardiopulmonary bypass weaning and heparin reversal, patients were randomized in ratio : to intervention group: ddavp ( . μg/kg) or control group. blood samples were drawn at three different times, at baseline (t ), hours (t ) and hours (t ) after study medication. blood coagulation and perioperative bleeding were analysed using laboratorial tests and thromboelastometry, chest tube drainage and requirement of allogenic transfusion within hours. results: a total of patients were allocated to intervention and to control group. blood levels of factor viii at t ( . conclusions: prophylactic use of desmopressin in heart valve surgery does not influence coagulation and thromboelastometric parameters. identifying the impact of hemostatic resuscitation on development of multiple organ failure using factor analysis: results from a randomized trial using first-line coagulation factor concentrates or fresh-frozen plasma in major trauma (retic study) p innerhofer introduction: to clarify how hemostatic resuscitation affects occurrence of multiple organ failure. methods: analysis of secondary endpoints of the retic study [ ] (coagulation factors, activated protein c (apc), thrombin generation, rotem parameters, syndecan- , thrombomodulin (tm) and d-dimer) measured at randomization, and after patients had received ffp or coagulation factor concentrates (cfc) at admission to icu, and hours thereafter. we used factor analysis to reduce the highly interrelated variables to a few main underlying factors and analysed their relation to mof before and after hemostatic therapy. results: the factors concentration, clot and hypoperfusion representing trauma-induced coagulopathy (table ) were comparable between groups at baseline (fig. ) and only high hypoperfusionscore predicted mof, while after therapy a low clot-score also predicted mof. only the changes of the clot-score independently affected occurrence of mof (p= . , adjusted or . , ci . - . ), while changes of concentration (p= . , adjusted or . , ci . - . ) and hypoperfusion (p= . , adjusted or . , ci . - . ) did not. a lower clot-score occurred after ffp transfusion than use of cfc, mainly through persistent thrombocytopenia (platelet count r - ffp vs cfc p< . ) (fig. ) . the higher concentration-score after ffp did not affect mof and ffp had no beneficial effect on fibrinolysis, syndecan- , tm or apc. conclusions: hemostatic resuscitation should augment the factor clot, which is feasible with early fibrinogen administration but not with ffp. the found platelet-saving effect of early fibrinogen administration is important as platelets play a major role in inflammation and transfusion of platelets did not correct thrombocytopenia. introduction: the trauma induced coagulopathy clinical score (ticcs) was developed to be calculable on the site of injury with the objective to discriminate between trauma patients with or without the need for damage control resuscitation (dcr) and thus transfusion [ ] . this early alert could then be translated to in-hospital parameters at patient arrival. base excess (be) and ultrasound (fast) are known to be predictive parameters for emergent transfusion. we emphasize that adding this two parameters to the ticcs could improve its predictability. methods: a retrospective study was conducted in the university hospital of liège. based on the available data in the register (from january st to december st ), the ticcs was calculated for every patient. be and fast results were recorded and points were added to the ticcs according to the ticcs.be definition (+ points if be < - and + points in case of a positive fast). emergent transfusion was defined as the use of at least one blood product in the resuscitation room. the capacity of the ticcs, the ticcs.be and the trauma associated severe hemorrhage (tash) to predict emergent transfusion were assessed. results: a total of patients were included in the analysis. ( %) needed emergent transfusion. the probability for emergent transfusion grows with the ticcs.be value (fig. ) . positive predictive values (ppv) and negative predictive values (npv) of the three scores are displayed in table . conclusions: our results confirm that be and fast results are relevant parameters that can be added to the ticcs for better prediction of the need for emergent transfusion after trauma. fig. (abstract p ) . probability for emergent transfusion with ticcs.be values. fig. (abstract p ) . boxplots show available measurements of extrinsically activated clot firmness at min (exa ), fibrin polymerization at min (fiba ) and platelet count at baseline (r ) and after therapy at admission to icu, and hours thereafter (r to r ) for the cfc (blue, n= ) and the ffp (yellow, n= ) group as well as for patients without (white, n= ) and with (grey, n= ) multiple organ failure. table ) for the cfc (blue, n= ) and the ffp (yellow, n= ) group, as well as for patients without (white, n= ) and with (grey, n= ) multiple organ failure. each factor is given at the measurement time point baseline (r ) and following haemostatic resuscitation at admission to icu, and hours thereafter (r to r ). introduction: the management of the critically ill polytrauma patient is complex and is often a challenge for the intensive care team. the objectives of this study is to analyze the oxidative stress expression in polytrauma cases as well as to evaluate the impact of antioxidant therapy on outcomes. methods: this prospective study was carried out in the clinic for anaesthesia and intensive care "casa austria", form the "pius brînzeu" emergency county hospital, timisoara, romania, with the approval of the hospital's ethics committee. clinicaltrials.gov identifier nct . the patients' selection criteria included an injury severity score (iss) of or higher, and age of or higher. patients were eligible for the study. they were divided in two groups, group a (antioxidant free, control, n= ), and group b (antioxidant therapy, study group, n= ). the antioxidant therapy consisted in continuous iv administration of mg/ h of vitamin c until discharge from icu. the patients included in the study presented with similar characteristics, and no statistically significant differences were shown between group a and b regarding age (p > . ), sex (p > . ), iss upon admission (p > . ), percentage of patients admitted in the icu more than hour post-trauma (p > . ), and associated trauma (p > . ). among patients in group b statistically significant differences were identified regarding the incidence of sepsis (p < . ), multiple organ dysfunction syndrome (p < . ), mechanical ventilation time (p < . ), and mortality (p < . ). no statistically significant differences were shown regarding the time spent in the icu (p > . ). conclusions: following this study we can state that the administration of substances with a strong antioxidant character has positive influences on the outcome of critically ill patients, decreasing the incidence of secondary pathologies as well as mortality rates. icc increased by . %, icd increased by . %, slightly increased ma, and ircl was nearly in the normal range. conclusions: rapid and accurate diagnosis of the coagulation system by lpteg method at different stages of traumatic disease allows for more accurate selection and adjustment of the therapy, which allows improving the prognosis of the disease. introduction: evidence for tranexamic acid (txa) in the pharmacologic management of trauma is largely derived from data in adults [ ] . guidance on the use of txa in pediatric patients comes from studies evaluating its use in cardiac and orthopedic surgery. there is minimal data describing txa safety and efficacy in pediatric trauma. the purpose of this study is to describe the use of txa in the management of pediatric trauma and evaluate efficacy and safety endpoints. methods: this retrospective, observational analysis of pediatric trauma admissions at hennepin county medical center from august to november compares patients who did and did not receive txa. the primary endpoint is survival to hospital discharge. secondary endpoints include surgical intervention, transfusion requirements, length of stay, thrombosis, and txa dose administered. results: there were patients [<=] years old identified for inclusion using a massive transfusion protocol order. twenty patients ( %) received txa. baseline characteristics and results are presented as median (iqr) unless otherwise specified, with statistical significance defined as p < . . patients receiving txa were more likely to be older, but there was no difference in injury type or injury severity score (iss) at baseline (table ) . there was no difference in survival to discharge, need for surgical intervention, or thrombosis (table ) . patients who did not receive txa had numerically higher transfusion requirements and longer length of stay, but these did not reach significance. conclusions: txa was utilized in % of pediatric trauma admissions at a single level i trauma center, more commonly in older patients. though limited by observational design, we found patients receiving txa had no difference in mortality or thrombosis. introduction: the risk of venous thromboembolism (vte) in trauma is greatly increased and one of the leading causes of morbidity and mortality after an accident [ ] . prophylactic measures to prevent vte primarily consist of anticoagulants. in instances in which anticoagulation is contraindicated or inadequate, inferior vena cava (ivc) filters can be used [ ] . however, insertion of ivc filter as a prophylactic measure is controversial as filter-related complications are well documented and increase with treatment time [ ] . the objectives of our study were to evaluate ivc filter insertion indications and filter related complications in pelvic trauma patients. methods: patients with pelvic fractures were operated during the study period / / - / / . all patients who received ivc filter during the period were included into analysis. relevant data was collected from electronic patient journal. results: thirty four patients received retrievable filters during the study period ( males and females) ( table ) . median age of patients was years (range, - ). the predominant indication ( %) was prophylactic insertion. the median indwell time was days (range - days). despite ivc filter insertion one patient experienced lung embolism and another -dvt. in eleven cases ivc filters were tried to be removed at the treating hospital. in two cases filter extraction was unsuccessful and in another two cases filters were left in place due to ivc thrombosis. conclusions: majority of ivc filters were inserted outside guidelines [ ] and proportion of prophylactic indications is significantly higher ( % vs %) than seen in registry studies [ ] . filter related complications were observed in % of patients. more restrictive approach to prophylactic ivc insertion should be exercised. the impact of preinjury antiplatelet and anticoagulant pharmacotherapy on outcomes in patients with major trauma admitted to intensive care unit ( conclusions: patients on preinjury anticoagulants and antiplatelet agents showed an increased mortality; this may be the result of the greater incidence of bleeding, the older age and more comorbidities in this groups. is enzymatic debridement better in critically burned patients? introduction: early debridement of burned tissue reduces infection rate, icu stay and mortality. the use of proteolytic enzymes such as bromelain allows a faster, more effective and selective debridement of denatured tissue, preserving and exposing healthy tissues, reducing debridement times compared to standard of care. methods: retrospective observational study performed in the critical burn unit (march to september ) including patients > years old with a total body surface area (tbsa) burned > % and < %, or > years old with a tbsa burned > %, who underwent enzymatic debridement. mean and standard deviation were used for normal quantitative variables and median and interquartile range in the opposite case. qualitative variables were presented by absolute and relative frequencies. results: mean age was . ± . years old, % males, apache ii (ri - ), absi (ri - ). median tbsa burned was % (ri - %), % (ri - ) were deep dermal or full thickness. time until debridement was hours (ri - ). . % (n= ) had incomplete debridement after first application, % (n= ) received regional anesthesia, % (n= ) didn't need blood transfusion. % of patients who didn't have vasopressors prior debridement, needed the use of it with a mean dose of , mcg/kg/min. % of patients with vasopressors prior treatment, required an increase of dose by a mean of . mcg/kg/min. median icu stay was days. mortality was %. conclusions: topical bromelain allows a fast start of tissue debridement with a low rate of failure. the need for fasciotomy and blood transfusion was very low. topical treatment involved a fast and simultaneous debridement of the tbsa burned, generating an inflammatory response that in some cases required vasopressors. . . / ). the bche activity was measured by using point-ofcare-test system (securetec detektions-systeme ag, neubiberg, germany). levels of the routine inflammation biomarkers, i.e. c-reactive protein (crp) and the white blood cell count (wbcc), were measured during the initial treatment period. measurements were performed at the admission, followed by , and -hour time points. injury severity score (iss) was used to assess the trauma severity. results: the observed reduction in the bche activity was in accordance with the change in the crp concentration and the wbcc. the bche activity measured at the hospital admission negatively correlated with the length of the icu stay in patients with polytrauma (r = - . , spearman's rank correlation coefficient). conclusions: the bche activity might be used as an early indicator for the magnitude of the systemic inflammation following polytrauma. moreover, the bche activity, measured at the hospital admission, might predict the patient outcome and therefore prove useful in early identification of the high-risk patients. pharmacological interventions for agitation in traumatic brain injury: a systematic review introduction: among tbi complications, agitation is a frequent behavioural problem [ ] . agitation causes potential harm to patients and caregivers, interferes with treatments, leads to unnecessary chemical and physical restraints, increases hospital length of stay, delays rehabilitation, and impedes functional independence. pharmacological treatments are often considered for agitation management following tbi. however, the benefit and safety of these agents in tbi patients as well as their differential effects and interactions are uncertain. methods: the major databases and the grey literature were searched. we included all randomized controlled, quasi-experimental, and observational studies with control groups. the population of interest was all patients, including children and adults, who have suffered a tbi. studies in which agitation was the presenting symptom or one of the presenting symptoms, studies where agitation was not the presenting symptom but was measured as an outcome variable and studies assessing the safety of these pharmacological interventions in tbi patients were included. results: we identified references with our search strategy. two authors screened after removal of duplicates. after searching the grey literature and secondary databases, a total of potential articles were identified. eleven studies in which agitation or an associated behavior was the presenting symptom, studies where agitation was not the presenting symptom but was measured as an outcome variable, and studies assessing the safety of these pharmacological interventions were identified. overall, the quality of studies was weak. in studies directly addressing agitation, pindolol and propranolol may reduce assaults and agitation episodes. amantadine and olanzapine may reduce aggression, whereas valproic acid may reduce agitated behavior. conclusions: there is weak evidence to support the use of pharmacological agents for the management of agitation in tbi. impact of decompressive craniectomy on neurological functional outcome in critically ill adult patients with severe traumatic brain injury: a systematic review and meta-analysis p bonaventure, ja jamous, f lauzier, r zarychanski, c francoeur, a turgeon chu de québec -université laval, québec, canada critical care , (suppl ):p introduction: severe traumatic brain injury is associated with high mortality and functional disability. several interventions are commonly used to control the intracranial pressure to prevent secondary cerebral injuries. among them, decompressive craniectomy (dc) is widely performed; however, its impact on functional outcome is still under debate. our objective was to assess the efficacy and safety of this procedure in adult patients with severe traumatic brain injury. methods: we systematically searched in medline, embase, cen-tral, web of science, conference proceedings and databases of ongoing trials for eligible trials. we included randomized controlled trials of adult patients with severe traumatic brain injury, comparing dc to any other intervention. our primary outcome was the neurological function based on the glasgow outcome scale. secondary outcomes were mortality, intensive care unit (icu) and hospital length of stay, intracranial pressure control, and complications. two reviewers independently screened trials for inclusion and extracted data using a standardized form. we used random effect models to conduct our analyses and the i index to assess heterogeneity. results: we identified citations, from which we included trials for a total of patients. we observed no impact on the [ ] . univariate logistic regression analyses were performed to identify predictors associated with the decision for icp monitoring. results: a total of adult patients were included (tables and ). the risk of poor outcome estimated by the impact model was associated to the decision to monitor icp (fig. ) . icp was more often monitored in patients with severe tbi, with one dilated pupil at admission and positive ct findings (in particular, high marshall scores). conclusions: according to our results, the clinician follows a multifactorial reasoning: the main determinants for the decision to monitor icp are gcs, pupils' abnormalities and, above all, ct findings. future studies will be needed to clarify specific indications for the clinicians in the identification of patients who would benefit from invasive monitoring. trajectories of early secondary insults after traumatic brain injury: a new approach to evaluate impact on outcome. introduction: secondary insults (si) occur frequently after traumatic brain injury (tbi). their presence is associated with a worse outcome. we examined the early trajectories of hypotension (sbp< mmhg), hypoxia (spo < %) and pupillary abnormalities from the prehospital settings to the emergency department (ed), and their relationship with -months outcome. methods: in this retrospective, observational study we included all tbi patients admitted to our neuro intensive care unit (nicu) from january to december . we defined the trajectories of si: -"sustained" if present on the scene of accident and at hospital admission, -"resolved" if present on the scene but resolved in ed, -"new event" if absent on the scene and present in ed, -"none" if no insults were recorded. we investigated the association of si trajectories with -months dichotomized outcome (glasgow outcome scale (gos); favorable= - ; unfavorable= - ). results: patients were enrolled in the final analysis. hypoxia and hypotension were related with unfavourable outcome when introduction: guidelines for management of pediatric traumatic brain injury recommend maintaining intracranial pressure (icp) < mmhg [ ] . use of . % sodium chloride (nacl) is considered safe and effective for management of icp in adults, but evidence for concentrations > % in pediatrics is limited. this study will describe the safety and efficacy of . % nacl in reducing icp among pediatric patients. methods: this retrospective study evaluated patients <= years old who received . % nacl and had continuous icp monitoring. cerebral perfusion pressure (cpp), mean arterial pressure (map), icp, and brain tissue oxygenation (pbto ) were recorded hourly and were compared to baseline for hours after each dose. safety outcomes included peak serum sodium, peak serum chloride, and the incidence of stage acute kidney injury (aki) (serum creatinine elevation >= . mg/dl or >= %) [ ] . results: between august and july , eligible pediatric patients received doses of . % nacl; doses were included in the analysis of perfusion parameters. mean age was . +/- years ( months to years), and the median initial glasgow coma scale score was . subjects received a median of four . % nacl boluses, with a mean dose of . +/- . ml/kg. significantly lower icp and higher cpp (p< . ) were observed at all post-treatment time points (fig. ) ; pbto was also significantly increased during of the hours recorded (p< . ). there was no difference in map. peak post-treatment serum sodium and chloride were +/- meq/l and +/- meq/l, respectively (fig. ) . stage aki was observed in . % of patients, and in-hospital mortality was . %. conclusions: our data suggests that . % nacl is a safe and effective therapy for elevated icp in pediatric patients. methods: we performed a prospective study in adult patients with mild head trauma (gcs and ) qualified for acquisition of urgent head ct scan. the clinical symptoms potentially related to intracranial lesion including abnormal vitals, vomiting, headache, persistent dizziness were recorded. ons as well as head ct were then performed. all ons examinations were executed by an experienced sonographer to eliminating interrater bias. head ct findings were dichotomized as positive or negative finding for ich based on formal radiology reports. the patients' disposition including admission, surgery and safe discharge were followed. results: patients were enrolled for the survey. patients had at least one symptom related to potential intracranial lesion ( . %). the mean onsd was ± mm. patients were found to have ich and underwent neurosurgery thereafter. no significant difference of onsd was found between the groups with and without ich, as well as the group receiving surgery or conservative treatment. with introducing a conventional mm threshold of onsd, the sensitivity, specificity, ppv and npv was . , . , . and . , respectively. while incorporating occurrance of at least one positive clinical symptom with the onsd measurement greater than mm as a composite threshold, the sensitivity, specificity, ppv and npv was . , . , . and . , respectively. conclusions: the diagnostic value of ons in mild head trauma is defective. nevertheless, with the supplemental aid of recognition of clinical symptoms relevant to potential intracranial lesion, the overall accuracy would improve. a correlation between ykl- concentrations in cerebrospinal fluid and marshall classification in traumatic brain injurypreliminary results g pavlov , m kazakova , p timonov , k simitchiev , c stefanov , v sarafian medical university -plovdiv, plovdiv, bulgaria, university of plovdiv, plovdiv, bulgaria critical care , (suppl ):p introduction: establishment of prognostic models in traumatic brain injury (tbi) would improve the classification based on predictive risks and will better define treatment options [ ] . in recent years, one of the most intensively studied glycoprotein is ykl- . it is expressed as a consequence of broad spectrum of inflammatory and malignant diseases [ ] . this is study aimed to investigate the level of ykl- in tbi patients and its relationship with several clinical models. methods: we determined plasma and cerebrospinal fluid (csf) ykl- levels in six ( ) patientson the th and th hour after the tbi. each patient was examined by physical and instrumental methods for somatic and neurological status, clinical assessment and prognostic scales (gcs, marshall classification, apache iii). routine haematological and biochemical tests were also performed. as control served the csf of age-matched suddenly deceased healthy individuals (n = ), which was examined post mortem for ykl- levels. results: we found no significant difference between plasma ykl- levels till th and th in all patients (mean difference ± sd: ± ng/ml ) and calculated cerebral autoregulation (ar) as correlation coefficients (pearson) for each ih wave. z-ratios were divided according to binary ar outcome and correlation calculated with intracranial pressure before, during and after the ih waves. results: our preliminary analysis demonstrated a negative correlation between intracranial pressure and z-ratio in the grouped ih waves with preserved ar, but no correlation in the grouped ih waves with impaired ar (table and fig. ). this indicates a decrease in power in the eeg low frequencies ( - hz) and/or an increase in the eeg high frequencies ( - hz) for increased values of intracranial pressure when ar is preserved. conclusions: features of ih waves differ depending on the ability of the injured brain to autoregulate cerebral blood flow. these features might include different signature of eeg frequency changes. the causative links and clinical significance of the different eeg patterns remain unexplored and might represent a signature of neurovascular coupling. introduction: targeted temperature management of patients who have suffered a traumatic brain injury is often used in the hope of preventing further insult to the brain; however, there is no uniform approach to managing temperature either locally, nationally or internationally, and maintenance of goal temperature in this patient population is often challenging due to hypothalamic injury. we sought to evaluate the feasibility and safety of an esophageal heat transfer device (ensoetm, attune medical, chicago, il) to perform temperature management of patients suffering from traumatic brain injury. methods: this was an irb-approved prospective study of patients undergoing temperature management after traumatic brain injury. patients were treated with an esophageal heat transfer device connected to an external heater-cooler, and maintained at target temperature for at least hours. patient temperature obtained via foley catheter was recorded hourly, and the deviation from goal temperature during treatment reported. results: a total of patients were treated from august to may . temperature targets during treatment ranged from . to . degrees c. maintenance of target temperature was successful, with % of readings within +/- degrees c of target, and % of readings within +/- . degrees c of target. one patient developed a small hydrothorax, not attributed to device use. all patients survived to discharge from the icu, with median cpc of (range to ). conclusions: targeted temperature management of patients with traumatic brain injury using an esophageal heat transfer device was feasible and safe, providing a tight maintenance of goal temperature in this challenging patient population. introduction: traumatic brain injury (tbi) represents a serious problem in europe. it still is the principal cause of death in us and europe. every year in italy people on , suffers of tbi and on , dies. disability and incapacity from tbi provides "strong ethicals, medicals, social and health economy imperative to motivate a concerted effort to improve treatment and preventions" methods: our hospital is the hub for modena's county for tbi and we took part in the past year on european project creactive (collaborative researce on acute traumatic brain injury in intensive care medicine in europa) as branch of italian group giviti (gruppo italiano per la valutazione degli interventi in terapia intensiva). our study concerned about patients with tbi dismissed from icu that "personally" or by the family will accepted the consensus to be included in our follow up conducted after months from the dismissal. we collected clinical data from the admission to the dismissale and measured impact of tbi on all day life with gos-e and qolibri-os using telephonical interview. results: we collected data about patients, answered to the telephonical follow-up and only compilated the qolibri-os. we found out that patients admitted with lower gcs has worst outcome in terms of quality of life. it also appears that anisocoria during icu staying represents an odds ratio for death and is connected with worst quality of life after months from the dismissal (tables & ) . inability to re-start a normal work-activity appeared to be the most important factor on the perception that our patient have of their new lives. conclusions: anisocoria seems to be an indicator of severe brain damage. gcs, despite it's simplicity, still represent the best and easiest way to score tbi. work impairment appear to be the most important disability to determine subjective perception of quality of life after tbi, so efforts have to be made to improve work rehabilitation after the dismissal from hospital. introduction: hyperventilation (hv) reduces elevated intracranial pressure (icp) by changing autoregulatory functions connected to cerebrovascular co reactivity. criticism to hv is due to the possibility of developing cerebral ischemia and tissue hypoxia because of hypocapnia-induced vasoconstriction. we aimed to investigate the potential adverse effects of moderate hv of short duration in the acute phase in patients with severe traumatic brain injury (tbi), using concomitant monitoring of cerebral metabolism, continuous brain tissue oxygen tension (pbro ), and cerebral hemodynamic with transcranial color-coded duplex sonography (tccd). methods: a prospective trial was conducted between may and may at the university hospital of zurich. adults (> years), with non-penetrating tbi, first gcs < , icp-monitoring, pbro and/or microdialysis (md)-probes were included within hours after injury. data collection and tccd measurements took place at baseline (a), at the begin of moderate hv (paco - . kpa) (c), after minutes of moderate hv (paco - . kpa) (d), and after return to baseline (e) (fig. ) . repeated measures anova was used to compare variables at the different time points followed by post hoc analysis with bonferroni adjustment as appropriate. p-value < . was considered significant. results: eleven patients were included ( % males, mean age ± years). first gcs was ( - : median and interquartile range). data concerning paco , icp, pbro , mean flow velocity (mfv) in the middle cerebral artery, and md values are presented in table . during hv, icp and mfv decreased significantly. pbro presented a trend of reduction. glucose, lactate and pyruvate did not change significantly ( table ) . conclusions: short episodes of moderate hv have a potent effect on the cerebral blood flow, as assessed by tccd, reduce icp and pbro , and do not induce significant changes in cerebral metabolism. outcome of pediatric patients six months after moderate to severe tbi -results of creactkids study from three picu in israel paco arterial partial pressure of co , cpp cerebral perfusion pressure (mmhg), icp intracranial pressure (mmhg), pbro brain tissue oxygen tension (mmhg), mfv mean flow velocity in the middle cerebral artery introduction: delirium is a major cause of complications in postoperative patient in icu. risk factors for delirium include poor cerebral hemodynamics and peri-operative cerebral desaturations. intraoperative target cerebral oximetry monitoring may decrease the incidence of postoperative delirium in elective major abdominal surgery patients. methods: a single-blinded, randomised controlled trial in patients undergo elective major abdominal surgery who received postoperative care in surgical icu with age more than years were randomised into two groups. the intervention group was received intra-operative target cerebral oxygen monitoring using cerebral oximetry whereas the control group was not. delirium was assessed in both group at , , hour postoperatively. other risk factors for delirium, mechanical ventilator day, length of icu stay, length of hospital stay and post-operative complication were recorded. results: from august -march , patients who met the criteria were randomised to patients in intervention group and patients in control group. overall incidence of delirium was . % (intervention . % vs control . %, p= . ). baseline cerebral oxygen in intervention group was . ± . %. desaturation below % from baseline was found in from patients ( . %) and was the only significant risk factor associated with delirium (p=. , odd ratio . ). there was no significant different in mechanical ventilator day, icu length of stay, hospital length of stay and postoperative complication between both groups. there was no complication associated with application of the cerebral oximetry probe in the intervention group. conclusions: from this preliminary report can not demonstrated the significant different of intra-operative target cerebral oxygen monitoring by using cerebral oximetry in prevention of delirium. however the reduction of cerebral oxygen more than % from baseline in intervention group showed significantly associated with delirium postoperatively. the set score as a predictor of icu length of stay and the need for tracheotomy in stroke patients who need mechanical ventilation introduction: set score was initially developed as an in-house screening tool based on tracheotomy predictors identified in several retrospective studies. it combined the categories of neurological function, neurological lesions, and general organ function/ procedure, and weighed by allocation of certain point values [ ] . in our study it was very interesting to us to find a tool to judge application of early tracheotomy, and as we have a good culprit number from stroke cases so we decided to try to apply this score in our icu after discussion with the inventor of this score. methods: stroke patients were prospectively included in the study as they were ventilated or were very little potential for ventilation and assessed by the stroke-related early tracheotomy score (set score, table ) within the first h of admission (table ) . endpoints were length of stay and ventilation time (vt) after doing early tracheotomy. we examined the correlation of these variables with the set score using standard analytical methods. results: the set score with a value cutoff point of had a significant effect on decision of making tracheotomy and hence decreasing ventilation time and length of stay in icu, which affected outcome (figs. & ) . conclusions: all efforts must be exhausted in neuro intensie care to decrease the secondary changes of brain injury after stroke,early tracheotomy is a good tool to decrease length of stay in icu and ventilation time in these patients.inventing a tool to judge these decisions of doing tracheotomy was a challenge. set score proved to be valuable.further multi center trials are needed. fig. (abstract p ) . specificity for the cutoff point of set score. cut point of is the best to predict tracheostomy with sensitivity of . % and specificity of . %. cut point of is the best to predict early tracheostomy with sensitivity of . % and specificity of . %. since no patients had score so the previous analysis that consider cut-point of should remain the same but just change the number in the text to contraindication for pharmacological vte prophylaxis ( . %). overall, ncc patients were more likely to receive mechanical ( . % icu days) than pharmacological vte prophylaxis ( . % icu days), however pharmacologic was more likely among younger patients with lower apache ii scores. guideline concordant care varied by recommendation; lower for pharmacological and higher for mechanical vte prophylaxis. conclusions: ncc patients uncommonly receive guideline concordant pharmacological vte prophylaxis. collectively, our findings suggest that current vte prophylaxis prescribing practices may reflect uncertainty around risks associated with vte prophylaxis among ncc patients. methods: we retrospectively analysed prospectively collected data from consecutive ich patients that received dvt prophylaxis in a tertiary hospital. he was defined as an increase of > ml measured using the abc/ method or the semiautomatic software based volumetric approach. using multivariate analysis, we analysed risk factors including early dvt prophylaxis for he> h, hospital mortality and poor -month functional outcome ( m modified rankin score> ). results: patients presented with a median gcs of (iqr - ), hematoma volume of ml (iqr - ) and were y old (iqr - ). % received early dvt prophylaxis, % late dvt prophylaxis and % had unclear bleeding onset. hematoma volume was smaller in the early dvt prophylaxis group with . ml (iqr - . ) vs . ml (iqr - ) in the late prophylaxis group (p= . ) without any other significant differences in disease severity. delayed he (n= / , . %) was associated with higher initial hematoma volume (p= . ) and lower thrombocyte count (p= . ) but not with early dvt prophylaxis (p= . ) in a multivariate analysis adjusted for known risk factors. early dvt prophylaxis was not independently associated with m outcome. conclusions: although limited by the retrospective design, our data suggest that early dvt prophylaxis (< h) may be safe in patients presenting with primary ich, which supports the recommendations given by the neurocritical care society. introduction: there is a paucity of literature describing the relationship between clevidipine and its impact on intracranial pressure (icp). the safety of clevidipine in patients with intracranial hemorrhage is often extrapolated from studies using nicardipine, which has demonstrated a neutral effect on icp [ ] . the objective of this study was to determine if there was a relationship between clevidipine initiation and changes to cerebral hemodynamic parameters. methods: this study was a retrospective analysis of adults admitted to hennepin county medical center between july and july . individuals were included if they had intracranial bleeding and icp data recorded prior to initiation of a clevidipine infusion. baseline demographic data was collected, including age, gender, type of injury, and initial glasgow coma score (gcs introduction: aneurysmal subarachnoid hemorrhage (sah) is an acute cerebrovascular event with high mortality and is an important cause of neurologic disability among survivors. many complications in the course of sah, such as hydrocephalus, also play a role in the poor outcome. the aim of the study was to describe the characteristics of patients with sah admitted to the icu to evaluate the factors associated with outcome. methods: this study was conducted in two reference centersone in rio de janeiro and one in porto alegre. from july to september , every adult patient admitted to the icu with aneurysmal sah was enrolled in the study. data were collected prospectively during hospital stay. the primary endpoint was mortality and dichotomized functional outcome (poor outcome defined as glasgow outcome scale to ) at hospital discharge and months. dichotomous variables were analyzed using two-tailed fisher's exact test. results: a total of patients were included. demographic characteristics are presented in table . frequency of clinical and neurological complications are presented in table . in univariate analysis, factors most frequently seen in patients with unfavorable outcome were seizure ( % vs %, p= . ), hydrocephalus ( % vs %, p< . ), meningitis ( % vs %, p= . ), rebleeding ( % vs %, p= . ), vasospasm ( % vs %, p= . ), pneumonia ( % vs %, p< . ), sepsis/septic shock ( % vs %, p< . ), postsurgical neurological deterioration ( % vs %, p= . ) and delayed cerebral ischemia ( % vs %, p< . ). at months, out of patients with follow-up, % had poor outcome. conclusions: sah is associated with high morbidity. both neurological complications as clinical complications were associated with unfavorable outcomes. therapeutic interventions to prevent those may have an impact on clinical outcomes. introduction: brain tissue hypoxia (brain tissue oxygen tension, pbto < mmhg) is common after subarachnoid hemorrhage (sah) and associated with poor outcome. recent data suggest that brain oxygen optimization is feasible and may reduce the time with brain tissue hypoxia to % in patients with severe traumatic brain injury [ ] . little is known about the effectiveness of protocolized treatment approaches in poor-grade sah patients. methods: we present a retrospective analysis of prospectively collected data of poor-grade sah patients admitted to tertiary care centers where pbto < mmhg was treated using an institutional protocol. treatment options were left to the discretion of the treating neuro-intensivists including augmentation of cerebral perfusion pressure (cpp) using vasopressors if necessary, treatment of anemia and targeting normocapnia, euvolemia and normothermia. the dataset used for analysis was based on routine blood gas analysis for hemoglobin data matched to hourly averaged data of continuous cpp, pbto , temperature and cerebral microdialysis (cmd) samples over the first days of admission. results: patients were admitted with a gcs of (iqr - ) and were (iqr - ) years old. overall incidence of brain tissue hypoxia was %. during this time we identified associated episodes of cpp< mmhg ( %), hyperglycolysis (cmd-lacta-te> mmol/l, cmd-pyruvate> μmol/l; %), pco < mmhg ( %), metabolic distress (cmd-lactate-to-pyruvate-ratio> ; %), pao < mmhg ( %), hb< g/dl ( %), and temperature> . °c ( %) (fig. ). of these variables only hyperglycolysis was significantly more common ( %) during episodes of normal pbto ( % of episodes). conclusions: underutilization of ivt despite the overwhelming evidence that support the effectiveness of such therapy can be partly attributed to the fear of hemorrhagic complications. this fear is not justified by current data. the estrangement of the emergency medicine community regarding ivt and the domination of stroke experts in decision making is also a barrier. regional wall motion abnormalities and reduced global longitudinal strain is common in patients with subarachnoid hemorrhage and associated with markedly elevated troponin k dalla sahlgrenska university hospital, gothenburg, sweden critical care , (suppl ):p introduction: stress-induced cardiomyopathy after subarachnoid hemorrhage (sah) is a life-threating condition associated with poor outcome. regional wall motion abnormalities (rwma) is a frequent finding, however, assessment of rwma is known to be difficult. in the present study we hypothesized that global and regional longitudinal strain (gls and rls) assessed with speckle tracking echocardiography can detect myocardial dysfunction indicated by increased levels of the cardiac biomarker troponin (tnt). methods: this prospective study comprised patients with sah. the tnt was followed daily from the admission up to days postadmission and elevated tnt was defined as > ng/l. a transthoracic echocardiography examination was performed within hours after the hospitalization. the peak gls was determined using the three apical projections and presented as the mean of the segments. reduced gls was defined as > - % and reduced rls was considered present when segmental strain was > - % in > adjacent segments. introduction: deviations from strict eligibility criteria for intravenous thrombolysis (ivt) in ischemic strokes regarding either license contraindications to alteplase or relative contraindications to thrombolysis have been reported in international literature, with conflicting results on patients' outcome.the aim of our study was to evaluate safety and efficacy for patients receiving ivt outside standard inclusion criteria. methods: retrospective analysis of our department's thrombolysis database.we compared patients with strict protocol adherence (strict protocol group) [mean age years and national institutes of health stroke scale (nihss) at admission /range - ] and patients with protocol deviations (off-label group) [mean age years and nihss at admission /range - ],in particular patients > years old, patients with mild stroke-nihss< ,and with symptom-to-needle time - . hours ( patients had deviations). results: patients in the off-label group were older but had no difference in baseline severity scores (sapsii, nihss). they had no statistically significant difference on short-term (nihss at days, need for critical care support, primary adverse event) and long-term (mortality,functional outcome at months) outcome measures when compared to standard protocol patients. conclusions: in accordance with international literature,off-label thrombolysis is save and equally effective to standard protocol thrombolysis.thrombolysis strict protocol needs expansion of inclusion criteria. introduction: most scales (gcs,nihss) don't consider the pathway of secondary acute brain failure (sabf). neuron-specific-enolase (nse) could be usefull in diagnostic and treatment pts. with sabf [ , ] . methods: prospective study incl. pts. with abf. pts. were identical in condition, age and comorbidies. in main group, nse examed and choline alfoscerate was used, pts. was divided into subgroups ia (n= ) with acute ischemic stroke(ais) and ib (n= ) pts. with posthypoxic encephalopathy. the control group (n= ) pts. with ais treated by loc.protocol № . clinical, laboratory, and imaging variables were fully compared. pts. examed by abcde algorithm, gcs and nihss. brain ct, carotid doppler performed. considering criteria:nse(days , , ), neurological status, length of stay in icu (icu los). "ss- . "was used. results: the baseline nse was higher and correlated to nihss ( . ± . , ÷ = . ) in all pts. in ia, ib sbgroups nse decreased for - days vs. control group - days (÷ = . ) and correlated with regression neurological deficit. icu los in main group was . ± . days vs. control group . ± . days. sensitivity and specificity of nse as a marker of brain injury in pts. with ais were and % and in posthypoxic pts. were and %, respectively, which showed nse as eligible diagnostic criterion of posthypoxic cerebral edema. in ia (ais) pts. and ib (posthypoxic edema) were confirmed by increasing nse in fold and -fold respectively more vs. pts. who had only brain ct at first day. nse also correlated with regression neurological deficit and improving of the neurological status. although, two pts. in iib group died with nse - ìg/ml conclusions: . nse is an effective marker of the severity of damages even in the sabf, and shoved efficacy efficacy of treatment. . negative outcome can be in pts. with sabf and more -fold increasing nse and increasing up to - ìg/ml is a mortality predictor. . we included nse in local protocols p n-terminal pro-brain natriuretic peptide as a bio-marker of the acute brain injury introduction: the detection of biomarkers levels facilitates an early diagnosis of brain tissues damage, allows assessing the prognosis of the disease and its outcome, and performs the monitoring of the patient treatment. methods: we studied patients ( m, f.). st group comprised patients with severe brain trauma: asurvivors with good outcome (on glasgow outcome scale groups i-ii) (n= ), bdead or severely disabled (on glasgow outcome scale groups iii-v) (n= ). nd group comprises patients with intracranial and sub-arachnoid hemorrhages: assignment to groups a (n= ), b (n= ) was done using the same criteria as group . rd group comprises patients operated in conjunction with brain tumor. assignment to groups a (n= ) and b (n= ) was done using the same criteria as groups and . we tested the level of n-terminal pro-brain natriuretic peptide in blood ( - pg/ml) between st and rd days after severe brain injury and then every - days for the total duration of days. results: : statistical analysis failed to demonstrate noticeable difference in the level of ntprobnp between groups , , . we detected the differences between subgroups (p< . ). patients from groups a, a, a (n= ) ntprobnp level stayed below pg/ml in cases ( %), in the cases ( %) the level was above pg/ml, but by - th day decreased to the normal values. for patients in subgroups b, b, b (n= ) in cases ( %) ntprobnp level was above pg/ml at least once, in cases ( %) level stayed below pg/ ml but remain high for the entire duration of the study without significant decrease. conclusions: all the patients with acute brain injury show the increased level of ntprobnp above normal values, irrespective of ethiology of injury. in case when ntprobnp level increases above pg/ml and/or does not decrease to the normal values it is possible to predict a negative outcome. introduction: cerebrovascular and coronary artery diseases share many of the same risk factors [ ] . cardiac mortality accounts for % of deaths and is the second commonest cause of death in the acute stroke population, second only to neurologic deaths as a direct result of the incident stroke. methods: this is a prospective observational study from july to april done on adult patients (groupi: pts acute ischemic strokes & group ii: pts as control) in kafr-elsheikh general hospital icu. inclusion criteria: all patients with acute ischemic stroke while exclusion criteria: patients with heart or renal failure/sepsis&septic shock/ischemic heart disease or hemorrhagic stroke,full clinical examination&labs including admission quantitative serum cardiac troponin i elisa immunoassay,ecg, d echocardiography&ct brain on day & ,alberta stroke program (asp) early ct (aspect) to predict neurological outcomes and mortality in patient with acute ischemic stroke within days so survivors vs non-survivors in group were divided to g a & g b respectively. results: dyslipidemia, hypertension, diabetes mellitus were significant comorbidities in all ischemic stroke pts.tlc, urea, inr and troponin were significantly higher in case group vs control group.gcs was found to be lower in non-survivors at day &at rd day follow up while aspect was significantly lower only at rd day follow up.troponin level was significantly higher in non-survivors g b, it was also higher in patents who developed convulsion later during their icu stay& it was significantly inversely correlated to gcs and asp. troponin had sensitivity % and specificity % (roc curve analysis) conclusions: troponin level was predictor for mortality in patient with acute ischemic stroke.it is well correlated to gcs and asp on admission.it was a predictor for occurence of convulsions later in icu stay. introduction: based on examination and treatment of hyperkinetic disorder in patients with uws and mcs, we supposed that hyperkinesis manifesting the formation of the generator of pathologically enhanced excitation in cerebral cortex, basal ganglia, which subsequently causes the formation of hyperkinesis. halogencontaining anesthetic sevoflurane had a good clinical effect in patients with prolonged impairment of consciousness. methods: the study included patients with uws ( -hypoxia, -encephalitis) and patients with mcs ( -hypoxia, -encephalitis). hyperkinetic disorder presenting as permanent myoclonus of arms and legs, face. all patients were performed head mri and eeg (before, during and after anesthesia), crs-r assessment, patients -[ f]-fgd pet. initial anesthesia: propofol - mg/kg, rocuronium bromide (esmeron) , mg/kg, fentanyl - mg/kg and clonidine (clophelin) . - . mg/kg. maintenance of anesthesia is carried out due to the following scheme: inhalation anesthesia using sevoflurane ( . - . vol%, mac . - . ). additionally, during the nd - th hours of medical anesthesia was prescribed the intravenous injection using ketamine - mg/kg/hr. the anesthesia is used during hours. the patients were nurtured by balanced mixtures through nasogastric tube. after hours the patients were gradually transferred to the autonomous breathing. the control clinical and instrumental studies to evaluate the therapy effectiveness (eeg, crs-r) were performed. results: in patients ( mcs, uws) was observed the hyperkinetic disorder regression as decrease of hyperkinesis manifestation, patients didn't have a significant dynamics. conclusions: the artificially formed "pharmacological dominant" (using sevoflurane and ketamine) may decrease the activity of pathological system of the brain, which clinically presented as significant decrease of hyperkinesis manifestation in out patients. -year experience of using benzodiazepines in predicting outcomes and targeted treatment of patients in unresponsive wakefulness syndrome (uws). introduction: we accepted a hypothesis that in some patients uws is a consequence of a pathologic system (ps), that limits the brain functional activity. identification of a ps allow to predict consciousness recovery. eeg registration under benzodiazepines test (bt) has become the method of ps identifying in uws patients. methods: we examined uws patients ( -traumatic, -non traumatic). crs scales assessment, eeg with bt, mri of brain were performed for all patients. the midazolamum was administered iv . mg/kg,.in - min after bzd was recorded eeg for min. the test was considered to be positive if against the background of bzd eeg pattern restructuring was observed: the low-amplitude eeg activity was rebuilt with the advent of alpha-and beta-spectrum.in patients with slowwave activity of theta-and delta-spectrum appeared stable fast forms, and in patients with baseline polymorphic eeg pattern was recorded prevalence of alpha activity and (or) the alpha rhythm. in order to confirm the correlation between the bzd effect and eeg pattern restructuring, flumazenil was administrated at rate of . mg every to minutes until the original eeg pattern has been registered again. results: the bt was true positive (recovery consciousness in - month later) in traumatic and non traumatic patients. true negative (permanent uws month later) in traumatic and non traumatic patients. false positive - traumatic, non traumatic. false negative traumatic, non traumatic patients. sensitivity bt to vs/uws = . % sensitivity to mcs = . % conclusions: our data confirmed the correctness of hypothesis that a ps limits the activity of the brain in patients in a uws. we proposed diagnostic method of a ps activity and suppression. apparently, bzd are the drugs of first stage examination choice in the treatment of uws patients. early identification of sepsis-associated encephalopathy with eeg is not associated with short-term cognitive dysfunction introduction: septic-associated encephalopathy (sae) affects approximately % of septic patients. recent studies showed sae is associated with short-term mortality and long-term cognitive disability. however, diagnosis of sae is one of exclusion and its association with short-term cognitive deficit is uncertain. the aim of this study is to evaluate the sensitivity of clinical examination in detecting sae. the association between sae and short-term cognitive impairment is also assessed. methods: prospective observational study enrolling adult septic patients admitted to a mixed icu. exclusion criteria were: encephalopathy from another cause, history of psychiatric/neurologic disease, cardiac surgery. all patients received continuous eeg monitoring and were assessed for sae for up to days after inclusion. we performed a comprehensive consciousness assessment twice daily during the icu (gcs; full outline of unresponsiveness, four; coma recovery scale-revised, crs-r; reaction level scale , rls ; confusion assessment method for the icu, cam-icu). we defined altered brain function as gcs< , no correlation between cognitive function at hospital discharge and severity of eeg alteration was found. conclusions: eeg was more sensitive than clinical assessment in detecting sae. altered eeg was not associated with short-term cognitive function. analysis of the training needs in italian centers that use brain ultrasound in their daily practices: a descriptive, multicenter study r aspide introduction: as mission of siaarti neuroanesthesia and neuroicu group of study, we are mapping out the brain ultrasound training needs in our centers. although brain ultrasound is widely used to study the intracranial vessels and other issues, it is still not clear the homogeneity of the skills required in both neuro and general icu in italy. the aim of this study is to explore the use of us-tcd and validate a collection of criterea which would prove useful in any future national wide survey. methods: starting from sept. the seven center involved (bologna, catania, pisa, verona, bergamo, cesena, roma) collected clinical and sonographic data, basing on a crf of twenty criteria such as: kind of hospital and icu, number of beds and neuro-patients/year, the physicians specialization trained to perform us-tcd, the kind of us doppler device used and the kind of training course followed. as a second step, data were analyzed by coordination team, as third step, during annual siaarti conference, these centers had a deep discussion on these selected items, further modifying and adapting the content of the items. results: the result is a ready list of items, an available tool for all the participant centers, that are going to start with an internal test survey for a final validation. conclusions: there is more than one path to train a physician on brain us in italy and there are new possible applications, even outside of the neuro sub-speciality. from the preliminary discussion, it is clear that in italy we have a inhomogeneous frame of training and use. this group of study believes that among the anesthesiologists/intensivists, it is possible to find a useful number of physicians interested in training on this topic. the main aim is the production of a validated criterea collection, available for eventually future national survey, useful to help map out the real national training needs in italy on us brain. perinatal neurosurgical admissions to intensive care c nestor, r hollingsworth, k sweeney, r dwyer beaumont hospital, dublin, ireland critical care , (suppl ):p introduction: beaumont hospital is the neurosurgical centre for ireland serving a population of . million. we present data on all perinatal patients who required icu admission for neurosurgical conditions over an year period. our data presents an insight into the incidence and outcome of neurosurgical conditions during pregnancy methods: searching our database identified pregnant and recently pregnant patients admitted to icu with neurosurgical conditions. patient data was collected retrospectively by review of charts and of an electronic database. a further pregnant patients were admitted for neurosurgical intervention but did not require critical care. results: intracranial haemorrhage was the most common diagnosis ( subarachnoid haemorrhage and had intra-cerebral haemorrhage). patients presented with intracranial tumours and patient had a traumatic brain injury. patient was admitted post spinal tumour resection. patient was referred with an ischemic stroke after iatrogenic injury to the carotid and vertebral artery. the requirement for organ support in this cohort of patients was high; % required ventilation and % inotropes. patients underwent neurosurgical intervention & medical treatment. maternal deaths occurred at & weeks gestation. the modified rankin score (mrs) on discharge from hospital was <= for of the surviving patients (median= ). of the pregnancies (all singleton) there were foetal deaths. patient miscarried spontaneously at weeks, had a medical termination of pregnancy at weeks to facilitate chemotherapy and foetus died after maternal death at weeks. the remaining patients delivered normal babies. conclusions: neurosurgical disease requiring icu admission during pregnancy is rare; our data suggest an incidence of case per million population. maternal outcomes were mixed with more than half having a mrs> on discharge. foetal outcomes were good with only one miscarriage and good neurological outcome in all surviving infants. stepwise multivariable analyses that included interaction between time of day and arrest location were performed in a stepwise manner. results: prehospital als (adjusted or, . ; %ci, . - . ) but not good-quality of bystander-performed ccs ( . , . - . ) was associated with sustained return of circulation (rosc). neither provison of good-quality ccs nor prehospital als was a major factor associated with on-month survival. however, good-quality of bystanderperformed ccs ( . , . - . ) in addition to shockable rhythm ( . ; . - . ) and bystander-witnessed ohca ( . ; . - . ) were associated with higher chances of neurologically favourable one-year survival, whereas prehospital als ( . ; . - . ) and elderly ohca ( . ; . - . ) were associated with lower chances of the survival (fig. ) . the impact of good quality ccs on survival were preserved in bystander-witnessed ohcas with shockable initial rhythm. noncentral region (adjusted or for good-quality, . ; %ci, . - . ), lack of bls training experience ( . ; . - . ), elderly-only rescuers ( . ; . - . ), cc initiation following dispatcher-assisted cardiopulmonary resuscitation ( . ; . - . ), and female-only rescuer ( . ; . - . ) were associated with poor-quality ccs. cc quality in athome ohcas remained low throughout the day, whereas that in outof-home ohcas decreased during night-time. conclusions: provision of good-quality ccs before ems arrival but not prehospital als was essential for neurologically favourable survival. new protocol for start of chest compressions before definitive cardiac arrest improved survival from out-of-hospital cardiac arrest witnessed by emergency medical service introduction: healthcare providers including emergency medical service (ems) personnel usually confirm absence of carotid pulse before starting chest compressions. at the end of , ishikawa medical control council implemented new criteria for start of chest compressions encouraging ems to start chest compressions when carotid pulse was week and/or < /min in comatose adult patient with respiratory arrest or agonal breathing. methods: data were prospectively collected for out-of-hospital cardiac and respiratory arrests during the period of - . definitive cardiac arrest was recorded when loss of carotid pulse was confirmed by pulse checks performed every min after the early start of chest compressions. the effect of early chest compressions on the proportions of definitive cardiac arrest was analysed in cases with respiratory arrest and circulatory depression in initial patient evaluation. before/after comparison of neurologically favourable -y survival was performed in cases with ems-witnessed ohca. results: the early start of chest compressions did not significantly prevent definitive cardiac arrest that followed respiratory arrest with circulatory depression in the initial patient evaluation (fig. ) . time interval between start of chest compressions and definitive cardiac arrest confirmation (median; iqr) was ; . - min. the survival rate of all ems-witnessed ohcas after the implementation of new criteria was significantly higher than that before the implementation: adjusted or; % ci, . ; . - . (fig. ) . no complications related to early chest compressions were reported during the study period. conclusions: start of chest compressions before definitive cardiac arrest improved survival from out-of-hospital cardiac arrest witnessed by emergency medical service. healthcare providers including ems personnel should be encouraged to provide chest compressions on cases with respiratory arrest and severe cardiovascular depression. introduction: our study sought to determine if there is a difference in time to tracheal intubation between direct and video laryngoscopy during cardiac compressions. guidelines suggest no more than seconds should be taken to perform intubation to minimise any delay in compressions [ , ] . it is unclear if use of video laryngoscopes results in faster intubation times during cardiac arrest. methods: observational trial involving emergency, anaesthesia and intensive care doctors. participants' baseline data obtained by questionnaire. resusci-anne™ manikin with airway trainer™ head [laerdal] with grade airway was utilised. participants intubated the manikin times, once with each of: macintosh size blade, c-mac video laryngoscope (karl storz, germany) with size blade and portable mcgrath mac enhanced video laryngoscope (medtronic, usa) with size blade. order of laryngoscopes was randomised by computer generated sequence. continuous cardiac compressions were performed throughout attempts. results: total participants. there was a statistically significant difference in time to intubation between the devices using friedman test (p< . ). wilcox signed-rank test demonstrated time to intubation with videolaryngoscopy was longer, c-mac (p= . ) and mcgrath (p= . ) compared with direct laryngoscopy. there was no significant difference between the two videolaryngoscopes (p = . ). when controlled for participants level of seniority and previous experience with device, direct laryngoscopy was still significantly faster than c-mac (p = . ) and mcgrath (p = . ) conclusions: our study showed a disadvantage of video laryngoscopy during cardiac compressions. faster intubation times with direct laryngoscopy could result in less pause in compressions and decrease periods without perfusion. direct laryngoscopy is an appropriate first choice for tracheal intubation during cardiac arrest. introduction: the aim of this study was to describe the coronary angiographic findings in relation to specific ecg changes and comorbidity in survivors after cardiac arrest. methods: a retrospective cohort study of out-of-hospital cardiac arrest patients with data retrieved between - from national registries in sweden. unconscious patients with coronary angiography performed within days after return of spontaneous circulation and available ecg were included (fig. ) . results: after exclusion, patients were analyzed (fig. ) , (table ) . ( %) were women and mean age were years. patients without st-elevation were separated into groups with specified ecg changes and comorbidities. differences were observed in the incidence of any significant stenosis, total occlusion and pci performed, between the specified ecg changes, as well as between the comorbidity groups ( introduction: fewer women after return of spontaneous circulation from out-of-hospital cardiac arrest (ohca) are undergoing coronary angiography (cag) with possible percutaneous coronary intervention (pci). the aim was to investigate gender differences in comorbidity, cag findings and outcome after ohca in comatose patients with a shockable first ecg rhythm. methods: a retrospective cohort study of out-of-hospital cardiac arrest patients with data retrieved between - from national registries in sweden (fig. ) . results: there was no difference in age or comorbidity except for men having more ischemic heart disease, . vs . % (p= . ). rates of previous myocardial infarction did not differ, . vs . %. no difference was seen in rates of ecg indicating prompt cag according to guidelines. still, more men underwent cag but no difference in numbers of cag leading to pci was seen (table ) . furthermore, in patients with st elevation or lbbb, no gender difference in cag and subsequent pci was found. men had lower rates of normal cag findings but more triple vessel and left main coronary artery disease ( table ) . year survival did not differ, . vs . %. conclusions: our study suggests, that despite no gender differences in rate of ecg findings indicating a prompt cag, men seems to have a more severe coronary artery disease while women have more frequently normal angiograms. however, this did not influence year survival. introduction: the circadian clock influences a number of cardiovascular physiological processes. a time-of-day variation in infarct size has recently been shown in patients with st segment elevation myocardial infarction. however, there is no clinical evidence of circadian variation in patients with out-of-hospital cardiac arrest (ohca) of cardiac etiology. methods: we performed retrospective analysis using data from japan's nationwide ohca registry from january through december , which includes all ohca patients presented with ventricular fibrillation as first documented rhythm, and consequently confirmed cardiac etiology. in order to eliminate the night and weekend effects, we enrolled only patients suffered ohca in the morning we conduct a retrospective cohort study focusing on the association between ohca outcome and icu bed availability. the ohca data was acquired from a regional emergency operation center, and the icu bed information was obtained from a regional sur it exceeds physiological levels in order to avoid insufficient oxygenation [ ] . hyperoxia has been associated with increased in-hospital mortality, though uncertainty remains about this association. multiwave pulse co-oximetry has safely been studied intraoperatively as a guide to monitor hyper-and hypoxia by calculating an oxygen reserve index (ori) which could add information to pulse oximetry measures when spo is > % [ ] . methods: this is a monocentric prospective study including patients with successful resuscitation following ohca. the aim of our study is to evaluate the feasibility and assess the availability of novel non invasive oxygen and hemodynamic variables. collected data principally concern blood oxygen and circulation such as ori, spo , total hb, perfusion index and pulse rates. recording is ideally started at time of rosc. results: we monitored consecutive patients for a total time of . min during transport from ohca place to the er. spo signal was present for . % of transport time.oxygen reserve index signal was present for . % of the total transport time. pleth variability index (pvi) signal was present . % of the total transport time. sphb signal was present . % of total time from rosc to hospital. the confidence interval for each variable is given in fig. . conclusions: our pilot study shows that noninvasive measurements of hyperoxia, fluid responsiveness and hemoglobin are readily available from the prehospital phase of post-rosc care allowing for early tailored and goal directed interventions. increase in sofa score was associated with € ( % ci - €) increase in the cost per day alive in the first months after ca. the sofa score is a good indicator of disease severity but the overlap between outcome groups does not allow its use for early prognostication in ca patients. the association of sofa and its sub-scores with -month outcome and healthcare costs highlights that in addition to neurologic damage the full spectrum of multiple organ failure affects the survival and morbidity of ca patients. public opinion on cardiopulmonary resuscitation decision and outcome in out-of-hospital cardiac arrest patientsquestionnaire study ty li introduction: metabolomics is a novel approach that can characterize small molecules (metabolites) and has the potential to explore genotype-phenotype and genotype-environment interactions, delivering an accurate snapshot of the subject's metabolic status. in this context, the aim of metabolomics is to improve early diagnosis, classification, and prediction over the development of a pathological condition. to this end, metabolomics have not been used in the characterisation of cardiac arrest (ca), cardiopulmonary resuscitation (cpr) and return of spontaneous resuscitation (rosc). the aim of the present study was to explore whether metabolomics can characterize the ca versus rosc in a swine model of ventricular fibrillation (vf). methods: ten animals were intubated and instrumented and vf was induced with the use of a cadmium battery. vf was left untreated for min and the animals were then resuscitated according to the guidelines. defibrillation was attempted in all animals. venous blood was drown at baseline, min, min, min during untreated ca and finally at min, min, h, h after rosc in order to determine the metabolomic profile during ca and during the early post-resuscitation period. rosc was defined as the presence of an organized cardiac rhythm with a mean arterial pressure of at least mmhg for > min. blood was centrifuged and serum was analysed by high resolution h-nmr spectroscopy. nmr spectral data were submitted to multivariate discriminant analysis. results: eight animals survived the experiment and were included in the analysis. metabolites upregulated in the immediate rosc versus ca were succinate, hypoxanthine, choline and lactate. metabolites upregulated in the hour rosc versus ca were ornithine and alanine. the measured phases are shown in fig. introduction: early outcome prognostication in successfully resuscitated out-of-hospital cardiac arrest (ohca) patients remains challenging. prediction models supporting the early decision to continue with full supportive treatment could be of major interest following ohca. we constructed prognostic models able to predict good neurologic outcome within hours after icu admission. methods: upon icu admission, targeted temperature management at °c, hemodynamic and neuromonitoring (cerebral oxygen saturation measured with near-infrared spectroscopy and bispectral index (bis)) was initiated. prediction models for good neurologic outcome at days post-ca were constructed at hour , , and after admission using variables easily collectable and known to be predictive for outcome. after multiple imputation, variables were selected using the elastic-net method. each imputed dataset was divided into training and validation sets ( % and % of patients, respectively). cut-off probabilities yielding a sensitivity above % were determined and performance of all logistic regression models was assessed using misclassification rates. introduction: in many venues, ems crews limit on-scene care for pediatric out-hospital cardiac arrest (pohca), attempting treatment during transport. hypothesizing that neuro-intact survival can be improved by prioritizing on-site care, strategies were effected to expedite on-scene drug delivery and intubation (with controlled ventilation). methods: from / / to / / , data for pohca cases were collected. in , new training prioritized on-site resuscitation (phase i) using expedited drug delivery and intubation with controlled ventilation (~ breaths/min). training included psychological and skills-enhancing tools to boost confidence in providing on-scene care. in , drugs were prepared while responding (phase ii). american heart association guidelines were used throughout and no other modifications were made. neuro-intact survival in - was compared to phase i & ii outcomes. results: over the . -years, ems faced consecutive pohca cases. the great majority presented in asystole throughout. in those resuscitated, mean time from on-scene arrival to the st epinephrine infusion fell from . min ( - ) to . min (phase i) and . min (phase ii). by , it was min. for resuscitated patients and . min. for all patients. intubation and intraosseous insertion occurred more frequently in phase i/ii, but there were no significant differences in age, sex, etiology, response times, bystander cpr or drug sequencing. neuro-intact survival improved significantly from / in - to . % ( / ) in phase i and . % ( / ) in phase ii (p < . ; -tailed fisher's exact test) (fig. ) . conclusions: although historically-controlled, the sudden appearance of neuro-intact survivors following a renewed focus on rapid on-site care was profound, immediate and sustained. beyond skillsenhancing strategies, physiologically-driven techniques and supportive encouragement from leadership, pre-arrival psychological and clinical tools were also likely contributors to the observed outcomes. fig. (abstract p ) . effecting neurologically-intact survival for children with out-of-hospital cardiac arrest p improved outcomes with a bundled resuscitation technique to enhance venous return out of the brain and into the heart during cardiopulmonary resuscitation pe pepe , ka scheppke , pm antevy , d millstone , c coyle , c prusansky , s garay , jc moore introduction: lowering intracranial pressure to improve brain perfusion during cpr has become a focus for our team. combined with devices that enhance venous return out of the brain and into the thorax during cpr, outcomes have improved using head/chest elevation in the laboratory (fig. ) . this study's purpose was to confirm the safety/clinical feasibility of this new approach involving mechanical cpr at an angle. methods: , consecutive out-of-hospital cardiac arrest (oohca) cases (all rhythms) were studied for . years ( / / to / / ) in an expansive, socio-economically-diverse u.s. county (pop. . mill). in , ems crews used the lucas© and impedance threshold (itd) devices on such patients, but, after april , they also: ) applied o and deferred +-pressure ventilation several min; ) raised the backboard~ °; and ) solidified a pit-crew approach to expedite lucas© placement. neuro-intact survival was not recorded until , so resuscitation by ems to hospital admission was used for consistency. quarterly reports were run to identify any periodic variations or incremental effects during protocol transition (quarter , ). results: no problems were observed with head/torso-up positioning (n= , ), but rates of resuscitation rose steadily during the transition period with an ensuing sustained doubling (fig. ) over the ensuing years when compared to those studied (n= ) prior to the head-up approach (mean . %; range - % vs. . %, range - %; p < . ). outcomes improved across subgroups. response intervals, indications for attempting cpr and bystander cpr rates were unchanged. resuscitation rates in - remained proportional to neuro-intact survival. conclusions: the head/torso-up cpr bundle was not only feasible, but also associated with an immediate, steady rise in resuscitation rates during the transition phase with a sustained doubling of resuscitation rates, making a compelling case that this bundled technique may improve oohca outcomes in future clinical trials. introduction: cardiac arrest (ca) often requires intensive care unit (icu) treatment, which is costly. while there are plenty of data regarding post-ca outcomes, knowledge of cardiac arrest associated healthcare costs is virtually non-existent. methods: we performed a single-center registry-based study to determine expenditure data for icu-treated ca patients between and . healthcare cost evaluation included costs from the initial hospital treatment, rehabilitation costs and social security costs up to one year post-ca. we calculated mean healthcare costs for one year survivors and for hospital survivors who died within the first year after cardiac arrest. we calculated effective costs per independent survivor (ecpis) as an indicator of cost-effectiveness. we adjusted all costs according to consumer price index (cpi) in finland as of . all costs are presented as euros (€). results: we identified , ca patients eligible for the analyses. at one year after ca % of the patients were alive and % were alive and independent in daily activities. one year survival stratified by cardiac arrest location group was % for out-ofhospital ca patients, % for in-hospital ca patients and % for in-icu ca patients. for the whole study population, mean healthcare costs were , € per patient. healthcare costs for hospital survivors were , € per patient and for hospital non-survivors , € per patient. healthcare costs for those who survived to hospital discharge but died within the first year were , € per patient, while for one year survivors they were , € per patient. healthcare costs stratified by ca location are presented in fig. . mean ecpis were , €. conclusions: for icu-treated cardiac arrest patients, the mean ecpis were close to , €. the best prognosis and the lowest costs were observed for out-of-hospital ca patients. introduction: in lithuania the incidence of out-of-hospital cardiac arrest (ohca) is unknown, as there is no official coding for ohca as a cause of death in the national death registry. kaunas emergency medical service (ems) underwent major stepwise changes since , including implementation of medical priority dispatch system and dispatcher-assisted cpr instructions. we sought to describe the epidemiology and outcomes from ohca in kaunas, the second largest lithuanian city. methods: the incidence, demographics and outcomes of patients who were treated for an ohca between st january and st december in kaunas ems, serving a population of almost . million, were collected and are reported in accordance with utstein recommendations. results: in total, ohca cases of ems treated cardiac arrests were reported ( per . of resident population). the mean age was . (sd= . ) years and . % were male. % ohca cases occurred at home and . % were witnessed by either ems or a bystander. in non-ems witnessed cases, . % received bystander cpr, whilst public access defibrillation was not used. medical dispatcher identified ohca in . % of all cases and provided over-the-phone cpr instructions in . % of them. average ems response time ( % fractile) was min. cardiac aetiology was the leading cause of cardiac arrest ( . %). the initial rhythm was shockable (vf or pvt) in % and non-shockable (asystole or emd) in . % of all cases. return of spontaneous circulation (rosc) at hospital transfer was evident in . % and survival to hospital discharge was . %. conclusions: rosc and survival to hospital discharge in kaunas were similar to those reported in united kingdom in [ ] . routine ohca data collection and analysis will allow us to track the efficiency of service improvements and should become a standard practice in all lithuanian regions. outcomes of patients admitted to intensive care following cardiac arrest j mcloughlin, e landymore, p morgan east surrey hospital, surrey, uk critical care , (suppl ):p introduction: patients who have return of spontaneous circulation following a cardiac arrest are haemodynamically unstable and require critical care input. outcomes are often poor, with unadjusted survival to hospital discharge at . %, following an in hospital cardiac arrest [ ] . the aim of the study was to assess the survival of patients admitted to intensive care following a cardiac arrest, reviewing whether age and gender impacted on their outcome. methods: the inarc database for a general intensive care unit (icu) at a district general hospital was reviewed. since , patients were admitted following a cardiac arrest (both in and out of hospital). their age, gender and survival to icu discharge and overall hospital discharge were recorded. results: female patients and male patients of varying ages were admitted to our icu following a cardiac arrest. the mortality for both genders increased with increasing age. overall survival to the time of icu discharge following a cardiac arrest was similar for both females ( . %) and males ( . %). figures (female) and (male) below show the number of patients who survived or died on icu discharge, by age and gender. mortality rates increased when reviewing hospital outcome, as some patients died following discharge to the ward. conclusions: overall mortality in our icu following a cardiac arrest at any age is at least %, with the general trend appearing to rise with increasing age. more male patients were admitted to icu following a cardiac arrest than female, with similar survival rates for both male and female patients. more research could be undertaken to assess whether survival rates following a cardiac arrest have improved since and also to compare outcomes following either an in or out of hospital arrest. introduction: raw simplified eeg tracings obtained by a bispectral index (bis) device significantly correlate with standard eeg [ ] . this study aimed to investigate whether simplified bis eeg tracings can predict poor neurologic outcome after cardiac arrest (ca). methods: bilateral bis monitoring (bis vistatm, aspect medical systems, inc. norwood, usa) was started following icu admission. six, , , , and hrs after targeted temperature management (ttm) at °c was started, raw simplified bis eeg tracings were extracted and reviewed by two neurophysiologists for the presence of burst suppression, cerebral inactivity and epileptic activity. at days post-ca, neurologic outcome was determined using the cpc scale, where a cpc - and cpc - corresponded to good and poor neurologic outcome, respectively. results: of the enrolled ca-patients enrolled, had good and poor neurologic outcome. with a positive predictive value (ppv) of . and a negative predictive value (npv) of . , epileptic activity within - hrs predicted a cpc - with the highest accuracy. epileptic activity within time frames - hrs and - hrs showed a ppv for poor outcome of . and . , respectively. cerebral inactivity within - hrs had a poor predictive power (ppv= . , npv= . ). in contrast, cerebral inactivity between - hrs predicted a cpc - with a ppv of . and a npv of . . the pattern with the worst predictive power at any time point was burst suppression with a ppv of . , . and . at - hrs, at - hrs and at - hrs, respectively. conclusions: based on simplified eeg derived from a bis device, both the presence of epileptic activity at any time as well as cerebral inactivity after the end of ttm can be used to assist with poor outcome prognostication in successfully resuscitated ca patients. the helicopter as first response tool -rio de janeiro fire department experience. (interquartile range= ) min, followed by tih with flights ( %) and median time of (iqr= ) min, and ( %) were neo missions with median time of (iqr= ) min. total time of aircraft usage was higher for tih ( %), followed by neo ( %). evam was the most frequent mission, however it accounted for % of aircraft utilization time, where most victims had traumatic brain injury (tbi) followed by other traumatic injuries ( and cases respectively). tbi victims were predominantly males ( %) with a median age of (iqr= ) years. most commonly, tbi is a consequence of transportation accident ( %), where a motorcycle was involved in %, car collision in % and pedestrian run over % of the cases. conclusions: goa utilizes the air ambulance helicopter as a first response tool in % of total missions, where respect for the trauma golden hour is paramount. traumatic brain injury is the most prevalent diagnosis at the scene of event. therefore, goa training and equipment must be tailored to meet this demand, which translates in stabilization of critical patients outside hospital environment with limited resources. introduction: the intra-hospital transport of critical patients is associated with adverse events and worse outcomes. the objective of this study was to evaluate the safety profile of intrahospital transport after the creation of a specific group for this purpose. methods: evaluated all the transports of critical patients from october to september , in a large hospital, after the creation of a group consisting of intensive care physician, nurse and physiotherapist. clinical and non-clinical complications related to the transport and outcome of the patients were evaluated. results: a total of , transports were performed, . % of the male patients and . % of the patients being hospitalized. . % were under mechanical ventilation and . % under vasoactive drugs. at the time of transport, . % were clinically stable. during transport, . % presented clinical complications, being more frequent hemodynamic instability ( patients) and respiratory failure ( patients). non-clinical complications occurred in patients ( . %), and communication failures were responsible for . % of the occurrences. in cases ( . %) there was worsening of the clinical conditions during transportation, and in only one case this worsening resulted in an increase in the length of stay in the icu and in the hospital, with no correlation with deaths. conclusions: the implantation of a group specialized in critical patients to carry out in-hospital transport made the process safer with complications rates lower than literature and guarantee better quality of care. clinical profile of patients admitted to icu due to acute poisoning mp benitez moreno , e curiel balsera , mc martínez gonzález , s jimenez jimenez intensive care unit, hospital regional universitario carlos haya, malaga, spain; hospital regional universitario carlos haya, málaga, spain critical care , (suppl ):p introduction: patients suffering from acute intoxication, whether voluntarily for autolytic or accidental purposes, often require life support in intensive care units. methods: retrospective observational study of all patients admitted for acute intoxication who required admission to the icu of the regional hospital of malaga between january and august , older than years with admission to the icu for intoxication of any kind. we study patient characteristics in terms of age, sex and medical history, type of toxicity, severity and evolution in our unit. results: we found cases of patients who required admission to the icu due to acute intoxication, of which . % were women. the average age was . (standard deviation . ). the average stay in icu was . (standard deviation . ). . % of patients had a psychiatric history. as other background highlights, . % were addicted to illegal drugs and % were hypertensive. most patients took more than one toxic . % and intoxication was voluntary in . % versus accidental in . % of cases. the toxic was known in %. the most used benzodiazepines in . % of the total. the main cause of admission to the icu was due to neurological deterioration in of the cases registered and mechanical ventilation was necessary in patients. the maximum time in mechanical ventilation was days. the infection occurred in . %, with the majority being respiratory infection. the . % died in icu. the hospital stay presented an average of . days. conclusions: the profile of a patient admitted to the icu due to acute intoxication is that of a woman of middle age and psychiatric history, with voluntary intoxication of several toxic substances and requiring mechanical ventilation for a low level of consciousness for an average of days. the survival is very high and it would be necessary to analyze the possible relapses of these patients. mushroom that break hearts: a case report e karakoc, k demirtas, s ekemen, a ayyildiz, b yelken eskisehir osmangazi university, eskisehir, turkey critical care , (suppl ):p a introduction: because of the high mortality and morbidity mushroom poisoning is a significiant medical emergency [ ] . amanita phalloides (a. phalloides) is responsible for the % of the mortality in adults caused by mushroom poisoning. it causes damage in liver, kidneys and rarely pancreas, causing encephalopathic coma, disseminated intravascular coagulation, hemorrhage, hypovolemic shock and death but its effect on cardiac functions has not been established yet. there are three main groups of toxins;phallotoxins, virotoxins and amatoxins;amatoxin is the common responsible toxin from the fatality. we aimed to present a -year-old woman poisoned by mushroom complicated with hepatic,renal and cardiac toxicity methods: patient with nausea and vomiting started hours after mushroom eating,creatine kinase mb . ng/ml and cardiac troponin i . ng/ml her blood urea nitrogen, creatinine levels and liver enzymes were higher than upper limits in lab tests (table ) ; she was admitted to icu, treated for acute renal failure by hemodialysis.plasmapheresis was applied against potent mushroom toxins. at .day in icu, hypoxemia and severe swelling resistant to ultrafiltration was evaluated as a global left ventricular hypokinesia with ejection fraction(ef) %, end-diastolic diameter of . cm, and systolic pulmonary artery pressure (spap) of mmhg. oxygen was administrated to treatment.urine output improved at .day, three more plasmapheresis sessions were performed. hypoxemia was recovered,liver enzymes and creatinin levels decreased results: at control ef measured was %, end-diastolic diameter of . cm, spap of mmhg.than at the .day patient discharged from the icu.after a year follow up assessment she has no complaints conclusions: one of the major problems for amanita poisoning is diagnosis. patients who had mushroom poisoning should also be evaluated especially in terms of cardiac dysfunction with clinic signs, ecg, cardiac enzyme tests and eco introduction: the characterization of clinical and/or biological variables found in the emergency room predictive of a secondary admission in icu would help to improve the identification of patients at risk of aggravation in order to avoid the associated consequences, such as, an increased mortality and increased hospital stay. methods: this is a retrospective monocentric study of years with patients admitted secondarily to a medical icu within hours of admission to the general wards from the emergency department in the pitié-salpêtrière hospital in paris. each case was matched to controls. different variables were collected in the emergency room. results: patients, of whom were cases and controls were studied. pneumonia is the diagnosis the most frequent in cases followed by sepsis (in and %, respectively). conclusions: the risk of being admitted secondarily to intensive care is higher if patients consult for dyspnea or fever, if they are old smokers, if they have a high igs score, if an arterial blood gas is requested and if an icu medical advice is taken. the meds score under and being an active smoker seems to be protects for the unexpected transfer. introduction: managing the special needs of patients who present with agitation or psychosis can pose a greater challenge to an already busy emergency department as their symptoms can escalate rapidly. traditional antipsychotics used in the ed, such as haloperidol or ziprasidone often do not fully relieve patient's symptoms and may require administration of repeat doses or additional medications such as benzodiazepines to achieve effective results. this can induce excess sedation which can lead to longer length of stay in the ed and requires additional time at the bedside by the ed physicians and staff to manage these patients. adasuve® is an antipsychotic drug that works in a single-use device providing an aerosol form of loxapine that is rapidly absorbed by the lungs which may offer faster symptom relief, allowing subsequent earlier psychiatric evaluation and disposition. methods: to test this hypothesis, data including time of physician assignment and time physician documented discharge disposition and number of hours physician was assigned to the patients was retrospectively collected from patients who arrived to the emergency department presenting with agitation or psychosis that received adasuve or other types of antipsychotic medication such as ziprasidone, haloperidol and benzodiazepines or a combination of the three. results: we found that physicians who administered adasuve spent an average of . hours assigned to their patient compared to . hours when the physician administered any other type of antipsychotic medication. this resulted in a significant . -hour difference (p < . ) between the two groups. conclusions: in conclusion, less time spent assigned to a patient that received adasuve can be attributed to faster symptom relief which allowed the physicians to complete their psychological evaluations and develop dispositions more rapidly than with patients that received other antipsychotic agents. clinical work in language-discordant emergency department introduction: emergency residents are particularly vulnerable to sleep deprivation due to persistent conflicts between work schedule and the biological clock. recent approaches to address fatiguerelated risk mainly focused on reducing work hours and ensuring sufficient recuperation time. such approach has demonstrated its limits due to growing emergency rooms visits and emergency residents' shortage. dawson & mcculloch ( ) introduced the notion of proofing as a complementary approach to manage fatigue-related risk [ ] . fatigue proofing strategies (fps) aim to reduce the likelihood a fatigued operator will make an error, in contrast of reduction strategies (frs) aiming to reduce the likelihood a fatigued operator is working. most formal risk control systems do not encompass the notion of proofing and fps typically develop as informal practices. in this study, we aim to ) identify informal reduction and proofing strategies used by residents and ) to investigate how they relate to fatigue-related risk indicators. methods: first, we organized focus-group with a total of residents in order to identify informal strategies used to manage fatigue-related risk. second, we designed a questionnaire assessing the frequency of use of each reported strategy. introduction: this randomized controlled study assessed the impact of a -hour intravenous medication safety simulation-based learning (sbl) on self-efficacy, stress, knowledge and skills of nursing students. medication administration error is a worldwide concern [ ], that has been linked with a lack of knowledge and skills in safe medication administration among new graduate and student nurses [ ] [ ] [ ] . preventing medication errors could therefore involve training through simulation. methods: participants (n= ) were randomly assigned either to the control group (cg, n= ) or the experimental group (eg, n= ). while cg and eg both had a traditional clinical internship, eg beneficiated in addition the -hour sbl, using standardized patients in the context of an intensive care unit. the two groups were assessed twice: at t and t (four weeks later), through an objective structured clinical examination (osce) and questionnaires. two blinded experts rated the students osce with an evaluation grid. results: mean participants age was , . there were no statistically differences between groups at t . compared to the cg ( %), the eg increased its self-efficacy (+ . %) with a significantly difference (p< . ) at t . the sbl conducted to a greater increase of knowledge and skills in the eg (respectively + %, + %) than in the cg (respectively + % and + %), with a statistically significant difference (p< . ). conclusions: results reinforce the interest of a short sbl using standardized patients to improve medication administration. clinical impact of these observations requires further evaluation to determine potential transfer in clinical settings and retention over time. introduction: medication errors occur frequently in the intensive care unit (icu) and during care transitions. medication reconciliation by a pharmacist could be useful to prevent such errors. therefore, the aim of this study was to determine the effect of medication reconciliation at the icu. methods: a prospective -month intervention study with a pre-and post-phase was performed in haga teaching hospital ( ) and erasmus university medical center ( ). the intervention consisted of medication reconciliation by pharmacists at icu admission and discharge. the severity of potential harm of the medication transfer errors (mte) (pade= ; . ; . ; . ; . ) was scored. primary outcome measures were the proportions of patients with >= mte at icu admission and icu discharge. secondary outcome measures were the proportions of patients with a pade score >= . , the severity of the pades and a cost-benefit analysis. odds ratio and % confidence intervals were calculated. results: table shows patient characteristics. figure shows the primary outcome measures (oradj admission = . [ % ci . - . ] and oradj discharge = . [ % ci . - . ]). the proportion of patients with a pade >= . at icu admission reduced from . % to . % and after icu discharge from . % to . %. the pade reduction resulted in a potential net cost benefit of € per patient. conclusions: medication reconciliation by pharmacists at icu transfers is an effective safety intervention, leading to a significant decrease in the number of errors and a cost effective reduction of potential adverse drug events. introduction: in intensive care unit, administration of numerous drugs in icu patients via a central venous catheter provide a high risk of drugs incompatibilities. it has been reported in experimental studies [ ] that particles issued of drug incompatibilities could induce thrombogenesis, microcirculation impairment and inflammatory response which could aggravate the occurrence of organ dysfunctions [ ] . the objective of this study was to evaluate the occurrence of particles by reproducing in vitro the intravenous system and the drugs combination used in icu for patients suffering either septic shock or acute respiratory distress syndrome (ards). methods: first, we registered during a period of months the most common central venous catheter system used in patients admitted for septic shock or ards in three university hospital in lille. the second part of the study was to reproduce in vitro the previous infusion system in order to quantify the amount of particles generated during a simulated period of hours infusion. the egress of the iv line was connected to a dynamic particle counter qicpic analyser (sympatec inc ; clausthal zellerfeld, germany) (fig. ) . results: the most common intravenous system observed was a three lumen central catheter. the proximal lumen was dedicated for vasoactive agents, the medial lumen for sedation and the distal lumen for the other drugs infused continuously and discontinuously..among the drugs infused via the distal lumen of the central venous catheter, introduction: insufficient identification of possible organ donors in the icu is one of the main factors contributing to the loss of donors after brain death [ ] . up to % of potential donors might not be identified [ ] . the aim of this study was to evaluate how active search of possible brain dead donors affect the potential deceased donor pool. methods: the strategy implemented at university hospital with specialized icus from december to october and data compared to the matching period of the previous year. donor coordinator visited all icus every day and selected patients who met possible brain dead donor criteria: ) gcs <= ; ) severe brain injury. all data registered in original color coded follow-up system according to the patient status. results: a total of patients were identified as possible donors. there was no significant difference of potential donor numbers in study period comparing to previous year ( vs ). main causes of brain death remain intracranial hemorrhage and subarachnoid hemorrhage. the length of hospital stay of potential donors was significantly longer in study period comparing to previous year ( ± . vs . ± . , p= . ). there was no significant difference of donor's demographic data, conversion rates to actual donor or frequency of family refusals and medical contraindications. conclusions: active search of brain dead donors neither increased total number of potential donors nor increased conversion rates and did not change a donor profile in our donor center. longer observational period and more sophisticated follow-up system might be required. a fast hug bid a day keeps the patient ok! e sousa, t leonor, r pinho centro hospitalar de entre douro e vouga, santa maria da feira, portugal critical care , (suppl ):p introduction: regardless the underlying diagnose, providing meticulous supportive care is essential to critically ill patients management. in , vincent jl introduced the fast hug (feeding, analgesia, sedation, thromboembolic prophylaxis, head of bed elevation, ulcer prevention, glucose control) mnemonic for recalling what he considered the key issues to review in daily clinical practice. our intensive care unit (icu) decided to add bid (bowel regimen; indwelling catheter removal; de-escalation of antibiotics) indicators following some published data. since , the adequate use of this mnemonic became an instrument for quality of care evaluation. objectives for each variable were designed; regular annual audits done. the present study aims to audit the use of this mnemonic in a portuguese tertiary hospital icu, in . methods: a prospective observational study was performed. admissions in icu staying at least one h min and h min period, during the first six months of were included. all mnemonic variables were recovered from icu medical record database, as well as demographics, severity scores and clinical information. data was analyzed with microsoft office excel software. results: we included admissions. the predictable global fast hug bid assessment was entries [one per each full day ( h - h ) in the unit, per patient]. the mnemonic was used in about % of the opportunities. the target thresholds were considered as achieved in % of entries (concordance equal or superior to %). looking to individual variables, the best performance was achieved in h and u; worse performance was seen in s. the daily use of this mnemonic aims to revisit important intervention sectors in critical patient. applying the "plan-do-check-act" policy, this study allowed us to identify growth opportunities, reviewing or creating protocols, adopting more frequent training measures and seeking to take this model to other hospital areas. impact of incidents and adverse events in intensive care unit and its characteristics on outcomes e siqueira, l taniguchi, j vieira junior hospital sírio libanês, sao paulo, brazil critical care , (suppl ):p introduction: critically ill patients are usually exposed to adverse events (ae) due to acuity and complexity of care. ae might potentially result in disability or death, and increase in length of stay. our aim was to assess the incidents and ae in a general intensive care unit (icu). methods: this is a prospective cohort study conducted in a private tertiary hospital (hospital sírio-libanês) in são paulo, brazil. all consecutive patients who were admitted to the icu and all incidents and ae reported in the study period were evaluated. univariate and multivariate analysis were used to identify risk factors associated with hospital mortality. results: between may to november we studied patients and reported incidents and ae. overall, patients ( %) experienced some incident or ae during icu stay. we found higher severity of illness (saps of versus ; p< . ), mechanical ventilation (mv), use of vascular lines, drains and catheters, physical restraints, delirium and also an increased length of icu ( vs days; p< . ) and hospital stay ( vs days; p< . ) and hospital mortality ( % vs %; p< . ) among patients who experienced any incident or ae. independent risk factors for hospital mortality in our logistic model were: higher saps , mv and at least one adverse event during the icu stay. mortality was higher among patients who experienced late ae (> hours after icu admission) compared to patients who experienced early ae ( % vs %; p< . ). saps , sofa and mv were predictors of moderate and/or severe ae and a negative correlation between these events and icu occupancy rate was found. conclusions: patients who experienced incident or adverse event during icu stay had poorer outcome. ae, mainly moderate or severe, mv and severity of illness were independent risk factors to mortality. there was a negative correlation between moderate or severe adverse event and icu occupancy rate. monte carlo modelling of patient flow can aid complex intensive care bed and workforce capacity planning. introduction: models for icu populations based on the queuing model use arrival rate, length of stay, and bed number [ , ] . these models lack the complexity of specialised icus with different admission types, and patient subpopulations. results: > % of patients reported satisfaction on all areas except noise, patient facilities for hand hygiene and being informed about timing of operations. staff survey results revealed confusion regarding the interventions that are provided. baseline capacity for new patients was %, bed occupancy varied between and per day (overflow to recovery) with overall capacity at . % and mean length of stay (los) was . days (sd= . , n= , =range - ). following intervention, the los was reduced to . days (sd= . , n= , range - ). new patient capacity was increased to % with a bed occupancy range - . introduction: in clinical practice, when harm or potential harm occurs to patients, this can adversely impact upon the morale of staff involved and thereby affect clinical care delivered to subsequent patients. the personal narratives behind clinical incidents contain learning opportunities and individuals involved may reflect on the course of events and make changes to their practice to avoid recurrence. the aim of this study was to evaluate whether sessions enabling trainees to discuss their mistakes in a confidential environment improved trainee morale and safe clinical practice in an anaesthetic trainee cohort. methods: we conducted a survey amongst anaesthetic trainees in a london teaching hospital before and after a monthly, hour long, confidential, semi-structured, trainee lead "confession session" was introduced. results: initial results demonstrated that % of respondents (n= ) had made a mistake resulting in patient harm with % of these individuals describing negative feelings about themselves as a consequence. additionally, % of respondents had made a mistake causing a near miss, with % of these describing negative feelings as a result. of note, only % of respondents felt comfortable discussing errors with more senior colleagues, whilst % felt comfortable discussing errors with their peers. a follow-up survey identified that % of respondents (n= ) agreed that the session had the potential to improve clinical practice and trainee morale with % agreeing that their own clinical practice had improved from attending the sessions. conclusions: clinical mistakes leading to harm and "near misses" are common and provide opportunities to improve care. this trainee lead "confession session" appears to improve trainee morale and may improve patient care by encouraging trainees to engage in a process that seeks to understand error through sharing stories in a non-judgmental setting. funnel plots for quality control of the swiss icu -minimal data set introduction: a clinical database should be representative of the labelled population and guarantee completeness and accuracy of collected data. without explicit permission of the patients, swiss laws regarding data protection do not allow external audits based on periodic checks of random samples, supposed to give a general pattern of accuracy. to test alternative methods for quality control we introduced the principles of statistical process control to derive funnel plots from the swiss icu -minimal data set (mdsi). the mdsi from all certified adult swiss icus ( and ) was subjected to quality assessment (completeness and accuracy). for the analysis of accuracy, a list of logical rules and cross-checks was developed as e.g. range of saps ii according to age. errors were classified in coding errors (e.g. nems score > points) or implausible data (nems without basic monitoring). we also checked for icus producing significantly more errors -outliers -(> mean ± standard deviations [sd] or > . % confidence interval [ci] of an adapted version of the funnel plots, which allows the presence of trends depending of the icu's size. results: a total of ' patient mdsi ( items/patient; items for trauma patients) from the certified icus.were investigated. we detected ' patients ( . %) with an overall sum of coding errors and ' implausible situations. implausible situations related to supposedly inaccurate definitions (diagnostic and patient's provenance prior to icu admission) and discrepancies in the logical rules between diagnostics and treatments. figure is an example for imprecise coding of the diagnostic: icus declared having treated - % of their patients without a defined diagnosis. conclusions: accuracy of data in mdsi needs further improvement. funnel plots may be useful for meaningful interpretation of data quality and permit to identify icus disproportionately generating inaccurate and/or implausible data. introduction: lung cancer is the leading cause of intensive care unit (icu) admission in patients with the advanced solid tumors. this study was aimed to elucidate the clinical factors associated with icu mortality of advanced lung cancer patients and the effect of intensivist's contribution on their clinical outcomes. methods: we included patients with advanced lung cancer including non-small cell lung cancer (nsclc) with stage iiib or iv and small cell lung cancer (sclc) with extensive stage who admitted to icu from to . multivariate logistic regression analysis was performed to find the variables associated with icu mortality and in-hospital mortality. we applied autoregressive integrated moving average (arima) for time-series analysis of the intenvention of intensivists. results: among total patients with advanced lung cancer, patients ( . %) were admitted icu before introduction of organized intensive care at , and ( . %) were admitted after (fig. ) . the leading cause of admission was the respiratory failure ( . %) and cancer-related event ( . %) in terms of intensivist's and oncologist's perspective. before and after , the -day icu mortality rate was . % and . % (p = . ), and the hospital mortality rate changed from . % to . % (p = . ) (fig. ) introduction: decisions when to refer and to admit patients to the intensive care unit (icu) care are very challenging. demand typically exceeds supply in icu beds, which results in a constant need for evaluation of the processes involved in icu referral and admission with a view to optimising resource allocation and patient outcomes. the aim of this study was to evaluate the theoretical impact of a newly designed triage tool for icu referrals on a cohort of patients referred to icu (fig. ) . methods: we reviewed all patients consecutively referred to our icu, whether admitted or not, in february . demographics, referring speciality, role of the referrer, comorbidities, the presence of advanced disease or terminal illness, the presence of acute organ failure, dnr status, reason for not admitting, and icu mortality were recorded. a retrospective analysis of icu referrals using a pilot triage tool was carried out independently by three authors. results: forty-six patients were referred to our icu over the study period. of these, ( %) were admitted. patients were declined icu if their admission was deemed unnecessary ( %), futile ( %), or were transferred due to bed shortage ( %). of the patients referred, ( %) had an advanced disease or a terminal illness. of those, ( %) were admitted, dnr status was unclear in ( %), family was involved in ( %) and their icu mortality was %. by analysing retrospectively these referrals with the aid of a triage tool, we propose that the overall referrals could have decreased from to ( % percentage difference). dnr status and family involvement would have been clarified in all patients with advanced disease or terminal illness before icu referral. kappa score for inter-rater agreement was . . conclusions: adopting a triage tool for icu referrals could reduce the overall proportion of inappropriate referrals and admissions. end-of-life discussion would also be proactively clarified prior to icu admission. introduction: intensive care unit (icu) admission triage occurs frequently worldwide and often involves decisions with high subjectivity, possibly leading to potentially inappropriate icu admissions. in this study, we evaluated the effect of implementing a decision-aid tool for icu triage on icu admission decisions. methods: urgent icu referrals before (may, to november, , phase ) and after (november, to may, , phase ) the implementation of a decision-aid tool were prospectively evaluated. our primary outcome was the proportion of potentially inappropriate icu referrals (defined as priority b or patients, as described by the or society of critical care medicine [sccm] guidelines) that were admitted to the icu in hours following referral. we conducted multivariate analyses to adjust for potential confounders, and evaluated the interaction between phase and triage priorities to assess for differential effects in each priority strata. results: of urgent icu referrals, ( %), ( %), ( %), ( %) and ( %) were categorized as priorities b, a, , and (sccm ) or ( . %), ( . %), ( %), ( %) and ( %) were categorized as priorities , , , and (sccm ), respectively. overall, ( %) patients were admitted to the icu in hours following referral. the implementation of the decision-aid tool was associated with a reduction of admission of potentially inappropriate icu referrals [adjor ( % ci) = . ( . - . ), p = . ] (fig. ) . there was no difference on hospital mortality for the overall cohort between phase and phase . conclusions: the implementation of a decision-aid tool for icu triage was associated with a reduction of potentially inappropriate icu admissions. introduction: the aim was analyze the icu bed rotation pattern, the epidemiological characteristics of patients and to correlate them with prognostic score after software implementation methods: this is an epidemiological and retrospective study. data were collected between june and november , using epimed® monitor software, applied in an adult icu of a public hospital in bahia/brazil. authorization for collection and use of data was granted by the institution. all patients hospitalized in the period were included regardless of other exclusion criteria. results: during the period evaluated, there were . new hospitalizations, men ( . %) and women ( . %). . % ( ) were in the age group of to years, followed by . % of the patients ( ), who were between and . the mean duration of hospitalization in our unit was approximately , days. during the period covered, . exits occurred: patients ( . %) were introduction: early debriefing after stressful events holds great value in reflection on both an individual and team-based level. our objective was to implement routine structured debriefing sessions for doctors working in intensive care in order to optimise learning and develop strategies to improve practice. methods: % of junior doctors (n= , pre-implementation questionnaire) on the intensive care unit expressed a need for regular debriefing sessions to discuss challenging and complex cases. weekly sessions were implemented and structured using the sharp performance tool [ ] . key learning points were collected and added to a debrief list to track progress and assimilate learning. informal feedback was obtained on a weekly basis with formal feedback assessed following one month of implementation. results: min sessions occurred on a weekly basis supported by a consultant intensivist. desired outcomes included assessment of team performance, identification of key learning points and psychological support. following one month, % doctors involved felt that debriefing sessions were important and should continue. % felt that they left every session with a key learning point applicable to future clinical practice. common themes in perceived benefits included improved team communication and creation of an open environment to address concerns. conclusions: working in intensive care exposes doctors to challenging and stressful situations. implementation of a regular structured debrief session provides an opportunity for clinicians to address concerns, consolidate learning and develop strategies to improve clinical practice. nurse staffing patterns, outcomes and efficiency in resource use in the context of icus with a "low-intensity" nurse staffing: a multicenter study in brazilian icus m soares introduction: studies investigating nurse staffing and outcomes were often conducted in high-income countries with low bed/nurse ratios. our objective was to investigate the association between nurse staffing patterns, outcomes and resource use in brazilian icus. methods: retrospective cohort study in , ( % medical) patients admitted to medical-surgical icus during - . we retrieved patients' data from an icu registry (epimed monitor system) and surveyed participating icus about characteristics related to icu organization. we used multilevel logistic regression analysis to identify factors associated with hospital mortality. we evaluated efficiency in resource use using standardized mortality rates (smr) and resource use (sru) based on saps . results: saps score was ( - ) points and hospital mortality was . %. intensivists were present / in % icus. median bed/ nurse ratio was . ( . - . ) and at least the chief nurse was boardcertified in critical care (bccc) in % icus. bed/nurse technicians ratio was . ( . - . ). adjusting for relevant characteristics at patientlevel (age, admission type, sofa, performance status, comorbidities, hospital days before icu) and icu-level (hospital type, checklist use, / intensivist, protocols), bed/nurse ratio was not associated with mortality [or= . ( % ci, . - . )]. however, mortality was lower in icus with at least the chief nurse bccc [or= . ( . - . )]. in multivariate analysis, bed/nurse ratios <= [or= . ( . - . )] and having the chief nurse bccc [or= . ( . - . )] were associated with higher efficiency. conclusions: in a "low intensity" nurse staffing scenario, bed/nurse ratios were not associated with mortality. however, having at least the nurse chief bccc was associated with higher survival. moreover, bed/nurse ratios <= and presence of chief nurse bccc were associated with higher efficiency in resource use. methods: a systematic search on the value of acute non-physician provider on the icu was conducted. the methodological quality of the included studies was rated using the newcastle ottawa scale (nos). the agreement between the reviewers was assessed with cohen's kappa. results: in total studies were identified. twenty comparative cohort studies were identified which compared non-physicians with either residents or fellows. all studies comprised adult intensive care. most of the included studies were moderate to good quality. a random effects meta-analysis from all studies regarding length of stay and mortality showed no differences between non-physicians and physicians, although there was a trend to better survival when implementing acute non-physician providers in the icu (figs. & ) . mean difference for length of stay on the icu was . ( % ci - . - . ; i = %) and for in hospital - . ( % ci = - . - . ; i = %); while the odds ratio for icu mortality was . ( % ci = . - . ; i = %) and for hospital mortality . ( % ci . - . ; i = ). conclusions: the acute care non-physician provider in the icu seems a promising clinician on the icu with regard to quality and continuity of care. whether they also can reduce mortality remains to be determined by designing studies, which adequately measure the contribution of the non-physician providers in icu care overall and per task. their role in europe remains to be elucidated. burnout and depression in icu staff members n bahgat menoufia university hospital, shibin elkom, egypt critical care , (suppl ):p introduction: family and success in work are the most important sources of person satisfaction in life, chronic prolonged exposure to stressful high workload in intensive care units (icu), create a bad psychological state named burnout syndrome in which person is depressed, exhausted and thinks to leave job. in this study we made a survey on icus staff members in egypt menoufia university hospital to explore and find risk factors increase depression and burnout among nurses and doctor. methods: questionnaires were given to all intensive care staff for estimating the prevalence and associated risk factors of burnout using maslach burnout inventory (mbi) with its three subscales emotional exhaustion (ee), lack of accomplishment (la), and depersonalization (dp). depressive symptoms using the beck depression inventory scale. blood sample was taken for assessing depression biomarkers including il- , tumor necrosis factor (tnf)-alpha, and coenzyme q (coq ), which appears to be one of the most reliable peripheral biomarkers. results: participants were respond in our survey from icu members the response rate was . %, the depression symptoms found increased in nurses more than physicians in icu with more desire to leave the job. there was strong correlation between the degree of depression symptoms and decrease percent of personal accomplishment. impaired personal relationships at work and increased night shifts were major risk factors of burnout syndrome. levels of the proinflammatory cytokine (il and tnf alpha) were elevated in members who recorded sever degree of depression score with decrease in concentration of co-enzyme q . conclusions: the health workers in icu had high liability for depression and burnout syndrome. the risk factors differ between nurses and doctors. il , co-enzyme q and tnf alpha concentrations had god correlation with degree of severity of symptoms. impact of a tailored multicomponent program to reduce discomfort in the icu on post-traumatic stress disorder: a casecontrol study p kalfon , m alessandrini , m boucekine , m geantot , s renoult , s deparis-dusautois , o mimoz , j amour , e azoulay , c martin , t sharshar , m garrouste-orgeas , k baumstarck , p auquier introduction: reducing discomfort during the icu stay should be beneficial on long-term outcomes. the aim of this study was to assess the impact of the implementation of a tailored multicomponent program to reduce discomfort in the icu [ ] on the occurrence of posttraumatic stress disorder (ptsd) months after discharge from the icu. methods: design: case-control study; the cases were patients hospitalized in the icus which implemented the tailored multicomponent program; the controls were patients hospitalized in the icus which did not implement the program. exposition: the tailored multicomponent program consisted of assessment of icu-related self-perceived discomforts by using the iprea questionnaire, immediate and monthly feedback to healthcare teams, and tailored site-targeted measures under control of a duo of local champions. general procedure: eligible patients were recalled months after the icu stay. data collection: sociodemographics, clinical data related to the icu stay, discomfort's levels assessed the day of discharge from the icu, life situation (home/care center), pstd (ies-r) and anxiety-depression symptoms (hads) months after the icu discharge. results: from the eligible cases and eligible controls, cases and controls were included (reason for exclusion: deaths after discharge from the icu, lost to follow-up, patient refusal, cognitive incapacity). a total of . % of the cases and . % of the controls presented certain symptoms of ptsd at months (p= . ). after adjustment for age, gender, iprea score, mccabe score, presence of invasive devices during the icu stay and considering anxietydepression symptoms at months, cases are less likely to have ptsd symptoms than controls. conclusions: our tailored multicomponent program for discomfort reduction in the icu can reduce long-term outcomes as ptsd. diffusion of such a program should be enhanced in the icus paving the way for a new strategy in care management. introduction: cognitive dysfunction is a major factor leading to disability and poor quality of life in icu survivors. in order to identify patients at risk for developing cognitive dysfunction due to critical illness or icu treatment, one has to discriminate between patients with pre-existing cognitive dysfunction and those developing new cognitive dysfunction or worsening of cognitive function during icu treatment. we investigated the incidence of pre-existing cognitive dysfunction in icu patients using the informant questionnaire on cognitive decline in the elderly (iqcode) and its relation with delirium during icu treatment. methods: patients relatives were asked to fill in the iqcode on admission. an overall score on cognitive dysfunction was calculated by the average of the score on each item of the questionnaire. the incidence of delirium was based on the cam-icu score. statistical analysis was performed using the fisher's exact test. p-values of less then . were deemed significant. results: in total consecutive patients admitted to our icu were analyzed, of whom . % (n= ) showed decline in cognitive function prior to icu admission. cognitive function was divided in four groups; no change . % (n= ), slight decline . % (n= ), moderate decline . % (n= ) and severe decline . % (n= ) (fig. ). incidence of delirium is shown in fig. . patients with moderate to severe cognitive dysfunction showed significant more delirium during icu treatment than patients with no change in cognition ( . % and . % respectively, (p= . )). conclusions: almost half of the patients admitted to the icu have cognitive dysfunction prior to icu admission. to assess ones cognitive function after icu treatment one has to take in to account the patients pre-existing cognitive functioning. patients with a moderate to severe pre-existing cognitive dysfunction develop significantly more delirium during icu treatment. introduction: our aim was to identify and analyse patients treated for pocd admitted to a thoracics/urology intensive care unit at university college london, uk. pocd is rising in the ageing high-risk surgical patient. early identification of those at risk and timely intervention could help reduce associated morbidity and mortality [ ] . methods: we identified patients treated with haloperidol, midazolam, lorazepam, olanzapine, clonidine or chlordiazepoxide from our electronic data system. these pharmacological interventions were used as surrogate markers of primarily hyperactive pocd, acknowledging other forms of delirium may be unaccounted for. of admissions ( . %) were shortlisted from august to july . patients were excluded if the drugs had been used for other indications. prevalence of known pocd risk factors were then detailed. on these data we performed a cluster analysis using r. results: of the patients ( . %) suitable for analysis, the mean age was . patients underwent elective procedures. were male and were female. % patients had thoracic surgery. the mean pain score in the first hours post-op was . (sd= . ), (with = no pain, = very severe pain). % had evidence of poor sleep and % evidence of anxiety. in the hours prior to evidence of pocd, the mean pain score remained . (sd= . ), % had evidence of poor sleep and % had evidence of anxiety. % of our population was septic during their itu admission. conclusions: our analysis demonstrates pocd is highly prevalent in male patients over undergoing thoracic procedures. we will now develop a pocd pathway targeting improved postoperative management of pain, sleep, anxiety and infection in this patient population. introduction: our objective was to determine the feasibility of employing family-administered tools to detect delirium in the critically ill. the use of family-administered delirium detection tools has not been assessed in the icu where patients are critically ill and frequently intubated. family members may be able to detect changes in patient cognition and behavior from pre-illness levels earlier than unfamiliar providers. these tools may be a valuable diagnostic adjunct in the icu. methods: consecutive patients and family members (dyads) in the largest adult icu in calgary, canada were recruited (aug. -sept. , ). inclusion criteria were: patients with a richmond agitation sedation scale (rass) >=- ; no primary brain injury and glasgow coma scale score of < ; ability to provide informed consent (patient/ surrogate); and remain in icu for hours. data were collected for up to days. family-administered delirium assessments were completed once daily (family confusion assessment method & sour seven). to assess feasibility, we assessed proportion of eligible patients and percent family member enrollment. barriers to enrollment were categorized. results: of admitted patients with family, ( %) met inclusion criteria and ( %) dyads consented. % of admitted patients did not have family and were thus ineligible. % of enrolled dyads assessed delirium at least once, with a median of (of total) assessments. the most common reason for non-enrollment was refusal by the family, who commonly reported feeling overwhelmed by the icu environment. barriers with nursing staff were encountered, including not providing access to patients and patient exclusion. conclusions: these data suggest that employing family-administered delirium detection tools in the icu is feasible for a subset of the population. future studies will validate the use of these tools in the icu, decrease modifiable barriers to enrollment, and test strategies to overcome attitudinal barriers towards employing these tools. introduction: psychological impact of critical illness and icu stay on patients can be severe and frequently results in acute distress as well as psychological morbidity after discharge [ ] . however, the stressful experience in icu and its influence on patient recovery, remain relatively understudied. we assessed patients in icu for acute distress and psychological symptoms with validated tools. methods: we conducted an observational study in a group of awake icu adult patients admitted in a tertiary centre for at least hours, from january until october , with mixed diagnosis on admission. we collected demographic factors, saps ii at admission, mechanical ventilation, day of sedation, history of psychopathological disorder. un-sedated and alert, critical care patients were assessed with tools such as intensive care delirium screening checklist (icdsc), hospital anxiety and depression scale (hads) and intensive care psychological assessment tool (ipat). results: patients were recruited, (mean age . ± . years, . % males). saps ii at admission was . ± . , . % was mechanically ventilated (mean duration . ± ), mean duration of sedation was . ± . days and a rate of . % had an history of psychopatological disorder. . % of the sample had clinical delirium (icsdc> ) and was not assessed with others tools, . % had subclinical delirium (icsdc <= ). regarding psychological outcomes, . % (mean score . ± . ) reported a score (>= ) on hads that indicates a possible diagnosis of anxiety and . % (mean score . ± . ) of depression. a rate of . % reported a score >= on ipat suggesting an acute distress. conclusions: the study's key finding was that acute psychological distress was high in awake icu patients. further work is needed to determine the efficacy of early psychological interventions to reduce the incidence of acute distress and psychological outcomes after icu stay. introduction: a high percentage of polytrauma patients require surgery within the first hours to stabilize primary traumatic injuries. one of the main intraoperative complications in this type of patients is due to hemodynamic instability [ ] . thus, it is necessary to implement multimodal monitoring involving both hemodynamic monitoring and monitoring of general anesthesia. the objectives of this study were to identify the possible implications of entropy monitoring on hemodynamic stability in critically ill polytrauma patients. methods: prospective observational study, deployed in the clinic of anesthesia and intensive care, emergency county hospital "pius brinzeu" timisoara, romania. clinicaltrials.gov identifier. there were two groups, group a (n = ), in which the depth of hypnosis was monitored through entropy (ge healthcare, helsinki, finland) and group b (n = ). results: the incidence of hypotension and tachycardia episodes was statistically significantly lower in group a, unlike the control group (p < . ). moreover, a statistically significant (p < . ) consumption of inhaled anesthetic agent was recorded in group a compared with group b. consumption of vasopressor was also lower in group a (p < . , difference between means . ± . , % confidence interval . - . ) conclusions: deploying monitoring for the depth of hypnosis in general anesthesia using entropy can significantly increase the hemodynamic stability of critically ill polytrauma patients. introduction: the use of methadone as a potent analgesic has been gaining ground in the intensive care setting, such as where it is possible to properly select the group of patients who will benefit from the drug, as well as monitoring of possible complications. the objective of this study is to evaluate the safety of the use of methadone in critically ill patients in a large hospital. methods: a retrospective analysis of all patients who used methadone in a neurological intensive care unit for a period of four months and the results were evaluated. results: in the four-month period, patients used methadone during intensive care. % of the patients were male, with a medical age of . ± . years. the main indication for the use of the medication was for analgesia in patients who were weaned from mechanical ventilation. the mean time of use was . days. in all cases evaluated, analgesia was effective, with methadone being used alone or in combination with other drugs, according to an institutional protocol. among the complications found, patients presented hypotension ( %); presented bradycardia ( %); presented constipation ( %); had excessive sedation ( %) and had other complications. all complications were reversible. patients of the studied population died, however, without correlation with the use of methadone. conclusions: the use of methadone, in the studied group, was effective in the control of analgesia, with no impact on patient safety when used in a monitored way. introduction: renal colic is a common disorder which presents with dramatic acute pain. providing rapid relief, using effective pain control medications is the clinical priority to treat the patients. this study aims to compare the effect of iv ketorolac versus morphine in releasing renal colic pain by measuring pain severity and duration and also the need for additional doses. methods: we performed a clinical pilot cohort study from during on patients with the clinical diagnosis of renal colic who recruited from the emergency department (ed) of rasool-e-akram hospital and firoozgar hospital. participants who were candidate to receive either morphine or ketorolac were divided into two groups who received either mg ketorolac iv or mg morphine. the pain was evaluated using the visual analog scale (vas) at four time points: before drug injection (vas- ), minutes (vas- ), minutes (vas- ), and minutes (vas- ) after injection. in cases when the pain was not controlled with the first injection of drug beyond minutes; additional doses (rescue) were injected. statistical analyses were performed using spss . results: one-hundred-fifty patients treated with morphine and ones with ketorolac were studiedthe group treated with morphine scored on average . before the injection, which was roughly . points higher than ketorolac. morphine reduced patients' vas scores more intensely (median: , iqr: versus median: , iqr: ; p value< . ). in general, patients treated with morphine were more likely to need a second (rescue) dose, when compared to ketorolac group ( . % vs %, p value= . ). conclusions: morphine is a better option for pain release in cases of renal colic. ketorolac released the pain to an acceptable level; but, because of its slower action time, we recommend it in cases with moderate than severe pains. effect of analgesics on cardiovascular and hormonal response to operative trauma d loncar stojiljkovic, mp stojiljkovic sgh, , serbia critical care , (suppl ):p introduction: objective of this study was to compare the effects of two analgesic regimens, one opioid and one non-opioid, on cardiovascular and hormonal reaction of patients undergoing elective surgery under general endotracheal anaesthesia. methods: a total of elderly patients, asa , scheduled for elective abdominal surgery were assigned to receive on induction a single dose of either fentanyl ( . mg, + . mg) or a fix combination of etodolac and carbamazepine (novocomb, dose mg+ mg iv bolus). haemodynamic parameters and concentrations of prolactin cortisol and growth hormone (gh) [ ] were determined at critical points and h after operation. results: both fentanyl and novocomb blocked the hypertensivetachycardic response to surgical trauma. cortisol was a more appropriate endocrine marker of stress than prolactin or gh since fentanyl as an opioid analgesic increased secretion of prolactin [ ] , while carbamazepine from novocomb did the same with gh [ ] (figs. & ) . conclusions: cortisol plasma concentration correlates positively with cardiovascular parameters in patients undergoing elective abdominal surgery who received fentanyl or novocomb as intraoperative analgesic. its suppression is better marker of analgesia than prolactin and gh. volatile anaesthetic consumption and recovery times after long term inhalative sedation using the mirus system -an automated delivery system for isoflurane, sevoflurane and desflurane introduction: the new mirus system as well as the anaconda uses a reflector to conserve volatile anaesthetics (va) [ , ] . both systems can be paired with icu ventilators, but mirus features an automated control of end-tidal va concentrations (etva). we compare feasibility and recovery times for inhalational long term sedation with isoflurane (iso), sevoflurane (sevo) or desflurane (des). methods: asa ii-iv patients undergoing elective or emergency surgery under general anaesthesia were included. patients were randomized into three equal groups iso, sevo and des. the mirus system was started with a targeted etva of . mac. we used the puritan bennett icu ventilator and performed a spontaneous breathing trial. if successful, the target concentration was set to mac and recovery times measured. results: patients were comparable in demographics, tidal volume, respiratory rate and sedation time (total h: iso ± h; sevo ± h; des ± h; p= . ). in all patients, a mac of . was reached. conclusions: mirus could automatically control end-tidal va concentrations in ventilated and spontaneously breathing patients. the recovery times are only prolonged in the iso group and could be shortened by removing the reflector. the higher etva required for a . mac using des and sevo were associated with an increased va consumption. introduction: intranasal analgesia is increasingly used in order to relieve pain in the emergency department. this non-invasive approach avoids discomfort, stress and risks related to the parenteral route of administration. the objective is to compare intranasal (in) fentanyl versus any parenteral opioid (intravenous, subcutaneous, intramuscular) for the effectiveness of acute pain relief in an adult population. methods: the systematic review was registered in prospero (crd ). the research of articles was conducted through embase, central, and medline databases. randomized clinical trials comparing the effectiveness of in fentanyl to any parenteral opioid for acute pain relief (<= days) in an adult population (>= years old) were considered for inclusion. studies on breakthrough cancer pain were excluded. two different reviewers extracted data and analyzed the quality of the selected articles. the main outcome was the difference between pain levels before and after analgesia. the effect size was approximated using the inverse of variance of standardized mean differences, based on a random-effect model. heterogeneity was quantified using a test of i . results are presented with % confidence interval. results: eight randomized clinical trials with cohorts and a total of patients were selected ( in fentanyl vs control group). selected articles contained a low risk of bias. there is no significant difference between the average levels of pain before and after analgesia comparing the two groups (smd . [ic % - . à . ], p= . ; i = %) (fig. ) . conclusions: in fentanyl is as effective as other parenteral opioid to relieve pain during the first hour of treatment. introduction: the aim of this study is to underline the importance of sedation protocol when performing the pegj procedure in advanced parkinson's disease (pd) patients. research about the use of sedation in endoscopy is getting more and more widespread as to answer to the increasing grade of complexity and duration of endoscopic procedures as to offer comfort to the patient in terms of analgesia, tolerability, and amnesia. sedation is also a way to assure quality and safety examination and to improve its outcome [ ] . methods: this observational retrospective study includes pd patients scheduled for pegj procedure (fig. ) in order to start therapy with duodopa gel. we propose an anesthetic technique (table ) to support pegj with both local anesthesia and moderate sedation so as to provide analgesia and patient's comfort. this technique ensures mean duration of pegj procedure was '± '. mean stay time in recovery room '± '. compared to our old experience, we collected lack of patient's discomfort, anxiety, and memory, high procedure compliance and improvement of the quality of procedure without use of opioids. conclusions: based on our experience, we consider this sedation protocol effective for different reasons: to relieve or abolish patient's discomfort, anxiety, and memory, to ensure compliance with the procedure, to ensure patient's analgesia and patient's safety and, finally to assure procedure's quality and rapid discharge. anyways, a multicentric study should be done to test our protocol. introduction: studies have shown that icu survivors exhibit longterm neurocognitive impairment and perceived reduction in quality of life after icu discharge, but studies examining sleep architecture and sleep disordered breathing (sdb) in icu survivors after icu discharge are scanty. the aim of our study was to assess sleep architecture and sbd in icu survivors. methods: icu survivors were screened for eligibility. inclusion criteria were: age - yrs, mechanical ventilation >= hours, gcs of at the time of hospital discharge. patients with a history of sbd, chronic neuromuscular disorders, chronic restrictive lung disease, congestive heart failure and respiratory failure at hospital discharge were excluded. patients were evaluated within one week after hospital discharge and months later. at both visits patients completed health related quality of life questionnaires (sf and epworth sleepiness scale), underwent a physical examination, lung function tests including maximum inspiratory and expiratory mouth pressures, and an overnight full polysomnography (psg). results: sleep quality at days of hospital discharge is poor, characterized by severe disruption of sleep architecture and excessive sdb, mainly of obstructive type which in % of patients was classified as moderate or severe. although at six months after hospital discharge sleep quality remained relatively poor, significant improvement in n stage and ahi was observed, with more patients to be classified as normal or mild sdb. both at hospital discharge and months later quality of life was reduced but there was no relationship between the health related quality of life and sleep disturbances. conclusions: icu survivors experience significant deterioration in their quality of life status with minor improvement months later and a variety of sleep disturbances that seems to start getting better months later. introduction: disrupted sleep in critically ill patients may be associated with delirium, prolonged stay in icu and increased mortality. polysomnography (psg), the criterion standard method of sleep monitoring, is challenging in icu due to interpretation difficulties, as the patterns defined by the standard classification for scoring sleep are absent in many critically ill patients. the aim of this study was to investigate if the presence of atypical patterns in critically ill patients' psg is associated with poor outcome measured by -days mortality in conscious critically ill patients on mechanical ventilation. methods: psgs (median duration hours) recorded in conscious critically ill mechanically ventilated patients were scored by an expert in sleep medicine blinded to patient characteristics. standard sleep scoring classification was used if possible. otherwise, modified classification for scoring sleep in critically ill patients proposed by watson et al. was applied [ ] . the association of sleep patterns (normal or atypical) and micro-sleep phenomena (sleep spindles and kcomplexes) with days mortality was assessed using weibull model by calculation of hazard ratios (hr). results: hr analysis showed twice as high mortality risk in case of atypical sleep compared to normal sleep; this was however not significant (hr . ; % ci . - . ; p= . ). the presence of sleep spindles in psg significantly reduced mortality risk to / (hr . ; % ci . - . ; p= . ). the presence of k-complexes in psg reduced mortality risk to ½, though not significantly (hr . ; % ci . - . ; p= . ). conclusions: the absence of normal sleep characteristics in psg in conscious critically ill patients on mechanical ventilation is associated with poor short-term outcome. antipsychotics (aps) prescribing in critically ill delirious patients, the reported versus the perceived practice e almehairi , g davies , d taylor introduction: aps are the most commonly prescribed drugs in hyperactive/mixed delirium and agitation in critical care (cc) [ ] . yet evidence in cc is scant, there are known adverse effects (ade) and prescription is out with the european license. meticulous observation of ap selection, prescribing and safety, alongside delirium assessment/plan is essential to gain new knowledge and patients. when accompanied by prescribing clinicians perspective of delirium ap treatment results are more interpretable. we conducted a two-part single centre cohort study that aimed to describe/compare real to perceived delirium assessment/plan, aps prescribing and safety in cc adult patients at gstt. methods: part : a prospective survey, of cc prescribing clinician's beliefs and attitudes to delirium assessment/plan, aps prescribing and safety over previous months. part : a meticulous audit of aps prescribing and safety and delirium/agitation assessment and plan, over period of months. results: part survey. of prescribers ( . %) completed survey. % of reported using aps to treat delirium, with % selecting atypical aps as first option. part audit. there were admissions to cc. aps were prescribed in . % ( prescription), . % ( prescription) were in delirium/agitation patients (table ) . survey (vs.) audit: in the survey % reported daily delirium screening whereas only . % undertook daily screening in audit (fig. ) . higher quetiapine and lower iv haloperidol maximum daily dose were prescribed in audit in comparison with survey reported doses ( table ) . lead ecg was used to monitor ap ade. in survey % reported assessing ecg once or more daily. audit revealed only % actually did so (fig. ) . conclusions: authors believe perceived vs actual can identify key areas for quality improvement (qi). major differences were in delirium assessment/plan and safety monitoring sedation practices in turkish icus, the aim was to provide knowledge on this matter. methods: an electronic survey form was generated with google forms. first part of the form included questions about demographics, and choices and routines of sedation administration. this part mostly contained multiple choice questions, which more than one choice could be indicated. second part was comprised of some statements to investigate the attitudes of physicians, which were indicated on a five-point likert scale. the link for the survey was posted to all email addresses registered in the turkish society of intensive care member database. results: of members, ( %) completed the survey form. demographics are given in table . sedation was generally applied by the physicians ( %). the indications were mechanical ventilation ( %), agitation ( %), seizures ( %), anxiety ( %), delirium ( %). drug choices of the respondents are shown in fig. . sedation level was evaluated daily by % of respondents, mostly using ramsay scale ( %). daily established sedation level was indicated in . %, and daily interruption of sedation was indicated in . % answers. sedation protocol was not used in . % of the answers. analgesics applied commonly, while % routinely evaluated pain and visual analogue scale (vas) was the preferred method in % of the answers. . % of physicians indicated routine use of neuromuscular blockers. in . % answers routine evaluation for delirium was indicated, mostly using cam-icu.when the knowledge of sccm guideline pain, agitation and delirium management, % indicated a positive answer.the respondents indicated their opinion for some comments on sedation, the answers are shown in the table . conclusions: it may be concluded sedation practices may need to be improved by increasing awareness on novel concepts in this area. fig. (abstract p ) . the prediction-corrected vpc plots for dexmedetomidine pk. the vpc plots show the simulation-based % confidence intervals around the th, th, and th percentiles of the pk data in the form of blue ( th) and gray ( th and th) areas. the corresponding percentiles from the prediction corrected observed data are plotted in black color methods: a prospective multinational cohort study was performed in icus in sweden, denmark and the netherlands. all adult patients with an icu stay >= hours were screened for inclusion. primary outcome was psychological problems three months after discharge from the icu, assessed with the questionnaires hospital anxiety and depression scale (hads) and post-traumatic stress symptoms checklist- (ptss- ). a subscale score > in the hads and a score > in the ptss- part b indicate clinically significant symptoms of depression, anxiety and pts and was considered an adverse outcome. we collected data on known risk factors for psychological problems post-icu. univariable and multivariable logistic regression modelling of risk factors was performed in order to create an instrument to be used bedside, predicting individual risk for adverse psychological outcome. results: patients were included and ( %) returned follow-up questionnaires. % of patients scored above the predefined cut-offs having symptoms of depression, anxiety or pts. age, lack of social support, depressive symptoms and traumatic memories at discharge remained significant after multivariable modelling and constituted the screening instrument ( table ) . the predictive value of the instrument was fairly good with an area under the receiver operating characteristics curve (auroc) of % (fig. ) . we developed an instrument to be used at icu discharge, predicting individual patients' risk for psychological problems three months post-icu. the instrument can be used as a screening tool for icu follow-up and enable early rehabilitation. improving the patients hospitalization experience in an intensive care unit by contact with nature w yacov , y polishuk , a geal-dor , g yosef-hay kaplan medical center, rehovot, israel; kaplan medical center, rehovot, israel critical care , (suppl ):p introduction: the intensive care unit is characterized by a noisy and threatening work environment using multi tecnologic equipment.the staff works very intensively caring for very complicated and unstable patients.whilst caring for the patients physical needs one must not forget the patients mentally needs.the improvement of the patients hospitalization experience by changing the environment improves the mood and responsiveness to treatment gives hope for healing to the patient and family. methods: a quality questionare with open questions relating to the subjective sensory experience of the patients and their families. the patients were transferred to the "sun balcony" for a period of - minutes having their families alongside. music was transmitted and the patients were offered food and drinks if their condition allowed. results: the patients reported a significant improvement of hospilizaton experience following their exposure to the "nature environment". patients described the sensory experience as a positive, pleasant, quiet and relaxing experience. the contact with the sun, wind, sky and grass and being outside on the "sun balcony" allows a disconnection from the threatening icu environment. conclusions: the "sun balcony" gave the patients a sense of hope and wish for healing. mobilizing complicated patients to the "sun balcony" is a big challenge which requires planning and preparation by the staff. yet by the proactive and creative thinking of the staff the patients are tranferred to the "sun balcony" to give them encouragement, a feeling of well being and hope for recovering. this intervention is costless and a routine procedure in the intensive care unit. introduction: long-term psychological outcomes of patients(pts) discharged from icu represent an emergent relevant matter of concern.systematic reviews refer prevalence of %- % for anxiety, %- % for depression and %- % for posttraumatic symptoms in ards patients.the onset of psychiatric symptoms after discharge, might be associated with patient's competence to process memories related with hospitalization and with memories. methods: we selected ards pts in icu of a tertiary centre (jan -dec ) at least hour, for months follow-up and pts for months follow-up after discharge. the psychopathological assessment was performed using scale as: impact event scale-revised (ies-r), hospital anxiety and depression scale (hads), icu memory tool (icu-mt). results: mean age was . ± . at months follow-up and , ± , at months. ptsd symptoms was fund respectively in % and . % pts at and months; anxiety symptoms % and . % of pts;depression symptoms in % and . %. significant correlations were fund between psychopathology at months and memories of icu: hads anxiety with delusion memories (r . ,p< . ); hads depression with factual (r . ,p< . ), feeling (r . ,p< . ) and delusion memories (r= . ,p< . ); feeling (r . ,p< . ). at months significant correlations was fund between hads anxiety and feeling memories (r . ,p< . ); ies-r and factual (r . ,p< . ), feeling (r . ,p< . ) and delusion memories (r . ,p< . ). the results of the study confirmed the importance of assessing psychopathology after discharge from icu. the onset of these symptoms appeared to be mediated by specific traumatic memories related with icu hospitalization. the main clinical recommendation emerging from this study is to investigate psychiatric history and develop psychological strategies to manage frightening or delusional experiences during icu stay. introduction: the aging of the population is a fact. the subgroup of very old (>= years (ys)) is the one that increases the most rapidly. intensive care unit (icu) admission of these patients is an ongoing discussion worldwide. our icu has designed the voolcano aiming its characterization and reviewing outcomes, to find some predictive indicators. the purpose of this first analysis is to evaluate specifically the group of very old patients (volds) admitted to a tertiary portuguese hospital icu. methods: retrospective observational study was preformed, included all volds admitted in icu during years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . demographic data, admission diagnosis, severity scores, charlson comorbidity index, length of stay and outcomes were considered. data analysis used spss software. results: we found a total of admissions. the median age was . ys with iqr ; mostly male with medical admission diagnosis (sepsis and respiratory failure due to infection). there was a median acute physiology and chronic health evaluation ii of (iqr ) and simplified acute physiology score ii of (iqr ). median charlson comorbidity index was . (iqr ). median length of stay was . days (iqr . ). concerning outcomes, we found intra-icu mortality of %; intra-hospital after icu discharge mortality of % and mortality after hospital discharge of %. identified as predictors of intra-hospital mortality the use of mechanical ventilation (p < . ), urgent surgical admission or medical admission versus schedule surgical admission (p < . ) and the absence of oncologic disease (p = . ). on multivariate analysis, only mechanical ventilation (p = . , hr . , % c.i. . - . ) and urgent surgical admission versus schedule surgical admission (p = . , hr . , % c.i. . - . ) remain significant. conclusions: recognizing the need to understand what is the biologic|funcional age (opposed to chronologic age) would be beneficial in the selection of volds to icu admission. organ failure and return to work after intensive care s riddersholm , s christensen , k kragholm , cf christiansen , bs rasmussen aalborg university hospital, aalborg, denmark; aarhus univeristy hsopital, aarhus, denmark critical care , (suppl ):p introduction: organ failure is associated with an unfavorable prognosis. nevertheless, the association with capability to return to work remains unclear. therefore, we investigated the association between organ support therapy as a proxy for organ failure and return to work in a nationwide cohort of icu survivors. methods: we linked danish registry-data on icu-and hospitalsurvivors working prior to hospital admission during - , - years of age, with an icu length of stay > hours and not previously treated with dialysis, to data on return to work. we reported cumulative incidences (chance) of return to work with death as competing risk, and compared rate of return to work in adjusted cox regression-models by number of organ support therapies including renal replacement therapy, cardiovascular support and mechanical ventilation and stratified on primary hospital-admission diagnosis. results: of , patients - years of age, % ( , ) survived to hospital discharge (tables and ). among these, the chance of return to work was . % ( % ci [ . - . ]) within two years (fig. (fig. ) . when stratified an increasing number of organ support was associated with a decreased chance of return to work among patients with infection, respiratory failure or trauma but not among patients with neoplasms or endocrine, gastrointestinal and cardiovascular diagnoses. introduction: mortality rates among people with moderate to severe learning disabilities (ld) are times higher than in the general population [ ] [ ] [ ] . this study was designed to examine critical care admissions with learning disabilities in terms of mortality, demographics and reason for admission. methods: data was retrieved for adult patients (> years old) between sept and . the ward watcher database for icus within surrey and sussex healthcare nhs trust was interrogated using search words including, learning disability, cerebral palsy, down's syndrome and autism. results: there were episodes ( . % of all admissions) of patients admitted with ld. % of the ld patients had more than admission. respiratory is the most common system affected ( %). logistic regression suggests survival is highest in those with a neurological reason for admission (p= . ). proportionally ld patients were young compared to the total population (fig. ) . we found that mortality appears to increase rapidly in those over years of age and overall mortality is greater in those with ld (fig. ) . conclusions: from april all uk trusts will be required to complete a detailed review for patients with ld who die whilst in hospital care. this follows mencap's report 'death by indifference' which exposed deficiencies in the care of people with lds who died whilst in nhs care and the subsequent confidential inquiry into premature deaths of people with learning disabilities. in our population, ld patients have an earlier death than the general population and the overall mortality from critical illness is greater. a multidisciplinary approach at the emergency department to admit potential organ donors for introduction: the aim of the present study is to improve the recognition of potential organ donors by implementing a multidisciplinary approach for organ donation at the emergency department (ed) [ ] . methods: in a prospective intervention study, we implemented this approach in six hospitals in the netherlands. when the decision to withdraw life sustaining treatment was made at the ed in patients with a devastating brain injury without contra indications for organ donation, an intensive care unit (icu) admission for end-of-life care was considered. every icu admission for end-of-life care was evaluated. interviews were conducted with emergency physicians, neurologists and icu physicians according to a standardized questionnaire. this interview focused on medical decisions that were made and difficulties arising during hospitalization. results: from january to november data were collected on the number of patients admitted to the ed with acute brain injury. in total, potential organ donors were admitted to the icu for end-of-life care. donation was either requested in the ed ( %), icu ( %), neurology department ( %), or donation was not requested ( %). out of donation requests, families ( %) consented to donation. this led to successful organ transplantations. in four of these patients family consent was obtained to intubate them solely for the purpose of organ donation. the most important points raised during the interviews were: explaining the non-therapeutic icu admission to the family, the location where donation should be requested (ed/icu) and utility of icu resources. conclusions: a close collaboration between the ed, neurology department and icu is necessary and achievable in order not to miss potential organ donors in patients with acute brain injury with a futile prognosis in the ed. introduction: there is a relationships between intensive care patients losing the ability to speak and negative emotions [ ] . nursing care is challenging when patients are unable to verbalise and factors like pain and comfort are misjudged.. our intensive care unit has introduced a communication tool intelligaze grid which enables patients with primary motoric disorders to communicate their needs. a quality improvement study reviewed the methods of communication and interactions that our nurses use for patients who are ventilated. the objective of the study was to promote areas of improvement with communication in the icu. methods: we used a mixed-methods qualitative and quantitative study to evaluate the communication tools used by our nursing staff to interact with ventilated patients. a convenient data sample for all nurses working on particular dates was collected which is % of the nursing workforce. the study has been approved as a quality assurance project by the human research ethics committee of nepean hospital. results: sixty registered nurses ( %) participated in the study. the most common communication tool used with patients was closed yes/no questions( %), followed by hand gestures( %), magnetic writing board( . %), lip reading( . %) and alphabet board( . %). the descriptive analysis identified challenges were levels of sedation, weakness, non-english speaking patients and delirium. a significant finding was that only % of nurses identified the patients message being understood and % acknowledged listening as effective communication. conclusions: communication is a vital aspect of icu nursing and is achieved through dialogue and specialised skills. the study concluded that icu nurses find it difficult to communicate effectively with ventilated patients. the introduction of intelligaze grid has improved patient communication and promotes holistic nursing care. p withdrawn introduction: substantial variability in eolp occurs around the world [ ] . differences in eolp were previously reported in europe in the ethicus i study [ ] . methods: icus worldwide were invited to participate through their country societies. consecutive admitted icu patients who died or had treatments limitations during a month period from . . to . . were prospectively studied. regions included north, central and southern europe (ne, ce, se), north and latin america (na, la), asia (as), australia (au) and africa (af). previous eolp definitions were used [ ] . results: icus in countries participated enrolling , patients. figure shows differences in eolp by region and figure in patient competency by region. conclusions: worldwide differences included more cpr in af, la, and se and less cpr in ne, au and na. there was more withdrawing (wd) in ne and au and less wd in la and af. more patients were competent in au and ne and less were competent in af, se and la. introduction: the decision of end-of-life care in the icu is very tough issue because the law, ethics, traditions and futility should be concerned involving family's will. especially, stop or withdraw therapy is a quite difficult operation in japan because of our traditions. recently there are few legal issues due to some guidelines. our hypothesis is some difference over time exists in thoughts about end-of-life care in the icu. the purpose of this study is to know changing methods: a questionnaire survey, which consists of questions with optional answers related to the thoughts of participants about end-of-life care of hopeless or brain death patients, was performed to nurses and doctors in our icu. the questions were; whether accept to withdraw therapy or not and with family's will, whether positive or not to donate of organs from brain death patient, necessary of icu care for brain death patient, feel guilty and stress for doing stop or withdraw therapy. the optional answer has gradations from 'yes' to 'no' for all questions. it was guaranteed to be anonymous for them in the data analysis. we conducted entirely same survey in . the answers between in and in were fig. (abstract p ) . patient mental compentency by region kidney disease: improving global outcomes acute kidney injury working group references nice clinical guidelines: idiopathic pulmonary fibrosis in adults: diagnosis and management references . zambon et al annual update in inten care references references references damage control management in the polytrauma patient crash- trial collaborators guidelines for the management of severe traumatic brain injury references references references . soar et al; european guidelines for resuscitation we acquired the confirmed date of death from the finnish population register centre database and gross -month healthcare costs from the hospital billing records and the database of the finnish social insurance institution. results: a total of patients were included in the study and were alive at months. median (interquartile range, iqr) -hour sofa score was ( - ) in -month survivors and ( - ) in non-survivors. the sofa score had an area under receiver operating characteristic curve of . ( % ci . - . ) for predicting -month mortality. in multivariate regression model with age and gender, sofa score had an odds ratio, or ( % confidence interval, ci) of . ( . - . ) for predicting -month mortality. all except cardiovascular sub-score also had p predictive factors for secondary icu admission within hours after hospitalization in a medical wards from the emergency room m cancella de abreu hôpital saint antoine p acquired neuromuscular weakness in eldery patients with femoral bone fracture, could we decrease the incidence? d pavelescu, i grintescu, l mirea emergency hospital floreasca p adasuve enables quicker dispositions of acute psychiatric patients in the emergency department k hesse , e kulstad , k netti , d rochford isi web of science and clinicaltrials.gov. data extraction: eligible studies were case reports and randomised controlled trials (rcts) that evaluated the effects of drug incompatibilities in critically-ill patients on morbidity or mortality as primary or secondary outcomes, or adverse events. two investigators independently reviewed the eligibility of the study from abstracts or manuscript data. data synthesis: twelve articles met the selection criteria (fig. ). the six articles reporting rcts concern only four rcts. rcts were single-centre studies comparing infusion with or without filter. two of them included adult patients. the others included pediatric and neonatal intensive care unit patients. primary endpoints were systemic inflammatory response syndrome (sirs), organ failure, overall complication rate, bacteremia, sepsis, phlebitis and length of stay. results: the results are mixed with one rct reporting a reduction in sirs, organ failure and overall complication rate, two studies in disagreement over the occurrence of sepsis and one study reporting no impact on length of stay. the six articles on case reports show different drug incompatibility situations european directorate for the quality of medicines & healthcare of the council of europe. guide to the quality and safety of organs for transplantation p current status and problems of organ transplantation before and after the enactment of the revised organ transplant law in p morale: introducing the anaesthetic trainee confession session results: of total patients admitted during study period, were eligible for study; . % were males and ( %) patients were transferred during after-hour. mean age of two groups (daytime vs. after-hour . ± . vs. . ± . years) was similar(p= . ) methods: retrospective analysis of prospectively collected data between october to february of a tertiary care icu in india. patient data collected on all consecutive icu admissions. primary and secondary outcomes were icu los and hospital mortality respectively. icu patients payer status were categorized as self-paid, corporate (paid-fully or partially-by-employer), and insurance (paid-fully or partially-by-third-party-payer). all analyses were adjusted for illness severity and icu support (vasopressor use, mechanical or noninvasive ventilation, blood transfusion). results: of patients admitted during study period significantly higher number of patients received icu support in self-paid and corporate groups compared to insured group ( . %and . % vs. . %; p= . ) braden scale is predictive of mortality in critically ill patients, independent of its efficiency as a predictive tool of pressure ulcer risk d becker , tc tozo discharged and died ( . %). the turnover rate of the icu was . . the occupancy rate calculated during the period was . %. there were only readmissions ( . %) within hours of admission. regarding the hospital evolution of these patients we had exits in this period, ( . %) were discharge and ( . %) were deaths, of these, ( . %) were after discharge from the icu. the mean saps score was . (ranging from to ). the probability of death, according to the standard equation was . % and the adjusted for latin america of . %. conclusions: the icu has a high occupancy rate and rotation turnover, as well as a higher mortality than predicted by the score. these indicators show the great population demand that we have and alert to the impact on the sustainability of the unit and patient safety methods: research/ethics approvals were obtained. surveys, interviews, round tables, targeted delphi exercises and non-participant observation were conducted across four adult critical care units, involving professionals. these methods were used to describe the baseline 'paper-based' workflow/inter-professional communication systems; and semi-quantitative quality improvement measures. secondly, critical care services worldwide were visited to generate a database of experience, lessons and models of optimised informatics delivery. results: key challenges at baseline in relation to workflow/communication information transfer between different healthcare professionals site visits revealed the importance of human resources; lead time technology advances; the prioritisation of nursing workflow and pharmacy medicines/prescribing database creation/testing and the importance of the hardware interface and ergonomics. improvements included patient safety/experience p work-related stress amongst doctors and nurses in intensive care, a&e, acute medicine, anaesthetics and surgery i lever *, h nawimana introduction: work-related stress is associated with anxiety, depression, days off-work, errors and 'near misses' [ ]. our objective was to references . kerr et al p pre-existing cognitive dysfunction in critically ill patients and the incidence of delirium during icu treatment p validation of the sos-pd scale for assessment of pediatric delirium: a multicenter study e ista , b van beusekom children's hospital, rotterdam, netherlands; umc groningen -beatrix children's hospital p introduction: delirium in critically ill children has gained attention in the last few years and the incidence seems higher than anticipated before. the sophia observation withdrawal symptoms-pediatric delirium (sos-pd) was developed to combine assessment of delirium with iatrogenic withdrawal syndrome, two conditions with overlapping symptoms. the current study evaluates the measurement properties of the pd component (pd-scale) of the sos-pd scale. methods: in a multicenter prospective observational study in four dutch picus, patients aged months to years and admitted for more than hours were included. these patients were assessed with the pd-scale three times a day. criterion validity was established: if the pd total score was or higher the child psychiatrist was consulted to confirm the diagnosis of pd using the diagnostic and statistical manual-iv criteria as the "gold standard". the child psychiatrist was blinded to outcomes of the pd-scale. in addition, the child psychiatrist assessed a randomly selected group of patients to establish false-negatives the pediatric delirium scale had an overall sensitivity of . % and a specificity of . % for a cut off score of points. the positive predictive and the negative predictive value were respectively, . % and . %. the icc of paired nurse-researcher observations was . ( % ci . - . ). in total patients were diagnosed with delirium during the picu stay. conclusions: the pd scale shows a good validity for early screening of pd. so, the pd scale is a valid and reliable tool for nurses to assess delirium in critically ill children p frequency, risk factors and symptomatology of iatrogenic withdrawal from opioids and benzodiazepines in critically ill neonates, children and adults: a systematic review of clinical trials ma duceppe , m perreault we also examined the grey literature. we included studies reporting frequency, risk factors or symptomatology of iatrogenic withdrawal of opioids, benzodiazepines (or both) in critically ill patients. we considered all study designs except case reports and case series. pairs of reviewers independently abstracted data and evaluated methodological quality using the cochrane collaboration tool, newcastle-ottawa or quadas- . pros-pero (registration number: crd ). results: we identified unique citations through database search and full-texts were assessed for eligibility. thirty-three studies were included; the majority were observational and only a few included adults proportion of perfused small vessels at to p use of methadone in critically ill patients p the use of intranasal fentanyl versus parenteral opioid for acute pain relief in adults: systematic review and meta-analysis p sleep disorders in icu survivors c alexopoulou, a proklou p impact of dexmedetomidine on the duration of invasive mechanical ventilation in pediatric intensive care patients -dexped trial m genest peri-operative dexmedetomidine in high risk cardiac surgerymulticentre randomized double blind placebo controlled pilot trial y shehabi we compared vasopressors, inotropes, pacing and cardiac complications for safety and severe acute kidney injury (aki), dialysis and death (major adverse kidney events make) for efficacy. methods: adults patients undergoing cardiac surgery [combined (valve + coronary bypass) or complex] or with preoperative glomerular filtration rate (egfr) < mls/min/ . m were included. salvage or transplant surgery, dialysis, egfr < mls/min/ . m and those on extracorporeal support were excluded. dex ( . ug/kg/hr) was started at induction of anaesthesia and continued up to hours after surgery. equivalent volume of saline was given to control group. standard intra and post-operative care was provided. results: we randomized patients in the dex group and in the placebo (pgp). the mean(sd) age . ( . ) and egfr . ( . ) in all patients. no significant differences at baseline. in the dex, . % underwent complex surgery vs . % pts in the pgp. the mean(sd) bypass time and aortic clamp was comparable ( ) and ( ) min. the vasopressor requirements methods: nine tracheostomized copd patients ready to be weaned from ventilation were enrolled.for each patient, the sleep architecture was studied by polisomnography (sleep profiler-advanced brain monitoring) performing recordings:basal registration, continuos infusion of propofol or dexmetomidine from pm to am. rass target was - /- . results: the mean dose was . mg/kg/h for propofol and . mcg/ kg/h for dexmedetomidine.quantitative analysis showed, a statistically significant longer total sleep time (tst) and less sleep fragmentation (awakenings/hour) using dexmedetomidine. qualitative analysis showed non statistical differences between the two regimens: longer n and n stage with propofol and a longer n and rem phase with dexmetedomidine. furthermore, a reduced number of dosage adjustment was needed during dexmedetomidine sedation methods: a -year prospective observational cohort analysis was performed. all patients consecutively admitted to the medical or surgical icu or burn unit of a university hospital with an icu-los of >= days were included. qol was assessed at baseline (bl) and at months (m), year (y) and lt (median . years (iqr . - . )) after icu discharge with eq- d and sf- surveys. at lt, questions about daily life were added. in subanalysis, we compared groups (g and g ) based on median icu-los. results: patients ( % men) with a median age of , an apa-che ii score of and a sofa score of at icu admission were included. patients ( . %) were lost to follow-up. median icu-los in the cohort, g and g was (iqr - ), (iqr - ) and days (iqr - ) respectively. during icu stay, g had significantly more and longer need for any type of organ supportive therapy (p< . ) and had higher maximum sofa scores (p< . ). icu, hospital, m, y and lt-mortality rates in the cohort were , , , and % respectively. these rates were similar in g and g and the outcomes were assessed by telephone interviews at month after discharge. factors associated with readmission and post icu mortality are presented as odds ratios. results: during the study period, elderly patients were discharged alive. the follow up was possible for ( . %) patients. predictors of one-month readmission in univariate analysis were coronary disease (p= . ), sapsii (p= . ) and decline in functional status (p= . ). in multivariate analysis ) were the independent predictors of early readmission. mortality rate at month was . %. risk factors of onemonth mortality in univariate analysis were sapsii (p= . ), heart rate at discharge (p= . ), world health organization(who) performance status at discharge (p= . ) and decline in functional status (p= . ). in multivariate analysis p= . ), decline in functional status (or, . ; %ci comorbidities don't have an important impact on short term outcome after critical illness, which is most strongly predicted by severity of illness and physiological reserve at discharge. p characteristics and outcome of elderly patients in intensive care unit i coelho health inequalities & people with learning disabilities in the uk: emerson & baines cipold p comparison of home and clinic follow-up visits after hospital discharge for post-icu patients: a cross-sectional study r rosa , c robinson , p berto , p cardoso , l biason in a post-icu follow-up service which is reference for tertiary hospitals in southern brazil. post-icu patients with a icu stay > h (for medical and emergency surgical icu admissions) or > h (for elective surgical icu admissions) who were discharged alive from the hospital were invited by telephone to participate in a clinic-based multidisciplinary appointment months after icu discharge. home visits were offered to patients who claimed impossibility to attend the clinic appointment due to the severity of their disabilities graph of total mortality in ld vs all patients fig. (abstract p ). graph of admission age in ld vs all patients references p evaluation of family satisfaction instrument in multicultural middle eastern critical care units a p breaking bad news in the emergency department: a randomized controlled study of a training using role-play simulation i bragard , jc servotte , i van cauwenberghe p introduction: this is a randomized controlled study aiming to assess the impact of an e-learning and a -hour role-play training in breaking bad news (bbn) each assessment included a video-recorded role-play with two actors playing the role of relatives, and questionnaires. two blinded experts rated the videos. results: out of participants, % were trainees and % were anaesthesia residents. eg (n= ) and cg (n= ) were not different at baseline on the several variables. there were significant group and time interaction effects. only eg increased their selfefficacy p deficits of end-of-life care (eolc) perceptions among physicians in intensive care units managed by anesthesiologists in germany m weiss , a michalsen , a toenjes p ethicus end-of-life practices (eolp) in worldwide intensive care units (icus)-the ethicus ii study a avidan p multidisciplinary team perceptions about terminal extubation in a teaching hospital in brazil s p changing thoughts about end-of life care in the icu; results of a survey the feel guilty for withdraw therapy in nurses was also significantly decreased in years ( % vs. %, p< . ). conclusions: some of end-of-life thoughts in the icu were shown differences in nurses compared with years ago introduction: workload resulting from in-flight emergencies has not been quantitatively analysed in the literature. for hospitals local to major airports, this may have significant financial implications. methods: review was carried out of all cases admitted to east surrey hospital from gatwick airport over a year period beginning in . data were collected by interrogating the icnarc database. demographics, presenting pathology and length of stay for each patient were recorded. in addition, the cost of care for patients admitted during was calculated using recent median figures for intensive care admission (local ccg rates). results: since , patients were admitted from gatwick airport. this was approximately % of our critical care admissions. the mean (sd) age was . ( . ) years, and the median [iqr] length of stay [ . - . ] days. around % of these patients were non-uk or eu nationals and therefore not entitled to nhs care. reasons for admission included cardiac ( . %), respiratory ( . %), central nervous system ( . %), and gastrointestinal issues ( %). during , patients were admitted resulting in a total of . patient days in critical care. the total cost attributable to this group of patients was calculated to be £ , . conclusions: there is a substantial additional financial burden on hospitals that regularly receive admissions from major airports simply due to their geographical location. there is no additional funding available for providing this service. the pattern of presenting conditions in our population is similar to that seen in previous reports describing inflight emergencies [ ]. given the increasing accessibility of air travel and the economic pressures on healthcare providers, further analysis of the financial impact of this patient group on certain hospitals would be welcome. methods: we developed a monte-carlo simulation [ ] with separate referral rates for emergency, elective, and ventilated patients. bed occupancy is classified according to admission type with a conversion to prolonged ventilated stays at a rate of % [ ]. we used data from our neurointensive care unit to complete the parameters required for the model e.g. beds and , referrals/day. outcome measures were bed occupancy, and failed admissions. we tested two scenarios: increased referral rate ( . /day), and increasing to beds. results: the model simulated our intensive care where we have a high occupancy rate. increasing referral rate led to a consumed icu and an increase in failed admissions (fig. ) . lastly, increasing bed numbers eased pressures with fewer failed admissions. conclusions: we recommend a personalised icu monte-carlo population model for specialist units for a more accurate representation of icu bed occupancy. these icu specific models should be more useful for predicting staff, bed and financial requirements in specialist units where healthcare resources are changing e.g. increasing geographical referral radius. conclusions: better patient flow increased occupancy and standards. staff education and clear protocols are needed to improve patient booking and efficiency. assess stress levels and causes of stress among doctors and nurses at university hospital lewisham and queen elizabeth hospital woolwich. we surveyed staff using uk health and safety executive's management standards (hsems), a -question validated tool which identifies stressful work conditions requiring intervention. methods: we conducted an anonymous survey of doctors and nurses working in intensive care, accident and emergency (a&e), acute medicine, anaesthetics and surgery over six weeks. results were analysed using the hsems analysis tool and broken down into seven areas: job demands, managers' support, peer support, relationships, role, level of control and possibility of change. each area was scored from - ( represents lowest stress). we compared the trust's results against national standards. results: healthcare professionals completed the survey. intensive care had the lowest stress levels and scored above average in all areas (n= , mean . , s.d. . ). this was followed by a&e (n= , mean . , s.d. . ), anaesthetics (n= , mean . , s.d. . ), surgery (n= , mean . , s.d. . ) and acute medicine (n= , mean . , s.d. . ) which had the highest stress levels. when compared to hsems targets peer support exceeded national standards. however, there is a clear need for improvement in staff's ability to control and change their working environment. conclusions: stress levels on intensive care were reassuringly low when compared to other departments as well as national standards. we identified areas that need improvement and with the support of hospital management we will initiate hsems-validated measures to reduce stress. p tools for sepsis-associated mortality in hematological patients and should be studied in larger cohorts.conclusions: our results present clinical data of protocolized pbto -targeted therapy and show that there is room for further optimization. a larger cohort with predefined interventions is needed to proof the effect on longterm outcome after sah. impact of phone cpr on rosc outcome a giugni , s gherardi , l giuntoli introduction: early cardiopulmonary resuscitation (cpr) improves survival in out-of-hospital cardiac arrest, and phone-cpr instructions can increase the number of victims receiving cpr before emergency medical service (ems) arrival. little is known about the impact of cpr phone instructions on the outcome of patients (pts) with return of spontaneous circulation (rosc). the target of this study is to investigate the impact of phone instructions on mortality, and on neurological outcomes of patients who survived an out-of-hospital cardiac arrest. methods: we enrolled pts admitted to icu after rosc following out-of-hospital-cardiac-arrest, from / / to / / ; pts younger than , in-hospital cardiac-arrest-victims, pts who underwent cardiac arrest in health facilities, and missing data records were excluded. written informed consensus was obtained for all pts during follow up. data about comorbility, mortality, neurologic outcome, cpr timing according to utstein style, complications in icu, metabolic state on er admission, were collected. study population was divided into two groups for statistical analysis: pts with immediate cpr guided by phone instructions (phone-cpr group) and those who did not underwent immediate cpr by laic bystanders. data were extracted from icu, ems databases and registered ems phone calls. results: pts met study criteria. phone cpr were given in cases, % of the whole study population. results are summarized in tables and conclusions: phone-cpr significantly reduced cpr-free interval. it correlates with a significative increase in shockable rhythms on ems arrival. there is no significative reduction in mortality and in disability, even if a decrease trend can be observed. phone-cpr seem to be a promising, effective and easy to use tool to improve survival and disability in rosc, and should be widely applied. early hemodynamic complications in cardiac arrest patients-a substudy of the tth- study j hästbacka introduction: our aim was to determine the incidence and severity of hemodynamic complications during therapeutic hypothermia and analyze whether these complications can be predicted from data available on admission. methods: this is a substudy of the tth- study, where cardiac arrest (ca) patients were randomized to receive therapeutic hypothermia treatment for either or h [ ] . hypotension within four days from admission was recorded and defined as mild, moderate, severe or circulatory failure. arrhythmias were recorded and classified as mild, moderate or severe. we calculated the incidence and distribution of severity of the events. we used multivariate logistic regression analysis to test association of admission data with any hypotension or any arrhythmia. results: of all patients, . % had hypotension which was mild in . %, moderate in . %, severe in . % cases. . % had circulatory failure. an arrhythmia was present in % of patients. of these, . % were mild, % moderate and . % severe. bradycardia (n= ), new ca (n= ) and circulatory shock (n= ) were hemodynamic reasons for preterm rewarming. in multivariate analysis age (p= . , or . ) and admission map (p= . , or . ) were significantly associated with hypotensive complications. only use of mechanical compressions was significantly associated with risk for arrhythmia (p= . , or . ). conclusions: hypotension and arrhythmias were frequent in cardiac arrest patients during days - from admission, but mostly mild or moderate in severity. age and admission map were associated with hypotension. only the use of mechanical compressions was independently (negatively) associated with arrhythmias. introduction: in a retrospective study from the pittsburgh clinic, which analyzed survival data from patients admitted to a hospital with a cardiac arrest outside the hospital, it was found that patients with opioid overdose showed significant improvements in neurological status when discharged from the hospital compared with patients who did not receive opioids [elmer j. et al., ] . methods: after local ethic committee approval case-records of patients with cardiac arrest and subsequent resuscitation for the period - in the clinic of traumatology and orthopedics in astana were analyzed. criteria for inclusion in the study were hospital cardiac arrest, trauma to the musculoskeletal system. results: out of case-records, ( . %) patients with out-ofhospital cardiac arrest were excluded. among all hospital stops of blood circulation, we found only successful cpr ( . %). among the patients who were successfully resuscitated, groups were identified: i - patients ( %) who received ketamine or/and opioids before the blood circulation stopped ( - minutes); ii - patients ( %) who did not receive these medicines. the mean age in group i of patients was . ± . years, in group ii - . ± . years (p> . ). patients of the second group had an average life expectancy of . ± . days, with a maximum postresuscitation life of days. patients of the first group were in the hospital for . ± . days (p < . ), with a maximum period of days. in the first group, the final neurologic evaluation according to the glasgow scale was . ± . points, while in the second group it was . ± . points (p < . ). conclusions: a retrospective analysis revealed a better survival and neurological outcome in patients who received ketamine or/and opioids before circulatory arrest.introduction: the revised organ transplant law was enacted in japan in . under the revised law, it is now possible to donate organs with the consent of the family even if the intention of the potential donor is unknown. organs from brain-dead children under the age of can also be donated. methods: the aim of this study was to assess how to provide prompt transplant medical care and improve the donor's condition. this was achieved by clarifying the problems encountered in the process leading to brain-dead organ transplantation at our institute before and after the enactment of the revised organ transplant law. there were cases of organ donation at our institute from january to june . among them, the background factors of cases leading to organ donation were examined. results: the causes of the brain-dead condition were cerebrovascular disease (n = ; subarachnoid hemorrhage, intracerebral hemorrhage), trauma (n = ), suffocation (n = ), cardiopulmonary arrest on arrival (n = ), suicide by hanging (n = ), cardiomyopathy (n = ), and lethal arrhythmia (n = ). the organs donated for transplantation were kidneys, eyes, lungs, livers, hearts, and tissues (i.e., heart valve, bone, and skin). the time lapses were as follows. the number of days from informed consent to family acceptance was . days before the enactment of the revised organ transplant law and . days after the revision. the number of days from informed consent to organ removal was . days before the revision and . days after the revision. even after the enactment of the revised organ transplant law in japan, it still takes about days from informed consent to organ removal, with no current initiatives to shorten the time to organ removal. conclusions: although years have passed since the enactment of the revised organ transplant law in japan, there are still administrative and management problems that need to be addressed to achieve optimal organ transplantation. the financial impact of proximity to a major airport on one critical care unit introduction: in septic patients, increased plasma levels of cell-free hemoglobin (free-hb) are associated with a reduction of perfused vessel density (pvd) of sublingual microcirculation and to adverse outcomes caused by hemoprotein-mediated lipid peroxidation. recent studies show that acetaminophen protects from damage due to lipid peroxidation in sepsis [ ] . the aim of this study is to detect changes in sublingual microcirculation after the infusion of a standard dose of acetaminophen in febrile septic patients. methods: prospective observational study on adult septic patients admitted to our intensive care unit. pre-infusion (t ), minutes (t ) and hours (t ) after the end of the infusion of acetaminophen, sublingual microcirculation was assessed with incident dark field illumination imaging; vital signs, plasma levels of acetaminophen and free-hb were assessed. results: preliminary descriptive analysis on the first patients shows a median sequential organ failure assessment (sofa) score of (interquartile range iqr - ) and baseline temperature of , c°( iqr . - °c). an increase of the proportion of perfused vessels (ppv) was evident both at t and t ( introduction: in common sedation is required during mri for adult uncommunicative patients or those with different psychiatric disorders [ ] . although it can be challenging to obtain the deep sedation level required to prevent the patient's movement while maintaining respiratory and hemodynamic stability. limited access to the patient may pose a safety risk during mri. objectives: to compare efficacy and safety of dexmedetomidine sedation versus propofol during mri in adults.methods: this prospective randomized study was conducted at department of anesthesiology and intensive care at postgraduate institute of bogomolets national medical university (kyiv, ukraine) during - . uncommunicative conscious patients with acute ischemic stroke were included in the study and randomly allocated to groupsdexmedetomidine (d) and propofol (p). the sedation goal was the same in the both group (rass to - ). patients in group d receive dexmedetomidine infusion in dose . conclusions: in this prospective randomized study dexmedetomidine comparing to propofol was associated with higher sedation quality and lower incidence of complication during acute ischemic stroke patients sedation for mri. the usefulness of dexmedetomidine after lung transplantation in intensive care unit. introduction: dexmedetomidine (dex) showed some advantages in the sedation of patients in intensive care unit (icu) [ ] . other studies described efficacity of dex in icu delirium [ ] . the aim of this study was to evaluate the efficacity and safety of dex after lung transplantation in icu. methods: we conducted a prospective monocentric study in our surgical icu between november at november . in the first part of the study (november at november ), lung recipients did not received dex; in the second part of the study dex was used for the sedation in mechanically ventilated patients after lung transplantation. we compared the duration of mechanical ventilation in the two groups and the occurence of adverse effects. results: in total lung recipients were enrolled. there was no difference between the two groups in demographic data, one or double-lung transplants, the cause of lung transplantation and the use of epidural infusion. in the dex group, mechanical ventilation support was hours versus . hours in the other group (p= . ). there was no difference between delirium in the two groups ( / , p= . ). the occurence of adverse events like hypotension and bradycardia was significantly higher in the dex group ( / for hypotension, p= . ; / for bradycardia, p= . ). conclusions: the use of dex after lung transplantation in icu was not more efficience for the mechanical ventilator weaning. lung recipients delirium was significantly the same in the two groups. the most notable effect was the occurence of bradycardia and hypotension in the dex group.introduction: dexped evaluated the impact of a prolonged exposure (>= hours) to dexmedetomidine on the duration of invasive mechanical ventilation (imv), length of picu and hospital stay and use of other sedative agents. methods: dexped is a retrospective cohort study that included patients aged to years, admitted to the picu of the montreal children's hospital between november st and april th , requiring imv and sedative agents for >= hours. patients exposed to dexmedetomidine during imv (n= ) were compared to non exposed patients (n= ) using a propensity score analysis ( : ratio). , and received more opioids and benzodiazepines. however, a secondary analysis redefining exposure as initiation of dexmedetomidine within the first hours from intubation suggested that exposure was associated with a greater short-term probability of extubation, although this study was not powered to perform this analysis. conclusions: dexmedetomidine was associated with a longer duration of imv. however, the association was inversed when patients received dexmedetomidine as a primary sedative agent. it is uncertain whether this difference of associations is due to immortal time bias or clinical features. timing of initiation of dexmedetomidine in relationship to other sedatives may impact patient outcomes and should be considered in the planning of future trials. is an α -agonist which has been increasingly used for analgosedation. despite of many papers published, there are still only a few concerning the pk of the drug given as long-term infusion in icu patients. the aim of this study was to characterize the population pharmacokinetics of dex and to investigate the potential benefits of individualization of drug dosing based on patient characteristics in the heterogeneous group of medical and surgical patients staying in icu. methods: all the subjects were sedated according to modified ramsay sedation score of - . blood samples for dex assay were collected on every day of the infusion and at the selected time points after its termination. the dex concentrations in the plasma were measured using lc-ms/ms method. the following covariates were examined to influence dex pk: age, sex, body weight, patients' organ function (sofa score), catecholamines and infusion duration. non-linear mixed-effects modelling in nonmem (version . . , icon development solutions, ellicott city, md, usa) was used to analyse the observed data. results: concentration-time profiles of dex were obtained from adult patients ( table ). the dex pk was best described by a twocompartment model (fig. ) . the typical values of pk parameters were estimated as l for the volume of the central compartment, . l for the volume of the peripheral compartment, . l/h ( . ml/min/kg for a kg patient) for systemic clearance and . l/h for the distribution clearance. those values are consistent with literature findings. we were unable to show any significant relationship between collected covariates and dex pk. conclusions: this study does not provide sufficient evidence to support the individualization of dex dosing based on age, sex, body weight, sofa, and infusion duration. seems to reduce the wakefulness time and the sleep fragmentation but, while we haven't found differences in sleep architecture using dexmedetomidine or propofol. introduction: the early mobilization program during intensive care hospitalization presents numerous benefits related to the outcome of the patient. the objective of this study is to evaluate the safety of the implementation of an early mobilization protocol within the first hours of admission and its impact on high functional status of the icu. methods: retrospective study, from march to may , evaluating patients admitted to the neurological icu, assessing the hemodynamic, respiratory and neurological variables in patients submitted to the early mobilization program, consisting of progressive therapeutic activities, including sedestation and orthostatism assisted on the board and evaluated the impact on the functional status/degree of high muscle strength of the icu. results: from march to may , , patients were admitted to a neurological intensive care unit, of whom , were included in the early mobilization program. the mean age of the patients was . years, with saps of . points (estimated mortality risk of . %) and real mortality of . %. during the program, % presented clinical instability, which was promptly reversed in all situations. ninety-one percent of the patients presented maintenance or gain of muscle strength/functional status. conclusions: the application of an early mobilization program within hours of patient admission was shown to be safe, positively influencing the rehabilitation of neurological patients. introduction: given the worldwide rapidly aging of the population, the demand of critical care for elderly is increasing. data on short -term outcomes of elderly patients after icu discharge are sparse. the objective of our study was to assess short term outcomes of elderly after icu discharge and their potential risk factors.introduction: patients aged years or older presently account for approximately - % [ ] of all intensive care unit (icu) admissions in europe. the major challenge nowadays is to admit those elderly patients who will benefit from icu treatment. the objective of this study is to describe the characteristics and outcomes of patients >= years old admitted to the icu. methods: retrospective observational study of all patients aged >= years admitted for > h in . demographic data, admission diagnosis, apache ii and saps ii scores, use of icu resources and mortality were collected. results: patients ( %) were included, with a mean age of , . female gender was more prevalent ( . %). mean length of stay was , days with mean saps ii and apache ii scores of , and , respectively. the most prevalent type of admission was medical, , % (n= ) and from these the main reasons for admission were respiratory disease (n= ; , %) and sepsis (n= ; %). icu mortality rate was , % (n= ), whereas -month mortality was , % (n= ).survival rate was often related with cardiovascular ( [ , %], p<. ) and respiratory diseases ( [ %], p=. ), whereas nonsurvivors were admitted due to sepsis and neurologic causes. mortality rate was independent from the mean length of stay, noninvasive ventilation and renal replacement therapy, but dependent for previously comorbidities. mechanical ventilation was an independent predictive factor of icu mortality (p<. ) and -month mortality (p=. ). conclusions: nearly % of patients aged >= years were discharged alive from icu, and less than % survived months after icu admission.our study revealed a better prognosis for admissions due cardiovascular and respiratory diseases. efforts should be done to identify earlier septic and neurological patients that benefit icu treatment, and reevaluate the critical patient pathway, in this special population.conclusions: more than % of icu-survivors returned to work. overall, the chance of return to work within two years was independent of the number of organ support therapies in patients with at least one organ support therapy. however, in subgroups, the chance of return to work decreased with increasing number of organ-support therapies. factors associated with non-return to work among general icu survivors: a multicenter prospective cohort study r rosa introduction: critical care patients may develop long-term health problems associated to their illness or icu treatments, which may affect their work capacity. unfortunately, studies evaluating the impact of critical illness on work-related outcomes are scarce.therefore, we aimed to investigate factors associated with non-return to work among icu survivors. methods: a prospective cohort study involving icu survivors of brazilian tertiary hospitals was conducted from may to august . patients with a icu stay > h (for medical and emergency surgical icu admissions) or > h (for elective surgical icu admissions) who were discharged alive from the hospital were evaluated through a structured telephone interview months after discharge from the icu. a stepwise multivariate poisson regression analysis adjusted by age, gender and years of education was used to evaluate the association of sociodemographic-and icu-related variables with nonreturn to work. results: in total icu survivors completed the -month follow-up. of these, ( %) were working before icu admission. only of patients ( %) returned to work within the first months after discharge from the icu. percentage of risk of death at icu admission (relative risk [rr], . ; % confidence interval [ci], . - . ), decrease in physical functional status in relation to the pre-icu period measured by barthel index (rr, . ; % ci, . - . ), not having a introduction: the aim of this study was to assess the accuracy of physician's prediction of hospital mortality in critically ill patients in an intensive care unit (icu) scarcity setting. methods: prospective cohort of acutely ill patients referred for icu admission in an academic, tertiary hospital in brazil. physicians' prognosis and other variables were recorded at the moment of icu referral. results: there were analyzed referrals. physician's prognosis was associated to hospital mortality. there were ( . %), ( . %) and ( . %) deaths in the groups ascribed a prognosis of survival without disabilities, survival with severe disabilities or no survival, respectively (p< . ) (fig. ) . sensitivity was %, specificity was % and the area under the roc curve was . for prediction of mortality. after multivariable analysis, severity of illness, performance status and icu admission were associated to an increased likelihood of incorrect classification, while worse predicted prognosis was associated to a lower chance of incorrect classification. physician's level of expertise had no effect on predictive ability. conclusions: physician's prediction was associated to hospital mortality, but overall accuracy was poor, mainly due to low sensitivity to detect mortality risk. icu admission was associated to increased incorrect classification, but there was no effect of physician's expertise on predictive ability. what are physicians in doubt about? an interview study in a neuro-intensive care unit. introduction: inescapable prognostic uncertainty, lack of decisionmaking capacity, risk of death or disability and long recovery trajectories complicate decision-making after traumatic brain injury. methods: to elicit experienced physicians' perspective we interviewed neurosurgeons, intensive care-and rehabilitation physicians from oslo university hospital about being in doubt about whether to offer, continue, limit or withdraw life-sustaining treatment and on how such cases were approached. interviews were audiotaped and transcribed verbatim, coded and analysed using systematic text condensation by a clinician (ar) and a medical ethicist (rf). results: the difficulty of decision-making when there is prognostic uncertainty was acknowledged, leading to adaptive approaches; willingness to change and adjust plans along the way. to have access to different opinions within the physician group was seen as constructive. time-critical decisions were based on team discussions and physician's discretion. none-time critical decisions were reached through a process of creating common ground between the medical team and family. themes physicians where in doubt about or expressed different opinions towards: ) appropriate aggressiveness of treatment in a given situation. ) if and when to initiate discussions on appropriateness of treatment. some believed that even addressing the issue in young patients or if small improvements were seen was inappropriate due to the possibility of late recovery. physicians questioned the value of previously expressed patient's wishes in this context. ) optimal timing and type of decisions. the need for nuanced individualized plans was recognized. to have a plan as opposed to just "wait and see" was seen as especially important in medical unstable patients. conclusions: physicians expressed different views on appropriateness and optimal timing of level of care discussions and decisions in traumatic brain injury. a need for a more structured approach was exposed. fig. (abstract p ) . association of physician's prognosis with hospital mortality (p< . ).introduction: this cross sectional study was designed to investigate the level of family satisfaction in intensive care units in a tertiary hospital in the united arab emirates (uae), which is a multicultural society methods: family members of patients who were admitted to intensive care unit for more than hours or over were included in the study. families were approached with a validated fs -icu family satisfaction survey questionnaire [ ] . one hundred questionnaires were collected over a period of months from january to march in our pediatric medical surgical and cardiac, adult cardiac and adult medical/surgical intensive care units. results: the overall level of satisfaction rate was comparable to other high-income and developed countries with total satisfaction score, medical care score and decision making score of . ± . , . ± . , and . ± . respectively (table ) . conclusions: this is the very first study from the uae demonstrating a high level of patient family satisfaction in both adult and pediatric intensive care units. this study also highlighted areas where further improvement needed to occur.introduction: in order to apprehend the structural aspects and current practice of end-of-life care (eolc) in german intensive care units (icus) managed by anesthesiologists, a survey was conducted to explore implementation and relevance of these items. methods: in november , all members of the german society of anesthesiology and intensive care medicine (dgai) and the association of german anesthesiologists (bda) were asked to participate in an online survey to rate items. answers were grouped into three categories: category reflecting high implementation rate and high relevance, category low implementation and minor relevance, and category low implementation and high relevance. results: five-hundred and forty-one anesthesiologists responded, representing just over / of anesthesiology departments running icu's. the survey revealed new insights into current practice, barriers, perceived importance, relevance, and deficits of eolc decisions. only four items reached >= % agreement as being frequently performed, and items were rated "very" or "more important". items attributed to category , to category , and to category , representing a profound discrepancy between current practice and attributed importance. items characterizing the most urgent need for improvement (category ) referred to desirable quality of life, patient outcome data, preparation of health care directives and interdisciplinary discussion, advanced care planning, distinct aspects of changing goals of care, standard operating procedures, implementation of practical instructions, continuing eolc education, and inclusion of nursing staff and families in the process. conclusions: the survey generated awareness about deficits in eolc matters in critical care. consequently, already available eolc tools have been made available through the website of the german society of anesthesiology and intensive care medicine (dgai): http:// www.ak-intensivmedizin.de/arbeitsforen.html.introduction: this study evaluated differences in eolp after years in european icus that also participated in the ethicus i study [ ] . methods: all previous ethicus i centers were invited to participate in the ethicus ii study. consecutive admitted icu patients who died or had treatment limitations during a month period from . . to . . were prospectively studied. previous eolp and region definitions were used [ ] . eolp in the different regions of the ethicus i study [ ] were compared to the same icus in the ethicus ii study. results: of the original icus participated again in this study. figure shows the differences in eolp by region. figure notes differences in patient mental competency at the time of decision, information about patient's wishes and patient discussions in both ethicus studies. conclusions: changes included less cpr (especially in the south) with more withholding and withdrawing therapies. there was a greater number of competent patients with discussions and knowledge of their wishes.introduction: palliative extubation is performed in patients with terminal ilnesses in which mechanical ventilation might prolong suffering. even though the procedure involves nurses, respiratory therapists and doctors, some professionals feel unconfortable performing a palliative extubation. the concept of withdrawing life support can be easily confounded with euthanasia, specially in low income countries, where there is usually less education on palliative care. methods: a questionary containing open ended questions concerning a hypotetical case of intracerebral hemorrhage and prolonged coma, with potential indication for palliative extubation was applied to members of an emergency department intensive care unit staff ( doctors, nurses, respiratory therapists (rt). results: more than half of the professionals ( %) had never participated in a palliative extubation. four professionals ( %) believed palliative extubation is euthanasia. when asked about their own preferences in such a situation, only two ( %) would like to be tracheostomized. symptoms anticipated by most professionals were dyspnea and respiratory secretions. four ( %) would feel very uncomfortable performing palliative extubation because they either felt to be killing the patient or unable to manage symptoms conclusions: most professionals in this tertiary emergency intensive care unit never witnessed a palliative extubation. however, most of believe this procedure is beneficial. some still cannot understand the difference between palliative extubation and euthanasia. education in palliative care and withdrawal of life support can be helpful to clear concepts and relieve moral distress in the team. key: cord- -yppi a authors: nan title: th european congress of pathology, ljubljana, slovenia, september - , date: - - journal: virchows arch doi: . /s - - - sha: doc_id: cord_uid: yppi a nan introduction formation of terminal villi with syncytiocapillar membranes is necessary for optimal maternal-foetal exchange and especially for oxygen diffusion. immature placentas with little number of syncytiocapillar membranes may worse foetal nutrition and gas exchange. the aim of this study was to estimate the role of villous tree immaturity in the development of intrauterine hypoxia. materials and methods placentas from singleton pregnancies were investigated. according to ultrasound and doppler velocime-try data, apgar score, placentas were divided into groups with chronic hypoxia ( ), iugr ( ), acute intrauterine hypoxia ( ), from normal pregnancies ( ). estimation of the degree of maturity according to gestational age was made on routine histological slides. vascular endothelial growth factor (vegf) and placental growth factor (plgf) concentration in placental tissue homogenates were investigated by elisa method in placentas. results the frequency of placental immaturity was -fold higher in placentas with hypoxia in compare with control group. preterm maturation of placental tree accompany with severe foetal hypoxia, a very high mortality and morbidity. concentration of vegf in placental tissue was elevated in placentas with terminal villi deficiency, and concentration of plgf was elevated in placentas with synchronous immaturity. conclusion due to importance of the placental maldevelopment it is necessary to devise methods of its early diagnostics and investigate mechanisms of villous tree development. determining of vegf and plgf may be useful for this purpose. molecular analysis of hereditary hemochromatosis g weirich, r langer, h nina, n jörg, h hoefler institute of pathology technische universität münchen, munich, germany hereditary hemochromatosis (hh) is an autosomal recessive disorder, common in individuals of northern european descent (prevalence close to : ) . hh is characterized by increased iron absorption and iron deposits in various organs. hh patients may develop liver and pancreas cirrhosis, primary liver cancer, diabetes mellitus, and cardiomyopathy. in the majority of cases, hh is caused by mutations of the hfe-gene on chromosome p. hfe encodes an mhc class-i gene, a putative negative regulator of iron uptake. three hfe mutation are common, c y, h d and s c. patients with a homozygous c y genotype most often endure a severe clinical course, whereas homozygotes for h d may develop mild forms of the disease. heterozygotes are usually symptom-free, but show elevated serum ferritin levels. it has been speculated that secondary iron overload (heavy alcohol, chronic hepatitis, ?-thalassemia) may be a critical co-factor in those heterozygotes that develop symptoms of hh. hh not associated with hfe mutations is much less common. within this heterogeneous group of non-hfe hh, three subtypes have been attributed to genetic alterations. juvenile hemochromatosis (hfe ) is a rare but severe disorder mapped to chromosome q. hfe has recently been mapped to the transferring receptor gene (tfr ) on chromosome q . hfe follows an autosomal dominant trait and is associated with mutations of the ferroportin gene (slc a ) on chromosome . except for juvenile hemochromatosis, hfe, hfe and hfe are amenable to mutation analysis. the advent of modern high throughput technologies such as denaturing high performance liquid chromatography (dhplc) has sparked clinical mutation screening programs, which also include screening of patients suspected to be affected by hh. in addition, dhplc-based mutation screening can also be performed using archival formalin-fixed, paraffin embedded tissues (ffpe). we present here results from hfe-analyses of ffpe from autopsy cases using dhplc and direct sequencing. introduction diseased tissues contain all the information on the genetic and epigenetic changes that caused the disease and determine its outcome (prognosis). recent developments in genome and proteome research offer the opportunity to unravel this information and provide new insight into the molecular pathogenesis of diseases. aims: we are establishing a unique human tissue resource for genome research based on a collection actually comprising . mio paraffin-embedded and frozen tissue samples stored at the temperature of liquid nitrogen. materials and methods this collection is being expanded by national and international interdisciplinary cooperations. blood samples, patient history, laboratory parameters, treatment and outcome information are included in addition to tissues. special emphasis is placed on quality control and compliance with ethical and legal criteria. all protocols follow established standard operating procedures in accordance with guidelines of the fda and recommendations of european countries. informed consent is obtained from patients and appropriate security measures guarantee patient confidentiality. results to make this resource available to a wider scientific community, we generate disease-specific gene libraries and produce tissue micro arrays. well defined expandable cell lines and nude mice xenografts are established for characterization of gene function. conclusion proper access to collections of diseased human tissues is currently a major limiting factor for genome research in medicine. there is an urgent need of tissue banks that meet highest quality and legal criteria. introduction neural cell adhesion molecule (ncam) is highly expressed on cells of the murine metanephrogenic mesenchyme at early stages of kidney development. during further development, ncam can still be detected on epithelial cells of comma and sshaped bodies as well as on interstitial mesenchymal cells. during maturation of the fetal kidney ncam gradually disappears from all epithelial structures and is confined to small areas of interstitial medullary cells. in the adult murine kidney ncam expression is virtually absent. materials and methods in the present study ncam expression was analyzed by immunohistochemistry and western blots in adult human kidneys, including healthy kidneys and kidneys with different glomerular diseases associated with incipient interstitial fibrosis (if). ncam positive cells were characterized by triple immunofluorescence staining using antibodies against human ncam combined with a panel of antibodies against neurofilaments, a smooth muscle actin (asma), hla class ii, cd and cd , and dapi for nuclei staining. digital pictures from every fluorescence channel were taken and superimposed for the specific staining using the analysis dokutm software from soft imaging systems. results in adult human kidneys, ncam expression was restricted to rare interstitial cells with a dendritic morphology, long cytoplasmatic extensions and elongated nuclei, which were localized predominantly in the outer medulla. in comparison to healthy kidneys, the number of ncam-positive interstitial cells increased in the initial phases of if in different forms of glomerulonephritis. western blot analysis of renal tissues with incipient if showed the exclusive expression of the kda isoform of ncam; other isoforms were not detectable. staining with antibodies against neurofilaments clearly differentiated nerve cells from ncam-positive interstitial cells, which are neurofilament negative. they are also asma negative, though the number of the asma+ cells increased at the early stages of if. however, some of the ncam-positive cells clearly express the stem cell markers cd and cd . conclusion these data indicate that a subpopulation of ncampositive interstitial cells may be renal progenitor cells, which can participate in the initial phases of if. introduction cell migration from the host to the transplanted organ results in chimerism ( ) , and seems to be associated with chronic transplant rejection ( , ). however, early detection of recipient cells might provide an important clue for anti-rejection therapy. materials and methods cases from sex-mismatched renal transplants (male kidney into female receiver) with consecutive biopsies (one, six, and twelve months) were analysed by fish and immunohistology (c-kit and smooth muscle actin). in additional cases of renal transplants each at day and twelve months after transplantation, glomeruli were microdissected and a rt-pcr for c-kit and ß-actin was performed. umbilical vein endothelial cells served as positive control. results glomeruli: transplant glomerulopathy shows increasing numbers of y-positive cells with progression of the sclerosing lesion. by lm -rt-pcr, increased c-kit transcription is observed compared to controls, while immunohistology is negative. arteries: recognition of vascular lesions as chronic transplant vasculopathy was easily possibly by fish, but not by light microscopy. tubuli/ interstitium: infiltrates of acute interstitial rejection change sizes from focal/large to disseminated/small over time. chimeric cells are seen in tubulitis but also in tubular epithelium with ischemic damage. conclusion transplant glomerulopathy is a lesion of chronic rejection associated with the appearance of c-kit positive, recipient cells. chimeric cells can be demonstrated in transplant vasculopathy and in damaged tubular epithelium, possibly homing to ischemic lesions as part of a repair process. . lancet ; : ; . liver transp ; : ; . transfusion ; : introduction the aim of our demonstration is to call attention to a unique pediatric case with as yet unknown ultrastructural changes in the glomerular basement membrane (gbm). case report the full-term female patient - g/ cm -has been developing well with the exception of early (intrauterine?) unilateral intraocular hemorrhage, which necessitated the enucleation of the bulbus at the age of month. nine months later, varicose enlargement of the left saphena vein was observed, and microscopic hematuria was detected. later selective proteinuria and mild hypertension was found. at the age of year an open renal biopsy was performed. light microscopy showed thick-walled and dilated capillaries of glomerular tufts. collagen iv staining demonstrated corrugated positivity in the gbm, also seen in col iv alpha chain. chains alpha and appeared normal. immunofluorescence gave only strong global igm positivity. electron microscopy showed peculiar mostly circular splitting of the gbm lamina densa with inclusions of small amorphous densities as well as of some remnants of cellular organelles. analogous changes were observed in adjacent arterioles. at present, the year-old child with signs of somatic underdevelopment is being treated for mild hyperazotemia, anemia and renal hypertension. her body shows some asymmetry, the skin is thin, pink, but no areas of hyperextensibility are seen as well as any hypermobility of joints. nmr investigation of the brain disclosed a slowly growing mass in the left thalamus. conclusion the classification of the case among connective tissue disorders is difficult, type iv of ehlers-danlos syndrome seems to be the closest. chronic renal thrombotic microangiopathy (tma) following radiation: study of cases introduction there is evidence for roles of the cip/kip family of cdki (p , p ) in mediating growth arrest in glomerular cells. mature podocytes, highly specialized cells with a complex cellular structure (interdigitating foot processes) leave cell cycle and may undergo nuclear division, but not cytokinesis, because this would involve the breakdown of the actin cytoskeleton. it has been recognized that mesangial cells proliferate and accumulate matrix in re-sponse to certain forms of injury. the aim of the current study was to elucidate the role of cdki expression in human glomerular diseases. material and methods the analysis was performed on groups of renal biopsies (every consisting of cases): minimal change disease (mcd), membranous glomerulonephritis (mgn), mesangioproliferative proliferative glomerulonephritis: iga (igan) and igm nephropathy (igmn). we examined the expression of p , p , ki and pcna by immunohistochemistry. adult nephrectomy specimens (n= ) without evidence of glomerular disease served as controls. morphometric analysis was additionally done in mcd, igan and igmn cases. color sampling was performed to extract "brown" nuclei stained for p and all nuclei of glomerular cells. then the number of segmented "brown" nuclei was calculated per area of glomerular profiles and related to the number of all nuclei. results immunostaining for p was abundant in normal podocytes and some mesangial cells. there was no evidence of p and proliferation markers ki and pcna in normal glomeruli. in mcd and mgn expression did not change. in contrast there was a marked decrease in staining intensity for p in mesangial cells in patients with igan and igmn. the ratio of stained for p nuclei was . % and . % for mcd and igan, igmn group, respectively (p= . ). interestingly also podocytes focally -in sclerotic portions of glomeruli -revealed a marked decrease of p . this loss of immunostaining occurred predominantly in mesangial cells and podocytes expressing ki and pcna. this was accompanied by the de novo nuclear immunostaining for p . conclusion the decrease in p level is required to induce podocyte and mesangial cell proliferation. also the increase of p was observed. thus changes in cell cycle regulatory molecules play central role in determining the renal response to injury and may underlie the development of progressive glomerulosclerosis. understanding mechanisms regulating cell proliferation may target future therapies on these molecules. comprised microhaematuric patients. the thinning was global in patients, and segmental in . the third cohort contained nonhaematuric patients who had a globally thinned gbm and focal proliferative lupus gn or minimal change np, respectively. in summary, cases of global tbmnp ( + nm; controls: + nm; p<. ), and cases of segmental tbmnp ( + nm; p= . ) were verified. conclusion tbmnp manifests with either a globally or a segmentally thinned gbm. tbmnp is not infrequently associated with other glomerular diseases. the clinical and morphologic data should be considered simultaneously when the diagnosis of tbmnp is made. supported by otka t- (budapest, hungary) grant to i.b. simultaneous quantitative gene expression analysis in human renal biopsies in patients with lupus nephritis (lgn) introduction inflammatory flares, enhanced proliferation and delayed apoptosis are important pathomechanisms in lgn. these are associated with increased expression of genes previously studied by semi-quantitative immunohistologic detection of an individual gene product. the aim of this study was to perform a simultaneous quantitative comparison of expression of genes tentatively relevant to pathogenesis of lgn. material and methods renal tissue samples, fresh frozen ( ) and formalin-fixed ( ), obtained by percutaneous biopsy of patients with lgn (who class ii, iii and iv) were used. formalinfixed zero transplant biopsies served as controls. from µm thick sections, glomeruli were laser-microdissected, rna was extracted and transcribed. a real-time, quantitative pcr analysis was performed using vcam- , fractalkine as markers of inflammation, il- , pdgf-ßr as markers of proliferation, bax, fas ligand and tnf-r as regulators of apoptosis and ß-actin as housekeeping gene. results frozen biopsies allowed detection of all genes; formalinfixed only of some. there was no correlation between levels of gene expression and age, sex, proteinuria or activity/chronicity indexes. who class ii cases showed increased levels of vcam- , pdgf-ßr and bax but not fractalkine as compared to controls. who class iii and iv cases showed higher expression of fractalkine, il- and pdgf-ßr than who class ii cases. in who class iii cases, il- , and fractalkine levels were clearly, while bax levels were slightly higher than in who class iv cases. conclusions . real-time quantitative pcr is useful for a simultaneous analysis of gene expression in frozen samples of human renal biopsies. . in this limited study, class ii lesions, as expected, showed lower expression of genes in comparison with classes iii and iv. however, class iii lesions seemed to exhibit higher expression levels of genes involved in proliferation, inflammatory cell infiltration and apoptosis regulation compared to class iv, possibly relating to a different pathogenesis of those two classes. haemorrhagic glomerulonephritis (gn) and massive pulmonary haemorrhage in goodpasture syndromeunique case report introduction diagnostic use of ttf- as an organ specific marker for thyroid and lung origin of carcinomas was documented mostly in tissue sections, while the information on ttf- in cytology samples is still insufficient. the aim of the study was to analyze the expression of ttf- by immunocytochemical detection in cytology samples. we obtained material by fine needle aspiration biopsies (fnab) of primary and metastatic neoplasms ( cases). first, methodological approach with ttf- was tested in thyroid tissue ( goiters, adenomas, carcinomas). afterwards, we analyzed primary and metastatic lung adenocarcinomas, primary and metastatic extrapulmonary adenocarcinomas, primary lung tumors and metastatic lung carcinomas of other types and metastatic carcinomas of different types. additionally, metastatic malignant melanomas were also included in the study. finally, we tested metastatic tumors of unknown origin. results all primary and / metastatic lung adenocarcinomas stained positive with ttf- . two of metastatic tumors of unknown origin stained positive, however primary tumor was not found. except for thyroid samples, normal lung, metastatic microcellular and macrocellular carcinoma of lung origin, none of other primary or metastatic tumors stained positive for ttf- . conclusion in fnab specimens, ttf- can confirm thyroid origin of carcinoma and more importantly, determine the lung origin of metastatic or primary adenocarcinoma. therefore, ttf- could be used for early identification of primary site (pulmonary vs. extrapulmonary) in fnab of metastatic adenocarcinomas skipping further expensive investigations. comparable to the digital radiology, recent significant developments in the microscopic slide scanning, data storage technology can contribute to the development of digital histology laboratory techniques. the aim of the study is to evaluate this technology in a routine setting. methods in the daily routine in a university pathology department to slides were prepared from to cases in a day. from the usual paraffin blocks µm sections were prepared and processed. the bar-coded slides were digitized and stored on a digital slide server. commercial short and long term storage may be used. the evaluation of the slides was done in local and remote access. for specific tissue types (colon, gastric) automated tissue component segmentation and analysis modules were developed. for the d reconstruction of serial sections a dedicated program was developed. results the daily prepared slides ( - pcs) could be scanned in the night. the virtual microscopy analysis yielded concordant results with the optical microscopy analysis. teleconsultation based on digital slides and virtual microscopy was applicable in selected cases. the automated algorithms could classify gastric biopsy specimen cases with high accuracy ( %). d reconstruction yielded a more detailed insight and diagnosis. reports including the low resolution digital slide image, high resolution selected field of views, alphabetical report were sent in e-mail to the referring specialists in higher safety and speed as compared to the traditional way. conclusions the digital histology laboratory technology improves the specialisation in pathology allowing remote access to selected tissue types, the reporting process' safety and efficiency. experiences in the production of digital slides by an automated high-resolution scanner system after automated slide preparation introduction this study aims to investigate the expression of ret/ptc and p in the local normal, benign and malignant thyroid lesions in order to shed light on the pathogenesis of papillary carcinoma and explain the high prevalence of this condition among the nodular hyperplasia (multinodular goiter) cases in the local population. archival blocks from follicular adenomas, nodular hyperplasia and papillary carcinoma cases were retrieved from husm pathology department files. they were studied by immunohistochemistry for the presence of ret/ptc and p mutant protein. normal tissues from cases served as controls. results . % normal thyroid tissue, % follicular adenomas, . % nodular hyperplasia cases and . % papillary carcinomas expressed ret/ptc mutation. ret/ptc expression in papillary carcinoma was not associated with coexistence of nodular hyperplasia lesion. p is expressed by % of papillary carcinoma. no association was found between p expression of nodular hyperplasia with or without coexisting papillary carcinoma. p , not ret/ptc was an excellent predictor of tumour lymph node metastasis and capsular invasion. it is also a significant prognosticator of survival outcome. conclusion ret/ptc mutation is highly prevalent in local papillary carcinoma, indicating a significant role in the pathogenesis of this tumour; with no apparent role in tumour behaviour and survival outcome. p on the other hand appear to be a significant factor in the latter events. the two genes appear to act in two different pathways; the former being the initiator, and the later perpetuator of papillary carcinoma. vascular invasion in pleomorphic adenoma of salivary gland: a possible consequence of fna biopsy introduction benign intravascular invasion in association with pleomorphic adenoma (pa) of salivary glands is uncommon. in none of the reported cases has it been associated with subsequent development of metastases. it may cause a diagnostic and therapeutic dilemma in salivary glands, which appears otherwise benign. no explanation of the etiopathogenesis has been offered in previously reported cases. aim: we suggest that pre-operative procedures undertaken such as fine needle aspiration (fna) of the salivary gland may cause iatrogenic seeding of tumour cells. materials and methods two cases of pa of the parotid gland showed vascular invasion. both presented with a palpable nodule in the parotid gland. one patient had two fnas the other one prior to surgery. both underwent superficial parotidectomy. results histologically both tumours were pas positive with little chondromyxoid component but both were rich in myoepithelial cells. clusters of myoepithelial and epithelial cells were seen within muscular and thin walled blood vessels, both outside the capsule and within the tumour. in spite of genuine vascular invasion there was no cytological evidence of atypia or malignancy. our speculation is that the previous fnas may have caused spillage of pa cells within vessels giving an impression of a potentially malignant tumour. conclusion we recorded two cases of pa with associated vascular invasion. we speculate that preceding operative procedures such as fna may be relevant to the pathogenesis. extra-cellular signal-regulated erk- /erk- pathway activation in human salivary gland mucoepidermoid carcinoma: association to aggressive tumor behaviour and tumor cell proliferation a handra-luca, a lesot, jc bertrand, p fouret université paris vi ufr pitié-salpętrire, paris, france information on oncogenetic events in salivary gland mucoepidermoid carcinoma is so far limited. activation of extracellular signalregulated kinases erk- and erk- is strongly correlated to cancer. using an antibody specific for phosphorylated (active) erk- /erk- , we examined human salivary gland mucoepidermoid carcinoma samples by immunohistochemistry. the comparison in paired tumor and normal tissue samples showed that phosphorylated erk- /erk- expression was higher in tumor cells as compared to surrounding normal salivary parenchyma. using a threshold below which > % of normal samples expressed phosphorylated erk- /erk- , we showed that ~ % of mucoepidermoid carcinomas expressed high levels of phosphorylated erk- /erk- . those tumours where erk- /erk- pathway was activated had a more aggressive tumor behaviour as compared to the group where this pathway was inactive. the association of erk- /erk- phosphorylation to a worse prognosis was independent of histological grade. erk- /erk- phosphorylation was associated with an increased tumor cell proliferative index. there was no relationship between erk- /erk- phosphorylation and her- /neu expression. in conclusion, erk- /erk- pathway is active in salivary gland mucoepidermoid carcinoma and this activation is associated to a more aggressive tumor behaviour and a higher proliferative activity. these data suggest that deregulation of erk- /erk- pathway contributes to mucoepidermoid carcinoma phenotype and, possibly, represent a target for new anticancer drugs. introduction adenocarcinoma of the nose and paranasal sinuses is rare but has been shown to occur with increased frequency in workers exposed to wood dust. histologically the tumours resemble adenocarcinoma of the gi tract and show the same spectrum of histological types and differentiation. therefore tumours at this site may present a diagnostic problem in distinguishing between primary and metastatic disease. immunostaining has shown colonic adenocarcinomas to express cytokeratin ck and carcinoembryonic antigen (cea) but not cytokeratin ck . lung and squamous carcinomas of the head and neck are usually ck positive and ck negative. this prompted assessment of the immunohistochemical expression of ck , ck and cea in a retrospective series of primary nasal adenocarcinomas. the aims of the study were to establish the pattern of expression of ck ck and cea in primary sinonasal adenocarcinoma and to compare it with that seen in colonic adenocarcinoma. materials and methods cases of primary sinonasal adenocarcinoma were available from archival files. these were reviewed and classified into histological subtypes including papillary, tubular, mucinous and signet ring. representative paraffin sections were immunostained for ck , ck and cea. results normal respiratory epithelium included in the sections was positive for ck and negative for ck and cea. / ( %)of tumours expressed ck . all of the tumours expressed ck and all but one of the tumours expressed cea, with showing only focal positivity. there were tumours designated mucinous or signet ring type only one of which expressed ck . conclusion primary sinonasal adenocarcinomas express ck and cea. there is variable expression of ck , which may help to distinguish between primary sinonasal adenocarcinoma, which are positive, and metastatic colonic adenocarcinoma of papillary and tubular subtype, which are negative. poorly differentiated mucinous tumours are indistinguishable by immunohistochemistry alone. provisional extracellular matrix -indicator of oral squamous cell carcinoma (oscc) progression and target for therapy introduction pleomorphic adenoma is the most common tumour of the parotid gland. histomorphologic features and peculiarly tumour capsule play a major role in recurrences of parotid pleomorphic adenomas. cytogenetically, pleomorphic adenomas are characterized by recurrent chromosome rearrangements. the aim of this study was to correlate cytogenetics and histopathology features in pleomorphic adenomas in order to define cytogenetical characteristics of tumours with high risk of recurrence. material and methods histological and cytogenetical studies were performed in patients with pleomorphic adenomas of the parotid gland treated in our institution during the period may -november . structural and numerical chromosomal abnormalities were: rearrangement of chromosome (breakpoint at q - ), rearrangement of chromosome (breakpoint at q ), translocation between chromosome and : t( ; )(q ;q ), hyperdiploidy. results the studied population was distributed into histological subtypes according to seifert classification. hypocellular (stroma rich) pleomorphic adenoma was reported in %, hypercellular pleomorphic adenoma was reported in % and "classic" in %. thirty patients ( %) had normal karyotype while ( %) had clonal chromosomal abnormalities. chromosome rearrangement tumours and hyperdiploid ones tend to be hypocellular. tumours showing chromosome abnormality tend to be hypercellular. conclusions as recurrences most likely appear in hypocellular tumours, patients with hyperdiploidy and chromosome abnormalities could have a greater risk of recurrence because of their histomorphological characteristics. because of the lack of patients, not sufficient statistical significance was demonstrated. introduction pleomorphic adenoma is the most common tumour of the parotid gland. the main issue of pleomorphic adenoma surgery is postoperative recurrence. histomorphologic features and peculiarly tumour capsule play a major role in recurrences of parotid pleomorphic adenomas. the aim of this retrospective study was to define histomorphological characteristics of pleomorphic adenoma for better understanding of recurrence processes. this work corresponds to the preliminary prospective study of a long term follow-up for detection of recurrence. material and methods histological study was performed after reviewing of slides originating from patients with pleomorphic adenomas of the parotid gland. these randomly selected patients underwent parotid surgery in our institution during the period may -november . results the studied population was distributed into histological subtypes according to seifert classification for better analysis. hypocellular (stroma rich) pleomorphic adenoma was reported in %, hypercellular pleomorphic adenoma was reported in % and "classic" in %. thinness of capsule was significantly related to hypocellularity. pseudopodias and satellite nodules were reported in % of this series. conclusions due to capsular characteristics, surgical exerecise should avoid dissection in the vicinity of the tumour to minimize the risk of surgical induced recurrence. according to these findings, enucleation surgery on a pleomorphic adenoma should not be performed anymore. these tumours should now be followed up in order to detect and define risk factors of recurrence. trend of nasopharyngeal cancer at the ibadan cancer registry ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) increase in the incidence of npc over the last here decades. overall, the mean age was . years (age range to years). the females had a mean age of . years (age range - years) while the mean age for the males was . years (range - years). the peak age group of incidence for the females was - while in the males it was the - age group with an almost an equal incidence in the preceding three decades. the ratio of regaud to schmincke type cancer reversed with increasing age amongst the females with the schmincke type being more common in the first decade but this was not reproduced in the males. conclusions there is a steady rise in the incidence of nasopharyngeal cancer over the last three decades. the two main histological types showed differential variation between the sexes suggesting a biological effect in manifestation of this disease. there is a need for health education and increased physician awareness at all levels of health care to stem this trend and especially to detect a role of epstein barr virus infection in aetiopathogenesis of the nasopharyngeal cancer. lactate dehydrogenase (ldh) in peripheral blood lymphocytes (pbl) of patients with solid head and neck tumours b jakovljevic lactate dehydrogenase(ldh)is intracellular enzyme, which take part in process of anaerobic glycolyse. it is located in all cells, but in higher amount in the stromal cells. ldh activity increased in the malignant cells, as well as in the peripheral blood lymphocytes (pbl) of patients suffered from head and neck tumours. the authors present results of their investigations in activity of intracellular ldh in pbl, spontaneous ldh releasing from pbl and correlation between spontaneous releasing of ldh and increasing of intracellular level of ldh in patients with solid head and neck tumours. spontaneous releasing of ldh in all the patients with solid head and neck tumours were to times higher then in the health controlling group. there are correlation between clinical stage of the tumours and spontaneous releasing of ldh. the authors concluded that measuring of level of spontaneous released ldh from pbl, can prove the presence of head and neck tumours in the very early stage. introduction squamous cell carcinoma (scc) constitutes more than % of the malignancies from the head and neck. thereafter, the survival of patients in stage iii-iv is between %- % at years. as most stromal types, head and neck squamous cell carcinomas (hnscc) harbour deregulation in the expression levels of many proteins that participate in critical biological pathways leading to cancer development. the aim of the study was to evaluate the correlation between several molecules implicated in cell cycle and apoptosis in an attempt to define their importance as prognostic indicators in hnscc. material and methods hnscc specimens from stage iii-iv patients were collected prior to chemotherapy. we constructed a tissue-microarray with paraffin-embedded tumours to analyse, by inmunohistochemistry, the expression levels of proteins implicated in cell cycle arrest and apoptosis (p , cyclin-d , cyclin-a, rb, hdm , topoisomerase, chk , cdc , survivin, bcl- , cdk- , cdk- , cyclin d , cyclin e, cyclin b , p , p and p ). results alterations in the expression levels of proteins that participate in the g /s checkpoint were frequent. rb and p proteins were absent in % and % of the tumours, respectively, whereas high expression of cyclin d , cdk- and cdk- was observed in %, % and % of the cases, respectively. on the other hand, des-regulation of markers implicated in the apoptosis were also evident as shown by over-expression of bcl- protein in % of the tumours. this last observation seems to be related to bad prognosis. conclusions definitive conclusions from our results concerning expression levels of each marker isolately, according to tumour location and in relation to survival are still being evaluated. p and mib expression in basaloid squamous cell carcinoma of the larynx inversely correlates with p expression patients, two showed an inverse correlation between p and ki- expression and p expression. conclusion an inverse correlation between p and ki- and p and p was demonstrated in cases. image analysis of dnac showed aneuploidy in all cases. the present study shows that overexpression of p , and ki- , together with a down-regulation of p kip correlates with biological aggressiveness and consequent shortened survival in bscc of the larynx. the dna status doesn't correlate with any of the analysed parameters since all tumours in our series displayed an aneuploid pattern. altogether patients were operated on at the department of transplantation and surgery of the semmelweis university in the past four years, because of clinical symptoms of hyperparathyroidism. chronically impaired renal function was found in cases. the removed parathyroid glands showed histologically hyperplasia in , adenoma in and carcinoma in cases. the oxyphil/chief cell ratio and occasional mitotic and apoptotic figures were determined. the oxyphil component predominated both the hyperplastic and tumorous lesions. apoptosis and mitosis were rarely seen in hyperplasias ( - %) more frequently in adenomas ( - %) whereas in carcinomas - % of the tumor cells showed signs of mitosis and - % were apoptotic. immunohistochemical detection of p , bcl and bax revealed diversity between the various lesions. cytoplasmic p positivity could be observed in the majority of adenomas and in some of the oxyphil cells of the hyperplasias. the carcinomas and about one sixth of the adenomas showed nuclear p positivity. bcl was detected in the cytoplasm of the tumor cells of adenomas and in lower extent in the oxyphil cells of hyperplasias. colocalistion of bcl and bax was found randomly in all types of lesions. no significant differences in the p , bcl and bax spectrum were found regarding the primary and secondary (i.e. renal failure) parathyroid alterations. the very low incidence of carcinomas, the low mitotic and apoptotic ratio in adenomas and hyperplasias point to the potent antiproliferative defense mechanism in the parathyroid cell-population. this may be also reflected in the cytoplasmic co-localisation of various gene products which regulate cell death and cell proliferation. introduction at present the significance of occult axillary lymph node metastasis (om) in early breast cancer patients is not known. the aim of the study was to evaluate the prognostic role of om in stage i breast cancer. materials and methods we studied patients with t breast carcinoma who underwent axillary dissection and originally had negative lymph nodes by routine microscopic examination. patients who developed distant metastases within years after surgery (m group) were compared to age-matched patients who were disease free for years (nm group). we examined lymph nodes by three deeper h&e levels and one section stained with immunohistochemistry for keratin. results we detected om in / patients. all had micrometastases (< . mm). om was identified in patients ( %) in the m group and in ( %) in the nm group (p= . ). micrometastases larger than . mm were x more common in the m group ( / vs. / , p= . ) . tumors in the m group were significantly more often of higher grade, had a higher mitotic index (mi) and showed lymphovascular invasion. the two groups did not differ in size, histologic type, estrogen receptor status or type of treatment. in multiple logistic regression, only high mi and presence of micrometastases larger than . mm showed an independent significant correlation with the occurrence of distant metastases. axillary micrometastases are associated with occurrence of distant metastases and are important prognostic factor in t breast cancer patients. this was not significant for om smaller than . mm. the presence or absence of myoepithelial (me) cells has been considered as an important feature in the differential diagnosis of papillary breast lesions. the aim of this study was to evaluate the usefulness of monoclonal antibodies: alpha-actin (smooth muscle actin) and s- protein, which are known as good markers of me cells in breast tissue. material and methods the distribution of me cells in formalinfixed paraffin-embedded tissue sections of intraductal papillomas and papillary carcinomas were immunohistochemicaly stained by abc method. results alpha-actin reacted strongly and consistently with the me cells in all papillomas. in papillary carcinomas there were no alpha-actin reactive me cells. rare isolated me cells were present in two cases, but they were inconspicuous and these reactions were also considered negative. the me cells failed to express s- protein in four papillomas, while majority were weak positive. all the papillary carcinomas were s- protein negative. conclusions consistency and uniformity of me cells reaction is important because benign and malignant papillary lesions often coexist in the same tissue section. although vascular smooth muscle in the papillary fronds and stromal myofibroblasts may mimic me cells, the number of alpha-actin immunoreactive cells is much smaller and their distribution more irregular. s- protein has broad spectrum reactivity and it is of little value in the differential diagnosis of papillary breast lesions. alpha-actin is more specific marker than s- protein for recognition of me cells in breast tissue. introduction the utilization of lymphatic mapping for breast carcinoma has made intraoperative evaluation of sentinel lymph node (sln) attractive, because axillary lymph node dissection can be performed during the initial surgery if sln is positive. the aim of our study was to evaluate the accuracy of intraoperative sln examination by imprint cytology (ic). material and methods slns from women were examined. for intraoperative cytological examination, touch imprints from bisected slns were prepared, air dried and stained with quick staining method (hemacolor-merck). slns were than formalinfixed and embedded in paraffin. histological sections were evaluated with h&e stained levels and cytokeratin immunohistochemistry (ck-ihc). results histological examination of the sln revealed ( , %) cases with metastatic deposits: ( . %) macrometastases, ( . %) micrometastases and ( . %) cases with isolated tumor cells or clusters (itc) detected by immunohistochemistry. sensitivity and specificity of intraoperative ic was % and %, respectively. ic was significantly more sensitive for detection of macrometastasis: they were detected in out of cases ( %). ic generally failed to detect micrometastases or itc: only one case of micrometatasis was cytologically suspicious for malignancy. out of histologically negative slns, one ic diagnosis was false positive. conclusions ic is a simple and quick method of intraoperative screening for the presence of sln macrometastases in patients with breast cancer. if sln micrometastases and itc are used to determine the need for further lymphadenectomy, more sensitive intraoperative methods, such as rapid ck-ihc on touch preparations, will be needed to avoid second operation. introduction fine-needle aspiration cytology (fna) is an established, highly accurate method for diagnosing breast lesions. however, in recent years there has been increased use of core biopsy (cb) as a diagnostic alternative. this study aimed at comparing the value of fna and cb in palpable and non palpable breast lesions. materials and methods the material consisted of fna samples performed in our institution between and . correspoding histology results from lesions including cb were available for comparison. quality assessment parameters were calculated using metodology detailed in the national health service breast screening programme guidelines. results high specificity ( %) and sensitivity ( %) and low inadequacy rates were found for cb. fna showed high sensitivity ( %). low specificity ( %) for fna due to inclusion of many cell-poor lesions was particularly seen in the submitted material sampled by physicians lacking experience with fna procedures. conclusion cb may be an alternative method for preoperative diagnosis when experienced cytopathologists are not available. cb is superior to fna in fibrotic and collagenous lesions such as lobular carcinoma and radial scar. fna is most accurate when immediate assessment by cytopathologist is performed for evaluation of material adequacy so that additional aspirations can be performed if necessary. atypical ductal hyperplasia (adh): practical relevance in diagnostics and therapy introduction in contrast to ductal hyperplasias, adh belongs to intraductal neoplasias. adh can be distinguished from non-high grade dcis (among other criteria) by its size. therefore, a question that is asked quite frequently is whether such small findings can be removed with sufficient security by minimal invasive biopsy (mib). we prospectively investigated: . relative frequency of adh without associated intraductal or invasive carcinoma . relevance of such small findings in mib specimens. materials and methods between between and between , breastlesions could be clarified by means of mib in the interdisciplinary team. excisions were carried out in all invasive carcinomas and all dcis as well as in all cases with minimal parts of intraductal nonhigh grade neoplasias (with the differential diagnosis adh vs. dcis). additional adhs were diagnosed in excision specimens as incidental findings associated with other targets (except for dcis and invasive carcinomas). the mib-and operation specimens have been examined prospectively by two team pathologists according to the criteria of page and tavassoli. results we diagnosed altogether adhs and dcis. the proportion of adh in all operated intraductal neoplasias (adh+dcis) was . % ( / ). findings with the differential diagnosis of adh vs. dcis could be found in cases of mibs ( , %).the following excision specimens showed in of cases ( %) non-high grade dcis and in of cases adh ( %). the other adh were coincidental findings in excision specimen of benign lesions. conclusions adh is a very rare finding. in adh-like findings in mib specimens even specialised breast-pathologists cannot exclude a non-high grade dcis with sufficient security when applying strictly the most common morphological definitions. the high rate of % of dcis in the specimen of the following operation highlights the indication for clarifying by excision (according to the european guidelines for quality assurance in mammography screening). multifocal stromal invasion in microinvasive squamous cell carcinoma of the cervix -how to measure and stage these lesions o reich, h pickel dpt. obstet/gynecol, university of graz, graz, austria objectives about % of microinvasive squamous cell carcinomas of the cervix have more than one invasive focus at time they first break through into the cervical stroma. it is unclear how the lateral extent of lesions with multiple invasive foci should be measured to distinguish figo stage a and a carcinomas from clinically occult stage ib disease. we believe that three presentations of multiple invasive foci should be distinguished. type i shows plump and coherent infiltration of the cervical stroma at different sites in one ore more step-serial sections. they originate from the squamous epithelium outside the transformation zone or from metaplastic cervical gland epithelium. all foci are contiguous with the epithelium. in this case, the largest lateral spread of each individual invasive focus should be measured. these measurements are added up to determine the total of horizontal spread. the normal tissue separating the different early invasive foci is not measured. in type ii the origin of invasion cannot be seen in all early invasive foci but the greatest lateral extension can be seen in one of the step-serial sections. lateral extension is defined as the maximum distance from one most lateral point of the border between the invasion and the adjacent tissue to the other. the lateral extension of type ii includes the normal tissue separating the early invasive foci. type iii shows the same pattern as type ii, but the maximum horizontal spread cannot be measured in a single step-serial section. in such lesions the width needs to be measured across all the step-serial sections involved and the second dimension must be calculated by knowing the distances between the sections. conclusions these growth pattern of stromal invasion should be considered when measuring the width of early invasive squamous cell carcinomas with multiple invasive foci. lesions with multiple invasive foci taken together measuring more than mm in lateral extension should be classified as stage ib. introduction cyclooxygenases regulate the production of prostaglandins and play a role in tumor development and progression. the aim of this study was to investigate the prognostic impact of expression of the cyclooxygenase isoforms, cox- and cox- in primary breast carcinomas as well as in primary ovarian carcinomas. materials and methods cox isoform expression was determined by immunohistochemistry. results expression of cox- was detected in % of ovarian carcinomas and was associated with reduced overall survival in univariate analysis (p= . ) as well as multivariate analysis ( . ). there was no correlation with other tumor parameters such as grade, stage or type. in contrast, cox- was no prognostic parameter in ovarian carcinoma. expression of cox- was detected in % of breast carcinomas and was significantly associated with several clinicopathological parameters, such as positive nodal status (p< . ), larger tumor size (p< . ), poor differentiation (p< . ), vascular invasion (p= . ) and negative estrogen receptor status (p= . ). in univariate survival analysis a significant association between elevated cox- expression and decreased disease-free survival (p= . ) as well as decreased overall survival (p= . ) was observed. in multivariate analysis expression of cox- was of borderline significance for disease-free survival (rr( %ci) . ( . - . ) ). conclusions our data suggest that increased expression of cox- may play a role in progression of primary breast carcinomas as well as ovarian carcinoma. it remains to be investigated if treatment with selective inhibitors of cox- may be an additional therapeutic option for patients with gynecological tumors. simple endometrial hyperplasia: bcl- , hldf expression and clinical behavior ii the endometrial hyperplastic processes is characterized by major variety of clinical outcomes. the main feature of "spontaneous endometrial hyperplasia" is complete normalization after total curettage (lindahl b., willen r. ) ; there is also proof of recurring hyperplasia. the purpose of present research was to carry out clinical and morphological correlations between various types of endometrial hyperplasia and expression of pro-(hldf) and antiapoptotic (bcl- ) proteins. human leukemia cell differentiation factor (hldf) with molecular mass . kd, having dna/rna hydrolyzing activity, was originally allocated from hl- cell line of promyelocyte leukemia medium, processed by retinoid acid or c -ceramid (kostanyan i.a. et al., ) . previously we have shown that hldf is a useful tool for apoptosis visualization in prostate (babichenko i.i. et al., ) . we performed analysis of patients with histologically documented simple endometrial hyperplasia without atypia: women ( %) had spontaneous recovery after total curettage, in ( %) patients endometrium recovered after gestagen treatment and in ( %) cases persistent recurring hyperplasic process was observed during - years. immunohistochemical research showed that in samples of recurring hyperplasia hldf was expressed in cytoplasm of glandular epithelium, while in sections with spontaneous or aftertreatment recovery, hldf was revealed as a thin line on the surface of glandular cells. bcl- protein was found only in the cytoplasm of glandular cells in all investigated groups. thus expression of the hldf factor in cytoplasm of glandular cells in endometrium allows revealing the disturbance of apoptotic processes in cells and predicting the subsequent recurrence of simple hyperplasia. surface epithelial changes in endometrial adenocarcinoma b djordjevic, d mihailovic, d dimov, l velickovic, v zivkovic, z mijovic institute of pathology, university of nis, nis, serbia and montenegro introduction epithelial changes on the surface of endometrial adenocarcinoma (eac) show greater maturation and better differentiation than the underlying adenocarcinoma. these changes are relatively common and can be misdiagnosed as benign surface changes on curettings, including endometrial metaplasias (em), papillary syncytial change (psc), or microglandular hyperplasia (mgh) . the aim of this study was to investigate surface epithelial changes in eac. material and methods cases with eac ( endometrioid, serous, clear cell and mixed types) were studied. results ( %) of the eac showed surface epithelial changes: four with microglandular pattern simulating mgh; with syncytial aggregates of eosinophilic cell, frequently with papillary or squamoid appearance, simulating em or psc; and with mixed patterns. surface epithelial change often demonstrated focal conjunction with a frankly malignant gland or a fibrovascular core and ranged from rare foci to diffuse surface involvement. cytologic atypia was less pronounced than that of the underlying eac and varied from mild to moderate. mitoses were very rare. in some scanty curetting specimens, distinguishing these surface epithelial changes from benign changes was difficult, as was a diagnosis of eac. conclusion in postmenopausal women with curettings showing features of em, mgh, or psc, caution should be exercised in making that diagnosis, particularly psc, in the absence of evidence of benign shedding, and any associated cytologic atypicality should raise the possibility of the underlying eac. prevalence of cervical neoplastic lesions in egypt: a national cervical cancer screening project. final report introduction reducing morbidity and mortality is one of the main objectives of the health and population policies in egypt. however, data from egyptian studies provide widely varying estimates of the prevalence of pre-malignant and malignant cervical lesions. the main goal was ( ) to define the prevalence of pre invasive and invasive cervical cancer among egyptian women, and ( ) to identify risk factors including hpvs and associated co-factors, as bacterial vaginosis, hsv, cmv, chlamydia, schistosomiasis. the study was a community based full-scale cross sectional, household survey that included women aged between and years conducted between and . however, women with complete data were included in the study ( %). the bethesda classification was used for cervical cytology. three percent of cases were unsatisfactory. normal, metaplastic, infectious, and neoplastic lesions represented . %, . %, . % and . %, respectively. the most common type of infection was bacterial ( . %). neoplastic conditions, were categorized into ascus and agcus ( . %), ascus ( . %), agcuc ( . %), lgsl . % ( . %), hsil ( . %) invasive squamous and invasive adenocarcinoma ( . % for each). colposcopic-guided biopsy was performed on cases representing . % of the epithelial abnormalities. for standardization, a score of ten points including koilocytic atypia ( ) , binucleation ( ), papillomatosis, dyskeratosis, acanthosis and basal cell hyperplasia ( point for each), was applied to qualify a lesion as hpv-related ( points out of ten). unsatisfactory biopsies were encountered in . %. normal biopsies including inflammatory and metaplastic changes and atypical metaplasia represented . % and . %repectively. cervical intraepithelial lesions (cin) ( . %), further categorized as cin i ( . %), cin ii ( . %), cin iii/cis ( . %) were identified. endocervical lesions represented . % and were divided into endocervical glandular dysplasia (egd) ( . %) and adenocarcinoma in situ (ais) ( . %). combined dysplasia was found in . %, while invasive squamous cell carcinoma (sqcc) and lymphoma accounted for . %of the biopsies. on histological basis, hpv was found in association with cin i, cin ii, cin iii/cis and sqcc in . %, . %, . % and % respectively. neither egd nor ais showed evidence of hpvs. in situ hybridization (ish) using the broad spectrum hpv probe recognizing hpvs , , , , , , , , and was tested on biopsy specimens starting from the atypical metaplastic changes and was found to be positive among . %, negative in . % and non significant in . %. interestingly, . % of atypical metaplastic changes were positive. further subtyping with probes / , / and / revealed positivity in . %, . %, and . % of cases respectively. noteworthy, multiple infections with hpv / and / ( cases) and hpv / and / ( cases) were identified. to examine the main determinants of cervical cancer, multiple regression analysis was conducted using high-grade lesions as the dependant variable and risk factors as independent variables. this showed that the only determinant was hpv infection. when the regression analysis was conducted without hpv as one of independent vari-ables, history of treatment from schistosomiasis was found to have or of . ( %ci . - . ) but the model was not statistically significant. conclusion in the egyptian population, the prevalence of the precursor lesions of the invasive carcinoma is % while invasive lesions account for . % of the population. the prevalence of hpv histologically is . % and by ish . %. however, detection of hpvs by ish in this study cannot be precise due to technical limitations and limited number of probes used. evaluation of hpvs using pcr technology will be subject to another study. possible role of irf- in the genesis of endometrial adenocarcinoma. a series of such tumours was investigated using immunohistochemical techniques. relatioships were sought with thymidine phosphorylase (tp), conventional histological features and prognosis. malignant endometria were, by and large, deprived of irf- , as of the cases ( . %) were negative for this antigen. only of the cases were expressing irf- in inner tumour areas. at the invading tumor front, however, irf- was depressed in tumour cells in % of cases. this phenomenon was independent of the extent of lymphocytic response, but it was a strongly associated with tp expression. tp up-regulation and host's lymphocytic response in the area were directly associated. irf- derepression by invading tumor cells was associated with poor prognosis. this prognostic parameter was independent of stage. it is concluded that down-regulation of irf- is a constant finding in endometrial tumorigenesis. however, derepression of irf- may occur in a subset of tumours, and this event is associated with tp up-regulation and aggressive tumor behaviour. morphometric study of gnrh analogue/ hmg/hcg effects on ultrastructure of human endometrial epithelium in the early luteal phase introduction there is a little information about the effects of ovulation induction drugs on morphometry of human endometrium especially at electron microscopic level. the aim of the present study was to determine the effects of long protocol (gnrh analogue/hmg/hcg) on the ultrastructure of human endometrial epithelium at lh+ . material and methods endometrial biopsies were obtained from fertile women (n= ) as well as infertile women (n= ) who had undergone this protocol at lh+ . quantitative and qualitative studies on endometrial epithelium were performed by transmission electron microscopy (tem) and morphometry and the results were statistically compared between the two groups. results qualitative results revealed presence of nuclear channel system (ncs), sub vacuole of glycogen and giant mitochondria (gm) in both groups. similarly, in quantitative analyses, the volume fractions (vv) of glycogen, mitochondria and rough endoplasmic reticulum to cell and the also the vv of euchromatin to nucleus were statistically not different between two groups (p> . ). conclusion these results suggest that ovulation induction by long protocol is not associated with retarded or advanced endometrial epithelial development. introduction historically the diagnosis of mitochondrial encephalomyopathies relied, on the presence of ragged red fibres (rrf) as well as finding ultrastructural abnormalities in mitochondria. currently accurate diagnosis requires a multidisciplinary approach but the usefulness of electron microscopy has been questioned. the aim of this study was to define the diagnostic role of electron microscopy in comparison to histology and histochemistry. patients and methods thirty-five patients who fulfilled a clinical phenotype for mitochondrial encephalomyopathies, were separated into two groups. the paediatric group, which included cases, with an age range of days to years old and the adult group which included cases, with an age range of to years old. all patients underwent a muscle biopsy which was examined by histology, histochemistry and electron microscopy. results in the paediatric group, cases exhibited rrfs, cases showed rrfe and cases had cox abnormalities. electron microscopy revealed the presence of mitochondrial abnormalities in cases and mitochondrial aggregates in others. in cases light microscopy was normal, but in of these electron microscopy was abnormal. in the adult group all patients, showed cox abnormalities, cases had rrfe and others had rrfs. electron microscopy revealed the presence of mitochondrial aggregates in cases and structural abnormalities in cases. conclusions electron microscopy examination is a useful independent diagnostic tool in the investigation of mitochondrial encephalomyopathies. it is particularly helpful, in the paediatric cases, where the classic light microscopical findings are often not well developed. introduction tumour-associated tissue eosinophils (tate) have been observed in human tumours and experimental tumour models, but the mechanism by which eosinophils induce tumour cell damage remains poorly understood. aims: electron microscopy is an essential technique in evaluating sublethal and lethal cellular injuries. therefore, gastric carcinomas were studied by light and electron microscopy, focusing on the relationship between eosinophils and tumour cells and on the nature of tumour cell death. material and methods fresh tumour tissue was obtained in the operating room for immediate fixation and processed for both light and electron microscopy examination from until . results a light microscopy review of cases of resected gastric carcinomas identified cases ( of intestinal-type and of diffusetype) with a massive tate. in cases of intestinal-type adenocarcinomas, eosinophils formed varied-sized aggregates in the tumour stroma. some were seen passing through the neoplastic epithelium, and others were found lying within neoplastic tubules. in cases of diffuse-type carcinoma, eosinophil clusters were seen to surround single tumour cells. with electron microscopy, performed in these cases, tumour cells in intimate contact with eosinophils revealed sublethal and lethal cellular injuries. in particular, sublethal injuries, such as cytoplasmic vacuoles and indiscernible cell membrane, occurred at the contact region. eosinophil "satellitosis" was associated with lethal damage of tumour cells including brush border disorganization, dilation of nuclear envelope, rough endoplasmic reticulum and golgi apparatus forming empty spaces or vacuoles, small condensed chromatin particles, irregular distribution of nuclear pores. these lethal injuries were compatible with non-apoptotic (non-lysosomal vesiculate) cell death. the adenocarcinoma cells, not contacted by eosinophils remained morphologically well preserved. conclusions these morphological data suggest the hypothesis of a direct relationship between eosinophil infiltration and induction of non-apoptotic tumour cell death in some cases of gastric adenocarcinoma. a deeper insight into the molecular mechanisms acting as cytokines that stimulate specific eosinophil functions may assist in the development of novel therapies to better treat human malignancies expression of p and c-erbb- oncoproteins in chronic schistosomal urinary bladder lesions o hammam, h el baz, m wishahi theodor bilharz research institute, giza, egypt this study was conducted in a trial to better understand the genetic mechanisms underlying the proliferative, premalignant and malignant changes frequently displayed in chronic schistosomal cystitis (ch.sch.c.) and schistosomal associated transitional cell carcinoma (sch.tcc) of the bladder. tissue exepression of p (tumor suppressor gene) and c-erbb- (oncogene) was assesed immunohistochemically in bladder urothelial specimens of a well characterized cohort of male egyptian patients ( ch.sch.c; sch.tcc and normal urothelial specimens as controls). both p and c-erbb- oncoproteins were not expressed neither in morphologically normal nor in the hyperplastic epithelium. overexpression of nuclear p and membranous c-erbb- was detected in % of ch.sch.c cases in whom premalignant changes (metaplasia and dysplasia) were displayed. while, in the sch.tcc cases they were detected in % and % of cases respectively. on stratifying these patients according to the well recognized prognostic parameters (histopathological grade, stage, tumor size, multifocality and growth pattern) p was positively correlated with all the forementioned parameters. in contrast c-erbb- was only correlated with tumor size and growth pattern. in conclusion, the results of the current study may suggest the early involvement of both p and c-erbb- in the initiation of the premalignant changes occuring with ch.sch.c and the progression of these changes to malignancy. moreover, the high incidence of p and c-erbb- expression among sch.tcc cases with poor prognostic parameters (higher grade, stage; bigger tumor size; tumor multifocality and nonpapillary growth pattern) may point out to the possibility of using these biomarkers as early predictive markers in ch.sch.cyst. cases displaying premalignant lesions and as poor prognostic indicators for sch.tcc. introduction cd is a neutral endopeptidase which participates in the peptide hidrolysis in the renal proximal tubules. its immunohistochemical detection has been considered useful in the differential diagnosis of renal carcinomas because of its expression in - % of clear cell renal and papillary renal cell carcinomas and its absence in chromophobe renal cell carcinoma (chrcc), a histotype positive for parvalbumin, a protein of the distal nephron. material and methods we studied immunohistochemically chrccs including four with aggressive features (two with sarcomatoid transformation, one with renal vein involvement and one with pancreatic metastasis), for cd and parvalbumin developing the reactions with different methods (abc, envision peroxidase detection and labeled polymer-ap dako envision systems) to prevent false-positive staining due to endogeneous biotin. western blotting was done to confirm the results. as control we stained clear renal cell carcinomas with both antibodies. results cd immunoreactivity was observed in ( %) primary chrccs, three with aggressive features, using all the developing systems. all chrccs were positive for parvalbumin, but not the sarcomatoid areas. western blotting confirmed the specificity of the immunoreactivities. conclusions ) about % of chrcc express cd ) cd is not specific for clear cell and papillary carcinomas of the kidney; ) a panel including both cd and parvalbumin is useful in the differential diagnosis between chrcc and clear renal cell carcinoma; ) three out of four tumors with aggressive features stained for cd , but further studies are needed to highligh the prognostic significance of cd in chrcc. introduction tenascin (tn) is an extracellular matrix glycoprotein, which is expressed during embryogenesis at the epithelial-stromal interface. tn is decreased in normal adult tissue but reexpressed in inflammatory, reparative and neoplastic processes. tn seems to be involved in neoangiogenesis, promotion of invasion and metastasis of malignant tumors. the aim of the study was to investigate the expression of tn in carcinoma in situ (cis), invasive and superficial papillary bladder cancer. material and methods cases of bladder cancer were selected ( who grade i, grade ii, grade iii tumors, cis). we investigated the different staining patterns of tn by immunohistochemistry using a monoclonal antibody against tn (t h ). results immunhistochemical evaluation revealed stromal and cytoplasmic staining. stromal staining was found at the borders of invasive tumors and in the lamina propria of most cis. tn staining of blood vessels was located at the tips of the papillae or in invasive tumor. cytoplasmic tn expression was present in all bladder cancer specimens. in cis positive cells were present in all cell layers or distributed in a pagetoid pattern while adjacent normal urothelium showed staining of superficial cells. in who grade i papillary tumors tn staining was located in superficial cells, in grade ii tumors scattered positive intermediate cells were present, while in grade iii tumors tn was expressed focally in all cell layers. most invasive tumor cell nests showed extensive tn staining. conclusion expression of tn in bladder cancer seems to be associated with dedifferentiation and invasive potential. introduction synchronous, antecedent or subsequent appearance of secondary primary malignancy (spm) in patient with primary renal cell carcinoma (prcc) is yet considered to be extremely rare. recent surveys tend to confirm at least their higher if not even significant incidence. this study was performed to determine the incidence of spm in the patients with prcc as well as its localization and time of appearance in relation to prcc. material and methods of patients who underwent surgery for renal malignancies at department of urology, sestre milosrdnice university hospital during the period from to , data of were available in croatian national cancer registry. there were patients with prcc ( males and female patients) ranging in age from - years (median . years). results and conclusion in our series there were ( . %) patients with spm. secondary malignancies in descending order of frequency were cancer of prostate ( . %), colon ( . %), lungs ( . %), bladder ( , %) and skin ( . %). there were . % antecedent, . % synchronous and , % subsequent spm. only one patient had more than one synchronous second malignancy (urinary bladder, prostate and colon). spm in patients with prcc are of great importance for both the clinician and pathologist. therefore, the clinician should maintain lifetime high-technique follow-up of the patients with prcc. the knowledge of such an existence should raise an interest in pathologist for elucidating etiologic factors. namely, it seems that the frequency of spm in patients with prcc is much higher that previously expected. introduction in our recent studies we showed increased oxidative stress with p gene alterations in urinary bladder lesions in people living in radio-contaminated areas of ukraine, after the chernobyl accident. the aim of the study was to examined whether base and nucleotide excision repair is activated in bladder urothelium by chronic low doses of ionizing radiation in male patients with benign prostate hyperplasia and females with chronic cystitis living more than years in cs contaminated areas. materials and methods bladder biopsies from patients were submitted for histological examination and biopsies from patients -for immunohistochemical study of -hydroxy- 'deoxyguanosine ( ohdg), -oxoguanine-dna-glycosylase (ogg - ), apurinicapyrimidinic endonuclease (ape ) and xeroderma pigmentosum a (xpa). results chronic proliferative atypical cystitis with multiple areas of dysplasia and carcinoma in situ was observed in % of patients from radio-contaminated areas with greatly elevated levels of ohdg, ogg - , ape and xpa in bladder urothelium. conclusion these findings support the hypothesis that significant activation of dna damage repair (base and nucleotide excision repair) is induced by long-term low dose of ionizing radiation. the levels of dna oxidative adducts pointing to mutagenic and carcinogenic potential were in line with the histopatologically diagnosed urothelial lesions. introduction urinary cytology (uc) and cystoscopy remain the standard methods for initial diagnosis and monitoring of recurrences in urothelial tumors. low sensivity of uc and invasiveness of cystoscopy led to develop different ancillary methods to improve sensitivity of uc. specific genetic alterations occurr in bladder cancers (bc), represented by aneuploidia of chromosome , , and loss of chromosome . the aim of the study was to evaluate the use of thin layer techniques applied to uc diagnosis associated with multicolour interphase fluorescence in situ hybridization (fish) for early identification of initial bc and recurrences. methods a total of voided urine specimens were collected, before resection of bladder cancer, from patient with previous bc and flogistic control patient. the samples were processed with thin prep (tp) monolayer technique and cytospin preparation (cs) and in cases with morphological alterations, was performed fish urovysion (vysis) assay, consisting of four probes ( , , and p ) . cytomorphology. results in general tp technique was better for cytomorphology, cleaner background little overlapping, with difficulties when only few urotelial cells are present and in cases of contamination with squamous cells. f i sh technique was positive in all carcinomas, with multiple gain of chromosomes , , , while none of negative controls was aneusomic. only five cases in group of patients in follow-up with minimal atipia, showed fish positity, with prevalence of loss of chromosome ( %) compared to gain of chromosomes ( %). conclusions these preliminary findings suggest that the association of tp preparation with fish anlysis can improve the efficience of uc to detect bc and predict its recurrence. chromophobe renal cell carcinoma: the variant with the best outcome? introduction few large series comparing conventional, papillary and chromophobe renal cell carcinomas (rcc) have been published. most have been heterogeneous, including rcc subgroups of different stage and/or grade. the purpose of this study was to examine the clinico-pathologic features of a series of chromophobe rccs comparing their outcome with that of conventional and papillary rccs in a grade and stage matched fashion. materials and methods the clinico-pathologic features of chromophobe rccs, papillary and conventional rccs were examined, focussing on the following parameters: patient age and sex, tumor size, stage ( ptnm), fuhrman grade, and histology. survival was analyzed using the kaplan meier method. the most important prognostic factors were identified using the cox model. results for patients with localized disease at diagnosis; median, -year, and -year disease specific survivals (dss) were similar for chromophobe ( mths, and -yr dss: %) and papillary ( mths, and -yr dss: . %) tumors. conventional rcc patients had a significantly worse outcome ( mths, -yr dss: . %; -yr dss: . %). the best outcome in low grade (g +g ), low stage (pt +pt ) tumors was observed in chromophobe rccs. in multivariate analysis, conventional (nonpapillary) rcc histology was the major independent adverse prognostic factor whether or not stage and grade were included in the cox models. conclusion chromophobe rcc is a rare rcc variant of good prognosis. this favorable prognosis is maintained when low grade (g +g ) / low stage (pt +pt ) tumors are specifically examined. introduction c-kit is a transmembrane tyrosine kinase receptor, expressed at high levels in hematopoetic stem cells, mast cells, melanocytic cells, germ cells and the interstitial cells of cajal. recently, it has been shown that for certain tumors (especially gastrointestinal stromal tumors and mast cell diseases) c-kit mutation or activation is a major pathogenetic event. only one previous study has been published regarding c-kit expression in normal renal tissue, and none regarding renal neoplasms. in this preliminary report of an ongoing study, we investigated the expression of c-kit protein via immunohistochemistry in various normal and neoplastic renal tissues. material and methods our material included eight fetal kidneys ( - weeks of gestation), seven normal adult kidneys, two cases of renal dysplasia, and renal tumors: renal cell carcinomas, two nephroblastomas, three oncocytomas, one mesoblastic nephroma and one angiomyolipoma. staining intensity was recorded in a three-grade scale. results all fetal kidneys showed cytoplasmic staining of proximal tubules (++). henle loops were also positive (++), especially in older embryos. cytoplasmic and membrane staining (++) of renal tubules was also observed in all normal adult kidneys. the two cases of renal dysplasia studied, had c-kit expression in their normal but not in their aberrant tubules. of the renal cell carcinomas, all conventional type cases (n= ), one sarcomatoid and one papillary type case were negative, while one chromophobe and one granular type were positive (++ and + respectively). all oncocytomas were positive (+++ to ++), and quite interestingly the mesoblastic nephroma was also positive. the angiomyolipoma and the two nephroblastomas were negative. conclusion we conclude that c-kit is expressed in normal fetal and adult renal tubules, as well as in a subset of renal tumors. the expression of c-kit in the latter group may prove to have diagnostic significance and therapeutic implications. background relapsed/refractory acute myeloid leukemia (aml) is characterized by a deteriorating clinical course and resistance to therapy. biological mechanisms responsible for resistance remain unclear, since consistent molecular characteristics of aml at relapse and refractory disease have not yet been reported. methods we explored paired bone marrow biopsy specimens of patients (at diagnosis and relapsed/refractory aml after high dose chemotherapy) in an immunohistochemical study using anti human ki- antigen (mib- ) antibody to determine the proliferation fraction of leukemic blasts. gene expression was analyzed in a different sample set ( at diagnosis and relapsed/ refractory aml) using a "relapse specific" cdna microarray covering genes, selected by literature and suppression subtractive hybridization. microarray results were validated using quantitative real time pcr, immunohistochemistry and immunoblotting. results recurrent and refractory aml blasts demonstrate a highly significantly increased (p< . ) proliferation fraction compared to primary diagnosis. mrna levels of proliferation markers cd and pcna were elevated . -fold and . -fold, respectively, in relapsed and refractory aml compared to diagnosis. enhanced activation of the raf/mek/erk mitogen-activated protein kinase cascade was indicated by increased mrnas of b-raf ( . -fold), cyclin d ( . -fold), mkp- ( . -fold), c-fos ( -fold) , and egr- ( . -fold). additional immunohistochemical and immunoblotting analyses demonstrated an elevation of biphosphorylated erk / protein in recurrent aml, confirming enhanced activation of the raf/mek/erk pathway. conclusion our results provide for the first time evidence that high dose chemotherapy selects or induces leukemic blasts with increased proliferative potential via enhanced activation of raf/ mek/erk cascade. introduction diffuse large b-cell lymphoma (dlbcl) is the most common of the non-hodgkin's lymphomas (nhl), comprising approximately % of newly diagnosed cases. in order to define the role of angiogenesis in dlbcl, mrna and protein expression of the two most important angiogenic growth factors, vegf and bfgf, and two vegf receptors, vegfr- /flt- and vegfr- /kdr were evaluated by real time quantitative pcr (rtq-pcr) and immunohistochemistry in dlbcl. methods we analyzed dlbcl cases, low-grade follicle center lymphomas (fls) and cases with chronic lymphocytic leukemia (cll) for expression of vegf-a, bfgf, vegfr- /flt- and vegfr- /kdr. we used a real-time reverse transcriptionpolymerase chain reaction (qrt-pcr) method to quantify mrna levels of these angiogenic markers using an abi qrt-pcr system. protein expression of these angiogenic markers was assessed by immunohistochemical staining. the results of the current study show that both the mrna and protein expression of vegf and bfgf varied considerably among dlbcl patients, which do not correlate to the microvessel density. vegf mrna expression showed significant correlation with bfgf mrna expression. the vegfr- /kdr mrna expression was higher than vegfr- /flt- mrna expression in dlbcl but their expressions were strongly correlated. histological staining of both vegf receptors in dlbcl sections showed strong staining of both receptors on the microvessel endothelial cells but not on the tumor cells. our data suggest that vegf plays a role in the pathophysiology of dlbcl however autocrine/paracrine stimulation by vegf does not seem to be relevant in dlbcl. the expression of vegf and its receptors raises the possibility of using angiogenesis inhibitors as a novel therapeutic strategy. introduction ecm regulates cellular differentiation, life span, migration and contributes to lymph node compartmentalisation. the aim of this study was analysis of occurrence and distribution of embryonal fibronectin (fn), tenascin (tn) isoforms and laminin chains (ln) in reactive lymph nodes (rln) and follicular lymphoma (fl). material and methods shock frozen tissue of rln and routine material of fl and rln. primary antibodies: all fn variants (ist- ), ed-a fn (ist ), (bc- ), all tn-c variants , tn-cl (bc- ), ln-alpha -( h ), ln-alpha -(bm ), ln-alpha -( c ), ln-beta -( e ), ln-beta -(c ), ln-gamma -( e ), ln-gamma -chain (gb and d b ). apaap-technique. results rln: all fn's, ed-a fn and tn-cl were demonstrated in lymphatic / blood vessels and as reticular depositions in the stroma; spot-like depositions in the follicle center and ribbon-like at the border follicle centre / mantle zone. ln-alpha , -alpha , -beta , -beta and -gamma -chains were positive mainly in lymphatic and blood vessels with depositions in the stroma. ln-gamma -chain was restricted to follicular dendritic cells and ribbon-like codeposited with tn-cl at the border follicle centre / mantle zone. fl: in contrast to normal follicles, a total loss of ln-gamma -chain is regular observed in neoplastic follicles. conclusions . a provisional ed-b fn / tn-cl / ln-gamma chain matrix membrane controls the traffic follicle centre/mantle zone. . in analogy to thymic t cell maturation, a role of ln-gamma -chain (ln- ) can be assumed for b cell maturation mediated by ln-gamma -chain (ln- ) positive follicular reticulum cells. . the loss of ln-gamma -chain indicates neoplastic follicular structures in follicular lymphoma. follicular lymphoma grading by mann and berard are predictive of overall survival and time to treatment failure, however, only grade has favorable os and ttf follicular lymphomas (fl) are a heterogeneous group of tumors, varying in clinical features, immunophenotype, and cytogenetics. who recommends grading of fls by using the method of mann and berard, which recognizes three grades. the aim of this study was to examine whether mann and berard's grading has prognostic significance in patients with follicular lymphoma who were not uniformly treated. samples from patients with follicular lymphoma with follow up ranging from - months (median months) were included in the study. forty-three patients ( %) achieved a complete response (cr), ( %) partial response (pr), while ( %) were considered non-responders during the follow up period of months. twenty-seven ( %) patients died, patients ( %) from dissemination, from transformation to other lymphoma type and ( , %) patients died from non-lymphoma related causes. os rate was significantly worse in patients with ann arbor stage iv than patients ann arbor stage i-iii (p= . ). patients with lower ipi score did significantly better than those with a higher ipi score for os (p< . ) and ttf (p< . ). grade fl patients had longer os (p= . ) than grade and patients. a trend for longer ttf was also found (p= . ). cox regression analysis showed that these results were independent of stage, but were not independent of ipi score. higher grade was also associated with the presence of b symptoms (p= . ) and larger size of the primary tumor (p= . ). follicular lymphomas (fl) are a heterogeneous group of tumors, varying in clinical features, immunophenotype, and cytogenetics. the aim of this study was to examine interrelationship and prognostic significance of bcl and cd protein expression for overall survival (os), and time to treatment failure (ttf). samples from patients with follicular lymphoma were evaluated by immunohistochemistry. bcl- and cd expression levels were determined semiquantitatively. since almost all cases expressed bcl- , fls were designated either "low expression level-group" (llg and +, patients) or "high expression level group" (hlg, + and +, patients) . based on cd expression, fls were designated either "negative" ( patients) or "positive" ( patients). patients with high levels of bcl- expression had favorable overall survival (os) (p= . ) and ttf (p= . ) compared to patients with low levels of bcl- expression. cox regression analysis showed that the results for os, but not ttf were independent of ipi score. patients with cd -negative follicular lymphomas also had worse os (p= . ) and ttf ( . ). our results suggest that expression of cd and strong expression of bcl- protein could be indicators of welldifferentiated follicular lymphoma since such cases were associated with lower histological grade and better clinical outcome. "borderline lesions" with clinicopathologic features in between lyp and alcls. lyp nature (neoplastic vs reactive) is matter of debate because of its benign clinical course and variable molecular findings (t-cellular clonality in less than % of cases). borderline lesions have a favourable outcome similar to lyp but, due to their rarity, limited data are available on their biologic features and clonal status. the aim of this study was to compare possible divergences in the search for clonality in the same individual skin lesions using respectively dna extracted from laser microdissected cd + cells and dna from whole paraffin sections. materials and methods lyp and borderline skin lesional biopsies were tested for tcr-gamma rearrangements by means of pcr on dna extracted respectively from whole-tissue and a pool ( - cells) of cd + cells microdissected using the zeiss-palm robot-microbeam system. results and conclusions pcr analysis of whole-tissue dna documented tcr-gamma monoclonal rearrangement in / cases ( / borderline, / lyp); tcr analysis on dna extracted from microdissected cd + cells showed monoclonal rearrangement in / cases ( / borderline, / lyp). we confirm that pcr analyses on dna extracted by microdissected cd + cells enhance the rate of monoclonality detection mainly in lyp lesions, in which the limited number of atypical cd + cells and predominant reactive cellular background may be responsible for negative or ambiguous signalling when dna extracted by the whole lesion is tested. malignant testicular lymphoma accompanied with complete av block -case report m a -year-old male patient was admitted, with the signs of complete av block and bradycardia accompanied by syncopes. a complete lab examination with us, ct and mri was done which all confirmed a massive tumorous infiltration into the root of mesenterium, presence of lymphadenomegaly around it, as well as nonhomogeneous and unclearly demarcated infiltrative lesion of myocardial septum. the patient completed his anamnesis by imparting that his right testicle was slightly enlarged and periodically painful. semicastration was indicated and the removed tissue was prepared for pathohistologic analysis. the testicle had only peripherally preserved normal tissue, whereas the tumor was clearly demarcated, . cm in diameter. five-micrometre-thick tissue sections from the paraffin-embedded tissue were stained with h&e. the cells were quite variable in their morpholoric features and size. the nuclei were generally hypochromatic, with irregular chromatin distribution. the nuclear morphologic properties varied and included pleomorphic mono-and multinucleated giant tumour cells with multiple nuclear lobulations. nucleoli were conspicuous. also, numerous benignappearing lymphocytes and plasmacytoid elements were scattered throughout the background. this histologic picture could correspond either to spermatocytic seminoma or lymphoma. since the patient needed an urgent therapy, histochemically (pas-) and immunohistochemically (lca +, cd +, cd +), the diagnosis of lymphoma was confirmed. the patient received ct (chop protocol), which resulted in a satisfactory clinical response. in this case, it is interesting to point to the most probable infiltration of the myocardium by the diagnosed lymphoma which elicited the cardiologic symptoms and from which the diagnosing of the patient's disease was to start. diffuse large b-cell lymphoma of bone: an analysis of differentiation-associated antigens with clinical correlation l de leval * , k braaten, m ancukiewicz, e kiggundu, t delaney, h mankin, n lee harris * department of pathology, university of liège, belgium, massachusetts general hospital, boston, ma twenty-nine patients with diffuse large b-cell lymphomas (dlbcl) presenting with bone involvement, including localized primary bone lymphomas (group i), multifocal primary bone lymphomas (group ii) and patients with extraskeletal disease at diagnosis (group iii) were studied. the tumors were subclassified according to the criteria of the who classification and evaluated by immunohistochemistry for expression of antigens associated with germinal center (gc) and non-gc stages of b-cell differentiation (bcl- , cd , mum- , vs c, cd , bcl- and cd ). the presence of a bcl- /igh gene rearrangement was investigated by pcr. all cases were characterized by similar clinicopathologic and morphologic features, and had similarly good overall outcome. the patients ( m, f, median y) had tumors in long bones ( ), axial skeleton ( ), and limb girdles ( ) and multiple sites ( ) . most tumors ( ) were centroblastic, with multilobated cells in cases. almost half of the tumors ( / , %) were bcl- +cd + («gclike»), / cases ( %) were bcl- +cd -(«indeterminate» phenotype) and / cases ( %) were cd -bcl- -(«post-gc like»). the «indeterminate» phenotype was seen only in primary bone lymphoma. mum- was frequently expressed in gc-like and non-gc-like categories. we found no evidence of plasmacytic differentiation by cd and vs c immunoreactivity was distinctly rare ( / cases). cd was detected in tumors, all cd -. bcl- was expressed by % of the tumors but only / cases tested had a bcl- /jh rearrangement by pcr. a survival analysis showed that gc-like tumors had a longer overall survival duration compared to non-gc-like tumors (p= . ). in conclusion, a "gc-like" immunophenotype, characterizes roughly half of large b-cell lymphomas of bone and is associated with an improved survival. ultrastructural characteristics of liver-associated lymphocytes in chronic delta hepatitis b aliev, s khodjaev institute of virology, tashkent, uzbekistan liver sinusoids contain a heterogenous population of lymphocytes including 'pit cells' discovered by wisse in . however, ultrastructural patterns of liver-associated lymphocytes (lal) in delta hepatitis are still not well identified. in present work we investigated lal in chronic delta hepatitis (chd) with electron microscopy. liver biopsies from with chd were fixed in , % glutar aldehyde, postfixed with % osmium teroxide and embedded in epon. ultrathin sections were stained with uranyl acetate and lead citrate. ultrastructural study revealed migration of lymphocytes between hepatocytes in chd. they have heterogenous population of lymphocytes varying in morphology. some of them were large granular lymphocytes and could be natural killer cells. some of lal could correspond to a t lymphocyte. in electron microscopic study of lal we also observed presence of plasma cells and the pattern of intracellular membrane systems common to cells that secrete protein: well developed granular endoplasmic reticulum, large juxtanuclear golgi complex. a centriole occupies a position just marginal to the golgi. the chromatin in the nucleus of these cells is characteristically condensed into large masses just within the envelope. our results demonstrate a heterogenity of lal in chronic delta hepatitis including the presence of b cells. hepatic steatosis in relation to serum apolipoprotein level in egyptian patients with hcv and hcv-associated hcc: histopathological, biochemical and clinico-sonographic study t aboushousha chronic hepatitis c is a known risk factor for cirrhosis and hepatocellular carcinoma (hcc). liver steatosis is common in hcv patients suggesting that specific mechanisms might be involved. the aim of our study was to assess variability in serum apolipoproteins in relation to hepatic steatosis in hcv patients of genotype with or without hcc. material included egyptian subjects; (hcv), (hcv-associated hcc), and controls. clinical examination for stigmata of chronic hepatic affection and ultrasonography for assessment of liver size, surface, echogenicity and the presence or absence of a focal lesion were done. histopathological examination of liver biopsies was done for assessment of hepatitis activity index (hai) and stage as well as the grade of hepatocytic steatosis (hs). biochemical study included liver function tests, lipid profile and assessment of apolipoproteins. results showed a significant decline in apo-a, apo-b, apo-cii, apo-ciii and apo-e lipoprotein in hcv and hcv-associated hcc groups compared to the control group. analysis of hai in hcv patients showed significant association of hs with periportal necrosis, but not portal inflammation or lobular degeneration. in patients with hcv associated hcc, hs was significantly associated with portal inflammation and lobular degeneration, suggesting a correlation between virus activity and hepatocytic neoplastic changes. we concluded that steatosis should be searched for in patients with chronic hcv, being an important cofactor in accelerating the development of hepatic fibrosis and in increasing necroinflammatory activity. a correct therapeutic approach to steatosis would slow down the evolution of chronic hepatitis. introduction nonalcoholic fatty liver disease (nafld) is defined as a constellation of clinical conditions characterized by predominantly macro vesicular steatosis. it can be extremely difficult to reach the diagnosis of nash in the absence of correct clinical data. exclusion of excess alcohol intake is notoriously difficult and requires a desialylated transferin (the method rarely present in laboratories). aim: histomorphologic investigation of liver biopsies from patients with mild laboratory test abnormalities and steatosis complicated by necroinflamatory changes. a pilot study of morphometric characteristics of lipid droplets in nash and alcoholic hepatitis were also performed. material and methods forty liver biopsies with steatosis and inflammation were examined using the method of dixon. ten of these biopsies were morphometrically analysed regarding the lipid droplet features. following morphometric parameters were estimated: ) diameter, ) perimeter and ) area. we used olympus micro image-image analysis software v. . . . the presence and distribution of mallory hyaline was the most variable parameter. morphometric analyses confirm a statistically significant differences for all parameters tested in nash and alcoholic hepatitis, and were more pronounced in nash. conclusion in the cases of fatty change with necro-inflammatory changes and pericellular fibrosis in liver biopsy and presence or absence of mallory hyaline, morphometric analysis of lipid droplets can help in reaching the diagnosis of nash, if testing of desialilated transferring is not possible. the raf/mek/erk (mapk) signal transduction cascade is an important mediator of a number of cellular fates including growth, proliferation and survival. the braf gene, one of the human isoforms of raf, is activated by oncogenic ras, leading to cooperative effects in cells responding to growth factor signals. this study was performed to elucidate a possible function of braf in liver tumours. methods mutations of braf and kras were evaluated in hepatocellular carcinomas (hcc) and in cholangiocarcinomas (cc) by direct dna sequencing analyses after microdissection. the presence of active intermediates of the mapk pathway was assessed immunohistochemically. the results obtained were correlated with histopathological variables and patient survival. results activating braf missense mutations were identified in / cc ( %) and in one case of tumour surrounding liver. kras mutations were found in out of ( %) cc examined and in two cases of tumour-surrounding non-neoplastic liver tissue. in hcc, neither braf nor kras mutations were detected. all cc with kras mutations had an intact braf gene. we failed to observe a correlation between braf or kras mutations and histopathological factors or prognosis of the patients. conclusions our data indicate, that braf gene mutations are a relatively common event in cc, but not in hcc. disruption of the raf/mek/erk (mapk) kinase pathway -either by ras or braf mutation -was detected in about % of all cc and is therefore one of the most frequent defects in cholangiocellular carcinogenesis. prognosis and treatment of cholangitis after cholecystectomy n akhtar, ae kuzmenko, vv khatsko, ga grintsov, am dudin, yg kolkin donetsk medical state university, donetsk, ukraine introduction the purpose of our research was to study prognostic tests of cholangitis after cholecystectomy (ce) for prophylaxis and optimal treatment. materials and methods for years patients with so called "postcholecystectomic syndrome" (pces) were treated, ( %) had a clinical picture of acute cholangitis (ac), which was shown by pains in the right hypochondrium, yellowness of skin and scleras, shivering, high hyperthermia and leukocytosis. patients ( women and men) were - years old, of them more than years. initial operation (ce) was made in various hospitals in terms from months to years ago. the diagnosis was verified by: clinical, laboratory and immunological researches, peroxidation of lipids (pol), ultrasonic research, computerized tomography, fibrogastroduodenoscopy, endoscopic retrograde pancreatocholangiography, transdermic and transhepatic cholangiography, fibrocholangiograpgy, bacteriological researches of bile and blood. results according to investigations, in patients the reason of infringement of bile flow was choledocholithiasis (in a combination with stenosis of big duodenal papilla (bdp) or without it, in -stenosis of bdp, in -cicatricial stricture of hepatocholedochus, in extended stenosis of bdp and a terminal part of the common bile duct (cbd). laboratory prognostic tests (risk factor) ac concern: hyperbilirubinemia, increase of activity of alanine transpeptidase, aspartate transpeptidase, hypoproteinemia, dysproteinemia, decrease of a level of protrombin lower than %, leukocytosis, anemia, increase of the contents of urea in blood, bacteriocholia, concentration of molecule of average weight were higher than . unit, decrease of level of vitamin e, high contents of immunoglobulin m on a background of a low parameter immunoglobulin g. conclusions at the presence of risk factors prognosis was frequently in contrary to expectations and mortality reached to - %. all patients with acute cholangitis after cholecystectomy represented a complicated problem and demanded a complex approach. revealed prognostic tests of the development of acute cholangitis are necessary for taking into account for its prophylaxis and optimum treatment. structural alterations in c-myc oncogene, copy number and expression have been implicated in the pathogenesis and progression of several human neoplastic diseases. however, the biologic significance of c-myc gene in human hepatocellular carcinoma (hcc) is unconfirmed. in the present study we correlated c-myc gene amplification and protein expression with the clinicopathologic features. in hcc cases c-myc amplification in tumour tissue was determined using a differential pcr, a procedure for evaluation of gene amplification in comparison with a dopamine d receptor gene. the c-myc gene was amplified in out of tumor specimens ( %). amplification of c-myc was more frequent in younger male patients with hbv infection and in less differentiated tumors. all cases demonstrated positive staining using anti-c-myc monoclonal antibody with increasing percentage of immunoreactive cells in less differentiated tumors. however, the high protein expression was not statistically correlated with c-myc amplification. histological sectioning of brush bristles allows improved diagnosis of biliary tract and bronchial lesions g bussolati, g accinelli, l macri dept. biomedical science and human oncology, turin, italy brushing of thin ducts such as those of the biliary tract, pancreas and bronchial tree is often used by endoscopists in order to obtain diagnostic material proving the nature of related lesion. the material is spread on slides. cytological examination folows. preservation of the material so obtained is often sub-obtimal, partly because of the presence of fluids such as bile affecting cell preservation, partly because spreading of delicate cells may result in crushing artifacts. to circumvent such problems, we devised an original procedure, where brushes were not smeared, but instead immediately embedded in immersed methanol. then the tube with alcool and brush was sent to the laboratory. in order to induce formation of a glue surrounding the brush, this was immersed while wet into egg albumen (a mixture : of egg albumen and glycerol), then returned to methanol. for paraffin embedding, the metal handling was cut away and the brush was introduced as such into a cassette. sections parallel to the long axis were cut until the metal wire was almost reached, then the block was rotated and new section was obtained from the opposite side. sections were stained in haematoxilin-eosin and with the papanicolau procedure. small fragments of the mucosa, of inflammatory cell aggregates or of related carcinomas were observed. these resulted optimally fixed and allowed a definite histological diagnosis which proved mandatory for proper therapy. advantages and prospects of this novel procedure will be illustrated and discussed. is telomerase catalytic subunit gene re-expression an early event in gallbladder carcinogenesis? were to determine whether a.) differences in the levels of htert exist among different grades of gallbladder epithelial abnormalities, and b.) htert gene re-expression has any role in gallbladder carcinogenesis. material and methods the expression of htert was analysed in gallbladder tissue samples: normal epithelia, reactive hyperplasias, low grade dysplasias, high grade dysplasias and in adenocarcinomas by immunohistochemistry. at least nuclei were quantified per slide and the number of positive signals per nucleus was expressed as a htert index. results the mean htert index increased progressively with the degree of gallbladder epithelial abnormalities: from . (standard deviation= . ) in normal epithelia, . (sd= . ) in hyperplastic epithelia, . (sd= . ) in low grade dysplasia, . (sd= . ) in high grade dysplasia to . (sd= . ) in adenocarcinoma. according to the htert expression, three groups of gallbladder epithelial changes were found: .) normal and hyperplastic gallbladder mucosa, . low grade dysplasia, and .) high grade dysplasia and adenocarcinoma of the gallbladder. the differences between the groups were statistically significant (p< . ). conclusions we believe that occasional presence of htert in normal and reactively hyperplastic gallbladder mucosa merely reflects its regenerative capacity. nevertheless, significantly higher htert indices in low grade as well as high grade dysplastic epithelium and gallbladder adenocarcinoma are most probably the consequence of htert re-expression -an early event in the multistep process of gallbladder carcinogenesis. spontaneous intestinal perforation vs. necrotizing enterocolitis: different entities clinically and pathologically g de hertogh, p van eyken, m miserez, h devlieger, k geboes k u leuven, leuven, belgium introduction necrotizing enterocolitis (nec) is the most common neonatal surgical emergency. however, during recent years an increasing number of laparotomies has been performed for spontaneous intestinal perforation (sip) in premature infants. the aims of this study were to compare the clinical and pathological features of sip and nec and to identify parameters useful to make the differential diagnosis. materials and methods we reviewed the clinical files and biopsies from infants indexed as "necrotizing enterocolitis" or "intestinal perforation" between and . results twenty-six patients had sip and had nec. patients with sip had lower gestational age and birth weight. they presented early with abdominal distension. frequent radiological signs were dilatation of bowel loops and pneumoperitoneum. perforation was in the small bowel in all cases. % survived. patients with nec presented later with more systemic symptoms. pneumatosis intestinalis was present in more than half. the colon was involved more frequently than the small bowel. % survived. cases of nec were characterized by necrosis, inflammation and reparative tissue changes with or without pneumatosis intestinalis. in contrast, the bowel in cases of sip was not necrotic and showed little inflammation. its most distinguishing characteristic was the presence of one or more defects in the internal layer of the muscularis propia. the myenteric nerve plexus and interstitial cells of cajal had developed normally. conclusions spontaneous intestinal perforation and necrotizing enterocolitis differ in their clinical and histopathological characteristics. in our cases, sip was always associated with segmental absence of the intestinal musculature. impact of epitope retrieval in detection of cd (c-kit) in gastrointestinal stromal tumors (gists) using manual and automated immunohistochemical (ihc) procedures introduction gastrointestinal stromal tumours are solid tumours associated with c-kit and pdgf-r expressions. the recent introduction of gleevec/glivec, an effective inhibitor of the activated c-kit and pdgf-r has stimulated interest in standardizing the immunohistochemical detection of c-kit in gist-tissues, assuring an appropriate selection of patients for therapy with gleevec. aims: the dakocytomation anti-human c-kit antibody, code a , was investigated in four different set-ups: ) without heat-induced epitope-retrieval (hier), ) with hier, ) preabsorbing the primary antibody with the synthetic peptide used for generation of the primary antibody and ) testing on fresh versus archival tissue sections. materials and methods tissue sections were obtained from different cases of gist, confirmed by morphology and ihccharacterisation (c-kit, cd , s , sma, desmin). the ihc was performed manually as well as on automated platforms including the techmate™ and the autostainer instruments. results the use of hier consistently displayed a stronger and more uniform staining pattern as compared to an ihc protocol without hier. in few cases the expression of cd was found faintly positive in ihc without hier. automated and manual ihc methods displayed similar staining patterns. the specificity of detecting cd in a protocol using hier was confirmed by preabsorption of the primary antibody with immunogen. storing of fresh cut sections for more than months demonstrated a decrease in ihc cd staining intensity. conclusion epitope retrieval enhances the cd staining intensity in gist-tissue. the specificity of the cd detection in gist's can be confirmed by complete blocking of the positive staining in a parallel set-up, using preabsorption of the antibody by a synthetic c-kit peptide. introduction - % of gastric cancer patients worldwide are under and the clinicopathological features are different from the older age group. here we characterise some of the genetic changes in cases of early onset gastric cancer (eogc). methods using dna isolated from microdissected material, a panel of polymorphic microsatellite markers near known or presumed tumour suppresser genes was used to evaluate loss of heterozygosity (loh). microsatellite instability (msi) status was ascertained using polymorphic microsatellite markers in cases of eogc and in an additional biopsy cases. corresponding immunohistochemistry was performed for p , smad , ecadherin, mlh , msh and msh . ebv status of the carcinomas was determined using eber -mrna in-situ hybridisation. results the most common losses were at loci adjacent to cdh ( %), tp ( - %), runx ( - %) and smad / dpc ( - %). less frequently, losses were detected at p , q , and loci adjacent to apc, p ink a, pten, and tff. no msi was detected in the cases examined. immunohistochemistry revealed abnormalities for e-cadherin in % and p in %. all tumours examined were ebv negative. conclusion common events in eocg are genetic alterations in cdh , tp and runx whereas other loh findings were infrequent. protein abnormalities of e-cadherin and p were commoner than losses near the corresponding gene. in contrast to gastric cancer in older patients, msi does not appear to occur in young patients. these findings confirm that unique genetic alterations lead to gastric cancer in the young and highlight the need for further investigation to elucidate the mechanisms by which they occur. introduction a place of foveolar hyperplasia (fh) in benign epithelial gastric polyps (begp) classification, as well as its role in a development of hyperplastic polyps (hp) is still a matter of controversy. aims: two questions are to be studied: . does fh, hp, adenoma (a) and carcinoma (ca) represent a continuum in terms of ki- proliferative activity ? . are there any differences of the means of ki- labelling index (li) in hyperplastic areas of hp when comparison is made between hps without other lesions (hp-nos) and with hps with different focal lesions such as intestinal metaplasia (hp-im), dysplasia (hp-d) and/or carcinoma (hp-ca)? materials and methods begp from patients were selected to perform ki- immunohistochemical analysis. there were fh, hp (including hp-nos and hp-im, hp-d and/or hp-ca) and a. as controls cases of normal mucosa (n), cases of regenerative fh (fh-r) and cases of ca were used. paraffin sections were studied immunohistochemically for ki- li with application of mib- antibody. the data were analysed using one-way anova models. results it has been found that the means of ki- li between all the groups studied differed significantly (p< . ). ki- li for fh was high ( . ) and did not differ significantly from fh-r ( . ), a ( . ), and areas of low grade dysplasia in hp-d ( . ), but was significantly higher from n ( . ) and hp ( . ). conclusions .we hypothesize that fh may probably represent an early event in begp formation. .there were no significant differences of ki- li results for hyperplastic areas in hp ( . ) independently if there were focal im, d and/or ca simultaneously, or not. introduction among the malignant tumors that occur in stomach, carcinoma is overwhelmingly the most important and common ( - %). the aims of this study were to report how we histologically evaluate gastric carcinoma (gc) on endobiopsies, using who and lauren classifications. additionally, we tried to detect the rhabdoid features in specimens with diffuse gc. the study included gastric endobiopsies, gc being diagnosed in cases ( %), mostly in men ( cases - %). endobiopsies, routinely embedded, were stained by hematoxylin-eosin, giemsa, pas and alcian blue (ph . ). immunohistochemical studies were performed using vimentin and cytokeratin antibodies for detection of rhabdoid features. results and conclusions the highest incidence of gc was in - -year-old aged patients ( %). using lauren classification, cases were categorised as diffuse type ( %), intestinal type ( %) and ( %) mixed type gc. each of these three types were also histologically analyzed according to who classification: intestinal type gc (formed by recognizable well/moderately differentiated glands) and diffuse type gc (consisting in poorly cohesive cells diffusely infiltrating the gastric wall with little or no gland formation). in diffuse type gc with rhabdoid features we evidentiated vimentin and cytokeratin in cells with an eccentric nucleus and a paranuclear inclusion. finally, we pointed out that is very easy to diagnose gc by lauren and who classifications, but is difficult to evidence the mixed type gc due to reduced size of endobiopsies. recognition of the rhabdoid phenotype in diffuse type gc is important because this feature is associated with poor prognosis and unresponsiveness to conventional therapy. gastrointestinal tract. the patient had a -year history of dyspepsia, diarrhorea, mild diabetes mellitus and cholelithiasis. one hour after the admission, he died in hypovolemic shock. taken tissues from all organs were fixed in % formaldehyde and embedded in paraffin. laboratory sections were stained with: he, ab-pas, van gieson, grimelius, masson's argentaffine reaction and bsp methods, using antibody to somatostatin. results cafe au lait spots, multiple skin neurofibromas, mental retardation, skeletal deformities and a variety of tumours arising in the brain (craniopharyngioma), follicular thyroid adenoma and duodenal somatostatinoma, were found during autopsy. duodenal bleeding ulcer of gigantic size, was covered with coagula. in the bottom of the duodenal ulcer was discovered duodenal carcinoid of the glandular architecture, intermingled with solid acinar and trabecular growth pattern; its cells contained somatostatin. marked increase in number and thickness of nerve fibres also was seen, leading to disordered motility and to striking hypertrophy of the muscularis propria. conclusion having in mind that the patient has the sister, and that this disease has hereditary character, we will invite the sister as soon as possible and she will be in the future the target of our investigation. increased expression of muc and muc and decreased expression of muc in colorectal adenoma-carcinoma spectrum: a tissue array study introduction mucin-type glycoproteins are widely expressed in the gastrointestinal tract. little is known concerning the relationship of altered mucin antigens in colorectal polyps. the aims of this study were to determine the different patterns of mucin distribution of muc , muc , muc ac and muc and compare their patterns of expression with respect to histopathologic criteria of malignant potential in colorectal carcinogenesis by tissue array using immunohistochemistry. peritoneal dialysis (pd) is an alternative to hemodialysis for the treatment of end-stage renal disease. the long term exposure to dialysis solutions causes progressive peritoneal fibrosis and functional decline of the peritoneum. the pathologic process that leads to fibrosis is not well understood and most studies have focused on mesothelial cells, probably because they are easy to obtain from peritoneal effluents. the aims of this study were to establish diagnostic markers of peritoneal fibrosis and pathogenic clues to explain the fibrogenic process. the study was focused on submesothelial fibroblasts from normal controls and pd patients. materials and methods parietal peritoneal biopsies were collected from three patient groups: normal controls (n= ), non-pd uremic patients (n= ) and uremic patients on pd (n= ). in order to study myofibroblastic differentiation and mesothelial-to-mesenchymal transition, alpha-smooth muscle actin, desmin, cytokeratins, and ecadherin were analyzed. we also evaluated cd expression by submesothelial fibroblasts. results fibroblasts from normal controls and non-pd, uremic patients showed no myofibroblastic nor mesothelial markers, but an intense expression of cd . the opposite immunophenotypic pattern was present during pd-related fibrosis. expression of mesothelial markers (cytokeratins and e-cadherin) by fibroblastlike cells and alpha-smooth muscle actin by mesothelial and modified mesothelial cells are evidence that mesothelial-to-mesenchymal transition occurs during pd. loss of cd expression was another helpful indicator of fibrosis. conclusion the immunophenotype of submesothelial fibroblasts varies depending on the existence of a fibrogenic condition. this information results useful for the differentiation between quiescent and activated fibroblasts. in addition, it shows interesting information regarding the origin of this cell population. immunohistochemical and genetic high-throughput analysis of gastrointestinal stromal tumors tract. they are characterized by diffuse immunohistochemical positivity for c-kit protein (cd ). the aims of this study were to assess the immunohistochemical and genotypic features of a large series of gist using tissue microarray technique. methods gist were retrieved from the files of dpt of pathology of our institutions and a tissue microarray (tma) was built. immunohistochemistry for cd , actin, desmin, s , nse, mib was performed. interfase fish analysis was carried out for the following genes: mdm , egfr, c-myc, ccd and her- . results % of the tumors resulted positive for cd , % for desmin, % for actin, % for s , % for nse, % for mib . a significant difference between gastric and non-gastric gist was observed for cd , desmin and s . age, size, necrosis and nse positivity significantly correlated with aggressive behavior of the tumors. moreover, an amplification of c-myc, mdm , egfr, ccd in tumors was found. the tumors were all but two borderline or high risk tumors. cases of coamplification were also detected in clinically malignant or histologically high risk tumors. conclusion useful parameters for prognostic evaluation of gist are age, size and necrosis. furthermore, the observed amplification of c-myc, mdm , egfr suggests a role of rb-ccd pathway in the acquisition of malignant phenotype in a subset of gist. digital slide and virtual microscopy based routine and telepathology evaluation of routine gastrointestinal biopsy specimen l berczi introduction the aim of the study was the evaluation of a recently developed digital slide and virtual microscope system, its comparison with optical microscopy on routine gastric biopsy specimen in local and remote access mode. materials and methods h/e stained routine gastric, duodenal and colon (altogether ) biopsy specimen were selected, scanned and evaluated by two specialists on an optical (om) and virtual microscope (vm). the overall concordance of vm to a consensus diagnosis (con) was . % and % of the om to con. the clinically important concordance was % and % respectively. the two methods showed concordance in % and clinically important concordance in . %. the reasons of the discordance was image quality (one case), interpretation difference ( cases). the overall hard disc place for a gastric biopsy was between to megabytes. the scanning time was between to minutes on a commercial microscope (axioplan , carl zeiss, germany) and to minutes on an automated slide scanner (hi-scope, dhistech ltd., budapest) conclusions remote evaluation of the digital slides through internet shows the advantages of the previously used static and dinamic telepathology methods. the digital slide and the virtual microscope are real alternative techniques in the computerization of the histology laboratory and in teleconsultation services. the expression pattern of the muc glycoproteins muc , muc and muc ac may be useful in classifying the various types of intraductal pancreatic neoplasms (ipmns). recent studies have revealed that muc is expressed in ductal pancreatic carcinomas (pdac) only. this study investigates whether muc is expressed in ipmns and in particular in those with invasive components. in addition, muc reactivity was studied in panins of both ipmn and pdac. methods paraffin blocks from resection specimens from pdacs and ipmns ( invasive) were investigated immunohistochemically ([ihc] antibody clone ig ) and by in-situ hybridization ([ish] digoxigenin labeled oligomer nucleotide specific for sequences corresponding to repeat domains of muc ). the normal pancreas is muc negative. of pdacs were positive for muc in both ihc and ish. only ipmns were muc positive, and these cases were of the oncocytic type. invasive ipmn components of the dac type ( / ) and one of muconodular type ( / ) showed muc expression at both the protein and the rna level. in ipmns associated panin lesions of all grades were negative, whereas in pdacs a few panin lesions were positive. conclusions muc neoexpression in the pancreas seems to be a feature of invasive ductal neoplasms (ipmn, pdac), with the exception of oncocytic ipmns. the aberrant expression, in particular the shift from the negative intraductal to the positive invasive component in ipmns, is so far unexplained, but it may be related to the genetic alterations known in ipmns and pdacs. introduction hypermethylation of cpg islands represents an important epigenetic mechanism for silencing of tumor suppressor genes during carcinogenesis. in this investigation, the prevalence of hypermethylation of the dna mismatch repair gene hmlh and of the recently identified hpp gene was investigated in adenocarcinomas of the upper gastrointestinal tract. materials and methods using methylation-specific real-time pcr and fluorescence-labeled dna-probes, hypermethylation of hmlh and hpp was investigated in barrett's-esophagusassociated adenocarcinomas, cardiac carcinomas and in gastric carcinomas. additionally, hmlh protein expression was investigated by means of immunohistochemistry. in a subset of cases the presence of dna-microsatellite instability was tested. hypermethylation of hmlh was found in % of barrett's carcinomas, % of cardiac carcinomas and in % of gastric carcinomas, whereas hypermethylation of hpp was found more frequently in all tumor types ( % vs. % vs. %). in gastric cancer, hpp hypermethylation was found more frequently in tumors with concomitant hmlh hypermethylation ( %), than in those without hmlh hypermethylation ( %, p= . ). complete loss of hmlh protein expression which was present in carcinomas ( cardiac and gastric) was invariably correlated with hmlh hypermethylation and with microsatellite instability. conclusion our data indicate that microsatellite instability and loss of the mismatch repair protein hmlh , which is mainly caused by hmlh gene hypermethylation, is more prevalent in the carcinogenesis of the stomach and the cardia than in the esophagus. moreover, in gastric cancer hmlh hypermethylation is correlated with hypermethylation of the hpp gene. antral g-cells in sporadic fundic gland polyps patients: an immunohistochemical study introduction malignant melanoma is an increasing neoplasm in the western world. advanced tumors gain metastatic potential and are responsible for high mortality rates. during tumor progression a downregulation of the transcription factor ap- a and the receptor thyrosine kinase c-kit was observed. however, mechanisms leading to a loss of both proteins are unknown. besides genetic changes post-transcriptional downregulation by caspase- and - is recently discussed. aims were: i) to investigate malignant melanoma for ap- a and c-kit genetically and by protein expression, ii) to study the implication of activated caspases. methods ssms, nms and metastases were analyzed by direct sequencing analysis for all exons of ap- a and c-kit genes and by immunohistochemistry for the respective proteins and cleaved (activated) caspase- and - . results four tumors showed point mutations in the activation motif of ap- a (exon ). no genetic alterations were detected in the c-kit sequence. immunohistochemistry revealed a progressive loss of dermal ap- a and c-kit expression when comparing ssms with nms and ms which was paralleled by a strong expression of caspase- in the primary melanomas and ms, the later were also characterized by caspase- expression. conclusion tumor progression in melanoma is characterized by a loss of ap- a and c-kit. caspase- probably contributes to this down-regulation, as it was recently shown in vitro. the activation of caspases in melanoma might not only induce apoptosis but could be substantial for tumor growth. introduction in cancer patients, tumor-expression of the angiogenic factor vascular endothelial growth factor-a (vegf-a) correlates with high tumor vascularity and increased metastatis, but how these latter two relate is unclear. we investigated the mechanisms of vegf-a -enhanced metastasis of the human melanoma cell line mel . methods stably transfected mel cells, expressing vegf-a or egfp, were injected into the internal carotid artery or tail vein of nude mice to establish brain or lung metastases (colonization models). subcutaneous tumors were grown to examine spontaneous metastasis to lung. tumors and metastases were examined by (immuno)-histochemistry. results in colonization models, vegf-a expression did not give tumor cells a colonization advantage. metastases originated predominantly by clonal expansion of single cells. in contrast, spontaneous metastasis from subcutaneous tumors was enhanced in tumors with vegf-a expression, this enhanced metastatic potential was induced by a distinct architectural transformation of the s.c. tumors: while mel -egfp and parental mel tumors showed extensive necrosis, mel -vegf-a tumors presented a micronodular growth pattern, with nodules protruding into sinusoidal dilated vasculature. these micronodules proved to be polyclonal, had tissue characteristics and caused metastatic embolism in the pulmonary artery with subsequent metastatic outgrowth. conclusion vegf-a may enhance spontaneous metastasis not simply by increased single cell shedding into the circulation by an increased tumor vascularity but by induction of a micronodular transformation of a tumor resulting in enhanced shedding of (polyclonal)tissue fragments into the circulation. this step of tumorintravasation is probably a rate limiting factor in development of metastasis. correction of cytogenetic disturbances in patients with relapsing genital herpes la lebedinskya, op abaza donetsk medical state university, donetsk, ukraine introduction serious forms of relapses of genital herpes (gh) are accompanied by disturbances of chromosomal apparatus of lymphoid cells (l.a. lebedinskya, ) . correction of the given infringements is the important problem of practical public health service. the aim of our research was development of a complex method of correction of cytogenetic infringements in patients with gh. materials and methods we had investigated and treated patients (complex treatment) with gh in the age of - years, with frequency of relapses of one time in . - months. the control group was made by healthy persons, same age group. cytogenetic disturbances in t-lymphocytes of peripheral blood surveyed determined by metaphase method. complex method of treatment of patients with gh included acyclovir mg times per day before clinical recovery and phytopreparation "bacplan", received by an original way from quercus cortex. phytopreparation "bacplan" shows immunomodulation, anti-inflammatory and antimutagen properties. preparation "bacplan" appointed per os . g per day within days. external - % solution of bacplan in the form of lotion on affected body parts time in day. results average frequency of cells with aberrations of chromosomes (ac) in t-lymphocytes of peripheral blood of patients with gh before treatment were much higher in comparison with parameters of control group (accordingly . ± . and . ± . % p< . ). in patients were marked disturbance of chromosomal and chrmotoid types. in . % cases aberration of chromosomes were registered in - chromosome pairs. after complex treatment of average frequency of cells with ac in patients has decreases to days to . ± . % (p< . ) and practically come nearer to control parameter ( . ± . %). conclusions thus, use of viral specific preparation acyclovir in combination with phytopreparation "bacplan" reduces frequency of structural infringements of chromosomes in t-lymphocytes of patients with gh. different expression patterns of s- versus s- b in primary skin melanoma j timar, n udvarhelyi, z orosz national institute of oncology, budapest, hungary differential diagnosis of melanoma involves immunohistochemistry where s- is a traditional marker which is recently completed by gp /hmb , mart- and tyrosinase. the s- family of ca-binding proteins comprises the a ( - ) and b isoforms. recent microarray analysis identified s- b as the melanocyte lineage marker. in this work we have compared the expression patterns of s- proteins using antibody recognizing both isoforms versus that which is specific for s- b in human skin primary melanoma samples. there were expression patterns observed: focal, herogenous and diffuse for both antibodies. the most frequent expression pattern was the diffuse one ( - %) while the least frequent was the focal pattern ( - %) in case of both antibodies. when the individual cases have been analysed for the expression patterns for the two antibody we found % discrepancy. in about half of these cases ( %) the discrepancy was minor (heterogenous versus diffuse staining pattern), but in almost a third of the cases ( %) it was found to be considerable (focal pattern versus heterogenous or diffuse). we have concluded that the expression patterns of s- and s- b proteins in human melanoma are frequently different. since gene expression studies identified s- b as linage marker, it is highly recommended to use monospecific antibody for routine diagnosis. furthermore, s- b is validated as sensitive serum marker for melanoma progression accordingly it is another indication for the use of anti-s- b antibody in the routine diagnosis. introduction primary cutaneous b-cell lymphomas represent subtypes of extranodal b-cell lymphomas with distinct clinicopathologic features. they account for approximately % of primary cutaneous lymphomas. the most common forms include follicle cell lymphoma, marginal zone lymphoma, immunocytoma, and diffuse large b-cell lymphoma. we report cases of primary cutaneous diffuse large b-cell lymphomas, one in the left gluteal region ( / cm in diameter), and the other in the left leg ( / cm in diameter), both appearing clinically ulcerated. materials and methods routine paraffin embedding and usual stainings, followed by immunohistochemistry were used. results microscopy evidentiated in the papillary and reticular dermis a diffuse pattern of growth of cells with a moderate degree of morphologic variation, with moderate, slightly basophilic cytoplasm and round-ovalar nuclei, with vesicular aspect owing to margination of chromatin at the nuclear membrane, - nucleoli, and frequent mitoses. gomory staining revealed a network of reticulin with reduced intervening spaces. immunohistochemistry evidentiated a diffuse positivity of vimentin and cd (l ), s positivity in few cells, desmin negativity, mic negativity, cd (berh /ki- ) negativity, actin negativity in tumor, but positivity in vessels, ema negativity and pcna positivity in almost % of the cells. conclusion final diagnoses of primary cutaneous diffuse large bcell lymphomas were considered correlating the clinical, morphologic, and immunophenotyping features. although prognosis of most primary cutaneous b-cell lymphomas is favorable, with -year survival rates over %, diffuse large b-cell lymphoma is more aggressive. we appreciated an unfavorable prognosis of both cases, but especially in the patient where the lymphoma occurred in the lower leg, as this location is associated with a more aggressive behaviour. in malignant melanoma cd protein expression is associated with metastatic tumors, higher clark levels and tumor thickness according to breslow n department of pathology, the norwegian radium hospital, norway cd antigen is a kd a cell surface zinc metalloendopeptidase and is expressed by a variety of normal and neoplastic lymphoid and non-lymphoid tissue including melanomas. kanitakis et al. (melanoma res ; : - ) have recently demonstrated that cd expression is significantly more common in metastatic than primary melanomas. we have evaluated biopsies from patients with primary and patients with metastatic melanoma. formalinfixed/paraffin-embedded tissues were studied by immunohistochemistry using mab c from novocastra laboratories and envision+® from dakocytomation. overall, cd was expressed in / samples, but the percentage of cd -positive cell was significantly higher in metastatic tumors (p= . ) and also in primary tumors with higher clark level (p= . ) and tumor thickness according to breslow (p= . ). even though the intensity of expression was associated with depth of invasion (clack levels p= . , breslow p= . ), there was no definitive difference between primary and metastatic tumors (p= . ). we conclude that cd expression in malignant melanoma is associated with tumor progression. sclerosing adenosis of the skin g sclerosing adenosis is a lesion that occurs in the breast; rare cases have also been reported in other organs such as prostate and skin. we report a case of sclerosing adenosis of the skin incidentally found at the periphery of a basal cell carcinoma. a -year-old man had a polypoid lesion of the scalp measuring . cm in diameter. the lesion was surgically removed and, at histology, it was composed of a nodular basal cell carcinoma. below the basal cell carcinoma, there was a well circumscribed but not encapsulated lesion constituted by small, packed glands separated by cellular stroma, reminiscent of sclerosing adenosis of the breast. some glands showed open lumina bordered by cells with eosinophilic, granular cytoplasm while other glands were arranged in solid clusters or elongated cords. two distinct layers of cells were seen bordering the glands: a luminal layer of cuboidal cells and an outer layer of basal cells with scanty cytoplasm and spindle nuclei. at immunohistochemistry the outer cell layer was positive for actin, calponin, caldesmon and keratin antibodies showing therefore myoepithelial cell differentiation. the luminal layer was positive with low weight keratin; moreover luminal cells were decorated by gcdfp- antibody, a marker of apocrine differentiation. to the best of our knowledge this is the first case of sclerosing adenosis of the skin showing apocrine metaplasia of luminal cells. the case here reported is an additional example of the existence of occasional similar lesions between skin and mammary gland. immunolocalization of human sperm protein in skin cancer introduction a variety of cancer	estis (c\t) antigens has been found to be expressed in healthy testis and in a wide range of human malignancies, including melanoma. the effectiveness of these antigens as target for active specific immunotherapy has been largely demonstrated. recently a new human c\t, called sperm protein (hsp ) has been investigated in multiple myeloma and ovarian cancer. the aim of this study was to investigate the expression of hsp in healthy skin and melanocytic skin lesions, in order to evaluate the usefulness of this antigen to develop effective specific immunotherapeutic procedures. methods the authors assessed the immunolocalization of hsp in paraffin embedded formalin fixed specimens of healthy skin (n= ) and tissues representing cutaneous melanocytic lesions [common nevi (n= ), spitz nevi (n= ), blue nevi (n= ), atypical nevi (n= ) and melanomas (n= )]. results hsp was not detected in healthy skin. it was recognized with a high frequency in cutaneous melanocytic lesions in some cells of the dermal stroma, often containing melanin, compatible with melanophages. a higher expression of hsp was observed in hyperpigmented nevi. conclusion the emergent complex function of hsp suggests the necessity of further studies to investigate the relation between melanophages and hsp . although hsp was not detected in healthy skin, its limited detection in resident melanophages recognized in cutaneous lesions, and not in tumoral cells precludes its applicability as target in skin cancer immunotherapy. introduction crimean congo haemorrhagic fever (cchf) is endemic in many countries in asia, africa and europe. the virus, which causes cchf, is a nirovirus from the bunyaviridae family. although primarily a zoonosis, sporadic cases and outbraces of cchf affect humans. case report a -year-old female patient was hospitalized due to sudden onset of fever, headache, vomiting and abdominal pain. during the next days, her condition became worse, she was unconscious, anuric, cyanotic with multiple edema on extremities, large vaginal coagulums and with appearance of haemorrhagic secretion in aspired fluid from the respiratory tract. three days after admission, due to sudden onset of cardiac arrest, patient died. pathologic findings: severe bleeding from the mucous membranes and internal organs were found, particularly emphasized in the liver, kidneys, heart, brain and other organs. widespread hepatocellular necrosis with focal microvesicular steatosis and multiple intracytoplasmatic microvesicular inclusions were the most striking morphological findings. diffuse necrosis of renal tissue was also found. recent haemorrhages in lungs, cardiac muscle, suprarenal gland, spleen, and gastric mucosa were found. lymphoid depletion was detected in lymph nodes. the rt-pcr method for detection cchf virus has been applied in analysing serum and tissue samples. serological testing and testing from paraffin embedded tissue were positive. conclusion autopsy pathologic findings of cchf include widespread haemorrhages of the skin, mucous membranes, pleura, peritoneum. necrosis is frequent in all organs and tissues, often of ishaemic nature. autopsy results of our patient showed similar pathologic findings and by pcr method we confirmed etiopathogenesis of this disease. the modern morphological characteristic of placenta in syphilis z parpiev , g reymnazarova , b magrupov dermatology and venerology, tashkent, uzbekistan first tashkent medical institute, tashkent, uzbekistan we investigated the placentas in three cases of intrauterine death caused by inherited syphilis. grossly, they were small and medium lobular, showed a marked sclerosis of large vessels and they looked white-muddy. the umbilical cord was also sclerotic and showed obliteration of vessels. their weight corresponded to term of gestation, whereas their area was smaller and their thickness greater than in normally proceeding pregnancy, but these differences were not significant (p> . ). results light microscopic investigation revealed avascularized stroma and sclerotic villi with vessels showing obliterating angiopathy. these changes were combined with processes of compensatory character, such as sharply extended subsyntitially located capillaries and large number of small vesels. conclusion in the morphological study of placenta, the attributes of damaged placental tissue and development of compensatory reactions directed towards the maintenance of necessary balance in the mother-placenta-fetus system were revealed. in placenta, contrary to the descriptions of the last years, we found no significant increase of its weight and change in this connection fetus-placenta of factor. the basic changes in placenta were characterized by the development of productive vasculitis with obliteration of the vascular lumina and presence of avascularized terminal villi. the thickening of vessel walls of the main villi as a result of proliferative endarteriitis can be considered as a characteristic attribute for syphilitic infection. the latent membrane protein (lmp ) of epstein-barr virus is one of two postulated viral oncogenic proteins. previous reports have suggested that sequence variations, and in particular a base pair deletion variant called cao, may define different disease populations. we developed a cocktail of rat monoclonal antibodies that were specific for the non-wild type lmp and compared the presence of the antibody staining with lmp dna sequence analysis on clinical samples of nasopharyngeal carcinoma, peripheral t-cell lymphoma, hodgkin's disease and lymphoblastoid cell lines from normal volunteers and patients with npc. results and conclusion our results demonstrate specificity of the monoclonal cocktail for detecting the wild-type lmp and the ability to sub-differentiate between the mediterranean type of lmp and the cao-lmp . visceral leishmaniasis primarily diagnosed in duodenal biopsy: report of three cases f pardal, a silva, v velasco, m teixeira serviço de anatomia patológica, braga, portugal introduction visceral leishmaniasis (kala-azar) is a zoonosis caused by a flagellate protozoan, of the genus leishmania, which is transmitted to man from reservoir animals (like a dog), by a vector of the genus phlebotomus. generally it affects the mononuclear phagocytic system of the bone marrow, liver and spleen. the gastrointestinal system is rarely involved. diagnosis of the infection depends on microscopic identification of leishmanias amastigotes in tissues or blood cultures or by serologic means. aims: visceral leishmaniasis is a rare disease in patients without immunodeficiency, the authors report three cases diagnosed primarily in duodenal and gastric biopsy from immunocompetent patients. materials and methods from the files of pathology department of s. marcos hospital five cases of visceral leishmaniasis have been collected in a years period, all from immunocompetent patients, namely without hiv infections. the authors describe three of the five cases, which were primarily diagnosed by gastro-duodenal biopsy. lately, was noted the presence of amastigotes in other tissues. after histologic diagnosis resulted a full clinic diagnosis of systemic leishmaniasis with advanced stage of disease. conclusions pathology department files reveal a significant percentage of visceral leishmaniasis diagnosed by gastroduodenal biopsy, three of five cases. thus, in no endemic countries for this opportunistic infection and in immunocompetent patients, gastrointestinal biopsy can, eventually be a rapid and sensitive method of diagnosis, since most of the patients present at an advanced stage of disease. impact of the sudden acute respiratory syndrome (sars) on the pathology laboratory: a singapore experience ar chang, a wee, sm chong, t ming pathology department, national university hospital, national university of singapore, singapore the sudden acute respiratory syndrome (sars) is a new global health problem that has received unprecedented attention. the predominant route of infection is by droplets and close contact with an infected person poses the highest risk of being infected with the sars virus. the majority of cases among health care workers have occurred in doctors and nurses who have cared for sars patients. pathologists and laboratory personnel are regarded as low risk for infection because they are infrequently in direct contact with patients. however, they receive specimens, including sputa, bronchiolo-alveolar lavage samples, excised tissues, blood and body fluids from infectious cases. two further possible sources of infection are during autopsies and the onsite processing of fine needle aspiration specimens for immediate diagnosis. not uncommonly, few clinical details are attached with a specimen to alert the laboratory so universal precaution must be in place and all specimens regarded as infectious. but with a new infection such as sars where information on its natural history, infectiousness and mode of transmission are still evolving, greater vigilance and a pro-active approach are needed. during the period march -may singapore was faced with a potentially serious sars epidemic and to minimize the chance of personnel in the pathology department, national university hospital being infected and thus compromise the diagnostic service a contingency plan was implemented. this report describes the impact of the plan on the department. sars is a global disease and pathologists in countries who have not encountered it may find the information useful for preparing their laboratory for the eventual arrival of sars. angiotropic large cell lymphoma of the central nervous system -report of four cases introduction angiotropic large cell lymphoma (alcl), or intravascular lymphoma, is a rare form of high grade non-hodgkin's lymphoma, predominantly of b-cell lineage. it is characterized by extensive proliferation of lymphoma cells within the lumina of small blood vessels particularly of the cns and skin with tendency to disseminate into multiple organs. because of nonspecific manifestations the clinical diagnosis of alcl is difficult as well as the morphological diagnosis, which may be problematic and subtile. methods we studied four cases of alcl with dominant neurologic symptoms in the form of vasculitis, dementia and cauda equina syndrome. the diagnosis was made by autopsy in three cases and by brain biopsy in one case. in one autopsy case, the alcl was associated with aids in a -years old hemophilic boy. results microscopically, in all cases, small blood vessels of the cns were distended by collections of large atypical lymphoid cells which obstructed the vascular lumina. tumor cells cytoplasm was amphophilic, the nuclei were large, irregular with prominent nucleoli. mitoses were numerous. in the vicinity, there were small zones of spongy edema, reactive gliosis and foci of total or selective necrosis. in an autopsy case with diagnosis 'vasculitis' (female -years) there was dissemination into multiple organs. immunohistochemistry shows strong positivity for cd and cd , and the negative reaction for cd , cd ro and factor viii-related antigen. based on the above findings the diagnosis of angiotropic large b-cell lymphoma was made. conclusion the antemortem diagnosis of alcl of the cns may be established by brain biopsy with application of immunohistochemistry. evaluation of cell death in animal model of brain contusion treated by hyperbaric oxygen therapy e vlodavsky, j soustiel rambam medical center, haifa, israel cerebral contusion (cc) remains the most important consequence of traumatic brain injury and has unexplained unique evolving clinical course.the aim of this study was to evaluate the extent of apoptosis in perilesional area of cc and to examine the effects of hypoxia and hyperbaric oxygenation therapy (hbot).the model of cc was based on the technique of cortical dynamic deformation (shreiber et al., ) on sprague-dawley rats. one group of animals afterwards was placed in closed chamber and exposed to mild hypoxemia, simulating posttraumatic hypoxemia. both groups of animals (hypoxia-exposed and non-exposed) were treated by hbot. brains were cut through produced lesion and paraffin sections were stained by tunel method and for active caspase- . apoptotic cells (ac) were counted in five successive perilesional layers of . mm each. it was shown that in the group of rats that were exposed to hypoxia, the width of perilesional area and the number of ac were significantly higher than in non-hypoxic animals, raising from . % to . % at . mm (p< . ).one treatment by hbot induced significant decrease both in the radius of perilesional area and the number of ac in both groups of animals (in hypoxia-exposed animals this effect was even more pronounced).the results of our study prove the role of perilesional area in the 'growth' of cc. hypoxemia caused profound increase in cell death extension. hbot shows marked positive effect in both hypoxic and nonhypoxic animals. we used quantative pathologic monitoring of number of ac to develop the optimal regimen of hbot in animal model of cc. introduction surgery for seizures consists of surgical procedures made in the central nervous system to treat drug-resistant epilepsy. different lesions may be the cause. aims: we review the cases diagnosed between the years and in our hospital. materials and methods the surgycal specimens were stained with hematoxilin-eosin and neural or glial immunostains after paraffin embeding. results the most frequent lesion is mesial temporal sclerosis ( - % of the cases). other causes are tumors; dysembrioplastic neuroepithelial tumor (dnt), neuronal tumors and glial tumors. less frequent lesions are phacomatosis, malformative lesions like cortical dysplasias or vascular malformations, vascular or trauma lesions and inflammatory or unspecified lesions. mesial temporal sclerosis consists of neuronal loss and gliosis in sectors ca , ca , ca and dentate gyrus. between and we diagnosed cases; were women and were males. dnt is a very infrequent, intracortical tumor composed of glia and neurons, usually associated with cortical dysplasia. in our experience we diagnosed cases; women and men. we have found other tumors associated with epilepsy; cases of ganglioglioma ( women and men), cases of gangliocytoma ( women and men), and astrocytic tumors ( protoplasmic astrocytomas, mixed astrocytoma and fibrillary astrocytomas). we also diagnosed other processes associated with epilepsy: cases of cortical dysplasia, of glial scar, of gliosis or unspecified changes and cases of vascular malformation. conclusion pathology associated with seizures is very diverse; a multidisciplinary and experienced team is needed. expression of sperm protein , a novel cancer-testis antigen in human nervous system tumours introduction human sperm protein (hsp ) is a highly conserved protein originally isolated from a rabbit epididymal sperm membrane and testis membrane pellet. recently, hsp has been included in the cancer/testis antigens (ct) family and showed to be expressed in multiple myeloma and ovarian cancer. the aim of the study was to investigate the immunolocalization of hsp in specimens of nervous system malignancies, in order to establish the usefulness of this antigen as target for tumour-vaccine strategies for nervous system tumours. methods the authors assessed the expression pattern of hsp in formalin-fixed and paraffin embedded surgical specimens of nervous system malignancies, including neuroectodermal primary tumors ( astrocytomas, glioblastomas multiforme, oligodendrogliomas, and ependymoma); meningeal tumours; and peripheral nerve sheath tumours ( schwannoma, and neurofibroma), using a standardized immunohistochemical procedure. results hsp was found to be expressed in a low number of tumoral cases (nearly %), with a major expression in astrocytomas histological group ( %). no case among peripheral nerve sheath tumours was found to be immunopositive for hsp . the expression pattern was found heterogeneous in all of the positive samples and it does not correlate with the degree of malignancy. conclusions the low frequency and the heterogeneous distribution of hsp suggest the useless of this antigen as unique target for immunotherapeutic strategies. however, the present study shows firstly the immunolocalization of hsp in some cells of nervous system tumors tissues. the emergent complex function of hsp renders necessary further studies to understand the link between positive-cells and this protein. in vitro fddnp labeling of pathological protein aggregates in the cns of selected "conformational" disease cases introduction a molecular imaging probe - ( -{ -[( -fluoroethyl) (methyl)amino]- -naphtyl}ethylidene)malononitrile (fddnp), is a highly hydrophobic, fluorescent substance, known to label senile plaques and neurofibrillary tangles (nft) in the brain of alzheimer disease (ad) patients. the aims of this study were to evaluate in vitro fddnp labeling of protein aggregates in selected "conformational diseases" of the brain and to determine if they fulfill the tinctorial and polarizing optics criteria for amyloid. material and methods brain sections of patients with confirmed ad, variant ad (vad), amyloid angiopathy (aa), sporadic creutzfeldt-jakob disease (cjd), variant cjd (vcjd), gerstmann-sträussler-scheinker syndrome (gss), pick disease (pid) and progressive supranuclear palsy (psp) were labeled with fddnp, congo red (cr) and pas. analysis was performed using fluorescent microscope (fddnp), and light microscope (cr and pas) with polarizing optics (cr). results in addition to senile plaques and nft in ad and vad fddnp reliably labeled: prion plaques in cjd, vcjd and gss, lewy bodies in vad and vascular amyloid in aa. it did not label pick bodies in pid, and globoid nft in psp. with the exception of fddnp positive hirano bodies in ad and lewy bodies in vad, cr and pas stained all the fddnp positive deposits. all cr positive aggregates also showed birefringence. conclusion in our study, fddnp labeled all protein aggregates that were shown to posses tinctorial and birefringent characteristics of amyloid, but also some that cannot be classified as amyloid. aside from its potential for in vivo diagnostics of some neurodegenerative diseases, fddnp may prove useful in labeling certain pathological protein aggregates in vitro. work supported by mŠzŠ grants - and l - . aim to investigate the development and clinical significance of vascularization in adenomatous alveolar hyperplasia (aah) and peripherally located adenocarcinomas of the lung. material and methods histological slides obtained from patients with aah, and from patients with potentially curatively operated lung adenocarcinomas including normal lung parenchyma are immunohistochemically stained with an anti cd antibody, and subject to quantitative image analysis. syntactic structure analysis measures the absolute and relative features of vessels including the vessel-associated cellular densities. these data are compared in between and associated with tumor volume, post surgical tnm stage, and the patients' survival. results aah displays an increased level of vascularization characterized by regular size and increased number of newly formed vessels. spatial agglutination (clusters formation) of vessels is common in aah. the tumor vascularization (volume fraction vv) amounts to % in aah and to % in lung carcinomas, and increases in advanced tumor stages (pt , pn ). aah displays the lowest, advanced tumor stages the highest numerical vascular density. minimum diameter and circumference of vessels maintain. the density of epithelial cells decreases with increasing distance from the vascular surface in both aah and adenocarcinomas. it is the highest in advanced tumor stages. according to multivariate statistical analysis the patients' survival is closely associated with the pn-stage, tumor volume, cell type and the numerical density of tumor cells within a distance < m to the nearest neighboring vessel. conclusion aah is characterized by probably non-reversible changes in vascular density and spatial vessel clustering. vascularization of pulmonary adenocarcinomas becomes altered in advanced tumor stages. of prognostic significance is the distribution of tumor cells in relation to the nearest neighboring vessel only. changes in vascularization probably play an important role in genesis and development of pulmonary adenocarcinomas. cellular and connective elements between bronchial glands in sarcoidosis: a quantitative analysis z kosjerina, v kosjerina ostric institute of lung diseases, sremska kamenica, serbia and montenegro objective objective of the study was to quantify the inflammatory and connective cells, as well as connective fibres between the bronchial glands in pulmonary sarcoidosis (s). material the study included the bronchobiopsy samples obtained from sarcoid patients. the control group (cg) included young healthy subjects who lost their lives in an accident, having the bronchus sampled at autopsy. the quantity of inflammatory and connective cells was measured by the stereometric numerical density method and the quantity of the connective fibres by the volume density method. results in the examined group the total quantity of all cellular elements between the bronchial glands in s was estimated to range from . /mm to . /mm or . /mm on the average. in the cg, the quantity ranged from . /mm to . /mm , or . /mm on the mean. besides cellular elements, connective fibres were also registered between the bronchial glands. in s, the connective fibres made % of the interstitium volume and only % of it in the cg. this difference is statistically significant. conclusion in sarcoidosis, the total quantity of all cellular elements between the bronchial glands exceeds their quantity in the cg for . times. the most numerous are lymphocytes in both groups, but in s their quantity is . times as high as their quantity in the cg. the quantity of the connective fibres is times as high as their quantity in cg. these differences are statistically significant. depending on the lung cancer stage and type vs. - % by conventional cytology) at an acceptably reduced specificity ( % vs. %, for aqc and conventional cytology, respectively). the role of the aqc cytology test in a comprehensive approach to detection of early (non-invasive and minimally invasive) lung cancers will also be discussed. introduction characterization of bronchial preneoplastic lesions is based upon cellular atypia and disturbed tissue architecture. depending on the individual experience, the grading of such lesions varies considerably. we evaluated immunohistochemical staining for p and mib- in regards of their value in routine diagnostics of bronchial biopsies. material and methods bronchial biopsies ranging from normal bronchial epithelium to invasive squamous cell carcinoma have been stained with antibodies against p and mib- . the biopsies have been divided into groups: squamous cell metaplasia with basal cell proliferation to low grade dysplasia, high grade dysplasia, and carcinoma in situ. for comparison, normal bronchial epithelium and invasive carcinoma have been included. in normal epithelium % of the cells showed positivity for p . with increasing degree of atypia, the number of posititive cells per nuclei increased to % in carcinoma in situ. almost linear progression has been found in the proliferation activity assessed by immunohistochemical staining with mib- . in normal epithelium the activity was < . %, and the number of positive cells increased to % in carcinoma in situ. in bronchial preneoplastic lesions an increasing accumulation of p and mib- can be found in accordance to the degree of atypia. this provides additional and valuable information to facilitate differentiation between low grade and high grade lesions. in regards of an increase in less invasive diagnostic and therapeutic methods, immunohistochemical staining with p and mib- adds valuable information for a correct grading of these lesions, and is therefore of considerable clinical importance. pitfalls in diagnosis and assessment of lymph node metastases in lung cancer -a morphometrical analysis of pulmonary and mediastinal lymphnodes t gumprich, k junker, km müller institut für pathologie, bochum, germany introduction besides histological subtype and tumor size, metastatic spread in pulmonary and mediastinal lymphnodes in lung cancer is also an important factor concerning therapeutic strategies. prior to resection of the primary tumor a thorough staging of pulmonary and mediastinal lymphnodes is performed using computer tomography -but lymphnodes will be judged by size only. in an autopsy study of ten cases with advanced lung cancer, lymphnodes have been dissected. lungs have been resected en bloc, and were cut in horizontal sections according to computer tomographic layers. lymphnodes have been measured and histologically examined. lymphnodes were judged as normal with a transversal diameter of not more than mm. in the histological examination metastases were found in % of normal-sized lymphnodes, while % of enlarged lymphnodes presented as negative. using other parameters did not yield better specifity or sensitivity. discussion: there is a wide range of what maybe the normal size of a lymphnode which is influenced especially by the study collective. we found a variety of size-influencing factors (pneumoconioses, silicosis, previous infections). furthermore, there are differences in size of lymphnodes in collectives from rural and industrial populations. the high number of metastases in normalsized lymphnodes is explained by the highly advanced stage of disease in our study collective. conclusions for imaging diagnostics, sufficient size parameters for lymphnodes are not existing. we are convinced that preoperative staging of lymphnode status is important. in many cases the radiological evaluation on the lymphnode stations is not sufficient to differentiate between reactive enlargement and metastatic involvement. mediastinoscopy is still needed in preoperative diagnostics, because it allows taking biopsies with following histological examination. expert system dedicated on diagnosis in thyroid pathology introduction encoutering diagnostically difficult cases, pathologists usually asks consultations from more experienced colleagues or uses materials in form of journal articles, textbooks, atlases etc. these sources can provide the information in a passive way. usage of expert systems (special computer programs) let pathologists obtain the information in an interactive way and have more accuracy in the diagnosis. our purpose was to create an expert system capable to improve histological diagnostics in area of thyroid tumors and tumor-like conditions. materials and methods materials for our work consisted of more than cases of thyroid tumors and tumor-like conditions (near pictures), representing thyroid diseases. every case was described by two experts according to histologic features and then entered in pc data base. results our computer program can act in two principal ways. these are ) diagnostics -expert system propely, ) learningvirtual textbook. ) using the expert system, pathologist enters new data in pc and marks so many features as he can. then he obtains the information about all the possibilities of probable diagnosis and some other results. entering more features can help to narrow the borders of probable diagnosis. ) applying our program as a virtual textbook, it is possible to learn better the known significance of pathological features, to take a look on the descriptions the experts made etc. the program can also function as a virtual trainer and examiner. conclusion our computer program increases the diagnostic quality in the area of thyroid pathology by means of high capability of information integration and improving pathologist's qualification during his learning. introduction xenin is a biologically active -amino-acid peptide extractable from the gastro-entero-pancreatic system. the aim of our study was to identify the unknown cellular source of xenin and to analyze the expression of xenin in neuroendocrine tumors. methods normal tissue of humans, rhesus monkeys and dogs and a large series of neuroendocrine foregut and midgut tumors were investigated by immunohistochemistry, confocal laser scanning microscopy, immuno-electronmicroscopy and high pressure liquid chromatography, assessed by radioimmunoassay. results in all three species, xenin was expressed in a subpopulation of gastric inhibitory (gip)-cells of the upper intestine. immunoelectronmicroscopy demonstrated presence of xenin in secretory granules ( ± nm diameter). xenin immunoreactivity and extractable xenin was found in of duodenal neuroendocrine tumors, including gastrinomas, somatostatinomas, non-functioning and enterochromaffin cell tumors. in contrast, xenin was absent from gastric, pancreatic, ileal and bronchial neuroendocrine tumors. conclusions the localization of xenin in ultrastructurally characterized secretory granules supports the concept that xenin represents a further endocrine regulatory peptide. the finding that xenin expression distinguishes between endocrine tumors arising in the duodenum from those of nonduodenal origin may be useful for topographical tumor classification and the differential diagnosis of neuroendocrine tumors of the upper gut. (supported by dfg) introduction the tall-cell variant (tcv) is known as a rare but aggressive form of papillary thyroid carcinoma (ptc) with increased incidence of local recurrence and mortality. it is defined as papillary thyroid carcinoma with at least % of specific cellular changes within the tumor cells and occurs in - % of all ptcs. materials and methods in our series of paraffin embedded and h&e stained tumor tissues, tall cell morphology was exactly defined for the first time and then cases of ptcs, including all stages and variants, were investigated concerning tall cell morphology and associated changes within the tumors. results in contrast to previous reports, cases ( , %) were classified as tcv in our series. taken together with minor tumor parts, cases ( , %) presented with tc morphology. these parts were in a high percentage associated with fibrosis and lymphocyte rich areas and showed a higher mitotic activity than usual ptcs. discussion the differences in the occurrence of tcv and tcmorphology between the presented series and previously reported cases might result from until now not clearly defined tall cell morphology as well as from similarities to ptcs, such as the oxyphilic variant, which is extremely rare in our series, and maybe also from often described squamous changes within ptcs. due to these data it is not clear which tumor parts have relevance for prognosis and which tumors should be treated more aggressively than others. in accordance with previous reports concerning the prognostical impact of this variant, we think that the occurrence of tc morphology plays a major role in both development of extrathyroidal growth and metastatic disease. myocardial extensions around venae cavae as a potential substrate of atrial fibrillation altered endothelial permeability secondary to ischemiareperfusion e stefanovic, v kanjuh, n tasic dedinje cardiovascular institute, belgrade, serbia and montenegro introduction during open heart surgery some damages to myocardial capillary endothelium occur, with the consequence to the regarding structure and function of cardiomyocytes as well. cardioplegia (cpl), long term hypoxia and reperfusion are strong contributing factors for these lesions. the aim of the study is to assess ultrastructural changes and permeability of endothelium of myocardial capillaries due to hypoxia and reperfusion during open heart surgery. the study included consecutive patients (pts) who underwent open heart surgery. samples were taken from right ventricle anterior wall and apcal region. biopsies were taken at the end of cardioplegic period, during ischemic period and during period of reperfusion. all patients were divided in two groups depending on duration of period of ischemia or cardioplegia-group (clp< min) and group (clp- - min). all samples were analyzed by electron microscope using quantative stereological analysis. volume fraction of the pinocyte vesicles (pv), mitochondria (m) and endoplasmatic reticulum (epr) were calculated. results endothelium ultrastructure analysis showed increase in permeability of the capillary wall. the worse damage was found after min. of cpl usage: edema of the endothelial cells, widening of the cell junction and other degenerative changes of cardiomyocytes. analyses of result confirmed that the more significant damages were found during reperfusion in group . conclusion our study showed significant changes in endothelial permeability and function after ischemia and reperfusion. disturbances of transendothelial transport may play certain role in the development of heart failure after open heart surgery. the authors compared the clinico-pathological and immunohistochemical features of acute postinfarction cardiac rupture and control (with near the same clinical age without rupture) cases. material and methods cryostat sections of both groups from infarction/rupture and controls were stained with oil red o, sudan black b (bdh chemicals) and were reacted to anti-c-reactive protein (crp), to complement c a and c b- (dakopatts). clinico-pathological findings myocardial rupture occured in elder women with relative smaller weight of heart, thrombosis of one main coronary artery, location in the anterior wall at the first infarction within the first week. microscopically the main observation is the large amount of granular lipid deposition in the area of myocardial rupture even in the cytoplasm of the necrotic myocardial fibers using oil red o and sudan black b staining. immunohistochemistry: the anti-crp and c b- antibodies showed intense staining around the area of the rupture. the inflammatory cells were neutrophils in high numbers in both group. eosinophils were represented in low percentage (below %). conclusion the postulation is, that the granular myocardial lipids in the area of infarction/rupture are phospholipids (mainly mitochondrial cardiolipin), which through binding crp induce pathologic complement activation. in experimental heart infarctions complement target (recombinant etc.) molecules could reduce the neutrophil chemotaxis to the area of necrosis and the size of the infarction. nuclear factor-κb regulates apoptosis of intimal smooth muscle cells introduction apoptosis contributes to reduce intimal smooth muscle cell (smc) hyperplasia following angioplasty or during atherogenesis. nuclear factor (nf)-kb is involved in the regulation of many smc functions. aim of the work was to verify the role of nf-kb in bax-dependent smc apoptotic cascade and its possible targeting for novel biologically based therapies of vascular hyperplasia. methods apoptotic proteins were evaluated by immunohistochemistry and western blotting and nf-kb using a anti-p (rela) antibody recognizing its active form. apoptosis was induced in rat aortic neointimal smcs after endothelial injury in vivo and in vitro by propyonil-l-carnitine (plc). in vivo, expression of constitutive nf-kb activity of smcs of neointima was higher compared to underlying and normal media. treatment with plc associated to reduced neointimal relative volume and increased apoptotic rate of intimal smcs compared to controls. increased apoptotic rate associated to bax overexpression and rela reduced immunopositivity. in vitro, plc reduced g to s phase progression of intimal but not of medial smcs. hoechst staining, flow cytometry and ligation-mediated pcr showed increased apoptotic rate of intimal cells treated with plc together with bax overexpression and the release of cytochrome c. sn , an inhibitor of nf-kb nuclear translocation, induced an increase of apoptotic rate in intimal but not in medial smc cultures, prevented the apoptotic effect of plc and upregulated the cytoplasmic bax expression and the release of cytochrome c. conclusions our studies with inhibitors of nf-kb strongly suggest that this nuclear factor plays a crucial role in the control of intimal smc apoptosis. alpha-actin isoform distribution in normal and failing human heart: a morphological, morphometrical and biochemical study introduction two sarcomeric actins, α-cardiac (α-ca) and αskeletal (α-ska), are coexpressed in adult myocardium and represent the preponderant thin filament actin isoforms of cardiomyocyte contractile units. in the human heart, the relative amount of α-ska mrna increases steadily during development and after birth and becomes the predominant isoform in adults but data in the literature concerning hypertrophy and failure are scarce and controversial. aim of the work was to determine how and where α-ska isoform accumulates during heart development, ageing and with disease. methods by using monospecific antibodies, we investigated by immunohistochemistry and western blotting the distribution of α-ska, α-ca and α-smooth muscle actin (α-sma) isoforms. results at weeks of fetal life, α-ska was localized in a small proportion of subendocardial and papillary muscle cardiomyocytes, whereas a diffuse α-ca staining was observed, associated with a focal expression of α-sma. in normal adult subjects, α-ska positive cardiomyocytes were distributed in a transmural gradient with the highest proportion located subendocardially. in myocardial hypertrophy and cardiomyopathies, the amount of α-ska was increased and a diffuse staining was seen in all layers of ventricular myocardium, with the exception of idiopathic dilated cardiomyopathies. cardiomyocytes were always negative for α-sma. as expected, fibroblasts in post-infarct scars expressed α-sma and tgf-β , but were negative for these proteins in interstitial fibrosis. conclusions changes in the distribution of actin isoforms in hypertrophy and failure provide new insight into the mechanisms by which the heart adapts to work overload and help to define their role in these pathological situations. introduction arrhythmogenic right ventricular dysplasia (arvd) has received much interest, since it may cause sudden cardiac death (scd). yet, pathogenesis remains controversial, not at least because adipose and fibroadipose types are considered different entities by some. the present study has looked into the histopathologic features of hearts with arvd with a particular eye for a clue to pathogenesis. clinical history review and heart macroscopic/microscopic examination (with histochemical/immunohistochemical techniques) were performed on patients dying suddenly with arvd. twenty-three, m/ f were young ( - years) and , m/ f adults ( - years). results )one young had family history of scd. )one adult had cardiovascular antecedents. )seven patients had died during exercise. )both young and adults presented adipose (n= vs ) and fibroadipose (n= vs ) types, whilst each variant basically showed similar overall architectural arrangements. ) occasional inflammatory infiltrates were present in fibroadipose, but not in adipose type. ) left ventricular involvement occurred in young and adult heart. ) coexistent left ventricular pathology was occasionally identified. conclusions ) arvd can be manifest in young and older persons, either as adipose or fibroadipose variants. ) both types are morphologically identical, except that some may have additional fibrosis, occasionally accompanied by small inflammatory aggregates. subtle differences hard to interpret as features distinguishing different entities. ) preferential and almost selective involvement of the right ventricular wall suggests a congenital nature of the disease, particularly since recent insights in right ventricular development have showed "regionalization" of genetic expression in the formation of cardiac chambers. fatty/fibrofatty tissues may appear ab initium through an alternative mesenchymal pathway. a new method of quantitative functional morphology for systemic examination of the cardiac muscle t ghevondyan , h guski , g avtandilov national institute of health, yerevan, armenia medical faculty of humboldt university of berlin, berlin, germany introduction determination of the vital capacities of heart muscle has special importance for cardiac surgery. morphological methods could be the most trustworthy in this respect. but it was not possible yet to extract this information from myocardial specimens. the aim of this study was to elaborate a method, which will be able to determine the volume of vital reserve of myocardium taking into account all known morphological changes and alterations. the investigation was carried out on heart muscle tissue of healthy people, who died accidentally and of patients who died from myocardial infarction. the myocardium of white rats (normal, physically trained, during pancreonecrotic shock) was used. methods of histology, electron microscopy, cytoenzymochemistry, morphometry, micromechanography, statistics and mathematical modelling were used. results most informative parameters were chosen for characterisation of the microcirculatory bed and of the paths of ultracirculation. the property of contractility has been taken as a systemforming criterion. a mathematical model was elaborated, which allows to unite the most important structural changes and alterations from tissue, cellular, ultracellular and macromolecular levels of the heart muscle. the role of endomyocardial biopsy in end-stage heart failure introduction endomyocardial biopsy is considered to be an important diagnostic procedure for the evaluation of patients with end-stage heart failure. the aim of this retrospective study was to evaluate the role of apoptosis, proliferation markers, volume density of interstitium, and myofibril volume fraction for the prognosis in patients with end-stage dilated cardiomyopathy (dcm). methods endomyocardial biopsy was performed during openheart surgery in pts with end-stage dcm. patients were divided into groups, one with shorter survival ( ± months, mean ± standard deviation) and another with survival of more than years after operation. the tunel method was used for the detection of apoptosis, and immunohistochemical methods were used for the evaluation of inhibitor of apoptosis (bcl- ), and proliferation markers (pcna, ki- ). results the increased percentage of apoptotic myocytes, decreased expression of bcl- , pcna and ki- antigen, but lower myofibril volume fraction and lower volume density of interstitium was found in the group with early mortality compared to that with longer survival. conclusion morphometrical analysis of the endomyocardial specimens of the patients with terminal heart failure due to dcm may enable us to get access to crucial information about the status of the myocardium, which may help us to predict the prognosis and optimal treatment of patients with end-stage heart failure due to dcm. introduction trafficking studies in bone marrow transplantation (bmt) more often use fluorescent reporter molecules like the green fluorescent protein (gfp). dendritic cells (dc) represent an interesting population for trafficking analysis, because they undergo steps of maturation, which seem to be related to their localization in the tissues. the aim of this study was detection of ex vivo expanded dcs, transduced to express gfp, in tissues of mice that had received an allogeneic bmt. material and methods tissues of recipient mice were pretreated by fixation in % formalin followed by % sucrose, before embedding in oct and freezing on dry ice. in addition tissues were also fresh frozen and exposed to formaldehyde vapor as cryostate sections. the gfp signals were validated using an anti gfp antibody. additional markers investigated were cd c, cd , cd , h- kb and h- kd. results vapor fixation of slides showed equal properties in containing gfp in comparison with the immersion method. gfp+ dcs were detected in small bowel, lymph nodes, thymus and spleen for up to days after i.v. injection. many of these gfp+ cells were positive for cd c. the gfp signals could be validated on fluorescence and light microscopic level using anti gfp antibodies. conclusions allogeneic dcs survive in bmt recipients for up to days. they migrate into small bowel, mesenterial lymph nodes, thymus and spleen without causing gvhd. the visualization of survival and migration in bmt settings will provide new insights into the immunological role of dcs in vivo and might contribute to the optimization of dc based treatment strategies. breast hamartoma: cytologic, pathologic and immunohistochemistry study of cases introduction breast hamartomas enter the differential diagnosis of breast masses, necessitating an accurate diagnosis. it is still not quite clear into which group of lesions these masses should be categorized. the aim of our study was to investigate the cytologic, histologic and immunohistochemical profile of breast hamartoma in order to obtain a detailed picture of this somewhat unusual lesion. materials and methods this study presents cytological, pathological and immunohistochemical analysis of patients with breast hamartoma. the immunohistochemical panel included: estrogen and progesterone receptors, her -neu protein, p- , ki- , ckmnf , vimentin, alpha-sma. results the patients ranged in age between and years. all patients presented with a palpable unilateral mass. the aspirates contained sheets of both bland ductal cells and lobular units. adipose tissue was present in varying amounts. typical macroscopical and microscopical features were noted. immunohistochemical studies showed estrogen and progesterone receptor positivity in epithelial cells as well as in the stromal cells, in all hamartomas. her -neu protein over expression was noted, p- expression was not observed. ki- showed a - % positivity in epithelial cells in most cases. conclusions the finding of intact lobular units and a relative paucity of stroma in an aspirate from a well-circumscribed breast lesion, may suggest the diagnosis of hamartoma. typical macroscopical and histological features of breast hamartoma were noted. the immunohistochemical profile appears to be similar to that of normal and fibrocystic breast tissue, raising the possibility of a spectrum of lesions. introduction ck-pattern in nos breast carcinoma has been studied extensively, including high molecular weight types, such as ck- , present in rare cases. published data on ck- -expression in less common subtypes of breast carcinoma are limited the aim of this study was to learn more about the immunohistochemical profile of ck- in cmf, a systematic analysis on ck- -reaction in a consecutive series of this variant of breast carcinoma was undertaken, including correlation with some traditionally recorded tumor characteristics. forty-three consecutive cases of cmf were examined for ck- . extent of staining was assessed semiquantitatively and reported as a percentage; its correlation to tumor size and receptor status was calculated. results sixteen ( , %) of the cases comprised ck- labelled tumor cells. though ck- + tumors were less commonly receptor+ and tended to be larger than ck- -cases, statistically significant differences were not obtained (p= . and p= . , respectively). conclusion no specific immunohistochemical profile typifying cmf has been identified. nevertheless, most cmf seem prone to exhibit immunophenotypic aberrations with higher incidence of vimentin+, c-erb-b +, and p- +, lower incidence of her + and er/pgr+. we here demonstrate that ck- -expression can be added to this list. though not statistically significant, a trend towards an inverse relation between basal cell characteristics and receptor expression and a positive correlation between ck- + and tumor size was demonstrated. introduction residual disease leads to most local recurrences, especially in patients treated with breast conserving therapy. this study was undertaken to identify whether assessment of excisional biopsy margins accurately predicts the presence or absence of residual tumor in the lumpectomy bed. material and method the margin status of consecutive lumpectomy specimens followed by re-excision, taken from an equal number of patients with primary breast carcinomas ( infiltrating, in situ), were evaluated microscopically and classified as 'positive' if the tumor was found at the inked margin, 'negative' if the entire tumor was found in > . cm from the inked margins, 'close' if it was within . cm of the inked margins, but did not transected them and 'indeterminate' if biopsy specimen was not inked or the tissue was fragmented. the tumor size and grade of the initial biopsy were also analyzed, as potential predictors for residual disease. results residual tumor was found in % of the patients ( / ): in %( / ) of the cases with negative, in %( / ) with positive, in % ( / ) with close and in . %( / ) with indeterminate margin status. in %( / ) of the 'positive margins' and in %( / ) of the 'close margins' cases no tumor was found in re-excised specimens. in %( / ) of the cases the residual disease was composed entirely of an in situ component of the same histologic type as the initial biopsy. no relationship was found between tumor size or grade and residual disease. conclusions for breast tumors histologically negative margins in biopsy specimens do not guarantee complete excision. 'close' margins may be considered almost equal to 'positive' ones. residual in situ carcinoma in the immediate vicinity of the previous biopsy site seems to represent the advanced edges of the tumor, apparently difficult to be excised completely and most likely responsible for the locally recurrent disease. introduction syringomatous adenoma of the breast is a benign lesion of the nipple, which may be confused with an infiltrating carcinoma. the presence of the myopithelial cells and the immunohistochemical profile is still controversy in the literature. we present the case of an years old patient, with an left nipple mass. materials and methods after excision, the excised tissue was fixed and paraffin embedded and h-e stained. we performed also immunohistochemical staining: with cytokeratin, actin, er, pr, p . the excised tumor measured cm, had ill-defined margins and yellow color.microscopically, the lesion consisted of tubules and strands, composed of small and uniform basophilic cells, diffusely infiltrating the stroma of the nipple. the tubules were lined by two layers of cells, had a comma-like appearance and their lumen was usually open and round. the tumor cells lack pleomorphism. squamous differentiation resulted in keratotic cysts. immunohistochemically, the luminal layer of epithelial tumor cells was cytokeratin-positive and the peripheral myoepithelial cells were actin-positive. the tumor cells were negative for er, pr, p . conclusion syringomatous adenoma of the breast is a benign rare lesion. the pathologist must not confuse it with an tubular carcinoma or with an adenosquamous carcinoma. we demonstrated in this case the presence of the myoepithelial cells. the role of smooth muscle myosin heavy chain in diagnosing sclerosing adenosis of the breast with an infiltrative pattern introduction sclerosing adenosis (sa) of the breast can produce an infiltrative pattern mimicking invasive carcinoma. immunohistochemical markers for myoepithelial cells, such as smooth muscle myosin heavy chain (smmhc), have been shown to stain basal myoepithelial cells in normal mammary glands and fibrocystic changes. absence of myoepithelial cells is associated with invasive carcinoma; however, we have observed occasional attenuation of smmhc staining in sa. studies evaluating the role of smmhc in sclerosing adenosis have not been performed. the intent of this study is to further evaluate the staining pattern of smmhc in sa with an infiltrative pattern. materials and methods twenty cases of sa with an infiltrative pattern were identified, h&e stained, and immunohistochemistry performed for smmhc (m , dako corp), µg/ml, as primary antibody, using a polymer based envision+ detection system (dako corp). normal-breast tissue positive controls and negative isotype matched igg controls were used. cases were then classified into one of three categories: positive (staining > % of myoepithelial cells), intermediate ( % - %), or attenuated (< %). results three of the first ten cases ( %) showed attenuated staining with smmhc. the remaining seven cases demonstrated positive staining of myoepithelial cells. all cases exhibited positive staining within normal lobules, serving as an internal control for each case. ten additional cases of sa have been identified and are being stained with smmhc for evaluation. conclusions preliminary findings show that smmhc yields inconsistent results when applied to sa with an infiltrative pattern. such lesions can have features similar to invasive carcinoma on h&e, and application of smmhc could produce misleading results. co-expression of erbb family members in human breast cancer: her- /neu is the preferred dimerization candidate in nodal-positive tumors introduction overexpression of members of the erbb receptor family has been asssociated with malignant transformation and the amplification of her- /neu in tumor tissue is now an established prognostic factor in breast cancer. in order to initiate signal transduction, erbb receptor monomers need to form homo-or hetero-dimers. the composition of these dimers is thought to greatly influence both quality and quantity of downstream signalling pathways, and to ultimately determine the elicited biological response. material and methods the protein expression pattern of all four erbb receptors egf-r, her- /neu, her- and her- , and expression of their putative ligands egf, tgf-a and hrg was investigated in women with invasive breast cancer by membrane isolation and western blot analysis. results the co-expression of all four erbb family members was detected in , % of cases, and of all of the three investigated ligands in , %. while we did not observe a correlation between egfr and her- /neu or her- protein expression, egfr and her- (p= . ), and her- and her- (p= . ) were clearly coexpressed. the strongest overall correlation, however, was found between her- /neu and her- (p= . ) and between her- /neu and her- (p= . ). this was particularly true in nodal-positive tumors (p< . and p= . , respectively) whereas in nodalnegative tumors the co-expression was either less significant (her- /neu and her- : p= . ) or not significant at all (her- /neu and her- ). the co-expression of egfr/her- was associated with the expression of all three ligands, whereas the her- /neu/her- was correlated with hrg (p= . ), thereby indicating a functional relation between specific receptor-dimer combinations and putative ligands. conclusion taken together, we have performed a comprehensive survey of erbb system expression in breast cancer, and have demonstrated the presence of a co-regulated receptor/ligand system in vivo. her- /neu appears to function as the preferred coexpression partner in nodal-positive tumors, thus rendering him the most likely dimerization candidate in malignant breast tumors. introduction members of the ap- family of transcription factors (c-jun, junb, jund, c-fos, fosb, fra- and fra- ) are able to form jun-jun or jun-fos dimers which bind to the regulatory sequences of target genes. in a prior study on mammary carcinomas, we found that high fra- and reduced fosb expression are associated with indicators of poor prognosis. as most of the proteases involved in degradation of the extracellular matrix and basal membrane (matrix-metalloproteinases, members of the upa/paisystem) are regulated by ap- complexes, we assumed that the expression of single ap- proteins might also be important for the process of invasion of breast cancer cells. method in order to analyze the influence of the single fos family members (c-fos, fosb, fra- and fra- ) on the invasive behavior of mammary cancer, we performed western blot analysis of mmp and mmp and of the members of the plasminogen activator system pai- , upar, and pai- -upa-complexes in breast cancer samples, and correlated the expression of these proteins with that of the ap- proteins. results interestingly, c-fos, fra- (phosphorylated form), and fra- correlated with mmp expression levels. high expression of fra- was also significantly associated with that of pai- and the sds-insoluble upa/pai- complex. on the other hand, the expression of fosb was significantly associated with high levels of mmp . conclusion our results indicate that a shift in ap- protein expression, especially high expression of fra- and fra- , might be involved in invasion of breast cancer cells. (supported by deutsche krebshilfe, no. - -ba ) immunohistochemical study of estrogen receptors and progesteron receptors in primary breast carcinomas and their axillary lymph node metastases nh aksoy, he pestereli, s karaveli akdeniz university school of medicine, department of pathology, antalya, turkey estrogen receptors (er) and progesteron receptors (pr) was investigated in primary breast carcinomas and their axillary lymph node metastases to determine if the malignant cells retained or changed this phenotypic feature during the metastatic process. the data were also compared with the tumour size, histologic type, grade and age. immunohistochemistry with the er (dako- d -n ) and pr (dako-pgr -n ) on formalin-fixed paraffin embedded tissue was used. the er status in primary tumours and lymph node metastases was concordant in patients ( , %) and discordant in ( , %). six of these eleven patients had er-positive primary tumours and er-negative lymph node metastases. the pr status in primary and lymph node metastases was concordant in patients ( , %) and discordant in patients ( , %). ten of these twenty-four patients had prnegative primary tumours and pr-positive lymph node metastases. we observed higher pr positivity in axillary lymph node metastases. the parameters, tumour histology, grade and age showed no statistically significant relation with receptor status. there was a significant correlation between the tumour size and the number of axillary lymh node metastases. the discordance of hormone receptors status between the primary tumour and lymph node metastases might be due to the heterogenity of tumour cells or loss of the phenotypic features of metastatic cells. breast carcinoma in a cancer hospital p arapantoni -dadioti , o tzaida , v leodara , g sotiropoulou , e trichia , pk sotirakoglou pathology department metaxas cancer hospital of piraeus, piraeus, greece department of mathematics and statitics agriculture university of athens, athens, greece a total of cases of infiltrating breast ca, diagnosed in our hospital during the last decade, was studied. the material concerned mastectomies with ispilateral lymph nodes dissection specimens. the patients were classified according the tnm staging system, based upon the primary tumor size (t), the presence of regional axillary nodal involvement (n) and distant metastases (m). this categorization revealed a preponderance of patients with t tumors. the overall decade rate for t , t and t tumors was , , %± , %, , %± , % and , %± , %, respectively. there was a statistically significant difference between the three groups (p< , ). the annual distribution of these groups revealed that since the mean group rate had a tendency to approach the corresponding decade rate, a finding suggesting some degree of stabilization of these proportions. on the other hand, the lymph node metastases were more common in the t tumors. the mean rate for t n+, t n+ and t n+ was , %± , %, , %± , % and , %±- , %, respectively; the difference is statistically significant for the t n+ and t n+ (p< , ) as well as for t n+ and t n+ (p< , ). the annual overall rate of patients with lymph nodes metastases, independently of t (tn+) was , %± , %. in conclusion, there is no tendency of early patient presentation and a more careful intimate medical care. the infiltrating breast cancer in our material, is represented mainly by thet tumors and the great majority of patients come to the hospital in an advanced stage regarding the t and n. introduction breast cancer is a genetically complex disease, which involves the accumulation of various structural and numerical aberrations. in the present study, we assessed the numerical status of chromosomes and x in primary invasive breast carcinomas in relation to clinicopathological parameters, patients' overall survival, and indices of cell growth (c-erbb- , topoisomerase iia) and survival (caspase- , bcl- ). material and methods the number of copies of both chromosomes was detected by interphase chromogenic in situ hybridization with pericentromeric probes on paraffin embedded sections. er, pr, cerbb- , topoiia, caspase- and bcl- expression was immunohistochemically detected (abc/hrp). the results were statistically assessed by univariate and multivariate analysis. results polysomy of chromosomes and x was detected as the predominant aberration ( . % and . % respectively). gain of chromosome copies was associated with high nuclear grade (p= . ), increased tumor size (p= . ), advanced stage (p= . ), the expression of topoiia proliferation index (p= . ), and worse overall survival by multivariate analysis (p= . ). the levels of chromosome x polysomy were elevated in ductal carcinomas of high histological grade (p= . ), in high nuclear grade tumors (p= . ), and were associated with the expression of topoiia (p= . ) and loss of caspase- protein (p= . ). in addition, gain of chromosome x copies was an independent predictor of impaired prognosis of ductal carcinomas (p= . ). conclusion polysomy of chromosomes and x was observed as the predominant alteration in phenotypically aggressive breast tumors, characterized by poor differentiation, increased growth potential and impaired prognosis, whereas gain of chromosome x in particular, is probably implicated in cell survival. expression of survivin, bcl- , p and bax in breast carcinoma and ductal intraepithelial neoplasia (din a) f kayaselcuk , tz nursal , a polat , t noyan , s yildirim , a tarim , g saydaoglu introduction survivin is a recently discovered member of the family of proteins that inhibits apoptosis. this anti-apoptotic compound can be detected in most types of cancer and expression is associated with a poor prognosis. we immunohistochemically investigated the expression of survivin in breast carcinomas and intraductal epithelial neoplasia of breast to determine whether expression of this protein is associated with clinicopathological parameters such as grade, stage, mitotic rate. the study involved patients with invasive ductal carcinoma (idc) and patients with intraductal epithelial neoplasia with mild, moderate and severe, florid ductal epithelial cell hyperplasia. survivin, bax, bcl- , and p monoclonal antibodies were administered by immunohistochemical method. findings were analyzed with statistical methods. results in of cases ( . %) of breast carcinomas and of cases ( . %) of intraductal epithelial neoplasia with mild, moderate and severe ductal epithelial cell hyperplasia stained positively for survivin. none of the histological parameters analyzed were significantly correlated with survivin expression in breast carcinomas. in the carcinoma cases, survivin expression was positively correlated expression of bcl- , but was not correlated with expression of p , bax, c-erbb- and estrogen, or progesterone receptors. some of the intraductal epithelial neoplasia cases with moderate or severe ductal epithelial hyperplasia stained positively for both survivin and p . the breast carcinomas exhibited significantly increased expression of survivin, p , and bcl- than the breast with intraductal epithelial neoplasia. survivin was not correlated with any of the clinicopathological parameters studied, however, it could be a useful tool in early carcinomas and florid, severe ductal epithelial hyperplasia. introduction certain non-malignant and pre-malignant lesions cause dilemmas for the most appropriate management following lncb. the aim of this study was to determine the accuracy of lncb in diagnosising the most frequent non-conclusive findings: benign papillary lesions (bpl), radial scars (rs), fibroepithelial lesions with stromal hypercellularity (flsh), atypical ductal hyperplasia (adh) and intraductal carcinoma (dcis). material and methods in a retrospective review of , imaging guided lncbs ( - ), we found: ( . %) bpl - with surgical correlation (sc) and with mammographic follow-up (mf); rs ( %) with sc in and mf in ; ( . %) flsh all with sc; ( . %) adh -with sc in , and ( . %) dciswith sc in . results ) bpl: patients without changes in mf. at surgery: bpl - with adh and invasive carcinomas ( with mammographic histologic discordance and diagnosed years post lncb). ) rs: without mammographical changes and rs ( with adh). ) flsh: at surgery, fibroadenomas, benign and malignant phyllodes tumours. ) adh: at surgery, ( . %) adh, ( %) dcis, ( . %) invasive carcinomas - of which microinvasive. ) dcis: at surgery, ( . %) dcis; ( . %) microinvasive, and ( . %) invasive carcinomas. conclusions ) diagnosis of bpl at lncb seems accurate when correlating with image findings. ) rs at lncb can be followed mammographically. ) flsh at lncb always requires surgical excision. ) adh and dcis diagnosed at lncb need complete removal of lesion, due to frequent underdiagnosis. introduction estrogen receptor beta (erb) is known to be present in breast tumors; its prognostic and pathophysiological roles, however, remain to be established. the aim of this study was to investigate erb protein expression in a well documented series of invasive breast carcinomas. materials and methods standard immunohistochemistry with a specific monoclonal antibody (clone ppg / , serotec) was performed on paraffin sections; % of strongly immunostained carcinoma cells was used as a cutoff point to classify tumors as erb-positive. statistical correlations were sought with clinicopathological variables (including hormone receptor status) and patients' disease-free and overall survival. cell proliferation was immunohistochemically assessed by topoisomerase iia (topoiia) index. statistical analysis was univariate and multivariate. results erb immunoreactivity was detected in the majority of specimens ( . %)and was positively linked with era immunoreactivity (p< . ) and increased topoiia index (p= . ). a significant favorable impact of erb immunopositivity emerged with regard to disease-free and overall survival in both univariate (p= . , p= . , respectively) and multivariate (p= . and p= . respectively) statistical analysis; progesterone receptor expression was also found to exert an independent favorable influence on patient's survival with less statistical significance though (p= . and p= . ). on the contrary, patients' survival was not significantly impacted by era status. conclusions because of the positive association between erb immunoreactivity and topoiia expression, the presence of erb in breast cancer cells may be considered an indication of increased proliferation. nevertheless, erb immunoreactivity emerges as a valuable, independent indicator of favorable prognosis. aims to determine diagnostic value of lncb in patients with ilc using ec and ck sse . retrospective review of cases diagnosed as ilc either at lncb or at surgical biopsy (sb), between and . immunohistochemical (ihq) study with ec and ck sse was performed at both lncb and sb. three immunoprofiles were established: ec-ck sse + (ihq of ilc); ec + ck sse -(ihq of ductal carcinoma -idc) and ec + ck sse + (ihq of mixed ilc-idc). initial diagnosis at lncb was correlated with final diagnosis (morphologically and immunoprofile). discordant cases were analysed in order to determine usefulness of ihq at lncb. results in lncbs initially diagnosed as: ) ilc ( patients), final diagnosis was ilc in cases (ec-ck sse +) and idc in case (ec+ ck sse -); ) invasive carcinoma probably lobular type (ilcp) ( patients), final diagnosis was ilc in cases (ec-ck sse +), idc in (ec+ ck sse -) and mixed ilc-idc in (ec+ ck sse +); ) idc ( patients), final diagnosis was ilc in all cases (ec-ck sse +), of them ilc pleomorphic-type. in all discordant cases, immunoprofile at lncb was concordant with final diagnosis conclusion % of patients diagnosed as ilcp at lncb corresponded finally to idc or mixed idc-ilc. . % of patients finally diagnosed as ilc were initially interpreted as idc at lncb. our findings suggest that ec and ck sse are of great value to help characterise breast carcinomas at lncb, and improve management of patients. background her- status became an important prognostic and predictive factor in breast carcinoma. there are two main techniques of evaluation her status: immunohistochemistry (ihc) for the protein expression and fluorescence in situ hybridisation (fish) for amplification of her gene. the aim of the study was to compare the results obtained by ihc and fish methods in determination of her status in breast cancer. materials and methods two hundred breast cancer specimens were examined. ihc and fish were performed in every case. ihc was performed with dako herceptest, fish with oncor-qbiogene reagents. ihc results were classed into groups, accordingly to the intensity of membrane staining ( , +, +, +). fish results were divided into three main categories: na -no amplification, la -low amplification and ha -high amplification. the number of copies of chromosome was also assessed. results over % of cases described by ihc as + exhibited also amplification of her /neu gene. remaining cases were positive with ihc, but presented no gene amplification. this might be due to the subjective assessment of the membrane staining or to the procedure of material fixation. another possibility is that overexpression of the protein was caused by mrna stability or disorders in receptor circulation. the majority of cases classed by ihc as + were also negative by fish (over %). nearly one fifth of ihc + were found to exhibit gene amplification. remaining cases showed no amplification of her /neu gene, combined with aneuploidy of chromosome . all cases described by ihc as / + showed no amplification. conclusions ihc is well-established method of assessing her status in breast cancer. nonetheless, group of cases described as + should be additionally examined using fish method because the results are more reliable. in order to improve accuracy and gain the highest quality of her status evaluation, in those cases both methods should be applied. dcis of the breast with excessive cancerization of the lobules simulating invasive carcinoma b nielsen institute of pathology, randers, denmark a -years old woman had a right sided mastectomy with axillary dissection performed, because of suspicious mammografic microcalcifications and finding of malignant cells by fine needle aspiration. grossly, an cm large suspicious area with accentuaded consistency and multiple pale-yellow flecks, representing comedonecrosis, were found. multiple sections representing the suspicious area showed dcis. the ducts were dilated and contained malignant cells and central necrosis. in areas classical cancerization of the lobules were present. furthermore, in multiple microscopic areas the stroma of the lobules were oedematous and infiltrated by lymphocytes. the acini were slightly dilated and covered by one or two layers of malignant epithelial cells, but the central lumen was preserved. the morphology greatly simulated invasive ductal carcinoma. however, by immunohistochemistry the myoepithelial cells were showed to be preserved and the lobular unit were well demarcated with preserved circumscription. the axillary fat contained lymph nodes all without metastasis. it was concluded that the alterations represented a variant of lobular cancerization, earlier described by tavassoli ( ) . spindle cell tumors of the breast are rare entities with difficult differential diagnosis. we report four spindle cell tumors: a metaplastic carcinoma, a fibromatosis, a malignant spindle cell myoepithelioma and an inflammatory pseudotumor. the metaplastic carcinoma occurred in a -year-old woman as a . x . x cm nodule with scarce bland clear cells proliferation and very important desmoplastic reaction; immunohistochemical stains revealed positivity for cytokeratins (mnf ) and vimentin and negativity for actin and desmin. the fibromatosis occurred in a year-old man as an x x cm tumor with bland spindle cell morphology; very little atypia and rare mitoses were identified and immunohistochemical positivity for vimentin was demonstrated. the malignant spindle cell myoepithelioma occurred in a -yearold woman as x x cm nodule with central necrosis; histopathologic examination revealed a malignant spindle cell proliferation with many mitoses and atypical cells; focal positivity for mnf , vimentin, actin and s was identified. the inflammatory pseudotumor occurred in a -year-old woman as a highly cellular spindle cell proliferation with fascicular pattern admixed with myxoid areas and inflammatory cells -type i-ii mammary inflammatory pseudotumor. one important criterion which should be kept in mind in the process of evaluation of a spindle cell tumor of the breast is that these tumors may have deceptive histopathologic appearance -some of them have bland looking morphology despite of their biological behavior (our example of metaplastic carcinoma) and others with worrisome morphology were diagnosed as benign or intermediate malignancy entities (inflammatory pseudotumor). introduction calcitonin receptor (ctr) belongs to the g proteincoupled receptors and it binds calcitonin (ct), which acts on bone and kidneys to maintain calcium homeostasis. however, both of ct and ctr have also been identified in a large number of tissue and cell, suggesting it might has any unrecognized roles. although ctr expression has been found in several breast cancer cell lines and in primary breast cancer, quantitative analysis of ctr expression in matched normal breast tissue and primary breast cancer has not been explored up to date. here we present the detection and quantitation of ctr gene expression in matched normal breast tissue and breast cancers, by using laser capture microdissection. materials and methods fourteen breast cancers and matched normal epithelium from the same patient were laser capture microdissected to obtain pure cell groups and to submit to quantitative analysis by using one step real time rt-pcr. results both normal breast epithelium and cancer cells expressed ctr. as compared with paired normal epithelium, decreased ctr expression was found in of cases breast cancer ( . %) while increased ctr expression in cases ( . %) and no change in cases ( . %). conclusion our investigation revealed that ctr expression was constantly expressed in normal breast tissue and breast cancers. to the best of our knowledge, this is the first report, which revealed that ctr rna expressed in normal breast epithelium. downregulation of ctr is a common phenomenon in the breast cancer, suggesting that it may have important roles on the development of breast cancer. effect of neoadjuvant chemotherapy on her status in patients with breast carcinoma s popovska, t betova medical university-pleven, pleven, bulgaria introduction neoadjuvant chemotherapy is the standard of care for patients with locally advanced breast cancer and is being evaluated in patients with earlier-stage operable disease. the effects of chemotherapy on biological markers such as an oncoprotein expression are not well known. the aim of the study was to determine whether her expression was modified by neoadjuvant chemotherapy. methods forty-nine patients with t - n - m breast cancer were treated in a prospective trial utilizing fec regimen. matched pairs of pre and post-chemo therapy breast tissue were evaluated immunohistochemically for her status using herceptest kit (dako). results her overexpression was observed in / patients ( %). the her status of ( . %) patients was unchanged after chemotherapy. modification was found in cases-decreasing in , increasing in and loss of expression in patient. her status was not changed significantly following primary chemotherapy. conclusions our results showed that, in most patients her status is stable parameter in patients with breast carcinoma after primary treatment with neoadjuvant chemotherapy. the microvessel density in female breast cancer among younger and older age groups introduction breast cancer remains one of the most important oncologic problems worldwide. it seems that breast cancer first detected by the age of - years follows more aggressive clinical course than tumors developing later. young females with breast cancer more frequently present with axillary lymph nodes metastases. expression of the estrogene receptors is less frequent, and the histological grade is usually higher among this group. the main purpose of our study was the evaluation, quantification, and comparison of the angiogenesis in breast cancer among young women, below the age of years and older patients, above years. material and methods tissue samples of breast cancer from patients aged years and less ( cases), and from patients older than ( cases) were studied. ten specimens of non-neoplastic breast tissue from the normal breast in the tumor vicinity (younger patients) served as a control. microvessels were visualized immunohistochemically with use of cd- antibody and counted within the areas of the highest density ("hot spots"). six separate high power fields (hpf), . mm each, were studied in each case. results and conclusion the average microvessels count per hpf in the breast cancer tissue in younger group was higher than in the older age group and non-neoplastic tissue. the differences were statistically significant. the increased density of proliferating microvessels seems to play a role in the aggressive clinical behavior. total frozen section diagnoses have been performed mainly on sentinel lymph node of the mammary gland.the aim of the study was to analyze our result, and estimate whether the telepathology is of practical use or not. material total cases including lymph nodes diagnosed using telepathology. results and conclusion we failed to find carcinoma metastasis in out of sentinel lymph nodes of breast. it was very minute metastasis, and was not contained in the transmitted pictures. our transmission speed is kb that takes about seconds for each picture. there exists a limitation about the transmittable pictures within a restricted time. improvement of transmission speed may solve this problem. in two cases, while telepathologically negative of sentinel node, we found metastasis in the other dissected nodes by permanent section examination. the method of sentinel node identification should be improved. there was a confounding of the specimens that occurred between two patients on the same day. it was a case that happened at the beginning of telepathology. since the surgeon and the technicians are far away from the pathologist, and communication is done by the telephone, it is important for each party to keep in close contact with each other. our result is fairly good considering the limitation of the telepathology. although some issues are still remaining, we conclude that telepathology is now of practical use. pigmented mammary paget disease in a year old man-a case report ar monsef esfahani hamedan university of medical sciences, hamedan, islamic republic of iran mammary paget disease results from intraductal mammary paget carcinoma that extends to the epidermis of the nipple and areola through a lactiferous duct or from invasive breast carcinoma that reaches the epidermis via direct extension from the dermis. pigmented mammary paget disease is a rare clinicopathologic variant of mammary paget disease. it may mimic malignant melanoma clinically and histophatologically. it seems that involvement of the dermo-epidermal junction by neoplastic cells of the mammary paget carcinoma seems to be a prerequisite for the development of the clinical pigmentation. we report a case of pigmented mammary paget disease. the patient was a -year-old male who complained of an erythematous, pigmented scaly plaque around his right nipple measuring x cm with mild fissuring of two year duration. the histopathology revealed pagetoid spread of large cells in the epidermis with pigmentation of basal cells and melanocytes. the ihc confirmed the mammary paget disease and excluded malignant melanoma and squamous cell carcinoma. frozen section evaluation of sentinel lymph nodes in breast cancer introduction the use of sentinel concept as the newest approach in surgical treatment of breast cancer, apart from tumorectomy, means the extirpation and analysis of one or more regional lymph nodes which receives lymph drainage from primary tumor (guardian lymph nodes -sentinel nodes). the presence or the absence of secondary deposit in them is considered the most important predictor of the positive secondary deposit status of the other axillary lymph nodes. depending on histological analysis of sentinel node, the operation is finished with or without the axillary lymph node dissection. materials and methods sentinel concept in surgical treatment of the breast cancer is applied only in the cases where the largest dimension of the tumor is not more than cm (pt ). marking of the sentinel node is conducted before the operation by a combined method, the usage of patent blau color and technetium m as a radio marker. sentinel lymph nodes identity, before sending to a pathohistological analysis, is checked by gamma detection probe. two groups of prospective tests (a and b) were formed with cases each. sentinel lymph nodes from group a in the first stage of the testing were treated by pathohistological method (one hematoxylin and eosin preparation) and then microscoped. the cases in which secondary deposit was not noted, were subjected to a serial cutting and immunohistochemical staining by the ema markers, specific for intraductal epithelium of a breast. sentinel nodes from group b were submitted fresh for frozen section investigation, where they were approached with a series of cuttings and immunohistochemical analysis by the ema markers. the nodes without secondary deposits were fixed in formalin, paraffin embedded and, with the application immunohistochemistry (ema), submitted to serial cutting (similar to the second phase in group a) as a precaution. results in the first stage paraffin samples (group a) were first examined by h&e method, and additionally with immunohistochemistry (using ema). with this additional examination secondary deposits were found in cases ( %). this can only prove already known fact about statistically significant higher sensitivity and specifity of immunohistochemistry compared to h&e. in the second stage (group b) new samples of sn, first investigated by frozen section investigation, were examined by immunohistochemichal method (using ema). in addition, these samples were serially cut and treated like paraffin samples by immunohistochemistry method. the results of these two analysis were identical. facts mentioned above show that sensitivity and specifity of the frozen section analysis using immunohistochemical method (ema) is % (high percentage is probably the consequence of a relatively small number of samples). discussion acquired data suggested that implementation of one of the used methods (serial frozen section analysis with immunohistochemistry) from the sentinel concept is an efficient histo-morphological method in the evaluation of sentinel lymph nodes that make valid intraoperative staging of breast carcinoma possible. the authors came to significant data in both groups of tests and determined sensitivity, particularity and the efficiency of the applied methods. conclusion application of the suggested method would spare a considerable number of patients with pt breast cancer of subsequent axillary lymph node dissection and thus reduce the number of postoperative complications and long term morbidity. introduction needle core biopsy (ncb) of palpable lesion and stereotactic biopsy (smb) of non-palpable mass are the major preoperative methods of breast tumor diagnosis. the aim of this study was to evaluate methods accuracy and to emphasize the main detectable prognostic factors. materials and methods core biopsies ( ncbs and smbs) were performed between january and december . in / cases, the correlation between biopsy results and subsequent surgical excision was available. results the lesion diameter was < cm (in % of the ncbs and % of the smbs). with smb, the average number of tissue core obtained per lesion was . at histology, in % of ncb and in % of smb diagnosis of malignancy was given. the dcis/idc ratio was / for ncb and / for smb, respectively. grade and type of the invasive and in situ carcinoma were determined in both biopsy and definitive excision, and the results compared. the agreement for overall grade was in % with smb and in % with ncb. at surgical excision, / dcis showed foci of idc. in % of smb cases no residual neoplastic tissue was found. conclusions the accuracy of both methods is very high. smb shows highest reliability and accuracy, because of the increased quantity of tissue obtained. the possibility to assess tumour size is limited. the preoperative assessment of the other prognostic factors (type and grade, tumour markers) are key determinants in planning the optimal breast lesions management. expression of mcp- mrna and macrophage infiltrates in invasive breast carcinoma introduction monocyte chemotactic protein- (mcp- ) has been detected in many human tumors; however, its chemoattractant role for macrophages in breast carcinomas is still questionable. the aim of this study was to determine the possible correlation between tumor-associated macrophages (tam) and the number of mcp- mrna in the invasive breast carcinoma. material and methods tissues obtained from surgical specimens of invasive breast carcinomas and cases of normal breast tissues were frozen in liquid nitrogen and kept at - o c until they were used for quantification of mcp- mrna by rt-pcr. the expression was calculated as a number of mcp- cdna copies per copies of g- -phd mrna. paraffin embedded sections from breast carcinomas were immunohistochemically processed for cd staining. positively stained tumor associated macrophages (tam) were counted on three "hot spots" (x ) and mean value was calculated. results the result of rt-pcr showed that in all cases of breast carcinomas ( / ) and the majority of normal breast tissues ( / ) the number of detected mcp- cdna copies was above the detection limit. furthermore, carcinomas showed higher levels of mcp- mrna ( . ± . ) then normal breast tissue ( . ± . ). the value of tam within a single carcinoma was very inconsistent ( . ± . ). statistical analysis did not find a significant correlation between mcp- expression and macrophage infiltrations (r= - , ) . conclusion mcp- is an important factor in the recruitment of macrophages. however, the results indicate that mcp- is probably not the only and/or crucial factor involved in macrophage attraction to tumor locus in breast carcinomas. comparison of mitotic index, growth fraction (evaluated by ki- ), er, pr, cathepsin d, p , and bcl- status between primary breast cancer and corresponding axillary metastatic sites introduction it has been postulated that the equilibrium of different clones within a tumor is eventually overcome by a biologically dominant one with enhanced metastatic potential. therefore, the metastatic tumor should be composed of more aggressive tumor cell clones than the primary one. we analyzed mitotic index, proliferation antigen ki- , estrogen receptors (er), progesterone receptors (pr), cathepsin d activity, protein p , and bcl- oncoprotein status in order to explore the assumed differences in the clonal composition between the primary breast cancer and axillary metastasis. materials and methods er, pr, p , bcl- , ki- , and cathepsin d statuses in patients with the primary ductal invasive carcinoma of the breast and at least one axillary metastatic lesion were analyzed by immunohistochemistry (ihc -dako lsab system). mitotic index was assessed by counting the number of mitoses in primary and metastatic lesions. statistical analysis included t-test for dependent samples, linear correlation analysis, and roc-curve based contingency table analysis. results we found higher mitotic index (p= . , r= . ), higher growth fraction (ki- , p= . , r= . ), and higher level of overexpression of bcl- (p= . , r= . ) in axillary metastatic lesion than in primary breast tumor. there were no significant differences in er (p= . , r= . ), pr (p= . , r= . ), cathepsin d (p= . , r=- . ), and p (p= . , r= . ) status. higher mitotic and ki- rates were associated with lower er and pr expression, whereas higher cathepsin d level was associated with lower bcl- expression, both in primary tumor and metastasis. between the paired primary tumor and axillary metastatic lesions, samples had concordant er, pr, p , and cathepsin d status when analyzed by ihc. tumor clone with enhanced metastatic potential might be characterized with higher mitotic index and overexpression of both ki- antigen and bcl- oncoprotein. basaloid breast carcinoma with pleomorphic lipoblastlike giant cells and neuroendocrine differentiation js reis- filho , liposarcomatous differentiation in breast neoplasms is a rather infrequent phenomenon and so far restricted to rare cases of malignant phyllodes tumour and true liposarcomas of the breast. the terms lipid-rich and lipid-secreting breast carcinomas encompass breast tumours in which neoplastic cells accumulate or secret lipid; however, lipoblasts are not usually seen. recently, we have observed a distinctive type of breast carcinoma in which pleomorphic lipoblast-like cells were seen admixed with the carcinomatous component. an -year-old female presented with a cm hard lump in the right breast with palpable nodes in the right axilla. mammography and ultrasound disclosed two irregular dense central masses in the right breast, measuring cm in aggregate, and an enlarged axillary node measuring approximately cm. a diagnosis of breast carcinoma was made and the patient received neoadjuvant tamoxifen despite the lack of estrogen receptor (er) in the primary tumour. four months later, her disease had progressed and she underwent right mastectomy with axillary dissection.. histologically, both the primary tumour and the / lymph node metastases were characterised by a high-grade carcinomatous component which imperceptibly merged with pleomorphic lipoblast-like cells. immunohistochemistry demonstrated epithelial differentiation in the carcinomatous and liposarcomatouslike components (epithelial membrane antigen, cytokeratins / , / , , and mnf ) . both components were also positive for vimentin, s- protein, and focally for chromogranin, gcdfp- , and e-cadherin. hormone receptors (estrogen, progesterone and androgen receptors), her /neu, p , smooth muscle actin, desmin, synaptophysin were negative. based on the histological and immunohistochemical profile, we believe that this case represents a breast carcinoma with basaloid phenotype and showing divergent differentiation (liposarcomatous and neuroendocrine), features that have to our knowledge not been documented to date. collagenous spherulosis arising in an adenomyoepithelioma of the breast: a hitherto unrecognised association js reis-filho , , lg fulforf , b crebassa , s charpentier , sr lakhani collagenous spherulosis (cs) is a benign epithelial and myoepithelial breast lesion characterised by the accumulation of basement membrane material in the form of eosinophilic or rarely basophilic spherules that exhibit concentric and radiating fibrillar patterns. cs is an incidental finding that usually occurs in association with benign proliferative and pre-invasive lesions. adenomyoepithelioma is a biphasic neoplasm of the breast, composed of both luminal epithelial and myoepithelial cells. despite the shared histogenesis, cs has never been described in association with adenomyoepithelioma. we report a case of a year-old female who presented with cs of the breast arising in an adenomyoepithelioma. the differential diagnosis included adenoid cystic carcinoma. immunohistochemistry with antibodies for cytokeratins (cks) , and / , smooth muscle actin (sma), calponin, smooth muscle myosin heavy chain (smmhc), p , collagen iv, oestrogen receptor (er), progesterone receptor (pgr), ki , and c-kit was performed. myoepithelial cells of the adenomyoepithelioma and the cells surrounding the collagen spherules of cs showed a similar profile (cks and / , sma, calponin, smmhc, p , and s reactivity), luminal cells of both lesions also showed overlapping immunophenotypes (ck , er and pgr positivity). collagen iv highlighted the spherules in cs. ki labelling indices were similar in both lesions. c-kit expression was restricted to the adenomyoepithelioma and no expression was observed in the cs. the association is important to recognise as it could potentially lead the unwary to a misdiagnosis of adenoid cystic carcinoma, cribriform carcinoma or cylindroma of the breast. introduction lymphoepithelioma of the nasopharynx is an undifferentiated carcinoma with a prominent lymphoid infiltrate. tumors, with histologic features similar to nasopharyngeal lymphoepithelioma in other locations are referred as lymphoepithelioma-like carcinoma.(lec). in differential diagnosis of this lesions, medullary carcinoma and lymphoma must be considered. in this study, we report a case of lec of the breast which is very rare tumor.. material and method a -year-old female was noted to have a lesion of the right breast on mammography. an excisional biopsy was performed and sections revealed a well-demarcated elastic mass of cm in diameter. routine histologic examinations and immunohistochemical analysis were performed and compared with reported cases in literature. results clinical features, macroscopic and microscopic findings, immunohistochemical analysis were consistent with lec of the breast. on immunostaining, the tumor cells showed strong staining for epithelial membrane antigen (ema) and low weight cytokeratin (lcw).lymphoid cells stained positively for leucocyte common antigen (lca).the tumor cells showed no staining for cd . staining for uchl - and l demonstrated that there were more t cells than b cells. the tumor cells were immunohistochemically negative for epstein-barr virus (ebv). introduction this retrospective study was performed to investigate the role of dna-ploidy and s-phase fraction in determining prognosis in advanced breast cancer. methods the study included female patients with breast cancer, investigated for the period - . the nuclear dna-content has been measured by cas- (beckton dickinson, image analysis) on intraoperative cytologic samples of the tumour (imprints). the tumours have been divided into diploid, tetraploid, aneuploid and hyperdiploid. results of all patients had aneuploid and multiploid histogram, whereas % of them had developed distant metastases. lymph metastases have been registered in % of the cases with diploid histogram. s-phase has been considerably higher in patients with aneuploid than those with diploid histogram. the survival of of all patients has been analyzed as to the type of their histogram and as to the presence of metastases in lymph nodes and distant organs. the results showed that breast cancer patients ( . %) with aneuploid histogram and metastases in lymph nodes had a survival of less than years, compared to the better survival rate of those patients with diploid histogram and no metastases in lymph nodes. the higher s-stage has correlated to the metastases in lymph nodes and distant locations. conclusion the analysis of all results proved that the dna-morphometry could successfully be used as an independent criterion for evaluation of the biologic behaviour of breast cancer tumours and their prognosis. hypercholesterolemia impairs angiogenesis in patients with breast carcinoma and therefore lowers the risk of metastasis bh introduction angiogenesis plays a key role in tumor progression and it is also necessary for the development of distant metastasis. previous experimental studies indicate that both diet-induced and genetic hypercholesterolemia (hch) impairs angiogenesis. our aim was to investigate the effect of hch on angiogenesis induced by breast carcinoma and to elucidate the possible mechanisms by which it inhibits the progression of the cancer. material and method fifty-one patients with invasive ductal carcinoma were included in the study. of cases had hch and had no hch. all patients were followed for a mean of months after radical mastectomy. the intratumoral microvessel density (mvd) was evaluated immunohistochemically using anti-cd antibody and correlated with clinicopathologic parameters. also the expression of bfgf and vegf were examined immunohistochemically and graded semiquantitatively. results mvd was significantly correlated with tumor grade, vegf and bfgf expression, recurrence, lymph node metastases (lnm), distant metastases (dm) and survival (p< . ). patients without hch had significantly higher mvd ( . . ) than those with hch ( ) (p< . ). in addition the risk of lnm and dm were found higher in cases without hch when compared to cases with hch (p< . ). both bfgf and vegf expression showed significant negative correlation with hch (p< . ). conclusion we suggest that, hch impairs angiogenesis by suppressing bfgf and vegf expression and therefore lowers the risk of metastases in cases with invasive breast carcinoma. the cd antibody (calla) is usually expressed in lymphoblastic acute leukemia and in follicular center cells of lymph nodes. it is also used in breast cancer cell culture to differentiate epithelial cells from myoepithelial cells. usually the smooth muscle actin (sma) is used to identify myoepithelial cells in breast lesions, but this antibody is also positive in blood vessels. this study compares the expression of cd and sma as a marker of myopepithelial cells in breast lesions. we have compared breast lesions, both benign and malignant ( adenosis, fibroadenomas, intracystic papillomas, hamartoma, gynecomastia, intraductal carcinomas, invasive ductal carcinomas, tubular carcinomas, mucinous carcinomas, invasive lobular carcinomas, medullary carcinomas, phyllodes tumors). the antibodies used have been cd ( c, : , dako) and sma ( a , : , biogenex) . results we observed cd expression in the cell membrane of myoepithelial cells and also in some stromal myofibroblastic cells. sma expression was observed in the cytoplasm of myoepithelial cells, in some stromal myofibroblastic cells and also in smooth muscle cells. proliferative breast lesions and benign tumors contain myoepithelial cells expressing cd and sma. in malignant lesions the myoepithelial cell component is lost. conclusions the cd is a myoepithelial cell marker and yields a good, reproducible staining in the studied cases. we think that the use of cd combined with sma is helpful in the differential diagnosis between benign and malignant lesions (epitheliosis vs intraductal carcinoma, tubular carcinoma vs atrophy, adenosis vs invasive ductal carcinoma, papilloma vs intracystic papillary carcinoma). introduction the identification of myoepithelial cells in breast lesions remains of diagnostic value for the discrimination between benign and malignant lesions. p is a p homologue, which is expressed in epithelial basal cells of different organs. the aim of the present study has been to investigate the immunohistochemical expression of p in breast lesions. materials and methods we examined immunohistochemically formalin-fixed, paraffin-embedded, archival breast samples, which consisted of benign lesions and malignancies ( in situ carcinomas, invasive ductal carcinomas, nst and invasive carcinomas special type). the monoclonal antibodies anti-p (biocare medical/menarini), anti-a-smooth muscle actin (biogenex) and anti-s- protein (biogenex) were used. results in all cases, p expression was nuclear. in all benign lesions, there was an almost continuous basal rim surrounding the epithelial structures, whereas it was present but discontinuous in the in situ carcinomas. all invasive ductal carcinomas, nst, were devoided of p staining. p immunoreactivity was noted in a minor fraction of neoplastic cells in / ( . %) in situ papillary carcinomas and in / ( . %) invasive papillary carcinomas. the stromal cells were negative to p . there were s- positive luminal epithelial cells in almost all cases, whereas many fibroblasts of the stroma were positive to smooth muscle actin. conclusion it appears that p is a more sensitive and specific myoepithelial marker than those currently used, with no staining of stromal myofibroblasts. the observed staining in scattered cells, only in papillary neoplasms, might be a clue to the speculated different histogenesis of this specific type of breast tumors. prediction of aggressive outcome in t n m breast cancer introduction small tumour size at the time of diagnosis is one of the most significant prognostic factor of favourable outcome in invasive breast cancer. however, unpredictable breast cancer recurrences and deaths also occur among the group of patients with t n m breast cancers. aims: we set out to identify the clinically useful prognostic features predicting unfavourable outcome in patients with t n m invasive breast cancer. the study comprises cases of invasive ductal or lobular carcinomas diagnosed and treated in turku university hospital and jyväskylä central hospital during the years - . twenty-seven patients had an aggressive disease with a recurrence or death of breast cancer. the prognostic factors of each of the patients with aggressive disease were compared with control patients matched by tumour size, age at diagnosis and histological type of tumour. the follow up time was - years. the clinicopathological prognostic factors of the patients were surveyed. results the prognostic features indicating unfavourable outcome were immunohistochemically detected high ki- expression, high p expression, low estrogen receptor expression and positive her /neu chromogen in-situ hybridization. the number of mitotic figures (mitotic activity index, mai), histological type of the tumour or number of studied axillary lymph nodes did not provide prognostic information. conclusion our study summarizes the immunohistochemical features and criteria predicting unfavourable outcome in t n m invasive breast cancer. detection of overexpression of c-erbb through immunohistochemical and amplification of her /neu established by fish in breast cancer. a comparative study introduction the prognostic and predictive implications of oncogene her /neu activation are very controversial, due to the extensive variation of results, mainly due to the different methods applied. activation of her in node positive patients as an independent prognostic factor has been established and correlated with tumour sensitivity to different therapeutic agents. the overexpression of this membrane receptor has converted it into a new therapeutic aim, requiring the application of a more suitable methodology for each case. objectives to evaluate the most suitable method (immunohistochemical vs. fish) to determine her activation and its correlation with other prognostic factors. material and methods a study of cases of invasive breast carcinoma. histological type: % infiltrating ductal carcinoma; age: - , hormonal receptors: . % (rh+), . % (rh-); histological grade (bloom-richardson mod): . % (g ), . % (g ), and . % (g ). immunohistochemistry was performed in patients with (herceptest dako), and with anti c-erbb (dako : ). scores were used for evaluation: absence of membrane staining ( ), faint and incomplete in > % of tumour cells ( +), weak to moderate in > % ( +), strong complete in > % ( +). fish study was performed on paraffin sections through path vision system with evaluation of nuclei. a good correlation between immunohistochemical overexpression and amplification by fish was observed, especially in cases evaluated as ( +) / ( %), and as ( ) / ( %). no amplification by fish occurred in . % of ( +) / and in . % of ( +) / . % of negative hormonal receptor tumours showed amplification, while only . % of positive receptor tumours amplified. none of the tumours classified as (g ) showed amplification. conclusions we emphasise the necessity to study gene amplification through fish in cases with weak immunohistochemical overexpression ( +). introduction cell cycle progression is governed by cell cycle regulators and inhibitors such as cyclin dependent kinases (cdks), p , p /waf and p /kip . the purpose of this study was to correlate the immunohistochemical expressions of p , p /waf , p /cip and p cdc , with its clinicopathologic prognostic parameters in human breast cancers. materials and methods paraffin-embedded tissue sections from patients with human breast carcinomas were examined for immunohistochemical staining. primary antibodies used in immunohistochemical staining were mouse monoclonal antibody to human p , p /waf , p /cip and p cdc . results the expression rates of p , p /waf and p cdc were . %, . % and . % in breast carcinomas, respectively. in normal breast tissues, p , p /waf and p cdc were not expressed. the expression rate of p /cip was . % in breast carcinomas and % in normal breast tissues. the correlation between the expression of p and p /waf was noted(p= . ). the expression of p /cip was correlated with that of progesteron receptor(pr) (p= . ). the expression of p /waf was correlated with that of estrogen receptor (er) (p= . ) and pr (p= . ). no correlation was demonstrated between survival in patients and expression of p , p /waf , p cdc and p /cip . conclusion the loss of normal cell growth cycle by abnormal cyclin dependent kinases, inhibitors and steroid hormones may play an important role in human breast carcinogenesis. the p dependent p pathway, p gene loss and cdc overexpression were important in development and progression of human breast cancer. withdrawn p- interobserver variability in determination of her protein overexpression by immunohistochemistry using herceptest assay - cases study material and method among cases evaluated in population screening project total cases from all centers were selected and presented to representatives of those centers. the immunohistochemically stained slides came from all laboratories. all ihcs were done using fda-approved dako herceptest. evaluation was performed without knowledge of the original results the results from each researcher were coded. the study lasted hours. the average concordance was nearly %, while the lowest concordance was and the highest - %. this wide range of the results might be due to several things. firstly, the experience in ihc evaluation varied among the participant of the study. secondly, the quality of the stains differed significantly. thirdly, the researchers worked under time pressure and the material was selected to include more cases considered 'difficult' ( + according to dako herceptest or technically inadequate). conclusions to achieve higher concordance among the obtained results, evaluation should be performed by the experienced pathologists. * -participants from: bialystok, bydgoszcz, gdansk, gliwice, kielce, krakow, lublin, lodz, olsztyn, poznan, szczecin, warsaw and wroclaw. the population screening project study was supported by roche-polska. a morphometric analysis of early invasive breast carcinoma using serial sectioning and d reconstruction technique introduction mechanism of early invasion of breast ductal carcinoma has not been completely investigated not only from the genetic point of view but also morphologically. one of the reason is that starting sites of invasion from ductal carcinoma in situ (dcis) might be extremely diminutive that routine histopathological examination should hardly reveal them usually. thus, we examined a large number of complete serial sections from breast carcinomas so as to find out destroyed sites of duct wall from which carcinoma cells have started on invasion. also we reconstructed d images from the sections so as to visualize the sites and to measure the size of those. materials and methods used were three surgical specimens of breast cancer having extensive intraductal components with multiple invasive foci. after formalin fixed and paraffin embedded, six blocks from three cases were selected and sectioned serially in µm thickness. total amount of the serial sections reached sheets (mean / block) indicating . µm in actual thickness. after he stained, invasive lesions connected with dcis were searched and the lesions were reconstructed as d images with a computer-assisted- d-reconstruction system. results although numerous sections containing multiple invasive foci were examined, areas which connected with dcis to invasive lesion through the destroyed site of duct wall were only three. the site were approximately µm, um and µm in diameter respectively, should be called as 'hole' of the duct wall. invasive lesions were extended along the ducts with the holes. conclusion the holes, starting sites of invasion, were apparently smaller than surrounded invasive lesion. histological and immunohistochemical profile of invasive pleomorphic lobular carcinoma y erhan introduction invasive pleomorphic lobular carcinoma (iplc), a distinct subtype of invasive lobular carcinoma (ilc), shares the typical histologic patterns of classical ilc, but the nuclei are more pleomorphic and increased mitotic activity is a prominent feature. we reviewed cases of iplc and compared them with cases of clssical ilc. immunohistochemical analysis was performed in all cases for estrogen (er) and progesterone receptors (pgr), p , c-erbb- , and ki . in this series, the average patient age was . years (age range, - years) for iplc and . years (age range - years) for ilc. tumor size ranged from to . cm (mean size . cm) for iplc and . to cm (mean size . cm) for ilc. axillary lymph node metastasis was detected in % of iplc, and % of ilc. fifty percent of iplc and % of ilc cases had extranodal extensions (p< . ). tumor cells were large with eccentric pleomorphic nuclei and eosinophilic granular cytoplasms. high mitotic activity was observed. immunohistochemically er and pgr positivity in iplc was % and %, and in ilc % and %, respectively. iplc cases showed %, and ilc cases % p positivity (p< . ). c-erbb- was detected in % of iplc, and % of ilc. ki mean rates were % and % for iplc and ilc. conclusion iplc exhibits distinct histologic fetures, higher expression of p protein and ki rate in comparison with classical ilc. the aggressive clinical course of patients with iplc is supported by higher rates of axillary lymph node metastasis and extranodal extensions. introduction c-kit is a proto-oncogene that codes for a transmembrane tyrosine kinase receptor: cd . once activated, c-kit propagates signalling events throughout the cell via multiple signal transduction pathways. it was described an activating mutation in exon of c-kit gene in gastrointestinal stromal tumours (gist), which can be blocked by using a tyrosine kinase inhibitor (sti ). phyllodes tumours (pt) are rare biphasic breast tumours that similarly to gists show a monoclonal stromal proliferation and high recurrence rates. aims: to study the immunohistochemistry expression and prevalence of activating ckit mutations in pt in order to explore whether this disease could be a potential target for treatment with sti . we analysed pt ( benign and malignant) by immunohistochemistry for c-kit expression and direct sequencing of exons , , and of c-kit gene for evaluate the mutational status. c-kit expression was detected in out cases ( / benign and / malignant). no mutations were found for exons , and . in exon we found the same silent alteration in out of cases. conclusions although c-kit expression is a frequent finding in pt of the breast, we did not find activate mutations similar to those described in gists. recently, the role of cyclin d expression in breast cancer had received attention. it causes the activation of cyclindependent kinases in g phase and phosphorilation of the retinoblastoma gene, required for entry of cell into s phase of the cell cycle. recent investigations confer the role of cyclin d once again in g phase. the aim of this study was to analyse the expression of cyclin d in human breast cancer cells and to compare its value with the estrogen receptors and histological parameters. material and methods immunohistochemical analysis for cyclin d and estrogen/progesteron receptors (er/pr) was performed on formalin-fixed infiltrating ductal breast carcinomas. scoring was done using semiquantitative system. the stainining score was ranged from - (called cyclin d -negative) and score larger or equal to (called cyclin d -positive). results according to the staining score % of the breast carcinomas were cyclin d positive, and those carcinomas were associated with higher nuclear and histological grade, while only % were er-positive. conclusion these reslults suggest that higher expression of the cyclin d is related with poor prognostic parameters. c-erb b overexpression in breast cancer with negative lymph nodes background it is known that c-erb b overexpression in advanced breast cancer represents a predictive factor of tumoral agressivity. the aim of this study was to assess the involvement of c-erb b and other prognostic factors expression (hormonal receptors, egfr, pcna) in breast cancer with negative lymph nodes. methods we investigated histopathologically and immunohistochemically selected cases with g ductal invasive carcinoma and no lymph nodes involvement, from breast cancers. we used a monoclonal antibody panel (estrogen and progesteron receptors, egfr, c-erb b , pcna) in formalin fixed paraffin embedded tissues. results we found a significant increased c-erbb overexpression associated with a low er and pgr expression and minimal microangiogenesis as expressed by egfr. the average of proliferative rate assessed by pcna was . %. conclusion immunohistochemical c-erbb overexpression in negative lymph nodes breast cancer, may suggest an early amplification of its encoding gene, which can predict an aggressive biological behaviour (invasion and metastasis), so that this type of patients would benefit of humanized anti-her /neu monoclonal antibody treatment. introduction aspiration cytology of the breast is one of the three components of the triple test for breast cancer diagnosis. ultrasound (us) guidance increases the complete sensitivity of this technique. the aim of this study was to compare the results between a group of mammary lesions aspirated with or without us using the european quality assurance guidance. material and method we analyzed mammary lesions by aspiration cytology with or without us guidance. one group was formed by breast aspirates from women older than fifty years old, included in an screening programme, with palpable and non palpable lesions, using us guidance. another group was formed by breast aspirates from outpatients origin of all ages only with palpable lesions using no us guidance. we analysed and compare the results between both groups using using the european quality assurance guidance for breast screening pathology. results in both groups the positive predictive value of the c results were % (false positive rate= %). the complete sensitivity of us guided aspirates were . % and for the non guided aspirates were %. we compare the rest of values and analyze our deviations from the standards. conclusion the quality of our breast aspiration practice is between the margins of the standards in both techniques, with an increment in the sensitivity with us guidance and a light loose of specificity in the screening group (probably because of patients age characteristics). ultrastructural study of intercellular junctions in metastatic and non-metastatic breast cancer introduction functional and morphologic characteristics of inter-cellular junctions are involved in tumor dissemination. the purpose of this study was to investigate whether the number of intercellular junctions in breast cancer is predictive for the presence of lymph node metastases. materials and methods infiltrating duct carcinomas were the subject of this study, of them without (g ) and with metastatic disease (g ) in axillary lymph nodes. the number of intercellular junctions was counted, and the length of the cell-to-cell contact surfaces was measured in randomly taken electron micrographs. the number of desmosomes/ µm of cell membrane apposition has been statistically compared between both groups. results cell junctions in tumors with lymph node metastases were usually smaller and poorly developed. there were no statistically significant differences in the number of intercellular junctions between both groups [g = %, ( , %; %). g = , % ( , %; %). p= , ]. conclusions although intercellular junctions are more rudimentary in tumors that metastasize, their number is not significantly reduced. therefore, it will be necessary to combine number, size and development of cell junctions in a single parameter to attempt prediction of tumor dissemination. supported in part by grant fis / . introduction numerous publications have been devoted to effects of myoepithelial cells on biology of breast cancer. the cells are thought to be able to inhibit invasion of neoplastic cells by production of inhibitors for serine proteases. some authors suggest that, acting in a paracrine way, myoepithelium can affect breast cancer cells. present study aimed at analysis of the relation between presence of myoepithelial cells (smooth muscle actin, sma) in the structure of a ductal breast cancer and expression of the recognized prognostic factors (er, pr, her- , tgf alpha, ki and p ) in the cancer cells. the studies were performed on samples of primary ductal breast cancers originating from females, including cases at g , cases at g and cases at g grade. immunocytochemical reactions were performed using antibodies directed to sma, er, pr, her- , tgf alpha, ki and p . the study showed that the highest content of myoepithelial cells was noted in tumours of g grade while the lowest content of the cells was observed in tumours of g grade (kruskal-wallis anova rank test, p= . ). in the entire group (g -g ) a positive correlation was detected between the presence of myoepithelial cells and intensity of her- expression (gamma correlation, p= . ) and a negative correlation with proliferation intensity measured by expression of ki antigen (gamma correlation, p= . ). no relation was observed between manifestation of myoepithelium and expression of the other studied variables. our studies confirmed the potential for paracrine communication between myoepithelial cells and cells of ductal breast cancer. immunohistochemical vegf expression in breast carcinomas. correlation with prognostic factors a matilla, l vicioso, l pérez, m Álvarez, i ramírez dpto. anat. patológica. universidad de málaga, malaga, spain introduction vegf (vascular endothelial growth factor) is considered as one of the most important angiogenic factors in breast cancer and its expression in tumor cells correlate with microvessel density. several studies have proposed that vegf may be a relevant prognostic factor. aim: to study the immunohistochemical expression of vegf in different histological types of breast cancer and its relation to established prognostic and predictive factors. we have analyzed carcinomas ( of invasive ductal type, lobular, mucinous, papillary and ductal in situ). immunohistochemical staining was performed on formalin fixed, paraffin sections, using an avidin-biotin immunoperoxidase technique. a rabbit polyclonal antibody for human vegf was used at a : dilution. immunoreactivity was scored from to +. results ( , %) of all invasive carcinomas showed vegf expression (ductal: %, mucinous: %). all but lobular carcinomas were negative or weakly positive. both papillary carcinomas showed strong positivity. staining in dcis was generally absent or weak. vegf positivity correlated inversely with nodal involvement (p= . ) and re status (p= . ). there were no correlation of vegf staining with tumor size, histological grade, p and c-erbb- . conclusion expression of vegf is characteristically weak or absent in lobular carcinomas and them no relevant as a prognostic factor in this type of carcinomas. as vegf staining correlate with absence of nodal involvement, its prognostic value may be mainly due to facilitate invasion of blood vessels, more than to lymphatic spread. introduction squamous carcinoma accounts for approximately % of all primary vulvar carcinomas. although the anatomic localization of this tumor allows early diagnosis and considerably easy surgical accessibility, the prognosis for these patients remains relatively grim. the explanation for this finding should be sought in the fact that most of the patients are diagnosed in the advanced clinical stage of the disease. since radical vulvectomy (a complex and debilitating procedure) is often a therapy of choice, the recent studies have been focused on determining reliable prognostic parameters that would allow individualized, and hopefully simpler therapeutic modalities to be applied in a certain group of patients with the same effectiveness. the aim of this study was to determine the most important clinical and histopathological parameters that influence the prognosis and outcome of patients with invasive squamous carcinoma of the vulva in order to offer them the most suitable form of therapy. moreover, it was designed to assess the clinical significance of dna content analysis by flow cytometry. patients and methods cases of squamous cell carcinoma of the vulva, diagnosed between . and . were selected. in order to assess the influence of the various prognostic factors on survival, the study included clinical and pathohistological parameters as well as the results of flow cytometric dna analysis of paraffinembedded tumor samples from all cases. clinicopathological parameters focused on the age of patients, clinical stage of the disease, menstrual status, diameter and localization of the tumor, histological grade, nuclear grade, combined histological and nuclear grade, depth of tumor invasion, tumor growth pattern, presence of giant cells in the tumor and the form of therapy, while the flow cytometric dna analysis comprised dna ploidy, proliferative activity and dna index. five-year survival of our selected population of patients was , +/- , %. the results of univariate statistical analysis confirmed that statistically significant prognostic parameters included the age of patients (p= , ), clinical stage of the disease (p= , ), histological grade (p= , ), nuclear grade (p< , ) and the depth of invasion (p< , ). on the other hand, the results of multivariate statistical analysis showed that only combined histological and nuclear grade (p= , ) and the depth of tumor invasion (p< , ) can be considered independent, statistically significant prognostic parameters. conclusion the age of patients at the time of diagnosis, clinical stage of the disease, histological grade and nuclear grade are considered to be the parameters of crucial relevance for the prognosis of patients with squamous cell carcinoma of the vulva. however, only combined histological and nuclear grade, as well as the depth of tumor invasion were proven to be independent statistically significant parameters relevant for the outcome of patients with this disease. can a pleomorphic vulvar leiomyoma be a tumor with local aggressive behavior? a case report vulvar leiomyoma is uncommon and its pleomorphic or bizarre form is especially rare. bizarre vaginal and vulvar (bartholin's gland area) leiomyomas were reported in only few cases. this tumor is hard to differentiate from leiomyosarcoma. the main criterion to make a distinction between them is the mitotic activity, which is less than per hpf in the former. case report a -year-old female was referred to the clinic for the evaluation of paravaginal tumor in distal vaginal third and right vulvar area with a history of month duration. she had no history of any earlier disease, and other examinations revealed normal findings. macropathology: the tumor was a large solid mass measuring x . cm in diameter. the tissue was yellow and seemed partly necrotic. micropathology tumor consisted mostly of spindle cells arranged in bundles with round or oval nuclei and large prominent nucleoli or showed hyperchromatism in places where there were cells with giant nuclei. cytoplasm was eosinophilic, elongated with small vacuole. there were areas where cells had two or more nuclei with the earlier mentioned polymorphism. areas of hyaline or myxoid degeneration of the stroma were found. mitoses were not found although the tumor was examined by three independent pathologists from different countries. the tumor margin looked infiltrative. the tumor was immunohistochemically positive for vimentin, smooth actin and desmin. cytokeratin mnf , ema, s- , cd- , and cd- were negative. conclusion we describe a vulvar smooth muscle tumor with marked polymorphism, without mitoses, with myxoid changes in the stroma and with infiltrative margins. because of all these characteristics the tumor was considered biologically aggressive and additional surgery with resection of the tumor site and regional lymphadenectomy was performed. three years after the last surgery the patient is alive and well. trophoblast apoptosis and proliferation in preeclamptic placentas d staribratova , z zaprianov , d dikov , v sarafian plovdiv medical university, plovdiv, bulgaria hospital center lagny introduction preeclampsia is a specific disorder of pregnancy with an increased risk for both neonatal and maternal mortality rates. it is associated with shallow invasion of the placental cytotrophoblast within uterus developing decidual vasculopathy and results in dereased blood flow. the aim of the present report is to determine whether hypoxia influences the rates of apoptosis and proliferation and to compare them with those of normal controls. materials and methods samples were taken from liveborn, singleton preeclamptic pregnancies and normal controls. we used routine light microscopy, immunohistochemical and quantitative studies for bcl- , and bax (to assess apoptosis) and pcna (to assess cellular proliferation). bcl- -and pcna-positive trophoblast cells were counted in a minimum of high-powered fields, of consecutive sections free from any infarction of at least paraffin blocks. results while increased apoptosis has been estimated in study groups, the rates of proliferation seems to be unaffected. placental pathologic features of preeclampsia d staribratova , z zaprianov plovdiv medical university, plovdiv, bulgaria introduction the clinical and placental features of preeclampsia are subject of an extensive study. clinical evidence suggests that this pregnancy specific disorder may be demographically heterogenous. our purpose is to record the range of the most common pathologic features in placental specimens from a gypsy cohort and to compare them with those in nonethnic bulgarian population. review of preeclamptic placentas from liveborn singleton deliveries of gypsy mothers and matching controls from bulgarian population revealed histologic lesions that were considered as belonging to one of the following groups: ( ) vascular lesions; ( ) acute or chronic inflammation and ( ) coagulation-related lesions. for each separate case, additional demographic and reproductive history was collected from the patients' charts. all placentas were studied by previously published standard protocols. nonparametric statistical analysis was applied. results in gypsy preeclamptic group, lesions related to coagulation ( % vs %) and vascular lesions ( % vs %) were more frequent. inflammatory features were equally distributed among the two groups ( %). introduction versican is a chondroitin sulfate proteoglycan, which belongs to the aggrecan gene family. it has not been studied in epithelial ovarian cancer before. the aim of this study was to clarify the relation between versican and hyaluronan in epithelial ovarian cancer and to find out if versican expression affects prognosis in these patients. materials and methods localization of versican was studied immunohistochemically in primary epithelial ovarian cancers and their metastases, as well as in normal ovary specimens. the staining was scored according to the percentage area of strong versican signal of total peri-and intratumoural stroma as low or high. epithelial staining of the tumours was scored as positive or negative. results low and high levels of strong stromal versican staining were observed in and carcinomas, respectively. a low level of strong stromal versican was found to be a significant marker for early figo stage and mucinous histology. stromal versican staining correlated significantly with stromal hyaluronan staining. cancer cell-associated versican positivity was seen in tumours and correlated with clear cell histology and early figo stage. the -year prognosis of patients decreased with increasing stromal versican levels for overall survival. the -year prognosis for recurrence-free survival was slightly better when cancer cells were positive for versican. in cox's multivariate analysis neither stromal nor cancer cell-associated versican had any prognostic value. conclusion enhanced stromal versican expression correlates with hyaluronan accumulation and is associated with unfavourable disease outcome, but it is not an independent prognostic marker in epithelial ovarian cancer. cytobrush-collected malignant cervical epithelial cells display a cancer-specific gene expression pattern in cdna array analysis g hudelist , introduction although it is well known that persistent high-risk hpv infections are the principal causative agents of cervical cancer, the discrepancy between high infection rates and the relatively low rates of high-risk hpv positive women who actually develop carcinoma of the cervix suggest that development of cervical cancer is a multistep process involving additional factors and mutational events. therefore, differentially expressed genes in normal and malignant cervical epithelial cells and the feasibility of gene expression profiling on cervical cells obtained by regular cervical swabs were investigated. material and methods cervical epithelial cells obtained by regular cytobrushes from women with high-risk hpv positive invasive cervical cancer and from hpv negative women without suspicious pap smears were pooled and subjected to cdna array analysis. dot blotting was then performed to detect the proteins which corresponded to the most highly up-regulated genes in the cdna array analysis. results mrna expression of c-erbb- , c-kit, vegfr- , n-myc, k-ras, cyclin-dependent kinase inhibitor (p ink a), cyclin d , nm -h , nm -h , c-met, kgf, kgfr, and stat was increased in malignant samples. several genes associated with antiapoptosis, such as bcl- like protein, cell structuring and/or cell attachment were also upregulated in tumoral cells. conversely, decreased gene expression was observed for members of the transforming growth factor receptor superfamily (tgf-beta), interleukin (il- ), insulin-like growth factor binding proteins (igfbps) and for members of the integrin family. conclusions we identified a mrna and protein expression pattern that might have an important role in the pathogenesis of invasive cervical carcinoma and appears to be specific for malignant cervical epithelium. we hypothesize that the presence of a cancer-specific gene-expression signature assessed by cdna array analysis or immunohistochemical techniques could eventually turn out to become an additional tool to evaluate the dignity of routinely obtained cervical swabs. prognostic features and molecular markers in ovarian borderline tumors e nistor , ad stanescu , cd vrabie , e ionica bucur hospital, bucharest, romania v. babes institute, bucharest, romania university of bucharest, bucharest, romania introduction ovarian cancer represent the fourth most common cancer in women. borderline ovarian serous tumors (bsot) affect women of childbearig age and their prognosis is outstanding. the aims of this study were to characterize the group of patients with bsot and evaluate the significance of various molecular markers expression versus serous papillary ovarian carcinomas (spoc) material and methods we analyzed a total of cases including: cystadenoma, borderline and cystadenocarcinoma. for the bsot the median age was years. eight women with bsot underwent radical surgery and two fertility sparing surgery. the recurrence of disease appeared in one case with fertility sparing surgery. all the cases were analyzed on haematoxilin-eosin stained and immunohistochemistry (the indirect tristadial streptavidin-biotin method) for estrogen receptor (er), progesteron receptor (pr), p protein (p ), proliferative activity (ki ) and carcinoembrionic antigen (cea). results the immunostaining demonstrated a significant increase in the expression of er ( %) and a decrease for p ( %) and ki ( %) in bsot vs spoc (er- %, p - % and ki - %). conclusions the main differences between bsot and spoc was regarding the expression of p and ki . there was no significant correlation between ki and the known histologic parameters of prognostic significance. transvaginal ultrasound and ca serum levels are the most effective diagnostic techniques for the follow up of patients treated conservatively for bsot. introduction gonadoblastoma with dysgerminoma or other germ cell tumor occurs almost exclusively in girls and young women with underlying gonadal disorder. the aim of this study was to review biopsy examinations of the tumours, stage, treatment strategy, follow up and outcome of five girls with gonadoblastoma and germ cell tumours. material and methods retrospective review of patients with gonadoblastoma and germ cell tumours was performed. the patients were , , , and years old. the first -year-old girl (karyotype, xx, normal ovary bilateral) with gonadoblastoma, dysgerminoma and choriocarcinoma had iiic stage disease. she was treated by chemotherapy with cisplatinum and radiotherapy. four patients had gonadoblastoma and dysgerminoma. the second -year-old girl (mixed gonadal dysgenesis, karyotype, , xy) had stage ib and was treated by chemotherapy with cisplatinum. two patients were treated with surgery only: year-old girl (streak gonads, karyotype, , xy) -stage ib and year-old girl (karyotype , xx, der / , xx, - ) -stage ia. the -year-old patient (karyotype, , xx, normal ovary bilateral) -stage ia disease, had adnexotomy only, but because of recurrence (stage iiic) months after the original diagnosis, she was treated by chemotherapy. results our review confirmed the original diagnosis of gonadoblastoma and dysgerminoma and in one case gonadoblastoma, dysgerminoma and choriocarcinoma. all patients were followed up for to months. only one patient, who was initially treated with surgery only (stage ia), had disease recurrence, but achieved durable remission with chemotherapy and further surgery. the latest examinations revealed that all patients were in good health. conclusions because the gonads are often replaced by a tumour, a diagnosis of the underlying abnormality may be impossible. gonadoblastoma is regarded as in situ malignancy, and there is a high possibility for development of invasive germ cell tumour such as dysgerminoma. young girls with unilateral encapsulated gonadoblastoma and dysgerminoma can be treated only by unilateral oophorectomy or salpingo-oophorectomy and subsequent careful follow up to prevent damage of contralateral ovary and preserve the fertility. the patients with gonadoblastoma and mixed germ cell tumor are treated in accordance with other tumour structures. the paper is sponsored by ministry of health of the czech republic (international grant agency) no - , cz introduction cadherins and their associated cytoplasmic protein catenins are cell adhesion glycoproteins that are altered in tumor progression the aim of this study is to reveal the altered expression of e-cadherin, p-cadherin, α-catenin and β-catenin in cervical squamous cell carcinoma progression from dysplastic lesions (low grade squamous intraepithelial lesion-l-sil, high grade squamous intraepithelial lesion-h-sil) to invasive squamous cell carcinoma. material and method immunohistochemical method was used in formalin-fixed, paraffin embedded representative tissue sections of l-sil (cin i), h-sil (cin ii-iii) and invasive squamous cell carcinomas. the presence of immunostaining and the pattern of distribution of e-cadherin, p-cadherin, α-catenin and β-catenin were analyzed. results e-cadherin was detected in . %, . %, . % of l-sil, h-sil and invasive squamous cell carcinomas respectively. the difference was statistically significant (p= . ). the expression of p-cadherin and α-catenin was reduced significantly from l-sil through invasive carcinoma (p= . for p-cadherin, p= . for α-catenin). β-catenin expression was revealed in all lesions with nearly the same frequency, . % l-sil, . % h-sil and . % invasive carcinomas. conclusion loss of adhesion proteins, e-cadherin, p-cadherin and α-catenin is observed in cervical squamous cell carcinoma progression. the presence of β-catenin in h-sil and invasive carcinomas might suggest its role in tumor progression by its effect in wnt signaling pathway in cervical carcinomas. introduction p, e-cadherin and their cytoplasmic domains alpha and beta-catenins are epithelial cell adhesion complexes. their alteration is important in tumor progression. beta catenin is also involved in wnt signaling cascade which regulates cell proliferation. we investigated the altered pattern of cadherin/catenin complex in cervical squamous cell carcinomas. we also tried to find out if there was a correlation between adhesion proteins and clinicopathologic variables (stage, depth of invasion, lymph node metastases) and hpv status. material and methods e-cadherin, p-cadherin, alpha catenin and beta catenin expression in squamous cell carcinomas were investigated by immunohistochemical method. the presence of hpv / infection was detected by in situ hybridization. results there were large cell keratinizing, nonkeratinizing and small cell subtypes of squamous cell carcinoma. lymph node metastases were found in carcinomas. hpv / infection was detected in of carcinomas, all were large cell keratinizing except one. no correlation was found between the hpv status and cadherin and catenin expression of the tumors. e-cadherin was negative in carcinomas, p-cadherin was positive in only carcinomas. strong cytoplasmic beta catenin positivity was revealed in carcinomas. alpha catenin reactivity was seen in of carcinomas. neither cadherins nor catenins expressions were correlated with other clinicopathologic variables. conclusion our results reveal that e-cadherin and p-cadherin expressions are lost in squamous cell carcinomas. however alpha and beta catenin immunopositivity in cervical squamous cell carcinomas might suggest catenins' role in tumor progression in a different way other than their activity in cell adhesion. prognostic significance of karyotype analysis in ovarian carcinomas e introduction traditional prognostic factors of ovarian carcinoma (oc) include disease stage, age, histologic grade and residual disease after surgery. at present it is quite difficult to predict the survival benefit of platinum analogues based chemotherapy. the aim of this study was to evaluate the clinicopathological / cytogenetic profile in a series of ocs and the reliability of karyotype in predicting benefit of chemotherapy and prognosis. materials and methods a series of ocs ( serous, undifferentiated, endometrioid, mucinous and one mixed carcinomas) was investigated for grade ( / : % vs / : %), stage (i/ii: % vs iii/iv: %), residual disease after surgery ( %), chemotherapy ( %), remission ( %) vs progression ( %) after chemotherapy and follow-up (mean: , range: - months). cytogenetics were performed on direct preparations using the qfq banding technique and describing abnormalities according to iscn. karyotypes were classified as diploid/near-diploid ( %) and complex (hyperdiploid, multiple cell lines, fragmented chromosomes) ( %). statistical analysis using chi-square and fisher test was done. statistical analysis demonstrated that low stage (p= . ) and low grade (p= . ) were predictors of good prognosis, while residual disease correlated with a poor outcome (p= . ). diploid/near-diploid karyotype correlated with a favourable prognosis (chi-square: . ). complex karyotypes appeared much more frequently associated with chemoresistance ( % vs %). conclusion our results confirm the correlation between grade, stage, residual disease and prognosis of ocs. in addition, these data suggest that a diploid/near-diploid karyotype might predict benefit of chemotherapy and favourable prognosis. introduction the aim of this study was to critically assess the progression-and recurrence rates of microinvasive (mic) stage ia cervical carcinoma, based on medline search, and to compare these data with our own experience on these tumours in ljubljana medical centre. in the published studies covering the years - , a total of . squamous cell mics were reported, including . stage ia lesions, . in stage ia , and cases of occult stage ib, classified according to figo or sgo classifications. our experience in ljubljana is based on the management of stage ia squamous cell carcinomas (scc), accumulated in the past years and early invasive adenocarcinomas (ac) collected in years. results in the reported . scc mic cases, lymphatic space involvement was recorded in ( %) cases, and in of those, the disease recurred, and progressed to death in patients. in series, mics were associated with ( . %) recurrences. in seven series, ( . %) cases of death due to cancer were reported. lymph node metastases were found in ( . %) cases. even when stage ia and ia carcinomas were treated with conservative surgical approach, very low risk of recurrence ( . %), lymph node disease ( . %), or death caused by cancer ( . %) was reported by these studies. most authors conclude that mic with the depth of invasion < mm, without confluent growth or lymphatic invasion can be safely treated with conization. during - lymphadenectomy was included in operations of mic in ljubljana. the pelvic lns were invariably free of cancer. the -year survival was %, while patients were lost to follow-up. in medline search . cases of stage ia acs were analysed in a -year period. lymph node metastasis were found in ( . %) of cases with lymphadenectomy, complicated with recurrent disease in ( . %) cases compared to the scc mic, the risk of recurrence in ac was considerably higher, . % and progression to death . % ( cases analysed by Östör, ). in our ac patients diagnosed in stage ia there was no recurrence or death of disease. conclusions according to the world literature and our own experience, the prognosis of mic of both squamous and glandular type is very favourable. this suggests that conservative management of stage ia cervical cancer is indicated and safe when strict evaluation of tumour extension and surgical margins of the cone are assured. agnor counts, histological and immunohistochemical characteristics of placenta in preterm delivery with live and dead newborns g burkadze, g turashvili, n meckhvarishvili tbilisi state medical university, tbilisi, georgia introduction the pathology of placenta constitutes one of the most poorly understood domains of general pathology. the significance of histological characteristics of preterm delivery is disputable. the aim of this study was to investigate histological and immunohistochemical characteristics and agnor counts of placenta in preterm delivery with alive and dead newborns. we studied placental tissues in preterm deliveries of live (first group) and dead (second group) newborns (n obstetrics clinic of tsmu, tsmu, - . paraffin sections were stained using h&e, agnor (bio-optica) and immunohistochemistry by ki- , cd , cd , bcl- (dako). results in the first group the number and area of chorionic villi was times lower, the number and area of villous vessels . times higher, the number of villous lymphocytes is . times higher, neutrophils . times higher, hofbauer cells . times lower, syncytiotrophoblasts . times lower (their area was the same), syncytial knots times lower (their area is times higher). the width of nitabuch layer was times greater, decidual tissue . times greater, the number of decidual cells was . times higher, decidual lymphocytes . times higher, neutrophils . times higher, macrophages . times lower, agnor(+) syncytiotrophoblastic cells . times lower, agnor granules did not differ, agnor(+) decidual cells times higher, agnor granules . times higher, ki- (+) syncytiotrophoblasts and cytotrophoblasts times higher. conclusion preterm delivery shows incoordination between proliferation and involution of placental tissue. in death of newborns, morphological changes reflect non-efficacy of adaptative-compensative reactions of chorion-decidual system. institute of pathology, charité university hospital, berlin, germany clontech laboratories inc., paolo alto, california, usa introduction the ubiquitously expressed actin-binding protein gelsolin is known to play a role in modulation of the actin network and regulation of cell motility and cell growth. decreased gelsolin expression occurs in transformed cells and in carcinomas of the colon, bladder, breast, lung and prostate. in the present study we analyzed expression of gelsolin in matched human normal and tumor tissues using a cancer profiling array. we found a decreased expression of gelsolin in cancer tissue of female reproductive organs including ovary. further we examined the expression of gelsolin in human benign and malignant ovarian tissues by immunohistochemistry, observing a diminished expression of gelsolin in borderline tumors and ovarian serous carcinomas compared to epithelium of normal ovaries and benign adenomas. in addition, low levels of gelsolin protein were observed in four of six ovarian carcinoma cell lines in contrast to immortalized ovarian surface epithelial cells. re-expression of gelsolin in the ovarian carcinoma cell lines oaw and es- resulted in a suppression of tumor cell survival in vitro. finally, we showed an up-regulation of gelsolin in ovarian cancer cell lines after inhibition of both dna methylation and histone deacetylation using -aza- 'deoxycytidine and trichostatin a, respectively. conclusion our results suggest that the gelsolin gene has a potential function as a class ii tumor suppressor gene in human ovarian epithelium. steroid cell tumor of the ovary: presentation of two cases i lekka, o tzaida, v leodara, a lountou, p arapantoni-dadioti, i iakovidou pathology department, metaxas cancer hospital of pireaus, piraus, greece two cases of steroid tumor of the ovary, diagnosed at our department during the last five years among a total of ovarian tumors, are presented. steroid cell tumors, previously classified as lipid or lipoid cell tumors are rare neoplasms of sex-cord-stromal origin derived in almost all cases from ovarian stromal lutein cells or from leydig cells and rarely from adrenal rest cells. they have been subclassified as steroid cell tumors not otherwise specified (nos), stromal luteomas and leydig cell tumors. in our report we present two cases of the nos subtype: one occurred in a -yearold woman and the other in a -year-old postmenopausal woman. both patients presented with a pelvic mass and signs of virilization (resulting effect of elevated serum testosterone). both tumors were composed of characteristic eosinophilic-granular or vacuolated (lipid rich) neoplastic cells lacking crystals of reinke and expressing the appropriate immunohistochemical phenotype. based on thorough pathological examination and evaluation of several findings such as tumor size, necrosis, haemorrhage, cellular atypia, mitotic activity, we classified the first case as a malignant and the second as a benign one. various aspects of the clinical and pathological presentation, differential diagnosis and treatment of these tumors are discussed. choriocarcinoma following term pregnancy uncommonly choriocarcinoma follows a normal pregnancy. the aim of this study was to stress the importance of a correct and rapid diagnosis which will allow a high rate of success in therapy for this neoplasm. material and methods histopathologic and immunohistochemical studies were performed to an endometrial curettage and a hysterectomy specimen. case report a -year-old female presented with uterine bleeding three months after a normal delivery from a term gestation in which placenta was not submitted for study. endometrial curettage was performed, and it showed a dimorphic population of atypical cytotrophoblast and syncytiotrophoblast cells. cytotrophoblast cells had pale cytoplasm with single nucleus, eosinophilic nucleoli and prominent mitotic figures. syncytiotrophoblast appeared as large multinucleated cells with polygonal basophilic cytoplasm. extensive necrotic and hemorrhagic areas were found. there was no presence of placental villi. neoplastic cells expressed strongly ß-hcg and cytokeratin. with a diagnosis of choriocarcinoma, hysterectomy was performed and showed areas of normal proliferative endometrium, and hemorrhagic areas with nests of trophoblastic neoplastic cells infiltrating among myometrial muscle. there was no involvement of cervix or adnexa. treatment was completed with chemotherapy, and one year after diagnosis the patient has not evidence of disease. conclusions the modern treatment with chemotherapeutic drugs is highly effective in complete cure of choriocarcinoma. therefore a quick histological diagnosis has a very important role to reduce the risk of metastasis disease, even avoiding surgery to preserve reproductive function. the mechanism of action and the histological features of uterine leiomyomas (ul) treated with gnrh are still a matter of debate. recent reports suggest that neovascularization induced by specific angiogenic molecules may play a role in the response to gnrh. also a reduced proliferative activity was observed and postulated as a possible histopathological feature of ul treated with gnrh. the aim of this study was to assess the possible role of angiogenesis and to quantify the percentage of proliferative cells in uterine leiomyomas in response to treatment with gnrh from premenopausic patients. material and methods a total of patients were studied, with two groups comprising samples each, including patients treated with gnrh and age-matched control patients. clinical (age, length of treatment, assessment of response to treatment by ultrasonography) and histopathological dates (microvessel density (vessels/mm ) and cellular proliferation assesed by ki- stain in cells were studied. the study group showed cd = , vessels/mm (mean) and ki- = , (mean). the control group showed cd = , vessels/mm (mean) and ki- = , . conclusion the leiomyomas treated with gnrh showed a) high number of microvessel density, b) low proliferative activity and c) significant reduction in size compared with patients without treatment. introduction evaluations of expression of apoptosis related oncogenes are being increasingly called upon in an attempt to better understand the carcinogenesis of cervical carcinoma and to provide possible prognostic information. the aim of this study was to analyze the expression of bcl- , p and mdm- oncoproteins and cellular proliferative marker ki- in early stage cervical carcinoma, with an emphasis on their association with human papillomavirus (hpv) infection, recurrence rate and lymph node status. material and methods using immunohistochemistry, radical hysterectomy specimens with cervical carcinoma (pt b /pt b ) were studied. evaluation of expression of p , bcl- , mdm- and ki- was performed in surface area, center and invasion front of the neoplasms. the hpv presence was determined by card in situ hybridization. results and conclusion in the invasion front bcl- was expressed in ( %), p in ( %) and mdm- in ( %) cases. hpv infection was detected in ( %) cases. carcinomas with a higher ki- labeling index were more frequently hpv positive than hpv negative ( . % vs . %, p< . ). no association was found between p , mdm- or ki- and either lymph node status or recurrence rate. negative staining for bcl- was associated only with the presence of lymph node metastasis ( % vs %, p= . ), and not with the recurrence rate. significant correlation among expression of bcl- , p , mdm- oncoprotein and ki- values was also observed. these results suggest that further study of a larger series is needed to confirm whether bcl- , either alone or in combined evaluation with other markers, could be a useful marker to identify more aggressive behavior in early stage cervical carcinoma. introduction during the past three decades, the incidence of cervical invasive primary adenocarcinoma (aca) has increased. at the same time, incidence of squamous cell carcinomas of the cervix decreased, due to early detection of their well documented precursors lesions. the aim of this study was to determine if dysplastic endocervical cells (ec) have neoplastic potential as a precursor lesions of adenocarcinoma in situ (ais) of the cervix. the malignant potential was determined by assessing the ploidy status, proliferative activity and c-myc expression in normal, dysplastic and malignant ec separately. patients and methods serial sections from patients with diagnosed ais or primary invasive aca were analyzed. one representative slide of cervix which showed normal, dysplastic and malignant endocervical glands simultaneously was chosen from each patient. determination of ploidy status and s-phase by flow cytometry and expression of c-myc oncoprotein by immunohistochemistry in normal, dysplastic and malignant ec was done. results the morphologicaly normal ec were diploid, with normal proliferative activity and no expression of c-myc oncoprotein. the dysplastic and malignant ec had a significant proportion of cells with aneuploidy, higher proliferative activity and c-myc oncogene overexpression. the χ test showed significant association of malignant ec with aneuploidy (p= . ) and high proliferative activity (p= . ). as one third of dysplastic ec are aneuploid, with high mitotic activity, they probably have malignant potential. dysplastic endocervical cells had statistically significant association with c-myc oncogene expression (p= . ). conclusion our results support the existence of pre-malignant glandular lesions while the immunohistochemical detection of cmyc oncoproteine could be helpful in detection of ec with malignant potential even without dysplastic morphologic changes. introduction the attempts to determine the prognostic significance of c-erbb- oncoprotein expression (ope) and its relation to human papillomavirus (hpv) infection in cervical cancer have yielded controversial. the aim of this study was to evaluate the patterns of c-erbb- ope in early stage cervical carcinoma and to assess its prognostic value by exploring its relationships to various clinicopathological characteristics, hpv status and recurrence rate. materials and methods radical hysterectomy specimens from cervical carcinoma patients (pt b / b ) were investigated immunohistochemically for c-erbb- presence. the c-erbb- score (range: - ) was determined in the surface area, center and invasion front of each carcinoma. card in situ hybridization was used for hpv detection. results and conclusion strong c-erbb- ope was detected in , , and cases in the invasion front, center and surface area of the tumor, respectively. there was a significant difference in positive staining rate of c-erbb- between squamous cell, mixed carcinomas and adenocarcinomas ( %, % vs %, p= . ). c-erbb- ope was significantly higher in carcinomas with abundant than in tumors with less abundant peri-tumoral lymphocytic infiltration ( . % vs . %, p= . ). in hpv positive carcinomas ( ), c-erbb- was detected more frequently in type / versus type / lesions ( % vs . %, p= . ). no association was found between c-erbb- expression and recurrence rate, lymph node metastasis or any other clinicopathological variable investigated (age, tumor diameter, depth of invasion, grade, vascular invasion). therefore, immunostaining for c-erbb- is unlikely to be of use as a prognostic indicator in early stage cervical carcinomas, while further study is warranted to examine relationships between hpv infection and c-erbb- ope. the predictive values of estrogen (er) and progesterone receptor (pgr) status and cell proliferation kinetics in cervical carcinomas are still unsettled. the purpose of this study was to clarify the associations among er/pgr status and ki- expression and to determine their relationship to human papillomavirus (hpv) infection, recurrence rate and other clinicopathologic parameters (age, tumor diameter, depth of invasion, histotype, grade, vascular involvement, inflammatory infiltrate, lymph node status) in early stage cervical carcinomas. materials and methods er, pgr and ki- immunostaining was performed in cervical carcinoma radical hysterectomy specimens (pt b /pt b ). er/pgr staining was scored in a semiquantitative fashion, while to evaluate the cell proliferation, the ki- labelling index (li) was assessed in the surface area, center and invasion front of each tumor. hpv status was determined by card in situ hybridization. results and conclusion er positivity was detected in ( %), while pgr positivity in ( %) carcinomas. er/pgr values were in correlation with ki- li in all three tumors' compartments (p< . ). in contrast to er/pgr status, ki- li was strongly associated with hpv infection (p< . ). no relationship was found between pgr or ki- immunoreactivity and either recurrence rate or any other clinicopathological variable investigated. nevertheless, reduced er expression was significantly associated with larger tumor diameter (p= . ) and poor differentiation (p= . ), as well as lymphovascular involvement (p= . ) and lymph node metastases (p= . ). these results suggest that er, pgr and ki- expression are closely related to neoplastic cell proliferation, probably induced by hpv infection. their determination may provide additional prognostic information in early stage cervical carcinomas. immunohistochemical assessment of heat shock protein expression in epithelial ovarian carcinomas: relationship with apoptotic markers as over-expression of bcl- and p purpose heat shock proteins (hsps) occupy a central role in the regulation of intracellular homeostasis and especially hsp and hsp are potent antiapoptotic proteins. overexpression of hsp protects cells from stress-induced apoptosis. the aim of this study was to determine the distrubition pattern of hsp -expression in ovarian carcinomas by immunohistochemistry and to evaluate its relationship with the prognostic parameters and over-expression of bcl- and p proteins. materials and methods thirty-five patients with ovarian carcinoma were included in the present study. expression of hsp was assessed by immunohistochemistry. the relationship between expression of these proteins and other prognostic markers such as stage was evaluated. results hsp was expressed in all of ovarian cancer cells with different intensity. the staining was localized in the cytoplasm and/or nuclei. there was a negative correlation between stage and both intensity of hsp positivity and bcl- positivity (respectively: r= - , ; p< . ; r= - . , p< . ). intensity of hsp positivity was statistically associated with bcl- positivity (r= . , p< . ). there were no significant associations between p positivity and bcl- positivity, intensity of hsp or stage of ovarian carcinoma. conclusions these data show that the intensity of hsp positivity was significantly stronger in early stage than in advanced stage ovarian carcinomas. hsp expression detected by immunohistochemistry was correlated with bcl- expression but not with p protein expression. background avb integrin and pinopodes have been proposed as new markers of endometrial receptivity. there is also a very limited experience on the responses of these markers to hormonal therapies. the aim of this study is to evaluate the effect different hormone replacement treatment on these markers. design we studied fertile controls and women with ovarian failure receiving hormone replacement therapy (estradiol valerate (ev) and vaginal progesterone (vp), group e+ep). those women were divided randomly into two subgroups of patients. group e+p received ev for days and vp alone for days. group e+p+ep was given e+ep therapy but including episodic vp on days and . all women underwent two endometrial biopsies during a single menstrual cycle (days + to + and four days later). avb integrin was detected in frozen tissue using the envision system. pinopode formation was evaluated in tissue fixed in glutaraldehide using a zeiss dsm a scanning electron microscopy. both avb integrin and pinopode formation were semiquantitatively evaluated. results patients in group e+p+ep showed markedly decidualized endometria in the midluteal biopsy and a significant increase of avb integrin expression (p= . for both parameters). no significant changes in pinopode formation were observed in midluteal biopsies. no differences were observed in late luteal biopsies. conclusions avb integrin expression and pinopode formation are signs of endometrial maturation related to progesterone action but their significance in terms of endometrial receptivity in the clinical setting remains to be shown. supported by grant pi (fondo de investigaciones sanitarias). gestational trophoblastic diseases (gtd) are extremely rare conditions, especially the ones associated with ectopic pregnancies (ep). case reports only three cases ( . %, / ) of gtd associated with ep were diagnosed at the department of histopathology and clinical cytology in the last years. the first patient, age underwent salpingectomy for clinical suspicion of tubal pregnancy, whereas in the second, age hysterectomy with bilateral salpingo-oophprectomy (hsop) was performed for a clinical diagnosis of ovarian endometriosis. the third patient, age underwent hsop for malignant ovarian tumour which metastasised to lungs. pathological findings: chorionic villi were found in the tubal lumen of the first patient, showing marked hydropic degeneration, reduced/absent vascularisation and excessive trophoblastic cell growth. diagnosis of partial hydatiform mole was established, and the patient remained under surveillance for the hcg level. atypical trophoblastic cells, which penetrated the full thickness of the tubal wall and invaded the ovarian blood vessels of the second patient, led to the diagnosis of an invasive mole. the third patient was diagnosed with choriocarcinoma due to the presence of a tumour consisting of malignant trophoblastic cells that infiltrated the right ovary, tube and uterine cornu. the last two patients received chemotherapy and have been well for and months, respectively. conclusion due to extremely low incidence of gtd associated with ep, these entities are rarely clinically recognised. therefore, a careful histopathologic examination of the adnexal masses is essential for the establishment of the correct diagnosis and further treatment of the patients. in an organized screening programme for cervix cancer the diagnosis atypia (ascus) has always been a problem. the subsequent histological examination shows different diagnoses, such as negative, inflammation, cin i-iii (sil) and carcinoma. in the county of funen, a well-organized screening programme has existed since .using the cytological diagnosis of atypia, we distinguish between atypia (asc-us) probably inflammatory and atypia (asc-h) probably dysplasia. in previous studies on papsmears we have shown histological follow-up diagnoses for atypia (asc-us): negative . % and cin i-iii . %, and for atypia (asc-h): negative . %, cin i-iii % and carcinoma , %. since june we have implementated liquid-based cytology (lbc) thinprep, cytyc. the aim of this investigation is to show the histological follow-up diagnoses of cytological atypia when using lbc-technique. the total number of lbc-samples in were examined. the recommandations for atypia are a repeated cervical sample, and for persistent atypia or atypia colposcopy, cervical biopsies and abrasion within months. in a total of , smears, including , lbcsamples, were examined. the diagnoses of the lbc-samples were: negative , %, inadequate , % (a reduction of % compared with pap-smears), atypia , % and cin i %. preliminary histological follow-up diagnoses for atypia and were: negative % and cin i-iii %. conclusion thinprep shows two significant advantages: a markedly reduced number of cytological atypia diagnoses ( %) compared with pap-smears and a higher diagnostic quality with fewer false positive diagnoses. introduction ovarian sertoli-leydig cell tumors (slct) are very rare sex cord-stromal tumors and among them, tumors with heterologous sarcomatous elements are exceptional. aims: a unilateral ovarian stage ic slct with heterologous mesenchymal elements is presented. materials and methods a -year-old woman, para , was admitted to hospital with severe abdominal pain. at laparotomy, resection of a large right ovarian cyst was carried out. histological examination revealed a slct, and subsequently surgical staging was performed. no adjuvant therapy was given. at years followup she was well and without signs of recurrence. routine staining of slides from paraffin blocks and immunohistochemistry (ihc) were available. results gross examination revealed a x x cm large multilocular ovarian cyst with smooth interlocular septa and outer surface. microscopy disclosed a slct of intermediate differentiation with a very few leydig cells. major areas consisted of a hypocellular stroma with edema, hemorrhage and necrosis. in a few sections small foci of cartilage were seen. in a number of sections groups of small cells with indistinct cytoplasm and hyperchromatic nuclei were present. mitotic and apoptotic figures were common. ihc revealed a positive reaction for desmin, myf and myogenin, indicating rhabdomyosarcoma of embryonal type. conclusion the most important prognostic factors of slct are stage and grade of differentiation. variants of slct with immature skeletal muscle are often fatal. ihc with myf or myogenin with a high sensitivity and specificity for rhabdomyosarcoma, combined with inhibin is very important in differing immature sertoli cells from rhabdomyoblasts, in order to diagnose the rhabdomyosarcoma and to grade the slct correctly. expression of the nerve growth factor (ngf) receptors trka and p shows biological diversity in ovarian, breast and mesothelial malignancy b davidson , r reich , p lazarovici , va florenes , m skrede , b risberg , c bedrossian , jm nesland the norwegian radium hospital, oslo, norway department of pharmacology, hebrew university, jerusalem. israel department of pathology, northwestern university, chicago, il, usa neurotrophins and their receptors are known to have a central role in biologic processes in the nervous system. however, recent studies have additionally highlighted the role of ngf and its receptors trka (inducer of proliferation) and p (inducer of apoptosis) in the development and progression of malignant tumors, including those of non-neural origin. we studied protein expression of p and activated phosphorylated trka (p-trka) in serous ovarian carcinomas ( effusions, solid tumors), breast carcinomas ( effusions, solid tumors) and malignant mesotheliomas (mm) ( effusions, biopsies) using immunohistochemistry and immunoblotting. p-trka was expressed in ovarian carcinoma cells in effusions in only / ( %) specimens, compared to / ( %) solid tumors, while the opposite was true for p . in contrast, p-trka membrane expression was higher in effusions (p= . ) of mm patients, while the opposite was true for p (p= . ). in addition, p-trka (but not p ) expression was significantly higher in peritoneal mm compared to their pleural counterparts ( / vs. / positive tumors; p= . ). in breast cancer, p-trka expression in effusions was significantly higher than in primary tumors (p< . ) and lymph node metastases (p= . ), while p expression was lower in both effusions (p= . ) and primary tumors (p= . ) compared to lymph node metastases. our results provide the first evidence regarding the role of nfg receptors in tumor progression through site-specific changes in expression. specifically, they may provide biologic evidence for the uniformly and rapidly fatal outcome of breast cancer patients with effusions and of mm patients. the significance of mast cells in the differential diagnosis of uterine smooth muscle tumors bh ozdemir aim to assess the role of the mean mast cell count in the differential diagnosis of uterine smooth muscle tumors. material and method twenty-cases of ordinary leiomyoma, cases of atypical leiomyoma, cases of leiomyosarcoma, cases of mitotically active leiomyoma and cases of cellular leiomyoma were included in the study. the morphological features and clinical presentation was evaluated retrospectively. toludine blue stain was used to highlight the mast cells in the endometrium, myometrium and smooth muscle tumors. at least high power fields were counted. results considerable variation in mast cell numbers was found among smooth muscle tumors (p< . ). the intratumoral mean mast cell count was found significantly higher in ordinary leiomyomas ( . ), when compared with other tumors, including atypical leiomyoma ( . . ), mitotically active leiomyoma ( . ), cellular leiomyoma ( . . ) and leiomyosarcoma ( . . ) (p< . ). no significant differences were found between these tumor groups in regards of the mean mast cell count of endometrium and myometrium adjacent to the tumor. in the endometrium, a drop in the number of mast cells has been demonstrated with advancing age, particularly after menopause (p< . ). in addition cases showed eosinophilia, cases showed basophilia and cases showed allergic reactions to different causes. a significant positive relationship was found between the intratumoral, myometrial mast cell number and basophilia. conclusion these data suggest that intratumoral mast cell quantitation may allow the differential diagnosis in uterine smooth muscle tumors. ovarian carcinoma is the most frequent cause of death in the world among gynaecologic malignancies. diagnosis is usually late, and the biological behaviour is highly variable, depending on several factors such as the histopathological grading, the local and/or peritoneal spread and the proliferation rate. we choose a list of genes involved in cell growth and proliferation (igf , igfbp , ctnnbeta , cdk- c, fgfr ). among these, so far, we analyzed igfbp gene and studied loss of heterozygosity (loh) in tumour tissue in order to identify potential relevant genes in ovarian cancer homeostasis. twenty cases of formalin fixed, paraffin embedded ovarian carcinomas from the archives of the department of pathology of padova university and five effusions (from peritoneal or pleural recurrences) of ovarian carcinomas, were selected for this study. genomic dna and tumour dna for each case were extracted from blood cell, tumour or not-cancer surgery biopsy. loh was searched using published single nucleotide polymorphism (snps) in igfbp gene. pcr product covering the snps from genomic and tumour dna were dhplc separated. three of the twenty patients whose tumour dna was obtained from paraffin material, were heterozygous at nucleotide c/a (dbsnp ref. n. ) and a/c (dbsnp ref. n. ) of the igfbp gene in genomic dna. analysis of tumour dna failed to reveal loh (preserved heterozygosity). in effusion cases, one of five patients showed heterozygosity at the same nucleotides. in these patients, loh was also not identified. our preliminary results suggest that dhplc analysis for loh is feasible, rapid and maybe of potential interest in the identification of genes involved in ovarian cancerogenesis. the progression of low grade squamous intraepithelial lesion (l-sil) to high grade squamous intraepithelial lesion (h-sil) occurs in around % of cases. there are no morphologic changes to predict this progression. aims: to study whether the ki immunostaining pattern and labeling present upon diagnosis of l-sil is able to predict the regression or persistence/progression of the lesion to h-sil of the cervix over a two year period following diagnosis. materials and methods cervical biopsies from patients diagnosed cytologically as cervical squamous intraepithelial lesion (sil) were used. biopsies were performed immediately after the cytological diagnosis resulting in l-sil and h-sil. ki immunostaining was performed on all cases and was classified as suprabasal immunostaining pattern (sbip) for cases without ki- immunoreactive cells in the upper two thirds of the epithelium thickness, or dispersed immunostaining pattern (dip) for cases with ki- immunoreactive cells in the upper two thirds of the epithelium thickness. nuclei in hpf including the total thickness of the epithelial layer of each sample were counted to determine the mean number of cells which reacted against ki- antibody. in situ hybridization was used to demonstrate the presence of hpv and its typing. chi square test, fisher's exact test and student t test were used for statistical analysis with significance set at p< . . results of the biopsies performed cases resulted in l-sil ( s-bip and dip patterns) and in h-sil. % of the l-sil cases that resulted in a s-bip pattern showed persistence/ progression of the lesions while % of the cases that resulted in a dip pattern showed persistence/progression of the lesions. the difference between these values where statistically significative (p< . ). regarding ki- labeling index (li) in l-sil cases, we found that % of the cases ( out of ) with a ki- li less than % persisted/progressed, while % of cases ( out of ) with ki- li over % persisted/progressed. in this case there was also a statistically significative difference (p= . ). we found no statistical differences (p= . ) regarding hpv "in situ" hybridization. % of the cases ( out of ) where hpv was detected by in situ hybridization persisted/progressed while % of the cases did not show hpv by hybridization. conclusions the l-sil cases which showed dip and high ki- li were significantly related with persistence or progression to h-sil of these lesions, while l-sil cases which showed sbip and low ki- were significantly related to regression of the lesions. therefore, we conclude that ki- immunostaining pattern may be of prognostic value to predict regression or persistence/progression of l-sil. introduction sclerosing stromal tumor (sst) of the ovary is a rare tumor. it was first described by chalvardjan and scully in as a distinct subtype in the thecoma-fibroma group. most ssts occur in young patients below the age of years. the most common clinical symptom in patients is menstrual irregularity. in differential diagnosis, thecoma, fibroma, and hemangiopericytoma must be considered. aim: in this report, cases of sst of the ovary were described and compared with other ovarian tumors. material and methods two cases of ovarian sst were examined. the first case occurred in a -year-old female. at operation, the patient was found to have the ovary replaced by a tumor mass measuring x x cm. the second case occurred in a -year-old woman and the tumor mass measured x x cm. the surgical material was fixed in % formaldehyde solution and prepared for paraffin sections. in addition to h&e staining, immunohistochemical analyses were performed. results the clinical features, gross features, light microscopic findings and immunohistochemical results were described and compared with literature. the findings were consistent with sst, which is a very rare tumor of the ovary. the tumor cells showed positive staining for vimentin and desmin. we discuss the results and differential diagnosis. unususal chorangioma of the placenta -a case report w pokieser , w umek , r jahn , w ulrich institut of pathology, lainz hospital, vienna, austria institut of pathology, department of obstetrics and gynecology, university of vienna, austria chorangiomas (ca) are common lesions, occurring in of placentas. it is not clear whether ca are hyperplasias, hamartomas, or true neoplasms. depending on their size and location, they may be devoid of symptoms or may cause difficulties for the infant and the mother. we describe a case of manual removal of the placenta in association with ca. on gross examination the tumor had a nodule-in-nodule appearance and was histologically composed of two well defined nodules. the larger, outer one had the appearance of an usual chorangioma; the inner nodule showed highly cellular vascular proliferation. this architecture might represent a morphological variant of the same disease. in the present case, the placenta had to be removed manually. it remains unclear if this was due to impaired contractility of the uterine wall or due to a lack of decidualisation, following a worse vascular support in the surrounding area of the ca. it can´t be excluded that placenta accreta was caused by strictures after cesarian section which had been performed at the first delivery two years ago. on the other hand a placenta with a nodule form of ca could be less elastic than a placenta with regular architecture. however manual removal of the placenta may be regarded as a further complication of ca's larger than cm in diameter. are muc and muc ac reliable markers in the differential diagnosis of primary and metastatic ovarian carcinomas? a ensari , d ergun , a yorganci , a sertcelik , f ortac , n kursun ankara university medical school, department of pathology, ankara, turkey ankara university medical school, department of gynaecological oncology, ankara, turkey numune hospital gynaecology department ankara university medical school, department of biostatistic, ankara, turkey introduction aberrant expression of mucin glycoproteins has been observed during malignant transformation of human ovarian epithelium. however, there is limited information regarding the expression of these mucin proteins in primary and metastatic ovarian carcinomas. the aim of this study was to examine immunohistochemical expression of muc and muc ac mucin proteins in primary and metastatic carcinomas of the ovary in order to assess their value in the differential diagnosis. materials and methods forty eight ovarian tumours comprising surface epithelial carcinomas ( endometrioid, clear cell, serous papillary and mucinous type) and metastatic carcinomas of gastrointestinal primaries were included in the study. the age of the patients, the histological type and grade of the tumours were evaluated in relation to the expression (percentage distribution and staining intensity) of muc and muc ac studied immunohistochemically. results muc was expressed in ( . %) primary ovarian tumours while muc ac was expressed in ( %) primary tumours in comparison to % expression of muc and . % expression of muc ac in metastatic ovarian tumours. the differences in muc expression between non-mucinous ( . ± . ) and metastatic tumours ( . ± . ) and metastatic and mucinous tumours ( . ± . ) were statistically significant (p< . ). the difference in muc ac expression was statistically significant (p< . ) between non-mucinous ( . ± . ) and mucinous tumours ( . ± . ). conclusion muc proves to be highly reliable in the differential diagnosis of primary and metastatic mucinous tumours of the ovary. deregulation of sfrp and sfrp rna-expression in endometrial stromal sarcoma introduction endometrial stromal sarcomas (ess) are very rare uterine tumours. whereas histology and immunohistochemistry of this tumour are well documented, little is known about molecular mechanisms involved. to characterize ess-altered genes, we generated a genome-wide library by ssh-hybridisation and used it to produce cdna arrays. particular emphasis was also placed on data obtained from qrt-pcr analyses. materials and methods using ssh-library a gene-bank with app. different clones was established. total rna was extracted from frozen tumour tissue and used for cdna hybridisation. qrt-pcr analyses were performed both on frozen and paraffin-embedded tissue samples. results after cdna-array analysis more than genes were selected, sequenced and rearranged to different functional groups. among the most strongly deregulated genes were secreted frizzledrelated protein- (sfrp ) and sfrp . these are putative genes that regulate wnt-signalling pathway and can influence different cell events including cell proliferation. compared to post-menopausal endometrium the expression of sfrp and sfrp was increased in low-grade ess, but decreased in aggressive ess form. these results were additionally verified on paraffin embedded tissue probes by qrt-pcr analysis. conclusion deregulation of sfrp and sfrp expression appears to be one of the crucial features of ess. whereas in low-grade ess these two genes are up-regulated, their down-regulation could be associated with high-grade form of ess. therefore a sfrp and sfrp may not only represent useful markers for early ess diagnosis but may also have prognostic impact and help to distinguish between low-and high-grade ess. (this work was supported by lore-saldow -research fund) introduction fgt-cs is a highly malignant neoplasm with poor response to current chemotherapy. the proto-oncogen c-kit encodes a transmembrane-tyrosine-kinase (t-k) receptor involved in cell diferentiation, that has been found to be expressed in certain solid tumors and may play a role in their tumorigenesis. a t-k inhibitor specific for c-kit (sti ) has been reported to have therapeutic effects in tumors expressing the aberrant forms or high quantities of target protein. contradictory results are reported in the literature about the expression of c-kit in cs. the aim of this study was to investigate the immunoreactivity for c-kit in cs. immunostaining with anti-c-kit (cd ) polyclonal antibody (dako) was evaluated in cs ( endometrial, ovarian, cervical and tubal). only cases with membrane staining were considered to be positive. results c-kit was expressed in cases: in cases only in the carcinomatous component ( endometrial, tubal), in case only in the sarcomatous component (endometrial) and in case in both components (ovarian). positivity was focal and less than % of cells in all cases. conclusion cs of the female genital tract rarely express c-kit. it is unlikely that patients with these tumors will benefit from treatment with the currently avalaible t-k inhibitors. uterine heterologous sarcoma with the component of osteosarcoma on the base of lipoleiomyoma -a case report uterine homologous and heterologous sarcomas are rare neoplasms that are usually misdiagnosed as a component of malignant mixed mullerian tumor (mmmt). we present a case of a -year-old woman who had a heterologous sarcoma with a component of osteosarcoma on the base of lipoleiomyoma, that can be differentiated from mmmt by the absence of epithelial component. in heterologous sarcomas, the other components of neoplasm are rhabdomyosarcoma, chondrosarcoma, osteosarcoma, liposarcoma and combined forms. these neoplasms are misdiagnosed as endometrial stromal sarcomas or as a component of mmmt. they are more agressive than mmmt. immunohistochemical detection of er-β in ovarian sex cord-stromal tumors introduction since the discovery of a second subtype of estrogen receptor, er-beta (er-β), in , approximately years after the cloning of er-α, several reports have been published regarding the tissue distribution of this receptor. in mammals so far studied er-β predominates in the ovary. high expression of er-β was observed by in situ hybridization or immunohistochemistry in granulosa cells of the ovarian follicles. the aim of the present study was to examine immunohistochemically the expression of er-β in ovarian sex cord-stromal tumors. materials and methods ten cases of ovarian granulosa-stromal cell tumors (five adult granulosa cell tumors, two juvenile granulosa cell tumors, and sclerosing stromal tumors) and two cases of sertoli-leydig cell tumor were immunostained for er-β (polyclonal erb , biogenex). representative sections from ten cases of ovarian carcinomas were immunostained for comparison. results positivity for er-β was observed in % to % of the nuclei in adult granulosa cell tumors and % to % of the nuclei in sclerosing stromal tumors. only - % of the nuclei from juvenile granulosa cell tumors were positive for er-β. in sertoli-leydig cell tumors positivity was more extensive in areas of diffuse growth. four cases of ovarian carcinomas exhibited positivity. conclusion positivity for er-β is a common finding in ovarian sex cord-stromal tumors. these findings might have therapeutic implications. adult fibrosarcoma of the vulva ol mejia mejia instituto nacional de cancerología, bucaramanga, colombia introduction sarcomas are rare and unusual lesions of the vulva. the aim of this study was to present a case with analysis of clinical, morphologic and immunohistochemical findings. materials and methods a -year-old female patient presented a rapidly growing of a mass in the pubis and left labium major of vulva of x x cm associated with a second satellite lesion ( months later) in the right inguinal area of x x cm. results histologic examination of both lesions disclosed a malignant neoplasm composed of uniform and orderly spindle cells with occasional epithelioid cells, oriented in curving or interlacing fascicles, forming a herringbone pattern with mitotic figures ( / hpf) and areas of necrosis and hemorrhage. the immunohistochemical profile showed strong reactivity for cd and vimentin, and focal and weak reactivity for smooth muscle actin. immunoexpression for s , nse, bcl- , hmb- , melana, ae ae and desmin was lacking. discussion and conclusions we present a case of a malignant mesenchymal tumor of vulva. due to histological features and behavior, pathologists must discard others spindle cell tumors, such as malignant melanoma, malignant peripheral nerve sheath tumor, monophasic synovial sarcoma or leiomyosarcoma. fibrosarcoma is a diagnosis of exclusion and a wide immunohistochemical panel is useful to make differential diagnosis. introduction serous tumors of borderline malignancy (stbm) of the fallopian tube are exceedingly rare. we report a case of stbm of fallopian tube in a -year woman. material and methods a -year old woman was found to have right adnexal mass on her routine gynaecologic examination. serum ca- was not elevated. at laparoscopy a swollen fallopian tube was removed. during the operation a fine needle aspiration was performed. the cytological findings of the adequate giemsa-stained smears were recorded. haematoxylin and eosinstained sections from the routinely fixed and paraffin embedded surgical material were histologically analysed. results a papillary tumor, with maximal diameter of cm in the dilated part of the fallopian tube toward the fimbrial end, was found. histologic features of the tumor were similar to the atypical proliferative serous tumor of the ovary. two years after the operation the patient is well, without evidence of the disease. conclusion to the best of our knowledge only four cases of stbm of fallopian tube have been reported. our case is unusual due to lack of any symptoms. recent studies have suggested that in the setting of an unknown primary, cdx- immunostaining may be used in identifying a metastatic carcinoma as colonic in origin. aim: we sought to evaluate the immunoreactivity of cdx in a series of primary and metastatic ovarian mucinous neoplasms. materials and methods cases of mucinous tumour of the ovary, including benign cystadenomas, borderline mucinous tumours and mucinous adenocarcinomas, were tested for cdx immunoreactivity. cases of serous and endometrioid lesions as well as cases of ovarian metastases from colonic adenocarcinoma were also evaluated. results cdx immunoreactivity was detected in / ( %) cases of primary ovarian mucinous tumour. particularly, / ( , %) cases of cystadenomas, / ( , %) cases of borderline tumours and / ( , %) cases of adenocarcinomas were immunostained. immunoreactivity was usually related to an intestinal morphology. no immunoreactivity was observed in serous or endometrioid lesions whereas all five cases of ovarian metastases from colonic adenocarcinoma were immunoreactive for cdx . conclusions cdx immunoreactivity may be detected in the majority of benign, borderline and malignant ovarian mucinous tumour whereas serous and endometrioid lesions are unstained for this marker. cdx immunoreactivity is not useful in distinguishing between primary and metastatic ovarian mucinous carcinomas whereas it may be useful in the distinction between endocervical and intestinal type of mucinous tumour of the ovary, which may have clinical relevance. an ovarian primary should be added to the list of cdx positive metastatic carcinoma in the setting of an unknown primary. expression of p ink a in serous lesions of the female genital tract c heffron introduction a spectrum of serous lesions including benign, borderline and malignant tumours and endosalpingiosis commonly arise in tissues of the female genital tract. p ink a is a tumour suppressor protein which functions as a cyclin dependent kinase inhibitor and plays a vital role in the cell cycle control at the g /s phase transition. although well recognized as a discriminator of benign and potentially malignant squamous and glandular cervical lesions, the expression of p in ovarian lesions and their mimics is less well established. the aim of this study was to evaluate p ink a expression in serous lesions of the female genital tract and to investigate its potential diagnostic utility. methods immunohistochemical analysis of p ink a (mouse monoclonal anti-p antibody) was performed on cases of serous epithelial lesions of the female genital tract (n= ) comprising endosalpingiosis, borderline serous cystadenomas of ovary and peritoneum, benign serous cystadenoma of ovary, serous adenocarcinoma of ovary and peritoneum and normal fallopian tube epithelium. results all cases of endosalpingiosis were positive (definite cytoplasmic staining with occasional nuclear positivity) for p ink a expression, as were all normal fallopian tube epithelium samples. varying degrees of p ink a expression were found in the serous neoplasms examined, with no clear pattern associated with any histological subtype. conclusion diagnostic difficulties may arise in the distinction between benign serous glandular lesions and more sinister potentially malignant serous neoplasms. in this study the pattern and degree of expression of p , although showing some differences, does not allow definitive classification of these lesions. epithelioid trophoblastic tumor [ett] is an unfrequent gestational trophoblastic disease [gtd], whose epithelial-like cells derive from chorionic-type intermediate trophoblast. ett mostly shows a benign behaviour, but metastases have also been reported, and pathologic prognosticators are not as yet recognized. the kinase-inhibitor p kip has been seen to be lacking in malignant gtds, while different growth factors, such as the c-kit receptor, have been related to growing trophoblasts of p -null embryos. since c-kit is said to promote trophoblast growth and invasiveness, this study was aimed at immunolocalizing p and c-kit in ett, as compared to a proliferation antigen. materials and methods -after a preterm birth of a living infant, a -year-old woman underwent hysterectomy for a postpartum metratonia. the patient had an antecedent miscarriage. a cervical ett was found, and immunohistology was performed on paraffin sections, using c-kit, p , and ki antibodies, following a microwave antigen-unmasking. positive reactions were recorded either as a focal or diffuse immunostaining. an escavated, hemorrhagic, endocervical lesion was found, which focally infiltrated the myometrium. light microscopy showed poorly limited nodules of epithelial-like cells, arranged in cords and nests, with interposed hyaline material, extensive hemorrhages, and necrotic areas. atypical mononucleate and syncytiotrophoblastic cells occasionally occurred. immunohistology revealed a diffuse presence of c-kit-expressing tumor cells. the p nuclear staining was focally observed to be negative or weak, and ki was totally unlabeled. in conclusion, this slowly-growing ett is lacking in p , but the c-kit over-expression substantiates trophoblastic survival and invasiveness. carcinosarcomas of the corpus uteri r balan, c amalinei, c cotutiu histology department, university of medicine and pharmacy, iasi, romania the aim of our study was to analyze the clinical and morphological characteristics of carcinosarcomas of the corpus uteri. carcinosarcomas of the corpus uteri were studied in postmenopausal women. paraffin-embedded material was stained with hematoxylin and eosin, trichromic, reticulin and pas staining. antibodies against ema, cytokeratins, vimentin, desmin, and pcna were also used. the size of tumor, depth of myometrial invasion, presence of vascular invasion, necroses, cellular atypia and differentiation, and mitotic activity were analyzed. all tumors were characterized by large size, foci of hemorrhage and necrosis. morphological and immunohistochemical analysis proved biphasic structure of the tumors. epithelial component was represented by adenocarcinomas with high ( cases) and moderate ( case) degree of differentiation. all presented homologous pattern -leiomyosarcomas. no metastasis was encountered at the time of diagnosis. as ema was intensely positive, both in malignant epithelium and in the majority of stromal component, we conclude that carcinosarcomas of the corpus uteri represent combination tumors with both elements originating from a single common stem cell. this conclusion was emphasized by the presence of pas positive residues in both components. knowledge evaluation among albanian women on risk factors of cervix cancer k kule , n filipi institute of public health, unit of cancer, department of epidemiology, tirana, albania university hospital 'mother tereza', tirana, albania aim this study evaluates the rate of awareness of women on risk factors and the preventive ways for the cervix cancer. methods the data were obtained through the questionnaire in a sample of women aged - years randomly selected throughout albania (random cluster sample). the questionnaire included questions on: social-demography, sexual behavior, women health, and sources of the health information. results only % of interviewed women were informed on paptest. in % of cases it was the doctor notified the women of the cluster for this screening as an examination of cervix cancer prevention. the pap-test examination had been performed by only % of the women who had prior knowledge on pap-test. in about % of cases the examination was performed for diagnostic reasons and not for prophylactic control reasons. in proportion to total only . % had performed the test, which presents a very problematic situation. among the women who performed pap-test, % were aware of the need of periodical check-up every - year, but % of them never performed it. the reason for not doing periodical screening seemed to be the daily routine and fear of the unknown events. % of women who performed pap-test were from the cities. only % of women use contraceptive methods of the family planning. about % of women had undergone at least one abortion. conclusions the study supports the concept that information on health services as well as health education of women at risk plays an important role in early detection and prevention of cervix cancer. expression of checkpoint proteins p , hus- and rad- and its relation with apoptosis in ovarian epithelial tumours introduction eukaryotic cells show surveillance mechanisms (checkpoints) of genomic integrity. an impaired checkpoint has been linked to genomic instability, and, in higher eukaryots has been associated to risk of cancer. the genes to be studied are involved in the mitotic checkpoint and dna damage checkpoint (like p , the tumour supressor gene frecuently mutated in human cancers). these proteins are also involved in the checkpoint responding to incomplete dna replication (replication checkpoint) termed the rad/hus group of proteins. failure of this checkpoint progress can result in genomic instability, and, in higher eukaryotes may lead to tumorigenesis or certain degenerative disease states. material and methods we have obtained antisera against recombinant hhus and hrad . for this we will clone and overexpress in bacteria and immunize animals to obtain antisera. we will carry out extensive analysis of the expression levels of several proteins by western blot analysis. we looked for possibles associations among hus- and rad- immunohistochemical expression and prognosis in ovarian carcinomas prior to chemotherapy. we studied, in addition to the levels of expression of the mentioned proteins, the localization and modifications of these proteins in epithelial ovarian tumours (benign, borderline and carcinomas) in order to establish the probable relationship between these proteins and ovarian carcinogenesis. results increased levels of checkpoint hus- protein was related to malignant transformation across all types of ovarian carcinomas (p< , ). similar results were observed with the expression of rad- protein, however was not statistically significant (p> , ). in univariate survival analysis, the expression of hus- and rad- protein were not significantly correlated with shorter survival and shorter free period of illness (p> , ). there were positive correlation between the apoptotic index, p and bax and the expression of checkpoint protein hus- (p< , ), but none relation was detected with rad- expression (p> , ). conclusions -the expression of hus- is higher in ovarian carcinomas and low in benign and borderline tumours. -the expression of hus- shows a positive correlation with the apoptotic index and with the pro-apoptotic factors (p and bax). -there was not statistical significant differences in the expression of hus- and rad- among the different histological types of ovarian tumours. -there was a positive correlation between the expression of hus- protein with other prognostic factors such as the figo stages, and the histological grade. unilateral gonadoblastoma associated with , xy pure gonadal dysgenesis (swyer's syndrome): a case report with numerous microcalcifications. the patient underwent bilateral salpingoophorectomy and total hysterectomy. the authors underline the importance of the correct diagnosis and the need of bilateral salpingoophorectomy for preventing the possible progression of the gonadoblastoma into malignant germinal cell tumor. histological and electron microscopic identification and analysis of uncommon particles in tissue after use of orthopaedic implants introduction deposits of solid products occur widely in tissue either from endogenous sources due to pathological changes, or from exogenous sources. after use of orthopaedic implants, particles produced by wear are commonly recognizable and identifiable in tissue by the surgical pathologist. foreign body related tissue re actions may contribute to aseptic loosening of implants, which is regarded as one of the most significant complications in orthopaedic surgery. in the present study we report on very uncommon particles in periprosthetic tissue after aseptic loosening of metallic implants. our study was performed to identify particles in periprosthetic tissue and to clarify whether they may contribute to the loss of implants. materials and methods periprosthetic tissue including joint capsule, acetabular and femoral interface membranes of cases of aseptic loosened cementless total hip replacements was histologically investigated. four cases with present uncommon particles were selected for electron microscope investigation and dispersive x-ray analysis. results in four cases the histological investigation revealed uncommon green to yellow coloured foreign bodies. by the use of electron scanning microscopy and energy dispersive x-ray analysis, these particles were identified as deposits rich in chromium, phosphorus and oxygen. this detection indicates the presence of solid corrosion products derived from implant surfaces. conclusion particles produced by wear and/or corrosion are associated with an alteration of the environment and the development of periprosthetic osteolysis which may result into the loss of the implant. the surgical pathologist should be aware that corrosion products may occur. their identification is helpful to determine implant failures. paratesticular lipoleiomyosarcoma: a case report l kachko, r shaco-levy, i sinelnikov, j goldstein department of diagnostic pathology, soroka medical center, beer-sheva, israel introduction leiomyomatous differentiation in liposarcoma is a rare phenomenon and may occur as a well differentiated liposar-coma with an intrinsic malignant smooth muscle component, so called " lipoleiomyosarcoma" or in the context of "dedifferentiated" liposarcoma. material and methods we have studied a paratesticular lipoleiomyosarcoma in a man years old. gross examination revealed tumor nodules dispersed between identifiable testis and epididymis, the largest of which measured x x cm. the specimen cut surface revealed smooth yellow tissue with distinct areas of gray myxomatous change. microscopically the specimen consisted of a well differentiated lipoma-like, sclerosing liposarcoma with mature adipocytes and fibrous septa containing spindled and floret-like cells. the smooth muscle accounted for about % of the total tumor mass and consisted of fascicles and bundles of spindle cells with very little atypia or pleomorphism. mitotic activity was moderate at most and focal in distribution. the cells colored well with immunohistochemical stain against sma. results and conclusions an extraordinary rare combination-type tumor is presented. only two previous examples of paratesticular lipoleiomyosarcoma have been published. the nature of combination-type tumors and dedifferentiated liposarcoma is addressed. the existence of two lines of tissue differentiation in the same tumor suggests the possibility of two separate tumors arising together or two lines of differentiation appearing from one pluripotent precursor cell. the differential diagnosis includes angiomyolipoma, which should be hmb positive. expression of estrogen receptor (er) and progesterone receptors (pr) in renal angiomyolipoma n savelov, g chemeris, i sokolova cancer research center, moscow, russian federation introduction angoimyolipomas are the most common mesenchymal tumours of kidney. they are more common in female. possibly estrogen and progesterone influence on tumours growth. we investigated the expression of estrogen receptors (er) and progesterone receptors (pr) in renal angiomyolipomas. materials and methods renal angiomyolipomas from patients were tested. the expression of er and pr was studied immunohistochemically. the expression of hmb- , alpha-smoothmuscle actin and vimentin was also studied in all cases. results most angiomyolipomas were of classic morphology with one exception. in that case, classical angiomyolipoma was combined with cystic hamartomatous lesions and involvement of regional lymph nodes. the vast majority of cells in the cases with typical morphology expressed alpha-smooth-muscle actin. expression of hmb- was diffuse or focal. in the case with cystic hamartomatous lesions, an inverse correlation of expression of hmb- and alpha-smooth-muscle actin was observed in both renal and extrarenal components. of the tumours, two tumours were only er positive and three tumours were er and pr positive. in four cases, focal immunoreactivity for er was mainly observed in the spindle shaped cells. in two cases, the immunoreactivity for pr was diffuse, but less than percent of cells were positive. er and pr positivity was diffuse, strong and widespread only in the case with cystic hamartomatous lesions. conclusion to our knowledge, estrogen and progesterone are not critical players in all angiomyolipoma growth, but only in the specific cases. myofibroblastic tumors are sometimes difficult to be distinguished from smooth muscle tumors. recently, cd , a cell surface metalloprotease, was shown to be present in myofibroblasts within the stroma of infiltrating cancers. to clarify the specificity of cd expression in myofibroblasts, we performed immunohistochemical studies on myofibroblastic and smooth muscle tumors. methods and materials consisted of myofibroblastic and smooth muscle lesions, ranging from reactive to benign and malignant tumors. all myofibroblastic lesions arose in soft tissue and smooth muscle tumors in soft tissue and organs. using paraffin sections, immunohistochemical staining for cd (clone: c , serotec) was carried out by an automated stainer (benchmark, ventana). results significant cd -expression was demonstrated only in malignant or borderline lesions, including malignant fibrous histiocytoma ( of cases), low grade myofibroblastic sarcoma ( of ), inflammatory myofibroblastic tumor ( of ), and leiomyosarcoma ( of ). however, no positive reaction was seen in reactive lesions and benign tumors, such as scar ( case), nodular fasciitis ( ), su-perficial fibromatosis ( ), desmoid ( ), leiomyoma ( ), vascular leiomyoma ( ), angiomyolipoma ( ), and glomus tumor ( ) . furthermore, the intensity of staining was almost parallel to the microscopic anaplasia. conclusion the present study demonstrated that cd expression is not specific to myofibroblasts, but seems to be related to the biologic aggressiveness of myofibroblastic and smooth muscle tumors. therefore, cd expression may be a potential predictor of malignancy in these tumors. correlation of metallothionein (mt) and antigen ki- expressions with grade of malignancy (g) in some soft tissue sarcomas dysplasia may be found in the bones during the childhood and adolescence. they can cause pathologic fractures and deformities of involved bone. rarely, some of them (fibrous dysplasia), undergo malignant transformation. the aim of this study is to analyse all the cases of tumor-like lesions of bones in children and adolescents, during the period time - . the study was performed at the institute for pathologic anatomy, school of medicine belgrade. the data source was the bone and joint tumor registry. the study was a retrospective analysis of patients who had tumor-like lesion before the age of . results solitary bone cyst was the most common lesion ( patients). the median age was years for fibrous dysplasia and solitary bone cyst, years for aneurysmal bone cyst and eosinophilic granuloma, and years for non-ossifying fibroma. male to female ratio was : . for fibrous dysplasia, : . for aneurysmal bone cyst, . : for solitary bone cyst, . : for eosinophilic granuloma and : for non-ossifying fibroma. the most common sites were femur for fibrous dysplasia and aneurysmal bone cyst, humerus for solitary bone cyst, tibia for non-ossifying fibroma and bones of scull and vertebrae for eosinophilic granuloma. the most frequent symptoms and signs were pain, pathologic fractures and swellings. conclusion the results of our study mostly correspond to those of the current literature. extraspinal myxopapillary ependymoma. case report and literature review introduction ependymomas are glial tumors that on rare occasions occur in subcutaneous locations dorsal to the sacrum and coccyx. case report a -year-old woman presented with a soft tissues tumor in the intergluteal region. mri revealed a cm large mass, with solid and cystic areas, located below the coccyx, without bone alteration. surgical excision was performed. pathological features grossly, the tumor was encapsulated and showed solid, spongy and myxoid areas with a peripheral hemorrhagic focus. histologically it consisted of medium-sized cuboidalcolumnar cells, with round-oval nuclei, granular cromatin and eosinophilic cytoplasm. tumor cells showed myxopapillary and cystic-papillary growth pattern or were arranged on fibrovascular stalks, with a central hyalinized wall vessel, surrounded by a single layer of cuboidal cells. tumoral necrosis and hemorrhage were observed. the peritumoral stroma was highly hyalinized. the immunohistochemical stains showed vimentin(+), s- (+), gfap(+) and keratins(-). discussion and conclusion extraspinal ependymoma (ee) is a rare tumor usually localized subcutaneously in sacrococcygeal region of young adults; most are of myxopapillary type. ee may arise from normal remnants of the neural tube or from abnormal remnants resulting from embryologic malformations. ee has a greater propensity to metastasize than its intraspinal counterpart, because of easier accessibility to lymph channels. in a study of cases, elson found a metastases incidence of % and no clinical or histologic data was found to predict the biological behavior of the tumor. the differential diagnosis must be done with choroid plexus papilloma, myxoid chondrosarcoma, chordoma, meningioma, adenoid cystic carcinoma and paraganglioma. introduction fungal infections of bone represent about , - , % of all osteomyelitis cases. the disease most often affecting the feet -mycetoma pedis, is also known as madura foot. in our geographic regions mycetoma is extremely rare. it is endemic in tropical and subtropical countries. case report we present a case of mycetoma pedis -madura foot. the patient was a years old woman. the clinical signs were pain, indurations and local redness with a long history of years. the surgical material was routinely stained with hematoxylin-eosin (he). pathologically, a granulomatous inflammation of the bone was confirmed. all pathological characteristic pointed to fungal infection in the form of mycetona pedis. special stains (pas, grocott's hexamine-silver and giemsa) for fungi were performed: and the diagnosis of a mycetoma was confirmed. for the definitive microbiological analysis tissue inoculation on the sabouraud dextrose agar laboratory media was done. pseudoallesheria boydiia sexual staging of monosporium apiospermum was isolated. after microbiological verification of fungal infection the patient was treated surgically. seven months after first operation the patient developed similar clinical signs again. the diagnostic procedure was repeated and mycetoma was confirmed again. the surgical therapy was performed as a therapy of choice because pseudoallesheria boydii does not react to treatment with antimycotic drugs. spindle cell lipoma is a rare entity with an uncertain histogenesis; although the current classification includes this tumor in the lipomatous neoplasms, the immunohistochemical and electron microscopic data suggest a much closer link to the fibrous solitary tumor. we report the case of a years woman with a / / / cm nodule in the scapular area; the histopathologic examination revealed a tumor proliferation consisting mainly of giant cells, most of them multinucleated with floret-like appearance. the stroma consisted of an abundant collagen deposition with rope-like fascicles and prominent myxoid changes, most striking in the periphery of the tumor. the tumor proliferation was contiguous with nearby adipose tissue with no capsule in-between. immuno-histochemical tests revealed diffuse positivity for cd ; pcna was positive in % of the cells. smooth muscle actin, desmin and s -protein were negative in tumor cells. the patient is well with no recurrence of the tumor one year after the resection. despite the highly pleomorphic histopathologic appearance the tumor is benign with an uneventful clinical behaviuor. expression of p protein in gct of bone with lung metastases introduction the giant cell tumor of bone (gct) is a local osteolytic tumor with variable degrees of aggressiveness. in rare cases pulmonary metastases can be observed. the stromal cells are the neoplastic components of the gct, and are probably responsible for biological behavior of the tumor. in the last years cases of gct with lung metastases were diagnosed at the institute of pathology, school of medicine, belgrade. both tumors displayed characteristic histological appearance of gct: a high number of osteoclast-like multinucleated giant cells and two mononuclear cell types. the first one resembles a monocyte, the second are fibroblast-like stromal cell. mononuclear cells had benign cytological characteristics without polymorphism and mitosis. to elucidate the mechanism of metastasing, we searched for the molecular abnormalities of p . we examined the expression of p in stromal cells immunohistochemically. unexpectedly, both tumors were p negative and we could not show correlation between p expression and metastasing of gct to the lung. conclusion although p positivity in other tumors is closely associated with aggressive biological behavior we could not confirm this association for gct. trichoblastic fibroma or primary soft tissue adamantinoma? introduction benign extragnathic tumors that may mimic the histological features of odontogenic ameloblastoma (and ameloblastic fibroma) include trichoblastic fibroma and primary osseous and soft tissue adamantinoma. trichoblastic fibroma is a rare ectomesenchymal tumor of hair germ involving most often the dermis and subcutis of the head and neck. the mean age at presentation is , years.the youngest case reported was that of a shoulder tumor in a year old female. its occurrence in the soft tissue of the upper arm has not been documented. primary soft tissue adamantinomas are extremely rare with isolated cases reported in the region of the jaw and the leg ie. close to sites where odontogenic and primary osseous adamantinomas occur, respectively. no cases involving the upper arm have been reported. we report a case of a benign appearing adamantinoid tumor involving the deep soft tissue of the upper arm. a year old black male presented with a slow growing mass involving the deep soft tissue of the left upper arm without associated cutaneous or osseous abnormalities. results the adamantinoid features in this benign appearing biphasic tumor included nests and acini of palisading columnar epithelium exhibiting reversed nuclear polarity, areas reminiscent of stellate reticulum and an intimately associated spindle cell proliferation. conclusion our favored diagnosis was a trichoblastic fibroma but we discuss the complete differential diagnosis of all tumors with adamantinoid features with respect to clinical, morphological and immunohistochemical characteristics. intraosseous lipoma -a case report intraosseous lipoma is a rare benign tumor of mature adipocytes arising in the medullary canal, most often diagnosed incidentally. most of these tumors occur in the long bones, with propensity for the proximal femur, fibula, and tibia. ribs, calvarium, sacrum, metatarsus and calcaneus are other frequent sites. we report a case of a -yearold female with a histologically verified solitary intraosseous lipoma involving the distal part of the right fibula. radiographically the tumor was a lytic benign-appearing lesion with sharply demarcated borders surrounded by a zone of sclerosis. computed tomographic scan showed the lesion to have features of adipose tissue. the examination was made on surgically removed distal part of the right fibula. for histological verification of intraosseous lipoma, resected bone was decalcified, embedded in paraffin and stained with standard staining with hematoxilin-eosin. histopathologic examination revealed mature adipose tissue with widely scattered trabeculae of bone and central calcifications. this case emphasizes the characteristics of intraosseous lipoma, and highlights the need for clinicopathologic and roentgenographic correlations. fasl, c-erbb , cyclin d , p and tgfb expression in osteosarcomas: evaluation of relationship with clinicopathologic parameters introduction fasl, c-erbb , cyclin d , p and tgfb are molecules which were shown to be related to prognosis of tumors. in this study expression of these molecules were evaluated in osteosarcoma (os) cases. the correlation between the expressions and age, gender of the patients, location, grade, and histologic subtype of tumors were investigated. material and method fasl, c-erbb , cyclin d , p and tgfb expressions were detected immunohistochemically. results thirty-six os cases ( osteoblastic, fibroblastic, five chondroblastic) were included in the study. twenty-two were males and were females. os were located in the extremities ( ), jaw ( ), pelvis ( ), vertebra ( ). twenty-five of were high grade and were low grade tumors. fasl and p were detected in . % of the cases, tgfb in . %, c-erbb in . %, and cyclin d in . %. there were statistically significant correlations between fasl and tumor grade (p: . ), fasl and tgfb (p= . ), fasl and c-erbb (p= . ), p and tgfb (p= . ). no correlation was found among other parameters. conclusion expression of these molecules and detection of correlation between some molecules show that pathogenesis of os is a complex mechanism regulated by several molecular factors. better insight into tumorigenesis may help to provide new therapeutic approaches and idntification of patients with better prognosis. a rotter , s kovac , v pisot , r trebse institute of pathology, medical faculty, university of ljubljana, ljubljana, slovenia valdoltra orthopedic hospital, ankaran, slovenia introduction granulation tissue with macrophages is usually found around loose total hip prosthesis (thp), usually explained with deposition of wear debris from thp. however, we often found a lot of hemosiderin (an insoluble form of storage iron) in macrophages. the aim of this study was to evaluate the amount of hemosiderin in granulation tissue around thp removed after relatively short period of duration, and compare it with an interface tissue around thp of very long duration. we assessed the interface tissue around the loosened thp of the longest duration described ever (judet's thp was removed after years) and compared it with the granulation tissue around thp of short duration (less than six years). at histology h&e, giemsa, and weigert-van gieson staining were used. for the demonstration of hemosiderin perls' reaction and for macrophages cd were used. we compared the results of histologic evaluations performed according to modified mirra's classification: semi quantitative assessment of neutrophils, mononuclear histiocytes, chronic inflammatory cells, giant-cells, metal particles, polymethacrylate globules, necrobiosis, bone chips, necrosis and necrotic debris. but, we also included the assessment of the intensity of hemosiderin deposition. results comparison of granulation tissues of short duration thp to that of -year duration revealed a surprising difference in the amount of hemosiderin particles with intensive intracellular hemosiderin deposition in mononuclear macrophages and giant cells in the first group. in the -year-old thp there was predominantly hypocellular tissue with very little amount of mononuclear macrophages containing slight amount of intracellular hemosiderin deposition and no multinucleated giant cells at all. conclusions we don't know why hemosiderin deposition is more evident in early loosening of thp. hemosiderin deposition may give rise to accumulation of macrophages, perhaps increasing the process of osteolysis and granulation tissue formation. but more 'aggressive' forms of loosening may also cause recurrent bleeding. whether the higher level of hemosiderin is the cause or the result of the loosening of thp is to be determined. the types of tumor and peritumor stroma and biological behavior of fibrohistiocytic tumors introduction tumor-host interaction induces different types of tumor and peritumor stroma which may reveal some aspects of tumor biology. the aim of this study was to establish a correlation between different types of tumor and peritumor stroma of fibrohistiocytic tumors (fh tumors) and their biological behavior. the presence of colagenous-reticular (cr), myxoid (myx) and mixed (mx) tumor and peritumor stroma was determineted on selected paraffin sections stained by masson-trichrome, silver impregnation, alcian blue with and without hialuronidase pretretment and pas reaction of fh tumors: benign (bfh), dermatofibrosarcoma protuberans (dfsp) and malignant (mfh), all graded in three degrees of malignancy. the collected data were statistically evaluated by means of student t proportion test. results the difference in presence of myx and mx tumor and peritumor stroma in relation to the cr type was statistically significant between mfh and bfh (p< , ) or dfsp (p< , ). with an increasing malignancy grade of mfh percentage of tumors with cr tumor stroma was decreasing and percentage of tumors with myx and mx tumor stroma was increasing. however, mfh of g and g malignancy grade did not differ in distribution of peritumor stroma types, but , % of mfhg had myx and mx peritumor stroma. conclusion while myx and mx types of tumor and peritumor stroma are associated with agressive, cr type of tumor and peritumor stroma is associated with benign and less agressive fh tumors. dynamic angiogenic models of human soft tissue tumors transplanted into immunodeficient nude mice introduction animal models were used to study the vascular neogenesis of tumors. we undertook experiments using human sarcomas transplanted into the subcutaneous pad of immunodeficient nude mice. the aim of this study was analysis of: the microvasculature present within the tumor before the transplant; the early stages of the neovascularization; and the types of vascular connections established between the host and the tumor graft. material and methods implants of . - . cm in size of a ewing's sarcoma (es), an osteosarcoma (os) and a fibrosarcoma (fs) were analyzed. the study was successively followed for , , hours, one, two, three and four weeks. he, pas and immunohistochemistry for angiogenic factors were complemented with electron microscopy. after - hours, the implants over-expressed several angiogenic factors. at this stage, the tumors initiated an active angiogenic remodeling in the surrounding stroma where capillary congestion and microhemorragies occurred. endothelial sprouting of the host capillaries was seen. vascular co-option between the endothelial cells, newly formed endothelial cells and the tumor cells was observed. no clear basal lamina was seen. tumor-endothelial cell mosaics and vascular mimicry were detected only in the es and os. conclusions vascular expression and neogenesis varies considerably from the fast es to the fs while the os reproduces patterns that are common in all three. based upon present experience it seems evident that each tumor shows a different type of neovascularization. these models provide excellent examples of all the systems that are involved in the recapillarization of a sarcoma. this work has been supported by grants fis / and fis / from the ministry of health, madrid, spain. prognostic significance of intratumoral neoangiogenesis in childhood osteosarcoma and ewing sarcoma d mikulic , i ilic , m coric , l batelja , j stepan , s seiwerth institute of pathology medical faculty, zagreb, croatia childrens hospital, zagreb, croatia introduction intratumoral neoangiogenesis quantified by microvessel density (mvd) has been shown to be a strong prognostic indicator in a number of malignant tumors, primarily carcinomas. its association with prognosis in bone sarcomas has been subject to less extensive research. the aim of our study was to investigate clinical significance of neoangiogenesis in osteosarcoma and ewing sarcoma. patients and methods a retrospective immunohistochemical study was performed. patients with osteosarcoma and patients with ewing sarcoma were included. sections from diagnostic biopsies were immunostained using factor viii and cd (dako) antibody and microvessels were counted at x magnification on three microscopic fields showing highest mvd per patient. mvd was correlated with overall and event-free survival by kaplan-meier and log-rank analysis. the difference between the mean microvessel counts in patients with or without metastasis and alive or dead was assessed by mann-whitney test. results in patients with osteosarcoma significant statistical difference was found as regards the death risk and risk of development of metastasis between patients with high (> vessels/field) and low (< vessels/field) microvessel counts (log-rank test p= . and p= . , respectively). in patients with ewing sarcoma a trend was noted for the patients with lower (< . vessels/field) microvessel counts to have better outcomes than patients with higher vessel counts, however, the difference was not statistically significant. conclusion these findings strongly suggest that neoangiogenesis quantified by microvessel density is predictive of metastasis and poor prognosis in osteosarcoma. valorization of its role in patients with ewing sarcoma awaits further studies. epithelioid sarcoma -clinicopathological findings in cases m demiryont epithelioid sarcoma is a soft tissue sarcoma of unknown histogenesis with a predilection of young adults and hand/forearm location.the tumor is often multinodular showing central necrosis. epithelioid sarcoma has a high potential of local recurrence and metastasis. six cases were presented. five patients were male with a mean age of . tumor locations were finger, hand and forearm. cytokeratin and vimentin were positive in all cases. four cases showed positivity for cd . desmin and cd were negative. ki- (mib- )proliferation index was - % in cases. initial surgery performed in all of the patients has been local excision with negative margins.three patients received radiotherapy or chemotherapy after the primary excision.except for one patient who was lost to follow-up, local recurrence was detected in all the patients in a period of months to years.three patients died with distant metastasis. epithelioid sarcoma can be easily identified with its typical features, but it can be confused with non-tumor lesions in patients having a long clinical history and a small tumor. radical surgery and regional lymph node dissection may bring benefit; the incidence of the lymph node metastasis is high. radiotherapy and chemotherapy can be added to therapy in the recurrent or metastatic state of the disease. introduction intramuscular hemangiomas are relatively uncommon but significant lesions, and their unorthodox location and infiltrative pattern often raise the question of malignancy to clinician and pathologist. we present the histomorphological and immunohistochemical data of a hemangioma in a -year-old man who presented with an enlarging painful soft tissue mass of his right upper leg. methods the complete local excision of tumor arising in the quadriceps muscle was done. sections of formalin-fixed, paraffinembedded tissue material were stained with he, van gieson, pas, ptah, gomori's reticulin and trichrome, and immunohistochemically for detection of factor viii-related antigen. results grossly, the lesion ( x , cm) was poorly circumscribed, reddish brown and partially haemorrhagic. microscopically, it was composed both of small, capillary-sized and large, cavernous vessels lined by endothelial cells and surrounded by connective and mature adipose tissue. the adipocytic component wasn't prominent. many cavernous spaces were separated by dense fibrous tissue and some of them were thrombosed. foci of hemosiderin deposits and moderate lymphocytic infiltration were also noted. the small vessels in some areas hadn't discernible lumina so that areas appeared solid. mitotic figures and intraluminal papillary tufting were not seen, but infiltration of skeletal muscle bundles and rarely perineural spaces were present. the muscle fibres showed atrophy, degenerative changes and signs of regeneration. the cells lining both cavernous and capillary-sized vessels showed expression of factor viii-related antigen. conclusions presented case of tumor arising in the quadriceps muscle show histomorphological and immunohistochemical features of mixed type hemangioma with pronounced infiltrative pattern. alveolar soft part sarcoma: a review of cases at national cancer institute from colombia ol mejia mejia instituto nacional de cancerología, colombia, bucaramanga, columbia aims to review the histology and immunohistochemistry of alveolar soft part sarcoma with comparison of clinical features. material and methods histology slides, paraffin blocks and files of patients were reviewed. results and discussion there were patients retrospectively analysed, female and male, between year and years old. the initial symptom was mass. the most frequent location was thigh ( %), followed by the leg, orbit, chest wall, trunk, arm and forearm. six patients had haematogenous metastases at the time of diagnosis (lung , brain , lung and bone ). histologically, all tumours were composed of nests of medium sized cells arranged in pseudo-alveolar or lobular patterns, separated by fibrovascular stroma. pas & pas diastase were positive in all cases, with rhomboid or rod-shaped crystals. immunohistochemical staining for myo d showed cytoplasmic positive in cases ( %), desmin in and smooth muscle actin in cases. conclusion alveolar soft part sarcoma is an uncommon neoplasm. the microscopic picture is a constant and typical feature of the lesion, and immunohistochemistry is a useful complementary method for diagnosis. a jiménez sánchez, em huertas valero, ja ramos Ńíguez, r baeza guixot, p sánchez cańizares hospital francesc de borja de gandia, gandia, spain introduction malignant epithelioid schwannoma is a rare variant of malignant nerve sheath tumor (mpnst) that often causes differential diagnostic problems with other neoplasm. material and methods a -year-old woman presented with a palpable tumor located in the supraclavicular region. the lesion was partially resected. grossly, the tumor was firm, gray to whitish and slighty nodular. standard histological procedure and inmunohistochemical study was performed. results microscopic examination revealed a solid proliferation of moderately large, rounded epithelioid cells, with pleomorphic nuclei, prominent nucleoli and atypical mitoses. in peripheral areas the tumor showed smaller cells with nuclei arranged in palisades and central necrosis. immunohistochemical studies showed vimentine, s- protein, and cytokeratine positivity and hmb- negativity. the histopathology and the immunohistochemical results were consistent with mpnst, but a ssx /syt gene fusion was detected by molecular analysis, a characteristic chromosomal change of synovial sarcoma (ss). conclusions spindle cell tumors with epithelioid areas can be difficult to diferentiate by histologic pattern alone. cytogenetic analysis and molecular studies may reveal the diagnosis by demonstrating a characteristic chromosomal abnormality or molecular rearrangement. ssx/syt gene fusion results from the t(x; )(p . ;q . ). the translocation fuses the syt gene from the chromosome long arm to either of highly homologous genes on the chromosome x short arm, ssx or ssx . the translocation t(x; ) is currently regarded as a specific molecular marker of ss. our case shows, that we might consider that ss may have a larger histologic spectrum than previously thought. a case of idiopathic retroperitoneal fibrosis (ormond's disease) and renal supracapsular liposarcoma t georgiev , e nakov , r gajdarski department of pathology, faculty of medicine, sofia, bulgaria department of pathology, military medical academy, sofia, bulgaria background idiopathic retroperitoneal fibrosis is an uncommon inflammatory disease characterized by proliferation and fibrosis of retroperitoneal tissue complicated by obstruction and encasement of retroperitoneal structures. case report we describe a -year-old female patient who underwent a gynecologic operation for left ovarian cyst in october . a periaortic mass alongside with peritoneal nodules were biopsied which revealed endometriosis, necrotic xantomatous nodules and ormond's disease. the last diagnosis was rejected and tumor misinterpreted as malignant fibrous histiocytoma. the course of the disease progressed and on computed tomography a left renal supracapsular tumor measuring / / cm together with a diffuse retroperitoneal fibrosis was demonstrated. in november , a tumor localized in the adipose capsule of the left kidney was removed together with the kidney weighing , kg. the kidney was markedly atrophic. a parallel excision of ten retroperitoneal tissue masses with a size up to / / cm was performed. our final histological diagnosis was highly differentiated liposarcoma. four months later the abdominal ct and the tumor markers were normal. conclusion the symptoms in our case were not specific for renoureteral obstruction and included abdominal pain and mass, weight loss and ascites during the year prior to second operation and finally urinary symptoms. we interpret our case as a slowly growing perirenal lipomatous tumor gradually compressing the kidney and causing slowly progressing retroperitoneal fibrosis. a rare case of thoracic angiomatosis in an adult and review of the literature n lapidus, d andrejev, a arro north-estonian regional hospital, tallinn, estonia introduction angiomatosis is a rare condition in which large segments of the body are involved by proliferating vessels. the majority of angiomatoses present during childhood or infancy. a diffuse angiomatosis affecting thoracic organs is a rare, frequently fatal disorder. the origin of the lesion is unknown. the lesion consists of thin-walled sometimes bloodless capillary blood vessels. the definite diagnosis is usually made by open lung biopsy or autopsy. in our paper we are presenting the rare case of angiomatosis of pleura and lung in -years old woman and the review of the literature. the patient was presented to the hospital with complaints to the pain in the right chest, dyspnea, weakness. the lesion manifested on chest radiographs and ct scans with unilateral pleural fluid and nodular pleural thickening. thoracocenthesis was performed and light brown fluid was drained. cytologically the effusion contained erythrocytes and lymphocytes. further ml more fluid was obtained. the openlung biopsy revealed the extensive diffuse angiomatosis affecting visceral and parietal pleura and subpleural lung tissue. the lesion consisted of bloodless, thin walled, endothelium channels. factor viii-related antigen and cd were the most reliable immunocytochemical markers in highlighting the endothelia. the palliative methods of treatment were not effective, and the patient was treated by total pleurectomy. conclusion diagnosis is based exclusively on histologic finding as the only possibility of diagnosis. open pleurectomy is the most succesful treatment in preventing reaccumulation of the effusion. background chronic inflammation with remodelling of the airway wall structures is an essential characteristic in asthma patients. lysosomal proteinases are involved in extracellular proteolysis, which leads to matrix changes of subepithelial connective tissue in the airway wall. the aim of the study was to localise the expression of different cysteine proteinases and their endogenous inhibitors in lung tissue of asthma patients. material and methods we included ten specimens of bronchial biopsies of asthma patients and lung tissue specimens of fatal asthma case. tissue specimens were fixed in formalin and embedded in paraffin. h&e slides were used for morphological examination. immunohistochemistry was performed on an automated stainer (benchmark, ventana, tuscon, az, usa). we used monoclonal antibodies to visualize cysteine proteinases (cathepsin b, h, l and s) and their inhibitors (stefin a and b, cystatin c) (krka, ljubljana, slovenia). results cathepsin b showed the most intense and wide distributed positive reaction. it was localized in the respiratory epithelium, macrophages, lymphocytes, mucous glands and smooth muscle cells. cathepsin h showed intense reaction localized in the respiratory epithelium, macrophages, lymphocytes, mucous glands, but not in the smooth muscle cells. cathepsins l and s showed positive reaction only in macrophages. the positive reaction of all three inhibitors was weaker compared to cysteine proteinases; it was observed in the respiratory epithelium, macrophages and mucous glands. conclusion these results suggest involvement of cysteine proteinases and their endogenous inhibitors in asthma, showing distinct immunoreactivity and different distributions in the lung tissue of asthma patients. since the inhibitor expression is less intense we can speculate that remodelling of the extracellular matrix may be also a consequence of imbalance between cysteine proteinases and their inhibitors. the correlation between aberrant connexin mrna expression induced by promoter methylation and nodal micrometastasis in non-small cell lung cancer jt introduction reduced connexin (cx) gene expression has been shown in most of lung tumors and lung cancer cell lines. although aberrant cx gene expression was linked with lung tumorigenesis, our understanding to the mechanism was still limited. we hypothesized that the evidence of aberrant cx gene expression was gradually intensified from adjacent normal lung tissues surrounding tumors towards to tumor tissues. materials and methods in this study, lung tumors and adjacent normal tissues were collected to examine cx mrna expression by reverse transcription-polymerase chain reaction (rt-pcr). results our data showed that cx mrna expression in adjacent normal lung tissue was significantly correlated with nodal involvement (p = . ), but the similar trend was not observed in tumor tissues. to verify whether lack of cx mrna expression was resulted from promoter methylation, pcr-based methylation assay was performed for cx promoter methylation analysis. high frequency of promoter methylation was observed in cx mrna negative patients ( of , . %) compared with cx mrna positive patients ( of , . %, p < . ). to elucidate whether aberrant cx gene expression is originated from adjacent normal lung tissues, lung tumors and each of five adjacent normal tissues with various distances from tumor tissues were collected to examine cx mrna and protein expression by rt-pcr and western blot, respectively. as the results shown, cx mrna and protein expressions were gradually decreased from adjacent normal lung tissues to tumor tissues with a positive correlation to the distance from tumor tissues. gel shift assay data also revealed that shifted band binding with ap was only observed in adjacent normal tissues which were far from the tumor tissues. conclusion these results indicate that promoter methylation may interfere with ap binding to promoter to cause aberrant cx gene expression. thus, cx mrna in adjacent normal tissue surrounding lung tumor simply detected by rt-pcr may be act as a molecular marker of nodal micrometastasis in nsclc. introduction an adenoma-carcinoma sequence is recognised in peripheral lung. atypical adenomatous hyperplasia (aah) and bronchioloalveolar carcinoma (bac) are the pre-invasive precursors of invasive adenocarcinoma, which frequently has a 'residual' peripheral bac component. the biology of this neoplastic progression is poorly understood. the aim of this study was to examine the expression of the tumour suppressor gene fhit, cd v , e-cadherin, beta-catenin, mmp- , timp- , and the cell cycle marker mcm at different stages in the proposed sequence. materials and methods sections from formalin-fixed, waxembedded tissue blocks of aah, bac and invasive adenocarcinomas, stained immunohistochemically for the above molecules, were scored semiquantitatively. in invasive tumours, any bac component was scored separately. for mcm a labelling index was determined as the ratio of immunopositive to total cells counted. results fhit protein is abundant until the disease becomes stromally invasive (p< . ). cd v levels are high in aah and bac, but fall in invasive disease (p= . ). e-cadherin and beta-catenin levels rise between aah and bac (p< . ), and remain well expressed thereafter. mmp- and timp- expression is relatively low in aah, rises in bac but falls when tumour becomes stromally invasive (p < . ). the bac component of invasive tumours expresses some molecules in a manner similar to pure bac but mirrors expression in invasive tumour for others. mcm counts increase from . %(low grade aah) to . % in invasive adenocarcinoma (p= . or less) conclusion in peripheral adenocarcinogenesis, loss of fhit is a relatively late event, while cd v loss occurs earlier. fhit loss has potential as a surrogate marker of invasion. e-cadherin and beta-catenin expression probably reflects changes in lesion architecture. mmp- /timp- may be implicated in bac but down-regulated as stromal invasion develops. increasing cell cycle entry is consistent with neoplastic progression. immunohistochemical study of squamous and adenosquamous cancer of lungs g methods using formalin-fixed and paraffin-embedded tissues, we examined by immunohistochemistry tenascine, collagen iv, cd , mmp , mmp , timp , timp , cd , bcl , p , pcna, ki , cyclin d in cases of lung carcinoma - squamous and adenosquamous with (first group) and without (second group) metastases. results the positive staining with tenascine was observed in all cases of squamous and adenosquamous carcinoma, but the most strong expression was found in extracellular matrix and tumor cells of carcinomas of first group. the overexpression of mmp and mmp was found in cases with metastases in tumor cells and stromal cells. the reaction was localised on periferical zone of tumor complexes. at the same time reaction with timp was low in tumor of second group and very low -in first group, reaction with timp was moderate in metastatic tumor and low -in second group. overexpression pcna and ki changed from % to % in group and from % to % in group. the increase expression of cyclin d was only in adenosquamous lung carcinoma. the overexpression of p was found only in metastatic tumors. conclusion there are some difference between squamous and adenosquamous lung carcinomas in expression of proliferation markers, and cyclin d , but no difference in expression of metalloproteinases and their inhibitors. we found more prominent differences in groups of metastatic and nonmetastatic tumors. lack of her- /neu amplification or overexpression in malignant pleural mesothelioma (mpm) introduction the her- /neu receptor, a member of the epidermal growth factor receptor (egfr) family, represents a novel therapeutic target for the newly marketed recombinant anti-her monoclonal antibody herceptin®. mpm mortality continues to rise steeply ( % to % per year) with no known curative modality. approximately % of mpms have high levels of expression of egfr. two recent studies have reported expression of her- /neu in mpm but there was no analysis of overexpression or amplification. in this study, the amplification/overexpression of her- /neu gene has been evaluated in a series of consecutive mpm biopsy specimens. materials and methods the tumour specimens had been formalin-fixed and paraffin-embedded. immunohistochemistry (ihc) for her- /neu overexpression was performed using the dako herceptest kit. only membrane staining intensity and pattern were evaluated using a to + scale with + being the lower limit for a positive test. amplification of the her- /neu gene was tested with the fluorescent in-situ hybridisation (fish) method (ventana inform her- /neu probe) in out of the cases. cases were considered as amplified by fish when the mean number of fluorescent signals per nucleus was greater than four. results of the mpms evaluated for the overexpression of the her- /neu receptor, all scored on the ihc test and all cases additionally assayed by fish were negative. conclusions although the sample size was limited, these findings suggest that mpm do not overexpress or amplify her- /neu, which therefore should not be considered a prognostic and predictive marker in mpm. (this work was funded by the alessandria branch of the italian league against cancer). morphological changes of bronchial glands at the localisation of preceding biopsy introduction at the location of preceding biopsy, in sero-mucous bronchial glands, there are certain changes of regenerative type. hyper-plastic and meta-plastic squamous epithelia partially or wholly fills the acinus and duct of secretory glands. aims: regenerative atypical characteristics found in repeated materials can be misinterpreted as epidermoid or muco-epidermoid carcinoma. material and methods the research used materials made by re-biopsy of bronchia, with regeneratory changes in bronchial glands. presence of morphological parameters was examined semiquantitatively, and then processed with methods of descriptive statistics. results in . % lobular architectonics of the lesion was preserved; fibrin exudates were present in . % cases; granulocytes in stroma were present in . % cases; granulation tissue in . % cases; planocellular metaplasia of duct and acinus was present in every single case. in . % cases mucin-secreting cells were found in squamous epithelia. the squamous cells were diskeratotic in % cases; with polymorph nuclei in . % cases; hyper-chromatic in %; multi-nuclear in . %; with visible nucleolus in . %, and with mitotic activity in . % cases. in . % cases the squamous cells were located in the fibrous tissue. mucus in interstitium was present in . % cases; cystoid formations were present in . % cases. the changes are built of solid material, undifferentiated and/or squamous cells located in the granular tissue or in the fibrin. infiltrates of granulocytes are found in fibrin, stroma, and squamous epithelia. epithelial cells in regeneration show atypical cell characteristics in small percentage and therefore are hard to differentiate from carcinoma. immunohistochemical expression of her- /neu in patients with lung carcinoma g petrusevska , b ilievska, s banev, s smickova institute of pathology, skopje, republic of macedonia the her- protein or p her is a membrane receptor with tyrosine kinase activity encoded by he /neu gene. overexpression of her- /neu has been observed in many human cancer, including lung cancer. there are different reports about the expression of this protein in different lung cancer. the aim of the study is to determine the expression of her- protein in the spectrum of lung cancer (adenocarcinoma, squamous cell carcinoma and small cell carcinoma). the study population consisted of two groups: patients that have undergone to surgical treatment and patients that have undergone to fiber-optic bronchoscopy and biopsy for primary diagnosis.tissue specimens were neutral formaline fixed and paraffin embedded. standard histochemical and immunohistochemical staining were used for diagnosis. expression of her- /neu protein was determined by immunohistochemical staining with hercep testtm (dako). the results were graded - as negative and - as positive. overall incidence of her- /neu overexpression was , % ( of ). higher incidence was found in patients with adenocarcinoma , % ( of ); squamous cell carcinoma , % ( of ) and small cell carcinoma % ( of ). no statistical significant difference was seen with age and gender. her- /neu overexpression was more relevant for patients with advanced tumor: all patients with squamous cell carcinoma were in stage b and , and % with adenocarcinoma were in stage a and b. these results are satisfactory and encourage us to continue this work in the follow-up study to evaluate her- /neu role as predictive and prognostic factor for patients with lung cancer. we applied immunohistochemistry on six neuroendocrine lung carcinomas using moabs specific for extracellular matrix proteins and integrins; moreover transwell test migration assays evaluated the rate of transendothelial migration of ae- neuroendocrine carcinoma cell line throught a monolayer of eahy endothelial cell line expressing laminin-α -chain to establish wheather this protein may favour in vivo vascular invasion and metastasis. results %, %, %, %, % and % of vessels were respectivelly distributed within the parenchyma of these tumors. studies on contignous sections demonstrated that parenchymal vessels were positive for all ecmps, but laminin-α -chain, which was respectively expressed in %, %, %, %, % and % of parenchymal and in %, %, %, %, % and % of stromal vessels of these tumors. in all cases about % of neoplastic cells were α positive. preliminary results of transwell test migration assay indicate that the pretreatment of the ae- cell suspension with anti laminin-α -chain and anti α -integrin moabs reduced their migration through the eahy monolayer. conclusions as known α -integrin is a receptor of laminin-α chain, therefore the up-regulation of this protein in a large number of vessels during tumor angiogenesis may favour metastasis increasing neoplastic cell adhesiveness to newly formed vessels. brain death as a cause of primary lung graft disfunction in an isolated rabbit lung model ma introduction early lung dysfunction observed after lung transplantation has been attributed to an increase of vascular permability. factors involved in this mechanism are unknown. our hypothesis was that brain death (bd) is a preconditioning factor that induces primary lung graft dysfunction. methods twenty-four rabbits were randomized to control (crl) or induced bd (increasing intracraneal pressure above systolic pressure for minutes) groups and were ventilated in volume controlled mode (tidal volume ml/kg, positive end expiratory pressure (peep) cmh o and respiratory rate (rr) to obtain normocapnia) for minutes. isolated lungs were perfused with ml/min (constant flow) and ventilated in pressure controlled mode (peack pressure cmh o, peep cmh o and rr ) for minutes. pulmonary edema and lung injury were assessed by weight gain, change in ultrafiltration coefficient before and after ventilation; and extent of hemorrhage (scored by histology: intensity of alveolar hemorrhage, percentage of alveoli with hemorrhage and number of vessels with perivascular hemorrhage) mean values ( samples per lung) of the indices of hemorrhage showed above were scored ( to ) and added to obtain a score of overall lung hemorrhage (range to ) for each lunch. data are expressed as mean and % confidence interval and were compared with paired t test. conclusions under these experimental conditions bd contributes to pulmonary edema and lung hemorrhage. expression of cyclooxygenase- in nonsmall cell lung carcinomas n akyürek introduction cyclooxygenase (cox) is an inducible enzyme that catalyses the conversion of arachidonic acid to prostaglandins and thromboxanes. cox- is induced by cytokines and growth factors and has been shown to be important in carcinogenesis. the aim of this study was to investigate the expression of cox- and clinicopathologic factors in nonsmall cell lung carcinomas (nsclc) with regard to survival times. materials and methods seventy-seven nsclc specimens were evaluated for cox- expression by immunohistochemical method. staining patterns were assessed semiquantitatively and correlated with tumor histologic type, tnm stage and prognosis. chi-square and kaplan-meier survival analysis was performed. results cox- was not expressed in the normal bronchial epithelium. cox- expression was detected in ( . %) nsclc. expression of cox- was significantly higher in adenocarcinomas than in other histologic subtypes (p= . ). there was no significant relationship found between cox- expression and age, gender, tnm stage, and prognosis. conclusion this study suggests that an increase in cox- expression may be associated with the development of adenocarcinomas. but, prognostic significance of cox- expression is controversial. prognostic significance of cyclin-dependent kinase inhibitor p and bcl- protein in nonsmall cell lung cancer introduction the expression of p , which is known a cyclindependent kinase inhibitor, has considerable value for the prognosis of cancer patients. bcl- gen product (bcl- protein) is implicated in oncogenesis by its ability to prolong cell death through the inhibition of apoptosis. we studied the expresssion of p and bcl- protein to investigate their association between clinicopathologic factors and prognosis in nonsmall cell lung cancer (nsclc) materials and methods patients with nsclc were included in our study.there were patients( men, women), patients had adenocarcinoma (ac) and had squamous cell carcinoma (scc).tumors were examined immunohistochemically with p and bcl- protein expression, using formalin-fixed, parafinembedded tissue. for the evaluation of p expression, the number of nuclear staining was counted and showed as a percentage.bcl- protein was primarily identified in the cytoplasm of tumor cells. statistically, correlation between immunoreactivity and the clinicopathologic factors were evaluated. results p immunoreactivity was observed in ( %) of cases. there were ( %) scc, ( %) ac. statistically, these findings were found significant (p= , ). percentage of p positive nuclei, the average being %. positive bcl- immunostaining was found in ( , %) of cases. cases ( , %) of scc and ( %) of the ac were positive. these findings were not found significant (p= , ) conclusions there is no correlation between p and bcl- expression and clinical parameters, clinical stage, pathologic grade and prognosis. our study suggest that p immunreactivity in nsclc may provide prognostic information. pulmonary hamartoma -report of four cases introduction neuroblastoma is a malignant tumor of early childhood and is very rare in adults, thus we report this case. case report we describe a case of a -year-old man, never before notably ill. basic laboratory values were not significantly anomalous except of mild anaemia and high erythrocyte sedimentation rate. an x-ray scan showed a spherical opacity cm in diameter in the top right pulmonary field paramediastinally. ct displayed a low-density tumor x , x , cm in the apex of the right hemithorax. the tumor was well circumscribed and seemed to be in a subpleural localisation. it was subsequently punctioned with chiba and core needle under ct control. cytological and histological material did not contain any malignant cells. on mr scan there was a well encapsulated extrapulmonary tumor without destruction of ribs, probably of benign origin. tumor extirpation was indicated. the lesion was growing out of spinal chord. it was completely removed. grossly, the tumor looked like an old hematoma. histologically, it had the typical appearance of neuroblastoma -malignant tumor which is found in more than % of cases in patients under years of age. a scintigrafical examination and trephine biopsy showed massive bone marrow infiltration by neuroblastoma. conclusion a -year-old man was confirmed to have a typical early childhood tumor -neuroblastoma in a subpleural localisation. despite the poor prognosis of this tumor in adults and a wide bone marrow infiltration, the patient is well and without signs of disease after surgical resection and two cycles of chemotherapy over months after the initial diagnosis. measurements of dna amount and nuclear size by image cytometry: are these two features sufficient for diagnosis of early lung cancer? background lung cancer represents % of all cancers, but is responsible for nearly % of cancer related deaths due to the fact that it is most often detected in a very late stage. it has been proposed that selected nuclear features could be used to assist lung cancer detection in an early, operable stage. it was shown that both dna amount (dna ploidy) and nuclear size are key features for positive diagnosis in oral, laryngeal, bronchial, and gastric epithelial tumors. we used image cytometry to assess the potential of this approach using nuclei of epithelial lung cells from sputum samples. experimental design sputum samples were obtained by induction method, using hyperosmolar salinic solution, from lung cancer patients and high risk individuals. the cells were fixed and after breaking mucosa with mechanical and chemical treatment, they were cyto-centrifuged onto the microscopy slides. cell nuclei were stained by a dna specific and stoichiometric (feulgen-thionin) stain and dna amount (ploidy) and nuclear size of (on average) cell nuclei from each sample were measured by a high resolution image cytometer. the results showed that there were no statistical differences between the dna ploidy values between control and cancer cases, as very few cancerous cells were found in the sputa of lung cancer patients. interestingly, there was a measurable increase in the mean nuclear area of diploid cells from cancer patients in comparison to control cases. conclusions despite the slight difference in the size distribution the nuclear size feature alone does not provide effective discrimination between the negative and positive populations. pulmonary blastoma: report of cases d yilmazbayhan, mg gulluoglu istanbul university, istanbul faculty of medicine, department of pathology, istanbul, turkey introduction pulmonary blastomas (pb) are rare lung tumors having unique histomorphological features. although they were once regarded in the same group of lung neoplasms with well differentiated fetal adenocarcinomas, recently the two tumors were seperated from each other. we aim to discuss the morphological features and the changes of morphology on recurrences of pulmonary blastomas. we present ten cases of pb, six of which were biphasic, two were pleuropulmonary, and two were cystic. biphasic pb patients were five males and one female, with an age range of - . two female patients with pleuropulmonary blastoma were and years, and cystic pb patients were and years old female and male children, respectively. results one of our most striking histomorphological findings was that four of the biphasic pbs accommodate mature epithelium, not fetal epithelium. one of the other two cases presented with a fetal adenocarcinoma and the tumor recurred as a biphasic pb. one of the cystic pb, which arised in a background of congenital bullous emphysema, recurred with pleomorphic cells forming solid groups. the other cystic pb was diagnosed as congenital cystic adenomatoid malformation. conclusion because of the changing morphological features and composition of epithelial component, classification of the pulmonary blastomas should be reviewed. (romano et al., faseb j. : , ). aim of our study was to investigate in vivo expression of -lo in human mesothelioma. materials and methods immunohistochemical analyses were conducted in five micron sections from human pleural mesothelioma ( epithelial, biphasic and one fibrous type). -lo expression was evaluated using a -lo polyclonal antibody. results immunohistochemical staining was observed in all cases. the staining pattern was cytoplasmic in cases ( epithelial, biphasic and fibrous type), both nuclear and membranous in one case of the epithelial type, both nuclear and cytoplasmic in cases ( epithelial and biphasic type), nuclear, cytoplasmic and membranous in two cases of the epithelial type. conclusion these results are consistent with our in vitro data showing -lo expression in mm cells and strongly suggest that -lo may play a relevant role in the pathobiology of malignant pleural mesothelioma. the present study is scheduled to analyze the intratumoral expression of vascular endothelial growth factor (vegf) in human lung cancer and to determine the relation with microvessel density (mvd), e-cadherin expression and clinicopathological parameters. a -years old male presented with chest discomfort, dyspnea, weakness. heart function tests were normal. ct examination revealed a well demarcated mass in the anterior-superior mediastinum as well as pleural and pericardial effusions. there was no clinical/radiographic evidence of tumor elsewhere. a surgical excision of the mass was performed. grossly, the mass was round, well demarcated, measured x . x cm. the cut surface showed solid whitish or reddish with yellowish foci areas and cystic areas filled with mucinous fluid. histologically, the tumor consisted of sheets and nests of atypical squamoid cells intermingled with gland-like lumens. areas of clear cells were also present. in the tumor stroma, abundant amounts of mucin, foci of necrosis, lymphatic invasion, intense inflammation and cholesterol granulomas were observed. in some areas, the tumor cells were seen in contact to the lining of the cystic cavities. the latter were lined by a single layer of cuboidal or flattened or stratified epithelium with morphological features of squamous cells. at the periphery of the tumor, rare lymphoid follicles, residual thymic elements or degenerative hassall's corpuscles were seen. these histologic features were more consistent with a mucoepidermoid carcinoma arising in association with a thymic cyst. the patient died two months after chemotherapy administration. mucoepidermoid carcinoma of thymus is a rare entity and, to our knowledge, very few cases have been described in the international literature. however, in case of absence of metastatic disease or other common primary tumors of thymus, the diagnosis of a mucoepidermoid carcinoma should be taken into consideration. tissue array for immunohistochemical profiling of intrathoracic localized fibrous tumors ultrastructure of bronchial mucosa in chronic obstructive bronchitis n zoirova, s ariphkhanova uzbek institute of medical rehabilitation and physical therapy, tashkent, uzbekistan the purpose of this investigation was to determine ultrastructural peculiarity of bronchial mucosa in the patients with chronic obstructive bronchitis (cob). the study was performed in bronchial biopsy samples obtained from patients with cob. material was fixed in , % glutaraldehyde, postfixed with % osmium tetroxide and embedded in epon. ultrathin sections were stained with uranyl acetate and lead citrate. morphological three types of cob have been reported, including chronic catarrhal, catarrhal sclerotic and sclerotic forms. catarrhal cob was characterized with significant increasing of goblet cell count as compared to the bronchial mucosa in controls. hyperplasia of endoplasmic reticulum and golgi complex was observed. in the goblet cells, numerous secretory droplets were crowded together where they have been deposited from the surrounding cytoplasm. in ciliated cells, few cilia were seen in longitudinal section extending from the apical pole of epithelial cells, fragmentation of the endoplasmic reticulum and appearance of autophagosome were detected. in other types of cob, number of cell rows was decreased with different secretory activity of goblet cells. interepithelial migration of lymphocytes with the damage of the basement membrane was described. our findings demonstrated more aggressive changes of bronchial mucosa in sclerotic cob. chest trauma-induced rupture of benign mediastinal teratoma followed by a possible implantation of the tumor into the parietal pleura: a case report introduction mediastinal teratomas rarely rupture. an unusual case of chest trauma-induced rupture of benign mediastinal teratoma followed by a possible implantation of the tumor into the parietal pleura is reported. case presentation in a -year old woman, a pre-employment plain chest radiograph and ct of the chest revealed a large mediastinal tumor. two smaller tumors were located on the left parietal pleura. on operation completely obliterated left pleural space and three well-encapsulated tumors were found. microscope examination revealed three well-differentiated teratomas with no evidence of malignancy. three years before the detection of the tumor the patient had a blunt chest trauma, with a left-sided chest pain and shortness of breath, which gradually disappeared. at the time the plain chest radiograph was analyzed as normal. retrospectively an unusual mediastinal line, adjacent to the aortic arch, was disclosed. this line could be due to a small mass in the mediastinum. the left diaphragm was elevated, and a small leftsided pleural effusion could have been present. we suspect that teratomas located on the parietal pleura were caused by implantation of the tumor cells after the rupture of the mediastinal teratoma into the pleural space during blunt chest trauma. conclusion the chest trauma seen in presented case, could be at least a trigger, if not the only cause of the mediastinal teratoma rupture. the rupture was probably followed by both, obliteration of pleural cavity and possible implantation of benign tumor into the parietal pleura. the introduction malignant mesothelioma is an aggressive tumor with adverse prognosis (median survival - months) both in treated and untreated patients. in fact, only few patients survive more than two years. the identification of prognostic factors is critical to evaluate life-expectancy and crucial to approach novel therapeutical strategies. the study was performed to evaluate the use of mib- and p kip antigens as prognostic indicators of survival in malignant mesotheliomas. materials and methods a series of surgical biopsies of patients with known follow-up were immunohistochemically examined. the results were compared with survival data and correlated with clinical and histological parameters. for immuno-histochemistry, sections were stained for mib- and p kip antigens using abc method. number of positively stained nuclei was evaluated in consecutive high magnification fields ( neoplastic cells were considered the minimum number to include the case in the study). results mib- , which is largely expressed in sarcomatoid mm (p= . ), is more represented in patients with shorter (< months) then in subjects with medium ( <months< , p< . ) and longer (> months, p< . ) survival. on the other hand, p is more expressed ( ± . ) in patients with longer (p< . ) then in subjects with shorter survival. pearson's analysis showed no significant correlation between mib- expression and p , but this was predictive of survival in the entire population (r= . , p< . ). conclusion the findings suggests that p and mib- expression, although reliable attribute of mm, represent independent markers of prognosis in malignant mesothelioma. familial clustering of malignant mesothelioma without direct contact to asbestos. a genetic study introduction very few papers dealt with clustering of familial malignant mesothelioma (mm). most of these, who developed mesotheliomas, presented work or domestic history of exposure to asbestos, but only in very few of them asbestos did not demonstrated any association. the aim of this study was to contribute to the hypothesis of a genetic predisposition in the pathogenesis of the mesothelioma. methods we report two cases of pleural malignant mesothelioma that affected two young sisters as part of a nine-member family with enviromental exposure to asbestos. they were affected by marfan's syndrome and both developed pleural malignant deciduoid mesothelioma with long survival. we have performed comparative genomic hybridization (cgh) analyses of tumor samples to identify critical chromosomal regions involved in the onset of mm. we found similar chromosomal changes in both cases and in particular we found losses at q -q and q . -q chromosome. conclusions early onset s. and same genetic impairments in the two sisters suggest that genetic factors may induce the onset of this cancer in those subjects who are exposed even to small environmental amounts of asbestos. however, the specific chromosomal changes we found might provide evidence for locations of relevant suppressor genes of familial mm. video assisted versus needle biopsy of the pleura in patients with pleural effusion results correlation was found between p- -posivity tracheal mucosa and tnm classification system: p- index: control group= %, group t = %, t = %, t = %. conclusion the opinion that the presence of p- oncoprotein reflects mutation of the p- gene is commonly accepted. other data published evaluating the relationships between p- and tnm-stage, g-stage, tumor size and site, age and sex, did not reveal any dependencies, although some studies have suggested such correlations. our analysis had shown a correlation between tnm stage and p- index of tracheal mucosa, but is significant only between control group and t , and control group and t . authors expect such results that show the correlation between prognostic factors in laryngeal malignant epithelium and tracheal epithelium. undifferentiated nasopharyngeal carcinoma (lymphoepithelioma). report of four cases v blažičević, m mrčela, Ž kotromanović clinical hospital, osijek, croatia background nonglandular nasopharyngeal carcinomas are much more common in some areas of the orient than the other parts of the world. they are subtyped as keratinizing squamous cell carcinoma (type ), nonkeratinizing carcinoma (type ) and undifferentiated carcinoma (lymphoepithelioma). we present on four undifferentiated nasopharyngeal carcinomas and detail clinical and histopathological characterisation of these rare cases. methods all our patients were male, white and - years old. initial complaints were various: hearing loss, epistaxis, headache, and dysphagia. examination of the nasopharynx showed us entirely normal features, or fullness, surface granularity, or obvious carcinoma. but, all our patients had cervical lymph nodes metastases, two of them bilateral. involved lymph nodes were typically posterior of the sternocleidomastoid at the level of the angle of the jaw. results histologically, lesions show cytologically uniform cells with ovoid vesicular nuclei prominent nucleoli and indistinct cell borders resulting in a syncytial pattern. an inflammatory infiltrate rich in lymphocytes and occasionally containing prominent eosinophils is usually a component of lymphoepithelioma, but diagnosis is based solely on the nature of the neoplastic epithelial component. neoplastic cells are negative for lca, but positive for cytokeratin and ema. conclusion undifferentiated nasopharyngeal carcinoma (lymphoepithelioma) is very rare. about % to % of patients are initially seen with cervical lymph node metastases from an occult primary. such lesions may be different or impossible to distinguish from lymphoma on haematoxylin and eosin stained sections, particularly when the lesion appears as a lymph node metastasis from an occult primary. ancillary methods like immunohistochemistry and molecular techniques or detection of serum antibodies against viral proteins may be necessary. "atypical" pleomorphic adenoma of the parotid gland introduction pleomorphic adenoma is a benign, epithelial tumor, composed of cells that demonstrate both epithelial and mesenchymal differentiation, with the absence of abnormal cytomorphologic features. we present the case of -years old white women, with a mass localized in the superficial, lower part of the right parotid gland. on clinical examination, the lesion was nodular, painless swelling, of smooth surface, measuring x mm in diameter. the tumour was excised, fixed in formaline, embedded in paraffin and the sections were stained with he, pas and alcian blue. the tumour was composed of both epithelial and mesenchymal-like tissue, with a complete capsule at the periphery. there was no neoplastic tissue within or extending through the fibrous capsule. on the other hand, the epithelial component expressed mild, limited, abnormal cytomorphologic features, such as enlarged, pleomorphic and hyperchromatic nuclei. conclusions presence of prominent cytomorphologic atypias and capsular involvement in a pleomorphic adenoma causes concern about malignant transformation, but a lesion with mild or focally limited cytological atypias is designated as atypical pleomorphic adenoma and indicates an increase likelihood of malignant transformation if the tumor recurs. gene expression profiles were determined in fresh-frozen samples of mucoepidermoid carcinoma (mec), acinic cell carcinoma (acc), salivary duct carcinoma (sdc), and adenoid cystic carcinoma (adcc), using cdna microarrays containing cdna fragments of cancer-related human genes. the validity of findings was checked by means of real-time reverse-transcript polymerase chain reaction studies. seventy-five genes were found to be more than . times overexpressed and less than . times underexpressed than in samples of normal parotid gland. five genes, namely fibronectin (fn ), tissue metalloproteinase inhibitor (timp ), biglycan (bgn), tenascin-c (hxb), and insulin-like growth-factor-binding protein (igfbp ) were overexpressed in all of the types of carcinoma studied. sixteen genes, including mothers against decapentaplegic homolog (madh /smad ) and prostate-specific membrane antigen (psm/psa) were underexpressed in all types of carcinoma studied. average-linkage hierarchical clustering undertaken in relation to selected genes showed that high-and low-grade mecs formed one group of tumours, acc/sdc another. significance analysis of microarray findings identified genes related to the mec group, associated with the acc/sdc group. our results indicate genes that may be involved in carcinogenesis in the salivary glands. gene expression in normal and malignant salivary tissues was also found to be similar in several respects to gene expression in normal and malignant pancreatic and prostate tissues. rare tumours in the sinonasal tract p nagy, f salamon national medical center, dept. of pathology, budapest, hungary introduction sinonasal neoplasms include numerous groups of different histogenetic types. the epithelial tumours have the highest prevalence among them in the daily routine, but we can encounter such lesions, which may cause diagnostic difficulties. the purpose of this study is to determine the least frequent tumours in our sinonasal biopsy files. we collected those kinds of tumours which occurred only once in our series. we reviewed our archive material of a year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) five cases were selected. the histologic slides were re-examined. he, special stains, immunohistochemistry and electronmicroscopy were applied. the cases in the order of their occurrence: . fibrous solitary tumour, we supported our original opinion by cd immunostaining performed retrospectively. . chordoma, in addition to the morphologic features the s and cytokeratin co expression were pathognomic. . pnet, in this problematic case finally the cd positivity proved to be diagnostic. . intestinal-type adenocarcinoma, the mucocele-like appearance and the highly differentiated colonic type epithelial structures reminiscent of adenoma caused our dilemmas. . meningeoma, the immunohistochemical results were not convincing. we established the diagnosis by means of electronmicroscopy. conclusions the incidence of sinonasal neoplasms is low. the recognition of the unusual lesions in this region is a challenge for the pathologist. ancillary techniques may be necessary in the diagnostic process. squamous cell carcinoma: diagnostically problematic variants f salamon, p nagy national medical center, dept. of pathology, budapest, hungary the diagnosis of squamous cell carcinoma (scc) is seldom problematic. although it may cause difficulties for the pathologist to verify its uncommon varieties. the aim of this study was to distinguish the rare variants of scc from the conventional ones in our laryngeal tumour file and to present the most instructive cases. material and methods we reviewed our archive material of a year period ( ) ( ) ( ) ( ) ( ) . four cases were selected. the histologic slides of the preoperative biopsies and the surgical specimens were re-examined as well. he, special stains, immunohistochemistry and electronmicroscopy were applied. results . " carcinosarcoma" with rhabdomyosarcomatous differentiation. this case represents a unique example of the spindle cell carcinoma category. . verrucous carcinoma with verrucous hyperplasia. the interpretation of the latter term is a complicated issue. by virtue of our patient's follow-up we encountered this dilemma. . papillary squamous cell carcinoma (pscc). this -year long case history is a well-documented instance of a papilloma-papilloma with dysplasia-carcinoma sequence. . adenosquamous carcinoma. it was not easy to justify the clinical suspicion of malignancy preoperatively. furthermore we faced a differential diagnostic problem when we evaluated the removed larynx. conclusions in all the cases we managed to establish the definite diagnosis only by the thorough examination of the surgical specimens. additionally we found special features as far as the morphology and histogenesis are concerned. so we can confirm the subheading of the corresponding afip fascicle for this tumour group: diagnostically problematic variants. intraocular leiomyoma: case report introduction intraocular leiomyomas are rare tumours probably arising from the ciliary body smooth muscle. they represent a diagnostic dilemma and must be differentiated from neural tumours and, more importantly, from amelanotic melanoma. they occur more frequently in women, usually between the third and sixth decades of life. case report we report the case of a year-old woman with gradual loss of vision in her right eye. slit-lamp examination and binocular ophthalmoscopy showed a large and pigmented ciliary body mass located in the inferior quadrants. a and b ultrasound examination revealed a multicavitary tumor with low internal reflectivity measuring x . x . mm. enucleation of the affected eye was decided. histopathological examination showed a solid neoplasm composed of interlacing and tightly packet of spindleshaped cells with little intervening collagen. nuclei were oval with blunted ends with no significant atypia. mitotic activity was negligible. immunohistochemical stains for smooth muscle actin, hhf- , vimentin and desmin were positive. no stain was noted for s- protein, ae -ae cytokeratin, cam . cytokeratin, hmb- , glial fibrillary acid protein, neurofilaments, neuron-specific enolase and synaptophysin. final diagnosis was leiomyoma and the patient is free of disease two years after surgery. conclusions intraocular leiomyomas are of clinical concern since they are difficult to differentiate from more aggressive neoplasms, especially amelanotic melanoma. in this particular case, the situation was even more complicated because the lesion was clinically pigmented. once removed, the diagnosis was not difficult and was based on conventional histopathological examination along with confirmatory immunohistochemistry. results twenty-six of cases were male and were female. follow-up was available for cases and ranged between to months. eight cases died and had recurrences. the recurrent tumour histology changed from type to in cases, remained unchanged in . none of the clinical parameters were correlated with the survival. the type of therapy seemed to have no impact on survival. according to who classification cases were type , were type and were type and it showed correlation with survival (p= . ). lymphocytic infiltration, which, was added to who system, were seen by cologne classification in of tumours, but did not have an impact on survival. cellular morphology and atypia suggested by hsu's classification had no significance as well, although most of the tumours were classified as type a (% , ). ebv infection was found to be present in of cases. however no correlation with other parameters was found. conclusion in accordance to literature we concluded that who classification is the only parameter that has an impact on survival in npc. vascular endothelial growth factor expression and microvessel count in laryngeal squamous cell carcinoma -related antigen. paraffin embedded tumour specimens were stained with vegf and f-viii using immunohistochemical methods. vegf staining was evaluated as negative (<% of tumour cells) or positive (>% of tumour cells). staining intensity was graded mild, moderate and severe. for evaluation of f-viii staining, average counts of the three most vascular areas on an x field were recorded. statistically correlation between immunoreactivity and the clinicopathologic factors of laryngeal carcinomas was evaluated. results vegf expression in the tumour cells was found positive in all cases (% ). staining intensity was detected as severe of cases, moderate of cases, mild of cases. in evaluation of f-viii staining, average mvc of all cases was found , . statistically, no association was observed between the vegf expression, f-viii of carcinoma cells and histologic grade, tnm stage, tumour size and tumour site. association was observed between the vegf expression and mvc (p= , ). in additional, significant correlation was observed between the vegf percentage of positive tumour cells and staining intensity (p= , ). conclusion our data suggest that in laryngeal squamous cell carcinomas, vegf expression and mvc of carcinoma cells are not prognostic markers. acinic five cases of acinic cell adenocarcinoma, diagnosed in our laboratory during a period of years, are presented. four of them concerned salivary gland tumours of the parotid gland, the main site of their development, and the fifth was found as an endobronchial mass. the patients ranged from to years of age and the greatest stromal diameter varied from , to , cm. microscopically all neoplasms had the typical morphological features consistent with acinic cell adenocarcinoma. this neoplasm has distinct clinicopathological features and a rather indolent biological course, in spite of its malignant potential, responsible for the prevalence of the term carcinoma instead of "stromal". a broad histo-and immunohistochemical investigation was performed confirming the diagnosis. a review of the available reference is reported. relationship of p oncoprotein expression with histological grade and outcome of patients with oral squamous cell carcinoma introduction an alteration in the p tumour suppressor gene is the most frequent genetic abnormality in human cancers. overexpression of the p oncoprotein and histological differentiation were investigated in routinely formalin-fixed and paraffin embedded squamous cell carcinomas of the oral cavity. p oncoprotein was detected in all specimens with the monoclonal antibody do- . p oncoprotein expression was scored in the following way: score < %, score - %, score > % positive cells. results and conclusions using histological differentiation, all specimens are divided in three groups: group i -well-differentiated ( cases), group ii -moderately differentiated ( cases) and group iii -poorly differentiated carcinomas ( cases). in the first group % specimens were negative, %highly positive for the p oncoprotein. in the second group, positive detection of the p oncoprotein was observed as low in , % of cases, moderately in % and highly positive in , %. in the third group % expressed low positivity for the p oncoprotein and % of the cases had moderate and high positivity respectively. patients' survival was monitored for a five years. in the group with the highestp oncoprotein expression , % of the patients survived years or longer and , % survived less than years. mutation in the p tumour suppressor gene is highest in the well-differentiated squamous cell carcinomas, and its expression decreases in poorly differentiated carcinomas. immunohistochemical prognostic factors in laryngeal squamous cell carcinoma introduction the molecular mechanisms of growth and progression of laryngeal carcinoma are not studied well. the aim of the present study was to investigate the prognostic significance of over expressions of p protein, cyclin d , c-erbb , and markers of cellular proliferation (ki- and pcna). materials and methods primary tumours were studied on a series of patients. all patients were treated between the years and . the expression of p was analysed with monoclonal do antibody, cyclin d (clone dcs- ), c-erbb (polyclonal antibody hercep test), proliferate activity with ki- (clone mib- ) and pcna (clone pc ) results overexpression of the p protein was found in % of patients, cyclin d in %, and c-erbb -in % of patients with laryngeal squamous cell carcinomas. the reverse relationship of cyclin d with -year survival of patients (p< . ) was revealed. overexpression of the p protein was correlated with lymph node metastasis (p< . ). the value of pcna index in patients with metastasis is significantly higher than those in patients without metastasis (p< . ). the pcna index was correlated with the stages of the tnm. high level of the ki- index and the pcna index really decreases -year survival in patients. no significant correlations were found between positive p , cyclin d , c-erbb , ki- and pcna immunostaining and anatomical localization and histological grade. conclusions immunohistological examination of c-erbb is not a valuable prognostic factor in laryngeal carcinoma. high proliferation index (ki- and pcna) and expression of cyclin d correlate with worse prognosis of the disease. overexpression of the p protein is correlated with progression of laryngeal cancer. introduction warthin's tumor (wt) is a well-recognized benign neoplasm of salivary gland. granulomatous inflammation occurring in wt is a rare phenomenon. it has been suggested that prior fine needle aspiration (fna) biopsy might be the triggering factor. mycobacterial infection has also been reported as a cause of granulomatous change seen in wt. we report six cases of wt with granulomatous inflammation to analyse the possible relationship to prior fna. materials and methods a computerized search of pathology file of chang gung memorial hospital yielded cases of wt from to . granulomatous inflammation was described in six cases ( . %). fna cytology was performed in two cases before surgical excision. clinical history, histology and cytology slides were reviewed. ziel-neelsen stain was performed. results all tumours occurred in parotid gland. there were men and women. their age ranged from to yrs (mean ) and the tumor size ranged from to cm (mean ) in maximal dimen-sion. all six cases showed typical features of wt accompanied by multiple granulomas composed of epitheloid histiocytes and multinucleated langhans giant cells with or without necrosis. no acid-fast bacilli were found in any of these cases. history of prior fna was identified in two cases. both specimens also showed granulomas and features of wt. conclusions the pathogenesis of granulomatous inflammation in wt remains speculative. prior fna has been suggested to be the cause. however, this hypothesis cannot be supported by our observation of granulomas in the cytology specimens of two of our cases. it is most likely an immunologic reaction to the tumor, but a ziehl-neelsen stain should be performed to exclude the possibility of mycobacterial infection. malignant peripheral nerve sheath tumor masquerading as an allergic nasal polyp introduction approximately % of all malignant peripheral nerve sheath tumours (mpnst's) occur in the head and neck. of these, % are sporadic. the mean age at presentation is years. sinonasal tumours are extremely rare and whilst they share the morphology of mpnst's at other locations, they tend to be of low grade at this site. we describe a unique case of a high grade mpnst clinically simulating an allergic nasal polyp in an otherwise healthy child without identifiable risk factors. methods a year old black boy presented with an obstructive nasal mass, which was first felt months earlier. the clinical diagnosis was an "allergic polyp" and the mass was excised without antecedent roentgenographic investigations. results the x x cm tumor was unencapsulated but circumscribed, lobulated and friable. histologically, predominantly highgrade sarcomatoid and epithelioid areas were seen. however, differentiating features of peripheral nerve sheath tumor were also found. these included alternating hypercellular and hypocellular areas, palisading nuclei, perithelial accentuation of cells and serpentine, buckled nuclei. in low-grade areas, axons were demonstrated by silver staining. of the broad panel of immunohistochemical stains done, only s protein positivity was observed. the latter was uncharacteristically prominent. conclusion the young age of the patient, the tumor location and clinical presentation as an allergic polyp, the predominantly high grade microscopic appearance and the strong s protein positivity of this mpnst are unusual and hence worthy of documentation. follicular dendritic sarcoma in a black teenager -report of a south african case and literature review t n c) . histologically, the tumor cells were large with a low nuclear:cytoplasmic ratio, vesicular chromatin, and prominent nucleoli. the cells were arranged in organoid and trabecular patterns in a background of extensive necrosis and mitotic figures. ultrasound biopsy of the liver revealed metastatic disease. the patient died within weeks of surgery. the cause of death was unknown. no post-mortem examination was conducted. immunohistochemical expression of antikeratin ae /ae , chromogranin, and synaptophysin was evaluated. electron microscopy was performed. the tumor cells stained with anti-keratin ae /ae , chromogranin, and synaptophysin. electron microscopy revealed dense core granules. these findings, along with the morphologic criteria, fit with a lcnec. conclusion lcnec is a rare tumor in the larynx. recognition at this site is essential so that proper patient management can be initiated. analysis of blood serum lymphocytic phenotypes in chronic hepatitis c infected patients with advanced fibrosis and periodontium diseases introduction few studies focus on periodontium diseases in the course of chronic viral hepatitis c. the aim of this study was analysis of the relationship between the stage of periodontium disease and a number of lymphocytic phenotypes in blood serum of patients infected with chronic hepatitis c and advanced fibrosis. the study included patients (mean age of , years), whose blood serum revealed the presence of hcv-rna, demonstrated with rt-pcr method, while biopsies helped to reveal chronic hepatitis with septal fibrosis or cirrhosis. periodontium inflammation was assessed according to the following criteria: inflammation limbus, swelling, gingival pocket depth, presence of supragingival and subgingival calculus and gomphiasis. each criterion was assigned or point, cumulatively from to points. flow cytometry analysis included monoclonal antibodies: cd , cd , cd , cd /cd /cd , cd provided by becton-dickinson. analysis of morphological parameters and fluorescence was performed with cellquest computer software. results all patients with advanced liver fibrosis were found to show signs of advanced periodontum diseases (mean cumulative value of , points). the diseases most frequently encountered included: bleeding and calculus (n= ), deep gingival pockets (n= ) and gomphiasis (n= ). the degree of periodontal disease depended on the total number of t lymphocytes (p< , ) and on the number of t helper lymphocytes (p< , ). no significant dependencies were found between the degree of a periodontal disease and nk cells, b-lymphocytes or t suppressor. conclusion degree of periodontum disease in patients infected with hepatitis c is dependent on low values of t and t helper lymphocytes in blood serum. adenomatous ductal proliferative foci accompanied the warthin tumour in parotid gland t ohuchi , adenomatous ductal proliferation (adp) and intercalated duct hyperplasia (idh) which are two new similar disease concepts in the field of salivary gland have been reported recently focusing on the relationship of precursor lesion to some salivary gland tumour, differential diagnosis, and possibility of dedifferentiated lesion. we report here a case of warthin tumour accompanied by the foci of the adenomatous ductal proliferation in the parotid gland and these epithelial foci exhibited the histological and immunohistochemical findings resembling tubular type of basal cell adenoma. a -yearold female received the resection of warthin tumour in the parotid gland, which was diagnosed as a benign parotid gland tumour. macroscopically, this tumour showed two small legions in the parotid area, x mm and x mm in sizes respectively. the bigger legion was a typical warthin tumour consisted of papillary epithelial projections into cystic spaces associated with variable number of lymphocytes. papillary projections were lined by eosinophilic two cell layers having luminal columnar cells and basal polygonal to triangular shaped cells. on the other hand, histologically, the smaller legion resembled tubular type of basal cell adenoma. this lesion showed ductal proliferation with some admixed acinar cell complexes having a fibrous capsule in its half area. ductal proliferation consisted of bilayered structure (inner luminal cells were strongly positive for cytokeratin and weakly positive for s- protein). some stromal areas around the ductal components appeared to be cellular with spindle shaped cells strongly positive for s- protein immunohistochemistry. introduction malignant rhabdoid tumour of the oral cavity is very rare. to our knowledge, there has been one reported case of malignant rhabdoid tumour of the tongue so far. patient and methods a case of an -year-old female with malignant rhabdoid tumour of the tongue is presented. a patient presented with the induration of the anterior third of the tongue of months duration. the surface was bulging, berry-shaped and bleeding, suggestive of an animators lesion. the radial excision of the tongue was performed. results histopathological analysis revealed a solid tumour measuring cm in the largest diameter. the tumour was composed of epithelioid, eosinophilic cells with "rhabdoid" features; some of these cells contained rounded eosinophilic cytoplasmic inclusions that displaced the nuclei to the periphery. most of the cells showed strong diffusely distributed vimentin immunoreactivity and focal epithelial membrane antigen and keratin immunoreactivity. angioinvasion was present at the periphery of the tumour. following pathological report re-excision of the tongue was done and the patient received chemotherapy. seven month after the diagnosis, respectively, the patient showed no signs of tumour recurrence or metastases. conclusion although there has been a contradiction whether malignant rhabdoid tumour represents a distinctive clinicopathological entity or a phenotypic pattern shared by heterogeneous neoplasms, most of the authors support the diagnosis of "rhabdoid tumour" because the morphological pattern is attended by aggressive biological behaviour. a case of sarcomatoid salivary duct carcinoma ex pleomorphic adenoma in buccal mucosal region results and conclusion correlation of the presence of merkel and langerhans cells as well as the extent of mononuclear cellular infiltrate in the perimatrix according to the degree of ossicular defect and the destruction of the bony walls were made. we found that these cells are predominantly seen in the cholesteatoma with aggressive and destructive growth. they were seen in the less degree in the skin. the role of high-resolution flow cytometry in the grading of mucoepidermoid carcinomas malignancy with poor prognosis, but occasionally arises in the various mucosa of general site including nasal or paranasal sinuses and oral cavity. it shows wide variety in cellular morphology and histological architecture and, therefore, can be easily disregarded as other neoplasm in such instance above. we describe herein a series of malignant melanoma arising in the head and neck mucosa, which diagnosis was corrected in our review, and discuss its histological and immunohistochemical characteristic as well as important clues for diagnosis. materials and methods six cases were selected from the pathology files of kurume university hospital. histological sections were routinely processed, stained with h&e, and observed with a light microscope. immunohistochemistry and special stains were done as needed. among these, two arose in ethmoid sinus and the others in nasal cavity, inferior nasal choncha, tongue and palate, respectively. age ranged between and years old (average . ). the tumours showed undifferentiated morphology with anaplastic or sarcomatoid appearance and cellular population included ovoid, polygonal and spindle cells, occasionally intermingled with those with rhabdoid or plasmacytoid features. immunoreactivity for hmb , melan-a and cd , know as melanoma-related markers, considerably varied for each case, while that for s protein was relatively stable and useful for initial screening. melanin deposition was easily passed by, especially if it appeared in the stroma rather than neoplastic cells themselves, but quite important as well as intraepithelial spread of atypical melanocytes. if resected together, also mucosal tissue should be examined carefully. tenascin expression in salivary gland tumors: an immunohistochemical study in cases introduction tenascin is an extracellular matrix glycoprotein, which interacts with other extracellular matrix proteins and cells. it is reported that tenascin expression is detected in different localizations of normal salivary gland tissue and in most of salivary gland tumours. it is accepted as an indicator of invading potential in a report. the aim of this study is to detect whether tenascin expression patterns relate with type and malignancy of salivary gland tumours. material and method cases of salivary gland tumours: warthin's stromal, mixed stromal, myoepithelioma, basal cell adenoma, basal cell adenocarcinoma, acinic cell carcinoma, adenoid cystic carcinoma, malign mixed stromal were included in our study. antibody anti-tenascin was applied to the paraffin sections. results tenascin expression was observed in all tumours. most invasive expression was observed in mixed tumours, generally in extra cellular matrix localization and in the pattern of coarse clusters. warthin's tumours demonstrated dominantly epithelial tenascin expression, sometimes in globular pattern. in malignant salivary gland tumours tenascin expression is relatively rare compared with benign ones. conclusion our findings suggest that tenascin expression may show variations in patterns and localizations in different kind of salivary gland tumours. tenascin expression is not a feature of invasive potential but may be responsible of epithelial mesenchymal interactions, stromal growth, cell differentiation and production of mixoid and chondroid matrix. links between nucleolar and extracellular matrix proteins: tenascin and ki- in vocal cord biopsy m krstulja department of pathology, medical faculty of rijeka, rijeka, croatia introduction it is postulated that cancerogenesis goes through interchange of differentiation and proliferative processes. the aim of this study was to investigate morphogenesis and proliferation in the epithelial compartment of hyperplastic, dysplastic and neoplastic vocal cord mucosa with simultaneous expression of tenascin and ki- . materials and methods vocal cord biopsies were analysed: invasive squamous cell carcinomas, in situ squamous cell carcinomas, hyperkeratoses with low dysplastic change, papillomas and nodules with hyperkeratosis. immunohistochemistry was performed for each marker separately as well as simultaneously for both markers. results tenascin was expressed in differentiated and neoplastic tissues, decorating the membrane/cytoplasm of cells in carcinoma and dysplastic mucosa, but only the intercellular epithelial junctions in papilloma and hyperkeratosis. ki- , a nucleolar protein, decorated nuclei, nucleoli and chromosomes of cells engaged in mitosis in homotypic and heterotypic bioptic tissue. a double staining for tenascin and ki- revealed synchronous decoration of cytoplasms and nuclei in invasive squamous cell carcinoma ( / ), in cells of in situ squamous cell carcinoma ( / ) and occasionally in cells of dysplastic hyperkeratosis ( / ). simultaneous staining was not found in homotypic tissue. neoplastic cells in mitosis had tenascin stained membranes/cytoplasms or were tenascin negative. in dysplastic hyperkeratosis basal cells in mitosis had rarely tenascin positive membranes ( biopsy only). conclusion the observation that tenascin (a marker of morphogenesis) and ki- (a marker of proliferation) express simultaneously in neoplastic epithelial cells makes a difference regarding homotypic proliferation. introduction anaplastic thyroid carcinoma with an osteoclastoma like component is a rare type of thyroid neoplasm. the origin of the osteoclastoma like element has been a source of controversy, with conflicting theories emerging from the literature, some supportive of an epithelial origin with others favouring macrophage/ histiocytic lineage. ret/ptc is a fusion transcript associated with papillary thyroid carcinoma but not previously described in a tumour of this type. our aim was to examine more closely the osteoclastoma like component and assess the histogenesis of this tumour. materials and methods electron microscopy, histochemistry and a broad immunohistochemical panel were performed. in addition pure populations of each constituent cell type comprising the tumour were isolated using laser capture microdissection. after rna extraction, each of these was examined by rtpcr for chimeric transcripts of ret/ptc- and ret/ptc- . at this stage of our study, due to small differences in each epulis type, no far-reaching conclusions can be drawn. further studies of cd and mdm- protein in the same group of patients seem to be justified since in the authors' opinion, they will explain biological behaviour of that type of tumours. conclusions great proliferation activity of the cells in all types of epulides analysed with pcna, with low ki- and lack of p activity, was observed. adenoid cystic carcinoma and polimorphous low grade adenocarcinoma of salivary glands. a morphometric study c giardina results nuclei of plga resulted significantly larger and with a more regular shape than nuclei of acc. multivariate analysis discriminated the % of nuclei by utilizing variables: nuclear area and variables obtained by the nuclear asymmetry evaluation. conclusion morphocytological differences could have a discriminating power between plga and acc, they seem to be more important than architectural differences and could be related to their different biological behaviour. oral synovial sarcoma -a report of two cases and a review of the literature introduction the head and neck region constitutes the second most common site of involvement for synovial sarcomas, accounting for up to % of all cases. intra-oral synovial sarcomas are rare, with only cases having been reported. the aim of this study is to report additional cases of intra-oral synovial sarcoma, which occurred in the floor of the mouth and retromolar areas respectively in middle-aged black males and to review the clinico-pathologic features of all previously reported intra-oral cases. the current cases were immunohistochemically stained with ema, cd , bcl- , vimentin, cam . , mnf , ck , s- protein, hba , cd and calretenin; and subjected to ultrastructural studies. the literature was reviewed over a period of years, examining a total of cases of oral synovial sarcoma. the intra-oral cases differ from lesions occurring in other sites only in respect of a more marked male predilection, and a generally painless presentation. this is the first report demonstrating calretinin immunopositivity in intra-oral synovial sarcomas. even though in the oral cavity possible earlier detection, easy accessibility and small size renders them more amenable to surgical excision, their biological behaviour remains aggressive with a poor long-term prognosis. conclusion this study clearly demonstrates the histomorphologic, immunohistochemical and cytogenetic similarity of intra-oral synovial sarcomas to that of synovial sarcomas in general. the unusual intra-oral location often results in these lesions being misdiagnosed. these tumours should be considered, as both primary and metastatic tumours, in the differential diagnosis of intra-oral spindle cell malignancies. thirty nine years long follow up of the patient with dermatofibrosarcoma protuberans background dermatofibrosarcoma protuberans (dfsp) is an infiltrative, aggressive, nodular stromal with a great potential to relapse, that appears early in the life, in % of cases at the head and neck region. during last ten years there were five patients with the dfsp at the clinic for maxillofacial surgery of the military medical academy that makes . % of all cases with mesenchimal malignancy. here we present the most extreme case of the dfsp. case report s.s. was years old when she injured a small subcutaneous stromal at the right side of her forehead. ten years later it was cm wide and excised for the first time, as well as two years later when the relapse of the same size, this time involving the bone, was removed and the patient went through radiation therapy. after four corrective operations in a meantime, at her age of and the relapse cm wide from the right frontal region was removed. three years later, at her age of , stromal sized cm was excised from her right buccal mucosa. two years later, at her age of , local relapse was widespread into the right parotid gland, superior eyelid and frontotemporoparietal region including dura. two years after extensive ablative surgery and delicate reconstruction with scary compromised local cutaneous flaps, the relapse from the previously hardly mutilated right forehead region together with dura was removed. six years later, at her age of , the right orbit was exenterated together with excision of adjacent temporoparietal tissues. one year later the local relapses from the right infraorbital and buccal region were removed. two years after another stromal cm sized from the periorbital region was removed. after two years, at her age of , the lesion from her cheek was removed. it has been her tenth, but obviously not the last surgery. almost one year later there were no signs of local relapse or regional metastases at her routine postoperative check up. in spite of such a great mutilation of face and psychological disturbances connected with it, this is a case of successful surgical management of the dfsp. few times some differential diagnostic dilemmas appeared, but careful and detailed revision of all specimens definitely confirmed the dfsp. multiple and multifocal malignancy -a case report background it is well known that one either benign or malignant stromal can appear multifocally, as well as the fact that histologically different tumours can exist coincidentally. there is just a few papers concerning on how many different concomitant tumours can appear in the human body. this is a case of years old male with several tumours of different malignancy degree and morphologically benign or semimalignant cutaneous lesions. case report during previous years three times he underwent surgical excision of epitheliomas of the scalp, body and limbs. the third one has been removal of the epithelioma of the right frontoparietal region. at his age of because of the stromal sized cm in the right parotid salivary gland, followed by paralysis of the frontal and paresis of buccal branches, along with laboratory finding of . leukocytes, right-sided radical parotidectomy and suprahyoid dissection of the neck has been performed. pathohistologic analysis confirmed malignant mixed stromal of the parotid salivary gland. postoperative irradiation therapy has been applied in fraction and total dose of gy. nine months later the patient has been operated again because of an exulcerated, cm diameter cutaneous lesion of interscapular region, which has proved to be the infiltrative squamous carcinoma g- grade. at the same time the chronic lymphoproliferative disease in the form of chronic lymphocytic leucosis a grade has been diagnosed (although the reactivity following the neoplastic process could not be excluded), but specific haematological treatment has not been indicated. nine months later nine cutaneous facial lesions have been removed: malignant mixed stromal of the left auricle, senile keratosis from the left temporoparietal region, chronic dermatitis from the forehead, squamous carcinoma g- and seborrhoic keratosis one inch inferiorly, two lesions, sebaceous adenomas from the right zygomatic region, corneal squamous carcinoma g- from the right parietal region, baseocellular carcinoma from the left one and adenoid type of baseocellular carcinoma from the right supraclavicular region. the patient has been operated without complications and came five times for monthly control in a good general condition, without relapse, regional or distant metastases. later on we ascertained that the patient suddenly died during a sleep seven months after surgery. conclusion pathohistologic examination of removed tissues and revision of the former specimens undoubtedly excluded the spreading of the one and same stromal in different regions, but proved multifocal appearance of tumours of the same embryologic -ectodermal origin in very different structures. melanoma of the oral cavity -a case report background melanoma is a capricious malignancy followed by reputation of aggressive growth and dissemination, able to originate from any tissue containing melanin. in less than % it appears at mucous membranes. here we present a case of such localization. case report during last ten years there were patients with primary cutaneous head and neck melanoma who underwent surgery because of secondary deposits at the neck, but only one patient, r.m., years old (pale skin, dark hair and eyes, never working outside), who appeared four years ago with inoperable intraoral melanoma involving tongue, base of mouth, mucosa of the left cheek, retromolar region, tonsillar fossa and soft palate, including a single pendular mass from the left palatoglossal arc that almost completely narrowed his isthmus faucium. the first pigmentation he noticed eight months before his first admittance suffering of disturbed swallowing for few weeks. although there was no sign of regional or distant metastases, only the last-mentioned mass has been removed and pathohistologically verified as melanoma. patient was able to breathe normally, and continuing with his previous way of life. he received dtic during the first four postoperative months. one year later, smaller mass from the same location has been removed again. routine laboratory analyses, radiographic examination of the lungs, ultrasonographic examination of the neck and abdomen never revealed any changes. the third reduction under the same circumstances took place one year later and has been followed with minimal doses of adjuvant immunotherapy. conclusion this is a rare case of such a large, inoperable intraoral melanoma that has been three times reduced at the place of its exophytic growth into throat, otherwise demonstrating no signs of regional or distant spreading, as well as any disturbances in patient's general condition during last four years. introduction recent studies have shown that stromal reaction in cancer has an important diagnostic and prognostic significance. cd -positive stromal cells and myofibroblasts may play an important role in host response to cancer. the aim of this study was to analyse the expression and significance of cd , alfa-smooth muscle actin (sma), and tgfbeta in epithelial hyperplastic lesions (ehl) and squamous carcinoma (sc) of the larynx, and tried to reveal the mechanism of myofibroblast formation in sc. we investigated samples of resected larynxes with sc, laryngeal biopsies of ehl and sc, and samples of normal laryngeal mucosa. immunohistochemistry was performed with antibodies against sma, cd , cd , tgfbeta and tgfbeta receptor. the expression of tgfbeta mrna was detected by rna in situ hybridisation. results stroma of normal mucosa and ehl contained scattered cd -positive cells, but there were no sma-positive myofibroblasts. stroma of sc contained sma-positive myofibroblasts but there were no cd -positive stromal cells. in normal mucosa and ehl, tgfbeta and its receptor were present in epithelial cells and scattered stromal and inflammatory cells. in sc, tgfbeta , its receptor and tgfbeta mrna were found in stromal cells, inflammatory cells and some stromal myofibroblasts. conclusions disappearance of cd -positive cells and appearance of sma-positive myofibroblasts in the stroma is associated with transformation of laryngeal ehl to sc. this pattern of stromal reaction is limited to invasive carcinoma and should be regarded as an additional marker of invasion. our results also support the hypothesis based on experimental studies that tgfbeta may be one of the mechanisms of transformation of stromal cells to myofibroblasts in sc. introduction loss of heterozygosity (loh) on short arm of chromosome p is frequently found in squamous cell carcinoma of larynx and hypopharynx (lhscc). this is a region where potential stromal suppressor gene, frequently changed in pulmonary cancer, the fhit gene, is located. we wanted to determine whether there is presence of molecular and/or immunohistochemical changes in fhit gene in patients with lhscc. materials and methods dna was isolated from stromal and adjacent normal tissue using standard procedure. non-isotopic loh analysis was performed with micro satellite markers d s , d s , d s , d s , d s . formalin fixed tissue samples were stained immunohistochemically with antibody against fhit protein and reactions scored according to % of nuclear positivity in stromal cells. results loh at p was detected in ( . %) and microsatellite instability (msi) in ( . %) tumours, which were mostly moderately differentiated ( . %). introduction permeation of fixatives into tissue for optimal dna preservation for molecular pathology studies is related to tissue type and fixative but also to glycosaminoglycan content of the ground substance. this may alter with age, warranting further study. the aim of this study was to assess nuclear dna preservation related to age and fixation agent. materials and methods fresh standardised testicular tissue samples from dogs - months (i), months - years (ii) and years and over (iii) were used for immediate dna extraction (t ), extraction after hours (t ) and after days (t ) of immersion in formaldehyde-based and formaldehyde-free, commercially available fixatives. dna extraction used standard protocols, commercially available kits (qiaamp minikit, qiagen, the netherlands), standard primers for the betaglobin gene preserved between species (myo /my , digene/abbot, usa) and quantitative pcr (realtime light cycler, roche, amplification cycles). in formaldehyde free fixatives, initial loss of extractable dna in t samples of young (i) animals was % as compared to % in older (ii+iii) animals (p< . , student t-test). the same, with a significantly poorer result (p< . ) was found in formaldehyde based fixation, with loss of % in young (i) as compared to % (p< . ) in older (ii+iii) animals. at days, further loss to % of t values occurred in all age groups (p< . ), with formaldehyde free fixatives retaining the proportional age associated difference. in formaldehyde based fixatives at t , loss to % of t values was found (p< . ), again without statistically significant differences between age groups. the g a polymorphism of ccnd correlates with susceptibility and prognosis of breast cancer in taiwan cp yu a frequent g a polymorphism of ccnd gene located on the splice donor site on exon -intron boundary is implicated in influencing cyclin d mrna splicing and production of two distinct mrna transcripts. although cyclin d is believed to perform an important role in cell cycle progression, this g a single nucleotide polymorphism (snp) seems to be a critical modulator of its functions. it has been reported that the prognostic significance and mrna splicing regulatory effect of g a varies with tumor type and ethnic diversity. to explore the association between the ccnd g a polymorphism and the breast cancer susceptibility as well as other prognostic parameters, we employed infiltrating ductal carcinoma (idc) cases and native controls in this study. there is obviously correlation between the genotype distribution of these two groups (p= . ), and the aa genotype reveals a higher association and risk than the ag+gg genotypes (p= . with c test and or . , % ci . - . , p= . ). moreover, there is no statistical significance found between genotype or allele frequencies and tumor stage, grade, nodal involvement, or patient'¦s age. however, the trend tests of ccnd g a genotype distribution or allele frequencies to the increasing of tumor grade or tumor stage are significantly different when comparing the a vs. g allele (p= . in both tumor grade and stage) or aa vs. ag+gg genotype groups (p= . and . in tumor grade and stage, respectively) but no significance when comparing gg vs. ag+aa or ag vs. aa+gg genotypes. these results suggest that ccnd g a polymorphism correlates with idc susceptibility, and a allele reveals an increased risk in carcinogenesis of idc and worse prognosis. the new hope*-fixative as an enhancement in molecular pathology e during the last years the growing demand for the detection of prognostic and diagnostic biomarkers has been slowed down to a large degree by the use of formalin and its influence onto antigenic structures and nucleic acids, although other reasons also exist. with regard to morphology a limitation in the possibilities, compared to frozen sections, takes place. with the introduction of the hopefixation to date both has become possible; substantially enlarged possibilities concerning the detection of dna, rna and proteins together with a formalin-like morphology. this will be demonstrated by presenting several examples like preservation of nucleic acids (dna, rna), the detection of those by pcr and rt-pcr, in situ hybridization and the preservation and delectability of proteins by immunohistochemistry. we conclude that hope-fixation opens up new possibilities, especially within the growing number of diagnostic and prognostic biomarkers. *hepes-glutamic-acid-buffer-organic-solvent-protection-effect introduction high-risk human papillomaviruses (hpv) represent a major risk factor for the development of cervical cancer. quantitative real-time pcr for viral load determination of hpv in archival cervical cancer specimens could be of clinical and prognostic relevance. the aim: we investigate the prognostic value of hpv status and viral load. furthermore, we compared the applicability and sensitivity of three molecular hpv-detection methods. materials and methods all examinations were carried out from formalin-fixed, paraffin-embedded tissue of cervical carcinomas. hpv status was detected by signal amplified chromogenic in situ hybridization (sa-cish), conventional polymerase chain reaction (pcr), and detection and additional quantitation was performed using real-time pcr. results patients with low viral load of hpv in stage i carcinoma had a significantly better prognosis than hpv -negative patients (p= . ). additionally, high viral load of hpv in patients indicating a higher stage carcinoma strongly tended to benefit prognosis compared to hpv-negative patients. our evaluation of the molecular hpv-detection methods showed a higher sensitivity of real-time pcr and conventional pcr compared to sa-cish. conclusion it appears that cervical cancer patients can be distinguished in a hpv -negative subgroup revealing a worse prognosis, and a lower-stage subgroup with low viral load, respectively a higher-stage subgroup with high viral load, both indicating a better survival, maybe due to an altered immune status caused by hpvinfection. these findings are crucial to accord each patient the individual therapy, and point out the importance of quantifying viral load and the necessity of real time-pcr in hpv-diagnosis. laser capture microdissection in -d coculture models as a novel tool to study tumor-stroma-interactions introduction cellular adhesion, migration and invasion are essential processes in tumor progression and do include actions by malignant cells as well as by the stromal microenvironment. in vitro, these interactions can be studied in coculture models. in conventional coculture systems, the different cell types are grown together in glass-slide based chambers with medium. in situ analysis can be easily performed, however, for mutational or gene expression analyses the cell compartments have to be dissociated and sorted. we present a novel technique for co-culturing fibroblasts and carcinoma cells and separating them without cross-contamination. methods our method is based on cell cocultivation on a . µm thin membrane followed by laser microdissection of tumor and stroma cells. for identifying the tumor cell compartment, immunolabeling for the laminin gamma chain was performed, a marker that is expressed only in epithelial tumor cells. dna and rna was isolated from the microdissected cells. rna quality was tested by rt-pcr for a housekeeping gene transcript and for the laminin gamma chain gene transcript. results co-cultivation on the membrane did not influence growth behaviour and cell morphology. the rna quality from the microdissected co-cultured and immunostained cells could be successfully proved by rt-pcr. laminin cdna was amplificable only in tumor cells and not in the co-cultivated fibroblasts indicating no cell-cross-contamination during microdissection. conclusion our technique provides a suitable tool to study tumor -stroma interactions at the dna or rna level for expression profiling and genetic analyses. p expression in prostate cancer and its correlation with microvessel density i pavlenko, a matsionis rostov regional bureau of pathology, rostov on don, russian federation introduction angiogenesis is important in the development and progression of all cancer types, including prostate adenocarcinoma (pca). increased vascularization may be influenced by p status. the aim of this study was to evaluate mvd in prostate cancer and its relationship with p nuclear accumulation. methods paraffin-embedded tissue from patients with well-, moderately and poorly differentiated prostate carcinoma was examined immunohistochemically using monoclonal antibodies against cd , vegf and p (clone do- ). a modified semiquantitative weidner score and computerized image analysis was used to assess mvd. results expression of immunohistochemically detected p protein was found in of cases ( %). p nuclear accumulation was observed in two different groups of cancers -poorly differentiated pca with high vegf expression and high mvd, with high level of serum psa ( cases) and moderately differentiated pca without significant microvessels with low serum psa ( cases). we suppose p mutation in the first group of patients which leads to increased angiogenesis as the result of loss of wild-type p induced anti-angiogenic control. in our opinion p detection in the second group of p + patients is the result of overexpression due to stabilization but not mutation. conclusion p overexpression is observed due to either mutations or protein stabilization. increased angiogenesis seems to be influenced by p mutations, while low mvd is observed in cancers with non-mutated p . immunohistochemistry alone is not able to detect p mutations, additional techniques are need for this purpose, especially in patients with p nuclear accumulation. malignancy-associated x chromosome loh in foregut endocrine neoplasms: further evidences in lung tumors introduction association of x chromosome allelic losses (loh) with tumor malignancy has been found in foregut-derived gastropancreatic endocrine neoplasms, but not in midgut carcinoids. also lung endocrine tumors originate from the embryological foregut. they are classified into "typical" carcinoids (tc), "atypical" carcinoids (ac), large cell neuroendocrine carcinomas (lcnec) and small cell lung carcinomas (sclc), in order of increasing malignancy the aim of this study was to investigate x chromosome loh and its association with malignancy in a series of endocrine tumors of the lung. materials and methods dna extracted from tcs, acs and lcnecs from female patients was pcr-amplified using fluorescently-labeled primers for microsatellite markers spanning the whole x chromosome. for loh evaluation, amplimers were analysed in an automatic dna sequencer (ceq , beckman coulter). all samples were formalin-fixed, paraffin-embedded and dna from tumoral and non-tumoral adjacent tissue was available results allelic losses were absent in tcs, while loh on x chromosome was found in of acs ( %) and in of lcnecs ( %). allelic losses were generally wide, involving all or most informative markers investigated conclusions allelic losses on x chromosome, absent in benign "typical" carcinoids, progressively increased their frequency from intermediate-grade "atypical" carcinoids to high-grade lcnecs. therefore the observation that x chromosome loh is associated with malignancy, already demonstrated in gastro-pancreatic endocrine tumors, is extended to another group of foregut-derived endocrine neoplasms, the lung endocrine tumors we investigated formalin-fixed, paraffin-embedded tissue samples. from each paraffin-block four times one to two µm sections in three steps and two µm sections were cut and put to . ml reactiontubes. one tube of the thin sections and the thick sections were exposed to heat/cold shocktreatment, one tube had a proteinase-k treatment for only three hours instead of overnight, and the thin cuts in another tube were treated with a riboliser. dna amount and purity measured by spectrophotometry after extraction. pcr was performed with routinely used srdna-primers. results over all we obtained best results with cutting up thin sections and proteinase-k treatment overnight. this tissue yielded the best purification, the highest dna amounts and strongest bands in agarose gelelectrophoresis. second best were thick and thin sections with heat/cold shock-treatment and proteinase-k treatment overnight. conclusion the mechanical opening of the mycobacterial wall using a standard microtome is a feasable way to obtain higher dna-amounts -purity and -complexity resulting in stronger signals following pcr. impact of tumour suppressor gene pten on cell cycle and apoptosis in prostate cancer cell lines introduction the progression of prostate cancer from androgenresponsive to an androgen-unresponsive status remains the greatest problem in the treatment of this disease. aims: to study the relationship between telomerase activity and gene expression after bicalutamide treatment in prostate cancer cells. material and methods androgen-responsive (lncap) and androgen-unresponsive (du- ) prostate cancer cell lines treated with µm bicalutamide for hours were analysed by affymetrix hg-focus array chips and their expression pofile was compared with control. the decrease of telomerase activity which was associated with increase of p waf /cip and decrease of dyskerin and hsp were found in lncap cells only. dna damage-responsive genes were upregulated in both cell lines. in lncap cells, the increase of p waf /cip was associated with induction of p -dependent gene expression (gadd α, bax, mdm- and trail-r ). we have also found induced transcription of pro-apoptotic genes represented by bnip -like, bcl- , cbx and tradd and the decrease of anti-apoptotic protein, survivin. in du- cells, we observed an increase of mt p , trail-r , gadd , gadd α expression together with a decrease in expression of survivin and the pro-apoptotic bnip gene. conclusion the decrease of telomerase acivity in lncap cells after bicalutamide treatment could be explained by changes in expression of p waf /cip , dyskerin and hsp . bicalutamide upregulates dna-damage genes in androgen-responsive as well as androgen-unresponsive prostate cancer cell lines. this work was supported in part by msm and nc/ - . introduction bicalutamide, an androgen antagonist used in the prostate cancer treatment, has a significant cytostatic effect on cancer cells. the aim of this study was to analyse the changes of bcl- family members after bicalutamide treatment in androgen-responsive (lncap) and androgen-unresponsive (du- ) prostate cancer cells. comparing the toxicity and potential carcinogenicity of two antiestrogens. a short-term study with microarray analysis in female rat liver introduction tamoxifen and toremifene are triphynylethyle antiestrogens used in the treatment of breast cancer. tamoxifen is genotoxic hepatocarcinogen in the rat, whereas toremifene is not. in humans, long-term tamoxifen treatment causes an increased risk of endometrial cancer. the major difference between the genotoxicity of the two drugs is the formation of liver dna-adducts in tamoxifen-treated rats. differential gene expression in rat liver after administration of antiestrogens was studied by microarray analysis. materials and methods equimolar doses of antiestrogens were given p.o. to six week old female sprague-dawley rats for days. total rna was isolated using trizol reagent. equal amounts of total rna from four animals in the same group was pooled and then purified from mg total rna using mg oligo(dt)cellulose. our cdna array contained approximately cdna clones selected from the tigr rat gene index. the samples were hybridized to rat cdna array scanned with a gms scanner (afflymetrix). image analysis was performed using the genepix pro software. normalization was performed using lowess normalization. the results from rat cdna array were evaluated according to 'significance analysis of microarrays' (sam). results sam plot for tamoxifen vs. control revealed significant genes from which were positive significant (up-regulated, red) q < %, . particularly the nadph-cytochrome p oxidoreductase and microsomal epoxide hydrolase were upregulated genes which are apparently related to tamoxifen-induced carcinogenesis. sam plot for toremifene vs. control revealed significant genes from which were positive significant q < %, . conclusion microarray technology gives important information of the toxicity as well as carcinogenicity of antiestrogens in experimental conditions. the ret proto-oncogene tyrosine kinase receptor is activated by a ligand complex comprising glial cell line-derived neurotrophic factor (gdnf) and gdnf family receptor alpha- (gdfralpha ). they are expressed in multiple organs during development and also in some types of human tumors in adults. the aim of this study is to investigate ret, gdnf and gdfralpha expression in normal tissue and tumors derived from the gastrointestinal tract, circumstance that we have not found it published in the literature. material and methods ret, gdnf and gfralpha expression was analyzed in samples of fresh frozen and formalin-fixed tissues from tumoral zone, and adjacent non-affected tissue of biopsies from patients with gastrointestinal cancer using rt-pcr and immunohistochemical methods. results presence of ret, gdnf and gfralpha transcripts in most of normal tissues was confirmed by rt-pcr. immunohistochemical study showed positive staining in citoplasms of glandular epithelium of the mucosa, ganglionar cells and muscular fibers (only gdnf) of esophagus, stomach, duodenum, colon and rectum but not in jejunum and ileum. gastric oxyntic cells were negative. sixty four gastrointestinal tumors ( adenocarcinomas and cases of gist) were also studied. by immunohistochemistry, % of cases showed citoplasmic immunoreactivity for gdnf; % for ret and % for gfralpha . these findings were confirmed by rt-pcr. there was not association with microscopic type, size, grade or duke stage. our study shows ret, gdnf and gfralpha positive protein and mrna expression in normal tissues and in the majority of tumors derived from the gastrointestinal tract. there is no association with microscopic type, size, grade or lymph node metastasis. this expression gives no prognostic information in the clinical management after two years follow-up of our patients. expression analysis of ret and its gdnf/ gfralpha ligand complex in breast cancer introduction the ret proto-oncogene tyrosine kinase receptor is activated by a ligand complex comprising glial cell line-derived neurotrophic factor (gdnf) and gdnf family receptor alpha (gfralpha ). they are expressed in multiple organs during development and also in some types of human tumors in adults. in this study we evaluated the expression of ret, gdnf and gfralpha in normal mammary tissue and different types of breast cancer. material and methods ret, gdnf and gfralpha expression was analyzed in samples of fresh frozen and formalin-fixed tissues from tumoral zone, and adjacent non-affected tissue of mastectomies from patients with different types of breast cancer ( dic, lic, medullary carcinoma, mucinous carcimoma, papillary carcinoma and fibrosarcoma) using rt-pcr and immunohistochemical methods. results normal breast ductal epithelium express ret, gdnf, and gfralpha . by immunohistochemistry, , % of breast tumors showed citoplasmic immunoreactivity for ret, , % for gdnf and , % for gfralpha . rt-pcr confirmed mrna expression in , % of cases for gdnf, , % for ret and , % for gfral-pha . by chi-square analysis, ret expression was associated with less tendency to the regional lymph nodes metastases (p< , ) and low grade differentiation (p< , ). there was not association with microscopic type, size or stage. conclusions we found that ret and its gdnf/gfralpha ligand complex are expressed in normal breast tissues and in a high percentage of different types of breast tumors using immunohistochemistry and rt-pcr. univariant analysis also revealed that only ret expression was associated with less tendency to the lymph nodes metastases and low grade dics (highly differentiated tumors). the short time follow-up of our patients (less than two years) gave no information about clinical outcome. telomerase activity in chronic b-lymphocytic leukemia r telomerase, the enzyme that elongates telomeres, contains an rna template complementary to ttaggg repeats that permits de novo synthesis of telomeric dna onto chromosomal telomeric ends. recent findings have suggested that activation of telomerase is one of the most common and fundamental steps in cancer genesis, although reactivation or telomerase up-regulation alone might be insufficient for cells to proliferate indefinitely. telomerase expression seems to be concomitant with the attainment of immortality of cancer cells, but there are contradictory reports about telomerase activity in early and late b-cll stages. in order to investigate the telomerase activity in patients with cll and its correlation with the clinical stage, frozen blood lymphocytes samples from patients with cll ( males, females), and age matched controls ( males, females) were investigated for telomerase activity using the 'telomerase pcr elisa-plus kit' from roche, based on the telomeric repeat amplification protocol. binet and rai stages were evaluated at the time of sample collection, and re-evaluated after - months. results were analyzed with a commercial statistic software package. the study showed that peripheral lymphocytes telomerase activity from b-cll patients is significantly higher ( , times; p< , ) compared to normal lymphocytes. the age and sex of patients does not influence the telomerase activity, while it is age dependent in healthy controls (pearson correlation - , ; p< , ). the study also showed that telomerase activity is increased more significantly in advanced stages of the disease, and correlates with the disease course. introduction deltan-p isoforms may act as oncogenes, owing to their ability to bind to p -reporter genes without inciting their transcription, thus blocking the p -driven cell cycle arrest and apoptosis. a novel mechanism, linking p and wnt pathways has recently been proposed. briefly, in vitro studies have suggested that deltan-p may block the phosphorylation of beta-catenin, leading to its nuclear accumulation and triggering beta-catenin-responsive transcription of genes related with proliferation and oncogenic biological behaviour. to test this new mechanism, the authors evaluated the co-expression of deltan-p and beta-catenin in a large cohort of human neoplasms. methods two sections of tarp- multi-tumour tissue microarray, composed of normal tissue cores and human neoplasms (breast (n= ), colon (n= ), lung (n= ), prostate (n= ) and ovary (n= ) neoplasms, melanoma (n= ), and glioblastoma (n= )) were subjected to immunohistochemistry with deltan-p and beta-catenin monoclonal antibodies. p nuclear expression and b-catenin membranous, cytoplasmic, membranous+ cytoplasmic, and nuclear localisation were independently evaluated by three of the authors. results p expression and beta-catenin nuclear localisation were found in . % and % of squamous cell carcinomas, . % and % of breast carcinomas, . % and % of lung adenocarcinomas, . % and . % colon adenocarcinomas, % and . % of prostate adenocarcinomas, . % and % of ovary carcinomas, . % and . % of malignant melanomas, and . % and . % of glioblastomas, respectively. no statistically significant association between p and nuclear beta-catenin expression was found for all tumours. conclusions at variance with squamous cell carcinoma cell lines, p -driven nuclear accumulation of beta-catenin is an unusual phenomenon in human neoplasms. caution should be exercised when translating the results of studies performed on cell lines to human neoplasms. four gist had no identificable kit sequence alteration in exon . mutations in c-kit seemed to be associated with favorable response to sti- (p= , ). conclusion kit mutations in exon are common in diseminated gastrointestinal stromal tumors and appear to be associated with response to sti- . the use of macro-array to study the effect of intestinal trefoil factor on gene expression in caco- derived enterocytes intestinal trefoil factor (itf) is a member of the trefoil family of peptides. it increases resistance to apoptosis, enhances mucosal healing and restitution in vivo and promotes migration of intestinal epithelial cells in vitro. the aim of this study was to investigate the influence of itf on gene expression in intestinal epithelial cells. the human colon carcinoma cell line caco- develops structural and functional characteristics of normal enterocytes when kept in culture. enterocyte-like caco- cells were treated with recombinant itf during hours. rna was isolated and labelled cdna was synthesised. the cdna probe was hybridised to the human unigene set colony filters (rzpd). after several washing steps, the amount of signal was measured using a phospo-imager. spot intensities were measured and signal quality was evaluated. using a fold increase or decrease as a cut off, comparison of the gene expression between un-stimulated caco- cells and cells stimulated with itf using the macro-array technique revealed a few hundred genes that were potentially differentially expressed. our data show that the macro-array is a powerful technique to screen for differen-tial gene expression as a result of trefoil administration, helping to study signalling cascades. however, it is necessary that the huge amount of data obtained is filtered through repeated hybridisations, only to retain the relevant changes and these data must be confirmed using other methods like quantitative real-time pcr and eventually studies at protein level. introduction melanoma therapy still remains without notable success of any pharmacological agent. gastric pentadecapeptide bpc is a peptide with various pharmacological effects on different organ systems including wound healing and inflammation. its possible effect on cell growth and differentiation was not investigated on human cancer cell lines. human melanoma cells were maintained in rpmi- medium supplemented with % fbs and antibiotics. cells were grown to confluency in humidified incubator ( % air atmosphere, %.co ) at °c. upon reaching confluency, cells were maintained in chemically defined medium (cdm). bpc was added in the culture medium in the various concentrations ( pg. and ng, respectively) for a period of hours. cell morphology was observed daily under light microscope and the photomicrographs were taken. after harvesting cells were prepared in etoh for flow cytometry analysis. results microscopy did not reveal any changes upon treatment with bpc after h comparing to controls. flow cytometry showed % of cells (p> . ) were in g -g phase. control cells had total s-phase fraction of . %. however, upon introduction of bpc , in concentration of pg/ml, the percentage of cells in sphase was decreased by % compared to controls. moreover, the concentration of ng/ml bpc lowered total s-phase fraction by % comparing to controls and by % comparing to bpc in picogram values (p> . ). conclusion we assume that gastric pentadecapeptide bpc could act as a inhibitory agent during g -s transition state of cell cycle thereby preventing dna synthesis and cell growth. introduction histones play an important role in the structural and functional properties of chromatin. their protective role against radiation-induced damage of dna is well established. the aim of this study was to evaluate relation between expression of histones genes and radiosensitivity of brain gliomas in vitro. five human glioma cell lines obtained from dsmz (germany) were irradiated with gy and gy doses (co- ) and further grown for , and hrs. the expression of genes coding for histones h , h a, h b, h , h was measured with real-time quantitative rt-pcr assay (taqman). radiosensitivity of the cell lines was assessed with cytokinesis-block micronucleus assay. cell lines were regarded as radioresistant and radiosensitive at micronuclei per binucleate cell ratio (mn/bnc) < . , and > , respectively, as measured over a dose range of - gy. results the global number of copies of histone mrna did not differ in both groups. in radiosensitive cell lines (gamg, -mg-ba) expression of h b was highest in / cases, while in radioresistant (gos- , -mg-ba, u- -mg) h predominated in / cases. in both groups significant decrease of global histone genes expression after gy dose was found. relative increase of h and h b fractions after irradiation was observed. conclusion overall expression of histone genes does not seem to influence radiosensitivity of glioma cells. probably, more important is the profile of expression, e.g. differences between h and h b genes. this profile may be a useful adjunctive criterion in the choice of treatment protocol for brain glioma. introduction the detection of breast cancer (bc) micrometastasis in effusions is difficult since the malignant cells are rare and spread amongst the normal population. rt-pcr for human mammaglobin (hmam) has been described as a new, sensitive method for use in bc cell research. some authors have proposed using this assay for screening bc effusions for bc micrometastatic disease. the aim of this study was to investigate the possible application of rt-pcr for hmam for assessing bc cells in effusions and compare this methodology with cytological examination. the study was performed on fluid specimens ( bc, other types of cancer and without known carcinoma). the samples were analyzed by staining with ee, papanicolau technique, and by nested rt-pcr for hmam. results / ( %) cases of bc pathology were positive using nested rt-pcr for hmam. all cytology positives were also positive by nested rt-pcr. in contrast, bc cases that were positive in the molecular test were negative according to the staining assay. hmam was also detected in / ( %) specimens of other types of cancer and only / ( . %) samples of non-neoplastic origin. conclusion nested rt-pcr for hmam was more sensitive than cytology in determining bc micrometastasis in effusions. positivity was not restricted to samples from bc patients as specimens from other tumors and only . % of patients without cancer were also positive. this test could be helpful in investigating neoplasticity in effusions. introduction hepatic ischemia-reperfusion injury results from implementation of pringle's manoeuvre to prevent blood losses in patients undergoing liver segment resection. reoxygenation after the ischemic period leads to failure of hepatic microcirculation, leucocyte invasion and kupffer-cell activation. subsequent production of inflammatory cytokines and ros (reactive oxidative species) are triggered, thus causing oxidative stress and damage of liver parenchyma. the goal of our study is to evaluate markers associated with the severity of this particular type of oxidative stress at the gene expression level. we have analyzed liver tissue biopsies at different timepoints obtained from patients undergoing liver segment resection. in each case, the first sample is taken before clamping, the second sample is taken after minutes of ischemia, and the third sample is taken after minutes of ongoing reperfusion. we compared mrna levels of several genes (sqstm , hspa a, gpx , sod , hmox) in every set of samples by quantitative rt-pcr analysis. significant elevation of hspa a at timepoint was detected in of cases. this finding suggests that hspa a may represent a useful marker for oxidative injury of hepatic tissue. at the same time, we show that the detection of changes in gene expression within minutes of reperfusion is possible by quantitative rt-pcr from a single biopsy. we hypothesize that individual differences in gene expression may reflect severity of the inflicted ischemia reperfusion injury as well as patient prognosis. the clinical significance of our preliminary results is currently under investigation. automated tissue microarray evaluation and normalization using a dna scanner oridis-biomed gmbh, graz, austria institute of pathology, graz, austria introduction tissue microarray (tma) immunohistochemistry is gaining importance in drug target validation. hundreds of tissue samples on a single slide enable simultaneous immunohistochemical assessment of protein expression. correlation of expression levels of the target antigen with clinical parameters can facilitate determination of disease relevance and therapeutic potential. the aim of this study was to extend the scope of this technology, we developed a robot for automated tma production. we further assessed the use of a dna microarray two color laser scanner for automated analysis of tma immunohistochemistry and the use of an internal reference antigen for standardization to the tissue content. the tma robot was developed in cooperation with an engineering company. a breast carcinoma tma was stained with an estrogen receptor (er) antibody. lung carci-nomas tmas were double stained with combinations of rabbit and mouse antibodies. immunoreactivity was detected with fluorescently labeled secondary antibodies. the slides were evaluated using a cdna array scanner and software. fluorescence intensity for er ihc on a breast carcinoma tma correlated positively with independent assessment of the diagnostic er immunoreactivity score, suggesting that ihc quantitation can be achieved with the dna array scanner. double ihc on lung tmas demonstrated that one antigen reference can normalize tumor marker ihc signals for the cellular content of tma cores. ihc signal normalized in this fashion correlated with clinical parameters in agreement with published results. manifestation of metallothionein (mt) correlates rather with cell differentiation than with intensity of proliferation. introduction metallothioneins (mt) are proteins which are supposed to play role in the cell cycle. numerous publications describe positive correlation between intensity of mt expression and proliferative potential of cells. our study aimed at examining the relationship between mt expression and intensity of proliferation, measured using ki antigen. the studies were performed on samples of ductal breast carcinomas of g , g or g grade of differentiation as well as on samples of normal epithelium and planoepithelial carcinoma of uterine cervix. paraffin sections of the examined cases served to perform immunocytochemical reactions using mouse monoclonal antibodies to mt and ki . double staining reactions were also performed using the same antibodies. the performed studies showed that mt expression in breast cancers of g grade was significantly lower than in cancers of g or g grades (p= . ). in the case of ki , the least intense expression characterized cancers of g grade and the most intense reaction was noted in cancers of g grade (p= . ). no relation between mt and ki expressions was observed in g and g groups of breast cancers (p> . ) while in the g group as well as in the entire group of breast cancers (g to g ) a positive correlation between the two expressions was noted (p< . ). analysis of reactions in the non-keratinising stratified flat epithelium and in the planoepithelial cancers of uterine cervix showed no correlation between expressions of mt and ki . however, mt expression was detected only in the least differentiated cells of the epithelium. conclusion our showed that mt expression tends to correlate more with cell differentiation extent than with proliferative potential of the cells. is the activation of akt a prognostic parameter in colorectal cancer? akt (protein-kinase b, pkb) is a serine-threonine kinase that is activated mainly by insulin, igf- receptor and erbb family receptor signaling in a pi -kinase dependent manner, and is implicated in tumor proliferation in breast, ovarian, pancreatic and gastrointestinal cancers. the phosphorylation of its substrate proteins result in increased growth and decreased susceptibility to apoptosis. the activation of the pi k-akt pathway is downregulated by pten phosphatase, and mutations or a loss of pten activity results in a high constitutive activation of the kinase. the aim of the present study is to investigate the levels of the activation of the pi k-akt pathway in a series of colorectal carcinomas and to evaluate its role on tumor resistance to chemotherapy. we achieved surgical colorectal carcinoma specimens at pt stage. all patients received at least two chemotherapy lines based on platinum and cpt- after surgery. levels of activation of akt were tested by immunohistochemistry in primary tumors using a polyclonal antibody that recognizes the phosphorylated akt at ser . in the series, ( . %) showed staining for phosphoakt in tumor cells. phos-phoakt was detected in tumor as clusters of cells related to necrotic foci and differentiated areas and correlated with less response to chemotherapy. these results point out that . activated akt is often overexpressed in human colorectal carcinomas and .activated akt can be a parameter of chemotherapy resistance in colorectal cancer. mutational analyses of the ret proto-oncogene in slovenian men families introduction alport syndrome (as) is a progressive inherited nephropathy, characterized by irregular thinning, thickening and splitting of the glomerular basement membrane (gbm), associated with hearing loss and ocular symptoms. as is caused by col a mutations in its x-linked form and by col a and col a mutations in its autosomal recessive form. the mutations in col a and col a have been reported in familial benign hematuria (bfh). aims: we screened col a , col a and col a genes in slovenian families with x-linked as and in slovenian families diagnosed with bfh to determine pathogenic mutations, to correlate them with clinical features and to confirm or provide precise diagnosis. materials and methods genomic dna was isolated from blood. screening for mutation was done by the optimised ssca after pcr amplification of each exon of col a , col a and col a and changed samples were sequenced. we found six different mutations in col a gene in as suspected patients. one of the mutations was present also in three families with bfh. in col a gene three and in col a four mutations, all in heterozygous state, were identified only in patients with bfh. eleven of the mutations are new and private. four rare variants of unknown pathogenesis and many polymorphisms were found in the col a and col a genes. a mutation was detected in % of as patients and in % patients diagnosed with bfh conclusions our study broadened the spectrum of mutations in col a , col a and col a and demonstrated the involvement of the col a and col a genes in the pathogenesis of bfh. introduction prion diseases are a group of fatal neurodegenerative disorders. the commonest human prion disease is creutzfeldt-jakob disease (cjd). sporadic cjd is genetically characterized by a lack of pathogenic mutations in prnp gene but methionine/ valine polymorphism at codon determines the susceptibility to sporadic and other non-genetic forms of cjd. homozygosity for either methionine or valine increases the risk for acquiring cjd. aims: we searched for changes in prnp gene of healthy populations and scjd cases and compared genotypes of codon in order to prove differences among populations and non-familiar origin of scjd cases and also to confirm the influence of codon homozygosity on the disease development. material and methods blood samples from six populations (slovenian, afro-american, pima indian, cheyenne indian, finnish, german) and brain or blood samples from scjd slovenian cases were collected and dna was extracted. pcr-ssca was performed and changed samples were sequenced. introduction tumour suppressor gene rassf encodes different isoforms, derived from alternative splicing and differential promoter usage. the major transcripts a and c are expressed in all normal tissues, but transcript a is missing all cancer tissues. loss of expression is mainly corellated with methylation of the cpg island promoter sequences of rassf a but mutations in exons have also been found. we examined the status of promoter methylation and potential changes in the coding region of the rassf a gene in colon cancer tumours. materials and methods isolated dna from tumours of colon cancer was used for exon amplification of rassf a gene. for identification of mutations and polymorphisms ssca was used. abnormal patterns on ssca plates were sequenced. for determination of methylation status of the cpg islands we used cobra method. results cobra analysis revealed the hypermethylation of cpg islands. sequencing analysis of exons showed different nucleotide changes. we identified c>a mutation (r s), g>c mutation (d h), g>t mutation (a s), g>a mutation (r h), g>a mutation (r q) and c>a mutation (l i). r s, d h, r h and l i mutations have not been published yet. conclusions these results indicate that hypermethylation of the promoter of rassf a gene in colon tumours and missense mutations in protein itself could be involved in tumorigenicity of colon cancer. introduction pineal lesions are rare and comprise , - % of all intracranial tumors. various histological types of tumors arise in the pineal region. the aim of this study was to determinate histological types, immunohistochemical expression, age and sex distribution of lesions in pineal region. twenty-four expansive lesions in the pineal region, obtained between and , were analyzed. formalin-fixed, paraffin embedded surgical specimens were stained routinely and immunohistochemically for panel of antibodies; synaptophysin, neuron specific enolase, neurofilament, chromogranin a, glial fibrillary acid protein, cytokeratin, carcinoembrional antigen, β-hcg, human placental antigen, α-fetoprotein and ki- . results histology revealed six germinomas, seven pineocytomas, three pineoblastomas, five glial cysts and one ganglioglioma, pilocytic astrocytoma and epidermoid cyst. the study group consisted of females ( , %) and males ( , %) ranged from to years of age. all germinomas were in male patient while glial cysts were diagnosed in female patients. slightly female predominance was observed in pineal parenchymal tumors. immunoreactivity for neuron specific enolase, synaptophysin, neurofilament and for chromogranin a was positive in the pineocytomas, and partially expressed in pineoblastomas. the mean ki- index in pineoblastomas and germinomas were significantly higher than in pineocytomas. germinomas showed focal immunoreactivity for β-hcg, human placental antigen, α-fetoprotein and low immunoreactivity for cytokeratin and carcinoembrional antigen. conclusion the most common tumors are pineal parenchymal tumors and germ cell tumors. glial pineal cysts are also common. occasionally other types of tumor are found. immunohistochemistry is an important method in differential diagnosis of pineal tumors. immunohistochemical study of the metastatic brain tumors with accent of the role of thyroid-transcription factor- introduction the exact diagnosis of the metastatic brain tumors /mbt/ is challenge for the surgical pathologist especially in a case of unrecognized primary site. the aim of this study was to determine reliable immunohistochemical panel based on the histological features of the mbt. materials and methods sixty five cases with solitary mbt operated in neurosurgical department of the hospital were examined from the time period - ; thirty nine were of unknown primary origin ( %). immunohistochemical studies were performed using antibodies to ck-s, ema, nse, synaptophysin, psa, vimentin, s- protein, hmb , ttf- and gfap. results diagnosis of the mbt of unknown origin were as follow: squamous cell carcinoma - cases from total , small-cell undifferentiated - from , large cell undifferentiated - from , adenocarcinoma - from , adenosquamous - from , clear cell - from , papillary carcinoma - from , tubular - from , spindle cell - from , unclassified - from . the primary site of adenocarcinoma, undifferentiated small and large cell and clear cell carcinoma was established by using ttf- (positive in from lung cancer, . %), neuroendocrine markers, ck- and psa. after the investigation only three tumors were of unknown origin ( . %). the origin of the rest unknown before studies of mbt, confirmed with radiographic and endoscopic data were: lung - from total, breast - from , kidney - from , skin- from , thyroid gland - from , stomach - from , prostate - from . the colon, testis and ovary, at one case each, were known before operation. conclusions immunohistochemistry remains important and still very helpful method in determining primary origin of the mbt generally in undifferentiated neoplasmes and adenocarcinomas. among the most reliable tumor markers should be included ttf- , for its frequent expression in the lung cancer, predominant among mbt. brain calcification simulating brain tumour. a case report a shmeleva, s romodanov neurosurgery institute, academy of medical science of ukraine, kiev, ukraine objectives the aim of this study was to describe the plural calcifications in the brain. the patient was a -year-old man. he had a severe headache and disorientation, he felt weakness in the left arm. the patient was mentally handicap. st scan showed a tumour located in the deep parts of the right temporal lobe. with a working diagnosis of tumour, the patient underwent the operation. the surgical specimens were prepared by standard histological techiques. results macroscopically, the lesion appeared as a stone. a histological examination demonstrated a massive deposits of calcium in the parenchyma of the brain. calcification developed as small granules in the vessels and calcospherites of various dimensions were formed by confluence. there were zones of haemorrhage, neuronal loss, edema and proliferation of astrocytes. conclusions this patient is an interesting clinical case of dementia characterized pathologically by diffuse calcification. carcinoid tumour metastatic to the orbital muscle. a case report introduction optical contrast is sensitive to monitor dynamic and functional changes, such as blood concentration, tissue oxygenation, and cellular swelling. optical imaging has been widely employed in clinical applications including the investigations of functional neuroanatomy and neuroactivity. due to the overwhelming scatter of light during the propagation inside biological tissues, past attempts to visualize brain architectures non-invasively with the optical contrast have been severely restricted by the unsatisfactory spatial resolution. the aim of this study was to investigate the feasibility of a novel non-invasive transcranial imaging of the structure and function of brain in vivo accomplished with laserinduced photoacoustic tomography (pat). material and methods pat visualized the tissue structures in rat/mouse brain based on the high sensitive intrinsic optical contrast while utilizing the diffraction-limited high spatial resolution of ultrasound. results two-dimensional (or three-dimensional) rat (or mouse) brain structures, with and without lesions, were imaged clearly. in response to whisker stimulation, functional cerebral hemodynamic changes in cortical blood vessels around the whisker-barrel cortex were also mapped successfully. pat imaged hyperoxia-and hypoxia-induced cerebral hemodynamic changes as well. conclusions this study demonstrates that (i) structural pat of soft tissues lesions in the brain presents high intrinsic contrast, (ii) functional pat based on intrinsic optical signals can map the hemodynamic changes in the cerebral cortex and (iii) in contrast to other previously used optical methods, this technique enables completely non-invasive neuroimaging with high spatial resolution transcranially. this novel functional neuroimaging technique, will help to advance the research in neurophysiology, neuropathology, and neurotherapy significantly. microscopic disorders of cortical development of brain and the etiopathogenetic relevance of their detection in patients with temporal lobe epilepsy due to hippocampal sclerosis introduction hippocampal sclerosis (hs) represents a common structural basis of temporal lobe epilepsy (tle). however, the etiological factors and mechanisms leading to its development still remain unexplained. the aim of this study was to identify the disturbed neuronal migration and differentiation (nmd) in the temporal lobe resected for hs and to evaluate its potential role in the individual pathogenesis of hs. we present neuropathological findings in the resected hippocampus and the pole of the temporal lobe in patients with hippocampal sclerosis with an attention paid to the histopathological identification of defects of nmd in the temporal lobe. the morphological findings were correlated with the results of clinical examinations and the patients´ histories. results 'initial precipitating injuries' that are thought to cause the development of hs (febrile seizures in early childhood, head injury or meningoencephalitis) were present in the history of patients. in the remaining cases, no predisposing factors were found. defects of nmd were observed in cases; in three of these, no predisposing factors were identified in the patients´ histories. we suggest that in these cases, hs arises due to previously undetected disorders of cortical development. a latent neocortical malformation may also contribute to the development of hs in patients with an initial precipitating injury in anamnesis. conclusion histopathological examination of resected epileptic brain tissue can provide insights into the individual pathogenesis of epileptic disorders, especially by the detection of microscopic disorders of cortical development. supported by: gacr / /d , vz fnm , vz msmt and introduction cerebellar liponeurocytoma is a newly recognized rare clinicopathological entity of the posterior fossa, with advanced neuronal/neurocytic and lipomatous differentiation. the term 'cerebellar liponeurocytoma' was recently adopted by the who group to replace several other different terms used up to now. this tumour shows many morphological similarities to medulloblastoma and neurocytoma, but according to available literature has more favorable prognosis then typical medulloblastoma. we report a case of cerebellar liponeurocytoma in a -years-old woman who developed typical symptoms of a posterior fossa tumor. computed tomography (ct) scan disclosed a heterogeneous tumor mass in the left cerebellar hemisphere. the lesion was totally resected. methods the surgical specimen was rinsed in saline solution and fixed in % paraformaldehyde in phosphate buffer at ph . for hours, embedded in paraffin and prepared for histological and immunostaining. results microscopically, the tumor was composed of small less differenerentiated, round or oval closely packed medulloblastomalike cells and vacuolated cells with macrovesicular lipid accumulations giving in some large areas an appearance indistinguishable from mature fat cells. glial and neuronal differentiation was histopathologically and immunohistochemically (gfap, nse, nf) noted. these cellular components were intermixed in different proportions without distinct separation. many tumor cells of all types showed single or multiple smaller lipid vacuoles in their cytoplasm. conclusion our case provides evidence that mature adipose-like tissue in these tumors appears as result of progressive lipidization of neuroectodermal tumour cells rather than as result of adipose metaplasia. introduction determination of proteins taking place in the control of proliferation in normal cells helps a better understanding of cellular transformation and proliferation mechanisms. object although they do not arise from a tissue normally thought to be a target tissue for progesterone, meningiomas show a number of epydemiologic and clinical features which suggest that females sex hormones can play a role in their development (higher incidence of meningiomas in woman, rapid progression of symptomas and icreasing in size during the pregnancy and during the luteal phase of the menstrual cycle, as well as significant association of meningiomas with obesity and breast carcinomas). the aim of our study was to investigate the progesterone receptor contents of bening meningiomas (who gr. i), which is completly excised and evaluated possible relationship between receptor content and sex and age of the patients, histological tipe of meningiomas and localisation of tumor. material and methods tissue samples, fixed in formalin, and embedded in paraffin were evaluated immunohistochemically for progesterone receptors using specific monoclinal antibodies. the correlation between number of positively nuclei and progesteron status was determined by the analitic statistical test mann-whitney. % of the meningiomas tested were positive for progesterone receptors. progesterone receptors in the benign meningiomas in the male patients was significantly higher when compared to the female patients (p< , ). neonatal intractable seizures revealing diffuse and bilateral cortical dysplasia. a case report s bellefqih , c rambaud , t lacaze , jj hauw , g lyon , d seilhean groupe hospitalier pitié-salpétrire, paris, france hôpital antoine-béclre, paris, france cerebral cortical dysplasia is generally focal and sometimes related to tuberous sclerosis. it is believed to result from disrupted neuronal migration during cortical development. we report an unusual case of neonatal diffuse and bilateral cortical dysplasia revealed by refractory epilepsy. a male infant, born at weeks' gestational age (ga) without familial history of neurologic disease, presented at birth a convulsive encephalopathy, associated with severe hypoxia with pulmonary hypertension and iterative hypoglycemia. a foetal goitre was attributed to hyperdose therapy for maternal graves' disease between and ga. the patient died at weeks of life from respiratory failure after intensive care. all the iso-and allocortical areas examined were normal at gross examination, but microscopically dysplastic. there was disorganization of the laminar architecture and presence of large multipolar neurones diffusely distributed over the cortex. they showed positive immunoreactivity with neurofilaments and synaptophysin, and were negative with gfap and vimentin. numerous ectopic neurons were found in the white matter. in addition, c shaped thickened inferior olive was noted. the cerebellum, including dentate nuclei, and other brain stem nuclei were normal. focal cortical dysplasia lesions are localized malformation of the isocortex with positive gfap and vimentin in dysplastic neurons. in this case, the dysplastic lesions were diffuse and astrocytes were normal. no genetic investigation was available, but the negative immunostaining of large cells by gfap does not favour the diagnosis of tuberous sclerosis. the pathogenesis of this exceptional disease remains obscure but the responsibility of the foetal thyroid disorder cannot be excluded. structural genomic abnormalities of chromosomes and in myxopapillary ependymomas in an attempt to clarify the chromosomal status of these tumors and identify commonly aberrant regions in the genome we have combined molecular/cyto/genetic methods to study genomic abnormalities in mpe. comparative genomic hybridization analysis of / tumors identified concurrent gain on chromosomes and as the most frequent finding. the majority of the tumors were also studied using microsatellite analysis ( markers for chromosome and markers for chromosomes ) and interphase-fish with centromeric probes for chromosomes and . our combined results were consistent with polysomy and in cases, polysomy either or with partial gain in the other chromosome in cases, tetrasomy or partial gain either or with complex rearrangement in the other chromosome in cases. in the remaining cases allelic imbalance alone of either chromosome or was identified. other numerical abnormalities observed included gain of chromosomes , , , , , , , q, and x and loss of chromosomes and . the combination of gains of genetic material from chromosomes and seems to be common in mpe and may represent genomic events of importance in the development of the tumor. nonsymptomatic nontumor cysts of the pineal gland: frequency and morphological characteristics the effect of bcl- protein and ki- expression on the prognosis of medulloblastomas introduction medulloblastoma is the most common primary central nervous system tumor in childhood and accounts - % of all intracranial neoplasms in children. aim: in this study the correlation between the patients survival and prognostic factors (ki- and bcl- ) and the tumor size in ct scan were evaluated. material and method selected cases were analyzed. immunohistochemical staining was applied as polyclonal antibody for ki- (dako-a- ) and monoclonal antibody for bcl- (bcl- / /d novo castra) on paraffin blocks.fisher's qhisquare, correlation and mann-whitney-u tests were used for the statistical analyses. results the ages of these patients were ranged between - (mean . ).the size of the tumoral mass varied between to centimeter. patients were alive without illness. patients were lost due to tumor. we could not found a statistical revelance between neither immunohistochemical staining (bcl- , ki- ) nor tumor size on survival rates. conclusion due to radiotherapy and chemotherapy following surgery, the survival rates of medulloblastoma has increased despite the agresiveness of the tumor. there are reports showing no correlation between expression of the bcl- with the outcome of patients. further investigation about the correlation of the prognostic factors with the outcome is required. introduction results of glioma treatment are still unsatisfactory. an accurate histopathological study supplemented with examination of tumour parameters, like proliferation potential and apoptosis may be invaluable in designing an individualised therapy. the aim of this study was to analyze clinical data and histo-clinical correlations in recurrent brain tumours of astrocytic origin. one hundred surgically removed supratentorial gliomas were studied (mean age: . yrs). histological grade was determined according to who classification and the daumas-duport scale (st.anne/mayo). proliferation activity was measured using the pcna index and agnor count. the expression of bcl- protein was examined with immunohistochemistry. results and conclusion the initial symptoms of glioma were headaches and vomiting ( %), paresis ( %), epilepsy ( %) and aphasia ( %). the tumour location was predominantly in the left hemisphere, in the temporal ( %), parietal ( %) and frontal ( %) lobes. the pcna index correlated with who grade (giiindex %, giii - - % and giv - %). for grades i, ii, iii and iv progression free survival (pfs) was: . , . , . and . months respectively. the agnor count did not correlate with who grade, daumas-duport grade or pfs. bcl- expression was observed in single cells in gi and gii tumors, in % and % of cells in giii and giv, respectively. the daumas-duport scale is simple and useful in prognosing. bcl- expression does not correlate in a linear manner with tumour grade. as gliomas are extremely heterogeneous, for better characterization of the clinicopathologic correlations new prognostic factors are needed. introduction schilder's type of myelinoclastic sclerosis is rare variant of multiple sclerosis in children and young adults. usually, brain lesions occur in the white matter like solitary, or less often multifocal, acute plaques ranged in diameter more then cm. case report the -year-old female patient was referred to our hospital with progressive right-sided hemiparesis, motor dysphasia and frontal lobe syndrome. symptoms started days earlier with acute headache and no febrile state was reported. mri of the head revealed two oval lesions with hyperintensity in t weighted images of left frontal and parietal lobe. the first diagnostic impression was of glioblastoma multiforme. results from standard blood and urine tests, tumor markers and cytological analysis of bone marrow were normal. analysis of csf and culturing csf and serum for bacterial, viral, protozoan and fungal infections were negative. analysis of csf revealed increased immunoglobulins, ocb and increased intratecal synthesis of igg. a stereotactic biopsy was performed one month after first symptoms. neuropathology findings. the biopsy after neurosurgical treatment yielded five needle cores of grayish cerebral tissue. hematoxylin and eosin-stained sections of paraffin embedded tissue showed demyelinating white cerebral tissue with relatively sharply defined margins. lesion was infiltrated by macrophages (cd immunopositive cells and luxol fast blue negative) and large reactive astrocytes with ki and pcna nuclear positivity. around blood vessels were scattered perivascular cd and cd lymphocyte. silver impregnation and nf immunostaining showed that the axons within the plaque are attenuated but not destroyed. conclusion clinical and pathological findings suggested a demyelinating disease destroyed huge parts of white matter in before health mid-aged women, without previous infection or vaccination. accordingly we diagnosed schilder's type of ms. stereotactically guided brain biopsy: six years' experience of pathologic interpretations from turkey e erden , a okcu heper , a savas ankara university, school of medicine, pathology department, ankara, turkey ankara university, school of medicine, neurosurgery department, ankara, turkey introduction stereotactic biopsy is a widely used procedure in brain lesions. the aim of this study was to analyse the reasons of the discordance between the results of the intraoperative crush preparations (icp) and final permanent paraffine preparations (fppp) of stereotactically guided brain biopsies (sgbb) in our hospital, and find out the clinical benefits of this procedure. total ct and/or mri guided brain biopsies performed between - were analysed retrospectively. icp and fppp preparations were evaluated and discordant cases were detected. then we evaluated the reasons of discrepancies. results the correct diagnosis was achieved by stereotactic biopsy in . % of the patients. of them were diagnosed as neoplasia and were diagnosed as non-neoplastic pathology. there was discordance between icp results and fppp diagnosis in . % of the stereotactically diagnosed patients. the patients diagnosed as neoplasia were treated by rt and/or kt and the non-neoplastic pathologies were taken in suitable treatment and follow-up scheme. conclusion to improve the diagnostic accuracy of the sgbb, the following items should be taken into consideration: the quality of the icp with giemsa staining is very important. in the biopsies from the lesions, which are suspected as neoplasia having, microscopic features such as gliosis, edema, hemorrhage must be interpreted as non-diagnostic. the number of the biopsies must be increased in the presence of necrosis. epitheloid and pleomorphic cellular groups can mimic benign and malignant pathologies. interpretation of the icp and the fppp should be done by the same pathologist. intraneural capillary haemangioma of spinal nerve root. case report p xirou , s barbanis , i efstratiou , p sevastiadou , i tsitouridis papageorgiou general hospital, department of pathology, thessaloniki, greece papageorgiou general hospital, department of radiology, thessaloniki, greece intraneural haemangiomas of the spinal nerve roots are rare. the few cases reported in the literature are usually of the capillary and less often of the cavernous type. these lesions occur in adults, mainly males and the majority of them are located in the cauda equina. a case of intraneural capillary haemangioma involving one lumbar nerve root is reported. the patient, a year old male, presented with a -year history of severe intermittent low back pain. magnetic resonance imaging detected an intradural, extramedullar, space occupying mass at the level of l -l , causing displacement of cauda equina roots. laminectomy and complete removal of the lesion were performed without neurological problems. on gross examination the resected specimen was a redbrown, well demarcated, lobular mass, measuring . cm in greatest diameter. remnants of a nerve root were recognized at the periphery. histological examination showed that the lesion was located within the endoneurium. it consisted of multiple small dilated capillaries, often showing incomplete lobular pattern, dispersed within normal nerve fascicles. the endothelial lining showed neither nuclear atypia nor mitotic activity. in the substrate mild edema and focal inflammatory lympocytic infiltrations were found. haemangiomas of the spinal nerve roots often pose a challenging diagnostic problem, and knowledge of their existence is relevant since they can mimic other more frequent tumors of the region. introduction sensorimotoric polyneuropathy has rarely been reported as a presenting paraneoplastic neurological disorder associated with anti-hu antibodies. electrophysiological studies suggest a dysfunction of axon-schwann cells, but the exact pathological mechanisms remain unclear. case report a -year old woman with short history of weight loss and parastesias in the legs was admitted to the hospital. triparesis and dyspnea were found. mri scan showed leukencephalopathy, eeg revealed diffuse encephalopathy. sensorimotoric axonal polyneuropathy was present in emg, and small lesion in the lung was found on the ct scan. anti-hu antibodies were present in the serum and in the cerebrspinal-fluid. autopsy revealed macrocellular adenocarcinoma of the lung with neuroendocrine differentiation and sensorimotoric neuronopathy/ encephalomyelitis. methods the brain, spinal cord, sensory ganglia and a part of sural nerve were fixed in formalin, paraffin embedded and stained with h&e. other part of sural nerve was prepared for immunofluorescence, semi-thin and ultra-thin sections. results axonal degeneration without any inflammatory reaction and a very few signs of regeneration were found in the sural nerve. the inflammatory destruction of spinal ganglia neurons, axonal degeneration in dorsal columns and motor neurons inflammatory destruction in the spinal cord were found. neuronal degeneration, glial proliferation, perivascular inflammatory infiltrates and some cd + lymphocytes surrounding single neurons were a common finding in the brain. conclusions this study shows that inflammatory destruction of the spinal ganglia neurons and motor neurons in the spinal cord was the main cause of clinically rapidly progressive sensorimotoric polyneuropathy in the anti-hu positive patient with macro cellular lung carcinoma with neurendocrine differentiation. isolated extranodal spinal rosai-dorfman disease. a case report ai freitas rc silva l costa, v velasco, p monteiro, m teixeira, f pardal de oliveira hospital de sao marcos-serviço de anatomia patológica, braga, portugal introduction sinus histiocytosis with massive lymphadenopathy was first described in , by rosai and dorfman, as an idiopathic histiocytic disorder, which typically involves lymph nodes. lately, involvement of many other organ systems has been documented, either alone or in association with nodal manifestations. nowadays, rosai-dorfman disease is a wellrecognised clinico-pathologic entity. extranodal disease has been reported in % of the reported cases, occasionally representing the first and exclusive manifestation of the disease. although central nervous system involvement has been well documented, the spinal canal is affected only exceptionally. we report a case of an isolated extranodal spinal rosai-dorfman disease with review of the literature. the authors describe a old woman with a history of spastic hemiparesis in which radiology disclosed a dural-based intramedullary spinal cord lesion at c level. the authors describe the histologic and immunohistologic features of the lesion and discuss the differential diagnosis. conclusion isolated cns rosai-dorfman disease without contemporary lymph node involvement can be a diagnostic challenge. pathologists must be aware of this disease in order to make a correct diagnosis and avoid diagnosis of malignant histiocytic lesions. ezrin immunoreactivity: is it a usefull marker for the prognosis and grading of astrocytoma? ie gurer , ga gökhan , t uçar akdeniz university scholl of medicine department of pathology, antalya, turkey akdeniz university scholl of medicine department of neurosurgery, antalya, turkey introduction the actin-binding protein ezrin is supposed to increase the invasiveness of the malignant cells. in this study, the value of ezrin immunoreactivity (ir) was invastigated as a grading and prognostic parameter in astrocytomas. material and method ezrin ir was studied in low grade and high grade astrocytomas. the mean age of the patients was . . monoclonal ezrin antibody (ms- -r neomarkers) was applied on the sections of the paraffin-embedded tissues. immunostaining intensity of ezrin was estimated as semiquantitatively. when no staining was visible the score of , mild staining scored as , moderate , and severe staining scored as . also positive stained areas were evaluated as percantage ( %, - %, above % staining areas). statistically man-whitney u, kruskal wallis and spearman tests were used. results there was no correlation between prognosis and neither the grade nor the staining intensity of ezrin ir. conclusion there are controversial reports especially about the prognostic value of ezrin ir in different types of tumors. there is one report about the association of ezrin ir with the increasing malignancy of astrocytic tumors. results of our study revealed no evidence of correlation between prognosis and ezrin ir for grading of astrocytomas. we conclude that ezrin is not a usefull factor for the prognosis and grading in astrocytomas. introduction hereditary cystatin c amyloid angiopathy (hccaa), an autosomal hereditary disease uniquely found in iceland, usually leads to early death of young adults from cns vascular complications following a disease progress of several years. histopathological characteristics are cystatin c amyloid deposits in meningocerebral blood vessels, narrowing, splitting of media, segmental fibrinoid necrosis and microaneurysms of small arteries and arterioles. associated changes: hemorrhages, infarctions and reparative reactions depending on length of the disease course. this study is a part of an investigation mapping the distribution of cystatin c immunopositive deposits outside the cns in hccaa. material and methods formalin fixed, paraffin embedded autopsy material from patients, females and males, was studied by conventional light microscopy (he, congo red; thioflavin s) and immunohistochemistry (avidin-biotin-peroxidase) with cystatin c antibodies (abc-complex kit from vector). for electron microscopy and specific identification of cystatin c deposits specimens were fixed in macdowell's fixative and embedded in l.r. white resin and immunogold labelled (colloidal gold labelled protein a. sigma). results and conclusion cystatin c immunoreactive deposits were found in most organ systems outside cns. the deposits were primarily located in the adventitia and perivascular tissue of small blood and lymphatic vessels and vascular smooth muscle; in subepithelial connective tissue of intestinal surface epithelium and glandular epithelium; in peripheral nerves. cystatin c immunoreactive blood vessels were not obviously damaged as those in the cns possibly reflecting environmental factors different in these two separate locations not yet identified and characterized. details of cystatin c deposition in the vascular walls will be demonstrated. neurological disorders are among the most prominent clinical manifestations of antiphospholipid syndrome (aps). they are predominantly related to thrombo-occlusive vascular events in central nervous system, vasculitis playing little or no role. case report a -year-old female with a history of seven spontaneous abortions presented with sudden onset of pain and numbness in her right and later left foot followed by pruritic rash over her hands and back and livedo reticularis around knees. emg showed signs of axson injury in multiple nerves. laboratory tests showed lymphopenia and antiphospholipid antibodies of igg class in medium titer at the begining and in low titer three months later. anca, ana, ena, anti-dna were negative, platelet count, complement, lupus anticoagulant and tumor markers were normal. sural nerve biopsy revealed active necrotizing arteritis of small epineural arteries. intimal circular fibrinoid necrosis was accompanied by pyknosis, karyorexis and myofibroblast proliferation in media. inflammatory infiltration by lymphocytes, macrophages, plasma cells and segmented leucocytes was present in intima, but was most prominent in adventitia. thrombosis in organization was observed. vasculitis was present also in arterioles and venules. immunofluorescence showed scarce focal granular deposits of igm, iga class, and complement components c and c q in media of small epineural arteries, together with abundant fibrin deposition. it has been suggested that aps can not be the cause of vasculitis and that vasculitis in aps is associated with an independent underlying disease, such as systemic lupus erythematosus. except for suspected aps, our patient did not fulfill the criteria for any systemic autoimmune disease that could present with vasculitis. immunoautoradiographic characterization of serotonin transporter in human pineal gland m the mechanism that regulates human pineal gland melatonin synthesis is not completely clear. in fact, several studies performed on animals demonstrated the possible role of serotonin and the involvement of its receptors -ht( c) and -ht( a) in the modulation of this process even if is not clear how it is realized. the aim of our study is to verify the presence of serotonin transporter (sert) in the pinealocytes, a molecule involved in the reuptake of -ht from synaptic space, and to represent the action site of i.r.s. antidepressant drugs. we tested with immunoautoradiographic method (iarg) frozen slices conserved at - c o , derived from twenty cadaveric epiphysis ( men, women) by utilizing a mouse monoclonal anti-sert antibody followed by a secondary biotinilated anti-mouse igg antibody, consecutively linked with an avidine/[ h]-biotine complex for a precise localization of the researched molecule. the tritium sensitive films were exposited to treated slices in special cassetes. after thirty days of exposure at - c o , the films have been developed and fixed to obtain auto radiographic images in which the radioactivity distribution followed a continuum pattern in sequential slices of each subject. it was the expression of sert presence in epiphysis. this is the first study that demonstrate the presence of sert in human epiphysis. we suppose that serotonin in human is not only a melatonin precursor synthesized in the pinealocytes but it is involved in the neuroendocrine regulatory mechanism of the gland. loss of heterozygosity (loh) studies allow to identify sites harbouring tumor suppressor genes involved in tumor initiation and progression. this study was performed to establish the frequency of loh on chromosome q in glioblastoma. cases of glioblastoma were examined ( women, men; age: - years). two cases were secondary glioblastoma. in all cases the representative neoplastic tissue and normal brain tissue were cut out with lancet from respective paraffin blocks. dna was isolated with proteinase k with phenol/ chloroform extraction and isopropanol precipitation. polymorphic markers were localized close to three supressor genes pten (d s , d s ), lgi (d s ), dmbt (d s ) which are known to be lost or mutated in glioblastoma. the fith marker was d s q . . fragments were pcr-amplified and analysed using automated sequencer abi . signals from neoplastic and normal tissue were calculated. result under , was scored as loh. in cases at least one marker from chromosome q was lost. cases with loh were men, both secondary glioblastomas showed deletion in q. the mean patients' age with and without qloh was similar. cases showed loh only in pten locus. in cases deletions were stated in two or more loci, what might suggest loss of longer part of chromosome . cases with loh in q revealed additional changes in different chromosomes: loh in p ( cases), p ( ), q ( ), p ( ), q ( ), q ( ), q ( ), p ( ). our results are similar to the other studies, showing changes in q in about % of glioblastoma. histopathological changes of the skin in systemic lupus erythematosus ta vervekina, ba magrupov, gsh shamukhitdinova tashkent, uzbekistan introduction morphologic examination of the skin is of great importance for the diagnosis of various nosologic forms of rheumatic diseases. the aim of the present study was to evaluate histopathologic changes in skin biopsies of patients with systemic lupus erythematosus (sle). material and methods skin biopsies of patients ( women and men; age range from to years) with preliminary diagnosis of sle, based on clinical data and laboratory analyses, were studied with the purpose to specify the differential diagnosis. biosy tissue specimens were fixed in % neutral formalin, embedded in paraffin, and serial sections were stained with haematoxilin-eosin, picrofuxin, and the combined rhitter-olesson staining. after treatment of the specimens with . % trypsin, direct immunofluorescence technique was carried out for detection of immunoglobulins g and m at the dermo-epidermal junction (lupus band-test). results our study established the presence of hyperceratosis with formation of keratic clogs, epidermal atrophy with vacuolization of basal cells, vasculitis, eosinophilic degeneration of collagen and an atrophy of appendages. specific immunostaining for immunoglobulins g and m at the dermo-epidermal junction was observed in all except in cases. we did not observe inflammatory cell infiltrates in dermis in any case. conclusion the pathogenesis of skin histologic lesions in sle is most likely associated with immunological reactions and therapy carried out earlier. structural peculiarities of different nevuses and their prognostic value e stupina first tashkent medical institute, tashkent, uzbekistan for the time being the causes of skin melanoma have not been clearly understood. development of skin melanoma was related to preceding pigment formations in % to % of patients. among a variety of investigation methods histologic one is basic to establish the final diagnostic. complex morphologic study was carried out on skin biopsies with different types of pigment nevuses and melanomas. of them biopsies were selected for the thorough pathomorphologic investigation. light microscopy, electron microscopy and morphometric method were used. serial sections for light microscopy were stained with hemotoxylin and eosine, picrofuchsin-fuchselin by van-gizon, combined staining by riter and oleson. the findings have shown that the rate of pigment skin neoplasms of all the biopsy material of a specialized institution came to , % among neoplastic and , % among non-neoplastic skin lesions. pigment nevuses more frequently occurred in females aged to years applied for medical aid, while melanoma in ones above years. intradermal nevus was diagnosed in , % of cases, its proliferative activity was expressed in % of patients. in , % of patients skin melanona was assigned to - th grade of invasion according clark's classification. each form of pigment nevus had morphometric peculiarities, significantly differing in dimensions of the cell, nucleus and their ratio. the most reliable parameter of malignization was the length of the nucleus and cell axial section circle. of frequently occurred nevuses intraepidermal (borderline) one was more predisposed to malignization which was evident from significant increase of all morphometric parameters. introduction cutaneous ciliated cysts are a rare type of skin cyst, usually presenting themselves in women between the nd and th decades of life. their origin is unknown and has been related to müllerian remnants based on similarities of the epithelium to the fallopian tube, but the occurrence of cases in men has given rise to the possibility of a sweat gland origin. case report a year-old woman complained of an asymptomatic, longstanding, lesion located in the skin of the thigh. once removed it was seen to correspond to cyst with clear fluid inside. histopathological examination revealed a dermal cyst with ciliated cuboidal epithelium, usually double layered, but with some pseudostratified areas. occasionally, papillary projections were seen in the lumen. there was no evidence of cellular atypia or mitotic activity. immunohistochemical staining with oestrogen and progesterone receptors was strongly positive throughout the lesion. the clinical and histopathological findings fit in with the diagnosis of a typical cutaneous ciliated cyst of the lower limbs (cutaneous ciliated cyst). this is a rare cyst usually arising in the lower limbs of young women. its origin is unknown and the demostration of sex-hormone receptors has been used to favour the müllerian origin. nevertheless, some cases have been reported in men, which has diverted attention towards sweat glands as a possible origin of the cyst. the real incidence of the sex-hormone receptor if unknown, since it has not been clear in most published cases. introduction p protein is essential for the regulation of cell proliferation and its aberrant accumulation is usually seen in malignant tumors but, also, occurs in squamous epithelium of inflammatory skin diseases characterized by hyperproliferation. the aim of this study is to elucidate the role of the p tumorsuppressor protein in the pathogenesis of different hyperproliferative, non-malignant and malignant skin diseases, and association between p overexpression and cell proliferation. we also investigated the influence of ageing on p and ki- protein expression. material and methods hundred and fifty skin specimens, consisting cases of each, normal skin (ns), psoriatic skin (ps), keratoacanthomas (ka), basal cell carcinomas (bcc), squamous cell carcinomas (scc) were examined immunohistochemicaly to assess p and ki- protein expression. results p immunostaining of ns, ps, ka, bcc and scc was positive in . %, . %, . %, % and . % cases, respectively. p and ki- positive cells were present in basal (ns) and suprabasal layers (ps), and not only in cancer nests of ka, bcc and scc, but also in dysplastic and even morphologically normal epidermis adjoining cancers. the positivity of p and ki- protein differed significantly among the groups, with no differences in p expression between ns and ps, and in ki- expression between ps and ka. within all groups, there was a significant correlation between p and ki- protein expression. localisation and age were significantly related to p and ki- expression in all groups, except for localisation in ps, and age in bcc. conclusions our findings suggest that p overexpression occurs widely in neoplastic and non-neoplastic skin lesions. it is associated with the cell proliferation in normal, as well as, in changed epithelium. p accumulation is an age related process and significantly related to sun exposure, especially in ns and ps, as well as in ka and scc. we also suggest that p overexpression begins in the early stage of carcinogenesis, before the appearance of malignancies in skin, and may be a useful predictor for the detection of nonmelanocytic skin cancer. background maspin, a member of the serine proteinase inhibitor (serpin) family, has been recently pointed to as a tumor suppressor gene and angiogenic inhibitor. objectives of this study were to investigate role of maspin and beta-catenin in basal cell carcinoma (bcc). we studied immunohistochemically their expression in basal cell carcinomas together with trichoepitheliomas (te) and normal skin controls. microvessel count (mvc) was also done using fviii-related antigen. we examined the correlation of nuclear and/or cytoplasmic maspin expression with histological type, age, gender, invasion of safety margin, as well as stromal reaction (lymphocytic or fibroblastic. all primary antibodies (maspin, beta catenin and fviii-related antigen) as well as detection kit (abc peroxidase/dab quick test), were purchased from novocastra labs.uk. maspin expression was strongly cytoplasmic and membranously expressed in te and down-regulated in nodular bcc. nuclear maspin expression was found in . % of our cases. it was statistically positively correlated with invasion of safety margin (p= . ) and with infiltrative type (p= . ) and negatively correlated with a mvc > (p= . ). cytoplasmic maspin was correlated to a strong fibroblastic stroma (p= . ). beta-catenin expression was found in both te and bcc with the same intensity and was only correlated to younger age(p= . ). conclusion cytoplasmic maspin expression could differentiate between te and nodular bcc nuclear maspin expression could be related to aggressive behaviour of bcc and is realted to lower mvc (< ). introduction trichilemmal carcinoma (tc) is rare skin tumour occurring in the sun-exposed areas (largely on the face or ears) of the elderly. clinically, it may be mistaken for a squamous cell carcinoma, basal cell carcinoma, nodular melanoma or keratoacanthoma. although the histological picture suggests a high-grade malignant neoplasm, tc has an indolent course, and conservative surgical excision with clear margins is curative. aim: histological and histochemical examination of rare cases of tc of the skin. materials and methods we report two patients (males) with tc on the ears, presented as slow-growing nodules. tumour biopsy specimens were routinely fixed and processed. deparaffinized sections were stained by he, pas, pas-d. results histologically tumour cells showed a solid and a lobular growth patterns in continuity with the epidermis, with foci of pilartype keratinisation and peripheral palisading. tumour nests were mostly composed of large atypical cells with clear cytoplasm containing pas-positive, and diastase sensitive materials. these cases were treated only with surgical excision, and there has been no evidence since of local recurrence or metastasis. conclusion we believe that careful histopathological examination of pillar appendage tumours will help to classify the wide range of clinically and histologically different tumours and to establish the exact diagnosis. introduction pigmented cutaneous metastases from breast carcinoma are uncommon and may simulate malignant melanoma both clinically and morphologically. we report a case of a -year-old female who developed multiple cutaneous pigmented metastases twelve years after radical mastectomy for left breast carcinoma. materials and methods hematoxylin-eosin and immunohistochemically (streptavidin-biotin method) stained slides from three different regions of the chest skin and from the scalp plaque. results numerous darkly pigmented plaques and nodules have been developed over a -month period on the back of the chest spreading anteriorly to the right subcostal region together with large, focally eroded scalp plaque. histopathological examination revealed full thickness dermal infiltration and superficial subcutaneous fat involvement with cords and nests of neoplastic epithelial cells showing ductal structures and intracytoplasmic lumina in some areas. irregular nests and single tumor cells at epidermodermal junction were accompanied with melanophages in papillary dermis. immunohistochemically all tumor cells were cytokeratin positive and cytokeratin negative while epidermal and most superficial dermal nests showed hmb- and melan-a reactivity as well. scalp metastasis displayed less pronounced epidermotropism and only focal, single cell hmb- and melan-a positivity. conclusion epidermotropic breast carcinoma metastases may mimic malignant melanoma not just clinically and morphologically but also immunohistochemically and that might be related to the location of metastatic lesions. immunolocalization of lactoferrin in pigmented lesions of the skin g barresi, g giuffre, f fedele, m grosso, v barresi, g tuccari department of human pathology, university of messina, messina, italy lactoferrin (lf) expression has been immunohistochemically investigated in formalin-fixed paraffin-embedded bioptic skin samples ( nevi, melanomas, vulgaris or seborrhoic pigmented warts, pigmented basal cell carcinoma; specimens of normal skin were utilized as control. on µm thick sections, depigmentation and antigen retrieval procedures were performed. lf immunoreactivity was revealed by a rabbit anti-human lactoferrin (dako, denmark, : ), incubating all sections at c overnight; successively, bridging antibody and pap complex for min at room temperature (rt) were applied. for the demonstration of peroxidase activity, the sections were incubated with - ' diaminobenzidine tetrahydrochloride-h o substrate solution for min at rt in darkness; slides were then slightly counterstained with mayer's haematoxylin. quantification of lf immunoreactivity was performed using the intensity-distribution (id) score based on both the percentage and the staining intensity of positive neoplastic cells. an evident cytoplasmic immunoreactivity for lf was encountered in melanocytes, either in nevi or in melanomas; no ap-preciable differences were found among junctional, intradermic or compound nevi as well as between spindle or epitheliod cells melanoma. basal cell carcinomas were always unstained, even if some degree of positivity was found in areas which showed squamous differentiation; sheets and whorls of keratin also exhibited a strong immunoreactivity, when encountered in warts. if the lf immunoexpression could represent the result of an endogenous synthesis by cells in order to have greater availability of iron for their metabolism or to modulate an unspecific inflammatory or anti-oxidant response remains to be fully understood. cutaneous melanomas were detected at an increasing rate worldwide. even thought many patients are diagnosed at an early stage, the death rate continues to rise due to the increasing incidence of more advanced lesions. the aim of this study is to detect in cases of malignant melanomas. materials and methods analysis were performed in paraffinembedded cases of cutaneous malignant melanomas ( cases in situ and cases invasive melanomas). apoptotic index (ai) was determined using the in situ end-labeling technique(tunel), who quantify apoptotic cell death at single cell level and tissues. discussion and conclusion ai was high in the cases of in situ melanomas, but in invasive melanomas (nodular melanomas, superficial spreading melanomas with vertical growth phases, acral lentiginous melanomas etc) ai was decreased in tumor cells. we considered that usually apoptotic cells represent ~ % of tumor cells. at cases of cutaneous malignant melanomas in which ai was high ( %), frequently at in situ melanomas, the prognostic is good, when in the others cases in which apoptosis is missing or is very rare in cells ( %), the prognostic is reserved. this nonmorphologic technique to evaluate the prognosis of melanoma must be regarded as investigational and cannot yet be recommended for routine application. all necessary pathologic data, such as tumor location, size, depth, ulceration, mitotic activity and growth phase, can be obtained by examination of standard microscopic preparations of malignant melanoma as stained with hematoxylin and eosin. introduction small vessel vasculitis is a group of disorders of unknown etiology, possibly associated with connective tissue disease (ctd). the aim of this study is to find correlation between clinical, morphological and immunological changes in the skin and muscle biopsies of the patients with ctd, where small vessel vasculitis is the main finding. we analyzed skin and muscle biopsies from patients with ctd: dermatomyositis, systemic sclerosis, syndroma raynaud, vasculitis, sle, polyarteritis nodosa. were females, and males. the age of the patients was between - . standard histological and histochemical stainings (he, pas, van gieson-elastica) were done. small vessel vasculitis was found throughout skin and muscle biopsies, characterized with thickening of the basal lamina, tiny fibrinoid necrosis (if present), swollen endothelial cells and perivascular edema with lymfocytes. the muscles were necrotic with regeneration and fibrosis and reduction in the intramuscular capillaries. the changes were positive on pas and elastic tissue staining. direct immunofluorescence technique was done with antihuman igg, igm and iga antibodies. granular or linear immunofluorescent deposits were found at the dermo-epidermal junction zone and in the vessel walls. antinuclear antibodies were done by indirect immunofluorescence technique using serum from same patients of which % were positive. lymphoid cells around the vessels and in healthy muscle fibers were positive for markers for t cells (cd ro and cd ). conclusion there is correlation between morphological and immunohistochemical changes. the presence of immunologic deposits in the vessels suggests possible autoimmune etiology. cutaneous angiomyolipoma introduction angiomyolipoma is a benign tumor almost exclusively seen in the kidney. cutaneous angiomyolipoma (aml) is a very rare benign vascular tumor that consists of a proliferation of blood vessels, smooth muscle bundles, and mature fat tissue. aml occurs more often in adult male patients and is often seen in acral locations. case report a -year-old man who had a -year history of a painless, solitary, noninvasive nodule on the right auricle lobule. the patient had no signs of tuberous sclerosis. material and methods the lesion was cm in diameter and clinically appeared to be a lipoma. the lesion was excised. skin specimens was fixed in % buffered formalin, routinely processed, and embedded in paraffin. it was examined by routine light microscopy with histochemical and immunohistochemical stains. results on sections, the lesion was a well-circumscribed nodule in the dermis. there was fibrous pseudocapsule around it. the nodule was composed of an intimate mixture of mature adipose tissue, blood vessels, and bundles of smooth muscle cells. combination of different types and sizes of vessels were particularly evident. cellular pleomorphism, mitotic figures, and mucoid degeneration were absent. reactivity for hmb- was negative. the histopathological diagnosis was angiomyolipoma. conclusion amls are very rare at extrarenal locations. in , argenyi presented the first report of cutaneous angiomyolipoma in the upper helix of the ear. the reported lesions were located at acral sites. as most cases of angiomyolipoma were long-standing lesions located at acral sites, and therefore exposed to external forces, some angiomyolipoma could be considered to be a degenerated with replacement by fatty tissues. the primary b-cell cutaneous lymphoma is a low frequent disease in a general hospital. its nodal equivalent has very different behaviour and prognosis. aims: to study the incidence, behaviour and follow up of the b-cell cutaneous lymphomas in our hospital over a period of years. material and methods in a total of cases between and we have cases of b-cell cutaneous lymphoma. the skin biopsies were diagnosed acording eortc classification. we did histological and immunohistochemistry studies. these included cd , cd , cd , cd , cd , bcl- and ki . results eith cases of were salt and cases were folicular lymphomas. the ages are between and and is no sex predominance. salt lymphomas were located two in the face and six in the trunk. all the cases of folicular lymphoma were in the face. the immunohistochemistry study in salt lymphoma showed positivity for cd and cd and negative for cd , cd and cd . the expression of ki was very low. the reactive foliculars centers were demostrated with the negativity of bcl- . the folicular lymphomas showed positivity for cd and cd and the number of positive cells for ki was bigger. conclusions in a general hospital in our country the incidence of b-cell cutaneous lymphoma is very low. the majority of the cases arrive with surgical excision, that is a good therapeutic approach. the general pathologist must be aware with reactive limphoid infiltrates because the majority of the cutaneous lymphomas are low grade neoplasies. background cd expression is a distinct feature of both b and t cell activation. the presence of cd + large atypical lymphoma cells in a cutaneous infiltrate has been considered a characteristic feature of lymphomatoid papulosis/cutaneous cd +. recently, however, cd expression has also been described in some nonneoplastic infiltrates of de skin. design twenty skin biopsy specimens from patients with scabies were evaluated. of these, the lesions had been present for more than months in cases. the diagnosis of scabies was based on the presence of characteristic clinical features and the demostrations of sarcoptes scabiei mite. for each biopsy, a panel of histopathological and inmmunophenotypic features was independently assesed by two pathologists. cd , cd , cd , cd and s- protein expression was evaluated in each case. results cd + cells, either in isolation or in small clusters, were seen in biopsy specimens ( / ; %). cd + cell clusters were located in the papillary and superficial reticular dermis and tended to show a perivascular pattern. all biopsy specimens obtained from long-standing (> months) scabies lesions demonstrated the presence of cd + cells. in contrast, no cd expression was observed in lesions of less than months duration. cd + large cells can be detected in skin inflammatory lymphoid infiltrates associated with scabies, particularly in long-standing (> months) lesions. cutaneous cd expresion, therefore, is not an exclusive feature of neoplastic lymphoid proliferations. probably as the result of persistent antigenic stimulation, cd expression can also be detected in activated lymphoid cells of nonneoplastic infiltrates associated with insect bites, viral and bacterial infections and peculiar drug reactions. introduction malignant transformation of melanocytes is a multistep process characterized by distinct histopathological stages. differentiation between naevi, especially dysplastic naevi and melanoma, can sometimes be difficult to assess by conventional histopathological analysis. the aim of this study was to analyse the differences in proliferative activity and apoptosis between intradermal naevi (in), dysplastic naevi (dn) and cutaneous melanoma (cm). materials and methods fifteen in, dn and cm (thickness less than . mm) were immunohistochemically stained for ki- which was used as a proliferative marker, whereas bcl- and p were used, respectively, as an anti-apoptotic and apoptotic marker. statistical analysis showed a signifficant difference in proliferative activity and the overexpression of p (p < . ), while observed differences in bcl- expression were not statistically significant between these three groups. conclusion proliferative and antiapoptotic activity showed a progressive growth from benign to malignant melanocytic lesions. the strongest expression of p in dn suggests that its overexpression could be the first step in the loss of cell cycle regulation and possible malignant transformation of melanocytes. introduction it is now known that myofibroblastic transdifferentiation in glomerulus takes place during mesangial activation. material and methods we analyzed functional disorders (filtration, concentration insufficiency) and kidney biopsies of patients aged from to years with various forms of glomerulonephritis. we used standard histological, immunohistochemical, immunofluorescence methods as well as electron microscopy in our research. for studying myofibroblastic transdifferentiation we stained tissue immunohistochemically for alpha-smooth muscle actin (alpha-sma) and then carried out a quantitative analysis of the results. results seventy patients had myofibroblasts in kidneys. we found out that level of alpha-sma expression correlates with decrease of glomerular filtration. while disorders of concentration a lot of myofibroblasts appear in kidney interstitium. but we have not found any correlation between clinical forms of glomerulonephritis and those cell growth we had seen. and we should mention that for patients without glomerular or interstitial fibrosis we didn't reveal any changes in cells phenotype. conclusion so we conclude that myofibroblastic transdifferentiation must be considered as an early symptom of kidney sclerosis and can be used as a prognostic criterion. cc tsai , hc hsu dept. of pathology, far eastern memorial hospital, taipei, taiwan, republic of china dept. of pathology, national taiwan university hospital, taipei, taiwan, republic of china introduction to early detect renal and metabolic diseases, a mass urine screen in elementary and high school students was started in in taiwan. we retrospectively reviewed the nephropathologic features to elucidate its value. materials and methods one hundred students, boys and girls, who were found to have hematuria and/or proteinuria by this urine screen program and received renal biopsy, formed the basis of this study. the glomerular pathology was divided according to disease severity into two groups. results group i diseases ( %) showed minor histologic alterations, including minimal glomerular change in cases and mesangial cell proliferation in . among them, children had electron microscopic examination, ( %) had thin glomerular basement membrane (tgbm) disease. group ii diseases ( %) had more severe glomerular changes, including iga nephropathy in cases, membranous nephropathy (mn) in , lupus nephritis in , focal sclerosis in , chronic glomerulonephritis in , and type i and type ii membranoproliferative glomerulonephritis in one case each. these findings confirm that glomerular diseases often progress silently. we found a high frequency ( %) of iga nephropathy and mn in group ii diseases and a close association of mn with hepatitis b virus infection. conclusion we conclude that mass urine screen in school children and renal biopsy are very useful for the early detection of the progressing glomerular diseases and provide great opportunity for early therapeutic intervention and long-term follow-up to better understand the natural courses of glomerular diseases, including tgbm disease. introduction the purpose of the study was to establish a correlation between morphometric kidney biopsy parameters and routine laboratory findings in patients with nephrotic syndrome. material and methods kidney biopsies of patients with nephrotic syndrome were studied using standard techniques of paraffin sections stained with haematoxylin and eosin, picrofuxin van gieson and pas reaction. direct immunofluorescence on snap frozen sections was performed using commercially available antibodies against iga, igm and igg. of the patients, ( . %) were men and ( . %) women, with an average age of . ± . years. biopsy study revealed different types of chronic glomerulonephritis of various incidence: membranous gn ( ), mesangioproliferative gn ( ), mesangiocapillary gn ( ), focal segmental glomerulosclerosis ( ) and terminal sclerosing gn ( ) . morphometric analysis using the semi-automatic image analyser »integral- mt« included cross-section surface areas of the glomeruli and glomerular capillaries, the numerical density of total number of cells per glomerulus, numerical density of mesangial cells, cross-section surface area and numerical cells density of the proximal and distal tubules and cross-section surface area of the peritubular capillaries. routine clinical laboratory analysis included the level of proteinuria, serum creatinine and creatinine clearance, erythrocyturia, leukocyturia and cylinders in urine. a correlation of clinical laboratory parameters with mathematical morphometric models was established for each type of gn associated with nephrotic syndrome. the role of proliferation, growth arrest and apoptosis in the carcinogenesis and prognosis of renal cell carcinoma ga gökhan , g karpuzoglu , t köksal akdeniz university school of medicine department of pathology, antalya, turkey akdeniz university school of medicine department of urology, antalya, turkey introduction nuclear grade and stage are insufficient to predict the clinical behaviour of renal cell carcinoma (rcc). therefore additional prognostic factors are needed. in this study we investigated the role of proliferation, growth arrest and apoptosis in the carcinogenesis and prognosis of rcc using ki , cyclin a, bax, p and bcl- . material and methods formalin-fixed paraffin embedded tissue blocks from patients were studied. cases were divided into low/high grade and low/high stage. apoptotic index (ai) was evaluated as morphologically in h&e stained sections. proliferation index (pi) was detected by using ki and cyclin a immunostaining. ai, pi, p , bcl- and bax expressions in tumor tissue (tt) and in adjacent non-tumoral tissue (ant) and associations with clinical and histopathological parameters were analysed statistically. results the mean indices for apoptosis, ki and cyclin a were: . ± . ( - ), . ± . ( - ) and . ± . ( - ) in tt as well as . ± . ( - ), and . ± . ( - ) in ant, respectively. the number of cases in which the expression of p , bax and bcl- were detected was: ( . %), ( . %), ( , %) in tt, and ( %), ( , %), ( %) in ant, respectively. statistically, there was a significant relationship between the values of tt and ant for ai but not for the pi and the other parameters. only ai and pi significantly correlated with the grade. conclusion in this study the role of pi as a prognostic indicator in rcc was again confirmed. our observations suggest that apoptosis, cyclin a, bcl- and bax may have roles in the carcinogenesis of rcc and that ai may be used as a prognostic indicator. introduction isolated microscopic hematuria (imh) in children always raises the question of the necessity of renal biopsy. many authors consider imh as minor abnormality where glomerular changes are not expected, but general agreement has not yet been achieved. the aim of this study was to evaluate contribution of renal biopsy to diagnosis of glomerular disease in imh. material and methods biopsy was performed in children with imh of proven glomerular origin. mean duration of imh prior to biopsy was . years. biopsy specimens were examined by light (lm), immunofluorescence (if) and electron microscopy (em). results patients ( . %) were found to have glomerular abnormalities. on lm patients had normal glomeruli (ng), mesangial proliferative glomerulonephritis (mepgn), focal segmental glomerulosclerosis (fgs) focal glomerulonephritis (fgn) and membranoproliferative glomerulonephritis (mpgn). if revealed cases as iga nephropathy. em discovered gbm changes consistent with alport syndrome in patients and diffuse thinning of gbm in . in children, subepithelial hump-like deposits were found and considered as the sign of acute postinfectious glomerulonephritis in resolution. one of cases of mpgn showed to be type ii (ddd). on follow-up, of children with alport-like gbm changes developed full clinical picture of the syndrome. further surveillance is needed to confirm the significance of em findings in others. conclusion in children with imh renal biopsy is justified and should always be analyzed by light, immunofluorescence and especially electron microscopy, because em was decisive for final diagnosis in about % of all cases. mesoblastic nephroma of adult. report of a case introduction mesoblastic nephroma is a very uncommon tumor in adults, similar to the congenital mesoblastic nephroma of infancy, first described by bolande et al. microscopically the tumor consist in uniform spindle cells proliferations with numerous vascular spaces, nest of glomeruli, renal tubules that often cystic and dysplastic and lack of nuclear anaplasia or mitotic activity. case report a -year-old woman was admitted to the emergency services for acute abdominal pain in september . she was diagnosed with acute pancreatitis. in cat (without urologic symptoms) a solid mass in the upper pole of the right kidney was founded. with a clinical diagnosis of renal cell carcinoma a radical nefrectomy was performed. follow-up was without event and had no recurrence years afterwards. the right kidney weighed grs. and was unremarkable except for a cms-diameter circumscribed, yellow-tan, solid tumor in the upper pole. microscopic ex-amination revealed a tumor composed of spindle cells, mostly smooth-muscle cells and fibroblast, with numerous vascular structures and some areas of renal tubules with clear cytoplasm. in some places there was atrophic tubules. no mitotic figures were identified. immunohistochemistry findings: the majority of spindle cells were positive for actin, desmin and smooth-muscle actin, and vimentin. and the tubular epithelium stain for ema and keratins. conclusion a combination of histological and immunohistochemical findings is useful to distinguish mesoblastic nephroma from other tumor of the kidney with spindle cells. introduction hyperparathyroidism occurs in patients with chronic renal failure and is usually associated with multiglandular parathyroid hyperplasia. clonal analysis has suggested that in renal hyperparathyroidism glands initially grow diffusely and polyclonally. mechanism of monoclonal proliferation observed with appearance of nodular hyperplasia is not well understood. it might be induced by certain genetic disorders such as overexpression of prad/cyclin d induced by dna rearrangement of the parathyroid hormone gene. the aim of this study was to analyse the expression of cyclin d in normal and hyperplastic, diffuse and nodular parathyroid glands in order to ascertain the possible difference. materials and methods hyperplastic parathyroid glands, from uremic patients who underwent surgery during the period - , were analysed. immunohistochemistry for cyclin d protein was performed on normal parathyroid glands and selected hyperplastic, of diffuse and of nodular type. overexpression of cyclin d was considered to be present if % or more of the sample showed positive nuclear staining. results in normal glands, the mean value of nuclear positivity was . %. overexpression for cyclin d was present in / ( %) diffuse and / ( %) nodular hyperplastic glands. no significant difference was found. conclusion in comparison to normal, hyperplastic glands (nodular as well as diffuse) overexpress cyclin d protein. these results indicate that overexpression of cyclin d is not limited only to neoplastic proliferation, as the most studies showed, respectively this genetic abnormality is not the only responsible mechanism for the monoclonal proliferation. proteins of extracellluar matrix as predictors of glomerulonephritis outcome s Čužić , m Šćukanec-Špoljar , b jelaković , z sonicki , d kuzmanić , m laganović pliva inc., pharmaceutical industry, zagreb, croatia klinički bolnički centar "zagreb", croatia Škola narodnog zdravlja "andrija Štampar", zagreb, croatia introduction chronic renal insufficiency develops only in those cases of glomerulonephritis in which the lumina of postglomerular capillaries in the renal cortex are narrowed due to expansion of the extracellular matrix (ecm). aim of the study was to compare the composition of interstitial ecm proteins with clinical data in various forms of primary glomerulonephritis (gn). material and methods we examined renal biopsies from gn patients, while normal renal tissue was obtained from nephrectomy due to small renal tumour. specimens fixed in b and/or dubosque fixative were analysed by immunohistochemistry (appap-method) using a monoclonal antibodies against tenascin (tn), fibronectin (fn), collagen i, iii and iv (coi, coiii, coiv) (dako). the same fixatives were used for control renal tissue. evaluation of fibrin was performed on frozen sections by immunofluorescence. clinical data were: proteinuria and serum creatinine level, obtained by standard laboratory methods, immunotherapy and ace-genotype. results fifty patients had proteinuria at time of biopsy and of them continued to have it during the follow-up period. patients with persistent proteinuria had more often interstitial fibrosis with elevated content of coi and coiv. only % of patients who responded well to immunotherapy had deposits of fibrin. there were patients with elevated creatinine at biopsy with similar composition of ecm as patients with proteinuria. majority of patients with interstitial fibrosis had ace-genotype ii although this genotype wasn't the most common in the cohort. conclusion our study showed that persistent proteinuria could be linked to interstitial fibrosis and fibrin deposits. patients with ii ace-genotype are more prone to develop interstitial fibrosis. introduction haemorrhagic fever with renal syndrome (hfrs) in slovenia is caused by two hantavirus agents -puumala and dobrava serotypes. there is still a lack of clinical and pathological information, especially about the dobrava virus associated disease. the aim of this study was to analyse and compare the clinical course, outcome and pathological features of hfrs caused by these two virus serotypes. the clinical course of patients ( women) aged ± years (range - ) treated in the nephrological department for serologically confirmed hantavirus associated hfrs was analysed, a serological diagnosis was made using immunofluorescence test and enzyme-linked immunosorbent assay. kidney biopsy specimens of patients were analysed by light microscopy, immunofluorescence and electron microscopic techniques. a semiquantitative scale for gradation of cumulative tubulointerstitial lesions and interstitial haemorrhagic lesions was applied (scores - ). results seventeen patients ( . %) had puumala and ( . %) dobrava virus infection. all patients were febrile and had proteinuria, and other clinical features were: nausea and vomiting ( % of patients), oliguria ( %), abdominal pain ( %), headache ( %), haemorrhages ( %), myalgias ( %), diarrhea ( %), neurological and ophthalmological abnormalities ( %), hypotension ( %). pancreatitis ( %) and elevated transaminases ( %) were observed only in patients with the dobrava serotype. none of the patients in this study died and there was none with permanent haemodialysis dependence. comparison of clinical and pathological features of dobrava and puumala diseases is given in the a need for haemodialysis and the creatinine level at discharge were not associated with the age of patients. those patients who needed haemodialysis, had clinical haemorrhages or had elevated creatinine at discharge, also had higher haemorrhagic and cumulative tubulointerstitial lesion scores, but differences were not significant. elevated serum creatinine above basal levels was present at discharge in patients ( %), range - µmol/l and some patients remained with chronic renal insufficiency. conclusion our results show that dobrava virus infection is associated not only with a significant mortality, comparable to hantaan virus infection, but also with a worse clinical course of renal disease than puumala. the histopathology of the kidney in dobrava and puumala is characterised by haemorrhagic necrotising tubulointerstitial nephritis involving particularly the outer medulla, with quantitative and not qualitative differences between these two infections. renal parenchymal malakoplakia after kidney-pancreas transplantation. case report introduction malakoplakia is an unusual chronic inflammatory disease rarely involving parenchyma of the transplanted kidney. it represents an unusual host response, probably due to leucocyte bactericidal defects to an infecting agent, usually gram-negative organisms, of which escherichia coli is the commonest. malakoplakia in renal transplant is very rare (to date only six cases have been reported) and is associated with a high rate of graft loss and significant mortality. case report we report a -year-old female recipient of kidneypancreas allografts immunosupressed with tacrolimus (prograf, x mg) and mycophenolate mofetil (cellcept, x mg). the patient had suffered from recurrent urinary tract infections. three years after transplantation she was admitted to the hospital with decreased kidney graft function. percutaneous kidney needle biopsy was performed and diagnosis of malakoplakia was established. histologically, on the inflammatory background many mi-chaelis and gutmann bodies were present and confirmed ultrastructurally. the patient was treated with antibiotics and simultaneously immunosuppression (tacrolimus) was reduced. gradually, her renal function improved (with serum creatinine of umol/l). for the entire following year, the patient has been monitored regularly and her renal and pancreas function are stable and both her allografts remain in situ. morphometric study of transbronchial biopsies in pulmonary transplantation e conclusion in our series of tbb for transplant pathology, the aa and nv are the most important morphometric parameters of the biopsy to reach the diagnosis of ar. conversely, the nf does not show significant statistical difference between diagnostic biopsies and nd biopsies. the importance of glomerular deposits of von willebrand factor in human renal allografts bh ozdemir aim to evaluate the role and prognostic importance of glomerular endothelial cell alteration in human renal allografts. material and methods we examined patients with renal transplantation among whom showed acute rejection (ar) and chronic rejection (cr). biopsies were immunostained for von willebrand factor (vwf), fibronectin (fn) and cd . glomerular staining for vwf and fn was graded in a semiquantitative manner using the - + scale. results in the cr group there was markedly increased expression of vwf and fn in the glomeruli, whereas only of ar cases showed intense (grade ) glomerular vwf (gvwf). a significant difference was found between patients with ar and cr with regard to gvwf (p< . ). a positive correlation between the degree of gvwf and early interstitial fibrosis was found in cases with ar in follow-up biopsies (p< . ). the presence of transplant glomerulopathy was found significantly earlier in cases with grade gvwf in ar group (p< . ). we found strong correlation of both intraglomerular fn expression and macrophage infiltration with the degree of gvwf both in ar and cr groups (p< . ). the outcome of grafts that showed intense (grade ) gvwf was significantly worse than the outcome of those grafts with grade and glomerular vwf during the follow-up (p< . ). conclusion increased gvwf deposition in cases with ar is in risk of early transplant glomerulopathy, early interstitial fibrosis and early graft loss. in conclusion, it may be beneficial to use new therapeutic approaches such as anticoagulant medicine for the treatment of ar and cr in future. introduction acute renal allograft rejection is the most important threat to graft survival, and must be diagnosed and treated as early as possible. clinical, radiological and histopathological confirmation of the diagnosis is essential. several factors are being investigated as potential diagnostic markers for acute rejection (ar), and one of these is the hepatocyte growth factor (hgf). the aim of this study was to investigate the presence/density of hgf in core needle biopsies from renal allografts with ar using immunohistochemical staining. the study involved cases of kidney recipients whose allografts were investigated for an initial ar episode without any other pathology. all the patients received cyclosporine-a anti-rejection treatment. each archived slide was reexamined according to the modified banff classification, and patients were categorized as type i ar (group ; n= ), type ii ar (group ; n= ) and type iii ar (group ; n= ). normal histopathological findings in graft biopsies were obtained as controls (group ; n= ). the clinical findings of patients were reviewed from archived records. the sections were stained immunohistochemically with monoclonal anti-hgf antibody. the mesenchymal cells (interstitial macrophages and glomerular endothelium) that showed cytoplasmic positivity were then counted using ocular micrometer. the results were statistically analyzed using mann-whitney u test. results on analysis of the groups' mean cell count, the only significant finding was higher concentration of hgf in the ar patient group than in the control group (p< . ). concerning all other parameters studied, the only significant differences were higher blood urea nitrogen and creatinine levels in group compared to group (p < . ). conclusion our results showed that presence/density of hgf increases in favor of acute rejection and accompanies the histopathological findings. therefore we suggest that density of hgf, excreted in renal allograft tissue, may be a useful marker for supporting ar diagnosis. graft biopsies after renal transplantation in children: differences between fk and cya immunosuppression materials and methods biopsies were examined. besides light microscopy (lm) and electron microscopy (em), igg, iga, igm, fibrinogen, c and c d were detected by immunofluorescence (if). immunohistochemistry (ihc) was performed using cd , cd ro, cd , and cd antibodies to study the presence of different types of cells in acute rejection. banff's classification was used to evaluate the samples. results graft rejection was found in ( . %) biopsies -hyperacute rejection (har) ( . %), borderline changes (bch) ( . %), acute rejection (ar) ( %), and chronic rejection (chr) ( . %). cya and fk nefrotoxicity (tox) was present in ( . %) biopsies. c d ( biopsies from patients) showed linear positivity of peritubular and glomerular capillaries in patients, with har and ar. these three grafts failed and the same pattern was seen in the excised grafts. in all ar cases, ihc proved the prevalence of cd ro+ cells in rejection infiltrates, including tubulitis. the rejection infiltrate contained from % to % of monocytes-macrophages. em showed disjunction and tubular epithelia regression in tubulitis. ar and tox findings in patients receiving immunosuppression with fk were compared with a group given cya. no significant differences in the rate of toxic manifestation were found between the groups of patients on fk and those on cya. more frequent findings of toxicity were noted in fk patientsb iopsies (p= . ). ar was found more frequently both in the patients (p= . ), and in the biopsies (p= . ) of cya-treated subjects. conclusion fk seems to be more potent suppressant than cya in spite of its persistent toxic effect. the paper is sponsored by ministry of health of the czech republic (international grant agency) no: ne/ - . introduction bk polyomavirus causes a variety of infections in the urinary tract, involving transitional and renal tubular epithelium in immune suppressed patients, including transplant recipients. it can cause irreversible loss of graft function. we report a case of polyomavirus infection in a transplant recipient diagnosed by renal biopsy, urinary cytology and electron microscopy of the urine. patient and results a -year-old female patient underwent renal transplantation, and received immunosuppressive treatment with tacrolimus, mmf and prednisolone. serum creatinine level increased and hydronephrosis was observed in ultrasonography in the rd month. a renal biopsy was taken. no glomerular or vascular changes were observed. some tubular epithelial cells displayed pleomorphism, hyperchromatism with chromatin irregularities and clumping, and intranuclear inclusion bodies. no immunostaining was detected with anti-cmv, hsv and ebv antibodies. cytopathic tubular lesions in biopsy, many decoy cells in urinary cytology and intranuclear viral particles in electron microscopy of the urinary sediment proved the bk-polyomavirus infection. as the high serum creatinine levels persisted, despite alternative immunosupressive therapies, two more renal biopsies were taken, and acute rejection banff grade ib and iia was diagnosed respectively. the patient is still under a novel antiviral treatment as the focal tubular cytopathic changes were present in the latter biopsy. serum creatinine levels were still high, even though urinary cytology is normal. conclusion as we have seen in this case, the differential diagnosis between rejection and infection in renal transplant biopsies is critical and complicated for both clinicians and pathologists, as well as patients. introduction the analyses of serums or tissue specimens from the patients with autoimmune diseases are dispersed between microplate reader elisa techniques and immunofluorescence (if) microscopy techniques. the number and the complexity of if morphological parameters are becoming greater, as well as their association with some of the clinical conditions. the quantity of the morphological signs and the notice capability exceed the possibilities of the experts who are not morphologists. the aim of this paper is to present compilation of if morphological slides and their association with the clinical conditions, indicating the real position of this kind of diagnostics. material and methods more than serums and tissue specimens from different locations were used as study material. the methods used were indirect iif microscopy with commercial and own antigens, microplate reader elisa techniques (mpr-elisa) and direct if microscopy. the study showed that the morphology of antinuclear and anticytoplasmic antibodies, using hep- kits was easily examined, wider, and associations with some clinical conditions could be easily done. the antigens for mpr-elisa techniques derived from recombinated genetic technology, unlike those produced from extraction showed better correlation with indirect if microscopy. the own antigens originating from the domestic animals and human cadavers, used for indirect if microscopy in bullous diseases, had the same value as the commercial ones. conclusion in order to emphasize the importance of this paper, we can conclude that, undeservingly, very few papers from this area are being presented in the pathological congresses and are left to other specialities. the gastrointestinal stromal tumors (gist) are rare tumors. there have been few factors identified that predict survival and biological behavior. this study analizes the experience in two university hospitals. forty nine patients with gist were identified from the tumor registry of both institutions. a retrospective review of patient clinic data, tumor and treatment variable was done. expression of p and cellular proliferation antigens (ki /pcna) was also analyzed with overall survival as the main outcome variable. statistical analysis was performed by log rank test and cox regression model. significance was defined: p< . . as results we found that median age was years (range - years). twentyfive patients were women ( %) and were men ( %). hispanics were predominant race with patients ( %) followed by caucasians with patients ( %) and african american patients ( %). the stomach was the most common site of presentation ( %) followed by small bowel ( %). mean tumor size was cm (range - cm). complete resection was performed in patients ( . %). actuarial -year survival was . % with a median follow-up of months . univariable analysis identified overexpresion of p (p= . ), cellular progression antigens (ki /pcna) (p= . ), high grade (p= . ), tumor size bigger than cm (p= . ), and incomplete resection (p= . ), as significant negative factors, hispanic race (p= . ) and good performance status (p= . ) were significantly associated with prolonged survival. on multivariable analysis, overexpression of p was the only independent negative factor. in conclusion, p is the most significant negative prognostic factor for survival in gist. introduction granulomatous gastritis (gg) is a poorly understood entity, reportedly identified in less than % of all gastric biopsies. a precise definition of granulomas has rarely been given, in particular mg, well-described in intestinal disorders, have not been focused on in gastric lesions. aims: we summarize our experience with gg, including mg, and record prevalence as well as associated background morphology. materials and methods among gastric biopsies from . patients ( . gastroscopies), gg was diagnosed in patients. groups of histiocytes producing conspicuous alteration of gastric architecture were classified as well-defined granuloma (wdg); subtle collections of histiocytes failing to distort surrounding glands were labelled mg. the background morphology and presence of microorganisms were recorded. results the distribution of types of granulomas were as follows: mg only patients, mg and wdg patients, wdg only patients. the background morphology of cases with only mg/wdg with/ without mg included chronic gastritis (n= / ); chronic active gastritis (n= / ); ulcus (n= / ); lymphocytic gastritis (n= / ); carcinoma (n= / ); otherwise normal morphology (n= / ); h. pylori (n= / ). conclusion in concert with previous reports, we identified gg in less than % of all gastric biopsies. since the identification of mg requires assiduous histologic examination, such subtle features may be overlooked; hence our calculated prevalence of gg is a minimun value. the functional relation between mg and wdg is uncertain. however, their coexistence in a proportion of gg could support a precursor function of mg in the development of wdg. additionally, the background pathology of biopsies with mg and wdg were comparable. intravascular signet ring-like cells cd /lysozyme positive in gastric ulcer due to chronic use of nsaid, diagnostic implications in endoscopic biopsy and surgical management of an unusual invasive cancer mimicker j nuncio, j arista-nasr, b martinez pathology department, instituto nacional de ciencias medicas y nutricion salvador zubiran, mexico city, mexico a -year old man treated with naproxen during two years was admitted because of hypovolemia and peritoneal irritation. a panendoscopic study was performed and an ulcer localized at the large curvature of the stomach was disclosed. the microscopic examination of the endoscopic biopsy reveled invasive intravascular and stromal neoplastic signet-ring cells. because of the subsequent poorly differentiated carcinoma diagnosis, a gastrectomy was performed. in the specimen the ulcer showed necrosis, edema, fibrosis, chronic inflammatory infiltrate with lymphocytes and plasma cells. additionally atypical cells with irregular and hyperchromatic nuclei or vacuolated cytoplasm were seen in the lamina propia and infiltrating the muscular layers; isolated signet-ring-like cells were also seen. there was no involvement in regional lymph nodes. histochemical study with periodic acid-schiff, mucicarmin, and colloidal stains revealed mucosubstances in these cells. a poorly differentiated carcinoma was initially diagnosed. however the immunohistochemical studies were positive for histiocytic markers (cd- , s- protein and lysozyme) and negative for epithelial markers (cytokeratin, and ema). the positivity mucus stains in the histiocytes could be explained in this case by phagocytosis of mucous substances released from broken hyperplastic glands in the vicinity of the ulcer. to our knowledge, atypical histiocytic infiltration in gastric ulcers has not been previously described; thus, it should be included in the group of gastric carcinoma mimickers; with this basis, the pathologist must to be careful in the assessment of vascular permeation or stromal infiltration by neoplastic cells overall in endoscopic specimens. ileal mucosa changes after total colectomy in patients with juvenile polyposis and familial adenomatous polyposis a tertytchnyi , a talalaev , d sotnikov , v lukin russian state medical university, moscow, russian federation centre of children's health, russian academy of medical science, moscow, russian federation introduction we studied follow-up ileal mucosa biopsies from patients with juvenile polyposis and patients with familial adenomatous polyposis who had been previously underwent total colectomy with mucosal proctoectomy with the creation of straight ileoanal anastomosis. patients' age ranged from to years (mean . years). the follow-up ranged from months to years (mean . months). aim of this study was to identify the long-term changes in ileal mucosa after total colectomy in patients with polyposis coli syndromes. methods the biopsy specimens have been taken from the posterior wall of terminal ileum. paraffin sections were stained with h&e, van gieson, periodic acid schiff (pas) and gomori's aldehyde fuchsin -alcian-blue (gaf-ab) stains. six biopsies were subjected to electron microscopy analysis. results on histological examination ileal mucosa revealed focal shortening of villi and lengthened crypts. the villi were lined by increased number of goblet cells. mucin histochemical studies demonstrated partial conversion of the epithelium to a colonic sulfomucin mucin profile by positive gaf-ab staining in cytoplasm of goblet cells. only out of patients had increased number of mononuclear cells in lamina propria. the electron microscopy examination revealed shortening and rarification of microvilli of absorptive enterocytes. conclusion follow-up biopsies show incomplete and focal neocolonic transformation of ileal mucosa. nevertheless, in most of the cases ileal mucosa preserved its architectural and histochemical characteristics. we failed to identify evidences of chronic inflammation that made us suggest that chronic terminal ileitis is not a common long-term event in patients with polyposis coli syndromes after total colectomy. eosinophilic gastroenteritis with pleural outflow and ascites. a case report introduction in our region eosinophilic gastroenteritis is a very rare disease. etiology is unknown. case report a -year-old female patient was admitted to the clinic due to slight cough, right side pleural outflow and ascites, without other symptoms. gynaecological ultrasound, ultrasound of the upper abdomen, ct refer to ascites besides normal findings of abdominal and pelvic organs. laboratory examinations were normal except peripheral blood eosinophilia and increased values of ca . cytological findings of pleural outflow and ascites revealed a great number of eosinophilic granulocytes but without malignant cells. patohistological findings during explorative laparotomy resected parts of both ovaries, a lymph node, a hyperplastic part of pylorus, a knot from a small bowel designated as a tumor, and an appendix were taken out for a patohistological examimation. both ovaries reveal normal ovarial parenhima. a regional lymph node showed reactive changes with hyperplastic follicles and prominent germinative centers. the main histological finding reveals pyloric stromal edema and a dense infiltrate of eosinophilic granulocytes throughout the muscle layer as well as eosinophils situated in perivascular spaces which is accompanied with swelling of endothelium of capillary blood vessels. eosinophilic granulocytes were found in the smooth muscle layer of intestine as well as in the subserosal tissue. lumen of the appendix was obliterated and the muscle layer and the subserosal tissue contained eosinophils. conclusion from our review it is visible that eosinophilic gastroenteritis can represent a great diagnostic problem especially when it is accompanied with pleural outflow and ascites and increasing values of tumor markers. that can possibly mislead a diagnostic procedure to the neoplastic rather than the immunological or allergic disease. three years after surgery the patient is well. expression of tnf-alpha and il- in patients with chronic pancreatitis n shirinskaya , v akhmedov emergency hospital, omsk, russian federation omsk medical academy, omsk, russian federation introduction to study the serial levels of tnf-alpha and il- in patients with chronic alcoholic and chronic relapsing pancreatitis. methods consecutive patients with chronic pancreatitis admitted to the emergency hospital ( patients with alcoholic pancreatitis and -with chronic relapsing pancreatitis) were studied. serum levels of tnf-alpha and il- , were determined on and days after admission and in remission by immunoenzyme multiplied. results in group of the patients with chronic alcoholic pancreatitis on day one after admission the high levels of tnf-alpha ( , ± , pg/ml) and il- ( , ± , pg/ml) were marked with the subsequent consecutive decrease of these values for days (tnfalpha- , ± , pg/ml, il- - , ± , pg/ml) and in the period of remission (tnf-alpha- , ± , pg/ml, il- - , ± , pg/ml). in patients with chronic relapsing pancreatitis the low levels of cytokines on days one after admission (tnf-alpha- , ± , pg/ml, il- - , ± , pg/ml) were marked with the deferred peak of values on day (tnf-alpha- , ± , pg/ml, il- - , ± , pg/ml), and decrease in the period of remission ± , pg/ml, pg/ml) . conclusion the deferred peak of cytokines levels (on days) in patients with chronic relapsing pancreatitis can testify indirectly about more expressed cytokines disturbance. the majority of glomus tumors are benign neoplasms that occur in the dermis of extremities. however, rare case have been reported in the visceral locations, most often in the stomach. case report the tumor occurred in a -year-old male who presented ulcer-like pain. ct scan diagnosed a submucosal tumor. there was no endoscopic biopsy specimen. a wedge resection of stomach was performed with a frozen section study that conclude to a carcinoid tumor glomus tumor was confirmed by further study of multiple sections of a surgical specimen and by immunhistochemical study. conclusion correct identification of this essentially benign, very rare gastric tumor can prevent unnecessary radical operative procedures. composite carcinoid-adenocarcinoma of the ileum associated with transitional cell carcinoma of the urinary bladder i venizelos , d sioutopoulou , z tatsiou department of histopathology, athenes, greece it is well known that sometimes carcinoid tumor is associated with other tumors. approximately % of carcinoid tumors in the small intestine are associated with non-carcinoid neoplasms, most frequently adenocarcinomas of the gastrointestinal tract. the concurrent occurrence of carcinoid and other tumors in various organs is extremely rare. here, we present a case of a -year-old male who was admitted to our hospital with a -month history of haematuria. on cystoscopy a large tumor of the urinary bladder has found. a total cystectomy was performed. during the operation, while exploring the abdomen, a tumor with maximum diameter cm was found in the terminal ileum, from which a biopsy was taken. microscopically, the bladder tumor was a papillary transitional cell carcinoma grade ii and the tumor of the ileum fulfilled the criteria for a composite carcinoid adenocarcinoma. the carcinoid component was positive for chromogranin and nse and negative for ema, cea and ca - whereas the adenocarcinoma component was positive for ema, cea and ca - and negative for chromogranine and nse. -months after the operation there is no metastasis radiologically and the patient is in a good condition. due to the small number of tumors reported as composite carcinoid-adenocarcinoma there is need for larger number of similar cases as well as long term follow-up to determine their natural history and prognostic significance. we describe the first reported case of composite carcinoid-adenocarcinoma of the ileum associated with carcinoma of the urinary bladder. mutational analysis and expression of cdx homeobox gene in cases of colorectal carcinomas e pilozzi, m rapazzotti onelli, c fidler, v ziparo, js wainscoat, l ruco istopatologia ospedale sant'andrea facolta, roma, italy introduction cdx is a transcription factor specifically expressed in normal intestinal epithelium. it plays a role in the regulation of cell proliferation and differentiation. experimental evidences suggest that it could have a pro-oncogenic effect since cdx overexpression up-regulates bcl- and reduces p ; it is up-regulated by ras activation and its ectopic expression has been reported in intestinal metaplasia, in carcinomas of the stomach and in barrett's esophagus. despite these observations the role of cdx in colorectal carcinogenesis is not yet fully understood. in fact it has been shown to be down-expressed in colon cancers at mrna and protein level. the aim of the study was to investigate the presence of cdx gene mutations. materials and methods twenty cases of sporadic colon carcinomas were collected. total rna and dna from neoplastic and normal tissues were extracted. cdna was synthesized and used as template in rt-pcr using oligonucleotide for cdx and â-actin. cdx three exons were pcr amplified and directly sequenced. results we found lower expression of cdx in tumour samples in four out of ten cases. sequencing showed a transversion g>c ( / cases) of exon and a t>c transition in exon ( / cases) that, being present in the corresponding normal tissue, were regarded as polymorphisms. no base substitution was observed in exon three. conclusions our results showed that cdx expression is reduced in colon carcinoma. however cdx was not found to be mutated suggesting that alterations, other than base substitution, may affect cdx gene in colon cancer. we are now looking at cpg islands methylation in the same cases since methylation could be a likely explanation of the low expression of cdx . aim this study investigates tgfbeta , tgfbeta and tgfbeta proteins expression in patients with colorectal carcinoma and evaluates their correlation with classic prognostic markers and patients' survival. design the study comprised patients with colorectal carcinoma. according to astler-coller system, tumors were of stage a, -b, -c and -d, whereas tumors were low-grade and high-grade of malignancy. on paraffin sections the streptavidin-biotin technique, using antibodies to tgfbeta , tgfbeta and tgfbeta (santacruz, usa) was employed. staining results followed morphometric analysis and were correlated with clinicopathologic parameters. results tgfbeta protein was expressed in / ( %) carcinomas whereas tgfbeta and tgfbeta proteins were detected in all tumors examined. normal colonic mucosal epithelial cells expressed less tgfbeta (p< . compared to neoplastic cells) and less tgfbeta (p> . compared to neoplastic cells), but not at all tgfbeta . statistical analysis revealed higher expression of tgfbeta in low grade carcinomas (p= . ) and higher tgfbeta presence in advanced stage tumors (p= . ). tgfbeta expression was related with higher disease free survival and higher total survival (p< . respectively). tgfbeta presence was correlated with worse prognosis (p< . ). cox analysis revealed that besides tumor grade and stage, tgfbeta expression constituted independent prognostic factor. conclusions this study shows that in cases of colon adenocarcinoma there is different expression of tgfbeta , tgfbeta and tgfbeta . tgfbeta may be implicated in the pathogenesis of these tumors since it is expressed only within neoplastic and not normal cells. tgfbeta is related with higher disease free survival, higher total survival and constitutes an independent prognostic factor. in the late stages, tgfbeta seems to be involved in tumor progression and it is related with worse prognosis. cdx is useful in distinguishing primary colorectal adenocarcinoma form pulmonary, mammary and pancreatic adenocarcinomas metastatic to the colorectum g groisman, a meir, m amar hillel yaffe medical center, hadera, israel background the large bowel may be the site of metastasis from a number of tumors including pulmonary, mammary and pancreatic adenocarcinomas. the histological distinction of primary colorectal adenocarcinoma from these metastatic lesions may be difficult. the aim of this study was to evaluate the utility of the intestinal marker cdx in distinguishing primary colorectal adenocarcinoma from pulmonary, mammary, and pancreatic adenocarcinomas metastatic to the large bowel. design routinely processed mucosal biopsies of adenocarcinomas involving the colorectum [ primary, metastatic (lung , breast , pancreas )] and control cases of primary lung, breast, and lung adenocarcinomas were immunohistochemically stained for cdx (biogenex, san ramon, ca, usa). the intensity and extent of the staining were recorded semi-quantitatively. results cdx diffussely and strongly stained the normal colorectal epithelium as well as all cases of primary colorectal adenocarcinoma. in contrast, all cases of metastatic lung, breast and pancreas adenocarcinoma as well as all control cases were cdx negative. conclusions cdx immunostaining is useful in discriminating primary colorectal adenocarcinomas from pulmonary, mammary and pancreatic adenocarcinomas metastatic to the large bowel. we recommend its use as a component of any antibody panel put together to discriminate between primary and secondary colorectal tumors. infiltrative and proliferative activity in central versus peripheral parts of colorectal cancer introduction growth of primary and metastatic tumour is accompanied by formation of stroma composed of connective tissue and new blood vessels. colorectal cancer is a malignancy characterised by marked desmoplastic reaction both in primary tumour and in its secondary foci (metastases). presented report was aimed to describe quantitatively microvessel density in primary tumour and lymph node metastases from this neoplasm. materials and methods study material included cases of colorectal cancer with metastases to the regional lymph nodes. investigated group comprised women and men (aged - yrs); tumours were t and four were t according to tnm classification. microvessels were highlighted using monoclonal anti-cd antibodies. vessel counts were performed in five fields of each primary and metastatic focus (x ; . mm ). numbers of blood vessels in colorectal tumour were counted in areas free from prominent necrotic foci and non-specific granulation tissue due to process of reparation. vessel density in nodal metastases was determined in fields occupied by neoplastic cells forming their own connective tissue stroma. results in the primary tumour group mean vessel density was . vessel/mm (median value . ; range - ). in metastatic foci the same parameter was . vessel/mm (median value . ; range - ); no statistically significant difference was detected. only slight correlation was found between the microvessel densities in primary and metastatic tumours (r= . ; p= . ). conclusion presented results seem to prove the similar pattern of neovascularisation in both groups, whereas marked differences in this process can be observed between subsequent analysed cases. early diffuse-type gastric carcinoma, especially signet ring cell carcinoma, often shows the superficially spreading growth pattern, and one of the unsolved questions concerning the histogenesis of this type of carcinoma is whether it is monoclonal or multiclonal in origin. we have performed human androgen receptor gene assay (humara assay) based on the random inactivation phenomenon of x chromosomes in female and reported that most of this type of carcinomas were of monoclonal origin ( / cases). however, this method demonstrated only probability of monoclonality in each lesion. recently, % of diffuse-type gastric carcinomas have revealed mutations of the e-cadherin gene at the early stage of their progression, and in-frame skipping of exon has been seen frequently. thus, we performed an immunohistochemical analysis of early signet ring cell carcinomas using e-cad delta - , which is a specific antibody against a peptide spanning the fusion junction region between exons and of mutant ecadherin. e-cad delta - specifically reacts with tumor cells expressing e-cadherin mrna lacking exon . seven of cases were positive for this antibody. in each positive case, the paraffin blocks of the tissue slices that included the whole tumor were analyzed using e-cad delta - . although some signet ring cells with abundant mucin in the upper and/or lower layers of a layered structure did not react with this antibody, tumor cells were confirmed to express e-cadherin mrna lacking exon- by reverse transcriptase-polymerase chain reaction with paraffin-embedded formalin-fixed tissues. these findings suggest that they are of monoclonal origin ( / cases) and support our previous data using humara assay. e tsikou-papafragou , t papadaki , m tsamouri , e nikolaou , c barbatis korgialenion-benakion hospital, athenes, greece evangelismos hospital, athenes, greece introduction malt lymphoma is the commonest primary gi lymphoid malignancy but for correct diagnosis and classification, immunohistochemical and molecular analysis have been proven necessary. the aim of this study was to demonstrate the value of current methodology for diagnosing gimls by presenting four unusual cases. materials case . a years old male with common variable immunodeficiency. an obstructive ileal tumor cms was resected and multiple biopsies were taken along the gi tract from nodular areas. case . female years old with generalised lymphadenopathy, lung shadows, dyspepsia and duodenal nodularity. case . female age underwent gastrectomy with initial diagnosis of high grade b lymphoma. case . female age , had gastrectomy/ splenectomy for relapsed gastric lymhpoma which had been diagnosed as malt type. methods immunophenotypical analysis for detection of cd , cd a, cd , bcl- pr, bcl- pr, cd , cyclin d , cd , cd , cd ro, cd , ki- and genotypic analysis for the clonal igh, tcva genes (case ) and the igh/bcl- rearrangement (case ). results per case: . atypical burkitt lymphoma with diffuse lymphoid hyperplasia of the gi tract (cd / / a+, bcl- +/ -, ki %). . generalised follicular b lymphoma, grade according to the who classification with involvement of the duodenum. . diffuse large b cell lymphoma with aberrant cd ro expression. rearrangement of the igh genes and not of the tcva gene. . cd -mantle cell lymphoma with anaplastic foci in the spleen. clonal rearrangements of the igh and concomitant igh/bcl- gene rearrangements involving tonsils, stomach, spleen and abdominal lymph nodes. conclusion all cases represent unusual types of gimls easily misclassified or graded without thorough immunophenotypic and molecular analysis. the incidence of gastric cardiac adenocarcinoma has increased in the last decades. gaining insight in the pathogenesis of this lesion is hampered by the limited knowledge of the origin and histology of cardiac mucosa (cm). currently, the location, extent and even the existence of cm are controversial. aims: we studied the development of the gastro-oesophageal junction (goj) in embryos, fetuses and infants to clarify whether cm is a normal structure at birth and where it is located. materials and methods twenty-one autopsy cases were evaluated. age range: weeks gestational age (ga) - months. the distal oesophagus and proximal part of the stomach were embedded entirely. serial sections were stained with haematoxylineosin and alcian blue/periodic acid-schiff. the following parameters were measured: length of abdominal oesophagus; length of columnar-lined oesophagus; length of cm; distance from cm to angle of his. results cm was present in all evaluated sections. its mean length varied throughout gestation. a maximum value was reached at a ga of weeks ( , mm). after term delivery, it was very short ( , - , mm). cm was proximal to, or straddled the angle of his in all cases. during gestation, the mucin staining pattern of the cm was to a high degree similar to that of the developing pyloric mucosa. conclusions cm develops during pregnancy and is present at birth as a normal structure. if the angle of his is taken as a landmark for the goj, cm is located in the distal oesophagus. gastric mucosa-associated lymphoid tissue (malt) and non-malt lymphomas: clinicopathological study of cases s taban, a dema, n tudose university of medicine and pharmacy, timisoara, romania introduction histologic features of low-grade b-cell malt lymphoma of the stomach have been well described in recent years, but its relationship with the more common large b-cell gastric lymphoma has not been clarified. the authors investigate clinicopathological differences among low-grade and high-grade gastric lymphomas. methods clinical and histopathological aspects of consecutive gastric lymphoma cases found in gastrectomy specimens were studied: cases of low-grade malt lymphoma (lg malt lymphoma), cases of high-grade malt lymphoma appearing in low-grade malt lymphoma (hg/lg malt lymphoma), cases of high-grade malt lymphoma (hg malt lymphoma) and cases of diffuse large cell lymphoma (dlcl). results mean age were as follow: lg malt lymphoma- , years; hg/lg malt lymphoma- , years; hg malt lymphoma- , years; dlcl- , years. there was a male predominance of malt lymphoma patients (male to female ratio- / ). macroscopically, the most common pattern of lg malt lymphomas was the superficial spreading type with or without ulceration, whereas hg malt lymphomas and dlcl exhibited a solitary tumor-forming lesion. b-cell immunophenotype was confirmed in cases, only one case of dlcl was a t-cell lymphoma. conclusions in our study, the prevalence of high-grade malt and non-malt lymphomas was , %. our results suggests that some gastric lymphomas with high malignancy can arise through blastic transformation of the lg malt lymphomas, this process(change) seems to take about ten years at least. background the recently described serrated adenocarcinoma accounts at least . % of colorectal malignancy. it develops from serrated polyps. dna microsatellite instability (msi) is more common in serrated adenocarcinomas than in conventional adenocarcinomas, but the frequency of msi-low and msi-high in these tumours is unknown. materials and methods an unselected series of serrated adenocarcinomas were included. msi status was evaluated using panel of five markers d s , d s and d s ) . a tumour was considered to present msi-high if two or more markers showed msi, msi-low with one marker, and mss when none of the markers showed msi. results dna msi was observed in . % ( / ) of serrated adenocarcinomas, . % ( / ) being msi-high and . % ( / ) msi-low. msi status showed no association with gender, age, location, size, dukes stage, grade or mucinocity. msi-positive serrated adenocarcinomas tended to have better prognosis ( -year survival . %) than mss cancers ( -year survival . %), but this was not statistically significant (p= . , log-rank). conclusions serrated adenocarcinomas show prevalence of msilow higher than that reported for colorectal cancers ( to %), supporting idea that serrated carcinomas are formed through a pathway differing from other carcinonomas. absence of any association of msi and clinicopathological features could be due to homogeneity of these neoplasms although a more extensive material is necessary to show more conlusively absence of any association. a trend for better prognosis in msi -positive serrated adenocarcinomas probably reflects the biological behaviour of msi observed earlier in colorectal carcinomas in general. thyroid hormone receptor beta- expression in colorectal cancer is associated with polypoid growth type and k-ras mutations t hörkkö, tj karttunen, p jernvall, mj mäkinen department of pathology, university of oulu, finland background the action of thyroid hormones is mediated via their receptors (tra , tra , trb and trb ). trb expression is abnormal in cancer cells in vitro and in some malignant neoplasms, but the role trb in colorectal carcinogenesis is unknown. materials and methods trb expression pattern was evaluated by immunohistochemistry in operated colorectal cancers and correlated with k-ras mutations and clinicopathological features. results in normal mucosa, cytoplasmic trb immunoreactivity was seen mainly in the superficial parts, while nuclear reactivity was most prominent in the cryptal epithelium. in tumours, nuclear expression was observed in % of cases and cytoplasmic staining in %, both mostly co-existing. cytoplasmic staining for trb was more common in polypoid ( %; / ) than in flat carcinomas ( %; / ; p= . ). k-ras mutations were more common in tumours with cytoplasmic expression of trb ( . %; / ) than in those without ( %; / ). in lymph node metastases, occurrence of nuclear staining of trb was more pronounced than in the primary lesion (p= . , wilcoxon). conclusions expression of trb is present in normal colorectal mucosa and is mostly retained in carcinomas, suggesting that thyroid hormones and their receptors may be involved in the physiological regulation of normal colorectal epithelium and in the pathogenesis of colorectal cancer. association of expression with k-ras mutations indicate occurrence of functional linkage between trb and ras signaling. observations of a high expression in lymph node metastases and in polypoid cancers offer new clues to factors affecting metastatic cascade and growth pattern of colorectal cancer. gastric mucosal calcinosis in chronic renal failure patients materials and methods a review of the records for crf patients who underwent endoscopic biopsy revealed gmc (patient group) and non-gmc (control group) cases. for each subject we recorded the number and sites of biopsies, and reassessed for inflammatory activity, mucosal atrophy, intestinal metaplasia, lymphoid aggregates, helicobacter pylori, amyloid deposition, and gastritis type. age, sex, cause of renal failure, time from renal failure diagnosis to biopsy, type of dialysis, indications for endoscopy, saca use, and serum levels of calcium, phosphorus, calciumxphosphorus product and parathyroid hormone were also recorded. the gmc cases were classified according to pattern of deposition (nodular, granular, mixed) and disease severity (mild, moderate, severe). results the incidence of gmc was . %. in gmc group there was male preponderance ( %). compared to the control group, the gmc group had a significantly higher number of corpus biopsies; a significantly lower number of antral biopsies; a significantly lower frequency of mucosal atrophy; and a significantly lower parathyroid hormone level (p< . for all). none of the gmc patients had used saca. conclusion unlike previous reports, these results show that gmc is not linked with saca use or female gender in crf patients. there was also no correlation with mucosal injury. these findings suggest that gmc is probably a metastatic process, not a dystrophic one. the value of histology in diagnosis of inflammatory bowel disease (ibd) v tzioufa, g karayannopoulou, i venizelos, a asimaki, e vrettou, c kalekou, t kehaya, a kriaka, e nenopoulou, k patsiaoura aristotle university of thessaloniki, greece in patiens with colitis colorectal biopsy is helpful in the differential diagnosis between ibd and other forms of colitis and also between ulcerative colitis (uc) and crohn's disease (cd). however the histological features in biopsy specimens are not always sufficient for a definitive diagnosis and there is need to establish more sensitive and specific criteria for the distinction between uc and cd. a retrospective blind evaluation of biopsy specimens from patients with the endoscopical diagnosis of colitis was undertaken in order to assess the value of histology in the diagnosis of ibd and the degree of inter-observer agreement. twelve experienced pathologists participated in the study. twenty histopathological features according to a modified version of the british society of pathology guidelines for the evaluation of colorectal biopsies in suspected ibd were studied and the results were statistically analysed. the clinical diagnosis after follow up was uc in cases, probably uc in cases, ibd cases, cd cases and nonspecific colitis cases. higher than % agreement (by all or participating pathologists) on the diagnosis of uc based only on histologic parameters was reached in of the cases for which clinical follow up proved the diagnosis of uc. unanimous agreement on the diagnosis of non-specific colitis was reached in of the cases. our results indicate that although detailed assessment of a combination of histopathological features and the experience of histopathologist are important for the diagnosis of ibd, the final diagnosis depends on combination of histopathology with the clinical and endoscopical evaluation. s taban, a dema, n tudose university of medicine and pharmacy, timisoara, romania aim the authors presented two cases of polipoid tumor lesions (gastric and anal) with pseudomalignant changes. multiple sections from the stomach and anal mucosa were analysed by light microscopic and immunohistochemical methods. in the gastric hyperplastic polyp, there was surface ulceration with granulation tissue and acute and chronic inflammation. within the stroma were numerous atypical cells with bizarre cytomorphology and atypical mitoses. the second case was a fibroepithelial polyp of the anus with collagenous stroma covered by squamous epithelium. stromal cells with two or more nuclei were found and showed atypical nuclear features. in both cases, mast cells were frequently observed and sometimes intimately related to the stromal cells. immunohistochemical study revealed that the stromal cells stained positive for vimentine and negative for actine, desmin, cytokeratin, s- protein and leukocyte common antigen, so considered to be fibroblastic cells. clinical follow-up was available. none of the patients followed developed metastases or recurrences. prognostic value of nm and c-erbb- expression in colorectal cancer v delektorskaya, a perevoschikov, ne kushlinsky cancer research centre, moscow, russian federation increased expression of genetic markers is observed in a variety of malignancies, including colorectal cancer (crc). overexpression of these markers in the primary tumor is known to predict outcome after colonic resection. in this study we aimed to evaluate the expression level of the nm and c-erbb- proteins in crc and its correlation to prognosis and liver metastasis. protein expression was examined immunohistochemically in formalin-fixed, paraffinembedded tissue from colorectal patients. crc showed a high level of nm protein expression in % of primary tumors and % of liver metastasis. expression of c-erbb- was observed in % of primary carcinomas and % of distant metastasis. the positive expression of protein markers in primary lesion was significantly higer in the cases with liver metastasis than in those without metastasis. no significant relationship was observed between nm and c-erbb- expression and other clinicopathological parameters. these results suggest that nm and c-erbb- expression play an important role in the progression of crc and could provide additional information for the development of liver secondaries. introduction sporadic gastric carcinomas (gcs) with high level microsatellite instability (msi+) tend to be poorly differentiated adenocarcinomas with abundant lymphocytic infiltration and are associated with a relatively good prognosis. the aim of the study was to define whether the nature and the activation status of lymphocytes infiltrating neoplastic epithelial cells (iels)of msi+ gcs could be involved in an increased apoptosis of tumor cells and could be consistent with a tumor-specific immune response. materials and methods tumor cells apoptosis and immunophenotype of iels were investigated by immunohistochemistry in msi+ gcs. for comparison, a series of msi-gcs with similar histological features was investigated, including cases, which were positive for epstein barr virus infection (ebv+). results msi+ and msi-/ebv+ gcs displayed a significant higher mean number of cytotoxic iels than msi-/ebv-tumors (cd : . and . versus . ; cd : . and . versus . ; tia- : . and . versus . ; p< . ). in addition the activated iels were more frequent in msi+ than in msi-/ebv-gcs (mean granzyme b immunoreactive iels: . versus . ; perforin . versus . ; p< . ). the percentage of apoptotic tumor cells, evaluated with the m cytodeath antibody, was higher in both msi+ and msi-/ebv+ gcs than in msi-/ebv-gcs ( . % and . % versus . %; p< . ). the lymphoid infiltration in msi+ gcs was significantly higher than that of msi-gcs (except for ebv+ gcs) and this might explain the increased apoptotic index and the relatively better prognosis of these tumors. introduction goblet cell carcinoid (gcc), also known as mucinous carcinoid or adenocarcinoid, is a rare tumor of appendix, which exhibits both endocrine and adenocarcinoma differentiation. different mucin phenotypes are associated with neoplastic transformation in epithelial tissue in various organ systems. muc apomucin is a mucin gene product specific to intestinal goblet cells. muc is suggestive to inhibit cell-to cell adhesion. in the present study, we retrospectivelly studied the clinicopathological features and immunohistochemical expression of muc , muc and muc a in gcc. materials and methods three appendiceal gcc were retrieved from our pathology files from to . medical records and histologic slides were reviewed. the expression of muc , muc and muc a was assessed by immunohistochemistry. results all three cases were males and the age ranged from , and yrs. two patients presented with acute appendicitis. the other one had ruptured diverticulitis and renal cell carcinoma. two patients had appendectomy, and one patient had right hemicolectomy and right radical nephrectomy. histologic examination showed infiltrative small nests and glands of tumor cells with goblet cells and mucinous cytoplasm. perineural invasion was noted in one case. the tumors had invaded through the appendiceal wall to subserosa in two cases and to adjacent cecum in one case. the tumor cells are positive staining for synaptophysin. there was strong and diffuse reactivity in the tumor cells with muc , muc and muc a antibodies in all three cases. follow-up ranged from month, months, and months. all were alive and without recurrence. conclusions these observations suggest that there is no differential expression of muc , muc and muc a in gcc and both muc and muc may play a role in cancer cell growth and invasion. gastric parietal cell carcinoma: report of three cases ml gomez-dorronsoro, r beloqui, i amat, p de llano, a cordoba, b larrinaga, e borobio hospital de navarra, pamplona, spain gastric parietal cell carcinoma is an infrequent newly recognised variant of gastric carcinoma with only cases published in the literature. the present study describes the findings in three cases of gastric parietal cell carcinoma consisting of parietal cells. we have used light and electron microscopy, and histochemical stains. we have studied three cases, two men and one woman, aged between and years. the tumour size ranged from , to , cm. the surgical specimens were stained with hematoxylin-eosin, alcian blue and ptah. small pieces of formalin fixed tumor tissue were collected in one case, and fresh tissue fixed in glutaraldehyde in another both for electron microscopy. involvement of the gastric wall was observed in all tumours. the tumour pattern was characterised by an arrangement of tumour cells in sheets, elongated cords or in diffuse poorly cohesive sheets interspersed with a lymphocytic infiltrate. tubular differentiation was only focally present in one of the cases. all the cases were composed by a large number of parietal-like cells with abundant eosinophilic cytoplasm, with a mixture of signet ring cells population in one of the cases. alcian blue stain was negative throughout the tumour, whilst ptah stained many tumour cells. ultrastructurally the tumour cells were characterised by abundant mitochondria, tubulovesicles, intracellular canaliculi and intercellular lumina filled with microvilli. the three tumours presented are primary gastric carcinoma with cytological and ultraestructural patterns of parietal cell differentiation. they represent a morphologically distinct type of carcinoma, which has been said to have a favourable prognosis. aim the aim of study is to investigate do really cd + cells have cytotoxic or suppressor influence upon gastric epithelium. material and methods we have examined biopsies from patients with peptic ulcer and -with gastritis only. samples were formalin fixed, paraffin-embedded, stained with h/e, toluidineblue, gimsa stain, pas reaction. comparative immunohistochemical analysis of cd + lymphocytes, proliferative markers: mib- and pcna were performed. we evaluated the amount of cd + cells in mm and the proliferative activity of epithelium per nuclei. biopsies were examined electronmicroscopically for the detection of cell-to-cell interactions and subcellular alterations of gastric epithelium. results distribution, amount and characteristics of cd + cells are different in mucosa around ulcer and in gastritis (g.) cases without ulcer. in active g. around ulcer cd + cell are , ; without ulcer - , , but in inactive g.- , . in helicobacter pylori-infected subjects cd + are located in addition at the lymphatic follicles. we have not proved any rise of apoptosis, exfoliation or ultrastructural injuries of epithelial cells in the areas of collections of tlymphocytes of this subtype. in sites of increased amount of cd + cells there is high proliferation activity of epithelium ( , - , %) due to the broadening of labeled nuclei zone with mib- antibody. conclusions the amount of cd +cells correlates with activity of gastritis as this kd glycoprotein realize molecular reactions between mediators or against h.pylori, food and other antigens in lamina propria, but it has no external direct domain upon gastric epithelium, capillaries or glandulocytes. the incidence of gastric cancer decreases worldwide. despite declining (due to intestinal type), incidence still remains the second cause of death amongst all malignancies worldwide. diffuse type of gastric cancer shows constant incidence. therapy and prognosis directly correlate with extent of the disease and reliable prognostic factor is still lacking. the aim of the study is to establish a value of two morphometric methods -nuclear area and microvessel density and their influence to the survival of the patients with advanced gastric cancer. patients who had undergone gastric resections for gastric cancer were analysed in this study. we estimate size of the tumor, histologic type (according to lauren's classification), stage, nuclear area (median value of nuclear areas in cancer cells measured with computerised nuclear morphometry) and microvessel density (median value of f viii-positive microvessels in five x power field) for each case. statistical analysis was performed and p-values lower than , were considered significant. nuclear area shows statistical significant correlation with size of the tumor, tumor stage, tnm classification and metastases in regional lymph nodes, microvessel density does not. in univariate analysis to survival, size of the tumor, tumor stage and tnm classification have p< , . nuclear area only in intestinal type of gastric cancer correlates with survival (p< , ). in multivariate analysis, size of the tumor, tumor stage and tnm classification have an influence on survival. reliable prognostic factors in patients with gastric cancer are still stage and size of the tumor. diffuse type of gastric cancer is still an enygma. spreading and metastazing of intestinal type of gastric cancer could be predicted using a nuclear-area method as a support in therapy planning and prognosis. the role of microvessel density in prognosis is unreliable. f iordanidis, e vrettou, e nenopoulou, p hytiroglou, c papadimitriou pathology dept. medical school. aristotle univ., thessaloniki, greece introduction the kit receptor normally becomes dimerized and its tyrosine kinase phosphorylated (activated) upon the ligand binding, then enabling it to phosphorylate other proteins in the signal transduction pathway that ultimately carry the proliferation signal into the nucleus. the aim of this study was the evaluation of ki- (mib- ), proliferative cell index, in correlation to c-kit stain intensity, histological grade and immunophenotype in gists. we studied a series of gists (c-kit positive) in correlation to age, anatomic location, size, morphological features, mitosis and necrosis. also we stained with vimentin, cd- , smooth muscle actin (sma), s- protein and ki- with abc method on paraffin sections. results the average age of the patients was years (ranging from to ), included male and female patients. were located in the stomach, in the small intestine, in the colon and in the esophagus. microscopically the tumors showed a fusiform cytology and of them showed a mixed fusiform-epitheloid cytology. the average tumor size was , ± , cm (range , - cm). we found necrosis in tumor with size> cm. the tumor cells expressed vim %, cd %, sma %, s- % and ki- ranging from - %. the most gists showed c-kit positivity in % of tumor cells with a small minority showed more focal staining in as few as % to % of tumor cells. the stain intenisty was mild to moderate. conclusion in our study, the ki- expression was associated with tumor size and not with c-kit staining profile, other immunophenotypic features or histological parameters. expression of pcna and ki- protein in colorectal carcinomas. correlation with tumor grade v zivkovic, a nagorni, v katic, j gligorijevic, b djordjevic, m milentijevic, z mijovic institute of pathology, medical school, nis, serbia and montenegro introduction the prognostic significance of pcna and ki- proliferation markers in colorectal carcinomas is debatable. therefore, we evaluated immunoreactivity of the tumor for pcna and ki- antigen in colorectal carcinomas with different histological grades. methods the paraffin embedded tissues were immunostained for pcna and ki- antigen by employing streptavidin-biotin(lsab) method. results pcna was positive in % of carcinomas and localized in the nuclei of malignant cells.immnunoreaction for ki- was demonstrated in all carcinomas and mainly and strongly expressed in the nucleoli.positive staining for pcna and ki- correlated positively with increasing grade. the labelling index was significantly higher in the poorly differentiated carcinomas than in the well differentiated tumors. conclusion the expression of pcna and ki- proliferation markers clearly shows differences between colorectal carcinomas of varying differentiation grades and it is useful as a diagnostic and prognostic parametar. introduction collision tumours have been thought to arise from the accidental meeting and interpenetration of two independent tumours. here we present three cases of gastroesophageal junction tumours that could fill these criteria. we employ molecular and genetic techniques to ascertain the clonality of these tumours in order to determine whether they represent true collision tumours. methods p immunohistochemistry was performed, and p sequence analysis was carried out on rt-pcr material derived from fresh frozen tissue. mutations were subsequently confirmed in paraffin embedded material. standard and laser microdissection techniques provided tumour-enriched samples from which dna was isolated. analysis of loss of heterozygosity was performed using the microsatellite markers d s , d s , d s , d s , d s , d d , d s , tp , p alu and bat . results p immunohistochemistry was positive for both tumours in each case. all three tumours possessed a p point mutation that was identical in both components. polymorphic microsatellite analysis confirmed shared losses of heterozygosity with an identical pattern of retention and loss at six loci in each component. genetic differences were also observed between tumour components. conclusion a comparison of immunohistochemistry, p sequence and the pattern of loh for a spectrum of polymorphic microsatellite markers for three possible collision tumours suggests that both components are derived from a single precursor cell that undergoes divergent differentiation in the evolution of the tumour. the evidence presented here refutes the "collision hypothesis" and introduces a new histopathological entity of a cardia tumour with distinct diffuse signet ring cell and squamous components. a nasierowska-guttmejer, w michej department of pathology, cancer centre, warsaw, poland introduction gists are the most common mesenchymal tumors of the gastrointestinal tract. they are histologically heterogenous group and a practical diagnostic criteria for gists is c-kit (cd ) expression by immunohistochemistry. the aim of this study was to present morphological pattern of radically operated and disseminated gists. material and methods material included gists treated between and in cancer center, warsaw. thirty pts. had been radically operated of gastric gists and pts. -intestinal gists. fifty three pts. had peritoneal and liver dissemination. the histopathological diagnosis based on the type of cells, mitotic activity and tumor size. the immunohistochemical expression of cd (dako), cd (dako), sma (dako) and s p (dako) were performed in each of the case. results . microscopic spectrum. majority ( %) of cases had heterogenous pattern-spindle and epithelioid cells with high mitotic activity-more than mitoses per hpf. the intestinal and disseminated tumors had generally spindle cell histology with variable myxoid matrix or extracellular collagen globules reffered to as skeinoid fibers. the majority of gastric gists were composed of epithelioid, polygonal cells with perinuclear vacuolization. .the immunohistochemical analysis revealed strong and diffuse cd expression in of cases, whereas cd was expressed in cases. four cases were negative for cd and positive for cd . a minority of the tumors expressed smooth muscle actin which was focal. conclusions the heterogenous histologic pattern of gists cd (+) correlated with dissemination, diameter over cm and more than mitoses per hpf. carcinosarcoma of the esophagus: two cases of the unusual neoplasm m malinowska, a nasierowska-guttmejer department of pathology, institute of oncology, warsaw, poland introduction esophageal carcinosarcoma comprise approximately - % of all esophageal tumors. this is the first published report in poland of the unusual malignant neoplasm consisted of both carcinomatous and sarcomatous components. materials and methods two patients with esophageal tumors were presented. they were analyzed using endoscopic, histological and immunohistochemical procedures. an endoscopic examination showed polypoid tumors in the lower esophagus. esophagogatrectomy with lymph node dissection was performed. the resected specimens were fixed in % formalin and paraffin embedded tissue sections were stained with routine hematoxylin and eosin. immunohistochemical analysis for vimentin, cytokeratin, p and mib were performed. results histologically, the neoplasms consisted of two components, squamous cell carcinoma and sarcomatous components. in case , the sarcomatous component was with no specific differentiation and in case resembled malignant fibrous histiocytoma. a gradual transition between two components was found. in case regional introduction the cyclin-dependent kinase inhibitor p is a critical downstream effector in the p pathway and this protein acts as tumor suppressor in a negative cell cycle regulation. aims: we investigated the prognostic influence of p waf /cip reactivity in gastric carcinomas in relation to the p expression. materials and methods the expression of p waf /cip and p protein was revealed immunohistochemically in gastric carcinomas. staining patterns were assessed semiquantitatively and correlated with clinicopathologic variables and survival times. median follow-up time was months (range - months). chisquare and kaplan-meier survival analysis were performed as statistical analysis. results the p waf /cip protein was detected in ( %) and p protein in ( %) of cases. p waf /cip expression was significantly higher in stages i and ii carcinomas than in stages iii and iv carcinomas (p= . ). in tumors without lymph node metastasis, p waf /cip expression was significantly more frequent in tumors with lymph node metastasis (p= . ). low p waf /cip expression significantly associated with p protein expression (p= . ). the survival rate of patients with p waf /cip -positive tumors was significantly better than those without p waf /cip expression (p= . ). in patients with p positive tumors showed significantly poorer prognosis than in patients with p negative tumors. conclusion the status of p waf /cip expression may have prognostic value in gastric carcinomas and evaluation of the expression of both p and p waf /cip might provide more prognostic information. introduction the normal motility of the gastrointestinal tract depends on the enteric nervous system, the smooth muscle layers, and the interstitial cells of cajal (iccs). the aim of this study was to investigate both the distribution of interstitial cells of cajal and the pathohistology of the enteric nervous system in colonic inertia. materials and methods large bowels were obtained from patients with colonic inertia. the patients have been treated surgically with total abdominal colectomy and ileorectal anastomosis. control large bowel specimens were collected from patients with non-obstructing neoplasia. colonic specimens were investigated with monoclonal anti-neurofilament antibody and cd antibody and compared with those of control patients. the analysis of iccs included registration of the number and process length of the myenteric and muscular iccs. in the patients with colonic inertia the myenteric plexus showed moderate or severe hypoganglionosis compared with the control group. the apparently normal axon bundles in the myenteric plexus stained markedly less than normal ones with monoclonal antibody. myenteric iccs were evident as single cells or cell clusters closely related to the small myentric ganglia. the iccs did not form the typical networks seen in the normal bowel. muscular iccs were markedly reduced in number compared to the number seen in normal bowels and were mainly expressed at the innermost layer of the circular muscle layer. conclusion the enteric nervous system and iccs are altered in colonic inertia and may play a crucial role in the pathophysiology of colorectal motility disorders. immunohistochemical detection of the hmlh and hmsh proteins in hereditary and sporadic colon cancer tissues germline mutations of hmlh and hmsh mismatch repair genes (mmr) are associated with hereditary nonpolyposis colon cancer (hnpcc). somatic impairment of these genes can be detected in sporadic colon cancers (cc). all these tumours are characterised by microsatellite instability (msi). the aim of this study was to correlate the results of immunohistochemical detection of hmlh and hmsh protein with results of mutational and msi analyses. patients and methods there were included: cc samples from hmlh /hmsh germline mutation carriers, cc samples from non-carriers, and cc samples from patients not subjected to mutational analysis. immunohistochemistry was performed using mouse monoclonal antibodies (anti-hmlh , clone g - ; anti-hmsh , clone g - , pharmingen, usa). msi was analyzed at abi prism genetic analyzer, mutational analysis by dna sequencing. results loss of nuclear protein expression was detected in all tumours from mutation carriers, all of these exhibiting a high grade of msi (msi-h), and in of msi-h tumours from the other patients. none of the tumours with stable microsatellites or a low level of msi exhibited a nuclear protein loss. immunohistochemical analysis was able to detect msi-h tumours with a % specificity and a % sensitivity. conclusion immunohistochemical detection of hmlh and hmsh proteins is a specific method of detection of tumours with mmr gene inactivation and might be used as a screening method of hnpcc. the msi-h cases with retained nuclear protein expression might express non-functional protein or carry another mmr gene defect. suppported by nc - . study of mucin changes in colorectal adenomacarcinoma sequence m danciu , ms mihailovici , m stan , a trifan , c sfarti , s khder , am gruia university of medicine and pharmacy, iasi, romania institute of gastroenterology and hepathology, iasi, romania introduction mucins are known to have a protective role for the colorectal epithelium against extrinsic noxious factors (including carcinogens), changes of its characteristics being an early process in the adenoma-carcinoma sequence. aims: quantitative and qualitative evaluation of mucin changes in hyperplastic polyps (hp), adenomatous polyps (ap) with different degrees of dysplasia and adenocarcinomas (ac) of colon. material and methods we selected colorectal endobiopsies ( hp, ap and ac). thin serial sections were stained with hematoxylin-eozin, van gieson and alcian blue (ab) ph (for strongly sulphured mucins) and ph . (for acid mucins: weakly sulphured mucins, hyaluronic acid and sialomucins). observations were made only on intracellular mucins. intensity of the stain was analyzed and compared with non-tumoral (normal) adjacent mucosa. results and discussions normal mucosa and hp showed a preponderance of sulphomucins (ab ph ) comparing with sialic acid (ab ph . ). in ap (especially in those harboring high-grade dysplasia) we detected sialomucins in . % cases and the depletion of sulphomucins ( . %). in ac sialomucins were identified in . % cases, while sulphomucins only in . % cases. significant depletion of sulphomucins occurs in ap with moderate and severe dysplasia and in ac, but it was also observed in ap with mild dysplasia. this suggests the possibility that without a proper mucin secretion consisting mainly in strongly sulphured mucins, colorectal epithelium is more vulnerable to environmental carcinogens. histological this study is a continuum of the analysis until . we analyzed biopsy and operative materials from the stomach and small bowel. we used the following histochemical stainings: he, van gieson, reticulin, as well as immunohistochemical stainings with the following antibodies: ckws, lca, s , actin, desmin, nse, chromogranin, synaptophysin, vimentin. results and conclusion the analyzed group of cases consists of patients of age between - years with male predominance ( : ). four of the analyzed ten cases were located in the stomach and in the small bowel. cases were benign, histologically composed of bundles of spindle cells with slightly pleomorphic nuclei and eosinophilic granular cytoplasm, with hyalinised collagen between the cells. the mitoses were either rare or absent. immunohistochemical analyses were most frequently positive for s , actin, desmin and synaptophysin. three of the cases were ranked as malignant, using the following diagnostic criteria: size of the neoplasm, existence of metastases and histological appearance with anaplastic spindle cells arranged in bundles and whorls with high mitotic index ( mitoses per hpf) and marked positivity for actin, desmin and vimentin. what is the relation of age, gender and histological types to the subsite location of colon carcinoma? introduction characteristics that determinate the anatomic site within the colon where the carcinoma is most likely to occur would be very useful in choosing optimal factories for screening of colon cancer /cc/. aims: to study any association of gender, age or histological types with cc in the left or in the right colon. materials and methods retrospectivitaly are studied cases of cc in nmtb between and .the age and the gender of patients were determined. localization, histological type and tnm staging of the cancer are identified on the histological slides. results cases of cc at the age between - years old are diagnosed. gender, age and histological type were independently significantly associated with the frequency of the development of right and left colon carcinoma. the gender distribution of cc is in benefit of male independently of sub site location as they are suffered of cc in the younger age in comparison with the female. independently age, gender and localization prevails the histological type adenocarcinoma with different morphological and functional differentiation. one cc in the left colon is developed on the background of fap. solitary are the cases with congenital fap and lynch ii. in the most cases cc was diagnosed in advanced stage. solitary is the cases with tis and t . conclusion we consider: /cc is more frequently in the male colon; /in cc predominate histological type of adenocarcinoma; /cc is developed in the middle and in the age advanced in years; / cases with multicentrical cc with metachronic carcinoma are solitary. introduction cathepsin b (cb) and l (cl) are cysteine peptidases with capacity of degrading extracellular matrix. cb expression in colorectal cancer (crc) has been related with tumor progression. there are no data about the cl immunohistochemical expression. the aim of this study was to analyse the expression of both cb/l in crc and to relate these findings with clinicopathological data. material and methods epithelial and stromal immunohistochemical expression of cb and cl was studied in and samples respectively. cb was analysed in adenomas. global and local infiltrating edge data were recorded. clinico-pathological parameters were correlated with the immunohistochemistry. results cb/l expression in normal epithelium was apical, with scarce macrophages in the lamina propria. an increase of both cb/l was observed in tumoral stroma, with higher cb at the infiltrating edge. the both global and deep stromal cb increased according to the t (p< , ). neoplastic epithelial cb revealed a basal stain whereas cl was occasional. epithelial cb tended to show high expression in t (like high grade dysplasia) and low expression in t that increased progressively in t - (p= , ) . no differences were evidenced either as a function of n state, gender, site, differentiation or histological type. conclusions cb/l immunoexpression in colon have a distinctive pattern which is altered in carcinoma. whereas increased cb stromal expression ise related with local progression, epithelial positivity seems to play an important role in the first steps of carcinoma. high stromal cl isassociated with carcinoma but cl epithelial expression seems not to be contributory. introduction new approach on estrogen and progesteron receptors of the gastric signet ring cell carcinoma explains its histogenesis and poor prognosis. the pointed out facts are the reason for this study. material and methods the material was obtained from surgically resected stomach, together with ovaries. after two months from gastrectomy right mastectomy has been done. the specimens were fixed in % formaldehyde and embedded in paraffin. the sections were stained with he, pas, hid-ab ph= , methods and abc using estrogen and progesteron antibodies (dako). results histologically, mucin-producing signet ring carcinoma that diffusely infiltrates the antral wall and the ovaries known as krukenberg tumor, has been found. histochemically, type b signet ring cell carcinoma was discovered: cells contained blue positive (sialo) mucin. ductal type of breast carcinoma with lymph node metastases also was found. immunocytochemically, estrogen and progesteron positive receptors were discovered in cancer cells of the stomach, breast and ovaries. introduction primary gastric low-grade marginal zone b cell lymphoma of malt type is a distinct disease entity with a characteristic histological presentation and clinical behavior. the development of gastric malt lymphoma is dependent of h.pylori infection. many reports have stated that the cure of h.pylori infection can induce a complete remission of low-grade gastric malt lymphoma. we performed a prospective study to evaluate the outcome of patients with low-grade gastric malt lymphoma and the histological characteristics before and after therapy. we prospectively enrolled patients with h. pylori positive low-grade gastric malt lymphoma (stage i e except one patient in stage ii e). paraffin sections were stained with: he, giemsa, pas and immunohistochemical lab methods. the patients were examined by endoscopic ultrasound before and after eradication therapy. results endoscopically, enlarged gastric folds, erosions or ulcerations, hyperaemia or intragastric nodularity, with preferential localization in the antrum, were described. histologically, the neoplastic cells infiltrated between pre-existing lymphoid follicles, then colonized the lymphoid follicles. the resemblance of these cells to the centrocyte has led to the term "centrocyte-like (ccl)" cell-neoplastic component of malt lymphoma. in some cases the cells had monocytoid appearance, but plasma cell differentiation also was prominent. typical lesion for malt lymphoma -"lymphoepithelial lesion", was frequent, representing infiltration of the glandular epithelium by clusters of neoplastic lymphoid cells with associated destruction of gland architecture and morphological changes within the epithelial cells, including increased eosinophilia. after the eradication of h.pylori, the patients were regularly followed-up with endoscopic and histological assessment. patients achieved complete remission within weeks, one had partial gastrectomy induced by ulcer with severe dysplasia, but with regression of malt lymphoma (within weeks), but the remission of the patient with stage ii e was achieved within months. lamina propria appeared "empty" with gland loss. scattered lymphocytes and plasma cells were seen within the lamina propria and there were nodular collections of small lymphocytes. lymphoepithelial lesions were scanty or absent. conclusions the time taken for achieve remission of gastric malt lymphoma in these patients varied from to months. the only significant prognostic variables were stage and tumorgrade. comparative evaluation of the prognostic value of muc and muc antigens in colorectal adenocarcinoma introduction during the last decade, information accumulated regarding the experssion of human mucins. muc belongs to the group of membrane bound mucins. it is assumed to play various roles in tumor immunology. muc is marker of goblet cell or mucinous differentation of adenocarcinoma. the significance of muc and muc as prognostic markers in colorectal adenocarcinoma with mucinous differentation and mucinous adenocarcinomas was studied because previous investigations revealed inconsistent results. materials and methods tissues from operated patients with mucinous or mucinous differentiation of colorectal adenocarcinomas were investigated. all specimens were classified according to who and tnm classification, including lymph node status and distant metastases at the time of the surgical intervention. formalin-fixed paraffin-embedded colorectal cancer tissues were cut ( µm) and deparaffinized acording to standard histological techniques. classical he, histochemical pas and hid-ab ph= , and immunohistochemical bsp techniques were applied. the obtained results were evaluated by the x test. results the muc immunoreactivity showed a strong correlation with tumours progression (as suggested by advancing tnm stages) and also de-differentiation (as reflected by tumorous grading). localization and histological grading were also statistically signifficant. on the other hand, muc did not show any association with the data concerning prognosis. conclusions according to our data, only muc presents as an independent prognostic factor of colorectal adenocarcinoma. muc should therefore be considered as a potential target of immunotherapeutic strategies. sporadic form of colon cancer of a -year-old boy i stojanovic, v katic, j gligorijevic, k katic, m andjelkovic-matic institute of pathology, medical faculty of nis university, nis, serbia and montenegro introduction sporadic form of colon cancer is one of the most frequent cancers in adults, but very rare in children; thus we report this case. case report we describe the case of a -year-old boy who had the agressive sporadic coecal cancer, surrounded by nodular lymphoid hyperplasia.the boy underwent to partial colectomy cum omentectomy during the night with clinical diagnosis "acute abdomen". the surgical-pathological stage was: stage iii (t nlmo). the patient received postoperative therapy, but he died with liver metastases eight months from surgery. materials and methods formalin-fixed paraffin-embedded coecal cancer and surrounding nodular tissue were cut and deparaffinized according to standard histological techniques. he, pas, hid-ab ph , and immunohistochemical lab techniques were applied. results fungous advanced carcinoma, mm in diameter, induced stenosis and clinical symptoms of occlusion. histologically, it was poorly differentiated adenocarcinoma with high mitotic index(high activity of ki- ) and neuroendocrine differentiation; cancer cells were diffusely positive for p protein. immunological reaction to muc , muc ab and muc , as well as to b lymphocytes, was negative. microscopic examination of surrounding malt showed large, confluent lymphoid follicles without germinal centres within lamina propria, causing nodular appearance of the overlying mucosa. b lymphocytes were markedly depressed in this nonhereditary form of colon cancer. conclusions the authors have suggested that antibody deficiency, environmental, endocrine and genetic factors cooperated in the development of this nonhereditary coecal carcinoma. the histological findings in the gastroesophageal junction of fetuses introduction the histopathological concept of the gastroesophageal junction has been changed by american pathologists providing the evidence that the gastric cardia is not a physiological structure. instead, it develops through glandular metaplasia of the squamous epithelium of the distal esophagus due to gastroesophageal reflux. methods, results and conclusion the development of the esophageal and gastric mucosa in the gastroesophageal junction was studied in fetuses of - weeks of the gestational age. during the th - th week, the esophageal multilayered epithelium was covered by a continuous layer of columnar mucous ciliated cells which were present only focally till the th week and disappeared later. before the th week, the gastric mucosa was formed by pits only. the glands started as proliferating tubules in the basal parts of the pits in the th week. further, they differentiated into oxyntic glands. the mucosa of the corpus was fully developed in the th week. the cardiac mucosa was absent in all the fetuses examined between the th and st week of gestation. this supports the view that the gastric cardiac mucosa is not a physiological structure but that it results from glandular metaplasia of the distal esophageal mucosa due to gastroesophageal reflux. mr jalali nadoushan , a dievan beigi , n fallah , b mofid shahed university, tehran, islamic republic of iran shahid beheshti university of medical sciences, tehran, islamic republic of iran introduction there is not enough studies about relationship between colon cancer and abo and rh blood groups in compare to gastric cancer. therefore in this study we will examine abo and rh blood groups distribution and correlation of them with pathologic stage of colon adenocarcinoma. methods data on age, sex, abo and rh blood types and pathologic stage (wall thickness involvement and involvement of lymph nodes) of the patients with colon adenocarcinoma; were under surgical operation, were collected from three tehran hospitals. and also data on abo and rh blood groups from healthy persons from above hospitals collected by randomized selecting as control group. results the distribution of abo blood groups in patients was different from control group; however, blood group a in patients was . % higher than the corresponding control. there was no significant association between abo blood groups and pathologic stage of colon adenocarcinoma. the distribution of rh in patients was likely equal with control group; although, there was a significant relationship between rh (+) and wall thickness involvement (p< . ) and involvement of lymph nodes (p< . ). conclusion -abo blood group a is more common in patients with colon adenocarcinoma. -rh(+) has correlation with poor prognosis in colon adenocarcinoma. introduction vascular endothelial growth factor (vegf) is a cytokine involved in tumor angiogenesis. compelling data implicate that deregulation of p protein function may be associated with increased neovascularization and aggressive tumor growth. the aim was to investigate the prognostic significance of vegf overexpression and microvessel count (mvc) at the deepest invasive site in colorectal carcinoma tissue as well as their relationship with p protein expression in tumor tissue. material and methods surgical specimens of operated colorectal carcinomas were studied by immunohistochemical methods for detection of vegf and p protein in tumor tissue and cd positive microvessels. median folow up was . month (range, - months). results vegf expression and nuclear p protein overexpression were found in , % and % of colorectal carcinoma. vegf and p protein positive status was identical in . % of tumors. the dukes stage c and high mvc were significantly more frequent in vegf positive tumors ( . % and . % respectively) comparing with vegf negative tumors ( . % for both dukes stage c and high mvc). hypervascularity significantly correlated with advanced dukes stages, but not with the p protein expression. survival analysis showed that vegf and p protein expression as well as hypervascularity of colorectal carcinomas correlated with poor survival (p= . ). conclusion vegf is an important angiogenic factor in colorectal carcinoma, and its expression being dependent on p protein expression. our data suggest that combined analysis of vegf, p protein and mvc may be useful for predicting the more aggressive biological behaviour of colorectal carcinoma. occult involvement of lymph nodes in the splenic hilus and along the splenic artery in patients with proximal gastric carcinoma m bjelovic introduction the aim of this study was to find out the incidence of occult metastatic involvement in lymph nodes in the splenic hilus (lymph node group according to jrsgc) and along the splenic artery (lymph node group according to jrsgc) as well as to identify pathological features that might be prognostic factors associated with involvement of these lymph nodes in the patients with proximal gastric carcinoma. material and methods total of patients with advanced proximal gastric carcinoma and up to positive perigastric lymph nodes (t /t n category) have been studied in the period between and . histopathological features (tumor size, macroscopic and histologic type, grade of differentiation, depth of penetration, invasion of intramural lymphatics and veins) as well as lymph node involvement have been routinely examined according to tnm and jrsgc systems. detection of microcarcinosis (occult lymph node involvement) in lymph nodes groups and has been performed by multiple serial sectioning and using immunohistochemistry (monoclonal antibodies against cytokeratins and , lsab+ technique) and classified according to modified kikuchi criteria. results occult lymph node involvement in lymph node group has been observed in patients ( , %). three of them ( , %) had only single cell micrometastases (g type of microcarcinosis) and patients ( , %) had micrometastatic deposits greater than microns (g type of microcarcinosis). occult lymph node involvement in lymph node group has been observed in patients ( , %) expressing single cell micrometastases in one case and micrometastatic cell clustering (up to microns in diameter) in another case. conclusion occult involvement of lymph node groups and could be expected in lymph node positive patients with more than three positive perigastric lymph nodes. in the patients with advanced proximal gastric carcinoma examined pathological tumor characteristics could not be associated with the involvement of lymph node groups and . lymph node micrometastases in patients with gastric carcinoma: immunohistochemical evaluation introduction for patients who underwent curative resection for gastric carcinoma, lymph node status seems to be a major prognostic factor of disease recurrence. contrary to histologically overt lymph node metastasis, the biological significance and prognostic relevance of micrometastatic lymph node involvement are still controversial. we examined frequency and distribution of micrometastases in lymph nodes obtained from patients with advanced gastric carcinoma ( , lymph nodes per patient) without primarily histologically overt lymph node metastases. identification of lymph node micrometases was performed using multiple serial sectioning and immunohistochemical detection of cytokeratin and positive cells. the results were correlated to tumoral histological type, growth pattern, depth of penetration and vascular invasion. results the overall detection rate of micrometastases showed their occurence in more than half of examined patients ( / or , %) and in , % of examined lymph nodes ( / ). most of them were so-called single cell micrometastases ( , %), followed by cluster-type of micrometastases up to microns ( , %) and few greater than microns ( , %). the incidence of micrometastases was , % ( / ) in lauren`s diffuse type of carcinoma contrary to % ( / ) in lauren`s intestinal type of carcinoma. in addition, there was no significant difference in occurence of micrometastases in cases with and without penetration of muscular layer, contrary to cases with serosal tumoral involvement and obvious vascular invasion. conclusion detection of micrometastases might influence tumour stage migration to tnm stage iii in further % of examined patients with primarily stage ii determined diseases. the frequency of micrometastases seems to be closely correlated to poorly differentiated carcinomas, especially lauren`s diffuse type of carcinoma and higher pt stages, including serosal involvement. however, possible independent prognostic significance is still to be elucidated after survival analysis of larger series of these patientss ubgroups. introduction gastrointestinal stromal tumors (gists) are the most common mesenchymal tumors of the gastrointestinal tract with the stomach as the most common site. the term 'gist' is preferentially used for the tumors that express cd and cd /c-kit and the latter has been suggested as a specific marker for gists. as gists constitute a group of phenotypically heterogenous mesenchymal neoplasms with uncertain biological behaviour, we reevaluated their histogenetic differentiation and proliferative status. material and methods we reexamined clinically, histologically and immunohistochemically cases of paraffin-embedded gists noted in the tumor registry of clinical centre of serbia between and , and especially in regard to their proliferation, measured by mitotic index and immunohistochemically by ki- and pcna expression scores. in addition, evaluation of malignancy of gists was based on mitotic count greater than / hpf and/or tumor size greater than cm and extra-gastrointestinal spread. results most of gastric gists were composed of spindle cells ( %), epithelioid cells ( %) or both cell types ( %), and nearly % showed obvious clinical malignant behavior. immunohistochemical examination showed strong cd expression in %, cd in , % (two of cases exlusively cd positive) in nonmyogenic and non-neurogenic tumors. in addition, in gists with cd expression, focal expression of s- was found in , %, focal sma in % and desmin in , % of cases. ki- and pcna indices were correlated to mitotic index and other criteria of malignancy. conclusion phenotypic differentiation of gists toward smooth muscle were found to be correlated with proliferative indicators of poor prognosis more consistently than those toward partial/focal neurogenic differentitation or uncommited type. deep topographic compartments of colorectal adenocarcinomas: down-regulation of mlh /msh expression results in lack of physiologic cell kinetic balance background topographic tumor cell selection is not well characterized in colo-rectal adenocarcinomas (crc). the contribution of mlh- /msh- expression to cell kinetics by topographic compartments remains unknown in sporadic crc. design we selected ( low-grade, high-grade) consecutive sporadic crc, including stage i, stage ii, and stage iii. mitotic figure counting, ki- index, g +m phase fraction, in situ end labeling (isel) of dna fragments, and mlh- /msh- immunoexpression were scored by topographic tumor compartment (above muscularis propria vs. muscularis propria). statistical correlation between proliferation and apoptosis variables was performed in each topographic compartment. variables were studied by topographic compartments and considered statistically significant if p< . . physiologic correlations were preserved only in the superficial compartment for mitotic figures, ki- expression, isel index, and mlh /msh expression. g +m phase fraction correlated with mlh- expression only in superficial compartments (p= . ) and msh- expression only in deep compartments (p= . ). conclusions superficial compartments of sporadic crc are characterized by high cellular turnover and maintained cell kinetic balance. mlh- and msh- expression in sporadic crc is inefficient (no g +m phase fraction differences by topographic compartments) and is dissociated (only one gene product correlates with g +m), eventually resulting in mutation accumulation and cell progression. gastro the biologic behaviour of gists has been difficult to predict based on the original criteria proposed in the early s. many isolated histological features, such as site, size, extent of bowel-wall involvement, necrosis, cellularity, mitotic counts, atypia, etc., had to be evaluated and integrated into a single and reproducible result that had also to be as accurately predictive as possible. therefore numerous studies have been performed in order to reach the ideal combination of factors that may predict these tumors correctly. gists were diagnosed either originally or retrospectively after reviewing diagnoses of git spindle cell tumors, examined in our pathology department between the years - . all tumors were defined as gists only when displaying c-kit (cd ) immunopositivity. additional immunohistochemistry was performed to corroborate the diagnosis. we reclassified the tumors according to different proposed classifications and correlated the results with the clinical followup available for these patients. the followup periods ranged between - months for gastric gists (mean- . months, median- . months) and - months for patients with small-bowel gists (mean- . months, median- months). while the median disease-free survival was . months for patients with malignant gastric gists, it was only months for patients with small-bowel malignant gists. the results of the study show that all classifications stratified the patients in a very similar manner although some were more accurate than the others and more user-friendly and therefore probably also more reproducible. the relative high rate of deaths occuring in the smallbowel gist group ( %) as compared to the . % death rate in the gastric gist patients, strengthens the supporters of different criteria to be applied to the gists arising in these different sites. another important issue that has imerged in our study was the much higher incidence ( %) of malignant gists developing in the younger age group ( - years), compared to . % malignant gists in the age group of above years, making this feature to be probably of major significance. it should therefore be considered whether age should be a built-in criterion when evaluating the biological potential of a gist. introduction gastric ulcer disease is the most important disease of the digestive tract becouse this illnes have big frequecy and circle gastric ulcus presents many histologic features characteristics which may be precancerous lesions. gastritis is lesion which is always associated with gastric ulcer. epithelial metaplasias are transformation of one kind of epithelium to other type epithelium and circle gastric ulcus it is very frequency changes of epithelium. the aim of this study was to to find frequency of appearance epithelial metaplasias circle gastric ulcus, types of metaplasias and grade of gastritis. also we searched changes of epithelial mucins. we had citochemistry examination endocrine g, ec and d cells and we wanted to describe immunohistochemicaly feature characteristics in different kinds of epithelial metaplasias. material and methods for examination we use biopsy material:surgery and endoscopic of patients with gastric peptic ulcer. we use standard he method for identification micromorpholic changes; ab-pas (ph , ) and hid-ab method for illustration biochemistry alteration about mucins;grimelius ( ) and masson citochemistry methods; immunocytochemistry avidin-biotin peroxidasa (abc) with antiserotonin, antigastrin, antisomatostatin. results we found cases completly mature intestinal metaplasias (im), cases incompletly im; case imature im and case imature im with displasia. also we detected composition completely and incompletly im in cases, composition incompletly and pyloric metaplasia in cases.we find pyloric metaplasias in cases, colons metaplasia in cases. composition colons and incompletly mature im were detected in cases;composition pyloric and incompletly mature im in case.summary the bigest frequency of appearance metaplastic alteration were in older patients.histologicaly claracteristics metaplasias were imitation some segments of digestive tract. metaplasias include many biochemicaly alterations and it can be present with changes in secretion of mucins.gastric metaplasia is dynamic process with changes both in epithelial and endocrine cells. conclusion metaplasias in gastric mucosa circle gastric ulcer is sign very important alteration.standardisation of research this alteration may be very important guider about prognosis for patients with gaster ulcer disease. choice of immunohistochemical method for detection of defect mismatch repair system c fenger, o nielsen, tp hansen department of pathology, odense, denmark colorectal cancer (hnpcc) and in % of sporadic colorectal cancers, and in the latter the defect is associated with a better prognosis but posssibly also a higher risk for metachronous cancer and a different response to adjuvant chemotherapy. screening for such defects can be done by testing for microsatellite instability, but immunohistochemistry gives similar results with less costs. the aim of this study was to select the optimal antibodies and methods for immunhistochemical detection of proteins involved in the mmr system. material and methods twelve antibodies ( against hmlh , against hmsh , against hmsh and against pms ) were tested using different dilutions and hier-techniques on a material consisting of paraffin embedded tumours from patients with well defined mutations and from controls. the results were evaluated semiquantitatively. the following clones, dilutions and pretreatment regimens were selected: introduction colon's metaplasia may be variant of intestinal metaplasia in the gastric mucosa circle gastric ulcer.it is important precancerous stadium because % colon's metaplasias of gastric mucous membrane transverse in gastric carcinoma. aims: we want to find frequency of appearance colon's metaplasia in gaster mucosa with ulcer disease.also we want to describe histologicaly, histochemicaly and immunohistochemicaly feature characteristics colon's metaplasia in gastric mucosa. materials and methods for examination we use biopsy's matherial:surgery's and endoscopic of patients with gastric peptic ulcer. we use standard he method for identification micromorfologic changes; ab-pas (ph , ) for illustration biochemistry alteration about mucins;grimelius citochemistry method;imunocytochemistry avidin-biotin peroxydasa with antiserotonin, antigastrin and antistomatostatin. results we find two cases so-called colon's metaplasia gastric mucous membrane. it was males in vi decade of life.both of them were detected near parts with intestinal metaplasia and atrophic gastritis. histology's design metaplastic epithelium appear big changes than normal gastric mucosa watched on cellular and tissue level;it was alike epithelium of colon. there was winding and arborescent cryptas, and wasn't find villosity. cells in cryptas were voluminous and they group. predominant componentof cells were goblet cells. cylindric cells also was alike goblet cells. we didn't see paneth's cells. histochemycaly we detected sufficiently sulphomucins and less sialomucins. g cells and ecl cells were insufficient; ec cells were less multiplied. conclusions colon's metaplasia is sign of big intracellular alteration and we can detect this with changes in secretion of mucin. colon's metaplasia gastric epithelium is dynamic process with changes both in epithel and endocrine cells. upregulated expression of relp, a reg-like protein, in inflammatory, metaplastic and neoplastic gastrointestinal mucosa lc andersson we screened expressed sequence tag (est) databases to detect genes specifically expressed in the gastrointestinal tract. we identified a gene, called relp (regenerating protein (reg) family-related protein). the relp cdna encodes a amino-acid preprotein with a -amino-acid signal peptide. the amino acid sequence of relp is - % identical and - % similar to the previously characterized members of the reg protein family. the reg proteins, which all belong to the family of c-type lectins, have been implicated in cell proliferation, migration and differentiation in the gastro-intestinal tissues. the relp gene spans . kilobases and maps to chromosome p - . , whereas the genes of the previously known reg proteins cluster on chromosome . dot-blot hybridisation revealed expression of relp mrna mainly in the gastrointestinal tract, but also in prostate, and testes. immunohistochemical staining demonstrated expression of relp in mucosal neuroendocrine cells of in the small intestine and in the parietal cells of normal gastric mucosa. regenerating borders of gastric ulcera, the goblet cells of inflammatory mucosa in ulcerative colitis and crohns disesase, showed a strongly upregulated expression of relp. areas of intestinal metaplasia in the stomach and esophagus also displayed a robust content of relp. more-over, relp was strongly expressed in mucocellular and mucinous tumors of the gastrointestinal tract. the orthologous gene for mouse relp was also cloned. conclusions relp represents a novel marker of inflammatory, metaplastic and neoplastic changes in the gi-tract. current approach to the biopsy diagnosis of gastrointestinal stromal tumors (gists) -is it possible to predict clinical behaviour? introduction gists are the most common gi mesenchymal tumors showing cd positivity. although according to accepted criteria none of them are 'benign', their metastatic risk depends on the tumor size (ts) and mitotic count (mc). aim: reclassification of a series of gists using morphological and immunohistochemical analysis of paraffin-embedded material and evaluation of the relevant clinical data. material and methods patients with gists fulfilled the criteria of fletcher et al. ( ) . in addition to histological stainings, primary antibodies against vimentin, desmin, actins, s- protein and cd (all dakocytomation) and cd (immunotech) were used for the immunoanalysis. results majority of the tumors was localized in the stomach (n= ) and small intestine (n= ), one in the colon and two were extragastrointestinal. in relation to the accepted mc and ts criterias, of cases were of low and one of very low risk category. tumors belonged to intermediate risk category, mostly due to ts in contrast to low mc. the inclusion of cases into high risk category was based predominantly on the mc (> / hpf and ts - cm /n= / and > cm /n= /; in the last one it was > - / hpf in contrast to ts < cm). conclusion a prediction of clinical behaviour of gists requires a correct histopatological analysis related to initial staging data. although the categorisation of the gists into different risk categories uses both criteria of ts and mc, the significance of the mitotic activity evaluation in our set of cases seems to be higher. multiple gastric composite carcinomas (adenocarcinoma and endocrine carcinoma) with adenosquamous differentiation y kapran , n akbas , m aksoy , f dizdaroglu university of istanbul, istanbul medical faculty, pathology department, istanbul, turkey university of istanbul, istanbul medical faculty, general surgery department, istanbul, turkey a case of multiple gastric composite carcinomas composed of endocrine carcinoma and adenocarcinoma with adenosquamous differentiation is presented. tumours showed a composite architecture both within the site of origin and in lymph node metastasis. a year-old woman had a diagnostic upper gastrointestinal system endoscopic evaluation for her long term dyspeptic complaints. after determination of two concurrent tumours in the stomach she underwent total gastrectomy operation. gross examination of the stomach revealed a polypoid lesion in the anterior wall and an ulcerous lesion in the posterior wall of the corpus. also there were multiple minute nodular lesions both in the corpus and fundus. histopathological examination of the polypoid tumour revealed a well-differentiated tubular adenocarcinoma admixed with an endocrine carcinoma proved immunohisto-chemically. ulcerous lesion was composed of a poorly-differentiated adenocarcinoma showing adenosquamous differentiation admixed with an endocrine carcinoma. other nodular lesions were composed of endocrine tumours having different levels of invasion in the wall of stomach. non-tumourous mucosa harboured atrophic gastritis. this is a unique case of multiple composite carcinomas devoloped in the setting of atrophic gastritis worth to discuss. introduction one of the most common malignant soft tissue tumours in adults is malignant fibrous histiocytoma. these tumours are accepted as an aggressive tumour and mainly treated surgically. primary and metastatic malignant fibrous histiocytomas of the gastrointestinal tract are rarily described. our case is a -year-old woman who had a retroperitoneal malignant fibrous histiocytoma that had metastased to the lung after months following an adequate initial treatment. four months later, because of having recurrent attacks of vomiting and nausea, gastroscopic examination was performed. multiple nodular lesions in her stomach were seen and microscopic examination of these lesions revealed spindle-shaped, pleomorphic tumour cells. the positive immunoreactivity for anti-vimentin and anti-cd justified the diagnosis of malignant fibrous histiocytoma's metastases. total gastrectomy was performed following that diagnosis and she died after month due to renal failure. conclusions this case is presented because of the rarity of distant metastases of malignant fibrous histiocytoma to the stomach and to discuss the entities that should be considered in the differential diagnosis of these tumours. role of p ink a in gastrointestinal stromal tumours introduction the classification based on c-kit/cd expression reordered the formerly rather confuse category of gist. p ink a (p ) is a tumour suppressor gene of the cyclin d-cdk , /ink /rb/e f pathway, altered in > % human neoplasms. it is located on chromosome p , a region consistently involved in dna losses found in malignant gists. aims: we studied the role of p in gists. materials and methods cd -immunoreactive mesenchymal tumours with morphological and clinical features consistent with gist were studied, excluding smooth muscle (desmin+, cd -) and schwannian (s- +, cd -) neoplasms. cases ( gastric, small intestinal and colorectal; males, females; age at diagnosis: - years; follow-up: - -mean: . -months) were considered. immunohistochemistry, rna extraction with semiquantitative rt-pcr and methylation specific pcr (msp) were used. kaplan-meier method followed by log-rank test, and univariate and multivariate analyses with a proportional hazards model were performed (malignancy criteria adopted for uncensored events: recurrence, invasion of adjacent organs, peritoneal dissemination, metastases and death of disease). results a tumoral cell fraction with low/absent p immunoreactivity > % was associated with malignancy; semiquantitative rt-pcr confirmed this result. by msp, cases (all underexpressing p , six malignant) showed p promoter methylation. low/absent p immunoreactivity, together with size, cellularity, mitotic count and presence of coagulative necrosis resulted associated with malignancy by univariate analysis, with the former factor being the only prognostic one selected by multivariate analysis. conclusions p downregulation is implied in gist progression; p promoter methylation is one of its causes; p assessment opens possible perspectives in gist prognostication. introduction regenerative abilities of gastric mucosa glandular epithelium cells are the main mechanism which condition its right function both within the range of gastric mucosa integrity and normal activity of its epithelial cellular elements. the aim of the work was to evaluate dependence between proliferative activity of gastric mucosa glandular epithelium and sex, age, chronic inflammation type and helicobacter colonization. the examinations were conducted on paraffin blocks from gastric oligobiopsies taken from women (of average age- ) and men (of average age- ).to the examinations were rated only cases where oligobiopsies were taken from at least two gastric prepyloric parts (antrum) and corpus with recognized unspecific chronic gastric mucosa inflammation. chronic gastritis was graded according to modified whitehead's classification. helicobacter pylori (hp) was evaluated according to the sydney system. examination of the cells with pcna proliferative antigen expression were conducted separately for foveolar area glands and for glands below gastric mucosa foveolar area. all the measurements were performed separately for gastric mucosa prepyloric part and gastric corpus. in tissue sections, in which were carried out proper immunocytochemical reactions, measurements of the pcna positive cells number in circular, oblique short, oblique long and oblong gastric glands sections were conducted five times. the statistic analysis also included age, presence of hp colonization, gastric mucosa inflammation type and the area where an oligobiopsy section was collected. results no significant differences were found in proliferative activity depending on the place of collecting a section, age and hp colonization, while a higher proliferative activity was found in superficial chronic gastritis, particularly in gastric mucosa prepyloric part. conclusions . chronic superficial inflammation coexists with significantly higher proliferative activity of gastric mucosa glandular epithelium, particularly with connection to its prepyloric part. . changes in gastric mucosa glandular epithelium proliferative activity do not depend on its age and histotopography and hp colonization. introduction chromogranin-a-plus (cha) and d cells exist almost in the whole alimentary canal and in pancreas. these cells have an influence on secretory functions and normal gastric mucosa histostructure. up to now investigations confirmed participation of these cells in e.g hcl and gastrin secretion regulation and in some of the proliferative states of gastric mucosa. the aim of the study was to estimate participation of cha and d cells in microscopic superficial (gchs) and deep (gch) gastric mucosa inflammation's indices. material and methods paraffin blocks from gastric oligobiopsies was the material which was collected from women (of average age- ) and men (of average age- ). to the examinations were classified only the cases where oligobiopsies were taken from at least two areas of gastric prepyloric part (antrum) and corpus, with diagnosed unspecific chronic gastric mucosa inflammation. chronic inflammations were graded according to modified whitehead's classification. helicobacter pylori (hp)was evaluated according to the sydney system. neuroendocrine cells of gastric pylori were counted after proper immunohistochemical identification in circular, oblique short, oblique long and oblong gastric glands sections. all measurements were conducted separately for gastric mucosa prepyloric part and gastric corpus. the results of quantitative researches were analysed with the use of statistic methods. in gastric mucosa antrum there were twice more cha and d cells in comparison with corpus. gastric mucosa inflammation type did not have a significant influence on cells localization in gastric mucosa. the number of cha cells diminished in gchs gastric antrum among patients who were over years old, whereas the same number increased in corpus inflammations of this type. the increase of cha cells number was found in gchs gastric antrum with hp colonization. in these cases d cells number diminished. conclusions . in gchs gastric antrum with hp colonization cha cells number significantly increases while d cells number decreases. . quantitative changes of cha and d cells run differently in gchs and gch both in prepyloric part and in gastric corpus. response to preoperative chemoradiation on rectal adenocarcinoma: histopathological effects and relationship with level of p and pcna expression introduction adjuvant chemoradiotherapy delivered before surgery has been used to improve control and to reduce the likelihood of local recurrence in selected patients with rectal cancer. although the status of p gene and the expression of pcna has been widely studied in these tumors, little is known about their value to predict the responsiveness of rectal cancer to chemoradiation. the aim of this study was to to assess effects of preoperative chemoradiation in advanced rectal adenocarcinoma. we examined the histopathologic effects of chemoradiotherapy on rectal tumors and correlated the efficacy of treatment with the level of p and pcna proteins expression in pretreatment biopsies. results three patients showed no primary tumor in the resection specimen. another eight carcinomas showed a good response to chemoradiation with only small nests of viable tumor cells. grouping these two categories, we considered that the tumor response had been total or subtotal in cases ( %). nuclear accumulation of p protein was detected in ( %) specimens. thirty five tumors showed a high pcna index ( %). no obvious relationship seemed to exist between pretreatment, p immunostaining and response to chemoradiotherapy. tumors with high pcna index were more likely to respond to chemoradiation: / ( %) versus / ( %)(p= . ). conclusion knowledge of proliferative activity of rectal cancer, as determined by pcna immunostaining, should be useful in predicting the likelihood of response to preoperative chemoradiation. introduction mitotic count and tumor size are the main predictors of outcome in gastrointestinal stromal tumors (gist). however, they are not always useful in individual cases. the aim of the present study has been to assess whether mitotic counts performed using phosphorylated histone (phh ) antibody, expressed from the early steps of mitosis, could improve the prediction of prognosis in these tumors. materials and methods sections from gist were stained with phh antibody (upstate biotechnology, lake placid, ny; : , dilution). mitoses were counted per high power fields ( x, olympus bx). in addition, the h&e-based mitotic counts and tumor size were obtained from the pathology reports. patient outcome was recorded as the endpoint. conclusion in the present series, phh -based mitotic counts allow a better prediction of prognosis than h&e-based counts or tumor size. thus, phh antibody could be applied in the pathological classification and grading of these tumors, and in the more precise definition of cases with higher risk of progression. immunohistochemical expression of cyclooxygenase- (cox- ) in human colorectal cancer introduction recent studies have implicated metabolites of arachidonic acid, such as prostaglandin e( ) in colorectal carcinogenesis. cox- , a key enzyme in arachidonic acid metabolism, is present in the majority of colorectal cancer (crc). its overexpression seems to be associated with worse prognosis. the aim of this study was to examine the relationship between the expression of cox- in human crc and the clinicopathological characteristics of the tumor. materials and methods paraffin embedded tissue samples from patients (m: , f: , median age: yrs) with crc (tnm staging: i -iv), who underwent radical surgical treatment in thessaloniki cancer hospital "theagenio" from / / until / / , were evaluated. tumor sections were stained for cox- using a rabbit polyclonal antibody against human cox- and the staining was graded on a scale - , using mononuclear cells as reference. results cox- expression was found in tumor epithelial cells in . % of crc ( / cases) with diffuse mainly, cytoplasmic staining and in inflammatory cells, vascular endothelium and fibroblasts. low cox- expression (grade - ) was found in . %, high cox- expression (grade - ) in . % of cases and the remaining were negative. there was no correlation between clinicopathological characteristics of patients and intensity of cox- expression, although there was a slightly better overall survival rate in low expression group of patients (p:ns) . conclusions this small study shows that cox- protein is overexpressed in most cancer cells in colorectal carcinomas and may be related to overall survival. the expression of bcl family proteins in b-chronic lymphocytic leukemia introduction b-chronic lymphocytic leukemia (b-cll) is a neoplastic disease caused primarily by defects in the apoptosis mechanism. apoptosis is the process of programmed cell death or cell suicide. the bcl- proteins are a family of proteins involved in the response to apoptosis. some of these proteins (such as bcl- and bcl-xl) are anti-apoptotic, while others (such as bad or bax) are pro-apoptotic. materials and methods our study includes peripheral blood specimens from patients with b-cll and healthy individuals (as a control group). using western blot analysis, we examined the levels of bcl- , bcl-xl, bax and bad protein expression. the level of bcl (p= , x - ), bax (p= , ) and bad (p= , ) proteins were significantly increased in all analyzed patients while the level of bcl xl protein (p= , ) showed no difference between patients and healthy individuals. differences between the levels of analysed protein expression in group of patients had no statistical significance. conclusion increased level of expression bcl , bax and bad protein represents the most striking feature of b -cll cells. the variations in expression of only one protein of the bcl family can not represent the prognostic factorr in b-cll. introduction kikuchi -fujimoto disease (kfd) is a distinctive type of necrotizing lymphadenitis with unknown cause, has a selflimited clinical course and affects usually the cervical lymph nodes of young women. although kfd occurs most often in young women, only two cases have been reported during pregnancy. in one of these cases kfd developed initially years before. case report we report a case of a -year-old pregnant woman on her th week of gestation who was admitted with a history of swelling in the right side of the neck and fever of days duration. on physical examination a cm cervical lymph node was palpable. microscopically, the excised lymph node showed large areas of necrosis and extensive karyorrhexis. no neutrophils or plasma cells or eosinophils were identified. it was found an admixture of nonphagocytic histiocytes and t-lymphocytes in the necrotizing area. there was a predominance of cd + cells over cd + cells. the patient received no treatment and months later had no symptoms. later she delivered a healthy boy. five years ago the patient presented similar clinical history and histological diagnosis of the excised cervical lymph node. we present the second reported case of recurrent kfd during pregnancy and the third case of kfd developing during pregnancy. conclusion from our case and the other two reported cases it seems that if kfd occurs in a pregnant woman there is no need to terminate the pregnancy as there was no effect on both mother and fetus. monitoring of patients with follicular lymphoma carrying t( ; )(q ;q ) by real time quantitative pcr introduction follicular lymphomas (fl) are characterized by t( ; )(q ;q ) in a majority of patients. the identification of the translocation is utilized to monitor the disease behavior, and, specifically, to detect minimal residual disease (mrd). qualitative pcr is routinely used but without specification of the tumor cell quantity. real time quantitative pcr (rq-pcr) may be employed to address this issue. aims: rq-pcr was introduced to monitor mrd in patients with fl bearing the t( ; )(q ;q ). materials and methods samples of primary tumors, bone marrow and peripheral blood (bm/pb) specimens were taken in the course of the disease and were used for the t( ; )(q ;q ) assessment. for translocation screening, fish on interphasic nuclei was applied. qualitative pcr was used to detect the break in the major breakpoint region (mbr) of the bcl- gene ( q ). relative quantity of cells bearing mbr t( ; )(q ;q ) was performed by the rq-pcr. fifteen samples of primary tumors and bm/pb in duplicates were investigated with appropriate controls. the relative quantity of cells with t( ; )(q ;q ) was significantly higher in the primary tumors than in the bm/pb samples. the changes of the bm/pb infiltration were found during the course of the disease and included shifts toward the tumor progression or disappearance of the tumor cells. rq-pcr is a technique suitable for monitoring the disease response to the therapy or the disease progression and it is superior to morphology and immunohistochemistry. supported by: iga-mzcr-nc/ - , research project fn-motol/ . phosphatase activity dependent apoptotic effect of transforming growth factor beta in ht human lymphoma cells introduction transforming growth factor beta (tgfb ), a multifunctional cytokine, has antiproliferative and/or proapoptotic effect on lymphoid cells. the continuously proliferating lymphoma cells could be resistant to the endogenously produced tgfb . aims: to study the responsiveness of lymphoma cells using exogenously activated tgfb . the apoptotic effect and depolarization of the mitochondria was detected by flow cytometry, the different gene expression was studied by rt-pcr. the amount, the activity (western blot) and the localization (confocal microscopy) of the signal elements (smads, phoshpo-smad , erk / , jnk, p mapk) and other proapoptotic and survival proteins (bcl- , blc-xl, bid, bax, bad, nfkb, phospho-ikb) were also studied. the role of pp a phosphatase, mek kinase and caspase activity was estimated by different inhibitors (endhothal, okadaic acid, pd , z-vad-fmk, z-ietd-fmk, z-lehd-fmk) in vitro. results ht b cell lymphoma cells lost their sensitivity to the antiproliferative action of exogenous tgfb , but the cells were killed by apoptosis. smad phosphorylation, nuclear localization and the increased expression of tgfb induced early gene (tieg) proved the rapid activation of smad signal. the role of pp a phosphatase activation followed by decreased expression of active phospho-jnk and phospho-erk / was supported by the antiapo-ptotic effect of pp a inhibitors and the proapoptotic effect of specific mek inhibitor. the apoptosis was induced primarily through the mitochondrial pathway. it seems that both main iniciator caspases (caspase and ) took part in the apoptotic response. conclusion these data suggest that exogenous tgfb had double but interrelated actions on ht cells: a) suppression the survival signals produced by protein kinases, which b) allowed the smads to induce apoptosis. therefore, it is possible that the lost sensitivity of malignant lymphoid cells to proapoptotic regulators (such as tgfb ) could be reactivated especially by lowering the survival threshold. the work was supported by otka (t ), ett ( / ett ( / , / , fkfp ( / ) and békésy foundation ( / ). clinicopathological study of chromosome abnormality related hematological disorders introduction cytogenetic abnormalities sometimes determine the subtype of hematological disorders and are common in myelodysplastic syndromes (mds). although chromosome abnormality is frequently observed in mds, the specific characters of this type are not determined. in this study, we examined the clinicopathological characters of hematological disorders associated with chromosome abnormality. aim of this study is to assess whether these disorders are classified in special subtype or not. we selected hematological disorder cases with chromosome abnormality from the bone marrow files of the department of pathology, nagoya university hospital. clot sections of aspirated bone marrow were examined histopathologically. immunohistochemical study was performed using paraffin embedded tissues. results patients, males and femals respectively, with monosomy , with der ( ; ) and with other abnormalities were studied.the median age of the patients was . years (range, - years). pancytopenia was observed in , bicytopenia in and monocytopenia in cases. past history of aplastic anemia was in cases. histopathologically, they were cases of mds, of aml, in all and of others. hypoplastic mds (< % cellularity) were found in cases, of ra, of raeb, of raeb-t and case of mds with fibrosis. all cases of acute leukemia had dysplastic multi-lineage features other than blasts. histopathological characteristics were weak erythroid dysplasia, increased micromegakaryocytes and hypocellular tendency. these characteristcs were common in patients with monosomy and other abnormalities. concusion hematological disorders with chromosome abnormalities share similar clinicopathological characteristics. expression of topoisomerase i and topoisomerase ii alpha as an independent prognostic factor and evaluation of the overall survival in nhl e catalano cooper hospital/university medical center, camden, usa introduction topoisomerase ii alpha and topoisomerase i (topo i and ii alpha) are the key targets for some anti-cancerous drugs that inhibit these enzymes. the purpose of this paper is to examine the expression of topo i and topo ii alpha in different types and stages of nhl's the response of treatment with the overall survival. materials and methods immunohistochemistry techniques with anti-topo i and topo ii alpha were used. the results were evaluated with a semi-quantitative method. results and conclusion cases were studied with topo i and topo ii alpha. we include % of follicular lymphomas, % diffuse, % follicular and diffuse and high grade %. the stage of these tumors were stage i, %; stage ii, %; stage iii %; stage iv, %. the results show a higher intensity expression of the topo ii alpha, and topo i indices, in the higher grade nhl. there appears to be a similar expression between the intermedium and indolent nhl. the survival indicates that the large cell nhl's show a higher response rate and better survival than the mixed or small cell type. the expression of these two enzymes may be useful for selecting the appropriate chemotherapy in nhl. our data, although small, suggests an excellent correlation in response to treatment and longer survival in the nhl that have a high expression of topo i and topo ii alpha. mantle cell lymphoma (mcl): ki- antigen and chromosome ploidy in an estimate of the tumor progression introduction mcl belongs to prognostically unfavorable lymphomas. however, the behavior may vary and it is difficult to predict it. a more aggressive course tends to be associated with blastic and anaplastic subtypes. numerical chromosomal changes and proliferative activity may be of importance to improve the prediction. aims: risk of the tumor progression with the assessment of ki- antigen-positive cell count and ploidy status of chromosome . materials and methods patients with mcl characterized by t( ; )(q ;q ) and by overexpression of cyclin d . the proliferative activity was evaluated immunohistochemically (ihc) by double staining for ki- antigen and cd (to rule out counting admixed ki- positive t-lymphocytes). ploidy status of chromosome was evaluated by interphasic fish. results and conclusion trisomy and polysomy of chromosome ( patients) was associated with blastic/anaplastic forms of mcl with the same frequency as with the common variant. a finding of > % ki- and cd positive cells was associated with the blastic variant of the disease - patients. of them died of the disease progression, one of unrelated cause and one is alive with the disease. of the remaining patients in whom the follow up was available, died of the tumor, and the proliferative activity, measured by counting the ki- positive cells was < %. the assessment of proliferative activity with immunohistochemical demonstration of ki- antigen seems to be useful in prediction of clinical behavior of mcl supported by iga-mzcr-nc/ - , research project fn-motol/ . morphological criteria for differentiation of lymphocyte predominance hodgkin's lymphoma from lymphocyterich classical hodgkin's lymphoma aims to reveal morphological features of differential diagnosis between lymphocyte rich classical hodgkin's lymphoma (lrchl) and nodular lymphoid predominance (nlphl). retrospective analysis of lymph node biopsies (age - ) with histological diagnosis of "nodular paragranuloma" or "hodgkin's disease, lymphocytic and histiocytic variant". immunological data were available in all cases. all patients presented with the early stages of disease. we used the following morphological criteria: growth patterns (nodular, nodulardiffuse or diffuse), distribution and cytomorphology of tumor cells ("popcorn", lacunar, classical, mummified cells), cellular composition of reactive background, presence or absence of secondary and atrophic follicles. the results of morphological algorithm were compared with immunology data in every case. results among biopsies, cases ( %) were classified as nlphl. cases were attributed to lrchl, including cases which were characterized by interfollicular sheets of cells resembling lacunar cells ("cellular phase of nodular sclerosis"), cases had rare classical cells within expanded mantle zone ("follicular variant" of hodgkin's disease). all cases lrchl exhibited secondary follicles. there were no cases of lrchl with "pure" diffuse growth type; both nlphl and lrchl had nodular or nodular and diffuse pattern. cases corresponded morphologically to nlphl or lrchl and this division was confirmed with immunological analysis.. conclusion we proposed the algorithm of morphological criteria for differentiation of nlphl from lrchl bone marrow sinusoids in acute lymphoblastic leukemia (all) v rugal russian institute hematology, st.petersburg, russian federation introduction bone marrow sinusoids regulate the development of hemopoietic precursors and migration of stem cells and mature blood cells in blood stream. the purpose of the investigation was to study endothelium of bone marrow sinusoids in disordered hemopoiesis in all. pretreatment bone marrow trephine biopsy sections from patients with all were studied using morphometric and ultrastructural methods. results development of myelosuppression in all was accompanied by considerable changes in the morpho-functional status of sinusoid endothelium. most vessels became thinned, endothelial cells were flattened. in such vessels cells of endothelium came apart with formation of gaps between cells. the basement membrane was interrupted. however, blast migration continued to be transendothelial. there were vessels in which the structure of endothelial cells was identical to that of blast cells. there were no signs of endo-and exocytosis in such cells. intranuclear virus-like inclusions were found in endothelial cells of sinusoids of patients with all. the above data suggest the involvement of endothelial cells in the disordered haemopoiesis in all. defects of the bone marrow sinusoids in leukemia can be the cause of the early release of blasts into circulation. blast transformation of endothelial cells does not contradict the suggestion about existence of a common cell precursors of the endothelial and hemopoietic cells. complex diagnosis of follicular lymphomas e toth, e csernak, z melegh, n udvarhelyi, t schneider, a rosta, z szentirmay national institute of oncology, budapest, hungary introduction the second most common type of non-hodgkin lymphomas is follicular lymphoma (fl). moreover, follicular lymphomas are the most common type of the low grade lymphomas. in hungary they comprise about - % of all the lymphomas but its occurrence shows increasing tendency. our aim was to survey and revise fls diagnosed in the last years in the national institute of oncology. we studied the diagnostic relevance of histology, immunohistochemistry and the detection of immunoglobulin heavy chain (igh) and bcl- gene rearrangements. materials and methods we surveyed cases which were diagnosed as follicular or centrocytic, centroblastic lymphoma before. after the histological re-examination immunohistochemistry (cd , cd , bcl- , cd , bcl- , cd , p , cyclin d and ki- ) was performed on each case. we studied the igh and bcl- (mbr) gene rearrangement both with conventional and real-time pcr methods from the paraffin embedded blocks. the classification was made according to the new who classification. results after the revision of the cases we found follicular, diffuse large b-cell, mantle cell and marginal zone lymphoma, paragranulomas and follicular hyperplasias. the grade of the fls showed relation to the expression of different antigens. cd and bcl- expression decreased with the grade. p expression was very rare and occurred only in grade cases. the proliferation index with ki- showed good correlation with the grade of fls. the igh showed types of pattern: monoclonal, polyclonal and a sharp line in a polyclonal background. grade and grade - fls were monoclonal almost in the same ratio. we could detect bcl- gene rearrangement in % of the fls ( % grade - , % grade ). all the grade cases which showed bcl- gene rearrangement belonged to grade a group while all the grade b cases were negative. conclusion in agreement with others we found that grade , and a fls showed similar morphological, immunohistochemical and genetical features while gr b fls are more similar to diffuse large b-cell lymphomas. considering the diagnostic relevance of the different methods we can conclude that histology alone is not sufficient. % of our cases were solvable with the help of immunohistochemistry and in % of the cases the diagnosis based on the molecular pathological results. in the remaining % even with the help of all diagnostic tools no unambiguous diagnosis could be reached. the bcl- and p oncoproteins play important roles in carcinogenesis. mutation of the p gene is considered the most common genetic aberration in many cancers including hematologic malignancies. ki- , a proliferation antigen, evaluates the proliferative activity of a lesion. angiogenesis is also critical for tumor proliferation and has a prognostic value. the vascular density of tumor directly correlates with poor outcome in many malignancies. the aim of this study was to investigate correlation between ki- , p and bcl- immunostaining in b cell lymphomas and to identify any relation between these markers and microvessel density (mvd) and histopathological parameters including stage and tumor grade. materials and methods low grade and high grade non-hodgkin lymphomas (nhl) were immunohistocemically stained with p , ki- , bcl- and factor viii. the results were analysed statistically. results there was no correlation between stage and ki- li, mvd, p and bcl- expression. the cases which showed immunoreactivity for bcl- had decreased mvd counts compared with the cases negative for bcl- . p immunoreactivity was correlated with mvd. microvessel counts were significantly higher in patients with high grade nhls. statistical analysis showed association between ki- li, p , bcl- expression, mvd and histological grade. conclusions the levels of ki- , bcl- and p expression and microvessel counts were closely related with the grade of nhls. our findings suggest that apoptosis, angiogenesis and proliferative activity can be used as prognostic indicators in nhls. diffuse large b-cell lymphoma of the maxillary sinus complicated with blastomycotic leptomeningitis sinus; however such a lesion is more likely to arise from an infraorbital lymph node, part of the facial lymph node group. case presentation we present a patient with diagnosed diffuse large b cell lymphoma of the maxillary sinus as well as involvement of the infraorbital region, who suffered from infective complications. -years old male was admitted at the clinic of hematology because of tumor mass in nasal cavity. ct-scan showed tumor mass filling right maxillary sinus. surgical biopsy was done. histochemical and immunohisto-chemical findings suggested a diagnosis of diffuse large b cell lymphoma. other clinical investigations showed i-e clinical stage. treatment with four cycles of chop and mab-thera followed. after that adjuvant radiotherapy was delivered. because of increased body temperature and meningeal symptoms, this therapy was interrupted. microbiological investigations showed positive hemoculture for escherichia coli and staphylococcus aureus, and positive finding of blastomyces in cerebrospinal fluid, while serological analyses revealed positivity for cmv and ebv. beside severe antibiotic, antimycotic and antiviral treatment, the patient suffered from sepsis with main features of suppurative leptomeningitis and acute hepatitis. conclusion this case implies the conclusion that the clinicians should have in mind the possible presence of immune disregulation in patients with nhl, that could complicate the administered chemotherapy and radiotherapy. aim the aim of this study is to determine the most frequent pattern of involvement by nhl of head and neck and to correlate it with clinical outcome of the disease. material and methods a retrospective review was performed on patients with nhl during five years period. paraffin sections stained with standard histochemical and immunohistochemical stainings were histologically analyzed for classification of the nhl accordingly to the who classification of lymphoid neoplasms. clinical histories were used for clinical follow-up. results in fifty cases out of patients with nhl the disease was primary localized in the head and neck region. male-female ratio was , . twenty four cases were primarily nodal, primarily extranodal and had extranodal/nodal expression of the disease. diffuse large b cell lymphoma comprised % of the group: nodal, extranodal and extranodal/nodal. three of these cases were cd + and alk- -. six cases ( %) with b-cll nhl had nodal manifestation. malt-zone lymphoma ( %) showed extranodal involvement in cases and extranodal/nodal in cases. b-lymphoblastic lymphoma ( %) showed cases with nodal, one extranodal and one extranodal/nodal involvement. two cases with burkitt's lymphoma ( ) had typical mandibular localization. follicular lymphoma comprised %, with two nodal and two extranodal involvement. t cell nhl-s comprised % of the group with three nodal, one extranodal and one extranodal/nodal involvement. there was no significant predilection for clinical expression of the nhl of head and neck, and no difference between the mean survival of the groups for these parameter. expression of the bcl- family proteins, caspase (cpp ) and poly adp-ribose polymerase (parp- ) in multiple myelomas v zolota , m melachrinou , i xagoraris , a mouzaki , p aroukatos , d koumoundourou , ds bonikos dept. pathology, univ. patras med. school, patras, greece dept. laboratory hematology and transfusion medicine, univ. patras med. school, patras, greece introduction multiple myeloma (mm) is a malignancy of the bone marrow characterized by the clonal expansion of plasma cells with low proliferative activity. aberrant expression of genes regulating apoptosis/survival seems to be essential in the development of multiple myeloma. the aim of this study was to investigate the immunohistochemical expression apoptosisregulating proteins in bone marrow of patients with initially presented multiple myeloma. methods the expression of bcl- , mcl- , bak, bax, cpp and parp was examined on paraffin sections of bone marrow biopsies obtained from equal number of patients with newly diagnosed mm, using commercially available monoclonal and polyclonal antibodies and lsab technique. specimens containing > % immunostained tumor cells were considered positive. results bcl- , bak and bax positive immunostaining was detected in %, % and % of cases respectively. most positive tumors showed high percentage of tumor cells immunoreactive for the above proteins: > % for bcl- , > % for bak and > % for bax. the mean value for bcl- /bax ratio was . , and the mean bcl- /bak ratio was . . mcl- expression was detected in a small percentage of tumors ( %). cytoplasmic expression of cpp was observed in , % of cases and the number of positive cells was low. nuclear expression of parp was seen in , % of cases and no association was found with the other apoptosis-related antigens, bcl- /bax or bcl- /bak ratio. conclusion the above data demonstrate an overexpression of bcl- , bax and bak in myeloma plasma cells and an increased bcl- /bax ratio. cpp does not seem to mediate any apoptotic event in mms. the role of overexpression of parp remains to be elucidated. immunoexpression of bcl- family members, p , caspase (cpp ), and poly adp-ribose polymerase (parp- ) in diffuse large b-cell lymphomas introduction diffuse large b-cell lymphomas (dlbcl) represent a biologically and clinically heterogeneous group. although these tumors are curable with chemotherapy, their response to treatment varies. apoptosis-related proteins may play an important role in the chemosensitivity or chemoresistance of tumors. the aim of this study was to investigate if the expression of apoptosis-regulating proteins in dlbcl could be indicative of tumor chemosensitivity. methods formalin-fixed, paraffin-embedded tissue from cases of dlbcl [ nodal, extranodal, splenic ( centroblastic, immunoblastic, burkitt's-like, anaplastic, tcrbcl, primary mediastinal)] were immunostained with monoclonal [bcl- (dako), mcl- , cpp (neomarkers), p (biogenex)] and polyclonal [bax, bak (dako), parp (neomarkers)] antibodies using lsab method. specimens containing > % immunostained tumor cells were considered positive. clinical data were available for cases ( chemosensitive, chemoresistant). results bcl- , mcl- , bax, bak, p , cpp and parp positive immunostaining was detected in . %, . %, . %, %, . %, . % and . % of cases, respectively. mcl- , bax, bak and parp were overexpressed in > % of tumor cells in most cases. there was a significant association between the expression of bcl- and mcl- (p = . ). a higher immunoexpression of bcl- ( . % vs . %), mcl- ( . % vs %), bax ( . % vs %), p ( . % vs %) and cpp ( . % vs %) was observed in chemoresistant cases. parr expression was higher in chemosensitive cases ( . % vs . %). in the p -negative group of cases ( cases) those with a strong ( +) parp expression showed a significant better response to treatment (p = . ). a significant chemosensitivity was also detected in the group ( cases) with strong ( +) bax and weak (+) or negative (-) p immunostaining (p = . ). conclusion apoptosis-related proteins, though overexpressed in dlbcl, were not associated with response to treatment. a p (-)/parp( +) or p (+ or -)/bax( +) tumor status may reflect sensitivity to chemotherapy. introduction non-hodgkin lymphomas (nhl) are a heterogenous group of lymphoid malignancies classified according to their morphological, immunophenotypical and genotypical characteristics as well as their clinical behaviour. however, the progression of these diseases may be influenced by various others factors such as apoptosis, proliferation and angiogenesis. aim: a possible correlation between bcl- expression, apoptosis, disease outcome and overall survival in patients with nhl was analysed. material and methods nhl devided in low-(n= ) and highgrade (n= ) were immunohistochemicaly analysed for bcl- expression, while low-and high-grade nhl were procesed for terminate tdt mediated dutp nick end labeling (tunel) method in order to determine the apoptotic index of tumor cells. results were obtained by image analyser and statistically processed. results the expression of bcl- protein, as an antiapoptotic marker was significantly higher in low-compared to high-grade nhl, p= . , whereas the apoptotic index obtained with the tunel method demonstrated inverse results, p< . . in highgrade nhl, partial remission was observed in patients whose tumors expressed significantly higher values of bcl- , (p= . ), while complete remission was observed in a group with a lower expression of bcl- . furthermore, patients with lower bcl- expression showed longer overall survival p= . , whereas patients with a higher apoptotic index showed shorter survival, p< . . in both low and high-grade groups of nhl, bcl- has been found as an independent predictor of patients disease relaps, p< . . conclusion the expression of bcl- is a strong independent predictor of disease progression in nhl patients. the heterogeneity of anaplastic large cell lymphomas (alcl) o mederle, m raica dept. of histology and cytology, university of medicine and pharmacy, timisoara, romania introduction the aim of this study was to investigate the expression of cd and the distribution of the reticular network on the alcl. material and methods twelve cases of lymphomas were analyzed using morphologic and immunophenotypic features. the patients ( male and female) were from to years. five patients presented with generalized lymphadenopathy and seven with involvement of extranodal sites. alcl was composed of large cells that grow in a diffuse pattern and involve the lymph node sinuses. the tumor cells have an abundant eosinophilic or pale cytoplasm. the nuclei were irregular with indentation, multilobated, round to oval. multinucleated cells with wreath-like configurated nuclei were commonly seen. alcl cells may closely resemble cells of malignant histiocytosis. additional features include reed-sternberg-like cells, reactive infiltrate, partial lymph node involvement with localization of tumor cells in the paracortical region resembling hodgkin's diseases. tumor cells are cd +. the regular expression of cd antigen in both carcinoma and alcl (both are anaplastic large cell tumors) has important implication for the differential diagnosis of these tumors. leukocyte common antigen (cd ) positivity excludes an embryonal or any other non-hematopoietic tumor, but its absence does not rule out alcl (a significant portion of alcl are cd negative). antibodies to cytokeratin label embryonal carcinoma but not alcl. thus, if cytokeratin is expressed in an anaplastic large cell tumor simultaneously with cd antigen, it is most likely to be an embryonal carcinoma conclusion this study confirms the view that alcl are heterogeneous group of lymphomas and the cd is a useful marker for the diagnosis. leiomyosarcoma of the meckel's diverticulum. we describe a -years-old male developing a well differentiated leiomyosarcoma of the meckel's diverticulum synchronously with b-cll. the patient suffering disuria and malaise was admitted at the clinic for surgery. clinical examinations showed leucocytosis ( . x /l) with lymphocytosis ( %), anemia (hgb = g/l) and thrombocytosis ( x /l). ct-scan found a tumor mass near the urinary bladder and enlarged spleen. the fnab from the tumor mass revealed neoplastic tissue composed of ribbons of spindle-shaped cells with hyperchromic and pleomorphic nuclei and variable amount of cytoplasm, surrounded by a fine reticulin network. mitoses were rare ( - on hpmf). immunohistochemistry showed positivity for sm-actin and desmin. s- , cd and cd were negative. a leiomyosarcoma was diagnosed. three weeks after the biopsy a large tumor mass ( g) from the vicinity of the urinary bladder was extracted, together with incidental meckel's diverticulum. at the same time a splenectomy was performed because of splenomegaly ( g). pathohistologic examination of the tumor mass confirmed the previous diagnosis, and the pcna proliferative index was estimated to - %. the analysis of the meckel's diverticulum revealed a disturbance of the muscular layer structure caused by a tumor proliferation with the same histological features, infiltrating into the serosa. the pathohistologic examination of the extracted spleen showed partially presence of b-cll infiltration (monoclonal positivity for lambda-light chains, cd , cd , cd , cd ). follow-up shows that the patient is in binet a stage, and still in a good shape without any further treatment. it remains unclear which of the neoplasms developed first. introduction synchronous composite low grade b-cell lymphomas involving the same site is rare and few cases have been reported. we describe three cases of composite lymphoma. material and methods histological, immunohistochemical and molecular study. results the three neoplasms showed different morphological and phenotypic areas: case . years-old female with large splenomegaly. the splenectomy showed a blastoid mantle cell lymphoma (mcl) with nodular pattern, positive to cd , cd a, cd , cd and cyclin d , and a splenic marginal zone b-cell lymphoma cd , cd a and igd. the mcl progressed, with liver and bone marrow involvement, treatment failure and death months after diagnosis. case . years-old female with cervical and inguinal lymphadenopathy. a nodular mcl cd , cd and cyclin-d positive, p negative, was observed. the internodular areas demonstrated a small lymphocytic lymphoma (sll) expressing cd , cd a, cd , cd , and p . progression to peripheral blood involvement of sll, and gastric and nodal relapses of mcl two and four years after diagnosis. case . years-old female with nodal follicular lymphoma expressing cd , cd , bcl- , igd-kappa restriction. the internodular areas showed a lymphocytic lymphoma with plasmacelular differentiation, cd , cd a, cd , igd, and bcl- positive. igh showed a biallelic arrangement, and bcl- /jh rearrangement was obtained, suggesting the presence of two different clones. alive with disease after first chemotherapy cycle. conclusion morphology and immunophenotypic profiles may allow the identification of each component in composite lymphoma. molecular studies can recognize different clones originating the neoplastic compartments. introduction aitl accounts for about % of peripheral t-cell lymphomas (ptcl), presents with advanced stages at diagnosis and follows aggressive clinical course. in - % of cases oligoclonal or monoclonal b-cell populations are detected, usually associated with ebv infection. we describe three cases of aitl with clonal b-cell lymphoma non-related to ebv infection. histological, immunophenotypical, including ebv (lmp- , ebers), and molecular study. results three cases of aitl in three female, , and yearold patients were diagnosed. all of them showed atypical lymphocytes with aberrant t-cell phenotype (cd /cd + with loss of cd ), associated with vascular and dendritic proliferation, the latter showing t-cells cd +. in addition, a population of b-cells with plasmacelular differentiation and immunoglobulin light chain restriction ( kappa/ lambda) was identified. ebv was not demonstrated in these populations. tcrgamma and igh clonality was observed in two cases. the first patient presented isolated nodal aitl involvement, and she is in complete remission after chemotherapy six months after diagnosis. the second patient presented nodal aitl and developed skin involvement two months after the diagnosis. the third patient presented with an atypical ganglionar t-cell proliferation, developing cutaneous ptcl with associated clonal b-cell proliferation one year later and ganglionar ptcl with ailt features two years after the first biopsy. the three biopsies showed identical tcrgamma gene rearrangements in this case. conclusion aitl can show different morphological patterns. alternative mechanisms non-related to ebv infection may be involved in the development of b-cell lymphomas in aitl. introduction histopathological confirmation of clinical suspicion of sarcoidosis is based on finding of non-caseating granulomas in biopsy material, usually in prescalene lymph nodes. reactive sinus histiocytosis seen in relation to various inflammatory and noninflammatory diseases can mimic pregranulomatous phase of sarcoidosis. differentiation of sinus histiocytosis based on histopathological features alone can be impossible. aim of this study is immunohistochemical determination of lymph node cellular response in granulomatous sarcoidosis, pregranulomatous phase of sarcoidosis and reactive sinus histiocytosis using panel of antibodies. materials and methods patient groups under study, each contained patients include those with clinical and histopathological picture of sarcoidosis; the group of patients with clinical picture of sarcoidosis and histologically detectable sinus histiocytosis without granuloma formation and finally, the group free of clinical suspicion of sarcoidosis with 'reactive' sinus histiocytois in lymph nodes. lymph node biopsy tissue processed routinely and stained immunohistochemically using triple-layer apaap protocol with purified antibodies sp and sp from mycobacterium tuberculosis and monoclonal antibodies cd , cd , cd , cd , cd . intensity of immunostaining assessed semiquantitatively by two independent observers using the scale from to + results an increased cd :cd ratio, moderate increase of immunopositivity of cd and slight decrease of immunopositivity of cd , cd , and sp noted in psh when compared with rsh. the most notable difference between studied groups is the intensity of immunostaining with sp and cd antibodies. conclusion both immunostainings were more intense in lymph nodes with sarcoid granulomas and pregranulomatous sinus histiocytosis and can be used in differentiation of these lesions. haemophagocytic syndrome followed by a large b-cell lymphoma showing only bone marrow involvement: case report haemophagocytic syndrome (hps) is a rare disease characterized by generalized histiocytic proliferation showing phagocytosis of hematopoietic cells. it occurs mainly in adults associated either with an acute viral infection, or with non-hodgkin's lymphomas. the latter are usually t-or nk-cell lymphomas. the present case concerns a patient with hps followed by a large b-cell lymphoma showing only bone marrow involvement. this constellation is extremely rare in western countries and has been reported mainly in asia. the patient was a year old male admitted for persistent fever. peripheral blood examination showed pancytopenia. bone marrow biopsy showed haemophagocytosis by proliferating macrophages often situated into dilated marrow sinusoids. no viral infection was detected. the patient was treated with haemopoietic growth factors and showed improvement. after months his blood cell count began to fall again and a second bone marrow biopsy showed, apart from haemophagocytosis, a focal, mainly intrasinusoidal, infiltration by large b-cell lymphoma cells immunopositive for cd and cd ra. epstein-barr virus rna was not detected. dissemination of lymphoma to other sites was not apparent. the patient was treated with cycles of chop and mab-thera and showed remission. some authors believe that these rare cases represent a peculiar "asian" variant of intravascular lymphoma characterized by hps and early involvement of bone marrow without dissemination to other organs. this variant has a poor prognosis and might constitute a distinct biological and clinical disease entity which merits separate consideration because of the problems posed in the initial diagnosis and therapeutic approaches. introduction mycosis fungoides is a mature t-cell lymphoma presenting in the skin and characterised by epidermal and dermal infiltration of small to medium size t-cell with cerebriform nuclei. it is a rare disease wich accounts for no more than , % of all non hodgkin lymphomas. case report a year-old man was refered to the clinic of hematology because of the nodular red dermal tumours on the trunk. these lesions persisted for one year. the blood and bone marrow had not been involved. lymph nodes were normal. the patient had the so called d' emblee lesions, presenting with skin tumours to cm of diameter. the initial diagnostic lesions were rare limited patches and plaques. extracutaneous dissemination did not occur. formaldehyde fixed and paraffin embedded histological sections, taken from surgically resected skin tumours, were stained with he, giemsa, trichrome and immunohistochemical stains. morphology: epidermotropic infiltrates consisted of medium size cells with cerebriform nuclei. a minority of larger cells with similar nuceli and with many mitotic figures also were present. so called pautrier microabscesses consisted of aggregates of cerebriform cells in the epidermis (highly caracteristic for mycosis fungoides) were numerous. in the dermis, infiltrates were band like and diffuse, associated with inflammatory infiltrate consisting of small lymphocytes and eosinophils. conclusions in spite of the presence of bad prognostic factors (very old patients, extent of disease and tumorous form) he had a very indolent course of the disease. the role of the observed inflammatory small lymphocytes and eosinophils is probably very important for the excellent prognosis of mycosis fungoides in this patient. low expression of p protein combined with altered p and rb/p expression status is associated with increased expression of cyclin a and cyclin b in diffuse large b-cell lymphomas introduction reduced p expression combined with alterations in rb or p status, may have cooperative effects resulting in uncontrolled tumor cell proliferation and aggressive malignancies in experimental mouse models and in humans. the aim of this study was to investigate p expression in relation to a) the expression status of p , rb, p , and b) proliferation profile (ki , cyclin a, cyclin b ). expression of cell cycle regulating proteins was investigated immunohistichemically, in cases of de novo diffuse large b-cell lymphomas (dlbcl). results p expression was low/null in large tumor cells in / and intermediate/high in / cases. increased expression of p was observed in / cases. decreased expression of rb/p was found in / and / cases, respectively. low/null p expression was correlated to increased p expression (p= . ). there was a correlation between increased p and decreased rb/p expression levels (p= . ). these findings suggest a tendency for concurrent alterations of cell cycle regulators p , p and rb/p in dlbcl, which might result in impaired tumor growth control. indeed, combined p /p /rb/p expression status analysis, with respect to proliferation profile showed that: ) three alterations in the combined p /p /rb/p status were correlated with increased expression of cyclin b (p= . ) and ) two or three alterations were correlated with increased expression of cyclin a (p= . ). conclusions these findings suggest combined impairment of a complex cell-cycle control network involving the cdk inhibitor p , as well as p and rb pathways, which exerts a cooperative effect resulting in enhanced tumor cell proliferation. introduction the aim of this study was to examine a) cyclins d , e and d expression in relation to other proliferative features (ki , cyclin a and cyclin b ), apoptosis status and p , rb, p , p expression and b) whether distinct clusters of proliferation and apoptosis could be identified in dlbcl. materials and method immunohistochemical expression of cell cycle regulating proteins were studed in seventy-nine cases of de novo diffuse large b-cell lymphomas (dlbcl). results overexpression of cyclins d , e was found in / ( %) and / ( %) cases, respectively, whereas cyclin d was not detected. in / cases, overexpression of cyclins d and e was mutually exclusive, proposing different underlying pathways that induce deregulated expression of these cyclins. in / cases, cyclin d overexpression was equally exclusive with rb/p aberrant expression status, supporting an oncogenic role for cyclin d and suggesting that pathogenetic effect of cyclin d overexpression occurs through perturbation of rb pathway. combined alterations of p and rb/p /cyclin d expression profile were significantly correlated to higher mean values of cyclins a (p= . ) and b (p= . ) indicating that concurrent impairment of p and rb pathways induces increased tumor cell proliferation. cluster analysis of apoptosis and proliferation status permitted separation of dlbcl into distinct groups with low and high apoptotic activity, as well as into groups with low, intermediate and high proliferative activity. conclusions in the present study, identification of separate groups with respect to proliferation and apoptosis profile indicates that groups with discrete cellular kinetic properties can be defined in the dlbcl population. immunotopographical distribution of protein networks involved in cell-cycle and/or apoptosis regulation is useful in thymic histophysiology understanding. the aim of this study was to examine a) p and rb growth control pathways, b) proliferation, c) apoptosis in relation with age. materials and methods p , p , rb, p , ki , p , bcl , bax, bak, cyclin d , cyclin a, and cyclin b expression, and apoptotic index (ai) were investigated in adult, adolescent, infant and newborn normal thymuses, with immunohistochemistry. results and conclusions rb, ki , cyclins a and b expression was elevated in cortex with a decreased tendency toward medulla. apoptotic cells were mainly detected in cortex/corticomedullary junction, but rarely in hassall's corpuscles. mean values of ki and cyclins a, b immunoreactivity were . %, . %, . % (newborns), . %, . %, . % (infants), . %, . %, . % (adolescents), . %, . %, . % (adults), respectively. mean values of ai were . %, . %, . %, . %, respectively. most of hassall's corpuscles were p -positive. p expression paralleled aging, suggesting a role of p in cellular senescence. p was detectable within medulla, but not in subcapsular thymocytes expressions of ki , cyclin a and cyclin b were inversely related to p . p and p showed primarily subcapsular cortical epithelial cell localization. our findings suggest: a) thymocyte apoptosis is mainly p -independent, b) p function as negative cell cycle regulator seems redundant to other negative regulators (p / ), and c) p expression is chiefly p -independent. hassall's corpuscles were p -positive. bcl was principally detected in medullary thymocytes. expression of bax/bak was widely distributed, suggesting an advanced role in thymic apoptosis, compared to bcl . paraffin-embedded bone marrow biopsies of patients were examined by a standard panel approach and evaluated semiquantitativelly. the course of the disease was recognized by evaluation of instrumentalized questionnaires. results a/ mds with less than % of blasts (n= ) /either of myelo-(n= ), megaloblastic (n= ) or bilinear profile (n= )/ -aml evolution appeared in % of patients, b/ mds with more than % of myeloblasts (n= ) -aml diagnosis was established in % of cases. conclusion although the therapeutical aml managment requires 'clinical verification', the identification of the mds blastic proliferation higher than % is of a great clinical importance. however, the clinical manifestation of aml may be influenced by a delay of the increase of blasts in the peripheral blood. introduction there is increasing evidence that bcl and cd expression may be related to apoptosis and cell cycle progression. materials and methods to examine immunohistochemically the expression profile of bcl and cd in cases of de novo diffuse large b-cell lymphomas, in relation to a) the apoptotic index (ai) b) the proliferation-associated proteins ki , cyclins a and b c) the expression of bcl , p , rb, p , p . results and conclusions expression of bcl , cd and bcl was detected in / ( %), / ( %) and / ( %) cases, respectively. the bcl /cd patterns were as follows: bcl +/ cd + ( cases, %), bcl +/cd -( cases, %), bcl -/cd -( cases, %) and bcl -/cd + ( cases, %). significantly positive correlations were found between bcl /ki (r= . , p= . ), bcl /cyclin a (r= . , p= . ), bcl /ai (r= . , p= . ), cd /ki (r= . , p= . ) and cd /ai (r= . , p= . ). high expression of bcl was correlated with null/low bcl expression (hi-square-test, p= . ). these findings indicate that increased expression of bcl and cd is associated with increased apoptosis and proliferation in diffuse large b-cell lymphomas. association between increased bcl expression and enhanced apoptosis might be due to null/low bcl immunoreactivity, since previous in vitro data revealed that bcl overexpression induces apoptosis accompanied by bcl and bcl-xl downregulation. significant correlation was found between increased ai and bcl +/cd + pattern (t-test: p= . , mann-whitney test: p= . ). this result combined with positive correlation between ai and bcl and cd immunostaining may be in accordance to previous studies showing that expression of these proteins has favorable effects on the clinical outcome of these neoplasms. primary non-hodgkin lymphomas of bone: morphologycal and immunohistocehmical aspects introduction primary non-hodgkin lymphoma (nhl) of bone (plb) is a rare clinic-pathologic entity that accounts for approximately % of all malignant bone tumors and - % of all extranodal nhl. we analyzed morphological and immunohistocemical aspects of plb presented as solitary localized bone tumor. methods paraffin embedded biopsy specimens of all patients were diagnosed by the histomorphology and by immunohistochemistry using a wide panel of monoclonal antibodies (ema, lca, nse, tdt, cd , hla-dr, cd a, cd , cd , surface and cytoplasmic ig, cd , cd , cd , cd , cd , cd , cd , bcl , bcl and ki- ). the median age of our pts. was (from to ) with slight female predominance. various sites were involved: tumors were in tubular long bones, in pelvic bones and in spine with infiltration of soft tissue and without bone marrow involvement. all cases were classified as diffuse large b-cell lymphoma (dlbcl) according to morphology and immunophenotype. patohistological analyses showed markedly polymorphous cellular infiltrate with large cells with complex nuclear contours and multilobated nuclei, together with centroblasts-like cells and immunoblasts. all tumors were associated with some degree of fibrosis. immunologic studies showed strong expression of pan-b markers and hla-dr, weak expression of cd and cig (mostly igm) in half of tumors. bcl was positive in all cases as well as bcl . the plasmacytic differentiation was observed in / of cases. the proliferative fraction was high, > % cells in all patients. conclusion our analysis revealed that all plb were of dlbcl type with characteristic morphology and immunophenotype. further study will show the outcome of patients with plb, as well as the validity of various prognostic parameters. peripheral t-cell lymphoma with perifollicular growth pattern expressing cd inflammatory cells. ptcls with nodular or perifollicular growth patterns are very rare. only cases have been reported in the literature. we report an unusual case of ptcl showing perifollicular growth pattern with expression of cd and bcl- . the patient was a -year-old male who presented with a generalized lymphadenopathy, fever, and weight loss. hepatosplenomegaly and polyclonal gammopathy were not identified. cervical lymph node biopsy was performed. the histology showed nodular effacement of nodal architecture with proliferation of atypical lymphoid cells which mainly infiltrate perifollicular area. interfollicular area also showed proliferation of atypical lymphoid cells and high endothelial venules with a few immunoblasts and eosinophils. neoplastic cells were medium-sized, with irregular nuclei and clear cytoplasm. immunohistochemically, the neoplastic cells were cd +cd +cd +cd -cd +cd -cd -bcl- +bcl- +, demonstrating helper/inducer t-cell origin. the cd was strongly expressed mainly in the perifollicular tumor cells, whereas the normal germinal center (gc) cells showed down-regulation of cd . the distribution of cd + perifollicular tumor cells was closely related with cd + follicular dentritic cells (fdcs), suggesting cd up-regulation might be induced by the proliferating fdcs. tcr-gamma gene rearrangement using pcr-sscp was monoclonal. this case could be classified as ptcl, unspecified, and should be discriminated from other lymphomas, including marginal zone b-cell lymphoma and follicular lymphoma. further studies are necessary to clarify the distinction of this tumor from angioimmunoblastic t-cell lymphoma. introduction cd + anaplastic large cell lymphomas (alcls) frequently involve extranodal sites, mainly skin and gastrointestinal tract, but primary bone alcls are exceedingly rare. the aim of this study was to detail the morphofunctional features and outcome of cases of primary bone cd + alcls. materials and methods all the patients (m:f : , median age years, range: - ), but (with simultaneous occurring skin lesions) presented with bone confined lymphoma (osteolytic lesions of jaw, rib, sternum, iliac and pelvic bones). biopsies from all cases were analysed. results and conclusion according to the who lymphoma classification, all cases were cd + alcls ( / common type, / small cell predominant variant). lymphoma population showed a t ( / ) or "null" ( / ) phenotype, expressed cytotoxic associated molecules (tia , granzyme b and/or perforin); cd /alk was positive in / cases, whereas / expressed cd . tcr-gamma clonal rearrangement was detected in / cases. all patients received polychemotherapy; at last follow up they all are alive, in complete remission (mean: months, range: - ). in our cases, the morphofunctional features of the lymphoma population were similar to their nodal counterparts, including cd expression in the younger patients. on such bases, the hypothesis must be considered that primary bone cd + alcls represent the first extranodal site of presentation of a systemic disease. in contrast with similar reported series, our patients run a favourable prognosis and in the single positive case, cd expression does not negatively influence outcome. however, larger series of similar cases must be analysed before definitive conclusions can be drawn. introduction follicular dendritic cells (fdc) form a meshwork in the lymphoid follicle and take part in the regulation of the germinal centre reactions. fdc also interact with the neoplastic lymphoid proliferations. in b-cell chronic lymphocytic leukaemia/small lymphocytic lymphoma (b-cll/sll), fdc structures are reduced. the aim of this study was to evaluate the presence and patterns of follicular dendritic cells b-cll/sll using several anti-fdc antibodies. materials and methods formalin-fixed paraffin-embedded lymph nodes diagnosed as b-cll/sll according to the who criteria were studied using cd , cd , and cna. antibodies after microwave oven antigen retrieval results in cases ( %) fdc meshworks were identified in none of the reactions. in specimens ( %), fdc meshworks were exceptionally rare as follicle remnants at the lymph node periphery or as small irregular clusters not reminding of the normal follicle meshwork. in cases ( %) fdc formed either frequent small irregular clusters, or rings at the follicle periphery, or regular follicular meshworks. reticular structures in a given case were most frequent in cna. stain, scarcer in anti-cd , and anti-cd stains. the majority of cases showing fdc was obtained by cna. ( cases), cd ( cases) and cd ( cases). conclusion fdc structures were absent or scarce in up to % of b-cll/sll cases which can be used as an auxilliary diagnostic criterion. the positive cases showed small irregular clusters, rings at the follicle periphery, or normal follicular meshworks. best results were obtained with cna. antibody. this may be due to better antigen preservation or to non-specifity. introduction myelodysplastic syndromes (mds) are clonal haematopoietic stem diseases characterised by dysplasia and ineffective haematopoiesis. the dysplasia may be often associated with an increased number of myeloblasts in peripheral blood and bone marrow, which represents an important prognostic factor. immunohistochemical detection of blast cells in bone marrow histological sections using cd antigen and its correlation with smear blast count and mds classification are not well established. we report a quantitative study of cd blast cells in mds and acute myeloid leukaemia with multilineage dysplasia (amlmd), and analyse the relationship with both cytologic smear and clinical diagnosis. we have studied bone marrow biopsies diagnosed of mds ( with refractory cytopenia with multilineage dysplasia (rcmd), with refractory anemia with excess blast (raeb) type i and with raeb type ii) and with amlmd. we added controls and calculated the cd blast cells mean per high power field (hpf). cytologic smears were reviewed. results the results were: controls showed - blasts/ hpf, rcmd - / hpf, raeb i - / hpf, raeb ii - / hpf and amlmd - / hpf. conclusions -cd + blast cells density is a good parameter in the histological diagnosis of mds and has a close correlation (p< , ) with smear count results -cd does not distinguish between rcmd and raeb i. -more than blast cells/ hpf raise the diagnosis of raeb ii. more than blast cells/ hpf raise the diagnosis of amlmd. the extrapolation of these features to "dry tap" aspiration remains to be established. inroduction bone marrow angiogenesis has been recently implicated in the pathophysiology and course of various haematological malignancies. little is known, however, about the significance of this phenomenon in hairy cell leukaemia (hcl). methods we evaluated various morphometric characteristics of microvessels, highlighted by means of anti-cd immunohistochemistry, in the bone marrow of patients with typical hcl, before and after treatment with interferon-α. overall bone marrows from hcl patients and twenty control bone marrows were examined. microvessel density (mvd) and several size-and shape-related parameters were quantitated in the region of most intense vascularization using image analysis. results mvd, size-related parameters and the percentage of branching microvessels were higher in hcl than in controls and in partial/non-responders in comparison to complete responders. acvievement of complete response was accompanied by smaller calibre microvessels. interferon-α induced a decrease in mvd and branching values in cases with diffuse marrow involvement. in univariate analysis, progression-free survival was adversely affected by mvd and branching. multivariate analysis indicated that factors related to the size of the microvessels and mvd/ branching independently affected progression-free survival. mvd/ branching was also related to the likelihood of complete response. conclusions our data suggest that the generation of bone marrow microvessels connotes an increased risk for progression and interferon-α treatment failure in hcl. furthermore the prognostic significance of angiogenesis requires the concomitant assessment of mvd, the size of microvessels and the complexity of the microvascular network. key words: hairy cell leukaemia, bone marrow, angiogenesis, morphometry introduction inflammatory pseudotumors are uncommon and enigmatic benign lesions which may develop at several anatomical sites and recent studies demonstrated the frequent presence of epstein-barr virus (ebv) in them. the occurence of inflammatory pseudotumor in the spleen is rare. a case of inflammatory pseudotumor of the spleen is presented and its relationship to epstein-barr virus (ebv) is examined. material and method the case was a -year-old woman in whom a solitary splenic mass was discovered as part of the workup of idiopathic thrombocytopenic purpura. splenectomy was performed. results grossly, the removed spleen, weighing g, contained a tan-white, circumscribed mass, measuring . x x cm. microscopically, the mass was composed of a heterogeneous cellular population of acute and chronic inflammatory cells. plasma cells predominated, but lymphocytes, neutrophils, eosinophils, interlacing fibroblast-like spindle cells and rare multinuclear giant cells were found. amorphous, acidophilic material was present focally with the plasma cell proliferation. plasma cells presented light chains polyclonality. lymphoid cells were mature and mainly of t-lineage. spindle cells exhibited histiocyte phenotype (cd +++). immunohistochemical stain for ebv was negative. conclusions inflammatory pseudotumor of the spleen is a benign tumorous lesion that has been described in only a few cases in the world literature (< cases). its etiology and pathogenesis is unknown and association ebv is not always present. recognition of this rare entity is important, as the clinical manifestations and imaging features could be indistinguishable from a lymphoproliferative disorder or another malignancy of the spleen. introduction the diagnosis of nodal non-hodgkin's lymphoma (nhl) in montenegro has been done only in clinical center of montenegro -incidence of diagnosed nhl can be considered as the incidence in epidemiological sense.the use of monoclonal antibodies since , has improved our ability to diagnose and to treat nhl. aims: by revision of immunohistologically diagnosed cases of nhl between - , we wanted to estimate (a) the frequency of particular clinico-pathological types of nhl, (b) hypothesis about geo-socio-economic influences on patterns of nhl, and (c) the influence of immunophenotypisation of nhl on speciffic chemo-and immunotherapy. materials and methods nhls were diagnosed with the use of he, giemsa, mgp, pas, gomori, lca, bcl , tdt, cd , cd , cd , cd a, cd , cd , and ema stained slides and classified according to the working formulation criteria. results between ' and ' we diagnosed nhl. low, intermediate and high grade malignancy comprised , %, , % and , % respectively. the highest incidence was estimated in : , / . the nhls of fcc origin constitute , % of all our nhls. in % of patients ( ) low grade malignant nhls were highly cd +. nine patients recieved mabthera+chop/or +cop therapy during the last three years.all patients have been in remision. conclusion the estimated pattern of nhl -the most frequent nhl derivated from fcc-is comparable with geographic and socio-economic description of montenegro as ''underdeveloped, ecological, farming european country''.the high frequency of cd + and initial therapeutical results indicate future prospective patho-clinical studies of this issue. i oehri, m baumann, g cathomas kantonales institute for pathology, liestal, switzerland background the multicentric castleman's disease (mcd) is a lymphoproliferative disease with increased risk for non-hodgkin lymphoma. in aids patients, mcd is usually associated with human herpesvirus (hhv ), the infectious agent of kaposi's sarcoma but in contrast to kaposi's sarcoma, hhv infected cells in mcd show evidence of lytic viral infection. similar to other immunosuppression-associated lymphoproliferative diseases it has been suggested that anti-cd antibodies may be useful in the therapy of these lesions. aim of the present study was the analysis of cd expression in hhv associated mcd and their association with lytic viral infection. material and methods formalin fixed, paraffin embeded lymph nodes were analyzed by a double immunofluorescence assay using antibodies against viral proteins and cd . hhv proteins which were analyzed include the latent viral protein lana (orf ) and the viral interleukin (vil- ) and the orf , both associated with lytic hhv infection. results eleven lymph nodes of seven hiv-infected patients with mcd were analyzed. in the mantle zone of the lymphoid follicle, , %, , % and % of cells show positivity for lana, vil- and orf , respectively (p < , ). by double immunofluorescence, % of hhv infected cells showed co-expression of lana/vil- and lana/vorf and % showed co-expression of lana/vil- , respectively. in addition, there was statistical significant correlation between vil- and lana as well as vil- and vorf (p < , ). of the hhv infected cells, , % showed cd expression and no difference between the three viral proteins analyzed were observed ( , %, , %, , % of lana, vil- and vorf , respectively). conclusion the present data support the concept that hhv runs, in contrast to kaposi's sarcoma, through a lytic viral infection in lymph nodes of patients with mcd. however, only a small subset of infected cells show co-expression of cd , independent of the state of viral replication. this small number of infected cells expressing cd indicate little effect of anti-cd therapy. based on the evidence of lytic hhv infection, however, anti-viral drugs inhibiting hhv replication may be more efficient. anaplastic large cell lymphoma -pathological and immunohistochemicals aspects the who classification of nonhodgkin lymphoma (nhl) included also the cathegory of t and null anaplastic large-cell lymphoma (alcl). alcl is a very rare nhl (about %), with the systemic-aggressive variant, and the cutaneous variant. the presence of the t( ; ) and the formation of alk protein identified one subgroup of alcl with a good prognosis. the aim of our study is to analyze the histopathological and immunohistochemical characters of the alcl diagnosed in our department in the last years. cases of t and null alcl (m/f= / , more half of them younger of years) were clinical and immunohistochemical analyzed (by abc indirect methods, with a large panel of monoclonal antibodies). the pattern of lymph node infiltration was diffuse ( cases), parafollicular ( cases) and only with sinus infiltration - case. the pathological subtypes were common ( cases), lymphohistiocytic ( cases), small cell variant ( case), sarcomatous ( case), eosinophils-rich ( case) and neutrophil-rich ( case). immunohistochemically, the malignant cells presented with t-fenotype ( cases) and null ( cases); case (m, y) presents histiocyte markers (cd +cd +ema+alk+). all cases of alcl were cd +, but only cases were ema+ ( cases were cd ro+cd +alk-ema-). / of cases were alk+ ( -t and -null), with a nuclear and a membranous pattern. cases were bnh + ( cases alk+). only case presented cd expression(cd +ema+alk+bnh +). of the cases with t fenotype expressed cd markers (both were cd +cd -). the pcna and ki proliferation markers were positive in a very large percent of the malignant cells (between and %). numerous reactive t-lymphocytes presented a helper fenotype (cd >cd ), and leu- + cells were very rare. the null and t-cell alcl pose numerous problems of differential diagnosis and immunohistochemicals methods are very useful for diagnosis and prognosis of these nhl. myeloid sarcoma - cases analysis f vasilescu , c dobrea , , e niculescu-mizil , a colita , l caban , r stoia , d ostroveanu , a iofciulescu , d terzea , c iosif 'v babes' national institute, bucharest, romania dpt of haematology, 'fundeni' clinical institute, bucharest, romania myeloid (granulocytic) sarcoma (ms) -also known as "chloroma", is a localized tumor of primitive myeloid cells, that can present before, simultaneously with, or after the diagnosis of acute myeloid leukaemia (aml). rarely, ms may represent the first sign of blastic transformation of myelodysplastic syndrome (mds) or chronic myeloproliferative disorders (cmpd). the aim of this study is to present our experience in the diagnosis of ms. in the last years, we diagnosed cases of ms (m/f= / , between and year-old, with , years median). a large panel of monoclonal antibodies (lymphoid and myeloid cell markers) was used for the diagnosis of ms and for the differential diagnosis with nonhodgkin lymphomas (nhl). the tumor localizations were: lymph nodes ( cases, including a bulky inguinal tumor), lymph node and skin ( case), paravertebral ( cases), testis ( case). in our cases, patients presented with ms before the aml diagnosis (f, y, paravertebral ms, months before aml-m , and m, y, years after nhl diagnosis, presented with an inguinal lymph node ms, months before aml-m ). in cases, ms was diagnosed simultaneously with aml (aml-m ; aml-m ; aml-m ), and in cases after aml (m, y, ms with testis localization, years after aml-m ; f, y, lymph node and skin ms, years afteraml-m ). in one case (f, y), years after successful treatment of an acute lymphoblastic leukaemia (all), the patient presented with a lymph node ms, considered as a blastic transformation of a chronic myelo-monocytic leukaemia (cmml). the diagnosis of ms may be very difficult if this tumor precedes the myeloid proliferative disorders, and the differential diagnosis with nhl may pose a lot of problems. introduction b-pll is an infrequent disease, considered by the who lymphoma classification as an aggressive condition and characterized by the presence of b symptoms, massive splenomegaly without significant lymphadenopaty and peripheral lymphocytosis with more than % prolymphocytes. herein we report cases of b-pll to show the wide clinical and genotypic spectrum of this disease. case reports patient . a -year old male with a history of petechiae and ecchymoses of year evolution. a cbc showed significant lymphocytosis with > % prolymphocytes. physical examination revealed an enlarged cervical lymph node and splenomegaly. lymph node biopsy was diagnosed as infiltration by b-pll (cd +, cd a+, igm+, cd -, cd -, cd -and cyclin d -). a bone marrow biopsy showed infiltration by b-pll. cytogenetic analysis of the bone marrow showed a burkitt's variant translocation t( ; ) (p ;q ) molecular analysis of the lymph node showed igh rearrangement and germline bcl- and bcl- by pcr. he was treated with four cycles of fludarabine ( mg/m ) and rituximab ( mg/m ) and is in clinical and cytogenetic remission at year of follow-up. patient . a -year old female with a month history of multiple cervical lymph node enlargement and fever. physical examination was normal and she had no lymphocytosis on the cbc. lymph node biopsy showed infiltration by a non-hodgkin's lymphoma with a prolymphocytic morphology (cd +, cd a+, igm+, cd -, cd -, cd -and cyclin d -). bone marrow biopsy showed focal infiltration by b-pll. cytogenetic analysis of the bone marrow revealed a normal female cariotype and normal fish patterns were found for the following probes: chormosome centromere, q (c-myc), chromosome centromere, q (d s ), q . (igh) and p . (p ). she was initially treated with chop and then switched to fludarabine having achieved a good clinical response after one cycle each. discussion. the association between b-pll and translocation t( ; ) (p ;q ) has been reported in very few cases, however direct involvement of c-myc alterations affecting specifically q has been proposed as an important factor in the pathogenesis of b-pll. in patient , the observed genetic alterations could be of significance to define the genetic spectrum of b-pll. case corresponds to a b-cell prolymphocytic lymphoproliferation with isolated lymph node involvement and no leukemic component. to our knowledge this presentation has not been reported previously and it is not considered in who classification. morphological and immunohistochemical characteristics of this case are fully compatible with a b-pll. even though it has been considered that some cases of b-pll could in fact represent a morphological variant of mantle cell lymphoma, in this case the negativity for cd and cyclin d partially rule out this possibility. bcell prolymphocytic lymphoproliferations constitute an heterogeneous group of disorders in which c-myc rearrengement can be present. in this group of neoplasia therefore, the nodal involvement can be either predominant or the only clinical manifestation, thus we propose to consider the term b-cell prolymphocytic lymphoma/ leukemia instead of b-pll to denote these disorders. background alcl is a particular type of t-cell non-hodgkin's lymphoma originally characterized by a peculiar morphology and the consistent expression of cd . this entity is frequently associated with the translocation t( ; ) (p ;q ) or some of its variants resulting in the overexpression of the chimeric protein npm/alk (alk+), even though in the current classification alk-negative cases are also considered within this group. ebv is classically and constantly associated with certain specific types of lymphoma but its association with alcl is not considered a characteristic feature of this disease. the aim of this study was to investigate the frequency of the alcl-ebv association in a population of adult mexican patients. results eighteen patients with a morphological and immunohistochemical diagnosis of alcl with nodal involvement were included. immunohistochemical and ish analysis was performed for cd , cd , cd ro, cd rb, cd , cd , cd , ema, lmp- , alk.and eber . mean age was years and the male-tofemale ratio was . : . immunohistochemistry and in situ hybridization results are summarized in the next table. all the so considered ebv positive cases expressed lmp- and eber . conclusion in contrast to the information available in the literature we found a high incidence of the alcl-ebv association / ( %). the high incidence of alk-/ebv+ cases / ( %), with morphological and immunophenotypical characteristics of alcl gives rise to the possibility that this is a different subset of t-cell lymphomas with anaplastic morphology in which ebv plays a pivotal roll in the oncogenesis and evolution. these disorders have been considered so far to be alcl /alklymphomas. the high incidence of ebv infection in mexico leads to the development of peculiar lymphoid proliferations as well as associations (ebv/alcl) different from those considered to be frequent in world literature. lazzi s , bellan c , de falco g , schuerfeld k , micheli p , bartolommei s , pileri s cdk is a member of the cdc -like family of kinases. its cyclin partners are members of the family of cyclin t (t , t a and t b) and cyclin k. cdk /cyclin t complex is very important in the differentiation program of several cell types, controlling specific differentiative pathways. limited data are available regarding the expression of cdk /cyclin t in haematopoietic and lymphoid tissues. the aim of this paper is to analyze the expression of cdk /cyclin t complex in lymphoid tissue, in order to assess its role in b and t cell differentiation and lymphomagenesis. in reactive lymph nodes cdk /cyclin t expression was found by immunohistochemistry in germinal center and in b and t cell blasts in interfollicular areas, suggesting a role for cdk in the activation and differentiation of b and t cells. the staining of cdk and cy-clint complex in malignant lymphomas seems to reflect their normal counterpart, as it is highly expressed in lymphomas derived from germinal center cells, such as follicular lymphomas and classical hodgkin's lymphomas and from activated t cells, (i.e. anaplastic large cell lymphomas). diffuse large b-cell and burkitt's lymphomas showed a wide range of values. no expression of cdk and cyclin t was detected in marginal zone and mantle cells lymphomas. however, at rna level we found an imbalance in cdk /cyclin t ratio in follicular lymphoma and diffuse large b cell lymphomas with germinal center phenotype, and in the cell lines of classical hodgkin's lymphomas, burkitt's lymphomas and anaplastic large cell lymphoma, in comparison with reactive lymph nodes. here we report cdk /cyclin t complex deregulation in neoplastic conditions for the first time, representing a step towards better understanding of through which molecular mechanism cdk /cyclin t complex acts on the activation and differentiation program of lymphoid cells and the role of its deregulation in malignant transformation. introduction hairy cell leukaemia (hcl) is a chronic lymphoproliferative disease characterized by the presence of neoplastic b cells with hairy cytoplasmic projections in spleen, bone marrow and peripheral blood. complete or near-complete remission can be achieved by recent chemotherapy protocols. these treatment methods are quite different from the chemotherapy protocols used for the treatment of other lymphoproliferative diseases. an absolute and correct diagnosis, i.e. detection of hcl cells by specific methods, is necessary for the achievement of complete or near-complete remission by special chemotherapy programs. detecting intracytoplasmic tartrate resistant acid phosphatase (trap) enzyme activity in the peripheral blood and bone marrow aspirates is a classical, simple, sensitive and quite specific method for the detection of hcl cells and in the diagnosis of hcl. however, this method is insufficient in some cases. for example, the most of the hcl patients are leukopenic and there are a few number of neoplastic cells in their peripheric blood. an adequate number of neoplastic cells cannot be obtained by bone marrow aspiration because of the increase in reticulin fibbers of the bone marrow. in such cases, bone marrow trephine biopsy is almost the only and the most important method in diagnosis and follow-up of this disease. specific detection of trap enzyme activity in bone marrow trephine biopsy materials is not possible because of the effect of tissue fixation and processing on these materials. in conclusion, a new method for detecting trap enzyme activity in bone marrow trephine biopsy materials and for conforming the diagnosis of hcl is needed. a recently developed anti-trap antibody has been started to be used as an immunohistechemical marker in the diagnosis of hcl. the aim of this study was to investigate the specificity and the sensitivity of anti-trap antibody immunoreactivity in bone marrow trephine biopsy materials in the diagnosis of hcl. material and methods we divided the cases into two groups; a study and control group. the study group included the cases diagnosed as hcl by clinical, haematological and histopathological investigations. the cases in the control group were the cases characterised by non-hcl neoplastic or reactive lymphoid infiltrations, which raised the suspicion of hcl in the differentia l diagnosis. immunohistochemical staining techniques were applied to paraffin block sections of biopsy materials with anti-trap antibody. results and conclusion we found that there is a statistically highly significant difference between trap immunoreactivities of the study and the control groups, and hcl can be diagnosed by trap immunoreactivity in the bone marrow trephine biopsy materials with the specificity of , % and with the sensitivity of %. cathepsin l participation in collagen degradation during the recovery from experimental hepatic fibrosis v ryvnyak introduction cathepsin l is one of the most important lysosomale cysteine proteinase, indispensable for proteolitic processes. the enzyme is capable to degrade the main components of the intercellular matrix. aims: . to determine the participation of cathepsin l in collagen degradation in liver and to reveal the intracellular and/or extracellular localization of the enzyme activity. . to determine which cells of fibrotic liver are sources of cathepsin l. methods biochemically cathepsin l activity and hidroxyproline level was determined in normal, ccl -induced fibrotic rat liver and at , , , , days after discontinuation of treatment. the activity of cathepsin l in fibrotic rat liver at the th and st days was investigated electron-histochemically. cbz-phe-arg- mbna (bachem) served as the substratum. results biochemically in fibrotic liver an increase of cathepsin l activity as compared with normal liver was revealed. during fibrosis regression the maximums of enzymatic activity at the th day ( %) and at the st day ( %) after cessation of ccl -treatment were fixed. at the th day of recovery some diminution of cathepsin l activity was noted. at the th day after toxin abolition enzyme activity was close to control. a close correlation between cathepsin l activity and liver hidroxyproline level was found. electron-histochemically reaction product was revealed in the kupffer cells and fibroblast phagolysosomes containing fragments of collagen fibrils. we also found extracellular localization of cathepsin l in both terms of investigation. the reaction product was noted on the hepatocyte, kupffer cell and fibroblast plasmalemma and on adjacent collagen fibrils. conclusions cathepsin l is directly implicated in collagen resorbtion during liver fibrosis regression. detected extracellular activity of cathepsin l suggests that in addition to the intracellular proteolysis, cathepsin l is secreted by hepatocytes, macrophages and fibroblasts in intercellular space and can take part in extracel-lular collagen degradation. ryvnyak victor laboratory of morphology "nicolae testemitanu" state university of medicine and pharmacy bd. stefan cel mare, kishinev, md- moldova victorrivneac@yahoo.com introduction the solitary necrotic nodule (nns) of the liver is an uncommon lesion with a round appearance near the surface of the liver, with a dense collar of hyalinised collagen surrounding a necrotic core. case reports we present three cases of nns. two patients underwent surgery to remove liver metastasis. we suggest a relationship with the previous hepatic surgery and with the microwave tissue coagulator. the other case have an history of abdominal traumatism by a seizure. the radiological image of nns was misinterpreted as a tumor and the diagnosis by fnac or frozen section could not exclude a metastasis. the potential risk of a malignant secondary tumour existed, and that was why limited liver resection was recommended. several pathogenetic mechanisms have been avocated (infection, parasitic, traumatic, ischaemic, post chirurgical, iatrogenic, etc.) , all of them having an identical morfological appearance. conclusion nns is a rare non-tumorous lesion that might be misinterpreted as a tumor. the correct diagnosis can only be histological. it is important to differentiate the nns from metastases due to the great influence on the treatment. the significance of morphometrical analysis in staging of fibrosis in liver biopsies from patients with chronic hepatitis c a matsionis , e romanova , y kirichenko , y ambalov , p povilaitite rostov regional bureau of pathology, rostov on don, russian federation rostov central hospital, rostov on don, russian federation introduction prognosis of the course of chronic hepatitis c (chc) depends on fibrosis stage and its progression temps in the liver. semi quantitative methods are currently regarded as a routine diagnostic procedure. but it is obvious that these methods are subjective. morphometrical analysis with calculation of fibrosis index (fi) is an alternative method of evaluation. the aim of the study was to compare data obtained after morphometrical analysis of collagen formation to semi quantitative methods results and find out accordance with fibrosis stage. materials and methods liver biopsies from chc patients were used. we applied v.j.desmet ( ) semi quantitative method and software sigmascan pro . for morphometrical analysis of sections. all sections were stained by masson trichrome method for the detection of collagen. fibrosis index (fi) was calculated as collagen area divided all section area. results , % of patients had clinically significant level of liver fibrosis (desmet f , f , f ). f desmet stage was corresponding fi , - , , f desmet (moderate fibrosis) -fi , - , and high level of fibrosis (f and f ) -if , - , . / cases ( , %) showed differences between semi quantitative and morphometrical results. four patients ( , %) without fibrosis by semi quantitative methods showed if corresponding moderate fibrosis (f ). conclusion our results suggest that morphometrical analysis is beneficial in the evaluation of fibrosis stage and should be used for prognosis and monitoring the course of chronic viral hepatitis. introduction hepatic mucinous cystadenomas with mesenchymal stroma have been recognized as rare neoplasms that occur only in females and have recently been postulated as being hormonally dependent. because of the similarity of these neoplasms to ovarian mucinous cystadenomas, we compared the immunohistochemical profiles of these neoplasms arising in two different organs. the aim of this study was to establish whether these two tumors were phenotypically similar. materials and methods we employed the following immunohistochemical stains, estrogen receptor, progesterone receptor, inhibin, ck , ck and alcian blue/ periodic acid-schiff, to cases of ovarian mucinous cystadenomas and to cases of hepatic mucinous cystadenomas with mesenchymal stroma. results both the ovarian and hepatic neoplasms showed similar results with all of these stains. conclusions phenotypically, we have been unable to establish any difference between these two neoplasms. there appear to be two possible explanations for the origins of these tumors: one is that of a displaced ovarian anlage in the developing liver and the other would be that some of the primitive hepatic stem cells are capable of acquiring ovarian characteristics assessment of periodontum condition in hepatitis c infected patients with rapid and slow dynamics of advanced fibrosis p radlowski aim analysis of the relationship between the stage of periodontium disease and the extent and dynamics of fibrosis in patients infected with chronic hepatitis c. the study included patients whose blood serum revealed the presence of hcv-rna via rt-pcr, while biopsies showed chronic inflammation and either septal fibrosis, or liver cirrhosis. fibrosis was evaluated according to scheuer's point scale, with azan-staining method and the authors' own modifications. fibrosis dynamics (fu/y) was evaluated as a quotient of the number of points assessing fibrosis and the number of years of the disease. periodontitis was determined by the following criteria: inflammation limbus, gum swelling, gingival pockets depth, presence of supragingival and subgingival calculus and gomphiasis. each criterion was assigned either or point within the cumulative scale of - points. results all patients with advanced liver fibrosis were found to show signs of periodontosis. the patients whose periodontium condition scored points with the mean value of fu/y amounting to , , while those who scored points showed mean values of fyu/y equalling , . the group of patients with high values of periodontium disease showed significantly higher values of periodontum disease stage (most frequently assessed at points) compared with the group of nine patients with low fu/y values (mean value = p < , ). periodontium score of the patients with cirrhosis and bridge fibrosis showed similar values. conclusion the degree of periodontal disease was found to be dependent on the pace of fibrosis dynamics. molecular evidence for a toxic memory effect in chronic liver disease c stumptner, k wagner, h denk, k zatloukal institute of pathology, university of graz, graz, austria introduction alcoholic liver disease shows a toxic memory effect: patients with a history of alcoholic hepatitis show even after prolonged withdrawal from alcohol rapid reappearance of alcoholic hepatitis upon reexposure to alcohol. this type of liver injury can be mimicked in a mouse model by feeding , . after months of ddc intoxication mouse livers revealed ballooned hepatocytes containing numerous mallory bodies. within four weeks of recovery from intoxication most mallory bodies disappear but rapidly reappear within three days of reintoxication indicating the existence of a toxic memory effect. the aim of this study was to investigate the molecular basis of the toxic memory effect. materials and methods cdna-libraries were generated from normal and ddc-intoxicated mouse livers by subtractive suppressive hybridization. these gene libraries were used to produce cdna-arrays for expression profiling. rna was isolated from mouse livers at different stages of intoxication, recovery and reintoxication and hybridized to the cdna-arrays. expression profiles were analysed by genesight-and imagene software. results and conclusion results obtained demonstrated several groups of genes differently expressed in short-term intoxicated naive and reintoxicated mice. these genes comprised cyp a as well as genes involved in the cellular response to oxidative stress and methionine metabolism. the sustained elevated level of cyp a during recovery and the enhanced induction upon reintoxication could explain why certain drugs lead to enhanced liver toxicity upon repeated administration even after long drug-free intervals. introduction tgf-beta, fas, fasl molecules take part in the regulation of apoptosis. fas is a cell surface receptor present in most of the cells. fasl can be secreted from the surface of the cells and when it binds to fas, they activate the caspases to trigger the apoptosis. although the mechanism of tgf-beta is not clear yet, it plays a role in tumorigenesis. tgf-alpha may indicate inhibitory or stimulatory functions in conjunct with the stage of the tumors and cooperation with oncogenes and growth factors. we aimed to evaluate the correlation among the expressions of fas, fasl, tgf-beta molecules in hcc. material and method in this study fifty cases diagnosed as hepatocellular carcinoma (hcc) between the - years were included. tgf-beta , fas, fasl expressions were evaluated immunohistochemically. results fas, fasl expressions were observed together in % of tissue samples with hcc and % of the nontumoral liver tissue samples. it was noticed that fas and fasl staining were more densely in the lymphocytes of the tumorous areas and neighboring normal tissues than the control group. there was no statistically significant correlation between fas, fasl, tgf-b staining except the positive correlation between the tgf-beta and fas. the poor differentiated cases weakly expressed fas, fasl and tgf-beta . where as the majority of the cases stained cytoplasmic positive, some cases stained either cytoplasmic or membraneous positive. conclusion in hcc, tumor cells use variable pathways for apoptosis. the lymphocytes near the tumorous tissue have an important role in this process. dynamics of liver histology in patients with chronic hepatitis c after interferon-alpha and ribavirin therapy introduction interferon-alpha therapy for chronic hepatitis c improves hepatic inflammation and may change the evolution of disease to cirrhosis and hepatocellular carcinoma. accurate assessment of liver fibrosis is necessary for morphologic diagnostics. the aim of this study was to evaluate the effect of interferon-alpha and ribavirin on liver histology; to compare the semi-quantitative (according to ishak) and quantitative methods for evaluation of fibrosis. materials and methods twenty-two patients ( males, females at mean age years) with chronic hepatitis c were studied. within to months from the pre-therapy biopsy and at least months after the end of treatment patients were followed with second liver biopsy. histological activity in paired liver specimens was assessed by knodell modified score. fibrosis was evaluated according to ishak staging system. in addition, fibrosis was quantified in masson trichrome stained sections using morphometric image analysis. interferon-alpha (mean dose me) and ribavirin were administered for to months. patients were classified as complete sustained responders (n= ), relapsed after therapy cessation (n= ) and "non-responders" (n= ). results after treatment reduction of the histological activity score (at least one grade) was observed in patients ( %). lobular and periportal necroinflammatory lesions were decreased in both responders and non-responders (p< . ). after therapy, dynamics the fibrosis degree and calculated fibrosis ratio were not significant. fibrosis stage was improved in only sustained responders ( %); remained unchanged in patients, and progressed in patients ( %). conclusions improvement of liver histology after interferon-alpha and ribavirin treatment was constricted to the patients who achieved hepatitis c virus eradication. morphometry was the informative method for evaluation of fibrosis dynamics in addition to fibrosis assessment with semi-quantitative classification systems. introduction liver biopsy is one of the diagnostic procedures for neonatal hepatitis (nh)and intrahepatic bile duct paucity (ihbp). in this study we aimed to evaluate the prognostic benefits of quantitative analysis of histopathological changes in nh and ihbp. material and methods we studied liver biopsies in which were nh and were ihbp. the relationships between histopathological and prognostic parameters were analyzed. hepatic histopathological changes such as portal and periportal fibrosis, portal and lobular inflammation, bridging necrosis with fibrosis, pericellular fibrosis, giant cell transformation and extramedullary hematopoesis were evaluated and according to their absence ( ) or presence ( ) a histopathological score was assessed. the sum of these data was accepted as total pathological injury score. clinical prognostic parameters consisted of the patients height, presence or absence of hepatosplenomegaly and ascites, serum levels of alt, albumin, bilirubin, and the value of protrombine time. the sum of these data was accepted as the clinical score. the patiens were also divided into two groups whose clinical scores were < as good prognosis and ≥ as bad prognosis. for statistical analysis pearson's chi-square, mann-whitney-u and roc curve tests were used. results we found a statistically significant negative relation between prognosis and total pathological injury score (p= . ), so as pericellular fibrosis (p= . ). conclusion during the interpretation of liver biopsies of nh and ihbp, scoring of histopathological changes should be done in order to assess the clinical prognostic outcome. moreover, the presence of pericellular fibrosis should be evaluated and reported. immunohistochemical analysis of hepatocellular carcinoma and intrahepatic cholangiocellularcarcinoma using markers supposed to indicate respective levels of diffentiation of the hepatic cell lineage k ishida, m endoh, j takeyama, k sakamoto, m watanabe, t moriya, h sasano department of pathology, tohoku university hospital, sendai, japan it is widely recognized that there are diagnostically problematic cases among primary hepatic tumors. they cause difficulties in distinguishing between hepatocellular carcinoma (hcc) and intrahepatic cholangiocellularcarcinoma (cc). meanwhile, recent progression of study on hepatocyte-diffrentiation has revealed that both mature hepatocyte and biliary epithelial cell should originate from the common cell lineage called as hepatic-progenitor-cell (hpc), bipolar-cell (bc) and/or intermediate-hepatocyte-like-cells. thus, we performed immunohistochemical analysis for hcc and cc using markers supposed to indicate respective levels of differentiation of the hepatic cell lineage, in order to identify the origin of the tumors particular in the diagnostically problematic cases. materials and method surgical specimens of cases of hcc and cases of cc were used. ordinary immunohistochemical staining was performed with following antibodies; hepatocyte monoclonal antigen (hep), c-kit, ck , ck and ck . the results were compared from the view of the histopathological findings and immunohistochemical reactions. results rate of positive (> %) and focal positive (> %) were hep; hcc %, cc %, c-kit; hcc %, cc % and ck ; hcc %, cc; %. ck and ck were similar as previously reported. in addition noteworthily, double positive for hep and ckit was observed on two cases of cc having apparent glandular formation. conclusions ) hcc had a lower positive rate for hep compared with previous reports. ) cc with positivity for hep might exist. ) according to the c-kit staining pattern, we considered that there might be a peculiar variant of tumor cells in cc differentiating both hepatocyte and biliary epithelial cell. introduction proteus anguinus, the sole species of the european cave salamander and the remarkable cave dweller of underground waters in the karst of slovenia is well adapted to poor and discontinuous food supplies. remarkable accumulation of lipid droplets and glycogen deposits in the liver beside slow metabolism allow proteus to survive for long periods without food. the aim of this study was to establish morphological changes in the liver during starvation with particular emphasis on mobilization of the liver energy reserves. material and methods the liver was examined after food deprivation periods of one, four and eighteen months, respectively using light and transmission electron microscopy. glycogen and proteins concentrations were determined spectrofotometrically. total fat in the liver was estimated by folch method. results intense depletion of glycogen was present during first month of starvation. the glycogen wasn't formed in clumps typical for normal liver tissue. after eighteen months of fasting glycogen was re-synthesized, dense glycogen deposits appeared. lipid droplets were less condensed. numerous peroxisomes formed clusters with small and round mitochondria. particular mitochondria increased in size and lost cristae. lysosomes and autophagic vacuoles were numerous, too. dilated intercellular space included electron dense granular material. conclusions carbohydrate and lipid reserves in the liver of proteus serve for metabolic needs during food deprivation. while in many other vertebrates fasting causes depletion of liver carbohydrates, these reserves are maintained in large amounts in proteus. results of our study confirm that a detailed morphological analysis of the liver could be a relevant informative method to prove metabolic adaptability of this organ. evaluation of t lymphocyte subpopulations in chronic hepatitis-relationship with histological lesions ci iosif, f vasilescu, g butur, dc terzea, c dobrea, f andrei, c ardeleanu 'victor babes' national institute, bucharest, romania background intrahepatic t lymphocytes are believed to be involved in immunopathogenesis of chronic viral hepatitis. the aim of this study was to assess the correlation between morphological lesions and t lymphocyte subpopulations in liver and peripheral blood (pb) of patients with chronic hepatitis. methods and results liver biopsy specimens from patients serologically confirmed ( hbv and hcv) were studied by histopathological and immunohistochemical methods. t cell subtypes (cd , cd , cd ) were tested by using monoclonal antibodies on tissue samples and by flow cytometry in pb. results in pb, % of patients have t lymphocyte cd + decreased and % of them have augmented values of t lymphocytes cd +. in liver biopsy the prevalent subpopulation were cd + cell, being approximately twice higher than cd + cells. the observed histological lesions were quantified by ishak score as moder-ate\severe chronic hepatitis. conclusions decreased subpopulation of cd + t lymphocyte might contribute to the severity of liver disease. relatively more frequent cell type was cd positive t cell, having a significant association with a higher inflammatory activity in both types, b and c virus hepatitis. the role of survivin in regulation of proliferative and apoptotic activity of hepatocellular carcinoma introduction imbalance between proliferation and apoptosis is an important factor in progression of hepatocellular carcinoma (hcc). aims: the percentage of proliferative (pi) and apoptotic cells (ai) in hcc compared to non-tumor liver was investigated. the role of unprocessed as well as active form of caspase- , which is an important apoptotic protein was of great interest for this study. expression of survivin, an inhibitor of apoptosis was investigated, too. material and methods twenty patients with hcc were included in the study. two samples were obtained from each patient, one of hcc and one of the surrounding non-tumor liver. mib- antibody was used to determine the proliferative activity. immunohistochemical staining for the detection of active form of caspase- was used to determine the percentage of apoptotic cells and for detection of procaspase- and survivin expression, as well. results ai was higher in hcc ( , ± , ) compared to nontumor liver ( , ± , ), but the proliferative activity in hcc was much higher than apoptotic activity. % of hcc showed positive staining for pro-caspase . positive correlation between expression of pro-caspase and active form of caspase proved to be statistically significant. % of hccs were survivin positive. stronger expression of survivin was detected in hcc compared to non-tumor liver. positive correlation between survivin expression and the grade of tumor diferentiatiation as well as a significant association between survivin expression and both ai and pi was also detected. conclusion our results indicate that survivin promoting cell proliferation in hcc has an important role in hcc progression. the histopathological effects of offloading on liver of rat embryo a khaki , aa khaki , j solimany rad faculty of veterinary medicine of tabriz islamic azad university, tabriz, islamic republic of iran faculty of medicine science.tabriz medical science university, tabriz, islamic republic of iran introduction ofloxacin is an antibiotic from fluroqinolne with a wide range and widely used in various infection diseases. since there is little information about ofloxacin side effect on liver of rat embryo. this preliminary study was planed to see what kind of changes occurs in development of liver in rat embryo. the aim of present study was to determine the histopathological effects of offloading on liver of rat embryo. material and methods fourty nine wistar rats were selected and randomly divided into two groups; control (n= ) and test (n= ). the test group has been received mg/kg (po) ofloxacin daily during pregnancy. however, the control group just received plate. after delivery, liver tissue of neonatal in both groups were taken and prepared for light microscopy. staining method was h&e. results microscopic study of liver tissue specimens showed that in the test group hepatocytes were vesiculated. degeneration and vacuolated pycnotic nuclei were seen when compared to control group. weight of neonatal in test group was reduced when it was compared with the control group (p< . ). conclusion since ofloxacin had side effects on liver of rat embryo, it is not suggested to be used during pregnancy in human. introduction while the underlying etiology of hcc has been well characterized the molecular mechanisms of hepatocarcinogenesis are poorly understood. the extremely poor prognosis of hcc and the limited value of the current standard clinical markers underscore the need for improvent of diagnosis and treatment of this deadly disease. aims: we performed gene expression profiling using cdna microarrays in order to identify novel molecular markers and therapeutic targets for the treatment of hcc. material and methods we used the method of subtractive suppressive hybridization (ssh) to generate cdna libraries that are highly enriched with clones representing genes both up-and downregulated in the diseased liver tissue. the expression pattern of clones representing ~ genes was analyzed in surgically resected hepatocellular carcinomas, focal nodular hyperplasias, one adenoma, and cirrhotic livers by competetive hybridization on custom made cdna microarrays using a pool of non-neoplastic human liver as reference. the expression data were verified independently by quantitative rt-pcr (taqman). results we found genes which were consistently deregulated in more than one third of the hccs under investigation. of these, genes had been previously implicated in hcc, whereas known genes as well as novel genes (with unknown function) had not yet been linked with liver cancer. conclusions the present study revealed a number of genes specifically deregulated in hepatocelluar carcinoma. future work will aim to evaluate the medical relevance of the encoded proteins which will ultimately help to identify potential new markers for better diagnosis/ prognosis of hcc and new targets for therapeutic intervention. introduction actinomycosis is a suppurative and granulomatous chronic infectious disease caused by actinomyces sp. and most commonly affecting the cervicofacial area. aim: to study the clinical characteristics of patients with actinomycosis, with regard to clinical history, presentation, method of diagnosis and comparing to the literature. patients and methods from january to july , a retrospective review was performed on all cases of histologically proven actinomycosis. results ten patients were studied, men and women, - years old. two patients had a history of surgical procedures and/or dental manipulations. two patients had a long history of diabetes mellitus. locations were the liver (patient n ), the feet articulation (patient n ), the lung (patient n ), the jugular lymph node (patient n ), the skin (patients n and ), mandibular (patient n ), the psoas muscle (patient n ), the appendix (patient n ) and the large bowel (patient n ). three patients showed a tumoral presentation (patients n , and ) and two patients had a tuberculosis disease presentation (patients n and n ). the patient n had a clinical presentation of an inflammatory large bowel disease. one patient was diagnosed by cultures positive to a. israelii on microbiologic study and the others patients by surgical biopsy and detection of an actinomycosic granuloma. special stains were used in all cases. three patients received the classic initial regimen of iv. conclusion actinomycosis is an uncommon disease in our country. in these cases gastrointestinal locations were predominant. two uncommon locations were present. there was no iud associated infection. tuberculosis endemic in our country can mislead the diagnosis. further autopsy hazards: mycobacterium tuberculosis in the autopsy room r flavin, s o briain st. james hospital/tcd, dublin, ireland introduction tuberculosis has been the major occupationally acquired disease in the autopsy room. the risk of encountering tuber-culosis at autopsy has fallen with the decreased incidence of the disease and greater emphasis has been placed recently on the hazards of viral diseases. however, tuberculosis may still be found at autopsy. the aim of this study was to assess the magnitude of exposure to mycobacterium tuberculosis at autopsy in a large general hospital setting. methods retrospective search of the autopsy records from - . the patient record and histological slides were reviewed. the quantity of mycobacteria was assessed from the ziehl-neelson stains as scanty, moderate or abundant. results cases of active mycobacterium tuberculosis were identified in the -year period in which autopsies were performed ( per autopsies) of which cases were unsuspected ( %). these included cases of miliary tuberculosis and with pulmonary infection. cases contained abundant organisms. patients tended to be middle aged and male with complex clinical histories. patients were dead on arrival at hospital. conclusion the risk of unexpectedly encountering tuberculosis at autopsy continues and has implications for the health of autopsy room staff, autopsy room ventilation and design, protective equipment and for the involvement of the public health service. introduction the course of chronic hepatitis c virus infection is difficult to predict. although the disease is frequently asymptomatic, the development of fibrosis and cirrhosis are the major complications. among patients suffering from chronic hepatitis c (chc), special group are young drug abusers. immunological toxicity of narcotics modulates the total immunologic response to the viral infection with characteristic morphologic expression of this disease. the aim of this study was to asses which pathological features are associated with liver fibrogenesis and are predictive to fibrosis in chc drug abusers. methods eighty liver biopsies with chc from drug abusers ( actively consumers; free from drugs - months before liver biopsy and free for more than one year before performing liver biopsy) stained by he, trichrom masson, perls and reticulin were analyzed semi quantitatively using standard questioner for determination of patohistological features for histological activity index. results of fibrosis were correlated to all of them. results the fibrosis was , and in this group of young patients (mean age , years). there were no correlation between any of the patohistological parameters and fibrosis, even for lobular necrosis. conclusion histomorphological changes and the extent of fibrosis are in correlation to the duration of drug consumption. morphological expression of immune toxicity of narcotic drugs in chc patients make this disease special entity to which it is not possible to apply standard histopatologic parameters, nor the parameters predicting liver fibrosis. introduction epithelial tumors of the conjunctiva are rare diseases in europe. in sub-saharan countries, an increasing incidence was observed in connection with the hiv epidemic. the definite causes of these tumors are not known. aims: based on tumor material from africa, we search for possible cancerogenic agents and its pathogenetical interaction in conjunctival carcinoma. materials and methods conjunctival specimens of patients from three african centers with the following histological lesions were examined: papilloma ( case), pinguecula ( ), conjunctival intraepithelial neoplasia ( cin i, cin ii, cin iii), squamous cell carcinoma (scc, cases). immunohistological reactions for p and p were done. of tested patients were hiv positive. results and conclusion of the benign and precancerous lesions were associated with histological signs of a solar damage. of the cases showed immunohistologically an overexpression of p , among them all scc. this finding might indicate a p mutation as mostly seen in solar induced skin cancer too. % of the cases with cin iii and scc had an overexpression of p . corresponding findings are known from transformed or neoplastic cervical epithelium in strong correlation with an active hpv (type , ) oncogene expression. no significant differences occurred between hiv positive and hiv negative cases in comparison to the frequency of different histological lesions as well as the p and p expression. the average manifestation age for cin iii and scc in hiv positive cases ( resp. years) was years lower than that of hiv negative cases ( resp. years). the results suggest a multifactorial tumorgenesis (uv radiation, oncogenic viruses, hiv infection) for the conjunctival carcinoma in africa. introduction botryomycosis is an enigmatic pyogranulomatous infection, which may be caused by a variety of non-filamentous bacteria including staphylococcus aureus and pseudomonas aeruginosa. while the exact pathogenesis remains elusive, it is acknowledged that the interrelationship of host and agent factors is fundamental. we describe the clinicopathological features of a rare and particularly mutilating case of delayed onset post traumatic craniofacial botryomycosis. methods an immunocompetent -year-old black male presented with multiple sinuses draining granules involving the frontal, parietal, orbital and maxillary areas. nodulo-fibrous thickening was also present. this had evolved over a three-year period. apart from the history of a head injury requiring cranioplasty years earlier, no other predisposing factors were found. results the diagnostic features of clumped bacteria (cloxacillin sensitive staphylococcus aureus), splendore-hoeppli phenomenon, granulomata and intense fibrosis were confirmed histologically. there was no response to intravenous cloxacillin and the patient died before surgical debridement could be done. conclusion this case report serves to highlight several points. firstly, it illustrates that when considering the diagnosis of post traumatic botryomycosis, the time interval between the traumatic event and the onset of clinical features may span decades. we submit that this is due either to the small size of the bacterial load or their low virulence. secondly, it is our contention that the poor response to antibiotics is due to the severe, impenetrable fibrosis. finally, the destructive nature of the disease underscores the urgency in diagnosis and treatment. tuberculous meningitis in adulthood introduction tuberculous meningitis is a very frequent clinical manifestation of postprimary tuberculosis in childhood as the result of hematogenous dissemination of a pulmonary lesion; in adult patients tuberculous meningitis occurs less frequently, mainly associated with extrapulmonary disease, consequent to the rupture of a subependymal tubercle. case reports we report cases of tuberculous meningitis in adulthood diagnosed by autopsy examination -median age , yrs -in an autopsy series of tuberculous patients in years. all but one of the patients had disseminated disease (lung, lymph nodes, liver, spleen and kidneys). none of the patients presented subependymal tubercles. one patient had dual mycobacterial infection -miliary tuberculosis due to mycobacterium tuberculosis in all the extracranial affected organs and tuberculous meningitis with mycobacterium avium-intracellulare (mac). cerebrospinal fluid examination revealed high cellularity and high albumin concentration in all cases; glucose levels were low, except in one case with normal glucose content -the mac infected patient. one patient had associated systemic lupus erythematosus (sle) and low cd + cells count. the histopathologic appearance consisted of a granulomatous meningitis with giant cells and epithelioids in three cases and polymorphous inflammatory infiltrate including numerous positive bacilli in ziehl-neelsen stain in mac infected patient. conclusion the overall appearance suggested a hematogenous spread of the infection, the immune status correlating with the occurrence of the meningeal disease; in our series we had an immunodepressed patient (sle) and another patient with miliary tuberculosis and superimposed mac infection. also, mac meningitis had a different clinical and histopathologic appearance. introduction clinical presentation and lesion morphology are often suggestive, but not conclusive for mycobacterial (mb) infections. rapid and accurate specific diagnosis is mandatory since appropriate therapy can be chosen only on the basis of the precise identification of the causative agent. one of the most promising tools for rapid and sensitive identification of mb species is represented by amplification of specific sequences of the s rrna mb specific gene on the fragmented dna (max bp) obtained from fixed tissues. methods dna was extracted from cases selected from the archives of the department of pathology, university of padova, with histopathologic features of granulomas, caseous necrosis, and langhans-type giant cells. ziehl-neelsen staining for acid-fast bacilli and pcr/direct sequencing of a bp variable region of the mb s rrna gene were performed. h rv genome was employed as positive control. results mb specific sequences have been identified in of samples analyzed ( %). in two dna samples ( %) an inserted dna product was detected and it is currently under sequencing, while in one sample ( %) no evidence of mb infection has been gained. agreement with ziehl-neelsen was present in cases ( %). conclusion our study suggests that pcr is a rapid, sensitive method for the diagnosis of mb in routinely processed formalinfixed, paraffin-embedded histological specimens and is highly recommendable in cases of chronic inflammation without definite evidence of granulomatous inflammation. introduction cladosporium bantianum is a pigmented highly neurotropic fungus which can be identified easily in tissue sections due to their golden brown colour. cerebral lesions caused by this fungus are rare. case reports we present six cases diagnosed at our institute over a period of yrs. . there were males and female. all patients belonged to the second to fourth decade and had presented with symptoms of space occupying lesion. radiological investigations revealed well circumscribed lesions with ring enhancement. the smallest lesion measured . x . cm and largest measured x . x cm. only two of the six cases had detectable predisposing debilitating illness. one yr. old male had past history of liver tuberculosis and had taken anti-tuberculosis treatment and a yr. old female had systemic lupus erythematosus and was on immunosuppressants. we received four surgically excised specimens and two autopsy specimens of the entire brain. histopathology revealed necrotic areas, micro-abscesses and mainly foreign body type of giant cells. lying within the giant cells as well as freely within the tissue were numerous golden brown to deep brown spherical forms of cladosporium bantianum measuring - microns in diameter and their hyphal forms measuring - microns in diameter, - microns in length with septae and occasional branching. these were confirmed by gomori's methenamine silver stain for fungus and species identification was carried out by culture studies. all the four patients with surgical excision showed recurrence within - months. three succumbed to the disease and one is still alive. conclusion cladosporium bantianum can affect both healthy as well as immunocompromised individuals. it has a fatal outcome. cases are being presented because of the relative rarity. necrobiotic changes of skeletal muscle simulating myxoid sarcoma. report of a case with immunohistochemical and electron microscopic studies kw min , is seo deaciness hospital, oklahoma city, usa wishard memorial hospital, oklahoma city, usa background skeletal muscles are known to undergo bizarre reactive changes in response to traumatic injuries and may produce pseudosarcomatous lesions which may give diagnostic challenges to pathologists. such lesions usually produce proliferative myositis in which atypical spindle cells of fibroblastic and myofibroblastic nature predominate and may simulate the appearance of fibrosarcomas and myofibrosarcomas. however with proper setting of previous trauma history, their true nature can be easily appreciated. we are reporting an unusual case of myxoid cellular lesion found in the abdominal rectus muscle involved in a post hysterectomy abdominal hernia which simulated the appearance of an extraskeletal myxoid chondrosarcoma (emc). its true reactive nature was recognized by electron microscopic (em) study. design light brownish gelatinous material aggregating . x . x . cm was found around the sheath of rectus abdominis muscle of a year old female during a repair surgery of posthyterectomy ventral hernia. the tissue was fixed in buffered formalin and a representative portion of the tissue was fixed in phosphate buffered . % glutaraldehyde and post fixed in osmium with en bloc staining with uranyl acetate. epon embedded thin sections were stained with uranyl acetate and lead citrate. for immunochemistry, paraffin sections were stained for s protein, myosin, and actin by routine abc-peroxidase techniques. results on routine examination, the lesion was characterized by loosely arranged spindly to epithelioid cells in bundles with abundant myxoid stroma. the lesional cells varied in size with frequent bizarre hyperchromatic nuclei. mitosis was rare. the cells showed weakly positive diffuse cytoplasmic stain for all of above antibodies. with the initial impression of emc, an expert opinion confirmed the diagnosis of grade ii emc. however, em revealed the lesional cells to be consistent with skeletal muscle cells having of varying stages of degeneration and regeneration. no ultrastructural characteristics seen in the tumor cells in emc were present. the attending physician was advised of careful follow-up and close observation without any additional treatment. the patient remains with no evidence of disease by year follow-up in spite of incomplete excision of the lesion. discussion and conclusion the myxoid gelatinous material found in the abdominal rectus muscle presented herein showed histopathologic characteristics of emc, however, electron microscopic studies revealed the lesion to be necrobiotic process of the rectus muscle. evidence of no disease in years of follow-up with incomplete excision supports the conclusion the lesion was not malignant as em study indicated. this case exemplifies another variety of pseudosarcomatous reaction of skeletal muscles important in the differential diagnosis in the pathologic evaluation of cellular myxoid lesions. peritoneal psammocarcinoma. a case report with ultrastructural study is seo background psammocarcinoma (pc) is a very rare variant of low grade serous tumors that appears to arise from the peritoneum and ovaries. this tumor has been defined as a serous neoplasm displaying ) destructive invasion, ) no more than moderate nuclear atypia, ) no areas of solid epithelial proliferation except for occasional nests no more than cells in diameter, and ) at least % of papillae or nests are associated with or completely obscured by psammoma bodies. pc shares some clinicopathologic features with serous tumor of low grade malignant potential (lmp), but may have been under-recognized at surgery and gross examination. the present case was incidentally found during a routine hysterectomy procedure for leiomyomas. the pc involved the omentum, peritoneum and diaphragm. we report, to our best knowledge, the first electon microscopic (em) findings of pc. design tumor tissue was fixed in buffered formalin for routine examination. in addition, a representative tissue was fixed in phosphate buffered . % glutaraldehyde and post fixed in osmium with en bloc staining with uranyl acetate for em study. results this tumor met the diagnostic criteria of psammocarcinoma. there were numerous psammoma bodies with or without nests of epithelial proliferation with minimal nuclear atypia. more than % of papillae were either associated with or completely replaced by psammoma bodies. multifocal involvement was noted on the surfaces of both ovaries and fallopian tubes. ultrastructurally, the tumor cells showed markedly villous surfaces with abundant long slender villi. their length/diameter ratio (ldr) was with some variation of their diameter. the cytoplasm contained abundant cytoplasmic organelles and intermediate filaments. intracytoplasmic lumens were absent. decalcified psammoma bodies resembled cut surfaces of geode. discussion and conclusion our case met the proposed criteria for this tumor that arose de novo in peritoneum. ultrastructurally, this tumor shared some findings with serous tumors (junctional complexes, irregular microvilli), but differed by the lack of prominent desmosomes and frequent intercellular lumens. pc differed from mesothelioma in that significantly greater microvillus ldr, prominent desmosomes, tomofilaments, intracytoplasmic lumens, external lamina and glycogen were rountine findings in the latter. our findings justify classification of pc in the group of serous epithelial tumors arising from the coelomic mesothelium. application of electron-and immunoelectron microscopy in the differential diagnosis of pituitary adenomas m maksymowicz, w olszewski department of pathology, institute of oncology, warsaw, poland aim evaluation of practical implementation of electron microscopic techniques in diagnosis of pituitary adenomas. material and methods material consists of consecutive cases of surgically resected pituitary tumors. in pituitary adenomas diagnosed clinically, there were patients with symptoms of acromegaly, patients with hyperprolactinemia, cases of cushing's syndrome and case of tsh hypersecretion. there were clinically nonfunctioning tumors. all cases were diagnosed by histological examination and immunohistochemical identification of known pituitary hormones (growth hormone, prolactin, acth, tsh, fsh, lh and alpha-subunit). the cases evaluated at light microscopy level as pituitary adenomas were examined with electron microscopy and immunoelectron microscopy using a postembedding immunogold technique. results immunohistochemical investigation showed that about , % of specimens of pituitary adenomas contained more than one pituitary hormone. additionally, immunopositivity was discovered in % of tumors from patients with clinical and biological signs of silent pituitary adenoma. ultrastructural analysis provided proper diagnosis of selected cases, e.g. silent corticotroph adenoma or distinction between densely-and sparsely granulated growth hormone secreting adenomas. double labeling immunoelectron microscopy using gold particles of two different sizes greatly facilitated the distinction among mixed growth hormone/ prolactin, mammosomatotroph and acidophil stem cell adenomas. conclusions electron microscopy analysis was valuable to provide a useful informations regarding the diagnosis. our results confirmed practical value of who recommendation for five-tier evaluation of pituitary adenomas (clinical, neuroimaging, histological, immunohistochemical and ultrastructural) . on the basis of our results and the published data, diagnostic postoperative algorithm for proper pathologic management has been proposed. apoptosis, sarcomere disruption and myofibrilar degeneration in skeletal muscles of stable copd patients: an ultrastructural study md ferrer introduction in patients with chronic obstructive pulmonary disease (copd), the diaphragm muscle shows signs of injury, even during clinical stability. in addition, these patients have a markedly increased susceptibility to additional diaphragm injury following inspiratory loading. we have hypothesized that, if sytemic factors play a role in diaphragm injury, limb muscles may also be affected. the purpose of this study is to investigate whether apoptosis occurs in the diaphragm and quadriceps of copd patients, and to evaluate fiber injury in non-respiratory muscles. methods samples from both diaphragm and quadriceps muscles were obtained in patients undergoing thoracotomy for a lowstage lung neoplasm (ln) and stratified into two cohorts according to pulmonary function: ln+copd (n= ) and non-copd patients (ln+non-copd, n= ). in addition, samples form quadriceps muscle in healthy age-matched volunteers were also included (control group). all samples were processed for ultrastructural analysis. the proportion (%) of normal nuclei (nn) and those showing early (ean) and advanced (aan) signs of apoptosis were determined in all samples. digital images of longitudinal fiber sections ( x) were used to determine the area fraction (%) of abnormal myofibrilar structures (aab). results the level of apoptotic signs in the diaphragm of both copd and non-copd groups was minimal and very similar to that of control limb muscle. in contrast, quadriceps muscle of both copd and non-copd groups showed a two-and three-fold increase respectively in the apoptotic nuclei when compared to controls, mainly due to ean. apoptotic bodies were not found. in control quadriceps aab was , ± , %, mostly due to sarcomere disruption, while quadriceps in copd patients was associated with an increased aab ( ± %, p< , ) including myofibrilar disorganization and degeneration. conclusions in patients with copd, the diaphragm is not altered by apoptotic phenomena. muscle remodeling through apoptotic mechanisms as well as through structural changes, such as sarcomere disruption and myofibrilar degeneration, seem to be enhanced in the quadriceps muscle of these patients, regardless of the severity of pulmonary function impairment, suggesting that additional factors such as the degree of physical inactivity either related to the disease or to the preoperative status could also be involved. background renal chromophylic (papillary) carcinoma (cprc) has a propensity for storing hemosiderin in tumor cells. by transmission electron microscopy (tem), some tumors show a prominent lysosomal component, while in other cases, cells contain mostly isometric lipid vacuoles. it has been proposed that the latter would merely represent a papillary variety of clear cell renal cell carcinoma (ccrc). the aim of this study has been to analyze the lysosomal content in chromophylic (papillary) renal cell carcinoma by both immunohistochemical study of cd expression and tem, and to compare these results with those of conventional ccrc. design cases of cprc (n= ) and ccrc (n= ) are the subject of the study. the presence and relative amount of lysosomes and isometric fat vacuoles was investigated by tem (n= ). immunostaining with cd antibody (pg-m , dako, denmark) was performed in representative sections. the presence, distribution and percentage of cd staining in tumor cells was compared with tem data. results expression of cd was observed in all cases of cprc. the mean percentage of positive cells was % ( - %). distribution of positive cells was diffuse in % of cases. of the tem cases, contained abundant fat vacuoles, but only had extensive isometric vacuolation by light microscopy. electrondense lysosomes were less abundant than fat in cases, of which had massive cd expression. detailed examination of fat vacuoles in these cases suggested they were membrane-bound and of probable lysosomal origin. cd expression was also observed in cases of ccrc, all of them with focal distribution, involving a mean of % tumor cells ( - %). these differences were statistically significant (p< . ). conclusions diffuse cd expression is typical of cprc and may be a useful auxiliary diagnostic criterion. the isometric fat vacuoles in cprc are often membrane-bound and of probable lysosomal origin. these findings support the notion that the lipidcontaining, vacuolated variety of cprc is different from ccrc. introduction any lesion in prostate is followed by different proliferative activity of cells. one of the markers, which relate to proliferative activity, is ploidy. it can be determined by cytometry, morphometry or by other methods. aims: study of dna ploidy status in different lesions of prostate by morphometry. materials and methods samples from patients with atrophy, benign prostatic hyperplasia (bph), squamous cell metaplasia (scm), atypical adenomatous hyperplasia (aah), basal cell hyperplasia (bch), prostatic intraepithelial neoplasia (pin) and prostatic carcinoma were processed in formalin, dehydratated in graded alcohols, embedded in paraffin, stained by feulgen-stain. integral optical density was assessed by morphometry on image analysis system. integral optical density of lymphocyte was counted as c ploidy. integral optical density at different prostatic lesions was divided on c. results average ploidy at atrophy was . , bph - . , scm - . , bch - . , aah - . , low grade pin was . . average ploidy at high grade pin was . , high grade carcinoma - . , moderate grade carcinoma - . , low grade carcinoma - . . conclusion increase of ploidy status from atrophy to bph, scm, bch, aah, pin and to carcinoma was observed. regarding to ploidy lesions may be divided in benign and neoplastic processes, with cutoff point between them as . . pseudohyperplastic prostatic adenocarcinoma in transurethral resection of the prostate j arista-nasr, b martinez, j nuncio instituto nacional de ciencias medicas y nutricion salvador zubiran, mexico city, mexico background the pseudohyperplastic prostatic adenocarcinoma (phpa) is a recently described variant of adenocarcinoma, studied in needle biopsies and prostatectomy specimens. phpa is characterized by malignant glands that simulate benign hyperplastic glands of variable size with complex architecture, papillary enfolding, luminal undulations branching or cystic dilations, columnar cells with macronuclei and nucleoli enlargement. the aim of this study was to define the frequency and microscopic aspect of phpa in specimens originated in transuretral prostatectomy (tup). specimens of transurethral prostatectomy were analized from the surgical pathology department at incmynsz. cases were initially diagnosed as benign glandular hyperplasia (bgh) and as conventional adenocarcinoma (cc) results cases ( . %) with phpa were identified in specimens diagnosed as bhg. these specimens demonstrated phpa in two microscopic areas of mm. both patients are well and free of disease and years after diagnosis. the review of cases diagnosed as cc, three specimens had microscopic segments of phpa. in the outcome the patients developed early bone metastasis. the histopathology study revealed papillary projections, nuclear enlargement, crawled glands, macronucleoli ( / ); cystic glandular dilatation, straight luminal borders, pink amorphous secretions ( / ); nuclear hypercromasia and transition to small cell carcinoma ( / ) . other changes observed were corpora amylacea, double nucleoli and mitoses. conclusions the phpa is a rare neoplasm observed in tup specimens and is observed in only few areas. the false negative frequency in bgh is . %, and % in usual adenocarcinoma. the outcome for these cases is related to the main conventional adenocarcinoma component. vascular endothelial growth factor: an important angiogenic mediator in chronic urinary bladder lesions o hammam, h el baz, a el baz theodor bilharz research institute, giza, egypt vascular endothelial growth factor (vegf) is an overriding growth factor mediating tumor anigogenesis. this study was performed to assess vegf levels of expression in both serum and tissue in benign, premalignant and malignant urinary bladder lesions with or without schistosomal infestation in a trail to study the angiogenic phenotype of these lesions and to address any possible role of vegf as a prognostic biologic marker of bladder cancer. also the impact of schistosomal infestation on the vegf level of expression was assessed.the study included patients: chronic cystitis cases ( schistosomal and non-schistosomal), cases with schistosomal premalignant lesions (metaplasia, dysplasia and leukoplakia) and cases with bladder carcinoma ( schistosomal sqcc, schistosomal tcc and non-schistosomal tcc). eight cases with normal urothelium served as controls. vegf serum concentration was measured by the enzyme immunoassay (elisa) while, its tissue expression was detected by immunohistochemical staining.. significantly higher levels of vegf where detected in the premalignant and malignant cases in tissue (p< . & p< . respectively) and in serum (p< . ) compared to controls. also an aberrant increase in vegf serum and tissue levels was recorded in malignant cases compared to those with chronic cystitis (p< . & . respectively). schistosomal infestation was found to have a positive impact on vegf tissue and serum levels. tissue vegf positive rates was % in all the premalignant and malignant schistosomal associated cases. on stratifying malignant cases according to their histopathological grade and stage, an evident stepladder increase in vegf serum and tissue levels was recorded. vegf serum levels were well correlated with their corresponding tissue level which may indicate that vegf serum levels are reflecting intratumoral angiogenic status. although both vegf serum and tissue levels were positively correlated with tumor histopathological grade and stage, yet this correlation was more evident with the tissue expression (r= . , r= . , p< . in tissue, while r= . , r= . , p< . , p= . in serum with grade and stage respectively). in conclusion, our data indicate that vegf expression level in both serum and tissue may be used as a valuable angiogenic marker for prediction of prognosis. this may help in selecting patients for more intensive surgical or chemotherapeutic approaches. serum vegf concentration may be used as a non-invasive prognostic parameter especially in high risk patients who need continuous follow up. microvessel density in urothelial tumors of the upper urinary tract m raica , c suciu , f baderca , r minciu 'victor babes' university of medicine, department of histology&cytology, timsoara, romania 'victor babes' university of medicine, department of urology, timsoara, romania background angiogenesis in tumors of the urinary bladder is relatively well studied, in spite of some conflicting results and usually correlates with bad prognosis. few data are available about microvessel density (mvd) in urothelial tumors of the upper urinary tract (uut). our purpose was to investigate the mvd in patients with urothelial tumors of the uut and to check for its relationships with stage, grade, and survival. patients, material, and methods there were investigated patients with urothelial carcinoma of the uut. routine-stained slides were reviewed by two independent pathologists for the final diagnosis, t stage, and grade. only cases with invasive and mixed papillary-invasive tumors were included. two cases had lymph node metastasis. additional slides were stained for fviii, cd , and cd . mvd was estimated using the hot-spot method and mean value, calculated on consecutive fields from the tumor area and from the deeper connective tissue (x ). all cases had a follow-up of minimum years. results best results were obtained with cd and cd . in the tumor area, mean values of mvd were . for t , . for t , and for t . the hot-spot method consists of choosing the field with maximum density of blood vessels, and results showed for t , . for t , and . for t . the comparison between mvd and g showed a significant increase from g to g in the mean values and maximal density as well: . / for g , . / . for g , and . / . for g . no relationship was found between mvd and n positive cases. nine patients with high mvd died within years. the extra-tumor mvd had no prognostic significance. conclusions our results show a strong correlation between tumor areas mvd, t, g, and survival. mvd had no value as a predictor of lymph node metastasis. is there any prognostic significance for her protein in urothelial tumors of the upper urinary tract? of her protein in urothelial tumours of the upper urinary tract, and its relationships with the stage and grade. the final purpose was to conclude on the prognostic value of her protein in patients with tumours of upper urinary tract. patients, material and methods there were investigated cases with tumours of the upper urinary tract. routine he stained slides were reviewed for the pathologic diagnosis and grade. additional slides were stained with her- /neu (dako herceptest). interpretation of results was based on the score system (from to + ) already used in breast cancer. results obtained with her- /neu were compared with stage and grade. results eight from cases were positive for her protein ( . %). no relationship was found between her overexpression and 'g'. all but one case with g had a + score for herceptest. conclusions the overexpression of her protein does not correlate with tumour stage, and has no predictive value for lymph nodes metastasis. it strongly correlates with 'g'. introduction some authors consider postatrophic hyperplasia (pah), a glandular hyperplasia that mimics some patterns of prostate carcinoma (pca), without any correlation with neoplastic and preneoplastic condition of the prostate. the association of pah with pca recently suggested (mucci et al., ; tsujimoto et al., ) induced us to analyze the role of pah as precursor of pca. material and methods formalin fixed and paraffin embedded archival sections ( selected patients undergoing radical prostatectomy -mean age = . yr) were studied. twenty cases ( with pah and without pah) were selected for each group: a) bph (benign prostatic hyperplasia), b) pca-ghs< (gleason histological score) and c) pca-ghs=> . slides were immunocytochemically treated with psa, ße , cd , vimentin, cd , ar, nse, chromogranin a, pgp . , p , bcl , ki /mib , incubated with streptavidin-biotin complex (sbc) and revealed by diaminobenzidine (dab). immunohistochemical investigations revealed the presence of basal cells ( ße ) only in pah. the nuclear cell cycle proliferation (mib /ki ) and p mutation were quite similar in number of positive nuclei between pah and pca-ghs< . the chromogranin a were positive in pah, randomly in pca-ghs< , and in nests in pca-ghs=> . vimentin stained nests in pah, whereas were negative in pca. the bcl were positive in pah and negative in pca-ghs< . conclusion these findings suggest a strong overlapping of cell cycle nuclear proliferation and mutation markers, supporting a possible role of pah as a precursor of pca. eosinophilic cystitis: clinico-morphologic aspects d staribratova , d staikov , d dikov , v belovejdov , d staikov plovdiv medical university, plovdiv, bulgaria hopsital centre -lagny, paris, france collaborative study called for review of archived urinary bladder biopsy specimens with inflammatory lesions for the period - . features consistent with the diagnosis of eosinophilic cystitis were identified in cases, thus positioning it at th place with an incidence of , % from all inflammatory lesions. the distribution of clinical signs manifested in these patients often deceptive of interstitial cystitis or tumor processes is as follows: polakisuria, hematuria, suprapubical pains are evident in / , %/ patients; / , %/ presented with acute obstructive pyelonephritis as a result of bladder wall remodeling and case / , %/ revealed combined features of gastroeneteritis and cystitis. inflammed bladder wall and reduced bladder volume is estimated in / , %/ cases, ulcerations in / , %/ papillomatous and solid pseudotumoral lesions are / , %/ and / , %/ respectively. as all clinical signs are nonspecific, the only way to set a proper diagnosis is through bladder biopsy. morphologic confirmation is based on the standard protocols. histochemical (positive ziehl-neelsen stain) and ultrastructural identification of charcot-leyden's crystals are evident in some cases. adenocarcinoma of the male urethra in association with nephrogenic metaplasia f hostalet , je hernández , ja ruiz , a romero department of pathology, 'vega baja' hospital, orihuela, spain. department of urology, 'vega baja' hospital, orihuela, spain. we describe a case of adenocarcinoma of the urethra associated with so-called nephrogenic metaplasia in a year-old male patient that showed a polypoid tumor of the proximal penile urethra. histopathology examination of the biopsy specimen revealed two distinct patterns. the first showed a tumor composed of papillary fronds and glands lined by columnar epithelial cells with eosinophilic and clear cytoplasm, and contained atypical nuclei with frequent mitotic figures. this tumor was interpreted as adenocarcinoma. the second pattern was different, it consisted of small tubules some with mild cystic changes lying in an edematous stroma. the tubules were lined by a single layer of flattened cells with faintly eosinophilic cytoplasm and bland nuclei, mitotic figures were not identified. this area was interpreted as nephrogenic metaplasia and showed a direct transition into the adenocarcinoma. the immunohistochemical study revealed the presence of low-molecular-weight and some high-molecularweight keratins in both types of lesions. the adenocarcinoma cells also showed nuclear staining for p , in contrast, the cells of nephrogenic metaplasia were negative. the nephrogenic metaplasia as well as the adenocarcinoma cells were not stained with psa and pap. the histogenesis of adenocarcinoma of the lower urinary tract remains unclear. the association and direct transition of the nephrogenic metaplasia into the adenocarcinoma in this case suggest the proposed histogenetic pathway that the urethral adenocarcinoma may arise by malignant transformation of nephrogenic metaplasia. introduction benign prostatic hyperplasia (bph) is associated with a shift in sex hormone balance towards an increase in the oestrogen:androgen ratio. this is accompanied by elevated levels of oestrogen receptor alpha (er), predominantly in the stroma. recently, we described a simple, in vitro model to create moderate upregulation of er in human, prostatic stromal cells. the aim of this study was to investigate the hypothesis that in bph upregulated er and the action of androgens differentially regulate expression of several stromal growth factors. materials and methods eight human, prostatic stromal cell strains were subjected to a procedure to upregulate er alpha by exposing them to micro mol beta-estradiol for days, followed by passage and growth in the absence of steroids. four cell strains received instead n mol of dihydrotestosterone for hr. immunoexpressions of er alpha, ar, and six growth factors (fgf- , fgf- , igf- , tgf-beta , ngf and enos) were quantified by flow cytometry. results expression of er was significantly increased above control ( out of cell strains). expressions of all six growth factors were elevated but not significantly so. however, there was a significant positive correlation between the change in er (expressed as percentage of control) and the change in fgf- and fgf- . exposure of four cell strains to dihydrotestosterone reduced the expression of er and all six growth factors in comparison with oestrogen-treated cells. this reduction was significant for er and fgf- . conclusion upregulated er in prostatic stroma have a greater modulating effect on synthesis of certain growth factors than the direct action of androgens and hence may play a major role in the development of bph. the diagnosis of prostatic adenocarcinoma in needle core biopsy is based on major and supportive criteria. one of the supportive criteria is the presence of retraction clefting around neoplastic glands. the aim of our study was to analyze needle core prostatic biopsies in order to determine the frequency of periacinar clefting spaces in tumors and non-tumorous prostatic tissue. materials and methods we analyzed a consecutive series of prostatic cancer cases diagnosed by needle core biopsy to determine the frequency and extent of periacinar clefting. all tumors consisted of at least neoplastic glands. specimens were fixed in % buffered formaldehyde, embedded in paraffin, cut at µm thickness and routinely stained with hematoxylin and eosin. clefting was analyzed on neoplastic and normal glands in three different high power fields. results one third or more of analyzed glands with clefts affecting more than % of circumference were significantly more common in tumors ( . %) than in benign glands ( %). more strict criterion that designated as positive cases with at least % of neoplastic glands (fifteen out of thirty) with clefts that affected more than % of circumference revealed clefts in the malignant cases only ( . %) but not in benign cases ( %). fifteen or more glands with clefts regardless of their extension were also more prominent in malignant cases ( . %) than in benign cases ( . %). conclusion we conclude that retraction clefting represents a reliable criterion for diagnosis of prostatic adenocarcinoma. analyze the causes of ureteral obstruction in a series of patients managed at the department of urology, timisoara county hospital between and . there were selected only those particular cases of ureteral obstruction, others than cases with lithiasis, stenosis of the ureteropelvic junction and transitional cell carcinoma. an additional case was send for evaluation from another institution was also included in the study. for three of the selected cases we performed additional histochemical (alcian-blue-pas) and immunohistochemical study (anti-ck, anti-psa, anti-vimentin, anti-smooth muscle actin, abc and lsab system, visualization with dab). results we identified cases of ureteral obstruction due to unusual pathological lesions. they occurred in men and women. the mean age of the study group was years (range and years). there were malignant and benign lesions that produced ureteral obstruction. in cases, the compression was extrinsic and only in cases the obstruction was intrinsec. the site of ureteral obstruction was in the lower ureter in cases, in the lower and the middle ureter in patients and in the upper ureter in cases. the pathological lesions were: ureteritis cystica - cases, nephrogenic adenoma of the ureter - case, retroperitoneal fibrosis - case, reproperitoneal sarcoma - case, pelvic endometriosis - case, prostate cancer metastasis - case, signet ring cell carcinoma of the colon invading the ureter - case. conclusions after discarding the more common causes of extrinsic or intrinsic ureteral obstruction, the proliferativemetaplastic lesions of the urothelium, the retroperitoneal fibrosis and sarcoma, the endometriosis and metastatic/invasive carcinoma should be considered in the diagnosis. immunohistochemical study of androgen receptor and tgf alpha in human benign and malignant prostate a petrescu , g berdan , c ardeleanu , v jinga , s persu prof. dr. th. burghele hospital, bucharest, romania victor babes institute, bucharest, romania aims that androgen receptor(ar)and tgf alpha might be prognostic of hormonal response and biological behaviour in prostate carcinoma. methods ar and tgf alpha were studied in paraffin sections from men ( treated for prostate cancer and for bph by open, transurethral prostatectomy or prostate biopsy) no patient had undergone previous treatment for the prostate disease. the sections were stained with he to establish morphological characteristics (gleason score) and then were studied with indirect immunoperoxidase method applying monoclonal antibodies to ar(f . . biogenex) and antitgf alpha (clone , biogenex). results were semiquantified using histoscore.nuclei were graded for intensity of ar staining ( -absent, -weak, -moderate or strong) and the percentage of these intensity levels and a total intensity score were determined. we compared the ar and tgf alpha characteristics of prostate cancer (pca) with bph. results increasing gleason grade was correlated with decreasing intensity score and greater heterogeneity of ar staining and increased (+++) tgf alpha immunoreactivity. conclusions our data indicate that ar and tgf alpha content could be useful predictors of endocrine response and biologocal behaviour of prostate cancer. and ductus deferens samples), patients in group b were orchiectomised for the diagnosis of prostate cancer, teratocarcinoma of the testis and/or epididymal cyst (normal epididymal and ductus deferens samples) and subjects in group c were treated by radical prostatectomy or cystectomy for prostate or urinary bladder cancer ( samples of seminal vesicles without inflammatory changes). results hpv dna was detected in ( %) of patients in group a (hpv types , , , , , ) , in ( . %) patient in group b(at present unclassified type) and in ( . %) patients in group c(hpv types , and ).neither koilocytes nor dysplastic changes were observed. conclusion our data confirmed the presence of hpv, both lowand high-risk types, in the male genital tract. they support the idea of a male reservoir of hpv infection. spermatogenetic function of the testis in patients of different varicocele grades É magyar , e erdei , i lellei national medical center, pathology, budapest, hungary national medical center, andrology, budapest, hungary introduction varicocele is one of the main reasons of male infertility. surgical repair may improve sperm quality. the aim of this study is to investigate a grading system of varicocele and its correlation with the histological appearance using a multiple biopsy method. materials and methods bilateral double testicular biopsies of young infertile grade - varicocele patients were examined histologically. spermatozoa numbers counted in ten round shaped tubules, severity of atrophy and presence of maturation arrest was recorded. distribution pattern of observed spermatozoa numbers was evaluated. results grade and cases showed normal distribution. in grade cases five peaks were found indicating group inhomogenity. lower grade varicoceles presented with milder histological changes (mild atrophy or normal spermatogenesis) while in higher grade varicoceles more marked alterations (moderate-marked atrophy and/or maturation arrest) were seen. conclusion grade varicocele cases represent an inhomogeneous group, which should be divided into more categories. modification of the grading system is required. spermatogenetic activity of varicocelic patients cannot be predicted from clinico-radiological examinations so before art a diagnostic testicular biopsy is recommended. synchronous double urogenital cancer -a case report s we present a case of synchronous double urogenital cancer, comprised of invasive transitional cell carcinoma of the urinary bladder and adenocarcinoma of the prostate. cystoprostatectomy was performed in a -year-old male patient with previous cytological diagnosis of transitional cell carcinoma of the urinary bladder and no evidence of prostatic malignancy on preoperative clinical investigations. gross analysis of the urinary bladder revealed a cauliflower tumor mass filling the entire lumen and infiltrating the wall of the bladder. the size of the prostate was slightly increased. histological analysis of the urinary bladder specimens showed poorly differentiated transitional cell carcinoma, with only a few foci of preserved papillary architecture, infiltrating deeply into the muscle layer of the bladder wall. the specimens taken from the prostate gland for the purpose of staging of the neoplasm excluded the existence of infiltration of the prostatic urethra with the previously described neoplasm, but foci of moderately differentiated adenocarcinoma (gleason score ) of the prostate were discovered in its vicinity. the subsequent extensive sampling of the prostate showed organ confined adenocarcinoma. the review of the literature showed that the reported prevalence of synchronous existence of double primary malignant neoplasms of the urinary tract (transitional cell carcinoma of the bladder and prostatic adenocarcinoma) varies between % and %. the prevalence is noted to rise with increasing age. this leads to a conclusion that during standard cystoprostatectomy analysis, extensive sampling of the prostate is needed, even in the absence of macroscopic changes and preoperative clinical data suggesting prostatic neoplasm. multiple synchronous renal cell tumors d passetchnik rostov state medical university, rostov on don, russian federation rostov regional hospital , rostov on don, russian federation introduction the use of the nephron-sparing surgery demands detection of multiple renal cell tumors. materials we performed a retrospective analysis of nephrectomies and autopsies performed in our clinic. results of renal cell tumors ( , %) were multifocal. most of the patients were men. twelve cases were present where the histological subtype of the largest tumor was clear cell. satellite tumors were clear cell carcinoma ( ), papillary adenoma ( ), angiomyolipoma ( ), renomedullary fibroma ( ), bellini duct carcinoma ( ) . six multiple renal cell tumors were found in t , two in t , four in t a stage of the primary tumors. four patients had bilateral neoplasms. in thirteen cases only multiple papillary adenomas and carcinomas were found. usually tumors were no more than cm in diameter. in six cases multiple tumors originated on a background of nephrosclerosis of various genesis (chronic pyelonephritis, gouty nephropathy, amyloidosis). conclusion when conservative surgery of kidney cancer is performed, it should be remembered that % of patients with renal cell tumor have multiple neoplasms, which may cause local recurrence. the origin of multiple renal cell tumors may be bound up with hereditary predisposition or nephrosclerosis creating multifocal tumor field. introduction prostate cancer is a leading cause of cancer-related deaths in men and is the most common malignancy in american males. the heterogeneity of prostate cancer defines the current clinical challenges. one challenge is to identify in early, still potentially curable, stages of prostate cancer, molecular markers that predict aggressive or metastatic behavior. prostate cancer is characterized, like many other cancers, by molecular and genetics aberrations involving chromosome . parkin, mapped at the long arm of chromosome , is a amino acid protein with a molecular mass of kda, an ubiquitin-like domain at its amino terminus and two ring finger motifs flanking a cysteine-rich region. our aim was to investigated whether parkin alterations play a role in development and progression of prostate carcinoma materials and methods we examined parkin expression, by western blot analysis in eight prostatic carcinomas derived cell lines as well as in normal prostate, and in three prostatic intraepithelial neoplasias (pin) and in twenty primary prostatic carcinomas by immunohistochemistry. results parkin protein was undetectable in six out of eight prostate cancer cell lines tested and barely detectable in the remaining two whereas normal prostate showed a substantial expression. preliminary results using immunohistochemistry showed that parkin expression was absent in pin lesions, and in the prostatic carcinomas analyzed. conclusion our findings suggest that parkin might be a useful tool to detect early alteration in prostate cancer. the kdr/flk- receptor of vascular endothelial growth factor in urothelial bladder cancer: relation with clinicopathologic parameters and patients' survival introduction the impact of different angiogenic inducers and inhibitors in the switch of angiogenesis in urothelial bladder cancer, is not clarified. kdr/flk- is a receptor-tyrosine kinase that binds specifically vascular endothelial growth factor (vegf) on vascular endothelium, mediating its full biologic spectrum. although kdr/flk- expression was at first reported to be restricted to the classic endothelium there is increasing evidence that kdr/flk- is also expressed by normal and tumor cells other than endothelial. aims: as data about kdr/flk- protein in urothelial bladder cancer is very limited, we investigated its expression in a series of urothelial carcinomas in relation with clinicopathologic parameters and patients' survival. moreover, prompted by studies suggesting that kdr/flk- may have broader functions apart from angiogenesis we evaluated kdr/flk- expression in relation with markers of cellular proliferation and apoptosis (ki- , p , bcl- ). materials and methods immunohistochemistry (abc-hrp) was performed for the detection of kdr/flk- (mouse/a- , sc- , santa cruz), ki- , p and bcl- using monoclonal and polyclonal antibodies. statistical analysis was univariate (pearson's x , mann-whitney test, log-rank test) and multivariate (cox's model). results kdr/flk- expression was observed in the cytoplasm of cancerous cells in / cases. no significant associations were observed between kdr/flk- expression and clinicopathologic parameters, ki- , p and bcl- expressions. on the other hand, widespread kdr/flk- expression in more than % of cancerous cells, was associated with patients' increased survival, in univariate and multivariate analysis (p= . , p= . , respectively). conclusion although non endothelial kdr/flk- expression has not yet been elucidated, its association with better patients' survival may be related with the failure of non-endothelial kdr/flk- to mediate angiogenic and mitogenic effects, that has been reported in some previous in vitro studies. timp- protein expression in relation with cellular proliferation, apoptosis and survival of urothelial bladder cancer patients introduction the role of tissue inhibitors of matrix metalloproteinase (timps) in cancer progression remains a controversial matter since apart from the well established inhibitory action of timps on mmps, several new functions are now attributing to timps such as growth promoting activity, involvement in apoptosis control and in angiogenesis. the aim of this study was to elucidate the role of timp- in urothelial bladder cancer, we investigated its expression in a series of urothelial carcinomas in relation to clinicopathological parameters, patients' survival and the expression of the ki- proliferation index. materials and methods immunohistochemistry (abc-hrp) was performed for the detection of timp- and ki- proteins, using monoclonal and polyclonal antibodies. statistical analysis was univariate and multivariate. results timp- stromal cell expression was observed in / cases and associated significantly with urothelial carcinomas of high histologic grade (p< . ) and advanced stage (p= . ) as well as with poor patients' survival (p= . ). timp- expression in cancerous cells was found in / cases. timp- either stromal or cancerous cell expression correlated significantly with ki- expression (p= . , p= . respectively). conclusion the association of timp- with ki- supports the growth promoting activity of timp- . moreover, timp- expression in stromal cells may be a valuable marker of adverse prognosis in urothelial cancer patients. gleason score is important predictor for differentiation and biological potential of prostate cancer. nodenegative (p n ) prostate cancer is the best result after radical prostatectomy which is indicated in patients with localised prostate cancer. the aim of the study was to analyze gleason score in patients with nodal metastases of prostate cancer (pc). material and methods we analyzed cases of radical prostatectomies due to localised prostate cancer in the period - in clinic of urology in clinical centre of serbia, belgrade. nodal metastases (stage of disease), average age of the patients, grade and gleason score of tumors and premalignant lesions were analysed. immunohistochemical staining was performed and pathological analyzed. we used statistical analysis anova and h test. results the average age of the patients was . years (range - , pick - ). most cases ( %, p< . ) were in pt a n m , in pt b n m ( . %), in pt bn m ( . %), in pt bn m ( . %), in pt an m ( . %). positive nodal status was present in cases: ( %) in pt bn m -iliac (right , left ), obturatory (right l, left ) and cases in pt bn m -iliac left and obturatory ( right and left). we found gleason score in cases ( . %) in pt bn m versus cases ( . %) without nodal metastases. gleason score was found in cases ( . %) in pt bn m versus one case without nodal metastases (p> . ). gleason score was present in . %, in . %, in . %, in . %, in . %. grade tumors were found in cases ( %), grade in ( %), and grade in ( %). hg pin was present in cases ( . %), lg pin in ( . %). conclusion gleason score differ, but not significantly in prostate cancer with nodal metastases. pelvic lymphadenectomy is necessary for staging purposes in prostate cancer. radical prostatectomy is the most adequate method in surgical treatment of localised prostate cancer. immunohistochemical and molecular evaluation of c-erbb gene amplification and c-erbb protein overexpression in prostate cancer the amplification of oncogene c-erbb and overexpression of c-erbb protein found in some human cancers is associated with more aggressive development of tumor. the previous data suggested an independent role of c-erbb protein as a prognostic factor in human breast cancer. however, the role of c-erbb gene and its protein product in prostate cancer cells still remain unclear. the aim of our study is to show what is the role of c-erbb protein in prostate cancer and to examine association between c-erbb gene amplification and its protein product expression in the histologicaly graded prostate tumor. we have analyzed c-erbb gene amplification by rt pcr and c-erbb protein expression by immunohistochemistry in cases of paraffin embedded slides. the tumors were divided according to who by mostofi classification: cases of g -well differentiated cancer; cases of g -moderately differentiated cancer; and cases of g poorly differentiate cancer. these groups are equivalent to - , - and - gleason classification respectively. results the correlation between c-erbb protein expression and well, moderately and poorly differentiated cancer respectively existed (p< . ). there was no significant correlation between c-erbb gene amplification and c-erbb protein expression in all examined groups. our results suggest that the c-erbb protein expression is an independent factor on the c-erbb gene amplification in prostate cancer cells. it is possible that there are other ways, except gene amplification, for overexpression of c-erbb protein in prostate cancer. comparison of needle biopsy and surgical specimen in prostatic carcinoma s nordling, j vasama department of pathology, university of helsinki, helsinki, finland in finland carcinoma of the prostate is the most common form of cancer in men. the number of radical prostatectomies is increasing in most countries. the radical prostatectomy is normally preceeded by a needle biopsy. at the university central hospital of helsinki radical prostatectomies were performed between and . in patients, the preoperative needle biopsy was available. in many cases the preoperative psa value was also available. the mean psa value dropped from to less than ng/ml. the percentage of seminal vesicle invasion dropped from to . except for the earlier years, the men gleason score was about point higher in the radical prostatectomy specimen than in the biopsy. the mean gleason score has increased, while the stage and psa values have decreased indicating that the criteria for the gleason grading has changed ovewr the years. this makes the comparison of treatment results very difficult. introduction distinguishing atypical adenomatous hyperplasia (aah) from small foci of prostatic adenocarcinoma in needle biopsies of the prostate often presents as a challenge for pathologists. the aim of the study was to establish characteristic immunohistochemical patterns in benign and malignant prostatic lesions so they can be used to classify foci of aah as benign or malignant. materials and methods using immunohistochemistry, prostatic needle biopsies from forty-five patients were evaluated for cytokeratin , p and alpha-methylacyl-coa racemase (p s). twenty-five of these biopsies were benign and twenty contained prostatic adenocarcinoma. results % of the benign prostatic biopsies were positive for cytokeratin and p and % were negative for p s. only one case of benign prostatic tissue was focally positive for p s. when evaluating cases with adenocarcinoma % were positive for p s and % were negative for cytokeratin and p . p s immunostain showed consistently positive staining in areas of low and intermediate grade adenocarcinoma and areas with high grade pin. high-grade prostatic adenocarcinoma was frequently negative for p s. sensitivity and specificity for cytokeratin /p were % and % while sensitivity and specificity for p s were % and %. conclusion cytokeratin was as sensitive and as specific as p and can be used interchangeably in cases of aah. the combination of the two antibodies did not improve sensitivity or specificity. a combination of negative cytokeratin or p with positive p s may be helpful in positively identifying prostatic carcinoma in cases of aah. myofibroblastic stromal reaction in prostatic adenocarcinoma introduction reactive stromal changes that occur in different human cancers probably are involved in local tumor spreading and progression. it seems that myofibroblast plays very important role in stromal reaction to certain types of human cancer. we have analyzed prostatic carcinomas in radical prostatectomy specimens to determine the proportion of myofibroblasts around normal and neoplastic acini. myofibroblast showed positive staining for alpha-smooth muscle actin (sma) and vimentin. positive cells were counted in the hot spots areas under high power magnification (hpf). results were expressed as negative (-) for no staining, (+) for positive staining in up to % of stromal cells, (++) in - % of cells and (+++) for more than % of positive cells. stromal blood vessels were counted in ten hpf. the degree of desmoplasia was also analyzed by mallory staining and expressed semiquantitatively as weak, moderate and strong. results and conclusions highly increased number of myofibroblast was observed around neoplastic acini in ( . %) cancer cases, moderate in ( . %) and sparse in ( . %) cases while there were occasional myofibroblastic cells adjacent to normal acini. there was a positive correlation between the degree of stromal desmoplasia and the proportion of sma and vimentin positive cells in adjacent stroma. the number of vessels in the adjacent stroma was also significantly increased in comparison with normal glands (p< . ). it seems that myofibroblasts are present in the stroma and may play a significant role in the desmoplastic stromal reaction in prostatic adenocarcinoma. results among the srcc, ( %) showed no epithelial differentiation, and in the other cases the epithelial component was conventional rcc in cases ( %), papillary ccr in ( %), and chromophobe rcc in ( %). there was no sex predominance and the average patient age at the time of diagnose was years. sixteen cases ( %) presented an advanced stage at the time of diagnose, and ( %) died of disease. the immunohistochemical study showed that cases were positive for c-kit ( . %), diffusely (> % of the sarcomatoid cells positive), moderately ( - % of the cells), and focally (< % of the cells). conclusion the high expression of c-kit in srcc in our series and the existence of target therapy against cells expressing this marker (imatinib (sti- , gleevec, novartis, basel, switzerland) suggests its potential use in the clinical management of these patients in order to improve their prognosis, especially in disseminated cases. does hpv play a role in the development of bladder tcc? a comparison of pcr and immunohistochemical detection methods the role of human papilloma virus (hpv) in the development of bladder carcinomas remains controversial. varying techniques have been used to identify this virus in transitional cell carcinoma (tcc). here we used two different methods to detect the presence of mucosal hpv in tcc samples. the first, immunohistochemistry, involved using a polyclonal antibody that reacts with the l capsid protein of most known papilloma viruses. the second method is used on a general primer-mediated polymerase chain reaction (pcr) assay. this involves using type-specific oligonucleotide probes to identify different mucosal hpv genotypes from a bp pcr product from the l region of the hpv genome. the two methods produced contrasting results, % of the samples were positive for hpv antigen and % were positive for hpv dna. the reason for such conflicting results is that polyclonal antibodies are not specific and are likely to cross react with other antigens. pcr is specific, more sensitive, and it is widely used to detect hpv in a variety of clinical samples. the results obtained in our study implies that hpv does not play a role in the development of bladder carcinoma, and pcr remains to be the best method to detect hpv in tcc. does tgf-α prevent carcinoma spreading? o gladskikh introduction most human carcinomas including prostate cancer are associated with stromal reaction typified by changes in growth factor expression and over-accumulation of extracellular matrix. our study deals with the differential tgf-α production in neoplastic focuses and in adjacent paraneoplastic stroma in prostate. materials and methods tissue samples from radical prostatectomies were examined. to verify malignant material or benign the immunohistochemical staining against high molecular weight cytokeratin was performed on sections and in heterogeneous primary cultures of the same specimens. the immunohistochemical identification of tgf-α was also performed. the elisa technique for quantitative analysis of tgf-α soluble form in culture supernatants was applied. results majority of selected cancer cases were histologically estimated as small-sized glands with large desmoplastic fibromuscular stroma. the immunohistochemical staining for tgf-α in malignant focuses was much more significant than in neighbouring benign areas on sections in contrast to, the cultures obtained from neoplastic or paraneoplastic portions of prostate tissue which stained positively for tgf-α without any difference. considering that immunohistochemistry shows only latent tgf-α we evaluated its bioactive form in culture supernatans. we found dramatically high supernatant levels of active tgf-α in benign cultures compared to the cultures from the malignant areas. conclusion our data demonstrate that desmoplastic alterations in benign areas adjacent to malignant glands was associated with elevated expression of tgf-α active form. so significant alteration in factor production and accompanied tissue remodeling can be considered as a protective reaction of surrounding stroma against tumor invasion. introduction primitive neuroectodermal tumors (pnets) represent a family of neoplasms, of presumed neuroectodermal origin, that mostly presenting as bone or soft tissue masses in the trunk or axial skeleton in adolescents and young adults. the aim of this study was to report a case of pnet arising from kidney which is a rare localization. methods a year-old-man presented with abdominal pain and abdominal mass. the imaging methods revealed a mass nearly replacing the right kidney and he underwent a right nephrectomy. on gross examination the tumor measured cmx cm with cystic areas and necrosis. microscopically, it was a highly cellular neoplasm of consisting sheets of small-round-to-oval cells with irregular nuclei. immunohistochemical stains were positive for vimentin and cd . microscopic and immunohistochemical findings were compatible with pnet. conclusion although rare, pnet must be included in the differential diagnosis of renal tumors especially in children and young adults. we present a case of renal pnet as an unusual case and discuss the differential diagnosis pathologic stage of urinary bladder cancer at presentation in a non-selected patient population in a high-incidence region of the united states introduction most studies of pathologic stage in bladder cancer (ca) are retrospective, using selected, usually hospital-based, patient populations. the aim of this study was to determine the pathologic stage of bladder ca at initial presentation in a nonselected patient population in a high-incidence region of the northeastern united states. materials and methods all patients newly presenting with bladder ca in the state of new hampshire (u.s.a.) from july to december were identified through the state tumor registry. slides were classified according to who and isup criteria. results of cases, were diagnosed as non-malignant or technically inevaluable, leaving ca cases. ( . %) were carcinoma-in-situ (stage tis). ( . %) were papillary, of which ( . %) were low-grade and ( . %) high-grade. of the low-grade cases, only ( . %) were invasive, all limited to lamina propria (stage t ). of the high-grade cases, ( . %) were noninvasive (stage ta), ( . %) invaded lamina propria (stage t ), and ( . %) invaded muscle (stage ). cases ( . %) had no papillary component and all were invasive; ( . %) were stage t and ( . %) were stage t . cases ( . %) were nonurothelial, including squamous cell ca, small cell ca, and adenoca; of these presented as stage t and as stage t . overall, cases ( . %) were invasive (at least t ) at the time of presentation. this population-based series establishes the distribution of bladder tumor stage at initial presentation and documents a smaller percentage of invasive cancers than most hospital-based series the relationship between mitotic index and nucleolar organizer region with histologic grade in transitional cell carcinoma of urinary bladder mr jalali nadoushan, t rezaei nour, n fallah, sk foroutan shahed university, tehran islamic republic of iran background and object transitional cell carcinoma (tcc) of urinary bladder is the second most common cancer of the genitourinary tract, that the prognosis and treatment is related to several parameters such as proliferative cell markers. in this study relationship between two proliferative cell markers: -mitotic index(mi)& -agnor and tumor grade were studied. methods and materials in a cross sectional descriptive study paraffin blocks of patients with tcc of the urinary bladder in the period from to from pathology department of shahid mostafa khomeini hospital, were obtained and from each one micron sections were provided. tumor grade on basis of who/isup grading system, was determined and number of mitosis on tumor cells were counted. in the other section, after one-step silver nitrate staining, the number of nor also on tumoral cells were counted and the mean of it in each cell were determined. results the high grade tumors possessed more agnor per nucleus than did the low grade ones. significant relationship between tumor grade and mi (p= . , rs= . ) and agnor (p= . , rs= . ), and also between mi and agnor (p= . , rs= . ) were found. introduction the human epidermal growth factor receptor (her ) is overexpressed not only in breast, but in a range of other tumor types including, ovarian, salivary gland, endometrial, pancreatic, non-small cell lung (nsclc) and bladder cancer. however, non-standardisation in her status evaluation or population selection has generated conflicting results among the incidences of her expression in individual tumor types and bladder cancer. the aim of the present study was to evaluate her overexpression and gene amplification with standardized routinely performed assays (dako herceptest, fish-vysis, cish) on a selected population of poorly differentiated urothelial carcinomas of the bladder. materials and methods we analyzed formalin-fixed, paraffin embedded tissue samples of urothelial carcinomas of the bladder at g /pt - as well as cases at g / ptis ( )and pta- ( ) using herceptest to verify the her -status. staining and scoring was performed according to the manufacturers instructions. according to diagnosis of her , all herceptest positive ( +) tissue samples were used for further evaluation with fluorescence in situ hybridisation (fish; vysis) and chromogenic in situ hybridisation (cish) to approve the expected gene amplification. this procedure is in agreement with the standardized guidelines for breast cancer. results ( %) cases were considered as her positive ( + and +) in the primary tumor and therefrom cases ( %) + positive and cases ( %) + positive. out of the cases with + positivity, only two cases showed a fish/cish positivity. no polysomy for chromosome was detected. our results indicate that her may not only be a useful prognostic parameter in poorly differentiated invasive bladder cancer, but accurate determination of overexpression and verification of gene amplification may also have therapeutic importance. the prognostic importance of tumor volume (tv), nontumor volume (ntv), tv/ntv, fibronectin distribution, β-hcg and psa expression in localized prostatic adenocarcinoma bh ozdemir, an sar, fp uyar, b demirhan, a dirim baskent university, faculty of medicine, departments of pathology and urology, ankara, turkey aim to assess the importance of fibronectin (fn) distribution, β-hcg and psa expression in localized prostatic adenocarcinomas with regard to tumor volume (tv), non-tumoral volume (ntv), tv/ntv and with other clinicopathological prognostic parameters. material and method fifty-one radical prostatectomies were whole mounted, serially sectioned and examined for tv, ntv, tv/ntv, capsular invasion, vascular invasion, seminal vesicle invasion and gleason score. the fn distribution, β-hcg and psa expression were examined immunohistochemically. a fn-positive staining was defined as a constant diffuse, or pericellular demarcation of fn-positive fibers surrounding tumor cells at the invasive border. in lack of such staining pattern, fn-negative staining was recorded. results both tv and tv/ntv showed very strong positive correlation with grade, capsular invasion, vascular invasion, seminal vesicle invasion, β-hcg and psa expression (p< . ). β-hcg was detected only in cases ( . %). a significant relationship was found between β-hcg expression and grade, capsular invasion, vascular invasion, seminal vesicle invasion, psa expression (p< . ). the fn-positive staining reaction was significantly associated with lower incidence of capsular, and seminal vesicle invasion (p< . ). tv and grade was found higher in tumors with negative fn staining (p< . ). psa expression showed significant relationship with grade, vascular and capsular invasion (p< . ). ntv statistically showed no relationship with all parameters. conclusion these data suggest that, tv, tv/ntv, fn distribution, β-hcg and psa expression in prostatic adenocarcinoma have strong prognostic importance irrespective of gleason score. the fn distribution could be important for the invasion of the tumor cells during cancer progression. these may allow stratification of patients to type of treatment and may allow selection of expectant management for men with localized prostatic adenocarcinoma. neuroendocrine differentiation in prostate cancer: correlation with biochemical failure after radical prostatectomy s cerovic introduction focal neuroendocrine differenatiation (ned) is a commom feature of prostate cancer (pc), occuring in %- % tumors studied. published results of the evaluation of ned as a prognostic factor in pc after radical prostatectomy (rp) have been contradictory. the aim of this study was to correlate ned in pc in relation to biochemical failure after rp. materials and methods radical prostatectomy specimens from pc patients without preoperative hormonal or radiation therapy were followed for to months. neuroendocrine (ne) cells were identified using a panel of immunohistochemical ne markers: chromogranin a, serotonin, and neuron-specific enolase. ned was scored as ne-negative ( to +) or ne-positive ( to +) per hpf. biochemical progression (bp) was defined as a prostate-specific antigen (psa) level greater than . ng/ml in two consecutive measurements. kaplan-meier method was used to estimate bp-free survival time for each risk group. the cox proportional hazards regression analysis was the model for bp time using pathological and clinical variables. results the total of ( %) patients developed bp after rp. the average time for bp was months. the preoperative psa serum level range < ng/ml in % of the patients. postoperative staging confirmed that ( %) of patients had pt stage and ( %) of patients had pt stage. ned demonstrated in the ( %) pc patient with bp. the average time for bp was months. tumor volume (p< . ), pathological stage (p < . ), tertiary gleason grade (p= . ) and nedf (p< . ) significantly affect the level of postoperative psa progression. conclusion the expression of ned in pc correlates with tumor volume and tertiary gleason grade and represents an independent prognostic factor of bp after rp. expression of vascular endothelial growth factor (vegf) and correlation with microvessel density in benign hyperplasia and prostate carcinoma nj aim the present study is scheduled to evaluate the levels of vegf expression in benign prostatic hyperplasia (bph) and prostate carcinoma and to correlate them with angiogenesis. material and method formalin-fixed, paraffin-embedded tissue sections from patients who underwent radical prostatectomy or transurethral resection of the prostate were studied. our material consisted of cases of bph and cases of prostate carcinoma. microvessel density (mvd), as determined by cd , and expression of vegf were investigated by immunohistochemistry using the monoclonal antibodies cd (dako) and vegf (neomarkers), respectively. results expression of vegf was detected in / ( , %) cases of bph and in all ( %) invasive prostate carcinomas. cytoplasmic immunoreactivity for vegf was detected in epithelial and stromal cells. vegf expression was stronger in carcinomas, when compared to bph (p< . ), while it was minimal to absent in normal adjacent prostate tissue. a positive correlation between vegf expression and gleason score was found (p< . ). microvessel density (mvd) was higher in bph and prostate carcinomas, when compared to normal adjacent prostate tissue. a statistically significant association was noted between vegf and mvd expression (p< . ). our results indicate that generation of new capillary blood vessels begins in bph and keeps progressing in invasive prostate carcinoma. vegf seems to be a key functional regulator of angiogenesis in the prostate gland. the relationship between histologic grade and abo blood groups in transitional cell carcinoma of the urinary bladder b mofid , mr jalali nadoushan shahid beheshti university of medical sciences, tehran, islamic republic of iran shahed university, tehran, islamic republic of iran introduction according to the statistics of , the urinary bladder cancer is the fifth common cancer in iran. the majority of urinary bladder tumors are transitional cell carcinomas. different factors are effective in the prognosis of these patients. one of these factors is the histologic grade. another factor is to determine the abo blood groups and the relationship of it with the histologic grade. thus, this study is conducted to shed some lights on this issue. materials and methods a cross sectional study was conducted in patients with urinary bladder transitional cell carcinoma during - . results of patients, were female ( . %) and were male( . %). the mean age of patients was . +/- . there was no significant statistical relationship between of histologic grade and abo blood groups. there was no significant differences between the abo blood groups frequency in patients with urinary bladder transitional cell carcinoma and general population. conclusion although the existing differences between asian, european and american studies might be due to racial effects, it is better to carry out more studies in this respect in order to comment in this area with more confidence and certainty. introduction a variable degree of mucin secretion may be present in prostatic carcinoma (pc), but true mucinous tumors are rare. prostatic mucinous carcinoma (pmc) is a variant of high-grade adenocarcinoma, with a . % rate of prostate-specific antigen (psa) elevation and a similar rate of response to endocrine therapy. the aim of this study was to report on a case of pmc with signet ring cells treated with radical prostatectomy (rp). materials and methods a -year-old man presented with acute urinary retention and long history of difficult voiding. the serum psa was . ng/ml. the transperineal biopsy of the prostate gland was done and the histology showed a poorly differentiated pc with large lakes of extracellular mucins. isotope bone scan was normal and a ct-scan did not show evidence of extracapsular spread of the tumour. radical prostatectomy was performed. patient died seven month after rp. results histopathologically, over % of the prostate samples were infiltrated by a poorly differentiated pc with mucinous and signet ring patterns. mucin secretion is evident as large pools of mucin and periodic-acid-schiff-positive diastase-resistant intraluminal and citoplasmic globules. immunohistochemical staining for psa and prostate-specific-acid phosphatase was positive, and negative for carcinoembryonic antigen and cytokeratin . conclusion the diagnosis of pmc with signet ring cells requires exclusion of an extra-prostatic origin, mainly within digestive tract. since only small number of mpc cases treated with rp have been reported, treatment and prognosis of this tumour remain unclear. introduction cd is a well-known marker for hematolymphoid neoplasms and is expressed as well in various nonhematopoietic tissues and solid tumors. a systematic study of cd expression in tgcts, however, is lacking. the aim of this study was to investigate the immunoreactivity for cd in the different patterns of tgcts. material and methods immunostaining with mab against cd (clone c ) in unselected cases of primary ( cases: classical seminoma (cs); pure embryonal carcinoma (ec); mixed-non-seminomas; spermatocytic seminoma (ss) and metastatic ( cases) tgcts. in mixed tumors, the different histological patterns were evaluated separately. results cd was expressed in ( %) out of cases in the cs component, in ( %) of teratomas, in ( %) of endodermal sinus tumors (est), in ( %) of cases of choriocarcinoma (chc) or syncytiotrophoblastic giant cells (stgc) and in ( %) of ec. cd was focally positive in ( %) of cases of intratubular germ cell neoplasia (itgcn) and was negative in one ss. conclusions except for ec and ss, cd is expressed in the majority of histological types of primary and metastatic tgcts. cd is useful to highlight minute foci of est, chc or stgc in ec. a tgct is to be taken into account in the differential diagnosis of a cd positive metastatic tumor of unknown origin. further studies are needed to evaluate the eventual significance of cd as a prognostic factor or as a potential therapeutic target in tgcts. introduction it is generally accepted that the prognosis of renal cell carcinoma (rcc) differs according to the histological type, and, whatever the histological type, the tumor stage and nuclear grade are considered the main prognostic factors. however, in many cases of conventional renal cell carcinomas (crcc), these parameters are insufficient to predict the clinical behaviour of these tumors. therefore, several studies have focused on the evaluation of new markers. the cd proteins form a broadly distributed family of cell surface adhesion molecules involved in cell-cell and cell-matrix interactions. de novo expression of cd s and its variant isoforms has been associated with aggressive behaviour in various tumours. the aim of this study was to analyse the prognostic value of cd s and cd v in renal cell carcinoma. materials and methods the expression of cd s and cd v was immunohistochemically evaluated on rcc: were crcc, papillary, cromophobe and collecting duct carcinoma. the expression was compared to usual clinicopathological parameters. results in normal renal tissue no staining was observed. the cd s molecule was upregulated in crcc ( %), papillary, one cromophobe and collecting duct carcinoma. only tumors were focally cd v positive. the statistical analysis showed the correlation between cd s expression and fuhrman nuclear grade (p< , ) as well as ki proliferative index (p< , ). conclusion the expression of cd s molecule appears to mediate a more agressive phenotype to rcc. amplification of cerbb expression in bone metastasis of prostatic cancer: a pilot immunohistochemical and cytogenetic study introduction her- -neu expression is reported to increase in androgen-independent prostatic cancer. consequently, it has been suggested that trastuzumab, an antibody targeting the extracellular domain of her- , could be used in this setting. the possibility of assessing her- expression by immunohistochemistry could be used as a rationale for the treatment of advanced cases with this drug. the aim of this study was to assess whether her- expression is increased in bone metastases of prostatic cancer compared to the respective primitive tumors, and to determine whether this overexpression could be related to gene amplification. materials and methods in this pilot study, primary tumor needle biopsies and bone metastases from patients diagnosed with prostatic cancer were immunostained wit c-erb-b antibody (dako, glostrup, denmark), and the results scored using a threetiered system. in addition, in a bone marrow sample from one of the cases, her gene amplification was investigated using fish. results there was a significant increase in her- expression in four cases, with the same level of expression in primary and metastatic tumors in the remaining three patients. in addition, fish showed no amplification of her gene. conclusion her- overexpression is not a constant event in prostate cancer metastatic to bone. preliminary evidence suggests that in cases with overexpression, it is not related to gene amplification. a larger study will be required, however, to definitively determine the real therapeutic meaning of these findings. introduction sgs are known to occur in association with a variety of hematologic and solid neoplasms. concerning rcc-associated sgs, only isolated case reports have been published. the aim of this study was to disclose the prevalence and clinical significance of sgs in a series of rccs from a single institution. clinicopathologic review of consecutive cases of rcc surgically treated at the hub between january- and march- . immunohistochemical staining with cd , panb and pant antibodies. results sgs were seen in cases, both within the tumor and/or in the nontumor tissue nearby. patients were females and males aged to (median ) years. tumors were conventional clear cell rccs and chromophobe rccs. there were pt , one pt and one pt b. two tumors were fuhrman grade and were grade . in each case, the lymphocytes in the sgs were predominantly t cells. one patient was already known to have a crest syndrome. in another one sarcoidosis was subsequently diagnosed. in the remaining no systemic disease has been found to date. conclusions sgs are found in about . % of rccs. morphology and immunohistochemistry allow no distinction between local sarcoid-like reactions and sarcoidosis. the clinical profile of the patients and the pathologic features of the tumors are not different from those of rccs unassociated with sgs. the finding of tumorassociated sgs must be reported to the clinicians in order to rule out a systemic granulomatous disease, thus avoiding misinterpretation of clinical symptoms or overstaging of tumors. metanephric adenoma in the kidney coexistent with paraganglioma in the bladder: a case report s seckin, i paker ankara numune teaching and education hospital, department of pathology, ankara, turkey we report a case of metanephric adenoma in the kidney and paraganglioma in the bladder in a year-old woman. the patient presented with hematuria. abdominal usg and bt revealed a mass in the lower pole of the kidney and in the posterior wall of the bladder. left nephrectomy and transurethral resection of the mass in the bladder were performed. the tumor in the kidney which measured x x cm. had a yellow to white cut-surface and welldefined margin. histological examination demonstrated a monomorphous population of small cells with bland cytology arranged generally in tubular and occasionally in papillary structures. no atypia and mitotic activity were present. immunohistochemically tumor was diffusely positive for ema, focally positive for pancytokeratin and negative for vimentin. the tumor in the bladder was characterized by well-defined nests of cuboidal cells with granular cytoplasm which were seperated by highly vascularized fibrous septa. sustentacular cells were demonstrated with anti-s protein immunohistochemically. we didn't encounter the coexistence of these two tumors in the literature. we think that it is a coinsidence. co-occurrence of extra-adrenal myelolipoma, renal cell carcinoma and thymoma -a case report k steplewska, d sabat, w zajecki department of pathomorphology, medical university of silesia, zabrze, poland a case of never reported in literature of co-occurrence of a very rare tumour -extra-adrenal myelolipoma (eaml) with two other neoplasms, was presented in the report. -year man after a short hospital stay due to heart ischaemic disease died with the symptoms of acute circulatory insufficiency. an autopsy, which confirmed clinical diagnosis, was performed. a tumour of the size x x cm, which compressed the heart and aorta, was found during the mediastinum autopsy. the tumour was covered with a sack, lobular, gray and beige at the cross-section with blood extravasation, necrosis foci and calcifications (histopathologic result -medullary thymoma). the compressed heart was moved to the middle, right side of the chest. in the adipose capsule of the left kidney, near the lower pole, an encapsulated solid fatty tumour of the size x x cm was found. the tumour was connected to the kidney. histopathologic result -myelolipoma. the tumour was composed of fat cells with normal marrow hematopoietic elements including megakaryocytes. the third tumour, cm of diameter, was found on the front surface of the right kidney (histopathologic result -multilocular cystic clear cell, renal cell carcinoma). none of the tumours was diagnosed during the patient's life. signet ring cell carcinoma of the prostate: pathologic and immunohistochemical analysis of two cases m kowanski, t zabkowski military medical institiute, warsaw, poland introduction signet ring cell carcinoma of the prostate is extremely rare and was first described by giltman in . to date, there have been cases reported in the literature. we evaluated two cases formaline fixed paraffine embedded tissue by histochemical (mucicarmine, alcian blue) and immunohistochemical methods (psa, psap) to confirm our histological diagnosis. results both our cases were high grade adenocarcinomas gleason score ( + ) and were positive for psa and psap. one case contain a small amount of acid mucin, but both were negative for neutral mucin. the combined results from our and from previously reported cases: psa positive in . % ( / ), mucicarmine stain positive in . % ( / ) and alcian blue stain positive in . % ( / ) of cases. conclusion signet ring cell carcinoma is variant of high grade adenocarcinoma of the prostate but results of histochemical and immunohistochemical staining are variable. the isup classification of urothelial tumors was followed by a modified who classification in . the purpose of this study has been to assess the value of both systems in the prediction of progression, in a large series of cases with detailed follow-up. material and methods "superficial" (pta + pt ) urinary bladder tumors are the subject of this work. all tumors were reassessed strictly adhering to published criteria. progression (increased grade or stage) was used as the end-point. results with a relative risk (rr) of for g , progression rr for g was . ( . - . ) and for g . ( . - . ) (p< . ). with a risk of for pta, rr for pt was . ( . - . ) and for pt . ( . - . ) (p< . ). when combining grade and stage, rr for pta (g + ) was . ( . - . ) and for pt (g + ) was . ( . - . ) (p< . ). conclusions strictly adhering to the who grading and staging criteria, both systems result in a very efficient prediction of progression of urothelial carcinoma. grouping g and g into a single high grade category does not improve these results. "superficial" infiltration (pt ) introduces a relevant risk of progression when restrictively identified, thus suggesting that pt should not be lumped with pta for therapeutic purposes. neuroendocrine expression in prostate cancer l velickovic , v katic , v savic , b djordjevic , s zivkovic institute of pathology, nis, serbia and montenegro military hospital, department of surgery, nis, serbia and montenegro introduction presence of neuroendocrine (ne) cells that are suggested to be important regulators of cell growth and differentiation represents uncommon finding in benign and neoplastic prostate epithelium. in order to correlate cellular expression with histological differentiation in benign epithelium and primary prostate cancer, expression of chromogranin a (cga) had been determined. materials and methods he and immunohistochemical analysis with antibody against cga was performed in order to determine the coexistence of ne differentiation in tissues of twelve patients with prostatic adenocarcinoma (pc). results ne differentiation was found in ( , %) tumors. among them, ( , %) had cga positive cells scattered or focally distributed, ( %) intermediated and intensive. there was a significant correlation between the extent of ne features and gleason score (p< , ). these data support the concept that ne differentiation in human prostate cancer has a positive correlation with histological differentiation, i.e. patients with gleason score > had higher cellular expression of cga. the p retinoblatoma gene protein and p expression in transitional cell tumors s ramón y cajal , c corbacho , v fernández, j guinea, c parada, r sánchez hospital vall d´hebron, madrid, spain clínica puerta de hierro. madrid, spain background the retinoblastoma family of proteins (p , p and p ) are implicated in cell cycle regulation, differentiation and apoptosis. p (retinoblastoma supressor gene) alterations seem to be correlated with worse prognosis in urothelial neoplasms, and the status of the other two proteins has been less studied. p mutations are usually associated with intranuclear accumulation of p protein, and have also been correlated with worse prognosis in urothelial neoplasms. design formalin-fixed, paraffin-embedded archival tissue from low-grade and high-grade transitional tumors was immunostained with polyclonal and monoclonal antibodies against the retinoblastoma family of proteins, and with monoclonal antibody against p protein. the avidin-biotin-peroxidase (abc) method was utilized with every antibody (dako, clone rb for p ; santa cruz, clone sc- for p ; santa cruz, clone sc- for p and dako, clone do- for p ). immunostaining was scored quantitatively by pathologists, following previously described criteria, to study p , p and p . nuclear and/or cytoplasmic location was determined by pathologists to study p . results p expression: among low-grade tumors, ( . %) showed nuclear positivity and ( . %) showed a granular cytoplasmic pattern of staining. among high-grade tumors, ( . %) showed nuclear expression and ( . %) showed a granular pattern of staining. p expression: among low-grade tumors, ( . %) showed positivity and among high-grade tumors, ( . %) stained positively. we found no stadistically significative differences regarding p and p immunohistochemical stainings. conclusion due to granular cytoplasmic pattern of staining for p is more frequent among high-grade transitional neoplasms, we propose that p granular cytoplasmic immunohistochemical pattern of staining may be considered a marker of tumor progression in transitional cell tumors. the prognostic value of p cytoplasmic positivity among low grade cases, as well as the prognosis of tumors with p overexpression and p granular cytoplasmic pattern will be discussed. are there any relationship between bellini duct carcinoma and urothelial cell carcinoma? ( ) aexudative -at , productive -at , and mixed -at ., from them ( ) infiltrative -at and destructive -at patients, aexudative type of inflammation was also diagnosed at patients with nonspecific defeat of prostata. patomorfological data's not always can help in diagnostic of tuberculosis of prostate it ties with patomorfose of tuberculosis under influence of treatment. cancerogenesis in prostate: ploidometric differential diagnostics avtandilov background the problem of unification in diagnostics of various prostate tumours and tumour-like lesions has gained a special significance in the modern oncology. aim: use the ploidometry research for studying the epithelial cell clones in the prostate, forming the different stages of cancerogenesis. methods computer ploidometry test was carried out for nuclei of epithelial cells in biopsy specimen of the prostate, taken from patients in different stages of cancerogenesis. histological preparations of micron thickness, stained by feulgen's technique, were subject of the research. nuclei's ploidy was defined by means of the computer image analyzer "imager-ch" ("avtan-san" software version). the integral brightness of nuclei of small lymphocytes, found in histological sections, was tested to define the "tissue ploidy standard" ( c), which, in its turn, was used for obtaining the data on ploidy of epithelial cell nuclei of the prostate gland. inter-phase cell nuclei of clones with normal and hyperplastic prostate gland, areas of prostate intraepithelial neoplasia (pin-i-low grade -and pin-ii-high grade) and adenocarcinoma in different stages of dedifferentiation (well, moderate, poorly) were the subjects of investigation. the research determined that while the cancerogenesis progressed, the proliferative activity (indirect type information) of prostate gland cells and the ploidy of nuclei naturally increased. introduction calcitriol and its analogues affect function of several normal and neoplastic cells, including cells of medullary thyroid carcinoma originating from parafollicular cells. in the cells expression of calcitonin gene takes place, yielding due to alternative splicing calcitonin (ct) and calcitonin gene related peptide (cgrp). the aim of this study was examination of effects of calcitriol and of its two analogues, pri- and pri- on proliferation of two cell lines in vitro and on expression of calcitonin gene. the studies were performed on mtc - (rat cell line) and tt (human cell line) cells originating from medullary thyroid carcinomas. the cells were cultured with calcitriol or its analogues at (- ) to (- )m for days. the estimated variables included: cell number, proliferation-associated antigens (ki- , pcna), ct and cgrp levels in medium (ria), amounts of the two hormones and of their mrnas in the cells (immunocytochemistry or hydridocytochemistry accompanied by image analysis). results calcitriol and its analogues exerted low antiproliferative effect, more evident in mtc than in tt cells. pri- affected production and secretion of the two hormones. evident correlation was noted in tt cells, positive for ct and negative one for cgrp. in mtc cells, the effect was slightly less intense. pri- exerted a similar effect in the two cell lines but only at higher concentrations of the analogue. on the other hand, calcitriol manifested its activity only in mtc cells. effects of studied substances were also examined on cgrp/ct ratio of secreted hormones, which reflected corresponding ratio of alternative splicing of ct gene transcript. in tt cells the ratio decreased in presence of either analogue and in mtc cells the effect was observed following culture with calcitriol and the two analogues. conclusions calcitriol and its analogues exert a weak antiproliferative effect and an effect on alternative splicing of calcitonin gene. allelotyping analysis of gep endocrine tumors mixed medullary-papillary carcinomas are rare neoplasms and must be distinguished from medullary carcinoma with entrapped follicles, papillary variant of medullary carcinoma and solid growth pattern of sclerosing variant of papillary carcinoma. these mixed tumors could arise from uncommited stem cells; it is also possible that these neoplasms could be collision tumors. the aim of our study was to show that these mixed tumors have some particular features. we studied cases of thyroid carcinoma and for diagnosis we used immunohistochemical analyses for thyroglobulin, calcitonin, cea, chromogranin and cytokeratin . we found cases of mixed medullary-papillary carcinoma. these mixed tumors are not so frequent but the admixture of papillary and medullary components confer a different prognosis and a potential response to radioactive iodine treatment. results only four hereditary ( / ) tumours showed genomic imbalances. mtc appeared as sporadic forms. in of the sporadic tumours we detected dna sequence copy number changes (mean: per tumour, range: - ). the minimal common regions for the most frequent gains were narrowed down to q -q , p , and q ( percent), q -q , p , and q ( percent), p -p , p . -p , and q ( percent), and p pter, q -q , and p . -p ( percent). eight high-level amplifications were observed in four samples. p was affected twice. the minimal common regions for the most frequent losses were observed for p ( percent), and q ( percent). conclusion only limited genomic alterations could be detected by cgh for hereditary mtc, which share a germline mutation of the ret proto-oncogene as initial step of cancerization. additional genetic alterations, which are responsible for the progression of these tumours, are not identified yet. in contrast, sporadic mtc revealed a recurrent pattern of genomic imbalances. our data are in accordance in part with the few cytogenetic data, which are reported in the literature and can help to rule out parts of the genome on which further studies should focus on. immunohistochemical analysis of tumor infiltrating immunocytes in thyroid tumors v zolota, p aroukatos, s sidira, d koumoundourou, d papachristou, cd scopa dept. pathology, univ. patras med. school, patras, greece introduction the presence of host inflammatory cells within or at the periphery of human tumors has long been recognized and is commonly viewed as representing a host tumor immune response. in the thyroid gland, the occurrence of chronic lymphocytic thyroiditis (clt) in thyroid cancers has been reported and considered by some authors as a favorable prognostic sign. the inflammatory cell population in consecutive thyroid tumors ( papillary, occult, follicular, myeloid carcinomas and follicular adenomas), accompanied with chronic non-specific thyroiditis, were characterized imunohistochemically, using a panel of monoclonal antibodies against t-cells (anti-cd , anti-cd , anti-cd ), b-cells (anti-cd ), macrophages (anti-cd ) and dendritic cells (anti-s- ). the extent of lymphocytic infiltration was graded as: +(subtle), ++(moderate) and +++(intense and diffuse lymphoid aggregates). results were similar in cell block, although involucrine was negative in three pc. expression of mib- and p is variably detected in benign and malignant proliferative lesions. interestingly, galectin- , ck- and involucrin are invariably detected in papillary carcinomas, although heterogeneous positive expression was observed into the same lesion. conclusions our findings show that galectin- (p< . ), ck- (p< . ) and involucrin(p< . ) are useful to identify papillary carcinoma from other thyroid lesions; however, heterogeneous positive pattern expression is not useful for preoperative diagnostic of conventional cytology. introduction pheochromocytomas are rare neuroendocrine tumors that are highly vascular. their malignancy is extremely difficult to estimate on the basis of histopathological features. vascular endothelial growth factor receptor (vegfr- ) is a marker for lymphatic endothelium. its ligands vegf-c and vegf-d are expressed in many neuroendocrine tissues. our aim was to investigate the expression and the potential role of vegf-c, vegf-d, and vegfr- in various pheochromocytomas. materials and methods thirty-three pheochromocytomas, six of them metastasized, were studied using immunohistochemistry. thirteen tumors exhibited histologically suspicious features, such as necrosis, mitosis count over / hpf, vascular or capsular invasion, but they not metastasized, and were thus called borderline tumors. results and conclusions vegf-c immunohistochemical positivity was found in most pheochromocytomas. the expression of vegf-c was heterogenous and varied also within different tumor groups (benign, borderline, and malignant tumors). however, it tended to be stronger in extraadrenally located tumors. vegf-d positivity was also found in most tumors studied ( / ). interestingly, all malignant tumors (n = ) were totally negative for vegf-d. vegfr- expression was found in out of tumors, but the staining was mostly weak. the expression of vegfr- did not seem to correlate with the expression of vegf-c or vegf-d. in conclusion, vegf-c, vegf-d, and vegfr- are expressed in various pheochromocytomas, however, the diagnostic value of these markers needs further investigations. mixed corticomedullary tumor of the adrenal gland. a case report corticomedullary mixed tumors of the adrenal gland are quite rare, with only seven well-documented cases reported in the literature. we report the light microscope and immunohistochemical features of one case of this rare tumor. the patient is a -year-old woman who presented with hypertension, hirsutism, gain weight and ammenorhoea of -month duration. the surgically resected specimen consisted of a well-circumscribed, single adrenal mass, weighing , gr, and mm in diameter, surrounded by a rim of uninvolved adrenal cortical tissue. paraffin-embedded cut sections were stained by both hematoxylin-eosin and pas.the expression of inhibin, melan a, chromogranin a, synaptophysin, s- protein and acth was examined using the pap method, with appropriate antibodies being applied. the tumor was composed of cords and nodules of adrenal cortical cells intimately admixed with pheochromocytes. immunohistochemical investigations highlighted these two cellular components. the adrenal cortical cells revealed inhibin and melan a immunopositivity, whereas the pheochromocytes were strongly reactive with chromogranin a, synaptophysin, and acth, and the sustentacular cells with s- protein. thus, we report one additional case of mixed corticomedullary tumor of the adrenal gland. introduction the study of apoptotic markers seems to be important in understanding the pathogenesis of chronic inflammatory processes of the thyroid gland. aim: intensity determinations of bcl- and fas immunohistochemical reactions with the quantitative assessment of bcl- and fas gene expressions in inflammatory affected thyroid glands. the specimens were taken from women aged to . the type of inflammation and the intensity of lymphocytic infiltration were assessed according to the mizukami and the waterhouse and doniach classifications, respectively. the expression of bcl- and fas antigens was determined immunohistochemically. moreover, bcl- and fas genes were quantitatively analysed by rt-pcr assay using taqman technology. results intensity of immunostaining for bcl- antigen in patients with chronic thyroiditis was stronger than in patients without lymphocytic infiltration. an increase in the intensity of lymphocytic infiltration did not affect bcl- mrna levels. fas antigen got stained in subjects with mixed inflammation; a presence of oxyphilic cells enhanced the stain reaction. in the case of oxyphilic thyroiditis, the changes in fas antigen were accompanied by a concomitant increase of fas mrna levels. small differences, between various samples of the same specimen, in bcl- and fas mrna and protein levels were found in patients with focal thyroiditis. these differences were related to the intensity of lymphocytic infiltration. conclusions the thyroid gland is characterised by a high degree of antiapoptotic activity. each type of thyroiditis has its own characteristic pattern of bcl- and fas expressed as mrna and as protein. the use of galectin- and cytokeratin in differential diagnosis of thyroid tumors with follicular growth pattern a ryska aim to study the use of galectin- (gal) and cytokeratin (ck ) in differential diagnostics of thyroid tumors with follicular growth pattern. material and methods a series of thyroid lesions ( follicular adenomas (fa), follicular carcinomas (fc), follicular variants of papillary carcinoma (fvpc)) was studied retrospectively by immunohistochemistry using monoclonal antibodies. results the staining intensity of either antibody was evaluated as positive or negative using different thresholds ( , and % of positive cells). generally, the intensity of staining of gal was much higher than that of ck . using % threshold, / fa showed positivity of gal and none was positive in ck . in fc, / tumors were gal positive, / were also ck positive. among fvpc, all cases were gal positive and / were also ck positive. using % threshold, only / fa was gal positive, none was ck positive. among fc, however, all tumors were both gal and ck negative. on the other hand, / of fvpc were gal positive and / were ck positive. the sensitivity, specificity, negative and positive predictive value of gal were . ; . ; . ; . for % threshold and . ; . ; . ; . for % threshold, respectively. for ck it was . ; . ; . ; . for % threshold and . ; . ; . ; . for % threshold, respectively. conclusions the use of gal and ck may be helpful in differentiating fvpc from benign lesions. however, the use of these markers in differential diagnostics of fc from fa is of little value. moreover, due to low intensity of staining, its use in preoperative diagnostics (e.g. in fnac cytoblock specimens) seems to be questionable. adrenal cortical adenoma in association with cushing's syndrome -case report introduction morphological feature of adrenal cortical adenoma by itself doesn't allow reliable distinction between tumors associated with any particular endocrine syndrome. without being aware of the clinical setting and/or endocrinological data, it may be impossible to distinguish them from an incidental nonhyperfunctional macronodule. the aim of this investigation was to represent the only case of adrenal cortical adenoma in association with cushing's syndrome in our material. we have analyzed the only case of adrenal cortical adenoma with cushing's syndrome according to its morphological changes, laboratory data, ct-scan as well as mri of adrenal gland. results gross examination showed a small ovoid adenoma. on section, it appeared yellow to golden yellow with dark brown foci, blood and degenerative changes. microscopically, tumor contained cells with pale, lipid-rich cytoplasm, compact eosinophilic cytoplasm, arranged in trabeculae, short blunt cords, as well as in rounded nests. nuclei were somewhat vesicular with a single small dot-like darkly stained nucleolus. discussion and conclusion our data indicate that being aware of characteristic histologic feature in terms of architectural pattern and cell type for cortical adenoma associated with cushing's syndrome, this could be the purpose of more comprehensive discussion. correlation of histopathology and sequential analysis of gene expression in follicular thyroid neoplasms sj diaz-cano , , s arif , a blanes barts and the london school of medicine, university of london, uk university of malaga school of medicine, malaga, spain background the expression profile and diagnostic relevance of nuclear features, inflammation, and stromal changes have not been systematically evaluated in follicular thyroid carcinomas (ftc). design we selected ft neoplasms ( adenomas, minimally invasive carcinomas, widely invasive carcinomas, and anaplastic carcinomas), classified using standard criteria. histological variables including anisokaryosis, chromatin pattern, nucleolus, nuclear pleomorphism, nuclear/cytoplasmic ratio, necrosis, stromal changes, and tumor interstitial lymphocytes (til) were studied by histological diagnosis (significant if p< . ). oligo(dt)-primed double strand cdna was produced from total rna, and libraries were produced from normal thyroids and ftc. sequential analysis of gene expression (sage) was performed (ftc/control expression factor≥ , significance≤ . ). results til were absent in / neoplasms. minimally invasive carcinomas were distinguished from adenomas by conspicuous nucleolus, increased nuclear/cytoplasmic ratio, and coexistence of apoptosis and myxoid changes in adenomas. the most specific variables of high-grade carcinoma were coagulative necrosis, and nuclear hyperchromatism and pleomorphism. ftc sage showed ubiquitin c and sequestosome down-regulation, and tumor protein translationally controlled and malate dehydrogenase up-regulation. this sage profile correlated negatively with proinflammatory molecules expression (interleukin- beta, chemokine xc-receptor , interferon-induced transmembrane protein , protein tyrosine phosphatase c), brca , and protein phosphatase . the correlation was positive with proliferation markers (myb, mitogenactivated protein kinase , cyclin-dependent kinase , brca /cdkn a interacting protein, and ras oncogene family). conclusions proliferation up-regulation and apoptosis downregulation results in prominent nucleolus and high nuclear/ cytoplasmic ratio for low-grade carcinomas and hyperchromatism and nuclear pleomorphism for high-grade carcinomas. tumor down-regulation of proinflammatory molecules explains til absence. papillary carcinoma of the thyroid with bone formation. a case report introduction papillary carcinoma is by far the most common type of thyroid malignancy. however, ossification in papillary carcinoma is very rare. a case of papillary carcinoma of the thyroid metastatic to cervical and supraclavicular lymph nodes with associated bone formation and extensive calcification is presented. case report a year-old male with a history of gastric carcinoma was admitted to hospital presenting with lumbal pain. a computed tomography scan revealed a calcified nodule, measuring in mm diameter in the thyroid. total thyroidectomy and modified neck dissection were performed. the thyroidectomy specimen showed a well circumscribed, calcified, rock-hard nodule measuring x x cm. histologic examination of the hard nodule after decalcification showed spicules of bone formation and papillary carcinoma. foci of metastatic papillary carcinoma with bone formation were also seen in the cervical and supraclavicular lymph nodes. there was also bone marrow formation both in the thyroid nodule and in the metastatic lymph nodes. immunohistochemically, the tumour cells were positive for thyroglobulin. conclusion ossification in papillary carcinoma of the thyroid is an unusual finding. the mechanism of bone formation is not clear. the presence of ossification both in primary and metastatic tumoral masses suggests that ossification is not a dystrophic process in the preexisting benign thyroid tissue but somehow related to the papillary carcinoma in the present case. introduction c-kit gene encodes for a transmembrane tyrosine kinase receptor which is expressed in a variety of human normal tissues and malignancies, being small cell lung carcinoma one of the most frequent among the latter group. the search for c-kit expression in human tumors bears clinical implications since several tyrosine kinase inhibitors have been proposed in the treatment of c-kit positive tumors. the aim of our study was to investigate c-kit protein expression in a series of merkel cell carcinomas (mcc) and of other extrapulmonary poorly differentiated neuroendocrine carcinomas (pdnecs). merkel cell carcinomas (mcc) of the skin (from patients, of them with follow up information available), and cases of extrapulmonary pdnecs from different sites (bladder - cases, colon - cases, gallbladder and pancreas - cases, parotid - case) were analyzed by means of immunohistochemistry for c-kit protein expression. only a membranous staining was considered specific, and scored according to the percentage of positive cells. results c-kit protein was demonstrated in / ( %) mcc, and in / ( %) of other pdnecs. in mcc, a correlation, slightly below statistical significance (p= . ), was observed between the presence of c-kit expression and clinically aggressive behaviour. conclusion our data indicate that c-kit expression may play a role in the growth regulation of extrapulmonary pdnecs. therefore this group of tumors may be considered as a possible target for tyrosine kinase inhibitors therapy. carcinoid tumors in the thyroid gland. primary or metastatic? report of two cases m volante , m bongiovanni , p filosso , g bussolati , m papotti dept. biomedical science and human oncology university of turin, turin, italy dept. thoracic surgery university of turin, turin, italy introduction the occurrence of well differentiated endocrine tumors (carcinoid) in the thyroid gland is unfrequent and may represent both a differential diagnostic problem with medullary carcinoma, and a potential pitfall in the searching for its primary or metastatic origin. our aim was to determine the differential morphological and immunohistochemical profile of two cases of carcinoid tumors localized in the thyroid -one metastatic from the lung, and the other of unknown origin. materials and methods the first collected case had a clinical history of an atypical lung carcinoid diagnosed two years before, while the other lacked a clinical, instrumental and laboratory history suggestive of a possible primary carcinoid elsewhere. paraffin embedded material was histologically reviewed and analyzed by immunohistochemistry for thyroglobulin, calcitonin, cea, chromogranin a, s- , ttf , and ki- . results the first case (f/ ) presented as multiple nodules in both lobes, composed of poligonal eosinophilic cells arranged in the typical organoid pattern. foci of necrosis were present. the morphological features overlapped with those of the primary lung tumor. the second case (m/ ) presented as a single nodule in the left lobe, morphologically resembling typical carcinoid without necrosis. both cases were negative for thyroglobulin, calcitonin, s- and cea, positive for chromogranin a and ttf , and low proliferating (ki- < % in both). conclusion our data suggest that, even in the absence of a clinically detected primary tumor, the occurrence of a carcinoid tumor in the thyroid gland should be firstly considered metastatic in origin, the lung being the major candidate for the primary localization (as determined by ttf immunostaining). telomerase expression and proliferation activity in gastroenteropancreatic tumours s vural, y kapran, m gulluoglu, u cevikbas, f dizdaroglu university of istanbul, istanbul medical faculty, department of pathology, istanbul, turkey intruduction gastroenteropancreatic endocrine tumours have a variable prognosis and the prediction of biological behavior based on histopathology is not always possible. telomerase is a reverse transcriptase that synthesis telomere dna to stabilize telomere length.telomerase activity is increased in different human cancers. the aim of this study was to determine whether the expression of telomerase (htert) correlates with the histological typing of endocrine tumours and ki- proliferation index. material and methods formalin-fixed, paraffin-embedded tissue sections from gastroenteropancreatic endocrine tumours and normal pancreas were stained immunohistochemically for human telomerase reverse transcriptase (htert) and ki- antigen. results cases were diagnosed as well-differentiated endocrine tumour, were well-differentiated endocrine carcinoma and were poorly-differentiated endocrine carcinoma according to who classification of endocrine tumours. the percentage and intensity of positive neoplastic cells were assessed for each case. expression of htert was observed in one well-differentiated endocrine tumour ( %), in well-differentiated endocrine carcinomas ( . %) and in poorly-differentiated endocrine carcinomas ( %). there was a significant correlation between the expression of htert and histopathological diagnosis (p< . ). also the correlation of htert expression and ki- index was statistically significant (p< . ). conclusion immunohistochemical detection of htert expression in gastroenteropancreatic endocrine tumours may be a helpful tool in addition to morphological findings and ki- index in predicting the malignant potential of these tumours. proliferation, p expression and apoptosis in pituitary adenomas: relationship to tumor behaviour introduction pituitary adenomas are known to vary considerably from the stand point of their intrinsic aggresiveness that might imply a different therapeutical approach. the aim of this study was to estimate the relationship between proliferative activity (ki ), p expression, apoptosis and pituitary tumor behaviour. materials and methods immunohistochemical analysis of ki and p expression were performed in paraffin-embeded pituitary adenomas: functioning; non-functioning; invasive adenomas. apoptotic index (ai) was determined in adenomas by the in situ end-labeling technique (tunel). results ki expression in all adenomas was . % (significantly higher in functioning comparatively with non-functioning pituitary adenomas - . ± . % versus . ± . %). we noticed a positive correlation between the proliferative activity and the tumoral invasiveness (ki labeling index . ± . % in invasive and . ± . % in non-invasive adenoma). p nuclear positivity was identified in % of the invasive adenomas and only in % noninvasive adenomas, with a positive correlation between p and proliferative activity (ki : . ± . in p positive versus . ± . % in p negative tumors). apoptosis was found in % of tumors, higher in some of the invasive ones, with a positive correlation between the proliferation rates and apoptotic indices (ai: . ± . in total versus . ± . in invasive pituitary adenomas). also, some differences were recorded in functioning and non-functioning adenomas (ai: . ± . versus . ± . ). conclusions the data suggest that the assessment of proliferation, p expression and apoptosis might be used to evaluate tumor behaviour and susceptibility of adenomas to therapy. differentially expression of nesp in langerhans islets of the human pancreas and overexpression in endocrine pancreatic tumors nodules, while others recommend to do it only if clinical changes are present. this study was done to determinate the usefulness of systematic repetition of fna in patients with benign cytology result in the initial fna. materials and methods data were collected from patients referred to endocrinology service for evaluation of thyroid nodular disease between and . all patients underwent repeated fna of thyroid nodule. age of patients was . + . years, . % were females, % had uninodular goiters, nodule size was . + . cm. time elapsed between both fna was . + . months. results at second fna, aspirations had benign cytology, were non diagnostic, suggestive of follicular neoplasm and had malignant cytology results. excluding non-diagnostic aspirations, we get % of discordant results. uninodular goiters as compared to multinodular have a higher rate of discordant results. we did not find other variables between groups of concordant and discordant results. twenty-two patients with benign cytology underwent thyroid surgery, without any histological malignant result. conclusion -uninodular goiters with an initial benign cytology have a significant rate of discordant results after repetition of fna. however, in % of these cases the first diagnosis was based on limited material. -our results show that cases of thyroid carcinoma out of patients with nodular goiter were misdiagnosed by initial fna cytology. therefore we recommend systematic repetition of fna cytology in all patients with uninodular goiter. immunocytochemistry in fna biopsy material objective assessing diagnostic value of immunocytochemical methods in destained cytology smear specimens prepared from fine needle aspiration (fna) biopsy material. material and methods investigated material comprised samples from fna biopsies that were diagnosed in - . alcohol-fixed cytology smears were typically stained with hematoxylin-eosin. for immunocytochemical studies, preparations were first destained using alcohol series. following this, chosen antibodies were used either separately, or as a panel ckmnf, ema, lca, tg, ct, hmb- , s- , chr, nse, er, pr, cd (dako lsab system, peroxidase). results immunocytochemical staining was helpful in % of cases. initial diagnosis was confirmed in cases. immunocytochemical staining was important particularly in confirming diagnosis of poorly differentiated neoplasms. it was also helpful in identifying the primary site of metastatic carcinoma in fna cases. in ( %) cases diagnosis based on the investigated method failed. precise diagnosis was not possible either due to negative staining with single marker/panel or when only single cells were stained positive. conclusion immunocytochemical methods in destained smears allow basic as well as discriminating diagnosis even in cases of poor availability of cytologic material. fine needle aspiration of lesions in the thyroid bed. e chmielik, b szczesniak-klusek, d ponikiewska, e stobiecka, d lange oncology center, department of pathology, gliwice, poland introduction clinical suspition of recurrent thyroid carcinoma based on ultrasound examination of thyroid bed with correlation to increased thyreoglobulin level or calcitonin level and/or radiomarker uptake on scintigraphy can be supported or dismissed by fine needle aspiration biopsy (fnab). the aim of this study was assesment of specificity and possitive predictive value of ultrasound-guided fnab of the lesions in the thyroid bed after total thyroidectomy for diagnosis of recurrent thyroid carcinoma. material and methods ultrasound guided fnab of thyroid bed lesions of diameter . - . cm performed by pathologist in patiens after thyroidectomy. immunohistochemistry stain for calcitonin was performed using dako antibody in cases. the recurrent papillary carcinoma was diagnosed in ( . %) patients, the recurrent follicular carcinoma in ( . %) patients, hürtle cell carcinoma in ( . %) patients and medullary carcinoma in ( . %) patients (immunocytochemistry stain for calcitonin confirmed diagnosis in patients). pathologic correlation was able in cases: postoperative examinations confirmed recurrent carcinoma, and cytologic diagnoses were falsenegative. in the remaining patients granulation, purulent inflammation and benign lesions were diagnosed. in ( . %) cases material was nondiagnostic. specifity of the method was . %, possitive predictive value . %. conclusions ultrasound-guided fine needle aspiration biopsy performed by pathologist is valuable and specific method in the diagnosis of recurrent thyroid carcinoma in thyroid bed. introduction fine-needle aspiration (fna) is one of the most useful methods in the diagnosis of benign goiter. in consideration of the goiter; it is the most frequent lesion in the thyroid tissue, significance of fna as a diagnostic method become greater. material and methods in cases diagnosed as goiter we analyzed: ) sex distribution, ) age distribution, ) correlation between clinical and cytological diagnoses and ) goiter classification in accordance with cytological characteristics. results goiter was five times more frequent in females than males ( women, men). the majority of the patients were between and . the youngest was , and the oldest years old. almost % of cytologically diagnosed goiters had the same clinical diagnosis, in only . % of all patients tumor was suspected clinically. we confirmed high correlation between clinical and cytological diagnosis. according to the cytological characteristics all goiters were classified in categories: goiters with and without degenerative changes. hi-square test confirmed statistically significant difference in the presentation of such goiters (hi-square test= . ; p< . ). fna permits a substantial reduction or even elimination of other diagnostic procedures, such as imaging, with consequent saving in time and money. furthermore, benign cystic lesion may be cured by fna (a diagnostic and unexpected therapeutic value). samples, furthermore it is difficult to predict at patient's bedside which ancillary methods, if any, will be necessary. the aim of this study was to demonstrate the value of a universal short-term storage cell medium in processing fnab samples for different ancillary methods. materials and methods after diagnostic smear preparation, the needle and syringe were washed out with the short-term storage cell medium in fnab samples, obtained from to . microscopic smear analysis determined the choice of ancillary method used. cell suspensions were then processed as required for each individual ancillary method. results we used ( %) fnab samples stored in the medium for ancillary methods, while samples ( %) were discarded due to the clear morphology-based diagnosis or sample inadequacy. immunocytochemistry was performed on samples. for various membrane, cytoplasmic and nuclear antigens, adequate immunoreaction without background was obtained in samples stored in the medium overnight ( ) or over the weekend ( ). immunophenotyping by flow cytometry was performed in fnab samples where up to lymphoma antigens per sample were successfully determined when the samples were stored in the medium overnight. high quality flow cytometric dna histograms were obtained from all fnab samples suspended in the short-term storage cell medium. conclusion the short-term storage cell medium that we have been using, allows effective and easy processing of fnab samples for several ancillary diagnostic methods. it preserves cell morphology, various membrane, cytoplasmic and nuclear antigens as well as dna content. fine needle aspiration cytology of ovarian lesions introduction an improved understanding of the pathogenesis of cervical hpv-induced lesions has significantly changed the approach to diagnosis and treatment. the pap smear is still the most effective cervical cancer screening test. however, molecular testing for the presence of high risk hpv-dna increases the ability to identify women with an increased risk for cancer and true cancer precursors. the aim of the present study was to evaluate high risk hpv-dna test systems in cervical cytological material and the correlation with pap smear cytology. materials and methods we analysed routinely processed cytological cervical specimen. material was taken consecutively for pap smear cytology and for hybrid capture (hc) hybridisation assay (digene). the cytological report showed mild to severe dysplasia ( cases were scored as pap i/ii). after performing the hc-assay, dna was extracted from the same sample. hpv-dna detection with conventional pcr using consensus primer (my /my ), followed by subtyping of hpv and was carried out. from the specimens showing dysplasia ( . %), koilocytosis has been observed in % of pap smear cytology. hpv-high risk positivity with the hc hybridisation assay was detected in % and % showed positivity for hpv-dna content with conventional pcr. subtyping of hpv-positive cases resulted in hpv- positivity in %, . were positive for hpv and . % showed a coexistence of hpv and . conclusion our results indicate that hpv-detection with highly sensitive and widely used molecular methods show a good concordance with cytological findings. fine needle aspiration findings of two different types of gastrointestinal stromal tumor mg gulluoglu , d yilmazbayhan , y kapran , k acarli , f dizdaroglu istanbul university, faculty of medicine, department of pathology, istanbul, turkey istanbul university, faculty of medicine, department of general surgery, istanbul, turkey introduction gastrointestinal stromal tumors (gist) are the most common mesenchymal tumors of the gastrointestinal tract, derived from interstitial cells of cajal. the cytologic features of these neoplasms in fine needle aspiration (fna) have been described in several articles. aims: cytologic and histologic features of two gist cases one of which presented with liver metastasis and other with an intrathoracic mass mimicking lung carcinoma radiologically are presented comparatively. sixty year-old male patient with a previous history of gastric gist has had an fna from a liver mass. in the cytologic examination, epithelioid cells with round-oval nuclei, large cytoplasms and indistint cytoplasmic borders, forming three dimentional groups with thin fibrovascular stroma were observed. the other patient was a seventy two year-old female who had an fna from an intrathoracic mass. branching fascicles of spindle cells with indistinct cytoplasmic borders in a necrotic background were observed in the cytologic examination. mesenchymal origin was verified by vimentin immunopositivity. by detailed computerized tomographic evaluation, it was revealed that the mass originated from the gastroesophageal junction. both tumors were resected and histologically examined. cytologic and histologic findings correlated including immunocytochemical and immunohistochemical results which were positive cd and cd , and negative s and smooth muscle aktin immunoreactions. conclusion as they share common histomorphological features with other types of mesenchymal tumors of the gastrointestinal tract, cd immunopositivity is the only diagnostic marker to differentiate these tumors from other tumors of mesenchymal origin. cytologic diagnosis also requires detection of this marker in the neoplastic cells. peritoneal fluid cytology of sarcomas k zachou , e tzartza , a orologa , a skenderi , k patsiaoura , e kostopoulou , k boni hippokratio hospital of thessaloniki dept. cytopathology, thessaloniki, greece hippokratio hospital of thessaloniki dept. pathology, thessaloniki, greece material and methods peritoneal fluid smears of female patients of all ages, were studied. results cases were cytologically diagnosed as malignant ( , %), the majority of which was characterized as adenocarcinomas. histological diagnosis was available for cases. sarcomatous component was reported in only cases, cases were malignant mixed müllerian tumors (mmmt), one was leiomyosarcoma, one rhabdomyosarcoma and one liposarcoma. the cytological findings in the equivalent cases were « abnormal» neoplastic cells in isolation, with enlarged and hyperchromatic nuclei. adenocarcinoma cells were identified in peritoneal fluid smears of patients with mmmt. conclusion cytological diagnosis of sarcoma is rare. even when these «abnormal» cells are found, it is very difficult to give a definite diagnosis of sarcoma, based directly on the cytomorphological characteristics of peritoneal smears. however, such a possibility should be kept in mind by the cytopathologist to avoid missing the diagnosis. r bokun, z tatomirovic, v skuletic institute of pathology, military medical academy, belgrade, serbia and montenegro purpose the aim of this study was to show that imprint cytology is a valuable method in the evaluation of bone tumors as well as to determine its diagnostic accuracy in primary and secondary bone tumors. materials and methods from thirthy three surgical specimens of bone tumor imprints were made, air-dried and stained by may-grunwald-giemsa method. the cytologist gave detailed description of the smears, concluded whether the lesion was malignant and suggested a final diagnosis if it was possible. results were compared with the corresponding histopathologic diagnoses. results out of cases with primary malignant bone tumors (chondrosarcoma , ewing sarcoma , ameloblastoma , synoviosarcoma , malignant osteoclastoma , malignant fibrous histiocytoma , malignant schwannoma , leiomyosarcoma ) the cytologist recognized malignancy in of them and in suggested the final diagnosis. in patients with metastases (squamous cell carcinoma , anaplastic carcinoma , malignant melanoma ), the cytologic and histopathologic diagnoses correlated in all cases. conclusion cytologic analysis of the imprints of bone tumors is valuable as early orientation for the clinicians since the final histopathologic diagnosis needs time because of the decalcination procedure. the correlation of cytologic and histopathologic diagnoses was better for the secondary bone tumors because cytologist was more familiar with their morphology. the value of combined fine needle aspiration and needle core biopsy in diagnostic assessment of pancreatic tumors p sevastiadou , p xirou , s barbanis , i efstratiou , e athanasiou , i tsitouridis papageorgiou general hospital, department of cytology, thessaloniki, greece- papageorgiou general hospitaldepartment of cytology, thessaloniki, greece papageorgiou general hospital, department of radiology, thessaloniki, greece introduction due to the anatomical location of the pancreas, it is often difficult to obtain sufficient diagnostic material from pancreatic lesions. the aim of this study is to present the results and our experience from ct guided fine needle aspiration (fna) and needle core biopsy (ncb) from pancreatic tumors. materials and methods fna using gauge needles and ncb using and gauge needles were performed in patients with pancreatic tumors. both procedures were done under computerized tomography guidance, without complications. twenty one tumors involved the body and the tail of the pancreas results the diagnosed cases were adenocarcinomas, neuroendocrine tumors, lymphoma and pseudocysts. diagnosis was reached in cases by both fna and ncb and in cases by ncb only. other cases were "diagnosed" as suspicious for malignancy by fna only. finally in cases no diagnosis was reached by both methods, due to insufficient material. conclusion according to our experience, we believe that the combination of fine needle aspiration with needle core biopsy of pancreatic tumors under ct guidance improves the diagnostic accuracy. value of fine needle aspiration cytology in subtyping mucinous breast carcinoma background subtyping of mucinous breast carcinoma into pure and mixed type has prognostic implications. aims of the study were to evaluate a) the usefulness of fine needle aspiration biopsy (fnab) in differentiation between pure and mixed mucinous carcinomas, and b) to correlate key cytological features with survival. material and methods we reviewed fnab of women with mucinous breast carcinoma treated at the institute of oncology from to . key cytological features analysed were cellularity, amount of mucin, presence of capillaries, cell pattern, cytoplasmic characteristics and nuclear pleomorphism. type of mucinous carcinoma was determined histologically after resection of the tumour. association of cytological features with cancer specific survival was evaluated by univariate and multivariate analysis. results histological analysis revealed cases ( %) of pure and cases of mixed mucinous carcinoma. nuclear pleomorphism and amount of mucin in fnab differed significantly between the two subtypes of mucinous carcinoma. whereas cellularity of cytological samples, presence of capillaries, cell pattern and cytoplasmic characteristics were not related to prognosis, nuclear pleomorphism and absence of mucin in cytological samples were associated with poorer cancer specific survival. furthermore, the absence of mucin in fnab samples retained independent prognostic significance also in multivariate analysis. conclusions higher grade of nuclear pleomorphism and small amount or even absence of mucin in fnab favor the diagnosis of mixed mucinous cell carcinoma and are features associated with poorer prognosis. cardiac lipoma in a mexican patient -multidisciplinary approach in a right atrium tumor j nuncio , g najera-hernandez , g garcia-ramos pathology department, instituto nacional de ciencias medicas y nutricion salvador zubiran, mexico city, mexico internal medicine and neurology departments, fundacion medica sur, mexico city mexico primary tumors of the heart are rare. lipomas account for approximately % of all neoplasms of the heart and represent % of benign cardiac tumors. symptoms may be produced by large lipomas, but more often the patients are asymptomatic and the diagnosis is made by chance. recently, the ready availability of high-definition noninvasive imaging, such as echocardiography, computed tomography, and magnetic resonance image, has allowed easier diagnosis. therefore, more cases have been reported. to date up to cases of lipoma have been described. this case describes the multidisciplinary approach to the diagnosis of this rare entity with the use of open heart biopsy from right atrium, to sustain the correct diagnosis. after exhaustive internet-based search, this is the first case reported in latin-american literature, a condition not previously informed from in vivo patient in mexico. the cardiac hydatid cysts are rare cases, representing , - % from all human hydatid cysts. they are commonly located in the left or right ventricle and exceptionally in the interventricular septum. because the symptoms and clinical signs of the cardiac hydatid cysts are non-specific, the diagnosis may be difficult. material and methods we report an intramyocardial hydatid cyst, diagnosed at cardiology center iasi, with an early history of atypical chest pain, the death occuring through anaphylactic shock, secondary to the hydatid cyst endocavitary rupture. the study was made on necropsiy specimens, and the diagnosis was established by using routine morphological techniques. results the gross examination evidentiated an hydatid cyst of about cm in diameter, communicating through a small orifice with the left ventricular cavity and through a slit-like fissure with the right ventricular chamber. the systemic embolism was revealed, only grossly, by the presence of small "hydatid daughters" at the level of the ascending aorta and the pulmonary embolism was confirmed only histologically, by the presence of anhiste membrane emboli in the peripheral pulmonary vessels. the study revealed the morphological aspect defining hydatid cyst, emphasising the necessity of an early diagnosis due to a high risk of death through complications. a case report of arrhytmogenic right ventricular dysplasia -cause of sudden death c borza, d butcovan, c grigoriu, v astarastoaie university of medicine and pharmacy iasi, romania arrhytmogenic right ventricular dysplasia (arvd) is a new form of cardiomyopathy probable more frequent than commonly reported. arvd is a heart muscle disorder of unknown cause that is characterized clinically by an electrical instability associated with secondary ventricular arrhythmia and pathologically by fibrofatty replacement of the right ventricular myocardium. it is a rare but important cause of sudden unexpected cardiac death in young, otherwise healthy persons, especially those that are exercise related. we report a case of cardiac sudden death in a years old man without personal and familial cardiac history. the study was made on a necropsic biopsy specimens from the medico-legal laboratory. the diagnosis was made using routine histological techniques. grossly, we revealed a fibro-fatty right and left ventricular wall myocardial replacement and a focal white thickening of the left ventricular endocardium. histologically, we evidentiated a fibro-fatty myocardial replacement of the right and left ventricle suggesting an arrhythmogenic ventricular dysplasia of cardiomyopathic type and an endomyocardial fibrosis supported by the presence of a subendocardial fibrosis, affecting internal one third of the myocardium. there were no evidence of coronarian and valvular lesions and hypertensive cardiac changes, as well. the study revealed the morphological features defining a fibro-fatty myocardial replacement and an endomyocardial fibrosis evidentiating the case particular features, as well. registered. repeated biopsy revealed ongoing mc in / pts, latehealing mc in / pts, focal-healing mc in / pts, healed mc in / pts, and dilated cardiomyopathy in / pts. amount of cellular infiltrate, degenerative and/or necrotic changes, and fibrosis was reduced in , , and pts, respectively, remained the same in , , and pts, respectively, and increased in , , and pts, respectively (p< . , between groups). the significant reduction was achived in the amount of cellular infiltrate and degenerative and/or necrotic changes, contrary to the amount of fibrosis. applied immunomodulatory therapy made substancial reduction of inflammation with "relative" increase of fibrosis. conclusion interferon-α, as main immunomodulatory agent, has favourable effects on myocardial histology and contractility in patients with biopsy-proven myocarditis. morphological changes in heart died of a heart attack of a myocardium v ubaydullaeva the centre of emergency medical aid, tashkent, uzbekistan diseases cvs take conducting place among the most actual problems of modern medicine. from them it is possible to count the main thing ihd. ihd -the special form of pathology cvs including group of diseases which, according to definition the cart, are treated as follows: «dysfunction sharp or chronic, arising owing to relative or absolute reduction of supply of a myocardium by arterial blood». despite of significant number of the morphological researches devoted ihd, morphogenesis separate displays of it, in particular, ami, and also mechanisms of indemnification and decompensation of hearts are investigated insufficiently. in connection with, the purpose of the present research definition morphofunctional conditions of various departments of heart was above-stated at diagnostics of an intimate ischemia. material and methods for achievement of an object in view researches of hearts died of a heart attack of a myocardium have been lead (have been carried out), and also have been investigated morphometric parameters, such as: weight of a cardiac muscle, pure weight of heart, weight right and left ventricles, an index right and left ventricles, an index of blood supply of a myocardium. all received data have been processed statistically on personal computer with use of standard software package windows excel. results summarizing macro-and the microscopic changes which have been found out by us in a cardiac muscle, it is possible to make the conclusion that the long reorganization occuring in a cardiac muscle in conditions increasing hypoxy, results in an exhaustion processes, to use of all possible resources cardiomyocytes and causes development decompensation. introduction cardiac myxoma, the most common primary tumor of the heart, has a varying clinical presentation and immunohistochemical profile. an abundant mucopolysaccharidic matrix exists, including mucin, within the cardiac myxoma. this study elucidates the clinical presentation and expression of mucin genes in cardiac myxoma. materials and methods from december to february, , the retrospective study included consecutive patients with cardiac myxoma underwent surgical excision. detailed clinical parameters were reviewed as well. mucin genes, additionally, muc , muc and muc ac, have been studied by immunohistochemical method. the expression was scored from to . results ( %) women and ( %) men with a mean age of +/- years comprised the control group. the presentation included asymptomatic ( %), dyspnea ( %), stroke ( %), chest pain ( %), fever ( %), syncope ( %) and tricuspid regurgitation ( %). we divided these patients into two groups; group a contained the myxoma located in the left atrium, group b included three ( %) recurrent myxomas and ( %) myxomas other than in left atrium. they did not differ with respect to many pathological scores, such as vascular proliferation, inflammation, cellularity, and hyaline. however, although less calcification and thrombosis occurred, more congestion was found in group b (p < . ). moreover, muc / ac had a higher expression than muc (p < . ). interestingly, the group a displayed a stronger mucin expression than group b did. conclusion preliminary results demonstrate invaluable and different pathological patterns, including mucin genes, between the myxoma coming from the left atrium and the other sites. introduction nowadays understanding of atherogenesis, russell ross' response-to-injury paradigm, considers atherosclerotic lesions as "a protective, inflammatory-fibroproliferative response" to harmful stimuli. among these stimuli are the major risk factors, which contribute for atherosclerotic cardiovascular complications. arterial blood flow impairment is associated with the progression of intimal atherosclerotic lesions. that is why most of the research work is concentrated upon intima, while adventitia is neglected. several lines of evidence clearly show that adventitia is not an innocent bystander in atherogenesis. the aim of the present study is to evaluate morphologically adventitial changes in atherosclerotic arteries. the cellular components and adventitial thickness are followed in postmortem human coronary arteries. results mononuclear cellular infiltration (lymphocytes, mast cells), neoangiogenesis and collagen overproduction are established in this part of adventitia, that corresponds to atherosclerotic lesion. morphometric analysis reveals increased adventitia/media thickness ratio. the adventitial thickening represents an example of negative vascular remodeling, because of hampering the compensatory enlargement of the affected artery. on the other hand the cellular processes involved in adventitial thickening could be responsible for atherosclerotic lesion initiation. we need further arguments into the cell biology of atherosclerosis, viewed as a vascular healing process, involving also the adventitia, to provide new insights into atherogenesis and alternative therapeutical strategies respectively. study on postmortal autolytic changes of the myocardial blood vessels. experimental study l kostic-banovic , v katic , r karadzic , j stojanovic , g ilic , m zdravkovic , a antovic department of forensic medicine nis, nis, serbia and montenegro department of pathology nis, nis, serbia and montenegro introduction modern forensic medicine practice has not yet been given the methods of investigation that would enable answering with sufficient accuracy to the question of death occurrence time. present work is an attempt to make contribution to that very complex and significant problem in forensic medicine. the investigation has been done on wister rats. the sacrifice was exerted by strangling. to respond on questions how both temperature of microenvironment and passed time influence on coronary arteries, the experimental animals were divided into groups: i ( c), ii ( c) and iii ( c). every group had subgroups, depending of passed time from the sacrifice, beginning of hour, through , , , , , and up to hours. control animals were autopsied and myocardial sections were taken immediately after sacrificed animals. formaldehyde fixed and paraffin embedded blocks were cut and stained by he, van gieson and gomori methods. results in groups ii and iii almost all blood vessels of heart muscle had fragmented walls in the animals examined upon hours after sacrifice. the vessels were almost normal in the group i also up to hours after sacrifice. basal membranes of blood vessels were observed upon hours after sacrifice at the temperature of c. fragmented basal membranes in ii and iii group were found, in the form of spider's web residues. total hemolysis of erythrocytes was upon hour after sacrifice in iii temperature group. however, contours of erythrocytes could be recognized upon hours after sacrifice in i experimental group. conclusion autolysis of myocardial vessels is influenced by two factors: time interval from the death and micro environmental temperature. the temperature exerted more profound influence on autolysis than time interval. the observed autolytic changes could be used in the expertise of the time of death occurrence. introduction heart transplantation remains the only therapeutic option for pediatric patients (pts) with severe, end stage myocarditis. the aim of this study was to determine the presence of viral genome in native heart and the frequency of viral recurrence after heart transplant in pts with myocarditis. material and methods from march to november , heart transplants were performed in children ( month to years m/ f) at our institution. histology/immunohistochemistry was carried out in all native hearts; among inflammatory cardiomyopathy, cases were active myocarditis and dilated cardiomyopathy/ chronic myocarditis. foci of active myocarditis were also found in one case of hypertrophic/restrictive cardiomyopathy and one case of congenital heart disease respectively. retrospective pcr (polymerase chain reaction) and sequencing analysis for detection of cardiotropic viral genomes was performed in native hearts ( %) and in all serial post-transplant biopsies from viral pcr positive cases. results pcr amplified a viral product in native hearts ( %). pcr analysis on postransplant serial biopsies disclosed the same viral infection in of ( %). early enteroviral recurrent myocarditis with identical genotype was demonstrated in cases at month after transplant. fatal outcome occurred in / pts with viral recurrent myocarditis when prompt molecular diagnosis was not available; misdiagnosis of acute rejection in histological monitoring may have concurred in the fatal outcome. conclusion viral myocarditis frequently relapses after heart transplantation in children and is a risk of fatal outcome. molecular study in native hearts is mandatory to improve diagnostic accuracy allowing to a more strict surveillance after transplantation. sudden cardiac death induced by acute viral myocarditis introduction most commonly the sudden cardiac death (scd) is defined as unexpected death from cardiac causes early after of without the onset of symptoms. data suggested that scd is a multifactorial catastrophe involving in most instances myocardial lesions that we confirm by this report. materials and methods five cases were autopsied in institute for forensic medicine because they have died from scd. the mean age was , years, including one boy ( years) and one girl ( years). all specimens were fixed in % formalin. paraffin sections were cut and stained by: he, van gieson and ab-pas, ph= , . results clinical symptoms lasted short time: fatigue, dyspnea, palpitations and precordial discomfort, accompanied by fever. macroscopically, the hearts were normal or enlarged, with dilatation of chambers. the ventricular myocardium was typically flabby and mottled by either pale foci or minute hemorrhagic lesions. histological finding: myocarditis was characterized by an interstitial mononuclear predominantly lymphocytic inflammatory infiltrate and by injury of focal necrosis to myocytes adjacent to the inflammatory cells; focal aggregates of macrophages and microhaemorrhages, often surrounding the conduction system, were also observed. scattered incipient fibrosis inside the areas with disappeared myocytes was one of the features of myocarditis. conclusions the ultimate mechanism of death in viral myocarditis was fatal arrhythmia induced by inflammatory mononuclear infiltrates of the conduction system. surgical pathology of primary cardiac and pericardial tumors in the paediatric age background primary cardiac and pericardial tumors (cpt) are rare at all ages and even less common in infancy and adolescence. aim of this study is to assess the prevalence and pathologic features of paediatric cpt consecutively examined in a single institution. among surgically removed cpt collected at our cardiovascular pathology unit in the time interval - , ( %) occurred in the paediatric age (< yrs). we retrospectively analysed them by histotype, age and clinical presentation, location, type of surgery and outcome. they were male and female pts, age ranging from days to years (median months). the majority of cpt were diagnosed before the age of year ( %), including prenatal diagnosis by foetal echocardiography. in the remaining pts, clinical presentation of cpt was congestive heart failure in , cardiac murmur in , systemic embolism in , and constitutional symptoms in , whereas four were completely asymptomatic and the mass was an incidental finding at echocardiography ( ) or during cardiac surgery for congenital heart disease ( ). pct were located most frequently in the right ventricle ( ), followed by right atrium ( ), left atrium ( ), left ventricle ( ), tricuspid valve ( ), pericardium ( ) and ventricular septum ( ) . all had surgical resection except one who underwent cardiac transplantation. as far as histotype, myxoma was the most frequent ( ), followed by rhabdomyoma ( ), fibroma ( ), angioma ( ), pericardial teratoma ( ) and hematic cyst ( ). no recurrence was found at echo during follow-up and only one pt died three years after cardiac transplantation due to cerebral malignancy. with the improvement of cardiac imaging techniques, cpt have increasingly been detected even early during life. despite the benign histotype, cpt carry the risk of heamodinamic, embolic and arrhythmic complications. prompt surgical resection is indicated in all symptomatic pts and in those with tumour related obstruction. among surgically resected primary cpt in the paediatric age rhabdomyoma is less frequent than expected since it often does not require surgical resection due to its potential spontaneous regression. in vivo histologic diagnosis of primary malignant cardiac and pericardial tumors c basso, m valente, g thiene institute of pathology, padua, italy background primary cardiac and pericardial tumors (cpt) are rare and even less common are malignant ones. aim of our study was to assess the prevalence and histotype of malignant forms among a consecutive series of primary cpt examined in a single institution. in the time interval - among consecutive pts who had an in vivo diagnosis of primary cpt, either by surgical pathology and/or endomyocardial biopsy investigation, ( . %) had a malignant form. they were female and male pts, age ranging from to yrs (mean ± ). besides gross and histologic examination, tumour histotype was defined by immunohistochemistry using a large panel of antibodies and by transmission electron microscopy. primary malignant cpt comprised extracardiac ( pericardial mesothelioma and pulmonary artery sarcoma) and intracardiac masses. the latter group consisted of angiosarcoma of the right atrium +/-right ventricle ( ), undifferentiated sarcoma of the left atrium ( ), fibrosarcoma of the right atrium ( ), malignant fibrous histiocytoma of the left atrium ( ), b cell lymphoma of the right atrium ( ) and leiomyosarcoma of the right ventricle ( ) . in four ( %) a preoperative histologic diagnosis was achieved by transvenous endomyocardial biopsy (all right-sided). four malignant primary cpt, all located in the left atrium, had a preoperative misdiagnosis of myxoma. surgical resection was performed in all but two pts. all pts died with a maximum survival time of months. conclusions primary malignant cpt are rare and represent . % of all primary cpt in our series. the prognosis is poor and generally measured in months independently from the tumour histotype and from surgical resection and chemotherapy. endomyocardial biopsy is a safe procedure to achieve an in vivo diagnosis in the setting of right intracavitary masses. introduction primary sarcomas of the aorta are extremely rare neoplasms, described in occasional single case reports and antemortem diagnosis is difficult because of their polymorphous presentation. the tumours are classified into intimal and mural types according to their location and clinical behaviour. we describe a case of intimal sarcoma arisen in the thoracic aorta of a -years-old woman with multiple embolic abdominal metastases (spleen, kidney, adrenal). case report in november the patient was hospitalized for the embolic occlusion of the left popliteal artery. the recent clinical history revealed irritative cough, dispnea and fever. the laboratory tests reported anemia (hemoglobin: . mg/dl) and the ves was . electrolities, liver function tests and fibrinogen were within normal limits. the antiphospholipid antibody and lupus anticoagulant were negative. a ct-scan showed an intraluminal thrombus-like mass in the thoracic aorta and multiple geographic infarctions of the spleen suggestive for a primary aortic tumor. she died before undergoing to surgery, for left ventricular failure. results post-mortem examination showed mild atherosclerosis and a mass with grayish-yellow, solid, rubbery and mixoid aspects, attached to the wall of the aorta, just after the origin of the left subclavian artery. histologic sections disclosed a spindle-shaped sarcoma cells with pleomorphic nuclei in a myxoid stroma; necrosis was abundant. at immunohistochemistry tumor cells resulted positive for vimentin, actin and cytokeratins. conclusion the preoperative diagnosis of sarcoma of the aorta is possible but it should be supported with imaging techniques; the definitive diagnosis need to be confirmed histologically and immunohistochemically. arterial allografts cryopreservation antigenicity in pigs m santos background coronary surgery requires vascular grafts. donor fresh arterial grafts are useless because of rejection vasculopathy. cryopreservation can be a good way for banking purposes and may limit rejection. the aim of this study was to assess the utility of arterial cryopreservation in increasing the quality of grafts, in an animal model in pigs. material and methods small arteries, less than mm in diameters were implanted in pigs. three groups were done: group (n= ): fresh autograft (au) and fresh allograft (al) one in each side; group (n= ): cryopreservated au and cryopreservated al; group (n= ): fresh al and cryopreservated al. all animals got aspirin for three months and group also cyclosporine a. the implanted grafts were embedded in paraffin and microscopically studied with hematoxilin/eosin and elastic stains for morphology and morphometrics. a basic immunohistochemical study with cd and mac was also performed. results the patency rate of cryopreservated al and au was %, as it was in the fresh au. the inflammatory reaction, evaluated by cd and mac was present in all al arteries, and absent in au cases. in group , the infiltration was lower in cryopreservated, than in the fresh ones. conclusions in our series of pig's arteries, cryopreservation increases vascular patency and the inflammatory response is lower than in fresh arteries. this fact is independent of the immunosupressive therapy. introduction glandular cardiac myxomas are very rare tumors of uncertain histogenesis, displaying glandular structures within otherwise typical myxomas. origin of glands has been attributed to epithelial differentiation of a cardiomyogenic precursor cell or to entrapped embryonal rests. we studied four cases of glandular myxomas ( sporadic and one familial) to define the immunophenotypic profile of the glandular elements. materials and methods histology and immunohistochemistry were performed on serial sections. broad spectrum cytokeratin, cytokeratin (ck ), cytokeratin (ck ), cea, ema, chromogranin a, calretinin, thyroid transcription factor- (ttf- ), ki- and p were investigated. results three patients were males, aged , , , respectively and the fourth a y.o. woman. the glands were either scattered within myxomatous stroma ( cases) or in groups. in the latter case the glands featured villous projections, irregular profile, active inflammation or focal low grade dysplasia, and showed expression of acidic and neutral mucins (mostly sialomucins). cytokeratin and co-expression was found, similarly to foregut derivatives. there were scattered chromogranin-positive neuroendocrine cells in one case and ki- immunostaining showed a very low proliferative activity. there was no reactivity for ttf- , calretinin or p . none of the patients had adenocarcinoma or other neoplasm, either at diagnosis or at - years follow-up. conclusions our findings indicate that glandular component of cardiac myxoma is morphologically heterogenous. the isolated glands suggest a possible divergent (epithelial) differentiation of myxoma cells, but other findings point to the possibility of entrapped foregut rests with mature neuroendocrine and mucous cell populations. work partially supported by grants from the italian ministry of education (rome, to mp) and the associazione italiana per la ricerca sul cancro (milan). infection and immune inflammation peculiarities in atherosclerosis i zota, e foca, e melnic pathology department, the state university of medicine and pharmacy n.testemitanu, chisinau, republic of moldova introduction during the last decade the basic postulate of atherosclerosis etiology and pathogenesis has changed. this review presents a spectrum of data regarding the link between infection and immune inflammation development in atherosclerosis. material and methods this study has been carried out on the human aorta, coronary heart vessels collected from early performed autopsies and on the carotid arteries gathered during surgical vessels remodeling of persons. the patients with cardiovascular insufficiency on atherosclerosis background from to years were taken into study group. chlamydia pneumoniae was detected by routine microscopy on shtive fixed material, and by immunohistochemical reaction performed on cryophilic specimens marked with fits antibodies. hsp- and tnf-α implication have been studied trough immunohistochemical reaction using monoclonal antibodies. this material was fixed in % formaldechyde solution. results chlamydia pneumoniae has been detected in endothelial cells, macrophages, smooth muscle cells of fatty streaks and fibrous plaques. its detection incidence decreases in advanced arterial lesions. we also determined that chlamydia pneumoniae infection is capable to induce immune reaction against hsp- which can be considered like a target in autoimmune reaction. they produce an cytotoxic effect on the endothelial cells followed by permeability disturbances, faciliting the atherosclerotic lesions progress. among the inflammation mediators in increased quantity tnf-α have been detected being localized on the surface and in depth of atherosclerotic plaque around the foam cells. conclusions our outcomes demonstrate the toxic and infectious factors existence which can be considerated decisive in atherosclerosis pathogenesis. this data give us the reason to elaborate other diagnosis and treatment strategy. introduction primary tumours of the heart are rare, the majority are benign, myxomas representing - %. hemangiomas are extremely rare, with an incidence of . %- . %. they usually occur in adults, mostly are an incidental finding. we present a man with asymptomatic cavernous hemangioma of the left atrium. case report transthoracic echocardiogram of a -year-old man with arterial hypertension, otherwise healthy, with normal ecg and chest x-ray, revealed a wide based isoechogenic tumour, measuring . x . cm, located in the moderately enlarged left atrium, attached to interatrial septum and anterior wall, adjacent to mitral valve annulus, sparing oval fossa. it showed minimal mobility but did not cause any obstruction of the blood flow or mitral regurgitation. macroscopically, surgically removed tissue was spongy, partly haemorrhagic. microscopically, there were cavernous venous structures, filled with blood and focally thrombosed. focally, a few smaller capillary channels were found. there was no endothelial atypia and no papillary hyperplasia. discussion and conclusion histologically, hemangioma of the heart has two major differential diagnostic possibilities. in case of a myxoid background, it is possible to be misdiagnosed as myxoma, but in hemangioma there are no myxoma cells and no ring structures. grossly, opposite to myxomas, hemangiomas are rarely attached to the oval fossa. papillary hyperplasia, which is reactive endothelial proliferation in hemangioma, may lead to misdiagnosis of angiosarcoma. angiosarcoma can be excluded only when the whole tumour is examined and no marked endothelial atypia, cellular areas of spindle cells with poorly formed vascular channels, and necrosis are found. compression, obstruction, effusion and bleeding are responsible for clinical picture. symptoms depend also on the location, size and invasiveness. the natural history is unpredictable, for this reason surgical intervention is mandatory. introduction the limb-body wall complex is a congenital syndrome, which includes limb defects, abdominoschisis associated with facial and neural tube malformations. some authors believe that the limb-body wall disruption is separate from amniotic band syndrome. others suggest that both belong to a wider spectrum, with a possible overlap between these two categories. in the present study, we describe a case of lbwc and based on our findings we suggest a new pathogenic mechanism. case report a years-old cap-verdean female gave birth at weeks to a pair of twins. one foetus showed multiple malformations incompatible with life. physical examination showed partial lower extremity amputations. a large omphalocele was also noted. there was a large lumbosacral meningocele and the head showed micrognathia and high-arched palate. there was right hydronephrosis secondary to right ureteral obstruction and cloacal anomaly. the lungs were hypoplastic. the histology of the internal organs was characteristic for the developmental stage and cytogenetic testing revealed a normal male karyotype. discussion and conclusion we believe, that early amniotic bands may lead to vascular insults, proximally and distally by altered haemodynamics. the lower limbs were partly amputated as a result of the continued growth associated with altered vascular supply. the same mechanism may explain the other findings as well. vascular disruption by virtue of altered haemodynamic state may give rise to thromboemboli, which may affect the growth of external/internal structures, distant from the site of disruption. however, this vascular lesion was masked by continued growth of the foetus. therefore, the abs may precede and may cause the lbwc. two cases of pleuropulmonary blastoma k vuopala , h tuominen , r jauhola , p valmari , r herva lapland central hospital, rovaniemi, finland oulu university hospital, oulu, finland pleuro-pulmonary blastoma (ppb) is a malignant tumour of childhood. the most common clinical sign is respiratory difficulty. ppb appears as a pulmonary and/or pleural-based mass and is characterized histologically by a primitive, variably mixed, blastematous and sarcomatous appearance. no metastases have been reported in neonatal cases. we describe two cases that presented ppb. the first was a term male infant of a g p mother. the pregnancy was uneventful. after normal delivery, a male infant with severe respiratory distress was born. by ultrasound examination, a thoracic mass were identified. there was no response to the intensive care. the infant died at the age of . hours. at autopsy, a tumour of g, measuring x cm was found in the left lung. in addition, there was a smaller mass, of cm diameter in the mediastinum. micro-scopically, the tumour masses consisted of ppb. the second case was a -year-old female with persistent fever and respiratory difficulties. in ct scan, the lower lobe of the left lung was replaced with a tumour mass. during operation, the tumour was seen to be infiltrating to the mediastinum and was partially resected, followed by intense chemotherapy. histologically, the diagnosis of ppb was given. the child has shown no sign of the disease during follow-up of six months. the ppb is regarded as the pulmonary dysontogenetic analogue of wilms' tumour, neuroblastoma, and hepatoblastoma. the first case showed its highly aggressive nature, with mediastinal metastases found at birth. causes of intrauterine foetal death associated with placental pathologic features v blažičević , v Štitić , m mrčela clinical hospital osijek, croatia general hospital karlovac, croatia introduction improvements in antenatal and intrapartum care have reduced perinatal mortality, but the rapid advances in intensive neonatal care have had a dramatic effect in reducing neonatal deaths so that stillbirths have become relatively more important. the aim of this study was to identify the relationship between placental lesions and stillbirth. materials and methods we analysed the causes of intrauterine foetal death after the th week of pregnancy during the years - at the departments of obstetrics and gynaecology of the clinical hospital osijek and general hospital karlovac. a complete autopsy was made on each stillborn, including investigation of the placenta, cord and foetal membranes. histological specimens were studied from all internal organs of the foetus and from the placenta, cord and membranes. haematoxylin and eosin stain is used in routine causes, pas staining to assess thickening of the basement membrane and trichrome staining to assess stromal fibrosis of the villi when it was necessary. results there were stillbirths who died before labour - placentas of them were examined and weren't. abnormalities were found in ( . %) placentas and 'normal' placentas were ( . %). autopsy findings in stillborn foetuses: asphixia ( . %), maceration only ( . %), major malformations ( . %), vitium cordis ( . %), anencephalia ( . %), others ( . %). placental pathologic findings: infections ( . %), single chronic and acute infarction ( . %), multiple chronic and acute infarctions ( . %), placental failure for other reasons ( . %), chronic ischemic change ( . %), infections associated with circulatory disturbances ( . %), retroplacental haematoma ( . %), massive subchorial thrombosis ( . %), chorangiosis ( . %), umbilical cord tumour ( . %), intervillous thrombus ( . %), chorionic cysts ( . %). conclusion the most of women with a stillborn infant were quite healthy and did not reveal any risk factors when assessed on clinical grounds. there were patients in whom evident foetal growth retardation had been overlooked at the maternal health centre before the death of the foetus. the importance of routine ultrasound screening for detection of unrecognised risk patients and placentas is emphasized. introduction microscopic diagnosis of oligobiopsy material taken during endoscopic examination plays an important role in diagnosing syndromes of absorption disorders, especially in case of celiac disease. the aim of the study was a morphologic evaluation of the small intestine mucosa and comparison of the used from many years shiner/shmerling classification with a new modified marsh classification. materials and methods during the study, bioptates if small intestine evaluated in the chair and department of pathomorphology in zabrze in the years - were analysed again. out of the bioptates were with i of villous atrophy, with ii, with iii and with iv. study material was from the paediatric hospitals in zabrze and bytom. during routine histopathologic diagnosing, villus atrophy was evaluated in the shiner/ shmerling scale. presently, the marsh scale is being introduced into histopathologic diagnosing. it takes into consideration not only features of villus atrophy and glandular crypts proliferation but also intraepithelial lymphocyte infiltrations. another evaluation of villus atrophy was performed according to the modified marsh classification. the received results are presented in the modified marsh classification: type - ( . %), type - ( . %), type - ( . %), type a - ( . %), type b - ( . %) and type c - ( . %). our study allowed to compare two classifications used in the evaluation of the atrophic and proliferous processes and to select from the shiner/shmerling degree i a group of cases (type and according to marsh), which had no equivalents in the so far used scale. moreover, it was shown that the sub-groups of the type of destructive changes did not correspond fully with the so far used shiner's degrees ii-iv. it enables fast comparison of the atrophy degree with the results received before the introduction of the new modified classification. moreover, a routine application of precise descriptions of histopathologic results of small intestine mucosa in syndromes of absorption disorders facilitates retrospective selection, from the so far used shiner's degree i, of the cases corresponding with marshal types and . conclusions application of the modified marshal classification for an evaluation of the small intestine mucosa in celiac disease enables accurate presentation of atrophic and proliferous changes including selection of type and , which have no equivalents in the so far used shiner/shmerling classification. embryonal rhabdomyosarcoma: a case report s kocmanovska -petreska, b ilievski, p cvetkovski, l spasevska, s kostadinova -kunovska, s duganovska institute of pathology, faculty of medicine, skopje rhabdomyosarcoma is an aggressive malignant skeletal muscle neoplasm arising from embryonal mesenchyme. the head and neck region is the most common site for this tumour in children. neonatal presentation of this tumour is rare. we present an autopsy case of a female newborn having a large tumour mass ( x x cm) in the frontal region, covering the entire upper half of the face. similar subcutaneous noduli with diameter , cm, cm and cm were found on the left cheek, and another with diameter , cm, , cm, cm and cm on the right cheek. the histological examination showed a tumour composed of large spindle cells with myoblastic features and small round to elongated undifferentiated cells. associated with the spindle cells is various numbers of large round or globular cells with hyperchromatic nuclei surrounded by acidophilic granular or homogeneous cytoplasm. cross-striations were found in the spindle cells. imunohistochemically tumour cells were positive for desmin and vimentin. the final diagnosis was embryonal rhabdomyosarcoma. immunohistochemical staining helped to make a proper diagnosis. introduction apoptotic cell death represents an important mechanism for the precise regulation of cell numbers in normal tissues. various apoptosis-associated regulatory proteins may contribute to the rate of apoptosis in neoplasia. the present study analyses the inter-relationship between the expression of the pro-apoptotic bclx (s/l) protein and histological type and stage of wilms tumour. materials and methods bcl-x (s/l) expression was investigated using an indirect immunoperoxidase technique, applying antibodies to bcl-x (s/l) protein. correlation of semi quantitatively scored bcl-x (s/l) levels with histological type and tumour stage was performed for cases of wilms tumours ( classical and anaplastic). results the expression of bcl-x (s/l) protein was present in most cases of wilms tumour ( %). generally, bcl-x (s/l) was expressed in the blastemal and epithelial components of wilms tumour. in most cases, the expression of bcl-x (s/l) was moderate. blastemal bcl-x (s/l) expression decreased with tumour stage. there was no correlation between histological type and expression of bcl-x (s/l) protein. diffuse expression of bcl-x (s/l) protein was observed in cases of anaplastic wilms tumour. these two cases were stage i and of unfavourable histology. in cases of wilms tumour, no immunohistochemical staining was observed. so, these results cannot indicate whether absence of bcl-x (s/l) could play a role in the development of anaplasia. conclusion according to clinical follow-up, the results of our morphologic and immunohistochemical analysis suggest that decrease of the blastemal bcl-x (s/l) protein could be associated with the capacity of wilms tumour for local and distant spread. expression of alpha, beta and gama catenins in wilms tumour s radojevic background loss of catenins is suggested to promote tumour invasion and distant metastasis in tumour development. the aim of this study was to determine the expression of catenins in wilms tumour and their relationship with histological type and stage of wilms tumour. materials and methods catenins expression was investigated using an indirect immunoperoxidase technique, applying antibodies to alpha, beta and gama catenins. correlation of semiquantitatively scored adhesion molecule levels with histological type and tumour stage was performed on cases of wilms tumours ( classical and anaplastic). results beta and gama catenins were present in most cases ( % and % respectively) and were usually coexpressed. anaplastic type of wilms tumour displayed higher beta catenin and lower gama catenin level in comparison with other types. nuclear positivity, in each case, was found to be very strong, but was usually present only in % of tumour cells. beta and gama catenin expression was not correlated with stage of wilms tumour. alpha catenin was present in % cases of wilms tumour. stage iii displayed higher alpha-catenin levels than stage i/ii, suggesting that impairment of their function might exist without actual loss from tumour cells. conclusion our results suggest that the level of catenin expression is associated with histological type of wilms tumour, regardless of tumour stage. observed nuclear expression of beta catenin indicates that the activation of wnt-signaling pathway is crucial step in wilms tumour genesis. comparison of apoptosis and fas, fas-l and bcl- expression in wilms' tumor m ergin, a uguz, s erdogan, g gonlusen, n tunali cukurova university school of medicine dept. of pathology, adana, turkey background apoptosis is a complex process involving many genes that play role as antiapoptotic or apoptotic factors. it controls normal homeostasis of tissues. expression of these genes vary from one type of tumour to another type. the aim of this study is to evaluate the expression of bcl- , fas and fas-l and apoptosis in wilms' tumour (wt). method thirty paraffin embedded tissue specimens were included. immunohistochemical study was performed for bcl- , fas and fas-l and in-situ end-labelling technique (isel) for apoptosis. results the expression of these proteins varied among the tumours. there was no statistically significant correlation between the expressions of bcl- , fas, fas-l and. apoptotic index. conclusion apoptosis is an important mechanism in the growth of the tumours. we suggest that not only bcl- , fas and fas-l play role as regulators of apoptosis in wt but also other apoptotic and antiapoptotic genes involve this process. further investigations are necessary to understand the molecular mechanism of the progression of wt. uncommon tumours of the neuraxis in childhood j vila-torres hospital universitari sant joan de déu. department of pathology, barcelona, spain case a year-old girl presented with seizures and weakness in the left part of de body of -year duration. ct scan showed a mass that filled the right ventricle, with a strong mass effect, peritumoural oedema, midline shifting and slight ventricular enlargement. a partial excision was carried out and the pathological diagnosis was that of choroid plexus carcinoma. the patient died six months later due to adjuvant therapy side effects. in the last who classififcation of brain tumours, grade iii choroid plexus carcinoma is defined as a choroid plexus tumour showing features of malignancy: nuclear pleomorphism, frequent mitosis, high nuclear/cytoplasmic ratio, increased cellular, density, blurring of the papillary pattern, poorly structured sheets of tumour cells, necrotic areas, and often diffuse brain invasion. all those tumours classically displaying a papillary pattern must be considered in the differential diagnosis. case a month-old child presented with respiratory distress since months old. on rx and ct scan, a tumour in the left hemithorax was seen, with right shifting of the mediastinum. the tumour was partially removed. pathological diagnosis was that of spinal canal invasion by a soft tissue lipoblastoma. eight months after surgery the tumour relapsed, infiltrating the epidural spinal canal from c to d . the tumour was fully excised by means of microsurgery techniques, without neurological deficits. this case is an example of invasion of the vertebral canal by a soft tissue tumour previously removed. lipoblastoma is a rare fatty tumour occurring in children in the extremities or less commonly in the trunk or retroperitoneum. the tumour is benign but may recur. grossly, lipoblastoma showed a distinct lobulated pattern of yellow-grey myxoid tissue, histologically composed of highly vascular fat in a myxoid stroma resembling embryonic white fat. differential diagnosis, based on clinical-pathological grounds, include fibrolipoma and myxoid liposarcoma. case a year-old boy presented with partial complex seizures for year duration. nmr showed a discrete hypodense corticalsubcortical lesion in the left frontal lobe. neither oedema nor mass affect was detected on ct scan. the tumour was completely removed by surgery and the pathological diagnosis was that of dysembryoplastic neuroepithelial tumor. this is an intracortical grade i tumour composed of oligodendrocyte-like cells. macroscopically, is a nodular outward expansion of the superficial cortex. histologically, a low-power view of a perpendicular section of the cortical surface shows the characteristic pattern of multiple intracortical nodules and internodular tissue, both containing mucin. also seen, is a specific glioneuronal component of vertical columns of neu-rites transversing the cortex, sheathed by oligodendrocyte-like cells accompanied by mucin and with 'floating neurons' (cortical ganglion cells seen in individual small pools of mucin). case a year-old boy presented with diplopia and proptosis. the nmr showed a hypodense, diffuse lesion in the left temporal and parietal lobes that produced a slight collapse of the left lateral ventricle. two weeks later the patient developed symptoms of time and space cognitive disturbances, language difficulty and seizures. a biopsy was done and the pathological diagnosis was that of gliomatosis cerebri. this is a rare primary brain tumour characterized by a diffuse proliferation of neoplastic glial cells that typically involve multiple brain areas with preservation of brain structures. the diagnosis depends on both histologic and radiologic features. on nmr there is a uni or bilateral diffuse involvement of the white matter extending to the cortex with poor mass effect. microscopically, there is a proliferation of monomorphous astrocytes, grade ii or iii, infiltrating the brain parenchyma freely. some undifferentiated cells show 'naked' nuclei while others look like 'rod' structures. in cases of low cellularity and cytologically bland astrocytes, it may be extremely difficult to make the differential diagnosis with reactive gliosis. gc is associated with a poor prognosis. introduction production of materials for dental implants is of great social importance and is related to the progress in material technology. main directions of development in this discipline concern an accurate choice of implant material in order to fix an implant in a bone tissue firmly and to decrease tissue reactions. new direction of research on implant materials is powder metallurgy. in comparison with the so far used technologies, it has many advantages, such as homogenous fine grained material structure, possibility to make composites including biologically active implants, and also ability to overgrow the implant with bone tissue. aim of the study was morphological analysis of healing of dental alveolus canals filled with metal implants. evaluation of tissue reactions in bones and surrounding soft tissue from several types of metal implants. material and method the experimental study was performed on mixed breed rabbits of - g weight. after premedication with atropine with relanium, surgical procedure was performed in each animal. one of the incisors was extracted and after the canal was formed, metal implant was inserted. the first group (d ) consisted of animals whose dental alveolus canals were filled with cylinder of x mm made of pressed co-cr-mo alloy covered with calcium triphosphate. the second group (d ) consisted of animals whose dental alveolus was filled with implants of cylindrical shape of a size x mm made of pressed co-cr-mo alloy. the third group (d ) consisted of animals whose dental alveolus canal were filled with a titanium screw of a size x mm. the control group (k) consisted of animals whose dental alveolus canal was left only with blood clot. the postoperative wounds were sutured with dexon thread. the clinical and observations and histopathological introduction correct reconstruction of bone defects is a serious problem in orthopedics and in maxillo-facial surgery. hence, numerous experiments and clinical studies on a usage of natural and artificial materials being a scaffold enhancing a reconstruction of bone tissue (i.e. carbon fibre, hydroxyapatyte granulate). deproteinized bovine bone is a new material. it was elaborated in at the mineralogy faculty, mining and steel academy in kraków. the technology of natural animal bone tissue enables its use in filling bone defects, accelerates reconstruction of bone tissue and minimizes unfavorable tissue reactions through total immersion into the reconstructed bone. it gives no incorrect immunological response of the body to the implanted xenogenic tissue. the aim of the study is to evaluate healing processes of the defects made in rat femoral bones and filled with deproteinized bovine bone and to compared it with spontaneous healing. material and method the experiment was conducted on wistar rats divided into groups ( rats per group). the surgically made bone defects were filled with the study material. the animals, whose defects filled with blood clots spontaneously, made up a control group. the healing process in bone tissue was examined clinically and morphologically after , , , , and days after the experiment. results in histopathological estimation, the healing speed of the defect in femoral bone filled with blood clot (control group) was compared to the healing of the defect filled with deproteinized bovine bone (study group). no inflammatory reaction to the implant was observed. moreover, acceleration of the healing of the defect filled with deproteinized bovine tissue was observed. bovine bone was, in the study group, totally immersed in the body's bone tissue, i.e. was surrounded by the arisen on its surface sponge bone. in the last periods of the observation, on the borders of the observed synostoses no osteoblast cell activity was observed and normal bone marrow was found between osseous trabeculae. conclusions osseous wounds filled with deproteinized bovine bone heal without any inflammatory complications. no negative systemic reactions proves that the applied material was properly prepared for implantation. histopathologic studies showed that deproteinized bovine bone accelerates regeneration process of a damaged bone tissue. withdrawn p- the effect of specific inhibitors of caspases on apoptosis of thymocytes induced with paclitaxel although caspases are involved in molecular mechanisms of the execution phase of apoptosis, the precise mechanisms of their involvement in paclitaxel induced apoptosis are still not identified. the aim of this study was to investigate and compare the effects of inhibitors of caspases ( mmol/l) on apoptosis of rat thymocytes induced by paclitaxel ( mmol/l) and colchicine ( mmol/l). the effect of z vad and specific inhibitors of caspases (caspase , and ) after , and hours of incubation of thymocytes with paclitaxel and colchicine were analyzed. after incubation cells were fixed, processed for lm and em, and the percentage of apoptotic cells (apoptotic index) was determined. general inhibitor of caspases zvad and inhibitor of caspase led to a significant decrease of apoptotic index after hours of incubation with paclitaxel (from . % to . % and . %). inhibitor of caspase and caspase lowered the apoptotic index after hours incubation with paclitaxel from . % to . % and . % respectively. inhibitor of caspase did not affect the apoptotic index in controls, while the other used inhibitors reduced it. inhibitors of caspase , and and zvad had similar effects on apoptosis of thymocytes induced by colchicine. these results show that apoptosis induced by paclitaxel is caspase dependent, and that it, due to the effect of inhibitor of caspase , probably involves mitochondria. caspase activity might also be involved in mechanisms of induction of apoptosis of thymocytes by paclitaxel. effects of concurrent administration of lithium and gentamicin on the histoembryogenesis of rat fetus during the developing periods this study was planned to investigate the effects of gentamicin and littium on rat histoembryogenesis and to determine the effects, if any, of lithium as a potent gentamicin inhibitor. the rats were exposed subcutaneously to -mg/kg gentamicin on days - of gestation. lithium administered orally at doses mg/l on days - of gestation. fetuses were collected on day and compared with those of the untreated, and saline treated control as well as with those of the gentamicin and lithium treated groups. all control and cases embryos groups were killed and their tissues were obtained. then prepared for paraffin block, sectioning, h-e staining and light microscopic studies. we fond that gentamicin caused growth retardation versus lithium which dosn't did so. lithium has a state like control but no wary exactly. furthermore, concurrent administration of gentamicin and lithium caused regularity in histoembryogenesis cycle and the normal growth beside the lithium or gentamicin. of course the recent result is not exactly comparable to those of controls. t- toxin, a solitary hypergranular mcs were situated on the external wall of blood vessels. however, on days , and the number of perivascular mcs was increased. more than percent of these mcs showed degranulation. conclusion our results suggest that perivascular localisation and later degranulation of mcs may play an importantant role during the acute reaction in the heart of rats poisoned by t- toxin. effects of bromadiolone on rodent liver: pathohistological findings o- , o- takeda k, p- takeyama j, p- talalaev a, p- talan-hranilovic j, p- tammi m, p- tammi r, p- tanase c, p- tanaskovic italy author index the numbers are the abstract numbers p- o- gruia am o- , p- o- , p- sever m, p- sever-prebilic m skender gazibara m, o- , o- , m, p- p- , p- , p- , p- , p- , p- , p- srebotnik kirbis i, o- arrhythmogenic right ventricle dysplasia and sudden cardiac death. controversial aspects p- basal cell characteristics in breast carcinoma with medullary features (cmf) acknowledgement: dr chu is supported by nhri-ex - sc, nhri-ex - sc and bmrp . all chosen antibodies gave a specific and reproducible staining. there were no false positive or negative results. the panel can be recommended for screening for defects in the mmr-system. immunoexpression introduction several cytological features are taken into account in infiltrating duct carcinoma of the breast. the aim of this study has been to assess the prognostic value of the nucleolar area by means of ultrastructural morphometry. materials and methods forty-six cases of ductal carcinoma of the breast were included in the current study. all biopsies were processed for electron microscopy and electron micrographs were taken at x , magnification. nucleolar area measurements were done using sigmascanpro software and statistical analyses were performed. nucleolar area measures were categorized in terciles. a kaplan-meier estimation was performed to assess those measures related with disease-free interval. measures that reached statistical significance were dichotomized at the cut point with maximum likehood in a cox regression model and then were included in a multivariate analysis. results statistically significant differences were found in terciles per area (p= . ) and per variation coefficient (p= . ). in terms of nucleolar area measurements, any given nucleolar area with a standard deviation . , showed a relative risk for recurrence of . ( . - . ) (p= . ).conclusions ultrastructural morphometry shows that nucleolar features, particularly those related to size heterogeneity, have a significant impact on prognosis. determination of ploidy in different lesions of prostate a ibraeva , m alchinbaev , a seitaliyeva scientific center of urology, department of pathology, almaty, kazahstan scientific center of urology, almaty, kazahstan immunohistochemical correlation between pattern of postatrophic hyperplasia and carcinoma of the prostate ar botticelli penile leiomyosarcoma-morphological and immunohistochemical study g berdan, a petrescu, c ardeleanu prof. dr. th.burghele hospital, bucharest, romania introduction our case is about a years old male patient who was admitted with the diagnosis of a penile tumor, reason why a total penectomy was performed. material and methods fragments of the tumor and penile tissue were fixed in formalin %, embedded in paraffin and sections were stained with he and vg. immunohistochemical tests have been done: actin, vimentin, s , ae -ae , hmb , pcna. results on macroscopic examination, the tumor was bulky, ulcerative nodular, occupying the glans and the distal part of the shaft; it was gray white coloured, with hemoragic areas. microscopic examination revealed a tumorous proliferation of elongated cells with moderate nuclear pleomorphism and mitosis (typical and atypical), organised in a fascicular pattern, well vascularised; the tumor was superficially ulcerated and invaded the corpora cavernosa. the tumor was diffusely positive for actin and vimentin, focally positive for s , negative for ae -ae and hmb , and pcna was %. conclusions the morphological appearance and immunhistochemical results led us to the diagnosis of penile leiomyosarcoma, moderately differentiated. do human papillomaviruses infect proximal parts of the male genital tract? introduction human papillomaviruses (hpv) play an essential role in the pathogenesis of squamous cell carcinoma of the uterine cervix. the male urogenital tract is considered to be a reservoir of hpv infection. our previous finding of hpv in the squamous metaplastic epithelium with dysplasia in the epididymis prompted us to start a study focused on the presence of hpv in the male genital tract. aims: verifying the presence of hpv in the epididymis, ductus deferens and seminal vesicles. materials and methods samples from three groups (a, b, c) of patients were analysed by means of nested pcr for the presence of hpv dna extracted from a paraffin-embedded tissue sections. types of hpv were determined by dna nucleotide sequencing of the pcr products. group a consisted of patients (mean age , age range - , except for one patients years old), group b consisted of patients (mean age , age range - , except for two patients and years old) and group c consisted of patients (mean age , age range - ). patients in group a were surgically treated for non-tuberculous epididymitis ( epididymal introduction glucagonoma is an alpha-cell pancreatic neoplasm with incidence of one in million; the malignancy rate is unknown. the clinical, pathologic, immunohistochemistry and electron microscopy characteristics are described in a mexican cohort of patients. material and methods we reviewed the pathology archives of incmynsz and hocmnsxxi for pancreatic tumors with neuroendrocrine morphology and expression of immunohistochemistry markers for neuroendocrine and glucagon-related peptides. complete clinical history and follow-up were achieved. results six cases of glucagonoma were obtained. electron microscopy was available in two cases. three man and three women with median age of . years, were admitted with glucagonoma syndrome complaints. the tumor localization was: head of pancreas ( / ) and tail ( / ), with average size of . cm. two cases showed hepatic metastasis. the histopathologic study was constant with contrasting architectural, cytologic and mitotic count in all the cases. expression of neuroendocrine markers was observed in all cases, with positive glucagon stain, and negative for secretion markers (insulin, pp, serotonin, calcitonin). in electron microscopy, dense core granules were identified in two cases. discussion there are cases of glucagonoma described in english literature; no one is originated from latin american population. in this series, the neoplasms have equal prevalence for female and male patients, all from elderly group. the morphologic feature extremely varies in each tumor, the malignancy criteria were correlated in two cases with vascular invasion and this coincides with metastasis. a peculiar finding are the only expression of glucagon in tumoral cells, and two malignant cases with liver metastasis. estrogens regulate the development, maturation, and function of various organs, including the thymus. therefore it is suggested that estrogens play important roles in the development of human thymoma. however there is no study about influences of sex steroids to human thymoma. in this study, we examined the immunohistochemical localization of sex steroid receptors for estrogen (er)α and erβ, progesterone (pr)-a and pr-b, and androgen (ar) in human thymoma (n= ), and correlated these findings with various clinicopathological parameters. we used reverse transcription polymerase chain reaction (rt-pcr) and realtime pcr to further study the expression of these receptors in thymoma cases. results immunoreactivity for all sex steroid receptors was detected in the nuclei of thymoma epithelial cells. the percentage of immuno-positive cases and h-score values for each receptor (mean±sd) were: erα, . % and . ± . ; erβ, . % and . ± . ; pr-a, . % and . ± . ; pr-b, . % and . ± . , and ar, . % and . ± . , respectively. results of real-time pcr were consistent with those of immunohistochemistry especially results for erα, pr-b, and ar. a significant positive correlation was detected between immunoreactivity for erα and pr-b. erα immunoreactivity was inversely correlated with tumor size, clinical stage, who classification and ki- labeling index. in addition, the status of erα immunoreactivity was significantly associated with a better clinical outcome in thymoma patients. conclusions sex hormones receptors express in human thymoma, and especially erα may be related to sex, clinical stage and pathological cell type. galectin- immunodetection using a biotin-free system in a series of oxyphilic (hurthle) cell tumors of the thyroid m volante , f bozzalla , r depompa , c pecchioni , a bartolazzi , m papotti dept. biomedical science and human oncology university of turin, turin, italy s. andrea hospital, university of rome, rome, italy introduction galectin- was reported to distinguish follicular and papillary carcinomas of the thyroid from adenomas, but controversial results were obtained in oxyphilic cell tumors, possibly related to endogenous biotin reactivity. the aim of this study was to assess the role of galectin- immunodetection in a large series of benign and malignant oxyphilic tumors. materials and methods galectin- expression was retrospectively analysed in thyroid oxyphilic (hurthle) cell tumors, including adenomas [oa], carcinomas [oc], oxyphilic variant of papillary carcinoma [optc] and in control cases of goiter with oxyphilic changes and hashimoto's thyroiditis. a purified galectin- monoclonal antibody and a biotin-free immunoperoxidase procedure were used in paraffin embedded specimens. results of ocs were focally ( cases) or diffusely ( cases) positive. / optc were focally ( cases) or diffusely ( cases) reactive. overall, malignant oxyphilic tumors were positive in % ( / ). oa had a focal reactivity in % ( / ) of cases, with a preferential subcapsular immunostaining. sensitivity and specificity were % and %, respectively. control oxyphilic goiters were negative ( / ), as opposed to hashimoto's thyroiditis (oxyphilic cells positive in / cases). conclusion the role of galectin- immunoreactivity in the differential diagnosis of benign and malignant follicular lesions is confirmed also in oxyphilic cell tumors. the focal immunoreactivity observed in adenomas may be probably related to a true expression of galectin- , as confirmed by mrna expression by means of in situ hybridisation, and could be related to early malignant changes in tumors still lacking the currently accepted morphological signs of malignancy. introduction fine-needle aspiration (fna) is a very useful method for diagnosing various lesion in the thyroid gland, among them hashimoto's thyroiditis (ht). although many methods may be used, fna is a necessary diagnostic procedure nowadays in order to confirm the diagnoisis of ht. material and methods durind a period of years citologically aspirates were citologically analyzed, stained with he and mgg. the main cytological guidelines in the diagnostic procedure were: . lymphocytic cellularity of smears, . oncocytic follicular cells, . a lot of cellular debris. results from aspirates analyzed ( , %) were diagnosed as ht. there was a high statistical significance in sex and ages for the genesis of ht (χ = , ; p= , ). we analyzed correlation between clinical and cytological diagnosis: in cases initial clinical diagnosis was "thyroiditis", and among them ( %) were cytologically confirmed. from patients with an fna diagnosis of ht the same diagnosis was susspected clinically in cases ( %). several authors noted a high incidence of thyroid carcinoma in patients with ht. we researched association of ht and thyroid tumors, and we did not confirm that ht is a premalignant lesion (χ = , , p< , ). conclusion ht and its association with other lesions could be clearly diagnosed with fna, and we recommend fna as a first line investigation in ht. colposcopic and cytologic findings in hpv infection of the uterine cervix r zivadinovic, v lilic, b djordjevic, s petric gak nis, university clinical center, nis, serbia and montenegro introduction uterine cervical carcinoma is a sexually transmitted disease. hpv infection, especialy types , and oncogene is directly associated with occurrence of preinvasive and invasive changes in the uterine cervix ranging from - %. cyto-pathologic effect of this virus presence in a cell is called koilocytosis and occurs by the effect of fragment e on cytokeratin building protein.koss observed these changes back in , describing them as irregular cavities in cell protoplasm, but only later these cytologic findings were related to hpv infection. in our retrospective study we analyzed colposcopic and cytologic findings of examinees in which the diagnose of hpv infection was established by biopsy. material and methods the mean age of examinees was , , and in regards to parity and menarche there was no statistically significant difference between experimental and control group, since coefficient t was lower than , p< , . therefore we concluded that the sample was representative. results sensitivity of cytology in detection of hpv infection of the uterine cervix was , % and the specificity was %. positive predictive value was % and negative %. the most frequent colposcopic findings in the uterine cervix in case of hpv infection were aceto-white epithel in % and mosaic in %. other colposcopic findings were significantly lower (punctate %, leucoplakia , %). in examinees with colposcopically diagnosed hpv infection in external genitalia, the infection was also present in the uterine cervix in , % which was statistically significant for x = , >(x ( ; , )= , ). conclusion based on the results presented above, we concluded that sensitivity of cytology in the detection of hpv infection of the uterine cervix was low and that it was necessary to combine that method with colposcopy and directed biopsy. in case of colposcopically diagnosed condylomas of the external genitalia and presence of pathologic colposcopic findings of the uterine cervix (aceto-white epithel, mosaic), the presence of hpv infection in the uterine cervix can be expected with high probability. fine needle aspirate of papillary thyroid carcinomas in correlation with histological diagnosis material and methods cases of thyroid aspirates were studied in correlation with histological findings. the patients were - years old (mean age , ). cytological diagnosis was made according to morphological criteria such as arrangement of cells, nuclear atypia and special features (colloid, giant cells, psammoma bodies). cytological diagnosis was in agreement with the histological diagnosis in cases ( , %). cases were follicular adenomas and one hürthle cell tumor. in cases of disagreement between cytological and histological diagnosis the cytomorphological findings were analysed. conclusion cytological evaluation of papillary thyroid carcinomas is of high diagnostic accuracy, although overlapping of cytological criteria between the various pathological entities may lead to false evaluation. the value of universal short-term storage cell medium in processing fnab samples for ancillary diagnostic methods introduction the application of ancillary methods to fnab samples is mainly impaired by a limited quantity of cells in the introduction changes in the collagenous matrix may participate in the pathogenesis and progression of human aortic valve stenosis (as). we investigated the expression, localization, rate of synthesis and composition of type i and iii collagens in as. methods type i and iii collagen mrna expression and the immunohistochemical localization of the collagen antigens were studied from as and normal aortic valves. the concentrations of various type i (pinp, picp, ictp and synthetic peptide sp ) and iii (piiinp and iiintp) collagen antigens were measured by radioimmnoassays in soluble tissue extracts and trypsin solubilized calcified and noncalcified matrices of as samples, and healthy aortic valves of different ages. results the synthesis of type i collagen, localized in the myofibro-blasts adjacent to calcified nodules, was - -fold higher in as compared to controls. the proportion of collagen in total protein fraction was % in the healthy valves, % in the noncalcified matrix and % in the calcified matrix of as valves. in calcified valves the ictp content was -fold higher than in the age matched controls and -fold higher than the young control group. in the controls, ictp (r=- . , p< . ) and iiintp (r=- . , p< . ) decreased with age, whereas sp /ictp ratio increased (r= . , p< . ). conclusions type i collagen synthesis was increased in as. localization of this collagen adjacent to calcified nodules and the profile of the c-telopeptide cross-linking indicate that the ectopic aortic valve calcification may have similarities to bone matrix mineralization.introduction the objective of this study was to determine the potential value of digital thermography (dt) for the assessment of micro-and macroangiopathies of lower limbs in diabetes mellitus (dm). we have studied patients (pts) with dm ( male). pts had dm type i, pts had dm type ii, with age varying from to years. thermograms were acquired using an original pc-interfaced thermograph, averaged and reformatted to x -bit images. analysis included filtering, background cutoff, obtaining x-and y-axis profiles and averaged temperature curves (atc), determination of local maximums and minimums of the atcs, definition of anatomic regions, building regions of interest (roi). results following thermogram patterns were found: . asymmetric unilateral hypothermia of st toe (in % of dm i cases; probably indicating microangiopathy); . bilateral symmetrical hypothermia of both feet at the level of distal phalanges (in % of dm i cases); . unilateral hypothermia of foot ('thermo-amputation'); . unilateral hyperthermia of foot and tibial region; . focal hyperthermic regions (diameter = .. cm; indicating potential subsequent ulceration). atcs and symmetric left-right roi comparisons helped distinguishing between macro-and microvascular disease, between neuro-and angiopathy in dm, evaluating therapy effectiveness. dt was most valuable in surgical cases, permitting ( ) to locate the optimum level of amputation and ( ) to detect early the inflammation. conclusion dt results correlate well with pathomorphology, and depend upon dm type, dm duration, and presence of local inflammation. immunomodulatory treatment improves myocardial histopathology and function in patients with biopsyproven myocarditis aim the aim of this study was to determine the impact of immunomodulatory treatment (interferon-α) on myocardial histopathology and contractility in patients with biopsy-proven myocarditis (mc). methods a total of consecutive pts ( / male, mean age + years, baseline ef= . + . %) underwent endomyocardial biopsy which established diagnosis (using modified dallas classification) of mc (active mc in / pts, focal-active mc in / pts, borderline mc in / pts, and healing mc in / pts). all patients received interferon-α (sc application, miu, time pw, for months) on top of conventional triple therapy for heart failure. rebiopsy was performed in all patients after the termination of interferon-α treatment, and both baseline ef and repeated biopsies were analyzed. semiquantitatively we comapred the amount of cellular infiltrate, degenerative and/or necrotic changes, and interstitial fibrosis. repeated biopsies were than classified as improved, no change and/or deteriorated, for each histopathological variable (by pathologists, in a blinded manner). results by the end of interferon-α treatment ef improved significantly ( + . % vs. . + . %), and no deaths were introduction tumor necrosis factor (tnf)-alpha has been recognized as important physio-pathogenic factor in the initiation and continuation of inflammatory cardiomyopathies. experimental and preliminary human studies have demonstrated that tnf-alpha plays a crucial role in enteroviral-induced myocarditis. the aim of this study was to investigate the expression of tnf-alpha and both its receptors (tnfri and tnfrii) in the endomyocardial biopsies of patients (pts) with viral and non-viral myocarditis. myocardial expression of tnf-alpha was then correlated with different clinical and pathologic findings. material and methods tnf-alpha expression was investigated in endomyocardial biopsies obtained from pts with myocarditis and from control subjects by using reverse transcriptase (rt)polymerase chain reaction (pcr) and immunohistochemistry. viral etiology was diagnosed by pcr in cases. immunohistochemistry was also used to analyse both tnf-alpha receptors (ri and ii). score - was used to grade morphological findings. tnf-alpha mrna and tnf-alpha protein was significantly more present in viral myocarditis than in non-viral myocarditis ( / vs / , p= . ). remarkable immunostaining was observed for both receptors, particularly for tnfri. histological analysis revealed that myocardial necrosis (score . vs . p= . ) and cellular infiltration (score . vs . p= . ) were more prominent in tnf-alpha positive cases. among tnfalpha positive cases, tnf-alpha mrnas were greater in pts with more impaired cardiac function. conclusion our findings indicate that the expression of tnfalpha plays an important role in the pathogenesis of viral myocarditis of any etiology and may influence severity of cardiac dysfunction. cytokine effects are more strictly linked to overexpression of tnfri. recurrence of viral myocarditis after cardiac transplantation: a retrospective study in a pediatric population introduction the objectives of this study was tot verify comparatively clinical age reported antecedents and the morphological aspect of the intestinal mucosa in patients sensitive to gluten, hospitalised at iomc (alfred russescu hospital) in the last years. celiac disease is an inflammation most frequently affecting the proximal small intestine, depending on the presence of gluten in the diet, whose pathogenesis seems to be immunological in nature. methods cases were divided in three groups following clinical manifestations types at hospitalisation time: typical digestive, untypical digestive and extra digestive manifestations. intestinal biopsies, made with crosby probe, in children aged between . and years (one single case was diagnosed as late as at the age of ), regardless of gender. then we analysed morphologically (he usual and pas histochemical staining) and immunohistochemically (lymphocytes b, t with possible subtypes). the lesions counted according to the marsh score were at the first biopsy: - marsh i infiltrating lesions (normal mucosa architecture, villi epithelium infiltrated with lymphocytes; lymphocytosis score: lymphocytes / enterocytes); - marsh ii infiltrating lesions (almost normal villi, enlarged crypts with immature epithelium and infiltrated with lymphocytes); - marsh iiia destructive lesions (partial villi atrophy (va) shortened, flattened villi, slight infiltration with intraepithelial lymphocytes and hyperplasic crypts); - marsh iiib destructive lesions (subtotal va clearly atrophied villi, still recognizable, widened hyperplasic crypts containing immature epithelial cells with a higher growth rate and influx of inflammatory cells); - marsh ilic hyperplasic lesions (total va completely absent villi, with severe atrophy, atrophied, hyperplastic glands and infiltrating lesions). the immunohistochemical tests have indicated the prevalence of t lymphocytes (uchl , cd , cd , cd , gama-delta) both in the luminal epithelium with various degrees of aggression in lamina propria and also spread in stroma. b lymphocytes (l ) are distributed prevalently nodular in stroma. conclusion in conclusion, it is cd t cells that are present in particular in the control of the gluten immune response in patients with marsh i and marsh iii lesions. clinical morphological analysis of early forms of polyarteritis nodosa h mazur- introduction polyarteritis nodosa is a necrotic vasculitis of small and medium size arteries of not fully recognized aetiology. however, it occurs mostly in adults, it can also occur in children. the cutaneous form is one of the types of polyarteritis nodosa. it occurs in children very rarely. polyarteritis nodosa is diagnosed on the basis of histopathologic results and clinical criteria established by the america college of rheumatology. the aim of the study was to present cases of polyarteritis nodosa in children. case reports three cases of cutaneous polyarteritis nodosa in year old girls and case of general form of p.n. in a -year old boy at the beginning a tumour of pancreas head was suggested in the latter case. the final diagnoses in all cases were defined on the basis of histopathologic results the morphologic studies showed: skin and subcutaneous tissue specimens of mm diameter and mm thick were evaluated. epidermis and corium were of normal structure. abundant inflammatory infiltration consisting of neutral and acidophilic granulocytes, lymphocytes and plasmatic cells were observed on the boarder of corium and subcutaneous tissue. the infiltration was situated mainly in arterial walls and surrounding fibrous and fatty connective tissue. different degrees of change advancement were observed in the walls of the vessels. some changes were characteristic for an early stage of a disease and were demonstrated as swelling of the vessel wall and surrounding tissues (degeneration stage). in the oedematous wall fibrin concrement and only a few inflammatory cells were present. other cells included abundant transmural inflammatory infiltrations (inflammatory stage). vessel endothelium underwent desquamation and thrombi begun to appear in the arterial lumen. only in few vessels, the process of considerable advancement of changes was observed -a repair process with consecutive fibrosis and thickening of arterial wall with considerable narrowing of its lumen. the described children were treated successfully with corticosteroid therapy and antistreptococcal prophylaxis with long-term remission. comparative morphologic analysis of the small intestine mucosa in a course of coeliac disease p- effects of sildenafile on ipsilateral testis damage following testicular torsion in rats g kale , ih gol , d orhan , n kale hacettepe university, medical school, ankara, turkey gazi university, medical school, ankara, turkey introduction testicular torsion results in damage of the gonad and it is a surgical emergency. testicular torsion evokes infertility as a result of ischemia. the aims of this study were to determine the effects of a vasodilatator agent sildenafile on the testicular damage following testicular torsion. materials and methods forty-two rats included to the study were divided into groups: group ; control, group ; sham, group : torsion (detorsion is performed hours after torsion and orchiectomy is done at the th hour), group ; torsion, detorsion and sildenafile ( mg/kg), group ; torsion and sildenafile ( mg/kg), group ; sildenafile ( mg/kg) without torsion, group ; sildenafile ( mg/kg) without torsion. testicular specimens were examined histopathologically for johnsen tubular score and tubular diameter. the differences of these parameters between groups were evaluated statistically. results johnsen tubular score and tubular diameters were fond to be significantly different in control and torsion groups (p< . ). johnsen tubular score and tubular diameter were significantly higher in the torsion groups which were given sildenafile, and these parameters were again higher in the group which have taken sildenafile at a higher dose (p< . ). conclusion it is concluded that, by inhibiting cyclic guanosin monophosphate specific phosphodiesterase and resulting in vasodialatation, sildenafile reduces the testicular damage caused by torsion (ischemia). introduction autopsy studies in adult patients who had died of sepsis revealed a profound, progressive, apoptosis-induced loss of cells of the adaptive immune system (hotchkiss et al, new engl j med, ; : - ) . in neonatal sepsis and chorioamnionitis, thymus modifications and shrinkage have been exhaustively described (toti et al, hum pathology ; : - ), while morphology of the spleen has not. the aim of this study was to describe the morphology of the spleen in neonates with early onset sepsis and with chorioamnionitis. material and methods the study population has been described previously (toti et al, hum pathology ; : - . ten preterm or full-term neonates who died because of proven sepsis within hours after birth (mean gestational age±sd, . ± . weeks); foetuses spontaneously aborted ( ± . weeks) because of extensive ascending chorioamnionitis. controls included foetuses with induced termination of pregnancy ( ± . weeks) and babies who died suddenly in the perinatal period, without evidence of chorioamnionitis. spleen cell populations were studied by means of immunohistochemistry. results early onset sepsis in the neonates occurred with severe spleen depletion, involving both b and t lymphocytes. in particular, cd +, cd r + and cd + cells were dramatically diminished in the spleen of neonates with sepsis, in comparison to controls. foetuses with chorioamnionitis also showed spleen cell depletion. conclusion these results indicate that preterm and term neonates show an inflammatory reaction similar to that of adult patients, and that chorioamnionitis is associated with an unspecific inflammatory response comparable to that of sepsis. introduction hemophagocytic lymphohistiocytosis (hlh) is a disorder of an immunological disturbance with proliferation of cells of the mononuclear phagocyte system, with the histiocyte as a central cell. it includes two different conditions: primary or familial hlh, an autosomal recessive disorder in which most patients develop the disease very early in life, and secondary hlh associated with neoplastic, autoimmune and a variety of infectious diseases, occurring as sporadic cases throughout life period. clinically the disease is characterised by the occurrence of a hemophagocytic syndrome of prolonged fever and splenomegaly with laboratory signs of cytopenias, lipid, coagulation and liver abnormalities. hemophagocytosis is readily identified in bone marrow, spleen or involved lymph nodes. central nervous system spread of the disease may be present early, but is frequently seen later during the course of the disease. the aim of this study was to presentat an autopsy case of a months old boy. case report signs of hlh were present right after birth. he was treated by the treatment protocol hlh- . the disease later progressed with cns involvement. a complementary bone marrow donor was not found in time. tissue samples collected at the autopsy were proceeded with standard histological and immunohistochemical methods. results severe bleeding in the right lung with other signs of coagulopathy were found as the main cause of death. hepatosplenomegaly was a prominent feature. we detected hemophagocytosis in the bone marrow, liver and central nervous system. conclusions the diagnosis of hlh must be based on clinical, laboratory and cyto/histological findings. the pathogenesis of familial hlh is still not completely understood. introduction a changeable number of goblet cells in intestine epithelium is rarely a matter of consideration among other morphological factors of small intestine mucous membrane atrophy in celiac disease. it is also not evaluated in the current classifications of goblet cell condition in celiac disease. the aim of the study was to evaluate a number of goblet cells in small intestine epithelium with reference to the degree of atrophy in celiac disease. morphological analysis of bioptates of small intestine mucous membrane, taken for a routine histopathologic diagnosis from patients aged from to years, was performed. the patients were diagnosed and treated in paediatric university hospitals in zabrze and bytom in the years - . specimens were stained with haematoxylin and eosin (h.e.) and alcian blue-pas (ab-pas). villous atrophy was evaluated according to the modified marshal scale. results the following types were defined: type - cases, type - cases, type - cases, type a - cases, type b - cases, type c - cases. then, a number of goblet cells per enterocytes of small intestine epithelium of each oligobioptate were calculated. the received results were evaluated statistically with u mann-whitney test. the average number of goblet cells in small intestine epithelium was calculated in relation to the degree of atrophy with the modified marsh scale: type - . (+/- . ), type - . (+/- . ), type - . +/- . ), type a - . (+/- . ), type b - . (+/- . ), type c - . (+/- , ). the analysis used significant relations between an average number of goblet cells in small intestine epithelium and a degree of mucous membrane atrophy in celiac disease. moreover, a correlation according to rang spearmann test showed a coefficient r= . for p< . . conclusions significant relation between a number of goblet cells in epithelium and a degree of small intestine mucous atrophy in celiac disease. it allows an introduction of a new objective quantitive parameter in the evaluation of atrophic lesions. introduction microscopic evaluation plays an important role in diagnosing small intestine inflammatory diseases. defining a degree of villous and brush border atrophy, enterocytes changes, elongation of glandular crypts allows a correct evaluation of treatment clinical effects and child's body response to the applied selective diet. development of immunomorphological studies contributed to confirmation of the autoimmunological basis of several diseases and of the influence of exogenous factors on their development. due to the new approach, evaluation of the changeable character of inflammatory infiltrations including mast cells and marking activity of enteroendocrinal cells have become very important diagnostic elements. the aim of the study is to examine a changeable intensity of infiltrations from mast cells of small intestine mucosa in children in the course of celiac disease. material and method oligobioptates of small intestine mucosa taken in endoscopy from patients (age - years) at the department of pathomorphology in zabrze in the years - . the patients were diagnosed and/or hospitalised in paediatric university hospitals in zabrze and bytom. a degree of villus atrophy was evaluated according to the modified marsh classification. tissue material in paraffin cubes from the routine oligobiopsy of the patients with celiac disease was qualified for immunohistochemical study. immunohistochemical reactions revealed a presence of brown dyed mass cells in intestine mucosa. the cells were evaluated by counting their number in high power fields (magnification x) in each oligobioptate. the received results were calculated statistically with mann-whitney u test. results mean number of mass cells in intestine mucosa was calculated in relation to the degree of villus atrophy according to the modified marsh classification: type (status normalis) - . (+/- . ), type - . (+/- . ), type - . (+/- . ), type a - . (+/- . ), type b - . (+/- . ), type c - . (+/- . ). the analysis showed significant relation between a number of mass cells and a degree of mucosa atrophy in a course of celiac disease. moreover, a correlation after the rang spearman test showed a coefficient r= . for p< . . conclusions significant relation between a number of mass cells and a degree of small intestine mucosa atrophy in a course of celiac disease was shown. defining (marking) a number of mass cells in small intestine mucosa in a course of celiac disease allows an introduction of quantitive method of atrophic changes evaluation as a new objective parameter, especially in cases difficult to diagnose. morphological analysis of tissue reactions in mandible after dental implants of the pressed cocrmo alloy introduction schistosomiasis mansoni infection increases the level of prostaglandins and leukotrienes that are secreted mainly by macrophages within the granulomas. these mediators have a pronounced role in mediation and modulation of inflammation. most non steroidal anti-inflammatory drugs (nsaids) act mainly by inhibiting the cyclooxygenase pathway of arachidonic acid metabolism, thereby diverting it towards the lipoxygenase pathway. these leukotrienes are important in maintenance of acute and chronic inflammatory condition. methods in present study, we used mofebutazone (cylcooxygenase and lipoxygenase inhibitor) and tenoxicam (cylcooxygenase inhibitor) either alone or in combination with praziquantel (antibilharzial drug) in mice infected with schistosomiasis mansoni. we study their effects on liver pathology as pcna (proliferating cell nuclear antigen), granuloma diameters, percent of degenerated ova and type of granuloma after & weeks after infection. results shown that infection increased the percent of positive nuclei in granuloma and in hepatocytes to be about % & % at weeks and these percentages were reduced to be about % & % at weeks after infection respectively. treatment with mofebutazone and tenoxicam produced a reduction in pcna to be about % & % in granuloma and % & % in hepatocytes at weeks and more reduction occurred after weeks after infection. also, mofebutazone tended to produce more protection to isolated hepatocytes (% viability of hepatocyte) than tenoxicam in schistosomiasis mansoni infected mice. combined therapy with praziquantel produced more reduction in pcna and more protection to hepatocytes. it is evident from the present study that, mofebutazone when combined with praziquantel has shown good tolerability more than tenoxicam which was associated with an improvement in pcna, granuloma diameter, % viability of isolated hepatocytes, liver function tests, a fact that would seen to advocate the use of mofebutazone in bilharzial patient. patterns of injury in car and motorcycle accidents jm suárez peńaranda, c bellido, r rico, mt alvarez iglesias, m rodríguez calvo, i muńoz, l concheiro institute of legal medicine, santiago de compostela, spain introduction the role of the forensic pathologist in road-traffic accidents is to detect atypical injuries that could suggest an alternative cause of death, demonstrate natural diseases capable of creating sudden incapacity, and to collect samples for toxicological examinations. the main objective of this work is to study the different patterns of injuries in car and motorcycle fatalities. material and methods we have studied the autopsy reports of deaths related to road traffic accidents ( involving cars and motorcycles). a complete autopsy was performed in every case including toxicological investigation. results the most common cause of death was head injury, responsible for % and . % of deaths in car and motorcycle accidents, respectively. cranial base fractures were more commonly found in passengers rather than in drivers, both for cars and motorcycles ( % vs. % and . % vs. %, respectively). the distribution of cranial vault fractures was similar with percentages of and . for car and motorcycle drivers, versus and per cent for the respective passengers. nevertheless, brain injury was even more frequent in car accidents, accounting for % of the cases, and in motorcycle fatalities, where every single case showed some degree of brain injury. conclusion our results confirm the importance of head injury in road-traffic accidents, especially when motorcycles are involved, being the most common cause of death. although all motorcycle victims wore a helmet at the time of the accident, it did not seem to provide an effective protection, probably because of the high speeds involved. the incidence of cranial fractures and brain injury is higher for passengers than for drivers, probably due to the lack of attention to the traffic of these latter, and the fact that drivers are usually holding the handlebar or wheel at the moment of the accident. heat-induced epitope retrieval in immunohistochemistry c espersen, b crillesen, b jepsen, jw hansen, th veie, h winther, j askaa department of immunohistochemistry, dakocytomation a/s, glostrup, denmark introduction heat-induced epitope retrieval (hier) has dramatically changed the applicability of immunohistochemistry in routine pathology. hier has increased the number of primary antibodies useful on formalin-fixed paraffin-embedded material and in general improved the histochemical staining. the aim of this study was to compare various buffers for hier on a broad range of primary antibodies. materials and methods hier using four different buffers (citrate ph ; tris/edta ph ; dakocytomation target retrieval solution, high ph, code no. s and dakocytomation target retrieval solution ph , code no s ) for pre-treatment of formalin-fixed paraffin-embedded material has been compared using more than different primary antibodies and the envision+tm visualisation system.results hier with citrate buffer retrieve epitopes recognised by the majority of the tested antibodies. however, in several cases the epitopes could not be detected using this method but were retrieved using tris/edta and/or target retrieval solution, code no. s . also retrieval by means of the target retrieval solution, high ph can be used however, the morphology quite often was partly destroyed. furthermore, some antibodies could only be used after enzymatic pre-treatment whereas hier abolished the histochemical staining. conclusion although hier using citrate ph buffer is a standardised and widely used technique, it is in numerous cases sub-optimal or even obliterate the immunohistochemical staining. in general more epitopes can be retrieved using tris/edta ph or dakocytomation target retrieval solution. bone morphology and calcemia in ovariectomised (ovx) wistar rats l markovic postmenopausal oestrogen deficiency results in bone loss (osteoporosis) in humans and experimental animals. wistar rats provide a useful experimental model of post-menopausal osteoporosis. to demonstrate the histomorphometric and histological changes of bone weeks after bilateral ovariectomy in rats and to investigate the impacts of different hormone replacement therapies on the bone. specimens of proximal femur were embedded undecacified for histomorphometric analysis and of distal femoral metaphysis were procured for pathologic examinations. three weeks after ovx the femoral bmd, mean cortical thickness decreased significantly while the number of osteoclasts increased significantly as compared with sham group. the trabeculae became thinner and irregular which changed the bone microstructure in three dimensions. after treatment with different preparations, the above parameters restored to various extents to the sham operation levels. bilateral ovariectomy induced increased osteoclast activity and bone turnover, therefore caused accelerated bone loss. treatment with combined sex hormones preparation could inhibit bone absorption and stimulate bone formation. this investigation was supported by mstd of srbia. vilnius pathological anatomy in the first half of the th century d sabat department of pathomorphology, medical university of silesia, zabrze, polandthe beginnings of pathological anatomy as a separate medical subject were connected in the area of the republic of poland and lithuania with the vilnius university. the first post mortem was done in vilnius by a priest, stefan bisio only in year. at the end of the th century, jakub briotet, a surgeon and anatomist, created a modest anatomical surgery (study). in , jan piotr frank and his son józef arrived to vilnius and became professors of the university. jan piotr frank became the head of the teaching hospital and józef frank the head of the chair of pathology. in november , he started lecturing for students, which he recalled in his "memoirs": several days after my father, i also started a course with a dissertation "de meliori pathologiam tradendi modo" in this speech i put the main stress on a significance of the explanations at the patient's bed-side and of a good knowledge of pathological anatomy… when in , józef frank became the head of the teaching hospital, he founded the first anatomo-pathological study (surgery). most of the samples kept in spirit in the frank's study were eaten by the starving french soldiers during the retreat of napoleon's army. besides frank's study at the vilnius university at the chair of anatomy, there still existed the study founded by briotet. in , the emperor alexander i destined the ruins of the spaska's orthodox church for an anatomical theater. after seven-year redecorations, the building was opened in . besides the theatre itself, dissection room and veterinary institute, it also included a zoological, veterinary and anatomical museum. the growing anatomical museum had, in , preparations including anatomopathological preparations. after closing down the vilnius university and foundation of the academy of medicine and surgery, pathological anatomy was made an individual subject of study. the first lecturer of pathological anatomy in vilnius was ludwik siewruk. he held the classes till and then he took charge of the chair of anatomy at the moscow university. his successor was jan leonow who continued his work until the tsar's authorities closed down the academy of medicine and surgery in . after the academy had been closed down, all the exhibits of the vilnius anatomical museum, including anatomopathological preparations were moved to the anatomical museum of kiev university. few of them remained in the vilnius medical society. introduction t- toxin, a mycotoxin produced by fusarium fungi, is a well-known cardiotoxin that cause myocardial injury, capillary damage, haemorrhage and focal polymorphonuclear cell infiltration. mast cell (mc) is one of the the earliest multifunctional effector cells of the immune system and important constituent of microvasulature in the heart. aim: we wanted to investigate appearance and localisation of mast cells in the heart of t- toxin-poisoned rats. materials and methods adult female wistar rats were poisoned with a single injection of ld- of t- toxin ( . mg/kg sc). rats were divided into two groups: ( ) control group and ( ) t- toxin group. t- toxin was produced in laboratory conditions from fusarium sporotrichoides fungi. animals were sacrificed after the end of the day , , and of the study. cardiac mcs were counted in whole visual fields, magnified by -fold on paraffin section stained with haematoxylin and eosin (he) and giemsa methods. results in the heart of rats treated with t- toxin, blood vessels were congested with thickned walls, and a large number of mononuclear cells was present nearby. hours after administration of introduction bromadiolone is one of the most commonly used rodenticides. this coumarin anticoagulant blocks multiple steps in the coagulation cascade. it is absorbed through the gastrointestinal tract and accumulated in the liver, mainly. the aim of this study was to investigate pathohistological alterations in the liver after oral application of bromadiolone in rodents. materials and methods adult wistar rats and swiss mice, of both sexes, were fed with a ready-to-use baits of low bromadiolone concentration ( . %), for first three consecutive days. animals were sacrificed every day during the one week period, starting with h after the beginning of the experiment. liver paraffin sections were stained by haematoxillin and eosin (he) method. results the pathological alterations detected in all animals ranged from diffuse degeneration to a focal necrosis of hepatocytes and massive circulatory changes. parenchymal degeneration, diffuse oedema and hyperemia were predominant in the liver of animals sacrificed on the first three days of experiment. dissolution of cytoplasm with nuclear pleomorphism in round or ovoid hepatocytes were seen. thickening of the blood vessels with necrosis of endothelial cells were particularly prominent from the fourth to seventh day of experiment. the most interesting finding is the presence of massive hemorrhages with a focal mononuclear cell infiltrations. the majority of hepatocytes were irregular, with macronodular fat transformation of cytoplasm. these changes were the most intensive in male mice on the day of the study. conclusion multiple oral ingestion of bromadiolone induced prominent pathohistological alterations in rodent liver, especially mice. mobile telepathology -a new intringuing tool s seiwerth, l batelja institute of pathology medical faculty, zagreb, croatiathe mobility of information, patient data and images introduced by telemedicine/ telepathology systems designated a completely new viewpoint in pathology. mostly two areas of diagnostic work are so far covered by telepathology service -second opinion/expert consultation and frozen section diagnosis. frozen section diagnosis, is still a very important issue. smaller hospitals, with no sufficient material for a resident pathologist often could benefit by introduction of telepathology. as in many of these hospitals surgery requiring frozen section diagnosis is not performed on a daily basis the telepathology system is not in full use, producing an unfavorable cost-benefit ratio. also establishing a fully equipped frozen-sections lab yields additional costs and personnel cutting frozen sections only occasionally often produce suboptimal. in this the introduction of a mobile telepathology unit could solve some very important problems. the unit should include a fully equipped mobile frozen sections lab including a macro stand and a microscope with ccd tv color camera and a notebook (laptop) computer. the telepathology software used must be stabile and versatile like the pharos/issa system (vamstech, croatia) used by us. by such a system and synchronization of operation schedules hospitals in a radius of up to km around the referral center could be covered without exceeding standard working hours. the issa-server based system option alerting the consultant and referring pathologist by sms that a consultation case is in his mailbox at the server ads additional time effectiveness. a novel high throughput marker validation tool j korbelik, j matisic, c macaulay b.c. cancer agency, vancouver, canada high throughput genetic and expression screening is generating many possible diagnostic markers and therapeutic targets for wide variety of clinical conditions. the rapid validation of these markers is a challenging process. tissue microarrays can be used for the evaluation of many of these markers. however, they have drawbacks and unresolved issues, which are result of the sampling and sectioning problems. we introduce a novel microarray technique based on cell suspensions. multiple slides can be made, all of which are equally representative of the initial samples. a manually operated mechanical device was designed that can deposit distinct spots on the glass slide. each spot of cells deposited in this manner may correspond to unique source. controlling the number of cells per spot their uniformity and size can be achieved by modifying the viscosity of the cell solution or precisely regulating amount of fluid deposited. a fully automated analysis of quantitatively stained microarray samples has been performed to quantify the number of cells per spot, the size of spots, and how reproducible these parameters are. cellular material used in the experimental arrays constructed to date has been acquired from cell lines and liquid prepared lung and cervical specimens. a variety of molecular markers can be evaluated, with minimal cost. fish probes have been tested on cytology microarrays constructed from different lung cell lines. using cell suspensions generated by the dissociation of tissue would enable the creation of more representative samples for clinical marker/target validation or evaluation. key: cord- -fio cjj authors: nan title: peripheral nerve society meeting july – , sitges, barcelona, spain date: - - journal: j peripher nerv syst doi: . /jns. sha: doc_id: cord_uid: fio cjj nan the peripheral nerve society was founded in from two groups of academic investigators, peripheral nerve study group and peripheral neuropathy association of america, interested in the basic biology and function of the peripheral nervous system and its application to the clinic. their invite only biennial meetings involved - attendees in cloistered settings organized by shoestring and local initiative. from this, we have grown remarkably. we now have an annual meeting of over people including meetings within the meeting for the special interest groups in inflammatory, diabetic and hereditary neuropathy. with this substantial growth and the success of jpns, the journal of the peripheral nervous system the society continues to flourish. has proven to be a year full of exciting changes for the society. pns has transitioned from a biannual, to an annual meeting. next year, the meeting will be taking place at the renaissance baltimore harborplace hotel from - july in baltimore, maryland. the development of a new website has been completed, please visit www.pnsociety.com to see the new face of the society. finally, pns has adopted new executive staff. with their guidance and the leadership of an active and diverse board of prominent professionals in the field the peripheral nerve society continues to grow and anticipates more exciting changes in the year to come. the peripheral nerve society provides annual meetings, teaching courses, guidelines, and other resources to aid in the education of members. becoming a member of pns means collaborating with prominent global professionals in the field to develop and provide the best treatments for people with peripheral nerve diseases and setting standards of care within the field. please participate in our future by joining the pns, volunteering for a project aligned with your interests and sending your ideas for the future to the executive office, or board member. peles e . department of molecular cell biology, rehovot, israel. two schwann cell-dependent mechanisms control the presence of na + channels at the nodes of ranvier: i. clustering of the nodal complex by glia-derived proteins and ii. restriction of nodal proteins within the nodal gap by the paranodal junctions. these mechanisms depend on specific cell adhesion molecules that mediate the contact between myelinating glia and their underlying axons at the forming nodes and the paranodal junction. during myelination, na + channels initially clustered at heminodes that border each myelin segment. this process requires gliomedin, nrcam and neurofascin (nf ), three cell adhesion molecules (cams) that mediate the interaction between schwann cell microvilli and the axon. na + channels clustering activity of gliomedin is tightly regulated by two distinct and functionally opposing proteolytic events. while the clustering activity of gliomedin is enhanced by its shedding from the surface of schwann cells by a furin protease, its activity is negatively regulated by bone morphogenetic protein /tolloid-like (bmp /tld), and tolloid-like (tll ) metalloproteinase. cleavage by these enzymes restricts the activity of gliomedin to the nodal area and prevents the formation of ectopic clusters along axons that are devoid of myelin segments, as well as below the myelin internodes. hence, proteolytic processing of gliomedin facilitates, yet limits, the clustering of na + channels to specific sites along the axon in a timely manner. furthermore, axon-glial contact mediated by gliomedin and nf at the nodes, not only plays a role in na + channel clustering during development, but also contributes to the long-term maintenance of na + channels at nodes of ranvier. in addition to clustering by gliomedin, the distribution of na + channels is restricted between two growing myelin segments by the flanking paranodal junction. at this site, axon-glia contact is mediated by a distinct set of cell adhesion molecules (i.e., caspr, nf and contactin) that also delineate the underlying axonal and glial cytoskeleton. this paranodal junction-dependent restriction of na + channels to the nodes is mediated by the spectrin-based paranodal axonal cytoskeleton. illa i . neuromuscular unit, neurology department, hospital santa creu i sant pau, universitat autònoma de barcelona, barcelona, spain. chronic inflammatory demyelinating polyradiculoneuropathy (cidp) is an autoimmune disorder of the peripheral nerves with clinical and immunological heterogeneity. currently, the diagnosis of cidp is based on clinical and electrophysiological criteria and does not take into consideration the presence of immune biomarkers. several autoantibodies against proteins of the node of ranvier in patients with cidp have now been described. these antibodies define specific cidp subtypes sometimes referred to as nodopathies and can have diagnostic and prognostic implications. anti-contactin (cntn ) antibodies. we have described the presence of antibodies to cntn in a small subset of patients with cidp. these patients shared a phenotype and have poor response to ivig. the anti-cntn antibodies are predominantly igg . pathological studies from skin and sural nerve biopsies of patients show morphological changes in the paranodes. experimental data supporting the pathogenicity of anti-cntn igg antibodies include: a) demonstration in vitro that the antibodies disrupt the binding of the cntn -caspr complex to neurofascin- (nf ); b) intraneural injections of antibodies progressively and specifically disrupt the paranodal axo-glial junction; and c) chronic infusion of antibodies induced clinical and electrophysiological worsening in animals with experimental autoimmune neuritis (ean). anti-nf antibodies. antibodies to neurofascins were first reported in patients with guillain-barré (gbs) and cidp and subsequently, antibodies specific to the nf isoform were found in a small group (< %) of patients with cidp. studies by us and confirmed by others have demonstrated that patients with cidp and anti-nf antibodies have a distinct phenotype that often includes a low-frequency tremor and poor responses to ivig. the autoantibodies are predominantly of the igg subtype. the passive transfer of monoclonal anti-neurofascin antibodies (which recognize all neurofascin isoforms) to mice with ean strongly exacerbated the severity of the pathology, but no studies have yet demonstrated that patient-derived anti-nf igg antibodies are pathogenic. a pathogenic role of the antibodies is however supported by sural nerve biopsies from patients with cidp and anti-nf antibodies that showed paranodal demyelination in the absence of inflammation, the loss of septate-like junctions and, the interposition of cellular processes between the paranodal loops and the axolemma. these alterations are reminiscent of those found in nfasc-null mice suggesting that anti-nf antibodies may specifically disrupt the nf -cntn -caspr complex at the paranodes. antibodies to other nodal proteins. recently neurofascin- and neurofascin- were reported as the main targets of autoantibodies in five patients with igg reactivity against the nodes of ranvier; the antibodies were predominantly igg . these patients presented with clinical features distinct from those in patients with anti-nf igg antibodies. four of these patients had subacute onset of sensory ataxia without tremor. the presence of anti-caspr antibodies has been reported in two patients with inflammatory neuropathies, one classified as cidp, the other as gbs. both patients had intense neuropathic pain. the skin biopsy from both patients showed paranodal disruption. some patients whose sera show nodal or paranodal reactivity in teased nerve fiber preparations have antibodies against other nodal proteins, such as gliomedin or neuronal cell adhesion molecule (nrcam) . the skin is equipped with specialized mechanoreceptors that allow the perception of the slightest brush. indeed some mechanoreceptors can detect even nanometer-scale movements. movement is transformed into electrical signals via the gating of mechanically-activated ion channels at sensory endings in the skin. the sensitivity of piezo mechanically-gated ion channels are controlled by stomatin-like protein- (stoml ), which is required for normal mechanoreceptor function. under pathophysiological conditions following nerve injury or diabetic neuropathy the slightest touch can produce pain. it is at present unclear whether peripheral changes in sensory mechanotransduction may underlie hypersensitivity associated with neuropathic pain. here we have examined the role of the stoml modulation of piezo channels in mechanoreceptors and nociceptors to under pathophysiological conditions. we recently developed small molecules that act as inhibitors of stoml function. peripheral application of stoml inhibitors can alleviate hypersensitivity in models of neuropathic pain. our data strongly suggest that tactile evoked pain in models of peripheral neuropathy may be at least partly driven by sensitization of sensory mechanotransduction driven by stoml . coleman m . john van geest centre for brain repair, cambridge, uk. axons are lost early in many neurodegenerative disorders of peripheral and central nervous system. the degeneration of transected axons (wallerian degeneration) can be slowed tenfold by overexpression of a variety of nad-synthesizing enzymes, such as isoforms of nmnat or the related mutant fusion protein, wld s . wallerian degeneration is also delayed by deletion of tlr adapter protein sarm , a protein recently reported to promote nad degradation. it is important to understand fully the mechanism of wallerian degeneration because related mechanisms contribute to axon loss in a number of disease models, including models of peripheral neuropathies, parkinson's disease, multiple sclerosis and glaucoma. new data also suggest a role in hereditary spastic paraplegia. while depletion of nad is an attractive hypothesis for the mechanism of wallerian degeneration, especially as nad can be increased by dietary methods, it cannot explain a number of key observations. fk , an inhibitor of nampt, blocks the nad salvage pathway and strongly depletes nad, including within axons. however, instead of killing axons as the nad hypothesis would predict, it does precisely the opposite: it phenocopies the protective effect of wld s . moreover, ectopic expression of the bacterial enzyme nmn deamidase, a protein absent in mammals, protects injured axons both in transgenic mice and in primary neuronal cultures, but it has no effect on nad levels either under basal conditions or in degenerating nerves. these observations fit better with a proposed toxic role for the nad synthesis intermediate nmn, a model that can also explain the protective effect of wld s . a full understanding of the pathway should identify a number of points where intervention could be a treatment for multiple axonopathies. as with any medical discipline, expansoin of knowledge about the fundamental science behing a disorder of the human nervous system comes part and parcel with a change in our understanding of the epidemiology of any given disorder or groups of disorders. recent advances in our fundamental understanding of inflammatory neuropathies of the peripheral nervous system have been accompanied by drastic changes in our understanding of the neuroepidemiology of these disorders -the specific populationss affected by peripheral neuropathies, as well as the varying importance / contributions of select peripheral neuropathies to the overall burden of peripheral nervous system (pns) disease, and how this shift in epidemiological understanding influences the clinical approach to diagnosis and management of patients with pns disease. the past few decades have witnessed a paradigm shift in many aspects of pns disease diagnosis and treatment; from the association of human immunodeficiency virus (hiv)-associated neuropathies; to the increassing recognition of hereditary / familial peripheral neuropathies; to the increased recognition of specific neuropathies such as multifocal motor neuropathy with conduction block. in addition, timely events such as the recent, and increasingly irrefutalbe evidence for a link between zika virus and a guillain-barré syndrome, and the rather unexpected resurgence of peripheral neuropathies due to previously 'exotic' etiologies such as lepromatous neuropathy require prompt clinical attention. this plenary session aims to describe the evolving neuroepidemiology of peripheral nervous system disorders, and how these changes may influnece the clinical approach to the diagnosis, prognostication, and treatment of otherwise 'unusual' periphal nerve diseases. oxaliplatin chemotherapy for colorectal cancer is seriously limited by neurotoxic side effects which are not fully understood. oxaliplatin-induced peripheral neurotoxicity (oipn) comprises an acute syndrome and a chronic sensory neuropathy. the acute symptoms, notably cold hyperalgesia, have been attributed to transient ion channel dysfunction, and the worse they are the more severe the chronic neuropathy that ensues. we designed a combined in vitro and in vivo project, using neurophysiology to better understand the pathogenesis of oipn. in the in vitro study, differentiated f cells (rat drg neurons x mouse neuroblastoma n tg- cell line) were incubated for and hours in . m oxaliplatin, and their electrophysiological properties studied by patch-clamp. the treated f cells showed relatively depolarized resting membrane potentials, significantly decreased firing frequencies, and increased sodium current densities. moreover, a decrease in erg (ether-à-go-go-related gene) potassium current was also evident. in the in vivo study, we applied nerve excitability testing (net) to a wistar rat model of oipn. to investigate the acute syndrome, we compared behavioural and neurophysiological data of animal cohorts (controls and oipn rats, n= each) before and after oxaliplatin administration ( mg/kg, iv). twenty-four hours after the injection we observed differences between the groups in behaviour (cold plate test, p= . ) and in superxcitability of motor axons (p= . ). to investigate the chronic neuropathy, we compare a control group (n= ) with a treated group (n= , oxaliplatin mg/kg twice weekly x weeks, iv). both groups are studied with behavioural, neurophysiological (sensory and motor nerve conduction studies, net), and pathological (caudal and sciatic nerve, skin biopsy, drgs) methods. data are collected at baseline, end of treatment and weeks after treatment; to obtain a full net profile of all significant changes. in this highly translational approach to oipn, the in vivo net changes in the acute and chronic rat models can be matched on the one hand to findings from in vitro experiments, and on the other to clinical data, since net is also easily applied in humans. of these results. in denmark there is a unique situation to conduct epidemiological studies facilitated by the danish civil registration and the danish national hospital registry (dnhr). this enables us to identify all gbs patients in denmark in a given period. from the same period as the igos cohort was included we have identified all gbs patients admitted to or seen in outpatient's clinics of hospitals in denmark (september st to december st ). records from the population based danish cohort will be reviewed for demographic and clinical data and compared to the patients included in igos from denmark, as well as with the igos europe/america cohort. during this period patients from denmark have been included in igos. the danish group is comparable to the europe/america group not counting the danish patients (n= ) of the igos cohort in regard to sex and age at entry, gbs disability score at nadir, and percentage of patients needing mechanical ventilation. in the danish igos group % are males, the median age is ( - ) years, the mean(sd) gbs disability score at nadir . ( . ), and % of the danish group needed mechanical ventilation. in the europe/america group % are males, the median age is ( - ), mean(sd) gbs disability score at nadir . ( . ) and % of the group needed mechanical ventilation. at the meeting we will compare and present data from the danish population based cohort as well as epidemiological data. chronic inflammatory demyelinating polyneuropathy (cidp) is a common autoimmune disease of the peripheral nervous system (pns) that causes sensorimotor impairment. mice with a dominant autoimmune regulator gene (aire) g w mutation on the non-obese diabetic (nod) background (nod.aire gw/+ mice) develop spontaneous autoimmune peripheral polyneuropathy (sapp) resembling cidp. in sapp, demyelination is caused primarily by th t cells; however, the contributions of nerve-resident cells such as schwann cells are poorly understood. we identified a population of non-hematopoietic, integrin alpha + (itga +) cells in the pns that increases in frequency and number during sapp. these itga + cells coexpress numerous schwann cell markers including sox , p , s b, myelin protein zero, and peripheral myelin protein , suggesting that itga + cells are schwann cell-like. additionally, during sapp, these itga + cells upregulate the extracellular matrix protein periostin (postn), which has recently been shown to promote macrophage recruitment and activation in inflammatory disease and cancer. our data indicate that macrophages are pathogenic during sapp. therefore, we hypothesized that itg a+ cells promote macrophage recruitment during sapp via postn production. to test this hypothesis, we performed in vitro chemotaxis assays. conditioned media from nod.aire gw/+ nerve promoted significantly more macrophage chemotaxis than conditioned media from postn −/− nerve. furthermore, postn recombinant protein was sufficient to induce macrophage chemotaxis in vitro. our findings show that itg a+ schwann cell-like cells mediate macrophage chemotaxis by upregulating postn during sapp and suggests postn as a novel target for the treatment of cidp. "wear-off" frequency will be analyzed by assessing the proportion of subjects with any given degree of gs and rods intracycle fluctuation and the proportion of cycles in which gs and r-ods fluctuation occurs. to determine the extent of "wear-off" the degree of difference between maximum and minimum gs, r-ods, tugs, onls, and vas scores will be analyzed. currently subjects from different sites have been enrolled ( sites eligible for enrollment). this interim study report will provide preliminary representative data, demonstrating ivig "wear-off" effects on gs and other outcome measures. by better understanding the frequency and extent of ivig treatment-related fluctuations we expect that these results will help facilitate development of cidp treatment optimization strategies. we also expect that this information will be important in forming hypotheses to be tested in future studies (for example, comparing different dosage intervals, optimal ivig taper guidelines, or assessing the long-term outcome of short-term cycle to cycle clinical fluctuations). neuropathic pain is a frequent feature of peripheral neuropathy causing a significant impact on patients' quality of life and health care costs. resolving the genetic architecture of painful neuropathy will lead to better disease management strategies, risk stratification, and counselling. therefore, we aim to develop a reliable technique to rapidly and accurately re-sequence multiple genes in a large cohort of painful neuropathy patients at low cost. whole exome sequencing of thousands of samples remains expensive for clinical use. several targeted enrichment approaches are currently available to selectively enrich for genomic regions of interest. in this study, we compared the sensitivity, specificity, targeting efficiency, reproducibility of performance and cost effectiveness of truseq ® custom amplicon-next generation sequencing (tsca-ngs) and molecular inversion probes-next generation sequencing (mips-ngs) methods. for both methods, we constructed a targeted enrichment kit to capture the coding and exon-flanking intron sequences of nine sodium channel genes (scn a, scn a-scn a, and scn b- b) expressed in nociceptive neurons. probes were designed for the two methods using their respective informatics pipelines. in total, patients with diabetic and idiopathic neuropathy were tested by both methods. among the patients, patients were tested previously by sanger sequencing for scn a-scn a. approximately kb was captured and sequenced. % of the targeted regions showed an average coverage of ≥ x in tsca-ngs, and % in mips-ngs. we managed to identify potential pathogenic mutations and polymorphism variants by mips-ngs and tsca-ngs. moreover, we observed a perfect agreement ( %) between sanger sequencing data and those obtained using mips-ngs and tsca-ngs. both ngs approaches showed user-friendly software to design probes and exhibited a similar on-target efficiency. although the overall coverage per region varied across different dna samples, it was sufficient to detect any variant in these regions. mips-ngs has more versatile assay design, demonstrated a high degree of flexibility with probes re-placement and > x cheaper than tsca-ngs. mips-ngs is a reliable, flexible, and inexpensive method to detect genetic variations in thousands of patients. in our centers, this technology is currently implemented as a routine diagnostic tool for screening of sodium channel genes in painful neuropathy patients. alonso-jiménez a , , belvis-nieto r , diaz-manera j , , illa i , , querol l , . neuromuscular diseases unit, neurology department, hospital de la santa creu i sant pau, universitat autònoma de barcelona, spain; centro para la investigación biomédica en red para enfermedades raras, ciberer, madrid, spain; neurology department, hospital universitario dexeus, barcelona, spain. most acute demyelinating polyneuropathies have an immune-mediated pathogenesis and are included within the guillain-barré syndrome spectrum. occasionally, other mechanisms such as metabolic, infectious or toxic may lead to gbs-like presentations. thermatrim ® and pura alegria ® are different brands of the same illegal slimming product that is sold through online vendors and in which the exact composition is unknown. here we present a patient with an acute demyelinating polyneuropathy secondary to the intake of the slimming product "pura alegría". a year-old woman with no remarkable medical history reported days history of distal numbness in her feet that progressed in one week to her knees and her left hand. she had had an upper respiratory tract infection ten days prior to these symptoms. the neurological examination showed absent distal vibratory and arthrokinetic sensations and arreflexia in lower limbs, decreased vibratory sensation in her hands and a ataxic gate. the lumbar puncture showed . g/l of proteins with no cells. the emg fulfilled diagnostic criteria for acquired demyelination. intravenous immunoglobulin therapy was started but the symptoms kept worsening and corticosteroids were started. the patient mentioned then the slimming product. a brain mri showed diffuse leukoencephalopathy that was asymptomatic. steroids and the pura alegria slimming products were withdrawn and the patient recovered completely after one year of follow-up. "pura alegría", "thermatrim" and "thermatrim plus" are slimming products that were forbidden in spain after several cases of acute leukoencephalopathy and acute polyneuropathy. exact composition is unknown although the spanish drug agency detected the pesticide malonoben, a tyrosin kinase inhibitor, among the components. since nine cases of pura alegria/thermatrim neurological toxicity, including leukoencephalopathy and polyneuropathy have been described. all cases had good outcomes after treatment withdrawal, although recovery is slow and may be incomplete. our case highlights the need to carefully consider drug toxicity, including dietary supplements, in the differential diagnosis of gbs specially when evolution does not follow typical patterns. alvarez s , klein d , martini r , moldovan m , , krarup c , . center for neuroscience, university of copenhagen, denmark; department of neurology, developmental neurobiology, university hospital würzburg, germany; department of clinical neurophysiology, rigshospitalet, copenhagen, denmark. charcot-marie-tooth neuropathy type a (cmt a) resulting from peripheral myelin protein kda (pmp ) overexpression is the most common hereditary motor and sensory neuropathy in humans. the transgenic pmp (pmp tg) mouse line c carrying copies of the human pmp gene, has a slowly progressing neuropathy phenotypically like cmt a with thin and abnormally thick myelin profiles and supernumerary schwann cells. in addition, pmp tg nerves showed activated macrophages leading to axon-myelin compartment disruption and maldistribution of k+ channels (kohl b et al, am j pathol. ; : ) . the aim of the present study was to investigate the motor axon excitability in pmp tg versus wt littermates. multiple measures of motor axon excitability under anesthesia were carried out by stimulation of the tibial nerve at ankle and "threshold-tracking" the plantar compound muscle action potential (cmap). at age months, when the post-developmental maturation was nearly complete in the wt, the pmp tg cmap showed an increase in latency by %. the cmap amplitude was decreased by %, although the mean motor unit size (mscan method) appeared unchanged indicating a lack of collateral sprouting. furthermore, pmp tg showed abnormalities in both passive cable properties and voltage dependent parameters. at age month, the cmap latency of pmp tg was increased by % as compared to wt. in contrast to this marked conduction slowing along the tibial nerve from to months of age, the progression of excitability changes localized at ankle appeared modest. nevertheless, when pooling data from to months, the increase in pmp tg latency was correlated (spearman p< . ) with an increase in accommodation half-time during depolarizing electrotonus (+ % of threshold) from to ms and a reduction of the late subexcitable period of the recovery cycle from to % of threshold, both changes consistent with a redistribution of k+ currents consistent with the maldistribution of k+ channels. our data suggest that in the pmp tg cmt a model, a functional, thus potentially reversible abnormality in k+ channel distribution, accumulates along the nerve and aggravates the conduction impairment due to impaired myelin formation and maintenance. alvarez s , krarup c , , moldovan m , . center for neuroscience, university of copenhagen, denmark; department of clinical neurophysiology, rigshospitalet, copenhagen, denmark. mice heterozygously deficient of myelin protein p gene (p +/−) show a mild progressive dysmyelinating neuropathy, with conduction slowing and impaired excitability, phenotypically similar with charcot-marie-tooth disease type b (cmt b). we found that in p +/− the accumulating myelin abnormalities were paralleled by progressive changes in voltage-dependent motor axon function resulting in neurotoxic membrane depolarization (rosberg mr, et. al. neurobiol dis. : ) . the aim of this study was to investigate the relationship between demyelination and motor axon function in p +/−. demyelination of the right sciatic nerve by topic lysophosphatidylcholine (lpc) application was carried out in p +/− and wild-type (wt) mice, in year (mature) and years (aged) groups. multiple measures of motor axon excitability under anesthesia were carried out by stimulation of the tibial nerve at ankle (distal to lpc demyelination) and "threshold-tracking" the plantar cmap responses. live imaging studies by cellvizio (mauna kea technologies, paris, france) confocal laser endomicroscopy were carried out in transgenic mice expressing the fluorescent reporter yfp in peripheral nerve axons under the thy promoter. in mature wt the sciatic morphological and electrophysiological demyelinating features following lpc could be readily observed at hours but disappeared by weeks. no morphological changes could be observed at the tibial level. consistently, no conduction or excitability changes could be observed at the right tibial neve level as compared to the left tibial nerve in wt. in contrast, in p +/− the motor axon function was impaired at the tibial nerve level at weeks after sciatic lpc demyelination. in mature p +/−, although the cmap amplitude appeared preserved, the distal motor latency was prolonged whereas the excitability measures showed reduced deviations during threshold electrotonus and increased refractoriness at the expense of superexcitability of the recovery cycle, both consistent with membrane depolarization. furthermore, in aged p +/− the delayed tibial conduction was associated with a drop in cmap amplitude and a prolongation of the strength-duration time constant. taken together these data suggest that focal demyelination aggravates membrane dysfunction along the entire motor axon in p +/− providing a novel experimental model to explore the link between demyelination and axonal membrane dysfunction in cmt b. amass l , li h , gundapaneni b , schwartz j , keohane d . pfizer inc., new york, ny, usa; inventiv health inc., burlington, ma, usa. a number of factors can influence disease progression in transthyretin familial amyloid polyneuropathy (ttr-fap), a rare, fatal, hereditary amyloidosis. this analysis evaluated the specific role of baseline neurologic severity on neurologic disease progression in ttr-fap. a predictive model was created based on longitudinal data from val met patients who participated in the tafamidis (a selective ttr stabilizer) clinical development program. data from the intent-to-treat population of the double-blind, placebo-controlled registration study (tafamidis group, n= ; placebo group n= ) and its two consecutive open-label extension studies in which all patients received tafamidis were used. the second extension study is ongoing, but a formal, prospectively-planned interim analysis was conducted with the cut-off date of december , . this analysis focused on the first months of treatment for the overall study cohort analyzed. the neuropathy impairment score-lower limbs (nis-ll) was used to assess neurologic functioning at baseline and at subsequent study visits. a linear mixed-effects model for repeated-measures (mmrm) analysis, with baseline nis-ll, treatment, and their interactions with time as fixed effects, was used, and the slope and intercept for each patient were included as random effects. patients were primarily caucasian with early-stage neurologic disease (baseline nis-ll mean [standard deviation]: tafamidis, . [ . ]; placebo, . [ . ] ). across both groups, disease progression increased with increasing levels of baseline severity (nis-ll) (p< . ). however, the predicted magnitude of change from baseline to month for tafamidis was consistently less than that for placebo across a range of observed baseline nis-ll values, suggesting a disease-modifying effect of tafamidis. similar findings were observed for the nis-ll muscle weakness subscale. this mmrm analysis in patients with val met ttr-fap demonstrates that disease progression strongly depends on baseline neurologic impairment and highlights the disease-modifying effect of tafamidis across a range of baseline levels of neurologic severity. clinicaltrials.gov identifiers: nct , nct , nct . amino h , misawa s , sekiguchi y , shibuya k , watanabe k , suichi t , kuwabara s . department of neurology, chiba university, chiba, japan. guillain-barré syndrome (gbs) is a potential life threatening neurological disorder and respiratory insufficiency is one of the critical complications. eramus gbs respiratory insufficiency score (egris) is a method for predicting the chance of respiratory insufficiency in gbs. however, clinical characteristics and courses can vary for subtypes of gbs, whose occurrences differ for each region: acute inflammatory demyelinating polyneuropathy (aidp) is very common in european countries, whereas acute motor axonal neuropathy (aman) is frequently seen in asian countries. the aim of this study is to investigate the usefulness of egris in japan, where aman is more common than in the netherlands. clinical and electrophysiological profiles of consecutive gbs cases, who visited our hospital within days after symptoms onset between and , were reviewed. of the gbs patients, % were classified as aidp and % as aman according to the electrodiagnosis criteria by ho and colleagues. higher egris scores correspond to higher risk of respiratory insufficiency in total of the gbs patients, as well as in aidp patients. however, in patients with aman, egris scores did not always match the chances of respiratory insufficiency: up to % of the patients with low risk of egris showed respiratory failure, whereas only % of the patients with high risk of egris needs intubation/mechanical ventilation. in aman, associations with mechanical ventilation were seen for rapid progression (shorter duration between onset and hospital admission), more decreased vital capacity, and more frequent autonomic involvement. egris is useful also for japanese gbs patients. however, for aman patients, it should be used with discretion. another score to predict respiratory insufficiency might be required in asian countries. anandan c , litchy wj , laughlin rs , leep hunderfund an , naddaf e . mayo clinic, rochester, usa. in patients with suspected ulnar neuropathy, nerve conduction studies (ncs) are commonly requested to help with diagnosis and localization. however, routine ncs are often normal or not localizing. ulnar ncs recording from the first dorsal interosseous muscle (ncs-fdi) is thought to increase the diagnostic yield of electrodiagnostic testing, although not commonly considered. we developed a quality improvement strategy to routinely perform ulnar ncs recording from the abductor digiti minimi muscle (ncs-adm) as well as ulnar ncs-fdi in all patients referred for suspected ulnar neuropathy. we utilized the dmaic (define, measure, analyze, improve, control) model of process improvement to define our problem and create a map of the current process for ulnar neuropathy diagnosis in our electromyography laboratory. we determined baseline performance via review of distal sensorimotor polyneuropathy (dpn) is the most common complication of diabetes and risk factors beyond hyperglycemia have proven important particularly in type diabetes (t dm). only few prospective studies from early-stage t dm exist. we aimed to study the development of dpn during the first years after a screening-based diagnosis of t dm. from the addition-denmark study participants were eligible for this study. dpn was assessed by the michigan neuropathy screening instrument questionnaire (mnsi) at four time-points during follow-up. dpn was defined by a mnsi score ≥ . participants ( %) were positive in mnsi at baseline and thus excluded from this study. by kaplan-meier plot we evaluated the cumulative incidence of dpn and in cox proportional hazard models we calculated hazard ratios (hr) for the intervention groups in the addition trial and for various covariates proposed to influence the development of dpn. models were adjusted in steps for intervention group, age, sex, baseline mnsi, lipid-lowering and anti-hypertensive treatment. this study cohort consists of participants ( % men) with a median age of . years (p ;p : . ; . ) and median baseline hba c of . (p ;p : . ; . ). a cumulative incidence of % was seen during years of diabetes. there was no statistically significant difference in hr between the intervention groups or by sex but a significantly higher hr of . ( %ci: . ; . ) was seen for age (per year). the highest hr was found for a history of cardiovascular disease (myocardial infarction or stroke) up to ten years prior to the diabetes diagnosis with a hr of . ( . ; . ). weight, waist circumference, body-mass index and methylglyoxal (log transformed) showed modest but statistically significant associations with incident dpn with standardized hrs of . ( %ci: . ; . ), . ( %ci: . ; . ), . ( %ci: . ; . ) and . ( %ci: . ; . ) respectively. this study demonstrates a fairly low cumulative incidence of dpn in people with screen-detected t dm and provides evidence that macrovascular disease, obesity and oxidative stress are important risk factors for dpn even at the earliest stages of t dm. andermann syndrome, also known as agenesis of the corpus callosum and peripheral neuropathy (accpn), is an autosomal recessive disorder with a broad spectrum of mild to severe neuromuscular and psychiatric consequences. the gene variants causing disease were first identified in french-canadian families. in the present study, we intended to phenotype and genotype a series of non-french-canadian familial cases presenting with charcot marie tooth disorder associated with agenesis/dysgenesis of the corpus callosum. for this purpose, seven families, of consanguineous marriage, were studied. patients were clinically and para-clinically investigated using mri and electrophysiology (mncvs). for some, a sural nerve biopsy was taken. microsatellite markers around the accpn locus were used in two large families; followed by sanger sequencing of all the exons and intron-exons boundaries of the gene, in one patient from each of the families. the age at onset of the disease was at birth in the patients from the largest consanguineous family ( affected individuals). the biopsy from one patient showed a severe demyelinating neuropathy with many hypomyelinated fibres and mostly secondary axonal changes. these finding were compatible with electrophsiological data where the mncvs are of demyelinating range. dysgenesis of the corpus callosum in one patient and agenesis in another sib were revealed by mri. we identified one homozygous truncating mutation in this family. interestingly, no causative variant was found in a patient from another family and showing homozygous haplotype. two different heterozygous variants were identified at one hit in two patients from two non-consanguineous families. genetic investigations will be continued to identify the possible second hit. in the remaining families, no variant was found. the negative family cases will be subjected to ngs. at this stage, it is tempting to speculate on the genetic heterogeneity of accpn in our series. baba m , suzuki c , ogawa c , tomiyama m . department of neurology; diabetes center, aomori prefectural central hospital, aomori, japan. in we introduced a staging system of severity of diabetic polyneuropathy (dpn) by nerve conduction study (ncs) of the lower limb: sensory ncs of the sural nerve and motor ncs of the tibial nerve. the system consists of five stages; ncs- (normal): no abnormalities, ncs- (mildly abnormal): presence of delay of mcv, scv, minimal f-wave latency, or positive a-wave, ncs- (moderately abnormal): decrease in sural snap less than uv, ncs- (severely abnormal): decrease in plantar muscle-cmap to - mv, ncs- (ultimately abnormal): plantar muscle-cmap lost or less than mv with trace of sural-snap. to examine validity of the system, we conducted -year prospective observation on development of diabetic foot (df) by the ncs staging system. in addition, occurrence of ischemic heart disease (ihd) and stroke (is), and death of neuro-vascular events were also counted. n - , we carried out ncs in diabetics, and categorized them by the ncs staging system: % was ncs- , % was ncs- , another % was ncs- , % was ncs , and % was ncs- . we then followed them and prospectively counted the occurrence of df, ihd and is in patients (mean age ys). the occurrence of df during the following years was; ncs- : %, ncs- : %, ncs- : %, ncs- : %, ncs- : %. occurrence of any of df, ihd and/or is was as follows; ncs- : %, ncs- : %, ncs- : %, ncs- : %, ncs- %. there was no death from nsc- , − , and − groups (n= ), while two from ncs- group (n= ) were found dead in a bed or on a driver's seat, and other two from ncs- group (n= ) died of sudden cardiac arrest or infection after foot amputation. in summary, the present ncs grading system seems to work satisfactory not only for diagnosis of severity of the current dpn, but also for prognostic prediction of the dpn-related foot and vascular events. bacon c , feely sme , shy me . university of iowa hospital, iowa city, ia, usa. for patients with charcot-marie-tooth disease, also known as hereditary motor and sensory neuropathy, the rasch modified cmtnsv is a validated measurement of symptoms and impairment. the score is comprised of nine parameters of a clinical examination, including nerve conduction studies (ncs) . each parameter has an individual score ranging from zero to four, with the composite score having a maximum of prior to rasch modification. for patients who do not complete a ncs, the cmt exam score (cmtesv ) is used, with a maximum score of before rasch modification. one parameter of the cmtesv is the vibration sense. using a rydel tuning fork, a care-giver measures vibration sense in a patient's feet, ankles, and knees and a score is determined by the severity of reduced vibration sense. in cmt a patients, % received a score of out of , noted by a reduced vibration sense at the knee. in order to capture a more sensitive vibration measurement, we tested ways of taking the total raw score of the rydel tuning fork at each point of vibration sense, the toe, ankle, and knee bilaterally. scores range from zero to , with reflecting full vibration sense. in this modified measurement, vibration sense scores varied in wider distribution. for cmt a patients captured in this studied, a modified vibration sense score results in a potentially more sensitive total cmtesv score. bae dw , an jy . st. vincent's hospital, the catholic university of korea, suwon, korea. diabetic lumbosacral radiculoplexus neuropathies (dlrpn) are usually subacute painful, monophasic, asymmetrical lower limb neuropathies with incomplete recovery due to ischaemic injury and microvasculitis. the diagnosis relies mostly on clinical suspicion and characteristic electromyographic findings. however, in acute phase, neuroimaging has more important diagnostic significance than electrophysiological studies. here we describe mri and ultrasound findings in a -year-old woman with dlrpn who was diagnosed with diabetes three years ago, but has not received any other treatment. she had a -day history of acute-onset severe pain with weakness of muscles innervated by left femoral and obturator nerve and decreased sensation in left l -l dermatome. nerve conduction studies showed reduced amplitude in left femoral nerve and electromyography showed only increased insertional activity in left iliopsoas muscle and no volitional activity in muscles innervated by left femoral and obturator nerve. ultrasound revealed increased cross-sectional area (csa) of left femoral and lateral femoral cutaneous nerve. mri showed enhancement in left l , nerve roots and proximal femoral nerve and increased signal intensity in left iliacus and iliopsoas. we diagnosed her with dlrpn and started corticosteroid. nerve ultrasound has not been previously reported in a patient with cabin air in commercial airliners originates from aircraft engines or auxiliary power units. this bleed air may occasionally be contaminated with hydraulic fluids and engine oil that contains a number of potentially hazardous chemicals including tricresyl phosphate (tcp). over the last years reports are emerging about aircrew members that experience symptoms such as tingling or burning of extremities in addition to headache, and vertigo. this "aerotoxic syndrome" is controversially discussed in the literature and has been attributed to exposure to organophosphate contaminated cabin air. since tcp has been associated with peripheral neuropathy we aimed to determine the frequency of peripheral neuropathy among frequent flyers. civilian air crew members and frequent flying passengers (m:f = : , median age years, median exposition time in aircrafts of . hours) were examined at the university hospital of cologne or at the frankfurt airport (iata code fra) by a detailed questionnaire of past medical conditions, a standardized neurological examination and nerve conduction studies of sural, tibial, and ulnar nerves. we identified subjects with clinical and electrophysiological evidence for large fiber peripheral neuropathy. incidence of peripheral neuropathy was not correlated to exposition time in aircrafts. in addition subjects showed signs of ulnar neuropathy, subjects reported abnormal vibration sensation, subjects suffered from gait imbalance and individuals reported tingling of extremities. our study shows a . % prevalence of large fiber peripheral neuropathy among frequent flyers. comparison of these data with prevalence rate in an age-matched control group will reveal a possible association of chronic exposure to cabin air and risk for peripheral neuropathy. the high incidence of the symptom tingling in our cohort warrants further studies to determine the risk for small fiber neuropathy in this condition. intravenous immunoglobulin (ivig) are human igg derived from plasma pools of healthy donors. although there are studies in literature evaluating their effectiveness in different pathological animal models, there are no data about their possible role on bortezomib (btz)-induced peripheral neuropathies. female wistar rats were treated following a preventive schedule (btz and ivig co-treatment for and weeks) and a therapeutic schedule ( weeks of btz treatment followed by a -week ivig-btz co-treatment). caudal nerve conduction velocity (ncv), plantar and dynamic tests were performed at different time points. animals were sacrificed after ws (acute phase) or ws (chronic phase) and tissue samples (dorsal root ganglias -drg-, sciatic nerve, caudal nerve, skin) were collected for morphological, morphometrical and immunohistological analysis.in the preventive schedule, ivig was not able to rescue caudal ncv reduction caused by btz neither after nor after weeks of co-treatment. same results were observed in the therapeutic schedule. on the other hand, the evaluation of mechanical allodynia and cold hyperalgesia showed that ivig injection protected from btz effect in both treatment schedules. morphometric analysis evidenced that, even if not statistically significant only the preventive schedule has a tendency to protect the caudal nerve from btz damage. this result is consistent with the morphological evaluation of the nerve. also, intra-epidermal nerve fibers density was preserved in the preventive schedule but not in the therapeutic one. finally, sciatic nerve and drg macrophage infiltration levels tended to be reduced in the therapeutic schedule and were brought back to ctrl (rats not treated or injected with ivig alone) levels in the preventive one. in conclusion, we were able to demonstrate for the first time that ivig treatment especially used as preventive treatment option may reduce btz-induced neuropathic painful pointing out the possible role of inflammation in the pathogenesis of this invalidating pathology. this work was supported by kedrion spa. we studied the prevalence, the molecular cause and clinical presentation of hereditary motor neuropathies in a large cohort of patients from the north of england. detailed neurological and electrophysiological assessments and next generation panel testing or whole exome sequencing were performed in patients with clinical symptoms of distal hereditary motor neuropathy (dhmn, patients), axonal motor neuropathy (motor cmt , patients) or complex neurological disease predominantly affecting the motor nerves (hmn plus, patients) . the prevalence of dhmn is . affected individuals per . inhabitants ( % confidence interval: . - . ) in the north of england. causative mutations were identified in out of index patients ( . %). the diagnostic rate in the dhmn subgroup was . %, which is higher than previously reported ( %). we detected a defect of neuromuscular transmission in cases and identified potentially causative mutations in patients with demyelinating multifocal motor neuropathy. many of the genes were shared between dhmn and motor cmt , indicating identical disease mechanisms therefore we suggest changing the classification and include dhmn also as a subcategory of cmt. abnormal neuromuscular transmission in some genetic forms provides a treatable target to develop therapies. barohn rj , gajewski b , pasnoor m , brown l , herbelin l , kimminau k , jawdat o , parks c , shlemon p , dimachkie mm and the pain-controls study team . the university of kansas medical center, kansas city, ks, usa. cryptogenic sensory polyneuropathy (cspn) is a common slowly progressive neuropathy that affects adults and presents with significant neuropathic pain for which multiple medications have been tried including antiepileptics, antidepressants, topicals and narcotics. a web based survey among neuromuscular experts suggested pregabalin as being more effective than other medications, however there are presently no comparative studies to assess the most effective medication. the objective of this study was to determine which of the pharmaceutical therapies (pregabalin, duloxetine, nortriptyline or mexiletine) is most effective for neuropathic pain and best tolerated in cspn. to achieve this objective we performed a prospective randomized open labelled comparative effectiveness adaptive design study of cspn patients through the patient centered outcomes research institute (pcori). cspn patients who fulfilled the inclusion and exclusion criteria were enrolled into this study. patients underwent a baseline neurological evaluation and randomly assigned to one of the neuropathic medications for months. the primary outcome is the change in likert-like pain scale. the secondary outcomes included nih pain interference scale, nih fatigue interference scale, nih sleep disturbance scale, sf- and adverse events. the outcome measures are performed at baseline, month , and . statistical analysis using bayesian adaptive design developed by berry consultant software will be performed to determine winner and losers (winner = greater than point improvement in pain). total number of patients to be enrolled is . recruitment has been challenging and a number of recruitment techniques have been used. to date, there have been patients screened, patients randomized from us sites. anticipated completion of enrollment by june and end of final patient assessment by september . interim analysis performed after first patients completed their months as part of bayesian adaptive design analysis and occurs every weeks. the distribution of randomization of patients to the medications at last adaptive design randomization was . % to medication , % to medication , . % to medication and . % to the th medication. this study may give physicians and patients evidence for future management of cspn patients. transthyretin amyloidosis (attr), which encompasses a group of disorders with significant clinical variability, is caused by transthyretin (ttr) derived amyloid deposition. the clinical aspects of autonomic nervous system involvement in attr are only partially known. the ongoing, multinational, longitudinal, observational transthyretin amyloidosis outcomes survey (thaos) provides the opportunity to expand our understanding of dysautonomia in attr. data from all symptomatic subjects enrolled in the thaos registry with a diagnosis of attr (cut-off date: january , ) were assessed for the presence and temporal course of autonomic symptoms, genotype and phenotype associations, and clinical burden according to the frequency and severity of symptoms. of symptomatic subjects enrolled in thaos, ( . %) had autonomic symptoms at enrollment including: gastrointestinal ( subjects, . %), urinary ( , . %), erectile dysfunction ( , . %), orthostatic hypotension ( , . %), xerophthalmia ( , . %) and dyshydrosis ( , . %). subjects with autonomic manifestations, compared with those without, were younger (mean age [standard deviation, sd] of . [ . ] vs . [ . ] years), with a longer duration of attr symptoms ( . [ . ] vs . [ . ] years). autonomic dysfunction was less common with wild-type attr ( of subjects, . %) than in mutation groups: val met ( / , . %); non-val met/non-cardiac ( / , . %); and "cardiac mutations" (val ile, leu met, thr ala, or ile leu mutations; / , . %). similarly, time (mean [sd] , years) from first attr symptoms to onset of autonomic symptoms, was longest for wild-type attr ( . [ . ] ) followed by "cardiac mutations" ( . [ . ]), non-val met/non-cardiac ( . [ . ]), and val met ( . [ . ] ). autonomic symptoms were present at disease onset in over a third of subjects ( , . %) . autonomic dysfunction was less frequent in subjects with cardiac phenotype ( of subjects, . %), than with mixed ( / , . %) or neurologic ( / , . %) phenotypes. the burden of autonomic symptoms (mean [sd] ) varied by genotype, val met ( . [ . ] , non-val met/non-cardiac ( . [ . ], "cardiac mutations" ( . [ . ]), wild-type attr ( . [ . ]), and by phenotype, mixed ( . [ . ]), neurologic ( . [ . ]), cardiac ( . [ . ]). dysautonomia is common, and a significant burden, in subjects with hereditary forms of attr. its prevalence is higher in val met than in other genotypes, and in the neurologic or mixed phenotypes. the objective of this study is to assess the usefulness of motor unit number index (munix) technique in charcot-marie-tooth type a (cmt a) disease and to test correlation between munix and clinical impairment. munix technique was performed in abductor pollicis brevis (apb), abductor digiti minimi (adm) and tibialis anterior (ta) muscles in the non-dominant side. a munix sum score was calculated by adding munix of these muscles. muscle strength was measured using the mrc (medical research council) scale. disability was evaluated with several functional scales including cmt neuropathy score version (cmtnsv ) and overall neuropathy limitation scale (onls). cmt a patients with known pmp gene duplication were enrolled. the munix of the adm, apb and ta muscles were correlated with the mrc of the corresponding muscle (p< . ). munix sum score was correlated with clinical scales: cmtnsv (r=− . , p< . ), onls (r=− . , p< . ). in conclusion, munix correlates with muscle strength and clinical measurements of disability in cmt a patients. the munix technique evaluates motor axonal loss and correlates with disability. the munix sum score may be a useful outcome measure of disease progression in cmt a. the objective of this study was to assess the usefulness of mri in charcot-marie-tooth type a (cmt a) disease and to test correlation between muscle fat fraction and clinical impairment. mri was performed in the non-dominant lower limb of cmt a patients and healthy controls. fat fraction of tibialis anterior muscle, cross section area and volume of sciatic nerve were determined. muscle strength of dorsiflexion was measured using a dynamometer. disability was evaluated with cmt neuropathy score version (cmtnsv ). cmt a patients with known pmp gene duplication were enrolled. fat fraction of tibialis anterior muscle was significantly increased in patients compared to healthy controls. it was correlated with muscle strength (r=− . , p< . ) and cmtnsv score (r=− . , p< . ). cross section area and volume of sciatic nerve were significantly increased in patients compared to healthy controls. in conclusion mri fat fraction correlates with muscle strength and clinical measurement of disability in cmt a patients. it may thus be a useful outcome measure of disease progression in cmt a. basta i , peric s , cobeljic m , bjelica b , bozovic i , kacar a , nikolic a , rakocevic stojanovic v , stevic z , lavrnic d . neurology clinic, clinical center of serbia, school of medicine, university of belgrade, belgrade, serbia. there is a complete lack of data about epidemiological and clinical features of chronic inflammatory demyelinating polyneuropathy (cidp) in serbia and surrounding countries. furthermore, there is a striking scarcity of information about quality of life (qol) in cidp patients and all qol studies have been conducted in countries with high standards of health care. in august we have designed the iness (inflammatory neuropathy study of serbia) in order to comprise as many patients with cidp from serbia, republic of srpska (bosnia and herzegovina) and montenegro covering population of more than nine million people. our first aim is to analyze overall impact of cidp on physical, mental and social areas of life measured with generic, symptom specific and disease specific questionnaires -sf- , inqol and cap-pri, respectively. furthermore, we aim to analyze influence of the disease on patients' working status and presence of depressive mood measured by beck's inventory. following features of patients are included: sociodemographic data, clinical aspects of the disease, level of disability, severity of sensory symptoms, presence of comorbidities, electrophysiological characteristics, as well as fatigue, autonomic symptoms and neuropathic pain. we intend to define the most significant predictors of decreased qol in order to focus on patients with the highest risk and to improve care of cidp. we also want to see if cidp patients in complete remission as per clinical findings still have reduced quality of life. we have recruited patient so far and we expect to include around subjects overall. we will present the first data of the study at the pns meeting . beaudonnet g , prud'hon s , cauquil c , labeyrie c , not a , bouilleret v , adams d . neurophysiology chu bicêtre, le kremlin bicêtre, france; neurology chu bicêtre, le kremlin bicêtre, france. familial amyloid neuropathy (fap) is a life-threatening disease of autosomal dominant inheritance due to transthyretin (ttr) gene mutation, a liver-produced protein. current treatments slow down its natural course and are indicated from the very first objective symptoms. we aimed to evaluate two neurophysiological markers: sympathetic skin response (ssr) and heart rate variability (hrv) in the early detection of sympathetic damages due to fap. ssr and hrv were assessed in ttr gene mutated patients with neither clinic nor electroneuromyographic abnormalities and controls matched on gender and age. cases were recruited consecutively from current care in the french reference center for rare diseases of bicetre university hospital. ssr was recorded on the two palms and on the sole of the left foot with to stimulations between and ma. hrv was registered during three conditions of seconds each: normal breathing, deep breathing ( cycles of seconds of inspiration and seconds of expiration) and valsalva manoeuver during seconds. valsalva ratio, defined by the ratio between the longest and shortest rr intervals, was significantly higher in the control groups after bonferroni correction (means of . and . , respectively, p< . ). there was no significant difference between the two groups for any ssr parameter, although means of amplitudes were systematically higher in controls than among cases. our results confirm that autonomic nervous fibers are damaged early in both clinical and electroneuromyographic asymptomatic patients mutated on the ttr gene. valsalva ratio seemed to be the most discriminative marker. long-term follow-up with test repetition and confrontation with cardiologic assessment will help to precise how these tests could be used in current care. they might help to identify high risk patients to propose them an appropriate early treatment and could be used to follow treatment efficacy. familial amyloidotic polyneuropathy (fap) was originally characterized by andrade as an axonal neuropathy which subsequently was found to be associated with a number of mutations in the plasma protein transthyretin (previously named prealbumin). it is now recognized that cardiomyopathy may be a significant factor in a majority of patients with the hereditary form of transthyretin amyloidosis (fap) and many of the transthyretin (ttr) mutations are associated with cardiomyopathy with no or minimal signs of peripheral neuropathy. attr-wt also called senile cardiac amyloidosis and senile systemic amyloidosis is recognized as late-onset, usually in the th or th decade of life, and the fact that the majority of patients are males. transthyretin neuropathy proven by nerve biopsy has been rarely reported in this population. here we report our experience with patients having attr-wt characterized by cardiomyopathy but also with varying degrees of peripheral neuropathy. clinically, the neuropathy appears as typical axonal or mixed axonal/demyelinating neuropathy as is seen in fap. pathologically, two types of ttr deposition have been found, ( ) intraneural ttr amyloid deposits as seen in fap are present in some patients and ( ) other patients have extensive vascular deposition of amyloid in both perineural arteries and veins without deposits within nerve trunks. in conclusion, peripheral neuropathy may definitely be a part of the attr-wt clinical presentation and with the increase in numbers of attr-wt cardiomyopathy patients being identified, it is important to ascertain whether any evidence of peripheral neuropathy is due to the amyloidosis and not to compounding syndromes such as diabetes mellitus type ii. besora s , santos c , izquierdo c , martinez-villacampa m , simó m , bruna j , , velasco r , . neuro-oncology unit, hospital universitari de bellvitge-institut català d́oncologia, ĺhospitalet, barcelona, spain; medical oncology department, institut català d́oncologia, ĺhospitalet, barcelona, spain; department of cell biology, physiology and immunology, institute of neurosciences, universitat autònoma de barcelona and centro de investigación biomédica en red sobre enfermedades neurodegenerativas (ciberned), bellaterra, spain. oxaliplatin (oxa) is the first-line chemotherapy agent in the treatment of colorectal cancer (crc). oxa-induced peripheral neuropathy is the most frequent long-term side-effect. retreatment with oxa is frequently considered in patients as salvage treatment. patients receiving oxa-based chemotherapy regimen at least twice at our institution between and were reviewed. the aim of this study was to investigate whether retreatment with oxa increases the risk of developing or worsening previous oxa-induced peripheral neuropathy. the severity of neuropathy was measured by national cancer institute-common toxicity criteria (nci), total neuropathy score (tns) © and nerve conduction studies. one hundred twenty-five crc patients were included. median age was years. after first-line oxa-based chemotherapy, . % of patients developed neuropathy according nci, after a median of [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] cycles. severity of neuropathy was grade ( . %), grade ( %), and grade ( . %). median time to retreatment with oxa was months. frequencies of neuropathy before retreatment were as follows: . % grade , . % grade , and . % grade . after retreatment, severities of neuropathy were . % grade and . % grade . no patient developed grade . . % of patients did not develop neuropathy. peripheral neuropathy was the reason for stopping prematurely treatment after first-line and retreatment in . % and . % of patients, respectively. worsening of previous nci score was observed in . % of patients. the great majority of patients ( . %) remained within the same nci score than before retreatment after median [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] cycles. among those patients that did not develop neuropathy after first treatment (n= ), only and patients developed grade and , respectively, after a median of [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] cycles. among those patients who initially developed grade and neuropathy, no differences in tnsc © scores just before and after finishing retreatment with oxa were identified ( [ - ] vs [ - ], p= . ). retreatment with oxa in crc patients is a feasible option even in patients who developed moderate or severe neuropathy previously. lack of worsening of previous neuropathy is observed in the great majority of patients. neurological monitoring of patients candidates to retreatment with oxa should be considered. bessaguet f , sturtz f , magy l , , desmouliere a , bourthoumieu s , demiot c . ea -myelin maintenance & peripheral neuropathy, faculties of medicine and pharmacy, university of limoges, limoges, france; department of neurology, reference center for rare peripheral neuropathies, university hospital of limoges, limoges, france. prolonged pressure and the resulting local ischemia are widely accepted as the primary etiology of skin pressure ulcers (pus) but precise mechanisms of their formation remain unclear. in this study, we wanted to study the potential role of sensory small nerve fibers in regulation of inflammation during pus formation. to achieve this goal, we developed a mouse model of a purely sensory neuropathy and this was induced by resiniferatoxin (rtx). in this model, seven days after a single injection of rtx ( g/kg; ip), mice present a thermal and mechanical hypoalgesia associated with large substance p (sp) and calcitonin gene-related peptide (cgrp) depletion without neurodegeneration. this model mimic quite well what is observed in early stages of sensory nerve fiber defect. studies have shown that sp and cgrp are involved in cutaneous inflammation regulation. in fact, these neuropeptides are released by sensory fibers and are pro-inflammatory mainly through recruitment of immune cells and vasodilation. thus, we studied gene expression of pro and anti-inflammatory cytokines by a rna array approach during pus formation in control and rtx mice. seven days after a single injection of rtx, epidermis, dermis and subcutaneous tissue layer were pinched with magnetic plates during hours. pressure induced a stage pus. gene expression was evaluated in each compressed area h after pressure. results showed mainly a down-regulation of gene expression in pus of rtx mice compared to control mice. a decrease of cgrp/sp in skin sensory small fiber increased pus formation associated with an increase of interleukins (il)- , il- , il- and il- expression and a decrease of il- expression in rtx mice. supplementary experiments with rt-qpcr for each cytokine will be necessary to confirm these preliminary results. these observations suggest a cgrp/sp role in regulation of cytokines expression during pus formation. the new inflammatory profile exhibited in this study might help in the design of new treatments improving the quality of life of neuropathic patients prone to developing bedsores. bhattacharyya bj , jayaraj nd , belmadani a , ren d , rathwell ca , hackelberg s , miller rj , menichella dm . department of neurology, northwestern university, chicago, il, usa; department of pharmacology, northwestern university, chicago, il, usa. painful diabetic neuropathy (pdn) is one of the most common and intractable symptoms of diabetes, affecting % of diabetic patients. the hallmarks of pdn are neuropathic pain and small fiber degeneration, manifested by the loss of dorsal root ganglion (drg) nociceptor axons. neuropathic pain is associated with nociceptor hyper-excitability in the absence of physiologically appropriate stimuli. in states of neuropathic pain, drg nociceptors become increasingly responsive to a variety of excitatory influences, including inflammatory cytokines. in particular, we have shown that stromal cell derived factor- (sdf- ) and its receptor cxcr are necessary for the generation of neuropathic pain in mouse models of pdn. however, the molecular mechanisms leading to the hyper-excitability of drg nociceptors in pdn are unknown, as are the mechanisms leading to small fiber degeneration. this fundamental gap in our knowledge represents a critical barrier to progress in developing novel therapeutic approaches for pdn. the objective of this study is to identify the molecular cascade linking cxcr /sdf- chemokine signaling to drg nociceptor hyper-excitability, neuropathic pain, and small fiber degeneration in pdn. drg nociceptors can be identified by a series of molecular markers, including expression of the sodium channel na v . . indeed, > % of na v . -expressing drg neurons are nociceptors. feeding mice a high fat diet (hfd) for several weeks induces glucose intolerance, obesity, and mechanical allodynia, a particular pain hypersensitivity associated with pdn. using the hfd model combined with dreadd receptor technology, we have shown that reducing excitability of na v . -expressing neurons prevents and reverse neuropathic pain, neuronal calcium overload, mitochondrial dysfunction, and small fiber degeneration. furthermore, we have shown that cxcr receptors are necessary for neuropathic pain and small fiber degeneration in pdn. taken together these data demonstrate that na v . nociceptor hyperexcitability in pdn is driven through the activation of cxcr receptors. inhibition of hyperexcitability can prevent and reverse the development of pdn. furthermore, these observations will advance our understanding as to how changes in excitability, calcium influx, and mitochondrial dysfunction in nociceptors contribute to neuropathic pain and small fiber degeneration in pdn, which is a critical barrier to progression for effective and disease modifying treatment for pdn. bianco m , terenghi f , gallia f , nozza a , scarale a , fayoumi mz , giannotta c , morenghi e , nobile-orazio e . poems (polyneuropathy, organomegaly, endocrinopathy, m protein and skin changes) syndrome is an unusual multisystem disease with neurological disability due to a severe disabling polyneuropathy, with high mortality by multiorgan failure. peripheral blood stem cell transplantation (pbsct) is considered the treatment of choice for poems while lenalidomide is the most promising therapy for patients not eligible for pbsct. the aim of the present study was to compare the long-term effects on clinical, biological and neurophysiologic parameters in patients with poems treated with lenalidomide or pbsct. the clinical, biological and neurophysiologic data were reviewed in poems patients treated with pbsct (n: ) or lenalidomide (n: ). the mrc sumscore on muscles, onls scale, vegf serum levels and nerve conduction studies were assessed before (t ) and after (t ) and years (t ) of treatment and the differences were compared using anova. combining the two groups of patients, there was a significant improvement after treatment in the mean mrc sumscore (t = ± ; t = ± ; t = ± ; p = . ), in the mean onls score (t = . + . ; t = . + . ; t = . + ; p = . ), in the ulnar mean distal motor latency (t = . ± . msec; t = . ± . msec; t = . ± . msec; p = . ), distal compound muscle action potentials amplitude (t = . ± . mv; t = . ± . mv; t = . ± . mv; p = . ), motor conduction velocity (t = . ± . m/sec; t = ± m/sec; t = . ± . m/sec; p= . ) and serum vegf levels (t vs t : p = . ; t vs t : p = . ). the difference was also significant when we separately analyzed patients treated with lenalidomide and pbsct and there was no difference between the two groups in any of the analyzed parameters. treatment with pbsct and lenalidomide significantly and similarly improved clinical, biological and neurophysiologic parameters in patients with poems syndrome up to two years. since pbsct may not be suitable for all patients, lenalidomide may represent an effective and a valuable alternative in these patients or in those relapsing after pbsct inducing a prolonged clinical, biological and neurophysiologic improvement. bis d , tao f , abreu l , sleiman p , hakonarson h , zuchner s and inherited neuropathy consortium. dr. j.t. macdonald department for human genetics, hussman institute for human genomics, university of miami, miami, fl, usa; center for applied genomics, the children's hospital of philadelphia, philadelphia, pa, usa. inherited peripheral neuropathies are clinically and genetically heterogeneous diseases that can cause distal muscular atrophy and sensory loss. alleles in over one hundred different genes have been shown to cause peripheral neuropathies; yet, greater than % of axonal neuropathy patients do not receive a genetic diagnosis. large scale exome studies are now beginning to be sufficiently powered to perform mutational burden analysis. this approach compares damaging allele frequencies of cmt cases with a control group to identify additional causes for neuropathies. this approach will also identify genes that require an oligogenic inheritance to cause a phenotype. in a deviation from the classic linkage-based and heuristic variant filtering approaches to gene identification, we are performing burden analyses in a large cohort of cmt families. in known neuropathy genes, we saw that neuropathy cases carried on average . rare, non-synonymous variants, while unrelated non-neuropathy controls harbored . variants (p= . e- , mann-whiney u-test). enrichment of rare, non-synonymous variants in cmt disease genes within inherited peripheral neuropathy cases suggests the presence of multiple weaker alleles in individual patients. we also performed an unbiased exome-wide gene-based burden analysis and ranked genes after multiple testing correction. several new candidate genes were identified that need further follow up conformational studies. a number of known cmt and related genes were observed in the list of top candidates. we are currently analyzing additional aspects of this sample and are actively seeking more cmt exomes to enlarge our study. in summary, statistical methods traditionally reserved for more 'common' phenotypes' increasingly are becoming available for rare disease genetics. c bl/ mice were treated with bortezomib alone or in combination with monastrol. neuropathic changes were assessed by nerve conduction studies and histological analysis. analysis of axonal morphology was performed with light and electron microscopy. anti-neoplastic properties of monastrol alone and in combination with bortezomib were assessed in different blood cancer cell lines. prolonged treatment with bortezomib induced a sensory neuropathy in mice. significant changes in axonal morphology correlated with reduced function of peripheral nerves. the administration of monastrol substantially ameliorated morphological features of axonal alterations and sensory neuropathy. cytotoxicity studies in blood cancer cell lines showed no interference of monastrol with the cytostatic effects of bortezomib. our data indicate that monastrol may alleviate bortezomib induced neuropathy. the favorable cytotoxic profile of monastrol makes it an interesting candidate as neuroprotective agent to prevent bortezomib-induced neuropathy. boczonadi v , meyer k , gonczarowska-jorge h , , bartsakoulia m , roos a , , bansagi b , zahedi rp , talim b , bruni f , kaspar b , , lochmüller h , boycott km , müller js , horvath r . jwmdrc, wtcmr, igm, newcastle university, newcastle upon tyne, uk; rinch, columbus, oh, usa; leibniz-institute für analytische wissenschaften-isas-e.v., dortmund, germany; capes foundation, brazil; department of pediatrics, hacettepe university children's hospital, ankara, turkey; dbbb,university of bari aldo moro, bari, italy; department of neuroscience, the ohio state university, columbus, oh, usa; department of genetics, cheo, university of ottawa, ottawa, canada. while autosomal dominant mutations in gars, encoding the glycyl-trna synthetase, have been identified in patients with charcot-marie-tooth peripheral neuropathy (cmt d) and distal spinal muscular atrophy type v (dsma-v), autosomal recessive mutations cause mitochondrial disease affecting skeletal muscle and heart. gars is a bi-functional enzyme and it is responsible for normal protein translation both in mitochondria and the cytoplasm. in this study we have focused on the mitochondrial function of the gars by investigating a mouse model (gars c r) , human fibroblasts and induced neuronal progenitor cell lines (inpcs). mild mitochondrial abnormalities were detected in skeletal muscle of the gars c r mice while no other tissues were affected. control and patient fibroblasts harboring gars mutation were directly converted into inpcs. we identified tissue specific impairment of mitochondrial function in neuronal cells carrying not only recessive but also dominant gars mutations, suggesting neuron-specific effects of mitochondrial alterations.comparative proteomic analysis of inpcs showed significant changes in mitochondrial proteins. furthermore, the reduction of the vesicle-associated membrane protein-associated protein b (vapb) and its downstream pathways in gars-deficient inpcs suggests that altered mitochondria-associated endoplasmic reticulum (er) membranes (mam) may also contribute to the motor neuropathy. boczonadi v , king ms , bansagi b , roos a , , eyassu f , borchers c , lane m , ramesh v , lochmüller h , pyle a , griffin h , smith ac , chinnery pf , , alan j robinson aj , edmund rs kunji ers , horvath r . jwmdrc, wtcmr, igm, newcastle university, newcastle upon tyne, uk; mitochondrial biology unit, medical research council, cambridge; leibniz institute of analytic sciences (isas), dortmund, germany; uvic-genome bc proteomics centre, vancouver, canada; paediatric neurology, royal victoria infirmary, newcastle upon tyne foundation hospitals nhs trust, newcastle upon tyne, uk. members of the mitochondrial carrier family (slc ) transport nucleotides, keto acids, amino acids, fatty acids, co-factors and inorganic ions across the mitochondrial inner membrane. several inherited diseases with very variable clinical presentations are associated with dysfunctional mitochondrial carriers. we report a patient with childhood-onset spinal muscular atrophy and mitochondrial myopathy caused by a homozygous mutation in slc a , encoding the mitochondrial oxodicarboxylate carrier (odc). the mutation renders the carrier dysfunctional and, consequently, -oxoadipate cannot be imported into the mitochondrial matrix. computer modelling of the metabolic defect caused by the mutation predicted that the impaired transport leads to accumulation of -oxoadipate, pipecolic acid and the known neurotoxin quinolinic acid, which were precisely confirmed by targeted metabolomics in serum and urine. exposure of -oxoadipate and quinolinic acid reduced the level of mitochondrial complexes in sh-sy y cells in-vitro suggesting a possible pathomechanism. here we demonstrate that -oxoadipate and quinolinic acid are toxic for spinal motor neurons and their increased levels may contribute to neuropathy. and families have been reported. interestingly, most mutations target the same amino acid residue (k e, k m, k n, k t) in the highly conserved -crystallin domain of the hspb protein. the spectrum of diseases caused by mutations in the hspb gene was recently expanded to distal myopathy. hspb is ubiquitously expressed, but is highly expressed in motor neurons and muscles. the hspb is a chaperone that participates in clearing misfolded poly-q containing proteins such as mutant huntingtin and ataxin- involved in respectively huntington's disease and spino-cerebellar ataxia. hspb directly interacts with the co-chaperone bag and their role in chaperone-assisted selective autophagy is well described. to delineate the molecular deficits and functional consequences of hspb mutations we generated a knock-in (ki) mouse model for the k n missense mutation mimicking the neuropathy phenotype. we observed that homozygous mutant mice (hspb k n/k n ) develop a progressive axonopathy, with decreased compound motor action potential amplitudes, and loss of large and medium myelinated axons. this results in locomotor deficits with an impaired performance at the rotarod and grip strength tests. at the ultrastructural level, the hspb -ki model displays severe signs of axon degeneration and a clear myofibrillar myopathy, as observed in some patients with hspb mutations. interestingly, hspb positive aggregates were found in the sciatic nerve and gastrocnemius muscle of our mutant mice. additionally, our model allowed us to generate hspb knock-out (ko) mice using the same targeting vector. strikingly, the homozygous hspb -ko animals do not show any sign of axonopathy and display a much milder myopathy than the hspb -ki animals. these data suggest that part of the pathomechanisms is due to toxic gain-of-function of the mutant protein. boutahar n , reynaud e , nasser y , camdessanché jp , antoine jc . university hospital, saint-etienne, france. dysimmune sensory neuronopathies (snn) depend on neuron cell death induced by an inflammatory reaction in dorsal root ganglia. we have recently identified the intracellular tyrosine kinase (trk) domain of the fibroblast growth factor receptor- (fgfr ) as the target of antibodies in a subset of patients with non paraneoplastic snn. fgfr is one of the four fgfrs and has been involved in sensory neurons maintenance during development and cell death induction after axotomy. fgfrs ligand fixation results in the activation of several intracellular pathways through adaptator protein interactions with the trk domain. in particular ras activation may lead to cell proliferation or apoptosis through erk / or p map kinase signaling. the p mapk pathway is also involved in neuronal cell death induced by nmda and ampa receptor activation. as fgfr is a cell surface protein, human antibodies may interfere with the receptor functioning as a growing number of evidence has showed with other cell surface antibodies in neurological diseases. to test this hypothesis we developed an in vitro model using fvbn mice cortical neurons culture exposed to a rabbit polyclonal antibody reacting with the trk domain of fgfr . comparatively to normal rabbit iggs, the fgfr antibody induced neuron cell death in a dose dependent manner. neuron cells were exposed to fgfr antibody concentration leading to - % cell death in absence or presence of the p mapk inhibitor sb and the expression of fgfr , glur subunit of ampa receptors and nr subunit of nmda receptor was measured by quantitative rt-qpcr. the fgfr antibody induced an upregulation of fgfr while the glur and nr subunits were modulated. these changes were prevented in presence of sb . these preliminary results indicate that anti-fgfr iggs may interfere with the functioning of the intracellular domain of the protein and the expression of nmda and ampa receptors through the p map kinase pathway. this model may be used to test the effect of human anti-fgfr iggs in vitro. braathen gj , tveten k , holla Øl , busk Øl , hilmarsen ht , svendsen m , høyer h . section of medical genetics, department of laboratory medicine, telemark hospital, skien, norway. next-generation sequencing (ngs) has during the last years entered the clinical diagnostics. ngs has proven to be very efficient in the diagnostics of disorders where multiple genes can be involved. our ngs-based targeted gene panel consists of hereditary neuropathy genes, i.e. mostly charcot-marie-tooth genes. this study is a retrospective study of clinic samples received between may and february . we describe the identified novel likely pathogenic sequence variants, according to international guidelines. in this period we identified novel, not previously described, likely pathogenic sequence variants in the following genes: aars, fgd , gan, hint , litaf, lrsam , mme, mpz, nefl, pmp , sbf , sh tc and yars. there is now a large range of genes causing hereditary peripheral neuropathies and many likely pathogenic sequence variants. likely pathogenic sequence variants are not only identified in old well established neuropathy genes but also in the newer genes like mme. modelling brown-vialetto-van laere syndrome in c. elegans mutations in slc a and slc a , which encode the riboflavin transporters rfvt and rfvt . patients with rfvt deficiency exhibit proximal and distal limb weakness, sensory ataxia, diaphragmatic paralysis, optic atrophy, sensorineural deafness and bulbar palsy. riboflavin is critical for the biosynthesis of flavin mononucleotide and flavin adenine dinucleotide, essential cofactors for carbohydrate, amino-acid and lipid metabolism. mutations in slc a reduce or abolish rfvt expression resulting in impaired riboflavin uptake into sensory and motor neurons. high-dose riboflavin treatment can improve or stabilise a patient's condition, however the optimum dose and long term effects of riboflavin treatment, and disease pathomechanisms remains poorly understood. to further understand the pathophysiological consequences of slc a mutations, we propose developing an animal model for bvvl. caenorhabditis elegans (c. elegans) are small round transparent nematodes extensively used for studying the genetics and molecular biology of neurodegenerative diseases. there are two c. elegans riboflavin transporter genes, rft- and rft- . based on protein sequence homologies and expression profiles for both genes, rft- is the ortholog of rfvt . the expression of rft- is regulated by riboflavin availability and knock-down of the rft- gene by sirna perturbs c. elegans development. our aim is to develop a knock-in c. elegans model of bvvl. human rfvt and c. elegans rft- protein sequences were aligned with clustal omega to identify conserved amino acid residues associated with bvvl mutations. the amino acid involving the l p rfvt mutation is conserved in rft- (residue l ). to create our model, we will introduce the l p rft- mutation into the rft- locus in c. elegans genomic dna using crispr/cas- technology. this bvvl c. elegans model will allow us to explore the pathogenic consequences of rfvt deficiency underlying motor nerve degeneration and to evaluate drug therapy regimes by determining the optimal riboflavin dose and treatment initiation, and trialing other compounds that may improve benefits seen with riboflavin supplementation. chronic inflammatory demyelinating polyradiculoneuropathy (cidp) is an autoimmune-mediated inflammatory disease of the peripheral nervous system. cidp can present chronic progressive or relapsing-remitting courses and can predominantly affect motor but also sensory nerve fibers causing weakness of proximal and distal muscles. it represents the most common chronic autoimmune neuropathy and is pathologically characterized by focal inflammatory-mediated demyelination followed by axonal degeneration. recently, we have developed a new animal model for cidp, the chronic-ean, induced in lewis rats by active immunization with s-palmitoylated p ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) peptide. this model fulfills electrophysiological criteria of demyelination with axonal degeneration, a result confirmed by immunohistopathology. the late phase of the chronic disease is characterized by an accumulation of il- + cells and macrophages in sciatic nerves and as well as high serum il- levels. it is a reliable and reproducible animal model for cidp that can now be used for translational drug studies for chronic human autoimmune-mediated inflammatory diseases of the peripheral nervous system, particularly cidp, for which, there is a real need for new immunotherapies. the aim of this study was to test the therapeutic efficacy of ivig and a recombinant fc fragment (fcrec) in this new cidp animal model. treatments with ivig and fcrec proved effective in preventing further progression of cidp in rats. the therapeutic treatments not only decreased the maximal clinical scores of the cidp rats compared to albumin treatment but also abolished the disease chronicity. interestingly, a better efficacy of fcrec treatment compared to ivig was demonstrated at histological level, with the myelinated fibers well preserved and the greatly reduced accumulation of macrophages and il- + cells in sciatic nerves. ivig and fcrec therapeutic activities in this model can also be followed by measurement of antibodies in the serum and could therefore be used as biological markers. the current study provides for the first time direct evidence that ivig is effective in the treatment of cidp rats and suggests that a novel fcrec compound is more effective than ivig. it will contribute to the development of more effective and safer drugs for the treatment of autoimmune peripheral neuropathies like cidp. each time, one measurement with supramaximal stimulation according to the conventional ncs and another measurement with % enhanced stimulation intensity were conducted. we analyzed the results with special consideration of minimal and maximal fiber velocities and of the velocity with maximal fiber proportion. as a result, we detected statistically significant differences between cidp patients and controls in all these parameters. compared with controls, cidp patients had slower minimal and maximal fiber velocities and also the spectrum of motor conduction velocities was definitively shifted to slower velocities. slower minimal conduction velocities could be detected in some cidp patients by using the enhanced stimulation intensity. interestingly, in some cidp patients the conventional ulnar ncs were normal, but the collision technique showed fibers with a conduction velocity of less than m/s, indicating demyelination. to our knowledge, this is the first study using hopf's collision technique systematically in cidp patients. significant differences between the variation of ulnar motor nerve conduction velocity of cidp patients and controls could be detected. this method also showed signs of demyelination in some cidp patients with normal ulnar ncv. by enhancing stimulation intensity above the threshold of supramaximal stimulation in conventional ncs, the collision technique may be even more valuable. the clinical course of guillain-barré syndrome (gbs) is highly variable and some patients may develop treatment-related fluctuations (trfs) as an indication of ongoing disease activity and temporary treatment effect. other patients present as gbs, but subsequently develop repetitive relapses as an indication of acute-onset chronic inflammatory demyelinating polyneuropathy (a-cidp). this distinction is important because treatment may differ. we determined the frequency and clinical presentation of patients with gbs-trf and a-cidp in the first patients included in the international gbs outcome study (igos) with a follow-up of at least months. thirty-eight patients ( %) were excluded because of alternative diagnoses. of the remaining patients, ( %) had at least one trf, ( %) had a-cidp. preliminary analysis showed no significant differences between the groups (total-gbs, gbs-trf and a-cidp) for sex, age, sensory symptoms, cerebrospinal fluid results and mechanical ventilation. a-cidp patients had a median age of years (iqr - ), % was male, and all patients were treated in the acute phase of the disease (intravenous immunoglobulins (ivig) ( ), plasma-exchange (pe) ( ) or methylprednisolone (mp) ( )). gbs-trf patients has a median age of years (iqr - ), % was male and all patients received treatment (ivig ( ) and pe ( ). gbs-trf patients showed more antecedent events ( % versus %, p= . ), a higher gbs disability score (≥ ) at nadir ( % versus %, p= . ) and less frequently developed ataxia ( % versus %, p= . ) than patients with a-cidp. onset to nadir was longer in a-cidp than in gbs-trf ( days (iqr - ) versus days (iqr - ), p= . ) and the total gbs group ( days (iqr - ), p= . ). the time until the first clinical deterioration tends to be longer in the a-cidp patients (median days (iqr - ) versus median days in the gbs-trf group, not significant). the diagnosis a-cidp was made after a median of days . in conclusion, this first analysis identified distinctive characteristics of gbs-trf and a-cidp in support of a different pathogenesis that may help with early identification of these disorders in clinical practice. additional results will be presented at the conference. chronic inflammatory demyelinating polyneuropathy (cidp) is a disorder with a highly diverse clinical presentation, electrophysiological phenotype, response to treatment and outcome. this heterogeneity may indicate the presence of distinct subtypes of cidp, which may have a different pathogenesis and require more personalized treatment. the international cidp outcome study (icos) is a prospective, observational, international multi-center study that aims to describe this variation in clinical and electrophysiological subtypes and to define the clinical and biological determinants of these subtypes, disease activity, treatment response and outcome. in addition icos aims to provide an infrastructure for conducting new (therapeutic) studies in cidp, similar to the international gbs outcome study (igos). all patients fulfilling the efns/pns ( ) diagnostic criteria for cidp can be included in icos, independent of age, duration and severity of disease or treatment. we collect information on neurological deficits, diagnostic characteristics, various validated clinical outcome measures, previous and current treatment and we collect biomaterials (dna, cerebrospinal fluid, nerve biopsies and repeated serum samples). icos was started as a pilot study in dutch university centers. by february , patients were included in icos, patients recently diagnosed with cidp and previously diagnosed patients. included were ( %) males and ( %) females with a median age of years (iqr - ). the current cohort consists of classic (sensory-motor) cidp, madsam and pure motor variants. of the patients diagnosed in the past, patients ( %) were treated (intravenous immunoglobulins (ivig) ( ), prednisolone ( ), subcutaneous immunoglobulins (scig) ( ), dexamethasone ( ), plasma-exchange ( ) and ivig with methylprednisolone (mp) ( )). the recently diagnosed patients all received treatment (ivig ( ), dexamethasone ( ), plasma-exchange ( ) and patients were treated in a pilot study with ivig with methylprednisolone (mp)). the protocol has been evaluated and adjusted and will be shared with other researchers via the inflammatory neuropathy consortium and igos consortium. our aim is to include at least cidp patients worldwide with a minimum follow-up period of years. dominant mutations in glycyl trna synthetase (gars) cause inherited axonal neuropathy (charcot-marie-tooth type d). mutations in the mouse gars gene cause a similar phenotype, and represent valid disease models. we routinely use two mouse strains, one with a severe neuropathy, and one with a milder, later onset neuropathy. using these mouse models, we are exploring the mechanisms through which gars mutations cause peripheral axon degeneration. efforts include ribosome tagging to isolate ribosome-associated mrnas specifically from motor neurons, and non-canonical amino acid tagging to visualize and isolate newly synthesized proteins. taking advantage of the anatomy of motor neurons, we are able to analyze cell bodies separately from peripheral axons in both of these approaches. in addition, we are using these mouse models for preclinical studies testing gene therapy approaches to treat cmt d. consistent with our previous genetic studies in mice, knockdown of the mutant transcript, while preserving sufficient levels of the wild type, is a very successful approach when administered before the onset of neuropathy. we are now testing this approach in mice after the onset of symptoms, and in mice carrying a mutant gars allele associated with human disease. these studies are potentially translational, and also address mechanistic questions such as the timing and cell autonomy of the pathophysiology. burnor e , yang l , hao z , patterson k , quinn c , scherer ss , lancaster e . the university of pennsylvania, philadelphia, pa, usa; the second xiangya hospital, central south university, hunan, china. autoantibodies to two isoforms of neurofascin (nf and nf ) have been reported in patients with guillain-barre syndrome (gbs) or chronic inflammatory demyelinating neuropathy (cidp). it is not clear which of these responses reliably distinguish autoimmune neuropathies from other severe neuropathies, which responses are transient versus persistent, or which responses may target multiple isoforms of neurofascin. in addition, approximately % of neuropathy patients have no known cause, and it is unknown whether a subset of these patients may have autoantibodies to neurofascins. we have studied cohorts of patients with autoimmune neuropathy (n= ), genetic neuropathy (n= ), and idiopathic neuropathy (n= ) for igg and igm responses to neurofascins. neurofascin antibodies were found in ( %) of patients with autoimmune neuropathy, and ( . %) idiopathic neuropathy patients, but only % ( of ) in patients with genetic neuropathy. follow-up serum samples were available for positive cases. persistent responses were associated with chronic neuropathy while transient responses were seen in gbs or with remission of cidp. most patients had responses specific to either nf of nf . however, a particularly severe, treatment-resistant form of cidp, approaching a locked-in state, was seen in a patient with a unique response to all three isoforms of neurofascin (nf , nf , nf ). treatment of this patient with rituximab resulted in clinical improvement and resolution of the neurofascin antibody response. in conclusion, autoantibodies to neurofascins distinguish autoimmune neuropathies from severe genetic neuropathies, but the clinical phenotype may depend on the persistence and isoform specificity of the immune response. antibodies to the common domains shared by nf and nf may portend a severe but treatable neuropathy. a subset of idiopathic neuropathy patients may have an autoimmune mechanism. burns j , , sman ad , cornett kmd , wojciechowski e , , walker t , menezes mp , , mandarakas mr , rose kj , , bray p , , sampaio h , farrar m , , refshauge km , raymond j and the fast study group. university of sydney, new south wales, australia; sydney children's hospitals network (randwick and westmead), new south wales, australia; university of new south wales, sydney, australia. exercise has undisputed benefits for human health and potentially as a treatment for neuromuscular disease. but there is also a risk of harm due to overwork weakness. we report the results of a -month randomised, double-blind, sham-controlled trial evaluating progressive resistance exercise of foot dorsiflexor muscles in pediatric cmt. sixty patients ( cmt a, cmt e, cmt f, cmt a, cmt c, cmtx , cmtx ) aged - years were randomly assigned to undergo -weeks ( sessions) of moderate-intensity progressive resistance exercise or sham exercise. the primary endpoint was change in isometric dorsiflexion strength between groups assessed by hand-held dynamometry (expressed as a z-score based on age-and sex-matched normative reference values, positive values indicate an improvement in strength). the primary safety endpoint was change in muscle and fat volume of the muscles responsible for dorsiflexion by mri between groups. secondary outcomes were function (balance, long jump, -min walk test), walking ability ( d gait analysis), self-reported ankle instability, parent-reported quality of life (physical summary, psychosocial summary and global impression of change scores), and adverse events. fifty-five ( %) children completed the trial. adherence was comparable between exercise ( %) and sham ( %) groups. while patients experienced muscle soreness during training in the exercise group, adverse events did not differ between groups. the mean z-score for dorsiflexion strength increased in the exercise group by % at -months (from − . ± . to − . ± . ) and decreased in the sham group by %, mirroring the natural history of cmt (from − . ± . to − . ± . ). between-group ancova-adjusted difference at -months was . ( %ci, . to . ; p= . ). the mean scaled scores for mri muscle volume and fat volume were comparable between groups at months (p> . ). the global impression of change scores favoured the exercise group at -months (p= . ) and -months (p= . ). there was no other measurable effect of exercise. pre-specified subgroup analyses according to age ( - years vs. - years) showed a larger treatment effect with exercise in adolescents. targeted progressive resistance exercise was effective at halting progression of dorsiflexion weakness without detrimental effect on muscle morphology or other signs of overwork weakness in children with cmt. byung-nam y , yoon-ho h , suk-won a , seok-jin c , jung-joon s . inha university hospital, incheon, south korea; seoul metropolitan government boramae medical center, seoul national university, seoul, south korea; joong ang university hospital, seoul, south korea; seoul national university hospital, seoul, south korea. a years old female patient visited the hospital with weakness in both upper limbs from months under the suspicion of motor neuron disease with the finding of extensive denervation changes on electromyography. whole spine mri showed ventral nerve rootlet enhancement in the c and t bundles. the emg had confirmed active denervation changes in the muscles innervated by bilateral c ∼c roots. the cerebrospinal fluid culture test showed a protein (csf) elevation to mg / dl. she got a steroid pulse therapy. she had the symptoms of dry mouth and dry eyes during the recent years. a salivary gland scan test was performed for the possibility of sjögren's syndrome, and as a result, absorption of the contrast agent in both parotid and submandibular glands was decreased. the shammer test showed mm on the right side and mm on the left side. she was diagnosed of sjögren's syndrome. after weeks, overall strength improvement was observed, and bilateral shoulder abduction was improved to mrc grade or higher. the follow-up spine mri also showed that the initially seen ventral nerve root enhancement was disappeared. the case had visited the hospital with major symptoms of weakness and atrophy of the muscles, showing similar pattern to motor neuron disease, and was diagnosed as inflammatory polyradiculopathy and confirmed as primary ss during differential diagnosis. this case suggests that primary ss may induce inflammatory polyradiculopathy, which shows motor symptoms as major symptoms rather than sensory symptoms, and that a fast and accurate diagnosis is needed in terms that it can be treated with steroids and appropriate immune suppressive agents. traumatic injuries to peripheral nerves are frequent. however, effective pharmacological treatments are lacking. curcumin, a polyphenol found in rhizomes of curcuma longa, has been shown to develop antioxidant, anti-inflammatory, and neuroprotective properties. however, due to its poor hydrosolubility and its extensive metabolism, the use of large curcumin doses is required for therapeutic purpose. the aim of the present study was to investigate the effects of a local infusion of a low curcumin dose on nerve regeneration and functional recovery after sciatic nerve injury in rats. the experiments were conducted in g sd male rats submitted to unilateral sciatic nerve crush at d . curcumin was solubilized in polyethylene glycol and continuously administered using osmotic pumps ( . mg/day until d ) with a catheter delivering the drug near the lesion site. functional analyses using von frey, beam walking, static sciatic index (ssi) and grip strength tests were carried out at d (reference test) and every week after injury (d , d , d , d and d ). in addition, an evoked electromyogram was performed at d and d . after euthanasia (d ), nerve and muscle samples were collected and analyzed by light and electron microscopy. functionally, a significant improvement of the mechanical sensitivity (+ %) was observed at d in the curcumin-treated group (n= ) vs. vehicle group (n= ). in curcumin-treated group, skillful walking and finger spacing of the ipsilateral paw (ssi) were fully restored respectively at d and d contrary to vehicle group. furthermore, curcumin treatment improved the grip strength recovery (+ % at d ). the electrophysiological results indicated a full recovery of motor nerve conduction velocities (mncv) after days of curcumin treatment, while mncv remained altered in vehicle group ( % of the mncv at d ). morphometric analysis of nerve sections using g-ratio showed an improvement in the thickness of the myelin sheath in curcumin treated animals (+ % vs. vehicle group). histological investigation of gastrocnemius muscle indicated decreased neurogenic lesions in curcumin group. proteomic analysis is currently under investigation to understand the mechanisms involved in curcumin effects. our data could lead to the development of new therapeutic strategies in peripheral nerve regeneration using low doses of curcumin. previous studies suggest that the metabolic syndrome (mets) is associated with distal symmetrical polyneuropathy (dsp), and that diabetes, pre-diabetes, and obesity are the main metabolic drivers. the aim of this study is to investigate the association of mets components with retinal and cognitive function in a bariatric surgery cohort prior to surgery. patients were recruited from the adult bariatric surgery clinic at the university of michigan and lean controls from a research website (no mets components based on ncep/atpiii definition). participants underwent extensive metabolic phenotyping including a glucose tolerance test and fasting lipid profile. dsp was defined using the toronto consensus definition of probable clinical neuropathy. retinal function was measured with frequency doubling technology perimetry (average mean deviation), and cognitive function with the nih toolbox (composite score). univariate linear regression models were used to evaluate the association between mets components and retinal and cognitive function. to date, we have recruited bariatric surgery participants and lean controls. in the bariatric population, the mean (sd) age was ( . ) with % female compared with a mean age of . ( . ) with % female in the lean group. in the bariatric group, . % had diabetes, . % pre-diabetes, and . % normoglycemia. the dsp prevalence was % in lean controls, . % in normoglycemic, . % in pre-diabetic, and . % in diabetic bariatric participants (p< . for trend). retinal function was . ( . ), − . ( . ), − . ( . ), and − . ( . ) (p= . for trend), and cognitive function was . ( . ), . ( . ), . ( . ), . ( . ) (p= . for trend) in these same groups for lean controls, normoglycemics, pre-diabetics and diabetics, respectfully. pre-diabetes (− . , %ci: − . ,- . ) was the only mets component associated with retinal function, and waist circumference was the only one associated with cognitive function (− . , %ci − . ,- . ). dsp and retinal function, but not cognitive function decline with worsening glycemic status. similar to previous data for dsp, pre-diabetes and obesity are associated with retinal and cognitive function respectively. interestingly, while clinical dsp is common in this population, clinical retinopathy and dementia are not, indicating that dsp may be the first metabolic complication in the morbidly obese. and anti-cntn antibody-positive cases were confirmed by cba and were of igg subclass in half of them. by cba we identified additional / ( %) anti-caspr seropositive patients, whose isotype is currently being tested. sera of anti-nfasc and anti-cntn igg seropositive patients and patients with anti-caspr antibodies stained paranodes by indirect immunofluorescence on mouse teased nerve fibers. of note, seronegative patients for known antibodies showed reactivity against node and/or paranodes. compared to other seronegative cipd patients, seropositive patients had more frequently subacute onset of the neuropathy and a younger age at onset, particularly for nfasc or caspr antibodies. weakness was more severe and was often associated with proprioceptive loss, sensory ataxia and tremor. neuropathic pain was not a feature of caspr -seropositive patients. frequent findings were increased distal motor latencies and temporal dispersions on nerve conduction study and a higher protein level in csf. finally seropositive patients tended to have a higher disability and showed worst response to ivig. rituximab was effective in one patient with anti-nfasc antibodies and two patients with anti-cntn antibodies showed good and persistent recovery after cyclophosphamide. prevalence of antibodies was % in italian cidp patients and their presence was associated with distinctive clinical features. their determination, followed by characterization of igg subclass in positive cases, has clear clinical impact, by helping to guide therapeutic choices. the reactivity against nodal and paranodal components in sera from patients without known antibodies suggests that other targets could play a role in the autoimmune response in cidp and they still need to be identified. mutations in amynoacyl trna synthetases (arss), enzymes that catalyse the covalent attachment of amino acids to their cognate trna, are responsible for autosomal dominant cmt , intermediate cmt (cmt-i) and dhmn. we report the case of a male of italian ancestry who first presented with bilateral ankle clonus at three months, followed by toe walking and ankle instability. the ankle clonus subsided during adolescence. in the third decade he developed progressive walking difficulties followed by distal sensory loss. neurological examination at the age of revealed a steppage gait, distal lower limb weakness, decreased pinprick to the ankles, and reduced vibration sensation at the knees. reflexes were brisk in the upper limbs, reduced at the knees and absent at the ankles. muscle tone was increased in the lower limbs and plantar responses were extensor. nerve conduction studies revealed an axonal neuropathy. brain and spinal cord mri were normal. sanger sequencing of pmp , gjb , mpz , gdap and mfn were negative. sureselect focused exome sequencing (agilent technologies, santa clara ca, usa) demonstrated a c. g>a, p.arg his mutation in aars. the p.arg his mutation in aars has previously been reported in families with intermediate or axonal motor-sensory neuropathy, and in one case was associated with sensory-neuronal deafness. cns involvement has not previously been described with this mutation. mutations in aars have been associated with a range of phenotypes including cmti, cmt and dhmn with variable age on onset ranging from to years (mean years). of note, the aars p.gly arg mutation has been reported in a family with cmt and pyramidal signs. this study provides further evidence that pyramidal tract involvement can be an early feature of cmt n due to mutations in aars, further expanding the spectrum of arss-associated phenotypes. small fibres in the skin are vulnerable to damage in metabolic or toxic conditions such as diabetes mellitus or chemotherapy resulting in small fibre neuropathy and associated neuropathic pain (np). whether injury to the most distal portion of sensory small fibres due to a primary dermatological disorder can cause np is still unclear. recessive dystrophic epidermolysis bullosa, (rdeb) is a rare condition in which mutations of proteins of the dermo-epidermal junction lead to cycles of blistering followed by regeneration of the skin. damage is exclusive to the skin and mucous membranes, with no known direct compromise of the nervous system. it is increasingly recognised that most rdeb patients experience daily pain, the aetiology of which is unclear but may include inflammation (in the wounds), musculoskeletal (due to atrophy and retraction scars limiting movement) or np. in this study we investigated the incidence of np and examined the presence of nerve dysfunction in rdeb patients. around three quarters of patients presented with pain of neuropathic characteristics which had a length dependent distribution. quantitative sensory testing of the foot revealed striking impairments in thermal detection thresholds combined with an increased mechanical pain sensitivity and wind up ratio (temporal summation of noxious mechanical stimuli). nerve conduction studies showed normal large fibre sensory and motor nerve conduction however skin biopsy showed a significant decrease in intraepidermal nerve fibre density. autonomic nervous system testing revealed no abnormalities in heart rate and blood pressure variability however the sympathetic skin response of the foot was impaired and sweat gland innervation was reduced. we conclude that chronic cutaneous injury can lead to injury and dysfunction of the most distal part of small sensory fibres in a length dependant distribution resulting in disabling np. these neuropathic pain (np) following peripheral nerve injury is associated with hyperexcitability in damaged myelinated sensory axons which begins to normalise over time. we investigated the composition and distribution of shaker type potassium channels (kv channels) within the nodal complex of myelinated axons following injury. at the neuroma that forms after damage, expression of kv . and . (normally localised to the juxtaparanode) was markedly decreased. in contrast kv . and . , which were hardly detectable in the naïve state, showed increased expression within juxtaparanodes and paranodes following injury, both in the rat and in humans. within the dorsal root (a site remote from injury) we also noted a redistribution of kv channels towards the paranode. blockade of kv channels with dtx after injury reinstated hyperexcitability of a-fibre axons and enhanced mechanosensitivity. changes in the molecular composition and distribution of axonal kv channels, therefore represents a protective mechanism to suppress the hyperexcitability of myelinated sensory axons that follows nerve injury. members of the francophone anti-mag cohort group are listed in "appendix". appendix polyneuropathy with anti-mag igm antibodies is classically progressive, predominantly sensory, and distal with ataxia and sometimes postural-intention tremor. we assessed clinical, biological, electrophysiological, and histopathological features in patients with igm gammopathy and anti-mag antibody titres higher than btu. we focused on characteristics of patients according to the anti-mag antibody titres at diagnosis. we retrospectively and prospectively analysed standardized report forms of patients from fourteen french-speaking neuromuscular centres. mean age at onset was . years (range - . ). mean time between symptoms onset and last follow-up was . years ( . - . ). about . % of patients presented with a "variant" clinical phenotype independently of anti-mag titres (< or ≥ btu). this included acute or chronic sensorimotor polyradiculoneuropathies, paucisymptomatic sensory polyneuropathy and multifocal neuropathy. at the most severe disease stage, . % of patients were significantly disabled. anti-mag antibody titres at diagnosis were low (< btu), medium ( - ) or high (≥ ) in respectively , and % of patients. patients presented with mgus or waldenström's macroglobulinemia in respectively % and % of cases. sixteen percent of patients did not meet the electrodiagnostic criteria of definite demyelinating neuropathy, independently of anti-mag titres (< or ≥ btu). nerve biopsy, performed in nineteen patients, provided support to the diagnosis of anti-mag neuropathy in some particular issues (low titres of anti-mag, unusual clinical or electrophysiological phenotype). we assessed the degree of probability (probable, possible or uncertain) that patient neuropathies are directly related to anti-mag antibodies, according to anti-mag titre, electrophysiological data and nerve biopsy characteristics if available. it appears uncertain in patients with low anti-mag titres ( . % of the whole population). the clinical phenotype didn't appear to be different according to anti-mag antibody titre. many of the patients with low anti-mag titres presented "genuine" anti-mag neuropathy as demonstrated by edx studies, clinical presentation and sometimes nerve biopsies. for a small proportion of these patients, a direct relation between neuropathy and anti-mag antibodies is uncertain due to atypical clinical presentation, axonal neuropathy pattern or nerve biopsies, and positivity of antigangliosides antibodies. we assessed therapeutic management, response to immunotherapies and adverse events in a cohort of patients presenting with igm gammopathy and anti-mag antibody titres higher than btu. we retrospectively and prospectively analysed standardized report forms of patients from french speaking neuromuscular centres. mean age at onset was . years (range - . ). mean time between symptoms onset to diagnosis and last follow-up were respectively . ( - ) and . years ( . - . ). anti-mag antibody titres at diagnosis were low (< btu), medium ( - ) or high (≥ ) in , and % of patients. patients presented with mgus or waldenström's macroglobulinemia in respectively % and % of cases. seventy eight percent (n = ) of patients received immunotherapies. transient response to ivig or plasma exchanges at six month was observed in less than and % of patients respectively. chemoimmunotherapies and rituximab were more frequently administered in the group of patients with malignant hemopathies (n = ) compared to mgus (n = ) (mean lines of therapy = . , range - , sd . versus . , range - , sd . , p = . ). more than % of patients (n = ) received rituximab monotherapy. clinical worsening, mostly transient and reversible, was observed in / patients after rituximab. clinical response to rituximab at months and/or during - months follow-up period was observed in . % of patients, and correlated with anti-mag titre ≥ btu ( / responder versus / non-responder patients, p = . ). at - months follow-up, responder patients presented shorter symptom duration compared to non-responders, though not significant after logistic regression ( . years, range . - . , sd . in responder patients versus . years, range . - . , sd . , in non responder patients, p = . ). in some cases, electrodiagnostic studies were recorded during rituximab treatment follow-up and showed in responder patients a clear improvement of motor conduction velocities. these data may support another clinical trial to study benefice of rituximab in anti-mag neuropathies early in the disease. it raises issues about the value of incorporating electrodiagnostic parameters as end-points. schwann cells (scs) are essential for axon integrity and myelination in the uninjured pns. after pns injury, scs function as "first responders" , undergoing phenotypic re-programming and orchestrating many processes that lead to functional nerve repair. receptors in scs that contribute to sc repair programs remain incompletely understood. we identified a member of the ionotropic glutamate receptor (igr) family, n-methyl-d-aspartate receptor (nmda-r), in scs that is upregulated after nerve injury and acts as a co-receptor with ldl-receptor related protein (lrp ). lrp is a well-known regulator of the sc response to pns injury. herein, we used pcr to profile igr expression in cultured rat scs. obligate receptor subunits required for assembly of nmda-rs, ampa-rs, and kainate receptors were identified. treatment of rat scs with - microm glutamate or . - . microm nmda robustly activated akt and erk / . the response was transient and bimodal; glutamate concentrations greater than microm failed to activate cell-signaling. phosphoprotein profiling demonstrated other cell-signaling and transcription factors regulated by glutamate in rat and human scs, including p s -kinase, glycogen synthase kinase- , ribosomal s kinase, c-jun, and creb. activation of cell-signaling by glutamate in scs was blocked by eliminating calcium from the medium, by the selective nmda-r antagonist, mk , and by genetic silencing expression of the obligate nmda-r nr subunit. phosphoinositide -kinase/pi k functioned as an essential upstream activator of both akt and erk / in glutamate-treated scs. by activating pi k and erk / , glutamate promoted sc migration. glutamate ( microm) or nmda ( microm) injected into crush-injured sciatic nerves robustly activated p-erk / in both myelinating and non-myelinating scs in vivo. these results identify igrs as potentially important cell-signaling receptors in scs that may promote axon-glial interactions. understanding the function of sc nmda-r is important given current efforts to develop nmda-r-targeting drugs for patients with pain, depression, and alzheimer's disease. while frequently overlooked in a therapeutic context, scs are extremely important in the pathogenesis of chronic neuropathic pain. if these drugs modulate the activity of sc nmda-r and sc physiology, the response to pns injury may be altered and the possibility that neuropathic pain develops increased. candayan a , atkinson d , durmus tekce h , parman y , jordanova a , battaloglu e . department of molecular biology and genetics, bogazici university, istanbul, turkey; center for molecular neurology, antwerp university, antwerp, belgium; istanbul medical school, istanbul university, istanbul, turkey. charcot-marie-tooth (cmt) disease is a group of inherited peripheral neuropathies affecting one in individuals worldwide. the disease presents both clinical and genetic heterogeneity. so far, mutations in genes and loci are associated with cmt with autosomal dominant, autosomal recessive, x-linked and mitochondrial inheritance. despite the advances in genetic testing, approximately % of all cmt patients worldwide remain without a molecular diagnosis. we have investigated unrelated cmt patients of turkish descent, in all of which pmp duplication has been excluded previously. we used multiplex amplification of specific targets for resequencing (mastr) assay to sequence exonic regions of common cmt genes. recurrent mutations were identified in cases in mfn , gjb , mpz and hint genes. we have also identified novel variants in cases in mfn , pmp , gars, aars, ighmbp and gdap genes, all of which are very rare or not present in the variation databases and are predicted to be pathogenic by in silico tools. familial segregation analyses are ongoing for novel variations. mfn and gjb genes were the most commonly mutated causative genes in this cohort. cases without molecular diagnosis after the mastr testing are candidates for further analyses such as whole exome sequencing or whole genome sequencing. outcomes of the current study and our previous experience with turkish cmt patients suggest a high genetic heterogeneity. our insight is that different genetic strategies or larger panels are essential to determine the causes underlying cmt especially in regions where rare recessive types of the disease can be observed due to high frequency of consanguineous marriages. capoccitti g , giannini f , ginanneschi f , casali s , insana l , rossi a . university of siena, siena, italy. several efforts have been made to elaborate new electrophysiological criteria for early diagnosis of guillain-barré syndrome (gbs) and to differentiate demyelinating (aidp) from axonal (aman/amsan) forms. the aims were to verify the diagnostic power of total cmap (tcmap) duration, firstly applied in gbs field. this parameter was compared with commonly used neurophysiological measures, including negative phase cmap duration (ncmap), and was added to modified rajabally criteria. we reviewed the clinical and electrophysiological data of patients with gbs (level or of brighton clinical criteria). each patient underwent at least two neurophysiological studies, the first within weeks, the second between and weeks from symptom onset. at least four motor and three sensory nerve conduction studies were recorded for each test. regarding early diagnosis, the binary logistic regression model with multiple variables, including ncmap duration, showed that the features of predictive model presenting greater significance (p < . ) were tcmap duration, sural sparing and a-waves. among these, tcmap duration showed greater significance (p = . ). the tcmap was diffusely prolonged in aidp compared to aman/amsan, already in first examination and confirmed in the second one. roc analysis for tcmap duration in aidp vs. aman/amsan showed: cut-off . ms, auc . , ppv . %. we propose the tcmap duration as a new useful electrophysiological measure for early diagnosis of "generic" gbs and for early differentiation between aidp and aman/amsan. moreover, the prolongation of tcmap, the presence of a-waves and sural sparing represent a strongly diagnostic predictive triad of aidp. aifm (apoptosis-inducing factor, mitochondrionassociated- ) has captured great attention from biomedical researchers due its critical role in the regulation of cell apoptosis. this flavoprotein is typically located in the mitochondrial intermembrane space where it is associated with respiratory chain complex-i. upon a cell-death insult, aifm is cleaved into a kd protein that is released into the cytosol. the kd peptide may enter the nucleus to trigger chromosome condensation and fragmentation, initiating a caspase-independent pathway of apoptosis. however, this nuclear translocation may be blocked by cytosolic heat-shock protein- (hsp ) that binds with the fad domain (aa - ) of aifm . mutations in aifm gene have resulted in several clinical phenotypes, including a family with cmtx (glu val). clinical deficits in these patients usually involve multiple organs. in this study however, we identified a family with a novel missense mutation (phe leu) in aifm that developed a late-onset sensory motor axonal polyneuropathy by nerve conduction criteria. the proband and affected siblings exhibited distal muscle weakness and atrophy with normal cognitive and cranial nerve functions. there was no obvious phenotype from other organs. interestingly, this phe leu mutation affects a highly conserved amino acid at the center of the fad domain. we hypothesize that this mutation impairs the binding between aifm and hsp , leading to an enhancement of cell-death signaling. this family therefore provides a unique opportunity to explore how altered apoptotic signaling affects peripheral nerve system. supported by grants from ninds (r ns ) and the national center for advancing translational sciences (ul tr chronic inflammatory demyelinating polyneuropathy (cidp) can be the key symptom leading to diagnosis of associated lymphoma. patients with diagnosis of cidp according to efns/pns criteria associated with b cell lymphoproliferative disorders (bld), in one center, between november and november were included. demographical, clinical, nerve conduction, immunological, histological data and response to treatment were recorded retrospectively. eight patients ( men), median age yo were included. onset of polyradiculoneuropathy was either chronic (n= ) or acute (n= ). neurological condition led to diagnosis of bld in all but one case, because of onset (n= ) or worsening of neuropathy (n= ). clinical presentation was that of cidp in patients or pseudo-canomad in and plexopathy in one. lymphoma type was: lymphoplasmacytic (n= ), diffuse large b cell (n= ), small lymphocytic (n= ), marginal zone (n= ), unclassified small b cell (n= ). only patients presented with lymphadenopathies. bld was diagnosed in all patients on myelogram or bone marrow biopsy, performed because of cytopenia (n= ), atypical (n= ) or severe (n= ) neuropathy. monoclonal gammapathy was identified in / patients (igm n= , igg n= ). neuromuscular biopsy was performed in patients and disclosed endoneural infiltration in . anti-neuronal or antigangliosides antibodies were positive in patients. none of the patients presented a systemic autoimmune disease, hemolytic anemia associated with bld (n= ). immunomodulating treatment was administered in all patients (ivig n= , plasma exchange n= , steroids n= ) and immunosuppressants (n= ). immunochemotherapy for lymphoma was initiated because of lymphoma type or severity in cases, in cases because of the associated neuropathy. median follow-up was of months after treatment initiation. four out of patients treated within months of neurological onset improved as well as one out of patients whose preexisting neurological condition had worsened. two patients presented neurological relapse during progression of lymphoma. two patients died. unusual presentation of cidp -i.e., rapid progression or treatment failure -should lead to further testing for associated lymphoma. because general symptoms and lymphadenopathy often lack, diagnosis requires analysis of bone marrow with lymphocyte phenotyping. early treatment with immunochemotherapy was associated with better prognosis in our series. cardiac scintigraphy is a useful tool for the diagnosis, prognosis and pre-symptomatic early detection of familial amyloidosis-associated neuropathies three main types of familiar amyloidosis: transthyretin (ttr), apolipoprotein a and gelsolin. cardiac involvement is a leading cause of morbidity and mortality; one new described mutation strongly related with isolated cardiac amyloidosis is the ttr val ile. the discovery of tests that allow early diagnosis of cardiac involvement in amyloidosis and to infer about the etiology of the disease is of major importance. in a cohort of patients with different types of familiar ttr amyloidosis, we aimed to assess the role of mtc- , -diphosphono- , -propanodicarboxylic acid ( mtc-dpd) in detecting myocardial amyloid infiltration. we enrolled four patients diagnosed with late familiar amyloidosis, which mutations were documented at deoxyribonucleic acid analysis: three patients with ttr val met mutation and one patient with ttr val ile mutation. three patients were asymptomatic for cardiac involvement and one patient (val ile mutation) had a previous diagnosis of heart failure. myocardial uptake of mtc-dpd scintigraphy was semiquantitatively and visually assessed at five minutes and three hours.the uptake of mtc-dpd highly demonstrated amyloid in cardiac area in two out the three cases of ttr val met and in ttr val ile. ttr val ile case presented the highest uptake due to the exclusive deposition of amyloid in cardiac area resulting in severe heart failure. in hereditary transthyretin-related amyloidosis, including the mutations ttr val met and val ile, mtc-dpd cardiac scintigraphy can identify infiltration even in asymptomatic individuals, allowing an early diagnosis of cardiac compromise in this group of diseases. we can consider that this non-invasive test would be a tool with potential importance in the diagnosis, prognosis and pre-symptomatic early detection of cardiac amyloidosis, giving emphasis on its applicability in familial forms of amyloidosis. cervellini i , galino j , zhu n , birchmeier c , bennett dl . ndcn university of oxford, oxford, uk; max-delbrück-center for molecular medicine, berlin, germany. erk/mapk pathway has a critical role in pns development since its involvement in many physiological processes. sustained erk / mapk activation in schwann cells enhances myelin growth during development and overcomes signals ending myelination leading to a continuous myelin production. however, strong activation of erk has also been shown to cause schwann cells dedifferentiation and demyelination in vivo. our aim was to investigate whether a mild activation of this signalling pathway in adult schwann cells (scs), by expression of gain of function mek dd allele, could have a beneficial role in remyelination and regeneration after injury. erk/mapk activation in adult scs in plpcreer t ;mek dd mutant mice, did not affect myelination during development. following sciatic nerve injury, wallerian degeneration was enhanced in mutants pushing towards a dedifferentiation stage of scs as previously described. however, mapk activation was detrimental during regeneration with a delay in functional recovery and a negative impact in both myelinated and non-myelinated fibres compared to controls. one month after injury the total number of axons in mutant sciatic nerves was half of the controls. although no differences in g-ratio have been found in the two groups, mutants presented a higher number of myelinated axons showing myelin disruption with start of myelin decompaction, lack of cajal bands, abundant sc processes surrounding axons and a shorter sc elongation, as seen by decreased internodal distance. in addition, we found a negative effect of mapk activation also in small diameter axons with the presence of abnormal remak bundle structures, reduced number of c-fibres/remak bundle and a significant decrease in intra epidermal nerve fibres density in the skin. we concluded that mild mapk activation has a different role in development and remyelination where negatively affects axon survival, myelin stability, remak bundle formation and small fibres regeneration. cervellini i , galino j , zhu n , bao lu , bennett dl . ndcn, university of oxford, oxford, uk; harvard medical school, boston, ma, usa. neprilysin (nep) is an endopeptidase which has been of interest due to its potential role in neurodegeneration and pain as a consequence of its ability to degrade amyloid and substance-p respectively. nep expression is not limited to cns and it has been reported to be expressed in schwann cells, nodes and schmidt-lanterman incisures. our interest in this gene was related to recent findings that have associated homozygous and heterozygous nep mutations with charcot-marie-tooth type- . in old mice lacking nep subtle morphological changes have been reported. our aim was to determine whether nep expression was modulated by nerve injury and to investigate its role in axon regeneration and re-myelination. we find that nep gene expression was decreased after nerve crush and furthermore was dependent on the growth factor (and pro-myelin signal) neuregulin- . in control mice nep expression was transiently reduced and returned to baseline at day after injury, in neuregulin- knock-out (ko) mice, in which re-myelination was impaired, the expression was still decreased at day . in assessing behavioural measures of locomotor and sensory function one month after sciatic nerve crush, nep ko mice showed a functional regeneration comparable to wt, as seen by sciatic functional index measurement, beam and toe spreading tests. the only significant difference we observed between wt and ko was in the sensorial test, showing ko mice recovering faster in the pinch test by days after crush. the results for all the tests at baseline did not differ between the two groups. detailed histological analysis of nerve repair was undertaken using electron microscopy. there was no difference between wt and ko in total axon number, g-ratio, axon diameters and other myelin features one month post crush. in summary, although nep expression is regulated by nerve injury in a neuregulin- dependent fashion this endopeptidase is dispensable for axon regeneration and re-myelination after nerve injury in the rodent. diabetes neuropathy is a common complication of diabetes, and neuropathic pain has a detrimental impact on quality of life. this study investigated sensory nerve excitability properties to elucidate the axonal changes of diabetic neuropathy. a total of diabetes patients ( type ii, and type i) were enrolled in this study. clinical assessment, nerve conduction studies, and nerve excitability testing data were analyzed to determine axonal dysfunction in diabetic neuropathy. among those patients, seventeen subjects had complained of spontaneous painful sensation over feet or hands (painful cohort), and seventy-eight patients had no sensory symptoms or decreased the sensation over foot (non-painful cohort). sensory nerve excitability of the painful cohort showed reduced late subexcitability (p= . ), increased superexcitability (p= . ) in compared to the non-painful cohort. there is no difference in disease duration, blood glucose levels (hba c) between these two cohorts. these findings suggested the possible pathogenesis of painful sensory axons might be hyperpolarized or slow potassium channels dysfunction. these insights our further understanding of painful diabetic neuropathy, and may provide a basis for neuroprotective or therapeutic approaches for painful polyneuropathy. the main purpose of this study was to assess the clinical feasibility of diffusion tensor imaging (dti) for the diagnosis of chronic inflammatory demyelinating polyradiculoneuropathy (cidp). between march and december , we prospectively enrolled patients with definite cidp according to the efns criteria and two control groups: healthy volunteers matched on age and sex and patients with cmt- a. using a -t magnetic resonance imaging scanner, we obtained dti scans of brachial plexus of these groups and prepared fractional anisotropy (fa) maps, and compared these values between groups. adc values and cervical nerve roots diameters on stir sequences were evaluated too. two neuroradiologists, blinded to clinical informations, reviewed mri studies independently. in all patients with cidp, we also performed clinical evaluation and electroneuromyography. significantly decreased fa values (p< . ) and increased adc values were observed in cidp patients compared with healthy subjects. there is no significant difference between cidp and cmt group. inter-observer concordance was excellent for fa values ( c= . ; p< . ) and moderate for adc values ( c= . ; p< . ) and cervical nerve root diameters ( c= . ; p< . ). there is a significant correlation between fa and disease duration (r = − . , p < . ), inclusion mrc score (r = . , p < . ) and between fa mesured on c c and incat score at inclusion (r = − . , p < . ). no significant correlation is observed between fa and electrophysiological indices. compared with healthy subjects, cervical nerve root diameters were significantly increased (p< . ) in patients with cmt and cidp. contrary to fa values, moderate level of concordance was found between inter-observers measurements of diameters (cclin = . ). our preliminary data prove the clinical feasibility and reproductibility of dti for the evaluation of plexus and cervical nerve roots in patients with cidp. cheng yj , teng a , goh ejh , umapathi t . yong loo lin school of medicine, national university of singapore, singapore; department of neurology, national neuroscience institute, singapore. the sural-sparing pattern of the sensory nerve action potentials (snap) of guillain-barré syndrome (gbs) has been attributed to greater immunological injury of the blood-nerve barrier at its most vulnerable regions. we asked if entrapment sites, such as median nerve at the wrist, are more predisposed than the distal nerve endings to such injury. we compared the median snap with radial snap measured antidromically at digit in gbs patients whose nerve conduction study showed the sural-sparing pattern. the terminal nerves at digit are of similar length, but those of median nerve are prone to compression, often subclinically, at the carpal tunnel while those of radial nerve are not. we defined the sural-sparing pattern as a greater decrease in median and or ulnar snap than that of the sural, compared to age and height-matched normal controls. a total of gbs and miller fisher patients from our institution's database were studied. patients had the sural-sparing pattern, of whom had pre-existing carpal tunnel syndrome. of the remaining patients with sural-sparing, had abnormal median snap at digit , while had both abnormal median and radial snaps at digit . none had isolated abnormality of the radial digit snap. among the cases that had abnormal median and radial snaps at digit , the mean percentage decrease when compared to age and height matched norms was greater in median nerve compared to radial nerve ( % and % respectively). of the patients without sural-sparing pattern, had normal snaps; patient had inexcitable sensory nerves while the other had a length-dependent decrease in snap. in the latter patient, unlike those with sural-sparing, there was no differential decrease of median snap over radial snap at digit . our findings suggest that the disruption of blood nerve barrier at entrapment sites rather than the distal nerve endings may underlie the pathophysiology of the sural-sparing pattern seen in gbs. chiba a , uchibori a , gyohda a . kyorin university, tokyo, japan. serum igg anti-gq b antibody is the most specific biomarker for fisher syndrome and its related disorders (fs-rd), but approximately - % of the patients are seronegative for it in conventional assays (gq b-seronegative). some molecules need ca + cation to interact with their ligands, and antibodies with such a property (ca + -dependent antibodies) are reported. we have found that such a ca + -dependency is also present in igg anti-gq b antibody, and majority of gq b-seronegative patients with fs-rd have this type of antibodies. in patients with final clinical diagnoses as fs-rd (fisher syndrome, guillain-barré syndrome with ophthalmoplegia, bickerstaff brainstem encephalitis, and acute ophthalmoplegia), were seropositive for igg antibodies against gq b-related antigens (isolated gq b in , and gq b-conatinig complexes in two) in conventional elisa using phosphate-buffered saline. in the remaining patients, eight ( %) turned positive for igg antibody against gq b-related antigens (isolated gq b in seven and gq b-conatinig complexes in one) in elisa using ca + -added tris-buffered saline. the reaction strengths increased depending on ca + concentration, and reached to nearly maximum level in the physiological concentration. all the patients with the ca + -dependent antibodies were also positive for igg antibody against gt a-related antigens, suggesting that the terminal disialo residue common to both the gangliosides would be important as an epitope also for the ca + -dependent antibodies. in the patients with ca + -non-dependent antibodies, only two showed increased titers of igg anti-gq b antibody by adding ca + , and showed significantly decreased titers. this difference in the effect of ca + -addition between ca + -dependent and ca + -non-dependent antibodies suggests that ca + would not be just an enhancer of the antigen-antibody reaction. there are four single bonds between the two pyranose rings in the terminal disialo, and those rotatable bonds make it possible for the disialo structure to take various conformations. a molecular model shows that the distance between two minus-charged carboxy groups in the disialo could vary from nearly zero to approximately , pm and that the disialo would take specific conformations, if divalent ca + cation, which size is approximately pm in diameter, interacts with these two minus-charged groups. the ca + -dependent antibodies might recognize such particular conformations of gq b. charcot-marie-tooth disease (cmt) is a genetically and clinically heterogeneous disorder with variable inheritance modes. it is characterized by loss of muscle tissue and touch sensation, predominantly in the feet and legs but also in the hands and arms in the advanced stages of disease. as several molecules have been reported to have therapeutic effects on cmt, depending on the underlying genetic causes, exact genetic diagnostics have become important for executing personalized therapy. aminoacyl-trna synthetase (arss) genes encode enzymes responsible for charging trna with corresponding amino acids. arss are ubiquitously expressed, essential enzymes responsible for performing the first step of protein synthesis. specifically, arss attach amino acids to their cognate trna molecules in the cytoplasm and mitochondria. recent studies have demonstrated that mutations in genes encoding arss can result in neurodegeneration, raising many questions about the role of these enzymes in neuronal function. mutations in six cytoplasmic ars genes have been reported as the cause of cmt. this study was performed the whole exome sequencing to identify genetic defects in korean cmt patients from unrelated families. variants were sorted with cmt gene list that includes almost genes were related cmt neuropathy, and additionally sorted wes data as ars genes. capillary sequencing for family members and more than controls revealed five novel mutations, c. g>a (p.d n), c. c>t (p.s f), and c. c>a (p.p h) in gars; c. c>a (p.p t) in mars; _ ga>at (p.d i) in yars gene in each family. the mutation sites were well conserved between different species and each mutation were located in the well-conserved catalytic domain or between two catalytic domains or anticodon-binding domain. in silico analysis predicted all mutations may affect protein function. clinical features were similar to those reported in other countries, but differed in terms of age at onset and degree of disability. we believe that those novel ars mutations are the underlying causes of the each family. a -year-old man presented with a -year-history of weakness in biltearal upper limbs. he was complaining of intermittent fasciculation of upper and lower limbs with gradually worsening of paresthesia for years. dysphagia and dysarthria were also presented years ago. there was no patient affected muscle weakness and bulbar symptoms in his family members. in neurological examination, the patient had weakness in biltereal upper and lower limbs (mrc grade ) and prominent distal sensory loss were combined in length dependant pattern. deep tendon reflexes were absent on bilataral biceps and knee joints. in nerve conduction study, there was consistent with demyelinating sensorimotor polyneuropathy. molecular diagnostic analyses those spinobulbar muscular atrophy (sbma) and mutation related to peripheral myelin protein (pmp ) gene were performed and confirmed expansion of expansion of a polymorphic cag in androgen-receptor (ar) gene and deletion of pmp gene. smba, also known as kennedy disease, is an adult-onset, x-linked recessive trinucleotide, polyglutamine (poly-g) disorder caused by expansion of a polymorphic cag tandem-repeat in exon of ar gene on chromosome xq - . charcot-marie-tooth disease (cmt) is the most common hereditary neuropathies and cmt cases with motor conduction velocities(mcvs) of upper limb below m/s are defined as demyelinating (cmt ) and those with mcvs above m/s are defined as axonal (cmt ). most families with cmt linked to duplication of pmp gene on the short arm of chromosome ( p . ), called cmt a. the reciprocal deletion of pmp gene is a responsible genetic defect in % of hereditary neuropathy with liability to pressure palsy (hnpp). these "classical" phenotypes of cmt a and hnpp have been considered which are determined by different mutation mechanism of the same gene. however, an overlap of cmt a and hnpp due to pmp gene deletion was reported that suggestion the phenotype of hereditary neuropathies may differ variably. herein, we report a patient who simultaneously presented clinical and electrophysiologic features of smba and cmt a with genetical confirmation of cag expasion and deletion of pmp gene. charcot-marie-tooth type a disease (cmt a) is an inherited peripheral neuropathy stemming from overexpression of pmp protein in schwann cells due to the duplication of the pmp gene. this leads to abnormal schwann cell differentiation and dysmyelination, eventually leading to axonal loss and muscle wasting. no approved treatment is currently available for cmt a. we conducted a systems biology level analysis of the signaling network putatively underlying the processes driving cmt a pathology. based upon this, we identified and tested three repurposed drugs -baclofen, naltrexone and sorbitol -alone and in combination to determine their ability to rescue aberrant myelination in cultures derived from cmt a transgenic rats overexpressing pmp gene. to this end, we studied a validated in vitro co-culture model of sensory neurons and schwann cells adapted to -well culture plates. this model allows measurement of the appearance of myelin proteins as an index of the physiological process of in vivo myelination. total myelin length was quantified with an automatic image analyzer following pmp immunostaining. we first determined the full dose-response curves of single drugs, emphasizing their promyelinating activities. we then tested binary combinations of very low and inactive doses of each drug and compared these to the activity of the combination of the three, namely pxt . whereas combination of any two drugs was not significantly active at the doses tested, combination of all three produced a synergistic improvement in myelination. these findings clearly demonstrate the necessity of using pxt over its single components and highlight the value of pleiotropic combinational repurposing of drugs at low doses as a novel approach for rapid drug development in cmt a and other disorders. autonomic dysfunction is frequently observed in guillain-barré syndrome (gbs) and affects approximately % of the patients. it has been shown that the sweating function can be impaired in gbs. the aim of the present investigation is to summarize the current knowledge on sweating disturbances in gbs patients. we have used appropriate terms to systematically search for references published until and indexed in the following databases: medline, embase, lilacs and cochrane. the inclusion criteria were a diagnosis of gbs and a description of the methods used to test the sudomotor function. the search was limited to the english language. relevant information about study design, methods of assessing the deficit of sweating, patient's characteristics and main results were collected. we selected original references for the final analyses. the majority of the studies were cross-sectional in nature and there were two longitudinal studies. the severity of sweating impairment varied according to the applied method, ranging from normal to almost sympathetic nervous system failure. in seven research papers, the sympathetic skin response was used to evaluate the sudomotor function in patients, and approximately % demonstrated abnormal results. however, researchers used different stimulation protocols and parameters to interpret their results. regarding whole-body sweating test, four research papers applied the thermoregulatory sweating test in patients and they showed areas of anhidrosis on the lower limbs in all of them. eight patients presented sweating impairment on the upper limbs and abdominal wall. results on the sudomotor axon reflex test suggested a length-dependent pattern of sweating loss according to one case report. in another study, eight gbs patients were tested only on the distal leg and foot dorsum and the authors proposed an association between post-ganglionic sudomotor function and antiganglioside antibodies. the present literature review showed that the studies of sweating disturbances in gbs patients included only small cohorts. future studies with larger patients sample sizes are necessary to investigate the patterns of sweating loss in gbs and their changes along the follow up. funding: grants # / - and # / - , são paulo research foundation (fapesp). sensory neuronopathy (sn) represents a rare subgroup of peripheral neuropathies characterized by degeneration of primary sensory neurons at the dorsal root ganglia on the spinal cord. depending on the neuronal population affected, its clinical presentation may manifest as gait ataxia, proprioceptive sensory loss and positive and negative sensory symptoms. although a few reports have mentioned areas of anhidrosis in sn, we were not been able to find previous case series studies on the sweating function in sensory neuronopathies. the aim of the present investigation was to study the whole-body distribution of sweating on both anterior and posterior surfaces in patients diagnosed with sn. quantitative sensory testing for cold and warm sensation threshold (method of levels) was performed on the dorsum of the hands and feet in a randomized order. we tested the thermoregulatory sweating using a sweat chamber ( to ∘ c air temperature and % relative humidity). the oral and skin temperature was monitored and the test time did not exceed min. in order to study the sudomotor axon reflex we employed the q-sweat device on standardized body sites. the test was performed on both sides, simultaneously. we included seven patients (three male; mean age . years) with a mean disease duration of . months (range - ) and a confirmed diagnose of sn. patients presented an asymmetrical loss of cold and warm threshold on hands or feet compared with healthy control (p< , ). regarding the tst results, we found a striking variation of sweating disturbances, ranging from small areas of anhidrosis on the trunk to complete failure of the sympathetic nervous system. two patients underwent the axon reflex test and there was an asymmetrical and mostly distal pattern of sweating loss in one of them and a distal-symmetrical on the second one. our findings indicate a great variability of sweating losses in sn, not overlapped to the sensory loss areas. currently, we are testing more patients in order to confirm our results. funding: grants # / - , # / - and # / - , são paulo research foundation (fapesp). diet, exercise, and inflammation are established modulators of peripheral nervous system function, including pain. prior work examining exercise consistently demonstrates a benefit on heightened pain from a number of acute and chronic pain models. in the present work, we investigated several parameters of peripheral nerve function relevant to pain in rats bred for high (high capacity runners, hcr) or low running capacity (low capacity runners, lcr). the longtime selective breeding of these rat substrains has created divergent intrinsic aerobic capacities and predisposition of metabolic conditions between lcr and hcr rats. examination of the role of sex in the development of chronic pain has established key differences in males and females. to understand gender specific differences, this study focused on female rats to understand the role of metabolic status and peripheral nerve function in females. our analysis identified numerous parameters of peripheral nerve function relevant to pain and neuropathy that are different among lcr and hcr female rats. lcr female rats display reduced hind paw mechanical sensitivity, increased hind paw intraepidermal nerve fiber density and trka-positive epidermal axons, increased numbers of langerhans and mast cells in the hind paw dermis, and increased overall fat mass relative to body weight compared to female hcr rats. examination of sensory and motor nerve conduction velocities, thermal sensitivity, and mrna expression of selected genes relevant to peripheral sensation found no differences between hcr and lcr females. together these results suggest that a genetic component of aerobic capacity and metabolic status can influence sensory sensitivity and specific aspects of inflammation and immune responses in peripheral tissues, which may lead modify the animal's responses to tissue damage and painful stimuli. the lcr and hcr rat model will provide a useful model in the future to assess the involvement of metabolic status in the development of pain. ivig is often considered treatment of first choice in chronic inflammatory demyelinating polyradiculoneuropathy (cidp) because of its rapid onset of action and its relatively safe long-term adverse event profile. clinical trials published so far focused on a loading dose of . g/kg ivig and/or a standard maintenance dosage of . g/kg ivig once every weeks, but have not investigated different dosing options. this study is a prospective, double-blind, randomized, parallel group, multi-center phase iii efficacy study and will be conducted in centres in canada, eu, russia, ukraine and australia. adult patients with definite or probable cidp according to the efns/pns criteria will be enrolled and randomized : : to receive either . g/kg or . g/kg or . g/kg ivig (panzyga ® ) for seven maintenance infusions at -week intervals during the dose-evaluation phase. the starting loading dose will be . g/kg ivig (panzyga ® ) for all patients. primary objective: efficacy measured as percentage of responders (decrease in adjusted incat score by at least point) in the . g/kg ivig (panzyga ® ) arm (given every weeks) at week as this should corroborate the existing and published evidence on efficacy of ivig in cidp. secondary outcome: percentage of responders at week in the . g/kg and . g/kg ivig (panzyga ® ) arms relative to baseline and compared to the . g/kg arm. the procid study aims to confirm published clinical results obtained with the . g/kg standard dose and will in addition evaluate one higher and one lower maintenance dose, with the aim to offer cidp patients a more adequately dosed and effective treatment policy. * este medicamento no se encuentra comercializado en españa. understanding the rate of disease progression in patients with charcot-marie-tooth disease (cmt), both within and between subtypes is important for clinical prognosis and is crucial for clinical trial design. due to the progressive nature of cmt, intervening at the earliest stages of the disease is a priority. measuring progression of a disease with both motor and sensory deficits requires a multi-item composite scale. the cmt pediatric scale (cmtpeds) is a well-tolerated psychometrically robust -item scale measuring fine and gross motor function, strength, sensation and balance for children and adolescents aged - years with cmt. the aim of this study was to determine the rate of disease progression of children and adolescents within and between genetic subtypes of cmt. ( female) participants aged - years enrolled in the inherited neuropathies consortium were included in this study. demographic, anthropometric and diagnostic information were collected at baseline and -year follow-up. disease progression was measured with the cmtpeds. on average cmtpeds scores progressed at a rate of . points over -years ( % change from baseline, p< . ). there was no difference in rate of disease progression between males and females. of the most common genetic subtypes, participants with cmt a/pmp duplication progressed by . points ( % change from baseline, p< . ), nine participants with cmt b/mpz mutation progressed by . points ( % change), six participants with cmt a/mfn mutation progressed by . points ( % change) and seven participants with cmt c/sh tc mutation progressed by . points ( % change). participants with cmt a progressed faster than those with cmt a (p= . ). children with cmt a progressed consistently during childhood and adolescence while children with cmt b and cmt a progressed faster during childhood than adolescence. overall, children with cmt progress at a significant rate over -years according to the cmtpeds. understanding the rate at which affected children deteriorate is essential for adequately powering clinical trials of disease-modifying interventions. queen square, london, uk; department of neurology, university of iowa carver college of medicine, iowa city, ia, usa; department of neurogenetics, the national hospital for neurology and neurosurgery, ucl institute of neurology, london, uk; department of molecular neuroscience, ucl institute of neurology, london, uk and national hospital for neurology and neurosurgery, queen square, london, uk. in recent years, targeted ngs panels have changed the diagnostic work-up in patients with inherited neuropathies. however, there is limited data on the impact of targeted ngs panels on the diagnosis of cmt patients in everyday practice. the aim of this study was to investigate the impact of targeted ngs panels on the diagnosis of cmt across two tertiary referral centres in the united kingdom (london) and united states (iowa). in london, patients with a diagnosis of cmt (previous pmp duplication and common cmt genes excluded in appropriate cases) underwent targeted ngs panel sequencing covering genes associated with cmt and additional genes associated with hsp or als. a variable number of genes, ranging from to , were analysed depending on the clinical phenotype of the patients. a definite molecular diagnosis was achieved in cases ( %) including pathogenic and likely pathogenic mutations in sh tc ( cases), gjb ( cases, including cases with mutations in the promoter and 'utr regions), gdap ( cases), fgd ( cases), aars ( cases), ighmbp ( cases), mpz ( cases), nefl ( cases). vus were further identified in patients. the diagnostic rate was higher in demyelinating cmt cases ( / , %), compared to cases with axonal cmt ( / %), dhmn ( / , %) and hsn ( / , %). in iowa, patients were investigated by ngs panels covering to genes associated with cmt. a molecular diagnosis was reached in / ( %), and in particular / ( %) demyelinating and / ( %) axonal cmt cases. the most frequent genes identified were gjb ( cases), mfn ( cases), sh tc ( cases) and ighmbp ( cases). vus were identified in patients, including cases with novel variants in aars, warranting additional testing such as segregation of the variant in the family or functional validation studies. in clinical practise, targeted ngs panels represent an effective approach for the diagnosis of cmt. the lower diagnostic rate in london is likely to be due to prior sanger sequencing and exclusion of mutations in common cmt genes in this patient population. more than genes are known to cause cmt and an even larger number are known to cause peripheral neuropathy as part of a more complex neurological disorder. despite the use of custom panels, a significant proportion of patients with inherited neuropathy have no molecular diagnosis. the aim of this study was to investigate the diagnostic yield of a disease-associated gene exome (sureselect focused exome, agilent technologies, santa clara ca, usa) in the diagnosis of cmt and in cases with complex neurological syndromes associated with neuropathy. thirty-one patients with molecularly undiagnosed inherited neuropathy were analysed with sureselect focused exome sequencing. six patients had a more complex phenotype including learning difficulties, cerebral white matter changes, ataxia and pyramidal tract involvement. a genetic diagnosis was achieved in / ( %) of cases by detecting a mutation in cmt-associated genes mpz ( cases), aars, nefl, bscl , bicd and trpv . of note, six cases had mutations in genes which are not covered by currently available diagnostic targeted ngs panels, including kif a, polg, mme ( cases), dnajb , and a novel candidate gene. the average coverage was higher compared to the usual coverage of whole-exome sequencing; % of the targets were covered at x or more, and % of the targets were covered at x or more. this study provides evidence that the sureselect focused exome is a useful tool for the diagnosis of cmt and complex neurological disorders and provides further insight into the phenotypic spectrum of genes associated with inherited neuropathy. changes in the cis-regulatory sequences of a gene's untranslated regions (utr) are increasingly recognised as a significant cause of inherited disease in humans. for example, variants in the non-coding region of gjb account for % of all mutations in our cohort of cmtx patients. one of the biggest challenges in analysing the large number of non-coding variants in a gene is identifying those that are disease-causing and those which are polymorphisms. the aim of this study was to implement a reliable method for the in-vitro functional validation of non-coding variants in the promoter and 'utr regions of gjb . in our cohort of cmtx patients we have previously identified seven mutations (c.- _ inst, c.- g>a, c.- t>g, c.- t>c, c. t>c, c.- g>c, c.- c>t) in the promoter region and one novel mutation in the 'utr (c. c>t), which were considered likely to be pathogenic based on the clinical phenotype, segregation in affected family members and absence in control databases. we have now generated a luciferase-based reporter system and optimised it in a hela cell line. mutations in the promoter region were generated by site-directed mutagenesis using a commercially available gjb promoter clone (genecopoeia). our preliminary results show a reduction of luciferase activity for the c.- t>c and c.- _ inst mutations compared to the wild-type promoter. this difference was increased when transcription factors sox or egr were co-transfected with the t>c and c.- _ inst mutations respectively. validation of other variants is currently ongoing. if successful, our study will provide a useful tool for the validation of mutations in non-coding regions of gjb . moreover, it will constitute a proof-of-principle approach to the functional validation of non-coding variants in other cmt genes known to cause disease by a loss of function. recessive and dominant mutations in leucin-rich repeat and sterile alpha-motif-containing (lrsam ) have been associated with cmt p. lrsam is a ubiquitin e ligase containing a ring domain in its c-terminal, which is crucial for correct protein folding and ubiquitination activity. to date, the majority of dominant mutations reported have resulted in a frame shift disrupting a major portion of the ring-domain, although point mutations in this domain have also been described. the aim of this study was to report the prevalence, clinical features and genetic findings of patients with cmt p in our centre. we performed targeted next-generation sequencing in genetically undiagnosed cmt patients and identified cases with heterozygous mutations in lrsam ( . %) from unrelated families. the mutations identified included frameshift insertions and deletions, a non-frameshift deletion and non-sense and missense point mutations. all of the mutations were novel and were located in or flanking the ring domain. the average age of disease onset was in the rd decade but an earlier onset was reported in two cases. four had a positive family history in keeping with autosomal dominant inheritance. symptoms at presentation were heterogeneous and encompassed distal numbness, unsteadiness, distal weakness of upper or lower limbs and foot deformities. positive sensory symptoms, including tingling and shooting pains, and cramps were also frequently reported. neurological examination showed mild to moderate distal atrophy and weakness, with early ankle plantar flexion involvement in three patients. loss of vibration and reduced joint position sense were often prominent in the lower limbs and appeared to be disproportionate to the degree of weakness and impairment of pinprick sensation. ankle jerks were absent but knee and upper limb reflexes could be normal or brisk. after an average disease duration of years, all but one patient was able to walk independently. nerve conduction studies showed a sensory and motor axonal neuropathy with normal conduction velocities. our study highlights that mutations in lrsam are a relevant cause of cmt and are associated with prominent large fibre sensory loss. in recent years, the implementation of ngs panels for the molecular diagnosis of cmt has increased the number of patients with a genetic diagnosis. nevertheless the interpretation of a particular variant as disease causing can be challenging especially when multiple variants are identified in a single patient. we report two illustrative cases of such challenges. the first index case was born of non-consanguineous healthy parents. he presented with falls in early childhood. over the years he developed foot deformities and progressive length dependent weakness. he had multiple orthopaedic operations to his feet. the past history was also notable for kyphoscoliosis, sensorineural deafness from the age of and bilateral cataracts. nerve conduction studies at the age of revealed a demyelinating neuropathy consistent with the clinical phenotype of cmt . his younger brother had a similar, although more severe phenotype. a litaf (c. c>t,p.pro ser) mutation was identified by sanger sequencing and was present in both affected brothers but also in the unaffected sister. ngs for cmt -associated genes was therefore performed and identified two compound heterozygous pathogenic mutations detected in sh tc (c. c>t, p.arg *; delg, p.arg serfs* ), which segregated with the disease in the family. the second case describes a brother and sister with early onset demyelinating cmt associated with scoliosis and cranial nerve involvement. the male proband underwent ngs and a single previously reported pathogenic intronic splice-site mutation in sh tc (c. - a>c) was found. relative read-depth analysis of ngs was performed to look for possible copy number variants in sh tc , thus identifying a deletion of exon , which was confirmed by long pcr. cruz-velásquez gj , miramar-gallart md , alarcia-alejos r , roche-bueno jc , rodríguez-valle a , capablo-liesa jl . neurology service, university hospital miguel servet, zaragoza, spain; genetics unit, clinical biochemistry service, university hospital miguel servet, zaragoza, spain. charcot-marie-tooth disease (cmtd) defines a clinical and genetically heterogeneous group of inherited peripheral neuropathies characterized by chronic motor and sensory impairment. the type cmtd- also known as cowchock syndrome, is the product of the mutation in the apoptosis inducing factor mitochondria associated gene (aifm ). it is a slowly progressive, recessive, x-linked disease characterized by axonal neuropathy, deafness, and cognitive impairment. our purpose is to describe new cases, brothers, children of non-consanguineous parents, with a characteristic phenotype and a new mutation in the aifm gene. both siblings present from childhood, progressive weakness in lower limbs with diffuse amyotrophies. needing tenotomy before the year due to equinovarus foot. likewise they develops sensory deafness and one of them requires unilateral support at and the other wheelchair at , this one need a pacemaker for an atrioventricular block at . with brain functions and normal language, sensorial deafness, proximal and distal weakness in the four limbs with intense amyotrophies, predominantly distal. tactile and painful sensitivity decreased in glove and sock pattern. an extensive metabolic and biochemical study was normal. the electroneurography demonstrates an axonal neuropathy without response in most of the nerves explored. the electromyography shown a myogenic pattern with distal predominance. brain mri was normal in both cases. through a genetic study by exoma targeting genes associated with cmt and inherited related neuropathies was identified the homicigosis mutation in the aifm gene (p.glu lys), located in the chromosomal region xq . (cmtx ). cowchock syndrome is a rare entity, with few cases described in the literature. the in silico analysis indicates in of the predictors used (provean, sift, polyphen , lrt, mutationtaster, mutationassessor and condel) , that it is a deleterious variant. we audited all patients with peripheral neuropathy caused by a paraprotein, who received treatment and attended king's college hospital peripheral nerve service between - . patients were identified retrospectively from our database of patients attending the peripheral nerve outpatient clinic. clinical information was obtained retrospectively from hospital electronic patient records. we excluded patients with poems syndrome or in whom the neuropathy was not felt to be caused by the paraprotein. we identified patients with a diagnosis of paraproteinaemic neuropathy. we excluded four who did not fulfill the diagnostic criteria and eleven who had received no treatment or were under diagnostic study. we included patients in the final audit. ( %) had igm paraprotein. the haematological diagnosis was monoclonal gammopathy of undetermined significance (mgus) in %, waldenstroḿs macroglobulinaemia %, and lymphoma or plasmacytoma %. after treatment, overall ( %) patients improved neurologically, ( %) stabilised, and ( %) worsened. in the patients who received more than one type of treatment, we analysed outcomes according to the most powerful treatment received. patients received rituximab alone of which ( %) improved, ( %) stabilised and ( %) worsened. nine patients received rituximab combined with cyclophosphamide or bendamustine, of which ( %) improved, ( %) stabilized and ( %) worsened. eight patients received intravenous immunoglobulin, of which ( %) improved, ( %) stabilized and ( %) worsened. four patients received other chemotherapy, of which improved, stabilised, worsened. two patients received corticosteroids and both worsened. there was improvement in / ( %) with mag antibodies and / ( %) without. there was improvement in / ( %) with mgus and / ( %) with haematological malignancy. there was improvement in / ( %) with kappa light chains and / ( %) with lambda. factors associated with better outcome (by univariate analysis) were negative mag antibodies, kappa light chain, and haematological malignancy. there was no significant difference between treatments in the proportions who improved. cumberbatch m , cox a . addenbrooke's hospital, cambridge, uk. treatment of patients with autoimmune neuropathies such as chronic inflammatory demyelinating polyradiculoneuropathy (cidp) and multifocal motor neuropathy (mmn) has centred on the use of intravenous immunoglobulin (ivig). however, ivig therapy is associated with systemic side-effects, treatment wear-off effects and regular hospital attendance. subcutaneous immunoglobulin (scig) is an efficacious alternative that can be flexibly dosed, self-administered at home and avoids the 'peaks' and 'troughs' observed with ivig. these factors may combine to improve patient satisfaction and alleviate hospital capacity issues. here, we report on clinical and patient experience of switching from hospital-based ivig to home-based manual push scig for the treatment of cidp and mmn. this was a clinical case series of patients ( cidp, mmn; mean age . years) who were clinically stable on ivig and wished to switch to manual push scig. starting scig dose was equivalent to the final ivig dose for each patient (mean . g/kg week). clinical efficacy (medical research council sum score, -m walk, modified inflammatory neuropathy cause and treatment score, overall neuropathy limitations scale, romberg test) and patient-reported outcomes ( -item short form health survey , life quality index [lqi] ) were assessed at baseline and at regular intervals until the final visit ( - months after switching). at baseline, patients cited 'convenience' as their primary reason for switching to scig. eight patients completed the full assessment period and successfully undertook administrations at home (via hospital-at-home service in cases). dose adjustments, based on clinical need, were required in patients. treatment efficacy and patient quality of life, measured by sf- , were maintained after switching to scig; overall patient satisfaction, measured by lqi, increased from % to %. in the lqi, 'convenience', 'travel time/cost' and 'interference-work' were significantly improved (p< . ) after switching to scig therapy. adverse events included mild erythema and localised swelling, as expected for a ml subcutaneous injection. these findings suggest that manual push scig therapy is a viable alternative to ivig for patients with cidp and mmn, as it maintains disease stability, is more convenient for patients and may help ease hospital capacity concerns. cumberbatch m , soares regua d , cox a . addenbrooke's hospital, cambridge, uk. intravenous immunoglobulin (ivig) is used to treat a number of chronic autoimmune neurological diseases. in most centres, infusions are given at slow rates as there is a perception that this reduces the risk of adverse events (aes). this results in longer in-patient admissions, or frequent day case attendances, impacting on both the patients' quality of life and hospital capacity. however, there is little evidence to suggest that slow infusion rates are required. we used the manufacturer recommendations to optimise infusion rates and reduce the time patients spend in hospital. we report a retrospective audit which describes the impact of different ivig infusion rates on patients' clinical condition. the audit comprised three -month assessment periods: january-june (cohort ; infusion rates of . ± . ml/kg/hr, n = ); january-june (cohort ; . ± . ml/kg/hr, n = ) and july-december (cohort ; . ± . ml/kg/hr, n = ). clinical data were reviewed to determine: patient demographics, duration of infusion; time spent in hospital; and incidence of aes. the three cohorts were well matched in terms of patient demographics ( patients were treated in all treatment periods). cohorts and had significantly shorter treatment episodes than cohort ( . and . vs. . hours, p< . ), spent less time on the unit over the month period ( . and . vs. . hours, p< . ) and had fewer admissions/patient ( . and . vs. . , p< . ). the overall incidence of confirmed aes (mainly headaches) was similar across the cohorts (cohort : %; cohort : %; cohort : %). these findings indicate that increases in ivig infusion rate are well tolerated and significantly reduce treatment time, which benefits patients and offers potential cost savings and reduced pressures on hospital capacity for healthcare providers. cunningham me , yao d , meehan gr , barrie ja , willison hj . university of glasgow, glasgow, uk. one mechanism of injury in the acute motor axonal neuropathy (aman) form of guillain-barré syndrome (gbs) is the attack of peripheral nerve axons by anti-ganglioside antibodies (agabs). rodent models have demonstrated that that binding of these antibodies activates the complement cascade, resulting in the insertion of the terminal component, membrane attack complex (mac) into the axonal membrane. complement activation also results in the release of anaphylatoxins, which are known to recruit phagocytic immune cells to the site of injury. our current in vivo mouse model of agab and complement-mediated injury are acute and severe, resulting in respiratory distress over several hours of such magnitude to warrant termination of experimental procedures. to observe and potentially target immune cell infiltration following agab and complement-mediated injury, a subacute model extending over days is required. here, we demonstrate the development of such a model. to compare differences in immune cell infiltration subacutely under control and injury conditions, mice with endogenous expression of egfp in monocytes and macrophages underwent a modified agab and complement-mediated injury, resulting in a less severe phenotype than previously published models. six days following injury, immune cells in the diaphragm were compared by immunofluorescence and flow cytometry. flow cytometry found overall presence of neutrophils was significantly increased in the diaphragm. macrophages were also increased in injured mice, although did not achieve statistical significance at this timepoint. these results were reflected in immunofluorescent staining of the diaphragm where egfp+ macrophages were quantified surrounding the neuromuscular junction (the primary injury target in this model). the development of an extended mouse model of agab and complement-mediated injury is important, since acute models do not take into consideration either the late-term effects of complement-mediated activation at the nerve membrane, or the recovery phase. future studies will look at the effect of inhibiting complement activation on the presence of immune cells in distal motor nerves. family- is a large australian family with an autosomal dominant form of dhmn (dhmn : omim % ) -a group of length-dependent neurodegenerative disorders affecting the lower motor neurons leading to chronic disability. we recently reported a novel . mb chromosomal insertion within the dhmn locus which we hypothesise is likely to cause disease by dysregulating the expression of one or more nearby genes. studying gene dysregulation in peripheral nerve disease is challenging as the relevant tissues (spinal cord and peripheral nerve) are not easily accessible in patients. therefore, alternative strategies are needed to elucidate the disease mechanisms and pathways involved in peripheral nerve degeneration. to address this problem, we have devised a two-tiered strategy to assess dysregulation of candidate genes using patient lymphoblast and fibroblast cell lines. these cell lines can be easily established, are minimally invasive to obtain, and will harbour the natural mutation and genetic background of patients. our strategy firstly uses lymphoblast gene expression profiles as an initial screening tool to prioritise candidate genes for assessing altered expression. differentially expressed genes will then be modelled in c.elegans where behavioural and nerve morphology can be assessed. using rt-pcr, we have screened dhmn candidate genes in patient and control lymphoblast cell lines. eighteen candidate genes were expressed in lymphoblasts. twelve of the eighteen genes were prioritized for further analysis based on expression in both lymphoblast and neural tissues. quantitative analysis using qrt-pcr taqman assays revealed that ube c, was differentially expressed between patients and controls. it is important that patterns of differential expression can be recapitulated in neural cell-specific models. as part of our second strategy, we have generated patient and control induced pluripotent stem cell derived motor neurons (ipsc-mns) from reprogrammed fibroblasts. using this model, we will perform rna-seq and qpcr experiments to examine disease-relevant alterations in gene expression in neural tissue. we predict that utilization of these two strategies will shed light on the pathogenic mechanisms underlying the dhmn insertion and provide useful insights of pathways leading to peripheral nerve degeneration. the outcome of guillain-barré syndrome remains unchanged since plasma exchange and intravenous immunoglobulin were introduced over years ago. pathogenesis studies on gbs have identified the terminal component of complement cascade, the membrane attack complex, as a key disease mediator and thus a therapeutic target. the inhibition of complement in guillain-barré syndrome (ica-gbs) trial looked at the first use of c pathway inhibition with eculizumab in humans with gbs in a randomised, double-blind, placebo-controlled trial. its primary outcome was to look at safety and tolerability of administration concomitantly with ivig and in the context of severe (gbs disability score or greater) disease. participants were recruited for a month period, with regular follow up. subjects were screened, with ( %) being randomised. the two main causes for failure to proceed were participant concerns around eculizumab side effect profile, specifically the meningitis risk, and also intercurrent infection precluding treatment. five received eculizumab for four weeks, alongside standard intravenous immunoglobulin treatment, with receiving placebo. the safety outcomes, monitored via adverse events capture at each trial visit, showed eculizumab to be well tolerated and safe when administered in conjunction with ivig. the most common adverse events were mild derangement in transaminases or infection. there were no infusion reactions. primary and secondary efficacy outcomes were captured via gbs disability scores, mrc sum scores, rasch overall disability scores and overall neuropathy limitation scores. for the primary efficacy outcome at weeks after recruitment, of placebo and of eculizumab-treated subjects had improved by or more grades on the gbs disability score. all patients had improvements in other measured parameters. this trial highlights the challenges in recruiting acutely unwell patients, due to time constraints and intercurrent infection. although the small sample size precludes a statistically meaningful analysis, these pilot data indicate further studies on complement inhibition in gbs are warranted. charcot-marie-tooth disease (cmt) affects about one in . people. currently more than genes have been identified, with the most different phenotypes. the majority of cases in western countries are autosomal dominant and classified as demyelinating and axonal according to electroneuromyography (enmg). the clinical condition is characterized by weakness and predominant sensory changes in the feet and hands. sometimes there are different phenotypes. recently, variants in heterozygotes in the hars gene (histidil-trna synthetase) have been described associated with cmt called type w.to report a case of cmt-sensitive phenotype with a probable new mutation in hars gene (p.leu arg).a male patient, adopted son, caucasian, drug addict, for three years suffered pain in lower limbs, of great intensity, refractory to drug treatment. the examination showed retrognathism, abolition of patellar and achilleas reflexes, painful and thermal anaesthesia and apalesthesia in the feet.the enmg showed reduced sensory action potentials in sural and superficial fibular nerves. laboratory investigations for painful polyneuropathy of thick and fine fibres was normal. sural nerve biopsy revealed axonal predominance neuropathy. exome sequencing revealed a mutation in the hars gene with a pathogenic variant in heterozygosity, with replacement of the amino acid leucine at position by arginine. our patient, although we did not know the antecedents, presented painful polyneuropathy, whose genetic research, although not unequivocal, indicated a variant called cmt w. few cases of this variant were described, with several mutations. our case revealed mutation hitherto unknown (p.leu arg). we conclude by the importance of a thorough genetic evaluation, in cases of sensory polyneuropathy of unknown cause. small fiber neuropathy (sfn) is a condition that affects the small a -and c-fibers, leading to severe neuropathic pain and autonomic dysfunction. several sodium channel gene mutations have been found in patients with sfn, with scn a-gene mutations being the most frequent. because current available sodium channel blockers are not selective for na v . , these treatments often result in numerous side effects. lacosamide is an anticonvulsant that targets specific sodium channels with a slow-inactivation state, while sparing those with normal activity. several mutations of the scn a-gene with an impaired slow-inactivation of na v . have been found in patients with sfn. therefore, a positive effect of lacosamide on pain reduction in these patients is expected. the primary objective of this study was to determine the effect of lacosamide versus placebo on pain in subjects with scn a-associated sfn. secondary objectives were to determine the effect of lacosamide on autonomic symptoms, sleep interference, and quality of life, and to examine the safety and tolerability. the lacosamide-efficacy-'n'-safety in sfn (lenss) study was a randomized, placebo-controlled, double-blind, crossover-design study. subjects were randomized to start with lacosamide and end with placebo or vice versa. during both of the two phases of the study, the subjects were treated for a period of eight weeks of mg bid, preceded by a titration period, and ended by a tapering period. patients filled in a pain diary twice daily and scored a set of validated questionnaires on autonomic symptoms, sleep interference, and quality of life at multiple study visits. in total patients with scn a-associated sfn were included between november and february . the subjects had a median age of years, ranging from to years. sixty percent of the patients were female. the final results of the study, including the primary and secondary outcomes, will be presented. de la oliva n , del valle j , navarro x . department of cell biology, physiology and immunology, institute of neurosciences, universitat autònoma de barcelona and centro de investigación biomédica en red sobre enfermedades neurodegenerativas (ciberned), bellaterra, spain. intraneural interfaces must be in intimate contact with nerve fibres to have a proper function, but it has been shown that this is compromised due to the foreign body reaction (fbr). this fbr is the first response of the nonspecific immune system against an implanted device and is characterized by a first inflammatory phase followed by a second antiinflammatory and fibrotic phase. this process results in the formation of a tissue capsule around the interface causing function loss due to the physical separation between the active sites of the electrode and nerve axons. taking this into account, here we have tested several anti-inflammatory drugs such as dexamethasone, ibuprophen and maraviroc to reduce macrophage activation as well as clodronate liposomes to reduce monocyte/macrophage infiltration. moreover, sildenafil have been administered as an antifibrotic drug to reduce collagen deposition in a fbr model with longitudinal parylene c-based intraneural devices implanted in rat sciatic nerve. briefly, animals were systemically treated with dexamethasone, ibuprophen, sildenafil, maraviroc or clodronate liposomes for two weeks, and nerve damage, inflammatory reaction and matrix thickness around the implant were assessed. treatment with dexamethasone, ibuprophen or clodronate liposomes significantly reduced the inflammatory response in the nerve in comparison to saline group while sildenafil or maraviroc had no effect on iba positive cells infiltration in the nerve. however, only dexamethasone was able to significantly reduce the matrix deposition around the implant after two weeks of treatment. these results support the idea that inflammation triggers the foreign body response in peripheral nerves and a potent anti-inflammatory treatment with dexamethasone could have a beneficial effect on lengthening intraneural interfaces lifespan. de la oliva n , del valle j , navarro x . department of cell biology, physiology and immunology, institute of neurosciences, universitat autònoma de barcelona and centro de investigación biomédica en red sobre enfermedades neurodegenerativas (ciberned), bellaterra, spain. intraneural interfaces functionality decreases over time, among other factors, due to the foreign body response (fbr), which encapsulates the implanted devices and physically separates the active sites from the nervous tissue. here we have studied the fbr to parylene c or polyimide thin devices implanted in rat sciatic nerves, assessing thickness of the tissue capsule, signs of inflammation and nerve damage. we have characterized the responsible cells of this response and several molecular mediators over months of implant to find differences between the fbr to both materials. after weeks of implant, the inflammatory response due to the surgery was already decreased, whereas in the implanted nerves it reached its highest levels to then decrease at chronic time points. besides, the amount of foreign body giant cells (fbgc), as a result of macrophage fusion, found in the tissue capsule around the implant also increases progressively to reach a maximum after weeks. on the other hand, molecular analysis of the environment revealed a peak of inflammatory cytokines during the first day of implant to return to standard levels thereafter. however, an increase on ccls molecules was found at later time-points for both materials. with regard to the capsule thickness, all the devices were surrounded by a tissue deposition which appeared soon after the implantation. however, in the case of polyimide devices, the tissue capsule showed a peak weeks after the implant and signs of remodeling thereafter, while the parylene c devices showed a second increase from to weeks in comparison to polyimide devices. immunohistochemical and electron microscopy analysis revealed two different cell types implicated in the fbr in nerve to both materials: macrophages, in close contact with the interface, and fibroblasts which appear after weeks surrounding the tissue capsule. although further analyses are needed to elucidate the differences in the fbr to parylene c and polyimide polymers, these results can help to determine therapeutic targets in order to reduce this response and to improve the intraneural interfaces lifespan. delmont e , antoine jc , paul s , boucraut j , attarian s . referral centre for als and neuromuscular diseases, marseille, france; referral centre for neuromuscular diseases, saint etienne, france; immunology laboratory, saint etienne, france; immunology laboratory, marseille, france. peripheral neuropathies with antibodies against myelin associated glycoprotein (mag) are chronic sensory neuropathies characterized by the presence of an igm monoclonal gammopathy and high levels of anti-mag antibodies. these antibodies recognize a specific epitope called human natural killer (hnk ) shared by nk lymphocytes and several components of the peripheral nerve (mag, p , pmp , sgpg, phosphocan). recently an elisa test has been developed to detect antibodies against hnk epitope. our objectives were to determine the sensitivity and the specificity of anti-hnk antibodies in the diagnosis of anti-mag neuropathy and to know if these antibodies were correlated with the severity of the disease. anti-hnk antibodies were assessed in anti-mag neuropathies and in negative controls: chronic inflammatory demyelinating polyradiculoneuropathies (cidp), miller fisher syndromes, sensory neuronopathies, length-dependant axonal sensory polyneuropathies, healthy controls. in anti-mag neuropathies, were recorded age, disease duration, incat sensory sum score (iss), overall neuropathy limitation scale (onls), rasch-built overall disability scale (rods), mrc sum score, anti-mag antibodies titer, peak dosage of the igm monoclonal gammopathy. anti-hnk antibodies were measured with gangliocombi™ mag elisa test and anti-mag antibodies with anti-mag autoantibodies elisa test both from buhlmann company. anti-hnk antibodies were positive in / anti-mag neuropathies, and in / controls (sensitivity %, specificity %). in anti-mag neuropathies, anti-hnk titer was correlated with sensory deficiency evaluated with the iss score (r= . , p= . ) and with disability evaluated with the rods (r= − . , p= . ) and onls scales (r= . , p= . ). anti-hnk titers were not related to age, disease duration, mrc sum score, anti-mag antibodies titer, peak dosage of the paraproteinemia. anti-mag antibodies titers were associated with none of the characteristics of the patients with anti-mag neuropathy. anti-hnk antibodies have good sensitivity and specificity in the diagnosis of anti-mag neuropathy. compared to anti-mag antibodies, their value is that their titers are related to the disease severity. these results need to be confirmed in a larger prospective cohort. chronic inflammatory demyelinating polyradiculoneuropathy (cidp)is a heterogeneous and treatable immune-mediated disorder that critically lacks biomarkers to support diagnosis. recent evidences indicate that paranodal proteins (contactin- , contactin-associated protein- , and neurofascin- ) are the targets of autoantibodies in a subset of patients with cidp showing distinct clinical presentations. particularly, these biomarkers appear to have clinical relevance and help to orientate therapeutic choice. here, we examined five patients presenting an igg reactivity against the nodes of ranvier and the axon initial segment. using a proteomic approach, cell-based assays and elisa, we identified neurofascin- (nfasc ) and neurofascin- (nfasc ) as the main targets of autoantibodies at the nodes of ranvier. four patients displayed predominantly antibodies of the igg subclass, whereas one patient presented igg antibodies that activated the complement pathway in vitro. these antibodies recognized different epitopes than the previously described anti-neurofascin- igg suggesting different pathogenic functions. accordingly, patients with anti-nfasc / igg showed a distinctive clinical presentation. most patients had a severe phenotype associated with conduction block or decreased distal motor amplitude. tremors or neuropathic pain were not observed. four patients presented with a subacute-onset and sensory ataxia. of interest, the neuropathy occurred concomitantly with nephrotic syndromes in two patients and with an igg -related retroperitoneal fibrosis in one patient. this suggested that autoantibodies could be responsible for the occurrence of both disorders. intravenous immunoglobulin and corticosteroids were effective in three patients, and one patient improved following cyclophosphamide and rituximab treatment. clinical remission was found to correlate with the depletion of anti-nfasc / antibodies and the loss of igg reactivity toward the nodes of ranvier. in addition, recovery of conduction block and of distal motor amplitude were observed following remission and suggested a nodo-paranodopathy. our data demonstrate that nodal antigens are the target of autoantibodies in a subgroup of patients with cidp. this emphasizes that the pathogenic mechanisms involved in chronic immune-mediated demyelinating neuropathies are broad and may include dysfunctions of the nodes of ranvier. mutations in the neurofilament heavy (nefh) gene have been recently identified as a rare cause of autosomal dominant, axonal charcot-marie-tooth disease (cmt ). the clinical spectrum of this condition remains to be delineated. we report two french families with an axonal, predominantly motor, dominantly inherited form of cmt caused by two previously unreported mutations in the nefh gene. twelve patients belonging to two different families were included in the study. they displayed an axonal motor and sensory neuropathy, with no mutations in known axonal cmt genes. a remarkable feature in all patients was the early involvement of proximal muscles of the lower limbs, occurring approximately to years after the onset of motor deficit. proximal weakness affected predominantly the iliopsoas muscle, whereas quadriceps and hamstring muscles were relatively preserved. muscle weakness and muscle wasting progressed rapidly, with most of the patients requiring walking assistance after years of disease evolution. three patients in family had brisk reflexes. nerve-conduction velocity studies displayed evidence of a motor and sensory axonal neuropathy predominantly affecting the lower limbs. original deletions of nucleotides near the end of the coding sequence of nefh were identified: in family , c. _ del (p.lys argfs* ), and in family c. _ del (p.lys glyfs* ) causing a frameshift. interestingly, this frameshift leads to the loss of the terminating codon and to the translation of additional amino acids encoding a cryptic amyloidogenic element, suggesting that this type of mutations could induce protein aggregation. consistently, we showed that overexpression of the mutated forms of nefh in a human neuroblastoma cells induced the formation of protein aggregates. we also observed that it triggered caspase activation and apoptosis. using electroporation of chick embryo spinal cord, we confirmed in vivo that mutated nefh formed aggregates and triggered apoptosis of spinal cord neurons. altogether, this suggests that these mutations in nefh cause protein aggregation and neurotoxicity in neurons expressing nefh. progressive loss of such neurons would explain the early motor involvement and the pyramidal signs observed in some patients. our results provide a physiological explanation to the presence of cmt and als clinical features in affected patients. del valle j , , delgado-martínez i , righi m , santos d , , cutrone a , bossi s , d'amico s , micera s , , navarro x , . neuroprosthetic devices that are aimed to restore sensorimotor limb function of amputee patients require highly selective electrodes designed to establish a tight relationship with the nerve, allowing the bidirectional transduction of signals between nerve fibres and the interface and enabling close-loop control from the user. differently from extra-or intraneural interfaces, regenerative nerve electrodes are designed to enable electrical interface with regrowing axonal bundles of injured nerves, aiming to achieve high selectivity for recording and stimulation. however, most of the developed designs pose an obstacle to the regrowth mechanisms due to low transparency and cause an impairment of the nerve regeneration. in this work, we present a novel double-aisle planar regenerative electrode, a new type of highly transparent, non-obstructive regenerative electrode, which allows the selective stimulation and recording of separated nerve fascicles. the design consists of a thin and flexible double-sided electrode longitudinally inserted across a conduit thus creating two separated aisles in which regenerating fascicles can independently regrow after nerve transection. electrodes implanted in acutely transected nerves of rats showed the capability of selectively stimulating and recording different fascicles inserted in the aisles. moreover, chronic implantation of the electrode in a nerve gap of mm after sciatic nerve section allowed for fascicle regeneration and reinnervation of distal muscles as confirmed by the high number of myelinated axons inside each aisle, good biocompatibility, and adequate nerve conduction. in addition, three and six months after implantation, independent stimulation and recording of each separately regenerated fascicle were possible. our results demonstrate the potential contribution of the doubled-aisle regenerative electrode to selectively interface different fascicles of an injured nerve with no deleterious effects on nerve regeneration. therefore, this multi-aisle regenerative electrode may be suitable for neuroprosthetic applications, such as prostheses for the restoration of hand function after amputation or severe nerve injuries. demichelis c , garnero m , franciotta d , cortese a , callegari i , mancardi gl , schenone a , leonardi a , benedetti l . department of neuroscience, rehabilitation, ophthalmology, genetics, maternal and child health, university of genoa and irccs aou san martino-ist, genoa, italy; laboratory of neuroimmunology, irccs, "c. mondino" national neurological institute, university of pavia, pavia, italy; u.o. neurology, asl imperiese, imperia, italy. querol et al. showed that neurofascin (nf ) antibodies identify a chronic inflammatory demyelinating polyradiculoneuropathy (cidp) phenotype characterized by severe polyradiculoneuropathy, poor response to intravenous immunoglobulins (ivig), and disabling tremor. neurological improvement after therapy with rituximab has been previously reported in three patients with cidp with igg anti-nf antibodies. herein we describe the acute-onset of a case of cidp positive for nf igg antibodies resistant to conventional therapies and responsive to rituximab. the patient is a year-old woman who presented acute onset ataxia and gait disturbances; her symptoms progressed over two weeks and distal weakness, numbness and paresthesias appeared too. the nerve conduction study was suggestive for a motor-sensory polyradiculoneuropathy mainly demyelinating. the cerebrospinal fluid analysis showed elevated protein level and normal cellular count. the patient was initially diagnosed with guillain-barré syndrome (gbs) and treated with plasma exchange without improvement. an ivig cycle was started with a partial relief but at the time of admission to the rehabilitation center the patient still had a marked weakness in all four limbs. after six months she presented a further clinical deterioration and she was restricted to wheelchair. there was no response to additional treatment with ivig, while pulse corticosteroid treatment determined a significant clinical improvement. during the next months, despite the maintenance of steroid therapy, the patient presented a progressive deterioration and she was again restricted to wheelchair. postural and intention tremor appeared at upper limbs and became progressively more disabling. anti-nf ab dosage resulted positive. rituximab was administered at a dosage of mg/m /weekly for weeks. after three months the tremor improved, allowing her to eat independently and the patient was able to walk with bilateral support. antibodies anti-nf were negative. after six months she walked without support and she was able to stitch crochet. as previously reported, in this case a cidp positive for igg nf developed severe polyradiculoneuropathy with predominant distal weakness, ataxia, disabling tremor and resistance to conventional therapies. interestingly the onset was gbs-like. the correct identification of these cidp subtypes has diagnostic, prognostic and therapeutic implications. rituximab con be useful in these patients. demir Ö , yazıcı t . department of neurosurgery, university of gaziosmanpaşa school of medicine, tokat, turkey; department of neurosurgery, kent hospital, giresun, turkey. it is still challenging problem to maintain motor and sensory functions of peripheral nerve after nerve transection. after the nerve injury, calcium concentration in the damaged area increases. then the calcium ions act like cytotoxic agents in the damaged area. nifedipine is calcium channel blocker. we aimed to investigate the effects of nifedipine on nerve regeneration by modulating calcium in the damaged area. twenty-four swiss albino male rats were divided into two groups. left sciatic nerve transection surgery was performed to the all rats in both groups. then the all transected nerves were sutured primarily with epineural interfascicular method. in the experimental group, the anastomosis sites were wrapped with a piece of gel foam soaked into diluted nifedipine solution. in the control group, the anastomosis sites were wrapped with a piece of gel foam soaked into saline solution. we evaluated the effect of nifedipine by using functional, electro-physiological and histopathological studies after the surgeries. in the postoperative second week, walking test was performed and sciatic function index was calculated. in the postoperative third week electroneuronography (enog) was performed. there are significant differences between two groups. nifedipine improved nerve recovery functionally (p< . ) and electro-physiologically (p< . ). in the postoperative fourth week, we performed histopathological examination. in the experimental group with nifedipine there were more organized axons that reached the aim. we conclude from these results that nifedipine is an effective nerve protective agent when used locally at the anastomosis site after the transection of the nerve. the lack of effective, disease-modifying therapies for cmt highlights the need for novel preclinical models suitable for drug discovery. studies in rodent models of cmt tend to be time-consuming, and findings so far have translated poorly into clinical trials. primary and induced pluripotent stem cell (ipsc)-derived neuronal cultures are an established model of neurological diseases. however, due to the random distribution of neuronal bodies and neurites that happen when plating these cells, this system is not ideal to investigate axonal, length-dependent processes like peripheral neuropathies and particularly cmt. to optimize this well-established model system, we developed a robust human platform to study axonal morphology and physiology based on motor neuron neurospheres. we differentiated motor neurons from human induced pluripotent stem cells, purified them by magnetic sorting and cultured them in suspension until they formed neurospheres. floating neurospheres can be maintained in agitation for months as a reliable source of motor neurons. after neurospheres are platted, axons rapidly grow out of them in a radial fashion, resembling dorsal root ganglia cultures. this configuration allows for a better visualization of axons in imaging studies and for continued axonal growth over at least a -day period. axons grew at an average rate of micrometers/day and reached up to cm in length. neurospheres can be fixed and stained allowing for morphological analysis and investigation of protein distribution in axons. this system is also ideal for time-lapse imaging to study axonal transport of organelles and neurofilament kinetics. lastly, our motor neuron neurosphere system lends itself well for high content screening platform. neurospheres can be plated in -well plates where multiple compounds can be tested and the axons easily imaged by a high content screening microscope. in summary, we developed a new platform to investigate motor axons in vitro, which are particularly useful to study length-dependent processes such as inherited peripheral neuropathies and may facilitate the identification of new therapeutic compounds using high content screening systems. mutations in the neurofilament light chain (nfl) gene cause autosomal dominant axonal charcot-marie-tooth neuropathy (cmt e). nfl is a major component of the neuronal cytoskeleton, and is believed to function in conjunction with nfm and nfh to provide structural support for the axon and regulate axon diameter. despite the significant advances in understanding its biological basis, there is still no effective, disease-modifying therapy for cmt e, in part due to the paucity of preclinical models suitable for drug discovery. the development of novel preclinical platforms that can faithfully mimic mechanisms of axonal degeneration in vitro would be an essential and valuable resource to better understand the biology of cmt e and identify potential targets for therapy development. to address this, we generated control and cmt e patient-derived motor neurons and cultured them in suspension until they formed neurospheres. immunostaining of cmt e neurospheres with nfl and tubb antibodies revealed numerous areas of nfl accumulation in n s cmt e axons, resembling the accumulations of mutant nfl protein seen in the processes of catecholaminergic neuronal cell line cad overexpressing several nfl mutants. further analysis demonstrated that areas of nfl accumulation were also immunopositive for nfh, pnfh and nfm and that at least nfl and nfm co-localized in the same areas of deposits. taken together, these results demonstrate that abnormal axonal neurofilament distribution is a feature of cmt e ipsc-derived motor neurons and involve all three neurofilament subunits. we also developed an image analysis routine to allow for automatized quantification of neurofilament distribution. preliminary quantification of nfl signal intensity revealed that axons from patients have a weaker nfl signal compared to control axons, but present several signal peaks above the range observed in controls, which related to the areas of nfl accumulation. these results suggest that nfl accumulates in certain regions of cmt e axons but is reduced in the areas with no accumulation. these findings can be readily adapted into a high content screening platform and will be used to identify compounds able to reverse this axonal phenotype. in summary, we identified a strong axonal phenotype in human cmt e motor neurons with potential as a screening platform for drug discovery. nodal and paranodal proteins have been identified as antigens in peripheral inflammatory neuropathies, however the frequency and clinical relevance of antibody responses against these targets remain poorly investigated in gbs. patients with acute onset inflammatory neuropathies were identified by exploration of the local databases of the departments of neurology and the institute of neurology of the medical universities in innsbruck and vienna. patient data, electrophysiological classification and presence of anti-gangliosid antibodies were retrospectively retrieved by review of patient records. only patients with typical clinical presentation and electrophysiological results consistent with one of the subtypes of gbs were included in the study. among forty-nine patients, thirty-five were classified as aidp, six aman, three amsan, three mfs, and two pharyngo-cervico-brachial gbs. of the included patients had anti-ganglioside-antibodies. ten patients with the initial suspicion of aidp had a disease duration of more than months and were reclassified as cidp. all patient and twenty sera of control patients with non inflammatory polyneuropathy were screened by an optimized tissue based assay using rat brains for immune responses against surface antigens, and by cell-based assays with transfected hek cells for antibodies against contactin (cntn ), contactin (cntn ), contactin-associated-protein (caspr ) and neurofascin- (nf ). in the tissue based assay some of the patients showed a light neuropil staining. none of gbs patient's sera had antibody reaction to cntn , cntn , caspr or nf in cell-based assays. among the cidp patients, two patients demonstrated reactivity against cntn with similar clinical presentation as previously described. none of the control patients had any antibody reaction to the performed tests. our results suggest that antibody responses to cntn , cntn , caspr or nf are absent in austrian gbs patients, although more patients will be screened to substantiate these preliminary results. furthermore, it remains to be established whether antibodies against cntn may predict a chronic course in acute onset inflammatory neuropathies. a few variants of chronic inflammatory demyelinating polyradiculoneuropathy (cidp) have been described with a frequency of - %. their relation and possible evolution into typical-cidp remain unclear, as is their treatment response possibly because of differences in diagnostic criteria. we used the data from a web-based database on italian patients with cidp to determine the frequency and characteristic of these variants, the possible evolution into typical-cidp, and their treatment response. all the patients were assessed at study entry and the disease course before inclusion was analyzed. by february- , we included patients ( men, women), aged - years (median years) with a mean disease duration of . years (range . - years) and complete data available from . based on the clinical data and our revised diagnostic criteria, patients ( %) were classified to have atypical cidp at onset and for the following two years including with dads ( %), with motor cidp ( %), with sensory cidp and cisp ( . %), with lewis-sumner syndrome ( . %), and with recurrent cranial neuropathy. at study entry, patients ( %) had progressed into typical cidp after - years (median years) while ( %, % of total) still had atypical cidp after . - years (median years) with a similar proportion of progression ( - %) within each group. the diagnosis of atypical cidp at entry fulfilled efns/pns criteria in ( %). csf studies were diagnostic in / ( %) patients, nerve biopsy in / ( %), and nerve imaging in / ( %) tested patients. similarly to typical cidp, % of treated patients with atypical cidp improved after treatment with a proportion of response varying from % to % in the different forms. most patients with sensory or motor cidp had however an unsatisfactory response to steroids. this study shows that he proportion of patients with atypical cidp varies during the course of the disease with almost % of the patients evolving into typical cidp within years from onset. in addition, response to treatment is frequent in atypical cidp even if not all the forms respond to the same therapies. only few studies investigated the frequency of antecedent events and comorbidities in patients with chronic inflammatory demyelinating polyradiculoneuropathy (cidp), and little is known on the role of possible predisposing factors, dietary, and lifestyle habits, on the onset and progression of the disease. we used the data from a web-based database on italian patients with cidp to determine the frequency of antecedent events and comorbidities and the possible role of predisposing factors including lifestyle and dietary habits and exposure to toxic agents, using a structured questionnaire. partners of patients served as controls. impairment was evaluated using the mrc sumscore and disability with incat and r-ods scales. logistic regression was used to calculate odds ratio (or) with % confidence interval (ci) for the risk of cidp. sex and disease-duration were included as covariates. by february- , patients were enrolled, with complete data on patients for antecedent events and comorbidities and patients and controls for lifestyle habits. ninety-two patients ( %) reported an antecedent event, mostly infection or vaccination ( %). one or more comorbidity were present in % of the patients including hypertension ( . %), thyroid disorders ( %) and diabetes ( . %) and in % influenced the choice of initial therapy. exposure to toxic environmental agents (odds ratio [or] = . ; % ci, . - . ), cigarette smoke (or = . ; % ci, . - . ), and dietary supplements (or = . ; % ci, . - . ) were associated with a higher risk of cidp while rice consumption was associated with a reduced risk (or = . ; % ci, . - . ). concerning disease severity, more severely affected patients more frequently consumed raw-meat (or = . ; % ci, . - . ) and white meat (or = . ; % ci, . - . ), while rice (or = . ; % ci, . - . ) and soft drink consumption (or = . ; % ci, . - . ) and physical activity were associated with lower disability (or = . ; % ci, . - . ). this study confirms that comorbidities are frequent in patients with cidp and often influence the choice of initial therapy. in addition preliminary data show that toxic exposure and some lifestyle and dietary habits may influence the onset and progression of cidp. doppler k , schuster y , weishaupt a , sommer c . department of neurology, university hospital würzburg, würzburg, germany. autoantibodies against the paranodal protein contactin- have recently been described in patients with cidp. in most patients, autoantibodies of the igg subclass are predominant and are supposed to be pathogenic. the role of igg anti-contactin- is so far unclear. in the present study, igg of three different patients, one with igg anti-contactin- , one with a low titer of igg anti-contactin- and one with a high titer of igg anti-contactin- , and of controls were injected into the sciatic nerves of lewis rats. nerve conduction studies of the injected nerve and motor and sensory testing were performed before and after injection. conduction blocks and motor deficits were detectable in the two patients with high titers of igg and igg , not in the patient with low titers. the percentage of conduction blocks was . % in rats injected with igg of the igg patient and % in those injected with igg . motor deficits were detectable in both patients with conduction blocks but were most apparent in the patient injected with igg of the igg patient. no differences in sensory testing were observed. conduction blocks and motor deficits improved after five days and were normal after seven to eight days. our data give the first evidence of pathogenicity of igg anti-contactin- autoantibodies, not only igg . igg of the igg patient induced a more severe clinical and electrophysiological phenotype compared to the igg patient. remarkably, this reflected the clinical phenotype of the patients, as the igg patients showed an acute-onset of sensorimotor symptoms at the time of blood withdrawal whereas the igg patient presented with a more chronic course of disease. doppler k , frank f , koschker a-c , reiners k , sommer c . department of neurology, university hospital würzburg, würzburg, germany; endocrinology and diabetes unit, department of medicine i, university hospital würzburg, würzburg, germany. axoglial dysjunction and paranodal demyelination have been discussed as potential mechanisms of nerve fiber damage in diabetic neuropathy. studies on human tissue are limited, as nerve biopsies are invasive and only rarely performed in patients with confirmed diabetic neuropathy. skin biopsy has recently been suggested as a good tool to analyze paranodal and nodal changes of myelinated fibers. in the present study, we analyzed the paranodal and nodal region in myelinated fibers of skin biopsies of patients with diabetic neuropathy, patients with diabetes mellitus without neuropathy, and normal controls. immunofluorescence of skin sections with antibodies against caspr, neurofascin, sodium channels and myelin basic protein was performed to assess paranodal/nodal architecture, segmental demyelination and myelinated nerve fibers. staining with antibodies against protein gene product . was used to quantify unmyelinated nerve fibers. we found an increase of elongated ranvier nodes and a dispersion of neurofascin at the distal leg in patients with diabetes mellitus with and without neuropathy and at the finger in patients with diabetic neuropathy. an increased dispersion of caspr was only found in biopsies of the finger in patients with diabetic neuropathy. our data show that skin biopsy is an appropriate tool to analyze nodes of ranvier in patients with diabetes mellitus. structural nodal changes are detectable in diabetic neuropathy, and even in diabetic patients without neuropathy. dourado me , fernandes u , vital al , ramos e , urbano jc , sena a , queiroz jw , jeronimo smb . federal university of rio grande do norte, natal, brazil. the erasmus gbs outcome score (egos) is a validated prognostic model that uses acute phase and easy-to-obtain clinical characteristics to determine outcome at months in patients with gbs. this study aims to assess the validity of egos in rio grande do norte, brazil, and to compare with another european study. data collected prospectively from a cohort of patients with gbs of rio grande do norte, brazil, between june and august , was assessed. ninety patients were excluded for missing data or diagnoses of miller fisher syndrome and atypical forms of gbs. to calculate the egos, the gbs disability score was assessed in the second week of disease and at months. to compare this study with the european one in independent group proportions, we used the student's t-test, being considered statistically significant p< , . the patients included were divided in four groups based on egos. thus, patients had egos between and ; had egos between . and . ; had egos and had egos between . and . in the first, second, third and fourth group, ( %), ( . %), ( . %) and ( . %) of the patients were unable to walk independently after six months of the disease, respectively. overall, of the patients analyzed, ( . %) had poor outcomes in this study. in the european paper, based on the same group division, of ( . %), of ( %), of ( %) and of ( %) were unable to walk independently. comparing both studies, the patients of this study were younger, more seriously ill in the first weeks and with more sensitive deficits. there were no difference relative to sex, cranial nerves deficits and presence of anti-gangliosides antibodies. using the student's t-test for ability to walk after months according to egos stratification, we achieve in the first group p= . ; in the second p= . ; in the third p= . ; and in the fourth p< . .the egos did not have a good capacity to predict the ability to walk after months of gbs in rio grande do norte, brazil. historically, guillain-barré syndrome (gbs) epidemics are rarely seen. between and , we treated and followed cases of gbs in the state of rio grande do norte with a yearly incidence of . / , . no seasonality was observed. the mean age of the patients was years (range, - ), with % of the cases younger than years. demyelinating variant was the most frequent subtype of gbs. in march , the first report of autochthonous transmission of zika virus (zikv) was determined in natal, brazil. later that month, we documented an increase in incidence of gbs in natal, brazil. the incidence in was of . / . . of the cases of gbs diagnosed in , were diagnosed from march through may, which coincided with the outbreak of zikv in natal, brazil. eighteen patients ( % of the cases) had a history of rash and fever prior to onset of gbs symptoms, with the median age of years (range, - ) . the electroneuromyography studies of these patients indicated that ( . %) had acute inflammatory demyelinating polyneuropathy, ( . %) had acute motor axonal neuropathy, and ( . %) was inconclusive. the mean time from onset of zikv infection symptoms to onset of the gbs were days (range, - ). the mean time of nadir was days (ranged, - ) . cranial neuropathies were present in patients ( . %). nine patients were bedridden ( %) and ( . %) required mechanical ventilation. the mean protein content of the central spinal fluid was . g/l, with the white blood cell count below /mm in all patients. they were all treated with intravenous igev. they all improved quickly. anti-gm was negative in all patients. rt-pcr was negative for dengue, chikungunya and zika. serum mac-elisa igm for zika and dengue was made in patients and it had % of positivity. prnt for zika and dengue had % positivity. in summary, we report a geographically and temporally defined cluster of gbs associated with an outbreak of acute rash in the state of rio grande do norte, brazil. as the prevalence of diabetes mellitus continues to increase worldwide, diabetic complications represent a growing burden to patients and society. distal symmetrical polyneuropathy (dsp) is a common complication that affects up to % of diabetic patients. dsp reduces patient quality of life due to chronic pain, ulcerations, and may lead to lower extremity amputations. despite its high prevalence, the mechanisms underlying diabetic dsp are poorly understood and several mechanisms are believed to play a role. we hypothesize that diabetic dsp arises from microvascular complications characteristic to diabetes. specifically, capillary dysfunction -disturbances in capillary flow patterns -is a likely candidate to explain development of dsp, as it can limit oxygen and nutrient delivery to nervous tissue, causing nerve dysfunction and damage, and thus development of dsp. we will study this hypothesis utilizing the state-of-the-art blood flow imaging techniques to visualize and quantify endoneureal blood flow and then link these findings with measures of dsp (e.g. nerve conduction velocity; intra-epidermal nerve fibre density) in animal models. we will include several animal models of diabetic dsp caused by either type or type diabetes. two photon microscopy and optical coherence tomography allow visualisation and quantification of capillary transit times and blood flow within peripheral nerves at high resolution. we hypothesise that changes in blood flow patterns and subsequent impairment of nutrient and oxygen delivery to nervous tissue precede the onset of diabetic dsp. if our experiments support this prediction, we will attempt to develop interventions that improve capillary blood flow to prevent or delay the development of dsp. duman o , saracoglu m , haspolat s , bozkurt o . department of child neurology, akdeniz university hospital, antalya, turkey. axonal polyneuropathies are very heterogeneous group of diseases which are very rarely seen during infantile age. some of them may be accompanied by developmental retardation, severe muscle weakness and progressive course. we aimed to present two cases of axonal sensorymotor neuropathy with infantile onset and atypical course. our -year-old boy patient was admitted to our clinic for progressive gait loss since one month. he was the first offspring of consanguineous parents with normal prenatal and natal history. electromyography revealed axonal sensorymotor polyneuropathy. metabolic and cerebrospinal fluid (csf) examinations for etiology were all normal. brain and spinal magnetic resonance imaging (mri) were normal. he had partial benefit from oral steroid treatment. in the course of disease along with four neuropathy attacks he had significant benefit from serial intravenous immunoglobulin treatments in two years clinical course. a month-old girl who is the first offspring of nonconsanguineous parents was admitted to the clinic for acute tetraparesis. axial sensorymotor polyneuropathy was detected in the electromyography. metabolic and cerebrospinal fluid (csf) examinations were normal. she had three more acute polyneuropathy attacks during ivig cessation period. both patients revealed with serial immunoglobulin treatments but unresponsive to riboflavine treatment. we aimed to discuss our rarely seen and the pathogenesis is not completely understood cases' course. serial ivig treatment may be helpfull for such patients' treatment. transthyretin-related familial amyloid polyneuropathy (ttr-fap) is an autosomal dominantly inherited disorder caused by mutations of the transthyretin (ttr) gene. the mutant amyloidogenic transthyretin protein causes the systemic accumulation of amyloid fibrils that result in organ dysfunction. ttr-associated fap is a progressive and fatal disease, if left untreated, and should be considered in the differential diagnosis of any person presenting with a progressive polyneuropathy, particularly with accompanying autonomic involvement. the clinical, electrophysiological, histopathological, and genetic characteristics of patients from turkey ( female, male) from eleven families with polyneuropathy and mutations in ttr were evaluated. two patients had no family history of ttr-fap and were considered as sporadic cases, and the remainders were familial cases displaying an autosomal dominant inheritance pattern. sequence analysis of the ttr gene revealed five mutations (p.val met, p.glu gln, p.gly glu, p.glu gly and p.gly glu). most common mutation was p.val met (in unrelated families). mean age at disease onset was . ± . years (range - years). the most commonly reported initial complaint was paresthesia in the feet (asymmetric in three patients). four patients ( male) with the p.glu gln mutation presented with carpal tunnel syndrome. two patients with the p.gly glu mutation showed episodes of dysarthria and hemiparesis, consistent with this genotype. seven patients died during the follow-up period as a result of systemic involvement. this study suggests that our cohort of ttr-fap patients from turkey exhibits clinical and genetic heterogeneity. ebenezer gj , liu y , judge dp , cunningham k , truelove s , carter nd , sebastian b , byrnes k , polydefkis m . department of neurology, johns hopkins university, baltimore, md, usa; division of cardiology, johns hopkins university, baltimore, md, usa; department of epidemiology, johns hopkins bloomberg school of public health, baltimore, md, usa. effect of amyloid deposition on cutaneous nerves was assessed in subjects with pathogenic ttr variants and control subjects. three groups of subjects each including ttr-fap patients, age/gender-matched healthy subjects and disease controls as well as ttr mutation carriers without neuropathy (ttr-nopn) and with al-amyloid underwent neurological examination and mm skin biopsies. micron sections were stained with anti-pgp . , anti-ttr and congo red. amyloid burden with imagej, intraepidermal (ienfd) sweat gland (sgnfd) and pilomotor densities (pmnfd) measured and correlations between amyloid burden, fiber subtype, neuropathy impairment score-ll (nis-ll) and nis sensory subscore were evaluated. ienfd, sgnfd, and pmnfd were all significantly reduced in ttr-fap patients vs. healthy controls while mutation carriers had intermediate reductions. lower nerve fiber densities were associated with nis-ll (p< . ). congo red staining revealed brilliant red amyloid deposits with apple-green birefringence within dermal collagen, sweat glands, and arrector pili muscles. amyloid infiltration was observed in the endoneurium and perineurium of small fiber sensory and autonomic nerves that innervate sweat glands and arrector pili muscles. cutaneous amyloid deposition was detected in % of ttr-fap and not in healthy or disease controls subjects. both al and / ttr-nopn subjects were congo red positive. amyloid burden was inversely correlated with ienf (p< . , r=− . ) sgnf (p< . , r=− . ), pmnf (p= . , r=− . ) distal leg densities, and correlated with nis-ll (p= . , r= . ) and nis sensory subscore (p= . , r= . ). wild-type ttr staining was less prominent in pathogenic ttr carriers. the diagnostic sensitivity and specificity to detect amyloid in skin were % and % in ttr-fap. the repeat measurement of the amyloid burden from the same section with imagej was r = . , p< . and different sections from the same biopsy was r = . and p< . . we conclude that endoneurial amyloid contributes to sensory and autonomic nerve injury. amyloid burden correlated strongly with sensory/autonomic axon densities and nis-ll. skin punches offer a convenient alternative to establishing a tissue diagnosis. amyloid burden is an attractive biomarker marker for ttr-fap and treatment effect. the study was supported through a grant from pfizer. ebenezer gj , truelove s , polydefkis m . department of neurology, johns hopkins university, baltimore, md, usa; department of epidemiology, johns hopkins bloomberg school of public health, baltimore, md, usa. we investigated differences of unmyelinated sensory nerve fibers in the distal limb among healthy-weight subjects (bmi < kg/m ) and overweight/obese subjects (bmi ≥ kg/m ), aged - years. subjects underwent neurological examination and mm skin punches from distal leg (dl), thigh (dt), and proximal thigh (pt) sites, from which micron sections were stained with anti-pgp . antibody; intraepidermal nerve fiber density (ienfd; fibers/mm) and epidermal thickness were assessed. a second dl biopsy was processed for electron microscopic examination and both thick and thin sections were examined for ultrastructural changes. multivariable linear regression models were used to assess the effect of age, gender, height and weight. after controlling for height, age, and obesity, females were found to have lower distal leg ienfd (− . ; p= . ). increasing age and height were significantly associated with decreasing dl ienfd, with decreases of − . fibers/mm per years (p<. ) and − . fibers/mm per cm (p< . ), respectively. even after controlling for height, being overweight/obese was associated with reduced dl ienfd, with . fibers/mm lower dl enfd than healthy-weight individuals (p=. ). these findings remained consistent across distal thigh and proximal thigh enfd, though not all associations remained significant. the epidermis was thicker in obese subjects across the lower limb, most pronounced at the distal leg (μm, mean± sd, healthy-dl: ± . , dt: . ± . , pt: . ± . , obese-dl: . ± . , dt: ± . , pt: . ± . ). under em very few intact dermal nerve bundles were identified at the proximal thigh sites. the atrophic and degenerating axons were seen with perineurial infiltration by dense collagen in obsess/overweight subjects but not age/gender matched controls. obesity further accelerates attenuation of epidermal nerve fibers across the lower limb even after controlling for other associated factors. echaniz-laguna a , geuens t , petiot p , péréon y , adriaenssens e , haidar m , capponi s , maisonobe t , fournier e , dubourg o , degos b , salachas f , lenglet t , eymard b , delmont e , pouget j , juntas morales r , goizet c , latour p , timmerman v , stojkovic t . strasbourg university hospital, strasbourg, france; peripheral neuropathy group, vib department of molecular genetics and institute born bunge, university of antwerp, antwerpen, belgium; lyon university hospital, lyon, france; nantes university hospital, nantes, france; hôpital de la pitié-salpétrière, paris, france; nice university hospital, nice, france; marseille university hospital, marseille, france; montpellier university hospital, montpellier, france; bordeaux university hospital, bordeaux, france. in this study, we describe the phenotypic spectrum of distal hereditary motor neuropathy caused by mutations in the small heat shock proteins hspb and hspb and investigate the functional consequences of newly discovered variants. among unrelated patients with distal motor neuropathy, we identified mutations in hspb ( index patients/ ; . %) and hspb ( index patients/ ; . %) genes. patients have slowly progressive distal ( %) and proximal ( %) weakness in lower limbs, mild lower limbs sensory involvement ( %), foot deformities ( %), progressive distal upper limb weakness ( %), mildly raised serum creatine kinase levels ( %) and central nervous system involvement ( %). we found a broad range of disease onset with some patients presenting with foot drop at the age of years, and others presenting symptoms only after years. disease progression was slow in all patients, and even with a disease duration of more than years patients were still able to walk. none of our patients were wheelchair dependent. muscle pathology, nerve pathology and electrophysiology showed in all cases a slowly progressive, mostly symmetrical and predominantly distal motor axonal neuropathy. mild sensory involvement was observed upon nerve conduction studies, mostly the lower limbs, in % of cases. we identified hspb and hspb mutations, including respectively and not previously reported. transmission was either dominant ( %), recessive ( %) or de novo ( %). three missense mutations in hspb (pro ser, gly asp, gln arg) cause hyperphosphorylation of neurofilaments, while the c-terminal mutant ser leu triggers protein aggregation. two frameshift mutations (leu fs, ala fs) create a premature stop codon leading to proteasomal degradation. two mutations in hspb (lys met/asn) exhibited increased binding to bag . we demonstrate that hspb and hspb mutations are a major cause of inherited motor axonal neuropathy. mutations lead to diverse functional outcomes further demonstrating the pleotropic character of small heat shock proteins. eftimov f , querol l , rajabally ya and on behalf of all participants of the st enmc workshop. academic medical center, amsterdam, the netherlands; hospital de la santa creu i sant pau, universitat autònoma de barcelona, spain; aston university, birmingham, uk. although chronic inflammatory demyelinating polyneuropathy (cidp) is a treatable neuropathy further research is urgently needed to define the diagnostic clinical and electrophysiological boundaries of cidp and its subtypes, and to define the role of biomarkers in supporting the diagnosis, monitoring disease activity and predicting response to treatment and outcome. in recent years, several national registries and biobanks have been developed to enable systematic data collection in cidp. an international registry with large number of patients is needed to allow answering many important questions and develop validated prognostic models to predict outcome in individual patients with cidp. at the inflammatory neuropathy consortium (inc) meeting in , the inc members agreed that a european neuromuscular center (enmc) workshop would be the ideal setting to reach a consensus on the infrastructure of database and biobanks. the st enmc workshop will take place on may - , with participants representing different countries. primary objective of the workshop is to reach a consensus on inclusion and exclusion criteria, core sets and recommended sets of clinical data, diagnostic data and follow-up points and a manual of operations for collection of biomaterials. a secondary objective is to construct an infrastructure to allow sharing data between different databases and biomaterials. conclusions of the consensus meeting and outline of further perspectives will be presented at the peripheral nerve society meeting in . eichinger kj , burns j , cornett k , bacon c , shepherd m , mountain j , sowden j , shy r , shy me , herrmann dn . clinical outcome assessments that measure functional ability are important endpoints for clinical trials. dr. burns has led the development/validation of a functional outcome assessment (cmtpeds) for individuals with charcot marie tooth disease (cmt) ages - years in the inc rdcrn. the cmtpeds is reliable and sensitive to change. however a validated functional outcome measure (fom) for adults with cmt is needed. our data in - year-olds indicated that the cmtpeds could be modified for adult use. however, some items of the cmtpeds (e.g. balance beam and jumping) have floor effects in adults with cmt. we have developed an adult cmt-fom modeled on the cmtpeds, and refined based on literature review, patient interviews, a large-scale cmt patient survey and expert opinion. the cmt-fom is a performance-based scale comprising items that are combined to form a composite score to quantify functional ability of adults with cmt. the cmt-fom shares items with the cmtpeds. four items were added to measure functional abilities relevant to adults (sit to stand, meter walk/run, stair climb, and timed up and go test). the cmt-fom scoring mirrors the cmtpeds. to generate a score ranging from - , raw item scores are converted to z scores, based on age-and sex-matched normative reference values form the norms project and categorized to a - likert along a continuum of impairment levels. we have conducted a pilot study of the cmt-fom in adults with cmt a ( male, female, age . ± . yrs) of differing severity (cmt exam score (cmtes) range - ). the cmt-fom is feasible, individuals were able to complete all items, and takes minutes to perform. the mean cmt-fom score was . ± . (range - ). concurrent validity of the cmt-fom is supported by an association with the cmtes (r = . ). the overall score did not demonstrate floor or ceiling effects. in summary the adult cmt-fom is well-tolerated and captures upper and lower limb strength, dexterity, balance, speed, ambulation and endurance. the cmt-fom requires validation in a large longitudinal cohort, prior to application in clinical trials. estilow t , glanzman am , burns j , cornett kmd , menezes mp , shy r , moroni i , foscan m , pagliano e , pareyson d , laurà m , bhandari t , muntoni f , reilly mm , finkel rs , sowden j , eichinger k , herrmann dn , shy me , yum sw , ramchandren s and on behalf of the inherited neuropathies consortium. cmt is associated with progressive impairment of the hands. reducing this impairment by treating children who are in the early stages of the disease is crucial. studies assessing measures of cmt hand function in children and their associations with patient-reported outcomes are lacking. we analyzed the upper extremity items from the cmt pediatric scale (cmtpeds) and pediatric cmt quality of life scale (pcmt-qol) in children ages - years enrolled in the inherited neuropathies consortium, to explore the relationships between measures of hand function (impairment, activity, and activities of daily living), and patient-reported outcomes. weak grasp ( %), hand pain ( %), and tremor ( %) were prevalent impairments. performance on activity level tasks, the nine hole peg test ( hpt) and functional dexterity test (fdt), were impaired in % and % of the cases, respectively. patients reported difficulty "sometimes" to "always" in opening a jar/lid ( %), zipping/buttoning ( %), writing ( %), carrying a plate without spilling food ( %) and putting on shoes ( %). patients reporting tremor showed significant differences on the hpt (p=. ). grip strength was shown to have a moderately significant correlation with performance on the fdt (r=. ; p<. ). stepwise multiple linear regression showed that grip strength (beta=−. ; p<. ), hand pain (beta=. ; p<. ) and fdt (beta . ; p<. ) were predictive of ability to open a jar (adjusted r =. ; p<. . grip strength (beta=−. ; p<. ), and fdt (beta . ; p<. ) were predictive of ability to carry plate without spillage (adjusted r =. ; p<. ). grip strength (beta=−. ; p<. ), hpt (beta=. ; p<. ) and fdt (beta . ; p<. ) were predictive of ability to put on shoes (adjusted r =. ; p<. ). hand pain (beta=. ; p<. ) and fdt (beta . ; p<. ) were predictive of ability to zip/button (adjusted r =. ; p<. ). hand pain (beta=. ; p<. ) and hpt (beta . ; p<. ) were predictive of ability to use a pen/pencil (adjusted r =. ; p<. ). children with cmt present with frequent limitations in adl performance impacting qol. the upper limb measures of the cmtpeds are associated with hand performance and interventions to improve grip strength and reduce pain should be investigated further with respect to their impact on improving function, and ultimately qol. evans me , morrow jm , wastling s , sinclair cdj , fischmann a , shah s , emira ak , hanna mg , yousry ta , thornton js , reilly mm . mrc centre for neuromuscular diseases, ucl institute of neurology, london, uk; neuroradiological academic unit, ucl institute of neurology, london, uk; university of basel hospital, basel, switzerland. responsive outcome measures are needed in charcot-marie-tooth disease (cmt) to allow adequately powered clinical trials to test novel therapeutics. we have shown high responsiveness of mri quantified intramuscular fat accumulation in calf muscles of cmt a patients over months. the aim of the present study was to assess the responsiveness and longitudinal validity of quantitative mri over a year follow-up period. we undertook two further sets of quantitative mri, myometric and clinical assessments in the original mrc centre cmt a quantitative mri cohort. mri sequences included fat quantification using the point dixon fat-water separation method, t quantification and magnetisation transfer imaging. of the patients with genetically confirmed cmt a were assessed at baseline ( male, mean age . ± . years), underwent repeat assessments a median on months (data already published), underwent repeat assessments at a median of months, and underwent a final assessment at a median of months. the primary outcome measure currently being analysed is mean calf muscle fat fraction at a single axial slice a fixed distance distal to the knee joint. results of this analysis and correlation with clinical measures will be presented at the peripheral nerve society meeting. fainmesser y , dori a , , drory ve , . department of neurology and neuromuscular service, tel-aviv medical center, tel-aviv, israel; department of neurology, sheba medical center, ramat gan, israel; sackler faculty of medicine, tel aviv university, israel. the use of anabolic drugs by those who wish to increase lean body mass is widespread and not well supervised medically. a years old man was referred for evaluation of a slowly progressive sensory and motor disturbance in the distribution of the left ulnar nerve. his symptoms began months after repeated self-injections of anabolic steroids and vitamin e into the biceps and triceps brachii muscles bilaterally. his examination showed increased muscle mass of the injected muscles with a hard-rubbery consistency, atrophy and weakness of left interossei, mild weakness of the bilateral biceps brachii and sensory loss in an ulnar nerve distribution. nerve conduction studies showed a left ulnar neuropathy with reduced motor and sensory response amplitudes and denervation in the left first dorsal interosseus, as well as mild myopathic changes with significantly reduced insertional activity in both biceps muscles. mri of the soft tissues of the arms showed massive fibrosis and infiltration of fat in the arm muscles compressing the ulnar and median nerves on the left. neurolysis of the left ulnar nerve was performed, and the ulnar nerve was found enclosed in a fibrotic mass throughout the entire length of the upper arm. the brachial artery and the median nerve were similarly enclosed in fibrotic tissue and were released. a biopsy of the affected muscles showed muscle necrosis and fibrosis. the patient was treated with physiotherapy and losartan with only mild improvement in the consistency of the muscles, but without clinical improvement in ulnar nerve function, and worsening of nerve conduction. this case illustrates severe peripheral nerve damage due to entrapment in massive muscle fibrosis following improper intramuscular injection of anabolic steroids for cosmetic purposes. fabrizi gm , testi s , høyer h , braathen gj , squintani g , bertolasi l , ferrarini m , taioli f , cabrini i , pancheri e , cavallaro t , tonin p . department of neuroscience, biomedicine and movement, university of verona and department of neuroscience, aoui verona, italy; section of medical genetics, department of laboratory medicine, telemark hospital, skien, norway. inherited diseases of nerve and muscle may overlap phenotypically or coexists as facets of the same disorder. two families whose probands were initially diagnosed with a lower motor-neuron (lmn) syndrome and a hereditary distal motor neuropathy (dhmn) turned out to represent a vcp (valosin-containing protein)-related syndrome and a gne (udp-n-acetylglucosamine -epimerase/n-acetylmannosamine kinase)-related "distal myopathy" . both conditions shared the presence of rimmed vacuoles (rv) in muscle biopsies. in family , the year-old male proband had a lmn syndrome manifesting at age years (wasting/weakness, cramps, fasciculations of thigh muscles, later involving the distal upper limbs). his year-old brother had lower limb weakness and diffuse pain in bones/joints since age . the father was diagnosed with a "muscular dystrophy" thirteen years before dying a years; by age years he had developed a behavioural frontotemporal dementia (ftd). electrodiagnosis (edx) disclosed myopathic changes with ongoing denervation together with a mild sensory-motor axonal polyneuropathy in the proband, and a chronic sensory-motor axonal polyneuropathy in the brother. mri showed fatty replacement of weakened muscles in both siblings and diffuse changes of bones consistent with paget disease (pd) in the elder sibling. in family , a year-old african woman was affected by weakness and wasting starting at the distal lower-limb muscles at age years and soon progressed proximally; parents were not consanguineous and two sisters out of six siblings, deceased in their thirties for post-partum complications, had a similar disease. edx mainly disclosed a neurogenic process with ongoing denervation. muscle biopsies from the three family- patients and from the family- proband showed a myopathy with rv. next-generation sequencing demonstrated a heterozygous c. c>t change of vcp leading to a known pathogenic p.arg cys substitution in all family- patients, and two compound heterozygous c. g>a and c. g>a changes of gne in the family- proband leading to known p.ala thr and p.ala thr substitutions. vcp is known to cause autosomal dominant amyotrophic lateral sclerosis- , charcot-marie-tooth disease type y or inclusion body myopathy (ibm) with pd and ftd (ibmpfd); gne causes the autosomal recessive nonaka myopathy (alias ibm ). both cases emphasize the clinical and neurophysiological heterogeneity of those disorders. fargeot g , vandendries c , labeyrie c , viala k , theaudin m , adams d . neurologie, crmr nnerf, aphp, filnemus, chu bicêtre, le kremlin-bicêtre, france; neuroradiologie, crmr nnerf, aphp, filnemus, chu bicêtre, le kremlin-bicêtre, france; neurologie, groupe hospitalier universitaire pitié salpêtrière, paris, france. the diagnosis of cidp is often challenging, especially when electrophysiological signs of demyelination are lacking. plexus mri has documented nerve abnormalities in small series of typical cidp but its contribution in patients with no electrophysiological signs of demyelination remains to be proved. we report the results of plexus mri in a serie of patients suspect of having cidp without efns pns definite electrophysiological criteria. we did a retrospective study of patients consulting in kremlin bicetre and pitié salpétrière hospital. lumbar or brachial plexus mri (or both) were performed and we assessed nerve trophicity, t -stir signal intensity and gadolinium enhancement as well as the topography of abnormalities. a consensus diagnosis was made by a group of experts (based on clinical data and other supportive criteria) and allowed us to classified patients in "cidp" or "other diagnosis". the practical contribution of plexus mri to the diagnostic algorithm has been studied. diagnosis of cidp was made in patients. mri was abnormal in % of cidp patients and showed nerve roots hypersignal/hypertrophy/enhancement in respectively . / . / . % of patients. the pattern of abnormalities was often asymetrical ( . %), diffuse ( . %) or multifocal ( . %). after unblinding, the mri confirmed the diagnosis of experts in . % of patients and changed the diagnosis in % of patients. plexus mri has shown to be useful in our serie to confirm the diagnosis of experts or to modify it in patients ( %) . the "classical" pattern described in definite cidp (diffuse nerve root hypertrophy and hypersignal) was documented in % of our cidp patients whereas less typical pattern (focal or multifocal abnormalities, hypersignal without hypertrophy) was found in %. plexus mri seems usefull when facing patients suspected of having cidp when electrophysiological criteria are not met: both symetrical diffuse or asymetrical multifocal patterns can be found and should be always correlated to the clinical examination and other supportive criteria. the specificity of such abnormalities remains to be studied. feely sme , rebelo a , abreu l , tao f , bacon c , zuchner s , shy me . university of iowa, iowa city, ia, usa; dr. john t. macdonald department of human genetics and hussman institute for human genetics, miller school of medicine, university of miami, miami, fl, usa. mutations in bcle-associated athanogene (bag ) have been shown to cause a distal myofibrillar myopathy and cardiomyopathy that can severely affect children or only affect adults depending upon the particular mutation. children with severe cardiomyopathy and myopathy have also developed axonal peripheral neuropathy, consistent with the known localization of bag in neurons as well as in muscle. we have identified two large autosomal dominant families with adult onset charcot-marie-tooth disease (cmt ) with the identical novel missense mutation pro ser, a codon previously shown to cause severe or mild myopathy depending on the amino acid substitution. these families expand the phenotypes caused by mutations in bag to include cmt and provide an additional example of adult onset cmt that may previously have been diagnosed as chronic idiopathic axonal neuropathy (ciap). feely sme , saade d , shy me . carver college of medicine, university of iowa, iowa city, ia, usa. myelin protein zero (mpz), expressed only by myelinating schwann cells, has sequence alterations that have previously been reported to cause demyelinating, intermediate, and axonal forms of charcot marie tooth (cmt) disease. we describe a rare duplication in mpz which is causing an early onset, demyelinating form of cmt in our patient. patient was a product of a normal pregnancy and delivery. early milestones were delayed. she began walking at months of age. she was not able to keep up with her peers and was the slowest runner. she started wearing smos at years of age and afos by years of age. she was diagnosed with scoliosis at years of age and started wearing a brace at years. her examination at years of age showed that her fdi, apb, and adm were all / bilaterally. weakness in her lower extremities included / foot eversion and / great toe dorsi flexion. she had tight heel cords bilaterally. pinprick sensation was reduced throughout in her upper and lower extremities and absent at her toes bilaterally. vibration sensation with a rydel tuning fork was absent at her toes and ankles and reduced at her knees and fingers. nerve conduction studies were performed and revealed no responses in all sensory nerves tested with the exception of the radial nerve which had normal latency and mildly slowed conduction velocity ( m/s). prolonged latencies, demyelinating range slowing (between - m/s), and low cmap amplitudes in almost all segments of the median and ulnar motor nerves were also observed. these findings were consistent with a hereditary sensorimotor demyelinating polyneuropathy. she was diffusely areflexic and her total cmt pediatric score (cmtpeds) was / which is in the severe range. her cmt neuropathy score (cmtns) was / in the moderate range. the duplication of mpz has previously been identified as a rare cause of cmt b. inherited neuropathy consortium is part of the nih rare diseases clinical research network (grant# u ns - ). feely sme , saade d , shy me . carver college of medicine, university of iowa, iowa city, ia, usa. mutations in egr cause a severe, demyelinating form of cmt, cmt d. we describe a novel mutation in egr which led to extreme variability in severity in a family. proband was a year old girl who was the product of a normal pregnancy and delivery. early milestones were on time. problems with walking started at years of age. at . she was unable to use stairs, run, or jump. at she was wearing bilateral afos. by she was using a wheelchair and started breathing assist at night. she lost arm lift but could still hold a pen. by she could not ambulate independently and breathing assist was required day/night. she lost the ability to write and developed a head drop. by years she could not sit up. on exam her head and neck muscles were / . upper limbs, deltoids, biceps, wrist ext/flex, finger ext, fdi, and adm were / bilaterally. triceps were / ; finger flexors and apb were / bilaterally. lower limbs were / and she had contractures on the right. sensory examination was normal. she was diffusely areflexic. ncvs were absent. both the cmtns and cmt pediatric score were severe at / and / . exome sequencing revealed a r l variant in egr which was likely pathogenic. the probands' mother also had this mutation. she had no reported symptoms at the age of with strength at / throughout with the exception of left foot eversion which was +/ and great toe dorsi flexion which was -/ bilaterally. sensory exam showed a decrease of vibration and pinprick sensation at left toe. she had a normal gait, tandem gait and could toe walk, but not heel walk. she was diffusely areflexic. ncvs showed absent sensory responses. motor ncvs showed her latencies were prolonged and velocities reduced ( - m/s). cmtns was mild ( / ). additional family members who had the r l mutation were evaluated including maternal grandmother who was moderately impaired ( / ) and maternal aunt who was severe ( / ). no other mutations that could cause another known neuropathy or myopathy were identified and mitochondrial sequencing was normal. inherited neuropathy consortium is part of the nih rare diseases clinical research network (grant# u ns - ). fisgun a , luan x , hoke a . johns hopkins university, baltimore, md, usa. molecular mechanisms that underlie slow distal axonal degeneration seen in chemotherapy induced peripheral neuropathy (cipn) are unclear. however, several identified molecular targets suggest shared mechanisms with wallerian degeneration. since spontaneous mutation in wlds mice and genetic deletion of sarm gene lead to slow wallerian degeneration, we asked if wlds or sarm knockout (ko) mice are resistant to distal axonal degeneration induced by several chemotherapy agents. we chose chemotherapeutic drugs from different classes of agents, paclitaxel (taxane), cisplatinum (platin-based drugs) and bertozomib (proteasome inhibitor), to model cipn in mice. primary outcome measure was evaluation of epidermal nerve fibers in the hind paw plantar footpads. secondary outcome measures included thermal sensation and nerve conduction studies. sarm ko mice were almost % protected against development of sensory neuropathy but the protection in wlds mice was partial. this study confirms the pivotal role sarm plays in mediating axonal degeneration and identifies inhibition of sarm activity as a potential therapeutic target for prevention of cipn. florio f , scapin c , ferri c , feltri ml , wrabetz l , d'antonio m . myelin biology unit, san raffaele scientific institute, milan, italy; hjkri-university of buffalo, ny, usa. myelin protein zero is the most abundant structural protein in myelin of the pns. in humans, more than mutations in p are associated with hereditary neuropathies. deletion of serine causes charcot-marie-tooth (cmt) b disease in humans and a similar demyelinating neuropathy in mice (wrabetz et al., ) . p s del protein is misfolded and is retained in the er where it gives rise to a dose-dependent unfolded protein response (upr) (pennuto et al., ) . the upr results in the activation of transcriptional and translation control programs that reduce protein synthesis and increase the folding and degradative capacity of the cell. usually, when this first response is not sufficient the cells may activate apoptosis resulting in cell death. however, in p s del schwann cells there is no cell death suggesting that these cells may respond differently to chronic stress. transcriptomic analysis performed on p s del nerves showed increased expression of transcription factors normally present only in the early phases of differentiation such as c-jun, sox and id (d' antonio et al. ) . in order to understand the role of the expression of these factors in the peripheral nerve myelination we used ex vivo and in vivo approaches and we showed that sox and id act as negative regulators of myelination. these results suggest that the expression of sox and id may contribute to the hypomyelination observed in p s del mice. as such, we reasoned that their ablation could ameliorate the phenotype. surprisingly, the ablation of these factors in the p s del mouse severely worsens the neuropathy bursting schwann cell differentiation and increasing the expression of both p wild type and mutant allele with concomitant exacerbation of the upr. this suggests that the overexpression of early differentiation factors in schwann cell under chronic er-stress is an adaptive mechanism that limits differentiation and reduces the expression of toxic proteins. intravenous immunoglobulin (ivig) is the treatment of choice for the guillain-barré syndrome (gbs). the working mechanism of ivig in gbs is undefined, but most likely all potential effects are dose dependent. the pharmacokinetics (pk) and pharmacodynamics (pd) of ivig in gbs are highly variable between patients and a rapid consumption or clearance of ivig is associated with poor recovery. in the current study we developed a model to predict the pk of a standard dosage of ivig ( . g/kg for consecutive days) in individual patients with gbs. non-linear mixed-effects modelling (nonmem) was used to construct a model based on a cohort of gbs patients, with a total of sequential serum igg levels. the final model accurately describes the day to day increment in igg levels during the -day course and the initial rapid fall and graduate decline to steady-state levels thereafter. we explored several potential covariates that improved the predictive capabilities and decreased the between-subject variation in the model. the model including these covariates were evaluated successfully (bootstrap analysis) and through numerous simulation studies each based on (simulated) gbs patients. in conclusion, a first accurate and robust nonmem model for the pk/pd of standard ivig treatment in gbs was developed. the model can be used to predict the pk in individual patients applying a few simple baseline characteristics. in addition, the effect of different treatment regimens of ivig in gbs on a population pk/pd level can be simulated. this modeling technique is a new tool to optimize the pk in individual patients and the study design for new trials with ivig in gbs. forese mg , pellegatta m , rivellini c , podini p , quattrini a , previtali sc , taveggia c . axonal neuregulin (nrg ) type iii is an essential instructive signal for peripheral nervous system (pns) myelination, as its expression determines whether axons are myelinated as well as the thickness of the myelin sheath. we recently demonstrated that gamma-secretase cleavage of nrg type iii generates an axonal intracellular fragment, which translocates in the nucleus to upregulate the expression of the prostaglandin d synthase (l-pgds) gene in neurons. l-pgds catalyzes the conversion of prostaglandin h into prostaglandin d (pgd ). we also showed that specific inhibition of l-pgds activity impairs in vitro myelination. accordingly, myelin in l-pgds null mice is noticeably thinner, thus indicating that l-pgds is a new modulator of developmental pns myelination. previous studies have shown that prostaglandins are involved in the process of wallerian degeneration (wd) and axonal regeneration after injury. thus, to determine whether l-pgds and pgd could be important in pns regeneration and remyelination, we performed sciatic nerve crush injury in months old l-pgds null and wild type control mice and we analysed nerves by morphologic, biochemical, histological and molecular approaches at different time points (t) after crush. we focused on three phases: degeneration (t -t ), axon regeneration (t -t ) and remyelination (t ). our results indicate that in l-pgds null mice the amount of myelin proteins synthesized after crush as well as the number of remyelinated fibers do not change, suggesting that l-pgds might be dispensable for remyelination. however, we observed an increased number of macrophages in null nerves during regeneration (t ), possibly as a consequence of an increase in the blood-nerve barrier (bnb) permeability, indicating potential alteration in the regeneration process in l-pgds null mice. these results suggest that l-pgds could have a different role in developmental pns myelination and after injury. whether other prostaglandins and synthases might compensate for l-pgds activity is currently under investigation. fornasari be , , raimondo s , , ronchi g , , crosio a , budau ca , el soury m , muratori l , , tos p , battiston b , geuna s , , gambarotta g . department of clinical and biological sciences, university of turin, italy; neuroscience institute cavalieri ottolenghi, turin, italy; microsurgery unit, health and science city, cto, turin, italy; hand microsurgery and surgery, gaetano pini hospital, milan, italy. to repair nerve gaps following severe peripheral nerve injuries, chitosan tubes were proved to give good results, comparable with those obtained with nerve autografts, the gold standard technique. to further improve peripheral nerve regeneration using chitosan tubes, a conduit enrichment strategy was developed using longitudinal skeletal muscle fibres, which have been previously shown to be good fillers in the "muscle in vein" experimental paradigm, where they played a trophic and a structural role. to this aim, rat median nerve gaps were repaired using two different conduits: mm chitosan tubes filled with a longitudinal piece of pectoralis major muscle ("muscle in tube") and hollow chitosan tubes. samples were harvested at early time points ( , , , days) for biomolecular and morphological analysis, and later ( months) for stereological analysis. autologous nerve grafts were used as gold standard positive control in the early time points. biomolecular analysis carried out on in vitro degenerating muscle and on "muscle in tube" at early time points show that the muscle produces high levels of soluble isoforms of neuregulin , a key factor for schwann cell survival and activity, usually released by schwann cells after nerve injury. functional assay and stereological analysis carried out on the distal part of regenerated nerve months after nerve repair, show no significant differences in the regeneration outcome between hollow chitosan tube and "muscle in tube" groups. therefore, we conclude that for short gaps (≤ mm), both hollow chitosan tube and "muscle in tube" are good techniques to repair nerve defects and we suggest that the "muscle in tube", which spontaneously releases neureg-ulin , might be a promising strategy to promote regeneration when the gap is longer or the repair is delayed in time. foucquier j , bertrand v , jouve e , truillet r , mandel j , laffaire j , blin o , magy l , lehert p , , hajj r , guedj m , cohen d , attarian s . pharnext, issy-les-moulineaux, france; aix marseille université, aphm, marseille, france; hôpital dupuytren, limoges, france; university of melbourne, melbourne, vic , australia; faculty of economics, louvain, belgium. charcot-marie-tooth disease type a (cmt a) is a rare disease belonging to a group of inherited, progressive, chronic motor and sensory peripheral neuropathies. the charcot-marie-tooth neuropathy score (cmtns) (shy et al., ) and the overall neuropathy limitations scale (onls) (graham & hughes, ) are considered as the main clinical scales for evaluating progression of disability associated with cmt. as cmt a is a slowly progressive neurodegenerative disease, the choice of endpoints and their ability to monitor small changes over time remain a major concern for clinical drug development. with this in mind, we studied a cohort of french cmt a patients with a follow-up ranging from months to . years resulting from the merge of two multicentre clinical trials (micallef et al., ; attarian et al., ) and a non-interventional study (unpublished) . the sensitivity to change of both cmtns and onls were assessed using a mixed effect model estimating annual progression with time in years, cmtns or onls baseline value as covariates, study centre as a fixed factor and patients as a random effect to account for the repeated measures. disease progression was estimated to be + . points per year on the cmtns (p = . ) and + . points per year on the onls (p = . x − ), both corresponding to a deterioration of impairment and disability. while both endpoints have similar and favourable properties, our set of observations led us to conclude that the onls could be more promising to monitor disease progression in cmt a. frasquet m , , lupo v , mas f , , vílchez r , chumillas mj , , espinós c , sevilla t , , . hospital universitari i politècnic la fe, valencia, spain; instituto de investigación sanitaria la fe, valencia, spain; centro de investigación príncipe felipe, valencia, spain; eresa, valencia, spain; centro de investigación biomédica en enfermedades raras (ciberer), valencia, spain; departamento medicina, universitat de valencia, valencia, spain. mutations in the bicd gene are a cause of dominant spinal muscular atrophy, lower extremity predominant (smaled). we report six patients belonging to three spanish families who carry three different novel mutations in the bicd gene. we describe clinical, electrophysiological and magnetic resonance imaging (mri) data. we provide results of muscle biopsy of one patient and skin biopsy for the study of epidermal nerve fiber density (enfd) of other two patients. genetic diagnosed was reached using a gene panel for genetic testing of cmt and dhmn. three novel mutations in the bicd gene that segregated with the disease were detected: p.val gly; p.tyr his and p.s l. the most frequent clinical phenotype consisted of mild weakness in proximal muscles of lower limbs combined with foot deformities. one patient had prominent sensory symptoms and abnormalities on sensory examination. other two patients had minor sensory abnormalities on examination. in one patient sensory and motor nerve action potentials were reduced, in the rest of patients electrophysiological studies showed normal motor and sensory nerve responses, with chronic denervation predominantly in muscles of lower limbs. mri studies at the level of tight and calf were performed in all patients. the most affected muscles were rectus femoris, vastus lateralis and medial gastrocnemius. mri studies at the level of feet were obtained from five patients and showed that there was not fatty infiltration in intrinsic foot muscles. mri at the level of pelvis muscles performed in four patients showed marked fatty infiltration of gluteus medius muscle in two of them. muscle biopsy performed in one patient showed myopathic features. skin biopsy was performed in two patients of the same family. in the older patient, who had minor sensory abnormalities on examination, there was a marked reduction of enfd that followed a length-dependent pattern. in conclusion, we report three new pathogenic mutations in the bicd gene. in our study we include mri findings at the level of pelvis and feet, which allow us to better define the pattern of muscle involvement related with this gene. our results also raise the subject of a possible sensory involvement in the disease. hereditary neuropathy with liability to pressure palsies (hnpp) is an autosomal dominant disorder that usually results from deletions in the pmp- gene. the neuropathy is unique in that it manifests with recurrent mono-neuropathies at common sites of compression. while spontaneous recovery from episodes of nerve injury usually occurs, it is often incomplete, and over time patients may develop a length dependent polyneuropathy. given the relapsing/remitting nature of hnpp symptoms, standard clinical scores, such as the cmt neuropathy score, are not effective at capturing the severity or progression of the disease. a specific tool is therefore needed for measuring clinical severity of hnpp in preparation for emerging clinical trials. in the current study, we evaluate a new pilot measure, the hnpp severity score (hnpps). the score is composed of patient reported questions addressing current and prior sensory and motor symptoms, and the impact of symptoms on quality of life, followed by items based on a motor examination. total scores vary from - , with higher scores indicating increased disease severity. in this study, the hnpps was administered to patients with genetically confirmed hnpp at the ucl institute of neurology. subjects included males and females with a mean age of years (+/− , range - ). the mean hnpps was . points (+/− . , range - ) and the data did not demonstrate major skew. the cronbach alpha for the hnpps was . , and items based on the physical examination showed the least variability. a modest correlation was observed between the hnpps and the cmt examination scores (pearson correlation . , ci . - . ). we conclude that the hnpps may be a useful measure of clinical severity in hnpp, and should be refined in larger patient cohorts. fridman v , sillau s and on behalf of the inherited neuropathies consortium (inc) . university of colorado hospital, aurora, co, usa; university of iowa hospitals and clinics, iowa city, ia, usa. the most common of the hereditary neuropathies (hn) is cmt a, an autosomal dominant demyelinating neuropathy that results from duplications in the pmp- gene. recent advances in defining the pathomechanisms of the disease have led to an increasing number of potential therapies; however, the absence of reliable natural history data and the paucity of sensitive clinical outcome measures have been barriers to effective clinical trials. the charcot marie tooth neuropathy score (cmtns) was developed to quantify impairment and measure progression in hn. it was observed that while the score discriminates well between mildly and severely impaired patients, it tends to cluster together patients in the middle range of severity. to improve the score's sensitivity, rasch analysis-based weighted category responses were developed. we report a longitudinal study of weighted cmtns and cmt examination scores (cmtes) over a three-year time frame in patients with cmt a. baseline, one year, two year and three year wcmtnsv /wcmtesv scores were available for / , / , / and / patients respectively. mean wcmtns (sd)/wcmtes (sd) scores were as follows: . ( . )/ . ( . ) at baseline, . ( . )/ . ( . ) at one year, . ( . )/ . ( . ) at two years and . ( . )/ . ( . ) at three years. a mixed regression model showed significant change in wcmtns and wcmtes at years (mean change from baseline at years was . points (p=. ) for wcmtns and . points (p=. ) for wcmtes. significant change as compared to baseline was also seen at years (mean change from baseline . points (p= . ) for wcmtns and . points (p= . ) for wcmtes. we conclude that weighted cmtnsv scores show change over the first three years of the inherited neuropathies consortium natural history study and are a helpful measure of progression in cmt a. fridman v , novak p , david w , macklin ea , mckenna-yasek d , walsh k, oaklander al , brown r , hornemann t , eichler f . massachusetts general hospital, boston, ma, usa; university of massachusetts medical school, worcester, usa; university hospital zurich, zurich, switzerland. hsan is an autosomal dominant, severe sensory motor polyneuropathy caused by mutations to serine palmitoyl-coa transferase. mutations shift the substrate preference from serine to alanine leading to formation of neurotoxic -deoxysphingolipids ( -deoxysl). treatment with high-dose l-serine has been shown to reduce -deoxysl accumulation and improve neuropathy in transgenic hsan mice. we report a two-year, delayed-start, placebo-controlled clinical trial evaluating the safety and efficacy of oral l-serine in hsan . eighteen hsan subjects were equally randomized to l-serine ( mg/kg/d) or placebo for year. at -weeks, the placebo group crossed-over and all participants took open-label l-serine for one additional year. sixteen subjects completed their -week visit, and no serious adverse events related to l-serine were reported. participants randomized to l-serine experienced a decline in charcot marie tooth neuropathy scores (cmtns) over year relative to placebo (− . units, % ci − . to − . , p = . ). both groups improved in the second year of the study, with a diminished difference in cmtns at weeks (− . units, % ci − . to . , p= . ). skin biopsies from the distal leg site were largely devoid of intra-epidermal nerve fibers (ienf), but at year, a greater increase in ienf density was seen in participants on l-serine versus those on placebo (median change of vs. fibers/μm , p= . ). -deoxysl levels declined among participants on l-serine versus those on placebo after one year of treatment ( % decrease in deoxysphinganine vs. % increase on placebo, p < . ), and placebo participants experienced similar declines in -deoxysl levels after crossing over to l-serine. we conclude that l-serine is a safe and potentially efficacious treatment for hsan . fu liong h , yusuf r . regional neuromuscular clinic, queen elizabeth hospital, university hospitals of birmingham, birmingham, uk; school of life and health sciences, aston brain centre, aston university, birmingham, uk. the relationship between guillain-barré syndrome (gbs) and malignancy is uncertain. under the diagnostic criteria of paraneoplastic neurological syndrome (pns) by euronetwork, , neuropathy with no definite onconeural antibodies identified due to gbs has been classified as "non-classical" paraneoplastic disorder. we retrospectively analyzed data of consecutive patients admitted with gbs from birmingham, u.k. ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) to calculate the relative cancer risk using different definitions and determined characteristics of malignancy-associated gbs. patients were classified according to definitions: ) all cases of malignancies excluding preceding diagnoses > year before gbs and with no evidence of malignant disease activity at the time of gbs diagnosis, and ) malignancies diagnosed > years post-gbs onset as per pns criteria. total number of gbs patients with malignancy was ( . %). a total of patients ( . %) fulfilled requirements for inclusion as malignancy-associated gbs as per existing criteria for pns. associated malignancy consisted of angioimmunoblastic t-cell lymphoma ( ), poorly differentiated squamous cell carcinoma of nasal septum ( ), gastric adenocarcinoma ( ), hepatocellular carcinoma due to hepatitis b ( ), rectal carcinoma with liver metastasis ( ) and myelodysplastic syndrome ( ). malignancy was globally commoner in our gbs cohort compared to the general population (odds ratio: . ; ci: . - . ; p = . ). however, this was unconfirmed if paraneoplastic criteria were applied. gbs patients with cancer were significantly more likely to be older (p = . ), hyponatremic (p = . ) and demonstrate more electrophysiological axonal loss (p < . ). cerebrospinal fluid (csf) protein levels were lower in the malignancy group (p = . ) and neurological improvement was less likely (p = . ). in-patient mortality was significantly higher in patients with malignancy (p < . ). none of the patients in the malignancy group had positive anti-ganglioside antibodies or anti-neuronal antibodies (anti-hu, yo, ri, crmp ). we conclude global cancer risk is higher in gbs than in the general population, although definition-dependent. application of the strict published criteria for paraneoplastic syndrome reduced the number of cases and suggested absence of a link. malignancy requires consideration in elderly, hyponatremic subjects with normal csf protein, severe electrophysiological axonal loss who fail to improve post-treatment. fu liong h , aude-marie g , anne-catherine an , emilien d , julien c , shahram a , yusuf r . anti-myelin associated glycoprotein antibody (anti-mag) neuropathy is a slowly progressive neuropathy resulting in disability through distal sensory more than motor deficits and tremor. there are currently no evidence-based treatments for anti-mag neuropathy and the effect of the disease on quality of life (qol) in this patient population is unknown. our objective was to assess determinants of qol in patients with anti-mag neuropathy. the sf- questionnaire was assessed in patients, from marseille, angers (france) and birmingham (united kingdom). routine clinical evaluations included mrc sum score, incat sensory score, inflammatory rasch built overall disability score (i-rods), ataxia score, jamar grip dynamometry, timed meter-walk, neuropathic pain symptom inventory (npsi) score, and fatigue severity score (fss). there were males and females. mean age was . years (sd: . years). mean disease duration was . years (s.d.: . years). there were no significant differences between the french and u.k. cohorts in terms of gender distribution, age, disease duration, anti-mag antibody titre. all physical assessments, including mrc sum score (p= . ), jamar grip dynamometry (p= . ), onls (p= . ), irods (p= . ), incat sensory score (p= . ), -meter timed walk (p= . ), ataxia score (p= . ), tremor score (p= . ), were comparable. prevalence and/or severity of pain (p= . ), fatigue (p= . ), restless legs syndrome (p= ) and cramps (p= . ) were also similar. physical component summary (pcs) and mental component summary (mcs) of the sf questionnaire were significantly lower than in reported normal subjects of both countries (p< . ). all sf- qol domains correlated with i-rods, except mcs for which significance was however approached (p= . ). pcs correlated with mrc sum score, ataxia score, timed m-walk, tremor, jamar grip dynamometry, npsi pain score, fss and level of social support. mcs correlated exclusively with fss and level of social support. in multivariate regression, pcs was associated independently with i-rods (p< . ) and npsi pain score (p= . ), whereas mcs was associated independently with fss (p= . ). qol is accurately predicted in anti-mag neuropathy by the i-rods and fss, lending support to their use in clinical and research settings. effective measures to improve qol should include tremor and neuropathic pain treatment, fatigue management and improved social support. fu liong h , yusuf r . regional neuromuscular clinic, queen elizabeth hospital, university hospitals of birmingham, birmingham, uk; school of life and health sciences, aston brain centre, aston university, birmingham, uk. the electrophysiological diagnosis of guillain-barré syndrome (gbs) is dependent on a number of abnormalities affecting different parameters in peripheral nerves on nerve conduction studies (ncs). diagnostic sensitivity varies with different electrodiagnostic criteria, practices as well as extensiveness of nerve study. however, the most efficient method of performing electrophysiology for guillain-barré syndrome (gbs) is unknown. we retrospectively analyzed electrophysiological data of consecutive gbs patients from birmingham, uk ( - ), studied ≤ weeks post-onset. we first identify abnormal nerves from various regions which produced gbs electrodiagnosis using the recently described criteria by rajabally et al. we subsequently used pre-established hypothetical nerve conduction study protocols to determine the potential optimal method of achieving electrodiagnosis. we found the sensitivity of electrophysiology for each gbs subtype was dependent on the upper and lower limb nerves tested. in acute inflammatory demyelinating polyneuropathy (aidp), abnormalities were predominant in the arms, whereas leg abnormalities predominated in axonal gbs. in aidp, the most common abnormal parameters were distal motor latency ( . %) and conduction block ( . %), and the most frequently affected nerve was the median ( . %). prolonged f-waves were present in % and f-waves were absent in %. mcv was the least frequently abnormal ( . %) with demyelinating range slowing, significantly lower than cb or dml prolongation (p< . in both cases). in axonal gbs, reduced motor amplitudes ( . %) and conduction block ( . %) were the most common parameters, and the most frequently abnormal nerve was the tibial ( . %). f-waves were absent in . %. . % of all motor nerves were unexcitable, significantly more common in lower limb nerves compared to upper limb nerves (p= . ). on comparison of different hypothetical ncs protocols ( unilateral protocols with nerves, with nerves as well as the protocols with -nerves and with exclusive bilateral upper limb and lower limb testing), unilateral -nerve (median, ulnar, common peroneal and tibial) testing produced the highest diagnostic sensitivity for both aidp ( . %) and axonal ( . %) gbs. electrodiagnostic sensitivity in gbs is thus dependent on nerves tested and parameters considered. each subtype preferentially involves specific nerves and parameters. these findings may help per-procedure interpretation, improve electrodiagnostic sensitivity, and reduce patient discomfort. funakoshi k , nagashima t , kokubun n , hirata k , yuki n . department of neurology, dokkyo medical university, tochigi, japan; department of neurology, mishima hospital, nagaoka, japan. recently, igg anti-ganglioside complex (gscs) antibodies have been reported in patients with guillain-barré and miller fisher syndrome. some researchers (nobile-orazio et al., ) reported igm anti-gscs antibodies in multifocal motor neuropathy (mmn) and other chronic immune-mediated neuropathies. in ten of eleven mmn patients with anti-gm antibody, there was a decreased reactivity to gm /gd a compared to single antigen gm . similarly, in one of two chronic inflammatory degenerative polyradiculoneuropathy (cidp) patient with anti-gm antibody, there was a decreased reactivity to gm /gm , gm /gd a, gm /gd b, gm /gt b compared to gm . these relationships were defined negative interaction. in one cidp with anti-gd b antibody, anti-gm /gt b and -gm /gt b reactivity increased although gm and gm were negative (positive interaction). in japan, on the other hand, this correlation remains unclear. sera were investigated from one mmn patient ( y/o male) with anti-gm , and anti-gd a antibody, one cidp patient ( y/o female) with anti-gm , and one subacute sensory motor polyradiculoneuropathy ( y/o male) with anti-gd b, and anti-gq b. igm antibodies to gscs gm /gd a were tested with a mixture of gm and gd a (each pmol/well) as antigen. anti-gm /gd a antibodies were judged to have positive interactions when the optical density was . greater than the sum of the antibodies against individual gm and gd a, and negative interactions when the optical density was % or less compared to the antibodies against individual gm or gd a. antibodies to at least one combination of two of the six gangliosides (gm , gm , gd a, gd b, gt b, and gq b) were similarly tested and judged for positive or negative interactions. in one mmn, anti-gm /gd a had negative interactions. in one cidp, anti-gm /gd a, and anti-gm /gq b had negative interactions. in one subacute sensory motor polyradiculoneuropathy, various anti-gscs antibodies including gd b or gq b had negative interactions. in the cidp patient mentioned above, anti-gm /gt b or anti-gm /gt b had no positive interactions. the relationship between this attenuated reactivity presumably driven by adjacent gangliosides and the mechanism of chronic immune-mediated neuropathies needs to be clarified. galino j , cervellini i , zhu n , stöberl n , fricker fr , lee g , hütte m , lalli g , bennett dl . the nuffield department of clinical neurosciences, john radcliffe hospital, university of oxford, oxford, uk; wolfson card, king's college london, guy's campus, london, uk. schwann cells (scs) are the myelinating cells in peripheral nerve system and are important for normal peripheral nerve development and repair. rala and ralb are small gtpases that have been implicated in neural tube closure, neurite branching and have been described as upstream effectors of proteins involved in cell migration and membrane dynamics. due to their potential role in sc function here we investigated, by genetic ablation in transgenic animals of one or both gtpases, their importance in sc function in adulthood and in nerve repair. we showed that ral gtpases are dispensable for sc function in the naïve state. however ral signalling (provided by rala or ralb) is required for effective remyelination of axons following nerve injury. moreover, absent ral signalling produced defects in axon reinnervation of distal organs and a delay in motor function recovery after nerve injury. we also studied the ral dependent cellular mechanisms that may be responsible for impaired sc remyelination and noted abnormal sc lamellipodia formation that prevent normal axial and radial axon remyelination. this work demonstrates for the first time a novel mechanism for ralgtpases that controls sc lamellipodia formation and their importance in normal sc function during peripheral nerve repair. garcía-lareu b , , , ariza l , cobianchi s , , chillón m , , , , navarro x , , , bosch a , , . tumor necrosis factor (tnf) alpha has been implicated in the pathogenesis of diabetic peripheral neuropathy (dpn), among other inflammatory demyelinating diseases and neuropathic pain. tnf alpha is a pro-inflammatory cytokine that can act at several stages in the demyelination process. it is produced by schwann cells (scs) in the peripheral nervous system (pns) after nerve injury and released into the local environment to attract and activate macrophages at the site of injury, contributing to wallerian degeneration. in vivo studies demonstrated a local inflammation in the sciatic nerve of rats after injection of tnf alpha, followed by demyelination and axonal degeneration. furthermore, the application of tnf alpha resulted in acute mechanical hiperalgesia, a main characteristic of neuropathic pain and therefore tnf alpha is postulated as a biomarker for painful changes after nerve injury. with the aim to characterize tnf alpha effects in chronic neuropathic pain and in diabetic neuropathy, a transgenic mouse model overexpressing tnf alpha cdna under the peripheral myelin protein p promoter was generated. here we characterized the overexpression of tnf alpha in myelinated scs at different stages of myelination (postnatal days , and ) showing that high levels of tnf alpha in sciatic nerve leads to the downregulation of the major pns myelin proteins (p , mbp, pmp , mag) compared to wild type mice, correlating with the loss of structured myelin and an increase in p ntr, a marker for immature and non-myelinated scs in the sciatic nerve. iba staining showed high levels of macrophage infiltration in both sciatic nerve and spinal cord tissues, compared with wild type animals. stress conditions were induced by sciatic nerve crush surgery after which recovery and subsequent remyelination were delayed in the transgenic mice, as evaluated by the sciatic functional index (sfi) and electrophysiological tests. on the other hand, mechanical and thermal nociception seemed to be unaltered, with or without lesion. this model could be helpful in the characterization of the role tnf alpha in pain development, injury and dpn as well as in developing efficient therapeutic strategies to modulate such pathological conditions. garcía-sobrino t , , blanco-arias patricia , , vidal-lijó mp , quintáns bea , , sobrido mj , , pardo j , . department of neurology, hospital clínico, santiago de compostela, spain; neurogenetics research group, instituto de investigaciones sanitarias (idis), santiago de compostela, spain; genomic medicine group (u ), centre for biomedical network research on rare diseases (ciberer), spain; department of neurophysiology, hospital clínico, santiago de compostela, spain. charcot-marie-tooth (cmt) disease is a genetically heterogeneous group of hereditary motor and sensory neuropathies. more than genes were involved in the disease pathogenesis. the objective of this study was to assess the genetic distribution of cmt disease in galicia (northwestern spain). patients were diagnosed as cmt if they had a consistent neurological and/or neurophysiological examination or if they had sensory motor neuropathy with a positive family history. a total of cmt adult patients ( % females) were evaluated with a median age of [ - ] years. the molecular diagnosis was achieved in patients ( %) with a higher success in cmt ( %) than cmt ( %). globally, pmp duplication was the most frequent finding ( %), followed by mutations in mpz ( %), mfn ( %), gjb ( %) and gdap ( %). in cmt , with expception of the pmp duplication, pathogenic variants in egr , nefl and mpz gene were most common. pathogenic variants in mfn and gdap accounted for % of cmt patients. several patients referred to our institution as cmt were diagnosed as hereditary motor neuropathy (hmn) and pathogenic variants in the bscl gene were the most frequent. pathogenic variants not previously related to cmt were identified in mpz, mfn , gjb , egr , nefl and sh tc genes. sporadic or autosomal recessive (ar) cmt accounted for the % of all diagnoses. the genetic epidemiology of cmt in galicia follows a similar pattern to other populations, although some remarkable features are axonal gdap and demyalinating egr pathogenic variants as well a seemingly elevated proportion of ar cases. mutations in mpz gene are associated to a wide range of phenotypes. the r c, in particular, is associated to a severe and early onset disease. some cmt patients respond to immunosuppressive or immunomodulatory treatment, some of them harbouring mpz mutations. we present the case of a -year-old brazilian female with a severe cmt b (r c) that presented an acute episode of worsening after a febrile exanthematic disease. she complained of tingling, stopped walking without support, and could not raise her arms. her emg showed an asymmetrical reduction of motor cv, reduced amplitudes, severe temporal dispersion and possibly conduction block. csf protein was mg%, with normal cell count. diagnosed as gbs, she received ivig. curiously, she markedly improved, regaining the functional status of youth, recovering functions that she had long lost. on emg, motor amplitudes improved significantly, but cv remained the same. reviewing carefully her past history, we identified some motor fluctuations along her adult life. at age , while pregnant, she developed positive sensory symptoms, became unable to get up from the chair and could not walk without assistance. after delivery, she improved, but did not return to baseline. one year later, she presented a new transitory functional worsening after an influenza illness. her parents were healthy but two out her children have a severe cmt. her first daughter never walked and died at the age of six. six months after treatment with ivig, she faced a new relapse. we pulsed with corticosteroids, with great response. she remains stable to date, four months after treatment. the episodic fluctuations and the evident response to treatment clearly suggest an associated immunomediated process. the fast improvement of the amplitude with maintenance of cv suggests that another mechanism in addition to demyelination and axonal degeneration is involved. we propose the existence of an associated channelopathy. funded by cnpq, faepa, pronas (ministry of healthy) gbs is an acute, immune-mediated neuropathy that comprises three major subtypes: aidp, aman, and amsan. on clinical grounds, this distinction is based on nerve conduction studies (ncs): aidp is a demyelinating neuropathy, aman is an axonal motor neuropathy, and amsan, an axonal sensory and motor neuropathy. recently, it has been demonstrated that axonal gbs, in addition to axonal degeneration, may present conduction block (cb) that can progress to axonal regeneration or revert, characterising a reversible conduction failure (rcf), a finding usually associated to good prognosis. patients presenting axonal cb are frequently diagnosed as having aidp, a mistake that can be avoided with two sets of ncs, one as early as possible and the second after three weeks of disease. following these recommendations, we retrospectively classified a brazilian group with gbs followed in our institution that had been submitted to two ncs sets. from september to january , patients fulfilled clinical criteria for gbs at clinical hospital of ribeirão preto and had more than one ncs accomplished. at least four motor nerves (median, ulnar, peroneal, and posterior tibial) and five sensory nerves (medial, ulnar, radial, sural, and peroneal superficial) were evaluated in each examination, according to routine procedures. first ncs revealed patients with aidp ( %), cases of axonal gbs ( aman, amsan, %), and patients with equivocal results ( %). at follow-up study, patients ( %) had their classification changed. the main shifts were from aidp to axonal group and from equivocal results to aidp. aidp increased to % (n = ), axonal gbs increased to % (n = , aman, amsan), and there were no more equivocal patients. although the majority of studies have shown that aidp is more frequent in western countries while axonal gbs predominates in eastern countries, we found a different pattern of distribution in our population, with predominance of the axonal subtypes. the considerable increase of axonal gbs at follow-up studies reinforces that serial emg are mandatory for accurate diagnosis of gbs subtypes. prospective studies are now being carried out in order to confirm these results. in amyloid light chain (al) amyloidosis, misfolded light chain (lc) accumulates and causes progressive peripheral neuropathy (pn) and progressive failure of critical organs such as the heart and kidneys. progressive ascending sensorimotor neuropathy is often a related clinical finding. the deposition of toxic lc amyloid in peripheral nerves is associated with paresthesias, pain, muscle weaknesss, orthostatic hypotension, and diarrhea or constipation in approximately % of patients with al amyloidosis. there are no approved treatments for al amyloidosis. current therapeutic approaches for al amyloidosis are intended to limit lc production but do not directly target misfolded lc deposited as amyloid in organs. we report phase / trial results of neod , an investigational monoclonal antibody that targets misfolded lc and may neutralize circulating lc aggregates and clear insoluble deposits. trial inclusion criteria were one or more plasma cell-directed treatment completed before enrollment, partial or greater hematologic response to any previous therapy, and persistent organ dysfunction. neod was administered intravenously every days during a dose-escalation phase ( patients; . , , , , , , or mg/kg in a + study design) and an expansion phase ( patients; mg/kg). we assessed safety, tolerability, pharmacokinetics, immunogenicity, organ responses based on consensus criteria, and pn responses using the neuropathy impairment score-lower limb (nis-ll). neod treatment was not associated with dose-limiting toxicities or serious adverse events, drug-related discontinuations, or antidrug antibody development in any patient (n = ). of patients with measurable pn at baseline (n = ), % achieved pn response based on the nis-ll score after months of treatment, which resulted in a median % nis-ll score reduction (mean baseline nis-ll, . ). in a best response analysis, % of cardiac-evaluable patients (n = ) and % of renal-evaluable patients (n = ) met respective criteria for organ response. improvements in neuropathy have not been previously shown in al amyloidosis. these results demonstrated that monthly neod infusions were safe, well tolerated, and associated with responses across three different organ systems. gervais cbl , ross ma , goodman bp , khoury ja , muzyka i , smith be . mayo clinic in arizona, scottsdale, az, usa. this work describes clinical, examination and electrophysiologic findings in a cohort of patients with length dependent sensorimotor peripheral neuropathy (ldsmpn) with ventral abdominal sensory loss. ldsmpn affects the longest nerve fibers, namely those innervating structures in the feet and hands. what is less well appreciated is that length dependent involvement of sensory nerve fibers in ldsmpn from the thoracic segments gives rise to ventral abdominal sensory loss. consecutive patients seen for ldsmpn (n= ) were evaluated for the presence or absence of ventral abdominal sensory loss. demographic variables, symptoms and quantitative neurologic findings (neuropathy impairment score [nis]) were examined using descriptive statistics. final diagnoses were noted. ventral abdominal sensory loss to pinprick (which was asymptomatic in all patients tested) was documented in / ldsmpn patients ( . %), mean age was . years (range - ), m:f gender ratio was . ( : ), mean nis was . (range - ), ncs/emg abnormalities were found in / patients (the remaining showing objective evidence of small fiber sensory involvement). ldsmpn patients without ventral abdominal sensory loss (n= ) had a mean age of . (range - ), m:f of . ( : ), and mean nis of . (range - ). no patient ( / ) had dorsal torso sensory loss between the shoulder and buttock levels on either side. diagnoses of the ldsmpn patients with vs. without ventral abdominal sensory loss included charcot marie tooth or other hereditary neuropathy (n= vs. ), abnormal carbohydrate metabolism (n= vs. ), idiopathic (n= vs. ), hypothyroidism (n= vs. ), inflammatory (n= vs. ) and other (n= vs. ). ventral abdominal sensory loss appears to be common in patients diagnosed with ldsmpn of a variety of causes including inherited neuropathies; in addition to those innervating distal limb territories, distal sensory fibers from the thoracic region represent another category of length dependent involvement in ldsmpn; ) the clinical examination of ldsmpn should include the ventral abdomen. gibbons c , garcia j , casasola m , freeman r . beth israel deaconess medical center, harvard medical school, boston, usa. objective: to determine the relationship between measures of autonomic function, electrochemical sweat conductance (esc) and intra-epidermal (ienfd) and sudomotor nerve fiber density (sgnfd). background: structural and functional measures of small fiber neuropathy have been studied in patients with diabetes, but little information comparing these techniques exists. design/methods: we studied patients with diabetes (ages ± yrs, gender f) and healthy control subjects (age ± yrs, gender f). subjects underwent examination scores (nis-ll), quantitative sensory testing, autonomic testing (heart rate variability, valsalva maneuver, tilt test), esc, and millimeter punch skin biopsies at the distal leg and distal thigh for ienfd & sgnfd. results: there were strong correlations between exam scores (nis-ll) and biopsy ienfd (r=− . , p< . distal leg; r=− . , p< . distal thigh), and sgnfd (r=− . , p< . distal leg; r=− . , p< . distal thigh). moderate correlations were noted between exam scores and qst (r values . - . , p< . ), ienfd and qst (r= . - . ). modest correlations were noted between esc and parasympathetic function (r= . - . , p< . ). modest correlations were noted between esc and ienfd (r= . , p< . , but only at the distal leg) and esc and nis-ll (− . , p< . ). no correlations between exam scores and autonomic function were noted. no correlations were detected between esc and sgnfd (r=− . - . ) or esc and sympathetic adrenergic function (r= . ). conclusions: differences between tests are expected based on our understanding of the pathophysiology and natural history of diabetic neuropathy. exam scores, qst results and biopsy results do correlate, and are consistent with prior studies. in contrast, there was little relationship between tests of autonomic function and exam scores, similar to prior studies and our understanding of autonomic function and differences in p. esc had little correlation with either exam scores or biopsy ienfd or sgnfd. there was a modest correlation between esc and parasympathetic function. the exact relationship between esc and diabetic peripheral neuropathy is not clear, and further research studies are needed to determine the role this technique has in clinical practice. objective: to determine the optimal tissue thickness of skin biopsy sections for studies of cutaneous nerve fibers. background: although analysis of intra-epidermal nerve fiber density (ienfd) is routinely reported using μm thick tissue sections, many recent studies of peripheral alpha-synuclein deposition use or μm frozen sections, or μm paraffin embedded tissue sections. design/methods: we compared the results of biopsies from patients with parkinson's disease (pd), using tissue sections each of , and μm thickness. tissues were stained with pgp . and stained for phosphorylated alpha-synuclein (p-syn). the total number of dermal structures (hair follicles, sweat glands, pilomotor muscles) were quantified, nerve densities analyzed, and the frequency of p-syn positive results. we also studied μm paraffin embedded tissue samples from patients with pd. results: in the biopsies of patients with pd there were no differences in the number of sweat glands, hair follicles or pilomotor muscles in , or μm sections. there were significantly fewer blood vessels noted in and μm sections compared to μm sections (p< . ). ienfd and sgnfd declined with tissue thickness (p. . , all) and there was increased variability in results in thinner tissue sections. there was a highly significant reduction in p-syn positive sections in thinner tissue sections (p< . , all tissues compared to μm sections). paraffin embedded tissue sections had significantly lower nerve densities and positive p-syn results (p< . ) compared to all frozen tissue sections of , and μm thickness. thinner tissue sections carried a greater risk of false positive result or indeterminate results due to difficulty interpreting overlap with pgp . . conclusions: tissue sample thickness plays a critical role in interpretation of skin biopsy results. thinner tissue sections, or paraffin embedded tissue sections, do not provide equivalent data and significantly underestimate nerve densities and positive alpha-synuclein results with increase false positive results despite similar numbers of dermal tissue structures. ace- is an investigational protein therapeutic that acts as a localized ligand trap for myostatin and other negative regulators of muscle growth. local injection of ace- into the gastrocnemius muscle of wild-type, mdx, and sod mice produced dose-dependent increases in muscle mass and force without systemic effects. in a phase single-center, double-blind, placebo-controlled dose escalation study in post-menopausal women, unilateral injections of ace- into the rectus femoris (rf) or tibialis anterior (ta) muscle were generally safe and well tolerated. mean percent changes from baseline in muscle volume of the injected muscle were + . % in the rf and + . % in the ta at the highest dose administered with minimal changes observed in the contralateral side and placebo-treated subjects. frequent related aes (≥ %) included injection site pain, pain in extremity, injection site discomfort, and muscle twitching, with similar incidence in ace- and placebo-treated groups. all aes were grade - and reversible. together, these preclinical and clinical results support further studies of ace- in myogenic and/or neurogenic diseases with focal loss of muscle strength and function, including cmt. a phase study is ongoing in facioscapulohumeral muscular dystrophy (fshd). study a - is an ongoing multicenter, two-part, phase study to evaluate the safety, tolerability, pharmacodynamics, efficacy, and pharmacokinetics of ace- in patients with cmt and cmtx. part is open-label and will enroll up to dose-escalating cohorts ( patients per cohort); part is randomized, double-blind, and placebo-controlled, and will enroll an additional patients. ace- will be administered bilaterally to the ta muscle once every three weeks for up to five doses. a safety review team will meet periodically throughout the study to review safety data and make dosing recommendations, including the recommended dose level for part . eligible patients must have genetically confirmed cmt or cmtx with mild-moderate weakness in ankle dorsiflexion. safety and tolerability will serve as the primary outcome for part , muscle volume evaluated by mri for part . additional outcome measures of interest include strength by quantitative muscle testing, function by motor tests, and quality of life by the cmt-health index questionnaire. our study was aimed to evaluate the functional and morphological consequences of cellular and humoral responses in chronic inflammatory demyelinating neuropathy (cidp), using extensive standardized high-resolution sonography (hrus) and nerve conduction study (ncs) protocols in incident treatment-naive patients. we enrolled consecutive, newly diagnosed, treatment naive patients with cidp. in addition to all relevant clinical examinations, all patients underwent a standardized ncs and extensive hrus protocol, of median, ulnar, tibial, fibular and sural nerves. we assessed standard nerve and fascicle size, and echogenicity. we found focal sonographic enlargements in multiple nerves and nerve segments with and without ncs abnormalities. the degree of nerve hypertrophy was not associated with presence of ncs features of demyelination, i.e. / ( %) of median nerve segments showed enlargement without strong decrease in motor conduction velocity and / ( %) hypertrophic median nerve segments revealed no conduction block. a lower distal cmap of median nerve was related with lower mrc sums-scores (p < . ). we found no correlation between age, disease duration or mrc sum-score and nerve size. cellular and humoral responses in cidp may lead to nerve enlargement along the length of nerves, that can be detected by hrus, whereas ncs allows identification of its' specific focal disruption in nerve function. the most common complication of diabetes is peripheral neuropathy, which has prevalence as high as % and is characterized by damage to neurons, schwann cells and blood vessels within the nerve. the concept of schwannopathy as an integral factor in the pathogenesis of diabetic neuropathy is re-emerging, and it is now known that schwann cells cultured in hyperglycemic environments underproduce neurotrophins and exhibit loss of axonal associations, further indicating a non-optimal glial cell activation and function. furthermore, the increased expression of p ntr in myelin sheaths around fibers that are susceptible to axonal degeneration in diabetic neuropathy suggest an important role for this molecule in disease progression. with this project, it is our main goal to evaluate how disruption of p ntr signaling in the schwann cells affects the pathophysiology of diabetic neuropathy. by using a fluorescent live/death cell viability assay, our preliminary data indicate that wild-type schwann cell cultures present increased cell death rate h after stimulation with high levels of glucose. the p ntr has a highly recognized role in the activation of death signals and when absent, we observed that schwann cells are significantly more resistant to apoptosis in hyperglycemic conditions. the role of p ntr receptor signaling in neuron-schwann cell communication and myelination under in vitro diabetic conditions was investigated with primary schwann cell-sensory neuron co-cultures. after eight days of ascorbic acid stimulation, both under euglycemic and hyperglycemic conditions, myelination was assessed by confocal microscopy using specific markers for neurons and myelin. results highlight a compromised ability of wild-type schwann cells to myelinate axons when exposed to a hyperglycemic environment, which was even intensified in co-cultures with schwann cells lacking the p ntr . to complement the in vitro studies, we are modeling type diabetes in a p ntr schwann cell conditional ko mouse model and plan to investigate nerve mrna expression profile to disclose genetic regulation depending on this receptor signaling and its modulatory role in endoneurial hypoxia and neuroinflammation. the results from this project will provide an integrated vision of how impaired schwann cell activity guides neuropathy progression. gondim faa , barreira aa , cruz mw , cunha fmb , de freitas m , frança mc jr , marques w jr , nascimento ojm , oliveira asb , pereira rc , pupe c , rotta ft , schestatsky p . panelists on behalf of the scientific department of peripheral neuropathy, brazilian academy of neurology, brazil. neuropathy is one of the most common neurological manifestations of several diseases and sfn has been progressively receiving more attention in the medical literature. the aim of this study is to generate a set of recommendations to define and diagnose sfn in brazil. a group of neurologists, members of the scientific department of peripheral neuropathy from the brazilian academy of neurology reviewed a preliminary draft prepared by the first author that was distributed by email. the panelists got together on . . at the city of fortaleza, brazil, to discuss and finish the text for the first submission of the manuscript. sfn can be defined as a subtype of neuropathy characterized by selective involvement of unmyelinated or thinly myelinated sensory (sometimes also autonomic) fibers. it is usually characterized by sensory (pain/dysesthesias/pruritus) or combined sensory and autonomic complaints, associated with an almost entirely normal neurological examination (except for sensory changes). electromyography is normal. a growing list of medical conditions has been linked to sfn, although there is no evidence-based literature to support the use of any specific set of screening tests to diagnose the etiology of sfn (the panelists will suggest a basic screening panel). sfn may also serve as a fallacious but useful terminology to uncover discrepancies in the normal values from different neurophysiology laboratories. in brazil, skin biopsy is not usually performed and initial forms of leprosy may have predominant small fiber involvement. there are several tests to demonstrate involvement of small sensory and autonomic fibers. skin wrinkling test, sympathetic skin responses & heart rate variability (conducted on emg machines) and thermoregulatory sweat test may be low-cost screening alternatives. after the final meeting on . . , we finished the first draft for submission to arquivos de neuropsiquiatria (together with a translation to portuguese as supplementary material), the official journal of the brazilian academy of neurology to serve as a source for the definition and diagnosis of sfn in brazil. the final draft will be submitted after presentation at the pns meeting in barcelona on . . the lower cranial nerves (lcn) include the paired glossopharyngeal, the vagal, the accessory and the hypoglossal nerves. these are involved in the execution of swallowing, speech, phonation, tasting, as well as sensory and autonomic functions. lcn can be affected in central and peripheral nervous system diseases. this study investigates the use of ultrasound (us) to detect lesions of the peripheral course of lcn. in addition mri can be used in unilateral lcn local lesions to demonstrate indirect signs of nerve lesions such as muscle atrophy. the patients were examined in supine position with the neck in maximum extension with either a regular or a portable us system (logiq e and logiq e ge healthcare, milwaukee, wisconsin) and high frequency transducers ( to mhz). according to the detected pathology longitudinal or transversal images were recorded. a series of exemplary observations are demonstrated. in one case a paraganglioma in the glossopharyngeal nerve at the carotid sinus was found. in another patient an us of the thyroid gland revealed a nerve tumor, which was later identified to be a schwannoma. in another case multiple neurofibroma were identified in the vagal nerve during a routine neurofibromatosis screening. us has become also important in investigations of lesions of the accessory nerve, following damage by surgery. nerve continuity and scar formation can be distinguished. lesions of the hypoglossal nerve can be caused by tumor infiltration. in one patient an infiltration of the nerve by a squamous cell carcinoma, and in another case by a low grade sarcoma were detected. in addition mri demonstrated an atrophy of the tongue. identification and assessment of the lcn from the point of exit of the skull to their endpoint can be pursued by us techniques, which have been described for the individual nerves. us is easily applicable and -in addition to the "static" image of the mri -allows assessing nerve positions during different movements, as well as detecting muscle movements as fasciculations. mri can also be used to detect not only more proximal lesions, but also changes of the skeletal muscle by denervation. grümme l , hattenhauer st , wolffram k , kleinschnitz c , mausberg ak , stettner m . university hospital essen, essen, germany; heinrich-heine-university, düsseldorf, germany. in chronic inflammatory demyelinating polyneuropathy (cidp), t cells are suspected to play a crucial role in myelin destruction. cd and cd t cells contribute to the inflammatory process, while the exact mechanism of myelin damage is still under debate. to elucidate the molecular interaction of t cells and myelin sheets, we compared neuritogenic and control cells in a live imaging in vitro model. the myelinated fibres of rat dorsal root ganglia (drg) served as model for the peripheral nervous system. drgs of embryonic (e ) lewis rats were cultured; myelination was initiated after one week in vitro and continued for two additional weeks. lewis rats immunized with p and neuritogenic t cells of the lymph nodes were obtained ten days after immunization. control t cells were prepared from healthy rats. for vital tracking, neuritogenic t cells were stained with orange cell tracker, while the control cells were labelled with cfse. myelin detection in vital cultures was assessed by incorporation of c fatty acids conjugated with a fluorophore into the myelin layer. experiments were performed in a conditioned microscope chamber, the two t cell populations were added simultaneously to the drg culture and migration was tracked using live cell imaging. we observed differing migration patterns for neuritogenic and control t cells. the velocity as well as the directionality was altered. after initial contact, the non-neuriotgenic t cells in close proximity to myelin subsequently decreased over time, while the numbers of neuritogenic t cells close to myelin remained stable. long term incubation with neuritogenic t cells affected the myelin integrity in regard to the intermodal length as well as the myelin ratio. further experiments will elucidate the specific effects of neuritogenic t cells to decipher the role of t cells during inflammation in the pns, which could be useful in developing targeted therapies. gundapaneni b , sultan mb , keohane dj , schwartz j . inventiv health inc., burlington, ma, usa; pfizer inc., new york, ny, usa. transthyretin familial amyloid polyneuropathy (ttr-fap) is a rare, life-threatening disorder caused by protein destabilizing ttr gene mutations, broadly classified as val met (the most common mutation worldwide) and non-val met genotypes. tafamidis, a highly-specific ttr-stabilizer, is the only medicine approved to delay neurologic progression in ttr-fap. the objective of this post-hoc analysis was to compare the effects of tafamidis on neuropathy progression in patients with val met and non-val met genotypes. val met patients were participants in a randomized, double-blind, placebo-controlled clinical trial of tafamidis, while non-val met patients were participants in an open-label tafamidis study. patients were grouped into three cohorts: val met tafamidis (n= ); val met placebo (n= ); and non-val met tafamidis (n= ). baseline disease severity and change in disease severity from baseline to month was assessed using the neuropathy impairment score-lower limbs (nis-ll). the effect of tafamidis in the val met and non-val met cohorts versus the val met placebo cohort was determined using a mixed-effects model for repeated measures (mmrm). at baseline, patients in the non-val met cohort were older, had longer symptom duration, and more advanced neurologic impairment than the val met cohorts. at month , the baseline-adjusted mean ± standard error change in nis-ll was comparable between the val met tafamidis and non-val met tafamidis cohorts ( . ± . and . ± . , respectively). these changes were smaller than that observed in the val met placebo cohort ( . ± . ; p= . vs val met and p= . vs non-val met) indicating less disease progression. based on predicted values from the mmrm analysis, the size of the change in nis-ll across the full range of baseline nis-ll scores was remarkably similar in the val met tafamidis and non-val met tafamidis cohorts and was consistently smaller than that observed in the val met placebo cohort. moreover, in all three cohorts, as baseline nis-ll increased, the predicted level of disease progression also increased. in conclusion, while controlling for baseline disease severity, tafamidis delayed disease progression to a comparable extent in val met and non-val met patients. the similar trajectories of disease progression across val met and non-val met patients suggest that these two genotype groups may be more similar than previously considered. clin-icaltrials.gov identifiers: nct ; nct . gutmann l , shy m . university of iowa, iowa city, ia, usa. post tetanic potentiation (ptp) is a physiological phenonmenon seen with disorders of the neuromuscular junction (nmj). it is caused by the influx of ca++ into the terminal axon during the tetanus resulting in an increased number of acetylcholine (ach) vescicles released by each axonal action potential. in myasthenic syndromes it results in improved nmj function by increasing the probability of achieving a large enough end plate potential to generate a muscle action potential. ptp has different appearances depending on whether the nmj defect is pre-synaptic or post-synaptic. in pre-synaptic defects (the most common being lambert-eaton syndrome) there is an increased amplitude of the muscle action potential after a tetanus that persists up to minutes. prolonged ptp has now been reported in disorders, one on a genetically determined neuropathy/myasthenic basis and the other on an acquired toxic origin. prolonged ptp up to minutes was reported in families with a motor neuropathy (having leg weakness and foot deformites) and a congenital myasthenic syndrome caused by a heterozygous mutation of the synaptotamin ii (syt ) gene (c t>g p.pro [p.asp ala] and c g>a [p.pro leu]). electrophysiological testing showed features of a presynaptic defect with prolonged ptp persisting up to minutes. the same phenomenon has been noted in the acquired pre-synaptic defect caused by botululinum toxin. the ptp continued up to minutes. syt is the synaptic vescicle calcium sensor in the terminal axon, allowing for fusion of ach containing vescicles with the presynaptic membrane and the synchronous release of ach. the fusion requires a complex assembly process involving snare proteins. both the syt gene mutation and botulinum toxin affect normal syt function, the mutation by altering amino acids in the calcium-binding domain and the toxin by binding to syt as well as gangliosides gd a and gt b on the neural membrane. the mechanism for the ptp prolongation remains unknown. prolonged ptp appears to be a unique physiological abnormality resulting from altered syt . this phenomenon has been decribed to occur in syt mutations causing congenital motor neuropathy/myasthenic syndrome and botulism. the abnormality may represent a physiological marker for a presynaptic nmj defect involving altered syt . hachisuka a , , senger j , curran m , chan km , . division of physical medicine and rehabilitation, university of alberta, edmonton, canada; department of rehabilitation and medicine, university of occupational and environmental health, kitakyushu, japan; division of plastic surgery, university of alberta, edmonton, canada. background: motor unit number estimation (mune) techniques are valuable tools in neuromuscular disease. among them, the multiple point stimulation (mps) is one of the most common used. contamination by distant single motor unit potentials (smups) generated by neighboring muscles is a potential confounding factor. this is particularly problematic in ulnar neuropathy, one of the most common neuropathies in humans. reason being that the ulnar nerve innervates the majority of hand muscles. the goals of this study are to test the hypotheses that ) distant smups all have an initial positive deflection and ) elimination of smups generated by distal muscles will significantly lower the mune results in the hypothenar muscles. methods: to address the first hypothesis, we tested subjects by stimulating their median nerve while recording smups simultaneously over the hypothenar and thenar muscles. for the second hypothesis, we carried out mps mune of the hypothenar muscles using multi-channel recordings placed over ulnar innervated intrinsic muscles across the hand. when a smup with an initial positive deflection was detected at the hypothenar electrodes, its original was systemically tracked through all the recording channels. results: in the first series of experiments, in accordance with the dipole theory, all smups recorded at the hypothenar recording electrodes had an initial positive polarity. in the second series of experiments, of the studies carried out in subjects, distant smups generated by muscles other than those in the hypothenar eminence represented ± . % (mean±sd) of the overall sample. mune calculated using only smups generated by the hypothenar muscles was ± , compared to ± if all smups were included (p < . ). the extent of increase in mune was highly correlated with the proportion of distant smups found in each study (r = . , p < . ). conclusion: in contrary to some studies suggesting that smups from distant muscles could have an initial negative deflection, we found all smups from distant muscles had a positive deflection. exclusion of those smups from the sample had a significant impact on the mune results. hagiwara w , konno s , kihara inoue m , fujioka t . toho university, tokyo, japan. matrix metalloproteinase (mmp) plays crucial roles in developing immune-mediated neuritis as guillain-barré syndrome (gbs) and its animal model experimental autoimmune neuritis (ean). to investigate the intraneural expression of mmps during ean and the effect of a phosphodiesterase- inhibitor cilostazol (clz) on it, ean rats were treated with either mg/kg/day of clz or vehicle from one day post immunization (dpi). to induce ean female lewis rats were immunized with synthetic peptide from bovine p protein. cauda equina (ce) were removed in several time points, total rna was extracted and reverse-transcribed to obtain cdna that was subjected to real-time pcr analysis for expression of mmp- , mmp- and tissue inhibitor of matrix metalloproteinase- (timp- ) messages. mmp- and mmp- messages peaked at dpi, that is presymptomatic phase of ean. all rats developed motor paralysis at dpi, mmp- and mmp- messages subsided at this moment. however, timp- message reciprocally increased at dpi, persisted through dpi. treatment of clz suppressed motor paralysis of ean significantly. mmp- message peaked at dpi and mmp- message peaked at dpi. on the other hand, both messages at dpi were suppressed compared to untreated ean rats. timp- message in clz treated rats peaked at dpi coincided with motor paralysis peak. both mmp- and mmp- messages might result in subsequent upregulation of timp- that finally downregulates mmps activity and inflammatory process. clz treatment suppressed and delayed expression of mmps and facilitate timp- expression, resulting suppression of ean. the precise mechanism of expression of mmps and timp- remain unclear, however, that mmp- and mmp- messages peaked at dpi suggests involvement of pro-inflammatory cytokines such as tumor necrosis factor-alpha or interleukin- . clz might suppress these cytokines resulted in mmps down regulation. mmp- less affected by clz and thus stimulated timp- expression at dpi. clz might rational treatment for immune-mediated neuropathy via mmps modulation although further investigation especially in-vivo study is needed. haidar m , de winter v , asselbergh b , bouhy d , timmerman v . peripheral neuropathy research group, vib, university of antwerp, antwerp, belgium. the small heat shock protein hspb (hsp ) gene is ubiquitously expressed and encodes for a chaperone protein with essential cellular functions. our lab was the first to identify missense mutations in hspb responsible for axonal charcot-marie-tooth neuropathy (cmt f). since then we became interested in understanding the physiological functions of hspb and its association with cmt neuropathies. we demonstrated the involvement of hspb in microtubule stability. because of the link between autophagosome formation and its intracellular transport, and microtubules stability, we believed that the macro-autophagy process could be regulated by hspb . macro-autophagy is a cellular housekeeping process during which autophagosomes target, envelop and degrade aberrant protein aggregates and damaged organelles. there is strong evidence for an essential role for autophagy in the maintenance of neuronal homeostasis; hence its impairment can lead to a neuropathic condition. our data indicate that macro-autophagy is disrupted by hspb cmt-causing mutations. combining novel microscopy and interactomics techniques we unravelled the way different cmt-causing mutations in hspb impair the autophagic pathway. our data present the impairment of autophagy as a possible pathomechanism for cmt-causing hspb mutations. hajjar h , gautier b , berthelot j , gonzalez e , gess b , young p , tricaud n . institute of neurosciences of montpelllier, inserm, university of montpellier, montpellier, france; universitätsklinikum münster, klinik für schlafmedizin und neuromuskuläre erkrankungen, münster, germany. cmt a, the most common of charcot-marie-tooth diseases, results from the duplication of peripheral myelin protein (pmp ) gene. this gene encodes for a small protein of kda, pmp , mainly produced by schwann cells and the excess of pmp leads to demyelination. there is no cure for this disease but one approach for a treatment is gene therapy. a transgenic rat model exists for cmt a, which possesses copies of the mouse pmp gene. our goal is to provide a proof of principle for gene therapy in peripheral nerves using this rat model of cmt a. our strategy is to reduce the overexpression of mouse pmp protein in rats schwann cells using short hairpin rnas (shrnas). shrnas are small non-coding rnas that specifically bind to targeted mrnas resulting in their degradation. we tested for the efficiency of several shrnas targeting mouse pmp in vitro to find two shrnas that reduce pmp levels. the shrnas have been cloned in an adeno-associated serotype (aav ) viral vector together with green fluorescent protein in order to detect infected cells. aav was selected for its high transduction rate of myelinating schwann cells, for its good diffusion and low immunogenicity. we plan bilateral injections in the sciatic nerve of control and diseased rats. the efficiency of this gene therapy will be checked by assessing muscle strength (grip test), way of walking (catwalk), mobility (rotarod) and nerve conduction velocity of treated cmt a rats versus non-treated. the process of myelination and myelin maintenance in schwann cells will be analyzed by biochemistry and electron microscopy. biochemical tests include western blot for pmp protein expression in sciatic nerve, immunohistochemistry for pmp protein expression in myelinating schwann cells and pcr for mrna pmp expression. if the therapy is successful in rats, it could possibly be later on used in clinical trials. ultrasound is a widely-used tool in diagnosing carpal tunnel syndrome (cts). several different methods for sonographical evaluation of median nerve damage exist, such as calculating the ratio of cross sectional areas (csa) of median nerves in various sites. this enables detection of actual nerve swelling proximal to the carpal tunnel as an expression of median nerve damage inside the carpal tunnel (as seen in cts). in comparison to other diagnostic methods no data exist about the prevalence of cts like changes in an unselected population. a series of non-selected fresh cadavers were examined. arms of fresh, non-embalmed whole body cadavers were examined. the medical record did not allow to obtain conclusive information on the peripheral nerves. using a regular ultrasound system with a mhz transducer, median nerves were identified and tracked along their course in the forearms. csa measurements of the median nerves were performed at two sites in each arm: .) halfway between the elbow joint and wrist, .) directly proximal to the carpal tunnel. csa ratio was calculated with the following formula: csa ratio = csa wrist (cm ) csa forearm (cm ) csa ratio < . was found in ( . %) arms, csa ratio ≥ . in ( . %) arms and csa ratio ≥ in ( %) arms. csa ratio ≥ . was detected in . % of women and % of men. the overall mean (± sd) age was . ± . years. men ( . ± . ) were significantly younger than women ( . ± . ; p = . ). a weak but significant correlation between age and csa ratio was found in women (spearman -− . ; p= . ), but not in men (p= . ). the mean bmi for csa ratio ≥ . was . ± sd . . based on a csa ratio ≥ . as a criterion for cts, the present ultrasound results are consistent with the average cts prevalence reported in previous studies, which were obtained with electrophysiological methods. this study on a large unselected series of cadavers confirms the comparability of both methods. instrumental activities of daily living (badl and iadl), falls and gait patterns in the large, prospective, population based rotterdam study. in total, participants of this study (mean age years, % women) underwent a polyneuropathy screening involving a symptom questionnaire, neurological examination and nerve conduction studies. screening yielded four groups: no, possible, probable and definite polyneuropathy. participants were interviewed about badl (stanford health assessment questionnaire), iadl (instrumental activities of daily living scale) and frequency of falling in the previous year. in a random subset of participants, gait was assessed with an electronic walkway (gaitrite). associations of polyneuropathy with badl and iadl were analyzed continuously with linear regression, and dichotomously with logistic regression. history of falling was evaluated with logistic regression and gait changes were evaluated with linear regression. we found that participants with definite polyneuropathy had more difficulty in performing badl and iadl than participants without polyneuropathy. polyneuropathy related to worse scores of all badl (especially walking) and three iadl components (housekeeping, traveling, and shopping). participants with definite polyneuropathy were two times more likely to fall, and these falls more often resulted in injury. participants with polyneuropathy had worse gait parameters on the walkway, including lower walking speed and cadence, and more errors in tandem walking. in summary, chronic polyneuropathy is strongly associated with significant impairment in daily life. recognition of polyneuropathy and related disability is very important in order to inform, support and possibly treat patients, and to prevent future falls and dependence in daily functioning. patients with polyneuropathy often suffer from tingling sensations, numbness, weakness and pain. these symptoms are used in several screening questionnaires, most of which were developed for high-risk patient groups, such as individuals with diabetes mellitus. in most tools equal weights are applied to all symptoms, while some might be more informative than others. we evaluated the diagnostic value and frequency of occurrence of individual symptoms of chronic polyneuropathy and constructed and validated a simple screening questionnaire that can reliably help to diagnose polyneuropathy in low-risk patient groups. in a multi-step procedure, we initially compiled a twelve-item questionnaire concerning symptoms of polyneuropathy. the questionnaire was completed by polyneuropathy patients and controls (headache, transient ischemic attack, multiple sclerosis). we calculated the sensitivity, specificity and likelihood ratios of each individual symptom. next, stepwise multivariable logistic regression was used to create a compact model, able to discriminate cases from controls using only the most informative symptoms. a simple scoring system was subsequently developed based on the regression coefficients of this reduced model. external validation was subsequently conducted in a population of cases with chronic idiopathic axonal polyneuropathy and controls without polyneuropathy. performance was assessed with discrimination (area under the curve, auc), and calibration. numbness and tingling feet were most frequently reported by polyneuropathy patients and had the highest sensitivity. feeling as if walking on cotton wool and allodynia of the feet had the highest specificity. multivariable logistic regression yielded a model that contained these four symptoms, complemented with balance problems and tingling hands. based on this regression analysis, the erasmus polyneuropathy symptom score (e-pss) was created, a score ranging from to . this polyneuropathy symptom score had a good performance (auc . ) in de derivation set and proved to be valid in the external population (auc . ). in this study, we created a simple, validated polyneuropathy symptom score (e-pss) that takes both the individual value of only six different symptoms and its frequency into account. this tool can be helpful as screening instrument in clinical practice and for future studies on polyneuropathy. multiple sclerosis (ms) is traditionally viewed as a central nervous system disease. to date, there is no unequivocal evidence implicating involvement of the peripheral nervous system (pns). this study aims to prove whether the pns is additionally affected and if so, to detect, localize and quantify these peripheral nerve lesions in patients with multiple sclerosis (ms) by applying high-resolution mr-neurography (mrn) with large anatomical coverage in combination with standard electrophysiological and neurological tests. we prospectively enrolled patients with confirmed ms (> years), two patients with clinically isolated syndrome (cis), and age-/sex-matched healthy volunteers. any other potential causes for a concomitant polyneuropathy were excluded. all ms patients underwent detailed neurological and electrophysiological testing. tesla mrn with large anatomical coverage from lumbar plexus and spinal nerves down to ankle level was performed in all participants by using fat-saturated, t -weighted turbo-spin-echo (tse) sequences (tr/te / ms) and a dual echo tse sequence for t -relaxometry (tr ms; te /te / ms). a d t -weighted, fat-saturated space sequence (tr ms; effective te ms) was used for imaging of the lumbar plexus. manual segmentation of spinal/sciatic/tibial/peroneal nerves was performed on a total of , axial slices. besides evaluation of nerve t w-signal, detailed quantification of nerve lesions by analyzing morphometric (nerve caliber) and microstructural markers (proton-spin-density and t -relaxation-time) was conducted. mean lesion load at thigh level was higher in ms ( . ± . ) vs. controls ( . ± . ;p< . ). nerve proton-spin-density was also higher in ms (tibial/peroneal: . ± . / . ± . ) vs. controls (tibial/peroneal: . ± . / . ± . ;p< . ). in contrast, t -relaxation time was significantly higher in controls (tibial/peroneal: . ± . / . ± . ) vs. ms (tibial/peroneal: . ± . / . ± . ;p< . ). proximal tibial and fibular nerve caliber was also significantly higher in ms (tibial: p< . ; fibular: p= . ). for the first time, pns lesions in ms patients could be visualized and quantified in vivo by high-resolution mrn. lesions are indicated by an increase of proton-spin-density and a decrease of t -relaxation-time. nerve caliber as a morphometric criterion also significantly increased. this proof-of-concept study may offer new insights into the pathomechanism of ms and might have future implications on therapeutic approaches. immunoglobulin g (igg) fc-gammars confer diverse effector functions by linking the cellular and humoral arms of the immune system that has been involved in the pathogenesis of guillain-barré syndrome (gbs). in the post-polio era, the polymorphisms of fc-gammar and their relevant knowledge have become one of the main targets for new therapeutic strategies for the treatment of gbs patients. differences in severity and frequency of gbs subtypes found between south-asian and western populations can be attributed to their genetic susceptibility. therefore, we aimed to determine fc-gammar polymorphic alleles (fc-gammariia: h /r ; fc-gammariiia: v /f ; fc-gammariiib: na /na ) and their possible link with gbs on the currently available large gbs cohort in bangladesh. fc-gamma r polymorphisms of gbs patients and healthy controls were genotyped using sequence-specific pcr. for validation, we carried out the sequencing of some samples for fc-gammariia and fc-gammariiia alleles. no significant differences were found regarding the distribution of fc-gammar genotypes and allele frequencies in gbs patients and controls. fc-gammar-h/h- genotype was significantly predominant in patients with severe disease compared to patients with mild disease (p= . , or, . ; % ci, . - . ). no other significant associations were found in gbs patients for candidate alleles and disease severity. fc-gammariiia-f/f- was found to be significantly predominant in anti-gm antibody positive gbs patients compared to anti-gm antibody negative patients (p= . , or, . , % ci, . - . ). fc-gammariiia-v alleles were significantly higher in patients with poor prognosis when compared to patients with good outcome (p= . , or, . , % ci, . - . ). no significant association of fc-gammariiib genotypes and alleles were found with gbs patients, disease severity and disease outcome. extensive subgroup analysis revealed no significant association in genotype and allele frequencies between aman and aidp subtype. in conclusion, igg fc-gammar polymorphisms do not constitute significant risk markers for susceptibility to gbs, however homozygous fc-gammariia-h might be involved in the severe form of gbs. in addition, fc-gammariiia-f/f- might play an important role in the molecular mimicry against nerve gangliosides in gbs. further studies that enroll a large number of patients (e,g. igos) are required to confirm the present findings from different geographical areas. hayes jm , o'brien pd , backus c , feldman el . department of neurology, university of michigan, ann arbor, mi, usa. peripheral neuropathy (pn) is a common complication observed in patients with impaired glucose tolerance and type diabetes. male mice fed a high fat diet (hfd) develop metabolic impairments and pn serving as an appropriate animal model to study pn development and progression. it is well documented that female mice fed a hfd display a degree of protection against hfd-induced metabolic changes with mice retaining relatively normal insulin sensitivity. this protection is attributed to differences in fat accumulation and to the anti-diabetic effects of estrogen. based on these sex-dimorphisms we hypothesized that hfd-fed female mice would also exhibit resistance to developing pn. in the present study male and female c bl /j mice were fed either a standard diet ( % kcal fat; sd) or a high fat diet ( % kcal fat; hfd) from wk. at wk, wk and wk, neuropathy phenotyping was performed on all groups complemented with longitudinal metabolic assessments including insulin tolerance testing (itt). neuropathy phenotyping consisted of hindpaw latency to heat stimulus, motor and sensory nerve conduction velocities (ncvs), and terminal intraepidermal nerve fiber (ienf) counts. assessment of insulin resistance through itt demonstrated that during early hfd feeding, female hfd-fed mice exhibited relatively normal insulin responsiveness, while male hfd mice exhibited insulin resistance. despite this finding, wk female hfd mice displayed a similar pattern of pn to that of their male counterparts, with similar fold-changes in hindpaw latency and sensory and motor ncvs. therefore, although female hfd-fed mice exhibit resistance to hfd-induced metabolic changes, they display a pn comparable to male hfd-fed mice suggesting that systemic insulin resistance does not mediate pn. further studies are underway investigating the role of insulin signaling in the peripheral nerves of female hfd-fed mice. anti-mag (myelin-associated glycoprotein) neuropathy is a disabling autoimmune peripheral neuropathy caused by monoclonal immunoglobulin m (igm) autoantibodies that recognize the carbohydrate epitope hnk- (human natural killer- ). this glycoepitope is highly expressed on adhesion molecules, such as mag, present in myelinated nerve fibers. since the pathogenicity and demyelinating properties of anti-mag autoantibodies are well established, current treatments aim at a reduction of autoantibody levels. however, the therapies applied so far are primarily immunosuppressive and lack selectivity and efficacy. we therefore hypothesized that a significant improvement of the disease condition could be achieved by selectively neutralizing the pathogenic anti-mag antibodies with carbohydrate-based ligands mimicking the natural hnk- glycoepitope. in an inhibition assay, a mimetic (mimhnk- ) of the natural hnk- epitope inhibited mag-binding by pathogenic igm antibodies from patient sera, however only with micromolar affinity. therefore, considering the multivalent nature of the mag-igm interaction, polylysine polymers of different sizes were substituted with the mimetic. with the most promising polylysine glycopolymer pl (mimhnk- ) the inhibitory effect on patient sera was improved by a factor of up to , per epitope, consequently leading to a low nanomolar inhibitory potency. since clinical studies indicate a correlation between the reduction of anti-mag igm levels and clinical improvement, an immunological surrogate mouse model for anti-mag neuropathy, producing high levels of anti-mag igm, was developed. the observed efficient removal of these antibodies with the glycopolymer pl (mimhnk- ) represents a first step towards an antigen-specific therapy for anti-mag neuropathy. hinder lm , mendelson f , backus c , feldman el . university of michigan, ann arbor, mi, usa. in the united states % of children and young adults are obese and at risk of developing prediabetes. prediabetic patients largely develop the same macro-and microvascular complications as patients with type diabetes, including peripheral neuropathy (pn). moreover, recent clinical data suggest normoglycemic obese patients develop pn. central obesity, characterized by excess fat storage in visceral white adipose tissue, leads to systemic metabolic dysfunction largely due to an imbalance between pro-inflammatory/anti-inflammatory adipokine production. subcutaneous adipose tissue is considered 'benign', but adopts a visceral-like phenotype in response to metabolic stress, with reduced thermogenicity, reduced brown adipose identity, and increased pro-inflammatory gene expression. the popliteal adipose tissue (pat) depot, corresponding to subcutaneous adipose, is adjacent to the peripheral nerve affected in pn, contains the lymph node for lymphatic drainage of the hind limb, and expands following local, sterile hind paw inflammation. the aim of the current study was to characterize pat changes in the high fat diet (hfd) mouse model of obesity and pn, and consider its contribution to peripheral nerve dysfunction. we previously reported c bl /j mice fed % hfd from - wk develop obesity, 'prediabetes' and pn; and switching mice back to a standard diet from - wk improves metabolic and pn phenotypes. at and wk pat was bilaterally dissected and the lymph node removed. the left pat was processed for histomorphometry, and the right pat for rt-qpcr. at wk hfd was associated with a significant shift in adipocyte size-frequency distribution, with a greater number of larger adipocytes. switching the hfd mice back to standard chow from - wk restored the size-frequency distribution towards age-matched controls. rt-qpcr was performed to assess changes in thermogenicity (ucp ), brown adipose identify (cidea) and sterile inflammation (saa ). at and wk hfd pat had reduced thermogenicity and brown adipose identify, and increased sterile inflammation. this switch towards a visceral-like phenotype was reversed in the hfd mice switched back to standard chow. in summary, hfd-induced changes in pat histomorphometry and adipose identity closely associate with pn phenotype. these preliminary data suggest a potential role for pat-nerve signaling in pn. hinder lm , backus c , hayes jm , feldman el . university of michigan, ann arbor, mi, usa. peripheral neuropathy (pn) is a common and debilitating complication of obesity and diabetes that triggers pain and loss of sensation. substantial nerve damage occurs in many patients prior to noticeable symptoms and no treatments are currently available; therefore, there is a critical need to identify treatment strategies that impact the underlying disease pathogenesis. our in vivo fluxomics data in the bks-db/db mouse model of type diabetes (t dm) and pn suggest that 'metabolic reprogramming' occurs in the t dm nerve to downregulate mitochondrial oxidative phosphorylation of substrates derived from glycolysis and fatty acid beta-oxidation. therefore, we hypothesize that distinct systemic metabolic alterations occur in obesity and diabetes which induce tissue-specific metabolic reprogramming within the peripheral nerve, altering fuel utilization and ultimately leading to tissue dysfunction. we contend that identifying conserved bioenergetic profiles across mouse models of pn will provide insight into key pn mechanisms. the current study utilized two mouse models of pn: the % high fat diet (hfd) mouse model of obesity and prediabetes at wk of age ( wk hfd), and the leptin receptor-deficient bks-db/db model of t dm at wk of age. mitochondrial function was determined in primary dorsal root ganglia (drg) neurons and sural nerve tissue from both models using the seahorse xf analyzer. resting mitochondrial oxidative metabolism was upregulated in drg neurons from mice with pn, with increased resting atp production and maintained mitochondrial coupling. in contrast, resting atp generation was decreased in sural nerve from mice with pn, with decreased coupling efficiency. relative spare respiratory capacity was attenuated in both drg neurons and sural nerve from mice with pn, indicating that mitochondria were less able to increase respiration in response to an energetic challenge. moreover, mitochondrial copy number was unchanged in drg neurons, but decreased in sural nerve tissue of mice with pn compared with respective controls. these data suggest a change in absolute number and function of sural nerve mitochondria, and a conserved cross-model proximal-distal bioenergetic profile in pn. we are currently exploring the relationship between these changes and pn pathogenesis. hoang ttn , umapathi t . hospital, ho chi minh city, vietnam; national neuroscience institute, singapore. ho chi minh city (hcmc) is the biggest metropolitan city in southern vietnam. its population is more than ten million. adult patients with neurological disorders are seen at six city public hospitals, including , hospital. there has been no systematic study of guillain barré syndrome (gbs) at hcmc or in vietnam in general. we are in the process of starting a prospective gbs database that we hope to expand to the other public hospitals at hcmc. here we describe our experience from . we saw gbs patients at , hospital. most of the cases were admitted in the rainy season, from late april to november, when mosquito-borne flavivirus infections are more common. patients were seen in the first week of illness and reported antecedent fever. two patients had diarrhea. diagnoses were made largely on clinical features, cerebrospinal fluid analysis and nerve conduction study. clinical findings include limb weakness, numbness and vii cranial nerve palsy. extraocular eye movements were affected in one patient. none had respiratory involvement severe enough to require artificial ventilation or intensive care. there were no pure miller-fisher syndrome cases; we suspect this might be related to the mild deficits that did not prompt hospitalization. nerve conduction studies showed typical features such as loss of f waves and abnormal blink reflex. the electrophysiology of patients' was dominated by demyelinating changes, one case was largely axonal and the remaining patient had normal electrodiagnostic study. repeat nerve conduction studies were not feasible because of limited resources. neurologists use corticosteroids as the main treatment. intravenous immunoglobulin and plasma exchange are costly and not reimbursed by medical insurance. we are currently preparing to systematically study gbs in southern vietnam, specifically with regards to possible role of antecedent flavivirus infections. we are also exploring the possibility of using low volume plasma exchange as a feasible cost-effective therapeutic modality. about % of patients with guillain-barré syndrome (gbs) treated with intravenous immunoglobulin (ivig) or plasma exchange deteriorate after initial improvement or stabilization -a phenomenon that is termed treatment-related fluctuation (trf). it is important to distinguish acute onset cidp (a-cidp) from gbs-trf during early course of the disease, because their therapeutic strategies and prognoses are different. herein, we describe a patient with gbs-trf, but with an extended progression phase that exceeds weeks. a -year-old woman was admitted due to acute onset progressive leg weakness and diplopia that had developed weeks prior (onset, d ). on neurological examination, right facial palsy was also observed. lower extremity weakness was moderate in proximal and distal muscles (mrc grade iv) with absent knee and ankle jerks. sensory examination revealed no abnormality in all modalities. she denied any recent diarrhea or upper respiratory infection, and vaccination. albumino-cytologic dissociation was noted in csf analysis; white blood cell count of / l and protein level of . mg/dl. nerve conduction study revealed demyelinating sensorimotor polyneuropathy with prolonged distal latency and conduction blocks. anti-ganglioside antibodies (gm igm/g, gd b igm/g, and gq b igm/g) were all negative. following ivig treatment, she was discharged with considerable improvement (d ). days later, she was re-admitted due to deterioration of leg weakness and hand clumsiness (d ). after another ivig treatment, she was discharged with clinical improvement (d ). days later, however, she was admitted again (d ) due to another considerable deterioration with four extremity weakness being worst at this time (mrc grade ii-iv in upper extremity, grade ii in lower extremity). a-cidp was considered given the progression phase exceeding weeks, but, we decided to give another treatment with ivig instead of a switch to corticosteroids because of uncertainty regarding distinction between a-cidp and gbs-trf. she was significantly improved following ivig treatment, and finally discharged (d ). thereafter, there has been no further deterioration during long-term follow-up of year. conclusively, this is a rare case of gbs with extended progression phase and trf. we propose that this could be referred to as subacute inflammatory demyelinating polyradiculoneuropathy (sidp) with trf. hsieh s , chao c . national taiwan university hospital, taipei, taiwan. transthyretin (ttr)-related familial amyloid polyneuropathy (fap) constitutes a major etiology of adult-onset hereditary neuropathies worldwide, in particular, a mutant ttr of ala ser (ttr-a s) in taiwan, the most common cause of acquired genetic neuropathy with adult onset (> years of age) of taiwanese patients. fap is a pan-modality neuropathy involving motor, sensory, and autonomic components of the peripheral nervous system with early involvement of small fibers as a major symptom. the early symptoms of fap are sometimes minimal and difficult to ascertain, mainly related to the fact that conventional electrophysiological examinations were not sensitive enough to detect small fiber neuropathy. skin biopsy with quantification of intraepidermal nerve fibers (ienf) has become one of the standard approaches to diagnose small fiber sensory neuropathy based on pathological documentation of nociceptive nerve degeneration. to explore the issue of early biomarkers in fap, we performed skin biopsy and compared ienf density with parameters of nerve conduction studies (ncs) and quantitative sensory testing (qst) on subjects ( men, aged . ± . years) with genetic confirmation of ttr-a s: patients and carriers. the ienf densities were significantly reduced compared to the age-and gender-matched controls in carriers ( . ± . vs. . ± . fibers/mm, p = . ) and patients ( . ± . vs. . ± . fibers/mm, p = . ). the latter was consistent with our previous report (neurology, : - , ) . the abnormal rate of ienf density was significantly higher than that of ncs and qst, respectively. in conclusion, there was significant skin nerve degeneration in carriers with ttr-a s. compared with qst and ncs, ienf density assessment had the highest abnormal rate and highest sensitivity to detect neuropathic changes in the early stage of fap. charcot-marie-tooth type p (cmt p) has been associated with frame-shift mutations in the ring domain of lrsam (an e ligase). this study describes families with a novel missense mutation of lrsam gene and explores pathogenic mechanisms of cmt p. this american family with dominantly inherited axonal polyneuropathy reveals a phenotype similar to those in previously reported non-us families. the affected members in our family co-segregated with a novel missense mutation cys arg that alters a highly conserved cysteine in the ring domain. this mutation leads to axonal degeneration in the in vitro neuronal cell-line. moreover, using protein mass spectrometry, we identified a group of rna binding proteins (including fus, a protein critically involved in motor neuron degeneration) that interacted with lrsam . the interactions were disrupted by the cys arg mutation, which resulted in reduction of intranuclear rna-binding proteins. a knockin mouse of cys arg has been created for further explorations of cmt p mechanisms and therapeutic development. together, our findings suggest that the mutant lrsam may aberrantly affect the formation of transcription machinery. given a similar mechanism has been reported in motor neuron degeneration of amyotrophic lateral sclerosis, abnormalities of rna/rna-binding protein complex may play a role in the neuronal degeneration of cmt p. supported by grants from ninds (r ns ) and the national center for advancing translational sciences (ul tr ). this double-blind, multicenter, parallel-group trial randomized ( : ) adult participants (n= ) with chronic inflammatory demyelinating polyradiculoneuropathy being treated with intravenous immunoglobulin (ivig) or corticosteroids to . mg fingolimod (n= ) or placebo (n= ) once-daily. previous treatment was discontinued (ivig) or tapered (corticosteroids). in the total trial population, there was no significant difference between the groups in the primary outcome, time-to-first confirmed worsening (≥ -point increase on the adjusted inflammatory neuropathy cause and treatment [incat] scale vs. baseline), or time-to-first any worsening (confirmed on incat assessment or unconfirmed). no significant difference between the two treatment groups was shown on secondary outcomes; change from baseline in grip strength and rasch-built overall disability scale (r-ods) at six months or trial end. analyses of pre-specified subgroups were performed for primary and secondary outcomes. this trial evaluated the efficacy and safety of fingolimod in chronic inflammatory demyelinating polyradiculoneuropathy (cidp). corticosteroids, intravenous immunoglobulin (ivig) and plasma exchange are recognized treatment options but no other immunomodulators demonstrated efficacy in a controlled trial. fingolimod has been shown to be efficacious and is approved for the treatment of relapsing multiple sclerosis. results from experimental autoimmune neuritis in rats suggested that it might show an effect in cidp. in this double-blind, multicenter, parallel-group trial, cidp participants receiving ivig or corticosteroids were randomized to once-daily fingolimod . mg or placebo ( : ). participants were stratified by inflammatory neuropathy cause and treatment disability (incat) scores and prior treatment. previous ivig treatment was discontinued after one final course before randomization. previous corticosteroid treatment was tapered over weeks. the primary outcome was time-to-first confirmed worsening (≥ -point increase on the adjusted incat score versus baseline). secondary outcomes included change in grip strength and rasch-built overall disability scale (r-ods) score from baseline to month and at trial end. the trial was stopped for futility by an independent data monitoring committee after a pre-planned interim analysis based on pre-specified criteria. in all, participants received fingolimod (ivig: , corticosteroids: ; age: . ± . years [mean±standard deviation]; male: . %); received placebo (ivig: , corticosteroids: ; age: . ± . years; male: . %). the percentage ( % confidence interval) of participants free from confirmed worsening at the trial end was not significantly different between fingolimod ( . % [ . %- . %]) and placebo ( . % ( . %- . %); p= . ). in the first days, approximately % participants experienced worsening. at trial end, approximately % participants had no worsening. there was no significant difference after six months or at the trial end (whichever occurred earlier) in the secondary endpoints. adverse events were reported in / and / participants in the fingolimod and placebo group, respectively. there were no deaths. nine participants in the fingolimod group and in the placebo group had serious adverse events. adverse events leading to trial drug discontinuation occurred in ( %) participants on fingolimod and none on placebo. no new safety signals emerged in this trial. acknowledgment: the authors consulted for or were employed by the study sponsor novartis pharma ag, basel, switzerland. myelin sheath enwraps non-nociceptive mechanoselective abeta-afferents transmitting touch/vibration sense. a prominent reduction in the mechanical stimulus required to evoke a withdrawal response in rodents, a phenomena interpreted as mechanical allodynia, arises due to peripheral nerve/myelin damage. evidence has emerged that nerve injury-induced mechanical allodynia depends on the adaptive immune/t cell activity in female but not male rodents. having previously demonstrated both the release of the cryptic - peptide regions of myelin basic protein (mbp - ) following sciatic nerve chronic constriction injury (cci) and the direct, robust and t cell-dependent ability of the pure mbp - peptides to induce mechanical allodynia after injection into the intact sciatic nerve, we hypothesized that mbp - contributes to sexual dimorphism in mechanical allodynia. the pure mbp - wild-type (wt), its histidine (his) mutant or scramble peptides were administered into an intact sciatic nerve fascicle in male and female rats or mice, followed by von frey testing. intra-sciatic mbp - -wt peptide induced robust and lasting allodynia in females. in contrast, males responded with a brief and mild decline in mechanical sensitivity for one day post-injection of both wildtype and control peptides. the algesic ability of mbp - -wt was diminished in the his mutant. we here present the molecular changes in the sciatic nerve, drg and the spinal cord after the intra-sciatic mbp - injection in male and female animals. in addition, using the biotin-labeled mbp - peptide and the hrp-labeled goat anti-rat igg/igm antibodies, we developed an elisa to quantitatively assess seropositivity for the specific anti-mbp - peptide igm/igg autoantibodies in female and male rats post-cci. human serum from female patients with multiple sclerosis was used for control. our work corroborates the findings of sexual dimorphism of mechanical hyperpathia and suggests its potentially autoimmune nature in females. iijima m , nishi r , ikeda s , kawagashira y , koike h , sobue g , katsuno m . nagoya university, nagoya, japan. non-obesity diabetic (nod) b - knockout (ko) mice are characterized by chronic and progressive neuritis and expected as models of immune-mediated neuropathies, especially cidp. hindlimb-predominant weakness due to inflammatory demyelination followed by axonal degeneration begins from around twenty week-age in all female mice until thirty week-age. to clarify the efficacy of immunoglobulins as immune-regulating therapeutics and the similarity of pathogenesis of human cidp, we injected intraperitoneally human-derived immunoglobulins (ipig, mg/mg bw/week) and saline as a control to totally forty female mice. clinical and pathological estimations in sciatic nerves were performed in time series. as a result, the ipig-treated group was protected from weight loss which could be related to axon loss followed by muscle atrophy as well as inflammatory demyelination between twenty-five week-age and thirty week-age compared to the control. in addition, the pathological findings in sciatic nerves showed that ipig apparently suppressed inflammatory infiltrates. about the subsets of inflammatory infiltrates, while macrophages (cd +) and lymphocytes (cd +) highly existed and suggested to play a main role in the neuritis until thirty week-age, only macrophages naturally disappeared after thirty week-age without any therapeutic induction. immunoglobulins effectively suppressed only macrophages although that did not suppress cd + lymphocytes. in conclusion, nod b - ko mice respond to immunoglobulins in a similar manner to human cidp and this efficacy is due to the suppression of macrophage-dominant pathogenesis. therefore, macrophage-derived pathogenesis is for the main target of immunoglobulin therapy and we should focus on the lymphocyte-derived pathogenesis which might plays an important role in non-responders to immunoglobulins. ikeda s , nishi r , kawagashira y , iijima m , koike h , katsuno m , sobue g , . department of neurology, nagoya university graduate school of medicine, nagoya, japan; research division of dementia and neurodegenerative disease, nagoya university graduate school of medicine, nagoya, japan. chronic inflammatory demyelinating polyneuropathy (cidp) is an acquired immune-mediated polyradiculoneuropathy that is characterized by heterogeneous clinical manifestations. typical cidp is defined as neuropathy manifesting in a progressive manner, stepwise manner, or with recurrent symmetrical proximal and distal weakness and sensory impairment in all four limbs. although they occur at a lower proportion than the so-called typical cidp, atypical forms, such as multifocal acquired demyelinating sensory and motor (madsam), distal acquired demyelinating symmetric (dads), pure sensory, pure motor, and focal, are considered to cidp subtypes. thus far, pathological features characterizing each clinical subtype have not been fully elucidated. we analyzed clinical and pathological correlations in consecutive cidp patients who underwent sural nerve biopsy and fulfilled the definite or probable efns/pns criteria. there were male and female patients. the age at biopsy was . ± . (mean ± sd) years, and the duration from the onset of neuropathy to biopsy was ± months. fifty-five percent (n = ) of the patients were classified as having typical cidp. regarding atypical cidp, madsam (n = , %), dads (n = , %), and pure sensory (n = , %) subtypes were the major subtypes, while pure motor (n= , %) and focal (n= , %) subtypes were rare. no significant difference was found among these subtypes in terms of sex, age at biopsy, and disease duration. sural nerve biopsy specimens revealed that the densities of large myelinated fibers significantly decreased in the madsam subtype than in the other subtypes (p = . ). in addition, the variation in nerve fibers among fascicles was more conspicuous in the madsam subtype than in typical cidp (p= . ). patients with the dads subtype tended to show the formation of onion-bulbs. in conclusion, pathological findings of sural nerve biopsy specimens were different among the cidp subtypes. further studies are needed to clarify mechanisms leading to different pathological features. small volume plasma exchange (svpe) can be an affordable and potentially effective alternative form of plasma exchange. svpe is the repeated removal of small volumes of supernatant plasma over several days via sedimentation of patient whole blood. the aim of this study is to assess the clinical feasibility and safety of svpe in patients with gbs in low-income countries. twenty adult patients with gbs diagnosed as per the criteria for gbs of the national institute of neurological and communicative disorders and stroke (ninds) were enrolled for svpe at a centre in bangladesh. serious adverse events (sae) were defined as the number of patients developing severe sepsis associated with the central venous catheter (cvc) or deep venous thrombosis in the limb where the cvc is placed for svpe. the svpe procedure was considered safe if less than of svpe-treated gbs patients have a sae, and feasible if eight litres of plasma could be removed in at least of svpe-treated gbs patients. among the cases who received svpe, ( %) patients were male and the age range between to yrs. all the patients were quadriplegic and bedbound at enrolment for svpe with a median mrc score of (iqr, - ). cranial nerve involvement, autonomic dysfunction and requirement for assisted ventilation were observed in ( %), ( %) and ( %) patients respectively. electro physiologically ( %) patients were motor axonal and ( %) patients were sensory-motor demyelinating type. during the svpe none of our patients experienced sae and one patient experienced central line associated blood stream infection. common adverse effects were transient intravenous fluid responsive hypotension during the svpe sessions in ( %), cv catheter insertion site hemorrhage in ( %) and hypersensitivity reaction to fresh frozen plasma in ( %) patients. there was no hypo-albuminemia, anemia or electrolyte imbalance observed in most patients ( %) treated with svpe. improvement in one or more grade of the gbs disability score at four weeks after the onset of svpe was observed in ( %) patients. in conclusion svpe can be a safe, feasible and cost effective alternative to standard pe in the developing countries. guillain-barré syndrome (gbs) is a descriptive disease entity defined by a set of clinical, electrophysiological and laboratory criteria. various clinical phenotypes exist that may be triggered by different antecedent infectious events. although the disease appears to affect primarily the elderly in developed countries, but, scenario is different in developing countries. bangladesh has made an impressive progress towards the eradication of poliomyelitis, and no new cases have been reported since . gbs, an acute polyradiculoneuropathy, is the most frequent cause of acute flaccid paralyis. the crude incidence rate of gbs in < years of age reported here appears to be . × to × higher than that reported in the literature. we conducted a hospital based observational study including patients fulfilling the national institute of neurological disorders and stroke (ninds) criteria for gbs patients between and in dhaka medical college hospital, dhaka, bangladesh. detailed clinical, electrophysiological, serologic and microbiological data were obtained. gbs affected predominantly in young adults males (m/f= : ) living in rural areas. antecedent events were recorded in > % of patients; frequent events being gastroenteritis (> %) and upper respiratory tract infection ( %). more than % of the patients were bed-bound (gbs disability score ) at entry and about % patients required mechanical ventilator. about % patients did not receive specific treatment either intravenous immunoglobulin (ivig) or plasmapheresis due to high expensive treatment cost. % patients had died during hospitalization. % of patients had an axonal variant of gbs and evidence for a recent c. jejuni infection ( %). c. jejuni infection was significantly associated with serum antibodies to the gangliosides gm and gd a, axonal neuropathy, and greater disability. in conclusion, the majority of the patients do not receive standard treatment with ivig in view of its high price. therefore, we developed low-cost treatment strategies and conducted a safety and feasibility trials for small volume plasma exchange (svpe) on gbs patients in bangladesh. in future, it is essential to conduct a phase ii clinical trial to assess the efficacy of svpe for low-in-come countries. prognosis of guillain-barré syndrome (gbs) has not improved in last two decades. current therapies (intravenous immunoglobulin, ivig and plasma exchange, pe) had been proved to be effective on two third of patients in developed world. unpredictable and poorly understood clinical course of gbs hamper treatment development. in bangladesh, most patients affected by gbs cannot afford specific treatments with ivig or pe instead most of them receive only supportive care. therefore, we aimed to compare the outcome of ivig treated patients with supportive care patients in improvement of gbs disability score and mrc sum score by using world's largest gbs cohort in bangladesh. we conducted a prospective observational study enrolling gbs patients between and from dhaka medical college hospital and national institute of neuroscience and hospital, dhaka, bangladesh. only gbs patients ( %) received standard ivig treatment. in current analysis, ivig treated patients and age, sex and severity matched controls (supportive care only) were considered. outcome of both groups were compared using fisher's exact or chi square test and survival analysis were performed by kaplan meier method using log rank test. among patients (cases and controls), male/female ( / ), median age years, % patients were bed-bound, one-fourth patients required mechanical ventilation and % were axonal. we did not found any significant differences of treatment outcome in both cases and control groups in gbs disability score (week : p= . , months: p= . ) and mrc sum score (week : p= . , months: p= . ). survival analysis revealed, the differences of time required for independent locomotion, improvement of one gbs disability score and improvement of mrc score were not statistically significant between treatments (ivig) and supportive care patients. in conclusion, our analysis showed that standard dose of ivig use has no considerable advantage to improve specific outcome measures among gbs patients in bangladesh. as the phenotype of gbs in bangladesh is different from developed world; therefore, an efficacy trial for ivig is needed for developing countries like bangladesh or new targeted therapeutic strategies can append beneficial effects for gbs patients. isose s , , watanabe k , omori s , sekiguchi y , beppu m , shibuya k , amino h , suichi t , misawa s , kuwabara s . graduate school of medicine, chiba university, chiba, japan; national hospital organization chiba east national hospital, chiba, japan. diabetic neuropathy is a frequent cause of neuropathic pain, suggesting the small-fiber involvement. additionally, persistent peripheral pain-related inputs could cause neuronal hyperexcitability and complex interactions of the nociceptive pathways, i.e., central sensitization. to investigate the pathophysiology of neuropathic pain in diabetic neuropathy, we studied pain-related evoked potentials (preps) after selective intraepidermal electrical stimulation (ies) to a-deltaand c-fibers in diabetes patients with neuropathic pain (n= ) and without neuropathic pain (n= ). we also conducted a longitudinal study to assess changes in preps and pain profiles in patients with neuropathic pain months after the start of treatment with duloxetine. this study is registered with the umin clinical trials registry, umin . ies was applied in the hand and foot, and preps were recorded from the cz electrode referenced to the linked earlobes. we evaluated prep latencies, amplitudes, and amplitude ratios of preps after c/a-delta -fiber stimulation. in the conventional nerve conduction studies, patients with neuropathic pain significantly showed conduction slowing and decreased snap amplitudes in the median and sural nerves compared with those in patients without neuropathic pain. in pain-related sep studies, there were no significant differences in prep amplitudes and latencies after a-delta -or cfiber stimulation between the patients with neuropathic pain and without it. prep amplitude ratios after c/a-delta -fiber stimulation tended to increase in patients with neuropathic pain compared to patients without pain. after the treatment with duloxetine, c/a-delta -prep amplitude ratios were significantly decreased after both hand and foot stimulation, and as for numerical rating scale (nrs) scores as the intensity of pain. patients with less pain relief showed the tendency of higher c/a-delta prep amplitude ratios before treatment compared to patients with better pain relief. the correlation between reduction of c/a-delta prep amplitude ratios and nrs reduction did not reach statistical significance. this pain-related sep study demonstrated that abnormal cortical response in patients with neuropathic pain could improve after the treatment with duloxetine, this might reflect the cortical hyperexcitability as a central sensitization. this study is funded by shionogi & co., ltd. the sponsors played no role in the design and management of the study, collection and analysis of data, interpretation of the results, or the writing of the writing of the report. peripheral nerve injury is commonly associated with traumatic injury which is often amenable to surgery. despite improved methods in surgical repair, functional recovery remains a challenging clinical problem that often leads to significant morbidity in patients. alternative therapies that could augment surgical repair may be beneficial in functional outcomes. neuroinflammation is a complex pathway with different cellular components and cytokines that are activated following peripheral nerve injury. macrophages are responsible for the breakdown of debris following injury as well as promotion of regenerative signals. macrophage polarization is the process by which macrophages take on phenotypically distinct functions based on the local environment and signaling cues. exercise has been shown to drive macrophage polarization from a pro-inflammatory m phenotype towards an anti-inflammatory m phenotype in numerous tissues, but remains uninvestigated in the peripheral nervous system. the purpose of our study was to identify how exercise affects macrophage polarization, motor and sensory function, and neuroregeneration following sciatic nerve crush. c bl/ mice underwent sciatic nerve crush injury and were then given access to running wheels (exercised) or not given access to running wheels (sedentary) for weeks. exercised mice ran an average of . km per night. injured exercised mice were protected from the development of thermal hyperalgesia when compared to injured sedentary mice. exercised mice had fewer paw slips on beam walk testing compared to sedentary mice. no differences were measured in mechanical sensitivity or motor coordination and balance assessed by rotarod. while motor nerve conduction velocities were significantly reduced for injured mice compared to uninjured controls, motor nerve conduction velocities from injured exercised animals were significantly higher than injured sedentary animals suggesting improved nerve recovery with exercise. injured sciatic nerves from exercised mice demonstrated increased m macrophages compared to sciatic nerves from injured sedentary mice. the behavioral changes and altered macrophage polarization correlated with increased epidermal nerve fiber density, improved myelination, and increased in vitro neurite outgrowth from injured exercised animals. therefore, exercise alters macrophage polarization towards an anti-inflammatory phenotype which improves repair and recovery of the injured peripheral nerve. jack mm , shah k , everist b , reyna j , hylton p . university of kansas medical center, kansas city, ks, usa. diffusion tensor imaging (dti) has long been used to evaluate the location and integrity of white matter tracts in the brain. dti uses quantitative data and directionality of water diffusion to determine axonal connectivity of the nervous system. the technology has only recently been utilized in limited settings in the peripheral nervous system due to challenging technical factors and lack of widespread availability. magnetic resonance (mr) neurography or peripheral neurography is a technique which uses diffusion to differentiate between intraneural and perineural tissues. it allows for fascicle patterns to be visualized particularly in the setting of peripheral nerve sheath tumors. peripheral nerve sheath tumors of various pathologies cause surrounding nerves to be involved or displaced in a range of directions. this technique helps determine the anatomic location of these nerve fibers in relation to the mass, which is particularly helpful at distinguishing neuromas from schwannomas. this data is invaluable to the surgeon to ensure a safe and low morbidity operation. while this technology has benefit particularly with surgical planning, it has been underutilized due to the challenges of requiring complex software to produce fiber tracks and the inability to translate these images into the operating room. here, we utilized brainlab software that is commonly available and utilized in surgical suites to produce images of the radial nerve fiber tracts with an associated peripheral nerve sheath tumor prior to surgical resection. while the software is commonly used in the central nervous system, it has not been reported to have been used in the peripheral nervous system. this software offers a high usability and produces anatomically correct and reliable fiber tracts. this technique overcomes the reliance on highly specialized software and extensive training required for use that most other tractography software has. utilizing peripheral neurography in this case allowed for complete surgical resection without postoperative deficits. this data offers clinicians an option to investigate peripheral nerve fibers in various pathologic states, to plan appropriate operative trajectories to peripheral nerve pathology, and to improve surgical outcomes for patients with peripheral nerve sheath tumors. jacobsen b , parry g , allen j , walk d , muley s , ortega e . barrow neurological institute, phoenix, az, usa; university of minnesota, minneapolis, mn, usa. chronic inflammatory demyelinating polyneuropathy (cidp) is an immune mediated neuropathy that is responsive to immunomodulatory agents such as glucocorticoids, intravenous immunoglobulin (ivig) and plasma exchange (pe). the specific immunopathogenic mechanisms of cidp remain unclear but there is increasing interest in nodal proteins as a site of the immune attack. even though the majority of patients respond to one of the aforementioned immunomodulatory agents there are some who are unresponsive or incompletely responsive to these first line agents and other more aggressive treatments may be necessary. cyclophosphamide and stem cell transplantation may be effective but are associated with considerable morbidity. anecdotal reports suggest that rituximab may be beneficial for some patients that fail first-line therapy, especially if they have antibodies to nodal proteins. we present four patients with intractable cidp who responded to rituximab. one of the three patients had diabetes. disease duration prior to starting rituxan was short ( months) in two patients and longer and months in the other two. all patients had failed treatment with glucocorticoids and ivig, and in two, plasma exchange and ivig-pe were also ineffective. two of the four patients were quadriparetic and non-ambulatory. two gm doses two weeks apart of intravenous rituximab were instituted in all patients. all patient tolerated the treatments well without adverse effects. all patients responded within four weeks and continued to improve at six months. other immunomodulatory agents were successfully tapered but not totally discontinued. it remains unclear whether antibodies to nodal proteins were present in these patients. in conclusion, although rituximab efficacy remains uncertain on the basis of randomized controlled clinical trials, it may be beneficial in selected patients otherwise intractable to first-line treatments. further studies are necessary to better understand which patients may benefit most from rituximab and where in the treatment algorithm rituximab should be applied. neuropathic pain is a chronic condition seen in patients suffering a direct injury to the peripheral or central nervous system or an indirect injury due to, e.g., diabetes or multiple sclerosis. current treatment options fall short of preventing or completely relieving patients of their pain. for years, research has focused on understanding the role of neurons in neuropathic pain pathogenesis while overlooking the role of supportive cells in general and satellite glial cells (sgcs) in the dorsal root ganglion in particular. these cells not only buffer the neuronal microenvironment they are also involved in controlling the electrical activity flowing through the neurons and in neuropathic pain pathogenesis. the aim of this project is to understand the role of sgcs in neuropathic pain development and thereby aid the identification of new drug targets. to purify the sgcs from adult mice we optimized a fluorescently activated cell sorting (facs) protocol. the success of our purification method was confirmed using qrt-pcr and visual inspection of the sorted cells. finally, we are running rna sequencing on sgcs after peripheral nerve injury to compare their transcriptome to that of uninjured cells at different time points. the results from our study are likely to deepen our understanding of how sgcs contribute to the development and maintenance of neuropathic pain. guillain-barrésyndrome (gbs) is an immunemediated disorder in the peripheral nervous system (pns) triggered by molecular mimicry against nerve gangliosides. one of the cell surface receptors (fas)-ligand (fasl) interaction transmits apoptotic signal to eliminate the auto-reactive b and t-cells, which generates cross-reactive antibody against nerve cells. host genetic polymorphism of fas and fasl may alter their expression and induce aberrant apoptotic response to develop gbs. therefore, we determined the single nucleotide polymorphisms (snps) of both fas receptor (− g/a and - a/g) and fasl ligand (− c/t) in gbs patients (n= ) as well as healthy controls (n= ) using the lightcycler technique. serum level of soluble form of fas and fasl was measured using commercially available sandwich elisa kit. comparison of genotype, allele and haplotype frequencies was done with the gbs subgroups based on the clinical and serological data. ag heterozygote (p= . , or= . , % ci= . - . ) and polymorphic g-allele (p= . , or= . , % ci= . - . ) of fas receptor - a/g promoter snps were significantly associated with anti-ganglioside (gm ) antibody positive gbs patients. in addition, − g-allele (p= . , or= . , % ci= . - . ) and - g/- g haplotype (p= . , or= . , % ci= . - . ) were predominantly associated with the axonal variant of gbs patients. serum soluble form of sfas (median levels pg/ml vs. pg/ml, p= . ) and sfasl (median levels pg/ml vs. pg/ml, p= . ) were found to be elevated in anti-gm antibody positive gbs patients compared to anti-gm negative patients. no significant association was found in genotypic distribution between gbs patients and healthy controls. in conclusion, fas/fasl promoter snps are not a susceptible factor for gbs but could be one of the influencing factors to develop cross-reactive anti-ganglioside antibodies in gbs patients in bangladesh. furthermore, functional studies with a larger sample size (using cohort like international gbs outcome studies-igos) are required to explain the immune pathogenic role of these snps for gbs patients. jang sy , yoon ba , shin yk , yun sh , jo yr , park ji , shin kj , kim jk , park ht . dong-a university, busan, south korea; inje university, busan, south korea. myelination is essential for the proper function of the nervous system. schwann cells, which form the peripheral myelin sheath, have the unique ability to dedifferentiate and to destroy the myelin sheath under various demyelination conditions. during schwann cell dedifferentiation-associated demyelination in wallerian degeneration after axonal injury, schwann cells exhibit myelin and junctional instability, down-regulation of myelin gene expression and autophagic myelin decomposition. however, in inflammatory demyelinating neuropathy, it is still unclear how schwann cells react and contribute to segmental demyelination before myelin scavengers, macrophages, are activated for myelin clearance. here, we show that schwann cell dedifferentiation-associated demyelination is a mechanism involved in the initial demyelination observed in a mouse model of inflammatory demyelinating neuropathy using ultrastructural, biochemical and microarray analyses. myelin uncompaction and myelin membrane instability generated by dedifferentiated schwann cells lead to autophagolysosome-dependent cytoplasmic amputation between the axon-containing myelin sheath and the schwann cell body, resulting in the formation of the "myelin corpse", thereby allowing macrophages to phagocytose the myelin corpse in the end stage of segmental demyelination. we found myelin corpse formation in inflammatory demyelination to be a process similar to the myelin rejection during wallerian degeneration, which appeared to be dependent on schwann cell autophagolysosome activation since schwann cell-specific atg knockout mice exhibited delayed myelin rejection following nerve injury. finally, lysosome inhibition in schwann cells not only prevented segmental demyelination but also delayed the progression of clinical stages by suppressing the myelin corpse formation in inflammatory demyelinating neuropathy. thus, our findings indicate that demyelination by schwann cells and macrophages might be part of a process that includes sequential divisions of labor with respect to myelin rejection and digestion, respectively. in conjunction with previous studies showing schwann cell dedifferentiation and autophagy in toxic and hereditary neuropathies, the concept of "schwann cell dedifferentiation-associated demyelination" provides insight into the development of possible therapeutic strategies to prevent schwann cell demyelination in peripheral demyelinating neuropathies. methods: electrophysiological data, the charcot marie tooth exam score (cmtes), and bmi from patients with known cmt a were obtained and analyzed. results: when controlled for age, bmi does not affect studies of ulnar motor nerve conduction in ctm a patients, but rather specific components of the cmt exam scores (cmtes, loss of pinprick sensation and motor strength in the lower extremities). discussion: bmi and clinical components of the cmtes are correlated, but it is uncertain which is the primary effect -i.e., whether the reductions in pinprick sensation and motor strength in the lower extremities lead to a higher bmi, or higher bmi results in these signs. introduction: charcot-marie-tooth disease type c (cmt c) is a rare, dominantly inherited neuropathy caused by mutations in the lipopolysaccharide-induced tumor necrosis factor (litaf) or small integral membrane protein of the lysosome/late endosome (simple) gene. methods: we present a case series comprised of patients in whom cmt c is caused by a gly ser substitution in the encoded protein. we focus on clinical presentation, electrodiagnostic analyses, and our findings in the context of previously described cases. results: the gly ser mutation causing cmt c is a mild form of cmt, as patients walked on time, had less weakness than those with charcot-marie-tooth disease type a (cmt a), had a charcot marie tooth neuropathy score (cmtns) indicative of mild disease, and had faster ulnar and median motor nerve conduction velocities compared to those with cmt a. discussion: the g s mutation in litaf seems to be clinically indistinguishable from a mild presentation of cmt a. jha mk , russell k , lee y , rothstein jd , morrison bm . johns hopkins university, baltimore, md, usa. peripheral nerves are highly dependent on metabolic energy to maintain both basic cellular functions such as axon transport, na+/k+ ion gradients, and myelination, as well as to support regeneration following injury. though glucose certainly provides some metabolic support, our recent studies have shown that monocarboxylates, such as lactate, pyruvate, and ketone bodies, also contribute to recovery from peripheral nerve injury. monocarboxylate transporters, particularly mct , are the predominate transporters for monocarboxylates in the peripheral nerve. in a recent publication, we found that mct heterozygous null mice, which express % less mct in all cells, have slowed nerve regeneration and reduced myelination following sciatic nerve crush. this study was limited by the global reduction of mct , which is widely expressed in schwann cells (sc), dorsal root ganglia (drg) neurons, endothelial cells, macrophages, and perineurial cells within the regenerating peripheral nerve. to better understand the mechanism by which mct contributes to normal nerve function and nerve regeneration, we produced and validated conditional mct null (mct loxp) mice that allow selective deletion of mct from scs, drg neurons, endothelial cells, or macrophages through mating to cell-specific cre lines. we are currently quantifying peripheral nerve development, aging, and regeneration in each of these mouse lines. following sc-, but not drg-, specific mct knockdown, sensory peripheral nerves develop demyelination by months of age, manifest by reduced myelin thickness, increased g-ratio, and reduced conduction velocity. studies are ongoing in cultured scs to determine the mechanism for demyelination. neither sc nor drg knockdown of mct impairs nerve regeneration following sciatic nerve crush. these results suggest that sc-specific mct is critical for maintaining myelin in sensory, but not motor, peripheral nerves as they age. they also suggest that mct expression in peripheral nerve cell types, other than sc and drg, is important for nerve regeneration. ongoing studies are determining the contribution of mct in other peripheral nerve cell types, particularly endothelial cells and macrophages, to normal development and regeneration following injury. our results will clarify the role of lactate and its transporter, mct , in peripheral nerve function, potentially suggesting novel targets for demyelinating neuropathies or nerve injuries. small fiber neuropathy (sfn) is a condition in which the smallest nerve fibers are affected, characterized by neuropathic pain and autonomic dysfunction. according to international criteria, sfn diagnosis is based on clinical symptoms in combination with abnormal temperature threshold testing (ttt) and/or reduced intraepidermal nerve fiber density (ienfd) in skin biopsy. skin biopsy is moderately sensitive, invasive and the process is time consuming and expensive. ttt is a widely available diagnostic tool, but lacks specificity. previous studies introduced stimulated skin wrinkling (ssw) as an objective, non-invasive diagnostic tool to detect sympathetic nerve dysfunction in sfn by means of a categorical assessment. however, our unpublished data has shown that inter-observer reliability of categorically assessed ssw is quite low. in this current study we will use a new digital method for ssw quantification: the digit wrinkle scan© (dws©). the primary study objective is to define normative values for dws© expressed as total wrinkle length per fingertip surface (mm/mm ). subsequently we investigate the applicability of dws© in patients with definite sfn, based on abnormal iefnd and/or ttt, determining the dws© sensitivity and specificity, as well as its validity. for this cross-sectional study, we will include healthy participants and patients diagnosed with sfn. eligibility is based on meeting the inclusion and exclusion criteria and providing written informed consent. skin wrinkling is induced by emla (eutectic mixture of local anesthetics) cream© application and captured by taking pictures. the primary outcome measure is total length of wrinkles per mm as shown on the photographs, which will be calculated by a new software program. patients are stratified according to age and gender. based on the results of healthy participants, normative values will be defined. inter-and intra-observer reliability will be determined. in the sfn group, additional correlation analysis will be conducted to determine the correlation between dws© and different outcome measures (sfn-symptom inventory questionnaire, visual analogue pain scale, neuropathic pain scale, sfn-rasch-built overall disability scale, ienfd and ttt). we expect to provide digitally quantified ssw (dssw©) normative values that can be used in clinical practice in the diagnostic workup for sfn. cmt , characterized by axonal degeneration, is an inherited motor and sensory neuropathy accounting for about % of total cmt patients. the cmt subtype shows on its own, a vast genetic heterogeneity with more than mutations in known genes rendering the identification of relevant drug targets and therapies very challenging. so far, only hdac inhibitors have shown promising results in mouse models for hspb mediated axonal cmt (cmt f), albeit such a single gene approach may have a limited relevance at clinical levels owing to the limited number of patients per genotype. in this study, we investigated common causative molecular players of cmt associated axonal degeneration. for this, an itraq based proteome analysis was performed on five patient's derived lymphoblasts bearing different cmt causal mutations alongwith respective age and gender matched unaffected controls. software-assisted interpretations of the obtained data led us to identify two proteins which were significantly downregulated in cmt patients compared to controls. these two proteins were then validated using western blotting and qpcr on patient derived lymphoblasts and fibroblasts. our results prompted us to unveil whether these two proteins can be used as potential biomarkers for identifying cmt patients. therefore, through a europe-wide collaboration, we constructed a cohort of cmt patients and healthy controls. these two proteins exhibited significant downregulation in this cohort suggesting a potential new role of these proteins as cmt biomarkers. remarkably, we were also able to validate the significant decrease in ineurons (neurons differentiated from patient derived ipscs) strengthening the importance of our finding and also suggesting the relevance of these proteins in the pathogensis of axonal cmt. this will be the first study involving multiple cmt causal genes at once, thereby holding the potential to offer new drug targets and potential biomarkers with wider application both clinically and pharmaceutically. mesenchymal stem cells (mscs) represents a valuable source of stem cell therapy, can differentiate into various cell types. we investigated of the neuromuscular potential of human tonsil-derived mscs (t-mscs) for neuromuscular regeneration in trembler-j mice that is considered to be a model for charcot-marie-tooth disease type a (cmt a diseases), which is involving hereditary motor and sensory peripheral neuropathies. the t-mscs differentiated toward skeletal myocytes, as evidenced by increased expression of skeletal muscle-related markers (including troponin i type , and myogenin) and the formation of myotubes in vitro. in situ transplantation of t-msc-derived myocytes (t-myocytes) into gastrocnemius in trembler-j mice, a mouse model of cmt a, enhanced motor function, as identified with recovery by a compound muscle action potential (cmap) amplitude. and the regenerated shape of the sciatic nerve and skeletal muscle by immunochemistry, without the formation of teratomas. furthermore, the expression levels of nerve growth factor (ngf) and glial cell line-derived neurotrophic factor (gdnf) were significantly increased in t-myocyte compared with t-mscs in vitro. these results indicate that the transplantation of t-myocyte can be a therapeutic option of cell therapy for the neuromuscular regeneration in hereditary peripheral neuropathy, comprising cmt a disease. kagiava a , karaiskos c , richter j , tryfonos c , lapathitis g , sargiannidou i , christodoulou c , kleopa ka , . neuroscience laboratory, the cyprus institute of neurology and genetics, nicosia, cyprus; department of molecular virology, the cyprus institute of neurology and genetics, nicosia, cyprus; neurology clinics, cyprus school of molecular medicine, the cyprus institute of neurology and genetics, nicosia, cyprus. x-linked charcot-marie-tooth disease (cmt x) is a common form of inherited demyelinating peripheral neuropathy resulting from mutations affecting the gap junction protein connexin (cx ). using a cx knockout (ko) mouse model of the disease, we have shown that targeted expression of virally delivered cx results in morphological and functional improvement. since patients with cmt x express mutant forms of cx in schwann cells, that could potentially interact with virally delivered wild type (wt) cx through dominant-negative effects, we also treated mutant mice expressing the t i, r w and n d mutations associated with cmt x on a cx ko background. all three mutants were localized in the perinuclear compartment of myelinating schwann cells consistent with retention in the er (t i) or golgi (r w, n d) with loss of physiological expression in non-compact myelin areas. following intrathecal delivery of the human gjb gene we could detect the virally delivered wt cx correctly localized in the non-compact myelin areas only in t i/cx ko mutant mice, but not in the other two mutants, suggesting dominant effects of the r w and n d mutant but not of the t i mutant. gjb treated t i/cx ko mice showed improved motor performance, along with lower ratios of abnormally myelinated fibers and reduced numbers of inflammatory cells in all tissues examined compared to mock-treated animals. in contrast, gjb treated r w and n d mutant mice showed only slight but not statistically significant improvement. this study provides additional proof of principle for a clinically translatable gene therapy to treat cmt x even in the presence of endogenously expressed cx mutants, since at least one er-retained cx mutant did not interfere with the expression of virally delivered cx allowing a therapeutic benefit similar to cx ko mice. however, golgi-retained mutants may interfere with virally delivered wt cx and other approaches besides gene addition may be needed for effective treatment. funding: muscular dystrophy association (grant mda to kak). kaida k , kadoya m , koike h , iijima m , takazaki h , ogata h , moriguchi k , shimizu j , nagata e , takizawa s , chiba a , yamasaki r , kira j-i , sobue g , ikewaki k . national defense medical college, tokorozawa, japan; nagoya university graduate school of medicine, nagoya, japan; kyushu university, fukuoka, japan; university of tokyo, tokyo, japan; tokai university school of medicine, isehara, japan; kyorin university, tokyo, japan. antibodies to a glial protein, neurofascin (nf) have recently been identified in approximately % of patients with chronic inflammatory demyelinating polyneuropathy (cidp), which are igg -predominant. igg anti-nf -associated cidp may be a distinct subtype from typical cidp in terms of clinical features and response to immunotherapy. however, a diagnostic criterion of anti-nf -associated cidp has not established yet. to develop optimal criteria and design the best treatment plan for the anti-nf -associated cidp, procedures for determining anti-nf antibodies should be simplified, prevalent, and reproducible, as well as being accurate. cell-based assay (cba) has hitherto been utilized for determining antibodies to nf in sera from patients, results of which have been confirmed by immunohistochemistry (ihc) using teased nerve fibers from rodents. these methods are the most reliable techniques, while not necessarily easy-to-use and easy to maintain in most laboratories. in the present study, we aimed to validate the diagnostic utility of a conventional enzyme-linked immunosorbent assay (elisa) for determination of anti-nf antibodies and the igg subclass. sera from patients with efns/pns criteria-met cidp were examined with elisa using human recombinant nf . to verify elisa results, ihc on rat sciatic nerves, western blot (wb) and cba using nf -transfected and naive hek cells were conducted. the human nf -based elisa clearly distinguished between anti-nf antibody-positive and -negative sera. fifteen cidp patients ( %) were igg anti-nf antibody-positive, which were confirmed by wb, ihc and cba studies. none of disease controls or healthy subjects had positive results. twenty-five sera randomly selected from anti-nf -negative cidp sera were also negative on cba. the anti-nf activities on elisa were significantly positively-correlated with those on cba (p < . ). analyses of clinical and laboratory findings showed that anti-nf -associated cidp was characterized by younger onset, distal dominant phenotype, tremor, sensory ataxia, higher protein levels in cerebrospinal fluid, and poor response to ivig, which were consistent with those in previous studies. this elisa combined with determination of the igg subclass is a simple and reliable method for initial screening for anti-nf antibodies. the genetic abnormality responsible for x-linked charcot-marie-toothy neuropathy subtype cmtx was recently identified by whole genome sequencing to be a kb insertion into chromosome xq . . the clinical profile of cmtx in childhood is not well described. we reviewed the clinical characteristics, neurophysiological profile and cmt pediatric scale (cmtpeds) assessments of children with genetically confirmed cmtx . cmtx was characterized by early onset, and early and progressive hand weakness. most affected children were symptomatic within the first two years of life. the most common presentation was with equinovarus foot deformity in the first year of life. cmtpeds analysis in these children revealed that cmtx progressed more rapidly ( . ± . points/ year, n= ) than cmt a and cmtx . grip strength in the second decade of life in most affected males was two standard deviations below age-and sex-matched normative reference values. the most severely affected individual was wheelchair bound at years of age and two individuals had no movement in the small muscles of the hand in the second decade of life. there was only a single symptomatic female identified and she had mild signs. nerve conduction studies showed a demyelinating sensorimotor neuropathy with motor conduction velocity in eight children while one child had a length-dependent sensorimotor axonal neuropathy. understanding the unique phenotype of cmtx is essential for directing genetic testing, as the cmtx insertion will not be detected on the snp microarrays, multi-gene panels or whole-exome sequencing currently used for the diagnosis of cmt. the early onset of disease coupled with rapid progression means that many children with cmtx will have severe disability within the first two decades of life and hence early diagnosis is needed for early commencement of rehabilitation. kapoor m , catania s , sarri-gonzales s , lunn mp , manji h , reilly mm , carr as . centre for neuromuscular diseases, national hospital for neurology and neurosurgery, london, uk; department of neurophysiology, national hospital for neurology and neurosurgery, london, uk. the conventional dosing of ivig in cidp and mmn is based on treatment trials that used bolus and maintenance dosing of ivig between - . g/kg. there are rare published articles reporting the efficacy of higher maintenance ivig doses. we present three cases of inflammatory neuropathies, who are currently stabilized on ivig doses of mg- mg/kg of ivig per month, refractory to standard dose ivig and other immunosuppressants. the first case is a year-old-lady with cidp who presented with episodes of ascending sensory disturbance, weakness, and diplopia. she had activity related fluctuations and pre-dose deterioration on g/kg/month ivig. she then had an acute deterioration with mrc sum score dropping from to even with additional plasma exchange. her bilateral foot drop (mrc grade - ) and fluctuations persisted with an increase of ivig to . g/kg/month. she is now clinically stable (ankle dorsiflexion mrc grade - , mrc sum score ) on mycophenolate and g ivig weekly ( . g/kg/month). case is a -year-old male fitness instructor with mmn and sjogren's syndrome. he presented with recurrent proximal and distal weakness that responded to g/kg of ivig and deteriorated with iv methylprednisolone. he had peri-dose fluctuations, intermitted proximal weakness, and persistent foot drop (ankle dorsiflexion mrc grade - ) at . mg/kg/month, worsening to mrc grade - on . g/kg/month and fluctuating between mrc grade - on . g/kg/month. an increase of ivig to g weekly ( . g/kg/month), has resulted in mmn rods scores of / , improved distal power and return to full capacity at work. case is a -year-old man with predominantly upper limb cidp. he received g/kg ivig without any benefit, had no response to doses of plasma exchange, doses of cyclophosphamide or dose of rituximab between and . since , he has received g/kg/month ivig with improvement of mrc sum score from to . these cases highlight that some patients require a much higher than conventionally prescribed dose of ivig, and that these doses are tolerated over years without serious adverse events. idiopathic rapid eye movement sleep behaviour disorder (irbd) has been identified as a precursor of alpha-synucleinopathies, such as parkinson's disease, dementia with lewy bodies, multiple system atrophy. several studies linked changes in cutaneous innervation with central nervous system pathology in neurodegenerative disorders. recently small fiber neuropathy and alpha-synuclein deposition in the skin found to be a potential biomarker in parkinson's disease. we evaluated the epidermal innervation of irbd patients and age and sex-matched controls from skin punch biopsies from the distal leg using pgp . immunohistochemistry. furthermore, a battery of clinical examinations were performed on patients and controls alike, including structured interviews, clinical motor and non-motor questionnaires and rating scales (e.g. unified parkinson's disease rating scale [updrs], non-motor symptoms questionnaire [nms-quest] and beck depression inventory, epworth sleepiness scale, evaluation of cognitive and olfactory functioning as well as blood samples. irbd patients, compared to controls, showed a significant reduction in intraepidermal nerve fiber density (p = . ), whereas the axon swelling ratio, did not differ between groups. patients with irbd reported non-motor symptoms more frequently than controls (updrs i, nms-quest). olfaction and daytime sleepiness differed between both groups, whereas there were no differences regarding cognition. these in vivo findings demonstrate small fiber neuropathy in irbd patients that are associated with non-motor symptoms indicating that peripheral abnormalities may occur early in irbd. they warrant larger scale longitudinal studies in order to investigate their prognostic value. katz j , lewis r , spatafora d . california pacific med center, san francisco, usa; cedars-sinai medical center, los angeles, usa; neuropathy action foundation (naf), santa ana, usa. multifocal motor neuropathy (mmn) is a rare condition that affects . in every , individuals worldwide and is associated with motor dysfunction and moderate to severe disability. the neuropathy action foundation conducted a global survey to determine the impact of mmn on patient quality of life (qol) and gaps in patient/provider educational needs. the first global mmn qol survey was an item internet questionnaire available between january and july , . the survey focused on three primary areas: timely and accurate diagnosis, the efficacy of treatment, and the impact of the disease on patients qol. the survey was completed by patients from countries. the majority of respondents said they were diagnosed between the ages of and years ( . %), more than % reported that it took more than one year to be diagnosed and more than % reported that it took - years or longer to be accurately diagnosed. with respect to treatment options : . % reported receiving intravenous immune globulin and . % reported receiving subcutaneous immune globulin therapy. other therapies being used to treat mmn were gabapentin ( . %), and pregabalin ( %). almost half ( . %) said that mmn often impacts their overall schedule. half of the participants reported that mmn often or always interferes with their employment; % had difficulty typing on a computer or using a telephone, . % had trouble concentrating, and . % said they had to work really hard to pay attention or else they would make a mistake. this is the first assessment of mmn from a patient's perspective. the survey highlighted critical issues relating to the diagnosis, management, and impact on the qol of individuals with mmn. the data also identified gaps and insights in provider education relating to proper diagnoses and management of the condition from a patient's perspective. katz j , levine t , dimachke m , barohn r . forbes norris center, san francisco, ca, usa; phoenix neurological institute, phoenix, az, usa; kansas university medical center, kansas city, ks, usa. in the united states, cidp cases are submitted to insurance companies to determine whether ivig therapy is appropriate. this is done using specified diagnostic criteria, which reduce diagnosis to a boolean analysis, where a disease can only be present or absent. this leaves no room for uncertainty, even when it truly exists. boolean criteria are useful for clinical trials, but fall short where real decisions are made under uncertainty and based on perceived cost/benefit analysis. this project attempts to elucidate root causes of uncertainty and to find solutions to this dilemma. we asked cidp experts to select a single diagnosis in cases where ivig was approved using the submitted case records. while there was agreement on many cases, in the five most "uncertain" cases no more than reviewers agreed on a single condition, who chose up to four separate entities. among these, at least three reviewers diagnosed an immune neuropathy in all five. the root cause of the disagreement, to a large degree was unclear documentation (aunts) which consisted of pasted, missing, and disorganized data. reviewers missed useful information, admitting it was too difficult to fully parse records. to resolve uncertainty, reviewers admitted to discounting certain reported datum to help fit the entity they suspected, such as reported therapeutic responses or certain electrodiagnostic/exam findings. other disagreement, however, reflected the complexity of neuropathy diagnosis, such as knowing if improvement was due to natural history or treatment, unawareness of rare presentations, or analyzing a true uncle (complex case). reviewers used bayesian (select most likely diagnoses from a list) and fuzzy logic (compare best fits to base cases). when the "best" diagnosis did not fit the base case, they had to re-interpret the data. improving review procedures requires eliminating aunts by collecting all key information and simplifying how records are presented. it also needs more advanced data methods to analyze common and rare borderline presentations (uncles like mama v pma, cidp v cspn, etc..), developing diagnostic algorithms that address real uncertainty, educating prescribers and patients on process, and creating systems that measure outcomes longitudinally after induction or tapering of therapy. keisuke y , miyuki m , motoi k , susumu k . department of neurology, faculty of medicine, kinki university, osaka, japan. anti-ganglioside antibodies are closely associated with clinical phenotype and specific symptoms in acute immune-mediated neuropathies. igg anti-gq b antibodies are specifically associated with miller fisher syndrome (mfs), bickerstaff brainstem encephalitis (bbe) and guillain-barré syndrome (gbs) with opthalmoplegia (gbs-op). in addition, ganglioside complexes (gscs) containing gq b also can be targets in such diseases, and might be associated with the clinical features. however, factors regulating clinical phenotype in those gq b-associated antibodies-positive diseases have not yet been known. for investigating the differences of antibody reactivities among those diseases, we examined, using combinatorial glycoarray, igg antibodies to ten individual glycolipids [gm , gm , gm , gd a, gd b, gq b, galactocerebroside (gal-c), lactosylceramide (laccer), ga , sulfatide] and glycolipid complexes consisting of two of the glycolipids listed above in sera from patients with gbs-op who were positive for anti-gq b antibody by elisa (gbs-op-gq b), patients with mfs with the clinical triad (opthalmoplegia, ataxia, and areflexia), and patients with bbe. by combinatorial glycoarray, overall sensitivity of antibodies to gq b and gscs containing gq b was . % ( / ) in gbs-op-gq b, . % ( / ) in mfs, and . % ( / ) in bbe, respectively. there were no significant differences in antibody reactivities between mfs and bbe. it is notable that antibodies to gscs containing gd b were more frequently found in gbs-op-gq b patients than in mfs or bbe patients (e.g., gd b/sulfatide: p= . and p< . , respectively). presence of the antibody reactivities to gscs containing gd b may possibly be related with clinical features of gbs-op-gq b, including frequent need of artificial ventilation. kennedy r , , , carroll k , , paterson k , ryan mm , , , mcginley jl , . royal children's hospital, parkville, australia; university of melbourne, parkville, australia; murdoch childrens research institute, parkville, australia. problems with walking and footwear fit are often reported by children and adolescents with charcot-marie-tooth disease (cmt). a cross-sectional, case controlled study of gait was conducted in children with cmt and typically developing (td) children. gait was assessed barefoot and in two types of the participants' own typical footwear; optimal (e.g. athletic shoes) and suboptimal (e.g. slip-on footwear). the aims were to determine differences in spatio-temporal (s-t) gait variables between children with cmt and td children; and to investigate the effect of footwear choices. twenty-nine independently ambulant children aged - years with confirmed genetic or clinical diagnoses of cmt, and age and gender matched td children participated (mean age . years; males). exclusion criteria included developmental disorders, other neuromuscular conditions or musculo-skeletal diseases that could affect gait, and lower limb injury or surgery in the preceding months. assessment included s-t gait patterns, footwear characteristics, metre run, and cmtpeds. gait was assessed at self-selected speed with an electronic walkway (gaitrite™), with trials for each condition. the primary gait variable assessed was speed; other variables included step length, step time, cadence, base of support width and step-to-step gait variability. across all footwear conditions children with cmt walked more slowly ( regeneration of cutaneous unmyelinated axons is known to be slowed in dm-patients and after -months, the density of intraepidermal nerve fibers (ienf) does not return to baseline levels after chemical or mechanical axotomy. however, the long-term outcome of regeneration in dm or control subjects is not known. additionally, it is not clear if the regeneration of sensory distal axons is length-dependent. here we measured the rate of axonal regeneration -months after chemical denervation using a capsaicin model in dm patients (n= / dm /dm ) without neuropathy, and controls. dm skin punches were performed at distal thigh at baseline, -hours post-capsaicin, and at , , and days. blood glucose and hgba c were measured at baseline, , and days. healthy controls had skin punches at both distal leg and proximal thigh at baseline, after capsaicin chemical axotomy, and days , , and . regeneration rate was significantly higher at the thigh in healthy controls ( . fibers/mm/day ( % ci: . - . fibers/mm/day) compared to dm (p= . ), but no difference between dm ( . fibers/mm/day % ci: . - . fibers/mm/day) or dm ( . fibers/mm/day % ci: . - . fibers/mm/day) (p= . ). comparing regeneration rate at different time intervals, showed that regeneration was significantly slowed between day and dm patients, while it continued with the same rate in controls. blood glucose or hga c had no effect on regeneration rate. ienfd returned to baseline in controls by -months ( % of baseline) while it is did not in dm subjects, %/ % (dm /dm ) of ienfd baseline, (p= . dm vs. controls). there was no difference in regeneration rate ienfd %-baseline by -months at distal leg and proximal thigh in controls (p= . ). these results suggest that the rate and outcome of regeneration is independent of the length of the axon. additionally diabetic patient have incomplete nerve regeneration after months regardless of diabetes type or the level of glycemic control. regeneration of axons slowed down over time in patients with dm and reached a plateau after days. kiessling p , lledo-garcia r , watanabe s , langdon g , tran d , bari m , christodoulou l , price g , smith b , byrnes w , brock m , jolles s . ucb pharma, monheim, germany; ucb pharma, slough, uk; ucb pharma, braine-l' alleud, belgium; ptx solutions ltd, london, uk; ucb pharma, raleigh, durham, usa; university hospital of wales, cardiff, uk. ucb is a humanised high-affinity monoclonal igg antibody developed to bind human neonatal fc receptor (fcrn), selectively inhibiting igg salvage and recycling. conditions such as myasthenia gravis (mg) are characterised by pathogenic igg autoantibodies; inhibition of fcrn may provide a suitable therapeutic approach. this phase i, double-blind, dose-escalating, first-in-human study (nct ) evaluated the safety and pharmacology of ucb . forty-nine healthy adults (mean age years, range - ) were randomised and received a single dose of intravenous (iv) or subcutaneous (sc) placebo (n= and n= , respectively), or a single dose of iv or sc ucb ( , or mg/kg; n= per dose, per administration). subjects were followed up until day . one placebo iv subject did not complete the study. twenty-seven of subjects ( %) receiving ucb , and / ( %) receiving placebo, reported ≥ treatment-emergent adverse event (teae) of mild/moderate intensity. severe teaes occurred in four subjects, all in the ucb mg/kg iv group (headache [n= ], back pain [n= ]). no serious aes occurred. incidence of infections was similar with ucb and placebo. the most frequently reported infection was nasopharyngitis. treatment-related teaes were reported by % of subjects receiving ucb and % receiving placebo: the most common in the ucb -treated groups were headache ( / ; %) and vomiting ( / ; %); these occurred more frequently with the iv than sc route. non-linear increases in ucb plasma concentration-time profile with increasing dose were observed with ucb . serum igg was reduced in a dose-depended manner with ucb iv and sc: decreases from baseline to day with ucb iv were . %, . % and . % for , and mg/kg doses, respectively, and . %, . % and . %, with ucb sc doses, respectively. these data indicated that the fcrn inhibitor ucb effectively reduced serum igg, with sc administration generally better tolerated than iv. further to these observations, the efficacy, safety and tolerability of ucb sc for chronic-intermittent treatment of moderate-to-severe mg are being evaluated in an ongoing phase ii, multi-centre, randomised, double-blind, placebo-controlled study (eudract - - middle east respiratory syndrome (mers) has a high mortality rate and pandemic potential. however, very little information has become available on this syndrome since it first erupted in . this study aimed to evaluate the frequency of neurological complications and their clinical presentations in mers. we reviewed the medical records of all patients who were diagnosed with laboratory-confirmed mers coronavirus (cov) infections and subsequently admitted to a single reference center for mers treatment during the outbreak in korea. in total, patients ( . %) reported neurological symptoms during or after mers-cov infection. the potential diagnoses in these cases included bickerstaff's encephalitis overlapping with guillain-barré syndrome, critical illness polyneuropathy or other toxic or infectious neuropathies. neurological complications did not appear concomitantly with respiratory symptoms, but were instead delayed by - weeks. neuromuscular complications were not rare in mers-cov-infected patients, and they may have previously been underdiagnosed. understanding neurological manifestations is important in an infectious disease like mers, because evaluation is frequently limited during treatment, but it can interfere with prognosis and sometimes require modification of treatment. kim hj , hyun jk , kim tu . dankook university, cheonan, south korea. the diagnosis of carpal tunnel syndrome (cts) is based on clinical symptoms, physical examinations and supported by nerve conduction study (ncs). ultrasonographic examinations can be performed to assess peripheral nerves with less discomfort and the surrounding anatomic structures. while the usefulness of ultrasonography (usg) in the cts has been reported, no study to date has compared the diagnostic utility of various usg findings for cts. we investigated the correlation of various usg findings to the clinical symptoms/signs and ncs findings in patients with cts. twenty-eight hands ( patients) with cts based on electrodiagnostic criteria and clinical symptoms such as tingling sensation or pain in the first to third fingers, burning sensation, paresthesia and weakness of hand grip power. all subjects were examined with usg. cross-sectional area (csa) and flattening ratio (fr) of the median nerve was calculated at level of radio-ulnar joint, pisiform and hamate. swelling ratio of the median nerve and palmar displacement of the flexor retinaculum was also calculated. clinical assessment was conducted using the boston carpal tunnel questionnaire (bctq) scale and historical-objective (hi-ob) scale. the analysis of correlation between usg findings and clinical symptom scales/ncs findings was performed using correlation analysis. the csa of the median nerve at level of radio-ulnar joint was significant correlated with bctq scale, hi-ob scale, distal motor latency, and conduction velocity (cv). the csa of the median nerve at level of pisiform was significantly correlated with hi-ob scale, distal motor latency, and cv. the fr of the median nerve at level of radio-ulnar joint was significantly correlated with bctq scale, hi-ob scale, distal motor latency, and cv. the swelling ratio of the median nerve was also significantly correlated with distal motor latency and cv. in patients with cts, csa of the median nerve at level of radio-ulnar joint was most closely related to ncs findings and clinical symptoms. so, csa of the median nerve at radio-ulnar joint might be a complementary tool for the diagnosis of cts. kitaoji t , tsuji y , ashida s , yamada t , ishii r , tanaka a , mizuno t . department of neurology, graduate school of medical science, kyoto prefectural university of medicine, kyoto, japan. the case was a -year-old woman. first, she noticed paresthesia in the right plantar eight months before admission and in the left plantar four months before admission. three months before admission, she developed muscle weakness in her feet. the muscle weakness and paresthesia extended to the lower legs in a few months. twenty days before admission, she experience difficulty in walking. on admission, the muscle weakness was observed in the legs, especially in the right tibial anterior muscle (ta). there was severe sensory disturbance and loss of deep tendon reflex in the legs. she had trouble walking due to the weakness and sensory aphasia. in nerve conduction study (ncs), conduction block was observed between the ankle and popliteal in both tibial nerves. the blood level of angiotensin converting enzyme (ace) was elevated. cerebrospinal fluid analysis was normal. there was no enhancement in the lumbar nerve roots shown on mri. gallium- scintigraphy showed hot spots on bilateral hilar lymph nodes and mediastinal nodes and biopsy of mediastinal nodes showed non-caseating epithelioid granuloma. therefore, we diagnosed her with sarcoid peripheral neuropathy by sarcoidosis. by using the nerve ultrasound, partial spindle-shaped nerve enlargement was observed at the part of conduction block in the left tibial nerve. we started the treatment with methyl prednisolone ( mg, days) and oral prednisolone therapy ( mg/kg/day). after treatment, the paresthesia and muscle weakness in the legs had gradually improved. the partial enlargement in the left tibial nerve also improved on the -hospital day. in ncs, the conduction block improved, however, the compound muscle nerve potential of tibial nerve decreased because of axonal damage. this partial spindle-shaped nerve enlargement by using ultrasound has never been reported in sarcoid peripheral neuropathy before. the nerve ultrasound may be useful for evaluation of therapeutic effect of sarcoid peripheral neuropathy. peripheral nerve injuries are still debating problems in the world because of poor recovery. there is absolutely a need for new therapeutic agents to improve outcome by altering nerve regeneration. there are some studies in the literature about some therapeutic agents that used in the cases of peripheral nerve injuries. despite these studies, an agent with clinical use has not been presented yet. in this experimental study, we aimed to analyze the effects of curcumin (cur) in the cases of peripheral nerve injuries. forty rats were randomly and equally divided into four groups. the first group was control group. rats in this group were not operated. right sciatic nerve injuries were performed to the other groups. the second group was operation group with no therapeutic agent. the third group was operation and local cur applied group. the fourth group was operation and systemic cur applied group. electrophysiological evaluations were performed with electroneurography (enog) before and after the surgeries. systemic use of cur although caused improvement in the enog values but could not make a positive contribution to the nerve regeneration statistically. additionally local use of cur made negative effect to the nerve regeneration statistically. according to our statistical results we could not recommend cur as a nerve protective agent. klein cj , wu y , jentoft me , mer g , spinner rj , dyck pjb , dyck pj , mauermann ml . mayo clinic, rochester, usa. intraneural perineurioma is a hypertrophic peripheral nerve tumor having immunoreactivity to epithelial membrane-antigen, negative for s- . the origin of perineurial cells is debated to be similar to meningeal cells. ip does not metastasize, but motor deficits accumulate over time from tumor growth in nerve and plexus. after schwannomas and neurofibromas, perineuriomas are the most common nerve tumor of young adults. a chromosome q deletion has been reported in one patient. we identified ip cases from our previously published clinical cohort with available flash frozen ip tissue for dna isolation. wes with cnv analysis and cgh microarray analysis (agilent x k superprintg ) were performed on extracted dna; had available germline dna (lymphocytes and buccal tissue). we compared the exome data against online and in-house control data (∼ , ) examining variants less than . frequencies, predicted damaging or nonsynonymous. wes identified three novel, heterozygous, damaging mutations in tumor necrosis factor receptor-associated factor (traf ) in of ( %) cases; p.l p (n= ), p.h r (n= ) and p.s r (n= ). mutations were within the wd domain, p.l p, p.h r within exon and p.s r within exon , and mapped to a limited region of traf with protein structure modeling. two of cases ( . %) showed macroduplications/deletions on multiple chromosomes, including chromosome , confirmed with cgh microarray analysis and cnv results from exome data analysis. four of ( %) had no discovered mutation. age of onset or severity did not correlate with type of mutations. this study provides strong evidence that traf is a specific tumor driver of ip. mutations in traf are also linked to benign intracranial meningiomas suggesting a shared pathogenesis and close origins of perineurial and meningeal cells. study supported by: mayo foundation and the mayo center of individualized medicine. klein i , , bobylev i , , lehmann hc , . university hospital cologne, cologne, germany; center for molecular medicine cologne (cmmc), cologne, germany. peripheral neuropathy is a common side effect of paclitaxel. clinical evidence suggests that the delivery mechanism of paclitaxel formulations influence time course and severity of paclitaxel induced peripheral neuropathy. in a preclinical model we studied access, distribution and toxicity of two paclitaxel formulations (nanoparticle albumin-bound paclitaxel (nab) and solvent-based paclitaxel) in the peripheral nervous system (pns). c bl/ mice were treated with mg/kg or mg/kg of nab-paclitaxel or solvent based paclitaxel. kinetics of paclitaxel in neurons was assessed by a newly established immunostaining technique. neurotoxicity was evaluated by functional assays and nerve morphology. paclitaxel accumulated mostly in dorsal root ganglia, whereas distal nerve segments showed only low uptake of paclitaxel. treatment of mice with the two paclitaxel formulations resulted in paclitaxel uptake mostly in nf + larger fiber neurons. in ib +, and cgrp+ small fiber neurons, paclitaxel was less frequently detected. nab-paclitaxel was incorporated more rapidly compared to solvent-based paclitaxel but neurons also showed a faster clearance of nab-paclitaxel compared to solvent based paclitaxel. functional assays and nerve conduction studies indicated that nab-paclitaxel was less neurotoxic compared to solvent-based paclitaxel. this is the first study that characterizes in detail the access of nab-paclitaxel and solvent based paclitaxel into the pns. our findings have important implications to understand the pathomechanisms of paclitaxel induced neurotoxicity and to develop neuroprotective strategies by preventing access of paclitaxel to the pns. the aim of our study was to investigate the etiology of neuropathy in patients with rheumatoid arthritis (ra). subjects were neuropathy patients with ra admitted to our department. laboratory investigations, nerve conduction studies (ncs) and sural nerve biopsy were performed. mean patient age was . years (range, - years), and mean disease duration was . years (range, - years). clinical diagnosis for neuropathy was rheumatoid vasculitis (rv) in patients, rv with acute motor axonal neuropathy (rv-aman) in and chronic inflammatory demyelinating polyneuropathy with ra (ra-cidp) in . rheumatoid factor ( / ) and rheumatoid arthritis particle agglutination ( / ) was high and c tended to be lower in the rv group (rv and rv-aman). anti-ganglioside antibodies were examined in patients, with positive results in . an rv-aman case was diagnosed with motor-dominant clinical presentation and the presence of anti-galnac-gd a immunoglobulin (ig)g antibody. no other cases with rv were examined for anti-ganglioside antibodies. positive results for anti-gm and gm igg antibody were seen in one ra-cidp patient. we evaluated sural/median (s/m) ratio) for sensory nerve action potential (snap). s/m ratio was low in rv cases ( / ) and high ( / ) in immune-mediated cases, suggesting a so-called normal sural abnormal median pattern in immune-mediated neuropathies. the rv-aman case showed a moderate value in s/m ratio. nerve biopsy revealed thinly myelinated nerve fibers in ra-cidp cases compatible with demyelination, while the rv group showed the typical pathology for necrotizing vasculitis. rv cases were treated with prednisolone (psl), intravenous methylprednisolone, intravenous cyclophosphamide and increased psl dose. ra-cidp and rv-aman were treated with intravenous ig. in conclusion, neuropathy in ra can be divided into vasculitic and immune-mediated groups. ncs, and the s/m ratio of snap with some laboratory parameters in particular, may be of use in differential diagnosis and deciding treatment strategies. koh s , wong shj , loh kw , chng ysk , pawa c , ei ma , lee bjh , subramaniam t , umapathi t . national neuroscience institute, singapore, singapore; lee kong chian school of medicine, nanyang technological university, singapore; yong loo lin school of medicine, national university singapore, singapore; tan tock seng hospital, singapore; khoo teck puat hospital, singapore. treatment-induced neuropathy of diabetes mellitus (dm) (tind) is an acute painful autonomic neuropathy that develops with abrupt improvement in glycaemic control. typically, type or dm patients on insulin or oral hypoglycaemic agents (ohga), present with painful neuropathy and autonomic dysfunction within weeks of rapid improvement in glucose control. current emphasis to achieve good glycaemic control rapidly may inadvertently increase incidence of tind, hence the impetus to understand risk of over-zealous glycaemic control. we therefore set out to study the occurrence of tind in a dm cohort of a tertiary hospital. we screened all patients who had two hba c measurements between and . during this period, approximately patients were seen per year. we found patient-encounters that showed hba c decrease of ≥ % over months or ≥ % over months. we then used a structured checklist of tind symptoms to shortlist cases. these case-encounters were scrutinised and classified as; 'probable tind': acute painful neuropathy and acute dysautonomia with temporal relationship to the decrease in hba c; 'possible tind': acute painful neuropathy or acute dysautonomia or uncertain temporal relationship to decrease in hba c; unlikely tind: alternative explanation exists for symptoms. only one case was deemed 'probable tind'-a middle-aged man with newly diagnosed type dm who presented to emergency department with palpitations and worsening 'frozen feet' sensation that disturbed sleep. his hba c decreased by . % in weeks. his symptoms improved within a month with neuropathic pain medications and resolved months later. he also developed maculopathy and proliferative retinopathy. ten months later, he developed significant proteinuria. four other cases were classified as 'possible tind' while the remaining were unlikely tind. our study is limited by retrospective design and reliance on hospital records. nevertheless, our findings suggest that tind is uncommon in a general cohort of dm patients. on the other hand, the number of patients with painful neuropathy and acute dysautonomia symptoms contemporaneous with rapid decline in hba c raises the intriguing possibility that forme fruste of tind exists and one should interrogate the rate of hba c decline in dm patients with these symptoms. koike h , kadoya m , kaida k , ikeda s , kawagashira y , iijima m , kato d , ogata h , yamasaki r , matsukawa n , kira ji , katsuno m , sobue g . nagoya university graduate school of medicine, nagoya, japan; national defense medical college, tokorozawa, japan; nagoya city university graduate school of medical sciences, nagoya, japan; kyushu university, fukuoka, japan. we investigated the morphological features of chronic inflammatory demyelinating polyneuropathy (cidp) with autoantibodies directed against paranodal junctional molecules, particularly focusing on the fine structures of the paranodes. sural nerve biopsy specimens obtained from cidp patients with anti-neurofascin antibodies and patient with anti-contactin antibodies were assessed. these antibodies were examined using sera obtained from patients with cidp who fulfilled the criteria of the european federation of neurological societies/peripheral nerve society. thirteen cidp patients without these antibodies were also examined to compare pathological findings. characteristic light and electron microscopy findings in transverse sections from patients with anti-neurofascin and anti-contactin antibodies indicated a slight reduction in myelinated fiber density, with scattered myelin ovoids, and the absence of macrophage-mediated demyelination or onion bulbs. teased-fiber preparations revealed that segmental demyelination tended to be found in patients with relatively high frequencies of axonal degeneration and was tandemly found at consecutive nodes of ranvier in a single fiber. assessment of longitudinal sections by electron microscopy revealed that detachment of terminal myelin loops from the axolemma was frequently found at the paranode in both anti-neurofascin and anti-contactin antibody-positive cidp patients compared with antibody-negative cidp patients. patients with anti-neurofascin antibodies showed a positive correlation between the frequencies of axo-glial detachment at the paranode and axonal degeneration, as assessed by teased-fiber preparations (p < . ). in conclusion, paranodal dissection without classical macrophage-mediated demyelination is the characteristic feature of patients with cidp with autoantibodies to paranodal axo-glial junctional molecules. koike h , ikeda s , takahashi m , kawagashira y , iijima m , misumi y , ando y , ikeda si , katsuno m , sobue g . nagoya university graduate school of medicine, nagoya, japan; kumamoto university, kumamoto, japan; shinshu university hospital, matsumoto, japan. peripheral neuropathy is the cardinal feature of familial amyloid polyneuropathy (fap), but its mechanism has not been fully elucidated. we used electron microscopy to examine schwann cells and endoneurial microvessels. sural nerve biopsy specimens from fap patients with transthyretin val met mutation were assessed. patients were consisted of early onset cases from endemic foci and late onset cases from non-endemic areas. loss of nerve fibers with or without neighboring amyloid deposition was a common feature. the amount of amyloid deposition was greater relative to the extent of nerve fiber loss in early onset cases than in late onset cases. the atrophy of schwann cells, particularly nonmyelinating cells, that were apposed to amyloid fibrils was more conspicuous in early onset cases than in late onset cases. the numbers of endothelial cell nuclei, endothelial cell profiles, and occluded microvessels were significantly increased in the fap patients compared with patients with nutritional/alcoholic neuropathies (p < . , . , and . , respectively). findings suggestive of the disruption of blood-nerve barriers, such as the loss of tight junctions and the fenestration of endothelial cells, were also more frequently found in the fap patients (p < . ), irrespective of the presence or absence of amyloid deposition. in conclusion, these findings suggest that direct insult of amyloid fibrils causes schwann cell damage resulting in the predominant loss of small-fiber axons characteristic of early onset cases. in addition, vasculopathy may also participate in the pathogenesis of neuropathy, particularly in late onset cases. kolb n , smith ag , singleton jr , beck s , howard d , dittus k , karafiath s , mooney k . university of vermont, burlington, vt, usa; university of utah health, slc, ut, usa. chemotherapy induced peripheral neuropathy (cipn) is a major cause of morbidity due to numbness, pain, and gait instability. this prospective study compares the current standard care for cipn symptom management to a new care delivery model which utilizes an automated symptom tracking program paired with a nurse practitioner led intervention triggered by moderate to severe symptoms. all participants beginning taxane or platin based chemotherapy called a telephone based automated symptom tracking program daily (symptom care at home -sch) to report chemotherapy related numbness and tingling. sch tracked the presence and severity of neuropathic symptoms and their interference with activities of daily living (adls) on a - scale. participants were randomized to two groups. the usual care (uc) group was advised to call their oncology provider for recommendations on symptom management. in the nurse practitioner (np) group, when symptom severity was ≥ participants received automated self care strategies and a call from a nurse practitioner to provide treatment recommendations based on consensus guidelines. patients participated in the study. mean duration of follow up was . ± . days with . ± . calls. the np group had fewer days with any neuropathic symptom ( . % ± . vs. . % ± . , p= . ), with moderate to severe neuropathic symptoms ( . % ± . vs. . % ± . , p< . ) or days of distress from neuropathic symptoms ( . % ± . vs. . % ± . , p= . ). on days with moderate to severe symptoms participants also reported burning ( . ± . %), weakness ( . ± . %), balance problems, ( . ± . %), and tripping ( . ± . %). there was no significant difference between groups in the interference in adls (np . ± . vs. uc . ± . , p= . ). overall the automated telephone system effectively identified neuropathy symptoms and their severity. compared to usual care in which patients must independently reach out to their care team for symptom management, sch is effective in decreasing symptom prevalence, severity and distress. kouton l , kremer l , tard c , morales r , kuntzer t , attarian s , boucraut j , delmont e . referral centre for als and neuromuscular diseases, marseille, france; neurology department, strasbourg, france; neurology department, lille, france; neurology department, montpellier, france; neurology department, lausanne, switzerland; immunology laboratory, marseille, france. antibodies against proteins of the node of ranvier have been recently described in severe chronic inflammatory demyelinating polyradiculoneuropathies (cidp). they target paranodal proteins, namely contactin (cntn ) and neurofascin (nf ). cell-based assay and elisa are available in research, but no gold standard technic is admitted for the detection in routine of these antibodies. our objective was to evaluate if flow cytometry analysis is an efficient technic to detect antibodies against ctn and nf in a large cohort of cidp patients. flow cytometry analysis were performed on a bd facs-diva. human embryonic kidney (hek) cells were transfected either with nf or cntn . sera were diluted / . antibodies anti-cntn or nf were revealed using fitc conjugated anti human igg antibodies. delta mfi (mean fluorescence intensity) was calculated as mfi of transfected cells less mfi of non-transfected cells. measures were normalized using positive controls and negative controls from healthy blood donors. sera of cidp patients from different french neuromuscular referral centres were analysed with flow cytometry. respective delta mfi were (standard deviation ) and (standard deviation ) for antibodies against nf and cntn in cidp antibodies negative patients. antibodies against nf were found in patients (respective mfi , , ) and against cntn in two other patients (respective mfi and ). isotype of these antibodies was igg in patients and igg and igg in the remaining patient. all the patient had severe cidp. four patients had poor response to intravenous immunoglobulins (ivig) and have been treated with immunosuppressive drugs. as usually reported, the patient with anti-nf antibodies had postural tremor. flow cytometry seems effective to detect antibodies against nf and cntn . compared to other assays, benefits of flow cytometry are: to analyse a large number of sera in the same time and to give objective numerical results expressed in mfi that can be compared to the results of other samples. further studies are needed to confirm that flow cytometry can be the best test to assess antibodies against cntn and nf in routine. the mechanism by which intravenous immunoglobulins (ivig) improves peripheral nerve function in multifocal motor neuropathy (mmn) is unknown. the rapid clinical improvement following ivig could be related to blocking complement deposition on gm epitopes, change in ion-channel properties of affected motor axons, or both. the present study investigated median nerve motor excitability parameters at ∘ c just before ivig administration as well as at the peak of clinical improvement in patients with mmn. the investigated nerves were characterized either by conduction block (n= ), demyelinative slowing without block (n= ), or motor axon loss (n= ). the results of motor excitability testing in mmn showed no difference between pre-and post ivig recordings. clinical assessment of apb muscle showed increase in mrc score in patients and decrease in patient after ivig administration. in patients mrc score of the apb remained the same. those findings indicate that clinical changes following ivig administration are not related to excitability parameters of affected motor axons in mmn. where impulse conduction is blocked or markedly slowed in motor axons but is normal in sensory axons. sensory symptoms or signs are usually absent but have occasionally been reported in skin areas innervated by nerves with prominent motor axon loss. although the mechanism of selective motor involvement in mmn is unresolved, it may be related to differences in antigenic properties between motor and sensory axons or differences in biophysical properties. the objective of the present study was to compare ion-channel activity in both motor and sensory axons of nerves affected by mmn. affected nerves had to have motor conduction block, demyelinative slowing on motor ncs, or motor axon loss, whereas sensory ncs had to be normal. we performed excitability tests of motor and sensory axons in affected median nerves of mmn patients and healthy controls at ∘ c. conditioning and test stimuli were delivered at the median nerve at the wrist; cmaps were recorded from the thenar muscle and snaps from the rd digit. results of motor excitability testing in mmn showed fanning-out of threshold electrotonus, decreased i/v slope, and increased superexcitability, all compatible with persistent hyperpolarization of resting membrane potential in motor axons. sensory excitability testing in mmn showed decreased subexcitability but was otherwise normal. this may indicate minimal involvement of sensory axons in mmn. krarup c , , moldovan m , , alvarez s , ciano c , pisciotta c , pareyson d . university of copenhagen, copenhagen, denmark; rigshospitalet, copenhagen, denmark; fondazione irccs istituto neurologico c. besta, (incb), milan, italy. mutations in the gene coding for myelin protein zero (mpz, p ) are associated with different forms of charcot-marie-tooth (cmt) disease. we describe a family harboring a frameshift mutation (c. dela / p.asp thrfster ) in the p gene, predicted to result in a nonfunctional p truncated very early in the extracellular domain. this offered the rare opportunity to assess the consequences p deficiency in absence of the potential gain-of-function effects of the mutations itself. conventional conduction studies and multiple measures of nerve excitability by "threshold tracking" were carried out in heterozygote parents (aged and ) and their two homozygote sons (aged and ). in the homozygous patients, all distal limb cmaps and snaps were absent. for neurophysiological assessment, the spinal accessory nerve was stimulated at the neck and cmap was recorded over the upper trapezius muscle. eight normal subjects, mean age , were used as control. the two sibs showed a severe phenotype with early onset, severe scoliosis, complete loss of distal movements and relevant proximal weakness, cmt examination score (cmtes) - / ; both heterozygous parents had very mild adult-onset neuropathy with cmtes < / . control subjects had a trapezius cmap with a latency of . ms and an amplitude of . mv. heterozygotes had a mild cmt type b phenotype, with a cmap latency of . ms and an amplitude of . mv whereas the homozygotes had a severe neuropathy with a cmap latency of . ms and an amplitude of . mv. consistently, the homozygotes had a more severe impairment in excitability with a rheobase of . ma as compared to . ma in the heterozygote and . ma in controls. deviations in excitability measures were similar to our previous reports in p +/− and p −/− mice. mathematical modeling, indicated both altered passive cable properties due to dysmyelination and depolarizing features with increased na+ currents. our data suggest that p deficiency is associated with impaired axonal na+ channel function, arguing for the translational value of na+ channel blocker treatments as found in p null mouse models. krishnarajah s , divino v , mallick r , dekoven m . csl behring, king of prussia, pa, usa; quintilesims, fairfax, va, usa. chronic inflammatory demyelinating polyneuropathy (cidp) is a rare neurological disorder of the peripheral nervous system. the objectives of this retrospective real-world study were to compare demographic and clinical characteristics among cidp cases and matched controls and to assess cidp treatment utilization. adults newly diagnosed with cidp between / / and / / were identified in the quintilesims pharmetrics plus health plan claims database (first diagnosis date termed the index date). eligibility requirements were: confirmation of cidp (second cidp diagnosis or initiation of cidp therapy) within year of initial diagnosis, continuous health plan enrollment in the months prior to diagnosis (the pre-index) and the years following diagnosis (the follow-up), and no cidp diagnosis or use of cidp therapy in the pre-index. a total of , cidp cases met the study eligibility criteria. cases were direct-matched to controls based on age, gender, region, health plan, and payer type at index, and pre-index charlson comorbidity index score. the final sample consisted of cases matched to controls (both: mean [sd] age . [ . ]; . % male; . % commercially-insured). alternative pre-index diagnoses among cases included inherited neuropathies ( . %) and chronic acquired polyneuropathies ( . %). in the pre-index, neuropathic pain ( . % vs. . %), back pain ( . % vs. . %), and use of opioids ( . % vs. . %) and anti-convulsants ( . % vs. . %) were significantly higher among cases compared to controls (p< . for all). median total pre-index healthcare costs were . x higher for cases than controls ($ , vs. $ , , p< . ). over the follow-up, median total healthcare costs were . x higher for cases than controls ($ , vs. $ , , p< . [mean $ , and $ , ] ). cidp-related therapy costs accounted for . % of total healthcare costs for cases. the majority of cases ( . %) initiated cidp therapy over the follow-up, in a mean of . ( . ) days from initial diagnosis. half ( . %) of cases initiated treatment with corticosteroids only, while . % initiated ivig only. over the follow-up, . % of cases used any corticosteroid, while . % used any ivig. our findings suggest a substantial clinical and economic burden of cidp compared to matched controls. corticosteroids and ivig were most commonly used to treat cidp. kronlage m , baeumer p, pitarokoili k , schwarz d , schwehr v , godel t , heiland s , gold r , bendszus m , yoon ms . department of neuroradiology, heidelberg university hospital, germany; department of neurology, st. josef hospital, ruhr university of bochum, germany. objective: to evaluate large coverage magnetic resonance neurography (mrn) in chronic inflammatory demyelinating polyneuropathy (cidp). methods: in this prospective study patients with cidp and healthy controls were examined by a standardized mrn protocol at tesla. lumbosacral plexus was imaged by a t -weighted d-sequence ( mm isotropic voxel size); peripheral nerves of the upper and lower extremity by axial t -weighted turbo-spin-echo sequences ( . x . mm in-plane resolution). lesions were characterized by nerve cross sectional area (csa) and t -weighted signal (nt ). additionally, t -relaxometry of the sciatic nerve was performed using a multi-spin-echo sequence. all patients received a complementary electrophysiological exam. results: patients with cidp exhibited increased nerve csa and nt compared to controls (p < . ) in a proximally predominating pattern. roc analysis revealed best diagnostic accuracy for csa of the lumbosacral plexus (auc = . ) and nt of the sciatic nerve (auc = . ). csa correlated with multiple electrophysiological parameters of demyelinating neuropathy (f-wave latency, nerve conduction velocity) of sciatic and median nerve, while nt only correlated with f-wave latency of sciatic and not median nerve. t -relaxometry indicated that mr-signal increase in cidp was due to increase in proton-spin-density (p < . ), and not increase in t -relaxation time. conclusion: both nt and csa might aid in diagnosis of cidp, but csa correlates more robustly with electrophysiological parameters. since best diagnostic accuracy was shown for proximal nerve locations, mrn may be a useful complementary tool in select cidp cases. kühnemund j , wetzel c , bégay v , moshourab r , lewin gr . mdc & bih, berlin, germany; mdc, berlin, germany; charité, berlin, germany. damage of peripheral sensory nerves due to diabetes, herpes zoster infection, chemotherapy or trauma can cause chronic neuropathic pain. common symptoms include increased pain sensation (hyperalgesia), touch-induced pain (allodynia), paresthesia and spontaneous pain. we currently have poor understanding about the underlying molecular mechanisms at the peripheral level and treatment of patients suffering from neuropathic pain is inadequate. recent meta-analysis studies show that common first-line medications only yield nnts (numbers needed to treat) between . to . . it is still unclear to what extent allodynia can be attributed to changes in the physiological properties of intact sensory afferents. in this study, we aimed to elucidate whether changes occur in intact sensory afferents that innervate the plantar skin of the hind-paw following induction of neuropathic symptoms. this question was of particular interest considering that blocking mechanotransduction in the skin can alleviate mechanical hypersensitivity in neuropathic pain models (wetzel et al nature neuroscience ( ): - ). we used the chronic constriction injury (cci) model in mice which is behaviourally characterized by robust mechanical hypersensitivity. we made electrophysiological recordings from primary afferent neurons which had intact axons passing through the constriction to innervate the plantar skin using an ex-vivo skin-nerve preparation. we were able to record from myelinated afferent fibers and unmyelinated c-fibers with receptive fields in the control uninjured plantar skin as well as plantar skin of cci mice. we will present evidence that changes in the mechanosensitivity of sensory fibers innervating the glabrous skin may contribute to the symptoms of neuropathic pain. neuropathology, national hospital for neurology and neurosurgery, london, uk; irccs foundation "carlo besta" neurological institute, milan, italy; neurogenetics unit, national hospital for neurology and neurosurgery, london, uk; nuffield department of clinical neurosciences, oxford, uk; department of clinical neurophysiology, norfolk and norwich university hospital, uk. hsn secondary to sptlc / is a rare slowly progressive neuropathy resulting in marked sensory loss, especially nociception and significant motor deficit. despite most of the patients having the same c w mutation in sptlc , there is marked heterogeneity in the phenotype. l-serine oral supplementation has been suggested as potential therapeutic candidate however the lack of outcome measures is a major limiting factor in the initiation of a clinical trial. we undertook a natural history study to identify outcome measures that are responsive enough to be used in a clinical trial. the assessments used were cmt neuropathy score (cmtns version and cmtns version rasch modified), mri of calves and thighs, computerised myometry, quantitative sensory testing (qst), comprehensive neurophysiological assessment, proximal thigh skin biopsy for intra-epidermal nerve fibre density (ienfd), plasma dsl levels and patient based questionnaires (neuropathic pain symptom inventory and sf- v ). standardised response mean, srm (mean change/standard deviation of change) was used to compare responsiveness between tests. patients were recruited: with sptlc (c w) and with sptlc mutations. when analysed as a whole cohort, proximal calf mri fat fractions showed the most significant change over months. ienfd, plasma dsl levels, npsi and sf- v showed minimal change or the change was not in the clinically expected direction. for subsets of the remaining assessments which showed the highest responsiveness, the cohort was sub-divided into mild-moderate (cmtns ≤ ) and severe (cmtns> ) subgroups. in the mild-moderate subgroup, the greatest improvement in responsiveness was seen in computerised myometry (ankle plantarflexion: srm=− . and ankle eversion: srm=− . ). in the severe subgroup, qst (vibration detection thresholds on hands: srm=− . and face: srm=− . and pressure pain threshold on the face: srm= . ) and proximal calf mri fat fractions (srm range= . - . ) showed the greatest improvement. focusing on subgroups classified according to disease severity improved the responsiveness of some tests into the highly responsive range with mri still being the best outcome measure. this will reduce the number of participants required to power a clinical trial and might be a possible solution for designing a clinical trial for a rare, slowly progressive disease with a heterogeneous phenotype. kugathasan u , clark aj , suriyanarayanan s , laurá m , wilson e , , kalmar b , greensmith l , , hornemann t , reilly mm * , bennett dlh * . hsn secondary to sptlc / mutation is a slowly progressive sensory motor neuropathy leading to profound sensory loss with variable but often severe motor deficit. the genes sptlc and encode for the essential enzyme serine palmitoyltransferase (spt) which catalyses the rate limiting step in the sphingolipid de-novo biosynthesis. mutations in these two genes alter the substrate specificity of spt leading to the synthesis and accumulation of atypical metabolites called -deoxysphingolipids ( -deoxysl). plasma levels of -deoxysl are raised in hsn patients. deoxysphingolipids have been shown to be toxic in avian and by our group, in mammalian primary drg and motor neuron cultures. firstly, this study looked at the effects of -deoxysl on the survival and neurite integrity of human ipsc derived sensory neurons following exposure to different concentrations of deoxysphingolipids. later, we determined if there was autonomous -deoxysl production in hsn patient ipsc derived sensory neurons. sensory neurons were differentiated from human ipscs using a combination of small molecular inhibitors. deoxysphingolipids were found to be neurotoxic in this model after hours of treatment. in control lines, there is a significant reduction in neuronal survival following treatment with both -deoxysphinganine ( -deoxysa) and -deoxymethylsphinganine ( -doxmethsa). a clear dose-dependent increase in the expression of the axonal injury marker, atf , is seen with both -deoxysphngoid bases. in both instances, -deoxysa is more neurotoxic than -doxmethsa, which is similar to the findings in avian and mammalian primary neuronal cultures. autonomous -deoxysl production is seen in ipsc derived neurons obtained from three different hsn patients with the levels being significantly greater than that seen in multiple control lines. this is the first study to demonstrate that human ipsc derived sensory neurons can be used as an in-vitro model for hsn , providing a great opportunity both to probe the pathomechanisms mediating deoxysphingolipid toxicity and to test potential therapeutic agents. recent studies have demonstrated an association between autoantibodies directed against antineurofascin- (anti-nfasc ) and a subpopulation of cidp patients characterized by sensory ataxia, tremor and poor response to ivig treatment. here we report on the clinical features of three patients who developed acute changes in their phenotype during the course of their neuropathy, a potential clue to recognize a neuropathy with predominantly humoral dysimmunity. case reports: our index patient had developed sensory changes over weeks, followed by irregular locomotion, and muscle weakness with general areflexia. a first run of ivig improved the patient in a week, but he relapsed within days. a second ivig course with prednisone again normalized deficits within days. ivig runs and rituximab were still necessary to treat a nd , and then a rd relapse before obtaining complete improvement. the course of the neuropathy was months. two other patients were encountered with more chronic courses but in whom periods of worsening or improvement suggested a relapsing-remitting neuropathy, either spontaneously or following immunomodulating treatments. in all three, extensive work-ups were negative, anti-nfasc igg were positive, and detailed repeat nerve conduction studies demonstrated fluctuating conduction blocks. discussion: our report underscores that in chronic cidp patients a relapsing-remitting course could be encountered as a key feature of anti-nfasc neuropathy. this not yet described characteristic course could be of value when deciding using rituximab instead of immunomodulating treatments. kusunoki s , morikawa m , kuwahara m , ueno r , samukawa m , hamada y . faculty of medicine, kindai university, osaka-sayama, japan. anti-glycolipid antibodies are often detected in sera from patients with autoimmune neuropathies, such as guillain-barré syndrome (gbs), chronic inflammatory demyelinating polyradiculoneuropathy (cidp), and multifocal motor neuropathy (mmn). not only individual glycolipid antigens but also mixtures of two different glycolipids (glycolipid complexes) are sometimes recognized by serum antibodies. to investigate antibody activities against large number of glycolipid complexes in serum samples from patients with gbs, mmn, and cidp, we examined igm and igg antibodies against glycolipids [gm , gm , gd a, gd b, gq b, galnac-gd a, lm , galactocerebroside (gal-c), asialo-gm (ga ), and sulfatide] and glycolipid complexes consisting of two different glycolipids listed above, by using combinatorial glycoarray. serum was obtained from patients with gbs, patients with cidp and patients with mmn, all in the acute or relapsing phase. serum was also obtained from healthy controls and patients with other neurological diseases. we investigated the relationships between the clinical features and presence of those antibodies. high titers of igg antibodies were detected almost exclusively in gbs patients. in contrast, igm antibodies were frequently present in mmn and gbs. among the anti-glycolipid complex antibodies in gbs, anti-gm /sulfatide, anti-ga /sulfatide, anti-gm /gd a, and anti-gq b/sulfatide igg antibodies were common ( , , , and patients, respectively). igg antibodies against antigens containing gm were significantly correlated with pure motor gbs (p < . ) and those against antigens containing gq b were significantly correlated with gbs with ophthalmoplegia (p < . ). in seven of the patients with anti-gq b/sulfatide complex antibodies, the antibodies were specific to the gq b/sulfatide complex rather than the individual gq b and suldfatide antigens. moreover, four patients did not have antibodies other than those to the anti-gq b/sulfatide complex. in patients with mmn, igm antibodies to antigens containing gm or galnac-gd a were present in % and . %, respectively. glycoarray is efficient for detecting antibodies against numerous glycolipid complexes in immune-mediated neuropathies. we need further investigations on other immune-mediated diseases using larger number of antigens. kuwabara s , misawa s , sekiguchi y , susumu kusunoki and the jet-gbs study group . department of neurology, chiba university, chiba, japan; department of neurology, kindai university, osaka, japan; japanese eculizumab trial for guillain-barré syndrome, chiba, japan. guillain-barré syndrome is a monophasic immune-mediated neuropathy, but a substantial number of patients with severe disease have poor recovery, even if treated with immunoglobulin. recent studies suggest that complement activation plays a pivotal role in gbs-associated axonal degeneration, and eculizumab is a monoclonal antibody that specifically binds to complement component and inhibits complement activation. jet-gbs is an investigator-led, phase , randomized, placebo-controlled trial conducted in hospitals, this trial aims to investigate the safety and efficacy of eculizumab for treatment of severe gbs. patients were randomly assigned ( : ) to treatment with immunoglobulin plus either eculizumab ( mg/day; n= ) or placebo (n= ) once weekly for weeks. the primary outcome measures are safety and efficacy (the proportion of subjects who regain their ability to walk independently at week ). the secondary outcome measures included the proportion of subjects who were able to walk independently at week , and other measures such as mrc sum scores, nerve conduction parameters. enrollment for the trial began in august , and follow-up of the last patient was completed in october . analyses will be made in april , and the results will be presented at this meeting. this trial is registered with clinicaltrials.gov identifier: nct , and funded by the japanese agency for medical research and development, and alexion pharmaceuticals inc. neurofascin , a paranodal protein in peripheral nerve, is a target antigen for autoantibodies in a subset of chronic inflammatory demyelinating polyneuropathy (cidp). anti-neurofascin antibody-positive cidp is characterized by onset at younger age, tremor, and refractoriness to ivig. we have treated four patients with anti-neurofascin antibody-positive cidp at kindai university hospital. anti-neurofascin antibody was detected by both elisa and cell-based assay in those patients. igg subclass was predominantly igg in all four cases. the median age of the patients at admission was . years [range: - years]. among the four patients, three had tremor, and two had severe cerebellar ataxia. cerebrospinal fluid protein levels were remarkably increased [median: . mg/dl, range: - mg/dl]. although ivig treatment was administered in all four patients, the responses were poor or partial. in contrast, plasma exchange (pe) was performed in all four patients and the clinical symptoms dramatically improved in two of them. corticosteroids were also effective in those two patients. sural nerve biopsy was performed in all four patients. although sensory nerve action potentials of the sural nerves from those patients were not evoked, the transverse semithin sections of sural nerves from three patients revealed only slight or mild loss of myelinated fibers. partial paranodal demyelination was observed in teased-nerve fibers from three patients. in addition, abnormal paranodal lesions such as loss of the transvers bands were observed by electron microscope in all four patients. those electron microscopic findings were not observed in control patients with anti-neurofascin antibody-negative cidp. anti-neurofascin igg antibody-positive cidp shows distinctive clinical and pathological features. labeyrie c , besson f , vandendries c , cauquil c , beaudonnet g , not a , durand e , adams d . neurologie adulte, chu bicêtre, le kremlin bicêtre, france; médecine nucléaire, chu bicêtre, le kremlin bicêtre, france; clinique bizet, paris, france; unité de neurophysiologie clinique, chu bicêtre, le kremlin bicêtre, france. study of the proximal portion of the peripheral nervous system (pns) is difficult because less accessible to electrophysiological exploration and biopsy. the indications of mri are increasing in proximal neuropathies to analyse morphology of the roots, plexus and proximal nerves: integrity of the nerve bundle, inflammation or infiltration of these structures. pet-computed tomography (pet-ct) can detect infiltration of the proximal segments of the pns, with hypermetabolism of roots, plexuses and large nerve trunks. pet-ct is also useful in detection of solid neoplasm which can infiltrates pns and primary nerve sheath tumors. however, spatial resolution of pet -ct scan is limited to explore the roots and plexuses for moderate hypermetabolisms. we believe that a mild hypermetabolism could be highlighted in inflammatory neuropathies or in mild tumor infiltrations. we performed a fusion of whole body pet (performed because of suspected neoplasia) and plexus mri (pet-mri) images in ten patients with a peripheral neuropathy for which we suspected proximal involvement. the pet-ct and mri were first read separately, then with merge of the images by a nuclear physician and a neuroradiologist. five out of ten patients presented with hypermetabolism of pns (hmpn+) on pet-mri: root (n= ), and/or dorsal root ganglia (n= ). median sul of lesions was . . among the hmpn+ patients: hypermetabolism was already apparent on pet-ct in cases, the merge invalidated abnormalities seen on pet-ct in patients and mri detected additional lesions, not visible on pet-ct, in one patient. all hmpn+ patients had hypersignal and or hypertrophy of pns on mri either diffuse (n= ), or multifocal (n= ). among hmpn-(no hypermetabolism) out of ( %) had abnormal mri ( multifocal and diffuse). gadolinium enhancement was found in all patients receiving gadolinium in the hmpn+ (n= ) and only in / patients in the hmpngroup. final diagnoses of hmpn+ patients were neurolymphoma in one ( %), and idiopathic cidp in the others ( %) with histological proof on nervous root biopsy in one of them. final diagnosis in hmpn-patients was cidp in out of and sequelae of neuropathy in relation to lymphoma without relapse for the last one. cidp was more disabling (onls≥ ) in hmpn+ than in hmpn-group % vs. %. pet-mri could be helpful to detect a proximal inflammation of the pns, and to plan further testing. further studies are needed to evaluate the prognostic value of hmpn+. lancaster e , li j , liem r , scherer ss . perelman school of medicine, university of pennsylvania, philadelphia, pa, usa; columbia university school of medicine, new york, ny, usa. heterozygous nefl n s/+ mutant mice are the first animal model of a charcot-marie-tooth disease e (cmt e). people with this mutation have a severe, early onset axonal neuropathy. axons in the mutant mice have reduced number of neurofilaments and decreased diameters. they also show early onset of tremor and abnormal hindlimb clasping behavior. we measured the compound action potentials (caps) from tails every weeks from the same cohort of nefl n s/+ mutant mice and their wt littermates from to weeks. even at the age of weeks, the amplitude of mutant caps was only ∼ % of wt caps ( ± . microv, n= vs ± . microv, n= ), and the caps stayed substantially smaller than those in wt mice for weeks ( ± . microv, n= vs ± . microv, n= ). the conduction velocity and the duration of caps in mutants were slower and wider compared to those of wt. separate cohorts of mice (n= mutants and n= wt) were sacrificed at different time points for analysis by light microscopy. in caudal nerve of mutant mice, the number of axons was significantly reduced compared to that of wt at weeks and, by weeks, it was reduced more than %. this model system may be useful for preclinical studies of treatments for cmt e since the animals show progressive neuropathy over weeks, which can be objectively measured electrophysiologically and anatomically. despite more than cmt genes identified today, at least % of cmt patients do not carry a mutation in any of these genes. progress in gene identification in recent years suggests that there are still many more cmt disease genes to be discovered; however, it has become rare to gather support from multiple large families that allow for conclusive linkage analysis. we have studied multiple extended dominant cmt families with linkage support for a gene at chromosome p . . originally a czech family yielded a two point lod score of . at this locus and a family from southern italy showed a lod score of . . whole exome sequencing of multiple family members identified missense mutations in the gene atpase na+/k+ transporting subunit alpha (atp a ). atp a has not been associated with human diseases thus far. in expression studies on teased fiber preparations we already confirmed predominant expression in the nodes of ranvier of peripheral nerves. through collaborative efforts in the inherited neuropathy consortium and beyond we identified five additional multigenerational families via exome or sanger sequencing resulting in a total of seven unique segregating missense changes: leu arg, ile thr, ala thr, asp phe, pro ala, pro thr and asp ala. five of these mutations fall into a remarkably narrow motif associated with the sodium binding structure of atp a , flanking the flexible hinge motif. functional studies in different model systems (mammalian cell lines, xenopus oocytes, patient fibroblast lines) are underway to determine whether a loss or a dominant gain-of-function represents the disease mechanism. taken together, we show strong support for a major new dominant cmt gene, atp a . this finding represents a new pathway and an attractive new target for therapy development in axonal cmt. laurá m , ramdharry g , , singh d , kozyra d , skorupinska m , reilly mm . mrc centre for neuromuscular diseases, ucl institute of neurology, london, uk; school of rehabilitation sciences, st george's university of london/kingston university, uk; royal national orthopaedic hospital, stanmore, uk. charcot-marie-tooth (cmt) disease is the most common inherited peripheral neuropathy. foot deformities are frequent complications and orthopaedic surgery is often required. however there are no evidence based guidelines on the type or timing of the surgery. only few studies have described the long-term results of surgical procedures and evidence regarding optimal surgical management of these patients is lacking. we prospectively studied surgical management of cmt patients attending our centre. we collected data and assessed cmt patients before and after surgery. data included: history of ankle instability, pain, skin condition, details of physiotherapy and orthotic management, assessment of lower limb strength, charcot-marie-tooth examination score (cmtes), foot posture index, ankle dorsiflexion range of movement and specific questionnaires (foot index and manchester-oxford foot questionnaire, modified fatigue severity scale and modified falls efficacy scale), details of surgical procedures. patients were assessed yearly after surgery. so far patients ( males and females, age range - ) have been evaluated prior to surgery. all patients but one had genetically confirmed cmt ( cmt a, cmtx, cmt a). patients have been assessed after year, patients after years, patients after years and patient after years from surgery. a wide range of surgical procedures were performed by one dedicated orthopaedic surgeon. preliminary results showed reduction of number of falls in / ( %) patients and improvement of callosities in / ( %) patients at year follow up. there was also significant improvement of alignment of the operated foot (p= . ) and pain (p= . ). there were no significant changes in measures of strength and ankle range of motion. further analysis on a larger number of patients will be important to determine the long-term outcome of surgery. data acquired from this study will help develop orthopaedic intervention guidelines and identify areas for further research. lavigne-moreira c , oliveira mf , marques vd , onofre ptbn , dos santos acj , nascimento ojm , barreira a , marques w jr . division of neuromuscular diseases and neurogenetics, department of neurosciences and behaviour sciences, clinical hospital of ribeirão preto, university of são paulo, ribeirão preto, brazil; department of neurology, fluminense federal university, rio de janeiro, brazil. fap associated to ttr mutations is defined as a length-dependent axonal sensory and motor polyneuropathy that at early stages affects mainly the small nerve fibers, associated to autonomic and thermo-algesic sensations. the expected emg pattern was that of an axonal sensory and motor polyneuropathy, but in fact several unexpected patterns may be found. in this study we present the results found in a brazilian population with ttr mutation. patients were divided in three groups: ttr-met of early onset, ttr-met of late onset and ttr non-met . in the first group (ttr-met of early onset), ( . %) examinations were normal, ( . %) were axonal, were demyelinating fulfilling pidc criteria, one suggested a predominately motor polyneuropathy and the final one presented a lower motor neuron disease pattern. in the second group (ttr-met of late onset), ( . %) had an axonal pattern, ( . %) had an intermediate cv, ( . %) had a demyelinating pattern, had a lumbossacral pattern and the final one had no definite pattern. among the non-ttr met , two patients had the ttr -asp tyr, one presented an axonal pattern, while the second presented initially an axonal pattern, that changed to a demyelinating pattern in the second examination. patients with ile val mutation presented an axonal neuropathy associated to cts. most patients with demyelinating or intermediate pattern were treated with corticosteroids or ivig, with no satisfactory results. this small series of patients shows clearly that fap-ttr is associated to several emg patterns in addition to the expected sensory and motor axonal polyneuropathy. this variability is present in the same family and in the same patient in different occasions. clinicians should be alert to these possibilities to do not delay diagnosis and treatment. identifying the mechanisms involved in this variability could improve our knowledge of this intriguing disease. lavin tm . greater manchester neurosciences centre, salford royal hospital, manchester, uk. subcutaneous immunoglobulin (scig) has evidence from small trials for its use following intravenous igg (ivig) loading in chronic inflammatory demyelinating polyneuropathy (cidp). potential advantages of scig include stable igg levels and reduced complication rates. scig de novo can be considered as igg levels gradually rise with subcutaneous delivery and maybe beneficial for patients for whom complications are a concern. we present cases of cidp who were initiated on subcutaneous immunoglobulin g ( g/kg/month, % scig, hizentra, csl behring) following corticosteroids; without intravenous igg loading. patient is year old with a history of ihd with a progressive lower limb sensory changes and sensory ataxia over years. neurophysiology confirmed sensory demyelinating changes. he did not respond to corticosteroids. concerns were raised about the potential risk orf adverse cardiac events with iv immunoglobulin. scig therapy was introduced at g weekly. initial therapy has been well tolerated and objective measures (rods-cidp score, jamar grip strength, hole peg) have remained stable through initiation, and at months. patient is yr old male with a past history of branch retinal vein thrombosis. he developed a sensorimotor polyneuropathy over years with neurophysiology fitting efns criteria for cidp. given concerns regarding previous thrombosis, a trial of scig was given at g/week, with resolution of sensory ataxia and improvement in objective markers (jamar grip strength, rods-cidp score, hole peg) at months. unfortunately an adverse event occurred of an urticarial skin reaction. patient is a yr old male who presented with motor predominant cidp. there was no response to corticosteroids but improvement following plasma exchange. due to a past history of transient ischaemic attack, scig was started. there has been a positive response after months with improvement in walking distances and stable objective markers (rods-cidp score, grip and pinch strength). our cohort remained neurologically stable during initiation of scig, with adverse reaction. our experience would support further trials in this area regarding the efficacy of scig compared to ivig in both the short and long term. diabetic peripheral neuropathy is the most common and debilitating complication of diabetes and it is associated to neuropathic pain and non-traumatic amputations. despite the economic burden and human costs, nowadays there is not a specific treatment to cure diabetic peripheral neuropathy. hyperglycaemia and dyslipidemia-mediated oxidative and endoplasmic reticulum stress has been linked to diabetic peripheral neuropathy, among other altered pathways. in order to study in more detail the molecular mechanisms that lead to the development of diabetic peripheral neuropathy we set up in vitro models of the disease using nsc- (motoneurons) and med . (sensory neurons) cell lines or primary cultures of dorsal root ganglia and motoneurons exposed to saturated fatty acids. it has been reported that palmitic acid is able to induce endoplasmic reticulum stress and oxidative stress in multiple cell types including schwann cells and myenteric neurons, resulting in a good model of dyslipidemia-mediated stress. here we found that palmitate induces upregulation of the molecular chaperone bip/grp and the ccaat-enhancer-binding protein homologous protein (chop) mrnas and a dose-dependent downregulation of the apoptosis marker bcl- in primary cultures. moreover, palmitic acid induces loss of neuron dendrites and cell death at high doses and upregulation of heme oxygenase (ho- ) and chop at lower doses in the nsc- cell line. we are currently characterizing multiple molecules implicated in oxidative stress, endoplasmic reticulum stress and inflammation pathways in these cell types to find new therapeutic targets to treat type diabetic sensorimotor polyneuropathy, that will be subsequently validated in the db/db mouse model by pharmacological or gene therapy strategies. lee bjh , ohnmar o , wong j , koh sj , umapathi t . lee kong chian school of medicine, nanyang technological university, singapore; national neuroscience institute, singapore. treatment-induced neuropathy of diabetes mellitus (dm) (tind) is an acute painful peripheral neuropathy and autonomic dysfunction that occurs within weeks of tight glycaemic control. therapy with either insulin or oral hypoglycaemic agents (ohga) may result in tind. the quantum and rate of decline in hba c predicts development and severity of tind. both type i and ii dm patients are prone to this iatrogenic complication. besides the expected morbidity associated with painful somatic and autonomic neuropathy, tind patients also develop life-threatening eye complications such as maculopathy. with greater awareness, we picked up at least typical cases of tind in recent few months. however, there was a fourth possible tind case, whom we feel deserves special attention. the circumstances surrounding this case are common and may go under-recognised in acute hospitals. a year-old man with -year history of poorly controlled type ii dm was admitted with a partial left middle cerebral artery stroke. one month before admission, his hba c was . %. his hospitalization was prolonged because of his considerable disability that required rehabilitation. he stayed weeks. his blood sugar was difficult to control with hyperglycaemic episodes requiring ohgas and insulin. the highest capillary blood glucose recorded was mmol/l. he also had episodes of hypoglycaemia. three weeks into hospitalization, he developed severe orthostatic hypotension. he came to our attention two months later when he was sent for autonomic screening tests for severe postural hypotension, in spite of therapy with fludrocortisone and midodrine. his hba c was . %. he had marked orthostatic hypotension suggestive of sympathetic dysfunction. we were not able to discern if he had a painful neuropathy because of his aphasia. there was no recent ophthalmology review. we suggested a diagnosis of possible tind. he was discharged with lower doses of ohga. however, day after discharge, he attended the emergency department for a syncopal episode. this case raises intriguing questions on the safety of glucose control paradigms commonly employed in patients with acute stroke and myocardial infarction as well as the possible role of major fluctuations in blood glucose in the development of tind. lee hs , kim sm . presbyterian medical center, jeonju, korea; yonsei university college of medicine, seoul, korea. the occurrence of peripheral neuropathy by a tumor within or compressing a nerve in neurofibromatosis (nf) type and is relatively well known. however, nf presenting with demyelinating polyneuropathy unrelated to tumor masses is rarely reported. we report a rare presentation of an nf patient with demyelinating polyneuropathy of subacute onset. a -year-old woman was referred to our hospital with paresthesia on both limbs months before. she was healthy and had no family history. the symptoms worsened over the next months, tremor and weakness in both limbs occurred. although she treated as a chronic inflammatory demyelinating polyneuropathy (cidp) with intravenous steroid and immunosuppressant in another hospital, symptoms were getting worse. bifacial numbness and left eyeball pain occurred weeks ago and she visited our hospital. on neurologic examination, bilateral facial sensory hypoesthesia and symmetrical both limbs weakness (mrc grade iv+) were observed. decreased touch and pinprick sensation on both limbs were observed like stocking-glove distribution. the reflexes were sluggish. on nerve conduction study, sensorimotor demyelinating polyneuropathy with conduction blocks and temporal dispersions was observed. bilateral r , r responses were prolongation on facial blink test. mri of cervical spine and brain revealed contrast enhancing tumor-like enlargement of multiple nerve roots and cranial nerves. nerve biopsy was performed on right supraorbital nerve, neurofibromatous changes were observed. the symptom deterioration was stopped without treatment. gene test dose not revealed nf type and . on review of the literature, polyneuropathy in nf patient can result from tumor masses within the proximal nerve roots, or along the peripheral nerve, or in the extramedullary lesion affecting neighboring nerve roots. thus, axonal type polyneuropathy and focal amyotrophy have been reported in nf. demyelinating polyneuropathy has not been reported before in our knowledge. although the etiology of demyelinating polyneuropathy in nf requires further clarification, some authors claim that unknown local toxic or metabolic influences of the endoneurial pathological cells on adjacent nerve fibers. in this patient, atypical symptoms were observed in cidp such as cranial nerve involvement and stocking-glove sensory distribution. in this case, a nerve biopsy can be helpful the accurate diagnosis. lee jy , yoo jh , kang dk , bae js . department of neurology hallym university, seoul, korea. acute disseminated encephalomyelitis (adem) is an uncommon post-infectious inflammatory demyelinating disorder of central nerve system, while guillain-barre syndrome (gbs) is a prototype of acute post-infectious peripheral neuropathy. previous reports regarding the coexistence of these relatively rare diseases suggest that certain immunogenicity within central and peripheral nerves may share a common autoimmune process during the disease course. a previous healthy years old man was admitted because of fever, headache, nausea and myalgia in department of infectious disease. two weeks before admission, he suffered from watery diarrhea for days and spontaneously recovered. at initial presentation, he had high fever( ∘ c), headache and myalgia and intermittent horizontal diplopia. a few days after admission, he began to complain of drowsy mentality, bilateral extremities weakness, especially lower limbs, dysarthria, bilateral facial paralysis, urinary retention, dyspnea. on neurologic examination, he had mildly drowsy mentality, symmetric muscle weakness scoring of on bilateral hip, knee flexion and finger extension, but he had no sensory symptoms. he showed gazed evoked nystagmus with no extraocular muscle palsies. deep tendon reflexes were not present. pulmonary function test revealed a severe restrictive pattern. csf studies disclosed a dissociative increase of protein contents ( mg/dl) without pleocytosis. anti ganlioside antibody assay identified an anti-gt a igg positivity in his serum. nerve conduction study (ncs) showed prolonged motor terminal latencies and slow motor conduction velocity on multiple nerves. in contrast, sensory ncs revealed no abnormal findings. imaging studies unexpectedly revealed apparently symmetrical lesions across bilateral brainstem and basal ganglia suggesting a diagnosis of adem. after both ivig and high dose steroid treatment, he remarkably recovered from disturbed mental state and motor weakness. about month after the symptom onset, he could walk with assistant aid and discharge to other hospital for rehabilitation. our case suggest that certain component of autoimmunity simultaneously result in both cns and pns inflammation. specific immunological mechanism is remained to be elucidated. although we could not conclude whether cellular component or humoral component is dominant for our case, the presence of anti gt a antibody suggest a role of humoral mechanisms. the aim of this study is to evaluate whether peripheral neuropathies and headaches affect the same subgroups of patients with ibd. since , we have established a cohort study to evaluate the prevalence and incidence of neurological diseases in patients with ibd. over a period of years, all patients with ibd (either crohńs disease or ulcerative colitis) were invited to participate in a study designed to evaluate the risk factors for the presence of headaches and peripheral neuropathy in ibd. a separate group of control patients (age-matched relatives of ibd patients) was also formed. after a clinical interview and neurological examination, patients were invited to undergo skin wrinkling test (swt) to evaluate small fiber function and/or electromyography. headaches were present in . % of the patients with ibd, and were more common in patients with ulcerative colitis than in control patients (p< . ). migraine comprised . % of all cases of headache and was more prevalent in patients with crohńs disease than control patients (p< . ). tensional headaches were also common affecting . % of the ibd patients. electromyography was abnormal in . % of the ibd patients tested ( / ). swt was abnormal in . % of the ibd patients tested ( / ). . % of the ibd patients had abnormal swt but had no neuropathy symptoms. patients with abnormal swt or emg were not more likely to have headaches (p= . and . , respectively). overall, patients with symptomatic polyneuropathy were not more likely to have headache (p= . ). patients with abnormal swt or emg were also not more likely to have migraine (p= . and . , respectively). patients with abnormal swt or emg were also not more likely to have tension-type headache (p= . and . , respectively). in summary, although highly prevalent in this population of brazilian ibd patients, primary headaches and neuropathy do not affect the same subgroups of ibd patients. further studies are necessary to understand the mechanisms of both conditions in ibd patients. leitao amf , , araújo df , marques h , pamplona l , , souza mh , , nbraga ll , , gondim faa , . the aim of this study is to evaluate whether peripheral neuropathies and headaches affect the same subgroups of patients with ibd. since , we have established a cohort study to evaluate the prevalence and incidence of neurological diseases in patients with ibd. over a period of years, all patients with ibd (either crohńs disease or ulcerative colitis) were invited to participate in a study designed to evaluate the risk factors for the presence of headaches and peripheral neuropathy in ibd. a separate group of control patients (age-matched relatives of ibd patients) was also formed. after a clinical interview and neurological examination, patients were invited to undergo skin wrinkling test (swt) to evaluate small fiber function and/or electromyography. headaches were present in . % of the patients with ibd, and were more common in patients with ulcerative colitis than in control patients (p< . ). migraine comprised . % of all cases of headache and was more prevalent in patients with crohńs disease than control patients (p< . ). tensional headaches were also common affecting . % of the ibd patients. electromyography was abnormal in . % of the ibd patients tested ( / ). swt was abnormal in . % of the ibd patients tested ( / ). . % of the ibd patients had abnormal swt but had no neuropathy symptoms. patients with abnormal swt or emg were not more likely to have headaches (p= . and . , respectively). overall, patients with symptomatic polyneuropathy were not more likely to have headache (p= . ). patients with abnormal swt or emg were also not more likely to have migraine (p= . and . , respectively). patients with abnormal swt or emg were also not more likely to have tension-type headache (p= . and . , respectively). in summary, although highly prevalent in this population of brazilian ibd patients, primary headaches and neuropathy do not affect the same subgroups of ibd patients. further studies are necessary to understand the mechanisms of both conditions in ibd patients. the classic guillain barré syndrome (gbs) is characterized by motor weakness, hyporreflexia, but limited sensory deficits. sensory variants involving either small or large fibers or both are unusual and represent a diagnostic challenge. we described patients presenting with the sensory variant of gbs and retrospectively analyzed the clinical and electrophysiological findings of patients fulfilling the criteria for sensory gbs according to oh et al. criteria. six patients were identified (mean age years: range - years). four had a previous infection. they all consulted due to distal painful paresthesias and allodynia. on examination the patients presented normal strength and normal cranial nerves through the course of the disease with reduced knee and ankle reflexes in patients. distal hyperesthesia to pinprick was identified in and one of them additionally had hyperhidrosis and constipation. two additional patients presented hypoesthesia to pinprick and temperature. one patient had distal proprioceptive sensory loss with sensory ataxia. csf albumin cytological dissociation was present in patients. nerve conduction studies (ncs) identified a sensory motor demyelinating neuropathy in patients. among the with normal ncs, had abnormal cold and warm threshold in their qst evaluation. all patients received symptomatic treatment for the neuropathic pain and only two ivig therapies. longstanding pain, fatigue or both were persistent findings in patients after a mean follow up of months. in conclusion the sensory variant of gbs is both an infrequent presentation and a diagnostic challenge. longstanding pain and fatigue are common persisting findings. the epidemic of zika virus (zikv) throughout the americas and asia, and the subsequent rise in reported cases of guillain-barré syndrome (gbs) caused worldwide concern. as of january , countries have reported evidence of mosquito-borne zikv transmission and in of these countries, a sudden increase of gbs has been reported. moreover, case studies and a case-control study further indicate that zikv may trigger gbs. however, accurate diagnosis of both zikv and gbs in many of these studies is disputed, and a comprehensive description of the clinical phenotype of gbs related to zikv is lacking. the international gbs outcome study (igos) is a prospective observational study on the factors determining the onset, clinical course and outcome of gbs. at present, a research consortium of centers from countries has included patients in igos. our aim is to investigate zikv-related gbs in igos as is already occurring in colombia. in igos-zika, data on clinical features and ancillary investigations will be collected in zikv endemic areas according to the igos protocol with some modifications. first, igos-zika has a case-controlled study design to define the association between gbs and zikv and other arboviruses. second, urine samples will be collected and additional questions on preceding events will be asked, focusing on arbovirus infections. third, a more limited follow-up is required. our aim is to recruit additional centers via the inflammatory neuropathy consortium (inc) and centers in all arbovirus endemic regions that are willing to participate. the focus of igos-zika will be on the accuracy of the diagnosis of both gbs and zikv and on defining the associated clinical phenotype, course and outcome. igos-zika provides the opportunity to combine data and biobanks from various geographical regions using a standardized protocol and to compare these data with data and biosamples already collected in igos. studying these cases will help to optimize diagnostics and care for gbs patients in arbovirus endemic countries and provides a unique opportunity to further understand the pathogenesis of gbs. moreover, this study design and network can be used to adequately respond to other future viral epidemics related to gbs. lerat j , cintas p , dzugan h , , magdelaine c , , sturtz f , , lia as , . service de biochimie et génétique moléculaire -chu de limoges, limoges, france; service de neurologie et d'explorations fonctionnelles -chu de toulouse, toulouse, france; ea -université de limoges, limoges, france. pharc syndrome is an autosomal recessive neurodegenerative pathology leading to demyelinating polyneuropathy, hearing loss, cerebellar ataxia, retinis pigmentosa and early-onset cataract. these various symptoms can occur at different ages, so that pharc syndrome can be a differential diagnosis of charcot-marie-tooth disease (cmt) associated with deafness. only abhd mutations have been reported in patients. we described the th mutation and compared our results to the literature data. we analysed by next generation sequencing (ngs) strategy using a targeted cmt and associated neuropathies -gene panel the dna of a -year old male who has suffered from demyelinating sensory and motor polyneuropathy and ataxia since the age of . bilateral sensorineural deafness was diagnosed at the age of five. bilateral congenital cataracts were operated on at the age of . a new large complex homozygous mutation, with one deletion of seven base pairs and one insertion of base pairs, was detected. by analyzing our patient data and those of the literature, we evaluated that, in pharc syndrome, sensorineural deafness always occurs as the first feature in late teens. the ophthalmological symptoms are cataracts that occur at a mean age of yo and then retinis pigmentosa at a mean age of . demyelinating sensory-motor polyneuropathy is the most variable characteristics, which occurs in the thirties. we report the first large complex homozygous mutation in pharc syndrome, which is certainly under-diagnosed. therefore, it seems interesting to include abhd in the panels of the five symptoms, especially deafness ones. chronic inflammatory demyelinating polyradiculoneuropathy (cidp) is a chronic disabling disease that often improves with immune therapy. to date, the most reliable diagnostic criteria for cidp are the efns/pns revised criteria, with a reported sensitivity of % and specificity of %. we implemented a web-based database to collect data from patients with cidp followed by italian centers with expertise on cidp to determine the frequency and characteristic of cidp and it variants, the diagnostic criteria used for their diagnosis, the possible evolution into typical cidp, the association with specific anti-nerve antibodies, and their response to therapy. all the patients were evaluated at the time of inclusion and will be followed for two years to monitor their outcome and response to therapy. by february we included patients with cidp and variants ( men, women), aged - years (median ) with a mean disease duration of . years (range . - years). based on clinical symptoms, cidp was defined as typical in % and atypical in %. the diagnosis of typical cidp fulfilled efns/pns criteria in % of the patients while nerve conduction studies were not diagnostic in % (grouped as clinical cidp) or not available in %. we analyzed the frequency of supportive criteria for the diagnosis of cidp in patients with clinical cidp and found that increased csf proteins, demyelination or cell infiltration on nerve biopsy and imaging abnormalities consisting with cidp on us or nmr were present in %, % and % of the patients, respectively. a relapsing course was present in % of patients with clinical cidp, increasing the reliability of the diagnosis for cidp. in addition an improvement after one or more therapies was reported by % of the patients, with a positive response to ivig in %, steroids in % and plasma exchange in %, similarly to what observed in patients fulfilling efns/pns criteria. in % of the patients with clinical cidp two or more supplementary criteria for cidp were present. this study on a large population of patients is providing useful information that may help to revise the current diagnostic criteria for cidp. li j , cannell m , suragani r , pearsall r , kumar r . acceleron pharma inc, cambridge, usa. charcot-marie-tooth (cmt) is the most common hereditary peripheral neuropathy and is characterized by demyelination and/or axonal damage of peripheral nerves and muscle weakness. foot drop, steppage gait, and foot deformities are a typically seen in cmt patients. consequently, falls are commonly reported in these patients. improvement of dorsiflexor muscle function to prevent falls may improve quality of life and activities of daily living in patients with cmt. ace- , a locally-acting ligand trap that binds growth and differentiation factors (gdfs) and activins, has previously been shown to increase muscle mass and force in both duchene muscle dystrophy (dmd) and amyotrophic lateral sclerosis (als) mouse models. in the current study, we evaluated the therapeutic effects of ace- to improve muscle strength in the trembler (tr-j) mouse model of cmt a. these mice harbor a mutation in the peripheral myelin protein (pmp ) known to cause cmt a. seven-month old (b .d -pmp tr-j /j) mice were administered ace- ( g, twice weekly) intramuscularly to one of the unilaterally tibialis anterior (ta) muscle for weeks. the contractility of the ta muscle was evaluated during isometric contraction. all data were compared to the uninjected contralateral control hind-limb. after weeks of ace- treatment, ta muscle mass was increased by % (p< . ) and its physiological cross-sectional area was increased by % (p< . ). the increase in muscle mass correlated with an increase in strength, with maximum tetanic force and twitch force improved by % (p< . ) and % (p< . ), respectively. in addition, temporal properties during isometric contraction, such as maximum rate of contraction and relaxation, were accelerated by % and % respectively (p< . ) in the ace- -treated ta muscle compared to its contralateral hind-limb. pathological and biochemical assessment of ace- -treated mice showed enlarged myocyte area (+ %, p< . ) and reduced atrogin- mrna expression (− %, p< . ). together, these results demonstrated that ace- attenuates the degree of muscle atrophy and also improves muscle function in a mouse model of cmt a. the current study provides proof of concept for the use of ace- as a therapy for cmt to improve dorsiflexor muscle function and alleviate foot drop. we have generated a rat model of charcot-marie-tooth disease a (cmt a) harboring the p.arg trp mfn mutation, whose human counterpart results in a severe, early-onset axonal neuropathy. the mutation was made using zinc finger nuclease-mediated genome editing in fertilized rat eggs. a large cohort of mutant and wt littermates were characterized behaviorally and found to develop multiple motor deficits that worsened over time. nerve conductions of the tail (caudal nerve) was performed on a separate cohort of mutant (n= ) and wt littermates (n= ) every weeks from to weeks. mutant rats showed a progressively decline in the amplitude of the compound action potential after weeks, whereas the amplitude progressively increased in their wt littermates. separate cohorts of rats were sacrificed at , , and weeks and analyzed by light microscopy. in mutant rats, there was a reduced density of myelinated axons and active axonal degeneration in distal but not proximal nerves, and in the fasciculus gracilis of the cervical spinal cord at and weeks. these findings were not present in the -week-old cohort of mutant rats, or in wt rats at or weeks. a genetically authentic animal model of cmt a that develops a progressive, length-dependent axonal neuropathy will be a valuable tool for examining the pathogenesis and treatment of cmt a. lindborg ja , niemi, jp , defrancesco a , zigmond re . case western reserve university, cleveland, usa. traditionally the role of immune cells in nerve degeneration and regeneration has focused on the infiltration of inflammatory monocytes into the distal nerve after nerve injury and the phagocytosis by the resulting macrophages of myelin and axonal debris, thereby clearing a path for regenerating axons. therefore, it was surprising when we discovered that in ccr knockout (ko) animals, in which the entry of these inflammatory monocytes does not occur, that wallerian degeneration precedes normally. we now report that the reason for this is that neutrophils and schwann cells compensate for the decrease in macrophage accumulation. furthermore, nearly complete depletion of circulating neutrophils by systemic injection of an antibody to ly g leads to an inhibition of myelin clearance both in ccr ko and in wild type animals. on the other hand, we have demonstrated a second site of macrophage accumulation in wild type animals, namely around axotomized sensory neurons in dorsal root ganglia (drgs). blockade of that accumulation, for example as occurs in ccr ko animals, leads to a dramatic impairment of nerve regeneration. to examine the relationship between macrophages and regeneration further the monocyte chemokine ccl was overexpressed in drg neurons in intact animals by viral infection using an aav containing the ccl coding sequence. the resulting overexpression of ccl led to the accumulation of macrophages in drgs even though no injury had taken place and subsequently to an increase in the intrinsic growth capacity of the sensory neurons. examination of changes in gene expression in the drgs in these animals revealed increased expression of the cytokine leukemia inhibitory factor and an increase in its downstream signaling pathway that involves the phosphorylation and nuclear translocation of stat . strikingly, pharmacological blockade of stat activation inhibited the increase in the neurons' growth capacity produced by the virus. these results reveal unexpected interactions between immune cells and neurons facilitating nerve degeneration and regeneration and could lead to therapies to improve regeneration after injury or in disease. lin j , , qiao k , , huang j , , zhao cb , , lu jh , . institute of neurology, fudan university, shanghai, china; department of neurology, huashan hospital, fudan university, shanghai, china. we used terminal latency index (tli) as a tool in differentiation between poems syndrome and chronic inflammatory demyelinating polyradiculoneuropathy (cidp). comparison of median and ulnar nerve conduction studies including motor conduction velocity (mcv), distal motor latency (dml) and terminal latency index (tli) were studied in poems patients, matched cidp patients and normal controls. in this cohort, the average age at evaluation was . ± . years old in poems group and that of cidp patients was . ± . years old. except the ulnar terminal latency index in cidp group, poems and cidp patients demonstrated prolonged distal latencies, low conduction velocities and increased terminal latency indexes compared with the normal group. reduced conduction velocities and higher terminal latency indexes in poems group than in cidp group was found. increased tli was demonstrated in . %(median nerve) and . %(ulnar nerve) poems and that in cidp patients was . %(median nerve) and . %(ulnar nerve). decreased tli was found in . %(median) and . %(ulnar) cidp patients and none in poems. temporal dispersion (td) and conduction block (cb) were more often seen in cidp patients with increased tli than that in poems. compared with cidp and poems showed greater slowing of the intermediate nerve segments and relatively more uniform demyelination. about % cidp demonstrated more distal conduction slowing and more td and cb especially in those with increased tli. terminal latency index combined with td and cb may be helpful in differentiating poems from cidp. lin y , sung j , chang t , jowy t . department of neurology, taipei municipal wanfang hospital, taipei, taiwan. the purpose of our study is to exam whether electrophysiology changes could be detected in prediabetes patients and to discover the possible mechanism of nerve injury in prediabetes stage. we analysis and compare the nerve excitability test data between prediabetic patients and age-matched normal control subjects. prediabetes is defined by american diabetes association (ada) as one of the three following: hba c . % to . %, fasting glucose mg/dl to mg/dl, and hour oral glucose tolerance test to mg/dl. patients with radiculopathy, myelopathy, entrapment neuropathy such as carpel tunnel syndrome, and polyneuropathy were excluded. the strength-duration time constant (sdtc) and superexcitability showed significant difference (p< . ) between two groups. we also find increased threshold electrotonus in depolarization (ted) and reduced relative refractory period (rrp) and refractoriness in . msec. these early changes in prediabetic patient are similar in nerve excitability feature of diabetic patients. however, the above changes are not found in motor axonal excitability test. our data supports that nerve excitability test may be a useful, non-invasive, and less time dependent tool to detect peripheral nerve injury in prediabetic stage. the sensory axons are more vulnerable than motor axons. superexcitability is the most sensitive parameter in prediabetes. transthyretin-related familial amyloid polyneuropathy (ttr-fap) is an autosomal dominant disorder caused by mutations of ttr gene and is associated with variable penetrance. ttr-fap is rare, except for endemic areas. this is a retrospective study of ttr-fap patients diagnosed at our center between - . we identified four families with different ttr mutations. in one family with v a mutation, nine family members over four generations diagnosed with ttr-fap was followed since . in the other families the index cases with different mutations were identified between - . affected family members with v a mutation developed severe progressive polyneuropathy with cachexia, with onset of the disease between ages and . three patients presented with marked visual symptoms (one patient underwent vitrectomy). nine patients died to years after disease onset. two patients (sisters) underwent liver transplantation -one died after years of disease at age , second is years old and wheelchair-bound as her symptoms continue to progress. the ttr mutations diagnosed in the index cases of three other families are: d v, f l and v m. they all presented with similar clinical picture of late-onset ttr-fap with predominant progressive axonal sensory, motor and autonomic polyneuropathy. all three index cases were men, the onset of symptoms was between - years with numbness and paresthesia in the feet followed by weakness and autonomic dysfunction. all had excessive weight loss resulting in cachexia and were diagnosed with cardiomyopathy. no patient suffered from visual symptoms. all three patients progressed to stage ii of ttr-fap -walking with assistance. time to diagnosis was . - years. due to advanced stages of their disease these patients were not suitable for therapy with tafamidis or the liver transplantation. the ttr d v (p.d v) was confirmed as a de novo mutation, which is uncommon in ttr-fap. in the remaining families carriers of ttr mutations were identified and are followed up. pedigree analysis of the family with f l mutation revealed affected members who with high probability died from ttr-fap. our study suggests that patients with ttr-fap in poland exhibits clinical and genetic heterogeneity. liu x , fan d . department of neurology, peking university third hospital, beijing, china. objective: to identify the gene mutation of chinese charcot-marie-tooth pedigrees and investigate the correlation among the clinical manifestation, electrophysiology and mechanism of different genotype. methods: we included pedigrees with cmt enrolled in our hospital from january, to december . we recorded clinical features, cmtns and electrophysiological data at diagnosis. the patients underwent mutation analysis of pmp , cx , mpz, mfn , hspb , hspb using mlpa, dhplc and sanger gene sequencing. results: we found pmp duplication pedigrees ( . %), cx pedigrees ( . %), mfn pedigrees ( . %), mpz pedigrees ( . %) conclusions: in chinese han population, the proportion of pmp duplication is relatively low, the majority of clinical manifestation is classical cmt. axonal cmt can show isolated lower extremity injury, with central nervous system involvement. hmn may be an underestimated clinical types, the identification should be done with caution in differential diagnosis. liu y , liu b , sebastian b , wozniak km , wu y , slusher b , polydefkis m . johns hopkins school of medicine, baltimore, usa. chemotherapy-induced peripheral neuropathy (cipn) is a common dose-limiting toxicity in the treatment of many cancers. most cipn studies preferentially focus on sensory fiber loss and dysfunction. here, we compared the structural and functional recovery of autonomic fibers in sweat glands (sweat gland nerve fiber density, sgnfd) and sensory fibers (intra-epidermal fiber density, ienfd) in mouse footpads after exposure to a maximum tolerated dose (mtd) of several common chemotherapy agents. additionally, we assessed footpad sweat production as a functional correlate to sgnfd reductions. female balb-c mice ( -animals/group) were treated with a mtd of four anti-tubulin drugs: paclitaxel (pca, mg/kg), ixabepilone (ixa, mg/kg), eribuline (erib, . mg/kg), vinoelbine (vino, mg/kg), or corresponding placebo given intravenously, mwf for two weeks. recovery was assessed at -hours, , , , , and weeks following the last dose. footpads were processed to visualize epidermal nerve fibers using pgp . and autonomic nerve fibers with tyrosine hydroxylate and pgp . . ixabepilone-treated mice experienced significant reductions in sgnfd at hrs, while ienfd nadir occurred at a later time point, -weeks. the recovery to baseline levels occurred more quickly for ienfd ( -weeks) than sgnfd ( -weeks). in contrast, vinorelbine and eribuline treated mice experienced a maximum deficit in sgnfd and ienfd at hrs and sgnfd recovery was slower ( -weeks) compared to ienfd ( -weeks). pca-treated animals showed more severe ienfd and sgnfd deficits compared to the other agents with both ienfd and sgnfd not recovering completely until -months. reductions in th-sgnfd were comparable or more pronounced to decreases in pgp . -sgnfd for all agents and timepoints. pca-treated animals demonstrated reductions in footpad sweat droplet number thereby providing a functional correlate. together, these data indicate that in mouse models of cipn, autonomic nerve fibers are affected more severely than sensory nerve fibers, and also recover more slowly than intraepidermal nerve fibers. autonomic dysfunction may be an important and under-appreciated consequence of chemotherapy exposure. the pi -kinase vps (pik c ) synthesizes phosphatidylinositol -phosphate (pi p), a lipid critical for both endosomal membrane traffic and macroautophagy. human genetics have implicated pi p dysregulation, and endosomal trafficking in general, as a recurring cause of demyelinating charcot-marie-tooth (cmt) peripheral neuropathy. here, we investigated the role of vps , and pi p, in mouse schwann cells by selectively deleting vps in this cell type. vps -schwann cell knockout (vps scko ) mice show severe hypomyelination in peripheral nerves. vps −/− schwann cells interact abnormally with axons, and there is a delay in radial sorting, a process by which large axons are selected for myelination. upon reaching the promyelinating stage, vps −/− schwann cells are significantly impaired in the elaboration of myelin. nerves from vps scko mice contain elevated levels of the lc and p proteins, indicating impaired autophagy. however, in the light of recent demonstrations that autophagy is dispensable for myelination, it is unlikely that hypomyelination in vps scko mice is caused by impaired autophagy. endosomal membrane traffic is also disturbed in vps −/− schwann cells. we investigated the activation of the erbb / receptor tyrosine kinases in vps scko nerves, as these proteins, which play essential roles in schwann cell myelination, are known to traffic though endosomes. in vps scko nerves, erbb was hyperphosphorylated on a tyrosine known to be phosphorylated in response to nrg exposure. the overall level of erbb was also decreased during myelination. our findings suggest that the loss of vps alters the trafficking of erbb / through endosomes. abnormal erbb / signaling may contribute to the hypomyelination observed in vps scko mice. lombardi r , devaux j , cortese a , dacci p , benedetti l , demichelis c , lauria g . irccs foundation "carlo besta" neurological institute, milan, italy; aix-marseille université, marseille, france; irccs c. mondino national neurological institute, pavia, italy; university of genoa and irccs aou san martino-ist, genoa, italy. the recent identification of igg anti-neurofascin (nfascin) antibodies in a group of patients has widened the spectrum of presentation for chronic inflammatory demyelinating polyradiculoneuropathy (cidp). these patients can be distinguished by disabling tremor, poor response to intravenous immunoglobulin and distal and sensory disturbances. cell-adhesion molecule nfasc and cntn are expressed on the paranodal junction (pnj) of nodes of ranvier, and play key roles on sodium channel clustering and glia-axon interactions. quantification of unmyelinated intraepidermal nerve fibers (ienf) is a useful parameter employed in small nerve fiber pathology diagnosis. in addition the immunohistochemistry evaluation of dermal nerve fibers allows to examine morphological changes of myelin sheath and ranvier nodes structure. we performed immunofluorescent colocalization studies using antibodies to visualize axons (protein-gene-product . , neurofilament, tubulin), sheath of myelin (myelin-basic-protein) and specifically nodal/paranodal/juxtaparanodal structures (pannfascin, nfascin , nfascin , caspr, cntn , potassium and sodium channels) in skin tissues from seronegative and seropositive cidp patients. we analyzed axon and myelin sheath damage, abnormal nodal-paranodal-juxtaparanodal architecture and morphometric parameter as internodal length of ranvier nodes. our results on skin biopsies from three igg nfasc -positive cidp patients revealed complete loss of nfasc staining at the paranodes, asymmetrical paranodes and widening of the nodes of dermal myelinated nerve fibers. one igg cntn -positive cidp patient showed abnormal nodal/paranodal immunostaining with different features as compared with igg nfasc -positive patients suggesting specific changes. however, such alterations were not found in four seronegative cidp patients. our data support the hypothesis that examining specific axonal and myelin markers could provide diagnostic and prognostic clues on nodo-paranodopathies. the goal of this study is attempt a possible correlation between the presence of serum autoantibodies and structural changes in nodal/paranodal regions of dermal nerve fibers in cidp patients. knowledge of autoantibodies expression in the peripheral myelinated nerves of cidp patients could serve for stratifying patients and potentially guiding personalized treatments. lunati a , lerat j , dzugan h , , rego m , magdelaine c , , bieth e , calvas p , cintas p , gilbert-dussardier b , goizet c , journel h , magy l , toutain a , urtizberea j , sturtz f , , lia as , . charcot-marie-tooth disease is one of the most frequent inherited peripheral neuropathies ( / ). so far, mutations in more than genes have been identified causing either the demyelinating form (type ) or the axonal form (type ). duplication of pmp gene is the most frequent cause of autosomal dominant demyelinating form. autosomal recessive demyelinating form is often due to sh tc gene mutations. patients suffer then from early severe neuropathy starting in the first decade. scoliosis and deafness are often observed. we analysed patients suffering from peripheral neuropathy, by multiplex-ligation-dependant-probe-amplification (mlpa), followed by targeted next-generation-sequencing (ngs) using a -gene custom panel designed for the diagnosis of charcot-marie-tooth and associated neuropathies. mutations of interest were verified by sanger sequencing. diagnosis was positive for patients. as expected, the most frequent mutation was the pmp duplication detected in patients. deletion of pmp was observed in patients and pathogenic point mutations were detected in patients. sh tc gene appeared to be the most frequently mutated with nine patients diagnosed. associated with known mutations, four new mutations have been identified: two nonsense mutations and two missense mutations. all these patients presented deafness and/or scoliosis. sh tc appears to be an important gene involved in charcot-marie-tooth disease, often associated with deafness and /or scoliosis. it is important to pay attention to these associated symptoms in charcot-marie-tooth patients in order to guide their diagnosis and to improve their medical care. lupo v , , frasquet m , , sánchez-monteagudo a , , barreiro m , alberti ma , casasnovas c , quintáns b , , , camacho a , domínguez c , sedano mj , pelayo al , pardo j , sobrino t , sobrido mj , , , sevilla t , , espinós c , . mme (membrane metalloendopeptidase) mutations, inherited in an autosomal recessive fashion, have been recently identified in japanese probands (higuchi et al. ) . thus, mme has been included in the list of cmt genes as a new autosomal recessive axonal form, cmt t (mim ), and moreover, it is considered a strong candidate for the genetic diagnosis of unsolved late-onset cmt cases. in fact, few months later auer-grumbach et al. ( ) reported european probands with autosomal dominant late-onset cmt and mutations in mme. we have investigated a clinical series of patients diagnosed of motor or sensory-motor peripheral neuropathy using an updated version of our custom gene panel, which includes mme. in this study, we report probands with cmt , intermediate cmt or dhmn/cmt and homozygous or compound heterozygous mutations in mme, and proband with cmt and a heterozygous mutation in mme. we have identified different type of mutations: novel splice donor variant, frameshift, nonsense and missense mutations. the two nonsense changes, p.trp * and p.arg *, and the splice donor variant c. + g>a, were detected in homozygous or compound heterozygous state in patients, while the frameshift mutation, p.pro leufs* , was detected in homozygous or heterozygous in the remaining patients. strikingly, the two nonsense and the frameshift mutations had been previously reported as causative for autosomal-dominant cmt t (auer-grumbach et al. ) . out of three missense mutations, one is novel (p.his tyr), and two are reported in control databases (p.asn lys and p.arg trp). this study shows that the autosomal recessive cmt t is common in spanish population, and moreover, it suggests that screening of mme using gene panel testing could help to improve diagnosis of unclarified inherited peripheral neuropathies cases. funds: isciii (pi / , pi / ); fundació per amor a l' art. inherited peripheral neuropathies (ipns) encompass a group of disorders highly heterogeneous, clinically and genetically. charcot-marie-tooth (cmt) disease is closely related to distal hereditary motor neuropathy (dhmn) or distal spinal muscular atrophy (dsma), and some patients show additional signs associated with amyotrophic lateral sclerosis (als). targeted gene panel and exome sequencing are considered to be powerful and cost-effective tools for diagnosis of these disorders. we have investigated a clinical series of patients diagnosed of motor or sensory-motor peripheral neuropathy: families were investigated by exome sequencing and, cases were tested using different updated versions of a gene panel . each version comprises , or ipn genes, respectively and it shows a high coverage performance: percentage of analyzable target base with > coverage was , %. both exome and gene panel capture libraries were based on sureselect capture technologies (agilent technologies), and sequencing was performed in miseq or hiseq illumina equipment. we have identified novel genes and novel mutations in known genes, broadening the phenotypical spectrum associated with ipns. exome sequencing has allowed us to identify causative gene in % of familiar or sporadic cases: morc , aars, bscl , kif a, gars, egr , fig , dnajb , drp , ighmbp , dao, sod , fig . gene panel testing has been mostly performed in sporadic cases, and it has allowed us to identify either disease-causing or candidate mutations in % of cases: kif a and bicd were the most common genes mutated. update gene panels neuro and neuro have revealed novel mutations in genes recently associated to cmt and cmt disease: mme and pmp , respectively. in sum, both strategies have helped us to achieve a more accurate clinical and genetic reclassification of these disorders, an impossible challenge using conventional sequencing methods. our study expands the clinical phenotype previously associated to known ipn causing-gene, and emphasizes that gene panels should be considered as a first diagnosis method for unclarified ipn patients. funds: isciii (pi / , pi / , pi / ); fundació per amor a l' art. magy l , mathis s , goizet s , tazir m , vallat j-m . department and laboratory of neurology, national reference center for rare peripheral neuropathies, chu limoges, france; department of neurology, chu bordeaux, france; department of medical genetics, chu bordeaux, france; department of neurology, chu algiers, algeria. charcot-marie-tooth (cmt) disease is a hereditary neuropathy with a relatively homogeneous phenotype but is genetically heterogeneous. moreover, nerve conduction studies distinguish different forms, adding another level of complexity. the current classification of cmt being difficult to understand for physicians, scientists and patients, we presented and published a proposal for updating this classification, based on inheritance, nerve conduction findings and gene/mutation involved. inputs from colleagues prompted us to conduct a survey in order to try to reach some consensus about our proposals. we conducted an internet survey between october and december . the link to complete the survey was sent several times by email with an introduction to more than people. participants were contacted through the emailing list from the last cmt meeting in venice (september ) and additional physicians and scientists who are involved in cmt care and research were contacted as well. one hundred seven people from various countries (mainly france, italy and the usa) answered the survey. most ( %) of the participants were between and years of age, % being physicians and % being scientists. the vast majority ( %) considered the proposal constituted an improvement over the historical classification whereas % wanted to keep the old one. about the order of information, % of participants thought the mode of inheritance should come first, whereas % felt the phenotype should be placed at the beginning. ninety-one percent of people thought cmt should be kept as a generic name for hereditary sensory and motor neuropathy. for pure sensory neuropathy, % favoured hsn over hsan although % thought the opposite and % of participants felt dhmn should be kept for distal motor neuropathy. about nerve conduction findings, % of participants thought the intermediate phenotype has to be kept and % favoured our proposal to replace " " by "de" (for demyelinating) and " " by "ax" (for axonal). finally, % of responders thought that genetic information should be included in the classification of cmt. overall, our proposal of a new classification received a very good appreciation from physicians and scientists implicated in the care of patients with hereditary neuropathy. mallik r , hubsch a , gaida a , barnes d . csl behring, kop, usa; csl behring, bern, switzerland; csl behring, ottawa, canada. the risk of hemolytic events (hes) with intravenous immunoglobulin (ivig) therapy appears to be linked to the isoagglutinin (anti-a and anti-b) level of the specific ivig product. using published anti-a and anti-b titers for seven ivig products and corresponding he rates reported to the eudravigilance database, we developed a mathematical model to predict the risk of he to patients receiving ivig products of given anti-a and anti-b levels. modeling was performed separately for the risk to patients with blood groups a, b, ab and o and the overall population risk was estimated assuming a blood group distribution of % a, % b, % ab and % o. applying the prediction model, we calculated the he risk for an ivig product produced via a chromatographic process (privigen ® , csl behring) a) without any isoagglutinin reduction measures ( ) ( ) ( ) ( ) ( ) ( ) ( ) , b) with an anti-a donor screening program eliminating approximately % of donors with high anti-a titers ( ) ( ) ( ) , c) incorporating an anti-a/anti-b specific immunoaffinity chromatography (iac, igisolo tm ) step in the manufacturing process (since ) and d) with both measures (b and c) combined; as well as for an ivig product produced with a cohn-like cold ethanol fractionation process (carimune ® nf/sandoglobulin ® , csl behring). isoagglutinin titers in ivig products, measured by european pharmacopoeia direct assay, were provided by dr c bellac, swissmedic, bern, switzerland. the predicted risk was highest with the chromatographically purified ivig without isoagglutinin reduction ( . cases expected per kg ivig used). anti-a donor screening reduced the predicted risk to . cases/ kg. a greater risk reduction was predicted with the iac isoagglutinin reduction step ( . cases/ kg). the combination of both methods produced little benefit ( . cases/ kg) versus iac alone. the predicted hemolytic risk with ivig produced by cohn-like ethanol fractionation was low ( . cases/ kg). an observational cohort study to confirm these hemolytic risk reductions is in progress. at present, the observed hemolytic risk for anti-a donor screening appears consistent with the prediction calculated by the model; results for iac isoagglutinin reduction are expected in . the cmt infant scale (cmtinfs) is an outcome measure of functional ability for young infants and children aged < years. cmtinfs aligns with the cmt pediatric scale and cmt neuropathy score to measure disease severity across the lifespan. to measure gross motor and fine motor function, cmtinfs comprises of two subscales: gross motor (e.g. head control, crawling, walking, jumping and hopping) and fine motor function items (e.g. grasping, reaching, tearing paper and buttoning). overall and subscale-specific function is expressed as a z-score based on normative reference values (positive z-scores indicate poorer function). a total of controls aged - months (mean age , sd m) have been assessed across australia (n= ), thailand (n= ) and usa (n= ). total cmtinfs z-scores did not differ significantly between sites (australia vs thailand) (p= . ) or gender (p= . ). data collection is ongoing and infants aged < years are eligible for inclusion. to date, infants ( % male) aged - months (mean age , sd m) with a range of cmt subtypes ( cmt a, cmt d, cmt c, cmt x and unidentified gene) have been assessed with cmtinfs. mean total z-score for infants with cmt ( . , sd . , range: − . - . ) was significantly higher than controls ( . , sd . , range: − . - . , t=− . , p= . ). differences between affected infants and controls were larger in infants older than months. infants with cmt a (cmtinfs z-score . , sd . ) and cmt c (z-score . ) were less affected than cmtx (z-score . ) and cmt d (z-score . ). the gross motor function subscale differed significantly between cmt cases and controls ( . , sd . vs . , sd . ; p=. ) and a significant difference was also observed for the fine motor function subscale ( . , sd . vs . , sd . ; p= . ). reliability, factor and rasch analysis of the cmt-infs is underway to assess validity. initial results support the sensitivity of cmtinfs in distinguishing between infants with and without cmt. preliminary analyses also suggest the scale is sensitive to genetic subtype. with increased power, cmtinfs promises to become a useful outcome measure of disease severity and function in infants with cmt. manso c , querol l , mekaouche m , illa i , devaux j . aix-marseille université, marseille, france; universitat autónoma de barcelona, barcelona, spain. contactin- , contactin-associated-protein- (caspr ), and neurofascin- (nfasc ) are essential for the formation of paranodal axoglial junctions. igg autoantibodies to contactin- , caspr , and nfasc are associated with subsets of patients with chronic inflammatory demyelinating polyradiculoneuropathy (cidp) presenting with common clinical features. anti-contactin- igg autoantibodies have been shown to be pathogenic and to affect the paranodal axoglial junctions in vivo and in vitro. by contrast, the pathogenic effect of anti-nfasc igg have not been demonstrated. here, we purified anti-nfasc igg from cidp patients' plasma and investigated their effects after passive transfer. to determine whether these antibodies can pass the paranodal barrier, we performed intraneural injections of anti-nfasc igg autoantibody. by contrast to anti-contactin- igg , anti-nfasc did not penetrate the paranodal regions after intraneural injections, but bound to the surface of the schwann cell. to perform chronic exposure, lewis rats were implanted with intrathecal catheter and anti-nfasc igg were administrated in a daily manner during three weeks. igg to nfasc , but not control igg , induced progressive clinical deteriorations characterized by gait ataxia and hindlimb paraparesis. these deteriorations were associated with nerve activity loss in motor spinal nerves and with a selective loss of the paranodal specialization characterized by the disappearance of the caspr /contactin- /nfasc complex at paranodes. the passive transfer of anti-nfasc igg thus seem to induce similar pathogenic effects as the anti-contactin- igg . however, the pathogenic mechanisms leading to paranode disappearance appear different. our findings indicate that igg directed against nfasc are pathogenic and further show that these antibodies are reliable biomarkers of a specific subset of cidp patients. better fit the needs of the consortium and improve patient experience. these enhancements include creating mobile friendly webpages, updating enrollment form content, access to a customized dashboard, and the ability of registrants to explore their data in comparison to other registrants. we will review these enhancements in depth, and demonstrate their impact on the growth and development of the rdcrn inc contact registry. martinez c , hubsch a , watson dj , shebl a , wallenhorst c , simon tl . institute for epidemiology, statistics and informatics gmbh, frankfurt, germany; csl bering ag, bern, switzerland; csl behring llc, king of prussia, usa; csl bering gmbh, marburg, germany. hemolytic anemia (ha) is a complication of intravenous immunoglobulin (ivig) treatment, particularly in patients receiving high dose ivig for immune modulation, such as guillain-barré syndrome or chronic inflammatory demyelinating polyneuropathy. the primary mechanism for the increased risk is believed to be passive acquisition of anti-blood group a and b antibodies (isoagglutinins) from the ivig product. to reduce the quantity of isoagglutinins, an anti-a donor screening was implemented for the ivig privigen ® from - and donors with high titers were excluded from contribution to pooled plasma. anti-a donor screening was replaced since with an immunoaffinity chromatography step, which decreases isoagglutinins to a greater extent, but no data are available to test its clinical effectiveness. to test the effectiveness of the donor screening, two cohorts of patients treated with privigen ® before and after start of donor screening were identified from a hospital-based administrative database of us hospitals with in-and outpatient discharge diagnoses, procedures, drug utilization and laboratory tests between / and / (period ) and between / and / (period ). privigen ® dose per kg body weight was estimated from the daily quantity administered and age-and sex-specific us population body weight estimates. ha within days of privigen ® use was assessed from manual records review and the incidence rate of ha in the two periods compared. incidence rate ratios (irr) of ha were adjusted for sex, age, treatment setting, indication and dose per kg body weight using period as reference. the incidence rate of ha was . / , person-days ( % confidence interval: . - . ) in period ( has in , person-days) and . ( . - . ) in period ( has in , person-days). the adjusted irr was . ( . - . ). significantly less ha risk was found with high dose (≥ . g/kg body weight) privigen ® , irr . ( . - . , p= . ). we conclude that anti-a donor screening and exclusion of donors with high anti-a titers from plasma pools is associated with a decreased risk of ha with ivig. matsumoto a . department of neurology, keijinkai jozanki hospital, sapporo, japan. subacute myelo-optico neuropathy (smon) is the intoxication of clinoquinol with main clinical symptoms of paresthesia and spasticity of legs. these symptoms have been considered to be elicited by the disturbance of spinal cord and peripheral nerve as the intoxication of clinoquinol. however, as to the patients with smon who have been still living after the onset of disease, the examination of nerve conduction velocities are in normal ranges and the clinical symptoms of peripheral neuropathy are not observed now. in order to investigate whether the peripheral neuropathy were observed in the early stage of smon, we investigated the longtidunal changes of electrophysiological results in patients who could examine the nerve conduction studies from early stage of smon until the present time. as to the disturbance of pyramidal tract functions (myelopathy) in smon patients, the central motor conduction times were calculated by transmagnetic stimulation of motor cortex, cervical roots and lumbar roots. the peripheral nerve conduction velocities of sensory nerve were examined with the sural nerves. as the results, in patients with smon who could examine the electrophysiological examination from the early stages of smon until to years later, the central motor conduction times of leg muscles from motor cortex to lumbar roots were prolonged in the smon patients compared to the normal cases. these results suggest the presence of disturbances of conduction velocities of spinal cord. conduction velocities of sensory nerve velicities (sncvs) showed the delayed sncvs of sural nerves( - m/sec) at the first examination from the onset of - years. however from to years later, sncvs of these cases were covered to - m/sec. from these electrophysilogical examinations, it was suggested that the presenting main symptoms of smon were the disturbance of myelopathy, and the disturbance of peripheral nerve function had been recovered after onset of smon being elapsed a long time, natural killer (nk) cells are part of our innate immune system with regulatory and effector functions. they comprise the first line of defence in the recognition and destruction of virus-infected and pathologically altered cells. different studies suggest that the treatment with intravenous immunoglobulins (ivig) has an immunomodulatory effect on nk cells. ivig is a first-line treatment for various autoimmune diseases in particular in chronic inflammatory demyelinating polyneuropathy (cidp). the lack of a predictive marker for ivig responsiveness in cidp avoids the early preservation of non-responding patients. to better understand the effect of ivig in patients with cidp, we tested whether ivig treatment altered the nk cell status. additionally, we analysed if the alteration in the populations may serve as a surrogate marker in predicting the outcome of ivig treatment. using semi-quantitative pcr and flow cytometry in the peripheral blood of patients with cidp, we analysed the effects of ivig on the nk cell population before treatment initiation and h after first dose and correlated the changes with the reponsiveness to ivig. ivig administrations induced a reduction in the expression of several typical nk cell genes. interestingly, this ivig-induced reduction of nk cells was reversible four weeks after the ivig treatment. flow cytometry data revealed that ivig reduced the cytotoxic cd dim nk cell population, while regulatory cd bright nk cells remained almost unaffected or were even increased. interestingly, we found that the observed effects on nk cells almost exclusively occurred in cidp patients who responded to ivig therapy. correlation between the changes in the nk cell population and treatment efficiency suggests a crucial role for nk cells in the immunomodulatory mechanism of ivig. further studies are warranted to investigate whether the differences in the nk cell status of patients with cidp represent a reliable surrogate marker in predicting the outcome of ivig therapy. mccray b , sullivan j , woolums b , aisenberg w , lloyd t , sumner c . johns hopkins university, baltimore, usa. mutations in transient receptor potential vanilloid (trpv ), a calcium-permeable non-selective ion channel, cause charcot-marie-tooth disease type c (cmt c). trpv is unique in that it represents the only membrane-expressed ion channel in cmt and thus a potential therapeutic target. previous work has suggested that trpv mutations lead to gain of channel function and toxicity in cultured cells. neuropathy-causing mutations of trpv largely cluster in the cytosolic ankyrin repeat domain (ard) that is known to mediate protein-protein interactions, suggesting that pathogenesis may be related to disruption of such interactions. in order to identify trpv -interacting proteins, we performed two unbiased proteomics screens and identified multiple cytoskeletal-modifying proteins including syndapin- , a neuronal protein known to promote axonal outgrowth by influencing the actin cytoskeleton. in cultured cells, we have shown that trpv and syndapin- co-localize to highly dynamic actin-rich cellular processes and together stimulate robust neurite extension, but this facilitation of neuritogenesis is impaired by disease-causing mutations in trpv . we have also shown that over-expression of syndapin reduces trpv -mediated calcium influx in cultured cells and rescues toxicity of mutant trpv . in addition, syndapin over-expression suppresses mutant trpv phenotypes in a drosophila model of trpv -related neuropathy. further, we have demonstrated that treatment of drosophila with a specific trpv channel antagonist ameliorates trpv mutant toxicity. together, our data highlight the importance of trpv interaction with cytoskeletal proteins such as syndapin- in the pathogenesis of cmt c. specifically, our results suggest that mutations in trpv disrupt the normal role of trpv in regulation of cytoskeletal dynamics and that interactions with the cytoskeleton reciprocally modulate trpv channel function and influence toxicity of mutant trpv . mcgonigal r , yao d , barrie ja , crawford c , willison hj . university of glasgow, glasgow, uk. guillain-barré syndrome (gbs) is in part mediated by anti-gm ganglioside antibodies induced by preceding infections. anti-gm antibodies target plasma membrane gm that is extensively distributed in both glial and axonal membranes, particularly at the node of ranvier. antibodies deposited at this site in models of gbs are associated with complement deposition, conduction block, structural disruption of ion channels and macrophage infiltration. the wide distribution of the gm ganglioside target leads to unwanted complexity in ascribing pathological outcomes to injury of cell-specific membranes, in particular unravelling the consequence of paranodal schwann cell membrane injury on axonal function, and vice versa. to overcome this impasse, we have generated transgenic mice through glycosyltransferase manipulation that express gm exclusively in neurons or glia, thus allowing us to very specifically target and injure axonal or glial membranes with a single anti-gm ganglioside antibody. through this route we can create mouse models of both the axonal and demyelinating forms of gbs, induced by a single anti-gm antibody, thus creating otherwise highly comparable conditions. here, we show anti-gm antibody binding is restricted to the nodal axolemma in galnact −/− -tg(neuronal) mice and conversely to paranodal loops in galnact −/− -tg(glial) mice. when anti-gm antibody and a source of complement is added to a nerve-muscle ex vivo injury paradigm, there is a loss of axonal integrity (i.e. loss of neurofilament immunolabeling) when the neuronal membrane is targeted in galnact −/− -tg(neuronal). conversely, axonal integrity is maintained when the paranodal membranes are decorated by antibody and complement products ex vivo in galnact −/− -tg(glial) mice. in a passive immunisation model in vivo, galnact −/− -tg(neuronal) mice acutely develop weakness, respiratory dysfunction, associated complement deposition, and degenerative pathology in distal axons. in contrast, galnact −/− -tg(glial) mice have significantly fewer abnormalities under the same acute conditions. these data indicate the high vulnerability of axonal membranes to acute injury and underline the importance of developing specific axonal protection strategies. in summary, targeting the nodal axolemmal or glial membranes allows us to study associated nodal pathology, and determine the downstream consequences on function and axon fate, currently a major area in gbs clinical research. memon a , madani s , schultz l , grover k , arcila-londono x , sripathi n , ahmad bk . neuromuscular division, department of neurology, henry ford hospital, detroit, michigan, usa. objective: to differentiate sensory electrophysiology, tli and treatment response in patients with paraproteinemic cidp. background: low tli has been reported as a useful electrophysiological marker for mag-cidp. to our knowledge comparison of sensory electrophysiology and tli of paraproteinemic cidp subgroups have not been previously reported. methods: retrospective review(january -december ) of patients with cidp fulfilling electrophysiological criteria(aan ad hoc subcommittee and albers and colleagues).cidp patients with diabetes(n= ) were excluded. patients were divided into idiopathic (n= ) and paraproteinemic cidp(n= ). paraproteinemic cidp sub-groups: mag( ), non-mag( ) and igg( ) were compared to idiopathic cidp( ). these groups were compared for demographics, history of cancer, csf protein, sensory conductions, tli measurements and response to treatment using chi-square tests for binary and categorical variables and t-tests for continuous measures. results: there was a higher proportion of females in idiopathic-cidp compared to non-mag-cidp ( % vs %). idiopathic group having a higher proportion of patients on monotherapy( % vs %) and combination therapy( % vs %) compared to non-mag. higher mean csf protein compared to mag-cidp(p= . ) was seen in the idiopathic. the difference between idiopathic and igg-cidp was significant for overall rx response(p= . ) and rx response in patients with follow-up(p= . ). for both variables, patients in the idiopathic group had a higher proportion of patients on combination therapy and lower proportion of no treatment offered compared to patients in the igg-cidp. % of non-mag-cidp patients had a history of cancer vs % of mag-cidp. none of the other differences were significant. there were no group differences in sensory electrophysiology and tli. conclusions: sensory electrophysiology and tli may have no value in differentiating paraproteinemic cidp. csf protein is higher in idiopathic cidp compared to mag-cidp. idiopathic-cidp has a higher proportion of females compared to non-mag-cidp and a higher proportion of patients on combination therapy compared to igg-cidp. cancer screening should be considered in patients with non-mag-cidp. memon a , madani s , ahmad bk , schultz l , grover , arcila-londono x , sripathi n . department of neurology, henry ford hospital, detroit, michigan, usa. introduction: sensory electrophysiology and terminal latency index (tli) differences have been described in various cidp sub-groups. objective: evaluate electrophysiology, tli and treatment response in idiopathic and diabetic cidp. methods: retrospective review of patients with cidp who underwent electrodiagnostic evaluation (january -december . patients fulfilled electrophysiological criteria described by ad hoc subcommittee of american academy of neurology (aan) and albers et al. we excluded patients( ) with acute inflammatory demyelinating neuropathy, hereditary sensorimotor neuropathy, vasculitis and polyneuropathy with paraproteinemia. patients were divided into idiopathic( ) and diabetic( ) groups. these groups were compared for age, sex, history of cancer, csf protein, response to treatment, sensory response abnormalities and tli measurements using chi-square tests for binary and categorical variables and t-tests for continuous measures. all testing was at the alpha= . level. results: group differences for age, sex, history of cancer, csf protein and treatment response were not significant. comparing tli values in measurable responses, the difference between the two groups for tibial tli was significant (p= . ), with idiopathic group having a lower mean as compared to the diabetic. tli values differences for median, ulnar and peroneal nerves were not significant. the difference in abnormal rates of sensory responses was significant for the sural nerve with the idiopathic group having a lower rate compared to the diabetic group ( % vs %, p< . ). no differences were noted for the ulnar, median and radial nerves. tibial tli and sural sensory responses have some value in differentiating the two groups. larger prospective studies are needed to confirm our findings. ivig is an important treatment option for cidp. although recommended by treatment guidelines, little is known about the consequences of temporary ivig withdrawal to assess ongoing immunoglobulin need. path is a randomized, double-blind trial of the subcutaneous immunoglobulin (scig) igpro (hizentra ® , csl behring) in cidp. before scig randomization, subjects underwent periods of ivig withdrawal ( weeks or until pre-determined indications of clinical deterioration) and ivig restabilization (igpro ; privigen ® , csl behring). subjects not showing deterioration during withdrawal period were withdrawn from study. to proceed to scig randomization, subjects had to achieve "cidp stability" (no relevant change in incat score at last two restabilization visits and at least the same total score as at screening). subjects entered the ivig withdrawal period. ( %) of these qualified for igpro restabilization; subjects ( %) were not ivig dependent, and ( %) were withdrawn for other reasons. one subject withdrew consent before igpro dosing. at the end of the igpro restabilization period, cidp stability was achieved in % of subjects ( did not reach stability, were withdrawn for other reasons). post-study follow-up information was available for / subjects who did not reach stability: ( %) had improved to baseline clinical status and had not, meaning at least % of the subjects improved to their pre-study status. during the restabilization period, / subjects ( %) improved in at least one of the predefined outcome measures. on average, subjects improved by . points in incat total score, . points in i-rods centile score, kpa in mean grip strength (dominant hand), and . points in mrc sum score. improvement occurred with a median of days after the first igpro dose in one or more efficacy outcome measures and in % of cases after the third igpro maintenance infusion. headache and nasopharyngitis were the most frequently reported adverse events (aes) during restabilization. aes deemed causally related were mostly mild or moderate. no unexpected aes or laboratory or vital sign findings associated with igpro occurred during the study. in summary, igpro reversed neuromuscular disability and improved activity/participation after previous clinical deterioration during an ivig withdrawal period. pmp duplication is the most frequent cause of charcot-marie-tooth disease (cmt). since it discovery, more than genes have been identified to be potentially responsible for cmt disease. however only single nucleotide variations (snvs) or small indels have been described. this could be due to the new sequencing strategy (ngs), especially ngs by amplicon sequencing, for whose few convenient tools are available and easily usable to detect cnvs responsible for inherited disease. to overcome this problem, we designed "cov'cop", a user-friendly tool able to detect cnvs among amplicons sequencing data. using the run's coverage file provided by the sequencer, "cov'cop" simultaneously analyzes all the patients of the run using a two-stages algorithm containing correction and normalization levels and provides an easily understandable output, showing with various colors, potentially deleted and duplicated amplicons. we validated our method on several datasets, including those of our targeted ngs panel screening genes known to be involved in cmt and close pathologies. cov'cop detected easily pmp duplication and deletion in our patients, confirmed by mlpa. in addition, cov'cop permitted the detection of new cnvs different from the pmp duplication, in cmt patients. we confirmed these cnvs by quantitative pcr and cgh array. we present here one of these cnvs: the duplication of aars gene detected in cmt patients and we discuss the pathogenicity of this new cnv. additional cnvs responsible for cmt disease are probably still to be discovered and we believe that cov'cop will help molecular geneticists to rapidly identify them. poems (polyneuropathy, organomegaly, endocrinopathy, m-protein, and skin changes) syndrome is a rare cause of demyelinating neuropathy associated with plasma cell dyscraisia and vascular endotherial (vegf) overproduction. although number of therapeutic interventions for plasma cell dysorders have been applied to poems syndrome, there have been no randomized clinical trials. this phase / double blind, randomized, placebo comtrolled trial was performed to investigate the safety and efficacy of thalidomide for patients with poems syndrome who are not eligible for stem-cell transplantation. the primary endpoint was the reduction rate of serum vegf concentrations at weeks in intention to treat analysis. additional outcomes of long-term extension study included progression-free survival. twenty-five poems patients were randomly assigned to either thalidomide plus dexamethasone or placebo plus dexamethasone from nov , , to july , . one patient in the placebo group was excluded from analyses because of a protocol violation. the adjusted mean serum vegf reduction rate at weeks was . (sd, . ) in the thalidomide group compared with − . ( . ) in the placebo group (p= . ). the kaplan-meier rate of progression-free survival at months was . in the thalidomide group, as compared with . in the placebo group (hr, . ; % ci, . to . ). in the randomized study period, mild sinus bradycardia was more frequent in the thalidomide group than in the placebo group ( % vs %; p= . ). thalidomide suppresses serum vegf concentrations and lengthened pregression-free survival in poems patients who are ineligible for stem cell transplantation. although thalidomide treatment has a risk of bradycardia, the benefits would exceed the risk. this study is registered with the umin clinical trials registry, umin . montes-chinea ni , coutts m , vidal c , courel s , rebelo a , abreu l , zuchner s , saporta, ma , . department of neurology, university of miami, miami, usa; department of human genetics, university of miami, miami, usa. autosomal dominant mutations in synaptotagmin- (syt ), a synaptic vesicle protein that functions as a calcium sensor for neurotransmission, have been previously linked to presynaptic neuromuscular junction (nmj) dysfunction and motor neuropathy in two families. both pathogenic mutations (asp ala and pro leu) were located in the c b domain of syt , which is essential for neurotransmitter release at the nmjs. we report a family with a new missense mutation in the c b domain of syt and a similar phenotype characterized by a slowly progressive, predominantly motor neuropathy and evidence of presynaptic nmj dysfunction on nerve conduction studies. the index case is a year-old woman with gradually progressive weakness of her extremities. she had normal developmental milestones, but was found to have bilateral high arched feet and hammertoes and occasional falls around the age of . she gradually developed progressive leg weakness, worsening bilateral hand cramping, weak handgrip, and only mild paresthesias on distal extremities. family history is remarkable for similar symptoms reported by her maternal grandfather, two maternal uncles, her mother and a younger sister. her neurological exam revealed inability to walk on heels or toes, significant distal lower extremity weakness and absent ankle deep tendon reflexes. cranial nerve examination and coordination were normal and there were only non-specific sensory changes in the lower extremities. emg/ncs revealed normal sensory responses throughout; however, motor nerve evaluation demonstrated globally reduced amplitudes with a > % increment after brief isometric contraction. further electrophysiological evaluation with slow ( hz) repetitive nerve stimulation of the right ulnar motor nerve revealed a % decremental response in amplitude and a > % increase in amplitude immediately after a one-minute period of sustained muscle contraction, which rapidly extinguished after one minute. voltage-gated calcium channel (vgcc) antibodies and a chest ct were normal. targeted sanger sequencing revealed an ile lys mutation in syt , which is located in the c b domain and is predicted to impair protein function. syt -related neuropathy is a rare disease, but should be suspected in patients presenting with a combination of pre-synaptic nmj dysfunction (resembling lambert-eaton myasthenic syndrome) and a predominantly motor neuropathy, especially in the context of a positive family history. charcot-marie-tooth (cmt) disease affects roughly in , individuals and is described as an inherited peripheral neuropathy primarily affecting distal muscles. limited studies detail patient-reported impact of muscle weakness on functional activities. this anonymous survey was developed with input from clinical experts and patient interviews and aimed to better understand the prevalence and impact of various cmt clinical manifestations on patients' lives. the survey was administered online to the hereditary neuropathy foundation's (hnf) patient contact database and is ongoing through june . here we present preliminary data on patient characteristics and disease impact for cmt patients collected february - , . respondents were mostly female ( %) and mostly from the us ( %). median age (range) at symptom onset was years ( - years), at diagnosis was years ( - years), and at present was years ( - years). the sample was representative of all cmt types (cmt , , , ,and x). the most common physical and clinical manifestations of cmt were problems with balance ( %), ankle weakness/foot drop ( %), loss of feeling or abnormal sensation in the lower leg/foot ( %), and hand muscle weakness ( %). maintaining balance, walking long distances, and climbing up and down stairs were key challenges associated with ankle weakness/foot drop. foot drop was considered by % to be the primary factor contributing to falls, which averaged . falls to ground per month. of those with foot drop, % had bilateral weakness. a majority of respondents ( %) used some form of assistive device for mobility, including ankle-foot orthotics/below-the-knee leg braces ( %), canes/walking sticks ( %), and custom foot orthotics/inserts ( %). the most common drug therapy included pain and anti-inflammatory medications ( %). foot surgery was the most common surgical procedure received ( %) and toe surgery was the most common surgery considered ( %). key symptoms that affected quality-of-life "very much" included problems with balance ( %), ankle weakness (foot drop) ( %), and fatigue ( %). these data suggest a high prevalence of lower leg muscle weakness; therefore, therapies aimed at improving ankle weakness and the resulting foot drop and imbalance may be beneficial to patients' daily functioning and quality of life. morano m , , gambarotta g , ronchi g , , cillino m , fornasari be , , fregnan f , , tos p , cordova a , moschella f , geuna s , , raimondo s , . department of clinical and biological sciences, university of turin, orbassano (to), italy; neuroscience institute of the "cavalieri ottolenghi" foundation (nico), university of turin, orbassano (to), italy; plastic and reconstructive surgery. department of surgical, oncological and oral sciences, university of palermo, palermo, italy; hand microsurgery and surgery, gaetano pini hospital, milan, italy. nerve fiber regeneration and complete functional recovery after peripheral nerve injury do not always occur and can be influenced by many factors including patient age, gender, lesion site, injury severity, size of the gap between damaged nerve stumps and time interval that elapses before performing surgical repair. the poor outcome occurring after a long delay can be due to loss of the neuron ability to regenerate, loss of the schwann cell ability to support regeneration and, of course, progressive muscle atrophy. the aim of this study was to investigate the nerve regeneration after delayed repair and to study the degenerative processes of the denervated distal nerve stump and denervated muscle. in particular, the analyses were focused on the role of nrg/erbb system, that is expressed both in nerve and in muscle tissue, during degenerating and regenerating processes. functional recovery analysis performed after nerve repair showed that only the group repaired immediately and not the groups repaired with a delay of or months, recovered partially. nevertheless, morphological analyses demonstrated that, despite the delay, the nerve fibers are still able to regenerate, even if they are fewer and smaller than the immediate repaired group. moreover, the analysis of the nrg /erbb system showed a significant decrease of soluble nrg in both degenerating and delayed-repaired nerves. the poor outcome after delayed nerve regeneration might be explained by schwann cell impairment and the consequent ineffective support for nerve regeneration. as regards denervated muscle analysis, results showed that erbb receptors expression is related to the innervated state of the muscle, with an upregulation of erbb clearly associated with denervation state. interestingly, nrg isoforms are differently regulated depending on the type of nerve injury. future experiments will be needed to address the in vivo efficacy of different isoforms of nrg both in injured nerve and denervated muscle. we planned a multicenter, prospective, randomized, single blind, controlled study to evaluate the efficacy and safety of an innovative rehabilitation protocol based on the use of treadmill training in a cmt a population. the protocol required that subjects were blindly randomized into two treatment groups, spe (three months of respiratory, proprioceptive and stretching exercises) or trespe (the same treatment plus aerobic training at the treadmill). subjects were evaluated at baseline (t ), after three month of treatment (t ) and further three months of follow up free of therapy (t ). the full assessment included: -mwt (primary outcome measure), -mwt, walk- , short physical performance battery (sppb); lower limbs dynamometric strength evaluation; berg balance scale (bbs); cmt neuropathy score; medical outcomes study short form (sf ). a total of subjects (mean age of . ± . years) were recruited. at t we found a significant improvement in both groups in the -mwt (p< . ), -mwt (p< . ), bbs (p< . ) and sppb (p< . ), while at t only the -mwt was still significantly improved (p< . ) in the spe group. no significant differences between groups were observed for any of the outcome measures. performances on walk did not significantly change during follow-up (p= . ). concerning the sf , we did not observe consistent changes during follow-up or consistent differences comparing the two treatments. in conclusion, this multicenter, prospective, randomized, single blind, controlled study shows that the combination of respiratory, proprioceptive and stretching exercises has a positive impact on the performance of cmt patients, especially regarding walking tests. the aerobic exercise at the treadmill, is well tolerated but apparently does not add any further improvement to the conventional treatment. we speculate that the relatively low clinical severity of the patients, due to the selection criteria, may have prevented a positive effect of treadmill exercise. müller m , dohrn m , romanzetti s , reetz k , gess b . university rwth aachen, department of neurology, aachen, germany. muscle mri is increasingly used in neuromuscular patients to detect changes in muscle volume, muscle fat infiltration and edema. muscle mri are mostly analyzed by qualitative means as quantitative analysis is time-consuming and not well established. here, we developed a novel method for semi-automated segmentation of muscle mri data sets. based on axial t -weighted dixon mri stacks, muscle volumes were quantified by an adapted water-shed algorithm. muscle volumes of thighs and calves were determined separately and the ratio of thigh/calf was calculated. myopathy, neuropathy patients and healthy controls were included in the study. muscle volumes determined by semi-automated segmentation were very similar to manually segmented data sets, differences being < %. this was the case for patients as well as healthy controls. the time-saving effect of automated segmentation was very strong ( vs min. per patient). muscle volumes of the thigh and also of the calf of myopathy patients showed a highly significant difference (p< . ) compared to healthy subjects. in neuropathy patients there was a just significant difference (p< . ) of muscle volumes compared to healthy patients that did not sustain in bonferroni's multiple comparison test. the ratio of thigh/calf muscle volume was significantly different comparing patients with myopathy and neuropathy (p< . ). subgroup analyses of different groups of myopathy patients showed highly significant differences (p< . ) in myositis, limb-girdle-muscular dystrophy and metabolic myopathy, compared to healthy patients, but no significant differences in-between these groups. taken together, the data shows that automated segmentation of muscle mri allows for exact and fast quantification of muscle volumes in neuromuscular patients. higher patient numbers are necessary to test differences between specific disease groups. further studies should also address the possible use as a marker of disease progress for clinical studies or therapy monitoring. murakami t , nishimura h , nagai t , hemmi s , kutoku y , sunada y . department of neurology, kawasaki medical school, kurashiki, japan; department of pathology, kawasaki medical school, kurashiki, japan. familial amyloidotic polyneuropathy (fap) is an autosomal dominant hereditary systemic amyloidosis caused by mutation of transthyretin (ttr) gene, and usually shows sensory dominant polyneuropathy and autonomic neuropathy at the initial stage. the pathogenesis of neuropathy is not well understood, and explained by several mechanisms, including such as mechanical compression, vessel occlusion, ttr toxicity and schwann cell dysfunction. we describe a sporadic patient with late-onset fap due to ttr e k. she noticed dysesthesia first in the foot at age . the symptoms were slowly progressive, and abnormal sensations were extended up to the both upper arms and the both knees at age . distal muscle weakness and atrophy was also observed in the extremities. she noticed difficulties in walking and frequent diarrhea. echocardiogram revealed diffuse left ventricular hypertrophy, suggesting cardiac amyloidosis. amyloid deposits were not detected in the endoneurim or perineurium of the sural nerve years after the onset of the disease, but a marked loss of myelinaed and unmyelinated nerve fibers was observed in it. ttr-derived amyloid deposits were confirmed in the peroneous brevis muscle, salivary gland and heart tissue. dna analysis revealed the heterozygote mutation, p.e k (e k)/c. g>a, of ttr gene, and she was diagnosis as fap. these findings suggest that the proximal parts of peripheral nervous system might be strongly involved by ttr aggregates or amyloid fibrils. blood-nerve barrier in the distal part of peripheral nerves could be preserved until later in the patient. several biopsy sites other than nerve may be helpful and necessary for diagnosis of ttr amyloidosis in mild or late-onset fap as our case. amyloidgenic element (cae) encoded by the ' utr. this study also identified a de novo c. _ dup frameshift mutation predicting p.lys glnfs* in nefh from a cmt family with atypical clinical symptom of proximal dominant weakness. this mutation is located near the previously reported frameshift mutations, suggesting a mutational hot spot. these relatively frequent deletion/duplication events with this resign might be caused by the putative hairpin structure. patient's lower limb mri revealed a marked hyperintense signal changes in the hip muscles than those in the thigh or lower leg muscles. this study also observed an anticipation pattern of earlier onset ( yrs old for mother to yrs old for daughter) and more severe symptoms in later generation. therefore, this study suggests that the stop loss and translational elongations by the ' utr of the nefh mutations may be relatively a frequent genetic cause of axonal peripheral neuropathy with the specific characteristics of proximal dominant weakness and an anticipation pattern. neil j , haghi ashtiani b , choumet v , musset l , léger jm . department of immunology, pitié-salpêtrière hospital (ap-hp), paris, france; department of neurology, national referral center for rare neuromuscular diseases, pitié-salpêtrière hospital (ap-hp), paris, france; institut pasteur, emerging diseases epidemiology unit, paris, france. the myelin-associated glycoprotein (mag) is a transmembrane glycoprotein localized in periaxonal shwann cells and oligodendroglial membranes of myelin sheaths. mag contains a carbohydrate epitope (hnk- ) that is a target antigen in autoimmune peripheral neuropathy associated with monoclonal igm gammopathy. in these neuropathies, numerous studies report the absence of correlation between the titers of anti-mag antibodies and the disease course. anti-mag titers and igm level at diagnosis are not always associated with disease severity and there is not good correlation between pre-and post-treatment anti-mag titers in patients who respond clinically to immunomodulators. mag belongs to siglec- a family and the linkage of sialic acid to the underlying sugars is an important determinant of siglec binding. mag shows high affinity for alpha- , -linked sialic acid ( , -sa).moreover, human monoclonal igm possesses heavy chain glycosylation sites at asn , , , and with sialylated olidgosaccharides and high-mannose type oligosaccharides. igm may bind to mag via these glycan epitopes as an alternative and additional route of antigen binding other than through the fab v regions. this mag-glycans igm interaction may be clinically neutral but could lead to an overvaluation of the biological results. in this study, we analyzed sera from patients with igm reactivity against mag: of them had an anti-mag neuropathy with various degrees of severity, and the last one had igm monoclonal gammopathy, strong serum anti-mag reactivity but no neurological disease. igm were extracted and purified from these sera by affinity chromatography. for each batch, an aliquot was digested by jack bean alpha-mannosidase and anti-mag reactivity was performed by elisa and indirect immunofluorescence (iif), before and after demannosylation. these extracts, tested in an iso quantitative way with regard to the original serum, showed a decrease of activity (elisa) and intensity (iif) after demannosylation. furthermore, elisa anti-mag was carried out in sera from patients with igm monoclonal gammopathy without neurological impairment: of them ( . %) showed a significant biological response. taking into account the fact that anti-mag antibodies are pathogenic (in animals models), these results support the hypothesis of neutral intermolecular interactions between igm and mag. ng cjb , ng jph , tay lb, t , umapathi . yong loo lin school of medicine, national university of singapore, singapore; lee kong chian school of medicine, nanyang technological university, singapore; national neuroscience institute, singapore. recent developments have validated non-invasive means of measuring central arterial blood pressure (casp) and have shown that casp and peripheral blood pressure (pbp) are unidentical entities. patients with postural orthostatic tachycardia syndrome (pots) have marked tachycardia with no associated decrease in pbp. we asked if the reflex tachycardia, which corresponds to postural dizziness in these patients, could be a result of a decrease in casp. two male patients, and years of age, with clinical features typical of pots went through a complete battery of autonomic screening tests. the sympathetic and parasympathetic responses were normal other than a heart rate increase of and beats per minute, respectively, on standing. there was no significant decrease or increase in pbp on standing for and minutes. casp was measured non-invasively by a device bpro r that imputes the measured radial waveform onto the brachial blood pressure to generate a pressure waveform from which a numerical casp value is derived. the casp measurements for both patients did not decrease on standing for and minutes. our preliminary observation suggests that the basis of tachycardia in pots patients may not be a decrease in central blood pressure. we are proceeding to systematically study more pots patients to corroborate the above observation. we are also trying to compare the difference between pbp and casp in pots and age, gender-matched normal controls. the major limitation of the study is the model-based mathematical derivation, rather than direct measurement, of casp. we are proceeding to systematically stud y more pots patients to corroborate the above findings. ng jph , ng cjb , t umapathi . lee kong chian school of medicine, nanyang technological university, singapore; yong loo lin school of medicine, national university of singapore, singapore; national neuroscience institute, singapore. recent developments have validated non-invasive means of measuring central arterial blood pressure (casp) and have shown that casp and peripheral blood pressure (pbp) are unidentical entities. orthostatic hypotension (oh) is a prominent component of autonomic dysfunction (ad), the consequent hypoperfusion of vital organs responsible for considerable morbidity and mortality. these structures are exposed to casp rather than pbp. we sought to understand the relationship of casp to peripheral blood pressure (pbp) in patients with autonomic dysfunction exposed to orthostatic stress. we reviewed autonomic function tests of patients tested at our laboratory over a -year period. the patients were divided into cohorts: ( ) no ad and no oh ( ) no ad, with oh ( ) mixed ad ( ) parasympathetic dysfunction ( ) sympathetic dysfunction. casp was measured non-invasively by a device, bpro r , that imputes the measured radial waveform onto the brachial blood pressure to generate a pressure-wave form from which a numerical casp value is derived. the difference and ratio of casp to pbp was recorded at rest and after minutes of standing. out of patients had complete data and a definitive final diagnosis. cohorts - had , , , , patients respectively. mean casp-pbp difference in cohorts - were − . , − . , − . , − . , − . respectively at minutes, and − . , − . , − . , − . , − . respectively at minutes. mean casp/pbp ratio in cohorts - were . , . , . , . , . , . respectively at minutes, and . , . , . , . , . respectively at minutes. there was no significant difference in the response of casp and pbp to orthostatic stress across abnormal cohorts to and in comparison with the "normal" cohort (p= . to . ). there was also no relationship to symptoms, namely postural dizziness. in conclusion, autonomic dysfunction does not seem to affect the casp-pbp relationship as measured by non-invasive means. the absence of true normal controls, the exclusion of significant number of patients because of incomplete data and the model-based mathematical derivation rather than direct measurement of casp are limitations that we aim to address in follow-on studies. niu jw , guan hz , cui ly , guan yz , liu ms . the department of neurology, peking union medical college hospital, chinese academy of medical sciences, beijing, china. we aimed to explore the correlation between afterdischarges in motor nerve conduction studies and clinical motor hyperexcitability in patients with voltage-gated potassium channels (vgkc) antibodies. six patients with positive serum antibodies to contactin-associated protein-like (caspr ) or/and leucine-rich glioma-inactivated protein (lgi ) were recruited, including with autoimmune encephalitis, and with cramp-fasciculation syndrome. electromyography (emg), nerve conduction studies (ncs) and f waves were performed, and afterdischarges were assessed. one patient was followed up. five patients had clinical evidence of peripheral motor nerve hyperexcitability (myokymia or cramp), and four of them had abnormal spontaneous firing in concentric needle electromyography. prolonged afterdischarges following normal m waves were present in all six patients, including the two patients who had no emg evidence of peripheral nerve hyperexcitability (pnh). in the patient who was followed up, afterdischarges disappeared after treatment with intravenous immunoglobulin (ivig). afterdischarges in motor nerve conduction study might be more sensitive than needle electromyography for detecting peripheral motor nerve hyperexcitability in patients with vgkc antibodies, and could disappear gradually in accordance with clinical improvement and reduction of antibodies. in our research, multiple sites measurement of cross sectional areas (csa) by ultrasound was performed to differentiate charcot-marie-tooth type a (cmt a) and chronic inflammatory demyelinating polyradiculoneuropathy (cidp). twenty-eight patients with cidp, patients with cmt a, and healthy controls (hc) were recruited prospectively. consecutive ultrasonography scanning was performed from wrist to axilla on median and ulnar nerves. csas were measured at predetermined sites of each nerve. cmt a had significantly larger csas at all sites of median and ulnar nerves (all p< . ). in cmt a, csas increased gradually and homogeneously from distal to proximal along the nerve, except potential entrapment sites. cidp displayed three different morphological patterns, including mild enlargement in patients, prominent segmental enlargement in , and slight enlargement in one, among which different treatment responses were observed. all patients with mild nerve enlargement treated with intravenous immunoglobulin (ivig) were responsive ( / ), while less than half of those with prominent segmental enlargement ( / ) were responsive (p< . ). the patterns of csa enlargement were different in cmt a and cidp patients. consecutive scan along the nerve and multiple sites measurement by ultrasound could supply more detailed morphological feature of the nerve and help to differentiate cidp from cmt a. guillain-barre syndrome (gbs) mainly consists of acute inflammatory demyelinating polyradiculoneuropathy (aidp) and acute motor axonal neuropathy (aman). in aman, conduction block (cb) could be reversible or followed by axonal degeneration. we aimed to identify the correlation between existence of cb and the functional outcome for patients with gbs. gbs patients were prospectively recruited for serial electrophysiological tests and disability evaluation. all patients received treatment of intravenous immunoglobulin (ivig), and their disabilities were evaluated on the hughes functional grading scale before and month after treatment. patients were classified into aidp, aman, equivocal or normal according to electrodiagnostic criteria described by rajabally et al. aman patients who had follow-up nerve conduction studies were further classified into three groups. group was typical aman without conduction block, group had reversible conduction block, group had conduction block and subsequential axon degeneration. electrophysiological study results showed aidp, aman, equivocal and normal. probable or definite conduction block was observed in aidp patients and aman patients. aman with cb had higher reduction of hughes grade at one month ( . ± . vs . ± . ,p= . ), and lower percentage of patients with slow recovery (unable to walk independently at six months) ( % vs %, p= . ) compared with aman without cb. there were no significant differences between aidp with cb and without cb, in the reduction of hughes grade at one month. among the aman patients who were followed up, were typical aman without cb (type ), had reversible cb (type ), had cb and subsequential axon degeneration (type ). hughes grades at nadir were similar, while patients with reversible cb (type ) had the largest hughes grade reduction at one month (type - . vs type - . vs type - . ). none of the patients with axon degeneration (type ) showed rapid recovery, while % of those with reversible cb (type ) had rapid recovery (improvement by two or more hughes grades within four weeks after onset). electrodiagnosis of aman with conduction block, especially reversible conduction block, might be a marker of good recovery. we report a follow-up study of nerve ultrasound in a patient with primary neurolymphomatosis. a -year-old female presented with -months history of asymmetric limb pain, paresthesia, and weakness. electrodiagnostic studies and spinal cord mri showed an axonal neuropathy involving cervical and lumbosacral root, brachial plexus and left median nerve. detection of malignant b lymphocytes by cytology and flow cytometry of cerebral spinal fluid confirmed the diagnosis of b-cell non-hodgkin lymphoma. nerve ultrasound showed dramatic enlargement of upper, middle and lower trunks of left brachial plexus (cross sectional area-csas mm , mm , mm respectively), middle trunk of right brachial plexus (csa mm ), and proximal part of left median nerve (csa - mm ). five months later, after five chemotherapy of rituximab and high-dose methotrexate, and intrathecal injection of cytosine arabinoside and dexamethasone, the patient had clinical improvement. nerve ultrasound also showed alleviation of nerve enlargement. the csas of upper, middle and lower trunks of left brachial plexus were mm , mm , mm respectively; the csa of middle trunk of right brachial plexus was mm ; the csa of proximal part of left median nerve was - mm . peripheral nerve ultrasound could help locate the distribution of nerve involvement, and reveals disease progression. nolano m , provitera v , stancanelli a , caporaso g , saltalamacchia am , borreca i , lullo f , califano f , lanzillo b , iodice r , manganelli f , barone p , santoro l . irccs "salvatore maugeri" foundation, institute of telese terme (bn), italy; "maugeri" clinical and scientific institutes irccs, institute of telese terme (bn), italy; center for neurodegenerative diseases (cemand), department of medicine and surgery, neuroscience section, university of salerno, italy. a peripheral nerve involvement has been demonstrated in pd with the evidence of a small fiber pathology as possible intrinsic feature of the disease and a higher occurrence of large fiber neuropathy in patients longtime treated with l-dopa. however the role that disease itself and ldopa have on small and large fiber pathology in pd is still debated. we studied morphology and function of cutaneous innervation, in idiopathic pd patients ( male, aged . ± . ), including naïve and l-dopa treated subjects without electrophysiological signs of neuropathy, with the aim to assess and characterize small and large fiber involvement and the effect of l-dopa on it. all patients underwent a screening to rule out potentially neurotoxic conditions such as glucose intolerance, dysendocrinopathies, vitamin e, b and folic acid deficiency, hepatic or renal failure, hiv or connective tissue disorders. skin biopsies were obtained from thigh, leg and fingertip from the more affected side and bilaterally from thigh and leg in patients. samples were processed with indirect immunofluorescence technique using primary antibodies to mark different sensory and autonomic fiber populations. density of intrapapillary myelinated endings (ime), meissner's corpuscles (mc) and epidermal nerve fibers (enfs) was obtained as well as a semi-quantitative assessment of sudomotor, pilomotor and vasomotor innervation. further evaluation included sympathetic skin response, quantitative sensory testing and dynamic sweat test. morphological and functional findings were compared with data extracted from our age and sex stratified normative dataset. ienf, ime, mc densities were lower (p< . ) compared to controls in both naïve and l-dopa treated patients without differences between them except for mc density that was lower in l-dopa treated subjects ( . ± . vs . ± . /mm ). a loss of autonomic nerves was also found in both groups compared to controls. significant abnormalities (p< . ) of thermal sensory thresholds, tactile thresholds, mechanical pain perception and reduced sweating output were present and similar in both groups. our work confirms in pd an intrinsic peripheral nerve pathology involving both small and large fibers. small fiber pathology isn't affected by l-dopa treatment while sensory large fibers involvement, already present in naïve patients worsens with ldopa treatment. noto y , garg n , li t , timmins hc , park sb , shibuya k , kiernan mc . brain and mind centre, the university of sydney, sydney, australia. the diagnosis of amyotrophic lateral sclerosis (als), a progressive, fatal neurodegenerative disorder defined by combined upper and lower motor neuron involvement, remains clinically based. the purpose of this study was to determine the ultrasound appearance of peripheral nerves in als patients, and to investigate whether parameters such as distal/proximal ratios of nerve cross-sectional areas (csas) may effectively differentiate disease mimics from als. nerve ultrasound of the median, ulnar, and tibial nerves was performed in als patients compared to mimic patients ( patients with peripheral nerve hyperexcitability syndromes (pnhs) and patients with multifocal motor neuropathy (mmn)). comparison of nerve and the distal/proximal ratios was undertaken by ultrasound and compared across clinical and neurophysiological parameters.compared to normal controls, csa of the median nerve at the upper arm was decreased in als (p < . ). in comparison to als mimic disorders, csa at the proximal site of the median, ulnar and tibial nerve and the forearm/upper arm ratio of the median and ulnar nerves had diagnostic values. in addition to csa of the median, ulnar, and tibial nerves, the median and ulnar nerve forearm/upper ratios may provide a useful marker in for the diagnosis of als. approximately in , individuals are diagnosed with charcot marietooth (cmt) disease, making it the most common hereditary peripheral neuropathy. there is no documented cure for cmt, however, many of those affected, report difficulty with mobility, imbalance, and weakness of the feet and hands. in the general population, patients reporting difficulty walking, falls and/or fear of falling, and poor strength are often referred to physical (pt) and occupational therapists (ot) to skillfully address the impairments and help restore function and quality of life (qol). for patients diagnosed with cmt this is unfortunately not the norm, often leaving patients without any skilled guidance on managing their functional impairments. patients ( males) with a mean age of . years ( - ), went through a progressive and skilled pt intervention over the course of months. the program included: therapeutic activities and exercise, neuromuscular reeducation, and manual techniques to address the documented deficits. patients were progressed through the program based on the borg scale. each patient was assessed prior to and post the commencement of the program with the berg balance scale, minute walk test, timed up and go, sit to stand in seconds, foot self selected and fast gait speed, the lower extremity functional scale, activities balance confidence form, upper extremity functional index, oswestry, and the sf- qol measure. the patients were seen by the same skilled pt - a week for weeks. all but patients improved in all measures taken, indicating an improvement in function and overall quality of life. participants reported a total of falls in the months prior to the initiation of the study and only fall was reported during the month pt intervention. this study makes a strong case for the utilization of skilled pt to address deficits in patients with cmt. additionally, the utilization of objective, valid and reliable outcome measures in this population may help healthcare practitioners establish baseline function and response to change. a large randomized control trial is recommended to study the effects of a specific pt intervention on outcome measures in patients with cmt. ogata h , fujita a , yamasaki r , matsushita t , kira ji . department of neurology, neurological institute, graduate school of medical sciences, kyushu university, fukuoka, japan. clinical features of chronic inflammatory demyelinating polyneuropathy (cidp) patients with autoantibodies against neurofascin (nf) , one of the paranodal proteins, have been elucidated while the relation between anti-nf antibody levels and long-term clinical course in these patients still remains elusive. we retrospectively collected clinical, electrophysiological and immunological data of three anti-nf antibody-positive cidp patients. they were all males and their ages at onset were , , and years old. their clinical severity was evaluated by deep tendon reflexes (dtrs), grip strength and hughes functional scale. anti-nf antibody levels were measured by flow cytometry using hek cell lines stably expressing human nf . after immunotherapies of various combinations, including intravenous immunoglobulin, plasmapheresis, corticosteroids and other immunosuppressants, were introduced, their clinical parameters were gradually improved. decreased or absent dtrs were normalized and grip strength was increased by more than kg. hughes functional scale scores were decreased by at least one point compared with those at nadir. ncs findings of all three patients also showed obvious amelioration. for example, their f wave latencies in the right ulnar nerve were improved from to ms, from to ms, and from to ms, respectively. anti-nf antibody levels after treatment were decreased in two patients whose pre-and posttreatment sera were available. when dose of oral prednisolone was being tapered, they experienced re-exacerbation of clinical parameters, especially dtrs and grip strength. their ncs findings and serum anti-nf antibody levels were also deteriorated. exacerbation of these laboratory data in one patient preceded his clinical fluctuation, which suggests that ncs and serum anti-nf antibody levels could be used as early disease activity markers. in this case series, not only clinical but also laboratory data support a notion that anti-nf antibody-positive cidp patients were reactive to combined immunotherapies including corticosteroids. even though various treatments were administered to them, efficacy of oral corticosteroids seemed to be dose-dependent. optimal disease activity markers and immunotherapies for long-term maintenance of remission in anti-nf antibody-positive cidp should be identified. evaluated by deep tendon reflexes (dtrs), grip strength and hughes functional scale, after starting immunotherapies, ohnmar o , kamyw , ng lfp , t umapathi . university of medicine , yangon, myanmar; singapore immunology network, a*star, singapore; national neuroscience institute, singapore. singapore's zika virus (zikv) outbreak started in late august . over a period of months, we studied patients enrolled into our institution's prospective guillain-barré syndrome (gbs) database for relationship to zikv infection. we also studied gbs controls that were seen before the established outbreak and non-gbs controls. the index cases tested negative for zikv pcr in blood and urine. we proceeded to test zikv igg, igm, dengue virus (denv) igg and igm, and neutralization assays against zikv and denv. one patient with anti-gq b igg positive miller fisher syndrome had detectable zikv igm and zikv igg. the serum showed low titre denv igm and denv igg. follow-up serum at about months showed increase in zikv igg. we believe this patient has zikv-gbs. one patient with acute motor sensory axonal neuropathy and another with acute inflammatory demyelinating polyneuropathy had high zikv igm but low denv igm and igg. another patient with mfs showed high levels of zikv and denv igm but low igg. the latter two patients had gbs before the zikv outbreak in singapore. we suspect these patients could have zikv-gbs, but are awaiting convalescent sera for confirmation. two patients seen during the outbreak had detectable levels of zikv igg but serial testing showed a decline after a period of - months. the initial and follow-up sera showed raised denv igm and igg levels in one and raised igg levels in the other. in addition, both had stronger neutralizing capacity against denv than zikv suggesting that the initially detectable zikv igg levels was due to cross reactivity with previous denv infection. four patients, gbs control and non-gbs controls also showed serological response consistent with previous exposure to denv. one normal control showed nil exposure to both viruses. in summary, using various overlapping serological methods we diagnosed definite and suspect zikv gbs cases. our findings highlight ) insensitivity of blood and urine pcr to diagnose zikv-gbs ) the problems of interpreting zikv serology from cross-reaction with denv ) serial serology increases diagnostic accuracy. okar sv , ergunay k , bekircan-kurt ce , , erdem-ozdamar s , , tan e , . department of neurology, hacettepe university, ankara, turkey; virology unit, department of medical microbiology, hacettepe university, ankara, turkey; neuromuscular disease research laboratory hacettepe university, ankara turkey. guillain-barré syndrome (gbs) is an acute monophasic immune-mediated polyradiculoneuropathy. it is believed that acute inflammatory demyelinating poliradiculoneuropathy is caused by t-cell mediated autoimmune response targeting peripheral nerve myelin. molecular mimicry plays a role in the pathogenesis of some gbs cases. this mechanism has been well demonstrated in the acute motor axonal neuropathy (aman) variant, in which autoantibodies to camphylobacter jejuni share epitopes with peripheral nerve gangliosides. this molecular mimicry mechanism can be attributed to some cases with atypical triggers such as zika virus or west nile virus infections. moreover there are accumulating clinical data for vector borne viral infections triggering gbs. we evaluated vector-borne viral infections in our gbs and aman patients. eight patients with gbs, two patients with aman and as a control group, seven patients with normal pressure hydrocephalus were included. gbs and aman was diagnosed with clinical, electroneuromyograpic and cerebrospinal fluid (csf) findings. cerebrospinal fluid serum and urine samples were examined for vector borne viral infections via generic flavivirus and phlebovirus pcr. we also documented our patients prognostic scores such as modified erasmus gbs outcome score (megos) and modified erasmus gbs respiratory insufficiency score (megris). the mean age of the patients was , ( - years) , six of them were female. all csf, serum and urine samples of our patients and control patients were negative for flavivirus and phlebovirus families. the preliminary results of our study in this our small cohort did not show any correlation between the vector-borne viral infections and gbs. further studies with broad number of patients are needed for more suggestive results. neuromyotonia (nmt) consists of spontaneous motor unit activity that reflects increased peripheral nerve excitability, leading to involuntary, persistent muscle activity, visible as muscle twitching at rest, with generalized, easily provoked cramps. since the first electrophysiological (emg) description of nmt by denny-brown and foley ( ) , there has been discussion about the origin of the abnormal electrical activity recorded in needle emg studies. we studied two patients. patient 's nmt is aggravated by cold, and he has an associated non-progressive mild polyneuropathy with demyelinating features. he is now -year-old and has been followed in our centre for years. he is negative for anti-vgkc antibodies. firstly, he was treated with carbamazepine and phenylhydantoin with poor response, but he has shown major improvement on intravenous immunoglobulin (ivig) during the last years. patient is a year-old man with nmt, followed for year, with high titters of anti-vgkc antibodies ( pmol/l; normal< ). he improved on ivig during the last months. screening for neoplasia was unremarkable in both patients (negative anti-neuronal antibodies, in particular anti-hu, anti-yo and anti-ri antibodies; normal computerized tomography scan of the chest and abdomen). in addition to routine studies, we tested synchronicity to spontaneous discharges in different motor units in simultaneous recordings made with two needle electrodes in the first dorsal interosseus muscle. time-locked fasciculations in these double recordings would represent abnormal ectopic activity initiated in a nerve trunk with ephaptic stimulation of a nearby axon. in patient , this research protocol was applied once, years after regular ivig treatment. patient was investigated before and year after ivig. both patients improved after ivig, mirrored by a striking decrease in the amount of spontaneous activity on emg. moreover, our technique did not detect synchronous spontaneous activity (time-locked fasciculations) on the second assessment, although this was predominant before treatment in patient . in nmt, abnormal discharges originate both in distal axonal branches and in more proximal segments. it appears that ivig is more effective in blocking antibody activity in proximal axonal segments, perhaps related to factors such as blood-nerve barrier, temperature or differing ion channel distributions. celiac disease (cd) is a chronic, multisystem and immune-mediated disorder characterized by small-bowel sensitivity to dietary gluten in genetically predisposed individuals. neurological manifestations may occur in about % of patients, including peripheral nerve involvement. recent growing evidence strongly suggests that peripheral neuropathy in cd may be autoimmune and associated with anti-ganglioside antibodies. a -year-old woman presented with slowly progressive weakness of her right hand and fingers extensors. medical and family history were unremarkable. on examination, muscle strength (medical research council-mrc) was scored for right wrist and finger extensors, for right abductor pollicis longus and for right ankle dorsiflexion. right triceps brachii and brachioradialis reflexes were weak, but normal elsewhere. the remainder of the neurological examination was normal. neuroaxis magnetic resonance was unremarkable, specifically with no gadolinium-enhancing lesions. motor and sensory nerve conduction studies were normal. no conduction block or abnormal temporal dispersion was found. needle electromyography showed severe neurogenic changes with abnormal spontaneous activity in right radial-innervated muscles, and chronic neurogenic changes in homolateral tibialis anterior, peroneus longus and extensor digitorum brevis. ganglioside antibody testing was positive to igg anti-gm antibody, but negative to anti-gm and other anti-ganglioside antibodies. additional blood tests were unremarkable, in particular cryoglobulin testing was negative. intravenous immunoglobulin improved weakness, as right extensors of the wrist and fingers scored (mrc). a monthly treatment was initiated, which after months was changed to every weeks to preserve function. a diagnosis of mama was established. later, cd was diagnosed in her daughter due to chronic diarrhoea. our patient underwent anti-tissue transglutaminase antibodies determination and small-bowel biopsy after years disease' duration, and a diagnosis of cd was made. gluten-free diet was started, but her neurological picture did not change after six months. in our case the presence of igg anti-gm antibody may support a causal link between mama and biopsy-confirmed cd, and the lack of response to gluten-free diet may be explained by chronic axonal injury induced by memory t-cells. this case broadens our knowledge about neurological manifestations in cd, raising a probable association with purely axonal multifocal motor neuropathies and anti-ganglioside antibodies. Õunpuu s , , pogemiller k , acsadi g , pierz k , , . center for motion analysis, connecticut children's medical center, farmington, ct, usa; school of medicine, university of connecticut, farmington, ct, usa; division of neurology, connecticut children's medical center, farmington, ct, usa; division of orthopaedics, connecticut children's medical center, farmington, ct, usa. orthopaedic surgical intervention of the foot and ankle is performed in persons with charcot-marie-tooth (cmt) for improving foot pain, ankle instability, orthosis fitting/comfort issues and shoe wear. the impact of these surgeries on ankle function during gait is not known. therefore, the goal of this study was to measure gait changes in ankle function following surgical intervention by means of computerized motion analysis. fourteen patients with cmt ( ± years pre and ± years post-operative) with bilateral orthopaedic surgery were included. all patients had a plantar fascia release plus some combination of other soft-tissue (posterior tibialis and tendo-achilles lengthenings; extensor hallucis longus, peroneus longus and anterior tibialis transfers) and bony procedures (metatarsal and cuboid osteotomies). all patients completed two gait analyses (pre and on average . years post-surgery) during barefoot walking using a standardized d motion analysis protocol. the changes in ankle kinematics and kinetics and temporal-spatial parameters were analyzed in reference to a control group of patients with cmt without intervening surgeries with . years between gait analyses as well as normal reference data. the surgical group showed a significant increase in height between the pre and post-operative analyses and no changes in walking velocity (pre: ± , post: ± , normal: ± cm/sec). similarly, the ankle kinematics and kinetics showed no changes as a result of surgery. however, there was a trend for increased peak ankle dorsiflexion (pre: ± , post: ± , normal: ± degrees). as in the surgical group, the control group showed an increase in height but no simultaneous increase in walking velocity (test : ± , test : ± cm/sec). the control group also showed no changes in ankle kinematics and kinetics suggesting that the impact of the disease is, for the most part, not noticeable over . years. the results show that surgical intervention that primarily addresses foot alignment does not negatively impact ankle kinematics and kinetics during gait. the comparison with the control group supports this finding. however, there are some other findings such as the increase in peak dorsiflexion during stance in some patients that will need to be examined further in larger cohorts. Õunpuu s , , pogemiller k , pierz k , , , acsadi g , . center for motion analysis, connecticut children's medical center, farmington, ct, usa; school of medicine, university of connecticut, farmington, ct, usa; division of orthopaedics, connecticut children's medical center, farmington, ct, usa; division of neurology, connecticut children's medical center, farmington, ct, usa. ankle-foot-orthoses (afos) are commonly prescribed for patients with charcot-marie-tooth (cmt) to improve gait and reduce ankle instability and falling. there are no studies that examine bracing outcomes using objective evaluations. the purpose of this study was to examine the impact of various afo designs on gait parameters in children and adolescents with cmt. we predicted that the afos would improve excessive and delayed peak dorsiflexion in stance and equinus in swing. fifteen patients (mean age ± years) were analyzed barefoot and with their prescribed afos by means of a standardized motion analysis protocol. a full clinical examination was also completed including strength and passive range of motion measures. the afos included solid, hinged and posterior leaf spring (tapered, less supportive) designs. sagittal plane ankle kinematics and kinetics and temporal-spatial parameters were analyzed in comparison to normal controls. walking velocity improved from ± to ± cm/sec demonstrating the functional benefits of afos. ankle plantar flexion angle at initial contact improved from − ± to − ± degrees demonstrating improvement in drop foot in swing and at initial contact reducing the risk of tripping. however, the degree of peak ankle dorsiflexion in stance remained the same and excessive at ± degrees barefoot and ± degrees with afos suggesting that in many patients the afo design was not sufficiently supportive. peak ankle plantar flexor moment showed improvement from . ± . to . ± . nm/kg highlighting the improved base of support provided by the afos that compensate for ankle plantar flexor weakness. however, peak power generation was reduced from . ± . to . ± . w/kg indicating that some of the available ankle strength was impeded with the afos. the results of this study suggest that orthoses can provide improved gait outcomes which will improve overall function. however, there are individual differences in patient impairment (strength, range of motion and bony deformity) and associated gait presentation that need to be accounted for in afo design. afos do not always function as intended due to the complex interaction between patient impairment, orthosis stiffness and orthosis design. motion analysis can assist in identifying the specific afo needs for an individual with cmt. painous c , lópez-pérez ma , illa i , , querol l , . neuromuscular diseases unit, neurology department, hospital de la santa creu i sant pau, barcelona, spain; hospital san pedro, logroño, la rioja, spain; centro para la investigación biomédica en red en enfermedades raras (ciberer), madrid, spain. chronic inflammatory demyelinating polyradiculoneuropathy (cidp) is an autoimmune neuropathy with a heterogeneous clinical spectrum. specific autoantibodies define different clinical phenotypes. cidp with nf antibodies constitutes a specific cidp subset in which a high incidence of postural and intention tremor has been described and that responds poorly to immunoglobulins. we report a patient with an anti-nf positive cidp that presented head, voice and limb tremor that improved with immunotherapy. a -year-old man with unremarkable medical history, presented at the age of with progressive distal weakness and paraesthesia. numbness, gait ataxia and action tremor involving voice, head and limbs appeared sequentially. the emg showed features of acquired demyelination fulfilling cidp diagnostic criteria. a first course of intravenous immunoglobulins was ineffective. the weakness, ataxia and tremor worsened significantly, needing two walking aids first and becoming wheelchair bound later on. he received six plasmapheresis cycles that were also ineffective and oral corticosteroids ( mg/kg) were started with mild improvement. after corticosteroid tapering the patient developed a severe relapse and was referred to our centre. five plasma exchange cycles followed by rituximab ( mg/m , doses) were added to the corticosteroids. three months later the weakness, ataxia and tremor, including the head and voice tremor, started to improve significantly. six months later the patient presented a significant improvement and was able to walk unaided. the anti-nf antibody titres fell from / pre-rituximab to be undetectable. limb tremor is known to occur in patients with inflammatory neuropathies and, specifically in anti-nf + cidp patients but, to our knowledge, this is the first report of a cidp patient presenting with head and voice tremor ever reported. the improvement of tremor with immunotherapy strongly suggest that anti-nf autoantibodies are involved in its pathogenesis, expanding the phenotype of anti-nf specific clinical features. palaima p , peeters k , l. pelayo-negro a , garcía a , gallardo e , garcía-barredo r , de vriendt e , infante j , berciano j , jordanova a . vib and university of antwerp, center for molecular neurology, molecular neurogenomics group, antwerp, belgium; university hospital "marqués de valdecilla", santander, spain. charcot-marie-tooth disease type g is an autosomal dominant and slowly progressing inherited neuropathy which was first described over years ago. it has been attributed to a single spanish family consisting of individuals with affected members spanning four generation. initially, the genetic defect was linked to a . mb region in q -q . . however, extensive sequence and structural variant analyses using whole genome sequences (wgs) of three affected individuals did not reveal any known or novel genetic causes within the region. over the last decade, serial clinical re-evaluation of the entire pedigree was performed leading to changes to the affection status of seven individuals redefining the disease-linked region to chr q . -q . (z max = . at theta = ). additional family members were then submitted for whole exome sequencing. this has led to the identification of a novel missense variant in the e ubiquitin-protein ligase lrsam (p.cys tyr) that was previously not covered by wgs. the variants co-segregated with disease and were absent from controls. other mutations that are known to disrupt the ring domain of lrsam have been previously reported to cause both autosomal dominant and recessive cmt type p (cmt p). unlike prior reports, we demonstrated that the mutation does not influence overall protein levels of lrsam , nor of its ubiquitylation target tsg in patient derived lymphoblasts. transcriptomics analysis identified significant upregulation of another e ubiquitin-protein ligase (nedd l) and of a key regulator of axonal degeneration (tnfrsf ). notably, magnetic resonance imaging of lower-limb musculature systematically showed fatty atrophy in both clinical and subclinical mutation carriers emphasizing its use for the identification of mildly affected members. our findings demonstrate that the isolated genetic entity cmt g is caused by a missense mutation in lrsam and should be reclassified as cmt p. moreover, we reveal novel molecular players associated with lrsam dysfunction, and highlight pathways and therapeutic targets shared with amyotrophic lateral sclerosis and alzheimer disease. damage to peripheral nerves is a prerequisite for neuropathic pain. however, it remains unclear why some neuropathy patients have pain, but others with identical nerve conduction, qst and ienfd do not. we propose to examine the distribution of trpv and its co-localization with cgrp and sp in epidermal nerve fibers in patients with and without neuropathic pain. we aimed to define the expression pattern of trpv in normal healthy subjects first, and study the co-localization of trpv with cgrp and sp in normal controls and patients with painful neuropathy. skin biopsies from neuropathy patients and normal subjects were utilized. anti-trpv antibody generated in our university with support from ninds-funded dept. of neuroscience monoclonal core (ns ) was used. combined immunohistochemistry were performed to identify co-expression of trpv with cgrp, sp and pgp . . the distribution of trpv in controls revealed a proximal to distal gradient similar to that observed for ienf labeled by pgp . . trpv staining was more intense in nerve terminals in the epidermis. combined immunostaining revealed that % of pgp . labeled fibers in the epidermis were trpv +, while % of cgrp+ fibers trpv +. patients with pain had a higher density of trpv + fibers compared to that of patients with numbness. a greater proportion of cgrp+ fibers ( %) in the painful patients were trpv +. expression of trpv in controls exhibits a distal to proximal gradient. trpv expression and co-localization with cgrp were altered in neuropathic pain patients, suggesting that this receptor plays an important role in pathological states. activation of the nop-receptor (nop-r) by its endogenous ligand nociceptin/orphanin fq or non-peptide agonists modulates nociception and analgesia in neuropathic pain models. the wide distribution of nop-r and its endogenous ligand represents an attractive treatment target. since pain is the most prominent feature in pc, we defined expression of the nop-r in plantar skin biopsies and assessed whether alterations exist in pc-affected vs pc-unaffected and anatomically matched control skin. skin biopsies from k a pc and control subjects were immunohistochemically stained for nop-r. combined immunostaining for nop-r with pgp . , neurofilament h (nfh) and cgrp was used to define nop receptor expression in the epidermis and upper dermis. robust nop-r was detected in epidermal keratinocytes and a subset of pgp . + fibers in both epidermis and dermis. staining was inhibited through pre-incubation with a nop-r blocking peptide and western blot analysis using homogenized human skin tissue demonstrated a band at ∼ kd consistent with nop-r molecular weight. nop-r expression occurred in dermal nfh+ a beta-fibers in all groups though no cgrp+ fibers co-expressed nop-r. pc-affected skin had slightly lower nop-r expression than in pc-unaffected skin and a similar pattern in anatomically matched locations from healthy control subjects was observed. nop-r is expressed in human plantar skin epidermal keratinocytes as well as a subset of epidermal and dermal nerve fibers. these fibers are pgp . +, cgrp-and many co-express nfh. nop receptor is a viable pharmaceutical analgesic target in pc patients irrespective of its slight down-regulation as compared to pc-unaffected skin. this work was supported by grünenthal gmbh. pareyson d , stojkovic t , leonard-louis s , reilly mm , laurà m , parman y , battaloglu e , tazir m , bellatache m , bonello-palot n , sacconi s , guimarães-costa r , attarian s , latour p , megarbane a , schenone a , ursino g , sabatelli m , luigetti m , santoro l , manganelli f , quattrone a , valentino p , murakami t , scherer ss , dankwa l , shy me , bacon cj , herrmann dn , pisciotta c , previtali s , bolino a . milan, italy; paris, france; london, united kingdom; istanbul, turkey; algiers, algeria; marseille, france; nice, france; lyon, france; genoa, italy; rome, italy; naples, italy; catanzaro, italy; kurashiki, japan; philadelphia, usa; iowa city, usa; rochester, usa. cmt b and b are characterized by recessive inheritance, early onset, severe course, slowed nerve conduction, myelin outfoldings, association with loss-of-function mutations in myotubularin-related protein- and − (mtmr , mtmr /sbf ), respectively, involved in the metabolism of ptdins p and ptsins( , )p phosphoinositides, key regulators of membrane trafficking. in a multicentre retrospective study to better characterise cmt b, we collected a minimal dataset of information including cmtes/cmtns on cmt b patients, cmt b ( unrelated families) and cmt b ( families). cmt b patients were younger and with earlier onset than cmt b : last visit was performed at a mean age of years (sd . ; range - ) for cmt b and years ( . ; - ) for cmt b ; disease onset occurred at a mean age of . years ( . ; - ) in cmt b as compared to . years ( . ; - ) in cmt b ; delay in motor milestones occurred in / cmt b and / cmt b subjects. eleven cmt b patients became chair-bound, whereas all cmt b subjects but one are still ambulant, although with afos for patients and requiring unilateral support in two cases. both disease types are characterised by vocal cord involvement ( / cmt b and / cmt b ); respiratory involvement was seen almost exclusively in cmt b patients (n= , four requiring non-invasive ventilation and one tracheostomy, as compared to one cmt b patient on niv at age ); two cmt b subjects and an affected cmt b relative not included in the present study died of respiratory complications. glaucoma (n= ) and buphthalmos (n= ) occurred only in cmt b . cmtes/ cmtns scores were higher in cmt b patients in spite of their younger age, indicating more severe disease: cmt b = cmtes mean . (n= ; sd . ; range - / ), cmtns mean . (n= ; sd . ; range - / ,; cmt b = cmtes mean (n= ; sd . ; range - / ), cmtns mean (n= ; sd . ; range - / ). our data confirm that cmt b is more severe than cmt b . interestingly, mtmr interacts with mtmr . mtmr is a catalytically active phosphatase, whereas mtmr is a catalytically inactive protein, known to increase mtmr enzymatic activity. thus, in cmt b nerves a residual enzymatic activity of mtmr may result in a less severe clinical phenotype as compared to cmt b . the charcot-marie-tooth disease (cmt) national registry is fully operative (https:www.registronmd.it) with collection of clinical/genetic information (minimal dataset) and reporting of clinical scales; cmt patients have registered thus far and have chosen one of the reference centers; information collected during the ad hoc visit have been entered in the registry for of them. registered patients have the chance to participate to a study that requires filling online self-reported questionnaires related to five important issues: disease course and complications during pregnancy; use, efficacy and tolerability of orthotics and assistive devices; outcome of surgery for skeletal deformities; safety of anesthesia; occurrence of sleep disorders (including evaluation of fatigue, anxiety and depression). by february , patients and relatives/friends (as healthy controls) have filled the questionnaires. we are performing a first explorative analysis of results, but data collection on all questionnaires will be prolonged until novemebr , , to obtain a larger sample. pregnancy: / cmt women had at least one pregnancy; complications ranging from mild to severe occurred in / pregnancies vs / in controls. cmt worsened in pregnancies ( patients) with no recovery in instances. prenatal diagnosis was performed in / pregnancies. satisfaction related to surgical procedures for foot deformities, assessed with vas (score - ), was . ± . (n = ). repeat surgery was required in / instances. sleep: the epworth sleepiness scale questionnaire revealed abnormalities of sleep in / cmt patients ( %) and in / controls ( %). the vast majority of cmt subjects ( / ; mean . ± . ), but also of controls ( / ; . ± . ) were not good sleepers according to the pittsburgh sleep quality index (psqi) (range - , good sleep). fatigue: scores of modified-fatigue impact scale (range - , no fatigue) were higher for cmt (mean ± . ) than controls (mean . ± . ). hospital scale for anxiety and depression: / cmt subjects had mild-to-severe anxiety and / mild-to-severe depression as compared to / and / controls, respectively. data analysis on orthotics and anesthesia is ongoing. in conclusion, the first data analyses confirm that there are problems related to all the five domains explored, that will need to be specifically addressed in patients' care. supported by telethon-uildm grant gup . charcot-marie-tooth disease (cmt) is the most frequent motor and sensory peripheral neuropathy and is known to have the uniform demyelination. the traditional definition of conduction block is the reduction of negative peak of compound muscle action potential (cmap) of proximal segment relative to adjacent distal segment more than %. in this study, we tried to find the frequency of conduction block in cmt a patients and to investigate the differences of the clinical manifestation. we enrolled unrelated cmt a patients ( males and females) with pmp duplication and undertook nerve conduction studies from to . stimulation sites were wrist, elbow and axilla for median nerve study. eleven patients ( . % of all enrolled patients) had ncs features suggestive of conduction block. compared to cmt a patients without conduction block, functional disability scale was significantly higher in cmt a patients with conduction block (p < . ). however, onset age and disease duration were not different between cmt a patients with and without conduction block. in addition, conduction block was more frequently observed in distal segments than proximal segments. we suggest that the frequency of conduction block in cmt a patients is not low, and there is some heterogeneity of demyelination in cmt a patients. also, in cmt a patients, the conduction block might have relationship with clinical disability. park jg , park ms . yeungnam university college of medicine, daegu, korea. the subacute combined degeneration (scd) is diagnosed by a characteristic clinical manifestation, spinal mri, and decreased serum vitamin b levels. we report a case of scd with elevated homocysteine and methlymalonic acid level in the situation of spurious elevation of vitamin b concentration. an years old man presented with progressive gait disturbances and sensory disturbances. about a year ago, he felt both hands and feet paresthesia and gait disturbances. four months before the visit, nerve conduction tests were performed elsewhere due to symptoms. polyneuropathy was found. the laboratory test showed megaloblastic anemia. however, serum vitamin b concentration was increased to pg / ml (normal: - pg / ml). his symptoms progressed gradually. at presented, neurological examination showed spasticity of the lower limb without weakness, and vibration and position sensation were decreased in both lower limbs, and showed ataxic gait. spinal cord mri showed a lesion with a long t high signal intensity from c to t in the posterior column of the spinal cord. further laboratory test were added, then while folate was normal level but homocysteine at . umol/l (normal: - umol/l), and methylmalonic acid at . um / l (normal: - . um / l) were increased. finally, scd caused by vitamin b deficiency was diagnosed. in addition, gastric endoscopy was performed to find the cause of vitamin b deficiency and chronic atrophic gastritis was found. after cobalamine treatment for months, hemoglobin level was improved and his symptoms were all improving with a little gait disturbances. false-elevation of vitamin b level could lead to delayed diagnosis and cause irreversible changes in the nervous systems. one of the most commonly used methods to measure vitamin b concentrations is competitive-binding assay, which may result in normal levels even with vitamin b deficiency due to the effect of anti-intrinsic factor antibodies. when vitamin b deficiency is suspected, even if the vitamin b concentration is normal, additional tests of homocysteine and methylmalonic acid should be considered. parman y , durmus h , deymeer f , oflazer-serdaroglu p , battaloglu e . istanbul university, istanbul faculty of medicine, department of neurology, istanbul, turkey; bogazici university, istanbul, turkey. hereditary motor and sensory neuropathies, also called cmt neuropathies, are the most common group among the hereditary neuropathies. cmt subtypes are grouped by axonal, demyelinating or intermediate phenotype, or by autosomal-dominant (ad), autosomal-recessive (ar) or x-chromosomal inheritance. cmt- is considered axonal and characterized by distal muscle wasting, mild sensory loss and normal or near-normal nerve conduction velocities. mutations in more than genes are known to be able to cause autosomal dominant (ad) or recessive (ar) cmt- to date. the genetic heterogeneity in charcot-marie-tooth (cmt) is a challenge for genetic diagnostics. clinical clues and frequencies of mutations in cmt genes from large cohorts may help to develop strategies for efficient genetic testing. here, we present the clinical, electrophysiological and genetic features of patients from turkey, diagnosed as genetically confirmed cmt- in the department of neurology, istanbul faculty of medicine our clinic between and . genetic testing was performed for gdap by dna sequencing and samples from patients were exome sequenced (wes). twenty-one male and ten female patients from unrelated families were investigated. segregation was ar in eight, ad in six families and two were isolated cases. intraand interfamilial variability in the age of onset with a range of - (mean . ± . years) and disease progression rate were striking. slowly progressive weakness and atrophy of distal muscles in the feet and/or hands were the most common presenting symptoms. mfn was found in four unrelated ad kinship and in unrelated ar kinships and was most common gene mutated among whole cohort. gdap was the most commonly mutated gene among ar families ( / ). wes revealed further mutations in aars, nefl, kif b and hspb , however, the causative mutation could not be identified in known cmt genes in about % of patients. our data indicates the marked intra-and inter-familiar phenotype variability in cmt- as previously described in literature. many more genes causing arcmt- remain to be discovered. pasnoor m , veerapaneni k , murphy r , statland jm , kimple d , hamasaki a , glenn md , herbelin l , barohn rj , jawdat o , dimachkie mm . department of neurology, neuromuscular division, the university of kansas medical center, kansas city, ks, usa. electrodiagnostic (edx) studies involving electromyography/nerve conduction study (emg/ncs) are useful for diagnosis of neuromuscular disorders. although these are safe procedures, emg and ncs often evoke anticipated pain and anxiety. there are no published research studies to support the notion that providing detailed information to patients prior to these procedures would reduce procedural pain and ameliorate anxiety levels afterwards. the objective of this study was to perform a prospective survey to assess anticipated pain and anxiety in patients presenting for edx studies, design a detailed patient education form, and assess the change in perceived pain and anxiety pre and post procedure in the standard of care (soc) education versus the printed detailed education instrument group. after completing a brief pain/anxiety questionnaire, patients were randomly assigned to either soc verbal education group or to read the detailed education form. another brief questionnaire was completed post procedure. seventy-eight patients were enrolled at the time of abstract submission, in intervention and in soc groups. mean age of patients enrolled was ± years. pain was anticipated by % patients as a visual analog scale (vas) score mean of . ± . with no significant difference between both groups (p= . ). post-procedural pain was reported in % of patients with mean pain score of . ± . and no significant difference between the two groups (p= . ). anxiety pre-procedure was reported by % patients with a mean likert-like score of . ± . score in all cases (p= . between both groups). post-procedural anxiety frequency was reduced to % with mean level of . ± . (p= . between both groups). most patients reported pain with both emg and ncs ( %). we found that edx testing evokes moderate pain in most and in some cases moderate anxiety level. the detailed education intervention did not attenuate the frequency or severity of pain. post-procedural anxiety was expectedly reduced in severity and frequency in both groups with a suggestion that anxiety severity is lesser in the detailed education group but numbers were small. further studies with more detailed questionnaire and perhaps web-based education in larger population may be useful to reduce pain/anxiety in patients presenting for edx studies. pasnoor m , roach c , barohn rj , statland j , jawdat o , dick a , glenn m , dimachkie mm . department of neurology, neuromuscular division, the university of kansas medical center, kansas city, ks, usa. diagnostic criteria for chronic inflammatory demyelinating polyneuropathy (cidp) have been designed for use in clinical trials. there is limited data on the comparative diagnostic utility of these criteria in the clinic setting and it is unknown if some of these criteria are better for predicting treatment response. the objective of this study is to compare the sensitivity of various diagnostic criteria and review treatment response. after obtaining local irb approval, we performed a retrospective chart review of cidp patients seen at the university of kansas medical center between and . we abstracted the clinical, electrodiagnostic, and treatment information. we determined the frequency of patients fulfilling each of the following criteria: efns , aan, saperstein and incat. we defined treatment response based on treating physician's impression of change, patient-reported functional improvement or one point grade change in the mrc grade. fifty-three cidp patients charts were reviewed, were excluded due to missing data. mean age was . , and ( %) were female. elevated csf protein was seen in / ( %). twenty-eight ( %) fulfilled efns definite criteria, ( . %) efns probable, ( . %) aan, ( . %) incat, and ( . %) the saperstein criteria. treatment response in patients who fulfilled efns definite/probable criteria included / to ivig, / to iv or oral corticosteroids, / to mycophenolate mofetil; among patients who fulfilled aan criteria, these were respectively / , / and / ; among those meeting incat criteria / , / and / ; and for saperstein criteria it was / , / and / . half to two-thirds of patients responded to plex based on different criteria. while all cidp criteria can similarly predict ivig treatment response, the efns criteria are most sensitive for the clinical diagnosis of cidp. pellegatta m , canevazzi p , forese mg , podini p , quattrini a , taveggia c . division of neuroscience and inspe, axo-glia interaction unit, san raffaele scientific institute, milan, italy; division of neuroscience and inspe, experimental neuropathology unit, san raffaele scientific institute, milan, italy. axonal nrg type iii is an essential instructive signal for pns myelination, since its expression determines whether axons are myelinated and also the thickness of the myelin sheath. previous studies have shown that secretases' cleavage controls nrg type iii activity at post-transcriptional level. specifically, the beta-secretase bace- cleavage of nrg type iii promotes myelination, whereas the alpha-secretase tace inhibits pns myelination by inactivating nrg type iii. after a damage, the axon located distally to the site of injury degenerates and loses the myelin sheath, following a process termed as wallerian degeneration. unlike the cns, axons in the pns can regenerate and regrow. several studies have shown that regeneration is favored by the trans-differentiation of schwann cells, which start to create a permissive environment for axonal regrowth. in addition, it has been shown that nrg regulates the early stages of the dedifferentiation process and is essential for creating a permissive environment to regeneration. similarly, the beta secretase bace- promotes pns regeneration and remyelination. in the present study, we analyzed the role of the alpha-secretase tace during wallerian degeneration. our data indicate that tace is upregulated in sciatic nerves after injury, distally to the site of damage. since tace is expressed in schwann cells and axons, we analyzed the role of both glial and neuronal tace during degeneration and regeneration processes. thus, we performed crush injury in sciatic nerves of two different transgenic lines carrying a conditional deletion of tace either in schwann cells (p -cre//tace flox/flox ) or in neurons (chat-cre//tace flox/flox ). the analyses of the different phases of the wallerian degeneration in these animals suggest a role of glial tace during the early stage of the process. in fact, we observed an increased number of myelinated axons only in p -cre//tace flox/flox mice, while we did not detect substantial differences in mutant chatcre//tace flox/flox mice. these results suggest that even during regeneration tace has an inhibitory role, as deletion of tace in schwann cell likely induces the activation of a neuro-protective program that we are currently investigating. péréon y , nizon m , küry s , besnard t , quinquis d , boisseau p , magot a , mussini jp , mayrargue e , barbarot s , bézieau s , isidor b . reference centre for neuromuscular disorders; dept. of genetics; dept. of paediatric surgery; dept. of dermatology, university hospital, nantes, france. the hereditary sensory and autonomic neuropathies (hsan) constitute a clinically and genetically heterogeneous group. hsan are associated with sensory dysfunction, altered pain and temperature perception with varying degrees of autonomic dysfunction, and abnormal small fibers neurodevelopment. more than ten genes have been described so far in the hsan group. original classification encompassed four entities, but additional subgroups continue to be described. hereditary sensory neuropathies (hsan) type ii are characterized by autosomal recessive inheritance, onset at birth and self-mutilating behavior. until now, one homozygous frameshift variant, c.[ _ del], p.(lys phefs* ), was reported in arl ip (adprribosylation-like factor -interacting protein ) in a consanguineous family. patients presented with spastic paraplegia, diffuse sensory and motor polyneuropathy and acromutilation. the disorder was classified as autosomal recessive spastic paraplegia spg . here, we described a new patient with congenital insensitivity to pain, sensory neuropathy, self-mutilation, and spastic paraplegia. whole exome sequencing showed a homozygous frameshift variant c. [ _ del], p.(lys phefs* ) in arl ip . the protein harbours reticulon-like short hairpin transmembrane domains and has a role in endoplasmic reticulum shaping. the variant causes an additional c-terminus hydrophobic domain which could alter its function. arl ip interacts with atlastin- responsible for spg a and hsan type d. this report highlights the role of arl ip in pathophysiology of insensitivity to pain and spastic paraplegia. péréon y , nguyen a-l , leclair-visonneau l , fayet g , nguyen j-m , magot a . laboratoire d'explorations fonctionnelles, hôtel-dieu, nantes, france; département de statistiques médicales, hôtel-dieu, nantes, france. carpal tunnel syndrome (cts) is responsible for sensory and/or motor symptoms that may be increased by wrist flexion or extension (phalen sign). previous studies have shown that short duration (e.g. min or less) flexion or extension was not responsible for significant changes of median nerve conduction parameters. the objective is the study was to determine how prolonged extension (reverse phalen's test) affects median and ulnar nerve conduction parameters in normal subjects. after providing informed consent, normal subjects ( females, age rank - years) underwent motor and sensory testing of both median and ulnar nerves from the dominant side. edx testing was performed using standard techniques with wrist in neutral position, then during passive wrist extension ( ∘ ) for minutes, with sequential recording of both motor action potential (cmap) and sensory action potential (snap) latencies and amplitudes every minutes after extension onset. ulnar nerve conduction parameters remained unchanged in all the subjects. regarding median nerve, groups of subjects could be individualized: subjects with no changes; subjects with only significant decrease of snap amplitude (− %); subjects with both snap amplitude and velocity decrease; subjects with both cmap and snap significant changes. when present, changes did not appear before min, with snap decrease being the earliest observed abnormality. prolonged wrist extension was responsible for median nerve edx parameter modifications in / normal subjects. sensory fibers were firstly affected, corresponding to the chronology clinically encountered in cts. based upon these results, the same protocol will be used in patients presenting with mild clinical cts, in order to try and identify an additional edx technique being useful in the diagnosis of cts. one could also wonder whether the subjects with the most important changes would be more prone to present cts in the future. perez-siles g , , drew a , , ellis m , kidambi m , takata r i , speck-martins c e , hagerman k a , siskind c e , day j w , ginzberg m , nicholson g , , , kennerson m l , , . northcott neuroscience laboratory, anzac research institute, sydney, australia; sydney medical school, university of sydney, sydney, australia; molecular medicine laboratory, concord repatriation general hospital, sydney, australia; sarah network rehabilitation hospitals, brasilia, df, brazil; department of neurology, stanford health care, stanford, ca, usa; pediatric neuromuscular unit, wolfson medical center, holon, israel. mutations in the atp a gene cause of x-linked hereditary distal motor neuropathy (dhmnx). to date, missense mutations (t i and p s) in this copper transporting atpase are the only confirmed mutations causing dhmnx in two independent families. next generation sequencing (ngs), including whole exome and whole genome sequencing, is increasing the rapid detection of variants in genes known to cause disease, however the absence and size of additional families, make it challenging to determine the pathogenic or benign status of variants identified. we have recently identified new variants in atp a in patients with progressive peripheral neuropathy, suggesting further genetic heterogeneity of dhmnx. two of these new variants, pe v and pm v, are located at highly conserved amino acids within domains of atp a (a-domain and p-domain, respectively) that are critical for the catalytic cycle of the copper transporter. we have also identified a third variant (c. - a>g) located bases upstream exon that is predicted to abolish a conserved branch-site, a consensus intronic sequence necessary for the processing of immature rna during splicing. our recent investigations using both patient fibroblasts and an atp a conditional knock in mouse model for dhmnx expressing atp a t i , the orthologue of the human atp a t i mutation, showed reduced atp a protein levels and defective retrograde trafficking of atp a, as pathological hallmarks of dhmnx atp a causative mutations. to elucidate if the newly identified pe v, pm v and c. - a>g atp a variants are pathogenic, we have systematically assessed patient fibroblasts harbouring these mutations for altered parameters previously found in the pathogenic t i atp a mutation. we predict that functional characterisation of atp a using patient fibroblasts harbouring newly identified variants will provide the evidence to ascertain whether these variants are disease causing. establishing a systematic functional readout for atp a variants will improve accuracy of genetic counselling and patient management of dhmnx in those cases where genetic evidence is limited. this study represents a complementary and necessary approach to the use of ngs, for validating the pathogenic status of variants identified and for expanding the genetic heterogeneity of dhmnx. month of birth (mob) have been defined as a risk factor for more than diseases. for instance, susceptibility for multiple sclerosis (ms) seems to be associated with being born in may, while lower risk of ms is observed in those born in november. there are no studies that assessed potential association between mob and a risk for guillain-barré syndrome (gbs). we sought to determine if the risk of gbs is associated with the mob. study included gbs patients diagnosed in serbia, montenegro and republic of srpska in the period from january , until december , . mob of patients and of general population were compared. patients with gbs had tendency to be born in october ( % increase compared to general population, p= . ) and were less likely to be born in june ( % decrease, p= . ). when consider specific seasons, gbs patients were more likely to be born in winter months ( % increase, p< . ). no associations were found between month/season of birth and disease severity. results of this pilot study showed that gbs patients are more likely to be born in cold months, and less likely to be born in june. this might be explained by higher exposure to different pathogens during pregnancy in cold months. in accordance with this, it is well known that early exposure to infective agents reduces risk of allergic and autoimmune diseases. further studies are needed to test our findings in different cohorts and in regions with different climate. these results may shed new light on the disease pathogenesis. majority of patients with guillain-barré syndrome (gbs) tend to have a successful recovery, but in number of them significant long-term consequences may negatively affect their quality of life. aim of this research was to analyze the outcome of the disease one year after the acute episode of gbs. among patients diagnosed with gbs in seven tertiary centers in serbia, montenegro and republic of srpska during , subjects were retested after one year ( % males, mean age ± years). functional disability of patients was estimated based on the gbs disability scale (gds). severe form of the disease (gds score - ) was registered in % of patients at admission, % at nadir, and % on discharge. after one year follow-up period, % of patients had no symptoms of gbs, % had mild symptoms, % was able to walk but not to run, % needed unilateral support during walking, while % was wheelchair bound or bedridden. lethal outcome was registered in three patients during acute phase of gbs and in four more during one-year follow-up. paresthesias were present in % of gbs patients, musculoskeletal pain in %, and fatigue in % one year after acute phase of the disease. factors associated with the worse functional outcome (gds grade above ) after one year were: age above , preceding respiratory infection, and worse gds on discharge. one year after the onset of the disease, significant number of our gbs patients had neurological impairments including sensory symptoms, pain, fatigue and muscle weakness which may significantly affect patients' everyday functioning. phetteplace je , saade d , bacon c , shy me . university of iowa hospitals and clinics, iowa city, ia, usa. charcot-marie-tooth (cmt) disease, also known as hereditary motor and sensory neuropathy, is a heritable peripheral neuropathy caused by genetic mutations in many different genes. cmt type a is the most common form of cmt. individuals affected with cmt a commonly have distal muscle atrophy, foot deformities, abnormal gait, and reduced nerve conduction velocities caused by demyelination of the peripheral nerves. cmt a is known to be caused by a duplication of the pmp gene at p . . the proposed disease mechanism of cmt a is believed to be increased gene dosage of the pmp gene, although the exact function of pmp is not known. there have been previous reports in the literature of individuals who carry a homozygous duplication of pmp , therefore having four copies of the gene. however, many of these reports have focused on adult patients who symptoms may not vary significantly from individuals who harbor only a duplication of pmp . a month old male presented to the university of iowa hospital due to a family history of cmt a and concern for delay in independent ambulation. he was known to have both a maternal and paternal family history of cmt a, although the families were believed to be unrelated. on exam he was unable to walk independently, but could take a few steps when his hands were held. per report he began crawling and scooting at months of age. he was not found to have any structural abnormalities or atrophy in his upper or lower extremities. electrodiagnostic testing revealed a demyelinating neuropathy. only one nerve was tested, as the patient was unable to tolerate additional shocks. the peroneal nerve was found to have a nerve conduction velocity of m/s. based on the clinical presentation, electrodiagnostic examination and family history deletion and duplication testing for pmp was performed. this testing revealed a homozygous duplication of pmp , which has been previously reported to cause cmt a. this case supports the gene dosage disease mechanism, as our patient appears to be more severely affected than a typical infant or toddler affected with cmt a. piscosquito g , saveri p , provitera v , stancanelli a , ciano c , magri s , taroni mpz mutations are associated with the demyelinating early-onset charcot-marie-tooth (cmt) type b and with the axonal later onset cmt i/cmt j. paresthesias/dysesthesias and pain have been already reported in some cmt types and also in cmt i/j. we report patients ( from families, sporadic cases,) carrying the mpz c. dela mutation (p.asp thrfster ). this is predicted to be a loss-of-function mutation, leading to p haploinsufficiency. most of the subjects have genetic ancestry from puglia region (southern italy). two patients carried the mutation in homozygosity, showing a severe phenotype: onset at birth, severe scoliosis, proximal weakness, distal limb plegia, no autonomous walking, cmt examination score (cmtes) - / . all the other heterozygous patients had mild adult-onset (mean age , range - ) neuropathy, walked without aids or ankle-foot orthoses, had cmtes < / . five showed mild foot deformities, / had foot and / hand weakness (mrc never less than / ), / sensory loss in lower limbs (ll). paresthesias/dysesthesias (mostly tingling and burning in type) localized in hands and ll were reported by / subjects, neuropathic pain by / . in the homozygous patients, all cmaps and saps were absent. in all other subjects, motor conduction velocities (cv) were > m/s (range - m/s) and sensory cv > m/s (range - m/s). cmaps as well as saps were normal or moderately reduced in amplitude, indicating only slight axonal loss. we confirm that heterozygosity is associated with very mild cmt, whereas homozygosity causes a very severe neuropathy. our data suggest that paresthesias and neuropathic pain are very common and should be considered as part of the phenotype. although the clinical picture suggests a small fiber neuropathy, no such evidence is provided in the current literature. in the attempt to further investigate this field, we found in a -year-old male patient of our series that all thresholds were increased at quantitative sensory testing, and several abnormalities of small nerve fibers were present in skin biopsy. apparently, p aneuplody causes neuropathy and small fiber involvement through a mechanism different from other mpz missense mutations. poitras t , chandrasekhar a , singh v , martinez j , zochodne dw . neuroscience mental health institute, and division of neurology, department of medicine, university of alberta, edmonton, alberta, canada. a microarray mrna analysis of dorsal root ganglia examined in long-term diabetic mice yielded an unexpected upregulation of a unique set of proteins known as major urinary proteins (mups & ). originally, this family of barrel shaped proteins was described as including mediators of pheromone secretion in the urine of rodents, apparently unconnected to other functions. we identified its unanticipated expression in sensory neurons of adult mice and rats and explored its potential impact on the properties of these neurons. analysis of rat and mouse sensory neurons showed widespread and pan-neuronal cytosolic mup expression, not only in the cell body, but also in distal sensory projections located in the dermis of the footpad. to assess the role that mup might offer in the growth behaviour of adult neurons, we examined sirna-induced knockdown of mup on pre-injured dissociated drg primary cultures. mup knockdown in both species showed a significant increase in neurite outgrowth following mup sirna treatment when compared to a scrambled sequence control. mice treated with streptozotocin (stz) model features of human type diabetic polyneuropathy, including decreases in multi-fiber motor and sensory measurements, and changes in thermal sensation in the extremities. to explore the potential role of mup upregulation specifically in diabetes, we examined the impact of non-viral intranasal injection of mup sirna on indices of neuropathy in chronic type diabetic mice. following treatment, mice treated with mup sirna showed improvement in both motor and sensory nerve conduction velocities compared to scrambled controls. taken together, this data suggests that mup plays a growth-suppressive role in both diabetic and non-diabetic neurons and may also contribute to the electrophysiological and behavioral abnormalities associated with diabetic polyneuropathy. the repurposing of mups in sensory neurons identifies an interesting role for a supposed pheromone protein. [supported by cihr, cda and adi] enhancement of their outgrowth properties (singh et al, ) . here we asked whether similar activation, using low dose capsaicin, might similarly ramp up the regenerative activity of sensory neurons. using rat adult primary sensory neurons, we identified a dose dependent relationship between capsaicin exposure and their outgrowth with enhancement at lower doses and expected neurotoxicity at higher doses. doses that enhanced outgrowth were nonetheless associated with rises in intraneuronal calcium. we next tested whether a similar impact of trpv activation in vivo might exist. we used a high sciatic crush injury mouse model to assess the impact of capsaicin at low ( um) or high ( mm) doses applied directly at the site of axon outgrowth after injury. by days following the single application of capsaicin, low doses of capsaicin showed more rapid recovery of thermal, but not mechanical sensation, whereas high dose capsaicin showed no significant difference compared to vehicle treated mice. in parallel with the neurotoxicity observed in vitro, the high dose capsaicin resulted in a decrease in sensory nerve conduction velocity, while the low dose showed no significant difference when compared to the vehicle treated animals. there was no impact on motor axon recovery. taken together, subtoxic trpv activation with intraneuronal calcium mobilization, as applied to regenerating sensory axons, enhances their outgrowth after injury, and improves behavioural recovery similar to that following extracellular electrical stimulation. [supported by cihr] hereditary transthyretin (hattr) amyloidosis is a rapidly progressive, life-threatening disease caused by ttr gene variants, resulting in ttr misfolding and amyloid deposition in multiple organs, including peripheral nerves. hattr amyloid polyneuropathy has prominent small fiber involvement characterized by neuropathic pain and dysautonomia. measurement of intraepidermal and sweat gland nerve fiber density (ienfd, sgnfd) in skin biopsies has been useful in identifying small fiber abnormalities in hattr. we report the effect of patisiran, an investigational rnai therapeutic for the treatment of hattr, over a -month period on ienfd, sgnfd and dermal amyloid content from the phase open-label extension (ole) study. skin biopsies (distal leg, distal thigh) were obtained every months for up to years within the phase ole study (patisiran . mg/kg iv, q w, nct ) and analyzed in a blinded manner by a central laboratory. all analyses are exploratory; nominal p-values are reported without adjustment for multiple testing. twenty-seven patients enrolled; preliminary data indicated patisiran was generally well tolerated; resulted in sustained mean serum ttr lowering of ∼ % for > months and a mean . -point decrease in mnis+ (n= ). twenty-four patients underwent serial skin punch biopsies. at baseline, mean ienfd was . and . fibers/mm, while mean sgnfd was . and . m/mm for distal thigh and distal leg, respectively. amyloid was detected in ∼ % of skin biopsies, mean baseline dermal amyloid content . % and . % for distal thigh and distal leg, respectively, which inversely correlated with ienfd and sgnfd. overall, ienfd was stable throughout the -year treatment. sgnfd increased over time relative to baseline, reaching statistical significance at , , and months for distal thigh (p< . , all time points) and at months for distal leg (p= . ). dermal amyloid content decreased over time and reached statistical significance at , and months for distal thigh (p< . , all time points) and at , , , and months for distal leg (p< . , all time points). in summary, improvements in sgnfd and dermal amyloid content observed over a -year period suggest that these parameters have the potential to serve as biomarkers of response to patisiran treatment. polydefkis m , neuhaus s , doherty l , ebenezer gj . department of neurology, johns hopkins university, baltimore, md, usa. misdiagnosis and delayed identification of an etiology for sensory neuropathies hampers adequate management and delays initiation of therapy. we present several cases that illustrate variable presentations of amyloid neuropathy (an) and an complicated by amyloid arthropathy. a -year-old former college athlete developed painless difficulty walking. he was unable to keep up with family members during routine outings and subsequently was unable to navigate uneven ground during a hike, something he had previously excelled at. balance decreased, making bicycling difficult. neurological evaluation -months after symptom onset led to a diagnosis of peripheral neuropathy. a reversible neuropathy panel was normal though a c was elevated ( . %). over several months, his strength/sensation deteriorated despite diet improvement, losing lbs and a c improvement ( . %). upon referral, emg revealed a sensorimotor neuropathy with markedly reduced/absent sural, peroneal and tibial motor amplitudes. there was mild orthostasis. nis was . skin biopsies revealed severe ienfd, sgnfd reductions and positive congo red staining, confirmed with birefringence. a sural nerve biopsy confirmed amyloid deposits. genetic testing revealed the ttr-fap variant leu his. there was no history or suspicion for a family history of amyloid. a -year-old male with a history of controlled diabetes x years developed abrupt onset of rls months after a lymphoma diagnosis. treatment with rituximab led to radiographic resolution of the lymphoma though the patient developed progressive peripheral neuropathy confirmed by ncv/emg. new-onset early satiety, mild orthostasis and ed emerged. skin biopsies demonstrated a lichenoid pattern of amyloid deposition consistent with aa-amyloid. a -year old woman with leu his ttr-fap since developed progressive leg weakness, reduced ability to walk and low back pain. emg demonstrated progression of her sensorimotor neuropathy and superimposed multilevel radiculopathy. spine mri demonstrated severe lumbar stenosis requiring surgical decompression. postoperatively, she regained strength, walking more easily. congo red staining of vertebral bone demonstrated widespread positive staining with birefringence consistent with amyloid arthropathy. these cases illustrate to wide sprectrum of amyloid neuropathy presentation, an example of amyloid arthropathy-induced spinal stenosis and the utility of skin biopsy to diagnose and manage amyloid neuropathy. the differentiation between hereditary neuropathy and chronic inflammatory demyelinating polyneuropathy (cidp) in children is especially significant because of completely different treatment possibilities and prognosis in these conditions. the aim of the study was to compare electrophysiological abnormalities in a group of children and young adults with demyelinating neuropathy of chronic or subacute onset. retrospective analysis of clinical and nerve conduction study (ncs) data included children and young adults with charcot-marie-tooth neuropathy x type (cmtx ), children with charcot-marie-tooth neuropathy type a (cmt a) and children with cidp. in our study / cmtx had both axonal and demyelinating changes in ncs study. the aan and efns electrophysiological cidp criteria were fulfilled in / cmtx , / cmt a and / cidp patients. additionally patients with cmtx are classified with efns criteria as "probable/possible cidp". a distal compound muscle action potential (dcmap) was > ms in all cmt a and / cidp patients but none with cmtx . abnormal median/normal sural snap (amns) parameter was observed in // cidp and / ctmx patients but not any cmt a patient while abnormal sural/normal median snap (asnm) parameter was found in / patients with cidp. a difference between conduction velocities (cv) of two corresponding nerves > m/s was seen in / cmtx and / cidp patients but no one with ctm a. one patient with cmtx had especially conspicuous difference between nerve conduction in lower limbs, with axonal neuropathy and demyelinating features, and upper limbs with no changes. one -years-old patient with genetically confirmed cmtx had no abnormalities in ncs. electrophysiological data of cmtx , cmt a and cidp indicate diffuse demyelination, however in cmtx axonal changes coexist, seen in / patients, and asymmetrical abnormalities between corresponding upper and lower limb were observed in / patients. our study has showed that duration of dcmap is useful not only in diagnosing an inflammatory neuropathy but also in differentiating cmtx from cidp. however presence of the not homogenous abnormalities in ncs in patients with cmtx may mimic inflammatory neuropathy. prada v , mori l , francini l , accogli s , ursino g , gemelli c , schizzi s , grandis m , bellone e , mandich p , schenone a . department of neurosciences, rehabilitation, ophthalmology, genetics and maternal and child health, university of genoa, genoa, italy. the overwork weakness (ow) problem in cmt disease has been debated for long time. it has been reported that the non-dominant hand (ndh) of patients with cmt disease is stronger than the dominant hand (dh) as a result of ow and some authors verified this hypothesis using mrc on different muscles (van pomeren, ). more recently, piscosquito et al. ( ) found that the ow phenomenon does not exist using a dynamometer and the hole peg test, a dexterity test. we recruited cmt patients and healthy controls. we evaluated the strength of the -pinch and of the hand-grip with a dynamometer, the opposition ability with the thumb opposition test (tot) and applied an instrumental testing of hand function using the sensor engineered glove test (segt), which previously demonstrated its sensitiveness to measure severity of hands dysfunction in cmt patients. tot was significantly higher in the ndh compared to dh (ndh= , ± , ; dh= , ± , , p< . ) in cmt patients, instead there was no difference in dh and ndh in healthy controls. in the evaluation of -pinch and of the hand-grip, ndh performed slightly but not significantly better than the dh ( -pinch: dh= , ± , n; ndh= , ± , n; ± , n; ndh= , ± , n, p:ns) . in normal controls we confirmed the % rule (noguchi & demura, ). finally, segt results were similar between the ndh and dh in cmt patients but in normal controls there was a better performance in the dh. in conclusion, this study supports the existence of the overwork weakness in cmt, evident in every measurements. dexterity and overall ability of the hands impaired in the dh, probably because of compensating movements, compared with the healthy controls in the weaker hand. finally, our results support the importance of avoiding supramaximal exercises and educating the cmt patients to prevent incorrect movements, which may overload the hand muscles. prasad k , ohnmar o , teng a , cheng yj , umapathi t . national neuroscience institute, singapore; yangon general hospital, yangon, myanmar; yong loo lin school of medicine, national university of singapore, singapore. antecedent infections that have been linked to guillain-barré syndrome (gbs) include campylobacter jejuni, haemophilus influenza, epstein-barr virus, cytomegalovirus, mycoplasma pneumoniae and influenza a virus. in south-east asia, the burden of mosquito-borne flavivirus infections is considerable. even in a small country like singapore, with a population of only . million and in spite of excellent sanitation and public health measures, dengue virus (denv) infections can exceed , a year. both symptomatic and asymptomatic denv infections are associated with gbs. zika virus (zikv) infections were detected in singapore in late august . doctors working in south-east asia anecdotally report that gbs cases increase after rainy season when mosquitos breed. we are currently planning studies to estimate the hitherto unknown burden of gbs associated with denv, zikv and other mosquito-borne viruses in this region. as a preliminary step, we reviewed the gbs cases seen at our institution in for evidence of denv and zikv. three out of the tested cases were positive for denv serology. one of these was also positive for denv pcr. all these patients had symptomatic dengue. two had acute inflammatory demyelinating polyneuropathy (aidp) and acute motor axonal neuropathy (aman) subtype of gbs. none the patients tested were positive for zikv pcr in serum and urine. one patient, with miller fisher syndrome (mfs), had serological evidence of recent zikv. he did not have clinical zikv symptoms. in mfs cases, the initial detectable zikv igg was later proven to be due to cross reactivity with previous denv infection. in cases ( amsan, aidp, mfs) the initial zikv igm was raised. we await analysis of convalescent sera to decide if they indeed had zikv or the results were related to previous and co-infection with denv. our preliminary findings indicate that flavivirus infections may account for at least some of the gbs cases in singapore. the lack of symptoms in some cases and the interactions between zikv and denv antibodies make accurate diagnoses challenging. prior r , , benoy v , , vanden berghe p , van den bosch l , . ku leuven-university of leuven, department of neurosciences, experimental neurology and leuven research institute for neuroscience and disease (lind), leuven, belgium; vib-center for brain & disease research, laboratory of neurobiology, leuven, belgium; laboratory for enteric neuroscience, translational research center for gastrointestinal disorders, k.u. leuven, leuven, belgium. charcot-marie-tooth disease (cmt) is the most common inherited neurodegenerative disorder of the peripheral nervous system. it is divided into two main subtypes, a demyelinating subtype (cmt type ) and an axonal form (cmt type ). cmt is a length-dependent disease, in that it effects the longest neurons in the body, thus the muscles in the peripheral regions are affected first and foremost. moreover, the majority of cmt patients share a classical phenotype with shared pathological hallmarks, such as distal muscular atrophy, reduction in nerve conductions, etc. but also molecular pathological hallmarks, like the breakdown in the transport of organelles and vesicles in neurons in a process called axonal transport. currently, there is no cure or effective treatment available to cmt patients. histone deacetylase (hdac ) has been shown to be a key regulator in axonal transport. moreover, inhibiting hdac has been demonstrated to stabilize microtubules, which act as molecular tracks for motor proteins and facilitates axonal transport of cargos. our labs current focus is on cmt type a, the main cause of cmt, which is caused by a duplication of a segment of chromosome p . containing the gene encoding peripheral myelin protein (pmp ). pmp is mainly expressed by schwann cells, the cells that myelinate neurons in the peripheral nervous system. in the work presented, the commercial mouse schwann cell-line, sw cells, was transfected to overexpress pmp using a lentivirus vector system to mimic that of cmt a patient schwann cells. the overexpression of pmp was confirmed using immunofluorescence and western blot techniques. these transfected sw schwann cells were then co-cultured with primary mouse dorsal root ganglion neurons (drgs) isolated from adult mice. these co-cultures where then analysed after weeks in vitro for axonal transport. the investigated groups were: a co-culture of drgs + sw cells, a co-culture of drgs + sw cells transfected with pmp , and a co-culture of drgs + a sw cell-line transfected with green fluorescent protein using a lentivirus vector system, and a monoculture of drgs. furthermore, this work demonstrates that the overexpression of pmp in schwann cells can impair axonal transport in co-cultured drgs in comparison to the other co-culture groups. moreover, these axonal transport defects were able to be rescued by the treatment of a hdac inhibitor, tubstatin a. to conclude, selective hdac inhibitors have been shown to be a beneficial treatment for a number of cmt subtypes in preclinical studies in our lab and offer as a viable treatment for a currently, untreatable debilitating disease. provitera v , caporaso g , stancanelli a , piscosquito g , di caprio g , saltalamacchia am , santoro l , nolano m . "maugeri" clinical and scientific institutes irccs, institute of telese terme (bn), italy; department of neurosciences, reproductive and odontostomatological sciences, university 'federico ii' of naples, naples, italy. the observation of rate and patterns of cutaneous nerves regrowth after mechanical or pharmacological distal axonotmesis, has proven to be an excellent tool to study human nerve regeneration in normal and pathological conditions. most of the observations, however, are referred to small fibers, possibly due to the availability of excellent models of reversible distal cutaneous small fiber axonopathy. no such model is available to study the regeneration of myelinated fibers in human. we studied regrowth of cutaneous large fibers in fingertip of patients with carpal tunnel syndrome after surgical decompression. we recruited patients (m/f / ; age . ± . years) with carpal tunnel syndrome candidate to surgery. patients underwent clinical and electrophysiological evaluation, quantitative evaluation of discriminative threshold at rd fingertip. in the same site, patients also underwent mm punch skin biopsy. skin sections were stained by immunohistochemical techniques and cutaneous innervation was analyzed by confocal microscopy. meissner corpuscles and their myelinated afferences were assessed following previously published procedures. twelve months after surgery, patients repeated functional evaluation and underwent a second skin biopsy two mm apart from the first one. mean density of mcs/mm was . ± . at time and . ± . at follow-up, mean density of myelinated endings was . ± . at time and . ± . at follow-up. however, not in all patients regeneration occurred. based on the variation of mc density between time and follow-up we were able to identify patients in which active regeneration had occurred. in this subgroup mean density of mcs/mm was . ± . at time and . ± . at follow-up (p< . ) with a mean delta of + . . in the same group, mean density of myelinated endings was . ± . at time and . ± . at follow-up (p< . ) with a mean delta of + . . we describe morphological patterns associated to nerve regrowth in the biopsies of patients in which nerve regeneration occurs. we propose an in vivo model to study regeneration of large myelinated fiber endings in human skin. in addition to the count of nerve endings, the identification of patterns associated to nerve regeneration can increase the diagnostic yield of skin biopsy. the most common type of charcot-marie-tooth disease is caused by a duplication of pmp , leading to dysmyelination, axonal loss and progressive muscle weakness (cmt a). currently, no approved treatment for cmt a patients is available. among others, preclinical therapeutic approaches aim to correct the pmp overexpression in order to ameliorate axonal loss and muscle weakness. we previously reported that the novel polytherapeutic drug pxt , a low-dose combination of baclofen, naltrexone and sorbitol, improved dysmyelination and axonal loss after long-term application in adult pmp transgenic rats, a known animal model of cmt a. interestingly, after short-term application in young cmt a rats we observed a long-lasting prevention of muscle weakness as well but without obvious effects on dysmyelination and axonal loss. improved distal motor latencies in the electrophysiological recordings and a shift in the axonal diameter distribution raised the hypothesis that therapy may improve the neuromuscular endplate pathology as another therapeutic target for cmt a. here, we report a preclinical trial in adult cmt a rats treated from postnatal week for consecutive weeks as the most effective regimen in order to facilitate a deeper understanding of the mode-of-action of pxt . long-term therapy effects were confirmed by an ameliorated behavioral phenotype, improved distal motor latencies and also nerve conduction velocity in the electrophysiological recordings. histological analysis revealed an increased number of neuromuscular endplates, which were lowered to wildtype level after pxt treatment. further investigations include detailed analysis of peripheral nerve myelin thickness, internodal and nodal length, terminal axonal sprouting at the neuromuscular endplate and muscle fiber subtyping in treated cmt a rats. charcot-marie-tooth disease (cmt) is a rare hereditary neuropathy for which novel treatments are being developed and urgently needed. only few clinical trials and natural history studies have been performed. evaluation of intervention efficacy is hampered by slow progression and lack of sensitive outcome measures. the interindividual disease variability is high and prognostic disease measures are not established for cmt patients. previously, we have identified skin-derived disease and progression biomarkers in a large european and us-based cmt a cohort. within the german charcot-marie-tooth disease network (cmt-net, www.cmt-net.de) we aim to establish easier accessible biomarkers in blood of cmt a patients. blood analysis is less invasive and can be repeatedly performed during clinical trials and routine patient care. we have started clinically assessing approximately young, adolescent and adult cmt a patients at clinical centres (münster, münchen, göttingen) including a large set of clinical outcome measures (cmtnsv , onls, mwt, mwt, walk , hpt, sf- , fss, psqi, ess, bdi-ii). we will sample blood and skin tissue once a year at , and months for an observational period of years. tissue samples will be analyzed on the transcriptional, translational and epigenetic level. we envision that the diagnostic and progression biomarkers may be used to measure therapeutic effects within clinical trials and later in clinical routine monitoring. this is the first trial testing "circulating" biomarkers from blood in a prospective observational trial in cmt a patients. igm peripheral neuropathy is a slowly progressive and heterogeneous disease with symptoms ranging from mild foot numbness and minor imbalance to severe neuropathic pain and sensory and motor dysfunction. international consensus regarding assessment and treatment of patients with igm peripheral neuropathy is lacking. this might be caused by the repeated use of suboptimal outcome measures, the small trial sizes with low numbers of treated patients, the indolent disease course needing a longer follow-up period to capture relevant changes, or the possibility that administered treatments were not aggressive enough. the imagine study is an international, multi-centre, prospective, observational cohort study, which will result in a unique collection of a large number of prospectively collected and highly standardized clinical data, and a biobank from a large population of well-defined patients with igm peripheral neuropathy. the main objective is to describe in detail the variation in clinical subtypes, clinical disease course, past and current practice of treatment, antibody titres, and clinical picture at the various levels of assessing outcome. patients being at least years, and fulfilling the international criteria for igm peripheral neuropathy are eligible. exclusion is primarily based on concomitant diseases influencing peripheral nerve function. several study parameters measuring weakness, sensation, activity and participation, ataxia, pain, and quality of life are of interest. in february an enmc kick of meeting is organized, bringing together an igm peripheral neuropathy study group. the meeting will focus on the development of a core set of outcome measures to be used in future studies in igm peripheral neuropathy. the imagine study started in the netherlands in september , and to date patients were included. the imagine study starts in the united kingdom, italy, and france in the beginning of . centres recruiting at least patients with igm peripheral neuropathy are eligible to participate in the study. during the pns global recommendations from the enmc meeting, as well as the first results of the imagine study, will be presented. puget s , paolantonacci p , burlot l lfb biomédicaments, les ulis, france; lfb biotechnologies, les ulis, france. in dysimmune neuropathies patients (mmn, cidp, gbs), ivig have become the gold standard due to their efficacy and tolerability. acute renal impairment, a rare but serious adverse event, can be induced by all ivig. its incidence is not determined precisely for each ivig. it mostly occurs in patients at risk, with pre-existing conditions (prior renal insufficiency, diabetes, mellitus, arterial hypertension, elderly > years old, dehydratation, hypervolemia, sepsis, paraproteinemia or concomitant use of other nephrotoxic drugs) and treated by immunomodulatory doses. as the number of these patients increases over the years, the choice of ivig in association with the precautionary measures will be decisive to reduce or avoid the occurrence of this adverse event. from s to s, the nephrotoxicity of ivig has been explained by tubular toxicity related to osmotic nephrosis. sucrose, a stabilizer of some ivig, has been implicated as one of the causes of this. even if several new ivig without sucrose are used, renal impairment cases have been described and studies have highlighted that sucrose is not the only ivig stabilizer associated with tubular damage. however, in a recent study, renal impairment cases ( / ) have occurred in cidp elderly patients treated by free-sucrose ivig. the occurrence of renal failure seemed to be low (only / ) for patients treated with sucrose-ivig in association with precautionary measures (hydratation, adaptation of dosage according body mass index, rate infusion). otherwise, since s, cases of renal impairment secondary to hemolysis have been increased with some ivig but would be rare for full ethanolic fractionated products as they have been identified to generate very low occurrence of hemolysis. the occurrence of renal impairment related to ivig seems to be multifactorial, need to find out all causes (mechanisms of different stabilizers, hemolysis, and concentration of ivig). registries would be helpful for physicians to define the incidence, relative risk of ivig-related renal impairment and the right ivig in association with precautionary measures in these patients at risk. the published ultrasound (us) studies on chronic inflammatory demyelinating polyradiculoneuropathy (cidp) report diffusely increased cross-sectional area (csa) of nerves. these data have not been correlated with histological patterns. to date, no further information about us ultrastructural nerve modification has been provided because of limited frequency range ( - mhz) of the us probe. the aim of this preliminary study is to evaluate the correlation between histological findings from sural nerve biopsies and us patterns found with uhfus ( mhz) from sural nerve at the ankle. four patients with cidp underwent uhfus nerve evaluation of clinically affected sural nerve before undergoing a sural nerve biopsy. us findings included: cross-sectional area of the nerve, connective tissue depth and changes in echogenicity of fascicles. those data were then compared to the histological findings obtained in transversal and longitudinal sections. in all patients, uhfus nerve changes were as following: csa was increased; connective tissue was thickened and in two of the four patients hyperechogenicity of fascicles was observed. also, thanks to the ultra-high-resolution of the probe, a direct correlation of the histological and us images was possible, so as a direct measurement of internal microstructure of the nerve. uhfus may be of adjunctive diagnostic value in cidp assessment. more detailed images of sural nerve can be obtained compared with high-frequency us, allowing a better evaluation of the internal structure of the nerve. the increased csa observed in all our subjects seems to relate to an enlargement of connective tissue, as confirmed by the histological study. in particular, we have observed a hyperechogenicity of fascicles in most severe patients; in those cases, histology confirmed an increase of endoneurial depth. we speculate that those findings may explain a preliminary involvement of connective tissue in the pathogenesis of the cidp; our findings of nerve enlargement may be tool to monitor disease activity in cidp, and better understand disease pathogenesis. further studies are needed to confirm these findings and additional data are being processed and will be presented during the meeting. puma a , cambieri c , panicucci e , desnuelle c , raffaelli c , sacconi s . high-resolution ultrasound (hfus, mhz) of peripheral nerves is a valuable non-invasive, painless complement to neurophysiology, especially in the workup of cidp. nevertheless, the current spatial resolution of echographic images doesn't allow a detailed study of the nerves. ultra-high frequency ultrasound (uhfus, mhz) is a new tool with a - times higher spatial resolution than traditional hfus. the aim of this preliminary study is to evaluate sensory and motor nerves structural characteristics found with uhfus in patients with definite cidp. seven patients with cidp underwent uhfus nerve evaluation of median, ulnar, peroneal and sural nerves, bilaterally. us findings included: cross-sectional area of the nerve, connective tissue depth, nerve vascularization and changes in echogenicity of fascicles. patients also underwent electroneurography (eng) and plexus mri. in all patients, uhfus nerve changes were as following: csa was increased; connective tissue was thickened. two of the seven patients presented an epineural hypervascularization, observed at the doppler evaluation; none of them was treated by iv immunoglobulines. echographic changes were present even in the absence of mri abnormalities (root hypertrophy). eng characteristics correlated with the us patterns. uhfus may be of adjunctive diagnostic value in cidp assessment. more detailed images of nerves can be obtained compared with high-frequency us, allowing a better evaluation of the internal structure of the nerve. the increased csa observed in all our subjects seems to relate to an enlargement of connective tissue. in particular, uhfus allows a more detailed study of nerves, demonstrating that the structural abnormalities hit connective tissue, while -conversely to previous studies -fascicles anatomy seems to be spared. we did not show nerve vascularization except in non-treated patients. we speculate that those findings may explain a preliminary involvement of connective tissue in the pathogenesis of the cidp; our findings of nerve enlargement may be tool to monitor disease activity in cidp, and better understand disease pathogenesis. further studies are needed to confirm these findings and additional data are being processed. purcell l , , wojciechowski e , , gibbons p , , jamil k , , menezes, m , , burns j , . sydney children's hospitals network (randwick and westmead), new south wales, australia; university of sydney, new south wales, australia; universiti kebangsaan, kuala lumpur, malaysia. - % of children with cmt are reported to have hip dysplasia. we aimed to investigate the relationship between radiological hip dysplasia indicators and walking pattern in children with cmt. thirty children ( female; . ± . yrs; ± . cm; ± . kg cmt a, cmtx , cmtx , cmt f, cmt a) underwent d gait analysis ( dga), and had an anterior-posterior pelvis radiograph within months of assessment. radiographs were reviewed by two orthopaedic surgeons, and the reliability of measures of dominant limb hip health via radiograph was assessed. of the measures, measures had an intraclass correlation coefficient > . between raters, and the more experienced surgeon's measures were used for further analysis. the measures of acetabular index (ai), centre edge angle (cea), neck shaft angle (nsa), medial joint space, head width, lateral uncoverage, migration percentage and triradiate were used to investigate correlations with kinematic and kinetic dga variables of the pelvis and dominant limb hip, knee and ankle in planes, temporal spatial parameters and gait profile score. dga data were captured with an -camera vicon nexus motion capture system using the lower body plug-in-gait model. gait data were compared to typically developing children ( female; . ± . yrs, ± . cm, ± . kg). five of affected children had a migration percentage > ∘ , representing % of our sample. maximum hip abductor moment in terminal stance was significantly lower than normative reference values, and was moderately correlated with of the radiographic measures (ai r=− . , p= . ; nsa r=− . , p= . and medial joint space r=− . , p= . ). walking speed (normalised to leg length) was correlated with medial joint space (r= . , p= . ) head width (r=− . , p= . ) and triradiate (r=− . , p= . the ganglionopathies are a unique group of disorders with a varied etiology which includes autoimmune disorders, paraneoplastic syndromes and toxin induced causes. it has been observed that despite extensive investigations the cause of a sensory neuronopathy is often idiopathic in approximately - % cases. electrodiagnostic criteria to diagnose a possible ganglionopathy requires at least one sensory action potential absent or three sensory action potentials < % of the lower limit of normal in the upper limbs plus less than two nerves with abnormal motor nerve conduction study in the lower limbs. ulnar sensory-motor amplitude ratio values (usmar) lower than . is useful in differentiating ganglionopathy from axonal length-dependent neuropathy. we performed a retrospective analysis of patients who were either admitted or evaluated in the outpatient department in department of neurology, nizam's institute of medical sciences, with a possible ganglionopathy as per the diagnostic criteria proposed by camdessanchéet al. consecutive patients who sought treatment during a year period with a clinical pattern of sensory neuronopathy were analysed retrospectively. we reviewed the electrodiagnostic studies of patients and calculated the ulnar sensory-motor amplitude ratio values in comparison with patients with a clinical and electrophysiological diagnosis of diabetic axonal sensorimotor neuropathy. the clinical profile of a ganglionopathy from the indian subcontinent comprised of a prominent sensory ataxia as the initial presenting clinical manifestation with a predilection towards involvement of large-fiber sensory modalities. electrophysiologically a pattern of absent snaps was characteristically encountered with a significant value of usmar less than . , enabling differentiation from axonal length-dependent neuropathy. rahman im , jahan it , nahar s , khalid mm , jahan i , hayat s , , , islam z . guillain-barré syndrome (gbs) is a post-infectious autoimmune polyradiculoneuropathy where immune response is triggered by molecular mimicry between glycolipid antigens expressed by an infective agent such as campylobacter jejuni (c. jejuni) and human peripheral nerve gangliosides. cd molecules are mhc-like structures specialized in capturing and presenting a variety of glycolipids to antigen-specific t lymphocytes. the objective of this study was to investigate the possible role of coding region polymorphisms of cd genes in the pathogenesis of gbs in bangladeshi population. single nucleotide polymorphisms (snps) of exon of cd a (* /* ) and cd e (* /* ) in well defined gbs patients and healthy controls were studied to delineate their effect in developing gbs. we genotyped exon of both cd a (cys/tryp) and cd e (gln/arg) genes through pcr-rflp. to validate these findings, direct sequencing of pcr product was performed for at least samples for each position. we found no differences in genotypes and allele frequencies of both genes in gbs patients compared to controls. however, compared to control individuals with cd a* /cd e* haplotype were . times more likely to develop gbs, whereas individuals with cd a* /cd e* haplotype had a reduced relative risk by . times. a positive association of cd a* /cd e* haplotype was observed only in axonal form of gbs ( . % vs. . %, p = < . ). haplotype cd a* /cd e* was prevalent among anti-gm antibody positive gbs patient compared to anti-gm antibody negative patients ( . % vs. . %) though it was not statistically significant. snps in cd a and cd e were not associated with antecedent c. jejuni infection, disease severity and disease outcome at months of follow up. in conclusion, cd polymorphisms are not a susceptibility or disease causing factor in gbs. conversely, increasing knowledge of this field may offer new dimension for the research to elucidate better answer for disease pathogenesis and also contribute to conduct high power meta-analysis. extensive genetic testing was performed on a unique patient, who received national media attention due to her severe cmt phenotype. the index patient was never able to walk independently, had difficulty breathing and swallowing and demonstrated aspiration by a barium swallow study. nerve conduction velocity testing revealed velocities of m/s in her upper extremity. she required continuous positive airway pressure (cpap) for an upper respiratory infection and developed bilateral vocal cord paralysis. we used the combined brief assessment of motor function (bamf) scale to evaluate her disability. her fine motor scale was a / , her upper extremity gross motor scale was a / and her lower extremity gross motor scale was / . unfortunately, she died at age in her sleep, presumably from respiratory arrest. the proband's father was asymptomatic, however, his neurological exam showed pes cavus bilaterally and mild atrophy of the first dorsal interossei muscles in his hands. his nerve conduction velocities were slowed to m/s in the upper extremities and his cmt neuropathy score (v ) was / . we performed whole exome and subsequently whole genome sequencing in the trio. comprehensive structural variant analysis for copy number variations, large deletions, and recombinations was completed by a combination of software tools. known cmt genes were excluded as the underlying cause and the only viable candidate gene remaining was sh tc . we showed expression of sh tc in peripheral nerve and schwann cells. sh tc is a paralogue to sh tc , which causes the recessively inherited dysmyelinating form cmt c. sanger sequencing confirmed the variants in our family, p.v m (c. g>a, chr : ) and p. a p (c. g>c, chr : ) , and showed the segregation of the heterozygous variations. we hypothesize that the heterozygous paternal allele had a minimal effect and let to a very mild or subclinical form of peripheral neuropathy. of interest, the recessive sh tc gene has also been shown to cause mild aberrant forms of peripheral nerve degeneration in carriers of heterozygous disease alleles. in summary, this paper will present genetic and molecular evidence from an extensive n= study proposing a novel cmt gene. charcot-marie-tooth (cmt) is an important cause of morbidity worldwide. it is a heterogeneous disease manifesting as progressive weakness, wasting and loss of feeling in a length-dependent pattern. there are an increasing number of cmt-related genes in the literature. more recently, recessive mutations in the hint gene have been reported as causative of predominant motor axonal neuropathy associated with neuromyotonic discharges on emg. one of the characteristics of autosomal recessive cmt is it varying frequency in different populations and ethnic groups. we sought to evaluate the frequency of mutations in the hint gene in a brazilian cohort with axonal hereditary neuropathy. all patients included in this study born within south east area of brazil. the group consists of consecutive patients with axonal neuropathy screened for recessive or sporadic axonal neuropathy in the neurogenetics laboratory of clinical hospital of ribeirão preto. direct sequencing of the coding region of hint gene was done. among patients screened, were suspected of having recessive axonal neuropathy without neuromyothonic discharges, and two have axonal neuropathy associated with neuromyothonic discharges on emg. we did not find any disease causing mutations among our patients. some previously reported studies reported a high frequency of mutations in the hint gene among recessive axonal neuropathies in some european countries. our results demonstrated that frequencies of mutation underlying genetic hereditary neuropathies are different between different ethnic groups and have implications for the organization of services management of cmt, for genetic counseling, and for gene flow in different world populations. funded by cnpq, fapesp, faepa, pronas (ministry of health). rodriguez-menendez v , ballarini e , malacrida a , , ceresa c , semperboni s , , meregalli c , cavaletti g , nicolini g . school of medicine and surgery, experimental neurology unit, university of milano-bicocca, monza, italy; phd program in neuroscience, university of milano-bicocca, monza, italy. bortezomib (btz) is a proteasome inhibitor widely used for multiple myeloma treatment. btz induced peripheral neuropathy (bipn) is the most frequent adverse effect. bipn in humans, is a dose dependent painful sensory neuropathy characterized by nerve axonopathy and a tendency to recover in the follow-up period after btz withdrawal. bipn affects principally dorsal root ganglia (drg) and different rodent models have shown alterations in sensory neurons, small unmyelinated axons, large myelinated axons, axonal mitochondria and schwann cells. in this work, we evaluated the effects of btz in vitro on drg neurons isolated from adult mice. our interest focused on dystonin, a protein able to interact with all the three components of cytoskeleton (microtubules, microfilaments and intermediate filaments) and able to bind map b (a mt-associated protein) through which can influence golgi apparatus morphology. there are different neuronal isoforms of dystonin and in particular dystonin-a is able to modulate tubulin acetylation and stability through interaction with map b. it is noteworthy to underline that map b expression in the mature nervous system is restricted to sensory neurons. western blot analysis demonstrated that a treatment with nm btz induces a statistically significant decrease in tubulin acetylation. this result does not go along with our previous study where we observed a tubulin polymerization increase after btz treatment. therefore, we have decided to focus our interest on soma organelle organization that is well known to be dependent from cytoskeleton structure. immunofluorescence images showed an altered distribution of acetylated tubulin in soma cytoplasm after hour treatment. moreover, confocal analysis of cis golgi (gm ) demonstrated that in btz treated neurons the normal golgi structure is lost showing a spot-like non perinuclear labeling distribution. additionally, dystonin distribution seemed comparable to that of cis golgi apparatus suggesting that btz could induce a change in dystonin localization which in turn affects golgi organization, probably through map b.these data suggest that the cytoskeleton alterations, induced by btz, could probably cause wrong maturation and trafficking alteration of golgi vesicles consequently impairing the correct sensorial function. romão tt , aleixo bfl , wedemann d , herculano fgn , prado h , cal h , pupe c , bittar c , nascimento ojm . universidade federal fluminense (uff), rio de janeiro, brazil. acute motor and sensory axonal neuropathy (amsan) is a clinical variant of guillain-barré syndrome (gbs) which has rarely been reported in association with human immunodeficiency virus (hiv) and neurosyphilis. we describe a case of a -year-old woman who started with muscle weakness in the left leg followed by weakness in the right leg and in upper limbs in one month. motor symptoms were followed by urinary and fecal incontinence. no preceding symptoms, as diarrhea or fever were referred. neurological examination showed global areflexia with impairment of vibratory and tactile modalities, as well as loss of proprioception. pinprick sensation was moderately compromised. no impairment of higher mental functions was observed. other causes of neuropathies were ruled out. cerebrospinal fluid (csf) examination showed cell/mm , increased protein level, normal glucose level and negative vdrl test. blood analysis showed hiv and positive serology tests, vdrl : and positive t. pallidum hemagglutination assay. igm cytomegalovirus antibody was negative, cd was in normal range and hiv load was undetectable. cranial and spinal cord magnetic resonance imaging revealed extensive involvement of the posterior spinal cord tracts which supports the diagnosis of neurosyphilis. nerve conduction studies showed a significant reduction in compound motor action potentials amplitudes, particularly at lower limbs, and absent sural nerve responses. electromyography revealed positive waves and fibrillation at lower limbs. treatment with methylprednisolone, human intravenous immunoglobulin and ceftriaxone has been settled, resulting in improvement of upper limbs paresis and sphincters dysfunction. antiretroviral therapy was initiated. this amsan case is associated with central nervous system involvement, encompassing an encephalomyeloradiculopathyrelated to hiv/t. pallidum co-infection. c.jejuni is the main etiological agent associated with amsan, but there are some reports of hiv/cmv co-infected patients who presented this gbs variant. facing a patient with amsan, mainly when cns involvement is present, it is of crucial importance to undergo investigation of an ongoing infectious process, such as hiv and syphilis, considering the impact of early treatment on prognosis. roodbol j , , yiu e , doets a , , de wit mcy , monges ms , van nes s , catsman-berrevoets ce , van den berg b , , jacobs bc , and on behalf of the igos-kids consortium. only a few prospective cohort studies so far have investigated the clinical presentation and course of guillain-barré syndrome (gbs) in children using age-adjusted outcome scores. in we started a study based on the igos protocol but adjusted for children with gbs (igos-kids). (pediatric)neurologists from argentina, australia and the netherlands joined forces to determine the clinical and biological determinants of disease progression and recovery in gbs in children from different geographical areas. for each age category specific pain scales are used including the comfort score for children < years old, pain faces revised age - years old and numerical rating scale in children ≥ years old and outcome measures. a new strength score was developed: gbs kids score. this score will be used and validated in addition to the mrc-sum score. the onls, r-ods and fss are also be used in igos-kids. age-dependent quality of life questionnaires were added to the igos-kids protocol, namely the pedsql and the pedsql multidimensional fatigue scale. these scales are available for children ≥ years old. an activity score validated for neuromuscular disorders for children ≥ years old was also added. currently there are children included in igos-kids, eight children from australia and five from the netherlands. additional clinicians and researchers interested in gbs in children are most welcome to participate in igos-kids. prognostic models have been developed to predict the highly variable clinical course of guillain-barré syndrome (gbs) in adults. the clinical course of gbs is equally variable in children, but the current prognostic models have not been validated in children. in this study, we aimed to identify in children with gbs the characteristics at hospital admission that predict the clinical severity and outcome. the study was conducted in two patient cohorts from europe: one (largely) german cohort of children and one dutch cohort of children. clinical information was obtained regarding preceding infection, first symptoms, neurological deficits at admission and nadir, results of additional investigations (cerebrospinal fluid and nerve conduction studies). clinical severity, course and outcome was defined by the gbs disability score, especially the ability to walk unaided, at a follow-up of month, months, months and months after onset of symptoms. univariate and multivariate regression analyses were performed initially on the two separate cohorts. combined the cohorts consisted of children (age median years, range - years) including boys ( %). the median duration between onset of symptoms and hospital admission was days (range ). pain at admission was remarkably frequent and present in ( %) children. in the combined cohorts, children ( . %) developed respiratory failure and one child died. multivariate regression analysis showed that in both cohorts strong predictors of respiratory failure available at hospital admission were cranial nerve involvement, a higher gbs disability score and a shorter period in days between onset of symptoms and admission. this information was used to develop and validate a prognostic model for children with gbs that will be presented at the conference. in conclusion, based on the analysis of two independent cohorts of patients the predictors of respiratory failure and clinical recovery were identified and validated. similar factors were identified for adult patients, although the prognosis in children in general is better than in adults. this information will be used to develop a simple prognostic model for current clinical practice to predict the chance of respiratory failure and outcome in children with gbs. the negative trials of vitamin c in cmt a have highlighted the lack of sensitive outcome measures in charcot-marie-tooth disease (cmt). neurofilaments are abundant neuronal cytoskeletal proteins and their concentration in blood is likely to reflect axonal breakdown. we therefore examined plasma neurofilament light chain (nfl) concentration as a potential biomarker in cmt. blood samples were collected from patients with cmt and age matched healthy controls over a -year period. disease severity was measured using the weighted cmt examination and neuropathy scores. plasma nfl concentration was determined using an in house developed simoa assay based on the nfl antibodies from the nf-l light elisa kit (umandiagnostics). plasma nfl concentrations were significantly higher in cmt patients (median: . pg/ml; iqr: . - . ) than in controls (median: . pg/ml; iqr . - . , p< . ) and correlated with disease severity as estimated by the weighted cmt examination (n= , r= . , p< . ) and neuropathy scores (n= , r= . , p= . ) . concentrations were also significantly higher when subdividing cmt patients by genetic subtype; cmt a (n= , p< . ), sptlc (n= , p< . ) and gjb (n= , p= . ) or into demyelinating, cmt (n= , p< . ) or axonal, cmt (n= , p< . ) forms compared to healthy controls. there was no significant difference in the plasma nfl concentration after year in patients with cmt (n= , mean difference − . pg/ml, % confidence interval − . - . ) or healthy volunteers (n= , mean difference − . pg/ml, % confidence interval . - . ) which is unsurprising as cmt is a slowly progressive disease in which the rates of axonal degeneration are likely to be constant and elevated. in summary, we have shown that plasma nfl levels are significantly raised in patients with cmt and that they correlate with disease severity. this is of relevance not only for the field of cmt but for peripheral neuropathies in general, and suggests that plasma nfl holds promise as a biomarker of peripheral neuropathy in both routine practice and clinical trials. neurolymphomatosis (infiltration of the peripheral nervous system by lymphoma cells) is a rare and usually devastating condition belonging to the spectrum of lymphoma-associated neuropathies. cerebrospinal fluid examination with cytologic examination, flow cytometry and clonality testing by pcr may show malignant cells especially when nerve root involvement is prominent. however, nerve biopsy remains a useful tool to confirm the presence of malignant cells invading the nerve. neuropathological features are important and pcr-based immunoglobulin or t-cell receptor clonality testing on nerve fragments may add notable value for the diagnosis of neurolymphomatosis, although this has not been systematically investigated. we retrospectively studied clinicopathological data and clonality results of nerve biopsy samples in patients with nl from centres, performed between and . among patients with nl, we found % of b-cell lymphoma and one t-cell lymphoma. nl was the first manifestation in , % of patients. the main clinical pattern was symmetrical progressive sensorimotor polyneuropathy in % of patients and pain was a prominent feature in %. clonality testing showed a monoclonal rearrangement in ( %) cases, oligoclonal rearrangement and no amplification in ( %). the main histological pattern was perivascular infiltration of predominant b-cells in the epineurium, without signs of vasculitis. the extent of axon loss was highly variable between patients. various chemotherapeutic regimens were used and the median overall survival was months. only one case showed a monoclonal pattern among control nerve samples from patients with other types of neuropathy including vasculitis and cidp. overall, we found that clonality testing on nerve biopsy specimens may provide decisive information on the presence of neurolymphomatosis, with a sensitivity of . %, a specificity of . %, a positive predictive value of . % and a negative predictive value of . %. we confirm the utility of nerve biopsy for the diagnosis of nl and show the great yield of pcr-based clonality testing to assess the malignant feature of peripheral nervous system lymphoid infiltrates. despite an accurate diagnosis, neurolymphomatosis still remains a devastating disease with an overall poor prognosis. in the last years, cumulative data have shown that patients with amyotrophic lateral sclerosis (als) and mouse models of the disease present loss of small epidermal and dermal nerve fibers and sensory dysfunctions, in addition to the classical motor symptoms. our objective is to characterize this small fiber neuropathy and to clarify if axonal loss involves all sort of fibers equally, or if there is some specificity. for this purpose, we performed an immunohistochemical characterization of total intraepidermal nerve endings (protein gene product; pgp . ), peptidergic (calcitonin gene-related peptide; cgrp) and nonpeptidergical nerve epidermal endings (isolectin b ; ib ) of the sod g a mouse at different stages: presymptomatic stage ( weeks), disease onset ( weeks) and in symptomatic stage ( weeks). the sympathetic sweat gland innervation was immunolabeled for vasoactive intestinal peptide (vip) from very early stage ( weeks) to disease onset ( weeks). the results showed a marked reduction of the intraepidermal nerve fibers already in the presymptomatic stage compared to the wildtype littermates (p< . ). this axonal loss affected more markedly the nonpeptidergic axons from the disease onset stage ( % axonal loss, p< . ), whereas no significant differences were found in the cgrp positive fibers ( . % axonal loss). a reduction of the sympathetic innervation of the sweat glands was also found from the disease onset stage ( % axonal loss, p< . ). in summary, we have found that nonpeptidergic and sympathetic innervation of the skin are predominantly affected in the sod g a mouse model. these findings suggest that this specificity could be used as an accessible biomarker for the disease. hereditary and inflammatory neuropathies are peripheral nerve disorders of different pathophysiology whose identification is crucial for therapeutic approach. diagnosis of cmt is easy when there is a family history, disease course is slowly progressive, neurophysiological findings are homogeneously abnormal. cases of cmt patients with inflammatory-like phenotypes leading to a misdiagnosis of chronic inflammatory demyelinating polyradiculoneuropathy (cidp) have been described. the presence of "red flag signs", such as slowly progressive decline, mild sensory symptoms, minimal electrophysiological progression and no response to therapy should prompt re-evaluation of the diagnosis of cidp. the introduction of nerve neuroimaging has contributed to the diagnostic work-up. we describe cmt patients ( men, women, mean age . ± . yrs, mean neuropathy duration . ± . yrs) with genetically confirmed cmt, who were initially diagnosed with cidp. neurophysiology showed demyelinating features in patients, the remaining patients had axonal features. csf analysis showed albumin-cytological dissociation in patients, oligoclonal igg bands were present in patient. nerve ultrasound in patients with demyelinating neuropathy showed diffuse increased cross-sectional area. mr-neurography in one patient confirmed diffuse nerve hypertrophy and increased signal intensity, supporting the hypothesis of a overlap syndrome. all patients were treated with immunomodulatory therapies. among patients with demyelinating features, patients underwent ivig for months, without benefit; the remaining were treated with steroids, showing temporary improvement. the patients with axonal neuropathy complaining of a progressive history, underwent ex adjuvantibus plasma exchange and ivig, without benefit. given the lack of benefit from therapies, screening for hereditary neuropathies was performed. among patients with demyelinating neuropathy, had cmt a, cmt b, cmt d. among the patients with axonal neuropathy, one was diagnosed with cmt k. in patients an overlap syndrome was present. several clinical and laboratory features (csf protein elevation), might contribute to the misdiagnosis of cidp in cmt patients. refractoriness to immune-modulatory treatment should rise the suspicion of a hereditary neuropathy. an overlap cmt/cidp syndrome may be considered, in front of acute/subacute deterioration and/or proximal muscles involvement. two patient with an overlap syndrome showed benefit after either steroids or ivig. ruiz m , tripodi sm , campagnolo m , zara g , salvalaggio a , ruggero s , toffanin e , anglani m , briani c . neurology, department of neuroscience, university of padua, padua, italy; neuroradiology, padua hospital, padua, italy. facial diplegia is a rare regional subtype of guillain-barrè syndrome characterized by rapidly progressive bilateral facial palsy in absence of other cranial neuropathies, ataxia or limb weakness. the diagnosis is based on history, clinical examination, laboratory data. the outcome of this variant appears to be better than that of classical gbs. although about % of gbs patients clinically exhibit facial nerve involvement, there are only few reports that demonstrate mri gadolinium facial nerves enhancement. a -year-old previously healthy man sought neurological advice for the acute onset of right perioral paresthesias and hyposthenia at the extensor hallucis longus bilaterally. in the previous month, during a trip to china and japan, he had suffered from gastroenteritis. at neurological examination he presented with bilateral extensor hallucis longus hyposthenia. ankle jerk reflexes were absent. one week later, he developed bilateral facial palsy. neurophysiology disclosed absence of activity in the facial nerves innervated muscles bilaterally and signs of mild partial denervation at right l metamer. csf analysis showed increased protein levels ( mg%) and . leucocytes/ l. serological tests for infectious agents were negative and serum levels of angiotensin converting enzyme were normal. antibodies to monosialoganglioside gm of igg isotype were positive ( / ). t brain mri showed, after gadolinium administration, marked bilateral enhancement of the facial nerves in their extra-and intra-canalicular segments. t lumbosacral mri scan ruled out the presence of disc diseases as well as signal modifications within conus medullaris and cauda equine nerve roots. the patient was treated with iv immunoglobulins ( . g/kg/die for days) with benefit on facial weakness. at follow-up examination months later, the patient presented a further improvement of the facial diplegia and neurophysiology disclosed a partial recovery of activity in the facial nerves, with persistent axonopatic damage. bilateral extensor hallucis longus hyposthenia persisted. in conclusion, we report on a regional subtype of guillain-barrè syndrome with the curious association of facial diplegia and bilateral extensor hallucis longus hyposthenia, and igg anti-ganglioside antibodies, that are not commonly described in facial diplegia. moreover, we provide t brain mri evidence of facial nerve involvement. rumora ae , tabbey ma , lograsso g , dolkowski j , haidar j , lentz si , feldman el . department of neurology, university of michigan, ann arbor, usa; department of internal medicine, division on metabolism, endocrinology and diabetes, university of michigan, ann arbor, usa. diabetic neuropathy (dn) is the most common complication of diabetes affecting up to % of diabetic patients. the pathogenesis of dn in type diabetes is directly related to the metabolic syndrome associated with the western diet composed of elevated levels of long chain saturated fatty acids (sfas) and low levels of medium chain sfas. long chain sfas are associated with insulin resistance and dyslipidemia while medium chain sfas have been associated with decreased lipid accumulation and improved mitochondrial function. since dn is primarily a disorder of the sensory dorsal root ganglion (drg) neurons, we sought to evaluate the impact of sfa hydrocarbon chain length on mitochondrial trafficking mechanisms that are critical for distributing atp throughout drg axon to provide energy for synaptic transmission. we hypothesize that sfas with longer hydrocarbon chains will impair mitochondrial trafficking whereas medium length sfas will not impact mitochondrial movement along the drg axon. in this study, we examined the impact of sfa hydrocarbon chain length on mitochondrial trafficking, directionality and velocity in primary mouse drg neurons. drg neurons were treated with increasing concentrations of long chain sfas, stearate and palmitate, or medium chain sfa, laurate, ranging from . to micromolar for twenty-four hours. drg neurons treated with long-chain sfas, palmitate and stearate, showed a significant decrease in the percentage of motile mitochondria whereas medium chain sfa, laurate, does not alter mitochondrial motility. we next assessed whether motile mitochondria in drg neurons treated with palmitate or stearate exhibited altered directionality or velocity of mitochondrial trafficking. palmitate and stearate treatments resulted in a trending decrease in the number of mitochondria trafficking in both anterograde and retrograde directions. furthermore, . to micromolar palmitate and stearate induced a significant decrease in mitochondrial velocity. laurate treatment, on the other hand, retained directionality and velocity of mitochondrial trafficking. these results suggest that hydrocarbon chain length of saturated fatty acids plays an important role in regulating mitochondrial trafficking mechanisms in dorsal root ganglion neurons. impaired mitochondrial trafficking in drg neurons exposed to elevated levels of long-chain sfas may play a critical role in the progression of dn. dyslipidemia is a critical factor that contributes to the development of diabetic neuropathy (dn). the progressive nerve damage associated with dn correlates with the dyslipidemic state characterized by elevated circulating levels of harmful saturated fatty acids (fas) and low levels of beneficial unsaturated fas. in dn, primary sensory dorsal root ganglion (drg) neurons exhibit energy dyshomeostasis and mitochondrial dysfunction, however, little is known about the differential impact of saturated and unsaturated fas on mitochondrial mechanisms in drg neurons. mitochondrial trafficking is an essential mechanism for transporting mitochondria throughout drg axons to provide cellular atp for neuronal function and neurotransmission. since mitochondrial trafficking is regulated by metabolic flux, we sought to determine whether saturated fa, palmitate, and unsaturated fa, oleate, have differential effects on mitochondrial trafficking in drg neurons. we evaluated mitochondrial trafficking patterns and the mitochondrial membrane potential (mmp) in primary drg neurons treated with physiologically relevant concentrations of palmitate, oleate, and combinations of both fas. primary drg neurons treated with . to micromolar palmitate induced a significant and dose-dependent reduction in the percentage of motile mitochondria. these palmitate treatments also induced a dose-dependent reduction in mitochondrial velocity but did not impact the directionality of mitochondrial movement. alternatively, . to micromolar oleate treatments did not impair the percent of motile mitochondria, the direction of mitochondrial movement, or mitochondrial velocity. since palmitate and oleate have differential effects on mitochondrial motility, we next assessed whether oleate could counter the inhibitory effect of palmitate on mitochondrial trafficking. surprisingly, oleate/palmitate mixtures at ratios of : or : prevented palmitate-induced impairment of mitochondrial trafficking. we assessed the impact of palmitate and oleate on mmp by staining palmitate and oleate-treated drg neurons with tetramethylrhodamine methyl ester. drg neurons treated with micromolar palmitate exhibited an increase in the percentage of depolarized mitochondria while mitochondria in oleate-treated drg neurons retained mmp. interestingly, drg neurons treated with : oleate/palmitate mixtures also maintained polarized mitochondria. these results suggest that saturated and unsaturated fas have a distinct impact on mitochondrial trafficking mechanisms in drg neurons and that equimolar ratios of oleate/palmitate can prevent impairment of mitochondrial trafficking. of g alpha- in m r overexpressed sensory neurons significantly reversed the m r-induced reduction in relative levels of total neurite outgrowth (mean±sd: . ± . (control) vs . ± . (g alpha- knockdown), p< . , n= neurons). further, treatment of m r overexpressing neurons with mt or pirenzepine sequestered g alpha- / proteins at the m r and significantly reversed the impaired cytoskeleton-mediated reduction in total neurite outgrowth (mean±sd: . ± . (control), ± (+ nm mt ), ± . (+ micromolar pirenzepine); n= , and neurons, respectively; for treated groups p value= . vs control by one-way anova). mt and pirenzepine also significantly restored mitochondrial trafficking and abundance of mitochondria in the distal neurites. our findings suggest a novel mechanism in which modulation of m r influences tubulin polymerization, mitochondrial distribution in nerve terminals and controls axonal outgrowth and regeneration. funded by cihr and nih. muscarinic receptors are a group of five g-protein coupled receptors (gpcrs) that are targeted by drugs for the treatment of several human pathophysiological conditions. we have recently shown that selective (pirenzepine) and specific (muscarinic toxin : mt ) antagonists of the muscarinic acetylcholine type receptor (m r) induced elevated neurite outgrowth and protected from small and large fiber neuropathy in adult sensory neurons in various animal models (calcutt et al., ) . one of the major cellular effectors activated by gpcrs is extracellular signal-regulated kinase (erk). the erk signaling cascade regulates a variety of cellular processes including growth and proliferation. both g protein and beta-arrestin mediated signaling pathways can lead to erk activation by phosphorylation through different kinases. activated erk in turn can phosphorylate about cellular substrates, thereby mediating diverse functions. in this study, we have analyzed beta-arrestin recruitment, as part of the receptor internalization process induced by agonist/antagonist binding. in addition, we studied phosphorylation of erk by mt and pirenzepine using isoelectric focusing with phospho-erk specific antibodies and a variety of cell-based assays including beta-arrestin and g protein (gnas/gnasl/gnaq/gna /gna /gna ) knockout cell lines. our study revealed that beta-arrestin is recruited to the m r upon mt and pirenzepine treatment. treatment with nm mt and micromolar pirenzepine significantly increased the dual phosphorylation of tyr and tyr residues of erk / in primary rat sensory neurons (p< . ) in comparison to muscarinic agonist carbachol ( micromolar) and general antagonist atropine ( micromolar). we have identified multiple distinct phosphorylation events on the m r by isoelectric focusing that are specific to mt and pirenzepine induction. further, we have shown that mt and pirenzepine-mediated erk phosphorylation is dependent on both g protein and beta-arrestin recruitment to m r. finally, we reveal that increased erk phosphorylation by mt and pirenzepine significantly (p= . and . , respectively) increased phosphorylation of camp responsive element binding protein (creb) at ser . these results show for the first time that antagonists of the m r can activate the erk signaling pathway and possibly drive phenotypic change in adult sensory neurons. funded by cihr # mop- . charcot-marie-tooth disease (cmt) is representative of inherited neuropathies affecting an estimated in people. the immense advances in gene discovery gained from next-generation sequencing (ngs) projects have revealed the extent of cmt's genetic heterogeneity, with over loci already identified. this knowledge is rapidly translated into clinical comprehensive gene testing panels, often containing over genes. such a large genomic space will invariantly yield variants of uncertain clinical significance (vus) in nearly any person tested. this rise of the number of vus creates major challenges for genetic counseling. in addition, less individual mutations in already known genes are being published as the academic merit is decreasing, and most such testing now happens in clinical laboratories. we propose to capture more of this data in the cmt field to gain a more complete collection of alleles in cmt genes, ideally in conjunction with detailed phenotypic data. this represents a rational approach to eventually reduce the number of vus. thus, we have created a unique, community-driven variant database for cmt researchers and clinicians. the inherited neuropathy variant browser provides simple, user-friendly access to currently reported cmt variation, including patient-level genotypic and phenotypic information. we have also designed an interactive rating system of genetic variation to assist the community with interpretation of vus. for the initial release, we have collected genetic variation, along with genotypic and phenotypic data when available, from published literature, clinical lab reports, and our in-house database. we highly encourage new submissions of not only observed pathogenic variation, but also variation of unknown significance. the goal is to provide a platform for the cmt community to store, share, and discuss genetic data in order to resolve variation of uncertain significance as a joint-effort. with active participation, we aim to provide the community with a more complete mutational spectrum in cmt genes to assist allelic interpretation and patient diagnosis. neurofilaments are strictly neuron-specific intermediate filaments crucial for maintaining axonal architecture. pathogenic mutations in nefl, which encodes the light chain of neurofilament, cause dominantly and recessively inherited charcot-marie-tooth neuropathy (cmt). the nefl-associated neuropathy can be either axonal (type e) or demyelinating (type f). most pathogenic nefl variants are dominantly inherited missense mutations, which are thought to cause disease by inducing nefl aggregation, leading to the disruption of axonal transport. however, investigation of disease mechanisms caused by the mutations has been complicated by the neuronal specificity of nefl. we identified a homozygous nefl variant c. c>t predicting a nonsense change p.arg * in a patient with early-onset cmt. to elucidate the disease mechanism, we used pluripotent stem cells, reprogrammed from patient's skin fibroblasts, to differentiate patient-specific spinal motor neurons. the motor neurons revealed a near complete loss of nefl mrna, and absence of nefl protein. our results establish that nefl is not essential for the development of human nervous system but its absence causes progressive axonal neuropathy. we currently profile the transcriptomic alterations of the motor neurons lacking nefl using single cell rna sequencing to identify compensatory pathways. friedreich's ataxia (frda) is the most common autosomic recessive ataxia, due to a trinucleotide expansion within the frataxin gene. within the wide phenotype, frda patients present also with an axonal neuropathy whose pathological mechanisms are not completely known. eight patients ( women, mean age . yrs, range - ) with genetically confirmed frda underwent neurophysiological and nerve ultrasound evaluation at four limbs bilaterally. echogenicity and cross-sectional area (csa) of median, ulnar, radial, peroneal, tibial, and sural nerves were recorded. mr neurography and diffusion tensor imaging (dti) analysis were performed in one patient; fractional anisotropy (fa), radial (rd) and axial (ad) diffusivity of median, radial and ulnar nerve were calculated at proximal, intermediate and distal sites. all patients presented with sensory axonal neuropathy. seven patients ( %) presented with increased csa of median and ulnar nerves at arm and axilla. mean median nerve csa at mid-upper arm was . mm (normal values < mm ), mean ulnar nerve csa at mid-upper arm was . mm (normal values < mm ). mean median nerve csa at axilla was . mm (normal values < mm ), mean ulnar nerve csa at axilla was . mm (normal values < mm ). mr neurography (performed in one patient) confirmed diffuse swelling and signal hyperintensity of median and ulnar nerves at the arm and dti analysis showed abnormal values of fa, ad and rd along the whole course of evaluated nerves thus suggesting a wide alteration of nerves structure. frda patients presented with an axonal neuropathy characterized, at ultrasound, by a nerve enlargement strictly limited to mid-upper limbs in all patients, findings that cannot be solely explained by a dying-back axonopathy, as suggested by several authors. neither a dorsal root ganglia neural loss could explain by itself our findings, because a diffuse csa reduction would have been expected. on the whole, these findings represent a peculiar feature in frda, but its pathophysiologic meaning remains unclear. inherited peripheral neuropathies are an important health concern for which there is currently no disease-modifying therapy. dogs are affected by a variety of peripheral neuropathies that are breed-specific, indicating a strong genetic component. the use of in-bred populations, such as pure-bred dogs, is advantageous for genetic dissection of disease. acquired peripheral neuropathy (apn) is an inherited late-onset generalized polyneuropathy with high prevalence in labrador retrievers. the most prominent features of apn, laryngeal paralysis and pelvic limb weakness, are associated with the longest peripheral motor nerves in the dog. the pathologic features of apn are similar to human peripheral neuropathy. our aim is to understand the genetic and pathologic features of apn for development of this condition as a naturally occurring large animal model for human disease. we performed a genome-wide association study (gwas) and short-read high-depth whole genome sequencing (wgs) to investigate the genetic underpinning of apn in the labrador. our gwas data indicates that apn is an autosomal dominant disease. the initial analysis from the wgs study resulted in a potential causal variant with an autosomal dominant pattern; this variant is associated with an axonal gene. the neuropathologic progression and histologic features of apn are poorly defined. using genetic markers from our gwas study, we are able to confidently identify labradors with pre-clinical apn, from which nerve biopsies can be obtained. preliminary analysis of biopsies from labradors suggest apn is an axonopathy. further histologic data from preclinical and symptomatic dogs is being obtained to further define the pathogenesis in this model. mutations in morc lead to an axonal form of neuropathy (cmt z). to date, nine families have been published with mutations in the morc gene, showing that this gene is frequently involved in cmt. while the recent genetic data clearly established the causative role of morc in cmt z, its phenotypic consequences in patients and role in neuronal biology remains to be clarified. therefore, we aim to look for altered genetic and biochemical pathways with a transcriptomic approach in order to investigate the role of morc in hereditary peripheral neuropathy. we have performed transcriptomic analysis using a human gene expression microarray (v x k, agilent technologies), in three hek- t cell lines: control, morc knock-down (kd) and the overexpression of the most common morc mutation, the p.r w (np_ ) (kr). differential gene expression assessment was carried out using limma moderated t-statistics. standard analysis techniques perform one test for each gene. thus, for each gene, a t-test statistic is reported together with its corresponding p-value. in this analysis we have used the conventional multiple testing p-value correction procedures proposed by benjamini hochberg to derive adjusted p-values. the preliminary results reveals that kd shows up-regulated genes involved in transmission of nerve impulse and cilium metabolism, suggesting that morc might act at this level in the peripheral nervous system. otherwise, kr shows a major alteration of main axonal metabolic pathways, including the overexpression of genes related to the generation of neuronal action potential, transport through the axon and its targeting in synapse formation. kr also shows a marked alteration of gene expression related to organization, assembly and cilium movement and with the axonemal dynein complex assembly. this study provides an important step towards understanding the pathomechanism underlying to morc p.r w and its role in cmt z. aifm encodes a mitochondria associated apoptosis inducing factor. mutations in aifm lead to a wide spectrum of neurodegenerative disorders: cowchock syndrome; a combined oxidative phosphorylation deficiency (coxpd ) with severe encephalomyopathy; x-linked deafness with peripheral sensory neuropathy; spondyloepimetaphyseal dysplasia (semd) with mental retardation; and an infantile motor neuron disease. previous studies showed severe defects in mitochondrial metabolism, related to redox function, mitochondrial fragmentation, and respiratory deficiencies. in addition, some mutations impair the protein expression of aifm and cause an increase in caspase-independent apoptosis. by targeted next-generation sequencing, we detected the aifm c. c>t (p.phe ser), in a year-boy. this mutation was confirmed in his year-old affected brother. electromyography and nerve conduction velocities studies revealed an axonal polyneuropathy with exclusive involvement of motor fibers, with an early childhood-onset. both children currently show normal cognitive and cranial nerves functions. the in silico structural modeling of human aifm showed that the mutation of a phenylalanine to serine at position disrupts the hydrophobic interaction between phe and pro , and consequently, it destabilizes an alpha-loop domain. cartoon of protein superposition between two different human aifm structures suggest that a lack of constraints in this region could affect the interaction between - helix and the - -hairpin regions, a very important stage for the functional activity of the aifm protein. patient-derived fibroblasts were used to investigate the pathological effect of the p.phe ser mutation: fibroblasts from patients show a similar mrna but different protein expression of aifm compared to healthy control fibroblasts. however, they have an aberrant morphology, from fibroblastic to polygonal shape, and they are larger than control fibroblast; mitochondria from mutant fibroblasts are markedly fragmented compared to controls; the viability of the patient's fibroblasts is lower, but it does not correlate with an increase in apoptosis. instead, it seems to be caused by an increase in the expression of genes activating the senescent program, like p and p . our study confirms that variable effect of different mutations on the protein function may contribute to the clinical variability observed in aifm patients. funds: isciii (pi / ); fundació per amor a l' art. sango k , takaku s , niimi n , yako h . diabetic neuropathy project, tokyo metropolitan institute of medical science, tokyo, japan. coculture models of neurons and schwann cells have been utilized for the study of myelination and demyelination in the peripheral nervous system; in most of the previous studies, however, these cells were obtained from the primary culture with embryonic or neonatal animals. because it is recognized that some biological properties of both neurons and schwann cells change with maturation and aging, culture systems of adult animal cells appear to mimic peripheral nerve degeneration and regeneration better than those of immature animal cells. we have established spontaneously immortalized schwann cell lines from long-term cultures of adult fischer rat peripheral nerves. one of these cell lines, designated ifrs , has been shown to retain distinct schwann cell phenotypes, such as spindle-shaped morphology with expression of glial cell markers, synthesis and secretion of neurotrophic factors and cytokines, and fundamental ability to myelinate neurites in cocultures with adult rat dorsal root ganglion neurons and nerve growth factor-primed pc cells. our current investigation focuses on the establishment of the coculture system of ifrs cells and nsc- motor neuron-like cells. nsc- cells were seeded at a low density ( x /ml) and maintained for a week in serum-containing medium supplemented with non-essential amino acids and brain-derived neurotrophic factor (bdnf, ng/ml). after overnight exposure to mitomycin c (mmc, micro g/ml), nsc- cells were cocultured with ifrs cells ( x /ml) and maintained in serum-containing medium supplemented with bdnf ( ng/ml), ciliary neurotrophic factor (cntf, ng/ml) and coenzyme q ( micro m). under this culture condition, overgrowth of nsc- cells was prevented and gradual movement of ifrs cells toward the neurites emerging from nsc- cell bodies was observed. double-immunofluorescence staining carried out at day of the coculture showed myelin protein zero-immunoreactive ifrs cells surrounding the beta iii tubulin-immunoreactive neurites. this coculture system can be a beneficial tool to study the pathogenesis of motor neuron diseases (e.g. amyotrophic lateral sclerosis, charcot-marie-tooth diseases and immune-mediated demyelinating neuropathies) and novel therapeutic approaches against them. santos pp , torezani gs , maciero l , pagliarini lfd , romão tt , abunahman ms , ferreira is , bittar c , pupe c , nascimento ojm . universidade federal fluminense (uff), rio de janeiro, brazil. zika virus (zikv) is a flavivirus related to dengue, yellow fever and west nile viruses, and has been recently associated to the occurrence of neurological complications in children and adults. previous studies have linked zikv to the development of guillain-barré syndrome (gbs), myelitis, meningoencephalitis and ophthalmological manifestations in adults. guillain-barré syndrome (gbs) encompasses a spectrum of post-infectious neuropathies characterized by different distributions of weakness and sensory impairment. serum anti-ganglioside antibodies are often found and are related to different clinical patterns. recently we have encountered patients in rio de janeiro, brazil, with distal edema in lower limbs, acute weakness, pain and sensory disturbances during the acute stage of an acute febrile exanthematous illness. the symptoms persist for up to days, with complete resolution afterwards, without specific therapy. blood concentrations of muscle enzymes show normal values, and electromyography and nerve conduction studies (emg/ncs) are usually unremarkable. of note, all cases have had positive rt-pcr for zika virus, indicating an illness that occurred during the viremic phase of this arbovirus infection, and complete recovery within the expected timeframe for the resolution of the systemic viremia. there is a subset of patients who developed acute weakness very early after the initial viral symptoms, with clinical, laboratorial and electrophysiological findings that substantially differ from gbs. we describe three cases with similar features suggestive of an acute infective polyneuritis (aipn). one might hypothesize that zikv might lead to a direct neurotropic injury, significant enough to cause weakness and sensory complaints, but not severe enough to cause permanent damage, resolving in conjunction with decreasing blood viremia. we consider that these patients differ from classical gbs because their illness begins during the acute febrile stage of an infective illness and the clinical course is more rapid leading to complete resolution in a few days. savransky a , mozzoni j , massaro sanchez mp , reisin r , monges ms . department of neurology, hospital de pediatria j.p. garrahan, buenos aires, argentine; department of physical therapy, hospital de pediatria j. p garrahan, buenos aires, argentine; department of neurology, britain hospital, buenos aires, argentine. our objective is to describe a series of children with guillain barré syndrome (gbs) included in the igos protocol. as part of the igos multicenter protocol, pediatric patients meeting gbs diagnostic criteria, who consulted within the first weeks of symptom onset and had parental consent to participate in the study were included. patients were also offered to participate in the extended -year protocol. all patients were evaluated according to the igos protocol. patients were recruited between october and june . twenty-four patients, eight girls, participated. ages ranged from months to years (mean . years). all patients agreed to participate in the extended protocol, which was completed by of them. eight patients completed the -year follow-up and are still under evaluation. five patients were lost to follow-up.twenty-two had the classic variant of gbs and two miller fisher. radicular pain in the back or lower limbs was reported by %. twenty-three patients underwent lumbar puncture and albumin-cytological dissociation was found in . in all cases, csf was stored for proteomic studies. all patients underwent emg showing aidp in , and amsan and aman in each. one patient with aidp developed to cidp. in patients full-spine mri was performed and cauda equina enhancement was found in every case. three patients required ucip, two with invasive and one non-invasive ventilation. all patients were treated with gammaglobulin, with a second dose at weeks in cases with a poor response. all patients who followed the protocol were evaluated with the gbs disability score. median score was at baseline and between and at the -year assessment. we describe a series of children with gbs as a part of an international protocol including patients of different ages. pain was a frequent and early symptom and could be determined despite the young age of our patients. most patients fully recovered. we were invited to participate in igos kids to better assess this age group. saysavath k , somchit v , t. umapathi . mittaphab hospital, vientiane, lao pdr; setthathilath hospital vientiane; national neuroscience institute, singapore, singapore. laos people democratic republic is a country of . million people in south east asia. largely agricultural, its capital and metropolis is vientiane. adult neurological services are concentrated at mittaphab hospital, vientiane serviced by three neurologists. on the average about six cases of guillain-barré syndrome (gbs) are seen per year. it is believed that most patients do not seek medical attention. cases appear to cluster during the rainy season. most patients present late, often at the second week of illness when recovery is unapparent after seeking treatment from traditional medicine doctors and at district hospitals. a substantial number of patients seek treatment at hospitals across the border, in neighboring provinces of thailand. common antecedent symptoms are viral prodrome and diarrhea. miller fisher syndrome appears to be rare, possibly because of the mild deficits that do not prompt patients to seek medical attention. diagnosis is made largely from clinical features and from spinal fluid analysis. nerve conduction studies are not available. patients are often treated with steroids by internists. intravenous immunoglobulin and plasma exchange are not available. common complications include pneumonia, autonomic dysfunction (fluctuating blood pressure), pressure sores and depression. patients who develop respiratory failure are nursed at a twelve-bedded intensive care units. plans are afoot to set up a prospective gbs database, systematically study antecedent infections, including of flaviviruses, and develop low-volume plasma exchange as a feasible therapeutic modality. a gene therapy approach for treating cmt c neuropathy schiza n , markoullis k , richter j , tryfonos c , kagiava a , sargiannidou i , christodoulou c , kleopa ka , . neuroscience laboratory; department of molecular virology; neurology clinics, cyprus institute of neurology and genetics and cyprus school of molecular medicine, nicosia, cyprus. charcot-marie-tooth type c (cmt c) is the most frequent form among recessively inherited demyelinating neuropathies and results from mutations in the sh tc /kiaa gene. sh tc mutations cause loss of function of the sh tc protein suggesting that gene replacement therapy may be useful for treating cmt c. sh tc −/− mice develop all major aspects of the human pathology including early onset progressive peripheral neuropathy with hypo-and demyelination along with decreased motor and sensory nerve conduction velocities, offering a relevant model for testing treatments for cmt c. in order to develop a gene replacement strategy for cmt c, we generated a novel lentiviral vector, lv-mpz-sh tc .myc, to drive expression of the human sh tc cdna under the control of the myelin protein zero (mpz/ p ) promoter specifically in myelinating schwann cells. a c-terminus myc tag was included to facilitate expression analysis. a control vector (mock) was also produced in which the sh tc cdna was replaced by the egfp reporter gene. we first confirmed expression of hsh tc in hela cells transfected with the pcdna -cmv-sh tc .myc vector. immunofluorescence analysis confirmed a strong expression of sh tc specifically at the plasma membrane with additional localization in a dotted pattern intracellularly. for in vivo gene delivery we used both intraneural and intrathecal injections of the lv-mpz-sh tc .myc vector in -week to -month old sh tc −/− mice. expression of virally delivered hsh tc was assessed weeks after injection. immunofluorescence analysis showed hsh tc immunoreactivity in perinuclear schwann cell cytoplasm in sciatic nerve teased fibers of sh tc −/− mice following both intraneural and intrathecal delivery, while lumbar intrathecal gene delivery resulted additionally in expression of hsh tc in the lumbar roots. real time pcr analysis confirmed hsh tc mrna expression in both lumbar roots and sciatic nerves. thus, we have developed a novel lentiviral vector for schwann cell targeted gene delivery to treat cmt c and for testing possible therapeutic effects in the mouse model of the disease. hereditary neuropathies are a group of disorders which are characterised by the systemic impairment of peripheral nerves. more than neuropathies are associated with causative gene defects [ ]. charcot marie tooth (cmt a) neuropathy is the most frequent hereditary neuropathy, triggered by a mutation in the peripheral myelin protein gene (pmp ). cmt a leads to a primary loss of myelin sheath and afterwards to a degeneration of axons [ ] . symptoms appear with the degeneration of axons, whereas demyelination is thought to be largely asymptomatic. for that reason, we investigate in the mechanisms of axonal degeneration. for our analysis, we used purified axoplasma without detectable myelin proteins of the sciatic nerves of weeks old pmp -c mice. in this early stage of the axonal degeneration sarm was significantly increased. the nad + concentration in the axoplasma was dramatically reduced. this correlates to the previous finding that sarm promotes axonal degeneration by cleavage of nad + . additional studies showed an increase of the nad + -dependent axonal protective factor sirt in pmp -c sciatic nerves. nmnat- , known as the active component of the wallerian degeneration slow gene, was unaffected in axoplasma of pmp -c sciatic nerves. summarised, these results indicate that the pathway of sarm , nad + and sirt may play a critical role in axonal degeneration in neuropathy. we report two unrelated czech patients with cmt b , both sporadic cases in the family. patient is a year old man with congenital glaucoma after ophthalmological surgeries. his early motor development was normal. at the age of years parents noted gait problems, first neurological examination was at the age of years, when emg showed diffuse motor and sensory neuropathy with severely decreased ncv ( - m/s). he developed foot deformities (pes cavovarus) and underwent corrective orthopedic surgeries at the age of years. after several dna tests for demyelinating cmt the sfb gene was sanger sequenced and a novel missense mutation p.ile asn was found in homozygous state in the patient and in heterozygous state in both parents. the patient was later tested also by ngs of a panel of all genes to be causal for hereditary neuropathies and no other potentially causal variants were detected. patient is years old man, with normal early motor development. at the age of years parents noted gait problems with distal leg weakness which progressed into distal leg plegia at the age of years. hand weakness was noticed since the age of years. he has severe atrophies of distal muscles of all extremities, is self ambulant. at the age of , emg showed unrecordable responses from nerves of lower limbs and ncv was measurable only on ulnar nerve and was m/s. at the age of years increased intraocular pressure was diagnosed and he uses anti glaucoma eye drops. after many single gene tests for demyelinating cmt, we used ngs of a panel of genes known to be causal for hereditary neuropathies and two novel heterozygous, probably pathogenic variants affecting invariant splice sites were detected: c. - a>g and c. - _ del, both confirmed by sanger sequencing. the first variant is also in the father, but the second is probably de-novo (not detected in parents, despite correct parentity). sekiguchi y , kikuchi si , konno si , sekiguchi m . department of orthopaedic surgery, fukushima medical university school of medicine, fukushima, japan. carpal tunnel syndrome (cts) is the most common entrapment neuropathy. ultrasonography can be used to detect anatomic changes in cts. more recently, it has been shown that doppler ultrasonography can detect increased intraneural blood flow in cts. the purpose of this study was to determine the most suitable finding of pre-and postoperation in cts by ultrasonography. a total of wrists of patients with nerve conduction study (ncs) proven cts were evaluated with ultrasonography. we measured the median nerve's cross-sectional area (csa) and intraneural blood flow of median nerve by ultrasonography. the correlation between these ultrasonographic measurements, ncs severity and duration of clinical cts symptoms was analyzed. the csa (mean, mm ) was no significantly reduction after successful carpal tunnel release. morphologic median nerve changes may persist for a longer period regardless of successful surgery and clinical improvement. however, intraneural blood flow is increasing after successful carpal tunnel release. we conclude that doppler ultrasonography results strongly correlate with post operated cts improvement. hence doppler ultrasonography is a useful method for functional improvement of pre-and post cts operation. senger jl , chan km , olson jl , webber ca . university of alberta, edmonton, canada. the beneficial effects of a preinjury crush conditioning lesion (cl) on peripheral nerve regeneration is well-documented in animal models. no human studies have been attempted to date, given the ethical dilemma of deliberately injuring an intact nerve, and the difficulty in predicting the timing of a nerve injury. recent studies demonstrate that hour of electrical stimulation (es) produces effects similar to cl in neuronal cultures. this, coupled with a surgical environment favoring nerve transfers, in which an intact nerve is deliberately cut to reinnervated a denervated muscle, means that es may be clinically translatable to enhance regeneration. this study hypothesizes that es prior to nerve injury will enhance nerve regeneration. twelve sprague-dawley rats were divided into four groups based on conditioning-type to the mid-common peroneal (cp) nerve: es ( ), crush ( ), sham-es ( ), and naïve ( ). one week following conditioning, they underwent a cut/coaptation of the cp nerve at the sciatic trifurcation. post-cut day , nerves and dorsal root ganglia (drgs) were collected. axonal counts of nerves stained with nf- revealed similar regeneration between es and crush ( . vs. . mm, p= . ) that was superior to sham-stimulation ( . mm) or no-conditioning ( . mm, p< . ). a greater number of axons at the distal tip were present in animals that received either type of conditioning compared to the unconditioned cohorts. drgs were stained with neuronal injury marker growth associated factor- (gap- ), and satellite cell glial cells with glial fibrillary acidic protein (gfap). significant increase in gap- expression at three days was observed in es and crush cohorts compared to sham or naïve (p< . ) cohorts. the satellite glial cells of es and crush conditioning showed a significant increase in gfap expression ( . % and . % respectively) compared to sham ( . %) and naïve ( . %) drgs. by demonstrating similar improvements in axon regeneration, this proof of principle project suggests that es conditioning may produce regenerative outcomes comparable to the classical crush injury model. in turn, this suggests that es may be a promising method for delivering conditioning lesions in clinical trials for conditioning nerves prior to surgical intervention. we report a unique case of newly developed waldenstrom's macroglobulinemia (wm) in a patient with chronic inflammatory demyelinating polyneuropathy (cidp) with antibodies against myelin-associated glycoprotein (mag) and sulfatide who was undergoing treatment with intravenous immunoglobulines (iv-ig). subsequent rituximab infusions did not have a positive impact. patients with wm can develop demyelinating and axonal polyneuropathies and few patients have anti-mag and/or anti-sulfatide antibodies. anti-mag antibodies ( % of wm) are associated with sensorimotor axon loss and demyelination and anti-sulfatide ( % of wm) with sensory axonal loss. rarely, both antibodies can be present, with a more severe clinical phenotype. cidp associated with anti-mag and anti-sulfatide antibodies can represent independent entities, not associated with wm. there are no reports to date of patients with cidp associated with anti-mag and anti-sulfatide antibodies that developed wm during immunomodulatory therapy with iv-ig. in addition, subsequent rituximab infusions after the iv-ig were stopped have not been proven beneficial, as has been previously reported for anti-mag cidp patients. seventy-six year old right-handed gentleman presented with persistent numbness in his left foot, three months following artificial disc placement in his lumbar spine. gradually he developed sensory ataxia. no radicular signs were present on exam or impingement on serial spine mri's. ncs/emg studies were consistent with a cidp variant with severely prolonged distal motor latencies. serum anti-mag and anti-sulfatide antibodies were elevated. chronic therapy with iv-ig was able to partially stabilize the symptoms; however, six years later he newly developed wm. subsequent infusions with rituximab, after iv-ig was stopped, did not improve the clinical picture or the ncs/emg findings. wm can newly develop in an autoimmune setting, such as cidp associated with anti-mag and anti-sulfatide antibodies. in this particular case, there was an ongoing immunomodulatory therapy for our cidp patient, as he had monthly iv-ig infusions. this may reflect a possible induction of pathological b cell clone proliferation during the iv-ig treatment. subsequent rituximab infusions, after the iv-ig was stopped, did not improve the symptoms or the demyelination features on ncs/emg. he continues to be symptomatic despite efforts. charcot-marie-tooth disease (cmt) is an inherited neuropathy without known cure (prevalance: : ). duplication of the gene encoding the peripheral myelin protein of kda (pmp ) underlies the most common subtype cmt a. severely affected cmt patients suffer from sensory and motor symptoms with wheelchair-boundness. the clinical phenotype is highly variable and is determined by the amount of axonal loss, but the molecular mechanisms of the disturbed neuron-glia interaction are poorly understood. risk factors have not been investigated. therefore, cmt-net, a german network funded by the german ministry of education and research (bmbf, bonn, germany) includes interdisciplinary expertise from molecular biology, neurology, neuropathology and human genetics in order to identify genetic and non-genetic risk factors of disease severity of cmt by: (i) examining the mechanisms of the disturbed axon-glia-interaction and neuronal vulnerability, (ii) identification of genetic modifiers and (iii) novel therapeutic targets, (iv) validating outcome measures in children and adults, (v) establishing a biobank and (vi) exploring the disease burden via an internationally harmonised patient registry. cmt-net includes three service structures cmt-net will focus on cmt a, but also includes rarer subforms. we will provide the scientific basis for the development of translational approaches to therapy in patients. our approach bridges cutting edge molecular screening techniques, transgenic animal models of altered axon-glia interactions (fly, chick, mouse, rat), state-of-the-art genomic technologies and human patient trials in order to understand and treat the disease aggravation in cmt. sezer g , tekol y , sezer z , . erciyes university, betül ziya eren genome and stem cell centre, kayseri, turkey; erciyes university, school of medicine, pharmacology department, kayseri, turkey; erciyes university, good clinical practice and research centre, kayseri, turkey. analgesic effects of antidepressant drugs are well known for a long time, however, their systemic side effects limit their usage as an analgesics. venlafaxine is an antidepressant drug that has different structure. our purpose was to investigate whether systemic analgesic effect has been proved drug, venlafaxine, has local peripheral antinociceptive action. we applied vanlafaxine ( μl , , , μg) to male, sprague-dawley rats' paws by intraplantar injection and also by intraperitoneal route ( , , , mg/kg) in formalin test, a model for acute and tonic pain. we also pretreated another groups of rats with mg/kg naloxone (opioid receptor antagonist), mg/kg cpt (adenosine a receptor antagonist) or saline (ip.) before μg/paw venlafaxine injection. to check the effect is local or not, we determined the blood levels of venlafaxine in at different time points after both the local and systemic applications by gc-ms method. datas were expressed as number of flinches and total time for biting/licking of the injected paw over phase ( - min) or phase ( - min) and analyzed using the student's t-test. venlafaxine induced antinociception at , and μg concentrations by the local peripheral application and at , mg/kg doses by the systemic application in formalin test and the effects were comparable. pretreatment with naloxone diminished the effect of venlafaxine in the both phases, however, it was not statistically significant. pretreatment with cpt decreased venlafaxine induced antinociception only in phase . neither naloxone nor cpt changed formalin induced nociceptive behaviors alone. this is the first that determines the peripheral antinociceptive actions of venlafaxine in rat formalin test. with roles of opioid and adenosine a receptors in this action. our results suggest that venlafaxine has local peripheral antinociceptive effect and such an activity may led to trials for to use this drug as a cream-gel formulation for analgesia in clinics in the future. topical application might permit the attainment of higher and more efficacious concentrations in the region of the sensory nerve terminal, with limited systemic side effects. shah a , hoffman em , klein cj , staff np . mayo clinic, rochester, usa. cipn is a common dose-limiting complication for patients with cancer. the long-term disease burden of cipn is compounded by increasing cancer survivorship, yet there are minimal data on long term outcomes following onset of cipn, especially in population-based studies. we utilized the rochester epidemiology project to examine incidence and disease burden of cipn among individuals of olmsted county, minnesota with neurotoxic chemotherapy exposure between and . clinical records were queried for the presence of neuropathic signs, symptoms and icd- diagnostic codes as well as for patient provided information on impairment with activities of daily living and use of pain medications. a total of individuals with incident exposure to neurotoxic chemotherapy agents between and were identified. based on aan criteria for identifying peripheral neuropathy, ( . %) of these individuals were determined to have cipn, while ( . %) controls did not. the median time from incident exposure to reported symptom onset was days (iqr . - ). patients with cipn received a neuropathy icd- diagnosis in merely cases ( . %). median survival following incident chemotherapy exposure among all cases and controls was . years with a significantly longer mean survival in cases with cipn as compared to that of controls ( . years vs. . years, p< . ). in addition to acute effects in cipn, individuals surviving greater than years following exposure to neurotoxic chemotherapy continue to self-report increased symptoms of numbness (or . , % ci . - . ) and pain (or . , % ci . . . ) of the extremities. through utilization of patient provided information, our study was able to collect data on long-term impairment associated with previous history of exposure to neurotoxic chemotherapy. our results are consistent with previous reports of the high incidence of cipn in the first two years following incident exposure. additionally, our results provide evidence of high incidence of cipn independent of individual chemotherapeutic agent used. additionally, our results indicate icd- -cm diagnostic code attribution may dramatically underestimate the magnitude of cipn. increased survival following exposure to neurotoxic chemotherapy and its long-term disease burden necessitates further study of among survivors. the utility of quantitative muscle ultrasound as a marker of disease severity in charcot-marie-tooth (cmt) disease subtypes was investigated. muscle ultrasound was prospectively performed on individual muscles from cmt patients ( cmt a, cmtx , cmt a) and compared to muscles from age and gender-matched controls. muscle ultrasound recorded echogenicity and thickness in representative muscles including first dorsal interosseus (fdi) and tibialis anterior (ta charcot-marie-tooth (cmt) disease is the most frequent inherited peripheral neuropathy, and there is currently no available cure. the most common subtype of cmt, cmt a, is completely associated with duplication of the pmp gene, which encodes peripheral myelin protein of schwann cells. previous studies of cmt a mainly relied on rodent models, and it is not yet clear how pmp overexpression leads to the phenotype in patients. based on induced pluripotent stem cell (ipsc) technology, we herein developed a brand new in vitro cell model of cmt a, called cmt a-hipscs, in the hopes of simulating the developmental progress of the disease and gaining new insights into its pathogenesis. here, we efficiently derived ncscs from cmt a-ipscs and assessed the potential of the isolated cmt a-neural crest stem cells (ncscs) to differentiate into peripheral neurons and schwann cells using defined media. we found that, unlike normal control ncscs, cmt a-ncscs rarely generated schwann cells. instead, cmt a-ncscs produced numerous endoneurial fibroblasts in the schwann cell differentiation system. we further established a pmp -overexpressing ipsc model, and obtained similar results when pmp -ncscs were subjected to schwann cell differentiation. these results suggest that the development of schwann cells in cmt a patients is interrupted by the duplication of pmp . with the exception of the demyelination-remyelination process, developmental disabilities of schwann cells should be considered as an underlying cause of cmt a. shimoi t , yamada t . international university of health and welfare, tochigi, japan, cmt japan, tokyo, japan. charcot-marie-tooth (cmt) disease is the most common hereditary motor and sensory neuropathy. our preliminary report suggests that a certain cmt patient has the recruitment disorder of motor units during muscle fatigue and this disorder may be a factor of "super fatigability" in motor neuropathy patients. if the "super fatigability" occurs, we would expect patients with this characteristic to become slower in recovery from muscle fatigue than patients without this characteristic. in order to verify this hypothesis, we measured characteristic of recovery from muscle fatigue in charcot-marie-tooth patients with electromyographic study. twenty three participants were asked to maintain their % of maximal voluntary isometric contraction (mvc) of elbow flexor until exhaustion as the fatigue exercise. in addition, the participants asked to perform s of their % of mvc at , , , , , , , , , s after the fatigue exercise as recovery tasks. the surface emg (semg) signals of biceps brachii muscle were determined during the exercise and tasks. muscle force, median power frequency (mdpf) and the root mean square of semg amplitude (rms) were used as objective parameters of muscle fatigue. borg scale was used as a subjective parameter of muscle fatigue. six of twenty three participants showed significant decrease of rms during the fatigue exercise. in consideration of this result, we compared alteration of mdpf in recovery task between six participants with decrease of rms (abnormal group) and seventeen participants with increase of rms (normal group). as the result, the abnormal group had at least s as the recovery time from muscle fatigue in contrast with s of normal group. the recovery time from muscle fatigue in subjective parameter was shorter than the time in objective parameters in each group. our data support the "super fatigability" hypothesis. and that hypothesis may induce "hidden muscle fatigue". comparison between complex regional pain syndrome type and based on electrophysiologic, imaging and clinical findings shin jy , moon jy , sung jj . seoul national university hospital, seoul, republic of korea. complex regional pain syndrome (crps) is a constant regional neuropathic pain characterized by various kinds of motor, sensory, and autonomic changes. conventionally, the crps is divided into type i and ii according to the absence and presence of nerve injury. but the pathogenesis of crps is not fully understood yet. and there is still no systematic comparative study between crps type i and ii. we compared between crps type i and ii using multimodal approaches including electrophysiologic, imaging, and clinical findings. the patients ( type i and type ii) diagnosed with crps using the international association for the study of pain (iasp) diagnostic criteria were included. type i and ii were divided by electromyography and nerve conduction study. we obtained clinical information such as continuing pain, allodynia, hyperalgesia, edema, temperature, skin color, sweating, trophic change from patients. all patients were evaluated by bone scan, thermography, quantitative sudomotor axon reflex test (qsart), quantitative somatosensory test (qst). the ratio of qsart and temperature threshold abnormality in type ii was higher compared to type i ( . % vs . %, . % vs . % respectively, p = . and . ), among clinical symptoms, sweating change significantly high in type ii compared to type i ( . % vs . %, p = . ). other electrophysiologic and imaging, clinical findings were not significantly different in both type. in this study, we identified that crps type i and ii are distinguished not only by the nerve injury but also by the sudomotor function, and qsart can serve as a good technique to differentiate between crps type i and ii. it is estimated that there are two distinct pathogenesis in crps. our results may be helpful to diagnose crps correctly and understand the pathogenesis of crps. sjogren syndrome (ss) is an autoimmune inflammatory disorder of exocrine glands resulting in xerophthalmia and xerostomia. ross syndrome is a rare entity characterized by tonic pupil, hyporeflexia, and segmental anhidrosis. we present a -year-old hispanic woman with debilitating sensory and autonomic neuropathies, and persistently elevated anti-ss-a and anti-ss-b antibodies, without the classic sicca complex. she initially developed diarrhea and an ear infection, then felt toe and later leg numbness, which eventually spread to her cheeks and tongue, over few months. four years later, her thumbs and index fingers started tingling. also, she developed orthostatic lightheadedness, tachycardia, segmental hypohidrosis of the right abdomen, and hyperhidrosis of the remaining trunk, intermittent erythema, chronic diarrhea, and a -pound weight loss. her exam demonstrated orthostatic hypotension, bilateral tonic pupils and light-near dissociation, sectoral palsy of the right iris sphincter, stocking-distribution diminished sensation to all modalities, pseudoathetosis, areflexia, dysmetria, intention tremor, romberg, and sensory gait ataxia. mri of neuraxis demonstrated t -weighted hyperintensity in the dorsal spinal cord from c to the lower thoracic level, with mild atrophy. electrodiagnostic testing was consistent with moderate-to-severe, length-dependent, asymmetric, sensory polyganglionopathies. csf showed oligoclonal bands. serology showed elevated antinuclear antibody ( : , reference < : ), ss-a ( , reference < u), ss-b ( , reference < u), and rheumatoid factor ( , reference < iu/ml) titers. the remaining workup was negative for infection (syphilis, hiv, htlv, hepatitis, lyme disease), paraneoplastic syndrome (anti-hu and ganglionic nicotinic acetylcholine receptor antibodies), pyridoxine intoxication, malignancy (chest/abdomen/pelvis ct, breast ultrasound, axillary lymph node flow cytometry, colon and esophagus biopsy), celiac disease, vitamin deficiency, autoimmune disease (anti-aquaporin and anti-gq b antibodies), and adrenoleukodystrophy. the patient received ivig and steroid with some gait improvement and currently takes mycophenolate. midodrine and fludrocortisone resolved her dizziness. this case highlights an important, treatable sensory ganglionopathy and systemic autonomic neuropathy due to sjogren syndrome, and illustrates the overlapping clinical triad of ross syndrome, which may guide future management. siles am , , assylbekova d , , diaz-manera j , , rojas-garcia r , , cortes e , , gallardo e , , illa i , , querol l , . neuromuscular diseases unit, neurology department, hospital de la santa creu i sant pau, univeristat autònoma de barcelona, barcelona, spain; centro para la investigación biomédica en red en enfermedades raras (ciberer), madrid, spain. inflammatory neuropathies are a heterogeneous group of peripheral nerve diseases that respond to immune-therapies. chronic inflammatory polyradiculoneuropathy (cidp) and multifocal motor neuropathy (mmn) are two chronic inflammatory neuropathies responding to intravenous immunoglobulins (ivig). b lymphocytes are involved in their pathogenesis. while widely used in clinical practice, ivig's mechanism(s) remain not completely understood. ivig are reported to lead to b-cell anergy and to increase regulatory t-cell function and frequency. regulatory b cells (bregs) are a rare subset of b lymphocytes that suppress immunopathology acting upon several target cells in the immune system. impaired breg yields have been described in a plethora of autoimmune conditions. the presence of regulatory b cells in inflammatory neuropathies and the effect of ivig therapy on their frequencies has not been studied. the aim of this study is to describe the frequencies of bregs in cidp and mmn and the effect of ivig on their frequencies. patients fulfilling diagnostic criteria for cidp or mmn and matching controls were included. pbmcs were obtained by gradient centrifugation before ivig infusion and one week after treatment. b-cells were isolated with negative selection magnetic beads, cultured and activated with the tlr agonist odn and anti-human igg+iga+igm. il- secretion capacity was assessed by flow-cytometry. twenty-eight patients were included of whom where cidp and mmn. of all patients included, received ivig and were suitable for pre and post ivig breg frequency comparisons. breg frequencies did not differ in patients (before ivig treatment) and controls (p= . , mann whitney test, two-tailed). however, the frequencies of bregs significantly increased one-week after treatment with ivig (p= . , wilcoxon matched pairs test, two-tailed). when stratifying by disease subtype, breg frequencies increased in cidp patients after ivig (p= . , wilcoxon matched pairs test, two-tailed) and in mmn (p= . , wilcoxon matched pairs test, two-tailed) although results did not reach statistical significance in mmn. this is the first study that studies the breg frequencies in cidp and the first study that addresses the effect of ivig on breg frequencies. our study provides the proof of principle that bregs could become a biomarker for response to ivig but this would need a larger and prospective study. siles am , , martínez-hernández e , diaz-manera j , , rojas-garcia r , , gallardo e , , illa i , , graus f , querol l , . paraneoplastic neuropathies (pn) are rare, immune-mediated disorders of the peripheral nerve with important prognostic implications. ectopical expression of neural antigens in the tumor leads to the development of onconeural antibodies. several autoantibodies associate to pn, including anti-hu, anti-caspr or anti-cv antibodies but a significant proportion of pn lack identifiable antigens. adhesion molecules that are autoantigens in other neuropathies, like contactin- , are present in several types of tumors. our study proposes a systematic screening of autoantibodies against neural cell-adhesion molecules and neural structures to detect novel antigenic reactivies in pn. thirty-five patients followed in our centre and at the neuroimmunology-multiple sclerosis unit at hospital clínic de barcelona, with pn fulfilling diagnostic criteria of possible (n= ; . %) and definite (n= ; . %) paraneoplastic disease were included. serum samples were obtained and tested by immunocytochemistry against contactin- (cntnt ), neurofascin (nf ) and the cntn /caspr complex. primary cultures of dorsal-root ganglia (drg) and rat schwann cells were incubated with patients' sera to detect antibodies targeting neural structures. ten individuals ( . %) presented with a tumor and a neuropathy involving both sensory and motor symptoms. the remaining patients ( . %) presented with a tumor and a classical sensory neuronopathy without anti-hu or any other onconeuronal antibody. among the latter, ( . %) patients were diagnosed with small-cell lung carcinoma. the rest of the individuals ( . %) associated diverse malignancies. we did not detect any sera reacting against cntn , nf or the cntn /caspr complex. in igg antibody screening experiments, patients ( . %) reacted against drg neurons, of them ( . %) reacting strongly, and patients ( . %) reacted mildly against rat schwann cells. in igm experiments, patients ( . %) reacted slightly against drg neurons and patients ( . %) against rat schwann cells, of them ( . %) featuring strong staining. experiments screening antibodies against motor neurons and immunoprecipitation assays are ongoing. overall, % of patients reacted strongly against either neurons or schwann cells. our study did not detect antibodies against the neural adhesion molecules cntn , nf and the cntn /caspr complex in patients with pn. however, a significant proportion of pn patients harbour antibodies targeting neural structures, which suggests that novel neoplasm-associated antigens remain to be discovered. simmons m , tao f , abreu l , zuchner s , li j . department of neurology, vanderbilt university school of medicine, nashville, tennessee, usa; hussman institute for human genomics, university of miami, miami, florida, usa. objective: despite of a shared genetic mutation of the trisomy of chromosome p (c p ), patients with charcot-marie-tooth type- a (cmt a) present with a high variability of their disease severities. the underlying cause for the variability is still unclear. in this study, we tested a hypothesis whether a second genetic mutation known to damage the nervous system is also present in cmt a patients with early onset and severe phenotypes. methods: from a cohort of patients with cmt a mutation (chromosome p duplication), we identified patients with an early onset (< or = years of age) of the disease. four of the eleven also had dna testing for a panel of known cmt-related genes and sequencing of mitochondrial dna in addition to the dna testing for c p duplication. results: besides the c p duplication, we identified three additional mutations in the four patients with early onset. the mutations were a missense mutation of arg his in mpz gene, an a g mutation in mitochondrial trna for glycin and a homozygous mutation of c p duplication. three of the four had symptomatic onset at birth. one showed symptoms at years of age. conduction velocities were severely reduced in all four patients (from to m/s). interpretation: traditional approaches to identify genetic modifiers, including snp association, assume that those modifiers are clustered in a small region of human genome and shared by the studied patients. however, our study suggests that genetic modifiers in cmt a may be highly diverse and scattered throughout the genome, which could make the conventional approach via the genetic variants association difficult. supported by grants from ninds (r ns ) and the national center for advancing translational sciences (ul tr sjogren's syndrome(ss) is a systemic auto-immune disease that apart from exocrine glands may affect any organ. involvement of peripheral nervous system results in wide spectrum of neuropathic manifestations. the aim of our study was to evaluate the clinico-electrophysiological patterns and pathological characteristics of neuropathy in sjogren's syndrome (ss) patients presented to neuromuscular clinic in a tertiary hospital from south india. this is a retrospective study from the departments of neurology, rheumatology and pathology from nizam's institute of medical sciences. twenty one patients with diagnosis of ss and peripheral neuropathy between to were analysed. clinical records, conventional nerve conduction studies, lip and nerve biopsy reports were collected.in patients with ss associated neuropathy,male to female ratio was : . in ( . %) neuropathy was the initial manifestation,while in ( %)exocrinopathy preceded neuropathy. the patterns of neuropathy included mononeuropathy multiplex(mnm) in patients ( %),ganglionopathy in ( %),length dependant, trigeminal, autonomic neuropathy and cidp in ( %)and cranial neuropathy in ( %).eighteen( %) were seropositive..schirmer's test was positive in ( . %).nerve biopsy showed vasculitis in patients, demyelinating and axonopathy in patients each.we conclude that neuropathy is frequently the initial presentation of ss.mnm is the common pattern followed by ganglionopathy. pattern of neuropathy helps in arriving at the diagnosis of ss. confirmation of ss is not by mere serology. schirmer's test and lip biopsy are equally essential for the diagnosis especially in seronegative patients when clinical index of suspicion is high. siskind ce , tesi rocha c . stanford health care, palo alto, ca, usa; stanford university, stanford, ca, usa. here, we report the first case of a human found to have a homozygous, presumed disease causing variant in the arl ip gene, causing charcot marie tooth disease (cmt) with central nervous system findings. the proband was born at term with apgars of and at and minutes. he was found to have iugr and was hospitalized for days for weight gain. he developed respiratory distress during the admission and was intubated. due to inability to extubate, he was transferred to stanford children's hospital, where he remained for three months. noted during admission was hypotonia, areflexia, minimal voluntary movment, sinus tachycardia, and dysautonomia. brain mri found polymicrogyria and cerebral underdevelopment with generally normal-appearing brainstem, with moderate ventriculomegaly. ncs found length dependent polyneuropathy with axonal degeneration. follow up muscle and nerve biopsy found immature muscle and amyelinating neuropathy the patient had normal plasma amino acid, acylcarnitine, lactate, pyruvate, urine organic acid testing, opththalmology exam, newborn screen, and normal array cgh. genetics ordered whole exome sequencing through baylor genetics laboratory (houston, tx, usa), which found a homozygous nonsense variant in arl ip : c. c>t, p.r x. a second child had been identified by baylor with two variants in this gene. that child had hypotonia, respiratory distress and seizures, and a muscle biopsy consistent with sma. the parents of that child chose to withdraw care at months of age. our patient's parents continued with aggressive therapies, including tracheostomy and g-tube for feedings. he had several subsequent hospitalizations for respiratory distress, possible seizure activity, and buldging anterior fontenelle, but now, at two years of age, has made developmental progress and is living at home with his family. he is able to smile, reaching for toys and swatting objects. he has little voluntary movement, and no longer responds to light touch stimuli. overall, this is the first picture of a child affected with a severe amyelinating form of cmt that causes weakness, hypotonia, and possible seizures, with the main concerning feature being the severe respiratory distress that may be life threatening, but can be managed with extreme care. charcot marie tooth (cmt) disease is the most common inherited peripheral neuropathy. patients frequently ask whether pregnancy will affect their cmt, whether cmt will affect their pregnancy, the optimal delivery and whether they or their child will have a higher risk of complications during pregnancy or delivery. so far few studies address these questions. currently no guidelines exist for the management of pregnancy, delivery and postnatal care in cmt patients. the aim of the study is assess the impact of pregnancy on cmt and assess how cmt affects pregnancy, delivery and care of the new born baby. we designed a retrospective questionnaire with expert help from an obstetrician with a special interest in pregnancy in patients with medical conditions. the questionnaire is divided into four parts (prior, during, after pregnancy and delivery) and includes questions on impairment, falls, pain, fatigue and respiratory complications during those periods; type of delivery, possible complications, details of anaesthesia and difficulties looking after the baby in the first months postpartum. so far women ( pregnancies) with cmt and related disorders have answered the questionnaire. % of patients had cmt a, the remaining had various subtypes of cmt and related disorders. patients reported deterioration of cmt symptoms during pregnancy in % of pregnancies with resolution of symptoms after pregnancy in % of pregnancies. of symptoms questioned walking ( %), balance ( %), and hand function ( %) deteriorated the most. there was an increased use of orthoses and walking aids during pregnancy. the majority of women ( %) had natural delivery, % were assisted and % had caesarian sections which was similar to the uk population ( %). no complications with anaesthesia were reported. the survey is currently ongoing. we plan to survey consecutive patients. data acquired from this survey will provide valuable information on current practice and will inform future guidelines and standard of care in charcot marie tooth disease. multifocal motor neuropathy (mmn) is a slowly progressive disorder in adults, characterized by asymmetrical limb weakness, mainly affecting the arms. despite beneficial effect of immunoglobulins, weakness gradually progresses. a major determinant of muscle weakness is the degeneration of affected motor axons. treatments aiming to reduce loss of motor axons require objective tools to quantify such an effect. therefore, we applied the compound muscle action potential (cmap) scan, which is an electrophysiological method that, with increasing transcutaneous stimulus-currents, successively activates all motor units (mus) in a muscle. it captures the contribution of enlarged mus due to reinnervation by the presence of relative large discontinuities in the scan. the aim of the present study was to identify pathophysiological changes of mu-loss and reinnervation in mmn patients by means of the cmap-scan. recordings were obtained from mmn patients. cmap-scan recordings were performed in the median nerve at the wrist where motor responses were recorded from the thenar muscle. we determined the number of largest cmap-scan discontinuities by means of a novel marker, d , where a low number is indicative of mu-loss and enlarged mus. furthermore, we applied the recently developed method of professor hugh bostock for obtaining a mu-number estimate from the cmap-scan. the median peak cmap amplitude was . mv (range . - . mv) and median d was (range - ). in three mmn patients with a normal maximum cmap amplitude (> mv) a reduced d (< ) was found indicative of mu-loss and enlarged mus. furthermore, d and the estimate of mu number were significantly related (r = . , p < . , n = ). the findings suggest that the cmap-scan is a sensitive tool in detecting the underlying pathological changes of reinnervation and mu-loss in mmn, more so than standard maximum cmap amplitude. it is quick and easy to perform and has the potential to be useful for follow-up studies. smith ag , thurgood b , revere c , hauer p , aperghis a , singleton jr . university of utah, salt lake city, utah, usa. corneal confocal microscopy (ccm) directly and quantitatively assesses corneal innervation including nerve fiber length (nfl) and density (nfd). ccm has shown promise as a diagnostic test. we have previously demonstrated that ccm has a diagnostic performance for diabetic neuropathy (dpn) similar to skin biopsy with assessment of intraepidermal nerve fiber density (ienfd) and nerve conduction studies (ncs). the responsiveness of these surrogate measures to dpn progression and their relation to clinically meaningful outcomes has not been well explored. diabetic patients undergoing annual retinopathy examination were recruited. each underwent ccm, ienfd, ncs including sural sensory and peroneal motor responses, the utah early neuropathy score (uens), the norfolk quality of life -diabetic neuropathy (nqol-dn, a validated neuropathy specific qol scale), and a minute walk test ( mwt). with dpn based on symptoms ( %) or signs underwent repeat testing at months and at months. at baseline, nqol-dn correlated with sural sensory amplitude (ssa) (− . , p< . ), peroneal motor conduction velocity (pcv) (− . , p< . ) and ienfd (− . , p< . ). no ccm metric was related to qol. mwt distance correlated with ssa ( . , p< . ), nfl ( . , p< . ) and nfd ( . , p< . ). over months, there was a significant worsening in dpn signs assessed by the uens (increase . +/− . , p< . ). ssa declined . uv (p< . ) and ienfd . fibers/mm (p< . ). there was no change in any ccm metric, pcv or nqol-dn. these findings suggest measures of distal axonal integrity are most sensitive to neuropathy progression, with ienfd having the greatest responsiveness. in contrast, ccm was not responsive to dpn progression. both ncs and ienfd (but not ccm) were significantly correlated with neuropathy-specific qol, whereas ncs and ccm measures correlated with physical functioning. the responsiveness of ienfd and ssa, and their relationship to qol support their selection as endpoints in dpn clinical trials. chronic inflammatory demyelination polyradiculoneuropathy (cidp) affects in , people, and is marked by chronic autoimmune infiltration of peripheral nerves and destruction of the myelin sheath. with current therapies, only % of cidp patients achieve complete remission. to produce more effective, mechanism-based therapies, we study mice with a partial loss of function g w substitution in the autoimmune regulator (aire) gene on the non-obese diabetic (nod) background (nod.aire gw/+ ) that develop spontaneous autoimmune peripheral polyneuropathy (sapp) resembling cidp. autoimmunity can result from defective immunosuppression. the potent, immunosuppressive cytokine interleukin (il- ) is increased in the peripheral blood mononuclear cells (pbmcs) of active phase cidp patients relative to remission phase patients. further, pbmcs from cidp patients produce il- in response to the myelin protein p . despite these findings, whether il- is important for cidp pathogenesis is not known. thus, we sought to determine the role of il- in sapp. il- was highly upregulated in sciatic nerves of nod.aire gw/+ mice with sapp, suggesting it may play an immunosuppressive role in pathogenesis. however, genetic ablation of il- in nod.aire gw/+ mice lead to a paradoxical delay in disease development. age-matched il- -deficient nod.aire gw/+ mice exhibited no sciatic nerve infiltrate and no reduction in nerve conduction during electrodiagnostic studies. interestingly, the delay in sapp was specific, since the incidences of five other autoimmune manifestations in il- -deficient nod.aire gw/+ mice were unchanged relative to il- -sufficient nod.aire gw/+ controls. importantly, il- -deficient nod.aire gw/+ mice did not have colitis, which is consistent with previous studies of il- deficiency on the nod background. il- is known to perform effector functions in autoimmunity by promoting b cell secretion of immunoglobulins. however, genetic ablation of b cells did not affect neuropathy development in nod.aire gw/+ mice, suggesting b cells are dispensable for pathogenesis and unlikely to mediate the protective effect of il- deficiency. il- -deficient nod.aire gw/+ cd + t cells, which are sufficient to transfer sapp, exhibited increased activation, increased interferon gamma secretion, and preserved nerve-specific t cell activation. these data suggest t cell activation and priming are unperturbed and not the mechanism of protection. in summary, our data showed that il- was paradoxically an effector cytokine in sapp. long exercise test (let) has been used especially in myotonic syndromes and muscle channelopathies. marked decrement in compound muscle action potential (cmap) amplitude after prolonged exercise was previously reported in patients with paramyotonia congenita, hyperkalemic or hypokalemic periodic paralysis. we describe a patient with secondary hypokalemic paralysis who showed abnormal let results. a -year-old man presented with ascending flaccid paralysis which evolved in a hyperacute fashion. the patient became quadriplegic after two hours. initial laboratory evaluation revealed severe hypokalemia, with normal thyroid function. we performed electrodiagnostic studies including long exercise test as proposed by mcmanis et al. nerve conduction study was normal, but marked decrement in cmap amplitude (up to % decrease after minutes) was noted after prolonged exercise. despite oral and intravenous potassium replacement, serum potassium level was not corrected as expected. the unusual clinical course prompted for evaluation of secondary etiologies. abdomen computed tomography scan revealed a . x . cm-sized mass in the left adrenal gland. aldosterone to renin ratio was elevated, suggestive of primary hyperaldosteronism. genetic study for cacna s mutation turned negative. after receiving laparoscopic adrenalectomy, the patient experienced no further attacks, and also was able to stop his antihypertensive medication. let may show abnormal results in condition with reduced membrane excitability, even without true channelopathy. according to international criteria, the diagnosis small fiber neuropathy (sfn) is based on clinical symptoms in combination with a reduced intraepidermal nerve fiber density (ienfd) in skin biopsy and/or abnormal temperature threshold testing (ttt). the sensitivity of skin biopsy is moderate to good, although ienfd is normal in about % of patients with sfn complaints. furthermore, ttt is a widely available diagnostic tool, but lacks specificity. corneal confocal microscopy (ccm) has been described and is used in clinical practice as an objective, non-invasive diagnostic tool to detect small nerve fiber damage in patients with diabetes mellitus. this study examines the applicability of ccm in patients with sfn, and the value of ccm as an additional diagnostic tool in sfn. we will include healthy participants to compare the results with the recently published ccm normative values, and patients referred to the sfn center maastricht with the clinical picture of sfn. corneal nerve fiber density (cnfd), branch density (cnbd), fiber length (cnfl), and the tortuosity coefficient (cnft) will be determined in all participants. the results will be compared with the ienfd and ttt. preliminary results will be presented. southanalinh k , university of health sciences, vientiane capital, lao p.d.r. located in south east asia, lao pdr is a landlocked country with a population of about . million inhabitants. the health indicators are among the lowest in south east asia. the total health caregivers in consisted of , persons corresponding to a ratio of . health workers per inhabitants. the main network for health care service provision remains the public system. its health care facilities consist of four central teaching and referral hospitals; five regional hospitals, including one teaching hospital; provincial hospitals; district hospitals, and about health centers. only one in seven sick people receives modern health care treatment. most people rely on self-medication and/or reliance on self-healing. neurological care is a very new field. knowledge of common neurological disorders among both the lao population and medical staff is only beginning to be spread. there are three neurologists in the country. six neurology residents are currently being trained in a three-year program supported by the association pour la promotion des neuro-sciences au laos (association for the promotion of neuro-sciences in laos) and the asean neurological association. indeed, resources are scarce. in the peripheral nerve diseases domain for example, we have only one electromyography machine that was only temporary used when emg experts from france and from singapore came to teach residents. a significant mismatch between the provision of specialized neurologic services and the needs for them exists, especially in rural areas. also, health insurance is not available for the majority. as a consequence, patients have to bear the costs themselves, which constitutes a limit to the access of available healthcare facilities. neurologic training centers, laboratory facilities and equipments are limited. optimizing available human resources, integrating primary, secondary, and tertiary healthcare tiers and making medical treatment more affordable are need to improve neurologic care in the developing world. in certain low-income countries with limited human and financial resources, it may be difficult for governments to apply some of these recommendations on their own. in these circumstances, it is suggested that countries work with international agencies, nongovernmental organizations or other partners to put their plans into practice. spina e , topa a , iodice r , tozza s , dubbioso r , ruggiero l , santoro l , manganelli f . department of neuroscience, odontostomatological and reproductive sciences, university of naples "federico ii", naples, italy. chronic inflammatory demyelinating polyradiculoneuropathy (cidp) is a disabling disease and about % of patients may become persistently disabled over time. our aim was identify clinical prognostic factors of long-term disability in a large series of cidp patients. we collected data from cidp patients with definite diagnosis according efns/pns criteria and positive response to first-line therapies (immunoglobulin or corticosteroids) including sex, age of onset, phenotype, disease duration, course of disease (monophasic/relapsing-remitting or chronic progressive) and disability at the time of diagnosis assessed using the modified rankin scale (baseline mrs). all patients had clinical assessment of disability through mrs within the last months (last mrs). ordinal logistic regression model was applied to evaluate the relationship among the clinical parameters and last mrs, considered as ordinal outcome ( - ). anova test for repeated measures was applied to test the overall effects of different course on disability accumulation while t-test was performed to evaluate inter-group differences for parametric variables. we found a significant relationship between last mrs and the course of disease [p< . , z= . , or: . ]. disability accumulation was greater in patients with chronic progressive course than those with monophasic/relapsing-remitting course of disease [p= . ]. moreover, patients with progressive course were older [p= . ]. our data suggest that chronic progressive course of disease may be a major negative prognostic factor for long-term disability in cidp patients. to note that a chronic progressive course of disease is also associated with an older age from the beginning and a more pronounced worsening over the course of disease. sprenger a , lichtenstein t , henning t , lehmann hc . department of neurology, university hospital of cologne, cologne, germany; institute of diagnostic and interventional radiology, university hospital of cologne, cologne, germany; department of neurology, university hospital of cologne, cologne, germany. an unresolved problem in the treatment of inflammatory neuropathies is the lack of valid and reliable diagnostic biomarkers to evaluate axonal damage. we investigated if "diffusion tensor imaging" (dti) and mri t w multi echo dixon imaging are eligible methods to determine proximal nerve injury in chronic inflammatory demyelinating polyneuropathy (cidp). in this prospective observational cohort study the sciatic nerve of cidp patients and age matched healthy controls was investigated. all subjects underwent multimodal mri imaging to determine fractional anisotropy (fa) and muscle fat fraction of the biceps femoris and quadriceps femoris muscle. patients were evaluated by mri, clinical examination and nerve conduction studies at baseline and after six months. the mean fractional anisotropy (fa) value was significantly lower in the sciatic nerve from cidp patients compared to controls. fat fraction of the biceps femoris and quadriceps femoris muscle were significantly higher in cidp patients compared to controls. mri outcome parameters remained unchanged after six months. our study demonstrates the utility of mri imaging to differentiate between "healthy" and functional constricted proximal nerve segments. we postulate that dti and dixon mri might be eligible methods to assess proximal nerve damage in cidp. the presence of peripheral myelin protein (pmp ) has been known for decades, but its functional role was uncovered only recently. recent characterization of pmp -deficient mice revealed a role of pmp in the lipid homeostasis of myelinating schwann cells. in this study, we analyzed the functional impact of pmp on myelination. to decipher the role of pmp , experimental demyelination was performed in myelinating dorsal root ganglia cultures, and in vivo re-myelination was assessed after experimental peripheral nerve damage. we used the myelinating dorsal root ganglia (drg) model in pmp -deficient schwann cell cultures, combined with an established de-and remyelinating protocol in order to analyze myelination in vitro. we also performed experimental nerve crush in pmp -deficient mice. morphometric parameters were defined for the in-vitro experiments and functional parameters such as nerve conduction velocity and the clinical score were additionally measured for the in vivo experiments. structural analyses of the drg cultures revealed fibers expressing myelin basic protein (mbp) and pmp , as well as fibers positive for mbp alone. in contrast to our previous in vivo data, we were also able to detect myelin segments that stained positive for pmp , but were negative for mbp. pmp -deficient drg-cultures demonstrated slightly greater nodal lengths than the control cultures. this trend was significantly augmented after in vitro de-and remyelination, which also resulted in decreased internodal lengths only now, while conserving an intact myelin structure. concomitantly, in vivo nerve crush gives rise to a more severe phenotype in pmp -deficient mice than in wild-type controls. consistent with this, nerve conduction studies showed a delay in remyelination, and analysis of semi-thin sections demonstrated an altered fiber structure in the peripheral nerve biopsies. together, these data suggest that in addition to its role in glial cell lipid homeostasis, pmp also plays a role in remyelination of the injured peripheral nervous system. anti-mag neuropathy remains a difficult diagnosis to treat given its limited therapeutic options. of all interventions, rituximab has emerged as the most effective, although its effect has been with mixed results, especially in patients with advanced axonal loss. lenalidomide is another promising immune modulating therapy, whose effect has been well demonstrated in neuropathy associated with poems (polyneuropathy, endocrinopathy, organomegaly, m-spike protein, and skin changes) syndrome, a condition that has several striking parallels to anti-mag neuropathy. the use of lenalidomide has not been previously described in anti-mag neuropathy. herein, we describe a case of lenalidomide-responsive anti-mag neuropathy in a patient with advanced axonal loss. suichi t , misawa s , sato y , beppu m , sekiguchi y , shibuya k , watanabe k , amino h , kuwabara s . department of neurology, graduate school of medicine, chiba university, chiba, japan; clinical research center, chiba university hospital, chiba, japan. polyneuropathy, organomegaly, endocrinopathy, m-protein, and skin changes (poems) syndrome is a rare cause of demyelinating neuropathy associated with plasma cell dyscrasia and vegf overproduction. several diagnostic criteria for the disorder have been published, but sensitivity/specificity analyses, and their validation have never been performed. the aim of this study is to establish valid diagnostic criteria for poems syndrome. consecutive poems patients, seen at chiba university hospital since , were screened. of these, we have set a gold standard group of poems syndrome, based on treatment response and exclusion criteria during -year follow-up, and patients was diagnosed as having definite poems syndrome. we also collected patients with cidp (demyelinating neuropathy control) and with multiple myeloma, primary amyloidosis, or mgus (m-protein control). criteria for poems syndrome was defined as having two of the three major criteria (polyneuropathy, m-protein, and elevated serum vegf level) and at least two of the four minor criteria (extravascular volume overload, skin changes, sclerotic bone lesions, and thrombocytosis) which were determined by logistic regression analyses. according to the criteria the sensitivity was %, and the specificity was %. our results indicate that the proposed criteria have an excellent diagnostic accuracy, and are useful in clinical practice, presumably leading to early diagnosis and treatment. intraepidermal electrical stimulation (ies) is a new technique to that assesses the function of a-delta fibers in the epidermis. using this technique, we previously reported that the epidermal pain threshold was two-hold in asymptomatic diabetic patients than in normal subjects (muscle nerve : - , ). subsequently, we reported that the elevated pain threshold negatively correlated with intraepidermal nerve fiver density (jpns : s , ). empirically, it is known that lowering the skin temperature makes it less likely to feel pain. therefore, it is necessary to investigate whether the results of ies are affected by skin temperature. the aim of this study was to investigate the influence of a low skin temperature on pain threshold. we recruited subjects with a mean age of . years. for nociceptive stimulation, we used an ies method with a concentric micro-needle electrode that was developed specifically for the selective stimulation of cutaneous a-delta fibers. we placed the ies electrode onto the extensor digitorum brevis and began stimulation with intensity strong enough for the subject to feel a pricking sensation, then reduced the current in steps of . ma until no sensation was felt. we defined pain threshold as the minimum electrical intensity at which a subject felt a pricking sensation. firstly, we measured pain threshold at skin temperature above degrees celsius. then, we put an ice pack on the extensor digitorum brevis for min to lower the skin temperature, and measured pain threshold at skin temperatures below degrees. mean pain threshold values above degrees and below degrees of skin temperature were . and . ma (p< . ), respectively. our data indicated an elevated pain threshold in epidermis with a low skin temperature. one of most common methods for nociceptive stimulation is painful co laser stimulation. some co laser stimulation studies reported pain threshold increased with a low skin temperature. our result is similar to that of co laser stimulation. pain threshold using ies is very easy and non-invasive technique. it may be useful for the evaluation of small fiber neuropathy. svačina mkr , röth p , bobylev i , sprenger a , zhang g , sheikh ka , lehmann hc . department of neurology, university hospital cologne, cologne, germany; department of neurology, university of texas, houston, usa. intravenous immunoglobulins (ivig) are an effective treatment in guillain-barré-syndrome (gbs). in most patients, the optimal ivig dose and regime is unknown. in serum and ivig preparations, immunoglobulin (ig) g form igg dimers, which are assumed to consist of idiotypic/anti-idiotypic antibody pairs. however, data about kinetics of igg dimer formation in gbs are lacking. to study igg dimer formation, c bl/ mice were injected with ivig and anti-gd b antibody or pbs. blood sera were collected h, h and week post injection. a third cohort received an anti-gd a/gt b antibody and blood was collected h post injection. igg was extracted and subtyped into polymeric, dimeric and monomeric fractions using the Äkta fplc system. dialysed dimeric and monomeric igg fractions were examined for the presence of anti-ganglioside antibodies by anti-ganglioside antibody elisa. further, blood samples from gbs patients were collected before (pre-ivig) and after treatment with ivig (post ivig). serum samples were examined for igg dimers and monomers using the Äkta fplc system. in the mouse model, a maximum peak of igg dimer formation was observed h post injection. in gbs patients' samples, igg serum levels and igg dimer content was significantly higher after treatment with ivig. we demonstrate here the feasibility to assess igg dimer formation in an animal model and in gbs patients' samples after treatment with ivig. h after ivig treatment appears to be the optimal time point to assess igg dimer formation. further studies are warranted to determine the utility of igg dimer formation as surrogate marker for treatment response in gbs. svaren j , moran jj , wu x , gutmann l , shy m . university of wisconsin-madison, madison, wisconsin, usa; university of iowa, iowa city, iowa, usa. development of outcome measures for clinical trials in cmt a is a major challenge given the slowly progressive nature of the disease. outcome measures can be used to measure a) target engagement for a given therapy, as well as b) disease process and c) disease burden. several candidate therapies have been shown to reduce pmp levels in cmt a rodent models and thereby ameliorate the symptoms of pmp overexpression. measuring pmp mrna reduction in human trials has so far been limited to analysis of skin biopsies by qrt-pcr, which did not demonstrate clear elevations of pmp mrna during, nor a reduction following, ascorbic acid trials. the analysis of skin biopsies is hampered by variable amounts of schwann cells (sc) in skin biopsies, as well as the variable amount of pmp in sc as previously established by immuno-em in cmt a skin biopsies (katona et al., ) . therefore, it is important to develop optimal normalization criteria to address the variability inherent in skin biopsy analysis. ideally this will employ normalization to sc-specific genes that are not altered by cmt a status. to optimize normalization, we have performed rna-seq analysis of skin biopsies from patient and control skin biopsy samples. analysis of these data after normalization to read depth indicated that pmp levels were . fold higher in cmt a patient samples compared to control skin biopsies. however, there was significant variability in pmp levels particularly in cmt a samples, which may be due to variable amounts of schwann cells in cmt a skin. using a combination of sc-specific genes for normalization, we were able to reduce the apparent variability and optimize the differential levels between cmt a and control skin biopsy samples. we also identified other sc-specific genes that were apparently induced in cmt a skin biopsies relative to control. these studies provide a new framework for gene expression analysis in skin biopsies, enabling more precise evaluation of pmp levels in clinical trials for cmt a as a measure of target engagement. in addition, the normalization framework may also be applicable to other types of cmt. chronic inflammatory demyelinating polyneuropathy (cidp) is the most common chronic autoimmune neuropathy, with an estimated prevalence of between and per , people. it can cause temporary disability in the affected individuals and may eventually lead to permanent disability or death. cidp is commonly treated with intravenous immunoglobulin (ivig) therapy or corticosteroids. octagam ® % is licensed for cidp in france, while octagam ® % is licensed for cidp in germany and belgium. this analysis presents data from three open, multicenter, non-interventional, single-arm, non-controlled studies of a post-authorisation safety surveillance (pass) program for the subset of patients receiving octagam ® % or % for neurological indications, focusing on patients with cidp. briefly, data from in-and out-patients in austria, france, germany, and uk treated with octagam ® for neurological disorders were collected by physicians and analyzed to assess safety and tolerability of the treatment. of patients included in the three studies, patients ( . %) received octagam ® for neurological indications, of which patients ( . %; mean age . years [range - ]) had cidp. the mean dose of octagam ® per course was . g/kg bw for patients with cidp; for the other neurologic indications, the dose ranged from . (for multiple sclerosis) to . g/kg bw (for guillain-barré syndrome). premedication was not needed in . % of these patients. the development of clinical appearance since last observation (mean: every . months) was assessed for of the cidp patients by their treating physicians. the majority of observations ( . %) assessed the patients as stable and . % showed even an improved clinical appearance. only . % of the observation periods resulted in deteriorations. adverse drug reactions were rare: of the infusions received by patients with neurological disorders, . % of infusions were associated with an adr ( . % of infusions in cidp patients). overall, treatment with octagam ® was effective and well-tolerated in patients with cidp. these results are consistent with data for the overall patient population (including patients with primary and secondary immunodeficiencies, dermatological and other diseases). szepanowski f , szepanowski lp , kleinschnitz c , kieseier bc , stettner m . department of neurology, medical faculty, university duisburg-essen, essen, germany; department of neurology, medical faculty, heinrich-heine-university, düsseldorf, germany. lysophosphatidic acid (lpa) is a pleiotropic signaling lipid that acts as ligand for at least six specific g protein coupled receptors. schwann cells (sc) are known to mainly express the lpa receptor subtype. an emerging body of in vivo evidence has linked lpa with injury induced peripheral nerve demyelination as well as neuropathic pain. however, the molecular mechanism underlying its demyelinating effect has remained largely unclear. myelinated dorsal root ganglia (drg) cultures were treated either with lpa, lpa + am (lpa antagonist) or vehicle. we assessed myelin basic protein, tumor necrosis factor alpha (tnf-alpha) as well as the sc differentiation marker sox by immunocytochemistry. additionally, myelin was investigated by sudan black staining. to better understand the relevance of lpa signaling for demyelination in vivo, we performed sciatic nerve crush in c bl/ mice treated with am at mg/kg in order to study schwann cell expression of tnf-alpha, sox and sox , a marker for sc dedifferentiation, by immunohistochemistry. in drg cultures, lpa caused a significant reduction of myelin as demonstrated by both sudan black staining and immunocytochemical analysis of myelin basic protein. demyelination was paralleled by an upregulation of tnf-alpha as well as downregulation of sox . lpa mediated effects were found to be blocked by addition of the lpa receptor antagonist am . in c bl/ mice, am treatment prior to crush injury increased sox expression in scs in the distal nerve stump while reducing the number of cells expressing sox . these data indicate that lpa may be a critical factor to shift scs towards an injury-associated phenotype and contribute to the onset of wallerian degeneration. szepanowski lp , szepanowski f , kleinschnitz c , stettner m . department of neurology, university hospital essen, essen, germany. glyphosate-based formulations comprise the world's most commonly used herbicides. in non-resistant plants, glyphosate exerts toxic effects most likely via inhibition of aromatic amino acid synthesis by interfering with the shikimate pathway. while glyphosate is the active ingredient, herbicidal formulations contain several adjuvants, including polyethoxlated alkylamines (poeas). although glyphosate has long been considered safe for use in humans and animals, several studies have implicated glyphosate and/or the commonly used adjuvants in cytotoxicity, carcinogenicity and endocrine disruption. furthermore, glyphosate-based herbicide has been reported to mediate neurotoxicity in immature rat hippocampus involving glutamate excitotoxicity. however, it remains unclear whether glyphosate alone or in combination with its adjuvants may have detrimental effects on myelin integrity in the peripheral nervous system. myelinated dorsal root ganglia (drg) cultures were treated over the course of ten days with either pure glyphosate or a glyphosate-based herbicide at concentrations of . %, . % and . %. the concentration of the glyphosate-based herbicide was matched with regard to glyphosate content ( %). controls were treated with equal amounts of vehicle adjusted for the ph. subsequently, cultures were stained with sudan black and myelin content was assessed by determining the number of internodes per neurons. while glyphosate, regardless of its concentration, did not show any effect on myelin content, the glyphosate-based herbicide caused significant demyelination in a concentration-dependent manner. notably, at . %, drg cultures were completely devoid of myelin and appeared severely necrotic. these data raise the possibility that not glyphosate itself, but rather the adjuvants in glyphosate-based herbicide formulations may cause demyelination. the open question whether demyelination is a direct effect of the adjuvants or a consequence of increased cellular glyphosate uptake due to permeabilization warrants further investigation. tan cy , tan mp , yeoh ky , goh kj , shahrizaila n . department of medicine, university of malaya, kuala lumpur, malaysia. in guillain-barré syndrome (gbs), autonomic dysfunction is common and accounts for significant morbidity and mortality. there have been many studies investigating the electrodiagnosis of gbs but few have studied autonomic dysfunction in gbs. the current study comprehensively investigates quantitative autonomic function in patients with gbs and its variant. ten gbs patients were prospectively recruited and the results were compared to age-and gender-matched healthy controls. a series of autonomic function tests including computational (power spectrum analysis of heart rate variability (hrv) and baroreflex sensitivity (brs) at rest) and challenge tests (deep breathing, eyeball compression, active standing, valsalva manoeuvre, isometric exercise and ice-water hand immersion) were performed. parasympathetic function was represented by high frequency (hf) hrv, heart rate responses to deep breathing, eyeball compression, valsalva manoeuvre and active standing. sympathetic function was represented by low frequency (lf) hrv, blood pressure responses to active standing, sustained handgrip and ice-water hand immersion. in the frequency domain analysis of hrv, low frequency (lf: . ± . vs . ± . ; p= . ), high frequency (hf: . ± . vs . ± . ; p= . ) and total power spectral densities (psd: . ± . vs . ± . ; p= . ) were significantly reduced in patients compared to controls. the mean up slope ( . ± . vs . ± . ; p= . ), down slope ( . ± . vs . ± . ; p= . ) and total brs slope ( . ± . vs . ± . ; p= . ) were significantly lower in the gbs group. the diastolic rise in blood pressure upon ice-water hand immersion was significantly lower in gbs group compared to controls ( . ± . vs . ± . ; p= . ). our findings suggest that computation dependent tests (hrv and brs) were sensitive at detecting autonomic dysfunction and baroreceptor reflex insensitivity in gbs patients. in contrast, ice-water hand immersion was the only reliable challenge test making it useful as a bedside measure of autonomic function in gbs patients. sjögren's syndrome (ss) is an autoimmune disease that affects both east and west. nevertheless, we still have limited knowledge of how autoantibodies in ss affects the peripheral nervous system. in this study, we investigated the peripheral neuropathy in ss and sicca complex using the nerve excitability test, to elucidate how peripheral nerves are affected. we have enrolled a total of patients with ss or sicca complex. of these, two patients were excluded due to co-morbid carpal tunnel syndrome. each patient received clinical evaluation, examination for ssa/ssb antibodies titer, the nerve excitability test, conventional thermal quantitative sensory test, and conventional nerve conduction study. compared to normal control subjects, motor nerve excitability test of ss patients with positive ssa or ssb antibodies (n = ) were found to have increased rheobase (p< . ), increased relative refractory period (rrp) (p< . ), increased refractoriness at . ms (p< . ), increased accommodation toward depolarizing current in threshold electrotonus (te) (p< . ), and decreased superexcitability (p< . ). the sensory axonal study in seropositive ss also revealed increased rrp (p< . ), increased refractoriness at . ms (p< . ), and increased accommodation toward hyperpolarizing current in threshold electrotonus (te) (p< . ). meanwhile, in seronegative ss and sicca complex (n = ), we found no significant axonal properties changes. the present study revealed that peripheral nerves are affected differently in seropositive ss and in seronegative ss/sicca complex. in seropositive ss, motor axons tended to be depolarized, and both sensory and motor axons have increased refractoriness. the findings suggested that ssa and ssb antibodies might play a role in the inactivation of transient sodium channels. the effects of the antibodies on transient sodium channels might be the basis of peripheral neuropathies and even cardiac arrhythmias and heart block in ss. charcot-marie-tooth disease type a (cmt a), caused by the pmp duplication on chromosome p . , is the most common subtype of inherited peripheral neuropathies and affects in , individuals worldwide. while sharing the same genetic cause, cmt a patients often present great variability in their phenotypic presentation and disease severity. the cause of the phenotypic variability is largely unclear. in this study, we performed genome-wide association study (gwas) to identify novel genetic modifiers of various phenotypes in cmt a. dna samples from cmt a patients were genotyped on illumina omniexpress platform. after standard quality control, the dataset includes k markers in individuals ( individuals from european ancestry, and individuals from asian ancestry). we focused our analyses on the european population. logistic regression in plink was used to analyze the association between the clinical outcomes and patients' genotypes in an additive model. for cmt neuropathy score (cmtns), the analysis was performed using linear regression in plink, adjusting for patients' age. the analyses yielded several suggestive association signals. an association peak on chromosome was identified in difficulty with eating utensils (lead snp rs , chr : , p= . e- , odds ratio= . ). the peak is located within a non-coding gene linc . hearing loss showed an association peak on chromosome (lead snp rs , chr : , p= . e- , odds ratio= . ), located in an intergenic region near the megf gene. in foot plantar flexion, an association signal was identified in the dscam gene on chromosome (lead snp rs , chr : , p= . e- , odds ratio= . ). cmtns showed an association signal on chromosome (lead snp rs , chr : , p= . e- , beta= . ), located within an intergenic region close to dffb, c orf , and linc . while these suggestive signals require further validation, our study provides novel insights into the genetic architecture of cmt a. novel genetic modifiers may serve as potential targets for therapeutic interventions in the future. teng a , ohnmar , kalpana p , chai yh , umapathi t . yong loo lin school of medicine, national university of singapore, singapore; department of neurology, national neuroscience institute, singapore. we present an intriguing diagnostic puzzle, that was eventually cracked serendipitously. a -year-old man was seen for bilateral ptosis. evaluation for myasthenia gravis was negative. nevertheless, a diagnosis of ocular myasthenia gravis was made and he was put on pyridostigmine. he did not respond. the ptosis progressively worsened. he sought a second opinion. at this evaluation, he was noted to have complex ophthalmoplegia without diplopia, bilateral facial weakness and mild bulbar weakness. he had no sensory complaints. the limb examination was remarkable for slightly reduced reflexes, normal strength, and other than increased vibration threshold at the toes, intact sensory examination. repeat serological and electrodiagnostic work-up for myasthenia gravis was negative. a myopathic disorder such as chronic progressive external ophthalmoplegia was considered. serum creatine kinase and lactate were normal. he underwent biceps muscle biopsy which showed increased cox-negative and sdh positive fibers, supporting the then clinical impression of a mitochondrial cytopathy. at this point, he underwent blepharoplasty to improve his vision. routine histological examination of the levator palpebrae muscle showed amyloid deposits. this prompted a review of the earlier biceps biopsy, which revealed amyloid deposits that were not appreciated before. at this point, the significance of the patient and his son's history of lattice corneal dystrophy became apparent. he also reported that his late mother had similar facial appearance as his. the patient's nerve conduction study showed length-dependent sensory axonal polyneuropathy, right carpal tunnel syndrome and bilateral facial neuropathy. he had no definite symptoms of autonomic neuropathy. cardiac evaluation was unremarkable. the final diagnosis of familial gelsolin amyloid polyneuropathy was made. genetic confirmation for the patient and his family is being planned. we highlight the key clinical features of gelsolin neuropathy. the symmetric cranial neuropathy can resemble a muscle or neuromuscular junction disorder and the relative sparing of the cardiac muscle, somatic and autonomic nerves contrasts with transthyretin-related amyloid polyneuropathy. neuropathy is one of the most common long-term complications of diabetes. furthermore, % to % of diabetic neuropathy patients will develop neuropathic pain. the pathophysiology of neuropathic pain in diabetic peripheral neuropathy is complex and not fully understood. a potential mechanism is a change in voltage gated sodium channels, such as nav . . loss of function mutations in this channel cause insensitivity to pain, whereas gain of function mutations have been linked with different pain syndromes including small fiber neuropathy. in a cohort of patients with diabetic peripheral neuropathy we investigated whether mutations in nav . were associated with diabetic neuropathic pain. twelve nav . variants were identified in nine participants all within a cohort of participants with painful diabetic peripheral neuropathy. five of these variants were previously associated with pain disorders: v l, m l; w r, r h, l v. among the other variants two of them met the criteria of potential pathogenicity based on predictive algorithms and were further studied. functional analysis by whole cell patch clamp showed that one of these variants (m t) drastically impairs the inactivation of the channel by shifting the steady-state fast-inactivation towards more depolarizing potentials. there were no phenotypic difference between those participants with pathogenic variants and those participants without pathogenic variants. no rare nav . variants were found in participants with painless diabetic peripheral neuropathy. these observations suggest that mutations in nav . may contribute to painful diabetic peripheral neuropathy. tholance y , rosier c , f bouhour , psimaras d , kuntzer t , taieb g , créange a , delmont e , camdessanché jp , antoine jc . university hospital, saint-etienne, france; university hospital, lyon, france; university hospital, paris, france; university hospital, lausanne, switzerland; university hospital, montpellier, france; university hospital, creteil, france; university hospital, marseille, france. dysimmune sensory neuronopathies (snn) encompass paraneoplastic snn and snn associated with systemic autoimmune diseases such as sjögren syndrome, lupus or inflammatory bowel or rheumatic diseases but also a number of apparently idiopathic cases. biomarker antibodies are well-known in paraneoplastic snn but are lacking in non paraneoplastic cases. from a mono-center retrospective study we identified in anti-fgfr antibody as a potential biomarker of dysimmunity in patients with idiopathic or systemic autoimmune disease associated sensory neuropathy. the identified patients were more frequently women and had a non lenthg dependent neuropathy suggestive of snn. anti-fgfr antibody was the only immunological marker in / of cases at initial work-up although / of patients eventually developed with time systemic autoimmune disease. to confirm the incidence and the clinical pattern of patients with anti-fgfr antibodies we launched a prospective multicenter french study including patients with a sensory neuropathy suspected to be a snn of no paraneoplastic, genetic or metabolic origin. we present here the results on the first included patients compared to healthy blood donors. anti-fgcr antibodies were searched by elisa using the trk intracellular domain of the protein (invitrogen©). we found patients positive for anti-fgfr antibody ( . %). these patients were women and men aged . years as a mean ( - ). the neuropathy was acute and subacute in one patient respectively and progressive in the others. six patients fulfilled the diagnosis criteria of snn and the last one had a sensory neuropathy in the lower limb with abnormal sensory action potentials in the four limbs suggesting snn without reaching the requested criteria. one patient developed uveitis which is a new symptom with anti-fgfr ab. an unclassified dysimmune context was present at the initial work up in patients and one patient developed sjögren syndrome with follow-up. as a whole the clinical pattern of these patients is consistent with that of the initially published series. the lower prevalence of positive sera may be due to more stringent criteria used for elisa but needs to be confirmed on the complete prospective series. peripheral neuropathy research registry (pnrr) neurological assessment was scored using the total neuropathy score clinical version (tnsc), comprising pinprick and vibration sensibility, deep tendon reflexes, strength and patient symptom report. compound sensory action potential (csap) amplitudes were recorded antidromically at the lateral malleolus, stimulating the sural nerve at the mid-calf. of the total sample, % reported lower limb neuropathy, with % of patients reporting 'quite a bit' or 'very much' severity of tingling and numbness in their feet. the average sural csap amplitude was . ± . v and % of patients had sural amplitudes below the lower limit of normal for age. the total tnsc score correlated with the pro fact-gog ntx score (r = −. , p<. ) and sural amplitude (r = −. , p <. ). vibration sensibility correlated with the overall fact-gog ntx score (r =−. , p <. ), and sural amplitude (r = −. , p <. ). sural amplitude correlated with patient reported severity of numbness and tingling in the lower limbs (r =−. , p <. ) but not with the overall fact-gog ntx score. patient reports of neuropathic symptoms in the lower limb correlate with both objective neurophysiological and clinical measures of neuropathy severity. identifying links between objective neurophysiological markers and patient reported outcomes are critical to assess the impact of clinical interventions. tomaselli pj , gouvea sp , nyshyama kfs , nicolau n jr , lourenço cm , marques w jr , . division of neuromuscular diseases, department of neurosciences and behaviour sciences, clinical hospital of ribeirão preto, university of são paulo, ribeirão preto, brazil; neurogenetics, department of neurosciences and behaviour sciences, university of são paulo, ribeirão preto, brazil. mutations in the gab junction beta -protein gene (gjb ) are the second most frequent cause of charcot-marie-tooth disease (cmt), accounting for approximately % of cmt cases worldwide. the gjb codes for connexin protein (cx ). in the peripheral nervous system, the cx is expressed in the schwann cells and allows intercellular traffic of ions and small molecules between opposed cells. we analysed retrospectively detailed clinical and neurophysiological data of five families carrying novel gjb mutation submitted for testing at our neurogenetics laboratory. mutations were identified by bidirectional sanger sequence analysis of gjb coding region. we identified a total of subjects from five different kindreds with novel mutations (p.a v, p.l w, p.l q, p.f s, p.r l). these five novel mutations segregate with phenotype, are located in highly conserved amino acids among gjb and other gab junction protein sequences and among different species, are not present in any public database (exac, dbsnp and genome database), and were not found in normal brazilian controls. in silico analysis, predict these variants to be pathogenic, there was no male-to-male transmission; males were more severely affected than females. four out seven female have subclinical neuropathy and were only identified after clinical and electrophysiological evaluation. the conduction velocities were in the intermediated range in the males patients and higher in the females included in this study. we describe five new pathogenic mutations causing cmtx in a brazilian population and expand the number of causative mutations in the gjb gene. funded pure neural leprosy (pnl) is a slowly progressive, predominantly sensory patchy neuropathy presenting with positive and/or negative sensory symptoms, which are usually followed over time by distal asymmetrical weakness. despite rare, monomelic involvement in leprosy has already been reported. we sought to describe the clinical and electrophysiological patterns of an unusual leprosy neuropathy presentation. clinical data were retrospectively collected from nine patients who had monomelic involvement and were referred for further investigation to the emg lab. seven out nine patients were male. four patients had a brachial plexus like presentation and five have a lumbosacral plexus like presentation. the initial complaint was hypoesthesia in four patients, tingling in two patients and hypoesthesia with tingling in two patients. severe pain was observed in just one patient. all individuals from the group of patients with lumbosacral plexus-like presentation and three with brachial plexus-like presentation had no sensory nerve action potentials (snaps) for all nerves tested in the affected limb with or without motor involvement. one patient with brachial plexus-like presentation had focal slowing of conduction velocity with temporal dispersion of both median and ulnar nerves in the affected limb. one patient with plexus-like presentation had snaps with low amplitude of all nerves in the affect limb. the diagnosis of leprosy was confirmed by nerve biopsy findings, anti-pgl antibody, and positive response to specific treatment. nerve biopsy was performed in four patients, and the bacillus was found in two. the anti-pgl antibody was positive in four patients. plexus mri was performed in two patients and was normal. we found the distribution of motor and sensory symptoms were restricted to on limb in this group of patients. as a typically patchy disorder pnl may affect any nerve, although the reason why damage are restrict to only one limb has to be elucidated. the description of these cases increases the clinical spectrum of leprosy neuropathy. this possibility should be considered in the differential diagnosis of patients with plexopathy from endemic areas after excluding other causes. funded ataxia with oculomotor apraxia type (aoa ) is a very complex disorder characterized by an early-onset progressive cerebellar ataxia with cerebellar atrophy and peripheral neuropathy and it is caused by recessive mutations in the aprataxin gene (aptx ). when the neuropathy is present, it has been described in % of cases as primarily axonal. we describe a case of aoa due compound heterozygous mutations in aptx associated with demyelinating neuropathy. the patient was born from healthy and non-consanguineous parents and presented in the first decade with progressive cerebellar ataxia, multidirectional ophtalmoparesia, oculomotor apraxia, choreiform movements of limbs and peripheral neuropathy. he had normal cognition and stopped walking at age of . blood tests were unremarkable with normal levels of leucocytes, serum proteins, immunoglobulin, cholesterol, vitamin e, and alfa-feto protein. brain mri showed severe cerebellar atrophy. the motor conduction velocity in the upper limbs was slow with preserved amplitudes. the distal latencies and the minimal f wave latencies were prolonged. there was no evidence for superimposed acquired demyelinating neuropathy. direct sequencing of the aptx gene revealed two variants, c. - a>g, p? and c. g>a; p.w x. the first variant is novel and affects a highly conserved acceptor splice site of exon . the other variant is the most common portuguese variant, the nonsense mutation w x is located in exon . parental dna was tested and confirmed the variants were in different alleles. the presence of a demyelinating neuropathy in aoa suggests that phenotypic variability in this condition may be larger than previously considered. at the same time, it increases the differential diagnosis of inherited conditions with cerebellar ataxia and demyelinating neuropathy. finally, this finding opens the functional effects of the aptx gene. funded by: cnpq, fapesp, faepa, pronas (ministry of health). topa a , spina e , iodice r , tozza s , ruggiero l , dubbioso r , esposito m , santoro l , manganelli f . university of naples "federico ii", naples, italy. we report our -year experience of subcutaneous immunoglobulin (scig) in a cohort of patients with chronic inflammatory demyelinating polyneuropathy (cidp) from a tertiary care neuromuscular center. we analyzed data from cidp patients ( males and females, mean age: ± . years; mean age at onset: . ± . years; disease duration: . ± . years) treated with scig and with a follow-up period of months. all patients were previously responders to intravenous immunoglobulin (ivig). eight patients had a typical cidp and five patients had an atypical variant of cidp. five patients switched to weekly maintenance scig therapy (continuous regimen) because of short-lasting response to ivig therapy. eight patients with a longer lasting response to ivig received scig with a pulsed regimen similar to that used for ivig (from to cycles per year); seven of them because of difficulty in hospitalization and one for allergic reaction to ivig. changes in clinical status were assessed over the period of follow-up by using clinical evaluation of muscle strength, modified rankin scale, overall neuropathy scale and inflammatory neuropathy cause and treatmentsum score. in patients we evaluated also six minute walking test, hole-peg-test and meter walking test. all the five patients treated with a continuous regimen of scig remained clinically stable throughout the follow-up period. among the patients receiving pulsed scig treatment, out of ( %) responded to scig similarly to ivig, while three patients ( . %) worsened and needed to be treated again with ivig and the other one ( . %) stopped any therapy. subcutaneously administered immunoglobulin were well tolerated and no patients complained of adverse events. in conclusion, our findings confirm that continuous scig therapy is efficacious in maintaining clinical stability in patients with short-lasting response to ivig. moreover, our data suggest that pulsed therapy with scig may represent an alternative therapeutic option for the treatment of a subset of cidp patients. touvier t , ferri c , mastrangelo r , glimcher l , , wrabetz l , , , d'antonio m . myelin biology unit, division of genetics and cell biology, san raffaele scientific institute, dibit, milan, italy; department of cancer immunology and virology, dana-farber cancer institute, boston, usa; department of medicine, harvard medical school, boston, usa; hunter james kelly research institute, university at buffalo, buffalo, usa; department of biochemistry, university at buffalo, buffalo, usa; neurology, jacobs school of medicine and biomedical sciences, university at buffalo, buffalo, usa. mpz glycoprotein is an abundant product of terminal differentiation in myelinating schwann cells. the mutant mpzs del causes charcot-marie-tooth (cmt) b disease in humans and a similar demyelinating neuropathy in transgenic mice. mpzs del protein is retained in the endoplasmic reticulum (er) of schwann cells and induces an unfolded protein response (upr) characterized by activation of perk, atf and ire /xbp pathways. we have previously reported that activation of chop and gadd , two downstream mediators of perk, is pathogenetic in mpzs del mice (pennuto, ; d' antonio, ) but the role of the other upr branches remains to be investigated. in this study, we investigated the role of the er stress sensor enzyme ire and of xbp -a transcription factor specifically activated by ire -in mpzs del pathogenesis. we generated a new mouse model with schwann cells-specific ablation of xbp and in parallel we exploited mpzs del dorsal root ganglia (drg) explant cultures in which xbp signaling is modulated by gain/loss of function approaches. we observed that absence of xbp dramatically worsens hypomyelination and electrophysiological/locomotor parameters in young and adult mpzs del neuropathic animals. interestingly we observed that perk, atf and ire -mediated ridd signalings are upregulated in neuropathic animals lacking xbp . this suggests that activation of xbp targets have an essential role in limiting mpzs del toxicity, which cannot be compensated by other stress responses. moreover, we demonstrated in mpzs del drg cultures that inhibition of xbp splicing by u c (cross, ) decreases myelination whereas activation of xbp splicing by quercetin (wiseman, ) slightly ameliorates myelination. altogether, these data demonstrate that xbp pathway has a critical adaptive role in mpzs del neuropathy and suggest that activation of this pathway may be beneficial for cmt b and perhaps for a broad range of neuropathies characterized by upr activation. tozza s , bruzzese d , iodice r , esposito m , dubbioso r , ruggiero l , topa a , spina e , santoro l , manganelli f . department of neuroscience, reproductive sciences and odontostomatology, university of naples "federico ii", naples, italy; department of public health, university federico ii of naples, naples, italy. in cmt a patients, the clinical impairment progressively increases over time and correlates with the axonal loss. evidence has suggested that the decline of physical performance in cmt a patients may reflect a process of normal ageing. the aim of our study was to describe, by a case-control cross-sectional design, the progression of physical impairment with ageing in cmt a patients. we enrolled cmt a patients ( m; range - years) and sex-and age-matched healthy controls. to assess physical performance, all patients and controls underwent -meter walk test ( mwt), -minute walk test ( mwt) and -hole peg test ( hpt) of their dominant (d) and non-dominant (nd) sides. moreover, to assess clinical disability, impairment and quality of life in the cmt a group we used the charcot-marie-tooth neuropathy score (cmtns), the mrc sum score and the short form- (sf- ) questionnaire. the linear regression model was used to evaluate the changes over time of clinical measures in patients and controls. the chow test was used to determine whether the ageing had a different impact on clinical measures for the two groups. physical performance worsened with ageing in both patients and controls, but with a greater slope for cmt a patients [difference in slopes: mwt, . (c.i. . to . ), p< . ; mwt, − . (c.i. - . to − . ), p< . ; hpt-d, . (c.i. . to . ), p< . ; hpt-nd, . (c.i. . to . ), p< . ]. the rate of deterioration of physical performance was not different between patients and controls until the th year of age. after the th year of age the rate of deterioration became greater in cmt a group [difference in slopes: mwt, . (c.i. . to . ), p< . ; mwt, − . (c.i. - . to − . ), p< . ; hpt-d, . (c.i. . to . ), p< . ; hpt-nd, . (c.i. . to . ), p< . ]. moreover, in cmt a patients also cmtns, mrc sum score and sf- worsened with ageing and with a greater rate of deterioration after the th year of age. our study demonstrates that clinical decline in cmt a patients goes parallel to the normal ageing process until the th year of age, whereupon the clinical deterioration accelerates. tsouni p , devic p , moura b , planque e , bédat-millet al , devaux j , steck aj , delmont e , hottinger af , kuntzer t . dcn, chuv, lausanne, switzerland; centre de référence maladies neuromusculaires, hospices civils de lyon, lyon, france; cabinet médical, epinal, france; département de neurologie, chu de rouen, rouen, france; cnrs, crn m-umr , université aix-marseille, marseille, france; centre de référence maladies neuromusculaires et sla, hôpital la timone, marseille, france. new therapeutic options in immuno-oncology have allowed significant progress in the management of melanomas. treatment usually consists of a combination of two monoclonal antibodies targeting cytotoxic lymphocyte-associated protein and programmed cell death- . as a result, the immunologic barrier protecting tumor cells is overcome allowing an antitumor response. we report cancer patients with immune checkpoint inhibitor-induced neuropathies as a complication of this immunomodulating oncologic treatment. case reports: our index patient developed severe myalgia days after introduction of ipilimumab-nivolumab followed by painful paresthesias of the face and extremities day after the nd cycle of treatment. generalized areflexic quadriparesis (mrc ) with gowers'sign and distal loss of vibratory sensation were found. a -day course of ivig plus corticosteroids (cs) had no effect. three monthly ivig courses were necessary to improve the deficits at months. a survey of sfnp members revealed other patients with similar acute courses but with phenotypes varying from sensorimotor deficits with areflexia and myalgia to purely sensory ataxic forms following immunomodulating treatment. work-up including anti-nodal antibodies were negative in patients. from the other , had abnormal csf and had necrotizing myopathy. detailed repeat ncs demonstrated signs of nerve hyperexcitability and of demyelination or conduction blocks. evolution was slowly favorable following ivig and cs. discussion: our report underscores that atypical acute generalized demyelinating neuropathies are induced by these novel treatments. they may be associated with severe myalgia or other systemic toxic effects. discontinuation of the oncologic treatment depends on severity of symptoms. outcome was slowly favorable following ivig or cs, albeit slower than in the case of primary inflammatory neuropathies, probably given the long half-life of the monoclonal antibodies. gap junctions (gjs) are membrane channels found in most tissues connecting adjacent cells or different cell compartments as in schwann cells. they are involved in electrical connectivity and metabolic homeostasis allowing the passage of small molecules such as ions, second messengers, nucleotides and peptides. an important functional role of peripheral nerve connexins is suggested by their involvement in x-linked inherited neuropathy as well as in acquired neuropathy caused by oxaliplatin. although gjs play a role in electrical connectivity their specific role in the formation of the sciatic nerve compound action potential (cap) remains unclear. the aim of this study was to investigate the role of peripheral nerve connexins in the electrical responses of the mouse sciatic nerve under normal and stress conditions. for this purpose we used sciatic nerves of three different mouse models, the cx knockout (ko), cx ko and the cx /cx double knockout (dko) mice. using our ex vivo model for extracellular recordings we exposed sciatic nerves from different genotypes to three different gj blockers: octanol, -beta-glycyrrhetinic acid (gra) and octanoic acid (oa) and recorded the cap. amplitude and duration of the cap were used as an indication for the effects of the different blockers on the cap formation. all gj blockers caused a gradual decrease of the cap without any changes in the duration of the cap in all genotypes, suggesting progressive disturbance of axonal membrane excitability in the absence of one or two gj proteins. comparison of the three genotypes showed that cx may play a dominant role in the maintenance of the cap formation since nerves from cx ko mice proved to be more sensitive to the gj blockers compared to the cx ko nerves showing a faster decline of the cap amplitude. moreover the effect of gj blockers was similar in cx ko and dko nerves. finally, the effect of gj blockers on the dko nerves implies the presence of another gj protein. in conclusion, our results confirm the direct functional involvement of cx gj channels and cx hemichannels in the cap formation and indicate the existence of at least one more connexin in peripheral nerve. ca( +)-dependent anti-ganglioside antibody in seronegative guillain-barrÉ syndrome uchibori a , gyohda a , chiba a . kyorin university, tokyo, japan. we have reported ca + -dependent igg anti-ganglioside gq b antibodies in gq b-seronegative patients with fisher syndrome and its related disorders (fs-rd). in patients with fs-rd who were gq b-seronegative in conventional assays using phosphate-buffered saline without ca + , % turned seropositive for gq b-related antigens in assays using ca + -added tris-buffered saline. objective: we investigated whether ca + -dependent anti-ganglioside antibodies was present also in ganglioside-seronegative patients with other clinical disease types of guillain-barré syndrome (gbs) other than fs-rd. methods: the subjects were the following: patients with final clinical diagnosis as gbs (acute motor axonal neuropathy [aman], n = , and acute inflammatory demyelinating polyradiculoneuropathy [aidp], n = ), and patients with final clinical diagnosis as sensory ataxic neuropathy (san), n = . all subjects were ganglioside-seronegative in the conventional assays. we assayed serum igg antibodies against various gangliosides (including asialo-gm ) in elisa using tris-buffered saline as a basal buffer in both ca + -added and -non-added conditions. increase of the optical density (od) more than . in ca + -added condition compared with ca + -non-added one was taken significant, i.e. positive for ca + -dependent antibody. results: ca + -dependent antibody was negative in all aman and san patients. in aidp, the antibody titers (ods) against gainac-gd a were significantly increased in patients, and those against asialo-gm were increased in other patients in ca + -added condition. however, the titiers of those ca + -dependent antibodies were all at low level. conclusions: in clinical disease types of gbs other than fs-rd, ca + -dependent igg antibodies against ganglioside were detected in a few patients with aidp, but the positive rate and the antibody titers were low compared with case of gq b-seronegative fs-rd. ca + -dependent antibodies against ganglioside are considered to be more specific for gq b. the aim of the study was to investigate the relationship between median sensory conduction of median nerve and ulnar nerve in patients diagnosed with carpal tunnel syndrome. two hundred and eighty-six hands with carpal tunnel syndrome and hands in control group were investigated. patients were staged clinically and electrophysiologically. diagnosis of carpal tunnel syndrome was made according to the presence of paresthesia, pain in the innervation area of the median nerve, weakness and atrophy in the median nerve innervated muscles, positive phalen and tinel tests. median motor and sensorial nerve conduction study, including first, second, third finger and palm, and ulnar motor and sensorial nerve conduction of fifth finger studies were performed to all patients and control group. the ratio of distal latency and velocity of nerve conduction of first, second, third and palmar branches to fifth finger was calculated. distal latency of first, second, third finger and palm of patients with cts are longer and velocity is more slowly than controls. in addition to these findings, the velocity of fifth finger is also slower and distal latency of this one is longer than healthy subjects. the most sensitive method of classifying the carpal tunnel syndrome as normal, mild and moderate is the ratio of distal latency and velocity of second finger (p< . ). carpal tunnel syndrome is the most common encountered neuropathy. in nerve conduction studies can be used the ratio of distal latency and velocity of second finger as determine the degree of carpal tunnel syndrome. the most surprising finding of this report is the nerve conduction studies of fifth finger. the subclinical susceptibility of fifth finger can be explained by overusing of wrist. ursino g , gemelli c , grandis m , reni l , bellone e , geroldi a , gotta f , mandich p , ferrara m , schenone a dinogmi university of genoa, genoa, italy; irccs-aou san martino hospital genoa, genoa, italy. charcot-marie-tooth (cmt) neuropathy represents a clinically and genetically heterogeneous group of hereditary peripheral neuropathies characterized by chronic motor and sensory impairment. to date mutations in up to genes may cause cmt. the aim of this study is to describe our large population of cmt patients, and, within this, highlight specific phenotypes. the cmt clinic in genova, started in . during the years, patients underwent complete neurological, rehabilitative, neurophysiological examinations and genetic testing. the patients were routinely tested for common genes (as pmp , gjb , mpz, mfn ), while in specific cases we followed the candidate gene approach testing single genes based on the genotype-phenotype correlation. however, the ngs techniques were used when routine genetic testing was negative and a clear genotype-phenotype correlation could not be identified. cases are present to date in our database of cmt patients. in ( . %) patients, in spite of a clinical diagnosis of cmt, a genetic diagnosis is still lacking; ( . %) patients had alternative diagnosis (i.e hereditary spastic paraparesis etc.). instead, in patients ( . %) a defined genetic diagnosis was reached, of them being females ( . %) and males ( . %). among these, except for the more common cmt a, hnpp and cmt x phenotypes, we frequently observed patients affected by cmt b and cmt f. according to most literature data, we observed ( . %) patients with cmt b and patients ( . %) affected by cmt f. at the first visit, the cmt b phenotype was clearly length-dependent: . % patients showed impairment of the lower limbs and saving of the upper limbs; in terms of severity of the neuropathy, the mean cmtns was . and the mean age was . years. similarly, % of patients affected by cmt f, present with the same phenotype; the mean cmtns at the first visit was . and the mean age was . years. in conclusion, based on the experience of the genova cmt clinic, we describe a large population of cmt patients and a specific phenotype in cmt b and f patients, characterized by involvement of the lower limbs and selective sparing of the upper ones, which may help in addressing the diagnostic algorithm. non-freezing cold injury (nfci) develops following sustained exposure to cold temperatures, resulting in tissue cooling but not freezing. this can result in persistent sensory disturbance of the hands and feet including numbness, paraesthesia and chronic pain. both vascular and neurological aetiologies of this pain have been suggested but remain unproven. we prospectively approached patients referred for clinical assessment of chronic pain following non-freezing cold injury between february and november . of patients approached consented to undergo detailed neurological evaluations including: questionnaires to detail pain location and characteristics, structured neurological examination, quantitative sensory testing, nerve conduction studies and skin biopsy for intra-epidermal fibre assessment. of the study participants all had experienced nfci whilst serving in the united kingdom armed services and the majority were of african descent ( . %) and male ( . %). many patients reported multiple exposures to cold. the median time between initial injury and referral was . years. pain was principally localised to the hands and the feet, neuropathic in nature and in all study participants associated with cold hypersensitivity. clinical examination and quantitative sensory testing were consistent with a sensory neuropathy. in all cases large fibre nerve conduction studies were normal. the intra-epidermal nerve fibre density, however, was markedly reduced; ⋅ % of subjects having a count at or below the ⋅ centile of published normative controls. using the neuropathic pain special interest group (neupsig) of the international association for the study of pain (iasp) grading for neuropathic pain % had probable and ⋅ % definite neuropathic pain. chronic non-freezing cold injury is a disabling neuropathic pain disorder due to a sensory neuropathy. why some individuals develop an acute painful sensory neuropathy on sustained cold exposure is not yet known but individuals of african descent appear vulnerable. screening tools, such as the dn questionnaire, and treatment algorithms for neuropathic pain should now be used in the management of these patients. funded by the wellcome trust and the uk ministry of defence guillain-barré syndrome (gbs) is highly heterogeneous regarding clinical presentation, course, electrophysiological subtype and outcome. in part this variety is associated with differences between geographical regions, although this had not been investigated in a single comparative study. one aim of igos is to define the influence of the geographical origin on the heterogeneity of gbs. in igos all gbs patients within weeks of onset can participate, independent of age, variant, severity and treatment. in february , patients were included from countries. the first inclusions in igos were used in this analysis. seventy-five patients ( %) were excluded because of alternative diagnoses (n= , including a-cidp), protocol violations (n= ) or missing data (n= ). of the remaining patients, % were males and % female with a median age of years (iqr - ). at entry % presented with tetraparesis and % with paraparesis. during follow-up % needed mechanical ventilation and % died. of all gbs patients % received treatment ( % ivig, % pe). the remaining % received supportive care only (mild gbs or low social-economic status). antecedent events were reported in % of patients, including upper respiratory tract infection ( %) and gastro-enteritis ( %) as the most frequent events. the pure motor form was the predominant subtype in patients from bangladesh ( %). in europe/americas and asia (without bangladesh) the predominant subtype was the sensorimotor form ( % in europe/americas and % in asia). in asia (without bangladesh) there was a relatively larger proportion of patients with mfs/mfs-overlap syndrome ( %) than in other regions ( - %, p< . ). the proportion of patients able to walk unaided at months after follow-up was % in europe/americas, % in bangladesh and % in asia (without bangladesh). kaplan-meier analysis comparing electrophysiological subtypes of gbs (as reported by neurologist) showed that patients with inexcitable nerves or axonal neuropathy needed more time to regain the ability to walk unaided than the patients with demyelinating or equivocal result (log-rank test, p < . ). these findings demonstrate the extensive geographical differences in gbs. future igos studies will investigate the role of genetic and environmental factors that additionally could explain these differences. van den bergh pyk , attarian s , grapperon am , nicolas g , cassereau j , rajabally ya , delmont e , woodard jl , piéret f and the university of louvain gbs electrodiagnosis study group * . corticosteroids are considered as one of the first line treatments for chronic inflammatory demyelinating polyneuropathy (cidp). different types of corticosteroids are used and there are no comparative studies assessing the improvement rates, remission rates, tolerability and the side effect profiles of these treatment regimens. in addition, there are currently no reliable predictors of favorable treatment response to steroids, which would greatly ease the choice of first line treatment. in this retrospective study we will compare efficacy, tolerability and safety of three different corticosteroid regimens used as first line treatment in three large cidp centers in netherlands, serbia and italy. treatment naïve cidp patients who received either pulsed dexamethasone, pulsed methylprednisolone or daily prednisone will be included in the study. data will be extracted from patient charts. the primary outcome is the percentage of treatment responders at months after start of first treatment, in which treatment response is defined as subjects who improved after treatment and are either without treatment after six months or are still being treated with the first chosen therapy. secondary endpoints include the remission rates and in case of a relapse, the mean duration of remission to relapse; the discontinuation rate within months of treatment due to inefficacy, adverse events or intolerance; and the frequency of adverse events and serious adverse events (sae) during treatment or within month after stopping treatment. furthermore, we will explore the value of previously reported potential predictors of treatment response. results will be presented at the peripheral nerve society meeting . van lieverloo g , , musters a , adrichem m , esveldt r , doorenspleet m , klarenbeek p , van schaik i , de vries n , eftimov f . academic medical center, department of neurology, amsterdam, the netherlands; academic medical center/university of amsterdam, department of clinical rheumatology and immunology, amsterdam, the netherlands. following reports that pathogenic antibodies are present in a minority of patients with chronic demyelinating inflammatory neuropathy (cidp), we studied whether oligoclonal expansions of b-cell clones are present in patients with cidp. recently, we developed a new method for b-cell receptor (bcr) repertoire landscaping based on high throughput sequencing (hts) of rna extracted from blood. bcr repertoire was analyzed in patients with cidp: patients with active disease and starting treatment (group ), patients with stable disease using intravenous immunoglobulin (ivig) treatment in which treatment withdrawal was attempted (group ), and patients in remission (i.e. no treatment in the last months, group ). clinical parameters and sampling was performed at baseline (group , and ), at months after start of treatment (group ), at months or earlier in case of relapse in group and at baseline only in group . most cidp patients had highly expanded bcr clones, regardless of disease activity and response to treatment. however, in group , the most expanded b-cell clones at baseline showed no overlap with the expanded bcr clones after improvement. based on these preliminary data expanded bcr clones are observed in the peripheral blood of most cidp patients, regardless of disease activity (active, stable disease or remission/cure). functional characterization of these expanded clones remains to be performed. van rijs w , fokkink wjr , tio-gillen ap , brem md , jacobs bc , huizinga r . erasmus mc, university medical centre, rotterdam, the netherlands. myeloid cells, including monocytes, macrophages and dendritic cells, are critically involved in the induction of adaptive immune responses, clearance of pathogens and in the initiation of tissue repair. in the guillain-barré syndrome (gbs), macrophages are present in the peripheral nerve, where they phagocytose (damaged) myelin and axons. dendritic cells (dc) are increased in the cerebrospinal fluid of patients with gbs. however, the composition and phenotype of monocytes and dc subsets in the peripheral blood is unclear and it is unknown if these cells can be used as biomarker to monitor disease activity or response to treatment. here we investigated the frequency and phenotype of six myeloid subsets in the peripheral blood mononuclear cells (pbmc) using advanced -color flow cytometry. pbmc were isolated from patients with gbs, before and after immunomodulatory treatment, and age and gender-matched, healthy controls. the frequency of total monocytes, determined as percentage of cd + cells, was increased in gbs patients compared to controls (p< . ). the monocyte population was skewed towards more intermediate (cd +cd +; p< . ) and less non-classical (cd -cd +; p< . ) monocytes. classical (cd +cd -) and intermediate monocytes as well as cd c+ dc expressed significantly higher levels of cd compared to healthy controls. in contrast, the expression of cd and siglec- was significantly higher in the non-classical monocytes of gbs patients compared to controls. no differences were observed in the expression of cd , cd , cd and siglec- . immunomodulatory treatment strongly reduced the frequency of non-classical monocytes and all dc populations in cd + pbmc. the expression of cd , cd c and hla-dr was reduced in classical monocytes after treatment. in addition, siglec- expression was reduced in several monocyte and dc populations after treatment. in summary, our data identify significant changes in the monocyte compartment in gbs. the decrease in non-classical monocytes may suggest that these cells have migrated to peripheral tissues, promoting the differentiation of classical monocytes into intermediate monocytes. further analysis should reveal whether these changes are related to preceding infections, disease severity and response to treatment. in mme. the two mutations were absent from control databases (e.g. exac), affected highly conserved aminoacids and were predicted to have deleterious effects by in silico analysis. unfortunately, both parents were deceased and we were therefore unable to prove that the two mutations reside on separate alleles. mme encodes the metalloprotease neprilysin whose role in peripheral nervous system is still unclear. higuchi and colleagues have described japanese cmt families with late-onset sensory-motor axonal neuropathy and recessive loss-of-function mutations in mme. we report two novel missense mutations in mme in a case of late-onset cmt . we hypothesize an autosomal-recessive mode of inheritance as most likely given the clinical phenotype and the absence of a family history. anti-contactin- (cntn ) antibodies were recently identified in a subgroup of patients with chronic inflammatory demyelinating polyneuropathy (cidp) showing acute/subacute onset of severe sensory-motor neuropathy and poor response to intravenous immunoglobulin (ivig) and corticosteroids. these antibodies belong to the igg isotype and interact with cntn -neurofascin (nf ) complex at paranodes leading to loss of nodal integrity. a -year-old man presented with acute onset of distal weakness in the lower limbs, four limbs paraesthesias and sensory ataxia. at clinical examination ankle swelling was also observed. nerve conduction study showed a demyelinating polyneuropathy and cerebrospinal-fluid examination revealed cyto-albuminologic dissociation. sural nerve biopsy disclosed diffuse loss of myelinated fibres. at routine blood test serum albumin was reduced and proteinuria was gr/ hours, thus leading to the diagnosis of nephrotic syndrome. kidney biopsy showed changes consistent with membranous glomerulonephritis, together with sub-epithelial deposits of immune complexes and complement deposition. treatment with ivig and corticosteroids did not improve neurological status, while membranous glomerulonephritis showed moderate response to ivig. a six-month course of cyclophosphamide was started leading to normalization of renal function and muscle strength and partial improvement of sensory ataxia. the patient did not require any further treatment and after years his condition remains stable. cntn antibodies were tested on a recently collected patient's serum and resulted positive on both elisa and cell-based assay. the patient here reported showed the typical clinical features of anti cntn -associated cidp including older age, acute onset, severe motor impairment and sensory ataxia. the contemporary occurrence of membranous glomerulonephritis was reported in only one other case. contactin- is expressed at low levels in the kidney and a direct damage of anti-cntn antibodies could be hypothesized. alternatively, renal damage might have been secondary to unspecific immune complexes deposition. a good response to anti-cd rituximab was recently reported in patients with cidp associated with anti-cntn and anti-nf antibodies. notwithstanding this single-case observation, our report suggests that also cyclophosphamide may be considered an effective therapy in anti-cntn antibodies-associated cidp and membranous glomerulonephritis, leading to persistent clinical remission. velasco r , , besora s , santos c , sala r , izquierdo c , simó m , gil-gil m , , jiménez l , pardo b , calvo m , palmero r , clapés v , bruna j duloxetine is the only agent demonstrated effective in treating pain related with chemotherapy-induced peripheral neuropathy (cipn). patients with symptomatic cipn treated with duloxetine were retrospectively collected in a single-institution. aim of the study was to evaluate the drug's efficacy and rate of compliance. only patients with cipn with distressing positive symptoms (pain, numbness and/or paresthesia), and non-progressive disease were included. cipn was graded employing the total neuropathy score (tns © ) and national cancer institute-common toxicity criteria. response to duloxetine was assessed with patient global impression of change (pigc) scale ( : no benefit; : excellent response). consecutive first one-hundred cipn patients treated with duloxetine were analyzed. median age was ( - ). , , and received platinum, taxane, bortezomib and vincristine-based regimen, respectively. median tnsc © was ( - ). severity of neuropathy was grade ( %), grade ( %), and grade ( %). sixteen patients were on treatment with other analgesic agents. median time from finishing chemotherapy to duloxetine initiation was months [ - ]. median pigc score was [ - ]. among responders, . % and . % scored low ( - ) and high ( - ) benefit, respectively. fifty-seven ( %) patients discontinued early duloxetine due to intolerable side effects (n= ) the goal of this study was to determine whether predicted fork stalling and template switching (fostes) during mitosis deletes exon in peripheral myelin protein kd (pmp ) and causes a gain-of-function mutation associated with peripheral neuropathy in a family with charcot marie tooth disease type e. two siblings previously reported to have genomic re-arrangements predicted to involve exon of pmp were evaluated clinically and by electrophysiology. skin biopsies from the proband were studied by rt-pcr to determine the effects of the exon re-arrangements on exon mrna expression in myelinating schwann cells. transient transfection studies with wild type and mutant pmp were performed in cos and rt cells to determine the fate of the resultant mutant protein. both affected siblings had a length-dependent demyelinating neuropathy with severely slow nerve conduction velocities (< m/sec). rt-pcr studies of schwann cell rna from one of the siblings demonstrated a complete in frame deletion of pmp exon (pmp delta ). transfection studies demonstrated that pmp delta protein is retained within the endoplasmic reticulum and not transported to the plasma membrane. our results confirm that that fostes mediated genomic rearrangement produced a deletion of exon of pmp , resulting in expression of both pmp mrna and protein lacking this sequence. in addition, we provide direct experimental evidence for endoplasmic reticulum retention of the mutant protein suggesting a gain-of-function mutational mechanism consistent with the observed cmt e in this family. pmp delta is another example of a mutated myelin protein that is misfolded and thus likely to contribute to the pathogenesis of the neuropathy. in poems and cidp, distal limb nerve conduction studies are limited in identifying demyelination and detecting treatment effects in severely affected patients. blink reflex r latency may help to not only identify demyelination but also provide a meaningful treatment outcome measure especially in severely affected patients. poems and cidp patients having undergone routine nerve conductions and blink reflex testing were identified. correlation between r latency, limb nerve conduction studies and neuropathy impairment scores (nis) was calculated with treatment. blink reflexes were performed in patients ( poems, cidp; nis range: - points). overall, r latency prolongation occurred in . % of patients ( . % poems, . % cidp). patients with r prolongation (> ms) had more severely affected nerve conductions in both poems (ulnar cmap . mv vs . mv, p= . ) and cidp (ulnar cmap . mv vs . mv, p< . ). r latency correlated with nis severity in poems better than cidp (r = . vs . , p=< . vs. . ). follow-up nis and r latency evaluations after treatment were available in patients ( poems, cidp). the r latency changes were concordant with the nis changes in % of poems and % of cidp patients. in severely affected patients [ulnar cmap amplitude ≤ . mv ( . %: / )] except for one, all had prolonged r (> ms), allowing for treatment follow up and initial diagnosis. blink reflex r latencies are valuable in defining demyelination in severely affected poems and cidp patients, but also provide a sensitive, early treatment outcome measure among those same severely affected patients. watson dj , martinez c , wallenhorst c , hubsch a , shebl a , simon tl . csl behring llc, king of prussia, usa; institute for epidemiology, statistics and informatics gmbh, frankfurt, germany; csl behring ag, bern, switzerland; csl behring gmbh, marburg, germany. chronic inflammatory demyelinating polyneuropathy (cidp) rarely occurs in children. clinical trials in pediatric patients have not been performed and there are little data on therapy with intravenous immunoglobulin (ivig). we performed an observational trial to investigate the risk of adverse events of special interest (aesi) with ivig, i.e. hemolytic anemia, aseptic meningitis, acute renal failure, thromboembolic events and anaphylactic reactions. the study cohort was derived from the us premier perspective database and consisted of patients < years with a diagnosis of cidp (icd- cm diagnosis code . ) treated with the ivig privigen ® (csl behring, bern switzerland) between jan and dec . we identified pediatric cidp patients: preschool children (age - years at first treatment for cidp), children ( - years) and adolescents ( - years); females and males; white, one black and two allocated to "other race". six patients had a history of other ivig use for guillain-barré syndrome, one patient for myasthenia gravis and one for immunodeficiency before the diagnosis of cidp. the mean privigen ® dose calculated from the cumulative quantity of privigen ® per treatment episode and the corresponding age-and gender specific median of the us population body weight estimate was . g/kg body weight. the number of recorded treatment episodes per patient ranged from to . using an at-risk period of days for hemolytic anemia, and days for other aesi after each privigen ® administration, no aesi were observed in the patients with cidp with a total of person-days at-risk for ha and person-days at-risk for other aesi. this observational study shows that ivig (privigen ® ) is used for treatment of cidp in pediatric patients with or without concomitant conditions and revealed no particular safety issues in this patient group. hsn- is a peripheral neuropathy most frequently caused by missense mutations in the sptlc or sptlc genes, which code for two subunits of the enzyme serine palmitoyltransferase (spt). spt catalyzes the first and rate limiting step of de novo sphingolipid synthesis. it has been shown that mutations in spt cause a change in enzyme substrate specificity which results in the production of two atypical sphinganines, deoxysphinganine (dsp) and deoxymethylsphinganine (dmsp), rather than the normal enzyme product, sphinganine (sp). levels of deoxysphingolipids are elevated in the blood of hsn- patients and this has been shown to cause the peripheral nerve damage characteristic of the disease, which affects both sensory as well as motor axons. however, the underlying pathomechanism of how deoxysphingolipids damage neurons remains elusive. here, dsp and dmsp-mediated neurotoxicity was examined in primary mouse motor and sensory neurons, by assessing cell survival and neurite outgrowth following exposure to different concentrations of sp, dsp or dmsp. the abnormal enzyme products were found to have a rapid and dose-dependent neurotoxic effect in primary neurons. we also explored the potential mechanisms that underlie deoxysphingolipid neurotoxicity, by characterizing mitochondrial function and changes in calcium handling. we found that mitochondrial dysfunction and calcium handling deficits may be key mediators of abnormal sphingolipid neurotoxicity, in both motor and sensory cell models. specifically, we revealed mitochondrial abnormalities, signs of endoplasmic reticulum stress and dysfunction of store-operated calcium channels. we propose that early deficits in mitochondria and calcium handling may underlie deoxysphingolipid neurotoxicity and thus present potential therapeutic targets for hsn- . months. one patient was excluded because the decrease in hba c was not contemporaneous with weight loss. the mean and median decrease in bmi per month was . and . respectively. the mean and median interval between surgery and decrease in hba c was . and . days respectively. records of these patients were scrutinized and classified as: 'probable tind': acute painful neuropathy and acute dysautonomia with temporal relationship to the decrease in hba c; 'possible tind': acute painful neuropathy or acute dysautonomia or temporal relationship to decrease in hba c is uncertain; 'unlikely tind': when an alternative explanation exists for symptoms. only one patient was classified as 'possible tind': a -year-old woman who developed neuropathic pain in both lower limbs month after a rapid hba c decline of . % and about months after bariatric surgery. she had no documented autonomic symptoms. our study is limited by small cohort size, retrospective design and reliance on hospital records. nonetheless, it demonstrates that besides nutritional neuropathies, tind should also be considered in dm patients who develop peripheral neuropathy after bariatric surgery. in another study, we found tind is uncommon in a general cohort of diabetic patients. the occurrence of 'possible tind' in only dm patients corroborates earlier data that weight loss may act in tandem to increase the risk of tind. woolums bm , tabuchi m , sung h , sullivan jm , mamah c , yang m , blum id , wu mn , sumner cj , lloyd te . johns hopkins university, baltimore, usa. dominant missense mutations in the gene encoding the cation channel transient receptor vanilloid, family member (trpv ) cause inherited neuropathies including charcot-marie-tooth disease c (cmt c). in vitro, mutations in trpv that cause cmt c cause a gain of trpv channel function and increased intracellular calcium which subsequently leads to cellular toxicity. however, the mechanisms by which cmt c mutations in trpv lead to neuronal dysfunction in vivo remain poorly understood. we generated transgenic drosophila that express either wild-type or a cmt c causing trpv mutant (trpv r c ) to assess the effect of trpv r c on neuron function in vivo. selective expression of trpv r c in drosophila ccap neurons (n ccap ) results in a failure of drosophila wing expansion that is blocked by genetically inactivating the channel pore, demonstrating the requirement of channel function in mediating this phenotype. perforated patch clamp analysis of n ccap reveals that trpv r c causes a calcium-dependent increase in n ccap neuronal excitability. this hyperexcitability is restored to control levels by application of a trpv selective antagonist. high level expression of trpv r c causes synaptic and dendritic degeneration, both of which are rescued genetically by inactivating the channel pore or pharmacologically by feeding larvae a trpv selective antagonist. we conducted a genetic screen in n ccap and found that camkii knockdown potently suppresses the trpv r c mediated wing expansion phenotype and selectively rescues degeneration of synapses but not dendrites. we also find that trpv r c , but not controls, disrupts mitochondrial transport in axons by increasing the number of stationary mitochondria. our data demonstrate that trpv r c elevates neuronal intracellular calcium which disrupts mitochondrial transport and mediates neurodegeneration through compartment-specific calcium-mediated signaling pathways, and supports the further investigation of trpv antagonists as potential therapeutics for the treatment of cmt c. mood disorders, including anxiety and depression, are commonly observed among chronic pain patients with prevalence estimates ranging from to %. comorbidity between mood and chronic pain disorders has been linked to altered limbic regulation of the hypothalamic-pituitary-adrenal (hpa) axis. stress activates the hpa axis and can initiate and/or exacerbate symptoms related to both chronic pain and mood disorders. previous studies from our laboratory have investigated the influence of early life stress on mechanical pain hypersensitivity, visceral hypersensitivity and behavioral evidence of mood disorder later in life. here, we are testing the hypothesis that chronic stress exposure in adulthood can increase somatic and visceral sensitivity and anhedonic behaviors in a mouse strain with a genetic predisposition to anxiety. adult, female a/j mice were exposed to repeated foot shock stress for continuous days and tested for alterations in mechanical sensitivity, sucrose preference, visceromotor response (vmr) during urinary bladder distension, and serum corticosterone levels. mice that underwent shock stress had a significantly decreased mechanical withdrawal threshold in the hind paw compared to their baseline and sham group measurements. sucrose preference was measured prior to shock exposure and throughout the shock paradigm as an indicator of anhedonic behavior. mice that underwent shock stress displayed a trend toward decreased sucrose preference, indicating anhedonia, in comparison to mice in the sham group that did not display anhedonia. mice that underwent shock stress displayed significant increases in vmr during bladder distension compared to sham mice. finally, serum corticosterone levels were significantly higher in the mice that underwent shock stress compared to sham mice, indicating a stress-induced increase in hpa axis output. together these data suggest that chronic stress exposure can induce mechanical allodynia, visceral hypersensitivity, and depression-like behaviors in an anxiety-prone mouse strain. future studies will incorporate gene expression in the hypothalamus, amygdala, and hippocampus, as well as investigation of possible downstream peripheral neuroimmune modulation and neuronal morphology changes. guillain-barré syndrome (gbs) is an acute monophasic immune-mediated neuropathy. as prognostic markers of gbs, modified erasmus gbs outcome score (megos), erasmus gbs respiratory insufficiency score (egris), and Δigg have been reported. however, the proportions of subtypes of gbs are known to be different between the western countries and japan, it remains to be elucidated whether those markers can also be applied to gbs in japan or not. we here investigated retrospectively gbs patients and determined the megos and the egris of those cases. among them, Δigg could be obtained in cases. we evaluated the prognosis using gbs outcome score (functional grade: fg) at months; we called good prognosis when fg at months was less than and poor prognosis when that was or more. as a result, in cases with higher score than at megos on admission cases ( %) had poor prognosis and in cases with higher score than at megos at day of admission cases had poor prognosis. in cases with higher score than on egris cases ( %) needed the mechanical ventilator. patients with good prognosis had higher Δigg(average: mg/dl) than patients with poor prognosis(average: mg/dl). we calculated the cut-off value of Δigg in patients, which was mg/dl. patients with higher Δigg than mg/dl could significantly walk independently at six months (p< . ). patients ( %) had poor prognosis in patients with lower Δigg than mg/dl. ( %) of patients were treated with the single cycle of intravenous immunoglobulin (ivig). other patients ( %) were treated with the combined therapies, such as intra venous methylprednisolone and/or plasmapheresis or the second cycle of ivig in addition to ivig. although there was no difference in prognosis between patients with the single cycle of intravenous immunoglobulin (ivig) and patients with the combined therapies, in the patients who had fg> and megos > on admission, the combined therapies made better prognosis than the single course of ivig (p< . ). we found that megos, egris and Δigg were also available in japan. the efficacy of the combined therapies in severe gbs patients should be investigated in the future large scale prospective studies. yiu em , , , burns j , , , menezes mp , , ryan mm , , and for the paediatric cmt best practice guidelines consortium. royal children's hospital melbourne, melbourne, victoria, australia; murdoch childrens research institute, melbourne, victoria, australia; university of melbourne, melbourne, victoria, australia; university of sydney, new south wales, australia; sydney children's hospitals network (randwick and westmead), new south wales, australia. charcot-marie-tooth disease (cmt) often presents during childhood. common symptoms include weakness, limb pain and cramps, foot deformity, and balance impairment. guidelines for the optimal management of common problems experienced by children with cmt do not currently exist. development of these guidelines will provide an evidence base for the management and monitoring of children with cmt. a series of systematic literature reviews utilising the grade (grades of recommendation, assessment, development, and evaluation) approach were conducted to answer pre-specified key clinical questions related to the management of paediatric cmt. these included treatment recommendations for symptoms such as weakness, pain, balance impairment, joint deformity, and impaired upper limb function, and anticipatory monitoring for associated complications such as hip dysplasia. this yielded minimal to no evidence for the pre-specified clinical questions, and evidence-based management recommendations could not be made. consensus-based statements will therefore be formulated via a three-round delphi process, to be conducted in . the delphi panel will consist of local and international medical and allied health professionals who have experience in the management of children with cmt. efficacy of pxt in the treatment of adult patients cmt a (n= ) was shown in a multicenter, randomized, double-blind, placebo-controlled phase ii study (attarian et al. ) . pxt taken x/day, orally, for consecutive months was well tolerated and safe. significant improvement of disability was observed for the highest tested dose, thought indicative for an early, meaningful change in disease course (meta-analysis by mandel et al., ) . this formed the rationale to initiate a multicenter, randomized, double-blind, placebo-controlled pivotal phase iii study (clin-icaltrials.gov: nct ) of pxt in mildly to moderately affected cmt a patients in december . the primary objective is to assess the efficacy of doses of pxt compared to placebo on disability as measured by the mean change from baseline overall neurology limitations scale (onls) score at month and . furthermore, efficacy on the proportion of responders (i.e. improvement of onls), impairment (cmtns-v ), functional tests ( -mwt, qmt, -hpt), electrophysiological parameters (cmap, snap and ncv) and quality of life (eq- d, vas) are secondary endpoints. pursuant this study, patients will be eligible for a -month extension study, in which pxt assigned patients will continue with the previously assigned dose, whereas placebo patients will be randomized to one of the two pxt doses. the study is conducted in investigational sites in countries (eu, canada and us). in december patient randomization was completed (n= ). the screen failure rate was %, as expected ( patients were screened). the independent dsmb recommended to continue the study as planned following a safety analysis on the first patients treated for > months. preliminary baseline characteristics are based on patients (data not cleaned). the study population had a mean age of . ± . years (range - ; male . %) of which . % had a confirmed genetic diagnosis of cmt a. the mean cmtns-v was . ± . and the mean motor nerve conduction of the ulnar nerve was . ± . m/s. ten patients withdrew from the study, due to adverse events unrelated to study treatment. the last patient completing the study is expected in march . zhang g , ghosh p , lin j , ghauri a , sheikh ka . department of neurology, university of texas health science center at houston, houston, tx, usa. assessment of epidermal nerve fiber density and its structure integrity is critical for the diagnosis and evaluating the effectiveness of potential therapies in small fiber neuropathies. currently, skin biopsies, at multiple sites, are most commonly used to assess these diseases. these studies are expensive and time consuming due to cumbersome processing and quantification techniques and serial biopsies over time are often not feasible due to costs and patient acceptance. moreover, vast majority of normative data for skin biopsies in humans are available only for few distal sites and a significant proportion of patients with small fiber neuropathies have focal or regional symptoms not involving the commonly biopsied sites in the leg. live imaging could overcome these limitations and provide a noninvasive real time assessment of epidermal nerve fibers all over the body. we previously found that anti-ganglioside antibody (aga) is an effective neuronal delivery vector for transport of various cargos, such as fluorescent dyes, to peripheral nerves. in the current proof of concept study, we examined whether non-invasive multiphoton microscopy can be used to probe/image the epidermal nerve fibers in living animals after systemic and/or local delivery of fluorescently conjugated aga. we found that the individual nerve endings in skin and cornea are distinctly labeled, and visualized under two-photon microscope. the epidermal nerve fiber labelling by fluorescent-tagged aga was further validated using transgenic mice selectively expressing yellow fluorescent protein in their nervous system. in-vivo multiphoton imaging provide a tool with potential for dynamic longitudinal evaluation of small fiber neuropathies, including nerve degeneration and regeneration, without tissue removal. thus, the use of multiphoton microscopy in conjunction with fluorescently labeled aga as neuronal vector can have many research and clinical applications, such as labeling and live visualization of epidermal nerve fibers to assess small sensory nerve fibers in health and disease. zhou y , tavori h , lee s , al salihi m , fazio s , notterpek l . mcknight brain institute, university of florida, gainesville, florida, usa; knight cardiovascular institute, oregon health and science university, portland, oregon, usa. the majority of hereditary neuropathies are due to abnormalities in peripheral myelin protein (pmp ), whose genetic variants include increased expression (gene duplication), haploinsufficiency (gene deletion), or point mutations. phenotypic heterogeneity in clinical presentation is common among hereditary neuropathy patients even within the same family, the cause of which has not been determined. to investigate the role of pmp in the pathogenesis of the neuropathies we have generated and characterized pmp null (pmp −/− ) mice (amici et al., ) whose peripheral nerves show alterations in lipid metabolism (lee et al., ) . to examine the molecular changes underlying these abnormalities we determined the expression of cholesterol synthesis (srebp pathway), and cholesterol uptake, transport and efflux genes (lxr pathway). in affected nerves, we found the cholesterol synthesis pathway inhibited, while the lxr pathway, and particularly apoe and abca , upregulated at the mrna and protein levels. since pmp is expressed at low levels in the liver, the central organ for the regulation of cholesterol in the body, we studied liver tissue form pmp −/− mice. liver from pmp −/− mice showed significant hepatomegaly, clear features of microvesicular steatosis, as well as marked increase in lxr pathway genes and proteins (abca and apoe), as compared to wt. ultrastructural studies identified lipid droplets and significantly enlarged mitochondria in the liver of male pmp −/− mice, which is not due to mitochondria fusion, as the levels of mfn and remained similar to wt. as disturbed hepatic cholesterol homeostasis induces the activation of kupffer and stellate cells, we determined the extent of inflammation in nerve and liver tissues from pmp −/− mice with leukocyte (cd b) and macrophage markers (cd ). in nerve sections, we detected an increase in the number of cd b+ cells, which was confirmed by western blots. in the liver of pmp −/− mice we found a significant increase in cd -reactive kupffer cells and elevated levels of tnf-alpha. the severe dysregulation of cholesterol metabolism in nerve and liver, including neuroand hepatic inflammation in the absence of pmp − suggest that dysregulated cholesterol metabolism and inflammation may act as a disease modifier in pmp -dependent neuropathies. our aim was to ascertain frequency of and risk factors for tee, arterial (ate) and venous thromboembolic events (vte) in neuromuscular patients receiving regular ivig. we performed a retrospective case-note review of inflammatory neuropathy patients receiving regular ivig treatment. we collected the following data over a month study period this analysis suggests tee incidence is higher in ivig treated patients than comparable population-based rates. examination of tee occurrence in age and vascular risk factor matched ivig-treated and ivig-naïve individuals is required to appreciate the excess risk associated with ivig treatment. référence des maladies neuromusculaires et la sla, hôpital de la timone ha) and whether temporal dispersion (td) parameters are helpful. fifty-eight patients diagnosed according to asbury and cornblath ( ) were prospectively included between january and september . edx and were performed - (mean= ) and - days (mean= ) after disease onset, respectively. there were no differences in classification consistency between ho and ha at edx (p= . ) and edx (p= . ), but more patients were classified as aman when comparing ra with ho and ha at edx (p< . ). at edx , ra classified more patients as equivocal with ho (p< . ) and as aman with ha (p< . ) ) or edx (ho, fe p= ; ra, fe p= . ; ra with td, fe p= . ). gm , gd a, gd b and gq b igg antibodies were tested (willison at edx , only ho showed maybe more antibodies with aman compared to aidp (fe p= . , phi=− . ) and with aman compared to equivocal cases since correlation with factors associated with axonal gbs, in casu rcf and antibodies, is far from exclusive, the usefulness of edx subtype classification using specific criteria sets, remains doubtful. the frequency of rcf indicates that nodal/paranodal alterations may represent the main pathophysiology in more gbs patients than currently thought ruiz m , lessi f , cacciavillani m , riva m , salvalaggio a , campagnolo m , briani c . neurology, department of neuroscience, university of padua, padua, italy; hematology and clinical immunology unit, department of medicine, university of padua, padua, italy; cemes, data medica group, padua, italy.arsenic trioxide (ato) is highly effective in treatment of acute promyelocytic leukemia (apl). it is licensed in italy for treatment of relapsed-refractory apl and for first line chemotherapy in low risk patients. ato most frequent side effects are well described, but less is known on ato induced. we describe apl patients who were treated with all-trans retinoic acid (atra)/ato as first line therapy. the characteristics of ato induced neuropathy was prospectically analyzed by neurological evaluation using both the total neuropathy score, clinical version (tnsc) (a validated scale for chemotherapy induced peripheral neuropathy) and neurophysiological assessment. patients have been evaluated at baseline, at the end of the induction phase, at the end of ato/atra treatment and year after discontinuation of treatment. baseline neurophysiology was performed at the end of induction phase. both patients were men, respectively and -yr-old. none of the patients had previous history of neuropathy. baseline tnsc was (no clinical signs of neuropathy) in both patients. neurophysiological evaluation performed after the end of induction cycle did not reveal signs of peripheral neuropathy in both patients. patient received mg of ato during induction, total , mg. patient received mg of ato during induction, total , . both patients developed leg numbness during consolidation cycles and patient also hand numbness. tnsc at the end of therapy was in patient and in patient . neurophysiology at the end of therapy detected signs of sensitive axonal neuropathy in both patients. they received full doses of ato consolidation ( . mg/kg/day for days/week, on alternate months for total months and tretinoin weeks on weeks off). during the first year of follow-up both tnsc and neurophysiology year after the end of consolidation cycle were consistent with full recovery. our patients developed sensory axonal neuropathy during ato therapy, that clinically manifested during consolidation cycles and improved up to complete recovery during follow-up. published case reports show that outcomes may not be as good as in our patients. a multicenter prospective study evaluating the characteristics of ato-induced neuropathy in apl is ongoing. ruiz m , campagnolo m , salvalaggio a , cacciavillani m , taioli f , fabrizi gm , briani c . department of neuroscience, neurology unit, university of padua, padua, italy; data medica group, emg unit, cemes, padua, italy;mutations in the mitochondrial copper-binding protein sco , cytochrome c oxidase assembly protein, have been reported in several cases of fatal infantile cardioencephalomyopathy with cox deficiency. we identified compound heterozygous variants in sco in two unrelated patients with isolated length dependent axonal sensorimotor polyneuropathy of variable clinical severity (axonal autosomal recessive charcot-marie-tooth disease type , cmt ) by whole exome sequencing. although peripheral neuropathy has been described as a secondary feature in a few cases of fatal infantile cardioencephalomyopathy, the disease onset, clinical phenotype and survival in our patients differ significantly from the previously described cases. our patients developed predominantly motor neuropathy; moreover, they are still alive and they have not developed cardiomyopathy, which is the main phenotype and cause of death at early infancy in reported patients. both of our patients harbor mutations adjacent or near the conserved copper-binding motif (cxxxc), including the common reported pathogenic variant e k and the novel change d g. in addition, each patient carries a second mutation located in the same loop region of the protein, p t and r q. western blots from fibroblasts from these cmt patients showed reduced levels of cox , a subunit of complex iv, indicating cox deficiency. our findings demonstrate that cmt can be the predominant phenotype associated with sco mutations, pointing to a broader phenotypic heterogeneity. the mechanism linking mitochondrial respiratory chain dysfunction to isolated axonal loss of variable severity remains to be elucidated. the muscarinic acetylcholine (ach) type receptor (m r) is a metabotropic g protein-coupled receptor expressed by adult sensory neurons. cholinergic signaling through muscarinic receptors can modulate axonal plasticity in invertebrates and lower vertebrates. we have recently shown that selective (pirenzepine) and specific (muscarinic toxin : mt ) m r antagonists elevate neurite outgrowth and protect from small and large fiber neuropathy in adult sensory neurons in various animal models (calcutt, et al., ) . furthermore, we demonstrated that excessive cholinergic signaling due to m r overexpression caused a significant reduction in neurite outgrowth (calcutt, et al., ) . the mechanism of m r-antagonist driven neurite outgrowth remains poorly understood, however, we have proposed that ach constrains axonal outgrowth via m r activation. cholinergic signaling is mediated via recruitment of trimeric g proteins, of which g alpha- and g alpha- regulate cytoskeleton dynamics by control of tubulin polymerization. activated gtp-bound g-alpha proteins destabilize microtubules by increasing the intrinsic gtpase activity of tubulin. we have therefore tested the hypothesis that cholinergic signaling regulates neurite outgrowth via modulation of g protein mobilization and the dynamics of the tubulin cytoskeleton. we found that over-expression of m r in adult sensory neurons induced dissolution of the tubulin cytoskeleton in distal neurites. g alpha- expression in adult sensory neurons was significantly higher (p< . , -fold) than g alpha- . subsequent knockdown the peripheral neuropathy research registry (pnrr) is a multicenter collaborative research project sponsored by the foundation for peripheral neuropathy to advance the science in distal symmetrical polyneuropathies (dsp). the registry was designed to prospectively characterize clinical phenotype and natural history of patients with dsp and obtain biofluids to identify new causes and genetic modifiers of dsp with careful genotype/phenotype correlations, and to develop biomarkers. the enrollment in the registry is still ongoing but an interim analysis was carried at the end of december . eligible study participants were years or older with a diagnosis of idiopathic, diabetic, chemotherapy-or hiv-induced peripheral neuropathy. they were examined by a physician at one of the six consortium members (johns hopkins university school of medicine, icahn school of medicine at mount sinai medical center, beth israel deaconess medical center, northwestern university medical center, university of utah medical center and kansas university medical center). the collected data set included ( ) a detailed questionnaire, discussing their symptoms, medical history and family history, ( ) a standardized neurological examination form, ( ) electrodiagnostic evaluation and ( ) diagnostic laboratory testing. blood samples (whole blood, plasma and serum) were collected for future biomarker and genotyping evaluations. at the end of , complete data sets and blood samples were collected from patients. % had diabetic pn, % had hiv-associated pn, % had chemotherapy induced pn and % were diagnosed with idiopathic pn. detailed analysis of clinical presentation, examination findings and diagnostic investigations will be discussed at the presentation. standardized phenotyping with linked bio-specimen banking will help establish the minimum data set required for neuropathy diagnosis and support genotype-phenotype correlations with next generation sequencing technologies and development of novel biomarkers. pnrr data will improve our understanding of disease mechanisms paving the way for new therapeutic discoveries in painful and non-painful neuropathies. chemotherapy-induced peripheral neuropathy (cipn) is a major side effect of treatment, typically presenting as a sensory neuropathy. symptoms include pain, paraesthesia, and numbness in the extremities, resulting in functional impairment. increasingly, patient reported outcomes (pros) are utilized to accurately examine the impact of cipn symptoms on patient function. however, the links between objective neurological assessment and pro measures remain ill defined. this study aimed to identify links between neurophysiological measures and pros in patients treated with neurotoxic chemotherapy. assessments were conducted in patients (f= , mean age . ± . years) who had completed neurotoxic chemotherapy on average . ± months previously (platinum-based n= , taxane-based n= or taxane/platinum combination therapy n= ). patients reported the presence and severity of neuropathic symptoms via the fact-gog ntx , a validated patient questionnaire. clinical the most important neurological side effect of a large number of anti-cancer drugs is a painful peripheral neuropathy. mainly chemotherapeutics that interfere with microtubules, including the plant derived vinca-alkaloids such as vincristine, are well known to cause chemotherapy-induced peripheral neuropathies (cipn). to date, few treatments are available and focus on symptom alleviation and pain reduction rather than on preventing the neuropathy all together. for the first time, we highlight the potential of specific histone deacetylase (hdac ) inhibitors as a preventive therapy for cipn, using novel rodent models for vincristine-induced peripheral neuropathies (vipn), characterized by a sensory axonopathy. one reason so few therapies are available, is because the exact pathophysiological mechanisms are poorly understood. mounting evidence proposes axonal transport, a pathway frequently disturbed in neurological disorders, as a major player in the pathophysiology of vipn. proper axonal transport requires dynamic microtubules which are highly modulated by post-translational modifications. since vincristine interferes with the polymerization of microtubules, we reason disturbances in microtubule dynamics, and by extension axonal transport, could contribute to vipn. we illustrate that increasing acetylation of -tubulin after hdac -inhibition, can restore vincristine-induced defects in axonal transport in cultured dorsal root ganglion neurons. also in vivo, -tubulin acetylation was restored in the saphenous nerve and dorsal root ganglia, two sensory tissues that are affected by vincristine. ultimately, this correlates to a reduced severity of the neurological symptoms, both on the electrophysiological and on the behavioral level. moreover, we discovered that hdac -inhibition was not only protective against neurotoxicity, but also reduced tumor progression in a mouse model for acute lymphoblastic leukemia. taken together, our results show that hdac -inhibition is an ideal strategy to prevent vipn with beneficial effects both on the neurotoxicity as well as on tumor growth.approximately two-thirds of cidp subjects need long-term corticosteroids or intravenous immunoglobulins (ivig), with ivig being slightly preferred based on safety profiles. subcutaneous ig (scig) is an alternative option for ig delivery but has not previously been investigated in a large-scale clinical trial in cidp.we performed a randomized, double-blind trial in cidp investigating . and . g/kg weekly doses of scig igpro (hizentra ® , csl behring) versus placebo in subjects for maintenance treatment. ivig-dependent adults with definite or probable cidp according to efns/pns criteria were eligible. the primary outcome was the percentage of subjects with a cidp relapse ( -point deterioration on adjusted incat disability score) or who were withdrawn for any other reason during the -week scig-treatment period. multiple secondary endpoints were assessed. superiority of at least one igpro dose over placebo was tested one-sided using the cochran-armitage trend test for the primary outcome and the jonckheere-terpstra tests for secondary outcomes.the primary outcome occurred in % of high-dose scig, % of low-dose scig, and % of placebo subjects (p < . ); cidp relapse occurred in % of high-dose scig, % of low-dose scig and % of placebo subjects (p < . ), respectively. both scig doses were superior to placebo (low-dose vs placebo p = . ; high dose vs placebo p < . ). median incat score, mrc sum score, and grip strength remained stable in scig subjects. high-dose scig prevented the r-ods decline seen with low-dose scig and placebo (p < . ). all placebo subjects deteriorated on measures of strength and disability.causally related adverse events occurred in ( %) subjects ( % placebo, % low dose, and % high dose).scig igpro was efficacious and safe as maintenance treatment. mutations in metalloendopeptidase (mme) gene have been associated with autosomal-recessive late-onset charcot-marie-tooth type- (cmt ). to date, all patients have had at least one truncating mutation, either in homozygosity or in trans with a missense mutation. more recently, loss-of-function and missense heterozygous mutations were also identified in autosomal-dominant cmt. we report the case of a previously healthy caucasian woman, born to healthy unrelated parents, who presented at the age of thirty-nine with numbness and cold sensation in the lower limbs. subsequently she developed progressive gait disturbance and impaired hand dexterity. her homozygous twin presented at the same age with similar symptoms. the family history was otherwise uneventful, in particular neither neuropathy nor dementia were described. neurological examination at the age of fifty-three revealed a steppage gait, distal upper and lower limb atrophy and weakness, distal sensory loss and bilateral pes cavus. deep tendon reflexes were normal in the upper limbs and absent in the lower limbs. nerve conduction studies revealed an axonal sensory and motor neuropathy. a sural nerve biopsy revealed a reduction in myelinated nerve fibers and active axonal degeneration. targeted sanger sequencing of mpz , gjb , gdap , nefl, fkrp, bscl , hspb and mfn were negative. sureselect focused exome sequencing was therefore performed and identified two missense heterozygous mutations [c. g>a,p.c y;c. t>c,p.y h] or lack of efficacy (n= ). most frequently reported adverse events were cognitive ( %), gastrointestinal ( %) and genitourinary ( %). discontinuation due to perception of lack of efficacy was more frequently reported by men ( % vs % p= . ). women presented higher punctuations on pigc scale compared with men ( . ± . vs . ± . , p= . ). pigc scores were significantly higher in patients receiving taxane ( . ± . ) than platinum ( . ± . ) agents (p= . ). no significant differences according severity of neuropathy neither type of chemotherapy were observed in drop-out and retention rates. patients with long-lasting cipn (> months) reported lower pigc scores ( . ± . vs . ± . , p= . ) and higher frequency of suspension due to adverse events ( % vs %, p= . ) and less rate of continuation of duloxetine ( % vs %, p= . ). more than one-third of patients with disturbing cipn discontinued duloxetine prematurely due to intolerable side-effects. low tolerability, male gender and long-lasting cipn may limit duloxetine usefulness in the treatment of symptomatic cipn. verboon c , jacobs bc , and the igos consortium. department of neurology, erasmus medical centre, rotterdam, the netherlands; department of immunology, erasmus medical centre, rotterdam, the netherlands.the efficacy of intravenous immunoglobulin (ivig) in guillain-barré syndrome (gbs) has only been demonstrated in severely affected patients who are unable to walk independently. although there is no proof that ivig is effective in milder forms of gbs, some neurologists are treating these patients with ivig considering that even milder forms of gbs may result in poor recovery, residual deficits, fatigue or pain.we determined the effectiveness of a single course of ivig ( g/kg in - days) in relatively mild forms of gbs in the ongoing observational international gbs outcome study (igos). the gbs disability score, mrc sum score and patient reported outcome measures (prom) were compared at and weeks. ordinal logistic regression analysis was used to determine the effect of ivig on the gbs disability score, adjusted for previously identified prognostic factors.data were analyzed from the first patients enrolled in igos by december , including patients with mild gbs at entry, of which patients ( %) were treated with supportive care, while patients ( %) received ivig (start ivig after onset of symptoms in days, median , iqr - ). at baseline, patients in the ivig treated group compared to the untreated group less frequently had pure motor gbs ( % versus %, p< . ) and axonal damage or unresponsive nerves ( % versus %, p= . ), but a worse gbs disability scores at nadir (p= . ). the adjusted common odds ratio for a better gbs disability score at weeks was . ( % ci . - . ). at weeks, the median mrc sum scores and prom were not significantly different between treated and untreated patients. however, more patients in the ivig group showed complete recovery of muscle strength at weeks than patients in the control group ( % versus %) (p= . ) and more frequently showed full neurological recovery on the gbs disability scale ( % versus %, p= . ). additional results will be presented at the conference.based on the results of this interim analysis in observational data, we conclude that patients with a relatively mild form of gbs may benefit from a single course of ivig. despite treatment with intravenous immunoglobulin (ivig), many patients with guillain-barré syndrome (gbs) recover insufficiently. we primarily aimed to determine whether a second ivig course ( g/kg in - days) in patients with a poor prognosis improves outcome on the gbs disability scale after weeks. we included patients from the prospective, observational international gbs outcome study (igos) treated with ivig and who had a poor prognosis on the modified erasmus gbs outcome score (megos). of patients enrolled in igos, patients were eligible; patients ( %) were treated with one ivig course (control group); patients ( %) received an 'early' second ivig course ( - weeks after start first course) and patients ( %) a 'late' second ivig course (within - weeks). one week after study entry, patients receiving an 'early' or 'late' second ivig course had significantly worse gbs disability scores and mrc sum scores than controls, implying the need for adjustment of baseline characteristics. the adjusted common odds ratio for a better gbs disability score at weeks was . ( % ci . - . ) for the 'early' group, and . ( % ci . - . ) for the 'late' group, suggesting worse outcomes with a second course of ivig compared to controls. at months, patients ( %) in the 'early' second ivig group, patients ( %) in the control group and only ( %) in the 'late' second ivig group were able to walk unaided (p= . ). the adjusted common odds ratio for a better gbs disability score at weeks was . ( % ci . - . ) for the 'early' second ivig group and only . ( % ci . - . ) for the 'late' second ivig group. in gbs patients with a poor prognosis, we did not find a beneficial effect of a second course of ivig after weeks follow-up. our results suggest that an 'early' administered second ivig course might improve outcome at weeks. given the limitations of this observational study, a randomized controlled trial with a larger number of gbs patients with a poor prognosis being treated early in the disease course is needed to confirm or refute these results. vidal c , bhatt n , agudelo c , mahapatra a , saporta ma . department of neurology, university of miami miller school of medicine, miami, usa.multifocal motor neuropathy (mmn) is an inflammatory demyelinating chronic neuropathy characterized by progressive asymmetric weakness in the distribution of two or more peripheral nerves, without objective sensory loss or upper motor neuron signs. the cardinal neurophysiological finding is conduction block outside the usual sites of nerve compression. supportive clinical criteria include high titers of anti-gm antibodies, good response to ivig, increased cerebrospinal fluid (csf) protein (< g/dl) and magnetic resonance imaging (mri) with diffuse swelling of the brachial plexus. we report a case of a year old woman with a two month history of progressive muscular weakness which began in the right upper extremity, described as difficulty in gripping objects, writing and typing on the computer, followed by progressive lower extremity weakness with difficulty rising from a chair and left foot drop. she also complained of pain in her right trapezius and scapular area. she denied any tingling or numbness. on neurological examination there was right scapular winging and asymmetric weakness predominantly involving the right upper and left lower extremities. reflexes were absent throughout. lumbar puncture revealed albuminocytological dissociation (wbc and protein . g/dl). ncs revealed slow conduction velocities for both ulnar and median nerves and a median nerve conduction block at the forearm segment. sensory nerve action potentials were normal for all tested nerves. needle emg revealed acute denervation of right periscapular muscles. brachial plexus mri showed symmetric bilateral thickening from trunks to peripheral nerves. anti-gm igg/igm were negative. two days after lumbar puncture and the beginning of ivig, patient presented binocular diplopia on extreme left lateral gaze. brain mri with and without contrast showed no intracranial pathologies. after five days of ivig, patient was discharged with significant clinical improvement and recovery of the right scapular winging. diplopia improved a week after discharge. we report an atypical multifocal motor neuropathy case. although this patient fulfills all clinical criteria for mmn, we report some features usually not found in mmn such as scapular winging and a mild and transient left vi nerve palsy. mmn should be included in the differential diagnosis of scapular winging. vlckova e , , raputova j , , srotova i , , sommer c , Üçeyler n , birklein f , rebhorn c , rittner hl , kovalova e , , nekvapilova e , , belobradkova j , olsovsky j , weber p , dusek l , jarkovsky j , bednarik j , . despite many studies addressing biomarkers for pain in diabetic polyneuropathy (dpn), little is known about why it affects only a certain proportion of dpn patients. the somatosensory system plays a key role in the pathophysiology of neuropathic pain (neup) and subgroups with different sensory profiles might respond differently to pain treatment. we aimed to characterize sensory phenotypes of patients with painful and painless diabetic neuropathy and to assess demographic, clinical, metabolic, electrophysiological and psychological parameters related to the presence of neup in a large cohort of well-defined dpn subjects.this observational cross-sectional multi-centre cohort study (performed as part of the ncrnapain eu consortium) of subjects with dpn (non-painful, ndpn, n= ; painful, pdpn n= ) associated with diabetes mellitus of type and (median age years, range - years; women) comprised detailed history taking, neurological examination, laboratory tests, quantitative sensory testing, nerve conduction studies, neuropathy severity scores, and neuropsychological questionnaires. all parameters were analysed with regard to the presence and severity of neup. the presence and severity of neup were positively correlated with severity of neuropathy and thermal hyposensitivity (p< . ). a minority of pdpn patients ( . %) had a sensory profile indicating thermal hypersensitivity; this was associated with less severe neuropathy and better response to pain therapy. the presence of neup was also associated with female gender (p< . ) and with higher cognitive appraisal of pain as assessed by the pain catastrophizing scale (p< . ), while parameters related to diabetes (duration, hba c, microangiopathy) showed no influence on neup presence and severity. this study confirms the necessity of comprehensive dpn phenotyping and underlines the importance of the severity of neuropathy that should be taken into account in the stratification of patients with pdpn for analgesic treatment and drug trials.people with charcot marie tooth disease (cmt) experience slowly progressive muscle weakness, sensory loss and musculoskeletal changes over time. this leads to disability and risk of comorbidities due to inactivity. exercise is important to maintain general health but may also help to improve symptoms of cmt. we conducted a randomised controlled crossover trial of aerobic exercise to ascertain the effect of training on fitness levels, muscle strength, function and general well-being. in addition, we monitored the safety of training and feasibility of participation in this type of exercise in local community gyms. motivation, confidence and barriers to exercise were explored using qualitative interviews. the recruitment target was people. in total people with cmt a were approached to participate and were unable to commit to the trial or did not meet the study criteria on initial screening. thirty-one people underwent more detailed screening but three failed to meet the study criteria, five people withdrew before starting and three withdrew part way through the study. the data for the people who started the study were analysed using a random effects model. there was a % participation level in the training and it was well tolerated with no increases in pain or blood serum creatine kinase. an increase in vo peak (ml/min/kg) was observed in the cmt group with (pre training: n= , . ± . , % ci . to . ; post training: n= , . ± . , % ci . to . ; pre control: n= , . ± . % ci . to . ; post control: n= , . ± . , % ci . to . ) . there was wide between subject variation leading to a small overall effect size with cohen d of . ( % ci:- . to . ). a tentative regression model showed no effect of group or time point. there were no major changes in other measures of impairment, function or patient reported outcome measures. this pilot study showed that a community based model of training had a small effect on cardiopulmonary fitness, and was well tolerated with good participation. ankle-foot orthoses (afo) are commonly prescribed for children with charcot-marie-tooth disease (cmt) to manage foot drop, however the type and severity of functional impairment results in gait deviations that might require alternate orthotic designs. the aim of this study was to identify d gait patterns of children with cmt based on severity of functional weakness (based on heel walk, toe walk and foot drop items during gait using the cmt pediatric scale) to inform a design pipeline for d printed orthoses. d gait data were captured with an -camera vicon nexus motion capture system using the lower body plug-in-gait model in children with cmt ( male; ± . yrs, ± . cm, ± . kg), of various cmt types: cmt a, cmt e, cmt f, cmt a, cmt c, cmtx , cmtx and compared to typically developing children ( male; . ± . yrs, ± . cm, ± . kg). data were subdivided into three groups denoting increasing severity of dorsiflexion and plantarflexion weakness: no difficulty heel or toe walking (cmt nd ), difficulty heel walking (cmt dh ), difficulty toe and heel walking (cmt dth ). the cmt nd group showed a near-normal gait pattern. the only significant differences noted at the ankle were reduced peak dorsiflexion in stance (p< . ), indicating that an orthotic intervention may not be required. in addition to reduced peak dorsiflexion, the cmt dh group demonstrated significantly reduced dorsiflexion in swing (foot-drop) and a reduced dorsiflexor moment in loading response (p< . ). this suggest, the cmt dh group would require a flexible afo to allow activation of the plantarflexors during push-off, prevent foot-drop and restore a heel rocker in loading response. in contrast, the cmt dth group presented with significantly delayed and increased peak dorsiflexion in stance and reduced plantarflexion and power at push-off (p< . ). they also had significantly increased mean knee extensor moment (p< . ) revealing early signs of 'crouch gait'. therefore, the cmt dth group would require a rigid afo to limit the amount of dorsiflexion and assist movement of the ground reaction force anterior to the knee during stance. three distinct gait patterns at the ankle were identified in children with cmt, indicating patient-specific orthotic design pathways to target specific functional impairment. wojciechowski e , , chang a , cheng t , , little d , , menezes mp , , hogan s , burns j , . university of sydney, new south wales, australia; sydney children's hospitals network (randwick and westmead), new south wales, australia.children with cmt are often prescribed ankle-foot orthoses (afo) to manage lower limb impairment such as foot drop and foot deformities. they are handmade by plaster cast followed by thermoplastic moulding. this traditional approach provides limited design options, can be costly, with long outpatient wait times. d printing, also known as additive manufacturing, has the potential to transform the way orthoses are prescribed, designed and manufactured. the aim of this review was to evaluate the evidence of d printing afos compared to traditional manufacturing methods, for children with cmt. there are currently no studies evaluating the application of d printing afos for children with cmt. however, a small, but emerging evidence base exists for d printed afo's in adults from studies including healthy participants and populations with rheumatoid arthritis, post-polio syndrome, foot drop and ankle weakness secondary to injury. samples sizes ranged from - participants for studies related to in-shoe orthoses and from - for studies related to afos. the methods of d printing included sterolithography, selective laser sintering and fused deposition modelling using materials such as nylon , nylon , polylactide, polycarbonate and abs. d printed afos were comparable to traditional manufactured orthoses in terms of patient-perceived comfort, temporal-spatial parameters, plantar pressure measurements and d gait analysis. however, the effects of long-term usage and durability of d printed afos has not been investigated. d printing orthoses have potential advantages including increased design possibilities, improved productivity, higher compliance, and reduced labour needs. disadvantages include redesigning clinical pathways, limited evidence base for clinical effectiveness, limited biocompatible materials, occupational safety considerations and a high level of expertise required for software operation and fabrication of devices. further research is required to determine the feasibility of d printed afos for children with cmt, and the most appropriate and effective printing pathway, materials to improve health outcomes of affected patients. wong shj , koh sj , lee bjh , chng ysk , pawa c , subramaniam t , cheng ksa , umapathi t . lee kong chian school of medicine, nanyang technological university, singapore; national neuroscience institute, singapore; yong loo lin school of medicine, national university singapore, singapore; khoo teck puat hospital, singapore.treatment-induced neuropathy of diabetes mellitus (dm) (tind) is a complication of rapid glycaemic control. individuals present with neuropathic pain and autonomic dysfunction within weeks of improvement in glucose control. the use of both insulin and oral hypoglycaemic agents has been associated with tind. its severity is determined by the rate and quantum of hba c decline. other predisposing factors include anorexia and weight loss. we studied the incidence of tind in dm patients who have undergone massive weight loss and hba c decline after bariatric surgery. we screened electronic records of patients ( dm, non-dm) who underwent bariatric surgery between and . dm patients fulfilled the tind hba c criteria of a decrease of ≥ % over months or ≥ % over key: cord- -pu i jfe authors: baek, yae jee; lee, taeyong; cho, yunsuk; hyun, jong hoon; kim, moo hyun; sohn, yujin; kim, jung ho; ahn, jin young; jeong, su jin; ku, nam su; yeom, joon-sup; lee, jeehyun; choi, jun yong title: a mathematical model of covid- transmission in a tertiary hospital and assessment of the effects of different intervention strategies date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: pu i jfe novel coronavirus (named sars-cov- ) can spread widely in confined settings including hospitals, cruise ships, prisons, and places of worship. in particular, a healthcare-associated outbreak could become the epicenter of coronavirus disease (covid- ). this study aimed to evaluate the effects of different intervention strategies on the hospital outbreak within a tertiary hospital. a mathematical model was developed for the covid- transmission within a -bed tertiary hospital of south korea. the seir (susceptible-exposed-infectious-recovered) model with a compartment of doctor, nurse, patient, and caregiver was constructed. the effects of different intervention strategies such as front door screening, quarantine unit for newly admitted patients, early testing of suspected infected people, and personal protective equipment for both medical staff and visitors were evaluated. the model suggested that the early testing (within eight hours) of infected cases and monitoring the quarantine ward for newly hospitalized patients are effective measures for decreasing the incidence of covid- within a hospital ( . % and % decrease of number of incident cases, respectively, during days). front door screening for detecting suspected cases had only % effectiveness. screening for prohibiting the admission of covid- patients was more effective than the measures for patients before emergency room or outpatient clinic. this model suggests that under the assumed conditions, some effective measures have a great influence on the incidence of covid- within a hospital. the implementation of the preventive measures could reduce the size of a hospital outbreak. in late december , an outbreak of an emerging disease (covid- ) due to a novel coronavirus named severe acute respiratory syndrome coronavirus (sars-cov- ) originated in wuhan, china and rapidly spread across china and beyond. this outbreak began from a seafood and live animals whole-sale market in wuhan, but cases of patients suffering from the infection have been documented both in hospital and in family settings [ ] . people become infected by respiratory droplets from coughing and talking but aerosol transmission is also possible in cases of protracted exposure to elevated aerosol concentrations in closed spaces [ ] . transmission may occur indirectly through touching a contaminated surface, followed by touching their eyes, nose, or mouth. the coronavirus may also be unexpectedly transmitted by an asymptomatic carrier [ ] . in fact, patients considered asymptomatic released large amounts of viruses at the early phase of the infection, which posed enormous challenges to contain the spread of covid- [ ] , but . % of patients with covid- developed symptoms within . days [ ] . novel coronavirus can spread widely in confined settings, including hospitals, cruise ships, prisons, and places of worship [ ] . in particular, a healthcare-associated outbreak could become the epicenter of covid- . transmission in a hospital raises serious problems since many immunocompromised and aged patients live together and an outbreak in a hospital could paralyze its role of providing essential medical care within the healthcare system. therefore, effective strategies to contain covid- outbreaks in hospitals are required [ ] . however, even for a well-established hospital, coping with the unprecedented covid- outbreak would be a complex challenge. in this study, we developed a mathematical compartment model to predict covid- transmissions over time in a tertiary hospital, and to evaluate the effectiveness of different intervention strategies. we divided individuals into four infection classes: susceptible, exposed, infectious, and removed. (i.e., recovered, or otherwise no longer infectious). the susceptible, s, represents the people who can be infected by sars-cov- . the exposed, e, are those already infected but who did not recognize the disease and even front door screening could not detect it. the infectious, i, and removed, r, follow the usual immunizing infection [ ] . the study hospital consists of three main categories: ward, outpatient clinic, and emergency room. we divided people who entered the hospital into four main compartments: doctor, nurse, patient, and caregiver. doctors and nurses are a part of the medical staff who are fixed in the hospital, while patients and caregivers are visitors who vary from day to day. we assumed doctors work across departments while nurses work in their own departments. therefore, individuals in the hospital were divided into statuses: doctors as a whole and nurses, patients, and caregivers in each department (fig ) . because there are three factors that divided the population, we represented the compartment in the form of x y z . x indicates infection classes. y is the occupation and z represents the department to which the component belongs. we used the notations d for the doctors' group, n for the nurses' group, p for patients', and c for caregivers'. according to convention, we denoted adm as the ward, opd for the outpatient department, and er for the emergency room. the component of waifw (who-acquires-infection-from-whom) matrix w ði;i k Þðj;j k Þ represents the transmissibility from the (j,j k )-th infectious group to the (i,i k )-th susceptible group, where the index (i,i k ) indicates i-th occupation and i k -th department. note that the compartment for the doctors' group does not have the subscript z. usually, the exposed person does not participate in the infection, but this is not clear in case of covid- . therefore, we assumed the exposed person is involved in the foi (force of infection) λ with transmissibility reduced by ε. in this research, we set this value as . . public health authorities define a significant exposure to covid- as face-to-face contact with a symptomatic patient within six feet that is sustained for at least a few minutes. we estimate the contact rate matrix, c, based on the short survey and employ the reproductive number, r , from the literature. setting the population vector η as the number of staff, and the stabilized number of inflow and outflow to each department for visitors, we construct the waifw matrix, w, by assuming that it is proportional to the contact rate matrix [ , ] : the diagram for the seir (susceptible-exposed-infectious-recovered) model with compartments of doctor, nurse, patient, and caregiver. we assumed doctors work across departments while nurses work in their own departments; therefore, individuals in the hospital are divided into statuses. blue arrows refer to the in-and out-flow of patients and caregivers in the opd and er, with only inbound arrows for those in adm. abbreviations:-adm: admission; opd: outpatient department; er: emergency room. https://doi.org/ . /journal.pone. .g the proportionality factor q represents the transmission risk per contact, which can be calculated through the relation between waifw and r . here f is the rate that at which the exposed becomes infectious, and the γ is the rate that the infectious would recover. the population vector η denotes the number of staff, and the stabilized number of inflow and outflow to each department for visitors and ρ(c�η) is the spectral radius of the resulting matrix multiplying each row of c by corresponding element of η. fig shows the diagram for the seir (susceptible-exposed-infectious-recovered) model with compartments of doctor, nurse, patient, and caregiver. the patients and caregivers in opd and er come in and out, but adm does not have the inbound arrows, as we assumed that patients are not directly admitted to the ward from the outside but only from other departments. average contact duration matrix indicates the average hours of contact in a day among medical staff and visitors (fig ) . the horizontal axis indicates the compartments having the contacts and the vertical one indicates the compartments that are contacted. the matrix meets the reciprocity of contacts which makes the contact rate matrix symmetric. the study site was severance hospital, a tertiary care hospital with beds in south korea. there are wards for inpatients within the study hospital, and we assumed each unit had the same capacity of doctors and nurses. if two doctors work in a unit, there are doctors working in wards daily. other numbers based on epidemiology are shown in table . we retrieved data from the hospital administration department on the number of patients who were admitted from the er, hospitalized in wards, and had gone to outpatient clinics from february , to march , . the hospital administration department provided us with the data without identifiable private information. before we began this study, we confirmed with the institutional review board (irb) of severance hospital that ethics approval was not needed, since we did not utilize any personal or identifiable information of the patients. authors who were affiliated to the hospital devised parameters through anonymized data and work experience in the study site. at outpatient clinics, some patients are accompanied by caregivers, and we assumed half of outpatients visit clinics with one caregiver. on the other hand, we assumed one caregiver was assigned per patient in each ward and the emergency center as a hospital policy. we arbitrarily assumed exposed and infectious people from the patient and caregiver group came into the er every three days, while the same number from the patient group and half of them from the caregiver group came into the opd every five days. we presumed they had not been diagnosed by any reason when they entered the study hospital, which meant they were not detectable with the known data. all other parameters for the model are shown in table . impact of the exposed onto the infection the average inflow number of adm from the outside per day † - the average inflow number of opd from the outside per day † - . the average inflow number of er from the outside per day † - . the average number from er to adm per day † - . the average number from opd to adm per day † - . the rate of outflow from the adm [ /days] † - . the rate of outflow from the opd [ /days] † - the rate of outflow from the er [ /days] † - � the incubation period and infectious period are from reference [ ] , [ ] × rate at which the exposed persons become infectious † an average of data collected from the hospital administration department in the study site abbreviation:-adm: admission; opd: outpatient department; er: emergency room. https://doi.org/ . /journal.pone. .t the study site had implemented several controlling measures to prevent outbreaks within the hospital (table ) but, in this mathematical model, we set up four intervention scenarios for the model (fig ) . front door screening. according to one study, on admission, . % of covid- patients presented a fever, . % a cough, and . % with sputum [ ] . the sensitivity is the test's ability to correctly designate a subject with the disease as positive, and we calculated the sensitivity of front door screening at . . however, if we sought an epidemiologic relationship to confirmed patients or travel history along with their current symptoms, the sensitivity would increase, which we assumed at . . front door screening was performed on visitors of three different departments: amd, opd, and er. quarantine unit for newly admitted patients. even though the study hospital executed a pneumonia preemptive isolation unit, asymptomatic patients (usually in the exposed group) could be missed in this control. therefore, we assumed all patients who were admitted either from the er or outpatient clinics were sent to a quarantine unit for two weeks. early testing (within eight hours) of suspected people to detect the disease. we assumed the average time for diagnosis would be eight hours. as covid- patients in the hospital were confirmed, they were directed to isolated rooms (the removed group). as medical staff were aware of the clinical symptoms of covid- and patients' medical conditions were regularly and closely monitored, the groups were immediately tested when the related symptoms occurred. however, caregivers were not as attentive as patients were; therefore, we assumed they were tested three days later than other groups. personal protective equipment for both medical staff and visitors. the regulation of the study hospital specifies that all people in the hospital are required to wear masks. since sars-cov- is a respiratory virus like other coronaviruses or influenza, facial masks significantly reduce transmission of human coronavirus from symptomatic individuals, which could be a way to control of covid- [ ] . however, because the chance of catching covid- table . control measures to prevent covid- outbreak in the study site. inquiring about contact history and related symptoms (cough, sputum, sore throat) by a standard checklist triage clinics for high risk group separate clinics for persons who have either fever or respiratory illness, and who have a history of traveling abroad or visiting high risk areas, located in front of the entrance to the outpatient clinic and emergency room. the study site minimized the number of entrances to hospital buildings and restrict visiting to admitted patients universal mask wearing all healthcare workers, employees, patients, and visitors are obligated to wear masks in the hospital real-time reverse transcription polymerase chain reaction (rt-pcr) for any patients with related symptoms or suspected findings without specific causes the frequency of real-time rt pcr testing to diagnose covid- in the study hospital has increased from time/day to times/day during covid- outbreak since january the test results could be reported within four hours isolation ward with negative pressure isolation rooms in operation patients with either fever or pneumonia were preemptively isolated and treated within the ward healthcare workers for those patients are required to wear appropriate personal protective equipment (ppe). https://doi.org/ . /journal.pone. .t from a passing interaction in a public space is minimal, some people raise the question of effectiveness of universal use of masks by all healthcare workers and visitors [ ] . however, the effect of face masks, respirators and eye protection that result in reducing risk of outbreak had been verified [ ] . we assumed the protection rate of transmission by masks would be . , and the protection rates could reach . , . , or . as reinforcing personal protective equipment (ppe) with gloves, gowns, eye protection, etc. reproductive number. the vulnerability of results for each intervention required checking as the reproductive number varied since we set the waifw matrix from it. we employed , infectious class in seir diagram; green arrows indicate front door screening and brown arrows indicate testing the infectious patients. front door screening intervenes the inflow of the infectious patients and the tested patients are removed at the rate of /t. as we described, we assumed caregivers are tested three days later than other groups. (b), waifw diagram of each group; pink arrows indicate reduction of transmission by wearing a universal mask while red arrows are reinforcement of the protection device among medical staff. reinforcing the protection device among medical staff reduces the probability of transmission as in red arrows. (c), diagram for pre-isolating the patients who are to be admitted, which we named the quarantine unit. patients are usually admitted from opd and er (light gray arrows), but if all patients are directed to the isolated ward (iso) (dark gray arrow), isolated people are out of the dynamics for days. abbreviations:-adm: admission; opd, outpatient department; er: emergency room; iso: quarantine unit. https://doi.org/ . /journal.pone. .g the value . from the paper for early transmission analysis of covid- in wuhan [ ] . however, over time, many studies have been performed regarding an estimation of the reproductive number in different circumstances with control measures [ , ] . variability must be taken into consideration within the range of reproductive numbers for evaluating each intervention. therefore, we also simulated the impact of our interventions in case of a very high reproductive number ( . ) [ ] . incubation period and serial interval. the incubation period has not been determined yet and we set it at . days [ ] as a base case and . days [ ] for sensitivity analysis. the serial interval has not been determined and we assumed . days [ ] and . days for sensitivity, which is times of . days-that is the difference between . days serial interval and . days incubation period [ ] . note that these parameter values were to be fitted with different assumptions for distribution. however, in an average sense, they have few differences with other fitting results and can be used as parameters in our model. with these parameters, we set the base-, worst-, and best-case scenarios and performed the sensitivity analysis with them (see table ). the model simulated the epidemic curve of covid- in the study site with base parameters. fig shows the daily new incidence of covid- without any intervention for days. the horizontal axis represents time (days) and the vertical axis indicates the number of people who are newly confirmed patients within the past hours. this predicts daily new cases of infected people from four compartments over time within the hospital. since doctors work across departments, their epidemic is shown in fig a. other groups work or stay in separate departments, which indicate different epidemics (fig b) . the infected cases in er and opd are very small due to relative short duration of stay and low reproductive number, so the spread is r . [ ] � we set the best-and worst-case scenario parameter sets in terms of curbing viral transmission. if the virus has a long infectious period and low reproductive number, the transmissibility is low, which is helpful in curbing the spread of disease. on the other hand, with a short infectious period and high reproductive number, it would lead to high transmissibility even in a restricted condition. † /f is the incubation period; a reversal of the rate at which the exposed patients become infectious ‡ /γ denotes the infectious period, a reversal of the rate at which the infectious patients would recover § r denotes the reproductive number, an average number of secondary cases generated by a case in an entirely susceptible population. https://doi.org/ . /journal.pone. .t restricted and there is no remarkable outbreak in the er or opd. however, when confirmed cases are in wards, they become more transmissible since visitors have a high contact duration matrix within the group. fig indicates total epidemic curves of covid- . the number of the exposed and infectious people among visitors grows in the early period but this reaches a plateau. the curve of the recovered patients represents a trend of a totally susceptible population in the hospital before the ourbreak being immune to the disease. the total number of infectious people is about at the end of the dynamics. next, we simulated the model with various interventions. we set the sum of new incidence for days as an outcome measure. " -effectiveness of an intervention (%)" is defined as the ratio of the outcome with an intervention to one without any intervention, so effectiveness denotes the proportion of decrease of the confirmed cases due to an intervention. fig shows the effectiveness of all intervention scenarios and the effectiveness of the detection of infectious patients, . %, is the highest among the control measures. therefore, an examination of any suspected cases is the most important way to prevent an outbreak in the hospital. wearing universal masks by medical staff and visitors (see ppe dn . pc . in fig ) shows about . % of effectiveness. the impact of different protection rates of medical staff tested by three scenarios ( . , . , or . ) turned out to be insignificant ( . %, . %, or . %, respectively). in other words, reinforcement of ppe for medical staff does not show an expected improvement of effectiveness. quarantine of new hospitalized patients is another effective way to prevent outbreaks. the quarantine unit is as effective as . %, while front door screening shows less effectiveness, which is up to . %. the screening of patients who are admitted to the ward is the most effective method, followed by er and opd ( . %, . %, and . % with sensitivity of screening of . ). as expected, the more accurate the screening is, the more effective it is as a control measure. if the sensitivity of screening is . , the effectiveness of front door screening for inward, er, and opd is . %, . %, and . %, respectively. according to our mathematical model, screening of an opd is not a good measure to prevent an outbreak in a hospital setting. we performed a sensitivity analysis by taking various combinations of parameter values based on plausible ranges. the worst-case scenario has a short incubation period and high reproductive number, resulting in the biggest outbreak in the hospital. on the other hand, the reverse combination yields the best-case scenario. first, we estimated the outbreak in our hospital in the absence of control measures, which is shown in fig with sensitivity analysis. the exposed people in the worst-case scenario (fig b) rises to a peak of people, while the exposed people in the best-case scenario (fig a) only reaches people. a highly transmissible case is hard to control with an exponentially increasing number of exposed and infectious patients. additionally, we evaluated the effectiveness of different interventions in three scenarios: base, best, and worst cases (fig ) . the effectiveness of control is higher in the best-case scenario through front door screening and use of a quarantine unit. screening of inpatients through front door screening with a sensitivity of . shows effectiveness of . % and . % in best-and worst-case scenarios, respectively. regarding the er, the effectiveness is . % in the best-case scenario and . % in the worst-case scenario. effectiveness is about seven times higher in front door screening of admission wards and ers without reference to sensitivity of screening. in a low transmission setting, it is crucial to detect the patients with covid- from er and in wards before inflow to a hospital. a quarantine unit also helps prevent the outbreak in the hospital more in the best-case scenario than in the worst ( . % vs . %). a high transmission rate in the hospital offsets the effort of screening of infectious patients and on the other hand, the probability of control by testing and protection devices is higher in worst-case scenarios. ppe reinforcement decreases transmission effectively in highly transmissible conditions, which contributes to reducing the outbreak as with the worst-case scenario. strengthening protection has little impact on the new incidence of confirmed cases in sensitivity analysis. testing to detect and isolate confirmed cases is also more important in higher transmission cases ( . %). sensitivity analysis shows diagnosis of the disease within eight hours and isolation is still the best intervention strategy in a hospital. since the global outbreak of covid- , many control measures have been implemented to try and contain the pandemic: isolation of confirmed and suspected cases; contact tracing; social distancing; and, travel restrictions. suggestion of best strategies which offer greater benefits is difficult in the context of an epidemic. several mathematical models have been proposed to explain the system and help decision making beyond hospital settings [ ] [ ] [ ] [ ] . one study explored the spatial association of the early stages of the covid- pandemic in china [ ] . a dynamic mathematical model estimated that the growth rate of covid- is about twice that of the sars and mers, and the doubling cycle is two to three days without intervention [ ] . a stochastic transmission model assessed the potential for transmission in locations outside wuhan, if cases were introduced. it calculated that once there are at least four independently introduced cases, there is a more than a % chance that the infection will establish itself within that population [ ] . in this study, we simplified the transmission of covid- in a hospital to construct a mathematical model that would enable us to estimate the outbreak and determine the effectiveness of control measures. we conducted a sensitivity analysis with different assumptions because of the uncertainty of the parameters. early testing of infected cases and monitoring the quarantine ward for newly hospitalized patients are effective ways to minimize the covid- outbreak within a hospital. detecting the patients with covid- from the er and in wards before inflow to a hospital is effective in low transmission settings; ppe is important to control transmissibility in high transmission settings. our results could expand to many interventions implemented in society. in high transmissible and short latent cases, transmission reduction interventions including wearing universal masks are more important than restriction of inflow of patients by screening and isolating suspected cases. above all, quarantine and isolation efficacy should be increased by means of proper hygiene and personal protection. to our knowledge, this study is the first model to estimate the epidemics in a hospital and evaluate the effects of control measures for covid- . other studies about hospital outbreaks from infectious diseases were conducted with many different mathematical models: a multiagent model or seir transmission model [ ] [ ] [ ] [ ] . in the case of mers-cov, the emergency departments exercised great influence over the epidemic size for both patients and healthcare workers, and isolation and related strict measures (added ppe or environmental sanitation) suppressed the epidemics with the help of the seir compartmental model [ ] . the seir compartmental model was similar to our model, which is deterministic, multi-type, and spatial in a hospital setting. our model set the reproductive number with sensitivity analysis, assumed the regular inflow of covid- patients to a hospital, and compared the control measures. there are some limitations of this model. our model does not include people who enter the hospital and do not belong to the four occupations specified (doctors, nurses, patients, and caregivers). weekends, when most of the medical staff are off duty were not taken into consideration. various units and situations of the hospital have not been included in this model, such as the intensive care unit, operation room, and confirmed cases of medical staff. while the model assumes the same inflow of exposed and infectious people from the patient and caregiver group, the prevalence of asymptomatic infection has not been clarified yet. we set the rate at which the exposed individuals become infectious at . , which has also not been confirmed. in addition, we assumed that the sensitivity of the front door screening is low ( . or . ) and detects only infectious persons; however, thorough checklists and use of thermometers might detect more infectious or exposed people. therefore, it is cautious to assert that front door screening is effortless. more studies should be conducted on the outbreak and control measures from different perspectives. even though we did not include all the details, this study could improve our insights into epidemiological situations and identify which control measures are most efficacious in hospital settings. though this study was confined to one hospital, it can be tailored to the requirements of other hospitals, facilitating effective hospitalbased management during this rapidly evolving outbreak. clinical characteristics of coronavirus disease in china. the new england journal of medicine evaluation and treatment coronavirus (covid- ) transmission of sars-cov- : implications for infection prevention precautions: scientific brief unique epidemiological and clinical features of the emerging novel coronavirus pneumonia (covid- ) implicate special control measures pathophysiology, transmission, diagnosis, and treatment of coronavirus disease (covid- ): a review transmission potential of the novel coronavirus (covid- ) onboard the diamond princess cruises ship effective strategies to prevent coronavirus disease- (covid- ) outbreak in hospital. the journal of hospital infection an introduction to infectious disease modelling: oup oxford modeling infectious disease parameters based on serological and social contact data: a modern statistical perspective respiratory virus shedding in exhaled breath and efficacy of face masks universal masking in hospitals in the covid- era physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov- and covid- : a systematic review and meta-analysis. the lancet early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia. the new england journal of medicine estimation of the transmission risk of the -ncov and its implication for public health interventions time-varying transmission dynamics of novel coronavirus pneumonia in china incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china clinical characteristics of asymptomatic infections with covid- screened among close contacts in nanjing, china serial interval of novel coronavirus (covid- ) infections. international journal of infectious diseases: ijid: official publication of the international society for infectious diseases transmission dynamics of the covid- outbreak and effectiveness of government interventions: a data-driven analysis feasibility of controlling covid- outbreaks by isolation of cases and contacts the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak short-term predictions and prevention strategies for covid- : a model based study spatial epidemic dynamics of the covid- outbreak in china. international journal of infectious diseases mathematical model of infection kinetics and its analysis for covid- early dynamics of transmission and control of covid- : a mathematical modelling study. the lancet infectious diseases analysis of the healthcare mers-cov outbreak in king abdulaziz medical center role of fomites in sars transmission during the largest hospital outbreak in hong kong probable transmission routes of the influenza virus in a nosocomial outbreak the authors are grateful to all the medical staff who worked at the study site. key: cord- -wwnqupo authors: ji, jianlin; ye, chenyu title: consultation-liaison psychiatry in china date: - - journal: shanghai arch psychiatry doi: . /j.issn. - . . . sha: doc_id: cord_uid: wwnqupo consultation-liaison psychiatry (clp) was first established in china after liberation in . it has developed more rapidly over the last two decades but, despite major regional differences in the level of clp, the overall practice of clp in the country remains quite basic, largely limited to case-based consultation with other medical departments. there is little ongoing collaboration between departments of psychiatry and other departments, and medical students and non-psychiatric clinicians rarely get training in clp. according to lipowski, [ ] the article published by george henry in the american journal of psychiatry in marked the launch of consultation-liaison psychiatry (clp) as a scientific discipline. initially, the clp doctor was scoffed at as 'a pleasant, pipe-smoking gentleman wearing a tweed jacket who, with much time on his hands, proselytized for the psychosocial model'. [ ] such stereotypes have changed over time. today, clp physicians are expected to have the multidisciplinary knowledge and skills needed to carry out psychiatric interviews; to conduct risk assessments and manage threats of suicide, assault, and agitation in common clinical settings; to interpret laboratory results; and to consider the physical, legal, and ethical issues when managing the psychiatric problems of patients with concurrent physical illnesses. they are also required to possess good communication skills when interacting with non-psychiatrists, other health care professionals, and patients' family members. [ ] the specialty of clp was initially launched in the united states and subsequently adopted worldwide, but its development in china has not been a smooth one. prior to the founding of the people's republic of china in , psychiatric units had been established in some general hospitals in china, but there are no reports of clp-type services. after , the departments of psychiatry and clinical psychology established in many general hospitals started to provide clp services, particularly in university teaching hospitals. in parallel with the rapid economic and social reforms that started in china in the s, the concept of clp has become more widely accepted by medical professionals and administrators; this has facilitated increased cooperation between departments of psychiatry and other clinical departments. this article briefly introduces the development of clp in china and its current status. according to lipowski, clp may be defined as the part of clinical psychiatry which includes all diagnostic, therapeutic, teaching, and research activities of psychiatrists (as well as psychiatric social workers and nurses) in the non-psychiatric divisions of a general hospital. [ ] the clinical services include the provision of psychiatric consultations for non-psychiatric medical staff and promotion of the psychosocial perspective of care ('liaison'). the education component includes training basic psychiatric concepts and the psychosocial perspective of medical care to medical students, residents and other care providers in non-psychiatric departments. the research component includes study of the assessment and management of the psychological and behavioral problems that occur in persons with physical illnesses, co-morbid medical and psychiatric disorders seen in general medical settings, and the evaluation of clp clinical services and education. [ ] clp in general hospitals in china can be divided into three main types. c) despite the increased clp presence, a large proportion of general hospitals in the country still lack psychiatric support so they make neurologists responsible for psychological problems that arise in their patients. in these settings depression, anxiety and sleep disorders among outpatients and delirium and behavior disorders among inpatients are referred to general hospital neurologists for assessment and management. psychiatrists from specialty hospitals are only called in if it proves impossible to control a patient's behavior. in the s, the world health organization (who) conducted a multi-center study in countries to investigate the epidemiology of mental health disorders in patients treated in general medical institutions. [ ] in shanghai, which was one of the collaborative centers, outpatients treated in general hospitals were enrolled. depressive disorders were the most prevalent -the prevalence of depression and dysthymia were . % and . %, respectively; other less common conditions included neurasthenia, generalized anxiety, somatoform disorders, alcohol dependence, depressive neurosis, panic disorders, and phobic disorders. in he and colleagues [ ] conducted a national project on mental health service utilization. they found that the utilization of inpatient mental health services was much greater in large municipal and provincial institutions than in smaller institutions, which had much lower occupancy rates. the mean annual number of mental health outpatient visits at the institutions was , but the range in the number of visits varied by -fold. typically the outpatient volume at psychiatric hospitals operated by the ministry of health was greater than at those operated by the ministry of civil affairs hospitals (which more commonly provide services to patients with chronic mental illnesses). the library services at the psychiatric hospitals were extremely limited, subscribing to a median of four academic journals. among the psychiatric hospitals % had no residency training program and those that did have a training program lacked a uniform method and curriculum for training clinical psychiatrists. this shows the poor overall status of psychiatric services and training in the country, a fact that has seriously undermined the development of liaison psychiatry. in a review of clp in china by yu [ ] highlighted the weakness of the clp subspecialty in china. there was no network of practitioners, no professional organization, no plan for the development of clp, and no system for training and accrediting clp subspecialists. the psychiatric consultation rate was very low, the highest reported rate in general medical wards was . %. the survey found that almost all clp work was focused on providing diagnoses and treatment for difficult patients on general medical services; there was no genuine consultation between psychiatrists, non-psychiatric clinicians and patients, and there was no research about developing an appropriate china-specific model of clp. the ability of non-psychiatric clinicians to identify medically ill individuals with co-morbid psychiatric disorders was very limited. the many studies about clp conducted over the last decade have included few well-designed studies that provide an accurate overview of the status of clp in the country. one study by yu and colleagues [ ] reported that of the general hospitals in shanghai surveyed ( %) had established departments of psychiatry or psychology. the rate of referral for psychiatric assessment in the hospitals with psychiatry departments was . % while the rate in the hospitals without a psychiatry department was . %. none of the hospitals with a psychiatry department had established a clp group composed of psychiatrists and non-psychiatrists and % of the hospitals had never or only rarely provided clp services. so on the one hand shanghaiwhich is generally better resourced and progressive in mental health than most other parts of the countryhas been successful in getting psychiatric services into general hospitals but on the other hand it has been less successful in integrating clp services as part of the overall service delivery system of the hospitals. the limited clp services available at the hospitals with departments of psychiatry are single case-based consultations; there are no full-time clp psychiatrists who regularly participate in routine clinical care in non-psychiatric departments. in professor desen yang, [ ] a renowned senior psychiatrist from hunan province, wrote about his vision for the coming decade: 'it's necessary to expand the mental health workforce in the thousands of general hospitals around the country at the county level or above and establish departments of psychological medicine or psychiatry within these hospitals. mental health clinicians at general hospitals should be composed of psychiatrists (with -year medical degrees) and well-trained psychotherapists, and their numbers should increase from the current individuals to at least individuals.' in the ministry of health promulgated the china mental health plan ( - ) [ ] which stated that 'general hospitals shall establish departments of psychology (outpatient) or departments of psychiatry (outpatient).' the plan also set targets for rates of recognition of depression in district-level and municipal-level general hospitals and in county-level general hospitals: by the recognition rates were expected to be % and %, respectively and by the recognition rates were expected to reach % and %, respectively. unfortunately, these lofty goals were not achieved. official reports for suggest that there are specialized mental health practitioners in the country, most of whom work in large specialty hospitals in shanghai, beijing, changsha and other economically developed parts of the country. it is unclear how many of them work in clp at general medical hospitals. a dissertation by ge [ ] entitled 'status of medical workers in the psychological outpatient departments of general hospitals in wuhan city' reported that only . % of the general hospitals in wuhan offered mental health services ( % of which were high-level tertiary hospitals), and that only . % of the staff at these outpatient mental health departments were trained psychiatrists ( . % were other physicians and . % had degrees in psychology). clearly, clp in china still has much room for improvement. at present, china's clp research is still largely limited to psychiatric consultation in general hospitals. using the keyword 'consultation-liaison psychiatry', the authors searched for relevant literature in the comprehensive china wanfang database over the last years. the results for the articles identified [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] are shown in table . the study designs varied. only one of the studies was prospective; [ ] all the others were retrospective. most of the studies are descriptions of the proportions of referrals from different clinical departments and proportions of different diagnoses in the patients seen. only of the studies provided consultation rates (ranging from . to . %) and only of the studies reported the diagnostic criteria that were used to make the diagnosis. most consultation requests come from departments of neurology, possibly due to the historical relationship of the two departments in china (up until psychiatry in china was a sub-discipline of neurology). organic mental disorder was the most frequent reason for consultation, accounting for to % of all referrals. the findings varied by geographic region and by type of hospital. in the tertiary (highestlevel) hospitals in socioeconomically developed areas, the consultation rate was high and the proportion of referrals with organic mental disorder was relatively low (neurosis was a more common diagnosis in these settings); but in the less developed parts of the country consultation rates were low and the majority of referrals had an organic mental disorder or some other severe mental disorder. in recent years the study designs have improved and the range of issues addressed has expanded: more studies now include psychiatric follow-up of referred patients, [ ] comparisons between emergency consultation and regular consultation, [ ] and descriptions of the psychiatric consultation processes in specific medical departments. [ , ] the main focus of clp in china continues to be psychiatric consultations for disturbed patients in medical departments, but there has also been a gradual increase in the adoption of psychiatric theories and practices by other departments. in , the department of psychosomatic medicine at the university of freiburg, germany, together with the department of psychiatry at tongji hospital in shanghai launched a national continuing medical education (cme) project focusing on psychosomatic medicine that has sponsored a series of five annual training workshops on psychosomatic medical care in china. a subsequent collaborative 'asia-link' project between the university of freiburg, tongji university and other institutions in australia, vietnam, and laos (funded by the european union in ) enabled asian psychiatrists and other physicians to receive training in the basic skills of psychosomatic medicine. the training sessions included lectures, exercises using role playing, group discussions, on-site case interviewing, balint groups, and family sculpture exercises. to date over physicians from different clinical departments have attended the -hour courses; they report that the training is very practical because, in part, it promotes the concepts of 'human-centeredness' and 'psychosomatic concordance'. the success of the course has stimulated the development of similar cme projects: a balint group symposium chaired by professor jing wei at the peking union medical college hospital has continued for four years; the zhongshan hospital of fudan university has promoted the development of a local balint group in shanghai; and there are plans to establish the chinese balint federation (cbf) in . [ ] [ ] [ ] [ ] cardiovascular expert professor dayi hu proposed the concept of 'psycho-cardiology medicine' [ ] in . this approach integrates an understanding of the many biomedical risk factors for heart disease with an understanding of the psychological characteristics that are needed for individuals to effectively reduce their risk of heart disease in the complex social world and medical service network in which they have to function. cardiologists and psychiatrists have jointly compiled training materials for psycho-cardiology medicine, that include both detailed descriptions of the neurophysiology of cardiovascular diseases and of the common psychological problems that can occur in individuals who experience these conditions. there have also been a number of related studies: ling and colleagues [ ] found that . % of internal medicine outpatients have anxiety symptoms, . % have depressive symptoms and . % have both anxiety and depressive symptoms; fan and colleagues [ ] found that the anxiety and depressive symptoms occurring in internal medicine outpatients vary by gender and age; and lin and colleagues [ ] reported that the quality of life of internal medicine outpatients at general hospitals is closely associated with the severity and duration of concurrent anxiety and depressive symptoms. clp differs from mainstream psychiatry in several ways. [ ] one of the main differences is that in most psychiatric services the patient presents himself or herself to the psychiatrist for management of a perceived psychiatric problem whereas in clp the psychiatrist approaches the patient. it is inevitable that in some cases consultation from the psychiatrist may be unwelcome and the patient may react with surprise, denial or anger, amongst other emotions. another difference is the environment where the consultation takes place: traditional psychotherapy is usually conducted in a relatively private treatment room which facilitates doctor-patient communication, but clp consultations in general hospitals are typically conducted in noisy environments with relatively little privacy. although there are several psychotherapy regimens that could be undertaken in general hospitals (e.g., cognitive therapy, introspective treatment, group therapy, family therapy, etc.) in most cases patients in general hospital settings are most willing to accept general supportive psychotherapy. initially the psychiatrist develops a good therapeutic relationship with the patient by 'considerate listening' to the patient's problems and concerns, decreasing the intensity of their emotional response to their situation. the psychiatrist subsequently provides gentle encouragement to increase the patient's selfconfidence and psychological resilience and, thus, restore their psychosocial functioning back to baseline levels. general hospitals are usually cautious in their use of psychotropic drug, preferring to have them administered by psychiatrists. all the main psychiatric medications are available in general hospitals but they are typically used at lower doses than in specialty psychiatric settings. the chinese society of psychiatry of the chinese medical association has published a series of clinical guidelines for the prevention, diagnosis and treatment of seven common mental illnesses (i.e., schizophrenia, depression, bipolar disorder, dementia, attention deficit and hyperactivity disorder, anxiety disorder, and post-traumatic stress disorder) that can be used in general hospital settings. a simplified version of the guidelines for the treatment of anxiety disorders is also available. recently neurologists and psychiatrists have jointly formulated the consensus of experts on the diagnosis and treatment of nervous system disease associated with depression and anxiety disorders [ ] and the consensus expert panel on the definition, diagnosis and drug treatment of insomnia [ , ] both of which are suitable for use by clinicians in general hospitals. and a recent volume entitled psychiatry in the general hospital, co-edited by professors wenyuan wu and jianlin ji, provides a comprehensive overview of the recognition and management of psychiatric and psychosomatic problems that can occur in patients treated in general hospitals. it is not uncommon for patients with physical problems to have a comorbid psychiatric diagnosis. the psychological problems detected at organ transplantation centers are particularly prominent. despite a relatively large number of mental health studies related to transplants conducted in china in recent years, the quality of most such studies is quite low: among such studies reported in the last decade only one [ ] was conducted by a psychiatrist (a descriptive summary); the results of the studies are almost entirely based on the self-rating depression scale (sds) and/or the self-rating anxiety scales (sas); the studies either lacked controls or selected inappropriate controls; and there is inadequate description and standardization of the psychological intervention provided. therefore, any conclusions drawn from such studies must be interpreted with caution. with few exceptions, studies on the psychological status of patients following treatment for malignant tumors suffer from the same limitations. however, recently ye and colleagues carried out a well standardized study among patients receiving a heart transplantation [ ] and there has been a well-designed study on the nursing of patients with malignant tumors conducted by a psychiatrist. [ ] so there is some hope that the quality of research in the area will improve in the future. by comparison, clp studies carried out in internal medicine settings have been of a higher caliber. zuo and colleagues [ ] [ ] [ ] have carried out several in-depth clp studies about psychosocial factors and cognitive functioning among patients with type diabetes mellitus and zhou and colleagues [ ] conducted impressive clp research on hemodialysis in the early s. one area of clp which is comparatively well developed is the provision of post-disaster services. psychological intervention offered by psychiatrists to families of the victims in the 'northern airlines crash' was the first post-disaster mental health intervention in china. during the severe acute respiratory syndrome (sars) outbreak in , clp psychiatrists made significant contributions to the management of the psychological reactions of patients, medical staff, and the general public. after the wenchuan earthquake in , there was a surge of research relating to clp services during the disaster: these studies identified large numbers of earthquake survivors suffering from mental health problems [ ] [ ] [ ] and suggested that early provision of psychological assistance was practical and effective. [ ] in addition to post-disaster intervention for victims, attention should also be paid to the prevention and management of the psychological stress of the rescuers. tian and colleagues [ ] highlighted the importance of secondary traumatic stress in rescuers. [ , ] despite years of substantive research and increased administrative support clp in china has not seen a fundamental change. the main working model for clp in china remains being asked to provide case-limited consultations. collaboration with other departments is usually limited to collaborative research projects, and research fellows in clp have no trajectory for professional development after their graduation. some of the leading institutions in big cities have services that are approaching international standards but the level of development of clp across the country is very imbalanced and the overall quality leaves much to be desired. clp is not yet part of the curriculum for most medical schools and even where it is part of the curriculum the training primarily consists of theoretical classes taught by social scientists that are completely unrelated to the necessary skills in doctor-patient communication. psychiatrists who assume the role of clp physicians in general hospitals receive little specialized training beyond basic psychiatric training, so it is difficult for them to hone the skills needed to work effectively in the general hospital setting: evaluation and management of comorbid medical and psychiatric conditions; crisis intervention; psychopharmacology in medically ill patients; communicating with critically ill and terminal patients; and so forth. the continuing education opportunities for clp physicians that are available are limited to a few famous institutions in big cities. but rome was not built in a day. although clp in china is still lagging far behind clp in other countries, based on the accumulated experience of the last two decades and the continuing support of the government it will ultimately grow and prosper. chinese clp physicians are, as posited by lipowski, [ ] part of the small number of health care professionals in the country who have the broad perspectives on human health needed to provide comprehensive assessment and treatment for individuals with comorbid physical and psychological disorders. consultation-liaison psychiatry at century's end consultation-liaison psychiatry current trends in consultation-liaison psychiatry consultation-liaison psychiatry: the first half century world health organization collaborative study on psychological disorders in primary health care: the results from shanghai current status of psychiatric outpatient services in china current status and future plans for consultation-liaison psychiatry in china current situation of mental health service in general hospitals in shanghai prospects of community mental health for the new century in china ministry of civil affairs, ministry of public security and the all china disabled persons federation of people's republic of china. china's working plan for mental health study on situation of mental health personnel in the clinics of general hospitals of wuhan: - practice of consultation-liaison psychiatry in general hospital an analysis of cases of psychiatric consultations in a general hospital consultation analysis of somatic disease accompanied by psychological disorder in general hospital analysis of cases in the psychiatric consultation-liaison at a general hospital a two years consultation reviewed of mental department in shenzhen hospitals analysis of consultation-liaison psychiatry for inpatients in general hospitals analysis of patients treated by the psychiatric consultation-liaison service at a general hospital departments applying for consultation-liaison psychiatry and distribution of diagnosed different psychiatric diseases in general hospitals: analysis of cases psychiatric consultation for medical patients and follow-up study in general hospital clinical study of in-patients in a general hospital seen by the consultation-liaison psychiatry service analysis of the consultation-liaison psychiatry service in a general hospital analysis of the consultation-liaison psychiatry service provided the inpatient in general hospital consultation-liaison psychiatry service in general hospitals analysis of cases of inter-hospital psychiatric consultation clinical features of patients referred to a psychiatric consultation-liaison service in a general hospital consultation liaison psychiatry for elderly patients in general hospital: analysis of cases results of consultation-liaison referral for general hospital inpatients with a comorbid psychiatric illness analysis of psychiatric consultation cases in a general hospital analysis of consultation liaison for respiratory patients at a general hospital analysis of data from consultation-liaison psychiatry service for the inpatients in a tertiary general hospital role playing and balint group in psychiatric training course application of the balint group in general hospital qualitative study of doctor balint group cases in general hospital balint groups integrated management of cardiovascular disease and mental disorder-discussion of 'psycho-cardiology medicine use of hospital anxiety and depression scale (chinese version) in chinese outpatient in department of internal medicine application of the hospital anxiety and depression scale (had) among medical outpatients quality of life of medical outpatients with anxiety in a general hospital assessment of psychological disorders during the peri-operation period for hepatic transplantation psychological problem in adults after heart transplantation personality, coping style, immunity function in the patients with gastric cancer cognitive function of type diabetics with micro-angiopathy the relationship between the psychological disturbance and metabolic control in the adults with type diabetes a pilot study of cognitive function and related factors among the patients with type diabetes investigation on psychological distress of the dialystic patients with end-stage renal failure the psychological problems in the wounded of wenchuan earthquake in sichuan psychological status of survivors one week after the sichuan earthquake case report of acute stress reaction after the huge ' . ' earthquake analysis of psycho salvation for the wounded in the wenchuan ' . ' earthquake the effect of mental intervention on anxious-depressive mood in earthquake relieving officers and soldiers self-care for disaster relief workers during the provision of relief services psychotherapy in consultation-liaison psychiatry expert group for the diagnosis and treatment of diseases of the nervous system with comorbid depressive or anxiety disorders. expert consensus for the diagnosis and treatment of diseases of the nervous system with comorbid depressive or anxiety disorders expert group for the definition, diagnosis and pharmacological treatment of insomnia. expert consensus for the definition, diagnosis and pharmacological treatment of insomnia expert group for the diagnosis and treatment of diseases of the nervous system with comorbid depressive or anxiety disorders. expert consensus for the diagnosis and treatment of diseases of the nervous system with comorbid depressive or anxiety disorders (revised) the authors report no conflict of interest related to this manuscript. key: cord- - whai nr authors: nan title: esp abstracts date: - - journal: virchows arch doi: . /s - - - sha: doc_id: cord_uid: whai nr nan ofp- - intraoperative evaluation of breast cancer sentinel lymph node metastasis with an automated molecular detection method as an alternative to standard pathological evaluation f. beca * , e. rios, p. pontes, i. amendoeira * centro hospitalar de são joão, anatomic pathology, porto, portugal objective: one-step nucleic acid amplification assay (osna) from sysmex® is an automated system to detect sentinel lymph node (sln) metastasis in breast cancer patients. this assay is based on the detection of cytokeratin mrna amplification by reverse-transcription loop-mediated isothermal amplification. traditionally intraoperative evaluation of sln is accomplished by cytology and/or frozen section, accounting for heavy workload to pathology department. the objective of this study is to compare the osna assay with our standard processing for intraoperative sln evaluation. method: sln from patients with ck + and invasive primary carcinomas where simultaneously evaluated by cytology and/or frozen section and by osna assay. results where compared with gold-standard definitive h&e evaluation (serially sectioned at μm intervals). results: the sensitivity and specificity of osna assay was . % and . %, respectively with a positive predictive value (ppv) and a negative predictive value (npv) of %. for standard intraoperative evaluation, specificity was % and sensitivity was . %. conclusion: osna assay showed similar specificity and higher sensitivity than standard pathologic examination. these findings suggest it can be used as an accurate tool for intraoperative evaluation of slns metastasis and possibly contribute to reducing the need for re-intervention for axillary lymph node dissection. objective: antracycline-based chemotherapy represents a standard of care in breast cancer patients especially who overexpress her- . topoisomerase a has been considered a molecular target for antracyclines and its co-amplification with her- genes has been proposed. in our study we investigated if topoisomerase a overexpression can be used as a molecular marker on predicting response to antracycline-based chemotherapy. method: breast cancers tissues from patients underwent to antracycline-based neoadiuvantchemotherapy and treated with adiuvant therapy were collected into tissues microarrays, and classified according to pathological stage, er, pr, her- and topo a status. the expression of topoisomerase a has been correlated to response to chemotherapy. results: our results show that topo a expression is significantly higher in neoplasms with larger size, nodal metastasis, scant er end pr receptors, and amplification of her- gene (p < , , t-test). cancers in witch high level of topo a has been found exhibit a better clinical response to treatment with anthracycline (p < , , t-test). therefore topo a expression could be considered both as predictive and prognostic marker. conclusion: the employment of topo a as a predictive marker in clinical practice may be useful for the medical therapy of non-endocrine-responsive patients candidate to undergo treatment based on anthracycline, that is no free from adverse effects as cardiomyopathy and leukemia. ofp- - stem cells in triple negative breast cancer and associated in situ lesions m. comanescu * , m. dobre, g. bussolati * institutul victor babes, dept. of pathology, bucharest, romania objective: triple negative breast cancer (tnbc) (negative for expression of estrogen and progesterone receptors (er, pr) and her /neu protein) represent a subtype of breast cancer associated with poor prognosis and highly aggresive behaviour. genetic characterization of stem cell (cd , ....) in this type of carcinoma might provide important data concerning origin and evolution. data of the literature focused specifically on tnbc but, despite the interest shown to stem cells recently, there are no data concerning the genetic characterization of stem cells in the context of cell biology of tnbc as compared with associated dcis. method: we investigated, through immunohistochemistry, the expression and distribution of several stem cell/related antigens, exploring the association of tnbc with dcis and comparing the presence of stem cells in the invasive and in the in situ component. results: the multiplicity of parameters to be detected for characterising stem cells and of the diagnostic materials that are available would prevent a straightforward approach and a sequential combination will have to be planned. conclusion: optimization of detection, identification and characterisation of tumourigenic breast cancer stem cells might permit further identification of targeted treatment. over-and undergrading of breast cancer on core biopsies in comparison to surgical specimens t. decker * , c. focke, d. gläser * d. bonhoeffer medical center, dept. of pathology, neubrandenburg, germany objective: to evaluate the relevance of histological grading (hg) based on core biopsies (cb) for clinical decision making in breast cancer (bc) we evaluated the concordance with hg from surgical specimen (ssp) and the reasons for under-or overgrading. method: cb and related ssp of bcs were prospectively graded according to the nottingham grading system (ssp: g , g and g ). cb/ssp agreement rates and positive predictive values (ppv) of cb based hg were calculated. rates of over-and underestimation of glandular differentiation (gd), nuclear pleomorphism (np) and mitotic activity (ma) were calculated. results: cb/ssp agreement rates came out with % for g , % for g , and % for g . the ppvs of cb based hg were % for g , % for g and % for g . the overgrading and undergrading rates on cb were % and %, respectively. main causes for undergrading in cb were underestimated ma ( %) and a combination of underestimated np and ma ( %). conclusion: whereas overgrading on cb is an exception, undergrading derives largely from underestimation of proliferation. agreement of hg between cb and ssp ranges from almost perfect for g , moderate for g to slight for g tumours. ofp- - comparative histopathology of mammary alterations in women and dog v. deckwirth * , p. kronqvist, m. lintunen, a. sukura * university of helsinki, dept. of veterinary pathology, finland objective: companion animals such as dogs share the same environment with people. mammary tumours are the most prevalent spontaneous neoplasia in intact bitches. more animal models are needed for human mammary tumour research. our objective was to describe equivalent non-neoplastic and neoplastic mammary gland alterations in woman and dog. method: formalin-fixed, paraffin-embedded archived human and canine mammary gland tissue samples. epidemiological data were collected and analyzed from human (n= ) and canine (n= ) patients for the years - . histological comparison was performed with he-stained tissue sections and immunohistochemistry. applied antibodies included ck / , erα, pr, ki , her , p , sma, ecadherin and calponin. results: several comparable benign and malignant mammary gland alterations were identified, consisting of lobular, tubular and ductal as well as mesenchymal of origin. most of these have not been described previously. the epidemiological results show also shared characteristics. conclusion: although there are canine specific lesions there also exist equivalent entities. our results indicate the female canine as a suitable model for translational research. ofp- - st. gallen intrinsic subtyping of breast cancer: influence of proliferation assessment methods c. m. focke * , d. gläser, k. finsterbusch, t. decker * dietrich bonhoeffer klinikum, abt. pathologie, neubrandenburg, germany objective: the st. gallen conference strongly recommends intrinsic subtyping of breast cancer (bc) for therapeutic decisions. we analyzed the influence of different proliferation assessment methods on the bc subtype distribution. method: intrinsic subtyping was performed according to the st. gallen criteria on bcs. proliferation was assessed by mitotic activity index (mai) (area: , mm², cut-off ≥ ) and by several variants of ki -labeling-index counting any nuclear staining of ( ) tumor cells within the hot spot (ki - ), ( ) tumor cells in hpf in the tumor periphery, including the hot spot (ki - periphery), and ( ) tumor cells in hpf, including hot spot, cold spot and an intermediate area (ki - spectrum) using the recommended cut-off of < %. results: of carcinomas, % were triple-negative, % her +, % luminal b her +, and % special type. the rates of bcs after different proliferation assessment methods were: mai % vs. %; ki - spectrum: % vs. %, ki - periphery: % vs. % and ki - : % vs. %. conclusion: subtyping of luminal a and luminal b her neg bcs according to st. gallen is highly influenced by the method of proliferation assessment used. its biological relevance seems to be not unequivocal. ofp- - the utility of cytological smears allied to the osna method for intraoperative analysis of sentinel lymph-node metastasis in breast cancer patients s. foreid * , m. martins, h. pereira, m. oliveira * loures, portugal objective: one-step-nucleic-acid-amplification (osna) is a recently introduced pcr method to evaluate intraoperative sentinel lymph-node metastasis in breast cancer. it assesses the whole lymph-node in a -minutes protocol. many studies have reported it to be more sensitive than frozen section and/or cytology. yet, it is more expensive and takes longer to perform. method: between and at chlc, we have performed the intraoperative analysis of sentinel lymph-node using both osna and cytological smears in a group of patients. results: lymph-node evaluations were done. cases were osna positive ( micrometastasis and macrometastasis). of those, were also positive for tumor cells on cytological smears. cases were negative by both methods and cases were detected by osna but not on cytological smears. importantly, all macrometastasis diagnosed by cytology were confirmed by osna. of notice, in this series, % of the positive cases detected by osna were also detected by cytological smears. conclusion: like previously reported, osna showed a greater sensibility than cytology to diagnose sentinel node metastasis. however, the majority of metastasis can be detected by cytological smears alone. our results suggest that a less expensive and faster cytological analysis should precede osna, and if positive, the latter method could be disregarded. tuesday, september , . - . objective: tumor markers may be concentrated intraductally in early breast cancers. method: to test this hypothesis, her -ecd and ca - of the needle washout fluid from benign lesions, dcis, and invasive carcinomas of the breast were measured using chemiluminescence. the measuring limit for her -ecd ( . ng/ml) and that for ca - ( u/ml) were used as the cutoff values, respectively. results: the proportion of patients with any biomarker elevation was . % in cases of benign lesions, . % in dcis, and . % in invasive carcinomas. thus, biomarker elevation was most frequent in dcis, followed by invasive carcinomas (p< . ). her -ecd values over ng/ml or ca - values over u/ml were s een exclusively in dcis or invasive ductal carcinomas with an extensive intraductal component, supporting the hypothesis. conclusion: our approach may be useful to identify a subset of breast cancer patients who are suitable for intraductal molecular targeted therapy. ofp- - biological significance of proliferation and her overexpression in luminal/oestrogen receptor-positive breast cancer d. jerjees * , a. green, a. benhasouna, a. alshareeda, r. abduljabbar, f. barros, c. nolan, i. ellis, e. rakha * university of nottingham, dept. of oncology, united kingdom objective: in this study, we have compared the biological significance of proliferation; assessed using ki labelling index (ki -li), with respect to her expression in oestrogen receptor positive (er+) breast cancer to assess the impact on growth fraction and biological characteristics of luminal breast cancer. method: well-characterised er + breast cancers were assessed for expression of a large panel of biomarkers (no= ). results: % of the cases showed high ki -li (> %) and % showed her over-expression and both were positively associated with younger age, higher tumour grade, lymph node stage and shorter outcome. both markers were associated with up-regulation of er-coactivators (cd , carm , pi kca&tk ), p-cadherin, p and with lower levels of er expression and down-regulation of er-related genes (pgr, ar&gata ) and brca . neither of the two markers was associated with expression of basal-associated cytokeratins. high ki -li was associated with down-regulation of luminal enriched markers including luminal cytokeratins, muc , gcdfp- , fhit, and transcription and differentiation errelated genes (foxa and tff ). in contrast, her expression was associated with up-regulation of luminal cytokeratins, gcdfp- , fhit and e-cadherin. conclusion: unlike high ki -li, her overexpression is not associated with the down-regulation of luminal enriched genes. increased growth fraction in er + tumours may be driven by different mechanisms in her +&her -disease. ofp- - loss of drosha expression is associated with poor survival in breast cancer patients s. khoshnaw * , t. abdel-fatah, c. nolan, z. hodi, e. rakha, d. macmillan, i. ellis, a. green * university of nottingham, breast cancer pathology, united kingdom objective: drosha is a protein that plays a key role in the biogenesis of micrornas which are well known to be deranged in human breast cancer. the purpose of this study was to investigate the hypothesis that drosha is significant in the development and progression of breast cancer and has clinical relevance as a potential predictive and prognostic target. method: we have examined drosha protein expression, using microarray and immunohistochemistry, in a well-characterised series of unselected invasive breast cancer patients (n= ) with long-term follow-up and documented expression characteristics for a large range of biomarkers of known relevance in breast cancer. furthermore, a smaller cohort of selected breast cancer cases (n= ) was also investigated for differential drosha protein expression in distinct stages of tumour progression, including in situ (dcis), invasive and metastatic components. results: drosha cytoplasmic and nuclear expression was lost with cancer progression, and was associated with loss of brca expression. multivariate statistical analyses showed that drosha cytoplasmic expression was an independent predictor of breast cancer specific survival, tumour recurrence and metastases. conclusion: drosha cytoplasmic expression in breast cancer is an independent predictor of patient outcome, tumour recurrence and metastasis. these observations imply that alterations in mechanisms of mirna regulation can influence tumour behaviour. objective: determination of proliferation in breast carcinomas is highly prognostic and can have treatment implications. however, there is no consensus on issues such as counting area or cut-off values. our aim was to examine and compare ki- counts in various tumor areas, the novel mitosis marker phh , and standard mitotic count. method: we examined a nested case-control series (n= ) as part of the population-based norwegian breast cancer screening program. mitotic count (mitosis per mm ) was assessed on h&e-sections. the percentage of ki- positive nuclei among tumor cells was recorded for both hot-spots (hs; highest proliferation) and cold-spots (cs; lowest proliferation). phh counts (per mm ) were evaluated by immunohistochemistry. results: the upper quartiles for ki- -hs, ki- -cs, phh and mitotic count consistently showed the strongest associations with known unfavorable tumor features (high histologic grade, er negativity, her positivity, ck / +, p-cadherin+). univariate survival analysis showed comparable prognostic strength of ki- -hs, phh count and mitotic count. in multivariate analysis, mitotic count was the strongest prognostic factor among these. conclusion: by upper quartile, ki- -hs, phh and mitotic count all showed strong associations with various tumor features. in multivariate survival analysis, mitotic count was the strongest proliferation marker. objective: ki li is a good marker of breast cancer prognosis. we aimed at comparison of performance of ki antibodies. method: breast cancer cases were retrieved. immunohistochemical staining for ki clones ( - , b , mib , polyclonal, sp ) performed in tma-s in automated immunostainer. evaluation performed on digital slides utilizing linear - frequency score. objective: in breast cancer, classification systems are used to assess pathological response to neoadjuvant chemotherapy. biomarkers are still needed to better predict the efficiency of primary systemic therapy. dysregulation of connexin (cx) channels (gap junctions) is involved in carcinogenesis and tumor progression. method: we have correlated cx expression and the pathological response in neoadjuvant treated breast cancers. fifteen of the human cx isotypes were pre-screened. cx , cx , cx and cx were found widespread and tested in tissue microarrays of breast cancers prior to and after neoadjuvant chemotherapy. pathological response was characterized according to the ewgbsp, cps-eg, miller-payne, sataloff, and nsabp classification systems. results: only the cps-eg classification had prognostic relevance by score - cases presenting better overall survival (p= . ) than those scoring - . cx levels prechemo correlated with hormone receptor status pre-and post-chemo and had inverse correlation with her levels pre-chemo. reduced cx expression (< %) post-chemo correlated with better overall survival (p= . ). moderate or higher cx expression (> %) pre-and post-chemo was also associated with better survival in the ewgbsp tr b (ppre= . ), sataloff tb (ppre= . ; ppost= , ) and miller-payne g (ppre= . ; ppost= . ) subgroups. conclusion: classifications combined with testing for cx and cx expression can improve prediction of neoadjuvant chemotherapy in breast cancer. ofp- - atypical vascular lesions after radiation therapy for breast cancer: a clinicopathologic study and outcomes of cases h. gobbi * , c. fraga-guedes, m. mastropasqua, m. kneubil, e. botteri, g. viale * ufmg, dept. of anatomic pathology, belo horizonte, brazil objective: we assessed clinicopathologic features and outcomes of cases of atypical vascular lesions (avl) in patients submitted to radiation therapy for breast carcinoma. method: data from all patients were retrieved from the files of the european institute of oncology (eio), milan. histopathological review of all cases was carried out. results: all patients were women (median age: year, range: - year). median lesion size was . cm (range: . to . cm). median latency interval from radiation to avl diagnosis was months (range: to months). . % of cases presented as an erythematous unique papule confined to superficial/middermis with proliferation of thinwalled, vascular channels, lined by a single layer of bland endothelial cells. no prominent nucleoli, mitoses or blood lakes were seen. patches of chronic inflammatory infiltrate accompanied all avl. one patient ( . %) developed local recurrence, and two patients ( . %) developed angiosarcoma in the previous biopsy site, and months later. margin involvement was associated to unfavorable outcome. conclusion: our data suggest that post-radiation avl and angiosarcoma may represent a spectrum of the same disease process. the development of local recurrence and subsequent angiosarcoma indicate that avl must be completely excised, with free surgical margins, and patients must be accompanied by clinical exams and imaging. objective: gastric dysplasia is classified as gastric/foveolar and intestinal/adenomatous according to morphological (architectural and cytologic) features. the immunophenotypic classification of dysplasia, based on the expression of mucins and cd , recognizes three major types: gastric (muc ac and/or muc ); intestinal (muc and/or cd ); hybrid (gastric and intestinal markers). cdx is a transcription factor responsible for early intestinal differentiation. aldh is recognized as a stem cell marker in several organs. method: nineteen cases of dysplasia were classified as gastric/foveolar (n= ) or intestinal/adenomatous (n= ) and graded as low-grade (n= ) and high-grade (n= ). immunophenotypic classification showed gastric (n= ; %), intestinal (n= ; %) and hybrid (n= ; %) phenotypes. results: cases classified by morphology as gastric/foveolar-type displayed gastric ( %) or intestinal ( %) immunophenotype, whereas intestinal/adenomatous-type cases displayed gastric ( %), intestinal ( %) or hybrid ( %) immunophenotype (p= . ). high-grade dysplasia was identified in cases with gastric ( %), intestinal ( %) and hybrid ( %) immunophenotype (p= . ). cdx expression was significantly lower (p= . ) in gastric ( %) than in intestinal and hybrid immunophenotypes ( %). aldh expression was displayed only in gastric ( %) and hybrid ( %) immunophenotypes (p= . ). conclusion: gastric dysplasia is heterogeneous and morphology is insufficient to elucidate cell differentiation. high-grade dysplasia, decreased cdx expression and high aldh expression are associated with gastric immunophenotype. ofp- - tumor budding in pancreatic cancer: are we missing important prognostic information? d. born * , i. zlobec, m. montani, b. gloor, a. lugli, e. karamitopoulou-diamantis * universität bern, inst. für pathologie, switzerland objective: tumor budding is defined as single tumor cells or small cell clusters at the invasive front of gastrointestinal (including colorectal, gastric and ampullary) carcinomas and is linked to adverse prognosis. to date it has not been reported in pancreatic ductal adenocarcinomas (pdacs). we assessed the presence and prognostic importance of tumor budding in pdac. method: whole-tissue sections of pdacs with full clinico-pathological and follow-up information were stained with pancytokeratin. tumor budding was assessed in high-power fields (hpfs) by two pathologists and considered high-grade (hg) when an average of > buds was counted. measurements were correlated to the patient and tumor characteristics. results: inter-observer agreement was strong (icc= , ). hg-budding was found in . % of cases and was linked to advanced pt-stage (p= . ), lymphatic invasion (p= . ) and decreased disease-free and overall survival (p< , and p= , ). there was no association with pn, pm, r-stage or vascular invasion. in multivariate analysis the prognostic effect of hg-budding was independent of lymphatic invasion, pn and r-stage [p< , , hr ( % ci)= , ( , - , )]. conclusion: tumor budding occurs frequently in pancreatic cancer, is an indicator of worse outcome and adds independent prognostic information. routine use of tumor budding would help to better stratify patients into prognostic subgroups. ofp- - epstein-barr virus and p in the development of gastric cancer v. genitsch * , m. cathomas, l. terracciano, l. tornillo, a. lugli, a. marx, g. sauter, f. carneiro, f. hofstädter, n. willi, g. cathomas * kantonsspital baselland, abt. pathologie, liestal, switzerland objective: epstein-barr virus (ebv) is associated with a subset of gastric cancers (gc) . in this study, the prevalence of ebv and its presence in the development of gc were assessed. method: ebv was evaluated in gc by tissue microarrays using in situ hybridization for eber (n= ). non-tumorous, dysplasia, intramucosal and invasive carcinomas and metastasis of ebv positive gc were analyzed (n= ). p expressen was evaluated in ebv positive and a subset of ebv negative gc. results: . % of gastric cancers were positive for eber. all invasive cancers showed diffuse eber positivity and only lymph nodes revealed a focal loss of eber. in gc with foci of atypia/low grade dysplasia, no or only focal eber positivity was observed. p was overexpressed in of ebv negative but not in ebv positive gc ( . % vs. %; p= . ). conclusion: ebv is diffusely expressed in invasive gc and only occasionally lost in metastasis. in low grade dysplasia, however, ebv is often focal or missing, indicating that ebv infection may be associated with progression from low grade dysplasia to invasive cancer and this progression is p independent. ofp- - p x r attenuates colitis associated carcinogenesis p. hofman * , t. juhel, m. ilie, o. bordonne, o. boyer, x. hebuterne, s. adriouch, v. vouret-craviari * chu de nice, lpce, france objective: it is now well established that patients with inflammatory bowel disease presented a higher risk to develop a colon cancer. our previous works characterized the link that exists between bacterial infection and inflammation and highlighted the role of the microenvironment on the onset of chronic inflammation. here, we wished to understand the role of inflammasome, a complex of proteins that is activated by microbial motifs and the purinergic receptor p x and involved in the maturation of il- β. method: we treated p x r knockout mice to induce acute colitis ( % dss) or colitis associated colon cancer (aom and dss). results: we showed that p x r ko mice are more resistant than wild type mice to a dss-induced colitis. further, we demonstrated that p x r ko mice are highly susceptible to inflammation driven colon tumorigenesis. in addition, we showed that tumors from p x r ko contained more neutrophils (cd b+/ly g + cells) and less macrophage (cd b+/ly g-) than tumors obtained from wt mice. conclusion: we will present results on the characterization of the pro tumoral tumor associated neutrophils and the molecular mechanisms that are linked to the presence of such immune cells. ofp- - iel counts and distribution in normal duodenum, non-gse ielosis and gse: do we need a cut-off? b. a. karabork * , s. yuksel, b. savas, a. ensari * ankara university of medicine, dept. of pathology, turkey objective: intraepithelial lymphocytosis (ielosis) is a characteristic feature of gluten-sensitive enteropathy (gse), though, the cut-off is still debatable. we aimed to evaluate the number and distribution of iels in normal duodenum, and in non-gse ielosis and gse. method: the study group comprised of a spectrum of normal duodenal biopsies (n= ), non-gse ielosis (n= ), type (n= ) and type (n= ) serologically diagnosed gse cases. the number of iels/ enterocytes and distribution on h&e and cd -immunostained sections, were assessed for each group. chi square test was used for statistics. results: iels increased significantly through the spectrum ( , in normal, , , in type , , in type ) on h&e and cd , respectively (p< , ). iel counts ≥ on h&e and ≥ on cd had a sensitivity of , % and %, and a spesificity of , % and , %, respectively, for gse. iel distribution was diffuse in type ( , %), type ( %) but focal in non-gse ( %) (p< , ). conclusion: the current cut-off for iel counts seems to be sensitive for ielosis, though, not specific for gse and needs to be accompanied by the diffuse distribution of iels. ofp- - geographic analysis of the protein expression of metastasis suppressor gene rkip and its clinical relevance in colorectal cancer v. koelzer * , e. karamitopoulou, h. dawson, a. lugli, i. zlobec * university of bern, inst. of pathology, switzerland objective: loss of raf- kinase inhibitor protein (rkip) expression has been implicated in disease progression in several tumor types. the aim of this study was to evaluate rkip expression in colorectal cancer stratified by histological "zones" and to determine the zone responsible for its clinical relevance. method: immunohistochemical expression of rkip was assessed in colorectal cancers using whole tissue sections. four different areas were evaluated using highpower-fields (hpfs) each: normal mucosa, tumor center, invasion front and tumor buds. the average expression for each zone was assessed for its clinical relevance. results: expression of rkip was diffuse in normal mucosa and progressively lost towards the tumor center and front ( %, % and % rkip-positivity, respectively; p< . ). only % of tumor buds were rkip-positive. rkip loss in the tumor center only corresponded to more frequent lymph node positivity (p= . ), distant metastases (p= . ), lymphatic invasion (p= . ) and more advanced tnm stage (p= . ). rkip loss was highly prognostic (hr ( % ci): . ( . - . ); p= . ) independently of tnm and therapy. conclusion: the clinical relevance of rkip is restricted to the tumor center where it acts as an independent prognostic factor. its absence in tumor buds provides further evidence to support their hypothesized metastatic potential. ofp- - outcomes of neoadjuvant chemoradiation for rectal carcinoma g. ozgun * , f. oz atalay, n. ugras, o. yerci * uludag university, dept. of pathology, bursa, turkey neoadjuvant radiation and chemoradiation is currently the treatment of choise for patients with locally or advanced carcinoma of the rectum. patients treated with neoadjuvant chemoradiatheraphy with good clinical response and tumor regression present a controversial management dilemma. to assess the effects of chemoradiation on tumor regression and disease free survival, consecutive series of patients receiving neoadjuvant chemotheraphy or chemoradiation and a control series of patients without pretreatment were studied. the overall survivals and disease free survivals were compared in terms of variables such as tumor regression grade, stromal response in tumor bed, state of lymph node metastasis, and the localization of the tumor in between patients treated with chemoradiation and the control group. neoadjuvant treatment is one of the treatment modalities in rectal carcinomas. we want to present our experience between and in our institution. key words: rectal carcinoma, neoadjuvant treatment, pathologic complete response ofp- - identification of tissue microvascular invasion biomarkers in hepatocellular carcinomas by maldi imaging mass spectrometry n. poté * , t. alexandrov, j. le faouder, s. laouirem, j. belghiti, j. m. camadro, v. paradis, p. bedossa * paris, france objective: microvascular invasion (mvi), a major predictive factor of tumoral recurrence and mortality in patients with hepatocellular carcinoma (hcc), is only detectable on pathological examination. so far, there is no reliable tool to identify mvi prior to surgical procedures. maldi imaging mass spectrometry (ims) represents a new analytical tool to provide the relative abundance and distribution of the whole proteins expressed in a tissue section. the aim of this study was to compare, using maldi ims, the tissue proteome of hcc without and with mvi in order to identify surrogate biomarkers of mvi. method: a total of hcc samples obtained from surgical specimens, for which frozen samples were available, were retrospectively collected. two groups of tumors were defined ( hcc without mvi; hcc with mvi) and were analysed by maldi ims. a statistical comparative analysis of acquired mass spectra was then performed in order to identify protein peaks differentially expressed between the two groups. results: protein peaks were differentially expressed between the two groups, all overexpressed in hcc with mvi. protein characterization of some of these peaks is in progress. conclusion: these results highlight the potential of maldi ims to uncover new biomarkers in liver carcinogenesis. the identification of mvi biomarkers would be helpful in the therapeutic strategy of patients with hcc. ofp- - a histopathological scoring system can predict the recurrence of hepatocellular carcinoma in liver transplant patients treated with transarterial chemoembolization f. rosini * , f. vasuri, d. malvi, p. baldin, w. f. grigioni, a. d´errico-grigioni * university of bologna, dept. of anatomic pathology, italy objective: aim of this study is to define the histopathological features predictive of hepatocellular carcinoma (hcc) recurrence in patients treated with orthotopic liver transplantation (olt) after tumoral transarterial chemoembolization (tace), in order to establish a predictive "score" applicable by pathologists for recipient risk stratification. method: we retrospectively enrolled patients ( total neoplastic or necrotic nodules) who received tace for hcc downstaging before olt. the following data were collected: number of neoplastic/necrotic nodules, microscopic thrombosis, the residual neoplastic tissue (rnt), and dysplastic nodules. sizes, percentage of necrosis, edmondson's grade, clear cell features were also collected for each nodule. results: median follow-up was days: ( %) hcc recurrence cases were recorded. statistically rnt (best cutoff cm , p= . ), the total nodule number (best cut-off ≥ , p= . ), and the neoplastic thrombosis (p= . ) were the only variables predictive of hcc recurrence. scoring + each parameter, recipients with (n= ) had % recurrence rate; recipients with +/ + (n= ) had %; recipients with + (n= ) had % recurrence rate (p< . ). we were able to stratify olt recipients with tace-treated hcc in risk groups based only on histopathological analysis. ofp- - discovery of a new histopronostic factor in rectal adenocarcinoma treated by radiochemotherapy followed by surgical resection a. sannier * , j. lefèvre, f. bretagnol, d. cazals-hatem, y. panis, p. bedossa, n. guedj * paris, france objective: neoadjuvant radiochemotherapy (rct) followed by surgical resection became the treatment for locally advanced rectal cancer. pathological diagnosis is important for the prediction of prognosis and adjuvant treatment. study aim was to identify histopronostic factors in a consecutive series of patients treated by rct and surgery. method: patients were included, follow-up, tumor morphologic pattern and modified rectal cancer regression grade (m-rcrg) were assessed. univariate and multivariate analysis were used to assess predictors of disease-free survival (dfs). results: -years dfs was %. in univariate analysis, ypt, budding, calcifications, circumferential margin, node involvement, invaded margin, vascular emboles and perineural involvement were pronostic factors (p< . ). in multivariate analysis, presence of calcification in tumor bed (p= . ) and small circumferential margin (p= . ) were the only two independent factor of worse dfs. mrcrg was not correlated to dfs. among the mrcrg tumor, dfs was significantly better in patient with ypt than in other ypt stages (p= . ). conclusion: presence of calcification in tumor bed is a new major histopronostic factor described for the first time in rectal cancer. our results raised the question of whether ypt stage or histological tumor regression is more important in the prediction of patient prognosis. tuesday, september , . - . objective: the most widely used system for histological grading of colorectal cancer (crc) is based on the degree of gland formation, despite significant interobserver variability and low prognostic value. herein we analyzed the prognostic significance of a grading system based on the presence of poorly differentiated clusters in stage i crc. method: poorly differentiated cancer clusters were assessed by two independent pathologists in stage i crc characterized or not by disease progression. tumors with < , to , and > clusters were classified as g , g , and g , respectively. the prognostic value on disease-free survival and the association with other clinicopathologic characteristics of the conventional and novel grading systems were analyzed. results: k statistics for inter-observer variability in the assessment of histological grade based on poorly differentiated custers was . (good). high histological grade assessed with the novel system, but not with the traditional one, represented a negative significant prognostic factor for disease-free survival and it was significantly associated with venous invasion, lymphatic invasion, budding, invasive growth and nodal micrometastases. conclusion: we suggest that a tumor grading system based on the number of poorly differentiated clusters has a stronger power to stratify stage i crc patients by prognostic outcome than conventional grading. ofp- - cytokeratin : a marker for braf mutated colorectal carcinomas? s. gurzu * , z. szentirmay, i. jung * university of targu mures, dept. of pathology, romania objective: cytokeratin +/cytokeratin − (ck) is used as the characteristic immunophenotype of colorectal carcinomas (crc) . some new studies suggested that aberrant pattern ck /ck can be identified in colorectal cancer with microsatellite instability (msi). our aim was to establish which factors may determine changing in this immunophenotype. method: in crc, randomly selected, we performed immunohistochemical stains with ck and ck and analyzed the microsatellite status and braf mutations with real time pcr. results: from the crc, were msi and mss (microsatellite stable) cases. % of mss cases diffusely expressed ck without ck expression. from the msi cases, presented braf mutations. in msi cases with braf mutations, ck was focally expressed or negative and ck was diffusely expressed. conclusion: cytokeratin positivity may be used to select braf mutated msi colorectal carcinomas. both ck and ck should be used for differential diagnosis of colorectal cancer. ofp- - intratumoral budding in preoperative biopsies predicts local and distant metastasis in colorectal cancer patients a. lugli * , m. hädrich, d. inderbitzin, m. borner, i. zlobec * medizin. universität bern, inst. für pathologie, switzerland objective: in , the term "intratumoral budding, itb" was used to describe the presence of tumor buds within the main tumor body and was correlated to worse clinical outcome in colorectal cancer patients. here, we further elucidate the potential clinical role of itb in pre-operative biopsies using pan-cytokeratin stained tissues and a quantitative scoring system. method: pre-operative biopsies from patients with colorectal cancer underwent immunohistochemistry for pancytokeratin (ae /ae ). itb were counted in the area of densest budding ( ×) and classified as high-grade when > buds/hpf were observed based on receiver operating characteristic (roc) curve analysis. results: high-grade itb occurred in . % of cases and was associated with right-sided tumor location (p= . ), more advanced pt (p = . ) and pn (p< . ) classifications, distant metastasis (p = . ), higher tumor grade (p= . ) and lymphatic invasion (p= . ). the specificity and positive predictive value for lymph node metastasis was . % and . %, respectively. disease-free survival was significantly worse in patients with high-grade itb ( -year survival= %) in comparison to patients with low-grade itb ( -year survival= %) (p= . ). conclusion: the assessment of itb in pre-operative biopsies is predictive of local and distant metastasis in corresponding resections and should be considered in daily management of colorectal cancer patients. ofp- - alpha-methylacyl-coa (amacr) in gastric cancer -correlation with clinicopathological data and disease free survival a. mroz * , m. kiedrowski, z. lewandowski * cmkp, gastroenterology and hepatology, warsaw, poland objective: diagnostic and prognostic significance of alphamethylacyl-coa (amacr) has been established in many human cancers. its correlation with clinical and pathological data in gastric cancer has not been fully elucidated and its impact on surveillance has not been studied thus far. method: we analyzed consecutive gastric cancer cases in terms of amacr immunohistochemical expression and clinical/pathological characteristics and followed patients' postoperative history. results: amacr was expressed in / gastric cancers ( . %). we did not find correlation between amacr expression and gender, age, location, histological type, ptn staging, vascular and nerve sheaths invasion. overall disease-free survival tended to be worse in amacr positive patients (p= . ), and in adenocarcinoma subgroup it was significantly shorter (p= . ). conclusion: amacr expression might represent promising adverse prognostic factor in gastric cancer, particularly in adenocarcinoma histological type. ofp- - development of a rabbit monoclonal antibody for determining hent status and predicting response to gemcitabine in pancreatic ductal adenocarcinoma m. raponi * , j. isaacson, j. ranger-moore, j. clements, b. richardson, s. ormanns, k. winter, a. allen, r. andersson, v. heinemann, a. p. dicker * clovis oncology, san francisco, ca, usa objective: human equilibrative nucleoside transporter (hent ) is the primary membrane channel through which gemcitabine (gem) enters pancreatic tumor cells, and patients whose tumors have low expression of hent may derive little benefit from gem therapy. method: an analytically validated rabbit monoclonal antibody immunohistochemistry (ihc) in vitro diagnostic (ivd) for assessing the degree of hent expression in pancreatic adenocarcinoma using an automated ihc platform has been developed. results: using primary tumor samples (n= ) from a randomized controlled clinical adjuvant trial (rtog - ), we developed and verified a hent scoring methodology and cut-off for identifying patients least likely to benefit from gem (hent -low). the distribution of hent expression was similar between these samples and an independent set of pancreatic adenocarcinoma specimens from the aio-pk study of which were confirmed metastatic biopsies. overall, using this cut-off, approximately two thirds of pancreatic tumors displayed low-hent expression across the different data sets. conclusion: a robust hent ihc ivd has been developed using a rabbit monoclonal antibody and identifies two thirds of primary and metastatic pdac cases as having low expression of hent . ofp- - hypoxia activates pancreatic stellate cells: development of an organotypic culture model of thick slices of normal human pancreas v. rebours * , m. albuquerque, p. ruszniewski, p. lévy, a. sauvanet, v. paradis, p. bedossa, a. couvelard * beaujon hospital, pancreatology unit, clichy, france objective: pancreatic stellate cells (psc) promote oncogenesis by modulating cell proliferation. aim-to evaluate the early activation of psc in case of hypoxia in normal human pancreas. method: an organotypic culture model of thick sections of human pancreas has been developed and validated. slices of pancreas ( μm) were prepared from surgical specimens and cultured in hyperoxia conditions. half of the samples underwent an initial phase of culture in normoxia ( % o ) to reproduce hypoxia. the total duration of culture was h. cell viability, hypoxia, apoptosis and activation were monitored. results: sections per specimen were cultured. analysis was performed at baseline, h, h and h. morphological analysis showed gradual appearance of ductal/acinar dedifferentiation. at h, foci of necrosis were identified. hypoxia was confirmed by the expression of hif and ca at h ( % and % of labeled cells). apoptosis was limited, acinar cells expressed caspase at and h. analysis of proliferation using ki index showed significant activation of psc at h (× /baseline) and at h (× / baseline). activation of psc was confirmed by smooth muscle actin immunochemistry. conclusion: organotypic culture of normal human pancreas is possible with optimized cell viability at h. hypoxiainduced activation of psc occurs very early. objective: ipn are still poorly characterized precursor lesions of bile duct adenocarcinoma. we present a multicenter study with focus on morphology, subtyping and prognosis and provide a detailed molecular analysis in the stepwise progression from low-grade to high-grade lesions and invasive carcinoma. method: fourty-five patients with biliary ipn were included into the cohort, twenty-two patients with conventional adenocarcinoma of the bile duct served as control cohort. subtyping was performed based on histomorphology and expression profile of mucins and cdx expression. furthermore, low grade lesions (n= ), high-grade lesions (n= ) and invasive components (n= ) of ipn as well as conventional bile duct adenocarcinomas (n= ) were investigated individually for alterations of common oncogenic pathways using immunohistochemistry, real-time polymerase chainreaction and direct sequencing. results: ipn are mainly detected at preinvasive stage ( %), pancreato-biliary and intestinal type are the most common subtypes ( and %, respectively). detailed molecular analysis showed that p overexpression, k-ras mutation, loss of heterozygosity of p locus and nuclear ßcatenin expression are early events and loss of smad and overexpression of egfr and her are later events in the tumor progression of ipn. conclusion: stepwise alterations of common oncogenic pathways are required for progression of biliary ipn from non-invasive precursors to invasive carcinoma. ofp- - influence of braf mutations and rac b/rac mrna ratio or protein expression on outcome in patients with metastatic colorectal cancer (mcrc) treated with firstline chemotherapy m. cuatrecasas * , v. alonso-espinaco, p. jares, c. horndler, a. castells, j. j. lozano, j. maurel * hospital clinic, barcelona, spain objective: metastatic colorectal cancer (mcrc) patients with braf mutation v e present poor overall survival (os). rac b, a rac spliced variant, is overexpressed in crc and impairs apoptosis by activation of nuclear-factor-kb. we evaluated if rac b was an independent prognostic factor in mcrc. method: we examined braf (v e) mutational status, rac b by immunohistochemistry, rac b/rac expression ratio by mrna rt-pcr, and mismatch repair (mrr) deficiency by microsatellite instability (msi) analysis, in mcrc patients treated in firstline therapy with folfox or capox from three spanish institutions. we assessed whether these biomarkers were independently predictive of progression free survival (pfs) or os. results: % crc had braf mutations, % msi-h, % high rac b/rac ratio, and % rac b protein overexpression. five of crc ( %) with braf mutations had high rac b/rac ratio/protein vs / ( %) without braf mutation (p= . ). all braf mutated or rac b/rac high were mss. low rac b/rac ratio and braf wt had higher response rate ( % vs %; p= . ). multivariate regression analysis identified ecog ps as a significant variable for pfs and ldh levels, ps and high rac b/rac ratio for os. conclusion: high rac b/rac expression ratio or immunoexpression constitutes a marker of poor os and a potential marker of acquired chemo-resistance in mcrc treated with oxaliplatin-based therapy. objective: annually more than . new cases of papillary thyroid cancer, that is % of malignant tumors, are registered all over the world. method: there are clinical and morphologiсal methods: immunohistochemistry (mmp- , mmp- , timp- , timp- ), light, transmission, electron, probe and scanning microscopy with the trace element analysis. it was studied cases of thyroid cancer since. results: at the papillary thyroid cancer progression matrix metalloprotease and specific tissue inhibitors of metalloprotease (timp- ) increased in the cytoplasm of tumor cells, but the concentration of timp- decreased. tumors with low degree of ultrastructural differentiation were presented by cells with electron-dense dark cytoplasm and cells with poor cytoplasm organelles and differently formed nucleus with numerous deep invaginations. high level of some matrix metalloproteaseexpression (ММР- ) and low level of timp expression (Тimp- ) were observed in current cases more ( % and % respectively), than at more differential papillary thyroid cancer ( % and %). at performance of atomic force microscopy it was shown that connection between cells had become weak at the decreasing of malignancy degree. it was revealed the significant increasing of oxygen, magnium, potassium, calcium in tumor nodes. conclusion: conducted comlex morpho-chemistry analysis display diagnostic patterns of papillary thyroid cancer. objective: cytological features of btn-ph, sometimes interpreted as papillary carcinoma (pc) on fine-needle aspiration biopsies (fnab), have not been studied extensively. method: available material from btn-ph was reviewed retrospectively and compared with pcs. results: fnab diagnoses were: non-diagnostic (n= ), benign (n= ), aus/flus (n= ), suspicious for follicular neoplasm (n= ), suspicious for malignancy (s-pc) (n= ), and malignant (p-pc) (n= ). the extent of papillary hyperplasia on histology was higher in s-pc/p-pc diagnostic categories ( %; p= . ; range: - %). on cytology, papillary structures, present in % of bpn-ph cases, were more frequent and numerous in the s-pc/p-pc group ( %; p= . ). focal nuclear atypia was seen in all s-pc/p-pc cases, including rare grooves ( . %), enlargement/crowding ( %), chromatin clearing/rare pseudoinclusions ( %), but were less than in pcs (p< . ). nuclei were smaller in btn-ph than in pcs (mean diameter/range (μm): . / - vs . / - ; p= . ). all btn-ph tested (n= ) were immunonegative for hbme- , galectin- , and keratin- . conclusion: btn-ph diagnosed as s-pc/p-pc often show papillary structures and focal nuclear features of pc but they are significantly less than in classical pcs, stressing the need to apply strict criteria for pc diagnosis. ofp- - genetic alterations in glucagon cell adenomatosis t. henopp * , m. anlauf, s. biskup, g. klöppel, b. sipos * medizin. universität tübingen, inst. für pathologie, germany objective: glucagon cell adenomatosis (gca) was recently recognized by us as a multifocal neoplastic disease of the endocrine pancreas unrelated to men . multiple micro-and a few macrotumors are found on the background of a hyperplasia of glucagon cells. the disease may cause unspecific abdominal symptoms and only rarely a glucagonoma syndrome. recently a mutation in the glucagon receptor (gcgr) gene was described in one gca patient. method: the extracted dna of five patients with gca was sequenced and the gcgr gene analyzed for mutations. results: sequencing of the gcgr gene revealed germline mutations in three out of five patients. one patient shows two different heterozygous point mutations in the hyperplastic alpha cells as well as in the non-tumorous tissue leading to two premature stop codons. one patient harbors a homozygous stop mutation. the third patient shows two homozygous missense mutations of the gcgr gene that most likely also led to a dysfunction of the gcgr. in the two other patients no germ line mutations of the gcgr gene were detected. these variants were not identified in healthy subjects. conclusion: the finding of germ line and somatic "loss of function" mutations of the gcgr gene in three of five patients with gca suggests that a change in the signalling function of the gcgr may cause glucagon cell adenomatosis via glucagon cell hyperplasia. ofp- - timp- expression and hypoxia in papillary thyroid carcinoma: relationship to brafv e mutation and clinical behavior m. ilie * , s. lassalle, p. brest, c. bonnetaud, a. bozec, n. guevara, j. haudebourg, i. birtwisle-peyrottes, j. santini, p. hofman * chu de nice, lpce, france objective: brafv e causes up-regulation of timp- , promoting cell invasion in papillary thyroid carcinoma (ptc). hif- α is regulated by hypoxia but also by brafv emediated signaling pathway in ptc. we assessed the impact on clinical behavior in ptc of timp- , hif- α and the hypoxia-inducible caix and caxii. method: the protein expression was assessed by western blot in two cell lines, tpc- /brafwt and bcpap/ brafv e. tma-immunohistochemistry analysis was used to study protein expression in ptc samples. braf status was analyzed by pyrosequencing. data were correlated with clinicopathological variables of patients. results: higher expression of all proteins was detected in bcpap exposed to hypoxia. timp- expression displayed % sensitivity and % specificity for identifying braf mutation (p< . ), and was associated with pt-stage (p= . ), pn-stage (p= . ), and multifocality (p= . ). hif- α expression was correlated to pt-stage (p= . ). caix expression was related to pn-stage (p= . ), and both caix (p= . ) and caxii (p= . ) were highly associated with vascular invasion. conclusion: timp- protein expression is reliable surrogate of braf mutated status in ptc. timp- and hypoxiaregulated proteins have potential for future use as predictors of the malignant change in ptc, and warrant further investigation as new therapeutic targets for the treatment of highly aggressive form of ptc. objective: mtc are usually aggressive tumours which account for - % of all thyroid carcinomas. most of mtc are sporadic, the remaining tumours are due to hereditary forms with germline activating mutations of the ret proto-oncogene. the aim of this study was to assess the microrna profiling expression in both sporadic and hereditary forms of mtc. method: a total of frozen mtc from patients with welldocumented clinico-pathological parameters were used for microarray analyses ( hmtc and smtc) using human microrna mircoarray kit version (agilent technologies). after identification of a set of mirna of interest, validation was done using qpcr. results: when comparing hmtc harbouring germinal ret mutation with smtc, seven mirnawere significantly deregulated (mir- , − a, − c, − a, − - *, − b, − ). the most highly discriminative mirna in tumoral samples (> fold change) identify mir- , − - p, − , − c and − . moreover, mirna could segregate mtc with good prognosis and better clinical outcome (mir- , − , − , − and − ) . conclusion: a specific microrna signature in hmtc can be identified. moreover, detection of micrornas in tissue samples might be of interest for improved clinical management and treatment of patients with mtc. ofp- - focus on the follicular variant of papillary thyroid carcinoma: combination of the immunohistochemical markers ck , hbme and tpo is associated with histopathological diagnosis, better than molecular markers objective: the follicular variant (fvptc) is the major variant of papillary thyroid carcinoma (ptc), ranging from % to % of all ptc. it remains however a problematic entity. some consider that the encapsulated fvptc (enfvptc) have an excellent prognosis like follicular adenomas (fa); others showed that enfvptcs had potential for hematogenous spread like follicular carcinoma. its place in the spectrum the multivariate cox regression the flt -itd mutation (p= . ) was an independent poor prognostic factor, whereas the goodness-of-fit of the minkowski fractal dimension an independent favorable prognosticator (p= . ). the karyotype had no influence on survival. conclusion: flt -itd and chromatin fractal characteristics were more important as prognostic factors for overall survival than karyotype and gene methylation status. financial support: fapesp and cnpq. objective: the prevalence of cyclin d (cyd ) positive bcells with mantle cell lymphoma (mcl) phenotype in the mantle zones of reactive lymph nodes ("in situ" mcl/mclis). and related minimal mcl infiltrates in reactive lymphoid tissues of healthy individuals and in mcl patients are unknown. method: all . reactive lymph nodes from unselected consecutive surgical specimens of patients without a history of lymphoma obtained over a months´period were stained for cyd . additionally, all morphologically reactive lymph nodes and extranodal lymphoid infiltrates of mcl patients from to were studied. samples predating the lymphoma diagnosis for at least months were available from / ( . %) patients. results: a mclis was not identified. however, in four mcl patients, an early manifestation of mcl with mantle zone growth pattern was detected retrospectively, antedating the lymphoma diagnosis for - months. in six mcl patients, only small groups of cyd positive cells in morphologically reactive extranodal infiltrates were detected more than months before the diagnosis of mcl (range - months). conclusion: mcl "in situ" is an extremely rare phenomenon in morphologically reactive lymph nodes. in mcl patients, however, immunohistochemically detectable infiltrates of mcl cells antedating the lymphoma diagnosis were found in a significant proportion of cases ( / = %). ofp- - e f- 's relationship with tumor growth in hodgkin's lymphoma is regulated by p status e. georgiadi * , g. dimtsas, t. p. vassilakopoulos, v. g. gorgoulis, i. a. doussis-anagnostopoulou * larisa, greece objective: e f- is a member of the e f family group of transcriptional factors that play a major role in cell cycle progression and arrest, as well as in apoptosis. in different tumors e f can demonstrate opposing roles, acting either as an oncogene or as a tumor suppressor gene. method: we have previously established e f- 's immunohistochemical expression in hodgkin lymphoma (hl) and its correlation with p expression, although no relationship with either proliferation or apoptosis was demonstrated. a further investigation in a larger series of cases of primary hl with the addition of new apoptotic techniques and the use of p expression as an indicator of p functional status was undertaken. results: following stratification of our cases based on p functionality, e f- was inversely correlated with the proliferation marker topoiia. independently of p , high levels of e f- expression showed a linear trend with apoptosis and an inverse trend with proliferation (borderline p value in both cases). conclusion: both e f- and p activity is upregulated in hl, however it seems that p status is a major regulator of the relationship between e f- expression and tumor growth. alternatively, e f- may use p -independent pathways to induce apoptosis. objective: ptld represent a spectrum of usually ebv-driven lymphoplasmacytic proliferations in the settings of immunodeficiency associated with allograft. ebv infects cells in latent or lytic forms. although viral oncogenes are expressed in latency programs, lytic ebv replication is required to develop lymphomas in mouse models. the role of intratumoral ebv replication in ptld has never been addressed before. method: a series of ptld was reviewed and ebv latency genes were explored in all cases and included eber - , lmp and ebna . moreover, two early lytic genes involved in ebv replication, bzlf /zebra and ead were also analyzed. all clinical and pathological data were collected. results: the median age was years ( - ) with a male predominance ( m: f). ebv infection was observed in cases ( %). ebv replication was observed in % of the cases. these were more likely to be polymorphic ptld with latency iii in the context of stem cell transplantation. moreover these cases had atypical clinical presentations such as brain involvement or disseminated disease with aggressive behavior (os: months vs. months). conclusion: ebv replication occurs in tumor cells of ptld-patients associated with poor outcome and may be share common morphological and phenotypical features. in routine praxis, their differential diagnosis might represent a challenge requiring a specific work-up of immunohistochemical (ihc) and fluorescent in situ hybridization (fish) analyses. method: paraffin sections from cd +/cd + blastic b-nhl were examined for cyclin-d , cd , bcl- and mum- ihc expression together with fish method using probes for ccnd rearrangement and/or igh/ccnd translocation. the final diagnosis was established according to the criteria of who classification. results: / cases were diagnosed as bmcl showing cyclin-d positivity and ccnd rearrangement, other analysed ihc markers were negative. five of these cases were polyploid. / cases were diagnosed as cd + dlbcl in spite of coexpression of cyclin-d in of them, as they showed various cd , bcl- and mum- expressions and missed ccnd gene rearrangement. conclusion: cyclin-d positivity may appear in other than mcl lymphomas due to changes at transcriptional or posttranscriptional level. in spite of overlaping phenotypes, fish analysis of ccnd represents an effective tool to increase the diagnostic accuracy to distinguish cd + dlbcl from bmcl. supported by vega grant nr. / / and projects ceprii (imts: ) and mdcc (imts: ) co-financed by eu sources. ofp- - still's disease associated lymphadenopathy: report of two cases resembling malignant lymphoma with review of possible morphological findings k. kamarádová * , m. nova, m. kalinova, v. campr * prague, czech republic objective: still's disease (or systemic onset juvenile idiopathic arthritis, sojia) is a systemic inflammatory disorder characterized by fever, rash, and arthritis. it has a peak of incidence in early childhood with rare occurence in adulthood (adult-onset still's disease, aods). several other symptoms as hepatosplenomegaly, leukocytosis and lymphadenopathy may be associated possibly mimicking malignant lymphoma. method: we present two cases of still's disease associated lymphadenopathy in a child and in an adult simulating morphologically peripheral t-cell lymphoma and classical hodgkin lymphoma respectively. results: histological, immunohistochemical and molecular examination revealed non-neoplastic lymphadenopathy with atypical paracortical t-cell hyperplasia with immunoblastic reaction in the former and burnt-out histiocytic pattern in the latter, both falling into a broad spectrum of reactive lymph node changes associated with still's disease. the lymph node lesions in still's disease can be histologically divided into four major categories: ) simple atypical paracortical hyperplasia, ) burnt-out histiocytic pattern, ) exuberant immunoblastic reaction in paracortical hyperplasia and ) follicular hyperplasia. the second and the third pattern may closely resemble malignant lymphoma. extended and careful clinical examination with relevant laboratory findings and possible complex histochemical and molecular analysis are necesarry to rule out the suspition of lymphoma. objective: intravascular large b-cell lymphoma (ivlbcl) is a rare form of diffuse large b-cell lymphoma characterized by exclusive or preferential intravascular growth. ivlbcl often goes clinically unrecognized. we report three clinically unsuspected cases of classic variant ivlbcl. method: cases diagnosed as ivlbcl were collected from the pathology files of germans trias i pujol hospital. the diagnosis was reviewed in agreement with who criteria and immunophenotypic and clinical data were gathered. results: a -year-old male and an year-old-male showed neurological symptoms leading to progressive deterioration and death. a -year-old female presented with fever of unknown origin and died days after admission. at autopsy there were no gross findings suggestive of a neoplastic process in any instance. histologic study showed intravascular large b cells with vesicular nuclei involving predominantly the central nervous system in the first two cases and the adrenal glands, liver, and spleen in the third case. conclusion: the three cases of aggressive, advanced-stage lymphoma herein described illustrate how the clinical diagnosis of ivlbcl remains elusive due to its low frequency and variegated clinical presentation and how the pathologic diagnosis of ivlbcl continues to be highly dependent on autopsy examination. objective: the world health organisation (who) currently recognises four categories of ptld, which are lymphoid/ plasmacytic proliferations occurring due to immunosuppression after organ transplantation. the aim of this study was to examine the clinicopathologic characteristics of ptld occurring after renal transplantation in the republic of ireland. method: the national renal transplant registry from to (inclusive) was cross referenced with the national cancer registry to identify renal transplant recipients who had developed ptld up to the present day. review of pathology and chart review was conducted for each case. results: of , patients ( , allografts), cases of ptld were identified, with pathology review possible in cases. there were ( %) monomorphic ptld ( diffuse large b cell {dlbcl}, anaplastic large cell, burkitts-like, myeloma], hodgkin-type ptld, ( %) polymorphic ptld and ( %) early lesion. in addition, there was mantle cell lymphoma and lymphomatoid granulomatosis. the annual incidence of ptld was estimated as . % ( % ci . - . ). median time to diagnosis was . years (range to . years). conclusion: similar to other studies, monomorphic ptld is the most common type, with dlbcl representing the majority of cases. of interest, early onset ptld was very uncommon in this study. monday, september , . - . , forum hall ofp- oral free paper session head and neck pathology ofp- - human papilloma virus associated oropharyngeal carcinoma is strongly correlated with cancer of unknown primary s. ihrler * , g. assmann, p. zengel, m. mollenhauer * medizin. universität münchen, institut für pathologie, germany objective: human papillomavirus (hpv) associated oropharyngeal carcinoma has been identified as a distinct entity within squamous cell carcinoma of the head and neck and is preponderantly restricted to palatinal tonsils and base of tongue. these two primary locations have for long -and hpv-associated carcinomas have recently -been associated with the clinical situation of cancer of unknown primary (cup). method: to investigate the relationship between hpv and cup in detail, we studied consecutive patients who initially presented as cup and were finally diagnosed with carcinomas of these two locations. results: twenty-one carcinomas ( %) proved to be positive for high-risk hpv (p and polymerase chain reaction). they were frequently very small (smallest: . cm; cases: ≤ . cm; on average . cm) and located in a deep, submucosal position. conclusion: this demonstrates an overrepresentation of hpv-associated carcinoma in patients who were initially diagnosed with cup, supporting a strong causal relationship between hpv-association and cup. the frequent manifestation as cup presumably is caused by the unusual predisposition for small size and submucosal location, combined with frequent and early lymphatic metastization. in order not to miss these small, clinically occult carcinomas, consequent interdisciplinary cooperation and meticulous histological work-up is mandatory. ofp- - methylthioadenosine phosphorylase inactivation depends on gene deletion in laryngeal squamous cell carcinoma a. nadal * , l. conde, i. vilaseca, l. alos, m. bernal-sprekelsen, a. cardesa * hospital clínic barcelona, dept. of pathology, spain objective: methylthioadenosine phosphorylase is an essential enzyme for the methionine and adenosine salvage pathway in normal cells, frequently inactivated in many different human cancers. the mtap status could be important for tumor cell sensitivity to adjuvant chemotherapy. to date there are no reports on mtap status in laryngeal carcinoma. method: a series of laryngeal squamous cell carcinomas was investigated for mtap mrna expression through reverse transcription and quantitative pcr (qpcr) as well as for mtap gene deletion and/or promoter hypermethylation through qpcr and methylation-specific pcr respectively. results: low mtap mrna expression was found in % of cases, associated with mtap gene deletion in % (p< . ) but not to mtap promoter hypermethylation, indicating that in this tumors gene deletion is the main mechanism of mtap inactivation. neither low mrna expression nor gene deletion was associated with any of the clinicopathologic parameters investigated. conclusion: given the significance of mtap status for cell sensitivity to different chemotherapeutic regimes, our results suggest that determination of mtap inactivation could be useful for adjuvant therapy selection in laryngeal squamous cell carcinomas. ofp- - ercc , p and ki- immunohistochemical expression as predictive and prognostic markers in head and neck squamous cell carcinoma treated with platin-based induction chemotherapy h. roussel * , m. housset, h. tournat, p. ravel, s. hans, c. badoual * hegp, dept. de anatomie-pathologie, paris, france objective: ecc enzyme has been associated with resistance to platinum-based chemotherapy. the purpose of this study was to evaluate the role of ercc expression with p and ki- as predictive and prognostic markers in the response to platin-based induction chemotherapy in patients with head and neck carcinoma (hnscc). method: patients treated from to by an induction chemotherapy regimen for hnscc were included retrospectively. we assessed response to treatment, progression-free survival (pfs) and overall survival (os). results: % and . % of hnscc showed low expression of f and fl ercc . no correlation was found between the two clones (p= . ). in the patients treated with cisplatin- fu chemotherapy, a low expression of f ercc was associated with a better response (p= . ). over expression of p , ( . % of cancers of the oropharynx) was correlated with a better os (p= . ) and a better pfs (p= . ). conclusion: these results suggest that ercc expression might be a useful predictive marker of hnscc in patients treated by cisplatin-based chemotherapy. the f ercc clone appears to be the best for immunohistochemistry. our study confirms the prognostic value of the over expression of p in carcinoma of the oropharynx. objective: tumor-stroma ratio or proportion of tumor (pt) has been presented as a prognostic factor in colorectal and breast adenocarcinomas, but there is no information about squamous cell carcinomas (scc) and laryngeal carcinomas in particular. method: eighty-five laryngeal carcinoma cases were included in this series. five digital images of the tumor sections were obtained (h&ex ). percentage of epithelial tumor component was determined by software allowing the pathologist's selection of tiny areas as carcinomatous and stromal region for statistical analysis as a prognostic marker. results: median follow up was months (range - ). the mean pt was ( , + , ) . there was no difference for pt when tumor grade and stage were considered. although statistically insignificant, the mean pt was the lowest ( , + , ) for subglottic carcinomas and cases with perinodal invasion ( , + , ), and highest in pn cases ( , + , ) but there was no statistical significance. the over all and disease free survival analysis did not reveal significance for pt. only pathological stage was an independent factor for over all survival (p= , ). conclusion: although there might be an association with adverse prognostic factors and low tp, the findings in this series does not support pt as a prognostic marker in laryngeal carcinomas. ofp- - tumoral microvasculature in ameloblastoma subtypes c. h. siar * , k. h. ng * university of malaya, dept of. oral pathology, kuala lumpur, malaysia objective: angiogenesis is essential for tumoral growth and progression. the ameloblastoma is a benign but locallyinvasive odontogenic neoplasm with distinct behavioural characteristics of its subsets. whether angiogenesis contributes to a more aggressive course in these variants remains unclear. the aim here was to determine and compare the tumoral microvasculature in different ameloblastoma subtypes and to speculate on their significance. method: immunohistochemical staining for vascular markers (cd , cd , cd and vegf) was performed on archival tissues of cases solid/multicystic (sma), unicystic (ua), desmoplastic (da) and recurrent ameloblastoma (ra). mean microvessel density (mvd) at the tumour advancing front and centres were obtained. results: vegf was heterogeneously expressed in the tumoral epithelium in all ameloblastoma subtypes. protein localization was membranous/cytoplasmic. mean mvd was slightly higher in sma compared to ua but the difference was not significant (p> . ). mean mvds were not significantly different between primary and recurrent ameloblastoma; and between tumoral centre and advancing front of each subtype (p> . ). conclusion: although ameloblastoma subtypes are distinctive in their clinicopathologic presentations and behaviour, their tumoral microvasculature is not different. this suggests that angiogenesis is not a major factor influencing the progression of these ameloblastoma subsets. ofp- - an immunohistochemical study of e-cadherin and snail expression in laryngeal squamous cell carcinoma a. tanoglidi * , m. tsopanomichalou, c. barbatis, c. kostopoulos, o. pantzartzi, v. gorgoulis * hellenic red cross hospital, dept. of pathology, athens, greece objective: snail and (slug) are zinc-finger transcription factors, repressing the e-cadherin in epithelial tumors. published data in head and neck squamous cell carcinoma show either inverse relationship or unrelated co-expression, but e-cadherin reduction/loss and snail overexpression seem to confer an aggressive phenotype. method: thirty cases of laryngeal squamous cell carcinomas (lsccs) (gradei: , gradeii: , gradeiii: ) and one large cell neuroendocrine carcinoma (nec) were studied using double staining immunohistochemical method for e-cadherin (mab-dab) and snail + slug (pab-ap). the colocalization of both molecules was assessed and the expression was compared to the adjacent normal or dysplastic epithelium and the histological grade. results: normal squamous and dysplastic epithelium show strong nuclear snail expression and complete e-cadherin membranous positivity. reduction/loss of snail with or without e-cadherin membranous expression is observed in / ( %) lsccs with a tendency for inverse relationship with e-cadherin at the invasive front. / ( %) lsccs strongly express nuclear snail, without absolute relationship to the reduction/loss of e-cadherin, with a tendency for snail negativity in grade ii ( %). the nec is nuclear snail negative but cytoplasmic positive. conclusion: snail and e-cadherin may be retained, reduced or lost in lsccs, without a definite inverse relationship. these immunophenotypic combinations need further investigation. ofp- - non-sebaceous lymphadenoma of salivary glands: proposed development from intraparotid lymph nodes and risk of misdiagnosis c. weiler * , a. agaimy, p. zengel, s. ihrler * munich, germany objective: non-sebaceous lymphadenoma (nsla) is a recently described, rare benign salivary tumour composed of lymphoid and epithelial components, definitionally lacking sebaceous differentiation. method: nine cases of nsla were immunohistochemically stained for ck / , ck , ck , ck , p , and ki . results: all tumours ( males, females, mean age years) were located in the parotid gland and showed intimate intermingling of lymphoid tissue with islands of epithelium with a wide spectrum of histological differentiation. the immunohistochemical profiles mirrored the epithelial differentiation; tumours with basaloid or lymphoepithelial differentiation strongly expressed ck / , ck , p , while tumours with ductal differentiation showed strong positivity for ck /ck and ck / /ck /p in luminal and basal cell layers, respectively. a hilus structure with salivary inclusions or d - (podoplanin) positive marginal sinus were identifiable in and of the cases, respectively, confirming origin within intra-/periparotid lymph nodes. six cases were initially misdiagnosed as other benign (n= ) or malignant (n= ) tumours. conclusion: our study provides strong evidence that nsla belongs to the group of salivary tumours that pathogenetically develop from embryonic salivary inclusions in intra-/periparotid lymph nodes. knowledge of the wide histological spectrum of this rare tumour is important in order to avoid misdiagnosis. ofp- - crtc /maml fusion transcript in central mucoepidermoid carcinoma of mandible: diagnostic/ histogenetic implications d. bell * * md anderson cancer center, dept. of pathology, houston, tx, usa objective: mec typically arises from major/minor salivary glands. intraosseous salivary carcinomas are extremely rare ( - % of all mecs reported). the t( ; ) and its crtc / maml fusion transcript have been identified in mec at different sites and are associated with development of a subset of these tumors. we report examples of central mec of the mandible, including a case with a history of primary retromolar mec. method: rt-pcr and dna sequencing analyses used to study microdissected components of central mec and noncentral mec. of the central mec tumors, arose from ectopic salivary rests; others appeared to be of glandular odontogenic origins. results: we identified crtc /maml in central mec arising from ectopic salivary rests. this fusion transcript was not detected in non-central mec or in another central mec arising from a glandular odontogenic etiology. conclusion: central mec can manifest the fusion transcript in a subset of central mec originating from ectopic salivary rests, and may have diagnostic/histogenetic roles in the future analysis of this entity, given the absence of the fusion transcript in mec with glandular odontogenic precursors. since the initial clinical and radiological diagnosis in three central low-grade mecs was a benign odontogenic cyst, our findings support a future role for the fusion analysis in initial diagnostic efforts. ofp- - salivary duct carcinoma: morphological and immunohistochemical study of cases m. vazmitel * , a. dubrovskij, r. smoljakova, s. rjabceva * minsk, belarus objective: an evaluation of morphological and imunohistochemical features of salivary duct carcinoma (sdc). method: cases sdc were retrieved from tumor archives collected at belarusian cancer centre from to years. immunohistochemistry, fish. results: a man to women ratio was : ; median age , years (average . tumors arose in the parotid (n= ), submandibular (n= ) glands. sdc developed from pleomorphic adenoma (n= ) or de novo (n= ), there were foci of ductal carcinoma in situ (n= ), sialodochodysplasia (n= ) and pagetoid spread (n= ) additionally to usual features of sdc. as well, tumors demonstrated acinic cell carcinoma-like (n = ) and micropapillary growth patterns (n= ), oncocytic (n= ), clear cells (n= ), apocrine (n= ) and mucinous (n= ) changes. immunohistochemically, tumors were characterized by ar-expression (n= ), her /neu overexpression (n= ), of them score + in cases. ck and s- positivity, stat negativity was detected in one case with acinic cell carcinoma-like pattern. foci of sdc in situ were highlighted by ck and calponin. amplification of c-erb -gene was found in case, etv /ntrk gene was not identified in acinic cell carcinoma-like sdc. conclusion: salivary duct carcinoma, like breast cancer, is characterized by wide variability of morphological patterns and immunohistochemical features reflecting possible molecular heterogeneity, which need further investigation. sunday, september , . - . objective: quantification of protein expression based on immunohistochemistry (ihc) is an important step for translational research and clinical routine. however, routinely used eyeballing scoring systems are time-consuming and subject to significant intra-and interobserver variability. aim of our study was to explore, whether an image analysis software proves sufficient as an alternative tool to assess protein expression. method: prostate cancer specimens were stained with one nucleus specific marker (i.e., erg), one cytoplasmic specific marker (i.e., slc a ), and one marker expressed in both compartments (i.e., tmprss ). a pathologist visually quantified all stainings, applying a four-step scoring system. for digital quantification, an image analysis software (tissue studio v. . ) obtained a continuous spectrum of staining intensity. results: for each of the three antibodies we found a strong correlation of the eyeballing protein expression score and the score of the image analysis software (correlation coefficient of . , . , and . for erg, slc a , and tmprss , respectively, p< . ). conclusion: our data suggest that tissue studio is a powerful tool for the quantification of protein expression in ihc stainings. further, since the digital analysis is precise, it might help to overcome intra-and interobserver variability and increase objectivity of ihc based protein assessment. ofp- - is quality of histological and cytological slides a palatable issue?: the taste project m. comanescu * , g. bussolati, a. sapino, g. butur, f. schmitt, f. feoli, t. tot, e. ovcin * institutul victor babes, dept. of pathology, bucharest, romania objective: the taste (technological platform and repository of high quality images and slides) project aims at developing a novel tele-pathology system by means of modern icts (information and communication technology) and is addressed to technicians and doctors. method: histological and cytological preparations are the basis for pathological diagnosis performed in daily practice throughout europe in a number of several millions per year and correctness and reproducibility of such diagnosis are heavily dependent on the technical quality. yet, quality is variable in different places and countries, related to school level, technicians' dedication, standard of apparatuses and reagents. variation in technical quality of the preparations prevents their open circulation at european level and precludes optimal diagnosis. results: the taste project tackles these problems by building-up an ict environment taste system where professionals from different countries will submit, via web, "virtual slides" of their own preparations to a panel of internationally recognized experts who will give comments and suggestions on the quality of the preparation. conclusion: the present approach (unprecedented at world level) will fuel a web-based community, aimed to a levelling and improvement of histopathological and cytopathological preparations, thus leading to an innovative training and more reproducible diagnosis, a basic requisite for disease treatment. of the whole atlases. virtual microscope positions can be stored in the memory and users can navigate quickly back and forward similarly to web pages. all these features are available through any web browser without need to install any additional software. results: in addition to the current atlases (dermatopathology, fetopathology, pathology of the newborn and bone marrow), an interdisciplinary atlas of pathology for pregraduate students of medicine is under development. it will contain full size annotated virtual slides. the atlases are free of charge, but registration is required. in order to ease the access, the atlases are connected to national academic identity federations. the members of institutions connected to identity federations can use theirs home credentials without revealing them to the atlases. conclusion: the atlases can serve not only to the students as a source of information, but they can be used by teachers as a source of teaching material. proving experiment of international virtual slide telepathology, japan-vietnam and japan-china trial i. mori * , s. aida, y. osamura * international university of health, dept. of pathology, tokyo, japan objective: the communications between asian countries are growing. in the field of medical information and technologies, the necessity of communication is also required. in this work, as communication of pathology field, we tried to prove that international remote pathology diagnosis is possible using virtual microscopy (vs) telepathology. method: we put vs scanner and server to ) our hospital, tokyo, japan, ) cho-rai hospital, ho-chi-minh city, vietnam, and ) chinese rehabilitation research center, beijing, china. pathologists go and look the vs through leased optical line circuit and make diagnosis. discussion was made through teleconference system. results: the vs image maintained adequate quality for pathology diagnosis even looked cross-border. the diagnoses matched well between hospitals. the response of vs viewer was also good this time. when we use too much band width to the teleconference system or we sent too many data in the background, the response deteriorate, and was not good enough for diagnosis. conclusion: it was confirmed that the international vs telepathology diagnosis is now reached to a stage of actual use at least when connected by leased optical line circuit. challenges and solutions in the setup of a findings database for a large scale tissue collection r. reihs * , h. müller, s. sauer, k. zatloukal * medizin. universität graz, inst. für pathologie, austria objective: many medical centres have acquired through the last years huge data collections of great relevance for biomedical research. in order to utilize this knowledge it is necessary to analyse this records in a structured way. in our use case the starting point were approximately . million pathological findings of a non-selected patient group. method: we developed software tools for the classification of medical records using a phonetic a multi-level spell correction module and an ontology term extraction and decision tree text classification system. with the help of a visual editor a comprehensive decision tree ( nodes) was set-up by a team of bioinformaticians and medical experts. results: with our tool set we achieved in the icd- classification a f-score of , % (precession , % and recall , %) for the interpretation of the classification results we developed visualization tools and applied the whole software suite at several test cases, e.g. the analysis of a colon data-set with . findings over years. conclusion: we developed an automatic classification and visualization system and applied the results in a series of research projects. the software suite is currently used in several research projects and can be easily adjusted to specific phrases used in different institutions and languages. an image repository for decision support o. eichhorn * * aperio, vista, usa objective: pathology is a visual field, and pathologists make decisions based on visual information. an online repository of easily searched, well-categorized pathology images can be of immense use to pathologists, scientists, educators, and students. method: individuals and institutions all over the world have accumulated collections with thousands of slides representing a huge variety of pathologies. some collections are digitized and available online, while others remain libraries of glass slides, with a variety of formats for case information and other metadata. working with collectors to publish their slides and aggregating them together can yield an amazing decision support resource. results: long-term archival storage is a key issue for organizations adopting epathology. a cloud-based repository can provide an inexpensive and scalable solution. epathology is increasingly used for remote consultations. cases managed by online consultation networks can be de-identified and contributed to a common repository, increasing the value of the decision support tool while providing a long-term archive. conclusion: this talk will present concepts for an image repository for decision support, and discuss technical and business considerations for making it a reality, including ways to curate image metadata, organizational principles and search tools, relationships with users and contributors, access methods, and security and privacy considerations. ofp- - perfect diagnostic accuracy using pathomorphological diagnosis spectra constructed with the help of whole slide imaging k. furuya * , t. maeda, k. kito * ehime prefectural central hospital, dept. of pathology, matsuyama, japan objective: pathomorphological diagnosis (pd) is important for estimation of clinical trials and new medical equipment such as elastography. however, interpretation of pathomorphological findings is often subjective, and pathology publications show only a limited number of photographs. because pathomorphological changes occur in succession, we attempted to construct pd spectra to improve pd accuracy. method: pd spectra are defined as the series of pathomorphological images arranged in the order of disease progression or cell cycle procession. the images from the whole slide imaging (wsi) server were arranged in order in power point files at a fixed magnification, and pd spectra were constructed: chronic hepatitis staging, nuclear grading of hepatocellular carcinoma, nuclear grading of breast cancer, and ki- labelling index (li). the numbering of all images in the pd spectra corresponded with that of the wsi images so that the whole slides could be viewed alongside. next, these tools were tried out by people. results: these tools brought on perfect accuracy with regard to staging and grading, and very high precision of ki- li for breast cancer. conclusion: pd spectra are valuable not only for pd but also as learning tools and have a worldwide applicability for measuring pd online. ofp- - color correction of immunohistochemistry stained tissue section images by histogram transfer according to control tissues s. sarioglu * , s. seyrek, m. sakar * dokuz eylul university, faculty of medicine, izmir, turkey objective: for semiquantitative and quantitative analysis, previous normalization attempts of images of tissue sections are not satisfactory. in this study we evaluated, if color correction can be achieved by histogram transfer depending upon control tissue image (cti) differences. method: images from colon and placenta sections stained by anti-cd were used as cti and/or sample tissue images (sti). thirty-four but one (standard stained slide with images scti and ssti), was stained for different durations and dilutions than the standard procedures. digital images taken by a ccd camera connected to a light microscope without normalization was stored at a computer. software was prepared in order to find the histogram difference between two ctis and transfer the difference to the sti for achieving a corrected sti (corsti). ssti (one image) and sti and corsti ( images each) were semiquantitatively scored by two observers in blind fashion and the sti and corsti scores were compared with ssti score. results: the wkappa was , for two observers. the sti semiquantitative score was same as the ssti in , % of the sti but this was , % for corsti. conclusion: it seems histogram transfer depending upon ctis may be a valuable tool for color correction of tissue section images. sunday, september , . - . objective: there is a crucial need for identification of markers to choose the best treatment schedule and monitor the effectiveness of treatment in metastatic melanoma (mm) . the detection of circulating tumor cells (ctc) correlates with prognosis in different cancer subtypes. ctc can be detected by direct and indirect methods such as cytopathological approach, rt-pcr or immunomagnetic separation using the cellsearch (cs) method. method: from june to december , blood was drawn from patients with mm and controls patients and processed into h by the cs method. the primary end-point was the overall survival (os) of mm patients. results: enumeration of at least cmc was effective in . % of patients with mm (n= ) and in % of controls patients (n= ). nine patients ( %) had ≥ cmc. none of the controls patients had more than one cmc. mean os time was . months among patients with mm and < cmc (n= ) and mean os time was . months among patients with mm and cmc ≥ (n= ) (p= . ). conclusion: our results demonstrate that detection of cmc correlates with os in melanoma. thus, cmc monitoring should be developed to ensure the best treatment follow-up for patients with mm. ofp- - significance of circulating tumor cells (ctcs) detection using the cellsearch system in patients with locally advanced head and neck squamous cell carcinoma (hnscc) a. bozec * , m. ilie, e. long, o. dassonville, g. poissonnet, j. santini, e. chamorey, f. peyrade, k. benezery, a. sudaka, e. selva, p. hofman * centre antoine lacassagne, dept. of surgery, nice, france objective: the significance of ctcs in patients with hnscc is debated currently. we evaluated the potential detection of ctcs using the cellsearch (cs) assay tm (veridex, nj, usa) in hnscc patients and to identify the clinical factors predictive of the presence of ctcs in this population. method: forty-nine patients with locally advanced hnscc were included. the presence and number of ctcs were determined using the cs system in all patients prior to the initiation of therapy, in patients months after treatment, and in healthy individuals. results: the cs system was able to detect the presence of ctcs in of patients ( %) before therapy and in of disease-free patients ( %) after therapy. no ctc was found in the control group. when considering the presence of ctcs before or after therapy, the presence of ctcs was statistically associated with patients' age (p= . ; t-test) and n-stage (p= . ; fisher's exact test). conclusion: ctcs are identified in a relatively low proportion of patients with locally advanced hnscc and correlated with initial lymph node involvement. ctc detection could be a future useful prognostic tool to adapt the treatment intensity in hnscc patients. the diagnostic utility in identifications of an aneuploid chromosomal (ch.) pattern by using urovysion™: a fluorescence in situ hybridization (fish) commercial test, to improve the efficacy of cytology in peritoneal effusions l. baron * , m. postiglione, c. trombetta, f. quarto * p.o.s. leonardo, s.o.c. di anatomia patologica, castellammare di stabia, italy objective: the challenge in diagnosis of effusion is in differentiation of reactive and neoplastic mesothelial or metastatic cells and identification of primary neoplasia. the difficulties in this differential diagnosis derived from the low sensitivity (~ %) and specificity of effusion cytology. by identification of tumor associated aneuploidy fish could enhance the cytodiagnostic yield in effusions. method: we used urovysion™ (abbott), a fish commercial kit, designed for identifications of ch. , , polisomy and p loss in urothelial tumors. it has been applied to detect chromosomal aneuploidies as a marker of malignancy in effusions with or without known source primary tumors. also was evaluated reproducibility of molecular alterations with primary tumors and any their specific aneuploidies. results: fish positivity was observed in ( %) of cases, whereas were positive at cytology ( %). overall results of cytology and fish together rised to %. conclusion: urovysion™ test could be an useful tool to distinguish malignant cells in inconclusive effusions cytology but it doesn't seem to be used to provide definitive indications about primary neoplasia. ofp- - loss of imprinting of isulin-like growth factor (igf ) in colon carcinomas leads to the cell cycle genes activation -hints to intense proliferation d. belharazem * , j. kunanz, a.-k. henne, p. kienle, p. ströbel * inst. of pathology, university of medicine, mannheim, germany objective: the insulin-like growth factor (igf ) gene is regulated by imprinting in normal tissues. the loss of imprinting (loi) results in the bi-allelic expression of igf . its increased activity has been associated with many cancers including colorectal cancer (crc). to investigate the significance of igf in crc, normal tissue and tumor biopsies from patients were analyzed and correlated with clinical outcome and the kras and pik status. method: the igf g/a gene polymorphism and imprinting status were examined by restriction fragment length polymorphism of dna derived from normal tissues and tumors then of rna from heterozygous cases. igf protein analysis as well as an rna microarray were performed. results: % of the analysed cases were heterozygous. loi was detectable in both normal tissues and tumors in % of cases. tumors with loi had significantly higher igf protein levels. gene expression analysis revealed significance of cell cycle progression and mitosis genes in loi. conclusion: igf loi is a common and early change in patients with crc and in normal tissues, provides possibly a preneoplastic change. however increased igf protein levels as well as a different cell cycle specific gene expression profile were detected in tumors with loi. future studies must be performed to find out, whether such subsets of tumors differ in their response to chemotherapy or alternative therapies. objective: novel high-throughput technologies has revealed numerous genomic abnormalities in b-cell non-hodgkin lymphomas (nhl). this study aimed to detect point mutations involving ezh and cd b in a population of b-cell nhl by applying a multiplex mutation assay to minimal residual material from needle aspirates, and to determine the evolution of their mutational status overtime using all sorts of available samples from these patients. method: dna was extracted from residual cytological material stored on fta® cards as well as from archived cytological and histological specimens. the presence of point mutations was investigated by a specifically developed assay utilizing massarray spectrometry and confirmed by direct sequencing. results: all samples from b-cell nhl cases were successfully analyzed. mutations in ezh (y ) and cd b (y ) were detected in . % and % of the samples, respectively. mutational status varied in one third of the positive cases, with either gain or loss of mutations over the course of time. conclusion: minimal material from lymph node fine needle biopsy is a reliable source for high-throughput multiplex analysis for the detection of point mutation involving ezh and cd b. whenever possible, the most recent sample should be tested to verify the current status of the disease. ofp- - microrna expression profile identifies a distinct molecular signature between myc translocation-positive and negative burkitt lymphoma cases g. de falco * , a. onnis, f. morettini, f. fuligni, c. bellan, e. rogena, p. p. piccaluga, l. leoncini * university of siena, dept. human pathology and oncology, italy objective: the molecular hallmark of burkitt lymphoma (bl) is a dysregulation of myc oncogene, due to one of the three translocations leading to ig-myc fusion. however, about % of bl cases lack an identifiable myc rearrangement, although no significant difference of myc expression among cases has been observed. additional mechanisms alternative to translocations were explored by microrna profiling. method: ten myc translocation-positive and ten myc translocation-negative formalin-fixed and paraffin-embedded bl specimens were used for this study. for microrna and gene expression profile, the samples were hybridized on the mircury™ lna array and the illumina dasl whole genome assay, respectively. results: our results identified a panel of four micrornas which are differentially expressed between the two groups. importantly, these micrornas control relevant biological processes, such as the angiogenesis, apoptosis and cell proliferation, according to gene ontology categories. furthermore, the impact of microrna dysregulation on the gene expression pattern identified genes which more likely are regulated by the selected microrna. conclusion: using this approach, we showed a clear-cut microrna and gene signature between myc translocationpositive and negative bls. the identification of specific altered micrornas may represent an alternative molecular mechanism leading to myc over-expression in the absence of genetic alteration in cancer. ofp- - droplet digital pcr: a highly sensitive assay for b-raf, k-ras and egfr mutation detection j. frampton * , c. thorne, v. spivey, j. goodall, c. lowe * horizon discovery, dept. of diagnostics, cambridge, united kingdom objective: droplet digital™ pcr (ddpcr™) enables the absolute quantitation of nucleic acids in a sample. horizon discovery's patented gene editing technology enables it to manufacture reference material that is genetically defined and validated for the allelic frequency of the mutation. these reference standards were used to test the sensitivity of bio-rad's qx ™ droplet digital™ pcr platform. method: a panel of defined genomic dna allelic standards and formalin fixed paraffin embedded (ffpe) cell line samples were used in this study. this panel covered egfr (g s, t m, l r and l q), k-ras (codon ) and b-raf (v e and v k) mutations containing allelic frequencies between . % and %. droplet digital™ pcr was performed using mutation specific taqman custom snp assays. results: there was a strong correlation between the predicted and actual allelic frequencies even down to . %. the allelic frequency called by the ddpcr™ platform was highly reproducible between experiments particularly in the - % dilution range. conclusion: this study has demonstrated that the droplet digital™ pcr qx ™ platform can detect allelic frequencies down to at least . % using genomic dna purified from cell lines and down to at least . % using genomic dna extracted from ffpe cell lines. ofp- - chromothripsis and focal copy number alterations determine poor outcome in malignant melanoma t. gaiser * , d. hirsch, r. kemmerling, j. camps, t. ried * medizin. universität mannheim, inst. für pathologie, germany objective: genetic changes during tumorigenesis are usually acquired sequentially. however, a recent study showed that in - % of all cancers a single catastrophic event, termed chromothripsis, can lead to massive genomic rearrangements confined to one or a few chromosomes. method: in order to explore whether the degree of genomic instability and chromothripsis would influence prognosis in cancer, we applied high-resolution array comparative genomic hybridization to malignant melanomas (mm) that were, despite comparable conventional clinical and pathological parameters, defined by a profoundly different clinical course. results: we observed a striking association between both number and structure of chromosomal aberrations and outcome. mm associated with good prognosis showed only few chromosomal imbalances (average . alterations per case), predominantly presented as whole chromosome or chromosome arm gains and losses. mm with poor prognosis harbored significantly more chromosomal aberrations ( . per case; p= . ). these aberrations were mostly focal events, which culminated in two cases in a pattern consistent with chromothripsis. conclusion: here, we describe for the first time the phenomenon of chromothripsis in primary mm and reveal a link between focal copy number alterations and chromothripsis with poor outcome in mm patients (p= . ), providing a genetic approach to predict outcome in histopathologically indistinguishable mm. ofp- - targeting endometrial stromal sarcoma: histone deacetylase and pi k/akt/mtor signaling p. quan * , e. lederer, i. halbwedl, h. denk, k. zatloukal, j. haybaeck * institute of pathology, medical university of graz, austria objective: endometrial stromal sarcoma (ess) is a gynecological malignancy with few therapeutic options. up-regulated histone deacetylase (hdac) was observed in ess patients. the hdac inhibitor saha reduced ess cell growth by inhibiting mtor. the pi k/akt/mtor signaling cascade, vital to cancer growth is a critical target in cancer therapy. this study aimed at investigating if hdacs interact with the pi k signaling in ess pathogenesis and thus might serve as targets for ess therapy. method: tissue microarrays were used to determine hdac expression in ess specimens. western blots revealed protein expression levels of hdacs and pi k related molecules in two independent ess and one control cell lines (ess- , mes-sa and hesc). results: elevated hdac and levels were found in ess tissues and cell lines. increased cell growth and akt/mtor cascade hyperactivation were detected in ess cells. saha reduced growth of all cells, and induced cell death in ess cells. saha reduced phosphorylated ebp in all cells, but only inhibited activation of akt and p s k in ess- cells. conclusion: hdacs are linked to pi k signaling during ess pathogenesis. saha reduced cell growth via inhibiting pi k/akt/mtor components suggesting that a combination of saha with pi k inhibitors might be effective in treating ess. ofp- - usefulness of linking biobanking field and animal model: high successful rate of human primary non-small cell lung carcinoma (nsclc) xenografts in a model system separated by distance and time m. ilie * , l. blot, v. hofman, e. long, m. nunes, c. butori, e. selva, a. merino-trigo, n. vénissac, j. mouroux, p. vrignaud, p. hofman * chu de nice, lpce, france objective: with the ongoing need to improve therapy for nsclc, there has been an increasing interest in the development of reliable preclinical models to test novel therapeutics. the aim of this study was to evaluate the rate of establishment of patient-derived nsclc xenografts in the context of a long-distance research network. method: fresh surgically resected nsclc specimens were addressed from the human biobank hospital (nice) to the animal facilities (sanofi, vitry-sur-seine). shipment was performed in aqix medium at room temperature. within h post surgery, tumour fragments (~ mm ) were subcutaneously implanted in female scid mice. the growing tumours were passaged in new mice (≤ passages). the xenografts were histologically checked to eliminate human or murine lymphoma. results: overall, nsclc samples were implanted leading to ( %) nsclc xenografts. the rate of tumour growth was higher in non-adenocarcinoma specimens ( / ; %): / ( %) for squamous cell carcinoma, / ( %) for large cell carcinoma, and / ( %) for pleomorphic carcinoma, when compared to adenocarcinoma samples ( / ; %). conclusion: we report a high successful rate of xenotransplantation established from patient-derived nsclc tissues. our biobanking model system, regardless to extended time and distance, provides a stable and reliable animal model in human lung cancer research. monday, september , . - . objective: we tried to interpret "the job" of mf in different stages of tumor growth by monitoring the dynamics of their distribution. method: on a rat model of experimental tumorigenesis using bp fibrosarcoma cells injected intraperitoneally, we performed a semiquantitative analysis of the recruitment of mf in the tumor compartment (microenvironment) as well as in peripheral blood. results: we observed a slow increase of mf count in the initial phase of tumor growth followed by a slow decrease in the late phase within the tumor compartment. simultaneously peripheral blood showed constant increase throughout the experiment resulting in typical leukocytosis accompanying developed tumors. conclusion: increased mf in the initial phase could reflect their enrollment to "prepare a suitable microenvironment for tumor seeding". their decrease began after the tumor size was macroscopic, thus it was time for them to carry out a "different job". in the mean time their amount in peripheral blood started becoming significant, this is also the time when tumor -host interactions reach a systemic level. in futher experiments we will attempt to verify our assumption: when the tumor flourish in the host organism, it uses informed, transformed and recruited macrophages for growth and building construction of the tumor, and for communication with distant organs on a regulatory level. ofp- - wwtr and cyr are early markers of barrett's esophagus malignant progression m. mesquita * , j. cardoso, a. pereira, s. braga, m. bettencourt-dias, p. chaves, j. pereira-leal * ipolfg, dept. of pathology, lisboa, portugal objective: barrett's esophagus (be) is the major risk factor for esophageal adenocarcinoma (ea). be has a low risk of progression to ea, being imperative to identify markers to stratify the risk. our aim was to look for potential early biomarkers of be malignant progression. method: three available microarray datasets were analyzed with r statistical computing software complemented with bioconductor. biomarker prioritization included: ) expression barcode . ; ) filtering using differential expression analysis. candidate genes were validated by qrt-pcr on rna from paraffin embedded samples (rna-pes) of be patients with high-grade dysplasia/adc diagnosed during surveillance and of their index endoscopy dysplasia-free samples. as controls, we used samples from be patients who have not progressed. results: under conservative criteria, we identified upregulated genes that distinguish ea-progressed from nonprogressed be samples. a second filter, followed by qrt-pcr validation, trimmed the candidates to markers (wwtr and cyr ). qrt-pcr on time-series rna-pes of ea-progressed and ea-free be samples showed these genes are up-regulated years before the development of ea as compared to patients who did not developed ea. conclusion: wwtr and cyr were identified as early risk markers for be neoplastic progression and may have a potential role in be risk stratification. combined microrna in situ hybridization and immunohistochemical detection of protein markers b. nielsen * , t. møller, k. holmstrøm * bioneer a/s, dept. of molecular histology, hørsholm, denmark objective: micrornas are small noncoding rnas that constitute a novel group of biomarkers with exciting functions in cell differentiation, proliferation and apoptosis by mediating degradation or destabilization of target mrnas. mir- is highly prevalent in malignancies. previous reports on mir- in situ hybridization (ish) in colon and breast cancer identified expression in the stromal cell population that was related to recurrence and cell proliferation (nielsen et al., clin exp metastasis , : ; rask et al., apmis , : ) . here, we present a histological assay platform that allows parallel localization of micro-rnas and protein markers. method: routinely processed paraffin embedded breast cancer samples were analyzed. microrna ish probes were detected with fluorescent tyramine reagents and primary antibodies with compatible immunofluorescence. the reagents were introduced on a semi-automated platform, histoflex, which has a precise temperature control unit and utilizes continuous liquid flow. results: by combination of mir- ish and pdcd immunofluorescence we found differential expression in many but not all mir- positive cells. using the histoflex, the double fluorescence assay was reduced from to h without loss of sensitivity and specificity. conclusion: a -fold faster assay platform was developed and our in vivo findings support the assumption that pdcd is a target of mir- . the tnf-superfamily members april and baff and their receptors (baffr, bcma, taci) are differentially expressed in tumors and normal tissues and exert specific effects related to cell fate and differentiation v. pelekanou * , v.-i. alexaki, g. notas, m. kampa, e. stathopoulos, a. tsapis, e. castanas * university of crete, pathology, school of medicine, heraklion, greece objective: classically, tumor immune-related microenvironment was synonym of inflammatory cell infiltrate. recently, the detection of synthesis and secretion of immune mediators by tumor cells highlighted tnf-superfamily (tnfsf) members as key counterparts of cell fate-related signals. here, we assayed the synthesis-expression-function of a subset of tnfsf ligands and receptors (baff, april, baffr, bcma, taci) in normal epithelial tissues and tumors and resident adult mesenchymal stem cells. method: tissues (breast, cns, kidney, skin, adipose tissue) have been assayed by means of immunohistochemistry and real-time pcr. cell models were used for signaling, transcriptomics and functional assays. results: all tumors expressed this tnf-sf subset. baffr is absent, while its specific ligand baff is ubiquitously expressed; contrairewise, april, bcma and taci are expressed in tissue-specific manner. april relays on tumor evolution/grade and is involved in tumor proliferation/differentiation/apoptosis signaling through nfκb-related, or a novel pathway, implicating jnk/foxo a/gadd , triggering transcriptional events. conclusion: autocrine/paracrine effects of april and its receptors bcma and taci in normal/tumoral parenchyme and the recruitment/attraction of immune-related cells could orchestrate tissue response, regulating cell fate, differentiation, inflammation, tissue remodeling and cancer, with potential tailored-therapy application. objective: mutation analysis of kit and pdgfra genes is currently used in gastrointestinal stromal tumors (gist) as an important step in diagnostic protocol. method: dna samples obtained from parafin-embedded biopsy material of gist patients diagnosed in - were screened for mutations in exons , , and of kit and , and of pdgfra. results were tested for associations with clinical parameters of the tumor. results: causal mutations (according to in silico analysis with polyphen- predictor) were identified in . % of patients, most frequently in kit exon ( . %). the kit exon , pdgrfa exons and , kit exon , pdgfra exon and kit exon mutations appeared with frequencies . %, . %, . %, . %, . % and . % resp. genotype-phenotype correlation analysis revealed statistically significant association between intestinal localization of tumors and presence of kit exon p. - _dup mutation and gastric localization of tumors and presence of pdgfra exon p. d v mutation. conclusion: centralized and standardized gist diagnosis offers clinically and prognostically relevant informations and is necessary for the indication of appropriate targeted therapy of gist patients. supported by projects cepr ii (imts ) and mbcc (imts ) at cu jfm co-financed by eu and by grant novartis slovakia. objective: an association between cystic fibrosis transmembrane regulator (cftr) gene mutations and infertility may occur. this study investigated the frequency of mutations in the cftr gene, of a group of consecutive patients candidate for assisted reproductive techniques with the aim of identify subjects carriers of the most severe ones. method: we screened healthy subjects ( females and males) for cftr gene mutations and ivs -polit polymorphism utilizing the cftr inno-lipa amplification kit including both general and italian regional strips. results: cftr mutations were detected in . % of the patients, a percentage similar to that reported in the general population. the most common mutation was Δf /n observed in . % of patients. no difference in the gender distribution was evidenced. in the large group of patients analyzed . % were wt, . % carrier of one mutation, and interestingly . % compound heterozygous. conclusion: our data support the relevance of an accurate determination of mutations in the cftr gene in order to inform the couple of their carrier risk and the possibility on having affected child. moreover our findings highlight the potential of genetic screening as a tool to identify possible compound heterozygous subjects without cf-like symptoms. objective: a patient's response to cancer treatment can depend on their biomarker status. therefore it is important that laboratories perform their biomarker tests well. in an international external quality assessment scheme for kras mutation analysis on ffpe slides was set-up. method: this scheme was run for years by the coordination center, a medical and technical expert and scheme organizers under the umbrella of esp. participants received samples. genotype results were analyzed and labs with good performance were listed on the esp website. written reports of were evaluated in detail. results: in , % of participants identified all samples correctly. results seemed to improve over the years from . / to . / . genotype results from laboratories that participated for years appeared to improve overtime, although this couldn't be statistically proven. in the reports some important elements weren't always present. for example, the patient's name was only present in %, correct hgvs nomenclature in % and interpretation of results in less than %. conclusion: kras-eqa probably facilitates improvement of laboratory testing. the quality of reports of kras tests needs to be improved. a guideline for reporting molecular pathological results would be a good instrument for both participants and assessors. objective: microsatellite instability (msi) due to mismatch repair (mmr) deficiency is reported in a fraction of colorectal cancers (crcs) ( - %) complicating ibds (ibd-crcs). our recent findings argued for the existence of yet unknown mechanisms underlying mmr-deficiency in ibd-crcs, different from those involved in sporadic and hereditary msi crcs. here we hypothesized that over-expression of mir- and mir- , two inflammation-related mirnas that target core mmr proteins, could constitute a mechanism underlying mmr deficiency in ibd-crcs. method: we compared the expression of both mirs in ibd-crcs and non-ibd hereditary or sporadic crcs using nonneoplastic ibd and healthy mucosa samples as controls. results: overall, mir- and mir- were significantly over-expressed in both non-neoplastic and neoplastic mucosa of ibd patients as compared to healthy controls. mir- alone was preferentially expressed in msi vs. mss ibd-crcs. in contrast, mir- was poorly deregulated in non-neoplastic and neoplastic tissues of non-ibd msi or mss crcs. conclusion: mir- , alone or synergistically with mir- , may favor the emergence of msi ibd-ccrs. since its deregulation was not limited to neoplastic tissues but extends to non-neoplastic normal mucosa as well, the hypothesis of a mir- field defect promoting mmr deficiency and yet msi-driven transformation can be proposed. ofp- - pi k, akt and pten expression in enucleated brazilian uveal melanoma cases using tissue microarray g. freeman * , d. begnami, a. damascena, j. neves, s. nonogaki, f. soares * são paulo, brazil objective: in the world literature, little has been published on the molecular pathways in primary uveal melanoma or subsequent development of metastases. the pi k pathway has been implicated in regulation of apoptosis, cell cycle regulation, transcription and translation. method: we used immunohistochemistry with tma to investigate expression of pi k, akt and phos-akt, and pt in over formalin fixed paraffin embedded blocks of uveal melanoma from the a.c. camargo hospital, são paulo, brazil from to . fish was performed for pten copy numbers. results: in this study, neither immunohistochemistry nor fish results showed a statistically significant difference between the primary tumors and the tumors which metastasized. statistical analysis of all tumors together (tma) revealed only one molecular marker (pten), which gave results close to statistical significance. conclusion: this is the first large study of brazilian patients for pi k, pten akt expression by immunohistochemistry and pten using fish. expression values for molecular markers chosen did not reach statistical significance, although pten values were close. use of fish to distinguish metastatic from non metastatic cases also came close to statistical significance. these results suggest that the expression of pten in uveal melanoma may be a good topic to investigate further. objective: chronic antibody-mediated (camr) and chronic t-cell-mediated rejection (ctcmr) represent predominant reason for late graft dysfunction. both categories share similar morphological features. we ask the question whether there are differences between camr and ctcmr on the molecular level. method: graft biopsies (> m) were performed and evaluated according to the banff classification. biopsy specimens with camr (n= ), ctcmr (n= ) and from protocol biopsies with normal histology (n= ) were stabilized in the rna-later. using the taqman low density array, the intrarenal expressions of genes relating to immune response (b-cell activation, t-cell activation, chemokines, growth factors, immune regulators and apoptosis) were analyzed. results: both categories of chronic rejection were associated with up-regulation of many genes in comparison with the control group: chemokines (ccl , ccl , cxcl , cxcl , cxcl ), growth factor tgfb , mhc class ii (hla-dma, hla-dmb, hla-dr, ubd), and in t-cell dependent mechanisms (cd , cd , lag ), including cytotoxic t-cell associated transcripts (gbp , gzmk). in hierarchical clustering, camr and ctcmr gene expression profiles were similar. conclusion: chronic rejection very probably involves prolonged cooperation of innate immunity and allospecific immune response. our study showed that ctcmr and camr do not differ on the molecular basis. ofp- - podocyte loss and glomerulosclerosis in inducible mouse model of podocin mutation-related nephrotic syndrome i. simic * , m. tabatabaeifar, g. mollet, c. antignac, s. weber, f. schaefer * universitätskinderklinik, nephrologisches labor, heidelberg, germany objective: mutations in nphs gene, encoding podocyte specific protein podocin, cause hereditary nephrotic syndrome. knock-in mice carrying the r q mutation, murine analogue of the most common human mutation r q, show developmental arrest of podocytes and renal failure at neonatal age. the aim of this study was to quantify renal histopathological changes in mice with postnatally induced r q hemizygosity. method: c bl/ mice with nphs flox/r q, cre + genotype were injected with tamoxifen for days to induce hemizygosity for r q-mutant podocin. tissue samples were collected at defined intervals after induction. renal morphology was evaluated by quantitative histology, immunohistochemistry and electron microscopy. results: animals developed proteinuria within week that progressed into renal failure and advanced uremia at week - . the number of podocytes per glomerulus started decreasing at week ( ± vs. ± , p= . ), whereas glomerular sclerosis index increased from week ( . ± . vs. . ± . , p< . ). interstitial changes included fibrosis (up to % of section area in end stage renal disease), tubular atrophy and dilatation. conclusion: our results implicate that the expression of mutated podocin in induced r q-podocin mice leads to podocyte loss that precedes interstitial damage and glomerulosclerosis. quantification of histological changes will enable better evaluation of the efficacy of different pharmacological approaches directed to improvement of podocyte viability and attenuation of glomerulosclerosis. ofp- - heavy chain deposition disease in kidney biopsies a. vizjak * , j. mraz, j. lindic, d. ferluga * university of ljubljana, faculty of medicine, slovenia objective: heavy chain deposition disease (hcdd) is a rare and not yet fully explored monoclonal immunoglobulin-related disorder. method: we studied the histopathology in kidney biopsy cases of hcdd, representing a . % prevalence among native kidney biopsies. results: hcdd was diagnosed in kidney biopsies of women (mean age . years). light microscopy showed diffuse nodular glomerulosclerosis ( / ), associated with mesangial proliferation ( / ) and capillary aneurysms ( / ). immunofluorescence showed abundant mesangial deposits and ribbon-like deposits along glomerular, capsular, tubular and vascular basement membranes, positive for heavy chain igg ( / ) and igg ( / ), with deleted gamma ch domain ( / ). complement c and c q stained positive in all cases. by electron microscopy, punctate and powdery electron-dense deposits were found on the same locations. conclusion: immunofluorescence examination of kidney biopsies, including testing for immunoglobulin heavy and light chains, is crucial for diagnosis of hcdd. our study confirmed that hcdd is peculiar among monoclonal immunoglobulin deposition diseases not only because of its rarity but also because of uniform histomorphologic pattern of nodular glomerulosclerosis with pronounced capillary aneurysms and significant proliferation due to complement activation. deletion of the heavy chain ch domain and its significance in the pathogenesis has to be emphasized. ofp- - two cases of anca associated vasculitis with geographical necroses in the kidney tissue a. bartonova * , e. honsova, r. rysava * ikem, dept. of pathology, praha, czech republic objective: anca associated vasculitides (aav) are rare systemic autoimmune diseases affecting small to mediumsized blood vessels. in kidney biopsy samples, aav usually demonstrate pauci-immune necrotizing crescentic glomerulonephritis (gn). method: among cases of aav evaluated at ikem during years, had a very unusual pattern of renal involvement. results: the first patient had been treated for recurrent otitis media with unilateral hearing loss. he also suffered from artralgias and hematuria. an ultrasound study revealed a tumor-like mass in his kidney. during exploratory surgery, the lesion appeared to be infiltrative and a nephrectomy was performed. the second patient presented a granulomatous inflammation in a scar. a month later she developed multiple kidney and spleen "abscesses" with negative hemoculture, and underwent a nephrectomy with splenectomy. in both cases, the final pathological diagnosis was necrotizing granulomatous vasculitis of small and medium-sized vessels, with large geographical necroses of kidney tissue simultaneously with necrotizing crescentic gn. tests for anca antibodies were positive. no microbial pathogens including mycobacteria were detected. objective: polyomavirus nephropathy (pvn) is a common complication after renal transplantation. virus control is achieved by a reduction of immunosuppression allowing an effective t cell-mediated antiviral immune response. the morphology of resolving pvn has not been investigated. method: protocol biopsies of patients with pv viremia treated by reduction of immunosuppression only were included and scored according to banff criteria. the extent of interstitial inflammation was estimated as % of cortex. the number of tubular cross sections with sv + cells per mm of biopsy length was counted. findings were grouped as pre-, increasing, decreasing, and post-viremia. results: during the phase of decreasing viremia, we found a significant increase in the tubulitis score, the extent of tubules with intraepithelial lymphocytes, and interstitial inflammation (p< . ). these, to a lower extent, persisted after virus clearance. the number of sv + tubules correlated with the virus load in the serum, but sv immunohistochemistry was frequently negative ( / cases), especially if viremia was below geq/ml. conclusion: resolving pvn is characterized by a self-limiting acute interstitial nephritis. our findings are important because the diagnosis of interstitial rejection depends on the same morphological criteria. therefore, acute interstitial rejection cannot be diagnosed with certainty during pv viremia. ofp- - neural cell adhesion molecule and fibroblast growth factor receptor positive interstitial cells increase in interstitial fibrosis in different renal diseases j. markovic-lipkovski * , c. müller, s. cirovic, s. tatic, d. mitrovic, g. müller * university of belgrade, faculty of medicine, serbia objective: ncam + cells with dendritic morphology are rarely present in normal renal interstitium. the aim of this study was to evaluate presence of ncam + cells in kidney biopsies of different renal diseases with and without interstitial fibrosis (if). further immunophenotyping of ncam + renal interstitial cells was performed. method: kidney biopsies, after routine diagnosis, were stained applying antibodies against ncam clone c .d or cloneeric . for double immunofluorescence, antibodies against ncam cloneep y and fgfr , alpha beta integrin, alphasma, cadherin , cadherin were used. by rpcr, different ncam isoforms ( , , ) were detected using specific primers in renal tissues with and without if. results: ncam + interstitial cells were identified in cases: % lupus nephritis, % focal segmental glomerulosclerosis, % iga nephropathy, % membranoproliferative glomerulonephritis, % membranous glomerulonephritis. ncam + cells coexpressed fgfr and alpha beta integrin, and were increased in if. ncam + cells did not coexpress alphasma, cadherin and cadherin , although they were closely colocalised. all normal renal tissues tested for rpcr showed presence of all ncam isoforms, however ncam lacked in some tissues with if. conclusion: ncam + renal interstitial cells coexpress fgfr and alpha beta integrin and are increased in renal diseases with if, mostly in diffuse proliferative lupus nephritis. in contrast to normal kidneys, in renal tissue with if ncam is present in a lesser extent. reproducibility for c d immunohistochemistry in renal allografts: results from the banff trial m. mengel * , s. chan, j. climenhaga, p. randhawa, h. regele, y. kushner, r. colvin * university of alberta, laboratory of medicine, edmonton, canada objective: detection of c d is crucial for diagnosing antibody mediated rejection, yet formal reproducibility studies are limited. method: we conducted an international multi-center trial to assess the reproducibility for c d immunohistochemistry on paraffin-sections. a tissue microarray (tma) was constructed comprising kidney allograft specimens representing negative, focal, and diffuse c d positive cases. participants stained the tma slides, evaluated their stains and entered their scores online. stained slides were returned for centralized panel scoring. weighted kappa statistics were used to determine reproducibility. results: inter-institutional reproducibility, i.e. the product from variability between observers and staining methods was low (mean kappa . ). inter-observer reproducibility was fair (kappa . ), while inter-laboratory reproducibility was moderate (kappa . ). inter-observer reproducibility could be significantly improved by omitting the banff c d grading schema and only considering +/− calls (kappa . ). scoring only c d+/− inter-laboratory reproducibility improved considerably (kappa . ). higher dilutions of the primary antibody were associated with worse reproducibility. fixation < h or fixation in ethanol had significant negative impact on inter-laboratory reproducibility. conclusion: c d results reported from paraffin section are highly variable between institutions. simplification of the grading schema would improve reproducibility between observers. technical reproducibility between laboratories is acceptable but could further be improved by standardizing protocols. objective: heparanase is a predominant mammalian enzyme that cleaves heparan sulfate, the key polysaccharide found in the basement membranes and at cell surface. heparanase is overexpressed in the diabetic kidney; however, its role and mode of action in diabetic kidney disease remains largely unclear. method: applying heparanase-null mice we found that deletion of the heparanase gene protects diabetic mice from diabetic nephropathy (dn). recombinant heparanase enzyme and a specific heparanase inhibitor (sst ) were used to explore its mode of action in several in vivo and in vitro models. results: there is essential involvement of heparanase in the pathogenesis of dn. deleting the heparanase gene protects diabetic mice from dn and administration of specific heparanase inhibitor decreases the extent of albuminuria. in vitro, heparanase enhances macrophage activation by diabetic milieu components, and thus increases the kidneydamaging properties of macrophages. conclusion: our results validate the role of heparanase in dn and reveal the mechanism of heparanase action emphasizing its function in coupling chronic inflammation, macrophage activation and diabetic kidney injury. these findings will help in developing effective strategies to disrupt the heparanasedriven sequence of events in diabetic kidney disease, and in designing novel therapeutic interventions in dn. sunday, september , . - . , terrace ofp- oral free paper session neuropathology ofp- - microvascular angiogenesis occurs in a subset of only the arteriovenous types of vascular malformations and is more abundant in men than in women l. b. meijer-jorna * , c. m. van der horst, c. m. van der loos, a. c. van der wal * medical center alkmaar, symbiant pathology center, netherlands objective: episodic volume expansion may complicate the very slow growth pattern of congenital vascular malformations. we investigated the role of microvascular angiogenesis in this process of sudden growth. method: resection specimens of symptomatic vascular malformations were screened for presence and extent of sheets or clusters immature microvessels, interpreted as microvascular angiogenesis. microvessel density (mvd), mast cell density (mcd) and ki labelling index of endothelial cells (ec) were assessed immunohistochemically and quantified. extent of angiogenesis was correlated with the type of vascular malformation and clinical characteristics. results: of cases, were arteriovenous malformations (avm), were venous (vm), and were lymphatic (lm). microvascular angiogenesis was observed in % of all vascular malformations, of which % appeared to be avm. mvd, mcd and ki labelling indexes of ec were significantly higher in immature vessel areas. moreover, in affected patients these angiogenic responses were far more extensive (in terms of area involvement) in men than in women (p< . ). conclusion: microvascular angiogenesis appears a specific feature of the arteriovenous type of vascular malformations, and is much more extensive in men than in women. we suggest that these microvascular responses may contribute to onset of symptoms due to a mass forming effect. ofp- - the impact of ventricular assist device prior to transplantation on acute cellular rejection and antibody-mediated rejection in cardiac allografts with due consideration of seasonal behaviour: a prospective study k. wassilew * , e. potapov, c. knosalla, t. krabatsch, m. hummel, r. hetzer * deutsches herzzentrum berlin, germany objective: this study evaluated the impact of bridge-to-transplant ventricular assist device support on development of acute cellular (acr) and antibody-mediated rejection (amr) with due consideration of seasonal behaviour in cardiac allografts. method: we studied consecutive right ventricular endomyocardial biopsies (emb) between / and / prospectively. paraffin-embedded sections were evaluated for acute cellular rejection, endothelial cell swelling and capillary deposition of c d, c d and iga/m/g. the effects of vad (n= ) on acr and amr, classified according to the ishlt, were studied for seasonal effects and compared to results of emb harvested from patients without vad support (n= ). results: our results did not reveal significant differences between the two groups in any given parameter. a positive correlation was found for endothelial cell swelling and capillary c d deposition; the data failed to show a correlation between c d and c d deposition or c d deposition and endothelial swelling. complement and immunoglobulin depositions seemed to be more pronounced but without statistical significance in autumn and winter. conclusion: our results demonstrate only statistically insignificantly more pronounced capillary complement deposition in autumn and winter. the use of vad did not predict development of amr or acr. the c d staining does not add to the pathological diagnosis of amr. relevant changes of the molecular profile in the recurrence of glioblastomas with respect to the correspondent primary tumors m. idoate * , j. echeveste, r. diez valle, m. montanana, j. sola, t. labiano * university of navarra, dept. of pathology, pamplona, spain objective: in the literature, there is not enough information about changes of relevant molecular parameters in the recurrent glioblastoma. method: the study included a total of grade iv astrocytomas (oms) and their correspondent recurrences in a series of patients treated by -ala guided surgery. all patients received similar treatment. a comparative histologic and molecular study which included loh of pten region, egfr amplification sish, methylation of mgmt by msp-pcr and sequencing of egfr variant iii mutation on representative tumor samples was obtained. results: the recurrences appeared adjacent to surgical cavity in seven cases. the mean time between the diagnosis of primary and the recurrence was days ( - ). the primary glioblastomas showed loh q in % of cases, hypermethylation of mgmt in %, egfr amplification in % and egfrviii in %. in five cases ( %) the molecular profile of the recurrences was different to the primaries and most of them ( %) in the group of vaccines treated glioblastomas. the molecular profile change included one to several of the studied parameters. in one case all of the molecular parameters had changed. conclusion: the molecular profile change of the recurrences of glioblastomas in respect to the primaries is a frequent event that could be due to the selection of tumor cells due to both heterogeneity and treatment effect. objective: there is not literature reference on the prognostic significance of the proliferative activity in the border of tumor. a large series of patients with glioblastomas operated by fluorescence guided surgery with uniform treatment and enough follow-up have been studied. method: a total of samples of different fluorescence quality from glioblastomas, primaries and recurrences, were studied. for each tumor, the maximum value of ki- was determined by a semiquantitative counting by two observers and by an autoanalyzer. these values were compared with relevant oncologic parameters. results: the results of ki according both counting methods were concordant. the ki max values of red (center), pink (intermediate) and blue (border) fluorescence samples obtained by quantitative analysis were % % and %. in the cox regression analysis for overall survival, the ki value was an independent prognostic factor, stronger than other relevant clinical parameters studied (p= . ). in the kaplan-meier for a ki cut-off of %, the median overall survival was . months against . months (p= . ). for the patients with recurrent glioblastomas the overall survival according to ki values was also significant (p= . ). conclusion: the evaluation of the proliferative activity by ki- in the border of tumor defined by -ala fluorescence is a relevant independent prognostic marker of primary and recurrent glioblastomas. objective: according to the levels of estrogen receptor (er) expression, primary breast carcinoma (bc) cases are divided into two groups: er-positive and er-negative (godhirsch et al. ) . in metastatic bc, and especially in brain metastases (bm) of bc, the role of er expression is not clearly defined. aim: investigate er expression levels in brain metastases of bc and evaluate its prognostic significance. method: surgically obtained tumor specimens from sixty bc female patients (median age , ranges - ) with bm bc were stained with antibodies to er (dako). ihc expression was evaluated according to the semi-quantitative method. survival was estimated by means of kaplan-meyer curves. statistical analysis was performed using staitis-tica . software. results: er expression was detected in % of patients ( / ), and % ( / ) were er-negative. median time period between primary diagnosis and bm development was significantly (p< . ) longer in er-positive group compared to er-negative group ( and months, respectively). recurrent bm developed in both groups with a similar frequency ( % and %, respectively). general survival was significantly (p= , ) higher in er-positive patients compared to that of er-negative group. conclusion: er expression is considered to be an important prognostic factor for development of bmbc. nevertheless, further studies involving more patients with bmbc are required. ofp- - dopamine and alpha synuclein interplay in neurodegeneration: a rat animal model g. stoica * , g. lungu, n. bjorklund * texas a&m university, veterinary pathobiology, college station, usa objective: a spontaneous autosomal recessive rat model for neurodegeneration was developed in our laboratory. these rats demonstrate progressive increases in alpha synuclein (α-syn) in the brain mesencephalon followed by loss of dopaminergic terminals in the basal ganglia and motor impairments. method: histology, immunohistochemistry, transmission electron microscopy were used for morphological analyses. for α-syn assessment real-time pcr and western blot were used. dopamine measurements were performed by ion mobility mass spectral (imms). results: the severity of pathology is directly related to the overexpression of α-syn and parallel decrease in dopamine (da) level in the striatum (st) of affected rats. the neurodegeneration in this model is characterized by the presence of perikarya and neurites lewis bodies (lb) and diffuse marked accumulation of perikaryal α-syn in the substantia nigra (sn), brain stem, and striatum along with neuronal loss. light and ultrastructural analyses revealed that the process of neuronal degeneration is a "dying back" type. the disease process is accompanied by gliosis and release of inflammatory cytokines. conclusion: decrease dopamine and overexpression of α-syn in the brain mesencephalon may provide a naturally occurring animal model for parkinson's disease and other synucleinopathies that reproduces significant pathological, neurochemical, and behavioral features of the human disease. sunday, september , . - . objective: the mitotic index in thin primary melanomas replaced clark level in the staging system of the ajcc. however, the recommended quantification of proliferation by hot spots on he stains is criticized. an alternative may be the immunohistochemical proliferation marker phosphohistone h (phh ) visualizing all mitotic cells. and, when combined with the melanocytic marker mart , phh insures quantification of proliferating melanocytes, only. method: primary melanomas with a median follow-up of years for patients with event-free melanoma were included. phh /mart stains were performed by an indirect sequential immunoenzymatic technique. the number of phh /mart positive cells was counted in a fixed -mm frame in the dermal area with the highest concentration of positive cells (hot spots). results: in multivariate analysis, phh in hot spots was a strong independent prognostic marker for recurrent disease (hr= . , % ci, . to . ; p=. ) and melanoma-specific death (hr= . , % ci, . to . ; p=. ), when corrected for primary tumor thickness and ulceration. conclusion: cellular proliferation is an independent prognostic marker in primary cutaneous melanoma. however, accurate quantification is crucial for correct clinical staging. for this purpose, proliferation indices of the novel phh /mart double stains seem very promising. objective: some of the more common benign vocal fold lesions are polyps, nodules and polypoid corditis (reinke's edema). the majority of vocal fold pathology develops in the mucosal layer of the vocal fold, precisely in reinkes space. basic science and clinical research over past decades has led to advances in our understanding of benign laryngeal lesions. the aim of our study was compared contact telescopy findings with histological analyzes in a patients with reinke's edema. method: the our study included consecutive patients with clinical diagnosis of reinke's edema. videoassisted contact telescopy was performed in all cases under general anesthesia and mucosa was stained by methylene blue. tissue biopsies were taken from areas exhibiting visible pathological changes and sent to routine histopathology and immunohistochemical analyses. we analyzed expression of pancytokeratin antibodies, vimentin and cd . results: in the all case of reinke's edema, contact telescopic scans showed a change of direction or a disappearance of regular distribution and morphology of blood vessels (irregular shapes, positions, and patterns, apparently running in random directions) in vocal fold mucosa. marked pathological changes were noted by contact telescopic scans, confirmed with histopathology analyses. conclusion: contact telescopy is a useful additional diagnostic tool regarding reinke's edema. ofp- - volunteering in malawi: a snapshot of surgical pathology in sub-saharan africa s. berezowska * , t. tomoka, s. kamiza, d. a. milner jr., r. langer * universität bern, institute of pathology, switzerland objective: the breadth of material found in surgical pathology services in african countries significantly differs from the common spectrum of "the west". we report our experience in the pathology departments of blantyre and lilongwe, malawi. method: during a six-week period cases were processed ( histology, cytology). results: the vast majority of cases showed significant pathological findings (n= ; . %): ( . %) were non-tumoral conditions and ( . %) benign tumors or tumor like lesions. the large group of malignancies (n= ; . %) comprised pediatric tumors (e.g. rhabdomyosarcoma, small blue round cell tumors), and adult tumors. amongst women (n= ), squamous cell carcinomas (scc) of the cervix uteri predominated (n= ; . %), followed by breast carcinomas (n= ; . %), and esophageal scc (n= ; . %). males (n= ) most often showed scc of the esophagus (n= ; . %), and scc of the urinary bladder (n= ; . %). lymphomas (n= ) and kaposi's sarcomas (n= ) were less frequent. conclusion: providing pathology service in a low resource country may be handicapped by lack of personal, inadequate material resources, or insufficient infrastructure. rotating volunteers offer a bridge for capacity building of both personnel and the local medical service; in addition, the volunteer's horizons are broaden professionally and personally. objective: antinuclear antibodies (ana) are routinely tested by indirect immunofluorescence (if) and immunoblot. in this paper we aim to retrospectively analyze results of both methods. method: on two cohort groups: a (a total of samples), and b (a total of samples) we performed if on commercially obtained hep- cell, and immunoblot on (strips euroline). results: if revealed at least different morphological patterns of ana staining, which we grouped into easily distinguished categories: speckled nuclear fluorescence, homogenous nucleoplasmic fluorescence, multiple nuclear dots, nucleoli staining, and scattered nucleoplasmic dots. we compared these groups according to frequency, type of antibody and correlation with immunoblot resuts. we summed the characteristics of each if category, and noticed that both cohorts revealed . % and %, respectively of sera, which did not show positive if at an acceptable dilution (only by : ) or were fully negative in if test, but were clearly positive in immunoblot test. this was especially alarming with anti-scl- antibodies, which could be barely recognized in if test, but were clearly present in of positive stained strips (cohort a) and/ or out of positive stained strips (cohort b). ofp- - macrophages and their subtypes in tumorigenesis and growth o. el-hassoun * , l. maruscakova, z. valaskova, m. kopani, j. jakubovsky, i. hulin * alphamedical laboratories, dept. of pathological anatomy, martin, slovakia objective: it has been established that macrophages (mf) play a basic role in the tumor microenvironment. still, the definition of the function of mf with relation to tumors is still vague, mainly when mf are observed acting occasionally as pro tumor and elsewhere as anti tumor. method: in this paper we attempt to sum up the accumulating observations of mf function with respect to the microenvironment and the tumor entity. results: through the different stages of tumorigenesis and growth, macrophages are engaged in various signaling cascades that tame them to perform a certain function in a given microenvironment. this makes mf a multi-program cell with unique adaptivity. we assume that without the macrophages tumors cannot progress. conclusion: the available mf subtype analysis is still inadequate and doesn't bear into account the dynamics of tumorigenesis and growth. our presented mf schemes provide an insight on the tumor microenvironment with respect to stage. a complex view on the signaling cascades affecting mf is needed to formulate a novel classification of mf based on their programming. this consequently can be the basis of the development of "anti-mf therapy" or on a larger scale "anti-tumor microenvironment therapy". ofp- - lodox x-ray is an invaluable asset in autopsy procedures l. liebenberg * * university of cape town, dept. of forensic medicine, south africa objective: the field of autopsy performance has faced numerous challenges internationally. minimal background information on the deceased, various religious and personal objections regarding cutting a deceased body as well as health hazards face the pathologist regularly. lodox x-ray is a huge help for the pathologist. method: lodox x-ray (low dose x-ray) using the statscan has proven invaluable in busy forensic pathology laboratories in cape town, south africa. the digitally captured radiology images render a wealth of clear, recognizable, easily documented and user friendly images for use in diagnosis and court evidence. results: the use of the statscan has revolutionized the process of forensic autopsy procedures in cape town, south africa. the radiology images obtained in an unusually user friendly and time efficient way have improved efficacy, efficiency, accuracy and pro-active occupational health safety in our forensic laboratories. conclusion: lodox x-ray is a proven invaluable special investigation in forensic, and also academic, autopsy examination procedures. sunday, september , . - . objective: castration resistant prostate cancer (cr-pca) is the most aggressive form of prostate cancer (pca) posing a significant therapeutic challenge. our aim was to perform whole exome-sequencing on cr-pca/normal paired formalin fixed paraffin embedded (ffpe) samples using the solid next generation sequencing platform (ngs). we identified two promising genes-ywhaz and ptk , that could serve as novel potential therapeutic drug targets in pca. method: genomic dna was sequenced from cr-pca/ normal paired ffpe samples. a set of amplified/deleted genes were validated using fluorescence in-situ hybridization (fish) assays using a pca progression cohort consisting of cases for localized pca, patients with primary pca and corresponding ln metastasis, and samples for crpca. results: exome-sequencing identified regions of deletions/ amplifications, including nkx . , pten, cmyc and ar genes, known to play a role in pca. we identified several amplified genes as druggable targets such as ptk and ywhaz. for ywhaz we identified . % amplification in localized pca, . % amplification in ln metastasis and . % amplification in crpca. for ptk we % amplification for localized pca and % for both ln metastasis and cr-pca. conclusion: this is the first study to use exome-sequencing approaches on ffpe cr-pca to understand the biology of disease and its plausible treatment options. a study of d-np (p ) expression in tumours of stratified epithelium d. nonaka * * the christie hospital, dept. of histopathology, manchester, united kingdom objective: p can be expressed by a minority of adenocarcinomas. Δnp (p ), isoform of p , has recently been reported as more specific in lung squamous cell carcinoma (scc) than p , and it appears to be a more reliable marker for scc. there is no comprehensive study on p expression in tumours of different histotypes. method: tumours of various hisotypes were studied, including tumours of stratified epithelium such as scc ( cases) of the skin, head/neck, lung, cervix, and oesophagus, urothelial carcinomas ( ), cutaneous basal cell carcinomas ( ), thymomas ( ) and thymic carcinomas ( ), adenocarcinomas ( ) from multiple organs, germ cell tumours ( ), brain tumours ( ), lymphomas ( ), and sarcomas ( ). p immunostains were performed on tissue microarrays and staining extent was evaluated as focal ( - %) and diffuse ( - %). results: all but one tumours of stratified epithelium diffusely expressed p . the negative case represents spindle cell scc. other tumours except for basal/squamous component of two teratomas, one breast metaplastic carcinoma, and squamous component of adenosquamous carcinomas were all negative for p . conclusion: p is specific in tumours of stratified epithelium and its sensitivity appears comparable to p . p can serve as a marker for tumours of stratified epithelium. objective: although formaldehyde is the standard fixative used in routine histopathology, it is not considered an "ideal" fixative. formaldehyde presents carcinogenic properties, a slow fixation and produces cross-links with proteins and nucleic acids. formaldehyde-free fixatives are commercially available. method: from to we used glyo-fixx (thermo scientific, us), a glyoxal-based fixative, as formaldehyde substitute, analysing surgical pathology specimens and autopsies. all samples were processed and stained routinely. moreover we performed immunohistochemistry by an automated immunostainer and special stains with standard techniques, where needed. in tumoral cases we fixed cm sample in neutral buffered formalin and compared the results with gyo-fixx fixation. results: glyo-fixx fixation needed less hours than formaldehyde and not harden the tissues. on gross examination of the adipose tissue, lymph nodes were easily found, due to a more marked whitish appearance. morphologically we have not found differences between formalin and glyo-fixx, except for the eosinophils degranulation. special stains resulted similar to those with formaldehyde fixations. almost all antibodies not required pretreatment, but needed adjusts in the standardized protocol for formaldehyde. conclusion: our experience demonstrated glyo-fixx is a good non-toxic alternative to formaldehyde in routine pathology, capable to preserve morphology and protein integrity of the tissues. liposarcoma with solitary fibrous tumor-like dedifferentiated areas: clues on differential diagnosis m. aizpurua * * huvh/ics, dept. of pathology, barcelona, spain objective: well-differentiated liposarcoma (wdls) can undergo dedifferentiation to nonlipogenic sarcomas. solitary fibrous tumour (sft) characteristics have not been highlighted as a pattern of dedifferentiated liposarcoma (dls). however, this does occur and could be the cause of diagnostic pitfalls in atypical locations or partial tumoral resections. the aim of this comparative study is to demonstrate that some dls's may show morphologic features resembling sft's, and furthermore to describe the clue features supporting differential diagnosis. method: study comprised wdls-dls and sft ( malignant). histological features were systematically reviewed, and cd /cd /s /bcl immunostains and mdm fish-analysis were evaluated in all cases. results: there are many overlapping characteristics between dls and sft (table ). significant differences between both tumor types were observed in lipoblast-like cells (lpc); mature adipocitic cells within tumor (mac); stromal bands surrounding adipose tissue with atypical cells (sac); patternless (pa); keloidal-collagen (kcm) and haemangiopericytoid-pattern (hp). diagnostic accuracy of different features is shown in table . conclusion: the dedifferentiated component in some liposarcomas may resemble sft. in the dls/sft differential diagnosis, immunohistochemistry may be confusing. presence of wdls areas is the main diagnostic clue and mdm fish amplification is successful in distinguishing dls from sft. osteoblastoma and diagnostics pitfalls w. ouahioune * * ehs douera, dept. of pathology, algiers, algeria objective: osteoblastoma is a rare benign osteoblastic tumor with a potential for local bone destruction and aggressiveness. the most common site of osteoblastoma is the vertebral column particularly the posterior elements and the sacrum. method: in this study we present nine cases of osteoblastoma and the principal differential diagnosis. results: on a period of years, nine cases of osteoblastoma had been diagnosed including seven males and two females. the age of those patients ranged from to year old. the tumor was localized in the spine in five of the nine cases and the other ones in the long bones. the radiological diagnosis of osteoblastoma was made in just two cases. the diagnosis was made by histology in eight cases. all our patients had been treated with curettage. on the nine patients, just one of them had developed two successive recurrences. conclusion: osteoblastoma is a rare benign tumor which is rarely diagnosed by radiology alone. the pathologist should always suspect an osteoblastoma in front of a vertebral localization of any tumor. objective: congenital hepatic fibrosis (chf) is a developmental disorder of the portobiliary system. clinical findings usually include enlarged liver, well-preserved hepatocellular function and portal hypertension. chf is frequently associated with hepatorenal fibrocystic disease. method: a -year-old woman was referred to our hospital for further evaluation of hepatomegaly, and portal hypertension was found. laboratory tests were all negative. mri identified hepatosplenomegaly with hypertrophic left medial segment, high uptake nodular areas and homogeneous boundary liver. needle biopsy was performed. results: the biopsy demonstrated slight portal fibrosis and fibrous septa with proliferation of numerous biliary ducts, some of them containing inspissated bile. it was also noticeable the few number of portal vein branches. there was no inflammation or hepatocyte necrosis. therefore, our diagnosis was congenital hepatic fibrosis. we correlated these results with radiology. magnetic resonance cholangiopancreatography showed peripherally dilated biliary intrahepatic branches contrasting with preserved caliber of main intrahepatic branches. these findings were also diagnostic for chf. conclusion: the low prevalence of chf makes it hard to think about this entity in patients with portal hypertension and normal laboratory findings. the histological differential diagnosis must be done mainly with cirrhosis, but also with idiopathic portal hypertension and, in small biopsies, with biliary hamartoma. results: a total of cases of digestive tract lymphoma were reported ( males, females) with a sex-ratio of . . the patient age ranged between and years with a median age of years. stomach location was the most frequent with % of cases followed by intestine ( %) and colon ( %). among the digestive tract lymphomas, % were of marginal zone type (malt) and % were large b-cell lymphoma. according to the ann arbor staging system, % of patients were diagnosed at stage i and ii. conclusion: lymphomas of the digestive tract are still frequent in the centre of tunisia. the malt type lymphoma is main reported histological type. the association with the helicobacter pylori should be considered. collecting duct carcinoma in the west of ireland: a rare experience a. shalaby * , c. e. connolly * university hospital galway, dept. of histopathology, ireland objective: collecting duct carcinoma is a rare renal neoplasm arising from the epithelium of bellini's ducts in the distal part of the nephron. method: we describe our experience of this entity in university hospital galway with a series of four cases diagnosed between and . results: three patients aged between and years presented with either lymph node or bone metastases without evident abdominal mass. in each case the biopsy from the metastatic lesion showed adenocarcinoma with an immunohistochemical profile suggestive of renal origin and a renal mass was subsequently confirmed by radiology. the fourth patient was an year old male who presented with haematuria. abdominal ct scan revealed a . cm mass in the right kidney extending into the renal vein. biopsy of the renal mass in all cases confirmed adenocarcinoma with a tubular pattern with positive cytokeratin and vimentin staining and cd negative staining. one patient was treated with nephrectomy with post-neoadjuvant chemotherapy and died months after surgery. the other three patients died few months after their diagnosis. conclusion: collecting duct carcinoma is a rare renal neoplasm that can be difficult to diagnose on core biopsies, however, it can be identified based on radiological findings, gross, microscopic, histochemical and immunohistochemical features. objective: wilms tumors (wt) is the most frequent renal tumor of children. genetic alterations have been suggested as associated factors but the exact pathogenesis of wt is not fully characterized. tissue factor (tf) is a glycoprotein which happens to be a key receptor for factor vii/viia and a primary initiator of coagulation. tf has also been associated with angiogenesis. recent evidence pointed out an important role for tf in cancer progression and metastasis. method: in the present investigation the differential expression of tf in wt was assessed by real-time pcr of rna retrieved from paraffin sections using microdissection. results: different histological components of wt were analysed. the results revealed that tf was upregulated in blastema and epithelial components as compared to nonneoplastic tissue ( . and . -fold respectively, p< . ). stroma and non-neoplastic tissue presented low levels of tf expression. tf expression in wt metastatic lesions was also significantly upregulated as compared to non-metastatic wt. microvessel density was positively correlated with tf expression (r= . ). conclusion: as described in other tumors, tf seems to play a significant role in the behavior of wt. further investigations are warranted to better understand the pathways by which tf exerts its effects on tumor progression and its potential as a target for therapy. objective: biliary atresia (ba) is the most common neonatal cholestatic disorder and the prime indication for liver transplantation (ltx) in children. histopathological markers in liver biopsies emerge promise as indicator of early ltx in patients with ba. method: ductular proliferation, ductal plate malformations and type i, iii, iv and v collagen deposition were evaluated on kasai portoenterostomy (kpe) and liver transplantation (ltx) biopsies from children with ba. formalin fixed and paraffin embedded liver biopsies were stained with hematoxylin-eosin, picrosirius-polarization and immunofluorescence methods. there were analyzed liver histoarchitecture, biliary ductus and collagen deposition in hepatic compartments. pathologic findings were graded according to a -point semi-quantitative severity-based scoring system. impact of these markers was tested on ltx time (< year and > year). results: median age of kpe was weeks (range - ) and of ltx was months (range - ). in kpe liver biopsies, ductular proliferation, ductal plate malformations and collagen deposition were increased but these parameters presented no association with clinical evolution for early ltx. furthermore, collagen v prominent deposition was found along of hepatic sinusoids and type i, iii and iv were more frequent in portal compartment. conclusion: these results suggest that histopathological parameters evaluation presented may not determine early ltx in biliary atresia. the role of hofbauer cells on villous vasculature in early fetal losses e. Özer * , y. arman karakaya * dokuz eylul university, dept. of pathology, izmir, turkey objective: the aim of this retrospective study is investigate the role of hofbauer cells in early fetal losses. method: the slides obtained from archieval blocks of missed abortion (ma, n= ) and blighted ovum (bo, n= ) cases and unwanted pregnancies materials (control group, n= ) were stained by immunuhistochemical methods using cd and cd antibody to label hofbauer cells and endotelial cells, respectively. results: the mean number of vilous hofbauer cells was found to be significantly higher in both bo and ma in contrast to the control group (p= . and p<< . , respectively). however it was not significantly different between bo and ma (p= . ). chalkey method revealed no statisticaly significant difference in the control group in comparison with ma and bo in (p= . , p= . , respectively). higher microvessel scorring were found in ma in contrast to bo and the control group (p= . and p= . , respectively). however, there was no difference between the control group and bo (p= . ). conclusion: we think that hofbauer cells may be of biological importance in early fetal losses and play a role on defective vasculature formation in ma. placental vegf and its receptors expression patterns in preeclampsia k. pavlov * , e. dubova, a. shchegolev, g. sukhikh * v.i. kulakov scientific center, dept. of pathology, moscow, russia objective: placental angiogenesis anomalies play an important role in some complications of pregnancy development, including preeclampsia (pe). vegf and its receptorsone of the key placental angiogenic factor. aim: to evaluate patterns of vegf and its receptors (vegfrs , and ) expression in placentas from pe complicated pregnancies. method: we performed complex morphological and immunohistochemical study of term placentas from mild preeclampsia (mpe) cases ( st group), term placentas from severe preeclampsia (spe) cases ( nd group) and term placentas from uncomplicated pregnancies (control group). results: we revealed significantly increased syncitial vegf expression levels in preeclamptic placentas terminal villi and these changes were much prominent in spe. we also detected insignificantly increased endothelial vegf expression levels in preeclamptic placentas terminal villi. vegfr- syncitial expression levels in spe terminal villi were significantly higher in compare to the mpe and control groups. vegfr- endothelial and syncitial expression levels were significantly lower in both pe groups terminal villi and these changes were much prominent in mpe. patterns of vegfr- expression in preeclamptic and control groups were multidirectional. conclusion: revealed patterns of vegf and its receptors expression point on altered placental angiogenesis in pe and reflect different degree of such alteration in mild and severe pe. objective: chorionic villi vascularity disturbances, caused by abnormal expression of angiogenic factors could correlate with maternal and fetal complications in diabetic pregnancies. method: aim: to evaluate the patterns of vegf receptors (vegfr , vegfr and vegfr ) expression in placentas from gestational diabetes (gd) and type diabetes (d ) pregnancies and correlation between them and some clinical parameters in newborn (placental weight (pw), newborn weight (nw), placental/newborn weight index (pnwi), st day of life blood glucose test results ( bgtr)). term placentas from d (n= ) and gd (n= ) and term placentas from normal pregnancy (control group) were studied. results: in both d and gd group we revealed significantly higher level of vegfr (p= . ), vegfr (p= . ) and vegfr (p= . ) endothelial expression in terminal villi. difference in vegfr expression among d and gd groups was also significant (p= . ) as difference in its expression between d and control group (p = . ). among clinical parameters we only revealed significant increase in bgtr in diabetic groups (p = . ) with marked difference between d and control group (p = . ). we revealed multidirectional correlation between vegf and vegfr expression and nw in d and gd groups. conclusion: revealed changes reflect placental angiogenesis disturbances influence on intrauterine fetal development. microvillus inclusion disease (mvid) is a disorder of defective intracellular trafficking and disrupted epithelial cell polarity c. thoeni * * division of cell biology, medical university innsbruck, austria objective: mvid is a congenital enteropathy characterized by loss of microvilli and formation of microvillus inclusions (mi) in enterocytes. mvid is caused by mutations in the myo b gene, coding for the myosin vb (m b) motor protein involved in intracellular transport and maintenance of epithelial cell polarity. we examined the effects of loss of m b in enterocytes of mvid patient and in a caco- cell model. method: the expression and localization of cell membrane transporters (cd , na/k atpase) and various cell organelle markers : endosomal rab gtpases [rab , , , , ] ; early (eea ) and late endosome (lamp ), and golgi (giantin)) were analyzed using multilabel immunoflourescence and confocal microscopy of a duodenal biopsy from mvid patient and in caco- cells following m b si rna knock-down (hum mut : - , ). results: depletion of m b in both enterocytes and caco- cells resulted in disruption of epithelial cell polarity with loss of apical microvilli, formation of mi; mislocalization of transporters as well as aggregation of epitopes for different rab gtp ases, early and late endosomes. conclusion: m b plays a critical role in polarized organization of enterocytes in mvid -a disorder characterized by defective intracellular trafficking and altered endosomal sorting. caco- cells provide an excellent model to study the pathogenesis of mvid. ofp- - beta-catenin expression and mutational analysis of ctnnb gene in pediatic adrenocortical tumors (act) r. alaggio * , p. dall'igna, a. martines, e. lalli, r. boldrini, v. d´onofrio, g. esposito * università di padova, dipt. di pathology, italy objective: act have an unpredictable clinical behaviour, and no liable histological or molecular parameters are available to predict outcome. the activation of wnt/β-catenin pathway, involved in tumor growth and progression in adult act has been explored only in brasilian pediatric act. the aim of this study is the investigation of the possible prognostic role of β-catenin accumulation and/or ctnnb (β-catenin gene) mutations also in italian pediatric act. method: β-catenin immunostaining and mutational analysis of ctnnb gene at exons and , when possible, were carried on a series of act ( malignant and benign, according to wieneke classification), from patients enrolled in the italian pediatric rare tumor (trep) study. results: immunostaining for β-catenin showed membrane/ cytoplasmic staining in cases, benign and malignant, and nuclear staining in malignant. no mutations of ctnnb gene were found in the tumors analyzed. conclusion: ctnnb gene mutations do not appear to be involved in pathogenesis of pediatric act. the accumulation of protein might be related to different mechanisms. its presence in the majority of malignant act suggests a possible role in tumor progression. ofp- - neuroblastoma presenting like a wilms' tumor with thrombus in inferior vena cava: a case series h. sartelet * , g. gaetan, a. ouimet, c. lapierre, p. teira * chu sainte justine, dept. of pathology, montreal, canada objective: neuroblastomas and wilms' tumors are frequent pediatric solid tumors. the first is frequently detected in the adrenal gland and the second develops in the kidneys. the extension through the vena cava and the lung metastases are frequent in wilms' tumors and are rarely in neuroblastoma. we present the cases of three children with abdominal tumors with thrombus in the inferior vena cava and pulmonary metastases were discovered yet demonstrated a stage neuroblastoma. method: the three male patients were between and months old. they presented an abdominal mass, near the superior pole of the kidney. thrombus of the vena cava was evoked on imaging studies in all cases and pulmonary metastases were always found. catecholamine metabolites were present in the first case and negative in the two others. two out of three patients had a radical nephrectomy. results: the pathological analysis always found a neuroblastoma poorly differentiated or undifferentiated without mycn amplification and confirmed the tumoral thrombus in the second case. the evolution of the two first patients was unfavorable and the third is alive. conclusion: invasion of the inferior vena cava and pulmonary metastases in children with neuroblastoma is uncommon and can modify the surgical management. ofp- - epcam -a marker for tufting enteropathy (te) and a useful tool in the differential diagnosis of congenital enteropathies c. thoeni * * division of cell biology, medical university innsbruck, austria objective: congenital enteropathies (ce) are characterized by villous atrophy and disruption of apical microvilli in duodenal enterocytes. te is characterized by focal eptithelial tufts and mutations in the epcam gene, coding for epithelial cell adhesion molecule, important for cell-cell contacts. microvillus inclusion disease (mvid), shows loss of apical microvilli and formation of intracytoplasmatic microvillus inclusions. mvid is caused by mutations in the myo b gene, important for intracellular transport and organization of epithelial cell polarity. in this study, we identified a new epcam mutation in a patient with te and used anti-epcam antibody as a marker for the diagnosis of te and distinction from mvid. method: we used immunohistochemistry (ihc) with monoclonal epcam antibody (mouse monoclonal ab for epcam, ncl esa/leica microsystems) on routinely processed duodenal biopsies from patients with te, mvid and age matched controls. immunostaining for e-cadherin served as reference. results: epcam expression was completely absent in the biopsy from te patient homozygous for a novel epcam mutation (c c>g, ser x). e-cadherin showed normal expression and distribution pattern in the enterocytes. in mvid, expression and distribution pattern was comparable to controls for both epcam and e-cadherin. conclusion: loss of epcam is specific and a sensitive marker for confirmation of te. epcam antibody is useful in the differential diagnosis of ce. objective: in pulmonary adenocarcinoma egfr mutation analysis has become an important part of the diagnostic work-up. frequently the tissue of bronchoscopies is of limited diagnostic value. the aim of the present study was to evaluate the impact of rose on brochoscopy specimens with regard to egfr mutation. method: rose was used for adequacy of the specimen and for separating adenocarcinomas and carcinomas nos from other neoplasms in the lung. if it was not possible to retrieve material for histology, cytology and cellblock were made. if adenocarcinoma or carcinoma nos was suspected in rose, further two biopsies or two cell blocks were obtained. egfr mutation analysis was performed by pcr (light cycler ; egfr rgq pcr kit; qiagen). results: malignancy was diagnosed in of cases by histology or on cytology with and without cell blocks. adenocarcinomas (n= ) and carcinomas nos (n= ), scc (n = ), sclc (n = ), and rare tumors (n= ) were diagnosed, respectively. among the group of adenocarcinomas and carcinomas nos (n = ), egfr mutation analysis was performed in ( , %) cases and showed mutations in ( , %) and "wild type" in ( , %) tumors. no material was left in ( , %) cases. conclusion: rose supports bronchoscopic procedures to retrieve adequate specimens for tumor diagnosis and subsequent egfr mutation analysis. objective: patients with fibroblast growth factor receptor (fgfr ) amplified squamous cell lung cancers (l-scc) are treated in phase i clinical trials using small molecule inhibitors (smi). scc of the lung share common molecular alterations with squamous cell head and neck cancers (hn-scc). aim of our study is to assess if hn-sccs also harbor fgfr amplifications. furthermore, we aim to inhibit cell proliferation of fgfr amplified hn-scc cell lines using a smi. method: the cohort consists of patients suffering from hn-scc, of these suffering from metastatic disease. primary tumors and metastatic tumors were assessed for fgfr copy number status using fluorescence in-situ hybridization (fish). we tested cell lines for fgfr amplification status and inhibited these with smis. objective: the pulp of pequi has high levels of antioxidants properties. method: eighteen male balb/c mice divided: animals received by gavage , μl/mg/day of pequi oil (control + cbcoil= ) during days. after days, of these mices received two doses of , g/kg intraperitoneal of urethane (urethane + cbc oil= ). the other animals were only submitted to two doses of , g/kg intraperitoneal of urethane (urethane group= ). after days, groups were sacrificed. antioxidant activity was evaluated in the lung tissues by tbars (thiobarbituric acid-reactive substances), cat (catalase) and sod (superoxido dismutase) test. dna damage was estimated by comet test. results: the lung parenchyma from urethane groups without oil and with oil showed neoplasic formations induced by the chemical carcinogenesis in contrast with control + cbc oil group. the results of tbars test showed a significant decrease of lipid peroxidation in the urethane + cbc oil, than urethane group. the cat and sod test didn't show a significant difference. comet assay showed a significant decrease of dna damage in urethane + cbc oil when compared with urethane group. conclusion: the antioxidant components in the pequi oil diminish the oxidative stress status and dna damage in chemical carcinogenesis, suggesting that this type of strategies may have a greater impact in lung cancer treatment. financial support: fapesp. ofp- - an algorithm for gene mutation analysis in lung cancer m. comanescu * , c. iosif, m. dobre, l. buburuzan, g. bussolati, f. vasilescu, c. ardeleanu * institutul victor babes, dept. of pathology, bucharest, romania objective: somatic alterations of k-ras, egfr and alk which are increasingly requested in order to predict response to personalized therapies in lung cancer are mutually exclusive and are represented in over % of lung adenocarcinomas. the approach to be followed for planning analyses is not standardized in the literature. method: we have studied by molecular methods (pcr-rflp for k-ras, direct sequencing for egfr and fish for alk) formalin fixed, paraffin embedded cases of lung adenocarcinomas of different subtypes. results: based on rational, biological and economic considerations we started with k-ras analysis by pcr-rflp, which showed mutations in cases ( with mutation on codon and one case with mutation on codon ), the residual cases were all analyzed for egfr mutations. fish for alk translocation followed in egfr-wild cases. conclusion: the analysis for k-ras mutations allows to select the significant percentage (approximately % of adenocarcinomas) when egfr mutation analysis by direct sequencing can be postponed. k-ras and egfr wild cases will then undergo fish analysis for alk translocation. acknowledgements study conducted with the support of the following project: project persother -smis-csnr: / . ; with the support of sectoral operational programme "increase of economic competi-tiveness" priority axis : research, technological development and innovation for competitiveness. ofp- - gene mutation analysis in adenosquamous carcinomas of the lung m. comanescu * , g. bussolati, c. ardeleanu, l. daniele, g. gaina, c. luca, a. sapino * institutul victor babes, dept. of pathology, bucharest, romania objective: adenosquamous carcinomas of the lung constitute a rare and aggressive variant of lung cancers. the pressing interest in evaluating the mutational status in lung carcinomas for predicting responsiveness to targeted therapies is presently focused on adenocarcinomas (of different sub-types), which makes preliminary histological typing a crucial step in order to select cases to be genetically analyzed. hence the interest in deciding if adenosquamous carcinomas should be included among adenocarcinomas or, viceversa, if they should be interpreted as a variant of squamous cancers and excluded from the process of gene analysis. method: we have thus collected, from our two institutions a large number ( cases) of cancers showing the histological definition of adenosquamous carcinomas according to the who criteria and performed gene analysis for k-ras (codons , ) and egfr (codons , and ) mutations. the detection of rearrangements of the alk gene by fish was also performed. the results indicate that k-ras and, specifically, egfr mutations are detectable in a fraction of these tumors. in conclusion, adenosquamous carcinomas should not be denied the chance of genetic analysis eventually leading to a targeted therapy. acknowledgement project persother -smis-csnr: / . romania. ofp- - pathology of the lung progenitor cells and their niches in idiopathic interstitial pneumonias and lung sarcoidosis s. demoura * , e. kogan, v. tuong, o. kichigina * moscow, russia objective: the aim of the study was to investigate the morphological and the molecular-biological changes of the lung progenitor cells and their niches in idiopathic interstitial pneumonias (ipf) and lung sarcoidosis (ls). method: we performed an immunohistochemical study on open lung biopsies from patients (usual ipf - , desqvamative interstitial pneumonia- , nonspecific ipf - , cryptogenic ipf - , ls - , control - patients). immunochemistry was done on step paraffin sections with monoclonal and polyclonal antibodies: apo-cas, pcna, , , pdgf, fgf, igf ii, cd , mmp , , , , timp , cd , sma, ema. results: deep injury of clara cells together with pneumocytes ii and their nishes were found in usual ipf, sk with prominent ipf and desqvamative interstitial pneumonia. myofibroblast proliferation, neoangiogenesis, adenomatosis and fibrosis with high production of tnfα, tgf-β, pdgf, fgf, igf ii, cd , mmp , , , , timp accompanied proliferation of these epithelial cells. while in other variants of ipf pathological changes were localized in the interstitium, vessels and basal bronchiolar epithelial cells. conclusion: localization of injury and inflammation in progenitor cells niches results in pathologic reparation, sclerosis and precancer lesions. ofp- - a small immunohistochemical panel allows for accurate diagnosis of primary and metastatic lung cancer in biopsy specimens d. felizardo * , r. henrique, a. l. cunha * instituto de oncologia porto, dept. of pathology, coimbra, portugal objective: precise subclassification of lung cancer, mostly performed in biopsy or fine needle-aspiration specimens, is required for appropriate therapy. moreover, distinction between primary and metastatic carcinoma is critical. thus, the role of immunohistochemistry (ihc) has been emphasized, although an optimal ihc diagnostic algorithm has not been firmly established. herein, we evaluated the performance of the ihc panel used at our institution in subclassification of lung cancer and identification of metastatic carcinoma. method: cases of non-neuroendocrine lung carcinoma, diagnosed from march to april were selected. ihc was performed for ck , ck , ttf- and p . resection specimens were compared with the respective biopsy. results: of cases analysed, ( . %) were diagnosed as lung adenocarcinoma, ( . %) as epidermoid carcinoma, ( %) as other forms of nsclc, and ( . %) as metastasis. importantly, % of primary lung adenocarcinomas were initially suspected to be metastasis. in cases submitted to surgical resection, ( . %) were correctly diagnosed in the biopsy, revealing a substantial agreement (κ-value= , ). conclusion: our ihc panel allows for reliable subclassification of lung carcinomas in most cases and is decisive for appropriate diagnosis in patients suspected of lung metastasis, which is critical issue in a cancer institute. ofp- - rationale for treatment of metastatic squamous cell carcinoma of the lung using fgfr inhibitors f. göke * , a. franzen, a. schroeck, v. scheble, r. kirsten, r. menon, d. goltz, d. boehm, w. vogel, s. perner * universitätsklinik bonn, inst. für pathologie, germany objective: we previously identified amplified fibroblast growth factor (fgfr ) as a therapeutic target for small molecule inhibitor (smi) therapy in squamous cell lung cancer (l-scc), resulting in currently running clinical trials treating patients with stage iii disease. as most patients present with metastatic stage of disease, we attempt to demonstrate fgfr amplification in lymph node metastases of amplified primary tumors. our study aims to give a rational to include these patients in a targeted smi therapy. method: we assessed formalin-fixed paraffin-embedded (ffpe) primary l-scc samples. samples were primary tumours with corresponding ffpe lymph node metastasis. the biotin-labelled fgfr target probe ( p . to p . ) was used to determine the fgfr amplification status performing fluorescence in situ hybridization (fish). results: of assessable metastatic l-scc, samples displayed fgfr amplification ( %). all of these primary tumors also harbored fgfr amplification in their lymph node metastasis. non-amplified tumors never displayed fgfr amplification in corresponding metastases. conclusion: we found fgfr amplification not only in primary l-scc, but also in corresponding lymph node metastasis, suggesting that this genetic aberration is a clonal event in tumor genesis. our study provides data indicating new therapeutic possibilities for patients suffering not only primary, but also metastatic fgfr amplified scc lung cancer disease. kras mutation was a g to t transversion in % of the smoker nsclc population and a g to a transition in % of the non smoker nsclc population. mutations were noted at codon ( %), codon ( %) and codon ( %). a kras mutation was a negative prognostic factor with a hazard ratio for death of . ( % confidence interval, . - . ). a mucinous histological subtype was observed in more than % of kras mutated tumours. conclusion: kras oncogene substitution must be accurately determined in primary lung adenocarcinoma for correlation with tumour behaviour and clinico-pathological parameters. objective: there is an urgent need for diagnosis of nsclc at its early-stages and for improving the survival rate of patients. micrornas, small non-coding rnas, are frequently deregulated in nsclc. this study aimed to explore plasma micrornas for diagnostic value, and evaluated the correlation between expression profiles of plasma micro-rnas and disease-free survival (dfs) in nsclc patients. method: we selected eighteen most frequently expressed micrornas in nsclc. total plasma rna including micrornas was isolated and reverse-transcribed into cdnas. the level of micrornas was determined by quantitative real-time rt-pcr in resectable nsclc patients and matched cancer-free individuals. the correlation between the expression of micrornas in plasma and patient dfs were examined by log-rank and cox analysis. results: expression levels of mir- ,− ,− ,− a, − ,− ,− ,− ,− , and let- f in the plasma of nsclc including stage-i patients were significantly higher compared with controls (p< . ). the combination of these micrornas yielded % sensitivity and % specificity (auc= . ) in discriminating nsclc patients from controls. the levels of mir- , − , − a, − , − and mir- a were significantly associated with dfs (p< . ). conclusion: our results suggest that high expression of plasma mirnas signature would provide potential noninvasive blood-based biomarker for the prognosis of nsclc. monday, september , . - . objective: intratumoral disorganized neo-vasculature induces oxygen fluctuations which contribute to tumour growth and metastatic potential. although the activation by hypoxia of the carbonic anhydrases caix and caxii is well known, responses of these proteins under reoxygenation remain to be elucidated. method: in this study we evaluated the effects of hypoxiareoxygenation on caix and caxii expression and cell proliferation in a and h lung adenocarcinoma cell lines. we further investigated by immunohistochemistry on tissue microarray the value of the combined expression of these proteins to predict outcome in nsclc patients. results: caix expression was maintained at high level after reoxygenation in contrast of the rapid caxii downregulation, whereas the cell proliferation rate was significantly increased. survival analyses showed that high caix/ low caxii was associated with high cumulative incidence of relapse and with poor overall survival of nsclc patients (p< . ). conclusion: our results provide insight into understanding dynamic responses of caix and caxii expression under tumour cells reoxygenation and demonstrate a critical role for reoxygenation on caix and caxii levels that may select for aggressive lung cancer phenotype. these findings suggest that caix and caxii play selective roles in tumour progression and emphasize their significant prognostic and potential therapeutic value. ofp- - alk-gene rearrangement: a comparative analysis on circulating tumour cells (ctcs) and tumour tissue from lung adenocarcinoma patients m. ilie * , e. long, c. butori, v. hofman, c. coelle, v. mauro, k. zahaf, c.-h. marquette, j. mouroux, p. paterlini-bréchot, p. hofman * chu de nice, lpce, france objective: until now the alk status in ctcs isolated from lung cancer patients has not been characterised. we assessed the alk status in ctcs detected in lung cancer patients and correlated the results to the alk status defined in the corresponding tumour tissue. method: lung adenocarcinoma patients showing ctcs isolated using the isolation by size of epithelial tumour cell method were screened for their alk status both in tumour samples and in ctcs. alk break-apart fluorescence in situ hybridisation (fish) and immunochemistry using an anti-alk antibody were done on ctcs and compared with results obtained on corresponding tissue specimens. results: patients showed alk-gene rearrangement and strong alk protein expression in ctcs and corresponding tumour samples. negative results were found for patients in ctcs and corresponding tumour samples. conclusion: we demonstrate that the alk status can be determined in ctcs from lung cancer patients both by immunocytochemistry and fish analysis. a strong correlation was found for the alk status obtained from corresponding tissue specimens. these results favour non-invasive, alk-gene status pre-screening on a routine basis on ctcs isolated form lung cancer patients and open new avenues for real-time monitoring for adapted targeted therapy. ofp- - detection of egfr mutations and eml -alk rearrangements in lung adenocarcinomas using archived cytological slides e. imyanitov * , n. mitiushkina, a. iyevleva, a. poltoratskiy, a. ivantsov, a. togo, i. polyakov, s. orlov, d. matsko, v. novik * n.n. petrov institute of oncology, st. petersburg, russia objective: while the molecular analysis of egfr and alk in archival lung cancer tissues is relatively well established, the acceptability of genetic investigation of cytological material in clinical routine remains a subject of debate. method: islets of malignant cells were visually located on the archived cytological slides, lysed in situ by the drop of sds-containing buffer, and subjected to the standard dna and rna extraction. examination of paraffin-embedded tissue blocks from the same patients was done in parallel. results: cytological/histological lung adenocarcionoma sample pairs underwent the analysis for egfr mutation. cytological and morphological samples failed to produce dna. concordance for the wild-type and mutation status was observed in / and / informative pairs, respectively; pair was non-interpretable; and pairs had mutation only in the cytological or histological material, respectively. rna extraction followed by rt-pcr analysis for the eml -alk translocation was done for the pair; failures were observed for cytological and histological samples. / informative pairs were concordant for the norm, contained identical translocations, and were noninterpretable. pair demonstrated alk rearrangement in the tissue block but not in the histological slide. conclusion: archived cytological slides appear to be well suitable both for egfr and alk analysis. objective: non-small cell lung cancer (nsclc) represents a heterogeneous group of cancers consisting mainly of squamous cell carcinoma (scc) and adenocarcinoma (ad). increased sirtuin (sirt- ) expression leads to deacetylation of p that could be important in the pathogenesis of lung cancer. differences of the molecular mechanisms in nsclc subtypes may follow subtly different pathways to tumorigenesis. the aim of our study was compare sirt- expression in lung adenocarcinoma, squamous cell carcinoma and control group. method: patients with stage lung cancer were enrolled in the study. patients had adenocarcinoma, but patients had squamous cell carcinoma. lung tissue for control group were selected from autopsy cases. immunohistochemical and western blot methods were used to evaluate sirt- expression in lung tissue. results: obtained results showed that patients with lung cancer had increased sirt- expression compared to control group ( ± vs. ± cells/mm , p< . ). in addition, patients with squamous cell carcinoma had increased sirt- positive cells compared to patients with adenocarcinoma ( ± vs. ± cells/mm , p= . ). conclusion: lung cancer is characterized by an increased sirt- expression which ir more prominent in squamous cell carcinoma. objective: transplantation is the only treatment for several end-stage lung diseases but limited by chronic allograft dysfunction particularly obliterative bronchiolitis (ob) and its correlate bronchiolitis obliterans syndrome. the development of preclinical models is crucial to better identify immunological/non-immunological mechanisms leading to ob. [group b and c] post-transplant, animals were sacrificed. in animals from group c, cyclosporine was administered at sub-optimal dose. lung rejection was graded according to the working formulation of ishlt and the presence of circulating donor-specific (dsa) antibodies determined by flow cytometry. results: in group a, acute rejection (ar) or ob occurred in % and % of animals, respectively. ar occurred in - % of animals in group b and c respectively. ob was detected in % and in % of group b and c respectively. high levels of dsa igg were observed in cases with ar. conclusion: a novel model of pulmonary ob was developed in the rat. to obtain a reproducible onset of ob, shortterm and sub therapeutic cyclosporin administration appears indispensable, at least in our species combination. ofp- - epithelial dysplasia and lung cancer in end-stage idiopathic pulmonary fibrosis: padova experience n. nannini * , f. lunardi, e. balestro, e. rossi, m. loy, m. saetta, f. rea, f. calabrese * university of padova, italy objective: idiopathic pulmonary fibrosis (ipf) is associated with increased risk of lung cancer. the prevalence of high grade dysplasia/lung cancer was studied only in a small number of ipf patients. the aim of our study was to investigate the prevalence of precancerous/cancerous changes and their relationship with both metaplastic changes and clinical data. method: native lungs from ipf patients were studied. the degree of honeycomb changes and squamous, cuboidal and bronchial cell metaplasia were graded (score: - ). the presence or absence of precancerous/cancerous changes were also evaluated. results: three patients showed neoplastic transformation ( %) and nine high grade dysplasia ( %) ("cancer" group). the "cancer" group had similar smoking history, sex, age and duration of disease than the "no cancer" group. all lungs showed metaplasia, the score of squamous (p= . ), cuboidal (p= . ) and bronchial cell (p= . ) metaplasia was significantly higher in the "cancer" than in the "no cancer", while the honeycomb score was similar in the two groups. conclusion: advanced ipf patients have a high prevalence of high grade dysplasia/lung cancer, complex epithelial metaplasia, particularly squamous type, is more frequent in "cancer" group, independently from all clinical parameters, including smoking history. ofp- - primary pulmonary adenocarcinoma with enteric differentiation, morphologically indistinguishable from metastatic colorectal adenocarcinoma: case report with a history of metastatic colon adenocarcinoma s. percinel * , p. celepli, h. nalbant, y. yuyucu karabulut * ankara, turkey objective: according to a computerized medline search in the english literature, the present case is thought to be the first primary pulmonary adenocarcinoma with enteric differentiation, completely resembling metastatic colorectal adenocarcinoma morphologically, with a history of metastatic colon adenocarcinoma. results: a year old man with a history of colon adenocarcinoma which was detected in underwent radiologic evaluation. a chest computed tomography scan revealed a mm solitary nodule in the left lower lobe which enlarged in year. the patient underwent left lower lobe wedge resection. macroscopically, an irregular whitish nodule of . cm in greatest diameter was detected. microscopically, the nodule was entirely composed of glandular and papillary structures, some of which had a cribriform pattern, lined by tumor cells that were cuboidal to tall columnar with nuclear pseudostratification, eosinophilic cytoplasm, brush-border, luminal necrosis and nuclear debris. tumor cells were diffusely positive for cytokeratin (ck) and negative for thyroid transcription factor- , surfactant protein-a, cdx- and muc . only a very few tumor cells stained for ck . conclusion: enteric morphology with consistent expression of ck and a scattered positivity for ck helped in the distinction from metastatic colon adenocarcinoma and favored the diagnosis of primary pulmonary adenocarcinoma with enteric differentiation. expression of cxcr and cxcl in pulmonary carcinoids s. seiwerth * , l. brcic, a. sepac, a. zanko * zagreb school of medicine, pathology, croatia objective: cxcr and its chemochine ligand cxcl seem to play an important role in the process of tumor metastasis and, possibly, homing of metastatic tumor cells. the chemochine seems to be responsible for creating microenviromental predispositions for survival of metastatic cells, in a similar way it is done for developing immuno-competent cells. in contrast, expression of cxcl in primary tumor cells, is thought to be associated with lower metastatic potential. cxcr is expressed in a wide range of tumors, and is thought to be crucial for the metastatic process and tissue-specific spread firstly of breast and prostate cancer. the role of cxcr signaling has been poorly evaluated in carcinoids in general and not at all in pulmonary carcinoids. method: immunohistochemically we investigated the expression of cxcr and cxcl in pulmonary carcinoids. results: together tumors ( typical and atypical) where investigated. in there was a metastatic process (in typical and atypical). ligand cxcl expression was negative in all of the metastatic tumors and in two without known metastasis in contrast to only two non-metastatic tumors showing negative reaction. cxcr positivity was found in both metastatic and non-metastatic carcinoids. the other investigated parameters where present in both metastatic and non-metastatic tumors. objective: to evaluate col v and decorin expression in pulmonary tissue and to characterize biochemical profile of colv from lung fibroblasts culture from ssc patients. method: we evaluated col v and decorin expression and tridimensional reconstruction ( d) of patients with ssc without pulmonary hypertension that underwent surgical lung biopsy and as control was obtained lung fragments from normal individuals who died from trauma. col v amount in lung sections was evaluated with immunofluorescence. to biochemical characterization of col v from lung fibroblasts culture was used quantitative immunoblot. results: it was found that the structure of col v fibers was distorted and strongly thickened in lung tissue from ssc patients compared with thin fibers pattern in the healthy controls. decorin was distributed around col v fibrils in the bronchovascular interstitium and vascular walls. histomorphometric analysis of ssc lung demonstrated increased expression of both col v and decorin when compared to the control (p < . ). the semiquantitative imunoblot detected an increased high molecular weight colv fraction in patients when compared to the control. conclusion: the over expression and unusual organization of colv fibers with biochemical changes associated to increased decorin indicates that matrix signalization pathway is involved in colv fibrillogenesis process in ssc pulmonary fibrosis. objective: probe-based confocal laser endomicroscopy (pcle) is a new method used during bronchoscopy by means of special miniprobe alveoflex and based on the visualization of intraalveolar structures which possess autofluorescence. aim: to compare the visual signs of a healthy and pathologically changed lung tissue received at pcle in patients with infiltrative and local lung nodules with the diagnosis, delivered by light microscopy. method: an autopsy and surgical material was fixed in % neutral formalin solution and was analyzed by studying with a new method for visualization of structures. histological specimens were studied at that spaces, where the pcle was applied. we compared our results by using qualitative method. results: normal lung tissue structures include alveolar septum with the high light emission and light-negative spacesthe alveolar spaces. in case of pneumonia alveolar septum were saved, but the light density of alveolar spaces was higher in compare with the normal tissue. in case of alveolar proteinosis we observed unique globules, which had the highest light emission. we found out several authentic signs, which are representative for each kind of pathological feature. moreover, we revealed some other characteristics, which help us to distinguish some types of lung cancer. conclusion: pcle can be used as an additional method of noninvasive diagnostics in vivo. increased copy nember of alk gene is not associated with increased immunoreactivity of alk protein in lung adenocarcinomas t. balharek * , a. farkasova, z. kviatkovska, k. scheerova, p. tilandyova, z. hutka, l. plank * comenius university, dept. of pathology, martin, slovakia objective: anaplastic lymphoma kinase (alk) gene rearrangements represent an important predictive marker and promissing therapeutic target in small subset of non-small cell lung carcinomas (nsclc). immunohistochemical (ihc) screening of alk abnormalities in nsclc was reported to have variable reliability. we analyzed association between alk immunoreactivity and increased number of alk gene copies often seen in nsclc. method: we examined clinically selected egfr negative lung adenocarcinomas. alk protein expression was detected by ihc using antibody clone alk (dako). alk gene status was assessed by fluorescent in situ hybridization using lsi alk dual color rearrangement probe (abbott) and spec alk/eml tricheck probe (zytovision). results: increased alk gene copy number was identified in cases, of them showed cytoplasmic alk positivity. in of these cases we detected rearrangement of alk locus, once represented by alk-eml fusion combined with more complex cytogenetic abnormalities. remaining third alk + case was negative for alk rearrangement. conclusion: ihc seems to be useful method for initial screening of alk rearrangements in nsclc. there is no clear association between alk protein expression and number of alk gene copies. prognostic relevance of alk copy gains or amplification in lung adenocarcinomas remains to be determined, together with role of alk-inhibitors in those cases. expressions of egfr, ercc- , ß tubulin iii, rrm- in advanced non-small cell lung carcinoma n. bassullu * , e. namal, i. turkmen, r. yasar, p. y. korkmaz, z. akcali, g. demir, g. b. dogusoy * istanbul bilim university, dept. of pathology, turkey objective: egfr, ercc , rrm and βtubuliniii predicts sensitivity to therapeutic agents and provide prognostic information in nonsmall cell lung cancer (nsclc) which is the most frequent worldwide cause of cancer death. method: we investigated the expressions of egfr, ercc , βtubuliniii, rrm immunohistochemically in advanced nsclc cases and their correlations with other pathologic features. results: the age distribution was - with an average of , . male/female ratio was / . ercc protein was detected in nuclei of carcinoma cells in patients ( , %) (h score > ). Βtubuliniii expression was detected in cytoplasm of cancer cells in patients ( , %) (score ≥ ). ercc and βtubuliniii expression were not associated with pathological factors. rrm was negative (score< ) in ( %) cases and negativity was significantly correlated with male gender (p< , ). egfr was negative (score< ) in ( , %) cases and negativity was nearly correlated with absent necrosis (p< , ). no significant correlations were found between egfr, ercc , βtubuli-niii, rrm and the pathological parameters. conclusion: in our study, as a first step, egfr, ercc , βtubuliniii, rrm showed no significant correlation with pathologic features. we look forward to obtain further results in the next study consisting of correlations with follow ups. proliferative markers in idiopathic pulmonary fibrosis: clinical, radiological and functional significance e. parra * , m. cornati, v. capelozzi * fmusp, dept. of pathology, são paulo, brazil objective: natural course of idiopathic pulmonary fibrosis (ipf) could be predicted by proliferative markers of the fibrotic process, such as myofibroblasts and interleukins (il)- and il . our primary aim was to determine whether these proliferative markers influence the course of ipf course measured by a radiological/functional score. method: twenty-eight patients with biopsy-proven ipf disease, who underwent pulmonary evaluation by high-resolution computed tomography (hrct) fibrosis score and pulmonary function tests were studied. five normal lung tissues (nlt) were included biomarkers in lung tissues were detected by immunohistochemistry and quantified by histomorphometry for myofibroblasts alpha-smooth muscle actin (α-sma), anti-interleukin (il)- and il- . results: myofibrobalst amount, il- and il- expression were higher in ipf than in nlt (p< . ). myofibroblast expression of α-sma was positively correlated to il- and il- expression. lung tissue from patients with high hrct fibrosis scores expressed significantly greater α-sma+, il- and il- when compared with patients with low hrct fibrosis scores (p< . ). negative correlations were found between myofibroblasts α-sma + and vc and dlco. conclusion: proliferative markers, detected by immunohistochemistry, in lung tissue allowed recognizing a dichotomous distribution of hrct fibrosis course and influenced pulmonary function tests, suggesting that they may be promising markers of prognosis in these patients. objective: epithelioid mesothelioma is the most common histologic type of the diffuse malignant pleural mesothelioma, also having the best prognosis. although a great variety of histological patterns within epithelioid type has been described, a clear impact of histological subtyping on clinical outcome is unknown (kadota et al., .) . here we compared median survival of six histological subtypes of epithelioid mesothelioma. we examined hematoxylin and eosin-stained slides of patients diagnosed with epithelioid mesothelioma. according to previously described predominant histological features we grouped them into six subtypes: trabecular, solid, microglandular, tubulopapillary, micropapillary and pleomorphic. results: the median survival of all patients with epithelioid mesothelioma was . months. the best median survival was in trabecular and micropapillary subtypes (each months, n= and n= , respectively), followed by tubulopapillary ( months, n= ), microglandular ( months, n= ) and solid ( months, n= ) subtypes. the worst median survival was in pleomorphic subtype ( months, n= ). conclusion: epithelioid type of diffuse malignant pleural mesothelioma shows a great diversity of histological patterns that likely have an impact on the clinical outcome and patient's survival. further investigations of genetic variations among different subtypes may provide valuable information for better understanding of pathogenesis of these tumors. objective: genetic instability resulting in both aneuploidy and polyploidy are discussed to be involved in prostate cancer (pca) development and progression. aim of this study was to comprehensively characterize the ploidy status and proliferation levels in pca with regard to disease progression. method: using fish, we assessed localized pca, pca with corresponding lymph node metastases, and hormone-refractory distant metastases for losses and gains of all chromosomes. the proliferation rate was assessed using phh and ki immunohistochemistry. results: we observed significant increases in aneuploidy with advancing tumor stage (p< . ). chromosomes x, , y, , , and were most frequently numerically altered. increased levels of proliferation were significantly associated with the extent of aneuploidy and tumor stage (p< . ). combining aneusomy of chromosomes , , , and x with phh immunoreactivity resulted in a prediction model for lymph node metastases with a sensitivity of . % and a specificity of . %. conclusion: we present evidence that genomic instability leading to aneuploidy is an important factor in pca progression. furthermore, we demonstrate that increased ki- and phh expression are potential indicators of metastatic disease. lastly, we suggest a new approach to preoperatively determine lymph node metastasized disease in pca. ofp- - erg protein expression and genomic rearrangement status in primary and metastatic prostate cancer: a comparative study of two monoclonal antibodies m. braun * , d. goltz, z. shaikhibrahim, w. vogel, d. boehm, a. dobi, n. wernert, g. kristiansen, s. perner * universitätsklinik bonn, inst. für pathologie, germany objective: overexpression of the erg protein is highly prevalent in prostate cancer (pca) and most commonly results from gene fusions involving the erg gene. recently, an n-terminal epitope targeted mouse and a cterminal epitope targeted rabbit monoclonal anti-erg antibody have been introduced for the detection of the erg protein. here, we are the first to compare the mouse erg-mab to the rabbit erg-mab for their concordance on the same pca cohort. furthermore, we assessed if the erg protein expression is conserved in lymph node and distant metastases. method: we evaluated tissue microarrays of specimens containing localized pca, lymph node, distant metastases, and normal prostatic tissues. we correlated the erg protein expression with the erg rearrangement status using an erg break-apart fluorescence in-situ hybridization (fish) assay and ihc of both erg antibodies. results: erg protein expression and erg rearrangement status were highly concordant regardless of whether the mouse or rabbit erg-mab was used ( . % versus . %, respectively). conclusion: this is the first study to comprehensively compare the two erg-mabs. by demonstrating a broad applicability of ihc to study erg protein expression using either antibody, this study adds an important step towards a facilitated routine clinical application. ofp- - improved method of detecting the erg gene rearrangement in prostate cancer using combined dual-color chromogenic and silver in-situ hybridization m. braun * , j. stomper, d. boehm, w. vogel, n. wernert, g. kristiansen, s. perner * universitätsklinik bonn, inst. für pathologie, germany objective: the recently detected erg rearrangement revealed as a recurrent and prevalent prostate cancer (pca) specific event. to detect this alteration, fish is the method of choice. however, fish harbors disadvantages for widespread adoption in clinical practice. subsequently, the chromogenic in-situ hybridization (cish) and the enzymatic metallography silver in-situ hybridization (sish) emerged as promising bright-field alternatives. we aimed to develop a combined cish and sish (cs-ish) gene break-apart assay on the example of the erg gene. method: we assessed and compared pca and benign specimens for their erg rearrangement status applying a dual-colour fish and cs-ish erg break-apart assay on consecutive sections. results: we observed a highly significant concordance ( , %) between fish-based and cs-ish-based results (pearson's correlation coefficient . , p< . ). conclusion: we demonstrate that the erg rearrangement status can reliably be assesed by cs-ish. further, we confirm that the cs-ish technique combines the accuracy and precision of fish with the ease of bright field microscopy. we developed a tool which allows a broad spectrum of applicants to study the biological role and clinical utilization of erg rearrangements in pca. moreoever, our study is the first proof-of-principle for bright-field cs-ish gene fusion or break-apart assays. ofp- - rearrangement of the ets genes etv- , etv- , etv- and elk- is a clonal event during prostate cancer progression m. braun * , z. shaikhibrahim, w. vogel, d. boehm, r. menon, n. wernert, g. kristiansen, s. perner * universitätsklinik bonn, inst. für pathologie, germany objective: ets gene rearrangements are frequently found in prostate cancer (pca). recently, we observed that erg rearrangement in primary pca transfers into lymph node metastases, suggesting it to be a clonal expansion event during pca progression. here, we investigated whether this also applies to the less frequent ets genes, etv- , etv- , etv- and elk- . method: using break-apart fish assays, we evaluated the status of above mentioned ets gene rearrangements on a cohort comprising of primary pca, corresponding lymph node and distant metastases. results: etv- , etv- , etv- and elk- rearrangements were found in %, %, % and % of the primary pca, respectively, and in %, %, %, % of the corresponding lymph node metastases, respectively. rearrangements of etv- and etv- were not found in any of the distant metastases cases, whereas etv- and elk- rearrangements were found in % and % of the distant metastases, respectively. conclusion: our results suggest that rearrangement of the less frequent ets genes is a clonal event during prostate cancer progression. our findings provide insights into potential clonal expansion events during pca progression and may have significant implications in understanding the molecular basis of the metastatic cascade of pca. ofp- - comparative analysis of two prostate biopsy systems: a study of cases f. e. costa * , r. dias, j. r. vizcaíno * centro hospitalar do porto, braga, portugal objective: it's expectable that the higher the number of prostate biopsies the greater the probability of prostate cancer detection, presumably improving the diagnostic accuracy and treatment decision. method: under this assumption, since may/ , santo antónio's hospital implemented a prostate mapping system, increasing the number of biopsies performed from - to - and processing each core independently. we intend to establish a comparison between the traditional prostate biopsy system (ts) and the prostate mapping system (ms). for this study, all biopsy slides and corresponding surgical specimens from patients subjected to ms and patients subjected to ts were reviewed. gleason score, percentage of tumor present in prostatic tissue (expressed as small ≤ %, medium - % and large ≥ %) and presence of tumor in prostate apex and base were analyzed. results: comparing ms with ts, the correlation coefficient was , % and , % for gleason score and , % and , % for the percentage of tumor present in prostatic tissue, respectively. mapped biopsies were able to detect the tumor in the apex and base in % and % of cases. conclusion: these results suggest that prostate ms improves the diagnostic accuracy of prostate cancer and has a good ability to predict the presence of tumor in prostate apex and base. ofp- - frequency and prognostic significance of tmprss -erg gene fusion in lymph node positive prostate cancers a. fleischmann * , i. zlobec, t. visakorpi, g. thalmann * universität bern, inst. für pathologie, switzerland objective: tmprss -erg incidence and prognostic significance in lymph node positive prostate cancer are virtually unknown. method: a tissue-microarray was constructed from hormone-naïve nodal positive, surgically treated prostate cancers containing samples from all gleason patterns (gp) present in every primary tumor (pt) and corresponding lymph node metastases (met). tmprss -erg status was determined by fluorescence in-situ hybridization and correlated with various histomorphological tumor features (gleason score, stage, cancer volume, nodal tumor burden) and biochemical recurrence-free, cancer-specific and overall survival. results: tmprss -erg fusion was present in . % (homogeneous . %, heterogeneous . %) of the pt and in . % (homogeneous . %, heterogeneous . %) of the met. percentage of tmprss -erg in gp / / of pt and met were: %/ %/ % and %/ %/ %. concordance in tmprss -erg status between pt and met was poor (kappa . ) showing . % and . % of cancers with gene fusion solely in the pt and met, respectively. tmprss -erg fusion was not correlated with histopathological tumor features and predicted late biochemical recurrence independently (p= . ) when present in pt. conclusion: tmprss -erg fusion in pt is more frequent and its distribution more heterogeneous compared to met. the gene fusion in primary tumors independently predicts late biochemical recurrence. ofp- - wnt and shh pathways activation in penile carcinoma a. silva * , t. almeida, f. soares, m. buim * hospital ac camargo, investigative pathology, são paulo, brazil objective: penile carcinoma (pc) is rare in developed countries, accounting for less than % of all neoplasms in men, and biological characteristics of this tumor are poorly known. wnt and shh pathways are important for cell proliferation, differentiation and survival, and therefore, play a role in carcinogenesis of various organs. the goal of this study is to investigate the expression profile of wnt and shh pathway proteins in pc, characterizing the expression of target proteins from wnt (wnt- , wnt- , wnt- gsk β, β-catenin, d cyclin, mmp , c-myc, cd ) and shh (shh, smo, gli, egfr) pathways. method: for that, samples of pc were obtained from the files of anatomic pathology department from a.c. camargo hospital (brazil) and submitted to immunohistochemistry. results: we observed that wnt- and wnt- were expressed in and cases, respectively, out of the evaluated samples. strong shh expression was detected in / cases, whereas weak and negative expression was seen only in one case each. smo and gli- proteins were expressed in almost all cases ( / ), and also d cyclin, b-catenin and egfr were frequently expressed. conclusion: these preliminary results suggest that wnt and shh pathways may be active and participating in the progression of penile cancer. ofp- - expression of the multidrug resistance protein correlates with longer psa relapse free survival and androgen receptor and forkhead box a protein expression in prostate cancer m. montani * , g. kristiansen * medizin. universität bern, inst. für pathologie, switzerland objective: multidrug resistance protein (mrp ) a transmembranary transport protein has shown to be expressed in prostate cancer cell lines and cancer cell specimens and turned out to be among the highest upregulated genes in an arraybased transcription analysis. its expression is regulated in an androgen dependent manner, possibly modulated by forkhead box a (foxa), an androgen receptor (ar) co-activator. therefore, we investigated its expression in a large cohort of neoplastic and non-neoplastic prostate tissues (n = ) and evaluated its prediction of psa relapse free survival (rfs). method: tma (n= ) stained for mrp , foxa, ar, er, psa, ki- : radical prostatectomies (rpe) (n= ), castrate resistant prostate cancer (crpc) (n= ), metastases (n= ) and non-neoplastic (n= ). psa-rfs of patients; mean months. results: mrp expression decreases with tumor progression into castrate resistant disease, correlates with psa, ar and foxa expression and inversely correlates with gleason score. moreover, a strong mrp expression is significantly associated with a longer psa rfs in rpe patients. normal tissues from the transitional zone show a weak mrp expression compared to the peripheral and central zones. conclusion: mrp expression seems to predict psa relapse free survival in prostate cancer patients. since its expression is androgen dependent it decreases with tumor progression into crpc. ofp- - synchronous angiomyolipoma and renal tumors in patients without tuberous sclerosis: clinico-pathological study of cases f. j. queipo * , r. a. carías, Án. f. panizo, m. l. gómez-dorronsoro, f. j. pardo * clínica universidad de navarra, pathology, pamplona, spain objective: simultaneous existence of aml and renal neoplasia is frequent in tuberous sclerosis (ts) patients, but uncommon in non-ts cases. method: a total of cases of coexistent renal neoplasia and aml in non-ts patients were identified. clinico-pathological features were studied. results: patients: m/ f (mean age , year; range: - ) . mean aml size: , cm (range: , - , ). the main size of the renal neoplasms was , cm (range , - ). aml morphology: leiomyomatous, classic-triphasic, lipomatous, and epithelioid. three cases had multifocal aml. cases had ipsilateral tumors associated with aml: ccrcc ( sarcomatoid), chrcc, ro, tfe rcc, hybrid (ro-chrcc) renal-cell tumor, urothelial carcinoma, and case had tumors: mtsc-rcc and concomitant prcc. cases had contralateral tumours associated with aml: chrcc and ro. one patient had bilateral tumors associated with aml: an ipsilateral ro and a contralateral ccrcc. the median follow-up was , mths (range , - , ) : all patients were alive without disease. conclusion: the coexistence of renal tumors with aml is a rare event, usually incidental. if aml is found incidentally together with other renal tumors, it is important to exclude ts retrospectively. ofp- - primary renal synovial sarcoma: a clinicopathologic, immunohistochemical and molecular genetic study of cases j. schoolmeester * , j. cheville, a. folpe * mayo clinic, dept. of anatomic pathology, rochester, mn, usa objective: primary renal synovial sarcoma (r-ss) is a rare malignant neoplasm. approximately cases have been described, chiefly as case reports or as part of relatively limited small studies. we studied the clinicopathological, immunohistochemical (ihc) and molecular genetic features of well-characterized r-ss. method: all available slides for institutional and consultation cases of r-ss were reviewed. an ihc panel (tle , bcl , cytokeratins, s , cd , ini ) was performed. rt-pcr for ss -ssx / or fish for ss rearrangement was performed. follow-up was obtained. results: the patients ( m, f) ranged from to years (mean ). all tumors were of monophasic fibrous type. ihc results: all cases were strongly positive for tle and bcl ; focally positive or negative for cytokeratins; negative for s and cd ; and showed retained ini expression. molecular genetic results were: ss -ssx ( cases), ss -ssx ( cases), syt rearrangement ( case). follow-up ( cases): dead of disease, alive without disease. conclusion: our data show a striking overrepresentation of the ss -ssx fusion subtype among r-ss, in contrast to other ss, in which the ss -ssx fusion subtype accounts for two-thirds of cases. the reasons for this difference are unclear. the prognosis for r-ss appears similar to that of ss of more common locations. objective: new data related to the diagnosis and therapy of lung cancer have also affected the position of the pathologist in this area. principal changes in its classification have appeared in relation to adenocarcinoma and partly also in the large cell type of lung cancer. method: presented data represent a five-year retrospective study of a series of cases of lung cancers analyzed in our institute. besides routine he staining the following immunohistochemical reactions were used: antibody against ttf- , surfactant a, chromogranin, synaptophysin, ck , ae /ae , p , βe , cd and napsin a. results: using the who, classification of lung cancer, an unusual phenomenon of the return of squamous cell cancer (scc) prevalence over adenocarcinoma has been documented, which in the earlier years has equated the scc. the difference in obtaining the tissue samples, and changes in the geographical origin of certain patients of eastern slovakia may partly explain these differences. though the new travis classification (j thorac oncol, ) was not used, there prevailed mixed forms also in our series. conclusion: it is important to respect new information regarding the classification of lung cancer, especially in the category of adenocarcinoma. the constructive collaboration of pathologists with clinicians is recommended. objective: extranodal marginal zone lymphoma malt lymphoma and carcinoid are neoplasms occurring most frequently in the gastrointestinal tract and respiratory system. although each of them occurs relatively frequently and separately, the simultaneous appearance of these two neoplasms is exceptionally rare. method: we report an exceptional synchronous association of malt lymphoma and typical carcinoid in the lung. results: a -year-old male with sjögren's syndrome presented with cough and chest pain with no improvement after antibiotherapy. bronchial fibroscopy was normal. computed tomography showed a diffuse interstitial pneumopathy with a persistent left lower lobe nodule suspected of malignancy. a surgical resection of the nodule was achieved. histopathologically, it measuring . cm in diameter and was composed of association of malt lymphoma and typical carcinoid tumor which were focally admixed. immunohistochemical stains were strongly reactive to endocrine marker in carcinomatous component. tumor cells were diffusely cd positive in lymphomatous component. assessment of extent of lymphoma revealed a gastric location. the patient received chemoptherapy. he's still alive since months. conclusion: the best of our knowledge, this is the first report of such a collision lung tumor at the same anatomical site. the aim of this study is to describe the pathogenesis and clincicopathological feartures of such exceptional association. objective: primary mucoepidermoid carcinoma is rare comprise less than % of all lung tumors. it is characterized by the presence of squamoid cells, mucin-secreting cells and intermediate type. on the basis of morphological and cytological features, it is divided into low and highgrade types. method: we report a retrospective study of cases diagnosed during a -year period. diagnosis was made by histological examination of specimen obtained from lobectomy in cases and pneumonectomy in cases. no patient had history of salivary mucoepidermoid carcinoma. results: there were men and women ranging in age from to years. computed tomography showed a well circumscribed tumor arising in bronchus in all cases. a bronchial fibroscopy showed a main, lobar or segmental mass. bronchial biopsy revealed a non-small-cell carcinoma in only one case. histologically, tumors were classified into low grade mucoepidermoid carcinoma and high grade mucoepidermoid carcinoma. patients with low grade carcinoma remain alive after surgery alone. patients with high grade carcinoma received chemotherapy, four of them developed distance metastasis. conclusion: mucoepidermoid carcinoma is a rare primary malignancy of the tracheobronchial tree which is difficult to diagnose by limited biopsy. the prognosis is variable and depends upon the histological grade. objective: primary pulmonary malt lymphoma is considered to originate from malt of the bronchus secondary to autoimmune or inflammatory processes. although, it comprises more than two-thirds of all primary non-hodgkin's lymphoma of the lungs, it is a rare entity and accounts for less than % of all lymphomas. method: we report a retrospective study of cases of malt pulmonary lymphomas diagnosed during an -year period. diagnosis was made on surgical pulmonary biopsy in cases, bronchial biopsy in other cases and on lobectomy in one case. results: there were women and men ranging in age from to years. two patients had a history of sjoren's syndrome and one had a history of previous mammary carcinoma. computed tomography revealed bilateral nodules in patients, lung mass in patients and an area of consolidation in one patient. fiberoptic bronchoscopy showed bronchial stenosis in only cases. morphologically, the neoplasms had features typical of malt lymphoma. one patient was treated with surgery alone and received chemotherapy. five patients remained alive while one patient presented with recurrence. conclusion: pulmonary malt lymphomas are characterized by an important dissociation between clinical expression and radiological pattern. therefore, histological documentation is mandatory to ensure diagnosis. objective: malignant mesothelioma (mm) is an aggressive tumour with a poor prognosis. carbonic anhydrases and their inhibitors offer an opportunity for developing novel anticancer drugs, as well as diagnostic and prognostic tools. carbonic anhydrase ix (caix) is a membranous metalloenzyme involved in cell adhesion and ph homeostasis. it is a direct target of hypoxia-inducible factor and serves as a marker of hypoxia. this study was designed to assess systematically caix expression in mm of pleura and peritoneum, and their benign counterparts. method: mms of pleura ( epithelioid, biphasic, sarcomatoid) and peritoneum ( epithelioid), and normal or reactive pleural samples were analyzed. caix expression was determined using immunohistochemistry. membranous immunoreactivity was evaluated semiquantitatively. specimens were divided into five subgroups according to the staining pattern and intensity. results: , % ( / ) of mms expressed caix. all epithelioid mesotheliomas showed at least a weak focal ( , %, / ), but predominantly a strong diffuse ( , %, / ) staining with caix antibody, without any perinecrotic pattern. sarcomatoid mesotheliomas were negative. normal mesothelial cells were diffusely positive. conclusion: these data suggest that mechanisms of caix overexpression in mm are different than due to hypoxia and appear promising in prospective use of specific therapeutic caix targeting in advanced mesothelioma. objective: eml -alk crizotinib therapy needs validation at lower cost and rapid answer in pathology routine. method: histological/who and ck , ttf , ck . , cd /chromogranin and vimentin panel classifications with alk (clone a , novocastra laboratories ltd, newcastle, united kingdom) were applied to paraffin sections of bronchial-pulmonary carcinomas: adenocarcinomas, epidermoid carcinomas, pleomorphic carcinomas (mixed type adenocarcinomas with large/giant/fusiform cells), neuroendocrine carcinomas (nec) ( combined large cell nec with adenocarcinoma and with epidermoid carcinomas; sclc chromogranin positive combined with adenocarcinoma) and adenosquamous carcinoma. results: the applied antibodies specified bronchial pulmonary carcinomas subtypes clearly. in over years old nonsmoking females mixed type adenocarcinomas alk expression was over %: acinar, solid, micropapillary and microacinar patterns; one glandular mucinous pattern (mucinous ba pattern) and one ba pattern, all expressing ttf- . conclusion: in this study, / adenocarcinomas of older women had alk protein expression, only one with a mucinous pattern. as protein positivity cases comprise a lower number, fish described by s. lantuejoul seems to be the most appropriate method. it is now necessary to decide whether kras and egfr mutations have to be determined together and/or select ttf- positive adenocarcinomas (from terminal respiratory unit) raised by this approach. objective: the year survival of bronchial-pulmonary carcinomas remains poor, between % and %/men and % to %/women. treatment orientation is influenced by clinical staging and morphological classification in biopsies of % of the cases. method: this study comprised surgical specimens where we compared immunohistochemistry in-between adenocarcinomas ( ), epidermoid carcinomas ( ) and the heterogeneous groups of large cell neuroendocrine carcinoma ( ), small cell lung cancer ( ), large cell carcinoma ( ), adenosquamous carcinoma ( ) and pleomorphic carcinomas ( ) with max f-fluordesoxiglucose (fdg), a clinical parameter based in pet to preview diagnosis and prognosis. results: we found significant differences (p= . ) between ttf- positive and negative adenocarcinomas where the f-fdg capture was lower in ttf- positive cases, indicating lower metabolic activity. ttf- negative adenocarcinomas have similar and higher metabolic activity as epidermoid carcinomas. the other histological types have fdg capture similar in between the two defined groups. conclusion: immunohistochemical and f-fdg analysis correlate with clinical differences between adenocarcinomas and epidermoid carcinomas, where ttf- negative adenocarcinomas are biologically similar to epidermoid carcinomas, requiring a different medical approach as well as molecular pathology particular interpretation. these results strain the classification of bronchial ttf- negative adenocarcinomas because they are different from the terminal respiratory unit ttf- positive adenocarcinomas. objective: according to researchers pneumonias are characterized by increase number of alveolar macrophages population after increased migration of monocytes from bone marrow and blood into the alveolar space. method: we examined observations of pneumonia with bacteriological, histological and blood monocytes examination in all cases. bacteriological study was performed at the institute of antimicrobial chemotherapy. histological examination was performed in the smolensk regional institute of pathology. results: in the foci of pneumonias we discovered mainly mixed gram positive and gram negative microorganisms. ten observations were characterized by an increase in the absolute number of blood monocytes. fifty observations did not reveal excess levels of blood monocytes. in all cases with an increase in the number of blood monocytes, gram negative bacteria were isolated. in cases with normal number of blood monocytes some of the microorganisms were gram positive. conclusion: gram negative bacteria result in activation of the monocytes and their entry from the bone marrow into the blood more than gram positive bacteria. objective: bronchial carcinoids and schwannomas are uncommon, slowly growing, low-grade neoplasms. carcinoid tumors are thought to arise from neuroendocrine/kulchitsky's cells of bronchial epithelium. schwannomas are thought to originate from schwann cells. clinically they may be asymptomatic or present with non resolving recurrent pneumonia, hemoptysis, respiratory distress. conclusion: we present two cases of respiratory distress in two teenage patients. pulmonary hamartomas mimicking metastatic carcinomas h. erdem * , l. yilmaz aydin, a. k. uzunlat, m. oktay, a. n. annakaya, u. yilderim, f. basar * duzce university, dept. of pathology, turkey pulmonary hamartomas are usually found incidentally and they mimick metastic tumours. we report a case of a year-old man who admitted to chest disease service for cough. he had laryngectomy operation formerly and diagnosed as squamous cell carcinoma. chest-x-ray and computed tomography revealed pulmonary nodules. it was removed but there was not metastatic carcinomas. this case was presented because it can be difficult to make diagnosis when the patient has malignancy. objective: experimental models of pulmonary fibrosis (pf) has been proposed and its later phase tend to the resolution in different degrees depending on the drug/ strain/inflammatory-pattern. thus the maintenance of these mechanisms may participate in the pf-progression. our objective was to determine the immune-fibroticpattern in models of pulmonary fibrosis in the late stage ( d). method: distinct animal models were used, including balb/c, c bl/ and il ra-ko-c bl/ mice by bleomycin and paraquat. we analyzed the amounts of total peribronchiolar-interstitial collagen (tpc-tip) by picrosirius and col -col by immunofluorescence through the morphometric evaluation. these data were validated by rt-pcr. results: the tpc did not differ between the treated groups. tic was higher in the c bl/ strain, independent of the absence of il- ra. the col -immunoexpression was higher in control and blm-treated il ra-ko-c bl/ than in wild-mice and lower in blm-balb/c mice. the col immunoexpression was higher in blm-balb/c. likewise, the col gene expression was higher in the il ra-ko mice and lower in the blm-balb/c. conclusion: the perpetuation of fibrosis in pf-susceptiblemice can be modulated by il- -dependent col -hiperexpression and by col -subexpression. this suggests that col is an important component responsible for the development of pf. the prognostic role of filamin a protein expression in patients with non-small-cell lung cancer m. gachechiladze * , j. skarda * palacky university, pathology, olomouc, czech republic objective: an actin-binding protein filamin a (flna) serves as a scaffold in various signaling pathways. recently, it has been reported that flna interacts with brca protein and is required for efficient regulation of early stages of dna repair processes. as dna repair proteins are important prognostic markers for non-small-cell lung cancer (nsclc) patients, we aimed to investigate the role of flna protein expression in nsclc, as well as its correlation with brca protein expression. method: we performed a preliminary study of fnla and brca protein expression in nsclc patients. formalin-fixed paraffin-embedded tissue sections were stained by immunohistochemistry using antibodies against flna c-terminus (ep y, lsbio), brca n-termunus (ms ) and against phosphorilated forms of brca at ser and ser (abcam). staining intensity was estimated semi-quantitatively and correlated with all available clinico-pathological factors. results: flna expression was significantly higher in cancer, compared to normal lung tissue. positive correlation has been revealed between flna and brca phospho-ser expression. also, year overall survival rate was higher in patients with strong flna expression. conclusion: according to our preliminary study results the prognostic role of flna protein expression deserves to be a subject for further studies in patients with nsclc. ps- - pulmonary nodular lymphoid hyperplasia ("pulmonary pseudolymphoma") -the significance of increased numbers of igg positive plasma cells d. guinee * , a. gerbino, s. murakami, m. koss * virginia mason medical center, pathology, seattle, usa objective: pseudolymphomas of the skin, breast, and lacrimal glands show an increase in igg positive plasma cells. we hypothesized that a similar increase in igg positive plasma cells occurs in pulmonary nodular lymphoid hyperplasia (pnlh). method: immunohistochemical stains for igg and igg were performed in cases of pnlh, cases of balt lymphoma, cases of intraparenchymal lymph nodes (ipl) and case of follicular bronchiolitis (fb). the mean number of igg -and igg-positive plasma cells and the igg /igg ratio was obtained from a manual count of three separate high power fields (hpfs) of areas of highest cellularity. results: the average number of igg positive plasma cells and the igg /igg ratio was increased in pnlh (case : /hpf, ratio: . , case : /hpf, ratio: . ). in comparison, average igg positive plasma cells per hpf were much lower in balt lymphoma (range= - . /hpf, ratio= - . ), ipl (range igg / hpf= - , ratio= - . ) and fb ( /hpf, ratio= . ). conclusion: the increase in igg positive plasma cells and igg /igg ratio in pnlh aids in diagnosis and supports our current understanding of pnlh as a distinct form of reactive lymphoid proliferation. the relationship between pnlh and igg -related sclerosing disease requires further study. ps- - calretinin, ck / , ttf- , cea, ber-ep , and cd : a useful combination of immunohistochemical markers for differentiating pleural mesothelioma from pulmonary adenocarcinoma n. gursan * , m. calik, e. demirci, s. sipal, b. gundogdu, c. gundogdu * ataturk university, medical faculty, erzurum, turkey objective: the distinction between pleural epithelial mesothelioma and peripheral lung adenocarcinoma involving the pleura is still an important diagnostic problem for surgical pathologists. the aim of our study was to identify the most specific and sensitive markers for the positive identification of mesothelioma. method: paraffin-embedded blocks from surgical material of pleural epithelial mesotheliomas and pulmonary adenocarcinomas were retrieved from the files in our department. the primary antibodies used in each case were the following: antibody anticalretinin, ema; cea, berep , ttf- and cd . results: of the mesotheliomas, % stained for calretinin, . % for ck / , . % stained for ema and ae /ae . of the lung adenocarcinomas, . % cases showed reactivity for calretinin, . % for ck / , . % for cd , all for ttf- , % for cea, . % for ber-ep , . % for ema, and all for ae /ae . conclusion: calretinin were the highly specific positive mesothelial markers, whereas ck / showed high sensitivity but low specificity. among negative markers, we advocate the use of ttf- , cea and cd which were the most specific in differentiating mesotheliomas from adenocarcinomas. cyclooxygenase- expression in nsclc i. kern * , e. sodja, m. rot * university clinic golnik, slovenia objective: overexpression of cox- correlates with aggressive disease of nsclc. aim of our study was to determine the cox- expression levels by two methods. method: analysis was done on consecutive surgical specimens of nsclc fixed in paxgene tissue system. relative quantification of cox- mrna expression was performed by quantitative rt-pcr using intron-spanning primer-probe set. cox- protein expression was assessed by immunohistochemistry (ihc). scoring was performed using an intensity-extent system, both parameters on the scale - and multiplied to give ihc index. results: there were cases of adenocarcinoma, cases of squamous cell carcinoma and one typical carcinoid. cox- mrna expression was detectable in all specimens. the median cox- mrna expression value, normalized against he internal reference gene gadph, was , (range , - , ). we observed cytoplasmic and membranous immunohistochemical reaction patterns. average ihc index was , . there was positive correlation between mrna and protein cox- expression (r = , ). adenocarcinoma cases had average relative mrna expression value , and ihc index , , while squamous cell carcinoma had average relative mrna expression value , and ihc index , . conclusion: cox- is expressed in nsclc with various ihc reaction patterns. adenocarcinoma and squamous cell carcinoma have different cox- expression levels. objective: the akt/mammalian target of rapamycin (mtor) pathway is up-regulated in many human cancers, and agents targeting the mtor pathway are in various stages of clinical development and application. method: expression of pakt and mtor was studied by immunohistochemical analysis of surgically resected nonsmall cell lung cancer (nsclc) specimens on a tissue microarray (tma). results: the results were correlated with clinicopathological features. expression of mtor showed a strong correlation with the expression of pakt (p< . ) and was significantly associated with female gender, tumor size ≤ cm, adenocarcinoma (adc), non-smoker status, and lower pathological stage. expression of pakt was correlated with older age (≥ ), adc, non-smoker status, and lower t stage. univariate survival analysis revealed that the mtor and pakt positive group had a significantly longer cancer-specific survival than the mtor and pakt negative group (p= . and p= . , respectively). coexpression of pakt and mtor correlated with better prognosis than either single or double negative pakt and mtor groups (p= . ). however, multivariate analysis proved that mtor and pakt expression are not independent prognostic factors for cancer-specific survival. conclusion: expression of pakt and mtor expression is more significantly associated with adc than squamous cell carcinoma (scc) and expression of these proteins is associated with better prognosis. ps- - pak immunohistochemistry marker in non-small cell lung cancer (nsclc) a. kucukosmanoglu * , o. d. İlara colakkadıoglu, k. bakir * university of gaziantep, pathology, turkey objective: pak is a member of p -activated kinase family. many human tumor express and activate this family. because of their role in cell transformation, they become therapeutic targets. they have important roles in cell survival, cell proliferation and cell migration. they affect cell growth and tumor invasion. method: cases with nsclc reported in gaziantep university pathology department between and , reviewed retrospectively. immunohistochemically nuclear and cytoplasmic pak stainings were considered positive and scored according to degree of staining. results: our cases included squamous cell carcinoma, adenocarcinoma, adeno squamous carcinoma and large cell carcinoma. there was no significantly associated between tumor types and pak staining. of patients showed recurrence and of cases showed nuclear staining but there were no statistically significance (p: , ). cases died from the disease and in of these cases nuclear stainig was very intresting, inspite of statistical results. conclusion: in this study pak staining patern and score were compared with tumor type, size, recurrence, mortality and lymph node involvement in nsclc. and we found no statistically significance. of case with nsclc stained with pak . these results suggest that pak was expressed in lung like prostat, plasenta and breast. pleural fibroelastosis is a similar spectrum of histopathology in chronic fibrosing lung disorders l. marcal * , e. r. parra, l. antonangelo, v. capelozzi, f. vargas, e. c. nascimento, v. teodoro, k. c. silva * lia junqueira marçal, são paulo, brazil objective: parenchymal fibroelastosis in chronic fibrosing lung disorders has been much investigated, but little attention has been directed at the visceral pleura (vp) participation in these situations. our aim was to verify whether elastic deposition accompanies collagen deposition in the repairing process of chronic lung injury. in this work we studied the distribution of these fibrous components of vp in bullous disease type i and ii, smoking-related interstitial fibrosis and usual interstitial pneumonia (uip). method: we employed histochemical methods on conventional histological slides. we measured, by image analysis, the content of fibres of the collagenous and elastic systems of the visceral pleura in histological slides sampled from surgical lung biopsies and bullectomy, using the picrosirius-polarization method and weigert's resorcin-fuchsin stain, respectively. results: four groups were studied: i, patients with spontaneous pneumothorax due to type i bullous disease; ii, patients with spontaneous pneumothorax due to type ii bullous disease; iii, smoking-related interstitial fibrosis; and iv, patients with idiopathic pulmonary fibrosis. the first two groups were used as controls. patient diagnosed with idiopathic pulmonary fibrosis ( ), in which experimental transplantation was performed of type ii pneumocytes, ingress to the hospital for further study groundmass of the right lung. in the postmortem study a gr. mass was identified, the mass was formed by sarcomatous cells habit, undifferentiated and pleomorphic, with the presence of multiple implants and adhesions in rib cage, diaphragm, pericardial fat. ihc profile was performed: vimentin (+), ema focally (+), wt , ck , ttf , ckae /ae , s , cd , cd and cd (−) and low proliferation index, the diagnosis undifferentiated malignant tumor. with inconclusive ihc profile, so blocks were sent to clinic barcelona hospital, for study. the estimated prevalence of idiopathic pulmonary fibrosis is cases per , population in men, with a mortality of % at years of diagnosis. cancer rate of in transplanted patients is within the range between % and %. could the appearance of this tumor be related either to transplanted pneumocytes or it is inmunosupression the main risk factor? current treatments for idiopathic pulmonary fibrosis are not effective, which requires the study and development of new therapeutic options, using fibroblast proliferation inhibitors, as well as prospective studies, in the long term, the evolution of these patients and the development of secondary entities to it. objective: mediastinal hemangiomas are rare tumors accounting for , % of all mediastinal tumors. these tumors are challenging because of the lack of clinical and radiologic specific signs. their diagnosis is mainly based on microscopic study. method: we report a -year-experience of a single institution. we describe cases of mediastinal hemangioma. results: our study contained men and women with a mean age of . years. symptoms consisted mainly in chest pain. neurologic signs were observed in patients. surgical treatment was performed in all patients dealing with a total resection in patients. the most used surgical approach was a posterolateral thoracotomy. video-assisted thoracic excision was tried in one patient and was converted into a median sternotomy. microscopic examination concluded to a mediastinal hemangioma in all cases. all the patients presented no complications after a follow up periods varying from months to years. conclusion: mediastinal hemangiomas are rare tumors whose diagnosis is based on microscopic findings. their surgical management may be challenging because of their connection to the adjacent structures. video-assisted thoracic excision is being more frequently used by experienced surgeons. these tumors are benign with a good behavior. objective: actinomycosis is an infectious disease caused by actinomyce israeli in % of the cases. it is mainly observed in alcoholic patients and affects mainly cervicofacial, abdominal and thoracic regions. pulomnary actinomycosis accounts for % of the localizations and is caused by the inhalation of septic particles causing granulomatous lesions, the extension to the adjacent organs and a cutaneous fistulae. it represents a real pitfall and mimics malignant lesions, tuberculosis or other infectious diseases. method: we report a retrospective study about cases of pulmonary actinomycosis diagnosed over a -year-period. results: we describe the cases of men aged between and years who presented with respiratory signs. radiologic investigations showed in all cases parenchymal masses with irregular margins mimicking malignant processes. positivie diagnosis was based on microscopic examination. the treatment was based on surgical excision associated to a medical treatment without complications after a follow up period ranging from months to months. conclusion: pulmonary actinomycosis shares usually the same clinical and radiologic features as malignant lesions. positive diagnosis is based on microscopic findings. it inducesusually surroundng organs and may affect, in some cases, the vital prognosis. over expression of hyaluronan syntehase- activity has impact in the remodeling process and survival evolution in patients with idiopathic pulmonary fibrosis e. parra * , v. capelozzi * fmusp, dept. of pathology, são paulo, brazil objective: the idiopathic pulmonary fibrosis (ipf) is a terminal illness characterized by unremitting extracellular matrix (ecm) deposition in the lung. in this regard, the myofibroblasts and the ecm components such as collagen and hyaluronan (ha) have an important role in the fibrosis. we analyzed the expression of has (ha synthase ), has , has and hyaluronic acid receptor (cd ) by epithelial and myofibroblasts cells in patients with ipf and we correlated with a survival. method: has- , has , has and cd epithelial and myofibroblast expression were evaluated in surgical lung biopsies from patients with ipf in minimal and severe fibrosis by the point-counting technique. impact of these markers was tested on pulmonary functional tests and follow-up until death from ipf. results: has and cd expression were significantly increased and directly associated with severe fibrosis. myofibroblast has activity was indirectly associated to dlo/va (r= − . ; p= . ). kaplan maier curves determined a higher risk of death for patient with high ha (> . %) expression than in low expression (log rank p= . , figure) . conclusion: the increased has- activity in epithelial and myofibroblast cells have impact in the remodeling process and the survival evolution, suggesting that strategies aimed at preventing the effect of this ecm component may have a greater impact in patient's outcome. financial support: fapesp, cnpq. ps- - viral antigens are more frequently observed in acute interstitial pneumonia than in other types of idiopathic interstitial pneumonias e. parra * , g. c. dos santos, f. weisshaupt stegun, c. dos santos cirqueira, m. i. seixas duarte, v. l. capelozzi * fmusp, dept. of pathology, são paulo, brazil objective: the etiology of idiopathic interstitial pneumonias (iips) remains unclear. many researches assumed that viruses can represent an important factor of aggression to the lung provoking fibrosis. in this regards, we researched the presence of virus infections in patients with iips. method: biopsy samples from patients with idiopathic interstitial pneumonia (ipf); patients with nonspecific interstitial pneumonia (nsip); patients with acute interstitial pneumonia (aip) and patients with idiopathic cetrilobular fibrosis (iclf) were used to investigate by microarray and immunohistochemistry the presence of measles virus (mv), hepatitis-c virus (hcv), adenovirus (adv), respiratory syncytial virus (rsv), epstein-barr virus (ebv), herpes i and ii viruses (hvi and hvii). results: we detected the epithelial alveolar infection by mv and cmv in . % and . % in aip, respectively. endothelial cmv infection was observed in % of iclf group. when we compared with the age of these patients, patients with ≤ of years old had more infection by mv and cmv than the group with ≥ years old. the other viruses were not detected in the different groups. conclusion: the viral infections observed in aip and iclf groups reinforce the possible viral participation in these pulmonary diseases. financial support: fapesp. abnormal up regulation of cyclooxygenase- is observed in idiopathic pulmonary fibrosis e. parra * , f. lin, w. teodoro, a. p. velosa, v. l. capelozzi * fmusp, dept. of pathology, são paulo, brazil objective: several factors modulate fibroblast proliferation and collagen deposition in pulmonary fibrosis diseases, including cyclooxygenase (cox). the main of this study was observed the relationship between cox and cox in surgical lung biopsies from patients with idiopathic pulmonary fibrosis (ipf). method: twenty four patients ( ± . year) were characterized with ipf. immunohistochemistry and histomorphometry were used to evaluate the amount of cox and cox expression in lung specimens. the expression of these markers was tested with their pulmonary function tests. results: significantly a higher amount of cox- was observed in ipf patients principally in normal and vascular areas (p= . ) when compared with control group (figure) , contrasting with similar amounts of cox- in both groups. an important negative correlation was observed between total lung cox- expression and dco/va (r= . , p= . ) in ipf patients. conclusion: higher vascular expressions of cox probably mediated the inflammatory reaction in patients with ipf and have an important impact with pulmonary function tests, suggesting that a participation in the pathway of ipf. financial support: fapesp. error barr shows the correlations between cox- expression in normal and vascular areas of ipf compared with control group ps- - multiplex ligation probe-dependent amplification (mlpa) as an ancillary method for the diagnosis of malignant pleural effusion e. parra * , d. rosolen, l. kulikowski, r. dutra, v. l. capelozzi, f. vargas, m. acencio, l. antonangelo * fmusp, dept. of pathology, são paulo, brazil objective: a definitive diagnosis provided by the finding of malignant cells in pleural fluid (pf) can be established in around % of patients with pleural malignancy. however, underdiagnosis risk in cytological suspicious cases is high, which makes the cytological diagnosis quite limited. this is an important clinical problem, especially if we consider that some patients, in bad clinical conditions, can not be submitted to a guided thoracoscopic biopsy. method: using multiplex ligation probe-dependent amplification (p -mrc-holland) we have studied sequence variations of egfr gene and amplifications/deletions of chromosomal regions frequently associated to tumors (atg b, pahs, pros, nsd , and cdgif genes). results: forty-three malignant pf samples from patients with different cancers were evaluated, even in those cases with scarce pellet cells. four benign pleural effusions were used as control. gene sequence changes were observed in ( . %) cases, while others copy number abnormalities were found in ( . %). conclusion: the findings suggest that mlpa could be considered an alternative tool to detect molecular genetic changes in malignant pleural effusions, since this technique is relatively low expensive and not time consuming. our next challenge is to find the best combination of probes capable to recognize malignant cells of any origin in fresh samples of pf. multiple primary pulmonary myopericytoma: case presentation n. petre * , f. pop, d. leonte, s. bedereag * medcenter bucharest, dept. of pathology, romania objective: myopericytoma is described as a perivascular myoid tumor which usually develops as a solitary mass in the subcutaneous tissues of the extremities, in adults. method: the chest radiography of a -year-old woman showed multiple, bilateral lung nodules. after the surgical excision of one of them, the histopathologic examination revealed a well circumscribed nodule, composed of fusiform or oval cells, with eosinophilic cytoplasm and ovoid nuclei, without atypia, in a concentric pattern, intimately associated with thin-walled vessels, within a myxoid stroma. results: the spindle cells were diffusely positive for vimentin, smooth muscle actin (sma) and occasionally for desmin. cd and cd were positive only in endothelial cells. ki was positive in less than % of neoplastic cells. conclusion: the histological and immuno-histochemical findings led to the diagnosis of multiple primary pulmonary myopericytoma. ps- - five cases of lung pneumocytoma: clinico-pathological, immunohistochemical and ultrastructural study i. rodriguez * , a. panizo, b. larrinaga, i. amat * c. hospitalario de navarra, dept. of pathology, pamplona, spain objective: lung pneumocytoma (lp), also called sclerosing hemangioma, is an uncommon tumor of uncertain histogenesis. method: we analyzed the clinical, morphological, immunohistochemical and ultrastructural features of lp. results: all patients were women, with median age of year (range: - ). mean size was mm (range - mm). all tumors were located within the right lung (upperlobe: ; middle-lobe: ; lower-lobe: ). all cases showed solid, papillary, sclerotic, and hemorrhagic patterns. the tumors were composed of cells types: pale polygonal and surface cells. ema, ttf , and pr were observed in both type cells. the surface cells showed also positivity for ck , napsin-a, and surfactant-a, whereas the polygonal cells for vimentin. surface cells had short microvilli and lamellar bodies in their cytoplasm. polygonal cells contained abundant microfilaments and rough endoplasmic reticulum. all patients were alive and well without recurrence at the last follow up. conclusion: lp is likely to be an epithelial tumor with a differentiation toward type ii pneumocytes, which exhibits various architectural patterns. the ihc profile provides useful clues for the diagnosis of this lung neoplasm when typical features are absent. all our cases had an excellent prognosis with no evidence of recurrence following surgery. rare tracheobroncheal lesions diagnosed by small bronchoscopic biopsies a. sasmaz * , s. yuksel, h. nalbant, p. celepli, e. kadan, s. percinel, s. dizbay sak * ankara, turkey objective: six different, rarely seen tracheobronchial lesions, taken by bronchoscopy as small fragments were discussed with an emphasis on morphological findings and differential diagnosis. results: six patients were men and two patients were women with an age range of to years. most of the lesions were symptomatic and discovered as small masses by bronchoscopy. the tracheobronchial lesions varied from polypoid, nodular, well-demarcated, fragile masses to nodular thickenings. microscopically, a polyp composed of a fibrovascular stroma with scattered mononuclear inflammatory cells was compatible with fibroepithelial polyp. mature adipocyte proliferation in two cases, s- and cd positive polygonal or ovoid cells with abundant eosinophilic, granular cytoplasm having small, hyperchromatic nuclei, smooth muscle actin and desmin positive spindle cells in interlacing fascicles within a myxoid and collagenous stroma with mononuclear inflammatory cells, cd and cd positive thin-walled vascular channels, filled with red blood cells and s- positive spindle cells having palisading of wavy nuclei in two cases, located in the submucosa were main findings of lipoma, granular cell tumor, inflammatory myofibroblastic tumor, cavernous hemangioma and schwannoma, respectively. conclusion: tracheobronchial biopsies, even with small fragments of lesions can allow to render rare specific histopathological diagnoses, some of which need to be confirmed by immunohistochemistry. objective: small cell lung carcinomas (sclc) are aggressive neoplasms that give very early distant metastases. matrix metalloproteinases (mmps) are a family of endopeptidases which degrade extracellular matrix and modulate cell adhesion, playing a crucial role in cancer cell invasion and metastasis. the aim of the present study is to investigate the immunohistochemical expression of mmp- , mmp- (type iv collagenases) and mmp- (interstitial collagenase) in patients with sclc. method: formalin-fixed, paraffin-embedded lung biopsy specimens from patients with sclc (m:f= : , median age= . ) were immunostained for mmp- , mmp- and mmp- (anti-mmp- polyclonal antibody, anti-mmp- kda collagenase iv antibody, anti-mmp- kda collagenase iv antibody, spring bioscience). results: immunohistochemical expression of mmps was detected in the cytoplasm of neoplastic cells. immunoreactivity was designated positive when > % of neoplastic cells were stained. overall, mmps were expressed in the majority of sclc. specifically, mmp- was positive in % ( / ), mmp- in . % ( / ) and mmp- in . % ( / ) of sclc. non-neoplastic lung parenchyma did not stain for mmps. conclusion: the majority of sclc express immunohistochemically mmp- , mmp- and mmp- . given the role of mmps in cancer progression and metastasis, their expression in sclc may contribute to their aggressive course. objective: number of pulmonary adenocarcinoma (adc) patients incresease. treatment of non-small cell pulmonary carcinoma depends of its histological type in era of target molecular therapy particulary of adc: diagnosis of adc is established on small-sized pulmonary biopsies obtained on bronchoscopy and by transthoracic needle pulmonary biopsy. the aim of this study was to evaluate optimal panel of monoclonal antibodies in diagnosis of pulmonary adc on small-sized biopsy pulmonary samples. method: analysis of small-sized biopsy pulmonary samples. diagnosis of adc was established on hematoxillyn-eosin stained (h&e) samples and confirmed immunohistochemicaly by thyreoid transcription factor- (ttf- ), napsin-a, surfactant b and cytokeratin (ck ). descriptive statistical method (%) was used. results: ttf- specificity was %( / ), napsin-a- %( / ), surfactantb - %( / ) and ck - %( / ) in adcs. two monoclonal antibodies were positive in % ( / ) adcs, one of them was necessary ttf- or napsin-a. three monoclonal antibodies were positive in %( / ) and in %( / ) adcs, respectively. there is not statistical significans in number of monoclonal antibodies for diagnosis of adc. conclusion: no one monoclonalantibody is specific for one histological type of carcinoma and its origin. ttf- , napsin-a, surfactantb and ck belong in optimal panel for diagnosis of pulmonary adenocarcinoma. ps- - expression of cd , e-cadherin and bcl- in lung cancer i. strumfa * , a. abolins, j. gekis, k. pavlovs, a. vanags, j. grusina-ujumaza, g. volanska, j. gardovskis * riga stradins university, dept. of pathology, latvia objective: lung cancer represents major problem in oncology as the incidence and mortality is high (parkin et al., ) . molecular studies could reveal additional targets for intervention or prognostic evaluation. however, the published data are controversial (renouf et al., ; leung et al., ; maraz et al., ; ko et al., ) . method: consecutive lung cancer cases ( ) were retrieved by retrospective archive search. the diagnostics has been performed systematically in accordance with who classification (travis et al., ) . the expression of cd , e-cadherin and bcl- was analysed by immunohistochemistry and evaluated semiquantitatively. results: the intensity of bcl- expression was highest in small cell cancer, reaching the mean value . . no or very low bcl- expression was found in adenocarcinoma, carcinoid and squamous cell cancer. the membranous expression of e-cadherin showed significantly higher mean intensity in adenocarcinoma ( . ) and carcinoid ( . ) than in small cell cancer ( . ) and squamous cell cancer ( . ). cytoplasmic e-cadherin expression was observed in small cell cancer. cd expression was widespread and frequent in non-small cell lung cancer. conclusion: the main histological types of lung cancer show different immunophenotype. bcl- expression is found in small cell cancer. the expression of e-cadherin is characteristic in adenocarcinoma and carcinoid. cd is expressed in non-small cell lung cancer. localized nodular pulmonary and thoracic cage amyloidosis i. strumfa * , a. abolins, j. gekis, k. pavlovs, a. vanags, b. strumfs, g. volanska, j. gardovskis * riga stradins university, dept. of pathology, latvia objective: localised amyloidosis represents a rare differential diagnosis of neoplasms. however, in some cases amyloid deposits are manifestation of tumour itself. to increase awareness about these uncommon but important differential diagnostic issues, we show here three well-characterised cases of thoracic cage or pulmonary localised nodular amyloidosis. method: the cases were identified by systematic retrospective archive search, - . congo red stain, polarisation microscopy and immunohistochemical analysis was applied. results: there were males and female among the patients diagnosed with thoracic cage or pulmonary amyloidosis. the patients were - years old and had no history of previous malignancy. clinically, either lung cancer or sternal osteochondroma was suspected. radiologically, - nodules measuring . - . cm were found in lungs ( cases, one of these being bifocal) or sternum ( ). surgical treatment was applied in all cases. amyloid deposits were identified by congo red stain and polarisation microscopy. al type of amyloid was confirmed. in case of bone lesion, the plasma cells were monoclonal justifying the diagnosis of multiple myeloma. conclusion: localised amyloidosis can involve lung or sternum as tumour-like mass. the lung lesions can be single or multiple. association with haematologic neoplasm is likely if bone is affected. clonality analysis of plasma cells surrounding amyloid deposits is mandatory. pleural localization of castleman disease: a rare entity e. tastekin * , f. oz puyan, e. isler, u. usta * trakya university, dept. of pathology, edirne, turkey objective: castleman disease (cd) comprises a heterogeneous group of disease with various clinical presentations and prognosis. by definition; cd is a lymphoproliferative disorder of the mediastinal lymph nodes and extranodal tissues with follicular and interfollicular abnormalities. pleural localization is an unusual presentation of cd. method: a -year-old man applied to the hospital because of cough. chest x-ray and ct images showed an irregular, × × mm sized intrapleural-extrapulmoner mass in the paramediastinal region. surgical specimen was consisting of a × × . cm sized, irregular-round shaped, gray colored calcified mass. microscopically, a lymphoid proliferation with distorted follicles and increased dendritic cells (with cd ) was detected. lymphocyte depleted germinal centers resembling "onion skin" appearance with penetrated sclerosing hyalinized blood vessels were also seen. interfollicular region was composed of proliferating blood vessels lined by plump endothelial cells and few lymphoplasmositer infiltration. there was heterogeneous positivity with cd and cd . expanded mantle zones showed diffuse bcl positivity. ki proliferation index was low. the mass was diagnosed as "castleman disease, hyaline vascular type". typical appearance of the follicular and interfollicular abnormalities allowed definitive differentiation from mesothelioma and solitary fibrous tumor of the pleura. conclusion: pleural cd is a rare lesion but should be considered especially on young patients in the differential diagnosis of pleural masses. objective: to evaluate foxp expression in bronchus-associated lymphoid tissue (balt) and correlate with the inflammatory process and collagen content in the lung tissue in an experimental model of scleroderma (ssc) after type v collagen (col v)-induced nasal tolerance. method: female new zealand rabbits (n= ) were immunized with mg/ml of col v in freund's adjuvant (im). after days, six immunized animals were nasally tolerated with col v ( νg/day), during days (im-tol). animals (n = ) only tolerated served as control (ct). foxp expression in balt and inflammatory cells in pulmonary interstitium were evaluated by point counting method. types i, iii and v collagen gene expression were evaluated by real-time pcr. results: im-tol when compared to im presented decreased lymphocytes, macrophages and monocytes and types i (p= , ) and v (p= , ) collagen mrna expression in pulmonary tissue. t lymphocytes foxp were expressed in % of im-tol and , % of ct (p= , ). additionally, balt was higher expressed in im-tol in relation to ct. conclusion: col v-induced nasal tolerance in ssc model induces foxp regulatory t cells in balt which can trigger an immune regulatory mechanism resulting in decreased inflammation and collagen expression. it suggests that col v tolerance could be a promising therapeutic for human scleroderma treatment. igg -related lung disease t. tichy * , h. hornychova, j. jankova, j. skarda, b. krajsova * university hospital olomouc, inst. of pathology, czech republic objective: igg -related lung disease is one of the manifestations of igg -related systemic disease. obliterative vasculitis is considered an organ specific feature of igg -related disease in the lung. we report a case of a -year-old man with multifocal subpleural consolidations in both lungs. histologic examination revealed igg -related lung disease with obliterative lymphoplasmacytic vasculitis. method: histological sections from paraffin blocks were used for hematoxylin-eosin and special stains (elastica-masson trichrome, pas, geimsa, grocott), for immunohistochemistry (antibodies against kappa and lambda light chains, cd , cd , igg, igm, iga, igg , lmp ) as well as for eber in situ hybridisation and pcr. results: the lung tissue was irregulary fibrotic with dense lymfoplasmacytic infiltration concentrated in the walls of pulmonary arteries. some arteries were obliterated by intimal fibrosis. infiltrating lymphocytes were small and without atypias. the majority of lymphocytes were cd positive, nearly all plasmocytes showed igg positivity. igg /igg ratio was %. eber in situ hybridisation was negative and monoclonal reaarangement of t cell receptor or immunoglobulin heavy chain genes were not detected. conclusion: igg -related lung disease is rare. obliterative vasculitis and high percentage of igg positive plasmocytes are main histological features of this entity. objective: primary lung carcinoma with heterotopic osteocartilaginous formation is exceedingly rare. to date only cases have been reported in the literature and the pathogenesis is not fully investigated. we report a case of pulmonary adenocarcinoma with osteocartilaginous formation with immunohistochemical staining of bone morphogenetic proteins (bmps). method: a -year-old man was admitted to our hospital for a lung tumor in his left upper lobe. an open lung biopsy followed a lobectomy was done. the resected tissue was fixed with % formalin and embedded in paraffin. sections, cut from paraffin blocks, were subjected to hematoxylin and eosin (he) staining and masson-goldner staining, in addition to immunohistochemical staining. results: the tumor was poorly differentiated adenocarcinoma with heterotopic ossification. some of the tumor cells were positive for bmp- , , and . some of mesenchymal cells in tumor interstitium were positive for osteoblast (ob)-cadherin or bmp receptor-ia. conclusion: we report a case of primary lung adenocarcinoma with heterotopic osteocartilaginous formation and reviewed previously published reports. to our best knowledge, this was the first case that not only bmp was expressed in tumor cells but also ob-cadherin or bmp receptor in some mesenchymal cells of tumor interstitium. expression of transforming growth factor ß and e-cadherin in lung adenocarcinoma j. yoo * , s. y. park * st. vincent's hospital, pathology, suwon, republic of korea objective: there is evidence supporting the concept of tumor progression from pulmonary adenocarcinoma in situ (formerly bronchioloalveolar carcinoma, bac) to adenocarcinoma with varying degrees of invasion. the aim of this study was to investigate the role of tgfß in tumor invasiveness in lung adenocarcinoma, and to determine the potential relationships between its expression and immunophenotypes of cell adhesion molecules. method: tumor samples (n= ) from adenocarcinoma in situ (n= ), minimally invasive adenocarcinoma (formerly bac with ≤ mm invasion, n= ), and lepidic predominant invasive adenocarcinoma (formerly mixed adenocarcinoma showing non-mucinous bac features with > mm invasion, n= ) were examined for the expression of tgfß , e-cadherin, n-cadherin, and h-cadherin proteins using immunohistochemistry. results: twenty-five tumors ( %) were positive for tgfß . the frequency of immunoreactivity in patients with adenocarcinoma in situ, minimally invasive adenocarcinoma, and lepidic predominant invasive adenocarcinoma was % ( / ), % ( / ), and % ( / ), respectively (p= . ). loss of e-cadherin expression was more frequently observed in invasive adenocarcinomas than in adenocarcinomas in situ (p= . ). tgfß expression showed a statistically significant correlation with h-cadherin expression (p= . ), but not with e-cadherin expression (p= . ). conclusion: these results suggest that tgfß and e-cadherin may play an important role in invasive progression of lung adenocarcinoma through regulating epithelial-to-mesenchymal transition. ps- - lin a expression as prognostic indicator in lung adenocarcinomas v. zolota * , v. tzelepi, g. psiouri, i. lilis, n. panagopoulos, c. sirinian, c. scopa * medical school of patras, dept. of pathology, greece objective: lin a is implicated in stem cell pluripotency by blocking let- mirnas and oct- is a transcription factor highly expressed in embryonic stem cells. the present study investigates the prognostic significance of both markers in lung adenocarcinomas. method: we evaluated, by immunohistochemistry, lin a and oct- a expression in formalin-fixed, paraffin-embedded tissues from lung adenocarcinomas. immunoreactivity was scored as +, < % positive tumor cells (ptc); +, - % ptc; +, - % ptc; and +, > % ptc and was compared with clinicopathologic features and overall survival. results: regarding lin a expression % of tumors were recorded as +, % as +, % as + and % as +. the stratification for oct- expression was % ( +), % ( +), % ( +) and % ( +). lin a and oct- expression was not significantly associated with age, gender and tumor grade or stage. lin a + expression predicted a shorter overall survival (p< . ) on univariate analysis. oct- was not associated with patients' prognosis. cox multivariate analysis showed that age, tnm and lin a + expression were independent prognostic factors of survival. conclusion: lin Α expression appears to be an independent predictor of poor outcome in lung adenocarcinomas. further studies are warranted in order to investigate its role in stratifying patients at increased risk for poor outcome. comparison of the mutation status of egfr and kras on pulmonary adenocarcinoma and corresponding brain metastasis objective: egfr and kras mutation statuses have been known associated with the sensitivity of tyrosine kinase inhibitor treatment in pulmonary adenocarcinoma. however, the mutation analyses were usually performed on the primary tumors only, due to the availability of the tumor tissue. method: to compare the kras and egfr mutation statuses between pulmonary adenocarcinomas and corresponding metastases, we performed direct sequencing, followed by scorpion arms method on wild-type cases for egfr analysis, and allele-specific real-time pcr for kras analysis, on the paired samples of pulmonary adenocarcinoma. results: thirty-one ( . %) pulmonary adenocarcinomas and ( . %) brain metastases out of the paired specimens have egfr mutations, and ( . %) paired specimens were concordant for the egfr mutation status between the primary and metastasis. in addition, ( . %) pulmonary adenocarcinomas and ( . %) brain metastases out of the paired specimens have kras mutations, and only ( . %) paired specimens were concordant between the primary and the metastasis. conclusion: the status of egfr mutation is relatively consistent between primary and metastasis comparing to that of kras mutation in pulmonary adenocarcinomas. however, discordance for the mutation statuses does happen. accordingly, repeat analysis is recommended if tissue from metastatsis or recurrence is available. objective: we tried to measure and analyze characteristics of neuroendocrine tumors in lung by image analysis and help to diagnose them. method: it was analysed that sixteen cases of typical carcinoid tumors, five cases of atypical carcinoid tumors, fifteen of small cell carcinomas, fifty one cases of large cell neuroendocrine carcinomas. we analyzed the nuclear area, perimeter, major axis and minor axis using i-solution image analyzer software package. results: the mean nuclear area was . μm in the typical carcinoid tumors, . μm in the atypical carcinoid tumors, . μm in the small cell carcinomas, and . μm in the large cell neuroendocrine carcinomas. after the statistical results, every method was effective to distinguish large cell neuroendocrine carcinoma from other tumors and the circumferences of nucleus was the most effective to distinguish among them. conclusion: pulmonary neuroendocrine tumors were the nuclear morphologic differences of each tumors. therefore, diagnosis that considers morphologic differences of pulmonary neuroendocrine tumors contributes to increase reproducibility and accuracy. sunday, september , . - . an abundant growth of lactobacilli may result in lysis of vaginal epithelial cells, named as cytolytic vaginosis. this cytolytic process may cause the symptoms as seen in candidiasis. we observed pap smears to evaluate if cytolysis has a relationship with infertility. method: in the pathology department of mardin maternity hospital, - period, we examined pap smear cases suffering from the similar syptoms as candidiasis. of the smears, were diagnosed as "cytolytic vaginosis". no growth was observed in cultures. results: the number of the cases suffering from the infertility was (% . ) among cases. in the cytolytic vaginosis group this ratio was % . (n= ). the ratio of the infertil cases of cytolytic vaginosis group over general population was significantly higher (p< . ). conclusion: our results are in favour of supporting the hypothesis of the relation between cytolytic vaginosis and infertility. lactobacilli are thought to have inhibitive role in fertility by changing the vaginal ph and adhering to the epithelial cells so inhibiting the sperm penetration. penicillium and aspergillus spp. on pap smears from the surprising origin i. i. akgun * , b. a. borsa * mardin maternity hospital, dept. of pathology, turkey objective: fungal organisms are commonly seen on smears. some unusual species as aspergillus and penicillium are so rare and generally seen via contamination. in this study, we investigated the origin of the many extraordinary fungal organisms seen on pap smears in series in only a few months. method: in pathology department of mardin maternity hospital, we observed both smear and vaginal discharge materials, came from the same hospital but different clinicians, for months. results: smears came from clinician a and smears from clinician b. curious fungal organisms with huge branching hyphas and macrochonidias were seen in smears among smears ( aspergillus and penicillium species were recognized morphologically). no growth was observed in cultures. interestingly, among all smears came from clinician b, there was no abnormal funguses. the smear samples with unusual fungal components all came from the same gynecologist. this made us strongly consider the probability of contamination. conclusion: penicillium and aspergillus spp. are extremely rare in vaginal smears. in our study, these funguses are thought to be airborne passed from the thick layer of the mold spreading on the ceiling of the office. objective: nearly all cervical cancers are related to human papillomavirus (hpv) infection. hybrid capture -hc (qiagen, hilden, germany) is the method to determine the presence of high risk hpv (hr hpv) in cytology samples with the best clinical sensitivity. method: in our study we compared the results of the hpv test in thinprep® cervical samples using first hc and secondly cervista (hologic, madison). samples were divided in two groups for the statistical analysis. the first group were hsil cases confirmed by biopsy (n = ) and the second group cytology samples reported as negative, asc-us or lsil (without biopsy or biopsy, not hsil) (n= ). results: overall, concordance between the two techniques was % ( / ). there were cases hc + cervista−, and cases hc −cervista+. the average hc viral load in discordant cases was . . in our series the hc sensitivity for ≥ cin was % ( / ) and the specificity was . % ( / ). cervista results were . % ( / ) and . % ( / ), respectively. in the hsil cases the coincidence was . % ( / ). conclusion: cervista results showed good clinical sensitivity and high concordance with hc , with a slightly lower specificity. in conclusion, according to our data the determination of hpv with cervista is comparable with hc . mammary analogue secretory carcinoma of salivary glands: cases including cytology, histology, ihc, em, rt-pcr and fish p. farrajota * , e. tani, c. carvalho, j. wejde, g. elmberger * centro hospitalar do porto, dipt. do anatomia patologica, portugal objective: mammary analogue secretory carcinoma (masc) of the salivary glands was described in by skálová et al. in a series of cases. we present new molecularly confirmed cases with focus on detailed cytomorphological features and correlation with special studies. method: a year old man and a year old female presented with history of slow growing parotid and submucosal buccal tumors, respectively. two fine needle aspiration biopsies (fnab) were performed in each case. the surgical resection specimens were routinely processed and special studies applied on paraffin tissue section. the fnab smears were retrospectively studied. results: all smears showed similar features of abundant proteinaceous background, moderate cellularity including macrophages and irregular and variable sized groups of cells with slightly enlarged round hypercromatic nuclei and abundant bluish vacuolated cytoplasm frequently containing small reddish granulations. the first fnab reports confirmed salivary origin and the second ones alert for possible neoplastic nature, advising surgical resection. electron microscopy performed in the parotid case caracterized the granules as mucigen. subsquent pathologic evaluation and molecular confirmation was carried out. conclusion: masc is a low grade malignant tumor capable of simulating a benign salivary gland process so it is important to know its cytological characteristics. adenosquamous lung carcinoma: the importance of cyto-histologic correlation d. felizardo * , a. l. cunha, r. henrique, c. lobo * instituto de oncologia porto, dept. of pathology, coimbra, portugal objective: adenosquamous lung carcinomas (asc) are uncommon and aggressive tumors. identification of a squamous component within a nsclc is critical as it excludes anti-vegf therapy. likewise, recognition of an adenocarcinoma component is also relevant because it prompts the search for egfr mutations. since % of lung cancers are diagnosed in small biopsies/cytological specimens, cytohistological correlation is crucial for correct diagnosis. thus, we aimed at determining the relevance of combining cytologic and histologic findings in initial diagnostic workup of asc. method: we searched for cases of asc diagnosed at our institution from march to april . cytologic and histopathologic findings were evaluated and their accuracy for diagnosing asc was assessed. results: of cases of lung cancer in biopsy, ( %) corresponded to probable asc and in cases cytologic examination was also performed. in cases, cytology was not conclusive, but in cases it demonstrated cytomorphological features of probable asc. we emphasize one case in which only the squamous component was valued by histology, but cytology provided clues that prompted immunohistochemical analysis which led to the diagnosis of probable asc. conclusion: cyto-histological correlation augments the diagnostic accuracy in asc of the lung, emphasizing the complementarity of both procedures. the impact of the bethesda system for reporting thyroid cytopathology (tbsrtc): a retrospective study of aspirates with emphasis on the prior "indeterminate" objective: the material of this study is consisted of selected fna biopsies performed in the last mounths period and followed by the endocrinology department. method: the bethesda system of reporting thyroid cytopathology was used. slides were stained with papanicolaou preparations. results: totally cases were examined, of which were female and were male. age of the patients varied between and . cases were diagnosed as nondiagnostic or nonsatisfactory. cases diagnosed as consistent with a benign follicular nodule. only cases were diagnosed as a consistent with lymphocytic thyroiditis in corelation with the clinical features. only case diagnosed as a granulomatous thyroiditis. diagnosis as "atypia of undetermined significance or follıcular lesion of undetermined significance "was made only in cases whereas "follıcular neoplasm or suspicious for a follıcular neoplasm" was diagnosed in case. "suspicious for malignancy" diagnosed in cases. cases were diagnosed as malignant. conclusion: although diagnostic terminology and morphologic criteria for cytologic diagnosis of thyroid lesions are well established in the bethesda system, difficulty in categorizing the cases and underestimation or overdiagnosis are quıite frequent issues. to solve this problem, retrospective studies which include surgical and cytopathologic reports, to examine slides by at least two different pathologists in different times will be helpfull. metastatic pulmonary adenoid cystic carcinoma: report of a case diagnosed by fine-needle aspiration cytology p. karabagli * , s. ozbek * selcuklu medical faculty, dept. of pathology, konya, turkey objective: a rare case of adenoid cystic carcinoma of ceruminal gland with pulmonary metastasis presented with characteristic cytological and histological findings. method: the biopsy specimen of the patient, a year-old man with painfull, growing mass in his external auditory canal was interpreted as an adenoid cystic carcinoma. he was treated surgically and received post-operative radiotherapy. after years, a distant metastasis relapse was observed. computed tomography (ct) of the chest depicted multiple spiculated masses suggestive of metastases throughout both lung fields, the diameter of the largest measuring cm. ct guided percutaneous transthoracic fine needle aspiration biopsy was performed from the largest lesion. results: cytological examination of the aspirates revealed large spherical hyaline globules representing basement membrane material surrounded by neoplastic cells. the cells were cohesive, closely packed, and had uniform round to oval hyperchromatic nuclei with scanty cytoplasm. these features were suggestive of an adenoid cystic carcinoma. conclusion: patients with adenoid cystic carcinoma could be frequently encountered with disease recurrence confined to the lung. fine-needle aspiration cytology provided a conclusive diagnosis of adenoid cystic carcinoma. objective: often some of a fine needle aspiration (fna) sample is left behind in the hub of the needle when the specimen is ejected on the slides ( figure a) . method: we have designed a device that collects this material. it consists of a plastic adaptor that has a core of polyvinyl alcohol foam protruding from its lumen at one end ( figure b) . the other end of the adaptor then fits on to the syringe (figure c) . as the fna is being performed the sample material flows up the lumen of the needle's shaft and emerges into the hub of the needle where it is absorbed into the tip of the foam core ( figure d ). smears are made by ejected the specimen from the needle onto a slide by air pressure from an attached syringe. the air passes through the foam forcing some of the sample in the foam back down the needle but some remains behind. the device is then removed and placed in a formalin specimen pot. once fixed the core is pulled from the adaptor ( figure e ), processed and sectioned as for routine histology specimens ( objective: the presence of dcs has been studied histologically in ptc, but their presence and potential diagnostic value in thyroid fnas has not been evaluated. method: we assessed the presence of dcs in cytological samples of histologically confirmed ptcs (n= ) and benign thyroid nodules (btn) (n = ) using cd a. corresponding ptcs (n= ) and btn (n= ) from surgical excisions were stained with both cd a and langerin. results: cd a + dcs were identified in / ptcs on cytology ( %). they were either isolated in the background or more typically closely associated with tumor cell clusters. the ptc cases with the least dcs corresponded to the follicular variant on histology. in contrast, most btn ( %) lacked cd a + dcs. when dcs were present, they were primarily isolated in the background although / cases ( %) contained rare dcs among tumor cells. tumor-infiltrating dcs and background dcs were both higher in ptcs than in btn, but only the former was statistically significant (p< . and p= . respectively). similar findings were found on histology where all ptcs contained cd a + and langerin + dcs while only / btn ( %) contained rare dcs. conclusion: dcs are present in fnas of ptc, typically among tumor cell clusters, while they were absent or rare in fnas of btn. thus dcs may be useful as an additional diagnostic marker for ptc. significance of p immunostaining in postmenopausal women with atypical squamous cells a. repse fokter * , k. gornik kramberger, s. hutter Čelik, s. sramek zatler * celje general hospital, dept. of pathology and cytology, slovenia objective: the evaluation of postmenopausal pap smears can often be challenging. degeneration associated with atrophic vaginitis, hyperchromatic crowded groups, parabasal cells with organophilic cytoplasm or variations in nuclear size may be falsely interpreted as squamous atypia or even more severe lesion. method: the study included postmenopausal papanicolaou patients ( smears) with the initial cytological diagnosis of asc-us or asc-h. the smears were decolorized and immunostaining for p (ink a) was applied. in patients ( smears) tissue biopsy and histological examination was performed and four asc-us cases had cytological follow up only. results: among cases with histological examination positive p reaction was found in patients ( smears). the histological diagnoses were: cin ( ), cin - ( ), cin ( case), cin ( patients/ smears), ais ( case) and invasive squamous carcinoma ( patients). two p positive patients with three smears and initial negative histology had cin after years. among p negative patients there were two with cin and two with normal histology. four asc-us patients without histological examination had normal cytological follow up. conclusion: p is a useful marker in detecting of clinically significant cervical lesions in postmenopausal women. endoscopic-ultrasound guided fine needle aspiration cytology of intraductal papillary-mucinous neoplasms of the pancreas: report of two cases and review of the literature e. tejerina gonzález * , a. lópez garcía, c. gonzález lois, f. fernández garcía, a. herreros de tejada, e. sanz * hu puerta de hierro-majadahonda, dept. de anatomía patológica, spain objective: intraductal papillary-mucinous neoplasms (ipmn) of the pancreas are mucin-producing tumors recently recognized as a distinct entity among other mucinous pancreatic tumors. endoscopic-ultrasound guided fine needle aspiration (eus-fna) is a sensitive technique which can be very useful in the accurate diagnosis of these neoplasms. method: we present a case of a -year-old female with recurrent episodes of acute pancreatitis and a -year-old male with abdominal pain. tc showed a mm-cystic tumor at the uncinated process of the pancreatic head and cystic dilatation of the main pancreatic duct, respectively. in both cases eus-fna was performed. results: smears showed medium-to-large, cohesive groups and complex papillary clusters set in a clean, mucoid background, composed of cuboidal or columnar epithelial cells with abundant clear or mucinous citoplasms. a honeycomb arrangement was occasionally seen. although nuclei were predominantly medium-size and uniform, some groups showed some nuclear enlargement and pleomorphism with visible nucleoli. a diagnosis of "mucinous neoplasm with papillary pattern" was rendered in both cases, followed by partial pancreatectomy. the histologic examination was consistent with ipmn. conclusion: the cytologic features of intraductal mucinous papillary neoplasms of the pancreas, evaluated by eus-fna, seems to be quite characteristic of these tumors and allow to suggest a correct preoperative diagnosis. objective: the human igh locus at chromosome q is frequently involved in different translocations of non hodgkin lymphoma (nhl), and the detection of any breakage involving the igh locus should identify a b-cell nhl. the split signal igh fish-cish dna probe (ifcd) is a mixture of two fluorochrome-labeled dnas that binds the telomeric and the centromeric segments, on the igh breakpoint respectively. we tested the capability of the ifcd to detect igh translocations and diagnose b-cell nhl on cytological samples. method: fifty cytological specimens from lymphoproliferative processes were tested using the ifcd and the results compared to light chain assessment by flow cytometry (fc), igh status by pcr, and to clinical-histological data. results: ifcd analysis detected positive, negative and inadequate cases; there were true positive ( %), true negative ( %), false negative ( %) and false positive cases ( %). comparing the sensitivity of the ifcd with fc and pcr, the highest sensitivity was obtained by fc followed by ifcd and pcr. conclusion: the ifcd is effective in detecting any translocation involving the igh locus; it can be employed on different samples from different b-cell nhl whereas it is not useful to classify the specific entities. sunday, september , . - . objective: morphometric analysis of the glands and inflammatory cells proportions in colon mucosa may be crucial for distinction of subtle changes. the most important step is a recognition and proper segmentation of the separate glands, even branched, atrophic or distorted. method: new sequential algorithm has been proposed, based on mathematical morphology transformations, such as extended regional maxima, hit-or-miss, opening and closing operations. for lumen opened glands snake algorithm with closing has been applied to surrounding elements with sequential elimination of the closed contours under decreasing area criterion. proposed method has been used to evaluate cases of diversion colitis to compare specimens sampled from functional part of colon and defunctioned distal one. results: the appropriate results were obtained for specimens with different section planes with efficiency %. in comparison of the b to a was observed decreased participation of epithelium in the glands area measured in deep region (an average % instead %). in addition, the area of the gland was slightly reduced from % to % of the mucosa. conclusion: the proposed method can be useful to automatic morphometry analysis of the gland shape in colon mucosa. the recognition of the opened glands improves previously designed algorithms. objective: quantitative analysis of the immunohistochemical histological samples plays an important role in the diagnosis and prognosis of many cancers. the commercial and non-commercial software's to computerized image analysis of microscopic images based in several approaches. method: the advance segmentation scheme usually consists of preprocessing, nuclei extraction and classifier blocks. when the preprocessing step includes filtering and conversion to the most discriminative representation and the classifier can be realized by various tools, especially support vector machine as a state-of-art, nuclei extraction is the most crucial part of any algorithms. we compare single thresholding methods such as otsu, kurita, minimum error, entropy thresholding, with the sequential thresholding approaches combined with area criteria, local threshold value or extended regional maxima. all of them are accompanied by watershed method and filtration. results: for ki- stained meningioma specimens in the fields of view without overlapping nuclei the most advance methods are adequate. when increasing the cell number, only sequential thresholding with area criteria and extended regional maxima give acceptable results. the mean relative error is . ± . and . ± . % respectively. conclusion: the results confirm the efficiency of using sequential methods for segmentation of cell nuclei. for best results, use sequential thresholding with area criteria. ps- - nhs improvements: enhanced it project for histopathology f. mayall * * musgrove park hospital, dept. of cellular pathology, taunton, united kingdom objective: many histopathology laboratories are using antiquated software that hobbles their performance. we developed open source filemaker pro based histopathology reporting software with innovations based on lean principles to enhance work flow. these include: -colour coded visual workflow control -"one-click" extrawork requests with order tracking -user defined template reporting -reporting of complex cases using benchmark profomas -exportable data-sets using open database connectivity -easy local customisation and enhancement by the user. results: the software was used by staff to report more than histopathology specimens at two histopathology laboratories. many of these cases were complex cancer resection cases requiring key data capture. the histopathology staff using the software were surveyed on their experience of using the software. the key steps in lean it development: -start with a small idea -develop software with multiple plan, do, study, act (pdsa) cycles -ask users for more ideas for enhancements -recruit others into the project by allowing them to use the software and experience its benefits -standardise new reporting process by achieving agreement between users -design a project that requires minimal financial investment this open source software is available for download from www.freedp.org. sunday, september , . - . objective: myxopapillary ependymomas (mpe) often occur at the filum terminale but occasionally occur outside the central nervous system (cns). common site for these extraneural tumors is sacrococcygeal area. method: a cocygeal mpe with radiologic, gross and microscopic features will be presented. a year old female admitted neurosurgery department with painful coccygeal mass. magnetic resonance imaging revealed a coccygeal, well-demarcated, non-enhancing mass of × cm in diameter. the mass did not have any connection with the spinal cord. it was completely excised and grossly the cut surface of the encapsulated mass was soft. microscopically the tumor was comprimised of myxoid stroma with pseudopapillary structures around hyalinized vessels. the tumoral cells showed intracytoplasmic dot-like positivity with ema. there were no mitosis, and the ki labeling index was low. conclusion: extraspinal mpes are rare and the most common location is sacrococygeal area. these masses are often preoperatively misdiagnosed as pilonidal sinus. unlike the cns mpes, extraspinal mpes have a potential to metastasize even if they do not show any anaplastic morphological feature. long term follow-up is recommended as metastases can occur up to years after initial presentation. objective: cerebellar liponeurocytoma (cl) is a rare neoplasm with neuronal, astrocytic and lipomatous differentiation arising in adults. the entity is considered as a grade ii neoplasm in the last who classification of central nervous system tumours. we show two typical cases of this entity stressing the spectrum of histological changes and its differential diagnosis. method: patient is a -year-old woman with a history of headaches and instability. ct scans and mri showed a cm in diameter relatively ill-defined, poorly enhanced, round tumour mass in the left hemisphere. patient is a -yearold woman with a history of headaches and instability. mri showed a . cm in diameter well-defined triangular lesion in the right hemisphere. results: complete surgical resection was achieved in both cases. both tumours showed highly cellular neoplasms composed by round to polygonal cells with scant cytoplasm and round nuclei with fine chromatin pattern. mitoses were not seen. well differentiated lipomatous cells grouped in irregular nests were intermingled with the predominant neuronal component. conclusion: cerebellar liponeurocytomas are located in the cerebellar hemispheres and pursue a non aggressive clinical course, with local recurrences detected mainly after incomplete resections. the typical adipous tissue is the result of a lipidization process and not a true metaplasia. objective: giant cell tumor of bone is an uncommon neoplasm that accounts for about % of all bone tumors. it usually involves long bones and is very rarely encountered in the skull where it mostly involves the sphenoid and temporal bones. it is a benign neoplasm but can be locally aggressive. method: we present a case of a year old woman with history of multiple sclerosis whose routine ct scan revealed a mass with corrosive features and calcification situated at the petrous portion of her left temporal bone. a biopsy was sent to our laboratory. results: histopathologic examination revealed a neoplasm composed of sheets of oval mononuclear cells, with uniformly distributed nuclear chromatin, evenly intermixed with numerous giant cells that contain a variable number of nuclei with features similar to those of mononuclear cells. cytoplasm of either cell type was eosinophilic and cell borders were indistinct. mitoses were scarce and regular. foamy histiocytes, hemosiderin and microscopic nodules of cartilage formation were also noted. conclusion: although giant cell tumor is a benign neoplasm its' localization in this case posses a threat that should be managed surgically and by adjuvant radiotherapy if complete excision is unobtainable. leptin and leptin receptor expression in pituitary adenomas g. ayranci * , t. avsar, a. seker, t. kilic, s. bozkurt * marmara university, dept. of pathology, istanbul, turkey objective: leptin is a regulatory hormone which is mainly synthesized by adipocytes and regulates body fat mass. leptin also has regulatory function on anterior pituitary. in this study, we have investigated the expression levels of leptin (ob) and its receptor (ob-r) in various types of pituitary adenomas and normal anterior pituitaries. method: pituitary adenoma cases between and were selected. immunohistochemistry for leptin (ob) was performed for each cases of null cell, gh, acth, prolactin and fsh/lh secreting adenomas. western blot was performed for leptin receptor (ob-r) in cases consisting of all five subtypes. results: immunohistochemical staining showed greater immunoreactivity for leptin in normal pituitaries compared to adenomas. except for acth-secreting pituitary adenomas, all other four subtypes showed widespread and intense staining for leptin (p< . ). null and fsh/lh-secreting subtypes were mainly showed cytoplasmic and nuclear staining. western blot analysis showed leptin receptor expression in all types of adenomas except null cell. objective: primary malignant brain tumors often present local invasive growth. the study aimed to estimate the expression of kai protein, mmp- , cd v and their correlation in gliomas of different grade of malignancy. method: expression of mmp- , cd v and kai was evaluated on formalin fixed paraffin-embedded tissue blocks divided into: pilocytic astrocytoma (n= ), fibrillary astrocytoma (n= ), anaplastic astrocytomas (n= ), anaplastic oligodendrogliomas (n= ), glioblastoma multiforme (n= ) and normal brain tissue (n= ) using immunohistrochemistry. results: mmp- and cd v was observed frequently in gliomas with high grade of malignancy. kai immunoreactivity was mainly observed in specimens with low degree of malignancy. mmp- and cd v expression was significantly increased when the degree of malignancy of the gliomas increased (p< . ). whilst kai expression increased when the degree of gliomas malignancy decreased (p = . ). positive correlations between mmp- and cd v (p= . ) and inverse between kai and mmp- expression (p= . ) were found in gliomas. these results indicate that association between mmp- and cd v expression may increase dissemination of tumor cells. whereas, high expression of kai protein might suppress the function of mmp- in gliomas. pediatric glioblastoma: a case report a. barin * , s. ekici, c. altunkaya, s. yilmaz, g. s. yalcin, g. hatipoglu, m. caydere, h. ustun * ankara education hospital, dept. of pathology, turkey objective: glioblastoma is the most common malignant tumor of central nervous system in adults which characterized by malignant pleomorphic astrocytic cells with marked nuclear atypia, mitotic activity, necrosis and/or microvascular proliferation. glioblastoma may manifest at any age but usually affects adults especially older than years. in this case, we present a pediatric glioblastoma case because it has seen rarely under years and it is so important owing to its prognosis. method: an -year-old boy has had headache for days. according to radiological imagings × mm in diameter infiltrating mass has seen in temporal lobe contains × mm in diameter cystic component and contrast enhancement was noted. clinically grade astrocytoma has thought primarily and he has been operated. results: in microscopic examination nuclear atypia, mitotic activity and microvascular proliferation has seen without necrosis. objective: gliosarcomas are biphasic neoplasms composed of a glioblastoma admixed to a sarcomatous component with different lines of differentiation. histogenesis of these tumors is still discussed. our objective is to specify pathological characteristics of this neoplasm its related to or not to glioblastoma. method: cases of gliosarcomas diagnosed in our department of pathology. clinical, radiological, therapeutic and follow-up data were reviewed. histological features and immunohistochemical results were also established. results: female patients with a median age of years (ranging - years). intracranial hyperpressure and paralysis are main symptoms. the brain imaging showed frontal, fronto-parietal and intra ventricular expansive process, respectively. microscopically, a biphasic pattern, with anaplastic astrocytic cells alternated with malignant mesenchymal areas, demonstrating a fibrosarcoma pattern, in two cases and rhabdoïd pattern in one case. immunohistochemical stain confirmed the diagnosis of gliosarcoma in each case. patients were treated by surgical excision; one patient was lost on follow-up. one patient died by postoperative complications. conclusion: clinical, radiological and follow-up features of gliosarcomas share great similarities with glioblastomas. histopathological, histochemical and immunohistochemical studies are helpful in accurate diagnosis. cytogenetic and molecular data support a monoclonal origin for these tumors. objective: case of biphasic synovial sarcoma of nerve in a year-old female located between flexor muscles and radial diaphysis and adherent to median nerve and ulnar artery is presented. method: tissue was fixed in formalin, embedded in paraffin and stained with haematoxylin and eosin. periodic acid-schiff stain without diastase pre-digestion was obtained. ventana antibodies were employed: ttf- , er, ema, s , ck , ck and mnf . ss -ssx fusion gene transcript was detected with conventional rt-pcr and qrt-pcr. results: macroscopically nodule had smooth circumscribed borders, grey-yellowish colour and measured , × × , cm. histologically it was delimited by a dense sclero-hyaline capsule and constituted of numerous glands lined by one layer of cuboidal-columnar cells showing eosinophilic cytoplasm and round to ovoid nuclei with a single small nucleolus. they contained dense eosinophilic strongly pas and ema positive material. glands were immersed within tightly packed spindle cells. mitoses were scanty. necrosis was absent. ema strongly stained most of the glandular as well as scanty spindle cell elements. chromosomal reciprocal translocation t (x; ) with positive signal for ss -ssx transcript was seen. conclusion: synovial sarcoma of nerve is a rare condition that has to be distinguished from histologically similar lesions. rabdoid meningioma: presentation of a rare case i. dimitriadis * , a. heva, i. matzarakis, a. sekouli, p. sakellariou, l. sakkas * hospital of thessaloniki, dept. of pathology, greece objective: in , keppes and later perry suggested the term rhabdoid meningioma which was adopted into the who classification (grade iii) in . we present a rare case of a rabdoid meningioma and study the clinicopathological characteristics of the neoplasm. results: Α -year-old woman was submitted in surgical excision of an endocranial tumour (d: cm) in our hospital. the histological examination revealed entirely rabdoid morphology. the neoplastic cells expressed the following immunohistochemical phenotype: s +, vimentin+, ema+, gfap−, pr+, hmb −, a /ae +(focally), ck / +(focally), sma−, ki- (< )%. conclusion: rabdoid phenotype represents an indicator of malignant transformation regardless of the tumor's histogenesis. expression of ki- antigen correlates with recurrence even in meningiomas with minimal atypical features, which should prompt closer surveillance after excision. rabdoid meningiomas behave aggressively and have bad prognosis contrary to the classic meningioma. prognosis is influenced by it's complete excision and the expansion within the intracranial cavity. it has to be distinguished from glioma, melanoma and metastatic carcinoma. the patient after year is in generally good health, and is followed up by oncologists. atypical extraventricular neurocytoma (case report) s. ersöz * , u. yazar, a. reis, k. kuzeyli * karadeniz technical university, pathology, trabzon, turkey objective: central neurocytomas are rare intraventricular tumors with neuronal differentiation, typically located in the ventricles while tumors located outside the ventricles designated as ''extraventricular neurocytomas'' (evn). neurocytomas are classified as atypical if they exhibit a mib- labeling index > % or atypical features, like focal necrosis, vascular proliferation, and increased mitotic activity. we here report a case of atypical evn of the left frontal lobe. method: a -year-old woman patient admitted to hospital for headache. ct scan showed a large partially calcified cystic mass. mr imaging showed circumscribed, solid mural nodule within the cystic mass. the patient underwent a left frontal craniotomy. specimens were fixed in % formalin and stained with hematoxylin and eosin. for immunohistochemistry, sections were incubated with monoclonal antibodies to synaptophysin, neurofilament protein, map- , nse and gfap. the proliferative index was assessed with mib- . results: histopathological examination revealed a neuronal neoplasm composed of uniform cells in solid sheets. small necrosis areas and mitotic figures were evident. immunohistochemical examination revealed positive results for synaptophysin, neurofilament protein, map- , and nse. gfap staining was negative. mib- index was calculated as %. conclusion: in general, central and extraventricular neurocytomas have a good prognosis. atypical extraventricular neurocytomas are quite rare like this case with malignant histopathological properties. meningioma and schwannoma associated with neurofibromatosis type : a case report of rare genetic disorder o. e. gürer * , r. tuncer * akdeniz university, dept. of pathology, antalya, turkey objective: neurofibromatosis is a group of genetic disorders referred as phakomatoses. there are two main forms called nf and nf which have different incidence, molecular characteristics, and clinical exhibitio. both have higher risk for the development of certain rare malignant tumors that occur in the brain, nerves or spinal cord. method: here, we present a rare case in which multiple meningiomas and vestibular schwannomas diagnosed in the same operation. results: a year old woman presented with hearing loss clinically. she underwent surgical treatment for tumoral lesions in two different localization in the same session. one of them resected from pontoserebellar location was diagnosed as a schwannoma and the other one located on dura was diagnosed as a meningioma respectively. conclusion: nf is far less common than nf and strict diagnostic criteria have been described each of them. since difficulty to detect genetic abnormalities and no single criteria is pathognomonic, clinical characteristics much more valuable for differentiation. knowledge of associated clinical features will help to correct diagnosis and to predict much more devastating clinical course for nf . diagnostic confusion: central neurocytoma n. gursan * , e. demirci, m. calik, f. daloglu, c. gundogdu * ataturk university, medical faculty, erzurum, turkey objective: central neurocytoma is a rare intraventricular brain tumor that affects young adults and presents with increased intracranial pressure secondary to obstructive hydrocephalus. they are usually located in the supratentorial periventricular region. because of some clinical and radiological findings cns neurocytomas were confused with other intraventricular lesions. method: a -year-old male was admitted with chronic headache with months duration on july , , when there were no neurological deficits or physical abnormalities. computed tomographic (ct) scans showed × mm a mixed density mass with amorphous calcification in the right lateral ventricle, which was irregularly enhanced by contrast medium. light microscopy showed sheets of monotonously neoplastic cells with uniform round-to-oval nuclei and inconspicuous nucleoli. the cytoplasm was clear or eosinophilic with indistinct border. capillary networks were well developed and divided the tumor cells into groups. no nuclear pleomorphism or mitosis was seen. we present a case of intraventricular neurocytomas confirmed by immunohistochemical studies. conclusion: this rare tumor causing diagnostic confusion, discussed by the literature. a case of oligodendroglioma with neuronal differentiation t. hirose * , s. nobusawa, y. nakazato, a. sasaki * tokushima pref. center hospital, dept. of diagnostic pathology, japan objective: we report a case of oligodendroglioma showing marked neuronal differentiation. method: a -year-old female visited an emergency room because of an attack of convulsion. imaging analyses disclosed a calcified, . × cm tumor in the right frontal lobe. results: the resected tumor was composed of a mixture of oligodendroglioma-like (olg) and gangliocytoma-like (gc) areas. in the former, fried-egg appearance and more cellular nodules were recognized. in the latter, there were numerous small neuron-like cells with basophilic cytoplasm. olg areas showed immunoreactivity for olig , gfap and mutant idh , while gc areas were positive for synaptophysin and neun. ki- labeling index was about % in cellular nodules of olg areas. at least one allelic loss of p/ q was detected in . / . % cells in olg areas and . / . % in gc areas with fish analyses. furthermore, an identical mutation of idh (g a, r h) was demonstrated in both olg and gc areas. conclusion: genetic abnormalities including p/ q loss and idh mutation indicate that this case is an oligodendroglioma associated with prominent ganglion cell differentiation. oligodendrogliomas with neuronal differentiation like our case may suggest a close relationship between oligodendroglial progenitor cells and neuronal cells. gemistocytic astrocytoma with granulomatous inflammation o. ipci * , e. atik dogan, t. ozgur, h. gokce, n. yilmaz, a. yilmaz * mustafa kemal university, dept. of pathology, hatay, turkey objective: the coexistence of granulomatous inflammation and astrocytoma is extremely rare. hemostatic agents are used to control intraoperative bleeding in many surgical subspecialties, including neurosurgery. there are occasional reports of granulomatous reaction to biomaterials. method: we aimed to present a year old female patient, who was operated because of the tumor at left frontoparietal region. tumor was histopathologically reported as oligoastocytoma. however, no granulomatous inflammation was detected beside the tumor. after months, patient was reoperated because of tumor recurrence, abscess and inflammatory necrotic tissue beside the tumor. histopathologically, gemistocytic astrocytoma with granulomatous inflammation and abscess formation was reported. no micro-organism had grown in any kind of cultures. at our neurosurgery department surgicel is used after craniotomy as hemostatic agent. it's raw material is cellulose and absorbed in about months. results: in the literature, germinoma accompanied by granulomatous inflammation have been reported. however, astrocytic tumors don't express such an association. the patient doesn't use any drugs forming granuloma reported in the literature. conclusion: we encountered that surgicel causing granulomatous inflammation in very few cases in the literature. the findings might be secondary to surgicel that used in the first operation. objective: astrocytic tumors show various molecular and genetic alterations in its development and progression. glioblastoma multiforme (gm) develops as either de novo or by progression from diffuse astrocytomas (da) or anaplastic astrocytomas (aa) by genetic alterations. method: loss of heterozygosity (loh) and microsatellite instability (msi) was investigated in cases of astrocytic tumors (das [n= ], aas [n= ] and gms [n= ]) with microsatellite markers and microsatellite markers harboring p and pten, respectively. the patients' age ranged from to years (mean, years). results: loh was statistically significant in aas and gms, compared to that of das (p= . ). loh for p and loh-h group for q were statistically significant in aas and gms (p= . and p= . ). msi rate in das, aas and gms was detected in . %, . %, . %, but it showed no significant correlation with prognosis factors. msi and msi-h rates were correlated with younger (〈 years) group (p= . , p= . , respectively). conclusion: alterations on pten and p may contribute to the development and progression of astrocytic tumors. especially, loh-h for q and p is considered as clinical application of discriminating the aas and gms from das. msi might be involved in the tumorigenesis of relatively young patients. objective: charcot-marie-tooth disease (cmt) iii or dejerine-sottas syndrome is a severe hereditary demyelinating motor and sensory neuropathy presenting in infancy or early childhood with delayed motor milestone and extremely slow nerve conduction velocities. method: among unrelated korean cmt patients, mutational screen for well known cmt genes reveals three patients with pmp de novo mutation showing dss. the histopathological findings of distal sural nerves are analyzed in all patients twice; cases and with years interval and case with years. results: on semi-thin transverse sections, all the remaining axons (thinly myelinated or demyelinated) are surrounded by classic or basal lamina onion bulbs (obs). the first biopsy of case ( years-old) shows obs ( , /mm ), which consists of , ( . %) mfs with obs and , ( . %) demyelinated axons with obs. the second biopsy shows obs ( , /mm ), consisting of ( . %) mfs with obs, ( . %) demyelinated axons with obs, and ( . %) obs with no discernible axons. cases and show similar histopathologic findings with main differences in numbers of obs. conclusion: although the differences noted in two biopsies are probably due to age of the patients, correlations with clinical symptoms will be helpul for management of the patients. objective: two mutations of the seipin gene (n s and s l) have been reported and known to cause neurodegenerative disorders. we performed whole exome sequencing in two charcot-marie-tooth families and identified three patients with two causative heterozygous mutations (n s and s w) and s w is a novel mutation. method: the histopathological findings of distal sural nerves are analyzed in two patients (cases and ) with s w novel mutation (fc ) and a patient (case ) with n s mutation (fc ). results: transverse semi-thin sections reveal increased numbers of myelinated fibers (mfs) ( , /mm ; , / mm ; , /mm ) with increased small mfs forming regenerative axon clusters and loss of large mfs. histogram shows unimodal distribution pattern. cases and show the similar ranges and average of diameter of mfs ( . . μm, . μm). case shows more numbers of small mfs ( . ~ . μm, . μm). ultra-structural examination reveals mfs with myelin abnormalities, pseudo-onion bulb formation including single axon or axon clusters, and thick mfs. conclusion: the findings are consistent with axonal neuropathy with features of demyelination. additional cases will be necessary to know the significance of differences between these cases. immunohistochemical subtyping of primary and secondary glioblastomas k.-s. lee * * seoul national university hospital, republic of korea objective: glioblastomas (gbls) may develop de novo (primary gbl; p-gbl) or through progression from lowgrade or anaplastic astrocytomas (secondary gbl; s-gbl). for subtyping of gbls, we tried immunohistochemical anaysis. method: we collected cases of gbls in snubh and snuh. the mean age at the time of the primary surgery was . years (range - ). immunohistochemical studies were performed for egfr, p and idh- . results: according to clinical history, gbls consisted of primary and four secondary gbls. however, egfr(+)/ p (−) immunohistochemical features of p-gbl consisted . % and egfr(−)/p (+) immunohistochemical features of s-gbl consisted . % among cases. egfr(+)/p (+) was noted in . % and egfr(−)/p (−) in . %. immunohistochemical expression of idh- was noted in cases ( . %) out of cases. expression of idh- and egfr(−)/p (+) showed positive correlations with young age. characteristic features of s-gbl were noted in . % of clinically p-gbl. conclusion: we analyzed immunohistochemical subtypes of korean glioblastomas. combination of egfr and p was unsatisfactory but combination of egfr, p and idh- can be a good tool for immunohistochemical subtyping of glioblastomas. (also known as erbb- ) is a -kd transmembrane glycoprotein with tyrosine kinase activity. her is expressed in some human malignancies and can be a potential target for therapeutic intervention with selective inhibitors. there are only a few studies on the relationship between meningioma and her expression, and the results are different as well. the aim of this study was to determine this relationship. method: seventy-two paraffin blocks of meningioma were selected randomly and immunohistochemical staining was then performed for each specimen. results: thirty-one of the meningiomas were her -positive. her expression was observed in ( %) of the grade ii/iii, and ( . %) of the grade i meningiomas. conclusion: consequently, her expression was detected in % of meningiomas. no significant difference was seen between grade i and ii/iii meningiomas, primary and recurrent tumors, and males and females from the point of view of her expression. objective: in our previous papers we studied accumulation of iron and proteoglycans in the brain. the aim of this analysis is to build on our previous results alongside other authors to investigate the reason for the presence of excessively accumulated iron observed in parkinson disease (pd). method: postmortem samples taken from the globus pallidus were prepared for light microscopy for iron and proteoglycans detection. patients had neither iron metabolism disorders nor had clinical signs of neurodegeneration. the samples were analysed using electron paramagnetic resonance (epr) to investigate the bounds between iron and proteoglycans. results: epr measurements confirm the presence of complex bounds between fe(iii) and proteoglycans. conclusion: previous data showed a possible dependance between accumulated iron, proteoglycans, ferrireductive alpha-synuclein and lewy bodies. we propose a mechanism of toxic iron accumulation in the brain in pd. this cyclic process of amplification is presented by onward steps. it is completed by our own observations into one cycle. the initiator of this vicious circle is probably an impirement of the equilibrium in the presence of useful amount of iron. understanding these relations could bring new insights to the neurodegenerative disease. role of pdgfr overexpression in schwannoma, and its diagnostic and therapeutic implications t. neuman * , y. fellig * hadassah medical center, dept. of pathology, jerusalem, israel objective: platelet-derived-growth-factor-receptors (pdgfr) are transmembrane tyrosine kinase receptors that function as relay points for signaling pathways. they play a key role in numerous processes that affect cell proliferation, tumor genesis, cancer invasion, metastasis, and modulation of apoptosis. recently, pdgfr has been demonstrated to be overexpressed in schwannoma in vivo, and in a small series of acoustic neuromas. however, its phenotypic expression in different variants of schwannoma remains largely unclear. method: immunohistochemical staining was used to detect pdgfr expression in archived formalin-fixed, paraffin-embedded schwannoma tissue samples (n= objective: pancreatic ductal carcinoma (pdc) has one of the worst prognoses. up to % of pancreatic cancers are diagnosed at the locally advanced or metastatic stage. however, brain metastases from pancreatic carcinoma are extremely rare since less than cases have been reported in the literature since . method: we report a case of a brain metastasis from pancreatic adenocarcinoma occurred in a years old women. results: -year-old woman developed severe neurological symptoms and progressively decreased consciousness. ct revealed cystic tumor in cerebral peduncle and medulla oblongata. stereotactic biopsy revealed metastasis of carcinoma. the patient died from of the twelfth day after stb because of recurrent hemorrhage. autopsy revealed well-differentiated papillary adenocarcinoma in the head of pancreas and with multiple metastases in liver and two metastases in medulla oblongata and cerebral peduncle. ihc staining for cytokeratins , and , mucin and ac types was strongly positive. ki labeling index was %. conclusion: we reported an autopsy case of brain metastases from pancreatic cancer, in which the patient initially developed symptoms of a neurologic disorder without exhibiting any symptoms of pancreatic disease. the use of bone morphogenetic proteins (bmp ) with nunostrucnure grey implant in reparation of bone tissue defect t. pavlova * , l. pavlova, a. nesterov, i. goncharov, d. kolesnicov * belgorod state university, dept. of pathology, russia objective: the matters of materials development of scull bones defect plastic are obviously necessary this time. the experience in use of nanocostructive titans, composites, bone morphogenetic proteins was accumulated. method: implant, made of nanoconstructed titan grey, covered by layer (gelatin, dextran), layers ( -gelatin, dextran, -hydroxyapatite, collagen, dextran) and by layers with use of bone morphogenetic proteins bmp- . the experiment was conducted on rat-males. in order to study the regeneration processes it were used light, fluorescence, probe and scanning microscopy with the trace element analysis. results: the most active changes were registered in the experimental group with use of composite from titan grey with layers of covering and bmp- . the covering compound increase the rate of regeneration processes due to creation calcium and phosphorus ion depot and perform support function for again-formed tissue. increase in the concentration of calcium, phosphorus, sodium, magnesium in trabeculae of bones in comparison with matrix bone at term of weeks testify about active regenerative processes; the mature smooth surface with structured relief of bone trabeculae and diploic veins were detected. conclusion: results can be used in neurosurgery, traumatology-orthopedics, dentistry, plastic and cosmetic surgery. alpha-synuclein (as) pathology of the peripheral autonomic nervous system (pans) in parkinson disease (pd) and other lewy body diseases (lbd) t. ribalta * , e. tolosa, j. navarro otano, e. gelpi * hospital clinic of barcelona, dept. of anatomic pathology, spain objective: pd and other lbd have been associated with as aggregates in the central nervous system (cns). however, autonomic dysfunctions may appear at any time in the course of the disease. our objective was to investigate the distribution of as in the pans in synucleinopathies. method: we examined pans structures obtained at post mortem from subjects ( female, age range - , mean ) at our brain bank with a diagnosis of pd ( ); lewy body dementia ( ); alzheimer's disease ( ); mixed dementia or other ( ). a complete neuropathological study of pans was performed, including dorsal spinal ganglia, vagus nerve, paraspinal sympathetic ganglia, mesentery, adrenals, digestive and genitourinary systems, heart, and skin. routine and immune stains for as and tyrosine-hydroxylase were applied. cases were semiquantitatively assessed. results: % of cases showed as pathology in the cns. of them, as aggregates were additionally present in the pans in %. a gradient in involvement was observed, being the paraspinal chain (particularly the stellate ganglion) the most constantly involved structure, followed by digestive system, adrenals, and gu system. conclusion: these findings indicate that as aggregates are extensively found in pans in synucleinopathies. the highest expression is found in the paraspinal ganglion chain and decreases in other pans regions. our results provide valuable information about potential development of new diagnostic and therapeutic strategies. objective: chordoid meningioma is an uncommon histopathological variant of meningioma. method: we report one case of chordoid meningioma occurring in adult patient. paraffin embedded tissue was stained with hematoxylin-eosin. we used immunohistochemical markers such as cea, ema, vimentin and tle . results: a -year-old woman was hospitalized with clinic of an intracranial hemorrhage. axial computed tomography (ct) of the brain revealed a . * . * . cm lesion with perilesional edema in the left temporoparietal region. foci of intratumoral hemorrhage were also seen. compression of the left lateral ventricle and midline shift to right side was seen. the patient underwent a left temporoparietal craniotomy for resection of the tumor and died days after surgery. histologically, sections revealed sheets, trabeculae and lobules of tumour cells scattered in a pale basophilic myxoid matrix. some of these cells exhibited characteristic cytoplasmic vacuolization. a typical focal meningiomatous pattern was also observed. the tumor cells were diffusely positive for epithelial membrane antigen, vimentin and a strong nuclear immunoreactivity for tle . these cells showed negative immunostaining for cea. conclusion: chordoid meningioma should be distinguished from chordoma, chondrosarcoma, metastatic mucinous carcinoma and other variants of meningioma. morphology of non-specified encephalopathy in cases of polymerase chain reaction proved presence of human herpesvirus- s. roga * , i. strumfa, s. kuleznova, s. chapenko, s. rasa, m. murovska * riga stradins university, teaching department, latvia objective: the morphology of non-specified encephalopathy is a complex medical problem. human herpesvirus- (hhv- ) infection can be discussed as a predisposing factor. the aim of the present study was to investigate the presence of beta hhv- in non-specified adult encephalopathy cases. method: the blood, meninges and brain tissue were obtained in adult (aged - years) autopsies including cases with encephalopathy and cases in the control group. tissues were submitted for routine histology including haematoxylin-eosin stain. the presence of hhv- genome (dna) was analysed by nested polymerase chain reaction (npcr), hhv- variants by restriction endonuclease analysis. results: the gross and microscopic structure did not reveal any specific changes. in the encephalopathy group, hhv- dna sequence was found in meningeal tissues ( / cases; p= . ), in brain tissues ( / cases; p = . ), and both in brain and meningeal tissues ( / cases; p= . ). in the control group, the viral dna was identified in meningeal tissues ( / cases), in brain tissues ( / cases), both in brain and meningeal tissues ( / cases). hhv- b variant was detected in all cases. conclusion: on the basis of the present study it can be concluded that hhv- is a pathogenic factor that can predispose to encephalopathy. pathological variants of brain metastases of breast carcinoma and their prognostic and predictive role in different age groups d. objective: it is extremely rare that the intramedullary spinal cord metastases (iscm) are the first manifestation of cancer. method: in database of neurosurgery biopsies from to two cases of iscm were found without preoperative signs of primary neoplasm. surgically removed tissue was stained with hematoxylin-eosin and immunohistochemically using following markers: ae / ae , ck , ck , mammaglobin, ttf- , gfap, s- and vimentin. results: one patient was male aged and another female aged . they presented with neck pain and rapidly progressive upper and lower limb weakness. imaging analysis showed contrast-enhancing mass at the level c -c in male and c -c in female, reported as an ependymoma. grossly, tumor tissue was of soft consistency and grey white color with yellowish foci of necrosis. histopathology revealed moderately differentiated adenocarcinoma with distinct border to surrounded glial tissue. in both cases, tumor cells were immunopositive for ae /ae , ck and ttf- indicating primary lung origin. postoperatively primary cancer was found in upper lobe of the left lung in both cases, without evidence of lymphadenopathy and other distant metastatic lesions in female. conclusion: diagnosis of iscm in both cases without preoperative signs of neoplasm in other organs was surprising. immunohistochemical analysis was essential for determination of cancer origin. objective: tetraspanin cd is a positive effector of cancer invasion and metastasis in many tumor types. method: we investigated the protein expression of cd in cases of who grade i to iv gliomas. additionally, we performed o -methylguanin-dna methyltransferase (mgmt) methylation analysis using real-time methylation-specific pcr in glioblastomas, and the prognostic significance of these biomarkers in glioblastomas was evaluated. results: cd was overexpressed in a significant proportion ( . %) of glioblastomas, while it was not deetected in most of grade i to iii glial tumors except for rare overexpression in anaplastic astrocytoma ( / , %) and oligoastrocytomas ( / , %). cd overexpression was closely associated with mgmt methylation (p= . ), and it was a prognostic factor for predicting worse overall survival (os; p= . ) and progressionfree survival (pfs; p= . ). combination of cd overexpression and mgmt methylation better stratified the patients' os (p= . ) and pfs (p= . ). in multivariate analysis, cd overexpression was an independent prognostic factor for predicting os over mgmt methylation (p= . ). conclusion: cd seems to have a critical role for high grade progression in astroglial tumors. cd is a good tissue marker for predicting worse prognosis in glioblastomas. results: a gross total resection of the tumor was achieved. histological examination revealed a paucicellular tumor with lobulated architecture and abundant myxoid stroma, containing stellate or spindle cells lacking mitotic activity. alcian blue and mucicarmin histochemical stains were diffusely and strongly positive. immunohistochemical analysis showed diffuse reactivity for vimentin and scattered cells positive for cd . stains for ema, gfap, s protein, cytokeratin and smoothmuscle actin were negative. conclusion: primary intracranial myxoma should be distinguished from other myxoid intracranial tumors such as myxomatous meningioma, epithelioid hemangioendothelioma or sarcoma through appropriate pathological and inmunohistochemical analysis. a metastasic cardiac myxoma should also be ruled out through cardiac evaluation including an echocardiography. the distinction between this entity and the reported neurothekeoma of the meninges needs to be reevaluated. holocord pylocitic astrocytoma associated to syringomyelia j. trillo-tinoco * , t. garibay-huarte, e. gómez-apo, m. a. rodríguez-florido, l. chávez-macias, j. e. olvera-rabiela * hospital general de mexico, dept. of surgical pathology, mexico city, mexico objective: spinal intramedullary tumors sometimes extend both superiorly and inferiorly along almost the entire cord, and those diagnosed as pilocytic astrocytoma are rare. the syringomyelia is an ependimary or periependimary cavitation of the spinal cord and is considered a suffering of degenerative and irreversible type, % of the cases is associated with intramedullars tumors. method: a three-year-old girl with history of headache, progressive weakness, months before, she was hospitalized for pneumonia, had impairment of neurologic functions and died of cardiac arrest. the autopsy was performed. results: the neuropathologic study revealed a intramedullary holocord tumor with secondary syringobulbia, cervical and lumbar syringomyelia. histopathological examination of all specimen resulted in diagnosis of a pilocytic astrocytoma. although no signs of atypia were present, an elevated proliferative activity of endothelial vessels was noted. conclusion: gross total resection of holocord and longitudinally extensive intramedullary spinal cord tumors can be achieved with preservation of long-term neurological function and also solved the syrinx. objective: epithelial cellular adhesion molecule (ep-cam) has been studied in many tissues and neoplasm, including thyroid and thyroid tumors. this is a preliminary study to assess the immunohistochemical expression of ep-cam in thyroid tumors using ber-ep . we examined the expression of ep-cam using the monoclonal antibody ber-ep in cases of thyroid tumors, including adenomas, papillary carcinomas, follicular carcinomas, medullary carcinomas, poorly differentiated carcinomas, and anaplastic carcinomas. we assessed the positivity as a predominantly membranous staining of the cells, and was scored according to the estimated percentage tumor cells in the total tissue section (negative: - %; positive: ≥ %). results: ber-ep expression was detected in normal thyroid tissue (perilessional), in all the adenomas, follicular carcinomas, and medullary carcinomas. papillary carcinomas showed in % lacking areas of expression, coinciding histopathologically one case with poorly differentiated component. all of the poorly differentiated and the anaplastic carcinomas were negative. conclusion: the expression of ep-cam, using ber-ep , was related to normal thyroid tissue and well differentiated neoplasms. our study suggest that lost of expression is associated to dedifferentiation. this results match up with the literature. in addition, clinical data and follow up are required to correlate focal areas of lost of expression of ber-ep with dedifferentiated areas of the tumor. the pathological effects of estradiol valerate on testis tissue: size and weight in male rat f. bidhendi * , r. ahmadi * imamkhomeini hospital, dept. of radiology, tehran, iran objective: studies show that estrogens can influence reproductive system differentiation. the main aim of this study was to determine pathological effects of estradiol valerate on testis histology and morphology in male rats. method: adult male albino wistar rats were divided to control and estradiol valerate ( μg/kg/day) receiving groups. estradiol valerate was applied subcutaneously. after weeks, testes were excised and studied morphologically and histologically. data were statistically analyzed and compared between groups using anova. results: our findings revealed that estradiol valerate injection resulted in reducing of testes weight and size (p< . ). semeniferous tubules were apparently deformed in estradiol valerate receiving animals and cellular density was also reduced. number of spermatocytes, spermatids and sperms was decreased in estradiol valerate receving rats compared with control animals (p< . ). conclusion: estradiol valerate has considerable pathological effects on testes morphology and histology in male rats. key words: estradiol, testes. are tumor-dimension, galectin- and cyclind useful to characterize oncocytic adenomas and carcinomas?: mutations in about % of cases. the first clinical manifestation of this tumour is often represented by lymphatic metastases. method: twelve cases of ptc and respective lymph node metastases were retrieved from our archive from to present. formalin fixed paraffin embedded tissue sections were stained with routine hematoxilin-eosin and representative tissue areas for both tumour and metastases were microdissected and dna was extracted. after pcr amplification the mutational status of braf and ras was determined by dna sequencing. results: seven cases of twelve ( %) showed a braf-v e mutation. interestingly, only in three these cases ( %) there was concordance in the mutational status between primary tumour and metastases. moreover, all metastase of wild type carcinomas were also wyld type. conclusion: even with an overall good prognosis, ptc is characterized by high incidence of lymph node metastases. as braf mutational status correlates well with prognosis and tumour progression, a correct molecular assessment is of paramount importance. our data may indicate that, because the possibility of discrepancy in the mutational status between primary tumour and metastases, molecular analysis should be performed on the primary tumour. objective: diabetes may cause chronic and non-healing diabetic foot ulcers (dfu) decreasing the welfare of patients. some neuropeptides, substance p and neurotensin (nt), may act as inflammatory modulators and improve wound healing. natural biopolymers, chitosan derivatives, are receiving great attention as powerful wound dressing materials for wound healing applications due to their favorable properties. the work aim was to use -methyl pyrrolidinone chitosan (mpc) as a platform for the delivery of nt. method: diabetes was induced by intraperitoneal injection of mg/kg streptozotocin. mice were anesthetized and two mm excision wounds were created dorsally. mpc alone, nt alone, mpc loaded with nt or pbs were placed daily on wounds. histological analysis of skin, at days , and , was done through h&e and masson´s trichrome stainnings. results: in diabetic mice, the healing process was slower, showing an engulfment of acute inflammatory cells that triggered macrophage activity when compared with controls. at day , mpc treatment leaded to a faster healing with retraction of the wound site, nt induced a slower noncontracting healing and combined application delayed inflammatory repair with persistent neutrophils. conclusion: at day , all treatments induced a total healing however, mpc + nt reduced neutrophils infiltration compared with mpc alone. acth producing nasal paraganglioma: case report j. cassis * , a. galzerano, m. chorão * hospital egas moniz, dept. of anatomy pathology, lisboa, portugal objective: female patient with chronic sinusitis and hypertension presents with lipothymia, dizziness, polyuria and polydipsia. laboratory studies showed hyperglicemia, leucocytosis, hypokalemia, hypercortisoluria and elevated serum acth levels. head mri revealed tumor in the right nasal cavity with implantation at the cribiform plate of the ethmoid bone. method: microscopically the tumor had lobular architecture with big, round cells and with eosinophilic granular cytoplasm. these cells were nse+, synaptophysin+, cd +, cd + and acth+. surrounding the tumor lobules were several spindle cells s- + (sustentacular cells). results: the lobular growth pattern, the presence of sustentacular cells (s- positive) , and the acth producing granules favours an acth producing nasal paraganglioma diagnosis. conclusion: head and neck paragangliomas account for , % of the tumors in this region, and are mainly located in the carotid bodies. paragangliomas arising in the nasal cavity are rare, only cases reported so far. they affect the middle or upper turbinates, and also the etmoid, maxillary and sphenoidal sinuses. we report the third case in literature of a acth producing paraganglioma in the nasal cavity. sporadic aggressive silent somatotroph pituitary adenoma in the young: report of two cases l. chinezu * , a. vasiljevic, s. achard peyregne, g. raverot, e. jouanneau, j. trouillas * emergency county hospital, pathology, tg. mures, romania objective: silent pituitary adenomas are infrequent tumors in adults and exceptional in young. we describe two cases of -year-old girls with pituitary adenoma without genetic history, revealed by visual field defects, with panhypopituitarism in one patient. in both cases, mri showed giant pituitary adenoma, with invasion of the cavernous and sphenoidal sinuses. hormone assays revealed normal gh, prl and igf plasma values. surgery was incomplete in both cases. results: both tumors presented a diffuse pattern. the cells exhibited large nuclei with prominent nucleoli. by immunocytochemistry, focal and low percentages of gh-and prl-immunoreactive cells were observed respectively in both tumors (gh= - % and prl= - %). cga was positive. cytokeratin and others antibodies against pituitary hormones were negative. both tumors had high proliferative indexes: ki- > % ( - %) and elevated mitotic number ( - mitoses). detection of p was also positive ( . - . %). the cases were diagnosed as atypical adenomas, according to the who classification. conclusion: the pathological diagnosis of these aggressive gh-prl tumors has to be taken into account by the clinician to choose the optimal therapeutic strategies. despite of the important side effects of the radiotherapy, this aggressive treatment might be proposed earlier, even for the young patients, to avoid the tumoral progression. intrauterine growth retardation with high fat diet in rats markedly disturbs islet morphology characterized by peri-islet inflammation, fibrosis and haemosiderosis j. dahlstrom * , v. delghingaro-augusto, l. madad, a. chandra, e. bean, c. simeonovic, c. j. nolan * act pathology & anums, dept. of anatomical pathology, garran, australia objective: pre-and post-natal factors such as intrauterine growth retardation (iugr) and high fat (hf) diet contribute to type diabetes (t d). our aim was to determine if iugr and hf diets interact in t d pathogenesis. method: a surgical model of iugr (bilateral uterine artery ligation) in sprague-dawley rats with sham (sh) controls was used pups were fed either hf or chow (ch) diets from weaning. serial measures of body weight and glucose tolerance were made. at weeks, rat pancreases were harvested for histological assessment. results: iugr vs sh pups weights were % lower. hf diet caused excess weight gain, dyslipidaemia, hyperinsulinaemia and mild glucose intolerance not further aggravated by iugr. markedly abnormal islet morphology was evident in / sh-ch, / sh-hf, / iugr-ch and / iugr-hf rats (chi-sq, p= . ). abnormal islets were characterised by larger size, irregular shape, peri-islet inflammation with cd positive cells and marked haemosiderosis. overall beta-cell mass was not altered by iugr, with a trend for it to be mildly increased in both hf-fed groups. conclusion: hf and iugr independently and together contribute to islet injury. the marked islet haemosiderosis associated with iugr and hf diets warrants further investigation as iron is toxic to β-cells. objective: adreno-hepatic fusion (ahf) is defined as adhesion of the liver and right adrenal gland with or without a fibrous capsule dividing both organs. we report a surgical case of ahf in which a virilising malignant adrenocortical tumour protruded into the liver mimicking a hepatic mass. method: a -years-old woman presented with mid-right abdominal pain and marked hirsutism. computed tomography (ct) revealed an apparently intrahepatic solid tumour suggestive of a giant hepatic adenoma. the right adrenal gland was not visible on ct and the right kidney showed marked downwards displacement. a radical right adrenohepatectomy was performed, with a satisfactory outcome. results: grossly, a giant, partially encapsulated mass was seen to protrude from the right adrenal gland into the liver. microscopically, the tumour was constituted by atypical clear cells with nuclear polymorphism, necrosis and moderate mitotic activity. tumour cells expressed vimentin and melan-a protein. conclusion: to our knowledge, this is the first description of a malignant adrenal tumour in the setting of ahf. as illustrated by this case, awareness of ahf as an entity and attention to its distinctive gross and histologic features are essential to avoid confusion between adrenal and hepatic lesions, especially when imaging studies have provided misleading findings. objective: cushing's syndrome (cs) is a rare disease, resulting in the majority of cases from acth hypersecretion. % is of pituitary origin, % of adrenal origin, and only % from ectopic acth production. method: we reported a rare cause of ectopic acth dependent cs, caused by a pheochromocytoma. results: a -year-old male was hospitalized for severe high blood pressure, depression and weight loss. biological investigation revealed serious hypokaliema, severe acth dependent hypercortisolism with elevated urinary free cortisol secretion, loss of diurnal variation, and excess plasma acth level. ct-scan revealed a nodular lesion in the right adrenal gland with hyperplasia in the left one. the nodular lesion was assumed to be a pheochromocytoma based on the elevated serum and urinary catecholamine and metabolites and local uptake in right adrenal gland in i-mibg scan. right adrenalectomy was performed. macroscopic examination revealed a cm, well-circumscribed, tan-brown tumor, associated with diffuse adrenocortical hyperplasia. histological examination confirmed the diagnosis of pheochromocytoma, without signs of aggressiveness. the tumor cells were immunopositive for chromogranin a, synaptophysin and acth. after surgery, catecholamine secretion returned quickly to normal level. biological and clinical cs regression was noted. conclusion: despite the rare association of cs with pheochromocytoma, preoperative diagnosis is required to an appropriate therapy. a rare case: extralobar pulmonary sequestration mimicking neuroblastoma g. emiroglu * , n. Özsan, s. tiryaki, a. Çelik, y. ertan * ege university, dept. of pathology, izmir, turkey objective: extralobar intraabdominal pulmonary sequestrations are rare congenital malformations which are characterized by disorganized and nonfunctioning pulmonary parenchyma. these lesions have no communication with the bronchial tree and pulmonary arteries. they receive their blood supply from the systemic circulation. method: we describe a days old male infant admitted to the hospital with a left subdiaphragmatic, × × mm, hiperechogenic and, solid mass that was identified during ultrasonography on the th week of gestation. results: abdominal computerized tomography demonstrated a × × mm, solid, vascularized, encapsulated, mostly cystic suprarenal mass with no calcification reported to be highly suspicious for neuroblastoma. the mass was completely excised. gross pathologic examination revealed a well circumscribed spongy lesion that mimicked a lung tissue. on microscopic examination, a disorganized lung tissue that was composed of alveoli, alveolar ductus and bronchioles was seen. normal adrenal tissue was not observed. later, we learnt that the lesion's arterial blood supply was from the abdominal aort. based on these findings, our diagnosis was intraabdominal extralobar pulmonary sequestration. conclusion: intraabdominal extralobar pulmonary sequestrations should be kept in mind in cases of the adrenal masses as the surgical resection is the adequate treatment method for these lesions. axillary lymph node metastasis of papillary thyroid carcinoma showing anaplastic transformation with cutaneous metastasis s. erkilic * , a. ozkur, u. elboga, f. celenk, m. kanlikama * gaziantep university, medical faculty, turkey objective: papillary thyroid carcinoma (ptc) rarely metastasizes to axillary lymph nodes. although anaplastic transformation (at) may occur in the cervical lymph node metastasis from ptc, it is rarely observed in the metastatic axillary lymph nodes. furthermore, cutaneous metastasis from anaplastic thyroid carcinoma (atc) is extremely rare. method: a -year-old male patient who had operated for multinodular goiter years ago presented with neck swelling on the right side. residual thyroid tissue was detected and the lesion was removed surgically in combination with a right neck dissection. histopathologic examination was consistent with ptc and metastatic lymph nodes. the patient received radioactive iodine therapy. afterwards, the patient presented with a right axillary mass years after the first operation and underwent surgical excision. results: histopathologic examination showed ptc with anaplastic transformation. histopathologically confirmed multiple skin metastases from atc emerged in thoracic and abdominal regions months after the last operation. patient died months after the diagnosis of anaplastic carcinoma. conclusion: although most ptcs show an indolent course and have a favorable prognosis, distant metastasis and anaplastic transformation of the metastatic lymph nodes may occur even more than many years after the primary treatment. local "bystander"effect of gene therapy on human tumor cells of medullary thyroid carcinoma in vivo l. feketeova * , m. poturnajová, l. kucerová, p. babál * comenius university, inst. of pathology, bratislava, slovakia objective: gene therapy acts on change of prodrug into cytotoxic drug inside tumor cells transfected by foreign enzyme. it uses also "bystander" effect on surrounding tumor cells without enzyme. we used yeast cytosine deaminase (ycd) in combination with -fluorocytosine ( fc) converted into -fluorouracil ( fu) and its metabolites. medullary thyroid carcinoma (mtc) is a malignant tumor often with therapy resistant distant metastases. patients with sporadic form have metastases at the time of diagnosis, mostly in bones, lungs and liver. the aim of this study was to evaluate the efficiency of ycd/ fc in mtc treatment using xenotransplants derived from model tt cell line in nude mice. method: tumors were immunohistochemically stained with polyclonal antibody anti-egfp (enhanced green fluorescence protein) and monoclonal antibodies anti-pcna and anti-ki . positivity was semiquantitatively evaluated. results: diffuse positivity for pcna was seen in untreated and treated tumors, respectively. positivity for ki- was diffuse in untreated and only sporadic in treated tumors. conclusion: diffuse pcna positivity in treated tumors suggests that the tumor cells stopped in s phase. scattered positivity of ki- after treatment document suppressed proliferation mediated by ycd/ fc gene therapy, which implies therapeutic application in patients with metastatic mtc. (itms , vega / / , vega / / ). ps- - e-cadherin/ß-catenin immunoexpression in thyroid carcinomas k. ivanova * , e. onal, j. ananiev, t. vlaikova, m. gulubova * trakia university, general and clinical pathology, stara zagora, bulgaria objective: the aberrant activation of wnt signaling pathway may be a common denominator for the development of thyroid tumorigenesis. it was announced that the loss of ecadherin rather than β-catenin mutation represents a crucial event in determining the degree of differentiation of thyroid carcinomas. the aim of the study was to evaluate the expression of e-cadherin and β-catenin in the thyroid cancer tissue and to correlate these data with some histological and clinical parameters of the tumors. method: we investigated patients, having thyroid tumorspapillary, follicular, anaplastic and oncocytic carcinomas immunohistochemically with antibodies against e-cadherin and β-catenin. survival analyses were done. results: e-cadherin expression was focally retained in the tumor cell membranes and in the tumor cell cytoplasm of the papillary, follicular and oncocytic thyroid cancers, weather in anaplastic cancers it was almost lost (p= . , and p= . , respectively, fisher's exact test). the expression of β-catenin in tumor cytoplasm and membrane in papilary cancers was higher as compared to that in the other tumors (p= . , and p= . , respectively). conclusion: not surprisingly, the presence of aberrant expression of e-cadherin and/or β-catenin in thyroid cancer has been associated with better patients' prognosis and more well differentiated tumor histology. correlation between estrogen receptor and progesterone receptor with some prognostic factors in papillary thyroid carcinoma m. jalali nadoushan * , r. amirtouri, a. davati * shahed university, dept. of pathology, tehran, iran objective: the more prevalence of papillary thyroid cancer in women shows the probability of the role of sex hormones in the cancer. the aim of this study was determination of relation between sex hormones receptors and some prognostic factors. method: we studied patients with pathology report of papillary thyroid carcinoma after thyroidectomy between and . the specimens were stained immunohistochemically for er and pr. the other informations such as sex, age, tumor size and lymph nodes involvement obtained from the patients documents. results: the average age of patients was . + , . . % t of samples were er positive while this was . % for pr. the percentage of lymph nodes involvement was . %. the size of tumors was . + . cm. there was a direct relationship between female sex and positivity of er (p≤ . ). but there was no significant relationship between er and pr with age, tumor size and lymph nodes involvement. conclusion: it seems to be that er is more prevalent in females but for showing of its role in prognosis, further studies are recommended. objective: type diabetes mellitus (t dm) treatment aims to control metabolic effects, preserve pancreatic function and reduce complications, such as nephropathy. this study intends to evaluate the effects of sitagliptin, a dipeptidyl-peptidase- inhibitor, in pancreatic and renal lesions in zucker diabetic fatty (zdf (fa/fa)) rats, an animal model of t dm. method: male obese diabetic zdf (fa/fa) rats, -weeksold, were treated with vehicle or sitagliptin ( mg/kgbw/ day) for weeks, and compared with lean control zdf rats (n= each). biochemical parameters as well as pancreatic and renal lipid peroxidation and histopathology profile were assessed. specimens we stained with haematoxylin-eosin and periodic acid of schiff, and examined by light microscopy. lesions were evaluated by a semiquantitative rating. endocrine/exocrine pancreas and renal glomerular, tubulointerstitial and vascular lesions were assessed and scored ( / - ). results are mean ± sem; anova and duncan's post-hoc analysis (p≤ . was considered as significant). results: sitagliptin improved metabolic parameters, reduced lipid peroxidation (p< . ) in both organs and significantly prevented major diabetic pancreatic and renal lesions in obese diabetic zdf rats. conclusion: sitagliptin seems to comply with the three main objectives of t dm therapeutic management. underlying molecular mechanisms deserve further elucidation, but could be related with metabolic improvement and reduction of oxidative stress. objective: thyroid tumors of uncertain malignant potential (tt-ump) include follicular and well-differentiated tumors of ump (ft-ump/wdt-ump), as it refers to the presence of questionable capsular/vascular invasion or incompletely developed papillary thyroid carcinoma (ptc)-type nuclear changes. however, a diagnosis of tt-ump is difficult in most cases. we aimed to investigate whether immunohistochemistry (hbme- , cytokeratin- , galectin- , cd and p ) provides additional information concerning such lesions. method: we performed an immunohistochemical analysis on wdts-ump and fts-ump. results: in the wdt-ump group, hbme- was positive in / ( . %) cases. cd , a marker whose expression is reduced in thyroid carcinoma, showed a "malignant" profile (no expression) in / ( . %) cases. / ( . %) cases were positive for both antibodies. one case showed the coexpression of hbme- , cd , galectin- and cytokeratin- . only one ft-ump case was positive for hbme- . the follow-up data revealed no distant metastases or persistent disease. conclusion: tt-ump demonstrated very heterogeneous immunohistochemical profiles. wdts-ump revealed a certain tendency toward a ptc profile, suggesting a possible pathogenetic link between these two entities. however, immunohistochemistry is to be regarded more as a supporting factor, while morphological criteria should always prime in the diagnostic decision. results: there was a positive correlation between tpcfv and hmwck, ck , hbme , galectin , fibronectin (p< . ), but there was no correlation with tpcfv and ret/ ptc (p> . ). hbme- and ck stained strong and diffuse positive in tpcfvs but weak and focal in fas. our study suggests that morphologic features combined with immunohistochemical panel of hmwck, ck , hbme- , galectin- and fibronectin can help to distinguish benign and malign thyroid neoplasms and tpcfv from follicular adenomas. ret/ptc expression has been nonspecific but its detection can be a useful tool combined with immunohistochemistry for diagnosing tpcfv. morphological features of the system mother-placentafetus during pregnancy on diabetes mellitus t. pavlova * , v. petrukhin, e. malutina, a. nesterov, l. pavlova, i. goncharov, d. kolesnicov * belgorod state university, dept. of pathology, russia objective: combination of diabetes mellitus and pregnancy has a special concern. method: it were studied pregnants with diabetes mellitus type and pregnant with gestational diabetes mellitus (gdm). the methods were used: light, transmission, electron, probe and scanning microscopy with microelement analysis. results: the pregnancy at diabetes mellitus type and gdm proceeds with complications: treat of pregnancy termination ( , % and , %), hydramnion ( , and , %), preterm birth ( , and , %). it was displayed decreasing of oxygen in mother's erythrocytes. at the diabetes mellitus in uterus of women in birth there are violations of spiral arteries as well as circulatory disorders (stasis, sludge, thrombosis and diapedetic bleedings), that is significantly expressed at gestosis. tendency to cell form changing is observed in erythrocytes at diabetes mellitus, especially at diabetes mellitus type . the frequency of placental insufficiency in pregnant with diabetes mellitus type were %, at gdm- %. the gestosis accession were resulted to birth's increasing of children with prenatal injury of central nervous system at diabetes mellitus type in mother and diabetic fetopathy at gdm. the clinical and morphological parallels of the system mother-placenta-fetus were presiced ad diabetes mellitus type and gdm. sclerosing mucoepidermoid carcinoma of the thyroid in a year-old female a. polónia * , l. santos, c. eloy, r. celestino, p. soares, m. jácome, c. lobo * ipo-porto, pathology, rio tinto, portugal objective: sclerosing mucoepidermoid carcinomas (smecs) are low-grade malignant tumours with both squamous and mucinous differentiation representing less than % of thyroid malignancies. smecs are usually associated to hashimoto thyroiditis and classically disclose eosinophilia. results: a year-old female with hashimoto thyroiditis presented a . cm nodule in the left lobe of the thyroid. the total thyroidectomy specimen disclosed a firm, well circumscribed, non-encapsulated tumour. microscopically, the tumour was composed by anastomosing clusters of squamoid cells in a sclerotic background without eosinophils. intra-cytoplasmatic pas/diastase positive material was focally found. the tumour cells expressed ae .ae , ttf- and p whereas no expression was observed for thyroglobulin, calcitonin and cd . the ki- labeling index was %. in the molecular analysis no mutations were detected in braf or (k-, n-, h-) ras genes nor ret/ptc or pax /ppargamma rearrangements. the remaining thyroid showed hashimoto-type thyroiditis. a cervical lymph node metastasis was identified. the patient was treated with radioactive iodine and is alive without signs of disease after months of follow-up. conclusion: smecs may not disclose the classical eosinophilia and represent rare low-grade tumours that can give rise to metastases. the most frequent molecular alterations found in thyroid tumours were not detected in this case. ps- - alk and bmp- overexpression as a cause of ossifying papillary thyroid carcinoma objective: ossification is an often encountered finding in papillary thyroid carcinoma (ptc). we hypothesized that osteogenic signaling may be related to osteogenesis of ptc. bone morphogenic protein (bmp)- is the most osteogenic subtypes among bmps. and as a cellular receptor, activin receptor-like receptor (alk) has been emphasized in bmp- induced osteogenic signaling. we investigated the expression of alk and bmp- and their correlation with ossification in ptc. method: alk and bmp- expression were investigated by immunohistochemistry in tumors and adjacent normal follicles of ptcs with bone formation and ptcs without bone formation. alk and bmp- expression were further verified by quantitative real time polymerase chain reaction in each group of cases of ptcs with or without bone formation. results: alk and bmp- immunoreactivity were increased in ptc with bone formation when compared to those without bone formation (p< . and p= . ). both mean values of alk and bmp- mrna expression were elevated in ptcs with bone formation compared with those without bone formation (p= . and p< . ). conclusion: alk and bmp- overexpression may be underlying the molecular alteration that accounts for osteogenesis in ptc. objective: thyroid is an extremely rare site of metastases. renal clear cell carcinoma (rccc) is one of the most frequent primary malignancies causing thyroid metastases as a single nodule ( %) or multiple nodules ( %). we report the case of a -years-old female patient affected by multinodular goiter, who was diagnosed with rccc, treated with nephrectomy. method: due to compressive symptoms, years after nephrectomy, the patient underwent thyroidectomy and the thyroid was sent for histology. results: histology showed multinodular goiter. in the largest hyperplastic adenomatous nodule (left lobe, diameter mm ), multiple solide yellow-orange areas were detected grossly. these areas were microscopically composed of sheets of large cells with clear cytoplasm and small hyperchromic nuclei, with a focally infiltrative growth pattern. at immunohistochemistry clear cells were negative for ttf , hbme , galectin- and positive for cd . conclusion: this is a rare case of multiple rccc metastases within an adenomatous nodule in goiter. clinical diagnosis of rccc metastases to thyroid is extremely difficult, even more if metastases grow in multinodular goiter. it should be always suspected in patients with a clinical history of rccc. objective: follicular carcinoma, oncocytic variant, is a rare type of thyroid carcinoma. we examined a case of oncocytic carcinoma misdiagnosed as medullary carcinoma on fineneedle aspiration (fna) because it was associated with amyloid material. method: a -year-old female rheumatoid arthritis (ra) patient had a . cm mass in the right lobe of her thyroid, which showed no enhancement effect on ct scan and was diagnosed as a "cyst". fna was performed, and she subsequently died of unrelated causes. an autopsy was performed. results: cytology: large and small round-shaped tumor cells were present with round nuclei with granular chromatin. double-or triple-nucleated cells and amyloid material were observed. histology: oncocytic round cells proliferated diffusely in the fibrous capsule. extra-capsular invasion and vascular infiltration by the tumor cells were recognized. electron microscopy: the cytoplasm of tumor cells was full of mitochondria. therefore, we diagnosed this as follicular carcinoma, oncocytic variant. amyloid deposition was also observed in several other organs. conclusion: amyloid deposition was caused by amyloidosis secondary to ra. narrowing of the tumor feeder artery due to amyloidosis may have prevented early enhancement on the ct image. objective: whipple's disease is an infectious disease caused by tropheryma whipplei, an ubiquitous gram-positive actinobacteria. the incidence of the disease is less than per milion. we report five new consecutive cases, four males and one female, diagnosed in our clinic from august to january . method: diagnosis was reached with the help of gastroduodenal endoscopy and histopathological examination of the duodenal biopsies, by lymph node biopsy and by electron microscopy. results: the main symptoms were arthralgia, weight loss and diarrhea. the endoscopic aspect of the small bowel mucosa varied from congestion, granularity of the mucosa to whitish plaques. all patients showed pas positive, diastase resistant, ziehl-neelsen negative macrophages in the lamina propria of the duodenal mucosa and, in one patient, suspected for lymphoma, in an abdominal lymph node. the diagnosis was confirmed by electron microscopy in all cases. classic whipple's disease was the diagnosis in all five cases, but one patient showed involvement of the endocardium and two patients showed lymphadenopathies. conclusion: clinical evolution was favorable under long-term antibiotics (cephtriaxone/trimethoprim-sulfamethoxazole) and follow-up biopsies in three patients showed a normal endoscopical mucosa and a reduced but persistent number of pas positive macrophages in the duodenal mucosa. results: eleven cases of nen of gastrointestinal tract were identified. they were men and women with a mean age of . years. the most common localization was the appendix ( cases). the other cases were localized in the small intestine, the ileo caecal valve, the fundus and the bulb. the mean tumor's size was . mm. mitoses were absent in the majority of cases ( , %). all the tumors were well differentiated classified as grade in cases and grade in cases. the tumor was aggressive in cases. the small intestine's net was multifocal infiltrating the subserosa with lymph node metastasis classified pt n . the ileo caecal valve's net was also aggressive with lymph node and hepatic metastasis classified pt n m . all patients underwent surgical treatment. conclusion: gastrointestinal nens are complex tumors whose incidence is rising and whose treatment requires precise classification and risk stratification. multiple duodenal stromal tumors associated with neurofibromatosis- g. benkhedda * , y. lamouti * chu frantz fanon, dept. of pathology, blida, algeria objective: gastrointestinal stromal tumors (gist), most commonly occur sporadically, but there seens to be some increased tendency for these tumors to develop in patients with neurofi-bromatosis (nf ). there is no histological difference between the nf assocaciated cases and the sporadic cases. however, tumors associated with nf frequently show multiplicity. method: a case of multiple duodenal gastrointestinal tumor arising in a year old mal with nf is reported. the abdominal exploration revealed multiple solid nodules in the duodenum, and the pancretecticoduodenectomy was performed. results: macroscopy: the resected segment of the duodenal showed seven suberosal solid masses. the largest mass measured , cm× cm× cm, and is coupled with the bors lower pancreas but remains limited by a capsule. the cut surface was smooth and white in appearance. microscopy: the tumors were composed of interlacing fascicles of the uniform spindle cells with elongated cytoplasm. the tumor cells lacked pleomorphism, and mitotic figures were absent. immunohistochechemistry: the tumors cells were diffusely positive for cd , cd , and negative for desmin, aml and ps . conclusion: gist are rarely noted in association with neurofibromatosis- . duodenal gist are most frequently diagnosed in the workup of symptoms not specific to these masses. duodenal resection is rarely indicated except in the case of duodenal gist and early-stage adenocarcinoma or if the tumor appeared involve the pancreatic parenchyma on preoperative imagings. periampullary adenomyoma: a true trap diagnosis g. benkhedda * , y. lamouti * chu frantz fanon, dept. of pathology, blida, algeria objective: adenomyoma is a term generally applied to nodular lesions showing proliferation of both epithelial and smooth muscle components. it is usually presented as biliary obstruction. most cases are misdiagnosed as adenoma or carcinoma by preoperative endoscopic or radiologic. therefore, it is frequently treated with extensive surgery. method: we report a case of a year-old man with an adenomyoma located in the ampulla of vater diagnosed by endoscopic piecemeal resection. results: on histologic examination, the lesion consisted of hyperplastic glandular lobules, mainly located in the muscle layers of the vaterian system. the lobular formations consist of small glands surrounded by myofifroblastic, fibroblastic proliferation, sparse capillaries and inflammatory cells. ihc: ki : rare cells with a positive nuclear staining were presenting in the epithelial and mesenchymal components aml: the myofibroblastic of most spindle cells was confirmed by a strong cytoplasmic expression. conclusion: real incidence of adenomyoma of the vaterian system is difficult to appreciate as different names (adenomyoma, adenomyomatosis, myoepithelial hamartome) are used to designate the same histological lesion. adenomyoma was diagnosed only in adult patients -mean age: y). the histogenesis is still a subject of controversy. the most widely accepted hypothesis is that the lesion may represent a form of incomplete heterotopic pancreas. adenomyoma is considered as benign and slow growing, but its potential neoplastic nature cannot be excluded. however, the histogenesis of these tumors is subject to further study. carcinosarcoma of the digestive organs has been reported to exhibit aggressive behavior. carcinosarcomas in digestive organs have been reportedly associated with a poor prognosis. , however, some cases that have been treated with a curative operation showed long-term survival. analysis of her expression level in gastric carcinomas m. bialas * , a. sinczak-kuta, a. lazar, k. urbanczyk, k. galazka, j. szpor, s. demczuk, d. adamek * jagiellonian university, dept. of pathomorphology, krakow, poland objective: the expression of her an oncoprotein belonging to tyrosine kinase family belongs to recently evaluated prognostic and predictive factors in gastric cancer. overexpression of her is observed in about - % gastric cancers. according to many authors, overexpression and/or amplification of her correlates with poor prognosis. the aim of our study was to analyze her expression in gastric cancer in material routinely examined in pathomorphology department, jumc. method: we have analyzed cases of gastric cancers. the material came from females and males, age: - . immunohistochemical reactions were performed automatically on benchmark bmk classic (ventana) using path-way her- /neu ( b ) antibody. scoring system for her expression was ranged from to + where: and + were regarded as a negative, + as equivocal and + as positive. results: most cases of gastric cancers were her -negative ( / ): including score ( patients) and + ( patients). three cases were equivocal and two cases showed + expression level. the lower level of her expression in the analyzed material in comparison with literature could be related to a relatively small group of cases but one cannot exclude that there exist some other factors that stand behind this and surely the investigations should be continued. ps- - mapkap kinase overexpression influences prognosis in gastrointestinal stroma tumors, associates with copy number variations on chromosome , and expression of p map kinase and etv p. birner * * medizinische universität wien, institut für klinische pathologie, austria objective: etv has been proposed to be activated by kitmutations in gastrointestinal stromal tumors (gists). aim of the study was to evaluate the role of etv and associated proteins in gist. method: expressions of etv , mapkap kinase (map-kapk ), phosphorylated p map kinase (pp ), phosphorylated msk , phosphorylated rsk , cop and kit were determined immunohistochemically in gists. sequence analysis of kit, pdgfra and mapkapk and fish of etv and chromosome was performed. results: prominent etv expression was seen in % of gists, but no correlation with clinical outcome was found. correlation of etv expression and kit mutation was seen in % of cases. mapkapk overexpression (n = / . %) correlated with pp expression (p= . ) and alterations of chromosome (p= . ). in one cases with high makapk expression, a mapkapk gene mutation was found. all relapsing gists with very low/low risk showed high mapkapk and kit expression. map-kapk overexpression was an independent prognostic factor for disease free survival (p= . ). conclusion: etv is not universally overexpressed in gist and seems to be induced also by other pathways than kit-mutation. mapkapk -overexpression is associated with shorter survival in gist. patients with low risk gists overexpressing mapkapk might profit from adjuvant tyrosine kinase inhibitor therapy. gastrointestinal stromal tumors: comparison of two risk stratification systems in a multicenter study of turkish cases g. bulbul dogusoy * * gayrettepe florence nightingale, dept. of pathology, istanbul, turkey objective: a nationwide database was performed for gastrointestinal stromal tumors (gists) in a large series of primary gists surgically treated at centers all around turkey. the aim of this multicenter study was to analyze and compare the performance of the national institute of health (nih) and armed forces institute of pathology (afip) risk criteria to determine the ideal risk stratification system. method: statistical analysis of a nationwide database is consisted of age, gender, location, risk groups, histopathologic features and the results of cd , cd , desmin, sm actin, s- protein, and ki immunohistochemistry. results: in cases registered in database, male to female ratio was . and mean age was . years. most common location was stomach ( . %) followed by small intestine, omentum-peritoneum, large intestine, and esophagus ( . %, . %, . %, . % respectively). comparison of the two risk-stratification systems demonstrated that proposed modified afip seems to be better when compared with nih system. many histopathologic and immunohistochemical findings showed significant correlation with risk groups of afip, even with 'not sufficient data' group (p< . ). the results of this multicenter study demonstrates that although follow up results are not provided, afip risk criteria seems to be more useful in prognostication for gists among the two systems. objective: her /neu overexpression or amplification is an important biomarker for identifying patients with intestinal-type gastric cancer who respond to therapy with trastuzumab. moreover, intestinal type gastric cancer shares many phenotypic and molecular genetic changes with colorectal cancer. in particular a progression from chronic gastritis to intestinal metaplasia, dysplasia, and finally malignant transformation is probably the sequence of gastric carcinogenesis. somatic mutation of k-ras gene is common in colorectal cancer, being found in more than one-third of cases, but it seems to have, mostly in intestinal-type gastric cancer, a low incidence ( - %). the purpose of this study is to assess her gene amplification and k-ras mutational status in a series of intestinal-type gastric carcinoma patients. method: twenty paraffin embedded gastric cancer specimens were tested for her amplification by chromogenic in situ hybridization (cish) and k-ras mutational status (codon e ) by pcr-rflp. results: six ( %) cases were her amplified. only one case ( %) was found to have k-ras mutation (codon ), but it was her not amplified. conclusion: the frequency of k-ras mutation and her amplification are in agreement with other studies on this topic. in our study, the two seem mutually exclusive events. objective: gastric carcinoma is related with cancer genetic susceptibility that can be investigated as single nucleotide polymorphisms (snps) and as cytokine genes are known to predispose to malignant disease, several polymorphisms of interleukin- (il- ) gene have been reported to in some may be associated with tumour progression including inhibition of malignant epithelial cells apoptosis and stimulation of angiogenesis. method: the aim of this study was to clarify the association between il- polymorphisms and the risk of gastric cancer and chronic gastritis development or maintenance. pcr-ssp genotyping for il- - c>g polymorphism was performed in biopsies of gastric carcinoma and in biopsies of chronic gastritis. results: there was association between il- - c allele (p = , ) and - cc, low producer, genotype (p = , ) and gastric carcinoma, whereas il- g allele (p= , ) and il- gg (p< , ), high producer, genotype was associated with gastritis. conclusion: we conclude that il- - , low producer genotypes, may have an important role in gastric carcinogenesis and the polymorphism study of this molecule could be a good marker for gastric carcinoma susceptibility when high grade dysplasia is seen in biopsies. objective: in helicobacter pylori gastritis, constant antigenic stimulation triggers a sustained b-cell proliferation. errors made during this continuous dna replication are corrected by the dna mismatch repair mechanism. failure of this mechanism has been described in hnpcc and results in a replication error phenotype. inherent to their instability during replication, microsatellites are the best markers of this replication error phenotype. we aimed to evaluate the role of defects in the dna mismatch repair mechanism and microsatellite instability (msi) in gastric mucosa-associated lymphoid tissue (malt) lymphoma. method: we examined microsatellite loci (bat , bat , d s , d s , d s , tgfb, bat , d s , d s and d s ) for instability in patients with malt lymphomas. in addition, these tumors were also immunostained for mlh , msh and msh , as well as screened for the presence of t( ; )(q ;q ) by real time polymerase chain reaction (rt-pcr). results: we found msi in / ( %) lymphomas, with one tumor displaying high levels of instability. msi occurred in both t( ; )(q ;q )-positive and -negative tumors. conclusion: our data suggest that a mmr-defect may be involved in the development of gastric malt lymphomas, and mutations in the msh mmr gene or hypermethylation of the msh promoter might be associated with msidriven gastric lymphomas. mitosis-specific marker phospho-histone h in the diagnosis of gastrointestinal stromal tumors a. dolzhikov * , a. tverskoi, k. hizhnyakov * regional pathology hospital, dept. of oncomorphology, belgorod, russia objective: the assessment of proliferative activity is one of the major parameters in the proper grading of gastrointestinal stromal tumors (gists). in the low level of mitotic activity it is difficult to calculate dividing cells correctly. phospho-histone h (phh ) is a recently introduced immunomarker for mitotic cells. method: immunohistochemical study of cases of gists of different malignant potential, statistical analysis. results: the count of phh -immunoreactive cells demonstrates the strong correlation (gamma , ; p< , ) with malignant potential of gists detected by standard parameters. it clearly separates true mitotic cells from apoptotic and piknotic nuclei. in all cases phh count was slightly higher than the mitotic index in h&e stained slides. we have found that pph demonstrated the two types of staining: nucleosomal dot-like type and mitotic homogenous type. the first type, probably, reflects the fraction of cells just before the prophase, which cannot be identified in h&e slides. conclusion: immunostaining of pph is a useful additional marker in detection of proliferative activity in gists, helping to identify true dividing cells correctly. ps- - her assessment in gastric carcinoma using ihc and fish p. drev * , b. gazic, j. contreras * institute of oncology, dept. of pathology, ljubljana, slovenia objective: her in gastric cancer (gc) should be assessed following guidelines -recommended testing algorithm employs ihc as a screening tool and is followed by ish to clarify equivocal cases. reported incidences of her + gc vary substantially and discordant results are frequent. in a series of gc her was assessed by ihc and fish to determine incidence of her + gc, concordance of the methods and reevaluate the recommended algorithm. method: her was assessed by both ihc (pathway b ™) and fish (pathvysion™) in gc samples. reactions were evaluated according to guidelines. her was considered positive in case of strong protein expression ( +) and/or gene amplification (ratio ≥ . ). frequencies of ihc and fish scores, incidence of her + gc and concordance (chi-square) of applied methods were analysed. results: ihc score distribution: neg ( ) objective: gastric glomus tumors are rare neoplasms originated from modified smooth muscle cells of the glomus bodies. such lesions present a diagnostic challenge in biopsy material. herein, we report a case of gastric glomus tumor in a -year-old woman. method: a -year-old woman presented with refractory epigastralgy. a gastrointestinal stromal tumor of the gastric antrum was suspected. the diagnosis was made after ultrasound-guided endoscopic biopsy, followed by an endoscopic submucosal resection. results: the biopsy showed tight convolutes of capillarysized vessels surrounded by collars of small, rounded cells set in a hyalinized, myxoid stroma. immunohistochemically, these cells were positive for smooth muscle actin and type iv collagen (pericellular pattern), synaptophysin (focal positivity) and negative for cd , cd , desmin, s and cytokeratins. the diagnosis of gastric glomus tumor was rendered. the resection specimen revealed a submucosal well-circumscribed × , × , cm nodule with identical histological features. the patient was disease-free months postoperatively. conclusion: visceral glomus tumors are rare neoplasms. when they arise in the gastrointestinal tract, the stomach (antrum) is the most frequent location. the differential diagnosis includes net, epithelioid gist and hemangiopericytomas. they usually behave in a benign fashion, although malignant cases have been reported. surgical excision is the standard treatment. immunohistochemical evaluation of replication protein-a in gastric cancer: clinicopathological associations h. gakiopoulou * , e. fourtziala, g. levidou, a. stofas, n. alexakis, p. korkolopoulou, e. patsouris * university of athens, st dept. of pathology, greece objective: replication protein a (rpa ) is required for stabilization of single-stranded dna at early and later stages of dna replication being thus critical for eukaryotic dna replication. in this study, we investigated for the first time the immunohistochemical expression of rpa protein in a series of gastric carcinomas in relation with clinicopathological parameters (age, sex, lauren's histologic classification, histologic grade, lymphovascular invasion, tumor size, depth of invasion (t), lymph node metastasis (n) and stage). method: a standard immunohistochemical method and a semi-quantitative evaluation for the detection of rpa labeling index (li) were applied. results: nuclear rpa immunoreactivity was seen in all carcinomas with a mean value of . %. statistical significant correlations emerged between: . rpa li and low tcategory (p= . ) . rpa li and absence of lymph node metastasis (p= , ). rpa li was higher in cases without lymphovascular invasion; however this association did not reach statistical significance. conclusion: the widespread expression of rpa in gastric carcinomas suggests that this protein is implicated in gastric cancer growth. the observed significant associations between rpa li and low t as well as n tumors could imply that rpa might offer a growth advantage in the early stages of gastric cancer progression. pigmented histiocytic "pseudotumoral" reaction due to endoscopic tattooing of the duodenum with india ink r. hadhri * , c. objective: india ink has been used for endoscopic tattooing to facilitate localization of a luminal abnormality at the time of surgery or repeat endoscopic examination. recognition of this phenomenon is important to prevent misinterpretation of this _nding as other cause of black tissue deposits. some of them can be easily excluded by microscopic examination; the others, however, necessitate special stains or, as illustrated by our observation, an adequate clinical information! method: a -year-old man was referred for enteroscopy for microcytic anemia. the procedure revealed a cm flat umbilicated lesion of the duodenum. endoscopic tattooing was performed to guide surgical excision. results: histologic examination of the surgical specimen revealed a tubulovillous adenoma with low-grade dysplasia. the submucosa showed numerous aggregates of large cells containing a heavy black pigmentation. special histologic stains were inconsistent with melanin or iron. this submucosal cellular infiltration was linked to the preoperative use of india ink when the notion of tattooing was "kindly" provided by the surgeon! conclusion: despite a striking and misleading appearance, the microscopic finding of such phenomenon does not represent a pathologic state. nevertheless, communication between enterologists, surgeons and pathologists are mandatory to assure prompt recognition and avoid unnecessary investigations. objective: gastritis cystica polyposa is a unique lesion found on occasion at the stoma of a gastrojejunal anastomosis. however, gcp is rarely found in an unoperated stomach. method: a -year-old woman with abdominal discomfort and vomiting. physical examination, routine hematological examination and biochemical tests were within normal limits, exept mild anemia. results: upper gi endoscopic examination revealed a pedanculated polyp, in the greater curvature. endoscopic ultrasonography revealed a polypoid heteroechoic mass with cystic area and × mm diameter in posterior wall of gastric body. polypectomy was performed without any complications. histological examination of the protruding lesion revealed some misplaced cystic glands were entrapped in dense disorganized bundles of smooth muscle of muscularis mucosa surrounded by a rim of lamina propria. these findings were consistent with gastritis cystic polyposa. objective: human papillomavirus (hpv) infection is a known risk factor for the development of squamous cell carcinoma (scc) of the cervix, the oropharynx and the anogenital region. the aim of our investigation was to assess the prevalence of hpv dna in patients with esophagus cancer in the western population. method: formalin-fixed paraffin-embedded blocks from consecutive patients who underwent esophageal endoscopic mucosal resection or esophagectomy for scc were tested for the presence of hpv dna by polymerase chain reaction using consensus primers gp +/gp +. viral genotyping was determined by type-specific primers. results: among the total of cases, no hpv dna was detected in cases ( . %). cases were tested hpv positive ( . %) , of which was hpv +, was hpv + and were non-high-risk hpv type. the non-high-risk hpvs were detected in patients with previously treated scc of the mouth (n= ) and the oropharynx (n= ). patients with high-risk hpvpositive tumors had no history of oropharyngeal cancer. conclusion: our study revealed the presence of oncogenic hpv genotypes in a subset of esophageal cancer. the low rates of viral infection detected suggest that hpv unlikely represents a significant etiologic factor in esophageal carcinogenesis. further studies are needed to confirm these data in larger populations. objective: gastric cancer is the second leading cause of cancer mortality in the world. amplification of her- /neu oncogene has become an important biomarker for identifying patients who will respond to her- targeting therapy. the rate of her positivity in gastric cancer is variable, ranging from % to %. objective: gastrointestinal stromal tumors (gists) are primary mesenchymal tumors that arise in the gi tract. only - % of gists occur in the duodenum. here, we report a rare case of duodenal gist with extramural growth that mimicked a pancreatic tumor. method: a years old male patient was admitted to our hospital for duodenal ulcer and gastrointestinal bleeding which was diagnosed in an another clinic by endoscopy. abdominal mr of the patient showed a × , cm necrotic mass in the uncinate process of the pancreas which was excised by whipple operation. results: macroscopically, the resected specimen consisted of solid mass that was connected to the patient's duodenal wall but not to the parenchyma of the pancreas. microscopic examination of the tumor showed spindle shaped and epithelioid cells with mild nuclear pleiomorphism. immunohistochemistry revealed that the cells are strongly positive with cd , with focal expression of cd and sma. conclusion: gists are low-grade malignant mesenchymal tumors of the gi tract and are believed to originate from the neoplastic transformation of the cajal cells, which are located between the longitudinal and circular layers of the muscularis propria. they most frequently arise from the second part of the duodenum where they push or infiltrate into the pancreas. in our case report, the patient's tumor exhibited extramural growth and mimicked a pancreatic tumor. mantle cell lymphoma (mcl) is relatively a rare subgroup of non-hodgkin lymphoma. we have experienced an uncommon case of mcl. a -year-old man was admitted to emergency service for upper gastrointestinal bleeding as melena. gastric corpus wall thickness found increased and splenomegaly determined at whole abdominal ultrasonography. endoscopic examination revealed subsequently, cm diameter polypoid lesion at corpus anterior wall and cm dimensioned elevated and vascularised lesion at corpus posterior wall. endoscopic biopsy had reported as active gastritis and mucosal reactive hyperplastic changes with ulcerative background. after than total gastrectomy and splenectomy specimens examined diffuse infiltration of monotonous medium-sized, atypical lymphoid cells with hyperchromatic nuclei. these cells were positive for cd , cd , cd , bcl- and cd a, but negative for cd , cd and bcl- . atypical lymphoid cells were present even in splenic hilus and lesser curvature lymph nodes. we reported this case as primary gastric mantle cell lyphoma according to morphologic and immunohistochemical staining features. we report a -year-old man who had been searched for bicytopenia (anemia and thrombocytopenia). bone marrow examination revealed extensive bone marrow metastasis of signet ring cell carcinoma. pas, d-pas and mucin histochemical markers performed to bone marrow sample which were all positive. immunohistochemical markers were positive with muc- , muc- ac, muc- (focal staining), ck , ck , ema, cea and negative with vimentin, cd , chromogranin. according to morphologic and immunohistochemical results we thought primarily gastrointestinal system malignancy, particularly stomach carcinoma. upper gastrointestinal endoscopy performed subsequently, hemorrhagic ulcerative lesion had seen and taken biopsies. endoscopic biopsy results showed metastatic signet ring cells origin from stomach. we report this case because bone marrow metastasis can be found commonly in some malignant tumors but diagnosing a nonhematologic malignancy from bone marrow is an unusual event. the pathological effects of salvia officinalis extract on serum level of alkaline phosphatase in male rats e. abdollahi * , r. ahmadi * tehran university, iran objective: studies show that there is association between salvia officinalis extract administration and liver or heart functions. the main aim of this study was to determine the effects of salvia officinalis extract on serum level of alkaline phosphatase in male rats. method: male wistar rats were randomly divided into control, normal saline receiving and salvia officinalis extract ( , or mg/kg/day) receiving animals of in each group. after a period of weeks, blood samples were collected using cardiac puncture method. following serum collection, serum alkaline phosphatase levels were measured by spectrophotometry method. data were statistically analyzed and compared between groups using anova. results: the results indicated that serum alkaline phosphatase levels were significantly increased in salvia officinalis extract ( , or mg/kg/day) receiving animals compared with control rats. conclusion: our findings show that salvia officinalis extract is enhancer of serum alkaline phosphatase according to which, impairing effect of the extract on certain tissues is conceivable. the pathological effects of waterpipe smoking on serum levels of cea, alkaline phosphatase or creatine kinase in male and female rats r. ahmadi * , m. mafi * islamic azad university, dept. of physiology, hamedan, iran objective: various studies show that smoking can influence serum levels of tumor markers such as carcino embryonic antigen (cea) and kinase or phosphatase enzymes. the main aim of this study was to determine the pathological effects of waterpipe smoking on serum levels of cea, alkaline phosphatase (alp) or creatine kinase (ck) in male and female rats. method: male and female wistar rats were randomly divided into control and waterpipe smoking groups of in each. after a period of weeks, blood samples were collected using cardiac puncture method. following serum collection, serum cea, alkaline phosphatase or creatine kinase levels were measured. intestinal tissue was also examined histologically. data were statistically analyzed and compared between groups using anova. results: the results indicated that serum cea, alp or ck levels were significantly increased in male and female waterpipe smoking animals (p< . , p< . or p< . , respectively). there was not gender effect on serum cea, alp or ck levels. there were also histological changes in intestinal tissue including increased tissue plasma cells infiltration and inflammation. conclusion: our findings show that waterpipe smoking is an enhancer factor of serum cea, alkaline phosphatase or creatine kinase levels, according to which, damaging effects of waterpipe smoking on various tissues, particularly intestine should be considered seriously. the effects of acute or chronic immobilization stress on serum level of creatine kinase and alkaline phosphatase in male rats m. alinavaz * , r. ahmadi, m. mafi * islamic azad university, nutrition, tehran, iran objective: studies show that immobilization stress has a variety of effects on serum levels of liver enzymes. the main aim of this study was to determine the effects of immobilization stress on serum level of creatine kinase and alkaline phosphatase in male rats. method: male wistar rats weighing ± g were randomly divided into control, acutely or chronically immobilized animals of in each group. animals were immobilized for h/day or h/day for a period of weeks or week in chronically or acutely immobilized groups, respectively. blood samples were collected using cardiac puncture method. following serum collection, creatine kinase or alkaline phosphatase level was measured by spectrophotometery method. data were statistically analyzed and compared between groups using anova. results: the results indicated that serum creatine kinase level was significantly increased in rats enduring acute or chronic immobilization compared with control animals (p< . ), however, there was not significant difference between serum alkaline phosphatase levels in immobilized animals compared with control rats. conclusion: immobilization stress may leave pathological effects in liver or other organs leading to enhanced serum creatine kinase level. immunoexpression of lactoferrin in bone metastases and corresponding primary carcinomas v. barresi * , a. ieni, g. giuffrè, g. branca, g. tuccari * university of messina, dept. of human pathology, italy objective: with reference to primary bone tumors, we previously found lactoferrin (lf) immunoreactivity in chondroblastomas, chondromyxoid fibromas, giant cell tumours and osteoid osteomas, while no immunoexpression for this protein was detected in chondrosarcomas and osteosarcomas. herein we aimed to analyze lf distribution in bone metastases from cancers of different sites. method: lf immunohistochemical expression was investigated in formalin-fixed and paraffin-embedded specimens of human bone metastatic lesions as well as in the primitive corresponding carcinomas. the primitive sites of carcinomas were: breast ( ), prostate ( ), kidney ( ), lung ( ), colon-rectum ( ), uterus ( ). a lf intensity-distribution (id) score was calculated for each case by multiplying the values of the area staining positivity and the intensity staining. results: lf immunostaining, with variable id scores, was encountered in / ( %) metastatic bone lesions. immunoreactivity for lf was found in primary carcinomas with a percentage of neoplastic cells ranging between tand %, although this positivity decreased in breast carcinomas ( . %) and was totally absent in lung cancers. the immunohistochemical concordant evidence of lf in bone metastases and corresponding primary carcinomas strongly supports the hypothesis of an autoctone production of this protein by the neoplastic elements themselves in order to get a greater availability of iron for their increased turnover. results: it was observed a negative correlation between il /il and il /foxp concentration in the sf as measured by fc, before the treatment. in the sm, il and mmp were strongly expressed in macrophages, fibroblasts, endothelial cells and the extracellular matrix of control cases, but reduced significantly in the treated cases (p< , ). il and foxp positive cells remained costantly in a reduced number in the ms. conclusion: as the proinflammatory cytokines decreased after the therapy, we can conclude that these are more efficiently influenced than some immune cells participating in the autoimmune process. histological evaluation of the spleen after acute bleeding followed by blood replacement with two different physiologic solutions m. cabral * , a. l. ortiz, c. venâncio, j. objective: chondromyxoid fibroma is a rare benign lesion accounting for less than . % of all primary neoplasms of bone. a study was conducted to assemble a national study group for rare entities and share the experience of different centers. method: the data was collected from the pathology archives of referral hospitals in turkey. results: among the cases enrolled in the study, . % (n= ) of them were male. median age was ± yearsold (range: - ). the most frequent localizations were tibia ( %, n= ), femur (n= , . %) and pelvic bones (n= , . %), followed by feet bones ( . %), fibula ( . %), humerus ( . %), hand bones ( . %), cranium ( . %), costa ( . %), radius ( . %), scapula ( . %), and vertebrae ( . %). although the cases with appendicular skeleton involvement was younger than the others (median age: . ± . vs ± . respectively) no significant correlation was found between age, gender and localization. conclusion: cases displayed a wide age-range with a slight male predominance. the most frequent localizations were tibia, femur and pelvic bones. rare localizations such as temporal frontal bones, vertebrae and scapula were also observed. the study, which may serve as a preliminary work for future studies was presented to share our experience on this rare entity. histological changes and granulocytes redistribution in adjuvant arthritis l. feketeova * , p. jancová, p. objective: surgical treatment options of malignant tumors of the knee includes reconstruction with incorporation megaprosthesis. inguinal lymphadenopathy due to the lymphatic uptake of metal debris has been described, and may be clinically confused with tumor metastasis. method: we report the case of a -year-old woman with inguinal lymphadenopathy caused by metallic debris from a knee mega prosthesis for malignant fibrous histiocytoma. results: the histopathological changes seen in lymph node were metal debris containing sinusoidal macrophages in a background with numerous epithelioid granulomata in the remaining lymph node. conclusion: the identification of regional lympadenopathy in patients with past history of malignancy usually indicates metastatic disease. post-prosthesis lymph node histiocytosis resembling metastatic disease is described, and that is why we need resect and examine lymph nodes with the use of polarized light microscopy to identify birefringent particles of prosthetic debris for an accurate histologic diagnosis. objective: chordoma is a slow-growing malignant bone tumor that exhibits notochordal differentiation. nearly % of cases occur in the sacrococcygeal region and in the base of the skull. the remaining cases develop in the mobile spine, predominantly in the cervical and lumbar vertebrae. we report a rare case of paravertebral mediastinal chordoma without bone destruction. method: case report. results: a -year-old japanese woman was admitted to hospital after a tumor was incidentally detected on a plain chest x-ray image. the tumor was located in the paravertebral region of the mediastinum and did not show any destruction of the thoracic vertebra radiologically. the tumor was clinically diagnosed as a benign neurogenic tumor and the tumor was easily removed surgically. microscopically, the tumor mainly consisted of tumor cells with extensively vacuolated cytoplasm, arranged in cord-and nest-like fashion in a myxoid matrix background. immunohistochemically, the tumor cells showed diffuse positivity for pancytokeratin (ae /ae ), vimentin. the tumor cell nuclei were positive for brachyury, which is a key transcription factor of notochordal development. conclusion: these results confirmed the tumor to be an extraosseous chordoma in the paravertebral mediastinal region, which is rather an extremely rare location for usual chordoma. ps- - testicular papillary mesothelioma: a case with borderline features s. mavropoulou * , z. tatsiou, p. nasos * general hospital, laboratory of pathology, xanthi, greece objective: well-differentiated papillary mesothelioma occurs rarely in the paratesticular region, with only a few published case reports. method: we describe a case of a -year-old man who initially presented with discomfort in the left testis and underwent resection of a hydrocele in the left testis. a hydrocelectomy was performed, during which a pedunculated mass, , cm in greatest dimension, was found attached to the testis. results: microscopically, the mass was composed of multiple branching papillary structures with fibrovascular cores covered by a single layer of low cuboidal to cuboidal cells with predominantly bland nuclear and cytologic features and rare microscopical necrosis. immunohistochemical staining for calretinin and cytokeratines / was positive and proliferative marker ki was < %. accordingly the diagnosis of a well-differentiated papillary mesothelioma was made. the patient has not received additional therapy and is disease free months after diagnosis. conclusion: in conclusion, we report a rare case of a welldifferentiated papillary mesothelioma of the tunica vaginalis of the testis. the combination of benign and semimalignant characteristics can make the diagnosis of such a lesion problematic and pathologic distinction from malignant mesothelioma is crucial, although it may be difficult because of the variability of associated histologic features. objective: lipoma of the bone is a rare benign adipocytic tumor that arises intraosseous and rarely on the cortex or on the surface of the bone (parosteal lipoma). parosteal lipoma affects the long bones diaphysis of adults over years old. method: we present the case of a years old female with clinical diagnosis of femoral exostosis. conventional radiographs shows the presence of a cm length area of lucency on the femoral metaphyseal surface with a periostal reaction at the base of the lesion. results: gross examination reveals a cm osseous tumor, whitish on the surface and yellow on the section. on microscopic examination there are mature adipocytes with small foci of bone scattered throughout the adipocytes and hyaline cartilage at the perifery of the lesion. the gross and microscopic examinations correlated with conventional radiographs led us to diagnosis of parosteal lipoma. conclusion: this case is interesting being a rare bone tumor, the young age of the patient and the location on the surface of the bone. application of scanning acoustic microscope to evaluate lymph node lesions k. miura * * hamamatsu university, school of medicine, japan objective: a scanning acoustic microscope (sam) is a device that uses ultrasound (frequency, > khz) to image an object or tissue. because it is known that the harder the tissue, the more the speed of ultrasound, sam can provide data on the elasticity of cells and tissues. method: we compared lymph node lesions between acoustic and light microscopic images to evaluate the usefulness of sam. results: sam system discriminated lymph node components and demonstrated distinct acoustic images of the lymph nodes such as cancer metastasis, lymphomas, granulomatous diseases, and deposition diseases such as amyloidosis. areas with desmoplastic reactions associated with cancer invasion or post-inflammatory fibrosis showed the greater speed of sound than normal lymph nodes. these results corresponded well to those obtained using the conventional microscope. conclusion: sam provides the following benefits: ( ) images are acquired in only few minutes without requirement for staining, ( ) imaging pattern is similar to that of light microscope, and ( ) speed of sound from each lesion is digital and statistical analysis is possible among diseases. although resolution of sam is little lower than that of light microscope, the sam can be an ancillary tool for histological diagnosis and clinical research. objective: parkinson's disease (pd) is considered one of the major neurological disorders of the population, and there is increasing data provides enough evidences confirming the involvement of free radicals and other reactive oxygen species (ros) in a number of physiological and pathological processes. the aim of the present study was to evaluate, the effect of therapy in patients with parkinson disease on biomarkers of oxidative stress, such as products of lipid peroxidation by two different methods: electron paramagnetic resonance and visible spectrophotometry. method: the study was performed in blood samples of patients with pd -with therapy, patients with pd -without therapy and healthy volunteers as controls. the products of lipid peroxidation were measured as malondialdehid (mda), spectrophotometrically by thiobarbituric acid (tba) method. the levels of lipid radicals were determinated ex vivo at room temperature on an x-band emx-micro spectrometer, bruker, germany. results: by the present study we reported higher levels of oxidative stress in pd patients without therapy compared to those with therapy. these results were comfirmed by the epr method. conclusion: the increase of oxidative stress, in pd patients' might be an additional reason for many secondary complications. objective: primary aneurysmal bone cyst (abc) is a histologically complex and mainly cystic lesion that accounts for % of all primary bone tumors. information regarding its clinical presentation and management in hands and feet remains sparse. method: the medical records abc in hands or feet in hospital la paz pathology department from to were retrospectively reviewed and compared with existing data. we also propose pathological criteria for differential diagnosis between abc and giant cell reparative granuloma (gcrg). results: ten abc in hands or feet were identified, out of ( . %), five tumors were in metacarpals, in metatarsals and in phalanx. radiographs showed expansile lytic lesions in metadiaphyseal region, sometimes with aggressive appearance. histologically, abc showed a mixture of blood-filled spaces with connective tissue septae containing osteoclast giant cells and foci of osteoid. scattered areas of so called "blue bone" were present in cases ( %). there were two solid variants. five patients underwent resection and curettage, three of which relapsed ( %). conclusion: abc should be considered in the radiologic differential diagnosis of hands and feet tumours because these lesions can even mimic malignancies. although clinicopathologically some authors consider gcrg is related to the abc solid variant, we believe they are different entities. carb- is the superior anti-cd monoclonal antibody in optimized protocol settings r. røge * , s. nielsen, m. vyberg * inst. of pathology, aalborg, denmark objective: immunohistochemical detection of cd is important in diagnosis of hodgkin lymphoma and may be relevant in classification of renal tumours. in four tests with - participating laboratories conducted by the nor-diqc external quality assessment scheme only - % of cd stains were sufficient, mainly because of too diluted primary antibody concentration, insufficient hier and less successful antibody clone. the purpose of this study was to evaluate three anti-cd antibodies based on vendor and inhouse optimized protocols. method: multitissue blocks with various malignant lymphomas, renal tumours and normal tissues (n= ) were stained with three concentrated (conc) antibodies (carb- , mma and by ) according to predetermined in-house optimized protocols on two staining platforms. ready-to-use (rtu) solutions of carb- and mma were also examined. extension and intensity of stains was scored using the h-score method. results: carb- conc with an in-house optimized protocol gave the highest h-scores in classical hodgkin lymphoma, renal tumours and normal kidneys. carb- rtu and mmaconc gave slightly lower scores, while mmartu and by conc gave the lowest scores and a large proportion of false negative reactions. all in-house optimized protocols gave better staining results than vendor protocols. conclusion: the importance of antibody selection and protocol optimization in immunohistochemical laboratories is emphasized. objective: studies show that there is association between stress and pathophysiological changes in reproductive system. the main aim of this study was to determine the pathological effects of immobilization stress on testes tissue and serum testosterone level in male rats. method: wistar rats were randomly divided into control, acutely or chronically immobilized groups of in each. animals were immobilized for h/day or h/day for a period of weeks or week in chronically or acutely immobilized groups, respectively. after weeks, blood samples were collected using cardiac puncture method. following serum collection, testosterone level was measured by radioimmunoassay method. the effect of immobilization stress on testes histology was also examined. data were statistically analyzed and compared between groups using anova. results: serum level of testosterone was decreased in acutely or chronically immobilized rats compared with control animals (p< . ). in histological study, semeniferous tubules were significantly deformed and cellular concentration was reduced in immobilized rats compared with control animals (p< . ). the number of spermatocytes, spermatids or sperms was also decreased in immobilized rats (p< . ) and this pathologic change was more prominent in acutely than chronically immobilized rats. conclusion: this report underlines the importance of studying the archive material in order to thoroughly comprehend a single museum object. this handling of matters will help to turn anatomical collections into a unique teaching tool for modern medical practice and a noteworthy documentation of scientific, artistic and historical value. objective: extramedullary plasmocytoma is an uncommon plasma cell tumor localized preferentially in the upper aerodigestive tract, with no evidence of underlying multiple myeloma. it accounts for less than % of head and neck tumours. method: we report a case of a -year-old male patient with reccurent left-sided epistaxis and nasal obstruction. ct-scan showed a left maxillary mass eroding the lateral wall of the nasal cavity. the tumor was surgically removed. results: histologic examination showed a diffuse infiltrate of neoplastic cells in the submucosa, arranged in a scant vascularized stroma. the neoplastic cells were large to medium-sized with amphophilic cytoplasm, irregular nuclei and proeminent, eosinophilic nucleoli. mitotic figures were frequent. imunohistochemical stains were performed in order to make a differential diagnosis: the tumor cells were positive for cd and cd and they expressed cytoplasmic immunoglobulin with kappa light chain restriction. most of the tumor cells were also cd and ema positive. conclusion: even though extramedullary plasmacytoma of the sinonasal tract is rare, it should be included in the differential diagnosis. the cooperation among the otorhinolaryngolists, pathologists and hematologists are required to manage the patients effectively in order to provide optimal treatment. objective: sinonasal malign melanoma is a rare antity, mostly arising from nasal cavity and accounting for < % of all sinonasal tract neoplasms. method: we report two patients complaining of nasal obstruction and epistaxis. endoscopy revealed partially haemorrhagic mass obliterating nasal passage. in one patient diagnosis was done as a plasmacytoma by pathologist in an another hospital. multiple biopsies were taken. microscopically, the tumour was consisted of medium sized cells, which had high nuclear to cytoplasmic ratio with pleomorphic nuclei containing eosinophilic nucleoli and intranuclear cytoplasmic inclusions. the cytoplasms contained variable amount of melanin pigment. mitosesincluding atypical forms-were easily detectable. there were mild inflammatory infiltrate against the tumour and rare tumour necrosis. one was showed pseudopapillary growth pattern and lymphovascular invasion. results: immunhistochemically, tumour cells showed immunreactivity for s- , vimentin, hmb- and melan-a(mart- ). tumour cells were negative for cd- , cd- , cd- , cd- , sma, pan-ck and desmin. submandibulary lymph node metastasis was observed in one patient. this patient has undergone chemotherapy of temozolomide and cures of regional radiotherapy. for the other patient, there were no metastasis detected by pet-ct. conclusion: sinonasal malign melanoma is a rare malignacy, but this entity could be kept in mind to avoid missdiagnosis with other tumors sharing similar morphology. objective: significant changes in the voice occur after years. vocal quality is dependent on the vocal fold (vf) tissue biomechanics that derive from the extracellular matrix composition and organization. we studied muscularlamina propria interface of human vf in the aging. method: two authors evaluated density of vessels and the thickness of the deep and muscle layer by he and ihc (collageniv) with semiquantitative score. these data were validated by point-counting morphometric method. results: with the aging of the vocal folds we identified increased of vessels density in the muscle and deep layers, increasing the matrix density and thickness of the deep layer, and "dissection" of muscle fibers by dense connective tissue. the progressive structural changes in musclelamina propria interface play a crucial role in the remodeling and vocal quality. the increased density of vessels and matrix in aging may contribute to the preservation of vocal function by the physiological repairing. ps- - "lymphoepithelioma-like" thymic carcinoma in parotid gland m. bugdayci * , g. atay, b. sozeri, g. guler tezel * hacettepe university, pathology, ankara, turkey objective: we report a -year-old woman presented with a slow growing painless mass beneath the right ear. a fineneedle aspiration revealed whartin tumour. the patient underwent parotidectomy and histopathological examination showed thymic carcinoma with areas of thymoma. method: histopathological examination was done according to conventional protocols. immunohistochemical stainings were performed using lsab methods. panck, cd , cd , ck / , ck , vimentin, ki- , cd , bcl- , cd a, s , sma, tdt antibodies were used. results: histopathologically, a well circumscribed, nodular, hybride neoplasm finely seperated from parotid gland had two components, uniform spindle cells in basaloid form lobulated by fibrous septae and large epitheloid cells with vesicular nuclei and meganucleoli, suggesting thymoma and thymic carcinoma, respectively. prominent lymphocytic reaction with germinal centers, high mitotic activity, small necrotic foci and microabcesses were also seen. immunohistochemisty revealed panck, vimentin, cd and cd a positivity. the diagnosis of "lymphoepithelioma-like" thymic carcinoma was made. conclusion: thymic carcinoma is a rare tumor most commonly located in the anterior mediastinum. thymic carcinoma which originates from ectopic rests of thymic tissue caused by defective migration of the embryonic thymus, is extremely rare. in the presented case a thymic carcinoma was found in parotid gland which is an unusual site. objective: recent in vitro and in vivo studies have shown that several malignant tumors express an alternatively spliced variant of the receptor of growth hormone -releasing hormone (sv ), which operates by a ligand-dependent and independent manner. method: nine ( ) adenocarcinomas, pleomorphic adenomas and warthin tumors were studied by immunohistochemistry for sv expression and visualized by diaminobenzidine staining. results: sv expression was cytoplasmic and was detected in / malignant ( %) and / ( %) warthin tumors. however, only / ( %) pleomorphic adenomas expressed sv (p< . , x -test). immunoreactivity ranged from mild to intense in all positive specimens, with the exception of warthin tumors at which only intense immunoreactivity was recorded. conclusion: our study, for the first time reports the presence of anti-sv immunoreactivity in tumors of the salivary glands. furthermore, the high association of sv expression with the malignant as opposed to the benign neoplasms implies a role of sv in the progression of the disease. a surprising finding of our study was the high positivity for sv exhibited by the warthin tumors that implies biological similarities between these histopathological entities of the salivary glands. these results imply that the use of antagonistic analogs of ghrh merit further investigation. objective: sialadenoma papilliferum (sp) is a rare, benign neoplasm of salivary gland origin which manifests as an exophytic papillary excrescence of the mucosa. indeed, sp is both an exophytic proliferation of papillary stratified squamous epithelium above the mucosal surface and an endophytic salivary ductal proliferation beneath the mucosa. it arises predominantly in minor salivary glands and usually affects patients in the age range of - years, with reports in young patients being exceedingly rare. method: we report a case of a previously healthy yearold man diagnosed with a nodular mass in the upper lip buccal mucosa. the tumour was excised and submitted for microscopic examination. results: histologic examination revealed a biphasic proliferation of papillary stratified squamous and salivary ductal epithelia, both underneath the mucosal surface. conclusion: in this unique case, as the classical sp, the tumour has a biphasic proliferation of squamous and ductal epithelia. however, unlike the classical sp, both epithelia grow under the mucosal surface. as a result, it didn't manifest as an exophytic proliferation, but as a nodule. we excluded squamous papilloma, inverted ductal papilloma, intraductal papilloma and mucoepidermoid carcinoma, the principal entities in the differential diagnosis of sp, and concluded it to be a sp with inverted pattern. interest of histopronostic classification in three grades in the therapeutic management of primary epithelial parotid carcinoma v. results: microscopic examination showed a biphasic tumor with a prominent myxoid stroma and tumor cells with clear cytoplasm involving pleural tissue. immunohistochemistry showed tumor cells positive for keratin, s protein, smooth-muscle actin, p protein, vimentin. histological and immunohistochemical features confirmed the diagnosis of epithelial-myoepithelial carcinoma. the patient underwent a right parotidectomy years earlier for removal of . cm mass diagnosed as emc. conclusion: epithelial-myoepithelial carcinoma of salivary gland is a rare low-grade malignant neoplasm with a potential for local recurrence and metastases. rare metastases for lungs, kidney and brain were reported. we described an additional case of pleural metastasis. objective: salivary defense system recognized as an important protective factor of the child oral environment. research data reveal that bacterial infection, dental caries and periodontal diseases have a higher incidence in cases of salivary glands dysfunction. the aim of present study was to find out the morphological peculiarities of the fetal parotid gland in cases of restrictions of its intrauterine growth (iugr) at late gestation. method: parotid gland of twenty human fetuses with iugr from the late spontaneous abortions material were compared with fifteen fetal glands in cases of induced abortions due to psychological reasons (control group). tissue samples were stained with hematoxylin and eosin. stereological examination was done to find out volume fractions of parotid gland structural components. results: results have shown the reduction of the area of acini, large collected ducts, striated and intercalated ducts in iugr group. the volume fractions of vessels were also lower than on controls. the foci of immature secretory lobes in cases of growth restriction occupied wider zones within loose, poorly cellular, fibrous stroma. conclusion: our study demonstrates the delay of the parotid gland structural maturation in pregnancies complicated with iugr. impaired growth and secretory gland's dysfunctions may cause pathological changes in oral ecosystem of a child. objective: dermal fillers are injectable products commonly used in aesthetic medicine. this type of treatment, which often replaces traditional surgical procedures provides satisfactory cosmetic results. it is known, however, that there is a risk of undesired effects at the site of injection of the product or even at a distance. literature reports numerous cases of orofacial injuries caused by dermal fillers. the aim of this study is to evaluate two of the most widely used facial dermal fillers for aesthetic purposes in an effort to identify adverse reactions they may produce. method: two of the most commonly used materials for aesthetic purposes by dermatologists and plastic surgeons, polymethylmetacrylate and hialuronic acid were injected in rat tongues: % polymethylmethacrylate (n = ) and mg/ml hyaluronic acid (n = ), compared to an inert solution for control (n= ). after , and days, local clinical and histological alterations were analyzed. results: the following factors were verified: intensity of the inflammatory response (h&e), amount of newly formed blood vessels (ihc) and macrophages and collagen fibers density (picrosirius). results showed that both filling materials triggered local inflammatory response to a greater or lesser degree. objective: the aim of this study was to compare clodronate and zoledronic acid regarding their influence on the repair of surgical wounds in maxillae (soft tissue wound and tooth extraction) and their relation to osteonecrosis. method: thirty-four wistar rats were allocated into three groups according to the treat-ment received: (i) animals treated with zoledronic acid, (ii) animals treated with clodronate and (iii) animals that were given saline solution. all animals were subjected to tooth extractions and surgically induced soft tissue injury. histological analysis of the wound sites was per-formed by means of hematoxylineosin (h&e) staining and immunohistochemical staining for receptor activator of nuclear factor-kb ligand (rankl), osteoprotegerin (opg), von willebrand factor, and caspase- . results: the zoledronic acid group showed higher incidence of non-vital bone than did the clodronate group at the tooth extraction site. at the soft tissue wound site, there were no significant differences in non-vital bone between the test groups. rankl, opg, von willebrand factor, and caspase- did not show significant differences between the groups for both sites of surgical procedures. conclusion: both of the bisphosphonates zoledronic acid and clodronate are capable of inducing maxillary osteonecrosis. immunohistochemical analysis suggests that the involvement of soft tissues as the initiator of osteonecrosis development is less probable than has been pointed out. objective: the aim of this study was to evaluate the expression of cd a, cd , cd , cd , caspase- , tryptase and basement membrane thickness in oral lesions of lichen planus (lp) and lupus erythematosus (le). method: oral lesions of lp (n= ) and le (n= ) were biopsied. after confirmation of diagnosis, the specimens were submitted to pas and immunohistochemistry. results: cd a expression was significantly greater in epithelium and connective tissue in lp. epithelial cd and cd did not differ between the diseases, but were greater in connective tissue in lp. cd expression was greater in both epithelium and connective tissue in lp. caspase- did not differ between the groups, whereas tryptase was greater in le epithelium. basement membrane thickness did not differ between lp and le. conclusion: cd a, cd , cd , cd , caspase- and tryptase expression and the basement membrane thickness are not definitive criteria for differential diagnosis of oral lichen planus and lupus erythematosus. objective: odynophagia may be caused by inflammatory/ infectious conditions and tumors arising within the oropharynx. we present an unusual case of a follicular dendritic cell sarcoma (fdcs) of the tonsil manifesting with odynophagia. method: an year-old man presented with odynophagia refractory to medical therapy; a . cm left tonsillar mass was noted on inspection. bilateral tonsillectomy was performed. a panel of antibodies was applied on paraffin tissue section. results: grossly, the left tonsil featured a . cm well circumscribed grey lesion. histologic examination showed a proliferation of spindle to ovoid cells arranged in fascicles with swirling qualities admixed with scattered lymphocytes. frequent mitoses and apoptotic bodies were seen but no "tumoral" necrosis was recognized. tumor nests were separated by thin stromal septi containing a prominent glioblastoma-like microvascular proliferation with focal formation of glomeruloid tufts. the tumor cells were immunoreactive for cd , cd and vimentin. objective: salivary gland tumors reveal a broad morphology and immunohistochemistry may be helpful. method: we examined mucoepidermoid (mec), adenoid cystic (adc), asinic cell (acc) and salivary duct carcinomas (sdc); myoepitheliomas (me), basal cell (bca), pleomorphic adenomas (pa) and warthin tumors (wt) for sma, calponin, s , cd , gfap, p , cea, gcdfp , glut , be , ck , ck , cd and galectin , using tissue microarray. results: tumors expressing myoepithelial markers were adc (sma, calponin), bca (sma, calponin, p ), pa (sma, calponin, s , cd , gfap, p ), me (s , cd , gfap), mec (p ) and wt (p ); pa being the only tumor expressing all of the markers in the panel. gfap, s , ck , p , ck / and galec-tin expressions were higher in benign and ck was higher in malignant tumors (p < . ). some of our findings helping in differential diagnosis are as follows: in differentiation of pa from adc: gfap, cd , gcdfp positivity; higher expression of s ; lower expression of ck and cd favors pa. in differentiation of pa from bca: gfap and cd positivity favors pa. in differentiation of mec from sdc: cd , ck , p and ck / positivity favors mec. conclusion: we conclude that salivary gland tumors may be well characterized by using distinct markers in each differential diagnosis. objective: lobulary capillary hemangioma (lch) is a benign, rapidly growing vascular lesion of the skin and mucous membrans. it may rarely present as a mass of considerable size and thus entirely fill the nasal cavity. it occasionally appears in the nasal region as a pedunculated or broad base mass. trauma and hormonal influences are the most common presumed etiologic factors. lch usually involves the gingiva, lips, tongue, and buccal mucosa. the most common symptoms are epistaxis and nasal obstruction. method: in this report; a case of years old boy operated surgically of lcd of the nasal septum, which occurred post delivery was described. results: on examination, a red pedunculated bloody swelling , * cm was noted arising from the posterior part of the nasal septum to nasopharinx. histopathologically lch has characteristics consistent with lobular prolifeation of capillaries in a fibromyxoid stroma. conclusion: we emphasise that rarely seen lch must be kept in mind in the differantial diagnosis of a rapidly growing mass, who is cured surgically. follow up months later showed no recurrance. although the head and neck is not an uncommon region, the nasal cavity is extremely rare sites for lch in children. objective: claudins are integral transmembrane proteins of tight junctions, critical for maintenance of cell adhesion and polarity. altered claudin expression has been detected in carcinomas and correlates with tumour progression. actinic cheilits is a pathologic condition that affects the lower lip, caused by chronic exposure to solar radiation; it corresponds to the early phase of squamous cell carcinoma. we investigated claudin patterns in phases of actinic cheilitis, as alterations in adhesion molecules are considered important during the progression of this process. method: immunohistochemistry against claudins − , − , − , − and − was performed in cases of actinic cheilitis/squamous cell carcinoma; results were analysed qualitatively. results: actinic cheilitis (low grade intraepithelial squamous cell carcinoma), and the invasive front of superficially invasive squamous cell carcinoma and in situ squamous cell carcinoma were negative for claudins − , − and − . claudin − was present on all epithelial layers in most cases evaluated. claudin − was present in all epithelial layers in actinic cheilitis, but negative in cases of superficially invasive and deeply invasive squamous cell carcinoma. conclusion: altered expression of claudins is present in ac from its incipient phase throughout the progression of the disease to invasive squamous cell carcinoma. objective: metastases to the jaw bones are uncommon and are most likely to arise from primary lung, breast, prostate or kidney tumours. jaw bone metastases from a primary oesophageal carcinoma are especially rare, with only seven reports published in the literature. method: here, we describe the case of a year-old male patient where years elapsed between the diagnosis and successful treatment of a poorly differentiated, stage pt n primary oesophageal adenocarcinoma and re-presentation with jaw pain due to a metastatic mandibular deposit. results: the morphological appearance of the metastasis and immunohistochemical positivity with ck , ck and cdx strongly supported an adenocarcinoma of upper gastrointestinal tract origin. conclusion: this case is of particular interest as there is an unusually long time between the detection of the primary oesophageal adenocarcinoma and diagnosis of metastatic disease. the longest period of time we have found for this reported in the literature is months, although it is known that some oral metastases may appear more than years following the primary tumour diagnosis. melanotic oncocytic metaplasia of the nasopharynx -a report of three cases and review of the literature j. s. lee * , j. y. na * chonnam national university, hwasun hospital, pathology, jeollanam-do, republic of korea objective: melanotic oncocytic metaplasia of the nasopharynx is a rare condition which is characterized by the presence of usually a small, brown to black colored pigmented lesion around the eustachian tube opening. although it is a benign lesion, it may be clinically misdiagnosed as malignant melanoma. microscopically, melanotic oncocytic metaplasia is a combination of oncocytic metaplasia of the epithelium of the gland and melanin pigmentation in its cytoplasm. method: in our present study, we report three cases of melanotic oncocytic metaplasia of the nasopharynx. results: all the three cases occurred in men and were presented as multiple black pigmented lesions around the torus tubarius. microscopically, mucous glands with diffuse oncocytic metaplasia and numerous black pigments were observed. no cellular atypia was observed. immunohistochemically, the scattering of s- proteinpositive, and hmb- -negative dendritic melanocytes was evident. conclusion: this is the first report of cases of oncocytic metaplasia of the nasopharynx in korea. objective: angiokeratoma is a rare cutaneous lesion. mucosal involvement is occasionally found as part of a more generalized cutaneous disease. isolated angiokeratoma in the oral mucosa is extremely rare with only a few cases reported thus far. method: we report the case of a -year-old female presented with a painless lesion on the left bucal mucosa, of months duration. on clinical examination, a solitary purple lesion of approximately mm in diameter was found. results: the lesion was excised and the histological examination revealed a tumour involving lamina propria, composed of large dilated vascular spaces, lined by normal appearing endothelium and filled with blood or with fibrin thrombi. the overlying epithelium showed variable degree of acanthosis and hyperkeratosis. accordingly the diagnosis of angiokeratoma was made. on clinico-laboratory examination no angiokeratomas were found anywhere on the skin as well as no other malformation or metabolic disorder. the patient received no further treatment and years later remains disease free. conclusion: in conclusion we report a case of a solitary angiokeratoma of the oral mucosa. although rare, it should be included in the differential diagnosis when evaluating any lesion in this location and further investigations should be performed to rule out a metabolic or systemic disease. results: histopathologically in macroscopy, the cystic lesion was determined as a small part of tissue in white -grey color, in sizes of , × , × , cm. in microscopic evaluation, the epithelial tumor cells were formed mostly tubular, partially in solid form and broadly making pseudopapillary pattern in stromal tissue. in the luminal structures formed by tumor cells, there has been mucin as dark basophilic stained with pas/alcian blue (ph: , ). the tumor cells are strong and have common positivity with ck , and have negativities with ck (b-sa method). in the focal area that the tumor cells got the solid pattern, synaptophysin and chromogranin to evaluate the neuroendocrine differentiation wasn't determined. conclusion: the lesion in the medial part of the tympanic membrane of the patient was reported as colesteatom and the lesion in the middle ear was reported as middle ear adenoma. histopathologic evaluation for helicobacter pylori as a possible etiopathogenic factor in chronic tonsillitis e. Özgün * , d. altinel, a. albayrak, a. tan, s. sayhan, n. bozlak * nevehir devlet hastanesi, dept. of pathology, turkey objective: helicobacter pylori is the major gastric pathogen which has an important role in the etiopathogenesis of chronic gastritis. we investigated the presence of helicobacter pylori as an extragastric reservoir in the tonsillectomy specimens to display if it is an etiologic factor in the development of chronic tonsillitis. method: in the current study, cases with chronic tonsilitis were examined in bilateral tonsillectomy specimens. objective: salivary duct carcinoma (sdc) is a rare, aggressive malignancy with poor prognosis. its histomorphology is distinctly reminiscent of the ductal carcinoma of the breast. method: a -year-old man was admitted with a mass of the right preauricular area. the mass had been enlarging steadily for the past months. computed tomography (ct) of the neck revealed × × cm contrast enhancing solid mass with irregular borders at the right parotid region. thorax ct, abdominal and thyroid ultrasonography were unremarkable. as the aspiration cytology was malignant right parotidectomy and right cervical lymphadenectomy was performed. results: histopathological examination showed a mixture of ducts, nests and cords of cells often embedded in a desmoplastic stroma with comedonecrosis of some ductal structures. the tumor cells were polygonal with vesicular nuclei, prominent nucleoli and eosinophilic, oncocytic cytoplasm. the tumor margins were lobulated and irregular with perineural invasion. mucin stains were negative. we noted high proliferative index and cerbb overexpression. the tumor was classified as a salivary duct carcinoma, oncocytic variant of parotid gland. the resection margins were negative and the lymph nodes were reactive. conclusion: as high proliferative index and cerbb overexpression are predictive factors, close clinical follow up is recommended for the risk of local recurrences and metastasis. immunohistochemical expression of bcl- and ki- in oral lichen planus and leukoplakia with different degrees of dysplasia f. pigatti * , l. a. de assis taveira, c. t. soares * university of são paulo, oral pathology, brazil objective: the oral lichen planus (olp) is a chronic inflammatory disease of unknown cause, and its malignant potential is a very controversial issue. therefore, the aim was to evaluate the immunohistochemical expression of apoptosis-related proteins and cell proliferation in olp and epithelial dysplasia in order to investigate changes related to carcinogenesis and emphasize the importance of long-term follow-up of patients with olp. method: for this purpose, we selected samples of olp, samples of leukoplakia with epithelial dysplasia, and samples of normal oral mucosa as controls. the evaluation of the expression of bcl- and ki- was conducted in accordance with the immunoperoxidase technique. results: there was also a high expression of blc- protein in inflammatory cells in olp lesions and leukoplakia with epithelial dysplasia. the expression of ki- marker was higher in all analyzed tissue levels in the lesions of olp and leukoplakia with epithelial dysplasia when compared with the control group. objective: pleomorphic adenoma (pa) is the most common benign salivary gland neoplasm of the major and minor salivary glands. pleomorphic adenoma was shown sometimes to undergo malignant transformation in its natural course. carcinoma ex pleomorphic adenoma (cpa) is a rare salivary gland malignancy that may develop from either a long-standing primary or a recurrent pa. the genetic mechanisms involved in the progression of adenoma to a carcinoma is still unclear. to identify the predictors of disease, more knowledge about their genetic profiles is necessary. this study aimed to characterize alteration in the dna copy number of pa and cpa. objective: leukoplakia is an oral premalignant white lesion. although its etiology may vary, smoking has been implicated as a possible risk factor. the p protein has been shown to inhibit kinases, and it is known that its expression is decreased during carcinogenesis. the reduced expression of p has been correlated with poor prognosis in carcinoma. in this study a role for the smoking habit in the expression of this protein was investigated. method: forty cases clinically diagnosed as oral leukoplakias and that presented a mild to intense degree of epithelial dysplasia and could not be diagnosed as any other disease were selected. twenty cases were from current smokers (more than cigarettes/day for at least year) and neversmokers. thirty-six cases of leukoplakia without dysplasia were used as controls. histological sections of each lesion were subjected to the estreptoavidin biotin immunohistochemical method for detection of p . results: a semi quantitative analysis was performed and the results showed that the expression of p was independent of the smoking status of the patient (p= , ), using kruskal-wallis and mann-whitney tests. although not statistically significant, due to the small number of cases, the results indicate that the counting of p in leukoplakia correlates inversely with degree of epithelial dysplasia. low-level laser therapy may influence on the akt/mtor signaling pathway in oral cancer cells f. sperandio * , f. giudice, l. correa, d. pinto jr., s. de sousa * university of sao paulo, dept. of oral pathology, brazil objective: distinct cells respond differently to low-level laser therapy (lllt), while the exact molecular mechanisms involved in cell proliferation or growth inhibition, after light stimulation remain poorly understood. although lllt has shown promising results in accelerating wound healing and preventing or treating oral mucositis, there is no evidencebased consensus of what this energy could cause in cancer cells. this should be highly pondered when an oral cancer patient is treated with lllt due to oral mucositis, for example. method: two tongue squamous cell carcinoma cell lines (scc and scc ) were utilized to find the effect of low-level laser irradiation on the akt/mtor signaling pathway. laser irradiation ( and nm) consisted on mw of power and energy densities of , and j/cm . after a single irradiation the most significant energy densities found with mts assay were employed to analyze akt/mtor signaling pathway related proteins through immunofluorescence and western blotting. results: beyond modifying the growing rates of cancer cells, low-level laser irradiation was able to induce different variations in the studied pathway, however a direct correlation among the proteins was not found. conclusion: lllt may act on akt/mtor/cyclin d signaling pathway, which has a widely recognized role in head and neck cancer progression. mucins as predictors of recurrent pleomorphic adenoma of salivary glands: an immunohistochemistry analysis of over cases t. teshima * , r. ianez, c. coutinho-camillo, s. lourenço * são paulo, brazil objective: pleomorphic adenoma (pa) is the most common tumor of salivary glands and, despite its benign behavior, the recurrence after primary surgery is significant. in attempt to find a marker capable to predict the recurrence of this lesion, this study aims to analyze the expression of mucins muc , , , ac and in cases of pa, considering that mucins have been related to tumour growth of some organs. method: this study was performed in cases in pa, which of them presented recurrence after the initial surgery. all the primary tumors were histologically processed and submitted to the immunohistochemistry reaction. the antibodies for muc , , , ac and were used and then analyzed with conventional optical microscope. results: muc was the only mucin significantly expressed in most of all cases ( %), being present within ductal lumen and cytoplasm. the other mucins showed a focal positivity in few cases, where muc , ac and were cytoplasmic, while muc was expressed in ductal lumen and blood vessels. objective: drug resistance remains a major problem in the treatment of nsclc cancer patients for both, conventional chemotherapeutic and novel biological agents. intrinsic or acquired resistance is caused by a variety of mechanisms, including increased drug elimination, decreased drug uptake, drug inactivation and alterations of drug targets. recent data showed that drug resistance mechanisms might also be regulated by micrornas (mirnas). method: we tested lung cancer samples. the total rna was isolated from individual specimens and then rt-pcr and pre-amplification were performed. we detected levels of mir- , mir- a, mir- b, mir- , mir- , mir- *, mir- , mir- - p, mir- p, mir- x, mir- - p, mir- p, mir- , mir- and mir- using taq-man® microrna assays by lightcycler® real-time pcr system. we assigned obtained results using statistical methods. results: our results suggest that mir- - p and mir- are involved in apoptosis. the higher levels of mir- - p correlate with bcl- positivity and pro-apoptotic protein bax seems to be regulated by mir- . the level of lrp protein responsible for drug resistance in lung cancer patients seems to be regulated by mir- . conclusion: within our cohort of nsclc patients we did not find any correlations between the expression profiles of the abovementioned mirnas and survival. the modified methacarn fixation as an excellent preservation of histology, protein immunoreactivity and rna integrity in paraffin embedded tissue specimens p. babal * , r. milcheva, p. janega, p. celec * comenius university, dept. of pathology, bratislava, slovakia objective: fixation techniques preserving morphological fidelity, immunoreactivity and integrity of nucleic acids may have a high impact on both basic and applied research and diagnostic pathology. we investigated the effect of formalin, absolute ethanol and methanol; ethanol supplemented with acetic acid and modified methacarn fixative on the tissue morphology and immunoreactivity of different types of tissues and the preservation of rna fragments of different lengths. results: the modified methacarn fixation provided a histomorphological quality comparable to the formalin-fixed tissue specimens. the immunoreactivity was superior in the buffered than in the untreated formalin and the preservation of protein antigenicity in normal and pathologically changed tissues tested with several antibodies was excellent with the use of alcohols with acetic acid. the acidic ethanol and the modified methacarn fixative showed the best preservation of the integrity of rna in satisfactory quantity and quality of fragments up to bp, which was reliable for relative evaluation of gene expression. objective: cflip prevents the apoptosis by caspase inhibition, its overexpression correlates with the progression of different tumors. thymomas and thymic carcinomas are thymic epithelial tumors, in which the regulation of apoptosis is still unknown. we investigated the role of cflip in regulating the viability of thymus carcinoma cell line c using an rna interference. the cell line hacat was used as a control. method: c and hacat cell lines were transfected with an established "short hairpin" pires/puro cflip-shrna expression vector. cflip suppression and its effect on pro and antiapoptotic molecules were analyzed using q-pcr and western blot. apoptosis was quantified using the flow cytometry. results: the c-shcflip, but not the shcflip-hacat, showed sensitivity to trail (tumor necrosis factor-related apoptosis-inducing ligand), accompanied by an overexpression of both the pro-apoptotic protein noxa (p< - ) and the anti-apoptotic proteins birc , birc and xiap compared to the non-transfected cells (p< - ). conclusion: cflip shrna seems to induce apoptosis in the thymus carcinoma cell line. simultaneously antiapoptotic proteins (aips) birc , birc and xiap were up regulated in order to protect the cell from apoptosis. could these aips provide the way to escape the cell death? aips selective inhibitions could represent a promising therapeutic approach for malignant thymic carcinomas. objective: nucleolin is a multifunctional dna-, rna-and protein-binding protein, involved in fundamental aspects of transcription, cell proliferation and growth. it is located in the nuclei/nucleolus, cytoplasm and on the cell surface. the present study aimed at optimizing the histological identification of nucleolin. method: mamary invasive ductal carcinoma μm paraffin sections were pretreatead with pronase at room temperature ( - min) to epitope exposure. biotinilated peptide against nucleolin was applied ( / . mm dilutions), incubated at room temperature for min/overnight at °c; after phosphate-buffered saline, peptide binding was identified by peroxidase-conjugated streptavidin and , -diaminobenzidine tetrahydrochloride applied according to manufacturer's instructions before haematoxylin counterstaining. results: pretreatment for min at . mm of biotinilated peptide showed only nuclear expression, as mm/ min pretreatment with overnight peptide incubation; positive cytoplasmic expression was obtained also after min incubation/room temperature. at . mm concentration for min epitope retrieval, cytoplasmic and nuclear positivity raised over % expression, independently of peptide exposure (overnight/room temperature). conclusion: for optimizing peptides/antibodies, we have to be aware that nuclear/cytoplasmic expressions depend on digestion and peptide concentration. histological morphology is also important and discordant results may be erroneously obtained. ps- - kras testing in clinical laboratory: optimizing targeted therapy l. cheng * , l. miravalle * indiana university, dept. of pathology, indianapolis, usa objective: activating mutations in the kras gene are found in more than % of colorectal tumors, where they are associated with a poor response to anti-epidermal growth factor receptor therapies. mutation testing techniques have therefore become an urgent concern. several methods for kras mutation detection have been described in the literature. most of these are laboratory developed tests and only a few commercial assays are currently available. method: we studied the performance characteristics of a kras mutation detection assay on the abi- xl genetic analyzer using a new commercial mutation detection kit. samples were analyzed in parallel by different reference laboratories using alternative methodologies. various sample types were used including formalin-fixed paraffin-embedded tissue, fine-needle aspirates, and cyst fluid specimens. results: a high level of agreement ( % correlation for formalin-fixed paraffin-embedded tissue and fine-needle aspirate samples and % correlation for cyst fluid specimens) was obtained despite the use of different methodologies. conclusion: shift termination assay is a simple, robust, and sensitive method for the identification of kras mutations in wide variety of specimen types. objective: micrornas (mirs) are small rnas that modulate protein expression via post-transcriptional regulation of mrna. they are related to malignancy in several tumors. deregulation of mirs expression has been described in high grade astrocytomas of adult patients, however there is scarce information in pediatric patients. in this work we quantified the expression profiles of mirs in pediatrics astrocytomas. method: total rna was extracted from astrocytomas and normal brain (nb) tissues, formalin fixed paraffin embedded. the expression levels of mir- , mir- - and mir- were quantified by using mirna-specific taqman mirna assays. results: the mir- - was more abundant in nb against to mir- and - (p< . ). mir- and mir- - were significantly down-regulated in all grades compared to nb (p< . ) but in grade iv was more decreased: -and -fold, respectively. in patients with recurrent tumor, the expression of mir- was lower (p< . ). live patients expressed high levels of mir- (p< . ) and mir- (p < . ) against deceased. conclusion: micrornas are differentially expressed between astrocytomas and nb. the low expression of mir- and - could be a potential marker in recurrent pediatric astrocytomas, and both are associated to less survival. embedded tissue is useful to describe and evaluate expression of molecular markers of malignancy. objective: isolation of genomic dna from formalin fixed paraffin embedded (ffpe) tissues is a critical step for molecular diagnostic assays. horizon diagnostics has generated ffpe cell line reference standards containing defined mutant allelic frequencies, enabling the quality control of both assay sensitivity and dna extraction. method: a panel of x-man™ (gene-x, mutant and normal) cell lines were developed using our patented gene editing technology (genesis™) including; b-raf v e, v k; egfr Δe -a , t m, l r, l q; k-ras g a, g c, g d, g r, g s, g v, g d; pi kα e k, e k, h r. ffpe blocks containing specific allelic frequencies including: %, %, %, % or % were generated and sections cut. dna was extracted using five different extraction methods and analysed using droplet digital™ pcr. results: mutant alleles could be detected using droplet digital™ pcr at each defined allelic frequency and the reproducibility of each test was very high. the allelic frequency was consistent throughout each block. the total dna yield from each section was consistent using the same extraction method but varied between methods. conclusion: this study has demonstrated horizon diagnostic's ffpe reference standards have a highly accurate defined mutation specific allelic frequency together with a consistent dna quantity. transcript variants and isoforms of the phosphatase subunit ppp ca and its regulatory binding partners in haematological malignancies g. grech * , c. saliba, b. shawn, r. avellino, p. j. m. valk, r. delwel * university of malta, dept. of pathology, msida, malta objective: the importance of feedback mechanisms involved in suppression of growth factor-induced signals is gaining importance both to understand molecular mechanisms of disease and also as potential therapeutic targets. our previous studies show that erythroid differentiation can be blocked by constitutive expression of the pp a inhibiting subunit, alpha . the aim of this study was to identify variants and transcript isoforms of ppp ca and the inhibiting subunits alpha and set, using ( ) cell lines derived from haematopoietic disease, and ( ) objective: epithelial cells grow by proliferation and adhesion, which will form an organ/tissue. stat is involved in cell proliferation and various cellular events. in the present study, we studied the role of stat in cell adhesion in hepatocytes. method: stat knockout cells (s ko cells) and liverspecific stat ko (l-s ko) mice were generated. cellular adhesion was analyzed by light/electron microscopy. expression of adhesion molecules was examined by immunohistochemistry and western blot analysis. protein expression and cellular adhesion were also examined in the pre-/post-hepatectomy liver tissue in control and l-s ko mice. results: mrna and protein of e-cadherin were not expressed in s ko cells. il- up-regulated e-cadherin in control cells but not in s ko cells, and induction of constitutively active mutant of stat restored e-cadherin level in s ko cells. interestingly, membrane-bound beta-catenin expression was not affected, but released to cytosol in s ko cells. s -ko cells showed almost normal proliferation but did not form cell cluster due to lack of e-cadherin. electron-micrograph confirmed lack of intercellular adhesion structures (desmosome) in s ko cells. also in l-s ko mice, hepatocytes lack desmosome structure and cell adhesion. objective: alk positive anaplastic large cell lymphoma (alcl) is characterized by anaplastic lymphoma kinase (alk) expression, most commonly associated with the t ( ; )(p ;q ), fusing the alk and nucleophosmin (npm) genes. however, in a significant proportion of cases the alk gene has a number of other than npm translocation partners. the aim of the study was to detect the npm/ alk fusion gene and the other possible fusion genes. method: npm/alk was detected by rt-pcr, npm/ alk negative lymphomas were analyzed by alk specific rapid amplification of ´cdna ends ( ´race). we prepared q-rt-pcr assay for quantification of Á lk mrna. molecular findings were correlated with i-fish. results: we analysed alk positive alcl. chromosomal breakpoints affecting the alk locus were detected by i-fish in all patients. the npm/alk was detected in / patients. ´race identified atic/alk in , cltc/alk in patients. other fusion genes (tpm /alk, tpm /alk, alo /alk) were found in one patient. in all specimens, overexpression of ´alk mrna suitable for the minimal residual disease (mrd) detection was found. objective: a year-old girl, presented with an osteolytic epiphyseal lesion of the distal ulna. based on histopathological examinations, the lesion was classified as giant cell tumor of bone (gct). four years later, the girl developed a second lesion at the same site. the histopathological examination revealed aneurysmal bone cyst (abc) with solid spindle celled and giant celled areas which raised a question of a recurrent gct or a primary abc. the aim of this study was to analyze the clonality of these two processes. determination of maternal and paternal x chromosome activation status is useful in the diagnostic analysis of nonrandom x inactivation patterns. method: the human androgen receptor (humara) gene polymorphism assay was used to identify the clonality of these two processes. results: the patient was identified as heterozygous for the humara allele. the gct and abc samples exhibited a monoclonal pattern, but one of them was with maternal and the other with paternal x chromosome origin. conclusion: the findings of this case report demonstrate the clonal behavior of both lesions with different clonal patterns. the above investigation proved to be helpful in distinguishing between recurrent gct and de novo abc in the field of previous surgical intervention. . in all specimens gen her /neu was quantifed agains reference gen by qrt-pcr method (lyghtcycler® ii, roche). results: the results of cytogenetic analysis have been showed in % that didn´t corespond with the results of qrt-pcr quantification. on the contrary the results of ihc was correlated with the results of qrt-pcr in %. methods sish vs fish has in % different of results. in regard to the quality of ish signals the sish is more preferable for determination her /neu. conclusion: a pilot study conducted on a group of patients showed that among the methods used in the process of determining her /neu amplification are significant differences, even in evaluation and interpretation of test results. regardless of the histological type of tumors (diffuse and intestinal type) as problematic for the evaluation of samples proved to be endoscopic route. the use of molecular methods in diagnosis of malignant melanoma of biopsy s. libor * , p. dundr, s. lísová, c. povýšil * general faculty hospital, inst. of pathology, prague, czech republic objective: distinction between benign and malignant melanocytic lesions commonly represents a big challenge for the pathologist. in this case it appears as a useful auxiliary method of fluorescence in situ hybridization (fish). the aim of this study was by using fluorescently labeled probes detection of numerical changes occurring in malignant melanoma and thus supply or confirm the diagnosis. method: the retrospective study included samples tissue with an established histological diagnosis ( x malignant melanoma, benign melanocytic lesions x). for detection was used probe vysis lsi rreb /lsi myb/lsi ccnd / cep (abbott molecular, usa), olympus ax fluorescent microscope (immersion lens x). in the area of the tumor were calculated signals of individual probes and evaluated according to the manufacturer's instructions. results: evaluable results were obtained in / cases ( %) of the melanomas were and benign melanocytic lesions. in all four cases of malignant melanoma have been burdened with genetic changes, mainly in the ccnd (in %) gene amplification and preb (in %) and myb (in %). in contrast, for all benign melanocytic been demonstrated normal findings. conclusion: dna abnormalities detected by fish occurr in the vast majority of malignant melanomas but are not seen in benign nevi. this fact make the fish test an important extra step in the differential diagnosis melanocytic lesions with ambiguous or borderline histological findings. objective: egfr is a receptor on the cell membrane with tyrosine-kinase activity and which is a regulator of proliferation, apoptosis, angiogenesis, tumor invasion. he is found to be overexpressed in some lung cancer histological subtypes. men is a tumor suppressor gene, with a role in cellular growth and differentiation, dna reparation, and apoptosis. method: surgically resected specimen from patients (men n= ; women n= , age ± ) with lung cancer were studied: carcinoid tumors (ct)- , small cell lung carcinomas (sclc)- , large cell neuroendocrine carcinomas (lcnec)- , adenocarcinomas (ac)- , and squamous cell carcinomas (scc)- . the histological subtype, ptnm stage, and gene expression of men and egfr in tumor and normal lung tissue were evaluated. results: overexpression of egfr was observed in %(scc- %, ac- %, sclc- %, lcnec- %, ct- %). decreased expression was observed in %(lcnec- %, sclc- %, ct- %, ac- %, scc- %) (p< . ). overexpresssion of men was observed in % of all tumors (sclc- %, ct- %, scc- %, lcnec- %, ac- %) (p> . ). significant correlation between overexpression of men and early stage scc was observed (p= . ). conclusion: egfr is a target for therapy with monoclonal antibodies, so the tumors that overexpress egfr can be considered for treatment with these drugs. men can eventually be a marker for good prognosis and a potential target for therapy. objective: homeobox genes encode transcription factors controlling cellular proliferation and differentiation. altered expression of prox homeobox gene is related to many cancers, including breast, esophagus, lymphatic and oral. method: after overexpression of prox gene in scc cell line, total rna was extracted from three overexpressing-prox clones (oc) and one control-transfection cell clone (cc). microarray analyses were performed using the whole human genome k according to the manufacturer's instructions. genes with a fold change of greater or lower than . in oc versus cc, were considered as increased or decreased, respectivelly. gene ontology (go) was used to assign biological process related to significantly differentially expressed genes. results: down-regulated genes mmp , timp and notch were further validated by qrt-pcr. comparative gene analysis of oc and cc revealed up-regulated and down-regulates genes. pathways induced upon prox overexpression in go terms included vascular development control, cellular adhesion, regulation of proliferation, among others. mmp , timp and notch expression by qrt-pcr showed reduced expression leves in oc. these genes are commonly overexpressed in oral squamous cell carcinoma and have been related with metastatic tumors and worse prognosis. objective: barrett´s esophagus is the unique known precursor for esophageal adenocarcinoma (eac), in a gradual progression to dysplasia. our objective is to determine the correlation between the hypermethylation in cpg islands of the promoter region of p tumoral suppressor gen in epithelial dna and the histopathological pattern, as possible biomarker for risk of progression. method: . a study was performed about the evolution of precursor lesions, in a group of patients diagnosed following the vienna classification. . p hypermethylation is analyzed in paraffin embedding samples, through laser microdissection, dna extraction, pcr amplification, pyrosequencing and quantification. results: . of cases with to biopsies remained as nd, id or lgd, and cases progressed to hgd and/or eac. . within the control group the methylation grade is . % and in the diagnostic groups is . % (nd), % (id), . % (lgd), . % (hgd) and . % (eac). conclusion: . % remained stable, but those reaching hgd all progressed to ace (only in % of the latter, hgd is recognized with h&e). . methylation´s grade is higher in all diagnostic groups comparing to the control group, progressively increased as the dysplasia grade found with h&e, so it may be a good biomarker for neoplastic progression. objective: in high risk hpvs the expression of oncoprotein e is responsible for the degradation of p , while e inactivates prb and causes the progression to s phase of cell cycle, both sustaining the conversion to and the maintenance of malignancy. the aim of this study is to compare the performance in the detection of the e and e mrna expression of hr-hpv using the nuclisens easy q test (biomerieux) or hpv oncotect (incelldx) a test based on flow cytometry-fish method. method: we enrolled patients positive for hr-hpv dna and/or pap smears. all subjects underwent a colposcopy histological evaluation and were tested both for the nuclisens easy q test and hpv oncotect. results: out of subjects resulted positive for rna expression. the patients were divided into two cohorts based on the histological diagnosis: low grade lesions (cin ) and high grade lesion (cin +). patients with cin were with nuclisens easy q test and with hpv onco tect, those with cin + were with either tests. conclusion: these preliminary results suggest that hpv oncotect have a better specificity than nuclisens easy q test, while more samples need to assess the difference in sensitivity. detection of pik ca/akt mutations in human meningiomas a. saetta * , g. tomara, i. chatziandreou, p. tsioli, e. el-habr, i. sakalidou, g. vretakos, e. boviatsis, p. korkolopoulou, e. patsouris * university of athens, st dept. of pathology, greece objective: the pi k/akt pathway is a major signaling pathway frequently activated in human cancer due to pik ca and akt gene mutations thus representing a potential therapeutic target and prognostic biomarker. in this study, we examined the mutational status of pik ca and akt in meningiomas. method: meningiomas were screened for activating mutations in "hot spot" exons , of pik ca using real time pcr and high resolution melting analysis. pik ca wild-type samples were analyzed for mutations in exon of akt . the mutations were verified by sequencing and/or pyrosequencing results: mutations were detected in out of samples ( %) in exon of pik ca and were identified as p.e k and p.s f. regarding exon , out of samples ( , %) showed the following mutations: p.r q, p.t t, p.h v, p.m i, p.h r ( cases), p.h t. finally, in exon of akt , mutant cases were detected ( %) all identified as p.e k. in % of the patients the activation of the pi k/akt pathway is due to mutations in the two examined genes. conclusion: aberrant activation of the pi k/akt pathway due to pik ca and akt mutations is commonly observed in human meningiomas and these genes could be considered as potential targets in new therapies for cancer. study of pi k/akt/mtor pathway in urothelial bladder carcinoma a. saetta * , n. prekete, e. trigka, g. levidou, m. karlou, p. pavlopoulos, p. korkolopoulou, e. patsouris * university of athens, st dept. of pathology, greece objective: deregulation of the pi kinase-akt/mtor pathway is a frequent event in tumorigenesis. we examined the possible significance of the components of this pathway in bladder urothelial carcinoma (uc). method: cases with bladder uc were screened for mutations in exons , of pik ca gene and exon of akt by pcr-sscp, hrma, sequencing and/or pyrosequencing. the expression of p-mtor, p- e-bp , p-p s k, p-akt, fgfr and p-erk was evaluated by immunohistochemistry. results: , % of the cases were mutant in pik ca gene and % in akt . cases with wild type akt displayed higher fgfr receptor expression (p= . ). p- e-bp expression was more frequent in low grade (p= . ) and in pta-t tumors (p = . ). furthermore, superficial tumors presented higher levels of p-p s k expression (p = . ) and lower levels of p-akt expression (p = . ). in multivariate survival analysis, p- e-bp immunoexpression emerged as an independent prognostic factor of adverse survival (hr = . , p= . ), along with tumor grade and t-category. conclusion: activation of pi k/akt/mtor pathway in bladder uc is not exclusively related to the presence of akt and pik ca mutations. expression of p- e-bp could serve as an independent prognosticator. comparison of dna extraction methods of formalin fixed, paraffin-embedded archival tissues b. senguven * , e. baris, t. oygur * gazi university dental faculty, dept. of oral pathology, emek, turkey objective: formalin fixed, paraffin-embedded (ffpe) archival tissues are valuable resources for many molecular studies. the goal of this study is identify the optimal method for dna extraction from ffpe tissues. method: human gingival tissues which has obtained from patients with gingival hyperplasia were used. serial sections of μm thickness obtained using a standard microtome. half of the sections were deparaffinized on glass, the other half collected directly to a , ml tube. in order to identify the optimal method for dna extraction, we compared phenol-chloroform protocol and dna extraction mini kit. the duration of proteinase k digestion were also compared. spectrophotometric evaluation of the yield and purity of dna was conducted. to deteminate the amplifiablity of extracted dna, three different bp fragment of the beta-globin gene were amplified using pcr. results: the phenol-chloroform method had the lowest yield and purity. deparaffinized specimens on glass, digested for h and isolated using mini kit had the highest yield. amplification of the bp fragment of beta-globin gene was successful in all samples. conclusion: according to our results deparaffinization on glass, increasing the time of proteinase k digestion and using commercial kits for isolation seems the best method to obtain amplifiable dna from archival specimens. microrna signatures associate with fallopian tubal implantation in humans r. shao * * gothenburg university, physiology and endocrinology, sweden objective: micrornas are small non-coding rna molecules that regulate a large number of cellular pathways and deregulation or altered expression of mirnas is associated with many disease states. the function of the fallopian tubes appears to involve orchestrated spatiotemporal alterations in transcriptome profiles, the regulation of tubal gene expression and function by mirnas may thus be of primary importance in tubal ectopic pregnancy. method: both implantation sites and non-implantation sites of fallopian tubes from women with ep and decidual biopsies from women undergoing therapeutic surgical termination of pregnancy were collected and analyzed by mirna array. the unique mirna profiling results were validated by taqman qrt-pcr, and bioinformatics' analysis was employed to further predict the mirna targets. results: a total of mirnas were differentially expressed in implantation sites compared with those in non-implantation sites of fallopian tubes after comparison of decidual mirnas, among which were up-regulated while are down-regulated. the mir- was significantly increased, whereas let- i, mir- , and mir- were significantly decreased. differentially expressed mirnas were predicted to be related with several signaling pathways in normal intrauterine implantation. conclusion: our findings establish an mirna signature associated with tubal implantation and provide the experimental basis for further understanding the molecular and cellular mechanisms of initiation and development of tubal ep in humans. lung is an organ that can sense any perturbation of the air, due to its constant interaction (long live) of the air. our hypothesis was that lung could be an organ sensor of climatic change observed today. method: this preliminary study analyzed the expression of isoforms of the genes of hsp . the cases were chosen from archive of autopsies from to , with different diagnosis, and were matched in sex and age with a same number of cases chosen from to . the expression was studied by rt-pcr from lung tissue embedded in paraffin, samples of each decade. results: the expression levels of hsp were normalized to β-actine. we found expression in six cases of - : five for hsp aa - , and for hsp ab , one case expressed both. their matched cases in - never expressed any isoform. the cause of dead in all cases doesn't fit with any pattern. conclusion: with these results we propose than the lung could be a sensor of global warming, and the expression of these genes could be molecular markers of this climatic change. apoptosis associated genes and their role in predicting responses to neoadjuvant breast cancer therapy d. tvrdík * , h. skálová, p. dundr, l. stanek, c. povýšil, l. petruželka * general university hospital, institute of pathology, prague, czech republic objective: neoadjuvant chemotherapy is used in the treatment of breast carcinoma because it substantially reduces the size of the primary tumor and lymph node metastases. this present study is aimed at the investigation of biomarkers that can predict a pathologic response to the therapy. method: the transcriptional profile of key apoptosis genes was evaluated in both pre-therapeutically obtained tumor tissue by core needle biopsy and in specimens removed by final surgery, using a pathway-specific real-time pcr assay. results: on the basis of a hierarchical cluster analysis of significantly changed genes, we divided patients into good and bad prognosis groups, which correlate well with progression-free survival. in the good prognosis group, we found a statistically significant downregulation of the expression of mcl and igf r genes after neoadjuvant treatment. we also found a statistically significant overexpression of bcl l , bcl af , casp , casp , casp , cideb, fadd, hrk, tnfrsf , tnfsf and cd genes. in contrast, we found upregulation of igf r after the treatment in the group with poor prognosis. conclusion: as we have shown, gene expression profiling after neoadjuvant chemotherapy is a valuable research tool for investigating molecular markers, which may better reflect tumor biology and treatment response than standard prognostic and predictive factors. objective: non-small cell lung carcinoma (nsclc) is one of the most serious cancers. identification of genetic changes (mutations, amplifications or rearrangements) within egfr, kras and alk oncogenes, associated with nsclc, allows choosing the patients, benefit from biological therapy with tyrosin kinase inhibitors. method: dna is isolated from formalin fixed paraffin embedded specimens or cytology specimens. mutation detection is performed by real-time pcr, fragment analysis, primerextension analysis and mutant-enriched pcr. wt-egfr patients (e.g. with no mutation detected) are tested for alk gene rearrangement and egfr gene polysomy or amplification using the fluorescence in situ hybridization (fish) method. results: since / till / , dna samples were analyzed. out of these, patients ( , %) were found to be positive for activating mutations within egfr gene. since / till / , patients were analyzed for alk gene rearrangement, egfr gene polysomy or amplification. alk gene rearrangement has been proven in ( , %) cases, alk gene amplification in ( , %) cases and egfr gene polysomy or amplification in ( , %) cases. conclusion: determination of genetics changes in tumor can provide powerful tool for setting up strategy and therapeutic protocols in nsclc patients. objective: a year old gentleman, ex-smoker with a history of asbestos exposure presented to the emergency department with a day attack of severe abdominal pain and bilious vomiting. history of abdominal pain, lethargy, and weight loss over the last months and years of recurrent pleural effusion. pleural aspirates and a videoassisted thoracic biopsy were negative. method: x-ray confirmed small bowel obstruction and an emergency laparotomy performed. the terminal ileum was intussuscepted into the caecum causing proximal obstruction. a right hemi-colectomy was performed. results: on gross examination there was intussusception of the terminal ileum secondary to a polypoid mass at the ileo-caecal valve. histology showed an oncocytic tumour with neuroendocrine features arising from the serosa of the small bowel. the tumour cells were positive for ck , calretinin, and vimentin but negative for ck , chromogranina, cd and ttf- . the features were in keeping with a malignant peritoneal mesothelioma infiltrating the small bowel wall. conclusion: peritoneal malignant mesothelioma is an uncommon tumour which rarely causes mechanical small bowel obstruction. to our knowledge this is the first case of localised primary peritoneal mesothelioma presenting with intussusceptions. giant mesenteric cystic lymphangioma in adult; rare tumor, unusual location and uncommon age of occurrence: a tunisian case report s. attafi * , w. ajouli, n. bouchiba, a. chouchene, m. h. balti, k. bellil * fsi hospital, dept. of pathology, marsa, tunisia objective: cystic lymphangioma is a rare benign neoplasm arising from the lymphatic system. it occurs as a result of congenital malformations of the lymphatics, leading to the obstruction of local lymph flow and the development of lymphangiectasia. lymphangioma is common in pediatric patients, but it is extremely rare in adults, with only about cases reported in literature. most lymphangiomas are found in the head and neck; intraabdominal and specially mesenteric locations are very unusual. the aim of this work was to study its clinical, histological and therapeutic features and their diagnostic difficulties. method: we report the case of a years-old woman, who presented a painful syndrome of the right iliac fossae (rif). the physical examination found a mass of the rif. abdominal ultrasonography and magnetic resonance image showed a mesenteric cystic formation. at laparotomy, a large cystic tumor of the caecal mesentery, measuring cm, was found. histopathology showed a fibrous and thin walled cyst, lined by flat low lying epithelium with surrounding tissue of scattered lymphoid cells. results: the diagnosis of cystic lymphangioma was retained. conclusion: mesenteric lymphangiomas are very rare, but they can cause acute abdomen that requires an emergent surgery. therefore, they should be included in the differential diagnosis of cystic intra-abdominal lesions raises several possibilities, including both malignant and benign soft tissue tumours. objective: the spleen metastases from colon cancer are rare conditions and usually associated with extensive disease. there are only eight reports in english-language literature of isolated splenic metastases from colorectal carcinoma, which generally metastasize to regional lymph nodes, liver and abdominal peritoneum. method: we report a case of multiple splenic metastases in a -year-old woman. results: in november , the patient had undergone right hemicolectomy, lymphadenectomy and chemotherapy for stage iii tubular adenocarcinoma of the ascendant colon with positive pericolic lymph nodes. in december , she was admitted in our hospital for diffuse abdominal pain and intestinal transit disorders. computed tomography of the abdomen revealed multiple metastases of different sizes in liver and spleen. during the surgery, which was performed with the goal of curing metastatic disease, there were found two nodular hepatic secondary tumors, and numerous spleen metastases, with diameters from . cm to . cm. the histopathological evaluation of splenectomy specimen revealed a metastatic tumor deposit, histologically similar to the primary tubular adenocarcinomas of colon. conclusion: this is the ninth documented case of splenic metastasis from colon cancer. previously reported cases of this type were isolated tumor, this one being the first reported with multiple splenic metastases. the role of fatty acid synthase in inflammatory bowel disease (ibs) e. bas bozkurtlar * , n. ozkan, a. e. kedrah, c. celikel * marmara university, dept. of pathology, istanbul, turkey objective: it was demostrated that fas expression increases not only in mucosa involved by active colitis but also in normal mucosa of ulcerative colitis (uc) patients. our aims were to evaluate the role of fas expression in differential diagnosis of ibd, to search for any possible change during the progression of the disease in patients with clinical and endoscopic follow-up. method: among colonoscopic biopsy samples of uc cases, samples were classified as remission, as resolution, and as active period; samples of crohn disease (cd) cases were classified as active period. fifteen cases with normal endoscopic and morphologic findings comprised the control group. results: between uc and cd active periods and control group, a significant difference was found (p= , ). there was a statistical correlation between fas expression of basal crypt of normal mucosa in uc active period and the disease duration (p= , ). conclusion: the increasing in fas expression in patients with ibd can not be explained only by the inflammation. fas expression can not aid us in the differential diagnosis of uc and cd, but it seems that it is related to the extent of inflammation in uc. the relation between the disease duration and an increase in fas expression active uc, might have a significant role in carcinogenesis in uc. micropneumatosis -an (un) usual finding in gastrointestinal specimen? k. blaue * , m. plauth, j. knolle * städtisches klinikum dessau, pathology, dessau-roßlau, germany objective: a rather rare disease, micropneumatosis describes the findings of cyst-like cavities devoid of lining epithelium in the gastrointestinal wall. micropneumatosis is often secondary to intestinal bacterial infection or mechanical factors. this study evaluates the incidence of micropneumatosis in our institute. method: we analyzed all cases of micropneumatosis obtained in our institute between and . available data were retrieved from patients' records. results: out of . specimens obtained between and , cases ( . %) presented with micropneumatosis ( female, male; mean age years, age range to years). most common site was the colon ( cases), followed by stomach ( ), small intestine ( ) and greater omentum ( ). conclusion: micropneumatosis represents a rare but harmless diagnosis in gastrointestinal specimen. due to the histological picture, which may be confused with dilated lymphatic vessels, submucosal lipomas, and, to the untrained eye, even with signet ring cell carcinoma, incidence may even be higher. in unclear cases, where there seems to be a endothelial layer, immunohistochemistry may be necessary to confirm diagnosis of micropneumatosis. this study shows that micropneumatosis should be considered in differential diagnosis in every age and sex. predicting lymph node metastasis in pt colorectal cancer -a meta-analysis providing rationale for therapy decisions s. bosch * , i. nagtegaal * radboud university nijmegen, pathology, netherlands objective: we conducted a meta-analysis of published reports on the predictive value of risk factors for lymph node metastases (lnm) in pt colorectal cancer in order to provide a rationale for choosing follow-up or radical surgery after local excision. method: local excision is an attractive treatment option for colorectal cancer, but is only safe in the absence of lnm. several pathological factors have been associated with lnm, however it remains unclear how to integrate these in clinical decision making. results: a pubmed search revealed studies totaling patients. strong predictors of lnm were lymphatic invasion (rr . [ % ci . - . ]), budding (rr . [ % ci . - . ]), and high grade histology (rr . [ % ci . - . ]). deep submucosal invasion was also strongly associated with lnm, however in a risk stratification model this factor was of limited added value. conclusion: the absence of lymphatic invasion, budding and high grade histology may justify withholding radical surgery. the independent role of submucosal invasion depth is probably limited. models for risk stratification based on these factors need to be validated. objective: dendritic s + cells in intestines have been described in more studies. their connection to s + fibres of nervous system is lesser of an object of interest. method: we have processed the samples of intestinal mucosa of people with crohn's disease and colitis ulcerosa by the means of form-paraffine technique and anti s antibodies. results: in lamina propria and in submucosa at crohn's disease were s + the fibres of various width and orientation. outside of them the diffusely scattered round s + mononuclear cells could be seen. contrary to colitis ulcerosa the granulation tissue at crohn's disease contains in the area around abscesses a thick accumulation of s + cells and this is similar also in the formed lymphoid tissue. conclusion: the positive fibres can be seen in submucosa at the edge as well as in lpm between the bases of the glands. in between the plexus/ring and longitudinal muscle there are massive bands of connective tissue which contains bundles s + of ganglion cells and nerve fibres. the fibres are present in ring as well as in longitudinal muscle. in this area s + fibres can also be seen in vessel walls. numerous bundles of granulatory tissue do not contain positively reacting substance. in the basal part lamina propria there are visible s + cells as well as long, smooth, positively reacting fibres. ps- - ncf -deficient mice with impaired oxidative bursthave a more agressive progression of dextran sulfate sodium (dss) -induced colitis l. carvalho * , t. rodrigues-sousa, a. alarcão, a. f. ladeirinha, m. souto-carneiro * amadora, portugal objective: intestinal inflammatory disease (iid) as a primary immunodeficiency depends on mutations in the nadph oxidase complex, responsible for the production ofreactive oxygen species (ros). one of the most common clinical patterns in iid is chronic colitis. ncf -mutation in mice leads to deficiency in ros, rendering them susceptible to autoimmunity. here we studies how ros-deficiency in ncf -mutant mice influenced the immune response to dss colitis, its recovery and answer to a second induction. method: colitis was induced in wild type (wt) and ncf mutant (ncf ) b .q mice by administration of . % dss in the drinking water for week. after week recovery, dss was administered for another week. mice were sacrificed at days , , and , the colon was removed and folded into a swiss roll. sections of the colon were stained with he, and monoclonal antibodies against b cells (b ), cd + t cells; and macrophages (mac /cd b) were applied. results: colitis was more severe in ncf than wt mice, with epithelial dysplasia, hyperplasia of peyer's patches and poor epithelium recovery (hyaline scars). at all time-points the amount and location of colonic b cells, t cells and cd b + cells was distinct between groups. these results suggest that ros are crucial for leukocyte recruitment and tissue-repair in dss-induced colitis. histopathological pattern of polypoid lesions of colon in albanian population g. cekodhima * , a. cekodhima, a. beqiri, g. andrea * university hospital maria teresa, dept. of pathology, tirana, albania objective: our aim was to study histopathologic pattern of the polypoid lesions in albania. method: we studied lesions, polypectomies and colorectal surgery in patients in tirana. results: there were observed polypoid lesions of large intestine in males and females. ( . %) were adenomatous polyps, ( . %) were hyperplastic, ( %) were inflammatory polyps with ulcerative colitis, ( . %) were inflammatory ( . %) were juvenile polyps, ( . ) non hodgkin's lymphoma and ( . ) was fibrolipoma. tubular adenomatous polyps were the commonest polyps. they were more common ( . %) in male population as compared to female ( . %). high grade dysplasia was present in ( . %) and malignant change in ( %). the size of the polyps range from . to cm. conclusion: adenomatous polyps were the most frequently found polyps in our study; the approximately % were advanced lesions. the role of cancer stem cells in biology and prognosis of colon cancers a. f. Çiçek * , Ö. Öngürü, m. gamsizkan, a. günal * gülhane military medical academy, dept. of pathology, ankara, turkey objective: this study was designed as a retrospective clinicopathological observation based on immunohistochemical and statistical findings to show the relationship between the disease progression and the intensity of the stem cell population within the tumor for colorectal cancers. method: for this purpose, we investigated colorectal carcinoma cases, retrospectively. paraffin embedded blocks was obtained from pathology archive and demographical patients' data from the patient's files of gastroenterological surgery department. immunohistochemically, we used cd and musashi- antibody to determine the stem cells within the tumor. we noted the age of the patients, histopathological diagnose, tumor location, grade, tnm status, clinical stage, disease-free-survival and the outcome. then we statistically compared all prognostic data with the immunohistochemical findings results: all of the cases were immunoreactive for both antibodies, furthermore we found a significant statistical correlation (p= . ) between cd expression value and patient outcome. when the value of cd expression was high, clinical outcome was poor. in addition, there was a relation between high musashi- expression and poor outcome. conclusion: based on these findings we reported that overexpression of both cd and musashi- antibodies may be a poor prognostic factor in colorectal cancers. immunohistochemical evaluation of vegf expression in colorectal carcinomas d. crisan * , m. florea, d. fodor * university of medicine and pharmacy, pathology, cluj-napoca, romania objective: vascular endothelial growth factor (vegf) is an important angiogenic glycoprotein secreted by the tumor cells and host cells which proved to be a powerful prognostic factor in various human cancers. the aim of our study was the evaluation of vegf expression in colorectal carcinomas using immunohistochemistry, in order to identify the relationship between the presence of the protein in the tumor cells and a series of morphological parameters. method: we analyzed consecutive surgically removed colorectal carcinomas. immunohistochemistry was done on formalin-fixed and paraffin embeded tissue sections, using the anti-human vegf-a monoclonal antibody (clone vg , dako). the extent and intensity of staining were graded and used to calculate the immunoreactive score for each case. statistical analysis was performed with spss (statistical package for the social sciences), using nonparametric tests. the level of statistical significance chosen was p < . . results: vegf was expressed in all tumors, with a heterogeneous distribution. the only parameters that correlated with high vegf positivity were the extent of the tumor necrosis and the presence of lymph node metastases (p = , ). conclusion: high levels of the vegf expression may be an indicator of poor prognosis in colorectal carcinomas. collision tumour of the appendix: mucinous cystadenoma and carcinoid -report of a case c. dastamani * , a. paraskeva, e. carvounis, t. theodosopoulos, a. kondi-pafiti * aretaieion hospital, dept. of pathology, athens, greece objective: appendiceal carcinoids are usually located at the tip of the appendix and occur as incidental findings. epithelial neoplasms of the appendix are uncommon and consist of mucinous adenomas, carcinomas and neoplasms with features of both carcinoid and adenocarcinomas. method: a case of dual mucinous cystadenoma and carcinoid of the appendix is reported. results: the patient, a -year old-asymptomatic female presented with a cystic right iliac fossa mass. the excised specimen was appendix cystically dilated measuring up to , cm in diameter. the luminal content consisted of viscid mucin. the base of the appendix was thickened (up to , cm) and firm. microscopically the cystic part of the specimen had features of mucinous cystadenoma with adenomatous epithelium extending as well over the thickened appendiceal wall. at that area the wall was involved by a well differentiated neuroendocrine neoplasm who gr i (carcinoid). the neoplastic cells infiltrated the entire thickness of the appendiceal wall, the mesoappendix and reached the serosal surface. the two neoplasms where separate and there was no transitional zone between them. conclusion: dual carcinoid/epithelial neoplasia is a rare occurrence in the appendix. the prognosis appears to be no worse than for either of the two components alone. gastrointestinal stromal tumor (gist) of the anal canal: a case report l. de carvalho * , p. a. teixeira, v. g. siqueira, m. pereira, t. or, e. pereira * centro universitário lusíada, dept. of pathology, santos, brazil objective: gastrointestinal stromal tumors (gist) are mesenchymal tumors derived from interstitial cells of cajal. they are found more frequently in the stomach, small intestine while colon and rectum represent unusual sites. gist's of the anal canal are extremely rare. method: -years-old woman who presented bleeding, pain and constipation for several months. the rectal examination revealed a well defined mass located within cm of the anal verge. the magnetic resonance imaging confirmed a well-circumscribed mural mass without adenopathy. the local excision of the tumor was performed for pathological study. results: gross examination showed a . × . cm fibrous mass. histological examination revealed a spindle cell tumor with moderate atypia and mitotic count of mitosis/ hpf. neoplastic cells showed marked positivity for c-kit and cd and negativity for muscular markers. a diagnosis of gist with intermediate risk of aggressive behavior was made. conclusion: gists of the anal canal are extremely rare with only few cases reported in the literature. we described an additional case of gist of the anal canal with histological and immunohistochemical study. intestinal graft versus host disease with giant cells b. doganavsargil * , a. vink, e. j. petersen, g. j. arnold offerhaus * ege university, school of medicine, izmir, turkey objective: graft-versus-host disease (gvhd) is a common complication of allogeneic bone marrow transplantation in which immune cells in the transplanted marrow attack the immunocompromised host. it can occur in either an acute or in a chronic form and may affect various organs. intestinal gvhd is particularly important because of its frequency, severity and its effects on the general condition of the patient. method: here we report a -year-old man who developed gvhd, months after receiving allogeneic non-myeloablative peripheral blood stem cell transplantation for refractory chronic lymphocytic leukemia. colonic biopsies revealed an edematous and congested lamina propria, dilated crypts lined by flattened epithelium, increased apoptotic figures and vanishing crypts. notably there were some giant cells in between crypts. however subsequent sections and special stains didn't show any granuloma formation or presence of an infectious agent. results: to our knowledge presence of giant cells in gvhd hasn't received proper attention before. although we don't know the actual importance or clinical consequences of the entity yet, we report this case to increase awareness of this feature within the context of gvhd. we have seen more cases with giant cell gvhd afterwards; comparison with other cases of gvhd without giant cells may help clarifying their significance. differential mutation patterns of kras and braf in adenomatous and serrated neoplastic sequences o. erdogan * , b. savas, a. ensari * ankara university, faculty of medicine, turkey objective: colorectal carcinomas develop through adenomatous or serrated neoplastic sequence. different molecular mechanisms underly these morphologic sequences which may be translated into different therapies. we aimed to assess adenomatous and serrated neoplastic sequences in terms of kras and braf mutations. method: the study group comprised of adenomatous polyps (aps, n= , . %), conventional adenocarcinomas (conca, n = , . %), serrated polyps (sps, n = , . %) and mucinous adenocarcinoma (mucca, n= , . %). kras mutation was assessed for exon and exon using pyrosequencing while braf v e mutation was analysed using allele specific pcr. chi square test was used for statistics. results: kras mutations were observed in . % of carcinomas and . % of polyps. kras mutation rate was significantly higher (p< . ) in conca ( %) than in mucca ( %), and in aps ( %) than in sps ( . %). braf mutation was found in one mucca ( . %) while all sps were mutated. tsas had the highest kras mutation rate ( . %) in comparison to ssa/ps ( . %) (p< . ) whereas ssa/ps and hps had significantly higher rates of braf mutation ( . %, . %, respectively) than tsas ( . %) (p< . ). conclusion: kras seems to take part in adenomatous sequence while braf, seem to play a significant role in serrated neoplastic progression of the colorectum. objective: quiescent ulcerative colitis (q-uc) is morphologically characterized by typical architectural and cellular mucosal changes that define the process as chronic. it is not clear which of these changes are more ubiquitous in q-uc. our aim was to evaluate which classical histological findings of q-uc are more prevalent in rectal samples. method: rectal biopsies were collected from patients with clinical and endoscopical q-uc. the biopsies were evaluated for mixed inflammation in the lamina propria, crypt architectural abnormalities, basal plasmacytosis, fibrosis, and paneth cell metaplasia as well as for features of active disease (cryptitis, lamina propria neutrophils and erosion). results: forty-five patients ( % female; median age years) were included. thirteen ( , %) biopsies showed focal activity and four cases ( , %) had criteria for active disease. epithelial distortion, chronic inflammatory infiltrate and basal plasmacytosis emerged as features present in , and % of biopsies. overall, biopsies were histologically normal (no chronic features, no active disease). conclusion: rectal mucosa from patients with clinical and endoscopical q-uc can show microscopic active disease, which illustrates that endoscopy alone may be insufficient to identify quiescent disease. in q-uc, the most frequent changes (present in over % of the biopsies) were epithelial distortion and chronic inflammatory infiltrate. vacuum-based preservation of colorectal cancer specimens: a comparison with formalin fixation j.-f. fléjou * , s. el-naderi, p. cervera * hôpital saint-antoine, dept. de anatomie pathologique, paris, france objective: in pathology, an alternative to immediate fixation in neutral buffered formalin (nbf) is vacuum sealing and cooling (vsc) ("tissue safe" system). there have been few evaluations of vcs. method: we assessed msi, kras, braf in colorectal cancers, conserved with vcs before fixation ( cases with surgery in a hospital distant from our centre), or immediately fixed in nbf ( cases with surgery during the same period in our hospital). dna was extracted from paraffin embedded tissue. msi was assessed by mlh and msh immunohistochemistry and pcr; kras and braf were screened by multiwell-plate based real-time pcr (lightcy-cler® , roche), confirmed by sanger sequencing. results: there was no difference regarding morphological analysis. immunohistochemistry was interpretable in all cases, with negative cases in the vcs group ( mlh ), negative cases in the nbf group ( mlh , msh ), and a % correlation between immunohistochemistry and pcr. dna extraction was possible in all cases. kras and braf mutations were detected in and cases in the vcs group and and cases in the nbf group, respectively. conclusion: we show that analysis of msi, kras and braf is feasible in surgical specimens after vcs. this procedure can be an alternative to formalin fixation. clinical significance of cd -positive m macrophage in colorectal cancer s. fushimi * , m. matsumoto, s. takahashi, t. ogino, j. itakura, t. ito, a. matsukawa * okayama university, dept. of pathology, japan objective: tumor-associated macrophages are divided into two phenotypes, termed m /m macrophages. m macrophages promote tumoricidal responses whereas m macrophages assist tumor progression and metastasis. in this study, we have analyzed a clinical significance of m macrophages in excised sections from patients with colorectal cancer. method: patients who had surgical resection for colorectal cancer between and were identified from a prospective database. tissue sections with adenocarcinoma in pt category were employed in this study. the sections were stained with anti-cd , a marker of m macrophages. the relation between the staining pattern and tumor budding or patient prognosis was examined. results: fifty-two patients ( male, female) with a median age of years (range - ) were studied. the tumors were classified into four subtypes according to the staining patterns of cd -positive cells, i.e. sparse type (n= ), invading-tip type (n= ), peri-nest type (n= ), and dense diffuse type (n= ). only a dense diffuse type was related to the high degree of tumor budding. the prognosis with a dense diffuse type demonstrated a poor prognosis as compared to the other types. conclusion: even the case with comparable tumor depth, cd -positive macrophages with dense diffuse distribution was related to the poor prognosis. objective: the treatment of locally advanced rectal cancer has shown a significant development over the last decade. the total mesorectal excision and the use of pre-operative radio (chemo)-therapy are leading the patients to a gradual improvement of local control of the disease. the aim of this study is to evaluate the pathological tumour response to pre-operative treatment through correlation between the clinical stage (ctnm) and the pathological stage (yptnm). method: since , patients with locally advanced rectal cancer, assessed by high resolution magnetic resonance imaging (hr-mri) and tnm staging system, have been evaluated by the colorrectal multidisciplinary team. pre-operative radio (chemo)-therapy was mandatory before undertaking standard surgery. surgical specimens were evaluated according to the vikingo project's protocol implemented by the spanish association of surgeons. results: patients completed the pre-operatory treatment. after evaluation of clinical and surgical study specimens, we observed variable degree of downstaging in ( , %) patients, of whom showed complete response. the ( , %) remainig patients were assessed as stable disease. no local progression of tumours was observed. conclusion: in this study, approximately % of patients, who were staged by hr-mri and underwent preoperative radio (chemo)-therapy for locally advanced rectal cancer, showed some degree of downstaging. we remark the fact that nearly % of patients reached complete response. the density of macrophages in colorectal cancer is inversely correlated to tgf-beta expression and patients' survival m. gulubova * , i. manolova, j. ananiev * trakia university, general and clinical pathology, stara zagora, bulgaria objective: the role of macrophages in colorectal cancer tumorogenesis is complex because they can both prevent and promote tumor development. we investigated cd infiltration in tumor tissue and its correlations with proteins ot tgf-beta signaling pathway. method: a nonselected panel of primary tumors of colorectal origin was investigated immunohistochemically with antibodies against cd , tgf-beta , smad , smad , tgfrii and levels of tgf-beta were measured by elisa. results: lower cd infiltration in tumor nests was associated with expression of tgf-beta (chi = . , р = . ) and smad (chi = . , р= . ) in tumor cells and with tgfrii expression (chi = . , р= . ) in tumor cells membranes. there was not correlation between cd cell numbers in tumor tissue and tgf-beta serum levels. we have found higher frequency of liver metastases in patients with lower infiltration with cd in invasive margin (chi = . , р= . ). the survival time was shorter for patients with low cd infiltration in tumor nests and invasive margin, compared with the survival time for patients, with higher cd infiltration in both tumor compartments (p< . ). conclusion: the increased levels of tgf-beta in the tumor have an immunosuppressive effect on cd infiltration. inflammatory myofibroblastic tumor of the colon: the th reported case s. gurzu * , t. bara, i. jung * university of targu mures, dept. of pathology, romania objective: inflammatory myofibroblastic tumor (imt) is a very rare tumor of the colon in which the diagnosis is especially based on immunohistochemistry. in the colon, we report the th case of imt. method: case presentation results: we report the case of a -year old male who presented with symptoms suggesting colon cancer. a mm protruded tumor was endoscopically described in the ascending colon. right hemicolectomy was performed. macroscopically the tumor was well defined, covered by normal mucosa with a central depressed area, suggesting a gist (gastrointestinal stromal tumor). microscopically spindle cells with fascicular arrangement admixed with mononuclear leukocytes were observed. the tumor cells expressed vimentin, sma, desmin and alk and were cd and cd negative. intense angiogenesis and cd expression in the endothelial cells were also observed. conclusion: in the imt of the colon, clinical endoscopic and gross feature can imitate a carcinoma or a gist. the ihc pattern of imt can offer informations about its histogenesis. based on the immunophenotype, we hypothesize that this tumor seems to occur from the the pluripotent stromal cells, cd positive which can be either differentiated in the interstitial cells of cajal (telocytes), which are also cd positive or, during differentiation, can loss cd positivity. objective: determining the fraction of tumor cells in colon carcinoma samples analyzed for kras mutation is important for choosing the proper testing modality. however, when asked to determine tumor cell fraction in tissue samples, different pathologists give considerably different estimations, possibly leading to erroneous interpretation of kras mutation analysis results and poor treatment choices. method: we developed a free, easy to use computer program that estimates tumor cell fraction on colon carcinoma slides that are immune-stained with anti-cytokeratin antibody. sixty samples were evaluated by the program and results were compared to actual measurement of tumor fraction. results: the tumor cell fraction estimated by the computer program showed highly significant correlation with the actual measurements (r= . , p< . ). additionally, we found that a short calibration step prior to beginning the computer estimation increased the accuracy of the results. in four cases ( %) there was some discrepancy between the computer estimation and the actual measurements, however, this was attributed to lower quality immunohistochemical staining. conclusion: in conclusion, we believe that this program can be used for standardizing the evaluation of tumor cell fraction in colon carcinoma, and that its use might aid in making better diagnosis and treatment choices for these patients. magnetic resonance imaging assisted tumour block selection in colorectal cancer c. hunter * , g. brown, l. temple, m. abulafi, a. arnaout * croydon university hospital, dept. of colorectal surgey, united kingdom objective: inadequate sampling may result in understaging in colorectal cancer. fat clearance techniques and whole mount sections are time consuming and costly. we hypothesise that high resolution magnetic resonance imaging (mri) of the colorectal cancer specimen may aid histological sampling and result in upstaging. method: patients undergoing resection are prospectively recruited, and randomised to "conventional histology" or "mri assisted histology". in addition to routinely selected tumour blocks, additional blocks and any additional lymph nodes are selected with the aid of specimen mri or visual inspection and palpation according to group. t stage, depth of extramural invasion, distance to resection margin, lymph node (ln) number and involved ln are compared between the two groups. results: to date, of patients have been recruited. we present the methods and preliminary results. there is a trend towards greater t stage and ln yield. no difference in n stage, extra-mural vascular invasion or involved non-peritonealised resection margin has yet been observed. conclusion: early results suggest that specimen mri may upstage colorectal cancer specimens by aiding tumour block selection. we will complete recruitment of colorectal cancer patients over the next months to determine whether observed differences are significant. diverticular disease of transverse colon is rare and perforation may occur in crohns disease c. hunter * , a. arnaout * croydon university hospital, dept. of colorectal surgey, united kingdom objective: diverticular disease commonly affects the sigmoid colon in the west and the right colon in asia. perforation is uncommon affecting / per year. perforated diverticular disease of the transverse colon is therefore very rare. we present a case of crohns disease complicating transverse diverticular disease that lead to perforation and unfortunate death. method: radiological and histopathological features are presented with a review of the literature results: to the best of our knowledge, this is the first reported case of crohns disease complicating diverticular disease of the transverse colon. we suggest that distal stricturing leading to increased intraluminal pressure or increased weakening of the colonic wall due to coincident crohns fissure and diverticulum are possible pathogenic mechanisms. conclusion: crohns disease complicating transverse diverticular disease is uncommon, but may be one pathogenesis leading to the rare event of transverse colon diverticular perforation. results: there were episodes in patients. they start between day and ( ± days). duration ranged from to days ( ± ). the three moderate and the three mild ar reversed with treatment. of the severe ar, caused the failure of the graft. five episodes de ar began as moderate or severe directly. severity in the course of each episode was fluctuating. sixteen indeterminate rejections were seen in grafts (did not reach definitive criteria). they lasted - days (mean: ± days). conclusion: -acute rejection is the most common cause of morbidity in the intestinal transplant ( % of the grafts). -it can develop at any time and relapse. -the duration and severity of the episodes are fluctuating. -in our series, % reversed, but severe rejection often lead to graft loss ( %). histopathological study of intestinal grafts lost in a series of adult transplants. hospital octubre. madrid. method: we studied explants and autopsy. the autopsy was not authorized in one death. results: seven grafts were lost in patients ( multivisceral). two types of failure were seen. a) local: severe acute rejections (ar) (days , , ) and lymphoproliferative syndrome (lps) in day ; b) systemic: sepsis (days , , ). ar showed types of morphology: ulcerative, pseudomembranous and with disappearance of the villi preserving the crypts. lps was a high-grade b lymphoma and affected the graft and the lymph mesenteric nodes with venous thrombosis that cause ischemic necrosis. the sepsis were due to acinetobacter, to adenovirus in the graft and pulmonary aspergillosis and to pseudomona aeruginosa with necrohemorrhagic pancreatitis. conclusion: -the incidence of igl was %. -the cause of igl was local (ar and lps) in % and sepsis in %. -severe ar was the most frequent cause of failure. -histological examination properly determine and document the causes of igl. cap polyposis: report of two cases r. ivanova * , d. kyoseva, g. trifonov, r. nikolov * hospital of endoclinology, laboratory of pathology, sofia, bulgaria objective: cap polyposis is a rare colorectal disease characterized by mucoid, bloody diarrhea associated with multiple inflammatory polyps covered by a cap of fibrinopurulent mucous. the disorder was first described in and up to date a small number of cases has been reported in the literature. method: we report two cases with multiple polyps of rectum and sigma, which were histologically diagnosed as cap polyposis. results: the cases were two males on age of years and years. in both cases there was a history of mucoid and bloody diarrhea. on the basis of colonoscopy findings, in the young patient there was a broad differential diagnosis including m. crohn, inflammatory pseudopolyps and cronkhite-canada syndrome. in the second case the clinical diagnosis was polyps of sigma. endoscopic biopsies and polypectomy were done. in both cases, the histology showed typical histological features of cap polyposis -polypoid lesions containing elongated, tortuous and often distended crypts covered by a cap of inflammatory granulation tissue. conclusion: the recognition of this rare disease is of practical significance because its clinical symptoms have some similarity with inflammatory bowel disease or irritable bowel syndrome. histopathological findings in consecutive appendectomies: a retrospective analysis j. jeruc * , z. dolenc stražar, v. jovic, a. cerar, n. zidar * university of ljubljana, faculty of medicine, slovenia objective: appendectomy is one of the most common surgical procedures. histology usually confirms the clinical suspicion of acute inflammation, but sometimes other clinically relevant diagnoses are made. the aim of our study was to audit the appendectomies at our institution and summarise atypical pathological findings with emphasis on benign and malignant tumours. method: we reviewed the histopathology results of consecutive appendectomies received in a -year period. results: excluding three cases of metastatic process, appendiceal tumour was found in cases ( . %), which is a higher rate than reported in the literature. there were four endocrine tumours, all g , three cases of classical adenomas, cases of low-grade appendiceal mucinous neoplasm (one associated with pseudomyxoma peritonei) and three cases of carcinoma (one mucinous adenocarcinomas, one intestinal type, one undifferentiated carcinoma). we also diagnosed one case of multicystic mesothelioma. endometriosis was diagnosed in seven cases. in cases appendicitis was associated with diverticula, in cases changes were suggestive for crohn's disease and in one case for cystic fibrosis. negative appendectomy rate was . % that falls within the range reported in the literature. conclusion: histopathological examination of appendectomy specimens may reveal many different conditions not previously suspected; therefore, it should be performed in all cases. results: cdx , muc , muc , muc ac, and muc expression was observed in . % ( cases), . % ( cases), . % ( cases), . % ( cases), and . % ( cases), respectively. while siac patients with cdx expression showed less nodal metastasis (p= . ), those with muc expression tended to have siacs with nodular or infiltrative growth (p = . ), poor differentiation (p = . ), and more lymphatic invasion (p= . ). muc ac expression was associated with siacs with well differentiation (p= . ) and frequent pancreatic invasion (p= . ). patients with cdx +/muc -had more polypoid (p= . ) and well differentiated (p= . ) tumors and a significantly better survival (median, . months, p< . ) than those with other immunophenotypes (cdx −/muc +, cdx +/ muc +, and cdx −/muc −). patients with cdx expression (median, . months) had a significantly better survival than those without cdx expression ( . months) by univariate and multivariate analyses (p< . ). conclusion: cdx expression is an independent good predictor of survival in surgically resected siac patients. small neuroendocrine tumor of appendix with metastasis in the ileocecal lymphnode: a case report g. kalan * , s. tušar, n. zidar * general hospital jesenice, dept. of pathology, slovenia objective: neuroendocrine tumors (net) of appendix are believed to behave less aggressively than nets at other sites. separate staging criteria have therefore been proposed, and tumor size > cm appears to be the dominant criterion for aggressive behavior in appendiceal nets. however, it is controversial whether radical surgery is indicated in tumors measuring > cm. we report a case of a -year-old girl with acute appendicitis in whom appendectomy and right-sided hemicolectomy were performed. method: surgical specimens were sampled and processed according to standard histological and immunohistochemical (ihk) procedures. results: in the base of appendix, there was a tumor measuring . cm in diameter, focally invading mesoappendix, with free resection margins. microscopically, tumor exhibited characteristic features of net g , with positive ihk for chromogranine and synaptophysin, and ki index < %. ihk for podoplanin revealed focal lymphovascular invasion. in the right-sided hemicolectomy specimen, there was no residual tumor, metastasis was found in one ilecoecal lymphnode. conclusion: our case shows that appendiceal net smaller than cm can metastasize to regional lymphnodes. ihk against podoplanin might be helpful in searching for lymphovascular invasion, helping to separate it from the retraction clefts, thus providing additional information concerning risk factors for a more aggressive behavior. lipomatosis of ileocaecal valve causing small bowel obstruction mimicking crohn´s disease m. kalman * , p. szépe, j. marcinek, t. balhárek, l. plank * university hospital martin, dept. of pathology, slovakia objective: lipomatosis of ileocaecal valve is a rare cause of small bowel obstruction. method: we describe a -year-old male treated for crohnś disease and clinical and imaging presentation of chronic small bowel stenosis and obstruction. results: a right hemicolectomy was performed, and hypertrophy of bauhin´s valve causing intestinal obstruction was found. microscopical examination of the specimen revealed morphological changes consistent with lipomatosis of the ileocaecal valve. the ileum and colon were macroscopicaly unremarkable and histomorphological features of crohn´s disease were absent. conclusion: many patients with lipomatosis of the ileocaecal valve are asymptomatic, or the lipomatosis gives causes insignificant symptoms only or rarely obstruction may occur. then, as in the presented case, the surgical resection with ileo-colic anastomosis is the only effective treatment. overexpression of cxcr in tumor buds is a strong predictor of lymphatic invasion and lymph node metastasis in colorectal cancer e. karamitopoulou-diamantis * , d. kassahn, i. zlobec, v. koelzer, h. dawson, a. lugli * universität bern, inst. für pathologie, switzerland objective: cxc chemokines enhance tumor cell survival and proliferation. especially cxcr promotes tumor development by stimulating angiogenesis and favoring metastasis. in contrast, cxcr is angiostatic and may exert an anti-tumor effect. since tumor budding is linked to vascular/lymphatic invasion and lymph node (ln) and/or distant metastasis in colorectal cancer (crc), here we explored the expression of cxcr + in relation to tumor budding. method: a multiple-punch tissue microarray of crcs with full clinicopathological information including therapy underwent immunohistochemistry for cxcr and cxcr . expression was evaluated in tumor-center, -front and -buds and correlated to clinical data. results: cxcr -expression was homogeneous throughout tumor-center, -front and -buds (average %) and was unrelated to clinicopathological features or survival. cxcr -expression was high in tumor-center and -front but reduced (p< . ) in buds ( %, %, and %, respectively). maintenace of cxcr -expression within buds was predictive of ln-positivity (p< . ) and lymphatic invasion (p< . ) but not of venous invasion or distant metastasis. cxcr -positivity in buds was associated to poor outcome (p= . ) in ln-negative crcs (p= . ). conclusion: maintenance of cxcr -expression in buds has a profound effect on tumor aggressiveness and prognosis in ln-negative crc-patients. this would help in establishing a tumor budding "profile" especially linked to lnmetastasis in crc. objective: cox- expression was investigated in colorectal cancer and colorectal precancerous lesions. its expression in adenomas is associated with increasing size and neoplastic potential. little is known about cox- expression in subtypes of serrated colonic polyps, which constitute substantial number of colon cancer precursors. the aim of the study was to assess cox- expression in serrated polyps of the colon and to investigate its potential discriminative role. method: consecutive serrated polyps were analyzed. they included: traditional serrated adenomas (tsa), sessile serrated polyps (ssp) and hyperplastic polyps (hp). cox- expression was assessed semi-quantitatively ( - ). kruskall-wallis test was used for the comparison of cox- expression between serrated categories (α= . ). objective: in colorectal cancer (crc), tumor buds represent a more aggressive tumor cell type at the invasive front with apparently low proliferation. the aim of this study was to determine the proliferation potential of tumor buds by comparing ki staining across different tumor areas and adjacent normal tissue. method: whole tissue sections from patients with crc underwent immunohistochemistry for ki . high-powerfields were evaluated for each of the following regions: normal mucosa, tumor center, tumor front and tumor buds. ki -positivity was correlated to patient outcome. results: average ki -positivity was . % in normal mucosa and significantly higher in the tumor center ( . %; p < . ) and invasion front ( . %; p < . ). strikingly, only . % of all tumor buds showed ki -positivity (p< . ). although ki -positivity in the tumor center or front was unassociated with clinicopathological features or patient survival, the greater the number of ki -positive tumor buds, the worse the prognosis. this effect was also found after adjusting from tnm stage (hr ( % ci): . ( . - . ); p= . )). conclusion: a marked absence of ki staining is found in most tumor buds, suggesting a substantially decreased proliferation rate. however, the association of ki -positivity with worse prognosis in % of cases points towards a heterogeneous population of tumor buds. kayexalate and intestinal necrosis: an underrecognised entity p. luís * , a. alves, c. ferreira * hospital de santa maria, dept. de anatomia patológica, lisboa, portugal objective: there are only few cases of intestinal necrosis secondary to administration of kayexalate described in the literature, most of them from postoperative patients, having the largest study only patients in years. we report our experience in the last years with a brief review of the pathophysiology and histologic aspects of the lesions induced by the kayexalate. method: between and march seven patients were diagnosed with ischemic necrosis related to kayexalate administration, five in colon biopsy and two in resection specimens. they're comorbidities and clinical evolution was extracted from the medical records. results: the patients' age ranged between and years. in one case we had the clinical information of chronic renal insufficiency. in three of them, there was no previous history of renal impairment. one patient developed symptoms after one single administration of kayexalate. the clinical presentation ranged from abdominal pain, gastrointestinal bleeding and three of them had a fatal outcome. the administration of kayexalate can have associated risks with different clinical impact in any patient. we must be aware of the related complications, as the histological identification of the kayexalate crystals indicates the etiology of the ischemic lesions to the clinicians and alerts them to the dangers of this therapeutic. objective: egfr plays an important role in colorectal cancer (crc) progression and represents a natural target for molecular anticancer drugs. in this study we evaluated consecutive crc aimed to analyze k-ras mutational status in relationship to: different clinical-pathological parameters, egfr immunohistochemical (ihc) expression, response to cetuximab treatment. method: k-ras mutations and egfr expression were determined by direct cycle sequencing and ihc respectively in surgical specimens and biopsies. ihc findings were evaluated using four different score systems. results: the distribution of k-ras mutations did not significantly vary between surgical or bioptic specimens or with respect to different anatomic tumor localization. in contrast, k-ras is more frequently mutated in egfr negative/low score tumors than in positive ones (p< . ). focusing on the surgical treated crc patients, we found a higher percentage of k-ras mutations in t crc (p= . ) and in younger patients (p= . ). finally, we observed that % of primary crc, concomitantly evaluated with their paired metastases, changed k-ras mutational status during progression. conclusion: our data showed that tumor size, patient age and egfr ihc expression significantly influenced k-ras mutations. interestingly, we observed that cetuximab treated patients, had a better clinical outcome when egfr presented a high ihc score. multiple immunohistochemical investigation of signaling pathways in colorectal cancer t. micsik * , l. kopper, t. krenács, z. nagy, o. horváth * semmelweis university budapest, st department of pathology, hungary objective: despite the recent advances in therapeutic armamnet colorectal cancer (crc) remains one of the leading cancer deaths worlwide. crc has a heterogenous molecular background with known prognostic and predictive markers, but the whole picture is rather complex with many unexplored connections. method: we performed multiple immunohistochemical stainings on tissue microarrays (tma) made of crc cases to study the correlations between egfr-ras, cell cycling, apoptosis, cell adhesion and tumor invasion pathways. we evaluated digitized slides using matrix scores considering both the frequency and positivity of cells and statistical analysis followed. results: we found strong linear correlation between positivity and (p- , p- ) phosphorylation of the egfr receptor and p positivity detected with different clones. furthermore, phospho-nf-kb p positivity was strongly linked to survivin-expression. conclusion: activation of egfr-related pathways including nf-kb is a key factor in crc-growth. the strong link between cancer promoting egfr signaling and the mutational lack of the p driven apoptosis suggests a deadly cooperation, which can be further aggravated by forced tumor survival through survivin. correlation of these markers potentially predict poor disease outcome but can be specifically targeted by the upcoming new molecules of tailored therapy. objective: kras mutational status is important in colorectal carcinoma (crc). it is unclear, however, which is the most informative tissue source for study in crc cases showing more than one tumor mass. to explore this issue we determined kras status in a series of primary (pt) and metastatic crcs. method: a total of tumors belonging to patients ( males and females) with ages ranging between and years (average, years) were studied. kras mutation hotspots in codon and were analyzed by polymerase chain reaction and sequentiation. wt-kras cases were confirmed with the kras stripassay tm. objective: lynch syndrome (ls), the most frequent form of hereditary colorectal cancer (crc), is caused by germline mutations in the mismatch repair system genes. a recently identified mechanism involving the epcam gene is responsible for . % of msh -negative ls cases. we herein explore epcam protein expression in ls-associated, msh -negative crcs to evaluate its potential value in the algorithmic approach to ls population screening. method: we studied a total of msh -negative crcs from different patients in whom we were able to perform a complete germline analysis. expression of both msh ( : dilution, clone g - , pharmingen) and epcam ( : dilution, clone ber-ep , dako) was evaluated by immunohistochemistry (ihc). results: nine patients showed a deleterious germline mutation that involved the msh gene in three instances and the epcam gene exon in six instances. all patients harbouring the epcam mutation belonged to the same family. of the crcs, epcam expression loss was seen in only five, all of them were from patients with a germline epcam deletion. conclusion: due to the high specificity of epcam protein loss for identifying ls patients with an epcam deletion, we recommend adding epcam ihc to the ls diagnostic algorithm in msh -negative crc cases. objective: colorectal carcinoma with signet ring cell component (crc-src) is a rare and distinct subtype with little molecular information. we investigated the frequency of braf mutation in crc-srcs and its relation with clinicopathologic parameters. method: we categorized tumors into groups - %, - %, - % and > % according to signet ring cell component. genomic dna was isolated from parafin blocks and analyzed for braf v e mutation by polymerase chain reactionrestriction fragment length polymorphism (pcr-rflp). results: eleven of cases showed braf mutation ( . %). the results were also confirmed with sequence. no statistically significant differences were found in clinicopatologic parameters between braf wild-type and mutant crc-src. on the other hand, when we adjusted age, gender, percentage of signet ring compenent and stage, we found a statistically significant increased risk in braf mutant group compared to braf wild-type in cox regression analysis (hr= . , % ci= . - . , p= , ) conclusion: braf mutation is frequent in crc-srcs. this finding may support its diverse molecular pathogenesis and could have important therapeutic implications for those patients. to clarify the relation of braf mutation with clinicopathologic parameters and prognosis in crc-src, studies with multi-instutional larger series are needed. coexisting lipomas and adenocarcinoma of the colon: case report g. orgun sonmez * , u. bayol, o. akman, s. cumurcu, m. olmez * tepecik research and training hospital, izmir, turkey objective: lipomas of the large bowel are rare, they are invariably submucosal and therefore may intussuscept. infrequently lipomas may also present in the form of multiple polypoid masses in the colon. we present a -years old female with submucosal lipomas and a coexisting adenocarcinoma of transverse colon. method: -years old female patient was admitted to hospital because of rectal bleeding for months. colonoscopic examination revealed mucosaly intact polypoid tumoral masses and an ulcerated tumoral mass in transverse colon. biopsy of the ulcerated mass was diagnosed as adenocarcinoma. extended right hemicolectomy was performed. results: grossly, ulcerated tumor was , × × , cm and there were polypoid tumors in cecal area of the right colon which were . - . - . cm in their greatest dimensions. polypoid tumors were yellow, lipomatous on cut surfaces. microscopically ulcerated tumor was composed of adenocarcinoma morphology and the other polypoid tumors were composed of submucosal mature adipocytes with a thin capsule around them. the diagnosis was colonic adenocarcinoma (pt n m ) and submucosal lipomas of colon. the patient had no additional therapy and she is healthy with no evidence of recurrence. conclusion: this case is presented to remind that there may be multiple lipomas of colon with coexisting malignant epithelial tumors. objective: primary liposarcoma of the small intestine is exceedingly rare. to our knowledge, only cases have been reported so far. we report a case of the primary myxoid liposarcoma of the ileum. method: the patient was -year-old woman. ct and mri revealed a -cm-intrapelvic mass, which was proved to be a tumor of the distal part of the ileum, and, therefore, partial ileectomy was performed. results: the tumor was . × . × . cm in size, relatively well circumscribed and located within the intestinal wall without invasion to the neighboring tissues. microscopically, the tumor had mixture of cellular and myxoid areas, showing proliferation of short spindle and stellate shaped cells in a delicate capillary vasculature. univacuolated tumor cells and a small number of lipoblast-like cells were also seen. immunohistochemically, these proliferating cells were positive for s- protein. according to these pathological findings, we diagnosed the tumor as myxoid liposarcoma. fish methods showed the tumor had chromosomal translocation t( ; )(q ;p ). conclusion: the differential diagnosis of this includes other spindle cell tumors such as gist and myogenic tumors. but we could arrive at the proper pathological diansosis following the above morphological features and the specific chromosomal translocation. we will also discuss the clinico-pathological features of the cases including ours. prognostic significance of selected immunohistochemical markers in colorectal cancer e. paltseva * , o. samofalova, y. gorbacheva, p. tsarkov * first moscow state medical university, pathology, russia objective: the aim of our study was to identify a combination of markers whose expression is predictive of invasion and metastasis of colorectal carcinoma. method: the expression of e-cadherin, β-catenin, tenascin c, kai- , epidermal growth factor receptor (egfr) and vascular endothelial growth factor (vegf) was studied immunohistochemically and correlated clinicopathologically in primary colorectal carcinoma cases ( with metastatic lymph nodes). patients ( %) developed haematogenous metastases at median , months postoperatively ( - ). results: expression of following markers significantly correlated with depth of tumour invasion: cytoplasmic accumulation of e-cadherin (p= , ), nuclear staining for β-catenin (p= , ), increased tenascin c expression (p= , ), and loss of egfr and vegf expression (p= , and , , respectively). decreased tenascin c and kai- expression associated with the presence of lymph node metastases (p= , and , , respectively). weak cytoplasmic e-cadherin expression correlated with distant metastases (p= , ). conclusion: our results suggest that abnormal expression of proteins involved in cell adhesion and migration (e-cadherin, βcatenin, tenascin c, egfr) and angiogenesis (vegf) may be related to the invasion of colorectal carcinoma. detecting the expression of e-cadherin, tenascin c and kai- probably possesses clinical significance in evaluating lymph node and distant metastasis and predicting the prognosis of colorectal cancer. objective: in colorectal adenocarcinomas (crcs) microsatellite instability (msi) can be documented by immunohistochemical detection of mismatch repair proteins (mmr). the aim of the present study is to identify the percentage of msi-positive crcs, in the epirus region of greece and compare it to the international data. method: a total of cases of sporadic crcs, adenomas and hyperplastic polyps, formalin-fixed paraffinembedded, were examined immunohistochemically using standard methods (en vision system), with the antibodies mlh (clone es ), msh (clone pu ) and pms (clone m r g) (novocastra-menarini). immunostained sections were evaluated semi-quantitatively, taking in account the percentage of neoplastic positive cells and estimating nuclear staining intensity, compared to the internal positive controls (normal epithelium, lymphocytes). results: all hyperplastic polyps and adenomas expressed the examined mmr. two out of crcs were negative for msh and pms , while one of them was also negative for mlh . interestingly, one of these two crcs had an adjacent adenoma, which also showed negative staining for msh and pms . conclusion: immunohistochemical staining for mmr is possible in archival material. loss of mmr varies, depending on the protein examined. in crcs from the epirus region the estimated loss of at least two mmr is %. objective: matrix metalloproteinases (mmps) are a family of zinc-dependent neutral endopeptidases collectively capable of degrading essentially all extracellular matrix (ecm) components. genetic alterations in mmp- and mmp- have been implicated to play an important role in colorectal carcinogenesis (crc). the aim of this study was to investigate the hypothetic correlations between the mmp- and mrna expression and the clinicopathologic variables of the crc. method: the expression of mmp- and - mrna was assayed by rt-pcr for tunisian sporadic colorectal adenocarcinomas. results: mmp- was highly expressed in the cases. mmp- was not detected in cases and moderately or highly expressed in cases. absence of mmp- mrna expression was significantly related to an advanced tumoral invasion stage (pt ) (p= . ). conclusion: our study suggests that the overexpression of mmp- could be the result of an imbalance in the system of transcriptional regulation of mmp- , which would involve the loss of expression or activity of its inhibitor: timp- . a variable expression of transcripts of mmp- could be explained by the hypothesis of hypermethylation of the promoter or degradation of its transcript after protein translation. relationship between matrix metalloproteinases and promoter polymorphisms and colorectal cancer risk objective: the carcinogenic schema of colorectal cancer (crc) follows a multistep process governed by mutational events that affect multiple micro-environmental factors, including matrix metalloproteinases (mmps). this present work aims to contribute to a better understanding of mmp- and - promoter polymorphisms involvements in the genesis and progression of sporadic crc in tunisian population. method: the mmp- and mmp- promoter genotypes were determined by pcr-rflp in tunisian patients with sporadic colorectal cancer and healthy control subjects. results: no significant associations were found regarding mmp- (- c/t) polymorphism and crc susceptibility. there was a connection between the mmp- - promoter polymorphism and gender (p = . ). the mmp- (− c/t) was significantly associated with crc (or= . [ . to . ]). no implication of mmp- - promoter polymorphism in the clinicopathological parameters of crc was evident. conclusion: our findings suggest that the mmp- promoter polymorphism was not a predictive factor for the crc occurrence while the mmp- - ct genotype was a risk factor for crc susceptibility. hodgkin's lymphoma in distal rectum in a patient with crohn´disease treated by biologic therapy -a case report r. sampaio * , f. costa, e. diane, j. palla garcia, j. r. vizcaino * anatomia patológica, valpaços, portugal objective: rare cases of hodgkin`s lymphoma have been reported in the setting of inflammatory bowel disease. method: we report a case of hodgkin`s lymphoma in a years old male patient with corticosteroid-dependent crohn´disease (cd) who had been medicated with azathioprine for many years. in the last years he began periodical therapy with infliximab, till the time when he complained of worsening of symptoms and the appearance of asthenia, tenesmus and weight loss. infliximab was withdrawn and replaced by adalimumab. a colonoscopy with several biopsies revealed the presence of a hodgkin lymphoma. results: the histological examination revealed granulation tissues where we identified atypical cells (reed-sternberg cells) with the following immunohistological staining: cd +, cd +, lmp + lca-, cd -, cd -, alk-. these results in conjunction with the morphological aspects and the clinical history of cd favored the diagnosis of hodgkin lymphoma in a patient with preceding cd. the patient was subjected to radical colectomy. postoperative pathological examination showed cd with involvement of the distal rectum by hodgkin's lymphoma. conclusion: the present report may serve as a reminder to clinicians of the possibility of occult lymphoma in patients with colonic cd treated with biological therapy. objective: dna mismatch repair (mmr) status in sporadic colonic cancers (ccs) had provided valuable prognostic and predictive information in the appropriate clinical setting; however there are no definitive guidelines for microsatellite instability (msi) testing. we evaluated the expression of mmr proteins and correlated them with outcome in a cohort of patients with sporadic colon cancer. method: we reviewed cases of sporadic stage ii colonic cancer from abril th to december th . clinical data including tumor grade, prognostic factors, therapy and outcome were searched for. tissue microarrays using a manual beecher system were constructed and stained with antibodies for mlh , msh , pms and msh . results: % ( ) of ccs had loss of expression of one or more mmr proteins, including defect in protein . % ( ), proteins , % ( ) and tree proteins , %( ). the mean overall survival was months with no significant differences in patients between microsatellite stable and unstable tumors. conclusion: we detected a fairly low prevalence of the loss of immunohistochemical expression of mmr proteins. this result might have influence our mean overall survival between microsatellite stable and unstable tumors. the pathological effects of orchidectomy on intestine tissue and serum level of carcino embryogenic antigen s. sattari * , r. ahmadi * azad university of iran, science dept., hamedan, iran objective: carcino embryogenic antigen (cea) is a wellknown tumor marker influenced by carcinogenic changes in intestine tissue. the purpose of this study was to determine the effects of orchidectomy on serum level of cea and histological changes of intestine in male rats. method: male wistar rats were randomly divided to control, sham, uni-orchidetomised and biorchidectomised groups of in each. weeks after operation, blood samples were collected using cardiac puncture method. serum cea level was measured using elisa method. the effect of orchidectomy on intestine tissue was also histologically studied. the results were statistically analyzed using anova. results: serum level of cea was significantly increased in orchidectomised rats compared with control animals (p< . ). the increase in serum cea level was more in biorchidectomised than uniorchidectomised rats (p< . ). there was also an enhancement in tissue lymphocytes, plasma cells and inflammation in intestine of orchidectomised animals. the results showed that orchidectomy results in pathological changes in intestine tissue leading to increased serum cea level. the plasma cells density in pararectal lymph nodes of patients with rectal cancer after neoadjuvant therapy m. sezak * , n. ozsan, b. pehlivanoglu, s. ozkok, t. yoldas, b. daganavsargil * ege university, dept. of pathology, izmir, turkey objective: neoadjuvant chemoradiotherapy (nt) is standard procedure for locally advanced rectal cancer. in this study, we compared the morphology of lymph nodes and the amount of plasma cells in the interfollicular region of lymph nodes in rectal tumour surgical excision material, between two groups who had received and not received nt prior to surgery. method: fifty cases with nt and forty cases without nt were included. the number and diameter of lymph nodes were recorded. the morphology of the lymph nodes were evaluated, and the percentages of interfollicular plasma cells were demonstrated immunohistochemically (cd ). tumor regression grade was assessed using mandard scoring system. results: average number and diameter of lymph nodes were greater in patients without nt (p< , ). atrophy of germinal centers was noted as % in nt group, versus %. the amount of plasma cells in the interfollicular region was found to be higher than fifty-one percent in % of nt group versus % (p< , ), as well. complete response rate (mandard's: ) was %. no significant association was found between the amount of plasma cells and tumor regression. conclusion: nt leads to a decrease in the volume of the lymph nodes and atrophy of germinal centers, conversely, causes stimulation of the proliferation of interfollicular plasma cells. adenomyoma of the ileum: pathohistological features with reference to pathogenesis b. snezana * , b. andrejic, n. solajic * clinical center of vojvodina, center for pathology, novi sad, serbia objective: adenomyoma is a rare benign non-neoplastic tumor-like lesion. it originates from abnormal embryonic buds but its pathogenesis has not been fully elucidated. method: a -year old man with severe pain, intussusception and ileus underwent a resection of a part of the intestine containing a tumor mass acting as a lead point. tissue was analysed using h&e, histochemical and immunohistochemical stains. results: lesion located in the mucosa, submucosa and muscularis propria consisted of glandular structures varying in size and morphology, the larger ones containing papillary projections and the smaller ones being similar to brunner's and peribiliary glands, both of them surrounded by smooth muscle bundles. the lesion was not accompanied by ectopic pancreas, and it indicated a diagnosis of adenomyoma of the ileum. glandular elements were ck + and ck − and cdx- −, opposite to intestinal mucosa. conclusion: adenomyoma is a mass lesion rarely found distal to the duodenum, which bares close clinical and morfological resemblance to a tumor and some non-neoplastic conditions. cytokeratin expression favors the heterotopic pancreas theory of pathogenesis, but abnormal interaction between the endoderm-and mesoderm-derived tissues can not be excluded. smoothelin in biopsies of colorectal carcinomas as marker of muscularis propria invasion p. stoemmer * , p. torres-galea * gemeinschaftspraxis pathologie, forschungslabor, augsburg, germany objective: staging of colorectal carcinomas is of eminent importance for prognostication and treatment; preoperative distinction between high grade dysplasia, invasion of submucosa (with permigration of the muscularis mucosae mm) and infiltration of muscularis propria (mp) is difficult in biopsies, due to similarities of smooth muscle cells in mm and mp. smoothelin is a robust marker of the mp in normal colon, not expressed in mm.we analysed it value for distinguishing mp and mm near carcinomas. objective: tuberculosis can affect any part of the gastrointestinal tract. anal localization, in particular, has a very low incidence ( , %). method: a year-old male presented, complaining of perianal pain, constipation, weight loss of kilos the last months and night sweating. physical examination was normal, except for an ulcerated lesion in the anal region. the patient was submitted to computerized tomography (ct) and incisional biopsy of the lesion. results: the ct of the chest revealed multiple, scattered, calcified nodules in the upper zones of both lungs and histological examination showed confluent, non-necrotizing, epithelioid granulomas with the presence of langhans' multinucleated giant cells. acid-fast bacilli were detected both within the anal lesion and in the sputum. mantoux test was positive. the patient had a history of pulmonary tuberculosis years ago. a diagnosis of anal tuberculosis was made and the patient was put on a four drug anti-tuberculous regimen. in months the symptoms improved and the perianal lesion healed. conclusion: a tuberculous origin must be considered when the cause of anal and perianal lesions is unclear. therefore histological and bacteriological confirmation is essential in order to avoid undue delay in diagnosis and treatment. the relation of braf v e mutation and microsatellite instability in colorectal carcinomas i. turkmen * , n. bassüllü, b. toptas, t. Öztürk, r. yasar, p. korkmaz, n. saygili, o. Öztürk, g. demir, g. dogusoy * istanbul bilim university, dept. of pathology, istanbul, turkey objective: colorectal carcinogenesis is associated with various morphological and molecular pathways. microsatellite instability (msi) pathway has familial and sporadic forms. among crc's % of the sporadic cases are associated with msi and these have hypermethylation of the mlh promoter associated with braf v e gene mutation. familial forms do not show braf v e mutation. method: we investigated the microsatellite instability (msi) by immunohistochemical study of mlh , pms , msh and msh together with the braf mutation presence and their correlation with standard histopathological parameters in sporadic crc cases. results: the age distribution was - with an average of , . immunohistochemical expression loss of mlh , pms , msh and msh was seen in , %, , %, , % and , % of the total cases respectively. msi was seen in , % of the cases. the braf v e gene mutation was seen in cases and among these cases ( , %) showed msi, while msi frequency was , in non-mutated group. and this was statistically significant (p < . ). msi was found significantly correlated with grade and lymph node number (p< . ). conclusion: our study confirmed that sporadic cases of crc with msi are associated with the braf v e gene mutation. msi is correlated with histologic grade and dissected lymph node number. colon biopsy diagnostics may reliably be performed using virtual microscopy objective: virtual microscopy using whole slide images (wsis) is a feasible alternative to optical microscopy, offering major advantages for pathology practice. the present study aims to prove reliability of this promising technique for colon biopsy diagnostics. method: colon biopsies (n= ) were assessed (into main diagnostic groups) using both glass slides and wsis by pathologists and residents. two of the pathologists having ample experience using wsis, scored the biopsies in a primary diagnostic setting. for each case the criterion standard diagnosis was defined based on glass slide diagnoses. accuracy was defined as the percentage of concordance with the criterion standard. kappa statistics were calculated as a measure of observer agreement. results: the overall concordance rates were . % for wsis and . % for conventional microscopy. the intraobserver (wsis versus glass slides) agreement was good to excellent, with kappa values ranging from . to . (mean . ) and was higher than the interobserver agreement for glass slides (mean . ). concordance with the criterion standard varied less between wsis and glass slides in the diagnoses of pathologists with virtual experience. conclusion: this study showed good diagnostic accuracy and reproducibility for wsis, indicating this technology may be used for colon biopsy diagnostics. intestinal occlusion due to colonic lipoma: a case report f. vukmirovic * * clinical center of montenegro, dept. of pathology, podgorica, montenegro objective: lipomas of the digestive tract are rare benign tumor and most often found incidentally during a colonoscopy, computed tomography scan, surgery or autopsy. lipomas of the colon were first reported by bauer in and are most often located in the ascending colon. the incidence of this lesion is estimated between . and . % and represents . % of the colonic benign lesions. we report a case of patient with symptoms of ileus due to colonic lipoma. method: a -year-old man patient was urgently admitted with symptoms of ileus. right hemicolectomy was performed, and clinical impression was that it was a malignant tumor. results: examination of the cecum we found polypoid whitish yellow tumor, size × , cm. on histology the tumor was composed of mature adipose tissue without cellular atypia. the tumor was located into submucosa. larger parts of the surface mucosa was eroded. the postoperative course was uneventful and intestinal passage was quickly established. conclusion: although colonic lipomas seldom cause severe symptoms in patients and are easily removed by endoscope while they are small, severe symptoms like abdominal fullness, intestinal obstruction, intestinal bleeding and intussusceptions may appear as a lipoma grows larger. in some cases lipoma may clinically mimic colonic carcinoma. prognostic impact of lymph node ratio outperforms positive lymph nodes and lymph nodes harvested: a time-dependent analysis in mismatch repair-proficient and -deficient colorectal cancers i. zlobec * , e. karamitopoulou, l. terracciano, d. inderbitzin, a. lugli * university of berne, inst. of pathology, bern, switzerland objective: we compare the prognostic strength of the lymph node ratio (lnr), positive lymph nodes (+lns) and collected lymph nodes (lncoll) using a time-dependent analysis in colorectal cancer patients stratified by mismatch repair (mmr) status. method: stage iii-iv patients were included. multivariable cox regression analysis and time-dependent receiver operating characteristic (troc) curve analysis were performed. the area under the curve (auc) over time was compared for the three features. results were validated on a second cohort of stage iii-iv patients. results: the auc for the lnr was . and outperformed + lns and lncoll by - % in both mmr-proficient and -deficient cancers. lnr and + lns were both significant (p < . ) in multivariable analysis but the effect was considerably stronger for the lnr [lnr: hr= . ( % ci: . - . ); +lns= . ( % ci: . - . )]. similar results were obtained for patients with > lncoll. an optimal cutoff score for lnr = . was validated on the second cohort (p< . ). conclusion: the lnr outperforms the + lns and lncoll even in patients with > lncoll. its clinical value is not confounded by mmr status. a cut-of score of . may best stratify patients into prognostic subgroups and could be a basis for the future prospective analysis of the lnr. prognostic value of tumor-stroma ratio in rectal adenocarcinomas s. zoidze * , r. scheer, j. klaase, m. elferink, a. baidoshvili * laboratorium pathologie oost, enschede, netherlands objective: recently, tumor-stroma ratio (tsr) has been identified as a strong predictor for survival in colorectal cancer. despite an identical biology clinical implications are quite different for colon and rectal cancer regarding to anatomical differences. method: tsr was estimated on h&e stained histological sections of patients who underwent resection for rectal adenocarcinoma between and . none of these patients had received neoadjuvant chemo-or radiotherapy. the tsr was determined, by two independent investigators, in different layers of the rectal wall at the point of highest tumor infiltration and at the border of the tumor. tsrs were categorized into three categories: tsr-low, tsr-moderate and tsr-high. results: patients with stage i and ii disease (t - n ) and tsr-high showed significantly better year survival rates for overall survival compared to tsr-low and tsr-moderate (p= . ) and a trend to a better disease specific survival (p= . ) and disease free survival ( . ). in a multivariate cox regression analysis the tsr remained an independent prognostic factor for overall survival, when adjusted for age, pt-status and grading. conclusion: tsr as a prognostic tumor characteristic can be used to identify patients with a good and a poor outcome in lymph node metastasis negative cases. objective: goblet cell carcinoid (gcc) of appendix vermiformis is a rare neoplasm that share histological features of both adenocarcinoma and carcinoid tumor. while its malignant potential remains unclear, gcc's particularly show transmural dissemination and are more aggressive than conventional carcinoids. patients usually present with acute appendicitis. they usually lack the formation of a well-defined tumor mass; thus, it is somewhat difficult to accurately assess their size. method: case presentation: fifty years old male patient applied to the emergency service with abdominal pain and laparatomy was performed with suspicion of acute appendicitis. grossly, conjestion and exudation on the distal edge of appendectomy material were seen. a × cm lesion which was spreading into peripheral adipose tissue was seen on the cut surface. microscopically, tumor was composed of goblet cell groups resembling "signet ring cells". tumor was infiltrated into muscularis propria and mesoappendix. immunohistochemically, chromogranin, synaptophysin, cytokeratin , mcea and p were stained positive. ki (mib ) proliferation index was %. conclusion: adenocarcinoid of the appendix is a rare tumor, which is very difficult to diagnose preoperatively and even macroscopically, making histological examination essential. immunohistochemical staining is required for definitive and differential diagnosis. here, we present this rare case with literature reviewed. normal colon tissue and colon carcinoma show no difference in heparanase promoter methylation d. hershkovitz * , y. peerless, e. simon, e. sabo, o. ben-izhak * rambam health care campus, dept. of pathology, haifa, israel objective: heparanase, the sole heparan sulfate degrading enzyme, has a role in cellular invasion. accordingly, a large number of studies have demonstrated an association between heparanse expression and tumor stage and patients' prognosis. in colon carcinoma, heparanase shows increased expression in tumor compared to normal tissue and its expression correlates with the presence of metastasis. one of the regulatory mechanisms of heparanase expression is methylation on its promoter. in the present study we evaluated the role of heparanse promoter methylation in colon carcinoma. method: analysis of heparanse promoter methylation was done on samples of colon carcinoma as well as sample of normal colonic mucosa. dna was extracted from ffpe tissue and subjected to bisulfite conversion. the relative fraction of methylated and unmethylated dna was evaluated with real-time pcr. results: the fraction of methylated dna was %± . in the colon carcinoma group, and . %± . in the normal colon group (p= . ). only one case in the normal group and one case in the tumor group showed more than % methylation in the heparanase promoter. conclusion: we did not find any difference in heparanase promoter methylation between colon carcinoma and normal colonic mucosa, suggesting that heparanase overexpression in colon carcinoma is mediated by other mechanisms. objective: among b-cell non-hodgkin's lymphomas, neural cell adhesion molecule/cd expression is exceptional. the aim of this study is to report unusual cd (neural cell adhesion molecule, ncam) expression on diffuse large b cell lymphoma (dlbcl). method: the panel of antibodies included cd , cd , cd , bcl- , bcl- , mum- and cd . results: a total of cases of dlbcl were identified and one case was also detected positive for cd . the subject was female, years old. the patient had presented generalized lymphadenopathy. she had not documented involvement of extranodal sites. the case is alive with disease year after diagnosis and chemotherapy treatment. objective: a case of mediastinal t-cell lymphoblastic lymphoma with indolent clinical course in a -yearold man was studied by immunohistology and molecular biology. method: formalin-fixed sample. histology with ematox-ilin&eosin and giemsa; immunohistochemistry by apaap method. t-cell receptor gamma rearrangement by biomed protocols. results: after one fainting episode the patient was found to have pericarditis caused by a xx-cm-diameter mediastinal mass. the first biopsies were unsuccessful and the third diagnostic one was done months later. in this time-period the patient was well without symptoms and the mass stable. after two mediastinal biopsies with unspecific features (castleman disease?), the diagnostic one showed fibrosis, abundant small reactive lymphocytes (cd +/cd +) and areas with diffuse small-medium size lymphocytes positive for cd , tdt, cd , cd , lmo and high ki . t-cell receptor gamma genes were monoclonally rearranged. conclusion: indolent t-lbl is exceedingly rare: for this reason in our case lmo was a key marker for the diagnosis which was delayed for the presence of fibrosis and reactive b cells. objective: granulocytic sarcoma (gs), also termed myeloid sarcoma or chloroma, is a rare malignant solid tumor resulting from the extramedullary proliferation of myeloblasts or immature myeloid cells. gs most frequently occurs in patients with acute myeloid leukemia, myeloproliferative neoplasms or myelodysplasia. gs rarely presents in the absence of systemic myeloid disease. gs most commonly occurs in the soft tissues of the head and neck, bone, skin and less often in the central nervous system and spinal cord. results: a year old woman presented with month history of weakness of both legs. mri of the thoracal spine showed cm diameter epidural mass compressing the dural sac in the spinal canal at the t - levels. decompressive laminectomy and tumor removal were performed resulting in neurological improvement. histologically neoplastic cells have round nuclei with finely dispersed chromatin and scant cytoplasm proliferating in a diffuse pattern. immunohistochemically, tumor cells were positive for mpo, cd , cd , cd . diagnosis was gs without bone marrow involvement. conclusion: we report the case of gs due to unusual localization and nonleukemic presentation. results: there were males and female with a median age of years ( - years). physical examination shows splenomegaly in all cases and hepatomegaly in cases, hematological parameters shows lymphocytosis with peripheral hairy cells in all cases. flow cytometric immunophenotyping was done in cases, and confirmed the diagnosis of hcl with cd c, cd +, cd +, cd +, and cd -, cd -, and cd -. bone marrow biopsy was done in all cases, showing massive infiltration with villous cytoplasmic projection cells that were cd positive. the treatment consists of blood transfusion in all cases, associated with splenectomy in cases, only patient was treated with ( cda: cladribine) with a complete remission after a follow up of months. conclusion: hcl has consistent cytologic histologic and immunologic features that make classification reliable and reproducible; it remains problematic because of the variety of the disorders and the differential diagnosis of splenic lymphoma of the marginal zone. objective: primary cns lymphomas (pcnsl) are uncommon tumors in immunocompetent patients, they represent up to % of non hodgkin lymphomas (nhl) and - % of all brain tumors. the majority of pcnsl are diffuse large b cell lymphomas, - % are t cell lymphomas, in rare instances low grade b cell lymphomas. we determine clinical characteristics, histological findings and treatment outcome of pcnsl. method: five cases of pcnsl occurring between and were retrospectively reviewed. results: they were males, female, median age years, range ( - ). most common symptom was neurological deficits ( cases). mri of the brain revealed an expansive tumor affecting the parietal bone in cases, the temporal bone in cases and the frontal bone in case. immunohistological finding showed large b-cell nhl in cases, anaplastic lymphoma in cases, and large-cell immunoblastic lymphoma in case. treatment consists on exclusive tumoral resection in cases, surgery and chemotherapy ( case), complicated by death in all these cases. surgery followed by high dose chemotherapy and radiotherapy ( case) with complete remission after a follow-up of years. conclusion: chemotherapy followed by involved field irradiation appears to be an adapted therapy. objective: primary cutaneous non-hodgkin's lymphoma (pcnhl) is defined as lymphoma limited to skin without extra-cutaneous involvement at presentation. we describe here epidemiological and histo-pathological aspects of pcnhl. method: retrospective review of clinical data of pcnhl patients diagnosed in hematology department, frahet hached hospital, sousse ( . results: fourty three patients with pcnhl, median age: years ( - ), sex-ratio was . . the site of cutaneous involvement was upper lumb in cases, lower lumb in cases and disseminated in cases. pcnhl was small t cell lymphoma in cases, large b cell lymphoma in cases, anaplastic, cd + cd + hematodermic neoplasm, and follicular type in case respectively. according to tnm classification cases were t bnxmx, cases were t n m . after first line therapy, patients in cr, pr was obtained in case and failure in cases, patients relapsed within to months (median months), all of them were disseminated cases. conclusion: our study indicate that the extend of cutaneous involvement at the time of diagnosis is a significant prognostic factor in pcnhl. objective: follicular lymphomas (fls) account for one third of non hodgkin lymphomas (nhls) in adults. the disease is characterized by a response to initial treatment, followed by relapses, sometimes associated with histologic transformation into high grade nhl. analyze epidemiological characteristics of patients with fl. method: retrospective study of of adult fls diagnosed in hematology department ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results: median age was years ( - ), sex-ratio: . the most frequent clinical symptom at diagnosis was lymphadenopathy in cases. involvement of the spleen in cases. b symptoms were present in cases. performance status was more than in cases. according to the international prognostic index (flipi), patients have low index, have intermediate index, and have high index. grade fl was seen in the majority of cases. treatment modalities varied over time and according to the disponibility of drugs especially to anti cd monoclonal antibody. cr was obtained in cases, pr in cases; patients relapsed within - months. histologic transformation was seen in cases, we have noted deaths related to the disease in cases. conclusion: treatment results in fl might not only be improved by more effective induction regimens but also by maintenance treatment. objective: cd and fli- are widely used for their diagnostic utility in ewing sarcoma/peripheral neuroectodermal tumor (es/pnet). cd expression has been documented in a variety of tumors, including lymphoid malignancies of t cell origin. also fli- expression is common in different tumor types. however, few studies have investigated the cd and fli- immunoreactivity in diffuse large b-cell lymphoma (dlbcl). we aimed to determine the frequencies of cd and fli- immunohistochemical expressions in dlbcl which may lead to a misdiagnosis. method: cd and fli- expressions are retrospectively investigated by immunoperoxidase staining in prechemoterapy primary tumors of dlbcl cases. results: out of cases, cd and fli- expressions were observed in ( . %) and ( . %) tumors, respectively. concomittant expressions of cd and fli- proteins were found in / ( . %) cases. the present study revealed that cd and fli- are frequently expressed in dlbcl, thus dlbcl should be considered in the differential diagnosis of cd + and fli- + neoplasms. primary cutaneous marginal zone lymphoma with biclonality e. beretouli * , t. koletsa, a. bouzakis, s. mavropoulou, g. karkavelas, i. kostopoulos * ahepa hospital, dept. of pathology, thessaloniki, greece objective: primary cutaneous marginal zone lymphoma (pcmzl) represents a b-cell lymphoma which presents with papules, plaques or nodes. the presence of a monotypical light chain b cell population supports the diagnosis of pcmzl. we describe a case of pcmzl which showed different light chain restriction in two heterochronous lesions. method: Α year-old male patient presented in with a cutaneous nodule in the anterior surface of the tibia, which was totally excised. the patient did not show other lesions since , when a new cutaneous nodule located in the right ankle, was appeared. immunohistochemical analysis was performed in both biopsies. results: histological and immunohistochemical findings of both biopsies were consistent with marginal zone lymphoma of the skin with lambda light chain restriction in the biopsy of the first lesion and kappa light chain restriction in the biopsy of the second lesion. blood laboratory studies, chest and abdominal computerized tomography scans revealed no evidence of systemic involvement by lymphoma. conclusion: the finding of both kappa and lamda light chain restricted b cell populations in pcmzl is unusual. the monoclonal light chain switching in pcmzl is rare and its pathogenesis is discussed. objective: microvessel density (mvd) has prognostic significance in some malignancies. little information exists about angiogenesis in mantle cell lymphoma (mcl), although antiangiogenic drugs are used experimentally. prognostic factors of mcl are needed as outcome and therapy are heterogeneous and often unsatisfactory. the aim is to assess mvd in mcl and to evaluate its prognostic significance. method: mcl specimens (ffpe) were examined by immunohistochemistry with anti-cd antibody. mvd was quantified using systematic uniform random sampling and unbiased counting frames. clinical data were analyzed in kaplan-meier survival curves and log-rank test. results: median survival (ms) of all patients was months, median progression-free survival (mpfs) months. mean mvd was , microvessels/mm , median , /mm . dividing cases into quartiles: < , /mm , < , /mm , < , /mm and ≥ , /mm ( , , , cases), ms and mpfs did not differ statistically significantly between these groups (p= , ; similar for therapy groups). visible differences are only between the fourth quartile and the rest: objective: plasmablastic lymphoma (pbl) is a rare aggressive subtype of diffuse large-b-cell lymphoma which occurs primarily in the oral cavity of hiv-positive patients. it is extremely rare in immunocompetent patients. method: a total of cases of pb were retrospectively analyzed. all cases had tissue available for immunohistochemistry and in situ hybridization. results: the age range of the patients was - years (median ) and all were men. three patients were hiv negative. hiv + patients: tumors involved the oral cavity (n = ), and small intestine (n= ). hiv-patients: tumors were located in bone marrow (n= ) and lymph nodes (n= ). all tumors were composed of monomorphic plasmablastic cells. tumors were negative for cd and cd , while they showed diffuse positivity for cd , cd , mum and ema. by ish, monoclonal light chain restriction was detected. ebv (eber) was positive in all cases. the median overall survival was , months regardless of the intensity of chemotherapy. only one patient is alive month after diagnosis. conclusion: pbl may appear in non immunocompromised patients and other locations than oral cavity. any patient diagnosed with pbl should be tested for hiv. patients who had hiv-negative pbl have lower rates of oral involvement. spinal granulocytic sarcoma preceding clinical manifestation of acute myeloid leukemia v. cemerikic-martinovic * , n. drndarevic, n. andjelkovic, p. djordjevic, d. jovanovic, r. nikolic, t. martinovic * beo-lab, dept. of pathology, belgrade, serbia objective: granulocytic sarcoma is a rare malignant neoplasm of primitive myeloid cell origin, most commonly found in association with acute myeloid leukemia. granulocytic sarcomas generally occur in the soft tissues, bone, and skin. method: we report a case of a -year old man with spinal granulocytic sarcoma manifesting as rapidly progressive paraplegia preceding clinical manifestation of acute myeloid leukemia. results: magnetic resonance imaging revealed a tumor in lumbal spine (l -l ). baseline laboratory data were normal. he underwent emergent laminectomy and the tumor was totaly resected. histological examination of lesion demonstrated diffuse proliferation of large atypical cells with round nuclei with delicate chromatin and one or more prominent nucleoli. immunohistochemical studies revealed positive staining for lca, cd , cd , cd , lysozyme and cd while myeloperoxidase, lymphoid, neuroendocrine markers, s- and cd were negative. the final histological diagnosis was granulocitic (monoblastic) sarcoma. no chromosomal aberrations were detected by fish. a month later, acute myelomonocytic leukemia was diagnosed upon a peripheral blood and bone marrow examination showing an increased number of abnormal monoblasts. chemotherapy, with multiple regimens for leukemia in combination, did not affect the tumor and the patient died. conclusion: granulocytic sarcoma should be considered in the differential diagnosis of spinal tumors. objective: survivin, a member of the inhibitor of apoptosis family might play an important role in the pathogenesis of diffuse large b cell lymphoma (dlbcl). we investigate clinical and prognostic significance of survivin expression in nodal dlbcl. method: biopsy specimens obtained from patients with newly diagnosed nodal dlbcl treated with immunochemotherapy (r-chop) were immunostained for survivin. results: survivin immunoexpression (> % positive tumor cells) has been found in ( . %) patients. significant difference in immunoexpression was noticed between gcb and non-gcb subtype of dlbcl (p= . ). there was no significant association with ipi, "bulky"disease, ki- immunoexpression or other clinico-pathological parameters. univariate analysis showed that survivin expression was unfavorable factor for therapy response and shorter survival in patients with dlbcl (p= . and p= . , respectively). patients with survivin overexpression experienced relapse more often that the patients without expression of this apoptotic protein ( . % vs. . %), but this difference did not reach statistical significance (p= . ). the results of this study showed that disregulation of survivin expression had the important role in determination of course of disease in pateints with nodal dlbcl treated with r-chop. therefore, survivin represent potential therapeutic target in dlbcl. langerhans cell histiocytosis of the jaws: a report of ten cases with an analysis of the mechanism of eosinophilic infiltration y. objective: langerhans cell histiocytosis (lch) frequently presents eosinophilic infiltration. here we report ten cases of lch that involved the jaws and our investigation of the mechanism underlying eosinophilic infiltration in lch. method: we evaluated the ccl- /eotaxin- expression of lch cells via immunohistochemical staining. toluidine blue staining was used to inspect the densities of mast cells, with ten periapical granuloma specimens serving as a control group. results: every patient was classified as having single-system lch, even though acute lymphoblastic leukemia occurred in one patient during lch treatment. the ratio of mandible to maxilla lch was : . the jaw lesions were the earliest manifestation in seven patients with multifocal lch. toluidine blue staining revealed that the number of mast cells in lch lesions was not significantly higher than in periapical granulomas. however, upon immunohistochemical examination, most of the patients showed diffuse positivity for eotaxin- in lch cells, while few eosinophils/ t cells were immunoreactive. conclusion: we surmise that the eotaxin- expression of lch cells may be relevant to eosinophilic infiltration in lch. further studies of the eotaxin- functions including its influence on the immature state of lch cells may be needed to understand the pathogenesis of lch as well as the role of tissue eosinophilia in lch. method: we report a case of sant in years-old man presented with abdominal discomfort and pain in a left lumbal region. abdominal computed tomography scan revealed a massive haematoma extended from spleen to the enlarged left kidney and left retroperitoneal space. the patient also had a spontaneous rupture of right kidney years ago. results: macroscopically, the cut surface of spleen showed multiple well circumscribed red brown nodules. microscopically, sant consists of multiple well-circumscribed angiomatoid nodules showing plump endothelial cells and extravasated erythrocytes. nodular formations are surrounded by a variable lymphoplasmacytic infiltrate, spindle cells and collagenous stroma. immunohistochemical staining displayed endothelial phenotype that resembled splenic capillaries (cd +/cd +/cd −). expression of cd was also present. conclusion: the differential diagnosis of sant includes splenic hamartoma, inflammatory myofibroblastic tumor, littoral cell angioma and hemangioendothelioma. it has been postulated that sant represents a peculiar hamartomatous transformation of splenic red pulp in response to an exaggerated nonneoplastic stromal proliferation. sant has a benign clinical course and splenectomy has been supposed as curative. collision tumor of menningioma and non hodgin malignant lymphoma of cerebellum h. erdem * , a. k. uzunlar, u. yildirim, a. sav, m. dosoglu * duzce university, dept. of pathology, turkey primary central nervous system lymphoma (pcnsl) constitutes a rare group of extranodal non-hodgkin's lymphomas (nhls), primarily of b cell origin, whose incidence has markedly increased in the last three decades. immunodeficiency is the main risk factor, but the large majority of patients are immunocompetent. this report presents the case of a -year-old woman with a collision tumor of primary malignant lymphoma and meningioma in the cerebellum. collision tumor of primary malignant lymphoma and meningioma have not been described in the literature. the morphological aspect is interesting with regard to the problem of collision tumors. prognostic significance of immunohistochemical expression of the angiogenic molecules vegf-a, vegfr- and vegfr- in patients with classical hodgkin lymphoma e. georgiadi * , g. dimtsas, p. karakitsos, t. vassilakopoulos, i. thymara, p. korkolopoulou, e. patsouris, c. kittas, i. doussis-anagnostopoulou * larisa, greece objective: classical hodgkin lymphoma (chl) is characterized by the presence of a small percentage of malignant hodgkin and reed-sternberg (hrs) cells amongst a reactive background. the role of angiogenesis in chl is still unclear. the aim of the study was to evaluate the expression of vegf-a, vegfr- and vegfr- and their correlation with clinicopathological parameters and prognosis. method: the immunohistochemical expression of vegf-a (vg , dako), vegfr- (rb- , neomarkers) and vegfr- (sc- , santa cruz) was studied in a large cohort of patients with chl and the results were correlated with clinical characteristics and patient outcome. results: the neoplastic hrs cells expressed vegf-a, vegfr- and vegfr- in . %, . % and . % of the cases respectively and their expression levels were intercorrelated. expression of vegfr- and vegfr- was significantly and positively correlated with early disease stage, absence of b-symptoms, wbc < . , alb ≥ , ips ≤ . vegfr- was additionally positively correlated with male gender and esr < . all three molecules were statistically correlated with ramifications of blood vessels but not with microvessel density. conclusion: based on our results, we could speculate that, in contrast to solid tumours, the process of angiogenesis is probably an early event in neoplastic progression in the context of hodgkin's lymphoma. ps- - p upregulation is associated with proliferation and is not capable of inducing apoptosis in hodgkin's lymphoma e. georgiadi * , g. dimtsas, t. p. vassilakopoulos, v. g. gorgoulis, i. a. doussis-anagnostopoulou * larisa, greece objective: p is a tumor suppressor protein described as the "guardian of the genome". in a normal cell, p is inactivated by its negative regulator, mdm . once activated, p induces cell cycle arrest and apoptosis by activating various cell cycle related genes, like waf / cip encoding for p . although mutations that deactivate p are the most common genetic alteration found in cancer, they are rare in the context of hodgkin's lymphoma (hl). method: p immunohistochemical expression was investigated in a subset of cases of primary hl. the study of the p -downstream protein p was used as an indirect way of analyzing its functional status. p expression was correlated with proliferation, apoptosis, clinicopathological data and prognosis of the patients. results: p showed a median value of . %, suggesting an upregulation of the p gene in hl, and a significant correlation with p (p= . ) and the proliferation marker mib expression (p= . ). conclusion: although p overexpression is a frequent finding in hl and there is indication of its functionality, this upregulation does not lead to apoptosis. it can be speculated that this is possibly due to mdm -p interactions. ps- - simultaneous gastric adenocarcinoma and b cell lymphoma of the stomach f. gerin * , k. turkoz, b. kantarcioglu, c. ataizi celikel * marmara university, dept. of pathology, istanbul, turkey objective: the simultaneous association of gastric carcinoma with gastric lymphoma is a rare event. method: we describe a years old man, who had been diagnosed as marginal zone lymphoma in a cervical lymph node biopsy years previously.no endoscopic examination was evaluated then. there was no pathological appearance in the gastrointestinal system by ct scanning and patient was considered nodal marginal zone lymphoma. patient had taken cycles of chemotherapy which consisted of rituximab, cyclophosphamide, vincristine, and prednisolone. , years after completion of chemotherapy, a gastric wall thickening compatible with gastric lymphoma or linitis plastica was detected on ct and gastroscopic examination was indicated. endoscopic examination revealed an erosive, fragile, hemorrhagic, malignant-looking lesion with a diameter of . cm in the cardia. besides, rugae of fundus and corpus were severely rough and hyperemic suggesting a diffuse malignant infiltration. multiple biopsies were taken from cardia, fundus and corpus of the stomach. results: cardiac samples showed pancytokeratin positive signet ring cells which contain neutral and acidic mucine in microscopic examination. samples of corpus and fundus did not show similar carcinoma cells, instead, there was diffuse infiltration of atipical lymphocytic infiltration consistent with marginal cell lymphoma both morphologically and immunophenotypically. conclusion: co-occurrence of carcinoma and marginal zone lymphome is a rare event and dramatically exacerbates prognosis of a patient with such an indolent lymphoma. assessment of demographic data, staging and experesion of cd , cd , cd , bcl- in reed-sternberg cells of hodgkin lymphoma cases in their first admission in urmia imam komini hospital b. ilkhanizadeh * , p. mazlomi * imam komini hospital, dept. of pathology, urmia, iran objective: immunohistochemistry plays an important role in diagnosis of hodgkin lymphoma. beyond diagnostic importance of immunohistochemistry, so far many studies have investigated the correlation between cellular markers and the prognosis of patients with hodgkin lymphoma. amongst other markers, cd is one of the most studied marker with a lot of controversy around it. method: retrospectively eligible patients entered the study. clinical and laboratory data and immunohistochemistry findings analyzed for possible correlation between disease stage and other parameters. results: in our study . %, . % of cases respectively expressed cellular markers cd and cd while only . % of cases expressed cd . furthermore statistical analysis revealed that cd was inversely correlated with disease staging. (p= . ). in contrast we didn't find any relation between cd or cd positivity with disease staging. (p= . , p= . ). however in our study expression of cd was not related to stage or other parameters of poor prognosis which proposes that in our patients this marker possibly was not related to disease prognosis. conclusion: therefore we suggest that cellular marker cd is not beneficial beyond ips factors and its usage should be confined to diagnostic purposes. primary naturall killer cell lymphoblastic leukemia/ lymphoma of central nervous system g. karagkounis * , t. argyrakos, e. ronne, e. dimitriadis, d. papadopoulos, g. stranjzalis, d. rontogianni * athens, greece objective: a -year old woman with a -year history of a multifocal lesion occupying the cerebellum who periodically received cortisol and etoposide as it was considered tumor-forming multiple sclerosis. method: two years after initial clinical diagnosis a stereotactic biopsy was performed. immunohistochemistry and in situ hybridization were performed on the tissue sample. results: the perivascular (virchow-robin) space of microvessels was occupied by middle sized lymphocytes with blastic chromatin and scant cytoplasm. the neoplastic cells were negative for: . b-cell markers: cd , cd , cd , cd a, pax- , . myelogenous differentiation antigens: mpo, cd , cd , . plasmacytoid dendritic differentiation antigens: cd , tcl , . blastic cells markers: cd , cd . t-cell markers: cd , cd with restricted expression of cd and cd in a few cells, . cytotoxic enzymes tia- , granzyme-b and perforin. all cells expressed intensely cd and tdt and some of them cd . in situ hybridization for ebv virus (ebers) was negative. pcr analysis: t-cell receptor and immunoglobulin genes were in germ line. bone marrow was negative. objective: lymphomas constitute , cases on inhabitants annually, its frequency grows. method: this work presents epidemiological, morphological analysis of nodal/exstranodal lymphomas. analysis of data from izhevsk cancer center during - was carried out. results: lymphoma appeared in . % among first diagnosed malignant tumors. the panel of monoclonal antibodies was used for tumor immunophenotype identification. nodal lymphomas presented cases: -hodgkin lymphoma (hl), non-hodgkin lymphoma (nhl). exstranodal lymphomas presented cases, various variants of nhl were more frequent. small lymphocyte lymphoma - , diffuse large b-cell lymphoma (dlbcl) - , follicle center lymphoma - , mantle cell lymphoma - were frequent among nodal lymphomas. t-cellular nhl presented cases ( -peripheral t-cell lymphoma, -angioimmunoblastic tcell lymphoma). among other organs of lymphatic system lymphomas appeared in tonsils ( ), thymus ( ) and spleen ( ). exstranodal nhl were registered in stomach ( ), rarely in other organs -testis ( ), central nervous system ( ), nose ( ), breast ( ). as rule dlbcl was more frequent ( ). conclusion: results coincide with data on lymphoma's frequency and morphological characteristic in other regions. in situ mantle cell lymphoma in nasopharynx t. koletsa * , f. tsiompanou, c. poulios, g. karkavelas, i. kostopoulos * auth, dept. of pathology, thessaloniki, greece objective: the nasopharynx normally contains abundant lymphoid tissue and it can be the site of both lymphoid hyperplasia and lymphomas. we present the first case of the recently described in situ mantle cell lymphoma (mcl) in nasopharynx. a year-old woman presented with nasal obstruction in . a mass located in nasopharynx was found. biopsy was sent for histological examination. a new biopsy was taken years later. histological, immunohistochemical and fish studies were performed. results: histological examination of both biopsies revealed lymphoid hyperplasia, characterized by cd and cyclind positive cells of mantle zones, findings consistent with in situ mcl. the diagnosis of in situ mcl confirmed by fish analysis for t( ; ). the patient examined thoroughly and has remained free of an overt lymphoma to the present day. conclusion: pathologists and otorhinolaryngologists should be aware that in situ mcl may be observed in nasopharynx. it may be appropriate to perform cyclind immunostain, even in cases with clinical and histological findings compatible with lymphoid hyperpasia. the patients should be examined thoroughly, since in situ mcl may accompanied by an overt lymphoma in other sites or it may be a precursor of an overt mcl. multisystem langerhans' cell histiocytosis coexisting with metastasizing adenocarcinoma of the lung a. lovrenski * , m. panjkovic, z. eri * institute for lung diseases, dept. for pathology, sremska kamenica, serbia objective: langerhans' cell histiocytosis (lch) is an uncommon disease of unknown etiology characterized by uncontrolled proliferation and infiltration of various organs by langerhans' cells. to our knowledge, this is the first case reporting an association of multisystem lch with metastasizing adenocarcinoma of the lung. method: we present the case of a -year-old man, heavy smoker, with dispnea, cough, hemoptyses, headache and ataxia, who died shortly after admission to our hospital. on the autopsy, we found tumor in the posterior segment of the right upper pulmonary lobe as well as a right-sided occipito-parietal lesion which penetrated into the right ventricle resulting in internal and external hematocephalus. histologically and immunohistohemically, the diagnosis of primary lung adenocarcinoma with brain metastasis was made (tumor cells showed positivity for ck and ttf- which confirmed the diagnosis). light microscopic examination of the other organs showed lch involving the pituitary gland, hypothalamus, spleen, mediastinal lymph nodes, and lungs. immunohistochemical studies revealed cd , s- and cd a immunoreactivity within the langerhans' cells. conclusion: multisystem form of lch with extensive organ involvement was an incidental finding, while the metastatic lung adenocarcinoma to the brain, that led to hematocephalus, was the cause of death. langerhans cell histiocytosis associated with extramedullary hematopoiesis in a -year-old male patient l. lungoci * , l. elena, b. flavia, m. rodica * city hospital, pathology, timisoara, romania objective: langerhans cell histiocytosis is a rare disease histologically characterized by the proliferation of langerhans cells. method: a -year-old male came to our attention presenting with erythematous-squamous lesions all over the body, axillary and inguinal adenopathies and hepatosplenomegaly. we have taken a cutaneous and an axillary lymph node biopsy. results: microscopic examination of the cutaneous fragment revealed the presence of a dermal infiltrate of large cells with an eosinophilic cytoplasm and vesicular, nucleolated nuclei with an irregular nuclear margin, raising suspicion of a cutaneous lymphoma. immunohistochemical stains for cd , cd , cd a, cd , cd , cd , cd , and bcl- were negative, and the previous diagnosis was not confirmed. the microscopic examination of the axillary lymph nodes showed foci of extramedullary hematopoiesis, raising suspicion of a lymphoproliferative process, but the immunohistochemical stains and the paraclinical data didn't confirm it. based on the intense positive reaction for cd , s and ki- showed by the tumoral cells from the prelevated tissues, correlated with the clinical and paraclinical findings, a diagnosis of langerhans cell histiocytosis was established. conclusion: the particularity of our case consists in the presence of extramedullary hematopoiesis in the lymph nodes of a patient diagnosed with langerhans cell histiocytosis. unusual primary cutaneous presentation of b-cell chronic lymphocytic leukaemia s. mavropoulou * , z. tatsiou, g. xanthopoulidis, a. goutzouvelidis * general hospital, laboratory of pathology, xanthi, greece objective: b-cell small lymphocytic lymphoma/chronic lymphocytic leukaemia (b-cll) is a low-grade lymphoproliferative disorder and cutaneous lesions are rarely the presenting findings. method: we report the case of a -year-old woman who presented in winter with erythematous plaque on her nose, of months duration. laboratory data showed elevated white blood cell count ( . /mm ) with small mature lymphocytes predominance ( %). results: histopathologic examination of the skin lesion reveals infiltration of the reticular dermis and subcutis, consisting mostly of small lymphoid cells, without epidermotropism. immunohistochemical examination revealed positivity for cd , cd a and cd in the neoplastic cells. according to the laboratory and histopathologic findings the diagnosis was consistent with b-cll with a primary cutaneous presentation. a staging bone marrow aspiration and biopsy showed % infiltration by a clonal b-cell proliferation with typical cll immunophenotyping. ct-imaging was normal, so stage i according to binnet classification was confirmed. the patient received cycles of chemotherapy and remained in remission for year, when the skin lesion recurred in winter, at the same location. conclusion: in conclusion we report an extremely rare case of subclinical b-cll with cutaneous presentation. it is important to maintain a high index of suspicion for a lymphoproliferative process in skin lesions with atypical lymphocytic infiltration. myeloid sarcoma mimicking nasal polyp s. mungan * , u. cobanoglu, s. ersoz, g. guvendi, m. yilmaz * karadeniz technical university, pathology, trabzon, turkey objective: a myeloid sarcoma is a tumour mass consisting of myeloid blasts with or without maturation occuring at an anatomical site other than the bone marrow. every site of the body can be involved, skin, lymph node, gastrointestinal tract, bone, soft tissue and testis. % cases presents at multiple anatomical sites. method: the current case is year old woman presenting with nasal polyp and underwent polypectomy. the polyp was , cm in diameter and had a bloody appearance. by microscopic examination there was a diffuse infiltration of neoplastic cells under the cilliated epithelium. the mitotic index was high in neoplastic lymhoid cells. immunohistochemical study was helpful for the differential diagnosis. objective: the aim of this study was to describe the epidemiology and anatomo-clinical features of the ear, nose and throat (ent) lymphomas in the centre of tunisia. method: all ent lymphoma cases diagnosed in the pathology department, farhet hached hospital, sousse during a -year period were analyzed. results: a total of cases of ent lymphoma were reported ( males, females) with a sex-ratio of . . the age at diagnosis varied from to years with a median age of . years. the majority of ent lymphoma cases ( %) were of b cell type including large b-cell lymphoma ( %) and small-cell b lymphoma ( %). nasopharynx and tonsils were the most involved areas with % and % of cases, respectively. according to the ann arbor staging system, these lymphomas are diagnosed in the stage ii ( %) followed by stage i ( %). conclusion: the most frequent lymphoma developed in ent region was b cell lymphoma, especially located in nasopharynx and tonsils. results: a total of cases were reported ( males, females) with a sex-ratio of . . the median age was years (range: - years). lymph node lymphomas were the most frequent accounting for . %, followed by ent, mediastinum, and haematopoietic system ( . % each one); cutaneous and digestive location were less frequent ( . % each one). among the patients, ( . %) had had hodgkin's lymphoma and ( . %) had had non-hodgkin's lymphoma (nhl). diffuse large b-cell lymphoma was the most diagnosed ( %) followed by burkitt lymphoma ( . %) and t-cell lymphoma ( . %). according to the ann arbor staging system, . % of patients were diagnosed in an advanced stage. method: we present a case of composite ailt and diffuse large b-cell lymphoma (dlbcl) a -year-old woman with multiples lymph nodes. biopsy of inguinal node was performed. three months later the patient had enlarged cervical node which was removed. results: firstly, the inguinal lymph node was diffusely infiltrated by small-medium size lymphocytes with scanty cytoplasm. the nuclei were irregular. several large cells were observed in a background of prominent arborizing high endothelial venules. the small cells were cd positive. the large cells were cd a, cd positive. theses cells showed nuclear positivity for eber by ish. secondly, the cervical lymph node showed large areas of necrosis admixed with pleomorphic and medium size t lymphocytes. there were a population of neoplastic ebv + pleomorphic b lymphocytes; some of them with rs-like morphology. we performed b and t-cell clonality studies. we detected tcr-gamma t-cell and igh b-cell gene clonal rearrangement. conclusion: occasionally igh gene rearrangement has been detected but only a few cases have demonstrated, morphologically, composite ailt and ebv-associated diffuse large b-cell lymphoma (dlbcl). typhlitis as initial manifestation of granulocytic sarcoma of the appendix: a case report p. rohani doost * , b. ilkhanizadeh, f. noroozinia, a. objective: myeloid sarcoma is a localized mass of myeloblasts or immature myeloid cells involving any extramedullary site. reports in the literature documenting leukemic infiltration of appendix are uncommon and extremely rare when symptoms mimicking typhlitis. method: a -year-old man with a history of relapsed acute myelogenous leukemia (fab classification, m ) admitted for receiving induction chemotherapy. after days of chemotherapy, he presented with fever, nausea, vomiting, abdominal pain and severe neutropenia ( . × /l as absolute neutrophil count). this manifestation was attributed to typhlitis and he received antibiotic therapy, but he came back days later with acute abdomen prompting exploratory laparotomy which revealed inflamed appendix. results: histologic examination showed diffuse appendiceal wall infiltration of mononuclear cells with medium-to-large vesicular nuclei, conspicuous nucleoli and pale eosinophilic cytoplasm. immunostains showed the diagnosis of granulocytic sarcoma with myeloperoxidase, leukocyte common antigen, cd , cd and cd positivity and epithelial membrane antigen, keratin, cd , cd , cd , cd a and cd negativity. conclusion: our case declares that physicians and surgeons should be aware of granulocytic sarcoma in the differential diagnosis of mild tenderness on palpation of the abdomen as a complication of acute myelogenous leukemia. objective: angioimmunoblastic t-cell lymphoma (aitl), one of the most frequent entities among peripheral t-cell lymphoma, is characterized by lymphadenopathy, b-symptoms, and an aggressive behaviour. method: we reported cases of aitl during a period of years ( ) ( ) ( ) ( ) . results: the age of patients varied between and yearold. they hadn't any pathologic history. two patients presented with a multiple cervical lymphadenopathy, and weight loss. the other patient had fever and sweat. physical examination found multiple lymph nodes with hepatosplenomegaly in patients. abdominal ultrasound and ct-scan showed diffuse lymphadenopathy with features raising the possibility of lymphoma. the diagnosis of aitl was confirmed by a microscopic and an immunhistochemical study of lymph node or liver biopsy. patients received a cure of chemotherapy conclusion: angioimmunoblastic t-cell lymphoma (aitl) is an aggressive non-hodgkin t-cell lymphoma. aitl is frequently associated to immunological and hematologic diseases such as autoimmune hemolytic anemia, vasculitis, rheumatoid arthritis, and autoimmune thyroid disease. its natural history has been the subject of controversy, considered for many years to be a nonmalignant disorder or a dysimmune disease, until the clonal nature of aitl was proven by molecular studies. although patients are usually treated with corticosteroids, chemotherapy, and/or plasmapheresis, outcomes were dismal. objective: low grade lymphomas (indolent) are commonly located on extranodal sites. nodal location are relatively of low incidence. our aim is to describe the epidemiological status of nbcl and to assess their pathological features in the center of tunisia. method: we report cases of indolent nbcl diagnosed in the department of pathology, during a period of years ( - ) . clinical, pathological and immunohistochemical (large panel of antibodies), treatment and outcome data are collected. results: the mean age was year old ( and years). the sex ratio was . . nbcl was . % of all n h lymphomas and . % of indolent nbcl of any sites. nodal enlargement and hepatomegaly were the main symptoms. small lymphocytic lymphomas were the most frequent variant ( %), followed by follicular lymphomas ( %). mantle cell lymphoma and marginal zone b cell lymphoma were rare ( % and %, respectively). they were exclusively of b cell type. % of cases were in stage iii-iv. % of patients received chemotherapy. % of recurrence and % of death were found. conclusion: nbcl in the center of tunisia are relatively uncommon. small lymphocytic lymphoma is the most frequent in our population. they are still of relatively worse prognosis. objective: bone marrow metastases can be found in some malignant tumors, but diagnosing a nonhematologic malignancy from marrow is an unusual event. herein we present a case of metastatic signet ring cell carcinoma with an unknown primary site. method: a year-old woman admitted to the hospital with weakness and bone pain. positron emission tomography/computed tomography (pet/ct) revealed disseminated bone lesions showing increased metabolic activity. bone marrow biopsy and aspiration were performed. results: bone marrow biopsy revealed extensive necrosis and nearly total replacement of normal bone marrow elements by atypical tumoral cells. tumoral cells were arranged individually or in small clusters, having hyperchromatic, eccentric located nuclei and abundant cytoplasm with signet ring cell morphology. even after thourough investigation of all the systems, a primary site of malignancy could not be detected. she received nine cycles of chemotherapy. craial mri revealed multiple metastatic lesions. months after the initial diagnosis, she died of disseminated metastatic lesions. conclusion: even after thorough investigations, a primary site of malignancy could not be detected. in the literature, all the presented cases had very short survival varying from days to a few months. our patient lived for months with multidiciplinary approach. objective: approximately % of follicular lymphomas (fls) are bcl negative and - % of fls lack a translocation t( ; ). previously we have found that negative bcl staining in cases that do have a t( ; ) is caused by mutations in the epitope for the bcl- antibody, but this is never the case in bcl- negative, t ( ; ) negative cases. now that translocation detection is more commonly performed we noticed that many of the cases that were referred to us as translocation negative fl are actually often nodal marginal zone lymphomas (nmzls) with extensive follicular colonization. method: t( ; ) negative cases that on h&e sections look like fl were analyzed by morphology and immunohistochemistry, including antibodies against cd , bcl- , ki- , and cd . results: careful observation of the bcl- staining pattern revealed that follicles that appeared positive at low power contained negative cells at high magnification. the amount of negative cells varied from follicle to follicle and was associated with the extent of ki- positivity. conclusion: based on morphology and immunohistochemistry we reclassified many cases of bcl- positive, t( ; ) negative fl into nmzl. although there is presently no positive marker for nmzl, we believe that such cases are responsible for most t( ; ) negative fl. objective: recent studies do not provide a definite answer on the origin and pathogenesis of lichen planus (lp). histologic findings are the same, regardless of the area involved. electron microscopy is useful to confirm the diagnosis in atypical cases and monitoring lp development. this study aimed an ultrastructural characterization of keratinocyte degeneration in pemphigoides, hypertrophic, and follicular lp types correlating this with levels of gelatinolytic activity caused by metalloproteinase- (mmp- ). method: skin biopsies were processed conventionally and examined in a jeol transmission electron microscope. mmp- expression was detected immunohistochemically. results: lp pemphigoides demonstrated intact basal keratinocyte cell membrane, and the lamina densa lining blister cavity correlating with moderate basal mmp- expression of weak intensity. hypertrophic type demonstrated good preservation of keratinocytes and their junctions along with strong basal and suprabasal mmp- expression of moderate intensity. both types demonstrated diffuse and strong mmp- immunostaining in dermal lymphohistiocytic infiltrate. a hypertrophic type revealed an increase of expression within dermal sweat glands comparing with lp pemphigoides. a diffuse and strong epidermal and follicular mmp- staining was noticed in follicular variant of lp. conclusion: ultrastructurally keratinocyte involvement displays deviations in various types of lp, and these changes correlate with levels of gelatinolytic activity caused by mmp- . objective: clevudine is a recently introduced anti-viral agent that shows efficacy against hepatitis b virus related chronic liver diseases. however, it has been reported that certain patients who have received long-term administration of clevudine exhibit myopathy involving mitochondrial abnormalities. to make a differential diagnosis congenital mitochondrial myopathy and drug induced mitochondrial myopathy, we investigate ultrastructural findings of drug induced myopathy. method: we studied histopathological features of myopathy focused on the various ultrastructural mitochondrial abnormalities found in patients with long-term clevudine therapy. results: in every case, ragged red fibers and multinucleated fibers with eosinophilic granules were observed. additionally, type fiber atrophy was found in cases. mainly concentrated in subsarcolemmal or inter-fibrillar areas, the abnormal mitochondria were enlarged and swollen, showing a variety of morphological types. most of the abnormal mitochondria indicated structural abnormalities in cristae, including the apparent decrease in the number, concentric lamellar pattern, and structure that is branched or lattice-like. conclusion: from the overall analysis, clevudine-induced myopathy is characterized by ragged fibers showing proliferation of abnormal mitochondria with various forms of inclusion bodies and abnormal cristae. another particular feature of interest is the presence of multinucleated fibers, which, in most cases, are filled with abnormal mitochondria. ultrastructural features of human mature oocytes subjected to cryopreservation s. a. nottola * * university la sapienza, dipt. die anatomia histol., rome, italy objective: oocyte cryopreservation protocols have not been fully optimized yet. our aims were to evaluate and compare the ultrastructure of human mature oocytes frozenthawed (f/t) after slow freezing and vitrification. method: the oocytes, fixed at sampling (fresh controls) and after freeze/thawing, were processed for light and transmission electron microscopy (lm and tem) observations. results: by lm, both fresh and f/t oocytes were rounded cells surrounded by an intact zona pellucida (zp) and containing uniformly distributed organelles. by tem, numerous vacuoles were found in f/t oocytes after slow freezing. on the contrary, vacuoles were only occasionally detected in f/t oocytes after vitrification, and in fresh controls as well. amount and density of cortical granules (cgs) appeared abnormally reduced in f/t oocytes, irrespective of the protocol applied. conclusion: in conclusion, a) cryopreservation currently ensures a good overall preservation of the oocyte; b) however, vacuolization appears as a recurrent form of cell damage during slow freezing, whereas the quasi absence of vacuoles seems the most relevant marker of quality in vitrified oocytes; c) premature cg exocytosis -and the consequent hardening of the zp -seems a non-specific, ubiquitous phenomenon occurring during freeze/thawing, suggesting the appropriateness of the use of icsi as the preferred insemination method after cryopreservation. tuesday, september , . - . results: there were women and men with a median age of (range - years). symptoms were dominated by abdominal pain, jaundice, vomiting, and alteration of the general condition. radiologic investigation showed multiloculated cystic mass of the pancreas, associated to splenic thrombosis and bone metastasis in one case. in gross, we received multilocular cysts of to cm in wall, their wall was fibrous, and thick, the internal surface showed many papillary projections and mural nodules. there was no communication with the duct system. on histologic examination, cysts had a fibrous wall lined by mucinous atypical cells showing frank anaplasia, wall's cyst was invaded by anaplastic glands; the stroma was of ovarian type in all cases. conclusion: pmc are uncommon neoplasia, their diagnosis is based on the histopathologic exam, their diagnosis is better than duct carcinoma and depends on the extent of tumour invasion. heterotopic pancreas of the gallbladder associated with acute cholecystitis o. akman * , e. e. pala, u. bayol, m. emiroglu * tepecik training research center, dept. of pathology, izmir, turkey objective: pancreatic heterotopia is a rare entity, which is commonly found in the stomach, duodenum, jejunum and meckel's diverticulum. heterotopic pancreas is extremely rare in the gallbladder. despite being a congenital condition, it takes years to become symptomatic. it can be associated with cholecystitis or cholecystolithiasis. method: a -year-old female patient was admitted to emergency service with abdominal pain. on physical examination, right upper abdomen was tender without defense or rebound. abdominal ultrasonography revealed small sized gallstones and pericholecystic fluid. magnetic resonance cholangiography showed dilated intrahepatic and extrahepatic bile ducts. laparoscopic cholecystectomy was performed. results: cholecystectomy specimen was × × mm. on gross examination we noted a few milimetric yellow colored stones and mm yellow solid intramural nodule. the mucosa was covered with fibrinopurulent exudate. microscopic examination revealed acute cholecystitis and aberrant pancreatic tissue consisting of acini and ductules. the phlegmonous inflammation of the gallbladder infiltrated the aberrant pancreatic tissue. the patient recovered completely after cholecystectomy. conclusion: we found this case worth reporting because, pancreatic heterotopia of the gallbladder is a rare, clinically silent entity unless complicated with gallstones and acute cholecystitis. expressions of c-erb-b , egfr, p , pten, mtor, pi k in hepatocellular carcinomas and adjacent liver tissues method: fifty hcc cases were stained immunohistochemically with these markers. correlations between the markers and pathologic characteristics were analyzed. results: the cases had an average age of , . male/female ratio was / . hbv is more common in advanced stages and right lobe location (p< . ). tumor size is significantly larger in patients older than years (p< , ). no membranous c erb b staining was seen while cytoplasmic positivity was present in % and significant correlation was found with multiplicity (p< . ) and p positivity (p< , ). egfr membranous positivity was present in % and significantly correlated with stage (p< . ). p was negative in % and pten is reduced or absent in %. all markers were similarly expressed in adjacent noncancerous tissue. no significant correlations were found between pten, mtor, pi k and the pathological parameters. conclusion: in our study, as a first step, none of the markers among c-erb-b , egfr, p , pten, mtor, pi k was found significant in correlation with pathologic features. we look forward to obtain further results in the next study consisting of correlations with follow ups. the value of echo guided liver biopsy in the positive diagnosis of a rare primary liver tumorpathological approach g. becheanu * , v. herlea, v. serban-barbu, m. dumbrava, s. enache, g. smira, c. angelescu, a. pop, m. diculescu * bucharest, romania objective: hepatic angiomyolipomas are rare mesenchymal hepatic tumour. the most important problem about their diagnosis on biopsy specimens is to exclude a hepatocellular carcinoma. method: we present two cases of hepatic angiomyolipoma diagnosed in fundeni clinical institute, bucharest. both females patients, and years old, were imagistically diagnosed with a cm hepatic left lobe tumor in the first patient, respectively a . cm hepatic right lobe tumor in the second one. both tumors were echo guided biopsied. the biopsy specimens measured about mm, respectively mm. the tumors were surgical removed. the biopsy and resection specimens were analyzed in light microscopy, including immunohistochemistry. results: initial diagnosis on he stain was cell variant hepatocellular carcinoma, in the mm biopsy, respectively suspicious for angiomyolipoma in the second case. further immunohistochemical studies showed positivity for vimentin, hmb , melan a, s and actin, and negativity for och e , ck , ck / , cea, cd , ki and factor viii in both biopsy specimens, consistent with hepatic angiomyolipoma diagnosis, confirmed on surgical specimens too. conclusion: diagnosing a hepatic angiomyolipoma is not easy to do especially on a biopsy. the size of biopsy specimens plays a very important role in a correct diagnosis. results: a -year-old woman presented with a -day history of nausea, fever and diffuse abdominal pain. ct scan revealed a well circumscribed small lesion of the pancreatic body. on arterial phase imaging, the mass was of low density relative to the pancreas without marked contrast enhancement. based on these findings, the patient underwent surgical resection of this mass and a distal spleno-pancreatectomy was performed. microscopic examination showed a well circumscribed but non encapsulated soft tissue proliferation consisted of blood vessels lined by a single layer of uniform flattened cells, with dilated lumen filled with red blood cells and inflammatory cells. immunohistochemical staining confirmed the vascular nature of the lesion. the diagnosis of pancreatic hemangioma was made. conclusion: adult pancreatic hemangioma is an extremely rare tumor. the review of all published cases showed that this tumor often do not demonstrate the contrast-enhanced ct features typical of an hemangioma, so a poor arterial phase enhancement cannot rule out pancreatic hemangioma and the histological examination is very important in these cases. objective: hepatocholangiocarcinoma (hcc-cc) is an uncommon form of primary liver cancer with features of hepatocellular and biliary epithelial differentiation. it accounts for . - . % of all primary liver carcinomas. many of the demographic and clinical features of this tumor remain unclear. it was previously suggested that coexisting chronic liver diseases were rarely seen in patients with hcc-cc. method: we report a case of hcc-cc diagnosed in patient with cirrhosis. results: a year-old man presented with ascites, jaundice, vomiting and symptoms of portal hypertension. on abdominal ct scan the right hepatic segment was heterogeneous, hypervascular in the late arterial phase and low-attenuated on portal venous phase. based on a these clinicoradiological informations, diagnosis of infiltrating hepatocellular carcinoma was made and hepatic biopsy was performed. histopathologic examination showed, in addition to features of liver cirrhosis, the presence of malignant proliferation composed of tubular structures as well as microtrabecular and compact foci. on immunohistochemical stainings the tumor cells expressed cytokeratins and . cells lining the tubular structures reacted with cytokeratin allowing the diagnosis of hepatocholangiocarcinoma. conclusion: hepatocholangiocarcinoma is a rare primary liver cancer. preoperative noninvasive diagnosis with conventional radiography is often difficult especially when occurring in patients with liver cirrhosis or other hepatic chronic disease. the diagnosis is frequently made only after histological and immunohistochemical examination. morphological changes in different zones of the gallbladder in cholelithiasis m. bokhodir * , t. vervekina * tashkent medical academy, dept. of patological anatomy, uzbekistan objective: gallstone disease remains a serious problem of modern surgery. an important aspect of the problem is the question of the urgency of surgical intervention, depending on the condition of the gallbladder. method: it was carried out the analysis of case histories and excised gallbladder with different forms of cholelithiasis. . % were women in the age of - years. acute catarrh cholecystitis was found out in % cases, acute phlegmonousin % cases, acute gangrenous -in % cases, chronicin % and chronic relapsingin % cases. results: all forms of cholecystitis characterized by a maximum thickness of the body wall, minimal at the bottom of the gallbladder. in all forms adipose tissue inflammation in the connective tissue layer was increased and it was found out the atrophy of the mucosa. in the inflammatory infiltrate in acute forms of inflammation were found neutrophilic and basophilic leukocytes: with simple acute cholecystitis -in the bottom, and with acute phlegmonous and gangrenous cholecystitis -in the area of the body of the gallbladder. in the cases with chronic cholecystitis were dominated mononuclear cells in all areas, and in the cases with chronic relapsing -neutrophilic and basophilic leukocytes in the bottom and the body, and mononuclear cells -in the neck of the gallbladder. ps- - histological features of chronic hepatitis c in hemodialysis patients i. delladetsima * , a. kokkori, v. sypsa, m. psichogiou, s. sakellariou, j. boletis * athens university, st dept. of pathology, greece objective: chronic hepatitis c (chc) in hemodialysis patients has not been thoroughly investigated, despite its high frequency. the present comparative study aims to highlight the histological features of chc and its association with putative pathogenetic parameters in this specific group of patients. method: sixty-one biopsies of hemodialysis patients and biopsies from the general population with chc were comparatively evaluated for the severity and specific histological features of chc. results were examined in relation to age, time of dialysis, viral load and genotype. results: patients on hemodialysis were older than patients of general population (p= . ), showing a similar genotype distribution (p= . ) and lower viral loads (p= . ). chc on hemodialysis was significantly milder according to stage (p= . ), activity and its parameters (p< . ). significantly reduced was also the frequency of lymphoid aggregates (p< . ), bile duct damage (p< . ) and steatosis. (p= . ). severity of hepatits was not associated with time on hemodialysis. in multivariate analysis the differences were independent of age, which was associated with more severe disease. steatosis was associated with hemodialysis duration and age. conclusion: chc in hemodialysis patients is significantly milder than in general population. limited necroinflammatory activity and absence of immune mediated lesions are indications of defective immune response although involvement of low viral load cannot be overlooked. ps- - inflammatory (myofibroblastic) pseudotumor of the liver: case report e. demiralay * , s. altaner, h. Özdemir * baskent university, dept. of pathology, istanbul, turkey objective: inflammatory pseudotumor of the liver (ipt) is a rare, benign tumor-like lesion of which etiology is not fully known. it is confused with primary and metastatic malignant tumors as it seems as an occupying mass on radiologic examinations. method: thirtyeight-year-old male patient who had fatigue and dyspepsia was detected to have elevated liver enzymes and hepatomegaly. on computed tomography, two masses of which middle is mildly hypometabolic, measuring × mm in right liver lobe and × mm in left liver lobe were detected. biochemical tests were normal except elevated ast and alt levels. ultrasound-guided needle biopsy was done for two masses. results: on microscopic examination, a lesion composed of abundant fusiform fibroblastic cells and vascular structures among inflammatory cells composed of lymphocytes, plasmocytes, histiocytes and eosinophillic leucocytes and including sharp margins between regenerated liver tissue was observed. on immunohistochemical examination, sma was stained focal positive in fibroblastic cells. staining with desmin, s- , panck, cd , ki- and cd was not seen. conclusion: ipt does not have a specific radiologic finding and definite diagnosis is made with pathologic examination. this case is presented as it is rarely seen, radiologically resembles to malignant tumors and for review of pathological differential diagnosis. enhancer of zeste homologue (ezh ) expression in malignant and benign hepatic tumors k. dezso * , v. szabó, e. bugyik, k. schlachter, s. paku, z. schaff, p. nagy * semmelweis university, st dept. of pathology, budapest, hungary objective: the immunohistochemical demonstration of enhancer of zeste homologue (ezh ) proved to be a useful marker in several tumor types, including hepatocellular carcinomas.in order to recognize the diagnostic value of this protein in hepatic tumors we have investigated the presence of ezh in the most common liver neoplasms. method: the presence of ezh has been studied by standard immunohistochemistry in several formalin-fixed paraffin-embedded tumor samples (hepatocellular adenoma, hepatocellular carcinoma, cholangiocarcinoma, hepatoblastoma, metastatic liver tumors and primitive childhood tumors). results: forty of hepatocellular carcinomas, of cholangiocarcinomas, of hepatoblastomas and of metastatic liver tumors stained positively, but all the investigated hepatocellular adenomas (n = ) and proliferating biliary structures were negative. the other primitive childhood tumors that were examined all expressed ezh . conclusion: based on these results ezh is a sensitive marker of malignancy in hepatic tumors regardless of their histogenesis. in routine surgical pathology ezh could be helpful to diagnose hepatocellular carcinomas and it might be the first marker to distinguish transformed and reactive cholangiocytes. ps- - nuclear ploidy as a marker of intraductal papillarymucinous pancreatic neoplasms malignancy e. dubova * , o. mishnev, a. shchegolev * v.i. kulakov scientific center, dept. of pathology, moscow, russia objective: intraductal papillary-mucynous pancreatic neoplasm (ipmn) represents , to . % of all tumors of exocrine pancreas. our aim was to study nuclear ploidy of malignant and benign ipmns cells. method: we studied pancreatic surgical specimens from females and males. we performed histological, morphometrical and ploidy analysis of all specimens. results: ipmn cells nuclear perimeter and size was higher than in normal pancreatic duct cells. this parameters were higher in malignant noninvasive ipmn than in benign tumor. nuclear size and perimeter of invasive malignant ipmn were in intermediate position between benign and malignant noninvasive tumor. mean nuclear ploidy (mnp) of normal ductal pancreatic cells was . c. mnp of benign ipmns was . c, borderline tumors - . c. mnp of noninvasive malignant ipmns was . c, of invasive ipmns - . c. we also revealed that aneuploidy coefficient (ac) of benign ipmns was (there weren't aneuploid nuclei in its cells). ac of borderline ipmns was . . maximal level of ac was in malignant noninvasive ipmns whereas ac of invasive ipmns was lesser. conclusion: nuclear morphometric parameters and mean nuclear ploidy level as well as aneuploidy coefficient could be used as additional criteria for determining malignant potential of ipmns. ps- - an intraductal papillary mucinous neoplasm of the pancreas with concomitant neuroendocrine tumor: a case report j. garcia * , f. e. costa, r. sampaio, r. dias, a. duarte, j. ramon vizcaíno * lisbon, portugal objective: intraductal papillary mucinous neoplasms (ipmns) are a recently classified pancreatic neoplasm with an increasing incidence. ipmn of the pancreas is a lesion consisting of mucin-producing cells with neoplasic potential, characterized by papillary intraductal growth and varying degrees of cytologic atypia. neuroendocrine tumors of pancreas (pnet) are rare pancreatic neoplasms comprising - % of all pancreatic tumors. pnets express neuroendocrine markers, however the true cell or cells of origin are not fully understood. pnets are classified as functional or nonfunctional based on the presence or absence of a specific clinical syndrome associated with hormone oversecretion. intraductal papillary mucinous neoplasm of the pancreas with concomitant neuroendocrine tumor are a highly rare occurrence. method: a literature review of ipmns and pnet was made, as well as a review of the clinical data of a patient with ipmn and concomitant pnet. results: a -years-old caucasian female, underwent a laparoscopic distal pancreatectomy with splenectomy for ipmn. macroscopic examination revealed discrete dilatation of pancreatic ducts and nodule in the pancreas tail. hystologic examination revealed neoplasic lesion of intraductal papillary-mucinous in the body and tail of pancreas with moderate dysplasia (ipmn borderline) and neuroendocrine tumor grade (who ). conclusion: this case reports a highly rare occurrence. glypican and agrin expression in hepatocellular carcinoma and cholangiocellular carcinoma: a immunochemistry study n. gursan * , h. balta, b. gundogdu * ataturk university, medical faculty, erzurum, turkey objective: glypican (gpc ), which plays a role cellular growth, differentiation and migration is one of members of glypican family. although gpc expression in the liver, glypican upregulation of the vast majority of tumors are available. agrin is found the surface on the cells and the extracellular matrix, the micro-vessels method: in this study, formalin-fixed, paraffin-embedded surgical specimens from patients with hepotocellular carcinoma and patients with cholangiocellular carcinoma diagnosed between and years in ataturk university, faculty of medicine, department of pathology were studied with immunohistochemistry agrin and gpc . results: we detected agrin in around bile ducts and blood vessels within the portal areas in the normal liver. İn the malignant hepatocellular carcinoma (hcc) is seen in a dramatic increase in the quantity of agrin. gpc immunpositivity showed in % of hcc and % of cholengiocellular carcinoma. agrin immunpositivity showed in % hcc and % of cholangiocellular carcinoma. conclusion: gpc and agrin, that is useful in early diagnosis of hcc cases; cholangiocellular carcinoma, or not enough was understood to be very limited. value of glypican , hep par and alpha fetoprotein in diagnosis of hepatocellular carcinoma n. gursan * , h. balta, b. gundogdu * ataturk university, medical faculty, erzurum, turkey objective: glypican showed high expression of the embryonic liver and intestine, is silenced in normal adult tissues. it is an oncofetal protein. İn general, oncofetal proteins, while having a critical role in tumor progression or immunotherapy is a potent tumor marker used as a target. alpha fetoprotein, clone c localized, normally produced by gestational age, fetal liver and yolc salc, glycoprotein structure emerging marker for patients with hcc. hep par antibody was developed in using fixed liver as immunogen. method: İn this study formalin-fixed, paraffin-embedded surgical specimens from patients with hepatocellular carcinoma diagnosed between and years in ataturk university, faculty of medicine department of pathology were studied with immunohistochemistry gpc , heppar , and afp. gpc , heppar and afp expression was divided into categories negative (negative or weak under % tumor cells cytoplasmic staining) and positive (and % over of tumour cells) moderate or strong cytoplasmic with membranous accentuation. results: immunpositivity at gpc , hep par and afp were %, %, % respectively. objective: fibroblastic growth factor receptor (fgfr) family is known to be related to the development and progression of various types of cancers. the aim of this study is to determine the clinical implication of fgfr expressions in patients with hepatocellular carcinoma (hcc). method: immunohistochemical analysis was done in cases of hcc using tissue microarray. diffuse cytoplasmic staining for fgfr , , and in more than % of tumor cells were designated as positive. the results were analyzed in terms of various clinicopathologic parameters. results: on univariate analysis, the overall survival rates of patients with fgfr expression ( cases, . %) were significantly lower than those with no expression (hr . , % ci . - . , p< . ). however, the overall survival rates of patients with fgfr expression ( cases, . %) were significantly higher than those with no expression (hr . , % ci . - . , p< . ). there was no statistical significance between patients' overall survival rates and expressions of fgfr ( cases, . %) or fgfr ( cases, . %). on multivariate analysis, only fgfr expression is independently associated with reduced os (fgfr : hr . , % ci . - . , p< . ). conclusion: the fgfr expression can be used as an independent prognostic factor in patients with surgically resected hcc. objective: hurp (hepatoma upregulated protein) is a putative oncogene, overexpressed in many human cancers, including hepatocellular carcinoma. it has also been shown recently that high hurp protein levels correlate with resistance to chemotherapeutic agents. in the present study we investigate the expression of hurp and its correlation with pancreatic adenocarcinoma, prognosis and patient survival. pancreatic adenocarcinoma is one of the most aggressive types of cancer and represents the fourth most common cause of death, either in the male or in the female population of the united states of america. method: hurp immunoreactivity was assessed by immunohistochemistry in a series of primary pancreatic adenocarcinomas. in parallel, hurp expression was examined in normal pancreatic tissues. statistical analysis related hurp expression levels with clinicopathological characteristics and survival. results: results showed a positive correlation between hurp overexpression and grade as well as lymphovascular invasion. all non malignant biopsies were negative. furthermore, positive expression of hurp appeared to be an important independent prognostic factor too, related with poor survival rates. conclusion: our results showed that hurp overexpression is associated with poor prognosis in pancreatic adenocarcinoma and indicated a diagnostic potential of this protein. its role in the carcinogenetic process awaits further elucidation. hepatocellular carcinoma in patient with hepatic porphyria: a case report j. marcinek * , p. szépe, t. balhárek, m. kalman, l. plank * university hospital martin, dept. of pathology, slovakia objective: hepatocellular carcinoma (hcc) is frequently associated with liver cirrhosis or chronic hepatitis of various etiology, less often with other chronic hepatopathies, including hepatic porphyria. we present a case report of hcc diagnosed in patient with clinically unrecognized porphyria cutanea tarda (pct). method: a -year old male was admitted to hospital complaining of a pressure below low costal margin, anamnesis of a trauma year ago and clinical suspicion of a posttraumatic intrahepatic haematoma. by a surgery, a partialy necrotic and hemorrhagic tumor mass cm in diameter was removed. results: the mass corresponded histologicaly to moderately differentiated clear cell hcc, resembling renal clear-cell carcinoma. the surrounding parenchyme showed steatohepatitis with fibrosis and distinct intracellular porphyrin crystals. conclusion: development of hcc is a well documented complication of pct, a disorder of porphyrin biosynthesis. pct can be inherited (autosomal dominant trait), the acquired form (sporadic pct) is more common. known etiological factors of pct include toxins, alcohol abuse, estrogens or chronic viral hepatitis, or association with other hepatic diseases like iron overload (including hereditary haemochromatosis) or chronic hepatitis c, increasing the risk of malignancy. however, in the presented case none of these associations was recognized and its etiology remains obscure. objective: signet ring cell carcinoma is an extremely rare type of gallbladder carcinoma composed overwhelmingly ( %) of signet ring cells. only a few cases of this histologic type have been published and detailed knowledge of this disease is not available. method: we report a case of signet-ring cell carcinoma of the gallbladder in a -year-old woman who was admitted with epigastric pain. under the preoperative diagnosis of cholangiocarcinoma, which was based on findings of ct scan and ultrasonography. cholecystectomy was performed. results: microscopic examination revealed a signet ring cells tumor that arose from the sub epithelial layer of mucosa and involved all the layers of gallbladder. nuclear atypia and mitoses were present. periodic acid schiff (pas) stain highlighted the intracellular mucin in the tumor cells. lympho-vascular emboli were detected in the subserosal layer. the cystic duct surgical margins were invaded. conclusion: gallbladder adenocarcinomas are seen frequently, but signet-ring cell carcinoma is a rare entity. owing to the location of the gallbladder, dissemination of the tumour to the adjacent tissues is usually presented at the time of the diagnosis. it is necessary to exclude a gastric or colonic signet ring cell carcinoma secondarily involving the gallbladder. objective: gastrointestinal stromal tumors (gists) are mesenchyme neoplasms of the gastrointestinal tract which express cd . gists can occur in the entire length of gastrointestinal tract, but very seldom can also arise in omentum, mesentery and retroperitoneal space, kidney, urinary bladder etc. there they are located adjacent to stomach or intestine, but not originated from the latter. these tumors are designated as "extra-gastrointestinal stromal tumors" (egists). there are only description of the primary egists reported in the literature. method: we report a case of a pancreatic egist in a year-old female patient. results: ct scan showed a mass in the head of pancreas. grossly encapsulated tumor, cm in diameter, was found in the head of the pancreas (figure ) . histologically, tumor demonstrated spindle-cell pattern consisted of distinct fascicles and bands. the number of mitoses was - / high power fields in "hot-spot" areas. ihc revealed strong positivity for cd , cd in neoplastic cells and negative for sma, desmin, s- . ki labeling index was %. conclusion: we presented a rare case of pancreatic gist. the tumor has very good prognosis. hepatoblastoma is classified as epithelial ( %) or mixed epithelial/mesenchymal ( %). epithelial hepatoblastoma is further divided to pure fetal ( %), embryonal ( %), macrotrabecular ( %) and small cell undifferentiated ( %). aim: to increase the awareness regarding possibility of hepatoblastoma in adult age. method: we review four cases of hepatoblastoma epithelial type diagnosed in pathology department of fundeni clinical institute between and . immunohistochemistry was done in all cases: cea, vimentin, ck / , ck , ck , ki , ttf , cd , cd , cd , muc a, alpha-fetoprotein. results: two of the patients were males and two females with age ranging between and years. the tumors varying in size from to cm. on microscopic examination the tumor was composed mainly of epithelial elements. the pathological diagnosis was epithelial hepatoblastoma epithelial type. conclusion: hepatoblastoma is a rare tumor in adult age and epithelial type is the rarest from all type of hepatoblastoma in adult age. the pathological diagnostic is quite difficult even using immunohistochemistry because none of the markers are not specific for hepatoblastoma. submassive hepatic necrosis with regenerative nodules: a series of cases y. rodríguez-gil * , j. salazar, j. delgado sánchez, g. lópez alonso, c. ibarrola de andrés, f. colina ruizdelgado * hospital universitar de octubre, dept. of surgical pathology, madrid, spain objective: confluent hepatic necrosis is the morphological correlate of fulminant liver failure. a group of these livers develop a combination of areas of necrosis and regenerative macronodules (rmn). method: sequential biochemical and clinical data and tissues from two groups of patients were compared. group : cases of submassive necrosis associated with rmn; group : cases with total confluent necrosis without nodular regeneration. results: group : mean age was , years (ranged months- years); group mean age was , years (ranged months- years) (p> , ). a longer course ( , ± , days vs , ± , , p< . ) and higher maximum serum bilirubin levels ( , mg/dl ± , vs , mg/dl± , , p< . ) were observed in group . serum ast, alt and gamma-gt were lower in group (p> . ). morphologically livers from group showed well defined regenerative green-yellow nodules with large regenerative hepatocytes in acinar pattern without surrounding fibrosis. the remaining parenchyma showed confluent necrosis, haemorrhage, mixed inflammatory infiltrate and ductular proliferation. conclusion: a special anatomoclinical form of subacute liver failure was characterized by regenerative macronodules in a background of extensive confluent liver necrosis. illness duration was longer and had higher maximum bilirubin levels than those without rmn. immunohistochemical study of muc gene family in pancreatic cancer g. setdikova * , o. paklina * moscow, russia objective: investigation of the muc gene in pancreatic ductal adenocarcinomas (pda). method: in the present study, we examined the expression of muc , and ac types by immunohistochemical analyses in pda from patients. overall survival curves were drawn by the kaplan-meier method. for all analyses, p< . was considered to be statistically significant. results: in our cases most of the pda was presented as muc +/muc ac + phenotype - % cases ( / ). the group with intestinal phenotype mucin, which characterized by positive expression of muc and cdx , was only % ( / ). the group which characterized by positive expression only muc ac (gastric phenotype), was % ( / ). the survival rate of patient better in group with muc expression. cumulative survival at months after surgery was . and the median postoperative follow-up period was months. the most aggressive behavior was pda with expression only muc ("true pancreatobilliary type"). cumulative survival at months after surgery was . and the median postoperative follow-up period was months. conclusion: the mucin profile as a prognostic factor is important not only for intraductal pancreatic mucinous neoplasm, but and for ductal pancreatic adenocarcinoma. ps- - hepatocellular carcinoma microvessels density depends on tumor differentiation: radiologic-pathologic correlations a. shchegolev * , e. dubova, u. tumanova * v.i. kulakov scientific center, dept. of pathology, moscow, russia objective: prognosis and recurrence level in hepatocellular carcinoma (hcc) depends on microvessels density. method: we performed ct and pathological correlations in cases of hc ( cases of highly (h-hcc), cases of moderate (m-hcc) and cases of low differentiated hcc (l-hcc)). results: vessels number in w-hcc in compare to m-hcc was higher by . % (p< . ). total vessel area was higher in m-hcc and l-hcc than in w-hcc by . % and . % accordingly. we observed positive correlation between ct density of h-hcc and number and total vessel area. correlation between h-hcc ct density and mean vessel area was negative. we also revealed modest negative correlation between m-hcc density and the number vessels in all phases of ct. negative correlation between total and mean vessel area and m-hcc density was revealed in native and arterial ct phases in compare with venous and delayed phases where positive correlation was revealed. in all phases of ct we revealed strong negative correlation between l-hcc density and the number of vessels whereas correlation between l-hcc density and mean vessel area was strongly negative. conclusion: we revealed decreasing in angiogenic activity in hccs neoplastic progression and growth. ct signs correlate with hcc histological differentiation. ps- - primary sporadic liver schwannoma: an extremely rare diagnosis r. silva * , c. eloy, j. m. lopes * centro hospitalar de são joâo, serviço de anatomia patológica, porto, portugal objective: primary liver schwannoma (pls) is extremely rare. results: case report: a -year-old female with previous history of cholecystectomy, appendectomy, arterial hypertension and diabetes mellitus was admitted due to an intrahepatic nodular lesion identified in routine ultrasound examination. she was submitted to partial hepatectomy with postoperative uneventful evolution. macroscopically, the specimen disclosed a . cm nodular, well circumscribed, yellowish tumour. histologically, the tumour displayed an expansive growth pattern, comprising short bundles of spindle cells with mild atypia, without mitotic figures or necrosis. immunohistochemically, the tumor cells expressed diffusely vimentin, s- and gfap, in the absence of ae /ae , cam . , cd , and hmb ; ki- index was %. staging procedures did not disclose evidence of any other tumor. there was no personal or family evidence of neurofibromatosis. these features are consistent with sporadic pls. conclusion: schwannoma is a rare benign tumour in the gastrointestinal tract with few cases reported in the liver. the clinical presentation is usually an upper abdominal pain but they can be asymptomatic. secondary cystic degeneration and hemorrhage are common in large tumours. differential diagnosis by imaging evaluation includes several benign and malignant, namely metastatic, tumours. therefore, the pathological examination is crucial for the diagnosis of primary liver schwannoma. metastases of hepatocellular carcinoma to the costa and soft tissue: a very rare entity e. tastekin * , t. d. yalta, o. yalcin, t. ciftci * trakya university, dept. of pathology, edirne, turkey objective: hepatocellular carcinoma (hcc) is the most common primary tumor of the liver with a potential of metastasis primarily to the lung, abdominal lymph nodes and bone. however, metastases to the costa, soft tissue are rare. method: an -year-old man was admitted to hospital with weakness, anorexia. chest x-ray and ct-scan demonstrated a × cm sized, intrathoracic mass on the lateral-side of the left .costa and also infiltrating the axillary soft tissues.a secondary mass with the identical radiological features was also detected within the c -vertebra. whole-body ct-scan was planned.a × cm sized nodular, hipodense mass was detected in the upper segment of the liver. interestingly, none of these masses demonstrated a significant pathological fdg-uptake in the pet.a trucut biopsy was taken from the axillar. microscopically, large tumoral nests were observed in connective tissues. polygonal shaped tumoral cells were found to have granular cytoplasm, pleomorphic nuclei. immunohistochemistry results: positive cytoplasmic reaction with heppar, ttf- ; canalicular staining with polyclonal-cea, cd ; weak cytoplasmic staining with pankeratin, b . ; negative reaction with vimentin, afp, ck , ck . results: these histomorphological, immunohistochemical findings strongly supported to the diagnosis of hcc metastasis. conclusion: hcc that is, in general, morphologically similar to mesenchymal and epithelial tumors, should be considered among the differential diagnosis of unknown primary tumors. morphological justfication of using pulsed electric discharge in surgical treatment of echinococcosis m. tussupbekova * , d. kaliyeva, e. turgunov * medical university karaganda, dept. of pathological anatomy, kazakhstan objective: echinococcosis is characterized by lesions of internal organs, severe complications, often lead to disability and death. method: new method of processing of the residual cavity with impulsive electric discharge after echinococcectomy was experimentally developed and introduced into clinical practice. the effectiveness of the method is confirmed by morphological examination of operational bioptic of the liver tissue. results: patients underwent surgical treatment with the new method (patent of the republic of kazakhstan ¹ ). parasitic cysts with an inner germinal layer and protoskoleks, outdoor layer -chitinous shell with a productive reaction with lymphocytes infiltration, single eosinophils, separate groups of hydatid bubbles with their invasion in the liver tissue were detected in the histological examination of material taken intraoperatively prior processing of residual cavity with electropulse discharge. fibrinoid necrosis, destruction of germinal elements, single lymphoid infiltration, hyperemia of blood vessels, absence o inflammatory reaction were marked in the histological material after processing by impulsive electric discharge. the results showed that echinococcectomy with processing of the residual cavity with impulsive electric discharge is an alternative for pericystectomy and liver resection. objective: congenital peribronchial myofibroblastic tumor is a rare, solid mesenchymal tumor of the fetus and neonate, usually associated with nonimmune hydrops fetalis. we report the case with clinical, radiological and pathologic findings and review the other cases in the english language literature. method: we present a case of cpmt, whom a right lung mass was detected in intrauterine life. days after delivery by cesarean section, right lobectomy was performed. results: the tumor was limited to lung, and composed of spindle cells, proliferating around bronchial unit. central necrosis and - / hpf was present. patient is well months after surgery. conclusion: congenital peribronchial myofibroblastic tumor is a rare solid pediatric tumor of lung which was named differently in the past, such as congenital fibrosarcoma, congenital leiomyosarcoma, congenital mesenchymal malformation of the lung, neonatal pulmonary hamartoma. albeit it resembles sarcoma with high cellularity, mitosis and necrosis features microscopically, no additional therapy to tumor resection is needed. so it is important to keep in mind this scary looking, but innocent tumor both in prenatal and postnatal evaluation. morphologic alteration of metastatic neuroblastoma in bone marrow after chemotherapy g.-e. bae * * samsung medical center, dept. of pathology, seoul, republic of korea objective: the aims of our study are to evaluate the histologic features of metastatic neuroblastoma in bone marrow (bm) in comparison with those of primary neuroblastoma, and to compare the histologic characteristics of metastatic neuroblastoma in bm before vs. after chemotherapy. method: total biopsies from children diagnosed as stage neuroblastoma with bm metastasis were examined histologically; primary neoplasm biopsies, bm biopsies before chemotherapy, primary neoplasm excision biopsies after chemotherapy, and bm biopsies after chemotherapy. results: ) primary neoplasms were classified as neuroblastoma poorly differentiated (n= ), neuroblastoma differentiating (n= ), ganglioneuroblastoma intermixed (n= ) and neuroblastoma type unclassifiable (n= ). ) metastatic foci in bm before chemotherapy were composed of undifferentiated and/or differentiating neuroblasts but not ganglion cells, in neuropil but not schwannian stroma. ) metastatic foci of bm after chemotherapy showed differentiation such as ganglion cells and schwannian stroma, which was more prominent after more cycles of chemotherapy. ) metastatic neuroblastomas in bm after chemotherapy were as mature as or less mature than those in primary neuroblastomas after chemotherapy. conclusion: metastatic neuroblastomas in bm initially consist of more immature components than primary neuroblastomas, whereas they become differentiated as primary neuroblastomas after multi-cycle chemotherapy. morphometric evaluation and clinical correlations in malignant small round cell tumors c. bansal * , a. gupta, a. kumar, a. srivastava * csmmu, dept. of pathology, lucknow, india objective: nuclear size increases in malignant tumors and reflects dna content, ploidy and proliferation index. present study investigated; could nuclear morphometery differentiate histomorphologically similar paediatric malignant small round cell tumors in h & e stained sections for using in a poor resource country? method: morphometric analysis was done in confirmed but difficult to differentiate round cell tumors histomorphologically and were analyzed by cell images from different areas in each section, using leica q win images software. results: nuclear measurements were obtained for retinoblastoma ( ), hodgkin lymphoma ( ), wilms tumor ( ), medulloblastoma ( ), ewing's sarcoma ( ), alveolar rhabdomyosarcoma ( ), malignant hemangiopericytoma ( ), non-hodgkin lymphoma ( ) and neuroblastoma ( ). amongst the retinoblastomas, maximum mean nuclear area percent ( . ) was seen in cases with nerve involvement and metastasis, followed by cases with only nerve involvement ( . ) and smallest area ( . ) was in non-nerve involving, non metastatic cases. wilms tumor cases with metastasis had higher nuclear area ( . ) than non metastatic ( . ). non-hodgkin lymphoma nuclear area ( . ) was more than hodgkin's ( . ). amongst all tumors, minimum value ( . ) was seen in malignant hemangiopericytoma. conclusion: morphometric evaluation in paediatric malignant round cell tumors have generated useful data, and needs further multicentric confirmation for implementation. objective: survivin, a bifunctional protein that regulates cell division and suppresses apoptosis, may play an important role in tumorigenesis. the aim of this study was to determine survivin expression patterns in wilms tumor (wt) and to analyze it in relation to stage, prognostic category and histological type. method: immunohistochemical expression of survivin was analysed in cases of primary wt and in normal kidney specimens uninvolved by the tumor. results: fifty one out of cases of wt ( . %) showed decreased cytoplasmic survivin expression compared to the expression in normal kidney tissue. decreased cytoplasmic expression (in all components of wt) of survivin was found significantly more often in low stage compared to high stage wts ( . % vs. . %; p= . ). tumors of intermediate risk group showed more often decreased cytoplasmic expression of survivin in comparison to high risk group, but the difference was not significant. decreased survivin expression was found more frequent in wts with diffuse anaplasia and in epithelial wts compared to other histological types, but without statistically significant difference. conclusion: decreased survivin cytoplasmic expression may be associated with the favorable prognosis wt. objective: hepatic tumors accounted % of congenital neoplasms. mesenchymal hamartoma of the liver is a rare benign tumor of children. we report a case of hepatic mesenchymal hamartoma in a premature male neonate. method: a premature neonate born at gestational weeks from year-old mother, g p with non-consanguineous marriage; prenatal ultrasonography showed a fetal macrosomia, a highly vascularized abdominal mass occupying two-third of the abdomen and displacing the bowel loops associated with poly-hydramnios. the newborn examination showed abdominal firm lump. ultrasound found and anterior highly vascularized mass displacing the left lobe of liver. the infant died few hours later. a complete autopsy was performed. results: external examination showed a male neonate anatomically of - week having an increased periombilical diameter and a macrosomia, ascitis, pulmonary hypoplasia, cardiomegaly, pleuropericardial effusion, liver tumor developed in left lobe and dilation of renal vessels. histologically the tumor showed a mixture of normal liver tissues with blood or lymphatic vessels, bile ducts within an abundant edematous and myxoid stroma. conclusion: in neonate and fetus, prenatal diagnosis is possible by ultrasonography. large tumors can affect the viability of the newborn. adequate excision is curative in most of cases. ps- - ncam polysialylation as potential initiator of differentiation and proliferation of renal progenitors in human fetal tissue s. cirovic * , j. tadic, n. radunovic, c. müller, g. müller, j. markovic-lipkovski * inst. for pathology, nephropathology, belgrade, serbia objective: objective: neural cell adhesion molecule (ncam) is widely expressed on mesenchymal and early tubular epithelial cells during kidney development although with still undefined function. ncam can be polysialylated and as psa-ncam has been shown to be involved in proliferation and migration of neuronal cells during brain development. the aim of this study was to evaluate the presence of psa-ncam in nephron precursors in relation to the expression of renal progenitor and proliferation markers. method: human fetal and neonatal kidneys were analyzed using double-immunofluorescence (dif) staining and western blot (wb) analysis. specific antibodies against ncam, psa-ncam, epcam, cd and ki- were applied. results: on wb only fetal tissue samples have bands with ncam at to kda which suggest that ncam molecule is polysialylated; dif analysis of fetal tissue show psa-ncam + ki- + cells in all structures known as nephron precursors. while in neonatal tissue psa-ncam and ki- were positive only on rare single cells in intersticium. conclusion: psa-ncam expression appears to characterize a very early stage of induced nephron progenitors differentiating from ncam + epcam-mesenchymal cells. according to psa-ncam localization and coexpression with ki- during development and its practically absence in neonatal tissue, suggest that psa-ncam present potential initiator of proliferation and differentiation of renal progenitor. objective: cystic hygroma (ch) typically develops in utero, late in the first trimester to early in the second trimester of gestation. many of the fetuses with ch present additional malformations commonly associated with chromosomal anomalies. method: a review of fetal autopsies performed over a year period revealed cases of ch ( , %). the results of cytogenetic analysis and the prenatal ultrasound findings were retrieved and compared to the autopsy findings. results: fetal death was due to therapeutic abortion in / cases, intrauterine death in / cases, and spontaneous abortion in / cases. cytogenetic analysis was available in cases. the results showed an abnormal karyotype in cases ( cases of turner syndrome and cases of trisomy ). the mean size of ch was , cm. other findings suggestive of the cause of fetal death were diagnosed in / cases ( , %). the most common autopsy findings were hydrops and central nervous system anomalies. the autopsy findings were in agreement with the prenatal ultrasound findings in / cases, while in cases ( , %) additional findings were detected during autopsy. conclusion: our study is confirms the strong correlation between ch and chromosomal anomalies of the fetus. immunohistochemical expression of e-cadherin in primary and metastatic nephroblastoma cases i. franckevicha * , r. kleina * university children´s hospital, dept. of pathology, riga, latvia objective: in nephroblastoma cases association between decreased e-cadherin expression and higher stage of tumor (safford sd, ) and lower expression in metastatic tumors (alami j, ) was described. some authors considered that e cadherin is not likely to play tumor suppressor role in nephroblastoma ( shulz s, ) . purpose of this study was to compare the expression of e-cadherin in metastatic and primary tumor cases in latvia. method: cases of primary tumors, metastases and case of relapse were analyzed immunohistochemically using visualization system envision. the number of e-cadherin positive structures per field was assessed (magnification× ). comparison between primary tumors and metastatic/ relapse tumors groups was made using mann-whitney test. results: in primary tumor group the number of positive structures in the field ranged from to , average . , sd . . in the metastatic tumor group, the number of positive structures varied from to , average . , sd . . comparison of expression observed in both primary and metastatic tumors groups showed the decreased e-cadherin expression in metastatic tumor group (z= − . , p= . ). conclusion: expression of e-cadherin is lower in metastatic tumor group that may suggest about negative correlation between it and higher tumor grade. ps- - testicular fibrous hamartoma: a case report a. kilitci * , f. yilmaz, s. yanik, h. ozturk * abant izzet baysal university, dept. of pathology, bolu, turkey objective: fibrous hamartoma (fh) of childhood is uncommon benign tumor. they are generally seen in the head and neck region, gastrointestinal system and lung. as in the case we report, they may also occur in other unusual sites such as groin and testis. the clinical presentation is almost always a mass or swelling, however our case was admitted to our hospital because of a left testicular atrophy. we report a fh in the testis, which has a rarely location and clinical presentation. method: a -year-old male presented to department of pediatric surgery because of left testicular atrophy. left orchiectomy was performed. results: in macroscopic examination, testis dimension was . × . × . cm. its cut surface was smooth and dirtywhite. in microscopic examination, the tumor showed disorganized matur tissue that composed of fibrocollagen stroma, vessels, muscular and adipose tissue. by this findings, it was diagnosed as testicular fibrous hamartoma (tfh). conclusion: in conclusion, tfh should be always kept in mind with testicular atrophy not only testicular mass or swelling. and knowledge of this particular type lesion is important to distinguish the fh of childhood from other situations in testis such as testicular torsion, incarcerated hernia, malign neoplasm, etc. in order to allow a correct diagnosis and avoid inadequate treatment. placental pathologic features in diabetes and hypertension p. luís * , a. costa-silva, a. alves * hospital de santa maria, dept. de anatomia patológica, lisboa, portugal objective: the aim of this study was to evaluate the most frequent placental findings in diabetes and hypertension and their main differences. method: retrospective study of selected placentas from to weeks gestation, in a universe of placentas examined over the last years ( % associated with hypertension, , % with diabetes and , % with both diabetes and hypertension (dwh). results: in diabetes the most frequently found abnormalities were immature villi ( %) and infarction ( %). in dwh the most frequent lesions were the immature villi ( %) and inflammatory lesions (either acute or chronic) ( %). in the hypertension group the most frequently found lesions were infarction ( %) and accelerated maturation of the villi ( %). in % of placentas in diabetes, % in dwh and only % in hypertension, no lesions were found. the incidence of fetal death was % in diabetes, % in dwh and , % in hypertension. when evaluating placental weight, small placentas were more frequent in the hypertension group ( %), and large placentas were more frequent in diabetes ( %). conclusion: our findings may contribute to evaluate the consequences of diabetes and hypertension in fetal outcome. as inflammatory conditions are usually not directly attributed to diabetes or hypertension, placental examination may help in diagnosis of associated pathology like infection. placental villi morphometry in preeclampsia k. pavlov * , e. dubova, r. shmakov, a. shchegolev * v.i. kulakov scientific center, dept. of pathology, moscow, russia objective: terminal villi structure abnormalities could play an important role in preeclampsia (pe) and its complications development. our aim was to perform comparative morphometric study of the placentas from mild and severe pe pregnancies. method: complex morphological and morphometric study of term placentas from mild pe (mpe) cases ( st group), term placentas from severe pe (spe) cases ( nd group) and term placentas from uncomplicated pregnancies (control group) was performed. results: we revealed significant decreasing in terminal villi size in both preeclamptic groups in compare to control. this decreasing was much prominent in spe group. we also observed significant terminal villi perimeter decreasing in both pe groups without any difference between mpe and spe groups. morphometry of cd stained specimens revealed significant decreasing in mean capillary number in both pe groups. single capillary area and perimeter were significantly lower in mpe and spe groups and these changes were much prominent in spe group. total villous capillary area and perimeter were significantly lower in both pe groups with minimal values in spe group. degree of villous capillarisation was significantly lower in both pe groups. conclusion: revealed features reflect villous structure changes in preplacental hypoxia, caused by mild and severe preeclampsia. sudden intrauterine death: the usefulness of autopsy f. portelli * , e. orlando, e. di stefano, e. maresi * university of palermo, section of pathology, italy objective: we investigated in autopsies of stillbirths the usefulness of autopsy even in the absence of risk factors and/or apparent anatomical/clinical causes which could explain the death. method: from january to december (institute of pathology, paolo giaccone-palermo) autopsies on dead uterine foetuses were performed. cases were abortions (< weeks), were stillbirths (≥ weeks). in all cases the autopsy included a macroscopic and microscopic examination both of the foetus and the placenta. the final diagnosis of death was based on both the morphological and clinical data. of the stillbirths, cases were "risk factor pregnancies", non. results: the stillbirth mortality was classified as follows: -sudden intrauterine unexplained death (siud,"sine materia" and absence of risk factor autopsies), cases; -explained intrauterine death ("cum materia" with or without risk factor autopsies), cases; -borderline intrauterine death ("sine materia" and presence of risk factor autopsies), cases. conclusion: in the absence of autopsy in / cases it was possible to establish the cause of death based on the presence of risk factors. in the absence of risk factors the autopsy showed a certain anatomical cause in / , only in / it was "sine materia". the role of "traditional" and "tomography" autopsy in foetal congenital heart disease (chd) f. portelli * , f. p. busardò, l. gutsul, l. averna, e. orlando, e. maresi * university of palermo, section of pathology, italy objective: the role of systematic autopsy in foetal chd is to identify the morphology of cardiac and possible associated extracardiac malformations (ecm) and the correlation between morphology, suspected clinical etiology and genetics. we evaluated the role of autopsy in foetal chds with/without prenatal diagnosis. method: from january to december (institute of pathology, paolo giaccone -palermo), foetal autopsies were performed. the autopsy protocol used was "tomography" for abortions, the "traditional" technique was adopted for stillbirths. results: in cases chds were identified. in cases chd diagnosis was made only through autopsy, in after a certain ( ) or suspect ( ) clinical/genetic diagnosis. the etiology of chd associated to ecm ( ) was: chromosomic type ( ), syndromic/sequence type ( ), association type ( ). the etiology of chd without ecm ( ) was never syndromic. conclusion: "traditional" and "tomography" autopsy plays a key role in the diagnosis and counselling of chd, either when it represents the only diagnostic tool ( , %) or when it is preceded by a clinical/genetic study. in the latter cases, its value depends on the detection of ecm, useful to "consolidate" a suspect clinical diagnosis ( , %) and to "complete" a malformative picture etiologically known thanks to a clinical/genetic analysis ( , %). objective: deregulation of cell cycle control is a hallmark of cancer. we have examined protein expression and gene amplification of cyclin a in wilms tumor (wt) and to analyze it in relation to tumor stage, prognostic group and histological type. method: real-time quantitative pcr was used to detect gene amplification of cyclin a in tumor tissue from patients with wt, while immunohistochemistry was applied to detect protein expression of the same cyclin. results: cyclin a gene amplification was found in out of the ( . %) cases of wt. cyclin a protein overexpression was detected in all four cases, but was also found in . % of cases without detectable gene amplification. so, there was no significant correlation between cyclin a gene amplification and protein overexpression. all cases with amplification of cyclin a were of favorable histological type, intermediate risk group and three out of four cases were low stage wts. on the other hand, overexpression of cyclin a was found significantly more often in high stage wts compared to low stage wts (p= . ). conclusion: cyclin a gene amplification might be associated with the favorable prognosis of wt (low stage, intermediate risk group and non-anaplastic tumors). the gold standard to diagnose is lung biopsy or necropsy. up to % of cases have mutations or deletions in the gene foxf (cr q . ) who plays a crucial role in the development of the lung vasculature. method: we report a case of a term newborn female affected of acd/mpv who was diagnosed by a lung biopsy. she died at days of life. autopsy and molecular diagnosis were also performed results: in the biopsy and autopsy specimens a decline in the number of capillaries in the alveolar septa and detachment of the epithelial lining was observed. secondary proximal plexiform arteriopathy, muscularization of arterioles and venous-venular dilatation and proliferation were evident. a pathogenic mutation in the gene foxf (frame shift mutation in the first exon) confirmed our diagnosis. conclusion: acd is defined by a decrease in capillaries with alveolar septal thickening and hypertrophy of the middle muscular layer of arterioles. mpv suggests an imbalance of angiogenesis. the foxf mutation helps to prenatal diagnoses of high risk families and to give the diagnosis to patients who fail to perform biopsy or autopsy. objective: prognosis of rhabdomyosarcoma (rms) has improved significantly over the last years. overall survival (os) is> % in the majority of patients; even though, children with metastatic tumors have a dismal prognosis with an os < %. method: we analyzed in cases, the possible correlation of notch activation with histology, presence of metastasis and outcome. immunohistochemistry (ihc) was performed for the notch downstream effectors hes and hey . results: hes was strong or moderate in % of the cases. hey was positive in %. out of alveolar rms (arms) were positive for hes and was positive for hey . both stains were negative in the fusion-negative arms. in embryonal rms (erms), eight out the were hey positive and of the were hes positive. the patients whit metastases had staining for hes and hey . patients who died showed hes (+). of the patients in remission showed positivity for hes and for hey . conclusion: hes expression was found in the majority of rms while hey was more erms specific. is no correlation between pathway activation, metastasis or outcome. the blockage of the pathway with specific inhibitors could offer a new therapeutic option for this patients. a renal epithelioid angiomyolipoma in a young woman with tuberous sclerosis complex, cortical tubers by neuroimaging, facial angiofribromas and lung lymphangioleiomyomatosis j. trillo-tinoco * * hospital general de mexico, dept. of surgical pathology, mexico city, mexico objective: tuberous sclerosis (ts) is a genetic disorder affecting cellular differentiation and proliferation, which results in hamartoma formation in many organs like skin, brain, lung, kidney and heart. method: a seventeen-year-old female with history of facial angiofibromas a years before, right renal tumor diagnosed a year before as theratoid-rhabdoid tumor, with chemoradiation as adjuvant treatment, cortical tubers by neuroimaging a few months before, and diagnosis of lung lymphangioleiomyomatosis recently. after last diagnostics, we reviewed again the renal tumor, new orientation of tissue, with new histological sections were performed. (fig) results: at histological examination, the kidney showed an infiltrating tumor, very cellular, consisting mainly of polygonal cells with eosinophilic cytoplasm, other multinucleated similar to the ganglion cells, also small hamartomatous areas with smooth muscle, fat and blood vessels proliferation. the tumor cells expressed hmb , mart- , sma, vim and cd , ckae / were negative. (fig) conclusion: the majority of renal angiomyolipomas is sporadic and to % occurs as part of ts, and their partnership is more close with epithelioid variant, recently, a rare entity with aggressive behavior, difficult histological characterization and poor prognosis. pulmonary mast cells in sudden infant death syndrome (sids) c. zaharia * , c. loddo, p. schmidt, r. m. bohle * university of saarland, inst. of pathology, homburg, germany objective: several theories of the underlying mechanisms of sids have been proposed, one of them is focusing on shock including anaphylaxis. increased concentrations of mast cell tryptase in post mortem blood have been observed without increased mast cell numbers in lung tissue. the aim was to evaluate the age-related distribution of pulmonary mast cells in infants dying of sudden infant death syndrome and controls. method: infants (up to year of age) who died of sids and controls who died of other non-pulmonary causes were examined. peribronchial mast cells exhibiting tryptase immunoreactivity were evaluated and quantified in high power fields in lung sections. results: the number of mast cells in peribronchial regions amounted to , (± , )/mm in children aged month up to months. mast cells in sids cases were , (± , )/mm . the difference was not significant (p= , , student'st test). conclusion: it is unlikely that increased pulmonary mast cells are indicators of sids. the role of mast cells in sids remains controversial. trophoblast apoptosis in placentas from pregnancies complicated by preeclampsia s. zekic tomas * , i. kuzmic prusac, d. roje, i. tadin * clinical hospital centre split, pathology, croatia objective: to assess trophoblast apoptosis separately in cytotrophoblast, syncytiotrophoblast, total villous trophoblast and syncytial knots, as well as to investigate the expression of apoptotic factors fas ligand (fasl), bcl- and proliferation marker ki- in trophoblast of placentas from preeclamptic patients. method: the study included placental samples from preeclamptic and normal pregnancies. for the detection of apoptosis and proliferation antibody m and antibody against ki- antigen were used. expression of fas ligand and bcl- was assessed using semi quantitative hscore method. syncytial knots were expressed as the number of syncytial knots per individual villus and as the total number of syncytial knots in each placental sample. results: apoptosis in all stages of trophoblast differentiation, number of syncytial knots per individual villus and the total number of syncytial knots were significantly higher in preeclamptic placentas than in control group placentas. fas ligand expression was significantly less, and bcl- expression significantly greater in the villus trophoblast among the study subjects compared with controls. there was no difference in the trophoblast proliferation between groups. conclusion: our findings might suggests that increased apoptosis and syncytial knots formation combined with reduced fas ligand expression could be involved in pathophysiological mechanisms of preeclampsia. contribution of fetal autopsy for diagnosis of meckel-gruber syndrome m. jo * , i. guerra, g. perez de nanclares, p. morales, j. j. aguirre, z. s. quintero, c. gomez, n. t. villagra * hospital txagorritxu, pathology, vitoria, spain objective: meckel-gruber syndrome (mgs) is a lethal rare autosomal recessive malformation. the six implicated genes encode proteins involved in primary cilia function. groups of families in finland, india and north of africa have been identified. method: a fetus, xy, karyotype, therapeutically aborted at weeks with alobar holoprosencephaly in ultrasound. fetal autopsy was performed. genetic counseling was proposed to the family revealing moroccan origin and consanguinity, the parents were first cousins. results: a male fetus showing cyclopia, proboscis and a single opening with two rudimentary eyes was the external morphology. histological examination confirmed holoprosencephaly and also showed bilateral corticomedullary renal multicystic and periportal hepatic fibrosis with bile duct dilatation. the main diagnosis was mgs although other ciliophaties and non-ciliopathies conditions were considered, such as bardet-bield, joubert, smith-lemli-opitz syndrome and trisomy . however, the pathological characterization, parent's consanguinity and their north african origin makes mgs the likely diagnosis.a genetic study on paraffin-embedded material was requested, the poor quality of dna stopped definitive genetic diagnosis. conclusion: the pathologist may encounter atypical cases that require morphologic diagnosis to determine the type of underlying mutation and provide genetic counseling to parents.a meticulous autopsy is necessary to establish the diagnosis of mgs. fresh material would have to be frozen in order to make current diagnostic techniques of molecular pathology. mesenteric cysts in the pediatric age group r. jankovic * , j. sopta, m. stojanovic, b. lekic, b. jovanovic, z. stojsic * university of belgrade, faculty of medicine, serbia objective: mesenteric cysts are extremely rare lesions arising with an incidence of / , admissions in children. clinically, mesenteric cysts are generally comprehended as a unique diagnostic entity, although they exhibit histological diversity. the objective of this study was to determine the incidence and the histology of the mesenteric cysts in the pediatric age. method: all cases of mesenteric cysts operated at the university children's hospital belgrade over the -year period of to were reviewed using pathology reports from the files of the institute of pathology. histological slides were re-examined and immunohistochemistry was applied, when necessary. results: a total of cases of mesenteric cysts were identified. cysts of lymphatic origin (cystic lymphangiomas) were recorded in patients ( %), cysts of enteric origin -in patients ( %): duplication cysts and one isolated enteric cyst of the mesenterium. only one example of the cyst of mesothelial origin, i.e. benign cystic mesothelioma was diagnosed ( %). the most frequent site was mesenterium and mesocolon ( %), followed by omentum ( %) and the retroperitoneum ( %). conclusion: cysts of enteric origin are easily recognized. it is important to differentiate between cystic lymphangioma and cystic mesothelioma due to their different natural history. objective: myxoid liposarcoma belongs to the group of soft tissue sarcomas with lipomatous differentiation. breast is a rarely affected (only . % of breast sarcomas), and often misdiagnosed. method: a -years old woman presented with a painful timorous lump of the left breast. mammography showed oval, lobulated lesion between medial quadrants, while ultrasonography revealed hipoechogenic, inhomogeneous nodule. patient underwent core biopsy which was histologicaly inconclusive and followed by quadrantectomy with excision of both medial quadrants. results: a lump ( cm) was visible on the skin surface. serial sectioning revealed solid gray-white tumor with cystic and prominent necrotic areas. the tumor was located in the deep mammary tissue an it infiltrated the overlying dermis without involving the epidermis. it consisted of atypical stelate and spindle cells with infrequent mitoses and low ki- proliferative index. on the periphery mature adipocytes and lipoblasts were present. stroma was abundant, myxoid with plexiform capillary pattern. the myxoid substance stained slightly alcian-blue positive and tumor cells showed cytoplasmic immunopositivity for s . phylodes tumor was excluded because of absence of epithelial component. conclusion: myxoid liposarcoma has a distinct morphology, rarely confused with other soft tissue tumors, although on cytological smears or biopsy samples it may be unrecognized. objective: synovial sarcoma poses a difficult diagnostic challenge since it can be confused with other benign or malignant entities. method: four biphasic and one monophasic synovial sarcomas were studied. we used the break apart/split signal kit (vysis) to detect the t(x; ) translocation and we performed immunohistochemistry for tle- , ini- , d - , cd , cd , bcl- , ema, ck , cd , s- , desmin and claudin- . results: immunohistochemically we observed: tle- +( / ), ini- ( / ) with reduced nuclear and ( / ) with no expression, d - +( / ), cd +( / ), cd +( / ), bcl- +( / ), ema focal expression ( / ), ck −( / ), cd −( / ), s- −( / ), desmin−( / ), claudin- + ( / ). fish revealed the split signal between the centromeric and telomeric end of the syt gene. conclusion: t(x; ) translocation remains the diagnostic hallmark of synovial sarcoma. ini- which is typically negative in atypical teratoid/rhabdoid tumor, epithelioid sarcoma and myoepithelial carcinoma seems to be reduced or even negative in synovial sarcomas. the focal expression of d - must be considered when the differential diagnosis includes mesothelioma. finally tle- is a very sensitive marker for synovial sarcoma. ps- - "mixed aneurysmal bone cyst" and "simple bone cyst", represent a different group of cystic lesion e. ayhan cinar * , b. doganavsargil, m. sezak, f. oztop * ege university, pathology, izmir, turkey objective: there are some mixed cysts (mc) with overlapping histological features of aneurysmal bone cyst (abc) and simple bone cysts (sbc). method: we reviewed pure abc, sbc and "mixed cysts (mc)", and compared them by nonparametric tests. results: mcs, mainly showed two paterns as "type : sbc with secondary abc foci (n= )"and "type : cysts with fully developed sbc and abc areas (n= )". the median age for abc, sbc, and mc were ± . (range: - ), ± . (range: - ) and ± . years old (range: - ) respectively. mcs were more frequent in males than abc and sbc (p= . ) and the most frequently involved bones were humerus-femur-pelvic bones in descending order (p= , ). "type mc" showed more frequent cementum-like amorph material (p< . ), ectatic venules (p= . ), calcifications (p= . ), less cholesterol deposition, necrosis and no different fracture and osteoid matrix when compared with type mcs and sbcs. conclusion: cysts with overlapping features of abc and sbc are not uncommon. though they usually represent "sbcs with secondary abc component", they have dissimilarites with ordinary sbcs which needs to be further clarified with larger series. objective: percent of tumor necrosis after neoadjuvant chemotherapy, determined by detailed specimen mapping, has a high prognostic value. however both the mapping and grading systems has some practical problems. method: cases were reviewed for potential pitfalls in handling and reporting processes and correlated with radiological findings by nonparametric-tests. results: most of the tumors were osteosarcoma ( . %) and ewing sarcoma ( . %), located in femur ( %), tibia ( , %) and humerus ( . %). cortex, soft tissue and joint invasion was observed in %, . % and . % of the cases, respectively. a median of . tumor blocks ( - ± , ) were submitted for histology. tumors were totally necrotic in cases ( %) (huvos grade-hg-iv), hg iii in . %, hg ii in . % and hg i in . % of the cases. overall good (hg iii-iv) and poor responders (hg i-ii) correlated well with radiological findings (p< . ). discrepant cases showed extensive oedema and congestion enhancing contrast medium, patchy necrosis unabling accurate histologic evalation, or failure to prove tibiofibuler joint involvement because of sagittal sectioning (p< . ). conclusion: evaluating chemotherapy responce is a laborious work. radiologic orientation prior to grossing and applying morphometric technics may enhance more accurate evaluation. atypical ewing sarcoma/primitive neuroectodermal tumor with unusual melanocytic differentiation -a case report p. buzrla * , j. dvorackova, i. urbanovska, h. bielnikova * inst. of pathology, ostrava-marianske hory, czech republic objective: atypical ewing sarcoma/primitive neuroectodermal tumor with the melanocytic differentiation is a very rare, malignant tumor which occurs in infants and adolescents. it is localized mainly in soft tissues. its biological behavior is aggressive, but its response to the chemotherapy is prognostically good. method: a -month old male is presented with the × cm tumor of the soft tissue, localized in the right front over the cranial margin of the orbit. the tumor was surgically exstirpated and then sent to the histological investigation with the additional immunohistochemistry and the fish. results: microscopically, the tumor is hypercelullar and consisted of oval to polygonal cells with the vesicular nuclei, the prominent nuclei and the amphophilic cytoplasm. in other parts of the tumor, there are smaller neoplastic cells with hyperchromatic nuclei. some neoplastic cells contain the melanin pigment in the cytoplasm, which was positive in fontana-masson method. the immunohistochemical stains for vimentin, ae / , ck , cd , hmb- , fli- were positive. the fish investigation demonstrated the translocations (t ; , q ;q ) in % of neoplastic cells and (t ; , q ; ) of % ones. conclusion: in literature, the ewing sarcoma/pnet showing the myogennic differentiation is usual, but the melanocytic differentiation is rare and can be confirmed not only immunohistochemically, but also by fish investigation. objective: poly(adp-ribose) polymerase- (parp- ) is a nuclear enzyme involved in the repair of dna single-strand breaks. parp- inhibitors may be efficient in therapy of malignancies. this report evaluates the expression of parp- in primary testicular germ cell tumors and correlates expression patterns with histological subtypes and patient/ tumor characteristics. method: group of patients with testicular germ cell tumors were investigated for parp- expression by immunohistochemistry, scored by the multiplicative quickscore (qs) method and compared to parp- expression in normal testis. results: we observed higher expression of parp in testicular tumors compared to normal testis (mean qs= . vs. . , p< . ). the parp- overexpression (qs> ) was most often detected in intratubular germ cell neoplasia itgcn ( % of specimen with parp- overexpression), compared to . % of normal testicular tissue specimen. there was no association between parp- expression and clinical variables. conclusion: parp- expression is higher in tumor tissue than in normal testis. parp- could represent a novel treatment target in tgcts and the assessment of parp- expression in tumor samples may lead to the consideration of tgcts patients for parp inhibitor therapy. supported by / -nou- , vega / / and itms: cofinanced by european regional development fund. objective: gardner fibroma (gaf), a rare lesion, typically occurs in infants, children and young adults, with predilection for the trunk (particularly paraspinal region) and no gender predominance. gaf is an ill-defined plaque-like mass, with rubbery consistence, usually asymptomatic, ranging from . to cm. although benign, - % of the cases may be associated with apc mutations, familial adenomatous polyposis (fap) and/or gardner syndrome (gs). we report cases of gaf, which allowed the identification of families with gs. results: case : -month-old boy, with nodules in the left paraspinal region, the largest with . cm. case : month-old boy, presenting a . cm ill-defined deep right scapular mass. both lesions were infiltrative, paucicelular densely collagenized proliferations of bland spindle cells. a gaf diagnosis was made and clinical/genetic investigation advised. apc gene sequentiation revealed, in both cases, a frameshift germline mutation in exon . additionally, case presented a del( )(q q ). heredogram showed typical manifestations of gs: case : mandibular osteomas, epidermoid cysts, "soft-tissue tumours", colo-rectal carcinoma. case : hepatoblastoma, colo-rectal carcinoma. conclusion: given the high association with gs and the fact that it can be its first manifestation, gaf is considered a sentinel lesion for this syndrome. therefore, an accurate diagnosis is of the utmost importance. prognostic significance of bcl- , c-myc and survivin in synovial sarcoma d. demir * , b. yaman, y. anacak, b. keçeci, g. kandiloğlu, t. akalın * ege university, pathology, izmir, turkey objective: in this study, we evaluated synovial sarcoma cases, who had been referred to our tertiary tumor center during the last years. we applied bcl- , c-myc and survivin as immunohistochemical markers and evaluated the relation with conventional prognostic findings and prognosis for those patients who have follow-up. method: in this study; ten-year tumor free survival rate was % reflecting the agressive behaviour of synovial sarcoma. tumor grade was the most valuable prognostic input. progression free survival (pfs) was months for gradeii cases ( cases) and months for gradeiii cases ( cases) (p= , ). results: immunohistochemically, there was weak relation between bcl- staining intensity with prognosis. overall survival was months for weak or negative cases ( cases), months for focally intense cases ( cases) and months for diffuse and intense cases ( cases) (p= , ). there was also weak relation with c-myc staining pattern with prognosis. overall survival was months for c-myc negative cases ( cases), months for cytoplasmic positive cases ( cases) and months for nuclear positive cases ( cases) (p= , ). there was no relation between survivin and prognosis. conclusion: in conclusion; tumor grade is the most valuable prognostic parameter in synovial sarcomas. immunohistochemically c-myc and bcl- staining have weak relation with synovial sarcoma prognosis. immunohistichemical profile of primary and recurrent desmoids e. dubova * , t. sidorenko, a. shchegolev, a. adamyan * v.i. kulakov scientific center, dept. of pathology, moscow, russia objective: desmoids is a locally recurrent and invasive but not metastatic tumor. our aim was to study immunohistochemical profile of primary and recurrent desmoids. method: complex morphological study of abdominal desmoids. all the tumors were divided into groups: primary, first recurrent and second and more recurrent cases. we used antibodies against β-cathenin, cox- , apc, survivin and ki- for immunohistochemical study. results: nuclear and cytoplasmic β-cathenin expression levels were significantly higher in recurrent than in primary desmoids. apc cytoplasmic expression level was also significantly higher in recurrent tumors. we revealed only cytoplasmic cox- expression in desmoids, and its level was significantly higher in recurrent tumors with the activity increasing accordingly to the number of recurrences. survivin expressed both in nuclei and cytoplasm of the tumor cells and its expression levels were significantly lower in recurrent desmoids. conclusion: revealed immunohistochemical properties of primary and recurrent desmoids reflect tumor transformation and progression and could be used as additional prognostic markers in this disease. objective: many bone and soft tissue sarcomas (bsts) are aggressive tumors with fatal prognosis. the importance of angiogenesis for the growth and progression of solid bsts is now well recognized. a variety of chemokines have been described that either promote (angiogenic) or inhibit (angiostatic) angiogenesis. the aim of this study is to characterize the expression profile of some chemokines in a series of xenotransplanted human bsts. method: one ewing sarcoma (es), grade chondrosarcoma (chs), osteosarcoma (os), synovial sarcoma (ss), fibrosarcoma and gastrointestinal stromal tumor (gist) were xenotransplanted into the backs of nude mice (athymic balb-c nude mice). when the tumor size reached the cm, animals were sacrificed and tumors analyzed for the expression of cxcl / / , cxcl and cxcl , using two-color staining fluorescence on each slide under a confocal microscope (olympus fv ). results: we observed that angiostatic chemokines (cxcl and cxcl ) presented higher expression than angiogenic (cxcl / / ) chemokines in es, grade chs, os and gist whereas fibrosarcoma and ss were more positive for angiogenic chemokines. conclusion: the expression profile of angiostatic and angiogenic chemokines depends on the type of bsts and could be related to their different biological behaviour. other elements such as angiogenic or pro-inflammatory markers should also be considered. objective: the wide range of differential diagnostic possibilities of rhabdomyosarcomas (rms) shows the need for more specific and sensitive markers. low survival rates of high risk rms patients require new prospective therapeutic targets. method: archival material ffpe samples of rms ( embryonal -erms, alveolar -arms) and non-rms soft tissue tumors were evaluated by immunohistochemistry for myogenin, myod , egfr, vegf, cox- , p-akt and p-mtor expression. the presence of pax / -fkhr forming translocations, myogenin, myod , gamma subunit of fetal acetylcholine receptor (achr) and k-ras mutational state were determined by rt-pcr. results: / erms and / arms showed expression of myogenin, myod and gamma achr. non-rms tumors were negative. translocations were only found in arms. egfr expression was characteristic for erms, without the presence of activating k-ras mutation. strong expression of vegf was detected in all samples. p-akt and p-mtor showed overlapping expressions in , % rms. in most of the samples weak cox- positivity was demonstrated. conclusion: myogenin, myod and the fetal achr are specific and sensitive diagnostic markers of rms. rms subtypes are identifiable by pax / -fkhr detection and probably egfr expression. the results indicate vegf, egfr, cox- and akt-mtor pathway directed therapy to be considered in rms. supported by itms . immunohistochemical analysis of potential targets in desmoid tumor therapy a. janegova * , z. hlavata, p. babal, p. janega * comenius university, dept. of pathology, bratislava, slovakia objective: desmoid tumors (dts) are clonal fibroblastic/ myofibroblastic proliferations. although histologically benign, desmoids are locally invasive and often have an unpredictable clinical course. dts are infrequent lesions, but they have a high incidence in patients with familial adenomatous polyposis (fap). the treatment of dts needs to be individualized. method: to explore the molecular bases of potential pharmacologic targets in dts we evaluated the immunohistochemical expression of steroid hormone receptors (era, erb, pr) and cox- protein in sporadic (n= ) and fapassociated desmoid tumors (n= ) together with gi adenomas of fap patients (n= ). results: nuclear erb expression was found in / dts. all adenoma samples showed nuclear erb positivity, which was weaker than in the surrounding normal epithelial cell. era and pr expression were lacking in all samples. cox- was found in / dts. adenomatous polyps showed intense cox- expression compared to surrounding normal mucosa. conclusion: high incidence of erb positivity in dts supports the usage of hormonal therapy in these lesions. open question is the effect of anti-estrogen therapy in dt patients with adenomatous polyps, as in adenomas estrogen seems to have preventive potential. cox- expression suggests the benefit of anti-inflammatory treatment in dts adenomatous polyps. supported by itms: . retroperitoneal sarcomas: clinicopathological features in a series of cases e. kairi-vasilatou * , a. tsagkas, a. melloy, a. paraskeva, a. kondi-pafiti * aretaieio nosokomeio university, dept. of histopathology, athens, greece objective: retroperitoneum is the less common site of origin accounting for approximately % of soft tissue sarcomas. method: between january and december , our hospital's records of patients with retroperitoneal sarcomas were retrospectively studied. results: the patient median age was years and there was no sex predominance. median tumor size was . cm (ranging from to cm) with % of them being larger than cm. the most common histological type was liposarcoma ( / - , %), followed by leiomyosarcoma ( / - , %) and undifferentiated soft tissue sarcoma ( / - , %). the remaining tumors ( , %) included chondrosarcomas, well-differentiated fibrosarcomas, pecoma, hemangiopericytoma, ewing sarcoma and malignant peripheral nerve sheath tumor. of the sarcomas were high grade ( %) and ( %) low grade. -year recurrence rate was , %. the -and -year overall survival rates were , % and , % respectively. seven patients received adjuvant chemotherapy. conclusion: the most commonly encountered histologic subtypes are liposarcoma and leiomyosarcoma, which are consistent with the results of the present study. complete tumor resection at first operation is the only treatment factor that consistently predicts improved survival. abdominal desmoid tumor y. lorenzo mahia * , m. san martin alonso, b. iglesias rodriguez * hospital maixoeiro, anatomia patologica, vigo, spain objective: abdominal desmoid tumours are rare benign neoplasms. they are commonly found in the mesentery, while they are rarely found in the intestinal wall. most cases are sporadic, although there is a link with colonic polyposis, trauma, and oestrogen. they predominate in - year-old women. this present case is notable due to its location in the jejunal wall, possible relation with previous surgery, and the age and sex of the patient. method: we present a -year-old male patient previously operated for umbilical hernia years before. he came to the consultation on noticing an abdominal mass. since the initial suspicion was of jejunal wall gist tumour, surgery was performed. results: the histopathological and immunohistochemical findings, support the diagnosis of desmoid tumour. conclusion: desmoid tumours consist of fibroblastic monoclonal proliferation developed from aponeurotic muscle structures. some authors consider them non-neoplastic processes given their limited aggressiveness while others classify them within distinct low-grade sarcomas. their origin is not well established, although there are known factors involved such as mutations in the apc gene or beta-catenin and trisomy and . the originating cell, the myofibroblast, is involved in post-traumatic cellular regeneration. this explains why we find these tumours associated with previous surgery. treatment of advanced dermatofibrosarcoma protuberans with imatinib mesylate with or without surgical resection w. michej * * cancer centre institute of warsaw, dept. of pathology, poland objective: dermatofibrosarcoma protuberans (dfsp) is a rare soft tissue sarcoma of the skin characterized by the presence of specific col a -pdgfb fusion protein, which appears as a consequence of the t( ; ) (q ;q ) translocation. method: the aim of the study was to perform an analysis of patients with advanced dfsp treated with imatinib, with or without surgery. we examined patients ( male, female; median age years) with locally advanced/initially inoperable and/or metastatic dfsp treated with imatinib - mg daily between / and / . all diagnoses were ascertained cytogenetically (fluorescent in situ hybridization). median follow-up time was months (range: - ). results: metastases were present in cases (two lungs, two soft tissue, two lymph nodes). fibrosarcomatous transformation was confirmed in patients. after treatment with imatinib overall responses were: partial responses, stable diseases ( %) and progressive diseases ( %). seven patients ( %) after resection had residual disease confirmed by pathologic examination and remained free of disease. conclusion: we proved that anti-tumour effect of imatinib in dfsp with presence t( ; ) had in most cases good responses. imatinib therapy may in some cases leads to tumour resection because of lesser size. objective: at an estimated incidence of cases per million per year, osteosarcoma is the most common malignant primary bone tumor. method: we conducted a retrospective study to identify the osteosarcoma cases diagnosed at major tertiary care hospitals in turkey. results: our study group was made up of cases: men, women, aged - years (mean . year). all patients had been diagnosed with skeletal osteosarcoma between and at one of the tertiary care referral center. tumor was most frequently located in femur ( . %) followed by tibia. apart from the long bones, pelvic and gnatic bones were the next in location, . % and . % respectively. there were ( . %) secondary osteosarcomas, related to previous irradiation and various underlying diseases. for the histological types conventional osteblastic intramedullary tumors were most prevalent, making . .% of the cases. chondroblastic and telengiectatic osteosarcoma are the next common histologic types. surface tumors were detected in ( . %) cases. rare histological types like small cell, epitheloid, chondroblastoma like and fibrous dysplasia like were also reported. conclusion: this study is conducted as a preliminary work to form the basis of a pathologic database for the osteosarcoma cases diagnosed in our country. objective: kaposi's sarcoma is a rare disease likely associated with human herpes virus infection, and occurs predominantly in jewish, mediterranean and middle eastern men. since there is a paucity of reports on the pattern of its occurrence in tunisia, we here analysed the epidemiological pattern and anatomoclinical features. method: we retrospectively studied consecutive cases of kaposi's sarcoma diagnosed in the pathology department, farhet hached hospital, sousse during a -year period. results: kaposi's sarcoma represented % of soft tissue sarcomas. there were ( . %) females and ( . %) males (male-to-female ratio: . : ). median age at diagnosis was (range: - years). the age distribution showed that elderly (≥ years) were the most affected patients with a frequency of . %, followed by patients aged - years ( . %), and patients under years ( . %). the most common location was the lower limbs, particularly the distal lower extremity ( . %), followed by contiguous location ( %), and soft tissue, nos ( %). conclusion: kaposi's sarcomas were more frequently diagnosed in elderly. the distal lower extremities were more involved. objective: rhabdomyosarcoma is the most common soft tissue sarcoma in the first two decades of life. in this study, we analysed the epidemiological pattern and antomoclinical features of rhabdomyosarcoma in central tunisia. method: we retrospectively studied all cases of rhabdomyosarcoma diagnosed in the pathology department, farhet hached hospital, sousse during a -year period. results: there were ( . %) females and ( . %) males (male-to-female ratio: . : ). median age at diagnosis was (range: - years). rhabdomyosarcoma was more frequently diagnosed in childhood ( %) than in adults ( %). in children, the tumour size was higher than cm in % of cases, the embryonal subtype was the most frequent ( %) and the two most common sites of disease were the head and neck ( %) and genito-urinary tract ( . %). in adults, the tumour size was higher than cm in % of cases, the pleomorphic subtype was the most diagnosed ( %), and limbs were the most involved sites ( %). conclusion: rhabdomyosarcomas is more frequently diagnosed in children than in adult. head and neck locations were the most involved and embryologic type was the most diagnosed. in adults, rhabdomyosarcomas were more frequently localized in limbs and diagnosed as pleomorphic type. microarray-based dna methylation study in ewing sarcoma of bone h.-r. park * , y.-k. park * hallym university, sacred heart hospital, anyang, republic of korea objective: alterations in the dna methylation pattern are a hallmark of malignancy and also of ewing sarcomas. however, most epigenetic studies in ewing sarcoma have focused on the analysis of few candidate genes and comprehensive studies are required. method: here, we report for the first time a microarraybased dna methylation study of cpg sites of cancerrelated genes in ewing sarcomas. we used illumina's goldengate methylation cancer panel i microarray. results: using appropriate controls (n= ), we identified a total of cpg sites hypermethylated in ewing sarcoma. most of hypermethylated genes are related with cell adhesion, cell regulation, development, and signal transduction. we compared the methylation mean of each tumor according to the survival data. the methylation mean was significantly higher in the alive patient group ( . ± . ) compared to the dead patient group ( . ± . ) (p= . ). however, the methylation mean was not significantly correlated with age, sex, or tumor location. we selected the most popular hypermethylated genes, gdf , osm, apc, and hoxa , but, their methylation levels were not significantly correlated with the survival data. conclusion: we have characterized the dna methylation profile of ewing sarcomas and detected cpg sites that were significantly hypermethylated in ewing sarcomas. these might therefore play an important role in the development of ewing sarcomas. pleomorphic and dedifferentiated leiomyosarcoma associated with lynch syndrome: a case report h. quiceno * , f. j. queipo, r. carías, j. j. sola, f. j. pardo * clinic university of navarra, anatomical pathology lab, pamplona, spain objective: the lynch syndrome or hereditary non-polyposis colorectal cancer (hnpcc) is a hereditary syndrome that predisposes to different types of colonic and extracolonic cancer, mainly in endometrium, stomach, ovary, and hepatobiliary and urinary tract. occasional sarcomas have been reported in hnpcc patients. method: we describe a pleomorphic and dedifferentiated leiomyosarcoma of the gluteus in a patient with lynch syndrome. we study her clinical, pathology, immunochemistry and molecular alterations. results: we present a year old woman with previous colorectal, endometrium and breast cancers in a lynch syndrome with mutations in exons and of mlh , which appeared with a right gluteus mass. grossly, it was encapsulated, whitish-yellowish with necrotic areas and measured , cm. microscopically, the tumor was composed by a diffuse and polymorph spindle cells with fascicular pattern, focally myxoid and zones of necrosis and large hyalinization. the cells had large nuclei, sometimes giant multinucleated, with a brisk atypical mitosis activity. there was ihq variability: positivity to desmine, msa, calponin and negative to caldesmon and sm. there was loss of msh and msh repair proteins. conclusion: we must suspect a lynch syndrome relational sarcomas if we found one in a patient with hnpcc in order to test to mismatch repair proteins. immunohistochemical review of synovial sarcomas, including expression of tle : a "new" marker, with molecular confirmation in cases b. rekhi * , r. basak, s. desai, n. jambhekar * tata memorial hospital, dept. of pathology, mumbai, india objective: synovial sarcoma displays a wide clinicopathological spectrum and a specific translocation t(x; )(syt-ssx)(p . ; q . ). cost constraints limit molecular confirmation in every case. lately, tle has been recognized as a useful ihc marker. herein, we present ihc review of synovial sarcomas, including tle expression. method: forty-two synovial sarcomas included monophasic spindle-cell type ( ) ( . %), biphasic ( . %), calcifying ( ) ( . %) and poorly-differentiated type ( ) ( . %). tumors were confirmed with molecular analysis. tle immunostaining was graded from , +, +, +, with + or + grades interpreted as positive staining. results: on ihc, various synovial sarcomas were positive for ema ( / )( . %), ck ( / ) ( %), ck/mnf ( / )( . %), bcl ( / )( . %), mic ( / )( . %) and tle ( / )( . %), while negative for cd ( / ). among other tumors, tle was positive in schwannomas ( / ) ( %), neurofibromas ( / )( %), mpnsts ( / )( %) and pnets ( / )( %). sensitivity and specificity of tle for synovial sarcoma was . % and %. % of pnst ( % of schwanomas, % of mpnst and % of neurofibromas). in contrast, her positivity was observed in % of other mesenchymal tumors ( % uterine and % non-uterine leiomiomas, % uterine and % nonuterine leiomiosarcomas, % ups). conclusion: her overexpression is frequently found in pnst, including % of mpnst. due to the crucial role of her receptor in cell signalling as a main activator of the pi k pathway, these results support the rationale of developing new therapeutic approaches in mpnst. objective: nonneural granular cell tumour (nngct) is a rare neoplasm described in by leboit et al. till now, no more than cases have been presented in the literature, nearly all were limited to the skin. we report the first nngct of the breast and present its morphological and immunohistochemical characteristics. method: a year-old female underwent lumpectomy because of tumour of the breast. after routine histological examination, the immunohistochemical studies were performed using commercially available antibodies against cytokeratins (ae /ae ), cd , cd a, s , cd , smooth muscle actin, desmin, miogenin, inhibin, and ki antigen (mib ). results: microscopically, the tumour was composed of ovoid and polygonal cells with abundant granular, eosinophilic cytoplasm. the cells presented mild or moderate polymorphism and trace mitotic activity. they were arranged in diffuse sheets with no evidence of nesting or fasciculation. the histological texture of the tumour resembled that of classical granular cell tumour of abrikosoff. however, the tumour cells were strongly immunoreactive for cd and inhibin, whereas the reactions against s protein as well as other antigens studied gave negative results. the value of ki index did not exceed - %. conclusion: the differential diagnosis of granular cell myoblastoma (abrikossoff tumour) should include the nonneural granular cell tumour. low grade fibromyxoid sarcoma: a study of cases k. shelekhova * , a. konstantinova * petrov´s research institute for oncology, st. petersburg, russia objective: low grade fibromyxoid sarcoma (lgfms) is a specific type of fibrosarcoma with deceptively banal appearance and malignant behavior. method: a year retrospective study revealed lgfms cases. morphological and immunohistochemical analysis was performed. follow-up information was obtained for cases. results: all tumors occurred in adults (mean year). they developed in neck ( ), extremities ( ) and trunk ( ). beside classical morphology of lgfms following features were observed: necrosis ( ), rosettes ( ), areas of increased cellularity ( ), foci of epithelioid cells ( ), marked nuclear pleomorphism ( ), prominent myxoid change ( ), invasive border ( ), bone formation ( ), focal retiform pattern ( ) and sclerosing epithelioid fibrosarcoma-like areas ( ). immunoprofile was the follow: vimentin ( %), ema ( %), cd ( % focally), s ( ), sma( ), desmin ( ), ae /ae ( ). two patients were without evidence of disease, one developed lung metastasis after year. two patients developed secondary tumours in and years after initial diagnosis. there were differences in the location and histologic features compared with primary ones. secondary tumors were less cellular, without necrosis or epithelioid cells. behavior of secondary tumors did not fit to the classical concept of tumor progression that implies increase of malignancy. conclusion: lgfms is a distinctive but unusual type of soft tissue sarcoma demonstrating a wide histologic spectrum and behavioral range. immunohistochemical and mutational study of synovial sarcomas k. specht * , m. bettstetter, g. keller, h. rechl, r. von eisenhart-rothe, h. höfler, m. straub * technische universität münchen, inst. für pathologie, germany objective: synovial sarcomas are mesenchymal tumors of unknown histogenesis. their molecular signature is a specific t(x; )(p . ;q . ) translocation. no effective targeted therapies are currently available. the aim of this study was to evaluate the expression and mutational status of potential molecular therapeutic targets. method: molecularly confirmed cases of synovial sarcomas were included in this study. immunohistochemical stainings of the egf-r family (egf-r, her /neu, her ), and signaling molecules implicated in the mtor pathway (akt, mtor, pten), as well as e-cadherin and snail was performed. in addition, cases were screend for mutations in the egfr, pik c, b-raf, k-ras, and n-ras genes. results: egf-receptor family members as well as e-cadherin and snail are important for defining the tumor phenotype by determining epithelial-mesenchymal transition of synovial sarcomas. activation oft the mtor pathway is seen in a significant number of cases. mutations of the genes studied are an overall rare event in synovial sarcomas and other types of sarcomas studied. conclusion: egf-r expression is found in many synovial sarcomas, however, mutations of egfr or downstream molecules appear to be rare. activation of mtor pathway is frequently seen in synovial sarcomas. the benefit of targeted therapy against these genes in synovial sarcomas remains to be determined. collagen v induces differentiation of rabbit adipose tissue-derived stem cells in chondrocyte-like phenotype w. teodoro * , i. brindo da cruz, a. p. velosa, s. carrasco, c. goldenstein-schainberg, r. fuller, e. parra, v. capelozzi * faculdade de medicina da usp, disciplina de reumatologia, são paulo, brazil objective: stimulated mesenchymal stem cells (mscs) have capacity of differentiation in many cell types. it is being used in degenerative diseases treatment protocols. we evaluated the collagen v (col v) and collagen xi (col xi) influence in the differentiation of rabbits adipose tissue-derived mscs in a chondrocyte-like cell phenotype. method: mscs isolated of new zealand rabbits adiposetissue were maintained in culture by weeks. colv, colxi and colv/xi ( μg/ml) were added to culture during h. the cells aggregates were stained with toluidine blue, alcian blue and picrosirius. chondrocyte-like phenotype was confirmed by immunofluorescence to cd , vimentin and collagens i, ii and iii. results: mscs stimulated with colv expressed proteoglicans and collagen, when compared with colxi and colv/ xi and control. in the presence of colv, mscs was capable to increase collagen ii expression confirming its chondrocyte-like cell phenotype. in contrast, mscs cultured with colxi and colv/xi express collagen i and iii. conclusion: the data suggest that colv may facilitate the differentiation of rabbit adipose tissue-derived stem cells into a chondrocyte-like phenotype. further studies are urged in order to evaluate the influence of colv in the ability of chondrocytes to remodel osteoarthritic joint surface at ultra structural and molecular levels. objective: xrcc is essential for dna base excision repair, single strand break repair and nucleotide excision repair. method: we evaluated xrcc immunohistochemically in early stage breast (n= ), ovarian (n= ), gastric (n= ), colorectal (n= ) and pancreaticobiliary cancers (n= ). pre-clinically, we evaluated a panel of xrcc deficient and proficient chinese hamster ovary and human cancer cell lines. double strand break repair (dsb) inhibitors targeting atm (ku ), dna-pkcs (nu ) and atr (nu ) were evaluated for synthetic lethality and cisplatin alone or in combination with dsb inhibitors for chemopotentiation. results: in breast cancer, xrcc loss ( %) was associated with a -fold increase in risk of death and metastasis (p< . ). in ovarian cancer, xrcc positive tumours ( %) were more resistant to platinum chemotherapy (p= . ). xrcc positivity conferred a fold increase of risk of death (p= . ) and independently associated with poor survival (p= . ). pre-clinically, ku , nu and nu were synthetically lethal in xrcc deficient compared to proficient cells as evidenced by dsb accumulation, g /m cell cycle arrest and apoptosis. xrcc deficient cells were hypersensitive to cisplatin which was enhanced by dsb repair inhibitors compared to in proficient cells. conclusion: conclusions: xrcc deficiency in human tumours may be suitable for synthetic lethality application and exploited for cisplatin chemotherapy potentiation. analysis of bcl oncoprotein expressing breast cancer by molecular subtype a. abolins * , i. strumfa, z. simtniece, a. vanags, g. trofimovics, j. gardovskis * riga stradinš university, inst. of oncology, latvia objective: breast cancer is the most common malignancy in western women. despite the progress in morphological investigation, active research is devoted to potentially important targets for prognosis and intervention. bcl oncoprotein represents such factor. method: consecutive breast cancer cases were examined by routine protocol approach. the bcl oncoprotein expression was detected immunohistochemically. expression was considered positive if it was in more than % of tumour cells. the molecular subtype ( objective: breast cancer is the most common malignant tumour of latvian women (www.csb.lv). correct diagnosis, including identification of tumour histogenesis, is the prerequisite for appropriate treatment. method: consecutive breast tumour cases were selected by systematic retrospective archive search and were examined by breast cancer panel. if expression of oestrogen and progesterone receptors and her protein was negative, mammaglobin, cytokeratin ae /ae , vimentin, cd , cdx , cytokeratin , ttf- and melanosome protein hmb- were detected. results: five patients ( . %, % ci= . - . %) with secondary breast tumours were identified among cases. breast was affected by metastatic small cell lung cancer ( ), malignant neuroendocrine tumour of small intestine ( ) as well as by epithelioid melanoma metastasis in breast tissues ( ) or intramammary lymph node ( ). analysing medical records, multiple synchronous and/or metachronous metastasis, involving brain, kidneys and ovaries, were found in all patients with haematogenous tumour metastases in the breast. in contrast, the lymphogenic tumour spread was isolated. conclusion: . lymphogenic or haematogenous metastasis rarely ( . % of malignant breast tumours by morphology) can develop in breast tissues. it should be taking into account when planning the differential diagnostic approach, especially immunohistochemistry. . haematogenous metastases in breast are associated with a wide synchronous or metachronous extramammary tumour spread. the prognostic significance of tumor-associated stroma in invasive breast carcinoma objective: fibroblasts in the stromal component of a tumor may influence tumor progression in various organs. the prognostic significance of tumor-infiltrating lymphocytes is also frequently reported. however, the prognostic significance of the stromal component in breast cancers, particularly those of high grade, has not been established. method: in this study, we analyzed surgically resected specimens from patients with breast carcinoma, including high grade tumors, for tumor-stroma ratio, dominant stroma type (collagen (c), fibroblast (f) or lymphocyte (l) dominant type), and central fibrosis on hematoxylin-eosin stained histological sections. we correlated these features with clinical prognosis. results: among the specimens examined, ( . %) were of c type, ( . %) of f type, and ( . %) of l type. central fibrosis was found in tumors ( %). the dominant stroma type was a significant prognostic factor on univariate and multivariate analyses, together with t classification, nodal status and bloom-richardson grade. tumorstroma ratio and central fibrosis did not predict survival on multivariate analysis. even in high-grade tumors, relapse-free intervals differed significantly according to dominant stroma type. conclusion: conventional hematoxylin-eosin stained tumor slides may contain more prognostic information than previously thought; in particular, the dominant stroma type in invasive breast cancer may potentially be used to predict outcome. ps- - pathology in breast implants substitution l. alfaro * , j. serra, j. m. ibañez * valencia, spain objective: health alert concerning breast implants brand pip led to a review of patients harboring these prosthesis and in many cases replacement by new ones. anaplastic lymphoma described in these patients has been an additional problem to be faced by plastic-surgeons and pathologists. method: ninety two cases of women with breast implants were studied. most of them had pip implants (although no information of prosthesis type was available in all cases). eighty of them presented with ruptures of different size. after implant replacement, histopathologic analysis of fibrous capsules and liquid from seromas in periprosthetic cavities was carry out. following fda recommendations, immunohistochemical studies to rule out lymphoma was performed in cases. results: fibrous capsules showed synovial metaplasia in all cases. morphology was practically identical that in real articular synovial cells, and occasionally intracavitary nodules were seen detached from the surface in a process similar to synovial chondromatosis. no cases of lymphoma were seen and no expression of cd or alk markers occurred. a case of pericapsular ductal invasive carcinoma was discovered. conclusion: synovial metaplasia seems to be very common in capsules around breast implants. development of conventional breast carcinoma is probably much more frequent than lymphomas independently of the possible implant influence. post-radiation angiosarcoma of the breast: report of a case a. apostolaki * , m. sofopoulos, s. tsitsiou, e. pigadioti, n. mylona, n. arnogiannaki * agios savvas hospital, dept. of anatomical pathology, athens, greece objective: post-irradiation angiosarcoma generally occurs after breast conservation and radiation therapy. it affects the dermis of the breast within the radiation field. the incidence of post-radiational angiosarcoma is about . %. method: an -year-old woman who had undergone conservative surgery and radiotherapy for breast cancer years ago presented with multiple red-purplish papules on the skin of her right breast. excisional biopsy followed by simple mastectomy was performed. results: excisional biopsy revealed a neoplasm composed of highly pleomorphic cells with prominent nucleoli forming solid areas and neoplastic slit-like vascular channels. many mitotic figures and some individual apoptotic cells were also present. the tumor cells were positive for endotelial cell markers (factor viii, cd , cd ) and negative for ck . the gross inspection of the mastectomy specimen showed multiple reddish-purple papule-like lesions on the skin, spreaded in an area of × cm. sectioning showed numerous homogenous slightly hemorrhagic white nodules measuring from to mm located in the dermis. histopatology and immunohistochemistry findings were consistent to those of the excisional biopsy. infiltration of the subdermis was noted. conclusion: diagnosis was high grade post-irradiation angiosarcoma. simple mastectomy is the treatment of choice. adjuvant chemotherapy should be considered in high grade neoplasms like this one. prognostic factors in invasive lobular carcinoma of the breast g. askan * , g. ayranci, n. Özkan, h. kaya, u. ugurlu * marmara university, dept. of pathology, istanbul, turkey objective: determination of molecular features in breast carcinomas, such as hormone receptor expression, can guide clinicians to the optimal choice of therapy. in this study, the relationship between the histologic grade, pathologic stage and the prognosis of invasive lobular carcinoma of the breast, and the tissue expression levels of er, pr, her- /neu, p , bcl- , ki- and e-cadherin was investigated. method: cases of invasive lobular carcinoma of the breast, from to , were included in this study. a single best representative paraffin block was selected for each case and h&e staining and immunohistochemistry procedures were performed. ki-kare test was used for statistical method. results: of cases had classical lobular carcinoma, cases had tubulolobular, pleomorphic, signet ring cell, or apocrine features. the median age of patients was years. er and pr were positive in cases. all cases were negative for e-cadherin. ki- was greater than % in cases with pleomorphic lobular carcinoma. p positivity increased with grade. in cases p was negative and bcl- was positive. bcl- and p were positive in and cases respectively. conclusion: in contrast to the literature, there was no correlation between bcl- status and other molecular markers, including p . rapid immunohistochemistry in intraoperative sentinel axillary lymph node evaluation p. baldin * , m. c. cucchi, y. ishikawa, v. eusebi, m. p. foschini * university of bologna, dept. of anatomic pathology, italy objective: sentinel lymph node (sn) examination is the current procedure to establish the status of axillary lymph nodes in breast cancer. to avoid a two step delayed surgical procedure, a reliable and quick method of sn evaluation is advocated. rapid immunohistochemical technique (uich) for keratin has been only recently proposed. aim of this study is to apply keratin uich in frozen sections (fss) of sns. method: a consecutive series of (series a) sn cases was studied at fs level followed by two sections stained with keratin uihc. all procedure requires min. for comparison consecutive cases (series b) of sn were studied with fs only. all residual tissue from both series was paraffin embedded (ps). results: series a: sns showed tumour involvement in cases ( . %). in only cases ( . %), ps sections evidenced additional neoplastic cells (micometastases) not seen with keratin uihc, that led to a delayed axillary dissection. series b: ps sections revealed metastatic deposits (micrometastases) not seen in fs in . % of cases. conclusion: fs coupled with keratin uhic of all the entire lymph node accurately evidences carcinoma cells in sns. high concordance of her in situ hybridization methods with abbott fish j. boers * , l. krol, c. netjes, h. meeuwissen, c. prinsen, c. van krimpen, e. van der logt, j. bart, e. schuuring * isala klinieken, dept. of pathlogy, zwolle, netherlands objective: we conducted a comprehensive concordance study of ish methods with abbott fish in a large series of breast carcinomas. method: tissue micro arrays (tma) were constructed by taking tissue-cores from praffin blocks of primary breast carcinomas. up to cases were analyzable in ish assays. scoring was performed by two independent observers without knowledge of the other ish data according the asco-guidelines for her -testing. cases were considered positive when the ratio was ≥ . . discordant cases were reviewed and scores were reassigned on consensus of opinion. concordance and cohen's kappa score were calculated in relation to fish, abbott. results: in cases analyzable with abbott her fish, . % were her -positive. concordances (kappa-scores) of the other assays were: dako fish . % ( . ), dako duocish . % ( . %), zytovision fish . % ( . ), zytovision duocish . % ( . ), single probe sish ventana . % ( . ), dual probe sish ventana . % ( . ). conclusion: conclusion: concordance of her ish assays with abbott fish were shown to be . % or higher. in this study, dako assays had a lower kappa score with abbott fish than ventana or zytovision assays. which is the best method to measure multiple breast cancer? m. boros * , c. marian, o. pop, s. stolnicu * umph targu mures, pathology, romania the size of the breast tumor is relevant in a patient s management also affecting the prognosis. for unifocal lesions, tumor staging depends on the maximum diameter of the tumor, whereas in multiple lesions, this issue is not standardized. the aim of this paper is to study which is the best method in the assessment of the tumor size in multiple invazive carcinomas (multifocal and multicentric) in correlation with the lymph node metastases developement. two different assessments of the tumor size (diameter of the largest focus=ld, and combined, aggregate diameter of all the foci=ad) were used in primary invasive breast lesions ( multiple, unifocal) and compared with the nodal status (chi-test). the use of combined tumor focus upstaged ( . %) patients with multiple tumors ( upstaged from pt to pt and from pt to pt ). there was no difference in nodal positivity based on pt status between ld and ad. we observed a statistically significant difference in the mean diameter of the largest focus between the unifocal and multifocal group ( , vs , mm) (p= , ). aggregate diameter in multiple breast cancer is not correlated with an increase of axillary metasases and should not be used for staging. central nervous system metastases in women with invasive breast carcinoma, not otherwise specified, are associated with estrogen receptor status e. cambruzzi * , a. g. reginatto, c. g. zettler, k. l. pêgas, v. grings, j. m. venites, c. a. coelho * ulbra and ufrgs, dept. of pathology, porto alegre, brazil objective: central nervous system metastases (cnsm) from breast cancer (bc) are relatively common and can present as the first site of disease progression. lymph node status and tumor size are regarded as important prognostic indicators for disease-free and overall survival in bc. the aim of this study was to investigate prognostic/predictive pathological data in bc that could define a high-risk group to develop cnsm. method: the authors evaluated female patients with invasive breast carcinoma, not otherwise specified, previously submitted to setorectomy/mastectomy, in order to determine lymph node status, tumor size, histologic grade, estrogen receptor status (er) and immunoexpression of her /neu. of these cases, patients developed cnsm. results: the patients who developed cnsm were younger (median age . ± . years/p= . ) and more likely to have t n disease than patients with no cnsm. the presence of encephalic disease was associated with er (p= . ). lymph node status (p = . ), tumor size (p = . ), histologic grade (p= . ), and her /neu expression (p= . ) were not significant risk factors. conclusion: although the literature data discriminate that her /neu overexpression in bc is related with cnsm, the authors suggests that these lesions can be related to er too. efforts to determine other risk factor for development of cnsm may be warranted. androgen receptors and sex hormone serum levels in breast carcinoma: study of the ordet cohort l. cimetti * , s. sieri, a. m. chiaravalli, n. sahnane, f. sessa, c. riva, c. capella * university of insubria and ospedale di circolo, varese, italy objective: androgens and androgen receptors (ar) are involved in breast cancer (bc) pathogenesis. high testosterone serum levels increase the risk of developing mainly er + bc, especially after menopause, although androgen role in tumor progression is not clearly elucidated. method: correlations between serum sex hormones and clinico-pathological features of bc arisen among , women previously recruited for ordet study were investigated. prediagnostic estradiol, testosterone (free/total) and shbg serum levels were available. immunohistochemistry for ar was evaluated along with er, pr, her- and mib- . results: ar + was found in . % of bc. higher estradiol (p= . ), free testosterone (p= . ) and shbg (p= . ) were seen in premenopausal patients. in dead patients higher free testosterone was observed (p= . ). no correlation was found for hormone levels vs stage, histotype and grade. higher shbg was seen in pr-rich tumours (p= . ). her- +/er-cases showed a trend for a higher total testosterone (p= . ) and shbg (p= . ). testosterone, estradiol and shbg were similar in ar + and ar-tumors. among triple negative, ar + tumours showed higher free testosterone (p = . ). bc with few ar + cells showed higher total testosterone (p= . ) and a worse outcome (p= . ). conclusion: our results confirm the role of ar in bc and suggest the androgen involvement in tumour progression. mitotic count in metastatic breast carcinoma to lymph nodes: preoperative study a. córdoba * , l. gomez, f. vicente, i. amat, c. llanos, d. guerrero * hospital navarra, ap, pamplona, spain objective: axillary lymph node metastasis (alnm) is one of the most important prognostic factors in breast cancer. the reasons why tumours are capable to result in axillary metastasis remain unclear. the evaluation risk of alnm would improve the treatment planning. we study the metastatic breast carcinoma to the lymph node to obtain information about the metastatic risk. method: we study patients with metastatic breast carcinoma to the lymph node diagnosed preoperatively by needle biopsy. we study the mitotic average (× hpf), metastasis size, positive lymph nodes, total lymph node studied, lymph node ratio (nº of positive node/total nodes nº), primary tumour size and grade. results: all the cases with high mitotic count were associated with macrometastasis. we didn't find any relation between the mitotic rate or the metastatic size with the number of lymph node affected, and the lymph node ratio. breast carcinomas g , t , < mitosis/hpf lymph nodes showed - % of positive lymph nodes. conclusion: we tried to obtain information from the metastatic breast carcinoma to the lymph node to predict the axillary status. in our cases we couldn't predict the lymph node involvement based in the tumour size, grade, metastatic size, and metastatic mitotic rate. the preoperative study of a breast tumour and their lymph node metastasis don't allow predicting the lymph node status in our series. ps- - rassf a hypermethylation is associated to the presence of tumoral cells detected by one-step nucleic acid amplification (osna) a. córdoba * , f. vicente, n. perez janices, j. perez vizcaino, e. gochi, n. torrea, d. guerrero * hospital navarra, ap, pamplona, spain objective: one-step nucleic acid amplification (osna) is used in routine clinical use for sentinel lymph node biopsy (slnb). it consists of the molecular quantitation of a tumoral marker (cytokeratin-ck mrna). gene hypermethylation is one of the most common mechanisms of inactivation of suppressor genes. rassf a gene, is a region frequently hypermethylated in breast cancer. method: patients with breast cancer were included in the study, and a total of lymph nodes were analysed. results: %, . % and . % of the tumours were of low, intermediate and high-grade, respectively. in . % of the cases there are not tumoral cells, in contrast to . %, . %, . %, . % that showed low number of cells/itc (< copies/sample), micro-(< copies/sample) and macro-mtx, respectively. there is a very clear association between rassf a hypermethylation and the presence of tumoral cells (p= . ), being more frequent in macro-mtx compared to the rest of groups (p= . ). rassf a hypermethylation is also correlated to unfavorable histologic grade in the tumour (p= . ) and lymph node involvement at the diagnosis ( . ). conclusion: the analysis of rassf a hypermethylation could provide additional information to osna to detect tumoral cells in lymph nodes. the spare tissue material derived from osna could be good material to consider new molecular studies. results: of these, patients ( , %) had palpable tumor at presentation, ( , %) with palpable axillary adenopathy. in cases ( , %) the tumor diameter was over cm at the time of diagnosis. in cases ( , %) the histological type was infiltrative ductal carcinoma, with cases having high grade. most of the tumors expressed er and pr and were her- negative (none was triple negative). however, in cases ( , %) the ki- index was more than %. conclusion: young women with breast cancer have been shown to have a poorer prognosis because of the high grade and hormonal status. our study shows some similar aspects, but the hormonal status is totally different from the dates in the literature, revealing a possible better response to hormonal treatment and a better survival. immunohistochemical predictive markers for trastuzumab resistence a. cuesta diaz de rada * , e. honrado franco, m. baltasar moreira, f. m. izquierdo garcia * hospital de león, anatomía patológica, spain objective: her positivity defines a clinically challenging subgroup of patients with breast cancer with variable prognosis and response to therapy. the main aim of this study is to identify immunohistochemical markers to predict trastuzumab resistence. method: tumours from patients with invasive ductal carcinoma, who were previously treated with trastuzumab, were included in a tissue microarray and stained for er, ki , p , cyclin d , p and for her and sish (silver in situ hybridization). results: after years of follow up, % of patients with p negative tumours were disease free (p . ) and % were alive (p , ) and the patients cyclin d positive, % were alive (p . ) and % were disease free (p . ). among her +, % did not amplify (polysomy ). moreover, % of treated patients were her − + and did not amplify by sish. conclusion: the best immunohistochemical markers to predict a good response to trastuzumab treatment were p negative and/or cyclin d positive. all her positive + tumours should be confirmed by hybridization, since polysomy is found in %, and these tumours should not be treated with trastuzumab. variations in the immunostaining techniques could induce trastuzumab treatment to patients with her non amplified tumours. ps- - cd expression in breast carcinoma p. czapiewski * , j. szade, a. zaczek, m. welnicka-jaskiewicz, w. biernat * medical university of gdansk, dept. of pathology, poland objective: cd is a membraneous protein that is expressed widely among various soft tissue tumors. there is growing evidence that its expression in some carcinomas correlates with epithelial to mesenchymal transition (emt) and is a poor prognostic factor. its importance in the breast carcinoma remains unsettled. method: the analysis was performed on breast cancer samples from patients. tumors were graded histologically according to the nottingham system. cd expression was scored by grading system used for her- . only cases showing grade ( +) were regarded as positive. additionally, expression of estrogen (er) and progesterone receptor (pr), her- , e-cadherin, vimentin, twist, ki- , c-myc, cyclin d and topoisomerase alfa was performed. expression of the cd was correlated with all these markers and with clinical outcome. results: expression of cd was observed in patients and correlated significantly with negative pr status (p= , ), higher histological grade (p= , ), positive twist (p= , ) and topoisomerase alfa expression (p= , ). there was also a trend toward higher frequency of cyclin d positivity (p= . ). no impact on prognosis for cd expression was found. conclusion: expression of cd correlates with high histological grade, negative progesterone receptor status and expression of certain emt and proliferation markers, but it does not influence prognosis in breast carcinoma. primary plasmacytoma of the breast: a case report l. de carvalho * , g. g. monteiro, l. casagrande, t. ricci, t. lebrão, v. tarricone, p. dinamarco * centro universitário lusíada, dept. of pathology, santos, brazil objective: extramedullary plasmacytomas of the breast are extremely rare, especially those that are not associated with multiple myeloma and they can mimic mammary carcinoma. method: case report: -year-old woman presented a palpable mass in the left breast previously diagnosed as a lobular carcinoma by core biopsy performed in other service. in our institution a conservative surgery with lymph node dissection was proposed. results: frozen section was required and the gross examination showed a . × . × . cm firm-elastic nodule with surgical margins free of tumor and the microscopic examination showed tumor cells with abundant cytoplasm with hyaline appearance. the paraffin sections showed a proliferation of plasma cells with moderate atypia. the immunohistochemical study confirmed the diagnosis of plasmacytoma. there was no axillary lymph node involvement. there were no bone lesions in the additional investigation. conclusion: primary plasmacytomas of the breast are extremely rare and have to be included in the differential diagnosis with breast carcinomas especially in material of core biopsy. sentinel lymph node in breast cancer: form morphology to molecular examination l. di tommaso * , b. fernandes, b. fiamengo, c. navligu, p. spaggiari, s. manara, c. a. garcia etienne, g. masci, a. testori, c. tinterri, m. roncalli * irccs istituto clinico humanitas, dept. of pathology, rozzano, italy objective: sentinel lymph node (sln) examination is a standard in breast cancer treatment. it can be performed on formalin-fixed paraffin-embedded material (ffpe) or on frozen sections (fs). ffpe or fs suffer two drawbacks: ) partial examination; ) operator's dependence. to avoid these limitations, a molecular technique (osna) targeted to quantify a tumoral fingerprint (ck ), has been introduced. our aim is to compare the performance of ffpe, fs and osna. ps- - her assessment in invasive breast cancer using ihc and fish: results from consecutive cases p. drev * , b. gazic, j. contreras * inst. of oncology, dept. of pathology, ljubljana, slovenia objective: her in invasive breast cancer (ibc) should be assessed according to recommended algorithms employing ihc as screening tool and ish only in equivocal cases. therefore there is little data on possible missdiagnosis in discordant cases. method: her was assessed by both ihc and fish in consecutive ibc. distribution of ihc and fish scores, incidence of her + ibc, concordance and level of amplification in discordant cases were analysed. results: ihc distribution: neg( ) . %, neg( +) . %, equivocal( +) . %, pos( +) . %. fish distribution: nonamplified . %, amplified . %, equivocal . % of which in . % ratio was ≥ . . . % ibc were her + and . % were double-equivocal. . % of equivocal( +) were amplified. discordance was infrequent ( . %) (p< . ): among neg( ) and neg( +) , % and , % were amplified, while among pos( +) . % were nonamplified. ihc negative tumors, representing . % of all her +, were amplified, however in . % ratio was ≤ . . conclusion: % ibc are her +. application of two standardised methods results in excellent concordance and enables detection of all her + ibc, while recommended algorithms lead to missdiagnosis in % of her + ibc, but in these amplification is low-level. case report: unusual breast cystic lesion in a -yearold female p. farrajota * , p. cusati, d. esteves, c. dias, c. carvalho, g. falconieri * centro hospitalar do porto, dipt. do anatomia patologica, portugal objective: papillary carcinoma of the female breast may exhibit a broad phenotype. we present an unusual case of a pseudoencapsulated invasive papillary carcinoma featuring transitional cell features. method: a specimen of internal right female breast biquadrantectomy was routinely processed and a panel of antibodies applied on paraffin tissue section. results: grossly, the specimen showed a . cm cystic lesion with fibrino-hematic material and multiple pinkish-grey papillary structures, the largest measuring cm. the histological examination revealed a malignant epithelial papillary proliferation reminiscent of transitional cell carcinoma, with high nuclear grade, frequent mitotic figures, multiple areas of invasion and rare necrotic foci. tumor cells were immunoreactive for p , βe and ki- ( %) and negative for other stains including her /neu, estrogen and progesterone receptors. our differential diagnosis included a metastasis from a primary urothelial carcinoma, an intraductal papillary lesion, a metaplastic carcinoma and a papillary adnexal neoplasm, all reasonably excluded after careful clinico-pathologic evaluation. conclusion: metastatic involvement of the breast is uncommon but it should be considered if tumor phenotype is inconsistent within usual or "special type" breast carcinoma. yet, some rare primary misleading lesions are difficult to recognize. ps- - volume measurement of female sprague-dawley mammary tumors induced by n-methyl-n-nitrosourea: comparing ultrasonography and caliper a. faustino-rocha * , c. teixeira-guedes, j. pinho-oliveira, r. soares-maia, r. arantes-rodrigues, b. colaço, r. ferreira, p. oliveira, m. ginja * utad, dept. of veterinary sciences, vila real, portugal objective: n-methyl-n-nitrosourea (mnu) is a chemical carcinogen frequently used to induce mammary tumors in female rats, which experimental evaluation requires the monitoring of tumor's volume. for this purpose several methods are described, namely: caliper and ultrasonography measurement. the aim of this work was to compare data obtained by caliper and ultrasonography. method: twelve female sprague-dawley rats with . ± . g body weight were intraperitoneally injected with mnu ( mg/kg) at days of age. thirty-six weeks after mnu administration forty-one tumors volume was determined by caliper (vito®) and ultrasonography (logiqp ®, general electric healthcare) measurement. the tumor volume (v) was calculated according to the following formula v=π.〖s_ ^ 〗^.s_ ⁄ , being s_( ) and s_ the tumor diameters (s_( )<s_( )). results: the means tumor caliper and ultrasonography measures were . ± . cm and . ± . cm , respectively. the icc for scoring reproducibility was . ( % confidence interval, . to . ) and paired-sample t-test was significant (p< . ). conclusion: usually mammary tumors in rat are measured by caliper. however, our results showed that there are volume differences between both methods studied. ultrasonographic method is more accurate and more precise than caliper. therefore, we recommend the use of ultrasonography to rat tumor evaluation. objective: there is a significant percentage of patients with breast cancer and her receptor overexpression that do not respond to trastuzumab-directed therapy. the aim of this paper is to study the alterations of one of the her signalling pathways related to trastuzumab response in breast cancer. method: the study comprised cases of breast carcinoma in different stages of evolution with her overexpression (herceptest +) or gene amplification (fish). all patients were treated with trastuzumab. the assessment of pten and pakt expression was based on staining intensity and percentage of stained cells. we also determined the molecular alterations in pik ca. results: our series showed a statistically significant association between a positive expression of pten and the absence of pik ca mutations with better overall survival from treatment onset with trastuzumab (p= . and p= . , respectively). the association with the expression of pakt was statistically significant if survival is evaluated from the pathological diagnosis of the tumor (p= . ), pakt positive tumors had worse survival. objective: expression of mammaglobin a (mg-a) in breast cancer has been reported to be of prognostic value and to be associated to hormone receptor-positivity. mg-a is also useful in the diagnosis of metastatic breast cancer. the present study evaluates the differential mg-a expression in two subsets of primary breast cancer (metastasizing vs. non-metastasizing) and in their correspondent metastases. method: immunohistochemical analysis of mg-a (clone - a ) was performed in non-metastasizing primary breast tumors and paired primary and metastatic breast cancers. a percentage of % of stained tumor cells was considered positive. the expression of mg-a in the different groups, together with other clinicopathologic factors (grade, size, hormone receptors, her , etc.) was analyzed by t-test. results: expression of mg-a was significantly higher in estrogen receptor-positive (er+) tumors (p< . ). a trend was noted for er + metastasizing primary breast cancers to show a higher expression of mg-a, compared to those nonmetastasizing (p= . ). no significant differences were noted in the expression of mg-a between metastasizing primary tumors and their correspondent metastases, with a good correlation (p= . ). conclusion: these results suggest that mg-a might be of prognostic value in determining a subset of er + breast cancers prone to progression. larger series are needed to confirm these observations. concordance of st. gallen intrinsic subtypes in core biopsies and related surgical specimens of breast cancer c. m. focke * , t. decker * dietrich bonhoeffer klinikum, abt. pathologie, neubrandenburg, germany objective: to evaluate the relevance of intrinsic breast cancer subtyping (ibcs) on core biopsies (cb). results: samples were tested in . score was found in . % cases, + in . %, + in . %, + in . %. the amplification was revealed in . % of + cases, . % tumors were +/fish+. cases were tested in : score − . %, + . %, + . %, + . %. the amplification was seen in . % + cases and . % tumors became +/fish+. there was no significant distinction using % and % cells score system for + tumors, whereas for groups + and + it was. conclusion: asco/cap scoring criteria developed in have no effect on her -positive tumors detection but increases number of cases with equivocal result, what require retesting with ish. microvessel density in triple-negative breast cancer: characteristics and prognostic implications h. gobbi * , m. de brot, r. rocha, f. soares * ufmg, dept. of anatomic pathology, belo horizonte, brazil objective: we assessed topography and characteristics of blood vessels in triple-negative breast cancer (tnc) and examined their association(s) with clinicopathological features, basal-like phenotype and influence on patient prognosis. method: blood vessels were assessed in tissue sections from tncs stained for cd . slides were scanned using scanscope® xt and analysed with aperio image-scopetm, microvascular density v algorithm. microvessel density (mvd) was assessed in three areas: intratumoural (it), peripheral tumoural (pp) and peritumoural (pt), and correlated with clinicopathological features and prognosis. results: the majority of blood vessels were located largely at the peripheral tumoural and peritumoural areas. tumours with higher total mvd and pt-mvd were significantly associated with the presence of recurrence (p = . ; . ), distant metastasis (p = . ; . ), hematogenous metastasis (p= . ; . ); and shorter overall survival (os; p= . ; . ) and disease free interval (dfi; p= . ; . ). high pt-mvd correlated with a higher stage at diagnosis (iii and iv; p= . ), lymph node (ln) metastasis (p= . ), basallike phenotype (p = . ), high histologic grade (p = . ), presence of distant metastasis (p = . ), and shorter os (p = . ). conclusion: blood vessels are mainly located at the peritumoural and peripheral areas in triple negative breast cancers and seem to have a major role in tumour progression by representing means for disease dissemination. expression of cd and cd in primary ductal invasive carcinoma of breast and metastatic lymph nodes m. gudadze * , k. kankava, t. javakhishvili, m. sarishvili, g. burkadze * central university clinic, dept. of pathological anatomy, tbilisi, georgian, republic of georgia objective: cancer stem cells are believed to have certain role in progression, metastatic potential and outcome of ductal invasive carcinoma of breast. method: the archived materials of - years from the department of pathological anatomy, n. kipshidze central university clinic were used for the research. cases of ductal invasive carcinoma were chosen for the study. the cd , cd immunohistochemistry (biocare medical) was used for staining. evaluation was performed using spss software. results: the results showed: . % of grade ii cases and . % of grade iii cases were lymph node positive. cd positivity in grade ii tumors was seen in . % of primary site and . % of metastasis; in grade iii tumors- % of primary site and . % of metastasis. cd positive cases in grade ii- . % for primary tumor and % in metastasis, for grade iii- . % for primary tumor and . % for metastasis. the results show that cd positivity is significantly less frequently seen in metastasis than in primary tumor; cd positivity is more frequently seen in metastasis for grade ii cases. this indicates, that cells with stem cell phenotype decrease in metastasis reflecting heterogeneity between primary and metastatic sites, which should be taken into consideration for assessing progression and treatment. ps- - solid neuroendocrine breast carcinoma: three case reports b. ince alkan * , s. yuksel, e. kadan, s. percinel, s. dizbay sak * ankara university, turkey objective: it seems that neuroendocrine breast carcinoma (nebc) is underrecognized in routine practice. world health organization classification of tumors of the breast defined nebc as a subtype of invasive mammary carcinoma in which > % of the tumor cells express neuroendocrine markers. three cases compatible with solid nebc are discussed with an emphasis on identifying features useful in recognition of this tumor type. results: the patients were , and years old women. all patients presented with a palpable mass, two in the right and one in the left breast. microscopically, infiltrating, solid cohesive nesting pattern with delicate sinusoidal vasculature or peliosis and papillary pattern were observed. the tumor cells were round or polygonal with abundant granular, eosinophilic cytoplasm. the nuclei had hyperchromatic/vesicular or "salt and pepper" chromatin. two cases had ductal carcinoma in situ component. all cases were positive for synaptophysin and chromogranin a in > % of tumor cells. while a positive status for estrogen receptor was detected in all cases, progesterone receptor was observed in two cases. none of the tumors displayed her overexpression. conclusion: morphological clues suggestive of nebc must be recognized for immunohistochemical confirmation for appropriate classification of this clinically distinct subtype of invasive breast carcinoma. objective: automation of her fish may improve her gene testing. the aim of our study was to evaluate an automated her fish assay for assessing the her genomic status. method: core biopsies of invasive breast carcinomas were analysed in parallel using the manual pathvysion™ her- dna probe kit and the automated leica her fish system for the bond™ instrument. to assess intermethod agreement, concordance analysis was performed for various numerical and categorical parameters. results: carcinomas with all her immunohistochemical scores were included ( +: ; +: ; +: ; +: ). using either her /cep ratio > . or ≥ . as criterion for her amplification, high levels of concordance were observed between automated and manual fish (concordance rate %, k coefficient . ). high levels of inter-method agreement were also found for her copy number, cep copy number, her /cep ratio, the percentage of carcinoma cells with her /cep ratio > . , and the presence of her genetic heterogeneity, her clusters and cep polyploidy. conclusion: her testing using automated fish is feasible on breast carcinoma core biopsies. automated her fish using the leica her fish system for bond is an alternative to manual her fish in evaluating the her status of primary invasive breast carcinomas. myofibroblastoma of the breast: presentation of three cases e. kairi-vasilatou * , c. dastamani, a. tsagkas, a. paraskeva, a. kondi-pafiti * aretaieio nosokomeio university, dept. of histopathology, athens, greece objective: myofibroblastoma is a rare, usually solitary, benign spindle cell tumour composed of myofibroblasts. it affects both genders equally. method: three cases diagnosed in our laboratory are presented. results: two patients were postmenopausal females ( and years old) and one was male ( years old). the tumour was , cm in greatest diameter in the first case, cm in the second and cm in the third. microscopically, all neoplasms were circumscribed and consisted of uniform, bland spindle cells separated by broad bands of hyalinized collagen. the neoplasmatic cells had abundant eosinophilic cytoplasm, oval nuclei and were arranged in fascicles. cellular atypia was found only in one case and mitoses were scarce. immunohistochemically, all neoplasms were strongly positive for vimentin, cd and bcl- , while the expression of desmin and sma varied. s- protein was negative. the neoplasms of the female patients were strongly positive for er and negative for pgr. the stains for estrogen and androgen receptors were not carried out in the case of the male patient. conclusion: differential diagnosis can be complex. fibromatosis of the breast, nodular fasciitis, myoepithelioma, myofibrosarcoma, solitary fibrous tumor, inflammatory myofibroblastic tumour should be excluded based on the histological and immunohistochemical findings. method: using light-and transmission electron microscopy fragments of mammary gland tumors, received intraoperative, from patients - years with infiltrative ductal breast cancer were studied. results: most of the mast cells were localized in the areas of infiltrative growth, at a background of lymphohistiocyte infiltration and in peripheral part of the tumor. intratumourous mast cells were totally degranulated. the mast cells with intact structure at a background of cells and tissue destruction were also in mammary gland. in destructive mast cells the nucleus with electron-dense circle and chain of granules were observed. on transmission electron microscopy their deformations and the decrease of density were revealed. the mast cells were of elongated of rounded shape with large nucleus and invaginations of karyolemma. the nucleus occupies almost completely the cell's area. it has a ring of large but pale granules. small protuberances were observed on the surface of the cell membrane. their number decreased in direct proportion to the size of must cells and their remoteness from microvessels. such protuberances are necessary for mast cells in moving. destructively changed cells with the signs of swelling, vacuolization and clasmatosis were frequent in breast cancer. objective: determination of eligibility of breast cancer patients for treatment with anti-angiogenic drugs has been always considered as a challenge for oncologists. each mutation in the genes of proliferation phase enhances the angiogenesis of tumor. we aimed to determine the effect of concurrent mutations of her- and tp on angiogenesis. method: women affected by invasive ductal carcinoma (idc) sporadic breast cancer were included. immunohistochemical study was performed with her- , tp , ki- and annexinv markers. angiogenesis index was semiquantitatively calculated by mvd-cd technique. statistical associations between parameters were evaluated. results: prevalence of her- positive and tp positive cases were . % and . %, respectively. . % of patients showed concurrent mutation of these genes. concurrent mutation led to significant increases in both angiogenesis and proliferation and a significant decrease in apoptosis. there was no statistically significant association between concurrent mutation and tumor grade. conclusion: this study demonstrates that most of the tissue prognostic factors are poor in concurrent mutation of both genes. also, our study illustrates that the concurrent mutation correlates with a higher angiogenesis and thus an increased risk of recurrence. we can conclude that in priority setting for administration of anti-angiogenic agents, patients with concurrent mutations are more eligible. adenoid cystic carcinoma in male breast: a case report e. kimiloglu sahan * , u. karinoglu, a. akyildiz igdem, n. erdogan * taksim´s hospital, dept. of pathology, istanbul, turkey objective: adenoid cystic carcinoma of the breast is a rare variant of breast cancer that accounts for . % of all breast carcinomas and occurs commonly in women between the ages of to . in the literature, only a few examples have been reported in men. it is well-differentiated tumour with favorable prognosis and generally presents as a painful breast mass. method: here, we are presenting a years old male patient with a × mm diameter solid mass on left breast retroareolar region. on fine needle aspiration biopsy, there were 'atipical proliferating ductal epitelial groups'. then, hookwire localization and excision have been performed. microscopically, there were tubulary and cribriform islands composed of basaloid type cells with eosinophilic cytoplasm and myxoid material in the cribriform spaces at the center of the islands. we used immunohistochemical markers such as p , s , ck , cd , ck and smooth muscle actin for differential diagnosis. results: the diagnosis was 'adenoid cystic carcinoma'. the margins of the tumor were positive, so radical mastectomy was performed for treatment. conclusion: because adenoid cystic carcinoma of the breast in male is a very rare example, we present our case here. comparison between the bond oracle her immunohistochemical system, the polyclonal her dako antibody and chromogenic in situ hybridization in breast carcinoma h. kourea * , v. tzelepii, i. nikolatou, p. ravazoula, v. zolota * university of patras, dept. of pathology, greece objective: the sensitivity and specificity of immunohistochemical (ihc) methods for her testing are very important given the therapeutic implications. this study compares the concordance between oracle and the her dako polyclonal antibody (her ), in breast carcinomas (bcs) that were equivocal ( + or not evaluable/ne), by her staining, considering as gold standard the chromogenic in situ hybridization (cish). method: bcs (n= ), problematic by her staining ( − / + or ne), and studied by cish in our institution, and additional consecutive bcs were stained with her and oracle, and scored separately by three pathologists. consensus scoring for each ihc method and cish results were recorded. descriptive statistics and measurement of the cohen's kappa coefficient were performed. results: the overall agreement between the tests in a × analysis shows a concordance in % of cases (κ= . ). among the cases studied by cish, equivocal were and cases, for her and oracle, respectively. seventeen her equivocal cases were negative with oracle and cish. in problematic cases, using cish as gold standard, the sensitivity, specificity, positive and negative predictive values for her and oracle were , . , . , and , . , . , , respectively. conclusion: in problematic cases, oracle testing shows higher specificity and positive predictive value. stromal p and ki expressions of the mammary phyllodes tumors: are they the clues in determination of tumor grade? u. kucuk * , u. bayol, e. e. pala, s. cumurcu * tepecik training hospital, dept. of pathology, izmir, turkey objective: conventionally growth pattern, stromal overgrowth, stromal cellularity, stromal mitotic activity are the main parameters in grading of phyllodes tumors. recent studies revealed that p and ki expressions are both correlated with grade of phyllodes tumors of the breast. method: we searched for p and ki expression rates of benign and malignant phyllodes tumors in our archival data and correlated them with conventional parameters such as stromal cellularity and mitotic activity rates. benign, malignant phyllodes tumors were reevaluated as regards stromal cellularity (low/moderate and high), mitotic activity (low and high), p expression (low, moderate, high), ki expression (low and high) rates. statistical correlation amongst the whole parameters were searched with chi-square test. results: stromal cellularity, mitotic rate, p and ki expression rates were all closely correlated (p = . - . ) for benign and malignant histologic subgroups. ki expression was significantly correlated with histologic subgroups, stromal cellularity and mitotic rate (p= . - . ). similarly p expression was correlated with histologic subgroups, stromal cellularity and mitotic rate (p= . - . ). conclusion: both ki and p expression rates are statistically significantly correlated with grade of mammary phyllodes tumors, so they can be used in determination of tumor grade, especially for differential diagnosis of benign and malignant ones. quantitative measure proliferative markers by image analysis of invasive ductal carcinoma a. kudaybergenova * , s. kalantarli * rscrct, dept. of immunohistochemistry, st. petersburg, russia objective: we analyzed a total number of tumor cells) in invasive ductal breast carcinoma, proliferative activity (% ki -positive cells) and mitotic index (% phh positive cells) to establish absolute quantity tumor cells per sq.mm of histological slide and relations this measure with proliferation and mitosis. method: the study included patients diagnosed with breast carcinoma from baku oncology hospital during the - . after whole slide scanning by mirax scanner ( dhistech, budapest) of he, ki and phh stained slides we juxtaposed all three slides in one screen to the found area with maximal ki level in tumor and the corresponding area in other slides. morphometric analysis was performed using the pannoramic viewer software ( dhistech, budapest). for each case we analyzed a total number of tumor cells in mm , number of ki and phh positive cells. results: mean tumor cells in mm of histology slide was +\− cells, median - cells, +\− ( %) were positive for ki and +\− ( %) were in mitosis. there was moderate correlation between cell density and ki r= , (p= , ) and phh r= , (p= , ). conclusion: by analysis of breast cancer, was established a total tumor cell per mm and main proliferative characteristics for invasive ductal carcinoma. objective: adenomyoepithelioma of the breast is a very rare benign tumor with biphasic proliferations of epithelial and myoepithelial elements. it is morphologically and immunohistochemically identical to epithelial-myoepithelial cell carcinoma of the salivary gland. the histologic criteria of malignant ame is not well-established because of the rarity of ame. we report a case of malignant adenomyoepithelioma in a -year-old woman. method: on ultrasonography, a well-marginated and lobulated solid mass was found at liq of the right breast.. an ultrasono-guided core biopsy was performed. the diagnosis of core biopsy was myoepithelial lesion. she subsequently underwent a wide local excision of the lesion. results: microscopically the tumor mass was composed of biphasic patterns which showed formation of tubules lined by an inner layer of ductal epithelial cells surrounded by proliferation of myoepithelial cells that also formed solid nests. but this tumor had foci of infiltrating margins and proliferation of spindle cell components. also noted are numerous mitotic figures and increased mylepithelial ki- positivity ( - % of tumor cells). conclusion: breast lesions which have predominently myoepithelial cells can be divided into myoepithelial hyperplasia, adenomyoepithelioma and malignant adenomyoepithelioma. tavassoli divied ame into tubular, papillary, and solid subtypes. the criteria of malignant ame is not wellestablished but some criterias can apply to make a diagnosis of malignant ame. objective: neoadjuvant chemotherapy (nact) is available for patients with breast carcinoma. however, resistance to chemotherapy is still a main cause of mortality. method: differentially expressed genes were identified from previously published studies that examined chemoresistant and chemoresponsive cell lines or patients with breast carcinoma. the expression of selected gene products was assessed in tissue microarray slides comprising post-nact resection specimens from breast carcinoma patients using immunohistochemistry, and analyzed according to the molecular subtype and residual cancer burden (rcb) grade. results: most cases were positive for abcb ( . %) and myc ( . %), but negative for top a ( %). rcb-ii cases expressed much higher levels of muc (p= . ) and clu (p= . ) than rcb-iii cases. positive expression for calr (p= . ) and lgals (p= . ) was observed more often in triple negative types than in luminal types, and cytoplasmic cdkn b expression was observed more often in luminal types (p= . ). conclusion: positive expression of abcb and myc and negative expression of top a in the residual carcinoma after nact implies general resistance to nact. expression of calr, lglas and cytoplasmic cdkn b may be associated with resistance depending on the subtype. expression of muc and clu can be used to predict the rcb grade or response to nact. primary and metastatic melanoma of the breast-review of cases i. liepniece-karele * , l. osipova, m. sperga, s. isajevs, a. grjunbergs, j. eglitis * riga ecuh, dept. of pathology, latvia objective: primary breast melanoma is a very rare tumour accounting for < % of all malignant melanomas. the malignant melanoma can be with different manifestation in the breast (primary breast tissue or primary breast skin melanoma as well as metastatic melanoma). method: in this study cases of breast melanoma were identified from our records of the past years ( . % of all breast cancer cases). a histological and an immunohistochemical (ihc) study was performed using antibodies against ckae / , hmb- and melan-a on both the biopsy and operation material. results: obtained results showed that in cases pigmented, epitheloid and spindle cell melanoma, but in one case epitheloid cell amelanotic melanoma was found. by ihc the melanoma cells expressed hmb in three cases, melan-a and s in all cases. no expression of ckae / was observed. conclusion: careful histological and immunohistochemical examination of malignant tumour is essential for adequate diagnosis, follow-up and treatment of breast melanoma. stem cell expansion in ductal carcinoma in situ of breast c. lopes * , a. paula, o. marques, a. rosa, a. rema, f. carvalho * icbas, dept. of pathology, porto, portugal objective: the aim is to study the ability of a cell marker panel -aldh , cd and ki to identify breast stem cells in no malignant and ductal carcinoma in situ. method: double-color triple-immunohistochemistry -to aldh , cd and ki -was done in paraffin embedded tissue specimens from patients arrayed in tissue microarray blocks. statistical was done using chisquare probability test: differences were considered significant when p< . . results: significantly higher immunoreactivity was seen in dcis than in benign lesions of breast (p< . ) with used markers. in a total of specimens, cd +/aldh +/ ki -cells were identied in cases. the distribution was as follows: dcis ( / ); fibroadenoma ( / ), atypical hyperplasia ( / ); other benign lesions ( objective: data from in vitro and clinical studies suggest that casr expression can be associated with the development of bone metastases. most probably casr stimulates production and secretion of pthrp via egfr pathway. the aim of our study was to assess expression of casr in the primary breast cancer and correlate it with the risk of bone metastases. method: we have analysed patients with the breast cancer. bone metastases were diagnosed in cases, patients died without skeletal involvement (control group). casr expression was assessed in primary tumors using tissue microarray (tma) and immunohistochemical technique (polyclonal antibody pierce bio. pa - ). to evaluate cytoplasmatic casr expression we have used - point scale in which was defined as uniformly strong or medium staining in more than % of tumor cells. results: strong or medium staining in more than % was identified in most studied cases, however it was more predominant in patients diagnosed with bone metastases than in the control group ( , % vs , %), p= , . conclusion: expression of casr is common in primary tumors of patients with disseminated breast cancer irrespectively of the metastatic site. however, the patients with bone involvement have higher rate of expression, that is borderline significant statistically. as a result, a group of patients with very high risk of bone dissemination might be separated. bcl expression is associated with centromere alterations in luminal b breast cancer a. matsionis * , i. pavlenko, a. petrov * rostov refional institute, dept. of experimental pathology, rostov regional institute objective: bcl is an important established prognostic parameter in human breast cancer (bc) and chromosome centromere (cep ) copy number is proposed to be the same too. we evaluated bcl expression in different bc's molecular subtypes in relation to increased cep level (cep > per nucleus). method: immunohistochemistry for bcl assessment and fluorescence in situ hybridization for detection of cep alterations were used. statistical analysis was performed with fisher's exact test. results: a total of cases of female invasive bc's were analyzed ( ) ( ) . the tumour subtypes were as follows: luminal a (er/pr+, her /neu-, ki < %) - ; luminal b (er/pr+, her /neu-, ki > % or er/pr+, her /neu+) - ; her /neu+(er/pr-, her /neu+) - ; triple-negative - . in our study group, bcl -cases were preferentially er-in agreement with previous reports. however, , % tumours of luminal b subtype were bcl -too and all of them had increased cep copy number (p= , , rφ= , ). we therefore hypothesized that not only er had influenced bcl in luminal b bc but cep alterations also. conclusion: centromere alterations are associated to bcl downregulation in luminal b bc's. the mechanisms responsible for that remain to be established but the underlying cause could be promoter methylation or transcriptional repression. outcome of excision of radial scar diagnosed on core biopsy: a single centre analysis f. menezes * , m. caldas, n. coimbra, c. leal * ipo porto, dept. de anatomia patologica, portugal objective: radial scar (rs) is a sclerosing lesion of the breast which may be associated with a spectrum of epithelial proliferative lesions and carcinoma. it is frequently subject to biopsy when presenting as a mammographic abnormality. the need to excise rs diagnosed on core biopsy (cb) remains controversial. the aim of our study is to determine the frequency of upgrade in diagnosis after excision of rs. method: a retrospective study of rs diagnosed on cb in our department between / / and / / was performed. results: cases were retrieved, all women, with a median age of years. of these, pairs of cb/resection specimens were obtained. cb diagnosis was rs without atypia in cases, rs with atypia in cases and rs with in situ carcinoma in cases. after excision, / ( , %) cases diagnosed as rs without atypia were upgraded: to atypia, to in situ carcinoma and to invasive carcinoma. of those cases diagnosed on cb as rs with atypia, / ( , %) were upgraded: to in situ carcinoma and to invasive carcinoma. conclusion: our results support the excision of all lesions diagnosed on biopsy as rs. *fm and mc are joint first authors. outcome of excision of papillary lesions diagnosed on core biopsy: a single centre analysis f. menezes * , m. caldas, n. coimbra, c. leal * ipo porto, dept. de anatomia patologica, portugal objective: papillary lesions of the breast (plb) comprehend a spectrum of entities with different morphologies and malignancy risk, which present a diagnosis challenge on core biopsy (cb). although diagnostic accuracy has improved with immunohistochemistry, the need to excise benign plb remains controversial. the aim of our study is to determine cb diagnosis accuracy in plb, and subsequent need to excise all lesions. method: a retrospective study of plb diagnosed by cb in our department between / / and / / was performed. results: cases were identified, with a median age of years. cb diagnosis was benign in cases, some kind of atypia found in , and malignant lesions ('in situ' and encysted/invasive types of carcinoma) in . surgical excision was performed on cases, including all cases with carcinoma. following excision, / and / benign cb results were respectively upgraded to atypical and malignant; / with atypia were upgraded to malignant. overall, % ( / ) of benign and atypical plb cb diagnosis therefore missed malignancy. conclusion: our results show that, despite good correlation between cb and excision diagnosis, some cases of carcinoma are missed on cb, so the excision of all plb remains advisable. *fm and mc are joint first authors. myoepithelial carcinoma of the breast: a case report i. michalopoulou manoloutsiou * , b. christoforidou, p. xirou, v. bostani, e. goupou, i. themeli, f. patakiouta * theagenion hospital thessaloniki, dept. of pathology, greece objective: myoepithelial carcinoma of the breast is an extremely rare tumor, composed purely of myoepithelial cells, predominantly spindle, with identifiable mitotic activity. method: we report a case of a year-old female patient with a palpable, well demarcated lump in her left breast, measuring , cm in its maximal diameter. surgical excision and axillary lymph node dissection were performed. results: histologically, the tumor displayed an infiltrating growth pattern and consisted of spindle cells, that appear to emanate from myoepithelial cells of ductules entrapped in the center of the lesion. mitotic activity did not exceed mitotic figures/ hpf. immunohistochemically, the tumor cells revealed positivity for p , cytokeratin / , cytokeratin βΕ , smooth muscle actin, cd and s protein, whereas they were negative for desmin, cytokeratin , cd , hmb , estrogen, progesterone receptors and her- oncoprotein. approximatelly % of tumor cells showed nuclear positivity for mib- /ki- . all axillary lymph nodes were free of metastases. conclusion: myoepithelial carcinoma of the breast is a potentially highly aggressive neoplasm and its differential diagnosis is fairly broad, including metaplastic spindle cell carcinoma and a variety of myofibroblastic lesions. objective: we investigated the differential expression of several biological markers between primary invasive breast carcinomas and their paired lymph node metastasis analyzing separately epithelial and stromal components. method: representative samples of idc and paired compromised lymph nodes were arrayed in a tma and selected markers: hormonal receptors, her- , proliferation (p , pakt, pmtor, tgfβ ) , motility (cd and cxcr) and basal markers (ck , ck , c-kit) were evaluated by ic. results: in the primary tumor, p , mib- , tgfβ , cd and cxcr were more expressed in epithelial cells (p< . ), while pakt, pmtor, c-myc and c-kit showed a similar frequency in both components. hormone receptors, her- /her- and cytokeratins were not expressed in stromal cells. the proliferative biomarkers were concordant in the epithelial component. cd frequency was similar but cytoplasmic cxcr as opposite to nuclear was predominantly expressed in lymph nodes (p= . ). stromal cells from lymph node showed a reduced frequency of cd (p= . ) and c-myc (p= . ) when compared to the stromal component of primary tumors. conclusion: epithelial cxcr expression may facilitate lymph node metastasis whereas the low frequency of cmyc and cd in the lymph node stromal component indicated decreased proliferation enhanced motility of stromal cells in this site. expression of hypoxia-inducible factor- a and associations with vascular endothelial growth factor expression, high microvessel density and features of aggressive tumors in african breast cancer h. nalwoga * , j. b. arnes, h. wabinga, l. a. akslen * university of bergen, the gade institute, norway objective: breast cancer in africans is reported to have poor clinical outcome. whereas hypoxia-inducible factor- α (hif- α) expression has been linked to treatment failure and poor prognosis in breast cancer, there is a lack of reports about hif- α expression in africans. the aim of this study was to evaluate hif- α expression in relation to vascular endothelial growth factor (vegf) expression, angiogenesis, and other tumor characteristics in an african population. method: in total, we analyzed breast cancers by immunohistochemical staining. we determined microvessel density (mvd), proliferating microvessel density (pmvd), and vascular proliferation index (vpi) in the most vascularized areas as well as expression of hif- α and other biomarkers using tissue microarrays. results: expression of hif- α (in / tumors; %) was associated with vegf expression (p< . ), mvd (p = . ), high tumor grade (p= . ), high ki- proliferative rate (p< . ), and p expression (p= . ). conclusion: there is a high expression of hif- α in this series of breast cancer which is strongly associated with vegf expression and increased mvd. more studies are required to assess the therapeutic implications of hif- α expression in this population. the patient underwent lumpectomy. the gross specimen had a tan grey firm nodule of × × mm. histological examination revealed a proliferation made of signet ring cell and glandular structures, with islands of goblet cells. immunohistochemistry revealed strong positive staining with ck and ck , and a sparse positive staining with synaptophysin and chromogranin.er, pr and her were negative. the patient underwent appendicectomy with a final diagnosis of breast localization of a primary occult appendiceal gcc. conclusion: the differential diagnosis between primary carcinoid tumor of the breast and signet ring cell carcinoma metastatic to the breast is often controversial in surgical pathology. diagnoses need to be made correlating clinical and histological examination in difficult cases in which there is not a diagnosis of carcinoid tumor elsewhere. their histological appearance may mimic ductal adenocarcinoma of the breast. the distinction is important due to differences in management and prognosis. determination of her gene amplification by chromogenic in situ hybridization (cish) in breast carcinoma m. neagu * , c. ardeleanu, g. butur, a. florin * national institute of pathology, bucharest, romania objective: detection of her neu amplification is an integral part of breast carcinoma diagnostics to decide therapy. method: we study cases of breast carcinoma embended paraffin tissues, both cish and fish were performed on each case using (spot-light her ) for cish and both her- and chromosome probes for fish (vysis). sixty tumor cells were evaluated in each case. the scoring system and interpretation of cish -invitrogen. results: concordance between cish and fish was found in , % cases, considering fish as gold standard, sensitivity of cish was . % and specificity %. cish is more practical alternative due to lower cost, no requirement of fluorescence microscope, use of existing bright-field microscopy and techniques it s similar to ihc, archivable and quantitative results, it s easy to observe both the tissue morphology and the gene amplification evaluation of the cases analyzed, showed similar results for both methods. two cases were discordant. in these cases, low-level amplification was suggested by cish but nonamplification by fish. conclusion: our results, suggest that cish is a useful technique to determine her- /neu oncogene status, in breast carcinoma for paraffin embendded tissues, is a highly accurate, reproducible and practical technique, with a high sensitivity. usual ductal hyperplasia with central necrosis, microcalcifications and multiple foci of pseudoinvasion arising in a radial scar: a potential diagnostic pitfall a. nechifor-boila * , s. stolnicu * university of medicine and pharmacy, tirgu-mures, romania objective: the diagnosis of radial scar (rs) is often difficult, especially when associated with proliferative changes, pseudoinvasion and necrosis. method: a -year-old woman was referred to the surgery department for a palpable mass in her left breast, regarded as a possible fibroadenoma on ultrasonography. results: lumpectomy was performed and the macroscopy revealed a tan-white mm diameter lesion, with irregular margins and firm consistency. on light microscopy, a sclerosing lesion, with a stellate arrangement of ducts surrounding a central fibro-collagenous zone was identified. haphazardly arranged, distorted ducts associated with massive intraductal proliferation, highly suspicious of infiltrative were also present in the center of the lesion. the proliferating ducts showed slit-like, irregular, secondary lumens, several containing central necrosis and a heterogenous cell population. the presence of central necrosis and pseudoinvasion were, however, worrisome. immunohistochemistry for p demonstrated the presence of myoepithelial cells surrounding all the areas with pseudoinfiltrating features, while ck / displayed a heterogenous, mosaic-like positivity, characteristic for usual ductal hyperplasia (udh). conclusion: because pseudoinvasion in benign rs can easily be misinterpreted as invasive carcinoma, immunohistochemistry is mandatory to establish the presence of myoepithelial cells. although rare, central necrosis may occur in udh and should not be used as a single diagnostic criterion of malignancy. phenotypical and morphological heterogenity of breast cancer: our experience j. nieslanik * , j. dvorácková, m. uvírová, Š. laciok, r. ondruššek, d. Žiak * cgb laboratory a.s., dept. of pathology, ostrava, czech republic objective: breast cancer is the most frequent malignant tumor in women with a rising incidence. about new cases are diagnosed in czeck republic every year, up to % die on it´s account. in cgb laboratory are investigated of malignant breast tumors every year. we evaluate the morphology, grade of differentiation and phenotype properties-hormone receptors expression, overexpression and amplification of her- /neu gene. % of carcinomas posses significantly morphologically and phenotypically heterogenic tumor population in one and the same tumor leasion. results: the most often sign of phenotype heterogenity found is hormone receptors expression or overexpression of her- /neu gene. often we see two morphologically different tumor populations coexisting. the most interesting cases from our practice are on the poster. conclusion: as for now, studies about the origin of heterogenity inside the same leasions, did not find a single theory to resolve it. a possible answer gives the theory of tumor stem cells and the model of clonal evolution. our observations demonstrate and may explain the practical reason of different phenotype properties found in core cut biopsy where one population may be held, against the heterogenic properties of the tumor shown when resected as a whole. high grade infiltrating carcinoma with squamous features -a case report d. r. novac * , c. ardeleanu, s. taban, f. cadariu, a. dema * municipal clinical hospital, anatomical pathology, timisoara, romania objective: apocrine carcinoma is a rare and histologically distinct type of invasive breast carcinoma. method: the patient, a years-old woman was admitted to the hospital for a tumor mass in the upper internal quadrant of the left breast. tissue fragments from the quadrantectomy specimen were routinely processed by paraffin embedding. for the immunohistochemical (ihc) study we used the following antibodies: ck , androgen receptors (ar), estrogen receptors (er), progesterone receptors (pr), high molecular weight cytokeratin (hmwck), p , gross cystic disease fluid protein- (gcdfp- ), en vision system, visualization with diaminobenzidine. results: the gross examination revealed a nodular, well delineated mass of , / , / cm, firm, gray-beige with areas of necrosis on cut section. microscopically, the tumor had a predominantly solid, partially cystic and less tubular growth pattern. the tumor cells had abundant eosinophilic granular cytoplasm and pleomorphic high-grade nuclei. a small tumor contingent presented squamoid features. ihc stains showed the following profile: ck +, ar+, gcdfp- +, er-, pr-, p /hmwck + (focal/zonal). a diagnosis of high-grade infiltrating apocrine carcinoma with squamous differentiation was established. conclusion: there are only a few cases of apocrine carcinoma on record and our case is even more special because of his peculiar aspect, the squamous differentiation. the effects of treadmill exercise in the number and weight of mammary tumors chemically induced in female sprague-dawley rats: preliminary results j. oliveira * , c. teixeira-guedes, a. faustino-rocha, r. soares-maia, r. arantes-rodrigues, m. j. pires, m. ginja, p. oliveira, r. ferreira * utad, dept. of veterinary sciences, vila real, portugal objective: we hypothesized that moderate exercise in treadmill may affect the mammary tumor development. n-methyl-n-nitrosourea (mnu) is a commonly used carcinogen to induce mammary carcinomas. the aim of this study was to evaluate the influence of treadmill exercise in the development (number and weight) of female rat mammary tumors. method: in this experimental protocol were used female sprague-dawley rats. mnu was intraperitoneally administered at days of age in a dose of mg/kg. animals were randomly divided in two groups: sedentary (n= ) and exercised (n= ). the exercise program was started after carcinogen administration. animals were exercised in a treadmill control le ® after an initial period of familiarization. thirty-six weeks after mnu administration animals were sacrificed and tumors were counted and weighted. results: sedentary and exercised group presented and tumors, respectively. pearson chi-square value was not significant (p> . ). the mean tumors weight of sedentary group ( . ± . g) was lower than exercised group ( . ± . g). the difference between groups was not significant (p> . ). conclusion: we observed that exercised group showed minor number of tumors, however the lesions presented higher volume. future morphological and biochemical analysis of tumors will allow a better understanding of the relation between mammary cancer and physical exercise. objective: primary non-hodgkin's lymphomas is an uncommon disease representing approximately . % of all reported malignant mammary neoplasms. clinically they are mainly observed as solitary lesions but may also be seen as multiple foci. herein, we present a very rare case with the diagnosis of multifocal malignant lymphoma of the breast with a detailed clinicopathologic evaluation. method: a -year-old-female patient with a right palpable breast lump admitted to the hospital. mammography and ultrasonography findings showed different foci of hypoechoic solid mass forming lesion in the right breast. excisional biopsy has been performed. results: in the histopathological evaluation, both lesions demonstrated diffuse infiltration of mammarian tissue with foci of necrosis; mitotically active tumor cells with large nucleus and prominent nucleoli. the immunohistochemical analysis revealed diffuse and strong lca, cd , cd , focal cd positivity while pancytokeratin, ema, cd , sma were negative. the case was diagnosed as diffuse large b-cell lymphoma. conclusion: breast is an uncommon site for primary malignant lymphomas. we report a very rare case with a diagnosis of multifocal primary non-hodgkin's lymphoma of the breast. ps- - cytological, histopathological and clinical correlation at differential diagnosis of granulomatous mastitismalignancy t. ozgur * , e. atik, s. toprak, h. gokce, n. sengul, m. temiz * mustafa kemal university, medical faculty, antakya, turkey objective: idiopathic granulomatous mastitis (igm) is a rare disease that is difficult to diagnose by only radiological methods and clinical findings. method: first case; a years old woman with a well circumscribed mass of cm diameter at right breast applied to our hospital general surgery outpatient clinic. in the examination of fine needle aspiration biopsy (fnab), palisaded epitheloid histiocytes and scattered atypical cells have been seen on a bloody and inflammatory background. we suggested excisional biopsy. second case; a years old woman applied to our hospital general surgery outpatient clinic with a sore mass in her left breast. the mass has been excised for malignancy suspect. foci of abscesses, active chronical inflammation, areas of hemorrhage and numerous granulomas containing epitheloid histiocytes are observed microscopically. results: in microscobic evaluation of the excisional biopsy of the first case prediagnosed as granulomatous mastitis invasive ductal carcinoma has been our diagnosis. in the second case there have been numerous granulomas containing epitheloid histiocytes, microscopically. our diagnosis was granulomatous mastitis in this patient prediagnosed as malignancy. conclusion: especially fnab findings are easy to confuse with malignancy. we wanted to emphasize to clinician and pathologist to be more alert on distinction of granulomatous mastitis and malignancy. objective: triple-negative-breast-cancer (tnbc) that accounts for - % of all breast carcinomas is defined by the lack of estrogen receptor, progesterone receptor, her expression with agressive clinical behavior. tnbc is categorized into basal like subtype which is characterized by the expression of basal cell markers and normal breast subtypes. method: we studied on immunohistochemically tnbc patients to determine egfr, cytokeratine / (ck / ), p , ki , gcdfp expression patterns by immunohistochemistry, her /chromosome gene status by fish. results: most of the tumors ( , %) were invasive ductal carcinomas. p , ki , gcdfp mean positivity rates were , %; , %; , % respectively. gcdfp positivity was noted in cases of which were ck / (−). the cut-off value for ck / positivity was %. egfr immunoreactivity was grouped into , + as negative; +, + as positive categories. ck / was positive in , %, egfr was positive in , % of the patients. the relation between ck / and egfr expression was statistically significant (p < . ). her fish was negative in all cases. conclusion: as a result gcdfp alone is not a useful marker to detect the metastasis of basaloid type breast cancers. ck / and egfr coexpression can be used to diagnose basaloid tumors with % cut-off value. objective: lobular neoplasia (lns) of the breast include atypical lobular hyperplasia (alh) and lobular carcinoma in situ (lcis). because lns do not present typical clinical or radiologic findings, the diagnosis is incidental. many reports suggest that ln is not only a risk factor of invasive lobular carcinoma but also is as a precursor. it is important to know about the incidence of lns and associated disease in korea. method: a total cases of breast biopsy or excision from five major hospitals in daegu were reviewed independently by pathologists of the daegu breast pathology study group. the incidence of alh and lcis, associated disease, the presence of microcalcification and necrosis were reviewed. all suspected cases of lns were confirmed on e-cadherin immunohistochemical staining. results: only cases out of cases ( . %) revealed lns. associated disease were cases of invasive ductal carcinoma, cases of in situ ductal carcinoma, cases of invasive lobular carcinoma, cases o f other benign disease, and cases of florid ductal hyperplasia or columnar cell change. conclusion: the incidence of lns was similar to western women. incidental lns were frequently associated with invasive ductal carcinoma and further excision is suggested if it was present on the needle biopsy specimen. silver-enhanced in situ hybridization (sish) detection assay for her gene status determination in breast carcinoma: a four year experience in our laboratory f. patakiouta * , g. c. balis, v. theodorou, e. triantafillidou, c. fotiou, i. boukovinas, c. andreadis, g. sibilidis * "theagenion" cancer hospital, dept. of pathology, thessaloniki, greece objective: assessment of her status in breast cancer is important in the clinical management of patients and can be identified by a number of methods. in this study we present the results of the sish technique used in our laboratory in the last years. method: we analyzed cases of invasive breast carcinoma, including core biopsies, which were previously characterized immunohistochemically (cb ) as equivocal on a protein level (her +). all cases were evaluated by bright-field sish using the automated ventana benchmark xt machine. evaluation was independently performed by two pathologists (fp, gb) based upon the algorithms of the manufacturers and asco/cap guidelines. results: out of cases the her gene was amplified in cases ( . %), while in cases ( . %) there was no gene amplification. fourteen of the cases ( . %) were characterized as equivocal. the concordance between the two pathologists was high ( . %). conclusion: the sish method is new, fully automated and very rapid. furthermore the bright-field sish signal does not decay and can be visualized by any standard bright-field microscope even after long periods of time, making it particularly suitable for routine application in surgical pathology. objective: breast fibromatosis (bf) represents . % of breast tumours that simulate carcinoma. the aim of this study is to characterize the cases of bf diagnosed in our institution. method: bf cases diagnosed from to were evaluated with clinicopathological and immunohistochemical parameters. we also studied mutations in exon of the gene for β-catenin in cases. ultrastructural study (us) was performed in case. results: there were women between and years old. radiologically they showed deeply located hypoechoic irregular lesions. size ranged between and cm. histologically they were characterized by an ill-defined spindle cell proliferation without epithelial elements or atypia. immunohistochemical study was negative for ae /ae , ck / , p , cd and bcl . actin was diffusely positive in / , and s and desmin focally positive in / . β-catenin showed cytoplasmic( / ) and nuclear( / ) expression. the us showed double smooth muscle and myofibroblastic differentiation. three patients showed mutations in exon of the β-catenin gene ( with substitution at codon (t a) and deletion of base pairs (a _e del)). conclusion: focal desmin expression and us suggest smooth muscle differentiation in some bf. all cases showed cytoplasmatic positivity for β-catenin but nuclear expression was seen in only % of cases. % of the valuable cases showed genetic alterations of β-catenin. objective: breast cancer is a heterogenous disease consisting of distinct entities characterized by different gene expression patterns. gene expression profiling of breast cancer revealed major subtypes, including hormone receptor (hr) positive luminal a and b, her- positive and basallike breast cancer. most of the basal-like carcinomas are triple negative (hr and her- negative). as most triple negative breast cancers express egfr, mutations in the signal transducing cascade of ras/raf/map kinase might play a role in tumor progression. the aim of this study was to determine the incidence of kras and braf v mutations in triple negative breast carcinomas. method: total genomic dna was obtained from formalin-fixed, paraffin embedded, triple negative breast tumors. kras was analyzed by pyrosequencing of codon , , . braf (exon , v ) mutations were analyzed with autogenomics infiniti braf assay on the autogenomics infiniti analyzer. results: we found kras mutation in only one case ( . %), apocrine carcinoma which was gly asp (ggt> gat) mutation. the braf v mutations were not detected in all analyzed tumors. conclusion: we concluded that kras mutation was rare in triple negative breast carcinomas and high frequency of egfr overexpression in this subtype might be related to other pathways in egfr signaling. the pre-lymphatic system and the lymphatic network of the breast in menstruating and in menopausal women: a comparative study s. popovska * , i. ivanov, t. betova, t. dineva, z. ivanova * medical university hospital, dept. of clinical pathology, pleven, bulgaria objective: the pre-lymphatic system was initially described in the s by casley-smith and florey. it consists of cd positive fibroblasts lined stromal spaces communicating with the lymphatic capillaries. the aim of the following investigation was to compare the lympho-vascular density and pre-lymphatic network density of breast tissues in the context of the menstrual status of the patients. method: formalin-fixed, paraffin embedded tissue specimens from patients with primary breast cancer were studied. tumor-free tissue materials were selected. tissue processing and immunohistochemical staining with d - and cd antibody was performed in accordance to standard laboratory protocols. quantitative evaluation of the lymphatic and pre-lymphatic system was performed. the kruskal -wallies test was used to compare differences between the median values of the studied variables. statistical significance of the differences was considered if p< . . results: the pre-lymphatic network was found to be significantly more dense in menstruating, compared to menopausal women k-w= . ; p< . n= . lymphatic vascular density was higher in menstruating compared to menopausal women k-w= . ; p= . ; n= . conclusion: involution changes in the pre-lymphatic and lymphatic system of the breast were found to appear in postmenopausal women. this may be the explanation for the slow local progression of breast cancer observed often in elder patients. comperative study of herceptest and fluorescence in situ hybridization results in breast carcinoma: indeterminate ( +) group must not be a wide range uncertainty category y. saglican * , u. ince * acibadem maslak hospital, dept. of pathology, istanbul, turkey objective: herceptest is an exclusively used immunohistochemistry method for testing her /neu overexpression in breast carcinomas. the purpose of this study is to select the proper patients candidate to in situ hybridization, with an indeterminate her score. method: a retrospective analysis of cases with invasive breast carcinoma were evaluated for her status using immunohistochemistry and fluorescence in situ hybridization. İmmunohistochemistry of cases that had been previously evaluated by nine different pathologists in our department, were reviewed by two experienced pathologists. interpretation of the immunohistochemistry results was made without knowing the first results. results: compared to the first evaluation; cases with score , + and +correlated with the review of immunhistochemistry and none of score and + tumors were positive with in situ hybridization. gene amplification was detected in cases; of them with +score. three of + tumors and of + cases were negative with in situ hybridization. discordance was detected in cases in + score; of them were reclassified as negative and were technically unsatisfactory. conclusion: using a different cut-off value for indeterminate her results and training of pathologists to minimaze the interpretational differences, will maximize the accuracy, while not submitting to unnecessary molecular tests. objective: the excision repair cross-complementation (ercc ) enzyme plays an essential role in the nucleotide excision repair pathway and is associated with resistance to platinum-based chemotherapy in different types of cancer. the aim of the present study was to evaluate the clinicopathological significance of ercc expression in breast cancer patients. method: we used immunohistochemical to analyze ercc expression in a tissue microarray from breast carcinomas. ercc expression analysis was available for cases and was correlated with clinicopathologic factors and outcome data. results: ercc -positive was observed in ( . %) cases and was correlated with smaller tumor size (p= . ) and with positivity for estrogen receptor (p= . ). ercc expression did not correlate with overall and disease-free survival rates. the majority ( . %) of special histological types of invasive breast carcinomas was positive for ercc compared to invasive ductal carcinomas (ercc -positive in . % of the cases). similarly, triple negative breast cancers (tnbc) were more frequently negative for ercc ( . % of the cases) compared to the non-tnbc ( . %). conclusion: ercc expression correlated significantly with favorable prognostic factors, such as smaller tumor size and er-positivity, suggesting a possible role for ercc as a predictive and/or prognostic marker in breast cancer. a study of cd positive basal/myoepithelial cells in a consecutive series of in situ lobular neoplasia of the breast s. shousha * , g. forbes * charing cross hospital, dept. of histopathology, london, united kingdom objective: we have previously reported a few sporadic cases of in situ lobular neoplasia (iln) associated with marked proliferation of cd positive basal/myoepithelial cells. method: twenty consecutive cases of pure iln and dcis were studied. new sections were cut and stained for e-cadherin and cd . results: one out of the cases showed foci of invasive lobular carcinoma in the new cut sections. all iln cases showed increased proliferation of cd positive basal cells, varying from a focal mild increase to a marked proliferation surrounding or mingling with the lobular cells. cd positive cell proliferation was least observed in a case of iln with central necrosis and in foci of iln seen adjacent to the invasive carcinoma. the invasive tumour cells were cd negative. all cases of dcis had a thin layer of cd positive myoepithelial cells, that was incomplete or absent in some foci. conclusion: our findings confirm the presence of a unique relationship between excess proliferation of cd positive basal cells and iln; an association which is not seen in dcis or invasive carcinoma. this is particularly interesting as recent evidence indicates that cd is involved in the regulation of mammary stem and 'sphere forming' cells. objective: primary neuroendocrine carcinomas (nec) of the breast are defined by the who classification as a group of neoplasms that express neuroendocrine markers in more than % of the cells. these tumors can exhibit different morphologic appearances including solid, nested or alveolar pattern, papillary or mucinous differentiation or conventional ductal structures. the aim of this study is to identify histomorphological features useful in the recognition of this tumors. method: invasive breast carcinomas were reviewed, none of them previously typified as nec. were ductal carcinomas ( grade i, grade ii and grade iii) and lobullilar carcinomas. in all cases immunohistochemical staining for the neuroendocrine marker synaptophysin was performed. results: eight of the cases showed intense immunoreactivity for synaptophysin. all of them were predominantly composed of solid, confluent nests and cords of cells with medium-to high grade nuclear atypia. two cases showed intense desmoplastic or sclerotic stromal response. a colloid component was identified in another two cases. conclusion: due to its morphologic variability, mammary nec is frequently underrecognized. a predominantly solid pattern of confluent nests and trabeculae associated with a prominent sclerotic stromal response or colloid differentiation should prompt to perform additional immunohistochemical staining in order to exclude neuroendocrine differentiation. objective: association between centrosome abnormalities and response to chemotherapy has not been fully elucidated in breast carcinomas (bc). here we analysed the association between aurora kinase a (aurka) and gamma-tubulin (gt) and response to neoadjuvant chemotherapy (pst) in patients treated with bc. method: the immunohistochemical expression of aurka and gt was analysed in core biopsies of bcs taken before administration of pst. aurka expression was analysed using a modified allred-like scoring system (intensity and percentage of staining combined). cells containing one or two centrosomes as determined by gt were considered negative, whereas cells containing more than two centrosomes were regarded as positive. centrosome amplification was graded in each specimen as follows: negative ( - % of cells); weak ( - %); moderate ( - %); and strong ( %<). pathological response rates were assessed using chevallier's classification. results: centrosome amplification was significantly higher in patients achieving complete response when compared with the cases where partial remission or no response was defined (p= . ), whereas we found no significant correlation between the expression of aurka protein and response rate to neoadjuvant chemotherapy (p= . ). conclusion: bcs showing centrosomal amplification as determined by gt present higher response rates to neoadjuvant chemotherapy, but need further validation. breast granulocytic sarcoma with aleukemic presentation: a case report o. tzaida * , p. giagkazogloy, p. repousis, m. kotsopoulou, i. kasselaki, c. valavanis, i. iacovidou * anticancer hospital metaxa, peiraias, greece objective: granulocytic sarcoma (gs), a rare solid tumor of immature myeloid cells in exrtamedullary sites, usually occurs during the natural course of acute myelogenic leukemia (aml). rarely is presented without overt hematological disease. the breast is an uncommon site of localization. method: we report a case of breast gs with aleukemic presentation, condition that is extremely rare and requires a high index of suspicion for diagnosis. a year old woman, presented with a solitary, non-tender, palpable left breast mass. a lumpectomy was done. results: histopathology revealed breast parenchyma diffuse infiltration, in a targetoid pattern, by immature small cells intermingled with eosinophils. lobular carcinoma and lymphoma were considered in differential diagnosis. the myeloid origin of the neoplasm was established by immunohistochemical analysis that revealed lca, mpo, cd , hladr, cd (kp ) positivity. there was no evidence of leukemia in the peripheral blood and bone marrow. the patient was treated as aml with systemic chemotherapy and months after the diagnosis she is without evidence of disease. conclusion: breast gs is a challenging situation both for pathologists and hematologists. available evidence strongly favors the application of systemic chemotherapy despite the appeared localized nature of the disease. method: paraffin blocks of tumor tissue of breast cancer cases collected at our cancer centre for years. the immunohistochemical study was performed by standard techniques using following antibodies (dako): er, pr, her- , egfr, ck / , ck , ki . results: all cases were classified into the subtypes: luminal a (n = ; . %); luminal b (n = ; . %); her- -positive (n= ; . %); basal (n= ; . %); negative (n= ; . %). conclusion: luminal breast cancer phenotype predominates in our collection, predictive/prognostic value of molecular genetic subtypes is planned to be investigated. we recognized statistically significant differences (p< , ) in five-year survival rates between tumors of luminal (a, b) and basal subtypes. proliferating trichilemmal cyst with atypical cytological features r. g. wright * , c. gallivan, t. molden-hauer, r. liang * gold coast hospital, pathology queensland, australia objective: proliferating trichilemmal cysts are relatively common occurring within the scalp of elderly women. proliferating trichilemmal cysts of the breast, however, are rare. these cysts are benign with very few demonstrating malignant transformation. method: we report a case of proliferating trichilemmal cyst of the breast with atypical cytology which prompted excisional biopsy. cytological assessment was useful in this case as it indicated excisional biopsy rather than a more extensive excision. results: smears produced from the fna showed sheets of atypical epithelial cells with foamy histiocytes, multinucleate cells and fibrotic material with evidence suggestive of fat necrosis. a cell block was acellular. a specific diagnosis was not made. an excision specimen was advised and a proliferating trichilemmal cyst was demonstrated. objective: a large clinical value has determination of molecular subtype of breast cancer (bc). to clarify morphological and molecular biological similarities and differences between bc depending on age, we compared features between tumors of younger and older women. method: patients with bc are included in research: from till years, among them patients were till years. er, pr, her- /neu, p , p , ki , ck / , p , bag , mcl , ps , vegfr, her- were analyzed in all cases by immunohistochemistry. results: the younger patients with bc had higher expression of p , p , p , bag , mcl , ki- , vegfr, her- (p< , ) than older patients. there was a basal-like molecular subtype of bc -fold more frequent compared with older patients ( , % versus , %; p< , ). threeyears overall survival in patients till years was by , % and a five-year overall survival was by , % lower than in patients over years (p< , ). objective: breast her ish relies on correct enumeration of her /cep signal. however, as with immunohistochemistry, there are technical pitfalls which may render ish difficult/unreliable to interpret. the uk neqas has established a 'technical' ish module to provide feedback to laboratories using both chromogen and fluorescence based tehcniques. method: unstained slides consisting of breast cancer cell lines were distributed. laboratories were asked to demonstrate her gene amplification using their routine assay, and then return the slides for assessment. chromogen based methods were assessed around a multi-header microscope with assessors scoring each slides, whilst the fluorescent ish method was assessed by a single individual. assessors scored the 'readability' of each slide, without counting the probes, and provided feedback where the hybridisation technique could hinder interpretation. results: cish based methods showed acceptable staining in % (n= ) of cases. staining problems ranged from loss/poor her /cep signal, non-specific staining and morphological damage. the fish pilot assessment showed an acceptable rate of % (n= ), with the low pass rate being attributed to poor preservation/quenching of fluorescence signal. conclusion: greater emphasis needs to be placed on the 'readability' of an ish slide, prior to carrying out the process of enumeration. tuesday, september , . - . objective: intravenous leiomyomatosis is a very rare growth pattern variant of leiomyoma in which nodular masses of tumor grow within venous channels. occasionally the tumor can extend to vena cava and the right heart. method: we present a case of a -year-old woman, who was admitted in the emergency room with rapidly evolving exertional dyspnea. cardiac ultrasonography revealed a "big mass in the right chambers". she was submitted to a right atriotomy with resection of part of the tumor, which was sent for intraoperative consultation. results: grossly, the tumor was polypoid, firm, with a smooth surface. the frozen section showed a lesion composed of tortuous vessels and in some areas a fibrillar eosinophil extracellular matrix and others with spindle cells. no significant atypic or pleomorphic cells, mitosis or necrosis were observed. the diagnosis was deferred for definitive paraffin sections. in the definitive h&e and with immunohistochemical stains, the case was diagnosed as an intravenous leiomyomatosis, and the diagnosis was confirmed in the hysterectomy specimen. conclusion: intravenous leiomyomatosis with cardiac involvement is an extremely rare condition. clinical information is essential for the correct diagnosis in frozen section. characterization of a specific mechanism for late loss of cardiac allograft: the antibody mediated rejection (amr) as a major factor of cardiac allograft vasculopathy (cav) p. bruneval * , c. toquet, a. loupy, p. pouvier, a. cazes, j.-p. duong van huyen * france objective: the rational of this study was to investigate explanted failing grafts in the light of new concepts in rejection mechanisms, namely amr. method: this retrospective multicentric study collected explanted cardiac grafts failing ≥ year posttransplantation. the vasculature of the grafts was assessed from epicardial coronary arteries to myocardial microcirculation. immunohistochemistry was performed for c d complement fraction deposition and cd -positive macrophages in the explanted grafts and previous endomyocardial biopsies. donor specific antibodies (dsa) were retrospectively assessed using luminex sa technique. results: a pure classical coronary atherosclerosis pattern was observed in / ( %). a pure pattern of cav was present in / ( %) and a mixed pattern associating cav and atherosclerosis features in / ( %). interestingly the cav pure and mixed patterns were associated with vascular inflammation within the arteries and/or the microcirculation with c d deposits and macrophages ( / ) in the explanted grafts versus nil ( / ) in pure atherosclerosis pattern (p< . ). furthermore they were associated with previous amr episodes on endomyocardial biopsies ( / ) and by positive dsa ( / ) versus nil in pure atherosclerosis pattern (p< . and p= . , respectively). conclusion: in failing cardiac grafts cav lesions are associated with makers of amr. cav should be the consequence in coronary arteries of an ongoing amr process. results: in our cases increase in fibrous and adipose tissue concordant with age, indicating an age related nature, were detected. fibrous and fatty tissue infiltration appeared at the age of . fatty infiltration started at the age between and at sinoatrial node. in cases calcification and in cases inflammation was observed. amyloid accumulation was not present. in cases myocardial infarction not involving ccs was seen. in case fibroelastoma was detected. conclusion: in turkish population age related fibrosis and fatty infiltration in ccs appeared at the age of and increased with age. fatty infiltration in sinoatrial node started at a younger age than that of reported in the literature. in cases whom the cause of death could not be determined we could not detect lethal pathologic features. however we think that examination of the ccs will improve the quality of autopsy diagnosis. periadventitial adipose tissue in human coronary atherosclerosis: a neurotrophin study p. ghenev * , p. panayotov, g. chaldakov, l. aloe * medical university varna, dept. of pathology, bulgaria objective: recent evidence demonstrates that epicardial adipose tissue, including coronary periadventitial adipose tissue (tunica adiposa), are paracrine sources of bioactive mediators (adipokines, no, h s) which may be involved in coronary atherogenesis. because of the increasing interest for extra-neuronal effects (inflammation, wound healing, lipid and glucose metabolism) of the neurotrophins nerve growth factor (ngf) and brain-derived neurotrophic factor (bdnf), including in human coronary atherosclerosis in autopsy samples, the aim of the present study is to evaluate the expression of ngf and bdnf and their receptors (trka and trkb, respectively) in cardiosurgery biopsy samples of pericoronary adipose tissue. method: immunohistochemistry of ngf, bdnf and their trk receptors. results: ngf, bdnf, trk a and trkb expression was lower in periadventitial adipose tissue of atherosclerotic coronary arteries as compared to non-affected coronaries. conclusion: we provide the first evidence for a possible role of neurotrophins in the molecular remodeling of tunica adiposa in human coronary atherosclerosis. this study is dedicated to rd anniversary of rita levi-montalcini, the nobel laureate for the discovery of ngf. objective: in normal myocardium, apoptotic myocytes are usually absent, or if affected, with most of positive cells per million. method: the apoptosis was measured by the tunel method in patients with dilated cardiomyopathy (dcm) and myocarditis (mc), and expresed by apoptotic index (ai) in patients within both groups, and to correlated with ejection fraction (ef) and with different morphological stages of these entities. statistical analisys was performed, and p values ≤ . were considered statistically significant. results: ai in mc cases was , + , , and in dcm cases the value was significantly higher , + , (p= . ). in the group mc patients, we didn't found statistically significant correlation between ai and different values of ef (p= . ). the analysis of the value of ai between patients with different morphological stages of mc didn't show statistically significant correlation (p= . ), as well as in dcm (p= . ). conclusion: apoptosis play a significant role in dcm and mc but its significance in the progression to heart failure has still to be established. objective: cardiac lesions following blunt chest trauma are multiple and of various degrees of severity. "cardiac contusion" is a difficult diagnosis, especially antemortem and if signs of thoracic trauma are not evident on external habitus and on the underlying internal plans of cardiac area. is the contusion a cause of death per se? method: the authors present two cases of road accident male victims, aged and year-old, submited to complete postmortem examination with ancillary diagnostic methods. results: no traumatic lesions or underlying pathology was found at the autopsy. epicardial and myocardial haemorrhagic foci were histologicaly documented. toxicology was negative. conclusion: cardiac contusions are caused by one of the following mechanisms: ) heart compression between bone structures, ) sudden acceleration-deceleration movements and ) sudden thoracic/abdominal pressure increase. they may be asymptomatic or lead to rhythm disturbances responsible for unexpected death ( %) . they seem to be underdiagnosed, thus suspecting the entity "contusio cordis" is crucial, not only antemortem for correct surveillance and treatment, but also postmortem to adequately establish causality nexus in cases of post-thoracic trauma deaths. the influence of bone marrow-derived multipotent stromal cells on myocardial scar healing in experimental myocardial infarction l. kakturskiy * , t. fatkhudinov * institute of human morphology, central laboratory of pathology, moscow, russia objective: previous studies have shown the benefits of intracoronary infusion of bone marrow-derived multipotent stromal cells (bm-mscs) in heart disease. our aim was to study engraftment, differentiation of bm-mscs and its role in myocardial reparation. method: acute myocardial ischemia was produced by transient occlusion (total of min) of the proximal left anterior descending coronary artery and followed by reperfusion. bm-mscs were isolated, expanded by standard and labeled with pkh (sigma). cells were cd and cd positive. days after occlusion during cross-clamping of aorta the cells were administered into the cavity of the left ventricle at the concentration × in saline solution. in day, , and weeks after transplantation the labeled cells were detected in the cryosections and heart morphometry was performed. results: bm-mscs were detected only in the scar tissue and had a fibroblast-like phenotype. they neither differentiated into cardiomyocytes nor into the cells of blood vessels. in weeks after transplantation the scar thickness was higher in the group with cell transplantation (p< . ). conclusion: engrafted bm-mscs promote myocardial fibrosis only in the scar, but not in the perifocal myocardium, provided strengthening of the scar, remodelling of outflow tract, and improvements the myocardial function. objective: from january to december (institute of pathology and legal medicine, paolo giaccone -palermo) autopsies were performed on males and females who died of a massive pte. method: systematic autopsy. results: saddle pulmonary thrombosis in cases, in isolated in both the main pulmonary arteries. in all cases the transverse heart diameter was , - cm superior to the longitudinal one, the interventricular septum became rectilinear with a right ventricular dilation. the coronary artery anatomy was: critical stenosis through fibroatheromatous plaque of the dominant right coronary artery (rca, ), non dominant left coronary artery (lca, ); non critical stenosis of rca ( ), lca ( ); absence of stenosis ( ). histological ventricular examination showed hypoxic-ischaemic and/or reperfusion and overload lesions. in all cases, the lungs showed plurifocal occlusive thrombosis of intramural pulmonary arterial (ipa) vessels associated with adjacent infarctual necrosis ( ); acute partially haemorrhagic basal oedema ( ) and desquamative macrophagic alveolitis ( ). conclusion: in all cases of massive pte the thrombosis of ipa vessels associated with an adjacent infarction ( %) is constant. this suggests that death is nearly always preceded or triggered by one or more episodes (clinically silent or with non specific symptoms) of thromboembolism of ipa vessels. cardiac findings in routine fetal autopsies: more than it meets the eye? e. rios * , c. bartosch, c. ramalho, j. monterroso, o. brandão * centro hospitalar s joão, pathology, porto, portugal objective: congenital heart disease (chd) is the most common malformation in newborns. our aim was to evaluate the spectrum of chd in consecutively performed fetal autopsies and to correlate prenatal and postmortem diagnoses. method: a retrospective study of fetal autopsies was performed in a tertiary referral hospital. chd was classified in seven categories: left ventricular outflow tract obstruction-lvoto, right ventricular outflow tract obstruction-rvoto, septal defects, connection anomalies, conotruncal anomalies, complex anomalies and others. cardiac defects were also classified as isolated or associated with others anomalies. results: chd was identified in ( . %) fetuses. most common categories were septal defects and complex anomalies. associated anomalies were found in fetuses ( . %). in this group, septal defects were the most common chd, frequency being significantly higher than in the group of isolated cardiac anomalies (p= . ). comparison of prenatal and postmortem diagnoses ( cases) showed complete or partial agreement in and cases ( % and %, respectively) and complete disagreement in cases ( %). in the latter group, prenatal diagnosis had not been done by a pediatric cardiologist. conclusion: the high prevalence of chd in lost pregnancies highlights the importance of systematic fetal autopsy performed by a specialized pediatric pathologist. objective: the appearance of pathological calcification, which leads to significant changes of vascular wall, which underlie the development of atherosclerotic complications, has a great importance in the morphology of atherosclerosis development. purpose of the work is the study of pathological biomineralization in heart valves affected by atherosclerosis. method: the study was conducted on sectional material of mitral and aortic valves obtained during autopsy. the tissue of heart valves was studied by methods of histology, electron microscopy, x-ray diffraction, infrared spectroscopy. results: macroscopically mitral and aortic valves are thickened, opaque, dull whitish, sometimes with deformity and ulceration. histology observed the formation of atherosclerotic plaques, fibrous changes, and inflammatory infiltration. according to x-ray phase analysis biominerals in heart valves are represented by apatite crystalline phase. sizes of crystals have distinct age dependence. the results of infrared spectroscopy revealed absorption bands of carbonate apatite replacement; in all instances they correspond to the type of substitution b (co -replaces po -). conclusion: the study of pathological mineral formations on human heart valves by the range of morphological and physicochemical methods show that they are aggregates of interacting organic and mineral components, their ratio changes with "maturation": the organic component decreases and the mineral component, represented by carbonate containing hydroxyapatite doped with chlorine grows while improving, so the process is dynamic. relationship between myocardial injury, oxidative stress mechanism and sepsis/septic shock in infants submitted to surgery for congenital heart defects m. silva de oliveira * , e. medeiros floriano, p. henrique manso, r. nilsson sgabieri, j. guilherme klamt, e. zangiacomi martinez, w. vilella de andrade vicente, s. gusmão ramos * university of são paulo, dept. of pathology, ribeirão preto, brazil objective: a progressive ventricular dysfunction caused by ischemic myocardial injuries remains one of the leading causes of death during the postoperative course in congenital heart disease (chd). the aim of this study was to investigate the role of oxidative stress in these myocardial injuries. method: myocardial injuries and oxidative stress mechanisms were assessed by histopathology and immunohistochemistry and quantified by morphometrical analyses. results: myocardial injury was observed in pediatric patients submitted to surgery for chd with cardiopulmonary bypass, followed by lethal exit. oxidative stress mechanisms were directly related to these particular types of myocardial injuries. importantly, -hydroxynonenal ( -hne), a marker of lipid peroxidation, is strongly expressed, especially in irreversible myocardial lesions. although morphologically similar, myocardial injuries observed in patients who evolved with sepsis in the peri-operatory period exhibited a completely different set of oxidative stress mechanisms. increased concentrations of nitrotyrosine protein adducts were observed in these patients, suggesting that peroxynitrite-mediated protein nitration may be the predominant oxidative stress mechanism found in these situations. conclusion: the underlying mechanisms of these lesions seem to be related to the development of ischemia or ischemia/reperfusion followed by oxidative stress mechanisms that vary depending on whether sepsis was present. while the exact mechanism is not fully understood, it has been suggested that endogenous catecholamine release could have a role in this process. objective: a significant decrease of the mean cardiomyocyte dna content and increased numbers of diploid cardiomyocytes after ventricular unloading was demonstrated, suggesting a numerical increase of cardiomyocytes. the heart harbours several stem cells populations including c-kit (cd ) + cells and side population cells (spc), that might proliferate after unloading and generate diploid cardiomyocytes. it was tested, whether there is an increase of abcg + spc and cd + cells after unloading. method: in paired myocardial samples (before and after lvad), the number of cells with immunoexpression of abcg- , c-kit/cd and mef- was assessed by immunohistochemistry and morphometrically determined. results: a significant increase of spc and cells with coexpression of c-kit and mef- after unloading was observed (p= . ). a significant positive correlation between both spc and cells with coexpression of c-kit and mef- expression was observed (p= . and . ). no correlation was found between the number of spc and the mean cardiomyocyte dna content. conclusion: spc are significantly increased in the myocardium after ventricular unloading, suggesting a role of stem cell proliferation during "reverse cardiac remodelling". these cells might proliferate and commit to different cell lineages such as cardiomyocytes or endothelium, and thus ameliorate cardiac function. role of elastin gene polymorphism in ascending aorta aneurysm development in patients with essential hypertension v. zakharova * , v. dosenko, m. kostiv, e. rudenko * cardiovascular surgery institute, pathology, kiyv, ukraine objective: there is supposition about genetic propensity in the ascending aorta aneurysm (aaa) development. aim: to investigate role of elastin gene polymorphism (rs ) in aaa development in essential hypertension (eh). method: dna samples from persons with aaa and eh ( group), with eh only ( group) and healthy subjects ( group) were examined. polymorphism rs was studied with real-time pcr. histological examination of aaa walls was performed in group. results: distribution on genotypes a/a, a/g, g/g was the following: group - . %, . %, . %; group - %, %, %; group - . %, . %, . %. fragmentation of elastic membranes and media collagen component strengthening were revealed in persons with a/a, a/g, g/ g genotypes in . %, . %, . % respectively. persons with g/g genotype have more frequently ( . %) than others (a/a - . %, ag - . %) signs of inflammation, which promote aaa development parallel to eh. conclusion: we obtained evidence that elastin gene polymorphism (rs ) plays important role in eh and aaa development. in persons with allele a in rs risk of eh and aaa development is higher than in g/g genotype. mostly allele a in rs is accompanied with elastic membranes fragmentation and their substitution by collagen that decreases arterial wall elasticity. tuesday, september , . - . objective: our aim is to inform on the frequency, clinical aspects, and histopathological features of the tumor metastatic to the orbit. in adults, the most common tumor metastatic to the orbit are carcinomas, breast carcinoma the most frequent. less common are the metastases from gastrointestinal tract, kidneys, and prostate. cutaneous malignant melanoma is the most common nonepithelial tumor metastatic to the orbit. method: orbital metastatic tumors may occur at any age, but most often between and years of age. most reported statistics reveal a slight predominance of women, accounted for by the fact that breast carcinoma is causing metastases most frequently. a frequent finding in the cases of metastatic carcinoma is enophthalmos that is associated with scirrhous carcinomas. we present two cases of orbital metastatic tumors in which the primary tumors were a basal cell carcinoma and a cutaneous malignant melanoma. results: as to the metastasis from a basal cell carcinoma, the primary tumor was located in the external angle of the eyeball and metastasized the external / of the orbit. in the case of malignant melanoma, the primary tumor was located in the upper lid and invaded the orbital floor and fat. in both patients eyeball enucleation was performed. conclusion: we chose to present these cases given the differential diagnostic challenge and rarity of their location. uveal melanoma a. dumitriu * , s. dumitriu * umf iasi, dept. of neurology, romania objective: uveal melanoma which arises from melanocytes residing in the stroma is the most common primary intraocular cancer in adults. we report a case of uveal melanoma presenting as complicated cataract in a years-old male. results: the right eye was blind for months. the patient underwent extended enucleation and histopathology was consistent with uveal melanoma. conclusion: we present this case in order to provide the medical community a basic reference that would help to make further progress in this rare disease, which remains difficult to treat. results: there were more women than men ( % versus %). metastases developed in % (total group mean follow up of . year). mixed tumors were most common overall ( . %): for non metastasizing tumors there were . % mixed, . % fusiform and . % epithelioid types. for metastatic tumors there were . % mixed, . % epithelioid and . % fusiform types. the difference between cell type and metastatic development was significant in all but epithelioid compared with mixed tumors. epithelioid type had a relative risk of mortality of . and mixed had . compared to fusiform cell type. conclusion: our patients were younger, with larger tumors and different histological proportions from those of the collaborative ocular melanoma study. five year survival times were similar to those for europe. uveal melanoma between preserving vision and prolonging survival. pathological contributions to a better clinical management m. mera * , l. blaga * umf cluj-napoca, anatomic pathology, romania objective: uveal melanoma has a high metastatic potential which is invariably fatal. there is an ongoing debate on the impact of ocular treatment on metastatic disease and survival. improved prognostication is needed to identify cases that could avoid unnecessary loss of vision while avoiding unethical care. our study is aimed at contributing to the developing of reliable tools to assess the metastatic risk. method: an accurate prediction should include both clinical features and histologic parameters as biopsy techniques continuously advance. cases of uveal melanoma, either reviewed or prospectively managed in our pathology department, were included in a log-logistic multivariate survival model that we have considered would best accomodate our data. the performance of the model was assessed by bootstrap re-sampling. results: extravascular matrix patterns, optic nerve invasion, tumorinfiltrating lymphocytes, tumor cytomorphology, nucleolar size and the mitotic count together with initial visual acuity have been found to be the most important predictors, ahead of the traditional tnm stage. the results are provisional but encouraging. conclusion: there is still need for multidisciplinary approach and multicenter collaboration in an effort to elucidate the uncertainty related to the best management of one of the most traumatising types of cancer. orbital hemangiopericytoma: a case report e. omoscharka * , k. lankachandra * university of missouri, dept. of pathology, kansas city, usa objective: hemangiopericytomas are rare vascular tumors arising from zimmerman's pericytes, which ubiquitously surround blood capillaries and post-capillary venules. they rarely occur in the orbit, accounting for only % of all orbital neoplasms. in most cases the primary presentation is progressive proptosis. method: a -year-old female was first seen for the evaluation of a right orbital mass which has been causing proptosis. associated symptoms included peripheral vision loss in the right eye, persistent headache with occasional balance problems. a palpable, . × . cm well circumscribed mass with a smooth surface, resting on the inferior orbital wall was completely removed through right anterior orbitotomy. h&e stained histologic sections were studied. in addition, tissue sections were subjected to immunohistochemical stains for cd , cd , bcl , sma, desmin, ema and s- . results: the mass was composed of spindle cells with very low mitotic activity. staghorn vascular channels were evident, and in several areas the tumor cells invaded the pseudocapsule. the tumor cells were positive for cd , cd and bcl- supporting the histopathologic diagnosis of benign hemangiopericytoma. conclusion: orbital hemangiopericytoma is a slow growing tumor with a potentially malignant behavior, and a high local recurrence rate if incompletely excised. complete, intact removal prevents tumor recurrence and provides a good outcome. expression of sod family in rat lacrimal gland after intermittent light exposure c. l. zamfir * , f. e. zugun, e. cojocaru, r. o. temneanu, r. folescu, m. spataru * university of medicine iasi, dept. of histology, romania objective: any disturbance of chronobiological rhytms represents a potential stressor, acting like a strong oxidant trigger. sod family (cuzn-sod, mn-sod and ec-sod), is one of the most significant enzymatic complexes involved in antioxidant defense. monitoring local sod distribution in lacrimal gland after intermittent light exposure can be able to provide insights into the distinct links of antioxidant adaptative mechanisms.so long as lacrimal gland morphology and functions are dependent to a normal light exposure, mobilisation of its own antioxidant resources, especially sod, is an usefull starting point in antioxidant ophtalmic therapy. method: immunohistochemistry was performed in microscopic analysis of glandular fragments prelevated from male wistar rats, randomized in control/intermittent light exposed groups for days. there have been used specific antibodies for each enzymatic member of sod family. blood samples were prelevated to control sod levels. the study respected all imposed ethical criteria. results: lacrimal glandular tissue exhibits a strong cuzn-sod immunoreactivity, a moderate one for mn-sod and only a small ec-sod reactivity, while the level of sanguin sod is high, as a marker of oxidative aggression. conclusion: oxidative stress may be engagged in a deep alteration of lacrimal gland. mobilisation of sod, depending on their specific glandular location and tissular receptivity, should be regarded as a promising alternative for antioxidant therapy. tuesday, september , . - . objective: liposarcoma is the most commonly diagnosed soft tissue sarcoma in adults and occurs predominantly in the lower limbs and retroperitoneum. primary mediastinal liposarcomas are rare accounting for less than % of all mediastinal tumors. method: we report a retrospective study of cases of mediastinal liposarcoma during an -year period. diagnosis was made on mediastinal biopsy in cases and on resected specimen in the other cases. results: there were men and a women ranging in age from to years, explored for respiratory symptoms. radiological findings showed an anterior inhomogeneous mediastinal mass in all cases with extension to left hemithorax in one case. a surgical resection was achieved in only cases but was incomplete. histopathologically, tumors were classified into well differentiated lipoma-like liposarcoma, one myxoid liposarcoma and one mixed liposarcoma (sclerosing liposarcoma with myxoid liposarcoma). all patients received adjuvant radio or chemotherapy. one of them presented lung metastasis during the follow up and another died from respiratory failure. the two other are still alive. conclusion: mediastinal liposarcomas include a heterogeneous group of bulky tumours, the progression of which depends on the histological type. histopathologic examination is always necessary as much for diagnosis as prognosis. mediastinal epithelioid hemangioendothelioma with a highgrade clinical course a. konstantinova * , k. shelekhova, v. f. klimashevsky * st. petersburg state university, russia objective: epithelioid hemangioendothelioma (eh) is a rare neoplasm usually presenting in soft tissues. about twenty cases of eh have been reported in the mediastinum. most of these mediastinal eh exhibited an indolent course. results: a -year-old woman presented with focally encapsulated mass, . × cm in size, in the anterior mediastinum. the tumour of bone density was adhered to the lung tissue and occluded left subclavian vein. microscopically, the tumor consisted of foci of so-called blister cells typical for eh, anastomosing cords of small epithelioid cells embedded in myxohyaline matrix with haphazardly distributed metaplastic bone and hemorrhagic cellular stroma. spindling of the tumor cells was prominent. the tumor cells demonstrated moderate atypia, but mitotic figures were not found. immunohistochemically, cells of primary tumor were positive for fli , vimentin, cd and cd . focal staining with ema was observed. multiple metastases were subsequently found in the liver and lungs. metastatic deposits had the same morphology as a primary tumor. we present the case of rare mediastinum epithelioid hemangioendothelioma with peculiar histological features such as prominent spindling of neoplastic cells and abundant metaplastic bone formation in aggregate with aggressive clinical behavior that exhibited a profound metastatic poteintial. objective: thymic carcinomas comprise rare malignant epithelial neoplasms, which exhibit a disproportionately large variety of growth patterns. we present three cases of primary thymic carcinomas, including two squamous cell carcinomas and one papillary adenocarcinoma. method: all three patients were males, aged , and years, and presented with mediastinal masses measuring cm, . cm, . cm in maximal diameter respectively. results: microscopically the first two tumors were poorly differentiated squamous cell carcinomas, immunohistochemically positive for cd and cd , whereas the third tumor was a papillary adenocarcinoma, positive for cd and negative for cd and ttf- . immunohistochemical features of the tumors were supportive of thymic derivation. conclusion: primary thymic carcinomas are rare malignant tumors with clear-cut atypia, largely lack of organotypic features and a very diverse differentiation. squamous cell carcinoma is the most frequent subtype. they are often a diagnosis of exclusion, since metastases to thymus and anterior mediastinum, mainly from the lung, are far more common. immunoreactivity to cd , cd and cd may support the thymic origin of neoplastic squamous cells. treatment options include surgical excision, radiation and/ or chemotherapy depending on tumor stage and patient's condition. the prognosis is generally poor with squamous cell carcinomas having a slightly more favorable outcome. wednesday, september , . - . objective: surgical blood loss can lead to ineffective tissue perfusion of vital organs. physiologic solution chosen for blood volume replacement may be determinant for preserving renal integrity. our aim is to study kidney histopathological changes in a hemorrhagic model, followed by intravascular volume replacement with ringer's lactate or hydroxyethylstarch (hes) / . solutions. method: thirty one pigs under general anaesthesia with propofol and remifentanil underwent haemorrhage at a volume of ml kg- , over min. after a waiting period of min, intravascular volume was replaced using hes / . (g ) and ringer's lactate (g ). one hour after, pigs were euthanized with iv potassium chloride and sixty two renal samples were taken for histopathological examination, using pas staining. renal damage was assessed for glomerular, tubulointerstitial and vascular lesions. results: mean arterial pressure reached mmhg after bleeding, and recovered for values above mmhg in both groups after volume replacement. histopathological lesions observed in g were more frequent than those in g . conclusion: hes / . may reduce the incidence of histopathological lesions secondary to renal hypoperfusion after severe bleeding when compared with ringer lactate. results suggest that the reestablishment of intravascular volume with hes / . may preserve renal integrity secondary to blood loss. expression of aeg- , p and its clinicopathological significances in the malignant lesions of renal cell carcinomas h. erdem * , m. oktay, u. yildirim, a. k. uzunlar, m. a. kayikci * duzce university, dept. of pathology, turkey objective: astrocyte elevated gene- (aeg- also known as metadherin) is associated with various aspects of tumor malignancy. the aim of this study was to investigate p relationship between aeg- and prognostic parameters. method: this study was made paraffin blocks (tumoral samples), which were histopathologically diagnosed at department of pathology from to . subtypes of the cases were ( %) clear cell renal cell carcinomas (rcc) and ( %), non-clear rcc respectively. by immunohistochemical analysis, we investigated aeg- , p expression in carcinomas of kidney and we determined its relationship with clinicopathological parameters. results: there were significant relationship between increased aeg staining score and tumor capsule (p= . ), lymphovascular invasion (p= . ) and significant relationship between the increased diameter with the increase of p (p= . ). there were significant correlation between increased diameter of tumor and degree of increase the fuhrman (p= . ). conclusion: high aeg- , p expression correlates with prognostic parameters in the rcc. in addition, aeg- , p expression in rcc may be associated with tumor progression. relationship of cd , cox- and p in renal cell carcinomas with survival and other prognostic parameters: a tissue microarray study h. erdem * , u. yildirim, a. k. uzunlar, m. a. kayikci * duzce university, dept. of pathology, turkey objective: renal cell carcinomas (rcc) is the seventh most common human malignancy. rcc is now recognized to be a complex neoplasm consisting of several different tumor subtypes, each with distinct genetic and clinical features. the aim of this study was to investigate the expressions of cyclooxygenase- (cox- ), p and cd in rcc that has different clinicopathologic characteristics. method: this study was conducted on a total of paraffin embedded kidney samples (tumoral samples), which were histopathologically diagnosed at department of pathology from to . ihc stains for cox- , p and cd were performed on tissue microarray using standard procedures. results: there were significant correlations between cox- and subtype (p= , ), cox- and diameter (p= , ). significant relationships were found between p and age (p= , ), p and diameter (p= . ). besides, there were significant correlations between cd and furhman grade (p= , ). conclusion: cd , cox- , p expression correlates with prognostic parameters in the rcc patients. in addition, cox- , p , cd expression in rcc may be associated with tumor progression. objective: ebv related malignancies (skin cancers, lymphomas, kaposi sarcomas) complicates organ transplantation ebv-associated smooth-muscle tumors are rare. method: among kidney grafted patients, three developed ebv-smt. case . female y, with ebv-smt (generalized) case . female y, breast phylodes sarcoma, reviewed diagnosis: ebv-smt. case . male year, severe abdominal pain, gut tumor-like nodules were excised suspection of tbc. ebv-smt was microscopic diagnosis. results: progressive weight-loss all patients, chronic cough in patient , chest x ray multiple pulmonary lesions, on ct-scan paravertebral lesions. transthoracic biopsy: spindle cells proliferation with mixed cellularity eosinophilic cells intermingled fascicles resembling smooth muscle, mononuclear inflamatory cells and capillarie evoqued myofibroblastic tumor. no mitosis, mild nuclear atypia. negative immunohistochemestry: cd , cd , cd , ema, cytokeratin, s , cd . alpha-smooth muscle actin diffusely positive, evb-lmp negative. in situ hybridization : ebv + nuclei. ebv-smt was established. conclusion: smt in immunocompromised are ebv associated. primary target of ebv are b lymphocytes, may infect smooth-muscle through receptor for ebv cd mechanisms of ebv related-tumor genesis is integration of ebv-dna within alk locus in tumor cells. alkgene rearrangement and expression; associated with inflammatory myofibroblastic tumors, anaplastic large-cell lymphomas etc. clonally of multifocal ebv-smt using southern blot showed, multiple tumors constitute independent primary lesions. method: the degree of glomerulosclerosis was scored into - , mesangial proliferation was scored into (absent) and (present), and the degree of crescents was scored into - . glomerular injury score (gis) was obtained by adding the above scores and grouped into categories (group , score - ; group , - ; group , - ). results: serum creatinine level was significantly increased ( . ± . , . ± . , . ± . mg/dl, p= . ), estimated glomerular filtration rate (egfr) was significantly decreased ( . ± . , . ± . , . ± . ml/min, p= . ) and proteinuria was significantly increased as gis increased ( . ± . , . ± . , . ± . g/ h, p= . ). interstitial fibrosis of more than % of cortical area increased as gis increased ( . , . , and . %, p< . ). when a multivarate analysis was done, gis group was the most important predictive factor of egfr (p= . ) and proteinuria (p= . ). objective: the aim of the study is to evaluate the histopathological finding and the c d staining patterns of the patients who were biopsied due to graft dysfunction (gd) after initial well-function within month of deceased donor kidney transplantation (ddkt). method: histological analysis and c d immunostaining were performed on needle core biopsies. results: thirty-four patients (mean age: ± years, male: %) were included. histological analysis revealed acute rejection (ar) (n: ), acute tubular injury (ati) (n: ), allograft infection (n: ), borderline changes (n: ), normal morphology (n: ), and donor-related changes (n: ). c d staining was detected in % ( of ) biopsies; staining patterns were diffuse (n: ), focal (n: ) and minimal (n: ). diffuse (n: ) and focal (n: ) c d positivity accompanied of cases of ar. in remaining patients having non-ar histological picture, diffuse or focal c d positivity were detected in and cases, respectively. peritubular capillaritis was detected in . % ( / ) of biopsies, of which four had c d diffuse, one had c d focal positive. conclusion: beyond cold ischemia time-induced ati, immunological causes including antibody mediated process may play an important role in early impairment of graft function after ddkt. immunohistochemical analysis of the renal interstitial fibroblasts s. kostadinova-kunovska * , r. jovanovic, m. bogdanovska, v. janevska, l. grchevska, g. petrushevska * faculty of medicine, inst. of pathology, skopje, macedonia objective: renal fibrogenesis is a process common to all progressive kidney diseases. the main executive cell of this process is the fibroblast, by secreting and remodeling the extracellular matrix. the number of fibroblasts is minor in healthy kidney interstitium, but it increases during the process of fibrosis. their morphology and immunophenotype vary due to different intrinsic and extrinsic factors, thus making their identification and visualization, as well as determination of their origin, very difficult. method: we performed morphological and immunohistochemical analyses on kidney biopsies with primary glomerulopathy and interstitial fibrosis, using the following antibodies: vimentin, α-sma, s a , cadherin and cd . results: interstitial fibrosis with focal, rather than diffuse distribution, was present in all analyzed cases. the total interstitial fibroblast population was positive for vimentin, majority of the cells were positive for s a , and a smaller proportion of cells were positive for α-sma, cadherin and cd . furthermore, different cells in the fibroblastic population showed positivity for different markers. conclusion: the above stated observations contribute to the theory that different subpopulations of fibroblasts, with different origin, take part in the renal fibrogenesis. soluble epoxide hydrolase inhibition reduce blood pressure and organ damage independently of nitric oxide (no) in mice with goldblatt two kidney, one clip model ( k c) p. kujal * , l. kopkan, l. cervenka, z. vernerova * charles university, third faculty of medicine, prague, czech republic objective: investigate the role of no in the blood pressure (bp)-lowering effects of soluble epoxide hydrolase (seh) inhibition in k c model. method: the endothelial no synthase gene knockout mice and their wild-type controls were used. renal concentrations of epoxyeicosatrienoic acids (eets) and dihydroxyeicosatrienoic acids (dhets) were measured in nonclipped kidney. renal no synthase activity was determined by measuring the rate of formation of l-[ c]citruline. results: treatment with the seh inhibitor caused the same bp decrease that was associated with increase in daily sodium excretion in both types of mice. the ratio of eets/dhetes in the nonclipped kidney was increased and did not alter renal nos activity. seh inhibition reduced significantly glomerular and tubulointestitial injury. conclusion: bp-lowering effects of chronic seh inhibition in k c mice are associated with normalization of the reduced availability of biologically active eets in the nonclipped kidney and their direct natriuretic actions. total inflammation in -month surveillance renal transplant biopsies is associated with decreased renal function and de novo class donor specific antibody z. laszik * , s. chandran, f. vincenti * ucsf, dept. of pathology, san francisco, usa objective: the goal was to correlate inflammation and acute rejection (ar) with renal function and antibody status in -month renal transplant surveillance biopsies. method: relative risks of inflammation and ar in month biopsies was calculated by multivariable poisson regression. results: ar was seen in . % (n= ), borderline change in . % (n= ), and c d positivity in . % (n= ) of all biopsies. total cortical inflammation (ti), present in . % (n= ) cases, was associated with ml/min/ . m lower egfr at months ( % ci= − . , − . ). de novo hla class was identified in . % (n= ) and class dsa in . % (n= ), with most having mfi values < . increased risk of ar was seen with higher levels of de novo class (rr . , % ci= . , . ) or class dsa (rr . , % ci= . , . ). class (but not class ) dsa was associated with a higher risk of ti (rr . for ti-score ≥ , % ci= . , . ) at months. conclusion: both ti and ar in -month surveillance kidney transplant biopsies are strongly associated with de novo hla class dsa. total inflammation at months correlates with decreased kidney function. objective: tenofovir disoproxil fumarate has been used in the treatment of hiv patients producing occasional renal dysfunction and fanconi syndrome. method: a -year-old patient was referred with severe acute renal failure and important metabolic acidosis and glycosuria with normoglycemia in urine analysis, altogether with urinary alkaline ph and proteinuria with a protein/ creatinine ratio of . he was hiv and b positive diagnosed years earlier. his medication regimen consisted of lopinavir, ritonavir, tenofovir and lamivudine. the patient had a history of nausea, vomiting and some diarrhea with low fluid intake for a week. besides slight dehydration, the physical examination was unremarkable. renal ultrasound showed normal kidneys. with adequate fluid restoration, the renal function improved but other metabolic alterations like nephrogenic diabetes remained. results: renal biopsy revealed toxic acute tubular necrosis predominantly involving proximal tubules with prominent eosinophilic inclusions within proximal tubular cell cytoplasm, which represented giant, abnormal mitochondria, consistent with tenofovir toxicity. some histochemichal studies (cox and sdh) were performed. conclusion: although prospective clinical trials have demonstrated a low incidence of renal toxicity with tenofovir, there are several such reports in the literature. current recommendations suggest close monitoring of renal function after initiation of therapy with tenofovir, specially at the beginning and when used in combination with certain antiretroviral agents. objective: nutcracker syndrome (ns) is caused by compression of the left renal vein between the aorta and superior mesenteric artery. the main presenting symptom of this rare entity is haematuria, with various degrees of proteinuria. the diagnosis of ns syndrome is primarily by imaging and can sometimes be challenging. method: a -year-old male was referred to nephrology with a months history of intermittent gross haematuria. all blood test including blood cell count, biochemistry, immunoglobulin electrophoresis, antinuclear antibody were normal. urinary analysis revealed numerous red blood cells and a protein/creatinine ratio of . . a previous cystoscopic examination was normal. renal ultrasound revealed a diffuse increased echogenicity. results: renal biopsy showed a normal histology with no immunofluorescence deposits. ct scan revealed dilatation of the distal left renal vein with narrowing between the superior mesenteric artery and the aorta. conclusion: ns is a rare entity causing haematuria. there are few reported cases with histology, although it usually shows no abnormalities. the proposed mechanism for the haematuria is an abnormal communication between the submucosal venous plexus and the calyceal system presumably induced by renal venous hypertension. banff initiative for quality assurance in transplantation (bifquit): reproducibility for bkv immunohistochemistry in renal allografts m. mengel * , s. chan, j. climenhaga, h. regele, b. colvin, p. randhawa * university of alberta, laboratory of medicine, edmonton, canada objective: detection of bk virus associated large t-antigen is crucial for the diagnosis of polyomavirus nephropathy. method: in an international multi-centre trial we assessed the inter-observer and inter-laboratory variability for bk immunohistochemistry. a tissue microarray was constructed comprising specimens representative of the whole analytical spectrum from negative over mild to strong sv positive cases. participants at centers stained the tma slides using local protocols. participants evaluated their slides following a provisional banff grading schema. details regarding local staining protocols and evaluation scores were collected online. stained slides were returned for centralized panel re-evaluation. weighted kappa statistics were used to determine the variability. results: the bk inter-observer reproducibility was substantial (mean kappa . ), but inter-laboratory reproducibility was below chance (kappa − . ). separating components of bk evaluation schema into stain intensity and stain percentage showed no significant improvements in reproducibility. however, collapsing the proposed bk scoring schema into a simple positive/negative call improved bk inter-laboratory variability to . . conclusion: these results indicate a significant variability between laboratories for detecting the sv large-t antigen by immunohistochemistry in paraffin sections. any proposed grading schema for bk nephropathy, which is dependent on percentage and intensity of nuclear staining, will essentially not be reproducible between laboratories. objective: cryopyrin-associated periodic syndrome (caps) is a rare hereditary inflammatory disorder with three differents phenotypes: familial cold autoinflamatory syndrome, muckle-wells syndrome and neonatal-onset multisysten inflamtory disease caps results from a mutation of the nlrp gene ( q ) coding for cryopyrin, which forms intracellular protein complexes (inflammasomes). results: case report: year old women with chronic renal disease stage (creatinin , mg/dl and proteinuria mg/ h) who developed urticarial episodies since months old related to cold exposure. after years old patient describe associated to these episodios bilateral arthritis (knes, ankles and elbows), conjunctival inflammation, shivers, and asthenia, more frequently in winter and precipitated by cold exposure, air conditioning, stress and menstruatión. aditionaly the patient developed in last years bilateral hypoacusis a kidney biopsy showed a amorphous, acellular and acidophilic material congo red positive deposits at interstition, arteries and arterioles and less frequent at glomeruli. this material displays apple green birefringence by polarizad light microscopy. diagnosis: secondary renal amyloidosis conclusion: the clinico-pathologial findings of this case are compatible with muckle-wells syndrome. secondary amyloidosis is a severe complication which occurs in % of muckle-wells cases. amyloidosis is cause by increase of c-protein and a amyloid during the episodies before described and deposition of the a amyloid in differents tissues. glomerulocystic disease associated with thrombotic microangiopathy in two kidney allografts j. m. mosquera reboredo * , e. vazquez martul * complexo hospitalario universitario, dept. of pathology, la coruña, spain objective: glomerulocystic kidney disease (gckd) is a rare condition usually congenital and reported in infants and young children. only few cases of adquired gckd had been reported often following hemolytic uremic syndrome (hus). method: histological study of two kidney graft explants. results: we present two cases of kidney transplant who developed hus in allografts. both cases showed at the histological examination typical vascular and glomerular changes of thrombotic microangyopathy (tma). a cystic transformation with increase of urinary space and retraction of glomerular tuft was frequently observed. chronic transplant vasculopathy was found in the two cases. humoral active rejection was also demonstrate in one case with moderate peritubular capillaritis and glomerulitis and diffuse c d deposition at peritubular capillaries. conclusion: in a few cases gckd appear to develop after another kidney disease includes single case reports of gckd associated with mesangial glomerulonephritis, wegener's granulomatosis, progressive systemic sclerosis, after hus (include some case in adult patient). our two cases represent a initial stage of adquired gckd. the ethiopathogenetic relationship is not clear but some authors propous that cystic dilatation of the bowman's capsule associated to tma/ hus may be secondary to ischemic mechanism. case report: cytomegalovirus gastritis in renal transplanted man f. noroozinia * , k. makhdoomi, a. esmaeili, a. saffarifard * emam khomeini hospital, dept. of pathology, urmia, iran objective: cmv is an important pathogen in immunocompromised hosts, including patients with aids, neonates and transplant recipients. this infection develops in - % of transplant patients. upper gi symptoms in solid organ recipient are common ( %) and clinical signs are more serious in % of cases. method: we report a year old man with end stage renal disease underwent kidney transplantation from a cmv negative donor on june . after . months he admitted with fever, generalized body pain, oral aphtous ulcers and epigastric pain accompanied by malaise. endoscopic examination revealed multiple antral erosions with surrounding erythema. clinicopathological investigations revealed cmv viremia with a ig-m antibody titer and cmv gastritis confirmed by histopathological examination. results: the patient was started on intravenous (iv) ganciclovir mg/kg per day every h initially for weeks, afterwards the fever decreased; cell blood counts throwback to normal ranges and general condition of the patients improved. conclusion: cmv infection develops in - % of the transplant patients. the colon and stomach are the most common sites of gastrointestinal infection. though the rate of gi affliction by cmv is high, localization to the gastric antrum is not common. immunohistochemistry study of c-kit expression in renal cell carcinoma f. noroozinia * , f. abbasi, z. yekta, f. meisami, a. saffarifard * emam khomeini hospital, dept. of pathology, urmia, iran objective: renal cell carcinomas include about - % of adults neoplasms and - % of all renal tumors. in many cases, it is possible to distinguish. rcc subtypes on the basis of hematoxylin-eosin staining alone. however, overlapping morphologic features pose some difficulties in making a proper diagnosis. to render an accurate diagnosis, additional methods like immunohistochemichal staining against c-kit have been recommended. method: we reviewed cases of rcc diagnosed during years. formalin fixed, paraffin embedded specimens was available in cases. the expression of c-kit was evaluated using immunohitochemistry. results: six cases of clear cell type ( . %), of papillary type ( . %), and of chromophobe type ( %) were positive for c-kit that considering chi-square test there is significant relevation between rcc's subtypes and c-kit expression (p: . ). from cases with renal vein invasion, showed positive expression of c-kit ( . %) and in cases with no venous invasion, c-kit expression was detected in ( . ), so no significant relation was found between renal vein invasion and c-kit expression. conclusion: the expression of c-kit in rcc may have diagnostic significance. objective: igg -rsd shows abundant igg -positive plasma cells, diffuse fibrosis, and increased serum igg levels. although igg -rsd typically results in autoimmune pancreatitis (aip), any organ may be involved. thus, igg -rsd tin often goes unrecognized in the absence of aip. this is an igg -rsd tin case with mediastinal lymph node and pulmonary involvement. method: a -year-old male presented with rapidly progressive renal failure, hypergammaglobulinemia, hypocomplementemia, and enlarged mediastinal lymph nodes and bilateral pulmonary nodules on ct. renal and mediastinal lymph node biopsies were performed and igg ihc was done on both after standard techniques. results: the renal cortex and medulla showed diffuse interstitial fibrosis with tubular atrophy and abundant plasma cells ( igg -positive cells/hpf), numerous lymphocytes and some eosinophils. if showed igg, c , kappa, and lambda granular deposits in tubular basal membranes and bowmann capsules. lymph node follicular and paracortical hyperplasia with abundance of mostly igg positive plasma cells was seen. an igg -rsd diagnosis was rendered and high serum igg levels were demonstrated. steroid therapy resulted in lymph node and lung nodule reduction. conclusion: tin with abundant plasma cells and diffuse interstitial fibrosis, especially if accompanied by hypergammaglobulinemia, hypocomplementemia, or extrarenal involvement, should suggest igg -rsd and prompt serum igg level determination and renal igg ihc. objective: a -year-old woman was admitted for chronic renal failure. clinical examination was normal. biological explorations showed creatinin clearance around ml/min, tubular proteinuria with bence jones κ protein. serum immunoelectrophoresis identified abnormal monoclonal immunoglobulin g and κ-light chains (lc). bone marrow histology was normal. method: kidney biopsy revealed diffuse intracytoplasmic vacuoles in the proximal tubules resembling osmotic nephrosis. distal tubules, glomeruli, vessels and interstitial compartment were normal. immunofluorescence (including anti-κ and -λ staining) was negative. electronic microscopy (em) revealed intracytoplasmic immunoglobulinic crystals containing κ lc inside the vacuoles, leading to the diagnosis of light chain proximal tubulopathy (lcpt). results: lcpt is a rare complication of dysglobulinemia. it may be associated with crystals within the cytoplasm of proximal, less frequently distal, tubular cells, consisting more frequently in κ lc. rarely, diffuse tubular vacuolization is present, often indistinguishable from osmotic nephrosis. in our case, there was no proximal tubular dysfunction and immunofluorescence was negative. the first evocated diagnosis by light microscopy was "osmotic nephrosis". however, we failed to identify any causal factor. finally, the diagnosis was performed by immunoem. conclusion: in conclusion, before a picture of osmotic nephrosis without obvious cause, em and immunoem may be helpful for the diagnosis of lcpt, often revealing a dysglobulinemia. opportunistic infections in renal transplantation -a case series r. sampaio * , r. dias, p. farrajota, a. coelho, t. almeida, a. duarte, j. r. vizcaino * anatomia patológica, valpaços, portugal objective: oporto's hospital centre is one of the portuguese hospitals with more renal transplantation activity (performed since ). although increasingly rare, opportunistic infections (oi) in transplanted patients remain a major diagnostic challenge and are associated with high mortality rate. method: in order to evaluate the incidence of oi in renal transplant patients and to identify the location of infection, the respective techniques of diagnosis used and the survival time after infection, we conducted a retrospective study using the nephrology department's database on renal transplants. we consulted the registries from to . results: we investigated cases and found cases of oi caused by herpes virus (n= ), cytomegalovirus (n= ), polyomavirus (n= ), aspergillosis (n= ), alternaria (n= ), mucormycosis (n= ), candidiasis (n= ), tuberculosis (n= ), cryptococcus (n= ) and pneumocystis (n= ). the lung and urogenital system were the most affected systems. kidneys were affected in cases respectively by mucormycosis, tuberculosis and cryptococcus. of all the cases of oi, were diagnosed by the department of anatomic pathology ( by biopsy; by cytology; by biopsy and cytology). conclusion: in many cases the diagnosis could only be performed through histologic/cytologic examination. prompt diagnosis and treatment are necessary to avoid life threatening complications and may greatly improve prognosis. papillary renal cell carcinoma with osseous metaplasia and bone marrow elements: a case report l. l. santos * , a. polónia, r. henrique, c. lobo * ipo porto, dept. of pathology, viana do castelo, portugal objective: renal cell carcinomas might display foci of calcification and even ossification. this rare event has been reported mostly in the clear cell variant. herein, we present the case of a year-old man, previously diagnosed with colon cancer, incidentally found to have a calcified mass in the kidney, which was interpreted as non-characteristic for renal cell origin. results: radical nephrectomy was performed. a . × . × . cm tumor was found, with a heterogeneous brown cut surface, containing areas of necrotic tissue and extensive calcifications. histopathologic examination disclosed papillary structures covered by small cells with scant cytoplasm, dispersed among mature bone tissue enclosing marrow elements. epithelial tumor cells were imunorreactive for cytokeratins, cd and pax , and negative with hmb- . hale`s colloidal iron was negative. trisomy of p, p and p was detected by fish. a diagnosis of prcc type , fuhrman grade , with extensive osseous metaplasia was rendered. conclusion: ossification of renal cell tumors is rare, occurring mostly in clear cell type and the underlying mechanism is unclear. these tumors show atypical radiological features and might be confused with non-renal cell tumors. to the best of our knowledge, this is the first report of prcc with osseous metaplasia and bone marrow elements. the effect of doxycycline on glomerulosclerosis in / renal ablation s. sarioglu * , d. sonmez, a. celik, f. saglam, o. yilmaz, e. koraltan, z. cavdar, g. oktay * dokuz eylul university, faculty of medicine, izmir, turkey objective: the effect of matrix metalloproteinase (mmp) inhibitors in segmental sclerosis is unknown. the aim of this study is to investigate the effect of a mmp inhibitor, doxycycline, on glomerulosclerosis (gs) in renal ablation nephropathy. method: fourteen of the female wistar albinos were / nephrectomised. doxycyline was given to half of each group ( mg/kg/day total days). after sacrification, the gs, mmp- , mmp- , timp- expressions were analyzed histopathologically. pro and active mmp- and - were analyzed by gelatin zymography. timp- and timp- were measured with elisa assay. results: doxycycline administration to the / nephrectomy group improved gs, but did not inhibit glomerular mmp- or cortical pro-and active-mmp- and pro-mmp but increased timp- and timp- expression in all groups in cortical tissue. mmp- expression and gs were increased in all groups receiving doxycycline. conclusion: we have demonstrated improved gs in renal ablation model by doxycycline administration but also doxycycline has an unexpected adverse effect. the effect of doxycycline on the expression of mmp- and - cannot explain the improvement in gs, but increased cortical tipm- and - may be an important contributing factor for inhibition of mmps. digitally reinforced hematoxylin-eosine polarization in diagnosis of renal amyloidosis s. sen * , b. sarsik * ege university, faculty of medicine, izmir, turkey objective: systemic amyloidosis is a rare disorder, characterized by extracellular accumulation of congo-red (cr) positive fibrillar amyloid protein deposits. the kidney is the most commonly affected organ by systemic amyloidosis. cr staining which increases the positive birefringence of the weakly birefringent unstained amyloid. in this study we investigated potential power of digitally reinforced birefringence of routine hematoxylin-eosine (he) slides on the renal biopsies. method: we reviewed he stained slides for polarization. sixty five amyloidosis cases were diagnosed by renal biopsy from to at our laboratory. all biopsies were evaluated by light and immunofluorescence microscopy. slides were reevaluated blindly using a microscope (olympus bx ) attached polarization filter and connected to a digital camera (olympus dp , sal). depositions which show green birefringence on he with digitalized microscopy were considered as positive and results were confirmed using cr. results: of the cr confirmed amyloid positive biopsies, showed green birefringence with he. of the cr confirmed amyloid negative biopsies, two were considered as false positive. the sensitivity, specificity, positive and negative predictive values were estimated as %, %, % and %, respectively. conclusion: we concluded digitally polarized he sections can be used as a fast and first step diagnostic method for renal amyloidosis. sirolimus ameliorates cyclosporin-induced nephrotoxicity in a rat modelfocus on renal lesions, oxidative stress, inflammation, proliferation and angiogenesis j. sereno * , a. m. romão, m. teixeira, b. parada, c. mega, h. vala, e. t. lemos, f. teixeir, f. reis * ibili, medicine faculty, laboratory of pharmacology and experimental therapeutics, coimbra, portugal objective: sirolimus (srl) have been pointed as a feasible option for minimize the use of cyclosporin a (csa), especially because of putatively less nephrotoxicity. this study aimed to characterize the histological lesions and the molecular pathways implicated in csa-induced nephropathy and prevention when converted to srl. method: the following groups (n= ) were tested during weeks: vehicle, csa, srl and conversion (csa weeks + srl weeks). bp and hr were monitored. blood was collected and kidney gene expression of markers of inflammation, proliferation, angiogenesis and oxidative stress were assessed. histology: h&e, pas and gordon & sweets staining. statistics: anova and post´hoc tests (p< . ). results: after week of csa treatment, there was important kidney lesions, including glomerular, tubulointerstitial and vascular: mesangial expansion, atrophy, bowman capsule enlargement, hyaline cylinders formation, tubular calcification and vascular congestion, as well as arteriolar vacuolization and arteriolosclerosis. conversion to srl, ht and tachycardia were reduced, accompanied by amelioration of kidney dysfunction and lesions (glomerulosclerosis and tubulointerstitial fibrosis), together with reduction of oxidative stress, proliferation and angiogenesis. conclusion: in conclusion, srl ameliorates csa-induced nephrotoxicity in a rat model, which might be due to protection against oxidative stress, proliferation and angiogenesis, but these mechanisms deserve better exploitation. acknowledgements: fct(sfrh/bd/ / ). non-lupus "full-house" nephropathy in serbian population in last six years j. vjestica * , s. cirovic, s. tatic, r. naumovic, s. simic-ogrizovic, j. markovic-lipkovski * inst. for pathology, medical faculty, belgrade, serbia diffuse glomerular and sometimes focal mesangial staining of immune complex depositas (iga, igg, igm, c , and c q), also known as "full-house" pattern commonly indicates lupus nephritis. however, some non-lupus nephropathy also can be present with a "full-house" immunofluorescence pattern, mimicking lupus nephritis. the aim of this study was to define the clinicopathological spectrum of originally non-lupus "fullhouse" nephropathy. biopsies from january till december were analyzed in order to identify all renal biopsies cases showing "full-house" pattern. the study included "full-house" renal biopsy diagnosiss. from all analyzed cases ( %) had lupus nephritis expressing "full-house" pattern and ( %) cases had non-lupus "full-house" nephropathy. in the absence of clinical and/or serological evidence of systemic lupus erythematosus (sle), at the time of renal biopsy, in cases diagnose was membranous glomerulonephritis (gn), than mesangioproliferative gn, membranoproliferative gn, iga nephropathy, rapidly-progressive gn and membranous/membranoproliferative gn cases. nonlupus "full-house" nephropathy is present in broad spectrum of different types of gn, predominantly in cases of membranous gn. the possibility of "full-house" nephropathy preceding the emergence of overt sle remained to be clarified. objective: although the renoprotective effects of prostacyclin have been demonstrated in many studies, the protection mechanisms of prostacyclin in chronic kidney disease, especially at the terminal stage, are still remained unclear. in the present study, we performed pathological and pathphysiological analyses of prostacyclin renoprotective effects using a stable prostacyclin analogue, beraprost sodium, in the disease kidney of anti-gbm glomerulonephritis (gn) rats. method: beraprost was administrated from weeks after induction of gn. the condition of renal microvascular network and localization of apoptotic cells were examined using renal vascular corrosion casts, immunostainings and tunel-staining. the intracellular apoptotic signaling pathway was analyzed by western blot and qpcr. results: in the kidney of beraprost-treated rat, significantly high density of renal microvascular network was maintained, and apoptosis of vascular endothelial cells was suppressed even at the terminal stage of anti-gbm gn. pathophysiological analyses revealed that transcriptional and post-translational modifications of bcl and xiap, which were anti-apoptotic proteins in mitochondria dependent apoptotic pathway, were occurred in the kidney of beraprost-treated rat. conclusion: these results suggested that prostacyclin protects renal vascular network by inhibiting mitochondria dependent endothelial apoptosis, and it play an important role for preservation of renal function in the chronic kidney disease. wednesday, september , . - . objective: although villous adenomas commonly occur in the gastrointestinal tract villous adenomas of the urinary tract, including the bladder, are infrequently encountered. method: we report a case of urinary bladder villous adenoma in a -year-old man. the patient was undergone cystoprostatectomy because of diagnosis infiltrative urothelial carcinoma in the transurethral resection of bladder. results: histopathological examination of cystoprostatectomy specimen there was no urothelial carcinoma. a , cm polypoid mass was seen at the dome of the urinary bladder. histopathology confirmed that this tumor was a villous adenoma with a polypoid growth of the glandular epithelium consisting of small tubular glands, dilated cystic glands or papillary fronds lined by a columnar epithelium. the glandular epithelial cells displayed mild nuclear atypia and nuclear pseudostratification with some mucus cells admixed. the patient was diagnosed with a rare case of villous adenoma of the bladder. over the past months of follow up, the patient is alive and no metastasis. conclusion: patients with isolated villous adenomas in the urinary bladder have an excellent prognosis and surgical resection is curative. however, it is uncertain whether an untreated lesion might eventually develop into an adenocarcinoma. therefore, close follow up is recommended because of the possibility that this condition might be premalignant. caprin overexpression in urothelial carcinomas of bladder b. akkaya * , z. cetin, s. berker-karauzum, m. baykara * akdeniz university, school of medicine, antalya, turkey objective: caprin encoded by cytoplasmic activation/ protein- gene located in p chromosome region. it has been reported that caprin is associated with cell proliferation in various types of cell lineages. method: we researched whether caprin might be overexpressed or not in urothelial carcinoma of bladder and its overexpression could be correlated with clinicopathologic parameter (age, sex, invasion). fifty urothelial carcinoma of bladder ( infiltrative; non-infiltrative) were stained by immunohistochemically in tissue microarrays. results: the expression of caprin was observed in infiltrative urotelial carcinoma cases (% ) and non-invasive urothelial carcinoma cases (% ). age range was - . eight patients were female, patients were male. conclusion: in the literature caprin overexpression was reported in different types of tumors including esophageal, stomach, prostate, lung, liver. caprin overexpression might be correlated with the cellular proliferation potential. to determine of importance of caprin - overexpression new studies are necessary. objective: pseudohyperplastic squamous cell carcinoma of the penis (pscc) is a low grade tumor with specific clinical and pathological features. this very uncommon tumor occurs in association with lichen sclerosus, the main location is foreskin, and the high degree of differentiation may difficult its discrimination with pseudoepitheliomatous hyperplasia. method: a -year-old male presented a penis lesion involving glans and foreskin, clinically suspicious of malignancy. size was , × , cm and a conservative resection was done. pathological study was performed, and hpv detection with a commercially available kit: pcr amplification and reverse hybridization with probes to hpv types. results: the lesion showed a non-verrucous well differentiated squamous cell tumor. upper layers lacked any atypia but infiltrative growth was evident in basal layers, with atypical cells and mitosis. lichen slerosus changes were evident bordering the tumor. hpv was negative for all types studied. no further treatment was employed and after a months follow-up no recurrence has been observed. conclusion: pscc should be taken in mind when handling penis tumors. a correct differentiation from benign lesions and a knowledge of its low grade to avoid overtreatment will benefit patients. lichen sclerosus and not hpv seems to play a precancerous role. evaluation of sunitinib malate and meloxicam as single agents or in combination in bladder cancer cell lines r. arantes * , r. pinto-leite, c. lopes, l. santos, a. colaço, p. oliveira * utad, dept. of veterinary sciences, vila real, portugal objective: currently accepted for the treatment of advanced renal cancer, sunitinib malate is a small molecule inhibitor of the vegfr family, with ability to regulate tumor growth, progression, angiogenesis and metastasis. several reports have suggested that encouraging effects can be achieved by combining cox- inhibitors with anticancer agents. the goal of this work was to evaluate the effects of sunitinib malate and meloxicam isolated and combined on three human bladder cancer cell lines. method: t , and ht cells were treated with several concentrations of sunitinib malate and meloxicam, as single agents or in combined schedule. their influence on cell proliferation was determined by mtt method after h of treatment. control samples were processed in the same way as treated samples but in drug-free medium. absorbance values of each well were read at nm using an elisa plate reader. results: a reduction in cell proliferation rate was observed when all cell lines were treated either with sunitinib malate or meloxicam isolated. simultaneous exposure to both agents enhances the inhibition of cell proliferation. statistical significances were obtained when treatment groups were compared with control group. conclusion: these results suggest a potential clinical application of sunitinib malate in combination with meloxicam on bladder cancer. bcl- expression in prostate carcinomas b. balinisteanu * , a. dema, s. taban, c. lazureanu, d. herman, s. ursoniu, a. loghin, a. vaduva * municipal hospital, pathology, timisoara, romania objective: the disturbance of apoptosis represents an important event in the genesis of tumors with different localization. the study of anti-apoptotic protein bcl- expression from the perspectives of the prognostic and predictive value in prostate cancer has led to inconsistent results, even contradictory. method: expression of bcl- was analyzed in groups of prostatic carcinoma: localized, locally advanced and with distant metastases. for histological grading of carcinomas we used gleason score. classification of the tumors into prognostic subgroups was made according to nccn guidelines. for the immunohistochemical study we used anti-bcl- antibody (clone ), envision system, visualization with diaminobenzidine. the results of immunohistochemical reaction were assessed by evaluating the extent and intensity of immunostaining. statistical analysis was performed using stata . . results: of the analyzed cases of prostate carcinomas showed bcl- over-expression: , % localized carcinomas, , % locally advanced carcinomas and , % carcinomas with distant metastases (p< . ). although most of the bcl- positive tumors were poorly and moderately differentiated, the correlation between bcl- over-expression and tumor grade did not show statistical significance (p= , ). conclusion: bcl- overexpression in advanced prostate carcinomas suggests involvement of this marker in the progression of tumors in this location. urothelial carcinoma of the bladder: a clinicopathologic study of cases g. benkhedda * , s. khalifa, y. lamouti * chu frantz fanon, dept. of pathology, blida, algeria objective: urothélial carcinoma (uc) accounts for nearly % of urinary bladder tumors.a variety of histological variant of uc have been recently recognosed. some variants have prognostic and therapeutic implications. the aim to this study is to assess the pathological features from our series and to compare our results that of the literature. method: we retrospectively studied patients who were diagnosed histopthologically with urothelial carcinoma using the who classification system. results: the mean age of patients at diagnosis was (range, - years). , % were male ( h/ f). all tumors were classified as urothelial carcinomas: , % urothelial neoplasm with squamous differentiation, , % with glandular differentiation, , % urothelial tumors nested and % sarcomatoid. in this study most tumors were grade ( cases) and stage pt . conclusion: adult urothelium has the capacity to undergo several pathways of phenotypic cellular and structural differentiation as a result of the embryological origin of the bladder from the multipotent tissues of the cloacal endoderm and the mesodermal wolffian ducts. the clinical course of bladder cancer varies depending on the histological type of neoplasm, grade and stage of the tumor. hight-grade muscle-invasive urothelial cancers and tumors schowing variant microscopic morphology have in general hight mortality and poor prognosis. comparison of insignificant cancer detection rates in prostatectomies performed following and -core biopsy schemes u. berber * , a. haholu, i. yilmaz, z. kucukodaci, d. demirel * gata heh, dept. of pathology, istanbul, turkey objective: widespread use of extended biopsy protocols have increased the prostate cancer detection rates. besides this improvement, whether detection of clinically insignificant cancer detection rates are increased by extended biopsy protocols is not well documented. in the study, we aimed to compare the rates of insignificant cancers found in prostatectomy specimens performed following and -core biopsy protocols. method: retrospectively, we investigated the low volume/ low grade (lv/lg) prostate cancers in prostatectomy specimens. tumors volumes were calculated digitally as multiplying total tumor areas by mm for average block thickness, and corrected for tissue shrinkage by multiplying a factor of . . results: of the prostatectomies, were performed following sextant technique, and were performed after -core protocol. review of the h&e stained sections revealed insignificant cancers. number of lv/lg tumors found in and -core groups were ( . %) and ( . %), respectively. conclusion: when compared to sextant technique, detection of lv/lg tumors were significantly raised in prostatectomies performed following -core protocol, and this increase points out the need for new approaches in patient management to avoid overtreatment after extended biopsy protocols. ps- - impact of total core length for cancer detection in a lateral zone targetted -core prostate biopsy scheme u. berber * , a. haholu, z. kucukodaci, i. yilmaz, d. demirel * gata heh, dept. of pathology, istanbul, turkey conclusion: total core length is significantly associated with cancer detection rates and may be used as a reliable adjunctive tool in deciding repeat biopsies for patients with negative biopsy result. objective: primitive neuroectodermal tumors (pnets) are highly malignant tumors of neuroectodermal origin. we report a case of renal pnet in a -year-old male with a -month history of intermittent hematuria.. he underwent a right radical nephrectomy. macroscopically, the inferior pole was replaced by a multinodular, grey, glistening tumour measuring . / / cm, with foci of necrosis and hemorrhage. method: serial histological sections have been assessed using hematoxylin-eosin and van gieson stain and the indirect immunohistochemical analysis for antibodies: mnf , vim, cd , nse, mic /cd . results: histological examination revealed a uniform population of undifferentiated, small-to medium-sized tumor cells, arranged in alveolar-insular patterns, with round to oval nuclei, small nucleoli, numerous signs of mitosis and scattered apoptosis, geographic zones of necrosis. dispersed cells showed cytoplasmic vimentin positivity favouring the diagnosis of pnet. few tumoral cells appeared positive for mnf . expression of cd was positive in a large number of tumoral cells and an area of the tumour exhibit a milder reaction of positive nse. mic was positive with moderate staining in almost all tumoral cells. conclusion: diagnosis is based on histology and immunohistochemistry but pathological evaluation can be challenging because of the differential diagnosis with other small round cell tumors. nonamyloid fibrillary glomerulonephritis: presentation of two cases e. beretouli * , g. dimas, g. karayannopoulou, t. koletsa, d. grekas, g. karkavelas * ahepa hospital, dept. of pathology, thessaloniki, greece objective: fibrillary glomerulonephritis (fgn) is a rare disease, characterized by fibrillar deposits in the mesangium and the glomerular capillary loops. these deposits do not have an amyloidlike cross-β structure and are readily distinguishable from amyloid by the larger thickness of fibrils and lack of congo red staining. method: we report two cases of a -and -year-old women, who presented with severe nephrotic syndrome, rapidly progressive chronic kidney disease and lymphoproliferative disorders. glomerular crescents were present in about % of both renal biopsy specimens ( of and of glomeruli, respectively). immunohistochemical analysis, immunofluorescence and an electron microscopy (em) studies were performed. results: renal biopsy showed a deposition of an amyloidlike extraneous substance in the mesangium, as well as within the glomerular basement membranes. congo red staining was negative. the em examination revealed fgn. conclusion: fgn must be included in the differential diagnosis of rapidly progressive chronic renal disease. em confirm the diagnosis of fgn, which suggests a poor outcome. objective: urachal carcinomas represent less than % of bladder-related cancers. most are adenocarcinomas, but urothelial, squamous and small cell carcinomas may occur. there are pathological criteria for assessing an urachal origin. a specific staging system is lacking for these tumors. method: a mass of the bladder dome was found in two and year-old men. a year-old woman presented an urachal cyst. ct-scan revealed no other tumors and partial cystecomy was performed. pathological examination showed partially cystic adenocarcinomas, one enteric type g , and two mucinous type g . two tumors extended into the bladder mucosa and one was limited to the urachal cyst. surgical margins were negative. immunostainings were positive for ck , ck , cdx , cytoplasmic beta-catenin, and negative for p . results: with a follow-up of , months and years, all patients are free of disease. conclusion: no tnm classification exists for urachal carcinomas. specific staging systems have been proposed by sheldon, and more recently by the mayo clinic. two cases are sheldon iiia/mayo clinic ii, and one sheldon ii/mayo clinic i. since stage, grade and surgical margins are the main prognostic factors, a clear and relevant staging system is needed for these rare carcinomas. objective: renal cell carcinoma (rcc) with two different histologies must be included in the unclassified group (who classification). whether these cases should be included in this histological subgroup or be considered hybrid rcc is a matter of debate. we report one of such cases in which papillary and chromophobe phenotypes meet. method: a cm in diameter asymptomatic left renal mass was discovered incidentally in the radiological follow-up of a breast carcinoma diagnosed years before in a yearold woman. follow-up showed right adrenal gland metastasis. patient died months later. results: grossly, tumor well circumscribed, tan-yellow, with haemorrhagic and necrotic areas. the neoplasm showed two different histologies clearly defined: one showed solid nests of polyhedral cells, with eosinofilic cytoplasm, central and hyperchromatic nuclei, occasional mitosis recapitulating chromophobe rcc. the other component presented a well defined tubulopapillary growth pattern typical of papillary rcc. focally sarcomatoid transformation, with tumor necrosis and chronic inflammation. by immunohistochemistry, chromophobe and papillary areas retained their specific phenotypes. conclusion: hybrid renal carcinomas do exist, but they are most probably hidden in the unclassified group of renal tumors. however, the exact histological context for which a renal neoplasm deserves the name "hybrid" remains to be defined. objective: renal cell carcinoma with thyroid-like follicular pattern is a rare histological subtype of renal carcinomas that has been very recently described. method: a . cm in diameter asymptomatic left renal tumor was discovered during the study of a macroscopic hematuria in a years old man. the lesion was organconfined. results: grossly, the tumor was a well circumscribed, solid, brown and homogenous intraparenchymatous nodule. proliferating cells were arranged in a microfollicular pattern with colloid-like material resembling thyroid adenoma. cells displayed low grade nuclear features and had eosinophilic cytoplasm. some areas showed a solid pattern of growth resembling an oncocytoid neoplasm. by inmunohistochemistry, the tumor was negative for thyroglobulin and ttf , and positive for ema, ck , ae /ae , and ecadherin. conclusion: renal cell carcinoma with microfollicular thyroid-like features has been very recently identified in the literature. there is no agreement on the exact nature of this neoplasm so far, and the who classification of renal tumors still does not consider this phenotype as a distinct histological subtype. anyway, the tumor must be distinguished from metastatic thryroid carcinoma, another quite unusual condition. evidence for clonal fibroblast proliferation and autoimmune process in idiopathic retroperitoneal fibrosis l. cheng * , j. clevenger, a. lopez-beltran * indiana university, dept. of pathology, indianapolis, usa objective: we sought to determine if idiopathic retroperitoneal fibrosis is clonal process and if it is an autoimmune, or igg -driven, process. method: thirty cases of idiopathic retroperitoneal fibrosis, in whom known causes of retroperitoneal fibrosis were excluded and those for which paraffin blocks were available, were included in this study. we performed clonality analysis in female patients. genomic dna samples were prepared from formalin-fixed, paraffin-embedded tissue sections using laser capture microdissection. results: eight of information cases ( %) showed nonrandom x-chromosome inactivation, or a clonal process. of the patients for which igg analysis was performed, ( %) were positive for igg -positive plasma cells and all were negative for alk. of the patients, for which both clonality analysis and igg analysis were performed, were clonal and igg negative ( %), were clonal and igg positive ( %), were nonclonal and igg positive ( %), and were nonclonal and igg negative ( %). conclusion: our data indicate that a significant proportion ( %) of idiopathic retroperitoneal fibrosis cases in females is associated with a clonal expansion of fibroblasts. in addition, a subset of idiopathic retroperitoneal fibrosis cases could be classified in the igg -related sclerosing disease spectrum. although a conclusive association with malignancy, urologic disorder, or systemic disease has not been established, often the lesion carries a challenging clinical differential diagnosis that includes malignancy. we examined clinical and histopathologic characteristics in patients. medical records were assessed for presentation, clinical diagnosis, associated urothelial carcinoma, radiation treatment, tobacco use, immunologic/urologic disorder, and treatment strategy/outcome. results: the mean age was (range - years). presenting symptoms were: pain ( %), hematuria ( %), and dysuria ( %), in contrast to asymptomatic ( %). clinical diagnosis favored malignancy in % of cases. concurrent or subsequent urothelial carcinoma was present for five patients ( %), though none developed urethral carcinoma. histologic features included mixed hyperplastic urothelial and squamous lining, overlying a variably fibrotic, edematous, inflamed, and vascular stroma. invaginations of urothelium extending into the stroma were common ( %), showing rounded nests with cystic or glandular luminal spaces, similar to urethritis cystica/glandularis, without intestinal metaplasia. two lesions included an organizing thrombus, one with intravascular papillary endothelial hyperplasia. twenty patients were treated with topical medications without resolution. three lesions recurred ( %) after excision. conclusion: urethral caruncle is an uncommon lesion that may clinically mimic benign and malignant conditions, making tissue diagnosis critically important. human papillomavirus (hpv) is not involved in urothelial tumorigenesis l. cheng * , r. alexander, a. lopez-beltran * indiana university, dept. of pathology, indianapolis, usa objective: the purposes of this study were to investigate the possible role of human papillomavirus in the development of squamous cell carcinoma of the urinary bladder and to determine if p expression could serve as a surrogate marker for human papillomavirus in this malignancy. method: forty-two cases of squamous cell carcinoma of the urinary bladder and cases of urothelial carcinoma with squamous differentiation were investigated. hpv infection was analyzed by both in situ hybridization at the dna level and immunohistochemistry at the protein level. p protein expression was analyzed by immunohistochemistry. results: human papillomavirus dna and protein were not detected in cases of squamous cell carcinoma ( %, / ) or cases of urothelial carcinoma with squamous differentiation ( %, / ). p expression was detected in ten cases ( %, / ) of squamous cell carcinoma and nine cases ( %, / ) method: a review of clinical data from an adpkd patient with tcc admitted in our hospital and a review of current literature regarding adpkd and tcc were made. results: the patient is a year-old woman with chronic renal failure due to adpkd, on hemodialysis for years. she was admitted with left lumbar pain, hematuria and fever. radiological exams revealed various complex cysts with dense material that did not enhance with contrast, compatible with hematic cysts in the context of adpkd. the whole clinical findings suggested cystic infection complicated with sepsis, so nefrectomy was performed. macroscopic examination of the ressected kidney revealed a white granulous nodular formation with . cm diameter in the renal pelvis. histological examination confirmed a highgrade papillary tcc with parenchymal infiltration (pt ) and extense scamous differentiation. conclusion: the present case illustrates that tcc can occur in adpkd, despite its rarity. it can be difficult to successfully diagnose tcc on adpkd based on clinical-radiological findings. objective: carcinoid tumor is a very uncommon neoplasm in the kidney. we report the histopathologic and immunohistochemical (ihq) study of two new cases. method: case : year-old female with a cm asymptom-atic¨cystic¨mass discovered in a routine exam. the patient underwent tumorectomy. case : year-old female with a cm renal mass who underwent left nephrectomy. two months later a needle biopsy confirmed carcinoid tumor metastasis in the liver. both patients currently free of disease. results: both tumors showed similar histologic features. neoplastic cells were grouped in nests, ribbons, and pseudoglands with rosette-like appearance and showed eosinophilic granular cytoplasm and chromatic nuclei. low mitotic index. ihc: diffuse/intense cytoplasmic staining for cd , cd , ae /ae , chromogranin and synaptophysin. conclusion: primary renal carcinoid tumor is rare in the clinical practice. the histological findings correspond to a well differentiated neoplasm and are similar to carcinoid tumors in other locations, which makes the diagnosis feasible even without previous personal experience. ihc confirms the diagnosis. it usually behaves as a low grade neoplasm, but recurrences and metastases do occur. only single cases and short series have been published so far. there is no accumulated experience to establish long term prognosis. prostatic adenocarcinoma occurring simultaneously with large cell neuroendocrine carcinoma of the urinary bladder: an extraordinary collision tumor p. czapiewski * , m. sieczkowski, m. matuszewski, k. krajka, w. biernat * medical university of gdansk, dept. of pathology, poland objective: radical cystoprostatectomy is a standard surgical procedure for male patients with muscle-invasive urinary bladder (ub) carcinoma. vast majority of these tumors are urothelial carcinomas, while large cell neuroendocrine carcinoma (lcnec) is a very uncommon tumor with less than reported cases. invasive prostate carcinoma is incidentally detected in up to % of cystoprostatectomy specimens. it is usually well differentiated and shows low propensity for dissemination and local recurrence. method: clinical and pathological description of an extremely rare collision tumor composed of lcnec of the urinary bladder and a high grade acinar prostate carcinoma. results: a -year-old male patient was admitted to the urology department due to severe gross haematuria. cystoscopy revealed large tumor of the posteriorinferior wall of the ub with involvement of the left uretheral orifice. in the radical cystoprostatectomy specimen lcnec of the ub, involving bilaterally prostate and spermatic vesicle (pt a), was diagnosed. additionally both lobes of the prostate were involved by the acinar prostatic carcinoma (pt c, gleason score + = ). conclusion: high-grade prostate carcinoma may rarely coexist with ub tumors of uncommon histology. objective: despite of numerous researches in the field, data regarding immunohistochemical (ihc) expression of androgen receptor (ar) in prostate carcinomas, in terms of prognosis and therapy, are quite controversial. method: the ihc expression of ar was analyzed on groups, each of primary diagnosed prostate carcinomas: localized, locally advanced and distant metastasized. the anti-ar antibody (clone ar ) was used. for each tumor was determined the percentage of ar-positive nuclei, assigning a staining score ( to ). a value of % was considered to be discriminat o r y b e t w e e n t u m o r s w i t h h i g h a n d l o w a r expression. results: all the analyzed carcinomas showed ar. . % of tumors had high ar expression and . % showed low ar expression. / localized tumors (one tumor vanished during processing), / locally advanced and / distant metastasized tumors showed high ar expression (p= . ). / well-differentiated, of moderately differentiated and / poorly differentiated tumors showed high expression of ar (p= . ). conclusion: although not reaching statistical significance, the ar expression tended to correlate with the stage of disease and with the degree of differentiation in terms of an increased expression of ar in advanced, moderately and poorly differentiated tumors. objective: prostate lesions with atypical stromal component are rare and poorly characterized in terms of evolution and prognosis. method: we retrospectively analyzed cases of unusual prostate tumors diagnosed on prostate needle biopsy. the biopsies were performed due to an elevated serum psa and/ or phenomena of bladder outlet obstruction. for the immunohistochemical (ihc) diagnosis there were used the following antibodies: ck ae /ae , psa, psma, vimentin, sma, er, desmin, pgr, cd . results: two of the three patients, one and the other years-old, with serum psa level of ng/ml and . ng/ml respectively, were diagnosed with sarcomatoid carcinoma, the former presenting with liver metastases at diagnosis. in evolution, the death of the first patient occurred months after the diagnosis and the second patient refused surgery. the third patient, years-old, with a nodular prostatic mass of . cm, was clinically suspected to have an unusual malignant prostatic tumor considering that, despite his ng/ml of serum psa, he presented multiple bone metastases. the histopathological diagnosis was stromal tumor of uncertain malignant potential. conclusion: the prostate lesions with atypical mesenchymal component are rarities in urologic pathology. an accurate diagnosis relies on meticulous pathological examination techniques and supplemented, for rare cases, with other clinical and laboratory data. immunohistochemistery study in a case of nephrogenic bladder adenoma m. r. farzaneh * , a. safaei, a. amin shareefi * shiraz, iran objective: nephrogenic adenoma is a rare benign lesion of bladder that may be confused with malignant lesions. there is strong relation with urinary tract irritation and intravesicl instrumentations. nephrogenic adenoma was initially thought to originate from urothelial metaplasia however no solid proof is available. method: we present this years old lady with urinary problem. cystocopic examination show a sessile mass and biopsy show circumscribed proliferation of tubules, cysts, and papillae lined by cells with low cuboidal to columnar epithelial cell. nephrogenic adenoma can be a significant diagnostic pitfall as certain histological features, such as the presence of enlarged nuclei with prominent nucleoli results: immunohistochemistery study showed strong reactivity to ck , p s, cd , and ema but negative for ck , psa, and p . conclusion: we recommend that any lesion in cystoscopic examination should be followed and immunohistochmistery examination some times is mandatory to differentiate them from malignant tumors. regulators of apoptosis and the cell cycle are overexpressed in bladder cancer metastases and may predict survival a. fleischmann * , r. seiler, a. perren, t. george * universität bern, institut für pathologie, switzerland objective: expression of biomarkers and their prognostic relevance may differ between primary tumours (pt) and its metastases (met). there is little information about this phenomenon concerning apoptosis and cellcycle associated biomarkers in urothelial bladder cancer (ucb). method: nodal positive patients (n= ) with ucb underwent cystectomy and lymphadenectomy. immunohistochemical expression of bcl- , bcl- , mdm- , p and cyclind was quantified in tissue microarrays constructed from pt and corresponding nodal met. results: frequency of mdm- positivity increased from pt ( %) to met ( %, p < . ). this trend was not significant for bcl- (pt: %; met: %, p= . ) and bcl- (pt: %; met: %, p= . ). median percentage of p and cyclind immunostained cells increased significantly (p< . ) from pt ( %/ %) to met ( %/ %). mdm- and cyclind expression were positively correlated in pt (p< . ) and met (p< . ). p and mdm- positivity were inversely correlated in pt (p< . ). only high cyclind expression in the metastases predicted early death significantly and independently (p= . ). conclusion: biomarkers of apoptosis and cell-cycle associated are up-regulated in the metastases indicating differences in survival and proliferation of cancer cell compared to primary tumours. both tumor components may harbor different prognostic information and are not necessarily surrogates for each other. evaluation of histopathologic and histomorphometric changes of testicular tissue and gonadotropins levels following consumption of methylphenidate in male mice z. ghahri saremi * , s. fazelipour, z. tootian, m. shafii * tehran, iran objective: one of the most common psychiatric disorders in children is adhd (attention deficit hyperactivity disorder), which is treated extensively by methylphenidate. this study investigates the assessment of the effects of methylfenidate on histopathologic and histomorphometric changes of testes and serum level of gonadotropin in adulthood which produces gametes and has importance for future generations. method: in this study adult male mice (balb/c) were used. after determining the body weight, the animals were divided randomly into two experimental groups of and one control group. the experimental groups received ritalin via gavage as follow: the group received mg/kg/day and the group received mg/kg/ day for a period of days. after evaluation of body weight, general anesthesia was used for taking blood samples from the heart in order to measure gonadothropins levels in serum. then for the purpose of body weighing and measuring of diameter of germinal epithelium the testes were removed and the possibility of any pathologic changes was considered. results: the results showed that methylphenidate with different doses could decrease germinal epithelium and also body weight significantly. besides some significant changes in serum gonadotropins, without any pathological changes were observed. conclusion: our findings demonstrated that methylphenidate administration in adulthood due to influence of enhanced computed tomography and magnetic resonance imaging was characterized as × × cm sized welldemarcated left renal middle-superior polar mass with central necrosis and cystic changes. the contralateral kidney was normal. he underwent left radical nephrectomy by thoracoabdominal approach. gross examination of the specimen revealed yellowish white × × cm sized mass, with multifocal necrozis and cystic changes. histopathology of these resection specimens; scattered spindle cells and foam cells, fine vascular network and necrosis. immunohistochemistry revealed cd -positive xanthoma cells. the tumor also stained positive for vimentin, cd , but negative for cytokeratin, ema, desmin, sma and myod . a diagnosis of mfh was made. conclusion: mfh is a primitive mesenchymal tumor with some histiosytic and fibroblastic differentiation primary renal mfh is an extremely rare lesion. because this malign mesenchymal tumor is indistinguishable clinically and radiologically from renal cell carcinoma diagnosis and histopathology of this rare lesion are discussed. hyaline ring granulomas in the urinary bladder: a case report n. hammer * , n. gatt, j. de gaetano * swatar, malta objective: hyaline ring granulomas, or pulse granulomas, are rare inflammatory responses to vegetable matter, characterised by aggregates of hyaline rings and other inflammatory components around vegetable matter. the vast majority occur in the oral cavity and only a few specific extra-oral cases have been reported. we present a case of pulse granulomas in the wall of the urinary bladder, occurring in a year-old gentleman with a concurrent history of diverticulitis and colo-vesical fistula. pulse granulomas were recently described in the bladder in association with interstitial cystitis, in mesocolonic fat and mesocolonic lymph nodes in association with inflammatory bowel disease and in enterocutaneous and recto-salpingeal fistulas in association with diverticulitis. to our knowledge this is the first case reporting the direct association of the occurrence of bladder pulse granulomas in relation to diverticulitis. method: the tissue sections were fixed with % buffered formalin and stained with h&e. results: histopathological examination revealed several hyaline ring granulomas within the outer muscle layer and serosa of the urinary bladder, together with hyaline ring granulomata within the outer wall of the sigmoid colon associated with diverticula. conclusion: it is important to differentiate pulse granulomas from parasites, hyaline ring vasculopathy, granulomatous inflammatory disorders and even malignancy. objective: micropapillary carcinoma (mpc) is associated with poor prognosis, and may lead to immediate cystectomy irrespective of stage. we study mpc, with "classical" histologic features, to "stage-matched urothelial carcinoma (uca), not otherwise specified (nos)", and other uca with divergent differentiation to compare outcome. method: cases from patients with mpc, uca with squamous (sq) or glandular (gl) differentiation, small cell carcinoma (smca), and nested variant (neca) variant of uca were identified. histologic and clinical data including stage and outcome were collected. results: all groups show male predominance and similar age range. mpc showed the highest rate of nodal metastases (table ) . patients with mpc tumor volume of > % showed the highest rate of nodal metastases of all other subgroups. the majority of patients with mpc died, a large percentage from unknown causes. compared to mpc, sq showed similar presentation at higher stages and similar survival, but a lower propensity for nodal metastases. in our cohort, gl presented at lower stages, showed slightly better survival, and a lower rate of nodal metastases, when compared to mpc. our cohort included fewer cases of smca and neca. however, both patients with neca died of disease. conclusion: mpc, particularly when it represents > % of tumor volume, shows higher rate of nodal metastases than remaining subgroups, and is associated with a larger percentage of patient deaths. objective: müllerian-like stroma with er/pr expression is typical of renal mixed epithelial and stromal tumor and has been described in kidneys with obstructive pathology. wt overexpression is not reported in this setting. method: immunohistochemical study for er, pr and wt in autosomal dominant polycystic kidney disease (adpkd) (n= ), acquired cystic kidney disease (ackd) (n= ), xanthogranulomatous pyelonephritis (xp) (n= ), and renal lithiasis (rl) (n= ). controls: fetal (< w, n= ; > w, n= ) and adult autopsy kidneys (n= ). results: stromal er was found in % of adpkd, ackd, xp and rl; pr expression in % of adpkd, ackd and rl and % of xp, and nuclear wt in % of xp and rl. er were negative in % of controls. we found pr expression in % of fetal controls of second trimester. wt was negative in the stroma of adult controls ( %). % of fetal controls showed wt expression in the peripheral cortex. conclusion: er and pr expression is frequent in kidneys with chronic obstructive and inflammatory pathology. wt is expressed occasionally. more studies are needed to determine whether these findings are a consequence of renal obstruction or they are involved in its pathogenesis, as well as their potential therapeutic implications. telomerase expression in urothelial carcinomas of the urinary bladder: does it make sense for carcinogenesis or prognosis? d. kankaya * , s. kiremitci, k. zengin, c. tuygun, a. sertcelik * ankara university medical school, dept. of pathology, turkey objective: human telomerase reverse transcriptase (htert) has been reported as poor prognostic marker in several cancers. in the present study, we examined htert expression in urothelial carcinoma (uc) to investigate whether it has a role on the carcinogenesis or prognosis. method: immunohistochemistry was performed to detect htert protein expression in tisse microarray blocks consisting of cores of papillary uc (n = ) and infiltrating uc (n = ) cases. nucleolar staining was considered and staining scores (intensity × distribution) were determined. tumors were grouped as low or high in terms of histological grade, and as early (ta, t ), or late stage (t -t ) in terms of pathological stage. results: htert expression was significantly higher in the papillary uc group (p= . ). tumors in late stage were more likely to show low staining scores of htert (p= . ). no correlation was found with tumor grade and recurrence rate. no effect on survival.was detected. conclusion: these findings indicated an association of htert protein with early stage ucs as its expression significantly decreased with muscularis propria invasion. incidental multifocal renal cell carcinoma in graft nephrectomy with cellular rejection findings: concurrence of papillary renal cell carcinoma and renal carcinoma associated with xp . translocation d. kankaya * , s. kiremitci, a. ensari, a. sertcelik * ankara university medical school, dept. of pathology, turkey objective: malignancy represents the second main cause of death in renal transplant patients and increase markedly by years after transplantation. method: a year old male who has been on hemodialysis for months for chronic renal failure, underwent living kidney transplantation from his brother. he received immunosupressive therapy of siclosporin and prednisolon. twelve years later, due to the impairment of renal functions hemodialysis was started again and ultrasonography revealed chronic renal parenchymal disease. graft nephrectomy was performed with the pre-diagnosis of chronic rejection. results: macroscopic examination revealed two well-circumscribed tumor nodules with mm and mm in largest diameter. microscopically, both tumor nodules showed tubulopapillary organization. larger tumor consisted of clear cells with tfe positivity, whereas the small one showed eosinophilic cells with diffuse cytokeratin and amacr positivity, without any tfe expression. concurrence of papillary renal cell carcinoma and renal cell carcinoma associated with xp . translocation was reported. non-tumoral renal paranchyme revealed interstitial inflammation, tubulitis and transmural arteritis with fibrinoid necrosis compatible with type iii cellular rejection. conclusion: as far as we know this is the first case in the english literature demonstrating concurrence of papillary renal cell carcinoma and renal cell carcinoma associated with xp . translocation in a graft nephrectomy. the effect of postoperative intravesical bcg and mitomycin c therapy on recurrence in superficial bladder cancer d. kankaya * , k. zengin, a. sertcelik, c. tuygun, n. sertcelik * ankara university medical school, dept. of pathology, turkey objective: to evaluate the efficacy of two mostly used intravesical agent, bcg and mitomycin c, in case of tumor recurrence. method: between and , we performed tur-bt to patients whom pathology results were superficial bladder cancer. patients were treated with intravesical bcg once for week weeks then monthly up to one year beginning from . day postoperatively. patients were treated with intravesical mitomycin c, beginning from first h postoperatively and once a week for weeks. patients didn't get any further treatment, and excluded from study. results: for bcg group, expected disease free interval was . months, and . months for mitomycin c group. when two groups compared for expected disease free interval, statistically significant difference observed (p= . ). for bcg and mitomycin c group, recurrence was seen in and patients, respectively. for patients treated with bcg, and years disease free survival rate was % . and % . , respectively. in mitomycin c group and years disease free survival rate was % . and % . . conclusion: intravesical adjuvant bcg maintenance therapy is more effective for tumor reccurence than intravesical mitomycin c therapy. papillary cystadenomas of the epididymis: case presentation p. katafygiotis * , l. abou-asabeh, a. nomikos, s. chranioti * hospital of voula, dept. of pathology, athens, greece objective: papillary cystadenomas of the epididymis are rare, first described by sherrick in . they are considered hamartomatous lesions rather than neoplastic and may be seen as intrascrotal swellings in a wide age range. we report here the case of a -year-old male who presented with a swelling of the right testis over the past year. his past medical history was otherwise unremarkable. method: ultrasonography revealed the presence of an epididymal cyst. grossly the cyst had a cm diameter with a cyst wall of . cm thick attached to a part of epididymis measuring × cm filled with clear fluid. results: histologically the cyst showed pseudopapillary structures lined by monotonous clear cells. there was mild nuclear pleomorphism, no mitotic activity and no necrosis. immunostaining for ae /ae , ema, were positive, as well as focally for ck / whereas calretinin and cea was negative. similar pattern of staining was seen in the epididymal parenchyma. conclusion: papillary cystadenomas are benign neoplasms and there have been no reports of recurrence or metastasis in the recent literature. bilateral disease is often associated with von hippel-lindau syndrome. our patient received no further treatment and remains asymptomatic and well months after the intervention. effect of neoadjuvant sorafenib treatment on histology of clear cell renal cell carcinoma and occurrence of circulating tumor fragments g. kats-ugurlu * * umc st. radboud, dept. of pathologie, nijmegen, netherlands objective: clear cell renal cell carcinoma (ccrcc) generally presents with a micronodular phenotype (mp) due to high expression levels of vascular endothelial growth factor (vegf-a). earlier we have shown that mp is associated with shedding of multicellular tumor fragments (mtf) into the circulation and pulmonary metastasis. we hypothesized that vegf inhibition will destroy mp resulting in less mtf. method: ccrcc patients were treated for weeks by daily administration of sorafenib ( mg bid). three days after therapy, nephrectomy was performed and kidneys were perfused via the arteria renalis. venous perfundate was filtered and processed to agarcytoblocks for mtf. treatment effects were studied using immunohistochemistry. results: all tumors were ccrcc as demonstrated by high vegf-a expression. none of the tumors showed mp after sorafenib treatment. tumors showed large areas of necrosis and fibrinoid necrosis of the blood vessels, concomitant with profound perivascular inflammation. / ccrcc patients ( %) had mft vs % in a control group (p= . fisher's exact test). individual tumor cells in the mtfs showed increased mitotic activity. conclusion: sorafenib destroys mp in ccrcc, attacks tumor vasculature, causes extensive necrosis and inflammation. post-treatment mtf are increased in venous perfundate. care should therefore be taken with neo-adjuvant sorafenib treatment of ccrcc. objective: claudins are major transmembrane proteins of tight junctions. as the disruption of their function have important impact on tumorogenesis, invasion and metastasis. claudins became a focus of interest for targeting therapies. although their expression profiles have been studied in many organs, researches on claudin expression in bladder are in limited number. the aim of this study is to present the differential expression of claudins in invasive urothelial cell carcinoma (iucc), noninvasive papillary urothelial carcinoma (npuc), carcinoma in-situ (cis), papillary urothelial neoplasm of low malignant potentiall (punlmp) and control group (cg). results: cases ( iucc -further divided into: muscle invasive ucc, ucc with lamina propria invasion-, npuc, punlmp, cis and cg) were evaluated with claudin- , , . interestingly, high claudin- and - score in cg ( %, %), decreased significantly in all non-invasive lesions (mean %, %). claudin- expression appeared to decrease in iucc vs. others (% vs mean % ). conclusion: higher expression of claudin- in low-grade and non-invasive lesions may be used as a diagnostic tool. in terms of claudin- and - , their decreased expression in non-invasive lesions when compared to cg and their trend to show more increased expression in iucc needs to be studied further in larger studies. can we rely on alternative sampling method of radical prostatectomy specimens? t. d. kokenek-unal * , a. s. oguz-erdogan, m. alper * yb research and training hospital, dept. of pathology, ankara, turkey objective: prostatic adenocarcinoma is the most common cancer and second leading cause of cancer death in men. the incidence of prostate cancer has been increasing because of efficiency of modern cancer scanning programs and residual awareness of the patients. for that reason, there is a considerable increase in the number of prostatectomy specimens in the university and research hospitals.it is costly and time-consuming procedure and causes in turn increased workload. the aim of this study is to compare the results of total and alternative sampling methods and to delineate the differences if there are any. method: totally embedded radical prostatectomy specimens were randomly selected and evaluated for key pathologic parameters. these cases then were reevaluated with limited sampling. the limited sampling method was built to include similarly embedded apical margins, bladder neck margins and seminal vesicles. in addition to that new slices were selected by skipping every other slice as differently from totally sampling protocol. results: the % reduction was achieved in number of blocks. the concordance rates between two sampling methods were % , % . , % . , and % respectively for gleason scores, perineural invasion, extraprostatic extension and pathologic stages. conclusion: although the limited sampling protocol provides statistically significant results, because of critical role of pathological assessment in treatment of prostatic adenocarcinoma, they can be found unsatisfactory for many pathologists. objective: initially described in embryonic neuroepithelium, nestin is an intermediate filament involved in cell differentiation and transiently related to vimentin, keratin and glial fibrillary acidic protein (gfap). in tumoral and vascular proliferation, nestin is recognized in stem/progenitor cells. the octamer-binding transcription factor (oct- ) is a biomarker of this lineage. since there are few data concerning the presence of nestin in leydig cells and testicular tumors, our aim was to investigate a series of leydig cell hyperplasia and tumors. method: cases ( hyperplasia, adenomas, malignant leydig cell tumors and lymph node metastases) and controls were immunostained with anti-nestin, vimentin, keratin, gfap and oct- antibodies. results: twenty-six ( %) cases (tumors and hyperplasia) were nestin positive with mostly weak, finely granular cytoplasmic staining. four ( %) were negative, ( %) not interpretable. vimentin was expressed in twenty-seven ( %) cases. seventeen ( %) were focally keratin positive. only three ( %) showed oct- positivity. all were gafp negative. conclusion: in leydig cell hyperplasia, adenomas and malignant tumors nestin and vimentin are expressed frequently, sometimes with keratin. this would be a sign of epithelialmesenchymal transition. further investigations are needed to understand the relationship with the malignant potential of these tumors. morphological changes of testis in atherosclerosis n. krupnov * , a. astrakhantsev * bureau of forensic medical exp., ryazan, russia objective: up to now in the field of morphology of reproductive system of men the problems of testis involution and morphogenesis at atherosclerosis haven't been thoroughly investigated. we have investigated histologically testis of died patients aged - with general atherosclerosis and testis of men aged - with minimal manifestations of atherosclerosis died in an accident. results: the absolute volume rete testis of patients being ill with atherosclerosis decreases by - %. absolute volume of convoluted seminiferous tubules and interstitial tissue decrease by - %. in testis there are zones of focal sclerosis of seminiferous tubules, whose area goes as far as . % of shear section area. it was revealed that on the periphery of sclerosis zones there is a reduction of transaction area of seminiferous tubules by - % with sertolli cells quantity reduction by - %. it has been stated the downward changes in index of spermatogenesis in convoluted seminiferous tubules by - . %, accounted for the quantity reduction of all kinds of cells. conclusion: morphological changes of testis at general atherosclerosis characterize atherosclerotic testiculopatie, caused by chronic ischemia of testis. a leydig-cell tumor in a cryptorchid testis: report of a case e. lambropoulou * , a. datsis, p. morfaki, g. charalambopoulou * general hospital of messologhi, dept. of pathology, greece objective: leydig cell tumor is a rare form of testicular neoplasm, representing only - % of all testicular tumors. according to accepted medical knowledge, this type of tumor isn't linked to cryptorchidism, unlike germ cell tumors of the testicles. herein, a case of leydig cell tumor in a cryptorchid testis is described. method: a -year-old, unmarried man was admitted for surgical repair of inguinal hernia. his past medical history included untreated bilateral cryptorchidism first noted in childhood, as well as poliomyelitis that presented at age two. the past surgical history and review of systems were noncontributory. a ct scan of the abdomen and pelvis revealed two × cm testicles at the level of the inguinal canal. he underwent bilateral inguinal orchiectomy combined with surgical repair of his inguinal hernia. results: the right testis contained a solid, well-circumscribed, round, tan-colored tumor . cm in diameter. the histological appearance was that of a leydig cell tumor exhibiting no mitotic figure. there was no clinical or radiological evidence of metastatic spread. conclusion: although cryptorchidism is considered to be a risk factor for developing germ cell tumors, there have been a few reported cases of leydig cell tumors with a history of cryptorchidism. our case adds to the evidence that there may be a link between the two conditions. objective: cd , e-cadherin, β-catenin are "cell adhesion molecules" and appear to influence development, inflammation, cancer invasion and metastasis. we studied the expression of these cams in prostatic adenocarcinoma (pca), high grade prostatic intraepithelial neoplasia (hgpin) and nodular adenomatous hyperplasia (nh). method: specimens of radical prostatectomies were assessed. these cams were determined by immunohistochemistry. all sections included pca, hgpin, and nh. the expression of these markers was evaluated with three scores. the correlation of immunopositivity with gleason score and tnm stage was investigated. results: cd was strongly expressed in . %, . % and . % of nh, hgpin and pca, respectively. e-cadherin immunostaining was higly detected in . %, . % and . % of nh, hgpin and pca areas while β-catenin immunostaining was exclusively membranous in . % of nh and nuclear/cytoplasmic in . % and . % of hgpin and pca areas. all markers were unrelated to gleason score (p= . ). cd and e-cadherin immunopositivities were inversely associated with tnm stage (p= . and p= . respectively); such an association was not observed in β-catenin (p= . ). conclusion: cd and e-cadherin decreased expression is probably associated with invasive potential of prostate cancer. β-catenin staining pattern in neoplastic lesions differs from that in non-neoplastic prostate lesions. results: the loss of ecad expression was significantly higher at the tif when comparing with tscp and nnm. the loss of ecad was correlated with histological grade, infiltrative pattern, lymph node metastasis, perineural and vascular invasion. the vimentin expression showed association with histological grade, infiltrative pattern, t stage, lymph node metastasis, perineural and vascular invasion. conclusion: the loss of ecad and the gain of vimentin expressions occur more frequently at the tumor invasion front and are associated with classic factors of poor prognosis and low survival rates. prognostic value of immunohistochemical markers in bladder cancer i. m´sakni * , a. chaabane, f. bougrine, b. laabidi, a. bouziani * rades meliane, tunisia objective: the tumor stage and grade of bladder tumors are the major elements to define the prognosis. however, it is sometimes difficult to identify an infiltration of chorion or detrusor muscle. moreover, the evaluation of tumor grade is subjective and not reproducible. method: our objective is to study the prognostic value of the expression of proliferating cell nuclear antigen (pcna), ki antigen, the tumor suppressor gene p , the protooncogene c-erb b , the receptor for epidermal growth factor (egf-r), the apoptosis suppressor gene bcl , carcinoembryonic antigen (cea) and epithelial membrane antigen (ema). results: the study showed that the pcna expression was significantly associated with the early recurrence (p= . ) and the tumor stage (p= . ). the mib expression was correlated to the early recurrence (p= . ), and tumor progression in stage and/or grade (p= . ). the c-erbb expression showed significant association with the tumor grade (p= . ). the prognostic value of other markers has not been proven. conclusion: these findings may be useful providing better classification of bladder tumors thus the better management of patients. the c-erbb expression contributes to refine the tumor grading. pcna and mib can predict the early tumor recurrence; they could be relevant for the determination of endoscopic controls rhythms of patients. objective: primary urinary bladder neuroendocrine carcinoma (pubnec) is a rare tumor characterised by an aggressive behaviour and poor prognosis. method: we report five cases of pubnec diagnosed in the departement pathology of farhat hached hospital between and . results: our population is composed by four mens and a woman. all patient are heavy smokers. the most common presenting symptom is hematuria and dysuria in all cases. one patient presented a complete urinary retention. a cystoscopic examination with transurethral resection was performed in all cases. the pathological examination with use of immunohistochemical markers of neuroendocrine differentiation were consistent with a large cell neuroendocrine carcinoma in four cases and a small cell neuroendocrine carcinoma in a case. a cystoprostatectomy was made in two cases followed by chemotherapy. conclusion: the clinical presentation of pubnec is similar to other bladder cancers and is characterized by advanced stage at diagnosis and rapidly progressive disease. the diagnosis of poses several problems: a vesical metastasis has to be excluded and such lesions have to be differentiated from transitional cell carcinoma, lymphoma, paraganglioma and peripheral nerve neuroblastoma. there is no gold standard for the management of patients affected due to low disease frequency ps- - igg -associated inflammatory pseudo-tumor (ipt) of the ureter: a case report a. marando * , g. d´ambrosio, f. catanzaro, f. sessa * university of insubria, dept. of surgical, varese, italy objective: igg -associated inflammatory pseudo-tumor (ipt) is a novel clinico-pathologic entity characterized by intensive infiltration of igg -positive plasma cells, associated with systemic igg -related sclerosing disease. many reports described igg -related ipt in various locations such as pancreas, salivary glands, liver, breast, lung and recently also ureter. method: it is described a case of ureteral ipt with pathologic and immunohistochemical features of igg -related ipt, fibrohistiocytic type. results: the study case is a -year-old female with severe stenosis of the left ureter and hydronephrosis, who underwent to nephroureterectomy and endoscopic resection of multiple lesions in the bladder. the histological examination showed transmural fibrosing inflammatory lesion of the affected ureteral wall, with abundant plasma cells intermixed with many histiocytes, lymphocytes, fibroblasts and scattered eosinophils. the majority of infiltrating plasma cells were positive for igg . bladder lesions showed similar histological features. the diagnosis was igg -related ipt, fibrohistiocytic type. conclusion: igg -related ipt of ureter is extremely rare, with only few cases reported in literature. recognition of this entity is clinically relevant because this type of ipt can be treated with steroid therapy and may be associated with sclerosing autoimmune disease in other organs. a rare case of malignant fibrous histiocytoma of the urinary bladder s. mavropoulou * , z. tatsiou, i. amplianitis, p. nasos * general hospital, laboratory of pathology, xanthi, greece objective: malignant fibrous histiocytoma (mfh) is an extremely rare malignant mesenchymal neoplasm of the urinary bladder with only a few well-documented cases reported in the english literature. method: we report the case of an -year-old man who was brought to our hospital due to sudden massive haematuria. catheterization failed to obtain haemostasis so, a suprapubic incision and direct exploration of the bladder was performed. a large solid tumor was found with a shaggy haemorrhagic surface and biopsies were taken. results: histological examination revealed an infiltrating malignant neoplasm composed of variably pleomorphic ovoid neoplastic cells with eosinophilic cytoplasm, bizarre tumor giant cells and prominent stromal osteoclastic giant cell reaction. immunohistochemical examination was negative for cytokeratin, desmin, smooth muscle actin, psap, nse, s protein and hmb whereas it was positive for cd in a large number of tumor cells. accordingly, the diagnosis of undifferentiated pleomorphic sarcoma with histological features compatible with giant cell mfh of the urinary bladder was made. the patient died days after the diagnosis. conclusion: in conclusion, mfh of the bladder should be kept in mind when facing with an undifferentiated malignant tumor. despite the poor prognosis, early diagnosis and aggressive salvage therapy might offer the chance of long-term survival in selected cases. partial nephrectomy experience at a single tertiary-care oncology centre: a clinicopathologic study of cases s. menon * , g. bakshi, h. tongaonkar, v. noronha, a. joshi, k. prabhash, s. desai * tata memorial hospital, dept. of pathology, mumbai, india objective: partial nephrectomy (pn) is replacing radical surgery as a gold standard in the treatment of small renal masses. intra-operative frozen consultation for margin status is aimed at achieving a disease free state in order to reduce chances of recurrence. method: a retrospective clinicopathologic analysis of consecutive pns performed at our institute from to was undertaken. results: sixty cases of pn were analysed. male to female ratio was . : . median age was years. six cases were benign: oncocytomas ( ), angiomyolipoma ( ); while cases were malignant: renal cell carcinoma (rcc) -conventional ( ), papillary ( ), chromophobe ( ), mucinous tubular spindle cell carcinoma ( ) and one case of primitive neuroectodermal tumour. in patients, the renal tumour was a second malignancy. median tumour size was . cm with cases of stage pt . intra-operative margin was positive in cases. mean margin for all cases was . mm. median follow-up was of months. none of the tumours recurred or metastasized during follow-up. conclusion: conventional rcc is the commonest histology in pn cases. frozen section analysis has a definite role in achieving margin free status. pn is not associated with increased risk of local recurrence in small renal tumours. clear cell tubulopapillary renal cell carcinoma: a clinicopathologic study of two cases g. muñiz * , a. corominas, n. cerda, a. perez, v. caamaño, m. gonzalez, l. etxegarai, j. i. lópez * hospital universitario cruces, dept. de anatomía patológica, barakaldo, spain objective: cleal cell tubulopapillary renal cell carcinoma has been recently identified as a low grade renal cell tumor with distinct histological features. method: patient : year old female with a history of fibromyalgia and persistent loin pain. a right renal mass, . cm in diameter, was discovered in the rheumatologist's follow up. right nephrectomy was performed and the patient is free of disease months later. patient ; year-old female with a history of diabetes mellitus type , hypertension and renal failure grade with a . cm in diameter renal tumor in the routine studies. she underwent tumorectomy. results: grossly, both were cystic tumors with gelatinous fluid and white-yellowish solid areas. tumors showed a tubular and papillary architecture. proliferating cells displayed clear cell cytoplasm and hyperchromatic nuclei placed in the luminal side. ihc showed positive staining with e-cadherin, ema and ck . conversely, cd , cd and amacr were negative. conclusion: clear cell tubulopapillary renal cell carcinoma should be considered a distinct subtype of renal cell carcinoma according to its unique morphologic and inmunohistochemical features. the few cases reported so far behave in an indolent course. survivin expression in renal epithelial tumors: its usage in the differential diagnosis of eosinophilic renal epithelial tumors a. ozcan * , n. yigit, o. onguru, b. a. firat, s. ozaydin * gulhane military medical academy, dept. of pathology, ankara, turkey objective: the differential diagnosis of renal tumors can be problematic due to overlapping morphologic features. the purpose of this study was to assess the potential contribution of survivin expression in the differential diagnosis and determination of therapy modalities of these tumors. method: this study consisted of chromophobe (chrcc), clear cell (ccrcc) and papillary (prcc) renal cell carcinomas, and oncocytomas. sections were stained against survivin antibody. results: prccs and ccrccs showed diffuse and strong survivin expression. survivin expression was strikingly prominent in type prccs and cystic ccrccs. in ccrccs, survivin expression was more pronounced in low grade areas than high grade and sarcomatoid areas. in chrcc, survivin expression was more limited and weaker than that of oncocytomas and other malignant renal tumors. in non-neoplastic renal tissue, survivin expression was more pronounced in podocytes and atrophic tubules than other nephron parts. conclusion: our findings suggest that survivin may contribute to the differential diagnosis of renal tumors because of the partially unique staining patterns. it was purposed that knockdown of survivin reduced growth, induce apoptosis and enhance in vitro radiosensitivity of rcc cells. taken together, to be known different survivin expression patterns in renal tumors may help to determine new therapeutic strategies for rccs. objective: there are several tumor-like lesions and miscellaneous neoplasms of rete testis. we present a case with adenomatous hyperplasia of rete testis (ahrt). method: the patient was years old with undescended testis and referred to our hospital. there was no clinical or endocrin abnormalities. cryptoorchidism was unilateral and the other testis was normal. right orciectomy was performed and sent to pathology labarotory for examination. results: there was no tumoral lesion in gross examination but in microscobic examination there was gland like tubular structures. some of these were back to back position with little intervening stroma and mild to moderate atypia. ema and pancytokeratin immunohistochemistry findings with morphology confirmed the diagnosis of ahrt in this case. conclusion: ahrt is a rare proliferatif lesion and can be confused with malignancy. it is incidentally realised in microscobic investigation. it may present as a very small lesion detected in microscobic examination or solid-cystic mass lesion which is macroscobically evident. clinic history, localization, histologic features and immunohistochemistry are criterias for differentiating these lesions.we present this case for both surgeons and pathologists with its importance to be confused with malignancy. objective: prostate cancer is the second leading cause of death in men. the localized disease often responds to conventional therapies like androgen ablation via castration and/or administration of chemical inhibitors but advanced disease resistant to any curative therapies is still challenge for investigators. there are increasing efforts to enhance the possibility of finding positive and sensitive immune markers for diagnosing and treating prostate cancer. method: we applied immunohistochemical markers; amacr and inos. formalin-fixed parafin embedded tissues of prostate needle biopsy specimens diagnosed as prostate adenocarcinoma between and years were enrolled in the study. results: amacr expression has been found in ( . %) and inos expression in ( . %) of prostate adenocarcinomas.no significant relationship of amacr and inos has been obtained (p> . ). there was no significant correlation of histopathologic grade of the tumors with amacr and inos expression (p> . ). conclusion: the expression of amacr and inos might be important diagnostic immune markers for prostate adenocarcinomas especially in needle biopsies when the quantity and quality of tissue are limited. a tissue microarray study of napsin-a expression in renal tumors a. panizo * , f. j. queipo, j. j. sola, j. pardo * hospital de navarra, anatomia patologica, pamplona, spain objective: napsin-a is an aspartic protease present lung, renal, and thyroid cells. there are few studies evaluating napsin-a in renal neoplasms. therefore, we studied ihc expression of napsin-a in a wide spectrum of renal tumors. method: ihc for napsin-a (rabbit polyclonal antibody) was performed in a series of cases of primary and metastatic renal tumors on tma. cytoplasmic immunoreactivity was scored: intensity ( - +) and extent (% of tumor cells: - ). the scores were added: positive case: combined ihc score> ; negative if combined score of or less. objective: the diagnosis of prostatic carcinoma can be challenging on needle core biopsies. the aim of this study was to assess the utility of alpha-methylacyl-coa racemase (amacr/p ) antibody cocktail for prostate cancer diagnosis. a prospective analysis of consecutive radical prostatectomy specimens and prostate needle biopsy semples was performed to select histological sections showing foci of minimal prostatic carcinoma, high grade prostatic intraepithelial neoplasia (hgpin) and benign mimickers of prostatic carcinoma (atrophy, adenosis). method: serial histological sections were stained with hematoxylin and eosin, van gieson and immunomarkers: amacr and p using a prediluted antibody cocktail. results: the cocktail was very useful in highlighting prostatic carcinoma associated with hgpin (flat or cribriform) and distorted foci of minimal carcinoma. amacr was positive with moderate and strong staining in almost all cases for which the immunohistochemical result converted the atypical diagnosis to a final cancer diagnosis. the cases whose diagnosis was changed from "atypical" to cancer were all highly suspicious for cancer based on he histology and negative basal cell markers. conclusion: this cocktail would be of diagnosis utility when limited tissue is available for histopathological evaluation of small diagnostically difficult foci (prostate needle biopsy and surgical specimens). overexpression of cytokeratin , ki- and topoisomerase-ii-a can significantly stratify the recurrence risk in patients with bladder cancer after transurethral resection s. petrov * , k. malkhasyan, r. khasanov * kazan cancer center, dept. of pathology, russia objective: the current predictive models based on main clinical tumor features are not accurate for the biggest bladder cancer patient group, who underwent the transurethral resection (tur). method: overall patients with primary urocarcinoma after tur were included in this retrospective study. the follow up plan in all cases included cystoscopy and biopsy every months in the first years. the recurrence criteria were cystoscopical and pathological confirmation of the tumor growth. in all cases using tma technique (tma master, dhistech) there was done the ihc expression study of p , p , ck , e-cadherine, b-catenin, cd v , ki- ( % cut-off), topo-ii-a ( % cut-off) and her , as well c-erb-b amplification study (cish). results: there were no association found between the her expression and c-erb-b amplification in urocarcinoma patients. in multivariate regression analysis only ck , ki- and topo-ii-a showed the significant prognostic power in recurrence prediction. these markers were used to develop the powerful predictive index for bladder cancer patients after tur. conclusion: although the her overexpression is relatively common event in bladder cancer, c-erb-b gene amplification isn't main mechanism of its realization. the ck , ki- and topo-ii-a are promising prognostic markers for recurrence and should be validated in further prospective study. solitary fibrous tumor of the urinary bladder associated with a high-grade urothelial invasive carcinoma. a case report a. pitino * , s. squillaci, c. spairani, m. ferrari, m. f. cosimi, w. fusco, c. rossi, f. montefiore, g. l. bigatti, v. la paglia * san giacomo hospital, division of anatomic pathology, novi ligure, italy objective: solitary fibrous tumor (sft) is an unusual spindle cell neoplasm, which can exceptionally occur in the urinary bladder. method: we present a case of urinary bladder sft in a year-old man who complained of pelvic pain. cystoscopy revealed a large protruding, fleshy mass at the anterior wall of the bladder. a biopsy was first misclassified as inflammatory myofibroblastic tumor (imt). subsequent complete transurethral resection was performed. results: macroscopically, a × × cm greyish lobulated firm polypoid tumor was seen. microscopically, it consisted of uniform spindle cells with elongated tapered ends nuclei forming a patternless growth in a collagenous background. mitotic figures were rare. immunohistochemically, the neoplastic cells were positive for cd and bcl- , and negative for α-sma, desmin, ck ae / ae and alk- . the bladder urothelium showed foci of high-grade transitional carcinoma with lamina propria invasion. conclusion: initially, sfts were thought to be of mesothelial origin. then, these tumors have also been observed in extrapleural and extraserosal sites, which suggests a mesenchymal cell origin. the differential diagnosis should always include other spindle cells lesions such as sarcomatoid carcinoma, leiomyosarcoma and imt. to date, this is the first reported case of association of urinary bladder sft and high-grade urothelial invasive carcinoma. renal oncocytomas with unusual features: clinicopathological study of cases f. j. queipo * , h. d. quiceno, f. j. pardo, Án. f. panizo, m. l. gómez-dorronsoro, g. aisa, f. j. monzón, e. mejía, c. del agua, j. alfaro * clínica universidad de navarra, pathology, pamplona, spain objective: oncocytoma (ro) is a benign renal neoplasm, with a wide morphologic spectrum and excellent prognosis. recently, it has been described worrisome morphological features. method: ro treated in our centres were reviewed, and we focused on identifying the worrisome and the atypical features. results: we identified ro with at least one of the worrisome feature. patients: m/ f (mean age , year; range: - ). mean tumor size: , cm (range: , - , cm); right kidney: , and left: cases. invasion into the perinephric or renal sinus fat was the most frequent worrisome feature: tumors ( , %) and focal chromophobe carcinoma-like areas in cases ( , %). lymphovascular invasion, entrapped renal tubules-glomeruli, necrosis and mitosis were found in ( , %) respectively. all but two ros had at least worrisome features. followup was available for all cases (median months; range - ): all patients were alive without recurrence or metastasis. conclusion: ro is a tumor which often can show worrisome and atypical morphology. it is necessary to know and recognize the worrisome features to prevent diagnostic errors, if otherwise typical oncocytoma morphology is present. despite these atypical morphological data, the prognosis is excellent. ki and p expression in urothelial carcinomas and clinicopathologic correlation a. ribeiro * * chlc, epe, serviço de anatomia patológica, lisboa, portugal objective: the most important predictive parameter for the biological behaviour of urothelial carcinoma is histological grade, except for depth of invasion. the aim of this study was to investigate the expression of p oncoprotein and ki antigen in a series of transitional cell bladder carcinoma with papillary morphology (ptapapillary carcinoma and pt ) with histological grade and recurrence. method: this study included cases diagnosed with urothelial carcinoma with papillary morphology (pta, pt ). immunohistochemical expression of ki and p were examined in each case, and were graded accordingly to the percentage of cells stained, in low, moderate and high-expression groups. results: as described previously in other publications the expression of p and ki has a relationship with histological grade. we also noted that of the recurrences, were associated with moderate to high expression of either p or ki , or both. conclusion: we concluded that p and ki expression combined with histological grade and pathological stage may be helpful in assessing more accurately the biological behaviour of urothelial carcinoma. and the overexpression of p and ki are related with an unfavourable prognosis. objective: prostatic stromal hyperplasia with atypia is a rare lesion with fewer than cases reported worldwide. it can be mistaken for sarcoma because of the presence of atypical, bizarre cells. its malignant potential is uncertain. the follow up study of every case is important. method: a -year-old man with previously diagnosed atypical prostatic adenostromal hyperplasia with atypia of stromal cells was hospitalized with urinary obstruction after transurethral resection of prostate made years ago. repeat turp was performed and tissue specimens were investigated and compared with the initial biopsy. results: the second biopsy showed the benign hyperplastic prostatic glands with atypical, bizarre, frequently multinucleated giant stromal cells between them. they displayed intense immunoreactivity for actin, vimentin and androgen receptors. the microscopical picture was identical to that seen in the first specimens. the nuclear abnormalities looked like in an atypical symplastic leiomyoma of myometrium. no evidence of sarcomatous or carcinomatous transformation, mitotic index evaluation was noted. conclusion: this case maintains the viewpoint that the prostatic adenostromal hyperplasia with stromal cell atypia is a benign lesion. but it can recur and requires the repeat turp or radical surgery. cancer risk in patients with precancerous lesions of the prostate y. rogov * , v. zakharava, t. liatkouskaya, e. cherstvoy * belarusian medical academy, dept. of pathology, minsk, belarus objective: prostatic intraepitelial neoplasia (pin) and atypical small acinar proliferation (asap) has a high predictive value as markers for prostate cancer (pca). method: pca-risk in patients with precancerous lesions has been assessed on biopsy material in patients having morphological suspicious to pca. suspicious foci were estimated with use of cocktail amacr + hwc + p . results: according to our results revealing of precancerous lesions in biopsy specimens has been associated with pca identification in re-biopsies (f= , ). within the first- years the overall incidence of pca in re-biopsies made % in the group of precancerous lesions and %in the asap group. life-time-without-pca median made up -years with no reliable difference between pin and asap groups (ww= , ; p= , ). thus, the cumulative share of patients without pca in the asap group formed %- %- %- %- % at the end of the first-second-thirdfourth-fifth year of supervision respectively. conclusion: within the first years pca risk makes % in the general group of precancerous lesions of the prostate and % in asap group with no difference between asap and pin groups. Сumulative share of patients without pca in rebiopsy specimens decreased from % to % during these years. benign prostatic hyperplasia and prostate carcinogenesis after the chernobyl accident in ukraine a. romanenko * , a. chekalova, a. yurakh, p. harkonen, s. vozianov * institute of urology, kiev, ukraine objective: the prevalence as well as immunohistochemical (ihc) study of latent, incidentally found prostate cancer (lpc) as well as precancer lesions, in patients, who underwent surgery for bph were studied. method: bph samples were obtained by prostatectomy from ukrainian patients consisting of patients from areas without radio-contamination (control group ) and of patients living in cs contaminated areas of ukraine (group ). ki- , p , p kip- , p and bcl- proteins were ihc investigated in bph from all patients. results: the incidences of lpc (gleason score ), chronic prostatitis, pia and pin were . , . , , and . % in group ; . , . , . and . % in group , respectively. greatly elevated levels of p , ki- , bcl- associated with decreased levels of p kip- and p in areas of pia and less lpc and pin in group to compare with group patients were obtained with statistically significant differences. conclusion: our study suggests that chronic long-term lowdose radiation exposure might result in the increase of chronic inflammation and it is now found to be associated with increased incidences of pia and pin in bph accompanied by p , p kip- and bcl- alteration which in turn could lead to prostate carcinogenesis. eosinophilic globules in rete testis mimicking yolk sac tumor in a testicle with seminoma e. ronne * , t. argyrakos, d. rontogianni * evangelismos hospital, dept. of pathology, athens, greece objective: the recognition of a non-seminomatous component in an otherwise typical testicular seminoma changes the choice of adjuvant chemotherapy. method: a -year old male underwent orchiectomy for a testicular mass. serum tumor markers levels (β-hcg/afp/ ldh) were normal. results: macroscopical examination revealed a . cm white-yellow tumor. the tumor was composed of the characteristic for seminoma homogenous, clear cells arranged in nests and islands separated by septa and infiltrated by lymphocytes. immunohistochemically the tumor cells were positive for plap, oct / , cd and d - and negative for cd and ck . . there was also a regular pattern of tubular structures infiltrated by the seminoma cells while retaining a low columnar type epithelium. the presence of sphaerical eosinophilic globules (pas+/dpas+/afp−) within the tubular lumina was strongly reminiscent of the hyaline globules of yolk sac tumor. the tubular structures were positive for ck . and negative for afp, glypican- and oct / . conclusion: the presence of tubular structures with sphaerical eosinophilic globules creates a suspicion for a yolk sac tumor component. the absence of afp and glypican- expression, the regular pattern of the tubular structures and their continuity with rete testis excluded this suspicion. hyaline eosinophilic globules in rete testis should not be confused with the globules produced by yolk sac tumors. beta-catenin expression and ctnnb mutations in a series of wilms tumours r. santi * , p. pinzani, f. salvianti, g. baroni, m. pepi, g. nesi * university of florence, pathological anatomy section, italy objective: ctnnb mutations have been found in - % of wilms tumour (wt) cases. nuclear beta-catenin protein has been detected by immunohistochemistry in a higher proportion of wts, thus suggesting alternative genetic pathways leading to beta-catenin activation in these neoplasms. method: sixteen renal wts and secondary wt localizations were retrospectively investigated. the series included paediatric patients, females and males, with a mean age of . years and a year-old female patient. immunohistochemical analysis of beta-catenin was performed and findings were reported for each neoplastic component (i.e. epithelium, stroma and blastema). tumour dna was extracted for direct sequencing analysis. results: the majority of wts showed moderate to strong membranous staining for beta-catenin in the epithelial ( . %) and the blastemal ( %) components. nuclear betacatenin expression was observed in combination with cytoplasmic staining in the mesenchyma and/or the blastema of two primary renal tumours. in these cases the deletion of codon p.s del and the missense substitution p.t a were detected. conclusion: preliminary results of this ongoing study highlight beta-catenin cytoplasmic and membranous expression in the tumour cells of primary and metastatic wts, with few cases demonstrating nuclear expression. in our series, betacatenin nuclear expression was invariably associated to ctnnb mutation. a preliminary study on o -methylguanine-dna methyltransferase and type transglutaminase expression profile of renal cell carcinomas b. sarsik * , b. pehlivanoglu, d. tunali, a. simsir, e. gokmen, s. sen * ege university, faculty of medicine, izmir, turkey objective: o -methylguanine-dna methyltransferase (mgmt) repairs o -methylguanine in dna, therefore provides a tumor supressor effect. type transglutaminase (tgase- ) is a multifunctional enzyme involved in many biological processes. few data are available in the literature on their expression in kidney cancers. in this preliminary study, we evaluated immunohistochemical expression of mgmt and tgase- in renal carcinoma cases. method: forty cases of renal carcinoma including ten clear cell, ten chromophobe cell, ten papillary and ten urothelial carcinoma were randomly selected. thirty-one patients were male and average age was , . staining intensity and percentage of staining tumor cells were scored. total score was categorized as weak, moderate and strong. results: strong mgmt positivity was demonstrated in cases ( %). eight cases ( %) showed strong tgase- expression. fifty percent of clear cell carcinomas strongly expressed mgmt and tgase- . no correlation was found between mgmt and/or tgase- expression, tumor size and grade. eighty percent of urothelial carcinomas strongly expressed mgmt. conclusion: the prognostic value of mgmt and tgase- as well as their potential role in treatment response have been investigated recently. mgmt and tgase- may be prognostic factors in renal carcinomas. further investigation is required to verify our findings. three dimensional topographic analysis of cases of radical prostatectomy a. n. seo * , k. s. lee, g. choe * seoul national univ. bundang, pathology, seongnam-si, objective: prostate cancer is typically mutifocal, and there has been no report about the exact number of prostatic carcinomas in each case. we have performed topographic analysis using three dimensional mapping technique. method: we established data base including cases of radical prostatectomy consisting of individual adenocarcinomas, and performed comprehensive pathologic analysis. objective: tmprss -erg gene fusion is the most common genetic alternation in prostate cancer. it is associated with the expression of oncogene erg protein. recently, the immunohistochemical staining method that using anti-erg antibody was verified strong correlation with erg protein which is the product of genetic alteration. aim of this study is to declare that the relationship between erg expression and clinicopathological factor. method: otal cases of radical prostatectomy specimen were assessed. all cases were constructed tissue microarray and immunohistochemical staining was performed. results: erg-positive rate was . % ( / ) and significantly higher expression of erg expression was observed in the subgroup that has lower gleason score. (p< . ) analysis with the histologic pattern of prostate adenocarcinoma, tumors with discrete glandular unit (gleason pattern ) is shown higher frequency of erg expression (p= . ). conclusion: erg-positive case was smaller than that of western population (about %) and other factors including age, tumor volume, initial psa level, pathological stage and margin status were not significantly related with erg expression. in conclusion, positive rate of erg immunohistochemical staining is meaningful higher in the tumors with wellformed gland that is represented by lower gleason score. solitary fibrous tumour of the kidney mimicking renal cystic neoplasm t. tichy * , j. skarda * university hospital olomouc, institute of pathology, czech republic objective: solitary fibrous tumour (sft) can develop at any anatomic site, but in the kidney is described rarely. in general, sft forms an unencapsulated solid mass. we report a case of a -year old woman with benign sft of the left kidney. the tumour showed extensive pseudocystic change and mimicked renal cystic neoplasm. method: a nephrectomy specimen showed cystic tumour beneath renal capsule and in peripelvic adipose tisssue. histological sections were used for hematoxylin-eosin and for immunohistochemistry (antibodies against vimentin, smooth muscle actin, desmin, s- protein, cd , cd , bcl- , cd , ck , ae -ae , ema). results: microscopically the tumour showed uniform spindle cell proliferation with expansive tumour margins, without necrosis or hemorrhagies. mitotic activity was per high power fields. cystic spaces without epithelial lining contained eosinophilic proteinaceous fluid. imunohistochemically tumour showed difuse positivity for cd , cd , bcl- , vimentin and stained negatively for s- protein, cytokeratins, ema, smooth muscle actin, desmin and cd . conclusion: sft of the kidney is infrequent. some renal sft can undergo pseudocystic transformation and mimic renal cystic neoplasm both clinically and macroscopically. objective: renal angiomyolipomas are mesenchymal tumors that comprised of adipose tissue, smooth muscle like cells and abnormal thick walled blood vessels admixed in various proportions. epithelial renal angiomyolipomas are rare variants and may exhibit atypia. in the literature epithelioid renal angiomyolipomas with atypia are reported to have malignant potential. method: left radical nephrectomy was performed due to renal mass with flank pain and hematuria. results: in gross examination; . × . × cm gray white mass with occasionally necrotic areas at the middle portion of left kidney renal sinus and perinephritic fatty tissue, macroscopically. microscopic eveluation reveals; tumoral lesion comprised of adipose tissue, smooth muscle and blood vessels, showing areas of epitheloid morphology and moderate to severe degree of nuclear atypia. in addition to histomorphology positivity hmb- immunohistocemistry elaborated to the diagnosis of "epitheloid renal angiomyolipoma with atypia". conclusion: this case has been presented due to its infrequent occurrence and malignancy potential. correlation of minute focus of prostate adenocarcinoma on random multifocal needle biopsy with radical prostatectomy specimen a. urbanskiy * * russian research centre for ra, pathology, st. petersburg, russia objective: this work attempts to determine the importance of small foci of prostatic cancer in random multifocal needle biopsy specimens. method: patients with a microscopic focus confined to a single core specimen (which defined as tumor less than mm with a gleason score of or less) were identified from a retrospective review of needle biopsies of the prostate. twelve of these subsequently under went radical retropubic prostatectomy at our centre. clinically significant tumors were defined as those with volume greater than . cc. results: average tumor volume was , ± , cc (range , - , cc). in , % ( ) of the cases was less , cc (range , - , cc, mean volume - , ± , cc). there was ( , %) of patient with extraprostatic extension. conclusion: our data have shown high frequency of revealing insignificant tumours (mean ± %; Р= , ). however, about % of patients had clinically significant tumors warranting definitive therapy. the smallest focus of cancer on needle biopsy is not a guarantee of a clinically insignificant tumor. ps- - e-cadherin in mice: expression in normal urothelium, pre-neoplastic and neoplastic urothelial lesions c. vasconcelos nóbrega * , c. costa, r. arantes-rodrigues, a. henriques, h. vala, a. colaço, l. santos, c. lopes, p. oliveira * escola sup. agrária viseu, dzerv, portugal objective: e-cadherin is an adhesion molecule that promotes the integrity and stability of the urothelium. a decrease in its expression is associated with more aggressive tumour phenotypes, with the ability to invade and metastasize. our aim was to describe the expression of e-cadherin in normal urothelium and in urothelium with pre-neoplastic and neoplastic lesions of icr male mice. method: urothelial lesions were chemically induced by nbutyl-n-( -hydroxybutyl) nitrosamine in icr mice, and evaluated by immunohistochemistry in order to determine the staining pattern of e-cadherin. results: in normal urothelium, . % of e-cadherin expression was at the cellular membrane level. in simple hyperplasia, the same pattern was observed in . % of lesions. nodular hyperplasia exhibited a mixed pattern ( % membrane and % cytoplasmic pattern). in . % of dysplasia, a cytoplasmic pattern was seen. on invasive carcinoma the majority of invasive urothelial cells exhibited a pattern of membrane and cytoplasmic staining. on squamous metaplasia it was observed a membrane pattern on basal and intermediate layers, and a loss of immunoreactivity in the most superficial ones. conclusion: e-cadherin is a valuable tool for investigating the cellular adhesion status of the urothelium in mice. neoplastic lesions exhibited an abnormal, heterogeneous staining pattern. new potential prognostic and predictive factors in conventional clear cell renal carcinoma p. latalova * , p. flodr * fmd pu and fh olomouc, dept. of clinical and molecular pathology, czech republic objective: biological behavior of conventional clear cell renal carcinoma (ccrc) is associated with tumour stage and grade. cancer progression with metastasis is part of a process epithelial-mesenchymal transition (emt) and is joined with invasiveness due to adhesion and cytoskeleton change. the central role of the emt mechanism is attributed to snail factor. the intermediate filament expression is changed through the progression of many types of neoplasms. these changes are organ or tissue specific and depend also on the degree of malignant transformation (genome instability acceleration). the expression changes of cytokeratin (ck ) are signs of aggressive biological behaviour in some tumour types -e.g. colorectal and breast carcinoma (downregulation of expression) or ccrc (upregulation of expression). the expression of snail and ck molecules and mrna ck levels correlate to stage and grade of ccrc (according messai et al. ) . objective: study was based on the expression of immunohistochemical markers (ck , ck , vimentin, snail, cd ) in cases with evaluation of the primary tumour and its metastasis. results: the difference and similarity of intensity and percentage of positive neoplastic population between the primary and the secondary carcinoma will be presented. conclusion: snail and ck seem to be potential tumour progression factors and may be included in so called personalised medicine. objective: sarcomatoid carcinoma (sc) of the prostate is a rare variant of prostatic cancer representing less than % of prostate tumors. tumors are most commonly composed of an admixture of both malignant glandular and spindle cell elements. the sarcomatoid component can vary from % to %. method: we report the case of a -years-old patient with an invasive tumor of the prostate for which he had a radical prostatectomy. histopathological examination showed that the tumor was responding to an undifferentiated proliferation made of beaches and clusters of pleomorphic cells usually spindle-shaped, with eosinophilic cytoplasm, and elongated or oval nuclei, which are very irregular, sometimes monstrous, multinucleated, basophils with numerous mitotic figures. in some places, there were areas of glandular differentiation and foci of comedocarcinoma. immunohistochemical study showed immunoreactivity of spindle and pleomorphic cells with cytokeratin and vimentin. results: the diagnosis of sarcomatoid carcinoma of the prostate-grade gleason + was confirmed. conclusion: sc of the prostate is an exceedingly rare tumor. retrospective analyses render prostate sc as one of the most aggressive prostate malignancies. the prognosis is dismal regardless of other histologic or clinical findings. extra-uterine extension (figo stage ii-iv) were significant parameters of poor prognosis. no multivariate analyses were performed due series limitation. conclusion: detailed pathology evaluation, including histological subtype, and figo stage are essential in the adequate management decision/prognosis evaluation of u-lms. objective: over % of women with endometrial cancer show signs of uterine bleeding, so most cases are diagnosed at an initial stage. this study covers two patients who presented the first signs of this disease in an exceptional manner. method: case- a -year-old woman was afflicted with a six-month toxic syndrome. an omentum tumor was identified in the x-ray. eleven days after the excision, she demonstrated oliguria, dysuria, and scant uterine bleeding. the pelvic ultrasound revealed a uterine mass. case- a -year-old woman demonstrated disabling right inguinal pain. after an x-ray examination of her pelvis, a metastasis was suspected. a biopsy confirmed it. the immunochemistry pointed to a gynecologic, pancreatic or intestinal tumor. the computer tomography scan revealed a uterine mass. results: the first case only suggested an estromal gastrointestinal tumor or a mesothelioma, misdiagnosing and missing the endometrial carcinoma. the second case was uncommon as bone metastasis is found with solid tumors but seldom occurs with endometrial cancer and even less so as a first sign. conclusion: we must consider endometrial cancer at signs of uterine bleeding, however, further investigation is required in order to consider the % who do not show the common signs. extrapelvic endometriosis presenting as a retroperitoneal tumor a. alves * , p. luís, a. ribeiro, m. ferreira * hospital santa maria, servico de anatomia patologica, lisboa, portugal objective: endometriosis is a benign disease characterized by the presence of functional endometrial tissue in ectopic locations. retroperitoneal, liver or kidney involvement are extremely rare. method: we present a case of a -year-old woman, which was referred to surgical consultation because of a retroperitoneal mass that was found on a routine abdominal ultrasonography (us). a subsequent ct scan showed a cm tumor involving the liver, right kidney and adrenal gland. the gynecological us revealed ovaries with normal size and two probable uterine leiomyomas. she was submitted to a tumorectomy with segmental hepatectomy and nephrectomy. results: grossly, the tumor was × × cm, invaded the kidney, the liver and a segment of diaphragm. it was white, fasciculate and with hemorrhagic focus. histologically the tumor was composed of a biphasic proliferation of endometrial glands and endometrial stroma, both without atypia. the case was diagnosed as deep infiltrating extrapelvic endometriosis. with a years follow-up, the patient is doing well and without evidence of disease. conclusion: despite being an extremely rare presentation, endometriosis can involve retroperitoneal organs and simulate a malignant neoplasm, even without a previous history of pelvic involvement. objective: malignant melanoma of the female genital tract is a multifocal disease resulting from a disorder of melanocytes cotyledonoid dissecting leiomyoma is a benign smooth muscle tumor which can mimic a malignant lesion due to its alarming aspect. there are some variant forms of leiomyomas with an unusual infiltrative growth pattern. due to its worrying appearance of the gross specimen, it is often mistaken for malignant lesion and it is important to be aware of this entity not to over treat this benign smooth-muscle neoplasm. we report a case of a years old woman who underwent hysterectomy because of the suspect of a tumor growing from the right lateral uterine wall. on gross study the tumor measured mm in diameter and was nodular, brown in color and irregular on cut section. histological examination showed a nodular tumor composed of smooth muscle cells with a storiform pattern which dissects the uterine wall. the tumor was highly vascularized, included a myxoid component and showed some areas with invasion of vascular components. cellular atypia, mitosis and necrosis were absent. the patient has had a good clinical course, without relapses until the date, what supports the fact that these tumors have a benign clinical behavior, even though they may have a malignant appearance. uterine leiomyoma with lymphoid infiltration a. n. deger * , c. kocak * s.b. dpu. kec. ea hastanesi, patoloji bolumu, kutahya, turkey objective: although leimyomas of the uterus are common, lymphoid infiltration of leimyomas is a rare occurrence. we presented a case of a -year-old woman whose leiomyoma was diffusely infiltrated by lymphocytes. lymphoid infiltration was analyzed with immunohistochemical methods and infiltration was found to be polyclonal type. method: a -year-old woman with abnormal uterine bleeding was prediagnosed uterine leiomyoma and she was applied total abdominal hysterectomy and bilateral salphingo-oopherectomy. the analysis of the sample sent to pathology lab showed two leiomyomas. hematoxylin eosin -stained slides were prepared after sampling. ımmunohistochemical stains were applied. results: microscopic examination of leiomyoma in greater diameter revealed a lesion with well-circumscribed borders composed of interlacing fascicles of bland monomorphic spindle cells diffusely infiltrated by lymphoid cells. the infiltrate not extended into the surrounding myometrium. immunohistochemical analysis showed positive staining with cd , cd , cd . it was seen that inflammatory infiltration was polyclonal and involved t cells, b cells and histiocytes. leiomyoma with lymphoid infiltration was diagnosed. the postoperative course was uneventful within a month follow up period. conclusion: leiomyoma with lymphoid infiltration first described in by ferry et all. from that date on, the literature involves few cases. because it is rare and differential diagnose with malignant lymphoma is crucial, we presented the case and reviewed the literature. objective: vulvar intraepithelial neoplasia is divided into two groups: usual type and differentiated type. the differentiated vulvar intraepithelial neoplasia, which is frequently seen with invasive squamous cell carcinoma, can be confused with some benign lesions. the aim of this study is to analyse p , p , and ki- expression characteristics of different histological types of vulvar intraepithelial neoplasia, invasive squamous cell carcinoma, and benign lesions of the vulva. method: in this study, immunohistochemical analysis of vulvectomy cases with p , p , and ki- was performed. results: of patients who underwent vulvectomy, nine had invasive squamous cell carcinoma and nine had vulvar intraepithelial neoplasia. four additional vulvar intraepithelial neoplasia lesions were found accompanying the invasive squamous cell carcinomas. nine benign lesions were found accompanying the invasive squamous cell carcinomas and vulvar intraepithelial neoplasia. mean ki- proliferation index was . % in the usual type of vulvar intraepithelial neoplasia cases and . % in the differentiated vulvar intraepithelial neoplasia cases. no p expression was present in benign lesions. conclusion: ki- pi does not recognize the usual type or differentiated type of vulvar intraepithelial neoplasia. p positivity can be of value in distinguishing differentiated type vulvar intraepithelial neoplasia from benign lesions. an audit of surgical pathology reports of endometrial carcinoma: experience from a referral centre in india k. deodhar * , b. rekhi, s. menon, b. ganesh * tata memorial hospital, dept. of pathology, mumbai, india objective: the aim was to see, compliance to minimum data information in carcinoma endometrium reports, in a team of pathologists; and also to analyze these parameters e.g. tumor size, type, grade, depth of myometrial invasion, lymph node yield, ptnm stage etc. method: during the period of - , from the files of pathology department of our hospital, reports of operated carcinoma endometrium cases were retrieved and analyzed for various, above mentioned, parameters. results: the median age was . years and median tumor size was cm. endometrioid adenocarcinoma was the commonest type ( . %); followed by mmmt ( . %) and serous carcinoma ( . %). grade was the commonest tumor grade ( . %). less than half of myometrial invasion was seen in % of the cases, =/> half myometrial invasion was seen in . % of cases. (information-not available in cases). parametrial involvement was seen in . % cases. the ptnm stage was not mentioned in . % reports. the median lymph node yield was . conclusion: the compliance to adhere to minimum data information in carcinoma endometrium reports is generally good. lymph node yield is reasonable. parametrial involvement and mentioning of ptnm staging is to be done more meticulously. use of proformas/checklists is recommended. extraovarian granulosa cell tumor: a case report i. efstratiou * , s. pervana, e. pazarli, d. alataki * papageorgiou hospital, dept. of pathology, thessaloniki, greece objective: extraovarian granulosa cell tumor is a very rare neoplasm. we report a case of a tumor located in mesocolon. method: a -years-old woman presented with abdominal pain and fever. abdomen ct showed a mesocolic mass adherent to the left kidney and the spleen. she underwent resection of a cm long segment of the left colon with a circumscribed mesocolic tumor measuring × cm. the tumor was infiltrating the subserosa of the large intestine. intraoperatively normal ovaries have been identified. results: histologically the tumor is composed by monomorphous cells in solid nests developing cavities which contain serous or hemmorhagic fluid. the tumor cells have scanty cytoplasm and often grooved nuclei. mitoses are very rare. the tumor cells were immunoreactive for vimentin, inhibin and progesterone receptors. the postoperative course was uncomplicated and the patient is free of disease months later. conclusion: light microscopic and immunohistochemical features of the tumor are similar to those of ovarian granulosa cell tumors (gct). since the tumor was resected in toto and the mitotic activity of the cells is very low, we expect a favorable prognosis. extraovarian gct are very rare and only cases have been published during the last years. probably these tumors arise from residual tissue of the genital ridge (so-called secondary mullerian system). detection of amplification of terc and tert genes in cytology samples from cervical neoplasias by fluorescent in situ hybridization a. farkasova * , e. kudela, t. balharek, p. zubor, j. danko, l. plank * jfm cu, dept. of pathology, martin, slovakia objective: increased telomerase activity represents an early event in cervical carcinogenesis allowing cell immortality by recovering chromosomal telomeres. thus, detection of terc and tert gene amplification might represent a diagnostic and valuable prognostic biomarker of cervical neoplasias. method: cervical smears from patients classified according to bethesda as nilm (n= ), asc-us (n= ), l-sil (n= ), h-sil (n= ) and scc (n= ) were analysed for terc ( q ) and tert ( p ) gene amplification by fluorescent in situ hybridization (fish) in cells per slide using a four-color fish probe (fhact™). results: the numbers of terc and tert copies, average ratio of gene copies and average number of cells with ≥ terc gene copies were highest in scc, followed by h-sil, l-sil, asc-us and nilm cases. correlation between terc/tert amplification intensity and oncocytological findings was statistically significant (p< . ). conclusion: fish analysis of terc and tert genes could be effective tool for the diagnosis of cervical neoplastic lesions. using together with cytology and hpv dna testing it can achieve higher sensitivity and specificity to discriminate h-sil and invasive carcinomas from l-sil lesions. objective: ovarian stromal hyperplasia (osh) is characterised by non-neoplastic overgrowth of the ovarian cortical. mild hyperplasia of the cortical and medullary stroma is found in the ovaries of about one-third of perimenopausal and postmenopausal women. it is nearly always diffusely bilateral. we report a case of osh associated with endometrial carcinoma (ec). method: a -years-old caucasian woman, obese, smoker, with fatty liver, gilbert´s syndrome and cholelithiasis. she had endometrial curettage biopsy for dysfunctional uterine bleeding for month, which was diagnosed of complex atypical endometrial hiperplasia. a total abdominal hysterectomy whith bilateral salpingo-oophorectomy were performed. results: the diagnosis was well differentiated endometrioid ec and bilateral osh with focal stromal hypertecosis. conclusion: osh of moderate to severe degree may be found in women with disorders associated with androgenic and estrogenic manifestations including ec, obesity, hypertension, and glucose intolerance, but these findings are less frequent and less obtrusive than in stromal hyperthecosis. obese woman are at risk for developing endometrioid ec as a result of the increased capacity in adipose tissue to convert androstenedione to oestrone, and testosterone to oestradiol. a relationship in the origin of hormone-dependent endometrial pathology may exist between osh, blood androgen levels and ec. detection of micrometastases in para-aortic lymph nodes in patients with carcinoma of the uterine cervix after negative frozen section analysis l.-c. horn * , c. kellner, r. scherling, m. höckel, j. einenkel * medizin. universität leipzig, institut für pathologie, germany objective: previous studies considered the presence of micrometastases (mm) in pelvic lymph nodes as clinically relevant prognostic indicator. method: frozen section analysis was performed in all cases. after fs-examination nodes were examined by one h&e-stained slide. all nodes without metastatic disease after frozen section and permanent section examination were subject of the present study. patients and pan were enrolled and immunohistochemical staining using two cytokeratin-cocktail antibodies (ae /ae and kl-) was performed. results: in one case, one single node showed micrometastasis, representing an incidence of . % of the studied cases and . % of the examined lymph nodes. in three cases benign endosalpingiosis was seen. the patient with mm is alive without evidence of disease months after surgery. itc were not observed. conclusion: the frequency of mm in pan is very low. there are only limited data regarding their prognostic impact within the literature. after careful examination of all removed pan using h&e-staining (and step sectioning), immunohistochmeical ultrastaging cannot be recommend for routine use. serous tubal in situ carcinoma (stic) in tubal and primary peritoneal carcinomas l.-c. horn * , k. leonhardt, s. kafkova, j. einenkel * medizin. universität leipzig, institut für pathologie, germany objective: serous tubal in situ carcinoma (stic) has been defined as one important precursor of pelvic serous cancer. morphologically, stic is defined by are cytologic atypia, high proliferative index and strong staining for p . method: the present study evaluates the presence of stic and p -signature in consecutive cases of prophylactic salpingo-oophorectomy in women with brca- -mutaion (bso), macroscopically inconspicuous tubes of patients with primary tubal cancer (tc) and cases of primary peritoneal cancer (ppc) using immunohistochemistry against ki- and p (clone do- ). results: the frequency of p -signature and stic was % and % in cases of prophylactic surgery, % and % in tc and % and % in ppc. conclusion: stic and p -signature as precursor lesions of pelvic serous cancer is seen in macroscopically inconspicuous fallopian tubes in unilateral tc in patients with elective bso and patients affected by ppc. we propose that the sectioning and extensively examining the fimbria protocol be applied to all cases with ppc, tc and in women with prophylactic bso. objective: primary adenocarcinoma of the vulva is rare, and enteric differentiation is excepcional. only a few cases of neoplasms of pure intestinal-type in the low genital tract have been reported. they are considered to arise from cloacal remants or from intestinal heterotopia. method: we present the case of a year-old woman, with a histerectomy performed years before. on clinical examination a polipoid lesion in the vulvar vestibule was noticed. biopsy revealed a tubular adenoma of intestinal type with a focus of adenocarcinoma. the first histologic interpretation was a metastatic intestinal tumor. clinical examination, recto-colonoscopy and magnetic resonance imaging of the abdomen excluded this possibility. results: the immunohistochemical study showed reactivity with citokeratin but didn't with citokeratin . all this led to conclude that it was a primary intestinaltype adenocarcinoma of the vulva arisen from an adenoma. conclusion: on our knowledge there are less than reported cases of intestinal adenoma in the genital tract. they have been described also in the vagina and cervix but only a few developed an adenocarcinoma. it is important to be aware of this tumor type and to distinguish it from metastatic colorectal adenocarcinoma in order to plan appropriate treatment. ligneous cervicovaginitis and endometritis: case report m. koyuncuoglu * , e. dogan * dokuz eylul university, dept. of pathology, izmir, turkey objective: ligneous (wood-like) disease is a rare chronic pseudomembraneous inflammation of the mucous membranes which may also affect genital tract. the underlying pathogenesis is still unclear and an effective method of treatment has not yet emerged. method: here we present a years old female patient presented to our clinic with years of unexplained infertility. her diagnostic infertility work-up revealed no abnormality. however, at gynecologic examination there was a thick and hard granulation tissue at the cervix extending to the posterior vaginal wall. transvaginal ultrasound was unremarkable except for increased endometrial thickness. results: cervicovaginal and endometrial biopsy with diagnostic hysteroscopy was performed which demonstrated ligneous inflammation of both cervix and vagina. endometrial biopsy was reported as chronic non-specific endometritis with dense fibrin deposition. conclusion:. the disease may also affect other organs including oral cavity and eyes. this unusual condition is difficult to treat and lack of awareness makes the diagnosis also problematic. objective: differential diagnosis lm vs stump may be controversial, especially regarding necrosis evaluation; few studies address the relation between different treatments and their morphological effects. we aim to characterize a series lms and putative stumps harboring necrosis. method: consecutive putative stumps ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and a series of lms with necrosis diagnosed at chsj & ipop-porto. clinical files, particularly previous hormonal treatment (ht), gross specimen and histology features. results: putative stumps and lms with necrosis. lms mean age at diagnosis: years; mean size: . cm ( . - ); % with other lms; treatment: myomectomy ( %) and hysterectomy ( %); % peri-partum, . % post-uterine artery embolization; ( %) previous ht: progestin ( %), oral contraceptive-oc ( %), hormonal-iud ( . %), and medical assisted reproduction ( . %). stumps mean age at diagnosis: years; mean size: cm ( . - ); % with other lms; low mitotic index-mi (mean . ; median / hpf); slight cell atypia; variable ischemic/ tumor-type necrosis. treatment: myomectomy ( %), hysterectomy ( %) and radiotherapy ( %); ( %) previous ht: progestin ( %), oc ( %), hormonal-iud ( %); no recurrence in remaining cases (n= ): median follow-up: . months. conclusion: lms with necrosis and stump may display overlapping features. diagnosis of stump should consider previous ht, detailed morphology (necrosis type/atypia/mi), to prevent overdiagnosis of stump. positivity. plap and chromogranin were negative. ki- nuclear positivity was found in less than % of sertoli cells and in about % of leydig cells in hyperplastic areas. karyotype was xy. conclusion: although, surgical pathologists encounter tfs rare in a clinical practice, they should be aware of this condition, especially in lack of relevant clinical data, when it could be interpreted as a tumor. objective: frozen section (fs) diagnosis of ovarian mucinous tumors can be difficult due to the size of these tumors, heterogeneity and potential risk of metastasis from gastrointestinal (gi) neoplasms. method: we reported ovarian mucinous tumors submitted for (fs) evaluation between january and avril was conducted. results: fs and final pathology results were collected. the average tumor size was , cm ( - cm). the fs and final pathology diagnosis were concordant in , % ( / ) of the cases. of the ( , %) discordant cases, one ( , %) was downgraded and cases ( , %) were upgraded. of the tumors interpreted as borderline mucinous tumors (bmt) on fs, ( , %) were malignant at final diagnosis ( ovarian, gi), ( %) remain as bmt and ( , %) was benign. of the benign tumors on fs, cases ( , %) were upgraded to bmt at final diagnosis. tumors with a malignant diagnosis on fs ( cases) were % concordant with final diagnosis. conclusion: our study showed a , % rate of discordance between fs and final diagnosis. given that gi origin is a possible finding, intraoperative assessment of the appendix should be performed in all mucinous ovarian tumors. uterine müllerian adenosarcoma: a clinicopathologic study of cases a. nasfi * , l. charfi, k. mrad, s. sassi, r. sellami-dhouib, r. doghri, m. driss, i. abbes, s. nechi, w. jomaa, k. ben romdhane * salah azaiez institute, dept. of pathology, tunis, tunisia objective: müllerian adenosarcoma (ma) is a distinctive type of uterine tumor, traditionally regarded as a low-grade variant of mixed müllerian tumors. method: thirty one cases of adenosarcoma were examined during a period of years (may -february . results: thirty tumors were of the uterine corpus and one of the cervix. the mean patient age was , years (range: to year). the main clinical manifestations were vaginal bleeding and pelvic pain. physical examination showed cervical/vaginal mass or pelvic mass. treatment was known in cases: patients underwent hysterectomy with bilateral salpingo-oophorectomy in cases and lymphadenectomy in cases. tumor size ranged from , to cm (mean: . cm). microscopically, sarcomatous overgrowth was found in cases ( %), heterologous elements in ( %). eleven cases ( %) had myometrial invasion involving the internal half of the myometrial thickness in cases, and more than % in cases ( %). the cervical tumor presented as an endocervical polyp without invasion of the cervical wall. conclusion: uterine ma are low-grade neoplasms capable of local recurrence and much less commonly distant metastasis. surgical excision is the main treatment strategy with a good prognosis in the early stage disease. the most important adverse prognostic factors are deep myometrial invasion and sarcomatous overgrowth. spectrum of epithelium changes in adenomyosis n. nizyaeva * , e. kogan, t. demura * scientific center of obstetric, dept. of pathology, moscow, russia objective: adenomyosis (am) is a very common gynecological disorder. despite high incidence of the disease epithelial changes precise developmental events leading to the condition remain controversial. the aim of the study was to investigate and compare epithelium morphologicaly and markers expression of proliferation, apoptosis, invasion and neoangigogenesis in am foci. method: this study was done on biopsy samples of uterus taken from women with adenomyosis. immunohistochemical staining of tissues was performed with antibodies to apocas, ki- , mmp- , timp- , claudins , (cl , ), e-cadherin, cox- , egfr, vegf. results: four variants of epithelium changes were found in am foci such as proliferative type, hyperplastic type with and without atypia, and atrophic type. times during years and investigated using routine light microscopy and immunohistochemistry (ihc) to control the treatment response. results: in the course of progestin treatment the complex endometrial hyperplasia with intraepithelial neoplasia became histologically less complicated and than normal. ihc profiles and ki- expression had the same dynamics. in the youngest patient the unusual gland cell atypia with focal calcification was observed one time and hysterectomy was considered. conclusion: the study confirms that the repeated curettages with conservative treatment and histological studying can be successfully used in some cases of complex endometrial hyperplasia with intraepithelial neoplasia. value of ki , p and ck markers in differentiating cervical intraepithelial neoplasia and benign lesions a. safaei * , m. pourjabali, f. sari aslani, m. momtahan * shiraz university of medical sciences, iran objective: the cervical cancer is one of the most common cancers among women worldwide. diagnosis of cin affected by high rates of discordance among pathologists. therefore, we need to other adjunct methods for accurate diagnosis of cin versus benign lesions in equivocal cases. the aim of this study was evaluation of ki- (mib- ), ck and p ink a (p ) markers by immunohistochemical method in differentiating cin from benign cervical lesions. method: seventy-seven cervical biopsies that originally diagnosed as non-cin (n = ) and cin (n = ), were reviewed by three pathologists and re-classified as non-cin (n = ) and cin (n = ), based on agreement between at least two of three, to obtain a consensus diagnosis. consensus diagnosis was defined as the "gold standard". then immunostaining for ki , p and ck was performed on all cases and their results were compared with original and consensus diagnosis. results: the overall agreement between original and consensus diagnosis was . % (kappa = . , p-value < . ). the sensitivity and specificity of ki immunostaining were . % and . % and for p were . and . %, respectively. the sensitivity and specificity of ck negative staining for cin detection were . % and . % respectively. conclusion: we recommended using ki and p markers as complementary tests for differentiation between dysplastic and non-dysplastic lesions. ps- - wt expression in ovarian borderline and malignant surface epithelial tumors m. tahamtan * , f. sari aslani, a. safaee * shiraz, iran objective: wilms tumor gene product, a tumor suppressor gene, now is considered to have oncogenic functions. there seems to be differences in wt expression among surface epithelial ovarian tumor subtypes. method: immunohistochemistry for wt was done on serous & mucinous cystadenocarcinomas, borderline serous & borderline mucinous tumors, endometrioid ovarian carcinomas, clear cell carcinomas, malignant brenner tumor, metastatic adenocarcinomas and endometrial adenocarcinomas. a tumor was considered negative if< % of tumor cells were stained. positive reactions were graded : +, - %; +, - %; +, - %; +, - %. results: of serous cystadenocarcinomaes, ( . %) were positive, showed reactivity of< % of the tumor cells and one were negative. all borderline serous tumors were positive. all mucinous tumors, endometrioid carcinomas, clear cell carcinomas, metastatic adenocarcinomas and primary endometrial carcinomas were negative. the single malignant brenner tumor were positive for wt . conclusion: wt is a good marker to distinguish primary ovarian serous carcinomas from other surface epithelial tumors (especially endometrioid subtype) and metastatic carcinomas (especially endometrial serous carcinoma), other than malignant mesothelioma. degree of expression is not an indicator to separate high grade borderline serous tumors from low grade ones. objective: fatwo is a rare neoplasm originating from the mesonephric duct remnants that occurs predominantly in the broad ligament but also in the ovary. it is considered a lowmalignant potential tumor. however local recurrences and metastases have been reported. method: a year-old female, on routine gynecological physical examination, followed by pelvic ultrasonography and computer tomography was diagnosed with a mass at the right ovary. a salpingo-oopherectomy was performed. on gross examination a well-circumscribed, solid and focally cystic tumor measuring , × × , cm arose in the ovarian hilus. results: microscopically the tumor consisted of mediumsized, ovoid to polygonal cells arranged in a solid, tubular and sieve-like pattern. some cystic spaces were lined by low-cuboidal cells and contained amorphous, eosinophilic material. cellular atypia and mitoses were rare. the tumor cells were positive for vimentin, inhibin-a (focally), cd , cytokeratins / , and (focally) and negative for cytokeratin , epithelial membrane antigen, carcinoembryonic antigen and a-fetoprotein. conclusion: histopathological and imunohistochemical findings consistent with an ovarian fatwo. differential diagnosis includes endometrioid carcinoma, clear-cell carcinoma, sertoli-leydig cell tumors (retiform variant) and rete ovarii adenoma. surgical excision is the optimal treatment. radiation therapy, chemotherapy or even targeting molecular therapy is questionable. müllerian adenosarcoma is a rare mixed tumor of low malignant potential. usually presented as a large endometrial polyp in postmenopausal women. they are associated with tamoxifen or radiation therapy. microscopy shows a mixture of benign glandular epithelium and low-grade endometrial sarcoma is typically concentrated around the glands. the differential diagnosis is made with the adenofibroma, but now is doubted the existence of this tumor and is considered more of a distinct adenosarcoma. the treatment is total hysterectomy. sisters of and years with a history of dysmenorrhea. hysteroscopy was performed to the eldest one, in which multiple polyps are observed and partially resected. the pathological diagnosis was mixed mullerian tumor, adenofibroma/adenosarcoma. total abdominal hysterectomy was performed. histological examination showed a mixed tumor with glandular component and a low-grade sarcomatous, scarce mitosis, mild atypia and no necrosis. the diagnosis was: mullerian adenosarcoma. a year later, a hysteroscopy and endometrial biopsy was performed to the youngest sister, that showed endometrial polyps with stromal predominance, and no significant atypia. with the diagnosis of mullerian adenosarcoma, and taking into account family history, total hysterectomy was performed. adenosarcoma is a rare tumor whose family presentation is not described in the literature. gliomatosis peritonei is associated with frequent relapse but not affects overall survival in patients with ovarian immature teratoma n.-r. yoon * * samsung medical center, dept. of pathology, seoul, republic of korea objective: gliomatosis peritonei (gp) associated with ovarian teratoma has known to have no adverse prognostic effect. we investigated the clinicopathological features of ovarian teratoma associated with gp, and compared immature teratomas (its) with gp to its without gp. method: we investigated patients with ovarian teratoma with gp and patients with it without gp, who were diagnosed at samsung medical center (seoul) from january to august . results: six patients with it with gp ( . % of patients) had recurrence. when it with gp (n= ) was compared to it without gp (n= ), patient of it with gp showed larger tumor size (median, cm vs. median cm) (p< . ), more frequent relapse ( %, / vs. . %, / ) (p= . ), and frequently elevated pre-operative ca level ( %, / vs. %, / ) (p= . ). survival curves showed significantly shorter relapse-free survival in patients of it with gp (p= . ). two-year relapse-free survival rates were . % and . % in it with gp and it without gp, respectively. however, all patients except one case of it with gp alive. conclusion: ovarian it with gp was characterized by larger tumor size and frequent elevation of preoperative ca level, and gp was associated with frequent relapse in patients with ovarian it. corelation between histopathologic diagnosis with p and ki immunostaining, cytologic features in cervical neoplasia c. altunkaya * , s. yilmaz, a. barin, s. ekici, g. s. yalcin, m. caydere, h. ustun * s.b ankara e. a.h, pathology, turkey objective: frequency of cervical carcinoma decreases nowadays since cytologic screening methods have been using extensively. the incidance of cervical intraepithelial neoplasia increases. cytologic diagnosis og these lesions are substantially important. so we aim to identify the role of p and ki immunostainings for predictive factors of cervical neoplasia. method: the study was conducted january to january . ninety-three cases (mean age , ; range - years) diagnosed as squamous intraepithelial lesions were included, objective: there are several prognostic factors in melanoma. it was suggested that her- expression may influence the tumor behavior. the aim of the study was to investigate the relationship of her- expression with various prognostic factors. method: her- expression was evaluated in melanomas, without metastases and with lymph node and with distant metastases. membranous, cytoplasmic and nuclear her- expression was separately analysed. the staining intensity and percentage of positive tumor cells were evaluated. results: the cytoplasmic staininig was seen in all cases, with average intensity of and percentage of positive cells ranging from % to % (mean . %). the percentage of cytoplasmic her- positive cells was inversely correlated with clark and breslow stage (r=− . and r=− . ). cytoplasmic her- reaction was significantly stronger in cases with lymph node metastases ( . vs. . p< . ). in cases a dot-like cytoplasmic reaction was seen. membranous positivity was seen in cases ( %). conclusion: her- may play a role in melanoma progression. it may be involved in lymphatic dissemination. further studies of prognostic significance of her-expression in melanoma are needed. hypopigmented mycosis fungoides with unusual vitiligolike presentation in child h. erdem * , n. buyukbabani, h. turan * duzce university, dept. of pathology, turkey objective: mycosis fungoides (mf) is the cutaneous t cell lymphoma. classical, clinical and histopathological findings of mf are detected in most of the patients. however, some of the patients have defined atypical mf. hypopigmented mf (hmf) is one of the atypical forms. hmf could be misdiagnosed with clinical and histopathological examination. hmf is considered mistakenly vitiligo. therefore, it should be considered differential diagnosis. mf is usually seen in the middle aged and elderly. the occurrence of mycosis fungoides in children is very rare. method: an -year-old girl child attended dermatology clinic with complaints of pruritus and hipopigmented patches. lesions was performed punch biopsy and reported hmf. conclusion: herein, this case presented because it was considered vitiligo as clinically and diagnosed hmfas histopathologically. reducing block sampling in wide local excisions for melanoma c. fives * , c.c.b.b. heffron * cork university hospital, dept. of histopathology, ireland objective: it is established practice that wide local excision (wle) is undertaken for the further management of cutaneous melanoma, however, definitive guidelines for macroscopic sampling have not been established. our aim was to determine whether our sampling of wle specimens was adequate, inadequate or excessive and to establish guidelines for these specimens. method: cases which underwent initial biopsy and subsequent wle in were identified. we recorded the specimen size, macroscopic appearance, number of blocks sampled and margins of the original biopsy. results: there was wide variation in the number of blocks sampled (range - ). residual melanoma was identified in of the cases ( . %) which had clear margins on the original biopsy. of these, had evidence of a pigmented lesion on macroscopic examination. the remaining cases had margins of mm or less on the original excision. no subsequent surgery was performed on these cases. conclusion: our study has shown that in wle specimens with no evidence of a macroscopic lesion and in which margins of the original biopsy were clear by greater than mm, little is to be gained from extensive sampling. reduced sampling would result in saving laboratory resources with a predicted % block reduction in our laboratory alone. functioning oxyphil adenoma of parathyroid gland: a case report m. genadieva -yordanova * , s. hristova, a. vlahova, g. todorov, b. miserliovska, s. yordanov * alexandrovska hospital, dept. of pathology, sofia, bulgaria objective: the most frequent cause of primary hyperparathyroidism are adenomas of the parathyroid gland, the majority of which are composed of chief cells. oxyphil adenomas are uncommon and account for % of functioning parathyroid adenomas. up until year they have been considered non-functional. method: laboratory findings revealed calcium levels of . prior to operation. the serum parathyroid hormone level was . pg/ml. a ct scan of the neck showed normal size thyroid lobes with heterodense structure with an oval hypodense lesion in the lower right pole of the thyroid. results: at surgery a mahagony-brown mass measuring mm in diameter was removed and reported as oxyphil adenoma on frozen section. histopathological examination revealed encapsulated adenoma composed of oxyphil cells with abundant, granular pink cytoplasm and a rim of normal parathyroid tissue. mitotic figures were absent. postoperatively, a decrease of the serum calcium down to . mmol/l was declared. the followup period was unremarkable. conclusion: there appear to be a growing evidence that a big part of oxyphil adenomas of parathyroid gland can produce parathyroid hormone and contribute to the cases of primary hyperthyroidism. effectiveness of uvb phototherapy on mycosis fungoides using histologic guitart criteria in iranian patients a. ghanadan * , a.-h. ehsani, h. seirafi, m. khiabani * tehran university, razi hospital, iran objective: mycosis fungoides (mf) is the most common primary cutaneous lymphoma. mycosis fungoides often develops slowly over many years, presenting with a generalized erythroderma, skin patches or plaques. the diagnosis of mf requires the integration of clinical and histopathologic findings. narrowband uvb (nbuvb) is widely used to treat mf. to evaluate the effectiveness of therapy the histopathologic findings before and after nbuvb reviewed using guitart criteria. method: we enrolled patients ( women, men; age range, - years; mean age, . years) with clinically and histologically proven mf. the patients received nbuvb phototherapy three times a week. a biopsy was performed months after onset of the treatment and guitart criteria used to scoring mf before and after therapy. results: phototherapy was reduced the primary intraepidermal atypical lymphocytes (p value= . ), dermal atypical lymphocytes (p value= . ), epidermotropism (p value= . ), density of infiltration (p value= . ) and lymphocytic infiltrate without inflammatory features (p value = . ) in all patient. but the relationship between the reticular fibroplasia of papillary dermis and phototherapy was not proved (p value= . ). overall score of patients was significantly lower after phototherapy (p value= . ). conclusion: our data suggest that nbuvb therapy is reduces histiologic score of mf and is effective for the treatment of iranian patients. nodular colloid degeneration of the skin: report of three cases a. ghanadan * , k. kamyab-hesari, m. daneshpajouh, k. balighi, m. khosravi * tehran university, razi hospital, iran objective: nodular colloid degeneration (ncd) is a rare dermatological disorder and also a rare type of colloid milium. the degeneration may be related to sun exposure. method: three cases of ncd were enrolled from the archive of dermatopathology department of razi hospital during - . results: in this report, three cases, all presented with multiple plaques and nodules in the nose and the face, are depicted. histologically, these nodular masses were homogeneous, with eosinophilic clefted materials expanding the papillary dermis and extending into the deep dermis. histochemical review showed the reactivity of the colloid materials via the pas, crystal violet and methyl violet staining. all the three cases were finally diagnosed as nodular colloid degeneration. conclusion: ncd is a rare disease but it should be considered in any cases with a history of long exposure to the light. we suggest the long term exposure to the sun as an etiologic factor thus, sun protection would be the most preventive and available treatment. glypican- protein expression in melanoma: a immunocytochemistry study n. gursan * , h. balta, b. gundogdu * ataturk university, medical faculty, erzurum, turkey objective: glypican- (gpc ) is a cell surface heparan sulfate proteoglycan. serum gpc was shown to be expressed in % of melanomas (ms) but gpc expression in melanoma tissues had not been investigated.in this study, immunohistochemical analysis of gpc protein expression was investigated in histologic sections from melanoma tissues. method: melanoma patients, twenty patients with insitu melanoma, twenty patients stage and stage i melanoma, twenty patients stage ii and stage iii melanoma. all cases were stained with anti-gpc antibody. gpc expression was divided into categories: negative (negative or weak cytoplasmic staining) and positive (moderate or strong cytoplasmic with membranous accentuation). results: gpc immunopositivity. showed in , % of melanomas. gpc expression at stage , i, ii, iii were . %, . %, . %, % respectively. method: we report the case of a year old man presenting with an erythematous plaque of the right hemithorax. results: macroscopically the lesion had irregular borders and was mildly infiltrative with a violet hue. microscopic examination revealed tumor cells within lymphatic spaces, without infiltration of the adjacent stroma. the histologic and immunophenotypic characteristics of these cells were compatible with a carcinoma of lung origin. ct scan revealed a lung mass as well as multiple liver and chest wall metastases. conclusion: malignancies originating from the breasts, lungs and large bowl are the most common to involve the lymphatic net of the skin. melanoma on the other hand is more frequently presenting with lymphangitic invasion, whereas inflammatory carcinomas may also affect lymphatic vessels and may be confused with erysipelas. the revelation of the primary origin is not always easy and differential diagnosis should also include gynecological malignancies, kidney and urinary bladder carcinomas. in our patient the diagnosis was established on the grounds of histology and immunohistochemistry, and was supported by the clinical and radiological findings. objective: inverted follicular keratosis (ifk) is almost always a solitary lesion occuring mainly in adult life. men are affected twice as often as women. pathologically, they can be confused with a variety of lesions, both benign and malignant. squamous carcinoma is the most serious differential diagnosis. method: we decribe a retrospective study about cases of ifk diagnosed over a -year-period ( - ) . results: we collected lesions, all treated by surgical excision. haemalum eosin sections were studied in all cases. all lesions were single. five, of them, were situated on the face and two on the scalp. all the patients were adults with a mean age of years, average between and years. they presented mostly as asymptomatic papules and all were small lesions. the different sections of the lesion showed skin well delineated endophytic epithelial proliferations with inverted papillomatous and acanthotic components containing several circumscribed squamous eddies. they was no atypia, mitotic activity necrosis or stromal invasion. conclusion: ifk pose very real diagnostic problems unless one is aware of this entity. in fact, they may mimic malignant lesions especially squamous cell carcinoma, both clinically and pathologically. primary cutaneous follicular lymphoma with prominent spindle cell areas. so called spindle cell follicular lymphoma. case report g. ivády -szabó * , t. strausz, e. tóth * national institute of oncology, dept. of surgical oncology, budapest, hungary objective: spindle cell type variant of cutaneous follicular lymphoma is a rare histologic variant of primary cutaneous follicular lymphomas. it is caracterised by the presence of spindle and bizarr cells. we present a case of a years old man who had a nodule on his scalp and two smaller nodules on his frontal region. we examined an excisional biopsy specimen of the forehead. method: he, stains all and immunohistochemical stains were used. results: histology revealed dense lymphoid infiltrate showing nodular pattern in the dermis and in the subcutis. the lymphoid infiltrate predominantly composed of large centrocytes. there were areas where the neoplastic cells show spindle cell morphology with bizarre nuclei and in these areas the stroma were myxoid, mucinous. with immunohistocemical stains the neoplastic cells were positive for cd , bcl- , and negative for cd , cd , vimentin, cd , s , actin, desmin, ae /ae . cd showed residual network of follicular dendritic cells in the background. conclusion: spindle cell lymphoma is a very rare variant of cutaneous follicle centre cell lymphoma and the presence of the spindled bizarre cells can cause differential diagnostic problems. the main differential diagnostic entities are primary or metastatic spindle cell sarcoma and spindle cell melanoma. careful morphological and immunohistochemical analysis are required to the correct diagnosis. the histopathologic and immunohistochemical features of mycosis fungoides b. a. karabork * , a. okcu heper, s. yuksel, i. kuzu * ankara university of medicine, dept. of pathology, turkey objective: the histopathologic diagnosis of early mycosis fungoides (mf) is often difficult. the lesions can mimic a variety of inflamatory dermatitis. we aimed to establish and draw attention to the most frequent histopathologic and immunohistochemical features of mf. method: we reviewed skin biopsies of clinicopathologically diagnosed mf cases at medical university of ankara. we looked for a) epidermotropism, atypical lymphocytes, morphologic features in the epidermis, dermoepidermal junction and dermis b) immunohistochemical staining ratios of cd , cd , cd , cd , cd and expression loss of cd , cd . results: atypical lymphocytes) ( %), dermal fibrosis ( %), epidermotropism ( % single cells, % linear arrangement, % pautrier's microabscesses, % 'haloed' lymphocytes), epidermal acantosis ( %), basal vacuolar degeneration (focally %, marked %) and a perivascular lymphocytic infiltrate were the most common and important features. dermal edema ( %) extravasated erythrocytes ( %), spongiosis ( %), eosinophils ( %) and necrotic keratinocytes ( %) were the less seen and non-specific ones. immunohistochemical results correlated with a ratio of % cd , % cd positive mf. expression loss of cd was seen in %, cd in % of cases. conclusion: diagnosis of early mf requires the correlation of morphologic, immunohistochemical and clinical features. also due to the disease's heterogenity, biopsies from different locations and rebiopsies will enhance the diagnosis. connexins of cutaneous melanocytic tumours g. kiszner * , z. buday, i. teleki, e. varga, i. b. nemeth, i. korom, t. krenacs * semmelweis university, st dept. of pathology, budapest, hungary objective: connexins (cx) form transmembrane channels that can transport ions and small regulatory molecules between adjacent cells. they also function as hemichannels and through protein interactions and are involved in the control of cell replication and maintenance of multicellular homeostasis. method: we have tested the expression of connexins in melanocytic tumours using immunohistochemistry in tissue microarrays of common and dysplastic nevi, and primary and metastatic malignant melanomas. results: cx was not found in melanocytic tumours despite expressed in the basal epidermis. cx . reaction showed punctate cell membrane staining in % of naevi in their superficial regions including atypical nests, and displayed cytoplasmic staining in % of melanomas. low levels of cx were revealed in the cytoplasm of > % of naevi and melanomas but only % and % showed membranous positivity, respectively. cx perinuclear/cytoplasmic immunostaining was observed in % of naevi and % of melanomas and as cell membrane reaction in % and %, respectively. punctate cx reaction was detected in vertical tumour nests in % of naevi, while only % of melanomas proved positive and showed cytoplasmic cx delocalization. conclusion: therefore, most tested connexins were significantly down-regulated in malignant vs. benign melanocytic tumours that possibly contribute to their malignant phenotype. quantitative follow up study of cd a, cd and cd positive cells in multiple basal cell carcinoma cases after combined treatment r. kleina * , i. truksane, j. kisis, i. franckevica * riga stradins university, dept. of pathology, latvia objective: in last years appear more cases with multiple basal cell carcinomas (bcc). skin immune system reaction is especially important in nonsurgically treated cases. aim of study is to evaluate the dynamics of cd a, cd , cd marked cells in bcc and in skin adjacent to tumour ( and mm) before and after the treatment with cryotherapy and imiquimodum. method: from bcc cases with multiple tumours investigated immunohistochemically, in dynamics we have characterized patients. antibodies for cd a, cd , cd + cells in derma and epidermis were used. they were evaluated in fields of vision ( ×) before and after treatment. % imiquimod cream and double freezing was used. control group: three normal skin samples. statistical analyses of results were done. results: after treatment were erythema, then crust and exfoliation. microscopically expressed fibrosis instead bcc was found. amount of immune cells before and after treatment were: cd ± , / ± , (also in epidermis), langerhans cells ± , / ± , , cd ± , / ± , . conclusion: all immune cells of skin react to the combined treatment of bcc in radius of mm. there is significant statistical difference between the numbers of langerhans cells in normal epidermis and in bcc cases treated with cryomethod and imiquimodum. regulatory t-cells in invasive and in situ squamous cell carcinoma of the skin and actinic keratosis h. kourea * , a. stravodimou, v. tzelepi, h. papaioannou, h. papadaki, c. scopa * university of patras, dept. of pathology, greece objective: regulatory Τ-cells (Τregs) participate in tumor tolerance and facilitate tumor growth and foxp transcription factor is necessary and sufficient for their development and function. we investigated the presence of t-regs in invasive (in) and in situ (is) squamous cell carcinoma (scc) of the skin and actinic keratosis (ak). method: tregs were identified using immunohistochemistry for foxp and recorded using image analysis in cases of inscc (and their adjacent is, ak or benign tissue (bn), when present), in cases of is and cases of ak (and their adjacent bn tissue). statistical analysis was performed using the paired t-test. p-values < . were considered statistically significant. results: in inscc cases, Τregs in the tumor were more numerous than the adjacent Βn (n= ) (mean vs. , p < , ). additionally, adjacent is had more tregs than adjacent ak (n= ) ( vs. , p= , ). significant differences between inscc, and is or ak were not observed. in is and ak cases, Τregs were more numerous than the adjacent bn ( vs. , p< , and vs. , p< , ), respectively. conclusion: treg infiltration of the skin increases early from the precancerous ak, indicating early involvement of tregs in the development of scc. objective: mastocytosis is a rare disorder and its true incidence is unknown. skin is most commonly involved, followed by the bones and the gastrointestinal tract. method: five men presented with many brown lesions in the trunk and one woman with multiple redish brown nonpruritic macules in the extremities. we used immunohistochemistry for c-kit and tryptase for the definite diagnosis. the expression of cd and cd were also evaluated. results: histology showed five cases of urticaria pigmentosa with severe diffuse infiltration of the papillary dermis by mast cells and one case of telangiectasia macularis eruptiva perstans (tmep) with scattered mast cells around dilated capillaries and venules of the papillary dermis. the mast cells were positive to c-kit and tryptase and only in one case there was a coexpression of cd and cd > % of the mast cells. in that case involvement of bone marrow was observed and the diagnosis of indolent systemic mastocytosis was established according to who criteria. conclusion: urticaria pigmentosa is the most common form seen in adults while tmep is an uncommon form that occurs exclusively in adults. the skin involvement in indolent systemic mastocytosis is a part of the spectrum of the disease. ps- - subvisual nuclear characteristics are different between keratoacanthoma and keratoacanthoma-like squamous cell carcinoma k. metze * , m. tabai, r. adam, i. watanabe, a. de moraes, m. cintra * university of campinas, pathology, brazil objective: the differential diagnosis between keratoacanthorna and keratoacantoma-like squamous cell carcinoma may be extremely diffcult. our objective was to study whether computerized image analysis could be helpful. method: in patients biopsies of keratoacantoma-like lesions were taken at admission. one month later surgical excision was performed in growing lesions, whereas regressing lesions were left untreated. a final diagnosis was established combining clinical and histological evaluation, digitalized images from ki- immunostained and hematoxylin counterstained sections of first biopsies were obtained. tumor nuclei were marked interactively. an inhouse computer program analyzed the geometric relations between the nuclei. nuclear gray values and their histogram entropy were calculated. results: keratoacnthomas and keratoacantomalike squamous cell carcinomas entered this investigation. basic variables of the geometric analysis did not differ between the two entities regardless whether all nuclei or only the ki positive ones had been examined. chromatin gray values were significantly lower and their histogram entropy higher in the keratoacantoma-like squamous cell carcinomas. conclusion: basic geometric variables do not seem to be different beteen both lesions, but a shift in the gray value histogram to lower values with increased entropy in carcinomas indicated important differences of the chromatin structure, supported by fapesp and cnpq. non-infectious erythematous papular and squamous lesions of the skin in our institute, with clinicopathologic correlation t. ozgur * , a. c. dogramaci, e. atik, s. hakverdi, m. yaldiz, z. a. tas * mustafa kemal university, medical faculty, antakya, turkey objective: non-infectious erythematous, papular and squamous lesions of the skin are basic lesions that pathologists differentiate in routine laboratory examinations. our aim has been to analyse these lesions by pathologic and clinical findings in our institute with determining clinicopathologic correlation. method: in our study cases prediagnosed as erythematous, papular and squamous lesion by dermatologists and evaluated in pathology laboratory between and have been reviewed. results: the lesions comprised % . of the total load of surgical pathology and . % of total number of skin biopsies. the highest percentage was in the - year age group ( . %) with a female predominance of . %. the limbs were most frequently involved ( . %). psoriatic lesions were the commonest ( . %), classic generalized plaque variant psoriasis ( %) being the most frequent. correlation with the histopathologic diagnosis was positive in . % cases and negative in . % cases. conclusion: the contribution of histopathology to the final diagnosis was significant. it confirmed the diagnosis in . % cases and gave the diagnosis in . % cases. ps- - vulvar lichen sclerosus: a misnomer for an entity with decreased fibrillar components and increased amorphous components in extracellular matrix remodeling e. parra * , c. a. pires de godoy, v. l. correia feitosa, w. teodoro, a. p. velosa, v. l. capelozzi * fmusp, dept. of pathology, são paulo, brazil objective: the hyalinization of subepidermal skin is one of the histopathological characteristics of the vulvar lichen sclerosus (vls). it was found that patients with vls present autoantibodies against the extracellular matrix protein (ecm- ) and the deficiency of this protein is responsible for the development of a different disease, the lipoid proteinosis. this disease shows a similar histology with vls and has better characterized morphology. method: we analyzed vls patients biopsies and the control group was composed by vulva samples from authopsy. the biopsies and control samples were analysed by immunofluorescence for collagen i, iii and v and th total collagen fibers by picrosirius staining. the elastic fibers were stained with verhoeff and the proteoglycans and glycosaminoglycans with periodic acid-schiff and alcian blue. collagen quantification was performed through image analysis. results: it was observed a significant reduction in all studied collagens as well as in the elastic fibers. on the other hand, the proteoglycans were increased in the vls biopsies. conclusion: this study did not found an increase in collagen sclerosis that would justify the term used for the ls. it was observed a predominance of the edema area probably caused by the increase of glycoproteins as in lipoid proteinosis. combined high-grade basosquamous carcinoma and malignant melanoma of the scalp (malignant basomelanocytic tumor) metastasizing to the breast. a case report a. pitino * , s. squillaci, c. spairani, f. ottelli zoletti, m. f. cosimi, m. ferrari, a. tropiano, p. c. rassu, f. tuo, p. maiocchi * san giacomo hospital, division of anatomic pathology, novi ligure, italy objective: background. basal cell carcinoma (bcc) is a very low grade, usually not metastasizing skin malignancy, which needs to be radically excised. methods. an year-old woman was treated for a × , cm multinodular mass in the scalp. one month later an ultrasonography of the left breast showed a , cm mass which was excised with clean margins. axillary lymph nodes were free of metastasis. results: results. the dermal tumor presented well demarcated basaloid epithelial nests with squamous differentiation focally connected with the epidermis. they showed peripheral palisading and high nuclear grade with pleomorphism, brisk mitotic activity and multiple prominent nucleoli. atypical cells, arranged as strips, nests or isolated elements, were observed at the tumor edge, separated by a grey-zone from the overlying malpighian epithelium. immunostains were positive for cytokeratins, melanocytic (s- /hmb- / mart- ) and neuroendocrine (cd /nse/cromogranin) markers. the , cm breast tumor corresponded to a high grade metastatic bcc with reactivity for epithelial markers, s- and cd . objective: pyoderma gangrenosum (pg) was described at first by brocq and named by brunsting et al. in . superficial granulomatous pyoderma (sgp) was described as a variant of pg in . we present three cases of this rare variant. method: there were two women and one man with age ranging from to years. all of them had a long history of a slowly enlarging, eritematous and ulcerative plaque in different areas including leg and breast skin. a biopsy was performed in all cases. results: the superficial dermis showed neutrophilic inflammation with an admixture of granulomatous inflammation and sinus formation. there wasn't vasculitis and fat tissue was not affected. conclusion: sgp is a rare variant of pg. diagnosis of this entity generally is made on the basis of skin biopsy results with all features mentioned previously and a typical clinical appearance. most of times, these lesions are diagnosed as granulomatous dermatitis, thinking in infectious pathology. this is the most important differential diagnosis, because sgp is responsive to corticosteroids. the pathogenesis of pg is unknown, though is now believed to altered neutrophil chemotaxis and some authors suggest that sgp may be a delayed-type hypersensitivity to an unknown antigen. pathergy is the inciting factor in several patients. high concordance in braf status between native-braf malignant melanoma and matched lymph node metastases a. santos briz * , e. godoy, l. arango, p. antúnez, m. yuste, c. roman, e. fernández, m. d. ludena * hospital universitario salamanca, dept. de anatomía patológica, spain objective: the discovery of selective v-raf murine sarcoma viral oncogene homolog b (braf) v mutation as an oncogenic mutation in cutaneous malignant melanoma (mm) has changed the treatment paradigm for melanoma. selective braf inhibitors have demonstrated response rates far higher than standard chemotherapeutic options. braf mutation analysis is usually performed on primary tumour tissue; however, no conclusive data are available on the concordance of test results between primary tumours and corresponding metastases. we assessed the concordance of braf mutation status in a study of primary brafnative tumours and their corresponding lymph node metastases. method: patients with histologically confirmed nonmutated braf mm who underwent surgical resection of the primary tumour and positive selective lymph node biopsy or lymphadenectomy were included. mutation status was determined by means of a realtime pcr assay (cobas braf v mutation test, roche molecular systems). results: there was a % concordance of the braf results in primary tumor and corresponding metastases in analyzed pairs. conclusion: our findings show total concordance in braf status between primary braf native tumors and their paired metastases, and suggest that acquisition of braf v mutation in metastases from primary native tumors is a rare event. dermatoscopic and histologic score correlation in atypical spitz/reed nevi m. saravia * , z. pellicer, j. m. martin, c. monteagudo * hospital clinic university valencia, dept. of pathology, spain objective: different dermatoscopic scores of pigmented skin lesions have provided a valuable tool in daily routine practice to differentiate malignant from benign lesions. however, these semiquatitative methods have a high rate of false positives in spitz/reed nevi. we have compared semiquantitative histopathologic and dermatoscopic findings in a series of spitz/reed nevi. method: we collected cases ( female and men) of atypical spitz and/or reed nevi. all cases were microscopically confirmed. a histologic index (hi) was constructed scoring the following findings: symmetry, sharp demarcation, architectural dysplasia, melanocytic atipia and nest size, and compared with validated dermatoscopic scores (abcd score, -point checklist and menzies score). distributions of these scores for the different dermatoscopic patterns were also analyzed. results: median age at presentation was years (range to ). the hi varied from to points. we found a strong positive correlation between the hi and menzies score (r= , , p= , ). in addition, hi values differed significantly when the multicomponent dermatoscopic pattern group was compared with the other patterns (u = , z =− , , p = . ). conclusion: menzies is the only dermatoscopic score which strongly correlates with histologic findings in spitz/reed nevi and may be useful in the diagnosis of atypical lesions. correlation of nonmolecular and molecular subtyping of inherited epidermolysis bullosa k. veselý * , h. bucková, l. fajkusová, m. veselá, b. jerábková * st. anne's hospital, dept. of pathology, brno, czech republic objective: inherited epidermolysis bullosa (eb) is a heterogeneous group of hereditary mechanobullous diseases with skin blister formation of variable severity and numerous extracutaneous manifestations. eb comprises three main groups and many subtypes and their recognition is important for prognosis and genetic counselling. method: we examined skin biopsy samples of patients with eb using transmission electron microscopy, immunofluorescence antingen mapping (am) and their peripheral blood samples by mutational analysis. results: in the total number of cases, concordant results of molecular and nonmolecular methods were found in cases ( %). in patients ( %) mutational analysis did not confirm the results of ultrastructural and am analysis. conclusion: strong correlation in the results obtained by different methods was observed. using combination of nonmolecular and molecular diagnostics methods high diagnostic accuracy can be achieved. granulomatous slack skin (gss): a case report with evidence of t cell clonality i. yilmaz * , h. baloglu, u. berber, z. kucukodaci, m. arcila * gata heh, dept. of pathology, istanbul, turkey objective: gss is a very rare variant of mf. we describe an additional case of this rare disorder in a yo female that has been approved by tcrb&g tcell clonality assay. method: a yo female with a single bulky skin lesion in the inguinal fold which had first appeared y before and enlarged up to cm, referred to plastic surgery for esthetics. h&e section of the deep skin biopsy of lesion showed a granulomatous infiltrate in the dermis. nuclear atypia and epidermotropism is not significant. but there is numerous multinucleated histiocytic giant cells. elastophagocytosis are present. tcrb&gt cell clonality assay showed a clonal rearrangement in tcr gamma gene. she was referred to dermatology for treatment and now she is getting uva phototherapy. results: the diagnosis of gss is difficult in early stages of the disease. clonal rearrangement of tcr genes can be a useful diagnostic tool in early stages of the disease. conclusion: - % of patients with gss carry a risk for the development of a second malignancy. gss may be associated with lymphoproliferative disorders. therefore, follow up of the patient is important. this case report supports that gss is an indolent variant of mf due to clinical, histological and t-cell gene rearrangement results. unusual occurrence of multicentric reticulohistiocytosis with systemic involvement in childhood s. zurac * , c. dobrea, a. diaconeasa, a. colita, c. solovan, c. arion, f. staniceanu * colentina university hospital, dept. of pathology, bucharest, romania objective: multicentric reticulohistiocytosis (mr) with systemic involvement is an extremely rare disease afflicting mainly adults. method: we report a case of sr arising in a year month old boy with concomitant celiac disease. results: since - months, he developed several brown to dark-red skin nodules (up to . cm) located mainly on face and arms; current episode include hemorrhagic syndrome, severe pancytopenia and massive hepato-splenomegaly. bone marrow aspirate ruled out acute leukemia and tezaurismoses; bone marrow biopsy and skin biopsy showed important infiltration with numerous large cells with abundant fine granular/ground glass eosinophilic cytoplasms in a reactive inflammatory stroma (lymphocytes, few plasma cells and few eosinophils); bone marrow cells were mononucleated, cutaneous cells were both mono&multinucleated; tumor cells immunophenotype was consistent with histiocytes (cd +, s- protein + (faint), cd a-, langerin-) both in bone marrow and skin biopsies; no hemophagocytosis was seen. mr with systemic involvement of skin, bone marrow, liver and spleen was diagnosed. cyclophosphamide therapy was instituted with initial diminishing of splenomegaly; latter on, despite adding cyclosporine and etoposide, no further impact on pancytopenia and hepatosplenomegaly was recorded. conclusion: complete hematologic examination is mandatory for patients diagnosed with cutaneous reticulohistiocitosis, irrespective of their age, in order to identify mr and institute proper treatment. primary cutaneous follicle centre lymphoma: a case report and review of literature k. diamantopoulou * , c. zorzos, c. eftychiadis, i. famellos, g. piagkos, g. karamanis, i. babalis, s. binder, h. mahera * general hospital kat, pathology, athens, greece objective: primary cutaneous follicle centre lymphoma (pcfcl) is an indolent, primary cutaneous b-lymphoma with an excellent prognosis but a high incidence of reccurence. apart from standard surgery and local radiotherapy, targeted strategies with anti-cd (rituximab) has introduced new treatment modalities. method: woman, aged , with solitary skin lesion on her face. after surgical excision, histo-and immunohistochemistry with the abc system on paraffin embedded tissue was performed. results: microscopically, a non-epidermotropic perivascular and periadnexal neoplastic infiltrate with a follicular growth pattern was observed. the lesion consisted of predominantly medium-sized centrocytes and several centroblasts enmeshed in a network of cd (+) dendritic cells. immunohistochemically, the neoplastic lymphoid cells were cd , cd a, bcl and bcl positive. cd , mum and ig were all negative. the patient received one cycle of rituximab and months later is free of disease. conclusion: primary cutaneous b-cell lymphomas (cbcl) account for % of cutaneous lymphomas. pcfcl is one of the three major categories of cbcl, recently classified by who, (the other two: pcmzl and pcdlbcl, leg-type). bcl- , except for systemic follicular lymphoma, it can also occur in pcfcl, as in our case. pcfcl, usually locally treated with surgery and radiotherapy, could possibly offer a candidate for anti-cd targeted therapy, especially in multifocal lesions. objective: thirteen and ten years old male patients admitted with months interval, having diffuse hemorrhagic papules on extremities and trunk. the first has not responded to methorexate previously. the second had varicella infection months before and, his rushes spreaded out recently. method: multiple punch biopsies of the first patient revealed epidermal necrosis, basal vacuolisation and subepidermal diffuse infiltrate composed of cd and mostly cd positive t cells showing a striking angiocentric distribution. there were cd positive large cells with vesicular nuclei both in epidermis and dermis. some of the vessels exhibited lymphocytic vasculitis with fibrinoid necrosis. punch biopsy of the second patient revealed subcorneal pustule, dyskeratosis and basal vacuolisation, papillary dermal edema, erythrocyte extravasation and severe lymphocyte-rich cellular reaction infiltrating the interface. lymphocytes were cd and mostly cd positive. in between, there were large cells with vesicular nuclei exhibiting cd positivity. results: diagnoses were pleva based on the vascular and interface changes in accordance with clinical findings. both patients responded to oral antibiotics. conclusion: pleva is among the reactive conditions that can simulate cd positive lymphoproliferative diseases. although cd positive lymphomatoid papulosis is defined in pediatric patients, no response was seen to oral antibiotics. are hmb- and mib results reliable for safe diagnosis of nevi? z. yusifli * , o. kurtulan, Ç. aydin, m. bugdayci, Ö. gököz * hacettepe university, pathology, ankara, turkey objective: melanocytic lesions having subtle features suspicious for malignancy create considerable difficulty in decision-making.process. lack of deep hmb- positivity and low dermal mib- index can be reliable tools in association with morphology. method: twenty-seven acquired melanocytic lesions in which hmb- and mib- have been performed are reviewed to determine the importance of these markers in routine diagnostic practice. asymmetry, focal loss of maturation, presence of mitoses, epidermal consumption and lymphocytic inflammation were the morphological features that have created difficulty especially when seen alone in a bland appearing nevus. results: all cases with epidermal consumption and/or mitoses and nearly half of cases with inflammation, asymmetry and focal loss of maturation was associated with.focal deep dermal hmb- positivity. thirteen cases had an mib- index of ≤ %. two of cases with mib- index of > % had also hmb- positivity and/or inflammation. the case with a mib- index of % was an acral nevus bearing of the evaluated morphological features. conclusion: focal deep dermal hmb- positivity goes parallel with epidermal consumption and dermal mitoses, mostly used prevailing criteria of malignancy in melanocytic lesions but it's expression is not adequate for diagnosis of melanoma. low mib index can be a reliable marker of benignity. objective: leptospirosis in humans usually courses with hypokalemia and hypomagnesemia, and the putative mechanism may be related to nitric oxide production. methylene blue is a known inhibitor of inducible nitric oxide synthase, and have beneficial effects on clinical and experimental sepsis. method: serum creatinine and ionic changes were evaluated at various time points ( , , and days) in hamsters. we also determined the effect of methylene-blue treatment when used as adjuvant therapy combined with a late start of standard antibiotic (ampicillin) treatment. results: rather than k and mg depletion, hyperkalemia and hypermagnesemia were observed during acute infection. these findings are probably associated with an accelerated progression to renal failure, since this model is not feasible to mirror the supportive therapy (including fluid expansion) that retards progression to the oliguric/hyperkalemic state. infected hamsters at day presented diffuse tubular cell swelling with mild or no nephritis. at days and they showed variable degrees of acute tubular changes, regeneration of tubular epithelia and nephritis. survival and renal pathology did not differ among different treatment groups. conclusion: adjuvant methylene blue had no effect on the survival, renal pathology or mg and k serum levels during acute-phase leptospirosis in hamsters. occupation of the striated muscle fibre by trichinella spiralis is associated with increased intracellular sialylation p. babal * , r. milcheva, d. ivanov, s. petkova * comenius university, dept. of pathology, bratislava, slovakia objective: the knowledge about glycoproteome in skeletal muscle is limited and most of the information come from studies on aberrant glycosylation in inherited muscle diseases. this work describes the intracellular changes in sialylation of skeletal muscle fiber during the process of its transformation into a nurse cell after occupation by the nematode trichinella spiralis. results: the study was performed at defined time points post infection. lectin histochemistry with tml, mal and sna detected increased production of sialylated glycoproteins within the affected fibers, and it was evaluated by acidic ninhydrin reaction in muscle homogenates. increase of total sialyltransferase activity was estimated by measurement of incorporated cmp-n-[ c]-acetylneuraminic acid, and immunohistochemistry showed higher expression of α- , -sialyltransferases ii and iv within the affected fibers. sna lectin affino-blots showed at least four protein bands with approximate molecular weight between and kda, which were more reactive to sna compared to their counterparts from the control samples. conclusion: it is evident that skeletal muscle injury induced by trichinella activates biosynthesis of glycoproteins bearing sialic acids, which are not present in the normal muscle fiber. however, the protein identity, function and the biological significance of these sialoglycoproteins remain to be elucidated. bg po objective: protozoal and helminthic infestations of the central nervous system (cns) are rare and their incidence is less than %. they are more common among children, the elderly and immunocompromised individuals and tend to follow a fatal course. method: we report cases of cerebral amebic abscess occurring in immunocompetent men. results: they were men aged of and years old. headache; altered mental status and fever were common presenting symptoms. in the cases the diagnosis of cerebral abscess was suspected on cerebral ct scan. histopathologic analysis revealed extensive areas of necrosis and hemorrhage with granulomatous lymphoplasmacytic inflammatory infiltrate. other conditions such as malignancy and tuberculosis. it occurs normally in the mouth and tonsils, however, it can sometimes occur in the chest, abdomen, pelvis or other areas of the body. method: we describe a retrospective study about cases of actinomycosis diagnosed over a -year-period ( - ) . results: the cases were divided in cervicofacial actinomycosis, genito-urinary tract actinomycosis, cutaneous actinomycosis, abdominal actinomycosis and cases occur in central nervous system. all patients were symptomatic. the most frequent symptom consisted in fever. the diagnosis was based on histologic study in all cases. tissue histologic studies show suppurative and granulomatous inflammatory changes, connective proliferation, in which bacteria form typical granular colonies composed of radiating gram positive filaments. conclusion: diagnosis of actinomycosis is usually made retrospectively by means of histologic examination of surgically obtained specimens, but rarely preoperatively. it is generally treated with long term antibiotics. expression of angiogenesis factors in placentas with intrauterine transmission of hiv a. kolobov * , e. musatova, v. karev, v. zinserling, d. niauri * st. petersburg, russia objective: placenta plays an important role in the prevention of the mother-to-child transmission of hiv during pregnancy. the purpose of this investigation was to study expression cd , bfgf and tgfβ in human placentas in cases of intrauterine hiv infection. method: group a - placentas from women and children with hiv infection. in control -group b, were placentas from women without hiv infection. on paraffin slices expression of cd , bfgf, tgfβ and p was evaluated. we counted the area of positive cells related to the square of the slice. results: in all placentas with hiv infection p has been found in placental macrophages and villi's vessels. in group a expression of cd in endothelial cells was , ± , % of the slice's square (in control - , ± , %) (p> , ). expression of bfgf in villi's stroma was , ± , % (in control - , ± , %) (p> , ). expression of tgfβ in villi's vessels was , ± , % (in control - , ± , %) (p< , ). conclusion: thus, placentas in cases with intrauterine transmission of hiv are characterized by increased expression of tgfβ the significance of this fact is still to be evaluated. objective: unilocular cystic echinococcosis which echinococcus granulosis causes is seen frequently in the animal husbandry practised underdeveloped countries. method: the unilocular cystic echinococcosis cases which were seen in the eastern part of turkey, in years between . . and . . , except faculty of medicine of atatürk university are presented. results: organ distribution: female: liver (sd: . ), lung (sd . ), spleen (sd . ), abdomen (sd . ), kidney (sd . ); male: liver (sd . ), lung (sd . ), spleen (sd . ), brain (sd . ), soft tissue (sd . ) . conclusion: the frequently seen organs in both gender are liver and lung. the rarely seen organs were spleen , brain , abdomen , kidney , vertebrae , soft tissue , pleura , bone , breast . the others were very rare: eye , gallbladder , thyroid , neck , ovary , testis . relation of the length of appendix and parasitosis: preliminary report a. kurt * , s. a. Özmen, i. erdem * bölge egitim ve arastirma hastanesi, dept. of pathology, erzurum, turkey objective: is there an effect of the length of appendix vermiformis on the settlement of the bowel parasites? we have decided to research. method: it was studied retrospectively for not to be under the influence. randomly chosen from the archives, parasitic appendix ( women + men) and appendix vermiformis ( women and men) lengths were compared. the last appendix materials of the appendixes which include parasites ( e.vermicularis, a.lumbricoides, t.saginata) and operated any causes were examined. placeholder conditions such as fibrous obliteration and tumour were excluded. the premeasured length of the appendix in the series ( + = ) were listed with the gender. results: appendix length in the control series: the length of appendix in men: . the length of appendix in women: . the length of appendix in both gender: . cm. the length of parasitic appendix: the length of appendix in men: . the length of appendix in women: . the length of appendix in both gender: . . objective: on the basis of recently detected receptors for erythropoietin on the surface of mscs we hypothesized that introduction of epo together with mscs may enhance their effect and improve the results of sepsis treatment. method: wistar male rats were randomized into groups with animals in each: group -the healthy controls, - groups were intraperitoneally introduced bacterial lps mg/kg. group - got × allogeneic mscs, group - . μg of recombinant epo-beta, group -mscs and epo in the same doses. the morphological study of liver, spleen, thymus, lung and kidney was performed. histological specimens were evaluated by qualitative, semiquantitative and quantitative methods. results: in lung tissue the thickness of alveolar septums progressivly reduced from group to .in kidney and liver tissue the dystrophy of hepatocytes and nefrocytes and a blood vessel's dilatation in studied groups also reduced.in lien tissue we observed hyperplasia of white pulp in groups and . structural features of thymus were connected with patterns of t-lymphocyte proliferation and differentiation. conclusion: combined treatment with epo and mscs can reduce acute lung injury and kidney damage, cause hyperplasia of lymphoid tissue and enhance the immune response more than separate treatment in an experimental model of sepsis in rats. mycobacterial spindle cell pseudotumor of the liver a. alves * , a. costa, a. fernandes, g. do carmo, i. tavora * hospital santa maria, servico de anatomia patologica, lisboa, portugal objective: spindle cell pseudotumors are rare manifestations of mycobacterial infections. we describe a case in the liver in an immunocompromised patient with tuberculosis. method: a -year-old man, with active substance dependency, hiv- infection known for years and acquired immunodeficiency syndrome for years, was receiving tuberculostatic medication for disseminated tuberculosis and investigated for persistent fever. a liver ultrasonography confirmed a moderate hepatomegaly and showed multiple dispersed nodules in both lobes, with to cm of greater diameter. results: a needle biopsy from one of the nodules showed a proliferation of spindle cells without atypia, grouped in intersecting bundles, with immunoreactivity to vimentin, cd and lysozyme and negative for cd , ps , sma and desmin; a ziehl-neelsen stain revealed several acid fast bacilli in the spindle cells. they were pas negative. conclusion: pseudotumoral lesions in hepatic tuberculosis usually correspond to granulomatous inflammation. a spindle cell proliferation, like that seen in other organs are more frequently associated with non tuberculous mycobacteria, is very rare. we found only another case in the literature of liver spindle cell pseudotumor associated with tuberculosis. this lesion must be differentiated from mesenchymal neoplasms. sixteen months follow-up in a treated case of whipple disease (wd) c. popp * , m. petre, g. micu, a. bastian, r. chirculescu, r. mateescu, f. staniceanu * colentina university hospital, dept. of pathology, bucharest, romania objective: wd is a rare, multi-systemic infection caused by a ubiquitous environmental bacteria -tropheryma whippleithat affects the duodenum and small intestine but also the brain, endocardium, skin, lungs and joints. method: we are presenting a years old man with a years history of diarrhea, malabsorption and weight lost (about kg). endoscopical examination revealed an unspecific, yet unusual pattern of lesions: small, yellow, multiple, slightly elevated patches involving duodenum and jejunum. histological examination revealed numerous foamy macrophages in lamina propria with pas (+), ziehl-neelsen (−) material in cytoplasm. results: treatment with trimethoprim/sulfamethoxazole was initiated with a spectacular response: after days of therapy the patient had normal stool and in months he already gained back kg. after year of treatment the biopsy confirmed a partial remission with fewer macrophages persisting in lamina propria of duodenum. after months of treatment (march ), very few macrophages with pas (+) material are still identified on duodenal biopsy. conclusion: wd is a potentially fatal disease with unspecific clinical and endoscopical signs that can be diagnosed on duodenal biopsies. histological follow-up is a useful tool of managing the treatment and histopathological confirmation of the absence of foamy macrophages is mandatory in discontinuing therapy. small cell urothelial carcinoma (scuc) comtherapy. method: we report two cases of scuc. both of them refer to year-old males, smokers. they presented with gross hematuria. transurethral resection bladder tumor (turbt) specimens showed scuc, followed by cystoprostatectomy and pelvic lymphadenectomy, confirming the initial diagnosis. immunohistochemistry was used on paraffin embedded tissue. results: microscopically, the tumor cells show a diffuse architectural pattern with occasional nesting, are small, uniform, with scant cytoplasm, nuclear crowding, nuclear molding, inconspicuous nucleoli and finely stippled chromatin. numerous mitoses, azzopardi phenomenon and foci of necrosis are present, as well as areas of urothelial carcinoma. tumor cells are strongly (+) with ker ae /ae , cam . (dot-like perinuclear pattern), cd (the most consistent neuroendocrine marker), p , ki- ( %), focally (+) with synaptophysin and (−) with chromogranin, ker βe , ker , ker , ttf- , lca. conclusion: pathologic and immunohistochemical data identify scuc. differential diagnosis includes metastasis of a small cell carcinoma from another site rare variant: primary renal malignant fibrous histiocytoma n primary leiomyosarcoma of the kidney: three cases b renal pelvic and ureteral dilatation was seen in the first case because of the mass effect. microscopically the alternating spindle tumor cells were detected which were positive with actin, desmin, caldesmon and negative with s , pan-ck, cd and cd congress hall foyer rd floor ps- poster session gynaecological pathology although rare, u-lms is the most frequent malignant gynaecological mesenchymal tumor, usually disclosing unfavorable prognosis. u-lms diagnosis may be controversial. in this study we evaluated clinical-pathological features/prognostic factors of u-lms. method: all consecutive u-lms diagnosed ( - ) at chsj and ipo-porto and with available material were reevaluated. the clinical files were reviewed, including demographic, clinical, imaging, surgical, staging, and follow-up parameters. the pathology features, including immunohistochemistry evaluation, were re-evaluated and the tumors staged according to most recent consensus criteria. results: the mean age at diagnosis of the cases was years ( - ); % were multiparous and % postmenopausal women. the majority ( %) had symptoms at diagnosis, mostly abnormal bleeding. histological classification displayed: % spindle, % epithelioid, % myxoid, . % pleomorphic, and . % mixed u-lms. treatment included surgery ( %), radiotherapy ( %), and chemotherapy ( %). overall median survival was months portugal objective: u-lms is the most frequent malignant gynaecological mesenchymal tumor, disclosing dm results: our series: ( . %) with metastasis; literature: with metastasis. global mean age at diagnosis: years ( - ); initial treatment: hysterectomy ( %), radiotherapy ( %), and chemotherapy ( %) pancreas, vulva/vagina, salivary gland, oral cavity, heart, mediastinum, adrenal, and breast; % with metastatic related symptoms. overall median time to first metastasis: months (ci % . - . ). pancreas, heart and mediastinum were the earlier metastatic sites microglandular adenocarcinoma (mga) of the endometrium, a rare subtype of endometrial mucinous adenocarcinoma, has histologic similarities to the microglandular hyperplasia (mgh) of the cervix. it should not be misdiagnosed as cervical mgh especially in a small endometrial biopsy specimen. method: eight cases of mga of the endometrium and cases of control mgh of the cervix were immunostained for ki- , cd , p , p , p , vimentin, estrogen receptor (er), progesterone receptor (pr) and pten. hpv dna analysis was performed using paraffin-embedded mga tissue by polymerase chain reaction amplification endometrial carcinoma (ec) displays variable outcomes. method: immunohistochemistry for p , ki , egfr, her- (%positive), pten, estrogen and progesterone receptors (er/pr), perk, pjnk (h-score results: ade: er/pr mean h-score from / to / , from g to g , for pten, and for perk and pjnk, two adeg > % p and one % ki . ads: % > % p and % > % ki , / for er/pr, for pten, and for perk and pjnk. adcc: none er/pr; , and for perk -regulated) compared to ulm and myometrium, several known to be involved in cell-cycle and/or apoptosis pathways (p , rb, e f, cyclin-d /e) and/or metastasis. conclusion: albeit some overlap, mirna expression profile of ulms is different from ulm but relatively similar to non-ulms. ulms and non-ulms share deregulation of several mirnas that may be linked to specific cell-cycle/ apoptosis pathways %) included rhabdomyoblastic ( ), cartilaginous ( ), adipocytic ( ) & sex-cord-type ( ). four cases had leiomyomas; alivewith-disease (mean, . months) and free-of-disease (mean, months). conclusion: adenosarcomas are uncommon endometrial endometrioid carcinoma is the most common malignant tumor of the uterine corpus usually developing in postmenopausal women. more seldom it occurs in young reproductive age and sometimes develops from an endometrial intraepithelial neoplasia (ein). the ein diagnosis and treatment in such patients have some difficulties. method: we have studied curettage tissue specimens from three women with ages , and , with abnormal uterine bleeding and obesity. the severe complex endometrial hyperplasia with low grade intraepithelial neoplasia was revealed in all cases polypoid glands with sarcatomatous stroma (phylloides-like pattern). b. periglandular condensation. c. sarcomatous overgrowth. d. decidualization. e. cartilagenous dedifferentiation. f. rhabdomyoblastic dedifferentiation (inset). g. vimentin positivity. h. desmin in rhabdomyoblasts. i. er positive glands. which were examined histopathologically, and in terms of cytologic features, p and ki immunoexpression. results: cervical smear samples from patients were diagnosed as agus, ascus, asc-h, hgsil, lgsil cases three types are generally acknowledged: circumscriptum (or capillary), cavernous, and cystic. -years-old female. method: case report: a -years-old woman presented to the department of obstetrics and gynecology at our hospital. for uterin myoma, she underwent total abdominal histerectomy and bilateral salpingo-oophorectomy congress hall foyer rd floor ps- poster session dermatopathology atypical spitz tumor or spitzoid melanoma: which morphological criteria ensure the diagnosis? method: thirty-one spitzoid lesions were reviewed by a scoring system based on seven selected criteria reported previously appreciating characteristics of spitzoid lesions. as a prevailing criteria, presence of deep mitoses had a score of ; ulceration, asymmetry, epidermal consumption, solid growth pattern, loss of maturation, pigment heterogeneity were scored as for each. final diagnosis was sm for scores - , ast for - , sn for . results: the most frequently seen criteria, loss of maturation was solid growth pattern and pigment heterogeneity were nearly equally seen in sm and ast. first diagnoses of sn switched to ast, to sm, and of ast to sm. conclusion: presence of deep mitoses is the single criteria present only in sm. loss of maturation, epidermal consumption and ulceration can be used to differentiate ast from sm basal cell carcinoma (bcc) of the skin is the most common form of human cancer. sometimes the histological appearances of benign adnexial neoplasm of hair follicle apparatus tumors (trichoepithelioma, trichoblastoma) are diffucult to distinguish from bcc. the aim of this study is to investigate the usefulness of cd and p in distinguishing bcc and benign adnexial neoplasm of hair follicle apparatus tumor. method: this study included bcc and benign adnexial neoplasm of hair follicle apparatus tumor. we used immunohistochemical stains for p and cd in all cases. results: in bcc cases the expression of cd was noted in tumor cells in cases objective: a widely accepted adequacy criteria for histopathologic evaluation of prostate core biopsy protocols has not been defined yet. selection of patients for repeat biopsies after a negative initial biopsy result is also a matter of debate. we aimed to evaluate the impact of total core length for detecting prostate cancer in a -core transrectal ultrasound guided biopsy scheme. method: retrospectively, we investigated the core lengths of patients underwent initial prostate biopsy by a lateral zone targetted -core protocol between and . results: cancer was identified in ( . %) patients. mean total core length for positive and negative patients were . cm and . cm, respectively. cancer detection rates in groups for total core length < cm, - cm, and > cm were . % ( / ), . % ( / ), and . % ( / ), respectively. when a threshold of cm was selected for total core length, overall cancer detection rates for < cm and ≥ cm groups were . % ( / ) and . % ( / ), respectively. conclusion: although molecular confirmation remains its diagnostic gold standard, tle , ema, bcl- , mic , cks and cd constitute an optimal for sy-novial sarcoma. awareness of tle expression in other tumors and its correct interpretation are necessary. objective: malignant peripheral nerve sheath tumors (mpnst) comprise - % of sarcomas. prognosis is poor and the search for new treatments is ongoing. her is a crucial receptor for neuregulin signalling in schwann cells but to date, has not been studied in sarcomas. our aim was to determine the prevalence of her receptor expression in soft tissue tumors, including mpnst. method: her expression was evaluated by immunohistochemistry in a total of benign and malignant mesenchymal tumors, including neurofibromas, schwanomas, mpnst and other lesion (uterine and non-uterine leiomiomas and leiomiosarcomas, synovial sarcomas, undifferentiated pleomorphic sarcomas (ups)). results: her overexpression was found in % of cases. significantly, her positivity was present in ps- - breast cancer in young czech women: an institutional review f. sobande * , a. ryška * dept. of pathology, hradec kralove, czech republic objective: breast cancer in young women poses unique diagnostic and management challenges however, very few large studies investigating clinico-pathologic and immunophenotypic characteristics within this group exist and varied, arbitrary age-limits are used to define 'young'. method: an institutional archive search was performed for breast cancer diagnosed in women < in [ ] [ ] . age at diagnosis, tumor histological type and grade, estrogen and progesterone receptor (er and pr), her /neu, ki- and p status as well as clinical course during the follow-up period were recorded. patients were sub-classified into agegroups of -year intervals for statistical analysis. results: ninety of carcinomas were diagnosed in women < . they frequently displayed aggressive morphology, high proliferative activity, increased expression of p and high incidence of lymph node metastasis. we found a statistically significant decrease in her /neu over-expression with increasing age using as the cut-off (< : %, ≥ : %; p= . , chi-square test). no significant age-related differences in er or pr expression were observed within the group of women < . conclusion: we show that should be used as the cutoff for defining young women; in whom breast cancer is most likely to over-express her /neu. the mechanisms behind this finding and its significance are yet to be elucidated. objective: osna is a molecular assay for lymph node in breast carcinoma (bc) based on m-rna detection of ck . the aim of this study is to evaluate the rate of negative o heterogeneous immunohistochemical expression of ck in bc. method: ck was assessed in consecutive samples. cases were categorized as positive, negative and heterogeneous. other parameters recorded where histological type and grade (nottingham) and molecular subtype (st. gallen ). results: cases ( . %) were ck +. ten ( . %) were ck -and ( , %) were heterogeneous. there were intraductal carcinomas, heterogeneous and ck -. among invasive carcinomas, there were ck -: ductal, papillary and metaplastic. three cases corresponded to g , g , g and t mi not available. five cases were luminal a(la), luminal b/her -(lb-), her + and triple negative (tn). among heterogeneous cases, were ductal, metaplastic, and atypical medullary carcinoma. eleven were g , and g . four were lb-and cases were tn. conclusion: all lobular carcinomas expressed ck ck was negative in . % and heterogeneous in . % of bc. they represent a heterogeneous group but half of these cases are either g or tn. % of heterogeneous cases were tn and % lb-with no la cases in this subgroup. case report of an extremely rare tumor of the breast: mucoepidermoid carcinoma f. staniceanu * , c. socoliuc, a. birceanu, e. gramada, l. nichita, r. andrei, a. croitoru * colentina university hospital, dept. of pathology, bucharest, romaniaobjective: staniceanu and socoliuc are first authors in equal proportions mucoepidermoid breast carcinoma, classified in category of purely epithelial metaplastic carcinomas, is rarely encountered with only a few female cases described in literature. it is composed by mucous, intermediate and epidermoid cells, similar to its salivary gland counterpart. method: we present the case of a years old man with a , / , cm breast tumor located under the nipple, poorly circumscribed, with increased consistency and central cystic area containing serous fluid. tissue samples were preserved using % formalin. all sides were stained using hematoxylin-eosin. immunohistochemistry was performed using labeled streptavidin-biotin method. results: microscopic examination reveals islands and sheets of polygonal cell with clear/pale cytoplasm, "signet cells" figures, areas of squamous metaplasia and centrally located hyperchromatic nuclei, some with visible nucleoli and rare mitoses. tumoral parenchyma contains ducts and cysts of varying sizes, with pale eosinophilic luminal accumulation pas, d-pas and alcian blue positive (mucin). immunohistochemical tests were performed. differential diagnosis was made among several benign and malignant lesions, the final diagnostic being mucoepidermoid carcinoma, low grade. conclusion: mucoepidermoid carcinoma of the breast is an extremely rare entity; however its specific morphologic and prognostic features (similar to its salivary gland counterpart) allow proper diagnostic. endomyocardial biopsy value in differential diagnosis of hypertrophic cardiomyopathy j. markovic * , i. ranisavljevic katuca, s. glumac, r. jankovic, j. d. vasiljevic * clinical center of serbia, dept. of pathology, belgrade, serbiaobjective: endomyocardial biopsy (emb) may be used to diagnose different types of cardiomyopathies, to monitor transplant rejection, evaluation of myocarditis, heart failure of unknown origin, arrhythmias, drug toxicity and heart neoplasmas. the aim of this case is to show how noninvasive cardiac investigations are sometimes not sufficiently conclusive for distinguishing between hypertrophic obstructive cardiomyopathy (hocm) and the other cardiac diseases.method: thirty-one representative left ventricle biopsies were obtained following suspected hocm. samples underwent routine standard and special staining procedures. five histologic parameters were used for assesment (disarray and hypertrophy of myofibers, myocardial short runs, perinuclear halo and bizarre nuclei and fibrosis) and graded from to , presenting in summary histological hocm index (hhi-ranging from to ). results: the histological findings in emb of thirty-one patients, in ( , %) patients hocm diagnosis was confirmed, in ( , %) patients hhi was under or equal to % ( ) so hocm diagnosis couldn't be confirmed, amyloidosis in one ( , %) patient, myocarditis in ( , %) patients, dilatative cmp in ( , %) patients and unspecific cardiac changes in ( , %) patients. conclusion: a definitive diagnosis can be obtained by means of a multidisciplinary approach including emb findings. morphometric study of structural changes in the heart of people who abused alcohol for more than years l. mitrofanova * , e. naumova * almazov federal heart, blood and cardiomorphology, st. objective: the information about structural changes in the heart of people abused alcohol (paa) is very contradictory. method: we studied hearts of paa (> g per day), hearts of patients with ischemic heart disease (ihd) and hearts of healthy persons. at the morphometric study of heart we measured the mean cardiomyocyte diameter (mcd), the relative areas of fatty infiltration (fi), fibrosis, cardiomyocytes. immunohistochemistry was performed using antibodies against cd -antigens to count the number of antigen-positive cells per mm². the average heart weight, the mcd of the paa were not significantly different compared to the ones of the control group. the average relative area of fi of rv for the group of paa was ± % and was significantly different compared to the one of both the control group and the group with ihd. the relative area of rv fibrosis in the group of paa was . ± . % and was not significantly different compared to the ones of the other two groups. the mean number of cd + lymphocytes/mm² of % of paa was more than . conclusion: the paa did not have myocardial hypertrophy. % of them had chronic myocarditis. marked fi in paa was significantly higher than the other two groups. objective: the aim of the study was to evaluate the expression of angiotensin-converting enzyme (ace- ) in left ventricular myocardium in the presence of chronic myocardial ischemia. method: heart specimens with persistent ischemia (n= , pre-infarction ischemic heart disease (ihd) group) and postinfarction scar (n= , post-infarction ihd group) from dissected males and heart explants (n= , end-stage ischemic heart failure group) were studied. heart specimens (n= ) selected at autopsy from individuals who died from accidents were used as controls. the slides of myocardium were incubated with polyclonal antibody against the ace- ( : , ab , abcam). results: ace- expression in cardiomyocytes of the preinfaction ihd and post-infarction ihd groups did not differ from the controls and was increased only in the end-stage ischemic heart failure group (p< . ). ace- expression in vascular endothelial cells, smoth muscle cells and macropages of the pre-infarction ihd group did not differ from the controls; but the number of ace- expressing cells in the post-infarction ihd and in the end-stage ischemic heart failure groups was greater, as compared with the pre-infarcion ihd group and the controls (p< . ). conclusion: expression of ace- is increasing in progression of ischemia-induced myocardial dysfunction. thrombotic occlusion of the peripheral pulmonary arteries: anatomical "trigger" of the massive pulmonary thromboembolism (pte) f. portelli * , f. p. busardò, l. gutsul, p. fleres, p. pugnetti, e. orlando, e. maresi * university of palermo, section of pathology, italy objective: tubulocystic carcinoma of the kidney (tcrcc) is a rare variant of renal tumor showing unique gross and microscopic features. several recent studies favour its inclusion within the papillary renal cell carcinoma (prcc) group. method: patient was a year-old man with a left asymptomatic renal mass incidentally discovered by sonography. patient was a year-old man with aortic estenosis and coronary disease. a right renal mass was discovered in the work up for aortic valve replacement and coronary bypass. results: both tumors were well circumscribed masses with "sponge-like" appearance. on light microscopy, the tumors were composed of ectatic tubules and cysts of variable size, lined by a single layer of tumor cells with eoshinophilic cytoplasm, apocrine appearance, rounded nucleus sometimes overlapping, and prominent nucleoli. ihc showed positive staining with ck , e-cadherin, cd , and amacr. conclusion: tcrcc has been recently recognized as a distinct subtype of prcc by some authors. in fact, some few cases reported have histological transition between tubulocystic and papillary phenotypes on routine histological sections. additionally, tcrcc shows trisomies of chromosomes and . the exact location of this tumor within the who classification is a matter of debate. objective: our purpose is to evaluate her protein expression in urothelial carcinoma of the bladder. her /neu is a tyrosine kinase receptor (family of human epidermal receptors), showing overexpression in a large variety of tumor cells. method: bladder biopsy and cystectomy specimens were included in this study. the age of the patients ranged from to (mean ). among them ( . %) were male and ( . %) female. all cases were reevaluated histopathologically according to who grading system. her protein expression was detected by immunohistochemistry (cb ) using the same criteria as for breast cancer. results: all bladder neoplasms were low-or high-grade urothelial carcinomas. her protein overexpression was observed in ( . %) cases ( +: cases and +: cases), while ( . %) cases were negative ( : cases and + : cases). among her positive cases ( %) were high-grade carcinomas, while ( %) was low-grade carcinoma. among negative cases ( %) were lowgrade carcinomas, while ( %) were high-grade carcinomas. conclusion: these findings indicate that her protein overexpression is predominately correlated with high tumor grade in urothelial carcinoma of the bladder and patients with these characteristics could be potential candidates for targeted therapy. mucinous adenocarcinoma of the renal pelvis: a case report and review of the literature m. otani * , t. tsukamoto, h. serizawa * tokyo medical university, division of diagnostic pathology, japanobjective: primary mucinous adenocarcinoma of the renal pelvis is extremely rare and about cases have been reported to date. we present a case of mucinous adenocarcinoma followed by renal cysts. method: the patient is a -year-old male. a renal cyst in the right upper region was found incidentally. he had no symptom at that time. after years, he came to the hospital because of hematuria and back pain. the examination revealed that the renal cyst was enlarged accompanied with solid lesion. the high serum level of cea indicated malignancy and tumorectomy was performed. results: macroscopically, a renal cyst ( × mm) in the right upper portion was adjacent to a solid mass ( × mm). the tumor showed papillary growth ( × mm) in renal pelvis. microscopically, the tumor was consisted of adenocarcinoma with tubular or papillary structure, spreading from cyst wall to pelvis. the tumor cells contained mucin and some showed signet-ring celllike feature. conclusion: clinically, high serum level of cea is a marker of mucinous adenocarcinoma originated from renal pelvis. in our case, the tumor has already from pelvis to cyst wall. we thought it originated form renal pelvis, however, the renal cyst is also a candidate for its origin. results: an cm tumour was revealed in douglas cavity, histologically, deciduoid morphology was predominant with abundant atypical mitoses and massive neutrophyls infiltration. immunohistochemical positivity: calretinin, cytokera-tin - , cam . , cytokeratinae ae , e-cadherin, vimentin, hmbe , ca and negativity: cd , cd a, melan-a, myod , wt- , cd , hmb , actin, thrombomodulin, desmin, alpha-fetoprotein, moc , cerb- , estrogen and progesterone. normal dna-repair proteins expression. conclusion: mdm is highly aggressive neoplasm, differential diagnosis includes: squamous carcinoma, gist, deciduosis pseudotumoral, anaplasic large cell lymphoma, trophoblastic tumour, oxyphilic variant of ovarian clear cell carcinoma. this case represent a rare variant of mesothelioma, in which, was possible a complete resection with a probably better pronostic unlike most of these cases. objective: we evaluated morphological features of male gonad in an adult patient with tfs with an accent on its immunohistochemical properties. method: our years old patient had a primary amenorrhea. external genitals were female, without pubic and axillary hair. us confirmed cystic formation of the left gonad and lack of uterus. tumor markers were normal but testosterone was high. cystic formation of the left gonad was surgically removed, initially specified as a left ovary, as well as the other gonad. pathohistological examination and karyotyping was done. results: immunohistochemical analyzes of the gonad sample reveal that sertoli cells showed positivity for inhibin α, vimentin, cd , ckae /ae and calretinin and leydig cells showed positivity for inhibin α, vimentin, cd , ckae /ae and calretinin, and weak positivity for s- , synaptophysin i nse. immunoreactivity for cd in hyperplastic areas of leydig cells showed the most intensive conclusion: we conclude that cd and p expression may be a useful adjunct marker in distinguishing bcc and benign adnexial neoplasm of hair follicle apparatus tumor. objective: pigmented purpuric dermatosis (ppd) comprises a group of vascular disorders of unknown etiology. histologically, it is characterized by lymphocytic capillaritis in the papillary dermis. method: a retrospective and monocentric study concerning the cases of ppd diagnosed in the department of anatomopathology la rabta over years (from to ). these cases were studied clinically and histopathologically. hepatitis c and b profile was carried out to evaluate a possible relation. results: cases of ppd have been diagnosed; men and women, aged from to years. only one patient tested positive for hepatitis c with an elevated viral load. she had a profuse eruption involving the trunk and the limbs of years duration, contrary to the other patients in whom only the lower limbs were affected. she has been treated by alpha interferon and ribavirin with a disappearance of the eruption within months. in the five other patients, the lesions resolved spontaneously within a period of to months. conclusion: hepatitis c may play a role in the pathogenesis of ppd especially when the lesions are profuse and longstanding. in our patient, the disappearance of lesions months after the onset of interferon alpha therapy with a significative decrease of viral load is an argument supporting our hypothesis. objective: fibrolipomatous hamartoma of nerve is a benign lesion, very rare in medical practice, occurring in children or young adults. case report: a year old woman, g. n., presented with a slowly growing plantar mass in the right foot that had been present for years. neither the patient nor members of her family had a history of neurofibromatosis or other soft tissue tumors. she had no pain at rest, but she had shooting pain while running or walking. physical examination revealed a mobile, tender mass located in the plantar soft tissue. method: after surgical excision, the lesion was well circumscribed, / / mm, white colour with yellow areas. tissues specimens were fixed in % buffered formalin, routinely processed and embedded in paraffin, sectioned at μm, then stained routinely by hematoxylin -eosin, than examined by light microscopy. results: the lession is characterized by proliferation of mature fatty and fibrous tissue within the epineurium of the nerve accompanied by prominent concentric perineurial fibrosis. the histopathological diagnosis was fibrolipomatous hamartoma of nerve. conclusion: the tumour usually affects nerves of the upper extremities, most commonly the median nerve. involvement of other nerves is rare. the lesion is benign and the recommended treatment is surgical excision. objective: leishmaniasis refers to the spectrum of diseases caused by leishmania species, which are protozoa of order kinetoplastida. clinically leishmaniasis is divided into visceral (kala-azar), cutaneous, mucosal, and mucocutaneous syndromes. the final diagnosis of the disease, lesions of the parasites, as well as shown smear'lerde factor confirmed by histopathological and clinical evaluation. method: in our study, patients with the diagnosis of leishmania cutaneous between and in department of pathology, ataturk university faculty of medicine were presented. results: four ( . %) cases were females and ( . %) were males. age ranging of cases was found from to years and median age . ± . years. the lesions were found on the face in patients. facial skin biopsy specimens were taken in all cases. giemsa-stained touch preparation of the skin biopsy revealed amastigotes inside macrophages, consistent with leishmaniasis. lesions of patients who have long been different from the rest of them were those who migrated to the cukurova region. conclusion: leishmaniasis is public health problem in southeastern anatolia region of turkey, especially in sanliurfa and Çukurova region. autoimmune blistering skin diseases in east anatolia n. gursan * , o. ceylan, h. bilen, n. akdeniz, m. atasoy * ataturk university, medical faculty, erzurum, turkeyobjective: autoimmune blistering skin diseases can be divided into pemphigus diseases and subepidermal bullous diseases. in pemphigus, the autoantibodies are directed against intercellular contact structures; in the pemphigoid diseases, the autoantibodies are directed against adhesion molecules of the basal membrane zone. method: a retrospective study of cases of autoimmune blistering skin diseases obtained over a period of years from st october to st december in the department of pathology, medical faculty of ataturk university was designed. results: in the present study, the mean age was years and male: female ratio was , . the most commonly affected sites were the buccal mucosa and the palate. % of cases, the oral cavity was the primary site of involvement. in histopathological examination we showed intraepithelial vesicle formation, subcorneal separation with acantholysis, and the presence of tzanck cells in biopsy specimens. conclusion: the incidence of autoimmune blistering skin diseases in our department increased in the past years. pemphigus vulgaris is the most common of these diseases. % of autoimmune blistering skin diseases was pemphigus diseases. objective: acute febrile neutrophilic dermatosis (sweet syndrome) is the most common neutrophilic dermatosis. a dense dermal neutrophilic infiltrate is the usual histological findings. the absence of histological image of vasculitis has been considered a characteristic of the disease and a distinctive feature of the other neutrophilic dermatoses. however, recent reports suggest that vasculitis should not exclude the diagnosis. method: this retrospective study examines cases collected over a period of years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . we studied its clinical and histological characteristics. skin biopsy specimens were reviewed to determine the prevalence of vasculitis. results: sweet syndrome is significantly more common in women than in men (sex-ratio= / ). the patient's mean age was years. disease developed most often in autumn. atypical presentation was noted in patients. skin biopsy revealed a sweet syndrome pattern in all cases. the prevalence of vasculitis (vessel wall damage with fibrinoid necrosis) was % ( of the patients). conclusion: our series of patients is particular by the frequency of atypical clinical presentation and the presence of vasculitis in histologic examination, a feature that shouldn't exclude the diagnosis. it was suggested that vasculitis in sweet syndrome represents an epiphenomenon rather than a primary immune-mediated process. dermal lymphangitic carcinomatosis as a primary manifestation of lung carcinoma: report of an unusual case c. hadjileontis * , e. angelidou, a. kafanas * serres general hospital, dept. of pathology, greeceobjective: although dermal lymphangitic metastases are reported to range between and , % of all visceral carcinomas, their presence as a primary manifestation of the tumor is rather unusual. different structures (isolated or forming small clusters) with the morphological characteristics of amoeba trophozoites were identified in the areas of necrosis with and without an inflammatory reaction. the diagnosis of cerebral amebic abscess was then made. the patients received antibiotic treatment. conclusion: cerebral amebic abscess is rare but has poor prognosis. it should be considered as a diagnosis for any patient with subacute and/or chronic meningoencephalitis without evident bacterial etiology. more effective antibiotic drugs can be chosen for post-surgical treatment; furthermore, better survival may be achieved by diagnosing the disease in early stages. morphometric characteries of women placenta which can be different forms of syphilis m. bokhodir * , g. raimnazarova, z. parpiev * tashkent medical academy, dept. of patological anatomy, uzbekistanobjective: many literary information give us about getting down coefficient of fertitity -placenta at women which suffer from pregnancy with syphilis. method: verified data analysis about morphometric placentae and it's comparison with newly-born child at women which suffer from different forms of syphilis. results: research placenta with syphilis show us the area of placenta surface is decreased, it was formed primary syphilis − ,+− , sm, secondary − , ± . sm and with latent form of syphilis , ± . (at control . ± , sm p> o.l), at that time as a mass, placentary cell was been bigger and it formed (at primary- . ± . gr and at secondary- , ± , gr and at latent form of syphilis . ± . gr, then in control ( , ± , ) but all this different were been statistically unreliable (p> , ). comporision mass of placenta and mass newly born-child show us corfficient of fertitity-placenta is make up ( , ± , ) and actually it is not different at control fact group. conclusion: the change coefficient of fertitity -placenta was typifying for until penicillin era, that time. when actual condition, treatment syphilis with antibiotic to bring on development phathomorphism placentae with out different coefficient of fertitity -placenta. influenza b virus-associated pneumonia: report of one fatal case associated with sickle-cell trait l. de carvalho * , l. avila, h. camargo, c. torriso, r. penny, a. sementilli * centro universitário lusíada, dept. of pathology, santos, brazil objective: influenza virus pneumonia complicated with acute respiratory distress syndrome is rare and has a high mortality rate. patients with sickle cell trait are asymptomatic, however, complications with increased risk of thromboembolism can occur. method: case report: a -year-old woman with no preexisting medical conditions presented nonproductive cough and fever for days. for the next days, developed acute respiratory failure. she was treated for septic shock and acute respiratory distress syndrome without success with death. expectoration and blood cultures were negative and the real-time polymerase (rt-pcr) of the thracheal swab was positive for influenza b virus. results: the autopsy showed a diffuse necrotizing alveolitis and intra-alveolar hemorrhage with pulmonary infarction. there was no histological evidence of bacterial pneumonia. an evident blood cell sickling was observed associated with sickle cell trait. rt-pcr was also positive for influenza b virus in pulmonary tissue and the immunohistochemistry was negative for influenza a virus. conclusion: severe hypoxemia caused by the acute respiratory distress syndrome was a possible cause of the blood cell sickling and thrombotic events. objective: lupus vulgaris (also known as "tuberculosis luposa") are painful cutaneous tuberculosis skin lesions with nodular appearance, most often on the face around ears nose, eyelids and lips, cheeks. ıt is still a major health problem in developing countries. cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis. lupus vulgaris (lv) is the most common form of cutaneous tuberculosis. lv should make differential diagnosis other granulomatous disease. all three cases of old female patient. conclusion: herein, three cases were presented which they treatment with correlation clinical and histopathological examination. objective: actinomycosis is a rare, chronic, and slowly progressive granulomatous disease caused by filamentous gram positive anaerobic bacteria from the actinomycetaceae family. it is often misdiagnosed because it can mimic conclusion: the mean length of appendix in both series was about . cm. there were no important difference of the length of either parasitic appendixes or all cause appendectomy materials. in this study, it is concluded that there isn't an effect of the length of appendix on the settlement of bowel parasites. objective: cystic hydatid disease (chd) is an infection produced by larvae of the parasite platyhelminth echinococcus granulosus. living in a rural area is an important risk factor for this disease. it is still an endemic disease in some regions of the world, particularly in many mediterranean countries. the organs most commonly affected are the liver and the lungs. method: we present a new case of multiple thoracic hydatidosis. results: we present the case of a -year-old caucasian man who presented chest pain and dyspnea. chest-x-ray showed a well limited cardiac opacity of the upper lobe and of the right lung. chest-ct-scan showed a mediastinal cyst evoking a hydatid cyst in the left ventricle associated to a right pleural effusion. the patient underwent surgery that consisted in the drainage of multiple pericardial cysts, cystectomy of a left ventricle cyst and right pleural cystectomy. microscopic examination showed a pleura-pulmonary and cardio-pericardial hydatidosis. the patient was treated with albendazole and did not present complications or recurrences after year of follow up. conclusion: multiple thoracic hydatidosis is rare. cardiac location is the most challenging because it is difficult to manage and is life threatening. treatment modalities are mainly based on surgery. preventive measures are necessary to avoid disease recurrence. objective: lymphadenopathy is frequently present in hiv positive patients, especially in those with severe immune deficiency and consequently elevated risc of opportunistic infections and neoplasms. considering the large spectrum of possible differential diagnosis a thorough lymph node analyses should be performed. method: we examinated peripheral lymph nodes from patients from latero-cervical, axilar, inguinal and supraclavicular regions; nodes ( , %) had diameter less then cm. results: histopathological findings indicated mycobacterial infection in patients ( , %), reactive hyperplasia in patients ( , %), lymphoma in patients, metastasis from kaposi sarcoma in and supurative inflamation in . clinically suspected lymphoma was microscopically infirmed in all cases. cases of tuberculosis, of lymphoma and of kaposi sarcoma metastasis were identified, all of them without prior clinical suspicion we identified tuberculosis, lymphoma and metastasis in , % of nodes smaller then cm. conclusion: in % of cases lymph node biopsy identified tuberculosis or malignancy, and established a reliable diagnosis in various clinical suspicions. we consequently emphasize the importance of lymph node examination in the evaluation of lymphadenopathy in hiv positive patients, even is not prominent. stăniceanu and nichita are first authors in equal contribution. the importance of autopsy in hiv infected patients objective: nowadays possibilities of medical investigations offer miriads of accumulating data regarding hiv infected patients status. correlation and/or validation of these informations with pathological findings is mandatory to establish in order to ensure appropiate management of hiv infection. method: we performed a comparative study between clinical/paraclinical and autopsy findings in some of the most frequent afected organs in hiv infection; we studied in hiv positive patients autopsied between and ; all patients had no or incipient (up to year) antiretroviral treatment. results: patients presented lung pathology, clinico-pathological correlations revealing discrepancies, total concordances and partial concordances. most of these inconsistencies referred to opportunistic infections, clinically suspected and pathological refuted in cases and clinically unsuspected and pathological identified in cases. clinically suspected neurological alterations were microscopically infirmed in , % of cases, while cases presented unsuspected lesions. opportunistic infections were key: cord- -o hr mox authors: nan title: proceedings of réanimation , the french intensive care society international congress date: - - journal: ann intensive care doi: . /s - - - sha: doc_id: cord_uid: o hr mox nan rationale: expiratory muscles has recently been stated as the «neglected component» in mechanically ventilated patient. several authors stated these muscles importance in cough capacity, contractile efficiency of the diaphragm or reduction of hyperinflation. however, few studies reported potential factors leading to expiratory muscle weakness and its importance on weaning success or survival after mechanical ventilation. patients and methods: this study is a secondary analysis of our previously described cohort of patients ventilated for at least h assessed for respiratory muscles function. maximal expiratory pressure (mep) measurement was carried out during spontaneous breathing trial using a manometer with an unidirectional valve. mep diagnostic accuracy to predict icu-aw (icu acquired weakness), weaning success and sursvival within days were assessed using expiratory muscle strength as absolute values (cmh o), as %predicted values and as %lower limit of normal. results: due to the paucity of data reporting threshold value for expiratory muscle weakness, we considered our median value ( cmh o (iqr )) as the threshold value for expiratory muscle weakness group (mep ≤ cmh o) and normal expiratory muscle group (mep > cmh o). patients with low mep received more catecholamines (p = . ) and a higher duration of mechanical ventilation (p = . ). inversely, higher body mass index was associated with higher mep. patients with low mep presented more icu-aw compared to normal mep patients ( % vs. %; p = . ). no other outcomes were different between groups. mep was statistically able to predict icu-aw but area under (auc) receiving operating curves showed weak predictive ability (auc: . ( % ic . - . ; p < . ) for a threshold value ≤ cmh o. expiratory muscle weakness was unable to predict critical outcomes when adjusting mep to the %predicted or lower limit of normal. discussion: possible explanation is that contrary to inspiratory muscle weakness, cough inefficacy after weaning from mechanical ventilation could be managed with cough supplementation techniques (i.e. mechanical in-exsufflation). conclusion: in our cohort, mep was not associated with mechanical ventilation weaning or death. despite our results, different clinical techniques for quantifying expiratory muscle weakness may provide more beneficial results. compliance with ethics regulations: yes rationale: venoarterial extracorporeal membrane oxygenation (va-ecmo) is used to support tissue perfusion during extracorporeal cardiopulmonary resuscitation (e-cpr). shock, resuscitation and the extracorporeal circuit may trigger a capillary leakage and a vasoplegic shock. currently, in these situations, high doses of norepinephrine (ne) are required. because high ne doses may have significant cardiovascular side effects, alternative options to support arterial blood pressure are needed. in recent years, several approaches to decrease the administration of high ne doses have been tested, one of them is the administration of vasopressin (avp). randomized trials have shown that avp infusion increases arterial pressure and systemic vascular resistance, decreases catecholamine requirements in patients with or at high risk of vasoplegic syndrome and attenuates vascular dysfunction. currently, no data are available for the study of the effects of avp in shock state in post refractory cardiac arrest. patients and methods: pigs were randomized into two groups, in order to receive avp or ne. a refractory cardiac arrest of ischemic origin was surgically created and va-ecmo was started after a min period of cardio-pulmonary resuscitation. then, resuscitation lasted h in each randomization group. the evolution of the consequences of the shock was evaluated by lactatemia and microcirculation (sdf and nirs) at baseline hour, h (when ecmo starts), h and h . renal and hepatic functions were assessed. results: experimental conditions were met for animals (avp, n = ; ne, n = ). the groups were comparable on the shock impact and its severity. no significant differences were found between populations for ecmo flow and map. there was a significant difference on fluid volume resuscitation amount ( [ . - . ] ml in the ne group versus ml in the avp group, p < . ) (fig. ). no significant difference between the ne and avp groups for lactate clearance between h and h ( . [− . to . ]% vs . [ . - . ]%, p = . ). we did not find any significant for sublingual microcirculation indices and nirs values. renal and liver function evolution were similar in the two groups during the protocol. conclusion: avp administration in refractory cardiac arrest resuscitated by va-ecmo when compared to ne is associated with less fluid volume for similar global and regional hemodynamic effects. compliance with ethics regulations: yes. patients and methods: a single-center prospective study. patients younger than months with severe bronchiolitis and supported by niv or hfnc were included. niv/hfnc was discontinued according to the local practices and no protocol existed. exceptt the principal investigator, the attending team was blinded to the study. weaning failure was defined as the need to reinstate niv/hfnc in the h after discontinuation. ethical approval was not necessary for this study in accordance with the french data protection autority methodology reference number mr- . results: a total of patients (median age days, ( %) males) were included. respectively, ( %) and patients ( %) were supported by niv and hfnc at admission (fig. ) . regarding the mode of niv, a bilevel mode was used in patients ( %) (fig. ). in patients supported by hfnc, the ventilatory support was discontinued progressively by decreasing air flow in patients ( %) while it was stopped abruptly in ( %). in patients supported by niv, the respiratory support was stopped abruptly in ( %) of them while hfnc was used as a weaning method for ( %) patients. a total of ( %) patients experienced a weaning failure. patients supported by niv/ hfnc who experienced a prompt weaning had a lower pediatric intensive care unit (picu) length of stay as compared to patients in whom hfnc was used as a weaning method ( ± h versus ± h, p = . ). however, the hospital length of stay was similar according to the weaning method ( ± days versus ± days for prompt and progressive methods respectively, p = . ). the duration of the weaning process did not differ according to the bed-availability in picu. in patients with severe bronchiolitis, a prompt weaning from niv/hfnc was associated with a lower length of stay in picu. however, the hospital length of stay was similar according to the weaning method. we suggest that a prompt weaning should be preferred in order to reduce the risk of picu related complications. compliance with ethics regulations: yes. information and incitation to open a twitter account and to follow critical care journal feeds) or group (control group). ict were interrogated on their recent medical literature knowledge at and month on trials published in pre-selected journals. results: during the study period, on the french ict contacted, agree to participate: were already on twitter, were randomized to twitter incitation and to control group. at month, there were who answered electronic questionnaire. self-declaration of article knowledge was not different between groups (p = . ). knowledge of primary outcome of each trial was not significantly better in groups (p = . ). in per-protocol analysis of ict on twitter or not, knowledge of article and primary outcome were also not significantly different (respectively p = . and p = . ). short incitation to open a twitter account and follow major medical journals with specific focus on cardiac arrest did not improve knowledge of medical literature by intensive care trainees at month. further trials are needed to better imply intensive care trainees in scientific medical literature. compliance with ethics regulations: yes. - . ] ; p = . ) as independently associated with in-hospital mortality ( fig. ). discussion: triple therapy is the recommended first-line treatment of caps. however, herein, it was not significantly associated with better survival in critically ill, thrombotic aps patients. for the subgroup of "definite/probable caps" patients, double and triple regimens were associated with survival. but the bivariable analyses including the day- saps ii showed that survival was linked to in-icu anticoagulation and corticosteroids-not ivig or plasmapheresis. our findings indicate that corticosteroids should probably be added to in-icu anticoagulation to treat "definite/probable caps". frequent fever and elevated c-reactive protein in all thrombotic aps patients suggest a marked inflammatory state that could explain corticosteroid efficacy. neither plasmapheresis nor ivig impacted the prognosis of "definite/ probable caps", but that finding could be explained by a lack of power compared to caps registry data. conclusion: in-icu anticoagulation was the only aps-specific treatment independently associated with survival for all patients. doublebut not triple-therapy was independently associated with better survival of "definite/probable caps" patients. in these patients, double therapy should be used as first-line therapy while the role of triple therapy requires further evaluation. compliance with ethics regulations: yes. motor deficiency ( %) ( %) ( %) . cognitive impairment ( %) ( %) ( %) . intra-individual relationships between Δpdi and tfdi for mechanically ventilated (mv) patients (a) and healthy subjects (c). relationships between Δpdi and tfdi when breathing cycles were averaged for all participants during each condition for mv patients (b) and healthy subjects (d). − %: initial settings minus % inspiratory help, + %: initial settings plus % more inspiratory help, pep : zero positive end-expiratory pressure, sbt: spontaneous breathing trial. healthy subjects performed spontaneousbreathing (sb) and ventilation against inspiratory threshold at , , , and % of maximal inspiratorypressure (mip) groups. airway closure occurrence increased with bmi ( %, % and %, p = . ). when present, airway opening pressure was . cmh o ( . - . ) and similar between the groups. with increasing bmi, total peep increased from . to . cmh o between groups (p = . ). all values of esophageal pressure increased with bmi. endexpiratory esophageal pressure was strongly correlated with bmi (rho = . , p < . ), as illustrated in fig. . consequently end-expiratory transpulmonary pressure decreased from − . to − . cm h o with increasing bmi (p = . ). the ratio of eelv to predicted functional residual capacity was negatively correlated with end-expiratory pressure (rho = − . , p = . ), but not with bmi. driving pressure and elastance of the respiratory system, chest wall and lung were similar across all ranges of bmi. likewise, eelv was similar between groups. conclusion: in ards, increasing bmi is associated with increased occurrence of airway closure and increased values of esophageal pressure. conversely, chest wall elastance is not influenced by bmi, as well as lung elastance. including bmi in interpreting respiratory mechanics in ards patients can provide additional information for the clinical management. compliance with ethics regulations: yes. rationale: low tidal volume is the cornerstone of protective ventilation inthe initial phase of ards ( ) . whether such low tidal volume can still be achieved when the patient is allowed to breathe spontaneously under pressure support ventilation (psv) is unknown. in moderate-tosevere ards patients receiving neuromuscular blockade, we assessed the tidal volume and its potential association with the outcome during the "transition period" following neuromuscular blockade. patients and methods: retrospective observational study in two university intensive care units. patients fulfilling moderate-to-severe ards criteria less than h after intubation and receiving neuromuscular blockers were included upon entry in the "transition period". we defined the "transition period" as the h following neuromuscular blockers cessation. ventilatory and hemodynamic parameters were recorded every h during the "transition period". primary outcome was the association between mean tidal volume under pressure support ventilation (psv) during the "transition period" and the -day mortality after adjustment for confounding factors. data are reported as median [ st- rd quartile] or number (percentage). results: one hundred nine patients were included, with a pao /fio ratio of mmhg at intubation and mmhg at inclusion and a sofa score at [ . - ] . patients had been ventilated days [ - . ] before inclusion. during the "transition period", patients ( . %) were switched to psv. the median duration of psv was h . the mean tidal volume under psv was significantly lower in survivors than in non survivors at day ( . ml/kg [ . - . ] vs. . ml/kg [ . - . ] respectively, p = . ). by multivariate analysis (cox proportional hazards regression model), mean tidal volume during psv remained independently associated with the -day mortality after adjusting for sofa score and immunosuppression. patients with a mean tidal volume above ml/kg under psv during the "transition period" had a lower cumulative probability of survival at day as compared with others (log rank test, p = . ) (fig. ) . conclusion: in patients with moderate-to-severe ards, a higher tidal volume under psv within the h following neuromuscular blockers cessation is independently associated with the -day mortality.compliance with ethics regulations: yes. kaplan-meier estimate of the cumulative probability of survival according to the mean tidal volume (vt)-lower of higher than ml/ kg-under pressure support ventilation (psv) during the "transition period" transfusion is associated with adverse events, and equipoise remains on the optimal transfusion strategy in oncologic patients in surgical setting. patients and methods: this is a retrospective, single center study. all adults admitted to the intensive care unit (icu) after oncologic surgery from january to december were eligible. the following types of surgery for cancer or metastasis resection with a high risk of bleeding were eligible: thoracic, abdominal, neurosurgery, gynecologic, urologic, otorhinolaryngology or spinal surgery. the primary outcome was a composite outcome including post-operative complications (respiratory, cardiac, renal, thromboembolic, infectious and/or hemorrhagic) and/or hospital mortality. results: of the patients included, patients ( . %) had anemia (based on the who definition: hemoglobin level - . g/dl for female; hemoglobin level - . g/dl for male), patients ( %) had moderate anemia (hemoglobin level: - . g/dl) and patients ( . %) severe anemia (hemoglobin level < g/dl). fifty-six patients ( . %) received at least one rbc transfusion during their hospital stay. patients exposed to moderate and severe anemia required more often renal replacement therapy (rrt) for acute kidney injury (aki) ( . % vs. . %; p = . ), had more surgery-related infections ( . % vs. . %; p = . ). patients who received rbc had more often aki with rrt ( . % vs. . %; p < . ), thromboembolic events ( . % vs. . %; p = . ), sepsis ( . % vs. . %; p = . ), pneumonia ( . % vs. . %; p = . ), surgical site infections ( . % vs. . ; p < . ) and second surgery for infection ( % vs. . %; p = . ). the multivariate analysis found an association between moderate and severe anemia (moderate anemia: or . [ . - . ] ; severe anemia: or . [ . - . ]; p = . ) and severe post-operative complications (fig. a) . there was also an association between rbc transfusion and severe post-operative complications ]; p < . ) (fig. b) . conclusion: anemia was frequent in oncologic surgical patients. anemia, including moderate anemia, was independently associated to patient outcomes; however, rbc transfusion also negatively impacts on patients' prognosis. our study highlights the need for further research to identify the optimal hemoglobin threshold for rbc transfusion in surgical oncologic patients. compliance with ethics regulations: yes. rationale: right ventricular (rv) failure is a common complication in moderate to severe acute respiratory distress syndrome (ards). rv failure is exacerbated by hypercapnic acidosis and overdistension induced by mechanical ventilation. veno-venous extracorporeal co removal (ecco r) might allow ultraprotective mechanical ventilation strategy with a low tidal volume (vt) and plateau pressure (pplat). this study investigated if ecco r therapy could have beneficial effects on rv function. patients and methods: this prospective monocentric pilot study was conducted in a french icu from january to march . patients with moderate to severe ards with pao /fio ratio between to mmhg were enrolled. ventilation parameters, arterial blood gases, echocardiographic parameters performed by transthoracic echocardiography (tte), low-flow ecco r system operational characteristics, outcomes and adverse events were collected during the protocol. primary end point was evolution of rv echocardiographic parameters with ultraprotective ventilation strategy at ml/kg pbw during the -h following the start of ecco r. results: eighteen patients were included. efficacy of ecco r allowed an ultraprotective strategy in all patients. we observed a significant improvement of rv systolic function parameters assessed by tte (fig. ). tricuspid annular plane systolic excursion (tapse) increased significantly under ultraprotective ventilation compared to baseline (from . to . mm; p < . ). systolic excursion velocity (s') also increased after -day protocol (from . m/s to . m/s; p < . ). a significant improvement of aortic velocity time integral (vtiao) under ultraprotective ventilation settings was observed. there were no significant differences in the values of systolic pulmonary arterial pressure (spap). when patients were separated in two groups according to baseline paco level above or under mmhg, we showed the deleterious effect of hypercapnia on rv function, and observed in both groups a beneficial impact of an ultraprotective ventilation strategy on tapse. no severe adverse events directly related to ecco r were observed in our small cohort. conclusion: the low-flow ecco r allows ultraprotective ventilation strategy and improve rv function in moderate to severe ards patients. similarly to prone positioning, ecco r could become a strategy that enables to reconcile lung protective approach with rv protective approach in ards patients. large-scale clinical studies, including patients with severe rv dysfunction, will be required to confirm these results and to assess the overall benefits, in particular the best timing of beginning ecco r in ards patients. compliance with ethics regulations: yes. rationale: bronchoalveolar lavage (bal) is usually deemed to allow the diagnosis of a large array of pulmonary diseases and is usually considered as well tolerated in intensive care unit (icu) patients. however, recent data suggest that the diagnostic yield of bal could be rather low ( ) , and may question its innocuity ( ) . the present study aimed at assessing the benefit-to-risk balance of bal in icu patients. patients and methods: the study was approved by the appropriate ethics committee and registered with clinicaltrials.gov (nct ). in icus, from april to october , we prospectively collected adverse events (ae) during or within h after bal and assessed the bal input for decision-making in consecutive adult patients. aes were categorized in grades of increasing severity. the occurrence of a clinical ae at least of grade , i.e. sufficiently severe to need therapeutic action (s), including modification (s) in respiratory support, defined poor bal tolerance. the bal input for decision-making was declared satisfactory if it allowed to interrupt or initiate one or several treatments. results: we included bal in patients (age yrs ; female gender: [ . %]; simplified acute physiology score ii: ; immunosuppression [ . %], chronic pulmonary disease [ / ( . %)]). bal was performed either in non-intubated patients receiving standard o therapy (n = [ . %]), or noninvasive ventilation (n = [ . %]), or high-flow nasal cannula o therapy ( [ . %]), or in patients under invasive mechanical ventilation (n = [ . %]). a total of aes were observed in ( . %) patients. sixty-seven ( . %) patients reached the grade of ae or higher. the main predictor of poor bal tolerance identified by logistic regression was the association of a bal performed by a non-experienced physician (non-pulmonologist, or intensivist with less than years in the specialty or less than bal performed) in non-intubated patients (or: . [ % confidence interval . - . ] ; p < . ). ordinal regression also showed that when bal was performed by a non-experienced physician in a non-intubated patient, this was associated with an increased risk of ae of any grade (or: . [ . - . ]). a satisfactory bal input for decision-making was observed in ( . %) cases and was not predictable using logistic regression. conclusion: adverse events related to bal in icu patients are frequent, and sometimes serious. our findings call for an extreme caution when envisaging a bal in icu patients and for a mandatory accompaniment of the less experienced physicians. compliance with ethics regulations: yes. meningitis is a rare complication of critically ill patients with severe pneumococcal community-acquired pneumonia paul jaubert, julien charpentier, jean-daniel chiche, frédéric pene, alain cariou, guillaume savary, marine paul, jean-paul mira, mathieu jozwiak cochin, paris, france; mignot, versailles, france correspondence: paul jaubert (paul.jaubert@gmail.com) ann. intensive care , (suppl ): rationale: severe pneumococcal community-acquired pneumonia (pcap) is a frequent infection requiring intensive care unit (icu) admission. pneumococcal meningitis associated with pcap has been reported and could worsen the prognosis of patients. however, this complication is difficult to predict and lumbar puncture is not systematically performed, regardless the severity of pcap. thus, we investigated the characteristics of patients with pcap associated with pneumococcal meningitis. patients and methods: we retrospectively included all patients admitted for pcap in our icu between (inception of our electronic medical sheet) and the end of . community-acquired pneumonia was defined according to the criteria of the american thoracic society. we excluded all patients admitted in icu with initial suspicion of meningitis. variables regarding epidemiology, clinical and microbiological characteristics, management and prognosis of these patients were collected and analyzed. results: among the patients admitted for pcap ( ± years old, saps ii ± , % of men), % of the patients required mechanical ventilation and % vasopressors infusion. the icu mortality was %. s. pneumoniae was documented by a positive antigen test in % of the patient and/or by a positive sputum smear, tracheal aspirate or distal protected airway specimen in % of the patients, and/or by pleural aspirate in % of the patients and/or by positive blood culture in % (n = ) of the patients. a lumbar puncture was performed in % (n = ) of the patients with bacteriemia and in % (n = ) of the patients without bacteriemia, with a median delay of h [interquartile range: after the onset of antibiotherapy. alllumbar punctures (n = ) were performed for neurological signs: % of coma, % of confusion and % of seizures. when a lumbar puncture was performed, meningitis was diagnosed in % (n = ) of the patients with bacteriemia and in % (n = ) of the patients without bacteriemia (p < . ). the icu mortality ( % vs. %, respectively), age ( ± vs. ± years old, respectively), saps ii ( ± vs. ± , respectively) or icu length of stay ( ± vs. ± days, respectively) were not different between patients with and without meningitis (each p = ns). conclusion: meningitis is a rare complication of pcap and is more frequent in patients with bacteriemia. suprisingly, meningitis is not associated with higher icu mortality. further analyses are ongoing to identify independent risk factors of meningitis in patients with pcap. compliance with ethics regulations: yes. rationale: shock is the clinical expression of a circulatory failure that results in inadequate cellular oxygen utilization. whereas the host response to septic shock has been extensively described, knowledge of the pathogenesis of non-septic shocks remains limited. we aimed to characterize the systemic host response in shock related to non-septic conditions (nssh) as compared with septic shock (ssh). patients and methods: we performed a prospective study in two intensive care units (icus) in patients admitted for ssh (n = ) or nssh (n = ). immune responses were determined upon icu admission by measuring plasma biomarkers reflecting host response pathways implicated in the pathogenesis of critical illness (in ssh and nssh patients), and by applying genome-wide blood mrna expression profiling (in ssh and nssh patients). results: compared with nssh, patients with ssh had more chronic comorbidities, greater disease severity (apache iv score vs. , p < . ) and worse outcomes resulting in higher mortality rates up to one year after icu admission ( . % vs. . %, p < . ). plasma biomarker analysis revealed severely disturbed host responses in both ssh and nssh patients. however, ssh patients displayed more prominent inflammatory responses, endothelial cell activation, loss of vascular integrity and a more pro-coagulant state relative to nssh patients. blood leukocyte genomic responses were more than % common between ssh and nssh patients relative to health (fig. a) , comprising overexpression of innate pro-and anti-inflammatory pathways, and underexpression of lymphocyte and antigen-presentation gene sets. direct comparison of ssh to nssh patients matched for severity (fig. b) showed overexpression of genes involved in mitochondrial dysfunction and specific metabolic pathways, and underexpression of lymphocyte, nf-κb and cytokine pathways. conclusion: patients with ssh and nssh present with largely similar host response aberrations at icu admission; however, patients with septic shock show more dysregulated inflammatory and vascular host responses, as well as specific leukocyte transcriptome alterations consistent with greatermetabolic reprogrammingand more severe immune suppression. compliance with ethics regulations: yes. rationale: aki is associated with short and long term mortality and morbidity. although recovery has been demonstrated to be associated with outcome of critically ill patients, interpretation of available data is limited by time dependent nature of recovery and by competing risks. our objective was to describe renal recovery, pattern of recovery according to adqi definitions and risk factor of this later. monocenter retrospective cohort study. adult patients admitted in our icu from july to december were included. aki was defined according to kdigo criteria and recovery according to adqi definition. incidence of recovery at each time point was depicted using competing risk survival analysis. risk of transition between aki and no-aki was assessed by a semi-markov model. last, a trajectoire analysis was performed to depict most frequent recovery patterns. results are reported as n (%) or median (iqr). results: patients were included with a median age of ( - ). median sofa score at admission was [ ] [ ] [ ] [ ] [ ] [ ] . at icu admission, patients ( . %) had an aki stage , patients ( . %) an aki stage and patients ( . %) an aki stage . according to adqi criteria, aki was defined as rapidly reversed in patients ( . % of aki patients), persistent aki in patients ( . %) and as acute kidney disease (akd) in patients ( . %), remaining patients couldn't be classified (n = ). risk of recovery was of % per day until day then % per day (fig. a) . fine and gray model, taking into account death as competing risk, identified risk factors negatively associated with renal recovery, namely sofa score (shr = . per point; % ic = [ . - . ]), preexisting hypertension (shr = . ; % ic = [ . - . ]) and aki severity (stage vs. stage shr = . ; % ic = [ . - . ]). risk of de novo aki was maximal during the first days and ranged from to % per day. trajectoire model identified clusters of patients ( fig. b) , closely associated with patients' outcome: a) low patients' severity and no or mild aki (n = ; hospital mortality: %); b) moderate to severe aki but little associated organ dysfunction (n = , hospital mortality: . %); c) severe aki and multiple organ failure (n = ; hospital mortality: . %). conclusion: this study, assessing aki recovery patterns, is the first to our knowledge using adqi definition. despite the high rate of early recovery and of rapidly reversed aki, up to % of aki patients had not recovered at day and could therefore be classified has having akd. compliance with ethics regulations: yes. rationale: sepsis is the most frequent cause of acute kidney injury (aki). the "acute disease quality initiative workgroup" recently proposed new definitions for aki, classifying it as transient or persistent. we aimed to determine the incidence, attributable mortality and host response characteristics of transient and persistent aki in patients with sepsis. patients and methods: we performed a prospective observational study comprising consecutive admissions for sepsis in intensive care units (icus) in the netherlands, stratified according to the presence and evolution of aki. attributable mortality fraction (excess risk for dying with persistent aki relative to transient aki) was determined using a logistic regression model adjusting for confounding variables. in a subset of sepsis patients, plasma biomarkers indicative of major pathways involved in sepsis pathogenesis were measured. in a second subset of patients, whole-genome blood-leukocyte transcriptomes were analyzed. results: sepsis patients were included. aki occurred in . % (n = ), of which . % (n = ) was transient and . % (n = ) persistent. patients with persistent aki had higher disease severity scores on admission than patients with transient aki or without aki and more frequently had severe (injury of failure) rifle aki-stages on admission (n = , . %) than transient aki patients (n = , . %, p < . ). persistent aki, but not transient aki, was associated with increased mortality by day- (adjusted or . , % ci . - . ; p = . ) ( figure) and up to -year (adjusted or . , % ci . - . ;p = . ). the attributable mortality of persistent relative to transient aki by day- was . % ( % ci . - . %). persistent aki was associated with enhanced and sustained inflammatory and procoagulant responses during the first days, and a more severe loss of vascular integrity compared with transient aki. baseline blood gene expression showed minimal differences with respect to the presence or evolution of aki. conclusion: persistent aki is associated with higher sepsis severity, sustained inflammatory and procoagulant responses, and loss of vascular integrity as compared with transient aki, and independently contributes to sepsis mortality. compliance with ethics regulations: yes. rationale: to address the paucity of data on the epidemiology of patients admitted to intensive care units (icus) with in-hospital cardiac arrest (ihca), we examined key features, mortality and trends in mortality in a large cohort of patients admitted in french icus over the past years. patients and methods: from to database of the collège des utilisateurs de bases de données en réanimation (cub-réa), we determined temporal trends in the characteristics of ihca, patients' outcomes and predictors of icu mortality. results: of the icu admissions, ( . %) were cardiac arrests and were ihca ( . %). during the study period, the age of ihca patients increased by . years (p = . ) and patients presented more comorbidities (chronic heart disease, chronic kidney disease and cancer). patients were also more critically ill over the period as reflected by the increase of saps-ii by . % (p < . ). paradoxically, in-hospital management became lighter through the time with reduced respiratory support (p < . ), renal support (p < . ) and use of vasoactive drugs (p < . ). crude in-icu mortality decreased from % to . % over the past eighteen years (p < . ), fig. rationale: in surgery, prophylaxis antibiotic aims at preventing the occurrence of post-operative infections. for adults, it is currently recommended to only use prophylactic antibiotic therapy during the time of the intervention. but in pediatric cardiac surgery, there is no consensus around the optimal duration of use of antibiotic prophylaxis. the protocol was modified in in the icu and its time reduced to h. we aimed to determine whether h of post-sternotomy antibiotic prophylaxis was not less effective than h treatment to help prevent care-associated infections. patients and methods: after agreement of the ethics committee of our institution, we performed a retrospective non inferiority study, with an inferiority margin to %. the primary objective is to compare the incidence of care-related infections between a second-generation cephalosporin (c g) antibiotic prophylaxis during h and a -h protocols. the secondary objectives are to determine the infection's incidence, to identify the risk factors for nosocomial infections and to compare the incidence of multidrug-resistant infections. results: between january and july , children underwent cardiac surgeries with sternal opening. received h of c g antibiotic prophylaxis and received h of c g treatment. five previously infected children have been excluded. both groups were demographically and surgically similar. the median age was months (range a few hours of life to . years old) and the median weight was . kg. in the intent-to-treat analysis, incidence of care-related infections is at . % in the c g- h group and . % in the c g- h group. a multivariate analysis shows that the shorter -h time antibiotic prophylaxis is not inferior regarding infection prevention compared to h of antibiotic prophylaxis, p = . . as in the per protocole analysis, the c g- h group rate was . % and . % for the g g- h group. conclusion: it demonstrates that shortening the antibiotic prophylaxis treatment time to h does not affect or increase the rate of infections after a pediatric sternotomy surgery compared to -h protocole. prophylaxis in pediatric cardiac surgery should be short-lived. a multicenter prospective study would allow a consensus and confirm this decision. compliance with ethics regulations: yes. rationale: the use of "big data" is getting increasingly popular in the medical field, especially in intensive care where large amounts of data are continuously generated. however, big data can be misleading when essential clinical data are missing. the adequate adjustment for potential confounding factors (e.g., severity of respiratory distress) should be the key procedure in the big data analyses; however, it is challenging to capture the clinical severity within large electronic databases. bronchiolitis is one main reason for admission to pediatric intensive care unit (picu). the modified wood's clinical asthma score (mwcas) is widely used to assess the severity of bronchiolitis. the objective of the study is to build an automated mwcas (a-mwcas) to continuously assess the severity of respiratory distress in critically ill children. this retrospective study included all infants < years old with a clinical diagnosis of bronchiolitis, ventilated with non-invasive neurally adjusted ventilatory assist, in a canadian picu, between october and june . we developed an algorithm, using python . , which was directly connected to the electronic medical record. the components of the score were collected using structured query language (sql) queries and processed to derive the a-mwcas. for validation, the a-mwcas score was compared to the mwcas manually computed by a clinical expert (m-mwcas) . results: sixty-four infants were included in the study, for which of a-mwcas and m-mwcas were generated respectively. the cohen's kappa coefficient was applied to estimate the agreement between the two scores which was . ( % confidence interval) ( table ) which corresponds to . % of complete agreement. . % of the a-mwcas scores were within ± . of the m-mwcas. the kappa coefficient for the each score component were: . for the oxygen saturation, . for the expiratory wheezing, . for the inspiratory breath sounds, . for the use of accessories muscles and . for the mental status, respectively. discussion: the largest discrepancy was observed in the mental status, which clinical evaluation is relatively subjective and varies among care team members (doctor, nurse, respiratory therapist…). the automated score likely decreases this variability by consistently using the same source (respiratory therapist), but its validity should be confirmed in a prospective study. the a-mwcas provides a valid estimation of the mwcas that is fast and robust. after external prospective validation, it may help to add some clinical sense within large electronic databases, with improved assessment of the respiratory distress. compliance with ethics regulations: yes. rationale: in paediatric intensive care units (picu), survival rates have dramatically improved. this has been accompanied by increased morbidity, including psychological morbidity. these new impairments, that can affect the survivors and their families have been conceptualized under the frame of post-intensive care syndrome (pics) and picsfamily. the aim of this study was to explore the experience of critically ill children parent's during the stay in picu, and its impact on the family. patients and methods: we planned a prospective, single centre study for months. we collected qualitative written data from parents whose child had been admitted to the picu for the first time, for at least two nights. results: fifty-seven questionnaires were analysed from thirty-seven admissions. picu admissions were mostly unplanned. among parents % experienced very painful memories during admission and % have feared for their child's life. during the stay, noise has bothered % of parents, and many have described difficulties to rest at night. % had the sensation that their child was suffering, mostly from pain, tiredness, anxiety or fear. during picu stay, % of parents had to stop working, and siblings schooling was impacted in % of cases, % of parents considered themselves to be useful for their child and % have participated to nursing care. more than % were satisfied about information given and communication, % appreciated empathy and support from care givers. parents received support from family, friends, and also from other parents of hospitalized children. parents expressed relief ( %) and serenity ( %) to leave picu, % of them were in demand to meet picu staff again after discharge. conclusion: picu parent's experience is tough, and the impact on family is clear. these are known risks factors for pics. on a very positive note, parents seemed to be satisfied by family-centred care, and were able to preserve their parental role. however, there is still room for improvement of practices. compliance with ethics regulations: yes. the gut has been suspected to be involved in multiple organs dysfunction syndrome (mods) in the intensive care unit (icu). studies suggested a link between gastrointestinal dysfunction (gid) and outcomes. but these studies included very few patients and most of them were retrospective. patients and methods: this study is a secondary analysis of data from a previous study that included patients from french icus. gid is defined as the association of vomiting and constipation or diarrhea during the first week after icu admission. patients included were treated with vasopressors and mechanical ventilation. the first goal was to determine if gid is a risk factor of -day mortality in this population. secondary goals were to assess the impact of gid on nosocomial infections. results: among included patients, ( . %) had gid. by day- , ( %) of the patients with gid and ( %) of the patients without gid had died (odds ratio . [ . - . ]; p = . ). multivariable regression model did not show any association between gastrointestinal dysfunction and increased risk of -day mortality in patients (odds ratio . [ . - . ], p = . ). gastrointestinal dysfunction was strongly associated with other secondary outcomes ( table ). patients with gid had longer ventilation duration, icu length of stay and hospital length of stay. they also had more nosocomial infections, in particularly ventilator-associated pneumonia. this association still existed in a multivariable regression model for prediction of nosocomial infection including the same variables than the previous model (odds ratio . [ . - . ], p = . ). no association with day- mortality was observed. conclusion: gastrointestinal dysfunction was not a risk factor of day- mortality but was associated with an increased risk of nosocomial infection and an increased length of stay. this study is observational and no causality link can be done. however, our data suggest further studies on strategies aimed to limit gid. compliance with ethics regulations: yes. rationale: acute cholangitis (ac), a bacterial infection related to an obstruction of the biliary tree, may be responsible for life-threatening organ failure. however, little is known about the outcome and the predictive factors of mortality of critically ill patients admitted in icu for acute cholangitis. we aimed to describe characteristics of patients admitted in icu for ac and to analyze predictive factors of in-hospital mortality including the time to biliary drainage procedure. patients and methods: retrospective study of all cases of acute cholangitis admitted in french icus ( tertiary hospitals and non-ter- [ . ; . ] µg/l. % of patients (n = ) have positive blood culture, mostly gram negative bacilli ( %) and % producing extended spectrum beta lactamase enterobacteriaecae. at icu admission, persisting obstruction was frequent ( %) and therapeutic endoscopic retrograde cholangiopancreatography was performed in % of them. in a multivariable analysis, at icu admission, several factors were significantly associated with in-hospital mortality: sofa score (or = . [ % ic . ; . ] by point, p = . ), arterial lactate (or = . [ . ; . ] by mmol/l, p < . ), total serum bilirubin (or = . [ . ; . ] by umol/l, p < . ), obstruction nonrelated to gallstones (p < . ) and ac complications (liver abcess and/or pancreatitis) (or = . [ . ; . ] p = . ). in addition, time > h between icu admission and biliary drainage was associated to in-hospital mortality (adjusted or = . [ . ; . ] p = . ). conclusion: acute cholangitis is responsible for high mortality in icu. organ failure severity, causes and local complications of cholangitis are predictive factors of mortality as well as delayed biliary drainage. compliance with ethics regulations: yes. the united kingdom) were included (n = ). predictors of one-year mortality were retrospectively screened and tested on a single center training cohort. a predictive score was developed and tested on an independent multicenter cohort. results: four independent pre-transplantation risk factors were associated with one-year mortality after transplantation in the training cohort: age ≥ years (or = . , % ci = . - . , p = . ), pre-transplantation arterial lactate level ≥ mml/l (or = . , % ci = . - . , p = . ), mechanical ventilation with pao / fio ≤ mmhg (or = . , % ci = . - . , p = . ) and pretransplantation leukocyte count ≤ g/l (or = . , % ci = . - . , p = . ). a simplified version of the model was derived by assigning point to each risk factor: the transplantation for aclf- model (tam) score. a cut-off at points distinguished a high-risk group (score > ) from a low-risk group (score ≤ ) with one-year survival of . % vs. . % respectively (p < . ). the model and its simplified version were validated on the independent multicenter cohort. there was a significant difference between the high-risk and low-risk group with one-year survival of % vs. . % respectively (p < . ). conclusion: liver transplantation can be an effective treatment for critically ill cirrhotic patients with hepatic and extra hepatic organ failure provided patients are carefully selected and that they are transplanted at the optimal time in the intensive care. the tam score can help stratify post-transplantation survival and assist clinicians in the transplantation decision-making process at the bedside of aclf- patients. compliance with ethics regulations: yes. rationale: trans-thoracic echocardiography (tte) is commonly used in the initial management of patients with shock in icu. there is little published evidence for any mortality benefit. we compared the effect of echocardiography protocol versus standard care for survival and clinical outcomes. patients and methods: this randomized controlled trial included selected shocked patients (systolic blood pressure < mm hg and signs of organ hypoperfusion) randomized to early tte plus standard care versus standard care without tte. the primary outcome measure was survivalto days. secondary outcome measures included initial treatment and vasopressor weaning. results: consecutive subjects with circulatory shock (low systolic arterial blood pressure (sap) and signs of organ hypoperfusion) at the time of icu admission are included in the study. in the tte group: fluid prescription during the first h was significantly lower rationale: both the negative prognostic value and reversibility of left ventricular (lv) diastolic dysfunction in septic patients remain debated. the excess of mortality in septic shock patients with hyperdynamic profile has only been reported by small-size studies. accordingly, the primary objective of the prodiasys study was to assess the impact of lv diastolic dysfunction (and its severity) and of lv hyperkinesia echocardiographically identified during the initial phase of septic shock on -day survival. the secondary objective was to assess the potential link between lv diastolic dysfunction, cumulative water balance (on day ), and outcome. patients and methods: this was a multicenter, prospective, observational, cohort study. patients older than years hospitalized in icu for septic shock (sepsis- definition) were eligible. exclusion criteria were administration of inotropes, severe left valvular disease, constrictive pericarditis and moribund patients. in each patient, echocardiography was first performed within h after the diagnosis of septic shock and then daily until day , after vasopressor discontinuation, at icu discharge and on day or at hospital discharge, whichever occurred first. vital and biological parameters usually monitored for septic shock management were collected at each echocardiographic assessment. vital status was collected on day . associations between lv diastolic dysfunction or lv hyperkinesia and day- mortality were analyzed using a chi test. adjusted analyses were performed using logistic regression models, including variables known to be linked with the prognosis of septic shock (e.g., severity scores, delay of antibiotherapy). the relationship between the grade (i to iii) of lv diastolic dysfunction and -day survival were analyzed using a logistic regression model. the relationship between the presence of lv diastolic dysfunction and cumulated water balance on day were analyzed using a linear regression model adjusted on the body weight on admission. the relationship between the grade of lv diastolic dysfunction and cumulated water balance on day were analyzed using a linear regression model. diaphragm dysfunction and weaning induced pulmonary edema are two frequent causes of weaning failure but their coexistence and interaction have been poorly investigated. we hypothesized that diaphragm dysfunction may not induce a sufficient decrease in intra-thoracic pressure to increase venous return and generate a weaning induced pulmonary edema. we therefore investigated whether weaning induced pulmonary edema and diaphragm dysfunction are or not associated and evaluated the effect of diaphragm dysfunction on cardiac function and lung aeration during a spontaneous breathing trial (sbt). patients and methods: patients with readiness to wean criteria who had failed a first sbt were eligible. before and after a second sbt, diaphragm function was assessed by measuring the change in tracheal pressure induced by a bilateral phrenic nerve stimulation (ptr, stim), cardiac function (cardiac output, systolic pulmonary arterial pressure) was evaluated with echocardiography and lung aeration was estimated from the lung ultrasound score (lus). plasma protein concentration and hemoglobin were also sampled before and after the sbt. diaphragm dysfunction was defined by ptr, stim < − cmh o and weaning induced pulmonary edema was diagnosed in case of sbt failure associated with ) increase in plasma protein concentration or hemoglobin > % during the spontaneous breathing trial and/or ) early (e) over late peak diastolic velocity ratio > . or e over peak diastolic velocity ratio > . . results: fifty-three patients were included and / ( %) failed the sbt. diaphragm dysfunction was present in / ( %) of patients with weaning induced pulmonary edema, in / ( %) patients with sbt success and in / ( %) patients with other causes of sbt failure (p < . ). during the sbt, diaphragm dysfunction induced a significant increase in systolic pulmonary arterial pressure but no change in cardiac output. patients with diaphragm dysfunction had a higher lus as compared to their counterparts ( ± vs. ± , respectively, p < . ). conclusion: diaphragm dysfunction induces a loss of lung recruitment and a significant increase in systolic pulmonary arterial pressure during the sbt. coexistence of diaphragm dysfunction and weaning induced pulmonary edema is common in case of sbt failure but weaning induced pulmonary edema appears more likely to be involved than diaphragm dysfunction. compliance with ethics regulations: yes. rationale: diaphragmatic weakness in the intensive care unit (icu) is associated with poor outcome. prolonged mechanical ventilation is associated either with a decrease (atrophy) or an increase (supposed injury) in diaphragmatic thickness, both associated with prolonged weaning. shear wave elastography is a non-invasive technique that measures diaphragm shear modulus (sm), a surrogate of its mechanical properties. the aim of this study was to describe the diaphragm shear modulus during the icu stay and to describe its relation with diaphragm thickness. patients and methods: this prospective and monocentric study included all consecutive critically ill patients. ultrasound examination of the diaphragm (aixplorer; supersonic-imagine, aix-en-provence, france) was obtained by two investigatorsevery other day until icu discharge. demographics, diaphragm thickness, sm and outcomes were collected. a mixed model regression was used to study the relation between sm and diaphragm thickness. results: we enrolled patients from december st to june st, being invasively mechanically ventilated during the stay. diaphragm ultrasound evaluation was feasible in / ( %) patients. the duration of mechanical ventilation during the icu stay was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] days with [ ] [ ] [ ] [ ] [ ] days spent on controlled mechanical ventilation. sm was . ± . kpa and diaphragm end-expiratory thickness was . ± . cm upon icu admission. increase and decrease ≥ % during icu stay occured in and percent of the patients respectively for diaphragmatic thickness, and in and percent of the patients respectively for diaphragmatic sm. diaphragm thickness over time was inversely correlated with diaphragm sm and with time spent under mechanical ventilation (table) . diaphragm sm over time was correlated with time spent under pressure support ventilation or under spontaneous breathing (compared to controlled ventilation) and with time spent under deep sedation. diaphragm sm was inversely correlated with age, sepsis, exposition to steroids (table) . no association was found between diaphragm sm and outcomes. discussion: our results are in line with the myotrauma concept, suggesting alteration in diaphragm mechanical properties associated with increased diaphragm thickness in critically ill patients. we hypothesize that this observation most likely reflects muscle injury and tissue infiltration with edema and inflammatory cells. conclusion: shear wave ultrasound elastography suggests that in critically ill patients, the increase in diaphragmatic mass is associated with an alteration in diaphragm mechanical properties as measured by sm. compliance with ethics regulations: yes. rationale: diaphragm dysfunction and intensive care unit (icu) acquired weakness (icu-aw) are associated with poor outcomes in the icu but their long term impact on prognosis and health-related quality of life (hrqol) is poorly established. this study sought to determine whether diaphragm dysfunction is associated with negative long-term outcomes and whether the coexistence of diaphragm dysfunction and icu-aw has a particular impact on two-year survival and hrqol. patients and methods: we used a previous cohort study conducted in our institution to follow up mechanically ventilated patients in whom diaphragm and limb muscle functions were investigated at the time of liberation from mechanical ventilation. diaphragm dysfunction was defined by tracheal pressure generated by phrenic nerve stimulation < cmh o and icu-acquired weakness was defined by medical research council (mrc) score < . hrqol was evaluated with the sf- questionnaire. results: sixty-nine of the patients enrolled in the original study were included in the survival analysis and were interviewed. overall two-year survival was % ( / ): % ( / ) in patients with diaphragm dysfunction, % ( / ) in patients without diaphragm dysfunction, % ( / ) in patients with icu-acquired weakness and % ( / ) in patients without icu-acquired weakness. patients with concomitant diaphragm dysfunction and icu-acquired weakness had a poorer outcome with a -year survival rate of % ( / ) compared to patients without diaphragm function and icu-acquired weakness ( % ( / ) (p < . )). hrqol was not influenced by the presence of icu-acquired weakness, diaphragm dysfunction or their coexistence. conclusion: icu-acquired weakness but not diaphragm dysfunction has a strong negative impact on two-year survival of critically ill patients. the presence of diaphragm dysfunction appears more likely to be a determinant of early prognosis and does not appear to have a significant impact on long-term survival. compliance with ethics regulations: yes. rationale: influenza can lead to severe condition with acute respiratory failure and acute respiratory distress syndrome due to a massive pulmonary inflammatory in response to the viral invasion. lung bacteriobiota has been described to be associated with pulmonary inflammation in chronic respiratory diseases such as chronic obstructive pulmonary disease or cystic fibrosis. lung mycobiota has been poorly investigated despite the well-known role for fungi in numerous respiratory diseases. the aim of our study was to assess the prognostic value of lung bacteriobiota and mycobiota among critically ill influenza patients. patients and methods: we prospectively included influenza patients admitted to icu. sputum were stored a - °c. bacterial and fungal dna were extracted thanks to qiaamp ® powerfecal ® pro dna kit. s rrna gene v -v regions and its regions were amplified by pcr and sequenced on illumina miseq ® . taxonomic assignation was obtained by dada pipeline and microbiota analysis were performed according to day- mortality by the mean of phyloseq package on r . . software. results: thirty-nine patients were admitted to icu for influenza with sputa available and finally dna samples available after extraction. bacteriobiota alpha diversity was significantly lower among non-survivors than survivors when expressed by the mean of shannon index, simpson index or evenness (respectively p = . , p = . , p = . ). area under the curve to predict day- mortality was . , ci [ . ; . ] for shannon index, . ci [ . ; . ] for simpson index and . ci [ . ; . ] for evenness. β-diversity analysis also demonstrated significant differences between survivors and non-survivors (adjusted permutational multivariate anova, p = . ). nonsurvivors had a higher abundance of staphylococcus, haemophilus, streptococcus and moraxella. none of the fungal alpha-diversity index nor beta-diversity were significantively different between survivors and non-survivors. non-survivors had a higher proportion of candida albicans and malassezia but not of aspergillus. conclusion: the lung bacteriobiota profile, but not the mycobiota one, of critically ill influenza patients is associated with day- mortality and may be used to identify subjects with a poor prognosis at the time of admission. compliance with ethics regulations: yes. that takes into account the interaction between multiple cellular pathways. the pathway profiles between moderate and severe influenza were then compared to delineate the biological mechanisms underpinning the progression from moderate to severe influenza. results: patients ( severe and moderate influenza patients) and healthy control subjects were included in the study. severe influenza was associated with upregulation in several neutrophilrelated pathways, including pathways involved in neutrophil differentiation, migration, degranulation and neutrophil extracellular trap (net) formation. the degree of upregulation in neutrophil-related pathways was significantly higher in severely infected patients compared to moderately infected patients. severe influenza was also associated with downregulation in immune response pathways, including pathways involved in antigen presentation, cd + t-cell co-stimulation, cd + t cell and natural killer (nk) cells effector functions. apoptosis pathways were also downregulated in severe influenza patients compared to moderate and healthy controls. conclusion: these findings showed that there are changes in gene expression profile that may highlight distinct pathogenic mechanisms associated with progression from moderate to severe influenza infection. compliance with ethics regulations: yes. rationale: herpesviridae reactivation among non-immunocompromised critically ill patients is associated with impaired prognosis, especially during acute respiratory distress syndrome (ards). however, few is known about herpes simplex virus (hsv) and cytomegalovirus (cmv) reactivation occurring in patients with severe ards under venovenous extracorporeal membrane oxygenation (ecmo). we tried to determine the frequency of herpesviridae reactivation and its impact on patients'prognosis during ecmo for severe ards. patients and methods: we conducted an observational, retrospective study in a medical icu (ards and ecmo referee center) between and . patients with a severe ards requiring a venovenous ecmo for days or more were included. hsv and/or cmv reactivation occurring after ecmo insertion was screened for these patients. patients with immunosuppression, antiviral therapy against hsv and/ or cmv prior to inclusion, or hsv/cmv reactivation known at the time of ecmo insertion were excluded. hsv reactivation was defined by a positive qualitative throat sample (virocult ® ) pcr or positive bronchoalveolar lavage (bal) pcr. cmv reactivation was defined by a positive quantitative blood or bal pcr. results: during a five-year period, non-immunocompromised patients with a severe ards necessitating a veno-venous ecmo were included. sixty-seven ( %) experienced hsv and/or cmv reactivation during ecmo course ( viral co-infection, hsv alone and cmv alone). hsv reactivation occurred earlier than cmv after the beginning of mv ( ( - ) vs. ( - ) days; p < . ) and after ecmo implementation ( ( - ) vs. ( - ) days; p < . ). in univariate analysis, hsv/cmv reactivation was associated with a longer duration of mechanical ventilation ( ( - . ) vs. . ( - ) days; p < . ), a longer duration of . ) vs. ( - ) days;p < . ), and a prolonged vs. ( - ) days; p < . ) and hospital stay ( ( - . ) vs. ( - ) days; p < . ). however, in multivariate analysis, viral reactivation remained associated with prolonged mv only. when comparing patients having cmv (alone or combined with hsv) vs. hsv reactivation alone, cmv positive patients had a longer mechanical ventilation duration and fewer ventilator-free days at day- and a longer icu and hospital length of stay. conclusion: herpesviridae reactivation is frequent among patients with sevre ards under veno-venous ecmo and is associated with a longer duration of mechanical ventilation. cmv seems to have a proper negative role on pulmonary fiunction as compared to hsv alone. hsv and cmv deserve to be researched in severe ards patients under ecmo. compliance with ethics regulations: yes. charlotte vandueren , benjamin zuber , eve garrigues , antoine gros , nicolas epaillard , guillaume voiriot , yacine tandjaoui rationale: respiratory syncytial virus (rsv) is a common cause of pediatric bronchiolitis and influenza-like illness in adults. its involvement in severe infections in adults remains unclear. the captif study aimed at comparing characteristics and prognosis of icu patients infected with rsv and influenza, assuming that, based on the limited evidence, the mortality of rsv infection would be lower than the influenza related one. patients and methods: multicenter franco-belgian retrospective study. adults admitted to icus between /nov/ and / apr/ with respiratory rsv infection were included and matched : to influenza patients on center and icu admission date. patients' characteristics, clinical presentation, and outcome were compared between groups using univariate and multivariable analyses. results: we report here the results for the first cases among included patients. mean age was . ( . ) years and saps- score was ( ), not different between groups. compared to influenza patients, rsv patients more frequently had chronic respiratory failure ( % vs %, p < . ) or immune suppression ( vs %, p = . ). frequencies of cardiac, renal and hepatic chronic diseases were similar. almost all patients had respiratory symptoms (> %), extrarespiratory symptoms were more frequent in influenza patients ( vs %, = . ). rsv patients more frequently had bronchospasm ( vs %, p = . ). clinical presentation such as ards ( %), shock ( %) and pulmonary coinfection ( %) were similar, however sofa score was higher in rsv patients ( . ( . ) vs . ( ), p = . ). the p/f ratio was around mmhg in both groups, paco was higher in rsv patients ( vs mmhg, < . ). respiratory assistance at diagnosis tended to differ (p = . ), rsv patients receiving more non invasive ventilation ( vs %) and less high flow oxygen therapy ( vs %) but invasive ventilation was required similarly ( vs %). during icu stay, ards was more frequent in rsv patients ( vs %, p = . ), accordingly prone position ( . vs . %) and ecmo ( . vs . %) were more frequently needed. length of mechanical ventilation ( days ( - ) ) and icu los ( days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ) were not different. icu mortality was similar in rsv and influenza patients ( . % and . %), the multivariate analysis did not find an association between type of virus and mortality. conclusion: rsv infection is frequent in adult icu patients. it presents more frequently than influenza as an acute on chronic respiratory failure with bronchospasm. despite difference in case mix and clinical presentation, vrs severity and burden appear similar to influenza justifying effort to prevent and treat it. compliance with ethics regulations: yes. rationale: mortality in acute stroke patients requiring mechanical ventilation ranges from to % at year. studies evaluating indicators of outcome in these patients have limitations, including singlecenter, retrospective designs and no adjustment for withholding/ withdrawal of life-sustaining treatments (wlst). our objective was to identify factors associated with -year survival in acute stroke patients requiring mechanical ventilation. patients and methods: retrospective analysis of a prospective multicenter database between and . icu stroke patients entered in the database and requiring mechanical ventilation within h were included. were excluded patients with stroke of traumatic origin, subdural hematoma or venous cerebral thrombosis. factors associated with -year survival were identified using a cox model stratified on inclusion center, adjusted on wflst occurring during the first h. data are presented as median [q -q ] or percentages. cox model results are presented as hazard ratios (hr) and % confidence intervals (ci). results: we identified patients from icus, aged [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] years and % males. on admission, the glasgow coma score (gcs) was [ ] [ ] [ ] [ ] [ ] [ ] and the saps score was . types of strokes were ischemic ( %), hemorrhagic ( %) and subarachnoid hemorrhage (sah) ( %). ischemic stroke patients received thrombolysis or thromboaspiration in / ( %) cases, and hemorrhagic stroke/ sah patients received neurosurgery or embolization in / ( %) cases. reasons for endotracheal intubation were coma ( %), acute respiratory failure ( %), seizures ( %), cardiac arrest ( %) and elective procedure ( %). sixty-five ( %) patients received a decision of wflst in the first h. one-year survival year was %. variables independently associated with -year survival were stroke type (ischemic as reference, hemorrhagic hr . (fig. ) . inclusion period ( inclusion period ( - inclusion period ( / inclusion period ( - inclusion period ( / inclusion period ( - or having a stroke unit on site was not associated with -year survival. conclusion: in acute stroke patients requiring mechanical ventilation, the reason for intubation and the opportunity to receive a specific stroke therapy are independently associated with long-term survival. these variables should be integrated in the decision process regarding initiation of mv in acute stroke patients. compliance with ethics regulations: yes. rationale: international guidelines recommend targeted temperature management (ttm) between ° and °c for out-of-hospital cardiac arrest (ca) patients. however, it is unknown if this treatment is effective whatever the severity of the insult. we aimed to examine the association between ttm and long-term neurological outcome according to the risk evaluated at time of admission in intensive care unit (icu) using a dedicated and validated score. patients and methods: we used data prospectively collected in the sudden death expert center (sdec) registry (great paris area, france) between may and december and in the resuscitation outcome consortium-continuous chest compression (roc-ccc) between june and may . we used a modified version of the cardiac arrest hospital prognosis (mcahp) score to assess the risk of poor outcome at icu admission in each of datasets. we finally studied the association between ttm use and long-term neurological prognosis according to mcahp score at icu admission divided into tertiles of severity in each of the datasets. results: there were patients analyzed in the french dataset and in the north-american dataset. the mcahp identified categories: low risk (score < points, % of unfavourable outcome), medium risk ( ≤ score < , % of unfavourable outcome) and high-risk group (score > , % of unfavourable outcome). according to the mcahp score at icu admission, ttm was associated with a better long-term neurological prognosis in patients with low risk (aor = . [ . - . rationale: acute ischaemic stroke is associated with a high risk of mortality, morbidity and healthcare-related costs. over the last decades new treatments, such as thrombolysis and thrombectomy, have been introduced. because of their further improvement, complications have been decreasing. this also led to extending indications for treatment to patients who were previously not eligible. the impact of this evolution on long-term outcome and cost-effectiveness has mainly been assessed in clinical trials and simulation studies. patients and methods: this single-centre retrospective study included patients treated for stroke between january and february . functional outcome at days was assessed by the modified rankin scale (mrs). cost data were retrieved from individual invoices of patients. undiscounted total healthcare costs were calculated for the index hospital stay, capped at days. contribution of cost categories to total costs was analysed. mrs at days was used as a proxy for utilities to define quality-adjusted life years (qalys). multivariate analysis was done for gender, age, charlson comorbidity index, pre-stroke mrs, stroke severity (nihss) and treatment modality (thrombectomy, thrombolysis, thrombectomy + thrombolysis, no intervention). incremental cost-effectiveness ratios (icers), associated to each treatment modality, were calculated. results: no intervention was done in patients ( . %). patients ( . %) required thrombolysis, ( . %) thrombectomy and ( . %) the combination. total costs were mean , eur ) . hospitalisation costs (mean , eur, iqr - , ) represented % of total costs, compared with drug costs ( eur, iqr - ), procedural costs ( eur, iqr - ), honoraria ( eur, iqr - ), lab ( eur, iqr - ) and imaging ( eur, iqr - ). mean total costs differed between treatment modalities: , (iqr - , ) eur for no intervention, , ) eur for thrombolysis, , (iqr , ) eur for thrombectomy and , (iqr , ) eur for the combination (p < . ). drivers for total costs were treatment modality (p < . ) and nihss-stroke severity (p < . ). utility scores were . rationale: emergency endotracheal intubation (eti) in the intensive care unit (icu) often concerns hypoxemic patients with hemodynamic instability. a cardiovascular collapse (cvc) after eti is a life-threatening complication. french guidelines suggested systematic fluid loading prior to eti. our study aimed to predict cvc after eti, while using echocardiography, and to evaluate the impact of fluid loading. patients and methods: a prospective study of consecutive intubations was performed from june to november in three icus. patients were selected if mean blood pressure measurements ≥ mmhg before eti. cvc was defined as mean blood pressure < mmhg within min following eti. four echocardiographic examinations were performed: - min before and - min after eti (or when a cvc occurred); -after passive leg raising; - h following eti. patients were classified as fluid responders when the left ventricular outflow tract velocity-time integral increased by at least % compared with baseline. results: echocardiographic examinations were performed. cvc occurred in / procedures ( %). in cvc group, mean dose of diprivan, used for fast sequence induction, was higher ( . ± mg/kg vs . ± . mg/kg, p = . ). in the cvc group, fluid responsiveness was considered in % patients and left ventricular (lv) systolic dysfunction %. lv diastolic dysfunction did not concern any patient in the cvc group. systolic blood pressure (sbp) < mmhg was the sole independent risk factor for cvc occurrence in multivariate analysis: or . ci % . - . , p = . . fluid responsiveness independent risk factors for cvc patients was sbp < mmhg (or . , ci % . rationale: the autonomic nervous system is highly adaptable and allows the organism to maintain its balance when experiencing stress. heart rate variability (hrv) is a mean to evaluate cardiac effects of autonomic nervous system activity and a relation between hrv and outcome has been proposed in various types of patients. we attempted to evaluate the best determinants of such variation in survival prediction using a physiological data-warehousing program (reastoc clinicaltrials identifier nct ). patients and methods: physiological tracings were recorded at hz from the standard monitoring system (intelliview philips mp ) using the synapse software (ltsi inserm umr ), for a h period, during the h following icu admission. all measurements were recorded while patients were laying in bed, with the head at ° and without any medical intervention. physiological data were associated with metadata collection by a dedicated research assistant. hrv was derived using kubios hrv, in either temporal ( (sdnn), (rmssd) and triangular index (ti)), frequency ( (lf), (hf)), non-linear domains (poincaré plotting) and entropy. results: consecutive patients were recorded between may and april . a lower lf/hf (< . ) and sd /sd (< . ) ratios on admission were associated with a higher icu mortality. multivariate analysis enabled to develop a mortality predictive model (bicus) associating spo /fio and hrv parameters (lf/hf and shannon entropy) with an auc = . (p < . ) for a bicus value > (fig. ) . conclusion: hrv measured on admission enables to predict prognosis in the icu, independently of the admission diagnosis, treatment and mv requirements. bicus may help predict prognosis on a real time basis, using parameters derived from standard routine monitoring. compliance with ethics regulations: yes. rationale: stroke, in the context of type diabetes (t d) is associated with a worse outcome than in non-diabetic conditions, reflected by an increased ischemic volume and more intracerebral hemorrhage. an unbalanced diet is one of major risk for developing t d. we aimed at creating a reproducible mouse model of stroke in impaired glucose tolerance condition induced by high fat diet. patients and methods: adult c bl mice ( male and female) were fed for months with either high fat diet (hfd, % lipids, % proteins, % carbohydrates) or a normal diet (nd, . % lipids, . % proteins, . % carbohydrates) . we used a model of middle cerebral artery occlusion (mcao) by a monofilament for min. oral glucose tolerance test and insulin tolerance test were used for evaluating the pre-diabetic state. mice were euthanized h after reperfusion. systemic inflammation, cerebral infarct volume and hemorrhagic transformation were determined. results: hfd was associated with an increased glycaemia following the oral glucose tolerance test. plasma leptinlevels in stroke conditions were significantly higher in hfd vs nd group. the hfd group presented a significant increase of infarct volume (hfd: . ± . mm vs nd: . ± . mm p = . ) and hemorrhagic transformation (hfd: . ± . vs nd: . ± . p = . ) (fig. ) compared to nd group. discussion: in humans, one of the mechanisms leading to insulin resistance is low-grade inflammation. hfd increases gut permeability, which leads microbiota dysbiosis, thereby promoting metabolic endotoxaemia and a low-grade inflammation state. experimental mouse models available for diabetes studies use leptin receptor deficient mice which develop t d or destruction of pancreatic beta cells by streptozotocine injection (t d). studies using diet-induced insulin resistance models generally feed the mice for weeks or more. however, metabolic disorders could appear earlier such as increase inflammatory markers. in our model, a short exposition to hfd ( weeks) leads to an increase of the pro-inflammatory markers as plasma leptin and a more severe stroke status (infarct and hemorrhagic transformation). conclusion: two months of hfd in adult mice altered hyperglycemia control. this metabolic disorder was associated with significantly higher leptin production, increased infarct volume and hemorrhagic complications than in normal-fed mice. this new model is particularly relevant to study stroke under pre-diabetic conditions induced by hfd. compliance with ethics regulations: yes. eight weeks of hfd increase ischemic volume and hemorrhagic transformation. (a)-infarct volume (v) h after reperfusion, all value are mean ± sem, hfd: v = . ± . mm , n = , nd: v = . ± . mm , n = , *p = . (b)-hemorrhage transformation (ht) score h after mcao. all value are mean ± sem hfd: ht score = . ± . , n = , nd: ht score = . +/+ . , n = *p = . rationale: cardiac arrest (ca), as massive ischemia reperfusion (ir), is an universal health issue. medication taken at the time of the ca could have prognosis consequences. no medication has proven its benefit on ca prognosis. pharmacological pre-or postconditioning aims to reduce ir injury but with disappointing results. metformin (met) is a worldwide-prescribed antidiabetic drug, and several clinical reports plead for a potential protective effect in various settings of sterile and non sterile inflammation, including ir. our hypothesis is that met act as a preconditioning drug against ca-induced ir. patients and methods: retrospective single academic medical center survival study (french west indies) on resuscitated ca in icu (institutional ethical committee approval). data were extracted from medical charts, pmsi, and laboratory dbsynergy ™ software. anonymized data were entered on a excel ™ and transferred to ibm ® -spss ® software (v . . . ) for analysis. univariate study (chi- , fisher exact tests, student-t test, mann-whitney u-test if required) was followed by a multivariate model (odd ratio or and % ic: kaplan-meier estimator and non parametric logrank test-mantel cox model). assuming an overall in-hospital mortality for ca in icu of % with an expected mortality decrease of % by met, the number of patients to be included is . results: the inclusion period was to , with included patients ( diabetic patients among whom took met). the d mortality was % in met+ patients (n = ) versus % in nomet patients (n = ), p < . . comparing alive (n = ) versus deceased (n = ) at d in univariate then multivariate analysis, asystole on the first ekg, number of iterative cardiac arrest,sofa, no-flow, lactate, low-flow and sapsii appear as independent criteria associated with d mortality.conversely, met intake showed up as a protective criterion (or . , ci . - . ). the survival curve, including strata of low-flow duration at the cut-off min, is reported on the fig. . among diabetic patients (n = ), the mortality of patients in the met+ (n = ) was % versus % in the nomet (n = ), p = . . conclusion: in diabetic patients suffering of massive ir related to resuscitated ca, a current treatment by met is associated with a better survival. these results support a protective effect of met and are important to initiate prospective evaluations, because of millions diabetic people around the world and the potential benefit of met. the potential benefit in non diabetic patients and in sterile as well as non sterile inflammation should be addressed. compliance with ethics regulations: yes. rationale: during systemic inflammation, the accumulation of misfolded proteins in the endoplasmic reticulum (er) induces er stress (ers). in animal models, the inhibition of ers reduces inflammatory response and organ failure. cardiopulmonary bypass (cpb) induces a significant systemic inflammatory response but ers expression has never been described in cardiac surgery patients. our objective was to describe the variations of the glucose related protein of kda (grp ), the final effector of the ers, during cpb. patients and methods: we conducted a prospective monocenter study including patients undergoing cardiac surgery with cpb. two samples (paxgene ® tube + edta tube) were taken at three times: before cpb, h after the end of cpb (h -cpb) and h after (h -cpb). after rna isolation and reverse transcription, we performed a quantitative polymerase chain reaction to evaluate the expression of gene encoding for grp and determined the plasma level of grp using enzyme-linked immunosorbent assay. our main objective was to study the variation of grp between pre-cpb and h -cpb samples. our secondary objectives were to evaluate the association of ers with morbi-mortality: organ failure at h (catecholamines and/or invasive ventilation and/or acute renal failure), troponinemia and pao /fio ratio (lung damage control). fig. ). we found an inverse correlation between grp plasma level and troponinemia at h (r = − . ; % ci[− . ; − . ]; p = . ) and a correlation between the pao /fio ratio and grp plasma level at h (r = . ; % ci[ . ; . ]; p = . ). we showed a significant relationship between the variation in plasma concentration of grp and post-operative organ failure after cpb. further studies are needed to better understand the molecular mechanisms of ers in acute inflammatory organ failure in humans. compliance with ethics regulations: yes. patients and methods: in a retrospective monocentric study ( / - / ) conducted in cardio-vascular surgical intensive care unit (icu) in henri mondor teaching hospital, all consecutive adult patients who underwent peripheral va-ecmo were included, with exclusion of those dying in the first h. diagnosis of acute mesenteric ischemia was performed using digestive endoscopy, abdominal ct-scan or fist-line laparotomy. significative results in the univariate analysis were analyzed in a multivariate analysis using logistic regression. results: va-ecmo were implanted. median age was ( - ) years and median . va-ecmo was implanted after a cardiotomy in % of the cases and for a medical reason in % of the cases including % of refractory cardiac arrest. patients characteristics are reported in the table. acute mesenteric ischemia was suspected in patients, with a delay of ( - ) days after ecmo implantation. digestive endoscopy was performed in patients, ctscan in five patients and first-line laparotomy in three patients. acute mesenteric ischemia was confirmed in patients, i.e. an incidence of %. laparotomy was performed in six of the patients, two having a stage i colitis ischemitis with stable conditions and being considered too severe to undergo futile surgery. overall mortality was %. all the patients with acute mesenteric ischemia died in the icu. independent risk factors of developing acute mesenteric ischemia were renal replacement therapy , p = . )) and onset of a second shock state within the first days of icu stay (or . ( % ic . - . , p = . )). conversely, early enteral nutrition was negatively associated with acute mesenteric ischemia (or . ( % ic . - . ), p . ). conclusion: acute mesenteric ischemia is a relatively frequent condition among patients under va-ecmo for cardiogenic shock. its extremely poor prognosis requires low threshold of suspicion. compliance with ethics regulations: yes. ( ). it allows the computation of trans-pulmonary pressure ( ) and can be used to set positive end-expiratory pressure (peep) ( . ) . prone position(pp) can reduce mortality in patients with acute respiratory distress syndrome (ards), but peep selection in pp is controversial. in human ards end-expiratory pes at zero flow (peept,es) was not different between supine (sp) and pp at same peep ( ). as no study measured ppl in sp and pp in ards we aimed at comparing peept,es and end-expiratory ppl at zero flow (peept,ppl) in this condition. our hypothesis was that peept,es was close to dorsal peept,ppl (peept,ppldorsal) in sp and to ventral peept,ppl (peept,pplventral) in pp. in eight female pigs of kgs intubated, sedated, paralyzed and mechanically ventilated, ards was induced by repeated saline lavage until pao /fio < mmhg under fio and peep cmh o. pes was measured by nutrivent catheter. ppl was measured by custom-made pouch sensors inserted surgically into the right anterior and posterior sixth intercostal space. ppl sensors were filled with air. after ards induction animals were randomly assigned to sp or pp. in each position, a recruitment manoeuver was performed and peep decreased from to cmh o by steps of cmh o lasting min each, then the animals were crossed over into the alternate position where the same procedure was done. at the end of each step nonstressed volume and correct position (baydur maneuver) were determined for pes and ppl sensors, then a -s end-expiratory occlusion was performed and pes and ppl recorded. linear mixed model was used to compare the value of pes and ppl at each peep and position. results: box-and-whisker plots of pes and ppl in sp and pp are shown in fig. . there is marked dorsal-to-ventral gradient in ppl at each peep in sp, which is reverted in pp at peep and only. there was no interaction between pressures and peep or position. with increasing peep pes increased significantly from peep in sp and pp. peept,pplventral was significantly lower than peept,es in sp but not in pp. (medtronic) , carescape (ge)) were set in pressure support cmh o, peep cmh o, fio % and equipped with the same double limb ventilator circuit (intersurgical) without any humidification device. asl bench model was set with inspiratory/expiratory resistance (r) and compliance (c) combinations: r / -c , r / -c and r / -c mimicking normal, ards and copd conditions, respectively ( ) . inspiratory effort generated by asl consisted of consecutive breaths obtained from the esophageal pressure in a real patient at the time of a spontaneous breathing trial. for each icu ventilator and rc combination, two steps were performed: in the first, atc was not activated and ventilator attached to asl without ett (atc-ett-); in the second, atc was set on at % compensation for an ett mm id and such an ett (shiley hi contour, covidien) joined icu ventilator to asl (atc+ ett+). the null hypothesis is that vtatc+ ett+ minus vtatc-ett-is . primary end point was the breath by breath paired difference betwen atc+ ett+ and atc-ett-. it was tested to zero for each ventilator in each rc condition. results: median vt was ml. table displays mean (± sd) difference in vt (ml) between atc+ ett+ and atc-ett-: a negative value means that atc under delivers and a positive value that atc over delivers vt for a given patient's inspiratory effort and rc. in four ventilators (c , s , elisa and ) atc almost systematically under delivered vt. in several instances under compensation was greater than % median vt. by contrast atc performed better with the other three ventilators (evita xl, v and carescape ). conclusion: atc tended to under deliver vt. furthermore, there were marked differences between icu ventilators the clinician should be aware of when using the atc option. compliance with ethics regulations: na. rationale: during the last decades, identification of factors associated with ventilation-induced lung injury has led to improved survival in patients with ards. the mechanical power of ventilation is the total energy transmitted from the ventilator to the respiratory system per unit of time and comprises three different components: elastic related to peep, elastic related to tidal volume and resistive. this integrative variable has been recently proposed as an useful predictor of ventilationinduced lung injury and death among ventilated patients. our goal was to determine the respective impact of the total mechanical power and its three components on the outcome of patients with ards. patients and methods: we performed a post hoc analysis of a randomized, controlled study of patients with ards with a pao /fio ratio < . themechanical power at inclusion and averaged on the first days after inclusion (total and its three different components) was computed according to the following equation: powerrs (j/ min) = . respiratory rate tidal volume [peep ( ) + ½ driving pressure ( ) + (peak pressure-plateau pressure) ( )], where the ( ), ( ) and ( ) parts correspond respectively to the elastic related to peep, elastic related to tidal volume and resistive components. the association between each of these four types of mechanical power evaluated during the first days after inclusion and mortality at d was assessed one after the other through multiple logistic regression, allowing control for potential confounding variables at inclusion (age, igs score without age, group of randomization, pao /fio , arterial ph). results: data from patients were analyzed, among which ( . %) died before d . there was no difference concerning the mechanical power at inclusion between survivors and non survivors (either total or its three components). among the four different types of mechanical power tested during the first days after inclusion, the elastic component related to tidal volume was the only one that was independently associated with mortality at d (or . ; % ci . - . ; p = . ) (figure) . conclusion: our study shows that only the elastic component of the mechanical power related to tidal volume independently predicted mortality at d among patients with ards, whereas the total mechanical power, its elastic component related to peep and its resistive component did not. further studies are needed to better define how the mechanical power of ventilation could be useful to synthetize the risk of ventilation-induced lung injury. compliance with ethics regulations: yes. probability of death at d as a factor of mean value (on d -d ) of the elastic component related to tidal volume of the mechanical power. to examine the effect of early-stage mechanical ventilation (mv) on diaphragmatic contractility. in the nd step, if a diaphragmatic dysfunction was detected, we assessed its influence on the weaning from ventilator. patients and methods: we measured prospectively the ultrasounddiaphragmatic thickening fraction (dtf) between groups: a study group versus a control group (n = for each). the study group included all adult patients receiving mv, in whom, the dtf was measured within a minimum of h and a maximum of days of mv. for the control group, were enrolled after their approval for participation, adult volunteers in spontaneous ventilation (sv). patients with factors affecting the diaphragmatic contractility (neuromuscular disease, severe obesity, and neuromuscular blockers…) were excluded. the ultrasound measurements were obtained at the zone of apposition of the right hemithorax. teleinspiratory and telexpiratory diameters (tid/ ted) were taken on the medio-axillary lines: posterior, median and anterior. the dtf was calculated as following: dtf = (tid-ted/ted) x . at the st step, the dtfs were compared and at the nd step: the relationship between dtf and weaning was analysed. results: our groups were comparable in corpulence and co morbidities. the sv group was younger ( vs. years, p < . ) with a predominant female composition. the diaphragmatic exploration concluded that in the mv group, the mean tid tended to be higher but without significant difference ( . + versus . + mm, p = . ), the mean ted was significantly higher ( . + versus . + . mm, p = . ) and dtf was significantly lower ( . + . % versus + . %, p = . ). the ventilation mode had no effect on dtf ( . + % for control volume vs. . + % for psv mode, p = . ). fourteen among ventilated patients had a successful weaning with a mean duration of days. a negative correlation was found close to significance between dtf and weaning duration (rho = − . and p = . ). a dtf value > % wasassociated with weaning success (or = , % ci = [ . - . ] and p = . ) with sensitivity = . %, specificity = %, ppv = % and npv = %. conclusion: the diaphragmatic contractile function was altered from the first days of mv. weaning duration seemed to be negatively correlated with dtf, and a dtf at the first days of mv greater than % was predictive of weaning success. compliance with ethics regulations: yes. rationale: mechanical ventilation is a life-saving treatment that is however associated with lung injury and/or diaphragm dysfunction. the optimal ventilator settings to provide lung protective ventilation while maintaining safe diaphragm activity are difficult to determine. a noninvasive and bedside evaluation of the diaphragm activity could be helpful in this context. the present study investigated whether changes in diaphragm shear modulus (i.e. stiffness, Δsmdi) assessed by ultrasound shear wave elastography (swe) may be used as a surrogate of changes in transdiaphragmatic pressure (Δpdi) in mechanically ventilated patients. patients and methods: patients had to be ventilated for at least h without contraindications for the placement of an oeso-gastric catheter. pdi was monitored continuously and smdi was measured at the zone of apposition of the right hemi-diaphragm, at hz sampling rate. measurements were performed twice under initial ventilator settings and at the end of a weaning trial. pearson correlation coefficients (r) were computed to determine within-individual correlations between pdi and smdi and changes in pdi and in smdi occurring between initial ventilator settings and the end of the sbt were compared by a paired test. results: twenty-five patients were enrolled and displayed a significant correlation between Δsmdi and Δpdi (mean r = . , range = . - . , all p < . ) (fig. a ). compared to their counterparts, patients with significant within correlations had a lower respiratory rate ( . ± . vs . ± . breath/min. respectively; p < . ) and a significant increase in Δsmdi ( . ± . kpa vs . ± . kpa. p < . ) between initial ventilator settings and the sbt. patients without Δsmdi-Δpdi correlation only displayed an increase in Δpdi ( . ± . vs . ± . cmh o, p < . ) at the end of the sbt with no concomitant significant increase in Δsmdi ( . ± . kpa vs . ± . kpa, p > . ). (fig. b) . conclusion: smdi obtained by swe appears as a promising technique to assess diaphragm activity in mechanically ventilated patients but technological improvements are necessary to increase swe sampling rate before enabling its generalization in the icu. compliance with ethics regulations: yes. rationale: end-inspiratory (eip) and end-expiratory (eep) pauses are commonly used during volume assist control ventilation to assess plateau pressure and total positive end-expiratory pressure (peeptot). they can also be used during assisted ventilation (av) for muscle pressure assessment. it requires ventilators able to perform eip during av. plateau pressure (pplat) usually increases in av during eip due to "hidden" inspiratory effort. pressure muscular index (pmi) is equal to pplat minus the sum of peeptot (measured during an eep) and set pressure support (ps); it theoretically reflects patient's effort without esophageal pressure (pes) monitoring. pes is the gold standard method to assess inspiratory muscle pressure (pmus, difference of pes drop at neural end-inspiration and correction factor for chest wall elastance and tidal volume). we aimed to illustrate the feasibility of measuring pmi using a standard icu ventilator at the bedside and study the correlation between pmus and pmi. patients and methods: measurements were recorded in icu patients. pes was measured using an nasogastric probe (equipped with an esophageal balloon) inserted for advanced monitoring (severe acute respiratory distress syndrome-ards) or for a study protocol (difficult weaning after copd exacerbation). recorded eip, eep and pes were used for post hoc analyses. results reported as ranges and median [iqr] . correlation between pmus and pmi tested with spearman correlation test. results: out of eip and eep duos could be analyzed ( -esophageal spasm/ -calibration error). ventilator mode was pressure support ventilation (ps - cmh o). cmh o, pmus = . [ . - . ] cmh o, pmi = . [ . - . ]. for all recordings, spearman r coefficient between pmus and pmi was . (p = . ). conclusion: muscular effort can be assessed in av using eip and eep using icu ventilators. however, recordings can be influenced by expiratory muscles contraction. patient's ability to follow directions during the maneuvers is an important factor to obtain reliable values. there seem to be a correlation in our small sample between muscular pressure assessed without and with pes. compliance with ethics regulations: yes. rationale: severe pneumonia can culminate in acute respiratory distress syndrome (ards). an uncontrolled inflammatory response is a key feature favoring transition towards ards. however, the underlying mechanisms remain poorly understood. in this context, the contribution of "innate t cells" (itc) -a family of non-peptide reactive t cells comprising nkt cells, mucosal associated invariant t (mait) cells and γδt cells-has never been explored. itc have emerged as key players in orchestration of the host response during infections and inflammation processes. for these reasons, these cells are already seen as potential therapeutic targets in other medical fields (especially oncology). here, we hypothesized that a tight regulation of their functions could be paramount to control the inflammatory response and to prevent ards development. patients and methods: to explore this, we combined a murinemodel of influenza a virus (iav) infection mimicking ardssymptoms and a clinical study recruiting patients admitted in icu for severe pneumonia. using flow-cytometry approaches, we investigated ( ) the abundance and dynamics of itc in various compartments, ( ) their pattern of activation/regulation markers (respectively cd and pd- ) and ( ) their cytokine production. results: during experimental iav pneumonia, itc were transiently recruited into the airways. unlike γδt and nkt, mait cells phenotype was largely changed, displaying a progressive cd overexpression and increased il- a production. during the resolution phase, up to % of pulmonary maits expressed pd- (versus < % in controls), which can suggest emergence of regulatory functions. last, using gene-targeted mice, we suggested that mait cells confer a protective effect during pneumonia. in the ongoing clinical study, the proportion of circulating mait cells in patients was markedly decreased compared to controls ( . ± . % versus . ± . % of t cells), but not for nkt or γδt cells. notably, some patients with severe ards presented detectable levels of maits in their respiratory fluids. in addition, circulating mait cells in patients overexpressed cd and pd- ( . % and % respectively), but with a reduced proportion able to produce il- and ifnγ, compared to healthy controls. lastly, proportion of activated (cd +) mait cells significantly decreased with clinical improvement. conclusion: this translational approach combining in vivo animal experiments and clinical samples with ex vivo experiments indicates a preferential modulation in mait cells functions during severe pneumonia. these data justify an in-depth analysis of mait cells activation mechanisms and functions in this context, in order to further explore a potential use as a disease-progression marker and -in a long term perspective-as a potential therapeutic target. compliance with ethics regulations: yes. representative flow-cytometry dot-plots of mait cells labelling using fluorophore-conjugated mr tetramers loaded with -op-ru from lungs of an infected mouse (a) and blood sample of a patient with pneumonia (b). c: frequency of mait cells, proportion of cd and pd- + mait cells in bronchoalveolar lavage during experimental murine pneumonia. d: blood frequency of mait cells in patients with pneumonia compared with healthy controls (as % of total t cells) rationale: immune paralysis following hyperinflammatory states increases the risk of secondary infections and death. reversing t-cells exhaustion using recombinant il or immune checkpoints inhibitors may improve the prognosis of patients with sepsis admitted to the icu. however, there is an unmet need to better characterize the state of t-cells exhaustion in these patients, its reproducibility and its correlation with the outcomes before implementing immunotherapy in the therapeutic armamentarium against sepsis. patients and methods: prospective observational cohort study performed in two tertiary-care icus in a university hospital. peripheral blood mononuclear cells were collected at day in adult patients with sepsis admitted to the icu. the level of cd + and cd + t-cells exhaustion was quantified using multi-color flux cytometry targeting the following exhaustion markers: pd- , b and cd . cd + regulatory t-cells (cd + cd + cd hi cd lo cells) were also assessed. results: the patients included in the study could be split in five clusters according to their dominant pattern of exhaustion markers on cd + t-cell (i.e. no markers, pd- +, b +, b + cd + and b + pd- +) and independently of their underlying morbidities. no patients harbored a fully exhausted triple-positive pattern. by multivariate analysis, saps gravity score at day (p = . ), a dominant b and/or pd- cd + pattern (p = . ) and lung sepsis (p = . ) where associated with the risk of death at day , whereas hemoglobin level was associated with survival (p = . ). no cd + or cd + exhaustion pattern independently predicted the risk of secondary infections. neither the level of cd + regulatory t-cells nor the dominant cd + exhaustion pattern was associated with the outcomes. rationale: there is growing use of multiplex polymerase chain reaction (mpcr) for respiratory virus testing in patients with communityacquired pneumonia (cap). data on one-year outcomes in patients with severe cap of bacterial, viral and unidentified etiology are scarce. patients and methods: a single-center retrospective study was performed in intensive care unit (icu) patients with known one-year survival status who had undergone respiratory virus testing for cap by mpcr. one year after icu admission, mortality rates and functional status were compared in patients with cap of bacterial, viral or unidentified etiology. results: there were ( . %) patients in the bacterial group, ( . %) in the viral group and ( . %) with unidentified etiology. one-year mortality was . % (n = / ), % (n = / ) and . % (n = / ), respectively (p = . ). in multivariate analysis, one-year mortality was higher in the bacterial group than in the viral group (hr . , % ic . - . , p = . ), had a trend to be higher in the bacterial group compared to the unidentified etiology group (hr . , % ic . - . , p = . ) and was not different between the viral and unidentified etiology groups (hr . , % ic . - . , p = . ). severe dyspnea (mmrc score = or death), major adverse respiratory events (new homecare ventilatory support or death) and severe autonomy deficiencies (adl katz score ≤ ordeath) were observed in / ( . %), / ( . %) and / ( . %) patients, respectively, with no difference between groups. conclusion: cap of bacterial origin was associated with a poorer prognosis than viral or unidentified etiology. impaired functional status was observed in a substantial proportion at one-year, irrespective of the causative microorganisms involved. compliance with ethics regulations: yes. interest of unyvero multiplex pcr (curetis) for bal rapid microbiologic and antibiotic susceptibility documentations in immunocompromised patients under antibiotic therapy jean-luc baudel , jacques tankovic , redouane dahoumane , salah gallah , laurent benzerara , jean-remy lavillegrand , razach abdallah , geoffroy hariri , naike bige , hafid ait-oufella , nicolas veziris , eric maury , bertrand guidet rationale: our aim was to evaluate the interest of the unyvero rapid ( . h) multiplex pcr assay (performed on bronchoalveolar lavage [bal] samples) for the management of immunocompromised patients already treated with antibiotics and diagnosed with pneumonia (according to clinical and radiological findings). we thus performed an observational study that compared the results (and the length of time to obtain them) of routine microbiological evaluation and unyvero assay. patients and methods: from july to january and from april to august , we examined bal samples from immunocompromised patients (coming from hematology, oncology, hepatology, gastroenterology, internal medicine, and neurology units) diagnosed with pneumonia (based on clinical and radiological findings), and already receiving antibiotic treatment. the following data were collected: age, gender, saps score, lung ct scan ( %) or x-ray ( %) results, duration and content of prior antibiotic therapy, direct examination, culture, antibiogram and unyvero results, secondary confirmation of pneumonia or not, possible changes in antibiotic therapy that could have been made after obtention of unyvero results. informed consent was obtained from all patients. results: bal samples were analyzed in immunocompromised patients (m/f ratio . , saps . ± . ) mostly with hematologic ( %) or oncologic ( %) diseases. the patients received either corticosteroids ( %), or chemotherapy ( %), or immunotherapy ( %). % of the patients were under mechanical ventilation, % under optiflow. % presented a shock, % had aplasia or neutropenia, % were allografted, % were autografted. the duration of prior antibiotic therapy at the time of bal were . ± . days. direct examination was positive in . % of the cases, culture (both above and under the classical threshold of cfu/ml) in %, unyvero in . %. a retrospective analysis of all the cases confirmed the initial diagnosis of pneumonia in only % of the cases. compared to culture, the sensitivity of unyvero was %, its specificity %. unyvero could permit to rapidly deescalate antibiotic therapy in % of the cases and to rapidly stop it in %. the unyvero assay on bal samples is useful in this specific population for rapid obtention of microbiological results and also for confirmation of the negativity of cultures and thus permits a better management of antibiotic therapy, leading to a reduction of antibiotic resistance selection pressure in the icu. compliance with ethics regulations: yes. do not underestimate rsv pneumonia among critically ill patients erwan begot , suzanne champion , charline sazio , benjamin clouzeau , alexandre boyer , hoang-nam bui , marie-edith lafon , camille ciccone , julia dina , didier gruson , renaud prével chu bordeaux, medical intensive care unit, bordeaux, france; chu bordeaux, virology laboratory, bordeaux, france; national reference center for measles mumps and rubella, chu de caen, caen, france correspondence: erwan begot (erwan.begot@chu-bordeaux.fr) ann. intensive care , (suppl ):f- rationale: respiratory syncitial virus (rsv) is a well-known cause of respiratory failure among neonates but its pathogenicity in adults is now emerging as a potential cause of viral pneumonia. data are limited with conflicting results regarding rsv pneumonia severity in adults. data are lacking about critically ill rsv patients' characteristics and outcomes. the aim of this study is to compare rsv patients' characteristics, care and outcomes to influenza patients' ones. patients and methods: patients diagnosed with rsv and influenza pneumonia admitted to our medical icu were included. data were retrospectively recorded. quantitative data are expressed by median and interquartile range and compared by use of mann-whitney test. qualitative data are expressed by number and percentages and compared by use of fischer exact t-test. rsv strains were prospectively collected. results: eighteen critically ill patients with rsv pneumonia and with influenza pneumonia were included. rsv and influenza patients had the same characteristics at admission except for age (respectively yo [ ; ] and acute respiratory distress syndrome rates (respectively / ( %) vs / ( %), p = . ). they received similar treatment as suggested by oro-tracheal intubation rates (respectively / ( %) vs / ( %), p: . ) and antibiotics prescription (respectively / ( %) vs / ( %), p: . ). rsv and influenza patients also had the same rates of bacterial co-infections ( / ( %) vs ( %), p: . ). invasive aspergillosis remained a rare event but also occurred among rsv patients ( / ( %) vs / ( %), p: . ). acute coronary syndromes were as frequent in both groups (respectively / ( %) vs / ( %), p = . ). day- mortality was similar between rsv and influenza patients (respectively / ( %) rationale: respiratory distress from seawater drowning is commonly considered multifactorial. etiologies are debatable and include heart failure, infection and acute respiratory distress syndrome (ards). documented bacterial infections seems mostly related to the site of drowning. data in this regard are scarce with prospective studies lacking. the objective of our study was to describe prospectively the characteristics and determinants of respiratory distress from seawater drowning. patients and methods: all patients admitted for seawater drowning to seven intensive care units (icu) on the french riviera in the summers of and were prospectively included. recorded data included clinical features on examination, personal history, chest x-rays, echocardiography and biological results obtained within the first h. a paired student's t-test was used to study statistical differences between quantitative variables on admission and during early evaluation (i.e. first h). results: forty-eight patients were admitted to seven centers of which ( %) were diagnosed as having ards, ( %) early pneumonia and ( %) acute cardiogenic pulmonary edema. twenty-one ( %) respiratory samples were collected but bacterial culture was positive in only cases. multidrug-resistant bacteria were not observed, and amoxicillin-clavulanate as first-line treatment was effective in all cases. echocardiography performed in ( %) patients was normal and unable to identify specific patient profiles. the median clinical pulmonary infection score (cpis) on admission was (iqr, - ) and decreased rapidly and significantly (p < . ) within h to (iqr, - ) (fig. ) . conclusion: data from this multicenter cohort suggest that respiratory distress following seawater drowning can mimic bacterial pneumonia during the first h with subsequent rapid clinical improvement in patients admitted to the icu. probabilistic antibacterial therapy should therefore be limited to the most severe patients. isolate ards is often the only etiology found and is resolutive within h. this prospective cohort is the largest of its kind and gives a better insight into the limited impact of cardiogenic and infectious processes on sea drowning-related respiratory distress. compliance with ethics regulations: yes. rationale: patients treated with "extracorporeal membrane oxygenation" (ecmo) are at a higher risk of developing nosocomial infections and they are consequently often treated with beta-lactams. french guidelines recommend obtaining beta-lactam trough concentrations above four times the minimal inhibitory concentration (mic) of the causative bacteria. the ecmo device may alter the pharmacokinetics of these medications, which may result in underexposure to beta-lactam antibiotics. patients and methods: this observational, prospective, multicenter, case-control study was performed in the intensive care units of two tertiary care hospitals in france. ecmo patients with sepsis treated with piperacillin-tazobactam were enrolled. control patients were matched according to sofa score and creatinine clearance. the pharmacokinetics of piperacillin was described based on a population pharmacokinetic model, allowing to calculate the time spent above × the mic breakpoint for pseudomonas aeruginosa susceptibility after the first dose and at steady state between two piperacillin infusions. results: forty-two patients were included. the median age was years [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , the sofa score was [ ] [ ] [ ] [ ] [ ] [ ] , and median creatinine clearance was ml/min . there was no significant difference in the time above x mic in patients treated with ecmo and controls during the first administration (p = . ) and at steady state (p = . ). there was no significant difference between the trough at steady state (p = . ), with / patients ( %) exhibiting concentrations of piperacillin lower than x mic. ecmo support was not associated with a steady state trough concentration below x mic (or = . [ . - . ], p = . ). the only variable independently associated with this risk was a creatinine clearance ≥ ml/min, (or = . [ . - . ], p = . ). conclusion: ecmo support has no significant impact on piperacillin exposure. intensive care unit patients with sepsis are, however, frequently underexposed with piperacillin, which suggest that therapeutic drug monitoring should be strongly recommended for severe infections. impact of a visual support dedicated to prognosis of patients on symptoms of stress of family members rationale: family members commonly have inaccurate expectations of patient's prognosis. adding to classic oral information a visual support, depicting day by day the evolution of the condition of the patient, improves the concordance in prognosis estimate between physicians and family members. the objective of this study was to evaluate the impact of this support on symptoms of anxiety/depression of family members. patients and methods: we conducted a bi-center prospective beforeafter study. all consecutive patients admitted in the two icus were eligible. in the before period ( months), family members received classic oral information. in the after period ( months) , in addition to classic oral information, the visual support ( fig. ) was available for family members in the patient's room from the day of admission until discharge from the icu. at day and from admission, symptoms of anxiety/depression of referent family member were evaluated by hospital anxiety and depression scale (hads). results: patients and their referent family members were included ( in period before and after). characteristics of patients of the two groups were similar regarding age, reason for admission, saps ii at admission and sofa score at day . also characteristics of referent family members were comparable in terms of age, sex ratio, type of relationship with the patient and number of visits since admission. at day , total had score was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in the group before without the support and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in the group after with the support (p = . ). the prevalence of symptoms of anxiety (had-a score > ) and depression (had-d score > ) was similar in the two groups (respectively . % and . % in the group before, and . % and . % in the group after (ns)). at day , total had score was in the group before [ - ] and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in the group after (p = . ). by multivariate analysis the following factors were significantly associated with total had score > at day : age of patient ]), number of visits of referent ) and previous or current treatment of referent for anxiety or depression . ]). conclusion: in this study, the use of a visual support dedicated to prognosis of patients did not modify the level of stress of family members. compliance with ethics regulations: yes. rationale: the use of sedation and opioids at the end of life is a topic of considerable ethical debate. incidence of discomfort during the end-of-life of icu patients and impact of sedation on discomfort are poorly known. patients and methods: post-hoc analysis of an observational prospective multicenter study comparing terminal weaning vs. immediate extubation for end-of-life in icu patients, aimed at assessing the incidence of discomfort events according to levels of sedation. discomforts including gasps, significant bronchial obstruction or high behavioral pain scale score, were prospectively assessed by nurses from mechanical ventilation withdrawal until death. level of sedation was assessed using the richmond agitation sedation scale (rass). results: among the patients included in the original study, ( %) experienced discomfort after mechanical ventilation withdrawal. patients with discomfort received lower doses of midazolam and equivalent morphine, and less frequently had deep sedation (rass - ) than patients without discomfort ( % vs %, p < . ). after multivariate logistic regression, immediate extubation was the only factor associated with discomfort whereas deep sedation and administrations of vasoactive drugs were two factors independently associated with no discomfort. death occurred less rapidly in patient with discomfort than in those without discomfort ( . h [ . - . ] vs . [ . - . ], p < . ) (figure) . long-term evaluation of psychological disorders in family members of dead patients did not differ between those with discomfort and the others. discussion: despite the theoretically expected anticipatory titrated doses of opioids and benzodiazepines to alleviate any discomfort after withdrawal of mechanical ventilation, half of the patients did not receive sedation or opiate when the decision to withdraw mechanical ventilation was taken. a major point that could interfere with the continuous deep sedation practice until death is the fear of potentially hastening death, and there is much controversy regarding its proper use in end-of-life care. conclusion: discomfort was frequent during end-of-life of icu patients and was mainly associated with terminal extubation and less profound sedation. compliance with ethics regulations: yes. rationale: bereavement in intensive care unit (icu) is associated with psychiatric disorders on relatives called post-intensive care syndrome family (pics-f). no isolated intervention (such as condolence letter) has shown a positive effect on these disorders, despite a well acceptance by relatives. we thought that a more integrated bereavement program should be considered. the goal of this study is to evaluate a combined psychologist-physician post-death meeting (pdm) in a bereavement program to evaluate needs and adhesion of relatives, and the effect on symptoms of anxiety and depression. patients and methods: monocentric, prospective study focused on relatives of patient admitted > h and deceased in icu. during patient's stay, relatives' presence was allowed on a h-basis and they could meet a clinician psychologist. formal meeting between relatives and the staff was realized at patient's admission and after important decision-making treatment. two weeks after patient's death, the psychologist called relatives to offer emotional support and to invite to a pdm. pdm occurs weeks after patient's death with the psychologist and the physician in charge of the patient. the objectives of the meeting were to provide emotional support, to answer medical question, and to detect symptoms of anxiety and/or depression with the hospital anxiety and depression scale (hads). we hypothesized that pmd would be able to alleviate pics-f at months. we aimed to enroll families to detect a % lowering of hads. results: the rate of pdm acceptance was lower than expected. after inclusions, only relatives accepted the pdm, whereas the phone call was well perceived ( %). main association with acceptance of pmd was a short duration of icu stay ( . days [ - . ] vs . days [ . - . ] p = . ) and icu admission for acute respiratory failure ( . % vs . %, p = . ) ( table ) . we found no relation between the number of in icu meeting (psychologist of medical staff) and pmd acceptance. for relatives who accept pmd we found a high proportion of symptoms of anxiety and depression ( % and %) with a hads at . [ - . ] (median, iqr). no evaluation was performed at months. conclusion: post death contact appears well perceived by relatives but pmd quite useless. this result may be explained by the inclusion of only late death (> h) where psychologist and medical staff had the opportunity to support relatives. further study should focus on early death (< h). compliance with ethics regulations: yes. rationale: pediatric intensivists frequently question themselves on the issue of limitation or termination of life-sustaining treatments (llst) carried out on children. such a decision comes under the claeys-leonetti law which forbids doctors from applying unreasonable treatment however, every so often, parents oppose themselves to a collegial llst decision that the medical and paramedical team had taken. such cases can even end up in court. in order to sort out this problem, this study focused on the factors that underlie the disagreement and the solution brought forward by pediatricians whenever parents demand to persue treatments although considered as unreasonable obstinacy. patients and methods: we carried out a qualitative study involving three multipurpose pediatric critical care unit. all pediatricians operating within these units were contacted. those who volonteered were met individually for a semi-directed interview. every interview was recorded and entitled to a complete hand-written retranscription. the interviews were analysed following the phenomenological interpretive analysis method and were subject to dual listing. results: pediatricians out of took part in the study. / claimed they would increase treatments or carry out cardiopulmonary resuscitation acts if asked to do so by parents, even if this went against the initial collegial decision. / claimed they would persue treatments although not beyond the current level. / said they would oppose themselves to parents concerning blood transfusion for comfort reasons. several key factors were identified as leading a doctor to the non-application of a llst decision: the certainty regarding the child's death on a short or mid-term basis ( / ), the litigiousness risk ( / ), the apprehension of mediatic pressure ( / ), the fear of a violent reaction from parents ( / ), other self-interest positions within the medical team ( / ), empathy towards parents ( / ), the uncertainty concerning the neurological prognosis ( / ), the lapse of time needed to fully accept the application in force of a decision ( / ). pediatricians out of admitted their own-suffering when confronted to the situation. conclusion: this study points out that pediatricians tend to follow parents' position when confronted to parental opposition. in such situations, pediatricians go against their own decision in order to safeguard the parental alliance even if it leads to unreasonable obstinacy, thus conflicting with medical deontological code obligations. compliance with ethics regulations: yes. rationale: end-of-life management strategies are clearly a worldwide issue of major importance that intensivists have to deal with on a daily basis. advance directives may be the solution sought to guide physicians to take such difficult decisions. yet, health care directives are not legislated in tunisia. the objective of this project was to draw a general descriptive overview to assess patients' wishes in tunisia. patients and methods: data were collected from a -item-questionnaire based on the french intensive care society's form for advance directives which was filled by people of general population in tunisia, including doctors and paramedics, from may to mid-september . all people included were or older and well informed of the form's utility. results: a total of participants were included. the mean age was . ± . years with extremes of and and a sex ratio of . . fourty-one ( . %) were either doctors or nurses and ( %) did suffer from a severe medical condition. among all the participants, ( . %) thought that end-of-life decisions were up to the doctor. for the rest, they willingly chose to be hospitalized in an icu, to undergo cardiopulmonary rescuscitation and to have ventilation support with orotracheal intubation or tracheostomy respectively in ( . %), ( . %) and ( . %) of the cases. only ( . %) refused temporary dialysis. when asked about sequelae they can live with, participants accepted hemiplegia in . % and paraplegia in . % of the cases. on the contrary, ( . %) refused to live in permanent coma and ( . %) disagreed to undergo tracheostomy and ventilation for life. moreover, ( . %) found that serious un aesthetic sequelae was a fatal consequence they could not survive. as well, only ( . %) consented to live with deep intellectual deficiency. regarding palliative care, ( . %) participants wished to be profoundly sedated until death, ( . %) prefered to die home over ( . %) in hospital. sixtytwo ( . %) desired to see a representative of their religion. furthermore, ( %) were for organ donnation. gender, being a health care professional and age under versus equal or over were not significant in dependent factors (p > . ). conclusion: it is our duty ashealth care professionals to spread advance directives awareness and education. nevertheless, the law should keep the pace with ethics evolution. compliance with ethics regulations: yes. rationale: adapted organ support techniques are needed to enhance reliability of preclinical animal experiments in the intensive care setting (guillon, annals of intensive care- ). a few renal replacement therapy (rrt) models have already been developed in rats, mostly hemodialysis in chronic kidney disease models or hemofiltration techniques in sepsis experiments. mounting evidence from clinical (gaudry, nejm- ) and histopathological studies suggest that rrt for acute kidney injury (aki) could impair renal recovery by acting as a 'second hit' leading to a maladaptive repair of tubular epithelium. we aimed to study this hypothesis in a hemodialysis model in rats with septic aki. patients and methods: on day , sprague-dawley rats were injected with lipopolysaccharide or placebo (nacl . %) intraperitoneally. on day , anesthetized rats underwent femoral artery catheterization for hemodynamic parameters monitoring. at the same time, one femoral vein and one carotid artery were catheterized for arterio-venous sterile extracorporeal circulation with or without passing through a miniature sterile polyester sulfone hemodialyzer ( cm surface, kda pores, microkros ® ) filled with dialyzate liquid in the outer compartment (table ) . vessels were ligated after the procedure and rats allowed to awaken. on day , rats were sacrificed. results: all rats injected with lipopolysaccharides o :b mg/kg survived at day . anesthesia was much challenging: ketamine + xylazine and tiletamine-zolazepam + xylazine required induction and maintenance intraperitoneal injections. these medications induced important hemodynamic parameters fluctuations and high mortality. isoflurane gas inhalation enabled better stability, less hypothermia and quick awakening. adequate temperature was controlled with a heating pad during the procedure and an incubator after. supine position was maintained. the whole circuit was anticoagulated with ml of heparinized saline ui/ml, since clots occurred in the absence of anticoagulation and bleeding when higher dosing was used. circuit (< . ml including dialyzer) was filled with saline solution before initiation, and total restitution of blood at the end of the experiment prevented any blood transfusion requirement. hematocrit was determined at beginning ( %) and end of experiment ( %). a peristaltic pump provided a blood flow rate of . ml/min, (higher rate was not tolerated) for h. of note, rats who underwent sham procedure (vessels ligature only) survived and did not display aki. circulation of a counterflow dialysate in the dialyzer is planned but has not been performed yet. conclusion: this hemodialysis system for rats is feasible at a reasonable price and might help research involving rrt in either ckd or aki. compliance with ethics regulations: yes. there were no significant relationship between rri and past medical history or severity score. we observed a significant negative correlation between rri and diastolic arterial pressure (p = . ) and heart rate (p = . ) as it could be expected by rri formula. an increased rri was associated with higher potassium (p = . ) and higher creatinine levels (p = . ). although not significant, we found a higher rate of subsequent rrt in the high rri group ( % vs %, p = . ). over the first days, fluid balance was significantly different between groups ( ml vs - ml respectively for low and high rri group, p = . ). since standard of care were similar, this suggests different fluid volume status between the two groups. in the low rri group, the cause of aki could predominantly be prerenal since positive fluid balance was not explained by more severe aki with refractory oliguria as shown by the low rrt rate. nevertheless, we did not observed any relationship between rri and the evolution of serum urea or creatinine levels, nor with the presumed aetiology of aki. conclusion: when focussing on the first rri measurement once stage aki was reached, rri ≤ . seems to be in favour of prerenal and transient renal dysfunction even if this is not supported by creatinine serum evolution. compliance with ethics regulations: yes. rationale: critically ill patients are at higher risk of bleeding but also dialysis filter clotting (inflammatory state). intermittent hemodialysis with calcium-free citrate-containing ( . mmol/l) dialysate (cafcit-ihd) recently emerged as a new safe and simple alternative to continuous renal replacement therapy allowing heparin-free extended dialysis sessions (> h). in this study, we aimed to answer to two issues still unresolved: (i) can citrate contained in the dialysate accumulate and lead to citrate intoxication in patients with liver disorders, and (ii) can citrate be avoided using citrate-and calcium-free dialysate (ccf-ihd)? patients and methods: monocentric retrospective study. among the sessions performed with cafcit-ihd, the ihd sessions ( critically ill patients) with citrate measurement available before and after the dialysis filter were reviewed. estimation of the liver clearance was performed using the picco lemon ® system (pulsion). in addition, sessions performed using ccf-ihd were reviewed. results: all the patients had liver disorders (post-liver transplantation period n = ; cirrhosis with child > a ). among the eighteen cafcit-ihd patients, fifteen ( %) and six ( %) received mechanical ventilation or vasopressive drugs, respectively. the median time of the dialysis session was h [ ] [ ] [ ] [ ] , with hourly ultrafiltration rate of ml (one premature termination not related to dysfunctional catheter). in all patients, ionized calcium (ica) decreased below . mmol/l after the filter, whereas post-filter calcium reinjection according to ionic dialysance led to a stable pre-filter (i.e. patient) ica. median citrate concentrations were all below . mmol/l after the filter (minimal concentration to obtain anticoagulation mmol/l) and all except one below the normal value (< µmol/l) before the filter. during all the sessions, ionized to total calcium ratio was below . and the strong ionized gap decreased. when available (n = ), no correlation could be identified between serum citrate concentration and liver clearance. last, in ccf-ihd sessions performed in critically ill patients, no premature termination occurred (median time of the sessions h) and post-filter ica also decreased below . mmol/l. no citrate accumulation could be identified in critically ill patients (even with liver disorders) and receiving extended dialysis sessions ( h or more) using calcium-free citrate containing-ihd. interestingly, we demonstrated that citrate is not required to obtain optimal regional anticoagulation (i.e. post-filter ica < . mmol/l), and a citrate-and calcium-free dialysate could be a safe alternative. compliance with ethics regulations: yes. rationale: ventilator induced diaphragmatic dysfunction is highly prevalent in adult critical care and associated with worse outcomes. specificities in pediatric respiratory physiology suggest that critically ill children may be at high risk of developing this complication, but no study has described the evolution of diaphragmatic function in critically ill children undergoing mechanical ventilation. this study aims to validate a method to quantify diaphragmatic function in mechanically ventilated children. in this prospective single-center observational study, children between week and years old intubated for elective ent surgery and without pre-existing neuromuscular disease or recent muscle paralysis were recruited. immediately after intubation, diaphragmatic function was evaluated using brief airway occlusion maneuvers during which airway pressure at the endotracheal tube (paw) and electrical activity of the diaphragm (eadi) were simultaneously measured for consecutive spontaneous breaths, while the endotracheal tube was occluded with a specific valve. occlusion maneuvers were repeated times. in order to account for central respiratory drive and sedation use, we recorded the neuromechanical efficiency ratio (nme, paw/eadi), in addition to the maximal inspiratory force (mif). in order to determine the optimal measure of nme during an occlusion, the variability over the three occlusion maneuvers of different variables (first breath, last breath, breath with maximal paw deflection, breath with maximal nme value, and median nme value) was assessed using coefficients of variation and repeatability coefficients. results: patients had a median age of . years (interquartile range . - . ), a median weight of kg ( - ), and were male ( %). the median evolution of paw, eadi, and nme ratio over the occluded breaths are represented on fig. . nme values corresponding to the last breath and the breath with maximal paw deflection were the least variable, with median coefficient of variation of % and % and repeatability coefficients of . and . , respectively. conclusion: brief airway occlusions can be used to assess diaphragmatic function in intubated children through both mif and nme ratio, and the latter should ideally be computed on the last breath or the breath with the largest pressure deflection to improve repeatability and decrease variation. compliance with ethics regulations: yes. epidemiology is poorly understood due to the rare use of validated diagnostic tools. the main objective of the study was to determine, by systematically calculating the wat- score, the incidence of ws in our surgical picu. the secondary objective was to analyze the risk factors, consequences and management modalities of ws. patients and methods: following institutional review board approval, we conducted a prospective monocentric study between july and january . all consecutive mechanically ventilated children admitted in our surgical picu with sedation/analgesia by continuous intra-venous (iv) benzodiazepines (bzd) and/or opioids for at least h were included. as soon as sedation was decreased and during h following their total discontinuation, wat- score was assessed twice a day. ws was defined by a wat- score > . the search for risk factors and consequences associated with ws was performed by univariate analysis (mann-whitney and chi test). ethical standards were satisfied and the lack of opposition from patients and their parents was systematically checked. results: the incidence of ws was % among the patients of our cohort including % of children admitted postoperatively and % after severe traumatic brain injury (tbi). significant results are reported in table . our results show that even for sedation time less than days, children could develop ws ( / patients). on the other hand, age, severity (pelod score), number of previous surgeries and severe tbi were not associated with ws. our study also demonstrated that cessation of sedation and prevention of ws was not uniform in our unit. the high incidence of withdrawal syndrome in our study, even in children sedated for less than days, and its consequences require thinking about prevention. we suggest a systematic monitoring of the occurrence of this adverse event using a validated score, from days of continuous iv sedation/analgesia. compliance with ethics regulations: yes. rationale: severe traumatic brain injury (tbi) is a major healthcare problem. amplitude and duration of intracranial hypertension is highly associated with patient outcome. the intracranial pressure (icp) is therefore one key parameter to monitor in the acute phase. when icp is monitored with an external ventricular drain, the pressure recorded by the monitor does not always correspond to the real icp, depending on the status (open/closed) of the -way tap. misleading values could therefore be sent to the patient medical record. our hypothesis is that a machine-learning algorithm will be able to identify automatically and in real time the reliable and non-reliable values of the icp signal. we retrospectively studied pediatric patients having an external ventricular drain between july and july , in a single pediatric intensive care unit. the icp signals were extracted from a high-frequency database ( hz) and pre-processed adequately. to train the algorithms, an annotated database was manually created with two classes: reliable icp vs. non-reliable icp (drain system opened to allow cerebrospinal fluid removal). eleven signal characteristics were compared between the two classes (mann-whitney test), and significantly differing variables were tested in the algorithms. we compared the performance of two machine-learning algorithms: the k-nearest neighbors (knn) and the support vector machine (svm). using -fold cross-validation method, % of the data was used to train the algorithms and % was used for testing. the best classifier was further validated by simulating a real-time icp analysis, using a s sliding-window approach with % overlap. the study was approved by the localresearch ethics committee. results: sixteen patients were included in the study. the training database created from patients, contained segments (of s duration) per class and per patient. eight signal variables were identified and kept to define the segments. the knn algorithm, with k = , led to the best performance, with a mean of % (mean ± sd: % ± . %). the knn was then visually validated on icp signals from the remaining two patients ( figure) . by simulating a real-time icp extraction, our algorithm was able to efficiently identify the reliable icp segments, and to display a mean value only for valid segments. university hospital picu (paris). all consecutive children ( month- years) admitted for acute encephalitis were included and diagnosis was confirmed using the consensus conference criteria's. data regarding clinical, biological and radiological presentations were collected as well as data on the therapeutics used and outcomes at discharge and at the last medical consultation. results: patients were included with a mean age of . years (range . to years old). infectious causes were identified in % (n = ), autoimmune causes in % (n = ) and acute demyelinating encephalomyelitis in % (n = ) of cases. etiology remained undetermined in % of cases (n = ). the most common pathogens were, in order of frequency, influenzae virus, mycoplasma pneumoniae and epstein-bar virus. the main clinical features were fever ( % n = ); epileptic seizures ( % n = ) and coma ( % n = ). regarding therapeutics, % of patients required mechanical ventilation and % of patients required hemodynamic support. % received corticosteroids, % intravenous immunoglobulins and % plasmatic exchanges. the use of these specific treatments was heterogeneous, especially in infectious and undetermined encephalitis, where respectively % and % received boluses of corticoids. the mean length of stay in picu was . days (range - days). the mortality rate was % and the overall rate of sequelae at discharge was % and % at distance, with % considered as severe (gose-ped score > ). the use of mechanical ventilation and young age at diagnosis were risk factors associated with poor prognosis at discharge. the etiology of acute encephalitis remains indeterminate in more than % cases with a clear predominance of infectious causes when an etiology is found. this is a severe pathology responsible for significant mortality and morbidity requiring long-term follow-up. compliance with ethics regulations: yes. rationale: preserving neurological outcome of children under extracorporeal membrane oxygenation (ecmo) remains challenging. acute brain injury (abi) is a frequent complication of ecmo that could be prevented by continuous neuromonitoring. cerebral near infrared spectroscopy (nirs) is routinely used for detecting cerebral complications of cardiac surgery. in adults and infants under prolonged ecmo, cerebral hypoxia is associated with poor neurological outcome. the aim of this study was to assess the value of an impaired cerebral oxygenation on mortality and occurrence of an abi in children under ecmo. patients and methods: children under years old were included in this observational retrospective monocentric study if they needed veno-venous (v-v) or veno-arterial (v-a) ecmo for respiratory and/ or circulatory failure and had concomittant nirs monitoring. cerebral desaturation was defined as a rsco value under % or under % from the baseline; cerebral hyperoxia was defined as a rsco value above %. proportion of time in cerebral desaturation and hyperoxia were recorded. neurological lesions were identified on imaging (mri or scan) by blinded radiologist and classified as major or minor. abi was defined as any hemorragic or ischemic lesion on cerebral imaging, including brain death. results: patients were included. ecmo duration was [ ; ] days. the mortality rate was ( . %), and the proportion of abi was ( %) including brain deaths, ( . %) major lesions, and ( . %) minor lesions. mean rsco was ± % in the right hemisphere, and ± % in the left hemisphere. there was no significant difference in cerebral hypoxia between survivors and non survivors, and between patients with and without an abi. cerebral hyperoxia was associated with a better survival (p = . in the right hemisphere, and p = . in the left hemisphere). in v-v ecmo and at the right conclusion: in our study, cerebral hypoxia was not associated with poor neurological outcome, but cerebral hyperoxia seems to be protective especially in v-v ecmo. this is the first study assessing the value of cerebral oxymetry in all age ranges pediatric ecmo. in this population, multimodal monitoring might be better than nirs alone to predict neurological impairment. further prospective studies are needed to assess first the feasibility, then the impact of such a monitoring. compliance with ethics regulations: yes. cerebral autoregulation impairment is associated with acute neurological events during pediatric extracorporeal membrane rationale: children supported by extracorporeal membrane oxygenation (ecmo) present a high risk of adverse neurological complications. as some animal studies have shown, cerebral autoregulation (ca) impairment after exposure to ecmo, may be a key factor. our main objective was to investigate the feasibility of ca continuous monitoring during ecmo treatment. the second objective was to analyze the relationship between ca impairment and neurological outcome. patients and methods: an observational prospective study including children treated by ecmo in centers was conducted. a correlation coefficient between the variations of regional cerebral oxygen saturation (rsco ) and the variations of mean arterial blood pressure(map) was calculated as an index of ca (cerebral oxygenation reactivity index, cox) during ecmo. a cox > . was considered as indicative for dysautoregulation. cox values were averaged inside mmhg-map bins, allowing determining optimal map (mapopt) and lower (lla) and upper (ula) limits of autoregulation in -h periods. neurological outcome was assessed by the onset of an acute neurologic event (ane) defined by occurrence of hemorrhagic or ischemic stroke and/ or clinical or electrical seizure and/or brain death during the ecmo treatment. rationale: myocardial ischemia reperfusion (ir) injury is the leading cause of perioperative morbi-mortality. protective effect of pharmacologic preconditioning such as anesthetic preconditioning (apc) with sevoflurane (sev) has been widely demonstrated in animal and human models. apc seems to protect myocardial cells from apoptosis, a programmed process of cell death tightly controlled by bcl- family proteins. however, the involved mechanisms in apc have yet to be characterized. we hypothesized that apc protects against myocardial apoptotic cell death by regulating bcl- anti-apoptotic members. to study the sev-induced apc mechanisms against myocardial ir, we used a validated in vitro model reproducing ir injury. rat cardiomyoblast cells h c were cultivated in . % o hypoxia in the presence of ischemia-mimicking medium. after min of ischemia, the reperfusion injuries are induced by replacing the culture medium with a krebs-henseleit normoxic medium for min. apc was performed by adding sev directly into the culture medium at an initial concentration of mm, prior to ischemia, for min. we then used another preconditioning agent, metformin (met), to explore the same signaling pathways. apoptotic cell death was measured by caspase activity assay and western blotting (expression of cleaved caspase ) under ir and apc conditions. results: our model faithfully reproduced the protective effect of apc which results in a significant decreased apoptosis under ir ( % reduction of the caspase enzymatic activity, correlated with a decrease of caspase cleavage). we showed that sev induces overexpression of the anti-apoptotic protein bcl-xl, which is responsible for the protective effect of apc. furthermore, these observations were confirmed in vivo in mouse heart lysates. we demonstrated that bcl-xl overexpression was due to the activation of the protein kinase akt. interestingly, we were able to show that preconditioning with met reproduces the protective effect of sev by inducing an akt-dependent bcl-xl overexpression. indeed, sev and met, which are both complex inhibitors of mitochondrial respiratory chain, seem to share a common reactive oxygenated species-dependent protective mechanism responsible for bcl-xl protein regulation. rationale: despite early endovascular treatment with successful recanalization, % of acute ischemic stroke (ais) patients experience a poor functional outcome after a large vessel occlusion. sepsis is frequent at the acute phase of stroke and is associated with poorer short and long term outcomes. we aimed to investigate the cerebral consequences of sepsis after recanalized ais and explore possible mechanisms involved. patients and methods: male c bl mice were randomly assigned to a x factorial plan to one of the following groups: ) a -minute middle cerebral artery (t-mcao) transient occlusion under inhaled general anesthesia, followed min after recanalization by intraperitoneal (i.p.) sepsis (lps, µg/g diluted in µl of nacl . %), (tmcao/ lps group); ) t-mcao followed by i.p. placebo ( µl of nacl . %) (tmcao/placebo group); ) sham operation (cervicotomy without carotid catheterization) followed by i.p. lps. (sham/lps group); ) sham operation followed by i.p. placebo, (sham/placebo group). in all groups, animals received subcutaneous fluid resuscitation ( µl nacl . %) immediately after the procedure and h later. twenty-four hours after recanalization, animals were scored for sepsis features and neurological deficit (on the modified neurological severity scale), (mnss) before sacrifice. the primary outcome measurement was a composite of death and hemorrhagic transformation at h. secondary outcome measurements included neurological deficit, sepsis features, neutrophil activation reflected by plasmatic myeloperoxydase (mpo) levels, stroke volume, and microglial activation in brain parenchyma (infarct core, perilesional area, controlateral hemisphere). results: t-mcao/lps animals had higher mnss ( . fold, p = . ) and sepsis ( fold, p = . ) scores at h with increased plasma mpo levels at h ( . fold, p < . ) and h ( . fold, p < . ), as well as, lower temperature ( . °c reduction, p = . ) and glycemia ( . g/l reduction, p = . ) as compared to tmcao/placebo animals. t-mcao/lps animals had a higher risk of unfavorable outcome at h ( -group comparison: p = . ; x analysis: t-mcao/lps, / − %vs. t-mcao/placebo / - %-, p < . ), whereas stroke volumes were not significantly different between groups. detailed results are presented in table . compared to t-mcao/placebo group, t-mcao/ lps animals had . fold increase (p = . ) in the mean number of microglial cells in the hemisphere controlateral to t-mcao, whereas no significant difference was observed in infarct core or peri-infarct parenchyma. conclusion: early sepsis after experimental ais worsens outcome and neurological deficit, without impacting stroke volume. early sepsisinduced systemic activation of neutrophils and increased microglial activation in the hemisphere contralateral to ischemia may have an important role on neurological outcomes observed in this setting. compliance with ethics regulations: yes. rationale: extracellular vesicles (evs) regulate diverse cellular and biological processes via facilitating intercellular cross-talk. several studies have suggested an association between lung injury and the generation of evs derived from platelets, neutrophils, monocytes, lymphocytes, red blood cells, endothelial cells, and epithelial cells. every year more than , patients require cardiac surgery with cardiopulmonary bypass (cpb). this cpb allows a substitution of the heart pump function and an oxygenation of the blood permitting a stop of the mechanical ventilation (mv). stopping mv during cpb is responsible for lung damage, leading to postoperative systemic inflammation while maintaining mv with positive expiratory pressure (peep) diminished the occurrence of atelectasis and the postoperative inflammatory response. in addition, this surgery is marked by immune dysfunction, leading to real immunosuppression of patients in postoperative care. a link between pulmonary injury and postoperative immunosuppression has been established, however, the mechanisms underlying this association are not fully known and evs may have a role in this post-operative immunosuppression. the purpose of this study is to investigate whether lung injury induced during cardiac surgery with cpb lead to the emergence of evs. the effect of mv during cpb on the production of these evs has also been studied. patients and methods: patients were prospectively divided into two groups: without mv during cpb and dead space mv with positive end-expiratory pressure during cpb. pao (arterial oxygen tension)/ fio (inspired oxygen fraction) ratio, biological markers of lung injury (cxcl , ccl , tnf-α, il- β, il- , rage, il- ) and blood cell count were collected before, h and days after surgery. the quantification of plasma evs was performed using turnable resistive pulse sensing and characterization of evs was performed using flow cytometry before, h and days after surgery. rationale: the benefit of prone positioning (pp) during moderate to severe acute respiratory distress syndrome (ards) may be related to its impact on the inflammatory response to ventilator-induced lung injuries. [ c]-pk is a positron emission tomography (pet) radiotracer that allows the non-invasive quantification of macrophages. we aimed to evaluate the effects of pp on [ c]-pk lung uptake in animals with experimental ards. patients and methods: experimental ards (by hydrochloric acid) was induced in pigs in supine position (sp), to obtain a pao / fio < mmhg. animals were under general anesthesia, neuromuscular blockade, and ventilated with a ml kg − tidal volume, and cmh o of positive end-expiratory pressure (peep). immediately after experimental ards, animals were randomized to be prone positioned, or to remain in sp. pet and computerized tomography (ct) were acquired h after randomization (h ). [ c]-pk uptake was measured on the whole lungs, and by dividing the lungs into regions or slices-of-interest (soi) along the ventro-dorsal axis, and was quantified by the standardized uptake value (suv), corrected for lung tissue density. results: pp was performed in animals, and sp in . after ards induction, pao /fio was [iqr, [ . - . ] in sp animals (p = . ). in pp animals, [ c]-pk suv was significantly lower in ventral soi, compared to sp, and significantly increased in dorsal soi ( fig. , *: p < . between groups in a given soi). in univariate analysis, [ c]-pk regional suv was positively associated with regional ct-measured peep-related increase in gas volume, and negatively with peep-related lung recruitment, but not with regional tidal volume. conclusion: during experimental ards, pp redistributed lung macrophage recruitment estimated by [ c]-pk uptake from ventral lung regions to dorsal regions, without affecting global macrophage influx. the intensity of macrophage recruitment was associated with peep-related lung inflation. compliance with ethics regulations: yes. rationale: acute respiratory distress syndrome (ards) is a pleiomorphic disease characterized by a severe respiratory failure associated with an increased mortality. nowadays, predicting clinical outcome of patients suffering from ards remains difficult. therefore, identifying new biomarkers to predict patient outcome, to evaluate response to therapy and to identify new potential pathways of interest are highly needed. exosomes are extracellular vesicles involved in cell-cell communication by transferring micrornas (mirnas) from donor to recipient cells. thus, exosomal mirnas can significantly affect biological pathways within recipient cells resulting in alterations of cellular function and the development of a pathological state. as biomarkers are highly needed in the particular field of ards, we realized a monocentric and prospective study to identify a new potential biomarker of interest. therefore, a prospective plasma sampling at the diagnosis of moderate to severe ards according to the definition of "berlin" has been performed. we analysed mirna content of exosomes from plasma ards patients compared to healthy subjects (hs) in order to identify new potential predictive biomarkers in ards. during one-year period, patients hospitalized in the icu of chu sart tilman suffering from infectious moderate-to-severe ards have been included. the ethical committee review boards of the hospital approved the research protocol (b , ref: / ), and informed consents were obtained. exosomes were isolated from plasma samples of ards patients and hs with standard ultracentrifugation protocol. exosomal mirna content was analyzed using small rna sequencing method, and diseases/biological processes associated to altered mirs were determined by bioinformatic analysis. results: for the first time, exosomal mirna expression modifications were studied in patients with moderate-to-severe infectious ards. we identified a new signature statistically significant composed of three up-regulated mirnas (mir- , mir- a and mir- ) and one downregulated (mir-let- b). conclusion: we identified potential biomarkers for ards from plasma exosomes. our findings may thus lead to predict ards outcome but also a better understanding about the roles of these mirs in the pathogenesis of ards and thus open new avenues for therapeutic approaches. in particular, exploit and develop the pro-fibrotic pathway induced by down-expression of mir-let- b. but also confirm in the future the current interest about mir- in its ability to restore pulmonary integrity after trauma. compliance with ethics regulations: yes. rationale: diabetic ketoacidosis (dka) is a life-threatening emergency. microvascular hyporeactivity was reported in these patients and was completely reversibly when ph was corrected with treatment: aggressive rehydration, electrolyte replacement and insulin therapy ( ) . red blood cell (rbc), a component of the microcirculation, showed alterations oftheir shape in diabetic patients ( ) but no data were available concerning the time course of the rbc deformability during treatment for dka. we aimed to assess the rbc deformability during dka treatment in icu patients. patients and methods: after approval by the ethics committee, rbcs deformability was assessed, in all icu patients admitted for dka and without infection, by ektacytometry technique (laser-assisted optical rotational red cell analyzer-lorrca): at icu admission, + h, + h and at the end of the icu stay ( - h). elongation index (ei) was defined as (l − w)/(l + w), where l is the length and w is the width. at °c, ei values were determined in the function of shear stress (ss) in a range of . - pa, based upon the laser diffraction pattern changes. a higher ei indicates greater rbc deformation. rbc deformability from patients with dka was compared at icu admission to healthy volunteers (v) and to diabetic patients followed in consultation (d). we also studied the evolution of deformability during treatment. results: icu dka patients compared to d and v were studied. as expected, glycemia and glycated hemoglobin were significantly higher in dka compared to d (respectively: glycemia: ( - ) vs ( - ) mg/dl and . % ( . - . ) vs . ( . - . ); all p < . ). dka patients received ( - ) ml of fluids and . ui/ kg bw ( . - . ) of insulin during their first h of icu stay. rbcs deformability from dka patients was significantly more altered at icu admission compared to others groups ( fig. ) and these alterations persists despite treatment. no correlations were observed between these alterations and quantity of fluids or insulin received, glycemia, glycated hemoglobin, ph, natremia, age or length of diabetes history. conclusion: in contrast of reversible microvascular hyporeactivity, rbc deformability from dka patients was already altered at icu admission and remains altered despite treatment. these alterations could contribute to the blood flow abnormalities observed in these patients. compliance with ethics regulations: yes. rationale: sepsis remains the first cause of acute circulatory failure in the emergency department (ed). standardized fluid resuscitation may not be adapted in certain patients, especially those with early sepsisinduced cardiac dysfunction in whom excessive fluid administration could be deleterious. information on early hemodynamic profile of septic patients in the ed are scarce. accordingly, we aimed at describing hemodynamic profiles encountered in septic patients assessed shortly after their ed admission using focused echocardiography. patients and methods: we prospectively enrolled adult patients with sepsis (qsofa score ≥ ) from january to july in the ed (nct ). focused echocardiography were performed by emergency physicians previously trained to ecmu level. each patient was evaluated according to a standardized protocol based on a limited number of simple binary clinical questions. investigators interpreted on-line the echocardiographic examination, determined the hemodynamic profile based on simple yet robust criteria (hypovolemia, left ventricular [lv] or right ventricular [rv] failure, vasoplegia with hyperdynamic state, tamponade, severe mitral or aortic regurgitation, or apparently normal profile), and recorded any substantial change in planned therapeutic management (surviving sepsis campaign ). data were digitally stored and validated off-line by an expert in critical care echocardiography. results: focused echocardiography were performed in patients (mean age: ± years; men: %; source of infection: pulmonary %, urinary %, abdominal %) after a median fluid loading of ml (iqr: - ml). according to sepsis- definition, patients had sepsis and sustained septic shock. mean sofa score was . ± . (hemodynamic failure %, respiratory failure %, renal failure %), mean lactate reached . ± . mmol/l, icu admission involved % of patients and overall -day mortality reached %. hemodynamic profile was hypovolemia in patients ( %), vasoplegia in patients ( %), cardiac failure in patients ( %) (lv failure: n = ; rv failure: n = ) and without relevant hemodynamic abnormality in patients ( %). ongoing therapy was altered based on early echocardiographic assessment in % of cases. mortality rate was not significantly different between groups (p = . ). conclusion: although hypovolemia was predominantly identified in patients presenting to the ed with sepsis during hemodynamic assessment, early ventricular dysfunction involved one-quarter of patients. these results suggest that early focused echocardiographic assessment promises to help the front-line physician tailoring the therapeutic management of septic patients in ed, especially regarding fluid resuscitation. compliance with ethics regulations: yes. right ventricular failure in septic shock characterization, incidence and impact on fluid-responsiveness guillaume geri , amélie prigent , xavier repessé , marine goudelin , gwenael prat , bruno evrard , cyril charron , philippe vignon , antoine vieillard-baron ambroise paré hospital, boulogne-billancourt, france; ambroise paré hospital, medical icu, aphp, boulogne-billancourt, france; chu limoges, limoges, france; chu brest, brest, france correspondence: guillaume geri (guillaume.geri@aphp.fr) ann. intensive care , (suppl ):f- rationale: right ventricular (rv) failure was defined by rv dilatation with systemic congestion. tricuspid annular plane systolic excursion (tapse) could be of limited value. we report the incidence of rv failure in patients with septic shock, its potential impact on the response to fluids, as well as tapse values. patients and methods: ancillary study of the hemopred prospective multicenter study including patients under mechanical ventilation with circulatory failure. with septic shock were analyzed. patients were classified in groups based on central venous pressure (cvp) and rv size (rv/lv end-diastolic area, eda). in group , patients had no rv dilatation (rv/lveda < . ). in group , patients had rv dilatation (rv/ lveda ≥ . ) with a cvp < mmhg (no venous congestion). rv failure was defined in group by rv dilatation and a cvp ≥ mmhg. passive leg raising (plr) was performed. results: % of patients were in group , % in group and % in group . in group and , rv/lv eda was higher than in group , . [ . ; . ] versus . [ . ; . ]. cvp was [ ; . ] mmhg in group . a correlation between rv size and cvp was only observed in group . higher rv size was associated with a lower response to plr (figure) . a large overlap of tapse values was observed between the groups. . % of patients with rv failure had an abnormal tapse. conclusion: rv failure is frequent in septic shock and alters fluid responsiveness. tapse was not accurate enough to diagnose rv failure. compliance with ethics regulations: yes. rationale: weaning-induced pulmonary oedema (wipo) is a leading cause of weaning failure in high-risk patients (heart failure, copd, obesity). we hypothesized that hypervolemia associated with positive fluid balance facilitates wipo in high-risk patients. patients and methods: in this prospective, observational, singlecenter study, patients with copd and/or heart failure with reduced ejection fraction (< %) were studied. exclusion criteria were nonsinus rhythm, severe mitral valve disease and inability to obtain adequate echocardiographic views. echocardiography was performed immediately before and during spontaneous breathing trial (sbt, -min t-tube). patients who failed sbt were treated according to echocardiographic results before undergoing a second sbt. fluid balance and body weight were collected at each sbt. shows interesting performance to predict fluid responsiveness in spontaneously breathing patients. nevertheless, measurement sites of inferior vena cava (ivc) diameters remain controversial for that purpose. the aim of the study was to test the accuracy of different measurement sites of civc to predict fluid responsiveness in spontaneously breathingpatients. this study is a post hoc analysis of two prospective cohorts. we included spontaneously breathing patients without mechanical ventilation presenting with sepsis-related acute circulatory failure and considered for volume expansion (ve). we assessed hemodynamic status at baseline and after a fluid challenge (fc) induced by a min-infusion of ml-gelatin %. the ivc diameters were measured off-line with ultrasonography using the bi-dimensional mode on a subcostal long-axis view. the civc was calculated as [ (expiratory-inspiratory)/expiratory] diameters during standardized (civc-st) and unstandardized breathing (civc-ns) conditions. breathing standardization consisted of a deep inspiration with concomitant control of buccal pressures and passive exhalation. patients were referred to be responders to fc (i.e. fluid responsive) when the stroke volume increased by ≥ %. results: among the patients included in the study, ( %) were responders to fc. the accuracy of civc-st and civc-ns before fc to predict fluid responsiveness differed significantly by measurement sites (interaction p value < . and < . , respectively). measuring ivc diameters cm from the junction of the ivc and the right atrium provided the best accuracy to predict fluid responsiveness ( fig. ). at cm caudal to the right atrium, civc-st was significantly better than civcns to predict fluid responsiveness: area under roc curve . ( % ci . - . ) versus . ( % ci . - . ), p < . . at cm, a civcst ≥ % and a civc-ns ≥ % predicted fluid responsiveness with sensitivity of % and %, and specificity of % and %, respectively. conclusion: accuracy of civc to predict fluid responsiveness in spontaneously breathing patients depends on both measurement sites of ivc diameters and breathing conditions. measuring ivc diameters during a standardized inspiration maneuver at cm caudal to the right atrium is the most relevant mean to optimize civc performance to guide ve. compliance with ethics regulations: yes. rationale: intermittent hemodialysis (ihd) is increasingly used in patients admitted to intensive care unit (icu) with acute kidney injury (aki) requiring renal replacement therapy (rrt). however, this technique is associated with nearly % of episodes of perdialytic hemodynamic instability (hi), a common cause of increased morbidity and mortality. at the same time, trans-thoracic echocardiography (tte) has become widely used in intensive care units and is now one of the hemodynamic monitoring methods used daily in the icu setting. patients and methods: search for one or more pre-dialysis tte criteria predictive of perdialytic hi, defined by a systolic blood pressure (sbp) lesser than mmhg or a suddain decrease in sbp of more than mmhg. prospective, observational study of standard care in a medical icu. collection of demographic, clinical and pre-dialysis echocardiographic data from included patients. results: twenty-five patients with a total of sessions of ihd between november and november were included in the study. tte was performed for each patient before each ihd session. hi occurred in hemodialysis sessions. in univariate analysis, the existence of prior heart disease ( % vs %, p = . ), a greater diameter of the left atrium ( . vs . cm, p = . ), a lower cardiac output ( . vs . l/min, p = . ), a right dysfunction assessed by lowered tapse and s-wave ( vs mm, p < . and . vs . cm/s, p = . , respectively) and an increase in paps ( vs mmhg, p = . ) were significantly associated with the occurrence of perdialytic hi (fig. rationale: several transthoracic echocardiography (tte) parameters of left (lv) and right ventricular (rv) systolic function are available. we compared the ability of these different parameters to track changes in lv or rv systolic function and to detect lv or rv systolic dysfunction in critically-ill patients. in patients ( mechanically ventilated and with atrial fibrillation), tte examinations were performed before and after i) infusion of -ml of saline (n = ), ii) changes in norepinephrine (n = ), iii) or in dobutamine (n = ) dosage. for the lv systolic function, we compared the mitral annular plane systolic excursion (mapse), the systolic (s') peak velocity of the lateral mitral annulus and the global longitudinal strain (glslv) to the lv ejection fraction (lvef), considered as the gold standard. for the rv systolic function, we compared the tricuspid annular plane systolic excursion (tapse), the systolic peak (s) velocity of the tricuspid annulus and the global longitudinal strain (glsrv) to the rv fractional area change (fac), considered as the gold standard. results: after pooling all values, lvef ( ± % at baseline) was better correlated to glslv (r = . ) than to mapse (r = . ) and s' wave (r = . ) (each p < . ). the concordance rate between changes (in %) in lvef and in the other parameters of lv systolic function was % for glslv, % for mapse and % for s' wave. both mapse and s' wave could not reliably detect moderate ( % ≤ lvef ≤ %) or severe (lvef < %) lv dysfunction. conversely, a glslv > − % predicted moderate lv dysfunction with a sensitivity of % ( % ic: - %) and a specificity of % ( % ic: - %) and a glslv > − . % predicted severe lv dysfunction with a sensitivity of % ( % ic: - %) and a specificity of % ( % ic: - %). after pooling all values, fac ( ± % at baseline) was better correlated to glsrv (r = . ) than to tapse (r = . ) and s wave (r = . ) (each p < . ). the concordance rate between changes (in %) in fac and in the other parameters of rv systolic function was % for glsrv, % for tapse and % for s wave.both tapse and s wave could detect rv dysfunction (fac ≤ %) with moderate reliability only. conversely, a glsrv > − % detected rv dysfunction with a sensitivity of % ( % ic: - %) and a specificity of % ( % ic: - %). in critically-ill patients, glslv and glsrv seem to be the best tte parameters of lv and rv systolic function. enrolments are still ongoing, which may allow further analysis. compliance with ethics regulations: yes. rationale: passive leg raising (plr), pulse pressure variation (ppv), and the -second end-expiratory occlusion test (eexpo) are frequently used to assess preload responsiveness. however, there are conditions in which they are not valid or feasible, which may preclude their applicability in the daily clinical practice. the aim of this study was to estimate the prevalence of such conditions in critically ill patients with acute circulatory failure. between january and april , all patients of a -bed medical icu were daily screened and those with acute circulatory failure, defined by norepinephrine infusion or fluid therapy > l during the previous h, were included. in each of them, we screened the criteria of validity/feasibility of ppv, plr and eexpo. results: eighty-four patients ( % with septic shock, % with cardiogenic shock, % with hypovolemic shock, % with non-septic vasoplegic shock) were enrolled in the study. among them, norepinephrine infusion was ongoing at the time of enrolment in % of the patients whilst % were under mechanical ventilation, and % with acute respiratory distress syndrome. plr was not applicable in % of cases. this was mainly due to venous compression stocking ( % of cases), intra-abdominal hypertension ( % of cases), and either an absence of cardiac output monitoring or impossibility to perform echocardiography ( % of cases). among the intubated patients, ppv was applicable in % of cases, including cases with high ppv under conditions generating false negatives (low tidal volume or lung compliance) or low ppv values under conditions generating false positives (spontaneous breathing, cardiac arrythmias). however, ppv was not interpretable in % of cases. this was mainly due to low tidal volume ventilation ( % of cases), spontaneous breathing activity ( % of cases), while the remaining non-interpretable cases ( %) had more than one reason. in the intubated patients, eexpo was not applicable in % of cases. this was due to impossibility for patients to sustain a -s hold of mechanical ventilation in % of cases, and either an absence of cardiac output monitoring or the impossibility to perform echocardiography in % of cases. plr and eexpo were both valid and feasible in % of the patients, and the three tests were all feasible in only % of patients. rationale: comorbid association between chronic respiratory diseases and sleep apnea syndrome (sas) revealed frequent with systematic search in icu following icu stay. this association carries prognosis impact depending whether specific treatment is implemented or not. nosas and stop bang scores are proposed for screening of sas in general population. the aim of the present study is to report the prevalence of sas in icu patients admitted for hypercapnic respiratory failure and compare association of nosas and stop bang score with sas severity. the study was conducted between january and september . patients consecutively admitted in the icu for hypercapnic respiratory failure had calculation of a no sas and stop bang scores at admission. in survivors nocturnal polygraphic records was performed to weeks following icu discharge. the association between the number of apnea-hypopnea episodes, bmi, and clinical variables suggestive of sas, was tested by poisson regression model. results: during the study-period, patients (mean age: ± years, ph . ± . , paco ± ) were admitted for hypercapnic respiratory failure. non invasive ventilation was used in % and death occurred in six patients. polygraphic records were performed in ( lost to follow-up) mean apnea-hypopnea index was ± with a minimum of and a maximum of . poisson logistic regression showed that no sas (p = . ) but not stop bang (p = . ) was associated with the level of apnea-hypopnea index. rationale: patients with severe acute exacerbations of chronic obstructive pulmonary disease (copd) may benefit from high-flow nasal oxygen regarding its physiological effects and good tolerance. bronchodilator vibrating mesh nebulization through high-flow nasal oxygen circuit has been described to induce similar effect to standard facial mask jet nebulization in stable copd patients. we aim to evaluate whether vibrating mesh nebulization of salbutamol through highflow nasal oxygen circuit is efficient in unstable patients with copd. patients and methods: we conducted a monocenter non-randomized physiological prospective cross-over study, between january and september , including icu patients with severe acute exacerbation of copd and respiratory acidosis treated by salbutamol nebulization. spirometry and airway resistances records were performed after a -h wash-out period without bronchodilator, before and after vibrating mesh nebulization of mg salbutamol through high-flow nasal oxygen circuit. the primary endpoint was forced expiratory volume in s after salbutamol nebulization. secondary endpoints included other spirometry parameters, clinical parameters, dyspnea assessed by a borg scale. results: fourteen consecutive patients were included, forced expiratory volume in s increased significantly after salbutamol nebulization through high-flow nasal oxygen ( ± ml, p = . ), as well as forced vital capacity ( ml ± , p = . ). airway resistances were not significantly changed after nebulization (− . ± . , p = . ) as well as peak expiratory flow (+ ml ± , p = . ). no difference was observed on borg scale (p = . ) and respiratory rate (p = . ) after salbutamol nebulization, while heart rate increased significantly (p = . ). discussion: salbutamol nebulization using vibrating mesh nebuliser placed on high-flow nasal oxygen circuit induces a significant but moderate bronchodilation in patients with severe acute exacerbation of copd. moreover, improvement of forced vital capacity after salbutamol nebulization suggests a reduction of dynamic hyperinflation. conclusion: salbutamol vibrating mesh nebulization through highflow nasal oxygen circuit increases significantly forced expiratory volume in s. compliance with ethics regulations: yes. t-piece versus sub-therapeutic pressure support for weaning from invasive mechanical ventilation in patients with chronic obstructive pulmonary disease: a comparative prospective study amira jamoussi, fatma jarraya, samia ayed, takoua merhabene, jalila ben khelil, mohamed besbes abderrahmen mami hospital, tunis, tunisia correspondence: amira jamoussi (dr.amira.jamoussi@gmail.com) ann. intensive care , (suppl ):f- rationale: the best weaning strategy for patients with chronic obstructive pulmonary disease (copd) remains unknown. the spontaneous breathing trial (sbt) represents a crucial step of weaning, but the choice between the t-piece (sv-tube) or the sub-therapeutic setting of the level of pressure support without positive expiratory pressure (psv) is still a matter of debate. we aimed to compare the success of extubation between two groups of copd patients according to the sbt type (vs-tube vs psv). patients and methods: it was a prospective and comparative study, from april to march , at the abderrahmen mami hospital's intensive care unit (icu). copd patients who underwent invasive mechanical ventilation (mv) for at least h and met the criteria for weaning were included and randomized to sv-tube or psv. a multivariate analysis was performed to determine the association between the sbt modality and the success of extubation (no re-intubation during the h following extubation). results: during the two years' study, patients were included. the mean age was ± years, the sex-ratio was . . weaning process was simple in patients ( %), difficult in patients ( %) and prolonged in patients ( %). fifteen and patients were respectively randomized to the sv-tube and psv groups. the mean duration of mv before randomization was comparable between the groups (sv-tube . ± . days vs psv . ± . days, p = . ). mean weaning time (days) was . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] for the sv-tube group and . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] for the psv group. the mean total mv duration (days) was higher in the sv-tube group than in the psv group ( . vs . , p = . ). the number of re-intubated patients within h following extubation was higher in the psv group ( / vs / , p = . ) as well as the overall reintubation rate ( . % vs %, p = . ). in multivariate analysis, the sbt's trial was independently associated to the success of extubation (or = . , ic [ . - . ], p = . ) in favor of sv-tube' modality. the median length of stay in intensive care was days [ ; ]. the mortality was higher in the psv group ( / vs / , p = . ). extubation failure was a factor associated with mortality (or = . , ci [ . , . ], p = . ). conclusion: ventilation weaning was easy in % of intubated copd patients. sv-tube as sbt modality was associated to success of extubation in patients with copd. mortality in intensive care was significantly higher in re-intubated patients. compliance with ethics regulations: yes. rationale: non-invasive ventilation has become the mainstay in hypercapnic respiratory failure. delaying intubation and invasive ventilation is associated with a worse outcome in these patients. although a predictive score of niv failure has been validated for hypoxemic respiratory failure no such score exists in hypercapnic respiratory failure. the aim of our study is to compare the performance of two scores in the predictive niv failure hypercapnic respiratory failure. patients and methods: consecutive patients admitted between january and july for hypercapnic respiratory failure, were included. hacor score and rox score were calculated in each patient at admission. in patients ventilated non-invasively, the outcome (niv success or failure) was noted. the area under curve (auc) and operative characteristics were computed for both scores. results: during the study-period, out of patients admitted for hypercapnic respiratory failure received niv as the primary ventilatory mode. these patients were mainly men ( / ), had a mean age of . ± years and had the following pulmonary disease: copd exacerbation . %, obesity-hypoventilation syndrome . %, bronchiectasis . %, and other diseases: . %. niv failure occurred in patients ( . %) and icu mortality in . %. mean hacor score and rox score were . ± . and . ± , respectively. the auc under roc was higher for hacor than rox ( . and . respectively) ( fig. ). the hacor score (cut-off ) had a sensitivity of . and specificity of . . conclusion: hacor score seems more accurate in predicting niv failure in hypercapnic respiratory failure. further prospective validation is needed. compliance with ethics regulations: na. rationale: published data on outcomes in respiratory weaning centers are limited and seem to depend on the organisation of healthcare systems and patient case-mix. the weaning center of our university hospital (post intensive care rehabilitation unit) admits for weaning and rehabilitation patients from medical and surgical intensive care units without severe neurological pathologies. the aim of this study was to describe patient's characteristics and outcome (weaning outcomes and survival) and to compare in subgroups according to the initial medical, surgical or cardiac surgical context. patients and methods: we conducted a monocentric retrospective observational study between / / and / / . «successful outcome» was defined by the association of survival and weaning from invasive ventilation. factors associated with evolution were investigated by uni-and multivariate analysis. survival after discharge was analysed according to the initial context and according to the type of ventilation at discharge. results: among patients included, ( . %) had a successful outcome with high use of non-invasive ventilation (niv) ( %). respiratory history (p = . ), female gender (p < . ), igs score at admission to the srpr (p = . ) and non-cardiac surgical setting (p < . ) were associated with an adverse course. the -month survival rate was % in discharged patients. the outcome was not different in the tree subgroups. niv rate at discharge was high in the subgroup of cardiac surgery patients. a multidisciplinary and personalised approach by a specialized weaning unit can provide a successful service model for patients who require liberation from prolonged invasive mechanical ventilation. compliance with ethics regulations: yes. rationale: high-dose insulin euglycemic therapy (hiet) is recommended as first line therapy for calcium channel blockers (ccbs) poisoning because of its inotropic effect. our first objective was to study its hemodynamic impact. we performed a retrospective cohort study of all consecutive patients admitted for ccbs poisoning treated with hiet, in one icu at the university hospital of lille between january and july . the hemodynamic impact was studied through mean arterial pressure (map), vasoactive-inotropic score (vis) and map/vis ratio during the h following hiet initiation. metabolic parameters were also collected. results: patients admitted for ccbs poisoning. patients treated with hiet in icu ( patients without circulatory shock, patients with shock after hiet and patients with shock at baseline before hiet). among shocked patients at baseline (n = ), no hemodynamic improvement was found except an increased map/vis ratio at h (p < . ). on the contrary, an initial worsening of vis ( [ rationale: ketamine is used in the induction and maintenance of general anesthesia. recently, there were concerns regarding its liver toxicity. we conducted a study to investigate the link between ketamine use and liver dysfunction (ld) in intensive care unit (icu) patients. patients and methods: data were extracted from the [anonymized] study, a randomized controlled trial designed to evaluate the effect of cisatracurium on -day mortality rate in moderate and severe acute respiratory distress syndrome (ards) patients. the main endpoint was the occurrence of a ld defined as a total serum bilirubin superior or equal to micromol/l. a matched case-control cohort was created: cases, receiving at least day of continuous ketamine infusion, were paired for with controls according to treatment with cisatracurium, hepatic and cardiovascular sofa sub-score, total serum bilirubin level at the time of inclusion, age, sex, ards from septic origin, shock anytime after inclusion. an analysis was also made on the whole cohort comparing the patients receiving at least day of continuous ketamine infusion to all patients who did not fulfill this criterion. results: cases were identified and matched to controls. in the ketamine group, the median ketamine duration was ( - ) days, and median total cumulative dose . ( . - . ) g. the occurrence of ld was higher in the ketamine group than in the matched control group ( . % versus . %, p = . , fig. ). the hazard ratio (hr) for ld in the ketamine group was . ( % ci . - . , p = . ). there was an increased risk of ld of . % per day of exposure to ketamine (hr . , % ci . - . p = . ) and of . % per gram of ketamine infused (hr . , % ci . - . , p = . ), with a risk starting to be statistically significant after days and gr. in multivariate analysis on the whole cohort, ketamine exposure (hr . , % ci . - . , p = . ), cumulative dose in gram (hr: . , % ic: . - . , p = . ) and ketamine exposure in days (hr: . , % ic: . - . , p < . ) remained independent risk factors for ld occurrence. conclusion: ketamine use in critically ill patients treated for ards is associated to a higher risk of liver dysfunction, assessed by total serum bilirubin. this risk is dose-dependent and increases with duration of treatment. the prescription of high doses or prolonged treatment with ketamine should probably be avoided in critically ill patients. compliance with ethics regulations: yes. rationale: ciguatera is one of the most common cases of marine poisoning associated with fish consumption in the world. the incidence of this intoxication is largely unreported. in martinique, the incidence of this intoxication seems constantly increasing. during the last years, numerous cases of large collective poisonings have been reported in martinique, especially during summer. the spectrum of clinical manifestations is large including gastrointestinal, neurological andcardiovascular symptoms. ciguatoxin, the toxin responsible for ciguatera fish poisoning is considered as a sodium channel agonist with cholinergic and adrenergic activity. it is rarely fatal and management of poisoned patients is essentially based on supportive care. the objective of this study was to describe the clinical characteristics and complications of ciguatera poisoning in martinique, focusing on the cardiovascular ones. observational, retrospective, single-center study covering six-year period from october to september , including all patients admitted to the emergency department of the university hospital of martinique (chu), and all patients who were declared to the regional health agency (ars) for ciguatera intoxication. results: one hundred and forty-nine patients ( ) who were ciguatera-affected were included. the incidence rate found was to be . cases per . patient-years in martinique over the period. about % of patients had gastrointestinal symptoms such as nausea, vomiting, diarrhea, or abdominal pain; % neurological disorders and % cardiovascular symptoms including, bradycardia, hypotension and interventricular block. ingestion of carangue fish was related to a major risk of chronic signs. conclusion: the incidence of ciguatera in martinique is increasing, with . cases/ . patient-years. the clinical presentation is defined mainly by digestive signs, followed by peripheral neurological disorders and cardiovascular symptoms. ciguatera fish poisoning in martinique presents similar clinical presentation to that of the other caribbean islands. there is no specific treatment. acute ciguatera poisoning is responsible for significant cardiovascular complications. physicians should be aware of the potential cardiovascular risk of ciguatera poisoning. compliance with ethics regulations: yes. rationale: pesticides have represented the most incriminated products in severe acute poisonings, in the developing countries, due to the availability of these products. organophosphate poisoning accounts for million poisonings/year worldwide. organophosphate (op) pesticides are used mainly as insecticides in agriculture. the moroccan anti-poison and pharmacovigilance centrer shows that op poisoning are responsible for % of all poisonings combined. the aim of our study: epidemiological, clinical, management and prognostic factors. patients and methods: a retrospective study was conducted on patients with op poisoning admitted to our nine-bed medical intensive care unit between january and december . inclusion criteria were: all patients over years of age and the exlusion criteria were: pesticide poisoning other than op, alcohol poisoning, drug poisoning, scorpionic poisoning and snake bites. statistical analysis was performed with spss software. results: forty patients were admitted for acute op poisoning. in morocco, organophosphores are available over-the-counter in several forms: rodentocides, malathion, cockroach trap, baygon insecticide ( fig. ). the average age was years with a female prévalence of . %. the intoxications were mostly intentional ( %). the symptomatology was determined by the three syndromes: central syndrome in %, muscarinic syndrome in %, nicotinic syndrome in %. rhythm disorders in %, and cardiovascular collapse in %. the symptomatic treatment was applied to all patients, antidotic treatment was administered in % of patients. the average length of hospitalization was days. conclusion: acute op poisoning is a real public health problem. its associated symptomatic treatment (respiratory and neurological resuscitation) and antidotic treatment. the mortality remains high in our context, therefore, we must attach great importance to the prevention. compliance with ethics regulations: yes. ( ). over an -month period, health officials in guadeloupe and martinique reported more than . such cases. assault of these brown algae represents not only an environmental and economic disaster, but also a threat for human health. after h on seashore, large amounts of toxic gas are produced by matter decomposition, including hydrogen sulfide (h s) and ammoniac (nh ). the acute effects on humans after exposure to high concentrations of h s are well described and of increasing severity with concentration, leading to potentially fatal hypoxic pulmonary, neurological and cardiovascular injuries (table ) ; however, the association of long-term exposure to sargassum and health events is unknown. although less documented, long term exposures may result in conjunctiva and upper airways irritation, headaches, vestibular syndrome, memory loss, and modification of learning abilities. in the absence of any available antidote, management of h s intoxication relies on supportive care and prevention using individual protection. the objective of this study was to evaluate the clinical characteristics and consequences of long-term exposure to sargassum among the local population. we conducted a prospective observational cohort study including all patients admitted to the emergency department at the university hospital of martinique from march to december due to exposure to sargassum. patients were managed according to the protocol established by the research group on sargassum in martinique. we assessed the patients exposure to sargassum and air pollutants using monitor located near of the patient's residence. demographics and clinical data (including cardiovascular, neurological and respiratory events) were collected. data are presented as mean ± sd or %.comparisons were performed using univariate analysis. results: in months, patients were included (age: ± years, m/ w, past history: hypertension (n = ), diabetes (n = ), asthma ( ). patients arrived with referral letter from their general practitioner ( %) and presented headaches ( %), developed gastrointestinal disturbances ( %), dizziness ( %), skin lesions ( %), cough ( %) and conjunctivitis ( %). not all patients were clinically symptomatic. in the patients presented in june ( %), symptoms more frequently occurred in the workplace or at home (p < . ). initial lung function tests were normal ( %). three patients were admitted in intensive care unit. conclusion: our study indicates that the magnitude of health effects following long-term exposure to sargassum may be larger than previously recognized. efforts to limit long-term exposure are mandatory. compliance with ethics regulations: yes. rationale: liver consequences of out-of-hospital cardiac arrest (ohca) have been poorly studied. the aim of this study was to describe the characteristics of ohca-induced acute liver dysfunction and its association with outcomes. we analyzed all consecutive ohca patients admitted to two academic centers between and . patients treated with vitamin k antagonist were not included. acute hepatocellular insufficiency (ahi), liver failure (lf) and hypoxic hepatitis (hh) were defined as a prothrombin (pt) ratio < %, a hepatic sofa sub-score > and an increase in transaminases > times the normal values, respectively. indocyanine green (icg) clearance was used as the reference measure of liver function in a subset of patients. multivariate logistic regression was used to identify potential risk factors for day mortality. rationale: neuron-specific-enolase (nse) is commonly used as a biomarker reflecting the extent of brain injury in different settings. in post-cardiac arrest patients, previous clinical studies reported that an increase in nse was predictive of a poor outcome but did not specifically focused on neurological outcome. in this prospective study, we aimed to determine the nse performance for prediction of severe brain damage in post-cardiac arrest patients. patients and methods: all consecutive patients admitted in our icu after cardiac arrest between january and february that were still comatose at h and had at least one measurement of serum nse were included. blood samples for nse measurement were serially collected at (h ) and h (h ) after cardiac arrest and serum nse levels were measured within h. we used the following criteria for the definition of severe brain damage (primary endpoint): cerebral performance categories (cpc) or level at discharge, brain death or withdrawal of life-sustaining treatments (wlst) based on neurological status. we also assessed the predictive value of serum nse using allcause mortality as a secondary endpoint. results: during the study period, patients were available for the analysis. they were mostly male ( . %), with an age of . years. among these patients, ( . %) had a good neurologic outcome (cpc - ) and patients were classified as having a severe brain damage ( wlst based on neurological status, brain deaths and survivors with . in univariate analysis, patients with severe brain damage less frequently received bystander cpr, had longer duration of no-flow, less initial shockable rhythm, more post-resuscitation shock and higher nse values: mean at h were . versus . ; and . versus . at h (p < . ). nse levels at h and h were strong predictors of severe brain damage (auc of . and . respectively, figure ) and also predicted all-cause mortality (auc of . and . respectively). to predict severe brain damage with % specificity, best nse cutoff values at h and h were . and . µg/l, with a sensitivity of . and . % respectively. conclusion: a high serum nse measured at h and h after cardiac arrest accurately predicted severe brain damage with a high specificity. our results support the use of nse for neuroprognostication after cardiac arrest, in combination with other predictors. compliance with ethics regulations: yes. rationale: the psychological care of patients, their relatives and of healthcare workers is a major issue in the intensive care unit (icu). psychologists may provide emotional support during trying times. the intervention of a psychologist may alleviate long term mental health issues such as post-traumatic stress disorder. the main objective of our study was to describe the availability of psychologists in french-speaking icus. patients and methods: internet survey conducted between march and may using surveymonkey (san mateo, usa). survey consisting of questions sent to subscribers of the srlf mailing list via mailchimp software (atlanta, usa). frequencies and percentages were determined for categorical variables and median and interquartile range for continuous variables. the icus with or without psychologist were compared using nonparametric fisher exact test. stata used (lakeway drive, te, usa). results: responses were obtained from unique icus in france (n = ), belgium (n = ), switzerland (n = ), algeria (n = ), morocco (n = ) and tunisia (n = ). ( %) icus were part of public hospitals, ( %) of private facilities. ( %) icus cared for adult patients, ( %) for children. the median number of beds was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . ( %) icus were open to visitors / , ( %), to visitors > h/day and ( %) to visitors < h/day. psychological consults were established in ( %) wards ( icus did not answer). pediatric icus employed more psychologists than adult icus (p = . ). comparison of icus based on the presence or not of a psychologist appears in table . in icus where a consulting psychologist is available, their effective availability is . [ . - ] full time equivalent. consults are delivered to: patients ( %), families ( %) or healthcare workers ( %). out of the icus without a psychological consult, responders from ( . %) icus believe that a psychological consult is undesirable. out of the icus without psychological consult, ( %) responders cannot obtain a psychological consult, whatever the circumstances, ( %) can require an outside psychological consult when needed, while ( %) can require assistance from a psychologist working in another unit (several answers possible for each respondent). conclusion: psychologists consult in only half of adult icus but in almost all pediatric icus. % of icus are unable to provide a psychological consult. psychological consults are delivered in similar proportions to patients, their family and to a lesser extent to healthcare workers. responders from . % icus without an established psychological consult believe that the availability of a psychologist is undesirable. compliance with ethics regulations: na. rationale: comfort of patients in intensive care unit (icu) is now a real concern for the healthcare teams. perceived patient discomfort assessment is a daily practice for our staff. the primary objective of our study was to assess whether the overall discomfort score reported by patients hospitalized in a separate intermediate care unit differs from that reported by patients hospitalized in icu. a tailored multicomponent program consisting of assessment of icu-related self-perceived discomforts with a -item questionnaire, immediate and monthly feedback to healthcare teams and site-specific tailored interventions, was applied in our department, located in a general hospital, and comprising a -bed icu and a separate -bed intermediate care unit rationale: the transition period surrounding the discharge from icu to hospital ward is a critical period in the course of the patient. handoff of complex patients is at high risk for communication failures between providers, inaccurate cares and icu readmission. a transition program including a post icu follow-up has been proposed to improve handoff quality. post icu consults by icu team represent, also, an opportunity for improving feedback on the quality of icu cares. the goal of the present study is to assess the feasibility and the impact of a systematic early post-icu consult (epicuc) program on handoff quality in a bed mixed icu. patients and methods: before the development of the epicuc program, standardized handoffs were already applied including identified day and hour of discharge and both verbally communicate and written medical and nurse information for receiving team. from st march to th october , all patients who were discharged to the ward of our hospital were candidates for epicuc. epicuc were performed by icu staff (at least one icu physician) within the days following discharge. the epicuc consisted of a face-to-face discussion with the receiver team to assess the accuracy, completeness and understanding of passing information and of a patient visit. a standardized form was used for collecting data. the impact of epicuc on handoff quality was assessed by the number of communication failures and the number of patients in whom epicuc resulted in a management change. personal feeling of epicuc providers on its usefulness was assessed by a - rating scale. results: among the candidates for epicuc, were dead and already discharged alive from hospital at epicuc time. epicuc were performed in patients ( %) within ± days after icu discharge. epicuc ( %) were performed by both, nurse and icu physician. ( %) patients and receiver teams ( %) were available at epi-cuc time. epicuc duration was ± min. a communication failure was identified in epicuc ( %), either a rectification of passing information (n = ; %) and/or a change in patient management (n = ; %). the usefulness of the epicuc was rated at ± and ± by icu physicians and nurses, respectively. conclusion: the time spent for epicuc appears reasonable. epi-cuc identified a communication failure in one-third of handoffs and allowed care readjustment in one quarter of patients. factors associated with handoff failures will be presented during the congress. compliance with ethics regulations: yes. rationale: surviving a critical illness is a challenging condition for patients and relatives. the psychological aspects are directly affected by physical status and performance. patients can feel depressed or anxious facing difficulties during recovery time. the aim of this study was to correlate patients' perceptions of his health status and his clinical performance measured after icu discharge. patients and methods: this is a prospective pilot study of an icu follow-up clinic conducted in a single center from january to july . this clinic is multidisciplinary and includes two visits at and months after icu discharge. patients with more than days of icu los were eligible. all patients at and -m visit were evaluated with sf- , mwt, mrc and time-up-and-go test. we conducted an analysis comparing clinical performance data and qualitative data between and months after icu discharge. the investigation included patients who had at least days of icu length of stay. patients attended the consult at -m and patients attended the consult both times. the median age (iqr) was ( - ) and % were men. %, % and % of patients had medical, scheduled surgical and emergency surgical admission causes respectively, with median (iqr) saps iii score ( - ). %, % and % of patients had sepsis, delirium and mechanical ventilation as a support. the physical status was progressively increased overtime likewise the physical capacity assessed by sf- score with p-value . between and -m. however, no significant difference between the subjective dimension of sf- , which analyses the perception of the patient about his physical capacity, assessed at -m and at -m was demonstrated (p . ). in this pilot-phase of following a cohort of critically ill patients, the natural physical improvement does not seem to change the patient's perception of their performances. this paradigm rouses a different perspective that should take into account when setting up rehabilitation programs. compliance with ethics regulations: yes. post-traumatic stress disorder after discharge from an acute medical unit basma lahmer , naoufel madani , , jihane belayachi , , redouane abouqal rationale: post-traumatic stress disorder (ptsd) occurs after exposure to a traumatic event and comprises of symptoms of repeated re-experiencing of the said event, avoidance of reminders, emotional numbing and persistent hyperarousal. in individuals exposed to "medical stress", various studies found evidence of ptsd occurring after the onset, diagnosis, or treatment of physical illness. our study aims to determine ptsd's risk factors in patients of an acute medical unit (amu) after their discharge. patients and methods: it was a prospective, analytical study conducted over a period of months at an acute medical unit. we collected sociodemographic and clinical data, patients' medical history, and evaluated the symptoms of anxiety and depression during their stay using the hospital anxiety and depression scale (hads). the prevalence of severe ptsd symptoms was assessed with the impact of events scale-revised (ies-r) at weeks and months using a cutoff of . associations between ptsd as evaluated by ies-r at months and patients' characteristics, including hads scores at admission were investigated using unadjusted linear regression, for univariate and multivariate regression analysis. statistical analyses were carried out using spss for windows (spss, inc., chicago, il, usa). we included patients in our study with a mean age of . ± . . in our population, . % of patients scored higher than a ies-r cutoff at weeks compared to . % at months. the mean hads-anxiety score is . ± and that of the hads-depression score is . ± . . on one hand, higher hads-anxiety score during the stay in the amu was linked to higher ies-r scores at months β: rationale: objective of critical care includes restoration of functional capacities. prompt identification of muscle acquired weakness (icu-aw) is crucial to target efficient rehabilitation. in published literature, data of quadriceps strength (qs) cannot be compared because of insufficient standardization of measurement protocols. we recently validated a highly standardized protocol of qs measurement. in order to build basic and comparable knowledge and to identify the weakest patients, this study aimed to describe qs of critically ill (ci) patients during their short-term evolution, and to compare them to surgical (s) and healthy (h) subjects. patients and methods: this observational study included ci patients who spent at least days in icu, patients scheduled for elective colorectal surgery (s) and young healthy volunteers (h). maximal isometric qs was assessed using a handheld dynamometer (microfet ® ) and expressed in newton/kg (n/kg). dominant leg was tested in supine position using a highly standardized procedure. ci and s patients were tested at t (as soon as collaborative in icu) and month after discharge (m rationale: the post intensive care syndrome (pics) gathers various disabilities, associated with a substantial healthcare use. however, patients' comorbidities and active medical conditions prior to intensive care unit (icu) admission may partly drive healthcare use after icu discharge. to delineate the relative contribution of critical illness and pics per se to post-critical illness increased healthcare use, as opposed to pre-existing comorbidities, we conducted a population-based evaluation of patients' healthcare use trajectories. patients and methods: using discharge databases in a . -million-people region in france, we retrieved, over three years, all adult patients admitted in icu for septic shock or acute respiratory distress syndrome (ards), intubated at least days and discharged alive from hospital. healthcare use (days spent in healthcare facilities) was analyzed two years before and two years after icu admission. healthcare trajectories were next explored at individual level: patients were assembled according to their individual pre-icu healthcare use trajectory by clusterization with the k-means method. results: eight-hundred and eighty-two ( ) patients were included. median duration of mechanical ventilation was days (interquartile ranges [iqr] ; ), mean saps was , and median hospital length of stay was days (iqr ; ). prior to icu admission, we observed, at the scale of the whole study population, a progressive increase in healthcare use. however, clusterization of individual according to pre-icu healthcare trajectories identified patients with elevated and increasing healthcare use (n = ), and two main groups with low (n = ) or no (n = ) pre-icu healthcare use. patients with high healthcare use had significantly more comorbidities than those with low healthcare use. in icu, however, saps , duration of mechanical ventilation and length of stay were not different across the groups. interestingly, analysis of post-icu healthcare trajectories for each group revealed that patients with low or no pre-icu healthcare (which represented % of the population) switched to a persistent and elevated healthcare use during the two years post-icu. conclusion: for % of ards/septic shock survivors, critical illness appears to have a pivotal role in healthcare trajectories, with a switch from a low and stable healthcare use prior to icu, to a sustained higher healthcare recourse two-years after icu discharge. this underpins the hypothesis of long-term critical illness and pics-related quantifiable consequences in healthcare use, measurable at a population level. compliance with ethics regulations: yes. ( ) to describe the pre-hospital grading protocol developed by the northern french alps emergency network (trenau) for children, ( ) to evaluate its quality to detect the most severe trauma patients and ( ) to assess the accuracy of this procedure to perform an adequate triage. patients and methods: our regional trauma system included hospitals categorized as level i, ii or iii pediatric trauma centers. eachpatient was graded a, b or c by an emergency physician, according to the seriousness of their injuries at presentation on scene. the triage was performed according to this grading and the categorization of centers. this study is a registry analysis of an -year period ( to ). results: a total of children (mean age years, % were boys) with severe trauma were included in the cohort. fifty-seven, % and % of patients were admitted to a level i, ii and iii, respectively. road accident was the main mechanism of injury ( % of patients). thirtysix percent of patients had a severe trauma, defined as an injury severity score (iss) higher than . one quarter of patients had at least severe lesions and one-third of patients had a trauma brain injury. the pre-hospital gradation was closely related with injury severity score (iss) and intra-hospital mortality rate. the triage protocol had a sensitivity of % and a specificity of % to predict adequate admission of patients with iss more than . using a specific trauma score (including occurrence of death, an admission in intensive care unit and the need for urgent surgery), sensitivity and specificity reached and %, respectively. fourty-six percent of patients were not graded at the scene (non-graded group). undertriage rate was significantly reduced in the graded group compared with the non-graded group, ( % versus %), without significant modification of the overtriage rate ( % versus %). overall, mortality at discharge from hospital was %, but % in grade a patients. conclusion: implementation of a regional pediatric trauma system with a specific pre-hospital triage procedure was effective in detecting severe pediatric trauma patients and in lowering the rate of prehospital undertriage. compliance with ethics regulations: yes. rationale: critically ill children suffer from pathophysiological changes, leading to large between-subject variability in drug clearance. since piperacillin is eliminated mainly via the kidney, changes in renal function go along with a modified elimination, and possible subtherapeutic or toxic drug concentrations. we aimed to determine the most accurate glomerular filtration rate (gfr) estimation formula for assessing piperacillin clearance in critically-ill children. patients and methods: all children hospitalized in pediatric intensive care unit and receiving piperacillin were included. piperacillin was quantified by high performance liquid chromatography. pharmacokinetics were described using the non-linear mixed effect modeling software monolix. in the initial pharmacokinetics model, gfr was estimated according to the schwartz formula. in the study, gfr was estimated with additional formulas, developed with plasma creatinine and/or cystatin c. biases, precisions, spearman's rank correlation coefficient and normalized prediction distribution error (npde) were used to assess the models. results: we included children with a median (range) postnatal age of . ( . - ) years, body weight of . ( . - ) kg and estimated gfr according to the schwartz formula of . ( - ) ml min- . . m . piperacillin concentrations were best predicted with the model using the creatinine clearance. the correlations were most accurate: r = . between the population-predicted and the observed concentrations, r = . and r = . for the npde versus population-predicted concentrations and time, respectively. concerning the individual predicted concentrations, bias and precision were respectively − . mg l − and . mg l − . gfr estimations based on serum creatinine were higher than those based on cystatin c (p = . ). conclusion: in summary, the -h creatinine clearance is the best predictor of piperacillin clearance and this could be investigated for drugs with renal elimination. as a whole, literature and our findings strongly suggest using creatinine clearance to also estimate gfr in critically ill children. the gap between the gfr estimations is large depending on the formulas, with higher estimations with equations based on serum creatinine. compliance with ethics regulations: yes. rationale: acute pancreatitis (ap) incidence have increased dramatically over the past years. new guidelines in were recently published in order to standardize the definition and management of ap. the aim of this study is to describe the management of children that were diagnosed with ap from the pediatric intensive care unit (picu) in two french hospitals. patients and methods: this retrospective cohort study included children aged under years old, who were admitted to the picu of robert-debré hospital and trousseau from to with a discharge diagnosis of ap. data collected included management, severity and outcomes. we have also obtained data on clinical, biological and radiological presentation. results: sixty patients were included, the median age was years ( - ) and % had a co-morbidity mainly hematologic ( / ). most of the ap were moderate ( %) or severe ( %). hemodynamic failure was the main reason for picu admission requiring a median fluid resuscitation ml/kg complemented by a median intravenous fluid therapy of ml/kg/h ( - ) during the first h. twenty patients ( %) required mechanical ventilation. fasting has been instituted in patients ( %) for a median of days ( - ), whereas patients ( %) received parenteral nutrition, only patients ( %) received enteral nutrition. antibiotic therapy was given to patients ( %) including % for curative therapy. the median length of stay in picu was days ( ) ( ) ( ) ( ) ( ) . the mortality rate was %. conclusion: this is the first french study which precisely described the management of patients with ap in picu. it highlighted the differences withthe new international guidelines. this study could improve the management of pa in picu and open research perspectives. compliance with ethics regulations: yes. rationale: apheresis and therapeutic plasma exchange (tpe) for children diseases has been poorly investigated in mostly small-uncontrolled studies. the purpose of this study is to describe indications and safety of tpe in children. patients and methods: in this single center and retrospective study, we included patients who underwent tpe with an age < years old in the pediatric center of necker-enfants-malades hospital from january to december . data were retrospectively collected in an electronic case report form via a web-based data collection system. results: patients with a median age of . years [range . ; . ] were selected. they achieved a total number of procedures. indications were antibody-mediated rejection (n = ; %) or desensitization therapy (n = ; %) for solid organ or hematopoietic transplantations; microangiopathy (n = ; %); renal diseases (n = ; %) and pediatric inflammatory diseases (n = ; %); or hyperviscosity syndrome (n = ; %). each patient had an average of procedures for the first session [range ; ] with a median volume of ml [range ; ml] corresponding to a median (rang) total plasma volume (tpv) equivalent of . l/m [ . - . ]. within days since the beginning of sessions, patients ( %) present a total of adverse events (aes) potentially related to tpe. there was a median (range) of aes/patients [ - ]. there was no association between aes and diseases, severity of patients, venous access, plasma substitute and body weight. few of aes (n = for patients) were potentially life-threatening and concerned mostly critically ill children. allergic reactions represented only aes for patients (grade i n = ; grade ii n = ; grade iii n = ). at the months endpoint, ( %) patients died and ( %) patients had severe persistent disease. no death had been related to the tpe process. we describe one of the largest retrospective pediatric cohort updated to the last international recommendations. tpe in children is performed for specific and potentially refractory disease. it is feasible without a major risk of life threatening adverse events. compliance with ethics regulations: yes. yacine benhocine university hospital nedir mohamed, tizi-ouzou, algeria correspondence: yacine benhocine (yacine @yahoo.fr) ann. intensive care , (suppl ):f- rationale: although analysis of literature data shows that implantable chamber catheters (iccs) are less at risk of infectious complications than other central venous catheters, these complications can be serious, which may differ from ongoing treatments such as chemotherapy, and may lead to the removal of the implanted device. the literature on preventing these infections is quite disparate, as practices. purpose: to evaluate the incidence of infections, to identify responsible germs and to measure the impact of preventive measures. patients and methods: prospective, descriptive, mono-centric study, from january to january . all patients under the age of who have benefited from an implantable chamber catheter, whose insertion procedure is as follows: local anesthesia, surgical asepsis (polyvidone iodine) in an operating room, double disinfection, no antibiotic prophylaxis, routes used: subclavian ( %), internal jugular ( %) by anatomic registration. the main criteria of judgment are: the incidence of local and general infections, their time of onset, responsible microorganisms. statistical analysis used the statistical package for the social sciences software. results: patients were included, the average incidence density of early infection is . / day-catheters. the time of onset of infection is essentially between the nd and rd week post-exposure, of which % is general infection. ablation involved % of infected catheters. the causative organisms are mainly gram-positive cocci ( . %), gram-negative bacilli are less involved ( . %), with a significant number of candida infections ( %). discussion: higher incidence of data from the literature. to remedy this requires the implementation of additional hygiene measures: antiseptic showers preoperatively, chlorhexidine??, and practice changes: echo guidance, antibiotic prophylaxis or locks? second generation catheters? our practices are disparate especially since the recommendations specifically concerning the prevention of infectious risk associated with internationally published iccs are rare. conclusion: at the end of this work, our perspectives are to: update the procedure, highlight risk factors on which it is possible to act, the adhesion of the different staff to the protocols. compliance with ethics regulations: yes. rationale: the sepsis and septic shock pediatric guidelines advise to treat patients using care bundles. in the first hour, the «resuscitation bundle» contains an appropriate fluid resuscitation, a broad-spectrum antibiotics administration after blood cultures, and initiation of inotrope if needed. the objectives were to evaluate the resuscitation bundle compliance in a cohort of septic children with cardiovascular dysfunction, and to analyze the effect on severity and outcome in pediatric intensive care unit (picu). patients and methods: retrospective analysis of the diabact iii study. this study analyzed the care course of children with severe community-acquired bacterial infection, hospitalized in picus in france's west departments, between august and january . children with severe sepsis and cardiovascular dysfunction were retrospectively included. results: we included children of whom ( . %) had compliant bundled care. the severity scores at picu's admission were similar between groups (p = . for the prism score and . for the pelod ). there was the same proportion of fluid-refractory shock (p = . ), mechanical ventilation (p = . ), neurological dysfunction (p = . ) and cardiac arrest (p = . ). in the «resuscitation bundle compliant» group, . % died versus . % in the other group (p = . ). we highlighted a severity bias: the sickest patients were more likely to receive compliant bundled care. conclusion: in our cohort, the resuscitation bundle's compliance was low. we did not show some effect on morbidity nor mortality. however, this study helps understand the factors associated with resuscitation bundle's compliance. rationale: nosocomial infections with extended-spectrum β-lactamase (esbl) producing gram-negative bacilli (gnb) are an important cause of hospital morbidity and mortality. the objective of this study was to determine the incidence and risk factors of nosocomial esbl-producing gnb infections in a paediatric intensive care unit (picu). patients and methods: a prospective surveillance study was performed from january through march in a picu. all patients hospitalized for more than h were included. centers for disease control and prevention criteria were applied for the diagnosis of nosocomial infection. results: during the study period, patients (median age: ± days) were included. the average length of stay was ± days with a total of , days of hospitalization. newborns accounted for . % of patients. sixty-two per cent of patients were colonized with multi drug resistant gram-negative rods, on admission or during their stay in the picu. one hundred and nineteen bacterial infectious episodes were registered ( . / patient days). one hundred infectious episodes were caused by a gnb and ( . %) by esbls producing gnb with an incidence of . / patient days (bloodstream infections: episodes, ventilator acquired pneumonia: episodes). esbls producing gnb infection had a specific incidence of . per catheter-days, and . per mechanical ventilation-days. fifty-nine percent of patients infected with esbls producing gnb had a prior digestive colonization with a multidrug-resistant gnb. forty-one episodes ( %) occurred in patients with central venous catheters. klebsiella pneumoniae was the most frequently isolated bacteria ( . %). mortality in the esbls producing gnb group was high ( . %). associated factors of nosocomial esbls producing gnb infection were mechanical vrntilation (p < . ), central venous catheterization (p < . ) and colonization with multiple drug-resistant gram-negative bacteria (p < . ). conclusion: nosocomial esbl-producing gnb infection had an incidence of . per patient days in our unit and seems to increase the mortality rate. factors associated with this infection were identified. marie lemerle , aline schmidt , valérie thepot-seegers , achille kouatchet , valérie moal , mélina raimbault , corentin orvain , jean-francois augusto , julien demiselle chu angers, médecine intensive réanimation, angers, france; chu angers, maladie du sang, angers, france; chu angers-ico, angers, france; chu angers, pharmacie, angers, france; chu angers, labora-toire de biochimie, angers, france; chu angers, néphrologie dialyse transplantation, angers, france correspondence: marie lemerle (marielemerle@yahoo.fr) ann. intensive care , (suppl ):f- rationale: acute kidney injury (aki) is associated with high morbidity and mortality in the setting of tumor lysis syndrome (tls). thus, strategies aimed at preventing aki occurrence represent a major goal to improve prognosis of patients with tls. the role of hyperphosphatemia as a risk factor of tls has been poorly analyzed. the aim of this study was to study the association between hyperphosphatemia and aki, and to determine whether a cut-off value of phosphatemia or phosphatemia's variation was associated with aki development during tls. patients and methods: in this retrospective and monocentric study, we included all patients with tls and whithout aki at admission, admitted to hematology, nephrology and intensive care units of the university hospital of angers between / / and / / . results: one hundred and thirty tls episodes were identified in patients. aki developed during episodes of tls ( %). hospital mortality was much higher in aki patients ( . % versus . %, p = . ). phosphate maximal values ( . ± . versus . ± . ) and ldh maximal values ( . ± . versus . ± . ) were higher in tls with aki, before aki occurrence (p = . and p = . , respectively). we found no association between the other biological parameters of tls and aki (serum calcium, uric acid and potassium). after adjustment for cofounders, there was a strong association between a rise in phosphate level of . mmol/l (hr . ic % [ . - . ], p < . ), exposure to platinum salts (hr . ic % [ . - . ], p = . ) and increasing maximal ldh value (hr per ui/l increase . ic % [ . - . ], p = . ) with aki. conclusion: this study highlights the utmost importance of serum phosphate in the setting of tls: phosphate is an early relevant biomarker for the risk of aki development. further studies are needed to assess whether aggressive prophylactic treatment to control serum phosphate concentration, such as renal replacement therapy before aki onset, constitutes a valuable approach. compliance with ethics regulations: yes. retrospective cohort of patients admitted to the medical icu of university affiliated hospital after carts treatment between august and august . results: of the patients treated by carts in the haematology department, ( %) were subsequently admitted to icu. median age was [ . - . ] years, and ( . %) were female. carts were indicated for r/r lymphoma. the median time between carts injection and icu admission was [ . - . ] days. all patients had cytokine release syndrome (crs), and ( . %) developed car-related encephalopathy syndrome (cres). median sofa score and saps were [ - . ] and [ . - . ], respectively. four ( . %) patients had hypotension treated by fluid bolus (n = ) or vasopressors (n = ), and ( . %) had acuterespiratory failure requiring oxygen therapy (n = ) or mechanical ventilation (n = ). six ( . %) patients had neurological symptoms (impaired consciousness n = , confusion n = , transient aphasia n = ), of whom one developed refractory convulsive status epilepticus afterwards. all patients received broad spectrum antibiotics, of whom ( . %) had documented infections. six ( . %) patients received interleukin- inhibitor (single dose n = , multiple doses n = ), and ( . %) received intravenous dexamethasone. one patient died in the icu from septic shock. median icu and hospital length of stays were [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and [ . - . ] days, respectively. two ( . %) patients died from relapsing malignancy before hospital discharge. three months after icu admission, four ( . %) patients were alive in complete remission. conclusion: more than % of patients treated with carts required icu admission for the management of a crs or a cres. early icu admission, close collaboration between haematologists and intensivists, and prompt administration of appropriate therapy (il- inhibitor and/or dexamethasone) and supportive care resulted in a good prognosis. compliance with ethics regulations: yes. rationale: tisagenlecleucel (ctl ) is a chimeric antigen receptor t cell therapy that reprograms autologous t cells to target cd + leukemia cells, approved in the us since august and in the eu since august for children and young adult (< years old) with relapsed/refractory b-cell acute lymphoblastic leukemia (b-all). this study reports the experience of picu management of ctl toxicity in patients treated in robert-debré university hospitals. patients and methods: all patients (age < years old) treated by tisagenlecleucel infusions between march , and september , , included in sponsored-clinical trials or treated within the french compassionate program or with the commercial product, were retrospectively analyzed. results: twenty-four patients were infused and patients ( %) were managed in picu for stays. ( stays: n = and stays: n = ). median age at picu admission was . years old [ . ; . ] with a median delay after car-t cells infusions of days [ . ; ] . the median length of stay in picu was days [ . ; ] with a max at days. cytokine release syndrome (crs) was the main indication of picu hospitalization ( . %, n = ) with grade (n = ) and grade (n = ) according to american society for transplantation and cellular therapy (astct) consensus grading system and treated by corticosteroid (n = . ) and tocilizumab (n = , only one infusion). norepinephrine was the only vasopressor used. the median vaso-inotrope score (vis) for grade was [ . ; . ] with a maximum at . neurologic toxicity was observed in patients with a grade (status epilepticus) and grade (focal edema on neuroimaging with depressed level of consciousness) according to immune effector cell-associated neurotoxicity syndrome (icans) grading system from astct consensus. the status epilepticus was managed with anti-epileptic drugs without mechanical ventilation. the focal edema was related to hhv and toxoplasmosis encephalitis. evolution was positive with foscavir and ganciclovir and days of mechanical ventilation. one patient was hospitalized for septic shock secondary to gram-negative central line bloodstream infection in aplasia, with a vis score at . evolution was favorable with antibiotics and central line removal. no death in picu from severe tisagenlecleucel toxicity was observed since the beginning of the car-t cells program. conclusion: toxicity profile of tisagenlecleucel required frequent and early picu hospitalization after infusions for severe crs and icans management. compliance with ethics regulations: yes. rationale: car-t cell (chimeric antigen receptor t) therapy is a promising treatment in refractory acute lymphoid leukemia (all) and diffuse large b cell lymphoma (dlbcl). the main complication consists in a cytokine release syndrome (crs) leading to an inflammatory state that can be very severe with life-threatening organ failure. neurological toxicity is also reported. we aim to describe car-t cells-related complications in icu patients. patients and methods: this is a single-center prospective study conducted between july and august . all the patients who have received car-t cells and who required icu admission were included. crs grading was defined according to the most recent classification of the asbmt and neurological toxicity was assessed with the cartox scale. each admission is considered independent and therefore corresponds to one patient. results: admissions, representing patients ( men and women), were considered. the median age was years . twothirds of the patients have been diagnosed with dlbcl (n = , %) and one-third with all (n = , %), months [ - ] ago. they had received lines [ ] [ ] of chemotherapy and had a high tumor burden ( % of lymphomas classified stage iv). the majority of the patients was admitted because of hemodynamic failure (n = , %) or respiratory failure (n = , %), days [ ] [ ] [ ] [ ] [ ] after car-t cells infusion. sofa at admission was [ ] [ ] [ ] [ ] [ ] . all the patients presented at least one complication ( figure) , the most common being crs (n = , %) with a median grade of [ ] [ ] . neurological toxicity was reported in ( %) patients (worst grade at [ ] [ ] [ ] ). documented bacterial infection involved % of the patients and consisted in catheter-related infections for half of the cases. in the icu patients were managed with fluid resuscitation (n = , %) during the first day, vasopressors (n = , %) and broad spectrum antibiotics ( %). a single patient required mechanical ventilation and two patients underwent dialysis. tocilizumab (anti-il receptor) was given to patients ( % of crs) in a median time of . h [ . - . ] after icu admission. patients ( %) received corticosteroids. the median icu length of stay was . days [ ] [ ] [ ] [ ] . patients ( %) died in the icu and hospital mortality was %. the -fluorouracil ( -fu)-induced hyperammonemic encephalopathy is a rare but serious -fu adverse drug reaction, which could require the admission of patients in intensive care unit (icu). given the paucity of data regarding this -fu adverse drug reaction, we performed a retrospective national survey from the french pharmacovigilance database to better characterize -fu-induced hyperammonemic encephalopathy and its management. patients and methods: since the inception of the french pharmacovigilance database, we identified all patients that experienced -fu-induced encephalopathy. variables regarding epidemiology, characteristics, management and prognosis of these patients were collected and analyzed. results: from from to years-old, % of women) were included. overall mortality was % (n = ) and % (n = ) of patients were admitted in icu. the -fu-induced hyperammonemic encephalopathy started [ ] [ ] [ ] [ ] days after the onset of -fu infusion. the most common neurological disorders were consciousness impairment, confusion and seizures. abnormalities in ct scan, mri, electroencephalogram and lumbar puncture were found in %, %, % and % of the whole population respectively, similar in icu and non-icu patients. ammonemia was dosed in % of the whole population and in % of icu patients. hyperammonemia tended to be higher in icu than in non-icu patients ( [ - ] vs. [ - ] µmol/l, respectively, p = ns) and in patients with the lowest glasgow outcome scale, but was not different between survivors and non-survivors. among icu patients, % required mechanical ventilation and % anti-epileptic drugs administration. besides -fu discontinuation, lactulose intake, renal replacement therapy or ammonium chelators were used to decrease hyperammonemia in %, % and % of patients respectively. a complete neurological recovery was observed in up to % of icu and non-icu patients within a delay of [ - ] days. a dihydropyrimidine deshydrogenase (dpd) deficiency was found in % of tested patients. a -fu rechallenge was considered in % (n = ) of patients with complete neurological recovery, including a patient with a partial dpd deficiency, within a delay of [ - ] days after recovery. a -fu-induced hyperammonemic encephalopathy relapse was observed in % of patients with -fu rechallenge. no relapse was observed when -fu rechallenge was performed with a decreased -fu dosage. conclusion: we report the first national survey and the largest cohort of patients with -fu-induced hyperammonemic encephalopathy so far. this serious -fu adverse drug reaction must be known by intensivists, since more than half of patients are admitted in icu and specific treatments are available. compliance with ethics regulations: yes. immune related adverse events: a retrospective look into the future of oncology in the intensive care unit adrien joseph , annabelle stoclin , antoine vieillard-baron , guillaume geri , jean-marie michot rationale: immune checkpoint inhibitors (ici) represent a paradigmatic shift in oncology. with their new position as a mainstay in cancer treatment, new toxicities called immune related adverse events (iraes) have emerged. patients and methods: retrospective study including patients admitted in the icu within days after treatment with an ici in french hospitals. patients were classified into groups according to the reason for admission: irae, intercurrent adverse event (intae) or event related to tumor progression (tumprog). results: patients were admitted during the course of an ici treatment, including irae, intae and tumprog, with a significant increase between (n = ) and (n = patients, p for trend < . ). irae included pneumonitis, colitis, diabetes complications, hypophysitis, nephritis, myocarditis and cardiac disorders, hepatitis or allergic reaction and meningitis. the immune related nature of the complication was known before admission in only ( %) cases. mean age was (± ) years and % had a performance status of - . primary tumors were melanomas ( , %), non-small cell lung cancers ( , %) , urothelial carcinomas ( , %) and hodgkin lymphomas ( , %) . ici at the time of admission included anti-ctla ( , %), anti-pd /pdl ( , %) and anti-ctla /anti-pd combination in ( %) patients. mean duration of stay in the icu was . (± ) days. three patients required vasopressor therapy alone, with mechanical ventilation and one with extracorporeal membrane oxygenation. three patients required non-invasive ventilation and renal replacement therapy alone. six required only endocrine or electrolytic equilibration and others did not receive any form of organ support. icu mortality was %. compared with other admissions, anti-ctla or anti-ctla /anti-pd combination treatments were associated with irae diagnosis (or = . [ . - . ] , p = . for anti-ctla and . [ . - . ] for anti-ctla /anti-pd , p = . ) and so was the diagnosis of melanoma ( . [ . - . ] , p = . ). there was no difference in terms of icu and post-icu survival between irae (median post-icu survival months [ -na]), intae ( . [ . -na]) and ). six patients admitted for an irae were rechallenged with the same ici after icu discharge and achieved complete response. conclusion: we conducted the first study describing patients admitted in the icu for iraes. their specific and heterogeneous profile, along with the expected increase in the number of admissions, underlines the need for an in-depth knowledge for icu physicians in order to take part in the multidisciplinary care required by these patients. compliance with ethics regulations: yes. rationale: patients with advanced-stage non-small-cell lung cancer have high mortality rates in the intensive care unit (icu). in this context, acute respiratory failure due to cancer involvement is the worst situation. in the last two decades, targeted therapies have changed the prognostic of patients with lung cancer outside the icu. unlike cytotoxic chemotherapy, the fast efficacy of targeted therapies led some intensivists to use them as rescue therapy for icu patients. we sought to investigate the outcomes of patients with lung cancer involvement responsible for acute respiratory failure and who received tyrosine kinase inhibitor during icu stay. patients and methods: we performed a national multicentric retrospective study with the participation of the grrroh (groupe de recherche en réanimation respiratoire en onco-hématologie). all patients with non-small-cell lung cancer admitted to the icu for acute respiratory failure between and were included in the study if a tyrosine kinase inhibitor was initiated during icu stay. cases were identified using hospital-pharmacies records. we collected demographic and clinical data in icu charts. vital status was assessed at the time of study completion (august ). the primary outcome was overall survival days after icu admission. results: twenty-nine patients (age: ± years old) admitted to a total of icus throughout france were included. seventeen patients ( %) were nonsmoker. the most frequent histological type was adenocarcinoma (n = , %) and a majority had metastatic cancer (n = , %). epithelial growth factor receptor mutation was the most common oncologic driver identified (n = , %). during the icu stay, ( %) patients required invasive mechanical ventilation, ( %) catecholamine infusion, ( %) renal replacement therapy and one ( %) extracorporeal membrane oxygenation. in addition to tyrosine kinase inhibitor, ( %) patients received steroids (beyond . mg/kg/day) and ( %) cytotoxic chemotherapy during icu stay. seventeen patients ( %) were discharged alive from icu and ( %) were still alive after days (see kaplan-meier curve figure) . moreover, patients ( %) were alive one year after icu discharge. conclusion: despite a small sample size this study showed that, in the context of lung cancer involvement responsible for acute respiratory failure, the use of tyrosine kinase inhibitor should not be refrained in patients with severe condition in icu. compliance with ethics regulations: yes. rationale: acute respiratory failure is the leading reason for intensive care unit (icu) admission in immunocompromised patients and the need for invasive mechanical ventilation has become a major clinical end-point in randomized controlled trials (rct). however, data are lacking on whether intubation is an objective criteria that is used unbiasedly across centers. this study explores how this outcome varies across icus. patients and methods: hierarchical models and permutation procedures for testing multiple random effects were applied on both data from observational cohort (the trial-oh study: patients, icus) and randomized controlled trial (the high trial: patients, icus) to characterize icu variation in intubation risk across centers. results: the crude intubation rate varied across icus from % to % in the observational cohort and from to % in the rct. this center effect on the mean icu intubation rate was statistically significant, even after adjustment on individual patient characteristics (observational cohort: p-value = . , median or . [ . - . ]; rct: p-value: . , median or . [ . - . ]). two icu-level characteristics were associated with intubation risk (the annual rate of intubation procedure per center and the time from respiratory symptoms to icu admission) and could partly explain this center effect. in the rct that controlled for the use of high-flow oxygen therapy, we did not find significant variation in the effect of oxygenation strategy on intubation risk across centers, despite a significant variation in the need for invasive mechanical ventilation. conclusion: invasive mechanical ventilation has become an important endpoint in immunocompromised patients with acute respiratory failure. however, we found significant variation in intubation risk across icu in both an observational cohort and a randomized controlled trial. our results highlight the need to take into account center effect in analysis because it could be an important confounder. reasons for heterogeneity are various (case-mix differences, center practices). this gives opportunities to future improvement in care management and study design. compliance with ethics regulations: yes. rationale: influenza virus (iv) infection is a major cause of ards that has been the focus of attention since the pandemic h n (h n pdm ) iv. although iv-mediated damage of the airway has beenextensively studied emphasizing specificity compared to other causes of ards, the impact of iv infection on the prognosis of ards patients, compared to the other causes of ards, has been few assessed. patients and methods: systematic detection of iv in times of epidemic using rt-pcr in respiratory specimen is routine practice in our icu along with prospective data collection of patients admitted to our icu for ards with pao /fio ratio ≤ mmhg. all patients received lung-protective ventilation, the sequential organ failure assessment (sofa) score was calculated on the first days of mechanical ventilation. the primary endpoint compared the -day survival from the diagnosis of ards between patients with and without iv infection. results: from october, to may, , patients (pts) [median saps ii score = ( - ); age years ( - ); pao / fio ≤ mmhg, n = ( %)] were admitted to our icu for ards with pao /fio ratio ≤ mm/hg, including pts ( %) with iv infection (h n pdm iv a, n = ; h n a virus, n = ; b virus, n = ; associated bacteria, n = ). other main causes of ards were bacterial pneumonia without iv ( %), aspiration ( %), non-pulmonary sepsis ( %). ( %) received prone positioning, and ( %) extra-corporeal membrane oxygenation. the overall mortality rate at day- for the entire population was % ( pts ( %) with iv infection versus pts ( %) without iv infection, p = . ). kaplan-meier survival curves showed that survival was significantly higher in patients with iv infection than in those without iv infection. iv infection remained independently associated with a better prognosis at day- when entered as dichotomous variable (iv infection, yes/no) (adjusted hazard ratio (hr) = . , % ci . - . , p = . ) and when iv infection only was distinguished from other causes of ards including mixed infection iv plus bacteria (adjusted hr = . , % ci . - . , p = . ). of note, within the first days of mechanical ventilation, non-pulmonary sofa scores were significantly lower in iv patients although similar pulmonary sofa scores. conclusion: our results suggest that patients with iv related ards have less severe non-pulmonary organ dysfunctions than those with ards from other and a lower mortality at day- despite similar ards severity. compliance with ethics regulations: yes. rationale: acute respiratory distress syndrome (ards) remains frequent in intensive care unit (icu) with % to % mortality. according to joint theater trauma system, ards occurs among % of war casualties: direct lung trauma, blast lesions, burn, massive transfusion and systemic inflammatory response syndrome lead to ards development. however, there is no data reporting ards among french evacuated casualties from forward environment. our study's aim is to describe ards incidence and its severity concerning medical evacuations from war theater. patients and methods: this is an observational retrospective multicentric study analyzing all evacuated patient from war theater and admitted in icu. all patients developing ards according to berlin definition have been included. study has been approved by local ethic committee. primary study endpoint was ards developing. second study endpoints were ards severity, duration of invasive ventilation, ards treatments, icu length of stay and mortality. results: patients have been admitted in icu between and . have been excluded. a total of patients have been analyzed. % (n = ) were military aged ( - ) years. % (n = ) developed ards. we found % (n = ) war casualties, % (n = ) trauma not related to war and % (n = ) medical patients. among severe trauma, median iss was ( - ), ais thorax ( ) ( ) ( ) , and % benefited from surgery on forward environment and % (n = ) received massive transfusion. % (n = ) suffered from mild ards, % (n = ) moderate ards and % (n = ) severe ards. evacuation time was ( - ) h. at admission in icu, pao /fio ratio was ( - ) (fig. ). all patients were intubated. ards treatments used were curarization ( %, n = ), prone position ( %, n = ), inhaled nitric oxide (noi) ( %, n = ), almitrine ( %, n = ) and extracorporeal life support (ecls) ( %, n = ). invasive ventilation duration was ( - ) days, length of stay ( - ) days, and -month mortality % (n = ). conclusion: according to our study, ards among french evacuated patients from war theaters remains frequent: it occurs on % among icu admitted patients. % suffer from severe ards with % global mortality. those datas are consistent with us studies. also, we wonder if we must adapt our treatment capacities on forward environment for the most severe patients. in us army, a specialized team (acute lung rescue team) is trained to care the most hypoxemic war casualties with more treatment options as noi, ecls. compliance with ethics regulations: yes. rationale : we recently reported that septic shock patients with pneumonia exhibit a high risk of icu-acquired pneumonia, suggesting that a primary pulmonary insult may drive profound alterations in lung defence towards secondary infections ( ) . given their importance in lung immune surveillance, alveolar macrophages (am) are likely to play a pivotal role in this setting. the objective of this experimental study is to address the impact of primary pulmonary or non-pulmonary infectious insults on lung immunity. patients and methods: we established relevant double-hit experimental models that mimic common clinical situations. c bl/ j mice were first subjected either to polymicrobial peritonitis induced by caecal ligation and puncture (clp), or to bacterial pneumonia induced by intra-tracheal instillation of staphylococcus aureus or escherichia coli. respective control mice were subjected to sham laparotomy or intratracheal instillation of phosphate-buffered saline. seven days later, mice that survived the primary insult were subjected to intra-tracheal instillation of pseudomonas aeruginosa (pao strain). we assessed survival and pulmonary bacterial clearance of post-septic animals subjected to p. aeruginosa pneumonia, as well as the distribution and functional changes in alveolar macrophages. results: when compared to sham-operated mice, post-clp animals exhibited increased susceptibility to secondary p. aeruginosa pneumonia as demonstrated by defective lung bacterial clearance and increased mortality rate ( % vs. %, p < . ). in contrast, all postpneumonia mice survived and even exhibited improved bacterial clearance as compared to their control counterparts. when addressing whole-lung immune cell distribution at the time of second hit (day ), amounts of am were decreased in post-clp mice while preserved or even increased in post-pneumonia mice. antigen-presenting functions of am appeared similar in all conditions. percentages of apoptotic (annexinv + ) and necrotic ( -aad + ) am were comparable at day and day after the first hit. interestingly, both ly c high and ly c low monocytes were sustainably increased in the lungs of post-clp mice, while only transiently expanded following pneumonia, suggesting that differences in am counts could be related to modulated turnover from precursor monocytes. conclusion: using clinically relevant double-hit experimental models, a primary pulmonary infection conferred resistance to secondary bacterial pneumonia. ongoing investigations are aimed at addressing the antibacterial am functions, as well as the turnover-driving mechanisms.compliance with ethics regulations: yes. rationale: little is known on the role of exit-site signs in predicting intravascular catheter infections. the current study aimed to describe the association between local signs at the exit-site and catheter-related bloodstream infection (crbsi), which factors substantially influenced local signs and which clinical conditions may predict crb-sis if inflammation at insertion site is present. patients and methods: we used individual data from multicenter randomized-controlled trials in intensive care units (icus) that evaluated various prevention strategies regarding colonization and crbsi in central venous and arterial catheters. we used univariate and multivariate logistic regression stratifying by center in order to identify variables associated with redness, pain, non-purulent discharge, purulent discharge and ≥ local sign and subsequently evaluate the association between crbsi and local signs. moreover, weevaluated the role of thedifferent local signs for developing crbsi in subgroups of clinically relevant conditions. results: a total of patients, , catheters ( , catheterdays) and crbsi ( . %) from icus withdescribed local signs were included. redness, pain, non-purulent discharge, purulent discharge and ≥ local signs at removal were observed in ( . %), ( . %), ( . %), ( . %) and ( . %) episodes, respectively. the sensitivity of ≥ local sign for crbsi was by . %, whereas the highest specificities were observed for pain ( . %) and purulent discharge ( . %). positive predictive value (ppv) was low for redness ( %), pain ( %), non-purulent discharge ( %) and ≥ local sign ( %), but increased for purulent discharge ( . %). negative predictive values were high for all local signs. after adjusting on confounders, crbsi was associated with redness, non-purulent discharge, purulent discharge and ≥ local sign (fig. ). conditions independently associated with ≥ local sign were age ≤ years old (or . , % ci . - . , p < . ), sofa score (sofa < or . , % ci . - . , p < . ), non-immunosuppression (or . , % ci . - . , p < . ), catheter maintenance > days (or . , % ci . - . , p < . ) and insertion site (or for subclavian site . , % ci . - . , p < . ). however, the presence of ≥ local sign was more predictive for crbsi in the first days of catheter maintenance (or . , % ci . - . vs. > catheter-days or . , % ci . - . , p heterogeneity = . ). conclusion: this post hoc analysis showed that local signs were related to crbsis in the icu. local signs were independently associated with specific patient's and catheter's conditions. in the first days of catheter maintenance, local signs were predictive for crbsi. compliance with ethics regulations: yes. rationale: pneumococcal meningitis (pm) is the leading cause of bacterial meningitis in adult patients requiring icu admission and is associated with a high case fatality rate (cfr), ranging from to more than % ( ) ( ) ( ) . patients with pm may develop sepsis or septic shock that may impact management and outcomes. we aim to describe the epidemiology and outcomes of pm associated with sepsis in adult patients in france. we analysed the occurrence of pm with sepsis from to in adult patients, using the national french hospital database pmsi (programme de médicalisation des systèmes d'information). for all analyses, only the first hospital admission was considered. cases were identified using a combination of a diagnosis code for pm plus a diagnosis code for sepsis (either a code for organ failure or a procedure code for organ support). data recorded included comorbidities ( ), characteristics of the hospital stay, severity of the patients including major intracranial complications and characteristics of the infection. costs and endpoints were determined at the end of all the hospital stays related to the first admission for pm with sepsis. standardized incidence, hospital mortality, and cfr were estimated. temporal trends were assessed using cochran armitage tests of trends and linear trend analyses. results: a total of pm with sepsis aged ≥ years were hospitalized in france during - . the incidence of pm decreased from . to . per m inhabitants (p < . ) (fig. ) . most of them came from home ( %), were admitted in an academic institution ( %) and benefited from icu ( %). their median age was [ ; ] years. twothird of them had at least one comorbidity. the initial neurological presentations included coma ( %), focal signs ( %), seizures ( %) and brain stem involvements ( %). the saps ii score was [ ; ] points. the main neurological complications were cerebrovascular complications ( %), cerebral abscess ( %) and hydrocephaly ( %). pm was associated with pneumococcal septicaemia or pneumococcal pneumonia in % and % of cases respectively. the length of icu and hospital stays were [ ; ] and [ ; ] days respectively and only icu length of stay decreased over time (p < . ). the prognosis was poor since only . % of the patients were discharged to home. indeed, . % of them died and % were transferred to rehabilitation units. no temporal trends could be observed for these outcomes. the average hospital costs per case were , € [ . ; . ] . conclusion: pm with sepsis in adult in france remained a real burden associated with a high mortality rate, and disability. compliance with ethics regulations: na. rationale: mucormycosis is an emerging fungal infection, especially in patients with hematological malignancies. although this infection may lead to multi organ failure, no study has been dedicated to critically ill patients with hematological malignancy. the primary objective was to assess outcome in this setting. the secondary objective was to assess prognostic factors. patients and methods: this retrospective cohort study was performed in icus. critically ill adult patients with hematological malignancies and mucormycosis were included between and . mucormycosiswas classified as "probable"or "proven" regarding eortc criteria. variables are reported as median [iqr] or number (%). adjusted analysis was performed using cox model. results: twenty-six patients were included with a median age of years [iqr, . acute leukemia was the most frequent underlying disease (n = , %). nine patients ( %) were allogeneic stem cell transplantation (sct) recipients. nineteen patients ( %) had neutropenia and patients ( %) had received steroids. the main reason for admission was acute respiratory failure (n = , %) followed by shock (n = , %). the median sofa score at admission was [iqr, - ] points. only patients ( %) had received prior anti-fungal prophylaxis effective against mucorales. mucormycosis was "proven" in patients and "probable" in patients. diagnosis was made by histopathologic examination in patients, direct microscopy or culture in , and polymerase chain reaction in . rhizopus and mucor were the most frequent documented species. seven patients ( %) had concurrent aspergillus infection. mucormycosis was diagnosed day [− to + ] after icu admission. ten patients ( %) had pulmonary involvement whereas five patients ( %) had rhino-cerebral involvement. infection was disseminated in eight patients ( %). twenty-two patients ( %) were treated with liposomal amphotericin b. twelve patients ( %) received antifungal combination including posaconazole in . eight patients ( %) underwent curative surgery. multiple organ failure was frequent, patients ( %) requiring invasive mechanical ventilation (imv), ( %) vasopressors, and ( %) renal replacement therapy. icu and hospital mortality rates were % and %, respectively. only two patients were alive at day . three variables were associated with mortality in a cox model including allogeneic sct . ]; figure), sofa score (hr . [ % ic . - . ]) and dual therapy (hr . [ % ic . - . ]) (fig. ) . conclusion: mucormycosis is associated with a high mortality rate in patients with hematological malignancies, especially in allogeneic sct recipients. futility of icu management in these patients is to be considered and strategies aiming to improve these patients' outcome are urgently needed. compliance with ethics regulations: yes. rationale: sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. several mediators, alone or in combination, were proposed to characterize individual response, but none was proven to have good external validity. the aim of this work was to establish whether some combinations are linked to clinical phenotypes in patients with presumed sepsis, using the data collected in the captain multicenter cohort which methods and first results were previously published (parlato, icm ). patients and methods: patients were prospectively included at the time of sepsis criteria, ( %) of whom with a secondary confirmed infection. community acquired pneumonia was causal in % of infections. saps score = points [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , age = years , male sex = %. patients were followed for more than days, in whom usual icu clinical and biological parameters were collected, as well as plasma biomarkers and leucocyte associated rnas. patients were clinically classified according to their acute severity (sofa score, serum lactate), confirmed initial infection, outcome (secondary infection occurrence, icu survival). non-supervised principal component analysis of the maximal values of biomarkers assessed on first days of sepsis, and varimax rotation technique of the selected components using sas software. results: patients, med sofa day = pts, med serum lactates day = . meq/l, bacterial infection = ( %), enterobacteriaceae infection = ( %), vap and/or bacteremia after day = ( %), alive at icu d/c = ( %). five components explain % of the variance of the biomarkers. the first component ( % of the variance) was not linked to the clinical predetermined phenotypes. the second component ( % of the variance) was principally made of hla-dr rna, cd rna and cx cr rna, and linked to a lower initial severity (r = − . , p = . ), a less frequent confirmation of initial infection (p = . ), a lower occurrence of pneumonia or bacteremia (p = . ) or death (p = . ). conclusion: in our cohort, using non supervised analysis, we could separate a biomarker association linked to lower initial severity, lower rate of a bacterial cause to sepsis, and better outcome. the markers found are among those which are regularly considered as describers of the peripheral alteration of the immune system observed during sepsis (pachot, ccm ; friggeri, cc ; peronnet icm ) . compliance with ethics regulations: yes. ( ) compared a standard of care to a procalcitonin (pct) oriented use of antimicrobials for sepsis in icus. serial blood samples were biobanked in / icus ( / patients enrolled for pro-adrenomedullin (proadm) and pct concentrations). patients and methods: the aim of the study was to evaluate the respective impact of serial pct and proadm measurements in predicting relapse or superinfection and death on day *. relapse was defined as the growth of one or more of the initial causative bacterial strains (i.e., same genus, species) from a second sample taken from the same infection site at h or more after stopping of antibiotics, combined with clinical signs or symptoms of infection. superinfection was defined as the isolation from the same or another site of one or more pathogens different from that identified during the first infectious episode, together with clinical signs or symptoms of infection [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] points at amission, medical admission: ( %), immunocompromised: ( %), on mechanical ventilation ( %), pct and proadm at inclusion were [ . - . ] ng/ml and . [ . - . ] nm/l respectively. ( %) patients developed a first episode of recurrence or supereinfection after a median delay of days [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and ( %) died before d . the hr maximization process proposed an optimal cut point of ng/ml for pct and nm/l for pro adm to predict d death. in the multivariate cox model, both pct and proadm were associated with death but not with relapse or superinfection (table ) . conclusion: conclusion: both serial measurements of pct and proadm are independent predictors of death in patients treated for sepsis in icu. our study confirmed the use of nm/l as a good prognosis cut point for proadm. . compliance with ethics regulations: yes. rationale: the performance of serum ( - )-β-d-glucan (bdg) and its evolution to predict the occurrence of invasive fungal infection (ifi) in a high risk non immunocompromized population remains to be determined ( ). in a post hoc analysis of the empiricus randomized clinical trial ( ), we aimed to assess the prognostic value of repeated measures of bdg on the occurrence of invasive fungal infections. patients and methods: non-neutropenic, non-transplanted, critically ill patients with icu-acquired sepsis, multiple candida colonization, multiple organ failure, exposed to broad-spectrum antibacterial agents, and enrolled between july and february in french icus were included. bdg were collected in icu at day , , , and after inclusion. a value time of more than pg/ ml, pg/ml and an increase by more than % from the previous measurement (threshold of measurement error) were assessed at baseline and overtime. for that purpose, we conducted cause specific hazard models with death as a competing risk. we also planned subgroup analyses on the placebo and the micafungin groups. cumulative risk (cumrisk) of ifi at day were derived from models. [ . ; . ] ). neither a bdg > pg/ml, nor an increase by % of bdg over time were associated with the occurrence of ifi. similar results were found in the placebo subgroup. conclusion: among high risk patients, a first measurement of bdg over pg/ml was highly associated with the occurrence of ifi. neither a cut-off of pg/ml, nor repeated measurements of bdg over time seemed to be useful to predict the occurrence of ifi. the cumulative risk of ifi in the placebo group if bdg > pg/ml is . % questioning about the potential interest of empirical therapy in this subgroup. compliance with ethics regulations: yes. rationale: since the sepsis- conference, the distinction between sepsis and septic shock is based on blood lactate value. septic shock may be encountered in the pre-hospital setting. in order to reduce the mortality, the precocity of treatments implementation has been emphasized, particularly early antibiotic administration. prior antibiotic administration, and blood culture drawing must be performed. the aim of this survey was to clarify the capabilities of french prehospital emergency service (pems) to measure blood lactate and to draw blood culture prior to hospital admission for septic shock. patients and methods: we performed an electronic survey of auto-questions addressed to the deputy chair of the french pems in . results: sixty pems ( %) participated in the survey. twenty-five percent are able to measure blood lactate and % are able to draw blood culture in the prehospital setting. ninety-five percent declared lactate measurement is helpful in assessing severity. ninety percent claimed that the lactate value influences the hospital facility, emergency department vs. intensive care unit. twenty-eight percent believe that the impossibility to draw blood culture precludes prehospital antibiotic administration. sixty-three percent estimate that a protocol for septic shock management would be beneficial. conclusion: few french pems are able to measure lactate and draw blood culture in the prehospital setting. the impact of blood lactate measurement and blood culture drawing by pems on septic shock outcome requires further studies. compliance with ethics regulations: yes. rationale: head injury is a common cause of morbidity and mortality in the first four decades of life, accounting for approximately , annual hospital admissions in the united kingdom. the majority of patients recover without intervention, however some may develop a long-term disability or even die. the early detection of pathology is therefore absolutely critical in determining patients' prognosis, helping to provide appropriate timely management. the national institute for health and care excellence (nice) adult head injury guidelines, recommend that head injuries with specific risk factors should have a ct scan within h of risk factors being identified. furthermore the provisional report should be made available within h of the scan. this audit assessed the compliance of staff to the nice adult head injury guidelines. patients and methods: the previous adult ct head scans, requested due to head injury, from the emergency department (ed) at london north west healthcare nhs trust were analysed for compliance to the nice guidelines. the standards measured were: ( ) time from request of scan to completion of scan should be within h; ( ) time from completion of scan to publication of provisional report should be within h. the locally agreed target for both standards was %. results: on review of the ct scans, ( %) were completed within h of request. from the scans ( %) not completed within the hour, were due to porter unavailability, due to an uncooperative patient and the remaining reasons were not clear from documentation. following completion of the scan, scans ( %) were provisionally reported within h. conclusion: this study highlighted a good compliance by hospital staff in ensuring patients with head injuries are managed appropriately, following detection of risk factors indicating a ct head scan. having said that, the locally agreed targets were just short of being met. one factor resulting in delayed scans was porter availability. an intervention recently introduced is the use of the "e-portering" application, which will endeavour to save time for referrers requesting porters and allow patient tracking. it is also worth educating porters, via email bulletins, on the importance of priority scans, such as ct head following injury. furthermore, the findings of the audit were relayed to the radiology department to help improve reporting times and to the ed to re-emphasize prompt requesting of ct head scans when clinically indicated. compliance with ethics regulations: yes. rationale: continuous insufflation of oxygen (cio) performed with specific endotracheal tube during cardiopulmonary resuscitation (cpr) is as effective as intermittent ventilation on endotracheal tube. experimental data suggest that cio improves the efficacy of external cardiac massage and reduces gastric dilatation. as endotracheal intubation is a cause of cpr interruption and requires skilled staff, a specific device has been developed to perform cio without intubation. this device has been implemented progressively in our fire department since . we evaluated this practice. patients and methods: longitudinal study comparing the patients with out-of-hospital cardiac arrest managed by our fire department with cio or bag-valve ventilation between january and april . patients who received mechanical chest compression were excluded. the main outcome was hospital survival. secondary outcomes were the return of spontaneous circulation (rosc) and cpr quality. univariate and multivariate analysis was performed in the whole cohort and in the sub-groups of patient with shockable and non-shockable rhythms to take into account factors associated with survival (shockable rhythm, witness, age). results: among the patients included, have been ventilated with cio and with valve-bag. the mortality was similar in the two groups (cio: . % valve-bag: . % p . ). mortality and rosc were not associated with cio in the multivariate analysis (odds ratio or . %-confidence interval ci [ . - . ] and . [ . - . ], respectively). cpr quality was better with cio than with valve-bag regarding cpr fraction (ratio of duration of chest compressions on total duration of cpr, versus % p < . ) and adequacy to the guidelines of the rhythm and depth of chest compressions ( % vs % p < . and % vs % p < . , respectively). in both subgroups of patients, cpr quality was still better with cio than with valve-bag. in the subgroup of patients with shockable rhythm, univariate analysis showed a lower mortality among the patients with cio than among the patients with valve-bag ( . % vs . % p < . ) but this difference was not confirmed by the multivariate analysis (or . ci [ . - . ], p . ). conclusion: cio without intubation is associated with an improvement of cpr quality but neither with mortality nor return of spontaneous circulation in case of out-of-hospital cardiac arrest. compliance with ethics regulations: yes. rationale: cardiovascular accidents are a leading cause of death. a cardiopulmonary resuscitation (cpr) of quality has well shown that can reduce the mortality; despite this, survival rate has not changed significantly during last years. the aim of this study is to test a new wearable glove to provide lay people with instructions during out-ofhospital cpr. patients and methods: we performed a blinded, controlled trial on an electronic mannequin ambuman to test the performance of adult volunteers, non-healthcare professionals performing a simulated cpr both, without and with glove, following the glove instructions. the group without glove, also called "no-glove" is intended as control group. each compression performed on the electronic mannequin ambuman was recorded by a connected laptop computer, drawing a depth frequency curve over the time. primary outcome was to compare the accuracy of the two simulated cpr sessions in terms of depth and frequency of chest compressions performed by the same lay volunteers. secondary outcome was to compare the decay of performance and percentage of time in which the candidate performed accurate cpr. finally, the participants were asked if the glove was useful for cpr maneuvers. the difference between the two groups in regard to change in chest compression depth over time due to fatigue, defined as decay were also analyzed. results: chest compressions were included: in control group, in glove group (table ) . mean depth of compression in the control group was . mm versus . mm in the glove-group (p = . ). compressions with an appropriate depth were not statistically different ( . % vs . %, p = . ). mean frequency of compressions in the group with glove was . rpm vs . rpm in the control group (p < . ). the percentage of compression cycles with an appropriate rate (> rpm) was . % in the group with the glove versus % in the control group, with an observed difference of . % between the two groups, which was statistically significant (p < . ,ci = %). a mean reduction over time of compressions depth of . mm (sd . ) was observed in the control group versus a mean reduction of . mm in the group wearing the glove (sd . ), but this mean difference in the decay of compressions delivery was not statistically significant (f-ratio = . , ss = . , df = , ms = . , p = . ). conclusion: the visual and acoustic feedbacks provided by the device were useful in dictating the correct rhythm for non-healthcare professionals, translating in a significantly more accurate cpr. compliance with ethics regulations: yes. rationale: neuroprognostication after cardiac arrest (ca) is a crucial issue and current guidelines recommend delayed multimodal approach. we aimed to describe reasons for death in a prospective cohort of ca patients and evaluate the diagnostic accuracy of early combined neurological prognostication tools such as automated pupillometry (ap), continuous amplitude electroencephalography (aeeg) and cardiac arrest hospital prognosis (cahp) score performed h after return of spontaneous circulation (rosc). we set up a monocentric prospective cohort of adult ca patients admitted in icu after sustained rosc and collected data according to utstein style recommendations. reasons for death were described under recently proposed classification: withdrawal of life-sustaining therapies (wlst) for neurological reasons, wlst due to comorbidities, refractory shock or recurrence of sudden ca or respiratory failure. for patients who kept abnormal neurologic state after rosc with glasgow coma scale < , we analysed accuracy of early neuroprognostication tools (ap, aeeg and cahp score) to predict poor neurological outcome, i.e. cerebral performance category (cpc) > at hospital discharge. results: patients were admitted after sustained rosc from ca during the period ( . . to . . ). in-hospital mortality was %. neurological wlst was the first reason for death ( %). exhaustive early neuroprognostication with ap, aeeg and cahp score was available for patients. among them, poor neurological outcome at hospital discharge (cpc > ) was observed for patients ( % (fig. ) . this strategy would falsely misclassificate % of patients in a good neurologic outcome category. other survivors ( %) should then be investigated with further classical delayed neuroprognostication tools. compliance with ethics regulations: yes. rationale: management delay is one of the determining factors in the assessment of emergency department quality of care. asking for a specialized advice seems to increase the time of delay. our study aimed at measuring the delays in obtaining specialized advice and identify their major causes. patients and methods: we conducted a prospective study over the period of month. we included all adult patients presenting to the emergency department who required specialized advice. data of all patients was collected. waiting times and influencing factors were studied. results: a total of patients were included. the main reason for calling for a specialized advice was to ask for a department transfer in % of cases. the time of the day when specialized advice was solicited (n (%)): in the morning ( ); in the afternoon ( ); in the evening ( ). the main solicited specialties were (n (%)): visceral surgery ( ), trauma medicine ( ), cardiology ( ), urology ( ), and pulmonology ( ). the average waiting time between calling for and getting the specialized advice was ± min. seventy-five percent of the specialized advice was obtained within h. the causes of the delay were (n (%)): physician busy in the operating room ( ), unreachable physician ( ), physician in the outpatient clinics ( ). the impact of the waiting time was (n (%)): conflict ( ), worsening patient state ( ). the average time between calling for the specialized advice and reaching a management decision was ± min. conclusion: the increasing length of stay of patients in the ed is strongly correlated to the delay in obtaining specialized advice. the implementation of a strategy to reduce the waiting time is necessary to avoid overcrowding the emergency departments and provide optimal care. compliance with ethics regulations: yes. rationale: hypnoanalgesia has been used since few years to reduce icu-patients physical and psychological discomfort during invasive procedures. however, feasibility of overall well-being management of intubated patients with hypnosis has not been described. patients and methods: we report here the hypnotic accompaniment of a -year old patient without significant medical history hospitalized in our icu for a severe gbs during months. the gbs was diagnosed by electrophysiological study and immunologic markers. patient had nearly complete paralysis of all extremities, but no facial or bulbar muscles. he received mechanical ventilation during days, including weaning time. tracheotomy was performed at day . sedative drugs were stopped days after intubation. hypnosis sessions were startedvery early after intubation by one of our trained intensivist. eight hypnotic sessions of hypnoanalgesia or hypnotherapy were performed after approval of the patient and his parents. time distribution is reported in fig. . first and second sessions were performed in order to induce relaxation and reduce anxiety. following sessions were dedicated to: ) decrease pain intensity (initially neuropathic, then induced by physiotherapy), ) attenuate the negative perception of paralysis, ) reduce the discomfort of tracheotomy ) promote the belief in healing ) facilitate swallowing exercises. furthermore the patient was quickly trained to use self-hypnosis in order to dissociate him from pain, anxiety and icu pollutions. results: feasibility of hypnosis was judged satisfactory by the operating physician, despite mechanical ventilation. after extubation, final debriefing with the patient indicates that the most efficient sessions were those focused on anxiety disorders (using the suggestion of a safe place) and suggestions of mobility (using a mangas metaphor). the patient reported very positive perception of hypnosis use. he explained that self-hypnosis was effective to reduce many discomfort. he used it frequently (generally twice a day) for a puff of anxiety or before enoxaparin injection. our observation suggests that hypnosis seems feasible in icu-awake patients and may be an interesting way to improve their icu lived experience in combination with validated measures. further investigations are needed to evaluate its effects on post-traumaticstress disorder. compliance with ethics regulations: yes. rationale: there is little medical reference for hypnosis in the intensive care field. closed specialties such as anesthesia, emergency medicine can help and refer to hypnosis for certain technical procedures. objective: to propose landmarks for a successful implementation of hypnosis by intensivists within the intensive care unit. patients and methods: this monocentric prospective observational study was performed from february to june in the -bed medical icu of brest university hospital. collected data were: characteristics of patients and hypnosis sessions performed, demographic data, physiological parameters (heart and respiratory rates) and objective and subjective evaluation of hypnosis sessions quality. results: patients were included (mean age . ± years, saps ii . ± points). hypnosis sessions were performed, of which / under mechanical ventilation. patterns of hypnosis sessions were: anxiety/comfort ( %), during a technical procedure ( %): toe, cvc placement, thoracic drainage, upper digestive or bronchial endoscopy), initiation of noninvasive ventilation or before intubation. most of time, the hypnotic trance was permitted by formal hypnosis techniques with travel and nature themes suggestion. efficacy was qualitatively assessed and rated as "total effectiveness" for % of sessions. qualitative evaluation by hypnotherapist, technical operator and observers was respectively . ± . , . ± . and ± / . heart rate decreased from ± to ± bpm and respiratory rate/min decreased from ± to . ± rpm during sessions. discussion: after a meeting, the healthcare team carried out a brainstorming to propose hypnosis in our unit. several difficulties were observed to explain implementation failures such as: finding competent patient, respiratory assistance, difficult communication, noisy environment, many nursing care, unexpected emergencies, etc.…). this experience allowed writing a vademecum to perform hypnosis in intensive care. our aims are to get more trained caregivers and to integrate hypnosis during our postresuscitation consultation, especially for post-traumatic stress. conclusion: hypnotic tools can facilitate technical procedures and improve patients' and caregivers' quality of life within the icu. compliance with ethics regulations: yes. effect of a musical intervention during central venous catheterization in an intensive care unit: the music cat prospective randomized pilot study sophie jacquier, brice sauvage, gregoire muller, thierry boulain, mai-anh nay chr, orléans, france correspondence: sophie jacquier (sophie.jacquier@chr-orleans.fr) ann. intensive care , (suppl ):f- rationale: evaluate the effect of a musical intervention on patient anxiety during a central venous access or a dialysis catheter implantation in an intensive care unit. patients and methods: the music cat study was a prospective, single-centre, controlled, open-label, two-arm randomized trial, conducted from february to february . central venous catheterization with musical intervention was compared to standard care, i.e., the usual procedure of central venous catheterization without listening to music. eligible patients had to be able to hear, understand explanations and consent. randomisation was stratified according to ventilation type (mechanical ventilation or not) and catheter site (superior vena cava or femoral vein). the music care ® (paris, france) application was used to make the patients listen to music through headphones. each patient chose his/her musical topic on a digital tablet, just before the catheterization. the primary outcome was the change in anxiety visual analogic scale (vas) between the beginning and the end of the catheterization procedure (t -tf anxiety vas). secondary outcomes included the patient's pain vas at the end of the procedure (tf pain vas). results: patients were included in the standard care group versus in the musical intervention group. main reasons for admission were the need of central catheter for chemotherapy ( , %), and sepsis and/or shock in both groups ( , %). catheters were inserted in the internal jugular vein in most cases ( , %) and about one-third were tunnelled in both groups. there was no between-group difference regarding median t -tf anxiety vas: [iqr:− to ] in the standard care group versus − [− to ] in the music intervention group (p = . ) (fig. ) , with no significant interaction between the variables of stratification or the operator experience and the intervention. the median tf pain vas was not statistically different between groups: [ to . ] in standard care group and [ to ] in music intervention group (p = . ), with no significant interaction between the variables of stratification or the operator experience and the intervention. conclusion: in this first randomized pilot study of musical intervention for central venous catheterization in awake patients in the intensive care unit, the musical intervention did not reduce patients' anxiety as compared to usual care. as the study may have been underpowered, larger size trials are needed. compliance with ethics regulations: yes. rationale: sleep is markedly altered in icu-patients under mechanical ventilation and may be due to noise, light, patient-care activities, patient-ventilator asynchronies, or the result of acute brain dysfunction induced by sedative drugs. to our knowledge, sleep has never been studied at icu admission before any sedation. our study aimed at assessing sleep quality of non-intubated sedation-free patients admitted to icu for acute respiratory failure. patients and methods: observational study performed in a single centre of a teaching hospital. patients admitted to icu for acute respiratory failure (respiratory rate ≥ breaths/min and pao / fio < mm hg under high-flow nasal oxygen) could be enrolled. patients with hypercapnia, central nervous disease, intubated early after admission and those with a do-not-intubate order were excluded. sleep was evaluated by complete polysomnography (psg) that started in the afternoon following admission and was continuously performed until the next morning. results: over a -year period patients were screened and patients were included. among them, patients were excluded for the following reasons: patient was intubated shortly after psg initiation, psg was lost, and eeg recordings ( %) were stopped before midnight (electrodes turned off or loss of signal). therefore, patients in whom psg was complete during the nocturnal period were retained in the analysis ( rationale: convulsive status epilepticus (cse) is a common neurological emergency associated with high mortality and morbidity rates. there are strong experimental data suggesting a potential impact of secondary brain insults (sbi) on outcome after cse. however, there is no clinical proof to support this hypothesis. our objective was to evaluate the association between sbi (mean arterial blood pressure, arterial partial pressure of carbon dioxide, arterial partial pressure of oxygen, temperature, natremia, and glycemia) at day and neurological outcomes days after cse. patients and methods: this was a post hoc analysis of the hyber-natus multicenter open-label clinical trial randomized critically ill patients with cse requiring mechanical ventilation to either therapeutic hypothermia ( - °c for h) plus standard care or standard care alone. patients still alive at day after inclusion were enrolled from march to january in french medico-surgical icus. the primary outcome was favourable outcome days after cse defined as a glasgow outcome scale score of . results: median age was of years . a previous history of epilepsy was noted in ( %) patients. most episodes ( / , %) occurred out-of-hospital, and ( %) were witnessed from their onset. cse was refractory in ( %) patients and total seizure duration was min ( - ). a favorable -day outcome occurred in ( %) patients. maximal glycemia value and hyperglycemia > . mmol/l at day were the only sbi variables associated with outcome in univariate analysis. by multivariate analysis, age > years (or, . ; % ic, . - . ; p = . ), refractory cse (or, . ; % ic, . - . ; p = . ), and primary brain insult (or, . ; % ic, . - . ; p = . ) were associated with an increased risk of poor outcome, and a bystander-witnessed onset of cse (or, . ; % ic, . - . ; p = . ) was associated with a decreased risk of poor outcome. conclusion: in our population, secondary brain insults were not associated with outcome in critically ill patients with convulsive status epilepticus; whereas age, bystander-witnessed onset of status epilepticus, refractory status epilepticus and primary brain insult were identified as strong predictors of -day functional impairment. further studies are warranted to confirm our findings. compliance with ethics regulations: yes. rationale: acute stroke (as) is a leading cause of morbidity and mortality worldwide. however, data on the prognosis andfunctional outcome of patients with as requiring icu management is limited. our purpose was to identify factors associated with good outcome (defined by a modified rankin score (mrs) of - ) months after icu admission. patients and methods: retrospective cohort of patients admitted to the medical icu of a university-affiliated hospital between january and december and coded for acute stroke using the icd- criteria. patients with traumatic stroke and isolated subarachnoid hemorrhage were excluded. results: we identified patients. median age was [ . - ] years and ( . %) were males. main reasons for icu admission were coma ( %), hemodynamic instability ( . %), acute respiratory failure ( %), and cardiac arrest ( . %). glasgow coma score at icu admission was [ ] [ ] [ ] [ ] [ ] [ ] [ ] and points. types of stroke were hemorrhagic in ( . %) patients and ischemic in ( . %). mechanical ventilation was required in patients ( . %). seizures occurred in . % of the patients and convulsive status epilepticus in . %. pneumonia was diagnosed in ( . %) patients (aspiration pneumonia n = , ventilator associated pneumonia n = ). thrombolysis or thromboaspiration were performed in ( %) patients with ischemic stroke. surgical evacuation of expanding hematoma was performed in ( . %) patients, ( . %) had craniectomy, and ( . %) had external shunt for hydrocephalus. icu and hospital mortality were . % and %, respectively. six months after icu admission, ( . %) patients had a good outcome (mrs - ), ( . %) had significant disability (mrs - ), and ( . %) were deceased (lost follow-up n = , . %). on multivariable analysis, age (or . per year ( . - . ), p = . ), saps (or . per point ( . - . ), p = . ), and hemorrhagic stroke (or . ( . - . ), p = . ) reduced the likelihood of good outcome (mrs - ) months after icu admission. conclusion: in our study, prognosis of acute stroke requiring icu admission was poor and a good functional outcome occurred in less than % of the patients at months. age, severity at icu admission, and type of stroke predicted outcome. compliance with ethics regulations: yes. rationale: in intensive care units, severe spontaneous hemorrhagic brain injuries have a poor prognosis for mortality and functional outcomes. affected patients face particular ethical issues regarding the difficulty of anticipating their eventual recovery. in this context, prognostic scores can help clinicians in patients/relatives counseling and therapeutic decisions. the previous reviews pointed out many prognostic tools for intracranial hemorrhage and subarachnoid hemorrhage but did not focus on injuries explicitly severe nor assessed the methodological limitations of the models. our systematic review aimed to assess methodologically prognostic tools for functional outcomes in severe spontaneous haemorrhagic brain, with particular attention to their clinical utilities. patients and methods: following prisma recommendations, we queried medline, embase, web of science, and the cochrane by february , . we included multivariate prognostic models explicitly developed or validated on adults with severe intracranial or subarachnoid haemorrhage. we evaluated the articles following the charms recommendations (checklist for critical appraisal and data extraction for systematic reviews of prediction modelling studies) and the tri-pod statements (transparent reporting of a multivariable prediction model for individual prognosis. results: our review confirmed the multiple publications of prognostic scores, as we found articles aiming to develop or validate prognostic tools. relying on guidelines, we discarded articles due to the lack of prognostic capacities, validation, or predictor selection. articles developed and validated a prognostic tool and externally validated existing models (fig. ) . no score was of good methodological quality in intracranial hemorrhage. we highlighted two prognostic scores in subarachnoid hemorrhages: the sahit predicting unfavorable outcome or mortality at months and the fresh predicting unfavorable outcome at months. conclusion: although prognostic studies on haemorrhagic brain injuries abound in the literature, they generally lack of methodological robustness or show incomplete reporting. with the numerous published scores, we believe that it is time to stop developing new scores. ongoing validation, recalibration, and impact studies would keep improving existing good tools. the use of "patient-centered" approaches could also enhance them, and be more appropriate to inform patients and families about their long-term potential recovery. these considerations should drive future research in the modern era of neurocritical care prognosis. compliance with ethics regulations: na. rationale: respiratory pattern analysis by a visual examination is an important part of clinical assessment but is dependent on caregiver expertise and is subjective. furthermore, there is no easy medical device used in picu to measure tidal volume (vt) and minute ventilation (mv) in spontaneous breathing patients. the clinical research unit in critical care of chusj and ets have developed a non-invasive computerized d video analyzing system (retract system) to detect and perform a video analysis of respiratory status in children. the aim of this study is to test the reliability of the retract system to monitor respiratory distress in critically ill children. the retract system is detailed in reference . in summary, cameras reproduce in d the thorax and abdomen of a subject. the respiratory status (respiratory rate (rr), tidal volume (vt), minute ventilation (mv)) assessed by the retract system was compared on a bench test (high-fidelity mannequin) and in critically ill children, to the ventilator measurements and clinician expert evaluation (gold standard). bland-altman plots were used for comparison. results: we observed a significant agreement, on mannequin, between retract system and gold standard method in estimating vt, rr and mv, i.e. % of the paired differences were within the limits of agreement in bland-altman plots, as illustrated in fig. . in critically ill children (n = ), the correlation between the pairs of measures was also high (r > . , p < . ) and thecoefficient of determination with a high fit ( . < r < . , p < . ). for good correlation, the retract system needed to have a visual access to thorax and abdomen in a quiet subject. the retract system measurements of vt, rr and mv for respiratory distress monitoring in patients seems reliable. more testing are required to validate this method in usual practice and to develop the retractions signs video analysis. compliance with ethics regulations: yes. rationale: severe bronchiolitis requires hospitalization in paediatric intensive care unit (picu). non-invasive ventilation (niv) has been demonstrated to treat them since twenty years, its use is well defined but there is no consensus for the weaning. this study evaluated the application of a nurse-driven niv weaning protocol in hospitalized infants with severe bronchiolitis and verified its safety. this was a retrospective monocentric study in a picu of robert debré hospital-paris, france. in the epidemic period of bronchiolitis between and , all patients under one year old with severe bronchiolitis and requiring niv were included. two groups were compared: one group using the nurse-driven niv weaning protocol and one group without using this protocol. occurrences of complications, duration of ventilatory support and length of stay (los) in picu and total los were compared. results: patients were included in the study, in the no-protocol group, and in the protocol group. the nurse-driven protocol was using at the rate of % (n = / in the protocol group (p = . ). picu los were . days [ ] [ ] [ ] in the no-protocol group versus days [ - . ] in the protocol group (p = . ), hospital los was days [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in the no-protocol group versus days [ ] [ ] [ ] [ ] [ ] [ ] in the protocol group (p = . ) (fig. ) . the use of this first nurse-driven niv weaning protocol was feasible and simple with a very good application rate. its utilization was safe. the occurrence of complications did not increase by the use of this protocol. it would allow an optimal niv weaning without prolonging the ventilatory support duration nor picu los or hospital los. the professional practices appeared to be coordinated and the nurses appeared to be more autonomous. compliance with ethics regulations: yes. no-protocol and protocol groups comparison: cpap duration ( ), ventilatory support duration ( ), picu los ( ), hospital los ( ) rationale: first-line management of severe acute bronchiolitis in infants is mainly based on non-invasive ventilation (niv) and high-flow nasal cannula (hfnc) therapy. however, pediatric data regarding weaning from niv/hfnc are lacking. this study aims to identify the weaning practices from niv/hfnc in children with severe bronchiolitis. the weaniv-survey is a cross-sectional survey. a questionnaire was sent to french-speaking physicians with key roles in pediatric intensive care units. results: a total of % ( / ) of french university hospital were represented in the study. only % of pediatric centers used a protocol for weaning from niv/hfnc and nurses were considered as key-actors of the weaning process for half of participants. continuous positive airway pressure (cpap) was the mode of ventilation mainly used as the first-line therapy in clinical practice. the main criteriaconsidered toinitiate weaning process were: noor slight respiratory distress, a fio < %, a respiratory rate < /min and no significant apnea. three strategies to discontinue niv/hfnc were identified: /gradual decrease of ventilatory parameters (pressure or flow), /abrupt discontinuation and /gradual increase in off-ventilation time. abrupt weaning strategy was the most commonly used, no matter the mode of ventilation. a significant level of respiratory distress, the presence of apneas, an increase in oxygen requirement, and a respiratory rate > / min were identified as weaning failure criteria by most pediatric intensive care physicians. conclusion: in most centers, the weaning process does not follow any protocol. abrupt weaning seems to be commonly used as weaning strategy in children with severe bronchiolitis supported by niv/hfnc. based on the study findings, we suggest that criteria for weaning initiation and for weaning failure must be defined and weaning protocols generated. compliance with ethics regulations: yes. complications secondary to prone positioning occured for patients ( . %). conclusion: this first study, which evaluate prone positioning efficacy in severe p-ards shows evidence that prone positioning improves oxygenation parameters and survival rate. these results highlight the necessity to develop a multicentric prospective randomized study to confirm these conclusions. compliance with ethics regulations: yes. ( vs ) and vasoactive-inotropic score (vis) ( vs ) were significantly higher in the non-survivor group. cannulation was veno-venous ( %) or veno-arterial ( %) and patients ( %) were finally not initiated on ecmo. we observed an increase of patients cannulated in our picu over time (fig. ). there was no significant difference in mortality between patients transported on ecmo after cannulation in our picu and those who were transported to be cannulated in a referral ecmo center. the median time between the decision and the cannulation was . h and the median time taken in charge by picu transport team was approximately h. these periods were not significantly different between cannulation on site or in an ecmo center and between survivors and not-survivors. conclusion: in our study, multiple organ dysfunction, particularly hematologic and acuterenal failures, seems to be a risk factor of mortality. the delay between decision and management is similar whatever the cannulation site. specific ecmo mobile team and picu transport team seem to be essential, fast and trained to transfer these patients. it would be interesting to compare our cohort with children requiring ecmo already hospitalized in a referral ecmo center. compliance with ethics regulations: yes. rationale: life expectancy in patients with metastatic breast cancer (mbc) has substantially improved over the last decade. life threatening complications result from advanced diseases, infection and treatment-related toxicity. only few studies have assessed outcomes in this setting. we performed a hospital-wide study to investigate how icu resources are needed in patients with mbc. patients and methods: all patients with mbc managed at our hospital between and were retrospectively included. the primary outcome was overall survival (os). factors associated with icu mortality were identified using a multivariable cox proportional hazard model with sensitivity analysis. results are expressed as median [interquartile ranges] unless stated otherwise. results: among the patients managed at our hospital, ( %, including male) were admitted to the icu ( [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] patients per year). age was [ - ] years. patients were receiving their nd [ st- rd] line of treatment and had [ ] [ ] metastatic sites. sofa score at admission was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . main reason for icu admission was sepsis (n = , %), acute respiratory failure (n = , %), coma (n = , %) and metabolic disorder (n = , %). invasive mechanical ventilation was required for patients ( %) and renal replacement therapy for ( %). sixteen ( %) patients died in icu. following icu discharge, median os was . months ( % ci [ . - . ]) and / ( . %) patients died within months. an antineoplastic treatment was resumed for / ( %) patients alive after icu discharge. factors independently associated with mortality were performance status ≥ (hr . , % ic [ . - . ] ) and sofa score at day (hr . per point, % ic [ . - . ] ). after sensitivity analysis, the number of treatment lines at icu admission was not associated with mortality. conclusion: icu admission is required in the course of the mbc disease for % of the patients. determinants of short term outcomes rely on performance status and disease severity but not on the characteristics of the underlying disease. ongoing analyses will assess whether icu survivors reach life expectancy of patients never admitted to the icu. compliance with ethics regulations: yes. hubert gheerbrant , jean-françois timsit , nicolas terzi , stephane ruckly , mathieu laramas , matteo giaj levra , emmanuelle jacquet , loic falque , denis moro-sibilot , anne-claire toffart chu grenoble alpes, grenoble, france; aphp, paris, france; outcom-erea, bobigny, france correspondence: hubert gheerbrant (hgheerbrant@chu-grenoble.fr) ann. intensive care , (suppl ):p- rationale: the prognosis of critically ill cancer patients admitted in intensive care unit (icu), remains an issue. our objective was to assess the factors associated with -and -month survival of icu cancer survivors. patients and methods: based on the french outcomerea ™ database, we included solid cancer patients discharged alive, between december and november , from the medical icu of the university hospital in grenoble, france. patient characteristics and outcome at and months following icu discharge were extracted from available database. results: of the cancer patients with unscheduled admissions, ( %) were discharged alive from icu. the main primary cancer sites were digestive ( %) and thoracic ( %). the -and -month mortality rates were % and %, respectively. factors independently associated with -month mortality included ecog performance status (ecog-ps) of [ ] [ ] . . - . ). interestingly, cancer chemotherapy prior to icu admission was independently associated with lower -month mortality (or, . ; % ic: . - . ). among patients with an ecog-ps - at admission, % (n = ) and % (n = ) displayed an ecog-ps - at and months, respectively. at months, ( %) patients received anticancer treatment, ( %) were given exclusive palliative care. discussion: factors associated with -month mortality are almost the same as those known to be associated with icu mortality. we highlighted that most patients recovered an ecog-ps of - at and months, in particular those with a good ecog-ps at icu admission, and could benefit from an anticancer treatment following icu discharge. conclusion: these results should be taken into account when deciding upon icu admission. it is of paramount importance to have an evaluation of both patient's general condition and anticancer treatment opportunities following icu discharge. compliance with ethics regulations: yes. rationale: the decision to urgently initiate medical anti-cancer treatment in cancer patients admitted to intensive care unit for cancerrelated organ failure is an issue. we currently lack criteria to select patients who may benefit from the treatment initiation. the purpose of our exploratory study was therefore to evaluate the characteristics of patients whose medical anti-cancer treatment is initiated in icu and to identify prognostic factors for in-hospital mortality. in these patients. patients and methods: we analyzed retrospectively, over a period of years ( / / to / / ), cancer patients over -year old admitted to our icu bordet and in whose anti-cancer medicaltreatment was initiated during in-icu stay. to identify prognostic factors for in-hospital mortality, we carried out a multivariate analysis of the factors influencing this mortality, considered as a binary. we also analyzed the long term survival of patients alive after their hospital stay (from the day of going out of hospital). results: overall, patients were included, men ( %) and women ( %), with a median age of years ( - ). of these, patients ( %) had a solid tumor and ( %) had a hematological tumor. in-icu mortality is % ( % ci - %) and in-hospital mortality % ( % ci - %). the prognostic factors for in-hospital mortality were age (mean vs in those who survived), the sofa score (median vs ), the saps ii score (mean vs ), the charlson score (mean vs. . ), the number of organ failure (mean . vs . ) and the presence of a therapeutic limitation (ntbr stated within h: % vs %). survival at year of patients who survived the hospital stay was % and median survival time was estimated to be . year ( % ci . - . ). in patients with a solid tumor, -year survival was % and % in those with a hematological tumor (p < . ). conclusion: we observed, in selected cancer patients admitted to the icu for a cancer-related complication, that the initiation of an anti-cancer medical treatment is feasible and can lead to interesting results, particularly in patients with a hematological tumor. compliance with ethics regulations: yes. rationale: considerable progress in the management of onco-hematology (oh) malignancies led to an increase in the number of patients proposed for intensive care unit (icu) admission. several guidelines offer decision models for icu transfer of these patients. we aimed to describe prognosis, adequacy of icu admission and denial in oncohematology patients. we included all oh patients proposed for icu admission in a tunisian medical icu, between january and july . from an admission proposal registry, were collected patient underlying condition, functional status, malignancy and predicted prognosis, acute critical illness and its reversibility, adequacy of icu rationale: cancer patients frequently need intensive care support for a life-threatening condition due to the underlying neoplasm or an adverse therapy-related event. however, there are poor data on their characteristics and outcomes in the intensive care setting. the aim of the present study was to describe clinical characteristics and to identify factors associated with in-icu mortality in critically ill cancer patients. patients and methods: it is a retrospective study conducted in the medical icu of farhat hached teaching hospital between january and december . all cancer patients with complete records were included. baseline characteristics, clinical parameters, severity of illness, primary tumor location and outcomes were collected. univariate and multivariate regression analyses were carried out to identify factors independently associated to poor prognosis. rationale: prognostic impact of underlying malignancy seems limited in most studies assessing outcome of critically ill cancer patients [ ] . however, only limited number of characteristics, namely disease progression status and preexisting stem cell transplantation, were usually assessed [ ] . primary objective of this study was to assess influence of hematological malignancy aggressiveness on hospital outcome. secondary objective was to assess influence hematological malignancy aggressiveness on type of infection. patients and methods: post-hoc analysis of prospective multicenter cohort performed in hospitals in france and belgium and including critically ill adults with underlying hematological malignancy admitted in icu from jan to may . a cox model was used to adjust for confounding variables then a propensity score matching on characteristics associated with underlying malignancy aggressiveness was performed. results: of the included patients, ( . %) had low grade malignancy (lg), the most frequent being myeloma (n = ), chronic lymphocytic leukemia (n = ), and myelodysplasia (n = ). patients with lg malignancy were older, underwent more frequently autologous stem cell transplantation (sct) and had less frequently altered performans status. they had more severe organ failure at icu admission (sofa score [ ] [ ] [ ] [ ] [ ] [ ] vs. [ ] [ ] [ ] [ ] [ ] [ ] , p = . ). before adjustment, mortality was % (n = ) and . % (n = ) respectively in patients with and without lg malignancy (p = . ). after adjustment for confounder using a cox model, a higher mortality was associated with nonlow grade malignancy (or . ; % ic . - . ). a propensity score then allowed a : matching upon variable associated with malignancy aggressiveness. after matching unadjusted mortality was % (n = ) in patients with lg malignancy and . % (n = ) in patients with high grade malignancy (p = . ) (figure) . in the matched cohort and after adjustment for confounder, high grade malignancies were associated with lower mortality (or . ; % ic . - . ). risk of fungal infection was unchanged by underlying malignancy before adjustment ( % vs. . % of patients with and without lg malignancy; p = . ) or after adjustment (hr . ; % ic . - . ). conclusion: despite anti-cancer advances, aggressiveness of hematological malignancies is associated with overall icu outcome. lowgrade malignancies displaying a better prognosis than non-low grade. aggressiveness of the underlying malignancy is not associated with risk of fungal infection. compliance with ethics regulations: yes. rationale: guillain-barré syndrome is the most common cause of acute flaccid paralysis and is associated with pulmonary embolism due to the mobility limitation. the aim of this study is to describe the incidence, the severity of pulmonory embolism in patients admitted to an intensive care unit (icu) for guillain-barre syndrome (gbs). patients and methods: twenty-eight adults patients with confirmed diagnosis of gbs were admitted to the icu in our university hospital center over a -year period and they were all included. prevalence, risk factors and course of vte were analyzed in icu patients with various forms and severity of gbs. results: during the study period, adult gbs patients were included. five ( . %) developped pulmonary embolism. the mean age was . ± . years and the sex ratio was . . the comparaison betewen the groups with and without pe showed that factors associated with the development of this complication were: respiratory failure requiring mecanical ventilation (p = . ), infectious complications (p < . ), blood pressure lability (p = . ), the delay of icu admission (p = . ), the delay to treatment initiation (p = . ), the sofa score (p = . ) and the presence of quadriplegia (p = . ). conclusion: pulmonary embolism is a frequent complication in patients with gbs. factors associated with this complication were: respiratory failure requiring mecanical ventilation, infectious complications, the delay of icu admission, the delay to treatment initiation, a high sofa score and the presence of quadriplegia. preventive measures in this category of patients have to be improved. rationale: acute respiratory distress syndrome (ards) is a life-threatening pathology associated with very high morbidity and mortality ( - %) in intensive care units (icu) and with even higher mortality among the severly burned patients worldwide ( à %). the aim of our study was to describe in tunisia burn patients with ards and to identify prognosis factors. patients and methods: we conducted a descriptive retrospective study between - - to - - , in burns icu, in ben arous, in tunisia. all burns who presented an ards, according to the berlin definition, during their stay in the icu, were included. when clinical or gasometric data was uncomplete, these patients were excluded. results: during the study period, patients were admitted to our burn unit including ventilated patients. fifty patients presented an ards: fifteen patients were excluded for lack of information, and patients were retained. the sex ratio was . . patients had a mean age of ± years, an average burned area of % ± %, an average unit of burn skin score (ubs score) of ± and an average sequential organ failure assessment score (sofa score) of . none of the patients had a history of cardiovascular or pulmonary diseases. the average time of onset of ards was ± days. ards was mild in case, moderate in and severe in . the etiology of ards was pulmonary in cases ( %) and extra-pulmonary in ( %). the pulmonary ards had as cause pneumonia isolated in patients, an isolated pulmonary burn in patients and a combination of pneumonia and lung burns in patients. extra-pulmonary ards were all due to sepsis and mainly to bacteremia. septic shock was associated with ards in patients ( %). the treatment was a conventional treatment based on protective ventilation, curarization and prone positioning in addition to the etiological treatment. the average length of stay in icu was days and mortality was % in these patients. conclusion: mortality from ards in burns in tunisia, is important especially in those with pulmonary burns as well as those with sepsis. the introduction of new treatments, such as extracorporeal membrane oxygenation, remains essential to improve the prognosis of burn patients. compliance with ethics regulations: yes. rationale: aspiration pneumonia (ap) is common in intensive care unit (icu). the incidence of ap among adults hospitalized with pneumonia ranges between and . %. usually one or more risk factors are identified to be involved in ap. the aim of this study was to determine the risk factors and predictors of mortality on patients with ap. patients and methods: we retrospectively included patients aged more than years and who were hospitalized in our icu for ap. patients were excluded if they had history of tuberculosis, if they have bronchiectasis or metastatic brain tumor. results: a total of patients were included. history of diabetes, hypertension, epilepsy and ischemic stroke were found respectively in . %, . %, . %, and . % of cases. the reason of icu admission were coma ( %), acute respiratory failure ( %), poisoning ( %) and cardiac arrest ( %). the incidence of acute respiratory distress syndrome (ards) was %. the most common organism isolated was staphylococcus aureus ( cases). risk factors for ap were epilepsy ( %), swallowing disorders ( %), ischemic stroke ( %), copd ( %) and degenerative neurological disease ( %). the mortality rate was . %. the median duration of mechanical ventilation was days [iqr - ]. in multivariate logistic regression analysis; saps ii score (or = . , % ic [ . - . ], p = . ) and ards (or = . , % ic [ . - . ], p = . ) were independently associated with mortality. conclusion: risk factors for aspiration pneumonia were epilepsy, swallowing disorders and ischemic stroke. ards and saps ii score were independent predictive factors of mortality. compliance with ethics regulations: yes. undetermined. the aim of this study was to evaluate the impact of hyperoxia on morbidity and mortality. patients and methods: this was a prospective study performed in the icu of abderrahmen mami hospital during a -month period. all patients admitted in icu during the study-period were included. those who didn't need oxygen therapy or in end of life stage were excluded. arterial blood gases were analyzed daily and each day with at least one value of oxygen arterial saturation (sao ) > % was considered as a day with hyperoxia. for each patient included, the number of times and days spent in hyperoxia was recorded as well as complications during the icu stay and the outcome. results: during the study-period, patients were included but only were eligible. mean age was ± years. acute on chronic respiratory failure was the most frequent reason of admission ( %). non-invasive ventilation was required for % of patients and invasive mechanical ventilation was necessary in % of cases. overall mortality was %. hyperoxia was observed in % of cases, with an average of ± times during the icu stay and ± days. a statistically significant association was observed between a long duration of hyperoxia and the occurrence of ventilator acquired pneumonia (p < - ), ventilator acquired bronchitis (p = . ), acute respiratory distress syndrome (p < - ), atelectasis (p < - ), septic shock (p < - ), rythm disorders (p = . ), reintubation (p < - ) and tracheostomy (p = . ). on multivariate analysis, independent factors of mortality were: simplified acute physiology score ii, cardiac failure, need for invasive mechanical ventilation and septic shock. hyperoxia was not independently associated with mortality. conclusion: hyperoxia is frequent in icu. it is significantly associated with icu complications but not independently associated with mortality. compliance with ethics regulations: yes. experience of the practice of prone position in patientswith acute respiratory distress syndrome in intensive care (chu oran) nabil ghomari, soumia benbernou, djebli houria faculté de medecine d'oran, oran, algeria correspondence: nabil ghomari (nabilghomari@hotmail.fr) ann. intensive care , (suppl ):p- rationale: mechanical ventilation (mv) in the prone position (pp) and low tidal volume have become recommendations with a high level of scientific evidence in recent years. the pp has been practiced for years in the chu oran emergency resuscitation service. we wanted to report the service experience in the practice of pp in patients with ards. patients and methods: retrospective study performed in patients with severe hypoxia ards with spo < % under fio > % or pao /fio < during the period march to december . results: patients received ventilation in pp. ards was secondary to thoracic trauma in % of patients, septic shock in % and aspiration pneumonitis in %. analysis of the success factors and improvement of oxygenation found that lobar ards, the delay < h and a duration of pp ≥ h were statistically significant. conclusion: the pp must be integrated into the arsenal of care of the patients in ards especially in our country where we do not have all the therapeutic options. compliance with ethics regulations: yes. julien goutay, nicolas cousin, thibault duburcq, erika parmentier-decrucq chu de lille, pôle de réanimation, hôpital salengro, lille, france correspondence: julien goutay (julien.goutay@gmail.com) ann. intensive care , (suppl ):p- rationale: in veno-venous extracorporeal membrane oxygenation (vv-ecmo) therapy, blood flow is the main determinant of arterial oxygenation and should be - ml/kg/min in adults. this flow rate is determined by several factors including the size of the inflow cannula. the impact on clinical outcomes of arterial cannula's size in veno-arterial ecmo (va-ecmo) has already been studied, and showed no difference for survival to discharge, weaning success rate and initial flow rate between a small cannula group and a larger one. our first objective was to describe the impact of inlet cannula size on the assistance flow rate in patients treated with vv-ecmo. secondary objectives were to analyze its impact on ecmo weaning, mechanical ventilation characteristics and mortality. patients and methods: we retrospectively reviewed all cases of respiratory failure treated with vv-ecmo admitted in the medical intensive care unit (icu) of lille's teaching hospital from january st, through march st, . inlet cannula size was collected and divided into two groups: the "small cannula" group had inlet cannula less than or equal to fr, while "large cannula" were larger than fr. primary endpoint was the initial flow rate according to the inlet cannula size, and its changes during the first h of assistance. secondary endpoints were the analysis of predictive factors associated with the choice of a larger inlet cannula, and the impact of its size on clinical outcomes such as successful ecmo weaning. results: patients treated with vv-ecmo were admitted in our hospital. eleven ( %) were cannulated with a large inlet device. mean initial ecmo flow rate was statistically higher in the "large cannula" group than in the "small cannula" one: . l/min (± . ) versus . (± . ) respectively, p < . . the difference was also significant during the first h of assistance. we found no difference between the two groups on clinical outcomes such as ecmo weaning time. in univariate analysis, weight was heavier in the "large cannula" group [ (± ) kg] than "small cannula" [ (± )], p < . . conclusion: ecmo initial flow rate was higher in a "large inlet cannula" group (internal diameter more than fr) compared with a "small cannula" group. we found no correlation with cannula-related haemorrhagic or thrombotic complications. inlet cannula size did not influence ecmo weaning, and duration time, but this may be a lack of statistical power. further prospective studies should confirm this results. compliance with ethics regulations: yes. rationale: burn patients are at risk of multidrug-resistant (mdr) bacterial infections with high mortality rate. therefore, monitoring the emergence of mdr pathogens in these vulnerable patients is important. this study aimed to assess digestive colonization with carbapenemase-producing gram-negative bacilli (cp-gnb) in patients admitted to the burn intensive care unit. patients and methods: our study was prospective and conducted over a one-year period (january to december ). every admitted patient was subjected to the screening. a double swab set was used to collect rectal swab specimens. one swab was used for mdr screening by disk diffusion method on selective media; the other for multiplex real-time pcr (cepheid's genexpert ® ) allowing detection of the most common carbapenemase-encoding genes (ceg) (blaoxa- , blakpc, blandm, blavim and blaimp). results: among the studied patients, ( . %) were detected positive at admission for cp-gnb by the genexpert ® carba-r assay. eleven patients, initially not colonized, acquired positive faecal carriage subsequently during their hospital stay. forty-two colonized patients ( . %) developed cp-gnb infection during their hospitalization. the ceg blandm quantitatively dominated by far with detections; either alone ( cases) or associated with other ceg ( cases). the second most frequent gene was blaoxa- . it was detected alone eight times and in association with other ceg times. forty-three patients carried blavim gene, usually in association with other ceg ( %). however, only one patient carried blakpc gene. the parallel screening by classical microbiology methods (disk diffusion on selective media) detected the presence of cp-gnb in all molecular positive samples. conclusion: our study describes the characterization of carbapenemase in burn patients and highlights their alarming spread. this emphasizes the importance of an active surveillance program by early detection of cp-gnb carriers and an isolation policy to limit the mdr infections expansion. compliance with ethics regulations: yes. rationale: invasive fungal infections are increasingly observed in the icus especially in burn units. inthe absence of simple and accessible techniques for early microbiological diagnosis, the use of antifungal treatment is increasing. little is known about the extent of the problem of antifungal prescription in burn icus. we aimed to evaluate the antifungal prescription in major burn patients. patients and methods: during the study period ( - ), all prescriptions of antifungals were analysed. analysis concerned demographics, clinical circumstances, as well as the basis of antifungal prescribing (targeted vs. empiric). among the patients admitted in this period, patients were treated with antifungals (sex ratio: . ; mean age: ± years, with low associated comorbidity). the tbsa was . % [ . - . ], ubs was [ . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . most of the patients ( . %) were transferred from another hospital structure within ± h. antifungal treatment was started at the average of the seventh day post wound injury, more often on an empiric basis. sofa score at the beginning of the treatment was ± . . lymphopenia was present in % and thrombopenia was present in %. index of colonisation was positif only in cases. the average candida score was . ± . . microbiological results were tardily collected, within weeks, in %. fungal urine infections were found in cases. candidemia and catheter-related infections were considered only in cases. the risk factors of fungal infection as described in literature were found in most of the patients including mechanical ventilation ( . %), length period of stay ( days [ . - . ]), central venous line ( %), severe sepsis or septic shock ( %), large-spectrum antibiotherapy for more than days ( %). conclusion: the management of antifungal infections in major burn patients is still challenging. antifungal prescription is based on clinical presumption. the empirical prescription reflects the lack of efficient laboratory support and late microbiological results prompting physicians to rely on clinical informations. the management of fungal infections is based on the improvement of mycological investigations. compliance with ethics regulations: na. rationale: invasive candidiasis is a widespread and alarming infection in intensive care units (icu) patients. its diagnosis is often difficult because of the lack of specificity of clinical signs and the low sensitivity of blood cultures. while the candida albicans species remain the most common cause of bloodstream infections, non-albicans are emerging. these infections are serious, associated with high mortality rate and requiring early diagnosis and appropriate treatment. in tunisia, few data are available. we aimed to determine the epidemiological profile of a series of candidemia in icu, the risk factors associated with the occurrence of candidemia and to describe the modalities of the mycological diagnosis of candidemia and their etiological profile. patients and methods: a retrospective longitudinal descriptive study conducted in the parasitology-mycology laboratory with the collaboration of the medical icu of la rabta hospital-tunis over a -year period from january , to december , . all hospitalized icu patients with at least one candida-positive blood culture were included. results: forty-three patients among hospitalized patients during the study period had at least one candidemia infection. the main risk factors for development of candidemia infection include invasive procedures, a prior use of antibiotics and parenteral nutrition. c. albicans was the most common species, detected in . % of patients. nonalbicans candida species were prominent ( . %), represented by c parapsilosis, followed by c. tropicalis and c. krusei then c. glabrata and finally c. lusitaniae. all the isolates tested were sensitive to the common antifungal agents. the mortality rate of our patients was high ( . %), and the detection of the albicans species in blood cultures was the only prognostic factor identified (or = . [ . - . ], p = . ). conclusion: candidemia in the medical icu patients is common and is associated with high mortality rate. despite the progress of biological tools, the diagnosis is difficult and needs to take into account the risk factors of the patients as well as scores based on clinical and microbiological parameters. a better identification of risk patients may help to early initiate empirical antifungal treatment. compliance with ethics regulations: yes. necrotizing soft-tissue infections in the intensive care unit: a retrospective hospital-based study kais regaieg, sabrine nakaa, arnaud mailloux, madjid boukari, johana cohen, dany goldgran-toledano groupe hospitalier intercommunal le raincy-montfermeil, montfermeil, france correspondence: kais regaieg (kais.regaieg@gmail.com) ann. intensive care , (suppl ):p- rationale: the objective of our study is to describe the epidemiological and clinical characteristics of necrotizing soft-tissue infections (nsti) and to improve therapeutic management. we conducted a retrospective observational study that included patients admitted in the intensive care unit (icu) of general hospital between september and aout with a primary or secondary diagnosis of nsti. we collected demographic and clinical data, cultured pathogens, lengths of stay, and in-icu mortality. results: during the study period, a total of patients admitted to the icu were diagnosed with nsti ( . % of the total number of patients). the mean of age was years. the sex ratio (m/w) was . . ten patients ( %) were directly admitted to the icu, others were transferred from medical or surgical wards. the mean of saps ii was . ( . ). the main indication to admission in icu was shock ( %). the most common comorbidity was diabetes ( %). the other co-morbidities associated with nsti were cardiovascular diseases ( %), obesity ( %) and carelessness ( %). the sites most commonly affected were extremities in patients ( %) and abdomen/ano-genital in patients ( %). in icu, a total of patients ( %) were mechanically ventilated [ (median duration: . days ( . )], patients ( %) were given vasopressors, and patients ( %) underwent renal-remplacement. all patients underwent one or more chirurgical intervention. patients ( %) underwent radical necrosectomy. in cases, an amputation was necessary. polymicrobian infection was seen in patients ( %). in patients ( %), we used vacuum assited closure therapy, which in patients was followed by definitive reconstruction by split skin grafts. the mortality in icu was %. the mean stay in icu was days . the mean duration of hospitalization of the patients who survived was days ( - ). on the basis of a univariate analysis, higher saps ii score and lactate levels were associated with increased mortality (p < . ). conclusion: ntsi is rare in icu but it's a life-threatening and disabling disease with a high mortality requiring a multidisciplinary management. early diagnosis and adequate treatment are necessary to improve clinical outcome and must be known by everyone. more studies are needed to estimate the interest and delay of new strategies such as negative pressure therapy. compliance with ethics regulations: yes. rationale: nosocomial infections remain a major cause of mortality and morbidity in burn patients. providing information about the main causative bacterial agents and determination of their susceptibility to antibiotics may improve empiric therapy and early detection of emerging antimicrobial resistance. the aim of our study was to investigate the species distribution and antibiotic susceptibility of isolated strains from a burn intensive care unit (icu). patients and methods: this study was performed retrospectively on all bacteriological samples taken from the burn icu at the trauma and burn center in tunisia during a seven year period (from january to december ). all isolated microorganisms were identified on the basis of standard microbiological techniques. antibiotic susceptibility testing was carried out by the agar disk diffusion method, and susceptibility results were interpreted using clinical breakpoints according to ca-sfm guidelines. minimum inhibitory concentration of colistin was determined using the e-test ® method (biomérieux), then using the eucast broth micro-dilution method (umic, biocentric ® ) since may . results: during the study period, the most frequent identified species were pseudomonas aeruginosa ( . %), staphylococcus aureus ( %), klebsiella pneumoniae ( . %) and acinetobacter baumannii ( %). these strains have been mainly isolated from blood cultures ( %) and skin samples ( . %). pseudomonas aeruginosa resistance to ceftazidime increased from . % in to . % in and resistance to imipenem and ciprofloxacin was . % and . %, respectively. four strains were resistant to colistin. rationale: community-acquired peritonitis is a heterogeneous condition characterized by peritoneum inflammation in response to a bacteria injury. the aim of our study is to describe the epidemiological, clinical, bacteriological, etiological, therapeutic characteristics of community peritonitis, and to evaluate the prognostic factors. patients and methods: this is a retrospective descriptive and analytical study spanning three years (between january and december ) involving cases of community peritonitis, hospitalized in the surgical emergency resuscitation department p ibn rochd casablanca university hospital. our study included adult patients with community-acquired peritonitis who underwent medical and surgical management. the studied parameters are the demographic data, the clinical and paraclinical signs, the care taken and the evolution of the patients. the study showed that the mean age was . ± . years, with a sex ratio of . . patients medical history included tobacco ( . %), extra-abdominal signs [hemodynamic failure ( %), renal failure (n = , %), hematological disorders (n = , %) and respiratory disorders (n = , %)]. therapeutic management was based on perioperative resuscitation, treatment of organ failure, probabilistic antibiotic therapy and median laparotomy surgery. the main etiologies of community peritonitis were: digestive perforation ( . %), purulent effusion ( %), intestinal necrosis ( . %), cholecystitis ( . %). intraoperative bacteriological specimens yielded the following bacteriological profile: predominance of ngb ( . %) dominated by e. coli ( . %) followed by klebsiella pneumoniae and enterobacter cloacae ( . %) the mean hospital stay was . ± . days. the mortality rate was . %. conclusion: improvement in the prognosis of community-acquired peritonitis can only be achieved by constant assessment of very early diagnosis and initiation of appropriate resuscitation and antibiotic therapy associated with a complete surgery carefully codified according to guidelines. compliance with ethics regulations: yes. rationale: klebsiella pneumoniae carbapenemase (kpc)-producing bacteria are a group of emerging highly drug-resistant gram-negative bacilli causing infections associated with significant morbidity and mortality. the aim of our study is to point out the incidence of bloodstream infections (bsi) caused by kpc in icu patients, its clinical presentation and course. patients and methods: we conducted a retrospective descriptive study. all patients hospitalized in the icu of our hospital who developed bsi caused by kpc from january , to december , were included. results: during the study period, patients were included. the mean age was . ± . years ranging from to years. sex ratio (m/f) was . trauma was the major cause of hospitalization in cases ( %). the most common past medical diseases were arterial hypertension in patients ( %). length of hospital stay prior to icu admission was ± . days. at infection onset, mean saps ii was ± . , mean sofa was . ± . and mean apache ii was . ± . . during icu hospitalization, all patients required invasive mechanical ventilation during . ± . days, had a central venous catheter (cvc) and an indwelling urinary catheter in place, patients ( . %) had tracheotomy, ( %) underwent surgery, ( %) presented acute kidney failure and ( %) needed hemodialysis. before the isolation of kpc, all patients presented infections. antibiotics prescript were: colistin in patients ( %), carbapenems in patients ( %), amoxicillin/clavulanic acid in patients ( %), cephalosporins in patients ( %), fluoroquinolones in patients ( %), tigecycline in patients ( %), aminosids in patients ( %), rifampicin in patients ( %), fosfomycin in patients ( %), glycopeptides in patients ( %). the delay for kpc-bsi onset was . ± . days. the most common infection sources responsible of kpc-bsi were: cvc in patients ( %) and pneumonia in patients ( %). kpc infection was responsible of septic shock in patients ( %). resistance rates were: gentamycin ( %), amikacin ( %), colistin ( %), fosfomycin ( %) and tigecycline ( %). antibiotics used to treat kpc bloodstream infection were resumed in table . the mean length of icu stay was . ± . days. out of the included patients, patients died (the mortality rate was %). death was related to kpc infection in patients. conclusion: the high prevalence of kpc-bsi in icu patients dictates the importance of implementation of infection control measures and strict antibiotic policies. compliance with ethics regulations: not applicable. we identified episodes of nosocomial infections in patients, representing a cumulative incidence rate of . per exposed patients. the incidence density was . infections per days of hospitalization. the prevalence of pneumonia was . %, followed by urinary tract infections . %, central venous catheterization infections . %, bacteriemia . %, meningitis . % and surgical site infections . %. the incidence rate of intubation-related pneumonia was . / day of exposure. the incidence rate of bladder-related urinary tract infection was . / day of exposure. the incidence rate of positive culture of the central venous catheter was . / day of exposure. the incidence rate of bacteremia related to stay was . / day of exposure. the mortality rate was . % with a significant difference between infected and uninfected patients (p = . ). microorganisms were gram negative bacteria in % of cases. conclusion: epidemiological surveillance of healthcare-associated infections is needed to establish prevention plans. compliance with ethics regulations: not applicable. in the prehospital setting, early identification of septic shock (ss) with high risk of mortality is essential to guide hospital orientation (emergency department (ed) or intensive care unit (icu)) prior to early treatment initiation. in this context, the severity assessment is most of the time restricted to clinical tools. in this study, we describe the association between prehospital shock index (si) and mortality at day of patients with ss initially cared for in the prehospital setting by a mobile intensive care unit (micu in this study, we reported an association between prehospital si and mortality of patients with prehospital ss. a si > . is a simple tool to assess severity and to optimize prehospital triage between ed and icu of patients with ss initially cared for in the prehospital setting by a micu. the association of si with biomarkers may be helpful to improve the screening for ss and decision making of ss in the prehospital setting. compliance with ethics regulations: yes. the failure rate and complications were comparable between the groups, but the ultrasound-guided internal jugular catheter appears to be faster to insert and requires fewer punctures, so it could be an alternative to the femoral one in emergency situations. rationale: neuromyelitis optica (nmo) is a rare but severe disease. the prognosis of treated nmo attacks remains unclear. we evaluated our practice, the early evolution and the prognosis of nmo patients. patients and methods: an observational study was performed on patients with nmo attacks presenting with visual or medullar symptoms admitted for plasma exchange (pe) therapy from january to august . treatment efficiency was defined as a negative shift of the visual or motor disability score (edss). nonparametric mann-whitney and fisher exact tests were used for statistical analysis as required. results: twenty-four patients had pe sessions. characteristics of the cohort are described in table . ( . %) died from complications of nmo attacks. treatment had an effect in ( . %) patients. the shift in the ambulatory and visual edss was respectively − . + . and − . + . . the non-survivor patients had all aqp antibodies (p < . ). residual edss was higher in the non-survivor group ( . + . vs . + . , p < . ). pulse steroids were administered in ( %) patient in the non-survivor group vs ( %) patients in the survivor group (p < . ). twelve ( %) patients previously given pulse steroid therapy responded to pe. discussion: we assessed the handling of nmo attacks and identified our flaws. we concluded that pulse steroid therapy should not be withheld or replaced by lower dosage. we also need to find a way to make attacks identified by physicians earlier to shorten the delay between its onset and patient's admission in a specialized care unit. we observed that the mean improvement is modest during the early phase of our treatment. but a modest improvement in the edss can have a great impact in the patient's quality of life and even survival. conclusion: nmo attacks remain a threatening disease despite aggressive treatment. shortening the delay of treatment and ensure adequate pulse steroid therapy coupled to pe could be a way to improve the prognosis. compliance with ethics regulations: yes. rationale: acute kidney injury in trauma patients is a problem that has been little studied in the intensive care unit (icu). its occurrence has been shown to be associated with high morbidity and mortality. we aim to determine the outcome of icu trauma patients with acute kidney injury (aki), including the incidence of death in the icu, of nonreversible renal impairment and icu complications. patients and methods: this is a prospective study, conducted in the department of emergencies and icu, including trauma patients with a minimum icu stay of days. renal failure was defined based on the new kdigo classification. predictors of mortality and poor outcome were identified using univariate and then multivariate analysis. results: one hundred and fifty patients were admitted during the study period for the management of post-traumatic injuries, among which patients were included. the incidence of aki in the studied population was % ( cases) with ( %) diagnosed with stage one, ten ( %) with stage two and ten ( %) with stage three. the overall mortality of patients with post-traumatic aki was . % ( patients) with a mean icu lengh of stay (los) at ± days and of days on ventilator at ± . eight patients ( . %) needed renal replacement therapy and thirty-four had non-reversible renal impairement ( %). during icu stay, eight patients ( %) were diagnosed with pulmonary embolism. on univariate analysis, the following variables were associated to mortality in patients with post-tramatic aki including; age, hemodynamic instability on the day of diagnosis and bilirubin levels on the day of aki diagnosis. besides, according to our analysis, the use of renal replacement therapy and the non-reversibility of renal impairment during icu stay were also associated to icu mortality. among these factors, the non-reversibility of renal impairment in the icu was a predictor of mortality on multivariate analysis (p = . , or = , . in this cohort, the following variables were predictive of non-reversible renal impairment during icu stay; including age (with a best cut-off of years old), medical history of hypertension, higher iss and diuretics' administration. on multivariate analysis, the age (p = . , or = . , ci . - . ) and use of diuretics (p = . , or = , ci . - ) were associated to non-reversible aki in the icu. conclusion: our study confirms that post-traumatic aki in the icu is associated to high morbidity and mortality. the identification of outcome predictors could be valuable to guide the management of aki. compliance with ethics regulations: yes. rationale: the occurrence of acute kidney injury (aki) in trauma patients is a problem that has been little studied to date. its presence has been shown to be associated with an increased risk of morbidity and mortality in affected individuals. to determine the incidence of post-traumatic aki and identify its predictive risk factors that could be eventually prevented. patients and methods: this is a -month long prospective cohortstudy, conducted in the department of emergencies and intensive care unit (icu) of a university hospital, including trauma patients with a minimum icu stay of days. renal failure was defined based on the new kdigo classification. predictors of aki were identified using univariate and then multivariate analysis. results: one hundred thirty patients were admitted during the study period for the management of post-traumatic injuries, among which patients were included. the incidence of aki in the studied population was % ( cases) with ( %) diagnosed with stage one, ten ( %) with stage two and ten ( %) with stage three. on univariate analysis, older age and medical history of diabetes or hypertension were predictors of aki. injury assessment found traumatic brain injury (ais > ), glasgow (gcs) on admission, and the diagnosis of fat embolism to be associated to post-traumatic aki. moreover, hemodynamic instability on admission and during icu stay, shock-index on admission, the amount of fluid administered the use of vasoactive drugs, sepsis, hyperbilirubinemia, p/f ratio and acute respiratory distress syndrome (ards) were also associated to post-traumatic aki. among these factors, ards (p = . , or = , ci - ), fat embolism (p = . , or = , ci . ) without preload-dependence, and were unclassified. multivariate analysis (using variables collected prior to hypotension) identified the following variables as risk factors for the occurrence of hypotension associated with preload-dependence: preload-dependence before hypotension (odds ratio = . , p < . ), fluid removal rate by crrt (or = . per increase in sd, p < . ), and lactate levels (or = . per increase in sd, p < . ). in this single center study, preload dependence-associated hypotension was slightly more frequent than hypotension without preload dependence in icu patients undergoing crrt. testing for preload dependence to adjust fluid removal could help prevent hypotension incidence during crrt. rationale: few studies report the relation between functionnal brain alterations during and after icu stay and abnormalities of cbf displayed on tcd. using vti as hemodynamic parameter is unusual for evaluation of cbf. the purpose of this preliminary study was to compare the values of vti of healthy controls (c) versus icu (p) with usual parameters (i.e. diastolic (vd) and mean velocities (vm), resistance (ir) and pulsatility index (ip)). rationale: accurate diagnosis of the level of consciousness is a challenge and different states such as coma, vegetative state (vs) or minimally conscious state (mcs) are often confused while they convey meaningful prognostic information. this distinction rely on the coma recovery scale-revised (crs-r) gold-standard. however, this clinical scale is imperfect since unresponsive patients can exhibit genuine signs of consciousness using advance neuroimaging techniques. expanding the range of behaviors indexing consciousness at bedside is thus of decisive importance. patients and methods: we designed and proposed a new clinical sign of mcs, the habituation to auditory startle reflex (asr), based on the blink response to repeated sounds: either inhibition of the automatic asr response (extinguishable) or nohabituation (inextinguishable response). we prospectively tested this new sing in patients suffering from disorders of consciousness after severe brain injury and first compared its diagnostic performances with the current gold-standard (crs-r) using standard discrimination metrics (auc, sensitivity, specificity, likelihood ratios) and their % confidence interval. we then investigated the correlates of this new sign on two validated neuroimaging diagnostic procedures (multivariate eeg-based classification of the state of consciousness and fdg-pet metabolic index of the best preserved hemisphere) using an anova with the state of consciousness and the asr response as independent variable. rationale: although continuous electroencephalography (ceeg) is commonly recommended in neurocritical care patients, implementation of this monitoring in routine is facing the need for a specific training of professionals. we evaluated the effectiveness of a training program for the basic interpretation of ceeg to critical care staffs in a prospective multicentre study. patients and methods: after completion of a pre-test, participants (physicians and nurses) recruited in french intensive care units (icu) received a face-to-face eeg learning course, followed by additional e-learning sessions at day- (post-course), day- , day- and day- , based on training tests followed by illustrated and commented answers. each test was designed in order to evaluate knowledge and skills through correct recognition of predefined eeg sequences covering the most common normal and abnormal patterns. the primary objective was to achieve a success rate of more than % of correct answers at day- in at least % of participants. results: among participants, ( . %) completed the full training program and of these ( . %) full-training participants achieved at least % of correct answers at day- . paired comparisons between scores obtained at each evaluation demonstrated a statistically significant increase over time. at day , rates of correct answers were greater than % for all predefined usual eeg sequences, excepted for the recognition of periodic and burst-suppression patterns and reactivity, which were identified in only . % ( % ci . - . ) and . % ( . - . ) and . ( . - . ) tests, respectively. discussion: this multicentric prospective study, which evaluated a training program for the basics of electroencephalography offered to critical care teams, provides interesting information about the training process and its impact on learners according to their different characteristics. we believe that participants reflect the heterogeneity of the various use of ceeg in the critical care setting. participants came from university and non-university icus, and whereas some of them used to monitor patients with ceeg, others were in an implementation process when the last monitored neurocritical care patients with intermittent eeg. in accordance with previous studies, we focused to the entire medical and nursing icu staffs. conclusion: a -months training program aiming to teach the basic interpretation of continuous eeg in the intensive care units was associated with a significant attrition in participation over time. however, participants who received the full training program were capable to accurately recognize the vast majority of eeg patterns that are encountered in critically ill patients. compliance with ethics regulations: yes. mourad goulmane oran hospital and university center, oran, algeria correspondence: mourad goulmane (goulmane.mourad@univ-oran . dz) ann. intensive care , (suppl ):p- rationale: cerebral venous thrombosis (cvt) is a rare but very serious disease with various clinical and etiological aspects. unlike ischemic arterial accidents, epidemiological studies are limited. the aim of our work was to study the clinical, etiological and evolutionary features of cvt in the algerian population from a sample of patients. patients and methods: this is a retrospective observational study conducted in the neurology department of the chu d'oran between january and december . in a clinical context suggestive of cvt, the diagnosis of certainty was provided by brain mri coupled with mra. all subjects benefited from a complete etiological assessment. the anticoagulant treatment was based on the low molecular weight heparin relayed by the anti-vitamin k. the duration of the follow-up was months. results: the mean age was . ± . years, the sex ratio was ( f/ h), the onset was subacute in % of cases. the main early signs were headache ( . %), visual disturbances ( %), epileptic seizures ( . %) and motor deficit ( . %). thrombosis predominated in the upper sagittal sinus and lateral sinuses; parenchymal lesions were associated in / of the cases. gynecologic obstetric causes were by far the most frequent. the evolution was favorable in . % of the cases. discussion: cvt is characterized by its clinical polymorphism, its predominance in young women, and its most often favorable evolution. the causes are multiple and often intricate requiring the realization of a systematic etiological assessment even if the cause seems obvious. the treatment of choice remains early anticoagulation, based on heparinotherapy even in case of hemorrhagic softening. the characteristics of cvt in the algerian population are distinguished by a high frequency of gynecological obstetric causes. awareness campaigns for women of childbearing age are useful. compliance with ethics regulations: not applicable. rationale: the ct-dragon score was developed to predict longterm functional outcome after acute stroke in the anterior circulation treated by thrombolysis. its implementation in clinical practice is hampered by the plethora of variables included. in addition, the score has not been validated in important subgroups such as stroke patients undergoing thrombectomy. given these limitations, the current study was designed to evaluate the use of a simplified score based on machine learning, as a possible alternative. this single-centre retrospective study included patients treated for stroke, in the anterior and posterior cerebral circulation, between - and - . at days, favourable (modified rankin scale (mrs): - ) and miserable outcome (mrs: - ) were predicted by ct-dragon. machine learning selected the aim was to describe the adherence rates to gold guidelines in critically ill copd patients and to identify predictors of low adherence. patients and methods: a prospective cohort study conducted from december to april in a -bed medical intensive care unit of farhat hached hospital. all adult patients admitted for aecopd during the period of the study were included. demographic and clinical data were recorded. adherence to gold was evaluated. univariate and multivariate regression analyses were carried out to identify factors independently associated to non-adherence to gold guidelines. results: seventy-seven patients were recruited. patients' characteristics were : mean age, . ± years; male ( . %); median duration of the disease, [ - ] years; mmrc scale ≥ , ( . %); health insurance coverage rate, ( %); pulmonologist follow up, ( , %); frequent exacerbator (≥ exacerbations in the last year), ( . %); median exacerbations episodes, [ ] [ ] [ ] . long-term oxygen use and home mechanical ventilation were respectively used in ( . %) and ( . %). eight ( . %), ( . %) and ( . %) belonged to copd groups b, c and d, respectively. pharmacological treatment included: saba-ics combination, ( . %), laba-ics, ( . %), laba-lama, ( . %) and lama-laba-ics, ( . %). overall adherence to gold guidelines treatment recommendations for the different stages of copd was ( . %). two patients ( . %) were over treated and ( . %) were undertreated. inappropriate treatment rate was ( %) in gold b, ( . %) in gold c and ( . %) in gold d. univariate analysis identified two factors associated with non-adherence to gold : the absence of pulmonologist follow-up ( % vs. . %; p = . ) and the low income ( . % vs. . %; p = . ). in multivariate analysis only the lack of pulmonologist follow-up was identified as an independent risk factor associated with gold guidelines discrepancies (or, ; % ci [ . - . ]; p = . ). there is a lack of adherence to gold guideline treatment recommendations in tunisian copd patients. this may lead to severe exacerbations. discrepancies were due to the poor access of severe copd patients to an appropriate pulmonologist follow-up. compliance with ethics regulations: yes. the operating theaters concerned were: the otolaryngology block, ophthalmology, vascular and thoracic surgery, and gynecological surgery. all patients over years of age were enrolled using the clinical parameters of difficult intubation (arne score > ), which will benefit from orotracheal intubation. the main judgment criteria were: first-pass success rate, intubation time, which is defined as the time between inserting the slide into the patient's mouth and obtaining the capnography curve, the cormack-lehane score and the pogo score (percentage of opening of the glottis). statistical analysis used spss software. results: a total of patients were included. no cases of failure with this device were observed, the duration of intubation was on average . s (only cases required more than min). the cormack-lehane score and involved patients ( . %), and the pogo score greater than % involved patients ( . %). one case required the features of the simplified score. discrimination, calibration and misclassification of both models were tested. results: % had proximal anterior stroke, % proximal posterior stroke and % lacunar infarcts in either circulation. in % no thrombus was objectivated. % of patients were treated with thrombectomy, % received thrombolysis and % underwent both thrombolysis and thrombectomy. % only received anti-platelet therapy. the area under the receiver-operating-characteristic curve (auc-roc) for ct-dragon was . ( % ci . - . ) for favourable and . ( % ci . - . ) for miserable outcome. r ofct-dragon was . and . for favourable (lack of fit, p = . ) and miserable (lack of fit, p = . ) outcome respectively. misclassification rate was % for favourable and % for miserable outcome with ct-dragon. selection of predictors from the ct-dragon was done by logistic regression, bootstrap forest and decision tree analysis. nih stroke scale, pre-stroke mrs and age were identified as the strongest contributors to favourable and miserable outcome, and included in the simplified score. auc-roc was . ( ci% . - . ) and . ( ci% . - . ) for the prediction of favourable and miserable outcome respectively. r was . and . for the prediction of favourable (lack of fit p = . ) and miserable (lack of fit p = . ) outcome respectively. misclassification rate was % for favourable and % for miserable outcome with the simplified score. the simplified score had better discriminative power than ct-dragon for both outcomes (both p < . ). the ct-dragon score revealed acceptable discrimination in our cohort of both anterior and posterior circulation strokes, receiving a variety of treatment modalities. the simplified score had a better discrimination, while maintaining comparable and good specificity and misclassification rate for miserable outcome. the simplified score needs further validation in a prospective, multi-centre study. compliance with ethics regulations: yes. rationale: the gold report represents a major revision to gold strategy guidelines. it brings new recommendations regarding diagnosis, severity assessment, and both pharmacologic and non-pharmacologic treatment of copd. however, adherence to evidence-based therapeutic guidelines is often poor in low-income developing countries and represents a significant barrier to optimal management. the setting up of an lma-fastrach (desaturation). a case of glottic edema has been noted. discussion: this study shows a very high success rate with this technique ( . % in the first trial and . % in the second trial), in the context of a predictable difficult intubation. the video-airtraq allows a very good visualization of laryngeal structures, a shortening of the duration of intubation, and is rarely responsible for immediate or secondary complications. all the data in the literature go in the same direction. conclusion: at the end of this work, our perspectives are to update the difficult intubation procedure, integrating the video-airtraq into our algorithm, as well as into our difficult intubation trolley. to take into consideration the cost of this device to eventually generalize it to all our structures. compliance with ethics regulations: yes. ) and beds of continuous monitoring. the activity of the cp is organized in a medical visit in the morning and in conducting projects in the afternoon. the activity is presented using a -years balance sheet results: the activity of pharmaceutical interventions (pi) or answers to requests from teams is shown in table . the solicitations doubled the second year. the cp is involved in the conduct of internal or polar projects (set up of cooperative sedation, nutrition…), the good use of health products (relay iv/po, infusion, crushed tablets and compatibility with gastric probe, drug incompatibilities, proton pump inhibitors…), the efficiency of the drug circuit (link with the pharmacy, reflection on the improvement of the circuit, regular meetings with nurses), medico-economic analysis of health products spending and the formalization of actions by protocolisation. he is also very involved in clinical research: patient screening, clinical study setup: blipic study (beta-lactam's dosing in pneumonia in icu in patients treated by continuous renal replacement therapy; clinicaltrials nct ) or in candiarea project (invasive infections to candida and preemptive treatment guided by biomarkers; in progress). a satisfaction survey submitted at months to nurses ( answers/ ) or to doctors/ residents ( / ) reported cp competence in the accompaniment of teams (> %) [in medico-economical, contribution of knowledge, vigilance reflex…], relevance of information transmitted (> %) [administration of drugs, dosage adjustments, …] and his relationship adapted to the units (> %) [communication, availability] . the development of clinical pharmacy in icu involves mastery of the specificities of icu by the cp, requiring a learning period and relationships adapted to clinical situations and teams. many health products projects specific to critical care are coordinated by the cp and made possible by medical and paramedical involvement. the cp appears as a vector of good use both in medical (reasoned prescription) and paramedical (good practices) with increasing solicitation of teams since his arrival. this reception has been facilitated by an innovative approach of clinical pharmacy deployment in our icu on an impulse of the clinical pole compliance with ethics regulations: yes. predicting models such as the news has been developed in the emergency department, but it has only been fewly evaluated in the icu. heart rate variability (hrv) reflects the autonomic nervous system response in various pathological situations and may vary according to patients' physiological status. the rox index, which reflects the acute respiratory failure severity, seems to be a good predictor of high-flow nasal canula failure. the aim of this study was to evaluate the potential value of news, hrv and irox (inversed rox) as poor outcome predictors, using artificial intelligence and machine learning. a retrospective analysis of a prospective datawarehousing project (reastoc clinicaltrials identifier nct ) on icu patients who did not require invasive ventilation. physiological parameters were collected on admission, within a -h delay. news, hrv (in time, frequency, and non-linear domains), and irox were computed and integrated into the prediction model. analysis was performed using medcalc and matlab machine-learning work-package. results: one hundred and twelve patients were included. patients who died in the icu (n = ) had highest news as compared with icu survivors ( . [ . - . ] vs. . [ . - . ] respectively; p = . ). the irox was higher ( . [ . - . ] vs. . [ . - . ], p = . ) and most hrv parameters also depicted higher values for icu survivors. considering a composite icu prognostic outcome parameter (mortality and/or need for any form of respiratory assistance and/or an icu los > median los), there was also a difference for news, hrv and irox (p < . ). the best value to predict icu mortality for news was (auc = . , p = . ), irox > . (auc = . , p = . ) and hrv (shannon entropy) > . (auc = . , p = . ). the best model to predict the need fo respiratory assistance combines irox and hrv (sd /sd ; auc = . , p = . ). adding shannon entropy on this model predicts either the need for respiratory assistance and icu survival (respectively auc . , p = . and auc . , p = . ). in icu spontaneously breathing patients, news, irox and hrv are different in between survivors and patients who died. the best model to predict the need for respiratory assistance combines irox and hrv (sd /sd ). compliance with ethics regulations: yes. rationale: sepsis is known for its important mortality in critically ill patients. the last guidelines defined sepsis as life threatening organ dysfunction. it rejected the concept of systemic inflammatory response syndrome (sirs) associated to suspected or confirmed infection, and considered the concept of dysregulated response to infection. actual guidelines recommend the quick sequential organ failure assessment score (qsofa) to identify patients with sepsis especially when outside intensive care unit. thus, outcomes have mainly to judge the value of sirs in the sepsis- era. the purpose of our study was to compare whereas qsofa score or the sirs criterion are superior to predict in-hospital mortality, shock and mechanical ventilation use in sepsis. our study includes patients in whom the sepsis- definition is met. therefore, this inclusion was retrospectively performed throughout emergency department (ed) admission cases for clinically suspected infection. we collected patients admitted to ed for sepsis. mean age was years ± with bornes of and . men were % of the patients. death occurs in . % of patients, sepstic shock in % and the use of mechanical ventilation in . %. qsofa ≥ has a significant association with in-hospital mortality (p < . ) but not sirs ≥ ( . ). neither qsofa ≥ nor sirs ≥ has association with the use of mechanical ventilation (p = . vs. p = ). whereas, both have a significant association for prediction of septic shock. the absolute sensitivity and negative predictive value in our study can be explained by the small size of our sample. this needs confirmation with literature data about the fact that sirs criterion are superior in term of sensitivity and npv than qsofa to predict septic shock. despite the weak odds ratio (or) of sirs before that of qsofa and the poor specificity and positive predictive value (ppv), we can conclude that sirs according to its sensitivity and npv, seems to persist useful in the sepsis- era as a reliable prognostic tool in the ed. this may need more large studies for confirmation. conclusion: despite sirs has no significant association with mortality in sepsis, it has largely higher sensitivity and superior npv to predict septic shock than qsofa in ed. compliance with ethics regulations: yes. our study aimed to determine the predictive factors of mortality in our patients. retrospective study over years in the intensive care unit of the hospital august. all patients with septic shock were included. a p value < . was considered significant. results: patients were collected. the age ranged from to years old. the average duration of hospitalization in pre-intensive care was days. the reasons for admission: (febrile respiratory distress: % of cases, polytrauma: % and % for sepsis), the most frequent infections: pulmonary ( %) and blood ( %). % received prior antibiotic therapy and % were immunocompromised. the overall mortality was %. the analytical study of the data shows that the age, the length of stay before admission in intensive care and that in intensive care, fever, hypothermia, slimming, hypotension, collapse, failures (respiratory, hematological, renal, hepatic and neurological) and the use of catecholamines are correlated with mortality, whereas sex, chest pain, tachycardia or bradycardia and mottling are not predictive of mortality. conclusion: despite improved techniques for the diagnosis and treatment of patients with septic shock, mortality remains high, especially in the presence of certain risk factors, hence the value of prevention in immunocompromised patients and the reduction in their length of stay in a hospital setting. compliance with ethics regulations: yes. conclusion: p. mirabilis is among the leading bacteria responsible for nosocomial infections in icu. they are emerging highly drug resistant pathogens whose incidence is rapidly increasing in icu. so that, it early identification with in vitro testing is of paramount importance to the success of infectioncontrol efforts. compliance with ethics regulations: not applicable. rationale: influenza is a potential lethal disease causing dozens of thousands excess deaths per year both in europe and in the united states. besides hygiene procedures, vaccination is a cornerstone of influenza prevention and guidelines recommend for vaccination among health workers (hw), especially if they are in close contact with frail people. despite these recommendations, the vaccination coverage is low among health workers both in europe and in the us. the relevance of a mandatory vaccination for health workers is currently a hot topic but data are scarce regarding intensive care unit health workers' opinion. patients and methods: health workers from medical, surgical and polyvalent icus received a link to the electronic record of the survey. results: among the icus, icu health workers (hw) (medical: and paramedical: ) were questioned. three hundred and forty-one icu ( %) answered, ( %) medical health workers (mhw) and ( %) paramedical health workers (phw) (p < . ). among mhw / ( %) were vaccinated vs only / ( %) phw (p < . ). discrepancies exist between medical and paramedical icu health workers' opinions and beliefs about vaccination for influenza and its acceptance. medical health workers were more prone to consider influenza as a potentially lethal disease occurring not only among frail people but also in healthy people, to consider the vaccine efficient and safe. to agree with "vaccination for influenza is mostly related with gain for pharmaceutical industry" (or: [ . - ] ) and to disagree with "the risk of guillain-barré syndrome is higher after an episode of influenza than after vaccination for influenza" (or: . [ . - ] ) were independently associated to the disagreement with a mandatory vaccination for icu hw. conclusion: vaccination for influenza should be strongly recommended as a tool of individual protection for icu health workers as for general population. as confidence in vaccine efficacy and concerns about vaccine side-effects impact the vaccination rate, objective information should be provided to icu health workers about the efficacy and the side effects of vaccination for influenza. compliance with ethics regulations: yes. rationale: intra-abdominal infections are a major cause of morbidity and mortality. sfar recommendations on this topic were published in february . the purpose of this work was to evaluate whether our antibiotic therapy was adequate for these recommendations and whether they were adapted to our unit. the secondary objectives were to look for different risk factors for mortality, to evaluate the impact of inappropriate antibiotic therapy, to evaluate the relevance of carbapenem prescription. this is a single-center retrospective observational study of secondary peritonitis in the tourcoing intensive care unit. for each peritonitis, the epidemiological data and the co-morbidities of the patients were collected. bacteriology and anti-infectious therapies were described to determine the rates of adaptation of our antibiotic therapy and that recommended by sfar. the adequacy of our treatments to the recommendations was also quantifiable. the description of the stay, the occurrence of a death was specified. results: peritonitis were included. the rate of adaptation of the sfar antibiotic therapy was %. the rate of adaptation of our antibiotic therapy was % and its adequacy rate of %. the main differences in prescriptions concerned over-prescription of antifungals, molecule against gram positive bacillus and a sub-prescription of aminoglycosides and beta-lactams, in particular carbapenems. the different mortality risk factors found were sofa score > (or . % ci . - . ), the charlson score > (or . % ci . - . ), the hollow organ perforation (or . % ci . - . ). a comparison of the appropriate or not antibiotic groups did not reveal a significant difference in mortality, number of surgical revision and length of stay. in % of nosocomial peritonitis, antibiotic therapy with carbapenem was recommended. after recovery of microbiological data, it was only necessary for . % of cases. conclusion: our work showed a low rate of compliance with sfar recommendations. these recommendations are applicable to our service by providing a particular reflection for fungal infections. our study does not show a correlation between mortality and inadequate antibiotic therapy, surgery remaining the major treatment. compliance with ethics regulations:yes. rationale: acinetobacter baumannii is a gram-negative opportunistic bacteria that has gained several drug resistance mechanisms over the last decades. analysis of a. baumanii's resistance profile helps to establish a prompt control and a prevention program. the aim of this study was to evaluate the epidemiology and antimicrobial resistance of a. baumannii isolates in a trauma and burn center in tunisia. patients and methods: retrospectively, we studied all strains of acinetobacter baumannii isolated over a -year period (from january to december ). conventional methods were used for identification. antimicrobial susceptibility testing was performed with the disk diffusion method, and susceptibility results were interpreted using clinical breakpoints according to ca-sfm guidelines. data were analyzed using the sir-system. minimum inhibitory concentration (mic) of colistin was determined using the e-test ® method (biomérieux), then using the eucast broth micro-dilution method (umic, biocentric ® ) since may . results: during the study period, non-repetitive strains of acinetobacter baumannii were isolated representing . % of all isolates, % of gram-negative bacilli (gnb) and . % of non-fermenting gnb. in our center, infections due to a. baumannii were endemic with epidemic peaks. a. baumannii was mainly isolated from burn intensive care unit ( %) and anesthesiology department ( . %). the most frequent sites of isolation were blood cultures ( . %), catheters ( %), respiratory specimens ( . %) and skin samples ( % sampling duration is also reduced, improving workflow. evaluators consider that bronchosampler rationalizes the cumbersome sampling process and that the closed system design reduces the risk of losing sample or sample contamination. the set-up, the suction capacity, the sampling quality and quantity have all been evaluated better or far better than that usually observed with usual sampling techniques and devices. finally, ( %) of users prefer bronchosampler to commonly used method. conclusion: this satisfaction survey shows that with its simple but revolutionary design, bronchosampler brings a real effective benefit in sampling procedure enabling the clinician to perform it alone, and ( %) of the survey evaluators consider that bronchosampler should replace their current practice. compliance with ethics regulations: yes. rationale: the possibility of having a sensitive, specific and prognostic biological marker for bacterial infections is a considerable challenge. a step was taken with the discovery of pracalcitonin. patients and methods: this is a prospective observational cohort study of patients in the medical resuscitation department of the university hospital of casablanca during the -month period, including patients in whom the pct was dosed. the data collected allowed us to form two groups according to the pct value: pct+ group with pct > ng/ml and pct− group with pct < ng/ml. the statistical analysis of these different data was carried out using epi info software version . . . results: % of our patients had a bacterial infection and % did not have one. we also distinguished community infections ( % of i+ patients) and nosocomial infections ( % of i+ patients). we found that the highest rates of pct were in nosocomial infections and the lowest pct rates were found in community-acquired infections. then, in each type of organ involvement we tried to vary the pct thresholds to . - and ng/ml in order to find the best threshold for which pct allowed to diagnose bacterial infection, justifying our choice of departure. we concluded that the best pct cut-off value in general was ng/ml, because it gave us the best sensitivity/specificity ratio ( % and % respectively) with a positive predictive value of % and a negative predictive value of %. the link between pct and bacterial infection was moderate (yule q-factor at . ). by analyzing the different therapeutic aspects, we showed that % of our patients had been treated with atb before the pct assay and that the broadest spectrum antibiotics available to our service were used in patients with pct levels the highest. finally, concerning the evolution, the higher the rate of pct, the higher the death rate, especially since % of patients with pct > ng/ml died. conclusion: procalcitonin is considered to be one of the best markers of systemic bacterial infection. indeed, its elevation is earlier than that of crp and its specificity is better compared to il- and il- . the rate of procalcitonin remains low in the presence of viral infection. procalcitonin is also a prognostic marker, its elevation is correlated with the severity of the infection, and its decrease is a good indicator of the effectiveness of antibiotic therapy. compliance with ethics regulations: not applicable. rationale: due to induction immunosuppression infection is the most common cause of mortality within the first year after lung transplantation (ltx). the management of perioperative antibiotic therapy is a major issue, but little is known about worldwide practices. we sent by email a survey to ltx centers around the world dealing with daily clinical vignettes concerning perioperative antibiotic therapy. we considered perioperative period as the period of the transplant surgery (per operative) and the postsurgery time before any infection occurrence (postoperative). after general questions on local practices, we asked each center for colonization definition and their diagnostic methods for microbial screening in recipients and donors. the clinical cases were related to specific issues concerning the management of antibiotic therapy in different clinical situations, including no prior colonization, prior colonization with sensitive or multi-drug resistant (mdr) microorganisms including prior colonization with mdr bacteria not sensitive to beta-lactams. the invitation and a weekly reminder were sent to lung transplant specialists for a single consensus answer per center between june and september . we received a total of responses from countries, mostly from western europe (n = ) and the usa (n = ), (fig. ) . systematic screening for bronchial colonization before ltx was mostly performed with sputum samples ( %), regardless of the underlying lung disease. definition of colonization was very heterogeneous and the delay between the last bacterial isolation in pre-transplant and the ltx to consider if the therapy should target these bacteria varied between week and more than year. in recipients without colonization, antibiotics with activity against gram-negative bacteria resistant strains (piperacillin/tazobactam, cefepime, ceftazidime, carbapenems) were reported in % of the centers, and antibiotics with activity against methicillin-resistant staphylococcus aureus (mainly vancomycin) were reported in % of the centers. for these recipients, the duration of antibiotics reported was days ( %) or less ( %) or stopped when cultures of donor and recipients were reported negatives ( %). in recipients with pre-transplant colonization, antibiotics were adapted to the susceptibility of the most resistant strain isolated in pre-transplant samples and given for at least days ( %). conclusion: practices vary widely around the world, but resistant bacterial strains are mostly targeted even if no colonization occurs. the antibiotic duration reported was longer for colonized recipients. compliance with ethics regulations: not applicable. the vancomycin was therefore considered as justified or not and appropriate or not. occurrence of nephrotoxicity and supratherapeutic exposure in this study group was compared to critically ill children control group. results: thirty one children receiving vancomycin lines of treatment whose ( %) observed a risk of acute kidney injury (aki) (n = ) and an aki (n = ) during the vancomycin treatment period were included. there was a trend to inversed relationship between plasmatic concentrations of vancomycin and estimated creatinine clearance (r = . ). seven patients observed a nephrotoxicity related to vancomycin, they had a higher plasmatic concentration of vancomycin (p = . ). seven patients ( %) had a supratherapeutic exposure to vancomycin. nephrotoxicity and supratherapeutic exposure were higher in children with or combined liver-kidney transplantation than in comparative critically ill children group. we found blood stream infection due to the central catheter and blood stream infections probably due to the central catheter. one hundred thirtyfive bacteria were identified of which ( %) were staphylococcus coagulase negative. nineteen ( %) lines of vancomycin were appropriate and ( %) were justified. conclusion: vancomycin could have been avoided in one third of children with liver or combined liver-kidney transplantation during the early phase of postoperative stage. vancomycin is associated with a risk of both nephrotoxicity and supratherapeuric exposure. vancomycin should be used with caution, appropriate indications and dosing in this vulnerable population. compliance with ethics regulations: yes. rationale: early bacterial infection is a major and severe complication occurring within the first month after pediatric liver transplantation (lt). the rise of antimicrobial resistance, especially extended-spectrum beta lactamase producing enterobacteriaceae (esbl-pe), is henceforth a concern for these patients. this study aimed to assess the epidemiology of early bacterial infections, including those caused by multidrugresistant (mdr) pathogens, and to identify the risk factors for infection. rationale: the number of cancer patients admitted to emergencies is clearly increasing and digestive oncology is the leading cause of consultation. the aim of this work is to identify the epidemiological factors, the therapeutic modalities as well as the predictive factors of mortality and to compare them with the data of the literature. patients and methods: patients admitted to visceral emergencies for an urgent syndrome revealing or complicating a primary or secondary digestive cancer, and who required immediatemedical and/or surgical intervention and who had stayed at the surgical resuscitation level in our hospital center for a duration of years. several data were entered on excel and analyzed using the spss version software.-epidemiological, concerning age and sex; -clinics including risk factors, history, general condition of the patient and clinical examination data; -para-clinical, interesting biological assessments, and morphological examinations-medical and surgical therapeutics; -postoperative follow-up-treatment results. the three most frequent sites were rated in order of increasing frequency: colo-rectum ( %), pancreas ( %), and stomach ( %). the age group most found was age over years with % of cases, % of patients had under years. this series includes men and women with a sex ratio of , . the installation method was mostly gradual with % of cases. our patients have consulted for urgent clinical presentations mainly occlusive syndrome noted in % of patients. abdominal ct was the first examination performed, followed by abdominal ultrasonography in % and %, respectively. the therapeutic management was medico-surgical. the surgery done in % of patients, % for palliative indication: % were operated for an ostomy discharge, % for a digestive bypass, % for a palliative resection and % for a stoma feeding. postoperative outcomes were % morbidity and % mortality. the main cause of death was septic shock in % of cases, thanks to multivariate statistical analysis three factors were deduced significantly related to mortality: the asa score: p = . ; or = . ; ic: [ . ; . icu and hospital mortality rates were % (n = ) and . % (n = ), respectively. ten patients were alive months after with a median rankin score at [ - ]. more than half of the patients without stupor had a favorable neurological outcome (fig. ) . in univariate analysis, mechanical ventilation and stupor were correlated with mortality, whereas dic and apl were not. by multivariate analysis stupor was the only factor significantly associated with a higher mortality (hr: . [ . - . ] ). conclusion: intracranial hemorrhage is associated with a high mortality rate in al patients, stupor at the onset of intracranial bleeding being independently associated with poor outcome. up to one third of patients will nevertheless survive and experience a favorable neurological outcome. compliance with ethics regulations: yes. neurological outcome assessing by modified rankin scale according to stupor or coma at intracranial hemorrhage diagnosis (blank reflect missing data) rationale: sinusoidal obstruction syndrome (sos, previously known as veno-occlusive disease) is a complication of high dose chemotherapy, frequently occurring during bone marrow transplantation (bmt). severe sos is associated with a high mortality rate, related to multi-organ failure (mof). defibrotide being the only available option for prevention and treatment. prognosis of patients with sos requiring intensive care unit (icu) admission remains unknown. the primary objective was to assess the outcome of these patients. secondary objective was to assess risk factors associated with hospital mortality. patients and methods: retrospective study conducted between january and july in french icus. critically ill adult patients with sos (according to ebmt classification) who received defibrotide were included. results are reported as median [iqr] or number (%). adjusted analysis was performed using cox model. results: seventy-one patients were included with a median age of years . underlying hematologic diseases were acute myeloid leukemia ( %), lymphoma ( %),myelodysplasia/myeloproliferative neoplasm ( %) or acute lymphoid leukemia ( %). sos occurred during myeloablative allogeneic bmt ( %), reduced conditioning allogeneic bmt ( %), autologous bmt ( %) or chemotherapy ( %, including gemtuzumab ozogamycin in patients). median sofa score at icu admission was ]. ebmt prognostic score was often "very severe" ( %). main reasons for icu admission were respiratory failure (n = ), acute renal injury (n = ), shock (n = ), liver failure (n = ), coma (n = ) and monitoring (n = ). median bilirubin level at icu admission was µmol/l [iqr - ] and platelets count g/l . mechanical ventilation (mv), vasopressors, and renal replacement therapy (rrt) were required in % (n = ), % (n = ) and % (n = ) of patients, respectively. sixteen patients receiving defibrotide experienced bleeding events. icu and hospital mortality rates were % and % respectively, mainly related to organ dysfunction. in univariate analysis, delayed defibrotide initiation, bilirubin level, organ supports, sofa, and ebmt scores were associated with hospital mortality. cox model identified older age (hr . , % ci . - . ), mv (hr . , % ci . - . ), rrt (hr . , % ci . - . ), as associated with mortality. prophylactic defibrotide was correlated with a better outcome (hr . , % ci . - . ). similar results were observed after adjustment for center effect. conclusion: when organ support is required, icu management is associated with high mortality. organ support (namely rrt and mv) and older age were associated with poor outcome. prophylactic defibrotide was associated with survival either due to selection process or to efficacy in this setting. additional studies are needed to confirm these results. compliance with ethics regulations: yes. rationale: prognosis of critically ill immunocompromised patients (ciip) has improved over time. neutropenia is common and is found in one third of these patients. prognostic impact of neutropenia remains controversial and little data focus on ciip admitted in a context of acute respiratory failure (arf). primary objective was to assess prognostic impact of neutropenia on outcome of these patients. secondary objective was to assess etiology of arf according to neutropenia. patients and methods: retrospective analysis of prospective multicenter multinational dataset. adults immunocompromized patients with arf were included. adjusted analyses included ( ) a hierarchical model with center as random effect; ( ) propensity score (ps) matched cohort; and ( ) adjusted analysis in the matched cohort. results: overall, patients were included in this study. median age was [iqr - ] and patients ( . %) were of female gender. median sofa score was [ ] [ ] [ ] [ ] [ ] [ ] [ ] and ps was [ ] [ ] [ ] [ ] . main immune defect were hematological malignancy in patients ( %), solid tumor in ( %), systemic disease in ( . %), and other immunosuppressive drugs in ( %). neutropenia at admission was observed in patients ( %). initial oxygenation strategy was oxygen in patients ( %), high flow nasal oxygen in ( %), non-invasive ventilation in ( %) and invasive mechanical ventilation in ( %). before adjustment, hospital mortality was significantly higher in neutropenic patients ( % vs. % in non-neutropenic patients; p = . ). after adjustment for confounder in a mixed model, neutropenia was no longer associated with outcome (or . , % ci . - . ). after ps matching, neutropenic and non-neutropenic patients were compared. hospital mortality was similar in both groups ( % vs. % respectively; p = . ). after adjustment for variables associated with mortality, neutropenia was not associated with hospital mortality (or . , % ci . - . ). arf etiologies were distributed similarly in both neutropenic and non-neutropenic patients (fig. ) , main etiologies being bacterial pneumonia ( % vs. %), invasive fungal infection ( % vs. %), pneumocystis jiroveci pneumonia ( % vs. . %), and undetermined etiology ( % vs. %) (p = . ). conclusion: neutropenia at icu admission is not associated with hospital mortality in this cohort of ciip admitted for arf. surprisingly, arf etiology did not differ despite the multiplicity of observed immune defects. compliance with ethics regulations: yes. rationale: hepatic dysfunction (hd) is commonly observed in patients with hematologic malignancies and associated with an increased mortality in allogeneic hematopoietic stem cell transplantation patients. we aimed to assess incidence, risk factors and prognostic impact of hd in a large multicenter cohort study of critically ill patients with hematologic malignancies. patients and methods: this research was a post hoc analysis of a franco-belgian multicenter prospective study assessing the prognosis of patients with hematologic malignancies admitted to intensive care unit (icu) between january and may . hd was defined as serum total bilirubin ≥ µmol/l at icu admission. for patients with hd, a review of medical hospital records was performed by an expert panel to assess management of hd by attending physicians. results: among the patients with hematologic malignancies admitted to icu, were included in the study, mainly patients with non-hodgkin lymphoma ( . %) or acute myeloid leukemia ( . %). hd at icu admission occurred in patients ( . %). factors independently associated with hd were the use of cyclosporine (or = . , % ci . - . , p < . ) and antimicrobial treatment (or = . , % ci . - . , p = . ) before icu admission, abdominal symptoms at icu admission (or = . , % ci . - . , p < . ), ascites (or = . , % ci . - . , p = . ), hepatic charlson comorbidity (or = . , % ci . - . , p = . ), increased creatinine at icu admission (or = . , % ci - . , p = . ), neutropenia (or = . , % ci . - . , p = . ) and myeloma (or = . , % ci . - . , p = . ). hospital mortality was . % and . % in patients with hd and patients with no hd respectively (p < . ). hd appeared as an independent factor of hospital mortality after adjustment with other organ failure (oradj = . , % ci . - . , p = . ). factors independently associated with hospital mortality among patients with hd at icu admission are reported in table . etiologic diagnoses for hd by physicians were undetermined for patients ( . %) including ( . %) for whom the existence of hd has not even been mentioned in the medical record. investigations were performed in % and only % of patients received a specific treatment for hd. conclusion: hd at icu admission is common, underestimated, poorly investigated, and impairs outcome in critically ill patients with hematologic malignancies. hd should be considered and managed as other organ dysfunctions. it raises the importance of an early severity assessment of hd and a development of diagnosis strategies to get therapeutic options, in close collaboration between hematologists and intensivists. compliance with ethics regulations: yes. rationale: acute respiratory failure (arf) is the main cause for admission to the icu for patients with hematological malignancies (hm). viral pneumonia is poorly described in this population. respiratory viruses pcr is a rapid and sensitive diagnostic tool. thoracic ct allows to guide the diagnosis but is also poorly described. the primary objective was to describe ct features suggesting viral pathogenicity. secondaryobjectives were to assess risk factors associated with the use of invasive mechanical ventilation (imv) and icu mortality. rationale: high-dose methotrexate (hd-mtx) is commonly used in the treatment of solid tumours and hematological malignancies. severe toxicities are frequent, leading to organ dysfunction, multiple organ failure and death. outcome of these patients when critical illness occurs is poorly studied. this study aims to describe mtx-induced toxicities and to assess outcome in critically ill patients. in this retrospective study conducted in the icu of one university hospital between january and december , all the patients who were given hd-mtx (single dose greater than mg/m ) in the icu were included. results are presented as median [interquartile range] and number (percent). results: patients ( men and women) aged years [ - ], were included. b-cell lymphoma had been diagnosed in patients (burkitt, n = ; diffuse large b cell lymphoma with cns (central nervous system) involvement, n = ; primary cns lymphoma, n = ) and t-cell lymphoma in two patients. patients were mainly admitted for coma (n = ; %) or acute kidney injury (n = ; %). mtx was administered at a median dose of . g [ - ] . fourteen patients had concomitant medication interacting with mtx. median mtx clearance was days [ ] [ ] . frequent mtx-related complication were mucositis (n = , %), diarrhea (n = , %) or hepatic failure (n = , %). during icu stay, patients experienced acute kidney injury (kdigo stage . [ ] [ ] ). two patients received carboxypeptidase and three underwent dialysis. overall, patients ( %) required mechanical ventilation, ( %) vasopressors. hospital mortality was % (n = ). cox model identified mtx concentration h after administration higher than . µmol/l as associated with hospital mortality (hr . , % ci . - . ) (fig. ) . conclusion: to our knowledge this is the first study assessing characteristics and outcome of critically ill patients receiving hd-mtx. mtx concentration at h was associated with hospital mortality. despite underlying malignancy, icu support of these patients was associated with a meaningful survival. compliance with ethics regulations: yes. rationale: high-dose methotrexate ( g/m ; hdmtx) is the cornerstone of chemotherapy in acute lymphoblastic leukemia (all) and several high-grade non-hodgkin lymphoma (hnhl). despite standardized prevention, acute kidney injury (aki) and other life-threatening complications still occur. given the cost of glucarpidase, an enzyme that metabolizes mtx in few minutes, and the complexity of hematological patients admitted to the icu, a better comprehensive view of the factors that predict hdmtx toxicity, as well as the role of glucarpidase as rescue therapy in patients with organ failure, is mandatory. patients and methods: retrospective monocenter study including all the adult patients referred for all or hnhl in a french university hospital, and who received hdmtx. aki was defined according to the kdigo classification. univariate analysis (fischer exact or mann-withney tests) followed by multivariate analysis (stepwise logistic regression) were used to identify before hdmtx the clinical and biological predictive factors of aki. outcomes following glucarpidase were also addressed. results: from dec- to sept- , patients received hdmtx (median dose g/m ; all n = , hnhl n = ), totalizing hdmtx pulses. sixty-nine patients ( . %) developed aki after a median time of days (stage n = , stage n = , stage n = including one requiring dialysis in the first week). by multivariate analysis, only age, body mass index and a diagnosis of all were significantly and independently associated with the risk to develop aki. mtx exposure (maximal serum concentration at h - ) was also associated with aki (auc . , p < . ). glucarpidase was used in patients ( %) that differed by a higher age and bmi, and a lower basal egfr. glucarpidase was followed by a rapid renal improvement but serum creatinine did not return to baseline ( vs. micromol/l). thirty patients with aki or delayed mtx elimination did not receive glucarpidase but none required renal replacement therapy and egfr was only slightly but not significantly reduced at the end of follow-up. extra-renal adverse-events (rbc and platelets transfusions, neutropenia, hepatitis, severe diarrhea, mucitis) were more frequent in patients that developed aki. eighteen patients were admitted to the icu, including and that required mechanical ventilation or vasopressor drugs, respectively. conclusion: few actionable factors predict the development of aki after hdmtx, suggesting additional genetic factors. aki was reversed by glucarpidase but progression toward ckd was the rule. further studies will have to identify patients that will actually beneficiate from glucarpidase. compliance with ethics regulations: yes. khaoula ben ismail, sana khedher, ameni khaled, nassereddine foudhaili, mohamed salem usi digestif-service de gastroenterologie-eps charles nicolles.tunis-tunisie., tunisia, tunisia correspondence: khaoula ben ismail (khaoula @hotmail.fr) ann. intensive care , (suppl ):p- rationale: infection is common and accounts for major morbidity and mortality in cirrhosis. patients with cirrhosis are immunocompromised and have increased susceptibility to develop spontaneous bacterial infections, hospital-acquired infections, and a variety of infections from uncommon pathogens. we aimed to evaluate the impact of infection on hepatic encephalopathy. patients and methods: this is a prospective study, conducted over a period of years from january to december . consecutive patients with approved decompensated cirrhosis admitted to our department are included. all clinical and biological data were collected from the medical records. univariate and multivariate analysis were used to identify the impact of infection on hepatic encephalopathy. results: a total of patients diagnosed with decompensated cirrhosis were enrolled in this study. mean of age was years ( - ). sex ratio was . . hcv ( %) was the main etiology of cirrhosis. the reasons of hospitalization were: oedema with ascitic syndrome ( % of cases), digestive bleeding ( % of cases), fever ( % of cases), and encephalopathy ( % of cases). patients with infection seemed to have a high incidence of hepatic encephalopathy with % versus % when the patients are none infections. the results also showed that in those with hepatic encephalopathy, an effective antibiotic treatment accelerates significantly wakefulness under h with a rate of % vs. % (p < . ) . in addition, the infection does not influence mortality or length of stay compared to other complications such as digestive bleeding. conclusion: we found that infection caused more episodic hepatic encephalopathy than other complication and an effective antibiotherapy accelerate wakefulness. compliance with ethics regulations: yes. rationale: hepatic encephalopathy (he) is a common cause of hospitalization in patients with cirrhosis. pharmacologic treatment for acute (overt) he has remained the same for decades. to compare polyethylene glycol electrolyte solution (peg) and lactulose treatments in patients with cirrhosis admitted to the hospital for he. we hypothesized that rapid catharsis of the gut using peg may resolve he more effectively than lactulose. patients and methods: this is a prospective study, conducted over a period of years. from janury to december , we have been interested in cirrhotic patients with hepatic encephalopathy. all clinical and biological data were collected from the medical records. univariate and multivariate analysis were used to identify the difference beteween peg and lactulose in the treatement of hepatic encephalopathy. results: a total of patients diagnosed with decompation of cirrhosis were enrolled in this study. mean of age was years ( - ). sex ratio was . . hcv ( %) was the main etiology of cirrhosis. the hospitalization reasons were: edematous-ascitic syndrome in %, gastro-intestinal bleeding %, fever in %, and encephalopathy was present in % of cases. a total of patients were randomized to each treatment arm. baseline clinical features at admission were similar in the groups. twelve of patients in the standard therapy arm ( %) had an improvement of or more in hesa score, thus meeting the primary outcome measure, compared with of evaluated patients receiving peg ( %) (p < . ). the mean ± sd hesa score at h for patients receiving standard therapy changed from . ± . to . ± . compared with a change from . ± . to . ± . for the peg-treated groups (p = . ). the median time for he resolution was days for standard therapy and day for peg (p = . ). adverse events were uncommon, and none wasdefinitely study related. conclusion: we found that peg led to more rapid he resolution than standard therapy, suggesting that peg may be superior to standard lactulose therapy in patients with cirrhosis hospitalized for acute he. compliance with ethics regulations: yes. acute pancreatitis and pregnancy janati adnane, lina berrada obstetric intensive care unit, casablanca, morocco correspondence: janati adnane (adnanejanati@gmail.com) ann. intensive care , (suppl ):p- rationale: the association of acute pancreatitis and pregnancy is rare but not negligible, it often cause a diagnostic problem given the gravidal context that can lead to serious repercussions. the objective of our study is to assess the particularities in the diagnosis, management and prognosis of acute pancreatitis during pregnancy patients and methods: this is a retrospective study about cases of acute pancreatitis occurred during pregnancy over a -year period ( - ) at the obstetric intensive care unit of the meriem maternity hospital in the chu ibn rochd casablanca. a retrospective analysis of the medical files of these patients was carried out, considering epidemiological and etiological criteria, the treatments administered and maternal/fetal fate. we found cases during this period, with an incidence of / . the average age of onset was years, % of cases occurred in the rd trimester. epigastric pain and vomiting were the common symptomatology. ultrasound showed biliary lithiasis in % of cases with increased pancreas size in % of cases. maternal mortality was zero. uncomplicated benign forms are the most common ( %). severe hypokalemia was found in % of patients. neonatal morbidity was marked by six premature deliveries. among them, a newborn died at day- of life discussion: the association of acute pancreatitis and pregnancy is rare, more frequent during the rd trimester, it mainly affects the young woman. lithiasic biliary pathology remains by far the most frequent etiology. the diagnosis is clinical most often represented by epigastralgia with vomiting and biological via lipasemia and amylasemia dosage. uncomplicated benign forms are the most common. hydroelectrolytic disorders are often found. abdominal ultrasound allows the etiological diagnosis. the treatment is above all symptomatic whose objective is the digestive rest, the correction of the hydroelectrolyte disorders but first of all relieve the pain. conclusion: acute pancreatitis is a rare event in pregnant women, but can have a maternal and fetal prognosis. it must be systematically evoked in front of the acute abdominal pains of the pregnant woman because the confirmation of the diagnosis is easy and the maternal results depend mainly on therapeutic management. prematurity remains the predominant factor in neonatal morbidity. compliance with ethics regulations: not applicable. rationale: aclf is a clinical concept defined in patients with chronic liver disease who presented organ failure(s) secondary to an acute decompensated event. liver transplantation in this indication showed good results in selected patients. the aim of this prospective study was to evaluate the outcome and the factors associated with a favorable selection to liver transplantation in this population. patients and methods: all consecutive patients admitted to the icu with cirrhosis and aclf, were recruited. patient with age < years or with fulminant hepatitis were excluded. results: between july and february , cirrhotic patients were admitted to icu. mean age was . ± . years ( . % male). cirrhosis was due to alcohol in . % of the patients. aclf grading at admission was: . % aclf (n = ), . % aclf (n = ), . % aclf (n = ), and . % aclf (n = ). of the patients, . % (n = ) were considered to be eligible for a transplant project and were assessed for liver transplantation. the main reasons were alcohol abuse ( . %, n = ), death within days after admission ( . %, n = ) and rapid improvement of the liver disease. of the eligible patients, % were transplanted with a mean time between admission to icu and liver transplantation of . ± . days. twelve patients died on the waiting list ( % of the listed patients), mainly of septic shock. among those who were assessed for liver transplantation but not listed (n = ), . % died before the listing (n = ) and . % were not listed because of severe comorbidities (n = ). the global mortality rate was . % (n = ). the and days rate mortality were respectively . % and . %. the overall -month patient survival was respectively % and % in the transplant and non-transplant group (p < . ) for the entire cohort. among eligible patients, factors associated with the absence of liver transplantation, in the multivariate analyses, were mechanical ventilation (hr . , % ci rationale: body composition is known to be a prognostic factor in cirrhotic patients. however, the link between this and the prognosis of patients in intensive care unit (icu) is unknown. the computed tomography offer accurate estimations of muscle mass by analysing a cross-section usually going through the third lumbar vertebrae. this retrospective study aimed to assess the feasibility of body composition (bc) analysis in cirrhotic patients with septic shock, using computed tomography (ct) and evaluate the impact of bc (muscle mass, subcutaneous and visceral fat) on outcome. patients and methods: this retrospective study included cirrhotic patients with septic shock hospitalized in icu who underwent an abdomino pelvic ct scan within h of admission. we collected the surface areas of muscle mass and adipose tissue on the ct scans. we compared bc data with mortality and with the number of organ failures. the average age was years . the average child and meld scores were respectively . [ - ] and . . the prevalence of sarcopenia was %. it was not associated with a higher mortality rate at day (p = . ) or with a higher number of organ failures at day (p = . ). we observed a higher subcutaneous adiposity index in patients who died at day (p = . ) and in patients with renal insufficiency at admission (p = . ). there was a trend (p = . ) towards more visceral fat in patients who died in icu. the assessment by ct of body composition reveal evaluation of bc using ct is feasible and reproducible and may constitute a promising tool to evaluate in cirrhosis critically ill patients. visceral fat mass seems associated with poor outcome in cirrhotic patients with septic shock compliance with ethics regulations: yes. rachid jabi, mohammed bouziane chu mohammed vi, oujda, morocco correspondence: rachid jabi (jabirachid@gmail.com) ann. intensive care , (suppl ):p- rationale: the infection of the necrosis constitutes a pejorative element in the management of the necrotico-haemorrhagic pancreatitis, in the absence of the drainage the mortality approaches %. the morbidity and mortality of surgery can be avoided with minimally invasive treatments. purpose: to compare the morbidity and mortality of the two groups of post-ercp pancreatitis and the other etiologies. patients and methods: a retrospective study over years between and and a comparison between pancreatitis secondary to post-ercp and other etiologies of pancreatitis. a p value of . is considered significant. the surgical treatment used in cases of superinfection post ercp against seven cases of other etiologies of pancreatitis. high mortality in post-ercp pancreatic arm % vs. % (p = . ). high morbidity in the operated group % vs. % (p = . ) represented mainly digestive haemorrhages. duration of stay was significantly longer in the operated group vs. days (p = . ). thrombocytopenia and beta-lactamase-producing enterobacteria have further complicated management in the post-ercp infected pancreatitis arm. the antibiotic resistance of infected pancreatitis in post-ercp patients is . % for ciprofloxacin, . % for imipenem and % for amikacin. conclusion: pancreatitis the most common adverse effect of ercp with significant morbidity and mortality. the collaboration between the intensive care unit gastroenterologist and the surgeon improves management since the risk factors are mainly related to the patient and can not be modified. compliance with ethics regulations: yes. gautier nitel, aghiles hamroun, anne bignon, gilles lebuffe chru lille, lille, france correspondence: gautier nitel (gautier.nitel@gmail.com) ann. intensive care , (suppl ):p- rationale: liver transplantation (lt) has been recently experiencing an expansion of its indications, allowing patients with potentially more co-morbidities to access to transplantation. in our era of graft shortage, we should focus on the identification of the best lt candidates. the aim of our work is to study the determinants of early morbidity and mortality after lt from three angles: occurrence of a major cardiovascular event (mace) or acute renal failure (kdigo stage - aki) in the first days postoperative, and death in the year following lt. retrospective study investigating the occurrence of mace or aki (kdigo - ) within days post-operative and mortality at year after lt, including patients who received a first lt between january and december in our center. analysis of risk factors by a multivariate step-by-step analysis. statistical significance for p < . . data presented in odds ratio (or) rationale: infectious complications are frequently reported in critically ill patients supported by veno-arterial extracorporeal membrane oxygenation (va-ecmo) for refractory cardiogenic shock, but their diagnosis is challenging. no study has specifically studied bloodstream infection (bsi) in this population and some recommendations suggest performing systematic blood culture (bc). in our unit, systematic bc are daily sampled. we investigated the interest of systematic bc to detect bsi under va-ecmo. patients and methods: in a retrospective analysis ( - ), and after exclusion of patients dying within h, all adult patients from cardio-vascular intensive care unit supported by va-ecmo were included. systematic daily and "on demand" bc (at the physician's discretion) performed from va-ecmo implantation to days after withdrawal were analyzed. bsi was defined as at least one bc positive to a pathogen (except for contaminants bsi which required at least two positive bc with the same bacteria in h). multivariable logistic regression was performed to identify risk factors for positivity of systematic bc. rationale: fungal infections are constantly increasing in hospitals. indeed, the increase in these infections and especially candida yeast infections is almost parallel to the increase in the widespread use of a wide range of implanted medical devices such as catheters. for this reason, we have been investigating, isolating and identifying candida yeast colonizing vascular catheters and studying the epidemiological and clinical characteristics of patients with colonized catheters. patients and methods: it is a prospective, transversal study conducted at the intensive care and neurosurgery services of the sétif university hospital, evaluating the fungal colonization of vascular catheters. these are collected from hospitalized patients for a period of months. a culture of the distal end of the catheter is performed directly after its ablation. the results obtained showed that among the samples taken, six are colonized by the yeasts, the incidence is %. six yeast of candida spp were isolated, % of them were candida albicans species, . % candida parapsilosis and . % were candida glabrata. conclusion: it appears that colonization of catheters occurs most frequently in patients with the following characteristics: extreme ages of life, male sex, antibiotic therapy and length of hospitalization or prolonged catheterization. compliance with ethics regulations: yes. rationale: the threat of emergent extensively drug-resistant bacteria (exdr) dissemination worldwide is real. it has become a global public health issue. in fact, glycopeptides-resistant enterococcus faecium (gre) and carbapenemase-producing enterobacteriaceae (cpe) are the lead microorganisms in the high resistant bacteria category. the aim of our study was to characterize the molecular mechanisms and to determinate the antimicrobial susceptibility profiles of gre and cpe isolated from burn patients. patients and methods: prospectively, we studied all cpe and gre strains isolated from burn patients between january and december . all isolated microorganisms were identified on the basis of conventional microbiological techniques. antibiotic susceptibility testing was carried out by the agar disc diffusion method, and susceptibility results were interpreted using clinical breakpoints according to ca-sfm guidelines. molecular characterization was performed by multiplex real-time pcr (cepheid, genexpert ® ) allowing detection of the most prevalent carbapenemase encoding genes (blavim, blandm, blaimp, (blaoxa- and blakpc) as well as the genes vana and vanb of gre. results: during the study period, exdr were isolated from burn patients. the most frequent sites of isolation were blood cultures ( %) and skin samples ( . %). cpe represented . % of isolated exdr ( strains). among them, the most frequently identified species was klebsiella pneumoniae ( . %) followed by enterobacter cloacae ( %). twenty-four cpe ( . %) expressed the blandm gene. the blaoxa- gene was found in strains ( . %) and ten strains ( . %) carried both genes. of the cpe, . % revealed ertapenem mic > mg/l whereas most strains were susceptible to imipinem and meropenem with . % and . % of susceptibility, respectively. the antibiotics showing the highest resistance rates were cefotaxime ( . %), piperacillin-tazobactam ( . %), ciprofloxacin ( . %) and amikacin ( . %). the most active agents were colistin and fosfomycin with . % of resistance for each. seven strains of gre were isolated ( . % of exdr). all of them expressed the vana gene, with vancomycin mic > mg/l. however, teicoplanin mics ranged from to mg/l. all gre strains were beta-lactam resistant and highly resistant to aminosides. linezolid and tigecycline were the only active antibiotics. the dissemination of these extensively drug-resistant bacteria must be contained by implementation of strict isolation methods and better hygienic procedures in order to limit their economical and health consequences. compliance with ethics regulations: yes. rationale: stenotrophomonas maltophilia has emerged as an important pathogen that induces nosocomial infections. it is a non-fermentative, gram-negative bacillus that causes severe infectious diseases, particularly bacteremia in the hospital setting. morbidity and mortality due to stenotrophomonas maltophilia seems to be high, particularly in critically ill patient. the aim of this study was to describe the clinical features, management and outcome of patients with stenotrophomonas maltophilia infections. patients and methods: this was a retrospective analysis of prospectively collected data of patients hospitalized in intensive care unit (icu) between january and december . collected data were: age, gender, comorbidities, severity scores on admission, prior infections, use of antibiotics, use of invasive devices (urinary tract catheter, or mechanical ventilation), microbiological data, and antimicrobial therapy and outcome. results: during the study period, patients with stenotrophomonas maltophilia infection were included, with a mean age of ± years. the simplified acute physiology score ii and acute physiology and chronic health evaluation ii on admission were respectively ± and ± . bacteremia caused by stenotrophomonas maltophilia was observed in patients ( %) and ventilator acquired pneumonia in two patients ( %). twenty four episodes were classified as primary bacteraemia and only one as secondary bacteraemia due to urinary infection. four patients ( %) developed septic shock. mean sofa on the day of stenotrophomonas maltophilia infection was ± . prior antibiotic use was observed in % including an antipseudomonal agent in % of cases. infection due to stenotrophomonas maltophilia was considered in cases. empiric antibiotic therapy was administered to patients ( %) and had included an appropriate agent in only five cases ( %). after adapting antibiotics, monotherapy was the choice for six ( %) patients while a combination of two antibiotics was indicated in the others ( %). the most used antibiotic was the colistin in episodes ( %). intensive care mortality was %. univariate comparison between dead and survivors showed a significant difference in prior nosocomial infection and respiratory comorbidities. no independent risk factor of mortality was found in multivariate analysis. rationale: thrombocytopenia is a frequent disorder in critically ill patients, and several studies have reported its correlation with poor prognosis. considering the major role of platelets in hemostasis, a significant drop in platelet count is an alarming sign in septic patients. the aim of this study was to show the relationship between thrombocytopenia and platelet level changes and mortality in septic patients. patients with criteria for septic shock (based on the third international consensus definitions for sepsis and septic shock) at admission or at any time during hospitalization were included in a prospective study conducted for a period of months (january -august , ) in a medical surgical intensive care unit. patients hospitalized for less than h were excluded. thrombocytopenia was defined as a platelet count less than . /mm , and recovery was defined as returning to levels more than . /mm after presenting thrombocytopenia. we assessed the platelet count during the hospitalization and its outcomes. we included patients. the mean ± sd age was . ± . years. sex ratio was . . thrombocytopenia during sepsis (group ) was found in patients ( %) with a mortality rate at %. the mortality rate among patients not showing thrombocytopenia (group ) was significantly lower % (p = . ). the receiver operating characteristic showed that in (group ), a drop in the platelet count (from admission to septic shock day) more than % was associated with poor outcome (sensibility = %, specificity = %, auc = . ). among the (group ), % showed recovered platelet counts. the mortality was significantly higher in the patients with uncovered thrombocytopenia ( % vs. %, p = . ). conclusion: thrombocytopenia was shown to be an indicatorof poor prognosis in our study. in addition, drops of > % and failure to recover the platelet counts were further determinants of unfavorable outcomes. compliance with ethics regulations: yes. mehdi gaddas , sarra dhraief , karim mechri , imen jami , amenallah messaadi , lamia thabet rationale: pseudomonas aeruginosa is known as an opportunistic pathogen frequently causing serious infections. multidrug resistance in this bacterium is increasing worldwide and poses a major problem in the treatment of infections due to this microorganism. analysis of resistance profile to antibiotics of p. aeruginosa helps to establish a prompt control and prevention program. the aim of this study was to evaluate epidemiological profile and antimicrobial resistance of p. aeruginosa isolates in a trauma and burn center. patients and methods: retrospectively, we studied all p. aeruginosa isolates over a -year period (from january to december ). conventional methods were used for identification. antimicrobial susceptibility testing was performed with disk diffusion method and susceptibility results were interpreted using clinical breakpoints according to ca-sfm guidelines. data were analyzed using the sirsystem. minimum inhibitory concentration of colistin was determined using the e-test ® method (biomérieux), then using the eucast broth micro-dilution method (umic, biocentric ® ) since may . results: during study period, non-repetitive strains of p. aeruginosa were isolated, representing % of all isolates. in our center, infections due to p. aeruginosa were endemic with epidemic peaks. p. aeruginosa was mainly isolated from burn intensive care unit ( . %) and anesthesiology department ( . %). the most frequent sites of isolation were skin samples ( . %), blood cultures ( . %), catheters ( . %) and urines ( . %). the survey of antibiotic susceptibility showed high percentage of resistance to the different antibiotics: . % of strains were resistant to ceftazidime, % to ticarcillin, . % to pipercaillin-tazobactam, % to imipenem, . % to ciprofloxacin and % to gentamicin. resistance to colistin was rare. it concerned only four strains, isolated from burn patients. the survey of antibiotic susceptibility evolution have shown a global increase of resistance to commonly prescribed antibiotics between and : from % to . % to imipenem, from . to . % to ticarcillin-clavulanate, from . % to % to ceftazidime and from . to % to gentamicin. whereas ciprofloxacin resistance rate have decreased from . to %. antibiotic resistant strains were mainly isolated from burn intensive care unit, with % of resistance to imipenem and . % to ceftazidime. the dissemination of multidrug-resistant strains of p. aeruginosa in our center must be contained by the implementation of strict isolation methods and better hygienic procedures. compliance with ethics regulations: yes. acinetobacter baumanii: therapeutic impasse sabah benhamza, mohamed lazraq, abdelhak bensaid, youssef miloudi, najib el harrar réanimation de l'hôpital du août, casablanca, morocco correspondence: sabah benhamza (benhamzasabah @gmail.com) ann. intensive care , (suppl ):p- rationale: acinetobacter baumanii (ab) is frequently responsible for nosocomial infection in the intensive care units, and its resistance to antibiotics continues to increase. the objective of our study is to determine the epidemiological profile and antibiotic sensitivity of isolated bacteria in the intensive care unit august , in order to optimize the probabilistic antibiotherapy of bacteremia in intensive care. patients and methods: this is a retrospective study performed in the intensive care unit of the hospital august , , spread over a period of years from january to january . results: the incidence of ab infection in our department was . % for all patients admitted to intensive care. the average age was years ± , male predominance (sex ratio . ). the average time to onset of infection was days. during the study period, ab strains were isolated, % of which were pulmonary, % blood, and % urinary. resistance to c g reached % in , % in and % in . for imipenem resistance was % in , % in , % in . for amikacin, resistance was % in , % in , and % in . for fluoroquinolones resistance was % in , % in and % in . cotrimoxazole resistance was around % in the last years conclusion: the resistance of ab to antibiotics has reached very alarming levels, especially for carbapenems. this requires resuscitators to change their antibiotic prescription behavior and to invest in the prevention of nosocomial infections. compliance with ethics regulations: yes. this is a prospective observational study conducted at the ed during the period of year. data of all patients admitted with suspected infection of any cause were collected. poor outcomes were defined as death and transfer to an icu within h. results: during the study period, a total of patients with a mean age of ± were included. % were male. within h of management in the ed, % of patients were transferred to the icu and % died. independent predictors of icu-transfer and death included low systolic blood pressure, fever and tachycardia. a prediction model containing these independent predictors had a good predictive accuracy with an area under the curve of . ( % ci . - . ). sensitivity was %, specificity %, positive predictive value % and negative predictive value %. conclusion: assessing readily available clinical variables at arrival to the ed can aid in predicting poor outcomes. [ ] [ ] [ ] [ ] [ ] [ ] . the most common co-morbidities were chronic respiratory failure (crf, n = ) and hypertension (n = ). respiratory distress (n = ) and coma (n = ) were the major indications for iv. us diaphragmatic exploration was performed at a median delay of iv at days [ ] [ ] [ ] [ ] [ ] [ ] . % of patients received sedation and . % received neuromuscular blockers. the ventilator mode was control volume in patients via endotracheal tube (n = ) and tracheostomy cannula (n = ). no major incident was detected during the turning of patients. both tid and ted decreased from the sp to the pp (fig. ) : tid (mm) ( in sp vs. . in pp, p = . ), ted (mm) ( . in sp vs. in pp, p = . ). the observed dtf was lower in the pp but without significance ( . vs. . %, p = . ). no difference was showed when the comparison between sp-dtf and pp-dtf was adjusted on the ventilator mode, obesity, neuromuscular blockers and crf. the positioning in pp in ventilated patients reduces both tele-inspiratory and tele-expiratory diameters of the diaphragm but not altered its contractile function. compliance with ethics regulations: yes. significance was considered at p < . . results: results are presented in the table below. discussion: nebuliser type influences the efficiency of aerosol delivery, with the vmn delivering a significantly higher % aerosol dose than the jn at the two circuit positions (p = . on inspiratory limb; p = . at the dry side of humidifier). in agreement with previous reports using bias flow, for both nebulisers, the location within the circuit has a significant effect, with the nebuliser on the dry side of the humidifier delivering more aerosol than on the inspiratory limb (p = . for vmn; p = . for jn). conclusion: for a mechanically ventilated adult tracheotomy patient, the type of nebuliser and the location of the nebuliser within the circuit influences aerosol delivery. rationale: automatic tube compensation (atc) is a mode available in most icu ventilators. it compensates for the resistive pressure into endotracheal tube/tracheostomy canula by continuously providing a pressure assistance based on internal diameter of a new endotracheal tube/tracheostomy tube. its use in icu is unclear. we designed a survey to further explore this. patients and methods: the survey was endorsed by the acute respiratory failure section and the clinicaltrials group of the european society of intensive care medicine (esicm). the pool was sent out via an email on june to the esicm members worldwide. the following closed questions were: country, years in icu, kind of icu, kind of hospitals, kind of respirators, atc use (never, always or in some patients), reasons to or not to use atc, ventilatory mode in which atc was used. the database was frozen on august st after two reminders. we used the gross national income per capita (usd) provided by the world bank to transform the respondent's country into a geographical-economical variable with levels: high-europe, high-noneurope and middle ( ) . atc use was coded as yes or no. the primary end-point was atc rate of use and the hypothesis was that less than % of the respondents do use it. variables were expressed as counts. groups were compared by chi square test. a logistic regression analysis was performed to explore the contributing factors to atc use. we received responses without any doublons, of which six were empty, from countries. four-hundred and nine respondents used atc always or in some patients ( % atc rate of use). this rate was not different between economical-geographical regions, icu, hospitals and years in icu. for those respondents who did not use atc the reasons were: atc mode not available in icu ventilators ( . %), atc not helpful mode ( . %), atc not known ( . %) and atc provides too much pressure assistance ( . %). for those respondents who used atc the reasons were: helpful in weaning ( . %), set by default ( . %) and physiological benefit ( . %). they used atc during spontaneous breathing trial ( . %), with any assisted mode ( . %) and with specific modes ( . %). we found no risk factor for atc use in the logistic regression model (fig. ) . the atc rate of use was unexpectedly high in this survey. this may result from respondents selection bias or from an a priori underestimation of its use. compliance with ethics regulations: yes. rationale: during pressure support ventilation (psv), adjusting the level of assistance mainly aims at maintaining the patient's respiratory effort within a normal range. however, respiratory effort measurement is impeded in clinical routine by the need of esophageal pressure recording. in this study, we evaluated the accuracy of assessing the respiratory effort from the flow and airway pressure signals using several machine learning algorithms based on the equation of motion of the respiratory system. patients and methods: using the asl simulator (ingmar medical) connected to a pb ventilator (medtronic) set in psv, we simulated a massive number of different respiratory cycles. each simulated cycle represented a unique combination of compliance and resistance of the respiratory system, duration and intensity of the muscle pressure (pmus), positive end-expiratory pressure (peep) and pressure support levels. using least squares regression methods, the flow waveform was fitted according to the equation of motion of the respiratory system to determine the compliance and resistance of the respiratory system, and the pmus. the hypothesis used (alone or in combination) to constrain the system were: linearity of pmus at the onset of the inspiratory effort, nullity of pmus at the end of insufflation, and nullity of pmus during expiration. thus, nine methods were built and tested. calculated and actual peak pmus values were compared using the bland-altman method. the nine methods of pmus assessment were evaluated using different simulated cycles. by limiting the analysis to selected cycles with a predefined applicability criterion (intrinsic peep less than cmh o), a limited inspiratory effort (peak pmus less than cmh o) and a high quality of fitting (r > . ), the method using the three hypothesis together to constrain the system was characterized by a bias of . cmh o and limits of agreement of - . and . cmh o. however, when widening the analysis to all the simulated conditions, no method allowed an accurate estimation of the peak pmus : the best one exhibited a bias of - . cmh o and limits of agreement of − . and . cmh o. conclusion: among the nine machine learning methods tested, some provided an accurate estimate of the respiratory effort in selected cycles but none allowed such accuracy across all simulated conditions. this incites to assess automated methods using a more complex physiological and physical model. compliance with ethics regulations: not applicable. rationale: there is a growing interest in esophageal pressure monitoring in mechanically ventilated patients. esophageal pressure can be measured with a specific nasogastric catheter equipped with esophageal balloon and connected to a pressure transducer. it is used as a surrogate for pleural pressure and may be considered as a corner stone in advanced care of ventilated patients to better assess lung and chest wall mechanics and easily detect patient-ventilator asynchronies. however, this promising technique is still seldom used in clinical practice. trained icu nurses may perform oesophageal pressure measurements which may help facilitate its implementation in the usual patient care. this study aimed at assessing whether a specific educational program to train nurses to perform esophageal pressure monitoring allowed reliable measurements. this was a prospective monocenter study performed in an academic icu. written informed consent was obtained from the nurses before inclusion in the study. the specific educational program consisted of a -min online theoretical course, a -h group theoretical teaching and a -min simulation training on a mannequin. then each participating nurse performed three esophageal pressure measurements (using nutrivent ® catheters and an icu monitor connected to arterial line pressure transducers system) on three different mechanically ventilated paralysed patients under supervision. a knowledge assessment was performed with a short written mcq test. the skill evaluation was by two trained experts. concretely the trained nurses performed an esophageal pressure measurement without assistance. their ability to control the esophageal balloon position by an occlusion test, to measure the inspiratory and expiratory airway and transpulmonary pressures and to calculate of respiratory system, lung and chest wall compliances was assessed at the bedside using a standardized evaluation form. we present here the preliminary results of the first nine included nurses. the written knowledge assessment was considered as rationale: several modalities of ventilatory support have been proposed to gradually withdraw patients from mechanical ventilation. we conducted this study to compare t-piece and pressure support ventilation (psv) ( cmh and peep ) in the process of weaning of mechanical ventilation in burns. patients and methods: it was a prospective randomized trial in burn icu in tunisia during months. mechanically ventilated patients who met standard weaning criteria were included [ ] . patients were randomized into two groups: group under t-piece and group under psv. duration of the test: - min. the tolerance of the vs test should be judged on clinical criteria. stopping the test if occurred: agitation, tachypnea > cycles/ min, tachycardia > / min, spo < %. successful withdrawal was defined as the ability to maintain spontaneous respiration for h after extubation. results: thirty patients were included, randomized into two groups. the mean age was ± years with a ratio sex of . the average tbsa was ± %. the cause of mechanical ventilation was essentially a face neck burned ( %). the following table shows the weaning outcome of both modalities. eighty percent of succeeded extubation for both groups (n = / ). the cause of failure of extubation was secretion retention and clutter in majority of cases followed by neurological and cardiac distress. the duration of mechanical ventilation does not influence the outcome of the weaning test (p < . ), with a mean of duration of ± days. conclusion: our study did not show any difference between the two weaning modalities in the matter of outcome of extubation. the choice of weaning test of mechanical ventilation is to be judged by the clinician according of the state of his patient. compliance with ethics regulations: not applicable. rationale: when expiratory tidal flow does not go up after increasing expiratory driving pressure expiratory flow limitation (efl) occurs. it is thought that efl heralds airway closure (ac). we investigated the role of chest wall elastance (ecw) in both efl and ac in acute respiratory distress syndrome (ards) patients. our hypothesis was that the lower the ecw to lung elastance (el) ratio the higher the likelihood of efl and ac. patients and methods: twenty-five moderate to severe ards patients were prospectively included in two centers. mechanical ventilation was delivered in volume-controlled mode with tidal volume ml/kg predicted body weight at positive end-expiratory pressure cmh o in semi-recumbent position. airway (paw) and esophageal (pes) pressures and flow were continuously recorded during min by a data logger (biopac ). then, end-expiratory and end-inspiratory occlusions were performed for s, then respiratory system was slowly inflated at constant flow. finally, patient was allowed to breathe out freely to atmosphere by using a three-way stop lock by-passing expiratory valve. ac and airway opening pressure (aop) were determined according to chen et al. ( ) . efl was assessed by the atmospheric method ( ) . dynamic elastance of chest wall (edyn,cw) and lung (edyn,l) were obtained from least square linear regression method over consecutive breaths. static elastance (est,cw and est,l) were determined by classic formulas and also by taking into account aop (est,cw_aop and est,l_aop, respectively). the performance of ecw/el ratio to predict efl and ac was assessed by the area under receiver operating characteristic (aucroc) curve. results: efl was observed in patients ( %) and ac in ( %). median aop was . cmh o ( % ci . - . ) . aucrocs for ecw/el ratios to detect efl and ac are shown in table . edyn,cw/edyn,l ratio was better to detect efl than est,cw/est,l ratio with edyn,cw/edyn,l ≤ . % sensitivity and % specificity. correction for aop made the performance of est,cw/est,l ratio as good as that of the edyn ratio. ac was poorly predicted by edyn and est ratios but its prediction greatly improved with aop correction. however, with the est,cw/ est,l_aop the critical ratio was . (sensitivity %, specificity %) and . (sensitivity and specificity %) for predicting efl and ac, respectively. conclusion: efl and ac are frequent in ards at peep cmh o. edyn,cw/edyn,l ratio lower than best predicted efl occurrence. once ac is taken into account est,cw/est,l ratio greater than accurately predicts ac. efl and ac are two distinct phenomena. compliance with ethics regulations: yes. rationale: anesthesia outside the operatingroom (aoor) in a pediatric environment was giving increasingly increasing indications and a lot of progress because of its interest in carrying out diagnostic and/or therapeutic explorations: % of the acts of anesthesia are performed outside the operating room. the objective of our study is: to clarify the importance and the frequency of the practice of the ahbo, to define its particularities, as well as an evaluation of the ratio: benefit/risk in order to reduce the morbidity and mortality. patients and methods: we report in this study the experience of the service of the resuscitation mother-child on the gestures of aoor. this is a prospective observational study, spread over a period of months: from / / to / / , dealing with acts performed for endoscopic digestive and bronchial procedures, cures in dermatology and radiotherapy, and medical imaging (ct and mri). results: of the procedures performed: were performed for ct, for mri, for arteriography and for endoscopic digestive procedures, for bronchoscopies, for radiotherapy treatments, for laser treatments in dermatology. anesthesia techniques use intravenous induction in % of cases using: hypnotics (propofol, midazolam, ketamine), morphine (remifentanyl, fentanyl), inhalation induction in % of cases (sevoflurane, halothane) and curare for cases of bronchoscopy (rocuronium). this anesthesia was marked by the occurrence of accidents in order of frequency: cardiac in % of cases (tachycardia, hypotension and rhythm disorders), and then respiratory in % of cases. the most serious accidents were admitted in reality and are represented by cases, of which required an intubation (bronchoscopy), a case of cardiorespiratory arrest recovered, cases of severe hypoxia associated with bradycardia and which required the ventilation with the mask (radiotherapy), and cases of bronchospasm requiring the deepening of the anesthesia (absence of tci). a good knowledge of the patient and the intervention, and difficulties specific to each specialty is necessary, as well as a preanesthetic consultation. the aoor must obey the same safety rules as in the operating theater and that in terms of: equipment, monitoring (integrate the capnograph to respiratory monitoring whenever deep sedation and when the continuous control of vas is difficult), anesthetic technique (tcbi) and post-procedure wakefulness management that must meet the same requirements as the sspi, especially for prolonged sedation. compliance with ethics regulations: yes. umbilical vein catheterization through wharton's jelly: a possibility for a fast and safe way to deliver treatments in the delivery room? suzanne borrhomée hôpital rené dubos, france correspondence: suzanne borrhomée (suzanne.borrhomee@gmail. com) ann. intensive care , (suppl ):p- rationale: a fast and safe venous access can be a critical issue in the delivery room during neonatal cardiopulmonary resuscitation, or before endotracheal intubation. here, we describe a new method to inject drugs using the umbilical vein, directly punctured through wharton's jelly. this method was performed in newborns between november and may . umbilical vein was identified and punctured easily and a reflux was obtained in all patients. the first step was antisepsis, and then the umbilical vein was punctured. the puncture was made approximately to cm above the navel. after checking for blood reflux, the nurse injected the treatment. the cannula was left in the vein during the injection and removed as soon as the intervention was over (intubation was performed, or the heart rate had increased). results: here, we report ten cases of emergency injection in the delivery room using this method: -four cases of cardiopulmonary resuscitation using this method to deliver epinephrine. cardiac massage was performed on all patients.-six cases of intubations in the delivery room using this method to administer the premedication. in all patients, the umbilical vein was identified easily. the equipment was the one usually used for venous injection in our unit and was manipulated and handled with ease. venous access was obtained in a matter of seconds, and blood reflux was observed in all patients. the treatments were efficient in all but two patients, which was imputable to the method in one patient. discussion: although this method has been known in our nicu for several years, there has been no publication regarding this method in neonates. inserting an umbilical vein catheter in the delivery room has been validated for resuscitation but this technique is lengthy and requires some sterility conditions that makes it even longer, and thus non-fitting for an emergency tracheal intubation. our method is fast and can be performed easily with no specific training. the whole manipulation procedure, from the beginning of the puncture to the end of the flush-out takes to s. we only identified few specific risks related to this method, mostly infectious, and the risk of drug diffusion. we describe a new route for administration of drugs in the delivery room that was successfully used in nine neonates. umbilical vein needle catheterization is not only safe and efficient, but is also fast and easy to perform without any special training. compliance with ethics regulations: yes. rationale: liver transplantation (lt) is the only option for children with end stage liver disease. recent advances in surgical procedure and immunosuppression have permitted a better patient and long term graft survival. however, acute cellular rejection remains a frequent complication occuring in to % of the cases according to different studies. it is more likely to occur during the first weeks post lt. many predictive factors of acute rejection have been described in litterature and results differ from one study to another. pediatric studies regarding this topic are few. the aim of this work is to study acute cellular rejection prevalence in the days following lt and to determine predictive factors. rationale: sedation practices for pediatric magnetic resonance imaging (mri) are highly heterogenous. the main challenge is to keep children immobile while being alone in a traumatizing environment for a long time. clinicians have to ensure hemodynamic and respiratory stability in this isolated environment while minimizing sedation neurologic adverse effects. in this series, we report the potential usefulness, feasibility, efficacy and safety of dexmedetomidine sedation for pediatric mri. patients and methods: a single center retrospective review of six children sedated with dexmedetomidine for mri in an emergency context. all children were hospitalized in the pediatric intensive care unit of a university hospital at the time of mri. results: data on six patients aged months to years is reported. five patients received dexmedetomidine by intravenous route (bolus of - µg/kg over min, followed by a continuous infusion of µg/ kg/h). one child received dexmedetomidine by intranasal route ( µg/ kg with atomization device). one child experienced bradycardia that did not require any intervention. very few movements were recorded during the mris for which images were rated as good quality. conclusion: dexmedetomidine seems a promisingly useful sedation agent for pediatric mri, thanks to its efficient sedative properties and good tolerability without respiratory compromise. compliance with ethics regulations: yes. rationale: computational models, or virtual patients, could be used to teach cardiorespiratory physiology and ventilation, determine optimal ventilation management as well as forecast the effect of various ventilatory support strategies. currently, there is no virtual patient specifically designed for modelling children cardiorespiratory system. thus, our research team has developed a cardiorespiratory simulator for children called "simulresp©". according to summers et al., the quality of a physiologic model is evaluated by three specific criteria: qualitatively, which relates to the model's ability to provide directionally appropriate predictions; quantitatively in steady states and in dynamics, which is the ability of the model to provide accurate predictions in steady state situations as well as dynamic transitions. the purpose of this study was to evaluate the quality ofsimulresp© according to these criteria. this study consisted in a prospective evaluation of the simulresp©'s predictions with simulated healthy subjects. the tests were performed with patients from to years old ( , , , , , years), with different characteristics; gender (m, f) and weight ( th, th and th percentile). blood gas values (ph, pco , po and spo ) were simulated for several virtual healthy patients with different characteristics. this study was conducted for both spontaneously breathing and mechanically ventilated patients. simulresp©'s quality and reliability were evaluated in terms of accuracy, robustness, repeatability and reproducibility. results: simulresp©'s validation procedures are ongoing. we intend simulresp© to be accurate when simulating healthy spontaneously breathing patients. but we hypothezised that simulresp© would not be able to simulate accurate blood gas values of mechanically ventilated patients conclusion: simulresp© is a promising computational model that will serve to perform calibration and validation procedures of clinical decision support systems and help clinican to determine optimal respiratory support strategies at bedside. further calibration procedures are yet required. compliance with ethics regulations: yes. the isthmic surgical tracheostomy, which was performed in the operating room by otolaryngologist under general anesthesia. the cutaneous incision was transversal in all cases.the choice of the cannula was adapted to the age, and the decanulation was carried out according to the evolution of the underlying disease. complications associated with tracheotomy are diverse, and common complications are such as careassociated pneumonia ( . %), tracheostomy tube obstruction ( . %), accidental decannulation ( . %), pneumothorax ( . %) and cases of tracheal stenosis ( . %). the mortality rate amounted to . %, where in most cases was due to the poor prognosis of the underlying diseases. the main factors of evolution are the patient's previous condition, cranial trauma, guillain-barré syndrome, tracheostomy time, prolonged tracheal intubation and the presence of complications. conclusion: regardless of the indication, the tracheotomy is an act of survival whose usefulness and effectiveness are certain. rationale: aspiration pneumonia (ap) is a frequently suspected complication of drug overdose requiring mechanical ventilation (mv) and admission to intensive care unit (icu). in the absence of reliable biomarkers for distinguishing between aspiration pneumonia and aspiration pneumonitis, antibiotic therapy is frequently prescribed. latest studies suggest that a care protocol could better select patients requiring antibiotic therapy. the objective was to determine the impact of a care protocol on the antibiotic prescription among patient admitted to icu for toxic coma with mv. we conducted a prospective observational cohort study in four icu. we included all patients admitted for toxic coma with mv. in the university-affiliated icu, a care protocol was applied. in the three others icu, physicians declared that they did not follow formalized conduct within the service and did as usual. results: we included patients in care protocol group and in control group. the mean saps ii was . (± . ) with a mean glasgow coma scale score at . (± . ) before intubation. within the total population, patients ( %) had a pulmonary bacteriologic sample (pbs), mostly because purulent tracheobronchial aspirate and new infiltrates on the chest x-ray (respectively . % and . % of the population with a bacteriological sample). among the patients with a bacteriological sample, ( %) were culture positive. the incidence of probabilistic antibiotherapy did not differ between the care protocol group (n = ) and the control group (n = ) . there was no difference for the incidence of pbs ( in each group). the others secondary outcomes did not differ either (table ) . conclusion: our study does not show that a care protocol allows a reduction of antibiotic prescription among patient admitted to icu for toxic coma with mv. our incidence of antibiotic prescription is lower than the previous studies. the absence of difference can be explain by two reasons: some of the physicians of the control group had been trained in the university-affiliated icu in the last years and may follow a management approach similar to that of the control group; despite our precautions, the existence of the study could have modify the practices in the control group. compliance with ethics regulations: yes. rationale: pancreatic surgery is associated with high morbidity, mostly due to infectious complications, so that many centers introduce post-operative antibiotics for all patients. such systematic prescriptions are not consensual and often rely on local practices. the aims of the study were to describe the occurrence of surgical site infection (ssi) and the antibiotic (atb) prescription after pancreatic surgery, and to determine the risk factors of post-operative surgical site infection, in order to better define the clinical indications for the prescription of antibiotics after major pancreatic surgery. patients and methods: all patients undergoing a scheduled major pancreatic surgery from january to november were included in the study. patients were classified in four groups according to the occurrence of a surgical site infection and to the post-operative antibiotic prescription as follows (ssi+/atb+; ssi-/atb+; ssi+/atb-, ssi-/ atb-). in addition, risk factors (fever and pre-operative biliary prosthesis) associated with the occurrence of a surgical site infection and with the antibiotic prescription, were analyzed using a logistic regression model. results: data from patients ( pancreaticoduodenectomies and splenopancreatectomies) were analyzed and classified as presented in the table. thirty patients ( . %) experienced a surgical site infection and ( . %) received post-operative antibiotics. we did not find any difference on post-operative antibiotic prescriptions ( . % versus . %, p = . ) between patients who developed a surgical site infection and those who did not. amongst the patients who were not prescribed antibiotics post-operatively, ( . %) did not develop a surgical site infection while ( . %) did. in-icu mortality did not differ between infected and non-infected patients ( versus %, p = . ). post-operative fever was different between ssi+ and ssi-( . versus . %, p < . ), while the prevalence of pre-operative biliary prosthesis was similar ( . versus . %, p = . ). amongst patients who did not develop a surgical site infection, antibiotic prescription was not associated with fever (p = ), but associated with a higher prevalence of preoperative biliary prosthesis ( . versus . %, p = . ). conclusion: non-systematic antibiotic prescription after major pancreatic surgery allowed to appropriately spare antibiotics in ( %) patients at the cost of under prescription in ( . %) patients. these results suggest that systematic post-operative antibiotic prescription could be excessive. fever appears to be a relevant clinical sign for individual-based prescription, whereas the presence of a biliary prosthesis does not. compliance with ethics regulations: yes. ( , ) . however, there is little evidence to support those recommendations ( ) . we aimed to describe care paths of pm with sepsis in french hospitals and to assess outcomes depending on their hospital trajectory. we conducted a retrospective analysis of the french medico administrative (pmsi) database of consecutive patients with pm and sepsis admitted to french hospitals, between and . only the first hospital admission was considered. cases were identified using a combination of a diagnosis code for pm plus a diagnosis code for organ failure or a procedure code for organ support. hospital trajectories were determined from the first admission to death or discharge, taking into account all potential transfers. costs and endpoints were determined at the end of patients' trajectories. five groups of patients were defined, according to care pathways: direct icu admission ( sticu); secondary icu admission, after initial admission to another unit including wards (ward ndicu) rationale: new-onset atrial fibrillation (af) is a common complication in patients with sepsis and is associated with increased mortality and morbidity rates. this condition results from a complex chain of events in response to infection, involving immunologic, humoral and cellular process and sympathetic overactivity. landiolol, the new injectable beta-blocker, with high beta selectivity and minimal impact on arterial blood pressure, may have beneficial effects in such a context. in this study, we aimed to investigate whether landiolol decrease the newonset of atrial fibrillation in a mice model of endotoxin-induced sepsis. patients and methods: thirty c bl/ male mice were randomly allocated to the following groups: sham (administration of µl of isotonic saline intraperitoneally-ip), septic (administration of µl of isotonic saline with mg/kg of lipopolysaccharide-lps-of e. coli o :b ip) and septic + landiolol (administration of isotonic saline with mg/kg of lps and, two hours later mg/kg of landiolol ip). four hours later, an attempt of af occurrence was triggered by a transesophageal electric pacing at fixed rate (as previously reported) in all mice previously anesthetized by isoflurane %. ekg was continuously recorded. results: ten mice per group (mean weight: ± g) have been included and analyzed. among the sham group the mean heart rate was at bpm versus bpm in the septic group. among the septic + landiolol group the mean heart rate was at bpm (p < , ). after transesophageal stimulation, none mice in the sham group had af, seven mice ( %) in the septic group had an af, and mice ( %) in the septic + landiolol group had an af. landiolol decreased the incidence of new-onset, sepsis-induced atrial fibrillation in mice (p = . ). conclusion: landiolol seems to have a protective effect against sepsis-induced af in mice. however, the mechanisms, including sympathetic activation and inflammasome pathways, should be investigated before drawn definitive conclusion regarding to efficiency of landiolol to prevent new-onset af during sepsis. compliance with ethics regulations: yes. - mg/l at or h, proportion of patients with a vancomycin serum concentration < mg/l, previously associated with resistance emergence and assessment of mortality and test of cure. results: a serum vancomycin concentration between - mg/l was reported in out of included patients ( %). a serum vancomycin concentration < ml/l and > mg/l were reported in patients ( %) and patients ( %), respectively. vancomycin serum concentrations during follow-up are shown in fig. . in multivariate regression analysis, a longer time between admission and initiation of vancomycin was the only parameter associated with a serum vancomycin out of this target, while acute kidney injury (aki) was associated with a lower incidence of subtherapeutic concentration. acute kidney injury rate was significantly higher in patients with a serum vancomycin concentration > mg/l. discussion: an adequate therapeutic target of serum vancomycin concentration was reached in % patients with nearly % < mg/l, which was similar to previous studies. aki and rrt requirement were higher in patients with serum vancomycin concentration > mg/l, whereas it is hardly to know whether it is a cause or a consequence. conclusion: these findings highlight the importance of a larger loading dose, vancomycin monitoring and measured creatinin clearance to improve vancomycin dosing protocol. compliance with ethics regulations: yes. rationale: suicide is a global phenomenon and one of the leading causes of death in the world. tunisia ranks second in the suicide rate in the maghreb, with . cases of suicide per , inhabitants. the aim of this study was to reconstruct the state of suicidal subjects before the act in order to identify their psychiatric profile. patients and methods: a -year prospective observational singlecenter ( -bed intensive care unit) study including all patients hospitalized for suicide attempt (sa). psychiatric evaluation of patients and contact with their families were done before intensive care unit discharge. results: seventy-one patients were enrolled with female predominance (sex ratio . ). mean age was ± years. familial or personal history of mental illness were found in ( %) and cases ( %) respectively. personal mental disorders were depression ( %), bipolar disorder ( %), schizophrenia ( %) and border line personality disorder ( %). twenty-five per cent had prior sa. sixty-three per cent were single, % married and % divorced. the common methods of suicide included drug ( %), chloralose ( %) and pesticide ( %) poisoning. mean igs ii and apache ii scores were ± and ± respectively. on admission, % of all patients were in coma, % had shock and % developed aspiration pneumonia. mechanically ventilation was done in % of all cases with mean duration of days. the mean length of stay in intensive care unit was days. mortality rate was %. psychiatric evaluation and contact with families deduced that the main precipitating factors for suicide were traumatic events. in fact: relationship problems (familial, marital or breakups), school failure and mourning were found in %, % and % of all cases respectively. reactional sa accounted for %. rationale: poisoning is a worldwide problem, associated with high morbidity and moratlity. in tunisia, the rate of fatal poisoning has been increasing in the last years, with emergence of new toxic substances. regardless of the toxic, fatal poisining is considered as a non natural death, that requires medico-legal investigation, to assess whether it is suicidial, crimnal or accidental death. this study aimes to determine the epidemiological characteristics of the cases of fatal poisoning in south, to identify the toxics used in oder to deduce the preventive measures. patients and methods: we conducted a retrospective study of all cases of fatal poisoning recorded in the forensic department of habib bourguiba university hospital in sfax, tunisia, over a -years period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results: during the study period, cases of fatal poisoning were autopsied. the number of victims recorded per year varied between and cases with an average of cases per year. the average age was years with extrems ranging from months to years. nearly half ( . %) were younger than years. a male predominance was noted with a sex-ratio of . . the majority of victims were single, loweducated and from rural origin. personal antecedent of psychiatric pathology was found in . % of cases. psychotic disorders (schizophrenia) and depression were the most common pathologies. in our study we noticed that death occured every weekday without significant difference between days. however, the frequency of fatal poisoning was slightly higher in cold seassons ( . %). in . % of cases, victims were found dead at home. accidental fatal poisoning was the most common ( %). no criminal cases have been observed. we noted a male predominance in accidental forms and a female predominance in suicidal forms. carbon monoxide poisoning was the most common ( cases) followed by the organophosphorus poisoning which was noted in cases. conclusion: decreasing the mortality rate from poison ingestion requires increasing public awareness about poisons and improving emergency service equipment and health personnel training. compliance with ethics regulations: yes. severe acute poisoning by organophosphate pesticides: report of cases at the oran hospital and university center mourad goulmane hospital and university center of oran, oran, algeria correspondence: mourad goulmane (goulmane.mourad@univ-oran . dz) ann.intensive care , (suppl ):p- rationale: organophosphate pesticides are synthetic organic pesticides widely used in agriculture mainly as an insecticide, nemacid or acaricide. these are the agricultural products, the most incriminated in poisoning in our context. the objective of this work was to determine the clinical, paraclinical, and progressive characteristics of this poisoning in a resuscitation environment. patients and methods: retrospective study of cases admitted to intensive care (january -december ). inclusion criteria were clinical, para-clinical, therapeutic and progressive. results: cases were identified: women and men, mean age = . ± years. the suicide attempt was the main reason for the intoxication ( cases). the glasgow coma score averaged ± . the central syndrome was present in % of our patients, followed by muscarinic syndrome % and nicotinic syndrome in % of cases. therapeutic management consisted of mechanical ventilation in % of cases, the use of vasoactive drugs in % of cases and the administration of antidotal treatment in % of cases. the overall mortality was . %. conclusion: organophosphate pesticides intoxication is a real health problem in algeria. it is a serious condition dominated by the respiratory and neurological distress that causes most deaths. it concerns in our context especially young women who ingest the product for the purpose of autolysis. the diagnosis is based on the clinical and dosage of cholinesterase activity in the plasma. treatment combines symptomatic measures that rely primarily on respiratory and neurological resuscitation to antidotal treatment. the clinical course in this type of intoxication is generally favorable under treatment with regression of signs in a few days. mortality is high in our context, so it should be considered a diagnostic and therapeutic emergency. the commercial availability of these products is worrisome, justifying the use of a broad prevention program to inform the public and authorities of the danger of organophosphate pesticides compliance with ethics regulations: not applicable. . the clinical examination revealed that five patients met the criteria for serious intoxication with the following signs: coma in four patients requiring the use of mechanical ventilation, seizures (n = ), rhabdomyolysis (n = ), shock (n = ), toxic takotsubo (n = ) and hepatocellular failure (n = ) leading to patient's death. the use of mechanical ventilation was necessary in patients. the analysis of the severity factors did not show a statistically significant association between severity, age (p = . ), sex (p = ) and chronic consumption of psychoactive substances (p = . ). on the other hand, we did not find a statistically significant association between serious intoxication, the number of tablets ingested (p = . ), the apacheii score (p = . ) and the average length of stay (p = . ). conclusion: ecstasy acute poisoning is becoming more common in our country and can potentially be very serious regardless of age, sex, medical history or number of tablets ingested. on the other hand, the concentration of nmda could be the only factor to be taken into consideration upon admission. compliance with ethics regulations: yes. quarter of early trauma-related mortality, in some series. early identification of poor outcome predictors could be valuable to guide the most appropriate care. we aim to determine factors associated to mortality in patients with severe non-penetrating chest trauma admitted to the icu. patients and methods: this is a prospective cohort study, including all patients with isolated severe blunt chest trauma (abbreviated injury scale ais > ) admitted to the intensive care unit of a university hospital, over a one-year period. the primary objective was to analyse risk factors associated to death and poor outcome using univariate and multivariate analysis. results: one hundred-thirty patients were admitted to the icu for blunt chest trauma among them were diagnosed with severe isolated chest trauma and were included. the mean age was at ± , mean iss at ± and mean tts at ± . twenty-eight ( %) patients were diagnosed with acute respiratory distress syndrome, ( %) with post-traumatic acute kidney injury and fourteen ( %) with post-traumatic pulmonary embolism. the mean length of icu stay (los) was at ± days and mean number of days on ventilator was at ± days. thirty-two ( %) patients underwent elective tracheostomy for prolonged intubation. thirty-seven patients ( %) developed infections, among them thirty ( %) were diagnosed with pulmonary infection and seven ( %) with non-thoracic infections. overall mortality had an incidence of . % ( patients rationale: early hyperglycaemia in traumatic brain injury (tbi) is a part of the stress response. it is an important indicator of severity and a reliable predictor of prognosis. we aimed to describe the epidemiological, clinical and paraclinical characteristics and to assess the prognostic impact of this hyperglycaemia on the tbi. we conducted a retrospective study in the intensive care unit (icu) of our hospital between and . were included all patients with tbi and blood glucose > mmol/l at the first h post-trauma. results: during the study period, patients were hospitalized in our icu with tbi. early hyperglycemia (> mmol / l) was found in patients ( . %). in univariate analysis, glycaemia > . mmol/l (= mg/dl) at admission was significantly associated with mortality (p = . ). we observed that glycaemia > . mmol/l at h , > . mmol/l at h , > . mmol/l at h and > . mmol/l at h was significantly associated with mortality (p = . ; p < . ; p = . and p = . , respectively). the risk factors significantly associated with mortality were age > years (p < . ), saps ii > (p < . ), initial shock (p < . ), glasgow coma scale (gcs) < / (p < . ), coma period > days (p = . ). the ct scan lesions statistically associated with mortality were: subdural hematoma (p < . ), cerebral oedema (p < . ), intra cerebral haemorrhage (p = . ), cortical contusion (p = . ), contusion of cerebral trunk (p = . ), contusion of the corpus callosum (p = . ), thalamus contusion (p = . ). in multivariate analysis, independent risk factors statistically associated with mortality were age > years old (or = . ic [ . - . ]; (p = . )), glycaemia > . mmol/l at admission (or = . ic [ . - . ]; (p = . )),gcs < / (or = . ic [ . - . ]; p < . ), intracerebral hematoma (or = . ic [ . - . ]; p = . ). we recommend a mandatory control of the blood glucose levels during a tbi with a target between . and . mmol/l in the acute phase. compliance with ethics regulations: not applicable. the fat embolism syndrome (fes) is a set of clinical, biological and radiological signs resulting in the obstruction of microcirculation by micro-droplets of insoluble fats.the clinical signs of the fes are not very specific, the diagnosis is difficult and the risk of misunderstanding this syndrome is very real.the fes appears after a trauma, often few days later. however, it sometimes occurs without previous trauma; and it is particularly difficult to recognize in these cases. the aim of this work is to define the epidemiological profile, the clinical and para-clinical features of this syndrome and its therapeutic management. rationale: sedative and analgesic treatment administered to critically ill patients with mechanical ventilation need to beregularly assessed to ovoid complications of oversedation mainly in elderly patients. our objective is to evaluate our sedation practice in the elderlyin our unit patients and methods: it was a prospective observational study, including elderly patients over years of age without acute brain injury requiring sedation more than h of hospitalization in the intensive care unit of our university hospital between april and december . thirty patients were included. the aged was . years, the sex ratio was . . respiratory distress was the most common reason for hospitalization %. the most accepted diagnoses were the decompensation of copd in % of cases and septic shock in % of cases. the saps ii averaged ± points, sofa averaged ± . points. renal failure was found in patients ( %), hepatic impairment was noted in patients ( %), hypoproteinemia was marked in patients ( %). midazolam was used in % of patients. it was in combination with fentanyl in % of cases and remifentanyl in % of cases. the median ramsay score . ± . on the first day of sedation and . ± . on the second day of sedation. the median rass scale was − . ± . on the first day of sedation and − . ± . on the second day of sedation. the median bps scale . ± . on the first day of sedation and . ± . on the second day of sedation. the mean wake up time was ± , days. neuromyopathy of resuscitation was suspected in seven patients ( %), withdrawal syndrome was observed in two patients ( %) and acute cognitive dysfunction in two patients ( %). the median duration of sedation was . days ± . days, the median duration of mechanical ventilation was . ± . days, the median length of stay was . ± . days. ventilator-associated pneumonia was diagnosis among % of patients. the mortality in intensive care was %. conclusion: sedation analgesia in the elderly person should be adapted according to age, ideal weight and renal and hepatic function by decreasing the initial doses. it should be evaluated by the recommended scores by setting a sedation objective according to the pathology. compliance with ethics regulations: not applicable. rationale: more than original articles are newly indexed in pub-med every day. journal club (jc) is one way to cope with this abyssal amount of medical information. we aimed at ( ) describing journals and articles analyzed during our jc sessions ( ), reporting the proportion of published articles being analyzed during jc sessions and ( ) assessing the clinical impact on our daily practices for each journal. patients and methods: a retrospective analysis of prospectively collected data over a -year period from to in a universityaffiliated icu. jc sessions were scheduled weekly and participants were free to choose and expose orally an article recently published in any medical journal (general, icu or non-icu specialized). clinical impact of a journal was retrospectively and independently assessed by two attending intensivists (dc, hm) and was defined by the ratio of articles considered as having a direct impact on our daily practices over the number of articles of the same journal read during the same period. results: from august to august , jc sessions were held and articles-mostly original (n = / ; %)-from journals were analyzed, accounting for . % of the articles ( . % of the original articles) referenced in pubmed during the same period. median number of articles exposed per session was [ ] [ ] [ ] [ ] . median number of doctors attending each session was [ ] [ ] [ ] (attendings: [ ] [ ] , fellows: [ ] [ ] , residents: [ ] [ ] ). general, icu and non-icu specialized journals accounted for %, % and % of the exposed articles, respectively. most of the reported articles dealt with intensive care (n = , %) especially infectious diseases (n = / ; %), hemodynamics (n = / ; %) or icu-organization (n = / ; %). compared to general and non-icu specialized journals, the proportion of read-over-published articles was higher for icu-specialized journals ( . % vs. . % vs. . %, respectively; p < . ). among original articles, only ( . %) [interventional (n = / ; %); observational (n = / ; %) studies] were considered as having a clinical impact on our daily practices. compared to icu and non-icu specialized journals, general journals had a higher clinical impact ( . % vs. . % vs. . %, respectively; p = . ). data regarding the most read general, icu and non-icu specialized journals are detailed in table . in a french university-affiliated icu with regular jc sessions, the proportion of read-over-published articles and the clinical impact of medical journals appear minor. in the ocean of medical literature, general medical journals appear more worth reading by intensivists than icu-specialized journals. compliance with ethics regulations: yes. rationale: the world's population is aging and the and over's age group is growing fast (+ . % per year). this aging population is impacting intensive care units with exponential rates of elderly patients ( . % in , % in ) , associated with significant mortality (from % to %). the evolution and the prognostic factors of these elderly patients in intensive care are therefore a public health issue for optimal management. patients and methods: we included all patients aged and over who were operated and admitted to surgical resuscitation in our center, with a duration of stay greater than h, from april to july . the data collected were: general characteristics of this population, mortality in intensive care, at day and at months and the prognostic factors guiding their evolution in intensive care and at months. results: of the patients included in our study, mortality was . % in intensive care, . % at day and . % at months. the prognostic factors in the intensive care unit were the average dose of noradrenaline at day (threshold at . mg/h), the sofa score at day (threshold at points) and the igs score (threshold at points). the prognostic factors at months were ventilatory autonomy on day (spontaneous ventilation, non-invasive ventilation, invasive ventilation), the reason for admission to intensive care (acute respiratory distress or septic shock) and the fragility score (clinical failure scale with a threshold at ). conclusion: the mortality of patients aged and over is influenced by prognostic factors easily obtained daily at patient's bed. these prognostic factors could be an aid for the resuscitation teams to evaluate the relevance of the care undertaken in elderly or even very elderly patients admitted in an acute situation. compliance with ethics regulations: not applicable. assessing patient safety culture perception in the intensive care unit in tunisia oussama jaoued, chaoueh sabrina, sik ali habiba, wael chemli, gharbi rim, fekih hassen mohamed, elatrous souheil hôpital taher sfar, mahdia, tunisia correspondence: oussama jaoued (oussamajaoued@gmail.com) ann. intensive care , (suppl ):p- rationale: in tunisia health care system, patient safety has become a priority of quality assessment. the aim of our study was to describe the safety culture perception of the intensive care unit staff. patients and methods: the safety attitude questionnaire (saq-icu) was distributed to all intensive care unit staff by email. the questionnaire explores safety culture domains: "team work", "safety climate", "job satisfaction", "stress recognition", "perception of the hospital and intensive care unit management" and "work condition". results: eighty participants responded to the questionnaire, % of them were women. participants were doctors in . %. the coordination between physicians and nurses was very good only in %. thirtynine participants thought that the workload was high and % like their work. medical errors are handled appropriately in % of cases and it was difficult to discuss errors in % of cases. the hospital is a good place to work in % of participants, % of participants were less effective at work when there were tired. the hospital did a good effort of training new personal in % of cases. the number of medical staff was lower than expected in % of cases. half of participants would feel safe being treated as patients in their respective units. all domains explored by saq-icu could be improved according to attendants. conclusion: safety culture perception among intensive care unit staff had several deficiencies, mainly the working conditions, the ignorance of medical error reporting procedures and the lack of communication. rationale: the simplified acute physiology score ii (saps ii) is an icu scoring system used to predict the mortality risk in patients presenting at the icu. however the majority of critically ill patients present initially at the ed and their transfer to the icu may be delayed for hours. therefore, the ability to accurately assess mortality risk at ed may have a great impact. the purpose of this study was to evaluate the performance of saps ii in predicting early and late mortality in ed patients. patients and methods: this prospective study was conducted at the ed during a -month period. data for adult ed patients were evaluated. saps ii score was used to predict early and late mortality rates at -h and -day respectively. discrimination was evaluated by calculating the area under the receiver operating characteristic curve (auroc). results: during the study period patients were enrolled. the mean age was ± years, % of the patients were men. the mean saps ii was . the early mortality rate was % and late mortality rate was %. saps ii was efficient in predicting early mortality, with an auroc of . ( % ci . - . ). however, it demonstrated no value in predicting late mortality with an auroc of . ( % ci . - . ) conclusion: in this study, saps ii score was accurate in predicting early mortality, however this tool appears less suitable for predicting late mortality. compliance with ethics regulations: yes. oussama jaoued, chaoueh sabrina, sik ali habiba, yosri ben ali, fekih hassen mohamed, elatrous souheil hôpital taher sfar, mahdia, tunisia correspondence: oussama jaoued (oussamajaoued@gmail.com) ann. intensive care , (suppl ):p- rationale: the aging of the population increased the number of hospitalizations in icu. the aim of our study was to determine the impact of hospitalization of patients over the age of on morbi-mortality and consumption of care (omega score). patients and methods: this is a retrospective study carried out in the icu in the hospital of taher sfar in mahdia over a period of years. all patients hospitalized in the icu were included in this study. two groups of patients were individualized: g : patients over years old, g : patients under years old. results: during the study period, patients ( < years old and ≥ years old) with a mean age ± years and with a mean sapsii ± were included. the common reason for hospitalization was acute respiratory failure in % of cases. comparing the two groups, the severity score sapsii was higher among patients older than years ( ± vs ± , p < . ). the use of mechanical ventilation was more common in the first group ( % vs. %, p < . ). the incidence of nosocomial infections was similar in both groups ( % in the group g and % in group g , p = . ) and the use of renal replacement therapy was also similar in tow groups ( % in the g group and % in the g group, p = . ). the duration of mechanical ventilation and length of stay were similar between the two groups. workload evaluated by the omega score was higher in the first group ( rationale: icu outcome depends on quality of pre-icu care. we aimed to assess the chain of care of deteriorating ward patients (dwp), through evaluation of preadmission severity and delays before admission, and association with outcome. patients and methods: retrospective observational study in a single center ( beds general hospital) for year-may th of to . all adult patients admitted in the icu from the wards were included, except for scheduled surgery, or unexpected event in the operative theater. preadmission severity was assessed through levels of national early warning score (news ): group with news inferior to , group with news between and , and group with news superior to . these scores were established from vital signs during the h before icu admission. patterns of patients, including sofa and saps , knaus index, charlson comorbidity score, cause of admission and technics used in the icu, length of stay in the icu and in the hospital, limitations of life-supporting care, and mortality at and days after icu stay. satistical analysis was performed through chi and fisher tests on qualitative parameters, and with kruskal-wallis, student and mann-whitney tests for quantitave data. results: sixty-eight patients were studied: in group , in group and in group . most patients (all except ) had not respiratory rate monitoring before icu admission. icu mortality was associated with rising preadmission severity (group : . %; group : . %; group : . %). base patterns (charlson comorbidity score, knaus index) did not differ between the groups, and . % of patients presented with sepsis. main causes of admission were respiratory ( . %), hemodynamic ( %) or neurologic ( . %) failures. all patients admitted after cardiac arrest resuscitation ( patients) belonged to group . acute severity scores (sofa and saps ) followed preadmission severity. limitation or withdrawing of life support in the icu was higher in group ( . %) than in groups ( %) and ( . %) . median delay between first news equal or superior to and icu admission was h, and h between news equal or superior to . diffrences in delays were not associated with outcome. discussion: our study outlines weaknesses in the chain of care of dwp. emphasis should be put on respiratory rate monitoring and better assessment of severity. rationale: access to critical care is controversial in older patients for reasons: lack of available icu-beds and speculation on induced costs. in contrast, admission of young patients aged or under is infrequently questioned even though they develop catastrophic multiple-organ failure requiring full care. in addition, emotive reaction triggered in staff by these patients often represents a heavy psychological burden when icu-stay is < h. information on the epidemiology, clinical information and induced costs regarding such patients is lacking. patients and methods: this study retrospectively assessed the records of patients aged or under, and admitted from january to august . cost-related expenses charged to care-payers were obtained from our medical information department. data (number, percentages or medians) were reported and discussed by comparison with those of nonagenarians during the same period. results: of , icu-admissions, were aged or under ( %), of whom ( . %) died within the icu, with ( %) dying within h of admission despite full intensive care. the latter represent our study population ( . % of the screened population). the median age was . years , male gender was prevalent ( %). half the patients (n = , %) were referred from the emergency department, ( . %) from hematology, from oncology ( . %), from medical intermediate care units ( . %), and one from digestive surgery ( . %). the first diagnosis at admission was septic shock (n = , . %), followed by post-anoxic encephalopathy (n = , . %), coma (n = , . %), acute respiratory failure (n = , . %) and cardiogenic shock (n = , . %). sapsii was . all patients were ventilated and infused norepinephrine. two patients underwent ecmo, and others mars. mean (± sem) retribution per stay was , ± €, and mean retribution per "day of stay" €. discussion: full care of these icu-patients, with early mortality has a financial impact similar to that of nonagenarians at , ± , €; the cost per "day of stay" is therefore on average % higher than that of nonagerians (mean length of stay: . days), and, in our experience, % higher than that of average patients. conclusion: icu-patients aged or under represent a small percentage of admissions and display half our overall mortality: one third of them die within h of admission with a not insignificant financial impact for cost-payers. septic shock is the first cause of referral, followed by unexpected cardiac arrest. compliance with ethics regulations: yes. rationale: severity scores in patients with sepsis are useful for triaging and predicting mortality. mortality in emergency department sepsis (meds) score is validated in patients with sepsis in the emergency department. curb- is validated in patients with communityacquired pneumonia but not in sepsis. curb- is a simple bedside tool that has many common elements with new sepsis identification score-q sofa. the study aimed to assess the accuracy of curb- score in predicting icu admittance and mortality compared to meds score. patients and methods: this prospective study was conducted at the ed during a -month period. we enrolled all adult patients with sepsis admitted to the ed. meds and the curb- scores were calculated at admission. patients were studied using curb- score and their icu admission and in-hospital mortality were ascertained. results: a total of patients were enrolled. the mean age was ± years. % of the patients were men. % of patients had a curb- score ≥ points with a mean meds score of %. among these patients, % were admitted to icu and % died. the curb- score,was efficient in predicting both icu admittance and in-hospital mortality with an auroc of . ( % ci . - . ) and . ( % ci . - . ), respectively. conclusion: a higher curb- score was correlated with higher rates of icu admittance and mortality in patients with sepsis due to any cause. compliance with ethics regulations: yes. abderrahim achouri, hadil mhadhbi, khedija zaouche, hamida maghraoui, radhia boubaker, kamel majed university hospital center rabta of tunis, tunis, tunisia correspondence: abderrahim achouri (achouryabderrahim@gmail. com) ann. intensive care , (suppl ):p- rationale: sepsis is a major cause of mortality. in other hand, preexistent chronic diseases seem to worsen outcomes among critically ill patients. the acknowledgement of this fact may motivate studies in this type of situations in order to improve survival in sepsis. on that purpose, our study tried to check the impact of chronic pre-existent illnesses on outcomes in this type of emergency patients. patients and methods: we have included patients in whom the sepsis- definition was met throughout emergency department admission cases for infection. in this study, considered outcomes were in-hospital mortality, shock occurence and the use of mechanical ventilation. results: we collected patients admitted to ed for sepsis. mean age was years ± with bornes of and . men were % of the patients. cormorbidities were: insulin dependent diabetes mellitus in . % of patients, non insulin dependent diabetes mellitus in . %, chronic obstructive lung disease in . %, chronic renal failure in . % with % in chronic replacement therapy from total patients, coronary artery disease in . %, with stent in . % and . % with aortic coronary graft from total patients, arterial hypertension in %, chronic heart failure in . %, atrial fibrillation in . %,. death occurs in . % of total patients, septic shock in % and the use of mechanical ventilation in . %. we did not find any association between comorbidity and the use of mechanical ventilation, but association with in-hospital mortality was found in pre-existent coronary artery disease (p = . ) and in patients with coronary artery stent (p = . ). odds ratio (or) was respectively . ( % ic = [ . - . ]) and . ( % ic = [ . - . ] ). we found significant association between chronic heart failure and shock (p = . ) with or = . ( % ic = [ . - . ] ). discussion: the small size of our sample may enlimit the contibution of other comorbidities on outcomes in sepsis such chronic renal failure, especially with renal replacement therapy and diabetes mellitus. whereas, we can conclude that cardiac diseases have the most important impact on outcomes in sepsis. outcomes in sepsis can be affected by comorbidities, especially cardiac diseases. therefore, that needs large studies to check it. compliance with ethics regulations: yes. micafungin population pk analysis in critically ill patients receiving continuous veno-venous hemofiltration or continuous veno-venous hemodiafiltration nicolas garbez , litaty mbatchi , steven c. wallis , laurent muller , jeffrey lipman , jason a. roberts , jean-yves lefrant , claire roger chu nîmes, nîmes, france; university of queensland, brisbane, australia correspondence: nicolas garbez (nicolas.garbez@umontpellier.fr) ann. intensive care , (suppl ):p- rationale: to compare the population pharmacokinetics (pk) of micafungin in critically ill patients receiving continuous veno-venous hemofiltration (cvvh, ml/kg/h) to those receiving equidoses of hemodiafiltration (cvvhdf, ml/kg/h + ml/kg/h). critically ill patients in septic shock undergoing continuous renal replacement therapy (crrt) and receiving mg micafungin once daily were eligible for inclusion. total micafungin plasma concentrations were analyzed using pmetrics ® . probability of target attainment (pta) was calculated from monte carlo simulations using -hour area under curve/minimum inhibitory concentration (auc - /mic) cut-offs (c. parapsilosis), (all candida species) and (c. non parapsilosis). daily dosing regimens of , and mg were simulated for the first days of treatment. results: eight patients were included in the study. micafungin concentrations were best described by a two-compartmental pk model. no covariate, including crrt modality (cvvh and cvvhdf), was retained in the final model, confirmed by internal validation. the mean parameter estimates (standarddeviation) were . ( . ) l/h for clearance, . ( . ) l for the volume of the central compartment, . ( . ) /h and . ( . ) /h for rate constants. the standard mg daily dosing was unable to reach % of pta for all candida species except c. albicans on the second day of therapy (fig. ) . conclusion: there was no difference in micafungin pk between equidoses of cvvh and cvvhdf. a dose escalation to mg is suggested to achieve the pk/pd target of candida species with mics exceeding . mg/l in this population. these "off-label" dosing regimens should be further investigated in clinical trials knowing the favourable toxicity profile and the post-antifungal effect of micafungin in order to ensure efficacy and to prevent the emergence of resistance due to an inadequate initial antifungal dosing regimen. compliance with ethics regulations: yes. rationale: sepsis is an important cause of morbidity and mortality in hospitalized patients. recognizing and responding to patients who experience clinical deterioration remains challenging in daily practice. our purpose was to assess the ability of the quick sequential organ failure assessment (qsofa) score to identify, among patients reviewed by an intensivist, those at risk of adverse outcomes. patients and methods: retrospective cohort of patients with suspected infection reviewed by an intensivist in a university-affiliated hospital between january and june . outcomes of interest were hospital mortality and a combined criterion of hospital mortality or icu stay of days or more. results: during the study period, patients were reviewed by an intensivist, of whom ( . %) had suspected infection according to the sepsis- criteria. at the time of review, ( . %) patients with suspected infection were qsofa positive (≥ ) and ( . %) were qsofa negative ( - ). following the review, ( . %) patients were admitted to the icu, among whom ( . %) had a prolonged stay (≥ days). in-hospital mortality was . %, and . % of the patients met the combined criterion of in-hospital mortality or prolonged icu stay. qsofa positive patients required more frequently mechanical ventilation ( . % vs. . %, p = . ) and vasopressor support ( . % vs. . %, p < . ) than qsofa negative patients. moreover, qsofa positive patients had higher hospital mortality than qsofa negative patients ( . % vs. . %, p = . ). for the prediction of in-hospital mortality, a positive qsofa had a predictive positive value (ppv) of %, and a negative predictive value (npv) of %. for the prediction of in-hospital mortality or prolonged icu stay, a positive qsofa had a ppv of % and a npv of %. conclusion: hospitalized patients with suspected infection for whom a review by an intensivist was requested, are at high risk of hospital mortality. although the accuracy of qsofa for identifying patients at risk of adverse outcomes is limited, its integration in a multimodal risk assessment approach may help distinguish the subset of patients who will benefit from an escalation of care. compliance with ethicsregulations: yes. rationale: according to the sepsis- consensus, sepsis is identified as an increase of at least points in the sepsis-related organ failure assessment (sofa) score in patients who presented infection. the quick sofa or qsofa is considered as a predictive tool of sepsis and mortality when it is equal to points or more. systemic inflammatory response syndrome (sirs) criteria are of limited utility because of their low sensitivity. hyperlactatemia, as known is a determinant of tissue hypoperfusion. our objective was to evaluate the prognostic value of sofa > , sirs > , qsofa > and lactate level > mmol/l in infected patients. nine-month prospective cohort study. patients aged years or older who had a proven or suspected infection were included. sofa score, sris criteria, sofa q and lactate levels were determined within the first h of infection. the primary endpoint was hospital mortality at days. the predictive power of the studied parameters was determined using using the area under the receiver operating characteristic curve (auroc). results: a cohort of cases was studied with mean age at . years. bacterial pneumonia was the most common infection site ( %). in the first h of onset of infection the medians [iqr - ] of the sofa, sris, and sofa scores and lactate levels were respectively [ ] [ ] [ ] [ ] [ ] [ ] [ ] , [ ] [ ] , [ - ] and . [ . - . ] . the progression to severe septic status was observed in patients ( %) and norepinephrine was introduced in cases. median length of stay was days [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and mortality was %. overall, the accuracy in predicting mortality of the studied parameters was poor. an increase of sofa score by at least points had greater accuracy with auroc = . [ . - . ], sensitivity = % and specificity = %. conclusion: in infected patients, the sofa score had greater prognostic accuracy than the sirs criteria, the qsofa score or the lactate level. these results suggest that sirs, qsofa, and high lactate level may be useful in screening for sepsis, but this utility is limited in predicting mortality. compliance with ethics regulations: yes. rationale: quick sequential organ failure assessement (qsofa) has been validated for patients with presumed sepsis and others in general emergency department (ed) population. however, it has not been validated in specific subgroups of patients with a high mortality. the aim of this study is to evaluate the ability of qscore to predict prognosis in patients with decompensated liver cirrhosis. patients and methods: this is a retrospective study, conducted over a period of years from january to december . consecutive patients with decompensated cirrhosis, admitted in our department are included. data of all patients were collected and the qsofa score was calculated at admission. the main study endpoints were length of stay, complications and in-hospital mortality. results: a total of patients diagnosed with decompensated cirrhosis were enrolled. mean of age was years ( - ). sex ratio was . . hcv ( %) was the main etiology of cirrhosis. the reasons of hospitalization were: oedema with ascitic syndrome in % of cases, digestive haemorrhage ( % of cases), fevers ( % of cases), and hepatic encephalopathy was present in % of cases. the mean duration of stay was days ± . in-hospital mortality rate was % and mean score qsofa was . .the qsofa score was significantly correlated with length of stay (p = . ) and complications(p = . ) but not with in-hospital mortality (p = . ). conclusion: the qsofa score was not useful for predicting in hospital mortality in patients with decompensated liver cirrhosis but it was significantly correlated to the length of stay and complications. compliance with ethics regulations: yes. angioedema associated with thrombolysis for ischemic stroke: analysis of a case-control study clara vigneron , aldéric lécluse , thomas ronzière , sonia alamowitch , olivier fain , nicolas javaud médecine interne, centre de référence associé sur les angioedèmes à kinines (créak), hôpital saint-antoine, aphp, paris, france; neurologie, chu angers, angers, france; neurologie, chu pontchaillou, rennes, france; neurologie, hôpital saint-antoine, aphp, paris, france; urgences, centre de référence associé sur les angioedèmes à kinines (créak), hôpital louis mourier, aphp, colombes, france correspondence: clara vigneron (claravigneron@hotmail.fr) ann. intensive care , (suppl ):p- rationale: bradykinin-mediated angioedema is a complication associated with thrombolysis for acute ischemic stroke. risk factors are unknow and management is discussed. the aim of this study was to clarify risk factors associated with bradykinin-mediated angioedema after thrombolysis for acute ischemic stroke. patients and methods: in a case-control study conducted at a french reference center for bradykinin angioedema, patients with thrombolysis for acute ischemic stroke and a diagnosis of bradykinin-mediated angioedema, were compared to controls treated with thrombolysis treatment without angioedema. two matched control subjects were analyzed for each case. results: thrombolysis-related angioedema were matched to control subjects. the sites of attacks following thrombolysis for ischemic stroke mainly included tongue ( / , %) and lips ( / , %). the upper airways were involved in ( %) cases. three patients required mechanical ventilation. patients with bradykinin-mediated angioedema were more frequently women ( ( %) vs. ( %); p = . ), had higher frequency of prior ischemic stroke ( ( %) vs ( %); p = . ), hypertension ( ( %) vs. ( %); p = . ), were more frequently treated with angiotensinconverting enzyme inhibitor ( ( %) vs. ( %); p < . ) and were more frequently hospitalized in intensive care unit ( ( %) vs. ( %); p = . ). in multivariate analysis, factors associated with thrombolysisrelated angioedema were female sex (odds ratio [or], . ; % confident interval [ci], . - . ; p = . ) and treatment with angiotensin-converting enzyme inhibitors ([or], . ; % [ci], . - . ; p < . ). discussion: because of theretrospective case-control design and the lack of the total number of thrombolysis for ischemic stroke, the incidence of this complication could not be evaluated in our study. previous studies reported an incidence of . to . % of angioedema in patients treated with a thrombolytic therapy for acute ischemic stroke. our case-control study permits for the first time to analyse more cases to evaluate associated risk factors of this rare complication. conclusion: this case-control study points out angiotensin-converting enzyme inhibitors and female sex as risk factors of bradykininangioedema associated with thrombolysis for ischemic stroke. compliance with ethics regulations: yes. rationale: patients with inflammatory bowel disease (ibd), frequently treated by immunosuppressive drugs, are more susceptible to be admitted to the intensive care unit (icu). however, outcome and predictive factors of mortality are little known. therefore, we aimed to assess the outcome and prognostic factors for critically ill ibd patients. patients and methods: we retrospectively studied data of consecutive ibd (i.e. crohn's disease and ulcerative colitis) patients admitted in icus between and . in-icu and one-year mortalities were estimated and predictive factors of in-icu mortality were identified by univariate and multivariate analysis. results: seventy-six patients (male: %, median age: . [ . - . ] years, charlson index: [ . - . ]) entered the study. ibd type was largely represented by crohn's disease ( . %) and its localization was mostly extensive: l ( . % of crohn's disease) or e ( % of ulcerative colitis) according to the montreal classification. twenty-seven patients ( . %) were treated with corticosteroids and ( %) with immunosuppressive therapy (azathioprine: . % and anti-tnfα: %). reasons for admission were shock/sepsis ( . %) and acute respiratory failure ( . %). icu diagnoses were infection ( %), ibd flare-up ( . %) or both ( . %), and pulmonary embolism ( . %). at admission, sofa score was [ . - . ] and . fifty-three patients ( . %) required mechanical ventilation, ( . %) vasoactive drugs, and ( . %) renal replacement therapy. twenty-three patients underwent emergency surgery ( . %) and six urgent endoscopic treatment ( . %). in-icu and one-year mortality rate were . % and . %, respectively. prognostic factors of in-icu mortality were sofa score (hr . , % ci [ . - . ], p < . ) and azathioprine treatment before icu admission (hr . , % ci [ . - . ], p < . ) (fig. ) . previous immunosuppressive treatment with anti-tnf did not alter the prognosis and even the type of ibd. conclusion: our study showed that more than % of ibd critically ill patients were discharged alive from the icu and a majority of them survived after one-year ( . %). we also found that sofa score and previous azathioprine immunosuppressive treatment worsened icu outcome. higher severity of the acute event affected short-term prognosis and should be taken into account for best icu triage and management. intensivists should pay particular attention to patients treated by azathioprine. compliance with ethics regulations: yes. fig. outcome of ibd patients admitted to the icu according to precious treatment with azathioprine status all aps patients with any new thrombotic manifestation(s) admitted to icus. results: one hundred and thirty-four patients (male/female ratio: . ; mean age at admission: . ± . years), who experienced caps episodes, required icu admission. the numbers of definite, probable or no-caps episodes (fig. ) , respectively, were: ( . %), ( . %) and ( . %). no histopathological proof of microvascular thrombosis was the most frequent reason for not being classified as definite caps. overall, / ( . %) episodes were fatal, with comparable rates for definite/probable caps and no caps ( % vs. . % respectively, p = . ). the kaplan-meier curve of estimated probability of survival showed no between-group survival difference (log-rank test p = . ). discussion: our results suggest that the caps criteria do not sufficiently encompass all the parameters responsible for thrombotic aps patients' disease severity in the icu. the absence of items referring to organ dysfunction/failure in the caps criteria probably limited their ability to predict mortality. albeit useful for the retrospective classification and comparison of patients, the caps criteria may be too stringent and not yet ready-to-use for the management of icu patients. for physicians outside expert aps centres, the absence of caps criteria could be misleading and lead to rejection of the diagnosis for near-caps patients, thereby preventing them from receiving the appropriate aggressive treatment they indeed require. we think that, when confronted with a critically-ill thrombotic aps patient, caps criteria should be interpreted with caution and should not be the only elements taken into account to decide the intensity of the therapeutic management. rationale: % of resuscitation patients develop anemia during their stay, it can worsen the prognosis, prolong the length of stay and lead to transfusions that can be the cause of complications. the objective of our work is to specify the incidence of anemia in our unit, its etiologies and its therapeutic management. patients and methods: we conducted a descriptive and analytical retrospective study within the surgical emergency resuscitation department of ibn rochd university hospital of casablanca, over a period of years from to . we included all anemic patients. statistical analysis was performed with spss statistics . p < . was considered significant. results: we included patients with an estimated incidence of %, the average age was years, the sex ratio h / f was . . % of admissions were for traumatic pathology and % postoperative digestive surgery. % had hypotension at admission and the mean temperature was . % .the onset of anemia and its depth were related to length of stay with . % of patients who were anemic beyond the th day of hospitalization with a hemoglobin level that became < . g / dl beyond the th day. % of the patients had a normochromic normocytic anemia becoming microcytic with the lengthening of the duration of stay. ferritinemia dosed in % of patients and was normal. % of our patients had exclusive parenteral nutrition while % had an enteral / parenteral combination. % were transfused in red blood cells (rbc) and % of patients were transfused more than once. % received between and rbc units. in patients who received transfusion episodes costing euros, the transfusion was inappropriate. the total cost of the transfusion was estimated at around , euros. % were supplemented with oral iron with an increase in hemoglobin in % of them. % of the patients came out of the intensive care unit with a hemoglobin level < g/dl/l. the mortality rate of our patients was % with as predictive factors in multivariate analysis, hyperthermia, coagulopathy, the transfusion appears as a factor of good prognosis. the prevention of blood spoliation and the fight against inflammation and nosocomial infection remain the pillars of the management of anemia in intensive care but in view of our results and the protective role of transfusion it would be interesting to see again the transfusion thresholds in our context. compliance with ethics regulations: yes. (fig. ). discussion: we described a series of patients with severe acute viral myopericarditises associated with anti-rnapol autoantibodies, an association that has never been reported previously. the fortuitous association of these autoantibodies with acute myopericarditis is highly unlikely. acute myocarditis is a very rare disease with a reported incidence of / , inhabitants. anti-rnapol -antibody detection is also very rare: . % positive tests (including the patients in this series) out of samples during a -year period in our immunology laboratory. this % proportion of patients with proven influenza-virus infections suggest that such severe infections could trigger anti-rnapol autoantibody production. however, influenza is a common disease and anti-rnapol autoantibodies are very rare. furthermore, no anti-rnapol autoantibodies were detected in the patients with severe influenza-related ards. last, anti-rnapol autoantibodies remained detectable several months after the viral infection had been cured. conclusion: this previously unknown association between severe acute viral myopericarditis and anti-rnapol autoantibodies is probably not fortuitous. anti-rnapol antibody detection in acute myopericarditis patients could imply individual susceptibility to severe viral infection. further studies are needed to investigate the pathophysiological mechanisms involved in this entity and potential specific therapeutic strategies. fig. relative frequencies of digestive manifestations in critically ill tma patients rationale: arrhythmia-induced cardiomyopathy has been recognized for several decades, but most severe forms, i.e. cardiogenic shock and refractory cardiogenic shock requiring mechanical circulatory support, were rarely described in adults. in this retrospective study, we described patients admitted in our tertiary care center for non-ischemic acute cardiac dysfunction (or worsening of previously known cardiac dysfunction) and recent onset supraventricular arrhythmia who developed cardiogenic shock requiring veno-arterial ecmo (va-ecmo). results: in a years period, patients had va-ecmo for acute non ischemic cardiac dysfunction and recent onset supraventricular arrhythmia (table ). fourteen ( %) patients had known nonischemic cardiomyopathy and ( %) known paroxystic atrial fibrillation. cardiogenic shock was the first manifestation of the disease in patients. atrial fibrillation was the main cause of arrythmia ( % of cases). at ecmo implantation, sofa score was [ - ], inotropic score , lvef % [ - ] and lactate level was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] mmol/l. twelve patients had sustained successful reduction after amiodarone and/or electric shock, all were weaned from ecmo and survived without transplantation nor long term assist device. among the patients with failure of reduction, underwent an atrio-ventricular ablation while on ecmo and had atrial tachycardia ablation; all were weaned from ecmo and survived. among the remaining patients without reduction and without ablation procedure, only the patients who were bridged to heart transplantation or left ventricular assist device survived. in univariate analysis, factors associated with unfavorable outcome were previously known heart disease, heart rate, renal replacement therapy, nt-probnp level, failure of rhythm reduction after amiodarone load and/or electric shock. among the patients who recovered and survived ( with successful reduction and with successful ablation), lvef increased from [ - ]% before ecmo implantation to [ - ]% at long term follow-up. discussion: this is the largest cohort of arrhythmia induced cardiomyopathies on va-ecmo and the first description of atrio-ventricular node ablation with favorable outcome in this setting. conclusion: arrhythmia induced cardiomyopathy is probably underrecognized and should be considered in any patient with nonischemic acute cardiac dysfunction and recent onset supraventricular arrhythmia. recovery is possible in the most severely ill patients on va-ecmo, even with severe left ventricular dilation. aggressive rate control by av-node ablation may be warranted in case of failure of reduction, and may allow recovery and favorable outcome. compliance with ethics regulations: yes. rationale: diagnosis of sepsis is a major challenge in intensive care units and is associated with a high morbidity and mortality. sepsis identification is even more difficult in patients with extracorporeal membrane oxygenation (ecmo) because of many confounding factors. the primary objective was to study the ability of c-reactive protein (crp) and procalcitonin (pct) values measured at ecmo support initiation (day ) to predict the occurrence of early sepsis in patients undergoing venoarterial ecmo (va-ecmo) or venovenous ecmo (vv-ecmo). the secondary objectives were to study the association between these biomarkers and mortality rate during ecmo support and in-hospital mortality rate. furthermore, we investigated the relationship between early sepsis and mortality. patients and methods: we performed a retrospective, monocentric study in the cardiovascular intensive care unit of the university hospitals of lille, france. between november , and december , , we included patients over years old, who underwent an ecmo support for a medical or surgical indication, and for whom biomarkers (crp and pct) levels were available for at least the first days of admission. biomarkers and blood cultures were daily assessed for the first ecmo support days. early sepsis was defined by sepsis diagnosis in the first days after circulatory assistance initiation. in-hospital mortality rate was censored at days. after univariate analysis, a cox multivariate regression model was used to assess if the association between biomarkers levels and early sepsis or mortality rate was independent. a kaplan-meier survival plot was used to describe the association between early sepsis and mortality. results: among patients included, underwent va-ecmo and underwent vv-ecmo. an early sepsis diagnosis was made in . % of va-ecmo patients and in % of vv-ecmo patients. pct and crp levels on day were significantly associated with early sepsis diagnosis (fig. rationale: fluids are one of the most prescribed drug in intensive care, particularly among patient with circulatory failure. yet, very little is known about their pharmacodynamic properties and this topic has been left largely unexplored. several factors may impact the haemodynamic efficacy of fluids among which the infusion rate. the aim of this study was to investigate the influence of the rate of fluid administration on the fluid pharmacodynamics, in particular by studying mean systemic pressure (pms). we conducted a prospective observational study in patients with septic shock to compare two volume expansion strategies. a fluid bolus, ml of normal saline were administered and several haemodynamic variables were recorded continuously: cardiac output (co), arterial pressure (ap), mean systemic pressure (pms, estimated from ci, pvc and map). infusion rate was left at the discretion of the attending physician. a "slow" and a "fast" groups were determined based on the median of the infusion duration. fluids effect was measured by the area under the curve (auc), maximal effect (emax) and time to maximal effect (tmax) for each haemodynamic variable. the effects of fluid on psm disappeared in one hour on average. compared to patients of the "slow" group, those of the "fast" group had a shorter tmax and a higher emax for pms (p = . and . respectively). the auc for pms was identical between group, while in case of similar effect of infusion rates, it should be larger in the "slow" group. regarding co, tmax was also shorter in the "fast" than in the "slow" group (p = . ). the decreasing slope from maximal effect was comparable between groups, for pms as for co. the effect of a ml fluid bolus with normal saline in septic shock patients vanished within one hour. a faster infusion rate increased the maximal and total effect of the fluid bolus and shortened the delay to reach the maximal effect. rationale: significant hypotension following spinal anesthesia is a common issue in everyday clinical practice. toavoid this potentially harming situation, an empirical fluid administration is usually performed before the procedure. inferior vena cava (ivc) ultrasound has been demonstrated effective in guiding fluid therapy in critical care patients. the purpose of this study was to evaluate the ivc ultrasound guided volemic status optimization in order to decrease post-spinal hypotension rate. patients and methods: in this prospective, controlled, randomised study, consecutive patients were recruited and patients were randomly assigned to a control group, consisting of pre-anesthesia empirical fluid administration (itt), an ivc ultrasound group in which fluid management was based on an ivc ultrasound evaluation, and a passive leg raising test (plrt) group in which volume optimization was performed following the above mentioned test. primary outcome was the hypotension rate reduction after spinal anaesthesia following fluid optimization therapy between the groups. secondary outcomes were the total fluid amount administered, the total vasoactive drug amount used and the time needed to realize the whole anaesthetic procedure in all three groups. results: % reduction in hypotension rate ( % ci - %, p = . ) was observed between the echocardiography group and the control group, and there was a reduction of hypotension rate by % (ci % - %, p = . ) between the echocardiography group and the plrt group. the total fluid amount administered was significantly greater in the ultrasound group than in the control group ( ml; sd ml, versus ml; sd ml, p = . ). the total amine consumption was % in control group, % in ivc group and % in plrt group. an increased of total study time was observed for the echocardiography group min (sd min) in comparison with the control group min (sd min) and ptlr group min (sd min), (p < . ). the study showed a faint but positive trend toward the use of ivc-ultrasound to identify patients in spontaneous breathing needing fluid optimization before spinal anesthesia compliance with ethics regulations: yes. rationale: we performed a systematic review and a meta-analysis of studies investigating the ability of the end-expiratory occlusion (eexpo) test to predict preload responsiveness, through the changes in cardiac output (co) or its surrogates, in adult patients. this meta-analysis was prospectively registered on prospero (crd- ). we screened pubmed, embase and cochrane database to identify all original articles published between and evaluating the ability of the eexpo test to predict a significant increase in co or surrogate, compared to the one induced by a subsequent volume expansion or by passive leg raising (plr). the meta-analysis determined the pooled area under the receiver operating characteristics curve (auroc) of eexpo testinduced changes in co to detect preload responsiveness, as well as pooled sensitivity and specificity and the best diagnostic threshold. subgroup analysis and sensitivity analysis were planned to investigate potential sources of heterogeneity. results: thirteen studies ( patients) were identified and included in the analysis. nine studies were performed in the intensive care unit and four in the operating room. preload responsiveness was defined according to co changes induced by fluid administration in studies (fluid-induced increase in co ≥ % or ≥ %) and according to co changes induced by plr in one study. the duration of the respiratory hold ranged between and s. for the eexpo test-induced changes in co, the pooled sensitivity and specificity were [ - ]% and [ - ]%, respectively, while the pooled auroc curve was . ± . (fig. ) . the corresponding best diagnostic threshold was . ± . %. when changes in co were monitored through pulse contour analysis compared to other methods the accuracy of the test was significantly higher ( ( ). continuing (decrease to % of peak level) or modification (decrease < %) of antibiotic therapy was guided by a serum pct assay from the third day of treatmentand every h until antibiotic was stopped. this last was stopped when pct levels had decreased of % from the initial value. results: a total of patients had been diagnosed as sepsis (n = , %) and septic shoc (n = , %). mean age was years ± . an average ubs and absi score of % and . the average length of stay in icu was days. patients were assigned into two groups: group a (favorable evolution, n = ); group b (unfavorable evolution, n = ). the therapeutic attitude according to the kinetics of the pct are presented in the table . we found a significant difference between patients with unfavorable evolution compared to those with a favorable evolution (in whom we stopped antibiotics) (p < . ), in terms of hemodynamic state, pct concentration and renal clearance. pctguided antibiotic treatment has been proven to significantly reduce length of antibiotic therapy in our patients. the average duration of antibiotic was . ± days. conclusion: pct measurement may help with the decision to initiate antibiotic therapy in low risk acuity of infection and allows more judicious antibiotic use by reducing antibiotic exposure. compliance with ethics regulations: not applicable. rationale: reducing the risk of severe hypoxemia during endotracheal-intubation (eti) is a major concern in intensive care unit but little attention was paid to co variations during this period. we conducted a prospective observational study to describe transcutaneous co (ptcco ) throughout intubation in patients who received preoxygenation with standardoxygen therapy (sot), non-invasive ventilation (niv), or high flow nasal cannula oxygen therapy (hfncot). patients and methods: patients over years undergoing eti in icu were continuously monitored for ptcco during intubation and the following h under mechanical ventilation (mv). haemodynamics and respiratory parameters were also recorded as well as arterial partial pressure of co (paco ) to evaluate reliability of the transcutaneous measure. results: two hundred and two patients were included in the study. we found a strong correlation between ptcco recorded at preoxygenation and the last paco available before intubation (r = . , p < . ). in % of patients ptcco values recorded at initiation of mv were out of - mmhg ranges. ptcco recorded at eti, at initiation of mv, min and h of mv were significantly higher than ptcco during preoxygenation (p < . by anova). variations of ptcco were significantly different according to the preoxygenation method (p < . for interaction in anova). lastly, a decrease in ptcco higher than mmhg within half an hour after the beginning of mv was independently associated with postintubation hypotension (pih) (odds ratio = . , % confident interval . - . , p = . ). conclusion: ptcco is a valuable tool to record paco variation in patients requiring invasive mechanical ventilation and could be useful to prevent pih. compliance with ethics regulations: yes. rationale: intubation in intensive care unit (icu) is a critical procedure which leads to serious adverse event in to % of cases. several recent trials were conducted to help physicians to choose medications, devices and modality of intubation. especially, videolaryngoscope (vl) led to several publications in the last few years, with increasing tools marketed and spread use (difficult airway management, routineintubation). we designed an online survey to take a picture of intubation process and devices availability in france. toolbox. it was positioned as a first line laryngoscope for every intubation in critically ill patients to reinforce the vl skill training. present study was performed using prospectively collected data from a continuous quality improvement database about airway management in a -beds french teaching hospital medical icu. all consecutive intubation procedure performed with vl from september to june were included. "first attempt success" group and "first attempt failure" group were compared by univariate and multivariate analysis in order to analyze the first attempt intubation success rate according to the level of operators' expertise, identify factors associated with first pass intubation failure and describe the intubation related complications. results: we enrolled consecutive endotracheal intubations. overall first attempt success rate was ( %). comorbidities, junior operator, the presence of cardiac arrest and coma were associated with a lower first attempt success rate. the first attempt success rate was less than % in novice operators ( - previous experiences with vl, independently of airway expertise with direct laryngoscopies) and % in expert operators (greater than previous experiences with vl) (fig. rationale: tracheostomy in intensive care unit (icu) has many advantages. but only patient comfort and shorter icu and hospital stay were demonstrated. the timing of this procedure is still debated. the aim of this study was to determine the impact of early tracheostomy on prognosis. we performed a retrospective study in a medical icu ( beds unit) from january to november . the technique of tracheostomy was exclusively surgical in the operating room made by the surgeon. the primary endpoint was mortality in icu. the secondary outcomes were post-tracheostomy incidence of ventilator acquired pneumonia, duration of mechanical ventilation and length of stay in icu. these criteria were assessed in relation to timing of the tracheostomy defined as early when performed before day of mechanical ventilation. results: forty-two patients were enrolled during the study period. mean age of patients was ± years. median length of stay in icu was of days. mortality rate was of %. comparing the two groups, early vs late tracheostomy, no difference was found with respect to mortality ( % vs. %, p = . ), vap occurrence ( % vs. %, p = . ), post-tracheostomy duration of mechanical ventilation ( ± d vs. ± d, p = . ), or length of stay in icu ( ± d vs. ± d, p = . ). in multivariate analysis, the only factor independently related to mortality was the sofa score patient on tracheostomy day with p = . and or = . (ci % [ . - . ] ). conclusion: tracheostomy in the intensive care unit remains a justified alternative despite the discordant data in the literature. in our study, the delay of the procedure didn't interfere with the evolution. however, the patient severity as attested by sofa score at the day of tracheostomy, was the only independent prognostic factor. those results should be confirmed by other large prospective studies. compliance with ethics regulations: not applicable. sabah benhamza, mohamed lazraq, youssef miloudi, abdelhak bensaid, najib el harrar réanimation de l'hôpital du août, casablanca, morocco correspondence: sabah benhamza (benhamzasabah @gmail.com) ann. intensive care , (suppl ):p- rationale: many unknowns remain as to the place of tracheostomy in intensive care. reluctance to perform a tracheotomy is numerous, especially when pre-exists chronic respiratory failure, but some data suggest benefits. we report in this work our experience in tracheotomy in the intensive care unit of the august hospital, casablanca. patients and methods: this is a retrospective descreptive study over years (january to january ) including all patients that have been tracheostomized in the intensive care unit of the august hospital . results: during the study period, patients were tracheostomized with a prevalence of . % in years, the predominance was male (sex ratio . ). the average age was ± years old. the indication for tracheostomy was prolonged ventilation in % of cases, extubation failure in % of cases, and intubation failure in % of cases. tracheostomy was performed on average on the th day of intubation. all patients were tracheostomized in the operating room by ent surgeons. the main complications attributable to tracheotomy were hemorrhage of the tracheostomy orifice in patients ( %) immediately resumed, cases of subcutaneous emphysema ( %), case of pneumothorax ( %), cases of orifice infection ( %). no patient died of a tracheostomy related cause. the tracheotomy in intensive care is still a subject of debate especially concerning the time of its realization. however it seems to reduce the duration of mechanical ventilation, facilitates the care and also the ventilatory weaning. compliance with ethics regulations: yes. rationale: hfnco is a frequently used device providing heated and humidified high flow oxygen with several advantages: decreased work of breathing, decreased dead space, increased end expiratory lung volume (eelv), more stable fio . the increase in eelv is relying of the positive expiratory effect generated by the device. the level of generated pep seems however to largely depend on whether the mouth is open or not. this study was aimed to assess the impact of mouth opening on eelv increase induced by hfnco using electric impedance tomography. patients and methods: the following hfnco trial was proposed to healthy subjects who used hfnco on a regular basis for patients care. oxygen flow was set successively during min periods at , and l/min (optiflowtm; fisher & paykel healthcare, auckland, nz). these three conditions were tested in semi recumbent and supine position chosen at random. measurement started in supine position with no flow (baseline) and each period was separated from the following by a wash out period on min during which the subject could breath normally with no supplemental oxygen. electric impedance tomography (pulmovista ® , dräger medical gmbh, lündbeck, germany) was performed applying a electrodes belt placed between the th and th intercostal space, including a reference electrode located on the abdomen. as no spirometer was used, the data of eelv computed on the eit device were expressed as percentage of variation of the value measured in supine or semi recumbent position with no flow. demographic data were expressed as median and extreme values. comparisons were performed using u mann whitney test. [ . - . ] accepted to participate to the study. when subjects received hfnco with open mouth (whatever position) no modification of eelv was observed (table ) . conversely, a significant increase in eelv was noted with closed mouth, whatever position. in the semi recumbent position the increase in eelv was even more important with l/min. conclusion: electrical impedance tomography illustrates the impact of mouth closure on eelv increase among healthy subjects receiving hfnco. compliance with ethics regulations: yes. rationale: in stable copd patients, nasal high flow oxygen (nhf) use can be associated with reduction in respiratory rate (rr) and minute ventilation (mv). in thesepatients, paco remains stable or decreases under nhf. this suggests a possible dead space reduction related to a washout effect of nhf. the aim of this study was to assess the physiological effects of nhf in hypercapnic patients with acute copd exacerbation. patients and methods: crossover study in hypercapnic patients suffering from acute copd exacerbation and treated with intermittent non-invasive ventilation (niv). nhf l/min or standard oxygenotherapy (stand o ) were randomly administered during h between niv treatments. rr, tidal volumes (vt), mv and corrected mv (cormv = mv x paco / ) variations were recorded during the last min of each study period using a respiratory inductive plethysmography vest. blood gas analysis was performed at the end of each oxygen administration period. visual analogic dyspnea score (vas) quoted from to was assessed by the patient after and min. results given as median [iqr] . wilcoxon tests were used to compare data between stand o and nhf. results: twelve patients were included and data could be recorded in ( (fig. ). dyspnea scores were not different between the modalities. conclusion: in case of acute copd exacerbation, using nhf between niv treatments was associated with paco and rr decrease. mv concomitantly decreased suggesting a deadspace volume reduction related to a washout effect of nhf. corrected mv decreased in all the patients except one. these results suggest that nhf could be used to deliver oxygen between niv treatments to copd patients suffering from acute exacerbation and could contribute reducing paco . compliance with ethics regulations: yes. rationale: the role of atypical micro-organisms in acute exacerbation of chronic obstructive pulmonary disease (copd) that require mechanical ventilation is poorly none. the aim of this study was to determine the role of atypical pathogens in severe acute exacerbation of copd. patients and methods: in this prospective study we included all patients admitted for acute exacerbation of copd requiring mechanical ventilation. atypical pathogens (chlamydophila pneumoniae and mycoplasma pneumoniae) were searched by serological diagnosis and by culture of sputum samples. in this study we included patients aged ± years. sixty-eight percent of sputum culture were considered significant. six cultures were positive with different microorganisms. neither chlamydophila pneumoniae nor mycoplasma pneumoniae were found. the prevalence of chlamydophila pneumoniae was . % (positive igg serum). the demographic characteristics was similar between patients with and without positive culture. the rate of noninvasive ventilation (niv) failure was % in positive serology group versus % in negative serology group (p = . ). the mortality was similar in both groups. in multivariate logistic regression analysis only positive serology (or = . ; % ic [ . - . ], p = . ) was an independent factor of niv failure. conclusion: a positive serology of chlamydophila pneumoniae was a predictive factor of niv failure without an impact on the morbidity and mortality of copd patient treated with mechanical ventilation. compliance with ethics regulations: yes. rationale: emergency departments (ed) receive a growing up number of patients with acute exacerbation of chronic obstructive pulmonary disease (copd) .non-invasive ventilation (niv) could be a good alternative to achieve a respiratory support, avoiding as much as possible the complications of invasive ventilation. the study aimed to assess the clinical outcomes of using niv in acute exacerbation of copd at ed and to identify whether clinical variables present at admission are predictive of niv failure. we conducted a prospective study conducted at the ed over a period of one year. data of all patients admitted for acute exacerbation of copd for all causes and requiring non-invasive ventilation were collected. niv failure was defined as need for endotracheal intubation or death. results: during the study period, a total of patients with a mean age of years (± ) were included. acute exacerbation of copd was due to bronchitis in %, to pneumonia in % of cases. % of patients had no apparent etiology of acute exacerbation of copd. bilevel positive airway pressure was performed on all patients, during a mean period of h (± ). clinical niv success was observed in patients ( %). the predictors of niv failure were advanced age, tachycardia, and hypercapnia. conclusion: the efficiency of niv in the management of acute exacerbations of copd at ed is well documented. this is further supported by our study which showed a clinical success in % of patients with acute exacerbation of copd. compliance with ethics regulations: yes. rationale: non invasive ventilation (niv) is often performed in elderly patients with acute respiratory failure (arf) at emergency department (ed). this technique may be subject to many difficulties, due to the presence of frequent co-morbidities. the aim of this study was to identify the predictive factors of niv failure in elderly patients with arf at ed. patients and methods: this was a retrospective study conducted at ed on year and months including patients aged more than years and who required the use of niv for an arf. all data were collected and analyzed using the spss software. patients were divided into two groups: niv failure and niv success. niv failure was defined by inhospital mortality, requirement of intubation or hospitalization at intensive care unit. results: during the study period, a total of elderly patients that required niv for arf were included. median age was years (min = , max = ) and sex ratio was . . the median charlson index was (min = , max = ). the etiological diagnoses of arf were acute decompensation of chronic obstructive pulmonary disease ( %), acute heart failure ( %), pneumonia ( %) and pulmonary embolism ( %). the arf was hypercapnic in % of cases and nonhypercapnic in %. niv failure concerned %. predictive factors of niv failure were clinical signs of right heart dysfunction (p < . ), c reactive protein (p = . ), initial ph (p = . ) and kidney dysfunction (p < . ). conclusion: in our study, niv failure in elderly patients with arf at ed was influenced by clinical signs of right heart dysfunction, c reactive protein, initial ph and kidney dysfunction. these clinical and biological factors could be useful to identify the most critical elderly patients and to better guide therapeutic decisions. compliance with ethics regulations: yes. rationale: the interest of ecco r in the management of very severe acute asthma exacerbations is still unclear. since it could help to control respiratory acidosis and /or to limit dynamic hyperinflation, its clinical benefits are uncertain, even in mechanically ventilated patients. the rexecor observatory is a prospective ecco r cohort in the great paris area. tencases of severe asthma treated by ecco r were retrospectively reviewed. mainly, arterial blood gases (abg), duration of ecco r and imv were collected and in-icu mortality were assessed. data are reported as median (iqr). results: ten patients ( men, age: (ic: - ) years, bmi: . (ic: . - . ) kg/m , fev- : . (ic: . - . ) l, ( (ic: - ) %), saps : . (ic: . - . ) points) were included. one patient suffered from cardiac arrest before admission and one had pneumothorax at icu admission. nine patients were under imv (started on the day of admission for ). before ecco r, patients received systemic corticosteroids, paralyzing agents, epinephrine and salbutamol. two patients suffered from pneumonia. ecco r was started (ic: - . ) days after intubation. venous vascular access was achieved via the right internal jugular route in patients and via the femoral route in . the hemolung device was used in patients, the ila activve in and the prismalung in . abg before and after day of ecco r are reported in table . duration of ecco r was (ic: . - ) days and patients were weaned from imv under ecco r. for the remaining patients, duration of imv after ecco r was (ic: - . ) days. icu stay was . (ic: - . ) days. the only one niv patient was not intubated. ecco r as stopped in patients because of complications (one hemolysis, one internal bleeding and one membrane clotting). one patient died in icu after limitation of life-sustaining therapy decision. we report a preferential use of ecco r in imv patients, contrasting with a marginal use in only one niv patient to prevent intubation. the mortality rate was low, in line with previous case series of severe acute asthma with ecmo or ecco r support. more studies are needed ( ) to better delineate the pathophysiological benefits of ecco r in asthma patients and ( ) to confirm strong clinical benefits. compliance with ethics regulations: not applicable. rationale: acute exacerbations of chronic obstructive pulmonary disease (aecopd) are the most important events characterizing respiratory illness progression. their management often needs noninvasive or invasive ventilation (iv). data of literature confirm that the mortality of aecopd requiring iv is high but are discordant about prognostic factors. the aim of our study was to describe the epidemiologic and clinical features of patients admitted for aecopd requiring iv, the treatment and the evolution in intensive care unit in order to deduce the independent factors of mortality. patients and methods: a -year retrospective analytic observational single-center study including patients hospitalized for aecopd requiring iv. results: fifty-eight patients were enrolled. mean age was ± years with sex-ratio of . . eighty one percent were smokers and % were classified gold stage . history of intensive care hospitalization and prior iv were found in % and % of all cases respectively. mean apache ii score was ± . the predominant precipitating factor for aecopd was respiratory tract infection ( % of all cases). twenty two percent of all patients presented septic shock. iv was initiated on admission in % of all cases and after noninvasive ventilation failure in % of all cases. forty-eight per cent of all patients developed septic shock as evolutionary complication. mortality rate was %. in univariate analysis: male gender (p = . ), duration of respiratory disease progression (p = . ), annual exacerbations frequency (p < − ), gold stage (p = . ), prior iv (p < − ), duration of symptoms before hospitalization (p = . ), apache ii score (p = . ), ph (p = . ), shock on admission (p = . ) and septic shock as evolutionary complication (p = . ) were predictors of mortality in our study. besides; shock on admission (p = . ) and as evolutionary complication (p = . ) were the two independent prognostic factors in multivariate analysis. conclusion: vital and functional prognosis of aecopd requiring iv depends on the severity of the underlying respiratory illness, the severity of the exacerbation and the quality of an early management. this emphasizes the importance of controlling modifiable risk factors including smoking cessation, basic treatment improvement and early appropriate treatment of these exacerbations. compliance with ethics regulations: yes. medical background, biological parameters, death-rate and outcome of patients have been compared. results: in total, patients have been included in the "hlh" population. death-rate in intensive care unit was % in the "hlh" group compared to % in the "not hlh" group (p = . ). we used more extrarenal cleansing in the "hlh" group ( % vs. %, p < . ), the duration of assisted ventilation was longer ( . days vs. . days, p < . ), as well as the duration of extrarenal cleansing ( . days vs. . days, p < . ) and those of amines ( . days vs. . days, p = . ). the average time of hospitalization was significantly longer in the "hlh" group ( . days vs. . days, p < . ). the secondary hlh to sepsis in intensive care unit, not well known and understudied, seems to have a different profile and a more serious outcome but no change in death-ratehas been found considering the pairing with the sofa. further studies are needed to plan a better therapeutic strategy within this population. compliance with ethics regulations: not applicable. serum and peritoneal exudate concentrations after high doses of ß-lactams in critically ill patients with severe intra-abdominal infections: an observational prospective study lisa leon, philippe guerci, elise pape, nathalie thilly, amandine luc, adeline germain, anne-lise butin-druoton, marie-reine losser, julien birckener, julien scala bertola, emmanuel novy chru nancy, vandoeuvre les nancy, france correspondence: lisa leon (lisaleon @gmail.com) ann. intensive care , (suppl ):p- rationale: critically ill patients with severe intra-abdominal infections (iais) requiring urgent surgery may undergo several pharmacokinetic alterations that can lead to ß-lactam under dosage. the aim of this study is to measure serum and peritoneal exudate concentrations of ß-lactams after high doses and optimal administration schemes. patients and methods: this observational prospective study included critically ill patients with suspicion of iai who required surgery and a ß-lactam antibiotic as empirical therapy. serum and peritoneal exudate concentrations were measured during surgery and after a h steady-state period. the pharmacokinetic/pharmacodynamic (pk/ pd) target was to obtain ß-lactam concentrations of % ƒt> x mic (minimum inhibitory concentration) based on a worst-case scenario (highest ecoff value) before bacterial documentation (a priori) and redefined on the mic of the isolated bacteria (a posteriori). results: forty-eight patients were included with a median [iqr] age of [ - ] and a saps ii score of . septic shock occurred in % of cases. the main diagnosis was secondary nosocomial peritonitis. piperacillin/tazobactam was the most administered ß-lactam antibiotic ( %). prior to bacterial documentation, patients ( . %) achieved the a priori pk/pd target. iai was documented in patients ( %). enterobacteriaceae were the most isolated bacteria. based on the mic (n = ) of isolated bacteria, % of the patients achieved the pk/pd target ( % ƒt> xmic). in the fig. we presented serum ß-lactams pk/pd target attainment and observed total concentrations of piperacillin-tazobactam at each timepoint in serum and peritoneal exudate. in critically ill patients with severe iais, high doses of ß-lactams ensured % ƒt> xmic in % of critically ill patients with severe iais within the first h. a personalized ß-lactam therapeutic scheme with a pk/pd target based on local ecology should be warranted. compliance with ethics regulations: yes. rationale: intensive care unit acquired bloodstream infections (icu-bsi) are frequent, and associated with high morbidity and mortality rates. the objective of our study was to describe the epidemiology and the prognosis of icu-bsi in our icu (cayenne general hospital). secondary objectives were to search for factors associated to icu-bsi caused by esbl-pe, and those associated with mortality at days. patients and methods: we retrospectively studied icu-bsi in the medical-surgical intensive care unit of the cayenne general hospital, during months (january to june ). we assessed survival at days from the diagnosis of icu-bsi. results: icu-bsi was diagnosed in . % of admissions giving a density incidence of . icu-bsi/ days. the median delay to the first rationale: necrotizing soft tissue infections (nsti) are a heterogenous group of severe infections. among them, group a streptococcal (gas) infection represent a subgroup that could benefit from specific therapies targeting the toxinic pathway, such as intravenous immunoglobulins or clindamycin. nevertheless, previous trials evaluating these treatments suffered from a low rate of gas infection among the study population. early identification of patients at high risk of gas infection would allow for assessing targeted treatment strategies. patients and methods: we conducted a secondary analysis of a previously published cohort of patients admitted to our tertiary center for surgically proven nsti between and . admission characteristics and microbiological documentation based on surgical samples, blood cultures or subcutaneous puncture were recorded. we compared patients with a documented gas infection to all other patients regarding admission characteristics. a generalized linear regression model was used to identify admission characteristics associated with a subsequent documentation of gas infection. results: among patients, ( %) had a gas infection, which was monomicrobial in ( %) cases. admission characteristics associated with gas infections by univariate analysis were nsaid treatment before admission ( ( . %) for gas infections vs ( . %) for others, p = . ) and leukocytosis as a continuous variable ( , /mm [ , - , ] vs. , [ - , ], p = . ). those inversely correlated with gas infections were immunodeficiency ( ( %) vs. ( . %), p = . ), and an abdominoperineal topography ( ( . %) vs. ( . %), p > . ). after multivariate analysis only immunodeficiency (or = . [ . - . ], p = . ) and an abdominoperineal infection (or = . [ . - . ], p = . ) remained associated with the absence of gas infection. using these criteria allowed for identifying subgroups of patients with increased likelihood of gas infections: from % overall (n = ) to % for non-abdominoperineal infections (n = ), % for patients without immunodeficiency (n = ) and % for both non abdominoperineal infections in patients without immunodeficiency (n = ). a sensitivity analysis for monomicrobial gas infections yielded similar results with the addition of younger age and non-nosocomial infections as predictors. conclusion: upon admission, the absence of immunodeficiency and of an abdominoperineal infection in nsti patients were covariables associated with gas infection. compliance with ethics regulations: yes. rationale: sickle-cell disease is the most common genetic disorder in the world. a complication of this disease is the acute chest syndrome (acs) which is associated with a high risk of death. respiratory tract infections are often mixed up and the introduction of betalactam antibiotics is recommended. glomerular hyperfiltration is common and responsible of a high risk of underdosing. this study compares cefotaxim continuous infusion to intermittent bolus in adult patients with acs. patients and methods: this observational retrospective monocentric study included acs admitted in intensive care unit and treated by cefotaxim with at least one plasmatic dosing between may and august . results: thirty patients received bolus administration while the others received continuous infusion. we observed patients ( %) and patients ( %) with a cefotaxim trough level ≥ mg/l in the bolus and continuous group, respectively (p < . ). the median residual concentration was mg/l [ - ] and . mg/l [ . - . ] in the bolus and continuous group, respectively (p < . ). there was no toxic effect induced by overdosing of cefotaxim. conclusion: compared to intermittent bolus infusion, continuous cefotaxim administration maximizes the pharmacokinetics parameters by obtaining a plasmatic concentration times above the minimal inhibitory concentration of usual germs associated with acs. continuous infusion of time-dependant antibiotics seems to decrease the risk of underdosing in patients with sickle cell disease. compliance with ethics regulations: not applicable. (n = , %), followed by esophageal varices rupture (n = , %), ulcer bleeding (n = , %) and diverticular hemorrhage (n = , %). infectious diseases were diagnosed in three patients ( %), including one clostridium colitis, one erosive gastritis with helicobacter pylori and one esophageal candidiasis. conclusion: gib is associated with a high mortality rate in immunocompromised patients, especially in patients with hematological malignancies. specific malignant lesions were the main etiology and may be difficult to treat. comparison with critically ill non-immunocompromised patients with gib will help physicians to provide specific therapeutic strategies in this population. compliance with ethics regulations: yes. risk factors for delayed defecation and impact on outcome in critically ill patients: a multicenter prospective non-interventional study benoît painvin ,* , arnaud gacouin , antoine roquilly , claire dahyot-fizelier , sigsimond lasocki , chloe rousseau , denis frasca , philippe seguin anesthésie-réanimation/chu rennes, rennes, france; réanimation médicale/chu rennes, rennes, france; réanimation chirurgicale/ chu nantes, nantes, france; réanimation chirurgicale/chu poitiers, poitiers, france; anesthésie-réanimation/chu angers, angers, france; centre investigation clinique/chu rennes, rennes, france; anesthésie-réanimation/chu poitiers, poitiers, france; réanimation chirurgicale/chu rennes, rennes, france correspondence: benoît painvin (painvinbe@gmail.com) ann. intensive care , (suppl ):p- rationale: delayed defecation is very common in intensive care units (icu) and it increases length of mechanical ventilation (mv), icu length of stay (los) and possibly mortality. the objective of this prospective multicenter study was to determine risks factors for constipation in icu and to evaluate their impact on mortality. patients and methods: it was a prospective multicenter non-interventional trial performed in university icus in france from january to october . all patients ≥ years old who had an expected los of days and mechanically ventilated for at least days were eligible. defecation was defined as the time of the first stool passage. results: patients were included in the analysis. a stool passage was observed in % of the patients during their icu stay with a mean delay of ± days. in multivariate analysis, risk factors for delayed passage of stool were non-invasive ventilation use and time spent under invasive ventilation whereas alcoholism, laxative treatment (before and after icu admission) and nutrition ≤ h favoured passage of stool (table ) . no relations between constipation and mortality were found. conclusion: we highlighted new and important independent factors for constipation in critically ill patients leading to a better prevention of this phenomenon.. compliance with ethics regulations: yes. rationale: community peritonitis is a frequent medical-surgical emergency of the adult, acquired by the patient in a non-hospital setting. careful multidisciplinary care is essential, involving surgeons, anesthetists, microbiologists and radiologists. the objective of our study is to determine the bacteriological aspects of intra-abdominal sepsis, to describe their sensitivity profiles and to propose treatment regimens for the management of community peritonitis. we conducted a descriptive retrospective study spanning a period of two years from january to january involving cases of community abdominal sepsis operated in the operating room of surgical emergencies of our hospital. we included in our study adult patients admitted for suspected or confirmed abdominal sepsis who had undergone bacteriological examinations on the abdominal collections. samples taken are sent directly to the bacteriology laboratory for bacteriological analysis of the results. the studies showed the mean age is . years old, with a sex ratio of . . we found positive results mainly of peritoneal origin with a percentage of . % peritonitis, dominate by intestinal peritonitis . % followed by the appendicular origin . % then peritonitis by perforation of ulcer. the most incriminated organism in intraabdominal sepsis is e. coli with a percentage of . % of the total germs found, followed by streptococcus spp . %, enterococci . %, non-fermenting bgn composed mainly of pseudomonas aeruginosa . %, staphylococci . % and acinetobacter baumanii . %. note also the presence of bacteroides fragilis is %. e. coli had a very low sensitivity profile for amoxicillin/clavulanic acid ( . %), unlike ceftriaxone, gentamicin, amikacin and ertapenem, which had a sensitivity of . %, respectively. . %, %, . %. conclusion: knowledge of the bacterial ecology of intraabdominal sepsis is important in the choice of probabilistic antibiotherapy, pending bacteriological findings. no data are yet available about nutritional management and risk of malnutrition in tunisian medical intensive care units (icu). the purpose of this study was to describe nutritional management in medical intensive care patients and to evaluate the risk of malnutrition. patients and methods: we conducted a prospective observational cross-sectional study in medical icus all around the tunisian country on the th september . all participant units received a questionary form about routine nutritional management and data of all patients hospitalized in icu on the study day. collected data were: demographic characteristics, reason for admission, severity scores and subjective evaluation of nutritional status on admission, type and volume of nutritional support on the study day and the day before, nutritional status, nutric score and biological data on the study day, reasons for nutritional interruption and other supports prescribed. results: thirteen icu all around tunisia participated to the study. no icu had a nutrition team and only one had a written nutrition protocol. four icus evaluated systematically the nutritional status on admission. all icus were aware and practiced early enteral nutrition in patients unable to maintain oral intake with a systematic supplementation of oligoelements and minerals. neither target energy nor protein intake were calculated. on the study day, patients were hospitalized with an occupation rate of %. mean age was ± years. mean body mass index was ± and % of patients were judged well nourished. enteral nutrition support was prescribed on admission in % of cases with a mean caloric intake of ± kcal/day. the mean caloric target on the study day was ± kcal/day with a mean caloric intake of ± kcal/day and a mean caloric gap of ± kcal/day. the mean nutric score and body mass index on the study day were ± and ± respectively. twenty patients were judged malnourished by the nutric score and twenty two by clinical evaluation. a good correlation was found between nutric score and clinical evaluation of nutritional status (k = . ). conclusion: tunisian icus don't have nutrition team or nutritional written protocol. early enteral feeding and supplementation is common. a good correlation exists between nutric score and clinical nutrition status evaluation. compliance with ethics regulations: yes. rationale: whether more intensive glycemic control (gc) is beneficial or harmful forcritically ill patient has been debated over the last decades. gc has been shown hard to achieve safely and effectively in intensive care. the associated increased hypoglycemia and glycemic variability is associated with worsened outcomes. however, modelbased risk-based dosing approach have recently shown potential benefits, improving significantly gc safety and performances. the stochastic targeted (star) gc framework is a model-based controller using a unique risk-based dosing approach. star identifies modelbased patient-specific insulin sensitivity and assesses its potential variability over the next hours. these predictions are used to assess hypoglycemic risks associated with a specific insulin and/or nutrition intervention to reach a specific target band. this study analyzes preliminary clinical trial results of star in a belgian icu compared to the local standard protocol (sp). the mean age in our series was . years with a male predominance (sex ratio = . ). the main revealing symptoms were epigastralgia, weight loss and vomiting. subtotal gastrectomy was performed in . % of cases and total gastrectomy in . % of cases. curative resection could only be performed in . % of cases. operative mortality was . % and morbidity was . %. the main factor influencing operative mortality was age greater than years. in univariate analysis the main prognostic factors; tumor size, degree of parietal invasion, presence of ganglionic invasion, presence of more than ganglia invaded, presence of metastases, locally advanced tumor, tumor stage and curative nature of resection. patient-related factors such as age associated blemishes and biological factors have a significant influence on the patient's prognosis. the prognosis of gastrectomies, although it has improved overall, remains mediocre. the only way to improve the prognosis remains the early diagnosis with an effective surgical management and the introduction of an adapted resuscitation. compliance with ethics regulations: yes. efficacy of multiple second line agents in refractory status epilepticus in a pediatric intensive care unit lea savary, claire le reun chu tours, tours, france correspondence: lea savary (lea.savary@hotmail.com) ann. intensive care , (suppl ):p- rationale: convulsive status epilepticus (cse) is the most common neurological emergency in children. refractory status epilepticus (rse) occurs whenseizures are not controlled with first-and secondline agents. in adults, rse requires pharmacological induced coma. in pediatric patients, association of second line treatment is often used to avoid general anesthesia although there is currently no data on the efficacy of this association. we performed a monocentric retrospective study to assess the efficacy of multiple second line agents in pediatric rse. all children admitted to clocheville hospital (tours) between january and december with a diagnosis of rse were included. our population was divided into two groups: need of general anesthesia (midazolam+) or not (midazolam-). results: children were included ( in group midazolam+, in group midazolam−) during the study period. among the patients with multiple second line agents, % did not need general anesthesia (n = ). in group midazolam+, cse was % longer in patients treated with multiple second line agents ( rationale: drowning is an acute respiratory failure resulting from immersion or submersion in a liquid. patients and methods: we report cases of drowning collated in the pediatric reanimation department during a period from to . the aim of our retrospective study was to analyze and compare the different epidemiological, clinical, parcalinical, therapeutic and evolutionary of drowning in our study. results: our study contains boys and girls, with a sex ratio (m/f) of , in an age between months and years. for cases studied, no one was classified stage i, . % classified stage ii, % stage iii, and . % stage iv. all cases collected by ou service were victim of accidental drowning, . % were secondary to the lack of parental supervision. among cases, had respiratory complications, cases of hydroelectrolytic disorders, case with infectious complications, cases of neurological and cases of cardiac or hypothermic complication. in our study, cases recovered well and cases died. the survival of the drowned person depends on the speed and efficiency of the intervention, which in thefirst place is prehospital, thus ensuring the first actions at the scene of the accident, which will have repercussions on the hospital care. this has an equal share in the improvement of the victim's prognosis. compliance with ethics regulations: not applicable. epidemiology of severe pediatric trauma following winter sport accidents in the northern french alps emilien maisonneuve , nadia roumeliotis , pierre bouzat , guillaume mortamet chu grenoble, grenoble, france; chu sainte-justine, montréal, canada correspondence: emilien maisonneuve (emilienmaisonneuve@orange. fr) ann. intensive care , (suppl ):p- rationale: this study describes the epidemiology of severe injuries related to winter sports (skiing, snowboarding and sledding) in children, and assesses potential preventive actions. we did a single-center retrospective study in our pediatric intensive care unit in the french alps. we include all patients less than years old, admitted to the intensive care unit following a skiing, snowboarding or sledding accident from to . results: we included patients (mean age . years and % were male); of which ( %), ( %) and ( %) had skiing, snowboarding and sledding accidents, respectively. the average iss (injury severity score) was . the major lesions were head (n = patients, %) and intra-abdominal (n = patients, %) injuries. compared to skiing and snowboarding, sledding accidents affected younger children ( vs. years, p < . ); most of whom did not wear a helmet ( % vs. %, p < . ). severity scores were similar amongst winter sports (iss = for skiing, for snowboarding and for sledding accident, p = . ). rationale: best strategies for the management of severe pediatric traumatic brain injury (tbi) are still not clearly established and wide variations among professional practices have been reported in the literature. unfortunately, these variations in practice have an impact on the patient's outcome. the objectives of this work were to assess the adequacy of professional practices to the guidelines for the management of severe head injury and to assess the level of agreement of respondents in the absence of guideline. patients and methods: a practice survey was conducted in frenchspeaking hospitals in canada, belgium, switzerland and france from april st to june th, . the survey was conducted as a progressive clinical case with questions based on guidelines and the literature from to . the questions related to the assessment and management of tbi during the acute and intensive care phase. results: seventy-eight questionnaires were included. the adherence to guidelines was good, with items out of obtaining an adherence rate of more than % regardless of the annual number of tbi managed by the centre. there was strong agreement among clinicians on the intracranial pressure (pic) (> %) and cerebral perfusion pressure (> %) thresholds used according to age. guidelines for indication of pic monitoring were almost perfectly followed in the case of glasgow score < and abnormal brain ct scan (n = , %). on the other hand, the natremia and glycemia thresholds and the role of transcranial doppler were not consistent. strong adherence to recent recommendations was achieved: seizure prophylaxis with levitracetam (n = / , %) and capnia threshold (n = , %). assessment of o pressure in brain tissue (n = , %) and autoregulation (n = ; %) was not a common practice. conclusion: overall, practices for the management of tbi appear to be standardised. variations persist in areas where there is a lack of literature and guidelines in paediatrics, so clinicians seem to refer to adult guidelines. compliance with ethics regulations: yes. choubeila guetteche chu constantine, constantine, algeria correspondence: choubeila guetteche (cguetteche@gmail.com) ann. intensive care , (suppl ):p- rationale: ingesting a coin cell is a common household accident in children, which can have serious consequences. the goal is to determine prognostic factors to improve management and reduce complications. patients and methods: we conducted a retrospective study including children under admitted in pediatric intensive care between january and may for ingestion of button cells, with epidemiological, clinical and paraclinical data collection. results: twenty-six children boys ( %), and girls ( %) were included, with an average age of months ( - ), increased incidence in recent years. clinical signs indicative were dysphasia with hyper-sialorrhea in cases, cervical pain in one case, respiratory distress in one case, the cell was located in the upper third of the esophagus in cases, third average in cases, third inferior in cases, the mean time before extraction was h. complications: cases of mediastinitis, cases of oesotracheal fistula, a case of perforation. conclusion: the young age of the child, the diameter of the battery, and especially the time of care are risk factors for the occurrence of complications, the prevention passes through the education of the general public and creation of channel of taking into account fast charge. compliance with ethics regulations: not applicable. yacine benhocine university hospital center nedir mohamed, tizi-ouzou, algeria correspondence: yacine benhocine (yacine @yahoo.fr) ann. intensive care , (suppl ):p- rationale: inhalation of foreign bodies is a common and serious accident in children, especially between and years old. at this age, children use their mouth to explore their environment. asphyxia is the immediate risk and respiratory sequelae may appear secondarily. the severity of this incident has been considerably reduced due to the progress of the instrumentation and anesthesia which condition the smooth running of the therapeutic act. aim: to evaluate the anesthetic modalities of the extraction of the foreign bodies of the airways in children, in order to optimize our care with a maximum of security. a prospective, mono-centric, descriptive study from january to november of patients treated for inhalation of foreign bodies in the airways. study population wasdefined by: age, sex, hospitalization context, physical and radiological examination data, anestheticmanagement. results: the average age of the patients was . months, the male predominated ( %), and the hospitalization context was polymorphic. general anesthesia was necessary in all cases, sevoflurane mainly for narcosis; the combination of an opioid in . % of cases and a curare in . %. spontaneous ventilation is desirable, but % was manually broken down intermittently between extraction attempts. cases of desaturation, bronchospasm, bradycardia, and pneumothorax have been reported. . % had a good evolution. discussion: the results of the epidemiological data are consistent with those of the literature. the penetration syndrome is very revealing. the chest x-ray is the key examination, the diagnosis is often based on indirect signs. in case of asphyxia by foreign body enclosed above or between the vocal cords, laryngoscopy and oxygenation is the first step to perform. in other cases, a rigid bronchoscopy is performed under general anesthesia; inhalation induction with sevoflurane is the technique of choice for many experienced authors. controlled ventilation is used in the majority of cases because spontaneous ventilation is not often not possible. the heterogeneity of anesthetic practices accounts for the multiplicity of clinical situations. conclusion: the inhalation of a foreign body is a diagnostic and therapeutic emergency. extraction of the foreign body takes place under general anesthesia, which is difficult and at risk. compliance with ethics regulations: yes. non-invasive neurally adjusted ventilatory assist (nava) in infants with bronchiolitis: a retrospective cohort study alex lepage-farrell, sally al omar, atsushi kawaguchi, sandrine essouri, philippe jouvet, guillaume emeriaud chu sainte justine, université de montréal, montréal, canada correspondence: alex lepage-farrell (alex.lepage-farrell@umontreal.ca) ann. intensive care , (suppl ):p- rationale: bronchiolitis is one main reason for admission to pediatric intensive care unit. most infants are successfully managed with nasal cpap or high-flow nasal cannula, but about a third of these patients are not sufficiently supported and require an alternative support. non-invasive neurally adjusted ventilatory assist (niv-nava) improves patient-ventilator interactions and could therefore improve the effectiveness of non-invasive support. our hypothesis is that niv-nava is feasible in infants with bronchiolitis and that it reduces the respiratory effort. patients and methods: we retrospectively studied all patients under years of age with a clinical diagnosis of bronchiolitis ventilated with niv-nava in our pediatric intensive care unit, between october and june . patients characteristics, respiratory and physiologic parameters, including diaphragmatic electrical activity (edi) were extracted from an electronic medical database (data collected every s). respiratory effort was estimated using the modified wood clinical score for asthma (mwcas) and the inspiratory peak edi, and -h periods before and after niv-nava initiation were compared (wilcoxon rank test). the study was approved by the local research ethics committee. results: during the study period, patients were admitted with bronchiolitis; infants ( boys) with a median ( th- th percentile) age of ( - ) days were treated with niv-nava after a failure of other non-invasive support methods, and all were included. twentyfive subjects ( %) had at least one comorbidity. the interfaces used were predominantly face masks ( %). the maximum ventilatory settings were nava level of . ( . - . ), peep of ( - ) cmh o, fio of % ( - ) and maximal pressure of ( - ) cmh o. total duration of non-invasive ventilation was ( - ) hours, including ( - ) hours in niv-nava. as detailed in the table , mwcas significantly decreased after niv-nava initiation, from . ( . - . ) to . ( . - . ), p < . . a decrease in inspiratory peak edi was also observed, which was particularly clinically relevant in infants with high baseline edi (> mcv). capillary blood ph and pco also significantly improved after niv-nava introduction. six patients ( %) needed escalation to endotracheal intubation. conclusion: this study confirms the feasibility of niv-nava in infants with bronchiolitis after failure of first line non-invasive support, with a low failure rate. niv-nava initiation was followed by a decrease in respiratory effort and an improvement in blood gases. this observational study supports the needs for prospective interventional trial. compliance with ethics regulations: yes. rationale: the use of blood transfusion is frequent in pediatric intensive care units and has increased significantly since . considered as therapeutic, it requires an assessment of the benefit / risk balance before making the transfusion decision. the aim of our study is to describe the transfusion practices in the pediatric resuscitation department of the ehs canastel, algeria. patients and methods: a retrospective observational study over a -month period from january of any blood transfusion performed in hospitalized patients, in the pediatric intensive care unit. we studied : the age, the sex, the history of blood transfusion, the indication of transfusion, the haemodynamic and respiratory parameters, the transfusional accidents, the length of stay in intensive care, the evolution after a blood transfusion. results: these included transfusion patients out of hospitalizations during the -month period, mean age was months.all patients had no transfusion history, % of patients had their anemia admission and % developed it during their stay. the reason for hospitalization was respiratory distress in %, convulsive condition in %, polytrauma in %, and head trauma in %. the indication of the transfusion was placed on a hb inferior or equal to g / dl in % of cases, in % on an hb superior to g / dl in addition to the clinical criteria of intolerance to anemia; in % of the cases no clinical or biological criteria found, the nature of the blood products was of the red cell in % of the cases and of the plasma concentrate in / of the cases and pfc in %. % received a+, % of a-, % of b+, % of o+ and % of o-. % of the patients had a transfusion-like reaction at min after the start of the transfusion; % of the patients were under artificial ventilation and % were under hemodynamic support, % under diuretic.the average length of stay was days; the favorable outcome was % of the patients after the transfusion with an increase in the hb level beginning, % of the patients had complications of their pathology and the death in % of the cases. conclusion: current transfusion practices in children often do not reflect the implementation of our current knowledge of the need for transfusion. hence the need to review the protocols and practice other transfusion alternatives to avoid complications and improve the quality of care. compliance with ethics regulations: not applicable. rationale: bacterial multi drug resistance is medical actuality nowadays, because of its morbidity and mortality especially in intensive care, it constitutes a real problem in our hospitals. we conducted a retrospective descriptive study, to identify bacterial drug resistance profile of patients with cross infections in the department of intensive care in august hospital. this study included patients hospitalized between st january and st december . the data was collected from medical records of this unit as from the register of the bacteriology service of ibn rochd university hospital. results: patients were hospitalized in the resuscitation service, of which had nosocomial infection, an incidence of . %. the mean age of the patients was years with male predominance (sex ratio . ), the average stay in intensive care was days. the site of infection was pulmonary in % of cases, blood in % of cases, urinary in % of cases, central catheter in %, neuro-meningeal in . % of cases. the germs isolated were: acinetobacter baumanii in . % of cases, pseudomonas aeroginosa in . % of cases, klebsiella pneumonia in . % of cases, enterococcus feacalis in . % of cases, e.coli in . % of cases and staphylococcus aureus in % of cases. acinteobacter baumanii showed resistance rates of up to % for the impenem and % for amikacin. regarding pseudomonas, it was resistant to impenem in % of cases and in % of cases to amikacin. compared to klebsiella, resistance to imipenem was % and % for amikacin. the mortality rate of infected patients was % conclusion: in the light of this work, we found that important emergence of multidrug resistance bacteria in intensive care unit is related to not only the immunocompomised state of patients but also to daily bad practices of health professionals such as the misuse of antibiotics. compliance with ethics regulations: yes. overnight culture of escherichia coli, klebsiella pneumoniae, staphylococcus aureus and pseudomonas aeruginosa, was also sequenced. results: twenty-four samples and the pc were analyzed. amplicon sequence analyses found similar results with the two primer pairs in % of cases. cultured pathogen was found in % ( / ) for human primer pair and in % ( / ) for earth primer pair. for each eta, ngs revealed bacteria unknown as pathogen globally identified as oropharyngeal flora in conventional microbiology (table ) . alpha diversity decreased for all vap patients overtime, average shannon . ( ; . ) versus ( . ; . ), and was higher in upper respiratory tract (os) versus lower respiratory tract (eta): average shannon . ( . ; . ) vs. . ( . ; . ) (ns). conclusion: this pilot study highlights the impact of s rdna amplification procedures (especially oligonucleotide sequences) used on the results in microbiome research. concordance between ngs and bacterial culture, as well as similar evolution of the alpha diversity than previously described ( ), enables us to validate our methodology using the "gut primers" pair f- r. these findings allow furthers major studies on the pulmonary microbiome of icu ventilated patients including comparison according to the occurrence of a vap or not. compliance with ethics regulations: yes. rationale: in the field of intensive care only few studies have explored bacterial microbiota whereas virome remained hardly considered. it appears essential to describe both evolution in mechanically-ventilated patients to improve the pathophysiological understanding of ventilator-associated pneumonia (vap) development. to date no study had been simultaneously conducted on lower respiratory tract with a single nucleic acid extraction before metagenomics analysis of bacterial microbiota and virome. we conducted a preliminary study to validate our methodology based on a common automated extraction of nucleic acids. patients and methods: twelve mechanically ventilated patients were selected: five who developped (vap) and seven controls (c) who did not. endotracheal aspirate (eta) were collected between intubation and day (or dvap for vap patients). conventional bacterial microbiology and multiplex respiratory viruses pcr were also performed. total nucleic acids were extracted using nuclisens easymag extractor. for the bacterial microbiota, region v of the s rrna genes was amplified. for the virome, the nextera dna xt kit (illumina) and rna seq trio kit (nugen) protocols were used to prepare viral dna and rna libraries. libraries underwent paired-end sequencing on the illumina miseq (bacteria) or nextseq- (virus) platform. after bioinformatics analysis we compared the performance of metagenomics analysis with conventional bacterial culture and other common viral detection methods. results: for culturable bacteria, concordance between conventional microbiology and sequencing was found in % ( / table . our preliminary results confirm the feasability of exploring both bacterial microbiota and virome on the same sample using a common extraction method. data from metagenomics were highly concordant with conventionnal detection methods for known pathogenic viruses and bacteria in lower tract respiratory sample and enables identification of other microorganisms. this is the first step for a large cohort study that aims to compare evolution of global lung microbiome in patients at risk of vap and assess how bacteria and virus interplay. compliance with ethics regulations: yes. references . clancy department of medical and toxicological critical care, lariboisière hospital one microorganism was isolated in . % and two in . % of cases. the main isolated microorganism were enterobacteriaceae in . % of patients. they were esbl-producers in . % of cases. initial antibiotic therapy was appropriate in . % of cases. factors independently associated with esbl-pe as the causative microorganism of icu-bsi were esbl-pe carriage prior to icu-bsi the sensitivity of esbl-pe carriage to predict esbl-pe as the causative microorganism of icu-bsi was . %, and specificity was . %. mortality at days was . % in the general population in multivariable analysis, there was no parameter which was independently associated to mortality at day from the occurrence of icu-bsi. conclusion: icu-bsi complicates . % of admission to icu and was associated with % in-hospital mortality assessing and applying individualized treatment for group a streptococcal necrotizing soft-tissue infection is possible service de réanimation médicale intensive care decompressive craniectomy in traumatic brain injury: about cases karama bouchaala sex ratio of . . the mean (sd) length of stay in icu was . ± . days. the mean glasgow coma score (gcs) (sd) was . ± . and gcs ≤ in . %. sofa score > was found in patients ( . %) and sapsii score ≥ in patients ( . %). the cerebral ctscan at admission showed acute subdural hematoma (asdh) in ( . %), cerebral oedema ( . %) and cerebral contusions ( %) teaching: fresenius medical care; patent or product inventor: gml czech republic banydeen rishika: no conflict of interest baptiste amandine: no conflict of interest baptiste olivier: no conflict of interest barbar saber davide: no disclosure barbier françois: no disclosure barbierlouise: trainings, teaching: ethicon, astellas; invitation to national or international congresses: sandoz, astellas barnerias christine: no disclosure baron aurore: no disclosure baron elodie: no conflict of interest barr att -due andreas: no disclosure barrau stephanie: no disclosure barraud damien: no disclosure barraud helene: no disclosure barrois brigitte: no conflict of interest baruchel andré: no disclosure bastide marie anaïs: no conflict of interest baudel jean-luc: no conflict of interest baudin florent: invitation to national or international congresses: dr baudin has received speaking fees from maquet critical care (epnv teaching: drager; invitation to national or international congresses: msd; hill rom beganton frankie: no conflict of interest begot erwan: no disclosure beinse guillaume: research support/scientific studies: association pour la recherche contre le cancer ion and fresenius kabi bensaid abdelhak: no disclosure bensardi fatimazahra: no disclosure benyamina mourad: no disclosure benzerara laurent: patent or product inventor: aphp benzerdjeb nazim: research support/scientific studies: amarape, icap; consultancy, expert: alphasights, msd; trainings, teaching: msd beqiri erta: no disclosure bÉranger agathe: no conflict of interest berard emilie: no conflict of interest berdai adnane: no disclosure berger patrick: no disclosure bernal william: no disclosure bernardin gilles: no disclosure berrada lina: no conflict of interest berthaud romain: no conflict of interest berthet guillaume: no conflict of interest berti enora: no conflict of interest bertoli sarah: no disclosure bertrand pierre-marie no conflict of interest besbes lamia: no disclosure besbes mohamed: no conflict of interest besch camille: invitation to national or international congresses: abbvie no conflict of interest boisseau chloé: no disclosure boissel nicolas: no disclosure boissier florence: no conflict of interest boivin alexandra: no conflict of interest bonacorsi stéphane: no conflict of interest bongiovanni filippo: no conflict of interest bonnardel eline: no conflict of interest bonnefoy-cudraz eric: no disclosure bonnet sixtine: no conflict of interest bonnevie tristan: research support/scientific studies invitation to national or international congresses: fresenius kabi and fresenius medi-calcare bucur petru: no disclosure buetti niccolo: research support/scientific studies: swiss national science foundation research grant and bangerter rhyner foundation supporting my postdoc bui hoang-nam: no disclosure burelli gabrielle: no conflict of interest burgel pierre-régis: no disclosure burghi g: no conflict of interest bustarret olivier: no conflict of interest butin-druoton anne-lise: invitation to national or international congresses expert: astra-zeneca; invitation to national or international congresses expert: hamilton medical; invitation to national or international congresses: hamilton medical chemli wael: no conflict of interest chenouard alexis: no conflict of interest cherkab rachid: no conflict of interest chevret sylvie: no disclosure chhun stephanie: no conflict of interest chiche jean-daniel: no disclosure chicoisneau maxence: no conflict of interest chlilek abdelaziz: no disclosure chocron richard: consultancy, expert: aspen chommeloux juliette: no conflict of interest chomton maryline: no conflict of interest chosidow olivier: no disclosure chouchana laurent expert: biotest; invitation to national or international congresses: sanofi research support/scientific studies: fresenius medical care; consultancy, expert: fresenius medical care; invitation to national or international congresses: xenios novalung, heilbronn, germany dachraoui fahmi: no disclosure dahoumane redouane: no conflict of interest dahyot-fizelier claire: no disclosure daix thomas: no conflict of interest daly foued: no conflict of interest damonti lauro: no conflict of interest dantan etienne: no conflict of interest darmon michaël: research support/scientific studies: msd no disclosure das vincent: no disclosure daubin cedric: no conflict of interest daubin delphine: no conflict of interest daudon michel: no disclosure daufresne pierre: no conflict of interest dauger stéphane: no conflict of interest daviet florence: invitation to national or international congresses: sandosz de courson hugues: no conflict of interest de jong audrey: trainings, teaching: baxter, medtronic; invitation to national or international congresses teaching: cardiosleep delhaes laurence: no disclosure delignette marie-charlotte: no conflict of interest dellamonica jean: trainings, teaching: medtronic; invitation to national or international congresses: msd, general electrics delpierre clément: no conflict of interest delville marianne: no conflict of interest demailly zoé: research support/scientific studies: srlf demarest elsa: no disclosure demaret pierre: no conflict of interest demiselle julien: no conflict of interest demondion pierre: no conflict of interest demoule alexandre: research support/scientific studies: drager, philips; consultancy, expert: baxter, respinor, lungpacer; trainings, teaching: fisher & paykel, hamilton, baxter; invitation to national or international congresses: fisher & paykel denis manon: no conflict ofinterest depeyre fanny: invitation to national or international congresses: pfizer deplante yvon: no conflict of interest dequin pierre-françois: research support/scientific studies: medimmune combioxin ferring pharmaceuticals a/s asahi kasei pharma america corporation derauglaudre lucie: no conflict of interest derbel karim: no disclosure derkaoui ali: no disclosure dervin krystel: no conflict of interest desaive thomas: no conflict of interest desguerre isabelle: research support/scientific studies: ptc inc, avexis; consultancy, expert: avexis, ptc inc, biogene; trainings, teaching: roche, ptc inc, avexis; invitation to national or international congresses: sarepta, biogen, avexis, biomarin desnos cyrielle: no conflict of interest desroys du roure françois: no conflict of interest detollenaere charles: no conflict of interest devaquet jérôme: invitation to national or international congresses expert: lungpacer; invitation to national or international congresses: lungpacer dreyfuss didier: research support/scientific studies: grant from french ministry of health drouot xavier: no disclosure du cheyron damien: no conflict of interest dubÉ bruno-pierre: consultancy, expert: novartis, gsk dubert marie: no conflict of interest dubost baptiste: no conflict of interest dubost jean-louis: no conflict of interest duburcq thibault: no conflict of interest duchemann boris: consultancy, expert: bms, msd, roche; invitation to national or international congresses no conflict of interest frÉrou aurélien: no conflict of interest fritz caroline: no disclosure fromentin mélanie: research support/scientific studies: msd; invitation to national or international congresses: msd frouin antoine: no conflict of interest frugier alexandre: no disclosure gaboriau louise: no conflict of interest gaci rostane: invitation to national or international congresses: bard gacouin arnaud: no disclosure gaddas mehdi: no conflict of interest gaillard arnaud: trainings, teaching: zoll medical gaimard sophie: no conflict of interest gainnier marc: no conflict of interest galbois arnaud: no conflict of interest galerneau louis-marie: invitation to national or international congresses: agir À domicile galicier lionel: consultancy, expert: novartis, eusapharma; trainings, teaching: baxalta, pfizer; invitation to national or international congresses no conflict of interest ichaÏ philippe: no conflict of interest imen sioud: no conflict of interest ioos vincent: no disclosure iserin franck: no disclosure issa nahema: no conflict of interest jaber samir: consultancy, expert: drager, fisher-paykel; medtronic; baxter xenios fresenius; invitation to national or international congresses: drager no conflict of interest jacq gwenaëlle: no conflict of interest jacquet emmanuelle: research support/scientific studies: unicancer (esme and storm studies invitation to national or international congresses: pfizer université laval-qc-ca labbe vincent: no disclosure labro laura: no disclosure lacaille florence: no conflict of interest lacampagne alain: no disclosure lacan claire: no conflict of interest lacherade jean-claude: no conflict of interest ladjemi maha-zohra: no conflict of interest lafon charles: no conflict of interest lafon marie-edith: no disclosure lafon thomas: no conflict of interest lagache laurie: invitation to national or international congresses advertising documents: philips; trainings, teaching: novartis, gsk, astra zeneca, boeringher; invitation to national or international congresses: chiesi, astra zeneca, sos oxygene, novartis, boeringher lamoth frédéric: consultancy, expert: gilead, msd, basilea; invitation to national or international congresses: msd expert: norgine; trainings, teaching: fujifilm, boston scientific lebreton guillaume: no disclosure lebrun-vignes benedicte: research support/ scientific studies: novartis; consultancy, expert: ansm lebuffe gilles: no disclosure leclerc maxime: no conflictof interest lÉcluse aldéric: research support/scientific studies: pgrx avc study; consultancy, expert: bms-pfizer, boerhinger ingelheim, bayer; invitation to national or international congresses: bms-pfizer, boerhinger ingelheim ledoux didier: no disclosure lefebvre francois: no conflict of interest macloughlin ronan: research support/scientific studies: aerogen ltd no conflict of interest mari arnaud: no conflict of interest marie damien: no conflict of interest marijon eloi: no disclosure mariotte eric: consultancy, expert: sanofi-aventis marjanovic nicolas: no disclosure marjanovic zora: no disclosure maroni arielle: no conflict of interest marot benoit: no conflict of interest marque sophie: no conflict of interest marti teaching: zambon, chiesi; invitation to national or international congresses no conflict of interest matusik elodie: no conflict of interest mauchien benedicte: no conflict of interest maury eric: research support/scientific studies: doran international, drager; trainings, teaching: vygon maxime virginie: no conflict of interest mayaux julien: invitation to national or international congresses stock shareholder: tanderev; patent or product inventor: tanderev mercat alain: research support/scientific studies: fisher-paykel, general electric; consultancy, expert: faron pharmaceuticals no disclosure merhabene takoua: no conflict of interest merle jean-claude: no disclosure mesotten dieter: no conflict of interest messaadi amenallah: no conflict of interest messika jonathan: invitation to national or international congresses: cslbehring; fisher&paykel metaxa victoria: no disclosure metogo mbengono junette arlette: no conflict of interest meunier anne: no conflict of interest meurice jean-claude: no disclosure meybeck agnes: consultancy, expert: janssen, gilead; 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consultancy, expert: msd, gilead, pfizer; invitation to national or international congresses: gilead, pfizer nesseler nicolas: no conflict of interest neviere remi: no disclosure nguyen alexandre: no disclosure nguyen khoa thao: no conflict of interest nicolau-travers marie-laure: no disclosure niÉrat marie cécile: no conflict of interest nieszkowska ania: no disclosure nigeon olivier: no conflict of interest nitel gautier: no conflict of interest nodea elena madalina: no conflict of interest noel marine: no conflict of interest nogier marie-béatrice: no disclosure noorah zaid: no disclosure nouira wiem: no conflict of interest noumeir rita: stock shareholder: softmedical noury norbert: no conflict of interest novy emmanuel: research support/scientific studies: msd; invitation to national or international congresses: pfizer expert: air liquide medical system ollivier veronique: no conflict of interest onimus thierry: no conflict of interest oppenheimer anne: invitation to national or international congresses: gedeon richter orkisz maciej: no conflict of interest orliaguet gilles: research support/scientific studies research support/scientific studies: oxynov; patent or product inventor: oxynov patrier juliette: no conflict of interest paugam catherine: no disclosure paul marine: no conflict of interest paul-bellon rachel: no disclosure paulo nicolas: no conflict of interest pavot arthur: invitation to national or international congresses: fresenius medical care france pehlivan jonathan: no conflict of interest peigne vincent: invitation to national or international congresses: air liquide pÉju edwige: no conflict of interest pene frédéric: consultancy, expert: alexion pÉpin-lehalleur adrien: invitation to national or international congresses: chiesi pere morgane: no conflict of interest pereira bruno: no disclosure perez didier: no disclosure perez pierre: no disclosure perez yonatan: no conflict of interest perier françois: no disclosure perin nicolas: no conflict of interest biomerieux robin emmanuel: no conflict of interest robin nicolas: no disclosure robineau olivier: no disclosure roch antoine: no disclosure roche anne: no conflict of interest roger claire: consultancy, expert: pfizer, fre-senius medical care; 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consultancy, expert: fresenius medical care france; invitation to national or international congresses: xenios novalung, heilbronn no conflict of interest sirault bruno: no disclosure sirodot michel: no disclosure slama michel: no disclosure slim amine: no disclosure smielewski peter: no disclosure soares marcio: stock shareholder: epimed solutions teaching: gilead; invitation to national or international congresses: pfizer spagnoletti marco: no conflict of interest steckelmacher claire: no disclosure stockx luc: research support/scientific studies: phenox, medtronic; consultancy no conflict of interest voiriot guillaume: research support/scientific studies: biomérieux, sos oxygène, janssen; consultancy, expert: biomérieux; invitation to national or international congresses: biomérieux von kietzell matthias: invitation to national or international congresses expert: aguettant; invitation to national or international congresses: vifor yacoubi wejden: no conflict of interest yager hélène: no conflict of interest yahya yosra: no conflict of interest yakini khalid: no disclosure yakouben karima: no disclosure yonis hodane: invitation to national or international congresses: lvl medical et pfizer younan romy: no conflict of interest youssoufa atika: no disclosure zacharia mahi: no disclosure zafrani lara: research support/scientific studies: jazz pharmaceuticals zambon olivier: no disclosure zaouak nadia: no conflict of interest zaouche khedija: no conflict of interest zarrougui wafa: no conflict of interest ze minkande jacqueline: no disclosure zeghdoud dalila: no disclosure zerbib yoann: no conflict of interest zerhouni amel: no conflict of interest zerhouni amine: no conflict of interest zerimech farid: no conflict of interest zerouali khalid: no disclosure zheng yi: no conflict of interest zimmerli stefan: research support/scientific studies: msd, pfizer, gilead; consultancy, expert: msd, pfizer; trainings, teaching: gilead; invitation to national or international congresses springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations farhat hached hospital, sousse, tunisia; yassminet regional hospital, ben arous, tunisia; habib bougatfa regional hospital, bizerte, tunisia; larabta hospital, tunis, tunisia; carthagene private hospital, tunis, tunisia; regional hospital of zaghouan, zaghouan, tunisia; regional hospital of tozeur, tozeur, tunisia; habib thameur hospital, tunis, tunisia correspondence: samia ayed (samia.ayed@yahoo.fr) ann. intensive care , (suppl ):p- geoffroy hariri, kyann hodjat-panah, laurene blum, jean-rémi lavillegrand, idriss razach, naike bige, jean-luc baudel, bertrand guidet, eric maury, hafid ait-oufella médecine intensive-réanimation, hôpital saint-antoine, paris, france correspondence: geoffroy hariri (geoffroyhariri@hotmail.com) ann. intensive care , (suppl ):p- rationale: hemolytic anemia (ha) is a common condition in intensive care unit but its diagnosis remains challenging. free hemoglobin (and heme) degradation leads to co release that can bind to hemoglobin to form carboxyhemoglobin (hbco). we hypothesized that hbco concentration could be used as a reliable diagnosis tool for ha. patients and methods: we performed a monocentric retrospective study in a -bed intensive care unit at st antoine hospital, paris, between and . all patients hospitalized for ha with arterial hbco dosage at admission were included. arterial hbco was measured in routine in our department with an il system ph/ blood gas analyzer. demographic and biological data were collected. a group control of patients with non-hemolytic anemia (hb < g/ dl) (nha) was also included. finally, we analyzed patients outcome according to hbco changes during icu stay. results: between and , patients with ha were included. nha patients were included in the control group. patients with ha were younger than patients with nha ( [ ; ] vs. [ ; ] years old, p = . ) but admission sofa was not different between groups ( [ ; ] , vs. [ ; ] , p = ns). among patients with ha, % had thrombotic microangiopathy, % had autoimmune hemolytic anemia and % had sickle cell disease. at icu admission, ha patients had higher hbco level than patients with nha ( . [ . ; . ] vs. . [ . ; . ] %; p < . ). hbco was a reliable biomarker of hemolysis (auc . ( . ; . ) p < . ). an hbco level threshold at . % identify hemolysis with a sensitivity ( - ) % and a specificity ( - ) %. in ha group, hbco was negatively correlated to hb level (r = . ; p < . ). in ha patients, changes of hbco level during icu management were associated with outcome, decreasing in survivors ( . [ ; . ] vs. . [ . ; . ] ; p = . ) but not in non-survivors ( . [ . ; . ] vs. . [ . ; . ] %; p = . ). conclusion: carboxyhemoglobin is a reliable diagnosis and prognosis biomarker for hemolytic anemia in icu compliance with ethics regulations: yes. rationale: thrombocytopenia is the most commonly hemostatic disorder encountered in intensive care, present in to % of patients. the mortality associated with this thrombocytopenia, the numerous pathological contexts associated with resuscitation and the lack of a recommended management strategy led to the establishment of these guidelines. the aim of our study was to determine the incidence, causes and risk factors associated with the occurrence of thrombocytopenia, as well as the impact of thrombocytopenia on the mortality and length of stay in the icu ibn medical resuscitation unit. rochd de casablanca, over a period of months. patients and methods: this was a prospective study, carried out in the medical resuscitation department of ibn rochd university hospital in casablanca over a period of months. there were two groups: ''sick'' group with thrombocytopenia with a platelets count < , / mm , and a ''control'' group without thrombocytopenia. patients with previous platelet disorders, hematologic malignancies, and patients undergoing chemotherapy were excluded. of the patients included, episodes of thrombocytopenia were identified, anoverall incidence of . %. sepsis was incriminated times ( . %), followed by ards in patients ( . %), massive filling in patients ( . %), disseminated intravascular coagulation in patients ( . %), and massive transfusion in patients ( . %). the drug origin was incriminated in patients ( . %). it was due to quinolones and imipenem. the mortality rate was deaths ( . %) which was inversely proportional to the lowest platelet count in the thrombocytopenia group, compared to deaths ( %) in the control group. the mean duration of stay in the thrombocytopenia group was ± days with extremes ranging from to days. conclusion: thrombocytopenia was a common abnormality in the intensive care system, it occured in many pathological situations and was a factor of morbidity and excess mortality. the most common etiology in this study was sepsis. the diagnostic and therapeutic approach depended on the particular clinical context in which thrombocytopenia occurs. its onset may constitute a hematological emergency, particularly when there is a major mucocutaneous and / or visceral hemorrhagic syndrome, which necessitates a rapid etiological diagnosis, and the establishment of an effective treatment, both symptomatic and specific. compliance with ethics regulations: not applicable. marc pineton de chambrun , romaric larcher , frédéric pene , laurent argaud , alexandre demoule , rémi coudroy , elie azoulay , yacine tandjaoui-lambiotte , stanislas faguer , alain combes , charles-edouard luyt , zahir amoura sorbonne université, aphp, hôpital la pitié-salpêtrière, institut de cardiométabolisme et nutrition (ican), service de médecine intensive-réanimation, paris, paris, france; rationale: catastrophic antiphospholipid syndrome (caps), the most severe manifestation of antiphospholipid syndrome (aps), is characterised by simultaneous thromboses in multiple organs. diagnosing caps can be challenging but its early recognition and management is crucial for a favourable outcome. this study was undertaken to evaluate the frequencies, distributions and ability to predict mortality of "definite/probable" or "no-caps" categories of thrombotic aps patients requiring admission to the intensive care unit (icu rationale: septic acute kidney injury (s-aki) is a frequent complication in critically ill patients and is associated with high morbidity and mortality. it is well known that chronic kidney disease increases the risk of pulmonary embolism (pe), but few studies have investigated the relationship between acute kidney injury (aki) and pe occurrence in septic patients. the aim of this study is to determine whether patients with aki are at increased risk of developing pe. patients and methods: were included, in a prospective study conducted over months (january -june , ) in a medical surgical intensive care unit, all the patients older than years with septic shock at admission or during hospitalization. two groups were compared: patients with kidney injury (aki+ group) and patients without kidney injury (aki− group). we studied the occurrence of pe in these two groups. results: we included patients. the mean (sd) age was . ( ± ) years. sex ratio was . . thirty one ( . %) patients developed pe. the occurrence of pe was significantly higher in (aki + group) [ patients ( %) vs. patients ( %); p = . ]. the incidence of pe according to kidney injury severity was patients ( %) kdigo i, patients ( %) kdigo ii, patients ( %) kdigo iii. in the aki+ group, pe was significantly associated with increased sofa score at admission ( points vs. points; p = . ), lower platelets count ( , vs. , ; p = . ), higher lacatatemia at septic shock day [ . vs. . mmol/l; p = . ] and higher c reactive protein level [ mg/l vs. mg/l; p = . ]. in a multivariate analysis the pe risk factors in (aki+ group) were thrombopenia (odds ratio = . ; ci [ . - . ], p = . ) and c-reactive protein value (odds ratio = . ; ci[ . - . ], p = . ). discussion: the increased risk for pe with aki may be due to endothelial involvement, vascular injury and the related changes found in procoagulant proteins (increased levels of fibrinogen, factor vii, factor viii, von willebrand factor, and plasminogen activator inhibitor- ). in our study, lower platelet and higher c reactive protein level were found in patients with pe, suggesting the participation of disseminated intravascular coagulation. these factors may contribute to increase pe risk. conclusion: the risk of pe is higher in septic patients with aki than in those with normal kidney function. therefore, because of paucity of evidence, larger studies are needed to understand pe pathway in septic aki and to establish efficient prophylaxis protocols. compliance with ethics regulations: yes. and of these patients ( . %) required intensive care. the lasted were males ( %) and a majority ( %) were younger than years of age. in intensive care patients, only ( . %) had nosocomial infection, majority were community acquired infections ( . %) with ( %) pneumoniae, ( . %) profound abscess, pyelonephritis ( . %), ( %) meningitidis. patients( %) required mechanical ventilation for days ( % ci - ), length of stay in icu was days ( % ci - ) and mortality rate was %. conclusion: hmkp infections lead young patients in intensive care unit in one third of case with a majority of pneumoniae requiring mechanical ventilation and with a high rate of mortality. furthers studies are needed to investigate the role of this particular strain in severity. compliance with ethics regulations: yes. rationale: infections secondary to snakebite occur in a number of patients, and are potentially life-threatening. bothrops lanceolatus bites in martinique average thirty cases per year and may result in severe thrombotic and infectious complications. we aimed to investigate the infectious complications related to bothrops lanceolatus bite. patients and methods: a retrospective single-center observational study over seven years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) was carried out, including all patients admitted to the hospital due to bothrops lanceolatus bite. clinical and biological data were reported using the dx care, x-plore et cyberlab softwares of the emergency medicine and analyzed. one hundred and seventy snake-bitten patients ( males and females) were included. thirty-nine patients ( %) presented grade or envenoming. twenty patients ( %) developed wound infections. the isolated bacteria were aeromonas hydrophila ( cases), morganella morganii ( cases), group a streptococuss, and group b streptococcus (one case each). patients were treated empirically with third-generation cephalosporin (or amoxicillin/clavulanate), aminoglycoside and metronidazole combinations. outcome was favorable. the main factor significantly associated with the occurrence of infection following snakebite was the severity of envenoming (p < . ). our findings clearly point towards the frequent onset of infectious complications in b. lanceolatusbitten patients presenting with grade and envenoming. conclusion: infectious bite-related complications of bothrops lanceolatus account for approximately % of the cases, with a strong predominance for grade iii and iv. thus, based on the bacteria identified in the wounds; we suggest that empiric antibiotic therapy including third-generation cephalosporin should be administered to those patients on hospital admission. compliance with ethics regulations: yes. rationale: endocrine abnormalities have been reported with varying frequencies, following traumatic brain injury (tbi). few studies have examined the clinical features and outcomes of isolated acute thyrotropic hormone deficiencies after tbi. theaim of the study was to evaluate the early changes in thyrotropic hormone levels after traumatic brain injury (tbi) and to evaluate whether hormone changes are related to outcome patients and methods: we conducted a months long prospective cohort, including all patients admitted to a university hospital icu with moderate to severe traumatic brain injury (tbi), defined as a glasgow coma scale below twelve (gcs < ). blood samples for basal hormone values of thyroid-stimulating hormone (tsh) and free thyroxine (ft ) were obtained on days , , and . tsh serum concentrations were considered normal at > . mu/l; ft at > pmol/l. a thyrotropic insufficiency was defined as low ft and low tsh plasma levels. all patients were screened with a brain mri. patients were also monitored for neurological deterioration, including cognitive decline, convulsive seizures, increase in cerebral edema and brain herniation that were simultaneous to the diagnosis. results: during our study period's, trauma patients were admitted to our icu and met the inclusion criteria. on admission, our patients had a mean age at . ± , a mean injury severity score (iss) at ± , a mean abbreviated injury severity (ais) of the head at . ± . and a mean gcs at ± . of the patients a thyrotropic insufficiency was diagnosed in patients ( %) during the first days. the median delay to thyrotropic insufficiency diagnosis was days. in three of ( %), the thyrotropic insufficiency was nonrecovering during the patient's icu stay and was transient for the rest. none of the patients with acute thyrotropic insufficiency had direct hypothalamic or pituitary lesions on the brain mri. factors associated to the occurrence of acute thyrotropic insufficiency were: the ais of the head ( . ± . vs. ± . , p = . ), cerebral contusions ( % vs. %, p = . ), subarachnoid haemorrhage ( % vs. %, p = . ) and subdural haematoma ( % vs. %, p = . ). thyrotropic insufficiency was associated to neurological deterioration (p = . ) on the day of diagnosis but did not affect icu mortality ( % vs. %, p = . ). in this study, low pituitary-thyrotropic axis hormone levels were found in the acute phase of tbi and were associated to neurological deterioration but with no perceived effect on icu mortality. compliance with ethics regulations: yes. rationale: acute diabetes insipidus following head injury and its effect on patients outcome have not been sufficiently evaluated in large prospective studies. the aim of this study was to determine the incidence of acute cdi, delay of onset predictive factors and its impact on tbi patients. we conducted a prospective cohort, including all patients admitted to icu with moderate to severe tbi, defined as a glasgow coma scale (gcs) below twelve. for each tbi patient plasma sodium was measured daily, and if abnormally high, urine specific gravity and osmolality were measured. cdi was diagnosed using the seckl and dunger criteria. acute cdi was defined as cdi diagnosed in the first week following injury. all patients were screened with a brain mri. results: during our study's period, trauma patients were admitted to our icu, presented with moderate to severe tbi and were included. on admission, our patients had a mean age at . ± , a mean injury severity score (iss) at ± , a mean abbreviated injury severity (ais) of the head at . ± . and a mean gcs at ± . twenty-three percents ( patients) of the patients developed hypernatremia and % ( patients) were diagnosed with acute cdi. in of ( %), the cdi was nonrecovering. the median delay to develop transient cdi was h and for non-recoviring cdi was h (p = . ). none of the patients with acute cdi had direct hypothalamic or pituitary lesions. factors associated to the occurrence of acute cdi were: younger age ( ± vs ± , p = . ), neuro-surgery ( % vs. %, p < . ), hemorrhagic shock ( % vs. %), p < . ), cerebral edema ( % vs. %), p < . ), and fractures to the base of the skull ( % vs. %, p = . ). patients who developed cdi had a significantly higher mortality than those who did not ( of ( %) vs. of ( %), p < . ). there were no difference in terms of mortality between non-recovering and transient cdi ( % vs. %, p = . ), similarly the onset of cdi did not affect mortality ( h vs. h, p = . ). patients with acute cdi had poor glasgow outcome scale ( ± . vs. . ± . , p < . ) and longer icu los ( ± vs. ± , p = . ). conclusion: acute cdi is associated with higher mortality and poor outcome. therefore it is essential to diagnose and treat it promptly and correctly. compliance with ethics regulations: yes. acute glucocorticoid deficiency following traumatic brain injury mariem dlela, rania ammar zayani, abir bouattour, najeh baccouche, mounir bouaziz habib bourguiba hospital, sfax, tunisia correspondence: mariem dlela (mariem @gmail.com) ann. intensive care , (suppl ):p- rationale: published data demonstrates that long-term hypopituitarism could be common after traumatic brain injury (tbi).however, few studies focused on radiological, clinical, and repetitive endocrine assessment in the acute phase. the aim of the study was to evaluate the early changes in the adrenal axis following (tbi) and to evaluate whether hormone changes affect patient's outcome. we conducted a prospective study, including all patients admitted to a university hospital icu with moderate to severe traumatic brain injury (tbi), defined as a glasgow coma scale below twelve (gcs < ). each patient underwent sequential measurement of plasma cortisol (pc) on days , , and after tbi. we defined adrenal insufficiency as pc less than ng/ml. patients who received glucocorticosteroid therapy were excluded. outcome was measured by incidence of death, and glasgow outcome scale (gos) on day thirty. souhila sadat, dalila zeghdoud, dalila bougdal, kamel guenane ehs salim zemirli, alger, algeria correspondence: souhila sadat (sadatsouhila@hotmail.fr) ann. intensive care , (suppl ):p- rationale: the renewed interest in the pathophysiology of severe traumatic brain injury (tcg), allowed the understanding of the pathophysiological mechanisms leading to neuronal death.the non-invasive, easy, patient-based technical dtc allows evaluation of cerebral blood flow. purpose of the study: to determine the contribution of transcranial doppler (dtp) in the prevention of post-traumatic ischemia. patients and methods: a monocentric, observational, prospective study over a period of years, including tcg in the monitoring of cerebral blood flow (dsc) was provided by the dtc. we collected the following data: age, gender, lesion mechanism, lesion association, glasgow score at admission, time to perform the initial scan, time to perform the initial doppler, various abnormalities found at the initial dtp, the analysis of the level of map according to each situation of cerebral blood flow, the proposed therapies, the time to obtain a correct dtc. ( %), the statistical analysis showed no difference between the delay in setting up a hypohemia and the presence of a correct cerebral blood flow (p = . ), the statistical analysis of the map in the dtc group hypohemia compared to the correct dtc group objectified the absence significant difference between the two groups. the realization of dtp allowed therapeutic prioritization, the introduction of norepinephrine was in % of cases, osmotherapy in % of cases, optimization of sedation in . % of cases, the introduction of penthotal in . % of cases and the completion of decompressive in . % of cases. statistical analysis of mortality showed a significant difference in mortality (p = . ) in the hypohemic dtc group compared with the correct doppler . conclusion: ttc is an essential monitoring tool of cerebral hemodynamics, which may in prove the neurologic outiome of tcg. compliance with ethics regulations: yes. rationale: hyponatremia is a frequent electrolyte disturbance in hospitalized patients. it is particularly common in brain-injured patients with significantly elevated morbidity and mortality. the aim was to study the prevalence of hyponatremia in the acute phase of post-traumatic cerebral aggression, its degree of severity, its predictive factors as well as its prognostic impact in the population of post-traumatic brain injury. patients and methods: this is a retrospective study, carried out over a period of years about all traumatized head patients who developed hyponatremia during the first h of their stay. the descriptive part treated all patients who developed hyponatremia by detailing its different stages of severity.the analytical part treated the patients who developed a hypo-osmolar hyponatremia with a threshold of mmol/l retained to define the severity. during the study period, the incidence of hyponatremia in head trauma patients was . %. the occurrence of hyponatremia was associated only with the occurrence of early seizures (p = . ).severe hyponatraemia was associated with paroxysmal occurrence (p = . ), mass effect (p = . ), and hemostasis disorders. the multivariate study revealed that severe hyponatremia was associated with the glasgow score (p < . ) and pupillary changes (p = . ). on the other hand, it is the initial variation in serum sodium that was associated with both the severity of the initial neurological examination; glasgow (p < . ), saps (p = . ), pts (p = . ) and prism scores (p = . ), haemodynamic instability (p = . ) and neurovegetative disorders (p = . ). lesional features have also been found.regarding the prognosis, the occurrence of initial hyponatremia had a protective effect: a more favorable gos score p = . and a lower mortality (p = . ). a poor neurologic prognosis as well as a high mortality were associated with the most severe hyponatraemia and particularly with the initial variation of the sodium level (p = . ;). the mortality was . %. it was also particularly related to the initial change in sodium levels (p < . , . ). we concluded that there is no association between post traumatic early hyponatremia and the severity of the initial clinical presentation. however, the depth of hyponatremia and especially the initial change in sodium levels have been associated with more severe clinical pictures and a more limited prognosis. compliance with ethics regulations: yes. rationale: post-traumatic epilepsy (pte) is one of the complications described in the aftermath of headtrauma. its incidence is variable in the literature because of its clinical polymorphism. objectives of the study was to analyze the epidemiological profile (clinico-biological, radiological, therapeutic and evolutionary) of the patients having presented pte and to determine the risk factors for this pathology by comparing them with the rest of the traumatized brain patients. patients and methods: our study was retrospective. it was conducted in the intensive care unit (icu) of our university hospital between and . were included in our study all patients admitted to the service with brain injury and a glycaemia above mmol/l during the first h post-trauma. results: the incidence of pte was . %. ( among ) the average age was . ± . years. the sex ratio was . . the average of gcs was . ± . . three ( . %) patients had initial motor impairment. seizures were observed in ( . %) patients during the first h of hospitalization. the mean delay of occurrence of pte was ± . months. pte was diagnosed before the end of the first post-traumatic year in patients ( % of cases). the most commonly observed brain lesions were cortical brain contusions ( rationale: electrolytic disorders are common in neuro-resuscitation, especially dysnatremias and dyskalemias. hyponatremias are the most frequent, including the main etiologies: the syndrome of inappropriate secretion of antidiuretic hormone (siadh) and the "cerebral salt wasting" syndrome (csw). diabetes insipude of central origin secondary to a lack of dha secretion is the second most common disorder. patients and methods: it is a prospective study, analysing all the brains injured admitted to the a intensive care unit of chu hassan in fez, morocco. study spread over a -month period from / / to / / . the objective of the study is to detect the most frequent hydro-electrolytic disorders and to evaluate the therapeutic effectiveness of the service protocols. results: all these brains injured have caused he disorders over a period of time varying between d and d : * cases of hyponatremia ( %)/ cases of hypernatremia ( %), * cases of hypokaliemia ( %)/ cases of hyperkaliemia ( %), * cases of hyperchloremia, or %/ cases of hypochloremia ( %). * cases of diabetes insipidus, or . %. * cases without he disorder ( . %). the treatment for these disorders was: *for hypona; it reached mmol/l, initially corrected by a -hour water restriction, followed by an increase in the basic ration and furosemide boluses according to the ecv, even sodium loads for a single case of salt loss syndrome, while the main etiology remains the siadh. *for hyperna, it has reached mmol/l, evaluated by the extracellular volume, corrected by enteral tap water after calculation of the hydric deficit. if hperna is associated with polyuria greater than cc/kg/h; we speak of: *insipude diabetes, with polyuria up to cc/kg/h, compensated with potassium-containing solutions and blood ionogram monitored every h. desmopressin was used in titration, by bolus of . µg, with a diuresis objective between and . ml/kg/h. *for hypokalemia, up to . g/dl, observed mainly in the acute phase of brain aggression, corrected by increase in br for a k between . and g/l, and by potassium loads if k below . g/l. the evolution: deaths or . % ( cases of uncorrected diabetes insipidus), the restriction of disorders were corrected. conclusion: a knowledge of the hydroelectrolytic disorders encountered in this context is essential, as well as the implementation of a diagnostic and therapeutic protocol, which will reduce the time required to correct these disorders. compliance with ethics regulations: yes. . ] u/h). however, workload was increased under star ( vs. measurements per day), as expected from measurement interval difference between star ( -hourly) and the sp ( -hourly). conclusion: this unique patient-specific risk-based dosing approach gc framework was successful in controlling all patients safely and effectively. these preliminary results are encouraging and show gc can be achieved safely and effectively at lower target bands. in turns, these improved gc outcomes could improve patient outcomes. compliance with ethics regulations: yes. rationale: although its incidence has declined in recent years, gastric cancer remains common worldwide and is the leading cause of gastrectomy. his treatment is mainly surgical, but his prognosis remains poor. many studies on survival and prognostic factors have been carried out in foreign series. patients and methods: this is a retrospective study covering a period of three years from january to december interesting patients who had a gastrectomy and hospitalized in emergency resuscitation department surgical uhc ibnou rochd from casablanca. the statistical analysis of the different clinical, paraclinical and therapeutic data was carried out thanks to an exploitation sheet. rationale: gram-negative bloodstream infections (gnbsi) require timely appropriate antimicrobial therapy in intensive care units (icu) patients. conventional techniques usually take - h for antimicrobial susceptibility testing (ast). innovative approaches (accelerate pheno ™ system) provide pathogen identification in ~ h and ast including minimal inhibitory concentrations (mics) in ~ h. we report, in icu patients with gnbsi, results of implementation of the accelerate pheno ™ in our laboratory. we prospectively screened all gnbsi episodes reported in adult icu patients between september and september . to allow integration into the laboratory workflow, the accelerate pheno ™ was run on blood bottles positive before am (day ), in parallel with routine procedures: maldi-tof identification after short incubation on solid media (day ), β lacta (bio-rad ® ) test (day ) and disk diffusion method for ast (day+ ). for each episode, antimicrobial regimen was reassessed by a multidisciplinary team of bacteriologists, infectious diseases and icu physicians by the end of day . we measured: (i) concordance of accelerate pheno ™ results with conventional techniques, (ii) number of antibiotic adaptations on day and (iii) number of patients within the therapeutic range (free fraction over x mic and below concentration at risk of adverse events), based on real-time measurement of beta-lactams concentrations. results: of patients reported with gnbsi over the study period, were included. mean age was of ± . years, / were males. main sources of gnbsi were pulmonary (n = ) and digestive (n = ). bacterial identification of the accelerate pheno ™ was concordant with standard techniques in ( %): enterobacteriacae (n = ), pseudomonas aeruginosa (n = ). overall categorical agreement for ast was of % ( errors including very major errors). by the end of day , the antibiotic regimen was de-escalated in ( %) patients, which was appropriate in ( %). in cases, de-escalation was possible, but not fulfilled by icu physicians. twenty patients had beta-lactams concentrations measurements: were in the therapeutic range, below and over. conclusion: accelerate pheno ™ provided rapid and accurate results for most microorganisms isolated in blood cultures of icu patients with gnbsi. however, in a laboratory with routine maldi-tof early identification and β lacta test performed on day , the impact on early adaptation of the antibiotic regimen was evident in around patient over . compliance with ethics regulations: not applicable. jean-luc baudel , jacques tankovic , redouane dahoumane , jean-remy lavillegrand , razach abdallah , geoffroy hariri , naike bige , hafid ait-oufella , nicolas veziris , eric maury , bertrand guidet service bactériologie, hôpital saint-antoine, paris, france; service réanimation médicale, hôpital saint-antoine, paris, france correspondence: jean-luc baudel (jean-luc.baudel@aphp.fr) ann. intensive care , (suppl ):p- rationale: evaluation of the accurateness of the accelerate phenotest bc kit for rapid analysis ( . h for microorganism identification and additional hours for antibiotic susceptibility testing) of positive blood cultures from icu and hematology patients. patients and methods: from february to august , we included patients from the icu and hematology units with positive blood cultures. the following informations were collected : gender, age, duration of prior antibiotherapy, source of the infection, results obtained by conventional microbiological methods and by phenotest (data obtained and time to obtention of results). informed consent was obtained from all patients. results: blood cultures were analyzed in patients (m/f ratio . , age . ±, from the icu and from hematology). % of the patients were receiving antibiotics at the time of blood culture collection (mean duration : . days). the source of infection was unknown in % of cases, urinary in %, catheter-related in %, ascites in %, pneumonia in %. in cases ( %), there was a perfect match between phenotest and conventional results (identification and antibiotic susceptibility testing). in cases ( %), the bacterium responsible was not present in the phenotest panel. in cases ( %), phenotest identification was correct, but some discrepancies were observed regarding antibiogram. in cases ( %) phenotest identification was again correct but no antibiogram was available. in cases ( %), where two bacteria were present, phenotest could not identify one of them. in cases, phenotest did not provide bacterial identification because too few bacteria were present in the blood culture bottle. conclusion: the phenotest panel covered % of the bacteria implicated in this study. when the bacterium responsible was present in the panel, the results given by the phenotest correlated in % of cases with those of conventional methods. some rare discrepancies were observed regarding antibiotic susceptibility testing that have to be analyzed further. in the remaining % of cases, where too few bacteria or two different bacteria were present in the blood culture bottle, technical limitations did not permit to correctly identify microorganism(s) present or to obtain an antibiogram. compliance with ethics regulations: yes. mélanie fromentin, antoine bridier-nahmias, constance vuillard, jean-damien ricard, damien roux inserm umr iame infection antimicrobials modelling evolution, paris, france correspondence: mélanie fromentin (mel.fromentin@wanadoo.fr) ann. intensive care , (suppl ):p- rationale: studying human lower respiratory tract microbiota by using ngs (new generation sequencing) method is complex because of many unexpected biases due to dna extraction and amplification procedures. lung microbiota evolution under mechanical ventilation evolution may be highly informative to evaluate the actual risk of vap (ventilator-associated pneumonia) development. before starting a large study on the lung microbiome of ventilated icu patients, a methodological study was mandatory. patients and methods: five control and three vap patients were selected. endotrachealaspirate (eta) and oropharyngeal swab (os) were collected at icu admission for control patients and, days before and on the day of vap diagnosis for vap patients. after automated extraction of total dna, hypervariable region v of the s rdna genes was amplified with two different pairs of primers f- r: oligonucleotides from the earth microbiome project (earth primer pair) and from the gut microbiome project (gut primer pair), followed by sequencing on illumina miseq plateform. after bioinformatics analysis with mothur ® software, we compared the performance of ngs alongsideconventional bacterial culture. differences in alpha diversity (microbial diversity in a sample), expressed as the shannon index, across respiratory tract site (upper or lower) and across time (before and at vap time) has been investigated. a positive control (pc), rationale: colistin is used as a last-line treatment to combat multidrug-resistant (mdr) gram-negative bacilli (gnb). worryingly, colistin resistance in klebsiella pneumoniae, pseudomonas aeruginosa and acinetobacter baumannii is increasingly reported worldwide. we hereby report the prevalence of colistin resistance among gnb isolated from burn patients in tunisia. the study was carried out on strains of gnb isolated from microbiological samples of burn patients hospitalized in the intensive care unit between october and december . identification was performed by conventional methods. antimicrobial susceptibility was tested by disk diffusion method and the results were interpreted according to ca-sfm guidelines. minimum inhibitory concentration (mic) of colistin was determined using the eucast broth micro-dilution method (umic, biocentric ® ) results: pseudomonas aeruginosa was the most frequently isolated bacteria ( strains), followed by acinetobacter baumannii ( strains) and klebsiella pneumoniae ( strains). the most common sites of isolation were blood cultures ( %), catheters ( %) and skin samples ( %). most of p. aeruginosa isolates were multidrug-resistant with high levels of resistance to imipenem ( . %), ceftazidime ( %) and ciprofloxacin ( . %). however, all of them were susceptible to colistin. in fact, mics of colistin against all p.aeruginosa isolates were less than or equal to . mg/l. a. baumannii strains had high resistance rates to beta-lactams : % to ceftazidime and % to imipenem. only one strain was resistant to colistin with a mic equal to mg/l. all k. pneumoniae isolates were resistant to extended-spectrum cephalosporins. one third of these strains were resistant to imipenem and more than half ( . %) were resistant to amikacin. two strains were resistant to colistin with high mics (> mg/l). both were carbapenemase-producers, carrying oxa- and ndm carbapenemase encoding genes. conclusion: these data suggest that colistin-resistant or pan-drug resistant gnb clinical isolates are still relatively rare. however, they have important global public health implications because of the therapeutic problems they present, especially for vulnerable populations such as severely burned patients. hence the need to test colistin regularly in the laboratory and to set up a monitoring program for mdr pathogens. compliance with ethics regulations: yes. rationale: descending necrotizing mediastinitis (dnm) are medicosurgical emergencies whose forecast is closely related to the precocity of the therapeutic assumption. the purpose of our work is to profile these patients as well as the therapeutic and evolutionary aspects. patients and methods: retrospective study over years in the intensive care unit of the hospital august. all patients with dnm on cervicofacial cellulitis were included. results: cases were collected, % of cellulitis, incidence of . patients / year. average age , sex ratio of . . smoking, chronic alcoholism and diabetes are the most common antecedents. the favoring factors were: (poor dental conditions: % of cases, non steroidien anti-inflammatory drugs: %, diabetes: %). in % of cases the front door was dental. average time taken to take care of days. c-reactive protein and procalcitonin were positive in all patients. in % the chest x-ray was normal. all patients received tri-antibiotic therapy. intubation were difficult in all patients, we used nasofibroscope in % of cases and a rescue tracheotomy in one patient. only one patient had a cervico-thoracic surgical approach; for all the others she was cervical alone. streptococcus was the most isolated germ. the complications were (septic shock: %, ards: %). the average hospital stay was days with a mortality rate of %. conclusion: dnms are poorly prognostic. the best treatment remains prevention by better management of dental abscesses and tonsillar phlegmons. rationale: the initial, empirical antibiotic therapy of ventilator-associated pneumonia (vap) is often based on timing of its occurrence in relation to the onset of mechanical ventilation. this is due to reported differences between causal pathogens associated with early-onset (e-vap < - days of mechanical ventilation) compared to late-onset vap (l-vap ≥ - days of mv). e-vap is most often reported to be due to antibiotic-sensitive pathogens while l-vap is frequently attributed to antibiotic-resistant pathogens. however, there is emerging evidence that the isolated microorganisms may be similar regardless of onset time. the aim of our study was to compare the clinical outcomes of critically ill patients developing e-vap and l-vap and to compare the causative pathogens of the two groups. patients and methods: all the patients with the diagnosis of vap admitted between january and december were retrospectively included. vap was suspected on the basis of clinical and chest x-ray findings. the identification of the causative organisms was performed with endotracheal aspirate (eta) cultures. results: ninety patients developed vap. e-vap was observed in patients ( , %), whereas patients ( , %) developed l-vap. among patients with early-onset vap, % received antibiotics prior to the development of pneumonia, compared to % with late-onset vap (p = . ). otherwise, no differences (sociodemographic factors, antecedents, severity score, length of stay, length of mv) between the two groups were observed. the most common pathogens associated with e-vap were enterobacter species ( . %), pseudomonas aeruginosa ( . %) and oxacillin-resistant staphylococcus aureus (orsa , %). enterobacter species ( . %), acinetobacter baumannii ( . %) and pseudomonas aeruginosa ( %) were the most common pathogens associated with l-vap. no difference was noted in the contribution of multidrug resistant bacteria mdr ( % vs. %). hospital mortality was significantly greater for patients with l-vap caused by mdr ( %) compared to patients with e-vap ( %) (p = . ). conclusion: this classification is no longer helpful for empirical antibiotic therapy, since both early-onset and late-onset vap were caused by mdr bacteria. this justifies the need of intensive care unit-specific knowledge of causal agents associated with vap to reduce the rate of administration of inadequate antimicrobial therapy. compliance with ethicsregulations: yes. key: cord- - tapkjb authors: nan title: th escp-nsf international symposium on clinical pharmacy: clinical pharmacy tackling inequalities and access to health care. oslo, norway, – october date: - - journal: int j clin pharm doi: . /s - - - sha: doc_id: cord_uid: tapkjb nan pharmacy, sint maartenskliniek, ubbergen, pharmacy, radboud university medical centre, nijmegen, clinical pharmacy and toxicology, maastricht university medical centre, maastricht, netherlands please specify your abstract type: research abstract background and objective: according to literature adherence to statins ranges from to %. medication adherence is affected by both practical barriers and patient's beliefs about medication. however, physicians also have their beliefs about medication. several studies have shown that these beliefs also impact the decision of patients to agree with a particular treatment or not. as current published interventions on medication adherence (which focus predominantly on patients) are not or just partly effective, physicians' beliefs might be a promising target for interventions to improve adherence. however, there is currently no information available on physician's beliefs about statins and whether these beliefs affect patient's beliefs and adherence. therefore, the objective of this study is to examine whether physicians' beliefs about statins influence the beliefs and adherence of patients using a statin. setting and method: this cross-sectional study was conducted in gp practices and community pharmacies, between september , and march , . physicians' and patients' beliefs about statins were assessed with the beliefs about medicine questionnaire (bmq) specific. patients' adherence on statins was assessed with both the mars- and the morisky- questionnaires. please specify your abstract type: research abstract background and objective: nhs highland and nhs western isles are the most remote and rural health boards in the united kingdom, with high numbers of dispensing medical practices. a pilot is underway in dispensing practices with clinical pharmacists undertaking targeted medication reviews. a previous quantitative service evaluation demonstrated its value, with pharmaceutical care issues identified in almost all patients, the vast majority of which ( . %) were managed by the pharmacist without any need for general practitioner (gp) referral. the objective was to undertake a qualitative exploration of the service. setting and method: all patients and staff involved in the service were invited to participate. a semi-structured interview schedule was developed and piloted. telephone interviews were conducted with all consenting staff and a purposive sample of consenting patients recruited to the point of data saturation. interviews were audiorecorded, transcribed verbatim and analysed thematically. nhs ethics and research and development approvals were obtained. were the most confident with doacs (range from . to . %) please specify your abstract type: research abstract background and objective: patients are at risk of drug-related problems (drps) at transition points during hospitalization. the community pharmacist (cp) is often the first healthcare professional patients visit after discharge. cps lack sufficient information about the patient and so they may be unable to identify problems in medications, which may lead to dispensing the wrong drugs or dosage, and/or giving wrong information. we aim to assess the impact of a complex intervention comprising of medication reconciliation performed at discharge by a hospital pharmacist (hp) with communication between the hp and cp on drps during the days following discharge. setting and method: cluster randomized crossover trial involving medical and surgery care units (each unit corresponding to a cluster) in french hospitals during two consecutive -day periods, randomly assigned as 'experimental'(e) or 'control' c (usual care) periods. during the experimental period, the hp performed a medication reconciliation that was communicated to the patient's cp. main outcome measures: the primary outcome was a composite outcome of any kind of drp (prescription/dispensation, gap or patient) during the days following discharge assessed at day seven post-discharge by phone from patient and cp. the secondary outcomes were /unplanned hospitalizations assessed by phone contact at day after discharge and /the iatrogenic potential exposure scale from to for each patient established by a clinical team. analysis was conducted in intention to treat. results: hospitals corresponding to clusters enrolled patients ( e group v/s c group). no difference was observed on age, sex, autonomy, and number of drugs in home medication at admission and discharge. at day ; ( . %) patients in e group had at least one drp v/s ( . %) in c group (or . ; ic % [ . ; . ] p = . ). intervention was especially efficient for patient discharged from surgery unit (or . ic % [ . ; . ]) and aged less than years (or . ic % [ . ; . ] . although intervention decreased patient exposure to drp with high iatrogenic potential (from . to . % p \ . ), un-planned hospitalizations at day weren't different between groups ( . vs. . % p = . ). conclusion: medication reconciliation associated to communication between hospital and community pharmacists is efficient to decrease patient exposure to drp but not sufficient to decrease un-planed hospitalization. hp-pc : clinical pharmacists bridging health care levels by medication reviews in primary care katherine wendelbo *, , kristine lundereng namsos hospital pharmacy, central norway hospital pharmacy trust, namsos, levanger hospital pharmacy, central norway hospital pharmacy trust, levanger, norway please specify your abstract type: descriptive abstract (for projects) background and objective: nord-trøndelag county is sparsely populated and many inhabitants live far from the hospital. additionally, only half ( of ) of the municipalities have a local pharmacy. traditionally, namsos and levanger hospital pharmacies have performed quality audits of the implementation of drug administration procedures in primary care units. since , a service where clinical pharmacists participate in multidisciplinary medication reviews in municipalities throughout the county has been established. the objective of this poster is to describe the practical approach and design of the service. design: a descriptive report of an implemented clinical pharmacy service in primary care where clinical pharmacists, as part of multidisciplinary teams, perform medication reviews. results: medication reviews are performed on patients admitted to nursing homes and patients in home care, receiving help with handling of their drugs. primary care nurses prioritise patients (by selecting frail elderly with multiple co-morbidities and polypharmacy), usually five patients in each meeting. prior to the review, nurses collect medical information using a checklist including; diagnosis, drug-related symptoms, standard laboratory tests and an updated medication list. the clinical pharmacist receives de-identified medical information by postal mail or e-mail before the meeting. based on this information the pharmacist identifies possible drugrelated problems (drps) and provides recommendations on how to solve them. this is performed in a structured approach according to the integrated medicine management (imm) model. subsequently, the pharmacist visits the municipality and discusses the medication reviews in a multidisciplinary team meeting with nurses and physicians. in addition, the pharmacist gives lectures in a medication related topic (e.g. treatment of insomnia and anxiety, oral anticoagulants and cognitive side effects). following the meeting, the pharmacist reports the drps and suggested interventions to the multidisciplinary team, for further follow-up. during , totally medication reviews were performed in municipalities. in the same period, lectures were given by the clinical pharmacists. conclusion: this clinical pharmacy service enables multidisciplinary medication reviews even in municipalities with limited health professionals and resources. as a part of multidisciplinary teams, the clinical pharmacists contribute with medical competence. camille castel , arnaud de la blanchardière , vincent cattoir , guillaume saint-lorant *, pharmacy, infectious and tropical diseases, microbiology, chu caen, caen, france please specify your abstract type: research abstract background and objective: antimicrobial stewardship have clearly demonstrated their efficiency towards a more adequate use of antibiotics. since , the use of daptomycin, a ''critical last resort antibiotic'' has intensified in our hospital, occasionally outside the scope of its approved indications. this situation has led to the implementation of an antimicrobial stewardship and the drafting of local guidelines. the aim of this study is to analyse the evolution and pertinence of daptomycin prescriptions, after distribution of these guidelines within our institution. setting and method: a monocentric prospective study was conducted between july and november in a -bed university hospital. each daptomycin prescription recorded by pharmacy department was analysed by an infectious diseases specialist in the presence of the prescriber and considering local guidelines and the patient's clinical conditions. main outcome measures: the indicators chosen to determine prescription pertinence were: treatment indication, prescribed dose and other antibiotics associated with the daptomycin prescription. results: daptomycin prescriptions were analysed. observed indications were: sepsis ( %), infective endocarditis ( %), bone and joint infections ( %) and vascular prosthetic infections ( %). identified pathogens were: mrsa ( %), methicillin-resistant coagulase-negative staphylococci ( %), methicillin-sensitive staphylococcus aureus ( %), enterococci ( %) and methicillinsensitive coagulase-negative staphylococci ( %). daptomycin was prescribed as first-line treatment in % of cases. the mean dose was mg/kg/day [ - mg/kg/day] for a mean duration of days [ ; days] . local guidelines were followed in % of cases. daptomycin use was relevant for % of prescriptions. the irrelevant prescriptions triggered the modification or stoppage of antibiotic therapy in % of cases, respectively, generating an % decrease in consumption and an economy of over € for our institution. conclusion: this study shows the efficiency of antimicrobial stewardship in adequately using antibiotics, limitating ecological impacts, improving patient care and decreasing healthcare costs. it also shows that guidelines alone are insufficient to ensure a proper use of antibiotics. without a close prescription follow-up, constant reminders and sustainable evaluations, guidelines only affect a few prescribers. within the context of an ''antimicrobial crisis'', further development of guidelines and antimicrobial stewardship is essential to fight increasing bacterial resistances and requires a close collaboration between all healthcare professionals including pharmacists. interviews were transcribed verbatim and data were analysed using systematic text condensation. results: three major themes were identified: benefits, unrealised potential and criteria and barriers for success. ( ) benefits described by physicians included increased patient safety, increased awareness on drugs, and an ease of workload. drug interaction management was emphasized as one of the clinical pharmacists' most important work tasks, as well as being a resource for collaborating healthcare professions and to the patient himself. ( ) the clinical pharmacists expressed that they had an unrealised potential and could contribute to a greater extent in the multidisciplinary team than they did already. they mentioned education towards physicians and nurses, contribution in treatment decision-making and patient counselling as examples for possible extended work tasks. ( ) as criteria to succeed as a clinical pharmacist, physicians highlighted the importance of oral communication and physical presence on the wards. as barriers for integration in the team, the clinical pharmacists identified the physicians' lack of knowledge about the clinical pharmacists' skills as well as unclear expectations regarding their responsibilities. conclusion: physicians agreed that the clinical pharmacist represent a valuable contribution to the multidisciplinary team, where patient safety and drug interaction management are highlighted as main benefits. clinical pharmacists should to a greater extent educate healthcare professions in drug related topics and provide patient counselling. continuous effort on making the clinical pharmacist a natural part of the multidisciplinary team is crucial for the development of clinical pharmacy. by gathering perceptions from the collaborating professions as well as educating them on what clinical pharmacists can provide, we can develop a multidisciplinary team that enhances patient safety. hp-pc : assessment of dual antiplatelet therapy following acute coronary syndrome using grace and crusade sadeer fhadil * , paul wright, sotiris antoniou please specify your abstract type: descriptive abstract (for projects) background and objective: mortality and morbidity benefits of dual antiplatelet therapy (dapt) following acute coronary syndrome (acs) have been unequivocally demonstrated in a large body of evidence. with the availability of more potent antiplatelet agents, balancing ischemic and bleeding risks to prevent adverse outcomes is an on-going challenge, in particular, recognising that patients with high bleeding risk were excluded from clinical trials. grace and crusade scores stratify risk of mortality and in-hospital major bleeding post acs respectively. these tools should be used to support antiplatelet choice in light of newer more potent agents that equally pose a greater risk of bleeding. design: grace and crusade scores were calculated for patients presenting with acs. clopidogrel was recommended for patients with a high or very high crusade score (greater bleeding risk). ticagrelor was recommended for patients presenting with st-elevation myocardial infarction (stemi) or those with nsteacs with a grace score of intermediate or above (greater ischemic risk) and a crusade score of moderate or less (low bleeding risk). in either case, treatment was at the discretion of the clinician and patients received concomitant aspirin. a registry was collated of risk scores, diagnosis and choice of antiplatelet therapy. results: patients were included in the registry, of which ( %) presented with stemi and ( %) presented with nsteacs. of ( %) patients with a greater ischemic risk received ticagrelor as part of their dapt regime. advanced age, concomitant anticoagulation and those awaiting surgery were the most common reasons for patients with a greater ischemic risk to receive clopidogrel. ( %) had a high or very high crusade score. of these, ( %) received clopidogrel as part of their dapt regime. conclusion: risk stratification was streamlined using the data collection tool and useful to support choice of dapt. european society of cardiology (esc) guidance recommends use of established risk scores for prognosis and bleeding; however evidence to correlate to choice of dapt is lacking. outcome data is currently being reviewed and will provide further evidence to correlate choice of dapt to grace and crusade scores. please specify your abstract type: descriptive abstract (for projects) background and objective: in europe, approximately % of the patients with the human immunodeficiency virus (hiv) infection are co-infected with the hepatitis c virus (hcv). treatment recommendations in hiv/hcv co-infected patients are identical to those in patients with hcv mono-infection. however, potential drug-drug interactions (ddis) between antiretroviral agents and new direct-antiviral agents (daas) imply the need of a careful selection of the hcv treatment regimen. the aim of the present study was to evaluate the need of a change in the antiretroviral therapy (art) due to potential ddis in patients with hiv/hcv co-infection who started treatment for hcv with new daas. we also assessed the effectiveness of hcv treatment weeks after hcv treatment completion. design: we retrospectively registered clinical data about hcv and hiv management: hcv genotype, fibrosis metavir score, initial hcv viral load, hcv treatment and previous art regimen. we recorded the changes in art prior to starting hcv treatment and the reason of this switch (ddi, simplification or duplication of the therapy). results: between february and january , hiv/hcv coinfected patients started hcv treatment with a daas regimen. of them, had advanced liver disease (fibrosis score: f /f ) and were infected with hcv genotype . prior to starting hcv treatment, patients needed a switch in art regimen due to potential ddis with daas. simeprevir and the co-formulation ombitasvir/paritaprevir/ritonavir were the daas most frequently implicated in ddi with protease inhibitors or non-nucleoside reverse transcriptase inhibitors: / and / , respectively. also, we observed some changes of art due to other causes. five switches occurred to adequate the regimen (discontinuation of ritonavir in candidates to take the co-formulation ombitasvir/paritaprevir/ ritonavir or art improvement to decrease pill burden). as for hcv treatment effectiveness, / ( %) patients achieved sustained viral response weeks after therapy completion. conclusion: a large proportion of patients with hiv/hcv co-infection who initiate treatment with daas for hcv need to switch art due to potential interactions that may impact on effectiveness and safety of both treatments. additionally, some changes in art treatment are made to facilitate therapeutic adherence. these results highlight the need of a multidisciplinary approach in which interactions between art and hcv treatments should be carefully assessed. please specify your abstract type: descriptive abstract (for projects) background and objective: the potential impact of polymedication, iatrogenic events and medication error is a serious concern in hospitalized patients. clinical pharmacists can limit these risks by identify high risk. the aim of this study are to identify in six medical units high risk patients by using three predictive scores of rehospitalisation ( ps) , early mortality (charlson) and drug related problems (drp) . design: clinical and therapeutic variables in patients were collected through medical records and prescriptions by clinical pharmacists. scores were calculated during months in six units (internal medicine, n = ; nephrology, n = ; geriatrics, n = ; rheumatology, n = ; cardiology, n = and endocrinology, n = ). the data were analysed by mann and whitney test for the continuous variables and chi square test for the qualitative variables. the coefficient of correlation between the three scores were calculated by a pearson test for normal distribution and by a spearman test for non normal distribution. patients were considered at a high risk for re-hospitalization ( ps [ ) , early mortality (charlson [ ) and iatrogenic events (drp c ) . results: in the general population, the average age was . ± . years old and the sex ratio was . . the average treatment used was . ± . charlson scores were higher in geriatric unit ( . ± . ) follow by medical interne unit ( . ± . ). the ps and drp scores were higher in nephrology unit respectively . ± . and . ± . follow by internal medecine unit . ± . and . ± . . on contrary the rheumatology unit presented the lower level for the three scores. patients were considered at high risk for three scores, % (n = ) in nephrology unit (almost % of unit), % (n = ) in geriatric unit, % (n = ) in internal medicine unit, % (n = ) in cardiology unit, % (n = ) in endocrinology unit and % (n = ) in rheumatology unit. conclusion: knowledge of the variables associated with these predictor scores could help clinical pharmacists to prioritise various medicine units and target those at risk. we identified especially three units at risk: nephrology, geriatric and internal medicine. thanks to these results, clinical pharmacists can rapidly and efficiently target patients who present iatrogenic and/or re-hospitalization risks. design: a retrospective observational analysis was conducted in our hospital, based on medical records of patients presenting atrial fibrillation (af) and treated by doacs from january to may . to identify patients hospitalized due to severe bleeding, we analysed prothrombin complex concentrates (pccs) and activated pccs prescriptions, as well as pharmacovigilance declarations. results: patients were treated with doacs: with rivaroxaban ( . %), with dabigatran ( . %) and with apixaban ( %). fifty-nine ( . %) patients experienced at least one bleeding leading to hospitalization: with rivaroxaban ( . %), with dagibatran ( . %) and with apixaban ( . %). thirty-eight severe bleeding were identified ( . %): occurred with rivaroxaban ( . %), with dabigatran ( . %) and with apixaban ( . %). they included intracranial bleeding ( %) and gastro-intestinal bleeding ( %). seven haemorrhages resulted in hypovolemic shock (dabigatran: , rivaroxaban: , apixaban: ) and of them were fatal (dabigatran: ). rates of bleeding (p = . , v test) and of severe bleeding (p = . , v test) were not statistically different for the three molecules. in case of major haemorrhage, the recommended factor concentrate in our protocols differs between the anticoagulant. with dabigatran, the antidote idarucizumab ( g, intravenously) should be administered, without waiting for plasma concentration results. with rivaroxaban, apixaban or unknown doacs, pcc ( - units/kg) is indicated. in case of pcc failure, activated pcc ( - units/kg) is suggested. pcc, activated pcc or idarucizumab ( ) were used in / patients ( %). in rivaroxaban and apixaban-related haemorrhages, patients received activated pcc: two had a ui/kg dose and one had a ui/kg dose. regarding dabigatran-related bleeding, one patient received pcc instead of idarucizumab. compliance with local recommendations was % ( , p [ . , v test) . pharmacovigilance reports were issued. conclusion: management of doacs-associated severe bleeding in our hospital respects local protocols. it should also be pointed out that patients with life threatening bleeding may benefit from pcc. however, the risk of thrombosis associated with pcc must be weighed against the risk of haemorrhage. since specific antidotes are emerging, like idarucizumab or andexanet alpha, new guidelines for doacs-related haemorrhage are expected. please specify your abstract type: descriptive abstract (for projects) background and objective: this project is part of a prospective quasi experimental proof-of-concept investigation of a clinical pharmacist intervention to reduce drug-related problems among people admitted to a ward in a rural hospital in northern sweden. the aim of this particular study is to explore doctors' and nurses' expectations of having a ward-based pharmacist providing clinical pharmacy services in a rural hospital. design: eighteen face to face semi-structured interviews were conducted with a purposive sample of doctors and nurses working on the ward were the clinical pharmacy service was going to be implemented. semi-structured interviews were digitally recorded, transcribed and analysed using thematic analysis. results: the majority of participants had limited experience or a vague idea of what pharmacists are able to do in a ward. most participants described traditional roles such as inventory, drug distribution and dispensing. most respondents were unaware of the pharmacists' knowledge, skills and competences. for some it was unclear how having a clinical pharmacist in the ward was going to impact on their workload this was particularly important for the nurses. some doctors (mainly experienced) were concerned that having a pharmacist may mean losing or not gaining competence on drugs. for others it was unclear how the pharmacists' will work with patients or what clinical skills they have. however most participants were positive about the implementation of the new service. conclusion: this study provided a rare opportunity to explore the doctors' and nurses expectations of the role of clinical pharmacists before a clinical pharmacy service was implemented. the results showed that the participants' expectations of the clinical pharmacist role were unclear. to successfully implement clinical pharmacy services in a clinical pharmacy ''naïve'' setting; roles, clinical competence and responsibilities should be clearly described. furthermore, it is important to focus on inter professional collaborations between doctors, nurses and pharmacists. practical for the local hospital setting. seven out of experts agreed with pharmacist prescribing for the conditions identified. pharmacists (n = ) were more willing to prescribe antihypertensive and antidiabetic medication ( . %) when compared to oral anticoagulants ( . %). these values are higher than those obtained by vella in . the majority of pharmacists ( . %) recommended that pharmacists should take up further studies to a master or doctorate level degree in a clinical aspect in order to be authorised to prescribe. conclusion: the developed framework for pharmacist prescribing and the guidelines developed for pharmacist prescribing of oral anticoagulants and pharmacotherapy of hypertension and diabetes mellitus were shown to be reliable and were accepted by pharmacists and physicians. please specify your abstract type: research abstract background and objective: valproic acid (vpa) and its derivates and mycophenolate mofetil (mmf) and mycophenolic acid used during pregnancy increase risk of congenital malformation and cognitive impairment. thus, the french national agency for medicines and health products safety (ansm) decided to establish new conditions of prescription and dispensation of drugs containing vpa (may ) and mmf (april ). a signed care agreement and a co-prescription of contraceptives are now mandatory in the drug dispensation for reproductive-age adolescent girls and adult women. this study will describe the impact of these new guidelines on our practice. our objective is to compare the vpa and mmf media coverage and the impact on the prescriptions. setting and method: we compared the mass communication between vpa and mmf on social media, webpages and journal article (public and professional journal) on google and googletrends in the first months around these new rules. we combined different keywords such as ''accord de soins'' and the drug name. in the same time, we collected and analysed vpa and mmf prescribing and dispensing data and compared it to the data for the first months. main outcome measures: results: just before the vpa rule, the vpa was presented in the general press as the new health scandal after benfluorex mediator°w ith google searches in march compared to searches usually per month. simple research combining keywords reveal always more than twice more webpages concerning vpa than mmf. at the same time, a patients association (renaloo for renal failure) wrote to the ansm to contest the new rule with the double contraception and without any consultation of patients association. in our daily practice we also faced some physician reluctant to sign this prescription agreement with patient (too many agreements already asked, decision of ansm without any consultation of learned societies). the care agreements are kept in the patient records, a statement ''care agreement signed'' is reported in the electronic prescription of vpa and mmf. the overall consumption of mmf and vpa increase for respectively the first and months after rule implementation (from + to + %) except for the micropakin mg. the months mmf data will be presented for the final communication. conclusion: the media pressure and the new regulation have an impact on prescription trends. these new prescription and dispensing rules concerned two different contexts: pathology, media coverage, possible drug alternatives. we were faced to some difficulty in implementing the new guidelines, which reveals a certain reluctance of the prescribers or the patients represented by associations. tdmp : vancomycin trough serum concentrations are frequently subtherapeutic in a population of critically ill patients: a prospective observational study please specify your abstract type: descriptive abstract (for projects) background and objective: to design and characterise a framework of international pharmacy standards for pharmaceutical care application on oral anticoagulation for prevention of atrial fibrillation (af) related strokes. design: literature review (including existing international guidelines and quality measures) was conducted to characterise the standards and design an international framework for pharmaceutical practice application on oral anticoagulation for prevention of af-related strokes. expert opinions were sought through a delphi method to reach consensus on the framework domains and standards. results: the framework consisted of twelve overarching standards, which were defined and grouped into four domains as follows; ([personal care package]:-communication with patients, support decision making process, education and counselling, adherence. [medicines optimisation]:-clinical review and therapy optimisation, initiation and control, maintenance, supply and transfer between care settings. [workforce]:-workforce planning, training and development, analysing information; and [governance]:-assurance of service provision) specific to oral anticoagulation in prevention of af-related stroke. each standard was also categorised within dimensions and supporting statements to describe what a quality pharmacy service should deliver. a total of forty-five dimensions and twelve statements were incorporated into the framework. conclusion: a clearly defined framework of international standards was developed as a clinical tool and quality assurance to optimise the delivery of care for oral anticoagulation in prevention of af-related strokes. it will support pharmacists and their teams to develop their professional practice, improve services, and deliver safe and high quality patient care across all pharmacy settings. poster discussion forum i: community pharmacy and public health cp-pc : nurses' and pharmacists' learning experiences from participating in inter professional medication reviews in primary health care: a qualitative study hege t. bell *, , anne gerd granås , ragnhild omli , ingela enmarker , aslak steinsbekk nord university/ntnu, trondheim, hioa, oslo, nord university, namsos, norway, department of nursing, Østersund, sweden, ntnu, trondheim, norway please specify your abstract type: research abstract background and objective: traditionally, drug prescription and follow up have been the sole responsibility of physicians. however, interprofessional medication reviews (imrs) have been developed to prevent drug discrepancies and patient harm. what participating nurses and pharmacists learn from each other during imr is poorly studied. the aim of this study was to investigate nurses' and pharmacists' perceived learning experience after participating in imrs in primary health care for up to years. setting and method: a qualitative study with semi-structured focus group interviews and telephone interviews with nurses and pharmacists with experience from imrs in nursing homes and home based services. the data was analysed thematically by using systematic text condensation. main outcome measures: a qualitative method is useful when looking at objects from the perspective of how they are experienced. results: sixteen nurses and four pharmacists were interviewed. the nurses' perception of the pharmacist changed from being a controller of drug management routines towards being a source of pharmacotherapy knowledge and a discussant partner of appropriate drug therapy in the elderly. the pharmacists became more aware of the nurses' crucial role of providing clinical information about the patient to enable individual advice. increasingly the nurses learned to link the patient's symptoms of effect and side effect to the drugs prescribed. with time both professions jointly spoke of an increased awareness of the benefit of working as a team and the perception of contributing to better and more individual care. conclusion: imrs in primary health care meet some challenges especially concerning how to ensure participation of all three professions and how to get thorough information about the patient. possible solutions might be to use shared communication tools like internet based communication programs and to introduce the patient as a participant at the imrs. please specify your abstract type: research abstract background and objective: international good pharmacy practice guidelines describe how pharmacists should counsel the patients about their medicines, offer additional services where needed, and intervene at drug related problems. daily practice often differs from theory. this study aimed at illustrating the whole process of prescribed medicines dispensing in daily community pharmacy practice. part b of the project focuses on pharmacists' opinions. setting and method: community pharmacies in basel, switzerland, were invited in random order for study participation. one master student in pharmacy performed non-participant observations during day at each included community pharmacy. at dispensing of prescribed medicines, patient data, content of counselling, communication style, and provision of further services (e.g. follow-up offer) were documented on a checklist with predefined themes. interventions were documented systematically. a semi-structured interview on the pharmacists' opinions about the counselling, triggers, facilitators and barriers, and the documentation of interventions was conducted at each community pharmacy. main outcome measures: counselling content at prescription dispensing by numbers and by pharmacists' opinions; barriers, facilitators, and triggers for counselling at prescription dispensing. results: in march and april , of invited community pharmacies participated in the study. out of documented observation periods, encounters were analysed (first prescription: /refill prescription: ). counselling was provided to ( . %) clients with an average of . (± . ) themes per encounter. a total of clients refused counselling. themes most counselled at first and refill prescription dispensing were: drug intake ( / ), dosage ( / ) , and administration ( / ). for the pharmacists (n = ), most important themes to be discussed at first prescription dispensing were indication ( ), administration ( ), and anamnesis ( ); for refill prescription dispensing they were adherence ( ), therapy benefits ( ), and adverse effects ( ). the majority of pharmacists ( ) felt that it was their obligation to ask questions about patients' health during the dispensing of prescription medicines and named trigger (e.g. patient knowledge gap, patient motivation, interactions), but one-third reported difficulties with it. barriers were refusal by patients ( ), communication problems (language, ), lack of medical data ( ) , and lack of time ( ) . conclusion: a discrepancy in counselling content by observation compared to pharmacists' opinions was revealed. this might indicate that pharmacists are aware but hindered by barriers to practice according to good pharmacy practice guidelines. please specify your abstract type: research abstract background and objective: the workforce vision in scotland envisages 'making more and better use of technology …to increase access to services and improve efficiency' across the healthcare interface. services offered by community pharmacy remain limited by lack of shared access to patients' clinical information. in scotland, every patient has a unique identifier, their chi (community health index), which facilitates identification of/searching for patient records. the aim of this research was to explore the experiences of community pharmacists granted clinical portal access to patients' records. setting and method: from april , community pharmacists across nhs tayside (n = ) who had completed technical and information governance training were invited to maintain a portal log of their experiences of using the clinical portal to access patient records. each was asked to record when/why they considered accessing a patient's record and whether their information needs were met. portal logs were subject to independent summative content analysis by two researchers. this study gained ethical approval from robert gordon university. main outcome measures: not applicable. results: clinical portal logs were received from most participating pharmacists (n = / ). two were unavailable (moved to hospital setting; maternity leave). a third had not had occasion to access the clinical portal which he speculated was due to not working at weekends but also raised concerns about gaining patient consent. frequency of seven identified themes provided a partial indication of balance of reasons for usage. firstly (# ), to confirm a patient's prescription (n = ), secondly (# ), for additional information (n = ). less frequently (# ), portal access was to check repeat medications (n = ). other reasons for access were (# ) to check hospital discharge (n = ) followed by (# ) check on multi-compartment appliance aid status (n = ) or (# ) check the emergency care summary (n = ). there were also instances (# ) when portal access was not found to be helpful (n = ) so traditional offline routes were followed. conclusion: preliminary findings indicate mainly positive experiences with no technical issues raised and community pharmacists' information needs largely met. although limited to a small number of pharmacists in only one health board, findings support scottish policy aims, including 'prescription for excellence.' further work is underway around patients' perspectives of community pharmacist access. please specify your abstract type: research abstract background and objective: multicompartment compliance aids (mcas) such as the multidrug punch cards pharmis Ò are used to support patients in the daily management of their medication. solid oral medicines are unpacked from their original packaging and repacked in mcas although controversy exists about the stability of repackaged medicines. different countries published contradictory lists of medicines not recommended for repackaging. we aimed to define and apply criteria able to assess visual alteration of medicines repackaged in mcas. setting and method: eight criteria describing physical alteration of tablets/capsules were retrieved from the who international pharmacopoeia : chipping, swelling, capping, rough surface, cracking, crushing under pressure, mottling, and discoloration. absence of one criteria gives point. a maximum score of points can be obtained. twenty-two critical medicines and three half tablets were repackaged in the multidrug punch cards pharmis Ò and stored at accelerated conditions ( °c/ % rh) for weeks. original blisters of medicines were stored at room temperature as control. each tablet/capsule was visually inspected after , , and days. main outcome measures: score according to eight criteria. results: after weeks, tablets/capsules including of the half tablets showed no visual alteration and were identical to controls. a reduced score ( - points) was given to seven repackaged medicines and one half tablet within weeks: madopar Ò ( ), pravastatin sandoz Ò ( ), carvedilol mepha Ò ( ), plavix Ò ( ), pantoprazol nycomed Ò ( ), adalat Ò cr ( ). swelling and rough surface were the most frequent. chipping and capping were not observed. conclusion: our eight visual criteria are able to detect physical alteration of repackaged solid oral medicines under stress conditions. in absence of reliable data we suggest to apply this simple quality control for repackaged medicines in pharmacy practice. because chemical stability testing is not feasible in practice, pragmatic solutions are sought. further studies are needed for storage at room temperature. cp-pc : drug-related problems and symptom burden in nursing home residents kerstin bitter *, , ulrich jaehde , christina pehe , gabriela heuer , manfred krü ger clinical pharmacy, university of bonn, bonn, aok rheinland/ hamburg, pharmacists' association north rhine, düsseldorf, germany please specify your abstract type: research abstract background and objective: drug-related problems (drp) are common in the elderly due to polymedication. community pharmacies supplying drugs to nursing homes may play an important role in detecting and solving drp in nursing home residents. this project aims to evaluate whether community pharmacists can enhance the medication safety of nursing home residents by solving drp by means of a simple medication review (mr). furthermore, the applicability of a new tool to detect symptoms as potential adverse drug reactions in elderly patients should be tested. setting and method: nursing home residents at the minimum age of years insured by aok rheinland/hamburg and regularly taking at least five drugs per day were invited to participate. pharmacists performed a mr based solely on the patients' medication data, including dosage regimens of the nursing home and self-medication data. the detected and solved drp were counted. additionally, a simple questionnaire (sympel) was distributed to the patients periodically in order to assess their symptom burden. main outcome measures: frequency and type of the patients' drp as well as their symptom burden before and after the mr. results: after testing the feasibility of this intervention in a pilot study, patients were included in the main study so far. in average, the pharmacists identified two drp per patient and reported to the responsible general practitioner (gp) . as in the pilot study, most frequent drp documented by pharmacists were drugdrug-interactions ( %). % of the pharmacists' recommendations were accepted by the gp. % of the patients took at least one drug considered as potentially inadequate in the elderly. out of six different symptoms, patients reported dizziness and bruises most frequently. conclusion: pharmacists can detect many drp in nursing home residents by means of a simple mr. however, the full potential of this service to solve drp can only be exploited if the cooperation with the gps is improved. please specify your abstract type: research abstract background and objective: medicines for rare diseases (rd) are costly and have limited efficacy evidence but they represent around % of all innovative medicines. therefore, countries are facing challenges in providing patient access to them. the purpose of the study was to assess the patient access for slovenia and compare it with other european countries in the last decade. setting and method: the medicines for rd that obtained marketing approval between and via centralised procedure were included in the study based on the orphanet list from january . using the quarterly ims health database, sales data were analysed for slovenia and other european union countries, norway and switzerland. patient access was assessed for each country and comparisons between the countries were made using the three main outcome measures. main outcome measures: the number of medicines for rd available; time to first continuous use after marketing approval; total pharmaceutical expenditure for medicines for rd in euros. results: altogether, medicines for rd were approved between and . complete sales data were available for medicines which were included in the comparison. for germany and the united kingdom the continuous use of ( %) and ( %) was observed, respectively. the following italy, france, denmark and sweden use - % of all the medicines. in slovenia, ( %) medicines for rd were introduced. germany and the united kingdom times to first continuous use were the shortest (median time - months after marketing approval). median times below months were observed for norway, sweden, austria, the netherlands, france and switzerland. other countries were slower in enabling first continuous use (median time from to months). germany, france, switzerland had the largest pharmaceutical expenditure per inhabitant in ( . , . and . euros/inhabitant) while slovenia amounted to . euros/inhabitant. in slovenia more than a half of the medicines for rd approved in europe are used which ranks it in the middle of all the countries in comparison. comparing to the important european pharmaceutical markets like germany, united kingdom, france and italy, slovenia's median time to first continuous use is longer and pharmaceutical expenditure per inhabitant for these medicines is lower. pec : mapping of the dlqi scores to eq- d utility values using ordinal logistic regression and monte carlo simulations: is it plausible? please specify your abstract type: research abstract background and objective: converting dermatology life quality index (dlqi) scores to generic measure data would allow utility calculations and enable cost-effective analysis. this would meet the needs of health technology assessment agencies (htas) such as nice, who preferentially use the general health measure eq- d. the dlqi is a specialty-specific measure unlike the eq- d, a generic measure from which utility values can be derived. often several measures are implemented in studies with increased cost and patient burden. ordinal logistic regression (olr) was used to develop a model to convert dlqi scores to eq- d based utility values for use in economic appraisal of medicines. setting and method: data from patients were randomly divided into estimation and validation sets to fit and test the model. a series of ordinal logistic regressions were fitted in spss v for the five eq- d dimensions based on age, sex and all individual items of the dlqi as predictors. the model produced three estimated probabilities per subject per eq- d domain. using these estimated probabilities, a series of monte carlo (mc) simulations were run for each subject resulting in predicted domain responses. from these, utility values were calculated and compared to actual patient values. main outcome measures: conversion of dlqi scores to eq- d domain data results: there are conceptual overlaps between items of the dlqi and eq- d. the validation data set (which was not included in the creation of the model), demonstrated that the models were highly predictive compared to actual responses, except for minor differences for the pain/discomfort domain. for example, for the eq- d ' mobility' domain, patients answered 'no' (predicted and patients answered 'some or extreme' (predicted ) . we examined the model's latent variables, which also demonstrated high predictability at individual level. for example for the 'usual activities' domain the mean latent variable scores were - . , - . and - . for those responding 'no', 'some' and 'extreme' respectively, showing a clear increase in the scores with response. after excluding subjects with missing variable data there were patients in the estimation set and in the validation set. the model was shown to be highly predictive and repeated simulations demonstrated a stable model. the average predicted utility value for the entire validation set ranged from . to . across the mc simulations compared to the actual average utility value of . . conclusion: using olr, we have developed a method of mapping the disease-specific dlqi onto the eq- d: utility values may then be derived for population data sets, and possibly for individuals. the olr technique could be used to convert data from other disease-specific quality-of-life measures to generic utility data for incorporation into cost-effective analyses, greatly enhancing the potential value of such information. tomi laptoš *, , tanja kersnik levart hospital pharmacy, the division of paediatrics, department of nephrology, university medical centre ljubljana, ljubljana, slovenia please specify your abstract type: descriptive abstract (for projects) background and objective: having to take medication during time in school may present certain discomfort for some children. suboptimal dosing regimens (i.e. dosing more frequent than determined by drug's trough:peak ratio) can be prevented by a clinical pharmacist's overview and therapy optimization. the aim of the study was to review and evaluate dosage regiments in paediatric patients on antihypertensive therapy. dosage regiments are defined as schedule of doses of a therapeutic agent per unit of time and the amount of a medicine to be given at specific time. design: electronic health records (ehr) review, evaluation of actual dosage regiments against regiments recommended in smpcs and clinical database (uptodate Ò ), a consecutive case series study. results: ehrs of patients, admitted to or discharged from the department of nephrology of the division of paediatrics, umcl in with suspected icd- diagnoses from i to i were reviewed. patients were excluded (diagnosis not confirmed or lifestyle-change disease management only). the remaining patients (average age . years (range - )) received daily on average . medications (range - ) in . individual doses (range [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . most frequently used drugs were perindopril (n = ), ramipril (n = ), amlodipine (n = ), bisoprolol (n = ) and doxazosin (n = ). patients received ex tempore oral suspensions. dosage regimen was not optimized in % (n = ) of the patients, among those % (n = ) receiving one medication only and % (n = ) receiving more than one medication where at least one was not optimized. furthermore, % (n = ) patients on stabledosage therapy (no dosage change of either medication in last months with satisfactory clinical outcomes) were eligible for fixeddose combination medication. with optimized dosage regimens patients would receive daily on average . medication (range - ) (- %) in . individual doses (range - ) (- %). the difference was statistically significant ( % ci, p \ . ) in both cases. conclusion: our data show that the majority of the paediatric patients on antihypertensive therapy ( %) received their medication in optimal dosage regimens. however, with an estimated every fifth patient not being on optimal dosage regimen, a multidisciplinary approach is crucial to assure that the individual patient achieves the best clinical, humanistic and economic therapy outcomes. ph : polypharmacy management programmes in the elderly: a case study in greece dimitra gennimata *, , christos kampolis , aggelos vontetsianos , jennifer mcintosh , alpana mair , on behalf of simpathy consortium please specify your abstract type: descriptive abstract (for projects) background and objective: polypharmacy management and medication adherence in the elderly are significant public health issues throughout the european union (eu). simpathy (stimulating innovation management of polypharmacy and adherence in the elderly) is a consortium of organizations representing eight european countries, aiming at stimulating innovation around management of appropriate polypharmacy and adherence, ultimately providing tools for eu policy makers to develop and/or improve, implement and evaluate programs addressing these issues. design: a mixed-methods case study was carried out in greece, to identify policies on the management of polypharmacy and adherence issues in the elderly. a desk review of the polypharmacy and adherence policies at the government, regional and institutional level has been completed. key informant interviews were conducted with policymakers and health professionals responsible for developing and implementing strategies. focus groups consisting of policymakers, clinicians and patients validated the research findings. results: although e-prescription implementation is widespread (& % coverage nationwide) and disease-specific guidelines have been developed, polypharmacy management is only associated with direct economic indicators. no formal policies or programmes are identified. significant contributions are coming from different health professional organizations that have chosen to provide expanded services to their patients, aiming at optimising drug therapy and thus polypharmacy management and medication adherence in the elderly. community pharmacists offer pharmaceutical care to patients, which includes management of prescribed medication, otc remedies, vitamins and supplements and food-drug interactions. hospital pharmacists in some state (public) hospitals review medication for inpatients and out-patients, communicate with prescribers and confirm the ''benefit-no harm'' principle in the prescribed medication (e.g. incompatibilities, side effects, -rights of medication). medical doctors, mostly general practitioners and some specialized ones, usually in primary healthcare settings, keep health records of their patients and have an overview of all administered medication. however, key barriers still remain the lack of coordination of institutions and authorities and overlap of their responsibilities, healthcare workforce and infrastructure shortages and several cultural issues. conclusion: all initiatives to medication management and medicines optimisation are provided without directive from national policies or guidelines. therefore, these activities rely on the goodwill of the health professionals to address pharmacotherapy and therefore polypharmacy management but they are not necessarily representative of what is happening nationwide. a national policy to implement the management of polypharmacy nationwide could mobilise the willingness of health professionals and ensure consistency of care. development and implementation of this policy should build on the grassroots efforts currently underway in this area. ph : clinical profile and treatment discontinuation in a tuberculosis control state programme in brazil: preliminary results from sinan database simone s. bezerra , mara guerreiro *, , , nathany pessoa , maria paula athayde , rodrigo auad , joão josé gomes , josé lamartine soares sobrinho post graduation program in therapeutic innovation, federal university of pernambuco, recife, pernambuco, brazil, centro de investigação interdisciplinar (ciiem), instituto superior de ciências da saúde egas moniz, monte de caparica, please specify your abstract type: research abstract background and objective: challenges remain in tuberculosis (tb) control. discontinuing treatment can leave patients infectious and contributes to the emergence of resistance. this study aimed to describe the clinical profile and cure and discontinuation rates of tb patients enrolled in the pernambuco tuberculosis control programme (pect). setting and method: the study was conducted in three sites in recife, brazil, designated a (one polyclinic plus eight general practice units), b (one hospital for medium-complexity patients) and c (one hospital for high-complexity patients). data were extracted from the notifiable diseases information system (sinan) for all pect outpatients, from / to / (n = ). analysis was performed with the aid of action for excel; there is on-going analysis to further explore differences across sites. ethical approval was granted. main outcome measures: clinical form of the disease, hiv testing, new cases, cure and treatment discontinuation. results: sociodemographic data were available for sites a and b only. most patients were male ( %, n = ), with age raging from to years old ( . %, n = ); most had a low education level ( %, n = ) and low socioeconomic status ( %, n = ). the most common clinical presentation was pulmonary tb. most cases were new ( . %, n = ); recurrence and enrolment after discontinuation were respectively . and . % (n = and n = ). with respect to hiv, . % of patients were seronegative (n = ); about a third ( %; n = ) had not performed hiv test. rates for cure were respectively . % (n = ), . % (n = ) and . % (n = ) in the sites a, b and c. correspondent rates for treatment discontinuation were . %(n = ), . % (n = ), . % (n = ), respectively. tb-related mortality ranged from in site c to . % in site b. conclusion: missed hiv tests may represent undetected tuberculosis/ hiv coinfection. site b presented the highest rates of intrapulmonary plus mixed tb forms, discontinuation of treatment and tb-related mortality; additionally, it had the lowest rate of enrolment after treatment discontinuation. patients co-infected with tb and hiv are firstly referred to this site, which may explain this finding. our findings may help managers allocating resources and assist clinical pharmacists in planning their interventions. findings also suggest the need of more intensive interventions in tb patients, such as pharmaceutical care programmes. please specify your abstract type: research abstract background and objective: pharmacists working in primary health clinics have various roles. pharmaceutical care is one of them. how to provide this service varies across countries and settings. the most optimal way to provide pharmaceutical care is important to define when developing clinical pharmacy services in a new setting such as primary care practices. general practitioners are key stakeholders in this endeavour. the aim of this study was to find the most optimal approach to providing pharmacist-led pharmaceutical care in primary health care clinics in iceland in collaboration with general practitioners. setting and method: action research provided the framework for this research. data was collected from pharmaceutical care interventions with patients, field observations, field notes, and interviews with general practitioners over the period of the study. the study ran from september to june . three separate semi-structured in-depth interviews were conducted with five general practitioners from one primary health care clinic in iceland at different time points throughout the study. pharmacist-led pharmaceutical care was provided to patients (n = ) before and between general practitioners' interviews. the study settings was a primary health care clinic in reykjavik area and the patients' homes. main outcome measures: how to provide pharmaceutical care in collaboration with general practitioners in the icelandic health care environment. results: direct contact between pharmacists and general practitioners over short distances are essential to providing optimal pharmaceutical care services. pharmacist's access to medical records is necessary even though face-to-face communication between pharmacist and patients are most effective in providing pharmaceutical care. pharmacist-led clinical service was deemed most needed in dose dispensing polypharmacy patients. patients require more information about drugs prescribed to them coupled with an accurate drug list with greater detail. conclusion: the most efficient collaboration when pharmacist and general practitioner is obtained when they work side by side at the primary health care clinic. when new services are developed it is vital to identify different requirements of the primary health care clinics to optimize the running of a clinical pharmacist service. ph : accompaniment of patients treated with oral chemotherapy: a survey on patients' experience laure napoly *, , pascal paubel , , sylvie burnel oncorif -regional cancer network, health law and health economics deparment, health law institute, inserm, umr s , paris descartes university, sorbonne paris cité, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: antineoplastic agents taken orally are more and more used in cancer care. these medicines confer autonomy to patients. although, they may cause adverse effects that can lead to treatment adherence issue, unjustified hospitalizations, or premature treatment interruption. proper accompaniment of patient can prevent these issues. in order to define how to organize this accompaniment, we conducted a survey on patients' experience. the objective is to describe patients care pathway and identify their needs. design: a descriptive, qualitative, prospective, survey was conducted using self-administered questionnaires, in hospitals of ile-de-france region. inclusion criteria were: having being treated with oral neoplastic agents during minimum months, age [ , solid tumor, no concomitant iv chemotherapy. collected data were: patients' sociodemographic and clinical profile, their insight about different steps of care pathway (information, treatment delivery, follow up), their behaviours and interactions with healthcare professionals, and their overall opinion. results: patients were recruited in six hospitals. their sociodemographic and clinical characteristics were variable. % were treated with targeted therapy, % with cytotoxic agent, and % with endocrine therapy. patients showed high satisfaction for given information at the beginning of the treatment. principal source of information identified was the oncologist ( %). while the delivery of treatment, % of patients beneficiated of advices from the pharmacist. accompaniment of patients during treatment seemed unequal, with: a frequency of visits with the oncologist ranging from less than - months; % of patients not knowing any telephone number they can call in case of worries or questions about their condition or treatment; % not remembering any particular accompaniment treatment (visits or calls from nurses or doctors for example). for adverse effects management, three principals actors were identified: oncologist ( %), general practitioner ( %) and pharmacist ( %). regarding the use of oral chemotherapy, patient are satisfied with: it's comfort ( %); being more actively involved in their cancer care ( %); and state not having any anxiety taking chemotherapy home ( %) . asked openly about their concerned and needs three major concepts were identified: high concern about adverse effects, positive feedback about maintaining contact with health professionals between cures and difficulties of communication between health professionals. conclusion: there is a high satisfaction regarding oral chemotherapy and health professionals. the oncologist has a primordial place in patient pathway, whereas implication of pharmacist and general practitioner stays variable. adverse effects are a major concern that needs proactive accompaniment. the variability of our results suggests that accompaniment must be flexible and adapted to the needs of each patients. the key to flexibility could be good coordination and communication between healthcare professionals. ph : general beliefs about medicines among independent elderly adults in sweden: data from an rct lina hellström *, , , victoria throfast the pharmaceutical department, kalmar county council, ehealth institute, linnaeus university, kalmar, sweden please specify your abstract type: research abstract background and objective: there is a need to improve prescription and use of medications by the elderly. the objective of a recent rct was to investigate the effects of e-learning about medicines among elderly adults. a positive impact on the primary outcome measure, knowledge about medicines, is reported elsewhere. a secondary outcome measure, general beliefs about medicines, is reported below. setting and method: the study was a randomized controlled trial in elderly people (aged c years). participants were recruited from patient associations and pensionerś associations. participants were randomized to either an intervention group that participated in the e-learning, i.e. internet modules with video and audio, or a control group that did not take part in the e-learning. post-intervention data was collected using paper-based questionnaires, completed within two weeks after agreeing to participate in the study. the general beliefs about medicines questionnaire (bmqgeneral), comprising the subscales necessity, harm and overuse, was used to elicit beliefs. higher scores indicate stronger endorsement of scale constructs (range [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . main outcome measures: bmq-general subscale scores. results: a total of elderly people were included in the study, in the intervention and in the control group. the mean age in the total population was . years and % were women. eleven percent did not use any prescribed drugs while % used more than five prescribed drugs. the patients' scores were very similar in the two groups for all three bmq subscales. the median ''overuse'' score was in the intervention group versus in the control group, the median ''harm'' score was (iqr - ) in both groups and the median ''necessity'' score was in both groups. in the total population the most commonly expressed negative beliefs referred to overuse of drugs. . % of respondents agreed with the statement ''if doctors had more time they would prescribe fewer medicines'', . % stated ''doctors prescribe too many medicines'', and . % stated ''doctors place too much trust in medicines''. a majority of the respondents agreed with the four items on the ''necessity'' scale. for example ''medicines help people to live a better life ( . % agreed)''. conclusion: the studied e-learning intervention was not shown to have any impact on general beliefs about medicines. beliefs about medicines have been associated with a number of background variables which might explain why increased knowledge about medicines alone cannot change such beliefs. in general, respondents in the study had highly positive beliefs about the necessity of medicines. nevertheless, the results indicate that overuse of medicines is regarded as a problem. ph : maf-plus: pharmacists' contributions to provision of financial assistance for medications ian wee * , charlene ong, niron naganathar changi general hospital, singapore, singapore please specify your abstract type: descriptive abstract (for projects) background and objective: the medication assistance fund plus (maf-plus) is a government scheme introduced in singapore in to provide financial assistance to needy patients who meet pre-set criteria based on means testing. unlike previous schemes, maf-plus provides broader discretion to institutions when providing financial assistance. in our institution, pharmacists reviewed patients' case and medication histories, and filed recommendations to a multidisciplinary committee tasked with approving deserving maf-plus applications. the pharmacists' contributions to the committee, and the outcomes of the applications, are presented in this study. design: all maf-plus applications received between st october and st december were reviewed. pharmacists' comments for each application, where provided, were noted, as well as the range of medicines applied for, review approval rates, and cumulative percentage of available funds utilised. the effect of a recent widening of the scheme's scope to include notable high-cost items was also evaluated. results: between and , maf-plus applications were reviewed, of which ( . %) were approved. of the rejected applications, ( . %) were channelled to alternative financial assistance schemes on the recommendation of the pharmacists. the medicines most commonly applied for were intended for the treatment of cardiac ( . %), respiratory ( . %), and psychiatric ( . %) conditions. pharmacists' recommendations also led to a gradual expansion of our institution's list of pre-approved medicines-from in - to by end- . from onwards, pharmacists previewed increasing numbers of applications for high-cost medicines, particularly those for treatment of retroviral disease, hepatitis c, and rare diseases. cumulative utilisation of maf-plus funds (inclusive of annual replenishment) rose from . % in - to . % by end- , representing an average year-on-year growth of . %. conclusion: using a process of judicious previewing of maf-plus applications, and recommendations to the maf-plus committee, pharmacists contributed to a high percentage of patients receiving financial assistance for medications. despite a steep growth in the number of applications received between and , this approach helped to prevent over-extension in fund utilisation. pharmacists will likely be increasingly relied upon due to an anticipated rise in the number of applications for high-cost medicines. please specify your abstract type: research abstract background and objective: adolescents often treat themselves and take medications without parental supervision. lack of experience and knowledge of medicines in this age group frequently leads to inappropriate use of medicines and adverse drug reactions. data about the use of medicines among slovak adolescents and their knowledge of medicines have not been studied yet. setting and method: for our study we used the questionnaire method. the questionnaire contained multidimensional items with closed-ended and open-ended questions, which focused on the characteristics of the adolescentś health status, use of medicines, also in relation to parents and adolescentś knowledge and perception of medicineś risk. we distributed validated questionnaires for adolescents aged from to at secondary schools in all regions of slovakia. response rate was . %. questionnaires were finally analysed. the differences in the distribution of categorical variables between groups were evaluated using the chi square test. sas . . was used as statistical software. main outcome measures: to determine adolescentś knowledge of medicines in terms of efficacy, self-medication, safety of therapy and analyse which medicines are the most frequently used by adolescents. to compare adolescents with chronic disease and healthy ones from the perception of pharmacotherapy point of view. results: in the analysed group . % (n = ) of adolescents are treated for chronic disease. mostly they suffer from allergy ( . %, n = ) and skin diseases ( . %, n = ). adolescents with chronic disease use regularly prescription medicines ( . %, n = , p \ . ) and over the counter medicines ( . %, n = , p \ . ). this group of adolescents better accept the pharmacotherapy with parental supervision ( . %, n = , p = . vs. healthy adolescents) and they believe in effectiveness of prescription medicines ( . %, n = , p = . vs. healthy adolescents). most frequently prescribed medicines were azithromycin, levocetirizine, ofloxacin and over the counter medicines were ibuprofen, paracetamol, ascorbic acid. we found out in all group of adolescents that . % (n = ) prefer self-medication without check-ups, . % (n = ) used drugs in the last months without a prescription, . % (n = ) take over the counter medications independently without the supervision of parents, . % (n = ) buy medicines themselves in the pharmacy, . % (n = ) do not take medications as recommended, . % (n = ) believe that they have enough knowledge of medicines which they take, . % (n = ) resp. . %, (n = ) believe that prescription medicines resp. over the counter medicines are safe. conclusion: questionnaire analysis pointed out that slovak adolescents have not enough knowledge of medicines. the study provides new information in the field of risk perception and adolescentś knowledge of medicines in the slovak republic and highlights the areas that need to be studied in the future in terms of adolescentś education. federal university of pernambuco, state technical school prof. agamenon magalhães, recife, pernambuco, brazil please specify your abstract type: research abstract background and objective: the effectiveness of tuberculosis (tb) control programmes depends critically on patients completing appropriate treatment. this study aimed to outline the cure and discontinuation rates of patients enrolled in the pernambuco tuberculosis control program (pect), based on dispensing data. setting and method: the study was carried out in three sites in recife public health system, brazil, designated a (one polyclinic plus eight general practice units), b (one hospital for medium-complexity patients) and c (one hospital for high-complexity patients). data were collected between - / , through reports from the stock management software for public pharmacies (horus) for pect outpatients. reports corresponded to a total of patients ( , and in sites a, b and c, respectively). horus defines ''cure'' as medicines collection for three, six or nine consecutive months without interruption, depending on the treatment scheme; discontinuation is defined as non-sequential collection of medicines or treatment interruption for two consecutive months or more. patients were assigned an ''undetermined'' status if treatment was ongoing. data were inputted onto an excel spreadsheet and checked for accuracy. quisquared test, fisher's exact test and bootstrap analysis were performed with r statistical computing. ethical approval was granted. main outcome measures: cure and discontinuation rates for pect outpatients. results: demographic data are not available for the sample. rates for cure were respectively . % ( ), . % ( ) and % ( ) in the sites a, b and c, while rates for treatment discontinuation were . % ( ), . % ( ) and % ( ), respectively. discontinuation rates were significantly different among the sites a, b and c (p \ . ). bootstrap analysis showed that overall the proportion of patients with an ''undetermined'' status in each site did not significantly change these differences. conclusion: only site a had an acceptable discontinuation rate, in light of the world health organization recommendations. this deserves attention as default treatment leaves patients infectious for longer, increases the risk of poor outcomes and fosters resistance to antibiotics. pharmacists could use dispensing data to signal tb patients at-risk of discontinuation, and subsequently tailor interventions addressing its causes. site b had the greater number of patients which discontinued treatment. patients co-infected with tb and hiv are firstly referred to this site, which may explain this finding. our findings suggest the need of more intensive interventions in patients co-infected with tb and hiv, such as pharmaceutical care programmes. please specify your abstract type: research abstract background and objective: many efforts are done to organise good quality and safe pharmaceutical care. in general, the involvement of a hospital pharmacist or hospital pharmacy personnel in the process of medication reconciliation results in a reduction of the number of medication discrepancies. however, in case of emergency admissions this topic is still insufficiently studied. the introduction of good medication reconciliation on the emergency department (er) requires firm logistical and organisational efforts. we investigated the effects of a drug reconciliation intervention by pharmacy personnel during emergency admissions in order to identify discrepancies between medication lists taken by er physicians and by pharmacy personnel. setting and method: this observational, comparative, non-randomised intervention study was performed in . we calculated that a population size of patients was sufficient to perform reliable measurements. inclusion criteria: all patients presented at the er and admitted to a hospital ward \ after presentation with usage of one or more prescription drugs. exclusion criteria: age \ years, residency outside the region delftland, inability to undergo an oral interview, absence of a medication list of the public pharmacy (ozislist), decease of the patient during er-stay and patients undergoing surgical procedures. discrepancies between both medication lists taken by an er physician or pharmacy technician were classified in four categories of increasing severity ( = no discrepancy to = clinical relevant discrepancy) using the index of the national coordinating council for medication error reporting and prevention (www.nccmerp.org). discrepancies were categorised by a panel consisting of a pharmacy technician, a (senior) hospital pharmacist and a th year pharmacy student. statistical analysis was carried out with a statistical software package (spss ) using the mann-whitney u test and chi squares test. main outcome measures: during the intervention measurement we analysed the reconciliated medication by comparing the er's physician's list with the list of the pharmacy technician after a medication verification interview. the number of discrepancies were measured and judged by the panel. discrepancies were given a category , , or as defined. results: during the intervention measurement patients were admitted to the er. sixty-five ( ) patients ( . %) met the in-and exclusion criteria. the number of medication discrepancies decreased significantly after intervention of the pharmacy technician by %, from to discrepancies. the average number of discrepancies per patient after intervention decreased by . %, from average . to . discrepancies per patient. conclusion: medication verification by pharmacy personnel in the er reduces the number of medication discrepancies by half. medication lists generated with a standard interview by pharmacy technicians in combination with an ozis-list on admission of patients at the er is more complete and accurate than the current method. hp-pc : discharged patients: a problem for community pharmacists? information transfer, as well as the role, needs, and objectives of pharmacists when they care for recently discharged patients. setting and method: a focus group was conducted with a sample of six community pharmacists from personal contacts to represent different characteristics. the focus group consisted of different questions and the recording was transcribed, fragmented and categorised. based on these results, a nationwide online-survey was created with the following questions: a) responder's characteristics, b) number and origin of prescriptions, c) role fulfilment of the joint-who/fip-guideline on good pharmacy practice, rated with a -point likertscale, d) information items derived from the focus group discussion grouped into four categories and evaluated for their availability and for their usefulness by likert-scales, e) goals for discharge optimisation, f) additional comments. the questionnaire was piloted and translated forward and backward to french and italian by native speakers. it was sent to all managers of pharmacies belonging to the swiss pharmacist's association in summer (n = ). main outcome measures: conclusions from focus group discussion and responses to questions a-f from the nationwide questionnaire. results: the focus group participants ( . ± . years, % female, % employees) emphasised the importance of an expanded information transfer, especially for medication changes, unclear prescriptions, and information about a patient's medication acquisition. they were concerned about their extensive workload of discharge prescriptions, and mentioned treatment continuity as one of their goals. the questionnaire was answered by pharmacists (response rate . %, . ± . years, . % female). there were . % of responders who reported to fulfil their role (to manage a patient's therapy, function b) not satisfyingly. unavailable but essential information were allergies and the specification of off-label use prescription. unavailable although desired information were the reasons for therapy changes, indications, appointments, contact information, or compounding formulations. concerning design and transfer, information should be written in a structured way but no clear preference for a transfer method was found. goals of community pharmacists were: improved treatment continuity, patient safety, and pharmaceutical care. conclusion: swiss community pharmacists rarely receive sufficient information on discharge prescriptions. appropriate pharmaceutical care is therefore impeded. the knowledge and application of the findings enable directed optimisation of discharge. hp-pc : patients attitude for using antipsychotic medication in the norwegian early intervention in psychosis, tips study rafal yeisen *, , stein opjordsmoen , , , inge joa , , jan olav johannessen , , jone bjørnestad on behalf of centre for clinical research in psychosis, psychiatric division, stavanger university hospital, stavanger, norway background and objective: poor drug adherence in patients with psychosis leads to relapse, re-hospitalization, poor outcome and increased consumption of health services. pharmacoclinical studies have demonstrated that the treatment response decreases with each relapse. it is estimated that % of patients suffering from chronic illness are not taking medication as prescribed after months. the purpose of this study is to investigate which experiential factors that potentially might affect adherence with medication in adults with psychotic disorders. setting and method: in a descriptive qualitative sub-study in the ongoing norwegian early intervention in psychosis, tips study, where twenty-first episode patients ( male, female) participated in semi-structured interviews years after inclusion. they were still using or had used antipsychotics during the last years. data were analysed using interpretative phenomenological analysis. main outcome measures: adherence to antipsychotics. results: the data suggested four main themes, reflecting the patients' subjective experiences and their impact on the desire to adhere to antipsychotics: ( ) admission experience as a psychotic's patient; ( ) information from healthcare staff; ( ) limited involvement in decision-making; ( ) attitude to antipsychotics. conclusion: a number of factors had a positive influence on adherence to antipsychotics. pleasant admission/stay experiences, feeling that antipsychotics had therapeutic effects, mild or no side effects, and believing that antipsychotics are necessary and useful, were typical statements. please specify your abstract type: research abstract background and objective: the hospital-to-home transition is a vulnerable stage in a patient's care. patients can experience problems with medication supply, which possibly lead to therapy interruptions. the objectives of this study were to investigate medication supply after discharge, and patients' and physicians' opinions about the current discharge process and possible optimisations. setting and method: a telephone interview was conducted with discharged patients from the surgical and internal medical wards from the cantonal hospital in baden (switzerland). inclusion criteria were: patients c years old, discharged home with a discharge prescription. patients were called between the nd and th day after discharge and a piloted, structured interview was performed, consisting of questions on experiences and optimisations. afterwards, semi-structured interviews were conducted with five physicians from the study hospital. results from patient interviews and the general discharge process were discussed. main outcome measures: proportion of filled prescription, frequency and type of supply problems including therapy interruptions. opinions of physicians and patients on current discharge process and possible optimisations. results: discharged patients were . ± . years old, % female, % from internal medicine, and % regularly visit the same pharmacy. of the interviewed patients, have not filled their prescriptions yet and had their prescription filled when they were called. of these, % of them visited the pharmacy on the day of discharge, but it took up to the th day until all of them received their medication. supply problems were encountered by patients ( %), mainly because of the medication not being in stock in the community pharmacy. only four patients experienced therapy interruptions, which took up to the rd day post-discharge. patients discharged from internal medical wards had more supply problems compared to surgical wards (relative risk = . , p = . ). patients experiencing supply problems had statistically significant more medicines on a daily basis ( . ± . vs. . ± . , p = . ). physicians were surprised about the late prescription filling and worried about the disease outcomes. however, interruptions were interpreted as unfrequent. when asked if, in future, hospitals should transfer prescription to the community pharmacy prior to discharge, % of patients refused and physicians were undecided, mainly because of a questionable benefit. but both groups indicated that giving some bridging supply would be welcome. conclusion: this study showed that patients discharged from a swiss hospital encounter supply problems, but therapy interruptions are seldom. giving some bridging supply was preferred over an early information transfer by patients and physicians. interventions should consider these opinions and focus on internal medicine patients with high number of medication. please specify your abstract type: research abstract background and objective: adherence to secondary prevention evidence-based medical (ebm) therapies for patients with st-segment elevation myocardial infarction (stemi) is essential to reduce long-term rates of major adverse cardiovascular events. current guidelines recommend the long-term use of low-dose aspirin, highintensity statins, angiotensin-converting enzyme inhibitors (acei)/ angiotensin receptor blockers (arb) and beta-blockers (bb), in addition to p y inhibitors for year. we aimed to assess the adherence to secondary prevention ebm therapies from discharge to one-year follow-up among patients with stemi undergoing primary percutaneous coronary intervention (pci) in contemporary practice. setting and method: observational single-centre study including consecutive patients with stemi undergoing primary pci in a tertiary hospital in switzerland over a one-year period. secondary prevention ebm therapies were assessed at discharge and at one-year follow-up. main outcome measures: prescription of key secondary prevention ebm therapies (aspirin, p y inhibitors, statins, acei/arb and bb) from discharge to one-year follow-up after stemi. bb was recommended only for patients with heart failure or left ventricular ejection fraction (lvef) \ %. results: a total of patients were included. ebm drug prescription at discharge was . % for aspirin (n = ), . % for p y receptor inhibitor (n = ), . % for statin (n = ), . % for acei/arb (n = ) and . % for bb (n = , among patients with lvef \ %). ticagrelor ( . %) was the major p y inhibitor prescribed. overall, ebm drugs were missing at discharge, with of these missing drugs having no justification for no-prescription (contraindications, allergy or intolerance). at one-year follow-up (median . months, n = ), aspirin, statins and acei/ arb prescription rates were . % (n = ), . % (n = ) and . % (n = ) respectively. out of patients ( . %) with lvef \ % received a bb. among patients treated with ticagrelor at discharge, ( . %) were receiving ticagrelor at follow-up, whereas ( . %) were switched to another p y inhibitor. among patients who discontinued ticagrelor (n = , . %), duration of dual antiplatelet therapy was months for % (n = ) and discontinued prematurely (\ year) for % (n = ) patients. reasons for ticagrelor early discontinuation or switch were not specified. conclusion: in a real-world cohort of patients with stemi undergoing primary pci, prescription of recommended secondary prevention medications at discharge is excellent. adherence to ebm therapies at year remains high with more than % of patients receiving all ebm drugs. early discontinuation of dual antiplatelet therapy was observed in % of patients, whereas ticagrelor was switched for another p y inhibitor in . % of patients. these observations highlight key opportunities to improve longitudinal use of secondary prevention therapies after stemi in routine clinical practice. although side effects are less common than traditional chemotherapies, certain ones such as pain, fatigue, nausea and vomiting can still be bothersome. in oncology outpatient clinics, side effects are monitored by oncology nurses; however due to high patient turnover and limited numbers of nurses, the assessment of side effects might not be performed adequately. therefore, aim of this study was to determine side effects of immunotherapy and targeted therapy and to compare the severity assessment of side effects by clinical pharmacist and nurses. setting and method: the study was conducted in the hacettepe university oncology hospital outpatient clinic. the patients who have been taking ipilimumab, nivolumab, pembrolizumab, bevacizumab, panitimumab or cetuximab during october -march were included. the assessment of side effects were undertaken by a clinical pharmacist and nurses separately on each visit using the common terminology criteria for adverse events version- toxicity assessment scale. an independent clinical pharmacist compared the side effects' assessments by pharmacist and nurses for analysis. ethical approval was obtained from hacettepe university ethics committee. main outcome measures: to compare the severity of side effects of targeted drug therapies which were assessed by a clinical pharmacist and nurses. results: during the study period visits of patients were evaluated. a total of side effects assessments were recorded. among those assessments ( . %) was assessed in different ranking by nurses and pharmacist. the differences in the number of assessments were mainly seen in criteria related to pain (n = ; ), sensory loss (n = ; ), fatigue (n = ; ), stress (n = ; ), insomnia (n = ; ) which was performed by nurses and pharmacist respectively. other side effects detected only by clinical pharmacist were oedema, cough, gastrointestinal complaints (heartburn, cramp) and sensitivity of odour which require close monitoring and in-depth counselling by clinical pharmacist. conclusion: this study explores the differences in assessment of side effects by pharmacist and nurses in targeted therapies. routine assessment of side effects between chemotherapy cycles might yield to misinterpretation or inadequate assessment due to workload of outpatient clinic. therefore, inter-professional interactions in outpatient clinics might close the communicational gaps and improve patient care. hp-pc : implementation of clinical pharmacy in the acute psychiatric wards: improving quality of medical treatment across health care sectors amila zekovic *, , signe kristensen , lisbeth lund pedersen clinical pharmaceutical services, capital regional pharmacy, head of clinic, mental health services, copenhagen, denmark please specify your abstract type: descriptive abstract (for projects) background and objective: a study from shows that people with a mental disorder had a two-to threefold mortality compared with the general population in denmark. life style diseases are the major reason for the excess mortality, partly due to undertreatment of physical disease and well known side effects from medicines such as obesity, diabetes, and heart disease. in may , a clinical pharmacy service (cps) was implemented in all acute psychiatric wards (apw) in the capital region as a part of a three-year project funded by the danish health authorities. the objective is to illustrate how the implementation of clinical pharmacy in the apw in copenhagen increases the focus on drug related problems, rational pharmacotherapy and side effects, increasing the quality of medical treatment and patient safety across health care sectors. design: data was collected at the apw in copenhagen which consists of three wards and has a total capacity of beds. inclusion criteria were patients to which two or more of the following apply: • c years of age • c drugs • high risk drugs (clozapine, sertindole and opioids) • combination of antipsychotics and benzodiazepines • diagnosed with liver/kidney disease the secondary inclusion criteria were all patients receiving c drugs as a single criterion. to obtain a valid medication history and secure medication reconciliation, the pharmacist interviewed included patients. the patients were also asked about side effects, compliance, and perceived effects of treatment. a medication review was conducted based on the patient interview, screening for interactions in an interaction database, and consideration of biomedical data in order to evaluate if treatments should be adjusted, initiated or discontinued. the pharmacist's input was discussed with the doctor, as inputs are more likely to be considered if they are communicated orally. finally, all inputs were documented in the patient's journal as a pharmacist note. the model for improvement was used as a tool for implementing the cps and is being used continuously for improving the service. results: between may th and june th , patients were screened at admission to the apw, of which . % met the inclusion criteria ( patients). in this period the pharmacist conducted notes, indicating that . % of the included patients were seen by the pharmacist. in april , patients were in average admitted with . drugs and . inconsistencies between the hospital's medication orders and the medications that the patient had been taking. regarding patients who are discharged to community care shortly after admission, the pharmacist note is sent to their general practitioner for follow up. conclusion: overall, the implementation of a cps in the apw has been successful. medication reconciliation ensures that the patient is provided with correct medicine at admission, transfer or discharge. by performing a thorough medication review based on a consultation with the patient, the service contributes to an increase in quality of medical treatment. please specify your abstract type: descriptive abstract (for projects) background and objective: the importance of the role of a clinical pharmacist resident in the operating room during months, in a private hospital belonging to a group devoted to healthcare for over years. the hospital is recognized as a reference centre of excellence of hospital care in portugal. it has inpatient beds, two surgical blocks with rooms and beds in the intensive care unit. the aim of the clinical pharmacist in the operating room is to ensure compliance with good clinical practice, safety and pharmacotherapeutic effectiveness, as well as optimization of drug costs. design: . logistics restructuring of pharmaceutical services and the need of the physical presence of the pharmacist in the operating room. . furthermore, the workstation of the pharmacist is moved to the operating room and the in-depth study of all medicines used in the operating room. . in compliance with the joint commission, definition, optimization and adjustment of drug stocks to the needs of the service itself. in close collaboration with the nursing staff, consumer kits were created for registration of drugs by type of surgery in order to facilitate registration and ensure billing efficiency. control of the analgesic drug's dispensation circuit in hospitalized surgical patients that stay less than h in the hospital. ensure compliance with the project through which the health regulatory authority evaluates several hospitals in the country, creating a national ranking among hospital specialties. . clinical phase: creation of prescription protocols by type of surgical intervention based on national clinical guidelines. validate prescriptions in the intra-surgical block in compliance with antibiotic prophylaxis, antiemetic and thromboembolic, checking deviations in therapy according to good practice. identify pharmacologic hypersensitivities of patients by consulting the clinical process and anaesthesiology records. provide information on drugs, drug efficacy monitoring and adverse drug reactions in risk management platform. check off label use of drugs. results: of a total of interventions, relate to revenue optimization and relate to clinical interventions. there was an increase of approximately % in billing. on what regards to clinical interventions, the majority of them showed deviations from good clinical practice. the physical presence of a clinical pharmacist in the surgical block is essential as the prescription and administration of drugs is carried out simultaneously, allowing immediate therapy validation, in order to increase the safety and efficacy. the pharmacist has the ability to interact with the multidisciplinary team, as well as monitoring the patient's clinical process, the pharmacotherapeutic profile and drug allergies, allowing the detection of any adverse drug reaction on-time. all these interventions are possible in the pre, intra and postoperative phases. results: counselling (av.(±sd) duration: ± min) was performed in patients ( . % female; av.(±sd) age: . (± ) years; av.(±sd) medicines at discharge: . (± . )). in % of patients mrps were intercepted. the five most common mrps (%) were: need for organisational support ( . , e.g. proper prescriptions' writing), therapy-related discussions ( . ), untreated indications ( . ), errors in documentation ( . ), and medicines without an indication ( . ). patients ( . %) classified for study inclusion, of whom ( . %) consented to be followed-up and ( %) provided data. roughly % of patients report having received information about medicines at discharge, of which three-fourths remember being informed by the pharmacist. more then every second patient ( . %) reported having received valuable new information. changes in chronic-use medicines occurred in . , . , and . % of patients at -, -, and -month, respectively. at -month, in . % of patients chronic-use medicines were newly prescribed, in . % discontinued. medical specialists initiated these changes in . % of patients. one out of five patients couldn't recall the reasons for changes in medication. nearly % of patients showed moderate to little medication adherence at -month. it did not significantly change during the follow-up period. conclusion: clinical pharmacists' counselling prevents mrps at the transition from hospital to home. follow-up data show that changes occur in one out of three patients. medication adherence remains stable, but generally needs to be improved. please specify your abstract type: research abstract background and objective: until , prescription analysis was based in our hospital pharmacy. clinical pharmacy has been deployed in care units since . many clinical pharmacy services were developed: medication reconciliation, patient's therapeutic education and counselling, and prescription analysis unit based. the purpose of this study is to assess the impact of the clinical pharmacist as a direct patient-care team member on prescription analysis. setting and method: we collected pharmaceutical interventions (pis) of the first months of and at the same period of the year in the neurology unit when the pharmacist was unit based. we studied and compared type of pis (medication, drug related problem-drp), rate of pis acceptance and clinical impact. focus was made on high alert risk medications and potentially inappropriate medications. . % in versus none in . when prescription analysis was based in the pharmacy unit, % of drp detected by the pharmacist had a potential clinical impact versus % when the pharmacist performed prescription analysis in the care unit (p \ . ). three drp detected in had serious potential harm. results: ward-based prescription analysis allowed detecting five more times drp with a significant more important clinical impact than pharmacy unit based prescription analysis. the clinical pharmacist as a direct patient-care team member is more efficient in detecting serious potential harm. indeed, the pharmacist has a greater knowledge of the patient's clinical condition. nevertheless the global rate of acceptance of pis was greater when the prescription analysis was based in the pharmacy unit even if the difference is not significant. but prescription analysis is more complex when performed in the care unit, taking account adherence of the patient, and potentially inappropriate medications resulting in much higher risk-taking by the ward-based pharmacist. conclusion: this study showed that unit based prescription analysis is the best way to detect drug related problem. it must be competed by medication reconciliation and medication review to improve medication safety process. hp-pc : qt-prolongation in an acute psychiatric setting: fact or fiction? eva jacxsens *, , hans van den ameele , jü rgen de fruyt , yves vandekerckhove , frank vancoillie , veerle grootaert pharmacy, psychiatry, cardiology, az sint-jan brugge-oostende av, bruges, belgium please specify your abstract type: research abstract background and objective: several psychotropic drugs can induce qt-prolongation, which is a well-known risk factor for developing torsade de pointes (tdp) and sudden death. the clinical relevance of this side effect of psychotropic medication remains unclear, especially in patients hospitalized in an acute hospital. to interpret the clinical importance of psychotropic drug induced qt-prolongation, we investigated the prevalence of these electrocardiographic changes. setting and method: a prospective study was conducted on four psychiatric wards in a general hospital: two acute, short-term psychiatric units (asp and asp ), one addiction service unit (asu) and one geriatric-psychiatric ward (gpw). all adult patients admitted between october st and march th on a psychiatric ward were eligible for inclusion. at admission, an ecg (ecg ) was performed and creatinine and potassium levels were measured. a second ecg (ecg ) was performed at least days after the start of a psychotropic drug associated with a risk of qt-prolongation. qtcprolongation was defined as ms for males and ms for females. clinically relevant qtc-prolongation was defined as c ms. statistical analysis (r software) was done as appropriate. main outcome measures: prevalence of psychotropic drug induced qtc-changes and correlating factors. results: patients (mean age years, %female) were enrolled in the analysis. in patients, an ecg was performed. qtc + were prolonged in . %( / ) of females and . %( / ) of males. no clinical relevant prolongation (c ms) was registered. higher qtc intervals were measured in the geriatric population. . %( / ) of all measured qtc were situated between [ c qtc + b ms] in gpw versus . %( / ) in the other units. significant difference in qtc-changes was associated with sex (p = . ). there was no correlation assessed between qtc-prolongation and age, number of psychotropic drugs or a specific single psychotropic drug (p [ . ). conclusion: in this study qtc-prolongation due to psychotropic drugs is less common than previously described. ecg monitoring may be unnecessary in the follow up of patients without risk factors and could reduce hospital and community costs. however, considering the potential harm associated with tdp, qt-prolongation should be avoided. we recommend recording an ecg before the start of a qt-prolonging psychotropic drug in risk patients: patients with a chronic alcohol or drug addiction, a cardiac history, on concomitant therapy with at least two qt-prolonging psychotropic drugs, or geriatric patients ([ years). hp-pc : implementation of medication reconciliation aase m. raddum *, , anne-lise sagen major sykehusapotekene i midt-norge, sjukehusapoteket i Å lesund, avd. volda sjukehus, volda, sykehusapotekene i midt-norge, sjukehusapoteket i Å lesund, Å lesund, norway please specify your abstract type: descriptive abstract (for projects) background and objective: a correct and accurate medication list should accompany patients at transitions in care from one setting to another, including admission to hospital. complete information on drug use is a prerequisite for all hospital treatment, whereas incomplete information represents a potential patient safety risk. medication reconciliation is defined by the world health organization (who) as ''…the formal process in which health care professionals partner with patients to ensure accurate and complete medication information transfer at interfaces of care.'' the objective of this study was to investigate the quality of the medication history obtained for admitted patients. furthermore, measures to improve the quality of medication histories, i.e. implementation of medication reconciliation, were initiated. design: the study included patients admitted to the internal medicine ward. a comprehensive medication history was determined by performing a standardized patient interview and/or by using relevant sources of information. the primary endpoint was discrepancies between the medication history obtained on admission and the one determined prospectively by a clinical pharmacist. the clinical relevance of the discrepancies was not determined, but sorted according to six major categories, such as: medication not in chart, but patient reports using (omission) and medication in chart, but patient reports not using (commission). further on, in order to minimize the risk of discrepancies, it was focused on implementation of medication reconciliation. a campaign was initiated, where a clinical pharmacist held information meetings regarding the medication reconciliation procedure. for the next weeks, the degree of medication reconciliation was recorded. to spur the degree of medication reconciliation, each ward's weekly numbers were published and the ward with the highest degree of medication reconciliation won a prize. results: among the patients included, a total of discrepancies were revealed. in summary, patients had at least one discrepancy in their medication history, resulting in discrepancies in the medication lists of % of the included patients. at the start of the study, the level of medication reconciliation varied among the wards ( - %), while at the end of the study the levels were increased ( - %). conclusion: all the included wards improved their level of medication reconciliation during the study period. however, these new combinations have potential drug-drug and herb-drug interactions which can affect the safety and effectiveness of the treatment. in our clinical practice, the clinical pharmacist provides patient education about direct acting antiviral drugs (daa) based-regimens, promotes medication adherence and manages potential interactions with hcv treatment. the aim of the present study was to determine the prevalence of use of herbal products in the patients on hcv treatment, and to describe the potential hepatotoxicity of the herbal products and their interactions with hcv treatment. design: we included all adult patients on daa treatment for hcv who were dispensed drugs from / / to / / . we retrospectively recorded demographic data (age and gender), clinical data related to hcv infection (hcv genotype, fibrosis stage, daa regimen and treatment outcomes) and type of herbal products consumed. we then assessed the presence of herb-drug interactions and the potential hepatotoxicity of herbal products. results: we obtained data from patients on daa-based treatment for hcv. the prevalence of consumption of herbal products prior to starting the treatment was . % ( / ). the most consumed herbal products were (prevalence [ % among herbal products users): milk thistle, green tea, chamomile, valerian, pennyroyal, boldo and artichoke. we detected four herbal products with potential hepatotoxic effects according to the literature: milk thistle, green tea, pennyroyal and aloe vera. the prevalence of consumption of these hepatotoxic plants among herbal products consumers were, respectively: . , . , . and . %. we detected herb-drug interactions or potential for hepatotoxicity in out of patients who consumed herbal products. the management of these potential interactions consisted of stopping the herbal product before starting the hcv treatment. conclusion: the consumption of herbal products in our hcv patients was frequent. the management of potential interactions was conservative, recommending to stop herbal products. clinical pharmacists have an important role in the counselling, detection and management of potential herb-drug interactions and herbal products-related hepatotoxicity. poster discussion forum iii: hospital pharmacy and pharmaceutical care please specify your abstract type: research abstract background and objective: anaemia is a common comorbidity of chronic kidney disease. intravenous (iv) iron is used when oral iron formulation became insufficient or to reduce the use of erythropoiesis-stimulating agents (esas) in haemodialysis (hd) patients. the lack of generic group for iv iron sucrose (is) preparations leads to a controversial issue about their clinical effectiveness. in this study, we evaluated the effectiveness of original is compared to is similar (iss) in hd patients. setting and method: a retrospective monocentric observational cohort study was conducted from / / to / / , in a stable hd population to compare is and iss. the follow-up periods lasted weeks and were separated by a one-month wash-out period. original is and iss were administered respectively during the first (p ) and the second (p ) periods. the comparisons were performed using the paired student's t test or the paired wilcoxon test for continuous data and the fisher's exact test for categorical data. main outcome measures: the main endpoint was the difference in haemoglobin (hb) levels between p and p per patient. anaemia parameters (serum iron, serum ferritin, transferrin saturation ratio), the number of transfused patients, the doses of iv is and the doses of erythropoiesis stimulating agents (esas) were compared before and after the switch from is to iss, as secondary endpoints. results: a total of patients were included. there was no significant difference in mean hb value between p and p ( . ± . mmol/l versus . ± . mmol/l p = . ). anaemia parameters were significantly different between p and p (mean serum ferritin, serum transferrin and transferrin saturation ratio) with p \ . , except to the mean serum iron. the mean monthly dose of iv iron per patient and the mean dose of esas were respectively in p and in p : . ± . mg versus . ± . mg (p = . ) and . ± . ui/kg/week versus . ± . ui/kg/ week (p = . ). transfusions occurred less frequently in p than in p (p = . ). conclusion: this study showed that iss was as effective as original is regarding hb levels. however anaemia parameters appeared to be in favour of is; the mean dose of esas seemed to be higher after switching from is to iss. these outcomes should be further explored using prospective comparative clinical studies. please specify your abstract type: research abstract background and objective: the pharmacy residents are sometimes up to deliver chemotherapy when they are on night or week-end duty at the hospital. a dispensation's error (delivery of metoject Ò (methotrexate) for intrathecal (it) injection whereas it doesn't have the indication for this use), led us to test the pharmacy residents' knowledges about the it access in order to underscore the points to be improved. the final aim of this work is to secure the pharmaceutical care of the patient h a day, days a week. setting and method: an online and anonymous survey of questions was sent to the residents of our area. it was composed of three parts: specific general information, questions about the chemotherapy specifically (indication, maximum dose and volumes, molecules used), illustrated questions about real situation for the dispensation on duty. the answers were collected over a two weeks period. main outcome measures: we studied the rate of good answers in global and by respondent. results: twenty-five residents answered the survey, among them % never achieved any internship in a centralized unit of reconstitution of chemotherapy (urc). all the levels of internship are represented: st year (n = ), nd year (n = ), rd year (n = ) and th year (n = ). only % know where a medicine is injected intrathecally on the spinal column, % know on which level of the meninges. three residents think that a nurse can inject intrathecally. they also had to select the molecules which can be injected by this access: % answered vincristine, % vinblastine, % bortezomib; despite these three molecules are mortals if they are injected intrathecally. the majority know the indication of the it chemotherapy: prevention and treatment of cancers' meningeal localizations. sixty percent do not know that several molecules can be injected for the same patient in the same time. the maximum dose of methotrexate is known for half of the respondents, but only % for the cytarabine'one. only residents out of know that ml is the maximum volume allowed to be injected for an adult. six residents would have delivered metoject Ò mg in pre syringe filled if a doctor had asked for an it during a night. lastly, there are only two people who know that aracytine Ò (cytarabine) mg must be reconstituted with sodium chloride for it use and not with the provided solvent containing benzylic alcohol. the score of the residents having already done an internship in an urc is . / compared with . / for those who never did. the respective scores per year of internship are . ( st year), . ( nd year), . ( rd year) and . ( th year). conclusion: results and answers have been presented in a meeting and sent to the residents. we initially note many gaps in knowledge. the residents who already worked in an urc and the elders got better results. all the residents could be on duty at the hospital and all must be formed. a second session will be organized in a month to evaluate the formation's impact. it also has been presented to the assistants during an interactive lesson. this formation is essential to guarantee the dispensation of the adequate product and a secured medical care of the patient. please specify your abstract type: descriptive abstract (for projects) background and objective: patient adherence to prescribed medications is crucial for reaching metabolic control goal. to better understand the impact of polypharmacy on medication adherence, we undertook a detailed survey of medication use among patients with endocrinologic diseases. the aim of this study was to determine medication adherence in a cohort of patients with endocrinologic diseases and to test the hypothesis that adherence decreases with increased number of medicines prescribed. design: we conducted structured interviews to determine self-reported adherence of patient on a scale of (high) to (low observance) (srap- ) and a measurement using morisky medication adherence scales . demographic and medication information were collected from medical record. for statistical analysis, mann-whiney u-test for continuous variables, with chi square for categorical variables and kendall test for correlation were used. results: our cohort included patients, % were women and % were diabetic ( % suffering from type diabetes). the mean age was ± years, the average number of medication was . ± . . ( %) patients were not able to estimate their adherence. patients reported srap- scale with an average of . ± . , this estimation was significantly higher than mmas- with an average of . ± . (p \ . ). the proportion of adherence level were identical between srap- and mmas- with respectively and % of high, and % of medium and and % of low adherence. a significand correlation between srap- and mmas- scales (r = . , p \ . ) was found. however no correlation between adherence scale and number of treatment (r = . for mmas- and . for srap- scale) nor number of daily doses (r = . for mmas- and . for srap- scale). on the medications, % presented difficulties with observance. cardiovascular ( . %), diabetes ( . %) and psychiatric ( . %) treatment are the three most involved drug classes in nonadherence. conclusion: in this cohort, patients reported high medication adherence. we highlighted a correlation between srap- and mmas- scales. surprisingly, we didn't find correlation between adherence scales and number of treatment or dose by day. the next step of this work will be the identification of risk factor of nonadherence using logistic regression analysis. hp-pc : the office of access to healthcare: how to optimize secured access to treatments? claire chatron, adeline flatres, claudine hecquard, guillaume saint-lorant * , alexandra muzard pharmacy, chu caen, caen, france please specify your abstract type: research abstract background and objective: office of access to healthcare (oah) is an organization which offers a medical and social coverage to people who can't access to care and to medication because of the absence of social welfare, living conditions, or financial difficulties. medications are free dispensed thanks to retrocession activity in hospitals pharmacies. the aim of this study is to analyse this activity and to improve communication with patients and access to treatments by an adapted pharmaceutical interview. setting and method: this study includes all dispensations of year . in order to get medications in our hospital, a social worker and the patient come at the hospital's pharmacy. one people of retrocession team (four assistants, two externs, two residents and two pharmacists) dispenses necessary drugs to the patient according to hospital drug formulary and operating protocol. a switch or a special order can be purposed if the drug is not available. then, we give the patient a medication management plan (mmp) to explain him how to take his treatment at home. retrocession team filled a quiz about this activity and ways to improve it. main outcome measures: the main topics included in the quiz and evaluated were: dispensation organization, english talking, feeling during the interview and evaluation of the mmp. results: three hundreds and ten patients were admitted in oah . these patients come mainly from the eastern europe and do not speak french in most of cases. social workers, who can help for communication, are not always present because these patients can come during on-call duty. quiz results showed that weak points occurred during the interview: explanation of the mmp, languages barriers, mention '' if needed '' not understood by the patient. explanation of the order for a particular drug was difficult to operate too. mmp were only drafted in french which was not convenient for foreign people. however, modalities of dispensation were well understood by the retrocession team. following quiz results, mmp was translated into english by the retrocession team. mentions '' if needed '', '' number of maximum tablet a day: … '', ''your medication is in order, thank you for coming to look for this treatment back to the hospital on … '', '' … is the same as …, prescribed by your doctor on your medication list '' have been added and translated. results of the study and new mmp will be presented to the pharmaceutical team and to social workers in staff. an index card for ''communication in english with a patient'' has also been drafted. it contains sentences meadow drafted in english. conclusion: access quality health care service is important to achieve health equity and to increase the quality of everyone's life. these documents improve communication with patients and by the way their understanding about their treatment. the use and the impact of these documents on well understanding will be soon evaluated with social workers and patients. hp-pc : improve the medication in an associated to general hospital nursing home luisa alonso * , marta vidal iglesias, lucia gómez carrasco, guillermo goda, laura garcia, laura marin, ana hernandez, alvaro moreno please specify your abstract type: descriptive abstract (for projects) background and objective: in order to improve the medication reconciliation and to implement training programs for the medical team in an associated to general hospital nursing (asnh) home we measured the discrepancies between pharmacy registered treatments (prt) and medical prescriptions (mp), and we analysed potentially inappropriate prescriptions according to ''american geriatrics society beers criteria'' and ''stopp-start criteria. design: retrospective observational study that included patients admitted in the asnh. the ''consensus document on terminology and classification in medication reconciliation'' was considered for discrepancy classification. data collected: discrepancies between mp and prt. in patients from the original group of , we reviewed potentially severe drug interactions, potentially inappropriate mp and drug classes to avoid in older adults and medications to be used with caution in older adults (according to stopp-start and beers ) . all data were registered, measured and analysed in excel Ò . results: patients and a total of mp were reviewed. discrepancies ( . %) were found between the medical order and the prt, those discrepancies included errors of omission in prt ( . %), absence of discontinuation of medication ( . %), incorrect dosage ( . %). potentially moderate to severe interactions: the most frequent drug groups were proton pump inhibitors (ppis) ( . %), benzodiazepines (bzds) ( . %), oral hypoglycemiants ( . %), other groups with frequency over %, oral antihistaminic, statines, low molecular weight heparine (lmwh), laxatives, calcium salts and iron salts. stopp criteria were identified that affected to mp and the distribution was as follows: laxative combinations ( . %), long term ppis ( . %), cns depressants combinations ( . %), long half life bzds combinations ( . %), aspirin incorrect drug strength ( . %) and other groups with lower frequencies, nsaids and prokinetics. start criteria: being all of them by omission of the drug at the time of admission. beers criteria: prescriptions in the ''avoid prescription in adults'' group of which corresponded largely to concomitantly cns depressants and long term use of ppis in no risk patients. conclusion: the difficult working conditions, the excessive workload and the high staff turnover, where doctors have a patient ratio over / , make difficult to update treatments according to patient daily needs. a clear communication problem between the hospital pharmacy and the asnh prescribers exists due to lack of infrastructures, and it has been demonstrated with the high percentage of discrepancy, that implies an important logistic problem (not a safety problem) since the nurse team works directly with the original medical orders. the analysis of prescriptions showed the need for updating the medical knowledge. the high volume of stop and beers criteria and lack of doctors time made impossible the individual acting upon each patient, so short summaries of continuous training related to most frequent problems have been designed. please specify your abstract type: descriptive abstract (for projects) background and objective: our french university hospital is one of the most active centre for liver transplant ( transplants annually). various professionals are involved in the graft patient care and education. much information and education sessions are exempted before and after the transplant. the objective of this work was to realize a short movie for patients ( ) to get them ready for transplant ( ) to give the key messages to support their transplant ( ) to make family understanding the process and to promote the life behaviour changes. design: three members of the pharmaceutical team with nurses-led care coordination and a surgeon wrote the scenario. we requested two directors for days of shooting. we defined the key points for the patient and places to film, and fixed the duration ( - min). the scenario was validated by the chief of the liver transplant unit and nurses-led care coordination. after the days of film shooting, we selected sequences. results: the movie was a succession of six parts. ( ) the movie has been burned onto cds, put on flash-drives and will be uploaded on the internet. because of the international origin of our patients, the video will be subtitled at least in english. the video will be broadcast to hospitals which do not transplant patients and refer them to our hospital. since the medical team was involved in a collaborative project, the making of the video has permitted to strengthen the cohesion. indeed, this work would not succeed if everybody did not express himself. patients understood the interest to testify about their lived experience with the liver transplant, because they wished to have such information when they were waiting for the graft. conclusion: this movie is very useful for patients and families who are looking for information before and after liver transplant. it is a tool to get them into condition patients. this video presents the advantage of being personalized (local and caregivers that the patient will encounter are filmed). furthermore, it maintains a dynamic involvement of the pharmacy (already well established with clinical pharmacy, patient education and medication reconciliation) in the liver transplant unit. the making of the film has been an opportunity to bind the members of the team together, by valuing the work of everyone. the film could be screened if this abstract is selected for an oral communication. please specify your abstract type: descriptive abstract (for projects) background and objective: numerous procedures on medication management at oslo university hospital aim to minimize the risk of medication-related errors. error reports and observations show great variation in the use of these procedures, primarily due to difficulties in their implementation and maintenance. our aim was to assess the effect of a novel teaching strategy, the impala project, on doctors and nurses compliance with the medication management procedures. design: the project was carried out at general medicine wards at oslo university hospital for a period of weeks at each ward. assessment of medication-related error reports yielded the following areas of focus: (i) correct medication prescription, (ii) specification of doses for medications given on an ''as required''-basis, (iii) double control of medication dosing, (iv) correct and documented generic substitution. weekly presentations by pharmacist(s), lasting for a maximum of min, were given to doctors and nurses as part of daily ward routines. this was repeated over weeks. data on medicationmanagement procedure compliance were recorded before the start of the intervention, during and after each intervention period. the results were presented and made available to both leaders and employees throughout the project period both as an incentive to improvement and as a motivation factor for continued effort. results: there was a marked increase in medication-management procedure compliance among the nurses, especially after the second week of intervention. the most marked increase was shown for double control. increase in medication-management procedure compliance was also present among the doctors, but was less prominent. the data presented gave an extra motivational kick according to the participants. the leaders and the employees stated that the impala strategy was easy to follow and gave results without much organizational effort. conclusion: fifteen minutes presentations given by a pharmacist(s) as part of daily ward routines, combined with presentation of results demonstrated considerable improvement in medication-management procedure compliance. please specify your abstract type: research abstract background and objective: high unexpected serum vancomycin concentrations (svcs) were observed in patients without impaired renal function during the therapeutic drug monitoring (tdm) in our pharmacokinetic service. the aim of this study was to analyse the evolution of the svcs and its relationship with the markers of renal function. setting and method: retrospective study conducted at a university hospital with a follow-up period of months. only adult patients having at least two tdm were selected. trough svcs were measured by cmia (architect i- analyser, abbott Ò ) and fitted to a two-compartment model by using bayesian analysis (pks Ò , abbott). clinical and demographic data and daily dose, as well as timings of vancomycin administration and of blood sample collection were accurately recorded. spss Ò , version . was used to compare data from both tdm by student t-test (parametric data) and wilcoxon (nonparametric data). main outcome measures: concentration-to-dose ratio (cdr: trough concentration * /daily dose); glomerular filtration rates (gfr) estimated by cockroft-gault formula; measured and predicted svcs levels. results: adult patients were included (females: %); median age [ - ] years).the first and the second tdm were carried out after . [ . - . ] and [ . - . ] days from the beginning of the treatment, respectively. in the first tdm, no difference was found between the measured concentrations ( . ( . ) lg/ml) and those predicted ( . ( . ) mg/l. however, predictions were less accurate in the second tdm and predicted concentrations were significantly higher svcs ( . ( . ) mg/l vs. . ( . ) mg/ml, p \ . ). the median cdr in the second tdm was significantly higher than that calculated in the first one ( . [ . - . ] l - vs. . [ . - . ] l- ; p \ . ), indicating a lower clearance and a drug accumulation. however, no statistically significant differences in the glomerular filtration rates were found ( [ - ] ml/min vs. ml/min) in the first and second tdm, respectively. conclusion: although the markers of renal function did not change during the treatment, a decrease in vancomycin clearance was observed. the pharmacokinetic model does not accurately predict evolution of the svcs over the treatment. the introduction of covariates such as the length of treatment or the cumulative dose in the pharmacokinetic model could improve its predictive performance. please specify your abstract type: descriptive abstract (for projects) background and objective: genetic polymorphism or major physiological changes have to be considered in patient therapeutic management. clinical pharmacists have a role to evaluate and optimize the appropriateness and effectiveness of patient's medications. we report here the impact of the clinical pharmacist and his collaboration with the clinical pharmacologist in the therapeutic management of a patient suffered from anorexia nervosa, a psychiatric disorder leading to body composition change that may influence drug pharmacokinetics and efficacy. design: case report. results: the patient was a -year old woman hospitalized for chronic pulmonary aspergillosis previously treated by voriconazole, posaconazole and itraconazole. her medical history included anorexia nervosa since with a body mass index of . kg m - , pulmonary tuberculosis in with relapse in , and chronic pulmonary aspergillosis since . at admission, a treatment by oral voriconazole at mg/ h was introduced. the trough concentration of voriconazole at steady state was . mg/l (therapeutic range - mg/l) despite taking drug on empty stomach. although the voriconazole dosage increased in mg/ h, the trough concentration did not increase significantly ( . mg/l). we hypothesized anorexia led to a significant mucosal atrophy and accordingly, a significant decrease in intestinal absorption surface which is a major determinant of the level of drug absorbed. thus, a switch from oral to intravenous route was performed (voriconazole mg/ h). according to subtherapeutic voriconazole concentrations (trough concentration: . mg/l) despite the use of intravenous route, we decided to perform genotyping to look for mutations of cytochromes p a * , c * and c * , particularly implicated in voriconazole metabolism. the presence of an ultrarapid metabolizer genotype ( * allelic variant of the c isoenzyme) in our patient should lead to increase drug dosage from to %. finally, the patient was treated by intravenous voriconazole at mg/kg/ h (i.e., increase by %). the maximum concentration performed h after iv route initiation was at . mg/l, suggesting a better efficacy. conclusion: this case report highlights the potential complexity of therapeutic management in some patients given anatomical and functional changes or genetic polymorphism, which can affect drug efficacy. clinical pharmacists in collaboration with clinical pharmacologists have to be able to help physicians in this type of situations. please specify your abstract type: research abstract background and objective: posaconazole (pcz) is widely used for invasive fungal infections as prophylactic, pre-emptive or curative therapy in lung transplantation. recently, a new formulation of pcz has been available in enteric-coated tablets. this new formulation improves pcz bioavailability, as compared to the oral suspension, which leads to increase pcz plasma trough concentrations (c min ) in haematological patients. no data related to pcz exposure and its effects on tacrolimus (tac), an immunosuppressant with narrow therapeutic index widely used, exists in lung transplantation. we aimed to assess the consequences of the treatment by pcz entericcoated tablets on pcz and tac exposure in lung transplant patients. setting and method: a single-centre retrospective study was conducted among lung transplant patients receiving tac and either enteric-coated pcz or both galenic forms. main outcome measures: pcz and tac exposure were estimated by the measurement of c min . to overcome the influence of dose (d), c min were adjusted on dose (c min /d) for both pcz and tac. a spearman test (nonparametric distribution) was performed to assess the correlation between pcz c min /d and tac c min /d. results: eighteen lung transplant patients (median age [q ; q ] = . [ . ; . ] years; % female) were included between june and march . eight patients received only pcz entericcoated tablets. pcz enteric-coated tablets were associated to an increase in pcz c min /d as compared to oral suspension ( . ± . l - vs. . ± . l - , p \ . ). overall, pcz therapy initiation led to an increase in tac c min /d ( . ± . l - before initiation vs. . ± . l - after initiation, p = . ). tac c min /d was significantly higher with pcz enteric-coated tablets, as compared to pcz oral suspension ( . ± . l - vs. . ± . l - , p \ . ). a weak correlation was observed between pcz c min /d and tac c min /d, independently to pcz galenic form (r = . , p = . with pcz enteric-coated tablets and r = . , p = . with pcz oral suspension). conclusion: this pilot study in lung transplantation confirms the better bioavailability of pcz enteric-coated tablets as compared to oral suspension. our results show a more important increase in tac exposure with pcz enteric-coated tablets compared to pcz oral suspension, suggesting a concentration-dependent cyp a inhibitor effect of pcz. these findings are of interest in clinical practice to monitor transplant patients treated by the new formulation of pcz. further analyses, including the consideration of confounders, will be conducted. please specify your abstract type: descriptive abstract (for projects) background and objective: within months, two patients receiving apixaban developed agranulocytosis. based on temporal and clinical plausibility as well as published literature, the objective was to determine the causal relationship between agranulocytosis and apixaban. design: description of two agranulocytosis cases reported in our hospital. results: first case is an years old male, admitted to the neurology unit (d ) for ischemic stroke. at admission, blood count showed no abnormalities. four days after admission, treatment administered consisted in: dextrose % infusion iv, sodic heparin iv, acetaminophen, atorvastatin, metoprolol. neutrophils count was normal ( . g/l). heparin was stopped at d and replaced with apixaban according to following dose regimen . mg twice a day. at d , patient presented with hyperleukocytosis (neutrophils count g/l) and high crp ( mg/l). thus, a cytobacteriological urine test was performed. at d , patient presented with hypothermia followed by hyperthermia related to acute sepsis. blood count showed agranulocytosis (neutrophils count . g/l). broad spectrum antibiotherapy was started (ceftriaxone and gentamycin). despite treatment, death of patient occurred at d . the suspected cause of death was septic shock added to severe febrile neutropenia. following haemocultures confirmed sepsis (e. coli) possibly originating from urinary tract infection. second patient is a years old male, admitted to the cardiology unit (d ) for bronchopneumopathy associated with tachycardia and atrial fibrillation. a treatment with heparin was immediately started in association with patient usual treatment (bisoprolol, valsartan, rosuvastatin, hydrochlorothiazide and manidipine). in addition, broad spectrum iv antibiotherapy was started with ceftriaxone and spiramycine followed at d by an oral treatment with cefixime and spiramycine until d . heparin was replaced by apixaban at d ( . mg twice daily). antihypertensive treatment was adapted throughout patient's stay. patient presented neutropenia at d (neutrophils count . g/l), followed by agranulocytosis at d (neutrophils count . g/l) when it was decided to replace treatment with apixaban by fluindione. the following day, neutrophils count was about . g/l and patient received filgrastim. a myelogram showed a possible peripheral neutropenia. in the absence of other confounding factors (hiv, hbv, hcv, cmv), an iatrogenic agranulocytosis related to apixaban was suspected. conclusion: causal association with heparin is unlikely as neutropenia is not an adverse drug reaction known included in the smpc of this drug having a well-established safety profile. since the two patients were taking their usual treatment for a significant period of time, a causal relationship is deemed unlikely. temporal and clinical plausibility seem to indicate a possible relationship between agranulocytosis and apixaban. as this medicine has been recently approved, this might explain why no case has been reported in the literature and the absence of agranulocytosis as an adverse drug reaction of apixaban. please specify your abstract type: research abstract background and objective: taste is tightly connected to children's acceptability of medicines. two ways to overcome lack of acceptability are to administer solid formulations which are easier to taste mask and change to better tasting medicines. dicloxacillin is an antibiotic known for its unpalatability, and taste studies suggest that this might jeopardize its adherence. the aim of this study was to explore if prescription data can be used to estimate acceptability of antibiotics among children on a population level using dicloxacillin as an example drug. the research questions were: when comparing dicloxacillin with other antibiotics commonly used in children, ( ) is there a difference in the age of conversion from liquid to solid formulation and ( ) is there a difference in re-prescription rates on day and after the initial prescription? setting and method: we included all initial prescriptions of oral dicloxacillin, phenoxymethylpenicillin, amoxicillin and erythromycin for children - years registered in the norwegian prescription database (norpd) - due to dicloxacillin mixture being discontinued from the norwegian market in . the age of conversion was defined as the age where half of the children were prescribed liquids and the other half prescribed solid formulations. re-prescription rates were defined as re-prescriptions of a different antibiotic or formulation on day and after the initial prescription, divided by the total number of prescriptions. main outcome measures: age of conversion and re-prescription rates of dicloxacillin compared with other common antibiotics. results: the age of conversion for dicloxacillin was . years, compared to years for other common antibiotics. the average represcription rate for dicloxacillin was . % for children - years and . % % for children - years. the highest re-prescription rate of . % was found in -year olds. corresponding numbers were . , . and . % for common antibiotics. conclusion: the lower age of conversion from liquid to solid formulation and higher re-prescription rate of dicloxacillin mixture compared to common antibiotics indicates that prescription data can be used to identify antibiotics with low acceptability for children - years. further studies are needed to investigate if this also holds true for other antibiotics. please specify your abstract type: research abstract background and objective: attention deficit/hyperactivity disorder (adhd) or hyperkinetic disorders (hkf) is among the most common mental disorders in children, and may persist through adolescence into adulthood. pharmacotherapy used for treating the disorders also has potential for misuse/abuse. the aim was to describe the prevalence and magnitude of use of stimulant drugs and atomoxetine, and compare consumption in the nordic countries. setting and method: a descriptive pharmacoepidemiological study from the * million inhabitants of the five nordic countries in the period - . data were collected from national prescription registers, public drug reports and by correspondence with public health institutions. population data were obtained from official statistical databases or by correspondence with public health institutions. main outcome measures: trend over time, comparison between countries, type of pharmaceutical, gender, age, comparability of data. results: the annual consumption has been increasing from to , both in volume and prevalence of use. denmark had the largest increase in volume, from . to . ddd/ inhabitants/day. sweden had the highest increase in prevalence of use over the period, from . to . users/ inhabitants. iceland had the largest consumption of adhd medications in , . ddd/ inhabitants/day. prevalence data was not available for iceland but sweden was highest in prevalence of use among the other countries in : . users/ inhabitants. males aged - years had the largest volume and prevalence of use in , but females' consumption had been increasing faster both in terms of numbers of users (* . faster) and in volume (* faster) than men's consumption. conclusion: variation in consumption is considerable and cannot be explained by diagnostic and prescription guidelines, as these are similar in the five countries. consumption has been increasing fast in the period in all the countries, and faster for women than for men, although men still consume larger volumes than women, and are more frequent users. please specify your abstract type: research abstract background and objective: in and , regulatory bodies in usa (fda) and europe (ema), issued warnings on use of metoclopramide due to an increased risk for serious adverse drug reactions (adr), especially neurological adrs. ema recommended that metoclopramide only should be prescribed for up to days while fda concluded that treatment longer than weeks should be avoided. metoclopramide is commonly used to treat nausea and vomiting in pregnancy (nvp) and deficient breast milk production ( days course). ema did not make any recommendations concerning use during pregnancy and lactation. the objective of this study is to assess the disproportionality of reporting of adr from metoclopramide, with special emphasis on neurological adrs and women in reproductive age. setting and method: data from whos global adr database vigibase Ò for the time period november to may was used. the measure of disproportionality of reporting calculated was the proportional reporting ratio (prr), and % confidence intervals (ci). analyses were performed according to gender and age. time-toonset of adr was calculated. main outcome measures: proportional reporting ratio (prr) results: vigibase contains over million adr reports. metoclopramide is a suspected/interacting drug in of the reports, most common ( %) are neurological adrs. the majority ( %) of the metoclopramide adrs occurred within the first days of use. a total of % of the reports was received the last years ( ) ( ) ( ) ( ) ( ) . the reporting of neurological adrs was higher for metoclopramide than other medications in vigibase. women in reproductive age ( - years) reported higher proportion of neurological adrs (prr = . , % ci . - . , n = ) than women + years (prr = . , % ci . - . , n = ) but a similar proportion as men - years (prr = . , % ci . - . , n = ). conclusion: there is a . to three fold higher proportion of all reports regarding neurological adrs for metoclopramide than for other drugs. patients initiating treatment with metoclopramide should be informed about risks of adrs and that most adrs occur within days, and instructed to contact health care personnel and stop treatment if adrs occur. please specify your abstract type: descriptive abstract (for projects) background and objective: self-induced drug intoxications (sidi) are one of the most frequent reasons of hospitalization in emergency service ( %) with around - / inhabitants and represent around % of admissions in intensive care unit (icu). it is the most frequently used method of suicide attempts (sa) and the leading cause of hospitalization for young people under . the main objective of our study was to analyse, stratify and pharmaceutically map the different sidi identified in our icu. design: this is a prospective study over months, including all icu patients following sidi from june to january . we have collected psychiatric history and previous sa by sidi, usual treatment, state of consciousness, incriminating drugs, drug classes stratified according to the clinical severity score igsii, evolution, transfer in a specialized centre and average cost of stay. results: ninety-two cases were reported, representing % of icu admissions. the average hospital stay was days for an average cost of . €. this amount is low compared with the average cost of all stays gone through the icu for the period ( , €). ninety percent of patients had a psychiatric history and % a previous sa. the usual treatment was involved in % of sidi. half of the patients arrived conscious with an average of severity score igsii of / , being the highest found for a patient who had swallowed simultaneously pregabalin and nitrazepam. clinical severity of these patients is less than that found on average for all patients in the icu in this period ( / ). eighty-seven percent had a favorable evolution. only one death was observed after ingestion of propranolol. fifty-six and a half percent of patients were then hospitalized in a specialized centre. the great family of psychotropic is the most frequent with benzodiazepines %, neuroleptics %, antidepressants . % and antiepileptic . %. the main drugs involved are oxazepam %, alprazolam %, cyamemazine %, bromazepam % and quetiapine %. antihypertensives then arrive and represent % of sidi. the stratification of severity scores does not appear to show significant differences between drug classes, nor between mono or polydrug ingestions. conclusion: sa by drug ingestion are very common and are often linked to risky behaviours. for these epidemiological and economic findings, it is necessary to continue and develop prevention strategies avoiding the appearance of intoxication (primary), limiting the consequences (secondary), and reducing the risk of recurrence (tertiary). please specify your abstract type: research abstract background and objective: interpretation of quality of life scores to render them meaningful to aid clinical decision-making is an ongoing challenge. interventions often result in statistically significant quality of life (qol) improvement, but may not reach the threshold of clinical importance. the minimal clinically important difference (mcid) is the minimal score change of relevance clinically. the aim of this systematic review was to assess the impact on quality of life of topical, systemic and biologic treatments for psoriasis in randomised controlled trials (rcts). setting and method: prisma guidelines were followed. all available articles describing rcts of therapies for psoriasis that included qol measurements published up to november were identified. six databases were examined with search terms. abstracts of articles were reviewed independently by two assessors: a third adjudicator resolved any opinion differences. risk of bias was assessed using the jadad scale. main outcome measures: reporting of the use of qol endpoints and impact of interventions in psoriasis. results: of screened article abstracts, articles were selected for detailed review: trials met the eligibility criteria, describing research on a total of , patients. reports of psoriasis interventions that fulfilled inclusion criteria have gradually increased over time : - = , - = , and - = ( ) to evaluate the relationship between the use of different therapeutic agents and the severity of osa, and ( ) to determine the effects of commonly used medications on continuous positive airway pressure (cpap). setting and method: patient medical records (n = ) of patients, that underwent sleep studies between the years and were collected over an eight-month period from the sleep laboratory department at mater dei hospital using a random sampling technique. data collected included body mass index, gender, age, epworth sleepiness score (ess), drug history, apnoea hypopnoea index (ahi) and cpap therapy prescription. likelihood ratio chi square test, paired samples t-test and multinomial logistic regression were the statistical tests used for data analysis. main outcome measures: assessment of the drug history in response to osa control using the ess and ahi scores. results: one hundred and seventy ( . %) patients of the patients ( males, females) were diagnosed with osa. forty-five ( . %), ( . %) and ( . %) patients suffered from mild, moderate and severe osa respectively. patients had a mean age of years. angiotensin ii receptor antagonists (arbs) (p-value = . ), sulphonylureas (p-value = . ), insulin therapy (p-value = . ) and non-benzodiazepine sedating agents (p-value = . ) were found to be associated with the presence of osa. a decline in the use of the arbs (p-value = . ), angiotensin converting enzyme inhibitors (p-value = . ) and non-benzodiazepine hypnotics (pvalue = . ) was observed over the study year period. reduction in the cpap therapy benefit was detected with the use of histamine (h ) antagonists (p-value = . ), b-adrenergic blocking agents (pvalue = . ) and antiplatelets (p-value = . ). conclusion: it is confirmed that hypertension and diabetes mellitus type ii are the main co-morbidities associated with the presence of osa. reduction in the use of certain therapeutic agents is observed secondary to cpap therapy use. patients using specific drugs have been identified as being at risk of a reduced cpap therapy benefit. please specify your abstract type: research abstract background and objective: people are using increasingly more common of social networks such as facebook, twitter and youtube for different purposes. many people are using these networks with the aim of getting information and knowledge sharing. there are many groups that pharmacist is a member in social networks at turkey. the largest of these groups has , members. pharmacists are shared common problems, information and experiences in these groups. but the accuracy of the information shared on social networks are not always conclusive. the study aim to evaluate the impact of social network information sharing in the knowledge and attitude of pharmacists. setting and method: clinical pharmacy group has been created to share information on facebook. pharmacist joined this clinical pharmacy group. the group was fed by information which include new drugs, fda alerts, adverse event and case report and also drug related problems during the months. pharmacists were assigned in two major groups, group a active pharmacist who becomes a member of our clinical pharmacy group, share and discuss information through the network and group b who is not a member. a knowledge measurement survey (ams) was given to both of them. main outcome measures: acknowledge measurement survey (ams) was developed and the difference in the score was used to evaluate the difference between the two study groups. results: pharmacists participated in the study, . % of the participants were a member of our facebook group and . % of participants were not. . % of the participants have doctoral degree or student, . % have master degree or student, % have bachelor degree from year-pharmacy faculty, . % have bachelor degree from year-pharmacy faculty. the education level distribution between the two groups was not statistically significant. while . % of the ams questions were answered correctly in the member group only . % were answered correctly in the non-member group. conclusion: the study emphasizes the importance of social network in providing the accurate and fastest information for the daily use of the pharmacists, there is a significant difference in knowledge between the pharmacist who join, share and discuss information on the social network and the one who do not join. cp-ce : impacts of a community pharmacy practice experiences on student professionalism yunn-fang ho , , hung-wei lin *, , fang-ju lin , , sheng-ping chang , yen-ming huang graduate institute of clinical pharmacy, school of pharmacy, college of medicine, national taiwan university, taipei, taiwan, r.o.c please specify your abstract type: research abstract background and objective: professionalism is valued globally and pharmacy schools are expected to nurture competent practitioners to better serve the public with humanity attitudes and behaviours. the study aims: ( ) to understand possible differences in professionalism between pharmacy students and potential community pharmacist preceptors, and ( ) to evaluate student changes in professionalism upon completing the community pharmacy practice experiences (cppe) at the end of the third (p ) year. setting and method: a modified chisholm's pharmacy professionalism instrument ( -item, -point likert scale) was administered to p students, pre-cppe and hopefully post-cppe in september, and community pharmacist practitioners who participated in a two-day preceptor training workshop. participants also provided their significance ratings toward ten traits, namely altruism, accountability, excellence, duty, honor and integrity, respect for others, communication, ethics, humanism, and teamwork. main outcome measures: differences or changes in chisholm professionalism scores. results: thirty-two students and fifty pharmacists participated in the survey. honor and integrity ( . ± . ) and communication ( . ± . ) were recognized by students ( . %) and pharmacists ( . %), respectively, as the most significant trait. humanism was rated the lowest in both groups (students, . ± . ; pharmacists, . ± . ). the -item professionalism scores ranged from . ± . (''i do not expect anything in return when i help someone.'') to . ± . (''i am respectful to individuals who have different backgrounds than mine.'') in the student group; whereas . ± . (''i do not expect anything in return when i help someone.'') to . ± . (''it is wrong to cheat to achieve higher rewards (i.e., grades, money).'') in the pharmacist group. in general, pharmacists' professionalism scores were higher and, in certain items, statistically significant differences were achieved. conclusion: professionalism might grow with professional competency and practice experiences as demonstrated by potential pharmacist preceptors. upon completion of cppe, students could probably exhibit gains in professionalism. more investigations are still underway. please specify your abstract type: descriptive abstract (for projects) background and objective: in france, a significant consumption of benzodiazepines (bzd) is observed in prisons. they are widely used during incarceration to treat or prevent anxiety and insomnia. furthermore, it is known that, an important traffic exists with these drugs because of the releasing properties of bzd in case of misuse. based on these observations, the pharmacist has set up a plan to improve the use of bzd in prison. the purpose of the study was to evaluate the impact of these measures after year of implementation. design: in january , we shared with physicians in a meeting to explain our plan for a better use of bzd and to set up new rules of prescription in prison: • regularly reducing the dose to limit drug tolerance • promoting the use of long half-life molecules which allow reducing addiction and misuse • advising sedatives anti-histaminics to treat insomnia • providing information to patients about addictives risks of bzd on the tv channel please specify your abstract type: descriptive abstract (for projects) background and objective: some drug combinations (described in thesaurus of national agency of drug) are contraindicated because they appear to increase the risk of torsade de pointes. the aim of this work is to standardize our pharmacists' intervention and to propose guidelines for doctors and pharmacists, depending on the situation and drugs, to limit these combinations and to reduce this risk at our hospital centre ( beds). design: a prospective survey was realized over a period of months to identify the drug combinations prescribed in medical prescription software, from the national drug agency thesaurus, that might be inducing torsade de pointes. a multidisciplinary staff was then constituted composed of a cardiologist, a geriatrician, a paediatrician, an anaesthesiologist, a psychiatrist and pharmacists to identify the different situations and to establish guidelines. results: from the survey drug combinations were found to be contraindicated due to increased risk of inducing torsade de pointes on a list interventions realized by pharmacists. the work group identified three drugs with a therapeutic alternative: hydroxyzine, domperidone, escitalopram, the other drugs can't be switched because they are vital or have no alternative. the work group decided to maintain hydroxyzine but only on premedication and child anxiety, to eject domperidone from our therapeutic index and substitute it with metoclopramide or metopimazine, to not initialize escitalopram but to keep it if the patient has no have others risk factors associated or no contraindication. if the patient has a contraindication with a risk factor the doctor could prescribe other ssri. in addition, pharmacists alert doctors about the risk of torsade de pointes on medical prescription software if some contraindications are identified. conclusion: the contraindications identified must not be underestimated. this work allows identification of torsadogenic drugs commonly prescribed and provides guidance for doctors and pharmacists regarding drug combinations. the collective decision will be disseminated to sensitize all the doctors in the establishment. some treatments could not be substituted despite the contraindication; these must be retained but with clinical monitoring. conclusion: a substantial proportion of medication waste in the community pharmacy could have been prevented. unused medicines in the community pharmacy are generally of low economic value, making it unlikely that the costs that pharmacies will make with the redispensing of unused medicines will be covered. therefore, other actions to decrease medication waste in the community pharmacy, such as preventing that too much medicines are dispensed, should be considered. please specify your abstract type: research abstract background and objective: flaws in usage technique for inhalationmedicines is common, as much as half of the users may need some correction measures, to get the active substances down to the lungs and provide the intended effect. inadequate compliance, especially for regular-use preventive medications, is common. good guidance in pharmacies enhances correct use of medicines. the new norwegian pharmaceuticals policy (legemiddelmeldingen) from opened up for paid cognitive services, leading to the first such service being implemented in march . the service can contribute to a more correct use of the medicines and, as a consequence, lead to better control of the symptoms for patients with asthma or copd. our objective was to map the variation in pharmacies' handling of an inquiry regarding lack of effect of an inhalation-medicine. the study was done prior to the implementation of the standardized service ''inhalation-guidance'' in norwegian pharmacies. setting and method: simulated patient (mystery shopper) visits in pharmacies in oslo, akershus and buskerud in november/december . the mystery shopper expressed just having started to use an inhaler because of her asthma, but not experiencing effect. structured data collection sheets were used to register the handling immediately after the visit. main outcome measures: scoring of the quality and contents of the information based on the products' patient information leaflets. results: the issue of inhalation-technique was mentioned in of the pharmacies, whereof asked the ''patient'' to show their inhalationtechnique, in order to correct and advice and used an inhaler or demo-inhaler as an aid in the guidance. going through the instructions or watching a video-demonstration with the simulated patient also occurred, or referring the patient to read the instructions and/or watch the video-demonstration on his own. half of the pharmacies discussed the difference between use for preventive treatment of asthma and inhaler that is being used for treatment of attacks. sixty-five pharmacies gave no information about the importance of regular use of the preventive treatment. conclusion: there was considerable variation in how the pharmacies guided, which indicates a potential for improvement. the new guidance-service, implemented in norwegian pharmacies in march , will contribute to better guidance. please specify your abstract type: research abstract background and objective: in portugal, tobacco addiction was responsible for over , deaths in ( % of the total deaths). the community pharmacist's contribution to control this public health problem is insufficiently documented. the aim of this study is to assess the contribution of the community pharmacist for smoking cessation. setting and method: a retrospective and longitudinal study of a convenience sample of patients integrating quit tobacco consultations, as part of a pharmaceutical care programme implemented by an outsourced pharmacist was performed at several community pharmacies. the smokers, aged or over, were invited to join the programme. patients signed an informed consent and were submitted to a comprehensive approach by face-to-face consultations and telephone contacts. richmond and fagerström tests were used to evaluate motivation and nicotine dependence, respectively. the therapeutic plan (pharmacotherapy and behavioural counselling) was personalised to each smoker. the quit rates were evaluated by patient selfreport and confirmed by carbon monoxide measurements. the continuous variables are expressed as mean ± standard error of the mean. main outcome measures: quit rates at , , and months. results: between january and june , smokers joined the programme, dropouts ( . %). the remaining smokers, ( . %) were male, with mean age of . ± . years. on average, each smoker consumed . ± . cigarettes per day. the mean age of initial tobacco use was . ± . years with . ± . years of consumption. about % reported moderate or high motivation and % medium or high dependence. a total of consultations were held and, on average, each patient received . ± . interventions. all smokers received non-pharmacological interventions (e.g. motivational approach) and ( . %) also accepted pharmacological interventions, usually nicotine replacement products. the quit day was achieved by patients ( . %). a month after quit date, patients were abstinent ( . %). the number reduced to after months ( . %), to after months ( . %) and to after year ( . %). these data upgrade and are consistent with our previously published results ( ). the smoking cessation consultation in the scope of a pharmaceutical care programme in community pharmacy seems to effectively contribute to the reduction of tobacco addiction in portugal. cp-pc : patient counselling at dispensing of oral anticancer drugs in european countries from the pharmacists' perspective andreja eberl * , on behalf of epic working group pharmacy, institute of oncology ljubljana, ljubljana, slovenia please specify your abstract type: research abstract background and objective: the number of oral anticancer drugs (oads) available on the market grows constantly. consequently the number of patients, which have to manage the complex treatment with oads at home is increasing. the pharmacists present an important member of healthcare team, since they are dispensing oads to the patients, which need a high quality information at that crucial moment. therefore, our aim was to evaluate pharmacists perceived confidence and needs for specific continuing education in connection to oads dispensing in european countries. setting and method: we used an electronic mailing approach and a standardized online survey to ask practicing pharmacists in european countries about their experience with dispensing of oads. main outcome measures: frequency of patient counselling and fields of counselling, assessment of knowledge and skills. results: the frequency of patient counselling varied widely in participating countries between ''never'' and ''more than %'' at initial fill of an oad. at following refills the frequency of counselling was generally even lower. counselling mostly encompassed directions of use, the proper use of antiemetics and side effects. however many pharmacists stated, that they do not feel comfortable counselling patients of oads ( %) and even more acknowledged that they were uncomfortable with managing patients' side effects ( %). on the other hand only % of pharmacists believed, that they have received adequate knowledge of oads through undergraduate program, continuing education (ce) events and professional practice. many of pharmacists ( %) have not attended any of ce events related to oncology in last years. pharmacists' responses differed little between the countries. conclusion: the proportion of pharmacists who regularly counsel their patients on oads is insufficient in view of importance of the patients' needs to manage their therapy at home. however the pharmacists seems to be aware of their knowledge deficits and educational needs. the field of oads needs better coverage in under-and postgraduate education. the number of ces has to be increased in order to improve the knowledge and skills in the areas of oads counselling. please specify your abstract type: research abstract background and objective: treatment guidelines for diabetes recommend that patients are well-informed about their disease, treatments and treatment goals, e.g. glycosylated haemoglobin (hba c). the objective was to describe diabetes patients' self-monitoring of blood glucose (smbg) and potential need of guidance. please specify your abstract type: descriptive abstract (for projects) background and objective: in , the international pharmaceutical federation collected data of remuneration models for community and hospital pharmacy and identified large variations between remuneration models and highlighted that the focus is largely on products and not on cognitive services. the aim of the study is to map the remuneration models of different pharmacist-led cognitive services in primary care across europe, with a special interest on medication reviews and to update a prior survey by bulajeva (bulajeva a et al. medication review practices in european countries. res social adm pharm ; : - .). the definition of terms is pivotal for such a european survey to avoid results based on pseudoconceptions. hereafter we present the development of the survey and we will present first results from pilot tests. design: pharmacist-led cognitive services were selected based on a previous study by our group and by searching the literature, official government websites, the pcne wiki and arising links. the definitions of the terms of these services were based on searches in the mesh browser, medline and google scholar. additionally, a search in grey literature and in the internet was conducted to find appropriate foundation for the formulation of the definitions. the questionnaire will consist, of a first part about the remuneration of the pharmacist-led cognitive services. the focus is on country-specific differences in remuneration and the different levels of supply across europe. the second part of the survey is about the different types of medication review services with a focus on e.g. the implementation level, addressed issues, eligibility criteria. this survey will have a cross-sectional study design with an online questionnaire specific for invited participants across europe. to achieve the best quality of answers we will send this survey to at least two researchers with references in pharmacy practice, in each european country (purposive sample). the answers from each country will be checked for discrepancies and these potential discrepancies will be solved by a discussion with the responders. results: by the end of the pre-pilot phase, different pharmacist-led cognitive services were identified and the correlating definitions of the terms were developed. conclusion: at the time of submission the pre-pilot phase has been finished and the pilot will start july . please specify your abstract type: research abstract background and objective: medication adherence is one of the key aspects in assuring optimal health outcomes in majority of chronic diseases. the aim of the study was to evaluate copd patients' medication adherence in slovenia and its association with health outcomes. setting and method: patients were recruited by community pharmacists at the time of dispensing medication for copd. medication adherence was evaluated by using morisky medication adherence scale (mmas- ). patients who scored b points, . - . points and points were regarded to have poor, moderate and good adherence, respectively. quality of life was evaluated by saint george's respiratory questionnaire (sgrq) and the impact of disease by copd assessment test (cat). the study was conducted in september and february . the association between potential predictors and copd impact or quality of life was estimated using multiple linear regression in ibm spss statistics version . main outcome measures: medication adherence rate (mmas- ), quality of life (sgrq total score) and impact of disease (cat score). results: of patients, majority were men ( %) with mean age years. in average, patients were prescribed . medicines for copd and . medicines for other diseases. good, moderate and low adherence to copd medication regimens was found in . , . and . % of patients, respectively. mean cat scores and sgrq scores were . (range - ) and . (range - ), respectively. thirtyeight percent of patients experienced an exacerbation in the past year. linear regression showed no statistically significant association between medication adherence and quality of life or copd impact on patient. factors that statistically significantly predicted patients' quality of life were exacerbation in the past year, education level and number of concomitant medicines for other diseases. the latter was found to be the only factor associated with copd impact. conclusion: the study showed half of the copd patients to be optimally adherent to their treatment and only a small proportion of patients not taking their medicines regularly. due to the nature of the disease medication adherence does not seem to play the most important role in assuring optimal health outcomes in copd patients. please specify your abstract type: descriptive abstract (for projects) background and objective: intermediate care units (imcu) are designed to serve patients in need of more advanced medical care than the ordinary nursing home units can provide. the aim of this study was to see; ( ) how medication information follows patients in and out of icmu and nursing home short-termcare units (stcu) ( ) the type and amount of drug related problems (drp), focusing inappropriate drugs, and ( ) if there are differences between the icmu and stcu in drug use and drps. design: patients c years old admitted and submitted at the imcu or stcu in the study period ( weeks) were included. transfer of medication information were evaluated and given a score. the clinical pharmacist provided medication reconciliation upon admission, medication review and monitoring, and presented identified drps and a suggestion for solving the problem, to the multidisciplinary team. inappropriate drugs, identified by screening tools (stopp/norgep), and systematic medication reviews, were recorded. results: patients from imcu and five from stcu were included. a hospital discharge summary including medical history followed mostly all patients. the score of the medication history was . points out of . by submission from either imcu or stcu, the score was . . systematic drug review identified . drp in the imcu and . in the stcu. imcu patients used . drugs, stcu patients . in the icu, % of the identified drps was inappropriate drugs, none in the stcu. the clinical pharmacist in the multidisciplinary team presented % of the identified drps. the doctors agreed in % of the suggestions for solution, and started immediate changes in %. conclusion: a hospital discharge summary followed the patients, but the medical history part needs improvement. although few patients, the results suggest that imcu patients had more complicated medication and more inappropriate drugs than stcu patients did. clinical pharmacist in a multidisciplinary team provides useful contribution to identify, solve and prevent clinical relevant drps, including inappropriate drugs. please specify your abstract type: research abstract background and objective: lack of clinical effects of medication review on health-related quality of life of older people may be due to insufficient focus on health-related complaints. goal attainment scales (gas) are an instrument to formulate specific health-related goals. the objective of this early process-evaluation of the dreamer-study (drug use reconsidered in the elderly using goal attainment scales during medication review) is to investigate if pharmacists are able to formulate gas during a medication review of older people with polypharmacy. setting and method: older patients aged years or older using or more medicines are included in this study. half of the patients were randomized into the intervention group, where they received a medication review. during the patient interview, the pharmacist formulated gas in concordance with the patient. recommendations were made to reach these goals in collaboration with the gp. main outcome measures: number of performed medication reviews, total number of formulated gas and the three most frequent types of gas. results: until now patients have been included in the drea-mer study ( % of the target). half of them ( ) were randomized into the intervention group. by now ( %) of these patients have received a patient interview. goal attainment scales were formulated yet. the number of gas ranged from to per patient. the four most frequent gas were: polypharmacy-reducing the number of medicines ( ), reducing pain ( ), increasing mobility ( ), reducing fatigue ( ). conclusion: gas seem to be a feasible approach during medication review that increased focus on patient's needs and health-related complaints. cp-pc : oral transmucosal fentanyl citrate: a regional survey of dispensing practices in community pharmacy please specify your abstract type: descriptive abstract (for projects) background and objective: oral transmucosal fentanyl citrate (otfc) is an opioid analgesic indicated for management of breakthrough cancer pain in patients with malignancies who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain. otfc are usually use off-label prescription, especially in noncancer patients or patients without opioid maintenance treatment. this practice can expose to iatrogenic risks, lack of efficacy, abuse and addiction. the observatory of drugs, medical devices and therapeutic innovation of upper normandy, conducted a study to assess the knowledge of pharmacists on these medications and assess dispensing practices (pharmaceutical analysis and advice to patients). design: between june and september , two quizzes were sent to the pharmacists and pharmacies in upper normandy: one included questions of knowledge and general practice, the other assess dispensing practices of otfc prescriptions received at the counter, regarding indication, dosage and associated opioid medication. results: of the pharmacists who participate in the survey, % know the all of the oftc specialties, % of them confuse transdermal and transmucosal fentanyl specialties. indication, dosage, titration methods and the main interest of oftc are known by , , and % of them. only % have dispensed oftc more than times over the past months, % never have. they already have dispensed oftc in noncancer patients ( %) or without opioid maintenance treatment ( %). they consider not know enough about these drugs to be able to provide the necessary advice to patient ( %) and would like specific training on oftc ( %). of the analyzed prescriptions, only % are consistent with the marketing authorization: otfc medicines are prescribing in noncancer patient ( %) and/or dosage is higher than four units per day ( %) and/or there is no prescribed opioid maintenance treatment ( %). only two prescriptions have been discussed with the prescriber, and all were approved and dispensed. conclusion: otfc specialties are occasionally dispensed and often misunderstanding by pharmacists. a good knowledge of otfc is necessary to achieve the pharmaceutical analysis and provided appropriate advice to patients, in order to guarantee the good use of these medicines. support tools for dispensation, recalling indication, . the most frequent interventions were drug substitution (n = ), dose adjustment (n = ), and clarification of information (n = ). common services were reconstitution of suspension (n = ), provision in advance for continuing supply (n = ), and follow up offers (n = ). conclusion: the observation of the dispensing process in community pharmacies revealed a broad range of tasks performed by the pharmacy and identified several variables likely to influence the counselling. in addition, pharmacy activities could be pictured by the documentation of pharmaceutical interventions. please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation (mr) is a multidisciplinary process to correct medication errors resulting from miscommunicated information at transitions of care. development of this activity is essential but it is hindered by the time required for its implementation. we must carefully choose which services can develop this activity. as it was recently introduced in cardiac surgery unit, this study aims to evaluate impact of this process to hospital admission (severity of potential harm of medication error intercepted) and to determine the relevance of this activity in this unit. design: prospective study conducted from january to april . the data is recorded in an excel table, filled after each mr. there are five items: patient's age, best possible medication histories (bpmh), implementation period of the mr, inadvertent discrepancies (ids) and clinical impact. to assess the severity of ids, a scoring method was used (doerper et al. ) with the cooperation of surgeon and pharmacist. results: eighty-two patients (mean age ± years old) were included in the study, which represents % of the patients hospitalized in this service. the mean number of drugs per patient was ± . the bpmh were obtained within h to h of admission to hospital. a total of ids were detected, with a mean of . ids per patient. the most frequent type of ids was omission ( %, n = ), error of dose ( %, n = ). the three most common classes involved in ids were hypolipaemic drug (n = ), antidiabetic drugs (n = ) and the drugs for acid related disorders (n = ). the mean of ids per patient ( . ) as well as the percentage of patients affected by a ids ( %) are less important in cardiac surgery than those observed in other services of the institution and in the literature. about clinical impact, % of patients presented with ids considered as minor, % significant and % major. among the major ids, none was evaluated as critical or catastrophic. in our study, this process remains retroactive. conclusion: one of challenge experienced when implementing mr process in hospitals is demonstrating its clinical impact. in order to address this concern, we found that the little ids with a serious clinical impact in this unit. mr is an interesting process to detect drug errors. to optimize our study we will improve our organization in order to be closer to the patient and to strengthen the doctor-pharmacist collaboration. please specify your abstract type: research abstract background and objective: special packaging like multidose drug dispensing (mdd) may optimize medication use in patients with a decreased ability to manage their own medication. however, it remains unclear how a 'decreased ability to manage medication' is defined. the objective of this study is to assess potential medication problems that contribute to a decreased ability to manage medication in patients starting with mdd compared to patients who use manually-dispensed drugs. setting and method: patients starting with mdd (cases) and patients using manually-dispensed drugs (controls) were interviewed in community pharmacies. questions to assess potential medication problems covered three domains; medication adherence ( ), practical management issues ( ) and medication knowledge ( ) . every potential medication problem was scored with one point. cognition was assessed with the mini-cog and frailty with the groningen frailty index (gfi). main outcome measures: mean scores of potential medication problems on the domains medication adherence, practical management issues and medication knowledge. results: patients starting with mdd and patients using manually-dispensed drugs were interviewed. patients starting with mdd scored more potential medication problems on all domains: adherence . versus . , practical management issues . versus . , medication knowledge . versus . . on the three domains together, patients starting with mdd scored . [ . - . ] potential medication problems compared to . [ . - . ] for patients with manuallydispensed drugs. forty-two percent of the patients starting with mdd might be cognitive impaired and % was classified as frail compared to and % respectively of the patients using manually-dispensed drugs. conclusion: patients starting with mdd reported significantly more potential problems on three domains that may contribute to a decreased ability to manage their medication. cp-pc : fifteen key questions to assess patient knowledge on new oral anticoagulants corina metaxas * , valerie wentzky, sonja luginbü hl, kurt e. hersberger, isabelle arnet please specify your abstract type: research abstract background and objective: knowledge on new oral anticoagulants (noacs) is crucial for their safe and effective use. validated tools that assess patient knowledge exist for vitamin k antagonists, but not for noacs. we aimed to identify which questions are relevant for patient knowledge on noacs. setting and method: based on a systematic literature search, questions were compiled for the assessment of noacs knowledge. key questions were selected through three rounds of ranking by an expert panel (four physicians, four pharmacists, four nurses). round (online survey; importance): the questions grouped into the nine educational topics of wofford,adapted for noac (disease, mode of action, risk-benefit, adherence, accessing healthcare professionals, diet/life-style, lab-monitoring, medication interactions, self-care) were to be rated as important/not important and educational topics were to be ranked according to decreasing importance. round (online survey; relevance): the questions were to be ranked according to decreasing relevance. round (focus group): number of questions was reduced by voting. main outcome measures: ranking of educational topics and questions ( = most important/relevant) in march/april . results: experts ranked adherence ( . ± . ) as the most important topic, followed by risk-benefit ( . ± . ), disease ( . ± . ), accessing healthcare professionals ( . ± . ), self-care ( . ± . ), lab-monitoring ( . ± . ), medication interactions ( . ± . ), diet/life-style ( . ± . ) and mode of action ( . ± . ). one question was judged as unimportant by all experts. out of the remaining questions, ( . %) were selected as relevant for basic knowledge, ( . %) were combined into four questions and one new question was generated. a total of key questions remained after the focus group discussion. conclusion: a multiprofessional expert panel was able to select key questions retrieved from literature and ensured content validity. the selected questions will be compiled into a tool to assess patient knowledge on noacs. background and objective: medicines use review (mur) was defined by the slovene chamber of pharmacies in december and an education program was set to assure pharmacists competencies. in june the first pharmacists were certified and implemented the service in the community pharmacies. additionally, an online database was established to collect mur reports and provide feedback on pharmacists' performance. the aim of the study was to evaluate identified drug related problems (drp) as well as pharmacists' interventions from mur documentation. setting and method: a preliminary retrospective analysis of documentation for mur services provided in the first year after implementation was performed. drps were classified using a slovenian drp classification system, which is based on the pcne classification v . [ ] . data were analysed with descriptive statistics measures. main outcome measures: number and type of identified drp and pharmacists' intervention. results: a preliminary analysis was performed on mur cases, performed by certified pharmacists. in total drps were identified: ( . %) manifested and ( . %) potential. patient had on average two drps, however patients had none. main risk factor for potential drps was inappropriate use of medicines. adverse drug events (ades) presented . % of manifested drps; the main risk factor was again inappropriate use. in two cases ades happened due to an allergic reaction. different medicines were the cause of ades; mainly statins resulting in muscles pain and sleeplessness. another frequently manifested drp was insufficient effectiveness of treatment. drug interactions were risk factors in cases of manifested drps, mainly in connection with antidepressants: serotonin syndrome due to escitalopram, bleedings in concurrent use of escitalopram and ginkgo, sleepiness, etc. pharmacist intervened independently in . % of cases; times recommendations were given to physicians. however, in . % of cases the outcome of intervention is unknown. the preliminary results of the first mur cases points to a high number of identified manifested drps. however, the knowledge of intervention outcomes is lacking and therefore more attention has to be put on establishing adequate follow up on this issue. official definition represented harmonisation of several similar activities that have already been performed in slovenian pharmacies and also provided an educational program to assure pharmacists competencies. in may the first pharmacists were certified and implemented the service in the community pharmacies. therefore, the aim of the research was to get an insight into the implementation of mur in slovenia from the perspective of the first community pharmacists that provide the service in practice. setting and method: a focus group with seven community pharmacists, that provide mur in practice, was run in february . guided discussion included three main themes: the development and assurance of competencies, experience with the provision of service in practice and the future of the service. the discussion was voice recorded and analysed with the nvivo . written consent from included participants was obtained. main outcome measures: views, challenges and opportunities for the medicines use review service in slovenia. results: in total themes were identified and organized in three main categories: competencies for quality provision of mur, mur's recognisability and organizational aspects of mur provision. participants emphasized broad knowledge in pharmacotherapy is pharmacists' key competence and advantage in performing mur when compared with other healthcare professions. recognisability of mur among other health care professions as well as participants' work environments is low. hence a comprehensive approach in marketing of the service is needed. positive patient's feedbacks were reported, however persuading patients to attend mur presented a challenge. another barrier was the time to perform mur, which could be overcome by suitable work organization and special time intended for mur. conclusion: participants of the focus panel had positive experience with the development of competencies and implementation of the service in the practice. several challenges were presented connected with the recognition of the service by patients, physicians and health care payer. they strongly believe that continuing professional development forms the base for quality of the service in the future. cp-pc : evaluation of rational antibiotic dispensing in the community pharmacy setting: a simulated patient study betul okuyan * , mehmet ali savan, fikret vehbi izzettin, mesut sancar please specify your abstract type: research abstract background and objective: in the present study, it is aimed to evaluate rationale antibiotic dispensing without prescription in the community pharmacy setting; this will be done by using a simulated patient methods. setting and method: this study was conducted in malatya, located in the east part of turkey. the simulated patient visited the community pharmacies to meet the pharmacist, posing as the husband of a patient with acute uncomplicated rhinosinusitis. the simulated patient was trained regarding the standard information to be provided by the researchers and informed about the privacy of all information that would be gathered during the present study. the sample size was sixty-seven pharmacies, with a confidence interval of % and error of margin of %. the study was conducted over a total of pharmacies. all the pharmacies were listed alphabetically and were randomly selected and allocated random numbers by a computerbased program. main outcome measures: after each community pharmacy was visited, the simulated patient filled the check list which had been drawn up for the purpose of the present study. due to ethical concerns, no audio or video records were used during the study. any suggested medications were not purchased from the community pharmacy. results: of the total community pharmacies that were visited . % of them had female pharmacists and . % were run by male pharmacists. the mean number of questions asked by pharmacists to the simulated patient was . ± . . only eleven pharmacists did not suggest any medication for the simulated patient. however, thirty-two ( . %) pharmacists recommended various medication regimens, including antibiotics. of them, . % referred the simulated patient to a physician. conclusion: in conclusion, it was observed that dispensing antibiotics without prescription was still high, pharmacists did not take comprehensive medical or medication history from patients, and pharmacists provided insufficient medication information to the patient regarding suggested medications at community pharmacy setting. to avoid irrational antibiotic dispensing, it is essential to educate both health care providers and the general population. although dispensing antibiotics without prescription is illegal in some countries, it is necessary to actualize new regulations to avoid antibiotic dispensing without prescription. please specify your abstract type: research abstract background and objective: the medication adherence is an important part of active (as well as passive) attitude of a patient to the disease treatment. it represents the level of keeping the treating procedure as well as the recommendations of doctors, pharmacists and other healthcare professionals. this study deals with the adherence in patients with hypertension. the hypertensive patients are a substantial part of patients, daily visiting the community pharmacy to pick their prescriptions. these patients represent group of patients with typical asymptomatic disease. this means that they do not take the medicines or use them according to their own will. the result of their non-adherence could lead to later complications. the aim of the study was to evaluate the level of adherence and its relation to the clinical outcome-the blood pressure in hypertensive patients. setting and method: the methodology was based on a single anonymous questionnaire survey combined with the blood pressure measuring in a community pharmacy in slovakia. the modified morisky -item medication adherence tool was used in this study. main outcome measures: the results of medication adherence were evaluated as follows: - points = full adherence, points = partial adherence and - = non-adherence. each participant should use at least one antihypertensive agent and fulfil the anonymous questionnaire in the community pharmacy. the pharmacist measured the blood pressure in each participant twice, within the interval of min and used the average value in data sheet. results: the research included hypertensive patients ( . % females and . % males). the results showed that almost % of the respondents were non-adherent to the prescribed pharmacotherapy ( . % of those were males and . % were females). the group of partially adherent patients consisted of . % of the respondents ( . % of those were female). only . % respondents were fully adherent according to modified morisky score ( . % of those were women). fully adherent patients reached an average blood pressure . / . mmhg; partially adherent hypertensive patients recorded an average blood pressure . / . mmhg; and in the non-adherent patients has been observed the average blood pressure . / . mmhg. the results showed an alarming situation, and confirm the published data. non-adherent patients could not goal the good clinical outcomes. this leads to adding of another medications, raising the risk of interactions and adverse drug reactions, complications of undertreated disease, and finally, to pharmacotherapy costs increasing. please specify your abstract type: research abstract background and objective: in psychology, depression is a mental state characterized by feelings of sadness, dejection, inner tension and indecision. in psychiatry, the depression is defined as a severe mental affective disorder which paralyzes clarity of thought, psychomotorics, sleep cycle and raises pessimistic and depressing emotions often lead to pathological changes of personality. during treatment of depression is often needed psychotherapy and pharmacotherapy as well. using of antidepressants requires the sufficient level of medication adherence in patients. non-adherence to antidepressant medication significantly contributes to the undertreatment of depression in primary care populations. the aim of this study was to evaluate the level of medication adherence to antidepressants to better understand the socio-behavioural factors associated with non-adherence. setting and method: the anonymous, face-to-face questionnaire survey was set in the community pharmacy in slovakia. questionnaire obtained questions on socio-behavioural factors and adherence tool-modified -item morisky score (mmmas- ). main outcome measures: respondents were patients ( males, females) using at least one antidepressant. the results were evaluated as follows: points = full adherence, - points = partial adherence and - = non-adherence. results were evaluated in relation to socio-behavioural factors. results: average level of the medication adherence in our group was , which means the line between partial and full adherence. the results showed non-significant higher medication adherence level in males ( ) compared to females ( ). the highest level of medication adherence ( ) has been shown in patients - years old, the lowest average adherence level (non-adherence) was observed in patients up to years old ( ). patient living in the city were more adherent to their medication ( ) compared to patients living in countryside ( ). the highest level of the partial medication adherence has been shown in secondary educated patients ( ). partial adherence level was higher in patients with monthly income over € ( ) compared to non-adherent patients with monthly income up to € ( ). in patients using no other medications, only antidepressant, we have observed the highest partial adherence ( ). conclusion: our survey showed the partial antidepressant medication adherence levels in our study group. poor adherence results in low stabilization of clinical state in patient, in using more types of therapy and in increasing costs. there might be very important role of the community pharmacists and other health care professionals to improve the medication adherence and persistence through counselling and education patients on importance and need of antidepressant medication. ( ) and medication regimen complexity was assessed by using the medication regimen complexity index (mrci) ( ) . five and more medication usage has been defined as polypharmacy. results: a hundred and two elderly subjects ( . ± . ; male) were included in this study. of them, . % had two and more chronic diseases. the most common chronic diseases determined in study population were cardiovascular diseases (especially hypertension), diabetes and hyperlipidaemia. the polypharmacy has been defined in . % of them. the mean of mrci per elderly patient was . ± . . one or more pims use was observed in seventy-four elderly subjects ( . %). of all elderly subjects, . % were dispensed one and more medicines with a potential for drug-disease/ syndrome interaction. pims use was more frequently determined in patients with polypharmacy ( . vs. . %, p \ . ). the total score of mrci was significantly increased with elevated number of pims (r = . , p \ . ). conclusion: this study highlights a significant association between utilization of pims and both polypharmacy and higher total score of mrci in elderly patients. pharmacists could be evaluated utilization of pims in especially elderly patients with used five or more medications and/or higher total score of mrci. please specify your abstract type: research abstract background and objective: nursing home patients with multimorbidity often use multiple drugs simultaneously, which makes these patients more susceptible to adverse drug events. several studies have pointed to a need to increase the quality of prescribing to this population. to achieve this there is a need for reliable information about patients' diagnosis, and what is recorded as the drug's indication in different electronical and handwritten health records. the aim of this study was to examine the registered diagnoses, and indications for drug use in nursing home patients. we also wanted to study the extent to which diagnoses are untreated with drugs, as well as the extent to which drugs have a registered indication for use and a suitable recorded diagnosis. setting and method: data was collected for long-term patients, on average years old, and % females from four nursing homes in tromsø municipality, norway. we retrieved information about patients' diagnoses and indication for drug use from the electronic health record and written drug charts. two pharmacists conducted the linkage between the reported diagnoses and drug use. main outcome measures: percentage of untreated diagnoses and the percentage of drugs with a registered indication for use. results: as considered by the pharmacists, % of the registered diagnoses was untreated with drugs. dementia, gout and osteoporosis were the most commonly untreated diagnoses with, , and %, respectively. in comparison, the indication for use listed on the patients' drug charts was reported for % of the drugs. the drugs with the highest percentage of recorded indications were acetylcysteine (n = ), oxycodone (n = ) and zopiclone (n = ), where , and % had a listed indication, respectively. conclusion: a high percentage of nursing home patients' diagnoses seem to be untreated. however, most drugs that patients received were listed with indication for use in the drug charts. to increase quality of drug prescribing, one should put emphasis on improving the recorded information in electronical health records. cp-pc : personal changes in drug regimen: dangerous for health system? inga urtane, raivis pastars, dace bandere please specify your abstract type: research abstract background and objective: patient compliance is a key factor for a successful treatment and lack of it is the main reason for predicting treatment failure. in multiple researches patient adherence is determined to be as low as %. therefore it is important to identify the reasons of patients not following their drug regimen. objective. to analyse the patient comprehension of their drug regimen depending on the duration of hypertension and received treatment. setting and method: during the period from december to march a quantitative survey was conducted to include respondents who have been diagnosed with arterial hypertension and whose regimen includes at least one fixed dose combination drug. main outcome measures: in an anonymous survey data was collected about their demographic information, co-morbidity, other prescribed medication, intake regime, the average blood pressure during treatment, and patient's assessment of the prescribed therapy. collected data was analysed with spss. results: the study included participants, most of whom ( . %) were women. participants average age was . ± . years and the median arterial hypertension duration was ( ; ) years. the study participants, who sometimes consciously adjusted dosing regimen, observed arterial hypertension for a longer period of time compared to the group, which follows the prescribed regimen according to their doctor's recommendation, respectively, ( ; ) vs. ( ; ); p = . . group of respondents (n = ) receiving c prescription drugs, more often deliberately adjusted treatment regimen compared to respondents (n = ) treated with b prescription drugs, respectively . versus . %; p = . . respondents who deliberately adjusted drug were more often not satisfied with the number of longterm daily use of tablets (n = ) compared to the group (n = ), which had to intake fewer tablets every day, respectively, . versus . %; p = . . conclusion: arterial hypertension duration was associated with more frequent conscious adjustment of therapy without consulting a doctor. more individual prescriptions (c ) and an increase in the number of tablets per day at the same time also increases the risk of patients deliberately changing their dosing regimen. long-term drug users should receive additional attention during pharmaceutical care process to their respective treatment schedule in order to promote proper use of medication. please specify your abstract type: research abstract background and objective: diabetes is a health issue and real burden for in belgians. better adherence to the treatment could potentially reduce complications, decrease morbidity and mortality, and have a beneficial economic impact due to fewer consultations and hospitalizations. setting and method: a one-year program was started in belgian pharmacies to accompany diabetes patients taking dpp- inhibitors and encourage them to be compliant with their treatment. this study concerns of these pharmacies, all part of the same cooperative group. all pharmacists received prior training in motivational techniques and reviewed the bases of diabetes therapy with an e-learning program. materials developed for the patients included brochures on diabetes and its treatment, nutritional advice, physical exercise, foot care and tips and tricks for diabetics. main outcome measures: the impact on pharmacological adherence was measured using mmpr and pdc. two control groups were included: a historical control group and a group of patients that were not included in the project. non-pharmacological adherence was assessed using questionnaires. results: in the subgroup of pharmacies, patients were included in the program. by the end of april , only of them had completed the program; patients came only once to the pharmacy. they either stopped their treatment after one prescription, or were occasional clients. adherence rates were found to be high in all groups ( . - . % of patients with mmpr b %). only for the pdc, a statistically significant difference was measured between the intervention and control group ( . vs. . %; p = . ). no other statistically significant impact was measured (neither pharmacological, nor non-pharmacological). conclusion: adherence was very high in all groups. the underlying reasons still need to be investigated (choice of adherence measure, healthy user effect, etc.). however, both patients and pharmacists were very pleased with this type of program. this new role of the pharmacist will definitely be more developed in the future. please specify your abstract type: research abstract background and objective: oral anticoagulants (oac) have a beneficial effect on the long term survival of patients with atrial fibrillation and venous thromboembolism. however oacs have also side effects such as bleeding, especially when used inappropriately. pharmaceutical care interventions aim to optimize medicines use and improve patient health outcomes. the literature lacks a review on the impact of pharmaceutical care interventions in patients using oac. therefore, we systematically assessed the impact of pharmaceutical care interventions on the effective and safe use of oac compared to usual care. setting and method: a systematic review was performed in pubmed and embase with synonyms/detailed specifications of the terms oral int j clin pharm ( ) . it was motivate for the need to sort the instruments for urm, including professional participation, and on the basis of the clinical management unit, and reduce variability in decisions. the p&t or ''multidisciplinary commission rational use of medicines'' is constituted by people: one hospital medical director (president), head of pharmacy (secretary), and three directors of healthcare centre, three directors of department of specialities, one epidemiology, one hospital pharmacy, one primary care pharmacy and one paediatric. because some of these members are far between them, and normally dose not have too much time, we create an online platform to work, discuss and download all the necessary documents. setting and method: we used the facilities of the andalusian agency for healthcare quality (www.acsa.junta-andalucia.es), and as a base the law of the administrative decision. we have organized a session to discuss methodology with the participation of all members. main outcome measures: number of meeting and number of internal discussion emails. drug or protocol decisions. design of the platform. results: the design platform consists of five tabs: ( ) has the member information, position, telephone and address, ( ) email forum, following a subject line, ( ) a place for meeting requests and then hang up the meeting minutes. ( ) a tool allows you to upload documents to the portal ( ) a search engine. two sessions are schedules and total of mails. we have of members who have never participated online. at this moment we have adopted two decisions. conclusion: it is an online experience of one andalusian p&t committees, the low turnout makes go slower than expected, therefore physical meetings are necessary in this moment. we are working how to get more participation and involve in the project the committee members. please specify your abstract type: research abstract background and objective: liver cirrhosis can have a major impact on drug metabolism, requiring evaluation of drug safety and dosage in individual patients. currently, there are no guidelines on safe prescribing for medications in patients with liver cirrhosis, and these patients have many questions about safety and side effects of medication. the objective of this study is to explore the patient's needs on information about medication. setting and method: qualitative, semi-structured interviews were performed in patients with a (history of) liver cirrhosis. the patients were approached through an item in the newsletter of de dutch association of liver patients. topics in the interview guide were preferences about information about medication, side effects, safety, drug dosage, and how patients preferred to receive this information. interviews were audiotaped and transcribed verbatim. interviews were analysed using thematic content analysis. main outcome measures: the experiences and needs of patients with liver cirrhosis concerning information about medication. results: patients indicated they had received sufficient information about the indication, possible drug-drug interactions and the duration of treatment. they preferred (more) information about how medications work, what adverse drug reactions could be expected and practical aspects concerning intake of medication. informational needs were related to questions 'how to act': patients with more informational needs took a more active role in responsibility for their own medication management. patients needed information to know what to do, e.g. in case of adverse drug reactions or when a dosage was forgotten. the doctor and internet were the preferred sources of information: doctors because of the personal contact and internet because of the accessibility. facilitating factors were 'taking time' in healthcare provider-patient contact and 'everyday language' for texts on the internet and in package leaflets. a combination of verbal information by the healthcare professional and written information was preferred. conclusion: patients with liver cirrhosis need information about medication to take an active role in their drug management. comission for medicines and medical devices, chu de toulouse, toulouse, france please specify your abstract type: descriptive abstract (for projects) background and objective: due to its common use, insulin is often considered as a harmless medication by lots of health professionals while an overdose can lead to dramatic consequences and death. between january and june , in our university hospital, % ( out of ) of the declared adverse drug events have involved insulin: were caused by prescription errors and by administration errors. all were discovered after the medicines have been administered but thankfully none had serious consequences. the british national health service (nhs) and the french medication safety national agency (ansm) made a list of ''never events'': avoidable events which should never happen and misadministration of insulin is among them. the objective was to increase patient safety in the hospital by setting different actions to promote and improve the appropriate use of insulin and warn health professionals about the real dangers of this medicine. design: different actors participated in the implementation of these actions: the commission for medicines and medical devices (which is composed by doctors and pharmacists) directed a group made by physicians and clinical pharmacists from the department of cardiological and metabolic diseases'. results: in addition of the usual analysis of any adverse event linked to medication declared in the hospital, several actions were set up: • a didactic document summarizing all the ''sensitive'' steps during the prescription, stocking, dispensation and administration of insulin has made the front page of the hospital's intranet and was also diffused throughout the establishment. • a chart resuming all the different insulins commercialized in france has also been diffused. it contains their types, durations and onsets of action, conditions of storage and pictures of their packaging. • the computerized protocols involving insulin are going to be reviewed in order to lower their numbers and harmonize their content. • a revision of the list of insulins available at the hospital is in progress to reduce their number and avoid any confusion between the different products. • an evaluation of insulin's computerized prescription practices will be made via a data request. : this topic about insulin shows a greater willingness to secure the medication circuit in the hospital. other action plans such as this one will be set up involving other medications among the never-events list. meanwhile, the commission for medicines and medical devices pursues its actions of promoting the appropriate use of medication. please specify your abstract type: descriptive abstract (for projects) background and objective: one of the hospital pharmacist tasks is to suggest substitutions to ensure conformity of medical prescription with the hospital formulary. indeed, when an eye drop isn't available at the hospital, there is a specific supply circuit which has to remain exceptional: it's ordered directly to the pharmaceutical wholesaler. in this context, ophthalmologists and clinical pharmacists created a table proposing therapeutic equivalencies with eye drops available at the hospital. after approval by the commission for medicines and medical devices, this tool has been diffused within the establishment via the intranet website since the beginning of to the medical and paramedical staff. the purpose of the study is to evaluate professional practices concerning the use of the eye drops' equivalence chart. design: in the study, we compared eye drops' orders made to the pharmaceutical wholesaler before and after the table's diffusion, thus between january and december . for each order, we used the table available at this time to determine if equivalencies could have been proposed or not. if so, we identified the hospital ward and the pharmaceutical specialty. market changes have also been considered. results: we noticed a decreased frequency of eye-drops ordered despite available equivalencies: % in (before the table's diffusion), % in (after its diffusion), % in and % in . prisons units are responsible of % of these orders: they have the lowest rates of substitutions. their most ordered pharmaceutical specialties are ophthalmic glaucoma agents: % ganfort Ò (bimatoprost . mg/ml/timolol . %), % xalacom Ò (latanoprost + timolol . %), % azopt Ò (brinzolamide) for which the authorized substitutions are for the first two specialties: monoprost Ò (latanoprost) + ophtim Ò (timolol . %) and for the third: dorzolamide Ò . conclusion: equivalence table diffusion throughout the hospital has facilitated and improved the prescription and substitution of eyedrops. orders of pharmaceutical specialties despite authorized equivalencies available have declined by half. probably for practical reasons regarding long-term treatments, prison units make less substitutions but an awareness campaign will be carried out to reduce these rates. please specify your abstract type: research abstract background and objective: the patient's education and information is a mean to reduce medicine misuse and it can be performed with support of a leaflet or informative material about medicines. in brazil, there is a lack in regulation about this type of informative material to compounded medicines. the aim of this study was to evaluate the quality and effectiveness of leaflets developed to compounded medicines' users through knowledge's level and medicine treatment adherence. setting and method: analytical and quantitative study; month prospective study through interviews, at time zero (t ) and after days (t ) in a university pharmacy in goiás, brasil; fisher's exact test to measure effectiveness; ethics committee number / . main outcome measures: categorization into high adherence and low adherence by morisky test; categorization into sufficient, regular or insufficient knowledge about medicine prescription; perceptions and suggestions about delivered leaflet in medicine dispensing process. results: of patients ( . % female, mean = . years), . % considered as relevant the leaflet's content, as well . % of them kept it and . % of them read it. suggestions of . % included a desire in increase font size, more emphasis on drug interactions and images. there was a predominance of regular knowledge in both analysed times ( . % e . %), however there was a decrease in high adherence to medicine treatment ( . - . %). among patients who read the leaflet, no statistically significant association was found on these two variables at t and t (p = . and p = . , respectively). knowledge about ''administration schedules'' showed a significant improvement after intervention (p = . ). . % of patients considered that there was no need to obtain more information. conclusion: this study demonstrates the evaluated leaflets had relevance to patients and demonstrate clinical relevance. however was not observed statistically significance. this highlights the need of using different ways to measure the effectiveness of an informative material to promote rational use of medicines and depth studies and stimulation of greater attention from the health professionals to the topic. di : chlormethine gel: effectiveness and tolerance to treat mycosis fungoides françois dugre *, , anne lefebure , sonia martelli , marion pin , eve maubec , philippe arnaud pharmacy, dermatology, bichat-claude bernard hospital, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: to determine the effectiveness and tolerance of chlormethine gel in treating mycosis fungoides. design: mycosis fungoides is the most common form of cutaneous t-cell lymphoma (mf-ctcl). early stages (ia and ib) can be controlled by skin-directed therapies such as chlormethine and carmustine. these drugs which are solutions for injection are usually used for skin application. chlormethine or mechlorethamine gel is an alkylating agent representing an alternative for previously treated patients diagnosed with mf-ctcl, in case of therapeutic failure and intolerance, or in case of chlormethine and carmustine solutions supply disruption. a retrospective observational analysis was conducted based on medical records of all patients treated by chlormethine gel in our hospital from the first of july to the first of september . the following data were collected with an excel table: body surface area or bsa affected by disease, location of the lesions, therapeutic management, effectiveness and treatment tolerance. results: fourteen patients ( women, men, mean age [min ; max ]) were treated with chlormethine gel in our hospital. twelve ( %) were treated three times per week, ( %) once a day. before treatment by chlormethine gel, ( %) patients were treated by dermocorticoids, ( %) by dermocorticoids and phototherapy, and ( %) by bexarotene, all of them stopped their treatment on account of inefficacity. one ( %) patient was treated by carmustine and dermocorticoid, and ( %) by only carmustin, all of them stopped it because of supply disruption. one ( %) patient received it in first line therapy. ten ( %) patients showed a response (partial or complete), one ( %) experienced a stabilization of his disease. before treatment with topical chlormethine, seven patients ( %) had an involved bsa [ % and four of them ( . %) experienced adverse effects. seven patients ( %) had an involved bsa \ % and three of them had ( . %) side effects. a total of seven patients ( %) presented at least one adverse effect. five patients ( %) stopped the treatment on account of adverse effects; two of them ( %) interrupted it temporarily. reported side effects were: irritant dermatitis and erosive toxicity ( ), rash ( ) and telangiectasia ( ) . conclusion: our results indicate that chlormethine gel can be effective to treat mycosis fungoides. however, it involves side effects that seems to be more frequent than those observed with chlormethine solution (used for skin application). indeed, the french national authority for health reports % of adverse effects for chlormethine solution versus % in our study for chlormethine gel. moreover, telangiectasia was never documented with chlormethine. this significant number of side effects of chlormethine gel can be explained by the gel formulation which induces patients to apply more product, especially in patients with plaques affecting more than % of the bsa. it is important to explain to patients to apply a thin film of chlormethine gel to involved skin areas and allow the skin to dry completely. sophie dumas *, , capucine devaux , nathalie le guyader diaconesses croix saint-simon hospital, diaconesses croix saint-simon hospital, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: aprepitant, a neurokinin- receptor antagonist, prevents nausea and vomiting due to high and moderate emetogenic chemotherapy in combination with other antiemetic agents. it induces cytochrome p (cyp) c and moderately inhibits cyp a . drug-drug interaction could occur with intravenous anticancer or antiemetic drugs metabolised by these isoenzymes. it may lead to adverse effects or loss in efficacy. regarding recent international antiemetic guidelines, emergence of new intravenous chemotherapy and lack of bibliographic data, a report on aprepitant interactions is performed in oncology. the aim of this study is to review pharmacokinetic interactions with aprepitant in order to prevent potential toxic effects of intravenous anticancer or antiemetic agents and provide the best patient care. design: anticancer and antiemetic agents metabolised by cyp a and c were identified. pharmacokinetic literature review was performed using medline Ò database and laboratory data. clinical assessment and non-aprepitant pharmacokinetic studies were excluded. a table was established to summarize data. results: ten intravenous anticancer agents used in oncology are identified as cyp a substrates. pharmacokinetic assessments are achieved for docetaxel, cyclophosphamide, vinorelbine, irinotecan and trabectedin. studies dealing with the five other drugs are strictly clinical assessments. among the different pharmacokinetic studies, only trabectedin showed relevant interaction with aprepitant. in this association, aprepitant dose needs to be adjusted. cyp c catalyses the cyclophosphamide activation pathway with minor contribution. however, it would have few repercussions on cyclophosphamide pharmacokinetic. corticosteroids and hydroxytryptamine type ( ht- ) receptor antagonists are also metabolised by cyp a . aprepitant significantly increases corticosteroid plasma concentrations. in this case, corticosteroid dose adjustment should be applied. furthermore, no interaction has been found with ht- receptor antagonist. conclusion: regardless of the emetogenic level of anticancer agents, all drugs have been studied because of theirs potential combinations. two relevant pharmacokinetic interactions have been demonstrated leading to dose adjustment recommendation. corticosteroids doses, in association with aprepitant, should be reduced one-fourth for intravenous form and one half for oral form. aprepitant first dose should be decreased to mg when it is co-administrated with trabectedin. these two results lead us to re-evaluate our prescription practices. please specify your abstract type: research abstract background and objective: nsaids are associated with serious adverse reactions which in turn are responsible for significant risks of morbidity and mortality. the aims of this project is to identify risks involved in nsaid administration including over-usage and significant drug interactions, and to analyse occurrence of side-effects. the trends of nsaid prescribing by physicians and pharmacists are also determined. setting and method: a pharmacy from each electoral district was chosen by stratified sampling. a sample population (n = ) was obtained from pharmacies in malta. data was collected through the completion of questionnaires carried out by the patients. the trends of nsaid prescribing were determined by another questionnaire directed to pharmacists and physicians that was available online. main outcome measures: use of nsaids by patients and prescribing trends. results: back pain (n = ), muscular pain (n = ), headache (n = ) and arthritic pain (n = ) accounted for the most frequent use of nsaids. diclofenac accounted for the most commonly administered nsaid, taken by of the patients, of which use the mg dose. chronic disorders of symptoms experienced by the patients included hypertension (n = ), heartburn (n = ), dyspepsia (n = ), asthma (n = ) and a history of helicobacter pylori infection (n = ). other disorders suffered by single individuals include epilepsy, crohn's disease and renal dysfunction. more than half of the respondents (n = ) admitted to self-prescribing regardless the fact that the majority of nsaids are prescription-only medications. epigastric pain ( . %), stomach ulcers or gi bleeding ( . %) and elevated blood pressure ( . %) were the most common sideeffects that pharmacists and physicians come across. nsaids were frequently found to be co-administered with antihypertensives ( . %) and ssris ( %) regardless of their significant risks of interacting with nsaids. . % of the pharmacists and doctors believe that nsaids are being over-used and . % state that closer monitoring of nsaid adverse effects is necessary. conclusion: the risk involved with nsaid administration due to over-usage and drug interactions is identified, and healthcare professionals are aware of this risk. pierre leduc, antoine lanneluc, christophe gellis * , sylvie poux, dominique plats, regine larnaudie corrèze, ch brive la gaillarde, brive la gaillarde, france please specify your abstract type: research abstract background and objective: proton pump inhibitors (ppi) are widely prescribed in hospital while their long-term use may be responsible of many potentially serious long-term side effects (hypomagnesemia, neutropenia, gastric cancer) and drug interactions (ppi are inhibitors of cyp c ). the objective of this study was to assess the appropriateness of ppi prescriptions in a geriatric department in order to optimize their conditions of prescriptions. setting and method: this prospective study involved patients hospitalized between january and april in a geriatric department. the accordance of the prescriptions with the marketing authorization indications and the french guidelines was analysed. data collection was done using a table excel. main outcome measures: collected information were related to patients (age, sex) and ppi prescriptions (active substance, administration route, dosage, duration of therapy, therapy indication and reassessment of ppi therapy). results: ninety-one patients were included: sr: . , mean age: . years [ ; ]. ppi therapy prevalence over the period was %. the ppi were prescribed in the geriatric department in patients (mostly esomeprazole) whereas patients had ppi therapy (mostly esomeprazole) at the admission, for more than years in patients. oral route was the most frequent one (n = ). ppi were administered once a day and only three ppi were administered in the morning. % of ppi prescriptions were considered unjustified; the indications were prevention of haemorrhage with antiplatelet therapy (n = ), prevention of haemorrhage with corticoid (n = ), prevention of haemorrhage with anti-vitamin k (n = ), dyspeptic disorders (n = ), gastralgy (n = ) and others reasons (n = ). % of ppi prescriptions were considered relevant. the reassessment of ipp therapy (n = ) lead to prescribe another dosage (n = ), to stop therapy (n = ) or no change (n = ). conclusion: the study showed that the majority of ipp prescriptions were not in accordance with french guidelines. limiting the prescription to the indications, reassessing the therapy or respecting the therapy duration should reduce the risk of long term side effects and the economic burden of ppi in a long term use. please specify your abstract type: descriptive abstract (for projects) background and objective: to evaluate the effectiveness and safety of the use of high dose of tigecycline ( mg followed by mg every h) a tertiary care hospital. design: retrospective observational study. period: january to december . inclusion criteria: episodes use of tigecycline ( mg followed by mg every h. exclusion criteria: time less than days treatment. data source: corporate program stories electronic health. results: we identified episodes in patients ( men, mean age: years ( - )). treatment was directed to multidrug-resistant organism infection in cases (seven klebsiella pneumoniae oxa- , two enterobacter cloacae, two enterococcus faecium and one methicillin resistant staphylococcus aureus. in one episode they coincided e. cloacae and e. faecium). in cases had severe sepsis or septic shock (seven abdominal focus, six respiratory focus and one unknown focus). the median number of days of treatment was ( - ). tigecycline was administered as monotherapy in three cases, bitherapy and triple combination therapy in . the antibiotics were associated were: beta-lactam ( ), aminoglycosides ( ), quinolones ( ) colistin (three, two inhaled cases), cotrimoxazole ( ) and vancomycin ( ) . in episodes produced clinical and/or microbiological resolution and antibiotics are rotated by progression picture or lack of improvement, death occurred in three cases and was suspended on suspicion of hepatotoxicity. among the seven episodes of klebsiella pneumoniae oxa- infection there were four pneumonias, three with favourable evolution and one patient died, two bacteraemia, both with resolution clinical and microbiological, and one urinary tract infection resolved. among the episodes in severe/ septic shock were five cures, six cases of antibiotic rotation progression or lack of improvement and three deaths while patients receiving therapy tigecycline. patients showed an adverse effect possibly related to therapy tigecycline: diarrhoea after days of treatment and case of liver toxicity after days of tigecycline and piperacillin-tazobactam which led to their withdrawal. int j clin pharm ( ) : - conclusion: tigecycline has been used in double dose defined in data sheet especially in situations of severe sepsis or septic shock and infection multiresistant microorganisms. the effectiveness is conditioned by the clinical situation patient, being worse in severe/septic shock sepsis. tigecycline high dose was well tolerated and there was only a case of stopping the medication for suspected damage hepatic. di : wikipedia and medicines: who edits medicine articles on the english wikipedia? kristian husvik skancke , kristian svendsen *, department of history, uit -the arctic university of norway, hospital pharmacy of tromsø, tromsø, norway please specify your abstract type: research abstract background and objective: the medical profession and pharmacists are divided on the usability of wikipedia for looking up health information. nevertheless wikipedia is widely used, more than half of us physicians and percent of all medical students use wikipedia as a source of health-related information. there is a potential for incorrect and biased information being added by the pharmaceutical industry. the aim of this project was to examine who edits wikipedia articles on medicines and to investigate whether the pharmaceutical industry edits these articles. setting and method: two different groups of articles has been examined; the top ten bestselling medicines (substances) in the world in and the ten most recently approved medicines on the european market (until december ). the top ten medicines were selected from a consultancy report by evaluatepharma/ep vantage. the ten most recently approved medicines (new substances) were found on the european medicines agency webpage. we queried the english wikipedia on january and information from the edit history and the editors' user information were extracted. unregistered editors were checked using a whois service. for the new medicines all editors were checked, while for the bestselling medicines large edits and initial edits was checked. main outcome measures: edits suspected of being made by the pharmaceutical industry. results: ten bestselling medicines: there are many users editing these articles and/or watching them, limiting the risk of misinformation from the industry. there was no indication that the pharmaceutical industry had edited any of the articles. ten most recent medicines: no article existed for dasabuvir. for the nine other substances there were relatively few editors and watchers. in four out of the nine articles we found evidence of edits from the pharmaceutical industry. these edits, were done by registered editors with very few edits except for the medicine in question and they had made large additions to the articles sometimes even before the medicine was marketed. conclusion: the pharmaceutical industry seems to edit articles about medicines on english wikipedia however we found no evidence of harmful edits and bestselling medicines have many editors monitoring the quality of articles. please specify your abstract type: research abstract background and objective: the pharmaceutical professional service of the monitored dosage systems (mds) tries to improve the adherence of the patients to the treatment. the aim was to analyse the relevance of the repackaging of the most sold medicines in our country being used by patients included in the mds professional service and to determine the information discrepancies according to the source used by the pharmacist. setting and method: cross-sectional descriptive study. community pharmacy and healthcare institutions. all the patients included in the pharmaceutical professional service of mds on june , . data source: patients' records in the professional service, database of medicines ranked by sales in units in our country to december ( medicines), information sources on medicines: ( ) vademecum of medicines and ( ) the centre of drug information of our agency of medicines. main outcome measures: number of institutionalized and ambulatory patients included in the professional service of the mds and demographic characteristics, sum of different repackaged medicines belonging to the studied patients, analysis of the repackaged medicines of major use, number of discrepancies on the repackaging of the medicines according to the information source. results: patients were included in the professional service of the mds. of them were institutionalized (average age: . years, . % men, . % polymedicated defined as using c prescribed chronic medicines) and the remaining were ambulatory (average age: . years, . % women, . % polymedicated). different medicines prescribed in the institutionalized patients were taken into account, of them included in the sales ranking in our country. according to the first source, of medicines were eligible for repackaging, medicines could be repackaged according to the laboratory manufacturer and the remaining ones could not be repackaged. according to the second source, of medicines could be repackaged, and the remaining ones could not. different medicines prescribed in the ambulatory patients were taken into account, of them included in the sales ranking in our country. according to the first source, of medicines could be repackaged, medicines would depend on the laboratory manufacturer and the remaining ones could not be repackaged. according to the second source, of medicines could be repackaged, and the remaining ones must remain in the original package. discrepancies were observed in the information for ( . %) and ( . %) medicines in institutionalized and ambulatory patients, respectively, based on the sources used. conclusion: a considerable number of discrepancies in the information on the relevance of the repackaging of medications in the mds were found between two analysed sources. these findings have already improved the quality of this professional service. it would be necessary to alert the pharmacist of the existence of the above mentioned discrepancies to be able to prevent errors from occurring at the time of repackaging the medicines in the mds and, thus, increasing patient safety. please specify your abstract type: research abstract background and objective: despite the global advances of pharmacy practice and subsequently pharmacy education, students experience insufficient opportunities to practice the activities, tasks and processes essential to deliver pharmaceutical care. objective: to describe the development, implementation, and assessment of a clinical pharmacy practice (cpp) experience course in internal medicine, cardiovascular, respiratory clinics and drug information centre that is newly integrated into pharmacy curriculum at a university in north cyprus. setting and method: a weeks structured pharmacy practice experience was designed for fifth year students. student competence was assessed using formative osces and summative written exams before and after the course, and mapped in eight main cpp competences. the course utilized a wide variety of learning and practical activities including rounds participation, morning case reports, interdisciplinary activities, carrying interventions, role-play, direct patient care, formal case presentations, journal clubs and answering drug queries. competencies tested and strengthened include: taking medication history, response to the symptoms, pharmacotherapy knowledge application, comprehensive patient assessment, data interpretation using evidence-based approach, public health counselling, drug related problems management, patient counselling and communication skills. student perceptions and experience was assessed using semi-structured group interview and a questionnaire. main outcome measures: student scores in osce; student's perceptions. results: student reported that the course met pre-set objectives with substantial learning in different areas of cpp. students scored best in communication skills ( . ± . %), public health promotion ( . ± . %) and patient counselling ( . ± . %) than in resolution of drps ( . ± . %) and pharmacotherapy application ( . ± . %), while they significantly enhanced in di manipulation ( . ± . %) compared to baseline assessment ( . ± . %)(p = . ). conclusion: the course provided a rich experiential learning environment rather than just theoretical knowledge of clinical pharmacy. students well perceived the course structure assessment and knowledge attained. this could be implemented in other faculties of pharmacy through turkey. please specify your abstract type: descriptive abstract (for projects) background and objective: clinical pharmacy and clinical pharmacology have many similar aspects. both areas present professionals who have groundings in drug therapy principles and who aim to optimize the efficacy and safety of therapies for patient's benefits. however, there are clear distinctions. clinical pharmacologists are in general doctors with an additional education in clinical pharmacology. many of these are prescribers of drugs in practice but are in usual connected to academic parts responsible for education and research. they belong to a well-recognized but small sub-specialty of medicine. in contrast, clinical pharmacists are part of a much greater group of professionals working in most hospitals in developed countries. while the former one is restricted and subordinate to distributing the drugs requested by the medical prescribers, the role of the pharmacist has increasingly developed to encircle monitoring outcomes of medicine treatment and report management, patient safety and budgetary responsibilities. pharmacists are currently capable to take on prescribing responsibilities in developed countries and have been actively involved in collaboration in practice of prescribing with doctors. they also take on a great part in education related to rational prescribing that was once thought the area of the clinical pharmacologist. given the difference in size of the two areas there is understandably increasing confusion in the minds of managers in health services as to the continuing role and identity of clinical pharmacology. this may illuminate, in part, the diminishing in numbers and visibility of clinical pharmacologists in certain countries. in fact, some might see the continuous development of clinical pharmacy as a direct danger to the viability and future existence of the specialty of clinical pharmacology. however, clinical pharmacy and clinical pharmacology working synergistically would serve for the well-being of the public. design: . results: . conclusion: . maxime apparuit *, , lea boissinot , ngauv melodie , stephanie charles weber , isabelle lopez , françois chast pharmacy, hopital cochin, pharmacy, hopital hotel-dieu, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: hereditary angioedema (hae) is a rare disease characterized by episodic attacks of swelling which can be life-threatening. treatment for hae involves prophylaxis and management of acute attacks. the objective of this study was to evaluate patients' knowledge of their disease and their treatment. design: a questionnaire about the disease and drug treatment has been implemented. it was distributed to patients through either a pharmacist during patients stay at the hospital, or the french association des malades souffrant d'angioedèmes (amsao). answers were collected by electronic or conventional mail. results: patients completed the questionnaire. the average patients age is . ± . years. all of those interviewed could name their disease. for % of patients, the crisis happened unpredictably but in most cases a triggering factor was described, such as stress ( %), fatigue ( %) or an emotional shock ( %). oedema were located mainly in extremities ( %), abdomen ( %), ent sphere ( %) or face ( %). patients ( %) reported having more than crisis each year (eligible to prophylaxis), among them, patients ( %) said they had no preventive treatment. all patients knew the difference between prophylactic and curative treatment of crisis. among the patients receiving treatment for crisis, were able to define which treatment to be used depending on the intensity and location of the crisis. the majority of patients used icatibant during a crisis, but the most frequently cited prophylaxis treatments were tranexamic acid ( %) and danazol ( %). for injectable drugs to treat acute episodes, icatibant (subcutaneous) and c esterase inhibitor (intravenous) were self-administrated respectively in and % of patients. conclusion: this study showed that patients generally knew their disease and its treatment. however, they are insufficiently informed on drugs to be used according to the clinical situation and especially intravenous self-administration. therefore, it seems necessary to increase pharmacist involvement in patient's information about therapeutic strategy and drugs routes of administration. this for a major objective: an optimal self-care in a skilled patient. please specify your abstract type: descriptive abstract (for projects) background and objective: hospital pharmaceutical educations (hpe) on patients with oral anticoagulant (oa) can improve their overall management by providing skills on proper use. an ambulatory monitoring is necessary to ensure good compliance and understanding of the treatment. our study aimed at the establishment of hpe for patients with oa, the establishment of a hospital-city link in burgundy, and an evaluation of the expectations of ambulatory health professionals (ahp). design: the development of hpe has been performed in our centre for patients with oa and assessed between may and september . in order to ensure continuity in their support, patients then received a binding document to the attending physician, pharmacist and nursing home stating the treatment and acquired skills. a satisfaction survey, with anonymous electronic questionnaire circulated by the representative boards evaluating the expectations of ahp, took place in order to improve and make the programme more attractive. results: two hundred and ninety-one patients could benefit from hpe and came out with an oa. one hundred and forty-three answers were collected: officinal pharmacists and nurses. ninety-seven percent of ahp have judged relevant the following stated security goals: the name of the drug, its use, its risks and to be able to inform all ahp. ''associated pathologies and treatments,'' ''the last coagulation test'' and ''potential factors for non-adherence'' seem necessary for the binding document. more than % of participants found that this action will facilitate the establishment of pharmaceutical anticoagulant educations in cities, the dialogue around the oa with the doctor, patient's compliance and will secure the treatment. conclusion: hpe certainly help patients. its implementation for patients with oa in our hospital has generated a real interest. the addition of an ambulatory link allows continuing at best their support. the questionnaire has also allowed us to know the opinions of ahp involved and some improvements to the binding document may have been done. participants were asked to associate the task to the profession by determining whether each profession had the main responsibility for undertaking the task, a supportive responsibility, or whether they should not be involved at all. data was analysed using spss Ò, version . the chi squared test was used to assess any significant association between categorical variables. main outcome measures: perception of the oncology pharmacist's role by healthcare professionals. results: from a total of completed questionnaires, it was found that for tasks listed as ''patient education and counselling'', % were considered as the pharmacists' main responsibility, whereas % were believed to be supportive roles. main tasks included educating the patient regarding which medication to avoid during their treatment. for tasks listed as ''drug related problems'', and % of tasks were found to include pharmacists as having main and supportive roles respectively. supportive tasks included dose calculation of anti-tumour therapy required per patient. in the ''authorisation of medication'' category pharmacists' main roles carried a total of % and supportive that of % of the total number of tasks. this included ordering anti-tumour medication. further analysis of data revealed that years of experience did not have a significant association with results obtained (p-value = . ); however physicians, pharmacists and allied healthcare professionals were found to involve the pharmacist most extensively (pvalue = . ). conclusion: tasks associated with the pharmacist were representative of the current role they possess within the oncology setting; however this association was limited to professionals having a close working relationship with pharmacists. this may be due to the lack of an established multidisciplinary team approach within this scenario thus limiting the perception of the oncology pharmacist's contribution. an implemented multidisciplinary team may improve communication between the professionals involved and optimises patient care. the aim of the study is to analyse from a qualitative and quantitative point of view the pharmacy resident's activity in pneumology service. setting and method: the study included all the daily prescriptions of three units of pneumology from january to april . pi and data were extracted from the software pharma Ò and collected in a summary excel Ò table: nature of potential errors, nature of the proposals offered by residents, way of transmitting pi, and rate of pis' acceptance. main outcome measures: potential errors are collected by following the validated and standardized criterions of french society of clinical pharmacy. results: over months, lines of prescriptions from patients aged years old (median [ - ]) were evaluated. sex ratio (m/f) was . . one hundred and two medication problems have been found: overdose ( . %), contraindication (ic) ( . %), under dosage ( . %), wrong rhythm of administration ( . %), forgotten treatment ( . %), dose unit error ( . %), antibiotic indication missing ( . %), drug not listed in the hospital formulary ( . %), potassemie unchecked ( . %), dose unadapted to renal function ( . %) or to inr ( . %), treatment not indicated ( . %), wrong administration route ( . %), antibiotic unreevaluated ( . %), redundancy ( . %). the proposals made to the doctors were: stopping treatment ( . %), posology adaptation ( . %), substitution ( . %), dose unit modification ( . %), adding information about the indication ( . %), treatment renewal ( . %), administration modalities changing ( . %), biological monitoring ( . %), therapeutical monitoring ( . %), antibiotic treatment reevaluation ( . %). all pi were made by informatical way. all medicinal classes were found in this study. hydroxyzine, cyamemazine and escitalopram were often found in contraindication errors. they are involved in cardiac disorders with qt extension. pis' acceptance rate was %. conclusion: this study shows the importance of pharmaceutical analysis on the quality of access to healthcare. the statement of pi allows us to identify the most frequent errors, warn and prevent doctors from these potentials errors by proposing solutions. the rate of acceptance is high which means that doctors agree with our proposals. pharmacists' implication in clinical pharmacy activities and their participation to medical rounds will improve this activity and by the way optimization of the management of the patient. please specify your abstract type: descriptive abstract (for projects) background and objective: ppis consumption is largely practiced in europe, because of their excellent tolerance in short time, and their misuse with regard to indications, dosage and treatment duration (in , france was the nd,ppi consumer in eu). the result is drug iatrogenic disease and unjustified expenses in health insurance. objectives: assess the ppis consumption and appreciate conformity according to the latest recommendations for relevant prescriptions of ppis. design: prospective study via an audit (model created internally), every hospitalized patients with a ppis prescription, in two hospitals, on a given day. data collected through the patient's medical record. prescriptions conformity defined, by taking account of indication level ( : approved by the ma (marketing authorization), : non-valid but certified by international publications or learned society, : nonvalid without scientific proofs, : non-indicated), dosage and treatment duration. analysed situations with no conformity (inappropriate dosage despite conform indication, treatment duration unjustified and ppis prescribed in wrong indications ( and ) . results: patients have ppis prescriptions ( male, £ years] among patients ( %). % ppis prescriptions began during the hospitalization. ( %) of the ppis prescriptions are in accordance with the experiment (indication + dosage +treatment duration), as well in community than in hospitals. details: indication level ( . %), indication level -gi bleedings-( . %). of the ppis prescription aren't in accordance. details: treatment duration ( %), dosage ( %), indication level -prevention of iatrogenic bleeding risk without nsaids prescription-( %), indication level ( %). regarding level indications, ppis are always taken with anticoagulant and/or platelet aggregation inhibitors and/or corticoid. conclusion: the part of ppis prescriptions in this study is high. the majority of non-conformity is caused by ppis prescribed with an indication level . the improvement program will involve feeding back ppis' good use, to educate physicians (junior and senior) about the relevant ppis prescription and give advice in complex situations (indication and ). in collaboration with prescribers, shutdown protocol of ppis, prescribed in long term, could be implemented in order to avoid the acid rebound effect after brutal treatment discontinuation. hp-ce : impact of a self-management program on inflammatory bowel disease patient in a university hospital caroline egon * , xavier pourrat please specify your abstract type: descriptive abstract (for projects) background and objective: inflammatory bowel disease (ibd) is a group of chronic inflammatory diseases that affects the colon and the small intestine. crohn's disease and ulcerative colitis are the principal types of ibd and involve severe diarrhoea, pain, fatigue and weight loss. ibd affects young adult with an increasing annual incidence ( . million concerned people in europe). patients with ibd are affected by somatic or psychosocial problems and patient education may contribute to their well-being. since september , individual educational sessions have been set up and since september , collective educational sessions. these sessions have been developed to improve patient's understanding of treatment options and medical adherence. the aim of this study was to demonstrate that a therapeutic education program (tep) could have a significant effect on ibd patient's skills with regards to their disease. design: after individual education sessions with a nurse, a group education session was introduced for outpatients with ibd. the collective session include approximately six to ten patients and is organized in a half day workshops (about disease and treatment) conducted by a multidisciplinary team. the workshops were performed by an education nurse, two hospital gastroenterologists, two hospital pharmacists and a community pharmacist. these sessions were wrapped up by a short satisfaction and knowledge questionnaires. results: in total, ibd outpatients participated to the educational program, patients with crohn's disease and patients with ulcerative colitis ( . % male; median age: ). for the individual educational sessions, two competence questionnaires were performed about anti-tumour necrosis factor alpha (tnfa) therapy: one about general knowledge, another one about self-administration subcutaneous injection. patients completed these questionnaires. for the collective educational session, the competence questionnaire developed consisting of six questions covering few items: disease, symptoms, treatment and complications. patients completed this questionnaire. after the questionnaire, each participant received a summary document about drugs, side effects, therapeutic and medical advice. conclusion: the patient education program contributes to the improvement of self-management skills when it comes to ibd. pharmacists joining medical specialists and nurses provided pharmaceutical care with a positive impact on compliance, which is a determining factor for the success of the treatment and the quality of life in patients living with an ibd. this program will be continued and a new program for teenagers is to be established as well. hp-ce : desensitization study of paclitaxel and carboplatin drug in the ovary tumor protocol in cuf descobertas hospital miguel  . freitas * , daniela brites, ana bota pharmacy, hospital cuf descobertas, lisbon, portugal please specify your abstract type: descriptive abstract (for projects) background and objective: the hospital pharmacy should be an integral part of the multidisciplinary team and implement strategies that meet the patient's needs. pharmacy, in oncological area, is in constant renewal. josé de mello saúde uses paclitaxel/carboplatin protocol as first line in ovarian tumor. although the antineoplastic agents are essential for the treatment of cancer, they can also cause hypersensitivity reactions, which may carry serious consequences. both immunoallergologist and oncologist create a desensitization protocol, which allows the reintroduction of the drug with greater security. the desensitization protocols involves the gradual administration of small quantities of the drug, resulting in a refractory period of the white blood cells (mastocytes) and a lower production of cytokines until the dose has been totally administrated. objective:to evaluate the efficacy of methods used to prevent and treat hypersensitivity reactions of carboplatin and paclitaxel, in order to carry on the treatment. design: a retrospective review of the patient files was performed in the day hospital between and . we included only patients with moderate to severe immediate hypersensitivity reactions (b h) receiving carboplatin and paclitaxel. the desensitization protocol brigham and women's hospital was applied using three solutions with increasing concentrations (dilution : , : and : ) in twelve successive steps for about h. results: in the period - were desensitized five patients with platinum group drugs, carboplatin (n = ) and paclitaxel (n = ) and the total elapsed six desensitization. almost all patients reached the scheduled daily dose, except a patient, which suspended the desensitization program for disease progression. conclusion: the desensitization protocol allowed the successful reintroduction of antineoplastic drugs in patients with a history of hypersensitivity reactions, in order to treat the disease. please specify your abstract type: research abstract background and objective: in the context of harmonization of clinical pharmacy activities within our region, a common medication reconciliation project was developed between two general hospitals. the objectives of this study were to initiate, a common medication reconciliation activity in the two hospitals, to analyse the results, and to communicate to all professionals in the area. setting and method: a working group composed of pharmacists of each hospital was formed to develop analytical documents. a -month prospective study was conducted in two general hospitals: in the first one, in an emergency department, and the other one, in a medicine department. patients included in the study were either elderly and/or had polypharmacy and/or were hospitalized for iatrogenic reason. at int j clin pharm ( ) : - the point of admission and discharge for each patient, the pharmacist has completed a conciliation record, and has detected potential discrepancy. unintentional discrepancies were reviewed and corrected by doctors. at the discharge, medication changes were sent to general practitioner and community pharmacies. a satisfaction survey about this process was sent to healthcare professionals (gp, pharmacist and nurses). a medication reconciliation's workshop was organized for a hundred healthcare professionals in the area. main outcome measures: at the point of admission, the conciliation record included the list of patient's home medication, admission medical orders, and the types of discrepancies. at the discharge, drugs prescribed were compared to admission medical orders. the satisfaction survey included seven questions to assess the process. results: during the study period, patients were included corresponding to prescription lines. reconciliation process required about min per patient. we identified at admission unintentional discrepancies. the most common unintentional discrepancy was the omission of medication ( %). % concerned alimentary tract and metabolism group. at the discharge, no discrepancies were found; the process required min per patient. % of healthcare professionals answered to our satisfaction survey to date. % are satisfied and believe that the process of medication reconciliation secures the patient medicinal treatment. healthcare professionals were present at the medication reconciliation's workshop, indicating an interest in the process. conclusion: in this experience of medication reconciliation, due to unintentional discrepancies observed, we had better implement this activity in the two general hospitals. a pharmacist devoted to this activity will be hire in each hospital. this relevant practice is well accepted by clinician. thus, we will improve communication with gp and community pharmacies. please specify your abstract type: descriptive abstract (for projects) background and objective: the sickle cell disease (scd) is a genetic, chronic disease, paroxystic in its unpredictable and polymorphic acute events. this most frequent genetic illness in the world is a major public health concern in french overseas territories. haute autorité de santé (has) recommendations for the care of scd advocate the development of therapeutic patient education (tpe). in martinique (french west indies), we consider the population of patients with scd in among which are followed in the adults sickle cell centre (ascc). one of the actions carried out by the ascc of our hospital is the tpe. the objective is to set up an original (because specific in the scd) tpe method, which enables the patient to live better with his disease on a daily basis, by teaching him and his family to recognize prematurely certain complications. design: we analysed needs from the outcomes of a national french survey has which one participated martinique and retained the following themes: the red blood cell, the genetic transmission, the main symptoms, the role of the water, the medicinal treatments and the questions of everyday life. we chose the innovative educational tools called the ''malles des savoirs Ò **'', a set of unusual experiments, accessories and models, which, by using a method of active pedagogy ''omca*: observer, manipuler, comprendre, agir ***'', value the learner by offering to him to manipulate and to experiment by himself. results: in , healthcare professionals (doctors, pharmacists, nurses) and a president of patients with scd association followed one week of formation in the omca* method for the animation of six workshops for - teenagers and adults. every ''malle des savoirs Ò **'' contains the necessary material for the animation and a guide of the organizer, including, for every tackled issue, a generic introduction, a presentation of the themes, the index cards of educational animations proposing the activities and one time of synthesis grouping the approaches concepts. the interactive manipulation allows the appropriation of the discoveries become then long-lasting experiences. a final evaluation allows to spot the problems met by learners to understand, to analyse the difficulties and to proceed to the useful adaptations during the next activity. conclusion: this tool, playful and perfectly adapted to the scd, engages, accompanies and helps patients in the construction of their own knowledges to return them actors of their disease. in , we shall estimate the impact of the development of this specific tpe programme of the patient with scd. please specify your abstract type: research abstract background and objective: to investigate the frequencies and clinical relevance of unintentional medication discrepancies, between preadmission medication lists and discharge medication lists, at discharge from hospital. a discrepancy is considered unintentional if there is no documentation explaining the intent of the medication change or if it is unintentional according to the prescribing physician. setting and method: systematic literature review. main outcome measures: frequency of unintentional medication discrepancies per patient and per medication; frequency of clinically relevant medication discrepancies. results: of the patients included - % experienced at least one unintentional medication discrepancy. of the medications used by the patients, - % were involved in unintentional medication discrepancies. of unintentional medication discrepancies found in five studies, - % were clinically relevant. conclusion: the review documented a high frequency of medication discrepancies, of which many were clinically relevant. ensuring sufficient communication of correct and complete medication information in transitions of care is a process which should be better implemented, to enhance patient safety. please specify your abstract type: research abstract background and objective: to investigate the frequency of medication changes not documented in the discharge letter, at discharge from hospital, for both regular, as needed and over-the-counter medications, supplements and herbal remedies (otc). secondary, differences between variables and patients with undocumented medication changes were investigated. setting and method: the patients included were all part of the intervention groups from an intervention study, conducted by one of the authors (tg), from april to december . the best possible discharge medication list was compared against the medication list in the discharge letter and any discrepancy between the two lists was noted, taking into account the text in the discharge summary. main outcome measures: the proportion of patients affected by at least one undocumented medication change at discharge and proportion of medications with undocumented changes. the proportion of patients was compared using a test according to gender, age, number of preadmission/discharge medications and length of hospital stay. results: two hundred patients were included in the study. the proportion of patients experiencing at least one undocumented medication change for the three subgroups: regular medications; as needed; otc, were , and % respectively. the proportion of medications involved in undocumented changes for the three subgroups were , and % respectively. the proportion of patients experiencing undocumented medication changes was significantly higher in patients with more than five regular medications at admission, (p \ . ) and at discharge (p \ . ). in both regular and as needed medications, the proportion of patients experiencing undocumented medication changes was higher in patients hospitalized longer than days (p \ . and p: \ . respectively). for otc, the rate of patients experiencing undocumented medication changes, was higher in females (p: \ . ). conclusion: a high proportion of patients are affected by at least one undocumented medication change and many medications are involved in undocumented changes. correct and complete medication information at admission and discharge may resolve many of these errors, ensuring patent safety at transitions of care. hp-ce : participation in courses at learning and mastery centre and the impact on patients' beliefs about medicines merethe nilsen *, , erik oie , kirsten k viktil diakonhjemmet hospital pharmacy, department of internal medicine, diakonhjemmet hospital, oslo, norway please specify your abstract type: descriptive abstract (for projects) background and objective: patients with chronic diseases are referred to learning and mastery centre (lmc) where the main objective is to support patients to cope with chronic diseases. education about the disease(s) (by a physician) and the medication treatment (by a clinical pharmacist) are important elements of these courses. little is known about how the participation at lmc influences the patients' beliefs about medicines. design: patients c years participating at a days course at lmc regarding acute coronary disease or atrial fibrillation were included in the period september -december . the patients filled out 'beliefs about medicines questionnaire'(bmq) before and immediately after the course, and also months after the course to evaluate their concern (bmq-concern) and necessity (bmq-necessity) of their cardiovascular medications. the bmq scores were dichotomized at scale midpoint (scale - ) to evaluate high and low concern and necessity, and these scores were combined to calculate the 'ambivalence'and 'acceptance', 'sceptical', and 'indifferent'rate to medications, and also the mean scores of the bmq were calculated. results: fifty patients were included, mean age years, % were women, using a mean of . cardiovascular drugs taken regularly. fifty-eight percent of the patients had high concern prior to the course, whereas and % had high concern immediately after and months after the course, respectively. ninety-nine percent of the patients assessed their medication as highly necessary before the course, % immediately after, and % months after the course. the mean score for bmq-necessity was . (sd . ) prior to course and . ( . ) and . ( . ) immediately after and months after the course, respectively. the corresponding scores for bmq-concern were . ( . ), . ( . ), and . ( . ), respectively. the proportions of patients classified to be 'accepting'were , , and % at the three time points, respectively, and the corresponding numbers for patients classified as 'ambivalent'were , , and %, respectively. conclusion: the lmc course had an immediate positive influence on the patients' concern about their medicines and on 'acceptance'. however, the effect seems not to persist over time. a closer follow-up could be discussed. please specify your abstract type: research abstract background and objective: the narrative-based medicine was intended primarily for health care professionals, and the use of narratives can be applied in any settings to better understand the meaning of own profession, to rediscover/strengthen the motivation to work as a team. the italian society of hospital pharmacist (sifo) promotes a qualitative study aimed at getting the real picture of pharmacist's role within the national health system (nhs), the interaction with other health professionals and patients through the narratives of under specialization pharmacists (ui) and pharmacists already working in the nhs (hp). these data can be further investigated to increase the perceived value/role of the pharmacist. setting and method: sifo hps and uis joining the national pharmacy school specialization network were invited to participate. all pharmacists participating to the study were given a semi-structure interview. the methodology was developed within the conceptual framework of the grounded theory (gt) a research methodology that arises in the context of qualitative research. gt is a systematic methodology involving the construction of theory grounded in data systematically gathered and analysed. main outcome measures: analysis of narratives. narratives were analysed according to the classifications of kleinman, frank and launer and robinson together with transitional analysis (ta). results: a total number of narratives were collected ( ups and hps). narratives from both group of participants show the need of strengthening the professional identity already in the early years of the pharmacy curriculum and more effectively during the years of specialization as well as the need of being educated to deliver patientcentred care as members of an interdisciplinary team. conclusion: this is the first step of a study that also includes patient's contribution to the definition of pharmacist's professional identity. hp-ce : impact of pharmaceutical counselling on cancer patients' information desire and treatment satisfaction stephanie wuyts *, , jacques de grève , veerle foulon , hilde collier , pieter-jan cortoos pharmacy, medical oncology, university hospital brussels, brussels, faculty of pharmaceutical sciences, catholic university of leuven, leuven, belgium please specify your abstract type: research abstract background and objective: appropriately educating onco-/haematological patients is a prerequisite to improve patient empowerment, satisfaction and outcomes. objective: to quantify patients' information need and satisfaction on cancer drug therapy and how this can be improved by clinical pharmacist's counselling. additionally, the pharmacist's impact on therapy quality and costs is assessed. setting and method: setting: prospective, randomised study in the ambulatory ( beds) and in-hospital onco-/haematology unit ( beds) in a tertiary hospital. inclusion criteria: adult patients on intravenous or oral cancer therapy, with informed consent. methods: all patients were asked to complete standardised surveys (extent of information desired, eid; patient satisfaction with cancer treatment education, ps-cate and cancer satisfaction of treatment questionnaire, ctsq) on three occasions (at the start of a new therapy, during the second cycle and after months). patients in the intervention group received additional counselling by a clinical pharmacist including medication reconciliation and review. control patients received standard of care (information on drug therapy was provided by the onco-/haematologist, followed by limited administration instructions by nursing staff). main outcome measures: patient information desire and satisfaction on cancer treatment results: patients were included over a period of months (control (n = ); intervention (n = )). no significant differences were found between contact moments or patient groups for eid, ps-cate and ctsq-scores. however, scores for ps-cate on medication side effects were positively correlated with contact moment (r s = . ; p = . ). multiple linear regression analysis showed a similar trend (b = . ; p = . ). patients receiving first-line therapy (b = . ; p \ . ) and ambulatory patients (b = . ; p = . ) were more satisfied on treatment education. the clinical pharmacist documented more drugs than were recorded in the patient file ( vs. . drugs/patient; p \ . ). on average, each patient required two pharmacist's interventions per occasion. intervention acceptance rate on drug related problems was high ( %). during the study, interventions shifted from therapy adjustments towards advice on supportive measures ( st contact: %; rd contact: %). improved medication stock control on the ward led to a savings of € , . conclusion: the clinical pharmacist can play an important role on the onco-/haematological ward, leading to improved drug reconciliation, patient counselling and cost savings. hospitalised patients and patients receiving salvage therapy appear to have higher educational needs, making them possibly overlooked target groups. finally, pharmaceutical counselling should be repeated and primarily focused on side-effect management to have a meaningful impact on patient satisfaction. please specify your abstract type: research abstract background and objective: europe is ahead of the usa and canada on approval, regulatory and marketing aspects of biosimilars. however, there is still uncertainty about interchangeability and substitution of biosimilars. the aim of the study is to assess pharmacists' perceptions about biosimilar interchangeability. setting and method: a cross-sectional study was carried out in june-july . hospital pharmacists from quebec and france were invited to respond to an online survey of nine questions (surveymonkey Ò , palo alto, ca, usa). the survey focuses on pharmacist's exposition to biosimilars (general knowledge, dispensing) and their perceptions about biosimilar interchangeability. a -item likert scale was used to answer to statements based on key issues about biosimilar interchangeability. main outcome measures: levels of agreement on biosimilar interchangeability key issues. results: a total of pharmacists responded ( % in quebec vs. % in france). the global response rate is: % ( % quebec vs. % france) (n = / ). % attended at least to one conference on biosimilars ( vs. %). % had already dispensed biosimilars ( vs. %). more than % of the pharmacists knew that: biosimilars can cause immunogenicity, clinical studies are requested for their approval, automatic substitution is not permitted. % considered that post-marketing surveillance for biosimilars should be reinforced. pharmacists considered that biosimilars are cheaper than the reference product ( vs. %). there was no difference between the level of agreement of french and quebec pharmacists for the statements. pharmacists agree that a list of biosimilar and interchangeable biologic products is necessary ( vs. %), using the international nonproprietary name to prescribe a biological product can create confusion between the reference product and its biosimilar ( vs. %), pharmacists should check if patients already experienced an immunogenic reaction before dispensing a biological product ( vs. %). pharmacists disagree that a biosimilar can be used for all the indications of the reference product ( vs. %). conclusion: perceptions of quebec and french hospital pharmacists about biosimilar interchangeability issues are very similar. this study highlights the need to deal with the lack of clarity of national guidances. clinical studies on biosimilar interchangeability must be conducted in the future to help pharmacists and physicians to take clear-headed decisions. please specify your abstract type: research abstract background and objective: analgesics are essential drugs in hospitals and especially in emergency units. medical and nurse staffs are used to the narcotic status of opioids. for some drugs, a regulatory change to narcotic status can discourage their use. for others, it could limit their access particularly in developing countries; that's why who did not recommend ketamine to be placed under international control (http://www.who.int/medicines/access/controlled-substances/ recommends_against_ick/en/). yet, the french drug agency has recently considered to register drugs containing ketamine as narcotics. the aim of this study was to assess the impact of this possible regulatory change on the pharmaceutical and medical practices in some paediatric french hospitals. setting and method: the survey was conducted in january-february in four parisian paediatric hospitals: four pharmacies, paediatric neurology and anaesthesia departments, intensive care units and pain management services. main outcome measures: pharmacists, clinicians, health managers and nurses were interviewed, using a standardized questionnaire with closed and opened questions, on the drug circuit including ordering, storage, distribution, prescription, administration and destruction. results: all the health professionals (five pharmacists, ten clinicians, five nurses) indicate that the change to narcotic status would not preclude the use of an analgesic drug. they consider that the pharmaceutical aspects (dispensation, storage and transport, etc.) are not limiting, provided that clinical usefulness is demonstrated: short action onset allowing rapid efficacy, short duration of action allowing the replacement by another drugs if needed, and moderate clinical monitoring. change to narcotic status was rather seen as advantageous since allowing better traceability, use and prescription. half of the pharmacies (n = / ) had a computerized register of narcotics and % of care units (n = / ) had a drug staffing in addition to nominative prescriptions, which was used in all care services. the drugs were kept into secured rooms. none of the emergency units (n = / ) had a computerized secured cabinet. conclusion: according to this survey, narcotic status is not a limiting factor for a drug use in paediatric hospitals, when its clinical usefulness is clearly demonstrated. to promote its use, it is important to inform medical and nurse staffs and include it into care protocols. beyond the nominative prescription, implementation staffing is a key step. please specify your abstract type: research abstract background and objective: port-a-cath is an implanted venous access device most commonly used for frequent or continuous chemotherapy administration. however, the procedure and its subsequent maintenance are not free of complications and requires additional intervention by the clinical pharmacist who can provide further patient care to make a positive impact on. to assess the effective provision of appropriate patient counselling offered by a clinical pharmacist on reducing port-a-cath relatedcomplications in cancer patients. setting and method: a controlled prospective observational study carried out on patients newly diagnosed with cancer eligible for chemotherapy administration at the oncology unit. assessment of port-a-cath related-complications were assessed at regular schedule of chemotherapeutic protocols administration. main outcome measures: to assess, reduce and solve port-a-cath related-complications. results: the most significant port-a-cath related complications were skin rash . % (p \ . ) with occurrence in males (n = ) and females (n = ), skin erythema . % with equal occurrence in both genders, followed by skin discharge . % with also equal occurrence in both genders. a high occurrence of skin rash . % occurred among diabetic cancer patients. a significant improvement in port-a-cath related complications after the provision of patient counselling by the clinical pharmacist was observed as skin rash ( . %), skin discharge ( . %), and skin erythema ( . %). conclusion: results of this study pointed out the essential role of clinical pharmacist in argumenting patient care and improving port-a-cath related-complications in cancer patients. please specify your abstract type: research abstract background and objective: polytherapy, frequently used in the elderly, is associated to an increased risk of potential drug-drug interactions (pddis) and adverse drug reactions (adrs). literature demonstrated that medication reconciliation and medication review performed by hospital pharmacists are correlated to drug related problems (drps). aim: to define a structured and feasible model where hospital pharmacists support clinicians identifying drps and promote the safe use of medicines. setting and method: prospective, feasibility study conducted in four internal medicine wards of a hospital in northern italy. inpatients (c years old, treated with c drugs) were consecutively included; the recognition/reconciliation process was performed by pharmacists in order to identify changes between prescription profile at home and during the admission (active principles, dose, administration route). these changes were classified as intentional documented discrepancies (id), not documented (ind), not intentional (ni). prescriptions during the first -hours of hospitalisation were analysed to retrieve drps (ddis, inappropriate medications for elderly, off-label, over/ under dosage, duplications, adrs) then discussed with clinicians. based on literature, referring almost drp in % of patients, a sample size of patients should allow an estimate of drp rate over % (need of intervention) with a % power and a confidence interval of % (software stata version . ). main outcome measures: rate and type of: discrepancies, drps at admission and discharge, pharmacists consultations accepted by clinicians. results: ad interim results are presented. between october/ -february/ , inpatients ( male, . mean age) were included. overall, patients were admitted with drugs used at home and prescribed during the first -hours; pharmacists retrieved discrepancies ( %id, %ind, %ni) and drps, of which % ddis, % off-label, % overdoses, % duplications, % inappropriate drugs, % not notified adrs. the % of drps was known to clinicians and % considered clinically relevant for the patients. please specify your abstract type: research abstract background and objective: hypertension is a major risk factor for cardiovascular morbidity and mortality worldwide, for which management is based on two principal, complementary approacheslifestyle modification and lifelong treatment with antihypertensive medication. adherence to hypertension therapy is a major public health challenge, despite the availability of multiple classes of antihypertensive agents. factors contributing to non-adherence are multifactorial and include intolerances to drugs at standard doses that result in therapy discontinuation. medication intolerance (mi-htn) refers to patients who experience adverse drug reactions (adrs) to at least one antihypertensive medication, without a known immunological mechanism and the need to discontinue them. we sought to determine factors associated with mi-htn and to identify patients' beliefs and concerns about their antihypertensive treatment and medication in general. setting and method: a cross sectional survey consisting of selfreported questionnaires including beliefs about medicines questionnaire (bmq), perceived sensitivity to medication (psm) and quality of life was undertaken in an unselected patients attending a hypertension centre of excellence out-patient clinic based in london. main outcome measures: to determine factors associated with mi-htn and the impact of health beliefs and self-reported perceived sensitivity to medications on mi-htn and bp control. chi squared tests for comparisons between cases/controls and multiple logistic regression analysis were used for statistical analysis. results: participants were included, of which ( %) participants had mi-htn. two-thirds were female (p = . ) with a mean age of ± years (p . ), of whom . % had uncontrolled hypertension (p = . ). calcium channel blockers were the most commonly reported intolerance by drug class followed by diuretics. being female and age [ were statistically associated with a greater likelihood of reporting medicines intolerance (p \ . ). patients who believed that medicines are harmful were [ -times more likely to report mi-htn (p = . ) and -times more likely to have uncontrolled bp ([ / mmhg) (p = . ). patients with high self-perceived sensitivity to medication was -times more prone to mi-htn (p = . ). conclusion: our findings suggests the need for greater focus on behavioural change interventions to both improve patients' perception of the necessity to persist with lifelong antihypertensive medication and allay concerns regarding harmful effects of drugs may help with long term control of hypertension. please specify your abstract type: research abstract background and objective: today, the number of medical problems in heart transplant recipients has increased due to aging and complications common to immunosuppressive drugs. the co-existence or emergence of other disease states such as renal dysfunction, infection, diabetes, obesity, hypertension, hyperlipidaemia, malignancies, and osteoporosis necessitates the use of other medications. the use of these medications in combination with immunosuppressive agents increases the risk of drug-drug interactions. the aim of this study is to identify the frequency and significance of drug-drug interactions for the patients who received cardiac transplantation. setting and method: this retrospective study was conducted at a cardiovascular specialty hospital. all patients who received cardiac transplantation from the same surgery team between and ( years) were included in the study. all data were collected from the medical records of the patients. only the most recent prescription before discharge was analysed for the presence and significance of drug-drug interactions. drug-drug interactions were checked using micromedex(r) interaction checker. main outcome measures: main outcome measures were the frequency and significance of drug-drug interactions. results: a total of patients met the inclusion criteria and prescriptions were analysed. each prescription contained an average of drugs. a total of drug-drug interactions were identified: . % was classified as moderate; . % as major and . % as contraindicated. almost half of all interactions (n = ) included immunosuppressive agents ( . % was classified as moderate; . % as major and . % as contraindicated). conclusion: cardiac transplant recipients were found to have a high number of drug-drug interactions. in order to advise on these interactions which increase with poly-pharmacy, drugs with narrow therapeutic index or drugs that require intensive monitoring, it is recommended to include a transplantation pharmacist in the transplantation team. please specify your abstract type: research abstract background and objective: the aim of our study was to assess the impact of patient education provided by the pharmacist on gylcemic control, medication knowledge level and medication adherence of patients with type diabetes. patients who were diagnosed with type diabetes for at least one-year time and were receiving at least one antidiabetic medication, attending to the outpatient diabetes clinic for the control visit were informed about the study and invited to participate in the study. patients who gave their informed consent were included in the study. setting and method: the setting is a diabetes outpatient clinic of a state hospital. the medication knowledge levels, medication adherence scores, fasting blood glucose levels, hba c levels and blood pressure of the patients were measured before pharmacist's education. after provision of standard information and individualized patient education all these parameters were measured again after monthstime and the impact of the education was assessed. main outcome measures: main outcome measures are change in the clinical parameters (hba c; fasting blood glucose; blood pressure), as well as improvements in medication knowledge and adherence levels. results: the study was conducted on patients who met the inclusion criteria; none of the patients were lost to follow-up. majority ( %) of the patients was female and the mean age was . years. pharmacist intervention resulted in positive outcomes at all clinical parameters. systolic blood pressure decreased by mmhg, while diastolic blood pressure decreased by . mmhg (p \ . ). hba c level decreased by . % (from . to . %; p \ . ) and fasting blood glucose level by . mg/dl (p [ . ). on the other hand, the number of patients reaching the blood pressure goal increased from to ; and those reaching to hba c goal increased from to (p \ . for all). similarly, the medication knowledge level [usual range - ] increased from . to . (p \ . ); and the medication adherence score [usual range - ] increased from . to . (p \ . ). conclusion: it can be concluded that pharmacist's contribution results in positive outcomes in glycaemic control and management of co-morbid conditions of type diabetic patients by improving medication knowledge and adherence levels of the patients. pharmacists should take active role in management of chronic diseases. hp-pc : impact of a pharmaceutical care program on glycemic control, medication knowledge and medication adherence levels of type diabetic patients residing at a nursing home nimet saglam *, , sule apikoglu-rabus , betul okuyan , fikret v. izzettin , nuran yildirim clinical pharmacy department, marmara university faculty of pharmacy, darulaceze nursing home, istanbul, turkey please specify your abstract type: research abstract background and objective: the aim of our study was to assess the impact of pharmaceutical care provided by the pharmacist on glycaemic control, medication knowledge level and medication adherence of patients with type diabetes residing at a nursing home. setting and method: this prospective cohort study was conducted in a state nursing home (darülacaze nursing home) in istanbul, turkey on patients who completed the whole study. all the patients received pharmaceutical care provided by the pharmacist. this pharmaceutical care program was held for months. it consisted of an initial visit, followed by ''care and control'' visits and a final control visit; each visit was held at two-week time intervals. at the initial visit, demographic and general clinical data were collected and medication knowledge and medication adherence levels of the patients were also assessed. pharmaceutical care needs were identified for each patient and recommendations addressing these issues were structured. education regarding the medications of the patients was provided in both verbal and written forms using the standard patient education leaflets prepared by the pharmacist. at each visit pharmaceutical care needs are assessed and pharmaceutical care is tailored accordingly. main outcome measures: main outcome measures are change in the clinical parameters (hba c; fasting blood glucose), as well as improvements in medication knowledge and adherence levels. results: majority ( %) of the patients was male and the mean age was . years. pharmacist intervention resulted in positive outcomes regarding hba c levels. hba c level decreased by . % (from . to . %; p \ . ) and fasting blood glucose level by mg/dl (p [ . ). similarly, the medication knowledge level [usual range - ] increased from . to . (p \ . ); and the medication adherence score [usual range - ] increased from . to . (p \ . ). conclusion: it can be concluded that pharmacist's contribution results in positive outcomes in glycaemic control of type diabetic patients by improving medication knowledge and adherence levels of the patients. pharmacists should take active role in management of type diabetes at the nursing home setting. please specify your abstract type: research abstract background and objective: haemoglobin variability is related to mortality and morbidity in haemodialysis, renal transplantation and pre-dialysis patients. some demographic, haematological and pharmacological variables may affect hb variability. but there are some controversies about the influences of different erythropoiesis stimulating agents (esa).the objective of this study is to determine the influence of different esa on haemoglobin variability in pre-dialysis patients. setting and method: we conducted a prospective observational study with chronic kidney disease patients recruited from outpatients of nephrology department of a tertiary university hospital (from january to june ). exclusion criteria were: stage i and ii, not treated with esa, haemodialysis, peritoneal dialysis, renal transplantation, thalassemia, and deficit of glucose- -phosphate dehydrogenase . main outcome measures: patients included were treated with esa in maintenance phase (stable months prior).hb variability was calculated by standard deviation (sd) and residual standard deviation (residual sd) of hb levels. statistical analysis was performed with spss . (spss inc, chicago). observation period was months and data were recorded from the clinical records. ( ) . %, sofosbuvir/daclatasvir/ribavirin ( ) . %, sofosbuvir/simeprevir ( ) . %, sofosbuvir/ledipasvir ( ) . %, sofosbuvir/ledipasvir/ribavirin ( ) . %, dasabuvir/ombitasvir/paritaprevir/ritonavir ( ) . %, dasabuvir/ombitasvir/pari taprevir/ritonavir/ribavirin ( ) % ombitasvir/paritaprevir/ritonavir/ ribavirin ( ) . %, sofosbuvir/ribavirin ( ) . %. viral load at week was \ iu/ml in patients and at the end of treatment . conclusion: the results of rapid viral response at end of treatment were similar to those obtained in studies published to date. due to its recent access to these treatments it is necessary to continue monitoring these patients to assess virologic sustained response at weeks after end of treatment. please specify your abstract type: research abstract background and objective: fragile patients are considered those vulnerable patients with a certain degree of complexity in their care (polypharmacy, multi-pathological, palliative and/or residents in social and healthcare institutions). to ensure their continuity of care and safety in the use of drugs we applied a medication reconciliation process at admission, transition of care and/or hospital discharge. objective: to analyse the results of the medication reconciliation process of a fragile patient. setting and method: we developed a list of current medication with the following sources of information: medical history, clinical databases and information provided by the patient (interview). clinical case: -year-old woman admitted through emergency department due to severe dyspnoea. no known drug allergy. background: heart failure, chronic hypertension, hypercholesterolemia, hyperthyroidism, hyperuricemia, gouty arthritis, chronic kidney disease and cognitive impairment by alzheimer disease. exploration and complementary tests: echocardiogram and analytical control. clinical judgment: acute decompensated heart failure. acute myocardial infarction. prerenal acute kidney injury. main outcome measures: medication reconciliation made at admission with the detection of discrepancies and deprescribing criteria at hospital discharge. results: fragile patient (high-risk) with medicines as home treatment. patient was hemodynamically stable during the hospital stay. discrepancies were detected between the prescribed medication and the home treatment. discrepancies justified ( ): five by omission of medication (two new clinical situation, two therapeutic exchanges to adapt to the pharmacotherapy guide and one wrong drug) and two beginning of medication. discrepancies unjustified ( ): by omission of medication. to discharge: one antiplatelet therapy was. after the comprehensive review, we made the following recommendations of deprescription: suspend one non-steroidal anti-inflammatory drug-nsaid (by risk of bleeding in association with concomitant antiplatelet and antidepressant therapy) and one benzodiazepine (central nervous system-cns side effects); modify treatment: reduce doses of diuretics (blood pressure lowering effect). pharmacotherapeutic recommendations were accepted. conclusion: detection of discrepancies in the medication reconciliation and deprescription process are effective and safe strategies that allow optimization of pharmacotherapy in fragile patients. the use of drugs such as nsaids (gastrolesive effect), the combination of drugs with cns side effects and hypotensive action (associated with falls) in elderly patients constitute situations of risk that should be reviewed in fragile patients, as an essential part of the clinical evaluation. please specify your abstract type: descriptive abstract (for projects) background and objective: there are no positions for clinical pharmacists at the hospital, so we are dependent on projects to be able to show how pharmacists can contribute in the clinical team. our aim in this project was to introduce pharmaceutical knowledge by implementing medication reconciliation and medication review in different hospital wards. we wanted to show that many patients have discrepancies in their medication lists during hospital stay and that some of the drugs or doses given can cause drug related problems for the patient. our final goal was to get the physicians to be more aware of these issues when treating their patients. design: the method used was based on the two first parts of the integrated medicines management. the pharmacist conducted a standardized drug interview with patients who prior to admission were responsible for their own drugs. for patients who could not be interviewed or were not responsible for administering their own drugs, a current medication list from relevant care level was obtained. the medication lists obtained were compared to the documentation in the patient's drug chart and discrepancies communicated to the physician. during the hospital stay, a medication review and monitoring was also conducted by the pharmacist. results were presented to the patients physician and discussed. results: a total of patients were included and of these % had c discrepancy identified by the process. the most frequent type of discrepancy was the use of a drug that was not registered on admission (omission discrepancies). other discrepancies were wrong dose, dosage or formulation and registration of a drug the patient didn't use. drug-related problems were discovered in % of the patients and the most frequent were use of anticholinergic drugs in elderly, interactions, lack of treatment and monitoring and too high doses regarding kidney function. many of the detected drug related problems results in change in medication, other times the physician addresses the problem to the gp. the physicians were surprised of the high numbers of discrepancies in medication lists and drug related problems discovered. almost all the physicians considered that the pharmacist could be an important part of the treatment team and they wanted the participation of the pharmacist to be permanent. conclusion: the project led to increased awareness of the importance of medication reconciliation and medication review and showed the importance of pharmaceutical knowledge in the treatment team. unfortunately this was not sufficient to create positions for pharmacists in our hospital. new projects will focus on pharmacists teaching interns to improve the reconciliation at admission. please specify your abstract type: descriptive abstract (for projects) background and objective: we aimed to assess the quality of fluoroquinolones (fq) prescriptions at the toulouse university hospital emergency department as part of significant increase in consumption. design: retrospective mono-centric study of fq prescriptions written to adult patients managed at the emergency department (february th, -march th, . a pair consisting of a biologist pharmacist and a clinical pharmacist has analysed them using tools provided by the centre de coordination de lutte contre les infections nosocomiales (cclin). various criteria (pertinence of prescription, choice of antibiotic, dosage, duration of treatment, method of administration…) were faced with the guidelines issued by the société de pathologie infectieuse de langue française (spilf). results: about files were examined, contained fq prescriptions for systemic use. the most frequently prescribed antibiotic was ofloxacin ( %) and the most frequent indications were urinary tract infections ( %). among the prescriptions of fq, the establishment of fq was justified in % of cases and the antibiotic chosen was always the most suitable. nonconformities of dosage and/ or treatment time were found in a quarter of cases. overall, % did comply with guidelines. the prescriptions, due to the particularity of emergency were still permormed probabilistic. however, a reassessment of them was scheduled for two-third of outpatients. conclusion: this study highlights the conformity of less than half of the prescriptions. this demonstrates that there are still actions to ensure the accuracy of fq prescriptions. and it is in this sense that this audit should be registered under the impetus of the committee on anti-infectives. it will raise awareness among doctors in the proper use of this family of antibiotics. please specify your abstract type: descriptive abstract (for projects) background and objective: the number of persons suffering from end-stage renal disease (esrd) is growing worldwide, mainly due to the aging of the population. esrd incidence has been increasing by - % per year for years. it is estimated that worldwide, more than . million patients with established renal failure are being treated with haemodialysis (hd). water for haemodialysis must meet the physicochemical and bacteriological compliance standards defined by the european pharmacopoeia. as a medicine, this water is placed under the responsibility of hospital pharmacists. addressed to hospital pharmacists, this methodology guide will enable them not only to validate controls of haemodialysis water as well as drug prescriptions for dialysis patients, but also to familiarize themselves with the best currently existing dialysis techniques and medical devices. we have tried to simplify and synthesize existing circulars and guidelines so as to render them more readily understandable for the pharmacist in charge of a haemodialysis service, and thereby help to ensure optimally safe treatment of haemodialysis patients. design: the themes developed in this guide are: • a review of the different existing dialysis techniques, • a review of the different sampling points for controls of hd water, • a review of the physicochemical and bacteriological standards of these controls according to the latest recommendations of the european pharmacopeia, and of appropriate conduct for exceeding established thresholds, • a review of the main international recommendations with regard to clinical signs of chronic kidney disease: anaemia, mineral and bone disorders (ckd-mbd), high blood pressure. • a review of the various medical devices used in haemodialysis and haemodiafiltration. results: the recommendations of good practices summarized in this guide are integrated perfectly adapted to the concept of quality assurance and its role in the accreditation process. they are focused on improving patient safety by harmonizing pharmaceutical haemodialysis practices in different dialysis centres. conclusion: these types of recommendations may be transposable to other pharmaceutical fields and/or be used as a training tool for pharmacy students or young pharmacy school graduates. the format of this guide makes it convenient, easy to use every day. it will be revised regularly to ensure the sustainability of quality plans. please specify your abstract type: descriptive abstract (for projects) background and objective: combination antiretroviral therapy (cart) has strongly improved disease control in hiv-infected patients. however, aging and comorbidities are becoming a major problem in this group of patients. most hiv-infected patients are treated with five or more medications, and harms by polypharmacy increase proportionally with number of medications. possible risks include: poor medication adherence and consequently inefficient care, increased risk of drug interactions and adverse events, with prolonged hospitalization. the problem is worsened when patients are of nonnative language and so their comprehension and adherence to drug therapy can be very poor, compromising efficacy. the hivig study is designed to evaluate the impact of the interventions promoted by the clinical pharmacist in the optimization and comprehension to personal drug therapy, favouring compliance, in a cohort of patients, hiv infected with comorbidities like cancer; the cohort includes a high number of non-native italian language individuals. design: hivig is a randomised, parallel groups clinical trial. in april the study protocol was approved by the local ethical committee, aviano. the project is scheduled to start in autumn . main objective: evaluation of the impact of a series of tools-''drug therapy setting interventions'' (dtsis) applied by the clinical pharmacist on a cohort pf hiv-infected patients with comorbidities, afferent for care at cro aviano. the treatment arm will be submitted to dtsis. dtsis interventions (treatment group) consist in: motivational interview, sharing and delivery of printed, explanatory material in the patient's native language, reconciliation of patients medications at hospital admission and at discharge; identification of potential risks due to drug-drug interactions; monitoring of compliance to drug therapy, and finally detection of adverse drug reactions (adrs) occurring in the course of care. the control group will undergo only to scheduled standard medical visits at cro. results: we expect to recruit a total patients for a -months period of follow-up. statistical analysis will be performed by intention-to-treat and by protocol. at cro aviano, the italian cooperative group on aids and tumors (gicat) has studied malignancies in hiv-positive patients since and has a leading role for studies conducted in italy (vaccher, ) conclusion: previous collected data from the previous trial performed at cro aviano (target-vig), showed a positive impact in the optimization of individual drug therapy and in the reporting of adrs. hiv has an enormous impact on life of infected patients and represents a priority issue for the entire community. we consider the method of dtsi, combined with a close monitoring of patients by means of telephonic motivational interviews, the best added value performed by the profile of the clinical pharmacist in optimizing drug therapy and personal awareness about medicines. please specify your abstract type: research abstract background and objective: the world health organization reports that ''one in four people in the world will be affected by mental or neurological disorders at some point in their lives. around million people currently suffer from such conditions, placing mental disorders among the leading causes of ill-health and disability worldwide». to review the evidences published about the roles and the impact of pharmacists in psychiatry. setting and method: literature review. a literature search was conducted using pubmed and the following terms: pharmacists, clinical pharmacy, pharmaceutical services, pharmaceutical care, pharmacy, mental illness and psychiatry from january st until june th . manual search was also conducted using selected articles. the selection of articles was based on abstracts. selected articles were reviewed, analysed and entered in impactpharmacie.org website according a standard operating procedure. relevant key data were extracted for each article including the type and the description of pharmaceutical interventions and descriptive and outcomes indicators with their results. no statistical analysis was conducted. main outcome measures: proportion of outcome indicators associated to pharmaceutical interventions with a positive impact in psychiatry. results: a total of articles were included. described pharmaceutical interventions included patient-pharmacist relationship ( ), medication reconciliation ( ), patient care needs assessment ( ), drug therapy assessment ( ), patient follow-up ( ), interdisciplinary work ( ), knowledge transfer ( ), competencies maintenance ( ). the impact of pharmacists interventions was studied using a total of indicators from which ( %) had outcome measures. of these outcome indicators, ( %) were positive, neutral and negative (knowledge transfer strategy). positive impacts of pharmaceutical interventions were identified in the following areas: morbidity ( ), patient adherence ( ), patients or clinicians satisfaction ( ), side effects management ( ), medication errors prevention ( ), mortality ( ) please specify your abstract type: research abstract background and objective: the world health organization reports that . million people die each year from cancer, an estimated % of all deaths worldwide and that there is a % increase in new cases of cancer expected over the next two decades. to review the evidences published about the roles and the impact of pharmacists in cancer. setting and method: literature review. a literature search was conducted using pubmed and the following terms: pharmacists, clinical pharmacy, pharmaceutical services, pharmaceutical care, pharmacy, neoplasms from january st until june th . manual search was also conducted using selected articles. the selection of articles was based on abstracts. selected articles were reviewed, analysed and entered in impactpharmacie.org website according a standard operating procedure. relevant key data were extracted for each article including the type and the description of pharmaceutical interventions as well as descriptive and outcomes indicators with their results. no statistical analysis was conducted. main outcome measures: proportion of outcome indicators associated to pharmaceutical interventions with a positive impact in cancer. results: a total of articles were included. described pharmaceutical interventions included patient-pharmacist relationship ( ), patient care needs assessment ( ), drug therapy assessment ( ), drug compounding/dispensing ( ), patient follow-up ( ), interdisciplinary work ( ), knowledge transfer ( ). the impact of pharmacists interventions was studied using a total of indicators from which ( %) had outcome measures. of these outcomes indicators, ( %) were positive, ( %) neutral and ( %) negative. positive impacts of pharmaceutical interventions were identified in the following areas: morbidity ( ), patient adherence ( ), patients or clinicians' satisfaction ( ), side effects management ( ), medication errors prevention ( ), mortality ( ), costs ( ) setting and method: literature review. a literature search was conducted using pubmed and the following terms: pharmacists, clinical pharmacy, pharmaceutical services, pharmaceutical care, pharmacy, myocardial infarction, acute coronary syndrome from january st until june th . manual search was also conducted using selected articles. the selection of articles was based on abstracts. selected articles were reviewed, analysed and entered in impactpharmacie.org website according a standard operating procedure. relevant key data were extracted for each article including the type and the description of pharmaceutical interventions and descriptive and outcomes indicators with their results. no statistical analysis was conducted. main outcome measures: proportion of outcome indicators associated to pharmaceutical interventions with a positive impact in myocardial infarction. results: a total of articles were included. described pharmaceutical interventions included patient-pharmacist relationship ( ), medication reconciliation ( ), patient care needs assessment ( ), drug therapy assessment ( ), drug compounding/dispensing ( ), patient follow-up ( ), interdisciplinary work ( ), knowledge transfer ( ). the impact of pharmacists interventions was studied using a total of indicators from which ( %) had outcome int j clin pharm ( ) : - measures. of these outcome indicators, ( %) were positive, ( %) neutral and ( %) negative. positive impacts of pharmaceutical interventions were identified in the following areas: morbidity ( ), patient adherence ( ), side effects management ( ), mortality ( ) and others ( ). conclusion: the role and the impact of pharmacists have been studied in myocardial infarction and % of outcome indicators used in these studies show a positive impact of pharmaceutical interventions. pharmacists should pay attention to these evidences to improve their practice, contribute to prevention or insure treatment of patients with potential or found myocardial infarction. hp-pc : impact of pharmaceutical care in vaccination: a review of literature please specify your abstract type: research abstract background and objective: the world health organization reports that ''immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine and a proven tool for controlling and eliminating lifethreatening infectious diseases and is estimated to avert between and million deaths each year. it is one of the most cost-effective health investments, with proven strategies that make it accessible to even the most hard-to-reach and vulnerable populations». to review the evidences published about the roles and the impact of pharmacists in vaccination. setting and method: literature review. a literature search was conducted using pubmed and the following terms: pharmacists, clinical pharmacy, pharmaceutical services, pharmaceutical care, pharmacy, vaccination and immunization from january st until july th . manual search was also conducted using selected articles. the selection of articles was based on abstracts. selected articles were reviewed, analysed and entered in impactpharmacie.org website according a standard operating procedure. relevant key data were extracted for each article including the type and the description of pharmaceutical interventions and descriptive and outcomes indicators with their results. no statistical analysis was conducted. main outcome measures: proportion of outcome indicators associated to pharmaceutical interventions with a positive impact in vaccination. results: a total of articles were included. described pharmaceutical interventions included patient-pharmacist relationship ( ), medication reconciliation ( ), patient care needs assessment ( ), drug therapy assessment ( ), patient follow-up ( ), interdisciplinary work ( ), knowledge transfer ( ), competencies maintenance ( ). the impact of pharmacists interventions was studied using a total of indicators from which ( %) had outcome measures. of these outcome indicators, ( %) were positive, ( %) neutral and negative. positive impacts of pharmaceutical interventions were identified in the following areas: cost ( ), errors ( ), morbidity ( ), patient adherence ( ), patients or clinicians satisfaction ( ) please specify your abstract type: descriptive abstract (for projects) background and objective: evaluating the appropriateness and effectiveness of the patient's medications by analysing prescriptions is pharmacist side work. bedside drug administration and computerised drug administration traceability (cdat) in nursing care plan (ncp) are nurse's one. however, in order to check adherence, efficiency and tolerance of a drug, pharmacist has to ensure that the patient takes the medication appropriately. therefor ncp could be a useful tool. the aim of this study is to evaluate the effectiveness of cdat, and if not, define causes of divergences with real life situation. design: • comparison between unused drugs remained in individual patients' seven daily pill dispensers (considered as not taken) which come back from the evaluated service to the pharmacy, and their cdat status completed by nurses (taken, not taken or no status) • two recorded data, each collecting a three-week period, separated by a period of discussion with nurses: first results presentation, analysis of divergences by taking into account their feedbacks, and actions to raise their awareness about the importance of cdat. • pill dispensers' cdat is correct only if all returned drugs' status in ncp is ''not taken''. results: during the first period (n = pill dispensers), . % of pill dispensers had an incorrect cdat status. on average, . drug per pill dispenser didn't have an appropriate status in ncp (taken or no status). major causes of divergences were the lack of time and insufficient human resources, the fact that they often are interrupted in the middle of this task, a software which isn't ''user-friendly'' and a deficit of information about the issue. corrective actions were implemented, prior to the second recorded data period, targeting human factor of divergences (oral and written reminders about cdat with didactic memorandum on computers). after awareness actions, results (n = ) were . and . respectively. conclusion: efforts about cdat have been done but not enough to observe a significantly improvement in short terms. ncp's level of reliability is not optimal yet and still dependent on nurses' practices. this study allowed us to strengthen the relationship between clinical service and pharmacy, and opens the way for further works particularly through corrective actions targeting material and organizational causes of divergences. please specify your abstract type: descriptive abstract (for projects) background and objective: in , our teaching hospital has participated to a worldwide survey (global point prevalence survey (global-pps)) aimed to explore antimicrobial consumption and resistance in hospitals. because broad spectrum antibiotics have to be followed with the attention of resistance prevention, we focused our analysis on these antibiotics in our hospital (carbapenems, piperacillin/tazobactam and amoxicillin/clavulanic acid). design: the survey was performed by pharmaceutical team (senior and resident) with help of microbiologists and referring physicians. all wards of the hospital were included. hospitalized patients treated with antimicrobial agent (j , j , j a, p ab, a , j ah, p b from the atc classification) prescribed at a.m. on the day of the survey, were involved. from those who were treated by carbapenems, pip/taz or amx ac, following data were collected: age, gender, weight, doses, indications (probabilistic? documented? and if documented microbiological data), and mention of stop/review date of prescription. results: the survey was carried out from april to june in wards. among the patients included, patients ( . %) were treated with antimicrobial agents. patients ( . %) were treated with broad spectrum antibiotics: ( . %) with amx-ac, with pip-tz, with imipenem and with meropenem. the mean age of patients was . ± . and the weight was . ± . kg. their prescriptions were concentrated in three types of wards: ( . %) in icu, ( . %) in medicine, ( . %) in surgery. moreover, we observe that bsa were used to treat ( . %) community acquired infections, ( . %) nosocomial infections, ( . %) used as medical prophylaxis, or surgical prophylaxis (n = , . %). in relation to the type of treatment: were empirical treatment (including prophylaxes) and were targeted treatments ( bacteraemia, joint and bones infections, cardiovascular system infection, urinary tract infections, lower respiratory tract infections, skin and soft tissues infections and others infections). finally, extended spectrum beta-lactamase (esbl) producing enterobacteriaceae and third generation cephalosporin resistant enterobacteriaceae non-esbl producing were targeted by bsa regimen. conclusion: in this survey, use of bsa is globally compliant to french guidelines and we identified no improper prescription: multidrug resistant bacteria infections, several diseases and empirical treatments with limited duration of regimen. this shows that control of the proper use of antibiotics especially those with a broad spectrum is efficient in our hospital and has to be continued. this has been made possible due to a multidisciplinary approach including physicians, bacteriologists and pharmacists. please specify your abstract type: descriptive abstract (for projects) background and objective: in , our teaching hospital has participated to a worldwide survey (global point prevalence survey (global-pps)) aimed to explore antimicrobial consumption and resistance in hospitals. from these results, we observed that sulfamethoxazole/trimethoprim (tmp/smx) was largely prescribed in our hospital. we focused then our analysis on these results with the attention of check of its proper use. design: the survey was performed by pharmaceutical team (senior and resident) with help of microbiologists and referring physicians. all wards of the hospital were included. hospitalized patients treated with antimicrobial agent (j , j , j a, p ab, a , j ah, p b from the atc classification) prescribed at a.m. on the day of the survey, were involved. from those who were treated by tmp/smx, following data were collected: age, gender, weight, doses, and indications (probabilistic? documented? and if documented microbiological data), and mention of stop/review date of prescription. please specify your abstract type: research abstract background and objective: in france, benzodiazepine (bzd) is frequently prescribed in elderly people (ep). long-term efficacy is often questioned, and treatment has to be regularly re-examined, especially in ep. in our geriatric day-hospital for assessment of frailty, a multidisciplinary team evaluates the patients and gives them preventative measures against the loss of autonomy. medication evaluation is part of these measures. the aim of our study was to evaluate the impact of a standardized intervention on the optimization of bzd treatment. setting and method: after a short interview and the delivery of an information booklet about bzd, patients were proposed an optimization of their bzd treatment (dosage reduction, occasional medication, switch to a short half-life bzd, or total discontinuation). patients were followed up monthly by a phone-interview over a -months period. main outcome measures: the main outcome measure was the prevalence of bzd optimized treatments after a months follow-up. results: patients were included. among them, % have been taking a bzd for more than years, and % were prescribed a long half-life bzd, which can be qualified as inappropriate in ep. % of the subjects were frail and % pre-frail according to the fried criteria. at the end of the study, % of the patients had their bzd treatments optimized, including % of total discontinuation. conclusion: in frail or pre-frail elderly population, a standardized intervention can be useful to improve bzd treatment. an extension to this intervention would be the creation of an organisation tasked with routinely monitoring the patients withdrawal over a month period. hba c and weight were significantly reduced by . ± . %, p \ . and . ± . kg, p \ . , respectively; systolic bp ( . ± . mmhg, p \ . ), diastolic bp ( . ± . mmhg p \ . ) and triglycerides ( . ± . mg/dl, p . ).genital-and urinary tract infections were reported by . % patients. any diabetic ketoacidosis case was reported. conclusion: sglt- inhibitors added to other oral antidiabetic drugs or insulin in patients with uncontrolled t dm significantly improved glycaemic control, reduced weight, blood pressure and triglycerides, and was generally well tolerated. in conclusion, sglt- inhibitors, appears to be an important addition to the therapeutic options for the management of type diabetes, particularly when used as add-on therapy. ( ). treatment safety takes part of the decision to undergo bariatric surgery. during multidisciplinary team meetings, the clinical pharmacist must rely on guidelines to limit drug-induced iatrogenesis. this review aims at assessing influence of bariatric surgery on the clinical impact and pk of cardiotropic drugs so as to document pharmacists' notifications. setting and method: literature review on medline- to may -with terms: cardiovascular drugs and bariatric surgery or malabsorption syndrome. related articles were reviewed. main outcome measures: pharmacokinetic or pharmacodynamic data and clinical impact of cardiotropic drugs. results: a total of titles, and abstracts when necessary, were screened for eligibility. after reviewing process, studies were included: nine concerning digoxin, five beta-blockers (bb) and one amiodarone. published studies varied in methodology: five case report, seven case control and three cohort studies. studies reported variations of digoxin plasmatic concentrations among patients versus , suggesting liquid oral form are preferred. no clinical event was notified. more the bb is liposoluble (propranolol), the higher the toxicity is, such as heart rate and blood pressure decreasing, with potential fatal outcomes. a case of amiodarone-induced hyperthyroidism is described after bariatric procedure showing an increase plasma concentration adjusted to weight. conclusion: while the impact on narrow therapeutic range drugs is documented, others cardiotropic drugs may cause serious patient injury justifying their monitoring. therefore, risk must be identified for all patients undergoing bariatric surgery to setting up closely therapeutic monitoring. further studies are still expected to lead to recommendations about posology and treatment withdrawal to improve patient safety. please specify your abstract type: research abstract background and objective: the issue of non-compliance to prescribed medical treatment has been reported to be a crucial problem in psychiatric outpatients. the aims of this study were to assess the extent of non-compliance in a cohort of psychiatric outpatients in malta and to investigate the applicability of using a -day multi-dose pill box in terms of practicality, ease of use and impact on compliance within this patient group. setting and method: the study was conducted at mount carmel hospital, a psychiatric hospital in malta. twenty outpatients were recruited by convenience sampling. the study was divided into two phases. during phase , patient compliance was assessed using the medication adherence rating scale (mars) survey and patients were administered part a of a questionnaire entitled 'assessment of the -day multi dose pill box'. this questionnaire evaluated the patients' opinion regarding the -day multi dose pill box before and after its use. in phase , the chosen patients were given a demonstration on how to use the -day multi dose pill box and the device was given to them to use at home for one week. after one week, part b of the questionnaire was completed and compliance was re-assessed using mars . main outcome measures: evaluation of adherence before and after use of the compliance aid device. results: of the patients recruited, were male and were female. the mean age was years (range - ) and the mean number of daily medications (range - ). upon initial scoring using mars, patients were adherent and patients were nonadherent. a higher adherence was observed in patients taking or more medications daily. ten patients accepted to move on to phase of the study and took the device home to use for one week. out of these patients, felt that the way they take their medication improved following use of the device and out of patients would consider buying the device since they found it practical and easy to use. statistical analysis of mars score before and after use of the device showed no significant improvement in compliance (p [ . ). there was no significant association between level of adherence and type of psychiatric condition (p [ . ). furthermore, results did not indicate increased adherence in patients who have a carer in-charge of their medication administration or in patients using a compliance aid device (p [ . ). conclusion: the use of a compliance aid device in psychiatric patients is challenging due to difficulty in establishing patient communication and motivation. the pharmacist is in a position to identify patients who would benefit from the compliance aid device. adrien borowik * , anne fratta, fabien hernandez pharmacy, ap-hp, armand trousseau paediatric hospital, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: enoxaparin, a low molecular weight heparin, is the most prescribed anticoagulation treatment in paediatric indications. however, the marketing authorization mentions that due to the lack of data, the use of enoxaparin is not recommended to children nor anyone weighing less than kg. thus, expert recommendations described specific dosage for the paediatric use: we aimed to compare these with our hospital practices. ( ), sofosbuvir/ledipasvir ( ), ombitasvir/ paritaprevir/ritonavir ( ), ombitasvir/paritaprevir/ritonavir + dasabuvir ( ), simeprevir + ifn ( ) . twenty-six patients ( %) were treated for weeks ( week pay-back policy). twenty pharmacists' interventions were carried out with an acceptance rate of %. the interventions included treatment adjustments due to drug interactions ( ), inappropriate treatment according to genotype ( ), duration of treatment ( ) and switch to a more cost-effective therapy ( ). seven pharmacists' interventions concerning treatment switch were applied ( %) resulting in a cost saving of € , . . all assessable patients ( ) have a negative serum hcv rna weeks after the end of treatment (svr = %) while patient died during follow-up (due to the disease). conclusion: the hospital pharmacist, as an active member of the multidisciplinary team, has an essential role in guaranteeing optimal care for hcv patients at the best cost. monitoring has also shown to be fundamental to evaluate the real world effectiveness of these drugs approved with surrogate endpoints. hp-pc : are hospital pharmaceutical staff educated on the criticality of thermosensitive drugs? camille castel, guillaume saint-lorant * please specify your abstract type: research abstract background and objective: in the use of thermosensitive drugs, the safety of patient care involves compliance with allowed temperatures. having the right information at time of care is essential. the aim of this study is to assess, within a french university hospital, pharmaceutical staff knowledge on the criticality of thermosensitive drugs and to educate them accordingly, including associated patient risks. setting and method: an assessment of knowledge using a questionnaire was led in january among pharmaceutical staff in a -bed hospital ( pharmacists, pharmacy residents, pharmacy technicians). evaluation criteria were: storage temperature of refrigerated drugs and frozen drugs, thermosensitive drug retention period after removal from the refrigerator, highest risk situation for a thermosensitive drug (t [ °c or t \ °c) and action to be taken during a temperature excursion. main outcome measures: to determine shortcomings in the management of thermosensitive drugs in order to adapt appropriate tools. results: completed questionnaires were collected. collected questionnaires included % from pharmacists (n = ), % from pharmacy residents (n = ) and % from pharmacy technicians (n = ). regulatory variations in storage temperatures of refrigerated and frozen drugs are known in respectively and % of cases. % of pharmaceutical staff are aware of thermosensitive drug retention periods after removal from the refrigerator and % of the highest risk situation for a thermosensitive drug (t \ °c). the measures to adopt during a temperature excursion are understood in % of cases. conclusion: this study highlights the lack of knowledge on the management and criticality of thermosensitive drugs and the lack of information available to pharmaceutical staff. dissemination of data and questionnaire reponses have been beneficial for the pharmacy department and have reduced inequalities in available information among pharmaceutical staff. subsequent to the study, thermosensitive drug management procedures have been revised. the deployment of this questionnaire is continuing via the university hospital intranet in order to train all health professionals in good patient care. please specify your abstract type: research abstract background and objective: temocillin is a beta-lactam antibiotic exclusively active against gram-negative pathogens. its use can avoid that of broad spectrum antibiotics, such as carbapenems, for the treatment of infections due to extended-spectrum beta-lactamase producing enterobacteriaceae. however, the absence of recommendations by learned societies on temocillin use could lead to misuse and the emergence of resistance. the aim of this study is to identify the role of temocillin in a french university hospital arsenal in order to limit ecological risks. setting and method: a retrospective study was conducted in a -bed university hospital. all adult patients having received at least days of treatment between june and april were included. data collected for the study were: age, sex, treatment indication (type of infection, identified pathogen, dosage and treatment duration), previous antibiotics and therapeutic outcomes. main outcome measures: the indicators chosen were: treatment indication, prescribed dose and treatment duration. results: two patients were included. in july , temocillin was used in a year old female as first-line treatment of intraperitoneal haematoma infection due to multiresistant klebsiella pneumoniae. prescribed at a dose of g twice daily by an infectious diseases specialist, treatment was continued at the same dose for up weeks with therapeutic success. in august , temocillin was used in a year old male for the treatment of bacteraemia due to multiresistant enterobacter aerogenes. previously treated by imipenem/cilastatin, temocillin was prescribed as second-line treatment at a dose of g twice daily by an infectious diseases specialist. treatment was continued at the same dose for up weeks with therapeutic success. conclusion: the dissemination of antibiotic resistance among gramnegative enterobacteriaceae continues to be an increasing threat for healthcare worldwide. within this context, temocillin could be an interesting alternative. determining the role of temocillin in a therapeutic arsenal is essential. our hospital considers temocillin as a ''critical antibiotic'' although its use is not exclusively limited to the new drug application. therefore, temocillin prescriptions are monitored permanently by infectious diseases specialists, microbiologists and pharmacists in order to improve the good use of this antibiotic and to optimise patient safety. please specify your abstract type: research abstract background and objective: drinkable solutions are more susceptible to deterioration and can lead to a potential risk for patient care. having the right information at time of care is essential. the aim of this study is to assess nursing staff knowledge in a french university hospital on the management of drinkable solutions to elaborate tools to help health professionals and to enhance equality of information in order to optimise patient care. setting and method: an assessment of practice using a questionnaire was conducted in may among a share of the nursing staff in a int j clin pharm ( ) results: completed questionnaires were collected. % of nursing staff replied that the period-after-opening is the same for all of drinkable solutions. this period is estimated at month in % of cases, weeks in % of cases and days in % of cases. % of nursing staff do not know how to store drinkable solutions after opening. the date of opening or the date of expiry after opening are specified on the medicine bottle in respectively and % of cases. only % of nursing staff have tools pertaining to the management of drinkable solutions. these observations led the pharmacy to create and distribute appropriate tools. storage methods for the drinkable solutions available in our hospital were collected directly from pharmaceutical laboratories. this information has been made available to nursing staff via drug control software (pharma Ò , computer engineering, paris). conclusion: this study highlights the lack of knowledge on the management of drinkable solutions and the lack of information available to nursing staff. in our hospital, the dissemination of appropriate data reduced inequalities in available information between care units. data will soon be integrated within the drug prescription software (mc kesson usv Ò , crossway, san francisco) in order to homogeneously train all health professionals in good patient care. please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation (mr) is a process which allows prevention of iatrogenic injuries during patient's hospitalisation and transfers. since , a clinical pharmacist has been integrated into the orthopaedic surgery care. he has performed mr at patients' admission. the aim of this study was to evaluate the impact of medication reconciliation performed by a clinical pharmacist. design: a prospective monocentric study was conducted on patients admitted in an orthopaedic surgery care (elective or unplanned surgery), during months. the clinical pharmacist established the best possible medication history (bpmh) from at least three sources of information (including patient interview when possible). then, it was compared to the admission medication order (amo) (from anaesthetists when elective or orthopaedists when unplanned). unintended medication discrepancies (umd) detected were discussed with prescribers in order to be corrected. epidemiological data, number and type of umd, therapeutic classes involved and the percentage of corrected umd were collected and their potential clinical impact was assessed. results: in this study, patients were included during months. elective surgeries were concerned in % of the cases. at least one umd was identified in patients ( %) (median age: . years old; male/female ratio: . ). of these, ( %) were older than years old. finally, umd were detected, being . by patient. main therapeutic classes concerned cardiovascular system ( %), nervous system ( %) and digestive system ( %). of the umd detected by mr, there were % of omissions, % of inappropriate dosing and % of renewal prescriptions stopped by the patient. finally, % of umd were corrected. of these umd, % were major errors (i.e. causing potential harm), % were significant errors (i.e. monitoring or intervention potentially required to preclude harm) and % were minor errors (i.e. without potential harm to the patient). conclusion: medication reconciliation process performed by a clinical pharmacist allows detection and correction of umd on half of patients in surgery care particularly on elderly patients. the high proportion of umd can be explained by the multiplicity of actors involved in medication management. health information technology could help to focus mr on patients at high-risk of adverse drug events. please specify your abstract type: research abstract background and objective: darunavir plus ritonavir (drv/r) have shown optimized results in simplification strategies (monotherapy (mt) or dual therapy (dt)) for selected hiv + in randomized clinical trials and real life experience. recent introduction of one pill drv plus cobicistat co-formulation (drv/c) may be particularly suited for both mt/dt allowing once daily administration optimizing dosage and adherence. the objective of our study is to evaluate efficacy and security of drv/c in mt and dt. setting and method: all hiv + adults with antiretroviral change to drv/c in mt/dt at a reference hospital in the northwest of spain were included in this retrospective study. a statistical analysis was performed using the spss v. .software. main outcome measures: epidemiological, clinical, antiretroviral regimen, serum creatinine, lipids and inmunovirological data (rna-hiv and lymphocytes cd ) were compared previous and after change to drv/c. results: hiv treatment-experienced patients have received drv/c in dt ( ) or mt ( ). . % were men with a mean age of years. main risk factors were: . % heterosexual, . % msm, . % injection drug users, . % mother-to-child transmission, . % transfusion in haemophiliac patient and . % unknown. cdc category distribution was . % a, . % b, . % c and . % unknown. overall mean nadir cd counts were . ± . cells/mcl. mean time since drv/c prescription to discontinuation or until analysis was . days [range - ]. . % drv/c mt were prescribed to patients with prior drv/r mt in order to simplify treatment and the mean time of the duration of these prior therapies were . years. in case of dt, . % were prescribed on patients with prior drv/ r + tc with a mean duration of . years. serum creatinine increases ( . vs. . ; p \ . ) and cd decrease ( . vs. . ; p = . ) when patients move to drv/c. no significant change in the other analytical parameters and all patients maintained undetectable. patients discontinue drv/c due to intolerance and inability to swallow in each case. conclusion: this preliminary study concludes that drv/c in mt or dt is efficacy (no viral rebound) and safety. although an increase in creatinine was observed, it would not be considered clinically significant. of note, lymphocytes decreased significantly and it will be important closely monitored to check that maintain effectiveness during the follow up. hp-pc : developing clinical pharmacy in emergency department setting up a medication reconciliation process marion collignon *, , antoine gantier , florent lapacherie , hélène dewaele , laura foucault , anne-laure raso , emmanuel cirot , said laribi , xavier pourrat pharmacy, emergency department, chru tours, tours, france please specify your abstract type: descriptive abstract (for projects) background and objective: in emergency department (ed), if a drug related problem (drp) happens at the patient admission, the risk is the error remains until discharge. one part of drp may be avoided with using medication reconciliation (mr). the objective of this study was to evaluate the feasibility of setting up a medication history (mh) of patients in ed in an acceptable lap of time before they were transferred in another unit or discharged. design: a months prospective study was conducted in ed in a university hospital in france. two junior pharmacists coached by a senior pharmacist, after a months training for mr, were in charge of the data and mh collection. for all patients, we collected age, mh according to number of sources, discrepancies identified, adherence to treatment (according to the social security questionnaire), type of sources. mh were established according to community pharmacies, patients, previous electronic patient files, prescription sheets, patient's family, packs of pills and to the general practitioner (gp). for patients from long term care facilities (ltcf), the mh was established only by communication with the ltcf. then, the current prescription was compared with the home medication regimen. mh and discrepancies (omitting medication, incorrect dose, ambiguous name) were recorded in the electronic patient files to be available during hospitalization. because ed does not have a pharmaceutical review of prescriptions, only major discrepancies were transmitted to physicians. results: we collected mh ( from ltcf), with a sex ratio of . and a medium age of . years old. it represented an average of . mh per day or min per mh. among patients who did not come from ltcf, sources used by pharmacy students were patient's community pharmacy ( , % of cases), patient ( , %), previous electronic patient file ( , %), prescription sheets ( , %), call to gp ( , . %), gp mail ( , . %), patient's family ( , . %), packs of pills ( , . %), community nurse ( , . %). finally, patients ( %) had been hospitalized, others were discharged. we analysed mh for patients: at least one drp occurred for patients ( %). among patients, ( %) had an immediate pharmaceutical intervention because of the risk due to discrepancy. among patients who did not come from ltcf and who could communicate, were good adherent to treatment ( %). conclusion: this study highlights the great interest of the mh by pharmacists at ed, which avoids many drp. the presence of pharmacists in ed contributes to maintain a safe environment for medication and to assist prescribers in the continuity of treatment between home and hospital. spending min by mh, we identify one drp every min. nevertheless, it could be benefit to develop this activity because of the satisfaction of the emergency physicians. currently, mr is the first step to develop clinical pharmacy in the ed. please specify your abstract type: research abstract background and objective: emerging evidence in the literature suggests a high prevalence of suboptimal vitamin d (vitd) and an association between lower serum levels and higher mortality in cancer. the objective of this study was to quantify vitd deficiency in patients after surgery for head and neck cancer, and to determine the effect of one cholecalciferol intramuscular dose. setting and method: intervention study with a follow-up period of months (november -february ) performed on patients followed by the nutrition support unit after surgery for head and neck cancer. demographic and physiopatological data, including admission diagnosis, age, gender, calcium, magnesium and phosphate were collected. nutrition screening by conut index was carried out. a single intramuscular dose of . ui cholecalciferol (vitamine d bon Ò ) was administered to vitd-deficient patients and serum -hidroxy-vitamin d (s ohd) records after the administration, including primary carés records after discharge, were evaluated (reference range - ng/ml). main outcome measures: s ohd (\ ng/ml: deficiency; - ng/ml: insufficiency; c ng/ml: sufficiency). results: data from patients with a mean (sd) age of . ( . ) years were collected (males: %). the admission diagnosis was laryngeal squamosis cell carcinoma (n = ), glottis carcinoma (n = ) and nasopharynx, tongue and skull base cancer (n = ). at baseline, , and patients were considered have high, medium and low risk of malnutrition, respectively. the mean (sd) serum ohd was . ( . ) ng/ml (deficiency: patients; insufficiency: patient). despite the role of vitd in mineral balance, calcium, magnesium and phosphate mean (sd) serum levels were between the normal range . ( . ) mg/dl, . ( . ) mg/dl, and . ( . ) mg/dl, respectively. s ohd records were available week after the administration (mean (sd) = . ( . ) ng/ml). and patients still showed deficiency and insufficiency, respectively. primary care's records from patients were available after discharge ( . , . and . ng/ml). conclusion: poor nutritional status and high prevalence of suboptimal vitd in patients with head and neck cancer were found. a single dose of intramuscular cholecalciferol slowly raises s ohd. follow-up after discharge is essential to evaluate the achievement of the therapeutic objective. setting and method: this is a descriptive retrospective study. it took place in a teaching hospital. antifungal broad spectrum therapies (liposomal amphotericin b, caspofungin, micafungin, posaconazole, voriconazole) used between st january and st december were included. main outcome measures: indications, type of combination and patients specifications were analysed. results: only patients ( . % over all patients receiving antifungal therapy; n = / ) received an antifungal combination therapy during the study period. majority of patients presented risk factors: % of patients had an organ transplant (n = ), % suffered from malignant blood disorders (four acute myeloid leukaemia, two chronic lymphoid leukemia, one non-hodgkin's lymphoma, one hodgkin's lymphoma and two refractory anaemia with excessive blast), % suffered from solid cancer (one lung cancer and one breast cancer) and % suffered from chronic obstructive bronchopneumopathy (n = ). antifungal combination therapy was used against invasive aspergillosis in % of cases (n = ) among which complications such as brain and cardiac impairment were found in % of patients (n = ). the six remaining patients ( %) were co-infected with candidiasis for three patients and mucomycosis for three patients. voriconazole was logically the most used in combination, and just one patient received oral form. it was in majority prescribed with caspofungin ( %, n = ) and intravenous liposomal amphotericin b ( %; n = ). combination including liposomal amphotericin b and caspofungin (n = , %) or posaconazole with liposomal amphotericin b (n = ) were found in our study. five patients deceased during the hospitalization of the fungal infection ( %) which shows the gravity of these cases. majority of patients ([ %) was treated less than days with these combinations. conclusion: this retrospective study shows that patients who received antifungal combination therapy were mostly immunocompromised, co-infected or experienced a severe infection with severity factors. the antifungal combination was in majority initiated because monotherapy failed to cure the patient. all prescriptions were discussed with a mycologist who tried to shorter the combination treatment duration. this multidisciplinary approach is a major key in the process of these type of treatments. please specify your abstract type: research abstract background and objective: because of its broad spectrum and the risk of resistance mutation, delivery of posaconazole is nominative and controlled by hospital pharmacists. the aim of this work was to describe the use and pharmaceutical follow-up of posaconazole tablets over a -months period. setting and method: this is a descriptive retrospective study over a -months period from november to may in a teaching hospital. all patients who received posaconazole tablets were included. main outcome measures: indications and dosage were reported. results: patients were included in the study. posaconazole tablets were used for: fungal invasive infection prophylaxis in case of stem cell transplantation ( %; n = ), fungal invasive infection prophylaxis if a chemotherapy was started to treat a chronic myeloid leukaemia or a myelodysplasic syndrome ( %; n = ); treatment of invasive aspergillosis ( %; n = ); mycetoma ( %; n = ); zygomycosis or mucormycosis while patient had renal impairment ( %; n = ). all of these indications were approved for posaconazole (marketing authorization and local guidelines). only patients ( %) received a loading dose ( milligrams twice a day) as recommended in approval authorization. posaconazole blood levels were monitored by pharmacologists: % of patients (n = ) did not need dosage modulation which shows that variability is not so important. but three patients did not have any assay to monitor posaconazole blood concentration. patient received a loading dose and was switched to intravenous voriconazole after icu transfer. patients needed increase and/or reduction dose to obtain optimal posaconazole blood levels. conclusion: this study describes the use and the follow-up of posaconazole tablets during the first months after its approval in europe. all indications are approved for posaconazole but this analysis shows that pharmacist have to remind the necessity of a loading dose. dosage can be adjusted according to assays results. please specify your abstract type: research abstract background and objective: due to the acute, hectic environment in a fast-paced work-flow emergency department (ed) it is a challenge to verify the correct and updated medication list for the admitted patients. when performing medication reconciliation (mr) in this environment, these challenge has to be taken into account and prioritizing patients for mr could be necessary. the objective of this study was to identify risk factors correlated to clinical relevant medication discrepancies (crmds) among patients admitted to ed, and based on these revealed risk factors, develop a model for prioritizing patients for mr in the fast-paced work-flow at the ed. setting and method: patients continuously included at the ed, diakonhjemmet hospital (dh), oslo, norway. trained pharmacists and emergency nurse conducted mr. patient specific factors and revealed crmds, between hospital admission records and information about prehospital medication use, were recorded. binary linear regression was used to identify risk factors correlated to crmds. the prioritizing model was built using statics and clinical experiences. main outcome measures: what risk factors is correlated to crmds and how precisely do the prioritizing model classify the patients as high-and low-risk patients. results: % of the patients had c crmd. the following were identified as risk factors correlated to crmd and were suitable for inclusion in the prioritizing model; gender (woman), age (c ), c admission to hospital last months, admission causes; surgical, malfunction, cancer. the model correctly classified . % of the patients with crmds as high risk. further, . % of the patients with crmds were classified by the model as low-risk patients (false negatives). the model classified . % of the patients who did not have a crmd as high-risk patients (false positives). conclusion: the prioritizing model developed can be helpful in identifying what patients are at increased risk of having crmds in the fast-paced work-flow at the ed. identifying these patients will result in using the resources available in the ed in the most efficient manner and utilizing the full potential of the mr method. as a consequence of this, patient safety would be increased. hp-pc : intravenous potassium chloride: quick audit of prescribers knowledge and recommendations regarding safe practice and proper usage asmaa damou * , vincent zaugg, martine postaire please specify your abstract type: descriptive abstract (for projects) background and objective: our hospital has established methods that try to ensure the safe use of high alert medications. intravenous potassium chloride (kcl) was the subject of preventive measures: separation of different dosages (kcl . % vials reserved for paediatric services and kcl % vials reserved for adult services); creation of an advice record for doctors and nurses; specific labelling of storage areas; double-check the prescription and administration. the objective of this study was to evaluate the knowledge of the safe use of intravenous kcl by prescribers. design: multiple-choice questions were developed for prescribing recommendations established by our hospital with the collaboration of the doctor who is chairman of the central committee of vigilance and risk associated with care (cvris). a link to the online survey was sent by email to physicians practicing in departments (eight paediatric services and six adult services). the results were extracted and interpreted in excel Ò . results: % of physicians responded to the survey ( medicine residents, hospital doctors). in paediatric services, % of doctors know that only the kcl . % should be used. % know the unit of prescription to be used (mmol/kg or meq/kg), and % know that the maximum recommended infusion rate is . mmol/kg/hour (or mmol/kg/h in recovery unit). in adult services, the recommended maximum rate of infusion ( g/h) is known to all prescribers, but only % know that the concentration of kcl must be less than g/l. % of paediatric doctors say that their kcl prescriptions are checked by a second doctor, but the answers in the same service area are sometimes contradictory. in adult services, only % of physicians say that the prescriptions are double-checked. the information brochure available on the intranet of the hospital is known by % of prescribers. the response rate of physicians to the survey was satisfactory. therefore, the recommendations are rather well known by prescribers, except the value of the maximum concentration of infusion for adults. the results of this audit were returned to the doctors, accompanied by a reminder stating the need to double-check the prescription and the existence of advice records on the website of the hospital. conclusion: this audit is an approach to increase the safety of the use of high alert medications. it will be completed a second time, by an evaluation of prescriptions collected and the storage conditions of potassium chloride in the care units. please specify your abstract type: research abstract background and objective: data listed behind each unit dose of a primary packaging of a pharmaceutical product are essential for a safe identification for the patient. however, the last medical services of the lausanne university hospital where nurses remove the solid form drugs (sfd) from their blisters when they prepare in advance the week container were in the vaud's prisons. the aims of the study were: ( ), quetiapine ( ) and ibuprofen ( ) and were psychotropics ( . %). part . the four data identified as essential: brand name, dosage [mg], batch number, expiration date. the sfd unit doses were classified as green when the blister included four data, yellow with two or three and red with less than two. of the sfd in cupboards, were green ( %), yellow ( %) and red ( %); an infovigilance was sent to each manufacturers. part . potential barriers identified: trays' sizes and space in drug's cupboards; preparation time to cut versus to remove the blisters; risks of self/hetero-aggression with pre-cut blisters; drugs packaged in bulk; multidose liquid medications. using containers larger than is usual was rarely necessary; space in cupboards was sufficient. the preparation time gradually decreased during the study. ingestion or aggression with pre-cut blisters was considered as limited, based on literature and experiences of two others prisons (geneva; lyon). for bulk sfd and multidose liquid drugs: proposals to the pharmacy to store some alternatives blistered sfd; blistering expensive bulked drugs; availability of the entire package delivered to inmates. the pilot phase was initiated in may . conclusion: a majority of inmates takes a drug treatment. half of sfd unit dose is identifiable (trade name and dosage) but an effort from manufacturers would better secure the drug supply chain. the study of the barriers helped to further implement the pilot phase. since early , none of the five prisons medical wards are removing the blisters and no incident was reported. please specify your abstract type: research abstract background and objective: nefopam is a widely used antalgic in hospital. its use is contraindicated in the epileptic patient as it results in lowering the epileptogen threshold and is likely to trigger epileptic seizures. the clinical pharmacist should systematically warn the prescriber against this contraindication when analysing prescriptions. following the onset in our establishment of an epileptic condition in a patient treated with nefopam, who had not been subject to any pharmaceutical intervention (pi), we set about analysing the validation practices regarding this contraindication and possibly implementing actions designed to improve those practices. setting and method: retrospective collection over a period of months of prescriptions for patients hospitalized in hospital beds with clinical pharmacy service (associating med-reconciliation, checking prescription according to medical file and participation to medical rounds): orthopaedic surgery, hepatic-gastro-enterology, general surgery, liver transplant and chest surgery. records of patients with nefopam prescription associated to medication belonging to the therapeutic class of antiepileptics were consulted with a view to finding cases of epilepsy. the pharmaceutical alerts were extracted from the pharmaceutical software. main outcome measures: number of epileptic patients treated with nefopam, number of pharmaceutical interventions issued when prescribing nefopam in epileptic patients. the study focused on , patients. ( . %) of them were prescribed nefopam, and ( . %) of them were prescribed nefopam associated to medication belonging to the therapeutic class of antiepileptics. after analysis of the patients' records has shown that of them were really epileptic. only pi's were effected ( . % of problematic prescriptions), and ( %) of them had an immediate prescription change. . % ( / ) of the patients have a pi in medicine services compared to . ( / ) in surgery services (p \ . ). the results of this study show that % of the contraindications related to the use of nefopam in epileptic patients are not reported to the prescriber. these results will be presented to our pharmacists so they can take them into account. subsequently a new study will be conducted to measure the relevance and efficiency of this program. hélène dewaele * , anne-laure raso, emmanuel cirot, marion collignon, laura foucault, xavier pourrat please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation (mr) has been demonstrated to reduce drug-related problems in inpatients. in our university hospital, mr has been performed for beds for years at the same time as prescriptions review. the aim of this study was to assess the impact of mr on pharmaceutical interventions (pi) during prescriptions review. design: a -month prospective study in orthopaedic surgery, hepato-gastro-enterology, general surgery, liver transplant and chest surgery was conducted. during medication review all pis were collected and those related to mr (rpi) were identified. thereafter for each patient we collected age, type of hospitalization unit (med or surgery) and for pis the drug associated and its acceptance by the medical team. results: during the study patients had a daily prescription review. patients ( %) had at least one drug-related problem. lines of prescriptions were mentioned to have at least one rpi. rpi represent % of drug-related problems. ( %) discrepancies were corrected by prescribers. the age of the patient was significantly different between patients with rpi (mean age: years old) and with pi (mean age: years old; p \ . ). the type of unit did impact the percentage of prescriptions with drug-related problems (medicine: . ; surgery: . ; p \ . ), the rate of corrected pi (medicine: %, surgery: %, p \ . ), but did not impact the rate of corrected rpi (p = . ). in surgery units the rate of corrected rpi ( / ) is significantly higher than corrected pi ( / ; p \ . ). medicines belonging to the four classes of: digestive and metabolism system, blood and blood flow, cardiovascular system, neurological system represent more than % of all the medication concerned by a resolved pi or rpi. the proportion of medicines from the digestive and metabolism class is the only class among those four that is not significantly different between resolved pi and rpi. conclusion: mr highlights a large number of discrepancies in inpatients. a modification of prescriptions due to mr occurs in % of the patients. in surgery units, these rpi are more frequently taken into account than drug-related problem warned by pis. indentifying patients for whom mr has the bigger impact could help us to reinforce our actions. please specify your abstract type: research abstract background and objective: diabetes is very frequently causing cardiovascular complications, thus impairing various systems and organs. therapy for these multiple conditions has to be revised and improved constantly. the aim of this closed retrospective study lead in bucharest emergency clinical hospital was the assessment of some of the diabetes mellitus (dm) complications and the related medication. setting and method: data was collected from cardiology, neurology, gastroenterology, internal medicine wards from bucharest emergency clinical hospital. only patients diagnosed with type dm were included in the study. there were analysed records from patients aged - of whom were men, following the presence, signalling and monitoring of diabetic nephropathy and arteriopathy. main outcome measures: we investigated the relationship between diagnosis and/or biochemical signs of kidney disease (serum urea, serum creatinine levels), diagnosis of arteriopathy, and the drug therapy administered in the respective cases. we also assessed the sex and age distribution of the patients diagnosed with diabetes mellitus and facing at least one of its complications. results: kidney disease, as a dm complication, was present in % of cases, patients aged - , of whom % were men. patients received diuretic treatment, of them being given hydrochlorothiazide, contraindicated in dm because of its hyperglycaemia-inducing effect. of the patients, had high serum urea levels ([ mg/dl), had high levels of serum creatinine ([ . mg/dl), and presented risen levels for both, but only were also diagnosed with kidney disease. patients with kidney disease were given furosemide, known for altering the renal function. circulatory failure was found in % of the patients, aged - and % of subjects, aged - , had both diabetic complications. conclusion: the present study emphasizes the role of the clinical pharmacist in adapting the medication of the diabetic patient, an inappropriate pharmacotherapy worsening dm complications. this is essential especially for elders, where polypathology and polymedication lead to a significant increase of dm complications risk. hp-pc : epileptic seizure after treatment with thiocolchicoside: discussion about a case report valérie dobremez *, , adeline martin-dupray , jacqueline berlioz , pierric giraud pharmacy, neurology, centre hospitalier annecy-genevois, metz-tessy, france please specify your abstract type: descriptive abstract (for projects) background and objective: thiocolchicoside is a semisynthetic derivate of naturally occurring colchicoside, which is largely used in humans as a centrally acting muscle relaxant. this compound also has anti-inflammatory and analgesic effects. the objective of this work is to report a recent case of serious adverse effect of thiocolchicoside occurring in context post traumatic brain damage without sequalae. design: a -year-old woman suffered from headaches and neck pain since days, she was treated with thiocolchicoside. she took mg in the evening and mg the next morning. five generalized tonic-clonic seizures, without recovery of normal consciousness between seizures, have occurred suddenly - min after the second administration. the patient was admitted to intensive care unit in order to control the epileptic seizures. a status epilepticus was diagnosed requiring intravenous drugs with clonazepam, phenobarbital and propofol. the patient was controlled and transferred in neurologic unit in order to complete paraclinical investigations. its main antecedent was a severe head injury at the age of years following a public road accident. the brain scan revealed an old frontal hypodensity. rest of etiological assessment was negative (lumbar puncture, no infectious disease), numbers were normal. the definitive diagnosis was a status epilepticus on post-traumatic sequelae, sensitized by taking a proconvulsant drug. a treatment with levitiracetam was initiated at mg twice a day. outcome was favourable with no recurrence months later, a recommendation was requested to pharmacovigilance. results: the muscle relaxant activity of thiocolchicoside results of an agonist action on glycinergic receptors located primarily in the brain stem and spinal cord. however, thiocolchicoside also acts as an antagonist of the gaba-a receptor (mainly located in the cerebral cortex), this pharmacological action can cause a proconvulsant effect. epilepsy is a very rare adverse effect, only few cases have been reported in literature. the epileptogenic activity of thiocolchicoside occur mainly in patients with a history of epilepsy, acute brain injury or possible blood-brain barrier disruption. the chronology is consistent with the responsibility of the drug as a promoting factor. pharmacovigilance retains after analysing drug causality. conclusion: the case history indicates that thiocolchicoside has a powerful epileptogenic activity. thiocolchicoside can precipitate seizures in predisposed patients, and that its use should be avoided in patients with brain diseases (and therefore lower seizure thresholds) or blood-brain barrier disruption. pharmacists could warn physicians and should verify the absence of notable history before dispensing thiocolchicoside. hp-pc : acute exacerbation generalized myasthenia after red yeast rice use: a case report valérie dobremez *, , amélie serra , déborah grosset-janin , jacqueline berlioz , aymeric dopter , jean-henri ruel pharmacy, neurology, centre hospitalier annecy-genevois, metz-tessy, nutrivigilance, french agency for food, environmental and occupational health and safety, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: many drugs can induce acute exacerbations or reveal myasthenia gravis. self-medication or complementary and alternatives medicines expose patients. the objective of this work is to report a recent case of acute exacerbation of myasthenia gravis because of a dietary supplement use. design: intermittent vertical diplopia and ptosis of the left eye settled in a -year-old man. its main antecedent is hypertension treated with perindopril. the neurovascular origin was ruled out. the electromyogram (emg) found a significant decrement ( %) of a postsynaptic block in the tongue and right orbicularis muscle. acetylcholine receptor-antibodies were positive. myasthenia gravis was diagnosed (osserman score / ) and the patient was treated with pyridostigmine. the identification of carotid atheroma required a treatment with a statin that the patient refused. he preferred a cholesterol lowering dietary supplement, containing red yeast rice. six days later, he was hospitalized for an acute decompensation of myasthenia with bilateral ptosis, oculomotor paresis, drooping head, int j clin pharm ( ) : - chewing trouble and dysphagia (osserman score / ). the patient is treated with high-dose intravenous immunoglobulins then corticosteroids. the dietary supplement is stopped. an opinion was requested to the clinical pharmacist of neurology. the osserman score gradually increases to / . results: red yeast rice contains a range of compounds known as monacolins, of which monacolin k-renamed lovastatin, which was found to be an inhibitor of cholesterol synthesis and the progenitor of the statin family. a literature review has highlighted the responsibility of statins in acute exacerbations or reveal myasthenia gravis occurrences. in this case, the chronology is consistent with the responsibility of red yeast rice. the case was reported to the french system of nutrivigilance, which retained after analysing a probable intrinsic imputability score. conclusion: dietary supplement with red rice yeast are not recommended in case of myasthenia gravis. this is the first case of acute decompensation of myasthenia recorded with red yeast rice in the french system of nutrivigilance. multidisciplinary collaboration (neurologists, clinical pharmacist) has optimized the patient management. fanny durand * , camille lambert, antoine dupuis please specify your abstract type: descriptive abstract (for projects) background and objective: development of computerized prescription highlights the need to harmonize pharmaceutical analysis practices. the aim of this study is to analyse the antibiotics prescriptions in the treatment of urinary tract infections, to develop a pharmaceutical validation tool. design: a prospective observational study was conducted for one week, in care units. pharmacists, interns, and pharmacy students were trained on spilf (french society of infectious pathology) recommendations, on pharmacist's role in the management of urinary tract infections, and on the data collection. all patients with antibiotic prescription for urinary tract infection were included. some data were collected: reason for hospitalization, clinical signs, results of susceptibility testing, risk factors for complications (organic or functional abnormality of urinary tract, male, pregnancy, elderly, severe immunodeficiency, severe renal impairment) and signs of severity (severe sepsis, septic shock, interventional surgical drainage). then, the treatments prescribed to the patient, probabilistic on the one hand and documented on the other hand, were compared to spilf recommendations. finally, during a multidisciplinary meeting (pharmacist, expert in infectious diseases), we selected the relevant pharmacist interventions. results: twenty-three patients were included ( women, men), % had a urinary catheter. . % of prescriptions were concordant with spilf recommendations: probabilistic and documented treatment, and duration. among the non-conforming prescriptions, nine pharmacist interventions have been formulated: four prescriptions did not specify the duration of treatment, one antibiotic was prescribed on an insufficient period, two cases of severe acute pyelonephritis without prescription of aminoglycoside, one prescription was not reassessed according to results of susceptibility testing, one pregnant woman with urinary colonization without clinical signs, was treated before obtaining results of susceptibility testing. three cases of poor management are identified: two cases which treatment began only after results of susceptibility testing (a urinary tract infection linked to care, an acute pyelonephritis with complication risk), and a cystitis treated with nitrofurantoin while the germ was resistant. conclusion: a synthetic tool was created. there are three elements for helping pharmaceutical analysis: the questions to ask oneself facing a prescription of antibiotic for urinary tract infection, a flowchart to identify the recommendation adapted to the case, and finally a summary table showing spilf recommendations. this tool will be distributed and evaluated. hp-pc : off-label use of rituximab in refractory antisynthetase syndrome (as) through a long-time experience in a neuromuscular diesases center lise durand * , carole metz, patrick tilleul, helga junot pharmacy, gh pitié salpêtrière, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: as is an idiopathic autoimmune inflammatory myopathy, characterized by presence of antisynthetase antibodies: anti-jo , anti-pl , anti-pl . patients are usually first treated by corticosteroids (cs) or immunomodulating drugs. rituximab (rtx) has become another option for refractory as, supported by few uncontrolled studies . because of its off-label use, our hospital pharmacy has implemented a controlled drug delivery. this work assesses a -years follow-up of patients treated by rtx and the resulted drug costs. design: patients registered in our database since december who received c injections of rtx to treat as, were analysed to describe their eligibility criteria, conditions of management and the clinical and biological effects of the treatment (creatine kinase (cpk) used as biomarker). patient files were consulted to collect all individual data and pharmaceutical software was used to review deliveries. drug costs were also reckoned based on prices from french health insurance. results: for months, patients (median age (min-max): ( - ), % women) have been treated with rtx for refractory as, the majority with anti-jo antibodies ( ). all patients suffer from muscular and lung affections, particularly interstitial pneumonia. many are also living with arthropathies ( ) or cutaneous disorders ( ). cardiac involvement is seldom ( symptomatic patients). the mean age of diagnostic is . years and the mean treatment period is . years. the common treatment is g at day (d ) and d , then g all months. before rtx treatment, seven patients received c other drugs such as cs ( %), azathioprine ( %), methotrexate or mycophenolate mofetil ( %). prednisone and azathioprine are also prescribed with rtx respectively for and %. treatment is associated with cures of intravenous immunoglobulins for four patients. to date, median number of administrations per patient is ( - ), d and d included. all patients have presented positive effects on both clinical and biological markers, mainly during the first months after treatment induction. wilcoxon tests show a significant difference in cpk level between d and m , also between d and the last known result. today, three complete remissions are specified in patient file; only one hepatitis b virus reactivation is reported. since , budget impact due to drug cost amounts to €. conclusion: whereas the use of rtx is controverted for treatment of all types of myopathy, as could have one of the best response . our cohort shows real clinical results and positive effect on usual biomarker. our experience demonstrates the safe and successful use of repeated administrations in refractory as. however, there is a need for further controlled studies to assess the efficacy/safety of rtx and to define its place in the strategy in view of its cost-effectiveness ratio. the pharmaceutical controlled drug delivery has to be continued to supervise, support and document its proper off-label use. please specify your abstract type: descriptive abstract (for projects) background and objective: as a part of the national patient safety program, the northern norway regional health authority are implementing new procedures for medication reconciliation (mr) in hospitals in the region. the procedure defines that mr is the doctor's responsibility and describes how it should be performed. the aim of this study was to investigate whether the implementation of the procedure reduces medication discrepancies (mds) in the charts at bodø hospital. and . % ( / ) of the patients died before discharge. parenteral nutrition was administered an average of . days ( % ci . - . ), of which . ( % ci . - . ) were with ipn. previous spn had been administered in . % ( / ) of the patients. before beginning ipn, the average triglycerides level was . mg/ dl ( % ci . - . ) but at the end of the ipn it was . mg/ dl ( % ci . - . ), which lead to a mean reduction of . mg/dl ( % ci . - . ; p = . ). regarding to the total amount of lipids provided with parenteral nutrition, with ipn there was a mean reduction of . g ( % ci . - . ; p = . ) comparing to those administered with spn. conclusion: usage of ipn in critically ill patients with htg permits to adjust parenteral nutrition formulations to meet specific nutrition needs, enables to reduce the total amount of lipids administered and, therefore, it allows to significantly decrease triglycerides levels. jennifer a. esteban gonzález * , elisabet nogué pujadas, angels andreu crespo, xavier bonafont pujol, nuria romero pascual please specify your abstract type: descriptive abstract (for projects) background and objective: the incidents involving patient misidentification (pm), or wrong patient medical errors (wpme), are medication errors (me), near-miss or close-call situations which can pose a considerable threat to patient health. pm may be under-reported due to the unawareness of the error or the difficulty of identifying them. the aim of this study is to describe the incidence and categories of wpme in a university hospital. design: observational, retrospective analysis of the voluntary reported wpme in the pharmacy database since march until june . these were classified in prescription, transcription, dispensing, administration and drug system errors. in addition, the national coordinating council for medication error reporting and prevention (nccmerp) taxonomy was used for classifying me according to the severity of the outcome. results: of me registered, of them were wpme ( . %). . % of them were due to prescription errors, which consist on wrong labelled medical orders, intermingled patient prescriptions or patient misidentification in computerized physician order entry (cpoe). the administration errors supposed a . % of the total amount of wpme and dispensing errors were . %. % of wpme were transcription errors, which occurred previously to the implementation of cpoe, and the remaining . % were system errors after cpoe. the wpme reported took place in the hospitalization wards ( . %), pharmacy ( . %), outpatient services ( . %), intensive care unit ( . %) and day-care hospital unit ( . %). . % occurred at working days and . % at the weekends. wpme were notified by pharmacists ( . %), nurses ( . %) and physicians ( . %). referring to the classification according to nccmerp, . % of wpme didn't reach the patient (category b) whereas . % reached the patient but didn't cause harm (category c) and . % required patient monitoring (category d). the remaining wpme ( . %) caused harm to patients and required medical intervention (category e). finally, in int j clin pharm ( ) : - more than half of wpme ( . %), reporters suggested measures to prevent these errors. conclusion: wpme represents near % of total me reported in our hospital. given that more than % reached the patient, safety measures must be implemented to reduce the risk of hazardous events. additionally, further encouragement in notification is necessary in order to improve patient safety. results: two men diagnosed with rrms aggressive evolution were included in the study. age: and . both of them without any treatment by the time they started being treated with alemtuzumab (previously one of the patients had been treated with fingolimod, suspended by inefficiency). the protocol design for the elaboration and control of alemtuzumab in the pharmacy service ensures greater safety and represents a saving strategy. in addition, the development of the protocol in the electronic prescription system (silicon Ò ) facilitates the prescription, proper administration and standardization of treatment among patients. the protocol includes daily alemtuzumab infusion for days and other necessary medications including premedication (metylprednisolone, omeprazole, paracetamol and metoclopramide) and anti-infective prophylaxis (aciclovir). developed adverse effects during infusion were skin erythema, pruritus and fever. it was not necessary to stop the alemtuzumab infusion in any patient. during treatment, one patient developed a severe lymphopenia and upper respiratory tract infection (influenza a). conclusion: the role of the pharmacist is critical at various stages, from the preparation and the administration guidelines, to detection, monitoring and reporting of adverse effects. alemtuzumab is presented as an alternative for those patients who do not respond to standard therapies or who have rapidly evolving severe rrms. because of its mechanism of action it is important to closely monitor patients, with particular emphasis on prophylaxis of possible infections. hp-pc : descriptive analysis of patients receiving oral anticoagulation following acute coronary syndromes sadeer fhadil * , paul wright, sotiris antoniou please specify your abstract type: descriptive abstract (for projects) background and objective: triple therapy with concomitant anticoagulant and dual antiplatelet therapy (dapt) following acute coronary syndrome (acs) increases bleeding risk by % compared to patients on dapt. bleeding post acs increases mortality and reinfarction risk; balancing ischemic and bleeding risks is particularly challenging in this population. european society of cardiology (esc) produced a consensus document, providing guidance for patients presenting with acs requiring concomitant anticoagulation; however optimal duration of triple therapy and safety and efficacy of novel oral anticoagulants (noacs) and more potent antiplatelet agents requires further evidence. design: a registry was collated of patients presenting with acs requiring concomitant anticoagulation. baseline characteristics, bleeding and ischemic risk scores, periprocedural treatment and antiplatelet/anticoagulant choice and duration was recorded and analysed for trends in prescribing. results: patients have been included in the registry between oct and june , of which ( %) were naïve to anticoagulation prior to admission, ( %) were taking warfarin and ( %) were on noacs. atrial fibrillation (af) accounted for ( %) cases, (average chadsvasc score of , hasbled score of ), and ( %) were for lv thrombus. of those naïve to anticoagulation, ( %) were initiated on warfarin and ( %) on a noac (last patients all received noacs). of those on a noac for af, ( %) were dose reduced on triple therapy; apixaban being the most commonly prescribed ( % apixaban, % rivaroxaban, % dabigatran). background and objective: solid oral formulations are more convenient than liquids to manufacture, store and administer for most adults. given this superiority, one would think that children were prompted to use solid formulations when available in an eligible dose. there are indications, however, that the conversion from liquid to solid formulation in children is influenced by characteristics of the liquid medication, rather than the child's ability to swallow solid medications. the aim of this study was therefore to explore if the proportion of oral liquid formulations differed between antibiotics commonly used for upper respiratory tract infections (urti) in hospitalized children. setting and method: we collected the sales data for for the children's department of the five university hospitals in norway. the three most common oral antibiotics used for urti in children were included: penicillin v, amoxicillin and erythromycin. the proportion of oral liquids was calculated by dividing the number of defined daily doses (ddd) of liquids by the total oral ddds for each substance. main outcome measures: the proportion of ddds of oral liquid antibiotics. results: a total of ddds of common oral urti antibiotics were sold in , distributed as % erythromycin % amoxicillin and % penicillin v. amoxicillin had the highest proportion of liquid with %, followed closely by erythromycin at %. in contrast, only % of the ddds sold of oral penicillin v were liquids. conclusion: higher proportions of liquid amoxicillin and erythromycin compared to penicillin v were sold to children's departments in hospitals. there are several limitations regarding the quality of sales data, as we lack information of the administered doses as well as the child's age, gender, infection and specific needs. infections in hospitals often require initial intravenous treatment, and oral switch will often be based on the initial treatment. despite these limitations, the results fit well with earlier findings which indicate that children prefer liquid amoxicillin and erythromycin to penicillin v. hp-pc : proactive medication reconciliation: a preliminary study to identify barriers before its implementation in surgery departments laura foucault * , marion collignon, hélène dewaele, anne laure raso, emmanuel cirot, xavier pourrat please specify your abstract type: descriptive abstract (for projects) background and objective: it's well known that medication reconciliation (mr) decreases drug-related problems at patient admission (pa). in surgery departments, for planned hospitalizations, mr is performed - h after the pa (pourrat x and al, ). during this period, some chronic treatments are unintentionally not prescribed to patients. the aim of proactive mr (pmr) is to anticipate the pa by collecting their medication history before their hospitalization. the objective of this study was to identify the barriers preventing pmr implementation in our hospital. design: one week prospective study in digestive and orthopaedic surgery units in a beds' university hospital. the main outcome is to identify which barriers prevent the collection of mr before pa including the evaluation of time required to collect the relevant information, reconcile any discrepancies after the pa and identify the right sources from which to perform the mr. results: eighteen patients with a median age of years old ( - ) were contacted by phone one week before their scheduled surgery. these calls were conducted by pharmacy residents mainly between and p.m. (a more practical time for patients and at the end of pharmacist's routine tasks). an average of . ( - ) calls per patient were conducted. one patient was unreachable by phone. the average duration of the calls was min ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . twelve community pharmacy (cp) were contacted. in all cases, cp have accepted to share information about the patient's prescriptions by phone and sending it by fax during the day. five pharmacists were not contacted because patients had no chronic treatment and consequently no regular cp. on lines of prescriptions, discrepancies between the patient's information and prescriptions were identified and between prescriptions and the anaesthesia records. drug history was reported in the patient's records by pharmacy students on the day of pa in order to be used immediately by prescribers. surgery was cancelled for one patient. conclusion: the first step of an mr is made by a hospital anaesthetist some weeks before hospitalization but we have demonstrated that this step is not able to avert all potential errors. our study highlights that the time necessary to perform an mpr appears to be shorter than for an mr. in fact, it's sometimes difficult to properly interview patients during hospitalization (patient in operating room, drug-induced drowsiness). additionally, a key hurdle is to obtain any necessary modification of the prescriptions by surgeons. pmr can be expected to produce time saving efficiencies given that at pa, prescribers will have their full medication history. this study also allowed us to highlight the good cooperation between patients, cp and the hospital. it is worth noting that efforts were made to accommodate the schedules of a majority of working patients. however, as we would expect pharmacy student to perform the pmr, they will most likely attempt to contact patients during standard working hours which may impact the number of patients they are able to reach. laura foucault * , hélène dewaele, marion collignon, emmanuel cirot, anne laure raso, xavier pourrat please specify your abstract type: descriptive abstract (for projects) background and objective: the french legislation has clearly defined and integrated the therapeutic education of patient (tep) for healthcare professionals. the pharmacist is invited to get involved in tep as a caregiver around the patient. in our study, we are investigating how the pharmacist's role is viewed by patients with chronic diseases that are included in a tep program. design: prospective study on patients included in a tep program (chronic inflammatory bowel diseases, rheumatoid arthritis, ankylosing spondylitis) between september and april . in july , the participants of group sessions (gs) conducted with health professionals, including a pharmacist, were interviewed on the phone. the principal outcome of the interviews was to evaluate how their view of the involved health professional's roles evolved before and after gs; to evaluate if they would consider being followed by their pharmacist for individual sessions (is) in a community pharmacy (cp); and if the information supplied by the pharmacist during gs was understandable. to health care. however, discussions between patients appear to be essential to facilitate their acceptance of a chronic condition. some patients also questioned the cp's skills and knowledge when it comes to their particular disease. nevertheless, . % of patients have found that the vocabulary and documents used by pharmacist during gs was adapted and that the information supplied was very useful. conclusion: this study highlights that although the pharmacist is the drug's specialist, a majority of patients will more likely ask their physician about medication. their participation to the gs hasn't changed their habits even if the pharmacist intervention was relevant and understandable. the fact that the pharmacists took into account the level of health literacy of each participant was an appreciated aspect. cp should be more proactive in their relationship with the patients in order to highlight their skills and the assistance they can provide in a chronic disease. however, it's important to take in consideration that in some cases, patients have lived with their disease since childhood. the role of is is likely to be much more limited than in other situations given their key need is to interact with patients afflicted with the same condition. hp-pc : use and safety of trastuzumab emtansin in her + metastatic breast cancer in a tertiary hospital c. chaguaceda galisteo * , alba manzaneque gordon, héctor josé del río torres, natália creus baró please specify your abstract type: descriptive abstract (for projects) background and objective: novel anti her drugs have changed the management of her + metastatic breast cancer patients. the aim of this study is to describe the use of trastuzumab emtansin (tdm- ) in clinical practice in a tertiary hospital and to evaluate its safety profile. design: we performed a retrospective study of patients who started tdm- between january and december . we recorded demographic data, clinical and treatment variables, number of doses received, reasons for discontinuation, progression-free survival (pfs) and adverse effects (aes). data were obtained from the chemotherapy prescription program and medical records. aes were classified according to the common terminology criteria for adverse events version . of the national cancer institute. results: eleven female patients with a median age of . years [ . - . ] and an ecog ( / ) were included. tdm- was prescribed as a third or further line treatment in / patients and as firstline in one patient who develop disease recurrence within months of completing adjuvant therapy. median number of tdm- cycles was . . all treatments discontinuations were due to disease progression ( / ). pfs was . [ . - . months] (patients that received less than three cycles were excluded (n = )). most frequent aes were plaquetopenia, neutropenia and transaminitis but only grade in three patients (two transaminitis and one neutropenia). conclusion: the lower pfs obtained comparing to the pivotal study ( . vs. . months) could be explained by the later use of tdm- in clinical practice ( / patients received tdm- as third or further line while % in the pivotal study were first or second line). tdm- safety profile was according to the summary product characteristics. few data are currently available regarding the use of tdm- in clinical practice. further data are required to position this drug in clinical practice. please specify your abstract type: descriptive abstract (for projects) background and objective: the hospital pharmacist for their specialized training in the area of medicines, possess a greater responsibility in the detection and reporting of adverse drug reactions (adrs), as well as other problems related to treatment, which may be subject to monitoring and reporting to the regulatory authorities and the respective laboratories. thus, the pharmaceutical services of the cuf infante santo hospital has implemented a pharmacovigilance program, with two main objectives: . optimization of the detection and reporting of problems related to therapy; . implementation of corrective and/or risk minimization measures. the pharmacovigilance program is based on the following methodology: . detection of adrs/problems related to therapy/medical device: the detection can be performed by the pharmacist or other health professional that guides the process to the pharmaceutical services. . information processing by the pharmaceutical services and realization of spontaneous reporting: the notification is performed both for the portuguese regulator (infarmed) as to the appropriate laboratory (if applicable). after evaluation by both entity, the conclusions are communicated to the pharmaceutical services, which has the responsibility to share it with all the other hospital services. . report of the event in the internal risk management platform: when applicable, the pharmaceutical services internally report the adverse event to the hospital's risk management department, leading to an internal evaluation of the current process. . completion of the process and implementation of corrective measures: when the regulatory authority and/or the laboratory sends the report/technical advice about the notification, the pharmaceutical service in partnership with the risk management team perform a reassessment of the whole process. if needed, corrective and/or monitoring measures are implemented. . monitoring of implemented measures: after the implementation of corrective and/or monitoring measures there is a period of evaluation. results: the implementation of this program for the period of year, has led to a total of fourteen spontaneous reports. from all of these notifications, seven were related to quality defect of medicines, four were of adr, one was due to suspected lack of therapeutic efficacy, and lastly, one of the notifications was medication error derived. conclusion: the obtained results, over a year period, by the pharmacovigilance program were satisfactory but the aim of the pharmaceutical services is to consolidate and optimize the same program with a view to achieving better results. the pharmaceutical services will continue to take responsibility for the pharmacovigilance circuit management in this hospital, by promoting a proactive approach to monitoring the safety, quality and efficacy of medicines, which possess the primary objective to patient safety assurance. please specify your abstract type: descriptive abstract (for projects) background and objective: for prematures, parenteral nutrition (pn) is essential for medical care but is complex (specific needs, daily change of intakes…). now, the software logipren Ò , developed by the french society of neonatology, allows the prescription of pn as well as all the childish therapeutics. it is also in link with our production robot (baxa pomp) for individual pn bags. our objective was to integrate this software while optimizing our pharmaceutical validation process. design: the software implementation was lead by a physician/ pharmacist collaboration with several preliminary steps: • identification of pharmaceutical validation settings (pertinence of individual pn vs. industrial bags, parenteral approach, elements…). before the life-sized use of logipren Ò , a base test has been experimented to identify possible difficulties and to realize some correctives actions of the software or our process. results: logipren Ò leads us to a change in our pharmaceutical validation process, by introducing new elements: • the pharmaceutical validation of pn bags is done in collaboration with the physician, during the prescription step. • all the therapeutics are known, which allow the pharmacist to take into consideration all the intakes (micro-nutrients, vitamins…). • remove the transcription step of pn bags in our production software (abacus Ò ) thanks to an interface with our production robot. • less production problems because of the coverage of those pharmaceutical aspects during the prescription. since months, this reorganization helped us to propose pharmaceutical notices for prescriptions: • omissions (remove lipids, levocarnyl Ò , micro-nutrients, electrolytes, remove industrial bags…) • modification (reduce proteins according to urea level, micronutrients and electrolytes posology, duration of lipids infusion…) conclusion: the implementation of logipren Ò enabled us to reorganize of the pharmaceutical validation process with a consolidation of the role of the pharmacist during the prescription step, in the paediatric ward. it had a beneficial aspect by the reduction of the validation and production time, a decreased risk of error (suppression of job interrupts and better communication) and an improved production by the end of transcription step to abacus Ò . furthermore, during our experimentation, we could bring to the software editor new ways to improve it and make it more efficient. % ( . % in ) , difficulties in swallowing/psycho-behavioural distress in . % ( . % in ) , and rejection of oral drug in . % ( . % in ) . physicians and nurses indicate the reason in the medical record in . % of case versus % last year. this year, drug were crushed versus drugs in : % concerned nervous system group (vs. % in ), % concerned cardiovascular system group (vs. % in ) , and % concerned alimentary tract and metabolism group (vs. % in ) . nurses use guideline in % of cases versus . % last year. as the previous year, in % of cases, washing hands before preparation and after administration are met. last year, none of them was wearing mask and gloves during this operation while this year, % was wearing mask and gloves. finally, in the two assessment, for each patient, drugs are systematically crushed together and then mixed with the patient's meal. conclusion: this study shows that crushing drugs is still problematic in our units. however, best practices were observed, such as the indication of the reason of crushing in the medical record, or the consultation of guideline. a new training for nurses will be conducted to create awareness about risks of crushing drug. please specify your abstract type: research abstract background and objective: in invasive candidemia, three echinocandins are indicated: caspofungin, mycafungin and anidulafungin. the aim of this work is to establish which echinocandin to prescribe in a french university hospital, given the scarcity of available clinical data in the literature regarding obese patients. setting and method: in a french uhc with beds, a multidisciplinary working group composed of a microbiologist, an infectious disease specialist and a pharmacist has been set up to analyse the various therapeutic options. main outcome measures: analysis of the literature, pharmacoeconomic study. results: four medications have been identified as possible therapeutic options. their adverse effects are similar and their administration rhythm is the same. according to recommendations by the esmid ( ) and the idsa ( ), the level of evidence for these three echinocandins in initial treatment of candidemia is equivalent. concerning obese patients, no weight limit is mentioned, int j clin pharm ( ) : - despite recommended dosage adjustment. caspofungin must be prescribed at a dose of mg/day for patients weighing over kg. micafungin must be administered at a dose of mg/day regardless of patient weight. in the case of persistence of cultures or if clinical condition does not improve, the dose may be increased to mg/day. anidulafungin, which is not referenced in our establishment, must be prescribed at the same dose regardless of patient weight. from an economic point of view, in our hospital, micafungin at a dose mg/day remains the least costly therapy. however, if its posology is doubled as indicated, caspofungin then becomes the most economic therapy. amphothericin b, an optional treatment, is never the most economically advantageous therapy. conclusion: as a result of this study, the chosen prescribed therapy for obese patients is caspofungin at a dose of mg/day. this work has improved access to healthcare for obese patients. pharmacokinetics and survival data must be collected on the basis of various patient weights in order to predict clinical efficacy. kristin f. heier * , liv czynski please specify your abstract type: descriptive abstract (for projects) background and objective: the aim of this study was to develop a system to prioritize patients for medication reconciliation by pharmacists in the emergency department. it also proved a useful setting for evaluating how other health care professionals perceived the role of the pharmacist performing medical reconciliations within the emergency department. design: the study was located in the Østfold municipal hospital, located in kalnes, norway. pharmacists used a prioritization model to identify ''high-risk patients'' having clinically relevant prehospital medication discrepancies between hospital admission records and the information obtained via medication histories, general physician referrals and nursing homes. pharmacists registered patient information such as age, gender and drug-related problems (drps). seventeen physicians and thirty nurses in the emergency department answered structured questionnaires anonymously. main outcome measures: • number of patients with medication reconciliation performed by a pharmacist. • number of drug-related problems denoted in the electronical journal and presented to the physician. • the overall experience physicians and the nurses had with pharmacists when located in the emergency department. results: pharmacists performed medication reconciliation for patients, identifying drps and potential drps in total. fourteen of the physicians had read the journal notes from pharmacist and found them helpful (n = , %) or greatly beneficial (n = , %). most physicians (n = , %) and nurses (n = , %) reported a good cooperation with the pharmacist in the care of the patients. some of the physicians (n = , %) and most nurses (n = , %) wanted more information about the pharmacists work in the emergency department. the majority of ed staff ( % of physicians and % of nurses) found pharmacist as a good academic resource in the emergency department. conclusion: the physicians reported an improvement regarding the quality in the medication reconciliation made by pharmacists in the emergency department and both physicians and nurses expressed a need that pharmacists work in the emergency department on a more permanent basis. more information in general and especially better communication with nurses regarding the care of the patients are important actions need to optimise collaboration with pharmacist in the emergency department. results: a total of patients were included in the study, median age was years and % were males. they used in average four drugs regularly (range - ). almost three-quarters ( %) of the patients reported high or moderate adherence to all their regularly used drugs (mmas- c (max )). of the patients using oral spasmolytics, % reported high or moderate adherence to these drugs. the majority ( % of the patients) had high perceptions of necessity to their treatment (bmq [ . (max )), and % had a high level of concern (bmq [ . (max )). logistic regression analysis showed that there was no association between adherence and pain, nor between adherence and spasticity. younger age was found to be associated with higher risk of nonadherence. conclusion: even though overall adherence was high, the patients were more concerned to take their medicines compared to other patients with other chronic conditions. further studies are required for understanding adherence and attitudes toward medication in this population, and to help the patients feel safe about their medication regime. please specify your abstract type: descriptive abstract (for projects) background and objective: errors in medication lists often emerge in transition between health care levels, and there is need for strategies to communicate medication information. therefor we aimed to describe reasons why medication discrepancies (md) occurs in the transfer of patients between hospital and primary care service. design: in conjunction to a study based on use of structured medication report at transition from hospital to primary care service, we observed different reasons to why mds occurs. our observations and experiences linked to communication between health care levels is outlined. results: we observed that many md's disclosed at discharge could most likely be attributed to lack of medicines reconciliation at admission to hospital. for instance, several medicines were prescribed in primary care service prior to admission, but not at admission to the hospital. in addition, at admission, some medicines were listed as prescribed medications although not found in the medication lists in primary care service. we also observed that newly started and discontinued medicines were documented in the hospital discharge letter, but not implemented in primary care service. according to health care personnel in primary care service, insufficient communication about the patients' medications at discharge from hospital, led to corrections in the medication lists based on their previous knowledge about the patients. in addition, justified medication changes at discharge from hospital were not always implemented in primary care service due to professional disagreement. some stated that lack of trust was one reason for not always taking changes into account, often based on earlier experience. conclusion: these observations indicated that mds occurred both with and without intent when patients from primary care service were admitted to hospital and returned back due to poor communication. medication errors during hospitalisation and unproven intentional changes may be the consequences. due to this, it is important to improve the communication and confidence between professionals in the hospital and primary care service in order to reduce the number of mds and to enhance patient safety. please specify your abstract type: descriptive abstract (for projects) background and objective: intravenous human immunoglobulins (iv igs), plasma protein products, may cause in patient to a range of adverse side effects (headache, skin rash, kidney failure, thromboembolic event). in the framework of securing medicinal care, an assessment of professional practices has been conducted within our university hospital. the overall goal of this study is to evaluate the process of intravenous administration of human immunoglobulins done by the nurse staff. design: this prospective study has been carried out in three departments of neurology. an observation grid was established on the basis of guidelines on good practices. all in all, criterions have been examined resuming: prerequisites before administration, patient setup, iv igs administration, monitoring, traceability of drug delivery and management of adverse side effects. results: during the course of this investigation, administrations were observed. only % of nurses deliver information about the treatment to their patients before administration and % question patients about previous hypersensitivity reaction. the presence of spontaneous diuresis is verified in % of cases. emergency cart is not reachable in % of all cases. % of nurses ask patients to decline their identity. the use-by date on the bottles is checked in % of cases. at the time of preparation of perfusion, labelling does not mention either patient's name ( %) or date and hour of perfusion ( %). int j clin pharm ( ) : - during perfusion, only % of nurses follow diuresis and % watch rate of administration. hydration is not always kept min after the end of perfusion ( %). patient monitoring varies between min and h after perfusion's end. in % of cases, diuresis is monitored after the end of administration. % of nurses explain to patients side effects that may occur remotely. finally, administration traceability is was conform in % of all cases and in the event of adverse side effects, statement was made in % of cases. conclusion: best compliance scores have been achieved in myology department where patients are fewer than in the two others departments ( vs. and ). a presentation of those results will be given in theses three departments in order to improve patient management and securitization of iv igs administration. this audit will be carried out soon in other departments. please specify your abstract type: descriptive abstract (for projects) background and objective: a new human polyvalent immunoglobulins dose ( g) for intravenous administration is available on our establishment since . in order to secure the administration, this new dosage was initially reserved for the healthcares using administration pumps (being four health-care). the aim of this survey was to evaluate the satisfaction of the nursing staff already user of the new g dose and to estimate the motivation of the nonuser nursing staff by the audit date. design: this satisfaction survey was carried out with the most igiv consumer services (being internal medicine, neurology, cardiology and haematology). the questionnaire was structured in two sections: the first section regarding igiv in general, the second section concerning the new g dose. the survey included multiple choice questions or questions with answers based on a four levels evaluation scale (not satisfied, mildly satisfied, satisfied, and very satisfied). results: the audit was realized on eight health-care, involving nurses. among the interviewed, ( %) have already used the g dosage. in % of cases, users were very satisfied and % were satisfied. the most positive points noted were: gain of time provided ( . % of satisfaction), less manipulation needed ( . % of satisfaction), and reducing of infectious risk ( . %). moreover, the influence of the injection technique on users' satisfaction was further reported. indeed, according to nurses interviewed, the use of an injection pump is safer and improves the job comfort of nursing staff, unlike the injection by gravity (used in % of cases), which seems to slow down the use of this new dosage. in two cases, a positive opinion given by patient was also reported. finally, negatives points noted were related to administration instruments (use of pump or not) and to less flexibility in daily dose regulation. among the % not-user of this new dose, the % showed a strong interest for the product apart from services making the igiv administration by gravity. conclusion: in light of these results, the use of g dose will be spread to other services. the general diffusion of this dosage will provide a gain of time also at the pharmacy, during the unitary delivery and the computer-based administration of every units. a second survey will be soon effected within patients involved in the switch g/ g. the capital region pharmacy, clinic of neurology, rigshospitalet, blegdamsvej, copenhagen, denmark please specify your abstract type: research abstract background and objective: the clinic of neurology, rigshospitalet, copenhagen, denmark experience continuous medicine-related patient safety incidents (psi) related to newly admitted patients and patient transfers between wards. in order to prevent drug related problems (drp), the pharmacists increased their focus on these patients and provided systematic medication reconciliation. thus, the objective of this pilot study was to investigate if the intervention would help identify drug discrepancies (dd) and prevent drp. four wards were included in this study; two neurological, one neuro-anaesthetic (icu), and one neurosurgical ward(s). three wards use electronic medication module (epm), whereas the icu uses critical information system (cis). furthermore, all patients' prescriptions are registered on shared medication record (smr), which provides an overview of prescribed medicine. prescriptions cannot be transferred from smr and epm to cis and vice versa. we suspected that psi resulted from these system incompatibilities. setting and method: patients admitted or transferred from may nd to june rd were included. medication reconciliations using smr, epm and cis were conducted by a pharmacist on weekdays. dd were presented to a physician orally and documented. only dd accepted by physicians led to drug prescribing change. main outcome measures: number of identified dd. results: the study included patients, of which ( %) were newly-admitted. patients ( %) were transferred between wards. of the transferred patients, ( %) were transferred from the icu to other wards and ( %) were transferred from other wards to the icu. of the newly-admitted patients, ( %) were admitted to the icu and ( %) were admitted to other wards. the pharmacists identified dd; dd ( %) in the transferred and dd ( %) in the newly-admitted patients. in the transferred, dd were all related to the icu. in the newly-admitted, dd ( %) was related to the icu and dd ( %) to other wards. of the dds, ( %) were accepted by the physician. an example of a severe dd identified was an omission of prednisolone to a patient admitted to the icu. conclusion: most dd were identified in patients admitted to or transferred from icu, which uses the incompatible system cis. pharmacist systematic medication reconciliation helps identify these dd and prevent drp. please specify your abstract type: research abstract background and objective: antibiotic related drug interactions are more likely in intensive care unit patients due to common polypharmacy and antibiotic usage. the aim of this study is to determine the antibiotic related drug interactions with three different online databases (micromedex-paid, medscape-free and drugs.com-free) and to evaluate these interaction information by clinical pharmacist. setting and method: a retrospective, descriptive study was set up in hacettepe university hospital's intensive care units, between november and december , . patients who use at least one antibiotic were involved in this study. all drugs were assessed by each three databases and only antibiotic drug interactions were evaluated. clinical significance of identified drug interactions were evaluated by clinical pharmacist. main outcome measures: clinical pharmacist's assessment in significance of drug interactions indicated by three online databases. please specify your abstract type: research abstract background and objective: an implementation of clinical pharmacy practice by postgraduate students in intensive care units is a new way of learning in postgraduate education which creates opportunities in multidisciplinary collaboration in clinical pharmacy research, and also has influence on clinicians' routine patient care process. this system in educational program was ongoing in the department of clinical pharmacy since . as a part of this educational program, drug related problems in intensive care units were described and analysed, an influence of clinical pharmacy postgraduate students on patient treatment process was sought. setting and method: a prospective, cross-sectional study was performed between the march-june in hacettepe university hospitals, department of internal diseases intensive care units which consists of beds. three postgraduate pharmacy students from the department of clinical pharmacy, faculty of pharmacy conducted medication reconciliation in order to identify any problems in patients' medical orders. drug related problems (drps) were identified by the students and recommendations for management were approved by a supervisor of clinical pharmacy department before they were directed to physicians for approval. the students were not authorized to undertake any action in patient care process, therefore all required interventions for drp were undertaken by physicians and the acceptance ratio of the interventions were recorded. the pharmaceutical care network europe foundation classification system (v. . ) was used to asses drps. main outcome measures: determination of drps by pharmacists and evaluation of their interventions' acceptance by physicians in intensive care units. results: during the study period, patients were admitted to the intensive care units. each patient's medication orders were evaluated and interventions were recommended by postgraduate students. the number of interventions per patient was . . the acceptability rate of interventions by physicians was . %. in addition, physicians were provided drug information on seven different occasions. recommendations regarding drug therapy were mainly related with treatment effectiveness and adverse reactions. the common causes of drps were requiring dose adjustment due to pharmacokinetic problems ( . %), no therapeutic drug monitoring ( . %), inappropriate timing of administration and/or dosing intervals ( . %), requiring dose adjustment due to deterioration/improvement of diseases ( . %), inappropriate drug selection ( %) and new indication for drug treatment presented ( %). the most common drugs responsible for drps were ranitidin, levothyroxine, allopurinol, pantoprazol, piperacillintazobactam and vancomycin. the study showed that the most common drps was dose-related, therefore close monitorisation of the intensive care unit patients by students in clinical pharmacy postgraduate program can help physicians in terms of detecting, preventing and minimizing drps in order to improve patients' health outcomes. please specify your abstract type: research abstract background and objective: antibiotic stewardship is the process of salvaging important antibiotic agents from becoming ineffective due to bacterial resistance. this is important because throughout the world antibiotics continue to be one of the most important classes of therapeutic agents due to their vital role in saving patient lives. key goals of antimicrobial stewardship are to improve clinical outcomes, prevent antibiotic resistance, promote patient safety, and reduce health care cost. pharmacist are in the frontlines because they perform antibiotic stewardship activities, such as selecting the most optimal antibiotic agent, adjusting drug-dosage, and stopping use of unnecessary antibiotics. as a result of the continuous rise in antibiotic resistance and decline in development of new antibiotics, antibiotic stewardship programs are proving to be indispensable in a health care settings. setting and method: adult and paediatric inpatients receiving antibiotic therapy in the hospital medipol university has been evaluated. patients were selected randomly in the hospital system. patients were evaluated for antibiotic susceptibility results and compliance with antibiotic management guidelines. main outcome measures: to evaluate the antibiotic therapy in patients with culture results and to determine according the treatment guidelines. results: it was observed different pathogens in blood culture results of inpatients out of patients who were treated with antibiotics in hospital. antibiotic susceptibility results for acinetobacter spp, staphylococcus spp, enterococcus spp, pseudomonas aeruginosa, klebsiella spp, e. coli spp, streptococcus spp, corynebacterium spp, streptococcus pneumonia and enterobacter spp are evaluated in the study. klebsiella spp was the most isolated pathogen at total of culture results. most frequently resistance were int j clin pharm ( ) results: a total of ( %) questionnaires were completed. of these, approximately % were answered by hospital nurses, the remaining mainly by physicians ( %) and % ''other''. on the question ''what is your general perception of the benefit of the clinical pharmacy service; for collaborating health professionals? for the patient?'' the total benefit was ranked . and . respectively (scale from (''no benefit'') to (''beneficial to a very large extent''). the open questions: ''what disadvantages/advantages have you experienced by the introduction of clinical pharmacist into multidisciplinary teams?'' received / comments respectively. physical obstacles regarding office space, interference with the decision making process, more time consuming processes and the issue of relying too much upon the advices given was reported as possible disadvantages. respondents answered ''none'' to this question. the comments regarding advantages dealt mainly with general increased patient safety and quality assurance. in addition, advantages as work-load relieve, time saved, collegial support, practical help, and learning interchange between professions, were highlighted. conclusion: health-professionals assessed the clinical pharmacy service as highly beneficial. the advantages outlined were higher patient safety and quality regarding medication, in addition to collegial support, practical help and learning interchange. please specify your abstract type: descriptive abstract (for projects) background and objective: in june , the french health authority, the «has», published an index resuming the recommendations of benzodiazépines (bzd) prescriptions and proposing an approach to stop using it. indeed, it has been established that there is a too high and too long consumption of bzd in france. a study of prescriptions' prevalence has been done in our hospital centre. the aim of this study was to know our situation regarding the use of bzd in order to set up some improvements and take part in their proper use. design: a prospective study has been done on a months period in different services: geriatric, post-op and rehabilitation facilities, endocrinology, internal medicine, pneumology and cardiology services. the data were raised on a given day in each services and recovered thanks to the prescriptions software but also through interviews with the patients and their doctors. it was examined whether there was a bzd prescription (hypnotic or anxiolytic), whether the duration was superior or not to the duration of the amm and whether the prescription was done in our hospital centre. if the prescription was already part of the patient treatment, we looked if it was possible for the patient to stop using it, according to the has criteria. on their discharge, the letters and bzd prescriptions were also analysed and some patients' general practitioner were contacted after their discharge. results: patients (median age years old) were included from november to march . . % ( / ) of the patients had at least one bzd prescription the day we collected the data. we found only one bzd in prescriptions ( . %) and among them . % ( / ) were anxiolytic bzd. among those prescriptions, . % ( / ) already existed before the hospitalization and . % ( / ) were given during the hospitalization ( were prescribed automatically). . % ( / ) of the prescriptions did not respect the legal duration of the amm ( pieces of data were not found). . % ( / ) already exceeded this duration limit. among the patients who already had a bzd treatment before going to hospital, . % ( out of ) could consider stopping their use of bzd. by the end of this study, patients were discharged from hospital, among them . % ( / ) with a prescription of bzd. . % ( / ) of the prescriptions established during the hospitalization had been renewed when the patient came out of the hospital, we managed to contact ten general practitioners (approximately . days after their discharge), nine patients carried on their bzd treatment, among them one patient had reduced his consumption. conclusion: this study is an example of the high proportion of bzd prescriptions in france which the majority doesn't respect the legal length of the amm. the prescriptions of bzd in the hospital are generally systematically renewed by the general practitioners. the patients must be informed about the risks of using those molecules. in order to ameliorate this practice in the hospital, a proper use leaflet, reminding the prescriptions of bzd, has been created and distributed in each services to make people aware. main causes of admission were infections ( %) (respiratory disease ( %) and other ( %)), hepatic disease ( %) and neoplasias complications ( . %). patients died during their admission; due to hepatic disorder, due to neoplasia, and due to infections. conclusion: last diagnosis of hiv or no art treatment are causes of admission. immunovirological situation is related with their adherence but isńt with admissions. coinfection with hcv or hbv or others infections are risk factors for admission. center for psychopharmacology, diakonhjemmet hospital, oslo, norway please specify your abstract type: research abstract background and objective: complex medical history and treatment can potentially cause problems. the objective of this study was to investigate the prevalence of drug-related problems (drps) and medication discrepancies in internal medical patients with complex treatment at hospital admission. further, to investigate to which extent drps were identified as a result of medication reconciliation, and to which extent drps could be associated to the hospitalization. setting and method: patients with at least four regular medicines from two different therapeutic groups were consecutively included at admission to an internal medicine ward at a university hospital in norway in the period . . - . . . pharmacists used the integrated medicines management (imm) model for medication reconciliation and medication reviews at admission. a medication discrepancy was defined as any discrepancy between the recorded medication list at admission and the patient's actual use of medications, as revealed by medication reconciliation. the patients' actual use of medications, medical journal and laboratory results, were used to perform a medication review at admission time and identify drps. the proportion of drps revealed due to medication reconciliation was calculated. moreover, the project group retrospectively assessed possible drp-induced hospitalizations based on clinical history, cause(s) of admission and identified drps. main outcome measures: the main outcome was the median number of drps per patient at admission. the proportion of drps revealed due to medication reconciliation, the proportion of patients with drps possibly associated to the hospitalization, and the median number of medication discrepancies, were included as secondary outcomes. results: patients were included, . % women. median patient age was (range - ) and most of the patients were home-living before admittance ( . %). in total drps were identified at admission, with a median number of (range - ) per patient. drps ( . %) were identified due to medication reconciliation. for patients ( . %) a causal relationship between the hospitalization and the drps was assessed as ''possible''. medication discrepancies were revealed in of the included patients ( . %), with a median number of (range - ) per patient. conclusion: internal medical patients with complex drug regime are frequently exposed to drps and medication discrepancies at hospitalization. medication reconciliation could be essential to identify drps, which is likely a common cause of hospitalization in the studied patient population. hp-pc : assessment of oral anticoagulant prescriptions and pharmaceutical analysis at the hospital by regional audit damien fuss *, , clélia monchablon , anaïs breteau , marie lefebvre-caussin , rémi varin , jean doucet , mikael daouphars , doreya monzat omedit normandie -chu rouen, chu rouen, please specify your abstract type: descriptive abstract (for projects) background and objective: oral anticoagulants (oa) are the most common drug class associated with preventable adverse drug events in hospitalized patients that require optimizing the pharmaceutical analysis (pa) process. in this context, a regional audit was conducted on pa of prescriptions oral of oa. the aim of this study is to provide an overview of the treatment by oa in the hospital by evaluating the consistency of the oa prescriptions compared with national and european guidelines and evaluate the pharmaceutical interventions. design: this study is based on the collection of pa data (demographics, indication, posology, drug interactions, monitoring) as well as the collection of pharmaceutical interventions and discordance int j clin pharm ( ) : - between guidelines recommendations and clinical practice. the inclusion criteria were any patient treated with oa (vitamin k antagonists (vka), non-vitamin k antagonist oral anticoagulants (noacs)). included patients were followed minimum months. the primary outcomes include description of baseline characteristics of patients, the number of inappropriate prescriptions compared to the different clinical recommendations, the number of pharmaceutical interventions, the number of adverse drug reactions (adrs) related to oa use and the assessment of patient monitoring. results: during the -months study period, patients were included in six health institutions. the average age was years ( % of patients over years old) and % of the patients were women. % of patients had renal impairment. % of patients were treated with vka, and % with noacs. it was the first prescription of oa for % of patients ( % with vka; % with noacs). the most common indication was the non-valvular atrial fibrillation ( %). in this indication, % of patients had cha ds -vasc score c , and nearly % had a high risk of bleeding (has-bled score c ). drug interactions were observed, and adrs occurred related to oa. % of patients with an adrs had a has-bled score c . . % of prescriptions were considered inappropriate, including % noacs (no monitoring renal function in % of patients over years initiating treatment, inappropriate posology in %, and % of contraindications). the rate of pharmaceutical interventions was %. nearly % of the prescriptions were already adapted when the pharmacist was starting analysis. conclusion: prescribers are sensitized of the risks on the oa prescriptions, which explained the delay upon pa and low rate of pharmaceutical interventions. however, the high number of inappropriate prescriptions shows the necessity to improve the pa process on these drugs, particularly by actions on therapy initiation and patient monitoring, especially for noacs. for this class, the impossibility of assess the level of anticoagulation by laboratory monitoring requires appropriate initiation and monitoring, especially an assessment of baseline renal function. please specify your abstract type: descriptive abstract (for projects) background and objective: the development of bacterial resistance these last years is a public health major problem in the world and needs to implement actions. in france, the national drug safety agency has defined a list of ''critical antibiotics''. this list includes antibiotics particularly generator of bacterial resistance (amoxicillinclavulanate, cephalosporine, fluroquinolone) and antibiotics called ''last resort'' (antibiotics against gram-positive cocci, car-bapenem…). at our regional level, an evaluation of prescription of these critical antibiotics was proposed to all medical centers. the aim was to evaluate the quality of prescription of these critical antibiotics. design: the regional working group (pharmacists, infectious diseases physicians and biologists) had developed a collection grid including data on patients, antibiotics and four criteria: adequate molecule, compliance with medical prescriptions, duration of antibiotic therapy and reassessment at h. this is a prospective study proposed to all health institutions (public and private), which had to be completed on a given day in all care units and had to be conducted by a team of multi-professional evaluators. the study included a quantitative part (number of patients hospitalized in the audited units, number of patients receiving antibiotics and number of critical antibiotic prescriptions) and a qualitative part (adequate to the four criteria). results: response rate was of %. the study investigated on patients hospitalized in the audited units, including patients ( %) receiving antibiotics. among the patients, % were hospitalized in medical, surgery or obstetrics units we recorded prescriptions of ''critical antibiotics particularly generator of bacterial resistance'' ( % amoxicillin-clavulanate, % ceftriaxone, % fluoroquinolone and % other third-generation cephalosporine) and prescriptions of antibiotics called ''last resort'' ( % carbapenem). the average age of the population was . years (± years). sex ratio was . . % corresponded to curative use and % to prophylactic use. the expertise of infections diseases physician was requested in only % of the cases. the antibiotics were prescribed in majority to treat bronchopulmonary infections ( %), urinary tract infections ( %) and intraabdominal infections ( %). ninety-two percent of the prescriptions had a proper indication. % of the prescriptions complied to the guidelines. the duration of antibiotic therapy was adequate in % of the cases. only % of the prescriptions were correct according to these three criteria. forty-four percent of the prescriptions were reassessed and adapted by the physician. conclusion: this study is original because of its regional dimension and antibiotic analysis. the number of analysed prescriptions was significant with an overall proper prescription in adequate with the guidelines. however, actions must be implemented on duration and reassessment and adjustment of treatment. these results were presented to the participating hospitals. these three points will be reevaluated during a new regional audit. the criterion «no more psychotropic drugs» has been met in . % of assessment. otherwise, or more psychotropic drugs are prescribed in . % of assessment from the point of admission. the criterion «no more a benzodiazepine drug» has been met in . % of assessment. otherwise, more than one benzodiazepine drug is prescribed in . % of assessment from the point of admission. no contra-indication is detected in . % otherwise, a contra-indication between two drugs causing torsade de pointes is detected from the point of admission in this department. no more anticholinergic drug is prescribed in . % of assessment. according to the french criteria, one or more inappropriate drug is prescribe in . % of assessment. the most common inappropriate drug group prescribed was alimentary tract and metabolism drug ( . %) (the hospital at home team needs these class of drug) followed by nervous system ( . %) (prescribed at the point of admission) and by cardiovascular drugs ( . %) (prescribed at the point of admission). finally, the criteria «no more one non-steroidal anti-inflammatory drug» and «no illogical association» have been met in all cases. conclusion: this analysis shows that most of criteria for «assessment of prescription among elderly in a «hospital at home» department have been met. when one has not been met, either the hospital at home team needs the drug prescribed, or this drug have been yet prescribed from the point of admission in this department. this study could be used for the next certification. hp-pc : access to health care: case of autologous serum eye drops batiste martel, fabien lindenberg, camille castel, guillaume saint-lorant * please specify your abstract type: research abstract background and objective: autologous serum eye drops (ase), prepared from patient's serum, are indicated in the treatment of severe dry eye syndrome and defective epithelial healing. its in-hospital preparation within a controlled-atmosphere zone unable it to be dispensed by non-equipped hospital pharmacies. the aim of this study was to implement security measures to allow transport towards distant hospital pharmacies and all patients even those residing far from a regional university hospital (uh). setting and method: this study was conducted in a -bed french university hospital. patient blood samples were taken within the university hospital every weeks. serum was then biologically controlled (negative tests for hiv, hbv, hcv, tpha, vdrl). preparation was conducted days after blood sampling. sterile preparations were then stored at a temperature of - °c. studies showed that eye drops were stable days after being thawed. transport of eye drops to distant hospital pharmacies requires to be conducted under controlled temperature i.e. below °c, to ensure the stability of eye drops. these pharmacies are located close to patient's homes. the entire process was examined by a pharmacy team in order to study and secure each step, transport in particular. main outcome measures: validation of each step of the autologous serum eye drop dispensing process, from sampling to receipt by different hospital pharmacies, transport in particular. results: patients benefitted from the preparation. all patients resided more than kilometres from a uh. a follow-up form was completed to qualify dispatching and to trace each step during transport. a temperature sensor was placed inside the box. the receiving agent was required to stop and control the sensor. a double retrospective control was performed by a pharmaceutical team via the recording of temperature sensors. a second follow-up form was drafted in order to track dispensation reviews, ongoing dispensation and future planning. a patient information booklet was distributed to hospital pharmacies to inform patients about good practice concerning eye drops. conclusion: technological necessities concerning autologous serum eye drop preparation and transport limit access to health care. in this study, the role of the pharmacist consisted in reducing inequalities among patients residing at a distance from the only regional uh. the role of the pharmacist is to ensure absolute quality of preparation between the uh and the patient. hp-pc : computerized medication reconciliation: overview of pharmaceutical software used and support for development of integrated modules julie mocquard, anaïs berthe, elise rochais * , nicolas prévost, jean-claude maupetit, on behalf of centre de ressources régional en conciliation médicamenteuse omedit pays de la loire, nantes, france please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation aims to improve continuity of care for patients. in , a national survey identified barriers for implementation of this activity in france, among which computerized systems were judged unsuitable for hospital practices. in the absence of appropriate hospital information systems (his), medication reconciliation remains a time consuming process implying manual transcriptions, potentially leading to a lack of traceability and medication errors. the objective of the study was to assess the current his used in a french region including the integration of medication reconciliation into the software and to define courses of action to assist this integration. design: an online survey conducted in may was addressed to head pharmacists of the health facilities in the region, giving a total of head pharmacists concerned. it included questions on the software used by the health facility, the development of medication reconciliation and its traceability, formulation of operational requirements to the editors of software and availability of a module integrating medication reconciliation provided by the software. results: seventy-eight pharmacists ( %) participated in the study, with all types of health facilities represented: public hospitals, clinics, home health agencies, haemodialysis structures and after care and rehabilitation facilities. thirty different software were identified in the region. ( %) pharmacists planned to develop medication reconciliation in their health facility and ( %) were already carrying out this activity. within these %, medication reconciliation was conducted on paper only for ( %) of them, while ( %) were using a computerized system (patient file, pharmaceutical software, other) for traceability. the most widely used software in the region contains a module enable for computerized medication reconciliation, and three other editors are currently developing one. no development is scheduled for another three editors nonetheless commonly used in the region. ( %) pharmacists had contact with the editor of the software, and had given thought to the preparation of requirement specifications to the editor to develop an integrated module of medication reconciliation. conclusion: despite the interest attributed to medication reconciliation and despite the need of a fully integrated module of medication reconciliation to his, only a few health facilities of the region possess an appropriate computerized system to develop this activity. this study underlines the approaches already made by pharmacists to editors in order to integrate medication reconciliation to the his. subsequently, retrieving these approaches and writing specifications common to all health facilities is scheduled, in order to assist them in providing a strong incentive for the editors to integrate medication reconciliation to existing his. please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation (mr) is an interactive and multiprofessional process that ensures the continuity of care by integrating the ongoing treatment to the new hospital prescription. this helps securing the patient's care pathway particularly at transition points. the objective is to initiate the mr process in our medical institution with a pilot study in the department of internal medicineemergency downstream to validate a methodology and adapted tools. design: the mr takes place in three steps performed by a pharmacy student: ( ) realization of best possible medication histories (bpmh), combining at least three sources of information and using sources' collection form. this research begins with a patient interview done in pairs with a medical student using an interview guide. ( ) comparison bpmh with the initial hospital prescription in the department (after passing through the emergency department) on the treatment reconciliation form. a status is assigned to each line of drugs and then the differences are identified (stopped, changed or added). these two steps are validated by a pharmacist. ( ) discussion and characterization of observed differences (intentional/unintentional and documented/undocumented) with the senior physician. results: twenty-six mr were performed over weeks in . the mr is performed within days after admission. on average, . information sources per patient were used for the bpmh: mainly drug prescription (dispensed in pharmacies community); analysis of emergency medical records and patient interview. for the patients included, drugs were listed. discrepancies were observed and were studied (status stopped or changed only): one documented intentional discrepancy, undocumented intentional discrepancies and unintentional discrepancies (ud). these uds affected patients ( - medication errors per patient) and corresponded to a non-prescribed drug in % of the cases. vitamins, antihistamines, anti-reflux and proton-pump inhibitors were involved in % of cases; cardiovascular drugs in % and antiinfectious in %. through this pilot study, the methodology was validated: (a) need to have a minimum of three sources to achieve a relevant bpmh and to confirm each information with two sources; (b) need for a dedicated time with trained staffs; (c) development of tools to improve the traceability of information obtained from each source and traceability of medication reconciliation activity. conclusion: the mr establishment in the internal medicine department was helpful in identifying medication errors that have been corrected. it is proposed to archive the treatment reconciliation form in the patient file to contribute to the traceability of information on treatment. this study strengthens the deployment of this method and mr tools to other services of the hospital. alma mulac * please specify your abstract type: research abstract background and objective: clinical pharmacists have an important role in improving healthcare services. there is lack of knowledge of clinical pharmacists' experiences in interprofessional collaboration. our objective was to explore the challenges and barriers experienced by clinical pharmacists in interdisciplinary teams in norway and incorporation of expanded pharmacist roles in hospital settings. setting and method: this qualitative study was conducted using semi-structured interviews. a total of clinical pharmacists from four (government) hospitals were included in the study. the interviews were audio recorded using a digital recorder. the recordings were transcribed verbatim. main outcome measures: challenges and barriers clinical pharmacists experience in interdisciplinary teams in hospital setting. results: the main findings are that the pharmacists' role is little known to other health care professionals, particularly at hospitals with short tradition for clinical pharmacy services. clinical pharmacists have great motivation from being able to influence drug treatment for patients. from the perspective of the participating pharmacists they succeed in interdisciplinary cooperation when their professional knowledge solves the patients' drug-related problems. communicating recommendations to physicians with professional credibility has great importance for the intervention to be implemented. using the theoretical framework of communicating tensions, we argue that the pharmacists in our study use indirect communication to prevent physicians defensiveness to recommendations. lack of education in interprofessional cooperation and communication is apparent in this study. the participants also stated that there should be some form of quality assurance or education requirements before one can work as a clinical pharmacist. conclusion: training in communication for graduates and interprofessional collaboration during the undergraduate pharmacy education, can possibly help pharmacists with integration in interdisciplinary teams. increased attention to teamwork from the hospital leadership is essential for the implementation of interprofessional collaboration in a larger context. please specify your abstract type: descriptive abstract (for projects) background and objective: antifungal therapy in the icu, particularly therapy targeting resistant aspergillosis, mucormycosis and systemic candida, is often of lifesaving importance. posaconazole and voriconazole are the antifungal agents of choice. our aim was to compile a tool that can be used at the icu to address aspergillosis, mucormycosis and systemic candida in an optimal manner. design: female patient, age + , liver transplant, crp [ mg/ l, creatinine [ lmol/l. abdominal x-ray imaging revealed four large abscesses and laboratory analyses confirmed mucormycosis. posaconazole intravenous ( mg one times daily) and liposomal amphotericin b ( mg/kg/day) were initiated. the inflammatory markers remained unchanged days following initiation of therapy with no change in size or number of abscesses and the patient developed sepsis. amphotericin b dose was increased to mg/ kg/day. after week the inflammatory parameters and size of abscesses began to fall. the dosage form of posaconazole was switched from intravenous to mixture. the dose remained the same and within h the crp rose to mg/l. results: pharmacist intervention revealed a missing loading dose of intravenous posaconazole as well as incorrect dosage of the per oral form due to bioavailability variation. posaconazole mixture dose was increased to mg two times daily. through serum concentration analysis of posaconazole was suggested prior to the dose increase. the serum concentration was . mg/l (range [ . - . ) . through serum concentration days later was . mg/l. both crp and abscess size were on the decline. a dosage and tdm pocket card for posaconazole therapy of mucormycosis, aspergillosis and candida was compiled. conclusion: optimal systemic fungal infection therapy is essential, especially in the critically ill. of special importance is tdm and correct dose adjustment when dosage-form changes occur. please specify your abstract type: research abstract background and objective: potentially inappropriate prescriptions and omission of prescription, respectively ip and op, are common issues in the pharmacotherapy, especially in vulnerable population, such as elderly and children. there are many available tools detecting ip and op for geriatrics, however, similar tools are less common in paediatrics. therefore, a first target tool for paediatric population: popi «paediatrics: omission of prescriptions and inappropriate prescriptions» was created and was validated by delphi method in . we aim to evaluate inter-rater reliability between health care professionals, who apply popi. our study also assessed their satisfaction and the accessibility of this tool. setting and method: twenty cases with or without ip or op were selected. these cases were identified in a previous retrospective ip-op prevalence study on . patients. these patients were admitted to the emergency department of a university mother and child hospital, between october and march . one doctor and one pharmacist, who participated in the creation of popi tool, identified ip and op in cases and composed ''standard answers''. these cases were then reviewed independently by eleven clinicians (including generalists, paediatricians, pharmacists, residents, general practitioners), who did not experience this tool before. inter-evaluator agreement was calculated by using the agreement kappa test. the satisfaction of users was also evaluated. main outcome measures: inter-evaluator agreement, the median time of use and the satisfaction of users. results: a high level of agreement of ip and op detection was recorded (ip: k median = . ; op: k median = . ). the easy use of popi was approved by % evaluators. the median time of use was min s per case (quartiles : . - . ) . as a result, there were % of clinicians satisfied with the provided popi and they would like to apply this tool in their daily practice. conclusion: popi demonstrated a good interrater reliability and is easy to use. this strong validation by many specialists prove popi is a reliable tool. it can be applied daily at work in paediatric section by doctors and pharmacists. other multicentre and prospective study should be conducted to evaluate economical and clinical impacts of popi. please specify your abstract type: descriptive abstract (for projects) background and objective: drug dosing during cvvh is challenging due to changes in pharmacokinetic parameters brought about by the patients' deterioration in health and factors associated with the physical process of filtration. this is of particular significance in the icu. in addition, there is the issue of the patients' diuresis or lack of such. this will affect the total clearance (cl total ) of the drug. the dose of antibiotics must therefore be calculated individually taking into account all of the above as well as changes of filtration parameters. our aim was to illustrate how such dosage calculations can be undertaken. design: a -year-old male patient, weight kg, diagnosed with stenotrophomonas maltophilia infection. the trimethoprim/sulfamethoxazole dose was . mg trimethoprim/kg/day every h as specified for anuric patients on cvvh. patient was initially anuric for days after which diuresis was started. the dose was recalculated. results: creatinine clearance (crcl) related to cvvh during the anuric period was calculated accounting for ultrafiltration rate, sieving coefficient, blood-flow, haematocrit concentration and pre-dilution. the value was ml/min. following diuresis on day , remaining kidney function was assessed by measuring urine and serum creatinine. the value for crcl renal ( ml/min) was added to the extracorporeal clearance, and gave a total clearance of ml/min. this warranted dose adjustment of trimethoprim/sulfamethoxazole since this drug requires normal dosage at crcl [ ml/min. conclusion: during cvvh, the presence or absence of diuresis must be taken into consideration when dosing antibiotics. in anuric patients, the cvvh-machine set up constitutes crcl total , but in patients with diuresis, the remaining crcl renal should be added. please specify your abstract type: descriptive abstract (for projects) background and objective: the aim of the study is; to evaluate patients' home (prescribed and non-prescribed) and hospital medication during hospital admission by computing medication regimen complexity index and investigating possible drug-drug interactions. design: patients (aged and older) who applied internal service during months ( days/a week) were included to the study. patients' medical profile were obtained from patients' file. their home medication and hospital medication were calculated with medication regimen complexity index ( ) and checked drug interactions with micromedex drug interaction program. results: a total of from of patients who applied to the internal service (male . %, female . ; the mean age of patients was . ± . .) were included to this study during months. of them, . % had low education level (\ education years), . % had and more chronic diseases of them, % hospitalized last months before this hospital admission. the most prevalent diagnoses documented at admission were kidney disease ( . %), cardiovascular disease ( . %) and cancer ( . %). the mean of patients' home medication number was . ± . and the mean of their mrci scores was . ± . . % in patients hospitalized in the last months. at least one possible drug-drug interactions were found in . % of patients at home medication and in . % of patients at hospital medication, respectively. the mean number of possible drug-drug interactions at patients' home medications was . ± . , while the mean number of possible drug-drug interactions at patients' hospital medications was . ± . . of them, . % had polypharmacy at home medication. the frequency of possible drug-drug interactions and the score of medication complexity index was found high among patients' hospital medications when compared with their home medications. conclusion: the potential role of pharmacist including medication reconciliation and medication review could improve rationale drug use during hospital admission. coronavirus. experts' local committee has approved to use oral ribavirin for the treatment of these respiratory viral infections. we aimed to assess the effectiveness and safety of oral ribavirin as main treatment in respiratory viral infections. setting and method: from may to october , we performed a retrospective monocentric study including patients who received oral ribavirin for non-hcv infections. main outcome measures: viremia negativation was used to determine the response rate to oral ribavirin. specific toxicities (anaemia, cytopenia, liver dysfunction) and renal function were assessed biologically. results: thirty-five immunocompromised patients (f/m: / , age: ) were included. underlying conditions were lung transplant (n = ), heart transplant (n = ), pulmonary fibrosis (n = ) and acute myeloblastic leukaemia (n = ). the median duration between transplantation and infection was . years ( . - . ). nine patients were exclusively infected by rsv, by hpiv ( hpiv- ; hpiv- ; hpiv- ; hpiv- ; non-identified hpiv), by hmpv and by coronavirus. there were six co-infections: rsv/ hpiv- , rsv/coronavirus, hpiv- /hpiv- and hpiv- or /coronavirus ( patients). all the patients were admitted in pulmonary division, except for the patient with heart transplant who was in cardiac intensive care unit. the administered dose was mg tid or mg tid if there was renal insufficiency ( patients). the median duration of the treatment was days . four patients prematurely discontinued the treatment due to severe toxicity or therapeutic change; three didn't respond to the treatment (no data for the last one). four patients were re-treated despite having a virological response to the first cure. one patient treated for a hpiv- /coronavirus coinfection had an hpiv- relapse days after ribavirin discontinuation. concerning the three other patients, they received a second cure to treat a new infection (coronavirus, hpiv- and hmpv, in opposition to hpiv- twice and hpiv- respectively). virological response rate was % ( / for rsv, / for hpiv, / for coronavirus and / for hmpv). two non-negative viremia patients (rsv and hpiv- /coronavirus) received intravenous ribavirin after oral ribavirin therapy. no patient died from viral infection. twelve patients presented specific toxicity: one hepatic cytolysis and cholestasis, eight haemoglobin decrease, two pancytopenia and one mucositis. conclusion: despite the poor number of patient, our study shows that oral ribavirin seems to be efficient to treat hpiv, hmpv and coronavirus in immunocompromised adults. we observed known side effects that could generally be managed. oral ribavirin may thus represent a therapeutic strategy in several respiratory viral infections. please specify your abstract type: descriptive abstract (for projects) background and objective: reconciliation of medicine lists is important to ensure correct medical treatment of patients both in hospital and other healthcare levels. while reconciliation upon admission is part of the normal routine at surgical ward b, molde hospital, there has been less focus on reconciliation at discharge. as such, this study aimed to ensure reconciliation and correct transfer of medical information at discharge. design: medicine lists of all patients discharged from surgical ward b, molde hospital between week and in (n = ) were investigated. the forms were gathered and counted based on the tasks signed for to ensure completed reconciliation and sufficient information given to the patient. the count was performed every - weeks, and the forms in each count was pooled together as one point of measure. the quality of medicine lists in discharge lists was evaluated based on the norwegian patient safety program criteria. medicine lists in discharge lists from week to (n = ) were pooled together and compared to medicine lists in weeks - (n = ). results: the results of reconciliation was divided into the subsections of surgical ward b, and represent the number of completed tasks as signed for in the reconciliation form. the surgical subsection showed a significant increase in patients with pre-checked medicine lists and reconciled medicine lists over the measured time period. similar results were not found in the orthopaedic subsection. as for the quality of medicine lists in the discharge lists, significant improvement was seen in all set criteria, with the exception of ''source'' in the surgical subsection. in the orthopaedic subsection however, no significant improvement was seen in any of the criteria other than ''indication for use''. conclusion: the implementation of reconciling medicine lists at discharge was successful. however, both subsections need to work further to ensure continuation and improvement of the process. furthermore we found varying results in the writing of medicine lists depending on subsection. still, regardless of the individual results of the two subsections there is big room for improvement to ensure that sufficient medical information is included in the discharge papers. please specify your abstract type: descriptive abstract (for projects) background and objective: from july clinical pharmacists began conducting medication histories and reviews (pharmacist notes) at the emergency surgical ward (esw), north zealand hospital (nzh). inclusion criteria are acute patients using c drugs or c risk drug (antidiabetics, anticoagulants, antipsychotics, benzodiazepines, opioids and digoxin). the aim of the service is to identify drugrelated problems and secure correct medication reconciliation between the medicine the patient is admitted with and the medicine in the electronic medication system (ems) in the hospital. the service ensures that the patients' medication follows across healthcare sectors. the objective is to determine if the discrepancies between the medicine the patient is admitted with and the medicine in ems (documented in the pharmacist notes) are used by the physicians. in addition to determine if the pharmacist interventions increase the physicians' acceptance rate of the discrepancies. design: data were collected at the esw at nzh (capacity of beds). data consist of pharmacist notes conducted from august to may . pharmacist notes were compared to the patient record and ems to identify if the pharmacist notes were considered by the physicians. in order to increase physicians' acceptance rate of the discrepancies suggested in the pharmacist notes, interventions were made according to the model for improvement. throughout the period, the focus was on oral delivery of the pharmacist notes. in december the pharmacist optimized the clinical relevance of the discrepancies, by creating and testing a list of products (including vitamins, herbal drugs, glucosamine etc.) which the pharmacist should not intervene on. in december the pharmacist also started to follow up on the pharmacist notes not considered by a physician the previous day to ensure that the physician considered the discrepancies. results: there were identified discrepancies between the patients' actual medication at admission and ems at the hospital in patient records ( . discrepancies per patient). in total discrepancies were accepted by the physicians ( . discrepancies per patient). the physicians' acceptance rate was based on the acceptance of one or more of the discrepancies in the pharmacist note. baseline data were collected from august to november , where out of pharmacist notes were accepted by the physicians resulting in an acceptance rate of . %. from december to may the interventions made by the pharmacist contributed to an increase in acceptance rate to . % ( out of notes accepted). if the pharmacist notes were not delivered orally to the treating physician the acceptance rate was % ( out of notes accepted). conclusion: the pharmacist interventions contributed to an increase in the physicians' acceptance rate of discrepancies from . to . %. a result indicating that the pharmacist notes contributes to an increase the quality of the medication process across sectors. hp-pc : how the centralization of medicines manufacturing enable to generalize the pharmaceutical validation? samantha oses * , soizic vandierdonck, vincent servant, dominique breilh please specify your abstract type: research abstract background and objective: the centralization of the reconstitution of injectable anti-infective drugs enhance to decrease costs and several risks. this minimization of the risks operates at several levels such as i) reduction of the staff exposure and external contamination of preparations during the reconstitution phase (with controlled atmosphere areas, isolators, etc.), ii) improvement in the quality of the management of infective diseases thanks to a pharmaceutical validation systematically performed after the prescription and before the reconstitution phase. the main objective of the study was to describe and quantify pharmaceutical validation on injectable anti-infective drugs prescriptions restored in a pharmaceutical reconstitution unit. setting and method: an observational descriptive study was carried out on each prescription with at least one injectable anti-infective drug that has to be reconstituted before administration. the process was as follows: -prescription by the physician on an electronic prescription software, -pharmaceutical validation and if necessary pharmaceutical intervention (pi) made by phone call, -reconstitution at the pharmacy, -administration to the patient. the pharmaceutical validation methodology followed the french society of clinical pharmacy (sfpc) guidelines ''prescriptions screening and analyses level'' published in the good practices of clinical pharmacy and one resident and one pharmacist were devoted to the activity every day. main outcome measures: the pharmaceutical validation was quantified by the number of pi by patient, which were categorized according to the sfpc guidelines. results: during months, a total of pi were collected. they concerned patients with an average of . pi per patient. among them, . % ( ) concerned paediatric population. antibiotics were involved in . % ( ) then followed by . % ( ) cases ( . % ( ) biological assessment issues, . % ( ) absence of therapeutic drug monitoring (tdm) and . % ( ) the drug hasn't been adapted to the weight), dosage adjustments in . % ( ), information missing concerning the treatment indication in . % ( ) and miscellaneous pi in . % ( ) such as wrong clinical service on the prescription, etc. approval rate of physicians was . % ( ). conclusion: this study has shown that even if prescriptions were secured by electronic prescription software, the pharmaceutical validation remains essential. in that case, the centralization of the reconstitution of injectable anti-infective drugs enabled to generalize this activity on all prescriptions of the hospital. however, the pharmaceutical validation was focused only on anti-infective drugs, that was not fully efficient and must be extended to the whole prescription. it is a priority to develop a comprehensive and exhaustive validation on every medical prescription; however, this activity is highly time consuming and needs larger and more trained staff. hp-pc : the start/stopp criteria as a helping tool to the pharmacists' medication review in the acute admissions unit of the regional hospital in horsens hans pedersen * please specify your abstract type: research abstract background and objective: polypharmacy occurs often increasing the need for patients' medications to be reviewed. the start/ stopp criteria help detects potentially inappropriate prescriptions in older people. in this study we aimed to measure and categorize the different start/stopp criteria found in medication reviews in the acute admissions unit of horsens and the acceptance rate. setting and method: patients admitted to the acute admissions unit were selected based on their age and the number of prescriptions in a period of months. patients years or more which received six or more drugs were included in the study. only patients who later were transferred to another medicine ward were included in the study. the pharmaceutical medicine review was performed by a clinical pharmacist using minimum two different sources; the electronic medical record and medication-lists. the guideline of pharmaceutical medicine review in the hospital pharmacy central denmark region was used as the standard-guideline. in addition, thestart/stopp criteria version was used. main outcome measures: the number of start/stopp criteria found in medication reviews. the different start/stopp criteria were scored equally with one point each. results: patients, males and females, out of , were included. the mean age was years and the patients received in average prescribed drugs. at admission the average number of stopp criteria were . ± . and . ± . for the start criteria. in average, % of the purposed stopp criteria were accepted by the physicians. the most frequently accepted stopp criteria were in the category of drugs that predictably increases the risk of falls in older people. the benzodiazepines where the most common drugs to be discontinued. in the start category, % of the suggested start criteria were accepted, which included: calcium and vitamin d supplement, beta- agonist and bisphosphonate. conclusion: the present study demonstrates that it was possible to integrate the start/stopp criteria as a helping tool in the medication reviews in the acute admissions unit of horsens. the start/stopp criteria were found within the different categories, however only a minor part of the registered start/stopp criteria were accepted by the physician. please specify your abstract type: research abstract background and objective: the objective of this work is to assess prescribing practices of somatostatin analogues in a surgery department, and to analyse the conformity of switching from immediateacting octreotide to the long-acting release (lar) form, in accordance to laboratories' guidelines. setting and method: retrospective observational study. a focus was realized on patients admitted in a digestive surgery unit between january and december , . the patients' medical records were reviewed for clinical features, diagnosis workup and treatment strategies. main outcome measures: medical records for patients with diagnosis of gastro-entero-pancreatic or endocrine tumors who had received injections of lar octreotide during hospitalization were reviewed and the economic impact of prescriptions errors has been evaluated. results: of the evaluated patients, ( %) were hospitalized in surgery digestive unit; mean age at first administration of octreotide was years and % were male. the male and female ratio was . : . reasons for hospitalization were: digestive system neoplasms ( %), fistula ( %), intestinal obstructions ( %) and other pathologies ( %). of the patients treated with octreotide, ( %) received a lar form. only four patients received doses in accordance with guidelines: one at mg/month lar form and three at mg/month lar form, after having respectively been treated by intravenous octreotide at and mcg/day during - days. medical prescriptions of the remaining patients did not comply: all patients received mg/month after an intravenous treatment of mcg/day, instead of mg/month. from a financial perspective, these misuses have led to an additional cost of . euros for the hospital, excluding tax ( mg: . €/unit and mg: €/unit). conclusion: despite the publication of octreotide release form proper use recommendation in our hospital, % of patients of digestive unit are not right treated. a new guideline will be written added by doses of long-acting release and economic data. this work will be transmitted to specialists by clinical pharmacists. hp-pc : pharmaceutical process for intrathecal analgesia in clinical oncology practice vivien pigeon * , guillaume binson, claire grignon, antoine dupuis please specify your abstract type: descriptive abstract (for projects) background and objective: in some cases, patients with cancer pain remain painful despite the use of high dose of intravenous opioids and intrathecal analgesia becomes the ultima recourse to manage acute pain. until , intrathecal syringes were prepared by nurses in the unit care which involve a risk for patients. therefore, the aim of this work is to describe the set-up of the prescription and preparation process with the potential benefits for the safety. design: multidisciplinary concertation took place between pharmacists, physicians and surgical teams and several points were discussed to secure the process: • identification of patients with high level of infection risk; • identification of critical points of the pharmaceutical process; • validation of quality control and drug stability studies regarding drug compounding involving morphine, ropivacaine, baclofen and clonidine, alone or in admixture. results: multidisciplinary concertation lead us to define the most important points to set up the pharmaceutical process for intrathecal analgesia: • chosen patients are cancer patients; • implementation of a prescription software to secure the prescription step; • production of syringes by the pharmacy department implying several criteria: • preparation in controlled atmosphere area; • training of pharmacy technicians; • implementation of quality control and drug stability studies at °c in syringe over h and at °c in pumps over month; • microbiological control and bacterial endotoxin level. the implementation of a pharmaceutical process for intrathecal analgesia gave us the opportunity to reorganize the care of cancer patients tolerant to high dose of opioids. in this process, the pharmacy department plays a major role leading to decrease the risk of infections and errors of dosing. ingrid plessala *, , xavier deviot , thomas sidibe , zohra mostefaï , michèle minvielle , marta wyrtwal , roselyne gervais pharmacy, geriatrics, saint-denis hospital centre, saint-denis, france please specify your abstract type: descriptive abstract (for projects) background and objective: proton pump inhibitors (ppis) are indicated in gastro-oesophageal reflux and peptic ulcer disease. they are widely prescribed, often in off-label indications. the objective of this work was to reassess ppis prescriptions in collaboration with geriatricians. proton pump inhibitors (ppis) are indicated in gastro-oesophageal reflux and peptic ulcer disease. they are widely prescribed, often in off-label indications. the objective of this work was to reassess ppis prescriptions in collaboration with geriatricians. design: prospective study in three geriatric wards. the study included ppis treated patients from these three geriatric wards. dose, indication of the ppi, age, gender and duration of treatment have been recorded for each patient. the relevance of each ppi treatment has been reassessed by a geriatrician, a pharmacist and a junior pharmacist, regarding the indication and the patient's clinical condition. following this re-evaluation, three situations arose: • to maintain ppi at the same dose ( mg or mg) • to maintain ppi but half dose (from mg to mg) • to stop ppi corrective actions have been recorded in patients' files to allow their traceability. results: patients were included in the study. % of ppis prescriptions were off-label, % had no indication mentioned in patient's file and % were conform to the marketing authorization. % of patients have been on ppis medication longer than months, which is the recommended treatment' duration in france, % longer than a year and % longer than years. in collaboration with the geriatricians, ppi prescriptions were maintained for % of patients. we reduced the dose in % of cases. finally, we decided to stop a third of the ppis prescriptions. conclusion: ppis prescriptions are often longer than recommended. this can lead to side effects for patients. in france, lack of new recommendations since may explain this frequent misuse of ppis. there is also a reserve from doctors to stop these treatments, especially with fragile patients. in our case, the relevance of each ppi treatment was re-evaluated in three geriatric wards and we succeeded in shortening and stopping ppis medications in half of the situations. to assess the impact of this action on our geriatricians, a new review of ppis prescriptions relevance is programmed in . ppis prescriptions are often longer than recommended. this can lead to side effects for patients. in france, lack of new recommendations since may explain this frequent misuse of ppis. there is also a reserve from doctors to stop these treatments, especially with fragile patients. in our case, the relevance of each ppi treatment was re-evaluated in three geriatric wards and we succeeded in shortening and stopping ppis medications in half of the situations. to assess the impact of this action on our geriatricians, a new review of ppis prescriptions relevance is programmed in . hp-pc : oral anticoagulants and heparin for children: standardized protocols for prescription, dispensation and administration alexandra liauzu , marie-françoise hurtaud-roux , ronan bonnefoy , caroline farnoux , philippe sachs , theresa kwon , olivier bourdon , sophie ajzenfisz , sonia prot-labarthe *, pharmacy, hématologie clinique, ap-hp hôpital robert-debré, cardiologie, néonatologie, ap-hp hôpital robert debré, réanimation pédiatrique, ap-hp hôpital robert-debré, néphrologie, pharmacy, ap-hp hôpital robert debré, coordonnateur de la gestion des risques associés aux soins/ responsable du système de management de la qualité de la prise en charge médicamenteuse, ap-hp hôpital robert-debré, paris, france please specify your abstract type: research abstract background and objective: high-alert medications (ham) are medications that are associated with a high risk of serious harm if used improperly. we already identified paediatric ham used in our institution to identify safety measures for their use. anticoagulants and heparin were part of these high-alert medications. we aim to write standard protocol of use for low weight heparin and oral anticoagulant used in our mother-child teaching hospital. our secondary objectives were to decrease medication errors, anti-xa and inr unexplained variability and to help nurses to administer the drugs (standard dilution, oral solution available) setting and method: we carried out a literature search on pubmed Ò , on websites of several learned or professional societies and agencies. the results of the literature search were compiled on written protocol and presented to our institute drug safety-steering committee composed of four doctors, two head nurses, two pharmacists, and one risk manager. main outcome measures: not applicable. results: the protocols concerned enoxaparin, tinzaparin, warfarin but we chose to also include protamine. the most difficult issue was to have standardized dilution and protocol for all ages and weight: from premature to adolescents and all units of care (from cardiology to intensive care unit, nephrology and neonatology). we took into account the administration errors we had in our hospital and the preexisting protocol to avoid any drastic error-prone change. the final version of these protocols will be presented on the final communication with web link to upload them. conclusion: for now we did note evaluate the impact of these protocols but a before/after analysis of error reports and users evaluation will be done. however, these protocols can help all health professionals working in paediatric units for benchmarking. hp-pc : does a hospital formulary system impact timely medication administration and quality of inpatient care? anne-valérie putallaz *, , vera jordan-von gunten , pierre-auguste petignat , pierre turini , johnny beney division of pharmacy, institut central des hôpitaux, division of internal medicine, medical coordinator for quality of care and patient safety, hôpital du valais, sion, switzerland please specify your abstract type: research abstract background and objective: the prevalence of drug omissions is often underestimated but their impact can be clinically relevant. we hypothesized that delays in the administration of non-formulary/nonstored drugs could impair the quality of care. the aims of this study were: °to determine the time between the prescription and the administration of the first prescribed dose and, if applicable, to calculate how many doses were omitted. °to analyse the clinical relevance of the identified delays. setting and method: three months retrospective study of electronic records of patients hospitalized on the internal medicine wards of a network of hospitals supplied by a centralized pharmacy. this pharmacy is located in one of the sites; other sites are - km apart. main outcome measures: . for the main hospital site and the three distant sites: • median time between the prescription and the administration of the first prescribed dose • mean number of omitted doses for formulary and non-formulary/ non-stored drugs. . categorization of patient's harm caused by the delays of timecritical drugs, according to the ncc-merp taxonomy of medication errors. results: ' prescriptions were analysed. calculated delays for non-stored/non-formulary drugs were longer than for formulary drugs. however, the median time to administration is less than h for both formulary and non-stored/non-formulary drugs; and more than % of formulary drugs and around % of non-stored/non-formulary drugs were administered within h following their prescription. there was no significant difference in the mean number of omitted doses or in the delays between the site where the centralized pharmacy is located and the other sites, except for one of them. a delay representing . or more omitted doses was found for ( . %) prescriptions. among them, only were considered potentially clinically relevant. none of them caused severe harm to the patients involved. conclusion: in our setting, non-stored/non-formulary drugs take more time to be delivered than formulary drugs, but more than % of formulary drugs and around % of non-stored/non-formulary drugs are administered within h following their prescription. none of the patients who experienced delays underwent severe harm. our study showed that delays also occur for formulary drugs but no systematic cause of omission was identified; further studies should focus on all dose omissions during hospitalization. penelope randuineau *, , roger jeremy , lauriane cornuault , anne lecoeur , franck lemercier , isabelle javerliat , thomas tritz service de pharmacie à usage intérieur, service de chirurgie vasculaire, hôpital ambroise paré, boulogne-billancourt, france please specify your abstract type: descriptive abstract (for projects) background and objective: a french national survey of inpatient adverse events reveals that nearly half of adverse drug events (ade) are preventable. medication errors behind these ade occur mainly during the transition steps of care pathway. in this context, medication reconciliation process has been implemented in our vascular surgery department. the objective of this study is to identify unintentional discrepancies (uid) and assess their potential clinical impact design: a pharmacy resident or a pharmacy student reconciliated patients: aged older than or with at least five chronic treatments at admission or suffering from chronic diseases. patients were considered reconcilable if at least two reliable sources on usual patient's treatment were available. these many sources of data (patient interview, prescription or interview of general practitioner, reference dispensary, drug box …) were compared to the admission prescription during the first h of hospitalization to detect and correct uid. based on gravity scale promoted by the french high authority of health, two pharmacists (a resident and a senior) and a vascular surgeon reviewed every uid in order to define their potential clinical impact. the uids were considered minor if it leads to no consequence for the patient, clinically significant if it leads to essential monitoring, major if it could cause temporary clinical consequences, and critical if it could result in permanent clinical consequences or the involvement of the prognosis. results: between february th and may st , a total of patients have been reconciled. patients were excluded due to a lack of reliable sources. mean age was . years old (± . ) and sex ratio m/f was . . % of the reconciliated patients' admissions were scheduled. the mean number of medication was . (± . ). patients ( %) had at least one uid and the mean uids per patient was . (± . ). the most common types of uids were omission ( %), incorrect dose ( %) and incorrect administration frequency ( %). more than % of these uid presented a potential clinical impact: an adverse effect (high blood pressure, hyperglycaemia) was observed for nine patients and lead to therapeutic optimization and monitoring; uid were considered to have potential clinically significant impact ( %), a potential major impact ( %) and a potential critical impact. conclusion: these results appear consistent with those reported in literature. vascular surgeons have appreciated the approach and would like systematic medication reconciliation before surgery. as a major part of admissions were scheduled, we would like to establish the reconciliation before the patient's hospitalization every time it's possible. this new organization should facilitate the care pathway before surgery and decrease preventable postoperative adverse events. hp-pc : delirium in elderly patients: successful use of melatonin gaëlle jouin , aurélie reiter-schatz , pierre bentzinger , fatem-zohra laalou , bénédicte gourieux *, pharmacy-sterilization, orthopedic's intensive care unit, university hospital of strasbourg, strasbourg, france please specify your abstract type: descriptive abstract (for projects) background and objective: postoperative delirium happens to about one-third of elderly patients and is a major cause of morbidity and mortality. it is reported that haloperidol, an antipsychotic, has been the agent of choice for managing delirium. however, it induces cerebrovascular adverse effects and greater mortality. the hyperactive type of delirium is known to be associated with a low melatonin level and the loss of a normal melatonin secretion rhythm. the postoperative administration of melatonin to elderly could decrease the symptoms of delirium. the purpose of this study was to evaluate melatonin effectiveness in a cohort of patients suffering from postoperative delirium. design: a retrospective study of melatonin prescriptions has been conducted over a months period. medical background, type of surgery, symptoms of delirium, use of antipsychotics and benzodiazepines have been studied in all patients who received melatonin in an orthopaedic surgery unit. length of hospital stay, time between delirium and melatonin administration and the effect of melatonin had been evaluated. results: a total of patients were included: average age was . years ( - ), sex ratio m/f = . twelve patients ( %) were hospitalized because of an infection (prosthesis or osteoarticular). in % of cases (n = ), the prescription of melatonin was started when the patients were hospitalized in our intensive care unit. nine patients ( %) were under chronic treatments like benzodiazepines or antipsychotics. the average length of hospital stay was days ( - ). melatonin was started on an average of days after surgery , and administered at the dose of mg xr in the evening, during an average of days ( - ). cognitive impairments requiring a prescription of melatonin were: confusion ( %, n = ), agitation ( %, n = ), daytime sleepiness ( %, n = ), temporal-spatial disorientation ( %, n = ), nocturnal awakening ( %, n = ), hallucination ( %, n = ), difficult falling asleep ( %, n = ). the average time to recover from confusion was days, agitation days, daytime sleepiness days, temporal-spatial disorientation days, nocturnal awakening days, hallucination days and falling asleep days. melatonin treatment helped stopping benzodiazepines treatment in six patients ( %). conclusion: after administration of melatonin, delirium symptoms were improved for all patients and benzodiazepines treatment stopped for six patients. earlier prescription of melatonin could regulate sleep-wake cycle and reduce the duration and incidence of delirium. please specify your abstract type: research abstract background and objective: denosumab (xgeva Ò ), a fully human monoclonal antibody targeting rankl, which inhibits bone resorption, is indicated to prevent skeletal complications in patients with solid tumors and bone metastases. about % of patients develop hypocalcaemia, a common adverse event that may induce spasms, muscle cramps, paraesthesia, prolonged qt interval, tetany, convulsions… we report the management of ionic supplementation and physicochemical incompatibilities in a case of hypocalcaemia due to denosumab. setting and method: the clinical case was analysed with the pharmacovigilance regional center. main outcome measures: a year old patient, with nodal and bone metastasis in prostate cancer, was treated with denosumab (stopped with the last injection months before, on the th of march). he went to emergency on the th of may with asthenia, anorexia, nausea, diarrhoea, qt prolongation. biological results showed hypocalcaemia (corrected calcaemic = . mmol/l) and hypophosphatemia (phosphorus \ . mmol/l). concomitant calcium and phosphorus intravenous supplementation started with loading doses ( g of calcium and . g of phosphorus) and then a week of following daily intakes: phosphorus ( g iv and . g oral); calcium ( g iv and . g oral). however, low-serum corrected calcium and phosphorus levels persist at . mmol/l and . mmol/l. results: incompatibility between phosphorus and calcium by formation of soluble or not-soluble complexes is described in literature. in our case, calcium and phosphorus were mixed in a same infusion. after a week of supplementation, calcium infusion is continued with increased dose ( g/day) and phosphorus infusion is stopped. phosphorus oral supplementation remains stable ( . g per day); calcium oral supplementation is increased ( . g per day). h between intakes is applied to avoid digestive complexation. h later, corrected calcium levels are normalized at . mmol/l and phosphorus levels are still low. therefore, as hypocalcaemia due to denosumab induced a secondary hyperparathyroidism and thus hypophosphatemia; phosphorus levels are expected to increase subsequently. conclusion: this case report shows that recurrent hypocalcaemia with denosumab is possible few months after administration. supplementation with large amount of calcium is needed and administration methods may impact the effectiveness of supplementation. indeed, it seems that the incompatibility between phosphorus and calcium did not allow an effective supplementation. gunnhild langdal *, , , ida rudberg , lone holst , anne-lise sagen major , central norway hospital pharmacy trust, Å lesund, centre for pharmacy, university of bergen, bergen, møre og romsdal health trust, Å lesund, norway please specify your abstract type: descriptive abstract (for projects) background and objective: drug interactions (dis) can cause side effects and lack of therapeutic effect. the objective of this study was to describe the prevalence of dis at the medical department of Å lesund hospital, and to investigate how dis were managed by clinical pharmacists and physicians. design: at the medical department, Å lesund hospital, clinical pharmacists serve seven out of ten wards, from which patients were included during a five weeks period. the clinical pharmacists selected patients for screening for potential dis (www.interaksjoner.no) as int j clin pharm ( ) : - usual (= pharmacist group). detected dis were classified according to a predetermined classification system, and it was registered whether the physician implemented suggested changes in prescription. for patients not selected by clinical pharmacists (= non-pharmacist group), a pharmacy student performed the search for dis. results: in total patients were admitted. on average, each patient had . dis, and . % of the admitted patients had at least one di. the prevalence of dis was significantly higher among the patients in the pharmacist group compared to the patients in the non-pharmacist group (median@@@ vs. , respectively, p \ . ). the groups differed significantly regarding number of drugs used, age, duration of hospital stay and number of warfarin users. . % of the dis detected in the pharmacist group were discussed with the physician. the remaining . % were considered not necessary to discuss for various reasons e.g. because they were considered not clinically relevant ( %) or already adjusted for in clinical practice ( %). for dis the clinical pharmacist suggested a change in prescription, and of these suggestions ( %) were implemented by the physician. conclusion: just over half of the patients were selected by the clinical pharmacist for screening of dis, and the pharmacist seemingly made a reasonable priority of patients with many drugs, old age, a long hospital stay and users of warfarin. only of dis was discussed with physicians. this indicated that pharmacists do a considerable work in assessing the relevance of dis before discussing with the physicians. it also seemed that changes in prescription suggested by the clinical pharmacist were reasonable. hp-pc : securing the paediatric use of oral chemotherapy: a proactive risk assessment samia mouffak *, , linda an , anne fratta , anne auvrignon , , nadia marquis , karine morand pharmacy, risk management committee, hematology, armand trousseau hospital -aphp, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: oral chemotherapy is an important part of the therapeutic strategy in childhood cancer or haematological malignancy. it also represents an emerging risk area in oncology practice. several medications errors involving oral chemotherapy were reported in children of our onco-haematology department, fortunately without clinical consequences. nevertheless, the potential severity of such errors led us to implement a failure analysis of the paediatric oncology care pathway in order to identify and prevent potential risks, and secure the paediatric use of oral chemotherapy. design: we conducted a failure modes, effects and criticality analysis (fmeca) which is a proactive risk assessment approach. first, process maps were detailed for each step of the oncology care pathway. it was performed by a multi-disciplinary group composed of physicians, coordinating nurse, hospital pharmacists and pharmacy resident. then, for each step of the medication-use process, the team identified the failure modes, their main causes and effects. finally, participants rated the expected severity, frequency and detectability for each failure mode, assigning a score on a five-point scale. a risk priority number (rpn) was then calculated by multiplying those three indexes. the risks getting a high rpn were categorized as critical risks and have been the object of safety improvements. results: failure modes were identified, including critical risk failure modes. critical failures were related to hospital discharge prescriptions and were about the dispensation of oral chemotherapy by pharmacy assistants. most failures were due to prescriptions heterogeneity, lack of clinical information reported on prescriptions, and lack of training of pharmacy assistants in reading oral chemotherapy prescriptions and in mistake detection. two improvement strategies were implemented. first, physicians' awareness led to the harmonisation of practices and to the standardisation of discharge prescriptions. then, to enhance pharmacy assistants' abilities, an educational program on oral chemotherapy dispensation was planned. conclusion: the implementation of a fmeca has highlighted the most critical risks of oral chemotherapy medication-use process. the awareness of all caregivers and the targeted changes in our practices allowed us to improve the safety of the paediatric oncology care pathway. please specify your abstract type: descriptive abstract (for projects) background and objective: the purpose of this study was to investigate if medication reconciliation and medication review, by using the integrated medicines management (imm) model, were suitable to assure the quality of patients' medical treatment at a gastrointestinal surgical ward. furthermore, to analyse frequency, type, handling and clinical relevance of medication discrepancies (mds) and other medication related problems (mrps). design: patients, above years of age, from two departments at a gastrointestinal surgical ward at a norwegian university hospital were included consecutively. medication reconciliation was performed at admission by a clinical pharmacist. the resulting medication histories were compared with the medications documented in the medical records. mds were detected and categorized. thereafter the clinical pharmacist identified mrps by reviewing the medical records systematically and categorized the revealed mrps. mds and mrps were presented for the physician with proposed solutions. the physician's actions to manage the mrps were registered. later a multidisciplinary team assessed the clinical significance of mds and mrps in a subset of patients. results: a total of patients were included. overall, mds and mrps were identified. at least one md was revealed in % of the included patients, whereas at least one mrp was identified in % of the patients. the most frequent type of mds was omission, whereas mrps most often were related to medications that were considered unnecessary. totally, % of the mds and mrps were discussed with the treating physician. the physicians followed the pharmacist's input in % of the discussed md-cases and % of the mrp-issues. longterm consequences of mds and mrps were considered more serious than short-term consequences for the patients. conclusion: medication reconciliation and medication review revealed, solved and prevented a large number of mds and mrps in this study. the results emphasize that pharmacist involvement, by using the multidisciplinary imm-model, contributed to more correct medical records and furthermore to quality assurance of the patients' medical treatment at a gastrointestinal ward. hp-pc : prevention and management of drug interactions in oncology day-hospital: results from a months study involving drug assessment and pharmaceutical report to oncologist pauline-saraï zeller *, , chloé hugard , céline mongaret , , juliette vella-boucaud , antonin maréchal , olivier bouché , dominique hettler , florian slimano , pharmacy, oncology day hospital, university hospital reims, clinical pharmacy, faculty of pharmacy, reims, france please specify your abstract type: research abstract background and objective: quality during transitions of care is a major concern in drug safety for patients. traditional hospitalization allows to reconciliation medication but there is not possible for dayhospitalization (patient's hospitalization short time and no outpatient medication prescribe by oncologists). however, lack of communication between health professionals may expose patients to drug-drug interactions (ddi). while ddi between oral antineoplastic and other drugs are well known, there is a lack of knowledge about ddi between parenteral antineoplastic (ak) and other drugs. in this pilot study, we aim to investigate prevalence and characteristics of ddi between ak and other drugs in real life and to propose a pharmaceutical report model to enhance patient's drugs safety. setting and method: during months, all new oncologic patients (thoracic and digestive) receiving chemotherapy in day-hospital have been recruited by clinical pharmacist. first it was conducted a patient-clinical pharmacist interview and carried out the best possible medication history (bpmh) by contacting at least three different sources of drug information. then, the bpmh has been confronted with oncologic treatment (including concomitant medications such as like antiemetic) with support at least with two different database of ddi analysis. finally pharmaceutical recommendations in order to manage potential relevant ddi were reviewed with oncologists then reported and inserted in personal health record (phr). main outcome measures: prevalence and description of potential clinically relevant ddi in an ambulatory oncology population. results: from november, to april, n = oncologic patients were included with following characteristics: mean age of . , sex ratio : , majority of oncologic thoracic localization ( %). number of oncologic concomitant medications per patient was . ± . (mean ± standard deviation). patients present an average of . ± . comorbidities (excluding cancer) and . ± . linked medications per patient. pharmaceutical analysis revealed potential clinically relevant ddi ( . ± . per patient): % of them concern antiemetics (ondansetron and aprepitant): pharmaceutical interventions were formulated (including recommendations to adapt chronic treatment) and % of them involved biological monitoring (for renal function, inr, potassemie or magnesemie). conclusion: our pilot study confirms high prevalence of ddi between oncologic and non-oncologic drugs. clinical pharmacy services with bpmh performing and pharmaceutical recommendation appears to be useful to enhance patient' drug safety in oncology dayhospital. we currently are deploying our study in order to convey a pharmaceutical letter to general practitioner and community pharmacist. hp-pc : loading dose of anti-infectives: elaboration of a tool helping pharmaceutical analysis julie soyer *, , cécile sanchez , guillaume beraud , nicolas venisse , pauline lazaro , antoine dupuis pharmacy, infectiology, pharmacokinetics, university of poitiers, poitiers, france please specify your abstract type: descriptive abstract (for projects) background and objective: the recent data on vancomycin and ceftazidime confirm that continuous infusion is the best way of administration of these antibiotics. moreover a loading dose before the administration is required for the antibiotics to prevent from the infratherapeutic period at the start of infusion and limiting the risk of resistance emergence. long half-life antibiotics and antifungals also require a loading dose to be effective. the aim of this study is to analyse the prescriptions of anti-infective requiring a loading dose in order to develop a tool to help pharmaceutical analysis. design: a prospective observational study was carried out during days in units. initially, pharmacists, residents and students were trained (role of the loading dose, drugs concerned). then, all patients with anti-infective requiring loading dose were included. some data were collected: weight patient, creatinine clearance, loading dose or not, dose, administration mode, monitoring of steady state concentrations (vancomycin and ceftazidime) and dose adjustment. the results were analysed and compared to bibliographic research before discussion during a multi-disciplinary meeting (pharmacists, infection control specialist and pharmacokinetic specialist). finally, a list of relevant pharmacist interventions was selected. results: out of the patients, were enrolled for prescription of anti-infective requiring loading dose. twenty-six prescriptions including vancomycin, ceftazidime, the others fluconazole, caspofungine, voriconazole and posaconazole. concerning vancomycin, the loading dose was prescribed in % of case, monitoring of steady state concentrations was performed in % of case and dose adjustment after first dosage was required in % of case. selected pharmacist interventions were: • to favour continuous infusion (excepted paediatric) • to keep loading dose at full dose even in patient with renal failure • to monitor steady state concentrations after the first h in patient with renal failure or obesity • to adapt dosage when the target concentration is not reached concerning ceftazidime, the interventions were: • to recommend continuous infusion: g/ h after loading dose of mg/kg • to monitor steady state concentrations in patient with renal failure a total of interventions (dosage, adaption of posology at the monitoring, patients with renal failure, obese, paediatric patient, administration…) were identified by the group of experts. conclusion: this study allowed creating a recap data sheet for students and hospital pharmacists. the selected interventions will allow the harmonization of practices. these recommendations have been validated by the commission of the anti-infective. finally, this study shows that the pharmacist has a key role in the management of antiinfective requiring loading dose. hp-pc : assessment of potentially inappropriate medications in orthogeriatric patients using the rasp list the detection of inappropriate prescribing. the objective of this study was to investigate if the rasp list (rationalization of home medication by an adjusted stopp list in older patients), an explicit screening method adapted to the belgian context, can be used to reduce the number of potentially inappropriate medications (pims) in orthogeriatric patients. setting and method: single-centre, interventional study conducted at the orthogeriatric department of the uz brussel, a -bed university hospital. the rasp list was first applied by a last year pharmacy student to the admission medication of orthogeriatric patients hospitalised in october . after potential adaptations to the medication by a liaising geriatrician, the rasp list was additionally applied by the same pharmacy student to the discharge medication of these patients. main outcome measures: detection and reduction of the number of pims. results: in total, orthogeriatric patients, from whom an informed consent was obtained, participated in this study. on admission, a total of pims were detected in this population. at discharge, the number of pims decreased to . the median number of pims per patient decreased from (on admission) to (at discharge). this difference was statistically significant (p \ . ; wilcoxon signed rank test). drugs of atc class n (nervous system) were responsible for the highest number of pims. conclusion: pims can be detected and reduced in the hospital using the rasp list. a structured and collaborative medication review between (student) pharmacists and physicians appears a good approach to reduce the number of potentially inadequate drugs. nevertheless, more research is necessary to substantiate this further as well as to assess the clinical impact of the findings. hp-pc : impact of implementing ward based dispensaries across a hospital site on both service delivery and patient care michelle sullivan, paul wright, christopher watson, malcolm smith, sotiris antoniou * please specify your abstract type: descriptive abstract (for projects) background and objective: waiting for medication at discharge is often quoted as a key factor for delaying patients leaving hospital. feedback from service users (patients and healthcare professionals) was for a more patient facing pharmacy service. this led to a phased installation of remote dispensaries on wards within the hospital to supply medicines. this new and innovative service enabled the supply function to be fully co-ordinated on the ward. this model was initially implemented on wards, which coupled with one-stop dispensing meant % of discharges require nothing to be supplied at the point of validation, % of discharge prescriptions meeting key performance indicator of being dispensed and ready within h with average turnaround time of min for a discharge prescription and a reduction in missed doses- . % in september to . % in march . this success prompted further installation of remote dispensaries in all clinical areas on site. design: implementation included; purchasing hardware, pharmacy labellers, locating appropriate computer terminals and stock cupboards. the main pharmacy labelling and stock control system was fully integrated at ward level, enabling the automatic reordering of replacement stock. identification of items and quantities to stock for remote dispensaries was also needed prior to role out. there was a need to scope staffing requirements including the redeploying of roles from a main inpatient pharmacy to patient facing areas. results: over items are supplied at ward level each month via satellite pharmacies for all wards, equating to more than % of the total dispensing workload for the site allowing for pharmacy staff to be redistributed from dispensary to the ward. this offered the benefit of being more patient facing and supporting other initiatives such as patient counselling and medicines reconciliation. the project has impacted the pharmacists as it has enabled them to focus on clinical aspects of service delivery, including attendance of ward rounds as well as supporting a ward team approach with the pharmacy technician. results of missed dose audit from june shows across the site % ( ) wards scored below the national . % target and ( %) wards had no unintentional missed doses. conclusion: ward based dispensing has led to pharmacists and pharmacy technicians being % ward based. as a constant presence on the ward, the team offer consistency within the pharmacy service for patients, nursing and medical staff. impact of pre-discharge planning has been beneficial to nurses, patients and work flow of the pharmacy teams. ward based dispensing has improved supply at discharge as well as promoting a more patient facing pharmacy service that has seen the pharmacy team instilled as integral to service delivery at ward level. kutay demirkan * , nursel surmelioglu, aygin bayraktar-ekincioglu clinical pharmacy, hacettepe university, ankara, turkey please specify your abstract type: research abstract background and objective: hacettepe university hospitals clinical pharmacy unit was established in april . this unit runs its services by clinical pharmacy postgraduate students under the supervision of two qualified clinical pharmacists as part-time and oncall basis, in adults, paediatrics and oncology hospitals. the aim of this study was to identify drug related problems and describe its management strategies in inpatient and outpatient settings by pharmacists in clinical pharmacy postgraduate education program. setting and method: during a total of months study period (period i: february-july , and period ii: november-february ), clinical pharmacy postgraduate students followed patients for - times in a week in different services in hospitals (internal medicine, internal medicine intensive care, infectious diseases, neurology intensive care, paediatric bone marrow transplant/haematology unit, paediatric intensive care, geriatrics and nutrition units) and drug related problems were identified and pharmacists' recommendations were listed. main outcome measures: determination and evaluation of drug related problems by pharmacist in hospital. results: a total of recommendations was provided for patients. those recommendations were classified as alteration or discontinuation of drug treatment ( . %), dose adjustment ( . %), change in drug administration time ( . %), inadequate treatment ( . %), healthcare staff training/consulting ( . %), patient education ( . %) and error/deficit in therapeutic drug monitoring ( . %). a majority of recommendations (n = ) were related with alteration or discontinuation of drug treatment provided mainly in departments of internal medicine (n = , geriatrics (n = ), neurology intensive care (n = ) and infectious diseases service (n = ). the following main reason for pharmacist's recommendation was related with dose adjustment (n = ) which were provided in departments of internal intensive care (n = ), infectious diseases service (n = ), neurology (n = ) and internal medicine (n = ). conclusion: clinical pharmacy practices are being carried out effectively in many services, particularly in internal medicine services, internal medicine intensive care unit and infectious diseases services. a collaborative and bed-side education in postgraduate programs in clinical pharmacy help to increase the knowledge and skills of students in real life circumstances and also maintain safe and effective drug therapy by an involvement of clinical pharmacists in hospital services. hp-pc : development of a tool to help pharmaceutical analysis in patients with hepatic failure barbara troussier *, , eric gautier , astrid bacle , florian charier , christine silvain , pauline lazaro pharmacy, gastroenterology, hepatology and gastroenterology, university hospital of poitiers, france, poitiers, france please specify your abstract type: descriptive abstract (for projects) background and objective: hepatic impairment can cause significant changes in the pharmacokinetics of many medicines. however hospital pharmacists can be helpless in performing pharmaceutical analysis behind the lack of precise guidelines. we need a strategy to first detect accurately patients with hepatic impairment, then lead us in dose adjustments. the objectives of this project were to develop a helping tool for hospital pharmacists in the pharmaceutical analysis of patients with hepatic failure's prescription and to select relevant pharmacist interventions. design: we first planned an investigation of patients with hepatic failure's management, with multidisciplinary experts groups. the study was conducted during one week in post-surgical, gastro-enterology, endocrinology, cardiology, pulmonology, geriatric departments and reanimation care units. a flowchart based on hepatic's biomarkers helped us including patients. criteria used to assess hepatic impairment could be: a stage c child-pugh score, prothrombin score inferior to %, bilirubin superior to micrograms per millilitres of blood without haemolysis, aspartate and alanin aminotransferases superior to three times the high normal value, and presence of a vitamin k antagonist interfering with those results. after a review of each included patient's prescription, we checked the major pharmacokinetic elimination pathway of each prescribed molecule (biliary or renal) and if hepatic biotransformation was expected. we also checked if the molecule could cause hepatic side effects. results: out of patients, patients were included for liver failure ( . %) and for a cholestasis ( . %) mainly in reanimation care units ( . %) and gastro-enterology ( %). among the lines of prescribed medicines, the main pharmacological classes encountered were cardiology, ( %) pain ( %), psychiatry ( %), haemostasis ( %) and antibiotics ( %). at the end of the investigation, the expert group decided on the relevant pharmacist interventions. these were based on dose adjustment of anti-infectious, psychotropic drugs, painkillers, oral anti-diabetics, anti-coagulants and corticosteroids. alternatives are proposed for each class. conclusion: to conduct a better pharmaceutical analysis, steps are necessary. first, any liver failure or cirrhosis must be detected thanks to the patient's biological results and medical record. then the patient's prescription can be analysed in order to highlight drugs that need a dose adjustment in a context of hepatic impairment. finally, the physicist and the pharmacist discuss about dose adjustments or alternatives if presence of contraindication with the drugs prescribed. soon the designed tool will be available to all pharmacists to harmonize clinical pharmacy practices. please specify your abstract type: research abstract background and objective: data regarding adherence rates to oral chemotherapy in lymphoma patients is limited. the aim was to assess pharmacist intervention on adherence to oral chemotherapy in patients suffering from hodgkin's (hl) and non-hodgkin's lymphoma (nhl). setting and method: following ethics approval, hl and nhl patients attending chemotherapy sessions at the medical investigations and treatment (mitu) at mater dei hospital accepted to participate. a questionnaire was compiled to evaluate adherence to oral chemotherapy and to assess pharmacist intervention. the questionnaire was divided into sections (a-c). the same questionnaire was used for both the first interview (t = ) and after weeks (t = ). an additional section (d) was incorporated at t = to evaluate pharmacist intervention. section a consisted of questions regarding patient management of lymphoma. section b incorporated the morisky -item medication adherence scale (mmas- ) to evaluate adherence to oral chemotherapy. a total mmas- score of zero indicates high adherence, a score between and indicates medium adherence and a score between and indicates low adherence. section c consisted of additional questions regarding medication adherence. between t = and t = , pharmacist intervention involved providing each patient with an information leaflet which was developed in this study, an individualised treatment chart and verbal advice. ibm Ò spss version and the wilcoxon signed-rank test were used to assess changes in medication adherence between t = and t = . main outcome measures: evaluation of pharmacist intervention on adherence to oral chemotherapy in patients suffering from hl and nhl. results: out of the patients with hl at t = , 'never' missed a dose, missed a dose 'once in a while' and 'sometimes' missed a dose. for the patients with nhl at t = , 'never' missed a dose, missed a dose 'once in a while' and 'sometimes' missed a dose. the reason for missing a dose was forgetfulness. all nhl and hl patients indicated the haematologist as their source of information about the management of lymphoma. of the nhl patients, scored low adherence and scored medium adherence at t = and after weeks (t = ) all nhl patients who participated scored medium adherence. of the hl patients, scored low adherence and scored medium adherence in the first interview (t = ) and after weeks (t = ) all hl patients who participated scored medium adherence. there was a statistically significant increase (p \ . ) in the number of patients who scored medium medication adherence between t = and t = for both nhl and hl patients. conclusion: this study shows how pharmacist intervention and extended professional services could be implemented in the clinical setting to impact on the management of hl and nhl patients. please specify your abstract type: descriptive abstract (for projects) background and objective: in may , an activity of medication reconciliation was implemented in the gastroenterology service to carry on the optimization of the medication care of patients due to the recent computerization of their prescriptions. design: this project, worked in collaboration with the gastroenterology service has been introduced in two medical committees. this activity gathers pharmacy students, the pharmacist, senior and junior doctors. reconciled patients are selected according to several criteria (advanced age, poly pathological, poly-medicated and those for whom a drug background is difficult to retrieve for the medical team). a minimum of information sources is used for the collection of the drug background. all information are synthetized on a paper, validated by the pharmacist and discussed again with the prescriber. results: on a -month period, patients were reconciled with on average age of . the reconciliation is executed on average . days after the entry in the service. . % of reconciliations are retroactive. the main sources of information used for the collection of the drug background are: in . % of the cases an oral interview with the patient and/or the family; in % of the cases the prescriptions, the hometown pharmacist ( . %) and a medical letter ( . %). . drugs are on average on the hospital prescription, and . % ( / ) of the patients are concerned with at least one non intentional divergence (nid). on average there are . nid/patient and . intentional divergences (id)/patient. the main types of nid are omissions ( . %), drug dose errors ( . %) and errors in administration frequency ( . %). after the detection of nid, the proposed modifications to the prescribers are accepted in more than % of the cases ( / ). the average time of a reconciliation is min. exchanges on the id and nid are made with the junior doctors in . % of the cases. conclusion: some nid are occurring for . % of the reconciled patients. it is therefore necessary to extend this new activity to reconciliation in other services in order to increase the interception of eventual medication mistakes and allow their correction. please specify your abstract type: research abstract background and objective: diuretic therapy is routinely used in the management of congestive heart failure (chf).,compliance with clinical practice guidelines is reported to result in improved outcomes for patients with chf such as reduced exacerbations. the aim was to assess the effect of pharmacist intervention on adherence to diuretic treatment in a hospital and community pharmacy scenario. setting and method: the study was undertaken at karin grech hospital (kgh), a geriatric and rehabilitation hospital, and in one community pharmacy. inclusion criteria for patients recruited from kgh were age over years, suffering from chf and on bumetanide therapy. the validated -item morisky medication adherence scale (mmas- ) was administered to patients on admission (t = ), repeated after two weeks hospital stay (t = ) and again one-month post-discharge (t = ). a total mmas- score of zero indicates high adherence, a score between and indicates medium adherence and a score between and indicates low adherence. in the community setting patients on diuretic therapy were chosen by convenience sampling. the same adherence scale was administered prior to pharmacist intervention (t = ) and one-month after pharmacist intervention (t = ). pharmacist intervention in the community setting involved dissemination of an informative leaflet regarding chf and diuretic therapy developed for the purpose of this study. main outcome measures: impact of pharmacist intervention on adherence to diuretic therapy in chf patients. results: a total of patients were recruited from the hospital setting, of whom were female and were male with a mean age of years (range - years). on admission (t = ), patients scored high adherence, scored medium adherence and scored low adherence to bumetanide therapy. following weeks at the hospital (t = ), the number of patients scoring high adherence increased from to and the number of patients scoring low adherence decreased from to . one-month post-discharge (t = ), patients scoring high adherence decreased from to and patients scoring low adherence increased from to (p \ . ). a total of patients were recruited from the community pharmacy, of whom were female and were male, with a mean age of years (range - years). after pharmacist intervention (t = ), the number of patients scoring high adherence increased from to , while the patients scoring low adherence decreased from to (p [ . ). conclusion: pharmacist intervention in the hospital setting improved adherence to bumetanide therapy. in the community pharmacy setting, there was a slight improvement in the compliance. pharmacist monitoring and patient support is important post-discharge to ensure patient compliance to therapy. conclusion: surveillance of aeds may be followed by combination of data from adverse drug reaction databases and drug utilisation data from prescription databases. focus on reporting adverse reactions is important for pharmacists and clinicians, especially for newly approved drugs. awareness of increased exposure of aeds to new groups of patients followed by data regarding safety aspects is important and contributes to improved pharmacovigilance. please specify your abstract type: research abstract background and objective: the medication review of polymedicated patients is a priority shared among all healthcare professionals. a multidisciplinary approach of these patients is necessary to achieve the best results for their treatment ( ) . the objective was to analyse the rate of acceptance of the recommendations made by the primary care pharmacist (pcp) to the general practitioner (gp) regarding the treatment of polymedicated patients. setting and method: setting: a primary health care centre ( , population). method: a review of the medical records of polymedicated patients (c chronic drugs for c months). the patients' data were collected from january to june from their clinical records. statistical descriptive analysis of data was performed. main outcome measures: drug related problems (drp) for each patient: interactions, contraindications, inadequate dosages, nonindicated drugs, omission of a necessary drug, duplications, medication with low therapeutic effect, and inappropriate medication for patients c years old. treatment alternatives proposed to gp's by pcp were also measured. results: patients were included in the study (average age: . ± . , % women). out of the patients, interventions were laid out to reduce the risks of drp's and to improve the efficiency of treatments. % of patients presented some drp or some intervention to improve the efficiency of their treatment, this mean an average . interventions for patient. the prevalence of intervention proposals were: non-indicated drugs ( %), interventions for improve the efficiency of treatments ( %), interactions ( %), inappropriate medication for patients c years old ( %), contraindicated drugs ( %), duplications ( %), medication with low therapeutic effect ( %), inadequate dosages ( %) and omission of a necessary drug ( %). % of these intervention proposals were accepted by the gp: % of the accepted proposals were carried out and from the remaining , . % led to a prescription from a specialist physician. in % of the cases, the patient did not accept the changes. . % were not carried out due to other issues. the main drug related problem was the prescription of non-indicated drugs and the most involved drug was omeprazole. conclusion: acceptance by gp's to changes proposed by primary care pharmacists was high. a significant number of changes was not accomplished due to the negative response by some patients and led prescriptions from a specialist physician. the gp greatly values the multidisciplinary aid in approaching the complexity of polymedicated patients. background and objective: case-reports provided evidence that influenza infections, particularly severe episodes, may exert neuronal damage in the cns and thereby increase the risk of depression. it was the aim of this study to analyse the association between influenza infections and the risk of developing incident depression. setting and method: we conducted a case-control analysis using the large uk-based primary care database clinical practice research datalink (cprd). this database contains anonymous longitudinal data from primary care. at present, it contains over million person-years of data from some million active patients. the study encompassed , patients below the age of years with an incident major depression diagnosis between and , and we matched each case to one control patient on age, sex, general practice, number of medical encounters, and years of history in the cprd prior to the index date. main outcome measures: major depression diagnosis was identified by read-codes based on icd- codes (f ), with a minimum of three prescriptions for antidepressant drugs recorded after the diagnosis. we calculated relative risk estimates of developing depression in association with previous influenza infections, stratified by the number, timing and severity of such events, and we adjusted for a variety of comorbidities, smoking status, alcohol intake, body mass index, use of oral corticosteroids, and benzodiazepines. results: patients with a previous influenza infection had an increased risk of developing depression (or . , % ci . - . ) compared to patients with no history of influenza infections. a recent influenza infection recorded within - days prior to the index date yielded an adjusted or of . ( % ci . - . ), and an increasing number of previous influenza infections was associated with increasing odds ratios (c recorded influenza infections, adjusted or . , % ci . - . ). we did not see any differences in the relative depression risk associated with influenza with regard to a previous influenza vaccination. conclusion: this study suggests that influenza infections are associated with a moderately increased risk of developing depression. please specify your abstract type: research abstract background and objective: warfarin is known for its interactions with many drugs. elderly patients are particularly sensitive to warfarin interactions. to evaluate the incidence of potential drug interactions when prescribing new drugs to elderly patients on warfarin, a prospective observational study was conducted. setting and method: patients on warfarin older than years were included and monitored for months in community pharmacies in croatia. data regarding new prescribed drugs was obtained from pharmacy records at the moment of dispensing or by patient selfreporting. the potential interacting drugs were identified using the lexicomp Ò lexi-interact online software. only the clinically significant (levels c, d, x of clinical significance as classified by lexicomp Ò lexi-interact online) interactions were included in this analysis. main outcome measures: number of new proscribed drugs, level of interaction with warfarin, mechanism of interactions. results: we included elderly patients with an average age of years. in the follow-up period, new drugs were prescribed to patients ( . %). there were prescriptions of new drugs and ( . %) of those were drugs with a clinically significant interaction with warfarin. there were prescriptions of drugs with level c of interaction ( . %), and ( . %) with level d. there were no drug interactions of level x. in the group with level c the most prescribed drugs were antibiotics with prescriptions: amoxicillin/clavulanate %, clindamycin %, ciprofloxacin %, norfloxacin %, azithromycin %, cefuroxime %, clarithromycin %, doxycycline %. the remaining prescriptions included tramadol with paracetamol %, rosuvastatin %, simvastatin %, fluvastatin %, levothyroxine % and torasemide %. the dominant mechanism of the potential interactions was pharmacokinetic. in the group with level d the most prescribed drugs were nonsteroidal anti-inflammatory drugs with prescriptions-diclofenac %, ibuprofen %, indomethacin %. among other drugs, prescriptions were antibiotic sulfamethoxazole with trimethoprim %, fenofibrate %, miconazole %, and fluconazole %. the dominant mechanism of the potential interactions was pharmacodynamic. conclusion: pharmacists should actively monitor prescribing of new drugs to elderly patients on warfarin in order to reduce the risk of clinically significant drug interactions. please specify your abstract type: research abstract background and objective: explicit criteria of potentially inappropriate medications in the elderly (pims) have been published in the usa, canada, australia and many eu countries. there is a lack of studies describing prevalence of pim use in central and eastern europe. the aim of the eu cost action initiative wg b ( wg b ( - is to evaluate the registration rates and use of pims in central and eastern europe compared to other eu countries participating in this initiative. this abstract describes preliminary findings on different registration rates of pims in different eu countries. setting and method: researchers/members of the eu cost action initiative from the czech republic, serbia, hungary, spain, turkey and portugal were asked to fill in evaluation tables for the list of pims in the period - / . items available in these evaluation tables related to: registration of individual pims on the pharmaceutical market, registered doses, drug forms, availability of pims on prescription or as otc drugs, prescription limits and the most frequently used brand names. data were evaluated using comparative descriptive statistics. main outcome measures: overall prevalence of registered pims in different countries, cross-country differences in availability of individual pims. results: of pims . % were registered in at least participating country. for the czech republic ( . %), turkey ( . %), spain ( . %) and hungary ( . %) overall prevalence rates of registered pims were found to be similar. however, these prevalence rates substantially differed in serbia (low prevalence- . %) and portugal (high prevalence- . %). substantial differences were found also in the lists of individual pims registered in different countries. these lists were similar in spain and portugal compared to the czech republic, hungary, serbia and to turkey. conclusion: although overall prevalence rates of registered pims were similar in the majority of evaluated countries (except serbia and portugal), availability of individual pims was substantially different. our pilot results confirmed that there are substantial geographical/ regional differences in europe in the lists of pims available (in spain and portugal compared to central and eastern europe and compared to turkey). please specify your abstract type: research abstract background and objective: inappropriate prescribing is a common circumstance found in polymedicated patients. screening tools for identifying potentially inappropriate prescription (pip) and pharmacist interventions for evaluating them have been developed to decrease this ( ) . the aim of this study was to evaluate the effectiveness of a pharmacist provided intervention to reduce pips in polymedicated patients. setting and method: the design was a quasi-experimental study focusing on a single group before and after intervention. the study took place from july to december of at three primary care centres ( , population). polymedicated patients were those using c chronic drugs for c months. main outcome measures: reduction in the rate of pip per polymedicated patient (number of pips found divided by the total number of polymedicated patients) before and after intervention, and the influence of the following variables: type of pip (inappropriate medication for patients c years old, medication with low therapeutic effect, duplication of benzodiazepines (bzd) or angiotensinconverting enzyme (ace) inhibitors, combination of anticoagulant and antiplatelet, combination of non-steroidal anti-inflammatory drug (nsaid) with a diuretic and ace inhibitor, nsaid in cardiovascular disease, chronic antipsychotic in dementia, chronic bzd, or chronic nsaid), gender and age of patients with at least one pip, and the main prescribed drugs involved in the pips based on atc classification system of world health organization. results: there were and polymedicated patients before and after intervention, respectively. . % (n = , before) and . % (n = , after) of the total patients had at least one pip. the number of pips was reduced from to , while the rate of pip per polymedicated patient decreased from . to . , achieving the limit established by the regional health authority. . % (before) and . % (after) of patients had more than one pip at the same time, up to pips per patient. before and after intervention, more than half of patients with at least one pip were c years old, and approximately out of were c years old. also before and after intervention, out of patients with chronic nsaid and with bzd duplication were women. out of patients with combination of anticoagulant and antiplatelet were men. the main pips before and after intervention were, respectively: chronic prescription of bzd ( . vs. . % of the total pip), medications with low therapeutic effect ( . vs. . %) and inappropriate medication for patients c years old ( . vs. . %). the main atc group involved in the total of pips was drugs for the nervous system, and the five most prescribed drugs were all bzd (lorazepam being the first). conclusion: pharmacist provided intervention was able to reduce pip in polymedicated patients. gender, age and atc classification of drugs involved were factors in the pips. please specify your abstract type: research abstract background and objective: up to % of women are exposed to selective serotonin reuptake inhibitors (ssris) during pregnancy. information on their effect on birthweight and gestational age remains conflicting. the aim of this sibling-controlled prospective cohort study is to address shared genetic and family-level confounding to investigate the effects of prenatal ssri exposure and maternal depression on birthweight and gestational age. setting and method: we used the norwegian mother and child cohort study (moba) and the medical birth registry of norway (mbrn). our study population consisted of siblings; were prenatally exposed to ssris and were unexposed to any antidepressant medication. random and fixed effects analysis with propensity score adjustment was used to evaluate the effects on birthweight and gestational age. main outcome measures: birth weight. gestational age. results: ssri exposure during two or more trimesters was associated with a decrease in birthweight of g [ % confidence interval (ci) to ] and a decrease in gestational length of . days ( % ci . to . ). neither maternal ssri use in one trimester, lifetime history of major depression nor depressive symptoms during pregnancy were associated with these pregnancy outcomes. conclusion: prenatal exposure to ssris during two or more trimesters may decrease birthweight and gestational length. our results indicate that neither maternal depression nor shared genetics and family environment fully explain this association. please specify your abstract type: research abstract background and objective: the drugs burden index (dbi) is a tool to evaluate the burden of medications with anticholinergic and sedative effects and this exposure has been associated with poorer physical and cognitive function in older people. objectives were; to determine the cumulative burden of anticholinergic and sedative medicines in older adults with intellectual disability (id) using the dbi, to examine the relationship between dbi score with demographics and comorbidity. setting and method: data from wave of the intellectual disability supplement to the irish longitudinal study on ageing (ids-tilda), a nationally representative study of ageing people with id in ireland. dbi scores were calculated for all participants with available medication data (n = ). bivariate associations between dbi and demographic and clinical characteristics were examined with a significance level of . main outcome measures: dbi scores of participants categorised into low ( ), medium ( - ) and high (c ). dbi score categories were related to demographics, cognitive effects and to a modified functional comorbidity index (fci), which is associated with physical function in older adults. results: of participants, . % ( ) had dbi exposure; . % were exposed to any anticholinergic medication, . % to any sedative medication; mean number of dbi medications . (± . ), mean dbi score: . (± . ). ( . %) participants had dbi score , ( . %) - , and ( . %) c . antiepileptics accounted for the greatest contribution to cumulative score ( . %), antipsychotics ( %) and antidepressants ( %). there was no significant association between higher dbi score and sleep difficulties (p = . ). there was a significant age gradient associated with higher dbi score (p = . ) and significant association between higher scores and increased comorbidity scores; mean fci of . in those with dbi c , . in dbi - and . in those with dbi . conclusion: cumulative exposure to sedative and anticholinergic medicines was high in older adults with id. higher dbi scores were associated with higher comorbidity and associated poorer physical function. optimising use of medications with anticholinergic and sedative effects through medicines review by pharmacists as part of multidisciplinary teams using a tool such as the drug burden index may reduce functional decline and improve quality of life among older adults with id. please specify your abstract type: research abstract background and objective: poor adherence to pharmacotherapy may have considerable consequences for the patients' health and for healthcare costs to society. there was observed that diabetes patients have higher risk of later health complications development. it is necessary to be adherent to non-and pharmacological recommendations as well, to improve the clinical outcomes and decrease the cardiovascular risk (cvr). the aim of this study was to evaluate the medication adherence and cvr in group of patients with diabetes, and to find an association between them. setting and method: the methods were based on a questionnaire survey using a modified -item morisky score and score charts ( ). medication adherence and cvr were evaluated in the whole group (n = , males and females, range - years) as well as in subgroups according to age, gender, (no-/ex-) smoking, level of education, residence, number of used medicines, exercises, compliance to the diabetic diet, and total cholesterol levels. the survey was realized in three ambulatory diabetic centres in slovakia. the study has been approved by ethics committee of university hospital bratislava -ruzinov. all participants signed an informed consent. main outcome measures: the results of medication adherence were evaluated as follows: points = full adherence, - points = partial adherence and - = non-adherence. the cvr (estimating -year cardiovascular attack risk) was evaluated according to score charts using data from questionnaire and medical records-gender, age, smoking, total cholesterol levels and blood pressure. the results showed a partial medication adherence in the study group in average ( . ± . ). the average value of cvr in the study group was . %. the highest average medication adherence has been observed in males b years ( . ), with elementary education ( . ), in ex-smokers ( . ), in patients with regular physical activity-at least times a week ( . ), in patients non-adherent to the diabetic diet ( . ), in patients using medications ( . ), and in patients with satisfactory ( . - . mmol/l) total cholesterol levels ( . ). the lowest cvr has been observed in females b years ( . %), in no-smokers ( . %), with elementary education ( . %), in patients with irregular physical activity ( . %), in patients adherent to the diabetic diet ( . ) , in patients using medications ( . %) and in patients with satisfactory ( . - . mmol/l) total cholesterol levels ( . ) . on the other hand, the highest cvr has been observed in males [ years ( . %), smokers ( . %), secondary educated patients ( . %), without any physical activity ( . %), in patients partially adherent to diabetic diet ( . %), using medications ( . %) and, surprisingly, in patients with satisfactory (\ . mmol/l) total cholesterol levels ( . %). conclusion: our survey has showed that medication adherence in our study group has been decreased and cvr has been increased. cvr and adherence to pharmacotherapy in the study group did not correlate with each other. the medication adherence, cvr and their relationships are specific in every patient. please specify your abstract type: research abstract background and objective: studies show that quality of life (qol) of patients with diabetes mellitus can influence medication adherence, satisfactorily improving clinical outcomes and reducing the morbidity and mortality rates and disease progression. this applies even upside down-medication adherence could significant contribute to improving patient qol. the aim of this study was to evaluate the medication adherence in group of patients with diabetes, to evaluate their qol and find a correlation between them. setting and method: the methodology was based on a questionnaire survey using a modified -item morisky score and questionnaire eq- d- l, including visual analogue scale (vas). medication adherence and qol were evaluated in the whole group (n = ) as well as in subgroups according to age, gender, level of education, monthly income, number of used medicines and type antidiabetic treatment. the survey was realized in three ambulatory diabetic centres in slovakia. the study has been approved by ethics committee of university hospital bratislava-ruzinov. main outcome measures: the results of medication adherence were evaluated as follows: points = full adherence, - points = partial adherence and - = non-adherence. the qol in levels of dimensions results were evaluated as follows: the lowest qol in every dimension = point, the highest = points. the highest vas evaluation has been points and every patient should mark number on the scale - to indicate his/her health on current day. results: the results showed a partial medication adherence in the whole group in average ( . ± . ). the average value of the qol in the study group was . and vas . . the highest medication adherence has been observed in males ( . ± . ), patients \ years old ( . ± . ), with primary education ( . ± . ), with monthly income over € ( . ± . ) and in patients using medications ( . ± . ). the highest qol and vas (qol; vas) has been observed in males ( . ; . ), patients \ years old ( . ; . ), university educated ( . ; . ) , with monthly income over € ( . ; . ) . qol has been highest in patients using medications ( . ), vas has been highest in patients using medication ( . ). we have observed the highest level of medication adherence in patients treated with combined therapy-with oral antidiabetic agents and insulin ( . ), the lowest in patients treated with only insulin therapy ( . ). highest qol was recorded in patients treated with oral antidiabetic agents ( . ), and the lowest qol in patients with insulin therapy ( . ). the highest vas has been observed in patients using only oral antidiabetic agents ( . ), the lowest in patients using combined therapy ( . ). conclusion: survey has showed that medication adherence and qol in our study group has been decreased. qol and adherence to pharmacotherapy in the study group did not correlate with each other. the medication adherence, qol and their relationships are specific in every patient. the role of health care professionals should be in education and counselling with patients to improve qol and medication adherence as well. please specify your abstract type: research abstract background and objective: to assess the appropriateness of antibiotic prescriptions used for urinary tract infections (uti) in the elderly. setting and method: we included patients aged years and older, hospitalized in the geriatric department and for whom a urine culture was performed between march and may . a prescription was qualified as inappropriate: when the antibiotic prescribed was not the narrowest compared to the culture result, or when there was a contra-indication, or when the treatment duration was shorter or longer than recommended. prescriptions were consistent with the guidelines when they were identical to those adopted by the french society for infectious diseases in december . main outcome measures: appropriateness of antibiotic prescription (type and duration) results: elderly patients were included (women: . % (n = ), mean age: . years). % of antibiotic choices were appropriate and % of treatment durations were consistent to the guidelines. urinary clinical signs were mentioned in the medical files for . % of the cases (n = ). patients received an empirical antibiotherapy ( . %). . % (n = ) of urine cultures were positive with bacteria, escherichia coli being the most prevalent (n = ). the urine culture results led to a change in antibiotics for . % of the cases. for cystitis, . % of the antibiotics chosen were appropriate (n = ). the main reasons of non-conformity were the lack of deescalation (to amoxicillin or pivmecillinam), and the prescription of ciprofloxacin when the bacteria was in vitro resistant to other fluoroquinolones. the average duration of effective antibiotherapy for cystitis was . days (appropriateness: . % (n = )). for pyelonephritis, . % of the antibiotics chosen were appropriate (n = ). the average duration of effective antibiotic treatment was . days (appropriateness: . % (n = )). . % of the patients had a transurethral catheterization (n = ). another infection was diagnosed for . % of the patients (n = ). conclusion: according to these results, it appears important to reemphasize to the prescribers the guidelines around the uti diagnosis and treatment in order to improve the prescriptions appropriateness in elderly patients. it is particularly necessary to promote the de-escalation of antibiotherapy (with pivmecillinam for example which has recently become available in our hospital) and to insist about the recommended durations of treatment. please specify your abstract type: research abstract background and objective: to measure the use of potentially inappropriate medications (pim) in the general elderly population several criteria lists exist, e.g., beers criteria. last year, a set of explicit criteria for assessing pharmacologically inappropriate medication use in nursing homes was developed; the norwegian general practice-nursing home criteria (norgep-nh). the aim of this study was to investigate the prevalence of pims in nursing home patients using this new assessment tool. furthermore, we studied possible associations between the use of pims and factors like gender, age, geographical area and the number of drugs used. setting and method: cross-sectional study comprising nursing home patients from two geographical different regions in norway; tromsø city (n = ) and lofoten islands (n = ). data was collected from november to january . pims were identified by norgep-nh. we used logistic and poisson regression to examine possible associations between the use of pims and factors like gender, age, geographical area and the number of drugs used. main outcome measures: number of pims per patient, and odds ratios (or) and marginal effects for associations. results: nursing home patient used a mean (sd) of . ( . ) drugs; . ( . ) regularly and . ( . ) as needed. at least % of patients used one pim. concomitant use of three or more psychotropic drugs was the criterion most commonly identified ( %), followed by the use of antidepressant ( %) and hypnotics ( %). an increasing number of regularly used drugs increased the odds of having pims (or: . ), as well as it lead to . more pims per extra drug used. on average, patients c years had . fewer pims than patients \ years. no statistical significant associations were seen between having pims and gender, nor geographical area and the use of as-needed medication. yet, statistical significant differences were identified in some criteria. conclusion: this is the first study that explicit uses norgep-nh. our results confirm that nursing home patients often use potentially inappropriate medications. this is an area where further work is necessary, not to measure the prevalence of pim, but to develop interventions in order to prevent pims from being used. pe : use of pharmacy dispensing data to measure adherence and identify nonadherence with oral hypoglycaemic agents please specify your abstract type: research abstract background and objective: a framework for calculation of adherence for oral hypoglycaemic agents (ohas) based on data from health-insurance claims is available. pharmacy dispensing data aid identification of nonadherent patients in pharmacy practices. however, use of these data for calculation of oha adherence requires additional methodological categories. we examined the impact of different methodological choices on estimation of oha adherence using pharmacy dispensing data. setting and method: a framework for adherence calculation for pharmacy dispensing data was developed from health-insurance claims. a basic scenario was developed from methodological categories. consequences of choices for different parameters within these categories on the scores of the three adherence measures were calculated from dispensing data. main outcome measures: for oha use between july and july , three adherence measures were calculated: ( ) average medication availability (ama); ( ) mean rate of adherent patients with an ama c % (mrap ); ( ) please specify your abstract type: research abstract background and objective: ulcerative colitis (uc) is a chronic inflammatory disease usually affecting young adults and impacting on patient's quality of life. although many biological agents (bas) have been approved for the treatment of moderate-to-severe uc in patients who have responded inadequately to conventional therapy, the selection of bas is controversial due to the lack of head-to-head trials. indirect economic comparisons of these costly drugs are available from national healthcare perspectives that are not the italian ones. therefore, the objective is to evaluate cost-utility of bas for the treatment of refractory moderate-to-severe uc both in italy and in the lombardy region. setting and method: a markov model (considering transition states: remission, clinical response, relapse) was constructed using the software r . . markovchain-package to evaluate incremental cost-utility ratios (icur) of adalimumab, infliximab, infliximab biosimilar, golimumab and vedolizumab treatments of patients over a ten-year time horizon from the perspective of the italian (n) and lombardy region (r) healthcare system. clinical parameters were derived from clinical trials. costs (which have been actualised- . %) were obtained from the national database and regional public tender. utility was expressed as qaly (quality adjusted life years). main outcome measures: icur. results: costs per treatment were different from a n and r perspective (adalimumab - %; infliximab - . %; infliximab biosimilar - . %; golimumab - . %; vedolizumab - %). direct healthcare costs (treatment cost, visits, lab tests, hospital admissions) were calculated over years of treatment per patient: adalimumab (n: € , . , r: € , . , - . %), infliximab (n: € , . , r: € , . , - %), infliximab biosimilar (n: € , . , r: € , . , - . %), golimumab (n: € , . , r: € , . , - . %), vedolizumab (n: € , . , r: € , . , - . %) with associated qaly respectively of . , . , . , . , . . from a n perspective, infliximab biosimilar was dominating compared to all other treatments. the icur of vedolizumab/infliximab biosimilar was € . for years (willingness to pay (wtp) € . /qaly). from a r perspective, adalimumab was dominating compared to all other treatments. the icur of vedolizumab/adalimumab was € , . for years (wtp € , . /qaly). conclusion: national and regional cua produced different results. as regional price discounts can occur, local analyses are needed to estimate the economic impact of therapies to ensure optimal choice. please specify your abstract type: research abstract background and objective: automated dispensing systems (ads) have been implemented to reduce overall medication errors related to picking, preparation and administration of drugs. costs of drug storage between ads and classic dispensing system (cds) had not been yet performed in france. our objective was to assess economic impact of ads compared to cds. setting and method: retrospective quasi experimental study was conducted in university hospitals in , one with ads ( beds, ads) and one with cds ( beds, cds ( ) for ads and ( ) for cds (p \ . ). mean number of costly drug per system was for ads and for cds. the global stock value in the wards was , € in ads and , € in cds representing respectively . and . % of total pharmacy stock value. conclusion: our data demonstrate that despite the same storage capacity, ads allow the storage of more expensive drugs such as innovative drugs fully reimbursed up to national reimbursement prices, due to the lower risk of pilferage. this preliminary study was focused mainly on stock value. subsequently, another study is conducted to evaluate cost of these two drug storage systems, satisfaction of pharmaceutical technicians and nurses and time allowed for systems reloading. please specify your abstract type: descriptive abstract (for projects) background and objective: in france, pharmacists are not entitled to substitute an original biological drug with its biosimilar, due to specific issues of efficiency, safety, and patient monitoring. our hospital referenced a biosimilar of infliximab on january . according to the french medication safety national agency's recommendations, it has been decided that naïve patients would be treated with biosimilars, and changes between specialties would be proscribed. the objective is to compare prescribing practices between infliximab and its biosimilar, year after its introduction. design: a database tracking patients treated with infliximab was set up. data comparing prescribing practices of biosimilar and reference treatment were analysed between june and may . regional and national infliximab consumption between january and february were used to compare the practices of our hospital with other hospitals. the past and future savings were estimated from repayments data of the regional health agency. results: infliximab was administered to patients, of which ( %) were naive. patients were treated with biosimilar (i.e. . % of all patients), of which were naive. in the end, nearly % of naive patients actually received the biosimilar and . % of patients treated with infliximab switched specialties during treatment. in % of cases, biosimilar prescriptions were consistent with the recommendations (vs. % for infliximab). in % of cases the off-label prescriptions of the biosimilar were explained in the patient record (vs. % for infliximab). in february , the share of biosimilars was % in france, % at regional level and % locally. in year, infliximab and its biosimilar's consumption in our hospital have increased by % in quantity and only % in expenditure (+€ m expenditure). negotiating a lower purchase price and costs has enabled the hospital to save € , (vs. € , during the previous year). because of the decline of refund rates, the gains would have been zero without using the biosimilar but € , if it had been prescribed to every naive patient. conclusion: current data from the literature on security and effectiveness of infliximab biosimilars are very reassuring and the french medication safety national agency doesn't exclude the possibility of changing specialties during treatment. in our hospital, there is room to improve the efficiency of treatment with infliximab. feedback on prescribing practices will be given to prescribers and a campaign to widespread prescriptions of biosimilars will be made. the arrival of biosimilars on the market is a real economic opportunity for hospitals, which are increasingly financially constrained in particular by the arrival of therapeutic innovations which are more and more expensive. setting and method: the study used health claims data on prescription ppis from st january to st july obtained from the health insurance institute of slovenia. to assess medicine use and costs before and after trp implementation data were aggregated into four periods: jan-dec , pre-baseline period; jan-dec , baseline period; jan-sept , transition period between announcement and introduction of trp; oct to jul , period after trp enforcement. main outcome measures: medicine costs; defined daily doses (ddds) dispensed per inhabitants per day; market share; herfindahl-hirschaman index (hhi); number of active substance switches; number of exceptions when medicine is fully reimbursed since physicians may choose option ''not to switch medicine'' when adverse consequences are predicted. results: average monthly cost of ppis declined from € , , in pre-baseline period to € , in period after trp introduction although the consumption increased from . to . ddds/ inhabitants/day. cost of ppis decreased the most in baseline period ( %), however trp induced . % cost reduction compared to the transition period. the reference pantoprazole was market leader already in the transition period, but its use increased significantly after trp introduction and represented % of total ppis consumption. manufacturers' market shares were constant before trp, whereas trp caused decrease of the largest market share for %. still, this resulted in the minor market concentration change; hhi was on average . before and . after trp introduction. further, at least one active substance switch was detected in approx. and % of patients before and after trp introduction, respectively. similarly, the proportion of exceptions when medicine was fully reimbursed increased from . % in transition period to . % in period after trp introduction. conclusion: enforcement of trp for ppi contributed to approx. € m annual cost savings. from the payer's perspective the new policy was proven to be effective in reducing pharmaceutical expenditure; however trp also affected physician prescribing pattern and use of ppis. pec : blood coagulation factor: improvements of the supply chain samantha oses * , serri traore, sonia caroline sorli, lea damery, philippe cestac, sylvie pomies, julien tourel please specify your abstract type: descriptive abstract (for projects) background and objective: most of the antihemophilic factor (ahf) must be held by a teaching hospital to face serious bleeding events. to ensure better availability, offsite-stocks at critical points are required (emergency unit, intensive care unit, etc.). however, this management system increases the risk of economic loss and alteration of the quality due to expired products. in this context, we carried out an optimization of the supply and management system of the ahf. to identify critical points of the supply and management system and to implement improvement solutions. design: a multidisciplinary working group belonging to a regional management centre of haemophilia was set up. two lines of improvement were discussed: i) optimization of stocks ii) optimization of the supply system. results: the optimization of stocks has led to the modification of the threshold of the lowest stock (ls) for ahf out of . in % of cases, this stock modification has exceeded %. the overall cost of ls has been reduced by . % ( , €) for the general stock at the central hospital pharmacy (hp) and by . % for offsite-stocks ( , €). the ahf mainly involved in this reduction was fvii mg ( , €), then followed by the strengths of mg and mg ( , € for each). in order to improve the ahf management, several propositions have been implemented: ( ) developing an online, easily accessible and monthly updated spreadsheet that displayed several accurate data such as the shortest expiry date and the storage location. this operative tool is shared between all pharmacists involved in ahf management in order to facilitate a stock rotation and decrease economic losses, ( ) regular reminders to physicians and health care staff concerning the guidelines for inventory management and the importance of checking the drug expiry date, ( ) presentation of the financial results and raising awareness on ahf costs to the medical consultant[ppip ] and ( ) optimizing stock distribution based on consumption on the different hospital sites for better patient care management (pcm). conclusion: this optimization of stocks and improvement of the supply chain have led to a direct cost saving of , €. however, a more accurate assessment has to be performed to quantify the direct and indirect impact on pcm and cost saving. this work has been done in a context of a sharing operative network at a regional level. the aim of such project is to share, to optimize and to improve practices, knowledge, human and medical health resources at a widespread level to enhance the security and quality of health services and to promote cost and time saving. please specify your abstract type: descriptive abstract (for projects) background and objective: the overall pharmaceuticals consumption in hospitals is rising, which has led to an increasing expenditure, challenging health care professionals and threatening patients safety. clinical trials in hospitals have increased over the past few years and currently play an important role, giving access to new investigational medicinal products and also avoiding costs with standard treatments. the objective of this study is to evaluate the savings of centro hospitalar do porto, a central university hospital with beds and currently clinical trials, with patients included in clinical trials between january and may . design: retrospective observational study over months. all the clinical trials ongoing between january and may were analysed and the data was collected based on: pathology and doses established; number of treatments per patient and the medium prices of standard treatments that patients would be receiving if they were not in the clinical trial. results: there were clinical trials ongoing between january and may , but only were selected to be included in this study. the total number of patients included was . the clinical trials selected for this study were conducted in medical specialties: in dermatology, in immunology clinical unit, in hemato oncology, in gastroenterology, in ophtalmology and in neurology. during these months, with all ongoing clinical trials, centro hospitalar do porto was able to save, in medical products, more than million euros. conclusion: during the period of time established, of the clinical trials ongoing, were not selected due to: not including patients or not having an alternative treatment. hospitals and patients can benefit from clinical trials not only financially but also by preserving resources and medication. on centro hospitalar do porto, the pharmacists specialized in clinical trials, as members of the study team, are more and more required to perform specific tasks, their contribution has been increasing over the years and also have become more aware of all the advantages from participating in clinical trials. these savings can be used to provide a better assistance and contribute, in general, to a higher quality health care. please specify your abstract type: descriptive abstract (for projects) background and objective: several studies show a misuse of opioid maintenance treatment (omt) in detention. in fact, buprenorphine (bup) when it's misused, could present the same effects as heroine. in order to reduce misuses, the pharmacist decided to switch all the patients under bup to buprenorphine/naloxone (bup/nlx). bup/ nlx prevents patients from misusing by a withdrawal syndrome when it's issued by another route of administration than sublingual route. in france, bup/nlx is more expensive than bup which may explain why this therapeutic strategy is not often observed. the purpose of this study is to evaluate the extra cost after switching patients from bup to bup/nlx in order to decide if this choice could be maintained. design: to identify our population, we used the administration reports drugs written by nurses. please specify your abstract type: research abstract background and objective: haemophilia b is an x linked genetic disorder characterized by spontaneous or prolonged haemorrhages due to factor ix (fix) deficiency . within the next few years, new treatments are willing to hit the market. among them are recombinant extended half-life products that will reduce by half the number of injections and will potentially improve the patient quality of life. the aim of the study is to describe the development of haemophilia treatments market between and and to forecast the potential impact of these new therapies on the haemophilia market. setting and method: national and french hospitals of paris (aphp) consumption data of fix between and have been studied. new therapies in development or soon to be marketed have been identified. potential benefits and interest in the therapeutic care of these new products were discussed with haemophilia's medical experts. main outcome measures: quantity (ui) and value (euros) of fix aphp and national consumption. results: in , recombinant (rfix) and plasma-derived factors (pfix) were on the french market. the ap-hp's purchases of these factors represent almost million ui and million euros, which comprise % of national fix expenditures. in france and aphp, ambulatory care is a major part of the use of these treatments with nearly % of the fix purchases in . french rfix consumptions are higher than pfix consumptions ( % against %). in the ap-hp hospitals, rfix even account for % of consumptions against % for pfix. both national and ap-hp rfix purchases have steadily increased between and . the added competition arising from new treatments may lead to more competitive market procedures in hospitals and may reduce costs of haemophilia treatments. according to haemophilia doctor, long-acting (la) fix would offer obvious benefits like fewer infusions and presumably fewer bleeds. these treatments will mainly be used in a prophylactic wayin ambulatory care-than in a curative way (such as surgical use). conclusion: the therapeutic extent of these new treatments is still hard to define. the choice of treatment must remain consensual between physicians and patients. please specify your abstract type: descriptive abstract (for projects) background and objective: good practice about medicines imposes to health institutions a close monitoring of prescriptions, especially off-label prescriptions. patient care should take into account clinical profile, respect of guidelines and health expense control. we report here a case highlighting the significant role of the clinical pharmacist in care units to ensure medication good use in a castleman syndrome, a rare disease due to human herpesvirus (hhv- ) and associated with human immunodeficiency virus (hiv) infection. design: case report. results: our patient, a years old man (creatinine clearance rate (crcl): ml/min), was diagnosed with hiv infection in february (cd at ui/l), leading to introduce a therapy by emtricitabine-tenofovir, darunavir, and ritonavir. the evolution was hampered by repeated episodes of acute renal failure (arf; crcl: ml/min) and pancytopenia (hemoglobinemia at . g/dl, leucopoenia at . g/l, and thrombopenia at g/l). because of hhv blood pcr at copies/ml, transient crises with pancytopenia, arf, and hiv infection, a diagnostic of kaposi sarcoma herpesvirus (kics), an atypical castleman syndrome, was retained. given the lake of data in literature for this rare disease, a multidisciplinary team (medical specialists and clinical pharmacists) was gathered to choose an appropriate therapeutic strategy. treatment regimen consisted of: day , intravenous etoposide at mg; day , rituximab at mg/ m ; following one week later by rituximab day and oral etoposide at mg the day after. good communication between medical specialists and pharmacists enables the patient to get an optimal and personal treatment. relaying the information by clinical pharmacists in care units to pharmacists in charge of good practice facilitate the reimbursement. conclusion: clinical pharmacists in care unit help to optimize therapeutic strategies according to their experiences and scientific works. cooperation with physicians is improved, as well as prescriptions follow-up of off-label drugs, and health patients fully respected. quality and relevance of prescriptions are strengthened, with a better control of economic expenses. please specify your abstract type: research abstract background and objective: the maltese government launched the hpv vaccination scheme in and the national healthcare system (nhs) has since provided the cervarix Ò vaccine free of charge to girls aged . the aim of this study was to assess the cost of the administration of hpv vaccines in the healthcare system of malta. this study was based on the scheme provided by the nhs. the number of girls born per year was used to estimate the annual cost for vaccinating year old girls, based on the wholesale price and tender price respectively. the estimated yearly cost using the wholesale price was approximately € , while the average estimated cost based on the tender price was approximately € , . this signifies that cost savings based on the tender price compared to wholesale costs were of approximately € , . the cost for the cohort who completed the three dose schedule using the tender price on average was of € , per year. this result proved to be more than the anticipated cost. a reason for this could be that the number of girls aged increased possibly due to an influx of immigrants. including boys in the vaccination scheme would increase costs by an average of € , per year. conclusion: this study shows that procuring branded vaccines using the tendering process reduces expenditure for the government and the tax payer. wholesale prices were found to be more expensive than tender prices. this proves that the tendering system in malta is a potent system with many advantages for the tax paying public. the impact of the tendering process must therefore, be safeguarded. please specify your abstract type: research abstract background and objective: with the old age, presence of comorbidities, and overcrowding in mass gatherings such as the annual hajj pilgrimage in saudi arabia, there is a high risk of spreading infectious diseases among pilgrims and then within their country of origin. knowledge and application of hygiene principles in such an environment is therefore important to reduce the transmission of infectious diseases. up to date, there have been no studies to evaluate pilgrims' knowledge, attitude and practices toward mers-cov during the annual hajj pilgrimage in order to see whether there is a need for these aspects to be improved. setting and method: a cross-sectional survey study was conducted with a convenience sample of participants. participants were pilgrims, aged over , and able to speak arabic or english. a selfadministered structured questionnaire was distributed during hajj season in mecca. descriptive and multiple linear regression analysis were used in data analysis. main outcome measures: assessing pilgrims' knowledge, attitude and practices regarding mers-cov. results: two hundred and fifty-seven participants completed the study, % of whom were female, and the median (iqr) age was ( . - . ) years. pilgrims had moderately correct knowledge and accurate attitudes towards mers-cov with median scores of (iqr - ) and (iqr: - ) respectively. they were less educated about management ( %), hallmark symptoms ( %), high-risk individuals ( %) and source of coronavirus ( %). almost % of participants showed a negative attitude towards the use of protective measures such as avoiding food prepared under unsanitary conditions and contact with live animals. some participants ( %) were unable to comply with hygiene practices, particularly washing hands with soap and water or disinfectant after sneezing/coughing and wearing a face mask in crowded areas. educational level and employment status were significantly associated with knowledge whereas gender and age were significantly associated with attitude and practices respectively (p \ . ). the correlation between knowledge, attitude and practices was significant (correlation coefficient: . ; p \ . ). better knowledge was found to be a predictor for positive practice. conclusion: these findings aided in the assessment of the adequacy of current pilgrims' educational measures. they will also provide insight when designing future interventions to promote specific messages to improve knowledge, change attitude and improve practice regarding mers-cov. please specify your abstract type: research abstract background and objective: the prevalence of type diabetes significantly increased in the paediatric population, which is affected by obesity worldwide. today, type diabetes accounts for % of all cases of new-onset diabetes in adolescents. preventive health care particularly taking place at community pharmacies may involve risk assessment for the children and the adolescents, early referral for seeking relevant medical care and patient education on healthy lifestyle choices. the aim of the study is to conduct a type diabetes risk assessment program for the kids b years of age of whose parents visited the community pharmacies involved in the study and also to identify the behavioural parameters that might be associated with this risk. setting and method: the study was conducted in community pharmacies. all patients with kids aged b years who visited the study pharmacies during one-week period were informed about the study and invited to participate in the study. patients who gave their informed consent were included in the study. all data were provided by the parents. demographic data, height and weight of the kid, as well as data regarding the behavioural features (eating habits, exercising, time spent in front of a screen, etc.) of both the children and the parents were collected using standardized forms. type diabetes risk test consisted of questions and identified subjects at risk. the parent of the kid who was identified to have risk for type diabetes was referred to a physician for further examination. also, information regarding type diabetes and the importance of preventive measures such as converting to a healthy life-style was provided. main outcome measures: main outcome measures were the percentage of kids identified to be at risk of developing type diabetes and the behavioural parameters associated with type diabetes risk. results: the study involved subjects. of the subjects % were identified to be at risk of type diabetes. more girls than the boys had the risk ( vs. . %). those with type diabetes risk were older, taller, heavier and had higher body mass index. they were spending more time in front of a screen (tv, pc, tablet, smart phone); . % were spending more than h a day. although the kids' eating habits were similar for those with and without risk, the parents' of the kids with risk ate out more frequently, consumed rice, pasta and pastry more frequently. both the kids with risk and their parents exercised more regularly and frequently. conclusion: this study shows that pharmacist have a vital role in identifying children and adolescents at risk for type diabetes; thus at early management of this condition. identifying and addressing the behavioural parameters associated with the risk will be helpful in lifestyle modification interventions. please specify your abstract type: descriptive abstract (for projects) background and objective: analyse and promote the reporting of adverse drug events (ade), to improve the quality and safety of care to be able to control the risks. design: a software is available on the intranet website of the institution, to enable health professionals to report ade. the drug and medical devices commission (comedims) of the hospital, centralizes these statements and always makes a multidisciplinary and overall analysis of the event, using a collection sheet which is based on the pdca model (plan, do, check, act). it proposes the nursing and medical teams axes of improvement. results: in , only ade were reported and analysed by the comedims, including from the paediatric centre ( %), particularly sensitized to this issue. health professionals are divided as follows: healthcare executives ( %), nurses ( %), pharmacists ( %), residential students ( %), doctors ( %) and others ( %). the main impacted steps of the drug circuit are: administration ( %), prescription ( %) and the use or implementation of a sterile medical device ( %). identified causes include related following factors: operational tasks and procedures ( %), health professionals ( %), work environment ( %), organization and management ( %), drugs or associated medical devices ( %). the number of ade reports, taking into account the size of the institution, remains very low. in january , the comedims decided to broadcast a communication campaign to promote ade reporting, on the hospital website via the intranet. three months after the release, this document was viewed times, and the number of reports increased by % compared to the same period in . conclusion: in front of the low number of returns of adverse drug events, and relying on the charter of non-punishment, the come-dims wants to increase health professionals' awareness. in our hospital, where e-learning about drug-related iatrogenesis is already available, the communication campaign with poster and analysis of adverse events seems to be a useful complementary tool to enhance awareness of medication safety concerns. please specify your abstract type: research abstract background and objective: the migration of modern social networks to the internet has facilitated the transition of traditional pharmacy networks online. the ubiquitous nature of social media (some) combined with merging of personal and professional personas have led to organisations publishing guidance on online behaviour and responsible use of social media. the research to date on the use of social media as a support for professional practice in general is limited. as the pharmacy profession evolves to embrace the technologies which underpin core services and mainstream online daily social activities, it is important that research tracks and evaluates its use and impact within the profession. the objective of this research was to explore and describe how and why pharmacists interact with hosted networks on social media. setting and method: two one-hour online hosted micro-blogging twitter chats were held in december via the #weph network. topic guides were developed around 'exploring the use of twitter and wepharmacists' in line with the wenetwork guidelines (#wecommunities), informed by existing literature, discussion with the #weph moderator after review by an expert panel. all research was carried out in accordance with university governance processes and association of internet researchers guidelines. themes were inducted from analysing the textual content of the chats using the topic guide as a framework. the research was approved by the school of pharmacy and life sciences ethics committee. main outcome measures: tweets per chat results: each of the chats had over million impressions with participants representing international pharmacy practice. themes of e-professionalism and online privacy emerged as concerns; however, the benefits included using social media for education, networking, support mechanisms and career development. tweets highlighted personal experiences of 'trolling' (angry, offensive behaviour) and the effect on user interaction with social media. twitter was also recognised as a career development tool and, in particular, collaborative outcomes around mentorship networking early career pharmacists with more experienced colleagues. conclusion: results support the responsible use of social media as a force for inclusion, breaking down geographical barriers in support of pharmacy practice. further research is underway including a systematic review of guidance on the use of social media by registered healthcare professionals. please specify your abstract type: research abstract background and objective: it is estimated that half of the , persons with diabetes in norway have not been diagnosed. with early treatment, life expectancy can be increased and the incidence of longterm complications and health costs reduced. community pharmacies may be able to help uncover undiagnosed diabetes, but being diagnosed with diabetes can lead to strong emotional reactions, and how the diagnosis is given may influence the experience. the aim of this study was to explore how norwegian people living with type diabetes (t d) experienced being diagnosed, and what led up to the diagnosis. in addition, their attitudes towards a planned community pharmacy service to identify undiagnosed t d was investigated. setting and method: three focus group interviews with people with t d were conducted using a semi-structured interview guide. eleven participants were recruited through a course about type diabetes. the interviews were audio-taped and transcribed in modified verbatim form and analysed in accordance with malteruds principles of systematic text condensation. the study was approved by the norwegian data protection authority, and did not require approval from the regional committee for medical and health research ethics. main outcome measures: how people with t d describe their experiences of being diagnosed with t d, how the disease was revealed and reactions towards using community pharmacies to perform risk assessment for t d. results: none of the participants were diagnosed due to their own suspicion of having diabetes. some saw their doctor because of unspecific symptoms such as fatigue and thirst, and were thereafter diagnosed with t d. others were diagnosed through a routine checkup. negative reactions like shock, discontent and denial were commonly used to describe the experience of being diagnosed with t d, but some participants also expressed a more relaxed attitude, especially if they were familiar with the disease through family members. participants expressed a strong wish for more and better information following the diagnosis. ''it's a jungle out there'' was used to describe how difficult they felt it was to find trustworthy and understandable information. they described change of lifestyle, side effects from drug use, and stigma as challenges following the diagnosis. while in general the participants were positive to using community pharmacies to uncover undiagnosed diabetes as this could help reduce the number of people who were undiagnosed, some were sceptical. they questioned whether the pharmacy staff had the necessary competence of the for this type of service, and saw it as the doctor's responsibility. conclusion: more information and support when people are diagnosed with diabetes may lead to that the experience being diagnosed will be more adaptable and that the challenges living with diabetes are reduced. community pharmacies are important healthcare providers, and risk assessment of t d at the pharmacy can be valuable. however, the pharmacies may also be helpful to reduce the information gap. please specify your abstract type: research abstract background and objective: chemotherapy-induced nausea and vomiting (cinv) is a disruptive and unpleasant side effect in chemotherapy patients and is associated with decline in patients' quality of life and decrement in the adherence to effective chemotherapy regimens. setting and method: chemotherapy naive patients were included in this study. consistency with guidelines were assessed according to mascc/esmo . flie questionnaire was administered to patients before chemotherapy, and days after receiving chemotherapy to assess the difference in the quality of life due to chemotherapy administration. main outcome measures: patients were categorized into two groups as consistent with guidelines group (acute (gcga) and delayed (gcgd)) and inconsistent with guidelines group (acute (giga) and delayed (gigd)). flie score differences between the two groups were assessed. results: the median flie score for patients prior to chemotherapy was and a dramatic decline was noticed post chemotherapy (flie score ; p \ . ). the post-chemotherapy score were for nausea and for vomiting ( . , respectively). although the flie score differed significantly between gcgd and gigd (p \ . ), these differences were not significant in gcga and giga. conclusion: the significant drop in flie scores in the study ( pre-to post-chemotherapy) reflected substantial declination in patients' quality of life. the lower postchemotherapy flie score of nausea emphasized the negative impact of nausea, and to a lesser extent vomiting on the patients ability to complete normal daily activities such as enjoying meals and maintaining social activities. although there were no significant differences in flie scores between giga and gcga groups for acute cinv prevention, significant differences were noted between gigd and gcgd (p \ . ). the flie score was lower for gigd patients. this result implied guideline inconsistency associated with high incidence of nausea which negatively affect patient quality of life. as for the degree of compliance with gp, the results are expressed as percentage of compliance compared to the ideal of %. prescription criterion was fulfilled to %: all requirements of pntb were performed using standardized procedure. in what concerns validation, % of pntb prescriptions were validated by a pharmacist. the invalidated prescriptions were made outside opening hours of the pharmacy service, which is open monday to friday from : to : and on weekends and holidays from : to : . % of the dispensations were individualized and not pntb stocks were found in hospital wards. as for preparation, % were supplemented with micronutrients. pntb of kabiven peripheral administration ml are not supplemented in our centre. of the remaining prescriptions central administration, % were supplemented. in all cases, the addition of micronutrients was performed in laminar flow hood in pharmacy service and the corresponding galenic validation was performed. finally, in the process of administration, % of pntb identified with a complete label: name of the patient, medical record number, type of pntb, qualitative and quantitative composition, date of administration and infusion rate. conclusion: use practices of pntb of our centre are far from those recommended by the sefh standards. this initial evaluation will serve for improvement measures that increase the quality of prescribing and safe use of pntb, in order to minimize errors that can occur with the use of this therapeutic modality. please specify your abstract type: research abstract background and objective: methadone maintenance treatment was developed in malta in and is provided to patients by sedqa, the national agency against drug and alcohol abuse. methadone is the most frequently prescribed opioid in opioid substitution treatment and is dispensed through a centralised service through the substance misuse outpatients unit. in , patients were in opioid substitution treatment, of who were on methadone. in , the government introduced a take-home methadone program. the prescribing, purchasing and dispensing of methadone are regulated by subsidiary legislation . . the objectives were to determine whether community pharmacists in malta would be willing to dispense and supervise the consumption of methadone and to investigate the involvement of community pharmacies in the development of a regionalised methadone dispensing service. setting and method: the study was set in community pharmacies. a cross-sectional study, through the use of a questionnaire, was performed to quantitatively analyse whether pharmacists in malta would be willing to dispense methadone. the questionnaire consisted of questions divided into sections, with each section assessing a particular aspect of community pharmacists' attitudes towards methadone dispensing. community pharmacies were then chosen via a systematic sampling procedure. a hard copy of the questionnaire, addressed to the managing pharmacist, along with a cover letter, instructions on how the questionnaire was to be returned, and a prepaid self-addressed envelope was distributed via postage to community pharmacies. an online format of the questionnaire was also circulated to community pharmacists through the pharmacy council. data was analysed using spss version . main outcome measures: community pharmacist's attitudes towards methadone dispensing. results: a total of responses were obtained and a response rate of . % was achieved. eighteen percent of the pharmacists (n = ) who responded to the questionnaire worked in a community pharmacy located in the north of malta, % in the centre, % in the south, % in the southeast and % in gozo. thirty-two percent of community pharmacists were willing to dispense methadone to drug misusers. the number of community pharmacists who are willing to dispense methadone increased to % if they were provided with appropriate education and support. twenty-nine percent of community pharmacists were prepared to handle the duty of supervising the consumption of methadone while % had never learnt about methadone and its clinical application within opioid substitution treatment. conclusion: community pharmacists should be provided with education and training regarding methadone substitution treatment before embarking on a new regionalised methadone dispensing service within community pharmacies. this would allow more community pharmacists to become involved in a new dispensing methadone service. pt : evaluation of regorafenib in patients with colorectal cancer please specify your abstract type: research abstract background and objective: the colorectal cancer is the second more frequent cancer in europe and the third in the world. regorafenib is only approved in adult patients with metastatic colorectal cancer who are previously been treated with available therapies or are not considered suitable candidates to these treatments. regorafenib is an oral anti-tumor drug that blocks the kinases involved in the tumor angiogenesis (vegfr , - , - , tie ), the oncogenesis (kit, ret, raf- , braf, brafv e) and the tumor microenvironment (pdgfr, fgfr).in this study, we are reviewed the reports of the patients with colorectal cancer who are been treated with regorafenib in our hospital and analysed the information in order to evaluate the efficacy and safety of regorafenib. setting and method: descriptive and observational study about the use of regorafenib from april to the present day. the variables studied, obtained from the software applications archinet and diraya, were: sex, age, pathology, location of metastasis, posology and adverse effects of regorafenib, tumor markers (cea y ca . ) before and after the treatment with this drug and the mutational state of kras. main outcome measures: the tumor markers cea and ca . only decreased in the . % of the patients after the regorafenib treatment. results: regorafenib was taken by patients ( %men).the average age of these patients was . ± . years old. the patients took regorafenib to treat: metastatic and non-intervened gastrointestinal stromal tumors (gist) e-iv that progressed with the previous treatment of imatinib and sunitinib ( . % patients), intervened colon adenocarcinoma e-iv ( . % patients), sigma adenocarcinoma e-iv ( . % patients) and unresectable and non-intervened rectal adenocarcinoma e-iv ( . % patients).all patients presented metastasis in different locations on the body: liver ( . % patients), diaphragm ( . % patients), intestine ( . % patients) and lung ( . % patients).the % of the patients started the treatment with mg of regorafenib, administrated once a day for weeks followed by one week without this drug; while the . % of the patients started the treatment with mg. however, the . % had to decrease the initial dose and the . % of the total patients had to get off the treatment because of the development of side effects. the most frequent adverse effects were: hypertension associated with headache, hyperbilirubinemia, elevation of ast and alt, intense asthenia. the . % of the patients presents native kras. the native kras was presented in the % of the patients treated with regorafenib who had an appropriate development of the illness (decrease of cea and ca . ) conclusion: the decrease of cea in the . % of the patients and the high development of side effects reveal that regorafenib has low effectiveness and security in the control of the progression of colorectal cancer. in addition, it is supposed that this drug has better results in native kras patients. however, more studies are necessaries in order to demonstrate the effectiveness of regorafenib in this pathology. pt : evaluation of nintedanib in patients with non-small-cell lung carcinoma (nsclc) please specify your abstract type: research abstract background and objective: the nsclc means a high rate of mortality in developed countries. patients diagnosed with nsclc who debut with advanced or metastatic disease have a median survival of months. one of the innovative drugs approved to improve survival in nsclc is nintedanib: an inhibitor of multiple tyrosine kinases, which can be found in some receptors on the surface of cells involves in the growth and spread of cancer cells (''pdgfr'', ''fgfr'' and ''vegfr''). nintedanib is not yet marketed in spain. hospital pharmacists are responsible for applying this treatment as ''expanded drug'', only after the elaboration of an exhaustive report. in this study, we have reviewed all the reports and classified the information in order to present our clinical practice. the objective of this study is to evaluate the effectiveness and safety of nintedanib in patients with nsclc treated in a tertiary hospital. setting and method: descriptive observational study of the use of nintedanib from november to september . sex, age, body mass index (bmi), pathology, smoking habits, line of treatment, posology and adverse reactions of the treatment with nintedanib and tumor markers (cea an ca . ) before and later the treatment with nintedanib were collected from medical history through archinet informatic application. main outcome measures: the tumor marker cea decreased in % of the patients and ca . no decreased in any patient after nintedanib treatment. results: nintedanib was used in patients ( % men and % smoker).the average age of these patients was years old. the average bmi was kg/m ( - ).all patients received nintedanib together with docetaxel for metastatic nsclc with adenocarcinoma histology and with non-mutated egfr and alk in third line treatments. posology: all patients started the treatment with nintedanib mg/ h from day to day every weeks; but patients had to reduce the initial dose to mg/ h ( patient) and mg/ h ( patient) because of some adverse reactions. the side effects were: asthenia, diarrhoea, alteration of transaminases, muscle pain and cramps, weight loss and mucositis. conclusion: the decrease of cea in % of the patients reveals that nintedanib is effective in controlling nsclc progression which involves an increase of the survival and the quality of life of these patients. however, more studies are required to demonstrate the efficacy of nintedanib in this illness. please specify your abstract type: research abstract background and objective: patients with sore throat symptoms often seek fast, meaningful relief when presenting to their local pharmacy. flurbiprofen is a non-steroidal anti-inflammatory drug, which has been developed as a spray and lozenge to provide targeted relief for the main underlying process responsible for the symptoms of sore throats, inflammation. to study the relief provided by flurbiprofen . mg delivered as a spray or lozenge, we conducted a multicentre, randomised, double-blind, double-dummy, parallel group, activecontrolled, single-dose, non-inferiority study. setting and method: adult patients with acute sore throat were randomly assigned to take one dose of either flurbiprofen . mg spray plus a placebo lozenge, or flurbiprofen . mg lozenge plus placebo spray at sites across russia. main outcome measures: patients rated sore throat relief using the sore throat relief rating scale (strrs; a -point scale, = no relief, = slight relief, = mild relief, = moderate relief, = considerable relief, = almost complete relief, = complete relief) at timed intervals throughout h starting from min post completion of first dosing ( min after administration of the spray, and min after the lozenge had fully dissolved). adverse events (aes) were recorded over h post-dose. results: patients were assessed (n = for spray, n = for lozenge). [ % of patients in either treatment group experienced some relief (a score of [ on the strrs) at min post-dose, which increased to % of patients by h. - % of patients reported 'at least moderate relief', which is a well-recognised measure of a clinically meaningful effect at min post-dose, which increased to - % of patients by h. over the h post-dose, a total of drugrelated aes were reported by patients across both treatments and no severe adverse events were reported. conclusion: flurbiprofen . mg delivered as a lozenge or spray provides fast, clinically meaningful relief from sore throat. pt : analising antiangiogenics prescription in an ophtalmology service after a protocol implementation silvia cornejo-uixeda * , ivan de la vega-zamorano, celia aparicio-rubio, olga carrascosa-piquer, manuel prieto-castello, agustin sanchez-alcaraz pharmacy, hospital universitario de la ribera, alzira, spain please specify your abstract type: descriptive abstract (for projects) background and objective: after some years using antiangiogenics in our hospital, we observed a large variety of use. considering the high cost of these treatments, we proposed ophthalmology service to develop a protocol of use, attending efficiency criteria. in this paper, we analyse the protocol implementation repercussion. design: a protocol of use was designed with the main of unify criteria and to use the most efficient treatment depending on the specific situation on each patient. once it was implemented, we compared two periods, the period after the implementation (january-may ) and the period before of it (january-may ). the protocol designed is the following: the cost for each injection and patient was the following: aflibercept €, bevacizumab €, ranibizumab €. results: in the period, patients were treated with antiangiogenics. ( %) with aflibercept, ( %) with bevacizumab and ( %) with ranibizumab. in the period, patients were treated, ( %) with aflibercept, ( %) with bevacizumab and ( %) with ranibizumab. the consumption of aflibercept decreased a %, bevacizumab consumption increased % an ranibizumab increased a %.we also observed, some patients had more than one diagnostic at the same time. once the protocol was implemented, the percentage of use was the following: % . please specify your abstract type: research abstract background and objective: drug prescribing is the most common medical intervention in the elderly. however, elderly patients are more sensitive to the drug's effects due to pharmacokinetic and pharmacodynamic changes associated with aging. chronic diseases and co-morbidities often require the use of a large number of medications. therefore, when prescribing drugs for the elderly, the choice of suitable drugs, dosage and duration of treatment should be carefully considered as well as clinically significant drug interactions. inappropriate prescribing is often associated with an increased risk of adverse drug reactions, increased morbidity and mortality, and health care costs. the aim of this study was to determine the incidence of potentially inappropriate medications (pim) prescriptions in the elderly (c years) using the original protocol developed by mimica matanovic and vlahovic-palcevski. setting and method: we enrolled patients hospitalized in clinic of internal medicine. data about patients' medications was collected during patient interview taken by the pharmacists on hospital admission. pharmacotherapy was analysed using the original protocol developed by mimica matanovic and vlahovic-palcevski in order to detect pims. main outcome measures: number and type of potentially inappropriate medications, potential clinically significant interactions. results: the average age of patients was years (range - ), and the average number of drugs per respondent was . (range - ). a total of patients ( . %) were taking at least one pim. the most common pim were long-acting benzodiazepines, central antihypertensive moxonidine and non-steroidal anti-inflammatory drugs (nsaids) in patients with hypertension. in the study population, patients ( . %) have taken at least one combination of drugs that could result in a clinically significant interaction. the most common combinations included application of nsaids and antihypertensive drugs or diuretics, concomitant use of multiple medications with effects on the central nervous system and drug combinations that can cause hyperkalaemia. conclusion: this study revealed the high prevalence of inappropriate prescribing. clinical application of this protocol could be an effective method for improving and optimizing drug prescription with the aim to reduce the number of side effects and the morbidity and mortality associated with the drug use in the elderly. please specify your abstract type: research abstract background and objective: to reduce adverse effects of conventional amphotericin b formulation (deoxycholate or d-amb) it can be infused in intralipid Ò (a fat parenteral nutrition), or lipid-based formulations can be used (i.e. amphotericin b lipid complex (ablc), amphotericin b colloidal dispersion (adcd) and liposomal amphotericin b (l-amb)). studies evaluating safety profiles present conflicting results. the aim of our study was to gather evidence on nephrotoxicity rates of d-amb versus lipid-based formulations in immunosuppressed patients susceptible to invasive fungal infection. setting and method: a systematic review, including randomized controlled trials (rcts) that compared the use of d-amb and amphotericin b lipid-based was performed. a search was conducted in pubmed, scopus, web of science and scielo. results were synthetized and meta-analysis was performed using software review manager . . main outcome measures: nephrotoxicity rates. results: eighteen rcts were identified (n = participants). the result from the meta-analysis favours the treatment with the lipidbased amphotericin b formulations (or: . ( . , . ) and presents a low heterogeneity (i = %). about % of patients from lipid-based treatment group presented an increase in serum creatinine of one to two times, which corresponds to stage one or two of acute renal failure (arf). and % presented an increase of tree times in serum creatinine achieving a stage three in arf (severe) which will require dialysis. while in group treated with conventional formulation int j clin pharm ( ) all of these patients, except one whose treatment adherence was inadequate, were cirrhotic ( / ), liver transplanted ( / ) and/ or presented hepatocellular carcinoma ( / ). / patients were coinfected with hiv. / patients ( %) were genotype . the total genotype patients treated with daas (svr /relapsed) were , which means that . % ( / ) of all genotype patients has had a relapse. / patients ( %) were treated with ledispavir/sofosbuvir ( . % of a total of patients (svr /relapsed) treated with this option). % of patients who suffered a relapse were treated with daas sofosbuvir, simeprevir, daclatasvir, previously to the introduction of the newest antivirals (dasabuvir + ombitasvir/ paritaprevir/ritonavir, ledispavir/sofosbuvir), which represents . % of the total of patients treated with the older option. conclusion: relapses rate was . %, slightly lower than reported in other studies. according to the references, these results show that genotype is the one presenting more relapses. all the patients presented a deteriorated performance status, except for one whose treatment adherence was inadequate. patients treated before april , when the newest daas where introduced, showed more relapses. more studies have to be developed in the near future since other daas will appear, the treatment options will be amplified and the number of relapses is expected to decrease. please specify your abstract type: research abstract background and objective: the inappropriate use of antibiotics remains a major issue since it causes bacterial resistance, longer hospital stay and increased mortality. antibiotic prescriptions must be monitored: the clinical pharmacist has a key role in ensuring patient safety and quality of pharmaceutical care. therefore, an antimicrobial stewardship program has been implemented as part of a national project of the italian society of hospital pharmacy (sifo). the objective is to describe the results obtained at the hospital. setting and method: a multidisciplinary antimicrobial management team has been implemented including clinical pharmacists, microbiologists and infectious disease specialists. the pharmacist examines drug charts on a daily basis in the department of medicine and supports clinicians to improve the appropriate use of antibiotics. data from time-points were extracted from medical records and collected in an excel database: t (november -january ) and t (february -april ). main outcome measures: type of infection, antibiotic consumption data, type of isolated pathogens, patient allergies, clostridium difficile infection assessment and adverse drug reactions (adr). results: records were analysed (t -t ), of which contained at least one antibiotic prescription. the most frequent infections were urinary tract ( %), respiratory ( %) and gastro-intestinal ( %). antibiotic therapy was started in . % of cases due to aspecific increase of c-reactive protein (crp). ddds were calculated for each treatment and were grouped by type of infection and setting (empiric vs targeted): ceftriaxone, meropenem and metronidazole were the most widely used antibiotics for empiric therapy. at t , an increase in the use of piperacillin-tazobactam instead of meropenem was observed. the ddd of ceftriaxone for targeted therapies decreased significantly, while an increase was observed for carbapenems, levofloxacin, glycopeptides and, in case of mdr bacteria, tigecycline. three allergies to antibiotics were reported in medical history. there were clostridium difficile infections ( relapses), confirmed by antibiogram. a total of adrs were identified: of these were related to antibiotics. conclusion: antimicrobial stewardship is a fundamental step to optimise antibiotic management, ensure patient safety and improve quality of care. the results obtained so far demonstrate the added value of a multidisciplinary team in controlling bacteria resistance and in the improving the use of antibiotics. please specify your abstract type: descriptive abstract (for projects) background and objective: the aim of this study was to analyse effectiveness and safety of pirfenidone, an anti-inflammatory and antifibrotic agent used for treatment of idiopathic pulmonary fibrosis. design: a retrospective, descriptive, observational study including all patients treated with pirfenidone at the hospital between march and june ( month) was carried out. to identify patients and collect data the outpatient medication dispensation software farhos Ò and the electronic medical record software hcis Ò were used. statistical analysis was carried out using microsoft excel Ò . demographic (age and sex), clinical (forced vital capacity (fvc), diffusing co capacity (dlco) and six-minute walk test (wt m)) and therapeutic (dosage and adverse reactions) variables were collected. results: throughout the study period, a total of patients ( males) started treatment with pirfenidone, with a median age of . years ( - ). during this period patients were excluded for lack of monitoring. the median fvc, dlco, wt m values prior to pirfenidone therapy, were % ( [ %), . % ( [ %) and m ( - m) respectively. all patients met the inclusion criteria of capacity trial according to fvc and wt m; however of them didn't meet the dlco criteria (at least %).'' all patients were monitored every months. the median in fvc percentage change at the end of the study was - % (- % to + %). patients ( %) showed an improvement on fvc during treatment with a median change of %. in the other eight patients fvc value decreased with a median of - %. only one patient would be candidate to discontinue treatment due to a lack of efficacy, according to discontinuation criteria established at the hospital (absolute decrease of c % in fvc during first year of treatment). dlco percentage was measured in patients, with a median change of % (- % to + %). dlco decreased in patients. wt m was monitored in patients, with a median change of - . m (- m to + m). adverse effects related to pirfenidone were gastrointestinal disorders ( / ), increase of hepatic ggt ( / ), and dermatologic toxicity ( / ). six patients ( %) required a dose reduction because of gastrointestinal adverse effects. five patients ( %) discontinued treatment with pirfenidone due to hepatotoxicity ( ), gastrointestinal ( ) and dermatologic effects ( ). one patient died. conclusion: half of the patients improved fvc during the period of the study. the other half, showed a decrease in fvc value which was similar to the median obtained in capacity trial. gastrointestinal disorders were the most frequent adverse effects and cause of discontinuing treatment. treatment monitoring is important to achieve therapeutic benefit and control the adverse effects. the national centre for epilepsy, oslo university hospital, oslo, norway please specify your abstract type: research abstract background and objective: systematic medication reviews in interdisciplinary teams can help to identify potential and actual drugrelated problems (drp). the centre for development of institutional and home care services in oslo, norway, conducted medication reviews for polypharmacy patients with mental disabilities in - , based on a lack of knowledge about drug-related problems in this patient group. the objective was to examine prescribing patterns, frequencies and types of drp in patients with mental disabilities. setting and method: the forms for medication reviews were developed by the national patient safety campaign in norway. the nurse/social educator recruited eligible patients, observed them, and ordered test if needed. the clinical pharmacist (jwa) reviewed the medications to identify drps. the interdisciplinary case conference took place at the different general practitioners' offices being responsible for the individual patients. the general practitioner, the nurse/social educator and the pharmacist were present, and in some cases, also patients took part. main outcome measures: an independent researcher (aqm) collected and analysed the data based on the drp-forms containing information on the prescribed medicines, strength, dose, indication, a description of drp and suggested interventions to resolve them. results: overall, patients with mental disabilities, aged - years, consented to have a medication review. they used on int j clin pharm ( ) : - average medicines (range - ). the team identified drp in of the patients (average . , range - ). overall, % of all drp were resolved. for one-third of the medicines, an action was taken to improve the prescribing. the most commonly medicines were analgesics ( %), antiepileptics ( %) and anxiolytics ( %). the most frequent drps were unnecessary drug choice ( %), side effects ( %) and too low dose ( %). drps were most common in antipsychotics ( %), antidepressants ( %) and anxiolytics ( %). conclusion: patients with intellectual disabilities take more medicines and have many drps compared to other patient groups. they are also more prone to taking combinations of cns-active medicines and therefore more at risk of side effects and drug interactions. pt : protocol feasibility and patient findings when using a dry extract of zingiber officinale roscoe (ginger extract gr ) during pregnancy please specify your abstract type: research abstract background and objective: there is limited information about the use of dry extracts of ginger root. the objectives of this study are ( ) to evaluate the feasibility of a pilot study with a food supplement among pregnant women ( ) to learn what the patient findings are when using the dry extract of ginger during pregnancy. this abstract deals with the intermediate evaluation of a study conceived to investigate the safety of the ginger extract gr during pregnancy. setting and method: a prospective, interventional and real life pilot study with pregnant women between and weeks of gestation and having symptoms of nausea and vomiting or digestive complaints. the included patients can use the ginger extract gr for digestive comfort during pregnancy when needed. during the use, the score of digestive discomfort is noted and the researcher reports adverse events. main outcome measures: ( ) number of included patients as an indicator of feasibility: including a number of patients was taken as a target ( ) analysis (qualitative and quantitative) of the patient diaries, more particularly patient behaviour, wellbeing and impressions. results: within twelve weeks, patients were included with an average age of . years and a median age of ( - ) years. patients used gr : patients were dissatisfied, patients had a neutral opinion and patients were satisfied to very satisfied. one miscarriage occurred at a gestational age of almost weeks (only tablets of gr were used, with no relevant medical history in preceding pregnancies). two patients were hospitalized, of which with hyperemesis gravidarum. one patient complained about heartburn and one patient experienced a bad taste and heartburn. three patients have indicated that they experienced more nausea after taking the tablets. patients experienced no adverse events. the remaining patients were not yet evaluated. of the included patients, six patients decided not to use the product: because their gastrointestinal complaints were not serious enough, because problems of swallowing (using ginger gums instead). one patient was afraid for the negative consequences for her unborn child. the last of the nonusers indicated that she had no confidence in the product. conclusion: conducting a pilot study with the ginger extract gr in case of pregnancy is feasible. the majority of the evaluated patients were satisfied. signing the consent form does not guarantee the intake of the product. pregnant women remain very cautious in the use of unknown products during their pregnancy, even though it concerns a food supplement and not a drug. the severity of symptoms does not give a good indication whether or not and how often the product will be used. please specify your abstract type: descriptive abstract (for projects) background and objective: to analyse effectiveness and safety of ibrutinib, an oral inhibitor of bruton tyrosine kinase, in patients with mantle cell lymphoma (mcl) who have received at least one prior therapy. design: a descriptive observational study was carried out. all patients with relapsed or refractory mcl who started treatment with mg of daily ibrutinib between september and june were included. patients were identified and followed through electronic medical record. demographic and baseline clinical characteristics of patients were collected: age, sex, ecog (eastern cooperative oncology group scale), number and type of prior regimens, simplified mipi status (mantle-cell lymphoma international prognostic index), and disease stage (relapsed or refractory). progression free survival (pfs) and response to treatment were recorded to evaluate effectiveness. adverse effects related to ibrutinib and possible interactions with concomitant medication were documented to measure safety. statistical analysis of the data was carried out using microsoft excel Ò and spss Ò . results: throughout the period of study a total of patients ( males and female) with a mean age of . ± . years started treatment with ibrutinib. the median of previous treatments were ( ) ( ) ( ) ( ) ( ) including first-line treatment with high dose chemotherapy ( %), steam-cell transplantation ( %), rituximab ( %), bortezomib ( %) and lenalidomide ( %). the median ecog value prior to ibrutinib therapy was (range - ). the mipi status was intermediate risk in patients and high risk in , the disease stage was relapsed in % of the patients. partial response was reported in patients. the mean pfs estimated at the end of the study period was months ( % . - . ). adverse effects related to ibrutinib were: fatigue ( %), diarrhoea ( %) leucocytosis ( %) and infections ( %), including upper respiratory and urinary tract infections, sinusitis and pneumonia. one possible interaction between ibrutinib and everolimus was found in a liver transplant patient. close monitoring of everolimus plasmatic levels was recommended. conclusion: the mean pfs estimated in our study was similar to the median obtained in the pivotal phase ii trial. infections were the most frequent adverse effects. concomitant medication to ibrutinib should be checked, as ibrutibib is metabolised by cyp a and interactions may be frequently present. pharmacy, hiv unit, germans trias i pujol hospital, badalona, spain please specify your abstract type: descriptive abstract (for projects) background and objective: dolutegravir (dtg) is one of the preferred options for initial antiretroviral therapy (art) due to its high efficacy, good tolerability and low potential for drug-drug interactions. nevertheless, an unexpectedly high rate of dtg discontinuation (up to %) due to adverse events in the clinical practice has been recently reported. therefore, we aimed at assessing the dtg discontinuation rate and reasons for discontinuation in our hospital. design: single-centre, retrospective study from september to june of patients cohort with art both naive and pretreated. patients who had started dtg-based art containing regimen were identified and the reasons for the discontinuations were analysed. data were collected using the primary care service program and the electronic prescription program. results: out of patients attended by pharmacy department in our hospital, patients ( males, mean age years (range - )) had started a dtg-based art. out of them, patients were art naive and art-experienced. at the moment of starting dtg, mean cd cells were cell/mm (range - ) and hiv- rna load in plasma was detectable in patients. treatment discontinuation was reported in / patients ( . %) with a median treatment time of days (range - ). / patients ( . %) were naïve and / patients ( . %) pre-treated. most of the patients ( ) were in single tablet regimens (str) containing dtg in combination with abacavir and lamivudine, whereas the rest were in combination with other antiretroviral drugs. the main reason for treatment discontinuation was toxicity in / patients ( . %). the rest of the patients discontinued due to other motives (clinical trial inclusion ( / ), treated in another hospital ( / ), exitus ( / ) and others ( / ). reasons for the discontinuation were classified in different side effects: / ( . %) related to central nervous system (cns) (insomnia, psychiatric disorders such as anxiety, nightmares and depression), / ( . %) gastrointestinal effects, / ( . %) headaches, / ( . %) musculoskeletal effects, / ( . %) fatigue, / ( . %) allergy and / ( . %) for other reasons. some patients reported various toxicities at once. conclusion: more than % of patients treated with dtg discontinued by toxicity reasons. it is important to note that half of these patients had cns adverse effects. please specify your abstract type: research abstract background and objective: hcv therapy has been revolutionised recently by the approval of antiviral agents direct-acting (daa) facilitating the treatment of patients coinfected with hiv/hcv. however, potential drug interactions and overlapping toxicities of both treatments represent the major challenges in adapting therapy. to analyse the prescription profile of direct acting antivirals (aad) in patients coinfected with hiv/hcv. setting and method: retrospective observational study from january to january in a specialty hospital. the data were collected from the hospital program of clinical stories, archinet Ò , and the outpatient program farmatools Ò . the results were analysed using the statistical program r-commander. main outcome measures: inclusion criteria: adult patients coinfected with hiv/hcv with undetectable viral load. the following variables were collected: age, gender, hcv genotype, degree of fibrosis, patient type (naïve or pre-treated), baseline cd count, cd levels end of treatment, sustained viral response (svr) and hcv treatment. results: patients, of whom were men, mean age years were included. patients received daclatasvir and sofosbuvir for hcv, patients had genotype a and b respectively, patients genotype and patient genotype . patients had fibrosis f f , . of the patients they had not received previous treatment (naïve) and had failed to treatment. hiv treatment was modified in patients, patients achieved svr. the cv was undetectable to hiv treatment change for all patients. cd levels increased in all patients at the end of treatment for hcv with a median of cells/ul and at the beginning and end respectively. patients received ombitasvir/paritaprevir/ritonavir and dasabuvir, who had a genotype a. these two patients had received previous treatment and had a f and f fibrosis. none of them was modified hiv treatment and only one got svr. cv remained undetectable and cd slightly increased after the treatment. patients received ledipasvir and sofosbuvir, patients had genotype a, patients genotype b and patient genotype . patients had f fibrosis and had f . patients had received previous treatment (naïve). the hiv treatment was modified only in one of the patients, patients achieved svr. cv increase in patients after the treatment while cd followed the trend of increasing. conclusion: the aad that caused fewer changes in the hiv treatment were ombitasvir/paritaprevir/ritonavir and dasabuvir followed by ledipasvir/sofosbuvir. sofosbuvir and daclatasvir present a greater number of interactions with hiv drugs so they behaved to a major change. more patients are needed to assess more accurately the aad leading to a minor modification. please specify your abstract type: research abstract background and objective: the simplification strategies reduce the amount of tablets and the toxicity in order to facilitate adherence in patients with virological suppression. the strategy more studied is monotherapy with a ritonavir-boosted protease inhibitors (pi/r). to analyse the effectiveness of monotherapy with pi/r in pre-treated patients infected with hiv. setting and method: retrospective observational study. selected hiv patients treated with pi/r monotherapy at any time of pharmacotherapeutic history to / / , with at least one clinical and analytical control months before the beginning. data were collected from the medical record archinet Ò and outpatient farmatools Ò program. variables included were age, sex, duration of monotherapy, virological failure, treatment failure, cd % during monotherapy. main outcome measures: inclusion criteria: virological suppression for year prior to the start of monotherapy, no previous ip virological failure, high cd count ([ cell/ml) and a high level of drug adherence. the effectiveness is defined as the percentage of patients without virological failure ( consecutive plasma viral load (vl) [ copies/ml) and without treatment failure (any event causing retirement monotherapy). results: patients with monotherapy, which represent % of patients with antiretroviral therapy (art) at our institution were identified. were excluded ( co-infected with hepatitis virus, with insufficient data and no had more than months included), including patients in the analysis, with a mean age of years and % were men. the median of time monotherapy treatment was . years ( . days), ( . %) patients received darunavir/r and ( . %) lopinavir/r. the effectiveness of monotherapy treatment during the follow up period was % with undetectable pvl at follow-up. the median of cd % over the treatment time was cell/ml ( %). conclusion: the effectiveness of treatment with ip/r monotherapy in our hospital obtained good results. according with our results treatment adherence plays a very important role. this is a current and valid strategy that brings benefits to the patient and to the healthcare system. please specify your abstract type: research abstract background and objective: the access to investigational drugs for patients who are not included in a clinical trial and without authorized therapeutic alternatives is known as compassionate use. the incorporation of the evidence-based medicine in the area of oncohaematology has implied that an important part of clinic therapy validated by evidence that could not be controlled from an administrative point of view. this is due to the continuous and progressive development of investigation and information on cancer treatment and the delay of the administration regulation. the use of drugs in this way is regulated by royal decree / ( / ). the objective of the study is to describe the use of cancer drugs through compassionate use in the last years in a specialty hospital. setting and method: descriptive retrospective study on a specialty hospital. all the applications for a compassionate use drugs were analysed from january until october . the data were obtained from medical records programme diraya Ò and from an excel database of medicines in compassionate use of the pharmacy service. main outcome measures: the following variables were registered: • number of patient clinic history • authorized medicine • authorization date • applicant service results: we recorded requests of cancer drugs in compassionate use during the years of study. oncology was the service that recorded more authorizations with %, followed with gynaecology with . % and finally endocrinology and haematology with . %. drugs of the requests were approved ( %) and unauthorized ( %) in the years of study. the year in which more applications were received was ( . %) and the least requests were received in ( . %), being the year where all requests were authorized. in fewer applications were authorized, %. in the years , and were authorized . , and . %, respectively. a total of different active drugs were received during the study, the most requested bevacizumab ( %) for grade iii oligoastrocytoma, ovarian cancer (monotherapy), metastatic gall bladder cancer and metastatic platinum-resistant ovarian cancer, everolimus ( %) for indications of neuroendocrine carcinoid tumour and metastatic breast cancer, nab-paclitaxel ( %) for invasive lobular carcinoma indications of high-grade and metastatic pancreatic cancer, ipilimumab ( %) for the indication of metastatic melanoma, and regorafenib for indications of colorectal cancer and metastatic gist i pre-treat with imatinib ( %). the solicitude of drugs through compassionate use needs effective commissions of pharmacy and therapeutics, along with the medical management to establish an agile and faster requesting circuit and the consequent use monitoring. please specify your abstract type: research abstract background and objective: to describe the standard procedure for the elaboration and control of a magistral formula (mf) to assess their effectiveness in two patients with cutaneous metastases of malignant melanoma refractory to other treatment. setting and method: medication for compassionate use was requested for two patients of and years with histopathologic diagnosis of cutaneous metastases of malignant melanoma in the left thigh and left heel in which the lack of response to first-line treatments made to be valued to start with adesleukina intralesional therapy. the first week was infiltrated mu ( ml) in lesions less than cm, mu ( ml) in the larger lesions and repeating each week until complete remission of the lesions. in the nd patient we proceed in the same way but the second week was infiltrated mu ( ml). the following week, infiltrated mml, in metastases and we turn to weekly infiltrations. the response was assessed by clinical disappearance of the lesions treated. complete response (cr) is defined as a clinical disappearance of lesions and partial response (pr) greater than % reduction of the lesion diameter. main outcome measures: we performed a literature search (pubmed, trissel, spc) for all studies published to determine the standard procedure for preparing and monitoring the mf (processing, preservation, stability, dose and indication). results: the standard procedure of preparation and quality control was carried out following the rules established in rd / . it was made in a vertical laminar flow cabinet. the aldesleukin vial was reconstituted with . ml api ( mu/ml) and then diluted with . ml of a solution of . % albumin, % glucose as stabilizer, to avoid aggregate formation, preparing ml syringes ( mu/ml). it was obtained a homogeneous and clear solution without precipitate or opalescence appearance. stable days in a refrigerator ( - °c), protected from light. initially patients had approximately a total of injuries. after months of treatment it was obtained a cr of most lesions in the first patient and rp of the second patient injuries. treatment was well tolerated. the side effects presented were only a flu-like syndrome in the second patient. conclusion: intralesional administration aldeslukina has been effective in treating malignant melanoma skin metastases in our patients, allowing the extension of its use in patients with the same involvement refractory to other primary treatments. the results are similar to those of the publications consulted. please specify your abstract type: research abstract background and objective: chronic infection with hepatitis virus c (hcv) affects about million people worldwide and is a leading cause of liver cirrhosis and hepatocellular carcinoma. the new direct acting antivirals against hcv have revolutionized the treatment of this disease. due to the high cost of these drugs it is necessary to assess their use in clinical practice. to evaluate the effectiveness of daclatasvir in combination with sofosbuvir in patients with hcv monoinfected in a specialty hospital. setting and method: retrospective observational study of patients who began treatment with the combination of daclatasvir and sofosbuvir from january to january in a specialty hospital. the data were collected from the hospital program of clinical stories archinet Ò and the outpatient program farmatools Ò . the results were analysed using the statistical program r-commander. main outcome measures: the sustained virologic response (svr) was considered the primary endpoint of the study. as secondary variables were analysed: sex, duration of treatment, naïve patients or pre-treated, degree of fibrosis, hcv genotype, concomitant use with ribavirin, viral load (vl) before treatment and medical service. results: there were included patients of whom were men. baseline characteristics were: patients with genotype , genotype b, with genotype a and genotype . the degree of fibrosis in the study was patients with f , f and to f . among the patients infected with hcv genotype , had not received prior treatment (naïve) and had failed therapy. the duration of the treatment was weeks to patients and weeks for patients. only patients receiving ribavirin of these had genotype and genotype b. from ribavirin patients it was greater the number of patients in whom the treatment duration was weeks ( patients versus with p-value = . ). the digestive service attended to patients while patients were followed by infectious. the median cv was , , iu/ml. svr was achieved in . % of patients with hcv genotype in . % with genotype b and % with genotype and a. after weeks of treatment % of patients achieved svr and % after weeks. only one patient died during treatment. the results are similar to those obtained in clinical trials. svr has not been influenced by hcv subtype, duration of treatment, degree of fibrosis, pre-treatment or by concomitant use of ribavirin. further studies are needed to evaluate the efficacy of this treatment. please specify your abstract type: research abstract background and objective: the safety and efficacy of medications can vary significantly between patients as a result of genetic variability. as genomic screening technologies become more widely available, pharmacists are ideally suited to utilize this tool to optimize medication management. the objective of this study is to evaluate the feasibility of implementing personalized medication services into community pharmacy practice and to assess the number of drug therapy problems identified as a result of pharmacogenomic screening. setting and method: the study was designed as open-label, nonrandomized, and observational. two community pharmacies in toronto, ontario offered pharmacogenomic screening as part of their professional services program. prior to initiation, participating pharmacists received structured, comprehensive training in pharmacogenetics. pharmacists then facilitated voluntary subject enrolment among patients who they believed would benefit from screening and met inclusion criteria. eligible patients received a simple buccal swab followed by dna analysis using pillcheck Ò . pillcheck Ò is a genotyping assay that translates genomic data and generates a personalized, evidence-based, report that provides insight into patients' inherited drug metabolic profile. upon receiving the report, pharmacists invited patients back to the clinic for interpretation of the results. clinically significant drug therapy problems were identified and recommendations for medication optimization were forwarded to the primary care physician. main outcome measures: number of clinically significant drug therapy problems identified by pharmacists as a result of pharmacogenomic testing. results: patients were enrolled in the study. average age was . years and patients were taking a mean of . chronic medications. pharmacists cited the most common reasons for testing as ineffective therapy ( . %), to address an adverse reaction ( . %), and to guide initiation of therapy ( . %). an average of . drug therapy problems were identified per patient. pharmacist recommendations included change in therapy ( . %), dose adjustment ( . %), discontinuation of a drug ( . %), and increased monitoring ( . %). generally, physician feedback was positive but did reveal an opportunity for a broader understanding of the technology. conclusion: these results highlight the readiness of community pharmacists to adopt pharmacogenetic screening into practice and their ability to leverage this novel technology to positively impact medication management. community pharmacists are ideally suited to both offer personalized medication services and interpret genomic results. please specify your abstract type: descriptive abstract (for projects) background and objective: visual impairment is a common geriatric syndrome and glaucoma/miotic eye drops treatment is a frequent therapeutic option. pharmacist's role in medication reconciliation is an effective process for reducing medication errors and supporting safe medication use. we observed that mentioned medication reconciliation was occasionally not performed during hospital stay and could be cause of delirium because of visual impairment. the aim of this study was to evaluate the influence of omission errors of eye drops treatment on incidence of acute confusional state. design: we conducted an observational, descriptive and retrospective study in an orthogeriatric unit with an average of patients with hip fractures per year ( % surgically treated). data collection was performed from june to march . reconciling medications at admission was performed by implementing the tools and resources of the canadian patient safety institute (cpsi). we extracted from our electronic database (filemaker pro Ò ): • demographic patient data (age and gender). • name and posology of the glaucoma/miotic eye drops treatment. • medication reconciliation performed and identification of professional in charge (pharmacist, geriatrician or orthopaedic surgeon) registration during hospital stay. • protocolar management of delirium with tiapride occasional intramuscular administration performed if necessary was also registered to establish the incidence of acute confusional state. results: thirty-two patients ( women and men) were included, median age year-old . in patients, eye drops reconciliation treatment was performed by the pharmacist in of the patients, the geriatrician in cases and the orthopaedic surgeon in . in patients, the mentioned medication reconciliation was not performed (pharmacist absentism). considering the patients on eye drops treatment during hospital stay, ( . %) of them suffer from acute confusional state. on the other hand, among the patients without medication reconciliation, delirium was registered in cases ( . %). concerning ocular topic treatment, . ± . active principles per patient were observed, being the most frequent timolol ( . %), brinzolamide ( . %) and latanoprost ( . %). conclusion: we consider of paramount importance the pharmacist evaluation availability at an orthogeriatric unit, minimizing the impact of acute confusional state during hospital stay by medication reconciliation. please specify your abstract type: descriptive abstract (for projects) background and objective: to report the therapeutic management of haemorrhagic rectocolitis onset in a lung-transplanted patient with mycophenolate-induced diarrhoea. design: case report. results: a -year-old-man lung transplant patient for alpha -antitrypsin deficiency in receiving mycophenolate mofetil, tacrolimus and corticosteroid developed chronic diarrhoea worsened by sigmoid and cecal necrosis in , and treated successfully by sigmoidectomy. severe diarrhoea attributed to mycophenolate mofetil reappeared in april , which motivated a switch to mycophenolate sodium. the absence of clinical improvement in june led to stop mycophenolate sodium and introduce azathioprine at mg/day (absence of mutation for the thiopurine methyl transferase gene). one month later, the patient presented melena, diarrhoea, bloating, nausea, and knee pain, attributed to azathioprine. this latter was stopped and mycophenolate mofetil was rechallenged associated with symptomatic treatment (i.e., diosmectite and loperamide). in january , a colonoscopy, performed in a context of profuse chronic diarrhoea with mucus during months, highlighted haemorrhagic rectocolitis. therefore, the patient initiated sulfazalasine therapy with no clinical improvement, and then high doses of oral corticosteroids. because high-dose of oral corticosteroids was not recommended as a long-term treatment, mercaptopurine was proposed as a new therapeutic option. mercaptopurine has no indication as an immunosuppressive treatment in solid organ post-transplant supportive care. however, as the active metabolite of azathioprin, an immunosuppressive drug widely used in transplantation, mercaptopurine has immunosuppressive functions towards t-lymphocytes. after multiprofessional collaboration between gastroenterology, pneumology and pharmacy specialists, it was decided to stop mycophenolate mofetil and introduce mecaptopurine at . mg/kg/day, as immunosuppressant for haemorrhagic rectocolitis as well as lung transplantation. this unusual lung transplant immunosuppressive therapy, associated with tacrolimus, improved digestive disorders and patient's quality of life. currently, mercaptopurine is biologically and clinically well tolerated. the dosage of blood residual concentrations of purinethol metabolites ( -thioguanine and -methylmercaptopurine) is going to be performed. conclusion: immunosuppressive therapy in solid organ transplantation is a real challenge for patients who have comorbidity onset. despite a lack of data in the literature, a multidisciplinary collaboration based on comprehensive pharmacology skills is essential to choose the best therapeutic option in this type of patients. please specify your abstract type: descriptive abstract (for projects) background and objective: the use of complementary medicines (cm) in oncology is the subject of broad but still controversial interest. a large part of patients with cancer uses cm, including complementary drugs, during their treatment period. indeed, according to different studies, this proportion ranges from to %. importantly, the risk of interaction between cm and anti-cancer drugs is not negligible; hence we need to identify these cm to ensure the security of our patients and the success of their treatment. design: to achieve this purpose, a monocentric retrospective analysis was conducted with collection of data by pharmacy students during medication reconciliation of hospitalized patients from january to june . collected data are patients' characteristics, prevalence of cm use and potential cm-anticancer drug interactions. results: patients were included in the study ( men- women); median age was [ - years]. a total of . % (n = ) were using a least one cm, most frequently homeopathy ( %, n = ) or phytotherapy ( %, n = ); some patients were using a combination of two cm ( %, n = ). cm are mainly used by women in comparison to men ( . % versus . % and p = . , chi square test). for phytotherapy, at least different herbs were described by patients and among them the most frequently used were mistletoe (viscum album), propolis and fireweed (epilobium angustifolium). data analysis showed that % (n = ) of patients were at risk of potential cm-anticancer drug interaction. moreover this risk was increased to % if we considered only patients taking phytotherapy. interactions included pharmacokinetic ( %, n = ), such as altered hepatic metabolism, and pharmacodynamics ones ( %, n = ). conclusion: in conclusion, our work clearly demonstrates that the use of cm by patients is associated with high risk of relevant drug interaction with their anti-cancer treatment. even if further investigations are necessary to clarify the clinical impact of these interactions, the use of cm must be considered during prescribing process. please specify your abstract type: research abstract background and objective: since their reimbursement, the direct oral anticoagulants (doacs) are increasingly used for stroke prevention in atrial fibrillation (af). the objective of this study was to identify the proportion of real life patients with af eligible for doac therapy, based on the inclusion and exclusion criteria used in the clinical studies and based on the officially approved indications as mentioned in the summary of product characteristics (smpc). setting and method: data for this retrospective cross-sectional study was extracted from the uz brussel stroke registry, containing anonymized data of patients with a suspected stroke. characteristics of patients with documented af were compared with the patient characteristics in clinical trials and the approved indications in the smpc. main outcome measures: proportion of real life patients with af eligible for doac therapy. results: data of patients with af was analysed. based on the selection criteria of the clinical trials, significantly less patients were eligible for treatment with rivaroxaban compared to dabigatran etexilate ( . % versus . %; p = . ), but not compared to apixaban ( . %; p = . ). based on the indications and contraindications in the smpc, significantly fewer patients were eligible for apixaban compared to dabigatran etexilate and rivaroxaban ( . % for apixaban, . % for dabigatran etexilate and . % for rivaroxaban; p \ . and p \ . , respectively). significantly more patients were eligible for doac therapy based on the indications and contraindications in the smpc compared to the inclusion and exclusion criteria of the clinical trials ( . % versus . %; p \ . for dabigatran; . % versus . %; p \ . for rivaroxaban and . % versus . %; p \ . for apixaban). conclusion: when taking into account the selection criteria from the pivotal clinical trials with doacs for stroke prevention in af, less than half of real life patients are eligible for therapy with one of the doacs. however, the indications mentioned in the smpcs of these drugs are less strict. please specify your abstract type: research abstract background and objective: idiopathic pulmonary fibrosis (ipf) is a disease in which tissue deep in the lungs becomes thick and stiff, or scarred, over time. the formation of scar tissue is called fibrosis. pirfenidone is an anti-fibrotic and anti-inflammatory agent, thus offers a new hope for treating progressive fibrotic diseases. int j clin pharm ( ) : - our objective is to set a description of idiopathic pulmonary fibrosis patients treated with pirfenidone, as well as the adverse reactions observed. setting and method: descriptive study in which all patients have received pirfenidone. the data were obtained through the dispensing program of outpatient (farmatools) and review of medical records of the hospital database (archinet) and clinical station (diraya). main outcome measures: we have extracted from each patient baseline data, comorbidities, dose received, reported adverse reactions and data about haematology and biochemistry. results: we have a total amount of patients treated with pirfenidone, all diagnosed with idiopathic pulmonary fibrosis, including women and men. the age of patients is between and years, with an average of . years. all patients are ex-smokers and one of them is also ex-alcoholic. concerning concomitant pathologies, patients have diabetes mellitus, have arterial hypertension, and one of them has ischemic heart disease. another has upper gastrointestinal bleeding prior, among others chronic pathologies. pirfenidone dose received was the usual dose in of the patients: days - mg every h, days - mg every h and a maintenance dose of mg every h. in one patient due to its low imc the dose received was smaller ( - days mg every h, days - mg every h and maintenance dose of mg every h). in relation with the adverse effects, digestive discomfort were observed in of the patients, causing the interruption of the treatment in one of them (with prior gastrointestinal bleeding). in the other patient it was relieved by lowering the dose received. also, one patient has experienced photosensitivity. alterations in transaminase levels were observed in patients but that didn't force to discontinue the treatment. no alterations were observed in the blood count. conclusion: treatment with pirfenidone is being generally well tolerated by patients. it has improved their life-quality and reached the objective data of a slowdown in disease progression. currently, the number of patients is no enough to give conclusive information in relation to the drug effectiveness. please specify your abstract type: research abstract background and objective: to describe the total amount of patients treated with a magistral formula of sodium cromoglycate mg without excipients: indications, concomitant therapy and the response to therapy. setting and method: we run a descriptive study in which we included the totality of patients in treatment with a magistral formula of sodium cromoglycate mg without excipients in a tertiary hospital. the data were obtained through paracelso (development of magistral formulas program), as well as with farmatools (dispensation program of outpatient) and the review of medical records from the hospital database (archinet), and diraya clinical station. main outcome measures: from each patient we extracted data relative to sex, age, diagnosis, time in treatment with the formula, dose received, response to therapy, concomitant antihistamines treatments and adverse effects. results: a total of patients in treatment with a magistral formula of sodium cromoglycate mg without excipients were reviewed: women and men with a mean age of . years old (range - years). regarding the indication of the prescription, patients have been diagnosed of indolent systemic mastocytosis and the remaining were diagnosed of mast cell activation syndrome. in all cases, the diagnosis was established by examination of the bone marrow in the mastocytosis studies institute of castilla la mancha (spain). on average, patients took the treatment . months, with a range between months and months. the dose received was mg every h in patients, having to be increased to mg times daily in a case with poor response to the therapy. in the remaining patients, the treatment response has been optimal. in relation to the concomitant anti-allergic treatment received, patients took fexofenadine daily during the study. no cases of adverse effects related to the therapy received have been reported. conclusion: both indolent systemic mastocytosis and mast cell activation syndrome are considered rare diseases, and we should indicate that in spain there are no commercial medicines available of sodium cromoglycate without excipients for its treatment. the treatment with this magistral formula of sodium cromoglycate mg without excipients has been effective and well tolerated in all patients, improving the symptoms associated with their condition as well as their quality of life, and also, assuming a solution to the lack of marketing of the drug currently in spain. please specify your abstract type: research abstract background and objective: to analyse the prescription profile, safety and effectiveness of new therapies available for the treatment of hcv genotype b in a tertiary hospital. setting and method: we run a retrospective observational study in which we included a total amount of patients infected with hcv genotype b treated with the new therapies against hcv from february to december in a tertiary hospital. the data were obtained through the outpatient dispensing program farmatools and the review of the medical records from the hospital database, archinet and prescription hepatitis c portal of the andalusian health service. main outcome measures: from each patient the following information was collected: sex, age, viral genotype (gen.), naive/nonnaive, hiv coinfection, presence of cirrhosis, degree of hepatic fibrosis measured by fibroscan, treatment prescribed and duration, adverse effects, sustained viral response (svr) and the service that made the prescription. results: a totality of patients with hcv gen. b were reviewed which . % of them were men with a mean age of . years (range - years). of the patients were naive and only of them were hiv co-infected, there were a . % of cirrhotic patients. regarding the degree of hepatic fibrosis, patients had grade f , f grade patients, patients grade f and f grade patients. the most commonly therapy prescribed was lepidasvir + sofosbuvir in patients ( without ribavirin and with ribavirin ) using a treatment schedule of weeks in of them. the treatment was discontinued in one case because of the adverse effects, achieving svr in the remaining patients. the combo treatment with paritaprevir/ombitasvir/r + dasabuvir was prescribed in times ( without ribavirin and with ribavirin) choosing only in one of them for a treatment period of weeks. there were no treatment discontinuations and svr was achieved in all patients treated in this way. patients received simeprevir + sofosbuvir for weeks ( without ribavirin and with ribavirin), one patient of the left the treatment due to adverse effects. svr was found in the remaining patients who completed treatment. sofosbuvir + daclatasvir was prescribed to patients, associating ribavirin in only one case. a treatment duration of weeks was used in patients and weeks in the remaining two. one patient failed rvs without any incidences of adverse effects in any case. interferon + ribavirin sofosbuvir + was prescribed to patients in -week regimen which was well tolerated achieving svr. digestivo service treated the % of the total amount of patients. conclusion: new therapies for hcv have been used in all the treated patients and the older drugs have been relegated. about the effectiveness, svr was achieved in . % of patients. regarding the safety, only patients have discontinued the treatment due to adverse effects representing less than % dropout rate of the therapy. please specify your abstract type: descriptive abstract (for projects) background and objective: thanks to pharmacogenetics we can identify and predict different responses to the same drug among different individuals. during these last years we have noted a big increase of dosing guidelines and advices about the use of several drugs due to the influence of different polymorphisms. the aim of this study is to describe and evaluate the use of pharmacogenetics in our hospital from april , when we started our first research about pharmacogenetics, to the actual time, using these information in our daily clinical practice; and indeed quantify the number of different tests and the number of different clinical advices done because of pharmacogenetic information, by different healthcare specialty areas and drugs. design: we reviewed all the pharmacogenetic test requests in our hospital from april to april , noting which health specialty and for which drug was asked the test. polymorphisms were genotyped using taqman Ò genotyping assays technology by independent laboratories to confirm the results. results: from april we were asked for pharmacogenetic tests from different healthcare specialty areas: rheumatology ( . %), infectious diseases ( . %), oncology ( . %), cardiology ( . %), vascular surgery ( . %), neurology ( . %), ophthalmology ( . %); this information was asked about different drugs: clopidogrel ( . %), trastuzumab ( . %), ranibizumab ( . %), azathioprine ( . %) and tocilizumab ( . %). from all the genotypes, ( . %) were done after using the drug (study phase) and ( . %) were done previous to the use of the drug in daily clinical practice to make a ''clinical recommendation''; from these recommendations affected to the prescription of clopidogrel. conclusion: during the last years we could implement the use of pharmacogenetics in the daily clinical practice in our hospital in different healthcare areas affecting drugs and we started research studies previous to its use on the clinical practice for other three different drugs. please specify your abstract type: descriptive abstract (for projects) background and objective: the drug burden index (dbi) is a tool used to quantify the anticholinergic and sedative burden of medication on an individual. it has been independently associated with poor physical and cognitive performance in community-dwelling older people. objectives were: to create an inventory of medications used in ireland with clinically significant anticholinergic and/or sedative activity and to decide upon the minimum daily dose (mdd) for each medication. design: medications with potential anticholinergic and/or sedative burden were identified by literature review and examination of the summary of product characteristics (smpc) for all medications registered in ireland. each medicine was classified as anticholinergic or sedative. drugs with both anticholinergic and sedative properties were classified as primarily anticholinergic. the mdd, a key component of the dbi score calculation, was selected by reference to the irish smpc. other options which were also considered for this value include the defined daily dose (ddd) of a medication, as available from the world health organisation (who), and the mdd as outlined in the british national formulary (bnf). mdds were decided upon regardless of indication as the lowest effective therapeutic dose as specified in the smpc for the medication. the final list of medicines and mdds to be included in the inventory was then defined by consensus of three pharmacists. results: in total, medicines with potential anticholinergic and/or sedative activity were considered for inclusion. a final list of medications was identified by consensus ( anticholinergic, sedative). of these, ( %) were agents which act primarily on the nervous system. the three main therapeutic groups contributing to the inventory of dbi medications were antipsychotics ( medications), antidepressants ( medications) and antiepileptics ( medications). conclusion: creation of an inventory of medications with anticholinergic and/or sedative properties, in combination with the individual mdds, was achieved. this is a useful resource for use in analysis of drug burden in an older population. it could help in both identifying patients who would benefit from medication review as well as analysing population medication data. please specify your abstract type: research abstract background and objective: vancomycin is an antibiotic widely used to treat infections such as bacteraemia, infective endocarditis, osteomyelitis, meningitis and pneumonia. nowadays, optimal trough concentration is stablished between and mg/l to avoid development of resistance or - mg/l to improve penetration in complicated infections. some articles have been published explaining the methodology to calculate an expected trough level in steady state. our aim was to compare the trough serum value estimated by the mathematical method with a two-compartimental bayesian forecasting model. setting and method: observational retrospective study carried out in a tertiary hospital from january to december . non obese adult patients with creatinine clearance (crcl) \ ml/min and who have achieved steady state level were included. vancomycin serum values were measured using a chemiluminescence's immunoassay (cmia) and bayesian analysis was performed with abbottbase pksystem Ò (pks Ò ). the statistical analysis was made with medcalc software Ò . bland-altman plot and passing-bablok regression were used to compare both methods. main outcome measures: sex, age, weight, dose, creatinine, and size were collected from clinical history. serum trough values (cminr) were collected from cmia. trough values were estimated using two methods: mathematical method (cminf) and bayesian calculations (cminb). results: patients were included, with a mean age of (± . ) years. % were male and % female. they received a median dose per h of ( - ) mg. the mean of cminr was . mg/l ( % ci . - . ), cminb . mg/l ( % ci . - . ), cminf . ( % ci . - . ) . correlation coefficients (r) comparing both methods were significantly different: r between cminf and cminr was . ( % ci . - . ), while r between cminb and cminr was higher: . ( % . - . ). bland-alman plot analysis showed both methods cannot be used interchangeably. the regression equations estimated by passing-bablok regression were y = - . + . x and y = - . + . x. conclusion: bayesian method has demonstrated better correlation with real measures than mathematical method. most part of our patients could be underestimated or overestimated using mathematical methods which could cause toxicity or lack of efficacy, so this method is unsuitable for clinical use. bayesian estimation remains the best option for optimal dosing of vancomycin. please specify your abstract type: research abstract background and objective: combination therapy with digoxin and acenocoumarol is common in patients with atrial fibrillation (af). getting optimal concentrations of digoxin leads an appropriate response; taking into account its narrow therapeutic range and all the factors which can affect to its pharmacokinetics. interaction between them has been studied, even though its mechanism is not clear yet. patients who are taking both drugs need higher doses of digoxin; because they get lower concentrations by using the same dosage. the objective of this study was to analyse digoxin concentrations in patients treated with this combination compared to expected concentrations according to population parameters. setting and method: retrospective observational study from december to march performed by pharmacokinetic unit. patients included had chronic treatment with acenocoumarol and digoxin, which determination were realized in the steady state before the next dosage. patients with toxics concentrations of digoxin, or who were suspected nonadherence, were excluded. the plasma digoxin concentrations were determined through the autoanalyzer architect c- Ò (petinia). dosage adjustment was realized by the program abbot pharmacokinetics system (pks). a comparative between the real measured concentrations in patients and estimated concentrations were realized based on population parameters. finally, in order to get optimal concentrations, some dosage changes were proposed based on pharmacokinetic monitoring. data collected: population characteristics (gender, age, weight, and height), analytical data (potassium, urea, creatinine and clearance). main outcome measures: digoxin serum concentrations (optimal range . - ng/ml). results: data from patients, . % women with a mean (sd) age of . ( . ) years were included in the study. at baseline, potassium, urea, creatinine and clearance mean (sd) was . ( . ) mmol/l; . ( . ) mg/dl; . ( . ) mg/dl; . ( . ) ml/min. . % of the patients had lower concentrations than expected according to population parameters. finally, digoxin dosage was increased in . % of patients, it was maintained in . %, and it was decreased in . %. conclusion: digoxin concentrations in patients with af in combination therapy of digoxin and acenocoumarol are lower than would be expected in most cases. it is important monitoring digoxinaemia to achieve optimal concentrations and a good clinical response. further studies are needed to determine the relevance of this interaction in clinical practice. please specify your abstract type: research abstract background and objective: tocilizumab (tcz) is a humanized monoclonal antibody inhibitor of il- receptor, indicated in combination with methotrexate in the treatment of rheumatoid arthritis (ra) in patients with inadequate response or intolerance to prior therapy. interleukin is involved in the pathogenesis of rheumatoid arthritis via its broad effects on immune and inflammatory responses. previous studies have shown that c-allele at the - g[c (rs ) polymorphism is related with a bad response to tocilizumab (according to eular criteria). the aim of our study was to explore the potential role of il- genetic polymorphisms as a predictor of tocilizumab efficacy in rheumatoid arthritis (ra) patients and check this association depending on the genotype. setting and method: the il- (g[c) (rs ) genetic variant was genotyped using predesigned taqman Ò genotyping assays technology and analysed on a viia Ò real-time pcr system. main outcome measures: clinical response was evaluated at , , and months according to the eular criteria. patients were classified as ''responders'' (good and moderate response according to eular criteria) and ''non-responders''. the statistical analysis was performed using spss v. . results: we recruited patients with ra treated with tocilizumab, these were aged . ± . (mean ± sd), ( %) were women. the mean das at baseline was . ± . . of these patients, the il- g[c genetic polymorphism was significantly associated with ''responders'' at months after the baseline (cc vs non-cc p = . , or . , % ci . - . ) but not at (p = . ), (p = . ) and (p = . ) months. conclusion: the il- g[c may be useful as a genetic marker of tocilizumab efficacy at months. other polymorphisms, clinical parameters and other pharmacological treatment during the follow-up may be checked about their influence on the response to tocilizumab. tdmp : daptomycin pk/pd profile in neutropenic cancer patients with beta-lactam-resistant gram-positive infection nancy perrottet *, , frederic tissot , laurent decosterd , thierry buclin , guy prod'hom , christina orasch , oscar marchetti , farshid sadeghipour , , thierry calandra , véronique erard pharmacy service, infectious diseases service, laboratory and division of clinical pharmacology, service of biomedicine, institute of microbiology, lausanne university hospital, lausanne, school of pharmaceutical sciences, university of geneva, university of lausanne, geneva, switzerland please specify your abstract type: research abstract background and objective: the pharmacokinetics (pk) and pharmacodynamics (pd) of many antibiotics are modified in neutropenic patients and few data are available on daptomycin in this population. this prospective study aimed to assess the pk/pd profile of daptomycin in the treatment of neutropenic patients with beta-lactamresistant gram-positive cocci infections. setting and method: this substudy was performed in the context of a prospective pilot study on daptomycin versus vancomycin in adult hemato-oncological patients with febrile neutropenia and proven or suspected infection with methicillin-resistant staphylococci or betalactam-resistant enterococci. patients received daptomycin mg/ kg/day ( mg/kg/day for enterococci) for c days as a -min infusion. main outcome measures: pk analysis using a published non-linear mixed effect model with nonmem Ò , followed by comparison of parameters with values published for healthy subjects. pd analysis based on auc/mic (area under the concentration-time curve/minimal inhibitory concentration). according to eucast, an auc/mic ratio [ is required for bacteriostatic effect against staphylococci and [ for a two-log reduction in bacterial count. for e. faecium, an auc/mic ratio of . has been suggested for bacteriostasis and . for a -log bacterial count reduction. results: model-derived mean auc observed in patients was . ± . mg h/l, maximum concentration (cmax) ± mg/ l, minimal concentration (cmin) . ± . mg/l. clearance was . ± . l/h and volume of distribution at steady sate . ± . l, both values found higher than those reported in healthy subjects. all patients ( / ) with a staphylococcal infection achieved auc/mic values predictive of bacteriostatic effect on staphylococci, and out of values associated with two-log bacterial killing. of note, infection relapse occurred in the only patient with suboptimal daptomycin exposure (auc/mic of ). the pd targets were also reached in the two patients with e. faecium infection. an asymptomatic elevation of creatine phosphokinase was reported in two patients ( u/l and u/l) with cmin of . and . mg/l, respectively. conclusion: daptomycin pk profile in neutropenic cancer patients indicated higher total clearance and volume of distribution, along with lower total exposure, compared to healthy subjects. despite this, standard dosages allowed attainment of pd targets in / patients with a staphylococcal infection (two-log drop) and / with e. faecium infection ( -log drop) . please specify your abstract type: research abstract background and objective: individual clinical response to infliximab can be influenced by their pharmacokinetics and immunogenicity, so therapeutic monitoring of drug levels (tdm) can guide these biologic treatments. the objective was to analyse the suitability of serum infliximab trough levels (sitls) in patients with inflammatory bowel diseases (ibd) receiving dose schemes based only on clinical response. setting and method: prospective and descriptive study of patients with ibd treated with infliximab and under tdm. medical records were reviewed. dose schemes were established according to clinical guidelines ( mg/kg every weeks) and optimized based on an index of clinical response (mayo, pcr…). sitls (therapeutic range - mcg/ml) and anti-drug antibodies (ada) were measured in all of patients by elisa (promonitor Ò ). ada presence was considered as a therapeutic failure indicator. informed voluntary consent was obtained from all patients. main outcome measures: sitls and ada. results: a total of patients, with a median age of years (range ), were included in the analysis. infliximab standard dose according to clinical guidelines were administered to patients: . % showed sitls under the therapeutic range ( . % with ada). in eight patients with maintained good clinical response, dose decrease or interval elongation had been implemented: % of these patients showed sitls below the therapeutic range ( % with ada). it had been necessary to increase the dose or shorten the interval in patients due to inadequate clinical response: . % of these patients with sitls below the therapeutic range ( % with ada). conclusion: optimization based on clinical response of infliximab treatments in patients with ibd is not always an effective strategy, since it leads to a high percentage of patients with sitls below the therapeutic range and adas. tdm together with clinical response should guide the optimization of infliximab treatments. please specify your abstract type: research abstract background and objective: in addition to its anticonvulsive properties, valproate is also used as a mood stabiliser in bipolar disorder and as augmentation treatment of other psychiatric disorders. the unpredictable relationship between dose-plasma valproate concentrations and correlation between concentrations-efficacy suggest therapeutic drug monitoring (tdm) of plasma valproate concentrations might be useful. the aim of our study was to evaluate the rationale of a new protocol for measuring valproate concentrations and the incorporation of a clinical pharmacist in the process of valproate tdm service, compared to pre-existing standard measuring. setting and method: in the retrospective study we analysed the process of measuring plasma valproate concentrations at the department of psychiatry and at the unit for forensic psychiatry of a large teaching hospital in slovenia before the enrolment of a clinical pharmacist. for the prospective study we created a protocol for tdm of valproate in adults based on literature research. the protocol included reference range, sampling time, indications for sampling and schedule of other laboratory tests that have to be monitored during valproate therapy. main outcome measures: percentage of plasma valproate concentrations in reference range (c trough = - mg/l) before/after the enrolment of a clinical pharmacist, percentage of measured valproate c trough . results: in the retrospective study randomly chosen patients with measured plasma valproate concentrations were included ( % male, age ± years, length of hospital stay ± days). plasma valproate concentrations were measured . ± . times per patient, % were in the reference range (other % subtherapeutic), % were drawn at c though , . % were drawn for assessing compliance (nontrough). in the prospective study patients were included ( % male, age ± years, length of hospital stay ± days). plasma valproate concentrations were measured . ± . times per patient, % were in the reference range (other subtherapeutic), % were drawn at c trough , . % were drawn for assessing compliance. conclusion: the inclusion of a clinical pharmacist in valproate tdm service increased the number of valproate plasma concentrations in the reference range by almost % and increased the number of concentrations drawn at c trough , when indicated. including a clinical pharmacist in valproate tdm is beneficial and the new protocol is useful for optimising valproate therapy. concurrent and predictive validity of a self-reported measure of medication adherence the effect of pharmacist-led interventions in optimising prescribing in older adults in primary care: a systematic review aflibercept: . neovascular membranes with visual acuity higher than . . one eye affection severe cardiovascular pathology (severe episodes in the last months) non-responders to other anti-vegf bevacizumab: . diabetic macular edema macular edema secondary to vascular pathology setting and method: a longitudinal study was carried out in primary care centres. participants: patients aged c , under treatment with or more drugs and belonging to primary care areas in different towns. patients should have at least one of the following potential safety problems: (a) concomitant use of a non-steroidal anti-inflammatory drug (nsaid) with an antihypertensive drug, anticoagulant or antithrombotic drug; (b) use of two or more benzodiazepines. two clinical management units (cmu) were randomized per area to be included in the study. thirty patients per cmu were randomized to be enrolled and monitored during months number of adverse effects ( . ; p \ . ) and number of clinical problems ( . ; p \ . ).with each year increase in age ) and a significant rise in physician ( . ; p \ . ) and nurse ( . ; p \ . ) home visits. women compared to men resulted in a significant decrease ) but a significant increase in visits to nurses ( . ; p \ . ), hospital admissions ( . ; p \ . ) and hospital visits ( . ; p \ . ). age, sex and npsp had no significant effect on falls, fractures or cardiovascular events. conclusion: the npsp in elderly patients contributes to an increase in the use of health services and comorbidity. effective interventions should be addressed to general practitioners to reduce inappropriate prescriptions bpa was found in the dialysate ( ng/l) and ls ( ng/l) wherein the concentration of bpa decreases over time to reach ng/l at the end of a session. finally, bpa was present in all tested dialysis at concentrations of up to . ng/dialyzer in the compartment mimicking the blood and to . ng/dialyzer in the dialysate despite prior rinsing with l of . % nacl. conclusion: our study is the first one to show the risk of exposure to bpa and bpa-clx hdf-ol. while assessment of the impact of this exposure in a patient under treatment remains to be done, it is now possible to better master contamination by bpa and its four chlorinated derivatives through better practices (choice of medical devices) and improvement of the overall water treatment process san cecilio university hospital, genomic unit san cecilio university hospital, genomic unit, genyo, centre for genomics and oncological research the aim of this study is to compare the apparition of stroke, acs, cardio-vascular death and the need of surgery in patients after percutaneous transluminal angioplasty (pta) or stroke depending on the presence of cyp c * * polymorphisms. setting and method: retrospective cohort study. we recruited patients treated with clopidogrel after a pta of the lower limb or stroke (without surgery) from to in our hospital. data collected: age, sex, cyp c * (rs ) and cyp c * (rs ) genotypes and the primary end-point: stroke, acs, cv death and surgery of the affected vessel during months after discharge. polymorphisms were genotyped using taqman Ò genotyping assays technology. main outcome measures: we recruited patients with stroke ( . % men; mean age . ) and patients after pta ( . % men; mean age . ) treated with clopidogrel after discharge %) suffered the primary end-point during months after discharge; of these patients had the cyp c * allele. among patients with pta of the lower limb: % of them had the cyp c * allele and no one a cyp c * allele; ( . %) of these patients suffered the primary end-point during months after the discharge and of these had the * allele of the cyp c isoenzyme * allele and treated with clopidogrel have a higher risk of the primary end-point than those patients not carrying it spain please specify your abstract type: research abstract background and objective: the engagement of fcgrs by tnf antagonists could affect to macrophage-mediated clearance of immune-complexes. the aim of our study was to evaluate the potential role of fcgr a (a[c) (rs ) single nucleotide polymorphism (snp) as a predictor of tocilizumab efficacy in rheumatoid arthritis (ra) patients. setting and method: the fcgr a (a[c) (rs ) snp was genotyped using predesigned taqman Ò genotyping assays technology and analysed on a viia Ò real-time pcr system. the statistical analysis was performed using spss v the mean age of the patients was . ± . years and % were women. the mean das at baseline was . ± . . we found no statistically significant association between our end-point and the genetic polymorphisms studied tdmp : therapeutic drug monitoring of infliximab biosimilar and anti-infliximab antibodies in inflammatory diseases patients with dermatological conditions and inflammatory bowel disease being treated with ifx-b ( mg/kg/ weeks after the induction dose) were included. the concentrations of ifx-b and ati-b were quantified by two sandwich-type elisa immunoassays (triturus Ò analyser). main outcome measures: plasma levels of ifx-b and ati-b, clinical response and infusion reactions. the clinical response was assessed according to pathology of each patient (based on specific clinical variables for the pathology into the electronic history) pharmacokinetic results (% assessments): (a) . % no ifx-b detection (c \ . mcg/ml) and positive ati-b (c [ ua/ml) ( assessments/ patient). atis = , y ua/ml. no clinical response (nr) in . % assessments. (b) . % ifx-b and ati-b (c b ua/ml) no detection ( assessments/ patient). nr %. (c) . % ifx-b detection (c [ . mcg/ml) and negative ati-b ( assessments/ patients) weight: ( - ) kg. twenty assessments, . ( - ) assessments per patient, ( - ) ifx-b doses, % concomitant treatment ( / -azathioprine, / -corticosteroid) the incidence of ati-b was low. a correlation was observed between the presence of ati-b and loss of clinical response, as infliximab original. tdmp : serum concentration of non-vitamin k antagonist oral anticoagulants (noacs) in older hip fracture patients ina linnerud , mette i martinsen estimation of t of noacs by t / = ln /kel [kel; elimination constant] using two s-concentration measurements. results: we included patients (median age years, . % women). noac use was detected be serum analysis in patients ( . %; % coherent with mr), while patients ( . %) used warfarin. of the noac users ( . %) had s-concentrations of noacs above the reference range at admission, and five patients ( . %) had s-concentrations within the reference range before surgery. patients using noac had significantly longer median waitingtime for surgery than warfarin-users ( vs h, p = . ). blood transfusions were given to . % of noac-users vs . % of warfarin-users (p = . ). mean estimated t of noacs were , . and . h for dabigatran (n = ), apixaban (n = ) and rivaroxaban (n = ), respectively. conclusion: mr is effective in detecting noac use in older hip fracture patients, but importantly s-concentrations are higher than expected in this population. this might reflect the significantly longer waiting-time for surgery this column is supplied with packing material made of totally porous spherical silica coated with a silicone polymer monolayer containing octadecyl (c ) groups. the mobile phase was composed of . % na po h o (ph . ), acetonitrile, and methanol ( : : , v/v/v), which was degassed in an ultrasonic bath prior to use. the flow rate was . ml/min at ambient temperature and sample detection was carried out at nm. plasma samples were obtained from patients with cml receiving nilotinib treatment. sampling was performed at the steady state. blood samples were collected by venipuncture h after oral administration of nilotinib. plasma was separated by centrifugation at g for min and stored at - °c until analysis. plasma samples ( ll) were then extracted as described above. the same samples were also sent to a commercial laboratory (bml, inc.) for assaying nilotinib concentration by liquid chromatography-tandem mass spectrometry (lc-ms/ms). in addition, we applied this method to tdm of cml patients receiving nilotinib at our hospital. main outcome measures: the calibration curve exhibited linearity over the nilotinib concentration range of - ng/ml at nm, with relative standard deviations (n = ) of . , . , and . % for , , and ng/ml, respectively. the detection limit for nilotinib was ng/ml due to three blank determinations (q = ). in addition, we compared the results with those measured by lc-ms/ ms at bml, inc. (a commercial laboratory). as a result, a strong correlation was observed between the nilotinib concentrations measured by our hplc method and those obtained by lc/ms-ms (r = . , p \ . ). in addition, tdm of nilotinib was performed to six cml patients. there was the case which participated in dosage adjustment of nilotinib in hepatic dysfunction and poor glycaemic control. results: we have developed a simple ultraviolet detection method for the determination of nilotinib, which has high sensitivity and large dynamic range please specify your abstract type: research abstract key: cord- - ae p w authors: liu, yu; saltman, richard b. title: establishing appropriate agency relationships for providers in china date: - - journal: inquiry doi: . / sha: doc_id: cord_uid: ae p w physicians play multiple roles in a health system. they typically serve simultaneously as the agent for patients, for insurers, for their own medical practices, and for the hospital facilities where they practice. theoretical and empirical results have demonstrated that financial relations among these different stakeholders can affect clinical outcomes as well as the efficiency and quality of care. what are the physicians’ roles as the agents of chinese patients? the marketization approach of china’s economic reforms since has made hospitals and physicians profit-driven. such profit-driven behavior and the financial tie between hospitals and physicians have in turn made physicians more the agents of hospitals rather than of their patients. while this commentary acknowledges physicians’ ethics and their dedication to their patients, it argues that the current physician agency relation in china has created barriers to achieving some of the central goals of current provider-side health care reform efforts. in addition to eliminating existing perverse financial incentives for both hospitals and physicians, the need for which is already agreed upon by numerous scholars, we argue that the success of the ongoing chinese public hospital reform and of overall health care reform also relies on establishing appropriate physician-hospital agency relations. this commentary proposes essential steps to establish such physician-hospital agency relations: ( ) minimize financial ties between senior physicians and tertiary-level public hospitals by establishing a separate reimbursement system for senior physicians, and ( ) establishing a comprehensive physician professionalism system underwritten by the chinese government, professional physician associations, and major health care facilities as well as by physician leadership representatives. neither of these suggestions is addressed adequately in current health care reform activities. chinese health system development and economic reforms in the past years have nurtured the current unique physician agency relations in china. between and , the chinese health care system was designed with the objective to provide "equal access for all regardless of ability to pay," an ideology championed by the chinese communist party under mao zedong. to achieve this goal, the chinese government inquiry assumed control of all aspects of health care and delivery-it provided funding for the construction of hospitals and clinics, paid health workers a fixed salary, and set the prices for medicines and services. at that time, all physicians became employees of public hospitals, establishing the foundation of the current dominating role of public hospitals, especially tertiary-level public hospitals in china. while the post- economic reforms and the marketoriented approach have helped develop the chinese health care system (eg, the number of hospitals in china has increased from to between and ), new challenges have also emerged. first, governmental subsidies to public health care facilities declined dramatically after . the government's subsidies to public hospitals fell to merely % of their total expenditures by the s, and % or more of chinese public hospitals' revenue continued to depend on drug sales and services in . while chinese public hospitals continued to have a bureaucratic and complex government-run regulation and management system, they also were expected to behave like for-profit entities to earn profit to survive and to continue being competitive in the health care market. second, because laborrelated medical services remained underpriced, the chinese government set a higher margin rate for high-technology procedures and diagnostic tests, and hospitals are allowed to charge a % to % mark-up on drug sales ( % for western medicine and % for traditional chinese medicine). such policies provided financial incentives for hospitals to begin a "medical arms race" to scale up their provision of high-technology diagnostics and interventions, as well as to overprescribe drugs. [ ] [ ] [ ] third, most of senior physicians' income from hospitals is still a combination of basic salary and bonus, with the bonus coming from hospitals' financial profit. to increase their hospital's profit, hospital management tied the physicians' bonus to their contribution to hospital profits, which has intensified the overprescription of drugs and overuse of diagnostic tests. , , , [ ] [ ] [ ] [ ] [ ] [ ] such an extrinsic bonus incentive method may also "crowd-out" physicians' intrinsic concerns for other important aspects of health care, for example, the health care quality and population health. some scholars have commented that these financial incentives even may have directly eroded physicians' ethics. , because of this strong alignment of financial incentives, senior physicians in effect can become more the agents for public hospitals rather than for their patients. there has been concern in the past that the rise of china's promarket health care delivery system between and had sown the seed for a major public health breakout, sars (severe acute respiratory syndrome), in in china. the sars epidemic combined with other health services issues, for example, increasing out-of-pocket health care expenditures and insurmountable access barriers to health care (in a popular chinese proverb: kanbingnan, kanbinggui), led to a comprehensive health care reform in . although some researchers may not completely agree, by , this chinese health care reform has achieved significant progress toward the first goals set in , including expanding social insurance coverage and public health services, improving the primary care delivery system, and establishing an essential medicines system. however, by , the pilot public hospital reforms in cities had failed to deliver meaningful results, and the progress of public hospital reforms had been slow. currently, public hospital reform remains one of the major issues on the chinese health care reform agenda. the number of public hospital reform piloting cities expanded to in , and all the city-level public hospitals and hospitals above this grade were expected to be undergoing reform by . the chinese government believed that health care reform had already entered the "deep water zone" in that public hospital reform was the most difficult component. in the chinese state council's "the thirteenth five-year plan for deepening healthcare system reform," the government listed several aspects of public hospital reform as one of the most important tasks. in addition to the general public hospital reform challenges shared with other countries (eg, the structural sources and the contextual sources summarized by edwards and saltman), china's current public hospital reform confronts several unique challenges. among these unique challenges is the lack of appropriate and clear physician agency relations caused by the combination of the dominating role of tertiary-level public hospitals, public hospitals' profitdriven behaviors, the existing strong financial ties between physicians and public hospitals, and the lack of a comprehensive physician professionalism system. chinese hospitals can be categorized as "public" and "nonpublic" by registration status, or "government owned," "social enterprise owned," and "investor owned" by ownership status. in this commentary, we use "private hospitals" as a general category for the "non-public hospitals." since , the former chinese ministry of health established a hospital accreditation system to categorize hospitals into grades ( , , and ), as well as within-grade levels (a, b, and c), mainly based on size ( - beds for primary hospital, - for secondary hospital, and above for tertiary hospital), and other factors including service, technology, and quality. almost all the tertiary-level hospitals are public hospitals. public hospitals hold a dominate position in terms of patient volume, medical technology, and high-quality practitioners. the percentage of total inpatient admissions made by public hospitals was about % by , the percentage of inpatient admissions by government-owned hospitals remained about % between and , and the percentage of inpatient admissions at tertiary-level hospitals during this latter period actually increased from % to % (see table ). the dominating role of public hospitals also can be observed in variation of occupancy rates: in , the bed occupancy rate was . % for public hospitals, . % for tertiary-level public hospitals, as against . % for private hospitals. public hospitals accounted for . % of the inpatient surgeries as of . public hospitals also are the employers of most high-quality practitioners, for example, . % of practicing physicians worked at public hospitals and . % of registered nurses worked at public hospitals as of . the public data from china health statistical yearbook are available up to ; however, based on the trend between and , the dominating role of tertiarylevel public hospitals has not changed much since . for example, china's public hospitals accounted for more than % of both inpatient and outpatient care as of . for most tertiary-level public hospitals, senior physicians are the attending physicians who control and manage a number of hospital beds, serving also as leader of a group of junior physicians and residents. attending or senior physicians have a significant role in generating hospitals' revenue, and such revenue is tied to his or her own income as mentioned above. therefore, even though physician-agency relation issues exist at all levels of public hospitals as well as private hospitals, the financial relation between specifically tertiary-level public hospitals and senior physicians remains a major barrier for the recent provider-related health care reform activities discussed below, reflecting the dominating medical role of tertiary-level public hospitals in china's health care system. as part of its new round of health care reform in , the chinese government tried to improve the overall efficiency, access, and quality of care with a series of provider-related policies. these policies include ( ) promoting private hospitals owned by domestic social capital and foreign investors, ( ) further establishing physicians' multilocation practice systems, and ( ) eliminating the drug mark-up for public hospitals. however, the current unbalanced set of physicianagency relationships has become one of the major barriers to the success of these reform measures. since , a new round of health care reform returned to a market-oriented direction for provider-related reforms, with promoting private hospitals as a major policy. the chinese government hopes to create competition among current lowefficiency public hospitals with newly established private hospitals, to improve the overall efficiency and quality of the entire health care system. the "national planning guideline for the healthcare service system ( - )" released in reemphasized "strongly develop non-public healthcare facilities" as one of the concrete tasks, though the government's goal of treating % of the patient population in private hospitals by seems not to have been reached. the policy of promoting private hospitals has faced a number of barriers due to current physician-agency relationships. in particular, recruiting physicians to new private hospitals, especially senior physicians, has been a significant challenge. senior physicians prefer to remain at tertiarylevel public hospitals for professional as well as financial reasons, where senior physician resources and service volume remain concentrated and where service volume is reinforced by the existing pattern of greater trust among patients in large public hospitals compared with other health care facilities. if new private hospitals are to emerge and establish themselves, the relationship between senior and/or more highly respected physicians and tertiary-level public hospitals will have to give way to a more balanced public/private set of physician relationships. second, the emerging private hospitals owned by social enterprise or investors are more likely to be for-profit, and such profit-driven nature will make the physicians practicing at their facilities profit-making agents as well. strengthened physicians' professionalism will be even more important in an environment where physicians are practicing at explicitly for-profit facilities. given that a central challenge for private hospitals' development has been the difficulty of recruiting senior physicians, an almost hand-in-hand reform initiative alongside promoting private hospitals was to allow physicians to practice in more than one hospital: for example, to enable physician multilocation practice. this multilocation practice policy also sought to redistribute patient flow to lower level health care facilities by better distributing more senior physician resources who previously had practiced only in tertiary-level public hospitals. on january , the chinese national health and family planning committee, the national development and reform commission, and other chinese national commissions under the state council released the newest regulation for the promotion of physician multilocation practice, further reducing the regulatory and administrative barriers for senior physicians to practice in other health institutes. by transforming currently employed physicians into "free agents" in the medical marketplace, the multilocation practice policy seeks to break the domination of physician resources by tertiary-level public hospitals. however, critical barriers still exist, and the establishment of multilocation practice will itself create new challenges. first, even though the chinese government seeks to promote physicians' mobility, it is not surprising that such policies have had little success due to resistance from the tertiary-level public hospitals. as described above, with physicians' income and hospitals' profit so strongly tied together in the existing tertiary-level public hospital arrangement, physicians have become in effect the agents of their hospital. in addition, the nature of uncertainty of medical services and the asymmetry of information , demonstrate the difficulty of evaluating physicians' performance at their own employer hospital. holmstrom and milgrom pointed out that a firm should restrict its agents from conducting outside activities if it is difficult to measure the performance of the agent's "inside firm activity." as a result, while physicians are still agents and employees of tertiary-level public hospitals, it will be difficult to design an appropriate profit/cost sharing mechanism between physicians' current employer hospitals and the facilities they choose for multilocation practice. in all these respects, the tertiary-level public hospitals become a natural barrier to the development of multilocation practices. second, the implementation of physician multilocation practice policy may itself create new problems, including health service quality and increased patient risk. to practice in additional health care facilities, some chinese physicians are establishing private physician-group companies. however, government regulations on physicians' groups or physicians practicing in other health care facilities are still vague and insufficient. even though the current regulations and code of conduct for chinese physicians may not be ideal, physicians are at least under the regulation and supervision of their employers: public hospitals. if physicians can practice at other health care facilities freely or as an employee of loosely regulated physician-group companies, the current immature physician professionalism system does not have the capability to substitute for the current regulatory role served by employer hospitals in terms of ensuring appropriate procedures, care quality, and risk control. to eliminate the perverse financial incentives related to drug mark-up policies described above, from , the chinese government began to eliminate the % drug cost markup for public hospitals (eg, zero mark-up drug policy). by september , , all public hospitals should have eliminated the drug markup (except for traditional chinese medicine). to compensate for the loss of revenue to public hospitals, most labor-related services such as physician service fees, inpatient bed fees, nursing fees, surgery fees, and traditional medicine rehabilitation fees have all been increased. the comprehensive payment structure reform required that, on average, the increased fee schedule will compensate % of the drug mark-up profit loss for countylevel hospitals and above. the goal of this policy is to eliminate the incentive for physicians to overprescribe expensive drugs and high-technology diagnostics tests. however, if physicians' incomes are still tied to public hospitals' profit, hospitals can design other financial incentive systems to reward physicians who help hospitals to increase profit. multiple studies have already reported that hospitals and physicians responded by increasing physician and other service charges. [ ] [ ] [ ] [ ] [ ] one recent study on a well-recognized reform model, "sanming," , also showed the zero mark-up drug policy's effect on reducing expenditure faded over the long term. lack of a proper professional code for chinese physicians could make physicians' and hospitals' fee response behaviors even more extensive. in summary, the post- chinese health care system's development has had the overall effect of making chinese physicians more the agents of hospitals rather than of their patients. substantial evidence has shown that the financial tie between physicians and tertiary-level public hospitals is a critical reason for much of existing inefficiency or even misuse of health care resources. , , more recently, the existing strong financial relation between senior physicians and tertiary public hospitals also has jeopardized efforts to create competition from emerging private hospitals as well as reform measures that allow physicians to practice among multiple health care facilities. the eventual goal of current chinese health care reforms is to create a market with providers of numerous ownership, including public and forprofit private hospitals, and to redistribute physician resources from currently dominating public hospitals to other settings. to achieve this long-term goal with sustainable physician-patient and physician-hospital agency relations, a systematically well-developed physician professionalism system will also be necessary. the chinese government has implemented policies to reduce overprescribing behaviors; however, more needs to be done to align physicians' incentives with the patient population. an important next step is to disconnect the close financial relationship between senior physicians and the profit earned by tertiary-level public hospitals. an existing tool the chinese government may consider is the us resource based relative value scale (rbrvs), which could be modified so as to represent chinese physicians' workload and value in a scientifically valid manner. the chinese version of an rbrvs system to pay physicians directly based on workload, specialty, length of training, risk, quality of care, service location, and so on would support both private hospital development and multilocation physician practice by cutting the current tight financial relationship between senior physicians and the currently dominating tertiary-level public hospitals. the chinese version of rbrvs could also increase physicians' current income by properly reflecting physicians' value, solving the issue of underpaid physician services, so that physicians will not rely on drug sales, inducement of services, or other financial incentive systems designed by hospitals. the chinese version of rbrvs could also incorporate health care outcome, patient satisfaction, population health, and other qualityrelated measures based on specialty, to create positive incentives on physicians' behaviors that align with the overall chinese health care reform goals of . of course, to design and implement an independent physician reimbursement system would require a substantial administrative and legal framework, for example, establishing billing and collection processes, and comprehensive malpractice insurance for physicians if they are practicing independently, all of which are public hospitals' responsibility in the current situation. we recognize the significant investment of time and funding necessary to implement an independent physician reimbursement system for senior physicians at tertiary public hospital level; however, given the current situation in china, the advantages of such a major reform outweigh the disadvantages, especially considering the expected long-term effects on efficiency and quality of service within the health care delivery system. in addition, as the function, goal, and financial sources for health care facilities in rural areas, and also for secondary level and community-based primary care systems in urban settings, are very different than those of tertiary-level public hospitals, physicians practicing at these lower intensity health care facilities should be paid using the current approach until the chinese version of rbrvs is operating and mature. changing financial relations will increase physicians' mobility; however, changing only the physician-hospital financial relationship will be insufficient to adequately regulate physicians' behavior, especially given the chinese government's expectation that the physician will increasingly practice in multiple locations. this observation leads to the conclusion that a comprehensive physician professionalism system will also be necessary to serve as the foundation for a long-term solution for the recently introduced provider-related health care reforms. as the base of a health care system, a physician's professionalism can be traced to the oath of hippocrates. in the united states, the flexner report in was an important landmark in the development of a modern medical profession, and some scholars further defined its physician professionalism framework based on flexner's perspectives. in an increasing complex health care delivery system, physician professionalism may be defined in various frameworks with multiple ways. to be sure, physicians in china with their confucian-based culture may not interpret or fully practice exactly the western standard of physician professionalism. however, china's health system development has demonstrated that market mechanisms alone do not have the capability to create a high-functioning professionalism structure for physicians. a comprehensive physician professionalism system tailored to chinese culture and social background may need the engagement and collaboration of government, professional physician associations, health care facilities, and physician leadership representatives. however, almost no efforts for physician professionalism have been implemented as part of the newest round of health care reform. the development of a comprehensive physician professionalism system should be implemented at macro, meso, and micro levels, a multipronged approach which has proved to be an effective health care reform strategy in a number of countries. at the macro level, the chinese government should design a high-level legal framework and regulation to prohibit hospitals using measures related to volume or contribution of profit to incentivize physicians. the us stark law and anti-kickback statute provide examples of how western legal systems keep the autonomy and professionalism of practitioners separate from health care facilities. a professional physician association, for example, the chinese medical association, should assume a larger role in developing, monitoring, and supervising high-level physicians' professional values and behaviors. such professional values and behaviors should also be incorporated into the competencies of physician accreditation. the chinese medical association may consider some of the standards designed by its western counterparts. in addition, physician professionalism will require broader social awareness, support, and an alliance between society and the medicine profession. (see table for summary of "stakeholder," "major responsibilities and goal," and "example," for the levels.) at the meso level, a physician governance body, either independent physician group companies or the physician governance body within a health care facility, should design, to be a role model for young physicians • • role modeling is a crucial area for physician professionalism development and mutually beneficial for both educator and learner monitor and evaluate physicians' professional behavior as part of the physicians' key performance review. health care facilities should seek to create a clear culture to support physician professionalism and to align their internal culture with an overall physician professionalism framework. physician leaders' roles in nurturing this new environment and to be a liaison between physicians and health care facilities are also important. at the micro level, physician professionalism is a lifelearning experience, and needs to be reinforced during already challenging daily practice. the establishment of physician personal professionalism requires a combination of medical school and graduate medical education, , self and peer assessment, role model of attending physicians, and specific values and behaviors to interact with patients, health care team, and health care facilities. a combination approach. we recognize that every reimbursement structure has its caveats, either in efficiency, quality, or cost control. however, in any reimbursement structure, a strong financial relationship between physicians and health care facilities can always enable health care facilities to design mechanisms to benefit their own financial goals. the current most important barrier for the chinese public hospital reform is the lack of competition caused by the existing financial relations between public hospitals and senior physicians. the chinese government has tried to leverage private hospital investment, use policy to promote physicians' mobility, and change reimbursement policy, to overcome these barriers. however, the financial relations between large public hospitals and senior physicians still allow public hospitals to design mechanisms to maintain their dominating positions. a rbrvs system reimbursing senior physicians directly will be able to eliminate such financial ties. separating senior physicians from public hospitals as "free-agents" will promote the current provider-side reform, even though this strategy may also create other issues, such as the need to more closely monitor and supervise physician behavior. therefore, a well-designed comprehensive physician professionalism system can serve as the foundation for a long-term solution that can promote provider-related reform activities. health systems in different countries have their own historical background and limitations, and even health systems in developed countries such as europe and the united states currently confront significant challenges. the chinese health system has gone through its own developmental phases and is facing unique challenges. we recognize that simply copying the health care reimbursement and managerial system from another country is unlikely to be successful in the chinese context, and that any health system reform needs to be aligned with a country's unique background and current stage of health system development. at the current health system reform stage in china, the physician agency issue has become a central operational factor, one that can systematically jeopardize other essential provider-side reform measures. physicians are multitasking agents in health care services, and some outcomes of their tasks are more difficult to evaluate than others. even in the united states and other western developed countries, establishing provider payment systems that create effective incentives for both cost control and quality improvement is difficult. the chinese health care system is moving toward case-based or diagnosis-related group-based reimbursement approach for hospitals. under such a prospective payment system, how physicians balance hospital interests, their own income, and patients' benefits is a crucial measure of the physicians' care decisions. if physicians' personal income is still tied to their employer hospitals' profit and hospitaldesigned financial incentives, however, it may be more likely that physicians will continue to prioritize hospital's or their own profit rather than patients' interest. a study on the impact of reimbursement method change from fee-for-service to per-diem for a chinese public psychiatric hospital illustrated that the payment policy had not achieved its anticipated goals because physicians' behaviors were still tied to the original financial incentives the hospital had designed. chinese health care professionals have demonstrated a strong commitment to society, especially during natural disasters. however, providers' behaviors in terms of health care service quality and quantity are associated with physicians' remuneration approach. in this commentary, we contend that a major barrier to achieving the government's prospective goals for its health care delivery reform in china is the lack of an appropriate physician-agency relationship. as a central strategy to overcome this barrier, we suggest reducing the direct financial tie between tertiary-level public hospitals and physicians, and establishing a comprehensive system of physician professionalism in china. to be sure, provide-side reform in china is more complex than only the issues described here. other factors will also influence the efficiency and effectiveness of health care reform efforts, for example, public funding to public hospitals, public hospital governance, resource allocation between rural and urban areas, , health care professional workforce development, patients' experience, community-based primary care, and associated referral system. however, as yip, wagstaff, and hsiao summarized earlier, more in-depth understanding of physicians' incentives are necessary, and as la forgia and yip pointed out subsequently, the critical reform direction for providers is the alignment of providers' interests with the general social welfare rather than their individual income. all of these directions require the aspects we propose: minimizing the inquiry financial tie between tertiary-level public hospitals and physicians, and establishing a high-standard physician professionalism system in china. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship, and/or publication of this article. yu liu https://orcid.org/ - - - chinese medical practice and thoughts of chairman mao from a national, centrally planned health system to a system based on the market: lessons from china. health aff (millwood) early appraisal 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china handbook of health economics research on chinas public hospital governance: from perspective of implementation issues equity in health and health care: the chinese experience health insurance benefit design and healthcare utilization in northern rural china health system reform in china china's human resources for health: quantity, quality, and distribution patient experiences with inpatient care in rural china evolution of primary care in china economic analysis of china's health care system: turning a new page key: cord- -ak pq authors: nan title: th european congress of intensive care medicine athens - greece, october – , abstracts date: journal: intensive care med doi: . /bf sha: doc_id: cord_uid: ak pq nan objectives: evaluate the levels of tnf, il- and pai-i in different moments of the ards and the possible relationships among them. methods: septic patients with ards were studied. also significant differences for: tnf, pai-i and il- in septic patients and both evaluations of ards with control gropup; pai- between septics and nd evaluation in ards, and between the ist and nd evaluation in ards; il- between septics and both evaluations in ards; and il-~ in both evaluations in ards patients in relation to mortality. conclusions: i) elevations of tnf, pai-i and il- , with clinical signs, are suggestive of infection; ) the persistent and progressive elevation of pai-i with any clinical criteria may suggest evolution to ards; ) due to its own kynetics, il- takes part later in the acute phase, its levels being related to the magnitude of the injury in the tissues. objectives: the influence of long-term volume therapy with different solutions on plasma levels of circulating adhesion molecules was studied. methods: according to a randomized sequence, patients with sepsis secondary to major surgery exclusively received either hydroxyethylstarch solution ( % hes, mean molecular weight (mw) , daltons, degree of substitution (ds) . ) or human albumin % (ha) for volume therapy for days. plasma levels of circulating (soluble) adhesion molecules (endothelial leukocyte adhesion melecule- [selam -i] , intercellular adhesion molecule- [sicam -i] , vascular cell adhesion molecule- [svcam -i] , and p-selectin ) were serially measured on the day of admission to the intensive care unit (='baseline ' value) and during the next days. results: selam-i, sicam-i, and svcam-i plasma levels were markedly higher than normal at baseline in both groups. in the hes-patients, selam-j decreased to normal range, whereas it further increased in the ha-group (from • to • during the study period, sicam-i and svcam-i plasma levels remained unchanged in the hes-patients, but further increased in the ha-group (from • to , • sgmp- increased significatly only in the ha-group ( • to • only pao /fio was significantly correlated to plasma levels of adhesion molecules. conclusions: sepsis is associated with markedly elevated plasma levels of adhesion molecules indicating endothelial activation or damage. by long-term volume therapy with hes, these levels remained unchanged or even decreased, whereas volume therapy with human albumin did not have any beneficial effects on soluble adhesion. central venous catheters are frequently used in the care of the critically ill patient. the incidence of catheter related sepsis varies in the literature. we investigated the occurrence of contamination and sepsis compared to results of the epic study as part of quality assesment in our intensive care unit. from january until august all removed central venous catheters were examined for microbiological culture. the patients who showed signs of sepsis were also registered. the results of the contaminated catheters and septic patients were compared with results from the epic study. during the month period , patients were hospitalized on our intensive care unit. central venous catheters were examined for microbiological culture. specimens appeared to be possitive ( %). patients showed clinical signs of sepsis. the incidence of sepsis due to contaminated central venous catheters was / ( %). the incidence of sepsis due to the presence of all central venous lines was / ( %). the microorganisms responsible for the sepsis syndrom were : stapylococcus aureus (n= ), escherichia colt (n= ), others (n= ). in the epic study the percentage for sepsis on the icu was . % for the netherlands and . % for europe. despite a high number of positive culture from removed intravascular lines, a low percentage of sepsis was seen compared to results of the epic study. we recommend routine bacteriological culture of all removed central venous lines and recommend to look at colonization and sepsis due to intravascular lines as a measure of quality control in the intensive care unit. objectives: prognostic assessment of simplified acute physiology score (saps) in granulocytopenie patients with septic shock (ss). methods: the medical records of admissions to an intensive care unit (icu) of granuloeytopenic patients with ss are reviewed. fiftytwo patients had haematological malignancies. seven patients had aplastie anaemia. patients were categorised as survivors (discharged from icl and non-survivors (died in the icu). saps index was calculated for patients daily during their stay in icu. all patients were severe granulocytopenic (total white cell count less than , ] ] ). results: five patients ( , %) were discharged from icu. fifty-four patients died in icu. non-survivors had saps on admission higher than survivors ( . + . and . + . , respectively, p< , , mann-whitney u test). no patient with a saps greater than survived. mortality among the patients with saps from to was , %o. the evolution of ss was rapid. the mean stay in icu among non-survivors was only hours. an analysis of the saps index on admission of non-survivors showed an inverse correlation with the duration of their stay in icu (r=- , , p= . ). all survivors recovered from granulocytopenia. they had normal white cell counts at the time of discharge from icu. there was inverse correlation in survivors between saps and white cell counts, when these parameters were evaluated daily. however, the saps index alone cannot be considered to be on individual predictor factor of mortality. patients who had failure of the malignancy to respond to chemotherapy and who had persistent granuloeytopenia died in icu despite saps index on admission and recovery from ss. conclusion: saps index greater than , failure of the malignancy to respond to chemotherapy and persistent leueopenia all point to a poor outcome of granulocytopenie patients with ss. introduction: antipyretics sometimes are used for fever control in febrile neutropenic patients with hematological malignancies(hm). we observed a dramatic fall of blood pressure(bp) and development of septic shock(ss) in some of the patients who received antipyretics. aim: to clarify can antipyretics provoke ss in neutropenic patients with infection. methods: retrospective review of medicat records of neutropenic(wbc < , / )patients with hm, admitted to the intensive care unit for ss, was performed. there was selected group of patients receiving antipyretics shortly before a fall of bp. results: there was a definite causal relationship between receiving antipyretics and fall of bp in from patients. all patients had fever due to infection and had normal level of bp before receiving antipyretics. hypotension developed within minutes up to , hours after administration of antipyretics. three patients received , g of metamisol and one , g ofparacetamol per os. in all cases we observed dramatic diaphoresis and the temperature fall to subnormal level ( . + . ~ accompanied'by hypotension. but in - hours the fever was coming back without blood pressure elevation. the fluid replacement was controlled by central venous or wedge pressures. there were required + ml colloid and cristalloid solutions for volume loading. in spite of fluid administration the hypotension persisted and all patients required inotropic therapy. only one patient survived and is alive now. conclusion: it seems to us that our data offer to state that antipyretics administration can initiate ss in febrile neutropeuic patients with infection. objectives: to assess the agreement between cardiac output (co) measured by odm t and by other methods used in icu patients. methods: we prospectively studied adu t patients requiring hemodynamic monitoring with a pulmonary artery catheter. an esophageal doppler monitor provided measurements of co (odm), stroke volume and flow time (ft) used as an indirect evaluation of patient's volume status. patient hemodynamic status was evaluated by a modified fast response pulmonary artery catheter (baxter health care corporation, santa ana, ca), allowing co measurements by thermodilution "d) and an evaluation of right ventricular ejection fraction and end diastolic volume (rvef and rv-edv). in the last six patients co was measured by transthoracic echocardiography (echo) and oxygen consumption was measured by a deltatrack ii metabolic monitor (datex) allowing co calculation according to the fick formula (fick). the agreement between methods measuring co and their reproducibility, were evaluated by bland and altman analysis. results: agreement between co measurements is expressed as bias (d) and % limits of agreement (l of a = d_+ sd . td-fick - . - . to . fick-echo . - . to . there was no correlation between ft and rv-edv. conclusions: although co measurements by odmil had the best reproducibility, the limits of agreement between the four methods tested were unacceptable for clinical purposes. further investigation is required in order to improve the accuracy of co measurement in the icu. phd, a. paltzev, v.bajbikov, b.dobryakov d.sc., a.ostanin phd, o.leplifia phd, h.chernykh phd munieip. hosp. n l, n ; inst. of clin. immunol., novosibirsk, russia objectivies: efficiency of native cytokines used in the treatment of patients with severe surgical infections has been studied. methods: for two years patients were treated with cytokine mixture (ssp) obtained by arterio-venous perfusion of swine spleen and contained the following cytokines: il- , il- , il- , tnfa, ifny, gm-csf. results: ssp intravenous infusions were shown to accompany with mortality decrease from . % to . % in patients with abscessed pneumonia and lung abscesses and from % to % if disease course was complicated with sepsis. in patients with purulent peritonitis and sepsis efficiency of ssp was decreased due to endotoxieosis. thus, we used adoptive immunotherapy with mnc activated in vitro with ssp or recombinant il- . intravenous infusions of such cells resulted in transformation of a pathologic process from destructive into productive one. moreover, clinical manifestations of sepsis were controlled in % and mortality was decreased from % to %. conclusions: the use of eytokines themselves as well as cytokine-treated lymphoeytes permits to control the disease and leads to the mortnlity decrease owing to stimulation of host defence mechanisms. background: although red blood cell transfusions (rbct) are used to increase oxygen availability in septic patients, several lines of evidence suggest that rbct may actually worsen tissue hypoxia. thus, rbct may negatively influence outcome of septic patients. objectives: to determine the association of ) rbct ; ) number of units transfused; and ) mean age of the units transfused on the first day of transfusion with mortality of critically ill septic patients. methods: we prospectively identified patients who met strict criteria for sepsis syndrome (ss) seen in the icu of st. paul's hospital from to and excluded patients who died in the first days after the onset of sepsis. we recorded clinical characteristics, multiple system organ failure score, and apache ii at onset of sepsis. then, we retrospectively recorded the total number and age of rbc units transfused during the first days after onset of sepsis. overall -day mortality was %. results: the main results are shown in the table. the mortality of patients who received rbct was nearly double the mortality of those who did not receive rbct even after adjusting for severity of illness using apache ii. objectives: gastric mucosal acidosis is frequently observed in patients with sepsis. the aim of this study was to determine whether volume infusion using pentaspan| decreases abnormal gastric mucosal pco (pico ) in patients who have sepsis syndrome (ss) who have already been resuscitated using clinical endpoints. methods: we prospectively identified patients who met strict criteria for ss, had a pulmonary artery catheter and a gastric tonometer in place, and pico > mmhg. pentaspan| ( ml) was infused in rain. measurements of hemodynamics, hemoglobin, arterial lactate, blood gas analysis, and pico were performed before and repeated miff and hr after pentaspun| infusion. we calculated the pico -arterial pco' difference (pico -paco ) and phi (using henderson-hasselbach equation). anova was used to assess statistical significance. results: all patients werereceiving adrenergie drugs. map was : : mmhg and lactate . : : . mmol/l. pentaspan| increased ci by % (p< . ) but did not change pico ( and increase m oxygen o* wery were simimny achieved in both groups. nevertheless, epinephrine was associated with a lactic acidosis and increased laetate/pyruvatemia ratio (l/p) that evoke a dysoxia rather than a metabolic effect. an higher gastric mucosal pco in the ep group compared to nor-rob suggests the hypothesis of an anaerobic production of co in favor of a splanchnic hypoxia. in both group, arterial ketone body ratio that reflects hepatic mitochondrial redox state, compared to a control group without shock was decreased but increased between and hours after restoration of arterial pressure. the association norepinephrine-dobutamine seems to be better for splanehnic circulation than epinephrine and should be used for dopamine resistant septic shock. moreover, the increase in arterial pressure with nor-dob improved gastric mueosal ph and hepatic mitochondrial redox state and argue to reconsider arterial pressure as a significant goal for resuscitation in septic shock. conclusion: significantly higher malondialdehyde and ghitathione levels and glutathione-peroxidase activity in group ns at the end of icu stay were related to mortality these findings indicate an increased generation of free oxygen radicals together with increased anfioxidant activity in this group and sapport the employment of antioxidant interventions in critically ill patients. oblecfives: to determine the role of nitric oxide (no) in the mechanism of septic shock induced by isolated limb perfuslen with recombinant tnfcr methods: we have measured tnfr~ and metebo~ites of no in patients with signs ot septic shock following treatment with isolated limb perfusion for nonresectable soft tissue tumors and melanomas of a limb. perfuslen was carried out with melphalan (burroughs wellcome) and recombinant tnfcr (boehringer). tnfc~ was determined by specific radiometric assay (medgenix diagnostics), nitrate and nitrite were measured with a modification of the guess reaction ~. results: results are shown in the table. conclusions: during isolated limb pedusion with recombinant tnf~ very high levels of tnfcr were measured in arterial blood in patients. they all showed signs of severe sepsis syndrome with shock from vasodilafion, probably due to leak of recombinant tnft~ from the peduslen circuit to the systemic circulation. tnfc~-induced vasodilation was not accompanied by a rise in serum no-metsbolites. our findings do not confirm the widely accepted theory, mainly based on animal experiments, that genera• of no is the key pathogenefic mechanism in septic vasodilafion , nor that tnfrt invariably induces forreafion of no. the precise mechanism of shock in these patients remains to be elucidated. references: . moshage h, kok b, huizenga jr, jansen plm nitrite and nitrate determinaiions in plasma: a critical evaluation. clin chem : / . . moncada s, higgs a. the l-argioine-nitrio oxide pathway. n engl j med ; : - ec is a commonly used for prolonged, stable animal anesthesia. noting that the hypotension after iv lps was attenuated by ec, we hypothesized ec also protects against lps toxicity. sprague-dawley rats received ip saline (s), thiobutabarbita mg/kg (tb), or varied doses of ec, followed hours later by bolus mg/kg iv lps. -day survival is shown below: group: s tb ec( . gmikgi ec( .sgm/kg) ec(i. gm/kg) alive (n) t ~ total (n) s s "signiflcant;y different from all other groups, p< . s / rats given lps followed hours later by ec ( . gm/kg) also died. additional rats were treated with s (n= ) or gm/kg ec (n= ) followed by mg/kg lps, then sacrificed at hours. blood glucose (bg, mg/dl),.hematocrit (hct), leukocyte count (wsc/mm~ platelet count (pltxl ~/mm ), bicarbonate (hco, mg/dl), gross bowel hemorrhage (bh, - scale) and lung myeioperoxidase activity (mpo, ~vmirvgm wet lung) are shown below ( we conclude that ec reduces the lethality and multiple organ toxit;~ty of lps. its diverse effects suggest asite of activity upstream from the cytokine cascade. these results are important for studies of lps which may use ec anesthesia and may have potential in the therapy of septic shock. [zo = hz impedance (z; {dyn.sec.cm " }); zl = first harmonic z; zc = characteristic z; z ph. = t'trst harmonic phase angle {radians}; f, #, * at least p < . between fio . and . , fio . and fio . &no - . _+ . - . _+ . # - . + . m - . + . * - . + . * - . + . * - . _+ . * in hyperoxia, compared to dogs at the same q, minipigs had a higher ppa ( + rnmhg versus + mmhg; p < . ). hypoxia increased (ppa-ppao) at all levels of q by an average of mmi-ig in minipigs and mmhg in dogs. inhaled no inhibited hypoxia-induced (ppao-ppa)/q changes in both species. conclusions: we conclude ~ that the minipig is an animal model of elevated pulmonary vascular resistance and impedance, and ~ that hypoxia-induced alterations in pvz spectrum are due to changes of resistance in small arteries. objectives: ) to determine the toxicity of ng-monomethyi-larginine (nma) administered by intravenous bolus to patients with refractory septic shock. ) to investigate the biologic activity of nitric oxide synthase inhibitors in septic shock. methods: from august to january , thirteen patients with vasopressor refractory septic shock received nma intravenously in escalating doses from to mg/kg. results: no hepatic, renal, gastrointestinal, or hematologic toxicity was observed at doses of nma as high as mg/kg. significant biological activity was observed at all dose levels consisting of increased blood pressure (systolic blood pressure from . mm hg + . to . _+ . s.e.m., p= . , systemic vascular resistance ( + to + dyne.sec/ cm s, p=. ), and a decrease in vasopressor requirements. the magnitude and duration of these effect were dose dependent. decreased cardiac output ( . _+ . to . _+ . i/min p=. ) and increased pulmonary artery pressure ( . _+ . to . _+ . mm hg; p=. ) were also observed. no significant effects on heart rate, pulmonary capillary wedge pressure, or central venous pressure were observed. four of patients survived for more than days, patients died of cancer complications (all patients had maintained blood pressure for h on nma) and patients died of complication attributable to septic shock (mods, ards, dic, refractory hypotension), and patient was unevaluable. conclusions: no adverse clinical effects have been observed in patients receiving bolus doses of nma as high as mg/kg. the increased pulmonary artery pressures observed in septic shock patients is further augmented by nma and may limit the dose which can be administered by intravenous bolus. other schedules of drug dosing may attenuate this effect. glucose-insulin-potassium (gik) solutions have been shown to improve cardiac contractility and increase oxygen availability in experimental and clinical settings of septic shock. several mechanisms have been proposed to explain these effects including a direct improvemeut of the energy balance by glucose, a direct influence of insulin on cardiac performance or an increase in intravascular volume due to the hyperosmolarity of the solution. to explore the role of hyperosmolapity, we compared the effects of gik to those of a isoosmolar hypertonic saliue solutiou in endotoxin shock in dogs. methods : the study included mongrel dogs ( • pentobarbitalanesthetized aud mechanically ventilated with air. thirty minutes after the intravenotls administration of mg/kg of e. coli endotoxin, the dogs were randomized to receive a ml/kg infusion in rain of a hypertonic ( mosm]l) solution iucludiug either a mixture of glucose % with u insulin and meq kcl/l (glk-group ) or hydroxyethyl starch . % in naci . % (hes-group ). in each dog, a . % saline infi~sion was continued to maintain the puhnonary arlery occluded pressure at baseline level. hemodynamic, blood gas aualysis and laboratory data were collecled at baseline and miu, rain, rain, and nunutes later.. results : eudotoxin administration was followed by a fall in mean arterial pressure (map) aud cardiac index (ci) and a rise in blood lactate levels. resuscitation with either gik or hes hypertoaic solutions resulted in similm increases in map, ci, oxygen delivery and left ventricular stroke index (table ) . we conclude that during resuscitation from endotoxic shock the use of gik solutions is not superior to hypertouic hes solutions. the higher blood lactate levels observed in the dogs receiving gik can be attributed to the glucose metabolism. , for group , for group ) were drawn and immediately analysed at ~ using the abl radiometer for po , pco and ph, and the osm radiometer for hbo %, hbco% and methb%. psost (i.e. the ps at ph= . , pco = mmhg and temperature at ~ c) was calculated automatically by the instruments on mixed venous blood, as was the ps "in vivo" (i.e. the ps at the patient's value of ph, pcoz and temperature), using siggaard-andersen's algorithm. the data were compared by the one-way anova test and by the t-test for paired and unpaired samples. results: the mean resulting values (in mmhg) with the statistical differences are shown in table i. in addition, the time series analysis shows the mean ps~st values as statistically below the psin vivo" in the septic patients while the opposite is shown for the cardiac patients. no differences in the time analysis are demonstrated for the second group. a possible clinical significance may be drawn from these different behaviours. objectives:toxemia degree and humoral immunity condition have been studied in patients aged from to with progressive course of sepsis and polyorganic insufficience. methods: such toxemia and humoral immunity findings as lencositlcindex of toxication (lii), level of oligopeptides of the middle molecular mass registered at the wave length of nm(mmi) & nm (mm ), distribution index (id), immunoglobulins a,m,g, concentration of circulating immunocomplexes (cici & cic ) and also some clinical and biochemical findings on the , , day after the operation serve as criteria for treatment effect. results: it was founded that in intensive therapy and detoxication, level of lii is successively decreased from . ~ . to . +. on the -th day after the operation. true decrease of the level mm from . ~. to . +. un & optimal density and increase of distribution index from . to . are argued. conclusions: in studlng the dynamics of the immunoglobulin's spectrum and the true increase of immunoglobulin g level from . +. g/i to i . +. g/i on the -th day after the operation simultaneously with the decrease of cic from . ~ to . ~ . (p . ) were founded. some stages of the investigation true increase of lymphocytes from . + . % to . + . % was noted and it appeared to be a favourable prognosis finding for disease outcome. high correlation dependence between bacillus-and segmentonuclear neutrophils and immunoglobullns g & m (r=. -. in p<. ) was discovered and it also showed positive dynamics of the course of the disease. a year old male patient was admitted to the icu with severe paraquat poisoning. treatment consisted of gastic lavage and oral administration of fullers earth. because of very high plasma levels hemodialysis together with charcoal hemoperfusion was started within one hour after admission. this treatment was further continued by continuous veno-venous hemofiltration in order to remove the circulating paraquat and also circulating cytokines. nevertheless patient s condition worsened necessitating artificial. ventilation and hemodynamic support. patient died hours after admission of acute multiple organ failure due to paraquat poisoning. serum levels of paraquat were determined by colorimetric method (table) . levels of interleukin (il ) and (il ), tumor necrosis factor (tnf-alpha), interleukin i receptor antagonist (il ra) were determined both in plasma and ultrafiltrate ( q~!ectives : evaluate in critically ill patients the effects of tow-dose dopamine on gastric mucosal blood flow (gmbf) using laser-doppler flowmetry, a continuous non invasive method of assessing microcirculation. methods : patients requiring both mechanical ventilation and pulmonary artery catheterization for multiple trauma (n= ), ards (n= ) and pancreatitis (n=l) were included. in each patient, the laser-doppler (ld) probe was inserted through a naso-gastric tube. the ld signal is proportional to the number of red blood cells moving in the measuring volume and the mean velocity of these cells. when the ld signal was satisfactory, an aspiration was created into a catheter which was fixed in parallel to the ld probe, to maintain the tip of the probe against the gastric wall at the site of measurement. data (systemic hemodynamic parameters and gmbf) were obtained at the end of a rain resting period (baseline), then min after dopamine ( mcg/kg/min) infusion, and finally rain after the end of dopamine infusion (recovery gmbf _+ (perfusion units) gmbf ~a% vs baseline) * p < . vs "baseline" and "recovery". conclusions : ) despite a slight increase in co (+ %), the dramatical increase in gmbf (+ %) with dopamine, strongly suggests a selective vasodilator effect of low-dose dopamine on gasaic mucosal perfusion. ) laser-doppler flowmetry appears a promising method to assess gastric microcircalation in critically ill patients. increasing evidence suggests that the activation of inos is the final common pathway for vasodilation in human sepsis associated with endotoxic shock. activation of the cellular immune system induces the excessive release of the pteridines neopterin (n) and , -dihydroneopterin (nh ) by human macrophages/monocytes. besides the well established diagnostic value of pteridines in several inflammatory diseases, it is speculated that these substances per se exhibit biochemical functions. thus we hypothesize that pteridines can modulate inos gene expression in vascular smooth muscle cells (vsmc) in vilro. cdtured rat aortic vsmc from female wistar kyoto rats were incubated with n ( pm), nh ( ilm), lipopolysaccharide (lps, ~g/ml), and interferone-~/(ifn-~/, u/ml) for h, respectively, inos gene expression was measured by competitive reverse transcription polymerase chain reaction. the results are summarized in the table. the present study demonstxates a neopterin induced increase in inos mrna expression at the transcriptional level in vsmc. while coincuhation of cells with n + lps resulted in an additive effect on inos gene expression, n + ifn- seem to have a more than additive effect nh did not alter inos mrna synthesis, but it suppresses the lps as well as the ifn-yinduced augmentation of inos gene expression. we speculate that this pteridine-mediated modulation of inos gene expression is involved in the regulation of the vascular tone in endotoxic septic shock. the relationship of sepsis and coagulation abnormalities is well known, mainly in severe sepsis and septic shock. still farther, the extreme expression of hemostasis abnormalities (disseminated intravascular coagulation) in sepsis, has been extensively described. we studied the changes in several coagulation and fibrinolysis markers in septic patients, trying to correlate them with the evolution of the sepsis phenomenon, with an emphasis in its early stages, where therapeutic intervention might be more drastic. in patients, with sepsis, with severe sepsis and with septic shock, as well as in healthy volunteers (control group) we measured : platelet (ptl), coagulation markers [fxii, fvii, fviii, fvw, fibrinogen (fibr) we conclude that all parts of the coagulation system are gradually changed during the evolution of sepsis phenomenon , even in the earliest stage of sepsis. the expression of an inducible nitric oxide (no) synthase (inos) plays a major role in the pathophysiology of septic shock (ss). inhibition of inos could therefore be of therapeutic value. however, such an inhibition has been shown to be detrimental, increasing tissue anoxia (and end-organ damage), possibly through the simultaneous blockade of constitutive nos (cnos). thus, selective inhibition of inos might be more suitable. we evaluated the effects of l-canavanine (can), a more potent inhibitor of inos than cnos, in an animal model of ss. method: in anesthetized rats, catheters were placed in the femoral vein and artery. rats were given an iv bolus of lipopolysaccharide (lps, mg/kg), at baseline (to). after h (t ), rats received at random an infusion of either can ( mg/kg/h; can group, n=l ) or an equivalent volume of . % naci ( cc/kg/h; nac group, n= ), giyen over h (t -t ). a third group (sham group, n= ) received . % nac in place of lps, and then was treated like the nac group. mean blood pressure (mbp), blood lactate and nitrates (no ) were measured each h. glucose, creatinine and asat were also measured in rats (n= in each group). the can _+ * + "t . + . "~ . +_ . "t + " + " *p< . can vs naci ?p< . vs sham can suppressed the hypotension, reduced the hypoglycemia and hyperlactatemia, and attenuated the biological signs of renal and hepatic dysfunction induced by endotoxemia. these effects were associated with a lesser elevation of blood no , confirming a partial inhibition of inos. conclusion: l-canavanine attenuates the hemodynamic and metabolic consequences of endotoxemia in the rat. these effects may be related to a partial inhibition of inos. they contrast with the deleterious effects described with non selective inhibitors of nos. l-canavanine could become a new tool for the treatment of septic shock. rocalc tonin :marker of sepsis, ii~flammaiiur% t~ boifi .cheval*~ jf.timsit*, m.assicot**, b.misset*,/.carlet*, c.bohuon** saint joseph heap, paris**biochemistry institut g roussy, villejuif, ce bi~)l~i~ttectives_: high serum levels of procalcitoaln (proct) have been shown to be ~ss-ocinted with bacterial infection. however, few data exist about the ability of proct to differenciate septic shock and shock from other origin in which an activation of intlmmamtory mediators has been also demonstrated. methods: thirteen patients with bacterial septic shock (ss), patients with non septic shock (nss), patients with bacterial infection without shock ( nf) and icu patients without shock and without infection (control) were compared for proct levels at dayl, , , , . patients were classified blindly and independently fi'om proct results. twelve patients were excluded because any classification was impossible due to mixed pathology. proct was measured with ebemoluminescenee (brahms diagnostica-berlin). results: dayl, proct levels are significantly different between the four groups. dayl proct levels are correlated with saps (p= . ), infection ( . +_ vs _+ ,p= . ), shock ( _+ vs +.- ,p= . ), death at day ( _+ vs _+ ,p= . ). when shock and infection are introduced in multifactor &nov& only infection remains correlated with day proct levels ( = . ) in patients with shock, dayl proct levels are correlated with saps, infection and death at day , but not with arterial lactate levels (p= . ), white blood calls (p= . ) or fever (p= . ). proct levels remain higher i~i septic shock patients at day , and ( figure) . i c edpsion: procalcitonin levels in the first three days of shock are differen[" between septic and non septic shock patients. in patients with diseases known to induce acute an inflammatory process, procaldtonin seems to be a marker o~ infection. obiectives-to evaluate the effect of endotoxic shock on the distribution of blood flow between the mucosal and the muscular layer of the intestinal wall. methods: in fasted pigs, mean aortic pressure (map, mm hg), cardiac output (co, ml/min-kg),superior mesenteric artery flow (q sma, ml/min.kg), and phi, where measured before (control) and after i.v. endotoxin ( gg/kg). the blood flow to the mucosal and the muscular layer was measured in regions (proximal jejunum (pj), mid-small intestine (mi) and terminal ileum (ti)) by colored microspheres, using adjacent samples in each region. the muscular layer was separated from the mucosa by blunt dissection, and the flow determined independently in each layer. results: endotoxin with fluid resuscitation induced the expected decrease in map ( . _+ . vs . -+ . , p< . ), and phi ( . !-_ . vs . _+ . , p< . ), with a constant co ( _+ vs _+ , p= . ) and qst, aa ( . _+ . vs . _+ . , p= . ). the results of regional pertusion are presented in the table. (flow in ml/rain g of tissue; mean _+ sem ; * p< . vs control by two-way anova) conclusions-these data indicate that the mucosal flow increased during septic shock. they suggest that a decrease in phi may be due to hypoper~usion of the muscular layer or to metabolic alterations within the mucosa, despite a % increase in flow. acute increase in wbc count (from a mean of lo.oo mm a to o /mm~), between the rd and the th day of therapy. there was a decline of the wbc count to an average of about . mm a after decreasing the daily dose of the medication to mcg there was no increase in tile absolute number of the eosinophils during the whole course of the medication. there was a slight decrease in the c complement between . to . g/i. normal values . to . g/i there was no change in c values. conclusions : an early increase in wbc count was observed ( rd day) without subsequent increase in the number of immature types from bone marrow, probably due to the mobilization of wbc from the periphery and this increase was dose dependent. there was a slight decrease in c fraction of complement, probably due to the consumption of this fraction in the process of opsonization. no adverse effects of the medication were observed, during the treatment with the above dose. these data sugest that cm csf may be a useful complement to tile main antimlcrobial treat,nent ~ of septic [cu patients. objectives: as part of a large multicentric, placebo-controlled, randomized clinical trial investigating the effects of interleukin- receptor antagonist (ii-lra) in the treatment of severe sepsis and septic shock, this substudy evaluated in dem.il the acute hemodynamic effects of ii-lra in patients who were invasively monitored. methods: in a total of evaluable patients in whom vasoactive support was little altered, hemodynamic measurements were performed at baseline (twice), and i hour, h, h, h, h, and h after the administration of mg/kg (n= ) or mg/kg (n= ) of i - ra or the corresponding placebo (n = ). / patients ( %) were treated with adrenergie agents and / ( %) with mechanical ventilation. data were analyzed by a kruskal-wallis test. results: during the study, there was no significant difference with time or between groups in arterial pressure, cardiac filling pressures, cardiac index or left ventricular stroke work (figure). burmester, "~ man and h. djonlagic medical university (internal medicine, "cardiology, *'microbiology) and "**southern city hospital, lfibeck, germany obiectives: evaluation of the incidence of bacteremia and sepsis in patients with nontyphoidal salmonella (s.) infections, specification of risk factors, need of icu treatment, clinical course, and mortality in the group of the patients who developed septic complications. methods: data of all patients with microbiologically proven s. infections hospitalized in the medical university of lobeck and in the southern city hospital of l beck from to . results: within the observation period s. was isolated from the stool cultures of patients. in patients (g m, f, median age yrs) s. could be detected in blood cultures ( s. enteritidis, s. typhimurium). in addition, in of these patients s. was also isolated from other specimens (urine, liquor, and tissue fluids derived from abscess punctures). in all patients with positive blood cultures the clinical course of s, infection was complicated: ? patients developed mof (acute renal failure, ards, hemodynamic instability, dic) and required icu treatment for at least up to days, of the patients died. the predisposing disorders in the patients with s. bacteremia were (n=): aids ( ), immunosuppressive drugs ( ), chronic alcoholism ( ), malignancies ( ), none ( ). septic complications in patients with nontyphoidal s, infections are relatively rare (in this study < % of all hospitalized patients with microbiologically proven salmonellosis) but severe (mortality of approx. %). patients at risk for a complicated clinical course are predominantly those with predisposing disorders but occasionally also patients without evidence for an underlying disease. age (yr) + + death (n) duration of shock (h) + + noradrenaline (rag/h) , _+ + temperature (~ , + , + pvr (dynxsecxcm - ) + + co (ljmin) , _+ , , + , lactate (mmol/l) + , , + interleukin- (pg/ml) _+ + interleukin- (pg/ml) , _+ , , + , tnf-alpha (pg/ml) , + , + neopterin (nmol/l) , + , + crp (rag/l) _+ +_ pro-ct (ng/ml) , + , , + there was no positive correlation between serum lactate levels, degree of shock, hypoxemia and pro-ct positivity. pts with septic shock of bacterial origin entirely developed hyperprocalcitoninemia, whereas pts with cardiogenic shock, who expired within h did not. however, in late cardiogenic shock (> h) all pts developed fever of unknown origin and consecutive hyperprocalcitoninemia. these data suggest bacterial inflammation and/or mucosal translocation of bacterial products in pts with prolonged cardiogenic shock. the use of a loading dose of quinine ( . mg/kg base in h) is recommended in previously untreated patients (pts) with sfm, particularly in multi-drug resistance areas. this protocol is difficult to validate, since the viability of microorganisms is not assessed routinely in parasitology laboratories. objectives: to examine the evolution of parasite viability during the early phase of therapy of sfm. methods: from / to / , pts with sfm (who ) treated with iv quinine for less than h were included prospectively. blood samples were collected at o, , , , , and h viability was assessed by culturing parasitized red blood cells in the presence of h-hypoxanthine, and radioactivity was determined at h by scintillation counting. viability was expressed as the percentage of radioactivity compared to the initial sample. plasma quinine was determined by liquid chromatography. tile ratio plasma quinine (pmol/ )xlo /icso for quinine (nmo]/]) was called the parasiticida/ index. results: pts were included, • saps . -+ . . the initial parasitemia was t. + . %. complications of malaria were coma ( pts), shock ( pts), renal failure ( pts) and acute lung injury ( pts). all strains were sensitive to quinine (icso -- nmol/ ). in pts who were not given a loading dose, parasite viability increased by and %, with concomitantly low quinine levels ( and #mow] at h); pt died. in pts that received a loading dose (serum quinine at h = . -- . ~mol/]) a marked decrease of parasite viability (by +_ % at h) was shown. viability was inversely correlated with plasma quinine (r=. , p-.o ) and parasiticidal index (r=. , p-.o ). conclusions: even with fully sensitive strains, the use of a loading dose of quinine seems warranted in severe falciparum malaria in order to reach rapidly adequate plasma quinine ]evels, necessary to inhibit significantly parasite viability. l nkka, e ruokonell j takala. critical care research program, department of intensive care, kuopio univ hospital, finland objective: to determine the incidence of positive blood cultures, their microbial subgroups and to evaluate the outcome of icu patients with different bacleremias. material and methods: we analysed all positive blood cultures in consecutive admission to a university hospital icu in - and the icu and hospital survival of the bacteremia patients. during these years patients had positive blood cultures that were considered as clinically relevant, excluding colonizations or contanfinations. results: patients with positive blood cultures had an icu survival of . % (vs. , % in all icu patients) and six month survival of . % (vs. . % in all icu patients). the most common bacteria were enterobacteriaceae ( , %), staphylococcus aureus ( , %) , coagulase negative staphylococci ( . %), pseudomonas ( . %) and slieptococci ( . %). obiectives: to evaluate prognostic factors and mortality in consecutive patients (pts) with hiv infection and septic shock. methods: from - to - , records of consecutivepts with septic shock (crit care med , : - ) admitted to the icu were reviewed retrospectively. results: among pts with septic shock admitted during the study period, had hiv infection- of whom had aids-(gr. i) and were hiv-negative (gr. ill. ten gr. ii pts ( %) were irnmunosuppressed because of neoplastic or immune dlsease. mechanica] ventilation was required in % gr. i and % gr. ii pts in gr . i pts ( %) a multivariate analysis demonstrated that hiv infection and sap i were independently predictive of death in pts with septic shock. ~onclusions: evidence of increased mortality, number of organ failures and higher severity scores (saps i does not take into account immunosuppression) is demonstrated in hi v-positive pts, infection with hiv appears to be an independent prognostic factor in pts with septic shock. the frequency of opportunistic infections (often responsible for delayed diagnosis and treatment) may contribute to the poor prognosis in this population. obiectives: to determine interleukin (il)-i levels in plasma of patients with sepsis and septic shock. to analyze the relationship between plasma il- and the proinflammatory mediators, tumor necrosis factor-aifa (tnf) and il- , the underlying severity of the disease and the evolution of patients with sepsis. methods: we studied critically ill patients ( men, women; - years old) in three diferents groups. group i: patients without evidence of infection, group i : patients with sepsis and with septic shock (group iii). we measured plasma il-lo, tnf and il- levels in the first hours of diagnosis. severity of illness was estimated with the acute physiology and chronic health evaluation (apache ii) scoring sytem. results: plasma levels of il- were higher in group iii (median, pg/ml; range, - pg/ml) than in group ii (median, pg/ml; range, - pg/ml; p <. ) and group i (median, pg/ml; range, - pg/ml; p <. ). median il- concentrations did not differ among patients who survived (median pg/ml; range, - pg/ml) and those who died during the overall follow-up period ( days) (median, ; range, - pg/ml); but patients who died in short-term (< hours) with catecholamine-refractory hypotension showed the highest concentrations of il-io (median, pg/ml; range, - pg/ml). in patients with bacteriemia ( %), levels of il- were higher (median, pg/ml; range, - pg/ml) than in those with negative blood culture (median, , pg/ml; range - . pg/ml; p< . ). there was a good correlation between plasma il-io concentration and levels of tnf (r= . ; p < . ) and il- (r= . ; p < . ). the correlation between levels of il- and the apache ii score was significant only in the septic shock group (r= . ; p <. ). conclusions: in septic shock, il-io and proinflammatory citokines are released in high concentrations. the significant correlation observed in patients with septic shock between il- levels and apache ii, short-term death and bacteriemia can possibly be explained by the massive inflammatory response in septic shock with fulminant course. intensive care department -calmette hospital - lille -france. in septic shock, inadequate splanchnic blood flow may play a prominent role in the pathogenesis of multiple organ failure. measurement of gastric phi has been propose to evaluate tissue oxygenation in splanchnic organs. objectives: to compare gastric phi values with hepatic icg clearance, an index of liver blood flow and function ; to determine if one of these two methods could be proposed to assess the entire splanctmic peffusion in septic shock. methods : patients (age : • years ; saps ii : • were prospectively investigated (septic shock : bone criteria). following parameters were collected during hours : systemic hemodynamic parameters (swan ganz catheter a h -ref computer -baxter lab.), calculated systemic oxygen transport (do ), oxygen consumption (vo ) by indirect calorimetry (deltatrac datex lab.), gastric intramucosal pco (pco ss) and phi (trip -ngs catheter -tonometrics lab.) and plasma disappearance rate of icg (pdr dye) (femoral artery fiberoptic/thermistor catheter , cold z computer -pulsian medizintechnik, germany). correlations were performed using a linear regression. elevated in all days with the highest value in second and third days of treatment. nonsurvivors had higher values of these parameters than survivors but differences did not reach statistical significance. another trend of changes were observed in selectin p (gmp- ) concentration. in all patients concentrations measured were elevated but in survivors after not significant decrease this parameter in second day another one had simmilar values. in patients who died we noted significant decrease in third day (p < . ) whereafter prominent increase, significant after seventh day, in comparison to third day value and value in survivors group. icam- concentrations in all patients reached high levels and in nonsurvivors after four day of treatment significant increase in comparison to survivors we found. conclusions: multiple trauma complicated with sepsis induce rapid elevation of concentrations of il- , il- and increased expressior of adhession molecules (selectin e, p, icam- ) measure of icam- and selectin p concentration determine lung injury severity and prognosis as to health and life. (clp) .pathophysiology of cip is unclear, but changes in regional bloodflow may be a ~ignificant factor. nerve blood flow (nbf)is reduced in rat models of hemorrhagic shock (g),but no information is available in sepsis. we studied the comparative effect of acute endotoxemic shock {etx)& h on perfusion of rat sciatic nerve. methods: male sprague-dawley rats were anesthetized with pentobarbital (ip), instrumented with a tracheostomy, carotid arterial & venous catheters and mechanically ventilated (fi = . ). the left sciatic nerve was surgically exposed. monitored variables included: a) mean arterial pressure (map,mmhg) ,b) nbf (ml/ o g/min) by laser doppler flow meter,c) nerve internal arterial diameter (id ~ m) by video image shearing and splitting method. after stable baseline measurements were obtained, acute hypotension was induced by randomly assigning the rats to etx ( . b , difco) in saline at mg/kg or h. both interventions produced % reduction in map within min., which recovered to baseline values spontaneously in etx group, & by reinfusion of heparinized withdrawn blood in m. data were analyzed by linear regression, two-way repeated measures analysis of variance followed by bonferroni-t method. experimental stages were:( )baseline, ( ) mid-point of map reduction; ( ) nadir of hypotension, ( )midpoint of map recovery, & ( ) after stable recovery of map. both etx & h induced shock result in similar reduction in nbf consistent with lack of autoregulation in peripheral nerve vessels independent of etiology. since cip is primarily associated with sepsis, it is not likely that acute reduction in nbf alone causes cip. direct & indirect neurotoxic effects of mediators of sepsis need to be evaluated. .':_.~::::o o:oc ., objectives : evaluate the relationship between il- , a cytokine which inhibits tnf, production and protects mice from endotoxin toxicity, and the other proinflammatory cylokines, tnf~, il and ils in severe sepsis and septic shock. methods : twenty-eight icu patients ( m, f, mean age + y) were studied as soon as they developped a severe sepsis (n = ) or a septic shock episode (n= ) as defined by a conference consensus in ( ). tnf~, il , il s and il- plasma levels were measured by immuno-radiometrie assays from medgenix (fleurus, belgium). lc mean and range. results : the comparisons between cytokine levels in severe sepsis versus septic shock were made using the logarithm of the value in order to normalize the distribution of data, and student test. il- plasma levels were higher in patients with septic shock than in patients in severe sepsis. there was a significant correlation (p < . ) between il- and tnf a (r= . ), il- and il~ (r = . ) and il- and il s (r = . ) as well as between il- and apache n score (r= . ). patients who died (n = ) had il- levels higher than patients who survived but this difference was not statistically significant ( pg/ml vs . pg/ml; p> . ). conclusions : during severe sepsis and sepsis shock, il- seems at least to follow the same evolution (increase in plasmatic level) with the severity of sepsis as the other cytokines. reference : ( ) crit care med ; : - . objectives: to evaluate the effects of steroids on hemodynamics and mortality in septic patients with konwn levels of cortisol concentration. methods: retrospectively we analyzed data ofpatients with documented septic shock who received steroids after assessment of adrenal function. in all patients hemodynamic parameters as well as the necessary vasoactive medication were assessed, before and hours after corticosteroid medication. immediately before administration of corticosteroids adrenal function was evaluated with cortisol levels before and after synthetic corticotropin ( . mg). finally we studied mortality. we defined a positive respons on corticosteroids as an elevation of map of at least mmhg and/or a decrease in the necessary vasoactive medication of at least % within hours. adrenal insufficiency was defined as a cortisol level after stimulation of less than nmol/l. results: of patients were found to respond to steroid medication, did not. mean cortisol levels before and after corticotropin were • and • nmol/l in the responder group (rg) and • and • nmol/l in the non responder group (nrg). in the rg out of ( %) were found to have an adrenal insufficiency, in the nrg out of ( %). in the rg -weeks mortality was . % (l out of ), the overall mortality % ( out of ). mortality in the nrg was % ( out of ) (p < . ) and % ( out of ) (p < . ) respectively. conclusions: in patients in septic shock there is a beneficial effect of steroids in case of adrenal insufficiency, but also in a subgroup with normal adrenal f{unction. obiectives: intercellular adhesion is a critical step in the accumulation of leukocytes. postischemic cardiac lymph has the capacity to stimulate icam-i. in the coronary microcirculation neutrophils can be trapped and in many cases obstruct capillaries, previously we found that troponin t (s-tnt) a marker for myocardial iechemia, was increased in septic patients. the aim of the study was to follow slcam- and s-tnt levels continuously starting at the beginning of sepsis. methods: patients were ingluded in this institutionally approved study after relatives had given their informed consent. all patients were included within hrs following the beginning of sepsis. blood was drawn every hrs in the first ;~ hrs, after hrs, followed once per day for days. s-tnt, icam- , elam (elisa's, boehringer mannheim inc, r&d systems ltd.) arterial and venous blood gases were determined, an ecg and a complete hemedynamir measurement including cardiac output were obtained. all patients received adequate volume and catecholamine therapy (norepinephrine, dopamine, dobutamine; median (range) . ( . - . ), . ( . - ), . ( . - . ) pg/kg/min, respectively). statistical analysis: wileoxon signed rank-sum test. . ( . - . ) . patients had s-tnt levels > . pg/l. of these died, whereas only of patients died with s-tnt values < . pg/l (p= . ). all patients that died had elevated sjcam- levels ( ilg/l:cut-off ) whereas in the survivor group only % had elevated icam- levels (p= , ). conclusions: increased slcam- and s-tnt levels were found during early sepsis in the majority of patients, a high sicam- and s-tnt value was associated with a higher mortality. the research of the noninvasive haemodynamic monitoring accelerated recently all over the world. the aim of our study was to test whether the changes of the haemodynamk parameters measured by impedance cardiography (icg) were corresponded to clinical changes in septic patients. investigations were performed on critically ill postoperative septic patients (their multiple organ failure score was - /with icg monitor. in cases the investigation~ were performed in septic shock. the measured parameters were: heart rate (hr), mean arterial pressure (map), cardiac output (co), peripherial resistance (svr),preejection period (pep), and ventricular ejection time (vet). these parameters were measured during - hours in every minutes, depending on the patients cl~tnical condition. results: at the septic patients the hr and the co ]~reased. in septic shock the co was significantly higher the svr lower than in the septic group. in the hr there was no difference between the two groups. in septic shock noradrenalin influenced more effectively the measured parameters than dobutamin. conclusion: the trend of the measured icg parameters correlated with the clinical changes of septic patient's state. the noninvasive haemodynamic monitoring by impedance cardiography helps the planning and leading the adequate intensive therapy of these critically ill septic patients. to evaluate the development of sirs, sepsis and septic shock in hospitalized patients with fever, a prospective study was performed on patients using previously defined criteria. methods: normotensive patients with fever (temperature > . ~ axillary), admitted to the department of internal medicine were evaluated for the existence of sirs during the first three days of the study and sepsis at inclusion. during a follow-up period of days the patients were daily evaluated for the development of sepsis or septic shock. results: most patients ( %) had or developed sirs within the first three days, patients ( %) did not. sepsis was present in % at inclusion. in patients with sirs, % did not progress to sepsis or septic shock, % progressed to sepsis (mean interval . • . days), and patient (< %) directly progressed from sirs to septic shock. in patients with sepsis, % progressed to septic shock (mean interval . • . days). sepsis was preceded by sirs in %. septic shock was preceded by sepsis in % and by sirs in %. conclusions: % of patients with fever in an internal medicine department develop sirs, or sepsis. furthermore, progression from sirs to sepsis or septic shock is poorly predicted by fever or sirs. nevertheless, all patients with septic shock were preceded bysirs or sepsis. taken together, this may indicate a severity hierarchy of the syndromes. however, fever, sirs and sepsis are relatively poor indicators of development of septic shock. this supports further research on additional predictors of septic shock. b. m.manuylov, v.b.skobelsky (moscow) in recent years sodium hypochlorite (sh) has been successfully used to eliminate pyo-septic complications. moreover, the mechanism of the sh effect on the immune system has not been sufficiently studied. the aim of the present investigation was to study the mechanism of sh effect in inflammatory pulmonary diseases. patients with double pneumonia were subjected to the evaluation. sh in the concentration of mg/l in the volume of - m / hours was administered by drop infusion into the central vein. to evaluate one of the defence systems the leukocytes activity by the chemoluminescence technique was studied. in all the patients baseline secondary immunodeficiency which was indicated by the decrease in the luminescence level was established. even hour after the sh administration the leukocytes activation exp-ressed by the enhancement of their chemoluminescence . - times was observed. this supports the available findings that accumulation and liberation of the oxygen active forms (ol'oh, ' , h ) are accompanied by the increased phagocytosis, i,e. the signs of "the oxydation explosion" testify to the favourable sh effect on the course of inflammation processes. the use of sh permitted to decrease the percentage of lethality in double pneumonia by % in the intensive care unit over the year. at the same time, excessive activation of free radical oxygen may be a damaging factor. therefore, precise individual control over the choice of concentration, dosage and the preparation administration rate is required. prospective, double-blind, placebo-controlled, trial of atiii substitution in sepsis r. a. balk objective: pilot study to evaluate the efficacy and safety of atiii substimtion therapy in patients with sepsis. efficacy assessed using change in mortality or organ failure/dysfunction. adult patients meeting a definition of sepsis and cared for in a tertiary care academic medical center in chicago were identified and prospectively randomied to receive either atiii (kybernin p) or placebo in a double-blind treatment protocol. all other therapy and patient management were under the direction of the patient's attending physician. all patient's were followed for days and the organ dysfunction/failure were scored using published scoring systems (jordan et al crit. care med. , goris et al arch. surg. , kuaus et al ann. surg. colldusions:wha~ we met the shomaeker objectiv% the mortality and the pro~os[s were i~ttc*. those criteria were obtained with file tradititmal t~ctor likr doht~mme, hut c.~vh ~,as ca in~aertam measure. they ac~s smxergically in the optimizatic~l of the fell vmtrictdar work index, tad fimdameatally cavh seox~s to have an impo.aat role in the better respiratory ev-altmtioa, leaving yet the possibility to coltrol the flui& r althou~l eomproved it's not aec~pt~xl file importmlce h* the diminution, of the sepsis modiat~lrs llke fnt and il- with h~wmotiltrafi(al, stopphlg the evolution to nmltiorganic failure mid de~easethe mortality. with ours clhlicals results, we could saythat cavii in multiol~atlie disfut~oa septic patieats, se~r~ to be an c xilna] supoa or troatmeat maesure. of anaesthesia and intensive therapy, medical university of prcs, p~csf hungary. objectives: since some biological effects of bacterial endotoxin require an interaction between the lps molecule and a serum factor(s), we hypothesized that lps-induced no production and cgmp accumulation in vascular smooth muscle cells (vsmc), a mechanism ~thought to underlie cardiovascular collapse associated with septic shock, is modulated by serum factor(s). methods: cultured vsmc from rat aorta were challenged with e. coli lps for - hours either in the presence or absence of fetal calf serum (fbs), and no production was monitored by radioimmunoassay determination of cgmp content of hci extracts. results: in the absence of serum, o ng/ml lps was required to increase cgmp levels, whereas the presence of % fbs shifted the lps concentration curve i times to the left. similarly to fbs, human serum also potentiated lps-induced cgmp accumulation. in contrast to lps, serum had no effect on cgmp accumulation elicited by sodium nitroprusside, a no releasing agent, suggesting that the sensitivity of vsmc to generate cgmp in response to exogenous no is not modulated by serum. heat inactivation (> ~ min) but not removal of small molecules (< , d) from the serum by dialysis, reduced the potentiation of cgmp accumulation by serum. time course studied indicated that serum is required within the first min of lps exposure to increase cgmp levels. to investigate whether the effect of serum is specific for lps, we treated the cells with increasing concentration of interleukin -~ (il-i). % fbs shifted the il-iinduced cgmp responses five times to the left. conclusions: our study suggests that lower concentrations of e. cell lps and il-i require a heat labile macromolecule in the serum in order to elicit no production. this factor is present in the human serum and it may play a potentially important role during no synthesis induction in vsmc. objective: to evaluate the factors of acquisition and the outcome of methicillin resistant staphylococcus aureus (mrsa) bacteremia in an intensive care unit (icu). methods: all patients in which bacterermia due to staphylococcus aureus developed > hours following admission to our icu, during a year period ( january through january ) were reviewed. patients (pts) were included, mean age , y (sd , ), saps , (sd , ), mac cabe ( and ) %, mortality directly due to sepsis %. pts had mrsa bacteremia and methicillin susceptible staph. aureus (mssa) . both groups were compared using the chi square (with correction of yates), fisher's exact, student's t or wilcoxon test. results: there was no statistically significant difference between mrssa and mssa regarding at age ( , + , vs , + , ) , saps ( , + , vs , + , ), use of vancomycin ( % vs %), mechanical ventilation ( % vs %), number of days (d) before the drawing of the first positive blood culture (median d, range - d vs median d, range - d). more mrsa than mssa pts had previous use of nonsteroidal anti-inflammatory drugs (nsaid) ( % vs % p< , ), central venous catheter infection due to staph.aureus ( , % vs % p< , ), but previous use of antibiotics was not significantly different ( , % vs %). the outcome of the bacteremic pts was not statistically different: saps at the first day of bacteremia ( , +_. , vs , + , ), severe sepsis and septic shock ( % vs %), persistence of the bacteremia ( % vs %), mortality directly due to bacteremia ( % vs %). conclusion: previous use of nsaid, infection of venous central catheter are more frequently associated with mrsa bacteremia. thus, similar to others studies (hershow infect control hosp epidemio ; : - ) , these results do not indicate that mrsa is associated with increased virulence. objectives: to closer definition of mosf formation mechanismes in nosocomial sepsis (ns) the complex clinicobiochemical, microbiological, immunological, functional exaroination of cases with ns had been done. methods: examination of cellular and humoral immunity, nonspecific immunologic reactivity, systemic and hepatic circulation, microbiological examination of blood,electro-and echocardiography, sonography and computer tomography of chest and abdomen organs were obligatory. autopsy findings of dead cases had been analized. results: in cases ( , %) opportunistic pathogen microscopic flora ( staphylococcus anreus,staphylococcus epidermidis, staphylococcus saprophyticus) had been found out in blood inoculations. in cases ( %) side by side with destructive process in lungs the bacterial endo-and myocarditis with blood circulation failure had been determined.in cases ( %) simultanious lesion of three organs (heart,lungs,liver) had been found. morphologic examinations of dead cases ( %) internal revealed involvement of them in mosf-syndrome.hyperplasia of adenohypophysis;sclerosis of adrenal glands cortical layer;perivascular brain oedema,paralysis of brain capillaries and plasmorrhagia, cerebral thrombosis and cerebral abscess,necrobiosis of epithelium tubules of the kidney,pletora of hepar, fatty and granular degeneration of hepatocytes had been found.atrophy of white pulp and hyperplasia of red pulp, supress of lymphoid tissue, plethora and formation of infarctious had been found in spleen. mentioned changes in spleen were indispensable in ns. conclusion: in ns spleen can not secure it functions to support and appropriate detoxication potencial of organism,elimination of microbes,toxines,antoallergenes. insolvency of immunological link of antimicrobic defence is the starting mechanism of mosf developmentin ns. %neviere, jl. chagnon, b. vallet, d. mathieu, n lebleu, f. wattel ] ept of intensive care, hop calmette, lille, france ~everal studies have described tiypoperfusion of intestine during sepsis. owever, it is unknow whether the mesenteric blood flow is associated with nucosal hypoperfusion. additionally, the effects of resuscitation on the ntestinal microcirculation remain controversial. bjectives : to describe the effects of endotoxin in a porcine model during ~hock and resuscitation. ~ethods : ten pigs ( kg) were anesthetized and instrumented for "neasurement of cardiovascular variables. gastric and gut oxygenation vere assessed by intra-mucosal ph and microvascular laser doppler lowmetry. after baseline data collection, a minute intravenous infusion )f escherichia colt (serotype h , sigma, st. louis, mo) was begun ~t a rate of pg/kg. an infusion of either saline at . ml/kg/min (group ; n= ) or saline and dobutamine at a rate of pg/kg/min (group ii; n= ) vas begun mn after the end of the endotoxin infusion. tesults : to td t ~ fl w fluid ioadin,q alone sfyras d, k perreas, e douzinas, k spanou, m pitaridis and c roussos critical care dpt, evangelismos hosp., athens univ, school of medicine. obiectives: much controversy exists concerning the beneficial effects of cvvh on sepsis. we studied the effects of cvvh application on septic patients with reference to the following parameters: i) survival rate ii) cytokines' removal and iii) timing of cwh onset. methods: patients with sepsis (criteria according to accp/sccm, ) underwent cvvh as soon as they developed renal failure or dysfunction (urinary output< ml/ h, cr> . mg/dl and bun> mgd'dl ). specimens were collected: blood samples before cvvh and therafter both blood and ultrafiltrate (uf) samples on , and hours. cytokines tnfa, i - and ii- were measured by the immunoassay method in all specimens (uf and plasma -p) and sieving coefficient ([uf]/[p]) and h solute mass transfer of tnf and i - were calculated (v h x [uf] ). the apache ii score before cvvh onset, the duration of icu stay and the timing of cwh application related to the sepsis onset in days (ta) were recorded.with respect the mortality two groups were formed, i.e. group a (survivors) and group b (non-survivors) . the morbidity period in days of those septic patients who died in the past year and were not subjected to cwh (group c) was compared to that of group b. results: group a included pts and group b pts with mean+sd age ( _+ vs _+ , ns) and apache scores( _+ vs -+ . , ns). the mean ta-+ sd was . + vs -+ , p< . . the mean_+se morbidity period of group b vs group c was _+ vs _+ . p< . . the mean values of cytokines are presented in the following figures. the sieving coefficient for tnf was . and for i - was . . the solute mass tranfer was -fold the actual plasma content at a given time. . o conclusions: i) early application of cvvh seems to favourably affect the outcome of septic patients, ii) cytokine plasma levels do not decrease although cytokine removal is substantial, iii) it seems that cwh application in sepsis of any stage helps to buy time for further treatment. the most commonly monitored variables in shock stages idclude : arterial pressure, heart rate, central venous pressure, pulmonary artery wedge pressure and cardiac index. with vigorous therapy it is possible to bring these values back into the normal range in both survivors and nonsurvivors. therapeutic goal in septic shock stages is to maximize the values of cardiac index, delivery (do ) and consumption (c ). objectives: the main purpose of this article is to determine the relationship betwee~ delivery an consumption as a sign of hypoxia. fifteen patitents with septic shock were treated with intention to maximize the value of ci,d and v . we compared the levels of these parameters between the survivors and nonsurvivors and found no significant differences after hours. high levels of do and v may not guarantee against tissue hypoxia in early stage of septic shock. zjar~iic, dj janjic, lj. gvozdenovic, a.komareevic. t.petrovic, &marjanovic, institute of surgery, novi sad, yugoslavia objectives: evaluation and mutual comparison of clinical signs, laboratory data and microbiological monitoring in the patients with burn sepsis. method: retrospective analysis of the recorded data of all burn patients treated in our department between january and december . specially attentions were given to data considering wound infection, positive haemocultures, positive urinocultures and characteristics of septic state. results: out of patient there were ( , ~) adults and ( , ( ~) children. almost two thirds of the patients ( - , ~) were males. the predominantly cause ( , ~) of children's burns was scalding b~y hot liquids and flame burns ~ , ~) in adult patients. the most frequdntly species isolated from surface swat~ were pseudomonas aeruginosa ( " in adult patients) and staphyloccocus epidermidis ( , % in children). in only five patients ( , ~ the haenmcultures were positive -pseudomonas aeruginosa was isolated in three and staphyloccocus aureus in two patients. urine infection was diagnosed in , % of all patients. the treatment protocol included use of imipenem and polyvalent pseudomonas vaccine again~ pseudomonas aeruginosa and vancomycin and aminoglycosides against staphylococcus aureus. total mortality rate in this group of burned patients was , ~, but the mortality rate caused of sepsis was low (i %) . conclusions: early detection of any signs of wound infection and symptoms of septic state is a foundation for prevention and treatment of burn sepsis. the burn sepsis could be reliable detected by continuously monitoring the patient's status and by systematic microbacteriological monitoring of the burned patients. hyperdynamic vasoplegic septic shock p.f. laterre, p. goffette, j. roeseler, j.p, fauville, a. poncelet, p. lonneux, m.s. l~eynaert. dept. of intensive care, st. luc univ. hospital, brussels, belgium. splanchnic ischemia is described as a common feature of septic shock and could determine the development of msof. therapy such as noradrenaline (na) aiming at improving blood pressure is expected to worsen splanchnic ischemia by its vasoconstrictive effect and subsequent reduction in intestinal blood flow. ob[ective: evaluate the effect of na on splanchnic blood flow. material and method : in a patient admitted for variceal bleeding, ards and sepsis with positive blood culture, a fiberoptie catheter was positionned in the portal vein after recanalisation of its portosystemic stent shunt. blood pressure (bp-mmhg) , ci, svr, do (vigilance ~ baxter), v (indirect colorimetry), arterial, mixed venous and portal vein blood gases, phi were determined before (to) and during (t ) na infusion ( , to , hcg/kg/min.) . changes in splanchnic flow were assessed by changes in portal oxygen saturation (sp ) and arterio-portal oxygen saturation gradient (sao, -spoe laterre, ,lp. pedgrim, th. dugernier, v. delrue, ph. hantson, p. mahieu, m.s. reynaert. dept. of intensive care, st. luc univ. hospital, brussels, belgium. aim of the study : prospective determination of plasma levels of in patients with ss and their correlation with the type of microorganism and outcome. material and methods : in patients (pts) with ss and severe sepsis, plasma levels of tnfti, ill-b, il and il were determined every hours for days and on day after fulfilling the criteria of ss and severe sepsis. results : in pts, sepsis was caused by a gram (-) microorganism, in pts by a gram (+) and in pts no microorganism was identified. there were survivors ( %) (s) and non-survivors ( %) (ns) . cytokines profiles and levels were not different between gram (+) and gram (-) sepsis. ill-b levels were seldom elevated whatever the group studied. tnfot and il- were significantly higher in ns than in s ( objective: to evaluate the effects on the nitric oxide synthase inhibitor l-n~ hcl ( c ) on myocardial performance in human septic shock. method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map< mmhg) or the requirement for a noradrenaline (na) infusion >_ .i ]tg/kg/min with a map _< mmhg. cardiovascular support was limited to na _+ dobutamine (db), c was administered for up to h at a fixed dose-rate of either , . , , or mg/kg/h iv. during c infusion, na was to be reduced and if possible withdrawn, whilst maintaining map above mmhg and the cardiac index (ci) as clinically appropriate. assessments were made at baseline (t = ); at i h from the start of treatment (t = ); and at the end of treatment (t = ) with c . conclusions: c can restore systemic vascular tone in patients with septic shock enabling na therapy to be reduced and/or removed. the ci tends to fall whilst lv performance is sustained over time. c is a novel vasoacfive agent for the treatment of septic shock, which is undergoing further clinical evaluation. laterre, f. thys, e. danse, j.p. pelgrim, e. florence, z roeseler, m.s. r eynaert. dept, of intensive care, st. luc univ, hospital, brussels, belgium. therapy aiming at improving blood pressure and cardiac index in septic shock (ss) might have deleterious effects on regional blood flow. objectives : compare the influence of volume loading (vl), dobutamine (dobu) and noradrenaline (na) on sushepatic oxygen saturation (shoe) and svoe-sho, gradient in treated ss. material and methods : in patients with ss, ci (thermodilution) , doe, svo,. sho,, svoe-sho e gradient and lactate (l) were determined before (to) and after (t ); vl, dobu and na. results: in patients with treated ss, tests were performed (vl n= ; dobu n= ; na n= method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map< mmhg) or the requirement for a noradrenaline (na) infusion ~> . ~g/kg/min with a map _< mmhg. cardiovascular support was limited to na + dobutamine (db), c was administered for up to h at a fixed dose-rate of either i, . , , or mg/kg/h iv. during c infusion, na was to be reduced and if possible withdrawn, whilst maintaining map above mmhg and the cardiac index (ci) as clinically appropriate. assessments were made at baseline (t = ); at h from the start of treatment (t = ); and at the end of treatment (t - ) with c . conclusions: c is a novel vasoactive agent that can sustain map in patients with septic shock, enabling na support to he reduced and/or removed. there is a tendency for the ci to fall during treatment, which may be reflex in response to the increase in systemic vascular tone. c is a promising new therapy for septic shock, which will now be evaluated in a randomised, placebo-controlled safety and efficacy study. k. guntupalli objective: to evaluate the acute effects of the nitric oxide synthase inhibitor l-n~ hc ( c ) on selected indices of organ function in patients with septic shock. method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map < mmhg) or the requirement for a noradrenaline (na) infusion --> . [xg/kg/ min with a map _< mmirlg. cardiovascular support was limited to na + dobutamine. c was given for up to h at a fixed dose-rate of either , . , , or mg/kg/h iv. during c infusion, na was to be reduced and if possible withdrawn, whilst maintaining map above mmhg and the cardiac index (ci) as clinically appropriate. indices of organ function were assessed at baseline (t = ); at the end of treatment (t = ); and h after treatment (t = ) with c . results. -median values (* assessment made at h or when c discontinued). conclusions: there was no appareut dose-dependent adverse effect on these indices of organ function either during or after exposure to c . the plmelet count tended to fall whilst creadnine appeared to increase over time in all dose cohorts. this novel and promising therapy for septic shock will now be evaluated in a randomised, placebo-controlled safety and efficacy sludy. pharmacokinetics of c in patients with septic shock preliminary results z. hussein, b. jordan, c. fook-sheung, k. guntupalli objective: to evaluate the pharmacokinetics of the nitric oxide synthase inhibitor l-n~ hc ( cg ) given by continuous infusion for h in patients with septic shock. method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map < mmhg) or the requirement for a noradrenaline (na) infusion --> . ~tg/kg/min with a map _< mmhg. cardiovascular support was limited to na • dobutamine. c was administered for up to h at a fixed dose-rate of either , . , , or mg/kg/h iv. plasma was collected from each patient over a h period and analysed for c . pharmacokinetic parameters were derived from plasma concentration-time profiles using non-compartmental pharmacokinetic analysis. results: the (cm~ -maximum plasma concentration; auc -area under curve; cl -plasma clearance; v,, s -steady state volume of distribution; t'/ -plasma elimination halflife). conclusion: the pharmacokinetics of c in patients with septic shock are dose-independent at infusion rates up to . mg/kg/h. at higher rates, clearance of c decreases without any marked change in volume of distribution. c metabolism may be partially saturable at dose-rates above . mg/kg/h. obiectives: investigate the effect of the no synthase inhibitor, l-nt-methylarginine hc ( c ) on the haemodynamics and survival rate in a conscious mouse model of endotoxin shock. methods: female cd- mice ( - g) were instrumented under gaseous anaesthesia (isofluorane, %) and connected to a swivel tether system for continuous monitoring of blood pressure and drug administration. results: after h recovery, endotoxin administration (e. col• :b , - . mgkg - i.v.) elevated the plasma concentration of nitrite/nitrate (nox) and caused a progressive fall in mean arterial pressure (map) from + to + mmhg (n= , p< . ) at h, with a survival rate at h, h and h of %, % and % respectively. c administered as a h continuous infusion ( mgkg-th -t i.v., n= ), h after endotoxin, inhibited the elevation of plasma nox and attenuated the fall in map from + to + mmhg (n= ) at h, with an improved survival rate at h, h and h of %, % and % respectively. conclusions: this study suggests that overproduction of no is involved in the hypotension and mortality characteristic of septic shock. inhibition of no synthase using c represents a novel and promising treatment for septic shock. cultures of e.coli ( , %) and candida( , %) were olso received from autopsy material of children;p.aeruginosa,unspored anaerobes,proteus sp.,s.aureus,b.pneumonia were found in the few cases. in adults the spectrum of bacterioflora was mo~ re limited speaking about the number of species and cultures. in generalized forms of bacterial pyo-septic pathology a wider specific spectrum of causative agents was revealed usua fly with associations. e.coli and k.pneumonia played the leading role in children as well as in adults. in general,k.pneumonia ( , %cultures) and common e.coli( , %)prevailed according to the date of microbiological investigations of authopsy material in pyo-septfc pathology in . objectives: .in spite of all clinical exertion sepsis is still the reason for high clinica! lethality. this study is characterizing the group of patients which survived a septi~ shock. methods: during a period of months all surgical patients on icu were registrated prospectively, more than parameters for each of them were documented'daily in a paradox file. results (see table ): of patients fulfilled the criterion of a septic shock (r. bone, ) , of them died at the lth day, while the surviving group of patients stayed almost days at icu. obiectives: to compare the effects of and % pentastarch solutions to a human albumin solution on oxygen delivery (do ) in septic patients. methods: this stud}, included septic patients with fever (t > ~ tachycardia flqr > /rain), tachypnea (rr > /min) or mechanical ventilation, leukocytosis (wbc> /mm ) or leukopcnla (wbc< ()/mm ) and a clinical source of infection, who required a fluid challenge. in each patient the pulmonary arterial occlusion pressure (paop) was < mmhg. patients were randomized to receive ml of % albunun (n:i ), hydroxyethyl starch (hes -mw /d.s. . ) % (n: ) or t % (n=i ); patients were also treated with adrenergic agents. results cardiac index (c ) increased significantly only in % lies (table) hemoglobin (hb) decreased significantly at min in the same group. there was not significant change in oxygen delivery ( do ). baseline ci alb . :: . (l'min/m ) hes % . = . hes % . polyneuropathy of the critically ill (pci ) is a well recognized complication, acquired in the course of severe illness. we undertook a prospective study, to estimate the severity, extension and time of onset of pci in a selected group of patient with established septic shock ( bone's criteria ). all patients received inotropic circulatory support and were mechanically ventilated. none received relaxants or aminoglycosides. pci was diagnose<by clinical investigation and by emg, and repeated weekly ( axonal degeneration ). after days ( day = onset of septic shock ) in % of the patients pci was demonstrable. after days % of the patients had pci. there was a strong correlation between pci and other mof and between pci and encephalopathy ( eeg ). we conclude that i. pci is a common complication after septic shock. . pci develops early in the course of illness ( % after days ). . pci can be considered as a part of mof, suggesting a common pathogenesis. objectives: we addressed two questions: ) can serial measurements of vapco and avph also reflect the onset of tissue hypoxia during endotoxemia? ) are whole body changes in vapco and avph associated with parallel changes in regional circulation? methods: in anesthetized, mechanically ventilated dogs exhaled gases were sampled for determination of oxygen consumption (vo ). a catheter was positioned into the pericardial cavity to induce cardiac tamponade. ultrasonic flow probes were placed around superior mesenteric, left renal and left femoral arteries, and the corresponding veins were cannulated. group l served as control (n= ), group (n-- ) received mg/kg of endotoxin. thirty min later, tamponade was induced to gradually reduce do . results: systemic do crit was higher ( . _+ . vs . + . ml/kg.min, p < . ) and critical oxygen extraction ratio (o ererit) was lower ( . +_ . vs . +_ . %, p< . ) in the endotoxie than in the control group. meslenteric and femoral do crit were higher in the endotoxic than in the control group ( . _+ . vs . _+ . mlll g tissue.min and . _+ . vs . _+ . ml/min, respectively, both p< . ). regional o ercrit were lower in we endotoxic than in the control group (mesenteric: . _+ . vs .i_+ . %, renal: . + . vs . -+ . % and femorah . -+ . vs . _+ . %, all p< . ). vapco and avph followed a similar pattern in both groups, increasing slightly before do crit was reached, but dramatically wh,en do fell below do crit. in the presence like in the absence of endotoxin, systemic and regional do crit calculated from vo , from vapco , or from avph were similar; do crit was also significantly higher in the mesenteric and the femoral beds of the endotoxic than the control dogs. systemic and regional do crit could be calculated from the blood lactate levels only in the control group. conclusions: during an acute reduction in blood flow i) vapco and avph can reflect hypoxic threshold in the presence like in the absence of endotoxemia. ) alterations in organ oxygen extraction capabilities induced by endotoxin can be reflected by regional changes in vapco and avph. objectives: enhanced nitric oxide (no) release has been incriminated in the vasodilation and myocardial depression characterizing septic shock, but the administration of no blockers has yielded equivocal results. the present study explored the systemic and regional effects of a no donor linsidomine (sin-i) during endotoxic shock. methods: anesthetized dogs received endotoxin ( mg/kg iv), followed min later by a saline infusion to keep cardiac filling pressures constant. oxygen uptake (vo ) was derived from the expired gas analysis. regional blood flow was measured by an ultrasonic flowmeter (transonic). results: the control endotoxie group (n= ) maintained low arterial pressure and systemic vascular resistance. the dogs receiving a continuous infusion of , , ~ug/kg.min of sin- starting min following initial fluid resuscitation (each dose for h), had a higher cardiac index ( . -+ . vs . _+ . l/min.kg, p< . ) and lower systemic and pulmonary vascular resistance than the control group ( -+ vs -+ and -+ vs -+ dyne.sec/cm , respectively, both p< . ). arterial pressure and pulmonary artery pressure were not influenced. sin- significantly increased the mesenteric blood flow from -+ to + % of baseline levels and renal blood flow from -+ to -+ % (both p< . ) but did not influence femoral blood flow. the relative blood flow was increased in the mesenteric bed (at all doses), and reduced in the femoral bed (at highest dose). systemic oxygen delivery, vo , oxygen extraction and blood lactate levels had similar course in the two groups. conclusions: in fluid-resuscitated endotoxic shock dogs, the no donor sin- increased cardiac index without deleterious effects on arterial pressure, and increased splanchnic blood fl w. objectives: sepsis syndrome is associated with the release of a variety of inflammatory mediators, such as interleukins, tumor necrosis factor and platelet-activating factor (paf). administration of paf, a naturally occuring phospolipid, to laboratory animals has been demonstrated to resullt in pathological changes that closely resemble those found in sepsis. in addition, paf antagonists of various origins have been demonstrated to attenuate cardiovascular collaps and to protect against lethality in endotoxemia. in the present study the efficacy and safety of the paf-antagonist tcv- g was investigated in sepsis syndrome patients. in addition, the putative inflammatory parameters tumor necrosis factor (tnf), interleukin il) - il- , and soluble (s) e-selectin were measured in both tcv- and placebo treated patients. metho.~a randomized, double-biind, multi-center study was undertaken to compare the safety and efficacy of intravenously administered tcv versus placebo (takeda chemical industries ltd., osaka, japan). tcv- was used as add-on to conventional therapy in the treatment of patients with severe sepsis and septic shock ( . mg/kg body weight intravenously over hrs, twice a day for one week). day mortality was registered, as well as vital signs, laboratory parameters, hemodynamic parameters, apache ii score and mof score. plasma samples for the determination of inflammatory parameters were collected twice a day for one week. the study was approved by each institutional review board and written informed consent was obtained for each patient. results: a total of patients were included in the study. one patient had to be excluded as a result of protocol violation of the remaining patients patients were randomised to receive tcv- and to be treated with placebo. there were no significant differences between the treatment group with respect to age. gender, and apache i~ score on admission. however, admission levels of il- and il- , considered to reflect severity of disease, tended to be higher in tcv treated patients: . . vs . ng/ml for il- (p. ) and . vs . ng/ml for il- (p. ) in tcv- and placebo treated patients, respectively. a remarkable difference in survival, however not significant, was observed at day i.e. the end of tcv treatment (mortality: out of in the tcv group and out of patients in the placebo group). the inc;dence ui ~-,~verse events, 'n both treatment groups were comparable. plasma il- and plasma il- levels tended to decrease more rapidly in tcv treated patients compared to controls (p=. and p=. , for il- and /l- respectively) conclusions: tcv- is safe as add-on treatment in sepsis syndrome patients. the data presented indicate that tcv- may enhance survival of sepsis syndrome which will be assessed in a phase ill study. objective: oxidation of lipids by free oxygen radicals playes an important role in sepsis. an important source of oxygen radicals is the respiratory burst of phagocytic leukocytes, especially~ polymorphonuclear leukocytes. clinically the hallmark of sepsis is the capillary leak, which is mediated in part by oxyradicals. the adult respiratory distress syndrom (ands} represents the most studied capillary leak phenomenon in sepsis. methods: in ii patients (df,~m, aged - y.) with verified septicemia had been included in this study. beginning from day oxidisable lipidautoantibodies (club), ~opterin and crp were determined in the patients serum and compared against the apache ii score during the days - . patients, f and m died @u= ring their stay at the icu, of them in less than h~urs: after admission. at the begin surviving patients showed olab values between - %, non-survivors between - %, com= pared to neopterin values of - m~ol/l in survivors and - ~mol/l in non-survivors. apache ii score didn t show any difference. during the following days olab sbowed an in= crease in survivors, while in non-survivors olab stayed equal or showed a decrease. no difference between both groups was found in neopterin, crp and apache ii score. as result we conclude, tbat lipidperoxidation playes an important role during septicemia. olab as a marker of this process are predictive for the outcome of patients. obiectives : to evaluate the influence of cardiopulmonary bypass ongastrointestinal transit. meth~xls; gastrocoecal transit time (gtt) in consecutive children on day after uncomplicated open heart surgery was compared to gtt in children after closed heart thoracic surgery and to healthy controls. gtt was measured by hydrogen breath testing, using lactulose (o, g/kg in a % aequous solution) as nonabsorbable marker. exspiratory hydrogen content was measured using a electrochemical system (stimotron). patients in both groups had continuous infusion of morphine and midazolam and were comparable in respect to catecholamine dose. children with a history of toddler's diarrhoea and children with elevated central venous pressure were excluded. results: gastrocoecal transit was delayed in all patients after cpb, no transit was achieved within minutes in / . after closed heart surgery gtt was delayed (+- ) min vs. (+- ) compared to controls, but transit was achieved in all aptients within rain. mean dopamine dose was , mcg/kgmin after cpb and , meg after closed heart surgery.. conclusions: after uncomplicated cpb gastmcoecal transit is extremely delayed. the degree of delay is not explained neither by the use of analgetic and sedative drugs neither by the use of catecholamines. factors directly related to cpb (e.g. low flow perfusion, hypothe,mia) may be responsible. these findings are of limited clinical relevance in ancomplicated cases. in critically ill patients delayed enteral feeding may contribute to infectious complications. studies of therapentic measures to accelerate gastrointestinal transit therefore are warranted. neonatal ecmo -czech experience. nekvasil r., penkova z, vasek l., plier p., bobula a novotna e., pavlicek v., hnilicka m. nicu and ecmo center brno and dept. pediatric surge ', children's hospital brno, czech republic. introduction. in spite of the fact that neonatal ecmo has been gradually considered a standard method of solving uncontrollable respiratol t failure in newborns in most countries of the western europe, the introduction of this sophisticated method in countries of the former communist block meets a lot of problem. material methods. in the course of two years, only newborns, b.w. - g, were reffered to neonatal ecmo because of uncontrollable respiratow failure. at the admission the average values of oxygenation index were + , and aado , -+ , kpa. results. newborns ( %) died shortly alter" admission or during transport without possibity to further is newborns ( , %) were treated using high-frequency ventilation (hfo or hfjv), one for conspicuous airway resistance paradoxically with low-frequency ippb. all ventilated newborns survived. ecmo was applied in newborns ( , %) and of them survived the mortality rate of group mentioned was %. conclusion. the fact that in the czech republic ( mil. population with natality rate of about . newborns/year) only small part of patients was reffered to neonatal ecmo has a number of causes. the most important are: unacquaintance of prognostic and indication criteria at forwarding workplaces and the aversion of neonatologist to all new.therapeutic interventions. last but not least, a negative role is also played by current change of health service systems when, under the influence of health-service insurance companies a newborn in serious condition given only a standard intensive care in primary and secondary nicu is literally "the golden calf", and therefore these workplaces either do not send him or send him too iate ~o an ecmo center. stndy aim: urfactant, which is being applied into the lungs for treatment of respiratory distress syndrome, can reach the circulatory blood system by absorption. it refinances local fimctiun of macrophages and lymphocytes and increases the accumulation of nentrophils into the hmgs this eunld influence the local acute phase reactiml in the hmgs after surfactant application. "ilia aim of the stud), was to investigate the influence of oatural and artificial surfactaat onto the acute phase reaction and the blood elottiog system. material :and methods: a) measurement of tnf-a, - , ltb and thromboxane b release in whole blood: each of . ml hepariaised blood of healthy adult volunteers was iucubated lbr hears with eillier ill ug/ml lps, mg/ml b&,ine smfactant (alveulhct/themae), rag/nil artificial surfactant (exosurf/wellcome), og lps + i mg/ml bovine surfactant or i ug lps + i mghal artificial sorfactant, tleparinised bhx-,d without additions was used for controls. ' e concentration of e)lokines and eicosanoids ".van measured semiquantilatively by eijsa or eia (dimmva/hamburg) after ceatrifagalion, b) measurement of platelet aggregation: each of . ml haparinised hltxxl of healthy adult vohmteers was inculmled lbr hours with eilher aghnl i,ps, i mg/ml bovine surfactant (alveafact/thomae), i mg/ml artificial snrlhctant (exosurf/wellcotne), it} ug lps + i mghnl bovine snrfactant or ug lps + i mg/ml artificial surfaetant, tlepminised blood withont additions was nsed for controls. platelet aggregation in whole blood was measured by impedance in the aggregometer (g~nstaedt). c) measurement of the dotting activity: citrated bleed of healthy adult w~lunlccrs was mixed with difl'ereul couccalrations of imvine or artificial snrfactant fad then prolhrombiu tiaras and imrlial thrmnlx~plaslia filues were ineasnrcd. for measurement of the prokoagulatioo acfivily the reagent in the qnick test was replaced by surfaclant. results: dependmlt on the dose both surfactants stimulated the release of - but not or tnf-a io wlmle blood. "illere was no suppression of the lps-indaeed eytokine-release. both surfaclants did not directly influence the extrinsic blood coagulation system, while both activated the inniasie activity dependant on the dose. platelat aggregatiun was slightly stimulated by bovine snrfactunt and strongly inhibited by by artificial surthctant. in comhinafion with . ~ both factors showed no difft.'renca to lps ahme.'fhe reltu.tse of eiconasnid~." was stimolated more by artificial surfactant then by bovine surfilctant with regard to the cyehmxygelmse (thromboxsne b ) and the lipooxygenase (lencotrieae b ) pathways. conclusion: we cooclude: ) i:lovine as well as artificial surfaelant stimulate the cellular inmnn]e response. ) bovine as well as artificial surfnctant activate the intrinsic ctmgnlation cascade. ) bovine surlilctant stimulates platelet aggregation, artificial sar-fijctant inhibits platelet aggregation.. introduction: although the use of modem noninvasive methods like measurement of tope , tcpco or san leeds to an carly infonnation about pathologic alterations of the gas exdmage of ventilated patients, these methods cannot replace invasive bloodgas analysis. a new noninvasive method to monitor the capillary gas exchange is the reflection spectrophotometry. to record reflection spectra with a ldgh sensitivity on the surface of tissue we eonstnmted a special mierolightgnide photospectronmter (empito). this spectrometer enables the investigation of local helerogenities of llbo and lb content, capillary flow rate and oxygen uptake rate. aim of the study: ) to compare the sousitivity and specifity ofthe empilo with other non-invasive method~ of monitoring the gas exchange in neonatal intensive care patients. ) to investigate the possibility of obtainiug infonnations about the local nptake and the venous as well as arterial satnration. patients and methods:we investigaled non-selected patients of oar pediatric intensive care unit. for coulinnons monitoring we conslracted a special sappert to fix file end nf the microlightguide+ during the investigation tope , tcpco and san were measured by standard methods. "fo investigate the local tisslm oxygen uptake we recorded spectres within minutes by moving the lightgnide over an described area of the skin of the patient. 'lhe reselting i(gx) l ibo vahms were sorted by a software package. on the assumption that the low values correspond to the tibo value of the veaons ends of the capillaries and the high values to those of the arterial ends we ) it is possible to gel infonnations about the local o -uptake and arterial saturation ia the peripheral tissue by photoslg'ctroscopy. ) in combination with noninvasive pl i-measorement it seems possible to reduce withdrawal of blood for invasivn bhmd gas analysis. objectives:improve ventilation,tissue oxygenation and acid base balance among extremly low birth weightand premature infants. methods: fourteen cases were s~udied,their gestational age ranged from( - )ws.continnous positive air way pressure was applied to six cases at peep level from ( - )cm h o through nasal pronge,(group i),the other cases were managed as routine,(group ii).blood gases, tcpo ,tcco ,resp.rate,depth and pattern were monitored for assessment of tissue oxygenation and ventilation, results: our rasults showed that early application of cpap improve ventilation among ( . %)of cases,while ( . %)of cases need imv.the cases of group ii need imv among ( %)of the studied cases during the second or the third day of life. conclusions:-this preliminary study showed the import-............ ance of early application of cpap before the onset of respiratory distress syndrom to improve spontaneous ve ventilation,tissue oxygenation and to gecrease the risk of intubation. comparative assessment of pediatric intensive care; a national multicenfre siudy. reinoud j.b.j. gemkc, gouke j. bonsel , the dutch picasso (pediatric intensive care assessment of outcome) study group. twilbelmina children's hospital and utrecht university, utrecht department of clinical epidemiology, academic medical center, : amsterdam, the netherlands the performance of all ( ) pediatric intensive care units (icus) in the netherlands ( tertairy and non-tertiary) was analyzed in an open prospective muiticenter study. effectiveness of care was defined as the ratio of observed to prism-score derived expected mortality aenee, standardized mortality rate). efficiency was determined by objective criteria (mortality risk > % or administration of at least icu-dependent therapy)'. consecutive admissions aged < years old were included. overall, observed and expected mortality were in good agreement (p > . ). between hospitals, crude mortality showed wide variations (mean . %, range - %). however, in each center, observed and expected mortality were similar (mean ratio . , range . - . ). in tertiary care centres, severity of illness corrected mortality in high-risk patients was less than in non-tertiary care centres; paradoxically, in low-risk patients the opposite was found. probably the large proportion of low-risk tertiary care patients suffering from severe, incurable chronic disease, explains the higher mortality in this group. this indicates that simultaneous assessment of circumstances of dying and of long term morbidity in similar future studies is imperative. the average proportion of efficient icu days was %, however large variations between units were found (range: - %). in conclusion differences in mortality rates among pediatric icus were explained by differences in severity of illness. high efficiency rates in combination with adequate effectiveness, found in several centres suggest that admission and discharge decisions might be improved by a better selection of high risk patients requiring icu-dependent therapies, especially in less efficient centres. objectives: previously published studies showed that serum lactate levels correlated with outcome of severe ill adult, 'we hypothesized that critically ill newborns are often incurred hypopeffusion manifested by elevated lactate levels. these initial blood lactate levels should be related to nicu outcome. design: prospective study with ethical comfnittee approval. setting: the -bed neonatal intensive care unit of a university hospital material and method: a total of consecutive outbem newborns admitted to nlod from , . to ., . were enrolled to the study. babies who died or were discharged from the unit within hours of treatment were excluded from the study, mean birth weight was g (+/- r), mean gestatational age was weeks (+/- . wks), mean age at the admission was h (+/- hi. multiple (~_ j organ system failure occurred jn . % of babies at the admission./~tertal lactates were measure/at the admission, among - hour and - hour of n[c'lj therapy. outcome was defined as a mortality and length of nicu stay. results" survival rate was . %, mean length of nicu stay for survivors was . days (+/- . day). we found high lactate levels at the admission in . % babies (~ . % with levels above . retool/i). the mean arterial lactate concentrations for nonsurvivors were signiftcahtly higher than for survivors durin~ consecutive da~ as follows: objectives: the purpose of our research was to analyze the frequency of bronchial asthma (b.a.) exacerbations in pregnant women and health status of infants. methods: the research was based on the epidemiological investigation and prolonged observation of pregnant women with b.a. during the gestation period. remission of b.a. before the pregnancy in excess of years was recorded in patients ( . %), patients ( . %) reported a - year remission and patients ( . %) had a remission lasting less than months before they became pregnant. results: seven patients ( . %) developed medium attacks in the second half of pregnancy, four patients ( . %) experienced light attacks of b.a. asthma attacks were most frequently caused by acute respiratory diseases and stress factors. in two cases with grave manifestation of b.a., the pregnancy ended in abortion within the first - weeks due to the frequent and heavy choking attacks. to fight b.a. attacks, five patients used adrenomimetics (salbutamol, becotid) in sprays, six women were administered theophyllinum and salbutamol in the form of tablets during - weeks. a significant portion of pregnant women with b.a. ( %) exhibited frequent complications during pregnancy (toxemia, late gestosis, threat of miscarriage). our findings prove that babies born from women with b.a. of domestic and pollen origin had a low body weight ( - gr), functional immaturity and chronic antenatal and intranatal hypoxia twice as often as the infants born from healthy women without allergic background. conclusions: preventive treatment of women with b.a. prior to pregnancy is required to maintain a stable remission of the disease, which is a key to having healthy children delivered by mothers suffering from b.a. introduction. intracerebral hemorrhage (ich) is a common event in human prematudty, affecting about % of newborns weighing below g who are born before weeks of gestation, however, little is known about the pathogenesis of ich with exception of the prematurity of the brain itself, (birth) trauma, and asphyxia. the postischemic production of oxygen free radicals (ofr) dudng reoxygenation as a cause of brain damage has been demonstrated in animal research. since almost all preventive antioxidant activity of plasma is associated with ceruloplasmin and transferdn we investigated the association of such iron-oxidizing resp. iron-binding proteins and ich. we could demonstrate significantly reduced levels of both, iron-oxidizing and iron-binding proteins, in premature asphyxiated newboms pdor to development of ich. an increase of suparoxide after hypoxia in the presence of iron ions facilitates the formation ofthe highly reactive hydroxyl radicals. our data support the theory that ich may be caused by ofr, which can damage any sensitive tissue including growing endothelial cells. the estimation of transferrin-saturation and measurement of ceruleplesmin levels might help to identify an infant at dsk before the onset of ich. with the new medos | hia-vad | cardiac assist system the missing tool in the armamentarium of cardiac surgeons is available in two pediatric sizes: i -ml and -ml pump volume. the right sided pumps are % smaller for biventricular use. between february and may we implanted this assist system in children. the indications and demographics are indicated in the following table (left ventricular assist device-lvad, right vad-rvad univentricular vad-uvad, post cardiotomy cardiac failure-pcf, dilated cardiomyopathy-cmr bland white garland syndrome-bwg, tetralogy of fallot-tof, hypoplastic left heart syndrome-hlhs). objectives: evaluate tile effeci'of inhaled nitric oxide (no) as puhnona] t vasodilating agent ill tile posloperalivc period after correclion of congenital heart defects in infant. patient n.l: kg, lnonlhs, down syndrome undenvcnl rep~fir of atrioventricular septal defect (avsd). after surgery the puhnonary arlcry pressure (pap) slowly rose to tile syslemic dcspilc tnaximal eonvcnlional fllerapy (fentanyl mcg/kg/h, hypocapnia of mmhg and metabolic alcalinization). no was delivered into tile inspiratory branch of!be breathing circuit at ppm, and the gas aoalyser for no and no (polylron dmger) were situated at the espiratory branch, a rapid dccrcasc of pap io i/ of systemic was obtained with a dramalic improvement. no was continued at ppm for six days and the baby was exlnbated if! days after surgery and discharged from the icu days after. patient n. : . kg, monlhs, onderwen! repair of avsd. the day after surgery the systemic oxygen salnralion was % wilh a pap at % of systemic. two hours of c wenlional therapy failed o improve ihc patient and no administration was slarled at ppm. so dramatically incrcased to %, but the pap dropped only to % of syslemic. nevertheless ihe clinical conditions improved and the no administration could be reduced at ppm in the following days. she was extubaled days after surgery and discharged from the icu days after. patient n. : kg, 'ears. underwen| hearl tral~splantalion for congenital heart disease with moderate hypoplasia of pulmonary arlcrics. at the end of cardiopulmonary bypass the transpnlnlonary al~erio-venoas gradient yeas higher than mnfflg and we speculaled !hat w'ls due to a degree of puhnonary vasocostrictiont. the nsnal dose of no was otilised, however no significant modilicalion of pulmonary pressure or systemic oxygen saluralion was noled, and after h no was discontinned. tile palienl was carried io the icu with maximal inotropic support, extubated after d;b's and disclmrged from the icu after days. in all patient no major adverse effect relaled to no admilfistration ",','as holed. conclusion: in our experience no ms a pulmonary vasodilaling agent is effective and easily adjustable to tile palienls requiemenls, however its use remains limited ill those palienl ill whoin tile alnonll! of fixed inlllllojliify vascular resistance is predominanl. we report the use of ecmo support in two unusual cases of severe tracheal disruption in which it had become impossible to achieve adequate ventilation. case : severe tracheal laceration due to aspiration of a share forelan bodv: a previously healthy month old toddler was referred for ecmo following aspiration of a porcelain foreign body (with razor sharp edges) which had become embedded in the right mainstem bronchus with massive extrusion of air. this was removed on veno-arteda[ ecmo support, as the patient was unventilatable prior to bronchoscopy due to ongoing airieak. ecmg was continued after bronchoscopy to permit airway healing without the presence of an endotracheal tube. unfortunately, an extensive pulmonary haemorrhage on day of ecmo necessited re-exploration of the airway. this revealed a posterior tracheal tear from the cricoid to the middle of the right lower lobe. following repair the patient was left on ecmo support together with high frequency oscillation ventilation (hfov), the latter being used to minimise potential aideak and maximise alveoli recruitment. ecmo was weaned after days ( hours) -the patient was extubated weeks later. case : tracheal wound dehiscence due to seosls -tracheal transelant on ecmo: a month old infant with a c[inically significant congenital long segment tracheal stenosis and left pulmonary artery sling underwent resection of the stenosis, followed by primary reanastomosis. this was complicated, days later, by severe mediastinitis and complete dehiscence of the anastomosis. an autologous pericardial patch was used to repair this, however, the tracheal wound again dehisced days later making mechanical ventilation impossible. in view of ongoing sepsis and a severely disrupted trachea ecmo was the only possible form of support. following resolution of the local sepsis ( days) a definitive procedure in the form of a tracheal homograft (transplant) was undertaken on ecmo. the patient was managed on ecmo and hfov for a further days, the hfov being used to optimize rapid lung inflation. unfortunately this patient died months after weaning from ecmo due to complete disintegration of the homograft, which was not deemed reparable. conclusions: ) ecmo can be used in the acute management of oxygenation when there is major airway disruption making mechanical ventilation impossible. ) hfov was a useful adjunct in aiding recruitment of lung volume on ecmo in these two patients. backoreund: persistent pulmonary hypertension of the newborn (pphn) consists of a heterogenous group of diseases ranging from transient reversibte pulmonary hypertension to fixed primary malformations of the lung (primary pulmonary dyspfasia-ppd). inhaled nitric oxide (ino), a selective pulmonary vasodilator, has been proposed as a treatment for severe pphn. obiective and methods: ino was administered to near term neonates with severe persistent pphn, oxygenation index > and echocardiogrephic evidence of pulmonary hypertension, in order to further determine the clinical role of ino in the treatment of pphn. the response to ino was also analysed retrospectively to examine whether this could be of diagnostic value in differentiating at an early stage patients with reversible from fixed causes of pphn results: twenty one of the patients studied responded to the initial trial of no ( ppm x minutes), as defined by a greater than percent improvement in pad as well as a fall in the el to < . these patients were continued on ino therapy, with patterns of response emerging: pattern babies (n= ) continued to show a sustained response to ino and were successfully weaned from it within days -all survived. pattern babies (n= ) failed to sustain their response to ino over hours, as definded by a rise in the el > . six survived, five with ecmo. pattern babies (n= ) had a sustained dependence on ino for - weeks. all three died and lung histology revealed severe primary pulmonary dysplasia (ppd). patients with ppd (pattern ) not only required ino for longer periods of time than did the sustained responders (pattern ), but also required significantly higher doses of ino we report on the air transport of paediatric intensive care patients. these transports fall into three categories: ) retrieval of critically ill neonates and paediatdc patients referred for either ecmo or inhaled nitric oxide (ino) (n = ). one patient was transferred on ind. mean transfer time . hours (se + . hrs). ) long distance international transport using chartered aircraft (n = ). the indications for these transfers included both urgent retrievals for cardiac surgery and semi-elective transfer of stable patients back to their referring unit following treatment in tertiary centres. mean transfer time . hours (se + . hrs) ) long distance international transport using commercial aircraft (n = ). indications for transfer were either semi-elective retrieval for tertiary treatment or the return of stable chronically ventilated patients to their referring hospitals. mean transfer time hours (se _+ .fhrs, longest hrs). the transport team consisted of a paediatric intensive care doctor of at least registrar grade and a registered sick chidrens nurse with intensive care experience. the administrative components of the transfer (ambulances, airlines, customs) were managed in collaboration with companies specializing in air ambulance transfers. outcome: all the patients were safely transported to their destination without mortality or morbidity. complications durino transfer ir~lv~; ) patient complications -semielective endotracheal tube change and central access needed in the only patient brought to the commercial aircraft by the referring hospital (all others retrieved directly from referral hospital), seizure in patient with known encephalopathy, severe cyanotic spells in patient with fallots tetralogy who was retrieved for urgent surgery for this indication ) mechanical compfications -ventilator failure, incubator battery failure, oxygen regulator failure -all occurred with equipment sent from referral hospital, this was unfamiliar and unchecked by our transport team -it was not the decision of the transfer team to use this equipment on this single occassion. ) administrative complications -confiscation of incubator battery by airport security police, excessive delay by custom officials ( hours) in the airport. the incidence of such problems were felt to be low and unpredictable. in conclusion: mechanically ventilated paediatric patients can be safely transported on both chartered and commercial airlines. these transports are best accomplished by trained intensive care medical and nursing staff with the backing of an air ambulance organization competent in arranging the necessary administrative details. it is essential to use your own equipment and to retrieve the patient _directly from the referrin(] hospital to minimise ootential complications. our experience with anaesthesia for paediatric electromyography _w_._pla_ti_k_a_n_o_v, r.eousseff, k.pavlova, d.marinova dpts. of anaesthesiology and int. care and clinika] neurophysiology, med. university, pleven, bulgaria ~)_b_j#~ti_v~. to t~st a " heavv sedation " regimen of anaest-es~a for the purpose of paediatric electromyography d#s~gil~ non-randomized,non-blinded human trial in the seting of an uriiversity hospetal. _m_a_t_eri_a_is_a_nd_ m_e_th_od_s_. children,asa i-if,median age years,range - who undervent eleetrcmyography required anaesthesia. they recieved low-dose ketamine + i~iazepam or midazolam via musculary route( children,age - yrs,ketamine , mg/kg, diazepam - mg total dose ) or per os ( children,ketamine - mg/kg,diazepam , mg/kg or midazclam , - , mg/kg ) _resu_l_t_s. - minutes after medication a state of heavy sedation with weak spontaneos and stimuli-provoked movements was achieved in all children, that lasted - minutes and allowed adequate needle emg and nerve conduction investigation. children recieved additional , - , vol.% halothane during the placement of the needle. non -invasive blood pressure , breath and heart sounds and hb sad by pulse oxymetry were monitored.none of the older children disclosed memories of pain when asked after they regained adequate verbal contact.no complicationes were observed. antenatal maternal steroids reduce the risk of periventricular-intraventricular hemorrhage in very premature neonates treated with natural surfactants. i.apostolidou, c.papagaroufalis, g.touloumi, m.xanthou, n.kalpoyannis a' and b" neonatal icu "ag. sophia" children" s hosp. athens, greece. dept of hygiene and epidemiology, athens university, greece. obiectives: the aim of the study was to evaluate the association of periventricular-intraventricular hemorrhage (p-ivh) in surfactanl treated premature neonates with pre-and postnatal variables. methods: the population of the study was neonates admitted during the years to , with gestational age _< weeks and severe respiratory distress syndrome (rds) (mechanical ventilation and arterialalveolar oxygen tension ratio (ajapo ) < . ), who received rescue therapy of at least two doses of natural surfactants (alveofact or curosurf) and examined with ultrasound and/or autopsy for the presence of p-ivh (papile's classification). the examined factors in each neonate were the following: gestational age, birth weight, sex, multiple pregnancy, antenatal maternal steroids (complete and incomplete course of betamethasone), a/apo before the administration of the st dose of surfeclant, delivery, apgar score at min, type of surfactant, pneumothorax and patent ductus arteriosus. the statistical methods used were x and one-way analyses of variance followed by logistic regression medels, results: the incidence ot p-ivh was . %. three factors were found to have an independent relation to p-ivh (final logistic regression model): gestalional age, a/apo before surfactant administration, and antenatal administration of maternal steroids (complete and incomplete courses). for every weeks of lower gestational age the neonates had an almost doubled associated risk of p-ivh (or: . , % c : . , . ). for every . on average decrease of a/apo before surfactant administration the risk of p-ivh in the neonates was . times higher ( % ci: . , . ). the neonates whose mothers received antenatally steroids had only one tenth of the risk of p-ivh of the neonates whose mothers had not (or: . , % ci: . , . ). conclusions: our results suggest that the antenatal administration of maternal steroids, even less than hours before delivery, reduce the risk of pqvh in very premature neonates treated with natural surfactants, whereas the small gestational age and the lung immaturity still remain the main risk factors tor the development of p-ivh. we analysed retrospectively the management of ( boys, girls) accidental ingestions of foreign bodies in children (mean age : . years, range : months- years). no child had ingested more than foreign object. the majority of the ingested foreign bodies were : coins (n : ), toy parts (n : ), jewellery (n : ), batteries (n : ), "sharp" materials such as needles and pins (n : ), "large" amounts of food (n : ). impaction of food occurs more frequently in children after oesophageal reconstruction in cases of oesophageal atresia. although according to literature "coca-cola" is reported to be effective, this was not seen in our experience. / patients had minor transient symptoms at the moment of ingestion, such as retrosternal pain. only children experienced severe manifestations (cyanosis, dysphagia). in these children, endoscopy revealed oesophageal and gastric erosions. children were seen at the emergency ward within a few hours after the accident ( mean : hours, range min. - hours). chest and/or abdominal x-ray was performed as first-line investigation ( / objects were radio-opaque), and revealed an (unexpected) oeeophageal impaction in children. in / the foreign body was in the stomach. batteries, sharp objects and objects trapped in the oesophagus were removed, either by endoscopy or by magnet-extraction whenever possible. the outcome of the patients was excellent. no complications were observed. extraction is recommended in symptomatic patients, and whenever the foreign body is trapped in the oesophagus, or if the foreign object is "sharp" or a battery. objectives: two strategies were used for management of malignant diphtheria in children aged from . to years. methods: protocol n consisted of intravenous administration of diphtheria antitoxic serum, prednisolone ( mg/kg bw/day), plasmapheresis and supportive care. protocol n included the use of antitoxic serum against the background of high-dose dexasone ( - mg/kg bw/day), hemocarioperfusion and a preventive use (before the clinical manifestation of myocardial damage) of inotropic medications, inhibitors of angiotensin-converting enzyme and pentoxyphylline. each of protocols included the monitoring of serum toxin (diphtherin) levels. results: the group of patients treated according to the protocol n consisted of children with malignant diphtheria, of them with severe malignant diphtheria (grade and ). all patients exhibited the circulation of toxin during at least three days after the start of treatment. all patients with severe grade of disease demonstrated heavy cardiovascular disturbances associated with malignant diphtheria. of the children in the group died seven. the children of the second group were treated according to the protocol n . out of total of patients of this group. patients had severe malignant diphtheria. in all children a significant reduction in serum toxin level was revealed after hemocarboperfusion. in all but one case the satisfactory control of cardiovascular function on was achieved. of children admitted to the trial survived, one child with malignant diphtheria of grade and congenital filbroelastosys of the left ventriculum died. the severity of neurological complications was similar in each of groups. conclusions: the use of hemocarboperfusion, high-dose dexasone and early prevention of heart failure as a adjunct to the standart treatment has been shown to be of benefit in the management of malignant diphtheria. t. schaible, i. reiss, j. m er, l. gortner med. university of lqbeck, children's hospital, kahlhorststr. - , l~beck, germany surfactant therapy seems a promising approach for the treatment of the biochemical and biophysical abnormalities of the pulmonary surfactant system in severe ards. patients and methods: over a months period non-neonatal pediatric ards patients (age - months) in a "pre-ecmo"-situation (oi over h) were treated with bovine surfactant (alveofact| the underlying conditions-of ards were pneumonia ( ), sepsis ( ), immunosuppression ( ), near drowning ( ), neurogenous ards ( ). a total of - mg/kg b.w. was applied in several fractions. before surfactant therapy, we first tried different ventilation (best peep-finding, inversed i/e-ratio, hfo-ventilation) while monitoring the pulmonary mechanics. for hemodynamic stabilisation both norepinephrine and epoprostenol were used to optimize pulmonary perfusion for max. hrs. if there was no improvement of the oi by at least , further treatment with surfactant was initiated. in addition to surfactant all patients received a treatment with dexamethasone of mg/kg in doses. patients with no benefit (oi remained unchanged or increased within the max. - hrs) were taken on ecmo. results: nine patients improved within hours after surfactant therapy: the oi decreased from a level of (mean, range - ) before our treatment to a level of (mean, range - ) thereafter. in patients we were able to continue the positive effects of our treatment and they could be weaned of the respirator within - days. the other patients got worse despite respiratory improvement, they suffered of multiorgan failure of more than organ systems. the last patient did not benefit from surfactant, he had to be put on ecmo, but died because of a complication (hemopericard)after days. the autopsy of the ecmo-patient showed a pulmonary fibrosis, but the other death were not due to pulmonary failure. conclusion: a different sequential ards treatment integrating surfactant therapy can reduce the number of patients requiring ecmo. but ecmo as a therapeutic tool should be available in centers involved in ards treatment. l.blindl, t.p.le, h.weinzheimer, centre for paediatrics, university of bonn, germany selective reduction of elevated pulmonary vascular resistance by inhaled prostacycliu (pgi) has been reported in adults with acute lung injury, neonates with persistent pulmonary hypertension and in one infant with idiopathic pulmonary hypertension. we report on the effect of aerosolized prostacyclin in two children with secondary pulmonary hypertension. patient : in a boy with down's syndrome an avsd had been surgically corrected at month of age. at , yr of age a catheter examination revealed a pulmonary vascular resistance of % of systemic vascular resistance in room air and at an fin of . . prostacyclin ( . mcg/ml) was administered with a jet nebulizer at an fin of . . pvr declined to . systemic vascular resistance and returned to baseline after stopping pgi-inhalation. subsequent intravenous infusion ( ng/kg rain) had to be stopped after minutes because of systemic arterial hypotension. patient : a month old male infant with bronchopulmonary dysplasia developed suprasystemic right ventricular pressure inspire of therapy with oxygen and nifedipin. while he was spontaneously breathing % oxygen via face mask pao was mmhg, arterial ph was . . systolic arterial pressure was mmhg, a rv-ra gradient of mmhg was measured by cw-doppler. while fio was maintained aerosolized prostacyclin was administered over minutes. rv-ra gradient was mmhg, systemic blood pressure mmhg, pao mmhg. two hours later nitric oxide ( ppm) was inhaled at an fio of ( , . rv-ra gradient declined from to mmhg, systemic systolic blood pressure remained stable at mlnhg. discussion: sporadic experience shows that aerosolized prostacyclin selectively reduces elevated pulmonary vascular resistance in some patients. in patient the poor response to inhaled pgi compared to inhaled nitric oxide may be explained by the fact that the action of pgi is not independent from endothelial function, limiting it's effect in severe vascular disease. during the last two years ( - ), infants weighing less than gr. admitted to our referral unit. thirty four of them ( %) survived, ( % of infants weighing - g and % of infants weighing - gr survived) for the years - - the survival of these infants was % and for the years - - , % (p< . ). we analyzed the perinatal and neonatal factors influencing the outcome of these infants. the comparison among neonatal survivors ( ) to neonatal deaths ( ) shows: gestational age: . w ( ) to . w ( ) (s). birth weight: . g ( ) to . ( ) (s). apgar score: , ( ) to . ( ) (ns). presentation and mode of delivery: breech presentation is associated with higher incidence of neonatal deaths. i.v.h. (at the age of weeks): no one of the survival infants had evidence of i.v.h. respiratory problems: intubation, at the admittance of the infants . ",,( ) to % ( ) (s) use of surfactant: % ( ) to % ( ). bpd observed in % of the babies and only one was dependent on oxygen at home. antenatal betamethasone was given in % of the mothers. in conclusion: ) a great improvement in the survival rate observed in these infants the last years in our unit. ) factors with positive effect are increasing gestational age and birth weight, the absence of i.v.h. and the use of surfactant. the breech presentation and the severe respiratory problems increase the incidence of death. animal experiments demonstrated, that brain temperature determines the amount of neuronal damage caused by hypoxia and that mild hypothermia may have a protective effect. until now there is no method described and evaluated to measure brain temperature in neonatal intensive care units. we non-invasively measured brain temperature analogues, nasopharyngeal (tnasoph) and zero-heat-flux temperature (zht) at the temple whereby under zero heat flux surface temperature represents deep head and thus brain temperature. the aim of our study was to investigate the practicability of the method, the relationship of the two brain temperature analogues to rectal temperature (trect) and their dependence on insulation, thermal environment, body activity and time course. we investigated healthy preterms less then weeks postnatal age (gestational age +_ . wks; x + sd, weight +_ g) in an incubator. tnasoph was measured by a thermistor within a feeding tube, advanced to the nasopharynx, zht temple by a thermistor and a heat flux transducers both covered by an insulating pad, and trect thermal environment was characterised by operant temperature (tair . . + twall . ). body activity was video taped. measurements were performed during the following interventions: i/ insulation increased by turning the temple with sensors onto the mattress ( rain). ii) insulation increased by a cap ( min), iii) min after its removal, iiii) increased operant temperature by . + . ~ ( min). results: seven children with ea had a gasless abdomen, the endoscopic procedure excluded ( ) or diagnosticated an upper pouch fistula ( ). in patients who suspected "h" fistula ( ) broncoscopy has strong advocated method to make diagnosis and established cervical approach. from july newborns with ea and lower pouch tef received a selective transtracheal incannulation. we were not able to proceed just in case with congenital subglottie stenosis. in these patients we provided gastric drainage by radiopaque and flexible - french catheter. the knowledge of the precise anatomic position of tef consent to adjust the tip of the endotracheal tube in order to achieve best ventilation. the presence of the catheter through the fistula helps the surgeon to identify, it quickly. no complications were correlated to the procedure and no babies had early pneumonia. alimentary continuity was achieved in all patients ( primary anastomosis, resections of tef, oesophagocoloplasty and died with gastrooesofagostomy). the late mortality . % ( ) was only directly related to the severity of associated malformations. conclusion: the advantages of this technical approach are unquestionable for the anaesthesiologist and the surgeon. in our experienc e the procedure improves perioperative management of babies and appears to be safe. relation between cytokines, prethrombotic markers and endotelial injury markers in children with septic shock objectives: to establish the relationship between cytokines (tnf, il- , il- ) prethrombotic markers (d.d., pcam) and endothelial injury markers (tm, uwf) in pediatric patients with sepsis and bacteriemia without shock, and patients with septic shock. design and methods: prospective study, children ( months- years) were admitted in our picu in with the following diagnosis: bacteriemia ( ) sepsis ( ) and septic shock ( ) according to jacob's r f criteria. measurements: il- , il- , tnf, tm, vnf, d.d. pcam and routine laboratory data on admision, , , hours and on discharge. the prism (pediatric risk of mortality score) was also recorded. results and conclusions: two patients in the septic shock group died. significant differences were found between non-shock and septic shock patients in relation to tm, dd, pcam, il- , il- and tne high levels of tnf and il- are closely associated with the severity of septic shock with purpura in children. low levels of pcam on admission were associated with severe shock. who underwent open hea~nt surgery, hypervotaemia with or without oliguria was the most frequent reason to start pd ( %). in patients pd lasted less then one week and there were no complications; in patients it lasted - days (one child had a peritonitis). instillation of dialysis fluid into the peritoneal cavity was associated with a significant increase in central venous pressure. there were no significant changes in cardiac output or arterial oxygeu saturation. in all patients pd dhnjnished fluid overload or improved the metabolic status. patients ( %) survived the postoperative course and all had complete reintegration of renal function. conclusion: pd is a useful method to treat the fluid overload and acute renal failure in paediatric patients following open heart surgery with file effects of little importance on the cardiovascular fimction. obieetives: with the marketing of computerised systems for lung function testing in newborns, there has been an increasing interest in clinical approaches. percentile curves of pulmonary parameters permit an appropriate and clinically useful interpretation. however, the manual evaluation of the results using different curves is an impractical technique. therefoi'e a computer programme was developed. methods: the percentiles ( %, %, ~ %, %) of the most important pulmonary parameters were determined non-parametrically in weight-classes. for the calculation we have taken results of our own as well as other laboratories using a meta-analysis of reference studies. in all, individual data of - healthy newborns ageing between - days were collated. using these percentiles, for every parameter in relation to the body-weight the cumulative distribution was calculated approximately using piecewise linear and exponential functions. as shown in the figure the results of computing are represented numerically as well as graphically and can be included in the patient report. conelusions: clinic~d experiences with the programme have shown that representation of all measured parameters on standardised % scales allows an easy interpretation at first sight and improves the detection of pathologic patterns in the parameters. ")supported by bmft, fp "risikoneugeborene" prism (pediatric risk of mortality) score is a well known, already validated scoring system that quantifies severity of illness based on routinely clinical and laboratory variables measuring physiological instability. once computed the score by summing up the weights corresponding to the most abnormal value recorded during the first hours, the overall risk of mortality can be predicted by using the coefficients estimated by a logistic regression where prism score is the main independent variable. (pollack mm et al, -pediatric risk of mortality (prism) score. crit. care med. ; : - . to assess the applicability and validity of prism in the italian setting we launched out a prospective data collection in a sample of pediatric icus. measures of calibration (goodness of fit statistics) and discrimination (receiver operating characteristics and area under the roc curve) are planned to be adopted in the cohort of patients recruited during year period. as the validation study started on july , data collection is still on going and validation analyses will be carried out on july . up to now centers recruited cases. at present, characteristics of the sample recruited are the following: most of the patients were male ( %); the mean age is years with % of patiens having less than days; more than half were medical cases ( %) admitted from emergency room or from hospital floor ( %); % cases were admitted with an organ failure while % to be intensively monitored. icu-mortality was l %. the paper will present final results of calibration and discrimination analyses that will be carried out in the whole sample and across subgroups known to differ in terms of clinical relevance and prognosis. if calibration and discrimination assessment will produce not satisfactoty findings, a customization of the current coefficients will be made allowing a formal comparision of previous and new parameters. jf riera-faneao, m wells, j lipman. baragwanath intensive care unit, university of the witwatarsrand, south africa. [background the prism score is designed to assess the likelihood of death in ipaediatdc icu patients, using only acute physiological disturbances, age and [operative status to predict mortality. there is no evaluation of chronic health status, [including malnutrition. this may significantly affect its ability to accurately predict outcome in a population where malnutdtion is common. aim to determine the influence of nutritional insufficiency, as indicated by a low weight-for-age on outcome prediction by prism. patients & methods we analysed prism, weight and demographic data co ected prospectively from consecutive paediatdc icu admissions over a year pedod. a proportional weight (pwt) was calculated as a percentage from the th centile of the who weight-for-age growth charts. the pwt was compared for survivors and nonsurvivors, and mortality compared for pwt categodes nho wellcome classification). multivariate statistical techniques were used to identity associations with non-survival and to develop a modified logistic regression equation including a measure of i nutdtional status. receiver operating characteristic (roc) analysis was performed including and excluding patients with low pwt for the odginal and modified equations. results non-survivors had a lower weight than survivors ( . kg and . kg medians p = ) a lower pwt ( % and % medians p = . " . the incidence of malnutdtion , in our icu population was %. the mortality of manoudshed patients was' significantly increased (p = . ), with a good correlation with the degree of malnutrition. the accuracy of prism was significantly improved when malnourished patients were excluded from the analysis (roc value increased from . to . ). ! logistic regression and discriminant analysis identified a significant association between prism, pwt and outcome; age and operative status were not significantly related to mortality. the use of a modified equation including the raw prism score, pwt category and age can significantly improve the discriminatory power (az dm/elopmental sample . , az validation sample . ). the modified formula is: legit = - . + . *prism score - . *age + . *weight category, where the probability of mortality is exp(iog/t)/ + exp(iogio. discussion although we can improve the prediction of mortality by a modified or recelibrated formula, this still does not compare with the reference prism population. the need for validation of the score itself, in the association with outcome of the acute physiological variables themselves, is thus apparent. we conclude that while the odginal prism formula can be improved significantly, a modification of the basic variables in this and other third wodd populations may be essential. a high incidence of malnutrition is an independent risk factor of mortality, and an important cause of the poor discriminatory performance of prism. in order to improve the accuracy of prism, nutritional status should be taken into account. objectives: to assess the value of inhaled no to differentiate between pulmonary vascular constriction or fixed anatomical obstruction. methods: we assessed the response to ppm inhaled no in patients( m, f, median age . months, range day to years) with signs of increased pulmonary vascular resistance, there were pre and postoperative patients. patients were divided into responders(+) or non-responders(-). a positive response was defined as a % reduction in pulmonary arterial pressure and pulmonary vascular resistance(pvr) or in the presence of a left to right shunt, a fall in pvr accompanied by increasing pulmonary blood flow. left atrioventricular valve atresia + mustard pat: pulmonary atresia vsd: ventricular septal defect asd: atrial septal defect pda: patent ductus arteriosus tapvc: total anomalous pulmonary venous connection the responders( / ) were characterised by left to right shunts or pulmonary venous hypertension( / ). patient# was weaned from ecmo with inhaled no. patient# , without congenital heart disease, underwent a lung biopsy which confirmed reversible pulmonary vascular changes. patient# had a pulmonary hypertensive crisis which responded to no. all non-responders( / ) had evidence of anatomic obstruction to pulmonary blood flow (# , , )or a low pvr(# ) on subsequent cardiac catheterisation. in patient # , lung biopsy confirmed severe obliterative vascular disease. conclusions: inhaled no appears to be an effective pulmonary vasodilator. a failed response may be evidence of either irreversible pulmonary vascular disease or a residual anatomical obstruction which may be surgically remediable in the postoperative cardiac patient. therefore, inhalation of no may be a useful diagnostic test to differentiate between fixed anatomical obstruction and reversible vasoconstriction. results: during these years, the incidence of sdra was . % of the total of admissions. the most common etiology was meningococcic septic shock. since , there is a decrease of its incidence. (from % to %) and an increase of pneumonia and immtmodeficiencies. mean age of our patients was , years ( % males, % females), total mortality by sdra was % and there is an increase up to % since mean time of stay of the dead was , days and , days those who survived. although during the late years we offer in the picu a better attendance quality to the patients with sdra and the mean stay is longer, both for those who die and for those who survive, mortality of patients with sdra have increased. the incidence of sdra secondary to the septic shock of a meningococcic etiology have decreased. on the contrary, the sdra secondary to infections by opportunistic germs in patients with congenital inmmunodeficiencies or acquired immuodeficiencies have a tendency to increase. in our series, this change of aetiology is the responsible for the increase in mortality. hospital infantil unlversitario "virgen de roclo". sevilla. espalqa aims:to assess the incidence, etiology, clinical course, sequelae and mortality of the patients admitted to a paedfiatic intensive care unit with the diagnosis of severe traumatism. material and method: cases of severe traumatism in children admitted to our icu in the period from january to june were reviewed. age of patient ranged from months to years, % were males. in our series, % of cases suffered traumatism due to a traffic collision and % had a fall from a considerable height. only in one case was traumatism due to violence to the child. we assessed the first assistance received in % of cases: where was it performed, interval of time since the accident, and steps taken. these data were also studied in relation to the latter evolution. results: % of our patients suffered cranioencephalic traumadsm (ct); in % it was an isolated picture and in % of cases was associated to other lesions. there was participation of thoracic and/or abdominal organs in % of cases. % of cases presented important maxillofacial involvement. only one case presented serious cervical medullar lesion. mortality in our series was . %. in . % important sequelae remained. all of these patients presented tepas on admission equal or lower than . % of those with traumatises had slight sequelae. . % of the total evolve towards healing. a polytraumatized child is a patient that benefits considerably of it admission in a paedriatic !cu. the rapidity in receiving first aid and its quality are essential to avoid sequelae and to make mortality decrease. after unilateral lungtransplantation % of the patients develop a lung failure with decrease of perfusion and increase of pulmonary blood pressure in the transplantated lung. the improvement of perfusion is an importent task in the postoperative period. case report: a year old girl with idiopathic pulmonary fibrosis received a left sided single lung transplantation. during the early postoperative period occured a higtter demand of oxygen and an increasment of the pulmonary vascular resistence in the left lung. the pulmonary ventilation and perfusion scintigraphy indicated in comparison with the right lung a reduced perfusion of only % in spite of a ventilation of % of the transplanted lung. to improve the perfusion of the transplant we administrated per inhalation prostacyclin in a maximal dose of ng/kg/min. the arterial blood pressure decreased but the perfusion continued nearly at the same level. during the following administration of ppm no in the respiratory air we achieved a significant reduction of the respiration pressure f~m to nun h and of the pulmonary arterial pressure. the perfusion in the transplanted lung increased to ca/of the total pulmonary perfusion. after days of administration with no we were able to withdraw the axtifical respiration without any following complications. conclusions: the perfusion of transplanted lungs is a major proble_r~ in the postoperative period. this case demonstrated the advantage of no towards the inhalativ application of prostacyclin. no showed a significant improvement of perfusion in the transplanted lung of a year old girl. results: a total of children with ards were treated with bovine surfactant (alveofact| cases were evalable. the median age was . years (range weeks to , years). in six cases ards was associated with pneumonia, in two cases with lung hemorrhage; in one case isolated ards followed hemihepatectomy. the first surfactant application was performed with a median latency of clays (range - days) after first symptoms of ards witha median doseof mg/ kg (range - mg/kg). in patients doses of surfactant were applied. during the hour before therapy, the median pao / fio -ratio was - . within min. after application of exogenous surfactant the pao / fio -ratio increased to with successive decrease over a period of hours to . accordingly, an increase in pao and oxygen saturation and (less significant) a decrease in ventilation parameters could be observed. analysis of broncho-alveolar lavage before surfactant application in children receiving repeated doses revealed in most examined cases either clear surfactant deficiency or pathological function. of treated patients survived ( of the , respectively). of the surfactant doses were applied in the surviving patients.conclusions: the application of exogenous surfactant in children with ards caused a significant increase in oxygenation, which declined over a period of - hours. the effect often could repeatedly reproduced, in one case after applications. the increase in oxygenation often allowed the reduction of fio and/or the inspiratory pressure. no side effects were observed after exogenous surfactant application.in many cases the application of surfactant wag too late after first symptoms of disease (median latency days). ards mostly due to pneumonia seemed to respond to surfactant therapy less well or not at all. permanent junctional reciprocating tachycardia (pjrt) is the most common incesant supraventricular tachycardia (svt) in children. it is usually drug resistant and its onset in early life has been associated with dilated eardiomyopathy. we report our clinical experience with patients detected antenatally and another diagnosed at months of age. method.diagnosis: negative p waves were detected in leads ii,iii and f, p'r > rp" and there was not warm-up at tachycardia onset.clinical records, ekg,x-rays, echo and holter were reviewed. ep studies were undertaken only with therapeutic purposes. results. in a year period patients under y of age fullfilled diagnostic criteria; were detected prenatally ( - weeks) and one was diagnosed at age mo. the fetuses had intermitent svt during gestation. all of them had pjrt in the first month of life at rates between and bpm. they were admitted to the icu but did not develop signs of heart failure. they were controlled with digoxine (d); d and quinidine; d and propafenone in to days. one was in sinus rhytm until age y; he then showed persistent pjrt over % of the day on repeated holters and underwent successful radiofrecuency catheter ablation (rfca).the other two patients showed initially a lowering of tachycardia rate followed by sinus rhytm for over % of the day (follow-up ran and y). the mo. old infant was admitted to the icu in severe cardiac failure. echocardiogram showed marked systolic dysfunction (shortening fraction %) treatment with digoxine, amiodarone and propafenone were unsuccessful despite lowering heart rate to ; rfca was performed at m. of age with restoration of sinus rhytm and rapid recovery of contractility. all patients were given atp at admission with transient ( to see) recovery of sinus rhytm. ff,s clinical course of pjrt is variable. atp is useful only as a diagnostic tool. initial treatment with digoxine + amiodarone or propafenone is adviced. rfca is a very useful therapeutic modality and can also be performed in young infants twelve patients ( %) died. these were meningitis, head injury, sub-arachnoid bleeds, status epileptieus, leukaemie, drowning, and multiple trauma. calculated from the a admission day p edialric risk of mortality score (prism), the probability of death (p) ranged from - %. of the deaths, i were predicted by prism analysis except for the leukaemie patient (p i%) who died from haematological complications following chemotherapy. two children predicted to die (p % & %) survived. the median length of stay was days (range - days). patlents( %) received ventilatn~ support and patienta( %) were transferred to specialist units ( neurosciences, liver, cardiac, bums). this data supports the view that many paediatric patients are being adequately treated in a dgh icu. meningitis and other neurological illness caused the majority of deaths and respiratory problems caused most admissions. most deaths ( of ) occurred within a few hours of admission. ectopic junctional tachycardia (ejt) is one of the most dangerous arrhythmias in the postoperative setting of congenital heart defects since it does not respond to antiarrhythmics or defibrilation. the object of this presentation is to report on two patients who presented f_jt in the early postoperative period and developed intense congestive heart failure which could be controlled after treatment with moderate topical hypothermia. two patients, m and y, diagnosed of atdoventficular septal defect and tetralogy of fallot developed intense heart failure in the early postoperative period. taehyeardia rate was and bpm. medical drug therapy included weaning from vasoactive drugs, iv digitalization and iv amiodarone treatment. there was not response. they were both surfaced cooled by placing plastic bags filled with cold water over the patient's chest and abdomen. temperature was monitored to obtain a central temperature of ~ there was a gradual decrease in heart rate in the following hours ( - bpm) paralel to the degree of surface cooling and clinical course estabilized.both recovered normal sinus rhytm in to hours. there were not significant arrhytmias after the procedure and postop, was uneventful. conclusions. moderate hypothermia is a very useful manuever for the treatment of drug resistant ejt. since it lacks side effects of other antiarrthymics we beleave it should be the treatment of choice for the treatment of ejt in the postoperative patient. present understanding of the pathogenesis of sepsis, based on the theory of systemic inflammatory reaction, has risen new interest in the more invasive methods of treatment, like plasmapheresis, leucapheresis and exchange transfusion (et). obiectives: evaluate the effect of et in the treatment of neonatal sepsis. material and methods: from september to december , a prospective study was carried out, where the severest cases of bacteriologically proven neonatal sepsis (n= ) were treated with et. in total newborns were treated for culture positive sepsis in the intensive care unit during this study period. diagnosis of sepsis was based on the clinical criteria of suspected neonatal sepsis, used by mc harris et al., laboratory data and positive blood culture. newborns with severe congenital malformations were excluded. et was carried out with fresh (less than hours old) adsol-conserved erythrocytes, from which buffy coat had been removed, and same donors plasma, using a slow continuous two-site technique. the mean volume of et was . ml/kg. the effect of et was assessed as a change in the score for acute neonatal physiology (snap), general treatment results were compared with a historical control group of newborns, treated for culture-positive sepsis in the same icu during the first eight months in . students ttest and chi-square test were used in statistical analysis of the data. results: with the use of el a significant decrease in mortality was achieved: death of cases during the study period, compared to deaths among the controls (p< . ). no baby, receiving et, died. the incidence of severe complications did not differ in the two groups. the snap-score showed quick improvement by the first post-transfusion day (p<o. ) and the effect persisted during the five following days. conclusions: we conclude, that the use of et in the treatment of critical cases may help to lower the mortality of neonatal sepsis. it provides a quick improvement in the clinical condition of septic neonates. the granulocyte-colony stimulating factor (g-csf) is largely employed in granulocytopenic patients. experimental studies have' demonstrated the effectiveness and safety of the therapeutic use, nevertheless the human employ is reported almost exclusively in neoplastic patients submitted to chemotherapy and in patients with fungal or pseudomona~ spp infections. the authors report the data concerning three non granulocytopenic children: in the first, o girl years old, affected by pseudomomm aerug/n~a pyeionephritis, the antibiotic therapy was not tolerated in consequence of renal and hepatic failure. the second patient, an infant months old, has been treated with salbactam-ampiciilin, ceftriaxone and chioramphenicol because of haemepldlw iafluem~ meningitis; a late neurological aggravation required the antibiotic therapy recommencement the last, a years old insulin dependent diabetic boy, was affected by cared/do spp systemic infection; the antifungnl therapy w~ not practicable in consequence of renal and hepatic involvement in all the g-csf was administred subcutaneously at the'dose of $ u for days. a significant increase of granulocytes was ever noted already after the second administration until hours after the last dose. clinical signs, fever and biochemical values are promptly influenced positively and all patients are restored to health. no side affects were noted. the granulocyte colony stimulating factor, at indicated doses, can prove of great help in critical patients, in who the antibiotic or antifangal therapies can result toxye or cannot be tolerated. the ~reptococcas p~, among the gram pmltlve~ represents the main causative organism of bacterial meningitis in children, with the majority of deaths occurring within hours of admission, the third generation cepohlosporim were indicated as antibiotic of first choice, and some literature reports have demonstrated no significant dlffereuces in dinical course of patients treated with ce~rlaxoae and of those treated with ampieibin and chlornmphenicol. the authors report the ease of on infant, male, months old, submitted to a neurosurgical interventiol after days the infant became febrile and lethargic and a bacterial meningitis by ~trepmcecctz ~ was diagnosed, in spite of he was given the eoftriaxone therapy.. an amelioration was found only when a systemic treatment with vaucomyein was added. after days an intrathecal administration of vancomyein m~day was started: the norbmlization of the spinal fluid profile was uoted two days later and the infant receve~d progressively. the follow-up after eight months doem't evidentiate motosensorini sequelae-the individuation' of ~cscc~ pmmmsm/ae strains heta-loctam antibiotics resistant requires alternative therapeutic regimens: the k~terity quead vitam and quoad valetudinem of these infections justifies an intrathecal therapy, especially failing o prompt answer to the systemic treatment objectives: to evaluate the incidence of the burnout (bo) of the staff in a picu in a university hospital. the bo is a syndrome charactedzed by many factors like emotional stress, lack of personality and reduced work ability. this syndrome represents a kind of abnormal response in the working habitat, above all, where psychological and personal characters are mostly involved. the symptoms of bo are represented by demoralisation, demotivation, incapability, boredom, isolation up to organic disturbances, like migraine, insomnia, dizziness and gastrointestinal disturbances. the major incidence of this syndrome was found in the hospital staff, especially among the nurses, working in an atmospher of high emotional dsk, just like in an intensive care unit. methods: from january ' till april ' , all the staff of the picu of the a. gemelli hospital of rome, underwent a test to evaluate the bo. the test used was taken from the book "bumout: from tedium to personal growth", by pines and aronson. twenty seven people were studied ( females, males)i out of which doctors, residents and nurses. it was considered sign!ficant as mild bo, a score between - and as severe, the score of bo >. . results: subjects ( %) resulted positive for bo, out of which were females ( %) and were males ( %). the subjects with mild bo were / : was a doctor, residents and nurses. the subjects with severe bo were / , out of which resident and nurses. conclusion: the results obtained show that bo is a condition well represented in the staff of our picu. the category most at dsk seem to be the nurses ( subjects), as well as residents ( subjects), as in literature, which shows a major incidence of the syndrome in younger subjects and having a limited partecipation of functional decision. the results obtained obliged us to start a programme of serial controls so that the subjects most exposed can have a necessary psychological support to react adequately to this condition. the term systemic inflammatory response syndrome (sirs) was adopted by the consensus conference to denote a type of systemic response to severe infection or otherinsults in critically ill patients. when sirs occurs from infection it is called sepsis. sepsis occurs more frequently in persons with perexisting illness or severe trauma. there has been tremendous advances in prophylaxis, diagnosis, and treatment of sepsis. a comprehensive model of the disease progression from sirs to mods should be developed giving priority to severity of illness scoring system and other predictive methods. some recommendations for future clinical trials include: trials should not start with humans. before proceeding to human trials, animal studies should indicate an acceptable risk/benefit ratio. appropriate patient populations must be defined and treatment protocols should be standardized. full and rapid reporting of all results should be mandatory and a central repository of published and unpublished study results could be helpful. accrual at each center should be of sufficient size, and should include the number of patients accrued, mortality rates, and patient characteristics. pivotal trial should be preceded by sufficient pilot or phase ii studies. correct drug dosage and usage should be delineated in pilot studies. large, multicenter, trials should be used to enhance the unversality of trial results. analyses should be planned a priori. definitions for the target population should be explicit, reproducible, and include illness severity scores. outcomes should be relevant reproducible and include both measures of benefit and harm. mods and its reversal should be considered as an endpoint. quality of life should also be considered as an endpoint. the estimators of overall treatment effects should be controlled for base-line prognostic factors and subgroup anaiysis should only be used for hypothesis generation and not to modify the conclusoin of the trial. economic analysis should be included as part of clinical design. evaluatin of source control should be a critical component of any study. standardized clinical mediator assays should be pursued. placebo patients in clinical trials should be studied for a better understanding of the pathogenesis and epidemiology of sirs, evidence based medicine should be used to evaluate the validity of clinical. introduction: use of inhaled nitric oxide (no) as a modulator for optimizing ventilation-perfusion or lowering pulmonary artery pressure is becoming increasingly common. no is a free radical but little toxicological research has been published. clearance of nebulized mtc-dtpa is known to be, a sensitive indicator for early function impaimaent of the alveolocapillary barrier. we investigated whether exposure to no increased clearance of ~tc-dtpa from the lung. methods: three groups of white sealand rabbits (bw . kg) were anesthetized, tracheotomized and paralyzed. groups were ventilated for six hours at pressure regulated volume control, set to deliver ml/kg with a frequency of /rain, i/e ratio = : and peep = cm hzo using a modified servo ventilator (siemens, solna, sweden) with computerized no delivery system. gas mixture per group was either / or / [no (ppm) / fioz]. after six hours of ventilation in these groups and immediately after anesthesia in group (control), ~tc-dtpa was nebulized into the inspiratory line of the breathing circuit and administered as a fine aerosol. gamma counting was measured for minutes, monoexponential curves were fitted to the data and the clearance half-time (t was calculated. the t~/ mean • sd of the different groups were: t~a (mean -sd) h"e,i witl~ arf : di.ff:erent kinds, aged .q-ore mon't.hes to [ gears o : (bodi weight .~rom ., to kg), is presen .... "ed ( i,,~u::trl:e i:ibstraclive d:lse~se... ~ .ards'- ; :~,;,,arf o~ ::entral genes:i s .- , ,~ :inc lud ing men ingeenceph it :is- ~ reye ' s ~yrtdro~e-..#~,bri~:ln pes~.re~nimatior~ disease.." ). int:lrl~]. pa-. "iiulle'i,~s ariel regymes o+ l;mv,l;i"t"v were cle'l'.ermllled by ba- 'i~ier was. about . tuber,, dopamin tiara-:. t.io; was ~.".,,'.r:~r~led. cmv,cppv d~.!"~tion raniled -~rom f to dayns.,~ < .-:in , "t -irl lo;and> davs'-in 'l~atierr~{s i'i"ai s:ltiol~ o ; patterers to imv, simv modee was per.r:)rmed, ~herl pif:' decrease.d to - ml~ar, fi ~ecreased to , . lind less with a = /,,. i:lesq.lts:{ in pat:i.ents e{ group :l, who were tre,~d.ed w&th f'f'v, teoph :i. : . l:i.r~ (is- .mg/kg/day), g lucecdr t icostei~oids ( .... :~;mg/kg/day), when r exceeded in , -.];, times normal va i tea the e aqes/,'!:l"oln ~j,, ite :i.~;::.!;, ~ml"lrj), it was possible 't'(' ce 'e~ e aad]t:..~rom ! . '.' i', to !..'; , - , mml-lg in ~}.. :~.[~ houi,!; ~d'l(:i to ru:}l",g'd!~l:i. e i::h,:~e,'~c['el';i.stil obieetives : this chapter will describe what is knovca of the psychlogical responses of infant and children to hospiuiisation and attendant procedures. the factors which may modify these responses will he discussed and important considemtiorts will be outlined for optimal anaesthetic management and postoperative period of infants and children which will minimised the rise of emotional upset. methods : in this paper the autors will discttssed the probl of: . health children (asa i, ii) facing single uncomplicated surgical elective procedures . various abnormal situations including neurotic children, children facing repeted operations, chronically ill, buaaes and tsaumatically impired ones . unfortunate young patient facing and often expoclting fatal outcome from le "ul'ukaemia, tumors, cystic fibroses or otheq" disease. : management of each child must vary greatly, ifi general the phases of emotional conditioning include home and preadmissiun preparation, admitiun preoperated and operative care and postoperative period. the authors would be happy if the child passes all stages without any trauma which could be prolonged in the future life. introduction ino is used to selectively reduce pulmonary vascular resistan(~e. we applied ino in the postoperative intensive care of patients with pulmonary hypertension and the risk of right ventricular failure after surgical correction of a congenital cardiac defect. methods - ppm no were added to the ventilatory gas mixture using a specially designed equipment (messer-griesheim, germany/austria). indications for application included pulmonary artery pressure > % systemic pressure, critically depressed right, ventricular function or an oxygenation index > . assessment of n oefficiacy consisted of on-off-on measurements according to the clinical stability of the patient including hemodynamic parameters, pulmonary gas exchange, continuous monitoring of ventitatory function and transesophageal echocardiography of the right heart. results in situations ( patients, age days- , years), ino was applied - h postoperatively. oxygenation was improved in situations from _+ to + mmhg pc ; pulmonary pressure was reduced in situations from -* % to _+ % of systemic pressure. in situations, no reduction of pulmonary pressure was present, but measurement of cardiac output or echocardiographic analysis indicated an improvement of right ventricular function (right ventricular stroke volume + -* %, cardiac output + -* %). in situations (immediately postoperativ with suprasystemic pulmonary artery pressures [n= ], multi-organ-failure [n= ]), no response to ino could be determined. conclusions for a special group of patients, the selective reduction of pulmonary vascular resistance by ino has become an important part of postoperative therapy. using this selective afterload reduction, postoperatively depressed right ventricular function can be improved. this effect of ino seems to be the most important one in the postoperative period. thus, ino appears justified to be appfleo when impaired right ventdcular function could be improved even when pulmonary artery pressure is not raised or remains unchanged. obiectives : premature infant are exposed to danger of apaea due to anaesthesia during their tirst months of life. it is yet unknown whether prematurity is corelated to any other kind of reslgratory disorder due to anaesthesia within the tirst year of life. methods : we theretbre researched retrospectively for respiratory disorders in all infants under months of life belonging to asa group . they all had been anaesthetised in . in our clinic for the following surgical reasons: ingvinal haemia, umbilical haemia, hydrocelae testis and phymosis. results : in cases we tbund: lafingospasm during induction in anaesthesia ( , %), bronchospasm during induction in anaesthesia ( , %), impaired intubation ( , ~ postanaesthetic laringospasm ( , %), supposed aspiration ( , %),postanaesthetic inspiratory stridor ( , %), postinductional inngoedema ( , %), death after months in consequative of infection pneumonie ( , %), none of these disorders was correlated the prematurity, infants suffered of post anaesthetic apnea, of them had premature medical history. concludions : prematurity does not enhance the risk of respiratory disorders due to anaesthesia within the first year of life, except the danger of postanaesthetic almea needs spetial cosideration. it could be demonstrated that aepgi lowers pulmonary vascular resistance and indirectly improves cardiac function. this effect seemed to be selective, and was comparable to ino in the doses we have examined. therefore, aepgi could represent a clinically useful alternate to inc. however, further research is necessary to work up the benefits of either therapeutic strategy. objectives: heat and moisture exchange filtem (hme) are used as artificial noses for intubated patients to prevent tracheo-bronchial or pulmonary damage resulting from dry and cold inspired gases. furthermore they are used for the prevention of bacterial contamination of the anesthetic apparatus by the patient's exspired air. so they are considered as a time-and money-saving device in anesthesia. filters are mounted directly on the tracheal tube, where they collect a large fraction of the heat and moisture of the exspired air, adding this to the subsequent inspired breath. the effective performance depends on the water-and bacteria-retention capacity of the filter. this study evaluates the efficiency of four different filters under clinical conditions. methods: four different types of filters ( dar hygrobac, gibeck humidvent, medisize hygrevent and pall bb ) were investigated dudng mechanical ventilation over a pedod of hours. minipigs with hemorrhagic shock were intubated and ventilated for days in an animal intensive care unit (icu). after hours of mechanical ventilation the filter was randomly replaced maintaining the individual ventilatory conditions. the weight of the filter was determined before use and after removal after hours. the airway pressure was monitored online to record changes during use. tracheal secretions and both sides of the filter were microbiolologically tested to see whether bacteria of the animal's respiratory system could be found on the patient's side of the filter or if they even would have penetrated the barrier. results and discussion: over a pedod of hours of types of filters showed an increase in weight of + % and airway pressure. bactedal celonisation ccured in nearly all fillers ( of ) on the patient's side, whereas only three of four types of filters showed identical bacterial colonisation on both sides. the only filter that did not show bacterial penetration, increase in weight or airway pressure was the pall-hme, a condensation humidifier without hygroscopic salts for moisture retention. with respect to our data one should use a condensation humidifier if airway conditions should remain stable dudng mechanical ventilation and desinfection of the anesthetic apparatus should be avoided after each patient. aim: to assess the clinical uses of, and experiences with, the hayek oscillator. this is a non-invasive device capable ef delivering not only continuous negative pressure (cnp) but also external oscillatory ventilation around a negative baseline (eov-nb) using an external cuirass. this type of ventilation avoids the need for intubation and intermittent positive pressure ventilation (ippv) and facilitates weaning in ventilator dependent patients. patients and methods: patients in respiratory failure, age range weeks to years in a total of patient episodes were treated using either cnp or eov-nb mode. duration of treatment varied from hours to days. indications for use ef the device were: ) to facilitate weaning from ippv ) prevent reintubation of patients following unsuccessful extubation, and ) avoid intubation and ippv altogether using the hayek oscillator as the on[y means of respiratory support. results: there was an increase in pao :fio ratio after cnp and eov-nb (p < . , and p= . respectively, wilcoxon signed rank test). patients who were in respiratory failure with hypercapnia showed a statistically significant reduction in paco both with eov-nb and cnp (p= . and p= . respectively) but the magnitude of change was individually greater in the patients who were treated with eov-nb. all patients, however, showed a fall in respiratory rate (p< . ) after the application of the cuirass in cnp mode. there was no physiological deterioration related to the application of external extrathoracic negative pressure in either cnp or eov-nb modes. conclusion: the improvement in pao :fio , the fall in paco and respiratory rate were indicators of an improvement in ventilation. the proposed mechanisms include improvement in frc, recruitment of additional alveolar units, and improvement in secretion clearance resulting in reduction in the work of breathing. meek to ~ month of the lifo,the bemodyuanicfacls were defined uitb the help of tetropolar reography method!. the excretion of !he catbocholauines fcfi] mith the urine gas detertend by taylor ll,laoorsy ~ iacg/dayl. hsaltl in the hypercuagulation stage of bic we deflorteeed the acliuutiun of the tbrubio and plasiin syaet~ mitb the increase of the inhihitnrs, in this case we registered in full uahe dot this process coabined uitb the dayl~ excreliou with lho urine epinopbr ne e], nor~pinopbr no tel and dophanine io], lbat shod the inlensificatiou of the s~nthosis prnoe-s~es and the release of ea in blood fron hissue deport the actffat on of the svnpathadrenui systen ]sfisl assisted to furl the b?perd~nanical rosins of the eircuidion and increase the ,icrocirculatinn, the klinicai sings of the insufissieutly of the circulalion have not defined,that has been associated the conpensatury character uf the ehan~es of ~ and heludy~enic status, t~e uun~u|p-lion ceugulupatby bus been donoustraled in the hypocougulatien stage ~bat man xauifosted b the exhaust of lhe confulalion nod oessel-platel heuostasis, the consuxptton of cnnpononts tbronbln ,plnstin, kallek~eiu-kinln s~slots and the forniration eat in fell canoe clot uas accoqaued bs docrea,e of fl,nfl,o, the products of the xotabolisx of c~ and the activation of xonoaninoxydasu. the decrease of the extoll'on g and the exhaust deport co indicahd about t!e ]ou fund/anal reserve of ~fl~. it was one of the lain reason of ~bo heiod~uanic disbroed iheat insnfissient]~] and the uicrncireulaflion lintestinal codeme with the low effectife periferal flow] and nul[iplay organ failure,the distrued deport of sos mitb throubocytupenin no; be one of the nechanisn the dislrood of uessej-plalol heioshasis, the correlation bolueeo changes of boiostosis c~ and circulation ore reguired aduinistration nedidns, thai reslore the love s of c~ in the blood, prevent uulliplay organ failure and hetorrnge in children with sepsis, ~b~ectives: multi-measured correlative analysis of the most number of non-invasive indices of the cardiorespiratory system function was made to determine the structure of their interrelation and the ways of their adequate and effective correction. hethods: spiremetry, capno~raphy, oxygenography, indirect fick method at recurrent respiration, plethysmography, integral rheography -in all indices were used. the received data were processed on a computer by a standard package of statistical bmdp programs. results: women with ~h-gestosis (i group) and somatically healthy pregnant women (ii group) were studied. cluster analysis has shown that the rate of the mean correlation connection between ventilation indices was % in the ist group and % in the iind group; gaseous metabolism - % and %, respectively; central hemodynamics was ~ in both groups. conclusion: cluster interpretation allowed to suggest that an increase of the rate of the mean correlation connection between the indices was characteristic of effective adaptation as the system was multi-component and well-regulated. on the contrary, the increase of the rate of strong correlation connection between the indices reveals the rigidity of the system and the tensity of adaptation mschaniams, i.e. the proximity to decompensation. it follows from this that in cases of eph-gestgsis, the reliability of regulating ventilation and gaseous metabolism decreases. seve/e hypoxemia in non intubated patients represents a major contraindicafion to fiberoptic bronehoscopy (fob) and bronehoalveolar levage (bal), but these procedures are often required for a correct diagnosis of the causative agent of pneumonia. aim of this investigation was to veaify the safety and efficacy of bronehoseopic procedures during pressure support ventilation administered through facial mask (fm-psv). five intensive care patients, all immunoeompromised, ( males and females; mean age . • were enrolled in the study. all patients presented criteria for pneumonia with pao /fio ratio ~ and were responders to fm-psv. fob and bal were performed afte~ topical anesthesia with fm-psv ( ps = em h ; peep = emh ; trigger = -lemh ) continuously admires" tered ( ' before fob fio = . ; during fob, fio = and for ' alter fob, fio = . ). pao /fio ratio as well as saturation (sat) did not show signifteative changes during the procodure (fig.l) . no complication was observed and hemodynamic conditions were stable for all patients. cmv, pnenmoeystiis ( ), legionella and mycobaetermm tuberculosis were identified from bal allowmg a prompt and targeted therapy. we concluded that mask psv can represent an excellea~ technique to pexform fob and bal in severely hypoxemic patients without deterioration of gas exchanges and avoiding endotraoheal intubation. intensive care unit, hospital general of albacete, albacet~ spain. objective: to analyze the current incidence and epidemiology of total parenteral nutrition (tpn) among critically ill patients placed on mechanical ventilation. design: prospective observational study. setting: medical intensive care unit in a tertiary hospital. patients: a total of consecutive l'ritically ill patients with non-coronary related disease needing mechanical ventilation admitted in our icu during a months period. measurements: data of sex, age, diagnosis, and outcome were recorded. severity of illness and therapeutic effort in the first hours were measured using acute physiology score and chronic health evaluation (apache ii) and therapeutic intervention scoring system (ties). r~ults: mechanically ventilated patients, male and female, were studied. only ten patients needed tpn and their main diagnoses were: five cases of multiple organ failure secondary to pneumonia ( ), ards ( ) and septic shock ( ); two eases of acute panereatitis; and one mesenteric throngmsis, one status epilepticas, and one ,prolonged cholinergic crisis b~ suicidal organophnsphate insecticide subcutaneous injection. no statistically significant differences between both tpn and non-tpn groups were found: objectives: evaluate the efficacy of prone position in ards and determine its importance in the therapeutic algorithm. methods: consecutive patients with severe ards (murray-score > , ; pao / fit < mmhg; male, female, mean age years) were conventionally ventilated (pcv, peep - mbar, i:e=i:i, ppeak < mbar). if after hours pulmonary function did not improve patients were placed in prone position. change from prone to supine position was done every hours. beside ultimate survival, parameters investigated were aado , pao /fio , and venous admixture (qs/qt). results: during the first hours in prone position of patients showed a significant decrease in qs/qt ( . % vs. . %) and aado ( vs. mmhg), and an increase in pao /fio ( vs. mmttg). changes were most pronounced in patients with high qs/qt, and in patients with an onset of ards less than hours before first application of prone position. after an average of position changes ( to ) of patients could be weaned from the ventilator. patient could leave tile hospital. i the later course letality was primarily determined by additional organ failures and by the severity of the underlying disease. negative side effects were minor, including slight cardio-vascular depression and increase in p~co , and never posed a limitation to continuation of prone position. especially in patients with septic shock skin lesions in exposed areas could not always be prevented, prone position could easily be combined with all ventilation modes and with all intensive care interventions. also immediately after major surgery and in patients with open packing prone position was possible. conclusions: in this investigation prone position proved to be an efficient and safe method in the treatment of severe ards. patients with a pronounced ventilation/ perfusion mismatch and patients in the early stages of ards appear to profit most from prone position. though the immediate effect on oxygenation is striking, still more the % of all patients die from multi organ failure and underlying diseases. a proposed therapeutic algorithm for ards is as follows: if under conservative ventilation (pcv, peep < mbar, ppeak < mbar) pulmonary function does not improve within - hours prone position should be applied. when after - position changes no lasting effect can be achieved further ventilation modes (e.g. pc-irv, aprv, no, etc.) should be used in addition to prone position. standard intensive care principles, such as fluid restriction and optimization of circulation, apply also to patients in prone position. objectives: nitric oxide reacts with superoxide to form peroxynitrite, an extremely reactive and toxic species. we quantified the presence nitrotyrosine, the stable product of the interaction ' of peroxynitrite with tyrosine residues in the lungs of pediatric patients that died with respiratory distress syndrome (rds). methods: paraffin embedded lung sections, obtained at autopsy, were incubated with a polyclonal antibody raised against nitretyrosine, followed by a secondary fluorescent antibody. alveolar structure-associated fluorescence was quantified using existing methods. results: tissue sections from patients who died with rds exhibited significant specific immunostaining which was uniformly distributed across the blood-gas barrier. in contrast only background levels of fluorescence were seen in the lungs of patients who died from non-pulmonary causes. intense staining was also seen in the lungs of rats that breathed % for h, a condition known to result in rds-type illness; no immunostaining was observed in air-breathing rats. conclusions: significant levels of peroxynitrite may be formed in the lungs of patients with acute lung injury. peroxynitrite may be contributing to the pathology of rds by damaging key components of the alveolar epithelium including the pulmonary surfactant system. mechanical ventilation time was prolonged ,g • days in patients with ardsvs , _+ l, days in control . mean staylcuwas lg _+ ,g days in the ards group vs , • , days in control group postoperative mortality rate was % in ards patients vs , % in those without respiratory failure. -ards incidence in liver transplantation is low ( , % in our sene) but it causes high mortality ( %) page, gas ventilation of the perfluorocarbon-f'dled lung, supports gas exchange and circulation in small animals (< kg) with lung disease. we hypothesized that large animals could be supported by page without adverse effects on bemodynamics. we first elucidated the determinants of gas exchange in normal sheep, and applied them to a model of adult respkatory distress syndrome (ards). methods: using the ventilator settings determined to be optimal in our pilot study (fio of . , peep of cm h , imv of bpm, it of %, and tv of ml/kg), sheep weighing . ~ . ) kg had lung injury induced by instilling ml/kg of . n hc into the trachea. ten minutes after injury, sheep with pao < ton" were randomized to continue gas ventilation (control, n= ) or to institute page (n= ). page was instituted by instilling . l of unoxygenated pefflubron into the trachea and resuming gas ventilation at the previous settings. abg's were drawn at baseline, minutes after injury, minutes after injury, and then every minutes for hours. objectives: inhaled nitric oxide (no) can improve oxygenation and decrease mean pulmonary artery pressure (papm) in hypoxemic patients with ards. in severe hypoxemic copd patients, it is not known whether inhaled no can exert a similar effect on hemodynamics and gas exchange. therefore, we investigated die response of inhaled no in hypoxemic copd patients and the results compared with those obtained in a group of ards patients. methods: ten copd patients (age _+ y;fev~ . _+ . l) and ards patients (age _+ ; lis . _+ . ) mechanically ventilated were studied. hemodynamic parameters were measured using a swan ganz catheter. arterial and mixed venous blood gas determinations, sao , svo , hb and methb were measured (abl ,osm ). mean intratracheal concentrations of no and no were continuously monitored using a chemiluminescence analyzer (nox ) . during the study the ventilatory pattern and fioz were kept constant. the protocol was for ards group: basalt, no loppm, basal~; copd group: basalz, no lo ppm, no ppm, no ppm and basal . after a steady state of rain hemodynamic and gas exchange measurements were performed. a positive noresponse was defined as a % increment in pao . results: papm was similar in both groups and decreased significantly after no (ards, basal . _+ . mmhg, no . + . mmhg, p < . ) (copd, basal . _+ . mmhg, no- . _+ . nrmhg, p< . ). all other hemodynamic variables remained unchanged after no. basal oxygenation was higher in copd group (paojfio _+ mmhg) vs ards group (paojfio _+ mmhg)(p< . ). after no- , pao increased ( _+ mmhg to _+ mmhg, p< . ) and qs/qt decreased ( + % to _+ %, p< . ) only in ards group. in both groups, significant correlations between basal papm and inhaled no-induced decrease in papm were found. inhaled no-induced increase in pao /fio was not correlated with basal paoflfio . no responders were / ( %) in ards group and / ( %) in copd group (p< . ). conclusions. in hypoxemic ards and copd patients, inhaled no decreased mean pulmonary artery pressure. however, oxygenation only ameliorated in ards group because die number of responders to inhaled no were higher in ards group and this effect seems not to be related to the basal hypoxemia. these results might be explained by the v/q abnormalities present in copd patients. grant fis / . objectives: it has been recently reported that expired con slope as a function of time is modulated by total respiratory system resistance (rrs) in critically ill patients (chest ; : - ) . in this study, we analyze the relative contribution of disease (dis), endotracheal tube resistance (rtube), airway resistance (rmin), additional resistance (~rrs), autopeep (peepi) and dylmmic/static elastance (ed/es) to the co elimination in different clinical conditions. methods: we have studied adult patients ( controls, acute respiratory failure, severe ards and copd) mechalfically ventilated (servo and c, siemens) without peep. we recorded tracheal pressure, airflow and capnograms. signals were analogic to digital converted for posterior data analysis. objectives: alveolar ejection volume (van) can be defined as the fraction of tidal volume (vt) with minimal dead space (vd) contamination. according to the classical paradigm: limvd_~ [vco /vt] =facoz, vco vs vt relationship tends asyntotically to a constant slope when approaches end-tidal volume. we have defined van as the volume that defines this relationship until a limit of % variation. methods: six subjects with normal respiratory mechanics were studied during anesthesia for minor surgery. two subjects, otherwise normals but having high values of total resistance and dynamic compliance, were also studied. capnograms were recorded in steady-state at levels of vt ( . , . and . l) and four levels of peep ( , , and cmh objectives: patients with ards presented lung abnormalities which originate an increase in airway resistance (rmin), in additional resistance (~rrs) and in static elastance (ers). application of peep further increases ~rrs. capnographic indexes reflect lung ventilation]per fusion inhomogeneities. in these conditions, the effects of peep on lung mechanics could be better understood by simultaneous measurement of capnographic indexes. methods: we studied groups of subjects. n: normal subjects scheduled for minor surgery; arf: critically ill patients with mild acute respiratory failure; ards: patients with early ards (< h). we recorded tracheal pressure, airflow and capnograms. signals were analogic to digital converted for posterior data analysis. respiratory system mechanics was assessed by constant end-inspiratory and end-expiratory occlusions technique. at equal tidal volmne ( . l) a peep level of , , and cmh was applied in all patients. we calculated ers (cmh /l), rmin, c~rrs (cmh /l/s) and autopeep. capnographic indexes were alveolar ejection volume (vae)/vt ratio and expired co slope beyond vae (sipco in contrast to synthetic surfactant natural suffactants (alveofact| are able to inhibit pmn-activation. after incubation of activated neutrophils with surfactant, l-selectin expression is decreased. these effects depends on which preparation is used. we conclude, that natural surfactant (aveofact| can perhaps influence early recruitment (,,rolling") of pmn in patients with respiratory failure like ards. with ards hormann cb, baum m, putensen c, knapp r, lingnau w, putz g . clinic for anesthesia and general lntensiv care medicine, university of lnnsbruck, anichstrabe , innsbruck objectives: in thoracic ct scans of patients with severe ards atelectasis and pleural effusion can be found in the dependent lung regions. by rotating these patients from left lateral position to right lateral position a redistribution of the ct densities, a recruitment of atelectasis and therefore an improvement of gasexchange is possible within a few days ( , ). the objective of this study was to find out the mechanism of alveolar recruitment during lateral positioning by ct scanning in left and right lateral position. methodes: after approvel by the local institutional reviewboard we investigated ventilated patients with severe ards (entry criterias: murray score > , ) in the ct scann of the university hospital. after a stabilisation period of minutes in supine position a thoracic ct scan slice cm above diaphragm was taken. then two different positions of the patients were studied in a randomized order: a) degree of left lateral position, b) degree of right lateral position. each lateral position was held for minutes. at the end of each of these periods a thoracic ct scan slice cm above diaphragm was taken. quantitative analysis of ct scan data was based on the frequency distribution of the ct numbers. to quantify the alveolar recruitment during lateral positioning by means of ct scan we defined compartments within the lungs: a) normaly inflated lung, b) poorly inflated lung, c) noninflated lung ( = atelectases) ( ). results: independant of the side of lateral positioning (l) in the non-dependent upper lung a significant increase of the normaly inflated compartment (s: %; l: %) as well as a significant decrease of the noninflated compartment (s: %, l: %) was observed in comparison to supine position (s). in the dependant lower lung the normaly inflated compartment decreased significantly (s: %, l: %) whereas the noninflated compartment increased significantly (s: %, l: %). throughout the whole studyperiode we did not observe any significant change regarding gasexchange and hemodynamic parameters. conclusions: in lateral position the non-dependent upper lung is decompressed. therefore a significant recruitment of atelectases is observed in the upper lung within minutes. on the other hand the dependent lung is compressed by the weight of the upper lung and the mediastinum. a great amount of the alveoli of the dependant lung collapse in this short time intervall. therefore the net effect of recruitment of one positioning maneuver is very small. when positioning patients one should be aware, that the patient is kept in each lateral position long enough to clean up the atelectases in the non-dependant lung and short enough to compress less lung tissue in the dependant lung. objective: to analyze effects of low-dose no inhalation ia patients with severe aeut~ respiratory distress syndrome (ards) over five days. methods: we prospectively studied patients ( men, woman) with severe ards admitted to our icu between may and may who required no inhalation with a dose of ppm for at least days. entry criteria for no injaalafioa were murray score >i . aud pat/fie < nun hg with peep >~ em i~o for at least hours. all patients were sedated, intubated and mechanicauy vantil~ed with volume assist-control ventilation, and had indwelling arterial catheters (pulmonary artery, and radial or femoral artery) to measure cardiac output (by thermodilufion) and relevant intravaseular pressures, and to calculate derived parameters. no was administered between y piece of the ventilator and endotraeheal tube and flow was adjusted to obtain ppm no in the inhaled gas. the no, no and no x concentrations were continuously measured at the distal end of the endouacheal tube by the chemiluminiscence method (nox , see-seres, france). metahemoglobinemia levels were mesured daily. no inhalation was manteined if paojfio ~ improved at least % and was stopped when the change in pao /fio ~ was below % or when the patient presented a paojf > mm hg a~er minutes without no inhalation. every day we made an on-off test to determine if no inhalation improved pao /fio ~. statistics: analysis of vmiance. data: mean + standard deviation. results: the mean age was . +_ . years and mean lung injury score was . • . . mortality was % ( / ), metahemoglobinemia . • . %, and no concentrations zero. paojf~o always improved significantly al~er ppm no inhalation (see :~ conclusions: reintubation in salf-extubated patients strongly depends on the type of meehamcal venfilatory support: the probability of needing a reintabation ff ese occurs during fult vontilatory support is higher than ff ese occurs during weaning. these data suggest that some patients may remain under weaning from mechanical ventilation for unnecessarily prolonged periods of time. objective: the aim of this study was to evaluate the acute effects on gas exehonge and hemodynamics due to positional changes from supine (sp) to prone (pp) in patients with severe acute respiratory distress syndrome (ards). methods: nine intubated, sedated, paralyzed and mechanically ventilated patients with severe ards were prospectively studied. all had a murray score > . , and a pao /f~o < with peep ~ cm h for at least h. all patients had indwelling arterial catheters in the pulmonary artery as well as in the radial or femoral artery in order to measure cardiac output (by thermodilution) mad relevont pressures, and to withdraw blood samples. arterial blood gases and hemodynamie parameters were measured first in sp, and then in pp after minutes of stabilization. vontilatoly parameters remaing unchanged during all the study. statistical analysis was done by the non parametric wdeoxon test. data are expressed as mean ~= sd. results: there were men and women with a mean age of . years ( - ) and mortality was % ( / ). main results are shown below: objective: to describe and compare a new method for obtaining p-v loops (p-vcv) by using a two-way collins valve (twv) with thosu obtained by the supersyringe method (p-vss). methodology: we prospectively studied patients who had an aeute lung injury and were intubated, sedated and paralyzed, and mechanieany ventilated. we performed the p-vev loops and p-vss loops in random order, and the static inflation pressure was limited to emh with both methods. pressure (p) was measured at the airway opening by means of a differential p transducer, and volume was obtained from flow (measured with a pneumotacograph) integration. the p-vse method has already been described (h~trf a,et al.bepr ; : - ) . the p-vev method consists in the following: the inlet of a twv is connected to the ventilator's y-piece, and both outlets are couneeted to the endotraeheal tube by means of an additional y-piece; one of this outlets has a one-way rudolph valve in order to allow inspiration but not expiration during the inflation maneuver. changing the twv tap position allows basal ventilation or progressiveinflation of the respiratory system. this maneuver is as follows: during an end-expiratory occlusion, the ventilatory settings are adjusted to deliver a ml v r with a respiratory rate of /min and i/e ratio : ; at the same time the twv tap is ehonged in order to divert flow through the one-way valve. inflation then begins alter releasing the expiratory oonlusion. pressure and flow signals were digitized and acquired by a computer for subsequent data analysis. we analyzed the following parameters: inflation compllonee ( objective: to analyze the variables which eventually may differentiate ards patients who do and do not respond to low doses of inhaled no. we prospectively studied patients ( men, woman) with severe ards admitted to our icu between may and may who were treated with no ( ppm). the onta'y criteria for no inhalation were murray score >/ . and paojfo z < mm fig and peep >/ cm i~o for at least hours. all patients were sedated, intubated and mechanically ventilated with volume assist-control ventilation. tidal volume was between and ml&g, with constant inspiratory flow, respiratory rate was - /rain, and i/e ratio between : to : . all patients had indwelling arterial catheters (pulmonary artery, and radial or femoral artery) in order to measure cardiac output (by thermodiintion) and relevant intravascular pressures, and to calculate derived parameters. no was administered between y piece of the ventilator and ondotracheal tube, and flow was adjusted to obi~a ppm no in the inhaled gas. the no, no and no x concentrations were continuously measured at the distal end of the endotracheal tube by the chemilumiinscenee method (nox , see-seres, france). metahemogtobinemia levels were measured daily. we considered a response to no inhalation when an improvement in paoz/fo above % was observed after the inhalation of ppm no (group r) . when the cha~age in paojfi z was below % it was considered a lack of response (group non-r small airways functional abnormalities have been recognized as a common feature of lung pathology. however peripheral airways contribute relatively little (~ %) resistance to flow and there disturbances can not be adequately estimated by conventional measurements of respiratory mechanics. the purpose of the study was to evaluate the relationship between raw and small airways conductance following weaning from ventilator methods. patients (age: - years; males) with no serious complications al~er mitral or multiple valves replacements and with more than hrs on mechanical ventilation have been enrolled in this study. the modified flow interrupter technique (ptg "gould" with fleish head # ; differential pressure transducer pm- -tc "statham" w amplifier "kistler ") and flow-volume recording of forced expiration (fleish head # ) have been applied before surgery and following operation on mechanical ventilation (my), after extubation (t:xtijb), on ( nay) and ( day) days. airways specific conductance (sg aw) has been calculated as a mean of - consequent measurements in each patient at each stage. the sac was estimated by max expiratory flow at and % of vc on - f-v curves (mef .~ , mef ) all the data were statistically analyzed with t-test introduction : noninvasive ventilation (niv) reduces the need for endotracheal intubation, the length of stay in icu and the mortality rate in acute exacerbation of copd. however, some patients failed to be ventilated with niv. .objectives...; to further delineate patients who failed to be ventilated with niv and to obtain predicted factors of failure. patients : a cohort of patients ( • years) presenting with acute exacerbation of copd (fevi: • ml, paco : • , ph: . • . ) and nonmvasively ventilated (pressure support through a full-face mask) between april and may twenty-seven ( %) were successfully ventilated with niv (discharged alive without the need for endotracheal intubation) while ( %) failed, requiring endotracheal intubation. .methods : patients successfully ventilated and those who failed were compared according to respiratory and nonrespiratory variables univariate analysis (wilcoxon rank-sum test and fisher-exact test) was performed to select variables included in a multivariate analysis by stepwise logistic regression. results : underlying disease assessed by the simplified acute physiologic score ( • vs • , p = . ), creatinine serum concentration ( • vs • gm/l, p = . ), blood urea nitrogen (bun : • vs mm/l, p = . ), age ( • vs • , p = . ) were higher and encephalopathy ( vs %, p = . ) more frequent in patients who failed. multivariate analysis showed that encephalopathic patients (or (odd ratio) = , p = . ) older than years (or = , p = . ) and presenting with bun >_ mmyl (or = , p = . ) failed to be ventilated with niv. variables related to the respiratory" status (i.e. paco , pao , fev ) were unable to predict tile failure of niv. conclusion : copd patients older than years, presenting with acute exacerbation, encephalopathy and bun > ram/l, should be carefully monitored because of high probability of failure with niv. methods:from february to december we studied pa_ timnts, males and females(mean age +/- ); of the se had emphysema,lo chronic bronchitis, dilatative car diomyopatia,with tracheostomy and emphysema.mean pac at admission in icu was +/- mmhg,while when weaningbegan, +/- .mean autopeep was cmh ( - ).all patients were ventilated in crpv as long as four hours to calculate st tic and dynamic cmpliance and autopeep.then the ventila tion was continued with psv+cpap(peep cmh objectives: analysis of the incidence of neurogenic pulmonary edema (npe) in a population of headtrauma patients with acute respiratory failure (arf). npe can occur after a central nervous system insult. differential diagnosis: cardiogenic pulmonary edema and other forms of non eardiogenic pulmonary edema. true incidence and pathophysiohigy remain poorly defined, however the role of catecholamines seems undeniable. early onset npe (within h after trauma) is characterised by hypoxemia, transient pulmonary hypertension and bilateral central fluffy infiltrates on chestx-ray. characteristics of cardiogenic edema or pneumonia are absent. late onset npe, (beyond hours after trauma), is more insidious. the clinical and radiographic picture has to clear within to hours. ( ) methods: all headtrauma patients admitted from january to december , in a nearotrauma icu setting were retrospectively analyzed for arf with as sole criterinm a pao -fio ratio < . results: neurotrauma patients were admitted during . patients ( %) presented with severe head injury (gcs< ), patients ( . %) with moderate (gcs - ) and patients ( . %) with minor head injury (gcs - ). overall mortulity was . % early (within h. after trauma) and delayed onset respiratory incidents were distinguished, counting for ( . %), respectively patients ( . %), patients ( . %) had early and late respiratory complications. early respiratory insufficiency was caused in patients ( . %) by aspiration, in patients ( . %) by lung contusion, in patient ( . %) by fat embolism and in patients ( %) by npe. in the late onset group patients ( . %) presented with pneumonia, ( . %) with fat embolism and ( . %) with npe. the npe group, patients, presented as follows: patients ( . %) developed early npe, and ( . %) delayed onset npe. patients ( %) died within the first days after admission, showing high mortality. gcs was less than in patients ( . %), indicating severity of head injuries. conclusions: high incidence of arf with various etiology ( , ~ was found in this population. in about % of all admitted hcadtrauma patients ( , % of arf) npe was causing attetial hypoxemia. occurrence of npe seems to be related to the severity of the brain injury and thus to outcome. these data call for extreme vigilance in respect of the insidious occurrence of npe. were included if recovering from respiratory failure and if in the opinion of the primary physician were ready for extubation. patients were excluded if undergoing compassionate withdrawal of support or had tracheostomies. the attending physicians were blinded to the measurements. included patients were placed on pressure support (ps) of em h with demand-flow continuous positive airway pressure (cpap) cm h . after a minimum of minutes on the above sehiogs: gastric intramucosai pc'o , abg, and a p . were measured. the padents were then disconnected from the ventilator for a period of one minute and the patients" respiratory rate and minute ventilation were measured using a wrights respirometer to calculate the frequency to tidal volume ratio (f/vt). patients were then extubated. extubafion failure was defined as the inability to maintain spontaneous ventilation for hours for any reason. results: twenty patients met criteria and were studied over one month period in october . six of the twenty patients ( %) failed weaning. the mean and standard deviation is outlined in failure . +/- . . +/- . . +/- . . +/- . comparison between roc areas shows phi and p . to each show a statistically significant difference from an area of . (p<o. ). the area at which the test has no discriminative value. this is not the case for either the integrative index or the f/vt ratio. the differences between areas for each curve is not statistically significant. the area's for each roc curve is shown in table #' . results. of the newborns referred to us for ecmo-therapy developed barotrauma, of the required ecmo and one of the three other patients who did not recieve ecmo-therapy died. to determine the correlation between the risk factor barotrauma and the severity of the pulmonary situation, we determined the oxygenation index of each patient referred to us for ecmo-therapy . the table demonstrates , d- giessen, frg. inhalation of nitric oxide (no) and aerosulizatiun of prostaglandin (pg) i: have been suggested to achieve selective pulmonary vasodilation and improvement of arterial oxygenation in patients with acute respiratory distress syndrome (ards). we directly compared these two modes of transbronchial vasodilator therapy in ards patients mechanically ventilated for - h (mean murray lung injury score [ ] . + . ). patients were randomized to receive either first no and then pgi (n= ), or vice versa (n= ), with an intermediate baseline period. each drug was titrated individually to find the lowest effective dose for maximum improvement of arterial oxygenation. gas exchange variables, including data from the multiple inert gas elimination technique (miget), and hemodymmaics under application of no/pgi were compared to pro-and past-challenge values. no (mean dose . + . ppm) increased the mean oxygenation index (pao /fio ) from + to + mmi-ig (p < . ) and reduced the shunt-flow from . + . to . : . % (p < . ). aernselized pgi (mean dose . + . " ng/kg rain) augmented pao /fio from + to + mmhg (p < . ), and decreased shunt from . + . to . + . % (p < . ). the miget analysis showed predominant redistribution of blood-flow from shunt areas to regions with normal ventilation-perfusion ratios in response to both agents. in patients, both no and pgi caused an increase in pao /fio by at least rnmhg. two further patients displayed a corresponding improvement of arterial oxygenation in response to either no or pgiz. the mean pulmonary artery pressure decreased from . : . to . : . mmhg in response to no, and from . : . to . : . mmhg (p < . ) in response to pgi . cardiac output, systemic arterial pressure, and right and left heart filling pressures were not affected by either agent. we r that individually titrated doses of inhaled no and aerosolized pgi~ effect selective pulmonary vasodilation and redistribute blood-flow from shunt-areas to weu-ventilated regions with nearly identical efficacy profiles. obieetives: the use of extraeorporeal bypass systems for oxygenation and co -removal is performed in patients with acute respiratory distress syndrome (ards) to reduce mortality and to improve restitution of pulmonary functions. high-dose heparin -commonly used in such patients to prevent thrombotic complications -might cause incurable bleadings as a major risk. this lead to the development of heparinized bypass systems; results of animal and first clinical studies proposed that such systems might run with low-dose heparin or even without any systemic anticoagulation. methods: since , patients with severe ards were treated with extracorporeal lung assist (ela) using heparin-coated systems (type maxima, medtronic, carmeda coating) in our icu. they received a moderate systemic heparinization. standard clotting assays (act, aptt, tt, ptt, at-ill, fbg, fsp) as well as special tests (tat, r~-tg, pf , pal-l, d-dimers, protein c, cl-inhibitor) were performed. results: covalent heparin-eoating of the ela-systems combined with lowdose heparinization could not prevent major changes in coagulation: ) in mean, platelets dropped from /nl to /nl within h after onset of ela. ) tat levels were already elevated before ela start ( ug/]) and demonstrated an additional peak h after onset of ela (up to ug/[). ) in parallel, there was a transient peak of pai-i levels (from to au/ml} h after onset of ela. ) in mean, fibrinogen levels dropped from to mg/ ml within h after onset of ela. ) in mean, cl-inhibitor levels dropped significantly from % to % after onset of ela and reached the initial levels within h. ) after membrane change, there were significant changes for c -inhibitor, fibrin-d-dimers and tt. ) global clotting tests such as aptt, ptt and tt were within normal range. conclusions: patients with severe ards develop a prethrombotic state already before they get connected to the ela bypass system. after onset of ela, they experience additional involvement of procoagulant, anticoagulant, fibrinolytic, and complement systems. in parallel to laboratory findings, clinical data suggest that the use of heparin-coated systems with accompanying systemic low-dose heparinization does not avoid thrombembolic and hemorrhagic complications in tong-term ela patients. thus, at the present, higher dosed individually adjusted heparin treatment has to be recommended. thereby, standard clotting monitoring is not sufficient. objective: poor muscle performance contributes to prolonged dependence on mechanical ventilation. longitudinal data on muscle function in icu patients is scarce. we evaluated changes in inspiratory and peripheral muscle performance during prolonged intensive care in patients with acute respiratory failure. methods: patients requiring intensive care for more than one week were studied. maximum inspiratory pressure (pimax) was measured twice a week for a maximum of three weeks. handgrip power (dynamometer) and subjective fatigue (keldet score) were obtained in survivors only. one measurement was done on the date of extubation. pimax pressure was obtained by occluding the airway for seconds or at least five inspiratory breath attempts. obiectives -measurement of peep-induced changes in lung volume helps to assess respiratory mechanics in acute lung injury (ali). we evaluated the accuracy and stability of a new respiratory inductive plethysmograph (rip), in the measurement of peep induced changes in end-expiratory lung volume (eelv) and tidal volume (vt) against volume reference, pneumotachograph (pnt), methods -two hours periods of basal ventilation and stepwise increases and reductions of peep ( - - - - cm h ) were recorded in patients with all. in addition, the new rip device (respitrace plus tm) was compared to an older rip (respigraph tm, nims, fl, usa) to determine its thermal stability using cold and warm devices and a ventilated lung model. results -the difference between the new rip and pnt in the measurement of vt was - _+ mi (x _+ se) or a - . _+ . % error. increasing peep from to cm h induced a + ml change in eelv. a difference of + ml ( . % of max. eelv change) (ns) was found between rip and pnt eelv readings. during controlled ventilation with constant settings the mean change in eelv was _+ ml/ min (fig.i) . validation of calibration showed a mean error of -+ . % after rain. the new rip had a higher drift when cold (cold + ml/ min vs warm _+ ml/ min), whereas the old rip was thermally stable (cold - + ml/ rain vs warm i + ml/ min). trauma icu, hospital traumatologia y rehabilitacidn. vall d'rebron. barcelona. spain. recent data suggest that the proportion of patients with relevant discrepancies between two jugular bulb (jb) oxygen saturation (sjo ) values is higher than suspected. objectives: determine the incidence, the significance and the pro nosis value of those differences,if they exist,in severe head injured-patients. material and methods: severe head-injured patients, coma glasgow scale (gcs) , with diffuse brain injury according to marshall criteria in the first ct scan, icp recorded, with an interval from accident-double jb monitoring < than hours, were studied. data from bilateral sjo were obtained simultaneously, every hours. discrepancies were considered significant, when differences in sjo were > %. no chan es in treatment protocol (hyperventilation, man• etc) were carried out due to this study. results: men and women were studied, aged • yrs. at arrival at hospital, gcs were < in and ) in to. the incidence of high icp() mmhg) were sz at the entry. the mean therapy index level required to control lop was ~l all patients required vasopressor therapy to maintain upp over ds mmhg. in patients a s.s f swan-ganz fiberoptic catheter was used to obtain a continuous recording of sjo . in the others , sj were intermittently controhed.the mean time of monitoring were d. • days. ten patients died within this period. a total of . blood samples were analized. at arrival, sjo discrepancies were found in patients, b %. at hours, the incidence were lower, / , . %. at th day, were h/ , z and at day , when the catheters were retired, ii[ , z showed discrepancies. the ct showed new injuries in g z of patients with differences > ~ in sd values throughout treatment period. none of those were considered for neurosurgical treatment. no correlation was found between iop and sjo values and sjo differences. conclusions: the incidence of discrepancies between sjo was higher than expected in severe head-injured patients. these situation could reflect disturbances between demands. when differences are known, and those lend to change, the ct scan, nearly always, will show new injuries. platelet-activating factor (paf) is an inflamatory mediator implicated in the pathogenesis of bronchial asthma and acute respiratory distress syndrome (ards). its inhalation in healthy subjects produces transient bronchoconstriction and mild ventilation-perfusion mismatch, together with peripheral leukopenia as a result of intrapulmonary neutrophil (pmn) sequestration. likewise our group has shown in healthy subjects and asthmatic patients that aaibutamol (s) inhibits both pulmonary and systemic effects of paf, suggesting that s may inhibit paf-induced venoconstriction in pulmonary microoirculation. the aim of the present study was to investigate if s inhalation decreases pmn by lung sequestration induced by paf. we studied healthy, non-atop• nonsmoking subjects ( m/ f, + yr), which were pre-treated with s ( ,ug) or placebo, with a randomized, double-blind, crossover, design, before paf ( ,ug) inhalation. we measured the respiratory system resistance (rrs) by forced oscillation, arterial btood gases and both total white cell and pmn count every min over a min. period. simultaneously, we recorded continuously the lung dynamics of inm-neutrophil and tc m-erythrocytes activity, with a gammacamara. after placebo, paf inhalation decreased white cells (from to x /l), and pmn(from to _+ x /l), and increased aapo (from . _+ . to . + . mmhg, p<o. ) and rrs(from . . to . . cmh .s.i q ) (p < . each). the fall in total white cell count correlated with the intrapulmonary pmn retention (r = . , p < . ). by contrast, after s, paf did not induce any change in white ceil count (from to + x /i), pmn count (from to x /i), aapo (from . to . + . mmhg), and rrs (from . . to . . cmh .s.i ). compared with placebo, after s there was a lower ~lln-pmn lung activity ( . . vs . . cts/mci/pixel, p<o. ), lower intrapulmonary pmn retention ( . . vs . . %, p=o, ), and a faster washout ( . . vs . . s ~, p= , ). our results indicate that s inhibits paf-induced intrapulmonary pmn sequestration, being consistent with the hypothesis that s may offset the venoconstriction of pulmonary microcirculadon caused by this mediator. supported inpiratory muscle fatigue with failure of force generation as def'med by a tensiontime index (tti)> . - . has been shown to occur in normal volunteers and in stable copd patients with a specific imposed breathing pattern. its role, however, in hypercapnic respiratory failure is less certain. we studied failed weaning trials in copd patients in which breathing pattern, tension-time index (tti) of inspimtory muscles, dynamic peepi, dynamic lung elastance, lung resistance, and arterial paco and ph were measured at the beginning and end of a t-piece weaning trial. in addition, the change in esophageal pressure during a mueller maneuver (apes max) was measured. a weaning trail has been prospectively defined to have failed if one of the following criteria was met: a rise in pco > mmhg from baseline accompanied by a fall in ph< . ; a respiratory frequency (f) > /min; excessive accessory inspiratory muscle recruitment; and a marked increase in dyspnea. values are expressed as mean • se. weaning failure was characterized by a more rapid, shallow breathing pattern, worsened mechanics, hypercapnia and respiratory acidemia despite an unchanged tri and pes max. we conclude that in this setting hypercapnic respiratory failure is not a consequence of inspiratory muscle fatigue. rather the adopted breathing strategy and resultant hypercapnia may represent an adaptation to forestall the onset of muscle fatigue. concerning the investigated elf-par~eters, no stadstically signhqcant differences were detected between the pgi and the control group. histopathologlcal changes occured in both groups and consisted in rare focal flaaaning f tracheal epithelium with loss of cilia and slight inflammatory cell infiltration, as well as slight swelling of alveolar typo pneumoeytes. sections of generation , and from bronchial tree were free of pathological changes. conclusion: alter h inhalation of p~ji no signs of respiratory-lract tissue damage caused by the aerosol could be detected. the minor pathological findings in the trachea are most likely due to mechanical irritation by bronchoscopy, changes of the alveolar epithelium are known for long-term mechanical ventilation . objectives: the aim of this study was to evaluate of efficiacy of ganglion stetlate blockade in patients with respiratory failure. methods: two groups of patients were investigated: group i (n = ) trauma patients with acute lung injury (ali), group if (n = ) patients with asthmatic status. in all cases continuous mandatory ventilation (cmv) was used with bennett ae. in both groups bilateral ganglion stellate blockade with antero-lateral approach was performed, using . % marcain. the following parameters were analysed: pao , sao , paco~, pip and c~t~t. results: in trauma patients with aij after bilateral ganglion stellate blockade short -lived and slight improvement of pao and sao , decrease of pacoz and pir and increase of static compliance of respiratory system were found. in second group bilateral ganglion stellate blockade interrupted the asthmatic status and significant statistical improvement of parameters of oxygenation, ventilation and respiratory system mechanics were observed. conclusions: we suggest that the bilateral ganglion stellate blockade is a very useful method in treatment of patients with obstructive respiratory insufficiency. the aim of the study was to analyse whether there exists serum and urine electrolyte disorder in patients(pts.) with acute respiratory insufficiency(ari). the study included t pts. with ari (pao : , @ , kpa. paco : , i- , kpa, ph: ~: , , hco : , :~ , mmol/ , sao : , ~- , %) who were hospitally treated due to pneumonia( pts.),emboly of the pulmonary artery( pts.) and severe attack of bronchial asthma ( pts). among tham there were ( , %) males and ( , %) females, average age , ~: , years, otherwise previously healthy. electrolyte concentracions were measured at the onset of the disease in serum and urine collected during hours (sodium-na,potassium-k, chlorine-c , calcium-ca,magnesium-mgand phosphorus-p). the measured serum and urine electrolyte concentrations were compared with respective referent values (rv). by serum electrolyte analysis, the following average velues were obtained: na:l o, the object of our investigation was a group of pts with massive pneumonias, males ( . %), females ( . %),mean age yrs.thirteen ( %) of them were smokers, ( %) nonsmokers. only pt ( . %) had pre-existing chronic respiratory disease, and ( . %) were admitted for the first lime,with no previous respiratory anamnesis. diagnose was based on anamnestic data of productive cough in pts( . %),physicaly ~onchial breathing in i~s ( . %),white cell count onder x /l in pts( . %). radiographicly, bilateral massive homogeneous shadows were found in pts ( . %), onilateral in pts( . %),pleural effusion in pts ( . %). abnormal renal function was found in pts ( . %). sputum culture was positive in pts ( %): slr.pneumoniae, str.pyogenes, pse'udomonas aerug, in , , cases respectively. all patients had remarcable hypoxernia (pao range from , to , kpa) without hypercalmea. all patients needed oxygenotherapy together with antibiotics and other .symptomatic therapy. nineteen pts had anaelioration of general condition and normalization of blood gas analyses, while pts with the lowest hypoxcmia died.in conclusion, massive pneumonias are frequently followed by respiratory insufficiency which is one of the markers of pneumonia severity. as existing hypoxemia complicates the course of the disease,prolonges the recovery, makes therapy more complexe and may be cause of death , frequent blood gas measurement is recomanded. we studied the effects of bosentan (bos), an eta and etb receptor antagonist, to examine if endogenous et mediates pulmonary hypertension in anesthetized and ventilated dogs with acute lung injury due to oleic acid (oa). the gradient between pulmonary artery pressure (ppa) and occluded ppa (ppao), and gas exchange (evaluated by arterial blood gases and sf intrapulmonary shunt) were measured at controlled flow. in dogs (treatment), data were collected at baseline, during long injury (obtained rain after intravenous administration of oa . ml/kg), and again after bos ( mg/kg intravenously). in dogs (pretreatment), data were obtained at baseline, after bos and then after oa. in treated dogs, oa increased (ppa-ppao, mmhg, table, means + sem, * p < . vs base) and deteriorated gas exchange. after oa, bos did not affect pulmonary vascular tone nor gas exchange. in pretreated dogs, bos had no effect on baseline pulmonary vascular tone but prevented the increase in (ppa-ppao) after oa. the deterioration in gas exchange after oa was not influenced by bos pretreatment. objectives: the alveolar tension is measured by the application of the alveolar air equation in which the arterial pco is used or by the simplified form of this equation in which the respiratory exchange ratio is taken at the value of . . the purpose of this study was to estimate the effective alveolar tension (pao eff) during spontaneous breathing with a new bedside technique which is simple non-invasive in normal subjects and patients with chronic bronchitis-emphysema. we also compared these values with the ideal alveolar po (pao (i)), measured from the alveolar air equation in which paco was substituted by the effective alveolar pco (paco eff) and with the alveolar po measured from the simplified alveolar air equation (pa ). this study is complemantary to previous work for the estimation of paco eff. methods: the subjects breathed quietly through the equipment assembly (mouthpiece monitoring ring, fleisch transducer head) connected to a pneumotachograph and a fast response and co analyzer. the method is a computerised calculation of the effective alveolar po quite similar to that of paco eff, obtained from the simultaneously recorded at the mouth expiratory flow, and co concentration versus time curves. results: the results showed a mean difference (pao eff-pa (i)) of - . kpa in normal subjects and - , in patients. the mean of the difference (pao eff-paq ) and (pad (i]-pao z) was much greater than . in all subjects. the limits of agreement for the difference (paozeff-pa (i))were - . to . kpa in normal subjects and - . to . in patients, while those for the differences (pao eff-pad ) and (pao (i)-pad ) were very large ( > - . to > . ) in all subjects. conclusions: the effective alveolar po is very close to the ideal one in normal subjects, tn patients pao eff may excessively deviate from pa (i) due to the observed significant difference between the alveolar/tidal volume ratio for o and that for co . the alveolar po measured from the simplified alveolar air equation (pao ) differed substantially from pao eff and pad (i) in all subjects. the essential role of glucoprotein hormone erythropoietin is to control red cell production. hypoxemia, reduced blood -carrying capacity and increased affinity of hemoglobin for are the primary stimuli for erythropoietin production. both anemia and hypoxemia induce rapidly erythropoietin secretion. kidney erythropoietin rna levels correlate inversely with hematocrit and directly with plasma erythropoietin level. similarly, hypoxemia increases kidney erythropoietin rna and plasma erythropoietin. the effect of hyperoxemia (pa >lo mmhg) on erythropoietin secretion isn't very well understood. the purpose of this study was first to evaluate the erythropoietin secretion in patients with acute respiratory failure and second to determine the effect of hyperoxemia on erythropoietin secretion in patients with and without anemia. sixteen patients with acute or acute on chronic respiratory failure needed mechanical ventilation were included in this study. these patient were divided in two groups. the patient who developed anemia were included in group i and the patients without anemia in group i . erythropoietin was estimated in venous blood in three stages. the first sample was taken during hypoxemia, the second during hyperoxemia and third during normoxemia. all the patients had high erythropoietin level during the hypoxemia period (mean value • mu/ml). during hyperoxemia etythropoietin levels were reduced in both groups ( mean value . + . mu/ml in group i, . • mu/ml in group ii). in normoxemia stage, erythropoietin increased again in anemic patients, and decreased more in the patients of group i . we conclude that hyperroxemia inhibit erythropoietin secretion in spite of anemia and tow arterial oxygen content. hyperoxemia may be a factor of the insisted anemia in with oxygen treated icu patients. the purpose of this study was to determine the relationship between clinical features of acute lung injury (all) and parameters like total proteins, total and individual phospholipids, the presence of paf, and acetylhydrolase activity in bal of mechanically ventillated patients. acetylhydrolase catalyses the cleavage of acetyl-group from the second position of the glycerylether backbone of paf, leading to its inactivation. mechanically ventillated patients were divided to three groups. group i includes patients without all; group ii, comprisespatients with moderate degree all, ( . <g-i < . ); and group iii comprises patients with severe ards (all score > . ). broncoalveolar lavage (bal) was obtained after infusion of normal saline at ~ to intubated patients and cooled immediately. cells were removed after mild centrifugation ( x g, min, oc). aliquots from the supernatant were used for total protein, phospholipid and paf analysis and determination. acetylhydrolase activity was assessed after incubation of bal with h-paf labelled on the acetyl group. released label was measured by liquid scintillation counter in the supernatant after trichloroacetic acid precipitation of the non-reacted substrate. kinetic characteristics of the enzymes were also studied. total phospholipids appear reduced in bal of patients with all, while total proteins increase. these factors appear to correlate with the severity of all. paf was not present in bal samples pretreatad with equal volume of % acetic acid to denaturate acetylhydrolase. detection limit for paf under our experimental conditions: pg paf/ml bal. instead, acetylhydrolase activity was detected in amounts increasing with the total protein content. background: intubated patients without lung injury or impaired breathing control normally display an inspiratory peak flow of below l/s. the aim of our study was to investigate the inspiratory peak flow generated by patients with acute respiratory insufficiency (ari). we had to take into account that both an inspiratory pressure support (ips) and the resistance of the endotracheal tube considerably influence the flow pattern generated by the patient. patients and methods: to investigate the non-influenced flow pattern we developed a new ventilatory mode which automatically compensates for the flow-dependent resistance of the endotracheal tube (automatic tube compensation, atc). furthermore, the mode maintains a constant tracheal pressure in inspiration and expiratio n . consequently, the measured flow pattern exactly corresponds to the flow pattern generated by the patient except that the ventilator modified for this mode (evita, driiger liibeck, germany) was not able to deliver a gas flow of more than l]s. we have investigated patients with ari arising from different reasons. results: the inspiratory peak flow measured in the atc-mode was . l/s _+ . l/s. the maximal deliverable flow of l/s was obtained in of patients. the figure shows the flow pattern under atc and ips in [~s] oi:) one of these patients. conclusions: patients with ari display a highly increased inspiratory peak flow. ventilators used for spontaneous breathing should therefore be able to deliver a gas flow of more than l/s. an overproduction of no and reactive oxygen species (ros) has been demonstratred in septic shock. ros and nitric oxide (.no) are free radicals which are known to react together leading to peroxynitrite anions that can decompose to form nitrogen dioxide (no ) and hydroxyl radical (oh~ thus, no has been reported to have a dual effect on lipid peroxidation (prooxydant via the peroxinitrite or antioxidant via the chelation of ros). in the present study we have investigated in different models the in vitro and in vivo action of no on lipid peroxidation. copper-induced ldl oxidation was used as an in vitro model of lipid peroxidation. ldl ( ~g apob/ml) was incubated with cu + ( , ~tm) in presence or absence of no donor (sodium nitroprussiate or glutathione-no) from to ~m. oxidation of ldl was monitored continuously with conjugated diene formation ( nm) and hydroxy nonenal accumulation (hne). exogenous no prevents in a dose dependent maner the progress of copperinduced oxidation. ischaemia-reperfusion injury (i/r), characterized by an overproduction of ros, is used as an in vivo model. anaesthetized rats were submitted to hour renal isehaemia following by hours of reperfusion. sham operated rats (sop) were used as control. lipid peroxidation was evaluated by measuring the hne accumulated in rat kidneys in presence or absence of l-arginine or d-arginine infusion. l-arginine, but not darginine, enhances hne accumulation in i/r but not in sop (< . nmol/g tissue in sop versus . nmol/g tissue in i/r), showing that in this experimental conditions, no produced from l-arginine, enhances the toxicity of ros. this study shows that the pro-or antioxydant effects of no are different in vivo and in vitro and could be driven by environemental conditions such as ph, relative concentration of no and ros, ferryl species...these conditions are impaired in circulatory shock. methods:" the diagnostic and therapeutic approach was standardized so that data collected over a -year period were comparable. a progressive deterioration of clinical conditions and/or pulmonary gas exchanges was considered as indication for my. variables potentially predicting the need for hv were derived from clinical and arterial gas data, extrapulmonary diseases, use of drugs, chest x-ray and ecg abnormalities. results: rv, performed with external and/or internal ventilators, was necessary in patients ( %). at the hospital admission, pac was higher and ph was lower in patients requiring rv ( pneumomediastinum, pneumothorax, ateleetasis and myocardial infarction are rarely seen in bronchial asthma. these complications occur as a result of the severe asthma.the aim of our retrospective study was to analyse the complications seen in acute asthma attacks. during the years through , patients were admitted to hospital in acute asthma episode. there were ( , %) pts with complications; mean age of yrs; females ( %). clinical history, ecg and chest radiogr~hs were analysed. the mean duration of bronchial asthma was yrs (range from months to yrs), all patients were atopics. there were four ex-smokem and one smoker. the worsening of asthma symptoms begun two days before the admission (range from to days). on ecg all patients had tschycardia. rightward shift of the qrs axis and st-t changes indicative of right ventrieutur strain were found in three pts. these were the transient fmdings that improved after curing the acute asthma attack. non-q myocardial infarction oeeured in one patlent and resulted from the hypoxaemia of asthma. hyperinfl~ion was the usual finding on the chest radiograpk pneumomediastinum and subcutaneous emphysema were apparent in five pts and required no additional treatment unilateral pneumothoraccs were present in two pts and needed eontimous intrapleural drainage; one of these patienst died in eardiorespiratory insufficiency. ateleetasis of right upper lobe was present in one patient. it oceured due to inspissated secretions and needed no additional treatment all these patients, except one who died, improved on lreaanent with oxygcr~ steroids, beta-two agonists, theophylline and antibiotics. in conclusion, complications occur in acute asthma episodes as a result of the severe asthma mediastir,*l emphysema and atelectasis are not serious complications. pneumothorax and myocardial infarction are very serious life-treatening complications and always have to i:m considered in taati~ts with sev~ asthma. acute bronchial asthmatic episodes represent one of the most common respiratory mnergendes, its maximmum expression "status asthmatiens" is one entity of low incidence, still it is a risk to the physical integrity of the patient. during a total of patients with diagnosis of status asthmabcas were hospitalized. out of these palients six had a near-fatsl asthma and they were subjected to a complex examination. near-fatal asthma was defined as either respiratory arrest or acute asttuua with paco greater than , kpa and/or an altered state of consciousness. mean age was , -d: , yrs, four male and two female sex. at presentation two patients suffered from coma, others were confused. they exh'bited severe dystmoes, diffieul~ speaking, used accessory muscles of respiration, increased whee~tg while two cases had silent chest on auscultation. cyanosis indicated a very severe asthma attack in all six patients. mean respiratory rate was ~ /min and puts rate .d: bts/imn. arterial blood gases revealed a pao of , ~ , kpa, paco of , • kpa and ph of , -+- , . area-careful evaluation they received conventional therapy (immediately continuous oxygen, impelled nebulization with high doses of betatwo agonists and ipmtropium bromide, intmvanous st~oids and theophylline). in two eases signs and symptoms of deteriorating airflow and respiratory muscle fatigue determined the need for mechanical ventilation. out of six near-fatal attacks aggressive lrealanent was suscessfull in four patients and fatal in two eases. one patient admittcxl in coma died in severe hypoxae~a upon one hour and one mechanicaly ventilated died from cardiac arrhythmia. life-threatening attacks in asthmatics in our group developed gradual worsening despite neatment which r symptoms in most other patients. one patient had "brittle asthma", other long-standing acute episodes ireated with systemic steroids. conclusions: idantitiechon of fatality prone subjects may lead to fttrther muetion of seveze episodes. respiratory affest and coma upon admission, severe dyspnoca with silent chest on ausouhation, oyanusis and use of accessory muscles of respiration constitute the basic cfinieal picture. hypoxasmia must be immediately eon'ected.the patients and physicians should be able to assess the severity of asthma, a major factor in near-fatal and fatal asthma attacks. objectives :our purpose was to asses if the evolution of patients with a adult respiratory distress syndrome (ards) ,shows any relation to the pulmonary or systemic origin of the disease and whether or not there were differences in the frequency of the syndrome in both groups. methods : randomized prospective study in multidisciplinary icu. one hundred and sixteen patients with a high risk developing ards were distributed into two groups. one was named systemic origin group(so) and the other pulmonary origth group (po).ai patients only showed one cause (pulmonary or systemic) with potential risk of ards.the patient's hemodynamic and respiratory status was evaluated every hours the first day and every hours the second and third day. at the end of hours the patients were diagnosed as ards or non-ards. measurements and main results : of the total patients, were finally included in the so group and in the po group.patients in so group and po group had comparable ages (p<. ).peep in both groups was comparable (=. ) at the mmnent of admission to the study. there were no statistically significant differences for cardiac index and systemic vascular resistances. the pulmonary vascular resistances (pvr) showed significant differences at h.(p<. ) and h. (p<. ).the oxygen comsumption (vo) in patients of the so group showed statistically significant differences at h. (p<. ) with respect to initial values.fifteen cases of ards ( . %) in the so group and twenty five cases ( . %) in the po group were identified. the time of onset of ards was _+ hours in the so group and + b hours in the po group.the final outcome was very similar th both groups : mortality of % in the so group versus % in the pc group. conclusions : the pathogenesis of ards depends on whether the lesion is originated at or outside the lung. the po group showed a sborter thne of onset of ards, a faster and more severe increase of pulmonary shunt and a higher percentage of patients developing ards compared with patients of the so group.the so group showed a higher and faster increase in puhnonary resitances tbat po group and a decrease th oxygen comsumption earlier and more severe than in the po group. these data thus seem to show that there could be two mechanisms involved in the genesis of ards depending on the cause. the fact that the ards genesis is shorter in the cases of pulmonary etiology with faster impairment of pulmonary shunt, and a slower increase in pulmonary resistances in this pulmonary group, would indicate that the underlying mechanisms responsible for the hypoxemia are different to those which thitiate the increase in pulmonary resistances. finally, the exclusive inapairinent of oxygen consumption, which appears earlier than the onset of ards in the systemic origth group, could show the generalized character of the process in this group. perfusion of prostacyclin (pgi ) to treat pulmonary hypertension in adult respiratory distress syndrome (ards) worse pulmonary gas exchange due to a marked impairement of ventilation/perfusion mismatch. recently has been shown that if prostacyclin is given by aerosol instead of intravenous the net effect is an improvement of arterial oxigenation due to a redistribution of blood flow to well ventilated areas. objectives: to asses the effects of inhaled proatacyclin on pulmonary haemodynamics and gas exchange in patients with severe ards. methods : two patients with severe ards (murray score > ) recived inhaled pgi at - ng.kg.min " using an ultrasonic nebulizer. haemodynamic measurements, arterial and mixed venous blood gas analysis were performed before and after rain of pgi inhalation. results: short-terro p~i inhalation improved pulmonary g-~ e-'~hange in both patients. arterial oxygen partial pressure (pao ) increased from to mmhg in patient and from to in patient , the ratio pao to the fraction of inspired oxygen increased from to (patient ) and from to (patient ). venous admixture decreased from % to % and from % to % in patient and respectively. mean pulmonary artery pressure decreased slightly from to mmhg in patient and from to mmhg in patient . no effects on systemic haemodynamics were observed in any patient. conclusions: pgi inhalation improves gas exchange and produces selective pulmonary vaaodilation, thus can be an alternative therapy for the treatment of pulmonary hypertension and hypexemia in patients with severe respiratory falllure. methods: we treated ards-patients (age yr ( - ) mean, range) during - . the lowest pao /fio -ratio was ( - ), the worst murray score . ( . - . ), icu-stay ( - ) days and hospital mortality %. the costs of intensive care were calculated according to intensivity of patient care as assessed by tiss-scoring (therapeutic intervention scoring system). the more intensive the care, the higher are the costs. costs per year of life saved (=life-year" in us $) were compaired by other medical treatments ( - ). it is assumed that the mean expected length of remaining life in ards-survivors after intensive care is years. treatment life-year ($) ' bone marrow transplantation (acute leukemia) lowering cholesterol using iovastatin treating hypertension using nifedipine heart transplantation intensive care of ards-patients conclusions: intensive care of patients with severe ards is highly more cost-effective as compared with many other routinely used medical treatment strategies, the usually good recovery and the reasonable quality of life in survivors justifies investments to care of these patients ( ). there is a close correlation between these two methods of measuring evlw. however there is an underestimation of . % in this kind of pulmonary edema ( oleie acid induced ) with the double dilution method. although the size of the sample is small, in normal lungs there appear not to be this underestimation. the effect of peep on evlw has been studied with contradictory results, probably as a consequence oft differences in methods of measuring evlw, variations in the type and severity of lung injury, and different timings of peep application. objective= ) to analyse the effect of different levels of peep ( , and omh ) on evlw during hpe; ) to establish whether increases in intrathoracic pressure due to high peep levels can obstruct lymphatic drainage. material and methodet hpe was provoked in groups of dogs by inflating a foley catheter in left auricular to a pressure of - r~uhg. peep levels of , i or m~hg were applied. resultst objective: to assess the effect on extravascular lung water (evlw) of the application of peep and the reduction of vt in an oleic acid pulmonary edema model in pigs, using three ventila~ary strategies. material and methods: twelve adolescent pigs (weighing over kg) were randomly divided in three gmups immediately alter infusing via a central vein . ml/kg of oleic acid to produce a permeability pulmonary edema. the ventilatory parameters for each group were as follows: group i (n= ) : vt: - ml/kg; zeep. group :(n= ) : vt: - ml/kg; peep: cm h . group :(n= ) : vt: - ml/kg; peep: emil . (resulting in permissive hypereapnla) after a four-hour period of ventilation the animals were killed and the lungs excised to calculate gravimetrically the extravascular lung water using a standardized procedure ( hemoglobin content method ). ill evlw (ml/kg) group obiective: in the postoperative period, maintenance of adeguate arterial oxygen tension is a major problem in morbidly obese patients probably because of a large reduction in functional residual capacity (frc). the aim of this study was to evaluate the effects of peep on respiratory mechamcs and gas exchange in this kind of patients. methods: in nine postoperative mechanically ventilated morbidly obese patients (bmi> kg/m ) we partitioned the total respiratory system mechanics into its lung ( ) and chest wall (w) components using the airway occlusion technique associated with the esophageal balloon, during constant flow inflation (jap ; : ) . at three different levels of peep ( , , cmh ) we measured: compliance (cst), airway (rim) and "additional" (dr) resistance, frc and gas exchange. obiectives. to describe the use of prone position in our icu we analyzed the clinical records of all patients admitted in - , selecting adult patients with arf defined as: intubation and pao /fio < mmhg plus an fio > . or peep> cm i . results. patients met the arf criteria: of them ( . %) underwent prone positioning (p+). prone position use began in the early phase of arf ( . • days from the beginning, range - , median ). out of p+ pts were treated with controlled ventilation (cppv or pcv), while were on assisted ventilation (simv+ps) and on spontaneous breathing (cpap). only pts were awake when turned prone, while pts required adjuncts of sedation to tolerate the change of position. the duration of prone positioning was variable (average lenght . • h, range . - h). only minor side effects were observed (eyelids and facial edema, chest and facial pressure bruises). we consider responders (r+) those patients presenting at least . mmhg increase in pao /fio : / patients ( . %.) were responders when first pruned. the pao /fio changes induced by prone position are reported in the figure. pao /fio increased when patients were pruned (*p< . ) and remained higher than baseline values when returning supine(*p< . ). paco remained unchanged. prone positioning was used at least twice in / ( conclusions. this retrospective analysis confirms that prone positioning improves oxtgenation in the majorib' of arf patients. altough we have no available criteria to discriminate in advance r+ from r-pts, we now routinely consider the use of prone position in the treatment of severe arf. palo a, otivei m*, galbusera c, veronesi r, sala gallini g, zanierato m, iotti g, braschi a.servizio anest. e rianim. i, *laboratorio biotecnologie e tecnologie biomediche irccs s. matteo, pavia, italy inhaled no can improve arterial oxygenation and reduce pulmonary hypertension in ards patients; little information is, however, available about the dose-response curves. methods seven ards patients (lis . +. ) submitted to mechanical ventilation randomly received inhaled no doses in increasing or decreasing sequence: . , , , , , and ppm. reference measurements were obtained before and after the entire period of no inhalation. hemodynamic parameters and blood gases were measured after min in each condition. cmv was administered under sedation and paralysis, with constant ventilation, peep (lol-_ cmh ) and fit (. +. ). the changes in vt and fit due to the no ( ppm in n ) injection in the ventilator external circuit were compensated for. results . the dose of . ppm, ineffective on papm, significantly improved oxygenation. the increase of pat and the decrease of q'va/q' and papm were nearly maximal at - ppm. no deterioration of arterial oxygenation was observed at no doses as high as ppm. co exchange was not influenced by no inhalation. systemic hemodynamic variables did not change throughout the study. these results suggest that a concentration around ppm is adequate for obtaining maximum effects on hypoxemia and pulmonary hypertension in patients with ards. low-dose inhaled nitric oxide (no) induces redistribution of pulmonary perfusion in patients with severe ards and causes improvement of oxygenation [ ] . however, addition of exogenous lowdose no in the inspiratory gas mixture might be only a replacement of missing atmospheric no ( - ppb) in hospital central-supplied medical air. [ ] we have realised nitric oxide measurements in ten healthy volunteers, ( smokers and non-smokers) breathing with a mouthpiece and occluded nostrils through a ventilator circuit, with separation of inhaled and exhaled gases by a valve. no concentration was measured with a double-chamber chemiluminometer (environnement sa, france) and with charcoal/silicate purified compressed air. there was no nitric oxide detectable in the inspirat ry limb of the ventilator. unfiltered central supply medical air contained : - ppb of no and - ppb of no , whereas central supplied oxygen was no/no free. samples were taken after equilibration periods of minutes, with increasing fit levels of . , . and . for subsequent minutes periods; paired values were recorded every s. the mean no value was . ppb (sd . ) and n o significant differences were found for different fit levels both in smokers and non-smokers. these data suggest that the no concentration of pulmonary origin in the exhaled air of' healthy volunteers is probably lower than that reported by other authors [ ] and that, previously reported, differences between smokers and non-smokers are not always striking [ ] . we suggest the use of activated charcoal/silicate filters for clinical trials in order to achieve standard conditions. [ objective: to compare efficacy and safety of two doses of salbutamol. methods: sixteen adults who had severe acute a~hma were randomly assigned to receive either rag (n= ) or rag (n= ) of nebulized sulbutamol. both groups were similar with respect to age, duration of a~hma, duration of attack before arrival at the hospital and severity of a~hma according to baseline measurements (table) . evaluation was performed , , and rain after the start of nebulization. results: compared with mg regimen, mg regimen resulted in the same improvement in peak-flow and fischl index (figure). the changes in heart rate, respiratory rate and pace did not differ significantly between both groups. the incidence of side effects, which included tremor, palpitations, cardiac arrythmlas and other symptoms, was not sj~ificanfly different in the two populations. conclusion:the results of this study suggest that nebulization of ng of salbutamol is not more effective than rag in the initial treatment of acute severe asthma in adult patients. the prognostic factors of neutropenic patients admitted to the icu remain poorly known. the aim of this study was to determine the respective weight of underlying malignancy and organ system failures on the outcome of these patients. patients and methods: the charts of neutropenic patients (wbc < /mm and/or pmn < /ram ), admitted to the icu between and , were retrospectively reviewed. the characteristics of the neoplastic disease (h~emopathy or solid tumor, tumoral evolution, duration of cancer disease and of neutropenia), the mac cabe's score, the organ system (respiratory, hemodynamic, renal, neurologic, hepatic) failures and the severity scores (saps, saps ii ,osf) were registred within the st day in the icu. when discharged from the icu, the patients were classified as alive or dead. results: fifty-seven patients ( . %) had a h~ematologic malignancy, and ( . %) a solid tumor. fifty-nine of the patients died ( . %); the mortality rate did not differ between both groups ( . and % respectively, p = . ). with univariate analysis, none of the tumoral features is linked to the prognosis; only the respiratory (p < - ) and cardiovascular (p < - ) failures, and the number of organ system failures (p < - ) are associated to the risk of death. the saps (p < - ) and saps ii scores (p < - ) were higher in patients who died. with multivariate analysis (logistic regression), only the respiratory failure is correlated to the risk of death (p = - ); neither the features of the underlying malignancy (p > . ), nor the duration of neutropenia before admission in icu (p = . ), nor the severity scores figs ii: p = . ) are linked to the outcome. conclusions: the tumoral characteristics do not modify the prognosis after admission to the icu. they should not influence the decision to admit or refuse a cancer patient in the icu. respiratory failure at icu admission has the predominent weight on the risk of death in the icu. patients with respiratory acidosis due to asthma occasionally require levels of mechanical ventilation that place them at risk for barotrauma. a few case reports have described the use of an extra-corporeal membrane oxygenator(ecmo) circuit as an alternative means of co removal. generally, this has been used for short periods of time (< h) without serious complications and with low blood flows through the extra-corporeal circuit. we report a case of refractory asthma who could not tolerate even small-volume breaths from a mechanical ventilator due to severe bilateral airleak. ecmo therapy was initiated at the referring hospital prior to helicoptor transport. high blood flows were used ( % of the patient's cardiac output), sufficient to achieve both co removal and oxygenation. satisfactory gas-exchanged was accomplished (pco = - mmhg) with nearly total lung rest for a prolonged period ( h). however, the long ecmo duration was associated with two severe complica-ti ns: ) bilateral hemothoraces due to anticoagu!ation in the extra-corporeal circuit, and ) prolonged weakness as a result of neuromuscular blockade for six days. the patient was discharged from the hospital in good condition. we present the respiratory and hemodynamic features of this case aw well as the potential complications of ecmo therapy in asthma. objectives: parameters derived from tidal expiratory flow ~e) and volume (vt) can be used to detect airflow obstruction in copd patients who might be unable to perform forced spirometry (e.g., icu). however, indices such as ave/v t and at/re are highly variable (thorax, : ; ) . methods: we investigated whether the standardized for v m effective time (teff~) of a tidal breath, which is derived by asimple mathematical procedure (teff,= j'vdt/vt ), is a more reproducible and sensitive detector of airways obstruction, we studied nine normal subjects ( male, -+ yr) and copd patients ( male, -+ yr) in the seated position, with a noseclip on. they breathed quietly, through a pneumotashograph to measure flow (v). volume was obtained by numerical integration of thellow signal. each subject had an initial - min trial run, in order to become accustomed to the apparatus and procedure. when regular breathing had been achieved, all breaths over a min time interval were recorded. the mean value of six consecutive breaths (ers criteria) for each subject was used for analysis under the condition that within session variation of tidal volume (vt) was < %. lung function tests were: in normals (mean-sd), fevl%pred = • fevl/fvc%= -+ % , and in copd patients, fev~%pred= __. and fevi/fvc%= --. %. results: values are shown as mean-..+-sd in the following a su~ve~ os literature sources p~oves that t~aditlona], i.e. medicinal medication and physiothe~apeutic methods os t~eatment often p~ove to be insufficientl~ effective both currently and in the ~emote future. the goal of this study was to investigate the efficacy os t~eatment of b~onchial asti~ma patients by means os speleo-and artificial sp~ay therapy. speleotherapy t~eatment was conducted in the conditions os mic~oclimate os salt mine in solotvino hospital. a~tis sp~ay the-~apy was conducted by means os a self-made device. ou~ method is based on the p~inci-~ le os using the majo~ facto~ of speleo-he~apy -highly dispe~sed sp~ay s sodium chloride. the obtained ~esults ~e~e analyzed in five g~adations. at the end os the speleothe~apy improvement and considerable improvement was observed in , ~ os patients; inconsiderable improvement -in , ~ os patients. having evaluated the e~s os t~eatment using a~tis sp~ay therapy the indices a~e , h and , ~ ~espectively. remote ~esults of t~eatment a~e an important index os t~eatment, the ~esult os ~hich ~e~e studied by means s a ~uestionnaive-method. patients ~ho had been t~eated by speleothe~apy mo~e f~eguently ~e-po~ted a ~elapse in disease ust afte~ the course o~ t~eatment ( , h). ho~eve~, in a ]ate~ phase the ~emission ~ould last ]on-~e~ (s months in , ~ os patients, till one yea~ in ~ ~). in , ~ os patients who passed the co~se os a~tificial sp~ay therapy a ~elapse was ~egiste~ed immediately as the co~se os t~eatment. then thei~ condition stabilized ~hile in , ~ os patients a period os ~emission lasted s ha]s a yea~. , ~ of patients dida't ~epo~t a ~elapse of the disease du~in~ one yea~. evangelismos hospital, critical care department, athens, greece method#: mechanically ventilated patients ( copd, ards, other pulmonary diseases) were studied in two phases: ) during the acute phase of respiratory failure; ) during recovery - days later. we measured mip and monitored the pattern of breathing while the patients were breathing spontaneously through the respirator (pressure support mode with - cmh ) until either the point they were unable to sustain spontaneous breathing (sb) any longer (phase ) or for two hours when they could sustain sb indefinitely (phase ). subsequently the patients were sedated, paralyzed and mechanically ventilated. then we simulated the pattern of sb at the end of the sb trial by manipulating the variables of the ventilator and assessed respiratory mechanics b y the end-inspiratory and end-expiratory occlusion technique. . during recovery, a combination of reduced inspiratory load and increased venfilatory capability makes a patient previously unable to sustain sb to breathe spontaneously. . inspiratory load is reduced during recovery, mainly because both intrinsic peep and breathing frequency are diminished. obiectives: although elevated concentrations of a few cytokines have been shown to be present in the bronchoalveolar lavage (bal) fluid (balf) of patients with the adult (acute) respiratory distress syndrome (ards), the pethogenesis of ards is largely unknown. leukemia inhibitory factor (lif), a growth factor recently recognised as a polyfunctional cytokine integrated in cytokine networks was measured in unconcentrated balf of patients from different patient groups. methods: lif was measured in balf by means of a specific and sensitive elisa (detection limit pg/ml)in balf (lavage of x ml in the right middle lobe). results: lif was not detected in the balf of healthy control patients and in only one ( pg/ml) out of patients at risk for ards (after cadiopulmonary bypass surgery) who underwent bal h after the end of the extracorporeal circulation. high and detectable levels were found in the unconcentrated balf of out of patients with full-blown ards ( + , mean + sem, range - pg/ml). there was a good correlation between the level of lif in the balf and a number of markers of inflammation: neutrophils/ml (r: . , p= . ), albumin ( r: . , p= . ) and protein level (r: . , p= . ). conclusions:the biological role of lif in these balfs is not readily explained by its currently known actions and it is unkwon whether lif contributes to or is a response to local tissue damage. our results indicate that this cytokine with lots of interesting _functions is a pert of the inflammatory cytokine cascade in ards. background and obiective : we recently demonstrated that cisapride -a new prokinetic drug -enhanced enteral feeding in a heter genoas group of ventilated icu patients by significantly accelerating their gastric clearance (crit care meal, ; : - ) . it remains unknown, however, whether certain subgroups of patients might benefit more from adding cisapfide to their enteral nutrition regimen than others. patients with chronic obstructive pulmonary disease (copd) might represent such a subgroup since their illness and its specific treatment put them at risk for gastric emptying disorders. design and setting : prospective, consecutive sample study in an adult medical intensive care unit in a university hospital. patients : mechanically ventilated and hemodynamically stable copd patients. interventions : gastric emptying was evaluated by bedside scintigraphy and expressed as the time at which % of a tcg~-labelled test meal was eliminated from the stomach (t / ). baseline data (do) were recorded after enteral nutrition reached to ml daily. scintigraphic measurements were repeated days after cisapride ( ml orally, q.i.d) had been added to this regimen (d ). patients were considered cisapride responders when gastric clearance improved by more than % from baseline. results : normal values for the test meal and for scintigraphic acquisitions obtained in the supine position were found to be + min. in healthy volunteers (crit care med, ; : - ) . five patients responded to cisapride (t / : + rain vs. + min at do and d , respectively) and five did not (t / : + min vs. _+ rain at do and d , respectively). in contrast with non-responders, all five responders had clinically significant maldigestion at baseline (excessive (> ml) gastric residues, vomiting (> times/day and abdominal distension) which disappeared in of them after the administration of cisapride. conclusion : copd patients who tolerate enteral nutrition well have basal gastric emptying times which are comparable with those of healthy volunteers and are not influenced by cisapride. however, cisapride treatment provides both scintigraphic and clinical improvement in those copd patients who exhibit clinically obvious gastric emptying disorders. cernv v., dostal p., zivny p., zabka l. dept. of anesth. and critical care, charles university, faculty hospital, i-irade~ kralove , czech republic objective: the aim of the study was to evaluate the effect of early entera nutrition started within hours of injury on the incidence of multiple orgar failure (mof) in trauma patients requiring vantilatory support. methods: after institutional approval patients were enrolled in the study enteral feeding was begun within hours of injury in trauma patients (en group) admitted to icu. nasuenteric tube was placed as soon as possible after admission into the distal duodenum under endoscopy. additional parenteral nutrition was used to meet patients energy and protein requirements. the control group (pn) consisted of patients fed during this period paretuerally. severity score apache ii, trauma score, cumulative balance of nitrogen (g), incidence of mof (three and more organs) and length of ventilatury support (days) were calculated. values are expressed as mean + sd. results: tab introduction : parenteral nutrition (pn) is an important aspect in the optimal treatment of patients on gastroenterology or intensive care. the aim of this bi-center study in patients has been to assess tolerence and efficacy of a new protein-lipid mixture for pn from a simple preparation. patients and m~hods : patients were selected in two hospitals (tenon and saint-lazare, paris) and were divided into two groups : group a (gastroenterology~ l short bowel syndrome) and group b (intensive care, surgical patients). all patients likely to require pig for a period of days (group a) or days (group b) were studied. the pn regimens administered were the following : combination with g of mct/lct fat emulsion end , g of nitrogen, in liter end glucose requirements were met by imfizsion of l liter of glucose - % via a "y " connection. lipid thus provided % of the non introgen calories. total daily calorie intake was to ] kced. this study monitored, before and at the end of infusions, the sennn albumin (alb), preaiburtun (prealb), triglycendes (tg), cholesterol (cs), and the serum ammotransferases (sgot and sgpt) end alkaline phosphatase (alp) activities. statistical significances were calculated using the wilcoxon-tost. introduction: many cu patients present a catabolic illness in response to inflammation and infection, characterized by a rapid loss in skeletal-muscle mass despite optimal nutritional support. growth hormone (gh) is responsible for a rise of lipolysis, enhancing the energetic balance, and of protein synthesis. recombinant human gh (rhgh) is nowaday available for clinical use, but its cost is very high. therefore, rhgh should only be prescribed to icu patients when its efficacy can reasonably be anticipated (ie. when the patients are catabolic or stressed, but in order to avoid overprescription for unstressed patients and for those who are overly catabolic). hence, we, as others, recently demonstrated that rhgh had no favorable effect in highly stressed icu patients. objective: to detect on a clinical basis, low (ls), mild (ms) and severe stress (ss) states in icu patients and validate this clinical judgement by objective metabolic mesurements, in order to select early those icu patients potentially able to benefit from rhgh therapy. methods: consecutive icu patients were prospectively stratified as ls, ms and ss by two experienced icu senior consultants (temperature; agitation; heart rate; arterial blood pressure; presence of an infection; respiratory rate; exogenous catecholamines). anabolic (insulin, igf- , gh) and catabolic (cortisol, ghicagon) hormones, and nitrogen balance were determined for each patient within hours after admission in the icu. metabolic and clinical data were then compared. the clinical stress states determined by icu physicians correlate with an objective metabolic assessment. therefore, the patients who will more likely benefit from adjuvant rhgh therapy can be detected simply and early. a prospective study on rhgh therapy in ms icu patients is in progress. berger mm md , chiolero r md , pannatier a phd , berger l , cayeux c , voirol p , hurni m md . surgical icu, pharmacy, and cardiac surgery, chu vaudois, ch-iotl lausanne, switzerland objective. nutrition of the compromised cardiac surgical patient is challenging. numerous factors influence the gastrointestinal (gi) absorption function, among which gut perfusion, which depends largely on the systemic hemodynamic status. patients in hemodynamic failure are prone to organ failure, and may benefit from an early jejunal feeding. the study was designed to assess the absorption function after cardiac surgery in patients with adequate and altered hemodynamic status, using paracetamol as tracer of gi absorption. methods. after cardiac surgery, patients, aged _+ years (mean_+sd) were assigned to groups (anaesthesia: fentanyl gg/kg + midazolam): group (n= ): reference group, with normal hemodynamic status, easy recovery. group ('n= ): patients in low output syndrome, cardiac index < . i/m on day (d ) after surgery, requiring prolonged intensive care, mechanical ventilation + nutritional support. paracetamol g, was given intragastrically on d + d : plasma levels measured (h.p.l.c), at administration (to), t - - - - - and rain. hemodynamic status assessed with pulmonary artery catheter. healthy subjects served as controls. results. compared to healthy controls, absorption was strongly reduced on d in all patients (no difference between groups). on d , peak paracetamol level was significantly lower in group (low cardiac output): in group the area under the curve on d and d were similar. there was a large inter-patient variability, reflecting the hemodynamic status. conclusion. gi absorption was decreased on d in all patients, and reverted to normal between d and d in case of normal cardiac function, but not in case of low output syndrome. the decrease on d can be attributed to fentanyl, known to slow down the gi transit. in patients with cardiac failure, correction of altered absorption was correlated with the hemodynamic status, suggesting that gi absorption is dependent on adequate splanchnic perfusion. the aim of the work was to define specific significance and evaluate efficiency of enteral component of infusion therapy in the intensive care of gastroenterotogic patients of surgical profile with pyo-septic complecations. there were used the methods of radial diagnostics and polyelectrography; the laboratory control on oxygen-transporting function, volumetric and hemodynamic state, changes in metabolic, hormonal and immunologic status was conducted. from january, [ till november, there was carried out the randomized study of patients with general purulent peritonitis; among them persons constituted the control group and -the main one. in the main g~oup the intestinal lavage, enterosorption, enteral introduction of nutrient solutions with gradual turn to enteral nutrition by equalized mixture "ovolaet" were started from the first hours after operation. the data obtained allowed to define the specifity of the program of artificial medical nutrition in the group of examined patients, based on necessity of individual selection of media for enteral introduction depending on the stages of intestinal insufficiency syndrome. it was shown that inclusion of enteral component into the program of infusion therapy during early periods stabilized circulation in the regime of moderate hyperdynamia, considerably decreases the deficiency of circulating blood volume, normalizes the values of oxygen transport, consumption an}d extraction, provides the optimal level of mycardial adaptive possibilities without tension of its compensatory functions and pulmonary circulation overload. due to combined application of parenteral and enteral nutrition the metabolic processes are shifted towards anabolism. this is supported by decrease to normal values in the contents of blood aggresive hormones (acth,hydrocortisone) and increase in somatotrophic hormone. the complete parenteral-andenteral nutrition influences positively on restoration of cellular and tumoral immunity, activates the factors of organism nonspecific protection and recovery from immunodepression, prevents the development of immunodeficiency. impact tm vs control. s atkinson, n maynard, r grover, e sieffert, r mason, m smithies, d bihari departments of surgery and intensive care, guy's hospital, london, u.k objectives: comparison of the effect of an immunonutrient enteral feed versus a control on the outcome of a mixed intensive care unit (icu) population. methods: admissions to this multidisciplinary adu)t icu thought likely to stay more than three days and with tube access to the gi tract ~r randomised to receive either impact tm, a feed with supplemental arginine, dietary nucleotides and omega- fatty acids, or an isocaloric and isonitrogenous control feed. study end points included mortality and icu stay. approval was obtained from the hospital ethics committee. rosults: patients were entered into the trial. the two groups were well matched for age, sex, and admission apache ii with an overall mean admission risk of death of . (std. dev. -+ . ). on an intention to treat basis, there was a no significant difference in icu mortality, icu stay or standardised mortality ratio (s.m.r.) between the two groups (see table) . similarly, there were no differences after stratification for patients receiving or more litres of feed. conclusion: there is no evidence of an effect of impact@, an enteral immunonutrient feed, on pre-determined end-points (icu mortality, icu stay or standardised mortality ratio) in a mixed intensive care unit population over that of an isocaloric, isonitrogenous control feed. objeeflves: evaluate changes of blood laatate levels according to patient medical status after cvvhd initj,~ion using dialysate solution containing lactate. method: review of medioal records of consecutive patients ~eated by cvvhd (dialysate solution hmnosol lg , hospal,uk, lactate concentration retool/l). date obtained hr before and - hrs at~er cvvhd initiation were analysed. results: all data are presented as mean + sem. in one patient, pre end post filter lactate levds were measured during standard cvvhd setting (blood flow ml/mlu, dialysate solution flow i /hr), and approximate daily lactate flux into the patient was calculated to be as high as mmol/d. lactate leveh measured after cvvhd initiation increased significenfly compared to baseline levels ( . + . axtd . + . ,respectively; p< . ,paired t-test). when patiente with increased basal lactete (~- ) were compared to paliente with normal basal values (n= ), no difference in laotete increase was fmmd (p= . , manova). patiente with severe liver dysfunction ( points in mop scomlg, n= ) had higher basal laotate levels than patiente with normal or slightly abnormal liver teste ( or point in mof scoring, n=ll), rite values being . + . and . + . , respectively (p< . , student t-test). increase in blood lactate did not differ between these two groups after cvvhd was stetted (p= . , manova). in pafiente with invasive hemedynamio mo~, no oorrelation batween changes in lactate levels and eitlm" changes in oxygen ddivery (t =o.ol; p--o. ) or oxygen consumption (reversed fie, k) (r -q).o ;p-- . ) were found after cvvhd initiation. conclusion: blood lactate increases on cvvhd with dialysate soh~on rich in lactate. this increase is predominantly caused by influx of lactate into the blood via the filter end does not seem to depend on the liver fimotion and/or oxygen metabolism changes. objectives: the study was designed in order to determine the effect on plasmatic proteins, of two types of aminoacids solutions of parenteral nutrition (pn) adapted to stress, having different concentration of branched chain aminoacids (bcaa), when applying to politraumatized critical patients. methods: a prospective study was performed using a randomized double blind design of polytraumafized patients, split in two groups of ten patients each, with mean ages of _+ an -+ years. due to their condition, all patients required p.n. for at least days. both groups were subjected to isocalorie and isonitrogenous solutions ( ci/kg/ day and . g of nitrogen/ks/day), varying only in the concentration of bcaa; solution a having a % concentration and solution b %. blood samples determinations during days , , , after the beginning of treatment with p.n. were total proteins., albumin, trandferrine, protein binding retinol; prealbumine and fibronectine. the anova test (one and two way) was used to compare the values between the two groups. results: the administration of solution a, showed statistically significant increases in the determinations of the values of protein binding retino] (p < . ) and prealbumin (p < . ). no significant increases were observed in the values of total protein, albumin, transferrine and fibronectin. solution b produced statistically significant increases only in the values of total proteins (p < . ). the remaining proteins did not changed from their control values during the whole period of pn administration. comparing both groups, no statistically significant differences were observed related to the type of diet. nevertheless, differences were found in total proteins, albumin, protein binding retinoi, fibronectin (p< . ) and prealbumin (p < . ) in relation to the time course of pn therapy. only the albumin values showed significant differences (p < . ) when considering the interaction of both the type of diet and the time course of pn. conclusions: . solutions of pn adapted to stress, can maintain the control values of slow turnover proteins and improve the values of rapid turnover proteins. . no significant differences on plasma proteins were found between the two solutions having % or % concentration of branched chain aminoaeids. &determination of rapid turnover proteins does not seems useful for discriminating different solutions of bcaa during pn. obiectives; the hormonal changes in the post-traumatic situation often leads to an elevated blood glucose and a negative nitrogen balance. to reduce the elevated glucose production by aminoacids the apprication of xylitol may be an alternative energy source. in a double-blind randomized study we investigated the effects of a xylitol/glucose solution (group a: aminoacids g/i; glucose/xylito g/ g/l) on metabolism and particularly on pancreatic and liver enzymes compared to a glucose based nutrition solution regimen (group b: aminoacids g/i; glucose g/i). methods: the clinical trial was carried out after the approval by the local ethical committee on patients with severe brain injury. there was no difference in body mass index bmi (group a: . +/- . kg/m and group b: . +/- . kg/m=), age, and sex. daily individual energy expenditure was measured by indirect calorimetry (deltetrac "~). nutrition was started - hours after trauma or surgery with carbohydrates and aminoacids. fat was added h after nutrition had started. to analyze the effects on pancreatic and liver enzymes we investigated the following parameters for days: blood gtucose, serum lipase, serum amylase, asat, alat, ~gt, ap, and serum cholinesterase (che). results: due to the daily indirect calorimetric measurements energy requirements were satisfied. there was no difference in blood glucose concentration and cumulative nitrogen balance between the two groups. neither were there any significant changes in asat, alat, ap, and che for days in both groups. serum tipase steadily rose to lull in group a and . lull in group b, respectively. conclusions: there was no measurable influence of either nutrition solution on liver enzymes. the xylitol/glucose nutrition regimen does not have any advantage over the glucose based nutrition solution concerning blood glucose level or nitrogen balance. the elevation of serum lipase to a -fold level in either group needs further investigation on trauma patients. the effects of fat emulsions in lung function, particularly in lungdamaged patients, have been attributed to alterations in pulmonary vascular tone caused by eicosanoid production modificatione. as the eicosanoid production may depend on the fatty acid profiles of the intravenous fat emulsion, haemodynamic, pulmonary gas exchange and plasma levels of prostanoids were investigated in acute respiratory distress syndrome (ards) patients, during different intravenous lipid emulsions (providing different prostanoid precursors). we studied in a randomized double-blind design groups (n= each) with ards. group i (lct) received a fat emulsion with long chain triglycerids (lct- %), group ii (mct) an emulsion containing a mixture of medium and long chain triglycerids (mct/lct / - %) and group iii placebo (control), during h ( mg/kg/min each). we measured before, at the end of h infusion, and h after the end of the infusion: lipaemia, arterial and venous blood gases, pulmonary and systemic haemodynamics, and plasmatic levels (arterial and in mixed venous sample) of eicosanoids (txb=, -keto pgf~,, and ltb ). at the end of the fat emulsion, groups (i and il) to , • to , • mmol/i), the paoz/fio z remained unchanged in the three groups; no changes in intrapulmonary shunt (qs/qt) were shown; neither in the mean pulmonary artery pressure. in contrast, only in the lct group: cardiac output and oxygen consumption increased significantly ( . % and %) (p< . ). eicosanoids were increased at baseline compared to reference values (p< , ). a decrease (p<o, l in the arterio-venous difference of the vasodilatador prostanoid ( -keto pgf~=) was shown in lct group. our results indicate that fat emulsions in ards patient do not influence pulmonary gas exchange, provided that the perfusion rate were keept at mg/kg/min. the present study was designed to evaluate the metabolic changes of a carbohydrate-based diet versus a fat-based diet on oxidation rate of substrates and energy muscle metabolism in patients with an acute exacerbation of chronic obstructive lung disease. patients were mechanically ventilated with a volume-cycled respirator. after an overnight fast, patients were randomnly treated with a continuous enteral feeding over a nasogastrie tube with a carbohydrate/fat ratio of / in group i (n= ) , and a carbohydrate/fat ratio of / in group i] (n = ) during consecutive days. indirect calorimetry was set at baseline and hours later the enteral feeding was started. muscular quadriceps biopsy was performed on baseline and on day of enteral feeding. urine was collected during hours and was used to measure h urea nitrogen production. the caloric intake was set according to the measured resting energy expenditure. respiratory gas exchange rate were measured using a computerized open-circuit indirect calorimeter. quadficeps femoral muscle samples were obtained by muscular biopsy after local anesthesia. analyses of glycogen, glucose -phosphate, lactate, phosphocreatine and adenosine triphosphate (atp) and enzymes (glycogen synthase and glycogen phosphorylase) were determined. after h of nutrition patients in group i showed an increase in carbohydrate oxidation (from . % to . %, p= . ), and in group ii a decrease in protein oxidation (from % to %, p= . ). after days of enteral feeding a tendency to increase in glycogen concentration (group i, p= . ; and group ii,p= . ) was observed. while patients in group i showed a tendency (p= . ) to decrease glycogen phosphorylase, patients in group ii maintained these enzymatic levels. the increased in glycogen was correlated in group li with degradation enzyme (p = . ). in group i, the pao /fio ratio increased after days of treatment (from . to . ; p= . ), but no changes in days of mechanically ventilation, length of stay in icu, or mortality rate was evidenced between groups. it is concluded that the oxidation rate of substrates used for energy production varies according to the caloric sources administered. with nutritional therapy muscle glycogen concentration increases in both diets, with different enzymatic influence. more studies are warranted to further assess the clinical implications of the different pathophysiologic behavior of the two diets. under certain experimental and human conditions (radiation and/or thermal injury) the gi mucosa is unable to perform this protective function and could play an important role in the pathophysiology of the syndrome of multiple organ failure (smof). the objective of the present multicenter study was to know the gi mucosal permeability in critically ill patients and the relationship with their outcome. the method used to assess the integrity of the gi mucosal barrier measured mucosal permeability to various hydrophilic compounds. specifically, we measured the urinary excretion ratio (uer) of two sugars (lactulose and mannitol) that had been previously administered through a nasogastric tube. urinary excretion rate was measured in healthy humans (control) and in patients admitted to the intensive care unit (icu) at days , and . the apache ii of the patients studied was _+ . there was an increase of uer in the critically ill patients compared with controls (o. _+ . vs . _+ . ) (p< . ). in contrast, no changes in uer between days , and were observed ( . -+ . . significant changes were also established in the different groups: major and minor surgery, general and epidural anaesthesia , transfused and non transfused patients except for iron and ferritin plasma levels which didn't change significantly in patients who had received blood. a positive significant correlation was established between crp and ferritin (r= . ) for patients under general anaesthesia, but not on epidural, regardless of the type of surgery. conclusions: iron and transferrin plasma levels fell acutely in surgical patients while ferritin and crp rose. transfusion implied an acute iron load.the established correlation between cpr and ferritin in patients on general anaesthesia suggests that ferritin behave as an acute phase reactant in that setting, while epidural anaesthesia may ameliorate the inflammatory response. objectives: to analize the effect of gastrointestinal complicacions (gic) related to the enteral nutrition (en) in the real volume of diet administered to icu adult patients. a prospective multicenter study was designed (comgine study) in wich en application, gic definition and his management were defined by collaborative consensus.patients treated with en in one month pedod were included. in each case, daily volume of diet prescribed (pv) and administered (av) was recorded and the volume ratio calculated (vr=pvxl /av). patients were divided for days of en according to the presence (group ) or absence (group ) of gic (abdominal distension, increase of gastdc residuals,vomits or regurgitation, diarrhea,constipation and bronchoaspiration). differences between groups were analized by anova and mann-whitney u test with p< . for statistical significance. (vr%) group (vr%) tolerance to the enteral nutrition (en) has been related to the severity of illness in icu patients. the aim of this study was to evaluate this relationship. methods. a prospective, multicenter, study was performed (comgine study) in wich en application and related gastrointestinal complications (gic) were defined by collaborative consensus. adult icu patients treated with en in one month pedod were included. gic were classified as: ) abdominal distension (abd), ) increase of gastdc residuals (igr), ) vomits (vom), ) diet regurgitation (reg), ) diarrhea (dia) and ) constipation (con). patients were divided in two groups: group a: patients with gic dudng their evolution. group b: patients without gic. differences between groups were analized for apache ii admission score or evolutive variables ( carbon dioxide production is a major determent of work of breathing. increase in co production during nutritional support may precipitate ventilatory failure and difficulty in weaning from mechanical ventilation. in the present study, co output was calculated while passive mechanically ventilated patient were fed with different amount of calories and different proportion of protein, carbohydrate and fat. four clinical stable and mechanically ventilated patients were studied. carbon dioxide was calculated while patients were paralyzed, sedated and mechanically ventilated. six nutritional regimens were used: a) no calories, b) t gr glucose/ h, c) calories equal to rest energy expenditure in special formula with low carbohydrates and high fat (pulmocare) d) calories equal to rest energy expenditure in standard formula (nutdson) e) calories double to rest energy expenditure in standard formula (nutrison) and f) calories equal to rest energy expenditure parenterel (tpn). carbon dioxide output was low while no calories and/or only gr/ h glucose was provided, the mean values of vco output were _+_ and !-_ ml/min respectively. there was no difference in vco output between with low carbohydrates and high fat regimen and standard regimen, mean values were t . -+ and _+ respectively.the high calories regimen and tpn resulted in higher vco output, mean values _+ and • respectively. we conclude that the special with low carbohydrates and high fat regimen did not reduce vco output, in the contrary, high calories intake as well as tpn increased vco output under tested conditions. klouche k., cristol j.p., vela c., canaud b., b raud j.j. m tabolic intensive care unit and nephrology department. lapeyronie hospital. montpeuier france. predictive factors for rhabdomyolysis (rh) -induced acute renal failure (arf) were studied in a retrospective study from january to january . patients (pts) (male: , female:lo; mean age: + y.o.) were admitted with rh defined as cpk> iu/ . etiologies were: traumatic and ischaemic , infectious , toxic , excess activity . factors studied were: simplified acute physiologic score (saps: . + . ), organ systemic failure (osf: . _-!- . ), diagnosis delay (d: +_ h), clinical parameters (sepsis, dehydration), blood chemistry data (cpk, bun, creatinine, potassium, phosphorus, calcium, proteins, hematocrit) and urinary ph. severity of rh was estimated by ward score determined according to phosphorus, albumin, potassium, cpk, dehydration and sepsis. urea appearance rate (uar) and creatinine index (ci*) were determined over a hours period. arf was observed in pts. in non-arf and arf groups respectively, saps ( . _+ . vs . + . ), deshydratation ( vs ), sepsis ( vs ), phosphorus ( . + . vs . -+ . ), calcium ( . + . vs . _+ . ), ward score ( _+ . vs . + . ) were significantly different. however, no significance was observed in uar ( -+ vs -+ ) and ci ( _+ vs _+ ). patients required hemodialysis (hd) ( : sessions) and remained dialysis free. only osf ( . _+ . vs . -+ . ), ward score ( . _-/- . vs . _+ . ) and ci ( +_ vs -+ ) appeared significantly higher in pts requiring hd. pts died from associated disease. all patients suffering from arf recovered a normal renal function. we confwmed that an elevated ward score (over ) is a good predictive index of arf. in addition we found that ci is a severity factor for arf requiring hd. thus, patients suffering for rh with elevated ward score and ci, have a fair chance of dialysis and should be treated more intensively. * ci (expressed in mg/kg) = (car + feces creatinine) / weight. where car: creatinine appearance rate; feces cr~t..= mean plasmatic creatinine x . . tr~er k., cetin t.e., tugtekin i., georgieff m., ensinger h. universit~tsklinik flir an~sthesiologie, uim, germany introduction: endogenous as well as exogenous adrenergic agonists have a profound effect on carbohydrate metabolism in human critical illness. in this study the effects of noradrenaline (nor) and dobutamine (dob) on carbohydrate metabolism during a hr infusion were investigated. methods: after approval by the local ethic committee healthy volunteers were studied. hepatic glucose production (hgp [mg/kg/min]), using , -d glucose as stable isotope tracer, as well as plasma concentrations of glucose (glc [mmol/i]) and lactate (lac [mmol/i]) were measured prior and during infusion of nor ( . pg/kg/min) and dob ( pg/kg/min). blood samples were drawn before and during the agonist infusion. results: no major changes in insulin and gtucagon plasma concentrations could be found during the study period. ::i:::: :iiiii~ ~ i ::i: ~:: : :: i:ii. mean-+sd are shown. # p< . , anova for repeated measurments. conclusions: the effect of nor on hgp and glc were smaller as compared to adrenaline (i) with a similar time course. in contrast to the effects of adrenaline and nor, dob had a different effect on carbohydrate metabolism: a decrease in hcp and glc, which is uncommon for a / -adrenoceptor agonist. since hgp is an energy consuming process that might deteriorate hepatic oxygen balance in critical illness, the differential effects of adrenergic agonists may be of importance and need further clarification. the nutritional insufficiency often accompanies post-operative hypercaloric states, inanition, serious infections and weakening chronic illnesses. that is why the early nutritional support, sufficient and appropriate for each individual base, is a fundamental component of intensive care unit as an indispensable factor for recovery. per this reason, our unit, developed a software for the implementation and nutritional control of t~e assisted patients. this software is incorporated is an expert system called ~i~su, designed and developed by the computational division of our unit. this system arrives to inferred diagnoses such as : respiratory, hepatic, renal(with and without dialysis) dysfunctions, pancreatitis, ards, decrease of consciousness, diabetes. according to these data objectives: to compare the effect of short term enteral feeding versus parenteral nutrition, when a isonitrogenous and isocaloric feeding solution is administered by either mute. methods: in a prospective controlled clinical trial patients were studied; all exhibited moderate degree of malnutrition, normal liver and kidneys, and a functi ning gastrointestinal tract. the patients were randomized to receive a free amino acid and small peptide diet ( patients) or an isonitrogenous isocaloric parenteral support (tpn) ( patients) (total energy: kcal, nitrogen: . g, carbohydrates: g, fat: g, n/non protein calories: / ) at least for days. results: there were no significant changes in anthropometric parameters within either group. nitrogen equilibrium was aqhieved by day in the tpn group and by day in the enteral group ( . % of the enterally fed patients and % of the tpn patients maintained in positive balance the day of the study). there were no significant changes in serum albumin within either group. serum level of transferrin reached a significant increase in both groups (p= . ). thyroxine-binding prealbnmin rose significantly in both groups as well (p= . and . respectively). statistically significant rises in lymphocyte counts (p= . and . respectively), in levels of c (p= . and . ) respectively), iga (p= . ), igg (p= . and . respectively) and igm (p= . ) occurred in either treatment group. there was a high incidence of negative skin tests at the start of the study in the enteral group ( . %) and the tpn group ( %). by the end of the study the incidence of negative responsiveness was . % and . % respectively. despite maintenance of similar glucose levels in both groups, tpn led to significantly higher serum insulin levels. the serum insulin increased almost linearly over the study period and eventually prevented fat mobilization and lipolysis, so that free fatty acid levels had fallen significantly. a significant elevation of the liver enzymes over the study period occurred in . % of the tpn group, but not in the enterany fed patients. conclusions: the present findings provide no evidence that enteral diets containing free amino acids and small peptides, as their nitrogen sources, are in any way inferior to isonitrogenous isoealoric regimes parenterally given. aim: the aim of this study is to describe and explore the expectations of the functions of the critical care nurse to enable the formulation of guidelines for the scope of practice for the critical care nurse with a south african context, methods: phase i was to determine the expectations of the critical care nurse, the nursing service managers and the doctors with regard to the functions of the critical care nurse. a focus group interview was held with a group of experts in the field of critical care. the results were used to compile a questionnaire. this questionnaire was sent to the critical care nurses, the nursing service managers and the doctors in south africa for completion. from these results the functions of the critical care nurse were determined. phase ii was to formulate guidelines for the scope of practice for the critical care nurse within a south african context. through usage of the date (phase i) the scope of practice was formulated. guidelines were formulated for the practise, education and research regarding the limitations of the professional-ethical authoration and the implementation of the scope of practice for the critical care nurse. objectives : high output gastric aspirates arc occasionally observed during fasting in critically ill paticnts, preventing any attempt of feeding via the enteral route. although these patients are often said to suffer from "gastroparesia", the motor correlates of this condition arc lurgcly unknown. in this stud?', wc recorded the gastrointestinal motility of critically ill patients with abundant (> ml/ hours) fasting gastric aspirates. methods : antral ( sites separated each other from . cm), duodenal ( site) and jejunal ( site) contractions were recorded simultaneously by ~eans of a multihimen tube assembly positioned trader fluoroscopic control (perfused catheter technique). tracings from prolonged recordings were obtained on a multichannel recorder ( a recorder, hewlett-packard) then anal) ,ed visually, with a special attention for the following abnormalities which are characteristic of intcstinal pseudoobstmctiou: l) absence or aberrant propagation of the migrating motor complex (mmc), ) presence of bursts (> min) of nonpropagated phasic pressure and ) presence of sustained (> min) uncnardinate pressure activity. patients with a volume of gastric aspirates of • (sd) [median ml/ hrs were investigated for - [median minutes. results : only one patient had no detectable motor abnormality. mmcs were either absent (n= ) or migrated abnormally (retrograde propagation : n= ; retrograde and stationnary : n= ) in pts. bursts of nonpropagated phasic pressure activity were present in the duodenum in pts and sustained uncoordinate pressure activity was found in pts. additional abnormalities included episodes of prominent pyloric activity. (n=l) and sustained antral pressure activity (n= }. conclusion : critically ill patients with large volume of gastric aspirates have manometric evidence of intestinal pseudoobstruction. prokinetic therapy in these patients should thus focus not only on enhancing gastric motility, but also on restoring a normal propagative contractile activity in the intestine. this prospective, open-label, randomized placebo-controlled study included patients with hypokalemia in whom rapid potassium replacement ( meq kci in h) was performed: patients received mg sulfate ( g in hours) and patients received a corresponding saline infusion. measurements were made at time , + , + and + hours results: k levels increased more in mg treated patients than in the patients who received saline infusion at time and h (p < . -students-newman-keuls). (table ). introduction. dual lumen uaso-gastrojcjunal tubes are a major ads'ance in nutritional therapy of mechanically ventilated critically ill patients since the " authorizc jejunal feeding with concurrent gastric decompression, there,, reducing the risk for aspiration. unfortunately, placcmem of these tubes in the jejunum regularly dictates to resort to endoscopy in order to facilitate pyloric intubation. recently, the remarkable gastrokinetic properties of the well known macrolide antibiotic er}lhromycin have been demonstrated in gastroparetic critically ill patients . aim. in the presem stu~,, we evaluated the feasibility of placing dual lumen naso-gastrojcjunal feeding tubes at the bedside without endoscopy, using edthromycin to help iranspy'loric migration of the tube under fluoroscopic control. methnd each patient admitted in our icu during a months period and requiring artificial ventilation and enteral nutrition for a period of at least days was included in the study.. after inserting the tube (stayput| sandoz, usa) in the gastric anmnn, e.rythromycin ( rag) was aduunistored intravenously, to help fluoroscopic positioning of the tube into the jejunum. the total duration of the procedure (from nasal intabatiun to jejunal placement), as well as the duration of ftuoroscopy were recorded in each patient. results. patients (male/female : / : mean age : . + . years; mean apacbell score : .t • . ) wore enrolled into the study.the procedure was performed within the dab,s following institution of mechanical ventilation. jejunal access was obtained in all patients without resort to enduscopy in , • . min.(total duration of the procedure). mean duration of fluoroscopy was . + . rain. conclusion. we conclude that placement of dual lmnen naso-gastrojejunal tubes can be obtained in mechanically ventilated critically ill patients without resort to endoscopy., provided that e rythromycin is used as gastrokinetic agent to help pyloric intubation. the following ad and dis parameters were considered in all patients: -mid arm circumference, triceps skinfold thickness, serum transferrin, albumine and lymphoeites and urinary creatinine/height index. patients whose results were bellow % of normal values in or more of the above criteria were considered undernourished (und).statistical analysis was performed using % analysis.statistical significance was established at p<o.o . results: a total of patients( female, male) -with a mortality rate (~) of , % -were studied, aged -+ years and a median ]enght of stay of days. -nourished (nou) at ad and at dis - ; ~ %; -nou at ad and und at dis - ; ) , % ; -und at ad and und at dis - ; ~ . %; -und at ad and nou at dis - ; ~ , %. we observed a p< . when we compared groups and (p= . ), and groups and (p= . ). variation in nutritional status and longht of stay: -nou at ad and nou at dis = > median lenght of stay days; und at ad and und at dis = > median lengbt of stay days; nutritional status and age at admission: -age > = years : nou ( ) , und ( ) -age < years: nou ( ), und ( ) nutritional status and age at discharge: -age > = years : nou ( ) , und ( ) -age < years: nou ( ), und ( ) we observed a p<o. when we compared groups and (p=o. ) and groups and (p = . ) conclusion: such study permits to conclude that most of our patients ( . %), staying in icu for more than days, were und, namely the elder. we observed that this kind ef patient had a longer median length of stay in icu, associated with higher mortality rate. in conclusion, the nutritional management is an essential element in suportive care of critical)y ill patients. ohiectives: sirs is associated with hypercataholisnl and resistance to nutritional support, despite raised circu&ting levels of growth hormone and insulin. serum igf- levels however are low; thercti~re rhigf-i administration might produce nsefnl anabolic effects. the pharmacokinetics of exogenously administration rhlge-i in such patients are likely to differ from that seen in the less seriously ill due to changes in circulating blood volume, increased capillary permeability, poor nutritional stares, and alterations in binding proteins. the ol jective of this study was to determine the clearance, apparent vohnne (if distribution (vd), time to peak concentration (tmax) and elimination half-like (tia) of a single subctkaneous il~ieetion of rhlgf-i in patients with sirs on the intensive care unit (icu). methods: icu patients with sirs were entered into the study, which had been approved by the ethics comjnittee. in each patient baseline hlood samples for circulating gf-i were obtained over a hour period, prior to il!iection of p.g/kg of rhlgf- subcutaneously. a further l samples were taken fi'om each subject over the next hours. circulating ige-i was measured in serum at each time point by radioimmtme assay, and the area under the curve tbllowing administration of rhlgf-i was derived tbr individual patients fixm~ baseline a~!justed igf-i levels. clearance values were caietdated by dividing the administered dose of rh[ge-[ by the total area under the etnve. vd and tv were calculated by regression analysis of the terminal part nf the log sertnn concentration time profiles. results: results are expressed as median (range). age ( - ) years, apache ii score ( - ), and length of icu stay ( - ) days. baseiine circulating igf- levels were low ( < - ) ng/ml reaching a peak of only ( < - ) ng/ml. of the patients had basal levels predmnhaantly below the inwel-limit of detection of the assay, and showed no appreciable rise in serum igf-[ levels tbllowing rhigf-i injection. parmacokinetic variables could not therefi)re be determined in these two patients. following rhlgf-i injection in the remaining patients tmax was at ( - ) hours, clearance was ( - ) ml/min, vd was . ( . - . ) l/kg, and tia . ( . - . ) honrs. conchlsions: there was marked patient wu-iability in response to rhlgf-i administration. vd was similar to that seen in poshq~erative maior surgery patients ( . vs . l/kg), but clearance was greater ( vs ml/min), tmax earlier ( vs hours) and t~a shorter ( . vs i . homts). if riaigp-i is to be administered to dtically ill patients the dose should he nlodified m the light of these findings. baekgronnd: acute bacterial endoearditis continues to be a condition with high morbidity and mortality. the majority of patients are treated with high dose antibiotics, but a patient group requires surgical treatment. methods and results: from january to march , patients underwent surgery for acute bacterial endocarditis: had native valve endocarditis and had prosthetic valve endocarditis. there were men and women. streptococcus viridans was the predominant infecting agent in native ~alve endocarditis and staphylococcus epidermidis in prosthetic valve endocarditis. progressive congestive failure, uncontrolled sepsis and peripheral emboli were the most common indication for surgery. although the mitral valve is more commonly involved in acute bacterial endocarditis, the aortic valve most often requires surgical inlervetion. the postoperative bleeding in the no-aprotinin group was + cc and in the aprotinin was :t: (p < , ). the mortality in icu was , %, the staphyloccocical endoearditis mortality was , % and the no-staphyloccocical endocarditis mortality was , % (p< , ). conclusions: the early surgery is indicated if endocarditis has no response with medical treatment. the mortality of staphyloceocical endoearditis involving left valves was higher than caused by other infecting agents. aprotinin treatment improved prosta#andin metabolism and preserved pletelet function during open heart surgery and could be useful in this type of interventions. urgent surgery had a high mortality ( %). selective digestive decontamination (sdd) has increasingly become the subject of critical discussion sine~ the development of multiresistant organisms has become an issue. moreover, a selection of gram-positive pathogens must also be taken into account when using the sdd regimen, which is primarily directed at the gramnegative bacterial specumn, with the methicillin-resistant staphylococcus aureus strains (mrsa) being of particular importance. the objective of our study was to determine the extent to which colonization with mrsa strains is promoted by sdd. method: patients (ventilation period > days) were randomized and allocated to the sdd group (n= ) or the control group (n= ). in their general intensive care theraw, there were no differences between the groups. the sdd regimen consisted of the four times daily administration of rag polymi~ mg tobramycin and mg amphotericin b in the nesc, mnoth and stomach. systemic prophylactic ~dmini~/rution of antibiotics was not part of the sdd regimen. smears were taken from the nose and the rectum twice wceldy and from the pharynx and trachea once wceldy, and tested for mrsa. further samples were taken as clinically reqnircr results: smears were examined in the sdd group. mrsa strains were detected in samples ( . %) from patients, and in patients they were detected for a period of up to weeks. the positive smears were districted as follows: tracheal / ( . %), nasal / ( . %), pharyngeal / ( . %) and rectal ( . %). severe mrsa-induced infections were observed in patients (infection rate . % of the colonized sdd patients). smears were examined in the control group. ivlrsa swains were r in samples ( . %) from patients, but only repeatedly over a period of up to days in patients. the po~tive snmars were distributed as follows: traclmal / ( . %), nasal / ( . %), pharyngeal / ( . %) and rectal / ( . %). there were no mrsa infections in the control group. conclusion: the data collected support the view that the use of sdd promotes a selection and persistence of mrsa strains. longer-term colonization with mrsa and sovere systemic inf~ons were only found in the sdd group. although the clinical and epidemiological impact of resistance develol~ng when sdd is applied ~maine unclear, this question should be given close scrutiny. tazobactam/piperacillin (taz/p p) is a new broad spectrum antibiotic, in which the acylaminopenicillin piperaeillin is protected by the betatactamase inhibitor tazobactam from hydrolization by bacterial enzymes. taz/pip has shown to possess a high antibacterial activity against almost all clinically relevant bacteria and is a registered drug in germany. obiectives: purpose of this investigation was to evaluate, whether faz/pip . g is suited for efficient antibacterial monotherapy of severe infections and what influence dosage frequency reveals on clinical efficacy. methods: hospitalized patients have been documented in this multicenter trial during a year period. as this investigation should reflect the usual clinical treatment, the only criteria for enrolment were the typical signs of infection as e.g. temperature > ~ leucocytosis or an isolated pathogen. exclusion criteria did not exist and the patients were treated in accordance to the severeness of infection, underlying diseases, risk factors etc. with taz/pip . g t.i.d, or b.i.d. results: patients suffered in most cases from infections of the lower respiratory tract (n= ), followed by intraabdominal (n= ) and skin and soft tissue infections (n= ). % of the lrtis wvre nosocomial acquired and in % the treatment was conducted as monotherapy. in % the lrti was treated with taz/pip b.i.d, and in % t.i.d. pseudomonas spp. (n= ) and staph..aureus (n= ) were the most isolated pathogens pretrcatment. the clinical response rates (cured/improved) after treatment with taz/pip . g b.i.d, and t.i.d, were % and % respectively. results for intraabdominal-and skin and soft tissue infections will be presented. conclusions: in hospitalized patients with severe infections successful treatment with taz/pip in monotherapy is possible. in this population a reduction of the dosage frequency to . g b.i.d, revealed equivalent clinical response rates. objectives. retrospective evaluation of cases of severe generalized tetanus (sgt), treated in our icu the last years. we review cases of sgt ( m, f), mean age . years. in eases the entry site of c.tetanus was a skin laceration, in case it proved to be the external genitalia, while in the rest no portal of entry could be determined. in the first cases incubation period was short ( - days) and so was the period of onset ( - days). all patients needed mechanical ventilation (range - days), initally through an orotracheal tube,and later through a tracheostomy, performed • days after admission. clinical manifestations of sgt included muscle rigidity and i generalized spasms, persisting for up to weeks in the most severe cases. significant autonomic nervous system dysfunction was present in cases occurring - days after the admission and following the time course of generalized spasm. besides general supportive measures, specific treatment included passive +active immunization, penicillin g, magnesium sulphate and sedation in a variety of regimens. neuromuscular blockade was required in cases. nosocomial infections occurred in eases, with sepsis and mof in one. average stay in the icu was - days. one patient died with severe septic complications and one was discharged with severe disability due to anoxaemie ancephalopathy, after a cardiac arrest on admission. ~ disinfectant in suspension test, without presence of organic load, disinfectants showed efficacy on lm. in the carrier test, in the presence of organic load, out of examined disinfectants did not exposed efficacy on lm. the results of examinations clearly showed that evaluation of disinfectant's efficacy partly depend on the used test method. antun basi , intensive care unit, kb firule split spin~ideva ! jugoslavia bacteremia and sepsis are frequent complications encouuntered in severe icu patients.microorganism identification with hemoculture presents the basis for adequate and successful antibiotic treatment.in many patients damage and vulnerability of the peripheral veins presents an obstacle for obtaining the blood culture from the central venous (cv) catheter sample could be also used. material and methods blood cultures were perfomed in lo patients on blood samples simultaneously obtained from the peripheral vein and cv catheter three times in a -hour period.criteria for the suspected bacteremia were body temperature above c and leucocytosis above ioooo leucocytes/dl. the site for venipuncture and the cv catheter stopcock port were cleansed with povidon iodine.after the initial ml of blood were discarded,lo ml were used for the blood culture.standard laboratory technique for blood cultures was used. results and discussion in ( %) patients hemocultures was negative at both sites,whereas in the remaining ( %) they were positive.for twentyone ( ~ of the positive patients the same results were obtained at both sites (peripheral vein and cv catheter),whereas in ( . %) patients the blood culture were positive only for the cv catheter samples.the cv catheters were in place for less than days in patients and for more than days in patients.from patients with positive blood culture from the cv catheter,one patient had the catheter for three days,whereas the other had the catheter from - o days. we neither found significant differences in hemodynamic dates : objectives: , to count and evaluate bacteria isolated from endotracheal (et) suctiori samples (with and without saline). . to establish the exogenous source(s) of pathogens isolated from carer's hands and the equipment involved in sampling in order to reduce the incidence of contamination and infection. method~: this prospective study included consecutive ventilated patients ( male and female, _ + yr; apache ii score -+ ) over a period of months. et aspirated samples with and without saline were taken daily from day of intubation until pathogen~ were presented in counts of _> per ml. at the same time, samples from both carer's hands were taken before and after et suction and a swab from the ventilator tube. results: the overall length of intubation varied between to days. bacterial transfer between staff and patients was noted in % of patients until day of intubation. there was no significant correlation between severity score and appearance of colonization. the incidence of pneumonia in studied patients was % with an overall mortality rate of %. acinetobacter anitratas (no ), staphylococcus aureus (no. ), klebsiella pna~moniae (no. ) and pscudomonas aeruginosa (no. ) isolates predominated in all our specimens. we noticed increased resistance to most antibiotics with the exception of imipenem for gram (-) bacteria and vancornycin for gram (+) bacteria. conclusions: i. tracheobronchial colonization appears directly in the maiority of intubated patients. . there is a close relationship between the microflora of personnel, patients and equipment. . bacteria transfer was noted both to and from patients. . strict hand disinfection policy remains an important measure for the proper care of mechanically ventilated patients to reduce respiratory infections. nnseeomial pneumonia is the most common nnsocomiai infection in the icu-settiag, reported in up to % of patients admitted to the icu following surgery. it is associated with significant mortality that ranges from ~ to %. enteric gram-negative bacilli have been implicated in % to % of ventilntor-associated pneumonias and pseudomonas aeruginosa accounts for % to % of these pneumonias. importantly, epidemics of/ - actamnse-pruducing enterobacter spp or klebsiella spp that are resistant to extended spectrum cephalosporins or penicillins, pose serious obstacles to effective antibiotic choices. carbapenems provide in ~tro activity against a wide range of enterobacteriaceaeand other gramnegative aerobic bacteria, except steaotrophomonns maltophilia. in vitro meropcnem is more active against pseudomonas spp than imipanem (especially p. aeruginosa and p. cepacia), imipenem and meropenem are effective against more than % of strains responsible for nnsocomial infections. all major pathogens associated with lrti are usually covered by the carbapenems, exceptions are pathogens involved in so-called atypical pneuomouia like mycoplasma, chlamydia and legionella. carbapenems are highly stable in the presence of most chromsomal and plasmid-mediated blactumases and usually offer a postantibiotie effect lasting for three hours against most of the enterubacteriaceae. reeent studies comparing imipenem/cilastatin with other ~-lactams and fluoroquinolones in severe lrti in icu patients resulted in favourable clinical cure rates and good tolerance, but development of resistance in p. aeruginosa and ;. aureus during treatment were of some concern. meropenem offers the advantage of greater stability against enzymatic degradation, so no concomitant administration of an enzyme inhibitor is necessary, and meropenem appears to be associated with a lower risk of seizures, particularly when used at high doses. results from studies with meropenem in lrti, especially in critically ill patients with acute exacerbations of chronic bronchitis, demonstrated excellent cure rates and better gastrointestinal tolerance of this new carbapenem. both earbapenems are effective candidates for use as empiric monotherapy in nosucominl infections of critically ill patients. qbl~ctives a favourable effect of iv immunoglobulins in septic surgical patients has been reported, but not sufficiently validated. we conducted this study on trauma patients to: i) investigate the effect of ivig on septic complications and il) quantify this effect by means of serum bactericidai activity (sba) assessment and iii) to explore the effect of temperature increase (from to ~ c) on the sba methods: twenty trauma patierits matched on admission for age, sex, inju~ severity score and glasgow coma scale, were allocated to receive either wig (ivig group; i patients) or equal volumes of human albumin % (control group; patients). wig (sandoglobulin) was administered in a total dose of g/kg divided in a four time regimen on days , , and post-admission. three blood collections were performe& before the first dose (day ) and hours after the third and the fourth dose (days and respectively). complement, lgg fractions, the sba at ~ and at o c and clinical parameters were recorded. results-similar lgg and igg] serum levels were found in groups ivig and control on day ( +_ vs • ns and + vs + , ns), whereas they were significantly higher (p< ) in the v g group on days ( _+_ vs + , p< ) and ( _+ vs +i , p< . ). the various complement-fractions increased in both groups without inter-group differences the mean (• sbas ( ~ c) at rain in ivig group vs control group were: - _+ vs - • ns for day , _+ vs - _+ p< for day and _+ vs - + p< for day . the mean (+sd) sbas ( ~ c) at rain presented a significant improvement over those of ~ c but for the control group remained negative a~d were respectively as following: -~ • vs - + , ns for day , +_ vs - _+ , p< . for day and _+ vs - _+ , p< . for day . the increase of temperature induced a -fold improvement of sba in iv g group and -fold ofcontrol-~oup positive blood cultures, and the product of the infectious episodes number multiplied by days of occurence, were significantly lower (p< ) in the ivig group than in the control ( vs , and vs , respectively). conclusions: our study shows a significantly favourable effect of ivig administration on septic complications and on sba of trauma patients. the increase of temperature results in a significant improvement of sba of patients that received ivig, which theoretically means a farther prevention of infection in the febrile state. pharmaceutical microbiology, university of bonn, meckanheimer aune , d- bonn, germany infectious diseases in intensive care patients are common in comparison to patients on other wards and out-patients. the main difference is that intensive care patients are much more sensitive even to less virulent bacteria. thus, the spectrum of infecting organisms is different. strains often regarded as pathogens with low virulence cause serious infections in these patients. strains such as serratia, however, have intrinsic resistance to most commonly used agents such as rd generation eephalosporins. furthermore, the common pathogens like staphylococci, psoudomonas aeruginosu, enterocneei and gram-negative bacteria, enterobacteriaeceae as well as the non-fermenters are less sensitive if isolated from intensive care patients. it is difficult to generalize on intensive care units as different patient groups are in different icus aud there are great changes from one hospital to another and from one country to another. if we take s. aurens strains from one study from the'overall resistance in intensive care units towards oftoxacin was %, whereas in other hospital wards the percentage of resistance was . %, in out-patients, however, only .$ %. the same trend was true for entercnecus faecnlis, coagulase-negntive staphylococci, and other bacteria as well as other drugs. one most striking difference was found with klebsialla pneumoniae and gantamycin resistance, which was $ times higher in intensive care units as compared with outpatients, whereas in the same species no difference was to be seen with the resistance towards carbapenems. however, differences between countries seem to be even more striking, as example gantamycin resistance and staph. anrens is given. the extreme difference is more than fold. thus, it is evident that there is a general trend towards higher resistance in intensive care units, but no generalizatiouis possible. therefore, surveillance studies in intensive care units are needed and the antibiotic policy has to be adapted to the specific needs of the unit. in the icu setting the most potent antimicrobial agents are required to address problem organisms including those resistant to penicillins, cephalosporins and aminoglycosides. carbapanems would appear to present a useful option in this setting. objectives of this study was the evaluation of systemic candid• in postoperative cardiac surgery patients (pts) with prolonged icu stay. methods: out of postoperative adults pts of mean age . + . years old, with a mean icu stay of . _+ . days, following an open heart surgery from july to april , pts ( %) remained in icu for more than days because of severe perioperative complications. patients were included in the protocol if they had clinical signs of infection or sepsis, and fungi isolated in blood culture or in culture from at least three different sites. the patients who developed systemic candidiasis received iv fluconazole ( mg/day) ( patients) or amphotericin-b for at least four weeks, and then they were closely monitored. results: out of postoperative pts with prolonged jcu stay, pts ( . %) developed systemic candid• usually after the th postoperative day. they were males and females of mean age +_ . years old. this group of pts had prolonged bypass and aortic cross-clamp time compared to control group ( min vs , and vs min). all these pts received inotropes per• (mean value= . ). during their icu stay, pts developed sepsis of bacterial origin, while the other two severe infection, and received antibiotic regimens for prolonged period. the patients were submitted to mechanical ventilation for a median period of days. the median icu and hospital stay was and days respectively. all pts have been improved and finally negative cultures were obtained. conclusions: . a significant percentage of patients who remained in the postoperative icu for more than days developed systemic candidiasis. . all patients who developed systemic candidiasis had received antibiotics because of sepsis or severe infection, for prolonged period. . fluconazole seems to be a very good alternative to amphotericin-b. . fluconazole is a safe antifungal agent with few side effects. botulism is the most severe and an odd food poisoning. although it is more commonly related to preserved meat derivatives, preserved fish and vegetables are also responsible for a number of cases. obiectives: to evaluate four familiar outbreaks of botulism . methods: we study the patients that were admitted in our hospital because of botulism from may to february . results: the thirteen pacients involved had a previous history of home preserved beans ingestion. after a -hours incubation period, gastrointestinal symptoms (abdominal pain, vomits, constipation) appeared and lead them to hospital consultation in the th to th day after ingestion. two patients died (acute respiratory failure before admission), seven were admitted in icu, two in ward and two of them were discharged from emergency room. clinical symptoms and the previous history of the ingestion established the diagnosis, that was emg confirmed. in all cases, symptoms were consistent with b-toxin botulism. b-toxin was isolated in serum and food proceeding from the third outbreak, and the serum was negative in the other ones. neurological symptoms were predominant: midriasis ( %), dry mouth ( %), dysfagia ( %), asthenia ( %), palpebral ptosis ( %), accomodation paralisis ( %) and urinary retention ( %). muscle weakness lead to acute respiratory failure in three patients (one of them required mechanical ventilation). four patiens developed infections (respiratory, urinary and phlebitis). both died patients and one another presented severe hypertension. all admitted patients were treated with polivalent anti-toxin. the two patients who underwent a more severe muscle weakness received also guanidine hydrochloride, with no answer in one case and provoquing a cholinergic crisis in the other one. icu length of stay was days. at hospital discharge, patients continued symptomatic, mainly with dry mouth, disfagia and impaired vision. conclusions: although botulism is a serious illness, the pronostic seems favorable if treatment and support measures are avaible. usually neurological symptoms we predominant and at discharge some of them could still persist. the arrow "hands-off" (aho) thermodilution catheter (tc) is completely shielded during balloon testing, preparation, and the insertion procedure. in order to assess the value of the aho thermodilution catheter in the prevention of systemic infections associated with pulmonary artery catheterization (siapa), we conducted a randomized prospective study over an -month period. methods : the patients (pts) were randomly assigned to two groups : group i for a standard tc customarily used in the department, versus group for the aho thermodilution catheter. the diagnosis of siapa was determined on the basis of a positive culture of tc and bacteremia with the same organism, with out any other nearby focus, in association with regression or disappearance of the clinical signs of infection after removal of the thermodilution catheter. results ( objectives: the mortality rate (mr) of tb requiring mechanical ventilation (mv) is high ( - %). the aim of the study was to evaluate mr, associated factors, and prognostic significance of mv and hemodynamic disorders from tb in icu in patients with tb. methods: clinical parameters on admission, and complications in icu were related by univariate analysis to icu, hospital, and month outcome. patients required mv; were immunocompromised (ic) including hiv. tb was pleuropulmonary in , disseminated in and meningeal in . results: mr was % in icu, % in hospital and % at month. / ( %) < . mortality was associated with a high saps score, initial shock, mv and nosocomial septicemia. the mr dramatically increased when ards occurred during illness, despite the lack of correlation between mr and initial po /fio ratio or initial murray score. the site of infection did not influence the mr. surprisingly, the mean therapy delay was shorter for non survivors. mr was not related to ic status, nor hivstatus, but was only related to previous steroid therapy. conclusion: mr of tb requiring icu is high ( % at month). need for mv increased mortality ( % vs %). general severity and respiratory dysfunction seem to be major prognostic factors in icu rather than tb per se or than therapy delay. in spite of the improvement in the prognosis of pneumococcal meningitis (pm) with third generation cephalosporins (tgc), this infection still presents a great mortality which could be increased with the appearance of antibiotic resistant streptococcus pneumoniae. objectives: to asses intensive care mortality and morbidity of pm and to define patients (pts) at risk of complicated evolution. patients and methods: a retrospective evaluation of pm cases (all diagnosed by csf culture) admitted in our icu from january tit march . in all pts we analized: demographic data, underlying disease, apache ii score, clinical symtomps, treatment, complications and outcome. statistical analysis was done using bmdp sofware package. results:a total f pts were studied, males; mean age , _+ ( - ); apache ii score , + , ; glasgow coma scale (gcs) at admission , _+ , ; ( %) pts suffer from cronic pathology; ( %) pts diabetes mellitus (dm), ( , %) pts had had a previous cranial traumatism. in cases the source of infection was otic and also in ( %) episodes of pm there were bacteriemia. in out of ( %) pts that ct was performed no radiologic abnormalities were shown, of them presented cerebral oedema and pts a cerebral abscess. twenty-eight percent presented seixures, % hemiparesia, , % respiratory failure, , % shock, i % renal failure, , % multiple organ failure (mof). as for treatment refers , % pts recieved only penicillin, , % pts only tcg, , % pts tcg followed by penicillin and , % pts tcg+vancomycin. seventy-five percelat of pts recieved corticosteroids and , % vasoaetive drugs. the mean icu stay was , : days ( - ). twelve ( , %) pts died, two of them presented pm relapse (resistant streptococcus pneumoniae) and another two pts developed neurological sequelae. factors associated statistically with bad prognosis were dm, the use of vasoactive drugs, shock, mof, the apache ii score at admission, the gcs at the and hours from admission in the icu but not the gcs at admission. didn't resulted statistiealy signifcative age, previous eronie pathology, seizures, baeteriemia, renal failure and coagulation disorders. conclusions: mortality was high and associated to apache ii score at admission, to gcs at and hours after admission, shock, vasoaetive drugs and mof. objectives:the aim of the study was to analyse some of significant immunologycai changes in surgical patients,requiring intensive health care,and to determinate the possibility for evaluation,dynamical examination and importance of immunologycal problems for treatment. methodes:the study concerns a number of patients with expanded surgical intervention or serious postoperative complications.the results has been carried out with fiowcytometryc analyses of lymphocytic suhpopulations and routins methods for investigation of humeral immunity.the"panel" for evaluation of (} immunologycal parameters has been offered:t-calls total/cd +/;t-helper/cd +/;t-supressor/cd +/ th/ts ratio;b-cells/cd +/;naturai kilier/nk/cells;skin test for cellular immune function;phagocytic and oxidative activity;serum levels of immunogiobulins-g ,a,m;protease inhibitors;c-reactive protein.all patients have been studied during suffering and after surgical procedures dynamicaly. results:there have been estimated significant changes in immunologycal parameters especially:decrease of t-cells: cd +mean= . %/ . %- . %/and cd +mean= . %/ % - . %/;inverted th/ts ratio ,mean=o. / . - , /;reduced or negative skin teste;reduced phagocytic and oxidative activity before septic complications. conclusions:dynamical examination of immunologycal parameters shows,that the prolonged t-total,t-helper lymphocytopenia with functional deficience of ceils-mediated immunity correlates with the stage of clinical condition of the patients and has prognostic importance.it's clear,that immunologycal monitoring gives a possibility for immunecorrection. patients (pts) with the human tmunodeficiency virus (hiv) infection have a decreased immune response and are particularly susceptible to infectious endocarditis (ie). the aim of our study was to analyze the prevalence of ie, its clinical and therapeutic implications in a hiv population we prospectively studied pts, . % ( / -group ie+) with ie during the clinical course of this disease. we analyzed the following parameters: age, gender, race, type of hiv, cdc classification, number of t and t type cell population and its ratio, therapeutic with azt, type and number of opportunist infections (inf, mycobacteriosis (mb), neoplasm's (nee) the echocardiographic parameters were lv internal diastolic and systolic diameters, lv percentage of fractional shortening, interventricular and posterior wall thickness, the degree of valvular regurgitations and the presence of pericardial effusion. el was located at the mv in . %, tv in . %, av in % and pv in . ~ and was multiple in . %. hiv el+ pts had larger lv diameters and more frequent significant valvular regurgitations ( % tr, pe %, mortality %). these two groups differed significantly in the following clinical parameters: the typical symptoms were watery diarrhea, high fever, tachycardia,luekocytopenia and oligouria within th postoperative days. the patients with mrsa enterocolitis had positive mrsa culture from the many materials except feces.mesa strains frequently had coagulase type ,enterotoxin a and toxic shock syndrome toxin- .eight of patients had postoperative organ failure.most of the mrsa strains in japan were similar in coagulase type to our hospital and our department.all of mesa strains were susceptible to vancomycin and arbekacin,tbough most of them showed resistant to many other antibiotics.we have employed guidelines for therapies such as oral or enteral administration of vancomycin and correction of the hemodynamics for dehydration and circulatory failure due to diarrhea from .futhermore we have placed colonized or infected patients in private room,worn gown and mask,and carefully washed our hands from . these countermeasures for prevention of nosocomial infections after significantly reduced the incidence of mrsa enterocolitis. conclusions:earlier diagnosis and treatment, and distric prophylactic measureres against mrsa infections are very important. -- cdo ivda leptespiresls affects all the organs with widespread hemorrhage that is more prominent in skin, mucosa, skeletat muscles, liver and kidneys. lung involvement is usually mild and less common. suli, it is very uncommon acute respiratory failure to be the pr sontirlg symptom. a case with leptosplrosl..,s which was presenting with acute respiratory failure is described. a year-old man admitted to icu becauso of fever, myaigla, aevere c~, hemopty~s. his blood gases showed: pao : mmhg with fio : . , pco : mmhg, ph: . , hco : mecl chest x-ray film demonstrated diffuse bilateral alveolar pattern occupying beth lung / ). trarmamlnase, bllllrubln, ~ and esr were elevated, wbc was . mm , platelet: . ram , hematesrlt: %, hemoglobin: .sgrldl=. there was no clinical or ecttlographlc evidence of left heart failure.patient fulfilled the criteria for diagnosis ards he was found to have an ~lutinatlon tlter for leptoq~lral antigens(indirect he~lutlnatlon atomy, ilia} very high ( / , negative<ill ) and iglm antibodies also very high (elisa, a= . , negative< . ) strongly suggesting leptospirosls. treatment with tetracycline and non-tnvaslve mechanical ventilation by nasal mask were started. pre~jre support mode and cpap was usod. the following days the clinical picture,the oxygenation and the chest x-ray of the patients were improved, and patient dl~herged from the icu. the control of leptosplremlc phase as well as his good cooperation during nipsv contributed to rapid recovery and excellent outcome in hiv infections, pneumonias (pnm), mainly due to pne~ mocystis carinii (pc) have an outstanding place in pu ! monary complications. the aim of this work was to compare two group> of patients admitted with pnm in our icu during the same period ( - ): group a, patients hiv+, and group b, patients hiv-. apache ii was identical in the groups (p=ns). group a required more often mechanical ventilation (p= ,o ), had a higher p(a-a)o (p= , ) and metabolic acidosis was more frequent (p= , ). regarding laboratorial parameters group a had a lower no. of linfocytes (p= , ), a higher ldh (p= , ) and a more marked hypoalbuminemia (p=o, ). mortality was higer in group a ( , %) than in group b ( , %), (p= , ). analysing the a group patients, we found no significant differences between alive and deceased patients, with exception for albuminemia, which was lower in the deceased patients (p= , ). in conclusion, the hiv+ patient's pnm have a more agres sive behavior when compared with community acquired hiv-patient's pnm. the prognosis was not influenced by the apache ii. perhaps other parameters such as p(a-a)o , metabolic acidosis, linfocytes, ldh and albumin shoud be more evaluated as possible predictive indices. some prognostic factors, usually accepted as predictive in the analysis of hiv+ patients do not seem to be worth in the late stages of aids, mainly when they reqquire intensive care. intensive care unit, onassis cardiac surgery center, athens, greece. objectives of this study was the comparison of two different antibiotic regimens as prophylaxis in cardiac surgery patients. methods: in a prospective randomised comparative study, two different forms of antibiotic regimens were investigated : a single dose of cefuroxime (zinacef, gr) (group a) given during the induction of anaesthesia, versus a four days combination of amoxiculine (amoxil, gr tid) plus netilmicin (netromycin, mg bid) (group b). a total of patients (pts) ( males and females, of mean age . + . years old) were included in the study over a period of one year; in group a and in the group b. patients were checked for the occurrence of infection during the first postoperative month. results: the total rate of infection in cardiac surgery pts was . %; . % in group a and . % in group b (p=ns). pts ( . %) developed infection following cabg, pts ( . %) following valve replacement and pts ( . %) after other cardiac surgery. they were males ( . %) and females ( . %). endocarditis has occurred . % in group a and . % in group b. severe wound infection was recorded in . % in group a and in . % in group b. one case of sepsis ( . %) in group a and in group b ( . %). respiratory infection occurred in pts of group a ( . %) and in pts of group b ( . %). two cases of urinary tract infection was in group a and one in group b. catheterrelated infection was occurred in ( . %) in group a and ( . %) pts in group b. pts ( . %) had fever of unclear aetiology in group b. conclusions: there was no statistically significant difference regarding the rate of infection in both groups. a single dose administration of cefuroxime is accordingly just as effective as a four days regimen of amoxicilline plus netiimicin. legionella pneumophila is a common bacteria of the environment, and it is an agent responsible for severe community acquired pneumonia (cap). we analyzed the patients with lpp admitted in our icu during the last years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . they represented . % of cap. seven patients were males and female, with mean age . + . years. tiss was . + . and apache ii . + . . all, but patient, were under mechanical yen tilation (mv) during a mean period of . • (min-l, max- ) days. two pneumonias occurred beyond the season, while patients had an epidemiological history. only patient had no risk factor. in all the others tobacco smoking and alcohol abuse was quite frequent. diagnosis was based on serologic test and culture or direct fluorescent antibody staining of bronchial secretions. seven patients had a multisystemic disease with hepatic dysfunction in , renal failure in (due to rhabdomy~ lysis in ). one patient had a prosthetic valve endocarditis and another developped ards. nosocomial septicaemie occurred in patients. mortality rate was %. deceased patients had initially higher apache ii, (a-a) , and lower natriemia. comparing lpp with the other cap (n= ), both submitted to mv, mortality rate was similar ( , % versus . %). in conclusion lpp can occur all over the year. there was a high incidence of severe complications and outcome was similar to the other cap when requiring mv. prospective specimen brash (psb) with culture > cfu cfu/ml. broncho-alv~lat lavage (bal) ~= c'fu/rnl or positive blood culture. were excluded for rapture of treatment ; were analysed (shift with oral antibiotic : ; prohibited antibiotics associations : ; resistant germ : ). clinical data : age , • , ; saps • , ; mac cabe i : , % -ii : , % -iii : , . , % of the patients were intubated and under mechanical ventilation. the pneumoaiae were : primitive in ( , %), copd ( , %), aspiration pneumonia ( , %). germs were isolated (psb , bal , blood culture ) : s. pneumoniac ( , %), h. influeazae ( , %), sttep~:occns ( , %), saar ns ( , %), enterobaetdrindr ( , %), mosexella catarrhalis ( , %), othem . / ( , %) were sensitive to freatment. the ltentment was mg/kg/d of ampiclllin and mg/kg/d of sulbactam in continuous iv adminisu'ation during at least days. clinical eff~ienev : success ( %), failures ( %) with superinfeetion , worsening or relapse , dead , side effects . there was no difference between etiologies : primiti~;e~ , %, copd , %, aspiration pneamoniae , %. the bacteriological effieieacy was evaluated only for patients with eradication ( , %), eradication but super~ection ( , %) : with pseadomoaas a&ogiuosa , eater~ac~ ; beeteriological failure ( , %). in conclusion, the aasor ampicillin -sulbactam is effective for the i~eatment of severe acquired community pneumonise. objectives : to assess the efficacy of chlorhexidine (cl) gel or suspension applied in the nose and in the op for the prevention of the tmcheobronchial colonization. methods : thirty-seven patients expected to be intubated for > h were randomized to received topical application oga cl suspension ( %) qshrs, a cl gel ( %) q hrs or a placebo. in addition all vpts received a nasal and a op spray ( %) of either cl or placebo administrated according to the same schedule. semi-quantitative cultures of the anterior nares, the oropharynx (op) and the trachea were obtained on admission and once a day until extubation (just before the next application). the results were assessed according to the following criteria: success = no acquisition of gnb in the trachea ; failure = acquisition of gnb in the trachea. acquisition was defined by a follow-up culture positive for a gnb not present in the trachea on admission. results : success failure nosocomialpneumonia overall morality clsusp. placebo clgel placebo n= n= n= n= / / / * / / / / * / / / / / / / / / i *p = , byfisher'sexacttest conclusions : these results suggest that topical cl gel administered q hrs may prevent tracheal colonization by gnb. f. daumal*, m. daumal**, c. plot**, v. vurmmen ~ e.colpurt**, b. manonry** * hygiene hospitali&e, ** service de r enmmtion, * service des admissiens-urgeuces centre hospitalier g- ndral - saint-quentin -france obiectives: evaluate the nosocemial risk due to peripheral venous inserted short catheters, and the quality of care. patients-methods: the intensive tare unit (i.c.u.) is a beds unit. the prospective study includes all the patients comn~ in from / / to / / . the recruitemont uses an evaluation schedule of local clinical signs. the nurses aimed to create this evaluation data which includes the place of entry site, the duration of catheterization and the cause ot withdrawal. only patients staying longer than days in the i.c.u. are accounted for. the diagnosis of uosoenmial infection is assured by the physician taking care of the patient and by the hospital epidemiologist on the next signs: evident pus at the catheter entry site, positive culture of the strain, with or without the same pathogen in the blood sla'uam,the patient having no other distant source of infection. analyses were performed on epi/nfo. results: the occurrence of nosoeomjal inthrtions: i abcess and bacteremia during the first part of the study lent the medical staff to modify the protocol of insertion end survey of the device. so we analysed different periods: period ( / / to / / ) and period ( / / to / / ) for all .e peripheral catheters inserted in the i.c.u. period , % , % en infection due to peripheral venous device is a daily threat. the severity of some clinical situations requiring admission in icu proves it. the motivation of nurses for rigid adherence to established protocol, the daily survey of the entry site, the withdrawal of the peripheral catheter every hours aimed to reduce significantly the local signs of inflammation end infection of peripheral catheters inserted inside the i.c.u. objectives: to investigate the use of a new metabolic monitoring device for different ips levels by comparing oxygen consumption (vo ) to measurements of the mechanical work of breathing (web) and p . . methods: the study was approved by the institutiotml ethics committee. eight patients were investigated during weaning after prolonged mechanical ventilation ( - days) for various diagnoses when the clinical physician judged the patient to be ready fur weainag. ips was setto , , , mbar far rain periods each. all patients had a peep between - mbar.. respiratory frequency (f), tidal volume (tv), minute ventilation (ve) were read from the ventilator display ( ae, puritan bennett, carlsbad, usa). flow and airway pressure were measured at the endotracheal tube site. esophageal pressure was measured using an esophageal balloon catheter (fa. ruesch, frg). web was determined as the area subtended by the pleural-pressure-vohime curve. p . was determined by using standard occlusion technique and graphical analysis of the airway pressure tracing. vo and vco were measured using the pb metabolic monitor (puritan bennett, carlsbad, usa) connected to the pb ae ventilator. all data are given as mean• deviation for each ips level. comparison between the different ips levels was performed using anova for repeated measurements. significance was considered at p< . , compared to ips mbar. results: the values for breathing pattern, web, p . , vo and vco are given in the table for the different ips levels; significance is indicated by ~. objectives: fluidized beds are often used in the management of critically ill mechanically ventilated patients. critically ill patients are increasingly colonized with resistent pathogens [ie: p. aeruginosa, methicillinresistent s. aureus (mrsa), extended spectrum i~-iactamase producing enterobacteriaceae ] that can ultimately cause nosocomial infection. methods: we prospectively monitored bacterial colonization of mechanically ventilated patients and of the fluidized bed (clinitron) inwhich they were treated. multiple samples for quantitative bacterial cultures were taken from oropharynx, trachea, feces and bedsores. samples of ceramic beads from the bed were also taken both during and after patient stay (after bed operation in the absence of patient). re,~ults: episodes in consecutive patients (mean age: . years) were analyzed. all had bedsores and/or urinary catheters and fecal incontinence, patients had nosocomial pneumonia, had urinary tract infection [ with extended spectrum imactamase producing k/ebsie//a pneumoniae (ki~lse)], one had positive blood cultures with mrsa, and one patient had a ki~lse found in high concentrations ( - s cfu/ml) in occasions in feces. patients were heavily colonized: the , samples from ceramic beads showed no growth or became sterile without any sterilisation procedure (even in one case of presence of kf~lse) during the patient stay. conclusions: fluidized beds do not put patients at high risk of acquiring nosocomin pathogens, and cross-contamination between patients seems unlikely, even when multiple resistent organisms were initially present. the recommandation from some manufacturers to undergo extensive sterilization of fluidized beds after use does not seem warranted, at least with the bed used in this study. ant. koutsoukou, a, tahmitzi, p. kithreotis, m. koutonlidou, k. stavrakaki, kainis e, g. vlahogiorgos and e. eliopoulos icu-centre for respiratory failure -chest diseases hospital of athens. the cost-effectiveness issue is becoming vital in modern medicine and may lead to moral dilemmas since sometimes certain groups of patients may not have access to highly specialised modalifies. objective: our study compared the mean daily cost for antimicrobial medication in copd patients treated in icu versus all other patients in the context of relevant epidemiological, prognostic and outcome data. methods: age, sex apache ii score, length of icu stay (los) and in -icu fatality were retrieved from the files of all icu admissions over . mean daily cost for antimicrobial therapy per patient (dcat) was estimated. these variables were statistically compared between copd and non-copd patients. significance was assumed at p< . results: of the total admissions were fully evaluable. of them ( %) were copd patients. data (m---sd) results for statistical test are given in table i . copd patients were significantly older spent more time in the icu and presented with significantly higher apache ii scores. outcome and dcat were comparable in the two groups. objectives: the use of heat and moisture exchangers (hmes) during long term mechanical ventilation (mv) is increasing. in icu patients, they are routinely changed every day, according to the recommendations of the manufacturers, but the clinical basis for such a daily practice is lacking. we therefore prospectively assessed whether changing hmes (dar hygrobac, spa, mirandola, italy) every h only would affect their clinical and bacteriological efficiency. methods: two consecutive groups of patients requiring mv for > h were compared: group = hme replaced every day, n= episodes of mv in patients; group = hme changed every h, n= episodes in patients. tubings were not changed in the same patient during the whole length of ventilatory support. diagnosis of nosocomial pneumonia (np) was based on a positive quantitative culture (~ cfu/ml) of a protected specimen brush in patients with clinical signs of pneumonia. quantitative cultures of pharynx, trachea and y-cannector were performed every h. results: the groups were similar in terms of age, indication for and overall duration of mv ( +_ . vs +_ days, p= . ), and severity of illness (saps: --- . vs . +_ . , p= . ). the maximal values for peak airway pressure were identical in both groups ( . -+ . vs . • cmh , p= . ). obstruction of the tracheal tube was observed in only one instance in a group patient who had tracheal bleeding. circuit colonization was very rare, and of low grade in both groups. the level of patient colonization and the type of organisms were identical in both groups. more importantly, the incidence of np was the same ( / vs / , p= . ), as was duration of mv before the occurence of pneumonia ( • vs . +_ . , p= . ) and overall mortality rate ( vs , p= . ). conclusions: the clinical efficiency of this hme does not seem altered after days of use. indeed, replacing this hme every h only neither affect circuit and patient bacterial colonization nor the incidence of np. therefore, substantial savings could be obtained changing hmes every other day only. obiectives: to evaluate the usefulness of different paraclinical investigations for the diagnosis and prognosis of acute viral encephalitis in icu patients. methods: we reviewed patients (pts) admitted to our icu from july to december with the diagnosis of acute viral encephalitis. all were in coma and were initially treated as presumed herpes simplex virus (hsv) encephalitis. the causative agents were: hsv ( cases), herpes zoster varicellae ( ), measle ( ), rabies ( ), unidentified ( ). eleven pts survived and three presented neurologic sequelae. twelve pts were investigated by mri, and eleven also by spect and multi-modality eps. including brainstem auditory eps (baeps). these investigations were obtained as soon as possible following admission and were repeated during icu stay when possible. the clinical outcome was noted. results: six pts ( / ) had an abnormal mri. among them, pts made a complete recovery, in comparison with / pts with a normal mri. in one hsv infected patient, mri remained normal despite clinical deterioration and bad outcome. when repeated, mri became abnormal in cases (with poor outcome in one) and was improved in one. spect was found abnormal in / pts (among them, pts had thus a normal mr/). the correlation regarding the topography of brain lesions was poor between mri and spect. the findings of spect could not be correlated with a poor outcome. the baeps confmned in % of the pts the clinical diagnosis of brainstem involvement. changes in visual and somatosensory eps were mild in all the pts and were not helpful for the prognosis. eps were otherwise interesting for the follow-up of the coma in these sedated and ventilated pts. conclusions: the value of mri and eps for the diagnosis of acute viral encephalitis is of limited interest. spect seems to show early modifications, even in pts with a normal mri, but this test is poorly specific and does not correlate with mri changes when present. concerning the prognosis, larger studies should probably confmn that a normal mri could usually result in a good outcome. this serie illustrates also that hsv encephalitis could be demonstrated only in a small number of cases and that the prognosis of non hsv encephalitis is not easily assessed. objectives: to study the influence of gram (-) bacterial lung infections on liver function i~ mv icu pts. pts and methods: we studied pts, # ( , %), ( , %). hean age: , • years ( - ). mean stay in icu: , • days ( - ). they were divided in groups: a( pts) who did not suffer from pneumonia and b ( pts) who developed a gram(-) bacterial pneumonia. both groups were consisted of pts with same age, sex and disease distribution and same systemic failures. we measured sgot, sgpt, total bilirubin(tb), direct bilirubin (db), alk.phosphatase (al.ph.), v-gt and albumin (alb.) times: on days o, and of the pneumonia for group b and respectively for g~oup a. conclusions: ) in elderly intubated pts of an icu, kp is isolated more frequently than in icu pts< years (p<o, ). ) the frequency of isolation of kp in icu pts during - was - %, but now ( - ) kp becomes more and more rare ( - %) and is isolated especially in elderly pts. ) its sensibility to antibiotics remains always the same. ) the prognosis of np in our study was independent from age (p<o, ), sex, presence of bacteremia (p< , ) and type of invading microorganism. gram neg bacteria and renal failure (rf) from aminoglycoside toxicity are common and serious complications in critically ill patients. the aim of this prospective, pilot study was to compare the safety and adequancy of the endotrecheal (et) vs the intravenous (iv) administration of aminoglycosides. were measured in the plasma and the bronchial secretions at and hours after the iv (bolus) or the et (nebulized) administration of mg of gm in seven criticcally ill patients ( with established renal failure). safety was defined as peak and trough plasma gm levels _< than and ijg/ml respectively and adequancy as gm levels in bronchial secretions _> , ijg/ml. results: gentamicin was administered by the et and iv routes in and separate sessions respectively. a total of samples were assayed, in bronchial secretions (bs) and in serum. the et route resulted in higher gm levels in the bronchial secretions compared to the iv route ( , + , vs , _+ , pg/ml respectively, p = ns ). adequate bronchial gm levels were achieved in % of patients after et administration, compared to % after iv aaministretion. the blood levels of gm were significahtly lower after the et vs the iv route ( , + , vs , • , pg/ml respectively, p _< . ). the et administration resulted in toxic bronchia~ gm levels in % of the specimens. % of these samples were from patients with renal failure, however toxic blood levels were reached in only % of these. gentamicin seems to be a safe and adequate alternative route of treatment for the lrti. however, in patients with renal failure the et administration of the aminoglycosides should also be modified and continuously monitored. in order to evaluate the pathogenic role of anaerobes in nosocomial pneumonia (np), we investigated the systemic humoral response in patients who developed a np with anaerobic bacteria, especially prevotella species. methods: blood samples from groups of patients were tested. group i: patients with a np in which prevotella spp. was isolated from protected specimen brush (psb), group ih a control group of patients with a np without anaerobic bacteria, group ill: a control group of patients with dental stumps but without pulmonary infection, group iv: a control group of healthy voluntary people with prevotella spp. isolated from the dental plaque. an elisa was used to evaluate the total antibodies level against a mixture of four prevotella strains and a western-blot method was done to identify the antigenic proteins. results: data are expressed as means .+ sd. the antibody levels in patients of group i ( • was statistically higher (p=o.o ) than in the control groups (respectively: + , _+ , _+ ). using western-blot method, the intensity of the response was roughly superposable to levels obtained by elisa and the profiles were different according to the prevotella species. the occurence of a np with anaerobic bacteria (prevotella species) isolated from psb leads to an antibody response which seems specific of the prevotella species isolated. fever is common in the intensive care unit, but is not always related to an infection. we sought to define the epidemiology of febrile patients in a general medical/surgical icu. methods: we prospectively analysed the source of fever (t > . ~ c) in all adult patients admitted for >- hours in the icu during a two month period. these patients were studied for consecutive days. and werc classified in groups according to the evidence of infection (center for disease control criteria) after complete evaluation: documented infection: cdc criteria + isolation of pathogen (d); possible infectron: cdc criteria without isolation of pathogen (p); unlikely infection: patients who did nol meet the cdc criteria (u). results: of a total of patients studied, dec'eloped fever ( %). including (after complete evaluation) d, p and u palients. both the highest temperature in tile first day of fever and the maximal temperature were higher in d than in u ( . • versus . • and . -~ . ~ versus . - . , respectively p= . and p= . ). most common sources of infection in d were the lungs in patients ( %) and urina .ry tract in ( %). of these patients had positive blood cultures ( %). the overall mortality was % ( % in d, % in p and % in u. differences ns). antibiotics were given in % of d, % of p and % of u ( patients). in p there was a non significant lower mortality." in patients who received antibiotics ( / ( %) versus / ( %) patients, respectively). conclusions: in febrile icu patients both the highest first day" temperaturc and maximal temperature are significantly higher in infected than in non infected patients, but the differences are too small to be useful clinicall). mortality rate is not significantly influenced either by the presence of an infection or by the administration of antibiotics, obiective: retrospective study to determine the influence of candida infection on icu outcome. methods: patieet with a stay of more than days in inteaasive care were screened for candida infection. patients were treated with antifungal therapy due to either an increased antigen titre of -> : or clinical evidence of candida colonization. serological candida-antigens (ramco, pastorex) and antibody titres (hemagglutination, lgg-, igm-elisa) were examined routinely. seroconversion was defined as a threefold increase of antibody titre or a titre of : or higher. results: the median length of stay was (ranging from to ) days, the mean apache ii score on admission was (+_ . sd) points. of patients patients died ( . %). in the group treated with antifungnls ( patients) patients died ( . %). although of the patients only ( . %) developed a candida infection as defined above the mortality in the group that showed signs of infection was significantly higher ( . % vs. . %, p < . [chi-square-test]). in patients an antigen concentration-> : was measured. seroconversion was found in patients. the most common fungus was candida albicans ( . %). furtberm re, candida glabrata was found in . %. most of the patients were treated with x mg fluconazole ( patients). in patients therapy was changed to amphotericin b/flucytosine. in patients therapy was started with amphotericine b and flucytosine. in patients a threefold decrease of candida antigen titre was found. patients showed a decrease of candida antibody titre. conclusions: meticulous screening for eandida infection seems to be necessary since the number of patients with fatal outcome is significantly higher in the group with signs of fungal infections and thus requires immediate antifungal treatment. objective: early diagnosis of patients with ventilator-associated pneumonia (vap), and subsequent identification of causative microorganism, and selection of the appropriate therapy are critical important points that affect morbidity and mortality. the results of the quantitative bacterial cultures are not available for at least hours, while a two hours period, since the specimen are obtained is enough to know the gram stain results. the aim of this study is to determine the usefulness of gram stain in specimens obtained by bronchoaiveelar lavage (bal), through the bronchoscope. material and methods: we studied patients ( males and females, age + ) with suspected ventilator-associated pneumonia. the bal gram stain was considered positive when the specimen after a centrifugation at rpm for min revealed: i) more than leukocytes per optic field, ii) squamous epithelial cell less than percent and iii) one or more microorganisms per optic field on magnification. all patients had been receiving antibiotics, with no change during the last days, prior to bronchoscopy. results: patients had vap and patients did not. in cases the bal specimens (quantitative bacterial cultures) established the diagnosis of vap in the remaining three patients the vap diagnosis was established by other procedures (blood or pleural fluid culture, clinical outcome, autopsy). apache fl score in patients with vap was , -+ , , while in patients without vap was , + , . there was a significantly higher incidence of vap in patients who had i) coma (gcs < ) and ii) been receiving neuromuscular blockade (p< . ) . the sensitivity of the gram stain for vap diagnosis was %, the specificity , %, the positive predictive value %, and the negative predictive value , %. conclusion: our data indicate that the gram stain of bal specimens is useful for the early diagnosis of vap and the subsequent administration of the appropriate treatment. the role of anaerobes in mechanically ventilated patients with pneumonia (mvp) have been poorly investigated aim of the study : analyse the prevalence of anaerobic isolation in mvp. methods : between october and february all suspected mvp were investigated using protected specimen brush (psb) technique. brushes were rapidly transported in shaedler broth to laboratory. a special care was tooken for anaerobic isolation. results : among the psb performed for suspected mvp ( nosocomial and community-acquired pneumonia), yielded at least one micro-organism (positive psb : %). of positive psb demonstrated only aerobic bacteria and ( %) yielded with anaerobes. in out patients, anaerobes were associated with aerobic bacteria. anaerobes were mostly isolated in nosocomial pneumonia ( / positive psb). strains of anaerobes were isolated. prevotella species represent out these strains ( %) the most frequent anaerobic species were prevotella oralis ( ) p. intermedia ( ) and p. buccae ( ). comments:using adequate methods, anaerobic bacteria are frequently isolated in mvp. it could be off importance to take in account anaerobes in the choice of empirical antibiotic therapy in mvp. objectives: the majority of patients with multiple trauma are considered immunocompromised. the aim of this study was to identify risk factors of pneumonia in mechanically ventilated patients with multiple trauma or after surgery. methods: in this prospective study we studied multi-trauma patients (mean age + years, apache ii . + ), admitted to a general intensive care unit (icu). all patients were intubated and mechanically ventilated. we were considered that a patient had ventilator associated pneumonia (vap) when the specimens of bronchoalveolar lavage (bal) or protected specimen brush (psi?,), ebb'ned through the bronchoscope, had one or more microorganisms in concentrations greater than and cfu/ml respectively. all patients had been receiving antibiotics, with no change during the last days, prior to bronchoscopy. results: patients had vap, and patients didn't. in the bivariate analysis, the glasgow coma scale (gcs)< (x = . , p< . ), the administration of neuromuscular blockade (x = . , p< . ), the duration of mechanical ventilation to be greater than days (x = . , p< . ), the flail chest (x = . , p< . ), the parenteral nutrition (x = . , p< . ), the ards (x = . , p< . ), the abbreviated injury scale (ais) of more than for thorax (:,: = . , p< . ), the pneumothorax (x = . , p< . ) were statistically significant related to development of vap. in multivariate regression analysis, using the stepwise technique, three of the seventeen studied factors showed to have an indepantent association with the development of vap:the administration of neuromuscular blockade (f: . , p< . ), flail chest (f: . , p= . ), and gcs (< ) (f: . , p= . ). conclusions: in patients admitted to icu for multiple trauma or major surgery, the administration of neuromuscular blockade, the flail chest, and the gcs (< ), in the population under study, were the indepedent risk factors for vap. mof is a sereous complication of differem states: infection, sterile inflamation, extensive fissure injure, intoxication, ets. there is close correlation between extension of mof and death, developement of nasocomial infection. immunologic disfunction. in order to prgnose probability of risk of mof development among the patients with sepsis and septic shock, we achived an eqation, allowing to recive a coeficient, closely connected with this probabiliti. we have used retrospective analisis of cases of sepsis. diagnosis of sepsis was based according to bone's criterions of sepsis. mof was assessed as disfunction of or more systems according to bone's classification of mof. having used correlation analisis we have estimated factors which have had high correlation coeficient with the probability of development of mof. there were: apache-ii score points, evidenceof septic shock, endocrinopathy. with the help of multyple regression analisis we acheved next equation: y= , + , x~ + , x + , x , were x i-apache-ii score points, x -evidence of septic shock, x -endocrinopathy. the explanatory power of this quation was evidenced by roc of . , se (v - . introduction: the presence of liver dysfunction in the process of multiple organ failure is associated with an adverse outcome, particularly when it becomes progressive to liver failure. disturbances of liver function may occur early and their detection may be of significant importance for the further development of organ failure. routinely used liver function tests appear to be inconsistent indicators of hepatic damage. in this study, we used p_lasma disappearance rate (pdr) of indocyanin-green dye (icg) as an early estimate of liver function. methods: we serially evaluated pdr and routine liver function tests (serum bilirubin, sgot, sgpt), as well as acute phase and non-acute phase proteins (crp, transferrin) in patients during the first week after trauma or the onset of sepsis. patients: group : (n = ) multiple trauma iss > , group : (n = ): abdominal sepsis, acute necrotizing pancreatitis (anp) grade iii. patients were selected on the basis of clin cal estimates that these patients would require continued icu observation. pdr was determined by means of a fiberoptic catheter and a computerized system (cold z- , pulsion), which permits repeated bedside measurements. the initial values of pdr, serum bilirubin and transaminases were not significantly different in trauma, sepsis and anp. in trauma patients pdr improved during the first week. in patients with sepsis and anp pdr remained low and worsened with time. the decrease in pdr preceeded an increase in biochemical liver function tests in these patients. + . &-_ ( - ) discussion: routinely available blood tests of liver function are usually altered several days after injury. however, they are generally non-specific indicators and they are influenced by extrahepatic factors. pdr seems to be useful to evaluate impaired liver function early after the onset of sepsis and trauma. objectives: to study frequency of organ system failure (osf) and it's influence on outcome in granulocytopenic patients with hematological malignancies and septic shock(ss). materials and method: retrospective review of medical records of granulocytopenie(wbc< , xl ) patients with hematological malignancies and ss, who were admitted to the intensive care unit (icu). frequency of osf before and after ss was analysed. the patisnts were categorised on survival and non-survival. results: signs of osf were observed in . % of patients before ss and in all patients after ss. only patients presented with hypotension refractory to inotropic therapy. nevertheless there was a significant increase of frequency of acute respiratory failure (arf), acute renal failure (arenf) and liver injury (li) after ss occurred(showed on the figure). only frequency of organ failure before and after objectives: statusmetria allows to define the effective level of oxygen status and accordance to it means of carbon dioxide and elec-trolyte in critical care. the conception of syndrome int~ive care (sic) is exhausted itself and invariable outcomes of sic of multiergan system failure (mosf) confirms that. therefore, an alternative to sic should be advanced. methods: efficlenoy of treatment has been asscsaed in patients with mosf using value of metabolic rate and ability of an organism to cover it by oxygen and substrate supply. oxygen pulse (op) and index of efficacy of oxygen transport (ieto ) was monitored. ~lt~.lntenaive care is considered to be homeostasis-securing therapy (hst) if energostructure deficit is eliminated and necessary for recovery regeneration rate is .restored. op in patients with mosf was . mt-m " , and le,~ and ie'i~ w~ . units in sic. we managed to maintain op of . - . ml.m " and ieto of . - . units in hst. patients from with mosf survived in sic and patients from survived in hst. efficiency of hst appeared to be two times as much as efficiency of sic. cr of homeostasia-se-'uring therapy is advancing. the conception provides restoration of regeneration rate due to effective then in sic elimination of en=gostructure deficit. the conception may be a basis of new technology for treatment of mosf. helen f goode phd, nigel r webster phd. anaesthesia & intensive care, university of aberdeen, ab zd, uk. objectives: xanthine dehydmgenase is converted under conditions of ischemia, reperfusion and endothelial damage to xanthine oxidase, with superoxide anion as a co-product of its catalytic activity. multiorgan dysfunction syndrome is associated with splanchnic vasoconstriction resulting in significant and prolonged gut ischaemia. aggressive volume resuscitation with prompt restoration of blood flow results in reperfusion of the tissue and is likely to cause xanthine oxidase-mediated release of oxygen-derived radicals. this study investigates xanthine oxidase activation and oxygen-derived free radical-mediated damage in such patients. methods: fourteen consecutive patients on itu who met established criteria for septic shock and secondary organ dysfunction were studied. serum xanthine oxidase activity was measured using oxidation of a chromagen in a dual enzyme system and plasma malondialdehyde was measured using a specific spectrephctometdc assay. apache ii scores, blood pressure, svr, cardiac output and day survival were also recorded. biochemical data were compared with results from healthy subjects. results: xanthine oxidase activity was . + . units/i in patients (mean :t: sem) and . + . units/i in controls (p<o. , mann whitney u test), and was highest in the patients who survived (p< . ). malondialdehyde concentrations were elevated ( . • . prnol/i compared with . • . pmol/i in controls, p< . ). xanthine oxidase activity did not relate to apache score or any of the cardiovascular parameters recorded, and was not influenced by the degree of organ dysfunction. conclusions: patients with sepsis and secondary organ dysfunction have xanthine oxidase activation and evidence of free radical damage. the finding that activity was highest in those patients who survived suggests that reperfusion was incomplete in patients who died, with decreased tissue xanthine oxidase ~tash out' into the circulation. influence objective : evaluation of the feasibility of measuring the intragastrie partial pr~sure of carbon dioxide (pco ) using a chemilumin~nt optode and fibre~ptics originally developed for intrav~cular blood gas monitorlng(p ) methods the pco electrode w~ calibrated i~-vitro according to the m~ufaeturers instructions the sensor w~ then stripped of its outer c~ing and threaded down the pile tube of a g~ c enema e (gt) so ha he ens ng portion sat well within the balloon. the modified gt was inserted n~og~trically after induction of anesthesia in ten patients undergoing c~diopuimonary byp~s throughout results: according to the datas of integral rheography % of patients were revealed to have hypodynamic type of blood circulation (cardiac output was decreased on - % and general peripheral resistance increased on - %). it was effective to use complamin (xantinoli nicotinas) in the complex therapy of su~h patients. the dosage was - mg/kg during - days. as a result of such therapy was also the oliguric stage shortening (ac n ).in , % of the cases unsatisfactory datas of central hemodynamic,combined with high (more than cm h ) venous pressure,lung oedema.then nanipruss ( , - , mkg/kg/min) was succesfutly used in complex with routine therapy.in the patients with low cardiac output and low general peripheral resistance mesaton ( , - , mg/kg) and dopamine ( - mkg/kg/min) were effective.change for the worse in the hemodynamics datas, inspire of therapy during - days,was prognostically unfavourable. conclusions:we consider early diagnostic of hemodynamic disorders and adequate correction of them is one of the most important factors, determined the outcome and prognosis in arf patients. obiective: to evaluate the results of renal replacement therapy (rrt) in surgical icu patients with acute renal failure (arf). arf in icu patients is associated with high mortality rates. we investigated the relation between mortality and organ failure in different categories of surgical icu patients receiving renal replacement therapy (rrt) for arf. methods: the records of surgical icu patients with arf requiring rri-(haemodialysis or cavhd) were examined. five different patient categories were defined; .ruptured aneurysm of the abdominal aorta (raaa) n = .elective vascular surgery (evs) n = .abdominal sepsis n - .trauma n = .others ( e.g. malignancy, obstetric emergencies) n- seven organ systems (cns,circulatory,respiratory,hepatic,renal,digestive,haematologic) were scored for possible failure using the mof score. results: mortality was as follows: all patients % , group % , group % , group % , group % , group % . mortality increased with the number of failing organ systems; mortality for all patients with > failing organsysterns was % the only exception being the subgroup of trauma patients where mortality under these circumstances was o% conclusions: mortality in surgical icu patients receiving rrt for arf is high. no significant difference in mortality is found between raaa and evs. mortality increases with the number of failing organ systems. the subgroup trauma patients shows a lower mortality compared to the group as a whole, even with > failing organ systems. to look for the most accurate scoring system to measure the severity of the complications occuring in the early phase ( first day) of kidney transplantation and to asses their prognostic value. methods: in our retrospective study we applied the apache li and the goris scoring system for the kidney recipients who developed multiple organ failure (mof) as a consequence of their pulmonary and. cardiovascular complications following kidney transplantation. we evaluated the recipients the distribution of the women and men ( % ~ % ) was the same as in the kidney recipients. applying the apache ii system most of the patients had their score between and , and the function of , or organs were affected at the time of the onset of mof. the apache ii system gave adequeate information about the disturbance of the function of other organs beside the kidney failure even at the time of the transplantation. the scores and the number of the affected organs correlated with the condition of the patients in the goris scoring system but not as sensitively as in the apache ii scoring system. conclusions: both the goris and the apache ii scoring system can be applied to measure the severity of the multiple organ failure occuring during the early phase of kidney transplantation. however the apache ii system is more suitable to follow not only the stateof the patients at the time of the admission but also the changes occuring in their condition during the complication. v.v.erofeev, v.v.ivleva scientific research institute for general reanimatulogy russian amsci, moscow, russia objectives: the analysis of ssc and results of their treatment in patients following critical states showed the necessity of developing a combined antibacterial therapy. methods: according to the protocol patients ( - years old) with combined trauma and massive hemorrhagy following vast aml traumatic operations were examined. microflora's composition and resistence to up-to-date antibiotics was studied using the anaiyser iems reader by "labsisteme"(finland). general clinical, bacteriological, immunological indices, as weil as the duration of the treatment and recovering rate served as criteria of the combined antibacterial therapy effectiveness. results: it was proved expedient to administer antibiotics in staphylococcus infection in the following combinations: riphampizin with fluoroquinolones; i-ii degeneration, cephalosporins with aminoglycosides; cephalosporins with fluoroquinolones. in case of singling out the exciters of the euterobacteriaceae family, including the pseudomonas aereginosa, -fluoroquinolones combined with modern amynoglycosides; fluuroquinolones with ureidopenicillines; ureidopenicillines with amynoglycosides; amynoglycosides with the ii-iii generation cephalosporins; cephalosporins with fluoroquinolones. in severe ssc caused by combined infection (including anaerobes) clindamicin with modern amynoglycosides was prescribed. conclusion: the combined antibacterial therapy allows: ) to increase the effect on microbic agents and the efficacy of treatment in combined infections; ) to lessen the possibility of the exciters'resistence to antibiotics; ) to prevent the development of superinfection: ) to decrease the doses of medicine and its toxic effect. objectives: two methods of blood volume measurement in a group of critically ill patients were compared to investigate the practical possibilities of a new easy to use method based on carbon monoxide (co) uptake. methods: all patients had multi-organ failure and haemodynamic monitoring with a swan-ganz catheter. mean apache ii score was ( - ). when indicated, patients had blood volume measurements simultaneously based on the techniques of, i) dilution of ~cr labelled red cells, and ii) inhalation of carbon monoxide gas with measurement of the rise of carboxyhaemoglobin produced. the co was administered via a newly designed, ventilator driven, fully closed circle system ensuring co retention and co removal with automatic addition of oxygen to m}ttch patient uptake. a portable computer performed all necessary calculations. results: volumes obtained by co uptake were compared with the "gold standard" radiolabelling method. mean blood volume determined by the co method was ml ( - ml) compared with ml( - ml) with slcr labelled red cells (r= . ). regression analysis produced an intercept at ml. the slope of the regression line was . ( . - . , % confidence limits). discussion: the co method produces volumes in excess of the radiolabelling method. there appears to be a systematic error, and one possible explanation is co binding to substances other than haemoglobin. conclusion: the co method is easier to use than radiolabelling and of the lower cost, since cohb measurement only is required. aceuraey is sufficient for clinical use and our preliminary findings suggest this system will meet the requirements. objectives: this study was conducted to determine the role of nitric oxide (no) in the pathophysiologic alterations and multiple organ damage, and the possible effects of " " " (l-n -monomethyl-l-arglnlne nmma) on hemodynamics and mortality in rats caused by a prolonged hypovolemic insult. methods: a prolonged hemorrhagic shock ( - mmhg for rain) was induced in anesthetized rats followed by adequate resuscitation. l-nmma was administered intravenously at doses of . mg/kg or . mg/kg at the end of resuscitation. results: infusion of . mg/kg l-nmma diminished the fall in mean arterial pressure, significantly increased the cardiac index (ci) and stroke volume (sv), together with remarkable protection from multiple organ damage compared to the controls. the h survival rate was significantly improved from . % in the control group to . % in the treatment group (p< . ). in contrast, the high dose of . mg/kg l-nmma resulted in a strong blood pressure response but a marked reduction in ci and sv concomitant with an increased total peripheral resistance index within the observation period, and caused severe damage to various organs at h after treatment. in addition, marked elevation in both endotoxin and tnf levels were observed in animals subjected to shock insult. conclusions: these results suggest that no induced by hemorrhagic shock in rats is an important mediator for pathophysiologic alterations associating with cardiovascular abnormalities, multiple organ dysfunction, and even lethality. thus, regulation of no generation and use of no inhibitors might provide new aspects in the treatment of hemorrhage related disorders, and the use of l-nmma would be either deleterious or salutary in a dose dependent manner. (hebert, chest- ) . the purpose of this study was to assess the risk factors for hepatic dysfunction in mosf. methods: patients have been hospitalized in our icu from january to may . , ( %) with mosf. among mosf pati~ts, ( %) have had hepatic dysfunction defined according to hebert (bilirubin ~ ttmop , chest ). thirty six of these patients acquired hepatic dysfunction after admission in the icu. these patients were compared with mosf patients without hepatic dysfunction selected blindly. chrorfic diseases, severity scores, eanse of admission, clinico-biologieal and hemodyunrrfic parameters, use of vesopressors, use of hepaiotoxic drugs, use of nutritional support and mortality were compared for hepatic failare and non hepatic failure groups.twenty nine patients had postmortem hepatic histologic examination, results: univaciate analysis: only parameters with p _< . are pre~nted. including these paramet~'rs in a multivariate analysis, anly c~hosis and vascular surgery remain independent risk factors for hepatic dysfunction. in particular, pao /fio , arterial lactate, do were not different between the two groups, some de~'ee of histological abnormalities was found in all liver samples, despite a normal bilirubin level in % of the cases conclusions: in our patients, conu'ary to previous studies, hypoxic and hemody~anfic parameters were not independent risk factors for hepatic dysfantion. this might be due to the inadequacy of the usual biologic definition of hepatic dysfunction as well as to the poor sensitivity of general hamodynamic parameters. critical states of various origin are complicated with the mldtiorgan farm (moi~ oceuzr~ce. due to their and functional features the lungs become the primmy damage target in various critical.states. ard that occurs in such states is associated with pulmonary edema development because of capillary permeability increase mediated by humeral and cenular responses to amag/~ factors exposure. r nmst be emphasized that mediators and effecto~rs of this respo~e affect not only puknonary capillaries, but other organs capiu~es as wellenhancing their permeability. orsans edema is a conmm~ finding at the autopsy of patients died from mof.clinical and radiolosial findings allow to have a diagnosis of pulmonmy edema before ~mi!ar lesions in other organs occm. additionally, there are some techniques that permit quantitative assessment of pulmonary edema flv.id (evlw) volume. in conclusion, we suggest that evlw changes in .dyn~rmcs in patients with mof are considered as a critical state severity measure which reflects indirectly the edema in other organs. objectives: we compared three different dialysis membranes to find out whether or not there were differences between their clearance characteristics on substances such as inuline, creatinine, urea, and phosphate to be eliminated in acute renal failure (arf). moreover, if a loss of clearance did occur we were interested in whether this was due to heparinization and a high production of the thrombine-anti-thrombine-complex (tat). methods: we carried out a randomized controlled study on consecutive critically ill patients presenting with arf, most of them in association with multi-organ failure, to be treated by continuous pump-driven arterio-venous renal replacement therapy on continuous low-dose heparinization. three different types of high-flux filter membranes (f tm [fresenius] , ct tm [baxter] , and filtra tm [hospal]) were assessed. each filter was changed intentionally after a hours" use. together the data of filters were evaluated, each at three different times (immediately after its onset [ hi, after h, and after h). the clearances of creatinine, urea, phosphate, and inuline were measured. results: there were some significant differences in clearance characteristics of inuline, creatinine, urea and phosphate between the filters (p< , ) showing the f tm membrane excelling filtra mand ct tm the more. the loss of inuline clearance ( mi/min/m ) after h, however, was insignificant for all filter types. a continuous low-dose heparinization scheme was applied without any relevant prolongation of the aptt. even lower losses were noted for the clearances of creatinine, urea, and phosphate. we found the tat-producfion increased after h (p< , ), but it did not rise any further. conclusions: as we could demonstrate in our study the clearance data of different types of filter membranes applied during continuous renal replacement therapy do show significant differences. on the other side, no relevant loss of clearance occurs during a hours" period indicating a high efficiency over time. to consider commercial aspects as well it shows that inexpensive conventional filter membranes can successfully be applied even for a longer renal replacement period, if needed. a retrospective study was performed on patients with acute renal failure (arf). we analysed survival in continuous (cd) and intermittent dialysis (hi)). mean age of the patients was years (y), patients ( % ) were < y, patients ( %) were >= y. the incidence of dialysed arf in our mixed intensive care departement is %/admission/y. statistics: fischer's exact test, mann-whitney-u test. efioloev: the contribution sepsis, cardiac failure and aminnglycosidcs was respectively %, % and %. treatment: cavh (cd) or cvvh (cd) was used in patients ( %), hemedialysis (hd) was used in patients ( %). data: mean apache scores were the same for cd and hd ( for both groups), patients treated with continuous dialysis techniques had significantly (p<o, ) more need for ventilation ( % vs %), elevated bilirubin ( % vs %) and a higher vasopresser need ( % vs %@ than patients treated with hemedialysis. there was a trend towards more sepsis ( % vs %; p= . ) mad coaguiation disorders ( % vs %; p= . ) in cd. taere were sign/ficantly more younger patients (< y) treated with cd ( % vs %, p< .os). mean apache score was significantly lower in patiants< y than as patienta>= y ( vs ; p< . ). patients< y had significantly (i}< . ) more coagulation disorders ( % vs %) and elevated bilirabin ( % vs %). there was no significant difference in vasopressur need and ventihatio~ between age groups. outcome:. hi) had a better sr compared to cd ( % vs ~ p< . ). patiants>= y had a comparable sr vs patients< y ( ") */e vs %; p----a.s.). tha global survival rate (sr) was % ( patients). conclusions : diaiysed arf has a well known lowsurvival rate ( %): hc~raedialysed patients had a better survival rate than patients treated with continuous dialysis. this can be explained by the fact that the latter were in a worse condition considering organ failure (more vantilatian, elevated bflirubin and need for vasepressurs), apache score couldn't illustrate that. patient~ y with arf have the same survival rate as patients< y: although patients >=- y have a higher apache score they have less organ faille. the avacbe score is not a good oredictor of survival in p with organ failure. departments of surgery and intensive care, guy's hospital, london, u.g-obiectives: a randomised controlled trial of a management protocol utilising the regular measurement of gastric intramucosal ph (phim) to control the administration of dopexamine. methods: patients admitted to a multidisciplinary teaching hospital intensive care unit (icu) undergoing insertion of a pulmonary artery catheter were managed according to a resuscitation protocol. randomisation was to either the protocol alone or to insertion of a nasogastric tonometer and subsequent management guided by phim. phim < . initiated volume and inotrope resuscitation and, if unsuccessful in elevating phim, dopexamine was commenced. approval was obtained from the hospital ethics committee. results: patients were considered for analysis and the two groups were well matched for age and sex. overall, there was a high hospital mortality of . %. there was no difference in icu or hospital mortality between the two groups (see table) . objectives: to compare cardiac output (co) measurements between continuous termodilution (cco) by thermal wire on pulmonary artery catheter (cco/svo vigilance. baxter critical care), and co measurement using a trans-esophageal doppler (dco) ultrasound system (odm ii, abbott laboratories), in the immediate postoperative period of cardiac surgery. methods: patients undergoing myocardial revascularization were monitored with cco by a swan-ganz catheter and an intra-esophageal dco probe, after induction of anesthesia. exclusion criteria were: aortic valve disfunction, previous valvular surgery esophageal disease, absense of sinus cardiac rhythm, and need of ventricular or intraaortic assistance. hemodynamic parameters, co by both cco and dco, svo . sao , diuresis, pha, and hemoglobin were repeatedly registered during the first hours after surgery, as the patients were kept under sedation and mechanical ventilation. results were compared using the method described by bland and altman. results: measurements of co were obtained, ranging . objectives: a decreased tissue oxygen delivery is responsible for a higher morbi-mortality rate among surgical patients; this diminished oxygen delivery/consumption rate (dojvo ) may origin the lactic acidosis observed in the gastrointestinal tract, reported in patients undergoing hypothermic cardiopulmonary extra corporeal surgery, and can be registered by tonometry as result of the gastric mucose ph. the purpose of this study is to evaluate the reliability of the intramucosal ph (phi) measurement by a nasogastric catheter as indicator of the do /vo > its co> relation to other parameters of do /vo disturbance, and with postoperative complications and clinical course. methods: patients ( male, female) undergoing cardiac surgical procedures were included ( myocardiai revascularizations, valvular substitutions, constrictive pericarditis). mean age was + years, mean weight _+ kg. a nasogastric probe (trie tonometrics) was placed after anesthesia induction; phi values were registered in the postoperative period ( ', ', ", ' and h after surgery end). the corresponding hemodynamic parameters, venous oxygen saturation (svo ), diuresis and arterial ph (pha) were also recorded. results: phi values ranged . to . (mean . ( . ); the mean values of clinical evolution were: extubation time, _+ hr.; discharge from postoperative care unit, - hr.; and hospital total postoperative time, _+ . days. complications registered were: perioperative acute myocardial infarctions, cases of respiratory insufficiency, occlusion of coronary bypass, an ease of hyperamilasemia. all patients with severe complications needing specific treatment showed either a low phi value, or a considerable descent in comparison with the initial register. statistic correlation between low phi and presence of complications was found; the low significance (p > . ) degree may be due to the low population size. conclusions: phi measurement in cardiac surgery patients is a non invasive, uncomplicated method for prediction of doz/vo disturbances, thus reflecting risk of increased major complications, and may precede changes in other usual indicators (svo , pha, cardiac output, ...). work-in-progress with a greater population size may offer more significant results. references: ( ) gutidrrez g: lancet ; : - . ( ) landow i: acta anaesthesiol scand ; : - . the haemoglobin-level (hb) is besides the arterial oxygen saturation and the cardiac index one of the relevant parameters of oxygen supply to the tissue. in contrast to otherwise healthy patients, there is no agreement on tile so-called transfusion-trigger in critically ill patients. in i?ont of this background the question arises, whether and to what extent blood transfusion in critically ill patients improves oxygen supply io tile tissue. this study was performed in critically ill/septic patients in the postoperative period alier an inlcclive/scptie revision operation of the hip or knee joint. on cardiac/seplic reasons monitoring consisted beside other measures of a pulmonary arlery catheter and of an indwelling arterial line li~r measurering/calculating standard haem~dynamic as well as systentic oxygen parameters. the indication for blood transfusion was given by hb together with the cliuical slatus of thc patienl (asa-scorc and multiple organ dysfunction (moi))). statistical analysis w~ks performed by mann-whitney-u-test. by fisher's exact-test and by wii.coxon-test: statistical significance was set with p< . . according tu the pretransfusion value of hb and of lactate (lac) palicnts ;,,'ere divided into groups as follows: a: hb< and b: >sg/dl: i: ac< . and ii: > .smm. in either group blood transfusion results in zt significant increase in hb (a: . _+ . to . + . g/dl; b: .(~ . tt, . + . g/dl; i: . -+ . to . -+ . jdl; i : . -+ . to . + . g/dl). wlailc, however, haemodynamic parameters do not difl)r significantly from each other before and alter blood transfusion, oxygen delivery (do, -ml/min x m-') increases significantly hi either group studied (a: -+ to -+ ; b: + to + ; : -+ to -+ ; i : -+ to -+ ), in contrast oxygen consumption (vo~ -ml/min x m e) does not change significantly in either group (a: i -+ to -+ ; b: -+ to -+ ; i: -+ tu -+ ; : -+ to +_ ); oxygen exlraction ratio decreases. this study in critically ill/septic patients demonstrates, that in this group of patients studied blood transfusion at a base-line-value of > . -+ . g/dl expectedly rises do~, however, it does not improve vo=; even not in septic patients with elevated lac-values. paclitaxel in a new anticancer agent, extract from the bark of the yew tree (taxus brevifolia), employed against breast and ovarian cancers resistant to chemotherapy. it promotes the polymerization of tubuline, and disrupts the normal microtubule dynamics. hematologic toxicity, hypersensitivity reactions (bronchospasm, urticaria and hypotension), and peripheral neuropathy are the main reported toxic effects. cardiac side effects are rare: atrioventricular blocks of higher degree are reported in . % of patients; congestive cardiotoxicity was discussed only in one trial in patients treated with paclitaxel and doxorubicin. we describe the history of a -years-old worn an with a breast cancer, diagnosed in , initial staging t nim , treated with mastectomy, axillary lymphadenectomy, andchemotherapy with a cumulative dose of anthracyclines of mg/m until august . the patient complained of dyspnea and severe hypotension immediately after an intravenous infusion of mg paclitaxel, given over hour for the treatment of bilateral, malignant pleural effusion. at echocardiography die left ventricular ejection fraction was reduced to %. she died days later because of a severe cardiac low output with hepatic and renal failure; an impressive hepatic cytolysis was observed. the post mortem examination confirmed the dilatation of the cardiac cavities, especially of the right ventricle, bilateral pleural fluid, and ascites. the histology was suggestive for a cardiomyopathy secondary to anthracyclines. the electron microscopy revealed a deposition of an unusual pathological pigment in the myocytes; subsarcolemmal deposition or membranous were absent. we hypothesize that paclitaxel was the cause of a major hypersensitivity reaction with shock and severe hepatic cytolysis, worsening the myocardial damage induced by anthracyclines. the possibility that a low doge of paclitaxel could directly increase anthracyclines cardiotoxicity -as decribed in the medical literature -will be discussed. objectives: activated endothelial cells release soluble intercellular adhesion molecule- (sicam- ), vascular cell adhesion molecule- (svcam- ), and e-selectin (selam- ). sicam- , svcam- , selam- , and inflammatory cytokines were determined. methods: sicam- , svcam- , and selam- were determined by elisa. tnf-a, il- , and il- were also measured by elisa. endotoxin was measured by an endotoxin-specific endospecy test after pretreatment of new pea method. results: the sicam- and s vcam-i levels were significantly higher in the septic multiple organ failure (mof) and sepsis groups than in the non-septic mof group. the selam- level was slightly higher in the septic mof group than in the sepsis withut mof group and non-septic mof group. the increases of soluble adhesion molecules were not in agreement with changes of plasma endotoxin level. levels of soluble adhesion molecules were correlated with the levels of plasma tnf-a and il- , but the level of il- . discussion and conclusion: the slcam- and svcam- levels in septic patients closely reflected the severity of the pathophysiological conditon. it was possible that the release of sluble adhesion molecules were not stimulated by plasma endotoxin, but endotoxin in the local infectious region. tnf-c~ and il- also were suggested to be involved in the release of these soluble adhesion molecules. obiectives: cardiopulmonary bypass (cpb) surgery is associated with a systemic inflammatory response attributable to the release of various inflammatory mediators and the activation of complement or coagulofibrinolytic system. in addition, adhesion molecules, such as icam- , elam- , and vcam- , appear to be of central importance in the inflammatory process following cpb surgery. we previously reported the effects of a synthetic protease inhibitor, fut- , reduced release of inflammatory cytokines (tnf, il-lg, il- ), activation of complement (c a, c a) or coagulofibrinolytic system (tat, pic, fpa) and protected platelet function (gpib, gpiib/llla) following cpb surgery. methods: in this study, we analyzed fut- on soluble adhesion molecules following cpb surgery. patients undergoing cpb surgery were divided into two groups, group a consisted of patients who received omg of fut- in priming solution, followed by a continuous infusion at mg/kg/hr during cpb in addition to initial heparin dose of mg/kg. group b, a control group, included patients who were injected with heparin only. the plasma slcam- , selam- , and svcam- concentration was measured by elisa. results: every soluble adhesion molecules decreased during cpb in both groups, and rose after cpb. selam- and slcam- reached their peaks on hours after cpb and on pod respectively in both groups, but they remained lower in group a (selam-i: . + . vs. . • ng/ml, p< . , slcam-i: • vs. • ng/ml, p< . ), svcam- , in both groups, remained lower than preoperative levels, but did much lower in group a. conclusions: fut- reduced adhesion molecules and suggested to be the effect on postoperative organ dysfunction. in the last few :,'ears the conditions of treatment in continuous hemofiltration/hemodiafiltration were discussed controversially. a significant removal of tnf-alpha and il-i could be demonstrated in cvvhd. the aim of our study was to investigate the elimination of tnf-alpha, l- , il- , il- , s-cd- and ifn-gamma in cvvh by measurement in plasma and hemofiltrate of critically ill patients with an acute renal failure. the patients of our study were treated with a continuous veno-venous-hemofiltration (polysulfone-filter, blood flow: - ml/h, filtration rate ml/h). the samples, hemofiltrate and plasma, were taken one hour after the start of treatment. the patients suffered from septic shock ( ), the so called hepatorenal s~aldrome ( ) and a severe pancreatitis ( ). the cytokine concentrations were measured with elisa-method. in contrast to elevated concentrations in plasma for tnf-alpha ( cases), scd ( cases), il- (l case) and il- ( cases), hemofiltrates contained no activities. only il- was removed in significant amounts with even higher levels in hemofiltrate than in plasma. this phenomenon was described so far for tnf-alpha and il- and may be due to the absence of metabolic properties (possibily enz~natic) in hemofiltrate. it can be shown, that tnfalpha, il- , il- could not be eliminated in cvvh with a filtration rate to ml/h. in contrast to findings of other investigators with a higher filtration rate (> ml/h), we found no significant concentrations of tnf-alpha and il in hemofiltrate. we conclude, that for a significant removal of important cytokines higher filtration rates (> ml/h) are necessary. objectives: multiple organ dysfunction syndrome including liver and renal impairment is a fatal complication in patients with the diagnosis of sever sepsis. this study focused to the effects of removing toxic substances from inflamnatory tissue by hemodiafiltration. ~ ethods: eleven patients were admitted to the icu in emergency center and met the criteria of systemic inflammatory response syndrome in association with infection. all patients developed liver and renal dysfunction and were treated by hemodiafiltration with high flux membranes (fb-u:nipro). the hemodiafiltration were performed times using nafamostat mesilate as an anticoagulant in hours with l of substitution fluid (hf-b:fuso). the serdm levels of endotoxin, cytokines, endothelin-i (et-]), human neutrophil elastase ~ -proteinase inhibitor complex (hne-pi), fibronectin (fn), lactate, and amino acids were measured before and after the hemodiafiltration. the hemodiafiltration would be effective to renal dysfunction by reducing endothelin and beneficial to tissue metabolism represented in fisher's ratio, but might be harmful to respiratory function by activating neutropila in patients of severe sepsss. background : intermittent hd may be poorly tolerated in the early phase of arf in hemodynamically unstable patients (pts). this technic may fail to achieve steady state urea low levels in hypercatabolic pts. method : nt = consecutive pts treated with hd; n = consecutive pts treated with cvvhf. hemodynamic unstability is defined by arterial hypotension and requirement of inotropie support despite adequate filling. rate of change in urea (u), ereatinin (cr), k + , ph were computed from a linear regression .analysis of data vs time in each treatment group during the first days of application of the two technics (anova). dally worst values were recorded. results : hd-group : apach% score = _+ ; mean number of organ system failure (osf) = . -+ ; mean blood pressure (mbp) = • mmhg (first day of application of hd). cvvhf-group : apachen score : + ; osf = -+ ; mbp = + mmhg (first day of application of cwhf discussion : during the first days of application of hd/cvvhf, u and cr decreased much more rapidly in the cwhf-group. k* and ph were maintained within normal range in the two groups. initial mbp which was much lower in the cwhf-group significantly improved during the application of cvvhf while mbp remained unchanged in the hd-group. conclusion : despite higher severity of disease in cvvhf group (apachen score, osf, lower initial mbp), we obtained a better performanco with cvvhf regarding the decrease of u and cr and the improvement of mbp. in relation to the different and continuous renal replacement techniques, the continuous venovenous one is the alternative method to continuous arteriovenous for critical patients with acute renal failure (arf). we present you our experience with cvvh in patients with mof. in our intensive care unit (icu) patients with mof were treated with cvvh in the period between january in to march in . the mean (• age of our patient population was , • years, being % male and % female the whole patient population was with mof iust at the moment the technique was accomplished; % was in mechanical ventilation, % needed vasopressor support and % required both of them (mechanical ventilation and vasopressor support) apache ii score mean of the patient population was , ~: , (range - ) and ati of them were with arf oligoanudc. technique: cvvh was accomplished using a single-d~al iumen catheter, ptaced in either a temoral or subclavian vein by the stand ard seld{nger technique. pol{sultone hemofitiers were also used, and the extracerporeal circuit used standard arterial-venous blcod tubing. blood flow and hence oltrafiltration pressure, within the circuit was generated by a roller blood pump. the modulus has a roller pump, a pressure transducer connected in an arterious and venous line, such as an air-transducer which is adapted to a drip-chamber in the return way. the replacement used was a peritoneal dialysis solution. medicine , st. george's hospital medical school, london. england. hepatic sinusoidal endothelium shows a major inflammatory response in porcine sepsis that can be attenuated by the administration of dopexamine hydrochloride. dopexamine is a beta and dopaminergic receptor agonist. the specific beta adrenoceptor antagonist ici has been shown to reduce the protective effects of dopexamine. we investigated the effect of this antagonist on hepatic ultrastructure in porcine sepsis. six pigs ( - kg) divided into groups were anaesthetised and intubated. cardiac output and portal blood flow were measured using standard techniques. the groups were; placebo, (peritonitis induced); blocker, (peritonitis induced and pg/kg ici bolus infused then given hourly). caecal content was aspirated and peritonitis induced. colloid was infused to maintain pawp at - mm hg for eight hours the animals culled, hepatic tissue removed and prepared for electron microscopy. in the placebo group hepatic endothelium was swollen and the sinusoids occluded by wbc. but in the ici blocker group, much of the sinusoidal endothelium was absent and there where large extra sinusoidal spaces among the hepatocytes. an assessment of the two groups showed worse hepatic architecture in the blocker group. the b antagonist blocked any protective effect of endogenous beta adrenoceptor agonist (adrenaline) on hepatic endothelium in porcine sepsis. george's hospital medical school, london. england. dopexamine hydr chloride, a beta and dopaminergic receptor agonist reduces hepatic damage in porcine sepsis. we tested dopexamine's effect on cerebral oedema. the beta adrenoceptor antagonist ici was infused to block any protective effect of dopexamine. nine anaesthetised pigs ( - kg) were randomised into groups; placebo, (peritonitis induced); dopexamine, (peritonitis induced and ~tg/kgdar of dopexamine infused); blocker, (as in dopexamine group but in addition pg/kg ici bolus given then infused at that rate hourly). caecal peritoneum was induced and colloid infused to maintain pawp at - mmhg for eight hours when the animals were culled, cerebral tissue removed, prepared for electron microscopy and digitisation. digitisation of the area of oedema surrounding the blood vessel and expressed as a percentage of the micrograph. . _+ . , dopexamine . + . ", blocker . + . . data expressed as mean + sd. significance p< . . * dopexamine compared to placebo and blocker. in the dopexamine group the area of tissue oedema was significantly lower than either the placebo or blocker groups. there were no significant differences between the placebo or blocker groups. the antagonist completely blocked the protective effect of the drug on cerebral oedema in porcine sepsis. beta adrenoceptor stimulation is protective of cerebral oedema in porcine sepsis. objectives: the hemodynamie~ of hepatic circulation during multiple organ failure (mof) have not been suffleienly studied. we investigated liver hemodynamics in two subgroups of patients with mof, those with either liver or lungs as the main organ of involvement. methods: three groups of patients were created: i) mof-hepatic involvement (mof-hi) ( patients) with bilirubin > . mg/dl and lung injury score < . , it) mof-ards ( patients) with respective values < . and > , iii) patients with head injury with respective values < and < , served as group control. all patients were in haemodynamieally stable state with an oxygen delivery index > ml/min/m prior to measurements. two swan-ganz catheters 'were inserted, one in the hepatic veins and one in pulmonary artery and the following measurements were determined: the hepatic vein free pressure (hvfp), the hepatic vein wedge pressure (hvwp), cvp, paop and co. the gradient of hvwp-hvfp represents liver perfusion pressures. by injecting contrast media at dose of iml/lokg with the balloon inflated to achieve sinusoidai image, the hepatic blood flow (hbf) was concluded by the time in seconds of media removal after balloon deflation. results: the co, cwp and cvp were comparable to all three groups. namely, for mof-hi, mof-ards and control groups the mean (+sd) value of co was . _+ . vs . _+ . (ns) and . _+ . respectively, of the paop was . +_ . vs +: (ns) and . + . respectively and of the cvp was .+. . vs . + . (ns) and . respectively. in contrast the two mof groups were different after the cut-offinclusion criteria ie the mean (+sd) value for bilirubin was . + . vs . + . ( < . ) and . _+ . respectively and lung injury score was . objectives: oxygen delivery (do ) and oxygen consumption (vo ) are increasingly monitored parameters in the icu. there still remain controversies about an oxygen supply dependency in critical illness particularly with respect to vo determination by either indirect calorimetry (vo m) or tick calculation (vo c). the purpose of this study was to investigate the changes in vo m and vo c following do increase. methods: the relatives of critically ill patients (mean age years, mean apache ii , mean mof-score ) gave their written informed consent to participate in this institutionally approved, prospective study. do was increased by fluid loading (hydroxyethylstarch %: mean volmne ml, mean duration of infusion min) and catecholamine support (dobutamine: mean dose , ~g/kg/min). changes in vo m and v c were recorded sinmltaneously before, during and following interventions. calorimetry was obtained with the metabolic monitor integrated in the ventilator (puritan bennett, carlsbad, ca adaptive endocrine response of organism to septic shock consisting in activation of the production of adrenal hormons, renin -angiotensin -aldosterone system (raas) and other hormonal systems has an influence over microvascular changes in these states and for development of multiple organ failure (mof). in patients with peritonitis of different origins ( nonsurvivors and survivors) were followed the changes in cortisol level and raas by radioimmunological methods and many variables for evaluation of respiratory, renal, hepatic function, coagulation etc. as a signs of mof. it was observed significant increase of the level of cortisol ( +_ , nmol/ i), aldosterone ( , • , nmol/i). by factorial statistical analysis we found significantly high correlations between hormonal changes and respiratory function (for example r=- , , p < , between cortisol and pao ; r = , , p < , between cortisol and d (a-v) ; olso renin -cao r=- , , p < , , renin d ~,vl o r = , , p < , ). such significant correlations was found and for raas with respiratory, renal function, byproducts of arachidonic acid thromboxan b and p fla, soluble fibrine degradation products etc. these correlations between the degree of endocrine changes and multiple organ failure in patients with septic shock produced by peritonitis suggest that their effects upon peripheral vascular resistance and constriction of the splanchnic, splenic, renal and other organ vasculatures are not always with physiologic expediency and there are perhaps the possibilities of therapeutic influence. intredu~on : dopexamlne has previously been shown to control hyperkalaemia ia patients with acdto renal failure (arf), however effects on the subsequent course of art are undomunente~ ob_iectlv~ : to evaluate clinical progress in patients with acute renal failure (arf) in an intensive care unit (icu) with regard to biochemical control, need for -and time to -dialysis, and outcome in patients receiving dopexamine. m~ods : consecutive patients meeting standard criteria for diagnosis of arf were included in the study. full cardiovas~dar, biechemical and intervention/outcome details were recorded. dopex.~min~ was infilsed at a dose of pg/kg/min in conjunction with a regimen of inotropir support and blood volume optimization. resn]~ : following the intzoduetion of dopc',~mine ilrinr vohlmes increased slightly over the next hrs fzom + ml/ hrs to + ml/ hrs (ns). data expres,uxl as mean + sem. three patients ( %) became polyuric with urine output > ml/hr within days and did not need dialysis. in the remaining patients the time to dialysis (to correct acid-base deficits or volume overload) was . + . days. serum potassium levels were well controlled. day or immediate pre-dialysis levels were . + . mmol/l compared with pre-lreatment . + . mmol/l overall mortality in this series was / ( %). duration of acute dialysis in survivors with renal recovery was . +_ . days. patients ( %) progressed into chronic renal failure and needed continuing renal replacement therapy. no adverse cardiovascular altects were seen at this low dopoxami~ dose although its competitive inhibition to adrenergic reuptake mechanisms meant that doses of pressor agents could often be reduced. : dopcx:~minr nsed in conjunction with inotropic support and blood volume oplimitntion, can safely postpone, or even avoid, the necessity for acute haemodialysis in icu patients. no evidence of tachyphylaxis to the effect on serum potassium levels was seen over the duration of the study. hen'era m., suarez g., dagn d., varela a., ramos j., garoia jm, aragdm c, jurado l, medina a. icu. hospital regional. malaga. spain. objective: to evaluate the haemodinamic tolerance to the veno-venous continuous hemefiltration (vvchf) system in patients with systemic inflammatory response sindrome (sirs), and the possible beneficial effect of this technique on the haemodinamics in these patients. material: patient admitted to the icu, with diagnosis of sirs and monitored with a pulmonary artery catheter at the beginning of wchf. we performed a complete haemodinamic study to all these patients (cardiac output, vascular resistanoss, ph and co in arterial and mixed venous blood samples, saturation of pulmonary mixed venous blood, do and vo calculations and temperature) and determined the respiratory mechanics (compliance and pao /fie relatinship) before starting the procedure, after minutes operating with the ultraflltrate branch closed (without filtered fluid production), afler and minutes of zero fluid balance bemofiltration and after minutes of filtration with negative balanos adjusted to the patients conditions. for the statistical analisis we have performed the anova test over the mentioned variables. results: we have not detected statisticaly significant differences of the analyzed variables before the beginning after operating the pun'@ for minutes without filtered fluid production and after minutes of zero fluid balance hf. only temperature shows a meaningful decrease in time. objectives: among many organs, playing the important role in pathogenesis of multiple organ failure, the particular place is taken by the intestine. ~ethods: the study was carried out in dogs !~n"~h pi was modelled by severe operative trauma (ot). the dcm was estimated by the indices values of work time (wt), contraction frequency (cf), mean amplitude of contractions (~ac) and motility index (mi) measured by method of tensography. "sl", created on the basis of sorbit and sodium lactate ( mosm/l), was injected in the dose of .o ml/ kg into v. cephalica antebrachii after hrs of ot. the results of the present study are the evidence of "sl" stimulative action on dcm and are experimental ground for "sl" using in complex therapy of pi in clinic. with splanchnic venous blood pc p.f. laterre p. goffette, j.p. fauville, a. poncelet, p. loneux, m.s. reynaert. intensive care unit, st. luc univ. hospital, brussels, belgium. determination of gastric intramucosal ph (phi) by gastric tonometry using the henderson-hasselback equation is expected to allow the detection of splanchnic ischemia in critically ill patients. because of bicarbonate concentration and acidbase balance influences on the calculation of phi, it has been proposed to use arterio-gastric pco,_ gradient [p(gast-a)co,] to assess splanchnic perfusion. htpothesis : pcoz in the gastric mucosa is in equilibrium with intraluminal co z and with co, in the blood leaving the stomach (mesenteric and portal blood). objective: mesure pco; and ph in portal vein blood and compare its value with pco and phi obtained simultaneously by gastric tonometry. material and method : in a patient ( y.), a fiberoptic catheter (baxter r) was positionned in the portal vein after transhepatic stent shunt repermeabilisation. hemodynamic parameters, do, (vigilance n baxter), gastric co and phi (tonometrics baxter) and portal blood gas were determined at regular intervals. results : sets of data were obtained and are expressed in mean + sd. gastric pco z was , + compared to , + . mmhg for portal pco . phi was . +._ , vs . +._o, for portal ph. no correlation was found for these parameters. p (gast-a) c was . + mm hg vs + . mm hg for p (portal-a) coz (no correlation). there was a good correlation between do e and p (portal-a) co z (r = , ) [figure] but no correlation with p (gast-a) c . obiectives: desaturation is a common finding during haemodialysis (hd). pulmonary oedema might be one cause for impaired gas exchange ( ). the aim of this study was to quantitate the amount of extravascular lung water (evlw) and gasexchange in chronic renal failure patients during and after a regular hemodialysis session. methods: chronic renal failure patients without symptoms or diagnosis of cardiac or respiratory disease were studied at the start (i), at the end (ii) and two hours after (iii) a regular bicarbonate hemodialysis session. the double-indicator dilution method, with indocyanine green and the stable isotope h as tracers, was used to measure evlw ( ). arterial bloodgases and endtidal co were registered. evlw data was compared to a group of renal healthy patients ( ). dcp n evlw, ml -pao , mmhg h~o +, nmol/l control group - -- l _+ "* -+ _+ crfgroup ii -+ ~ +- ns -+ "(" iii +- t _+ ns -+ t ** p < . dcp i from dcp , t p < . dcp li or i from dcp i, :~ p < . dcp ii from dcp i the evlw at the start of dialysis was larger in the crf group than in the control group. the evlw decreased significantly to a level not different from the control group in response to the reduction in weight after hd. pao~ was normal at the start of hd and showed a nun-signficant reduction after hd. paco ( . + . kpa) and etco ( . + . kpa) were unchanged while h o+ decreased and bicarbonate increased significantly. conclusions: the elevated level of evlw at the start of hd did not impair gasexchange. the decrease in evlw did not inhibit the decrease in pao . the reduction in h + followed by a fall in alveolar vantilation is the most plausible cause for the decrease in pao in bicarbonate dialysis. . prezant lung ; : - . . wallin j appl physio ; : - . a. dona~ d. battis& l col~ r danieli, d. achill~ l viglienz;~ c. giov-anaini, p. piaropao~ oblectives: to verify if intraoperative modifications of mtramucosal gastric ph (phi) below the normal lowest value . , can be predictive for important complications, as perforation, sepsis, mof or death. methocls: we have considered patients who andenvent major abdominal surgery. all patients received the same drugs in pre-anaesthasia, the same type of anaesthesia (balanced anaesthesia) and the same treatment with h -bloekers. after the induction of anaesthesia a gastric tonometer was positioned and a catheter was positioned in the radial artery. during the operation, every minutes, the following parameters were measured at the same time: phi, arterial ph (pha), blood lactate, mean arterial pressure. in follow up we considered death and complications happened during the hospital stay, in relation to intraoperative phi falls below . . results: among the patients, had a drop of phi below . during surgery. in three of them this fall was a single episode and happened within the first hour after the begiluting of the operation. after that phi rose to nomml values until the end of the operation these patients had a normal post-operative period, without complications, the other patients had a fall of phi during the demolitive manoeuvres. two paticots of them died. the first had a lowest phi= . and the second . . the first one ~zs operated on for hepatic istiecitoma, suffered a complete del'dseenco of the surgical wound on the th day after operation and died on the th day, the second one was operated on for a hepatic carcinoma had an intraoperative haemorrhage and died ~vo hours after the end of the operation. the other patients with a fall of phi had a lowest phi= . . . . . . . respectively.the first patient,operated onfor sigmoid carcinoma, underwent on a second operation for a transmural necrosis of the colic segment on the th day; the second one, operated for carcinoma of the right colon, had a cardiac ischelnia on the th pest-operative day and a dehiscence of the surgical wound on the th day: the third one, operated on for a sigmoid carcinoma, had melena in h post~ operative da b, and finally the fonrth patient, operated on for carcinoma of the tight colon, suffered a fistula of the surgical enteral anastomosis.all these patients were discharged alive from the hospital. the other patients, who had not reductions of phi ditring the operation, had a normal pest-operative period, without complications. conclusion: phi was able to predict the arising of some complications, probably due to intraoperative ischemic events. we can say that gastric tenometry, for its low invasivi.ty, can be included among the intraoperative monitoring in patients that tmdenvent on major abdominal surgery. (ttd),t"ea~rrerj.~ of hours duraticn. all l:atients nm.'-~ms_(~lly va~ ated in eantrol wcde ard_ la':'ad a a,~m--ganz catheter, with optic fibers for contirums mmsuremmt of svo mic studies were performed, c~e before the hegir~ of hd, c~e rain after the ~, ~ne at the middle, ~ne rain before lhe erd ard one rain after the erd of hd. paired t test ~as used far slatistical eval~ti~n. results: daring i~d there was a significant'reductton (p<o.~) of: c~tr~ venc~s eres~.re ( ve)emm to . ~ ~, ) ~arn'~w capil~ ~f~e pressure (i<~p) fr~n to ~mg hg, ) i~ from to . mmg hg. ~here was also a less pmnameed bat also-slatistics/ly significant r~ucticn (p<o. ) of: i) s~o~ from to patients undergoing surgical reconstruction of the aorta due to anenrysms of its abdominal part may develop transient and sometimes sustained episodes of dysoxia despite the conventional appeoreneas of being adequately resuscitated. indirect masurement of gastric mussel ph (phi) is being widely evaluated as a minimally invasive and sensitive means of assessing the adequaey of tissue oxygenation in these circumstances. the duration end degree of gastric intramucosal acidosis are related to the risk developing injured gastrointestinal tract end its putative consequences, i.e. translceation, cytokine release, organ dysfunction end failure, sepsis end death. measurement of phi is obtained indirectly by measuring pc in the lumen of the stomach with a silicone balloon tonometer (tonometrics, inc., worcester, ma, usa) and the bicarbonate concentration in arlz,,rial blood, end substituting these two values in the henderson-hasselbalch equation. objectives: to evaluate whether perioperative phi changes are predictive of complications end outcome end how they compare to standard haemodyuamic and oxygen trensport parameters. methods: patients ( males and female) urtderwent surgical replacement of abdominal aortic anonrysm with the aortic simple or bifurcated grail. patients were operated on eleetively, had an emergency surgery for raptured enentysm. haemodynamic, arterial ph and bicarbonate concentration measurements were taken before and after induction of anaesthesia, after cross-clamping and declamping of the aorta end at admission to itu. phi calculations ware done at the sime time except before induction, as tonometers were inserted after patient had been asleep. we used pulmonary utilizing a computer billing survey as well as hospital service transfer data from a month period ( / - / ), all obstetric patients that were transferred to the med/surg icu were identified, as well as their diagnoses and procedures. twenty-eight obstetric patients were transferred to the med/surg icu, compared to , deliveries occurring during that time period for a . % rate. the following procedural indications for icu transfer occured: insertions of endotracheal tubes, arterial catheterizations, temporary tracheostumy, and venous catheter. the following medical diagnoses were found: hypertensive/eclamptic episodes, hypotensive episodes, pulmonary embolism, mitral stenosis, and coagulation deficiency. there were four episodes of respiratory failure ( %). the historical rates of respiratory failure from the medical literature seen at a university hospital ore higher than those at our community hospital despite comparable icu transfer rates for critically ill ob patients. objectives: to evaluate the usefulness of several isss used in order to predict risk of death (rd). design: prospective data collection for months in a multidisciplinary -bed icu. methods: data from consecutive patients admitted to the icu from / / to / / were studied. all the necessary informations were stored in a computer using special software for every day computation of three isss (saps, saps ii, apache ii) and of the rd predicted by saps ii, mpm , mpm and odin. data from days of hospitalisation were used for comparative evaluation of isss and rd, while sensitivity and specificity in death prediction (cut off point of rd = %) were evaluated from data collected during the day of admission (saps ii, rpm , odin) or after hrs (mpm ). agreement between rd predictions was evaluated by bland and altman analysis. results:our results were the following: objectives: a) to create and validate software specially designed for the collection of demographic data and estimation of illness severity and predicted rd and b) to provide data necessary for the evaluation of the effectiveness and the efficiency of our icu. design: prospective data collection in a multidisciplinary -bed icu. methods: prospective data on specific physiological variables, selected demographic characteristics, comorbidity and the reason for icu admission were recorded every day for consecutive patients admitted to the icu from / / to / / . data were entered into a portable computer using specially designed software allowing the calculation of usual illness severity scoring systems (isss) and the corresponding predicted rd. results: we studied men and women, with a mean age of years. we conclude that, although observed mortality was higher than predicted rd, this difference was not statistically significant. the fact that the sd of predicted rd was too large, limits the usefulness of isss predictions for a comparative evaluation of different icus. objectives :the importance of objective evaluation of patients prognosis at their admission to an emergency department is clear. the aim of this study was to appreciate the prognosis of patients with the simplified acute physiology score ii (saps ii), and correlate this score to the prognosis and orientations of patients. methods : the score which is a reduced form of saps ii was calculated from clinical variables and laboratory items for patients. sensibili}y (se), specificity (sp) and accuracy (ac) were calculated to evaluate the performances of saps i . thresholds were calculated with the youden's test (se+sp- ). results : patients were admitted in the intensive care unit (icu)and patients in medical units; patients died. the saps ii was higher in patients which died than the survivors ( , + , vs. , + , , p< , ; respectively), the best threshold was , se was de %, sp was %, the ac was / . thus for patients admitted in icu than in medical unit ( , : : , vs. , + , , p< , ; respectively); the best threshold was , se was %, the sp was %, the ac was %. conclusions : these preliminary results suggest that saps ii can be used to determine the short term prognosis and the destination of patients seen in an emergency department. design: data was collected on all admissions over a six month period. all patients had a screening hiv elisa test. confirmatory ifa tests, western blot and flow cytometry were performed on hiv positive patients. the institutional ethics committee considered the major clinical impact of the study sufficient cause to waive the patient's right to informed consent, icu staff and patients were blinded to hiv results. following discharge patients were given the option of being advised of their hiv status. setting: the study was conducted in a bedded surgical icu at a tertiary care teaching hospital. patients, participants: all patients admitted during the period in question were included. interventions: "all patients were treated according to standard icu protocols. there were no interventions. results: most patients were admitted following trauma. there were no patients with aids, hiv positive and hiv negative patients. with respect to the latter two groups, the mean age and sex distribution was similar, there was a significant difference in organ failure ( % versus %, p < . ) and septic shock ( % versus %, p , : ) but no difference in icu/hosp[tal mortality or duration of icu/hospital stay. flow cytometry changes in hiv positive patients were consistent with the quiescent phase of hiv infection. conclusion: while morbidity is higher in hiv positive patients, there is no difference in mortality. hiv status should, therefore, not be an exclusion criterion for icu admission in this patient population. , n= ) and january-march (period , n= ) were studied. interventions: a resident micu team led by a trained intensivist took over the medical care from the primary physicians when the patients were admitted to the micu. the intensivist also vetted micu admissions and decided on micu discharge. in addition, there was a resident respiratory therapist to attend to vendlatory care during office hours. after office hours, the care of the micu was delegated to the on-call team on a rotational basis among the medical departments. results: the patients in the two groups were similar with respect to age, sex, race, source of admission and apache scores. the icu and hospital mortalities decreased from . % to . % (p=ns) and . % and . % (p=ns) respectively in period . the mean icu and hospital stay was also decreased from . __+ . to . + . days (p=ns) and . __+ to . • . days (p=ns) respectively. the improved micu length of stay for survivors in period was statistically significant ( . • . days vs . • . days = . ). there was no significant differences in the vse of peritoneal dialysis ( . % vs . %) and mechanical ventilation ( . % vs . %). however, utilisation of intra-arterial lines and pulmonary artery catheters increased from % in both to . % and . % respectively in period . conclusion: the duration of critical illness was reduced in period . hence, we believe that the closed |cu which was staffed by an intensivist and had the services of a respiratory therapist was beneficial for the care of the critically ill. the intensivist, was also more likely to utilise invasive monitoring. in the absence of liver transplantation, intensive care for patients with acute hepatic decompensation arising from alcoholic liver disease (ald) is indicated only for those who are likely to benefit from conventional means of organ support. we have attempted to elucidate potential risk factors and the efficacy of organ support in relation both to hospital outcome and icu costs so as to allow the earlier identification of relatively futile intensive care in this group of patients. methods: over a period of one year, ald patients ( males; females; median age years, median apache ii score ; hospital mortality %)with severe complications ( [ %] with bleeding oesophageal varices, [ %] with hepatorenel failure, [ %] with respiratory failure, [ %] with septic shock, and [ %] others) were studied in our liver icu. organ system failure, daily therapeutic interventions and icu costs were assessed using a patient management system (riyadh intensive care program). results: whilst survivors had a significantly lower admission apache ii score compared with non survivors (medians and , p< . ), or more organ systems in failure in the first hours of icu admission was associated with a % ( ) mortality. mortality was also related to child's grading and the numbers of organs supported. of the patients who received more than one form of organ support only one survived. organs supported mortality a (n= ) % none / ; % b (n= ) . % one / ; % c (n= ) . % two or more / ; % the icu costs for the patients were only s but s ( %, patient days) was utilised by the patients who died, giving an effective cost per survivor (ecps) of s . although the cost of treating the patients with or more organ systems in failure on the day of admission was s ( % of the budget) the ecps was s . conclusion patients with ald who have or more organ systems in failure early in their icu course have a poor prognosis and in the absence of liver transplantation, traditional strategies of organ support are ineffective. this begs the question whether such costly care is appropriate as although the ecps in this sub group is comparable with other patient groups with multiple organ failure, their outcome is considerably worse. objectives: to evaluate the economic impact to the healthcare sector of using dopexamine hydrochloride infusions to deliberately increase perioperative oxygen delivery in high-risk patients. methods: effectiveness data were obtained from a controlled clinical trial in which surgical patients were randomly assigned to either a control group (n = to receive best standard optimal fluid resuscitation perioperatively, or a protocol group (n = ) to receive, in addition, an infusion of dopexamine hydrochloride to increase the perioperative oxygen delivery index to greater than ml/min per square metre. resources consumed by patients during treatment were recorded prospectively and costs of resources at / prices were obtained retrospectively. cost-effectiveness ratios were estimated by dividing the total cost for each treatment group by the total number of patients in each group and by the clinical outcome of mortality days postoperatively. results: in the protocol group, there was a % reduction in mortality days postoperatively (p = . ), a significant reduction in the number of complications (p = . ) and a reduction in length of stay in the icu and surgical ward. the average cost per protocol patient to achieve a . % survival rate days postoperatively was s , , resulting in an average cost of s , per surviving protocol patient. the average cost of a control patient was s , to achieve a . % survival rate days postoperatively, resulting in an average cost of s , per surviving control patient. the use of dopexamine to deliberately increase oxygen delivery perioperatively generated a cost saving to the nhs of s , per patient together with a % reduction in mortality at days postoperatively. hence, the cost per surviving protocol patient was s . less than the cost of a surviving control patient. conclusion: the additional cost of dopexamine in protocol patients was offset by a lower incidence of complications and a shorter stay in the icu and on the surgical ward. hence, increasing oxygen delivery perioperatively in high-risk surgical patients saves both money and lives. objective: although king's college criteria are widely used, indication and timing for liver transplantation in acute liver failure is still far from certain. long-latency sensory evoked potentials -a proven measure of metabolic brain dysfunction (grimm et al. lancet ; : - ; madl et al. lancet ; : - ) -are markedly affected in patients with acute liver failure. serial sensory evoked potential recording should provide very useful information for the management of patients with acute liver failure. methods: recordings of standard bilateral sensory evoked potentials were performed in patients with acute liver failure. findings were focused on cortical n peak -a stable negative deflection occuring • ms after median nerve stimulation in healthy subjects, which can be recorded by skull electrodes over the sensory cortex. results: nine patients recovered spontaneously, patients were referred to emergency liver transplantation, and patients died. in all patients who recovered spontaneously, n peak was detectable between and ms. all patients who were referred to liver transplantation and of patients who died, developed a loss of a prior detectable n peak during the course of acute liver failure. objective: to determine high risk arid low risk patient groups in a medical intensive care unit regarding short term and long term outcome. methods: data on all admissions of the year were collected prospectively. according to their mode of admission patients were classified as admissions by the physician staffed ambulance service (as), admissions through the emergency department (ed)i referrals from non-intensive care wards (ni), and secondary referrals from other hospitals (oth). outcome was assessed in terms of in-unit mortality, in-hospital mortality, and long time mortality. patient groups were compared using the \ -test. life table analysis were per{ormed by kaplan-meier method comparing patient groups by log-rank test. the software spss for windows . . was used for statistical calculations. results: in-unit mortality: / patients ( . %) --oth . % > as . %> ni . % > ed . %; p = . . in-hospital mortality: / patients ( . %) --oth . % > ni . % > as . % > ed . %; p = , . mean survival time in days after discharge: as < ni < oth < ed ; p = . . conclusions: despite an excess in-unit mortality of secondary referrals from other hospitals the iongtime course of this special patient group is not different to others. solsuam, j, marrugat*, g, mirs, j, nolla, a, vazqu~z-sanchez, l alvamz, ~ioio s xndioina i~siw. ir~itate l(~icipal da l~sti~isn l~di~*, ~ospits dal objective: to study the influence of modifiable variables (complications derived from therapeutic activities) on the prognosis of ~atients admitted to the icu indapemently on thn severity of illnsss. patients am methods: between january asd ]lay data from , patients over years of aqe who retained in the icu for mare than hours ~ere pr~pectively regiatered. a cohort st~ly with follo~-~ nf patients durin~ ~eir stey in the hospital was deni~.el in all patients, reasons for a~issien, principal diagnosis sad severity of illn~s moasared by the saps scare vare recorded. fastens affecting patients' outcome that my be proventsd or modified included technical :omplisafioss, heapital-acqnired infections and in~pro~riate therapeutic decisions. a logistic regression model was used to assess the relative risk (l~} for in-heapital mortality adjusted for each variable. results: ic~ mortality ~s . % and in-hospitul mortality . %. patients who died showed a higher spas score then survivors ( , ~ i ,i). after adjusting hy severity of illness, co~;licetices that statistically increased the risk of in-hospital death were septic shock secomery to hoapitul-acqdired infection ( ~ . ; % el, . to . ), pmo~othor~x related to mocasnical ventilation (@ . ; % cl, . to . ) and delay in the insertion of a fln~-quidod catheter (ii~ . ; % ic, i.i to . ). col~lusien: registration of complicaticas derived from therapeutic activities is a valuable tool far quality central in the icu. g, ~i~ , j.l mle~ma, j, ~amqat*, j..~lla, a, vazquez-saltemz, f, alvamz , servioia de nndicina l~siu. i~stitutu ~icipal de ln~sti~acidn ~ i:a*, hospital dsl objective: to dstsr~ine the incidence of self-extebatien and its effect on ~ortality. patients and ]~etheds: betveen january and april , all i~tiente in whom selfextubatien w~s registered were inclnded in a prospective study. patients were divided into @nee who needed r~intabatinn within hoers and those who did not. in all patients, dsmoqraphie and ciinical data were recorded as well as icii mortality, in-hoapital mrtality and severity of illness according to saps score. eta were analyzed usi~ the cbj-square test for cathgorical verinbls, the analysis of varianc~ (anva) for aontinuc~ ~ria~les and a leqi tic regression anal~is to estimate the relative risk (iiii) for mortality as result of celt-nxtt~ation after adjusting for severity of illness. results: a total of intnmtsd patients amre stndied. self-extu~atien occurred in ( . %) patients and . % required reintuhot~pn. when a co,arise was made between patients who did not required reint@atinn and patien~.s who did, statistically significant differences in eqe ( . v_s . years, p = .~ ), ~verity of illness ( . ~ . spas score, p = . ), dia~isstia category ( s. % v_s . % of patients with res~iratury conditiono, p = , } and mean length of stay ( , ~ , days~ p = . ) were fo~m, a~ter ad~sti~ for severity, patients with self-ext@atinn who did not reqnired reintalatien showed a . iir for mortality ( % ci, .i to . ) as co~arod with patients in when self-ext@ation did mot occur. conclnsien: self-~extamtice that does not require reint@ation is associated with a isamr in-hospital natality probably dt~ to a prolonged period of weaming. patients' admissions to ices am often delayed doe to the shortage of beds available. @ile amaltieq icu admission, these patients are treated in observation nits of @e emergency services which bare ,either tile structure nor the trained ~reomenl that are available in leb~. objective: to daterdno the effect on the patient's proqusis of a delay in tile admission to the icu when criteria for icij admission are fulfilled. ~terials and methods: between jme am l?ece~ber all patients who fulfilled criteria to be almittod to the ic who for waste~r reason retained in tile observation unit for more than hours were included in a prospective stedy. in all patients, des~raphic end clinical dabs amre recorded as well as severity of illness aencrdi~j to saps score. a cesucontrol dasi~ was eend with a total ss~ln of , patients who suffered no delay is admission to icii over a period of years. data wen analyzed using the chl.-squ~re test (to aeons the association hetwenn in-patienty mortality end categorical vari~lns) and a maltipln logistic reqression model to sstimta odds ratio for) for in-hospital mortality as result of delay in icy admission as compared with early ad~issi| after adjusting for severity of illness end use of assisted mchenical ventilation. ~ &ults: a total of patients remained in the observation nit for more than hours with a del w in igd admission of . _+ . hoers. assisted mechanical ventilation was requited in % of patients and only monitericatien in %. itsse patients were cspared with ntients from the tet~l sample ratchod by age, sp~ score and rennoss of admission. in-hospital mortality for cases warn % as compared with . % for controls (p = s). after adjamtilg fen spas, age and mobamioal ventihtien, no statistically significant differences between both ~renpa were foam, altho~b there was a tendency towards a higher mortality amen@ patients with delay in icu admission (or = . ; % ci, , to , ). conclnnien: ~se findings suggest that prognosis of critically-ill patients is no worse as a result of admission to the loll being deln~d for borers. all data appropriate for the calculation of the apache ii score (aps) together wi'th other specific cardiac details relevant to these .patients were collected daily, verified and enter~ into a computer database. results: patients were studied. six patients died and five of thee underwent cardiac surgery. the mean aps was for survivors and t for non-survivors (p < . ). the mortality ratio was . and the major markers of mortality were apache ![ score, presence of chronic ill health, mean duration of ventiiation, mean length of icu stay and need for emergen~ surgery. sixteen percent ( ) of icu bed days were occupied by % of patients (non-sarvivors) which resulted in cancellation of cardiac sot#cat sessions in momhs. conclusions: this study concludes that apache t could be used as an audit tool in a cardiac surgical icu and demonstrates the severe compromis~don of cardiac surgical throughput by a few non-survivors, organ to determine the number of organ failure free days (offd) in a cohort of survivors and non-survivors with sepsis syndrome followed over a day period. ) to determine sample size requirements for clinical trials utilizing a increase in the number of organ failure free days as the primary outcome as opposed to mortality. methods: beginning december through to april , patients who met inclusion criteria of the "cardiopulmonary effects of ibuprofen in sepsis syndrome" and who did not have hiv/aids. brain death or moribund state were prospectively identified. presence or absence of failure of organ systems (pulmonary, cvs, renal, hepatic, gi, hematologic, & cns) was recorded daily until death or until days. a score of one was assigned to each organ system free of organ failure in patients still alive, ie, maximum daily off score= , maximum day off scorn= , sample size estimations were performed for variable detectable differences in off scores (delta). alpha was set at . (two-sided), with n/group = [(z a +z b ) o conclusions: a clinically relevant increase in off days may be detected with as small a sample size as to patients per group. this represents a significantly smaller sample size than needed to detect a change in mortality from % to % ( % relative risk reduction) where the n/group= . scoring patients in this manner prevents a lethal inte~entien from providing an improved organ failure score. in addition, an intervention that prolongs survival must also provide greater organ failure free days in order to be counted by this scoring method. survival as an outcome provides no information about the quality of that survival. off days provides a measurement of burden of illness. interventions which lessens this burden may be just as valuable as those that decrease mortality by providing a measure of the quality of survival and by decreasing costs of care. they may also prove to be an accurate surrogate marker of mortality. the advantage of this approach is that the event rote is much higher and sample size requirements are subsequently smaller. this would mean that clinical trials can be completed faster and at lower cost. outcomes such as mortality could then be assessed at a later date utilizing recta-analysis. we suggest that the use of off days is a valid outcome measure that may be utilized in clihieal trials of sepsis syndrome. the icu is perceived by many as being a stressful environment for both patients and staff. stress has been defined in three ways: a stimulus producing a particular response; the physiological and psychological response to a stimulus; an interaction butwom an individual and their environment. stress is currently thought to be a dynamic system of stimulus and. response which takes into account the individual's perception of the stimulus and their ability to respond effectively. stress may, therefore, be positive and allow personal development but an individual unable to respond effectively to a stimulus will experience negative effects or strain. critical illness is an intense stimulus to which the body needs to respond effectively. physiological responses are vital and most of intensive care involves supporting these. alternatively, blocking them, for instance with atom(date, increases mortality. psyehological responses are also vital but often poorly appreciated because of communication problems. many of the problems patients experience in an icu are evidence of psychological strain. this can be exhibited in various ways, for instance, anxiety, depression, passivity and confusion. dealing with critically ill patients is perceived as stressful. we recently studied occupational stress in our icu. most aspects of intensive care were not generally perceived as stressful indicating a self-selectien of icu staff. the most stressful aspects of icu work for nursing staff were the structure of the organization and career opportunities. medical and nursing staff had different stressors and different coping strategies. support for occupational stress, therefore, should focus on the individual and concentrate on information and communication. atmosphere, and especially at intensive care units, we face up to daily decision making. in most cases these are taken on the basis of personal opinion and the processing of a very limited amount of information. rising need to optimize the results of medical attendance becomes necessary to set structured system of d@cision making in which ethical basis have a sp@dial significance in view of next considerations: -we live into a pluralist society in which the importance of values is different. -most persons consider health as the first value only in the event of illness. -medical resources available are limited, whereas medical, attendance demand from population increases in a way many people consider it unlimited. in consequence, it becomes necessary to set up priorities in patients treatment. ehtical basis that rule decision making are essentially these ones: i. beneficence: to provide the patient that is being treated the highest profit. . non maleficence: it is our first duty to avoid hurting or damaging the patient."primum non nocere" . autonomy: in every particular medical attendance, the patient has ability to decide by himself. . justice: as equity: to provide the same treatment for those who have the same pathology, ignoring another factors such as age, sex or race. severe application of these principles can cause difficulty, which resolution requires a systematization of decision making. ( - ) . the lenght of stay between survivors and non survivors didn "t show statistical significance (p = . ). the mean aiii score when considering all admissions was , ( - ) . the initial score between survivors and non survivors showed ststistical difference ( . vs . ) respectively (p < . ). univariate logistic regresion analysis demostrated a % increment in death probability for every points augmentation in the aiii score with a sensitlbity of . % and specificity of . %, the roc curve showed that the best cut off point for death prediction was points with a sensitivity of . % and specificity of . %. if a patient is classified as high risk (> ) the bayesian analysis showed a . probability of death and for one class(fed as low risk (< ) a death probability < %. conclusions: the first day aiii score in this population showed to be a good discriminator between survivors and non survivors, and the risk of death augments as the aiii does. in this population an aiii score > points is asociated with a greater risk of death. using the aiii score in conjuntion with the clinical judgement will help clinicians reducing uncertainty in the every day decision making and better predict outcome, the results from this study should been taken with caution because the data were obtained from a small sample. objective: the quality of life has been considered a "uniquely personal perception" resulting from a mixture of health related factors and social circumstances [t. m. gill, jama , : ] . the aim of this study was to evaluate two measures of pqol in intensive care unit (icu) admitted patients. patients and methods: during icu stay and six-months after hospital discharge, co-operative icu admitted patients were directly interviewed about their pqol. we administered ftrstly the uniscale (pqolu) [sage et al crit. care med. , : - ] and then a step verbal scale (pqolv): best, good, fair, poor, worst. of the studied patients, at the first interview, were able to use both scales, but ( . %) understood only the verbal one. at the second interview, patients were not able to answer, used both scales and only pqolv. statistical analysis was performed using wilcoxon signed ranks, spearman rank correlation, student's t and chi square tests. results: of all cardiac surgery pts, pts ( . %) died in icu. they were males ( . %) and females ( . %). their mean age was (+ ) years and mean ef was . (+ . ). nineteen pts ( %) had low (< . ) preoperative ef. mortality was . % in the coronary artery bypass grafting (cabg) group (n= ) and . % in the valve replacement (vr) group (n= ). in the cabg +vr group, mortality was . % (n= ), and . % in the remaining pts (n= ). cardiogenic shock was the sole cause of death in pts ( %), septic shock in pts, whereas sepsis in combination with ards in pts, sepsis and stroke in two pts. in addition, pts died from cerebrovascular accidents, one from ards and one from pulmonary embolism. the pts who died in the icu had a significantly longer bypass and aortic cross clamp time and received more blood transfusions (p< . ) than a matched control group that survived to icu discharge. the duration of mechanical ventilation and length of icu stay were greater in the pts who died in the icu than in the control group. conclusions: . although cardiogenic shock is the main cause of death ( %)in cardiac surgery pts, sepsis and cerebrovascular accident are relatively frequent causes. . patients who died in the icu had longer bypass and aortic cross clamp time and received more transfusions, compared with the control group. . although renal or hepatic failure contributed to death in some pts, they were not the primary cause of death in any patient. objectives: evaluate the acute and follow-up outcome of patients (pts) treated with primary ptca (without prior thrombolysis) in acute myocardial infarction (ami) after and up to hours after onset of typical thoracic pain ("late" primary-ptca). methods and patients characteristics: from / to / consecutive pts with ami were treated by primary ptca in the wuppertal heart center pts ( , %) were admitted to our hospital > hours and < hours after symptom onset with ongoing chest pain and typical ecg-changes.mean age was years ( - ). pts were male, four female. % had an anterior wall myocardial infarction, % suffered an inferior/postero-lateral wall myocardial infarction.two pts were in cardiogenic shock at admission. singlevessel-disease was documented in . %, multi-vessel-disease in . %. average time of onset of pain to recanalisation was min ( - ). angiography revealed timi-flow in . % of the pts, timi-flow i in . %, timi-flow ii in . %. average follow-up (fu) period was months ( - months). timi iii lv-ef ~ -day major late re-late flow p.i.* aeute/fu mortality bleeds infarction mortality . % %/ % . % . % . % % early mortality occured in the two pts, who were in cardiogenic shock at admission no pt required emergency coronary artery bypass grafting.restenosis > % was seen in % of the pts. conclusions: "late" primary ptca achieves a favourable high recanalisation rate of about % (timi ill-flow) in our study group. additionally, there seems to be a trend for lv-ef improvement in follow-up. early high mortality is influenced by the patients admitted in cardiogenic shock. there might be a trend for increased major bleeding complications. objective: to assess the validity of saps ii (new simplified acute physiology score), comparing it with the previous version, (saps), in a sample of patients recruited by giviti, a network of icu's representative of the italian icu system methods: measures of calibration (goodness-of-fit statistics) and discrimination (receiver operating characteristics curve and area under the curve) were adopted in the whole sample and across subgroups differing in relevant prognostic characteristics. of the patients recruited during one month period, a total of patients were included in this study. for the purpose of the comparison of the two scores, patients with less than years, or having cardiac surgery or staying in the icu less than hours were excluded. vital status at icu discharge in the whole sample and at hospital discharge in half cases wher adopted as outcome measure. re$ ~: saps ii fits the data equally well compared to the older version (goodness-of-fit p= . and in the new and old versions, respectively) but its performance is somewhat better in terms of capability to distinguish patients who live from patients who die (areas under the curve . and . , respectively). furthermore, saps ii is better in terms of uniformity of fit across relevant subgroups, although substantial over prediction of mortality was observed in trauma patients and in patients admitted without organ failure to be intensively monitored. saps ii performed very wet] also in the subsample where hospital mortality was the dependent variable.satisfactory measures of calibration (goodness-of-fit p-- . ) and discrimination (receiver operating characteristics area= . ) were observed. c nr saps ii, a multipurpose scoring system developed in an international study, retains its validity in this independent sample of patients recruited in a large network of italian icus. although it has shown a good performance when adopted to predict icu and hospital mortality in the entire sample, further investigations are warranted. the observed over prediction of mortality in a few subgroups indeed call for a through assessment of the impact of confounders and biases on model performance when saps ii is adopted in samples that do not reflect the "average" icu patient. objectives: ) assess the effectiveness in a group of intensive care units by means of a quality performance index (qpi); ) assess the efficiency by means of a resource use index (rui); ) evaluate the performance of individual icus with respect to both indices (clinical and economical) while controlling for severity of illness. critical from ucis in catalonia patients alearic islands have been included in the study. inhospital mortality and weighted hospital lenght-of-stay (los) have been considered the outcome variables. severity of illness has been measured with the mpm ii at admission. in each icu, expected mortality has been obtained adding the probabilities of dying for its patients. expected los has been estimated adjusting a second order polynomial to the severity of illness. performance indices have been obtained by dividing the observed by the expected outcomes. re~ult~: the overall qpi was . and it ranged from . to . in the icus. the overall rui was and it ranged l~ont . to . . there was not a trade-offpattern between clinical performance and resource use. objectives: teaching hospitals often provide [cu care across a variety of specialized services. overall, this approach appears to result in the best risk adjusted survival rates, but at the highest cost (critical care medicine ; : - ): recently, there has been increasing focus on markers of overall hospital performance. however, in large teaching institutions, such markers may fail to detect intra-institntional variation at a large tertiary care medical center. methods: first intensive care unit (icu) day, acute physiology and chronic health evaluation iii (apache iii) and active therapeutic intervention scoring system (tiss) data were collected on random admissions to specialty icus with beds (range - ) between february i and december l, . post-operative solid organ transplant recipients were excluded. units included general medical, general surgical, and trauma, neurosurgery, cardio-thoracic surgery, and coronary care units. data were analyzed for risk adjusted outcomes: icu and hospital mortality and length ef stay (los); risk of requiring active cu treatment; and icu readmissinn using apache iii risk prediction models. results: the study icus cared for a diverse group of patients. mean apache iii scores ranged from . - . ; predicted risk of hospital death ranged from . - . %. standardized mortality ratios ranged from . to . with icus performing significantly better and performing worse than predicted (p< , ). los ratios and icu readmission rates ranged from . to . (ns) and . to . % respectively. patients predicted at low risk of requiring active icu treatment ranged from , to . % conclusions: there was wide variation in the mean level of patient severity between icus. after controlling for this severity, outcomes also varied widely. no clear pattern of overall institutional performance was evident. these data suggest that efforts to assess performance, improve quality, and maximize efficiency must be focused within individual units. programmatic evaluation of outcome allows for focused review of the processes of care contributing to good outcome (best practices) and where to focus ongoing quality improvement and cost reduction activities. background and method : we compared icu mortality in different age groups presenting with the same severity of disease. we assessed severity of illness by the physiological day -apache~ (physio-aa) score (thus excluding the age related points). for each of the following physio-a n score intervals ( - ; - ; - ; - ; > ) , we compared tcu mortality within age intervals (< ; - ; - ; - ; - ; > years - , - , - ) . in these groups mortality may be twice higher in the > years patients than in the _< years. mortality does not vary with age in low (physio a n = - ) and high (physio a n = > ) risk groups. in the low risk group, mortality is low in all the age intervals because of the begninity of illness. in the high risk group, extreme severity of disease probably blunts the impact of age and leads to high mortality rates in all age intervals. introduction: to access the actual social/clinical outcome of the patients who undenvent intensive care therapy oct) is rather difficult, quality of lilr is not easih.' defined and ohserver subjectivity is a prime factor in the evaluation. mortality ratio after discharge must be established and its causes understood. obieetives: the propose of this stud)-is to look into the mortality ratio that occurred on a series of patients that undorwent ict at our unit from of the ~iew point of severity of the original illness and the diagnostic groups. material and methods: during the period of one )-ear ( ), patients were treated at the unit, of them died, and ~ere not matched in our series because os incumpletc records. thirteen patients died in hospital after their reference to other departments, twelve patients were lost after discharge. thus. at the end. only patients were evaluated on the fu. the, were classified into the follov ng three groups: acute medical, elective surge d and acute and emergency postoperative. the patients were seen at , and months after discharge. the, were evaluated in accordance to their abili~, to being self supported in their daily life and capecity to fully return and hold to their pre~ ous jobs. apache scores were evaluated for each of the three groups and correlated to the icu dead, hospital dead, and mortality after hospital discharge, spss package was used for statistical analysis. remlts/conclasions: data shows that / patients died after discharge from the hospital, of ~itch nine died in the first three months. seventy-eight per cent of the patients were fully self supported in their daily life and % showed some kind of handicap. fosty-nine per cent of the patients wore on retirement either due to age or some form of chronic disease, when admilled to our unit. thirty-two peg cent had not been able to return to work, because the" were incapacitated on discharge. only % had return to their fully jobs but the period of the stu~, is not enough for all of them to be fully physically recovered. preliminmy statistical analysis shows us significant differences among groups. the aim of the present study is to compare the prognostic performance of five general severity indices ou coronary patienta and to find out if a proper ntatistical hundling of these indices could provide better results in these patients. methods: saps ii, mpm ii (mpm ii i mpmp ii ), apach ii end gaprik were evaluated o~ patients with acute myocardial infurction admitted to intensive care units from catulunye. calibration and discrimination were calculated for each index. calibration was calculated by th bosmer-lemeshow test. discrimination was evaluated by the area under the relative operating characteristic (roc)curve. if a model did not show a good performance it was customized using multiple logistic regression. finally, tworeduced models were developed, one fro~ the mpm series (mpm ii cor) and one from the group apache-saps (sapsiicor).their performances were again evaluated. results: discrimination was high enough for all models. neverthelees, oelibration of apache ii, saps ii and mpm was not satisfactory. thus,mpm ii , saps ii and gaprik were customized for coronary patients using the logits of both models, and obtaining good calibrations. mpm ii , and apache-saps were adapted and reduced to (mpm ii cor) end to variables (sapsiicor), respectively . both models showed better oalibrutions end discriminations than the original models. conolusion| models developed for multidisciplinary patients show a good discrimination when applied on aoronar i patients, but some needed customization in order to improve calibration. the number of variables of the principal model can be reduced (even to or variables) without loosing prognostic accuracy. objective: to compare the ability of two methods to predict outcome for intensive care patients. methods: we included consecutive intensive therapy unit (itu) admissions with an itu stay> hrs in a month prospective study (exclusion criteria: burn injury and age < yrs). data were couectsd applying the criteria described by the developers [ , ] . the definition of coma (mpm ii) was modified and the best assessment within in's, rather than the admission score, was used. statistical analysis included classification tables and receiver operaung characteristics (roc) curves to assess discriminative power, and lemeshaw-hosmer statistics and calibration curves to test accuracy of prediction. results~ average abe was yrs (ranse: - ) with a male:female ratio of . : . the actual hospital mortality was . %, mean predicted death rates were . % (mpmz ii) and . % (ap hi). non-survivors had siguitlcanfly higher predicted risks than survivors applying both methods (p< . l, t-test). the total correct classification rates (tccr) for apache iii were bett~r for all decision criteria applied (tccr, decision criterion %: apache ]/i . %, mpm ii . %). the area under the roc curve was . (ap iii) and . (mpm ii) confirming the better discrimination of apache ill. accuracy of risk prediction was similar for both models (ap nl ~ - , mpm b ;( - , lemeslmw-hosmer). showing some fluctuation, calibration curves lay close to the ideal line for predicted risks -< % with increasing deviation for higher risk groups (s. figure) . apache iii underestimated the risks of hospital death for almost all risk groups (curve above diagonal), whereas considerable overestimation for predicted risks > % ceenred with mpm~ii. objective: to assess the goodness-of-fit of the apache iii model for british itu patients. methods: we prospectively studied a cohort of adult patients consecutively admitted to a medical-surgical itu over a period of months. patients with burn injury, age < yrs and itu stay < hrs were excluded. using a eomputerlsed database, we routinely recorded hrs apache ill scores. predicted risks of hospital death were computed by critical audit ltd, london. accuracy of risk prediefion was assessed by hosmer-lemeshaw chi square (;( ) statistics and calibration curves [ ]. discrimination was tested employing classification tables and receiver operating characteristics curves (roc). restths: the mean age of the male and female patients was yrs (range: - yrs). of these patients, % were medical admissions, % were admired after emergency and % after elective surgery. the observed hospital mortality was . %, the overall mean predicted death rate was . %. mean predicted risks were siguifieanfiy greater for nonsurvivors ( . %o) than for survivors ( . %, p< . l, t-test). apache iii showed good calibration (z -~ , lemeshaw-hosmer). however, the calibration curve lay above the diagonal for almost all risk groups reflecting the tendency to underestimate actual mortality (s. figure) . the best total correct classification rate (tccr) was . % (decision criterion: %). the area under the roc curve was . % confirming the good discriminative ability of the model. objectives: the aim of this study is to point out the discrepancies between needs and actual treatment of less severely ili patients admitted in italian intensive cam units (icus) requiring only intensive monitoring, and verify the substantial likelihood of data comparing those collected from a national short term study with a regional long ternl use. ~: less severely ill patients ("observed patients") were only monitored; they did not require intubation, even if for a short period (less than houm) or major cardioeiranlatory supports, and were neurologically normal. epidemiologieal national data were obtained from giviti group (gruppo italiano valutazione interventi in terapia intensiva); this cohort study, collected patients, in two months in summer in all over italy. regional data were echieved in a three years entlection ( -i ) in lombardia' icus from archidia group (arehivio diagnostieo), including patients. mortality, severity score, diagnostic category and some typical intensive procedures were analysed and compared in both studies. patients' disgunstie categories were defined as surgical, medical and trauma, according to the main diagnosis and the presence/absence of surgical procedures. rr observed patients account for . % and % of all icu's patients respectively in national and regional data. very tow mortality rate was found in national data ( . %) and extremely low mortality in regional data ( . %). in both studies mortality, s.a.p.s. and length of stay were much lowor in "observed patients" than in general icu's population (mortality: . % and . %; .a.p.s. score: . and ; iength of stay: % and ). homologous distribution of patients in the two studies was noted for what concern their diagnostic category, aside from a slight prevalence of tranmatised patients in the giviti study. in the two groups the surgical patients were respectively % vs. %, medical patients were % vs. % and traumatised were % vs. %. % of "observed patients" in national study and % in the regional did not received any intensive procedure. only a minority of these patients availed haemodynamie eonu'ol with swan-ganz or renal haemofiltration. conclusions: these results underline that about one fourth patients admitted in italian icus benefit an oversized slructure i, relation to the real needs of their pathology. in hot more than % did non received any advanced treatment and mortality and s.a.p.s. score were substantially lower respect to general population. the results obtained from these two studies are similar, suggesting an uniform distribution of the case mix in italy, even if a different recruitment period and a different gengraphieal distribution were used. some discrepancies in the two studies were found in the diagnostic categories moreover regarding the tranmatised patients ( % vs. %); this can be explained from the seasonal (summer) characteristic of the national study. mutuality, yet very low, is different in the two groups, but these data do not allow any definite explanation. finally these epidemiologieal survey suggest need of further studies settling more strict criteria of admission in icu. this study aims to evaluate patients outcome, quality of care and effectivity of therapy in our intensive care unit. the main goal was to indentify factors that the most influence that outcome. during . the authors collected data of patients outcome and predictor variables. overall mortality rate was , %. the most common causes of death were infection. the diagnosis of sistemic inflammatory response syndrome (sirs) and multiple organ dysfunction syndrome (muds) significantly correlate with death ( %). average length of stay was . days ~. % patients died in the first ten hosiptal days and only % after days. age was directly correlated with death % of dead were older then sixty years. an analysis of physiological variables showed that serum levels of gl~cose ( %) and natrium ( %) were in optimal physiological values. serum proteins ( %) and haemoglobin ( %) levels were inversely related to death. multivariate showed that alveolo-arterio difference in content was the most informative of all mortality predictors (mean value , mmhg in % patients io>mrnhg). factor that most influence the patients outcome was infection (sepsis) and muds. use of predictive indicators of outcome in critically ill patients may help to assess treatment regimens and to compare patient groups. acute physiology and chronic health evaluation (apache if) score (crit. care had. ; : - ) and the sepsis score of elebute and stoner (br. h surg. ; : - ) have been used, objectives: to compare sepsis score and apache ii score in predicting outcome of critically ill patients. methods: overall survival during the past years for patients in our icu was calculated = % (prior probability). the outcome of patients who were admitted to our icu for > hours was observed. apache ii score on admission, patient predicted risk of death (apache ii risk) and the sepsis score on the first day of antibiotic course were prospectively recorded. discriminant function analysis of the scores in relation to outcome was performed. results: apache ii and sepsis scores in the survivors were significantly lower than in those who died ( . i . v~s . • . and . • v's . • . respectively p < . ). correct prediction of outcome by each score is shown in discussion and conclusions: although both scores have been previously evaluated in predicting outcome of icu patients, studies of the sepsis score were conducted in small numbers of patients or involved additional measurements not routinely available. this study demonstrates that the sepsis score alone or in combination with apache ii score is more effective than apache ii score in predicting outcome. objective to test the hypothesis that resuscitation titrated against gastric intramucosal ph (phi) improves survival in critically ill patients as suggested by gutierrez et al~. method emergency admissions to the intensive care unit were randomized into control and intervention groups. in the control group phi was measured at , and h while in the intervention group phi measurements were made hourly for h. both groups were managed according to the same guidelines to achieve the following targets: mean arterial pressure > mmhg, systolic arterial pressure > mmhg, urine output > . /ml/kg, haemoglobin > g/dl, blood glucose < mmol/ , arterial oxygen saturation > % and correction of uncompensated respiratory acidosis. if the phi was < . after achieving these targets, or after maximal therapy to achieve the targets, patients in the intervention group were given fluid to ensure an adequate cardiac preload and then dobutamine at then mcg/kg/h, titrated against phi. this additional therapy was continued until h after entry into the study. in each year patients were subdivided in two series with random selection, so that the st series contained abeat / and the nd / of the patients. the st series of all the years constituted the devdoping data set and the nd series the validation data set. with data of the st series ( patients), we created the predictive model, using stepwise logistic regression (bmdp, usa). each patient has been evaluated in die st, th, th and th day, calculating for each lime the apache ii score (for a total of records), independent variables were, besides time and apache ii of the time ( michaloudia g,, melissaki a., alexias g., gogafi c., kolotoura a., krimpeni g., pamouktaoglou f, filias n. objectives: to determine the medical staff's attitude towards various ethical issues methods : between january and february , anonymous questionnaires were sent to intensive care units, all over greece. results : questionnaires ( , %) were replied and returned back. of them , % were answered by male and , % by female. the doctors replied in the following rate : , % aged up to , % aged between and , % aged over . questions were answered and were divided into main topics, as following: . admission criteria: limited bed availability was the main cause for refusing admission in , % of icu's. , % evaluated each case's viability and only , % used some prognostic score system. , % of icu's accepted all cases and a significant percentage ( %) gave in to pressure coming from their colleagues ( , % female and , % male). . informing the patient/relatives: only , % was willing to tell the whole truth, while , % had given selective information.. in the case of iatrogenic incident, , % withheld it, because either they feared legal implications ( , %), or lost of trust ( , %). doctors are asking consent from the patient and/or his family, in order to include him/her in research protocols, in a rate of , %, while only , % found informed consent necessary for the proposed treatment procedure. . withdrawal of therapy/dnr orders/organ donation: , % were willing to withdraw complex treatment in patients with short life expectancy, except of administi'ating intravenous fluids, feeding and analgesics. in , % such a decis~n was unanimous, while the percentage of those carrying it out was , % ( , % female, , % male). in case of brain stem death , % ( , % female, , % male) withdrew any life support. , % would like therapy withdrawal to be legally established, while only , % would perform euthanasia, if there was substantial legal cover. for these cases, relatives' consent was considered to be necessary from a percentage of only , %. , % considered organ donation to be a necessary proposal, while , % refused to ask the patients' relatives for an organ donation, either because they didn't have the psychological strength for it ( , %), or because they doubted the procedures' objectivity ( , %). note: in greece, icu beds are less than % from the total number of hospital beds available. only a percentage of - % of these admissions comes from the same hospital, with a potentially direct evaluation. usually an icu doctor has to be informed through the telephone. finally, employment conditions in greece are such that any changes of the medical and nursing staffare limited. conclusions: the mathematical model we found has been validated also in the second series and the discrimination capability increases with time. using this model we can evaluate the probability of survive at every, time. its application at different times permits a better evaluation of haemodinamically instable patient trend. introduction: the feasibility to assess pulmonary capillary pressure (pcap) offers the opportunity to determine the longitudinal distribution of pulmonary vascular resistance (pvr). the purpose of this study was to measure pcap and to calculate pvr to determine whether relevant shifts in the distribution of pvr could be expected after routine cardiac surgery. methods: the study population consisted of consecutively admitted patients after cardiac surgery. surgical procedures included coronary artery bypass graft (cabg) (n= ) and mitral valve replacement (mvr) (n=t ). pcap was estimated by analysis of the pressure decay tracing after pulmonary artery occlusion. after estimation of pcap precapillary (ra) and postcapillary resistance (rv) was calculated. a complete set of hemodynamic variables was obtained at hour and at hours after operation. results: there were no significant hemodynamic changes during the first hours after surgery. the mvr group maintained pulmonary hypertension and higher levels of pcap. ra/rv, reflecting the longitudinal distribution of resistances, remained unchanged. however, rv predominated ra during the postoperative period in both groups. objectives: evaluation of the influence of long-term continuous i.v. administration of the ace-inhibitor enalaprilat on regulators of circulatory homeostasis. methods: t trauma and sepsis patients randomly received either . mg/h (group i, n= ) or . mg/h (group , n= ) of enalaprilat i.v. or saline solution (control, n= ) as placebo for days. plasma levels of endothelin- (et), atrial natriuretic peptide (anp), renin, vasopressin, angiotensin-ii, and catecholamines were measured before injection of enalaprilat (='baseline' values) and during the next days. results: except for et, plasma levels of all vasoactive substances exceeded normal range at baseline. angiotensin-ii significantly decreased during enalaprilat infusion ( . mg/h: from . • to . • pg/ml; . mg/h: . • to . • whereas it remained significantly elevated in the untreated control patients. vasopressin increased only in the control group (p< . ) and decreased after . mg/h of enalaprilat. et remained almostunchanged in group , whereas et increased significantly in the control patients (from . • to .t• on the th day). catecholamine plasma levels (epinephrine, norepinephrine) markedly increased in the control group (p< . ), but they did not change significantly throughout the study period in both enalaprilat groups. conclusions: continuous i.v. administration of the angiotensin-converting enzyme inhibitor enalaprilat beneficially influenced systemic and local vasoactive regulators of the circulation, which are normally increased in the critically ill. thus patients at risk of (micro-) circulatory abnormalities may profit from enalaprilat infusion. objectives: to determine the time taken for hemodynamic and gas exchange variables to a reach stady-state after a change from supine to trendelenburg position (trp). methods: we prospectively studied adult patients with severe sepsis or septic shock requiring hemodynamic monitoring. usual cardiorespiratory parameters were measured at baseline, min after the patient was placed in a trp and again min after the return to a supine position. a fiberoptic pulmonary artery catheter (svo~ oximetrix, abbott) allowing continuous svo monitoring wa~used. during the protocol we also continuously measured sao~ by pulse oximetry and vco~ and vo by monitoring partial concentration of o and co ir~ inspiratory and expiratory gases (deltatrac metabolic monitor, datex). therefore, we were able to monitor cardiac output variations by dividing vo~ with arteriovenous difference according to the fick equation (co-fick). results: no significant difference in hemodynamic status was observed min after the patients were placed in trp. despite the fact that no significant change was observed in co and vo~ estimated by thermodilution, co-fick had a tendency to dedrease continuously in trp and then to return to its initial value when patients regained supine position. respiratory gas analysis showed a small but persistent continuous increase in vco without a similar trend in vo values. conclusions: we conclude that no significant hemodynamic effect was detected in our patients after min in trp. evaluation of vo from respiratory gases analysis after a change in body's position should be interpreted with caution, since the patient may not yet have reached a stady-state after rain. since vo did not change, vco~ increase was probably due to position related changes in-pulmonary gas exchange and not to a change in patient's metabolic status. objectives: to determine whether changes in svo and/or other hemodynamic parameters during weaning trials could be used to predict successful weaning. methods: we prospectively studied adult patients with a history or clinical evidence of cardiovascular dysfunction, who were unable to tolerate spontaneous breathing (sb) for hours. for all these patients right heart catheterisation was considered necessary in order to detect hemodynamic alterations during weaning. a fiberoptic pulmonary artery catheter (svo ximetrix, abbott) allowing continuous svo monitoring was sod. hemodynamic status was evaluated ~t baseline and after one hour of spontaneous breathing through a t-piece. patients were assigned to one of two groups depending on whether they tolerated sb for hours. data were analysed by analysis of variance and unpaired student's t-test we also used multiple linear regression analysis to determine which hemodynamic variables were correlated with the magnitude of svo~ change and multiple discriminant analysis to determine if asy of the above variables were associated with toleration of sb for hours and/or successful weaning (s-w). (j physiol ; ." - ) . we tested the hypothesis that the ventilatory stimulation by dead space (vd) loading and % co inhalation is accompanied by a proportionate cardiovascular change. methods: six healthy subjects, mean age, year, performed three incremental exercise tests in a randomized order: ) inspiring air without vd (air control, ac); ) inspiring air with vd of ml (avd); ) inspiring % co ; % oxygen, balance nitrogen. the ventilatory responses were examined at matched heart rate (hr) equivalent to % peak hr. results: ventilation (vi) was significantly greater (p< . ) during the avd and co tests than during the ac test at the same work rates. end-tidal co (petco ) and estimated arterial co (paco ) were significantly greater (p< . ) at w and w. oxygen saturation was significantly lower (p< . ) during the avd test than during the ac and % co exerdse. at matched hrequivalent to % peak hr, vi was significantly greater (p< . ) during the avd and % co tests than during the ac exerdse ( l, l, and /). conclusion: we conclude that the increase in xri and petco due to vd loading and % co inhalation is not associated with an acceleration in hr. sup.ported by mrc (canada). objeetlve: the production of large amounts of oxygen radicals from the onset of ~en may be responsible, st least in part, for peroxidative damage to myocardial tissue. the aim of this study was to evaluate the time dependence of plasma tbars in patients with am] receiving thrombolytie therapy (tt). patients and m~hods: filiy eight patients admitted in icu ( men and women; mean age . - . years) rec~ving systemic tt for possible am] were ~died. all patients received recorabinant haman tissue-type plasminogen activator (r-tpa). the mean time fi'om the onset of symptoms and the be~nning of tt was . - . hours. peripheral veao~s blood samples were obtained fi'om each patient before and serially after tt ( , , and hours). tbars levels woe determined by using a spectrophotometrie technique. rq~r fusion was identified by the timing of ereatine phosphate kkmse (cpk) peak (< hours). table i list the variation of plasma eoneenlrations of tbars (mean -sd) in groups (a,b, and c) as a function of time from the beginning of tr. co,arisen oftbe time cuncentzatiens reveal a difference p<o. between group ami (a and b) versus group c. the between-groups (a-c) comparison showed significant differences (p<~). ) at , and hours fi-om de begin~g of'it. comparison ofthe , and hours eonocnlratiens did not reveafl any difference becween n~ (group b) and angor (group c). condmien: we have observed a maintenance of high level of tbars in reperfused patients enly. these results suggest that the increase of tbars levels may be due to phospholipid derangament of reperfused myocytes. objective: to detemline if tbars levels may be an early index reflecting peroxidative damage in ami patients. patients and methods: by using a spectrophotometric teclmiqtm, based on a modificatien oftbe buege and aust method, tbars levels ware determined in healthy subjects (group i) , patients with several risk factors of ischaemic cardiopathy (group if) and icu patients with possible aim ( were confirmed ami (group ma) and were angor (group iiib)). peripheral blood was obtained at the time of the icu admission in the group i . electrecardiographic data and eehocardiographic wall motion were used to identify ami location (anterior, inferoposterinr and indeterminate). statistical analysis was made with a standard statistical package (rsigma, horus hardware). , h , s, , h statistically significative increase of ' ix~e/ea.ee x~* tbars levels (p< . ) only in pstients with con/tuned ami (group ilia) . no differences were found between the rest of the groups. the figure shows the relationship between the tbars values and the time from the onset of the aim's symptoms. conclusion: we have found that in am/patients the tbars levels can be used as an early index reflecting peroxidative damage occurring to ischemie tissues. perioperative risk in patients with ischemic heart disease. the protective role of diltiazem. lg. hatziantoniou, p. tassiopoulos, c. fakiolas, ! g. foussas~ m. lycourinas perioperatlve morbidity and mortality are mainly of cardiac origin, particularly among elderly patients (pts) ~ith ischemic heart disease. we performed a randomized trial, in order to investigate the possible protective activity of diltiazem (d). methods: pts (aged zo• with a history of coronary insufficiency were subjected to major urological operations. they were randomized to two groups: group i ( pts) -p:ithout d and group ii ( pts) -d ~as administered . mg/kg iv bolus hours prior to anesthesia and . mg/kg/h upon the end of operation and for at least hours post-operatively. iv was substituted by oval administration of x mg starting the next day and for the rest of hospital stay. all pts underwent daily clinical, electrocardiographic and laboratory (ck-mb) control. results: are shown in the following interactions between the heart-lung unit and a cardiac assist device are the crucial issues for successful outcome of patients under mechanical circulatory support. several factors have been indicated and we can diffrentiate between anatomical and hemodynamic interactions. especially right heart failure and pulmonary hypertension have been proven to limit left ventricutar assist device (lvad) performance. in order to study the effects of right heart failure (rhf) and pulmonary hypertension (pht) on mechanical circulatory support, we designed an experimental study in dogs and combined in six groups left heart failure (lhf) and rhf and pht, respectively. in the control group we induced lhf with subsequent occlusions of lad and cx followed by reperfusion: in the next group we supported with an lvad during minutes starting minutes after cx occlusion (group if). in the next group we added right ventricular ischemia by occluding the rca simultaneously to the cx (group iii). these both groups we repeated only with pre-existing acute pht induced by the injection of o fm glass beads (groups vi and v). a last group was similar to group v (lhf and rhf and pht), but instead of a lvad, we used bvad support. in i and v no animal survived the second perfusion period ( hours). in ii and iii (no pht), all dogs survived in stable conditions. in iv (lvf, pht), % survived, the remainder died of incomplete recovery. in vi with bvad, only % survived. in iii and v, during occlusion of the rca, the right ventricle stopped contracting and right atrial pressure and mean pulmonary pressure equalized. this lead to a significant drop in inflow on the left heart side, which still provided sufficient lvad performance in case of absent pht (iii) and lead to death due to "low lvad output" syndrome in v. this "low lvad output" snydrome could be partly overcome by bvad support. we conclude that heart-lung interactions play a major role in lvad performance. by optimizing the perioperative management, they all can be overcome, except the occurrence of alveolar leakage syndrome. obiectives : we propose a new approach of transmural pulmtmary artery occlusion pressure (paoptm), in presence ef peep, from the folluwing hypothesis : if respiratory swings of paop are compared to those of alveolar pressure (apalv = plateau pressure -total peep), an index of transmission of airway pressures to pulmonary vessels is obtained (i t = apaop/apalv). the value of the product of it by peep can be substracted from end-expiratery paop (paopee) to obtain a calculated paoptm (paoptrnc). thus paoftmc = paopee -(apaop/apalv x peep). methods : we tested this hypothesis in patients by comparing paopee, paoptmc, and paopnadir obtained within the first seconds after disconnection from the ventilator, value of reference of paoptm in absence of intrinsic peep (peepi). at zeep, peepi was absent in patients (group a) but present in others (group b). patients were studied under the peep level chosen by the attending physician-(gr a : +_ ; gr b : _+ cmh ). results : l. gr a : paopee ( _+ mmhg) differed (p < - ) from paopnadir ( • mmhg) and paoptmc ( _+ mrahg). gr b : paopee, paopnadir, paoptmc differed between themselves ( " - , + , + mmhg respectively). . good correlatkm (r - (i. ) and agreement between paopnadir and paoptm were found in gr a, while there was no agreement in gr b (bland and altman analysis). . lung compliance (v t/bpah,) correlated well with i t in both groups (r - . ), suggesting that our hypt)thesis was strtmg even in patients with peepi. conclusions : paoptm under peep ventilation can be obtained, even in patients with peepi, from parameters easily measured at the bedside. introduction: cardiopulmonary bypass (cpb) may cause ischemia in several organ systems like the heart, brain and kidneys. reactive oxygen species (ros) are formed by subsequent reperfusion and stimulation of neutrophils by cpb. ros are harmful to biological systems e.g. cellular membranes, enzymes~ dna. many natural antioxidant systems protect against the effect of ros. in patients undergoing cabg we evaluated the production of ros by total plasma antioxidant status (tas) and lipid peroxidation measured by lipofuscin flip). methods: tas (randox, uk) and concentrations ofllp (tsuchida et al.) were measured in consecutive patients undergoing cabg. all the patients had a normal serum creatinine clearance (> ml/min). serum samples were obtained a) before operation, b) after removal of the aortic crossclamp, c) at admission to the icu, d) hours after operation, e) hours after operation. results: tas was significantly decreased after removal of the aortic crosselamp ( b, c and d lower than a), followed by a subsequent significant increase of lip ( c and d higher than b). the levels of tas and lip returned to baseline hours after operation. methods: patients with preoperative lvef< % undergoing coronary artery bypass grafting were studied. after surgery, a f femoral artery catheter was inserted and connoted to a fiberoptic monitoring system (cold z- t; pulsion medizintechnik, germany); this allows, with a double-indicator dilution technique, the calculation of cardiac index (ci,l/min/m ), intrathoracic bood volume (itbv,ml/m ), pulmonary blood volume (pbv,ml/m ) and extravascular lung water (evlw,ml/kg). with a f pulmonary artery catheter, wedge (w,nunhg) and central venous pressure (cvp,mmhg) were measured, while extraction ratio (o exr,%) and oxygen delivery (do ,ml/min/m ) was calculed. peak inspiratory pressure (pawp,cmh ) and mean airway pressure (mawp,cmh ) were measured with a varflex flow transducer (bicore,sensormedics,us). the patients were studied after minutes (to) of volume controlled standard ratio ventilation (vc), and after minutes (ti) of stabilisation period of pcirv ( % inspiratory time, % pause). vt,ve and total peep were held constant in every mode of ventilation. +_ . " *'p < , versus to conclusions: these data show that pcirv : is a safe ventilatory support also in cardiac patients with impaired ventricular function, and monitoring of itbv is more reliable to measure and optimise circulatory volume status, than w and cvp. c.ledeki-,g.rldisis,s.karotzai,c.micheilidis,m.agioutantb, g.beltapaulos. objeolivee:to evaluate the influence of lvswl on the well known correlation of sr and svo . paw eight patients ( melee end females) were included in this study regerdlen of the icu ~h"niseion couse. all paints were ,'~theta~ with e fiboroptir pulmonary artery catheter connected with an oxymetfir (r)~ so /co abbot computer.for any pulmonary artery catheter insertion, two pain= of sr and svo were obtained, one dudng inserlion and one during taking the catheter out. for any pair obtained, we eleo collected the deta concemig with the pedient's hemodynamir and oxygenation end we calculated the lvswi. were significantly (p<o. ) higher in group i. conclusion: breathing room air, the less hypoxemic patients had a rather satidactory do and tissue oxygenation (pro ) because they had properly adapted their ci. the absence of this mechanism (right heart impairement ?) in the hypoxemic patients, in spite of higher blood ne and e, was responsible for the poor do and pro . objectives: acute massive pulmonary embolism (pe) increases pulmonary artery pressure (pap) and dght ventdcular aftedoad, which may lead to dght ventdcular failure. inhaled nitdc oxide (no) selectively dilates pulmonary vessels. thus, inhaled no may be of potential therapeutic value in the management of the acute phase of pe. methods: following institutional approval, ten piglets (body weight + kg) were anaesthetised (midazolam/piritramide) and ventilated using a modified servo ventilator (siemens elema, sweden; fio . ). the following variables were obtained: systolic pap (spap), mean pap (mpap), diastolic pap (dpap), mean artedal pressure (map), central venous pressure (cvp), pulmonary capillary wedge pressure (pcwp), cardiac output (co), and artedal (pao ) and mixed venous (pvo ) oxygen saturation. pulmonary vascular resistance (pvr) was calculated. to induce pe, pm microspheres (sephadex g coarse, pharmacia biotech, freiburg, germany) were injected in an amount sufficient to increase mpap to mmhg initially. rain after embolisation when haemodynamics were in a steady state (control ), inhaled no was administered. further measurements were taken min after ppm no (no ), min after ppm no (no ), and min after discontinuation of no administration (control ). the administration of inhaled no resulted in a significant decrease in spap, mpap, and pvr. the cessation of no inhalation led to a complete return to pretreatment control values (table) . co, map, cvp, pcwp, pao?, and pv~ remained unchan no administration. objectivss:evsluate the yield of recombinant tissue plasminogen activater(rt-pa, actiiyse ~ oehringer ingelheim) as a thrombolytic agent ie pulmonary embolism ie .kr~auma patients. methods: in five patients with diagnosed pulmonary embolism(blood gases, chest x-ray, echocardiography, perlesion lung scans) were given rag of actij.yse as ~ hrs infusion, followed by heparin~single j. ihjaction snd iefusion ie doses - j./kg/day).the effectiveness of rt-pg thrembo].ytic sctier~ was svaluated im . . hrs(blood gases) amd on the third dayafter t~eat-,ment(~chocardiography and lung scan). results: three hrs after actilyse was given we observed significant clinical imprevemeet,confirmed by elevation of pao and sao in dlood.echocardiegr~m on the third day showed regression of pulmonary hypertension and lung scans showed % improvement in total lung perfusien. except slight bleeding from the site of injection nc~ more thromboiytic complicatioos were observed. conclusiens: actilyse used in five hrauma patients with pulmonary embol.ism was a very effsctive and safe thrombolytic agerlt, inducing rapid and evident clinical improvement. intermittent positive pressure ventilation ( ppv) by increasing pleural pressure, decreases the pressure gradients for systemic venous return and left ventricular (lv) ejection. we have previously shown that when inspiration is synchronized with systole using synchfjv in patients with severe cardiomyopathy, that cardiac output (co) was increased relative to both ippv and non-synchronized hfjv ( ). however, it is not known if similar effects could be realized in ventilatordependent patients with lesser degrees of lv dysfunction and fluid overload. we thus compared synci-ifjv to ippv in stable patients following coronary artery bypas grafting. methods: normothermic who were stable (< % variance/h.) were studied following admission to the sicu. heart rate (hr), mean arterial (pa), pulmonary artery occlusion pressure(ppao), co by continuous thermodilutiun (vigilance, baxter, usa), mixed venous saturation (svoz) and arterial blood gases (abg) were measured after rain. of each step. ippv was simv adjusted for a rate, tidal volume and fit to insure both normal abg and a peak airway pressure < cm h,o. syncfifjv was delivered by a hfjv ventilator (acutronic) during systole with ventilator parameters adjusted to optimize abg. protocol: patients received three ippv runs (ippvi. , ) with synchfjv runs interposed (hfjvz ). statistics: anova for repeat measures and paired t-test were used to compareruns and demonstrate variability. results:no significant difference in any of the measured hemodynamic variables were seen among the ippv and synchfjv runs (table) . post hoc separation of patients by preoperative ejection fraction (ef; ef > % ; n= and < %; n= ) did not alter these results. back~ound: in man, vascular endothelium-bound ace is expressed in concentrations greater than x that in serum and is believed to be the site of synthesis of circulating angioteusin il it is unclear whether ace inlubitors interact similarly with ace in different vascular beds. coronary vessels possess all the components of the renin-angiotensin system, including ace which may be involved in normalcardiac homeostasis, as well as in the pathogenesis of various cardiomyopathies. obiecfive: to develop a method for assaying the interaction of ace inkibitors with coronary endothelium-bunnd ace in man, methods: ace a~aty was meas~ed in five patients undergoing cabg surgery, from the transeuronary hydrolysis of the synthetic ace substrate h-bpap. trace mnou~ of ~fi-bpap ( gci) were injec~d as a bolus in the root of the aorta and simultaneously blood was withdrawn from a coronary sinus catheter into a syringe containing protease inhibitors which prevented the convession of umeaet~ ai-i-bpap by blood ace. the sample was later centrifuged to separate cells from plasma and the radioactivities due to formed product (~rl-bphe) and total sh were astimated in a [b-counter. two additional such determinations of ace activity were perform~ the second in the presence of . pg/kg e (coinjected with ~-i-bpap) and the third ten minutes after e. results: all subjects were hemodynamically stable throughout the course of the there were no noticeable hemodynamic effects of e. control transcorunary metabolism of~-bpap averaged g -a: %, in agreement with previously reported data. in the presence of e, % metabolism of ~-bpap was reduced to • reflecting a • inhibition of normal ace activity. ten minutes after e, ~ri-bfap metabolism had partially recovered to :l: %, representing a -a: % inhibition of control ace activity. from this data, the dissociation constant of e for coronary ace in vivo was estimated as . x " sec "l. conclusions: we have demonstrated the feasibility of repeated, reproducible measures of coronary endothelium-bound ace activity and of its inhibition by e. this procedure is safe and can be used to study the role of ace in normal cardiac function and in card pathologies. objectives. primary pulmonary hypertension (pph) is a progressive fatal disease of unlmown origin, with median life expectancy of less than three years after diagnosis. the responsiveness of pulmonary hypertension to a variety of vasodilator agents led to the speculation that, concomitant with vascular renmdelling processes, persistent vasoconstriction is an important feature of the disease. long term use of ca-channel blockers and intravenous pgiz may improve mortality in certain populations of pph patients, but both of these treatments lack selectivity for tire lung vasculature. the aim of this study was to test the efficacy of aerosolised prostacyclin and its stable analogue, [loprost for selective pulmonary vasodilatation in pph. methods: in three patients with pph, we compared aerosolisation of prostaglandin iz (pgi ) and iloprost to a battery of vasodilatory agents (diltiazem, nifedipin, inhaled nitric oxide, intravenous pgiz). results: nebulisation of pgi and iloprost tumed out to be most favourable for achieving effective and selective pulmonary vasodilatation. pulmonary vascular resistance decreased from + to -+ dyn*s*cm (p< . ) and pulmonary artery pressure from . + . to + . mmhg (p < . ), cardiac output increased from . + . to . _+ . i/rain (p < . ), mixed venous oxygen saturation from . _+ . to . + . % (p < . ) and arterial oxygen saturation from . + . to . _+ . % (mean _+ sem of trials in patients). -month iloprost nebulisation in one patient ( gg/day in six aerosol doses) demonstrated sustained efficacy of the vasodilator r~men. conclusion: aerosolation of pgi or its stable analogue may offer as new strategy for selective pulmonary vasodilatation in pph. endothelial adhesion molecules may play an important role in the pathogenesis of myocardial cell damage, and may contribute to the progression of heart failure. we measured the plasma soluble intercellular adhesion molecule- (sicam- ), vascular cell adhesion molecule- (svcam- ), and e-selecfin (selam- ) levels in patients with acute myocardial infarction admitted within hours after onset. peripheral venous plasma-samples were collected at the time of admission, , , , , and hours after onset. plasma soluble adhesion molecule concentrations were determined by elisa. patients were divided into groups as follows: group ; killip's class (k) and without thrombolytie therapy, group ; k and with thrombolytic therapy and group ; k and . both plasma sicam- and svcam- concentrations in group and were elevated rapidly and significantly and maintained at a high level during the first days. plasma selam- level did not change in any of the groups. these results suggest that the adhesion molecules icam- and vcam- may play a role in the pathogenesis of myocardial reperfusion injury and may indicate its severity in myocardial infarction. objectives: nitric oxide (no) is known to exert cytotoxic and negative inotropic effects on cardiomyocytes. no synthase activity has been reported to be increased in infarcted area in animal model of myocardial infarction. these findings suggest that no may be an important regulator for myocardial damage and cardiac function after myocardial infarction. we measured plasma no no -(nox) levels and estimated serial changes in acute phase of myocardial infarction. methods: subjects were patients admitted within hours after onset. venous blood samples were collected at -hour intervals on the first day, -bour intervals on the nd day and -hour intervals on the rd day and th days after onset. plasma nox concentrations were determined by griess method. results: the time course of the plasma nox levels (mea~+sem) displayed a tendency to gradually increase and to make a biphasic pattern with two peaks about hours and - days after onset (basal level; . _+ . , first peak; . !-_ . , second peak; . + . ram/l). plasma nox concentration was not influenced by the thrombolytic therapy, and nox values at the time of hours after onset were significantly correlated with maximal plasma creatine kinase level (r= . , p< . ). the levels of plasma nox in the early stage of myocardial infarction (from admission to the th day after onset) did not correlate significantly with the hemodynamic parameters (left ventricular ejection fraction, pulmonary capillary wedge pressure). conclusion: the early and late increase in no production after myocardial infarction may be implicated in the deterioration of myocardial contractility and induction of myocardial damage in the early phase of myocardial infarction. range - ) fullfilling the high risk criteria of shoemaker (colectomy , gastrectomy , pancreaticoduodenectomy , others ). patients were admitted to the icu preoperatively. arterial and pulmonary artery catheters were inserted and hemodynamics and oxygen transport were measured at admission and after stabilization to predetermined physiological end points. patients were considered stable when ci > . l/min/m , pcwp > mmhg, hb > g/l, sat >. . objectives: evaluate the acute effects of , mg ipratropium bromide and , mg fenoterol (ibf) inhaled dose on pulmonary function in nonsmocers (nb:m) and smocers (s) with sever (new york heart association class ii-iii), stabile congestive heart failure(chf) and healthy subjects. methods: pulmonary function tests were performed < h postprandial. the tests consisted el arterial blood gas aspiration followed by routine spirometry and pletismography, and single-breath gas analysis. after performance of these maneuvers, the patients was administred puffs-ipratropium bromide ( , rag) and fenoterol ( , rag). for , h, spirometry was repeated. results: in resting, pulmonary abnormalities observer in the s group were more severe then abnormalities observere in the nsm group. after treatment with ibf the improvement in pulmonary function was even more marked in patients who had smoked. the mean changes by forced expiratory volume in second(eevt) was , % (p< , t) improvement and , % (p< ,ob), forced expiratory flow betwen % and % of the forced vital capacity (fef . ) was , % (p< , ) and , % (p< , ) and maxamal voluntary ventilation (mw) was , % (p< , ) and , % (p<o, ) improvement. the mean changes in normal subjects were mild (fev increased by , %,fef - by , % and mvv by , %). we observed no adverse heamodinamie conseevence and no arrthytmogenicity. conclusion." in patients with chf the airway response to ibf is highly significant. further study is needed to determine whether therapy with ibf will load to improvement quality of life in patients with chf with dearly documented venti/atory defects. compared with unilateral ima grafts, usage of bilateral ima grafts in cabg patients causes greater thoracic trauma and further reduces blood supply to the sternum and intercostal muscles. these effects may be associated with increased postoperative respiratory complications obiectives: to study the effects of bilateral ima grafts on postoperative respiratory morbidity in cabg patients. methods: two groups of patients undergoing cabg were prospectively studied: group (n= ) received both imas as grafts and group (n= ) received only the left ima. the two groups were matched for age, smoking habits, total number of grafts and preoperative ejection fraction. pao /fio ratio was measured in all patients in the icu, at , , minutes on mechanical ventilation (mv), at , , minutes after extubation (ex) and on postoperative day (pod) . in addition, radiografic scores of atelectasis and pleural effusion were assessed postoperatively. results: group had significantly longer bypass ( _+ vs + . p< , ) and aortic cross clamp time ( +- vs + , p= , ). pao /fi ratio was significantly higher in group only at minutes after extubation (table) . there was no difference in the incidence or severity of atelectasis or pleural effusion between the two groups. the duration of mv was longer in group ( +_ vs _+ , p= , ), but the length of icu stay and hospitalization were similar. there was one case of pneumothorax in group and one case of pulmonary infection in each group. after extubation m[n min min min* rain min pod ' _+ _+ + -+ - -+ _+ _+ _+ _+ -+ _+ _+ -+ mean_+sd, *p=o, o conclusions: compared with unilateral ima grafts, the usage of bilateral ima grafts in cabg patients is not associated with increased postoperative respiratory morbidity. the diagnosis of rv ischaemia is difficult in the critical care setting. the purpose of this study was to determine the ability of rv endomyocardial and interstitial ph electrodes to detect rv ischaemia in an animal model of rv infarction produced by fight coronary artery ligation. we hypothesized that changes in transmural and interstitial ph would accompany the induced tissue hypoperfusion. rv interstitial (phint) and transmural endomyocardial ph (phendo) were measured in adult anaesthetized pigs before and serially after coronary ligation. phendo and phint fell progressively and significantly following coronary occlusion. this was accompanied by ischaemic ekg changes. the absolute and relative rates of change were greater for phendo compared to phint, particularly after minutes of ischaemia, ph was unchanged in control experiments when the electrode was placed within the fight atrial or ventricular chambers, as well as when coronary ligation was not performed. these data suggest that rv myocardial ph measurements reflect coronary ligation induced rv ischaemia, ph recorded from an electrode placed against the rv endomyocardial wall via a central vein was as useful as an interstitial measurement that required a thoracotomy. this newly described technique may be helpful in clinical settings where differentiation between ischaemic and nonisehaemic causes of rv dysfunction is important. centre. depts of cardiac surgery and anesthesiology, university of bari, italy. lung injury secondary to cardiopulmonary bypass (cpb) is well recognized. nevertheless, mechanical respiratory changes after cpb have been poorly investigated. aim of the study was to evaluate the effects of cpb on respiratory mechanics. elastance of the lung (est l), chest wall (est cw), and total respiratory system (est rs) were measured in patients without previous pulmonary disease undergoing elective cardiac surgery. there were males and females; no pleurotomy was done. cpb was carried out with membrane oxygenator. mean cpb and cross clamping times were _. and • min. flow (pneumothacograph), airway opening and esophageal pressures (pressure transducers and esophageal balloon) were measured on patients sedated and paralysed. measurements were obtained before sternotomy, at the end of cpb after chest closure, four and seven hours later. est rs, est l and est cw, were measured by occluding the airways and the end of a tidal breath. before end cpb- h after h after stemotomy closed chest cpb cpb estrs (cmh /l) . + . . - . " . _+ . * . - . * est cw " . _+ . . • . + . . -+ . est l " . -- . . - . " . -_ . " . _+ . " x + sd. * p < . : anova vs "before sternotomy". our data show that cpb induces increase in est l, whereas est cw remains unchanged despite sternotomy. impairment in est l after cpb evolves within the first hours and stabilizes hours later. during the clinical course of human imunodeficiency virus infection (hiv), patients (lots) can develop congestive and dilated cardiomyopathy syndrome (dcm). the aim of our study was to analyze the prevalence of dcm among an hiv population, its clinical and echocardiographic changes under a long term follow-up and therapy with an ace-inhibitor agent (captopril). we prospectively studied pts, % ( / ) developed dcm during the follow-up study. among this group % ( / pts) were in class i and ii and % ( / pts) in class iii and iv of the nyha classification. we divided this population in a acei+ ( pts) and acei-( pts), according to the administration of captopril. we analyzed the following parameters: age, gender, race, ivda, type of hiv, cdc classification, number of t and t type cell population and its t /t ratio, therapeutic with acei, type and number of opportunist infections, mycobacteriosis and neoplasm's. we analyzed several echocardiographic parameters, which included the initial (i), final (f) and variation (a) of the lv internal diastolic (lvdd/mm) and systolic (lvsdimm) diameters, lv % of fractional shortening (lv%fs/%), ivs and posterior wall thickness and lv mass (lvm/g). the two groups differed significantly in the following parameters: left ventricular functional indices of patients (pts) with iscjhemic dilated cardiomyopathy (idcm) have a critical value in terms of clinical prognosis of this disease. three-dimensional echocardiography ( -de) is a recently developed method that gives a better evaluation of lv morphology and function. the purpose of our prospective study was to assess the clinical applicability of this new -de method in a population with ischemic dcm diagnosis and calculate its lv indices of global and regional function. we studied a group of idcm pts, mean age _+ yrs, % male gender, using a combined -de tee approach. all pts were in class ill/iv of the nyha classification. first, ekg gated images were acquired through a mechanical pullback of the tee probe, and each set of data was transferred to a conventional ibm-pc system using a dedicated -de software. computer processing and analysis of the tee images led to a -de reconstruction matrix and off-line calculation of several lv global and regional indices. in all idcm lots the lv cavity was clearly reconstructed and end-systole and diastole in several orthogonat projections, out in multiple planes and its function quantitated using -de derived indices. mean values of -de lvesv= -+ ml, lvedv= _+ ml, lvstv= _+ ml and lvef= -+ % were obtained. for all these -de parameters, good correlations were observed with -de lv measurements obtained through biplane tee analysis of the lv cavity (r>. ; p<. ) as well as regional analysis of sequential -de cut planes. conclusion: in our group of patients with the diagnosis of ischemic dilated cardiomyopathy, this new -de method could be applied. our results show that this method allows a better assessment of the lv morphology and spatial geometry, with the calculation of global and regional indices with critical clinical and prognostic value in this particular cardiovascular pathology. simultaneous left atrial (la) and left ventricle (lv) inflow analysis assessed by pulsed doppler tee illustrate the loading conditions and reflect the hemodynamics of the left heart. we performed a prospective tee pulsed doppler study with recordings of the transmitral lv filling and pulmonary venous (pv) flow drainage in a group of patients with dilated cardiomyopathy (dcm). a group of dcm patients, mean age _+ yrs, % male were studied. this population was divided according to tee severe lv dysfunction (group slvd+ % pts; group slvd- % pts) in each pt we measured the peak velocities (vel/m/sec) and time velocity integrals (vti/m) of the transmitral early (e) and late (a) filing waves, the vel and vti of the pv systolic (s), diastolic (d) and atrial contraction (c) reversal flows. -de tee evaluation of the lved, lves, lvst volumes and lvef were obtained. we calculated other parameters, such as e/a, s/d and a/c ratios and the sum of c+a vel, that refelect la systolic function and lv compliance. + -_ . simultaneous and quantitative analytical approach of the pulmonary venous and transmitral flows and ventricular volumes improve the non invasive assessment and understanding of left ventricular diastolic function and cardiac performance in dilated cardiomyopathy patients. objectives : to assess the hemodynamic effects of fluid loading (fl) in acute circulatory failure (acf) due to acute massive pulmonary embolism. methods : hemodynamic measurements (fast-response thermistor pulmonary artery catheter) were performed at baseline (baseline) and after a rapid fluid loading with (fl ) and (fl ) ml of dextl'an (rhemacrodex| in patients free of previous cardiopulmonary disease ( • yrs) with acf (ci < . l/rain/m ) due to angiographicalty proven mpe (miller score > ) . results : are expressed as mean _+ sem and compared by anova. a significant negative correlation (r = . ) was observed between baseline rvedv[ and the effects of fl on ci. such correlation was not observed between baseline rap and the fl induced increased in ci. conclusion : fusibmificantly increases ci in acf due to mpe. however, the simultaneous decrease of arterial content due to hemodilution, limits the benefits expected from improved ci on peripheral oxygenation. obiective: to examine the hemodynamic effects of external positive endexpiratory pressure (peep) on right ventricular (rv) function in acute respiratory failure (arf) patients. methods: incremental levels of peep ( - - - cmh ) were applied and rv hemodynamics were studied by a swan-ganz catheter with a fast response thermistor for right ventrieular ejection fraction (rvef) measurement in mechanically ventilated arf patients (lis = . ~- . sd). according to the response to peep , two groups of patients were defined: group a ( pts.) with unchanged or increased rv end diastolic volume index (rvedvi) and group b (h pts) with decreased rvedvi. results: in the whole sample cardiac index (ci) and stroke index (sj) decreased at all levels of peep, while rvedvi , rv end systolic volume index (rvesvi) and rvef remained anchange d. at zeep the hemodynamic parameters of the two groups did not differ. in group a, ci decreased at peep , rvef decreased at peep (~ . %)~ rvesvi increased only at peep (+ . %) and rvedv[ reded unchanged. in group b, ci and rvedvi started to decrease at peep , 'rvesvi decreased only at peep (- . %), anf rvef was unchanged. individual behaviors of the hemodynamic parameters at the levels& peep were studied. rvedvi and ci were significantly correlated in out of:l patients in group b, and in no patient of group a. on the contrary, mpap and rvesvi were significantly correlated in out of patients in group a, and in no patient of group b. the slope of the relationship between rvedvi and rv stroke work index (rvswi) expresses rv myocardial performance. this relationship was significant (no change in rv contractitity)in patients of group b and in patients of group a. in some patients of group a, increments of peep shifted the rvswi/rvedvi ratio rightward inthe plot (rv function decrease). conclusions: in arf patients peep causes more often a preload decrease with unclmnged rv conctraetility. on the contrary, the finding of increased rv volumes during the application of peep is related to a decrease in rv myocardial performance. thus, these data suggest that application of peep might be considered as a stress test to assess rv function. right introduction: after heart transplant (ht), the right ventricle can be subject to an acute pressure overload, especially in cases where there is a preexisting severe pulmonary hypertension. this provokes right ventricular failure and, occasionally, circulatory collapse in intensive care unit. desire the advances that have been made in systems for preserving the donor heart and in post-surgical management, we have failed in our attempts to totally avoid this problem. the right ventricular function, although it usually remains within tolerable limits in these patients during the post surgery period, represents a factor which limits the results achievable in clinical transplant programmes. objectives: to determine the maximum tolerance of the right ventricle (mxtrv) when faced with acute pressure overload. to study the function of both ventricles of the healthy heart (donor) when faced with different degrees of pulmonary hypertension. to detect possible interactions between the ventricles in the absence of the pericardium to approximate the experimental model to the clinical model of ht. materials and methods: the pulmonary artery is progressively constrained in an experimental model until biventricniar failure is detected. this experiment is performed in two diffferent situations: with and without pericardial integrity. results: when pericardial integrity is maintained the mxtrv faced with a pressure overload is . + . nun hg. when this pressure is exceeded there is a circulatory collapse with a sharp fall in the cardiac output and in the aortic pressure. however, when pericardectomy is performed (model similar to ht), only • . nun hg is tolerated (p < . ). conclusions: with the pericardium open, as in heart transplant, the maximum pressure that the right ventricle can support is significantly less than with the pericardium closed. the pericardium has a positive effect in protecting the systolic ventricular interaction. it is, therefore, advisable to close the pericardium after heart transplant. jb prrez-bernal, a ordrfiez, a. heroandez, jm borrego, map camacho, c cruz, mac s~nchez, j monterrubio, c garcia, e. gonz~lez. hospital uulversitario " virgen del rocio ". sevilla. espaiqa. introduction: nowadays cardiomyoplasty isused incases of cardiac insufficiency as an alternative to cardiac transplant. after surgery the patients show a noteable improvement with the aid of this "biological circulatory assistance". some researchers suspect that the improvement could also be due to the formation of new blood vessels from the muscle that wraps the heart, nourishing the ischemic myocardium. objectives: our cardiovascular research group has proposed as an objective, the detection of any possible myocardial neovascularization through the muscle used for cardiomyoplasty. in the case that there are new blood vessels to the diseased myocardium through the wide dorsal muscle in which it is wrapped and which aids it mechanically, it would be possible to confirm the worldng hypothesis that cardiomyoplasty not only improves the cardiocirculatory funcfinn mechanically but also by facilitating a better blood flow to the ischemic myocardium. materials and methods: the cardiomyoplasty technique is described using an experimental model of myocardial ischemia. the vascular cast is achieved by injecting methacrylate simulataneously into both the coronary tree and the wide dorsal muscle, in five experiments the connections between the coronary vascular system and the vascular structure of the wide dorsal muscle are demonstrated, conclusions: we have demonstrated that cardiomyoplasty, as well as improving ventricular function, favours the revascularization of the myocardium. cardiomyoplasty could be indicated for cases of ischemic cardiopathy in patients in whom it is not possible to perform direct revacularization using conventional methods. a the therapeutic cardiological manouevres necessary in cases of ischeima reperfusion have increased considerably: fibrinolysis, transluminal angioplasty, coronary revascnlarization surgery and cardiac transplant. the appearance of a specific pathology ht acute reperfusion has been related to free oxygen radicals (for) generated by oxidative damage. objectives: to evaluate the appearance of for during a conti-olled process of ischemia-reperfusion in an experimental biological model and compare it with that in clinical cases. materials and methods: transitory cardiac ischemia was performed in five rabbits by reversible surgical ligation of the descending anterior coronary artery. after minutes coronary reperfusion was performed. blood samples were taken in the basal situation, at the end of ischemia and at , and minutes after the start of reperfusion. malondialdehyde (mda) was measured to evaluate the degree of lipid peroxidation (oxidative damage to the membrane). in ten patients undergoing conventional cardiac surgery the production of for was measured after aortic clamping. results: we observed that after minutes of reperfusion there was a highly significant increase (p < . ) in the mda values (mean = . /zmols/l). these returned to basal levels after and minutes of reperfusion. conclusions: an "explosion" of oxygen free radicals was detected very quicldy, just a few minutes after post-ischemia reperfusion. thus, if antioxidant agents are to be used to reduce the toxic effects of the for, these will ordy have a therapeutic effect if they are administered in the early phases of reperfusion. introduction: aortic connterpulsation is a ventricular assistance widely used in intensive care units in patients with cardiogenic shock as a provisional ventricular assistance. paraaortic or external aortic counterpnlsation is been investigated as a definitive veutricular assistance in those cases of terminal congestive heart failure and when heart transplantation is counterindicated. aims: to assess the haemodynamic effects of an aortomyoplasty in a biological model of congestive heart failure. material and method: as specimens, we used "large white" pigs. mean weight was kg. after the administration of conventional anaesthesia, dissection of the ladssimns dorsi muscle was performed on the samples at the laboratory of experimental surgery of our hospital. then we performed a thoracotomy at the level of the fourth intercostal space to reach the thoracic aorta. the aorta is dissecated centimetres from the exit of the subclavia and it is wrapped by the dissecated muscle. a cardiomyostimulator is provided in order to allow the synchronization between the diastole and the muscle contraction. the model of heart failure was provoked using verapamil plus propanolol i.v.. results: a significant increase of the aortic diastolic pressures and a significant decrease of the left ventricle telediastolic pressures were observed. this improvement in the parameters (dpti/tti) implies an increase of the coronary perfusion in a model of heart failure. conclusions: using the external aortic counterpulsation, the aortomyoplasty improves the coronary perfnsion and the heart efficiency in patients with heart failure in whom no conventional therapeutic action is possible. the permanent character of the paraaortic counterpulsation is it main advantage. the appearance of specific pathologies as a resuk of myocardial reperfasion has been related to the oxidative damage secondary to the release of oxygen derived free radicals (ofr). during the myocardial ischemia induced during heart surgery with extraeorporeal circulation, severalsubproducts of the oxygen are produced that shall cause toxic effects after the reperfusion which could be counteracted by the physiological antioxidant systems and/or provided by the medication. aims: to asses the ofr during heart surgery. to check whether an antioxidant treatment administered in the preoperative period make decrease the levels of ofr before and after the myocardial reperfusion and to verify whether its administration have any beneficial effect on the intra and extraoperative management. material and method: the study comprehends patients studied as two groups of individuals each (a and b). all patients underwent conventional heart surgery of valvniar substitmion or myocardial revaseularization. group a patients were administered rag/ hours of vitamin e (tocopherol acetate) hours prior to the intervention as antioxidant treatment. group b patient were not administered vitamin e. we assessed the quantity of malondialdehido (mda) to assess the degree of lipidic peroxidation or oxidative damage of the membrane during the myocardial ischemia and nm after the reperfusion. conclusion: patients who underwent heart surgery and were treated with tecopherol acetate in the preoperative period presented levels of rlo significantly lower than those who were not administered the drug, both during the intraoperative period and after myocardial reperfusion. we detected in these patients a need for antiarrhythmicals and pharmacoiogical support with catecholaminas, although not significant, both in the introaperative period and the immediate postoperative period. recommendations for the treatment of pulmonary embolism (pe) in the presence of right atrial thrombus (at) are conflicting. because of a significantly higher mortality rate due to fulminam or recurrent pe, there is a necessity to treat patients (pts) with mobile type a thrombi compared to pts with adherent type b thrombi. therapeutic strategies include anticoagulation, thrombolysis (t) or surgical thrombembolectomy. combination thrombolysis (cot), predominantly used for the treatment of acute myocardial infarction proved to prevent reocclusion of the infarct related artery at a comparable rate of hemorrhagia. benefit has been related to the alteration of hemostatic proteins by non-fibrinspecific thrombolytic s. administration of cot in pe has been performed sporadically. in the present case, a -year old male with no history of prior cardiovascular disease developed acute dyspnea which was related to pe in the presence of deep vein thrombosis of the left femoral vein. therapeutic anticoagulation was installed for a couple of days until there were several bouts of deterioration. biplane transesophageal echocardiography (tee) was performed and revealed a large, wormlike, hypermobile thrombus within the right atrium. computer tomography (ct) of the chest detected a saddle embolus in the bifurcation of the pulmonary tmnk almost occluding the entire left pulmonary artery (pa) and parts of the right pat consisted of mg frontloaded rt-pa and the subsequent continuous administration of urokinase in a dosis of . u/hr for hrs followed by therapeutic anticoagulation. symptoms, blood gases and ecg improved steadily during infusion, no adverse effects, i.e. minor or major hemorragia were registered. follow-up ct promptly after termination of t showed almost complete resolution of the saddle embelus, whereas tee showed complete dissolution of the at. ' finally, the patient was switched to oral anticoagulants and had an uneventful clinical course until he was discharged. conclusion: in the present case, cot was effective for the treatment of a complicated pe without any adverse effect. introduction: nowadays we can assist hearts with problems of insufficiency by techniques other than transplant. many researchers believe that the best way of assisting insufficient heart muscle is with another muscle from the patient. this technique of ventficular assistance is known as cardiomyoplasty. we describe the surgical technique of cardiomyoplasty using a biological model. the transformed skeletal muscle is transferred to the thoracic cavity where it wraps the heart and assists it. the choice and preparation of this muscle is currently under investigation. our group has focussed on the development of protocols for electrical stimulation to transform a skeletal muscle into a muscle which resists fatigue and which is functionally similar to the myocardium. we detect the optimum time at which this muscle has been transformed, by studying the transmembrane action potentials using intracellular electrodes. when the action potential of the trained muscle behaves like cardiac muscle we consider it ready for cardiomyoplasty. conclusions: cardiomyoplasty is an alternative surgical technique to cardiac transplant, which has a great future in the treatment of patients with advanced cardiac insufficiency. we describe methodology which, by intracellular techniques, allows selection of the optimum moment of transformation of a skeletal muscle trained to perform,like cardiac muscle, without suffering fatigue. purulent pericarditis is a rare disease. its treatment associate systemic antibiotics and drainage of the pericardium. we report a ease of purulent constrictive pericarditis in which intraperieardial fibrinolysis was use. a years old patient admitted in our icu for a constrictive pericarditis as a complication of a purulent pericarditis diagnosed seventeen days before. he had also an aehalasia and the o'esogastric endoscopy had found an oesophageal neoplasm. a fistula was not seen, indeed pericardial of flora was the same that oropharyngeal. hemodynamie and echographic study had confirmed a constrictive pericarditis. because of the poor state of the patient an intraperieardial fibrinolysis was prescribed ( . ui of streptokinase on days , , , ). fluid drainage was improved and cardiac output was also improved (day : . .min "i, day : . l.min'l). no change ofhemostasis was noted. a pericardeetomy and an oesophagectomy were performed after days of evolution. eighteen months latter the patient was still alive. intraperieardial fibrinolysis seems an interesting therapeutic way if rapidly prescribed in the purulent pericarditis course. the decrease in the systolic pressure following a mechanical breath, termed ddown (delta down), has been shown to be a sensitive indicator of preload ( , ) . however, the clinical use of this method necessitates the introduction of a short apnea. we have therefore developed a respiratory systolic variation test (rsvt) which obviates the need for apnea. the test is based on the delivery of successive breaths of increasing magnitude ( , , , and ml/kg). a line of best fit is drawn between the minimal systolic values (one after each breath) and the downslope calculated as the decrease in blond pressure for each increase in airway pressure ( mmhg / cmh ). in mechanically ventilated patients the rsvt was performed during controlled mechanical ventilation under sedation. the test was repeated after the administration of ml/kg of plasma expander. the initial mean downslope of the rsvt was -. + . mmhg/cmh . following volume loading the downslope decreased to -. + . (ns). at the same time, cardiac output (co) increased by . + . l/min (p<. ), end-diastolic area (determined by tee) increased from . + . to . + . cm (ns), and paop increased from + to + mmhg ( p < . ). the preinfusion downslope value of the rsvt correlated significantly with the increase in the co (r = . ) and the eda (r = . ). methods: an expert system has been constructed running on a multimedia computer with the two objectives in mind, viz training of inexperienced staff, and protocol guidance with treatment regimes for all staff. the system is based on experience gained from two previous systems, the one for dealing with acid-base and electrolyte problems in icu patients; the second for stabilisation of patients with heart rate and blood pressure abnormalities. the training section takes the form of a stage-by-stage account of the insertion of the pac and displays of correct waveforms, coupled with indications of possible incorrect placements, and guidance when failing to achieve the perfect positioning. the treatment protocol section extends an existing protocol for correcting abnormalities in heart-rate and blood-pressure, and now takes account of all the indices as measured by the pac. the system will suggest treatment to correct such things as abnormal wedge pressures concomitant with parameter values throughout the rest of the cardiovascular system. the type of patient eg post-operative cardiothoracic or i. c. u. trauma, will be taken into account when recognising abnormal parameter values and when prescribing treatment. results: a working system which will be improved by the finetuning being carried out. the results and lessons learnt will be presented at the conference. method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map < mmhg) or the requirement for a noradrenaline (na) infusion ~ . g/kg/ rain with a map --< mmhg. cardiovascular support was limited to na + dobutamine (db). c was given for up to h at a fixed dose-rate of either , . , , or mg/kg/h iv. during c infusion, na was to be reduced and if possible withdrawn, whilst maintaining map above mmhg and the cardiac index (ci) as clinically appropriate. assessments were made at baseline (t = ); at i h from the start of treatment (t - ); and at the end of treatment (t - ) with c . conclusions: c does not appear to increase mpap or worsen pulmonary gas exchange in patients with septic shock, when given by infusion for up to h. c is a novel vasoactive agent for the treatment of septic shock which will now he evaluated in a randomised, placebo-controlled safety and efficacy study. objectives : to compare cardiac output (q) data obtained for thermal indicators in pulmonary artery (qtpa) and aorta (qtao) and for the stable isotope hzo in aorta (q v~ o) with indocyanine green (icg) in aorta (qicg) as reference. methods : an indicator solution of ice cold h ( . ml), h ( . ml) and icg ( mg) was injected as bolus via the injection port of a swan-ganz catheter. qlco and qzmo was measured using a dual optical system (penn lab instruments, philadephia, pa, usa). qtpa and qtao was measured using a in contrast to the recoveries of thermal indicator in pa and h in aorta the :~covery of thermal indicator in aorta was significantly increased in group ii (n= boluses) over group i (n= boluses) ( . <- . vs. . +- . , p= . ). conclusions: the "overrecovery" of thermal indicator in aorta is in agreement with " biscks deconvolution study (i) and results in erroneous values for q. the most pausible explanation is the distortion of the thermal curve caused by the slow response time of the thermal detection instrument as shown by ganz ( ) objectives: to compare data obtained with the double indicator dilution method using indocyanine green (icg) and the stable isotope h for the estimation of extravascular lung water (evlw hzo) to gravimetriu lungwater data (evlwg~). methods: an indicator solution oflcg ( rag) and h ( . ml) was injected as bolus via the injection port of a swan-ganz catheter. dilution curves for icg and zh was registered in aorta with a dual optical system (penn lab instruments, philadephia, pa, usa). cardiac output and mean tranist time was measured for both tracers (qico, tlco, q n o, t o) ( ). data analysis: evlwg~av was reference for evlwzhzo calculated as q hzo times the difference in mean transit time between t nzo and rico (atm n). as reference for atzn o evlwg~,v was divided by q~cg to obtain atg~,. a reference distribution volume for h was calculated as the sum of central blood volume and evlwg=v. boluses were administrated in a group (i) of anaesthetized pulmonary healthy sheep while q was altered. another boluses were administrated in a group (ii) of anaesthetized sheep with stable oleic acid induced pulmonary oedema. evlwg~v measurement was performed postmortem. results: for boluses h parameters were not significantly different from their respective reference parameter: at vao . +_ . s vs. atg~, . + . s, evlwzh o -+ ml vs. evlwg~,~ + ml. in group i the ratio between hzo parameters and respective reference parameters (n= ) were independent of qlco from . to . l/min. obiectives: to assess the thermo dye method using indocyanine green (icg) and thermal indicator for the estimation of lung water (evlwt). methods: ice cold indicator solution of icg ( mg) in water ( ml the aim of the study was to assess left and right ventricular function in the early postoperative period after orthotopic heart transplantation to elaborate therapeutic approaches of heart function abnormalities correction. mathefial and methods. haemodynamic monitoring data of twenty one patients ( men, women ) age from to were studied. cardiac output, pulmonary artery, right atrium and pulmonary wedged pressure were measured with swan-gans catheter. central haemodynamic indices were calculated with the help of computer-based monitoring system. relations of ventricular stroke work index to it's end-diastolic pressure were used for ventficular function assessment. results. in most cases right ventricular disfunction was the main problem. isolated fight ventficular failure with high pulmonary vascular resistance (pvr) was observed in % ( pts), without high pvr-in % opts) and with left ventricular failure-in % ( pts). one of the most important reasons for fight ventricular failure was the time of heart ischemia more than min, which is of great importance in the ease of distance harvesting. the most effective treatment for cardiac failure was combination of dobutamine with i oprotherenol, atrial pacing and vasodilatators in case of right ventfieular disfunction. all cases with isolated right ventricular failure were treated sucsessfully. biventricular heart failure was a sighn of bad prognosis and the reason of death in cases. conclusion. right ventfieular disfunetion is the main problem during transplanted heart adaptation in the early postoperative period. optimal therapeutic management of cardiac disfunction includes infusion of dobutamine in combination with isoprotherenol, atrial pacing and vasodilatators. cardiology-department of clinical centre-kragujevac institution for occupational health "zastava"-kragujevac, sr yugoslavia the aim of the investigate is analisis five years survives patients with a.i.m.in dependence of locality and risk-factors. we ana~sed- ~-pat~e~ts ( males and woman), average , years. for statistic evaluation we used life-table slstem in oder to estimate prognostic determinants. patients with respkatory muscle paralysis may benefit from respiratory assistance by abdomino-diaphragmatie pneumatic belt. we used a non invasive technique, m-mode sonography, to assess the effect of this device on diaphragmatic excursion. we measured the amplitude of right diaphragm motion in seven patients with duehenne muscular dysl~ophy in supine position with various thoracic posture ( ~ ~ ~ without and during pneumatic belt respiratory assistance. without respiratory assistance, the thoracic posture had no significant consequence on the amplitude of diapttragm motion, either in quiet or deep breathing. the pneumatic belt increased the diaphragm motion amplitude from . +__ . mm to . +_ . ram (p = . ) at ~ tilt angle, and from . + . mm to . + . mm (p = . ) at " tilt angle. the tidal volume increased from + to + rut a * tilt angle, and from + to + ml at * tilt angle (p = . ). two patients could not bear the horizontal position ( ' tilt). in the five other patients, the pneumatic belt increased but not significantly the amplitude of diaphragm motion ( . + . mm to . + . ram). after an overnight respiratory assistance, pao increased from . +_. . to + . mmhg ( = . ), sao increased from . + . % to . +_. % (p = . ), and paco decreased from + . to . +_. mmhg (p = . ) according to the ventilatory pattern result, m-mode sonography allows to measure non invasively the improvement of diaphragm kinetics obtained by pneumatic belt respiratory assistance, and may be helpful for its adjustment. objective: to study the effect of flow triggering (flow sensitivity and l/min) vs pressure triggering (-lcmh ) on inspiratory effort during pressure support ventilation (psv) and assited/controlled mode (a/c) in stable copd patients non-invasively ventilated with a full face mask. methods: the patients were studied during randomized min. runs using a bird st ventilator at zero peep (zeep). trigger values for pressure (-lcmh ) and flow ( l/rain) were the lowest allowed by this ventilator. the transdiaphragmatic pressure time product per breath (ptpdi), dynamic intrinsic peep (peepi,dyn), maximal airway pressure drop during inspiration (apaw) andl ventilatory variables (ti,te,ttot,rr,vt and minute ventilation) were measured. results: no major problems due to airleaks or to auto-triggeriffg phenomena were observed in the patients, so that all of them were able to perform all the protocol runs. minute ventilation and respiratory pattern were not different using the two triggering systems. the ptpdi was significantly higher during both psv ( . + . cmh: x sec) and a/c ( . + . ) with pressure triggering, as respect to psv ( . + . , p< . ) and a/c ( . + . , p< . ) with flow triggering ( l!m). no differences were observed between and l/min flow triggers. apaw was also significantly larger during pressure triggering; peepi,dyn was reduced during flow triggering being . + . cmh (psv flow trigger) vs . + . (psv pressure trigger) and . +_ . (a/c flow trigger) vs'f~ +l (atc pressure trigger). conclusions: in stable copd patients non-invasively ventilated, flow triggering reduces the respiratory effort during both psv and aic mode as compared to pressure triggering. this may be partly due to a decrease in peepi,dyn using a flow-by system. objective. cardiac output is higher during alternating ventilation (av) (i.e. differential ventilation of the lungs with a phase shift of half a ventilatory cycle) than during synchronous ventilation (sv) of both lungs . we verified the hypothesis that the higher cardiac output depended on a lower central venous pressure and intrathoracic pressure, due to a lower mean lung volume, which we attributed to part of the expansion of the inflated lung at the expense of the expiring, opposite lung . we studied this interaction between the lungs during one-sided inflation, which we called cross-talk. method. in anaesthetized and paralyzed piglets we applied short periods ( s) of one-sided ventilation ( breaths per rain, bpm), while the other lung was open to the ambient air. the air flow into the non-ventilated lung during expiration of the ventilated lung was integrated to volume. we studied -to-r and r-to-i cross-talk at ventilatory rates of , and bpm. the amount of cross-talk was the volume displacement in the non-ventilated lung. results. during bpm the r-to-i crosstalk was _+ . % (mean +__ sd) of the tidal volume to the right lung and the -to-r crosstalk _ . % of the left tidal volume. both values increased at bpm to _ . % (p < . ) and _ . % (p < . ) respectively. the values at bpm were in between., conclusion. we concluded that the lower mean lung volume and lower thoracic expansion during av compared to sv depends on partial expansion of the inflated lung into the non-inflated lung, resulting in a lower mean intrathoracic pressure as the main reason for the higher cardiac output during av. obiective: natural surfactant given for rds in premature infants leads to a rapid improvement in oxygenation, but lung compliance did not improve in most studies. however, acute effects on lung mechanics during and immediately after surfactant administration have not been studied before. methods: a total of administrations of bovine surfactant in recommended doses was given via a small catheter into the distal endotracheal tube either as a bolus (n = ) or as a slow infusion (n = ) in infants with established rds. static compliance (c), resistance (r) and time constant (tc = cxr) of the lung were measured every minutes with a lung function cart (sensormedics ) without interrupting ventilation. infants receiving synthetic surfactant were studied as controls. results: after surfactant as a bolus or during infusion c first decreased but then increased, whereas r increased immediately with great fluctuations but did not return to baseline. this pattern was more pronounced in infusion than in bolus administration. change of c and r varied greatly in the individual case, maximum c was > %, maximum r > % of baseline value. retreatment was followed by an increase in r in all patients, but c increased only in the one who was responder. patients receiving synthetic surfactant had no change of c or r and were non-responders. ob~i ctives= acute lung injury (ali} sometimes induces severe hypoxernla which may be refractory to conventional modes of mechanical ventilation (mv). the elm of this study was to observe some cardio-pulmonary effects of an alternative method of ventilatory management of severe ali. five patients with severe ali (murray scores > ) requiring mv were studied. protocol inclusion was considered when a control-mode of mv (with a pzo~=l. and a peep level < cme=o} was not able to get either a p.ojf=o= ratio > or a s.o= > %. patients were sedated, paralyzed, and a ventilator (serve c) was used for pressuz'e-control ventilation (pcv). fio= was maintained at . and peep removed. continuous gas flow ( • ml/kg] was humidified and jet delivered through a tube ( ram id, ml capacity, . ml/cm h=o compllancel ended in a nozzle ( . mm is) attached to the endotracheal tube connector. a thermodilution flcw-dlrected catheter was inserted in pulmonary artery. following variables were recorded minutes before and after protocol started: tidal volume (vt), minute ventilation (vz), intratracheal pressures (p~w), wedge pulmonary artery pressure (wp), central venous pressure (cvp), mean arterial pressure (map), cardiac index (ci), arterial and mixed venous oxyhemoglobin saturation (sao=, svoa) , oxygen delivery (do~) , oxygen consumption (vo ) , intrapulmonary shunting (q./qt) , and oxygen extraction ratio (ero). this observation suggests that hfpv could allow to ventilate at lower fin and improve blood oxygenation during the acute phase after inhalation injury reducing toxicity risk related to high fin . further studies are necessary to confima these results and evaluate the possible implications on mortality alter smoke inhalation and for other icu pts. objectives: to design a system for volume controlled high frequency ventilation (hfv) and to estimate the dependence of the tidal volume (vt) on frequency (f) in normocapnic ventilation in rats at frequencies - hz. methods: a new system for volume controlled hfv was devised consisting of the generator of the constant flow during inspirium and the constant pressure during expirium. the ventilator allows ventilation at frequencies - hz with the relative inspiratory time (ti) . - . . the airway pressure was measured at the proximal port of tracheostomic cannula , at the same site inspiratory and expiratory flow was measured using modified lilly-type of pressure-differential flow sensor. non-linearity of flow sensor was compensated on line by derived equation based on calibration at static and dynamic conditions. flow and pressure data were evaluated on line using original software. value of the positive end expiratory pressure (peep) was serve-regulated by analogous feed-back. in animal experiments white wistar rats ( - g) narcotized with ketamine/xylazine with cannulated carotid and femoral arteries were kept at the rectal temperature ~ the arterial pressure was monitored. after traeheotomy the metal cannula ( mm [.d.) was inserted, animals were curarized and ventilated at the following condition: peep = . kpa, ti = . . the dead space of ventilator including canula was . ml. the initial frequency was hz and rain after each change of the ventitatory regimen the blood gases analysis was performed. the frequency was changed according to the following schedule : hz--> hz--> hz--> hz--> hz--> hz--~ hz--> hz. vt for each frequency was regulated to maintain normocapnie ventilation with arterial pco = + mm hg. the arterial po was always above mm hg. results: for normocapnie ventilation in rats the following tidal volumes vt [ ml/kg] were found : vt = . --+ . ml/kg for ft = hz, vt = . + . mukg for fz = hz, vt = . +_ . ml/kg forf = hz, vm = . + . ml/kg forf = hz andvmt= . + . mukg for fs = hz (presented as mean values _+ s.d., n = ). the regression analysis using the mean values resulted in the equation for normocapnic vt in rats in our experiments : vtn = . * f-e. . conclusions: the described system allowing ventilation in a wide frequency range - hz with accurate measurements of airway pressures and vt might be useful for optimisation of artificial ventilation in new-barns with different lung pathologies. supported by grants iga mz cr nr - and gacr nr . s intensive care unit. university. hospital of south manchester, uk. methods: measurements were conducted on ventilated patients (puritan bennett ac with metabolic monitor pb set to measure end tidal co ). all measurements were repeated with the patient stabilised at cm. cm and cm peep. inclusion criteria were: ) haemedynamic stab(l( .ty for hr; ) pulmonad" anon" flotation catheter in situ: ) volume control ventilation with plateau of . s: ) fio ~ > . to maintain pao~. > kpa with em peep: ) qs/ot > %; ) pao /fio ratio < . measured variab!es included: r minute volume: plateau ainvay pressure: applied and intrinsic peep: fractional end tidal co ; arterial and mixed venous blood gases and hacmod).ttamic variables. results: statistical analysis was performed using repeated measures anova. significant decreases in cardiac index (ch p< . ), compliance (p<t). ) and o,'gcn deliver, index (do , p< . ) occurred with increasing peep (table ) . no other variable showed any significant change. methods : all consecutive patients orally intubated in the micu between january to april were studied. etts were positioned according to the reference marks mentioned above (measurements from upper incisors). the position of the ett tip in relation to the carina was measured on the chest radiograph done with the patient's head in neutral position. results : a total of men and women were studied (n= ). the mean distance of ett tip to carina was . cm. using the reference markings, cases ( . %) had the ett tip < cm from the carina and cases ( . %) > cm. one case resulted in an endobronchial intubation. the mean height of all patients were cm ( - ) for males and cm ( - ) for females. of the patients with ett tip < cm from carina, the mean height was cm and cm respectively. ~ onclusion : adopting the above quoted reference marks did not result in ideal positioning of the ett in a significant proportion of cases ( . %). we postulate that [s because our asian population is generally shorter than those in previous studies. objectives: to measure the changes of pulmonary mechanics before and after tracheostomy in patients with prolonged mechanical ventilation and to determine factors that predict the outcome of liberation from mechanical ventilation. design: prospective. setting: respiratory intensive care unit (ricu) in a tertiary hospital. patients: twenty patients with chronic lung disease requiring long-term mechanical ventilation. tracheostomy is indicated for further care. intervention: tracheostomy. measurements and results: pulmonary mechanics including respiratory rate (rr), tidal volume (vt), peak inspiratory pressure (pip), intrinsic positive end ex~ piratory pressure (peepi), lung compliance (cld), mean airway resistance (rawm), work of breathing (wob), pressure time product (ptp) by bicore cp- pulmonary monitor were recorded hours before and after tracheotomy. ventilator setting parameters remained the same during surgical intervention and were also recorded for comparison. generally, the mechanics including pir wob, raw~x and ptp showed improvment after tracheostomy. but only pip was significantly reduced (pre . _+ . to post . _+ . , p < . ). changes of wobp showed significant correlation with pre-operation rr, minute volume (mv), wobp, and peep(. changes of raw m were also significantly correlated with pre-operation peep, vt, and raw m. the patients were divided into two groups according to their outcome after two week follow-up. group included eight patients who were completely weaned from ventilator; group included twelve patients who still remained ventilator-dependent or were mortality. there was no difference in age, duration of mechanical ventilation, pro, post or changes of several lung mechanics between the groups of patients. pre-tracheostomy peep i and cld showed significant difference between these two groups ( . _+ . vs . + . in peepi; . _+ . vs . _+ . in cld, p < . ). pre-tracheostomy ventilator setting in mode of assist/control also showed significant higher percentage in group ( % % in group vs . % in group ). conclusion: in prolonged mechanical ventilation patients with chronic lung disease, tracheostomy will significantly improve pip and slightly reduce wobp, raw m and ptr patients who used pressure support mode before tracheostomy had better underlying lung conditions (lower lung compliance and auto-peep) will have better chance to wean from mechanical ventilation. forty-eight infants with congenital diaphragmatic hernia presenting within the first hours of life, who underwent surgical rapair,were analysed prospectively in order to produce a reliable inde x of severity of disease that would reliably predict eventual outcome. there were survivors and deaths in this series (mortality %).using arterialpco values measured hours after surgical repairand correlating them with an index of mechanical ventilation,we have been able to clearly define two groups of diaphragmatic hernia based on their response to hyperventilation. the first group, with co retention and severe preductal shunting,was unresponsive to hyperventilation with high rates and pressures the mortality was %. the second group responded well to hyperventilation and demonstrated reversable ductal shunting only. survival in this group was %. arterial co accurately reflects the degree of lung development in this disease and separates those patients with severe pulmonary hypoplasia where the outcome is invariably fatal, from those with a well developed contralateral lung where there is excellent potential for survival. respiratory failure unit, dpt medicine, univ. thessaloniki, thessaloniki, greece the variability of arterial blood gases (po , pc ) and the ph (abg) was examined in stable icu patients, few hours before a successful weaning from the ventilator. all patients were lightly sedated and the ventgatory conti~ons were pressure support (ps) for and ps plus intermitted mantatory ventilation in ii. [n each patient, speciments of abg were measured at min intervals during a - study period. at the same time with abg the arterial blood pressure (bp), the heart rate (cf), the tidal volume (tv) and the respiratory rate (n r were measured. for all the patients, the mean coefficient of variation (c) was . percent for po , . percent for pco and . percent for hco . the average sd for ph was . , the corresponding c for systolic bp, diastolic bp, cf, tv, rf were . , . , . , . , . percent. we conclude that the spontaneous variability of arterial blood gases in icu patients is not substantial ~hen they have stable the heamodynamic and the ventilatory parameters. deptx?fa'aaesthesioiogy and reanimation, rhe sechenov medical academy, moscow, russia objective: ~he prevention and treatment of hypoxia in the critical patiems. methods: i~fusions of perphtoran -a blood substitute with gas-transporting fimclion based on perphtorhydrocarbon -in patients with acute hypovolemia, microcirculatory distnrbance~ tissue gas exchange and metabolism; pulmonary iavage in ; iongterm extrapulmonary oxigenation with tleoroearboa oxygenator in combination whb ~trafiltra!ion, hemosorption and hemodialysis -in patients. results: pe~htoran increases blood volume, co,sv, decreases svr, improves capillary blood flow, increases the blood oxygen capacity, tissue oxygen tension, del, vo by improving the rheologic properties of blood and plasma, normalizes ext., prevents and eliminates fat embolisation and ards. decreases the need for blood transfusions and infusions of plasma expanders by . - . limes. alveolar venti!ation-perfusion ratio remains unchanged with its increased effective utilization. there was no surfactant destruction during lavage. extrapulmonary oxygenation of small volumes of venous blood eliminates venous destruction and then arterial hypoxia and increases pulmonary oxygenation. the use of lluorocarbon cxygenators during hemosorption and hcmodialysis provides the atraumatic and iongterm oxygenation of arterial blood and increases elimination of co which prevents the development of hypoxic complications. conclusions: perphtoran and fluorocarb~n oxygenators are effective in the correction of hypoxia in the criticat patients. objeqtives: to determine if there are differences in oxygen consumption (vo ) during weaning from mechanical ventilation (during total ventilatory support and spontaneous ventilation with cpap), and to compare different predictive parameters of weaning in predicting success of weaning. methods; prospective study in critically ill patients treated with mechanical ventilation for at least h, who fulfilled at least of standard weaning criteria (vt> ml/kg; respiratory frecuency (f) < ; pimax > cm h ; pao /fio > ). baseline measurements: t, vt, p . , pimax, f/vt, p . *(f/vt), p . /pimax. study protocol: measurement of vo , vco (medgraphics), vt, f, ve, and arterial blood gases during total ventilatory support (cmv), and after and minutes of spontaneous ventilation with cpap cm h . the weaning trial was stopped, failure to wean diagnosed, and mv resumed it a patient presented significant tachypnea, tachycardia, bradycardia, cardiac rythm disturbances, hypertension, hypotension, hypoxemia or hypercapnia. results: four patients did not complete the weaning trial, were extubatad, and of them had to be reintubated before h, being considered also weaning failures. during cmv, vo /kg was . + . ml/kg/min, and . _+ . mlo- /kg/min after ' on cpap cm h (p < , ). of patients ( %) with standard criteria were extubated, while only of ( %) with criteria (p< , ). next objectives: compare the extent and distribution of lung injury in dogs preinjured with oleic acid (oa) and ventilated with high tpp and adequate peep in the prone and supine position. methods: lung injury was induced with oa ( . - . ml/kg) in anesthetized, paralyzed, and intubated dogs (n= ) during volume controlled ventilation: rate= /min, peep= cmh , ti/ttot= . , fio = . , vt= ml/kg. animals were rotated during the oa infusion and the following minute stabilization period to assure uniform injury. in the supine position, peep was set - cmh above the lower inflection point (as determined by the pressure-volume curve), and vt was set to obtain a tpp of cmh : animals were ventilated in either the prone (n= ) or supine (n= ) position for four hours. pulmonary artery occlusion pressure was maintained constant ( - mmhg) with saline infusion. at the end of the protocol the lungs were removed and divided by template into dependent (d) and nondependent (nd) sections for wet weight/dry weight (v~n/dw) and grading of nstologic lung injury (hli; scale - ). oseillatron | is a pneumatic device that generates high frequency, oscillation by means of a reciprocating system in the form of a membrane. it generates sinusoidai wave form at ( to ( cycles/rain. the system does not deliver gas but must be adapted to the proximal respiratory, circuit of a conventional ventilator, resulting in ci-ifo. it was developed to enhance intrapnlmona~ diffusion during mechanical ventilation and to mobilise endebronchial secretions. methods. we measured arterial blood gases and haemedynamics during a first period of conventional ventilation (cppv) followed by. two rain periods of chfo (sequences : ( and ) c/rain : group l, n = l: and c/rain : group , n = ). measurements were made at the end of each period. cardiac output was measured using thermedilution method: flu and peep were kept unchanged throughout the study. intrinsic peep was also evaluated by, means of an occlusive valve. results. pa is not significantly modified during chfo at or c/rain. paco is slightly decreased at c/rain (p = .( ). however, intrinsic peep remains unchanged. there is no sequential effect (gr. l vs gr. ). there is no more effect of chfo for patieets who are at a flu higher than . (n = ). no changes in haemodynurmcs are observed except a slight increase in central venous pressure (cvp) during ci-ifo (p < .ol). obiectives: to examine the effects of inspiratory muscles unloading on neuromuscular output at controlled levels of chemical stimuli. methods: the ventilatory response to co was examined in ten normal subjects using rebreathing method. ventilation ~) and respiratory muscle pressure output (pmus) at the same end-tidal partial pressure of co (petco~) were compared with and without combined flow and volumeproportional pressure assist in two protocols (a and b). protocol a (n = ): two levels of assist were studied; flow assist (fa) of cmh /i/sec and volume assist (va) of cmh /i (assist ), and fa of cmh /i/sec and va of cmh /i (assist ). all conditions were applied randomly. v~, tidal volume (vt) and breathing frequency (f) were measured breath by breath and plotted as a function of petco~. protocol b: in subjects, in addition to above measurements, esophageal (pes) and gastric (pg) pressures were measured and the time courses of transdiaphragmatic pressure (pdi) and pmus were calculated. one level of assist (assist ) was studied in this protocol. results: in both protocols inspiratory muscle unloading did not change the f response to c%. compared to control, with assist v t response was displaced upwards; at petco of mmhg v t was increased significantly by . + . i and . + . i in protocol a with assist end , respectively, and by . _+ . i in protocol b with assist (p< . ). ~/~ responses showed similar changes as vtresponses. in both protocols the slope of v~ response (s did not change significantly with unloading. at low petco~ ( mmhg), pdi and pmus waveforms did not differ with and without assist. with unloading, at high petco ( mmhg), pdi and pmus at the end of neural inspiration decreased by . -+ . % and . + . %, respectively, from control values. neither change was significant (p> . ). by theoretical analysis we estimated the expected changes in vt and ~/~ when the levels of assist used in both protocols were applied in the absence of : any change in neural output response to co z. the predicted response was similar to that observed, indicating that the small difference in pdi and pmus between control and unloading runs was due to intrinsic properties of respiratory muscles end respiratory system. conclusions: these results suggest that when chemical stimulus is controlled, respiratory motor output is not downregulated with unloading. the determinants of the response of the respiratory output to inspiratory flow rates (v~) were examined in awake normal subjects. subjects were connected to a volume-cycle ventilator in the assist/control mode and v~ was increased in steps from to i/min and then back to i/min. v~ pattern was square, and all breaths were subject-triggered. in six subjects the effects of breathing route (nasal or mouth) and temperature and volume of inspired gas (protocol a) and in subjects the effects of airway anesthesia (upper and lower airways, protocol b) on the response of respiratory output to varying v~ were studied. in protocol b, in order to calculate muscle pressure during inspiration (pmus), respiratory system mechanics were measured using the interrupter method at end-inspiration. independent of conditions studied breathing frequency increased . significantly and end-tidal concentration of c% decreased as v~ increased. the response was graded and reversible and not affected by breathing route, temperature and volume of inspired gas and airway anesthesia. with and without airway anesthesia (protocol ) neural inspiratory and expiratory time and neural duty cycle, estimated from pmus waveform, decreased significantly as v~ increased. at all conditions studied the rate of change in airway pressure prior to triggering the ventilator tended to increase as v~ increased. the changes in timing and drive were nearly complete within the first two breaths after transition with no evidence of adaptation during a given ~/~ period. we conclude that v~ exerts an excitatory effect on respiratory output which is independent of breathing route, temperature and volume of inspirate and airway anesthesia. the response most likely is neu~'al in origin, mediated through receptors not accessible to anesthesia such as those located in chest wall or below the airway mucosa. it has been shown, in mechanically ventilated awake normal humans, that increasing inspiratory flow rate (~/~) exerts an excitatory effect on respiratory output. it is not known if this effect persists during sleep. to test this seven normal adults were studied during wakefulness and nrem sleep. subjects were connected through a nose-mask to a volume-cycled ventilator in the assist/control mode and ~/t was increased in steps ( - breaths each) from to i/min and then back to i/min. v~ pattern was square, and all breaths were subject-triggered. forty-one trials during nrem sleep and during wakefulness were analyzed. both during sleep and wakefulness minute ventilation increased and total breath duration (ttot) decreased significantly in a graded and reversible manner as ~' increased. these changes were complete in the first breath after v{ transition. the response was significantly less during sleep than during wakefulness (p< . ); at i/min ttot, expressed as % of that at i/rain, was . +_ . % during sleep and . +_ . % during wakefulness. during wakefulness, at i/min, the rate of change in airway pressure prior to triggering the ventilator, an index of respiratory drive, was % of that at i/min (p< . ). the corresponding value during sleep, was % (p> . ). in four sleeping subjects the increase in v~ was sustained for . - min. there was no evidence for adaptation of the response; tro t, averaged over the last three breaths, did not differ from that obtained when vj was sustained for only - breaths. we conclude that ) vt exerts an excitatory effect on respiratory output, mediated by a reflex neural mechanism and ) the gain of this reflex is attenuated by sleep. chest radiographs is a common complementary technique for patients in critical care units, with a low cost and easily available. however, it has certain well-known limits in diagnosis, the most important derived from the low quality of some pictures. in this paper we make a general review of some new technical approaches developed for improving the quality of the images, and so incrensing the diagnostic value of conventional radiology. we begin deaeng with the correct positioning of the patient, trough the filtering techniques, the synchronization of radiology and ventilation, and we make reference to the new computerized systems for digital image processing. conclusions: the portable radiographic system is a device that probably with maintain for many years in critical care units as a basic non-invasive diagnostic tool. but we need an increase in the efficiency of it, applying means as simple as a correct positioning of the patient, or the use of fitlers or synchronizers. thus we should improve the general standards of portable radiography. "are circular circuits safe? quantifying undelivered tidal volume in pediatrics patients". objectives: to evaluate the overall influence of internal compliance of circular circuits on delivered tidad volume (vt). methods: we studied prospectively asa i pediatrics patients ( to yr. old) scheduled for elective general surgery. mechanical ventilation was supplied by an ohmeda excel (circular circuit). the internal compliance of the circuit (cc)-anesthesia machine plus external circuit-was determined by the supersyringe method: corrugated dar tubes of mm. id and . m. long (children < kg), and a corrugated dar set of mm. id and . m. long (children > kg) were respectively used for ccl an cc values of . and . ml/cm h . a vtof mlg/kg and respiratory frequency was adjusted for an end-tidal co (etpco ) between mmhg. tidal volumes (measured by spirometry) and airway pressure (paw) data were recorded every ten minutes. volumes and thorax-lung compliances were calculated as follows: (vt delivered = vtadjusted-vol compressible, being vol. compressible = co x ppeak (aw). apparent compliance (ca) = vt adjusted/pplateau(aw), and true compliance (ct) = =vt delivered/pplatean(aw)). comparative statistics were separately designed between calculated compliance data and tidal volumes on a paired sample ~test basis. results: calculated values for volumes and thorax-lung compliances were: conclusions: due to the elevated internal compliance of the circular circuit there is a remarkable dilference between adjusted and delivered vt: mean undelivered vt was . % and reached as high as . %. teere is also a significative error in calculating true thorax-lung compliance: its overestimation can be as high as . %. circular circuits are considered safe and cost-saving for anesthetical practice. nevertheless we conclude that anesthetists should bearin mind vt losses when using circular circuits, due to compressible volume. tracheal stenosis is one of the most serious complications of patients submitted to prolonged endotracheal intubation, in which the decrease in inner diameter of upper airway makes it very difficult to achieve a correct ventilation. objectives: compare the results of applying high frequency jet ventilation (hfjv) to some of these patients with conventional controlled ventilation (cmv). methods: we used a prototype of high frequency jet ventilator (santiago- ) developed in our university, and we developed a tracheal tube in wich we modified the distal tip (conic tip). we applied this system to two patients which were initially ventilated in the operating room with usuai controlled mecanical ventilation (cmv) following the standards of our department, and then intubated with the special endotracheal tube and ventilated with hfjv. results: we could verify a proper ventilation of both patients with cmv and hfjv. during hfjv, the airway pressures were lower than those recorded during cmv. a lower airway pressure prevents lesions due to high pressures. conclusions: hfjv is a good method of ventilation for patients with significative stenosis of the trachea, not only during surgical procedures, but also during ventilation for long periods in critically patients. the ventilatory setting is pressure support mode. the pressure level and fit were kept constant during h/d. arterial blood gas, wbc count, and mean bp was checked according to the schedule: '(immediately before h/d), ', ', ', ', ', '. respiratory drive (represented by poa), tidal volume(ti) and minute ventilation(ve) were continuously recorded by pulmonary mechanics monitor (bicore cp- ). the mean value of the breaths minutes before blood sampling were used to represent the ventilatory status of that period. anova test is used for comparison between groups. for poa, hierarchical cluster method is applied to divide the cases into two groups of similar change. conclusions: our data suggest that pl is very useful, non invasive and low-expensive emergenc e support for arf, expecially in the elderly with severe chronic pulmonary disease and relative controindications to eti. pl seems to be an effective alternative when it is not immediatly possible to perform etl. the multiple inert gas elimination technique (miget) can be used to assess the effects of any given mode of mechanical ventilation on the pulmonary and systemic factors determining arterial po and pco> however, a potential problem in mechanically ventilated patients is that the l mixing box (mb- l) placed in series in the expiratory side of the circuit of the ventilator to sample mixed expired gas may provoke substantial discrepancies between the tidal votume set in the ventilator and the effective tidal volume delivered to the patient, due to the increase in the compression volume (vc) of the circuit. the effects of the mb- l on the v c were compared with those produced by a new l mixing box (mb- l) specifically designed to produce adequate gas mixing and to prevent loss of the two most soluble gases (ether and acetone) used in the miget. at any given peak cycling pressure (p~ak, cm h~o), the v c (ml) provoked by the mb- l was substantially higher (vc= . *ppeak) than that provoked by the new mb- l (vc= . *ppeak). at a ppeak = cm h ~ the v c were ml (mb- l) and m{ (mb- l), respectively (p< . ). in a group of subjects ( m/ f, _+ years), for each of six the gases used in the miget, the regression line between the mixed expired partial pressures simultaneously obtained from mb- l and mb- l fell on the identity line. it is concluded that the new mb- l allows adequate assessment of the effect of different modalities of mechanical ventilatory support on pulmonary gas exchange, with less potential for gas compression and thus hypoventilation. objectives evaluate the influence of different pressure support ventilation (psv) levels on cardiovascular and respiratory funcion in icu polytrauma patients. metbed&we studied polytrauma icu patients , who were in weaning process , after long term mechanical ventilation for acute respiratory failure . mean age ( - ) yrs . they all were connected to servo ventilators siemens c , and all were in stable condition , without sedation , inotropes or diuretics. the hemodynamic studies were done with continuous svo , swan ganz catheter (oximetrix, abbott). they all were in spontanuous mode (spent) with cm h cpap for at least one hour. we turned them to psv with inspiratory assistance (psv cm h ) and after rain we applied psv cm h , and after min psv cm h . hemodynamlo and respiratory measurements were done before and after the application of insiratory assistance. the results were statistically analyzed with anova. resets . respiratory variables . no significant changes in minute volume (ve). tidal volume (vt) and mean airway pressure (mpaw) increased statistically significant (p< . ) . respiratory rate (rr) decreased significantly (p< . ) . blood gase showed no difference . cardiovascular variables. cardiac output (co) decreased ns , heart rate (hr) had no change , central venous pressure (cvp) , mean pulmonary artery pressure (mpap) , pulmonary capillary wedge pressure (pcwp) , increased ns , oxygen delivery (do ) decreased ns, oxygen consumption (vo ) decreased ns. conclusions. psv is a very useful respiratory mode helping patients to be weaned from long term mechanical ventilation . it has beneficial effects on respiratory function and oxygen consumption without affecting seriously the hemodynamic parameters, possibly due to a decrease of the work of breathing. a. michalopoulos, a. anthi, k. rellos, j. kriaras, s. geroulanos intensive care unit, onassis cardiac center, athens. objectives of this study was to examine the effect of different levels of peep on postoperative svo and pvo values in a group of patients, following open heart surgery. methods: upon transfer to icu, patients ( males and females) of mean age _-+ years, were randomly assigned to receive (n= ), (n= ), or cm of peep (n= ). there were no statistically significant differences in demographic data or preoperative respiratory status among the three groups. all patients were ventilated on the assist control mode with a tidal volume of ml/kg. the fraction of inspired oxygen (fio ) was adjusted to keep a pao around mmhg. mixed venous po and svo were measured at min, and hours after application of mechanical ventilation in the icu, just before extubation (be), half hour after extubation (ae), and at hours post-extubation. differences at each study time were analysed by anova. results: mean svo and pvo values among the three groups, for all study intervals, are presented in the table. conclusion: we found no differences (p=ns) in tissue oxygenation (expressed by svo and pvo ) among the three groups, at any study interval, in the early postoperative course of patients following open heart surgery. intrinsic peep (peepi), and high elastance and resistance increase inspiratory work load in copd. cpap reduces work of breathing by counterbalancing peepi. pav provides flow (fa) and volume (va) assistance proportionally to patient resistance and elastance and inspiratory effort. we studied the effects of partitioned support (cpap-fa-va) on breathing pattern and inspiratory effort in five copd patients on pav compared to spontaneous ventilation (sv) and full support (fs: cpap+fa+va). flow, volume, minute ventilation (ve) respiratory rate (rr), inspiratory swing in esophageal pressure (apes), and its integral per breath (pti/b) and per minute (pti/m) were measured. objectives: to evaluate airway pressure fluctuation (apf) during spontaneous breathing in a high compliance cpap system. methods: the cpap system consisted of two l weighted balloons in a wedge shaped holder. ventilating gas flowed from one balloon through a low resistance one way valve into a tracheal tube (ett) provided with a pycor co sensor to monitor rebreathing. the ett was connected to a piston drive mechanical lung. expired gas flowed through a low resistance valve into a second weighted balloon, from where it was exhausted through a peep valve connected in parallel with the second weighted balloon. we evaluated system performance at v r from to ml, at rr from to bpm, while closely monitoring cpap airway pressure swings. at v v of and ml the rr was limited to bpm. for comparison we explored aps of a one l balloon cpap system, the cpap mode of the puritan bennett , and siemens ventilators, when connected to a healthy adult volunteer breathing through an ett. results: the compliance (cpl.) of one l balloon system was linear over a range from . to . l, with a cpl. of . l/em h .the cpl. of the l balloon ( . l/em h ) was linear between a volume of and . l. apf of the weighted balloon system was under em h at all v r (except at a v r of ml aps was . em h ), while the apf in the l balloon was up to em h . apf witli human volunteers with the two commercially available ventilators in the cpap mode was about cm h ; while under identical conditions apf in the l balloon system was . emhzo; and in the two l balloon system was below lcm h . conelusions: cpap using the two balloon system exhibits lower airway pressure fluctuations than a single balloon system; and is substantially lower than found in the two commercially available ventilators when used in the cpap mode. objective: to perform independent lung ventilation (ilv) with individual tidal volume (vt) set at a value generating a plateau airway pressure (pplat) < crnh~o and to evaluate the usefulness of the continuous monitoring of endtidal co (etco ) as a guide to titrate individual lung vt during ilv and for the weaning from ilv. methods: in seven patients, ilv was performed with ttvo ventilators set with the same fio: and respiratory rate. each lung was ventilated with a vt that developed a pplat < cmh~o. this setting led to a lower vt on pathological lung (pl). vt was increased in pl following etco~ and paco -etco variations. ilv was discontinuated when etco~., vt and statical compliance (cst) were similar in both lungs. results: one hour after starting ilv (ti), pl mean vt was significantly lower than in normal lungs (nl) ( + ml vs + ml, p< ) two individual behaviours were observed on tl in pl: four patients presented low etco: (range - mmhg)and normal pacoz (range - mmhg), while three patients had normal etco (range - mmhg) with high pac (range - mmhg). one hour before stopping ilv (t ), vt, etc and paco were the same in each lung. the pao /fio: ratio improved in all patients from the beginning ofllv cst of pl was + % of the normal lungs' cst on ti and improved to . + % ofnl's cst on t (p< . vs conclusions: setting vt of pl to a value not overcoming a pplat threshold does not impair oxygenation and is helpful in avoiding barotraumatism. measurements of differential etco and of the differential paco -etco gradient can be used to titrate vt allocation during ilv and as a guide for the weaning from ilv. total respiratory resistance in mechanically ventilated patients exceeds values obtained in normal subjects, due to the added and highly flow dependent resistance of the endotracheal tube (rett). this can adversely effect the efficacy of pressure regulated modes of assisted ventilation, such as pressure support (psv) and proportional assist ventilation (pav). recent work demonstrates that the influence of rett during psv can be overcome by using tracheal (ptr) rather than airway opening (pao) pressure to regulate the pressure applied (intensive care med :$ , ) . the purpose of this study was to see if this approach would also be effective during pav. flow, volume, pao, ptr, and transdiaphragmatic pressure (pdi) were measured in intubated patients in which either pao or ptt were used to regulate the pressure applied during pav where volume assistance was varied from to % of respiratory elastance. representative results (mean + se) are shown below. compared to spontaneous breathing (pav %), pav increased tidal volume (vt) while reducing respiratory rate (rr) so that minute ventilation ('~e) also rose. this was associated with a reduction in inspiratory effort, as reflected by a decrease in the pressure-time integral ( [ p) of pes and pdi both per minute and per liter ~re. the effects on breathing pattern were similar for pao and ptr regulated pav. in contrast, the reduction in inspiratory effort was always greater for ptr regulated pav. in conclusion, the volume assistance provided by pav is more effective when ptr rather than pao is used to regulate the pressure applied. pav methods: retrospective data analysis of adult patients with normal pulmonary function before operation and uneventful course following coronary artery bypass graft surgery over an month period. we compared assist/controlled mandatory ventilation (s-cmv, patients), synchronized intermittent mandatory ventilation with inspiratory pressure support (s-imv/psv, patients) and biphasic positive airway pressure ventilation (bipap, patients). results: patients ventilated with bipap had a significantly shorter mean duration of intubation ( . h, p< . ) than patients treated with s-imv/-psv ( . h) and s-cmv ( . hi. with s-cmv . % of the patients required single or multiple doses of midazolam but only . % in the s-imv-/psv group and . % in the btpap group. the mean total amount of midazolam of these patients was significantly higher in the s-cmv group ( . mg) than in the s-imv/psv group ( . mg, p< . ) and in the bipap group ( . mg, p< . ). the consumption of pethidine and piritramide did not differ between s-cmv and s-imv/psv but was significantly lower during bipap (p< . ). after extubation the paco patients was highest in the s-cmv group. conclusion: ventilatory support with bipap reduces the consumption of analgesics and sedatives and duration of intubation. unrestricted spontaneous breathing as well as fully ventilatory support allow adequate adaptation to the patients requirements. bipap seems to be an alternative to s-cmv and sqmv/psv ventilation not only in patients with severe ards but also in short term ventilated patients. _objectitives: after end-inspiratory airway occlusion we examined the ensuing gradual decrease in tracheal pressure (ptr) with the following equations proposed by bates et al. and hildebrandt: pv = p'v e'~cccl~ +pst, rs (bates) [ ] where p'tr is tracheal pressure immediately after occlusion, to= is occlusion time, "r is viscoelastic time constant of respiratory system, and p t is static elastic recoil pressure of respiratory system. p~(t) = h -h log t (hildebrandt) [ ] where h~ and h are parameters depending on lung volume, and initial time is s for analytical reasons. materials & methods: we studied healthy patients intubated, anestethized with propofol, paralyzed with vecuronium, and mechanically ventilated with constant flow ( . i/s) at zeep for minor surgery. pressure was measured in the trachea. flow was measured with a pneumotachograph and volume was obtained by numerical integration. the rapid occlusions were produced by an external valve. the signals were sampled at a frequency of hz and processed on a pc. the influence of the cardiac artifacts during the occlusion time ( s) was reduced by a software low-pass filter kaiser finite duration impulse response of elevated order. results: the mean (+ sd) coefficient of correlation using eq. was , -+ . , and using eq. was . + . . the values ofz~ (eq. ), however, decreased with increasing the tidal volume (vt) according to the following equation: "~ = . - . v t, similary, the values of h~ and h increased with increasing v t according to the following functions: h~ = . + v i and h = . + . v t. conclusions: the behaviour of "% of eq. suggests that the linear viscoelastic model is not sufficient to further describe the mechanical properties of the respiratory system over the vt range ( - ml/kg) in ventilated patients. infect this model predicts that "c is constant and independent of tidal volume. on the other hand the plastoelastic model is not sufficient to further describe the mechanical properties of the respiratory system. in fact "r obtained by fitting an exponential for data of eq. , is determined by the time of endinspiratory airway occlusion. obiectives: according to the viscoelastic model, the viscoelastic pressure of the respiratory system pv=rs during lung inflation with constant flow e~ is t/ r wh t lsms ira tlmeand r given by:pv~c.~ = d~( -'e-~ )[ ] ere " ' p" tory " and "r are resistance and time constant of viscoelastic unit. in the past, the viscoaletic constants were determinated by performing a series of occlusions at different lung volumes, or a sedes of occlusions at a fixed lung volume achieved with various inflation flows. in the present study we have developed a new method for determining "c and r which requires a single constant flow inflation. our method is based on determination of pv~r, during a single breath constant flow inflation, and of z during the ensuing end-inspiratory airway occiusion. dudng the occlusion the tracheal pressure p~, declines according the following function: ptr = p'lr e " too= " z + e~t.r= [ ] where p'~r is tracheal pressure immediately after occlusion, toc c is occlusion time, p,i.rs is static elastic recoil pressure of respiratory system, and ~ is viscoelastic time constant. we first determinated "~ by analyzing the time-course of ptr according to eq and next determining r according to eq. , using the expedmental values of p,i=~, ~ and ti, as well as "~ obtained with eq. . materials & methods: we studied healthy patients intubated, anestethized with propofol, paralyzed with vecurenium, and mechanically ventilated with constant flow ( . i/s) at zeep for minor surgery. pres-sure was measured in the trachea. flow was measured with a pneumniachograph and volume was obtained by numerical integration. the rapid occlusions were produced by an external valve. the signals were sampled at a fi'equency of hz and processed on a pc. the influence of the cardiac artifacts dudng the occlusion time ( s) was reduced by a software low-pass filter kaiser finite duration impulse response of elevated order. results: the mean coefficient of correlation with eq. was . . with v t of ml/kg, the mean values (+ sd) of ': and r of the subjects amounted to . • . s and . • . cmh i "~ s. with the traditional multi breath method the corresponding values were . + . s and . _+ . cmh i " s, respectively. with the t-test the difference between new and traditional "~ was statistically significant, between new and traditional r was not significant. conclusions: with the single breath method it is possible to compute ': and r . the mean values of r with v t of nd/kg, however, was slighuy different than those obtained with the traditional multi breath method. the application of modem principles of respiratory care and mechanical ventilation in icus has resulted in increased survival of critically ill individuals with neuromuscular, skeletal and irrevers~le pulmonary diseases. in these chronically ill individunts mechanical ventilation, long term therapy (ltot) and continuous home care is considered a chronic life supporltng technique that can not be withdrawn after their discharge from an icu. the aim of this study was to present the results of a rehabilitation programme and home care that runs in our ward. twenw three patients were referred to our clinic f~om icus during - . a specific rehabilitation programme designed according to individual's needs was performed. patients that benefitted from this programme were grouped into the following disorders. ) post tb respiratow failure ( %) ) neuromuscular diseases, ( %) } undiagnosed sas { %) ) cope) ( %) ( patients had a overlap syndrom). the programme consists of : ) assessment and mechanical support ff needed of the respiratonj system with non invasive methods (nasal or via tracheostomy). ) group and individual respiratory therapy ) mobilization ) nutritional support ) educational classes for the members of the family. three from the patients passed away (during the year), are under nippv during night with or without supply, pts recieve ltot. conclusion: the development of a programme for chronically ill individuals in especially designed wards in hospitals and the overall care at home is considered necessary at least in hospitals with icus. a rehabilitation programme and home care permits the fast but safe discharge of these patients from units of acute medicine that the cost of treatment is high and besides permits beds that are invaluable. we considered that the rehabilitation prod'amine and home care in our ward is the first performed in greek chronically ill pts and even though there is no special administxative support we think that the results are quite saltsfactory. objective: we postulated that the product of the respiratory frequency (f) and the ratio of inspiratory pressure (ip) to maximal inspiratory pressure (mip) would predict the weaning outcome in deeompensated copd patients better than either variable alone or other indices previously proposed. methods: in decompensated copd patients with difficult weaning, we measured, daily, respiratory mechanics data both during mechanical ventilation and after ten minutes of spontaneous breathing. then we calculated weaning indices reported in literature and some new integrated indices. according to the results of the discriminant analysis, we considered the integrative index crop (acronym of compliance, rate, oxygenation and pressure), the rapid shallow breathing index f/vt, the load/capacity ratio ip/mip, and the following new index: f x ip/mip. we used receiver-operatingcharacteristic (roc) analysis by calculating the area under the curve considered as the overall probability of correct classification. results: main results are reported in the following objective: to evaluate the reliability of some indices of endurance in predicting the weaning outcome of decompensated copd patients. methods: in decompensated copd patients with difficult weaning from mechanical ventilation (mv) we measured, daily, blood gas analysis, ventilatory and airway pressure pattern during mv, breathing pattern (frequency (f) and tidal, volume (v~)), inspiratory pressure (ip), and maximal ip (mip) during spontaneous breathing (sb). thereafter we calculated the following weaning indices: crop (compliance * mip * (pao /pao ) / f), flvt, ip/mip. data obtained the day at which the patient was considered ready for a trial of sb on clinical grounds but weaning failed (wf) and those obtained the day of the successful weaning (ws) were compared statistically through the wilcoxon rank-sum pair analysis. in order to quantify the predictive accuracy for each index with respect to successful weaning we calculated sensitivity, specificity, and diagnostic accuracy according with the standard formulas. methods : five patients ( + yrs) suffering from ards (lung injury score > . ) for hours or less entered into the study. irv (volume controlled, decelerating flow, % inspiratory pause, lie = / ) was compared to conventional ventilation (cv) (volume controlled, constant flow, no inspiratory pause, iie= / ). these two modes were applied for hours in a randomized order, with the same levels of total peep (peept = peep + peepi), tidal volume ( . • . ml/kg), respiratory rate ( • "bpm) mad fit ( • %). measurements (respiratory mechanics, hemodynamics, arterial and mixed venous blood gases) were performed after , , and hours of application of each mode. rvsuils : are expressed as mean + sem and compared by anova. backeround and methods: periodic breathing (pb) is characterized by repetitive cyclic variation in minute ventilation. pb is considewxl to be provoked by an instability in the respiratory control. inintubated, spontaneously breathing patients conventional modes of pressure support ventilation, i.e., triggered inspiratory pressure support ps), do not allow patients to breathe with theirinherent breathing pattern. therefore, pb, if existing, will appear mainiy after extubation. since our new mode of pressure support ventilation" automatic tube compensation" (atc) continuonsly corrects for the flow-dependent tube resistance during insnmdon and expiration ("electronic" extubatim), it pemaits patients to maintain their own inherent breathing pattern. then, ff necessary, tracheal pressure can be additionally supported by volume-proportioead and/or by flow-proportional pressure support (proportional assist ventilation, pav). (~as~: we report the case of a -year-old male patient who was intubated due to acute respiratory insufficiency after acute myocardial infarction with left ventricular dysfunction. during ips of mbar the patient showed a regular breathing pattem which became periodic during atc. in addition, proportional assist ventilation of mbar/l increased periodic breathing in such a way that the typical cheyne-stokes breathing pattem occurred (see figure) . baqkground: the hering-breuer reflex (hbr) is characterized by an inhibition of inspiration during lung inflation. this response has been recognized as an important vagally mediated mechanism for regulating the rate and depth of respiration in newborn mammals. in adult man the hbr is considered to be active only at lung volumes well above functional residual capacity, i.e., at tidal volumes above ml. assessment of the hbr requires specialized methods such as single breath or multiple occlusion technique. methods; in the presence of desynchronization between ventilator and patient, which frequently occurs during triggered inspiratory pressure support ventilation (ips)(see figure) , prolongation of the interval between inspiratory efforts (indicated by negative deflection of the esophageal pressure) due to lung inflation exposes an active hbr. we examined the occurrence of hbr in intubated critically ill patients. strength of hbr was assessed by the formula: prolongation [%] = ((inspiratory interval of interest -preceding inspiratory interval)/preceding inspiratory interval) * ( . rr of patients examined showed moderate to severe desynchronization. in of these patients a (re)activation of the hbr was found. the strength of hbr amounted to + %. there was a significant correlation between tidal volume and strength of hbr. in contrast to previous reports, an active hbr was shown during lung inflation well below ml. b pck~round: triggered inspiratory pressure support ventilation (ips) is commonly used to support inspiration in intubated spontaneously breathing patients. despite its usefulness ips shows some disadvantages which can be deleterious in crificauy ill patients: -additional work of breathing to be performed by the patient due to the flow-dependent tube resistance -desynchronization between patient and ventilator due to inherent triggering failures of the ips mode suppression of the patient's inherent breathing pattern -inability to predict successful extubation in difficult-to-wean patients methods: based on the known flow-dependent tube resistance our new mode "automatic tube compensation" (atc) compensates for the pressure drop across the endotracheal tube ("electronic" extubation). then, if necessary, tracheal pressure can be supported by volume-proportional pressure support (vpps) and/or by flow-proportional pressure support (fpps). results: hitherto, we have examined patients after open-heart surgery and patients with acute respiratory insufficiency (ari) or ards using atc with/without vpps/fpps. preliminary results suggest that the new mode avoids additional work of breathing due to accurate compensation of the pressure drop across the endotracheal tube during in-/expiration prevents desynchronization between patient and ventilator allows patients to breathe with their inherent breathing pattern accurately predicts the outcome of extubation even in difficult-to-wean patients due to "electronic" extubation conclusions: the new mode atc with/without vpps/fpps allows to support ventilation in a more physiologic manner and overcomes the disadvantages of conventional modes of pressure support in intubated patients. backgound: cheyne-stokes respiration (cs) is characterized by regula]; recurring periods of hyperpnea and apnea. in normal subjects, cs may occur after hyperventilation, after arrival in high altitude, or during sleep. it has also been observed in patients with prolonged circulation time due to congestive heart failure, as well as in some neurological patients. there is no report about the influence of sedative drugs on periodic breathing (pb) and cs. methods: in intubated patients conventional modes of pressure support do not allow patients to breathe with their inherent breathing pattem. therefore, periodic breathing and cs are rarely seen. since our new mode of pressure support ventilation "automatic tube compensation" (atc) continuously corrects for the flow-dependent tube resistance during inspiration and expiration ("electronic" extubation) it permits patients to maintain their own inherent breathing pattem even if pathological, e.g., periodic. results: using this new mode of pressure support ventilation, periodic breathing was unmasked in of intubated patients, of which showed cs. in of these patients the occurrence of cs was linked to impaired left ventricular function with increased circulation time. normal left ventricular and neurologic function was found in the remaining patients. in of these patients cs disappeared after intravenous administration of the benzo-diazepine antagonist flumazenil (figure). consequently, in this patient cs was induced by benzodiazepine sedation. objecti',~s: in contrast to conventional rhodes for pressure supported spontaneous breathing, our newly developed ventilatow mode ,,automatic tube compensation" (atc) completely compensates for the flow-depandant pressure drop tlpm-r across endotracheal ttlbe (ett). in the atc mode, the ventilator supplies a flow v' in order to maintain a constant tracheal pressure p~,,~. to this end, pk,,= has to be oontinuousiy determined. since continued measurement of p,,~ by introducing a catheter via the ett is not reliable, we opted for its continuous calculation socordng to the following equation: p~ = p,,, -aperr, pw being the continuously measured airway pressure. this also requires the continual measurement .of flow v' to calculata apm-r using the non-fineer approximation: aport = kvv' + k .w. the constant tube coefficients k~ and k are mathematically determined by mesns of a least-squares-fit procadum based on laboratory investigations. tracheal secretions, however, reduca the omss-saction of the ett. consequently, ~ values of ki end k are changed rendering the p~,ch calculations inaccurate. therefore, k and ~ have to be pedodcally updated to ensure an a~urete monitoring of pn,~ and a complete tube compensation under atc at any time. background: one of the first steps in weaning patients from controlled mechanical ventilation is to stop muscle relaxation and to reduce sedation. it can take several hours, however, until the patient is able to trigger the ventilator and to breathe spontaneously. during this period, many patients display a sudden increase in peak airway pressure of up to %. patients and methods: to investigate the reason for this potentially dangerous effect, we continuously measured lung and chest wall mechanics in post-operatively ventilated patients. lung mechanics (airway resistance and lung compliance) was measured using the esophageal balloon technique as described in [ ] . chest wall mechanics (tissue resistance and chest wall compliance) was calculated from lung mechanics and total respiratory system mechanics as described in [ ] . results: we found a decrease of chest wall compliance (cw) to be the main reason for episodes of sudden airway pressure increase while lung compliance (cl) remained unchanged. the decrease of c w can be inter- gil cano a, san pedro jm ~, sandar d, herntndez . , carrizosa f, , herrero a. emergency and intensive care department, hospital of jerez, spain objective: ) to determine the incidence of hypoteasion (h) associated with emergency intabatian of mechanical ventilation, and ) to establish its relauonship with respiratory mechanics (rm) and arterial blood gases. mechanical ventilation performed in the emergency room, in a prospective eans~eative manner, were evaluated. data collected included patient demographics, diagnoses, blood pressure and arterial blood gas levels before and at~er intabatian, and p_m, including calculated pulmonary end-inspiratory volume above functional residual capacity (veic) and calculated dynamic hypetinflatien (dhc). all patients received midazolen and awaanrinm to facilitate tracheal intubatien and rm measurement. hypotension was defined as a decrease in systolic pressure higher than mmhg or an absolute decrease in systolic blood pressure below to mhg within hour of intabatian. patients were excluded because met at least one of the following exclusion criteria: preexisting shock or h ( ), cardiac arrest ( ) . there weren't any association between peepi or other airway pressures (paw) and h, but calculated pulmonary volitmes had tendency to be larger in patients with h (p < . ). high paco before lrasheal intubatian ( . - mmhg) with a quickly decrease alter starting mechanical ventilation was a usual finding (p < . ) in patients who developed h. paw. ) thexe was a good relatienship between h and high arterial paco before traqueal intahatian and its fast "washing" with mechanical ventilation. ) because cao patients had the highest incidence of h, controned mechanicel hypoventilatien driven by paco changes and pulmonary volumes monitoring instead paw, should be attempted in these patients to avoid this cemplication after tracheal intubatiert. introduction: the endotracheal tube (ett) and demand valve devices cause an added work of breathing (wobadd), which is the work necessary to overcome the resistive load of the ett and the breathing circuit ( ). application of ips has been shown to partly compensate this added work ( ). since tbe amount of wobadd is flow dependent, a fixed ips is not adequate to completly compensate the wobadd ( ). therefore, atc has been developed as a new form of assisted spontaneous breathing ( ), which provides a flow-dependent pressure support. thereby, it theoretically should compensate all the wobadd due to the tube. the purpose of this study was to evaluate the reduction of wobadd with ips and atc for different ett. methods: a mechanical lung model (ls , dr*alger, liibeck, frg) was used to generate a constant spontaneous breathing pattern. the ls was connected to an artificial trachea (at, cm long, mm id). the at was intubated with three different tubes of . , . , . mm id and connected to an evita ventilator modified to provide atc as an option (dfager, liibeck, frg). flow and airway pressure were measured between the y-piece and the ett for four different modes of ventilation: cpap, ips of and cm i and atc all with a peep of cm h . the tracheal pressure (ptrach) was measured in the at. total wobadd was calculated as the area subtended by the ptrach-volume curve below peep. results: the results for total wobadd in nd/ are shown in the figure for the three different ett: breath/mln, s=success, f=failur% *~p<. , **-p< , ns = non significant, f versus s neveltheless, in / patients, invasive ventilation was necessary in mean . _+ hours after beginning of fmpsv. there was no significant difference between the two groups (success, failure) in following parameters : sex, age, previous histoly, medical treatment, saps & , clinical signs (rr, spo , heart rate, blood pressure, glasgow score...), radiological and echocardiographic findings and standard biological parameters. only two parameters were related with failure : .a low value of pac on admission until the patients were intubated. . an increased level of cpk in relation with an acute myocardial infarction ( / cases in the failure group, vs / cases in the success group, x~(with continuity correction) : p<. ). conclusion : fmpsv is a noninvasive, safe, rapidly effective method of treatment in acpe, which may avoid tracheal intubation. further studies are necessary to precise if association of arf and low paco (< mmhg) and/er acute myocardial infarction represents an indication of immediate invasive ventilation. introduction: since the added work of breathing (wobadd) imposed by the endotracheal tube (ets and the breathing circuit is regarded as an important contribution to the total work of breathing, considerable effort has been tmdettaken to compensate for this added work. ips has been fotmd to decrease the wobadd imposed by different ventilators ( , ). because of the flow dependent pressure drop across the etf the tracheal pressure (ptr) should be measured to estimate the total imposed wobadd (wobtut) ( , ). the aim of this study was to assess the circuit imposed work (wobcirc) and wobtot (including ett) for different demand valve ventilators during cpap and/ps. methods: a mechanical lung model (ls , driiger, lfibeck, frg) generated a constant spontaneuus breathing pattern. the ls was connected to an artificial trachea (at), intubated with an . nun et]', end connected to one of four ventilators (servo c and servo , siemens,-elema, sweden; evita , driiges, liibeck, frg; pb ae, puritan bennett, carlsbad, usa). three different modes of ventilator settings were tested (cpap, ips and mbar; trigger set at maximal sensitivity, peep always mbar). flow and airway pressure (paw) were measured between the y-piece and the etr; tracheal pressure (ptr) was measured in the at. wobtot was calculated as the area under the ptr-volume curve below peep, wobcirc was calculated as the area under the paw-volume curve below peep. results: in the foti g., patroniti n., cereda m., sparacino me., giacemini m., pesenti a. inst.of anesth.and intensive care-univ.of milan -sgh monza i aim of the study was to assess cpl,rs measurement obtained by the airway occlusion method during psv. we therefore studied paralyzed cppv ventilated ali patients (lung injury score = . • that were weaned to psv. we performed end inspiratory and end expiratory airway occlusions using the hold function of the ventilator (siemens serve c), first during cppv and then within the th psv hour. airway pressure and flow signals were recorded (cpi bicore) for subsequent analysis. an airway pressure plateau was defined as a flow tracing in which airway pressure was stable for at least . sec. end inspiratory (pel,rsi) and end expiratory (pel,rse) recoil pressures were then measured as the mean airway pressure during plateaus. cpl,rs was computed as tv/ (pel,rsi-pel,rse i) cpl,rs can be adequately estimated during psv using the airway occlusion method; ) during psv inspiratory plateaus are longer than the expiratory ones; ) the length of plateaus is negatively affected by the respiratory drive. foti g., de marchi l., *tagliabue m., gilardi p., giacomini m., sparacino me., pesenti a. inst.of anesth.and intensive care,-univ.of milan *dept.of radiology-sgh monza i we retrospectively compared ct scan and gas exchange findings between a group of patients successfully weaned from vcv to psv (group s = ii patients) and a group who failed the weaning (group f = patients). we selected ali patients (lis= . • in vcv mode who had available a chest ct scan performed within days from the weaning trial. a psv trial was began as soon as the patient reached hemodynamic stability and a pao > mmhg, irrespective of fie (peep < cmh ). maximum psv level was < (pel,rs-peep) measured during vcv, where pel,rs was the respiratory system elastic recoil pressure at end inspiration. psv ventilation was considered successful if a respiratory rate < bpm, an increase in fie lower than . compared to vcv, a pace increase < % of vcv value and hemodynamic stability were maintained during the next hours of psv. if any of these conditions was not met the trial was declared a failure. interdisciplinary critical care unit, regional hospital lugano-ch *surgical critical care unit, university hospital, geneva-ch objective: to assess the degree of correlation of cardiac output measured by thoracic electrical bioimpedance and thermodilution in mechanically ventilated patients with different levels of positive end-expiratory pressure (peep). methods: prospective study with ventilated patients, after head injury and with postoperative sepsis, with normal cardiac output: simultaneous determination of cardiac output by thermodilution and thoracic electrical bioimpedance performed with different levels of peep ( - - cm h ). results: cardiac output measured by thermodilution during sequential increment of peep did not vary: . + . for peep , . + . for peep and . + . l/rain for peep . simultaneously the bioimpedance device recorded a significant increase in cardiac output from . + . for peep to . + . l/mi for peep . (p < , ). conclusion: cardiac output measured by bioimpedance cannot replace the invasive thermodilution methods of cardiac measurement output during mechanical ventilation with peep. we also isolated a subset (h) of patients who had been hypercapnic (paco > mmhg) for at least days (range to days) before the end of cv. the psv trial was started as soon as pao was > mmhg, irrespective of fie and with peep < cmh and the psv level had to be < (pplateau-peep) as measured during cv. pace , pha, base excess (be) were collected before discontinuation of cv and on the ist day of psv: ) . ) weaning is more difficult in pts with head injury(p<o, ) and iss> (p<o,ol), in elderly(p<o, ) and in pts who need fi > , (p<o, ) and peep>io cm h (p<o, ). ) pts with iss> need longer duration of mv (p<o,ol). ) the mortality rate is higher in pts with iss> (p<o,o ), with head injury (p<o,ol) and in elderly (p<o, ). ) paradoxally, compliance was found to be higher in pts> years than in pts< years (p<o, ). s. crotti, p.pelosi, d.mascheroni, m.cerisara, a.lissoni, l.gattinoni. istituto di anestesia e rianimazione -irccs, milano, italia. obiectives. we investigated by ct scan the effects of extrinsic peep (peepe) on lung inflation, tidal volume distribution and regional compliance in sedated, paralyzed chronic obstructive pulmonary disease (copd) patients with dynamic hyperinflation (peep• methods. two ct section (end expiration, end inspiration) were obtained at lung base level in patients (individual analysis for each of the eight lungs) at peepe levels: peepe = cmh (zeep) and peepe amounting to %, % and % of the peep• at zeep ( . • cmh ). tidal volume was kept constant ( • . ml/kg). each lung section was divided into zones equally spaced along the vertical axis: upper (the most ventral), middle and lower (the most dorsal) zone. for each zone we computed: gas volume at end expiration (gase) and at end inspiration (gas• tidal volume (dgas=gasi-gase) and compliance (cpl=dgas/dp;.dp=plateau pressureactual peep• we also computed the lung inflation as the entire ct section gas volume at end expiration (total gase). results. at each peep level both gase and gas• were higher in the upper than in the lower zone ( we cone!ude that in copd patients with dynamic hyperinflation only the application of peepe higher than peepi produces a further increase of lung inflation, decreasing cpl of the upper zone (the more expanded one) probably by stretching phenomena, and causing dgas redistribution from the non dependent to the dependent lung zones. i. ravagnan, p. vicardi, f. valenza, d. tubiolo. p. pelosi l. gattinoni. st . anestesia e rianimazione, universita' di milano, ospedale maggiore -irccs, italy objectives: to investigate the effects of peep and ps on respiratory. pattern and inspiratory effort during ps ventilation in patients with acute lung injury or acute exacerbation of chronic lung disease. methods: pts with acute (a) (paco = • mmhg, pao /pao = . • and pts with chronic (c)(paco = • mmhg, pao /pao = . : . ) lung disease were studied in ps ventilation during the weaning phase. measuring airway pressure, esophageal pressure and gas flow we computed respiratory rate (ril bpm), tidal volume (tv, ml) and pressure time product (ptp, cmh *s/min), which is an index of oxygen muscle consumption. measurements were collected, after rain of stabilization, at and cmh ps and at two different peep levels ( and cndd conclusions: during psv: ) breathing pattern and ptp are different between a and c; ) in both groups peep does not modify breathing pattern; ) peep reduces ptp in c but not in a; ) ps modifies breathing pattern and reduces ptp in c but not in a. to test the performance of a new heat and moisture exchanger (hme): twistair, baxter. this is a hydrophobic-hydrophilic hme without hygroscopic salts. method: we evaluated the hme performance with a previously described method (i); it consists of a "lung simulator" connected to a mechanical ventilator and a flow divider, with a dry and a wet thermal probe inserted into inspiratory and expiratory limbs. on average ps level changes were associate( with opposed changes in both p . and rr. changes in p . were remarkable, homogeneous and highly significant (p<. ), while changes in rr were less pronounced, inhomogeneous and less significant (p<. ). it seems therefore that p . is a better index than rr for estimating a change in load for the respiratory muscles. recently, the lsf method has been described as an interesitng alternative to conventional tecniques used to measure total respiratory mechanics, providing, over these latter, advantages such as no need for hold maneuvers and no need for particular flow patterns. data on the reliability of the lsf method, however, are still few. methods. sets of measurements were obtained in each of ards patients, paralyzed and ventilated in cmv with constant inspiratory flow and an end-inspiratory pause equal to % of ttot. the lsf method provided data for total compliance (ctotlsf) and total resistance (rtotlsf) by multiple linear regression analysis of airway pressure, flow and volume change, applied over the entire breath. the lsf measurements were automatic and continuous, and each value used for analysis was the average of consecutive cycles. conventional measurements of dynamic.compliance (cdyn), quasistatic compliance (cqs), minimum inspiratory resistance (rmin) and maximum inspiratory resistance (rmax) were obtained by the constant flow, end-inspiratory occlusion method, each value being the average of measuremts. ctotlsf was compared with cdyn and cqs, while rtotlsf was compared with rmin and rmax. results. ctotlsf showed a high correlation both with cdyn (cdyn=. .ctotlsf+l. , r =. ), and with cqs (cqs =. .ctotlsf + . , r =. ). the average difference between ctotlsf and cqs, yet, was much lower (+. + . ml/cmh ) than the one between ctotlsf and cdyn (+ . + . ml/cmh ). rtotlsf correlated much better with rmax (rmax=. *rtotlso+. , r =. ) than with rmin (rmin =. .rtotlsf +. . , r =. ). the average difference between rtotlsf and rmin was + . + . cmh / /s, while the one between rtotlsf and rmax was +. + . , confirming the better agreement between rtotlsf and rrnax. conclusion.the agreement between rtotlsf and rmax suggests that rtotlsf takes into account both the airway and the tissue components of resistance, unlike rmin which only expresses airway resistance. the agreement between ctotlsf and cqs indicates that ctotlsf expresses the pure elastic components of the respiratory system. in the paralyzed patient, the expiratory time constant (rce) of the unit represented by total respiratory system and ventilator can be calculated from the slope of the expiratory flow-volume curve. recently it has been suggested that an estimate of this slope is provided by the ve/v'epeak ratio, ve being the exaled tidal volume and v'epeak the peak expiratory flow.the reliability of this method is still little known. methods. sets of measurements were obtained in mechanically ventilated ards patients during paralysis and cmv. measurements of ventilator expiratory resistance (rext) and of total respiratory mechanics were performed in order to calculate these reference measurements for ve/v'epeak: rcdyn=(rmin+rext)ocdyn, rcstat=(rmax+rext)ocqs, rclsf=(rlsf+rext)~ cdyn (dynamic compliance), cqs (quasistatic compliance), rmin (minimum inspiratory resistance), rmax (maximum inspiratory resistance) were obtained by the constant flow, end-inspiratory occlusion method. clsf and rlsf respectively corresponded to measurements of total respiratory system compliance and resistance by the least squares fitting method. ve/v'epeak showed a high correlation with all reference measurements, rcdyn (ve/v'epeak= . orcdyn-. , r =. ), rcstat (ve/v'epeak = . rcstat -. , r = . ), and especially rclsf (see fig the static pressure volume curve of the respiratory system (p/vst) provides valuable information, but the extensive data analysis prevents its use in clinical routine. dynamic p/vcurves are simpler to record. the objective of this study was to develop an automated method to obtain quasi-static p/v-curves (p/vqs) during low flow inflation as well as to measure resistance. preliminary tests were done in normal subjects and subjects with varying degree of lung disease. methods: a computer/ventilator interface (cvl) was constructed for control of a servo ventilator c during an automatic sequence: a) a normal breath, b) a prolonged expiration at zero peep, c) a low flow inflation of a predetermined volume, d) analysis of ventilator pressure and flow. pressure was corrected for tube resistance. airway resistance was calculated from a) and used to derive p/vqs from c). as reference, p/vst was obtained by the occlusion method. results: in non-obstructive diseases the method performed well at volume and pressure controlled ventilation. static and quasistatic compliance were virtually identical. p/vqs clearly reflected the lower inflection point and, when present, the upper inflection point (uip). in some patients uip was more evident in p/vqs, especially at an increased inflation flow rate. in obstructive diseases, the method for subtraction of resistive pressure was inadequate. conclusions: the system for automated computer controlled studies of lung mechanics based on a standard ventilator provides comprehensive information. differences between p/vst and p/vqs imply that the latter reflects also other factors than p/vst that contribute to impedance at hyperdistension. the clinical significance of the two curves remains to be shown. obiective: to evaluate the effect of combined high frequency jet ventilation (chfjv) in patients with severe respiratory insufficiency (sri). methods: in a retrospective study of the period - we analyzed patients suffering from sri who were refractory to conventional mechanical ventilation and were treated with combined high-frequency jet ventilation (chfjv). refractory to conventional mechanical ventilation was defined as a pao /fio < , despite maximal ventilator settings: peep > cm hz , fit > . . a total of patients matched these criteria, males and females with a median age of ( - ) years. seventeen suffered from severe trauma. chfjv was started following a median period of ( - ) days of conventional mechanical ventilation. prior to chfjv ventilation parameters expressed as median were the following: fit . , pao /fio , peep cm h peak airway pressure (pap) cm h . chfjv consisted of high frequency jet ventilation with a frequency of to breaths/minute, driving pressure of . to . arm, and inspiration time of to percent, superimposed on the whole cycle of conventional mechanical ventilation with a frequency of l to breaths/minute and tidal volumes of to ml. results: following two days of chfjv of patients showed an improvement of ventilatory parameters; peep could be reduced to < cm h in patients, the pap was decreased with > cm h:o in patients, fio could be reduced to < . in patients and finally the median pao /fio ratio changed from to . during chfjv patients died, of respiratory failure and due to multiple organ failure, died within two days of chfjv. the median duration of chfjv in survivors and nonsurvivors was days in both groups. conclusions: our data show that with chfjv in the majority of patients with sri who are refractory to conventional mechanical ventilatior" the ventilatory parameters can be improved. backeround and obiectives: although ventilation with peep above the inflection point (pinf) has been shown to reduce lung injury by recruiting previously closed alveolar regions, it carries the risk of hyperinflating the lungs. in the present study we set out to develop a new strategy to recruit the lung during ventilation with small vt, while maintaining peep levels as low as possible. we hypothesized that if the lung was recruited with a sustained inflation (si) to total lung capacity, recruitment would be maintained as long as the peep level was higher than the critical closing pressure of the lung, as observed on the deflation limb of the pv curve (ajrccm ; ( ) :a ). the purpose of this study was to examine the hypothesis that a strategy using si and a peep<pinf would induce less lung injury during small tidal ventilation than ventilation at the same low peep level without using a recmitment strategy in a model of respiratory distress syndrome. methods: we used a randomized protocol with groups to ventilate nonperfused, lavaged rat lungs with small vt ( to ml/kg) for hours and studied the effect on compliance and lung injury. group : peep>ping group : peep<pin f with an si, inflation to on h over sec, to recruit volume; group : peep<pinf without si; group : control group, lungs were inflated at peep<pin f, but not ventilated. results: in group and group static compliance did not change after ventilation (table) . in group static compliance fell significantly. group showed significant changes in the pv curve, which were less severe than in group . results from morphological examination are pending but preliminary results showed less lung injury in group , compared to group . conclusions: small tidal ventilation following a recruitment manoeuvre in a model of respiratory distress syndrome allows ventilation on the deflation limb of the pv curve at a peep below pinf. this strategy ( ) minimizes lung injury as well as, or better than using peep above pint" and ( ) ensures a lower peep to minimize the detrimental consequences of high lung volume ventilation. i~peep>pin~ _objectives-this report is presenting the results of the clinical study for using eeg examination as a method of the evaluation of patients ability for weaning. methods: the study inclljqles eeg examinations with fourier spectral analysis' of patients ~vith respiratory insufficiency and prolonged control mechanical ventilation (cmv). all patients have had a-rhythm of eeg before weaning. we have followed respiratory rate, tidal volume, respiratory pa{tern, end-tidal co and blood gases during weaning. results: patients had invariable eeg activity or short -waves period (till one hour). the weaning of this patients was fast arid sucsessful. other patients have had a decreasing of a-activity, an appearence of -waves for an hour and more, a short episodes of a-and e-activity. after that this patients had gas exchange and respiratory disorders with regression of the weaning right up to cmv. conclusion: eeg could be used as a method of the evaluation of patients ability for weaning from cmv. some eeg signs shows the overstrain of compensatory systems before the change to the worse of gas exchange and respiratory pattern. s. elatrous, p. aslanian, d. touchard, d. corsi, h. lorino, l. brochard. medical intensive care unit, inserm u , hopital henri mender, cr~teil, france. in vitro comparison of flow triggering (ft) systems demonstrated advantages compared to pressure triggering (pt) systems for some ventilators (puritan bennett ) but not others (siemens serve ). we studied the two types of systems in two groups of patients mechanically assisted with pressure support ventilation ( + cmh ). in the first group (pb ) the effort of breathing, assessed by the esophageal pressure time index, was significantly lower with the ft than with the pt ( + cmh .s/min - vs + , p< . ). by contrast no significant difference appeared in the second group (serve ), as predicted by the bench study despite marked interindividual differences ( + cmh .s/min - vs + , p = . ). we conclude that ) rigorously performed bench studies can predict in vivo effects, ) mild advantages can be found for the new triggering systems on some ventilators. objectives: pressore-volume curves (pv) of the respiratory system is of interest for the determination static compliance (cs , lower (lip) and upper (uip) inflection points which indicate zones of airway recruitment and overdistension. this study aimed to compare an "automated low flow inflation" method (alfi) to the reference occlusion (oc) method. the ability of the former method to identify cst, lip and uip was tested in icu patients. me,otis: ( arf and ards) sedated paralysed patients were studied using a serve c ventilator linked to a computer which automatically forced the ventilator to insufflate at a low constant flow a velum up to - ml or a maximum paw of cm h (alfi). the quasistatic elastic pressure (pel,qs was obtained by subtraction of the resistive pressure of tubing and patient and related to volume for calculation of compliance cqst. for oc tidal volumes (v from up to - ml were followed by a s post-inspiratury pause for determination of static pal (pel,st) in relation to volume. compliance was defined from the linear part of the p/v curves. lip and uip were defined from the consistent deviation of p/v data from extrapolated the linear part. ~,~ i~: in ards, mean cst was . + . and cqst . + . ml/cm h (us), lipst . + . and lipqst . + . cm h (us), uipst . + . and uipqst . + ~ cm h (us). nosocomial pneumonias (np) are frequent and often unsuspected during ards (bell, ! ). in the present study, we evaluated prospectively the onset of np during severe ards (group b of the european study). patients and methods: the charts of patients with severe ards have been prospectively recorded. a plugged telescopic catheter (ptc) specimen has been systematically performed every hours, for quantitative bacteriological analysis. the diagnosis of np was defined by a number > colony forming units / ml. results: for the patients studied, the mean saps score (+ sd) was +_ , the initial pao /fio ratio was -&-_ , the duration of mechanical ventilation (mv) was + days. the mean delay before the onset of the first np was . + . days ( - ), and the mean pao /fio ratio was +- . respiratory symptoms (purulent aspirates, new pulmonary infiltrates, or gazometric changes) were present in % of the patients studied. alteration of gas exchange was present in of the patients ( np) . a new pulmonary infiltrate was present in only np ( %). an increase of fever was noted in patients, an increase of leukocytosis > % in patients, an increase of volume and purulence of sputum in of the patients with np. the degree ofgazometric worsening (pao /fio before np minus pao /fio during np) during the first episode of np was + mmhg. excluding the bacteriological criteria of np, the number of criterias of np present was in / patients, ( / ), ( / ) or ( / ). two patients only had a pulmonary colonization (ptc: < cfu / ml) before the first episode of np. the incidence of np is high ( %) during severe ards. the first episode occurs in average:at the th day, and is the cause of a severe hypoxemia (pao /fio ) . the onset of a np may contribute to the high mortality rate observed in our patients ( %). each worsening of hypoxemia during severe ards should induce to suspect a np. respiratory system during mechanical ventilation. the me~hod quantifies the dissipative energy consumption of the respiratory system in terms of energy loss aek, inefficiency ~k~ and respiratory dissipative resistance rk~ over a given partition of the tidal volume. the method can be applied in intensive care units with no interference to ventilatory support. it allows for monitoring the combined effects of inhomogeneities, non-linearities and visco-elastic effects, that are subject to change in the respiratory system. the method is studied on pigs~ in the presence of a log-dose response curve of methacholine (mch) induced disease. in healthy pigs~ we find a mean value of energy loss, ae, of . • j/l, a mean value of inefflency, ~ of . ~= . and a mean value of resistance, ~, of . • cm h s/ . the respiratory resistance, rk, shows a variation over the partition of tidal volume with armax ---- . • . cm h s/l. during methacholine provocation~ ae rises more than five-fold up to . • j/l~ doubles to . • and t~ increases to a maximum of • cm h s/l, with armax : . • . cm h s/ . the variation in rk becomes more pronounced with higher doses of methacholine. methods: ards patients were prospectively studied. initially they were ventilated in the amv (assist mechanical ventilation) mode with the settings prescribed by their primary physician. after stabilization, ventilatory gas exchange and hemodynamic variables were determined. patients were then ventilated in the mrv (mandatory rate ventilation) mode with breaths as the target rate. in mrv the target rate is set and the ventilator autoregulates the pressure support level delivered ~o achieve this rate. after stabilization, the measurements done on amv were repeated. finally, patients were sedated and paralyzed and ventilated in cmv (control mechanical ventilation) with the ventilatory variables they had during mrv. measurements done in amv and mrv were repeated and respiratory mechanics were assessed with the constant flow end inspiratory occlusion method. results: two groups were recognized based on their response to mrv. tn group patients responded to mrv by decreasing their v and increasing the t/t t ratio. ve, vo , and aado decreased while paco increased and tda vo ume and co remained unchanged. on the contrary, in group v, vr and ve increased; ppeak and trr t remained unchanged, paco~ decreased while vo and aado increased with constant co, the pressure support level needed to achieve the target rate was much lower in group than in group ( , -+ . vs . _+ . ). obiectives : in the newly developed mode of ventilatory support ,,automatic tube compensation" (atc) the ventilator compensates for the flow-dependent pressure drop across the endetracheat tube (ett) thus allowing ,,e]ectronic extubation". the aim of the study is to investigate whether healthy subjects perceive atc in inspiration (atc-in) and in expiration (atc-in-ex) and whether atc provides an increase in subjective comfort compared with the conventional assisted spontaneous breathing mode (asb). methods : healthy volunteers (no preceding lung disease, non-smokers, male, - years)breathed spontaneously through an uncut ett of . mm id via a mouthpiece. the ett was connected with a prototype ventilator evita modified by the manufacturer (drfiger, lebeck) for atc. flow and airway pressure were measured at the outer end of the ett. three ventilatory modes, ( ) asb ( mbarover mbar peep), ( ) atcin, ( ) atc-in-ex were selected in random order. immediately following the transition from one mode to another the volunteers answered by hand sign how they perceived the new mode compared with the preceding mode: ,,better" (+ ), ,,equal" ( ) or ,,worse" (- ). inspiration and expiration were investigated separately by presenting mode transitions (in total; including ,,placebo" transitions). results : the difference between atc and conventional asb is perceived in inspiration and in expiration. atc is positively judged; asb is nega ively judged. the diagrams show mean values _+ sd of five volunteers investigated up to now. the new mode atc is perceived as an increase in subjective comfort. our explanation is that atc preserves the natural breathing pattern better than conventional asb. objectives: to determine the role of cerebral vasoconstriction in the delayed hypoperfusion phase in comatose patients after cardiac arrest. to correlate the results with indices of cerebral oxygenation and the levels of several vasoactive hormones in the jugular bulb. methods: in comatose patients after cardiac arrest we measured the pulsatility index (pi) of the medial cerebral artery by transcranial doppler sonography. the pi is a reliable indicator of cerebral vascular resistance. we also sampled blood from the jugular bulb and measured cerebral oxygen extraction ratio and jugular bulb levels of endothelin, nitrate and cgmp. the first measurement was done within hours after cardiac arrest and repeated , , , , and hours later. results: we studied patients, females, mean age , + , years. the pi decreased s!gnificantly between th~ first and the last measurement from . _+ . to . + . (p = . ). cerebral oxygen extraction ratio decreased also from . + . to . + . (.p = . ). endothelin levels were high, but didn't change during the studied period. nitrate levels varied in a wide range, but didn't change significantly. however, cgmp levels increased significantly from very low levels in the first measurement to very high levels hours later, rasp. . pmol/ml (median; th . - th . ) and . pmol/ml (median; th . - th . ) (p = . ). eighteen and hours after the first measurement we found a strong correlation between pi and cerebral oxygen extraction ratio ( r = . , p = . and r = . , p = . ). we.also found hours after the first measurement a significant correlation between pi and cgmp levels ( r = . , p = . ). we found no correlation between pi and endothelin or nitrate levels. conclusion.~; our results show a high cerebral vascular resistance in the first few hours after cardiac arrest, gradually decreasing during the next hours. this is accompanied by an initially high cerebral oxygen extraction ratio and low cgmp levels, suggesting that the cerebral vascular resistance is induced by active vasoconstriction because of insufficient cgmp levels, leading to a decrease in cerebral blood flow and a compensatory ~ncrease in cerebral oxygen extraction. objectives: sudden cardiac arrest is a major cause of mortality in western countries accounting for over half of all cardiovascular deaths. in most cases the mechanism of death is prolonged cardio-circulatory arrest due to ver:tricular fibrillation (vf) preceding final asystole. recurrent syncopes due to idiopathic vf with good neurological prognosis have been reported in patients with and without cardiac etiology ( , ). in the past measurements of cerebral hemodynamics have been repeatedly done in humans during cpr, but until today no studies of cerebral blood flow velocity (cbfv) have been reported during controlled cardiac arrest in humans not under-going cpr. it was the purpose of our study to evaluate the acute hemodynamic effects of untreated vf on cbfv. methods: after approval by the local university ethics comittee, five male patients aged - years without evidence of cerebral disease were investigated during vf while undergoing implantation of a pacer cardioverter defibrillator system (model d; medtronic| a standard anaesthetic regimen was used (propofol, fentanyl). after implantation of the automated cardiac defibrillator vf was induced by electrical countershock to test effective sensing, pacing, and defibrillation. to measure cerebral blood flow velocities (cbfvmca) the doppler probe was placed above the zygomatic arch between the lateral margin of the orbit and the ear and directed towards the m segment of the middle cerebral artery (mca). results: a total of phases of vf were investigated. duration of vf ranged from to seconds, with cbfvmc a (mean_+sd, cm sec - ) flow pattern changing from pulsatile to laminar flow immediately after onset of vf. conclusions: the underlying mechanism of the laminar cerebral blood flow observed during vf in our patients is uncertain, but it may provide insight into the prognosis of patients with idiopathic vf. theoretically, the laminar cerebral blood flow observed in our pulseless patients may provide a substantial amount of cerebral perfusion even during clinical cardiocirculatory arrest objective: to investigate whether the intensive care nursing staff can inflate more accurately a specific air volume with the laerdal resuscitation bag when they receive feedback after each inflation about the delivered volume compared to no feedback. method: icu nurses were asked to inflate a testlung model times with a specific air volume ( ml, ,ml or ml) under three different conditions (normal, decreased compliance and increased resistance) without and with feedback. we measured the mean absolute difference from the specific airvolume after each ten inflations. results: the largest absolute difference was found when icu nurses inflated ml ( ml). the mean inflated volume for this group was ml. when the icu nurses had to inflate ml the mean absolute volume difference was ml with a mean inflated volume of ml. inflating ml produced an absolute volume difference of ml with an mean inflated volume of ml. the absolute volume difference decreased when the compliance of the testlung was decreased and even more when the resistance of the used endotracheal tube was increased. when the icu nursing staff received volume feedback after each inflation the mean absolute volume difference was reduced between the ml and ml for all specific air volumes. % of the last inflations with feedback were significantly smaller than ml from the specific air volume (p < . ). conclusion: the majority of nurses overinflated the specific air volumes. the largest over inflation occurred when ml and the smallest when inflating ml. when nurses were provided with volume feedback the performed significantly better. we concluded that icu nurses are not able to inflate a specific air volume with the laerdal resuscitation bag without receiving volume feedback. feedback is desirable in order to reduce the volume trauma. objectives: a pro_found impairment in systolic and diastolic myocardial function following successful cardiopulmonary resuscitation (cpr) has been demonstrated by using langerdorff method in rats. in the present study we have investigated post resuscitation myocardial dysfunction in a porcine model of cpr. methods: ventricular fibrillation (vf) was electrically induced by alternating current applied to the ep{cardium of the right ventricle in domestic pigs. following rain of untreated vf, precordial compression and mechanical ventilation was initiated and maintained for min. electrical defibrillation was then attempted and of animals were successfully resuscitated. results: following successful cardiac resuscitation, stroke volume index (svi) decreased from prearrest value of . ml/kg to . ml/kg (p< . ), and left ventricular stroke work index (lvswi) from . to . mmhg,ml/kg (p< . ). both svi and lvswi remained depressed for another hours. these decreases were associated with increases in heart rate from bpm to bpm (p< . ). no significant changes from baseline in mean arterial pressure, mean pulmonary pressure, right atrial pressure and pulmonary artery wedge pressure were observed. prehospital resuscitation efforts c. k ppel. g. fahron, h. lufft, a. kruger, c. th(jrk, f. bertschat, f. martens dept, of nephrology add medical intensive care, virchow-klinikum, humboldt-universit~t, d- bedin, germany obiective: the success rate of prehospital resuscitation in patients with cardiocirculatory arrest in an emergency medical system (ems) may reach - % depending on the time of calling the ems, the distance to cover by the emergency ambulance and the training of the emergency physician and his staff. in the berlin ems, which is associated with the berlin fire brigade, the time between alarm and arrival at the scene ranges from - min, mean min. resuscftation is based on the advanced cardiac life support (acls) according to the guidelines of the american heart association. if resuscitation efforts fail to restore circulation, they are terminated after - min, depending on duration of cardiocirculatory arrest, pre-existing disease, age, absence of an even transient response to cpr. however, there is a lack of practical criteria for termination of cpr in individual decision making. patients: we report cases of prehospital cpr with primary asystolia terminated after - rain of frustraneous cpr efforts including highdose epinephrine and dopamine. results: after termination of cpr, the ecg monitor remained connected and showed permanent asystolia in all patients while the emergency physician completed his records. spontaneous resumption of respiration and circulation was observed in these patients after - min and cpr efforts were immediately resumed, nevertheless, of the patients died at the scene, while could be hospitalized with stable circulation. one of them died hours after admission to the icu, the other survived for weeks in a vegetative state. spontaneous resumption of circulation and respiration is most likely due to the development of extreme hypercapnia and acidosis, which -at least in some patients -seems to be a stronger stimulant of the circulatory and respiratory brainstem centers than cpr with high-dose catecholamines, conclusion: because of the legal and ethical implications of this rare phenomenon, emergency physicians should continue ecg monitoring for at least rain. after termination of cpr efforts. pulmonary artery catheterezation is used for patient's monitoring [ ]. we reported our results on such monitoring in [f.coaobbeb,r.fe enb~-kap~monorm~, ,n ,p. - ] .however not all of the received criteria assessments meet demands that are necessary for early diagnosis of critical states. here we report the data on po ,pco (mm rg),so ,ph levels in femoral [af) and pulmonary (ap) arteries blood, as well as on summary gas pressure (sgp) calculated from pe=(po +pco ) in mm hg in ap blood. these data were derived from:i) subjects free of cardiovascular pathology according to catheterization data during their spontaneous air breathing (n group in ap blood appears to be a measure of adequacy ratio between pc and sgp in ap blood during air breathing; partly its characteristics and variations ranges are presented earlier [ j. in control group it is equal to , • mm hg. tests on sgp neither exclude nor substitute conventional (pc and pco ) tests, but rather include them as a part choosing only additive characteristic -pressure. they appear to be a part of general system of human metabolism regulation by pressure (arterial,venous,intracardiac, tissue,liquor,onco-osmotic,etc ietraabdeminal pressure produces perturbations of cardiac, pulmonary, and renal physiology. this most often occurs fonowing eeliotomy for peritonitis or intestinal obstruction; bowel edema and distention prevent wound closure without unacceptable compromise of blood pressure or pulmonary compliance. a variety of temporizing measures have been reported for managing wounds that cannot be closed: ) using towel clips to reapproximate skin only, )i sewing silastic, marlex or other prosthetic grafts to the fascia to "enlarge" the peritoneal cavity, ) using loosely tied retention sutures for partial closure, ) simply packing the wound without attempts at c~osure. these techniques either traumatize the abdominal wall (complicating definitive closure), expose the bowel to damage, or allow excessive loss of fluid and heat. since we have evolved a suturelees technique which permits the abdomen to be partially closed in a quick, safe, sterile, sealed, atraumatic fashion -while providin! decompression of unphysiologic intraabdominal pressure. methods: whenever possible omentum is interposed between bowel and the open incision. viscera are covered by a layer of sterile, non-reactive plastic, placed deep to the fascia and extending we~t beneath the edges. sump tubes are placed above the plastic and covered in turn by two layers of an adhesive plastic drape which sticks to the skin and seals the wound in all directions, the patients remain intubated and paralyzed. results: we have used this technique in a total of patients, four of whom suffered from compartment syndrome. all of the latter were males and ranged in age from to . all four showed immediate physiologic improvement. all four incisions were eventually closed without complication. one compartment syndrome patient died t days later of multiple organ failure. there were no complications related to the closure technique in any of the patients. conclusions; . selected patients with abdominal compartment syndrome will benefit from decompression using this temporary sutureless technique. the technique a) is quick, safe, sterile, sealed, and atraumatic, b) minimizes loss of fluid and heat, c) facilitates eventual definitive abdomina| closure. although m. brunner m. mitllncr objectives: to determine incidence and predisposing factors for cardiac arrest occurring during the first hours after open heart surgery. methods: the study included patients who, following open heart surgery, had adequate cardiac function and in whom cardiac arrest was not anticipated. all data were prospectively recorded and analyzed. results: from / through / , pts underwent open heart surgery at our hospital. of th~se, pts ( %) (age _+ yrs) had a cardiac arrest during the first hours after transfer to icu. they were operated on for coronary artery bypass grafting (cabg) ( pts), valve replacement (vr) ( pts), cabg and vr ( pts) and aortic aneurysm ( pt). the preoperative ejection fraction was _+ % whereas bypass and aortic cross-clamp time were + and + rain, respectively. prior to arrest, they had a cardiac index of . _+ . l/min/m and were receiving . + inotropes. arrythmias leading to cardiac arrest were ventricular tachycardia/fibrilation ( pts) and bradyarrythmia ( pts). closed-chest cpr was initially performed on all pts and was followed by open-chest cpr in pts. eighteen pts ( %) survived to icu discharge. causes of arrest included perioperative myocardial infarct (t pts, %), tamponade ( pts, %), rupture of the proximal vein gra& anastomosis ( pt, %), graft occlusion ( pts, %); no cause was found in pts ( %). conclusions: postoperative cardiac arrest in stable cardiac surgery pts is relatively infrequent (- % incidence) and is associated with a high survival rate following successful cpr. perioperative myocardial infarct is the most common predisposing factor. group ~deptof anaesthesia and intensive care, semmelweis univ. medical school, buda military hospital intensive care unit, budapest background: when a cardiac arrest occurs in-hospital, the outcome can be improved by a higher quality of basic life support provided by the witnessing health care workers until the code team arrives. this basic life ~pport (bls) should include the best available method for airway management as well. since not all medical staff are ready for carrying out endatracheal intnbation, we investigated the effieacy of the use of different airway management methods during bls. methods: we have investigated the efficacy of airway management of doctors and nurses from different hospital wards: internal medicine, department of surgery, trauma, urology and gynaecolagy. comparing the bag-valve-mask, laryngeal mask and the endotracheal intubafion, we have measured the following parameters: time needs for correct application (sec.), number of incorrect applications (out of ten trial), efficacy of artificial ventilation provided by the device. we used a computerised als trainer manikin for the evaluation of the performance. total performance score was created after the measurement between - . after the first screening we held a x hours training. doctors and nurses were trained for the endotracheal intubation (group it , t ) , doctors and nurses were trained to use the laryngeal mask (group lm , lm ) . all respondent were trained to use the bag-valve-mask device. day, month and month after the training we have carried out retention study using the same method. results: we have found that the efficacy of the artificial ventilation using the above mentioned devices were poor before the training. the average after-training performance scores of the groups are presented in the table below. (bls) should be initiated by the witnessing health care professional. the cpr study introduced a multi level code system, which means bls included sophisticated airway management, early defibrillation and early epinephrine administration provided before the code team arrives. our previous studies confirmed a poor level of cpr performance and a high demand for cpr training among health care professionals. method: we established a cpr training course centre, where doctors and nurses are being trained for in-huspital basic and advanced life support. x hours of training were held. after the theoretical introduction a step-by-step training method ws used for trainees to be familiar with all sequences of basic and advanced life support. then we synthetised all separated sequences. afterwards, a r e play of rescue groups was taken in simulated situations. we also trained the multi level alarm system fur the in-hospital resuscitations. after the training all respondents had to sit for examination. the quality of performance was scored and compared to our previous results. semi-structured interviews were carried out before and aider the training among all respondents to collect information about the course. results: we have found a remarkably high interest among doctors and nurses in our cpr training courses. it was very important to use proper equipment for the training: audio-visual training facilities, computerised als trainer manikin, manual and automatic defibrillator units. the evaluation of the examination held immediately a~er the training course showed a significant higher quality of performance than before the training. the self.-eonfidence of the trainees for initiating and carrying out resuscitation had increased. their overall feeling about the course was positive and % responded the course "very useful". . % of doctors and . % of nurses claimed fur regular training facilities with als trainers, conclusion: the cpr training for health care werkers is mandatory including the training of sophisticated airway management and use of elad~l~ills~tt~r wlaa ~en ~r a~ti~atir ~nel r rm~a'*h*nr m~thnd for training will improve the efficacy, the satisfaction of trainees, therefore their compliance for further co-operation will also increase. s objectives: the effect of reinfusion in emergency surgery and gynecology. methods: we had an experience of autologous blood transfusion in patients whom was produce t an emergency surgical or gynecological interventions in occasion with break tubal pregnancies ( . %), penetrating abdominal wounds with injuries of mesenterial vessels ( . %), injuries of the liver ( . %), blunt abdominal trauma with lien ruption ( . %). in . % patients had the previous somatic pathology. blood loss volume was - ml, & the reihfuside blood volume was - ml, consisting - % of blood loss. it was needn't to fransuse donor blood in . % in further but - ml of contanined erythrocytes were frasfused for supporting of hb concentration on the g/l ( g/dl) rate at the other patients with isovolemie hemodiluttion. results: the arterial blood pressure fast stabilisation on the perfusion level had noted after reinfusion, excluding the case, when the volume of reinfused blood had conisted just % of blood loss at the patient with massive blood loss. complications have noted in two cases. one patient with slash wound, injury of arteria gastrica dextra and total blood loss of ml, has an episode of asystoly, dic (disseminated intravascular coagulation) syndrome, acute renal failure, and acute pancreatitis that we haven't connected to reinfusion. all the complications were successfully corrected and at thirty first day patient with subcapsular wound of the lien that has happened days before complicated with external rupture of the capsull & massive intraabdominal bleeding, has the hemolytical shock, dic syndrome, acute renal failure developed after reinfusion. he was died. all another have no complications. posthemorrhagic anemia had corrected rapidly than in case when hemorrange corrected exclusively by donor blood. conclusions: we consider that simplicity, accessibility, high effectiveness, quite well further results of blood reinfusion, except the case of blood reinfusing that was for time-expired out of blood vessels (more than days in our case) will promote to the wide spreading of this method, especially in emergency surgery, in massive injuries, & in disarters, all the cases of insufficiently of time for selection of lot of donor blood. objectives: study of a reaction of the oardioreepiratory system of pregnant women to i/v microperfusion of clophelinum which is known to eliminate hemodynsmic and endocrine nociceptive reactions and can be used for treating hypertensive syndrome in pregnancy and labor. methods: the following non-invasive methods were used: capnography, spirometry, oxygenography, indirect fick principle based on the circle breathing, plethysmography and integral rheography~ functional indices of cardiorespiratory function were evaluated. results: pregnant women with ~h-gestosis were examined before and after i/v infusion of i ml of . % clophelin solution, . mg/kg/hour. before the treatment intensification of carbohydrate metabolism, hyperventilation with moderate hypooapnia and complete respiratory compensation of metabolic acidosis~ increased alveolar ventilation, decreased alveolar volume, predomination of perfusion over ventilation, hypokinetio type of circulation with dominated load by peripheral vascular resistance to the blood flow was observed in this group of patients. microperfusion of clophelin imp~-oved the ventilation/perfusion ratio, ventilatory and gaseous exchange efficiency, resulted in a decrease of congestion in the pulmonary circulation, possibly owing to a decrease of peripheral vascular resistance by %, of the heart rate by io. %, of the oardial output index by . %. conclusionm: the resulted type of circulation with a decreased load on the heart both by resistance and volume allowed to improve the cardioreepiratory system function in pregnant patients. objectives: the injury severity score is a measure of severity of anatomic injuries. iss is a sum of squares of the highest degrees of the abbreviated injury scale (ais) for each of three most severity injured regions. the purpose of the study is to establish correlation between the iss values and mortality rate in older, polytraumatized patients. methods and results: iss was determined for patients. the mean iss value was . + . while the median value was . minor injuries were present in ( %) patients with iss less than , while ( %) patients with iss more than had severe injuries. increased mortality of the older patients was noted in the range - . all patients older than died while % of patients below yrs of age survived, indicationg correlation between iss and mortality rate in polytraumatized patients above yrs of age. conclusions: this mode of evaluating severity of injuries may help in triage, determining appropriate level of care and as an indicator of future outcome of polytraumatized patients. objectives : tissue hypoxia is a non exclusive cause of hyperlactatemia. other serious medical situations induce hyperlactatemia. therefore, lactatemia could be a non specific indicator of severity in patients admitted in emergency unit. the aims of this study were to examine the correlations between lactatemia with the short term survival course prognosis and the unit of hospitalisation; intensive care unit (icu) or medicine unit, in patients admitted in our emergency department. methods -lactatemia was measured as soon as the admittance, in arterial blood sample of patients which needed arterial blond gas. sixty-one patients were included during months. to assess the statistical performances of lactatemia, sensitivity (se), specificity (sp) and accuracy (ac) were calculated for the threshold determined by the youden's test (se+sp- ). results : fifteen patients were admitted in icu and in a medical unit. fifteen patients died. a group of patients had a lactatemia up to mmol.l" . in this group of patients, had acidocetosis, had asthma, had cerebral vascular ischemia, had neoplasia, had cardiogenic shock, was epileptic, had congestive heart failure, had acute respiratory failure, had septicaemia, had hyperosmolar status finally had medicinal intoxication. lactatemia was significantly higher in non survivor than survivor ( . • vs. . + . , p<o.oool, respectively), the cut point of lactatemia was . mmoll" se was %, sp was % and the accuracy was %. on the other hand lactatemia was higher in patients admitted in icu than in medical unit ( . + . vs. . • p<o. , respectively). conclusions : this preliminary results suggest that lactatemia is a good indicator of the short term survival course in patients admitted in an emergency unit. furthermore, hyperlaotemia is present in several pathology seen in emergency. objective: to determine the pattern of injury, total peripheral white cell, neutrophil, and lymphocyte responses, and the outcome of trauma patients who are leucopaenic on admission to the icu. design: prospective, descriptive study of consecutive admissions over months. setting: a -bed surgical intensive care in a teaching hospital. patients: thirty consecutive adults admitted to the icu following trauma. leucopaenia was defined as a total peripheral white cell count of < x , neulropaenia < x , and lymphopaenia < . x ~ cells per litre. measurement and results: the total peripheral white cell count was documented daily and the neurtophil and lymphocyte counts and differential percentages on days , , and . the incidence of leucopaenia was significanfiy higher in patients with gunshot wounds (p < . ) and hollow visceral intra-abdominal injury (p < . ). eight ( %) patients died. no significant differences were found in the initial mean total white cell, neutrophil, or lymphocyte counts nor in the differential percentages between survivors and non-survivors. the total peripheral white cell count increased significantly in survivors compared to those who died (p < . ) and significant differences were found in absolute neutrophil counts (p < . ) and differential percentages (p < . ) on days and . no significant differences were found in lymphocyte counts or differential percentages. conclusions: there is a signficant association between leucopaenia, neutrepaenia, and intra-abdominal hollow visceral injury and peritoneal contamination. survival is related significantly to resolution of these white cell deficiencies. these findings suggest a possible role of granulocyte colony stimulating factor in the trauma patient with intra-abdominal infection and persistent neutropaenia. amelioration of organization emergency care team in order to improve caring for urgent cases. objectives: emergency care team (ect), as integral part of health, respectively as activity of primary health protection care all acute difficult conditions which vitaly danger patients and distressed. the aim of our investigations was to indicate on the possibilities of amelioration of organization ect in order to improve caring for urgent cases. methods: in our investigations we used epidemiologicai and statistical metods all informations and matherials from terrain ects. results: the number of traumatized in traffic accidents etc. have a epidemic character. it is well known that . % traumatized died in first two hours. ect isn't enough qualified to care a traumatized on the place of accident and during transport. because that medical personnel must have an education with solid qualities. conclusions: . besides a physician specialized (vii --+ vii -~ viii gradus) in urgent medicine, it's necessary to introduce two ( ) medical technicians instead of one as is existing now ( ~ ). .the medical technicians can drive cars and one of them always, drives the ambulance car ("b" category). .the technicians have been specially educated for urgent cases (iv ~ v ~ vi). . such a new team structure should be more capable in professional sense. .we can see an importance of team-work in ects. . such teams should also be more economic in comparison with existing one. . we think, that on the general medical studies need to include a new discipline-urgent medicine! objectives: to detoxicate an organism since we have used biological sorbents: isolated from liver and spleen of human or animal cells or tissue fragments. methods: cellular dialysis ( dialyses) in patients with an acute hepatic insufficiency poisoning by hepatotropic poisons: cc , dichloethane, mushrooms -were conducted using "artificial kidney" apparatus, by means of arteriovenous shunt, formed at forearm with disposable dialyzers. hepatocytes suspension was poured into dializing circuit of dialyzer at - mg of cells per i kg of patients weight. dialysis was performed during - hrs. patients with purulent-septic states were treated as for hemoperfusion through prepared sorptional column: . ml of hemosorbent and . ml of fragmented spleen or hepatocytes suspension with the help of roller pump with the rate of - ml/min, during - min. average volume of hemoperfusion made . . conclusions: in all cases we used both native and cryopreserved biomaterial. analysis of the dynamics of clinical, biochemical, scintigraphic and us-investigastions allows to conclude that application of cellular-sorptional method of detoxication enable to prolong life and reduce lethal outcome in some severe category of patients with endotoxicosis. after infusion of diazepam ( . mg/kg),thiopentone ( mg/ kg) and vecuronium (lmg/kg),patient was intubated and mechanical ventilation was adjusted to mantain normoca= pnia. ct scan showed left parieto-occipital hypodensity with brain swelling. after admission in neurological icu,dexamethasone ( mg/ kg/die),mannitol ( .smg/kg) and diphenylydantoin ( mg/ kg/die) were administred. two hours later neurological status of the patien~ was normal and she was extubated. the risks of stereotactie radiosnkgety are related to: hemorrhgge during the latency interval;transient radia= tion effects;permanent radiatio~einduced complications; radiation induced neoplasia. no epilepsy is reported in pts with avm and no seizure before radiosurgery. in c nclusion, epilepsy can be a posmib~e delayed eompli c~t~n, ~fe~r rgdi surgery for cerebral avm. serum potassium deficiency is a frequently reported finding in the time course of acute myocardial infarction (ami). if this is also correct for patients with ami undergoing primary percutaneous transluminal coronary angioplasty (ptca) is unknown.for that reason we analysed in patients ( m., f., + y.) serum potassium concentrations on ad ,mission and directly after ptca.the reference intervall for potassium in our clinical laboratory is , - , mmol/l. although more than % of the patients with ami undergoing ptca showed normal potassium serum concentrations on admission a measurable decrease of potassium could be found in % of patients ( ) after ptca.therefore for the majority of patients with ami potassium supplementation prior to ptca can be justified to avoid electrolyte disturbances as a possible trigger factor for cardiac arrhythmias in the setting of ami and acute reperfusion due to primary ptca. objectives: diagnostic procedures are very important in the management of abdominal injures in trauma. the aim of this paper is to present our experience with peritoneal lavage as diagnostic procedure in abdominal injury. methods: we analyzed patients to whom peritoneal lavage was applied in the surgical emergency from st of january till st of december . results; in this four years period there were abdominal injures. there were blunt injures. among them in patients peritoneal lavage was applied. results were positive in patients and negative in patients. false positive finding were in patients and false negative in two patients. in patients with positive lavage there were more than , /mm red blood cells, more than , /mm white blood cells and the level of amylase was up to u/i. the gall, urine and stool were positive as well. in patients with negative lavage there were less than , /mm red blood cells, less than /mm white blood ceils and amylase were negative. conclusion: peritoneal lavage is useful and important diagnostic procedure in the management of abdominal injures in trauma. our experience with urgent surgical management of the acute gastric and duodenal bleeding s.se en md, z.milo~evi md, *s.srdi md, k.sar ev md. clinic for abdominal and endocrine surgery, institute for surgery; *clinic for cardiology, institute for cardiovascular diseases; school for medicine novi sad, university of novi sad, yugoslavia objectives: acute gastric and duodenal bleeding are very common complication of gastric and duodenal ulcer. the aim of this paper is to present efficiency of our surgical management of these acute conditions. methods: in this paper results of surgical management of patients with acute gastric and duodenal bleeding, treated in our clinic from the st of january till st of december , are presented. results: among operated patients there were females ( . %) and males ( . %). there were patients ( . %) with gastric bleeding and patients ( . %) with duodenal bleeding. bleeding from gastric ulcer were treated with the following methods: excision of ulcer with suture in patients ( . %), ulcer suture in patients ( . %), billroth i in patients ( . %) and billroth ii in patients ( . %). heinecke-mikulicz-weinberger pyloroplastica was the most frequently used in the treatment of the duodenal ulcer bleeding. bilateral truncal vagotomy was done in patients ( %), duodenotomy with ulcer suture was done in three patients ( . %) and three patients underwent billroth ii operation. we had three complicationsduodenal dehiscence in pyloroplasty. there were no lethal complications. conclusions: based on our own experience we conclude that acute bleeding from gastric and duodenal ulcer can be safely managed with urgent and modern operative techniques. dept. of anaesthesiology. emergency center of serbia, belgrade, srj b ectives and methods: cardiac contusion was evaluated by serial determination of cpk-mb fraction and co using non-invasive doppler technique in patients with blunt trauma of the chest. results: miooardial contusion was diagnosed in ( %) patients, while in ( %) it appeared unaffected. cpk-mb of % and more in comparison to total cpkwas . + , % in patients, and , + , % in pts (p< . ).c of . + . l/min in patients with cardiac contusion, measured hrs after admission at the latest, was significantly lower than in group of patients with co of . + . l/min (p< . ). conclusions: co values were significantly lower in patients with cardiac contusion and correlated with pathological values of cpk-mb fraction. objectives: extracorporal plasmophoresis (pph) was implemented by non-stop method in patients with obstructive jaundice. methods: changes of serotonin (s) and histamine (n) in arterial (ab) and venous (vb) blood were investigated before and after one-time session of pph. s and h in blood serum were determined with fluoremetric method. results: before pph the average s contents in ab and vb did not differ. after one-time pph session s in the blood outflowing lungs was % lower than in the blood inflowing. hours after extracorporal detoxication implemented the indices kept the same level. similar dynamics after pph was observed in h. before the session h contens was equal both in the blood inflowing and in the blood outflowing lunge. after pph h contents in ab was % lower compared to the vb and did not change for hours. conclusions: dynamics of changes of biogene amines shows that under the influence of pph there takes place not only mechanical removal of their surpluses together with plasm, but there sharply grows inactivating role of lungs towards ba substances, which is confirmed by reduction of their concentration in the blood outflowing lungs. this effect is probably connected with the "deplasmation" of the lung cellular elements. simultaneously lungs' cells are freed not only from plasm but from toxic adsorbents on their surface. as a result the lung cells activate absorption of the surplus number of amines from the vessel channel. it is not excluded that s inactivation is due to growing activity of monoaminooxidase resulting in deminishing of intoxication. acute pulmonary embolism: thrombolytic therapy or pulmonary embolectomy? i.lodiena md, phd, s.shevchenko md, pphd., medical university, kharkov, ukraine objectives: pulmonary embolism (pe) remains a challenging problem for diagnosis and management for the emergency physician. the aim of this work is to identify the best treatment for massive pulmonary thromboembolism. methods: during recent years patients with symptomatic acute serious pe were reffered to our observations. selective pulmonary arteriography confirmed this diagnosis in all cases. ( . %) underwent urgent surgery, of them ( . %) with cardiogenic shock and ( . %) with massive pulmonary embolism. patients ( . %) underwent thrombolytic therapy. results: in the patients who received thrombolytic therapy successful results were achieved in cases ( . %), in ( . %) patients subsequent pulmonary embolectomy was performed. mortality rate was ( . %) in the patients who underwent pulmonary embolectomy after unsuccessful thrombolytic therapy and ( %) in the patients with cardiogenic shock and massive pe. lower extremity deep venous thrombosis caused pe in % patients. pe mortality rate is repoted to be %, but all patients with cardiogenic shock and massive pe died. this very high mortality rate related to the clinical status of the patients whose condition became worse despite intensive treatment. conclusions: the results of this study show that in most cases thrombolytic therapy is an effective rapid method of treating pe. however, surgical treatment is preferable when the patients reveal adverse effects to drug therapy, when medical therapy is unsuccessful or when the patients are seriously ill with reccurent cardiac arrest. high-quality pulmonary angiography remains the most accurate and reliable means of diagnosing pe. this prospective study was conducted to investigate the serum thyroid hormone levels in traumatized critical ill patients. serum thyroid stimulating hormene(tsh),total thyroxine(tr ),free thyroxine(ft ),total tri-iodothyronine(tr ),free tri-iodothyronine (ff ) levels were measured within hr.of intensive care unit admission(first day) in multiple tratmmtized male patients(injury severity score higher than ). in fifth day the same hormone levels were repeated. tsh,et ,ft ,tr and ft levels were determined by radioimmueoassay(ria). the levels of 'i~sh,xt ,fr ,et and ft in survivors and nonsurvivors were compared with first and fifth days (table) . in conclusion, we are convinced that there was a high correlation between low ser~n thyroid hormone levels and mortality, serum thyroid hormone levels are prognostic value in traumatized critical ill patients. objectives: glucagon improves myokardium contractility, intensifies kidney blood flow, stops bronchospasm ( ), these were the reasons of investigating its effect on hemodynamics and metabolism in hypovolemic shock expermentally and in clinic. methods : in experiments on white rats with traumatic shock glucagon (novo nordisk) was injected intraperitoneally in dose rocg/kg. patients with hypovolemic shock (trauma, hemorrage) were injected glucagon intravenously in dose mg on the background of infusion therapy. results : glucagon hightened recovery indexes of glucose in rats and patients with shock, whereas in groups without glucagon hyperglycemia developed. rats with glucagon injection had double times urea content than the norm ( , + , mmol& norm - , + , mmol/i ), whereas rats without glucagon had urea content , + , mmol/ ( p < , ). osmolarity of blood plasma in rats having glucagon injections was , + , mosm/kg h , without the drug - , + , mosm/kg h ( p < , ), ldh activity - , + . and , + , ( p < , ) mcmol cec- accordingly. lethality in the group of rats without glucagon was % /n= /, with glucagon - (n = ). in patients with hypovolemic shock in minutes after glucagon administration stroke volume increased to % (sv), miocardium contractility -to % (mc), peripheral resistance of vessels ( vr ) decreased to %. in - , hrs sv increased to %, mc-to %, pvr -decreased to %. conclusion : the study provides the evidence that glucagon has an anti-shock effect, improves hemodynamics and metabolism indexes in cases of hypovolemic shock. reference : picazo j. glucagon in acute medicine : pharmacological, clinical and therapeutic implications (norwell, mass:kluwer publishing, ), p. n, vasina (t) ,n.sebbota hph ( ). dept; of acute endotoxicosis, n.v. s~lifosovslay scientific research institute of ermergency ltealth care, boscow, lk'ussia (i}. institute for problems of cryobiology and cryouledicine of the national academy of sciences of the f/maine, kl'k r-key, [ maine ( ), objectives: the investigation of isolated hepatocytes using's efficacy in patients with acute hepatic fai lln-e. methods: native and crioconsrved allo-and xeno-!mmatocztes fixed on semi;ermeable ~mbr~s were used. results: the artificial supporting system with isolated hepatocttes as metabolic ~its was. ap-plied in patients. during tl~ treatmen~ with this cytotherapz an improvement of clinic state and biochemical rates were observed even inthe first we~s. for instance, the kncreasing of glutamin acid's level in blood up to normal value and decreasing of ammontes -concentration from i ~ mmol/l down to # mol/l were discovered. ~ae diminution of ence,%halo;athy was noted too. general lethality was' equal z, there of i z concerned acute hepatic failure (/k~). conclusions: the using of sum~rting hepatic system is able to cope the ~nenomenon of ~i~. objectives: fat embolism (ee) is an important and insufficiently studied problem of the intensive care medicine. fe is clinically diagnosed in % and morphologically in - % of the victims with severe multiple skeletal injury that is accompanied by the shock. methods: during the last years patients with the cerebropulmonary form of fe were treated in the icu. the prognosis of the probability of fe development was done using the computer system "cite-prognosis" in which the triss-method, dynamic and statistical prognosis of the injury outcome~ and the values of the most severe injury in points were realized. the treatment consisted of the surgical stabilization of the fractures with the authors' design of the rod apparatus in the acute period, long-term mechanical ventilation with peep via tracheostomy, complex fluid therapy using perfluorochemical emulsions (pe), and electrochemically active solution of na hypochlorite (snh) via the central vein. results: the treatment of patients with fe gave a good result that was manifested by the complete regression of psychoneurologic and respiratory disorders. conclusions~taking into account the prognostic data~ it is necessary to provide early complex of intensive care to the polytraumatized patients. it includes the surgical stabilization of fractures, fluid therapy using pe and snh~ early long-term mechanical ventilation. dr. alexandr e. poladko, station of medical aid. kiev ukraine. objectives: the reason of investigation is to prove the necessity of beginning of the intravenous infusion of nitroglycerin before the hospitalisation. methods: from january i to june protocols of treatment myocardial infarction patients in kiev medical aid station. results: the results of treatment are better if infusion began early or prolonged during hospitalisation. conclusions: there were patients with acute myocardial infarction treated before hospital by the cardiological groups. patients were treated with the early infusion of nitroglycerin and without. the results of treatment were: in the group with infusion: mortality in the first hours % the full disappear of pain % in the group without infusions mortality in the first hours % the full disappear of pain % that's why our opinion is that infusion of n. is necessary in the treatment of the patients with myocardial infarction from the first minutes of illness. dr. gennady d. kyrzhner, station of medical aid, kiev, ukraine. object: looking for safe medication which is good for the treatment of arterial hypertension and is simple for use. we inspected the effect of prazosin in the conditions of the cail during the year. method: we used mg prazosin tablets sub lingua and measured blood pressure ones during hours. the parameters were registrated in protocol. result." one hundred patients took part in investigation. the middle age of patients was . the reason of hypertension was not taken into consideration. in two hours after beginning of the treatment we caught the reliable lowering of blood pressure in % of patients. the general condition of patients became better in - min. it was only one accident of complication during the treatment -the orthostatic hypoter~sion, conclusion: prazosin hydrochloride in the dose mg sub lingua is safe and simple for use in the urgent situations. objectives: hypomagnesemia is frequently observed in severely burned patients during the early period after injury. increased urinary excretion is insufficient to explain the magnitude of the magnesium (mg) depletion. the possibility of exudative cutaneous mg losses has been proposed, but not yet demonstrated. the study aimed at measuring the mg content of the cutaneous exudates and urine during the first week after major burns. methods: patients, aged _+ years (mean _+ sd), and burnt _+ % of body surface, were studied from day (d ) to d . serum samples were collected at do, serum and urine from d to d , and on dio, d , d . cutaneous exudates were extracted from the textiles surrounding the patients, collected over h periods from d to d , using bidistilled acidified water. mg supplements ( . to mmol/ h) were prescribed from d to dio according to the severity of hypomg (serum mg < . mmol/i). results: mg serum levels decreased below reference ranges in patients between d and d , and normalised thereafter during supplementation. urinary mg excretion was increased in patients, mean excretion being . _+ . mmol/ h until d . mean daily mg cutaneous losses, were mmol/ h, i.e. mmo; in days. large inter-& intra-patient variability: the daily exudative losses ranged from to mmol/ h. conclusions: the mean daily mg cutaneous losses after burns were larger than the urinary losses, and equivalent to the recommended intakes for mg; the addition of the exudative and urinary losses largely explained the increased mg requirements after burns. complex immunologic alterations occur following thermal injury. the activation and consumption of the complement and dotting systems are suggested to play an important role in the development of the capillary leak syndrome, tn burned patients, a generalized inflammatory reaction as well as the impairment of the host defense are considered to be the major reasons for complications, such as sepsis and multiple organ failure. in a pig model we investigated a possible protective effect of cl-inhibitor (berinert, behring). before conducting the animal experiments the human cl-inhibitor concentrate was analyzed for its inhibitory capacity on purified pig cls and its pharmacoldnetic behaviour in pigs (t / ,id ). pigs received anesthesia and analgesia and arterial, venous and pulmonary (swan ganz) katheters were placed into the carotis and jugular veins. the pigs were scalded for seconds with ~ hot water to achieve a % tbs partial-thickness burn. blood samples were taken prior and after surgery as well as , minutes, , , and every further hours after thermal trauma. two control groups (each n= ) included animals which were either scalded or not scalded and treated only by resuscitation of ringers lactat solution. besides various parameters blood samples were analyzed for complement. the pigs (n= ) received c -inhibitor concentrate at an initial dose of u/kg body weight either immediately or hours after thermal trauma (n- ), followed by three further applications (of reduced amounts) every hours. the clinical outcome as indicated by vital parameters and as well as demonstrated by reduced edema and inflammatory tissue destruction suggested a protective effect of cl-inhibitor. complement analysis revealed a faster recovery of the alternative and classical pathway activities in cl-inhibitor treated pigs as compared to the control group but only if the regulator was given immediately after thermal trauma. from these results a protective function of c -inhibitor on thermal trauma can be assumed. objectives: the aim of study was to characterise the pattern of secretion of interleukin- (il- ) and tumor necrosis factor alpha (tnf alpha) in multiply injured or not injured critically ill patients and to relate these results to their outcome. methods: blood samples of multiply injured ( ( ) ( ) ( ) il- (nis) ( ) ( ) ( ) il- (nin) ( ) ( ) ( ) conclusions: this data suggest tnf alpha is a better prognostic marker in patients with multiple injury, than in critically ill patients without injury. il- is not significantly higher in nonsurvivors of both groups. sepsis is associated with an increased production of nitric oxide (no), as reflected by a rise in plasma levels of nitrites (no ) and nitrates (no ). severe bum injury is associated with similar symptoms of inflammation like hypotension, high cardiac output low vascular resistance and increased vascular permeability so that an increased no production may be involved. the present study included patients admitted to the intensive care unit of the burn center of brussels (age : - years; burned surfaee area - %), and control (non-septic) patients hospitalized in the neurological rehabilitation unit of the erasme hospital (age - years). the patients in both groups were fed enterally with to kcal/kg/day of a standard solution. in the burn group, daring the study period, patients were mechanically ventilated, required vasopressor (dopamine) therapy, and received antibiotics; patients were discharged alive from the intensive care unit, and no patient died during the study period. plasma was sampled for no /no determinations (griess reaction) daily from day to day (n=ll) or to discharge (day , n= ; day , n= ) in the burn group, and once the control group. in the burn group, no /no levels were elevated at day ( _+ #moles/i), reached a maximal value on day ( - p.moles/l) and progressively decreased to day (fig). these values were higher than in the control group ( . :t: . #moles/l, all differences p< . ). however, no correlation was found between the plasma no /no levels and the age of the patient or the total burned surface area; burned patients who became infected tended to have higher plasma no /no levels than those who did not ( + vs - #moles/i, ns). the present study indicates that burn noa/noa (llmol**/l) injury is associated with increasedloo] [__ ] ~ no /no plasma levels, which are ao so consistent with an enhanced no pro- o duction, ao obiectives:urapidil has been recommanded for therapy of hypotension in neurosurgical patients, because it was found not to increase intracranial pressure in patients with compromised intracranial dynamics ( ). in contrast several authors reported an increase of icp after urapidil administration in patients with head injury ( ). our study was designed to determin the influence of urapidil on mean lumbar cerebrospinal fluid pressure (csfp) in awake humans with uncompromised intracranial compliance. methods: after approval by the local university ethics comittee, six volunteers (asa , male, female) were studied in the lateral decubitusposition with the vertebral column positioned horizontally. a gauge needle was inserted into the lumbar subarachnoid space at level l /l and connected to a trancducer (mx | medex inc.) for csfp measurements. the volunteers were advised to keep respiratory rate and etco constant. after a resting period of minutes basline measurements were performed including csfp, cvp, map, hr, etco (cardiocap | datex). then the volunteers were given urapidil . mg/kg over a period of minute. minutes later measurements were repeated. results: statistics: wilcoxon signed rank test, p< . significant; values: mean_+sd, si = mmhg. - _ " _+ * _+ * - _+ " _+ csfp: cerebrospinal fluid pressure, cpp: mean cerebral perfusion pressure. conclusions: during normoventilation urapidil leads to a decrease in map parallel by an increase in csfp and therefore in icp, most likley mediated by an autoregulatory dilatation of cerebral vessels. if this cerebrovascular response is suppressed by hyperventilation, no increase in icp is found despite a uredipil induced drop in map ( ). after longterm hyperventilation cerebralbloodflow is normalized. this might be the reason why the drop in bloodpressure following urapidil administration again led to an increase in icp ( background and objectives: the intestine is one of the most sensitive tissues to ischemia-reperfusion injury. reperfusion of the intestine is often associated with increase in mucosal permeability and ulceration. d(-)-iactate is produced by indigenous bacteria found in the gastrointestinal tract and mammals do not possess the enzyme systems to rapidly metabolize it. the present study was designed to determine the kinetics of plasma d(-)-iactate alteration in rats paused by acute intestinal ischemia-reperfusion injury. methods: following the anesthesia, the superior mesentcric artery (sma) was exposed and it was occluded by a micro-bulldog clamp applied at its origin from the aorta. after min of occlusion, the arterial clamp was removed and the supply area of the sma was allowed to be reperfused ( h). plasma d(-)lactate levels were measured by an enzymatic spectrophotometric assay. the endotoxin content of plasma sample was assayed by the limulus amebocyte lysate test with a kinetic modification of the test kit procedure. results: intestinal ischemia for min resulted in a significant increase in d(-)-lactate levels within the portal vein as compared to sham-operated animals. plasma d(-)-lactate levels had a tendency to further increase after reperfusion up to h. it was showed that significant elevation of endotoxin concentrations in portal vein was alread~r detected at the end of -min ischemia, reaching peak at . h post-reperfusion and decreasing gradually throughout the study period. at the end of ischemia, marked mncosai damaged such as edema, hemorrhage and necrosis was observed. there was evidence of injury to ti, e muscuiaris propria together with diffuse mucosal damage and destruction following reperfusion, particular at h postreperfusion. in addition, penetration of bacteria was commonly found in the intestinal wall at various time points following ischemia/reperfusion injury. conclusions: these data suggest that acute intestinal ischemia is associated with permeability change of mucosal barrier resulting in increased plasma d(-)qactate, which is also remarkably influenced by subsequent reperfusion. plasma d(-)-lactate may be a useful marker of intestinal injury following both ischemia and reperfusion insult. objective: to assess the clinical usefulness of two methods of intracranial pressatre (icp) monitoring: intraparonquimatous recording (icpc) and epidural recording (icpe), versus intraventricular icp (icpv) as a gold standard. we prospectively studied patients with severe head injury (glasgow coma score < ) admitted to our icu between fobmaly and december . icpv was monitored in all pativrats by means of a multipzffolated catheter connected to a water coinnm. six of patients were additionally icpc monitored by a fiber optic transducer (comma r~), and seven of patients were icpe monitored by a couplvd fluid system (plastimedr). icpc was placed homolatetal to the focal, lesion m two cases and contralateral in three; icpe was placed homolateral to the focal lesiou in two cases and contralateral in three. all three systems were calibrated at the ear level. stali~cs: correlation coefficient and lineal regression were done between icpe and icpv, and between icpe and icpv with the hourly p~rs of values obtained dttting assistontial period. results: of the six icpc -icpv studied pa~onts, we observed a correlation coef~cieut r = . (p < . ) with a regres~on line y = . + . x. four of ~hx lcpc -icpv patients had r > . when correlaliou eoet~dent was obtained indixddually. of the seven icpe -]cpv studied patients, we observed a cortelafiau ooeffioiont r = . (p < . ) with a regression line y = . + . x. corralalmu eoetfieiont was inwer than . in all seven patients. corrdation eoelfieients for levals of icpv > man hg, > mm hg and > tuna hg with icpe showed r = . , r = . and r = . respectively; and with icpe r = . , r = . and r = . . the obtained values did not change during the study. conclusdns: in our study icpe was considered a good type of icp monitoring. /cpe signiticantly infravalorates icp values. we observed a good correlatinn between icpc and icpv values in patients with high inttacramal presanre. objective: midazolam is a benzodiazepine agonist widely used for sedation in emergency medicine. few studies in animals and humans point to a direct analgesic effect of midazolam probably mediated by spinal antinociceptive receptors and/or peripheral benzodiazepine receptors ( , ). in our experience in the berlin emergency medical system (unpublished results) with anecdotal cases of extreme chest pain due to binge drinking but no evidence of acute myocardial infarction or extreme abdominal pain due to peritonitis, acute intermittent porphyria, peutz-jeghers syndrome or testicular torsion, we found that small doses of midazolam ( - mg i.v.) were much more effective in relieving pain than repeated administration of high doses of buprenorphine or morphine, which may be associated with a considerable respiratory depressant effect. the dose of midazolam required for pain relief in these patients is non-narcotic and allowed further communication on the character and localization of' the residual pain, which might be very important for the further diagnostic procedure. patients: ten patients with abdominal pain due to acute gastrointestinal bleeding, suspected pancreatitis, suspected acute porphyria, and chest pain with no evidence of acute myocardial infarction received first-line midazolam i.v. at an initial dose of mg and were asked how it affected the intensity and character of pain. results: at the chosen dose of midazolam ( - mg), all patients were responsive to detailed questioning on basic orientation, the character, intensity and localization of the pain, and medical history. none of the patients required an additional opiate. all patients stated that the pain was tolerable after midazolam alone. conclusion: our preliminary clinical observations suggest that low-dose midazolam might be an alternative to opiates in extreme pain of presumably visceral odgin. objectives: it is known that severe head injury in elderly patients is associated with higher mortality than in younger patients. it remains however to be clarified whether the preinjury pathology which is frequent among these patients, affects the outcome. methods: in an attempt to investigate this hypothesis, patients aged over years suffering from head injury, with glasgow coma scale (gcs) of or less, were studied retrospectively. twenty-six patients ( . %) had preinjury pathology i.e. diabetes mellitus, arterial hypertension, heart failure, alcoholism, parkinson's disease etc. (group a) and fifty-three ( . %) did not (group b). the following data were recorded: mortality in the i.c.u., duration of hospitalisation, incidence of infective complications and neurologic status at discharge. results: groups were comparable in terms of mean gcs ( . vs. . ) and median age ( . vs. ). the incidence of brain pathology in the two groups was the following: epidural haematoma . % vs. . %, acute subdural! haematoma . % vs. . %, intracerebral haematoma . % vs. . %, subarachnoid haemorrhage . % vs. . %, diffuse haemorrhage . % vs. . %, contusion . % vs. . % and non-visible pathology (normal ct) . % vs. . %. unilateral pupilary dilatation was found to be . % in group a and , % in group b. the mortality during hospitalisation in the i.c.u. was almost the same: % iu group a and . % in group b patients. however, group a patients had significantly more infective complications, required longer hospitalisation and had lower gcs at discharge. conclusions: the results show that the existence of preinjury pathology does not seem to affect the short-term outcome of elderly patients with severe head injury. it has however an impact on morbidity and perhaps long-term survival of these patients. the assessment of clinical development in intensive care patients with severe head injury still remains a problem. to optimize the monitoring of intracraniel prassure (icp) we rautlr~dly implant an eplduml measuring device in our hospital. the aim of this study was to prove the correlation of the icp-values with ct findings and clinical development. during a month period ( - r the icp was monitored in p~,tients ( male, female) with severe head injury by an eplclural measuring device (epldyn~/$plegelberg| the mean age was . years ( - ). the glasgow coma scale at admission was . ( - ). in all cases the device was placed wfihln the first hours after admission. the tcp was compared with physical examination, radioidglcal or intraoperatlve findings and cunlca! outcome. the average time of measuring was . days ( - ) . the traatment depended on the !cp values recorded. rising icp-valuea ~ed to radlologlcal c ntra!s by ct-scan. in case an intracranlai hemorrhage was detected and drained. the overall survival rate was . %. showed a complete resolutl n, in other . % psychological residuals like decreased mentatlon, in . % sensomotorlc residuals like cerebral nerve dysfunction and aphasia, and . % of the injured remained in a comatous status. in % of our cases the measured values correlated with clinical course and management. in cases ( . %) we observed a displacement of the icp-pevice. there was no icp induced infecllon. istituto di anestesiologia e rianimazione, universit& ,,la sapienza", rome, italy * istituto superiore di sanit& -servizio di epidemiologia e biostatistica, rome, italy objectives: acute renal failure (arf) can be a severe complication of trauma. the current incidence of post-traumatic arf is associated with high mortality . identification of risk factors and prevention of this complication could improve the outcome of trauma patients. methods: one hundred fifty three consecutive trauma patients (age . _+ . , injury severity score . + . ) admitted to icu were studied. incidence of arf was . % ( / ). arf was defined as persisteat plasma creatinine > mg/dl with or without oligoanuria . arf was defined as early when occurring within the first hours (earf) and late when the onset was after the first four days (larf). results: earf occurred in patients while larf developed in patients. age, iss, and incidence of rhabdomyolysis and acute respiratory failure were not different in the two groups. an higher incidence of multiple organ failure (mof) and sepsis ( . % for both) were observed in larf group, when compared to earf ( % and % respectively). abdominal trauma was more frequent in earf group ( % vs %). the gs for earf and larf were respectively _+ . and _+ . while in the group who not developed arf (narf) the gs was . • conclusions: gs score difference seems suggestive and can be that an abnormal cerebral activity (hipofisary hormones?) may play a crucial role on onset of arf in these patients. moreover the frequency of acute respiratory failure in the group of arf was higher ( . versus . ) than narf group. the early ipoxia in the early phase of trauma, then, may be another crucial point for development organ failure. these are preliminary data. a more exact statistical analysis must be perform to have definitive conclusions. to compare the active compression-decompression cardiopulmonary resuscitation (acd-cpr) with the standard cardiopulmonary resuscitation (s-cpr) in out of hospital cardiac arrest patients. is a controlled, randomized study. two groups of patients with cardiac arrest out of the hospitalwere formed. group i, (acd-cpr) and group ii (s-cpr). for the acd-cpr groupweusedthecardiopumpdeviceofambulnternational. asfortherest, the erc ( ) algorithms for acls were followed. the utstein style (for out of hospitat cardiac errest) was used for listing and evaluating all cases of the study. the cpr was contucted by the crew and the doctors of our mobile intensive care units (micu). we studied consequitive patients ( in group i) and ( in .group ii). demographics pre-cpr characteristics (e.g. ecg form of cardiac arrest) and procedures (eg bystanders or second tiers crew cpr, defibrillation, drugs) were quite similar for both groups. the mean arrival time of micu was min. in group i we recorded r.o.s.c. (return of spontaneous circulation) , %, death %, continuation of cpr efforts , %. while in group ii, %, %, and , % respectively (recorded percentage until the admission to the hospital). no significant difference was found in anyofthe short term outcome parameters. no complications related to the acd-cpr technique, were noted. not any significant difference between the two methods was proven (from this small evaluated sample). the results of previous clinical studies are controversial (i) . more sophisticated studies proved the superiority, in a certain number of parameters (e.g pressures, flow, etc) of the new technique although there are many difficulties for establishing clinical results. in the pre-hospital setting that is related to many parameters (speed of the intervention, effectiveness of bystanders cpr, education ofparamedics, etc.)the evaluation is even harder. the superiority ofthe acd-cpr can be proven when it is performed in almost times increased number of studied patients as w~ll as improvement of the technique could lead us to more established results. objectives; infectious morbidity is the major cause of mortality after burn injury, and is due to multiple factors. trace elements (te), which are involved in both humeral and cellular immunity, exhibit severely altered status after burns. te supplementation has been shown to be associated with increased leukocyte counts and shortened hospital stay. the trial aimed at studying the immune responses in severely burnt patients receiving normal te supplies or early large supplements. methods: patients, aged _+ yrs (mean_+sd), with burns covering + % of body surface were studied from day (d ) to d post-injury, were randomised in groups (g): g -control receiving recommended te supplies + placebo; g -receiving in addition large supplements of cu, se and zn from d to d . enteral nutrition was started within hours of injury in all patients. immunological parameters: peripheral leukocyte counts, proliferation of mononuclear cells to mitogens, cell surface molecule expression, and neutrophil chemotaxis at d and d . infectious episodes and micro-organisms were monitored until d . results: the patients' characteristics were similar g & g . the total leukocyte counts were higher in g between d and d , due to increased neutrophils (significant from d to d ). total cd + and cdlg+ cells did not differ, whereas cd + (monocytes) were significantly increased at d . proliferation to mitogens was significantly depressed in all patients. chimiotactism was not altered. the number of infectious episodes was significantly decreased in g with a mean of . _+ . infections during the first days versus . _+ . in the control group (p < . ). conclusions: the large te supplements for days was associated with a significant decrease of the number of infectious episodes. supplementation was associated with increases in total leukocyte, monoeyte and neutrophit numbers. further studies are required to determine the precise mechanism underlying the improved immune defences. objectives: evaluate the efficiency of local adsorption (la) with the use of carbon adsorbents in case of severe burns in expertment and clinic. methods: experimental studies on la were performed on a model of % body surface area iiib-iv burn in rats. a burn eschar was excised on the rd day after burn, the wounds were dressed with the gauze bandages (control) or with adsorptive dressings (la), dressings were regularly changed. clinical investigations were carried out in the course treatment of patients with severe thermal and radiation ilia-iv burn. in the dynamics of bum disease some indices of proteometabolism and intoyacation criteria were evaluated. results: the experiments have demonstrated that the application of la after early excision of a burn eschar exerts a pronounced normalizing effect on a protein electrophoregram and the activity of proteases and their inhibitors in burned tissues preserving vitality. thus, by the th day after burn infliction the activity of cathepsin d in injm'ed muscles is times lower under an adsorptive dressing than under a gauze bandage (control) (p< , ), the activity of trypsin-like proteases is . - . times lower and the antitryptie activity does not differ significantly from the normal level. the cytotoxicity of extracts of burned tissues after the adsorptive dressing application fn vivo and adsorption in vitro is - % and - %, respectively, of the toxicity of control extracts. a similar normalizing effect of la is ok~rved for an intact muscular tissue and blood serum. the dectron-spin-resonance studies have demonstrated that la allows to normalize antitoxic activity of liver and functional activity of kidneys. the application of la in the treatment of patients with severe burns have been shown to localize a region of irreversible tissue changes, accelerate rejection of a burn eschar, attenuate an endogenous intoxication level and, as a result, shorten the time for grafting of a burn wound and accelerate wound heating. conclusions: proceeding from the obtained results, we can consider la as an effective method of localization of a region of irreversible tissue changes as well as of correction of local and general metabolism failures and overcoming burn autointoxication during burn disease. c de deyne, t vandekerckhove*, j. decruyenaere, b. vaganee, v vandewalle*, f colardyn depts of intensive care and neurosurgery*-university hospital gent-belgium. jugular bulb oximetry is the first bedside available cerebral monitoring technique providing an estimation of the adequacy of cerebral perfusion. its routine use in all patients suffering from severe head injury admitted to our ic unit enabled an extensive analysis of all very early cerebral perfusion data in order to evaluate the incidence of abnormal sjo~ data (and their possible causes) in this very eady period after traumatic insult and to search for possible implications as to the emergency management. these very early data were defined as the first hours icu data and icu admission had to occur within h of traumatic insult. over the last years, pts with severe head injury (gcs< ) were monitored by jugular bulb oximetry, starting immediately after their arrival at the icu (mean of . h after trauma, range between - h). in a total of pts (= . %), jugular bulb desaturatiens (< %) were noticed during this early h period. in pts (= %), jugular bulb saturations higher than % were observed, whereas pts (= . %) revealed no abnormal sjo data ( - %) during these first h. concerning the periods with too low jugular bulb saturations (n: ), we found the following correlation ; in pts (= . %) cerebral perfusion pressure (cpp) was below mmng, in pts (= . %) paco~ was below mmhg and finally in pts (= %) we found primary intracranial hypertension. for the high jugular saturations (n: ) we found a primary intracraniaf hypertension in f pts (= %), and a pace level above mmhg in pts (= %). in all patients we could restore jugular bulb saturation within normal range ( - %) with the correct!on of the presumed causative factor. we can conclude that ultra early jugular bulb saturation data revealed a high incidence of abnormal values, with a predominance of jugular bulb desaturations, confirming once again the high incidence of disturbed and too low cerebral perfusion within the first hours after severe head injury. these jugular bulb desaturations were especially correlated to systemic causes, as a too low cpp (caused in the vast majority by primary map insufficiency, and not by intracranial hypertension) and hyperventilation were the major causes of the desaturation periods. as jugular bulb desaturatione are known to be significantly correlated to a worse neurological outcome after severe head injury, one might improve outcome by an emergency management avoiding these possible causes of jugular desaturation. therefore, extreme attention should be paid to the maintenance of an adequate mean arterial blood pressure (above mmhg?) even duhng the few time spent at the emergency department. one should be as attentive to the maintenance of normoventilation during this very early period of admission and hyperventilation without any knowledge of icp or sjo should be abandonned. recently, indomethacine has been proposed for the treatment of therapy refractory intracranial hypertension in pts suffedng from severe head injury ( ). indomethacine, a cyclo-oxygenase inhibitor, gives rise to a significant fall in cerebral blood flow by inducing cerebral vasoconstriction. therefore, its use could result in a drastic lowering of the intraeranial pressure (;cp) in pts suffering from intracranial hypertension secondary to cerebral hyperaemia and in whom the use of other cerebral vasoconstrictive drugs (barbiturates or hyperventilation) appears insufficient to control icp. for the last months, we included the use of indomethacine in our therapeutic flow chart for severe head injury management. pts revealing intracranial hypertension (icp> mmhg) and cerebral hyperaemia (sjo~> %) and in whom icp was not efficiently controlled by the combined use of hyperventilation and barbiturates were given indomethacine in a trial to control icp. a total of head injured pts received treatment for intracranial hypertension over the last months. six of them met the criteria set for the administration of indomethacine. in pts, no decrease in icp or in sjo was observed and both pts died due to therapy refractory intracranial hypertension. in the other pts, a significant fall in icp and in sjo was observed shortly after indomethacine administration. in pts we observed a catastrophic fall of sjo= even below %, indicating an extreme cerebral vasoconstriction with the possible risk of inducing cerebral ischaemia. in one of the pts, icp remained under control without further administration of indomethadne, but he died days later in multiple organ failure. the other pts, needed multiple indomethacine administrations (for pt even during consecutive days) to finally control icp. in all pts, icp was finally controlled, but only pt survived. both other pts died from systemic causes (multiple organ failure in pt, massive gut infarction in the other tat, possibly due to the systemic vasoconsttictive effects of the indomethacine administration). in conclusion, indornethacine might have a role in the treatment of intraoranial hypertension, especially when caused by cerebral hyperaemia. we observed however a poor final outcome and a threatening high incidence of systemic events (multiple organ failure, gut infarction) in those pts receiving indomethacine for icp control. therefore, indomethacine in the treatment of intracranial hypertension should be reevaluated in controlled study settings, before its routine use can be considered. untill recently, intracranial hypertension (ich) in pts suffering from severe head injury was managed in a staircase approach, with csf drainage as first therapeutic step, mannitol as second step, hyperventilation as third step, and finally, barbiturates as the last rescue step for therapy refractory ich. this staircase approach for the treatment of tch was only guided by the intracraniat pressure, and not by other parameters such as e.g. the actual state of cerebral perfusion of the concerned pt. jugular bulb oximetry provides us with the first, bedside and continuous available, estimation of cerebral perfueion. its implementation in a rigourous flow chart, based on as well icp-as jugular bulb oximetry-data might result in an altered strategy for ich management. we adopted a '~ugular bulb saturation (sjo~)-guided approach" for ich management in consecutive pts, suffering from severe head injury (gcs< ). we maintained csf drainage as first therapeutic step, but the decision for the second step was guided by sjo information. pts revealing ich and sjo=values above %, were treated with hyperventilation, and did not receive mannitol. if ich persisted, barbiturates were added as a third step. on the other hand, pts with ich and sjo= vales less than %, received mannitol administration as second step. hyperventilation and/or barbiturates were only added if ich persisted and if no cerebral hypoperfusion was discerned (sjo=> %). our objectives were to prospectively analyze this new therapeuticstrategy, as compared to the formerly used staircase approach of ich. we managed pts with ich, with an overall mortality of . % due to therapy refractory ich. all pts received standard primary care with head elevation, full sedation and normovenfilation. fer pts, csf drainage alone was sufficient to control ice of the remaining pts, pts received mannitol and pts were hyperventilated as second approach. in the third line, pts were managed with barbiturates, with mannitol and pts with hyperventilation. finally, barbiturates were used as the final rescue in pts. these results reveal a less frequent use of mannitol as only pts received mannitol, compared to the pts that would have received mannitol using the former staircase approach. hyperventilalien was used much earlier in the treatment course, as lots were already hyperventilated in the second line approach, were this was formerly exclusively reserved for the third line approach. finally, also barbiturates were used much eadier ( pts received barbiturates as third approach). we may therefore conclude to a important change in the management of ich, induced by a sjo -guided flowchart. however, future studies will have to elucidate if this new strategy for the intensive care management of severe head injury will also result in an improved outcome. obsectives: in a first series of experimental brain injury we investigated the course of brain po , icp and cerebral blood flow after traumatic brain injury (tbi), whilst accordingly there are very few data available and the mechanisms leading to secondary brain damage are poorly understood. methods: in piglets ( days old, , - kg) of either sex we produced a moderate brain injury ( , arm., msec.) using a lateral fluid percussion {fp) device. complete measurements were made before and min. after brain trauma and after , and hours including blood gases, cardiac output (htermodilution), heart rate, eeg, laser doppler flow probe (ldf} and icp values (camino), brain temp., po by a clake type oxygen electrode (licox) and coloured microspheres for regional blood flow. results: immediately after the trauma a typical "cushing"response to the icp peak up to mm hg being highly significant (before mean i mm hg, range - mm hg) could be observed: mean arterial blood pressure rose from appr. mm hg to ii mm hg for - min. in two animals this was followed by an ischemic period lasting min. accordingly icp values gradually returned to starting measures within hours; in the ischemic animals they remained at a level of about mm hg.-no secondary increase of icp could be observed, once icp dropped to starting values within hours. cerebral blood flow (ldf) fell from mean values being i before trauma to appr. zero and recovered to around . brain po started at mean values of mm hg (range - mm hg) and fell to around zero depending upon the severity of the ischemic reaction. on average values of mm hg were reached over the time course. conclusions: with our fp trauma model we can reproduce the well known "cushing"-response after brain injury; secondary icp elevations cannot be achieved, although local edema is observed. direct brain po measurement seems to be a very sensitive variable for detection of cerebral ischemia and anticipates eventually following icp elevations by far. pulmonary aspiration s,traoaras. v. sgountzos, p. agouridakis, m eforakopoulou, e. ioannidou. intensive care unit (tcu) of "kat" hospital, athens, greece ob!e=ives: the reported mortality rate after pulmonary aspiration is variable in several series. the purpose of this study was to find out the influence of preexisting disease or situation on morbidity and mortality of intensive care unit (icu) patients with pulmonary aspiration. methods: patients who were treated in icu and had pulmonary aspiration, were studied, entrance's criteria in the study, all of them obliged, were: ) suction of gastric contents from trachea during intubation, ) presense of a predisposing factor, e.g. coma. ) recent hypoxaemia or new infiltrates in xray. preexisting disease was recorded and correlated with complications and outcome. patients with glasgow coma scale , because of cerebral injury, and patients who died within days from cause other than aspiration, were excluded from the study. method of statistical analysis: chi-square test, results: one hundred forty five patients were studied. the trauma patients were and the non trauma patients . from the trauma patients, had cerebral injury and were polytreumatized without cerebral damage. from the non trauma patients, had malignant neoplasms, neurological diseases in terminal stage, old age, drug overdose, and several diseases. eighty seven from trauma patients ( %) and from non trauma patients ( %) manifested several complications (pneumonia, ards, etc), so there was no statistical difference in complications' frequency between the groups (p> , ). the severity of complications was also proportional in the groups. eighteen deaths were recorded in the trauma patients (mortality %). only deaths correlated directly or indirectly with the aspiration ( %). in non trauma patients, deaths were recorded ( %). twelve deaths were recorded in patients with neoplasms, deaths in patients with neurological diseases, deaths in aged patients, death in drug overdose patients, and death in patients with several diseases, the mortality difference in trauma and non trauma patients was statistically significant (p< , ). in patients with drug overdose the mortality was significantly lower from the other non trauma patients and the difference was statistically significant (p< , ). conclusion: the preexisting disease or situation plays a major role in the outcome of the patients with pulmonary aspiration. the mortality of patients with aspiration seems to be caused by severe preexisting situations rather, that lead to death, than from the pulmonary aspiration per se, which may be a final happening in a predetermined course. obiectives; the purpose of this study was to compare fluconazole and amfotericin-b in the treatment of fungal infections in severe trauma patients. methods: thirty five severe trauma patients who were treated in intensive care unit (icu), were studied prospectively. they all developed fungal infections, prooved with blood positive cultures and at least one of the following: fever, positive urine or bronchial secretions cultures, infiltrates in xrays. the patients were separated randomly in groups. the patients of group a ( patients) received fluconazole rag/day for days. and the patients of group ( patients) amfotericin-b rag/day for also days. compaiison's criteria were the clinical responce to treatment (fever etc), the fungal elimination (blood and other cultures), the relapses of the disease, the side effects of drug, and the outcome of the patients. as method of statistical analysis was used the chi-square test. results: nine patients from of the group a ( %), and from of the group b ( %), presented remission of fever (patients of group b had better clinical responce than patients of group a, and the difference was statistically significant, p< , ). all the patients before treatment had positive for fungi blood cultures. after days of treatment, patients of group a and none of group b had positive cultures. eight patients (from who had positive cultures of bronchial secretions before treatment) of group a. and (from ) of group . had positive cuttures of bronchial secretions after days of treatment, so positive bronchial secretions were fewer in group b than in group a, but this difference wasn't statistically significant, (p< , and p> , ): ten patients (from ) of group a and patients (from ) of group b had positive urine cultures, after days of treatment (positive urine cultures were fewer in group b than in group a and this difference was statistically significant. (p< , ). two patients of group a and none of group b had a relapse of fungal disease. in group a, no side effects were obsepced, while in group b were observed only minor side effects (small increase of serum creatinine in patients, chills and fever during infusion in patients, and hypokalemia in patients). three patients of group a and patient of group b died, because of sepsis. conclusion: amfotericin-b (even i~ short regimen of days), is superior to fluconazole in the clinical and laboratory responce and also in the relapse of fungal disease, fluconazole is superior to amfotericin-b as it has no side effects. ob!ectives: flail chest after thoracic trauma is a serious injury. it is controversial if flail chest by itself orthe concomitant intrathoracic injuries e.g. pulmonary contusion, is the cause of the reported significant morbidity and mortality. in this study we searched the influence of concomitant thoracic injuries in the course and outcome of patients with flail chest. methods: eighty five patients with flail chest after isolated chest injuries were studied, for the purpose of analysis, we separated the patients into groups, patients with isolated flail chest were included in group a, patients with flail chest and hemo-pneumothorax in group b, patients with flail chest and pulmonary contusion in group c, and patients with flail chest and hemo-pneumothorax and pulmonary contusion in group d. complications from the chest, duration of mechanical ventilation and mortality were compared in the groups. statistical comparison of results belween groups was made using chi-square and t-studend tests. results: the patients were . all patients received mechanical ventilation, twenty eight patients were ihcluded in group a, in group b, in group c. and in group d. seventy three patients manifested complications from the chest, especially pulmonary infections. there was no statistical difference among the groups as to number of complications ( twenty four patients had chest complications in group a, in group b, in group c, and in group d. p> , }. the duration of mechanical ventilation was not statistically different among the groups (the mean duration was , days in group a, , in group b, , in group c, and , in group d, p> , ). there was also no statistical difference in mortality among the groups (six patients died in group a. in group b, in group c, and in group d, p> , ). conclusion: flail chest by itself is a serious thoracic damage with many complications, regardless of the presense of other thoracic injuries, which don't contribute to greater morbidity and mortality. the present study investigated the correlation between blood lactate mortality and organ failure in trauma patients admitting between december , and july , in the icu. road traffic accidents were the most common cause of trauma in this studded population. brain damage was the main cause of mortality .nevertheless, of patients died from sepsis and multiple organ failure without significant brain damage and these deaths were potentially preventable. respiratory failure was the most common complication and was developed in ( %) of survivors and in ( %) of non survivors .we noted low fncidence of renal failure may be do to the early and aggressive ittv'asive hemodynamic monitoring and cardiopulmonary support. as part of our routine case protocol serial blood lactate levels were measured in each patient at least times a day until the valses returned within the normal range or until death. we analysed the blood lactate levels on admission, the highest value and the number of days until the first normal value (<l.smeq/i). initial lactate and highest lactate levels were significantly higher in patients with than without organ failure.( . vs . , . vs . meq/l, p< . )the duration of hyperlactemia also was higher in the patients with organ complications. ( . vs . days, p< . ). both initial lactate and highest lactate levels were higher in the non survivors than in the survivors.( . vs . , . vs . meq/l, p< . ) the present study demonstrated that not only the degree but also the duration of hyperlactemia can be related to the development of posttraumatic complications. serial blood lactate measurements are reliable indicators of morbidity and mortality following trauma. s current evidence suggest that peep only affects intracrenisl pressure (zcp)when it interferes with systemic arterial pressure, although the effects of peep over cerebral oxygenation remains unknown. objective: determine the effects of peep over icp and cerebral metabolism measured by sj , kjdo and ceo in severe head injured patients. meterial ~ methgds: patients with glasgow coma scale l at arrival, with difusse brain injury in the first gt, according to marshall criteria,lop and jo monitored, under analgesia and sedation, normoventilated with zeep, without mannitol treatment in the previous hours, normal x ray chest and within the first hours from injury, were considered candidates. peep value where increased fro~ zero to cmh , in three different steps, each one with min of duration. all date were analized on line, pmax p'p ..... p.._, from the ventilator, systemlc haemodynem]c data, cerebra perfuslon pressure (cpp), icp and sjo , in the case of hemodynamic deterioration, during the study, ppc ommhg, extra-volume were administered. if persistence, dopamine were begun or increased dosage. if no good response were obtained, patients were retired from the study. results. patients were candidates, of them were exc;uded due to haemodynamic instability, k total of completed all steps and were e~amined, men and women, age ! . yrs. at hospite; arrival, glasgow were < in patients, and > in the rest . patients mmhg at the beginning. zeep ob/ectives. critically ill patients are transpoded to an intensive care unit(icu), under conditions, which have not been systematically evaluated. therefore, we set suite investigate transportation and admission condition of these patients to our department. methods. we studied patients( females), aged (mean-..+-sd) . _ . yrs, which were consecutively (from august to march ) admitted to the icu, through the greek national emergency transporta~on service. apache ii severity score upon admission was . -+ . (range - ). the following data were evaluated: ) number of medical departments, where health care was provided until final admission to the icu, ) ambulance transportation conditions, ) catheters and tubes inserted before admission, ) vital signs upon admission ) information provided by referring physician (scored on a to scale: history, electrocardiogram, chest x-ray, laboratory data, drug therapy already administered), ) comparison of the state of the patient described by referring physicians, to the actual state u pen admission. resu/ts. one to four medical departments had provided health care before the palient was admitted the icu ( : . %, : . %, : . %, : %). thirty/ ( . %) patients were escorted by a physician. twenty-six/ ( . %) were transported on oxyge n, fio (mean__.sd): -+ %, pao : . -+ . mmhg. five of the remaining , for whom no oxygen was provided, had pao : . -+ mmhg. twelve/ ( . %) were intubated and ventilated during transportation. thirtyfour/ had a peripheral venous line, / had an arterial line, / had a nasogastdc tube, / had a urinary catheter. eleven/ were sedated and / were paralysed. three/ were on inotropes. vital signs upon admission were: arterial blood pressure, systolic . -+ mmhg, diastolic -+ mmhg, heart rate -+ bpm, temperature . -+ cc. patient information score was --. . . the actual state upon admission was found substantially different, as compared to the description of the referring physician, in / ( . %) patients. conclusions. we conclude that several aspects of the greek national emergency transportation service to an icu should be reevaluated and further improved, i. e. ventilatory support, adequacy of information provided and accuracy of prior description of the patient's state. a new perspective must be applied for critically ill patients transportation since . % of the patients were evaluated and treated in more than one, medical departments, mostly primary care, before they were finally admitted to our icu. dclhb is a human derived hemoglobin molecule that has been cross-linked to stabilize and permit heat pasteurization to remove residual proteins and inactivate viruses. dclhb is mixed with a lactated electrolyte solution to yield a total hemoglobin concentration of log/dl objective: to present an overview of four recently completed clinical safety studies of dclhb in the u.s. and europe, and to discuss the properties, actions and potential indications for dclhb. method: patient populations in the four studies included males and females ranging in age from to years. dosing ranged from mglkg to mg/kg. the controlled randomized safety studies were conducted in chronic renal failure patients, surgical patients undergoing total hip replacement or abdominal aorta repair and in hemorrhagic hypovolemic shock patients. these very diverse patient populations allowed safety evaluation of the product in patients who were generally elderly, often hypertensive with some degree of cardiovascular disease, and receiving medications for treatment of other conditions. results: over patients received dclhb in the four:studies. no product related sarious adverse events occurred during the clinical trials. conclusion: results from phase itll safety studies of dclhb in patients undergoing chronic renal dialysis, abdominal aorta repair, or total hip replacement and in patients in hemorrhagic hypovolemic shock, indicate that the product was well tolerated in these distinct populations. although these studies were designed to evaluate safety, the data suggest clinical benefit. follow-up efficacy trials are indicated. prehospital emergency services represent the extension of emergency care into the community and constitutes the manpower, communications, transportations and facilities used to provide care for patients outside hospital. one of the main points of the system is how to decide the hospitalization of patients and what kind of facilities to provide : emergency medical service, fire brigade, locat general praclitionner or ambulance officers. objectives : to realize guidelines for using the prehospital emergency medical service in case of patient'calls outside hospital. methods : from st june to july , all the calls for emergency care were analysed using a questionnaire of items (origin of the call, responses to the questions of an emergency practitionner, kind of emergency service provided and the issue of the patient). after taking account of the appropriatness of the decision, statistical method used was a logistic regression. results : calls were analysed. the criteria, for prehospital emergency medical service using, given by the logistic regression were as following : existence of a call for emergency, thoracic pain, dyspnea, seizures, cyanosis, drug intoxication, fall of the patient, fracture, age, the state of consciousness and the neurologic reactivity. the minimal and maximal predictive values of the model given by the logistic regression are respectively % and %. the performance of the model is %. conclusion : it seems possible to help medical decision of emergency medicine by using only some easy criteria and a predictive model. (italy) objective: to evaluate the incidence of blunt carotideal injury (bci) in patients admitted to our icu after head injury. methods: we reviewed the medical records of all patients diagnosed to have a bci. at admission, the severity of trauma was assessed either with glasgow coma scale (gcs) and with ct scan. bci was demostrated by doppler ultrasography (us) and by angiography (ang). results:since may to april , patients were admitted to our icu with bci ( m, f, age + ). a history of direct trauma was present in patients. admission gcs was in all patients, and was associated with hemiparesis in of them; the last became paretic hours thereafter. two patients had concomitant injuries (a homoiateral clavicular and a controlateral zygomatic fracture, respectively). the initial ct scan was negative in every patient, and showed signs of ischemia after a variable timespan ( - days) after the onset of the symptoms. the bci was diagnosed with us and ang, which demonstrated a thrombosis of the internal carotid artery (ic). in two patients, an intimai dissection was also present. three patients were treated with heparin associated with antiaggregating agents and were discharged alive. the last patient was referred to our icu after the development of a massive hemispheric infarction, and died three days after the admission. at necropsy, the ic thrombosis was associated to an extensive homolateral extra and intracranial venous thrombosis. conclusions:the presence of focal neurological signs despite a negative ct scan should address the diagnosis toward a bci, thus implementing the diagnostic workup with us and/or ang. tab i: distribution of l~tients (%) in the groups the outcome were monitorett results were sabmitted to statistical analysis using a continence table x in z test. res.cl~s: of patients were submitted to thrombolysts and died. the higher incidence of bracb, ar~lhmias (ii degree gg p t e and av block. i degree av block. avsb . <ii. sinus arrest) that requited the insertion of avsc . <cl temporar~ pace-maker was recorded in group a b vs c . ns in % of the cas ~. the rapid recognition of life tab li:;~ test. threatening conditions suggests the monitoring of v r-lead r b' in the course of inferior ami. the authors report their own expirience in application of ringer lact.(rl)and , %nacl/ %dextran . methods:in polytraumatized patients with developed hae morrhagic shock,injures of the chest(qg)and abdomen(q ) prevalid.replacement of the volume loss egan in institutions of general medicine,frequently by rl and dextran or haemaccel.after receiving necessary medical aid,polytraumatized patients wer transported to mma by helicopter,continuing replacing of circulation volume by the same solution. results:average quantities of the solution dministered ~o the injured wer~ - ml.a group of the inoured which,after the admission to mma was resuscitated by adml nistration of the , %nacl/ %dextran @(groupii)( -sml/kg observed to the final surgical management,had statistically higher map(increase of % in relation to admission), cvp(average increase of , cmh~o),diuresis(averagely omi after min.),better gas ~nalyses and acid-base status in relation to the group which was administered only rl(groupi)(increase of the map of q %,average increase c~ of cvp , cmh and average diuresis oml after omin). total quantity of the administered solutions was significantly smaller in the groupii( ml: ml).the only ob served complication was hyperhatr~f~a::and~moderat~hyper osmolerity of plasma which disappeared within hours. the quantity of replaced blodd was considerably smaller in the groupii(qooofnl: ooml).in the group i interstitial pulmonary oedema was observed in two patients(qo%),while: in the group ii no complication was observed.coagulation i disorder and hypotension were not recorded because of the fast infusion of hypertonic/hyperoncotic solution in the groupil as the infusion of , %nacl/ %dextran lasted minutes. w.scherzer(l~,k.lechner( ),r.simon( ). ll)dept.anaesthesiology,trauma hospital,vienna-meidlin !( )neurotraum.rehabilitation center,vienna-meidling both austrian workers'compensation board,vienna,austria what we usually call"unconcious" means only that the patient is not able to interact in any kind of way.experiences in intensive care medicine (robinson, ) ,in general anaesthesia (bennet, ) and with evoked potentials show,that unconcious patients are not automatically unhble to process and recall information.this implicates a challenge to start the efforts to restore the traumatica-!ly desintegrated brain function as early as possible in the acute phase ia (zieger, ) .we present a method to ~repare the patient for the rehabilitation goals of the postacute phase ib,the phase of stabilisation ii and of rehabilitation iii within one concept. to achieve sensory stimulation in phase la we use: attempt at some kind of dialogue by speaking to and tou-ching the patient,to make him experience his body limits, ~acio-oral therapy by ice application,tast and smell pro vocations and trials of feeding,early adaption to circadian rhythm and guiding the patient in every-day-life-ac-tivities e.g.:in the brushing of teeth,washing etc. to achieve motor stimulation and orientation in terms of ~-ace,time and gravity in phase la we use: avoidance of perceptual impairment as produced by air-:sack-beds or habituation to supine position,using method~ according to affolter( ) ,basal stimulation (bienstein, ) , bobath-therapy( ) and facilitation of a physiological moving pattern(pnf)according to knott( ) . conclusions: by integrating all these measures in the ~herapy and nursing even in the acute phase la one prei ares the comatose patient for multisensory stimulation nd motor training and all other rehabilitation activities in the following phases of therapy. s objectives." measurement of cardiac output (co) and stroke volume (sv) requires insertion of a central venous catheter and is associated with a considerable risk for complications. non-invasive methods for determination of hemodynamic parameters have been introduced recently. one of these methods is the aortic modelflow program, which provides co and sv continously using a three-element windkessel model. the aim of the study was to evaluate the accuracy of the aortic modelflow program in critically ill patients. methods: patients (mean age: ) admitted to the emergency department after cardiopuimonary resuscitation (n=ll) and for myocardial infaction (n= ), acute congestive heart failure (n= ) and anaphylactic shock (n=l) were included to the study protocol. after stabilization all patients received a swan-ganz catheter (baxter~; edwards swan-g-anz) via a central vein. co and sv were measured by the use of a cardiac output catheter and injection of rrd ice-cold glucose % non-invasive cardiac output measurement was done by using the continuous cardiac output software package modelflow (tno; portapres| results: overall, paired measurements were used for the evaluation of the accuracy of non-invasive obstained sv and co. mean values, standard deviation and range of co and sv evaluated by invasive and non-invasive methods are summarized in the aortic modelflow provides reliable hemodynamic data in critically ill patients. it may be a useful alternative due to its non-invasive approach and continous measurement. objectives: to determine the feasability and accuracy of a rapid urine screening test (triage tm, merck-diagnostika) in an emergency department. methods: prospective analysis of the triage tm testkit (tt) in patients admitted because of suspected drug abuse during an observational period of months. the tt is a eompetitve immunoassay which gives qualitative results within i minutes for methadone, benzodiazepines, cocaine, amphetamine, opiates, barbiturates and cannabis. urine samples were analysed with the tt and compared to the results of a enzyme-lihked tmmuno-assay (el.a) in our labratory (gold standard). results: during the study patients were enrolled, in of these patients substance abuse was proven by tt and verified by eia. we recorded no false positive or false negative results for benzodiazepines, barbiturates, opiates, cocaine and cannabis. two results were false positive and one false negative for methadone; one result was false negative for amphetamines. the triage-testldt had an overall sensitivity of . and specificity of . . conclusions: the triage tm testkit seems to be a a useful rapid test device in addition to quantitative tests for drugs of abuse in an emergency department. objectives: the purpose of this study was to evaluate the influence of several factors of the renin-angiotensin-aldosterone system on blood pressure response in patients with hypertensive crises. methods: patients with systolic blood pressure > rorohg and diastolic blood pressure > nunllg were included into the study. prior to treatment blood samples for determination of plasma renin activity (pra), angiotensin converting enzyme (ace), angiotensin ii (ang ii) and aldosterone (aldo) were collected. all patients received rog enalaprilat intravenously. success of treatroent was defined as a reduction of systolic blood pressure below mmi-ig and diastolic blood pressure below mmi-ig within minutes after start of treatment. results: patients were included in our study, ( %) patients responded successfully to treatment. mean arterial pressure decreased in responders by . mmhg and in non-respenders by . mmhg (p< . ). responders and non-respenders differed signii'icantly concerning pra (p= . ), ace (p= . ) and ang ii (p= . ). . . the extent of blood pressure reduction correlated positively with the pretreatment pra and ang ii concentrations (correlation coefficient for pra: r= . ; ang ii: r= . ). conclusion: our data confirm that in patients with hypertensive crises blood pressure response to ace inhibition is mainly determined by circulatory pra, ace and ang ii. as the extent of blood pressure reduction correlates with pra, ace-inhibitors in patients with suspected high renin status cannot be recommended, as excessive blood pressure reduction, which carries a considerable risk for further organ damage, may occur. f. staikowsky, n. grillon, f.pevirieri, c.jedrecy, c. zanker, f. michard, a. haft medical emergency department. hospital bichat, paris epidemiology of acute intentional self medications-poisoning (smp) in france is especially known by data of poison control centei,s and intensive care units (icu). the purpose of this study is pro~,ided characteristics of this problem in a med for adults. method: july to june , files of patients consulting to the ed for smp have been retrospectively analyzed. results: patients, women and men, . + years old (range - ) have been admitted for episodes of smp ( % of all consultations) whose relapses during the period of study. psychiatric disorders, drug addiction or hiv patients was found for respectively . %, . % and , % of patients. the interval of time between the ingestion and emergency consultation was noted for % of smp ( + min, ranges - ). the involved products name was known in totality in % of cases with an average number by episode of . + drugs (ranges - ). the most often, ( %) or ( %) different products were interfered. the nonbarbiturate psychotropic drugs accounted for . % of the products (benzodiazepines %, antidepressants . %, neuroleptics %, carbamates . %, imidazopyridines . %, cyclqpyrrol nes . %). analgesics and nonsteroidal antiinflammatories represented . % of all drugs, anticonvulsants . %, cardiovascular drugs %, antiinfective agents . %, drugs against cough . %, muscle relaxants . % and antihistamines h . %. the benzodiaz pines were present in episodes, alone in episodes. in . % of cases, there was a simultaneous intoxication with alcohol. the processing consisted of gastric lavage in . % of cases, activated charcoal in . % of cases, flumazenil in . % of cases, naloxone and acetylcysteine in . % of cases; orotracheal intubation was performed in patients. admission in hospital was effective for patients, in medical ward (n = ), psychiatry (n = ) or icu (n = ); no fatal case was recorded. conelusion: smp to ed are often benign. the benzodiaz pines are the most often incriminated but the new anxiolytics and hypnotics (imidazopyridines and cyclopyrrolones) take a growing place. the latsion burn center of athens. its planning constructive and functional refinements j. ioannovich, a. petalas-vourekus, d~ serbetis, h. carsin a bed burns unit is under construction following a donation to the general hospital of athens. the plan of the unit, covering a surface of approximately . m is based on the principle of three identical bed satelites which may function totally independent from each other. in the center of the unit the common facilities are installed, like operation theatres, storage rooms etc. this new modification in the plan of a burn unit is presented in this paper. the advantages from the fucntional, administrative and medical point of view are discussed. tiffs anisotropic conduodon could favour the ocenrence of a circular movement of the impulse that leads to tachyeardias by reentry. purposes of this work were to study, with the help of epicardial mapping, the influence of a trieyclie antidepressant, clomipramine (c), on the conduction velocity longitudinal (vl) and transverse (vt) to myocardial fiber orientation and on anisotropy (a = ratio vl/vt), and their modificutions by the sodium bicarbonate ( ). method: a plaque of electrodes, positioned on the left anterior ventricular wall of anesthetized dogs, allowed to deliver, thanks to central electrodes, programmed electrical stimulations inducing vcuttienlar complexes, and to collect them. each entailed unipolar dectrogram was processed by a computer system that drew the isochrones and a map of activation allowing the calculation of v. the c was infused ( . mg/kg/min iv) during rain; at t , dogs received the b until the retuni of qrs to its initial value fro). a lengthening of qrs of at least % of its value at to was demanded before the administration of b. results: dog was excluded because of an.~nsufficient prolongation of qrs before the administration of b. all values (map : mean arterial pressure, i-ir : heart rate, qrs andqt intervals, v) differed significatively ( < . ) compared to values control fro)except qrs at t . the b ( + ml/kg; ranges . and . ml/kg) modified no studied dements outside of the ( }rs. to ti t t t t t a , + , , + , , + , , + , , + , , + , , +- ,~ conclusion : the c slowed v l and v t without modify the anisotropy. the b did not modify the v of~conduction while the qrs prolongation was corrected. the c acts as a class i antiarrythmie drug on the inward sodium current during the phase of action potential; the gap junctions have shown to be important in the conduction and an action on the gap junctions such as a modulation of the junctional resistivity, can not be rule out. is the doctor a heroe ? p. t.schies~.he, t. bauer, m. seyr dept. of anaesthesiology and intensive care, aokh krems, austria objectives: helicopter emergency services (hes) are getting popular more and more. the results concerning outcome are encouraging. however, some recent accidents with dead or badly wounded hescrew-members have shown the relatively high risk for the crews. therefore we were interested to eval ate the motivation of physicians to participate in a hes. this survey was designed to investigate current concerns about safety and motivation of doctors on emergency call. methods: a questionnaire was sent to doctors of the austrian emergency system. the survey consisted of multiple choice questions and subjective scoring tables from (--full agreement) to (=disagreement). overall, "/. of the active emergency physicians participated in the survey. results: . % of the doctors assume the system is basically safe, experienced doctors tended to have less trust in safety. only % would not hesitate to go into action by dark. . % stdctly refuse night flights to accidents outdoors. although defibrillations are assumed to be safe dudng flight, only % would do it. . % of the doctors would rather stop flying. the most common reasons for ,uitting were wish of family and fear of an accident. . % conclusioq: short transportation times help to avoid trauma related stress, pain and shock-induced organ complications. therefore the physiologic and economic advantages of hes are undebatable. however, the survey data indicate a considerable concern about safety of the medical personal in a hes. crash landings within less than years with deadcases and badly wounded crew members in a small country like austda make desire for safe flying conditions understandable. obiectives: to evaluate the clinical usefulness of trachlight. methods: trachlight is a new device facilitating endotracheal intubation. a stylet with a lightprobe is inserted into the endotracheal tube. intubation is guided by the light glowing through the neck tissues, thus rendering direct laryngoscopy unnecessary. intubation using trachlight was studied in patients (age - years). the indication for intubation was elective surgery in patients (asa i-ii) and emergency intubation in patients. in the elective patients, anaesthesia was induced with thiopentone supplemented with fentanyl, and intubation was facilitated with vecuronium. the cause for intubation in the emergency patients was dyspnea in , cardiac arrest in , trauma in, and unconsciousness due to drug overdose or seizures in patients. intubation was facilitated with medication in patients. results: of the elective patients, ( %) were successfully intubated. six patients ( %) needed two attempts before successful intubation. the duration of intubation exceeded seconds in patients ( %). of the emergency patients, ( %) were successfully intubated. six patients ( %) needed two attempts, and the duration of intubation was more than seconds in patients ( %). in % of all patients, intubation was assessed as easy. no or insufficient glow, prolonging intubation or necessitating two attempts, was noted in patients ( %). oesophageal intubation occurred in patients. conclusions: trachlight may be a valuable adjunct for intubation in varoius settings provided that adequate training is provided. a learning curve was found to exist. objectives: to compare enoxaparin and standard heparin in cavhd and calculate the value of laboratory controls in the treaanent. patients and methods: twenty patients needing dialysis for acute renal failure participated in the study. the main exclusion criteria were massive bleeding or a thrombocyte level < x e /i. in each treatment the same type (av- , fresenius ag, germany) of a polysulfone capillary haemofilter was used. the study scheme consisted of two consecutive four-day cavhd treatments, one course for each type of heparin. the order of heparin administration was counterbalanced between patients. the standard heparin was given as a continuous infusion aiming at an activated coagulation time between and s. the initial enoxaparin dose was rag every :th hour intravenously, but was modified by any signs of coagulation in the dialysis blood lines or bleeding complications. results: the dialysis treatment was adequate in both treatment modes, with mean blood urea levels . and . mmol/l respectively (ns). the bleeding complications were moderate and similar in both treatment modes. the mean life-span of haemofilter using enoxaparin as an anticoagulant was some longer than using heparin ( . + . h versus . + h, ns). the mean aptt-levcl during heparin treatment was s and during enoxaparin treatment s (ref. - s). the mean daily dose of heparin was nag, that of enoxaparin lg mg. the mean anti-xa activities were . u/mi and . u/mi, respectively, reflecting a better bioavallability of enoxaparin. conclusions: both anticoagniation modes were equally effective and well tolerated. the amount of enoxaparin needed for a proper anticoagulation was, however, less than half of that of standard heparin. the changes in aptt level were too slight to make its use possible in controliing the dose of enoxaparin. the use of enoxaparin seems to be rather safe in cavhd even without laboratory controls. the adv~ucea in the management of computerized data of an intensive care unit have been petalled to the clinical advauces and the increasing sophistication of methods of diagnosis fop the clinical application an therapy. this has led our unit to design and develop a computational system called timbu which is used to help physicians assist patients. among its various uses, this system has a software for the hemodynsmic control of a critic patient. this program was carried out to get as fast as possible the hemodynamic data of the patients in an intensive care unit. as an example, we can mention that when we load data obtained through direct measurement from the monitors and the lab, the program calculates parameters that guide, intelligently, to the diagnosis and therapeutic behaviour of the hemodynamic problem through screen messages. the validation of this program in the unit of intensive care has demonstrated that its use allows a more efficient handling of the patient with serious hemodynamics and respiratory disorders. ohieetlve: traema is a heterogeneotm 'disease' that ecatr~ a~"o~s all age ~oupe with v~ying degrees of severity. this imerogeneity has made the di~e, trmma, diflkaflt to r the ehn of this stady wa~ to assr the fitaen of saps in ibis popeleties. methode: in order to compute the ~ probability, a model derived from logistic regression w~ developed. meam'e of calibration (goodaess-of-fit stetislj.r and di~'riminafion (roc ou~e) were adopted in developmm~ and validetlon set randomly taken from a database of pts eeeseemivety admitted in icu (arohidia). ~ witho= salm, p~ yom~ am is yam, with los ~horter thma hotam wore exr fa'om thi~ mmly~ir thi~ model v~s then evahmed on the ~per ~mbgro~ (i.e., trmma pts). if'it did t~t fit the data well ~, new model wm developed rer the logit only on trm=~apm. reims: data were availabte for pts during aperiod of three .y~m , treama pts were . %), teats of calibration iadioaled probability model did mot provide m adequate refle~on of the mortality ezperieace in pm with ireutae, being the observed mortality lower flma the expected (figm'o). a aew model was then variable. this oastomized model fit~ the de~t of trmara pts very well (g =- a p> . ; roc = , ). the di:lferencea between the two modele were evident. conclusion: this ltudy shows that mortality in iramna pts is over wcfe~d when ~se~ed by menm of saps. however the r mode! meets high standmcd in terms of calibration mid dil~'iminat'~o~ ']"he advaatage of ~imd models meaas the colleotion of the ~ set of variables for all pm admitted in icu e~einat the ase of diasma specific ~oring syatex~. ("sl"): effects on cardiovascular and hemostasis systems (cvs, hss) a.oborin~ph, ~.~yndiuk~ph, b.kondratsky ~pt. of'""su~gery and transfusiology, research institute of hematology, lvov, ukraine objectives: great interest has been shown recently in the use of hoss for the initial resuscitation of hypovolemic shock. methods: the study was carried out in dogs -~h hs was induced by jet momentary hemorrhage (h) from a. femoralls (the bloodloss volume made . + . ml/kg). the treatment was begun after .u+o. hrs of h. "sl", created on the basis of-sorblt and natrium lactate ( mosm/l) was injected into v. femofalls at the dose of io. ml/kg. results: it is established that before treatmen-~rterial blood and central venous pressures (abp, cvp) diminished to . mm hg and - . + . cm h (p .o ), while heart rate (hr)-increased to . + . per min (p<.o ). by this the indices of ~latelet counts (pic) and plasma fibrinogen (pf) lowered by . % (p<.i) and . % (p~. ), while fibrin degradation products (fdp) enlarged by . % (p~ . ). after - min of treatment termination abp and cvp increased to . + . mmhg and . +o. cm h (p<.o ), and ~[r diminished to t . + . per min (p>. ). at the same time the indtces of pic and pf enlarged by . % and . % (p>.i), while fdp diminished by . % (p>.i). one of dogs survived. life duration of the other dogs was . + . hrs. conclusions: the obtained data are ~he evidence of normalizing influence of "sl" on cvs and hss, and allow to recommend it as a mean of initial resuscitation of hs in clinic. oblectives: we prospectively studied icu patients with severe head injury (hi), which cerebral lesions monitorized with sjo through opljcal fiber and the cerebral flux with tcd. methods: since january until june , we collected ht admitted to the icu, and of them monitorized with optical fiber in the right jugular bulb and tcd. all patients needed mechanical ventilation related to gcs <__ , with ct in admission (classifing lesions according to marshall and al.) . we related the final results to the evolution of sjo and tcd, with other monitorizing methods like gcs, ct and icp. ~sults: conclusions: in patients with gcs _< , sjo is useful to evaluate the evolution towards vegetative state, still more in cases with ct type ii in admission and higher apache ill. elevation of icp implies an evolutive nsk to brain death and data of tcd is a good indicator of brain death, the complete monitorization of these patients can improve the therapeutic control of this neurologic problem, , ( m, f) , (m. age: + years), divided in two groups (a and b) under specific criteria(tremor and/or fever during admission in i.c.u., or not). the injury severity score was > in all studied patients. tbe group a ( m, ") had no tremor and/or fever on admisskm, while em group b (tin, the above criteria were ix)sitive. bhx~d samplings were taken - hours after accident and - rain. after admisskm in i.c.u. micro-eli~ method was used for measuring cytokinc-levcls. statistic analysis was performed by studcnt-t test. as control group, healthy people were examined. _resu!_ts-il-lct, il-ii~, il- and tnf-tt levels were similar to control group levels in both groups a and b. i!,- and g-csf levels were found increased in both groups (p< jxjl), while il- levels were statistically significant comparing to group a. in con_tin_skin, during immediate post raumatic period,proinflamatory cylokines il-i~, il-i~ and tnf.-ct, produced in an earlier stage than ,. , cannot be detected,whereas .- was increased significantly, especially in group b. g-csf was fimnd in increawal levels in both gr(mps, without statistically significant difference between gnmps a and i|. objectives-l~valantc proteolitic activity, disorders in" eariy, period after combined trauma and p(~.ssibilit, i' of their correction by injection of proteo[ysis inhibitors contrycal and s-fto~:nracil in combination with driving an isotonic snlu~ion of sodlum chloride and polig[ucine. methods: biochemicai studies of proteolitic activity in dogs with limited deep burn and acute bloodloss, . result:s: in case of deep % burn, cornplicated by bloodshed the of blood grows at - times. it; is the restdt of the pancreas glandischemi demage, caused by the centralised circulation of blood and intensifies the deviations of haemodiaamics and albumin exchange. the degree of endogene intoxication by mean mofecular peptides which are the products of albumin decay reses to %, and % in hours. in hours after the trauma the-process is accompanied b ! , % lower inhibitory activity of blood, where as at the peak of the trauma it was , ~ higher. that proves the nnfavuurahle process of the shock in case a combined trauma. conclusion: the vein injection of 'proteolysis inhihitotz cnntrycal and -fforuraei[ in cumbination with driving an isotonic solution of sodium chloride and p.dligh]cine to refill lhe loss of blood helps to lower at times the profeolitic activity of blood. but it still remains above the initial level. the degree of endogene intoxication lowers at times; [ emodinamics aml albumin exchange stahilised. objectives: nimodipine, a known calcium antagonist, has been shown to dispose a beneficial effect on patients with subarachnoid hemorrhage, but its efficacy on traumatic or spontaneous intracerebral hematoma has not been justified. therefore, we studied the effect of nimodipine on the histopathological changes following an experimental intracerebral haematoma in rabbits. methods: twenty-three new zealand albin rabbits of both sexes, weighing - , kgr and at age of - months were anesthetized and a small burr hold in the left parietal aerea was carried out under aseptic conditions. the dura was opened and . ml (this volume assuring a normal incranial pressure after kaufman ) of autologous blood was injected into a depth of mm via a needle of . mm bore. the wound was closed and the animals were left to recover. nimodipine, of , mg/kgr of by weight per day was given via a nasogastric tube to fifteen animals for a period of time of fifteen days (group b). six rabbits were given water and served as control (group a). both groups of animals weie sacrified on the fifteenth day, their brains were removed and immersed into % formalin solution. tissue sections of ~ were embedded into paraphin and stained with haematoxyline and eosin, mason and gfap stain for gliac cells. results: two animals died after the surgical procedure, because they developed large intracerebral bematoma. no animal developed neurological deficit except one of group a which manifested a right side hemiparesis. the results of the bistopathological changes are the following: i) the mean -+ sd diameter of the lesions in the group a was --. ~t while that of group b was + ~t (p< , ) ii) secondary ischaemic neural tissue changes, characterized by the extravasatlon of red cells, the presence of haemosiderin-containing macrophages and signs of low grade inflammation zpredominated in the specimens of group a and were totaly absent from those of group b. iii) a ring of gliac hyperplasia and a low grade local fibrosis was found, encircling the lesions in the specimens of group a in contrast to those of group b. conclusions: nimodipine when administered in rabbits following the development of a non increasing the icp experimental intracerebral haematoma, prevents the extention and the severity of the lesion. objectives: to study the efficacy and side effects of adding intramuscular clonidine (clophelinum) to analgesic regimen in early management of patients with serious burn injury. methods: pts with - % bsa second to third degree flame burns (respiratory tact injury excluded) to yrs of age were randomised to study (n= ) and control (n= ) groups. burn shock was treated with hypertonic saline -bicarbonate solutions ( mmol/l na +) ml/kg/%bsa for the first hours and ml/kg/%bsa for second day. analgesia in control group for the first hours was provided by regular hourly intramuscular administration of mg of morphine sulphate and mg of analgesic -antipyretic analgin with mg of diphenhydramine (dimedrol). from the rd day regular administration of morphine was finished. in the study group ixg of clonidine was added -hourly for hours and dose of morphine halved. vas, verbal rating scale for sedation (vrs, - ), sleeping time, spo , hr, bp, diuresis, vomiting and other complications were comparatively evaluated during patients' stay in icu. results: addition of ~g of intramuscular clonidine daily allowed to achieve better analgesia and sedation with halved consumption of morphine. mean vrs in study group for the first days was . - . vs . - . in control group with twice longer sleeping time. there was significantly less tachycardia in study group; dynamics of bp for the first hours did not differ considerably; later, there, was tendency for hypotension in study group without adverse effects on diuresis or other indices of tissue perfusion. because of high incidence of chronic ethanol abuse among study population pts of control group suffered from psychomotor agitation or delirium, probably as a sign of alcohol withdrawal syndrome (aws). this made regular evaluation of vas impossible. in the study group only pt showed sign of aws. mean vas score was in . - . range for first postburn days. pts appeared excessively drowsy due to clonidine, but it had no adverse effect on their overall clinical course. mean spo values in study group were in - % range, among controls - %; vomiting was absent in. cionidine group vs cases among controls conclusions: clonidine could be a valuable addition to analgesic -sedative regimen in burns, especially for prevention of aws and deserves further study in this regard. hemodialysis -hemoflltration modifications and/or intratracheal gas insuflation have been recently used for blood gas exchange in several models of respiratory failure. objectives: evaluate the combination of cavh-m and igi for respiratory support in experimental acute lung injury. methods: five mongrel dogs ( -+ kgr) were mechanically ventilated inroom air, paralysed, heparinized, connected with a cavh-m system (diafilter- polysulphone membrane) and remained stable for one hour (pao~= . • peco = -+ mmhg, ph= . -+ . , bp= -+ mmhg and pap= -+ mmhg). all was induced two hours after oleic acid infusion ( . ml/kgr) into the pulmonary artery (poo~= . _+ -p< . , paco~- . _+ -p< . , ph= . -+ . -p< . , bp= -+ -p=ns, and pap= _+ -p< . ). fio % for the next minutes did not significantly altered the b ood gas abnormalities. afterwards, pure oxygen applied simultaneously a) through the inlet of the filtrate's compartment of the hemofilter ( l/min) while filtrate and gas were removed from the outlet port (bypass flow ml/min) b) through a thin intratracheal catheter positioned cm above the carina ( l/min). the fio given through the ventilator readjusted to %. results replacement fluids/filtrate during the next four hours were not exceed . l/hour, whilst the blood gases and pressures were improved as follow: cavh-inlet:pao.= . objective. to compare the changes in humoral immunity in trauma patients following massive transfusion of autologous and homologous blood. methods. we studied randomised clinical groups of patients each containing patients with trauma and operation of large arterial vessels. the amount of autologous or homologous blood transfused to the patients was exceeding ml, while the patients in the control group did not recieve blood or blood products. results. we recorded most pronounced and characteristic changes on the -st and on the -th day in the group of patients recieving homologous blood transfusion, i.e. decreased amount of igg,iga,igm,c and c fractions of the complement system, haptoglobin and significant and sustained rise of circulating immune complexes up to the end of the study period. in the control group of patients the decrease was weaker and lasted only during the -st post-operative day; the dynamics of the circulating immune complexes level were almost the same as in the first group of patients. in the group of patients recieving autologous blood transfusion, the parameter values did not change significantly from preexisting levels after the -st day, while on the -th and on the -th day showed a tendency towards aslight rise. conclusions. autologous blood has a favourable effect upon humoral immunity and should be the transfusion medium of choice in cases where autologous blood reinfusion is technically possible. ivan petkov, m.d., rumen farashev, m.d. and dimitar terziiski, m. d. medicine, military medical academy, g. sofiiski str., sofia, bulgaria objective. the amount of blood lost during trauma and operation could hardly be forseen and donor blood supplies are not always available in sufficient amounts. rare blood group types and/or unexpected haemorrhage pose a great challenge to the transfusion therapy and the methods of intraoperative autologous blood transfusion. methods. we report a case of a -year old male patient with extremely massive intraabdominal haemorrhage ( m( blood loss ) during an abdominal aorta reconstruction following a traumatic injury of the abdominal aorta. we achieved a successful reinfusion of ml of autologous blood using an original autotransfusion system developed by us ( pat. no / . . ) . results and conclusions. the autotogous blood in the case reported here was the only and the most suitable transfusion medium for the rapid intraoperative compensation of the acute haemorrhage and the favourable outcome of the patient. the post-operative period was smooth and no significant disorders in the clinical course as well as in the laboratory tests ( morphological,biochemical,coagulation and immunological) were recorded. there were no complications during the postoperative period despite the fact that the amount of blood reinfused to the patient was slightly exceeding his own volume of circulating blood. objective. the haemoglobin concentration and the perfusion pressure value could not be the only criteria for the early signs of tissue and organ dysfunction. because of this, we employed the extensive monitoring of oxygen transport during severe trauma in order to. achieve dynamic evaluation of physiologic compensatory mechanisms and to assess the efficacy of intensive care management. methods. we conducted a prospective controlled trial on the blood oxygenation, oxygen transport and tissue perfusion during the first days after the trauma in patients with polytrauma. we used a swan -ganz pulmonary artery catheter (beckton -dickinson, u.s.a.), deseret cardiac output computer (medical inc., u.s.a.) and hewlett -packard monitor (hewlett -packard, germany) to measure and calculate all the parameter values. the severity of the injury was assessed using the apache ii score system. all the patients had scores over . results. the results show a significant decrease in the arterial blood oxygen content and in the arterio-venous difference, as well as an increase in alveolo-arterial oxygen difference and in the transpulmonary right-to-left shunt. the tissue oxygen supply and the tissue oxygen consumption reveal a tendency towards a decrease below the physiologic minimum of adeqate values. the erythrocyte current velocity and the ratio between oxygen transport and erythrocyte current velocity also decrease inspite of the optimal blood rheology. conclusions. the dynamics in the parameters values are most pronounced between the -nd and the -th hr after trauma, which predisposes patients to the risk of developing stable hypoxemia and characterizes this period as the most critical for tissue metabolism and organ dysfunction. posttraumatic changes in immune mechanisms in lung compartment in trauma were analyzed in ao and da inbred strains of rats which differ in their immunological reactivity: the former being low responder and lat-~er hiperresponsive. methods: the levels of tnf-alpha activity in the supernatants of cultured lung lobes and dynamics of cells migration from tissue explants in h lung cultures were assessed in ao and da rats subject ted to severe burn trauma. results: increased levels of tnf activity ( + pg/ml compared to + . pg/ml in control) were found od day following trauma in lung sups of ao rats while no changes in the levels of activity of this cytokine were found in lung-sups od da rats more pronounced extent and dynamics of cell emigration were noted in da rats, while almost unchanged in ao rats sharp rise in pmn percentages h following trauma ( - % compared to rare pmns in control), followed by increase in lymphocyte numbers at later time points among lung cell emigrants was detected in ao rats. slower but persistent increase ( %, h following trauma and % and % on days and after trauma infliction, respectively) in pmn numbers among da lung cell emigrants was detected, which appeared to be activated, as judged by their nbt reduction capacity. increased percentages of peripheral blood pmns and increased state of leukocyte aggregation/adhesion were detected in both strains, but different levels of plasma tnf: increased levels in ao rats on days and following trauma, and initially but persistently high levels of plasma tnf alpha in da rats ( - fold higher compared to initial levels in ao rats). conclusions:different patterns of local (lung) and systemic changes in cell numbers and cytokine levels implicate differential posttraumatic migratory capacity of pmns vs. lymphocytes in lungs in ao and da rats. early diagnosis of acute intestinal ischemia by color doppler sonography e. danse, b.van beers, p.goffette, f.hammer,aav.dardenne, f.thys, p-f.laterre, m,s. reynaert, .lpringot dept of radiology (profb.maldague) and dept of intensive care ( prof m,s.reynaert), st.luc univ.hospital, brussels, belgium ob emergeny medical squad service is the most important segment in the process of saving the people, in the cases of mass accidents, like industrial accidents caused by the: explosion, fire, chemical poisoning, traffic accident, elemental catastrophes and the war. because of that, each emergency medical squad service needs to have in its motor-pool vehicle for the mass accidents/ for provoding at least people, wounded as well as the people became ill/. objectives: presentation of such special vehicle, produced by "zastava-kamioni" and it's medical-technical equipment. methods: descriptive and comparative analysis of the medical and technical characteristics, based on the actual norms/din, , iso , yus.../ results: on the base of doctrinaired requirements of the emergency medical squad in the case of mass accidents, our researches resulted in the following medical and technical characteristics -the vehicles for mass accidents are gvw/with a payload off cca - t, with the fixed, closed body, type: universal van, -technical equipment aggregates, stretches, anti-fire device, equipment for pitching the tent and for maintaing technical conditions of the work -medical equipment: linen bags with complete sets of bandage material, means for the reanimation and immobilization, for the infusion, medical instruments and remedies as well as the tent for lodging at least wounded and sik people. in federal republic yugoslavia, it was proposed such vehicles for the emergency medical squad needs. conclusion: we suggest to introduce this vehicle in the production range of the ambulance vehicles for saving, especially in the circles where can occur serious accidents. introduction : carbon monoxide (co) poisoning commonly generates central nervous system abnormalities though an important cardiac morbidity and mortality must be considered. long-term exposure to co with cohb levels < % may be more dangerous than short-term levels of - %. we report a case of an adolescent who after prolonged exposure to co developed a severe reversible cardiac dysfunction with low levels of bloed cohe c a.ase history : a year old boy was found comatose at home. his mother in the neighbouring bathroom died severn hours earlier of what was later proven to be a co intoxication. on arrival the gcs was / and the patient was breathing spontaneously. a postictal status with eventual postanoxic encephalopathy was suspected. a coh'b level of % was objectivated. the cardiorespiratory situation quickly deteriorated requiring mechanical ventilation. chest x-ray showed diffuse bilateral patchy infiltrates. ecg revealed signs of ischemia. severe left ventricular dysfunction was evidenced by pulmonary artery catheterisation and echecardiography and later by isotopic angiography (lvef %). treatment was intensified with inotropic support, intta-aortic balloon counterpulsation and oxygen therapy. the clinical course was further complicated by a crush syndrome and renal failure. the patient's condition gradually improved and he fully recovered without any residual lesions (lwf %) conclusion : even after prolonged exposure cohb levels can be misleadingly low. high tissue levels of accumulated co can be associated with coma and fulminant cardiorespiratory failure requiring advanced life support facilities. introduction : both neuroleptics (nlp) and tricyclic antidepressive agents (tca) can induce arrhythmias, prolongation of the qt segment and the pr interval and hypotension. we report a case illustrating that combined overdose of these agents increases the toxicity of each compound and the risk for adverse cardiac events. .c, gse history : a year old male ingested mg doxepin (sinequanr), a tca and mg prothipendyl (dominalr), a potent nlp in an attempted suicide. upon arrival in the emergency department the patient was unconscious (gcs / ), breathing superficially, and presenting signs of recent vomiting. physical examination revealed a taehycardia of b.p.m., an arterial blood pressure of / mmh g. ecg showed a brood qrs complex tachycardia. a chest x-ray revealed the presence of an aspiration pneumonia. laboratory investigation demonstrated increased levels of crcatine phosphokinase, lactate dehydrogenase and aspartate transaminase ; hyperglycemia and leucocytosis were present. the plasma concentrations of doxepin and prothipendyl were respectively gg/l (toxic level #g/l) and i.tg/l (no reference). treatment consisted of mechanical ventilation, gaslric lavage and administration of activated charcoal and iv fluids and antibiotics. a hemodynamically well tolerated veatricular tachycardia developed / h later. nahco ( meq/ h) was administrated inducing an ectopic atrial tachycardia with a normal qrs complex and prolonged qt. h after admission a normal sinus rhythm was present; the prolongation of the qt segment persisted for days. the patient fully recovered. conclusion : the treatment with nahco~, alkalizing the blood and thus increasing the protein binding of the tricyclic antidepressant molecule, can readily correct the potentially life-threatening cardiac arrhythmias and therefore should be part of the routine treatment of combined tca-nlp overdose. ob/ectives: the development of diabetes insipidus (di) in patients with brain injury is a known negative prognostic sign. the aim of this study was to investigate whether this is also a reliable early prognostic sign of brain death. methods: this is a retrospective study of patients treated" during a two year period ( - - to - - ) in our i.c.u who meeted the following criteria: ( ) coma score _< gcs within the first hours, ( ) positive brain ct scan on admission classified according to marshall's diagnostic classification (classes - ), ( ) normal renal function during the entire icu stay. for the definition of di were used the usual di criteria plus hypematriaemia (serum na" >_ meq/l). survival was defined up to the th postadmission day. conclusions: according to the findings of this study, the development of diabetes insipidus in brain injured patients seems to be a highly specific index for brain death (positive predictive value = . ). however, further prospective studies are needed for the definitive evaluation of these findings in such patients. emergency care in italy, despite all efforts, is still lacking a nationwide organized prehospital care system and, until today, there are only different regional solutions. the majority of these realities imply rather simple ambulance first-aid services without attending emergency physicians and without resuscitation equipment. the emergency medical service (ems) system in falconara m., italy, was implemented in august by a collaboration between the school of anesthesiology and intensive care of the university of ancona and the, already existing, volunteer rescuer organisation "yellow cross". according to the guidelines pubblished in [ ] the pre-existing equipment of the volunteers was completed with type a ambulances and special equiped motorcar (patient monitor, defibrillator) for ambulance indipendent physician transpur[. a special data collecting schedule was created to memorise every emergency intervention in a computerised data-base. the intraining members of the school of anesthesiology and intensive care provide hour ready intervention. in this report the authors describe their experience concerning primary firstaid medical interventions. for a preliminary evaluation we considered, retrospectively, consecutive emergency interventions in the time period from novembre , to april , . the emergency physicians treated male ( %) and female ( %) patients, patients died before hospital admission and patients ( %) were treated at home by the ambulance indipendent physician and did not need any further medical treatment. in the same time period year earlier (november to april ) without attending physician the volunteer rescuers transferred all first-aid interventions to near-by hospitals. we conclude that the presence of an attending, iudipendently motorised physician in emergency interventions is essential for the establishment of precise priorities and may be helpful to reduce hospital admissions by ambulance intervention, though reducing primary" health care costs. we have developed the method of liquor filtration which allows to purify the cerebrospinal liquor from blood and its decay products in the subarachnoid bloodstroke. the hemipermeable dialysis membrane was used as a filter, which lets only in water, electrolytes and substances with small molecular weight. the liquor filtration was used for the treatment of patients with the subarachnoid bloodstrokes of different etiology. the perfusion of liquor was performed at the rate ml/min in the recirculatory mode. its duration was - min depending on the bloodstroke intensity. the filtration makes possible the most completely purifying of the hemorragic liquor, the reducing of the content of blood ceils and its decay products - times as less. the monitoring of the patient's state during the perfusion didn't revealed the departure from the norm of the main vital part. the liquor filtration technique compares favo-~ rsbly with the routine method of cleaning by the absence of toxical effect of heterogenous solutions on the central nervous system. the filtrstion of the cerebrospinal liquor in the subarachnoid bloodstroke sllows to provide the the early cleaning of liqour, the regression of meningeal syndrome and to improve the patient's state of health. e tabli~mczr bd ~ of rei~idnal medical first-aid zhoulittoing, ed., tan zi, m.d. dept. of sargery, the first teaching t[ospitat, yejin-l)a-l)ao, wuhan fltlna objectives: the medical first-aid is the most important task of the public hc atth department. in general, single hospital model couldn't fatty, effective ly rescue mony severe patients who need mergant treatment in the scene. bub establishing the medical first-aid network, the severe patients can be given the most timely und the most scientific emergent treatment. so that, the suc cessfut rate of the saving wilt be greatly increased. methods..; our hospital is a general big hospital. through developing and cons tructlng for more than ten years, the medical first-aid network distributed art over the area under our jurisdiction has been set up. it consists of thr ee units: the medical first-aid unib center comartd and mnagment unit, co m~nlcation and tiaison unit. the principle of the network operation is with oat having to far to mergoncy, specialized emergency and the best merge acy. results: the results of the network operation were notable. cmpari~ the to tat successful rate of the saving ( . ~), the successful rate of saving tra ma ( .~), the suscessfut rate of saving shock ( .~) and the successful rate of cardioputmonary resuscitation ( . ~) daring the three years after t he network operated with these before ( . ~), ( ]. ~), ( . ~) and ( ft. ~), the successful rates after operating were remrk~iy higher ( p<i).o ). conctusions~ the above results showed estabiishmnt and mena emont of region at medical first-aid network had very si~nificont action during mergentty s avin the severe patients. moreover, the regi~at medical first-aid network atso take an important part in prevention and health protection of the mass. objectives: se related mortality is due to the occurrence of both rv and lv dysfunction evoking cardiogenic shock and pulmonary edema (f. abroug, intensive care med ; s. nouira. chest ) . prospective evaluation of scorpion antivenon (sav), the only available specific treatment, is lacking. the aim of this study is to assess the effects of sav on the basis of a case-control study. methods:among consecutive victims of se presenting to the emergency department, were managed using sav (group sav+). these patients were matched to envenomated patients who did not receive sav (group sav- chest injuries are the cause of death in % of trauma fatalities and a major contributing factor in an additional %. pneumothorax is a major complication of chest injuries and can be initially overlooked bringing to additional morbidity and mortality especially in patients who require mechanical ventilation. the real incidence of pneumothorax in severe blunt chest trauma hasn't yet been established, as many pneumothorax can be missed on the initial chest x-ray (cxr) and computed tomography (ct) has not been routinely used. to evaluate the incidence of pneumothorax in patients with severe blunt chest trauma. methods: a prospective study. from january to december , all trauma patients with one of the followings conditions: fractures of four or more ribs, signs of lung contusion on the initial cxr or presenting a severe hypoxemia on admission (pao /fio < ) in the absence of pre-existing pathologies, were evaluated by initial cxr and subsequently submitted routinely to a ct. results: severe trauma patients were considered. of them, presenting a severe hypoxemia on admission, had no evidence of major chest trauma (ais< ). hypoxemia was the consequence of severe trauma in other districts; these patients were therefore excluded. patients with severe thoracic trauma (ais>= ) were admitted into the study. the mean iss was . ( - ). thirty-six patients required artificial ventilation for at least hours during the icu slay. three of them, who had a tension pneumothorax, were submitted to an emergency thoracic decompression on the field by the emergency helicopter team. in cases pneumothorax was diagnosed an the initial cxr more patients had a pnx which was identified only on the ct. in cases a large pnx with lung collapse was missed on the cxr. in our group of severe blunt trauma patients, % ( / ) presented a pnx that required the insertion of a thoracic drainage. only one third ( / ) of the pneumothorax could be recognised on the initial cxr, while other were decompressed before performing the cxr. as many as % of the cases of clinically significant pnx were missed on the cxr, and a ct performed soon after admission allowed an early diagnosis bringing to changes in the treatment. (as the patients were mechanically ventilated a chest tube was inserted in all these cases). in cases, the initial cxr overlooked a huge tended pnx which was the cause of hemodynamie instability. conclusion: in patients with severe blunt chest trauma even large pnx can be missed on the initial cxr. moreover due to the non compliant compressible lung, a % pneumothorax which can be recegnised only on a ct, can bring to high intrapleural pressure altering eardiopulmonary function. n. andoeli , .~osid, m.zesevid, m.risovid, d.stepi , d.djokid b~rga~yc~qterclinicalcaqterafserbia, belgrade cb~ctives:~lis study ~ the use of ~rq]ofol earbired with k~t~ine (aq a~sjgh~ic s@~qt widn inirjrsic armlgesic pro~mities) or with fsqtmtyl,with psrtial azgmsis an hgenxlyn-a~ic ~ durirg ~ ~ re:~ver~ f~m ~ in hxh ~ of ~ti~. ~: yali~mial and ~bod: a~it p~tie~ts a~ i-ii were included in ibis shxly. patients were rsrd]nly dieided in two ~ns. all d~tie~ts ~me given - prcpofol bolus doses (o, ~gkg) for ird~iqn of ~. ~ia ~s m~sjn~ with an infusion ~ ~ropafol. as sdflitianal were given fan-i~l (o, n]g) ~tely before ~ anj trad~e~ irfojoation followad by feasted bolus of o,i mg in ~ro o l.patients in gr~ o received i~ (an initial bolus dose of rg slowly intcavax~ rd mg as infusion over ~ rain) .infusions of pro~fol or imcpofol with kg~mine ~ stopfsj - rain ]:~o~ extuhation.arterial blood ~ (sistolic arterial blood preassu-re~zap,mean ~rterial blood pr~,d~lic arterial preassure-[zp a~ h~art rate-~) ~ m~ before induction of a~ io, snd rain aftem ~ intutation. results: arterial blood preasstre ~s decreases duri~ irn~ction of sn~wd~sia in hy~ ~n~s,tnt mare in th~ ~ who r~eived fsqtanyl.~ere w~s statisticslly sifnific~ntly difemerme dmir~ m~ of an~ia. arterial blood r~easatre and heart rate were stable in the t-..e~min -~a ~. all th~,fl-e keta'nire grcqo hsd e~rly :~e~y time. ctrmlusi~s: ~e ombiretion of protxfol wilh keta/ne for irduorion a~d ~ of sn~sd~esis w~s yell accept~ by p~tierfcs anj coald he ~ as an alterrstive ~o ccnva~icrsl a~es -d~sia. objectives : assess the relation between cytokine or endotoxin release and indices of splanchnic malperfasion after hemorragic shock in multiple trauma patients. ]~r study was approved by the local ethical committee. trauma patients admitted to the emergency room who met the entrance criteria of more than hour map < mmhg or use of vasoactive agents or blood lactates > mmol/ were selected for study. a nasogastric tonometer (tonometrics, inc, plastimed, france) and a swan ganz catheter were placed on admission. phi, lactates, hemodynamics, plasma cytokine and endotoxin concentrations were measured on admission and at . , , , hrs. an immunoradiometric assay was used to determine plasma concentrations of il (n< . ng/ml) and tnfc~ (n< pg/ml). plasma endotoxin concentrations were measured using a chromogenic limulus assay (n< . eu/ml)( endotoxine unit= pg). results : severe multiple trauma patients (age = _+ yrs, iss = -!-_ , saps = +'~, mean-+sd) were studied. they received + packed red cells during the first h. mean duration of collapsus before inclusion was . _+ . hrs. death occm'red in ~tients. ~ pglml, *: ng/ml, etox : endotoxin(eu/ml), lact: lactate (retool/l) a significant correlation between initial il level and saps was observed. in the early post-injury period phi, sao , svo , vo were significantly associated with ;il release (p< . at ho, h , h ). later a significant correlation existed between lactates and ii (h , h ). a peak of tnf was detected at and hrs. it was associated with low phi and low arterial ph of the early post-injury period (p< . iat ho, h , h ,h , h ) and with high lactate levels of later period (_>h ). only the late release of endotoxins (i{ ) was correlated significantly with initial !oxygea-delivered parameters. iconclusion : there was a marked increase in il in the early phase of trauma . i and tnf release after major trauma iwith hemorragic shock is associated with splanchnic malperfusion, as assess by the ivery low values of phi. lactates seem to be a later indice. toxic effects are a well-known complication of an overdosage of prescription theophylline. what is less known is that over-the-counter (otc) asthma medications contain theophylline, and that in some cases this might cause toxic effects. a case seen by us involved toxic effects from theophylline in an otc medication and to date is the only published case in the english literaturet the rationale for this study was to delineate the otc products containing theophylline from whatever data sources available. hyperthermia frequently occurs in intensive care treated patients and intentional application of whole body hyperthermia together with chemotherapy is a therapeutical access to treatment of malignant disorders. anaesthetic support is required in either condition. due to the marked decrease in systemic vascular resistance seen in hyperthermia an additional vasodilatory effect of the anaesthetic is unwanted. the vascular effects of anaesthetics in hypertherm organisms is not known in detail. therefore, we performed an experimental study to detect the effects of inhalational anaesthetics in whole body hyperthermia. in sprague-dawley-rats katheters were inserted into trachea, jugular vein, and carotid artery. for continuous monitoring of cardiac output a flow probe was placed around the aortic arch. the rats were mechanically ventilated with different concentrations of inhalational agents in oxygen. we compared the effects of enflurane, isoflurane, and halothane in stepwise increased body temperature by submerging in a temperature controlled water bath. results: isoflurane lowers arterial pressure more than halothane or enflurane. the inhalational anaesthetics lower the cardiac output similarily and independently of temperature. isoflurane decreases systemic vascular resistance independently of core temperature and the decreasing effect of halothane on the resistance is completely abolished in hyperthermia. conclusions: the influence of hyperthermia on the systemic vascular resistance is dangerous. this allows no additional effect of the anaesthetic management. in spite of the vasodilating effect of inhalational agents in normotherm subjects, this effect is abolished in hypertherms using halothane. the condition of management of analgosedation in hyperthermia is different from normothermia. objectives: to evaluate a bedside computer processed cerebral function monitor for assessment of brain wave activity when clinical/visual clues are not present. methods: ten icu patients undergoing neuromuscular blockade monitored with the aspect brain wave monitor from january to june , . results: time to onset and depth of sedation were readily apparent to icu physicians not specifically trained in eeg reading. objectives: to determine whether non-depolarising neuromuscular blockade reduces oxygen consumption (vo ) in sedated, apnoeic patients. methods: haemedynamic. metabolic and oxygen transport variables were determined in sedated, apnoeic patients with severe acute lung injury. all patients were ventilated using a puritan-bennett ae ventilator with integrated metabolic monitor. inclusion criteria were; ) stable cardiorespirator s" status; ) systemic and pulmonary artery catheters already in situ; ) inspired oxygen < %. patients were sedated with midazolam or propofol to abolish response to verbal stimuli, and sufficient morphine or alfentanil to abolish all spontaneous respiratory efforts. following baseline measurements, neuromuscular blockade was induced with intravenous vecuronium, ug/kg, followed by an infusion of ug/kg/h to maintain the train-of-four ratio at . a further four sets of measured and calculated variables were obtained at min intervals. results: statistical analysis was by repeated measures anova. there were no significant changes in any variable over time. the changes in calculated oxygen consumption (vo fick) , and measured oxygen consumption (vo gas), and in energy expenditure (ee), are shown in the table. objetive: to study the effects on coronary hemodyrtamics and myocardiai metabolism of administering propofol during postoperation sedation of patients with normal coronary circulation and good ventricular function undergoing cardiac surgery. patients and methods: patients ( women and men) undergoing aortic and/or mi~-a/ valvular cardiac surgery were selected, with an ejection fraction greater than . and normal coronary circulation. for postoperation sedation propofol was administered in . mg/kg i.v. bolus, followed by a . mg/kgth perfusion. all data were registered before administering propofol and after minutes, the patients being hemodynamically stable and a rectal temperature of _+ . -~ systemic and pulmonary hemodynamics, and global, as well as regional myocardial blood flow, and metabofic variables were measured. results: the patients studied were about years old, and the average period of aortic cross-clamp was . min. the adminstering of propofol caused a decrease in the coronary blood flow (- %), great curonary vein flow (- %), myocardial oxygen consumption (- %), regional myocardial oxygen constanption (- %), myocardial oxygen extraction (- %), regional myocardial ooxygen extraction (- %), while coronary vascular resistances and global coronary vascular resistances did not change. oxygen saturation increased in the coronary sinus (+ %) as well as in the great cardiac vein (+ %). in no patient were significant changes suggestive of myocardial ischemia objectified. there was also found a decrease in systolic (- %), diastolic (- %) and mean (- %) arterial pressure, systemic vascular resistance (- %), and cardiac output (- %). conclusions: in accordance with the clinical conditions of this study, the administering of propofol is not likely to cause changes in coronary autoregulation, oxygenation and myocardial metabolism. obietive: analyse the effects of . % "end tidal" isoflurane (sedative dosage) on the metabolism and coronary hemodynamics during the postoperation period of patients undergoing cardiac surgery. patients and methods: patients ( women and men) undergoing aortic and/or mitral valvular cardiac surgery, with an ejection fraction greater than . and normal coronary anatomy, were selected. after the surgical operation, . "end tidal" isoflurane was administered for postoperadon sedation. the determination of variables to be studied was carried out before and minutes after administering isoflurane, die patients being hemodynamically stable and a rectal temperature of _+ . -+c. systemic and pulmonary hemodynamics, and global, as well as regional myocardial blood flow, and metabolic variables were measured. results: the average age of the patients studied was -+ . years. during surgical operation the period of aortic cross-clamp was . _+ . rain. the administering of isoflurane was followed by a statistically significant drop in coronary perfusion pressure (- %), coronary vascular resistance (- %), regional coronary vascular resistance (- %), regional myocardial oxygen consumption (- %), regional myocardial oxygen extraction (- %) and accompanied by a significant rise in oxygen saturation in the coronary sinus (+ %) and in the great cardiac vein (+ %). myocardial oxygen consumption, myocardial exu'action of lactate and regional myocardial lactate extraction did not change. in no patient were enzyme or electrocardiograph changes objectified. systolic (- %), diastolic (- %), mean (- % ) arterial pressure, and systemic vascular resistances (- %) decreased, while cardiac output did not. discussion: the administering of . % "end ddal" isoflurane, in the clinical conditions of this study, produced a decrease in systemic arterial pressure due to a reduction of systemic vascular resistance without deteriorate cardiac output. at coronary circulation level, has and effect on coronary autoregulation but had no effect on oxygenation and myocardial metabolism. the idea of tiva implies the realisation of major anesthesia components (los of consciousness, neurovegetative inhibition, analgesia, myorelaxatiou, providing the adequate gas-exchange) through i.v. introduction of drugs exclasively. aim: providing for the main tiva components with minimal side effects of the drugs used, taking into consideration the patients characteristics and the surgery specific character. methods: anaesthesias have been conducted in patients aged years ( females, males), undergoing planned and urgent operations with the pathology of lower, extremities, perinaeum, small pelvis, hypogastrium and with reserved spontaneus respiration against a background of % insnffladon through mask. operations lasted from . - . h. anaesthesia adequacy was assested by constant monitoring: "cardiocap" (nibr hr, rr, sao , t), through glykhaemia level and mimicry reactions. standart premedicatioo of m-cholinolytics ( . mg/kg) and h -blockers ( . mg/kg) on the operational table was sumplemented by administration of . - . mg/kg of lidocaine, . . mkg/kg of clonidine, . - . mg/kg of pentamidine by the tachifilaxia method. the premedication adequacy was assessed through haemodynamics characteristics. sedation: . - . mg/kg of droperidoi, .l- . mglkg of diazepam and analgesia: - mkg/kg of phentanyl, . -- . mg/kg of ketamine were introduced fractionally according to indications. infusion rate of ringer-lactat solution was - ml/kg/h and depended on the intraoperational blood loss volume and on the patients preoperational condition. the duration of postoperative analgesia was registered. results: clinical assessment of analgesia according to this techniques allowed to decrease the anaigetics dosage to the subauaesthetic levels. smooth stabilisation of haemodynamics (bp) at proper age norms in patients with the initial hypertension by the -th min. of anaesthesia as well as the absence of its increase in response to the additional introduction of anaesthetic have been achieved. (hr) had no abrupt changes and remained in the range of - per rain. adequate external breathing: decrease (rr) by - per rain., with sao increase from % to - %. hypoventilation was avoided by respirate ventilator. according to unauthentic data the glykhaemia level had been lowered by -t % to the end of the operation with the initial moderate hyperglykhaemia of up to mmol/l the cutaneous covering grew warm and got pink colouring. no mimicry reactions. in the postoperative period patients were in the superficial sleep state ( - ) and analgesia lasted - b. there were no complications due to anaesthesia. conclusion: combined using of bz, opiates, neuroleptics potentiate the i.v. anaesthetics effects allowing lowering of each tiva component dosage and, as a consequence avoiding their negative influence on respiratory and heart vascular systems. complex application of adrenergetics (therapeutic doses of cionidine and pentamini with using of taehfilaxy effects) permitted to provide for analgetic and neurovegetative components of general anaesthesia under subanacsthetic doses of tiva main components, and manifestation of hyperdynamic reactions of haemodynamics decreased while using of lidocaine -the economicai activity of heart-vascular system. good level of muscle relaxation was achieved allowing for widening of surgical intervention extent without respirator ventilators and inhalation anaesthetics application. anaesthesia is easily controlled due to fractional introduction of drugs with quick recovery of cns functions after anaesthesia. postanaesthetic analgesia is increased while concurrent opiates doses are decreased. absence of marced haemodynamic, endocrine and metabolic reactions during the operation and after it resulted in shortening the period of patients staying in hospital. a yo white man was admitted to hospital for dyspnea and a productive cough. he had cabg in past, but no recent cardiac ischemia. physical exam: decreased breath sounds over right lung. chest xray: consolidation of right lung. admission medications included diltiazem, furosemide (both were continued) and trazodone (which was discontinued). admission ecg: sinus rhythm, qt . /qtc . sec, with st and t wave abnormalities similar to prior tracings. he required intubation and mechanical ventilation for progressive hypoventilation and hypoxemia. between icu days and he received haloperidol, - mg/d (cumulative dose rag) for agitation and delirium. icu day : qt . /qtc . sec. icu day : for better control of delirium, trazodone " mg q hs was added. icu day : he developed frequent nonsustained ventdcular ectopy. icu day : qt . /qtc . sec, pha . , paco mm hg, pao mm hg, k . meq/l, mg . meq/l. later in icu day the patient had brief episodes of torsades de pointes, each responding to precordial thump, and finally rhythm stabilized with i.v. lidocaine and magnesium. haloperidor and trazodone were discontinued. ecg was unchanged and myocardial infarction was ruled out. next day, icu day : qt . /qtc . sec. torsades de pointes, a form of ventricular tachycardia characterized by a twisting qrs axis, is commonly associated with qt prolongation. haloperidol is used frequently in icu for control of agitation and delirium, with reported doses up to mg/day. over past decade, cases of torsades de pointes with prolonged qt related to haloperidol have been reported. trazodone may also prolong qt and cause ventricular arrhythmias, especially in patients with pre-existing cardiac disease. in this patient, trazodone likely exacerbated qt prolongation from halopeddol leading to torsades de pointes. critical care physicians must be aware of this interaction. it is imperative to follow the qt interval for patients receiving halopeddol, especially when another drug also known to prolong qt is added. one must consider discontinuing the drug when qt/qtc becomes prolonged. objectives: analgesics and intravenous anesthetic drugs are routinely used in critically fll patients, who often suffer from a secondary impairment of the immune system. previous in vitro studies have demonstrated inhibitory effects of these drugs on polymorpho nuclear cells (pmn). the potentially important role of endothelial cells (ec), however, was not investigated, since suitable test systems were not available until recently. therefore a physiologically more relevant in vitro migration assay through cultured human endothelial cell monolayers (ecm) we established. using this assay system, the comparative effects of fenlanyl, sufentanil, propofol and the known pmn inhibitor thiopontal were tested. methods: human umbilical vein endothelial cells (huvec) were isolated and cultured on microporous membranes (cyclopererm) until an ecm was grown. pmn from male and female volunteers were separated by standard procedures. ecm and pmn were preincubated with clinically relevant concentratious of thiopental ( m), propofol ( p_g/ml), the solvent of propoful (intralipid), fentanyl ( ng/ml) and sufentanil (sng/ml). after preincubatiun (ecm minutes, pmn minutes) with the reslx~tive drug, leukocyte migration towards the chemoatfractant fmlp ( o - m) was measured in a two chamber well system for hours. the migration rate of untreated (untr.) and treated (treat.) pmn through untreated and treated ecm were determined. as a control untreated pmn and untreated ecm were used. results are given as means from independent duplicate determinations and expressed as a percentage of control (table) . statistical analysis was done with student's t-test. results: clinical concentrations of fentanyl, sufentanil and prupofol showed similar inhibitor~ effects as the known pivin inhibitor thit e ). % conclusions: for the first time we could show that analgesics and anesthetics exert their inhibitory effects not only on pmn, but mainly on the interaction of pmn with endothelial cells. moreover, we could shmv a significant suppressive effect of the opinids fentanyl and sufentanil on both ec and pmn. the known inhibitory effect of thiopental obtained in ec-free test systems were also confirmed in our physiologically more relevant assay system. objectives: to investigate when and how sedation is used in a consecutive cohort of patients admitted in a large sample of italian intensive care units (icus), gathered in a network named giviti, representative of the italian icus system. methods; the study called for a recruitment period of one month, from january to february , , data collection included age and other demographic variables, acute diagnostic broad profiles, severity of illness scores, treatments, lenght of stay and vital status at icu discharge. as concerned sedation, each patient was observed until discharge or for a maximum period of seven days. information on all the drugs used for analgesia/sedation, the route and modalities of administration, the timing, dosages and purpose of the administration have been recorded. results: the study involved the cooperation of icus, of which enrolled at least one case. the total sample included patients. overall, . % of patients analyzed (t / ) received at least one prescription of sedative during their stay. globally, at least one sedative drug was prescribed to these patients in days in icu. although over drugs were reported to be used, pharmacological principles accounted alone for % of all prescriptions. opioids were actually used in % of prescriptions; propofol in % and benzodiazepine in . %. as regards the way of administration, intravenous administration was applied in % of cases and, followed by intramuscular in . %. moreover, non-steroidal anti-inflammatory drugs (nsald) were used in % of patients and neuromuscular blockade agents (nmba) in %. detailed analysis on certain subgroups (surgical, trauma, ventilated patients etc.) have been also carried out in order to describe the practice of sedation in these peculiar subgroups. findings will be widely discussed during the presentation. conclusions: these results should be interpreted keeping in mind how peculiar is the intensive care setting compared to many other less complex settings of hospital care. in conclusion we thought it was important to present the data currently available in the most neutral form, to start moving in a direction which will enable us -by means of more specific and detailed studies, and with the cooperation and involvement of all those participating in the project -to shed light on one of the many aspects of medical practice in the field of intensive care which deserve closer attention. introduction: the aged run perilously high risks in cardiac surgery: among others, of haemodynamic fluctuations, respiratory depresskm and organ failure. response to anaesthetics is a crucial determinant for post<)perative complications, none the less being reintubation due to mechanical ventilation difficulties which increase morbidity, mortality and intensive cdre unit (icu) stay. objective: we wanted to assess our a,aesthesia window (selection, and a view of the induction -extubation period) for predicting safe and swift awaking, thus: icu dismissal for the aged. methods: in , selected patients (pts) (> y, f) followed a regular elective cardiac surgery protocol (propofol given at precisely designated time intervals). upon cu arrival, they were subjected to an admission protocol. our predictive criteria for early extubation at h included: a) alertness and ready response to commands; b) adequate gag reflex and sufficient protection for respirak)ry tract; c) pao > mmhg with flu < . ; d) stable ph> . with spontaneous respiration; d) stable haemodynamics without dysrhythmias; e) adequate perfusion and diuresis (> .(i ml/kg/h); f) mediastinal bfeeding< ml/h for at least h; g) normothermia (core temp> ~ and no shivering). subsequent reintubation was for: ) rr> /min; ) spontancx)us ventilation for rain with paco > mmhg; ) pao < mmhg with fio > . ; ) ph> . ; ) heart rate>] bm; and/or ) non mental alertness; and ) other medical disorders, after which adequate weaning therapy was necessary. then, successful weaning after h was considered: ) spontaneous breathing without any forrn of mechanical assistance; ) stability in haemodynamics; and ) elimination of fever threat. results: pts ( %) were extubated at h without complication; other pts ( %) at h but had to be reintubated because they were hypoxic and began weaning therapy; finally, they were all re-extubated by h. only pts ( %) proved problematic. conclusion: a,aesthesia wimhlw options (selectkm, extubation, reintubation and weaning) predicted quick (times propofol administration) and safe (rigid criteria) extubation ( %= h and %= h), exempting pts with developed post-operative complications ( %=extubation< h) unrelated to al~aesthesia window or icu protocol. dismissal and recovery then became an abbreviated question of time. fifisetll p, domeneg~i ~, sforzini i., veronesi i~, maconi a.g. *, breg~ massone p.p h [] ic+pca request conclusions:using e~aprenorphine, a synthetic,long-acting, ago-antagemist opinid drug as analgesic, in the major surgery we obtained the best clinic results with association of conttheus infusion of haft dose drug with bohts of pca in the first - hours and just pca in the secmad day after surgery when the patient is less sleepy. in this way we dent have a great sav~g of suppled drug but the major well-belng of patient without ~erious side-effects and quick mobilization; the dosage used don't compromise a good awake of patient: all patients are sleepy but ready for answer, no allueinatian, bradipnea but not less than b/m without ipoxia. also the patient proffered this kind of truit meut than the traditional at demand. the ward staff feel it useful] and rehabl~ the negative feed-back technology of the electronic infuser system makes possible to use it safe in the ward with high drug's concentration too. the infusion rate of low dose of drug assure a continuative analgesic covering ~n the first postoperative periad; the pca mode involves the patient him-self in the managemenl of therapy and enables him to choose the best way to confront the dll~icuity of postoperative period without call medical stall using pca-device we have had no probicm~ no accident. analgesia during extracorporeal shook wave lithot ripsy a .levit, b.grinbezg regional hospital, ekaterinbu~g, russia b~ectives: our task was to compare ~he analgetic effect of norphin and tramel. methods: study was made of two groups of uro-li~patients aged - . group a ( patients) received baprenorphine hydrochloride (norphin) at dosages of #. • mg/kg. group b ( patients) received tramadel hydrochloride (t~aasl) st dosages of . z . mg/kg. before the procedure diazepam was administrated i.v. ( . ! . mg/kg). blood saturation (spoz), hemodynamics incides (bp, hr,sv,co,sap,svr) were examined and the patients' subjective assessments of snsesthesis quality were analyzed. the hospital ethics committee approved the investigation. results: when using norphin hr increased by . % on the onset of the procedure while sap and sv decreased by .%% and . %, respectively (p< . ). however, there were no reliable co chsnges. spoz ~educed by @. % (p< . ) and remained lower than the initial one after the procedure was oyez. when administrating tramsl min. after ste~ting the procedure sap and svr increased by ~ . % and . % respectively. sv and co decreased insignificantly. nine patients in group b saffeting some dlscomfo~t needed additional tm~msl in~ection. in the course of the whole p~oced~e spo, was constant and was highez than that in ~he case of nozphin (p<o. ). conclusion: respiratory suppression by no~phin can limit its use in case of lithotzip@y while the advantages of tremsl a~e: lack of dyspnoe and good contact with the patti-b_ the role of uncommon agents of antinociception, placed epidurally, in the control of pain transmission in the spinal cord is well documented. somatostatin as an inhibitory agent is found in the dorsal horn of the gray matter of spinal cord. the effects of somatostatin is similar to the opiates if injected into the epidural space (ref. i, , , ) . the aim of the present study is to present the clinical effect of above mentioned palliative therapy in the case of cancer and non cancer pain. informed consent had been obtained from every patient before treatment was initiated under the legalisation of the local ethics committee. using the permanent epidural catheter and continuous infusion pump, we administer somatostatin in the dose of up to microgram per hour for one up to three days. the patients paln feeling was evaluated using a vas (visual analogue scale). we found that the opiate resistant pain level decreased by %. the rest pain could be controlled by pereral opiate analgetics or by combination of somatostatin and an opiate plus a local anaesthetic agent epidurally. theoretically, it seems that epidural administration of somatostatin and local anaesthetic agent is useful in the control of acute pancreatic pain and systemic effect of somatostatin is beneficial in the treatment of acute pancreatitis. few studies have been performed in the critically ill (ci) and because of the complex pharmacodynamic and pharmacokinetic changes that occur, it is difficult to predict accurately drug responses and interactions in individual patients. midazolam (m) is a watersoluble benzodiazepine with a rapid onset and short duration of action in normal individuals; however its metabolism is decreased in the ci. critical care physicians every day experience suggest that among the ci there is a different pattern of response to m; here it is hypothized that such a response could be due to different metabolic behaviours of ci. m (i.v.infusion rate - rag/h) and antipyrine ( rag p.o.) were infused to ci with ( patients -group ) and without ( patientsgroup ) endotracheal intubation. blood samples were collected at fixed times during and after m infusion. total urine nitrogen and antipyrine elimination half-life demonstrated different metabolic characteristics in group chypermetabolizer") as compared to group chypometabolizer"). results follow. the results of our study are preliminary and more kinetic data in critically ill patients are needed to statistically confirm our approach of "hypometabolizer" and "hypermetabolizer". objectives: some clinieai and experimental studies suggest that propofol decreases myocardial contractility in coronary artery bypass grafting (cabg) patients. the intrinsic negative inotropic action of the drug may be independent from changes of preload and afterload, whereas the myocardial depression induced by propofol may depend on changes in ca ++ ious availability. aim of this study was to verify the hemodynamic effects of propofoi in a group of cabg patients with uneompromised contractile function and to minimize myocardial depression, during induction of anesthesia, choosing to associate calcium chloride (cac ) in an other group and to define its role in producing this effect. methods: fourty patients, randomly divided in two groups ( pts a and pts b), undergone elective cabg, were enrolled in this study. anesthesia was induced by senior anesthetist in both groups by means of fentanyl mg• kg < in ", pancuronium . mg x kg - and propofol mg • kg - in ". a blind investigator administered via another venous way at same speed ( ") saline in patients of group a and mg x kg - cac in patients of group b. hemodynamic data (heart rate hr, mean arterial pressure map, mean pulmonary artery pressure pap, pulmonary capillary wedge pressure pcwp, central venous pressure cvp, cardiac index ci, stroke volume index svi, systemic and pulmonary vascular resistances indexed svri and pvri) were obtained at baseline (to), ' after anesthesia induction (t ) and " after tracheal intubation (t ). results: hr decreased moderately in both groups (p = ns). map decreased as well, more markeatly in group a at ti and t . this trend was statistical significant (p < . ) in both groups. pap, pcwp and cvp unchanged following induction in any of two groups. ci decreased in group a (p < . ) dramatically dropping at t , while in group b it showed a negligible decrease at t (p = ns) and value similar to baseline at t . svri and pvri did not exhibit statistically significant changes. conclusions: the use of propofol as a starter of anesthesia in cabg patients allows to reduce total dose of fentanyi, dramatically reducing post-operative intubation time. propofol-fentanyl association prevented the hyperdynamic response to stress (i. e. laryngoscopy, intubation) but severely depressed ci and svi. cac simoultaneous administration effectively minimized the negative inotropic effect of propofol. moreover no unwanted side-effects due to cac were observed. diseoordinated labor activity (dla) is one of most serious in obstetric pathology.medication sleep effect to a woman in birth is of limitation of pathologic impulsation from the central nervous system, but it does not influence processes resulting in and supporting dla on the organ level. constant discoordinated uterine contractions during medication sleep (ms) imerease disturbances of uterine blood flow, organ hepoxemia connected with hyperergia of vascular wall and myometrium to catecholamines, that reduces efficiency of anesthesiologic protection. we applied hexoprenalin in complex with ms to primaparas. efficiency control was being accomlished through hysterograms, grade scale of analgetic effect where hemodynamics reaction to pain, significance of emotional reactions and their vegetative manifestations before and during ms were registered, and also through hydrocortisone level in plasma before and during ms. the examined women's average duration of ms was hours more than in control and made hours, though their average labor duration and in control was the same and made hours. % of the examined women experienced independant labor, as for the control group -only %. supplementary methods of anesthesia were required in % in control,that increased medicamentous depression of the fetus, but for the examined group -only in %. the examinees's newborns experienced favourable terminations, in control newborns were in state of light rate asphixia. analgetic effect was complete in control just in i %, and of examinees -in %. on the women's hysterogrnms before ms discoordinated contractions were registered on the background of increased tonus. during ms in control similar uterine contractions were constantly registered, but for the examinees they were not marked at all or had the proper character. the examinees' hydrocortisone level was reduced for % and in control only for %. the study has allowed to make a conclusion that hexoprenalin applications in complex with ms in case of dla make anesthesiologic care safer and more effective, promote simultaneous removal of patholgic processes in the central nervous system and uterus, which lead to dla development. objectives: the aim of report is to present a clinical study results for the evaluation of anesthesia for a patients in unconscious states by eeg examination: methods: the study was conducted on patients after a severe abdominal operations on stomach and intestine and on one patient after traumaticat exarticulation of upper extremity. all patients have different unconscious state levels from somnolence to coma ]. also thay hav~ had respiratory insufficiency and control mandatory ventilation have been used. we were used intrave,~ous injections of morphine hydrochloride from initial dose of mg. than we were increased the dose to mg i.v. by drops with an accompanying eeg monitoring and fourier spectral analysis. initially all patients have had -rhythm with slow and a-activity. an c~-activity index have been lower than %. results: after anesthesia the o-and a-activity have disappeared. the or-activity index have increased to %. also we have noted decreasing of the unconscious state levels to a possibility of a verbal contacts ( - points gcs). conclusion: the quality of anesthesia could be evaluated by eeg monitoring. a regaining consciousness afte~ the injections of high doses of morphine, probably, may be a result of an opiate deficiency (full or partial). anesthesia with the following drugs: clonidine, l-arginine, l-n-arginine-methyl-ester (l-name), and their combinations. tail-flick latency (tfl) was determined at time zero and min after each treatment. clonidine (i- ~g/mouse) prolonged tfl in a dose-dependent manner. at a clonidine concentration of gg/mouse, tfl increased . -fold compared to time zero. l-arginine increased tfl at a high concentration (i gg/mouse). l-name suppressed tfl . -fold compared to time zero at a concentration of gg/mouse. conclusion: we have found that no is involved in clonidine spinal analgesia. studies are currently being undertaken to assess the effect of combination treatment of the above drugs on clonidine supraspinal analgesia. objectives: hemodynamic changes ussualy accompany laryngoscopy and tracheal intubation.the aim of this prospective study vas tu present the effectivness sufentanil in preventing reflex circulatory respone of laryngoscopy and tracheal intubation and provides stable hemodynamio condition for induction of balanced anaesthesia. methods: adult asa i-ii patients sheduled for elective surgery.they were allocated randomly and divided into two groups:fifteen patients received single bolus of placebo prior to laryngoscopy.and tracheal intubation. anaesthesia induction was then performed with thiopental (smg/kg) and atracurium ( , mg/kg), followed by neurolept anaesthesia. mean arterial preassure (map) and heart rate (hr) were measured before, during and min after intubation. althought ecg was recorded at the same time intervals. results: the groups were compared with regard to the changes in arterial blood pressure,heart rate and electrocardiogram. mean arterial preassure and heart rate were incresed significantly during and after laryngoscopy and tracheal intubation in control group but remained unohange the baselin values in the group who received sufentanil. control group ecg suggested more changes than sufentanil group. conclusions: the results indicated that , mg/kg sufentanil for anaesthesia induction reducing the pressor response to laryngoscopy and tracheal intubation. obiective: the aim of this experimental study was to evaluate morphologically the influence of anesthesia in liver as well as in isolated hepatocytes (hc). methods: a total of female swine ( - kg) were used as liver donors and were randomly assigned to one of two groups regarding anesthesia protocol: group a (n= ): induction with intravenous sodium thiopental in a dose of mg/kg, group b (n= ): propophol in a dose of mg/kg for induction'and mg/kg/h for maintainance of general anesthesia. both groups were under the same preanesthetic regimen (diazepam, ketalar and atropin) and received standarised doses of fentanyl and pancuronium during anesthesia. in beth groups total hepatectomy was performed and the liver was perfused with - it of cold ( oc) university of wisconsin solution for a period of hours before hepatocyte isolation. liver tissue samples were fixed in formalin for the morphological study and stained with hematoxylin-eosin and pas. for hc isolation collagenase solution (type v, sigma, c- , . mg/ml) was infused via portal vein and the liver was incubated at oc for rain. cells were filtered and then washed in cold hanks' solution. isolated hc were fixed and prepared for staining or simply cryopreserved (- oc). results: histology was completed in / experiments ( in group a and in group b). mononuclear infiltration (halothane type injury) was found in all specimens ( / ). focal zonal necrosis and acidophilic bodies were found in specimens from group a ( / and / respectively) while portal inflammation with piece meal necrosis was found in one specimen from group b ( / ). smears of hepatocytes -beth formalin fixed and cryopreserved at - oc -were stained with hematoxylin-eosin and showed morphologically intact hepatocytes. conclusion: pre[imineq~' study of our material reveals mote frequent livet injury in the thiopental group, but this finding has yet to be established by increasing the number of observations. objectives: in this paper we present our experience and point out the importance of sedation of those patients who suffered severe head injuries/contusic cerebri with signs of decelebration/and who were put on ventilatory machine to obtain better mechanical ventilation in neurosurgical intensive care unit of emergency center in belgrade. methods: patients were treated from jan. till dec. results: in patients we successed to reduce agitation and decelebration. conclusions: the major demand of sedation in neurosurgical patients are that the patient should be calm, comfortable and painless. references we compared three analogous groups of patients in each, with orthopedic operations on lower extremities. in each group we applied different kind of analgesia: first group rece-ned local anesthetic ( ml . ~ bupivacaine) when analgesia was first demanded; second group received ml fentanyl via peridurai catheter when analgesia was first demanded, and third group received m] fentanyi intravenously on demand for analgesia. we used visual analog scale (vas) for estimation of pain intensity and success of applied therapy. statistical data analysis was performed using student's t-test. tha best vas had group in which local anesthetic was applied periduraly. second was the group with periduraly applied fentanyl, and third was the group with intravenously applied fentanyl the longest duration of the effect of analgesia ~/as in the second group. there were no adverse effects and complications, apart from mild sedation in the third group. for orthopedic operations on lower extremities, application of peridural catheter for anesthesia and successful postoperative analgesia with local anesthetic, or opioid analgesics is acceptable. background and obiective : tympanic temperature measurement (ttm) is a relatively new procedure which provides accurate estimates of core temperature in stable postoperative patients and in patients admitted to the emergency ward. however, experience with this technique in hemodynamically unstable adult icu patients is limited. design : prospective study with patients serving as their own control. se:ttijlg : adult medico-surgical icu in a tertiary care hospital. patients : consecutively enrolled patients with thermodilution catheters in place and without contraindieation for rectal temperature measurement and without hypothermia (core temperature < ~ interventions : tympanic temperature, measured by a commercialized tympanic thermometer (genius a first temp) was compared with pulmonary artery (pat) and rectal temperature (rt). within minutes, core temperature was assessed in each patient by the same trained individual using the three techniques in random order. measurements and main results : mean bias (ix~ and its variability (sdr of method comparison pairs were calculated using the methods comparison analysis as described by bland and alunan (lancet, ; i : - objective: to measure the prevalence of pressure sores on the intensive care unit and the effect of risk calculation on pressure score prevalence and pressure score severity. method:in during a period of months a series of prevalence studies was carried out on the sicu to investigate how many patient days with pressure sores were taken care for by the icu nursing staff, what kind of preventive interventions were done and what the patient risk was on developing a pressure score. results: on average there was a prevalence of pressure sores on the buttocks of . % on the short stay unit and . % on the long stay unit; preventive interventions increased when the pressure score was visible for the nurse and the majority of patients had a high risk or extra high risk for developing pressure sores according the pressure score risk calculator. as a result of these findings the nursing management decided in that nurses had to complete daily on every patient the pressure score risk assessment in order to be able to take adequate preventive interventions. when the results of the two studies were compared, the most important results were that: ) there is no indication of a reduction in patient days with pressure sores (short stay unit: %, long stay unit: %); ) there is a reduction in severity of pressure sores (grade iv decreased from . % to . %) because adequate preventive measurements are initiated by icu nurses in an earlier stage. possible explanations for the increase of patient days with pressure sores on the long stay unit are that the average pressure score risk score was increased from . to . and the mean frequency of nursing patients on alternate sides decreased from . to . times each day. conclusion: daily assessment of the individual patient risk on developing pressure sores does not decrease development but reduces the severity of the developed pressure sores. method: the conventional woundcare method of patients with an open abdomen is to change frequently the saline soaked ribbon gauze pads ( - times each day). this method is labour intensive for the itu nursing staff and rather uncomfortable for the patient. problems that often occur are: insufficient hygiene, frequent nursing interventions, a progressive risk for deterioration of the skin and underlying tissues, difficult to measure abdominal output and in case of bowel fistulas enteral feeding is hardly possible. in using the new method, stomahesive is applied on the skin surrounding the wound. a large size of surgical film dressing, opsite | is applied over the abdomen. two or more foley ~ catheters ch are inserted through an opening in the surgical filmdressing. the application of several lateral openings in the catheters is advised. the drains are held firmly in place between two layers of sterile opsite | "flexigrid ~'' x with the so called bookend method and are connected to a low vacuum suction system ( - kph) results: we studied the frequency of dressings changes on patients in the itu. in total they had days with an open abdomen. during this period there were dressing changes. this means one dressing change every days. further advantages of the new method are; more hygiene in patient care, no maceration and irritation of the skin, nursing on alternate sides is possible, output can be measured, in case of bowl fistula, enteral feeding is possible and an abdominal lavage is possible on the sicu by opening the opsite | conclusion: this new method of woundcare management is more patient friendly, prevents several nursing complications and decreases the work load for the nursing staff. objective: to investigate the interaction between the ventilator and the closed suction system related to possible induced negative pressure by this sytem. method: we studied in a testlung model what the effect was of the different ventilators (evita: dr~iger; servo c: siemens), ventilation modes ppv, simv) and ventilator settings (tv, trigger level, frequency, peep level) on the induced negative pressure by the closed suction system during suctioning. results: when using the evita the magnitude of the negative pressure increased when the ventilation frequency and tv decreased.. the largest negative pressure (- cm h ) was produced with a tv of ml and a frequency of /min in the ippv mode with trigger level on - cm h and a peep level of + cm h . the servo c showed a complete different pattern. the largest negative pressures were measured when no trigger level was set ( cm h ), the induced negative pressure was not depended on the tv or ventilation frequency but more depending on the ventilator mode. the simv mode produced the smallest negative pressures ( - cm h ) and the ippv mode the largest ( - cm h ). conclusion: the effectiveness of the closed suction system is very much depending on the kind of ventilator, ventilator mode and ventilator setting that is used. if the interaction with the used ventilator is not known by the icu nurse this piece of equipment can cause damage to the patient by inducing large negative pressure in the comprimised lung and there fore creating the possibility of alveolar collaps and atelectasis or oedema. introduction : ethical problems are daily and disturbing preoccupations for the icu staff. objectives : improving ethical management in icu by creation of an intelprofessional group of ethical reflexion ( iger ). methods : existing was evaluated by a preliminary formulated series of questions sended to the whole staff (q , n = , items) after two training sessions (laws, deontology, professional values, culture, norms of quality) followed by persons ( %) and directed by an external chairman, satisfaction and needs of the staff were evaluated by a second series of questions (q , n = , items). at the issue, iger was created. results : q : responders ( %). law's misinformation : to %, disagreement for limitation of intensive cares : %, hope to improve collective decisions and creation of iger : % q : responders ( %) : satisfied by the training sessions : %, non satisfied : %, want to continue the project : %, refuse : %. iger was constitute by physicians, nurses, secretary, dietetic (n = ). the first working theme was {< therapeutic's withholding and withdrawing decisions in icu ~>. four subgroups of iger's members (having access to an ethical library) worked independautly and submitted their reflexions in a tdmestrial plenary session of iger in the presence of an external chairman, allowing a synthesis. at the issue a report was writted to be used as a reference for bedside and individual decisions. conclusions : constitution of iger seems to improve ethical management in icu. the first result of iger is that it is now possible to began collectively a reflexion concerning therapeutic's withholding and withdrawing in icu. the work is going on and further subjects will be studied. objectives: ) to compare the value of heat-moisture exchangers with bacterial filters (hmef) and without bacterial filters (hme) in the prevention of colonization of ventilator tubing and ventilator-associated respiratory infections. ) to asses the temperature and relative humidity of inspired all using both types of heat-moisture exchangers. methods: mechanically ventilated patients were randomized, to either hmef or hme. endotraeheal aspirates, pharyngeal swabs and samples from tubing were collected for bacterial cultures on the st, nd day mechanically ventilation and weekly thereafter. temperature and relative humidity were measured in patients ( hmef and hme) h and h after placing the hme or the hmef. results: both groups were comparable as regards age, mechanical ventilation period, severity score (saps ii), leukocyte count, and number of patients with prior antibiotic treatment. from the hmef group, ( %) ventilator tubing yielded microorganisms in, at least, one sample as compared to ( %) of the hme group; p=ns. the incidence of respiratory infection was similar in both groups ( % vs %, p:ns, for hmef and hme respectively). among the bacterial species isolated from ventilator tubing in the hmef group, ( %) were not isolated from pharyngeal swabs. a similar ratio was shown in the hme group ( / , %). both heat-moisture exchangers were efficacious in keeping a good relative humidity of inspired air ( % • vs % • .%; p=ns, for hmef and hme respectively). relative humidity was significantly higher after h of mechanical ventilation in the hme group as compared to hme group ( . % • vs . % • %; p= . ). conclusions: both types of heat-moisture exchangers have the same effect on the prevention of colonization of ventilator tubing. similar relative humidities are achieved when using either type of heat-moisture exchanger. results: tumor and nontumer enhrgements of the thyroidea were present in ~ of the operated, surgicel adrenal disease in io!, hyperplssle or persthyroid gland tumor in ~ end endocrine pancreatic tumors in %. in the intensive oere unit, these patients wore screened by noninwsive monitoring in ~ of cases: and invasive monitoring was applied in % of ceses.the basic noninvesive methods included: electrocardiogram with standard end precerdial leeds, percutaneous eutomotlc measurement of systolic, diastolic and mean arterial pressure, measurement of hourly diuresis and body temperature, frequency, hearing capacity and rhythm of one s own breathbng bs well as pulse oxymetry. a special plece in monitoring and control of vital parameters in postoperative period belonged to the nurse, thoroughly trained for enelysis end interpretation of the observed parameters which would be discussed in the paper. it has been believed that the leader sits at the pinnacle of power. over the years, this has proven to produce frustruation and anguish instead of the expected results. leaders have not been able to produce the changes they know are essential to their organization's survival with this command-and-control paradigm. through literature reviews and evaluating leadership styles, one can clearly see the most effective form is that of empowering people to a new level of performance -not ordering it. changing the leadership paradigm to a manner/style that has been shown to be effective and one of people empowerment shifts the focus to personal responsibility for performance. removing obstae}es~ stimulating self-directed actions, and determining focus and direction are just a few elements used to create the successful environment of empowerment. with increasing pressure in the health care arena, it becomes critical that a leader's job is to get the people to be responsible for their own performance. developing ownership, creating an environment where people want to be responsible, being a mentor or coach, and learning faster while encouraging others to do so demonstrates the commitment to effective leadership. this presentation will illustrate the critical components that are achieved when every person in the institution is empowered to perform at a level that is directed toward positive, effective results. herrera m. (md) . icu. hospital regional. malaga. spain. the systems of veno-vanous continuous haemofiltration (wchf) have a high cost and a limited life span. in an attempt of lengthening their mean life it has been proposed to accomplish programmed washes of the ~-stems. this practice supposes an increase in nursing workload. in order to evaluate the real efficiency of this practice we have accomplished this study. material: prospective randomized study of all the filters of vvchf used during the last year in our icu. we have determined two groups of filters, in the first (group a) we accomplished washed in a programmed way, and in the other (group b) only when the alarms of the system suggested a clotting of the filter. for the statistical analysis we used the kaplan-meier test for survival analysis. results: we have studied a total of patient submitted to wchf during the last year. we used a total of filters with this results. objectives. sounding out the nurses about the need to inform patients" relatives and the rigth kind of such information, like a preliminary approach to an information cuality assessment, methods: we inquired all the nurses of the intensive care unit of an regional hospital by an semiestructurated questionary which included personal data: age, sex, contractual relation, professional experience.., and opinion data: do you think to inform relatives is a nurse task?. which of the next informafions do you think is more important?, please, write others topics about information you think are relevant. we process the data on epi-info estatistical program and use x test to compare the results. results" from nurses of staff refused to flu the quetionary, and were not available. of the remaining, %were v~men and % men. the mean age were . % had an svable contract and ( eventual, the mean professional experience were of years and % worked in the unit since more than years. the % answered that offer information to relatives is part of the nurse activities. we did not find differences with nurses who answered negatively comparing by sex, age, contractual relation or proffesional experience. the three information topics found out like more important were: ) to inform about patient mood. ) to inform about happenings from the last visit. ) to inform about dressing instrument required by the patient, nurses who answered negatively think that to inform is a doctors task or that nurses are not competent. conclusion~ intensive care unit teams (nurses, doctors and auxiliar personnel) should get accord on who and how to inform relatives, we consider the nurses' role on information as unquestionable. objective: investigate the respiratory and cardiovascular response after discontinuing oxygen therapy durir~ intr~/]o~pital transport. desiqn: fifty-one patients ( male and female, aged + , and , , years respectively, ~+sym) being on therapy were studied prospectively in two consecutive intrahospital transports. oxygen therapy was continued in the first transport while the second one was performed as usually, i,e, without . during transport each patient was monitored by pulse oxymeter and holter whereas arterlal blood gases were tested just before a~xl aft~-trar~portation. results: compared to daseline, pa and sa were signif~canthy decreased in the case of oxygen discontinuation (p< , i). paco was significantly inur~ds~i only in the subgroup of patients with obstructive lun[ disease (p< , ) . heart rate increased in all phases of the transport when administratlon was discontinued. blood pressure remained stable in either case. the percentage of supraventricu!ar extrasysto!es, ectopic v~r[hicui~r contractions and st-s ~ment depression was progressively increasing and became very high at the end of transport in the case of therapy discontinuation. other arrhythmias did not change significantly. conclusion: discontinuation of oxygen therapy during intrahospital transport causes severe drop of pao and sa , increases the heart rate and contributes to the appearance of arrhythmias which were not present before. methods:for evaluation of the functional state of brain the complex of methods was used,whieh included electro encephalngraphy ( brain mapping ), rheoencephalography, tetrapolar transtorax rheography. for the estimation of humoral status the level of histamine and serotonine, products of free-radical oxidation,enzimatic markers of ishemic damage of brain and of endogenous intoxication was investigated. results: patients with encephalopathies after resuscitation were observed.asystolia was as a result of:shock, trauma, asphyxia,poisonings,appiication of drugs, eclamp sia,injury of the heart,diseases of fhe cardiac vessels. all patients with postasystolic syndrome entranced in comafose condition.in the group (reconvalescents) the depth of coma by glasgo~ pittsburg"s scale was , +- , . the duration of coma was from rain. to hour,average , +- ,sh.ln the group (the deads) the depth of come was , +- , .the artificial lung ventilation was used in all patients:in the group , +- , days,in the ~ , +- , days.apallish syndrome developed in cases,in patients diagnozed <<brain death~. the th degree encephalopathy (coma) was found to be associated with disorganized eeg-pattern with predomi nant alpha-( group) and slow ( group) activity. the relative power of delta-and theta-ranges was about - per cent.the patients with apallich syndrome demonstrated greatly elevated theta-range power, that of beta -range was essentially decreased. the degree of disturbances of circulation in the both groups was different.cardiac index (ci) and stroke index (si) in the group decreased on , % and , z, in the -on , % and (; , %.general peripheral resistance (gpr) increased in the group on , %,in the -on (; , %.in the group brain blood flow was increased, in the -decreased on , n.in the group there was the normotonic type of reg-curve,in the -atonic or hypotonic type (without reaction on pharmacologic influ ence).disturbances of permeability of cellular membranes (enhanced free-radical oxidation with an increase in di enic conjugates on and n) and vascular ones (an increase of serotonin concentration on and %, hi stamine content on and %) resulted in hyperfermentia (an increase of concentration of creaune phosphoki nase in the group on %,in the - %.the level of middle molecules (mm) increased in the group on , %, in the -on , %,of polyamines (p) (spermidin,spermin,putrescin).coefficient of correlation between mm and p was , . immediate correction of neurocyte metabolism is impossible due to marked brain oedemaswelling,severe dis ordes of cerebral circulation, disturbances of membrane permeability.thus,the following treatment algorythm might be advisable: . protective inhibition of brain and reduction of its energy requirements. . recovery of cell and vascular membrane fuoctions. .recovery of blood circulatiom .oxygenation of nervous tissue and drainage of brain disintegration products.in patientshbo carried out. .active methods of detoxication (homo-and enterosorption). .correction of cerebral metabolism. . dehydrative therapy must be very cautious. conclusion: the activation of energetic metabolism in neurocytes must be carred out only under neurophysiolngical control and after definite preparation. ( ). the clinical estimation of acute cerebral failure carried out by olasgo-pittsburg"s classification of coma. we studied such groups of patients: poisoning co ( ), asystolia ( ), eclampsia ( ), acute renal failure ( ), control group ( ). methods: electroeneephalngraphy (brain mapping) was fulfilled by means of encephalograph <,medicor ~ in monopolar channels. the estimation of eeg patterns by zhirmunskaya method ( ) was carried out. there were analyzed and changes of eegb by results of rapid transformation furie after rhythmical photostimulation(phts) , , , hz. we studied also the figures of absolute and relative power in such diapason : delta ( - hz), theta ( - hz), alpha ( - hz), betal( - hz), beta ( hz and more). results: all eeo changes were divided into following types: -organized ( , groups); iii -asynehronic ( group); iv -disorganized with prevalence of alpha-waves ( , , groups); v -disorganized with prevalence of delta-and theta activity ( , , ; , groups) akkording to our model of hormonal-metabolic disbalance in pregnancy , one of the main reason of destosis is hypoergos , reesults in endotoxemia and neuro-endokrine disregulation. so, stady of central nervous system function give us the information about adaptation processes. the aim of our work is to study the degree of neurologikal deficit in destosis when olifen and lipin were used. there were studied pregnants with different severe forms of gestosis. the degree of neurologikal deficit was valued by datas of neurologikal status . eeg with ,~brain mappinng~, , electrikal resistance of the skin. the komplex inteensive therapy with applikation of olifen and lipin allowed to improve the patient,s condition , decrease the degree of neurolodikal deficit and mortality . kostenko v.phd,kabanko t.,phd,galalu s.md,beliavtseva n. ,shramenko k. phd intensive care department,donetsk medical university, donetsk, ukraine plasmapheresis (pph),as other extracorporal methods of detoxicatin,has a great importance in contemporary medicine. the role of pph is special,because of its simplicity, effectiveness, atraumatic.we incalcated pph in obstetrical clinic. there are rough changes in agregate condition of blood in more of pregnants.these changes lead to disturbances of central,organ and peripheral hemodynamic.the therapeutic effect of pph is due to influence on agregate condition of blood. we considered that application of pph is very effective in pregnants with:bronchial asthma, severe forms of diabet, psorias, gestosis, allergic diseases. we used the membrane pph in pregnants: apparatus-,,hemos-pf>,, plasmofllter pmf- ,with effective area- cm,the volume of extracorporal contour- ml.such pph has no the ~ agressive effect,,, as in cases of application another extracorporal methods. this method was incalcated in our practice recently, so results will be reported in further publications. ( ). post-operative cerebral neoplasm ( ), post-operative subdural hematoma ( ). icp was monitored via a catheter inserted in the lateral ventricle and values were continuously digitally recorded by means of a bedside computer data acquisition system (maclab). the fiberoptic tracheobroucosenpe, which guided the procedure, was passed between the nasotracheal tube and the trachea in order to avoid hypoventilalion. the patients had stable baseline hemodynaimcs. propofol infusion and fentanyl boli were administered to mantain stable mean arterial pressure values. peak (mean(sd)) icp duping the minutes pre-ciaglia procedure (baseline values) were compared with values during ciaglia procedure, and the minutes p st-ciaglia procedure. data were compared with repeated measures anova. results: ciaglia procedure duration was (mean(sd)) ( ) objectives: transient global amnesia (tga) is a syndrome caracterized by impairment of short-term memory, inability to form new memories, retrograde amnesia and repetitive queries, without other neurological signs and symptoms. the pathophysiology of tga is unknown; thromboembolic, epileptic, migrainous and metabolic mechanisms have been suggested. to address some of these issues, we undertook a study of cases of tga in whom we examined clinical, laboratory data, electroencephalogram, ct of the head, ultrasonography ecodoppler. methods: patients were included in this study: men and women. the mean age was years. all cases underwent a standard clinical examination, electrocardiogram, routinary humoral tests and x-ray, electroencephalogram (eeg), ct scan of the head, ultrasonography ecodoppler. results': the mean duration of amnesia was h. m. +/- h. m. hypertension was found in patients ( %), ischemic heart disease in patients ( %), hypercholesterolemia in patients ( %), hypertrigliceridemia in patients ( %), smoking in patients ( %), atrial fibrillation in patient ( %), history of epilepsy in patient ( %), migraine history was not recorded. ct scans of the head showed multiple small deep infarcts in patients ( %), a single hypodense lesion in patients ( %). in patients electroencephalogram was normal ( %), in patients there were widespread nonspecific electrical changes ( %), in patients there were focal nonspecific eeg abnormalities ( %). conclusion: in our study tga was more common in women ( %). we showed a prevalence of hypertension, hypercholesterolemia and cerebral infarcts compared to normal controls. we have demonstrated a higher incidence of nonspecific electrical changes in tga of lower length, while ischemic lesions in ct of the head were more frequent in tga of greater length. these data seem to be in agreement with the hypothesis that tga is a heterogeneous clinical syndrome, consisting of pure, epileptic, and ischemic types. however we did not find any correlation useful in discriminating pure from associated tga forms. from our study it is tempting to speculate that pure tga is a rare event, underlying still unknown mechanisms wich differ from ischemic, epileptic, migraineous causes. objectives: aneurysmal subarachnoid haemorrhage (sah) is special condition increasing intracranial pressure (icp) in various ways. at the other hand cerebral vasospasm and related delayed ischaemic deficit (did) could answer for the poor outcome. triple h therapy seems today a basic option to prevent did, but it may increase the icp worsening the altered intracranial pressure condition and thereby the cerebral perfusion pressure (cpp). is there any way to individualise the triple h therapy when it is necessary? methods: between sept. march thirty-seven patients with intracranial aneurysms were operated on within hours following sah. five patients were in hunt-hess iv at admission. all patients received triple h therapy in a preventive fashion following surgery and were monitored by daily transcranial doppler ultrasonography (tcd). icp and cpp was measured in twenty-four cases. twenty-two of them received lumbar liquor drainage (lld) and nineteen were administered induced hypertension. the other group was treated by basic triple h therapy. results: in group with monitored icp the outcome was twenty-one excellent, one poor, two died (one of them died from extracranial decease). in the other group four had excellent, six moderate, two poor outcome, and one died. conclusion: according to our recent observation the patients can be divided into two groups of therapy. in group i, the patients with elevated tcd values and either low or high icp reacted to lld. we are concerned that haemodilution and slight hypervolaemia should dominate in the triple h therapy. in group ii patients having high icp with tcd and/or symptomatic vasospasm should be managed by the induced hypertensionhypervolaemia dominated therapy focusing on cpp (icp) and focal neurological signs. air emboli were detected in lo% (n= ) of natients undergoing coronary srtery bypass craftin~ (cabg). central nervous system ~ysfunction occured in ~$ of the nstients with air embnli and in none of those ~ithhout air embo!i. hvtothermia is the classic form of oro-tect~on used dur~nc ~"~" " ~ ~ ca~.,~modu] :r, on~_,_. bj/oass. the surf~eon sho,;,ed thorough!~: evecnnte air from the heart, but the onesthesio!o[[ist can signifieamt!y influence the outcome by emt!oyin ~ methods to detect and treat air emboli. the changes in head rate are primarily due to alterations of autonomic tone. the heart rate variability (hrv), that express the degree of heart rate fluctuation around the mean heart rate, reflects somehow the condition of central nervous system. hrv may be measured by a number of techniques. short-term time-domain variables of hrv are reflect generally the vegal activity. in this study the changes in hrv variables of patients with brain damage, and in addition the changes in hrv measurements in comparison with the clinical evolution were evaluated. eight patient with brain damage and six normal individuals as control group were studied. a elecrocardiographer with availability of computation the sequence of beat-to-beat intervals for one minute was used. the following variables of hrv were measured: ) standard deviation (sd) of beat to beat r-r interval differences that reflects the respiratory control, )the maximum/minimum (max/rain) interval that reflect variability related to baroreflex and thermoregulation and ) the coel~cient of variation (cv), the results are shown in the in the patients with brain death and in vegetate state there were virtually no hrv. increased hrv pattern was found with clinical improvement, the changes of hrv precede of the changes of gcs, we conclude that time-domain hrv could reflects the degree of brain damage, it is good prognostic index of the brain damage and may change earlier than the gcs. objectives: cerebral co vasoreactivity is an important determinant of cerebral blood flow (cbf) and has been shown to be of prognostic value in head trauma (acta anaesthesiol. scand. ; : - ) . we wondered whether co vasoreactivity could be selectively altered in one hemisphere in comatose patients. methods: patients ( m/ f, age - yrs, glasgow - ) in coma due an acute brain lesion (trauma, hemorrhage, or infection) were studied. cbf was measured bilaterally using jugular thermodilution at paco , , , and mmhg by increasing pico with mechanical ventilation kept constant. normal co vasoreactivity was defined as an increase in cbf of at least i ml/min. g per mmhg paco . results: patients had normal co vasoreactivity bilaterally, patients had altered co vasoreactivity at both sides, and patients had a normal response at one side (left or right) with an altered response on the other side (dght or left). for the patients left cbf was in mean ! ml/min. g lower than right cbf (figure methods: following institutional approval piglets (body weight :tl . ) were anaesthetized by % fluothane. a catheter was placed in the right femoral artery for blood pressure monitoring and a fiberoptic catheter (oxymetncs- abbott) was advanced via the right internal jugular vein to the jugular bulb for sjo determinations. another catheter with a balloon on the tip was advanced in the right atrium via the right femoral vein. a mean arterial pressure (bp) at mmhg was achieved by appropriate balloon inflation for rain and two groups were cleated: i) the hypoxemic group by respirator disconnection (*) and it) the hyperoxemic group by fio =l on respirator (o). samples were obtained at time ( ), ' min at hypoperfusion ( ) arid at reperfijsion at ' ( ), ' ( ) and ' ( ). pao , pjo and oxidative brain stress evaluation was performed from jugular bulb blood. the latter included: i) no synthase (nos) and xanthine oxidase (xo) activities by a method based on the oxidation of scopoletin detected fluorometrically, it) no levels estimated as onoo-by luminol enhanced chemiluminescence in the presence of ~tm hydrogen peroxide (h ). resul'~s: the mean pao was mmt-ig for group i and methods: we retrospectively reviewed all upper gi-endoscopies, performed in the period january -july in patients ( men and women) admitted at the icu's of our hospital. results: it concerned surgical, medical, eardiological and neurological patients with a mean age of . yrs (range: - ). in %, the endoscopy was performed at the icu and in % at the endoscopy department. in % of the cases, the endoscopy was primarily diagnostic, of which % was performed for localization of upper gi blood loss. in % the endoscopy was primarily thempentic, of which % was performed for placement of a duodenal feeding canula. location of the upper gi bleeding was: variees ( %), duodenal ulcer ( %), oesophagitis ( %), gastric ulcer ( %), others ( %) and none ( %). as coincidental findings were noted: cesophagitis ( %), gastritis ( %), gastric deer ( %), duodenal ulcer ( %), duodenitis ( %), oesophageal ulcer ( %) and others ( %). conclusions: there were marked differences in indications and findings of endoscopy at the different icu's. these differences reflect an admission bias and differences in populations and treatment preferences. compared with cardiological and neurological icu's, substantially more endoscopies were performed at surgical and medical icu's. in a considerable number of cases, no source of upper gi blood loss could be found endoscopicaiiy. when upper gi blood loss was the icu admission diagnosis, the main cause was needing varices, which could be controlled endoscopically in the vast majority of cases. when upper gi blood loss was ndt the icu admission diagnosis, peigie ulcer and oesophagifis were the main causes of bleeding. because of the considerable number of coincidental almom~adities found at endoscopy, there is still room for debate whether antacid medication and/or motility stimulating agents should be given prophylactically at icu's. many studies have shown that blood lactate levels in survivors and nonsmvivors of traumatic and septic shock are significantly different. the degree of multiple organ failure is related to the duration of lactic acidosis ( ). the aim of this study was to evaluate blood lactate level as a prognostic marker of high risk postoperative patients who may benefit from invasive hemodynamic monitoring and aggressive fluids administration and early inotropic support based on oxygen transport parameters. methods: patients undergoing elective long term vascular and abdominal surgery (asa i-bi) were studied. blood lactate levels were measured after icu admission. in the case of blood lactate level above mmoltl, measurement was repeated every hours for hours or until normaiisation (blood lactate level less than mmol/ ). type of surgery, length of surgery, amount of fluids delivered intraoperatively and postoperatively, hemoglobin levels, hemodynamic variables, diuresis, postoperative complications, length of icu stay and clinical outcome were recorded. because no attempts were made to randomisr therapy or change our standard therapy protocol institutional approval was not required. rebuts: the frequency of postoperative complications was , % and mortafity was , % in a group of patients with blood lactate level less than , mmol/l (n = ). frequency of complications ( , %) was significantly increased in a group of patients with blood lactate levels , - mmol/l (n = ), mortality was , %. mortality ( %) and frequency of complications ( %) were significantly increased in a group of patients with blood lactate levels above mmol/l (n = ). conclusion: blood lactate levels can serve as early marker of high risk postoperalivr patients and may predict increased risk of postoperative complications mad ~e death. objective.~: investigated practicability and clinical value of the routine measurement of hepatic venous oxygen saturation (shvo ) after major liver surgery, as shvo is considered an indirect parameter for splanchthc and hepatic blood flow. methods: consecutive patients were included in this study after liver resections for primary or secondary liver tumors. patients suffered from liver cirrhosis (childs a). immediately after post-operative admission on the icu a pa-catheter ,was inserted under fluoroscopy via the right jugular internal vein into the hepatic vein contralateral to the resection area. hepatic venous and arterial blood samples were drawn every two hours. shvo was correlated to the clinical course, macro hemedynamics, abgs aug other established lab parameters. results: in out of attempts the catheter could be placed correctly. in four cases after right hemihepatectomy the left hepatic vein could not be intubated due to a dorso-lateral tilting of the left liver. this is also reflected in a significantly longer time of fluoroscopy for catheterization of the left hepatic vein ( . _+ % rain vs. . + . rain; p < . ). the procedure requires a total of between and minutes. relevant clinical complications were not observed except for short term supraventricular arrhythmias during passage of the catheter through the right atrium. hemodynamics and pulmonary function could be considered normal in all individuals at time of measurement. shvo showed a span from . % to . % with a mean of . % -+ . %. the following statistically significant findings could be obtained: (a) patients with liver cirrhosis showed a significantly lower shvq than patients without ( . % • . % vs. . % • . %; p < . ). (b) a negative correlation between shvo immediately after operation and the duration of intraoperative hepatic vascular occlusion could be observed (r = - . ; p < . ). this correlation could also be seen for the first post-operative hours (r = - . ; p < . ). (c) a negative correlation between shvo and the difference between arterial and hepatic venous lactate levels was found (r = - . ; p < . ). conclusions: the routine measurement of shvo appears to be a promising extension of post-operative monitoring after major liver surgery. it is a safe method easily feasible on any major surgical icu though relatively time consuming. a further validation of this method is necessary in larger studies. therapeutic recommendations on the basis of shvo findings cannot be given yet. methods: in cases after major liver resection, in which abnormally low readings of shvo suggested an impaired hepatic blood flow, pgi was applied at a dose rate of ng/kg/min. as shvo can be considered an indirect parameter for hepatic blood flow, the effect of pgi infusion on shvo was measured. moreover, the changes of macro hemodynamics and pulmonary function were monitored. results: before the application of pgi z mean shvo for all patients .was . % ( - - - ). in three cases without major structural alteration of the remaining liver tissue the continuous intravenous administration of pgi lead to a sustained increase of shvo z to an average of . % ( . - , ). the postoperative course in these three cases was uneventful. in two cases with compensated liver cirrhosis after hepatitis c no change in shvoz under pgi infusion could be observed. both patients died and days respectively after operation in protracted liver failure. side effects of pgi included a slight decrease of systemic and pulmonary vascular resistances. consequently map decreased by up to % as did intrapuimonary right-left shunt increase. in none of the observed patients did these side effects posed a limitation of continuous application of pgi z. conclusions: in patients without structural alteration of the liver the systemic application of prostacyclin at a dose rate of ng/kg/min could significantly increase an abnormally low hepatic venous oxygen saturation after major liver resections, tn two cases of severe liver cirrhosis a similar increase could not be observed. after first clinical investigations and with the results of recent studies in animal further controlled clinical studies of prostacyclin in the postoperative management after liver surgery appear justified. any delay in gastric emptying can promote micro-aspiration and give rise to ventilator associated nosoarnnial pneumonia. h -receptor antagonists have been suspected of promoting pneumonia by changing the gastric ph. in a few tri',ds on humans ranitidine was noted to delay gastric emptying. the aim of this prospective, randomised, blinded study was to evaluate in a ventilated icu population if there was a difference between cimetidine (c) and ranitidine (r) on the gastric filling index (gfi conclusion: in this population there was no difference in gfi between c and r; however the age and creatinine were significantly different and could have favoured the c group. also the very long t/ could have hidden smaller differences between c and r as has been described in volunteers. between april , and april , , patients with severe acute pancreatitis were admitted to participating hospitals. patients were entered into the study if severe acute pancreatitis was indicated, on admission, by multiple laboratory criteria (imrie score >_ ) and/or computed tomography criteria (balthazar grade d or e). patients were randomly assigned to receive standard treatment (control group) or standard treatment plus selective decontamination (norfloxacin, colistin, amphotericin; selective decontamination group). all patients received furl supportive treatment, and surveillance cultures were taken in both groups. results: fifty patients were assigned to the selective decontamination group and were assigned to the control group. there were deaths in the control group ( %), compared with deaths ( %) in the selective decontamination group. (adjusted for imrie score and balthazar grade: p = . ). this difference was mainly caused by a reduction of late mortality (> weeks) due to significant reduction of gram-negative panreatic infection (p = . ). the average number of laparotomies per patient was reduced in patients treated with selective decontamination (p < . ). failure of selective decontamination to prevent secondary gram-negative pancreatic infection with subsequent death was seen in only three patients ( %) and transient gramnegative pancreatic infection was seen in one ( %). in both groups of patients, all gram-negative aerobic pancreatic infection was preceded by colonization of the digestive tract by the same bacteria. reduction of gram-negative colonization of the digestive tract, preventing subsequent pancreatic infection by means of selective decontamination, significantly reduces morbidity and mortality in patients with severe acute necrotizing pancreatitis. ieco by sodium hypochlorite (nacio) infusion is considered to be a model of microsomal oxidation in liver on cytochrome p- . active c provides oxidation of toxic metabolic products in the blood and exfused during plasmapheresis plasma, and also hydrophobic to hydrofilic transformation of substanses. sterile nacio in necessery concentrations was obtained by electrolysis of saline ( , - , % naci solution) in electrochemical set e~io- (russin,moscow). methods: . the nacio in concentration ragfl ( - ml/ h ) was administred into central veins in patients with extensive peritonitis and endotoxicosis - /t. erytrocytes resistance to nacio, circulating blood volume glycemia and hemostasis were initially estimated. . after plasmapheresis exfused toxic plasma was mixed with nacio conccantration of i mg/t in : ratio in sterile "hemacons".the effectiveness of plasma detoxication and possibility of its reinfusion were evaluated by determination of albumin effective concentration (eca g/l), the concanlration of medium molecular oligopeptides (mm , ) and other biochemical tests (bilimbin, creatinine, carbomide and so on). results: . the intravenous administration of nac excels detoxicative effect of hemosortion by - % provides effictive presentation of protein components and blood cells and improves the transport function of albumin by %. . the return of exfused plasma after its purification ieco was - %. only the remaning - % of deficient plasma were compensated by fresh cryoplasma and albumin solutions. ischemic hepatitis (ih) is a severe complication in critically ill patients. acute circulatory failure of multiple etiology can lead to splachnic hypoperfusion and cause acute and reversible anoxic damage. over a period of mos pts, m and f, mean age + . yrs developed liver disease compatible with ih. eight pts had a documented hypotensive episode (six pts with septic shock and two hypovolemic shock), while cardiogenic pulmonary edema in the absence of hypotension was responsible for ih in the remaining four pts. all the pts had a rapid striking elevation of ast, &lt and ldh with equally rapid resolution of these parameters to near normal wimin days (mean . ). the mean peak level of ast, alt and ldh was iu/l (range to ), iu/l (range to ) and iu/l (range to ) respectively. serum total bilirubin levels rose transiently with a moan t:eak level of . mg/dl (range . to . ), while altered coagulation paran-,ete's (pt> . times normal) was observed in four pts and clinically significant coagulopathy with fibrin degradation products occurred in one pt ( . %). renal impairment (cr> . mg/dl) was manifest in all pts; six pts developed non-oliguric renal failure ( %) while two pts required hemodialysis. ten lots required vasoconstrictor inotropes [dobutamine (range - pg/kg/min) and dopamine (range - pg/kg/min), while replacement of circulatory blood volume was performed in two pts with hypovolemic shock. eight lots expired ( . %), but none died as a direct result of hepatic damage. the mortality rate was higher among pts with concurrent renal failure ( %). it is concluded that: ) ih is not uncommon complication in the icu with the prognosis depending on the underlying disease. ) clinically significant coagulopathy is uncommon complication of ih. ) titration of inotropes is required to obtain optimal cardiac output support and subsequently liver blood flow. it is difficult to ascertain the perfusion of free flaps such as jejunal loops after surgery. objectives: to assess ischaemia as evidenced by intramural ph of jejunal free flaps used for reconstructive surgery following total pharyngolaryngectomy. methods: the sigmoid ph tonometer ( tonometrics inc.,usa ) was used to monitor intramural ph of the jejunal free microvascular flaps ( phig ) in patients who underwent total pharyngolaryngectomy. a standard general anaesthetic was given and all patients were admitted to the icu for controlled ventilation and monitoring. all had similar postoperative care. phig was measured pre, post-revascularization of the flap and on icu admission, , and hours postrevascularization. objectives: to classificate the wide spectrum of itc of anp into distinct pathophysiological patterns according to presentation and course. patients (pts) and methods: pts, ~( , %), ( , %) were admitted in the icu because of anp and acute respiratory failure(arf), ilean age: , • years. hean stay in icu: , • days. pts were operated, of them twice. hean value of ranson's scale: , • ( - ). we analyzed hemodynamic measurements,arterial blood gases(abg), x-ray findings(xrf), ct-scans and operative records. results: patterns of pleuropulmonary complications were identified: a)early hypoxia without xrf - pts. b)early ards with typical xrf - pts( died), c)early arf with xrf(atelectasis,infiltrates)- pts( died). d)late ards with typical xrf- pts( died), e)pleural effusions in various combinations with the above patterns - pts. overall mortality rate: / = , %. conclusions: l)frequent x-rays and abg are important for the classification of itc of anp. )even though patterns of classification in anp are not clearly distinguishable,they facilitate an anticipatory management. )deterioration of abg and xrf indicates that preventive measures for arf must be intensified and agressive surgical therapy is required. )delay of surgical therapy is related to worse prognosis(p<o, ) and prolonged hospitalisation time(p<o,ol). in the contrary, the early timing of the operation before infection and extrapancreatic necrosis is essential for a better prognosis (p<o, ). objectives: the development of cholestasis during intensive care treatment is allied with an inferior prognosis. this study investigates the sensivity, specification and also the positive and negative forecast of patients survival -exemplary for bilirubine. methods: during a period of months all surgical patients on icu were registrated prospectively (n = ). for documentation of disease development a standard foldcrform based on a computer-data-system was used. the results of this kind of documentation showed aapprax. , m!ll. of single patient informatioas. results: of patients didn't suffer from liver disease or have any operation on liver or bile tract. of them have had a normal scale of bilimbine in the postoperative period, a higher scale of bilirabine was regisu'atcd by patients. at a ,,cut-off" of rag% (total-bilirubine) the sensitivity was , , specivity , , positive predicive level , , negative predictive level , for survival criteria of a patient. the max. reached level of bilirubine, also the daily increase turned out almost the same results as they were found for other parameters nf cholcstasis like ap or gamma-gt. objective: the aim of this experimental protocol was to evaluate the morphological and functional parameters of isolated pig liver grafts, perfused in an extracorporeal liver support system. methods: the system consists of the graft liver, a membrane oxygenator (oxygenation surface . cm z, flow= itlmin), a heater, a centrifuge pump and a fluid reservoir. twenty pig livers, mean weight gr (min , max gr) were obtained and after a mean cold ischemia time of min were perfused fo} a mean of . h (min . , max h). perfusion solution consisted of r/l and hemacell. inflow to the graft liver was performed through the portal vein at a mean pressure of ( - ) mmhg at ~ while outflow was secured through the suprahepatic inferior vena cava. during perfusion the following parameters were evaluated through pre-and posthepatic hourly (to-t ) sampling: po , " + + " pco , ph, hco -, na , k , ca , osmolality, glucose, lactate, ast, alt, alp, u bilirubin and coagulation factors i, v and viii. biopsies were obtained periodicallty. b_p_~: results were as follows: mean ph fell from . at t o to . at t while mean output po fell from at t o to at t . mean output ast values increased from at t o to > at t while mean output alp values increased from . at t o to at t . mean output k + values increased from . at t o to > at t . histology revealed lesions of ischemic necrosis, more prominent after t . conclusion: results show that the isolated liver graft presents satisfactory function and morphology at least for a five hour perfusion period in the described extracorporeal circuit. correction of ph contributed to an increase in bile flow. between and the practice of transplantation has changed drasticaily in switzerland -besides kidneys also hearts, heart and lung, lung, iiver and pancreas transplantation has started in several centers. major information efforts have been made, organ exchange rules were set up and a national coordination center was initiated. the aim of this retrospective single center study was to assess the influence of transplantation on organ donation. in the past eleven years organs were donated from potential donors i single, multi organ donations) analysis of refusal was evaluated categorized into medical and/or familiar reasons. the number of potential donors increased from ( ) ,to ( ) with a concomitant drastic reduction of donations from % in to % in ; amounting to a net unchanged number of donations over the last years ( = ; = ) . the import and export of donor organs was balanced since the introduction of the national coordination center. in contrast multi organ donation increased from % in to % in despite of the more stringeant selection criteria, in conc]usion the introduction of a full range of transplantation procedures at several new university programs and the increase of multi organ donation has not had the forecasted impact on organ donation despite a sustained informative and promotional campaign, objective: monitoring hepatic venous oxygen saturation (svho ) provides online information about hepatic-splanchnic oxygen supply-demand ratio [ ]. previously, x~ reported hepatic venous catheterization in patients undergoing orthotopic liver traru~lantation (olt) [ ] . in the present study, we assessed the effects of nitroglycerin (ng), a vasudilator that affects the venous capacitance vessels more than arterial vessels and prostaeyclin (pgi , flolan r~, wellcome, uk), an arterial and splanchnic vasodilator on hemodynamies and hepatic venous oxygen saturation (svho ) in human liver transplantation. methods: with institutional approval and informed consent, consecutive patients, mean age - -_ years, were studied following olt. postoperatively, fiberoptic pulmonary artery catheter was inserted into the right hepatic vein. timed infusions of ng at a rate of . gg/kg/min and pgi at ng/kg/min were initiated for a rain period. each sequence was followed by baseline therapy for rain. results are expressed as mean=tsd. statistical analysis was performed using friedman's-two-way-anova-test, significance was accepted at p< , . results: ng at . gg/kg/min induced a decrease of mean arterial pressure (map) ( _ [baseline] vs. + mmhg) and pulmonary artery wedge pressure (pcwp) ( j: [baseline] vs. : mmhg). cardiac index (ci) ( - vs. + l/rain/m ), oxygen delivery index (do i) ( -+ vs. + mgnfin) and svho ( _~ vs. -l-_ %) were decreased (p< . ). pgi at ng/kg/min induced a reduction in map ( • nm~. _g) and pcwp ( + mmhg). ci ( _+ l/rain/m ), do i ( : ml/min) and svhoz ( + %) were increased (!o< . ). vasedilatation induced by ng decreased systemic oxygen supply and impaired splanclmie oxygenation. pgi increased systemic oxygen delivery in parallel with svho , suggesting a corresponding improvement of hepatic-splanchnic okygenation. thus, if vasedilator therapy is indicated in th orient receiving liver grafting, pgi appears to be advantageous. however, due to its platelct aggregation inhibiting properties, the usefulness and safety of pgi in olt patients has still to be determined. objectives: to analyze the effect of steroid treatment given to donor on the early function of transplanted kidney. methods: from january, until now donors were involved into this prospective study. every other donor was treated with mg/kg solu-medrol one hour before organ retrieval. according to the steroid treatment of the donor the recipients were divided into two groups: group -steroid pretreatment goup (y~= ), and group -control group (n= ). the donors and the recipients were treated using the same kidney transplantation protocol onl~r the adults, and the first cadaver kidney transplanted patients were involved into the study. the daily routine parameters were analyzed pre-and intraoperafive, and on the - th, th and th postoperative days. results: we could not show any clinically important differences between the two groups in respect of donor parameters. preoperative, the patients in group had slightly lower ereatinin level ( -+ g.,non vs. -+ gmol/ ) which persisted into the early postoperative phase. the values of the other examined pre-and intmoperativc parameters were almost the same. during the first postoperative days the patients in group i needed less diuretics (furosemide and renal dose of dopamine) and their sodium excretion was closer to the physiological range than in group . the other parameters did not differ significantly. the less furosemide need in group ! pe~isted to the end of the first month. conclusions: according to our data the steroid treatment of the donors improves the early function of the transplanted kidney in some respects. to prove the real benefit of the donor steroid treatment needs more data and further analysis. objectives: severe infections may compromize the outcome of liver transplantation..determination of new parameters may increase the knowledge of pathophysiologic mechanisms and may lead to changes in postoperative therapeutic management of patients at risk. methods: between august and september , patients with transplants were monitored for cytokines and extracellular matrix pammeters on a daily basis. serious infections (n= ) included microbiologic evidence and more than secondary organ failures. patients with cholangitis (n=ll) or uneventful postoperative course (n= ) referred as control groups. results: -year patient survival was . % ( / ): patients died due to serious infections, while died for other reasons. mean bilimbin, stnf-rii-, ifn- -, il- -, il- -, il- -, laminin-and neopterin levels were significantly elevated in patients with serious infections compared with patients experiencing mild cholangitis or with an uneventful postoperative course. a further increase of all parameters was observed in patients who subsequently died; tnf-ri/: _+ pg/ml vs • pg/ml; ifn- : _+ pg/ml vs . -+ . pg/ml; il- : -+ pg/ml vs -+ pg/ml; il- : -+ pg/ml vs _+ pg/ml; il- : _+ pg/ml vs • pg/ml; laminin: -+ ng/ml vs -+ ng/ml; neopterin: _+ nmol/ vs _+ nmolb for non surviving vs-surviving patients. a significant decrease of sialic acid yeas observed in patients with serious infections; and a further decrease occurred in patients who subsequently died: -+ mg/l vs • mg/ . conclusions: the increase or decrease of various cytokines and extracellular matrix parameters may be indicative for severity of infectiolx routine monitoring of these parameters may improve current diagnostic tools and poss~ly lead to changes in therapeutic management of patients at ~k. objectives: evaluation of the cytokine network after liver transplantation may give some insight in pathophysiologic mechanisms of rejection and may lead to detection of patients at high risk. methods: patients with transplants were monitored for various cytokines on a daily basis between august and september . rejection was assessed by histology in combination with clinical signs of rejection and laboratory investigations. results: during the first postoperative month, patients ( . %) developed rejection; patients were successfully treated with methylprednisolone (steroid-sensible rejection), while further patients required additional treatment with fk or okt (steroid-resistant rejection). patients subsequently developed chronic rejection. mean levels of various cytokines and extracellular matrix parameters including tnf-rii, ifn- , il-ib, il- r, il- , il- , il- , hyaluronic acid and neopterin were significantly higher in patients with steroid-resistant than in patients with steroid-sensible rejection. a further increase of some parameters was observed in patients who subsequently developed chronic rejection; bilirubin: . -+ . mg/dl vs . -+ . rag/all; tnf-rii: -+ pg/ml vs _+ pg/ml; il- : +- pg/ml vs -+ pg/ml; neopterin _+ nmol/ vs -+ nmol/ ; hyaluronic acid: _+ ~tg/l vs _+ ~tg/l for patients with chronic versus patients with acute steroid-resistant ~ejection. sialic acid levels decreased in patients with acute steroidresistant rejection; and a further decrease was observed in patients who tieveloped chronic rejection: _+ mg/l vs _+ mg/ . ~onclusions: various cytokines and extraeeuular matrix parameters were indicative of severity of rejction. the extensive increase of bilirubin, tnf-ii, il- , hyaluronic acid and neopterin may indicate subsequent chronic ection. monitoring of these parameters may, therefore, lead to changes in immunologic management after liver transplantation. background : combined kidney and pancreatic transplantation is being performed with increasing frequency in patients with diabetes mellitus and renal failure, as it offers more chances of success and better results than kidney transplantation alone. mycotic arterial aneurysm constitutes a devastating complication following pancreatic transplantation. all cases of mycotic arterial aneurysms have been however reported with exocrine pancreatic drainage into the gastrointestinal tract. intervention : we describe a series of consecutive whole kidney-pancreas transplantation performed at the university of geneva hospitals ( beds) between december and may . exocrine pancreatic drainage into the bladder (epdb) was performed to improve early detection of rejection episodes. epdb was hypothesized to reduce the risk of contamination from the gastrointestinal tract and the subsequent possible occurrence of potentially fatal infectious complication. in all patients the dual transplantation was performed through a median incision according to the procedure described by nghiem. results : two out of the patients who received kidney-pancreatic transplant developed arterial mycotic aneurysms and days following surgery. aneurysms developed at the site of the arterial anastomosis used to rearterialize the homograft. both patients had peritonitis caused by candida albicans requiring surgical drainage and intravenous antifungal therapy. rupture with hemorragic shock occured in both patients leading to graft removal in one patient, and three episodes of lffetreateniug hemorragic shock followed by graft failure and removal days after transplantation in the other. conclusion : arterial mycotic aneurysm constitutes an early, lifetreatening complication of kidney-pancreatic transplantation; it mandates graft removal. although exocrine pancreatic drainage into the bladder consitutes a definitive advantage for caller diagnosis of graft rejection, it does not eliminate the risk for retrograde colonization and subsequent severe infection in our experience. s. bocharov, i. teterina, regional clinical hospital, irkutsk, russia acute profound loss of blood can result from the very different injuries and hepato-pancreato-duodenai operations enter such a rank. ill-timed and inadeguate correction of operation hemorrage is one of the reasons for postoperation complications, including polyorganic insufficiency. the pathogenesis seems to be very complex. in early stages of bleeding the liquid enters the vessel bed, followed by hypoproteinosis and hematocrit fall. however, as decompensation develops, the fluid leaves the vessel system in the result of increasing postcapillary resistance and lowering col-ioidnooncotic blood pressure (cop). the resulting hypovolemia causes primarily acute disturbance of central hemodynamics and then of microcirculations and transcapillary exchange. central hemodynamic failure after acute loss of blood manifests itself through cardiac output lowering and capillary blood flow deceleration. taking into consideration, that % is critical value for cpv loss and for cev it is %, we consider arising the level of cop to the immediate task. cop raising allows to normalize transcapillary exchange, which we assess through cop and mcp (mean capilary pressure) gradient. the next task is to make up for globular volume till homeostasis providing level. considerable attention is given to catabolism inhibition and maximum possible enegry provision. control over high proteolitic activity of blood and callicreinkinin system activity implies direct proteases inhibitors. reologic, membrane stabilizing, antihypoxanthine and anticoagulant therapies are obligatory. virehow clinic, dept. of surgery, humboldt university berlin, germany regarding a high mortality up to % of fulminant hepatic failure orthotopic liver transplantation seems to be the only promising therapeutic approach in many cases. this study shows experiences from a transplantation center. between june and april patients suffering fulminant hepatic failure were admitted to our surgical intensive care unit all patients showed severe liver dysfunction with grade ii to iv encephalopathy. after a period of diagnostics and conservative treatment ranging from few hours to days (mean . days) we reported of these patients as possible organ recipients to eurotransplant. all of these patients were transplanted within hours, ( %) of them even within hours. the principal aetiologies were hepatitis b ( ), hepatitis c ( ), nanb hepatitis ( ), mushroom poisoning (amanita phalloides ). after transplantation patients suffered from initial-non-function and underwent re-transplantation. the one-year-survival rate was %, patients died within months after transplantation due to various reasons. patients were not referred for liver transplantation. of them never met transplantation criteria, improved by conventional therapy and could finally be discharged from hospital. the known reasons for liver failure in this group were mushroom poisoning ( ), paracetamol intoxication ( ) and fulminant hepatitis a ( ). patients suffering from fulminant hepatitis ( ) or intoxication ( ) were excluded from emergency liver transplantation for various contraindications. of these patients ( %) died despite conventional intensive care. we don't know if some of the patients in the transplantation group would have survived without transplantation, because whenever we decided on transplantation we could perform the operation within hours. but the good survival rate in the transplantation group ( %) the % recovery rate in the group, where there was no transplant-indication in our opinion and the fatal outcome ( % mortality) in patients with contraindications are an encouraging proof of a successful therapeutic strategy in acute liver failure. these results are based on a close cooperation between experienced transplant surgeons, hepatologists and intensive care doctors, using sophisticated laboratory and imaging techniques in a specialized center. introduction: during brain death patients suffer from multiple endocrinologic disturbances. one of the most important are those related with thyroidal axis. it is well described the euthyroid sick syndrome whose more frequent pattern consist of decreased triiodothyronine (t ), increased reverse t (rt ) with normal levels of tetraiodothyronine ( " ) and tsh, this lacking in " " levels lead to a change from aerobic to anaerobic metabolism which results in tissular damage. objective: .to study thyroidal pattern in brain death patients potential organ donors. .to avoid organ impairment by administration of t . .to study the hemodynamic and hormonal changes after the administration of t in these patients. material and methods:population: brain death patients of any etiology potential organ donors admitted to the intensive care unit. patients were classified in hemodynamically stable (group ) and unstable (group ). group received a bolus of . p.gr/kg. and a perfusion at a dose of - . p.gr]h of t . hormonal assays: total t (tt ), total " (tt ), tsh. fxee t (ft ), free " (ft ) and rt were determine at the moment of clinical brain death ( hrs) and in group two these assays were repeted at hours , and . results: patients ( male) with a mean age of years (range to yrs.) were studied. the clinical brain death was confirm later with other explorations (eeg, doppler). there were patients in group ( , %) and patients in group ( , %). hormonal pattern: at the moment of brain death tt was normal in cases ( , %) and decreased in i ( , %); tt was normal in patients ( , %) and decreased in ( , %); ft was normal in cases (i , %), decreased in ( , %); fl' was normal in patients ( , %) , decreased in ( , %) .rt was normal in cases ( , %) and increased in cases ( , %). there were no statistically significant differences in hormonal pattern between the two groups. only t levels at hours , and were significant in group . in the cases with ft decreased, the tt was normal in ( %) and decreased in ( %), tt was decreased in ( , %) and normal in ( , %), tsh was decreased in i ( , %), normal in ( , %) and increased in i( , %) and ft decreased in ( , %) and normal in ( , %) and rt was normal in ( , %) and increased in ( , %). there were no statistically significant differences in cardiac index, vascular resistances and pulmonary shunt before and after the administration ef t . conclusions: . the hormonal pattern most often find in brain death patients was: normal tt , decreased tt , normal tsh, decreased ft , normal fr and normal rt . . there were discrepancies in the values of ft and tt . there were no statistically significant differences in hemodynamic and pulmonary parameters. objectives: magnetic resonance angiographie (mra), a non-invasive procedure, provides flow-related information additionly to the anatomy of the vascular system. measurement of signal intensity and edge detection of vessel structures permits to calculate blood flow velocity and vascular diameters. we examined whether cerebral hemodynamic changes by altering the arterial pressure of carbon dioxid (pace ) could be detected by mra. methods: following institutional approval and informed consent, mechanically ventilated patients without elevated intracraltial pressure underwent mra with defined periods of hyper-, hypo-and normoventilation (pace : , , mmhg; arterial blood gas probes; avl). mra was performed with a . tesla magnetom (vision, siemens). two different mra techniques were used: a conventional time-of-flight- d-angiography (tr: ms; te: ms; fl: deg; slab: mm) for vessel diameter detection and a flash- d-gradient-echo-sequence (tr: ms; te: ms; fl: dog) for measurements of blood flow velocity. an axial view parallel to the ac-pc-iine (anteriorposterior-commissur-line) was used for repeated imaging of identical regions of interest toi) of the proximal part of the internal carotid (ica) and middle cerebral artery (mca) as well as of peripheral branches of the mca and the posterior cerebral artery (pca). results: changes of pace correlated with changing signal intensities, whereby under hyperventilation a decrease of , % (p . ) and under hypoventilation an increase of . % (p . ) was observed compared with normoventilation. blood pressures were stable throughout the whole study period, pace dependent changes in vessel diameters were more pronounced in peripheral branches of mca and pca. a change from normo-to hyperventilation produced a decrease in proximal vessel diameter of - . % (p _< . ) and in peripheral diameter of - . % (p _< , ). a change from normo-to hypoventilation produced an increase in proximal diameter of + . % (p < . ) and of + . % (p -< . ) in peripheral diameter. conclusions: pace related changes of cerebral vessel diameter can be easily detected by mra without injecting a contrast agent. the results confirm that co -reactivity is more pronounced in peripheral cerebral vessels, which are subjected to greater changes in diameter than major basal arteries. hyperventilation leads to a decrease and hypoventilation to an increase in signal intensity thus reflecting the corresponding changes in blood flow velocity, intensive care unit (icu) of "kat" hospital, athens, greece, ob!ective$; the value of bronchoscopy in pulmonary atelectasis of icu patients is under question the presence of an air bronchogram sign in xrays, which is considered as evidence of central bronchus patency, is referred in several studies as a negative criterion for bronchoscopy, whereas its absence as a positive one. it is also referred that air bronchogram sign correlates with delayed resolution of atelectasis, probably because of obstruction of many periferal airways (not central). the purpose of this prospective study was the evaluation of the air bronchogram sign on frontal chest film as a negative criterion for bronchoscopy and as criterion of delayed resolution of atetectasis, methods: icu patients with atelectasis were studied prospectively. they underwent bronchoscopy, bronchoscopic findings, presense of air bronchogram sign, and outcome of atelectasis were recorded, correlations were made, between: ) bronchoscopic potency of airways and air bronchogram sign } resolution time of atelectasis and broncoscopic potency of airways. ) resolution time'of atelectasis and air bronchogram sign, methods of statistical analysis were the t-student test and the chi square test, results:the patients were , men women , seventeen patients had atelectasis of whole lung, of upper lobe, and of lower lobe. ten patients had atelectasis in right and in left lung. eight from patients had air bronchogram sign in x-ray, there was no statistical correlation between air bronchogram sign and bronchoscopic potency of airways [ from patients with air bronchogram sign ( %) and from without air bronchogram sign ( %), had bronchoscopic potency of airways, p> . ], resolution time of atelectasis didn't correlate statistically with bronchoscopic potency of airways (mean resolution time in patients with bronchoscopic potency , days and in bronchoscopically closed bronchi , days, p> , ). there was also not a statistical correlation between resolution time of atelectasis and air bronchogram sign (mean resolution time in patients with air bronchogram sign , days, and without air bronchogram sign , days. p> ). conclusion~i; the presense of an air bronchogram sign in x-ray of icu patients with atelectasis, does not coexist obligatorily with bronchoscopic patency of airways and cannot be used as a negative criterion for bronchoscopy, neither as a criterion of delayed resolution of atelectasis. th. wertgen chest sonography (cs) is routinely used in our department to examine icu patients with clinical symptoms of pulmonary embolism, pneumonia, pleural effusion or unclear chest pain. we perform cs with a sector transducer ( . mhz) and a linear transducer ( . mhz) using acuson xp/ c. the sonographic signs of pulmonary embolism and infarction are most well demarcated, mainly wedge shaped and triangular pleural based lesions, more roughly structured, observed with a hyperechoic reflex in the center corresponding to the bronchitic (fig. ) . pneumonia is characterized by homogenously hypoechoic, wedge shaped parenchymal lesions, containing air or fluid bronchograms; they move with respiration (fig. ) . pleural effusions are spaces of various echogenicities, from anechoic to homogeneously echogenic, which may contain floating strands or complex septa, located between visceral and parietal pleuras (fig. ) . from march to april we did examinations by cs in icu patients ( male, female; age from - ). patients examinations pulmonary embolism pneumonia pleural effusion us-guided thoracic punctions were performed in patients. in two patients we found pneumonia or pleural effusion caused by a lung carcinoma. another two patients showed a normal cs (diagnosis: inflammation of the gall bladder, inflammation of the myocardium). conclusion: cs is a very useful method for icu patients with chest diseases. it takes less time and is less expensive than ctand sometimes of a higher diagnostic value than x-ray. last but not least cs is invaluable for the icu patient, because the examination is done save and quickly at bed side and the results of cs are very helpful in diagnoses and treatment. results : inter-observer reliability was evaluated as an % concordance. results of the tee classification were : class : n = ( %) ; class : n = ( %) ; class : n = ( %) ; class : n = ( %) class : n = ( %). therapeutic implications of tee in class patients were : cardiac surgery in patients (two cases of acute mitral regurgitation, two valvular abscesses and one hematoma compressing the left atrium), discontinuation of peep in one ventilated patient with an atrial septal defect, weaning of mechanical ventilation in one patient with an atrial septal defect, prescription of antimicrobial therapy in patients with endocarditis and prescription of anticoagulant therapy in patients with left atrial thrombus. the only noteworthy complication was a case of spontaneously resolving supraventrieular tachycardia. conclusion : tee is safe and well tolerated, and is useful in the management of icu patients with shock, unexplained and severe hypoxemia or suspected endecarditis. the aim of this study was to determine whether ultrasound guidance can help interns to improve the results of jugular vein access in icu. methods : in a prospective and randomized study, we compared, in patients admitted to the icu, an ultrasound-guided method (ultrasound group : patients) with an external landmark guided technique (control group : patients). all jugular vein accesses were performed by young interns with an experience of < procedures. results : internal jugular cannulatian vein was aci~ieved in all patients in the ultrasound group and in patients ( p.cent) in the control group (p < . ). average access time was longer in the control group ( • sec. vs • see. ; p = . ) and puncture of the carotid artery occurred in patients in each group (p = . ). patients ( p.cent) in the ultrasound group and patients ( p.cent) ia the control group (p < . ) were cannulated in rain. or less. the cannula was therefore unabie to be inserted within minutes in patients in the control group, with failure of eannulation in of these patients ( p.cent). failure was due to thrombosis (n = ), small calibre of the internal jugular vein (< ram) (n = ), abnormal vascular relations (n = ) or cervical irridation (n = ). among the primary failures of cannulation, an internal jugular vein catheter was able to be inserted in cases by an experienced physician on the side initially selected and with ultrasound guidance in cases. the catheter was inserted into the contralateral internal jugular vein under ultrasound guidance in the remaining cases. jugular cannulation was obtained at the first attempt in p.cent in the control group and p.cent in the ultrasound group. conclusion : ultrasound guidance improved the success rate of jugular vein cannulation by inexperienced operators in icu patients. when the internal jugular vein has not been successfully eannulated within minutes by the external landmark guided technique, the authors recommend the use of the ultrasound guidance. in the majority of cases right atrial or ventricular thrombi represent pulmonary emboli in transit. these may be fatal in patients (pts) treated conservatively with anticoagulation only. in literature the incidence of right heart thrombi in pts with proven pulmonary embolism (pe) is said to be in the range of - %. extremely mobile, long, worm-shaped masses in the right heart cavities carry an especially high early thrombus-related mortality rate which ranges from - %. current therapeutic strategies favour fibrinolytic therapy with consecutive anticoagulation. we report five cases ( male, i female, - years) of right heart and pulmonary thromboembolism. in these pts diagnosis and regression of thromboemboli following systemic intravenous lysis therapy with recombinant tissue-type plasminogen activator (rt-pa) was documented by transesophageal echocardiography (tee). a submassive pe occured in pts, a massive pe in pts. one patient (pt) had a cardiac arrest. in all cases tee clearly identified the extensive thrombns formation in the right-sided cavities of the heart and in the central pulmonary artery in cases. all pts were treated with mg rt-pa, pts in a front-loaded regimen over minutes, pt over minutes, and, due to the life threatening situation, in one case a bolus injection as ultima ratio was performed with no intracerebral bleeding complication. regression of thromboembolic masses after fibrinolytic therapy was demonstrated by transthoracic and transesophageal echocardingraphy after to hours. all pts survived and were put on coumadine, pt developed an intracerebral bleeding with persistent hemiplegia. conclusions: the use of thrombolytic therapy is highly efficacious for the therapy of pts with pe and concomitant right or ventricular thrombus formation. transthoracic and especially transesophageal echocardiography are powerful bed-side diagnostic tools for the immediate diagnosis and follow-up of successful treatment in this life-threatening condition. although widely used, catheterisation of the femoral vein in the groin using "landmark" technique is frequently complicated by accidental arterial puncture. suboptimal hygiene and patient discomfort are also associated with this technique. with regard to these last two factors cannulation of the femoral vein - cm below the inguinal ligament would seem an attractive alternative. as "landmark" technique is not possible for the cannulation of the femoral vein in this part of the thigh, ultrasound was used to locate the vessel and the results of this technique were evaluated. methods: a portable compact ultrasound device (site rite,dymax corp.) featuring a . mhz transducer (ultrasound depth - cm) fitted with a needle guide and a cm screen was used by residents with no previous experience in ultrasound guided cannulation. patients consisted of a surgical icu population. results: in patients catheters were introduced.in cases more than one ( - ) attempt was made and in patients the procedure was unsuccesfull due to the fact that the vessel was situated out of reach of the ultrasound (vessel depth > - cm), during the procedures one accidental arterial punction was registered. the catheters remained in situ for a mean of days (range - ) and were used for volume suppletion, medication, parenteral nutrition and haemodialysis.co-ionisation rates compared to those of subclavian catheters in our icu. in the first patients cases of asymptomatic thrombosis of the femoral vein were seer on ct-scans performed for other indications, in the following patients duplex scanning performed after removal of the catheter yielded another cases of asymptomatic femoral vein thrombosis. conclusions: ultrasound guided femoral vein catheterisation - cm below the inguinal ligament is a safe and simple technique that can easily be performed by residents without prior experience. the incidence and impact of thrombo-embolic complications associated with this technique are still subject to further investigation. objectives: to estimate the cost of antibiotherapy (ab-cost) in a multidisciplinary -bed greek icu and to correlate ab-cost with total cost of drugs and consumables and with patient's outcome, severity of illness and type of admission. methods: prospective data from consecutive patients admitted to the icu from / / to / / were studied. a tick chart was designed to record all drugs, materials and consumables regularly used for icu patients, but did not include low price drugs and consumables, which are provided from hospital's pharmacy as stock and were included in a fixed icu cost calculated for a month period. the chart also contained demographic details and data necessary for the calculation of several illness severity scoring systems. obiectives: over years evaluate the necessary efforts and expenses to implement a cis in the routine of a -bed stcu. methods: in june a commercially available, unix-based cis was installed on a -bed surgical icu. the goal was a paperless documentation at the bedside. after more than years clinical experience two aspects were investigated: what effort is necessary to install and support a cis, and what is the benefit for patients and personnel on the icu? results: the installation and support of a full-fledged cis requires a considerable effort: (a) the conceptual framework for the cis has to be defined. this includes the definition of documentation standards, as well as nursing and therapeutic standards, which is the essential basis for the configuration of any cis. (b) configuring a cis, i.e. "fine-tuning" it to the user's specific needs, is always a laborious task. moreover, constant maintenance is necessary. these tasks require the following personnel: experienced health care professionals for defining the conceptual framework, - trained health care professionals for configuration, system administrator. on a single icu ( - beds) these are not considered full-time jobs. (c) training is best done employing the "train-the-trainers" approach. (d) beside the necessary amount of man power and money to install and purchase a cis, administrative and mis support is needed, especially when interfaces to the hospital and laboratory information systems have to be set up. in general, a cis needs the commitment of all people involved. without a really professional approach with a longterm goal any major cis can turn into an unnecessary but inevitable night mare. after years clinical use and a thorough implementation of a cis on a major sicu it can be said that full-fledged cis offers an opportunity to dramatically improve the working environment on an icu. moreover, it adds to patient safety, quality of care and cost efficiency in one of the most advanced and expensive areas of medicine. conclusion: a major investment in man power and money is necessary to install and maintain a full-fledged cis. a sincere professional commitment to the goals of a cis is necessary. in exchange, a well configured and well maintained cis dramatically improves the quality of therapy and care on the icu. even return of investment and financial profitability of a cis seem feasible todayl from the clinical perspective it appears that the users themselves are the central determinant whether a cis makes a dream come tree or turns into a night mare. objectives: to establish a relationship between the activities of the staff and the occurrence of auditory alarms on the i. c.u. ard to evaluate confusion between auditory alarms. methods: laboratory based studies which investigated aspects of confusion between alarms in current use on the i. c. u. the observational studies were conducted over an month period and examined the frequency and duration of alarms together with the concurrent activites being undertaken by staff on the unit. the laboratory based studies showed that there were enduring confusions between the alarms on various items of medical equipment, for example a ventilator alarm and an e. c. g. monitor alarm. the results of the observation studies demonstrated that alarms are activated when specific activities are being undertaken by staff. sounds could be used in future recommendations for alarms on medical equipment. suggestions are also discussed for improving and rationalising auditory warnings in the i. c. u. obiectives: we investigated inferior petrosal sinus (ips), the lowest affluent to jugular bulb (jb), as a possible source of contamination of samples in jb for monitoring oxyhemogiobin saturation (sjbo ). pulling back the catheter the oxyhemoglobin saturation usually rises indicating extracerebral contamination (jakobs en met al: j cereb blood flow metab ; : ). methods: the study was carried out on patients undergoing ips sampling to differentiate cushing disease from ectopic acth syndrome and to lateralize any resulting pituitary lesion. we studied the value of oxyhemogiobkn saturation high in jb (sjbo ), at ips (sipso ) and at mid jugular vein ( th cervical vertebra) (smj ) bilaterally. results: we found significant differences between right sjbo and both right sipso (p= . ) and right smjo ( p= , ) and between left sjbo and both left sipso (p= . ) and left smjo (p= . ) we did not fred any difference bilaterally. objectives: we studied various methods of receiving and editing of clinical datas in critically ill patients (different ethiology). patients were investigated in regional intensive care center. methods : the following datas were studied : anamnesis, status praesens objectivus ( organs and systems ) ,. clinical and biochemical markers of critical condition , datas of eeg ,rheography . the medical information complex contained : channel electroencephalograph, -channel roencephalograph, ad-converter ( analog inputs, bit resolution, k hz), ibm dx , software includes set of routines for spectral eeg analysis, eeg-mapping, correlative analysis, and brain bloodstream reg-monitoring (written in turbo pascal . ), expert programs for estimation objective and humoral patient status (written in clipper . ) and statistics. there were used following programme-language instruments : borland c++ . , nantucket clipper . , ca-clipper tools ii. as the methods of statistical processing of dates were used: t-students criterion , fisher criterion, methods of correlation analisis, calculation of the regression levels, dispersion analysis, results : there was created the optimal structure of hard and sofware complex of search steady objective regularity in dynamic of critically ill patients condition. conclusion : the created system allowed to value effectiveness of intensive care and give us new opportunities in study pathogenesis of systems disorders in critical condition . over a five year period a patient data management system has been installed which allows individualised patient data to be accurately collected. using this data a costing system has been developed which ascribes costs thus: . direct costs -drugs, fluids, consumables, interventions. these are ascribed to individual patients, according to data collected from the pdms. . indirect costs -energy, depreciation, admm costs, maintenance etc. these are summed for the year and ascribed as an overhead per patient day. n.b staffcusts contain art element of both cost types the aim is to make as many costs as possibie 'direct', hence 'activity costs' have been calculated winch comprise staff time, drugs and consumables -these are direct costs. these costs of patient care are then searnlessly integrated into the financial and budget management of the icu environment. it was found that by calculating costs in this manner % of the total cost of icu are captured within the 'direct' element, and so are able to be ascribed to individual patients. this is much more accurate than simply dividing the total costs of ~cu by the number of patient days. temporal costs (variations during patient stay) and cross sectional costs (cost differences between admitting specialities) were also noted with interest. results of the initial analysis of data captured by the system will be presented. little is known about the resource costs (not simply cash costs) of icu. even less is known about individual patient costs, with previous estimates of these costs varying widely. however, if cost effectiveness studies are to be undertaken accurate calculation of individual, group and total icu cost is an essential, prerequisite, which, via this system of costing, is now achievable. information about intensive care of cancer patients is limited in the literature, despite the increasing use of such facilities in oncology over the two last decades. in order to determine if and how critical care facilities can be used specifically for these patients, we performed a world-wide inquiry in anticancer centers selecting the hospitals by using the international directory of cancer institutes and organizations. we mailed a questionnaire to centers and we received responses ( . %). there was at least one uncological (i.e. with > % of cancer patients) icu in (% % an -year old woman with graves disease presents with sore throat, vomiting, diarrhea, sinus tachycardia at /minute and a temperature of ~ several weeks before, treatment with propylthiouraeil had been stopped (rash and fever) and replaced by methimazole and ledide prior to a minor surgery. however, both drugs were discontinued by the patient two weeks before admission. shortly after arrival in hospital, patient's condition progressed to respiratory failure (upper airway edema), delirium and shock requiring icu admission, intubation and resuscitation with fluids and vasopressors. white blood count was /mm ~ with neutrophils. patient's hemodynamic data showed initial hyperdynamic profile followed by low output state with decreased sv ( %) (n - %) and cardiac index ( , ) (n , - ). echocardiogram confirmed cardiac chambers dilation as previously described in thyroid storm. lithium carbonate, corticosteroids, antibiotics and beta-blocker perfusion were given. plasmapheresis was started. free t& (n= , - pmo/l) went from , to , after the first two pheresis. after a remarkable clinical recovery, sub-total thyroideetomy was done i days after admission. in life-threatening thyroid storm, plasmapheresis is a very effective therapy when anti-thyroid drugs are counterindicated. purpose: to compare the reliability of prognostic indexes in crhically iu patients admitted in an intesive care unit (icu) who had acute renal failure (arfi and were treated with different dialytic techniques. material and methods: patients were included in a prospective study from june to november . patients presented arf defined by creatinin serum leve(s greater than pmol/l and previous normal levels. patients were divided in three groups. group i (control) : patients with arf who did not receive substitutive techniques. group ih patients under intermittent hemodialysis (hd) or peritoneal dialysis (pd). group ii : patients under continuous hemodiafiltrstion (hf). the statistical analysis was chi-square test and analysis of variance. results: the table shows the results we obtained, we did not find any significant difference betwen the two groups of patients undergoing dialysis. d(fferences were observed only between group i and the other groups as shown below. we did not find any significant association between the theoretical mortality predicted and the observed mortality according to saps in the three groups. due to exposure to a wide variety of unpleasant stimuli, for example, tracheal suctioning, venipuneture and physiotherapy, most pataents admitted to the icu will require some form of sedation. this review will describe the suggested properties of an ideal sedative agent for use in the icu and review the current limitations of some of the available agents from this perspactive. methods used to quantify the level of sedation, such as the ramsay score, glasgow coma score, newcastle sedation score and visual analogue scores, and their deficiencies will be examined. consideration will be given to defining the optimal level of sedation and the circumstances under which sedation might be varied over the icu course will be discussed. preliminary results from an ongoing study examining the role of light versus heavy sedation and ischaemia in a cardiac surgical icu population will be presented. the pharmacceconomics of icu sedation will be briefly addressed. finally, the role that sedation may play in increasing morbidity, pastieuiarly nosocomial pneumonia, in the icu will be discussed. objectives : therapy cost(tc) in icu patients is a substantial component of total hospital care cost. estimation of tc during this year, partitioning to various groups of drugs used and attempt to minimise it, were considered practically useful. methods : in collaboration with the hospital pharmacy we were able to have a complete report of au drugs used for icu patients (including enteral and parenteral nutrition). mean apache ii severity score upon admission was . and mean length of tcu stay was . days. price per drug unit and cost per group of drugs were also available drugs were divided into two groups: antibiotics ( ) cardiovascular drugs ( ), gastrointestinal system drugs ( ), enteral and parenteral nutrition ( ), respiratory system drugs ( ), sedative, analgesics and paralysing agents ( ), parenteral solutions with electrolytes, vitamins and trace elements ( ), anti-inflammatory agents ( ), protein substitutes and immunomodulation agents ( ), anticoagulative agents ( ). antibiotics were further subdivided into those "freely" prescribed (a) and those whose prescription and administration requires filling of a relevant form (b). results : !) tc for icu patients/day was . drs ($ ). total tc/patient was . drs ($ . . ). ii) partitioning total tc per group of drugs reveals : ( ) %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %. t ) concerning antibiotics which consist the major cost component, group a and group b contributed by . % and . % to the total icu tc respectively. group b were administered to . % of all icu patients. conclusions : i) for the above studied patient population antibiotics consist almost half of total tc followed by protein substitutes and immunomodulation agents. ii) if tc control could be attempted in the icu, prescription of beth groups must be reviewed. appropriate treatment should be prescribed and readily provided to any patient. clinical significance of routine protein substitution, currently controversial, should be re-evaluated. new antibiotics (third & fourth generation cephalosporins, quinolones, carbaponems) should be prescribed on the basis of strict diagnostic procedures using modern technology available. rationalisetion of antibiotic therapy will lead to cost control, redistribution of icu expenses and substantial contribution to infection policy in our country. objectives: i -to investigate the clinic efficiency of the monitoring of the rso cerebral, in relationship to the stroke prevention, in patient undergoing carotid surgery. -to determinate the variations of the rso during the different surgical and anesthetic procedures in these patients methods: ten patients undergoing carotid endarterectomy. precise neurological exploration previously to the surgery and in the immediate postoperative period. angiography evaluation to the extend of carotid artery disease. invasive blood pressure, ecg, pulse-oximetry ( pso ) and rso were collected previousty to the induction of anesthesia. the premedication was administered intravenously -midazolam ( mcgr/kg) and fentanyl (i rncgr/kg) -. thiopental ( mg/kg),fentanyl ( mcgr/kg) and atracnrium ( , mg/kg) have been used for induction of anesthesia. co te is monitoring al~er the orotraqueal intubation ! the anesthetic maintenance is accomplished with lsofluorane ( , - , %) and bolus of atracurium and fentanyh the surgical procedure is standard (without arterial shunt during the carotid cross-clamping). we register each minutes: blood pressure, cardiac frequency, pso , co te and rso . the rso cerebral variate in relation with: the anesthetic induction, blood ~ressure, co te, cross-ulampping carotid and with the modifications of the head position. the maximum decrease of rso cerebral was in relation with the :ross-clampping carotid ( minimal value: ). no patient had neurologic complications and postoperative stroke after carotid endarterectomy were not observed. objectives: there are more than anesthesia in chelyabinsk emergency hospital every year. to % patients of it emergency anesthesia is applied. more than patients have ishemie heart disease (ihd), hypertansion (hp) and previos miocardial infarction (pmi). more than % of all patients are old patients (op). the resalts deep noninvasive bioimpedance monitoring (nbm) in surgical patients have been studied by us. methods: our nbm system "kentavr" includes parameters of cardiac and vessels function. it is realised by monitors in operation theatres and computer network. moreover we are able to examine surgery patients before anesthesia and perioperatively by using special computers system for cardiovascular reflex control by fast fourie transform (fft) of parameters simultaneously. results: pathients extremly needed peryoperative monitoring of hemodinamics. from these patients more % had stroke volume (sv) less than ml, n -co less than . /mim/m , % -ejection fraction (ef) less than n and % -puls bioimpedans microvessels (pbm) less than morn. patient had intensive care in special department. out of died. comparing with survived with these patients before operation hr was larger, sv, co,ef, pbm and puls bioimpedance aortha was smaller. much more of these patients were with ihd, pmi, hd, op. even with survived patients these parameters decreased the towards the end of operation. surgery patients had different variability of basic hemodinamical parameters with common tendency to increase power amplitude in low frequency by fft. conclusions: using of bioimpedanee noninvasive parameters allows to have criteria for corrections (infusies, vasodilatators, inotrops and others) and then us the final goal, to have more sucssesful surgery. with survived patients was perioperatively and postoperatively care more intensive. obiectives: the aim of the study was to compare the phi with the hemodynamically derived tissue oxygenation indexes as: oxygen delivery (do ), oxygen consumption (vo ), cardiac index (el), and arteriovenous difference in oxygen [(a-v)do ]. methods: patients ( males and females) with major trauma or major abdominal surgery were studied. on admission, a nasogastric tube allowing phi measurement was introduced and a pulmonary artery catheter was inserted for optimal hemodynamic management. each phi measurement was accompanied with a complete hemodynamic study comprising systemic and pulmonary artery pressures, blood gases, and cardiac output measurements with the thermodilution method. derived parameters vo , do , ci, (a-v)do were measured according to the standard formula. hemodynamic parameters were opt• as soon as possible with fluids, inotrepes, and vasopressors according to repetitive hemodynamic measurements. all patients were under mechanical ventilation. after hemodynamic stabilisation phi and hemodynamic measurements were repeated every eight hours, during a -hour study period. a total number of measurements were obtained and compared. statistics: results are presented as means + sd, correlations were performed between phi and the hemodynamically derived oxygenation parameters. a p< . value was considered as significant. results: mean values were phi= . + . , do = + , vo = + , c. = . + . , (a-v)do = . + . . no correlation was found between phi and do , phi and vo , phi and c.i, phi and (a-v)do . on the contrary in patients phi remained below . for more than hours despite adequate hemodynamically derived tissue oxygenation parameters. mortality in this group of patients was very high ( %). conclusion: no correlation was found between phi and the hemodynamically derived tissue oxygenation parameters our data suggest that phi is a better oxygenation indicator than the hemodynamically derived tissue oxygenation parameters, because it is closely related to the patient's outcome. objectives: the pathogenesis of septic shock and multiorgan failure is believed to be related to tissue hypoxia of the gastrointestinal tract. therefore new monitoring techniques, preferably organ specific, are required to establish the adequacy of tissue oxygenation. peep is used to reduce pulmonary shunt volume and improve blood oxygenation, but is accused to impair splanchnic perfusion. we studied mucosal oxygenation and perfusion on the capillary level in the stomach and the duodenum. methods: we used the erlangen microlightguide spectrophotometer (empho ll) together with a specifically designed fibre probe (bodenseewerk ger~tetechnik, berlingen) in combination with a standard gastroscope. measurements were performed on ventilated, traumatized patients (ages - years), with no evidence of shock or severe infection, after informed consent was obtained from the relatives. all patients were hemodynamically stable without inotropic support. an area of cm was analysed in the gastric corpus, the antrum and in the duodenum. in three patients we simultaneously measured the muc sal blood flow using a laser doppler flowmeter ( objectives: to investigate the influence of hb-o affinity in the monitoring of svo~ during improvement of cardiac index (ci) in cardiogenic shock. design: to state whether changes in svo: were associated in changes in actual pso (p~ ) and standard p~ (ps st) consecutive measurements of artero-venous bga, before an.d after therapy-induced changes in ci, were evaluated in patients (mean age -* y) suffering from cardiogenie shock, all under mechanical ventilation in psv modality. methods: together the hemodynamic measures, m~xed venous samples were analysed at ~ c using the abl radiometer for po , pco: and ph, and the osm radiometer for hbo %, hbco% and methb%. psost (i.e. the p~ at ph= . , pco:= mmhg and temperature at ~ c) was calculated automatically by the instruments on mixed venous blood as was the ps "in vivo" (i.e. the pso at the patient's value of ph, pco and temperature), using siggaard-andersen's computerizated algorithm. mean time between paired measurements was . -* . houm. the data were compared by anova test for linear regression and t-test for paired samples. results: a dose linear relationship was found between svo and oxygen extraction ratio (oer), r= . ,p= . . the improvement of ci ( . -* . to . + . l/min/m , p< . ) induced a significant increase in svo~ ( . -* . to . • . %, p<. ). a significant decrease in p ( . • . to . • . mmhg, p< . ) without any significant change in p~ st ( . • . to . • . mmhg, p=ns) was also found. these data show that either oer or the shift to the left of the oxygen dissociation curve account for increase in svo occurring with restoration of systemic blood flow. the program is intended to help the intensive care unit interne providing him with a practical tool when making decisions concerning patients in a critical condition. in his daily practice in intensive care unit, in this case the interne of the unit, uses this program for each patient as follows: on the first stage of data collection he should complete the following modules: ( )personal data ( )patient's pathology ( ) laboratory and~ monitor lug data ( )drugs prescribed or toxic elements ingested. in this way, the system allows optionally the consult with a computerized data base about the drugs prescribed, standardized parameters and techinques performed by the central laboratory. ( )reference to an antibiotics guide regarding becterian sensitivety in our unit, whitch ee checked every six month ( ) access to de questionnaired apache ii to load up new data. ( ) statistcs about patient's admission and discharge. results: once all data collection is finished the system performs the followin duties: ( )detailed drugs interactions, including toxic elements ( )diagnosis starting from the clinical, laboratory and monitoring data. in some cases, it also establishes therapeutic strategies, e.g. a coagulopathy ( ) give the l~narmacological incompatibilities between the drugs p~escribed and %he diagnosis established, and ( )perform dosage adjustments based upon the personal and pathological data. objeatve: to assess the power of diseri~,~ion ofa multiperpose severity score (sai~) when applied to subgroups ofpatieals (pta) according to their lemg~ of ~ay (los) in icu. design: in order to compute the saps probability, a model derived fi~m legible regression was developed. meaumree of calibration (goodmem..of.fit statistics) end discrimination (roc cm've and relative area under the cm've) were adopted in develotammtul asd validation set. the whole databue was ~ati~ed in five gronps reeked on los as follows: los = days, los = - days, los = - da~, los = - days, los > day~. area under the carve (auc) was ud~ninted for each ro~. s~ing: imlimlcus. patents: of ~ pts comec~ively admired ~ a period of three yeet~ ( ) ( ) ( ) , a total of was i~leded in this study. pts without saps, p~ yolmger them yearn, p~ with los shorter ~ hom'~ were excluded from this maly~is. iaterventinns: nose mema'onm~ end result: the logistic model developed gave good remits in terns of calibration md discrimin~on, both in developmental set (do.s g : . , p > . ; auc = . i- . ) and in validation ~t (g.o.g g : . , p > . ; auc = . ..+ . ). auc of each grottp showed a loss in di~zimination (i.e., prediaton) closely related with los, being . i- . in pts with los = days el . ~. ia tm with los > da~ (figure). following the present guidelines of integral management, in order to achieve optimization of sanitary resources and better use of facilities, we feel that the setting up of objetives is a key factor in the continuous process of improvement of quality care. postsurgical intensive care services maintain an interdepent relationship with other hospital services. within the general plan of the hospital it's of the utmost importance to delegate autonomy to the various depertments and service units in determining and achieving objetives. it's also necessary to establish mechanism for coordination of the activities in order to assure the succes of the program. the objetives cannot be improvised, they must be carried out in a specific manner in the following stages: .-analysis of the present situation (starting point). where are we?. defining objetives and making explicit the activities and methods to achieve them is to anticipate the future; it is of the utmost importance to comunicate said plans to all whom affect by encouraging them to attain the desired results. in the present paper we intend to show the guidelines to follow in carrying out a course of objetives. introduction:we presents results related to the quality of life (qol)of critical patients, from paeec project data. material and methods: the paeec project is a multicentre study define the type of patients cared for in spanish icus, and the therapeutic activity provided. ninety-five icus from spain are taking part. this study analyzes the qol of critical patients prior to their icu admission.for the evaluation of qol a questionnaire designed by our team for critical patients was used, with items grouped in sub-scales: physiological functions ( items); functional capacity ( items) and subjective aspects ( items). qol is classified in levels: normality ( points); slight deterioration ( - points);moderate deterioration ( - points); significant deterioration (>i points). the we present results related to therapeutic activity in critical patients and their age, from the paeec project. material and methods: the paeec project is a multicentre study to define the type of patients in spanish icus, and the therapeutic activity provided. ninetyfive icus from spain are participating. this study analyzes therapeutic activity in the first hours as evaluated by tiss, and related factors. results: the sample was , patients, sge . ~ . years. severity by apache ii system was . • points. the tiss score was . • points, distributed as follows: i (<i points): %; ii (i - points): %; iii ( - points): %; iv (> points): %.there is a positive correlation between the level of therapeutic activity and severity by apache ii (r = . , p < . ), and a very weak but negative correlation between tiss and age (r = - . , p < . ), so that an increase in age corresponds to a lower level of therapeutic activity.patients the multivariate analysis of the relationship between tiss and age took into account: severity, existence of previous history, need for mechanical ventilation, size of hospital, diagnosis and mortality. it indicated that there continued to be a relationship between therapeutic activity and age, so that as age increased, therapeutic activity diminished. conclusions: therapeutic activity performed on critical patients is less in the oldest patients, in whom excessively aggressive procedures are limited. a relational data base management system in the icu. c. kotsavassiloglou*, d.matamis, g. dadoudis, j. kioumis, d. riggos. icu dep., g. papanicolaou gen. hosp., exohl, thessaloniki, and * a' neurological clinic of aristotelian university, thessaloniki, greece. objectives: the introduction of the information technology in the i. c. u seems to be unavoidable because of the large amount of produced data and the need for their systematic analysis. such an information system should be a) easy to use, b) friendly to the user, c) powerful and d) modular. on that basis, we created a patient data management system (pdms) according to the expectations of the medical staff of an eighteen bed multidisciplinary icu. methods: we selected paradox for windows v . for the implementation of a relational data base because this program meets the above mentioned criteria. informations regarding the patients include a) demographic data, b) previous medical history, c)diseases upon admission, d)complications during hospitalization and e) outcome data. the diseases' registration consists of items classified in categories upon the principal system affected. specific informations about the need and duration of mechanical ventilation, nutrition, renal replacement, right heart catheterization and icp monitoring are also available. an extension was added concerning icu infections and related informations about antibiotic-resistant pathogens. all icu pathogens can be matched to their resistance or sensitivity and cost of antibiotics. the program can perform queries and various statistical analyses based on complex criteria. new modules can be added later according to the future needs and remarks of the users. results: the program was well accepted by the medical staff and patients were registered as a test. the first analysis of the data related a) observed mortality versus the apache ii predicted mortality, b) mortality according to the age, gender, pathology aud duration of icu stay and c) pathology upon admission and icu related complications. conclusions: the long term use of this pdms can be an efficacious research tool. it can be used in retrospective or prospective studies by addition of necessary modules. the first data analysis revealed the iack of an international diseases' classification system. the development of a worldwide common classification system is essential for the compatibility of the data analysis among various icus. this will allow the realization of multicenter trials on a large scale. s. nanas= n. sphiris, a. precates, a. lymberis, m. pirounaki, and ch. roussos dept. of critical care, university of athens, athens, greece the complexity of the cases submitted to an icu, the variety of underline disease, tbe severity, as well as the large number of substances administered to each patient constitute obvious the need of support with an easy available dss. this system will assure the safety of the administered treatment will help to adjust the dose according to the situation of each patient and it will screen for possible interaction and incompatibilities between the administered drugs. the goal of the present effort is the design and development of a software system acting as a decision support tool to physicians of icu. the application is organised around a relation database management system (rdbms) that consist of: a) all available substances ( . ), b) all generic names of medications available in our country for each substance, c) incompatibilities ( . cases) and d) interactions with other substances ( . cases). the following figure shows the structure of the rdbms. y ta~ortato~ [ c~rs using the stored parameters for each patient the dose and the rate of administration of selected substances will be possible to calculate. the continuous monitoring of the treatment for each patient supports the medical staff to make the necessary changes of the prescriptions. the application is currently developing in wireless pen based computer systems which place patients at the centre of "islands of information" located throughout icu. in conclusion this dss is a powerful and useful tool for icu staff because it provides without additionai work to the routine of daily practice, the currently available information for each order concerning drug interaction and incompatibilities as well as treatment monitoring is to obsea~ among critically ill pfdieats, stdjdivided following the diagn~s at the adn~ssio~ the diffmeax:es in the ~ and oxyplx~efic l~mmems bawe~ strvwors [s] and non sumvors ins] and to test the pc~'bih'ty to have soar survival criteria, as earliest as tx~able. method~ :we made a ~ study on consexa~e ~ilically ill paliffas, subdivided in series following the diastases at the admission: medical pafiea~ ( s and ns), surgical patients ( s and ns), a~d poliwauntas ( s and ns). follow up was done at d,.ays from the admission in ice. all the patienls were ramitored with a ~ c~eter and laeno:lymmi. "c and o .x.xyphorefic txuamaers va:~e couected at fin~es (t): at fiae ~draission (t ), at x~ars from t (t ), at (f ), (y ), (t ), % (t ) and horus from t cf ). in~,h ~ies, for ~y ~ a all the lin'~ n~an and sandaid d~viation was ~ tx~h for s and for ns. th~ betw~ s and ns tl~ roeaas of ~h porarneter ~e ccmpared tt~ng t-lest and p < . w~ considered ska~ significant in each series in the t wheae the mast significative diffemx:as ~goeamd bet~en s and ns, we made a txedictive criterion, asamting as predictive indices for stnvival the i:r values, higher or lower than flae treans of the ~rar~ers of au flae patients, axx)rdhlg to those ones t~iatistically diff~'e~ betw~m s and ns. fhmlly xse co:weatxt onaong the series the nrametees of the st~rs with the analysis of variance, to daserve the lxjsable differealt irea~ of sty hflices, following the diagn~s of admission: :nedkal, angical patient or poll~tam results: we c~ld not find ~ predictive criterion for politraonaas, perhaps ixx:ause of the few ntanber of l~fients. for high ri~ saw~cal patieras the following criterion at t has a sensitivi .ly of ~ ,and a ~ecificity of . %: sv > . nffmin/n~, map> mmhg, pmap< nmalqg cvp<i nunhg will nmah& lvswi> g m/m , sxo > ~ do > mlhnin/m , o er< %. for lx~dical l~tienls at t the following criteric~a has a ser~tivi.ty of % and a ~zificity of . ~ cvp< . mn~g, sao > %, s,g) > ~ vo i< ml/nfin/m , o er< %, shunt< % survlvops' data of the series ~ signitic~atly differenl~ both for the t~mody~nic a~ for fl~e ox rphomfic lxlmn~s; moreover we ~ that the vatt~ of hemodynamic mad ox.~ho~tic indices were higher in politrautms. conclus'ions: acx~ording to the fftffe~mt patho!o~es, the ~ rnelabo~c needs are diffeten~ so that it is juslified to mash ~ the~alceutic goals, following the type oflmthology. hen~ we foru~d for high ~k mrgical pmka~ and for medical patier~s assme, ff mllslied, a good prognosis while, if n [ ntljsfled~ the plinsliclioil ofdl~tth is no[ g(ioct finally, ab~ high iis~ supgical palieaats, according to what other atmhors say, txatws sh ~'n~ers ' therapeutic goalsvvould seem inadeqt~te, bec~jse they need a gear physiologic and themtx~ic elth~ in rdation to the rretabolic needs. figure ) . thus, the smaller european nations had a greater participation than ~e larger ones, with the exception of norway. a similar result was evidenced for contributions to intensive care medicine (figure ). these findings can be explained by different submission policies and language banners. however, there was no significant correlation with the gross national product of each country. conclusion: we conclude that the smaller european countries generally contribute more to international intensive care journals than the larger ones. objectives: to evaluate the agreement between a new and three old methods measuring ctp and to assess their reproducibility. methods: we studied patients ventilated with a siemens c respirator. we measured ctp by dividing the tidal volume with the increase in airway pressure (paw), either with the respirator setting used (ca) or with a fixed setting (cf). by modifing the inspiratory time (ti) without changing inspiratory flow, we were able to deliver two series of inflations ( , ,... ml) before and after curarisation of the patient. the same volumes were also inflated in paralysed patients with a super syringe. at the end of each inflation a plateau of sec was performed and paw was recorded. the above three sets of pressure-volume (pv) points were used to reconstruct the corresponding pv-curves (( , c , c the new method for ctp measurement without a super-syringe had the best reproducibility in paralysed patients and gave similar results without curarisation in the majority of them. however, agreement between the methods tested was unacceptable for clinical purposes. further investigation is required in order to improve the accuracy of ctp measurement in icu patients. m kunert, r.sorgenicht, l.scheuble, k.emmerich, h.g ker med.clinic b (dept.of cardiology) i heart center of wuppertal/university witten-herdecke,germany objective to determine the accuracy of activated partial thromboplastin time (apl-l) and activated clotting time (act) studies when samples are drawn through heparinized central venous catheters (cvc). methods a total sample of paired act/p't-/" values was analysed in patients ( m., f., + y.) for monitoring heparin therapy.all patients had a cvc (certofix trio,braun,frg) in the internal jugular vein receiving a continous infusion of . u heparin via the central catheter.act (hr-act, hemotec,usa) and ap'i-f (neothromtin, behring,frg) samples were drawn from the cvc using the double syringe technique (removing and discarding ml blood before drawing the sample). these blood samples were compared to act/ap'cf blood samples obtained by venipuncture (v.fem.) at the same time, act values were analysed directly in the intensive care unit (icu),api-i samples were measured in the hospital laboratory within minutes. results ac-i -~ pi-f~ cact/~pi r = , ) cvc samples + + . v.femoralis samples " + + p-value n.s. n.s. conclusion there is no difference in heparin anticoagulation studies drawn from heparinized central venous catheters compared to those obtained by femoral venipuncture,withdrawing ml blood prior to obtaining the blood specimen is a safe way for eliminating heparin contamination.not only the aptt test but also the act test is a useful method for heparin anticoagulation assessment in the icu. objectives: evaluation of the delicate balance between filter-coagulation and patient-hemorrhage using heparin as anticoagulant in continuous renal replacement procedures. methods: from january through august , we studied filter surviva[ and hemorrhagic complications during filter periods in critically d[ patients, treated with continuous arterio-venous hemo(dia)filtration, with special emphasis on the heparin dose, concurrent use of coumarins, systemic activated partial thromboplastin tirne(aptr), platelet count, mean arterial bloodpressure and the type of filter used. results: filters ( %) were disconnected because of coagulation. mean survival of multiflow an filters was twofold shorter compared to survival of fh gambm filters. a total of hemorrhagic complications occurred of which three patients died at aptt values of respectively , and seconds. after adjustment for mean arterial bloodpressure, platelet count and the type of the filter, the risk for filter-coagulation decreased % (relative risk . , %c . - . ) for each ten seconds increase in aptt. the risk for patient-hemorrhage increased % (relative risk . , %ci . - . ) at an aptt-increase of ten seconds. the occurrence of filter-coagulation and patienthemorrhage was not correlated with the administered dose of heparin. concurrent use of cournarines had a positive effect on filter-survival, without increasing the overall incidence rate of patient-hemorrhage. conclusions: the systemic apt]" is a good predictor of the risk for filtercoagulation and patient-hemorrhage. heparine therapy seems optimal at an aptt between and seconds, although one should realize that fatal hemorrhagic complications still can occur. objectives: the alterations in vascular tone which are primarily regulated by adreno-sympathetic tone(ast) are compensatory responses in hemorrhagic patients. this study was designed to evaluate the correlation between vascular tone and ast in patients with hemorrhage, methods: the vascular tone was expressed by volume elastic modulus (ev) that is defined as; ev = ap/(av/v) (ap; the arterial pulse pressure, av/v; the volume change ratio). ev was measured using a non-invasive transmittance infrared photoelectric plethysmography (tipp) and a volume oscillometric sphygmomanometer . we prospectively studied patients with hemorrhage. the initial ev measurement was performed on arrival and repeated for a hours duration. as a parameters of ast, serum concentrations of adrenalin (ad), noradrenalin (nor), plasma renin activity(pra) were measured simultaneously. we analyzed the correlation of ev and conventional parameters to ast by multivariate statistical analysis. results: ev values at transmural pressure mmhg on admission and hours later were respectively . + . mmhg, . +_ . mmhg (mean + sd). systolic pressure(pas) and serum hormones on arrival and hours later were respectively, pas; . _+ . , + . mmhg, ad; . _+ . , . _+ . ng/ml, nor; . _+ . , . + . ng/ml, pra; . _+ . , . _+ . ng/ml/hr. the ev values correlated significantly with ad (r= . , p= . , n= ), nor (r= . , p= . , n= ), pra (r= . , p= . , n= ). by multivariate statistical analysis, ev correlated more significantly with ad and nor and pra (p= . ) than the conventional parameters such as pas, heart rate and pulse pressure. conclusions: the alterations of ev correlates closely with ast. the compensatory mechanism in hemorrhagic patients can be detected noninvasively by ev monitoring. obiectives and method: autologous oxygenator blood was processed at the end of cardiopulmonary bypass (cpb) by either hemofiltration (hf , , m , fresenius) or by cell washing with a onntinous autologous transfusion system (cats, fresenius). prospectively the blood of patients for each group was processed and then retransfused intravenously to the patient. besides, volume and time requirements, standard hematologic chemistry, coagulation and complement activation were measured. results (mean values for oxygenator blood at the end of cpb, and results of concentrate after processing by filtration or washing): both processing techniques show excellent hemoconcentration of the diluted cpb blood with a good transfusion effect for the patient. filtration retains all plasma proteins and large molecular weight plasma bound waste products. in contrast, cell washing with cats significantly depletes plasma proteins and waste products. the newely developped cats machine gives eonsisinnt laboratory result in a fully automatic continuous processing mode. in conclusion, both filtration and washing are effective for processing cpb blood. filtra tion yields a highly concentrated whole blood, whereas cats washing produces a high quality autologous erythrocyte concentrate. soluble fibrin has during the last years gained interest as a marker for the activation of the coagulation in connection with various clinical conditions, e.g. disseminated intravascular coagulation, deep venous thrombosis and myocardial infarction. elevated levels of soluble fibrin in plasma can be detected by the chromogenic assay coaset fibrin monomer, relying on the ability of fibrin to enhance the tpa-catalyzed conversion of plasminogen to ,plasmin. using this test, it has been shown that the level of soluble fibrin can be correlated to severeness of illness in critically ill intensive care unit patients. a revision of the coaset fibrin monomer kit has now been made and the new product, coatest soluble fibrin, is considerably more convenient to handle and gives higher resolution at low fibrin levels. the test is performed by the addition of a buffer dilution of the plasma sample to a microstrip well containing the colyophilized mixture of tpa, plasminogen and the plasmin specific cbromogenic substrate s- . the reaction is allowed to proceed at,. room temperature for minutes before discontinuation. the absorbance at nm, measured in a microplate reader, is proportional to the content of soluble fibrin in the sample. the assay is carefully standardized and calibration curves are provided in the kit. the convenient and rapid assay procedure makes the coatest soluble fibrin test well suited for single test analysis in acute situations. objectives : blood coagulation abnormalities have been reported in the systemic blood of patients with cerebral lesions. the physiopathology of such events is not yet completely understood. we compare the coagulation profile of blood from the right jugular bulb with systemic blood of patients with head injury. methods: we studied patients, who were admitted to our neurosurgical intensive care unit between january and march with head injury and no other associated pathology (age - yrs), a glasgow coma score <= g, no abnormality in baseline coagulation profile and no history of coagulopaties. the patients did not undergo angiography. a one-way gauge certofix catheter was inserted through the right internal jugular vein up to the jugular bulb. an identical catheter was inserted through a subclavian vein. blood was sampled from either catheter (a=atrial; j=jugular) - hours after trauma (t ) and t hours later (t the inddence dpontolx'rative thmmhi~e and haumord~gic complieatiom were assessed in padents treated with indobefen, heparin calcine caeca), low mollecolar weight heparin (lmwh) (f.nosheparin) and undergoing hemodiludun, blood predeposhing, intra mad postoperative blood saving. ]'he indolmfon tempota~.norks platelet aggregation through ,,elective inhibition of the cyclatygenasis and thus atacbldonicadd( ).tbe n'mimum effect occurs after hours from the fast administration and is still present after hours. ~- patients, mean age --- yrs., weight --- kg were studied. ( . %) were male and ( . %) female. onderwent hip prosthesis ( previously plate and screw removal) hip revim'un ( stem, cop and stem + cop), tutal knee prosthesis, in the st anaesthesidogy depl from - to - - . as for antithromboembolic ptephylam, apart from hemodihitiun pts were with treated indobufen ndo), with heparin ealdum caeca) and with low mo!lecular weight hepam (lwr, ). as the slightest clinical and/or imtmmental suspidon of deep vein thrombosis (dv'i') or polmonary umbolism(pe), a phlebogram or sdndgram were respectively carried out. -the inddence of homologom transhisiom was significandy lower (p= . l) in the padeats treated with indobufen ( . ) compared .'ith heca ( . %). the con~gency table shows statistical signifleance for the use of heca in patients with vein deficiency in the lower limbs, past dvr and/or pe, coronary heart disease (cdh'), while there is no correlation for renal, cardiac or liver defidency, obesity, systemic hypertemion, atrhythmy, diabetes, chronic bronchitis and rheumatoid arthritis. by comparing the postoperative cumplications with the risk factors, there ks a highly significant correlation (p= . l) between cdh and thrombotic and humord~agic complieatiom (pe, death, he~atoma, die use of hum_ologous blood). thee data show that hep~in, preferred in patients with c'dh, roost likely for leagal-tuedical reasons, did not have the de~'ed effect. conclusions -the stastisfical aar~ais shows ~nifieanfly different efflea~ (pro . ) between the therapies (see table) : it can be seen that in patients undergoing autotramfusiun and hemedihidon, indobufen produo~ a lower incidence of haemotrhagic complieatiens compared to heca and lmwh and is more effective in the prevention d ~c complications at clinical e~idence. the duration of i~toperadve hospital stay is signi~cantlylonger for patients transfused with homologous red ceils and treated with hec, .a ( . -+ . days) and lmwh ( . +- a days) compared with indo(ll. _+ a days). one of the main causes for postoperative complications in major orthopaedic surgery is postopemtive bleeding with local effects in the operation site (hematomata, pain and delayed mobilization) and/or systemic and subsequent cardiodrculamry repercussions that are sometimes severe. the aim of this study is to assess the possibility to apply a new system of monitoring, control and saving postopemtive blood loss from the drainage. the bt recovery dideco (marandola, modena-italy) ~ used since it is the only apparatus capable of doing this. the apparatus consists of a pressure transducer, adjustable from - a + mmhg, which activates a peristaltic pump connected m drainage robes. the bt recovery display shows hourly bleeding in the first hours, total bleeding, time passed since the start of monito~g and subsequent salvage and the aspimtioo pressure on the drainage robes; the latter is inserted at - mmhg and then modified according to bleeding/minute, g bt recovery also has an alarm that sounds automatically if.' blood loss is more than ml/hour; air is in the circuit; the batteries are running low. materials and methods: pts were studied ( m and ~), aged . -+ .lyears, basal hemoglobin . -+ (range . - . )g/all, treated from st january, to mst december, in the st service of anesthesia and intensive care unit of our hospital. the patients underwent the following surgical treatment: total hip revision ( pts), cup revision (~ipts), stem revision ( pts), total knee revision ( pts). the average dumtion of the operations was -+ min. intranpemtive monitoring and blood salvage was applied to all patients. genera! anesthesia was used on pts. and integrated (epidural analgesia + light general) on the remaining t . anttthromboembolic prophylaxis consisted of external pressure bandage, isovolemic hemodilution with iodobufen in ( . %)pts., calalc heparin in ( . %)pts., low molecular weight heparin in ( . %)pts.; pt did not give a predepoalt of blood, gave unit, pts units, pts units, pts units. the data obtained was statistically analysed using contingency tables and anova. results: average intmop salvage was -+ ml, average postop salvage was -+ mi the average intra+postop +- ml. average postop loss was -+ ml. the global incidence of postop complications was: h~natomata . %, dvt . %, pulmonary thromboembolism , , myocardiac ischemia . %, acute myocardic infarction . %, respiratory deflciecy . %, arrhythmia %, cystitis . % there were nn complications in . % of pts. postop bleeding over ml in under minutes (with bleeding alarm activation) occurred in pts ( . %). this sta~tically correlates only with the type of operation performed (more frequently in total hip revision p= . ) and with a significant decrease (p~ . ) in the pruthrombic activity detected about hours after the operation. this bleeding, also made the alarm sound, calling the attention of staff who could act accordingly, by making the drainage pressure positive and incre~sthg the tension of the external pressure bandage. conclusions postop monitoring, control and blood loss salvage combined with predepoalting and intmop salvage has enabled allogenic transfusions in % of cases to be avoided in operations with high postop blood loss like hip or knee revision. the usefulness of the system can be seen by the fact that in the patients with so much bleeding to set off the alarm, there was no significant difference in the incidence of allotransfusions and complications. references )borghi b., bassi a., de simone n., laguardia am., fonnaro g. an injury of the brain may result in various disorders of hemostasis caused by the release of • into the circulation through a damaged blood-brain bar tier. disseminated intravascular coagulation(dic) is one of these disorders. it is a freguent but relatively rare ly diagnosed complication of subaraohnoidal haemorrhage. the aim of this study was to evaluate some parameters of both blood coagulation and fibrynolisis in patients with sah.in addition one wanted to find out wh~ther potential changes correlated with the pa• condition in the acute phase of sah and whether they influenced the course of this disease. patients with sah were studied. in of them sah was due to closed eraniocerebral injury and in the rema ining resulted from vascular malformation. the following parameters were evaluated:the prothrombine time,the activated partial thromboplastin time, the thrombine time,level of factor v,fibrinogen degrada tion products and fibrin monomers. the results let us show the presence of oic in patients with closed craniocerebral injury and in with vas. cular malformation despite the lack of clinical symptoms the tests in posttraumatic patients and in patients from second group showed incomplete dic.on admission patients with such changes in measured parameters were in poor condition.the course of the disease and the effe cts of treatment were also worse in these patients. the results showed ihal in patients with sah complex disorders of both coagulation and fibrynolisis occur, and they depend on clinical condition of the patient. they also influence the course of the disease. methods : charts of all patients admitted with d.i.c. over a ten year period ( - ) were reviewed. diagnosis of dic was based on the association of fibrinogen < g/ -platelets < / -fpd > ~tg/ml in the hours of the admission. results : patients -mean age + y -saps +_ -gestanional age _+ weeks -the two first conditions associated with d.i.c. were placental abruption ( %) and preeclampsia or eclampsia ( , %). bleeding episode was present in pts ( %) and surgical treatment has always been necessary. pts ( %) were given packed red ceils ( + u) and fresh frozen plasma ( + u). patients were given platelets packs. heparin was never administered. pts required mechanical ventilation and two patients hemodialysis. all the patients survived. correction of prothrombin time (p.t.) and fibrinogen (f) was quick (p.t. at t h ~ % -f at t h , + , g/i). but platelets count remained low (plat. at t h + / ) -no difference was observed in patients who received platelets. conclusion : prognosis of critically ill o.p. is good. blood loss is the main complication. correction of hypovolemia and anemia with concomitant surgical treatment are essential. the administration of coagulation factors or platelets is still under discussion. objectives: to evaluate the effects of antithrombin iii i at-iii) and a protease inhibitor, gabexate mesilate foy), on the coagulation and fibrinolysis in disseminated intravascular coagulation (dic). methods: after the approval of our institution and consent from patient's family, patients with a dic score ( , japan) more than points (dic or having a risk for dic) entered this study. they were randomly divided into two groups, foy (i- mg/kg/h for days or more) treated group and no foy group, each of patients. platelet count (plt), fibrinogen (fen), at-iii fibrin degradation product (fdp), d-dimer (do), fibrin monomer (fm), thrombin-antithrombin complex (tat), plasmin-plasmin inhibitor complex (pic), and prothrombin time ratio (ptr) were measured before the start of treatment (at admission) and i, , and days after the admission. at-iii at units for days was administered if the at-iii at admission was less than %. finally the patients were divided into four groups: group a, foy (+) and the at-iii ~ %; group b, foy (+) and the at-iii < %" group c, foy (-) and the at-iii %; group d, foy (~) anffthe at-iii < %, each of patients, to match the patients for backsrounds. all parameters, dic score and survival rate in a month following treatment were compared among the four groups. results: the at-iii and plt from day to were significantly higher in groups a and c than in groups b and d. the fdp, dd, tat, and pic after treatment decreased significantly from the baselines in groups a and c but not in groups b and d. the fgn and fm were not significantly different among the four groups. the ptr decreased in groups c and d but increased in group b. the dic score decreased significantly in groups a and c than in groups b and d. survival rates were %, %, % and % in groups a, b, c and d, respectively, although not significantly different. conclusions: in patients with dic or a risk for dic, foy had no expected effects but at-iii had suppressive effects on the coagulation and fibrinolysis mechanisms. a prognostic factor ? carbon monoxyde intoxication is a classical complication of inhalation injury. carbon monoxyda is also physiologically produced during the heme metabolism: heme is conversed to bi]irubin by the hemeoxygenase which is an intracellular stress protein. icu patients (pts) were studied prospectively for apache ii score and carboxyhemnglobin (hbco) arterial level to assess if hbco level could be correlated with the severity of the pts. objective: to evaluate a new technique of non-surgical tracheotomy. patients: adults, mean age years and children, mean age months ( me.- yrs). method: through a needle inserted in the trachea, a guide wire is retmgradely pushed out of the mouth and attached to a special device formed by a flexible plastic cone with pointed metal tip joined to an armoured tracheal cannula. this device is then pulled back through the oral cavity, larynx and trachea, and outwards across the neck wall by applying traction on the wire with one hand and counterpressure on the neck wall with the fingers of the operator's other hand. when the cone and / of the eannula have emerged, the cannula is cut off from the cone, straightened perpendicular to the skin, rotated and advanced caudally to its final position. results: endoscopic control facilitates and improves the safety of all manoeuvres. the pointed cone easily pierces the tissues, and the cannula is extracted without difficulty since it has the same outer diameter as the cone. tissue adherence around the cannula is absolute thus preventing local inflammation. the time in apnea required for dilation and cannula placement does not exceed see., and it is well tolerated because within safety limits in patients hyperventilated with oxygen. only one case of bleeding occured in a patient on dialysis with severe coagulopathy. autoptic findings in subjects who died due to progression of primary disease showed a very regular stoma with an almost complete lack of hematic and flogistie infiltration in recent tracheotomies. .conclusions: translaryngeal tracheotomy (tlt), by virtue of its greater inherent safety and lower tissue trauma than percutaneous techniques, can also be carded out in infants and children, a severe test bench for any tracbeotomy technique. further specific indications are recently stemotomized patients, since tlt is associated with a low rate of infection, and short term tracheotomies after laryngeal surgery, to prevent obstructive complications. references: fantoni a., translaryngeal tracheotomy, apice, ed. gullo, trieste, , . background: inhalation of no has been shown to reverse hypoxic pulmonary vasoconstriction , to reduce pulmonary pressure in pulmonary hypertension of different origin and to improve gas exchange. in putmoflary embolism, pulmonary hypertension is caused by mechanical vascutar obstruction and by reactive vasoconstriction. the effects of inhaled no in putmonary embofism has been partiatly studied' the purpose of this study was to investigate and determine the effects of no inhalation on pulmonary hemodinamica and gas exchange in a hypoxic canine model of pulmonary embolism. methods: two groups of adult mongrel dogs were studied: group (control} dogs and group (no inhaled) dogs. both groups were anestesized with tiopental, mechanically normoventilated with an hypoxjc mixture of and n~ (f[q , ) and instrumented (swang-ganz catheter, femoral artery catheter) pulmonary embolism (pe) was induced by fisher's method s. no inhalation ( ppm) in group was started rain. pdor to pe and kept constant throughout the experiment. no inhaled concentration was analyzecf by chemiluminiscence technique. pulmonary artery pressure (pap), central venous pressure and sistemic arterial pressure were continuosly recorded. cardiac output, artedat po~ (pan ) and mixed venous po~ were measured in both groups under hypo)dr conditions, before pe and , , and rain. after pe. pulmonary vascular resistance (pvr) and gas exchange (pao fio:~ ratio), were calculate using standard formulas. data were process and analyzed with non pararnetdc test, and reported as mean -so and statistical significance was considered if p < , . : no produced an increase in arterial oxigenation (pao /fio~ ratio) and reduced pap before pe induction in group . after pe we found no significant difference with .respect to the time eour.se of pap, pvr and gas exchange between beth groups throughout the experiment. probably, the severe mechanical obstruction produced in pulmonary embolism masked the small effects of no inhaled. obiectives: blood volume measurement would be useful in critically ill patient management if it were easy to perform. this is not the ease and current methods are based on radiolabelled red cell dilution. inhalation and uptake of a known mass of carbon monoxide (co) gas and measurement of earboxyhaemoglobin increase can give results accurate enough for clinical use. this requires a rebreathing system providing oxygenation and carbon dioxide removal, yet complete retention of all carbon monoxide administer&l, and so most authors hand ventilate with a bag and waters soda-lime canister, adding oxygen as necessary. we aim to popularise this method by; i)design of an automatic co administration system driven by the itu ventilator and ii)writing of software for a portable computer to perform all necessary calculations method: we show the computer is use estimating the co dose required and later estimating the blood volume. we also show the new gas administration system. this is a fully closed circle attached to a "bag in bottle", driven by the ventilator. the novel feature is the mechanism by winch driving gas (set to % ) spills automatically into the circle, balancing o uptake by the patient, yet allowing no co loss. conclusions: this equipment is easy to use, reduces human error and allows optimum ventilator settings to remain. the operator merely administers the volume of co determined by the computer and takes blood on two occasions. carboxyhaemoglobin measurement is easy to perform, thus there is a cost saving also. with our modifications use of this technique may potentially become more widespread, the video demonstrates the method in use in our itu. - ( %) underwent conventional surgical therapeutics. " ( %) with resection of tracheal stenosis with end-to-end anastomosis(rts). i ( %) with broncoscopic dilatation. one patient died and the others still have stable patency(sp) without continued treatment. - ( , %) have received endoscopic laser ablation with or without calibration tubes. of them ( , %) are receiving continued endotracheal treatment until now. ( , %) have sp wihout continued treatment. -i ( , %) endoscopic laser therapeutic case turned to rts and is having sp. conclusion: conventional surgical aproach has been progressively replaced in our hospital by endoscopic laser ablation and silicone calibration tubes. this study suggests that these technics are effective and could be the elective treatment for iatrogenic stenosis. obiectives: hemorrhagic disorders due to thrombocytopenia and thrombocyiopathia remain one of the most serious complications during long-term extracorporeal membrane oxygenation (ecmo) in patients with severe acute respiratory distress ~drome (ards). in the presented study, nitric oxide (no), kwown as a potent endogenous platelet antiadhesive, disaggregating and antiaggregating compound, was evaluated for its possible antagonistic effect on platelet trapping when added to the gas compartment of membrane oxygenators (mo). meti~ods: two parallel separated extracorporeal circuits, consisting of heparin bonded hollow fiber oxygenators (minimax, medtronic, carmeda eioactive surface), tubing systems, low pressure reservoirs, and roller pumps were prepared. for each measurement, a pair of circuits was simultaneously filled blood from the same volunteer. low-heparinized fresh warm blood was obtained from four healthy volunteers, who had no drugs for at least two weeks. the gas inlets of both oxygenators received dry gas ( % oxxygen, % carbon dioxide, % nitrogen); gaseous no ( ppm) was added to the gas of one of the oxygenators (no-mo), whereas the other one (mo) was used as control. after minutes no gas was switched off, so that the no-mo received no more no, and no was added to the gas inlet of the membrane, which had no no before_ to assure iutracircnit volume stability, drawn blood for measurements was replaced with saline, and platelet counts were corrected for dilution by hemoglobin values. the mean of four platelet counts (coulter counter) of each timepoint (start, , , , , , , , and minutes) was used for statistical analysis (paired sample t-test). results: in the no-mo platelets remained at + , % (percentage of baseline value, mean -+ sd) until min. in contrast, platelets of the mo continuously decreased after start and were significantly lower after minutes ( , + , % vs _+ , %(p< . ); min. , -+ , %vs , _+ , %(p< . ); min. , _+ , % ( p < . ). after switching of no gas to the mo, further decrease of plateleta was stopped and platelets remained at , +_ , % until termination of circulation. platelets of the former no-mo decreased slightly after cessation of no gas to , _+ , %. conclusions: these data indicate that gaseous no significantly attenuates platelet trapping in hollow fiber oxygenators, when added to the gas compartment. this might be a new therapeutical approach for membrane oxygenator induced thrombocytopenia during long-term ecmd. objectives: nitric oxide (no) plays a pivotal role in regulation of vascular hemostasis. several studies elucidated the antiadhesive, antiaggregating, and disaggregating properties of endothelially synthesized no to platelets. additionally, agonist-induced no production in platelets by the l-arginine-no pathway was found as a negative feedback mechanism after platelet activation. although noplatelet interactions were intensively studied by several investigators, no data exist, about changes in platelet surface molecule expression in no-modulated platelets measured by flow cytometry using monoclonal antibodies (moabs). methods: p-selectin (alpha-granule-membrane protein, gmp- , cd p) and glycoproteiu (gp , lysosomal protein, cd ) are expressed only after platelet activation and degranulation. activation was quantified in thrombin ( . u/ml) and adp ( . ram) stimulated platelet rich plasma samples (prp). blood was obtained from healthy volunteers (n= ), who had no drugs for at least days. for evahiation of no-modulated activation, the spontaneously noreleasing compound sin-i ( . mm) ( -morpholino-syndonimin-hydrochlorid) was added in parallel prepared samples prior to the addition of agonist. platelet surface molecule expression was evaluated with moabs directed against cd a (gpilbliia, fibrinogen-receptor, phycoerythrin(pe)-conjugated), cd p (fitcconjugated), and cd (fitc). only cd a-positive signals were gated in sideangled light scatter, and assayed for activation marker expression (defined as percent of gated population). results: basal p-selectin expression was . + . %, and increased to . _+ . % after thrembin-activation, and to . + . % in adp-stimulated samples. addition of sin- attenuated p-selectin expression to . - - % in thrombin (p<. , two-tailed paired t-test), and . + . % (p<. ) in adpactivated platelets. basal gp expression was . _+ . % and increased to . + . % in thrombin, and to . _+ . % in adp-stimulated samples. with sin-l, gp expression decreased to _+ . % (p<. ) in thrombin, and . : . (p . ) in adp-stimulated samples. conclusions: these data implicate, that no leads to a significantly reduced activation of surface molecule expression in thrombin and adp-stimulated platelets. in addition, flow cytometry might be a useful tool for studying modulation of platelet activation by no or no-releasing compounds. introduction: acute cadmium poisoning is very rare. on initial presentation may mimic metal-fume fever, but acute inhalation cadmium toxicity may produce fatal chemical pneumonitis. case report: we present a case of acute fatal respiratory failure secondary to cadmium-fume irthalation. a year old patient was trasferred from another hospital with acute respiratory failure presumably due to pneumonia. the last days before he had had commom cold symptoms. he had been cutting with a welder during one hour without any respiratory protective measure. three hours after exposure he developed progressive dispnea and was admitted to hospital. with presumtive diagnosis of respiratory infection, antibiotics were begun, however be failed to improve. all microbiological studies were negative. chest x-ray showed bilateral diffuse infiltrates. on seventh day he needed intubation and mechanical ventilation and on th he was admitted to our icu. antibiotics were stopped and new microbiological studies were performed including brochoalveolar lavage and virologic studies. all results were negative. he developed progressive hipoxemia and hipercapmia and finally, multiorganic disfunction syndrome. he died days after exposure. the metal he had been working with was a % cadmium alleation. blood cadmilam concentration days after exposure was . mcg cd/g cr, and urine cadmium concentration was . mcg/l. on postmortem examination, tissue cadmium concentrations were: blood ng/ml, liver ng/g, kidney ng/g and lung ng/g. these values confirm that cadmium was the cause of the fatal respiratory illness in this patient. conclusion: this case evidences the considerable hazard of acute poisoning after inhalation of eadmium-fume and stresses the need of appropiated safety measures against metal-fume poisoning. aim : lactic acidosis is considered the hallmark of cyanide poisonirig. however, the relationship between plasma lactate and blood cyanide levels has not been determined. the aim of this study was to determine the significance of plasma lactate concentration (plc) during the course of cyanide poisonings. methods : the patients were included according to the clinical suspicion of pure cyanide poisoning at the time of presentation. fire victims were excluded. serial blood samples were collected before and after intravenous hydroxocobalamin (hoco). blood cyanide concentration (bcc) was measured colorimetrically. plc was measured enzymatically. results : patients were studied. on admission, plc ranged from . to mmol/l, and bcc from . to gmol/l. mean systolic blood pressure was • mm hg, mean arterial ph . • . , mean anion gap was . + . mmol/l and mean pao . • . kpa. three patients died. before antidotal treatment, there was a significant correlation between plc and arterial ph (p = . ), anion gap (p = . ) and bcc (p = . ) but not with heart rate, pao , paco and blood glucose, or blood pressure. during the whole course of the poisoning, a plc _> retool/ was a sensitive and specific indicator of a blood cyanide concentration > ~tmol/ . sustained catecholamine administration reduces the correlation coefficient. conclusion : baseline measurement of plc allows assessment of severity of acute cyanide poisoning. thereafter, plc may be used to assess the adequacy of antidotal treatment, more especially in patients not requiring sustained infusion of catecholamines. aim: the aim of this case report was [o study the correlation between the plasma lactate levels and several clinical, biological, and toxicological parameters serially measured during the course of a cyanide poisoning treated with a high dose of hydroxocobalamin. a -year-old male ingested potassium cyanide leading to cardiac arrest. cpr was performed prior to hospital arrival where the patient received g hydroxocobalamin. sbp rapidly returned to normal allowing withdrawal of epinephrine. the patient remained comatose and died from brain injury days after the ingestion. methods plasma lactate and blood cyanide levels were measured serially. blood cyanide levels were measured using a colorimetric method.~ plasma lactate levels were measured using an enzymatic method. for correlation spearman rank correlation test was used. results. initial plasma lactate and blood cyanide levels were mmol/l and gmol/l, respectively. there was no overall correlation between sbp and either blood cyanide or plasma lactate levels. similarly, there was no overall correlation between arterialvenous oxygen saturation difference with either blood cyanide or plasma lactate levels. in contrast there was a strong correlation between blood cyanide and plasma lactate levels (r= . , p< . ). the time-course of the blood cyanide concentrations was described by a mono-exponentiai decay (r = . ) with a blood half-life of . h. similarly, the time-course of plasma lactate levels was described by a mono-exponential decay (r = . ) with a blood half-life of . h. discussion. in this case of acute human poisoning, sbp was a much poorer indicator of continuing cyanide effect both before and after antidotal treatment, than was lactate production. this suggests a potential clinical role for following serial plasma lactate levels as a marker of the evolution of cyanide toxicity. aim : cyanide (cn) poisoning in fire victims is frequent and rapidly fatal. in a prospective study we tried to assess the clinical tolerance of a high dose of hydroxocobalamin (hoco) administered at the scene of the fire in fire victims suspected of cn poisoning. methods : inclusion criteria : soot in mouth or sputum ~ any degree of neurological impairment. exclusion criteria : children, pregnant women, burns of total surface body area > %, multiple trauma. protocol desigrl following examination and the collection of a blood sample in dry heparin, a g dose of hoco ( g in case of cardiovascular collapse) was administered intravenously over min. the systolic blood pressure was monitored before and after the administration of hoco, and one hour later. results : there were females and males. the mean blood cn concentration was • pmol/ . the mean blood carbon monoxide was . • . mmol/ . nineteen fire victims eventually died. among the non-cn-intoxicated patients (blood cn < ~mol/ ), there was no significant change in arterial blood pressure. in the cn-intoxicated patients (blood cn > gmol/ ) a significant increase in blood pressure was observed both immediately (p < . ) and hour later (p < . ) after the admistration of hoco. no allergic reactions were observed. conclusions : in fire victims with cyanide poisoning, the administration of a high dose of hydroxocobalamin was associated with an improvement in systolic blood pressure. hydroxocobalamin is well tolerated in fire victims without cn poisoning. objectives: tricyclic antidepressant (tca) overdose can lead to serious complications including cardiac arrhythmias [ ] . because of the known risk of early deterioration and the implication for management, emergent evaluation is essential. we determined the diagnostic usefulness of the electrocardiogram (ecg) in tca poisoning. methods: retrospective study of all patients with tca intoxication (pos. ,toxicology screening in urine and/or pos. history) in a -beduniversity hospital from through . the severity was graded with mild= no symptoms or agitation; medium= disorientation, somnolence, tachycardia, or convulsions; and sever~ coma, significant arrhythmias or death. we analysed the first ecg after admission with a special emphasis on qrs-and qtc-intervals and the terminal ms frontal plane qrs-vector (tqrs), which, was reported to lie typically between + and * + + • the best correlation with severity grade was found with qrs-and qtc-duration (p= . ), the tca-dose (p= . ) and hf (p= . ); tqrs did not correlate. patients died ( . %). conclusion: qrs-and qtc-prolongation in the admission ecg, and the reported dose of ingested drugs are useful predictors for severity of poisoning due to tricyclic antidepressants. we did not find additional benefit in determining the terminal ms frontal plane qrs-vector. objectives: since treatment of amphetamine poisoning is usually symptomatic and often associated with a fatal outcome, a search for specific drugs to help the amphetamine-intoxicated victim is sorely needed. methods: we report a case of a suicidal ingestion of large amounts of the amphetamine-derivative , -methylenedioxy-ethamphetamine (mdea) and heroin (diacetylmorphine) and present the hypothesis that the two drugs produce opposing clinical effects. results: a year old caucasian male was admitted to the emergency ward because of acute-onset confusion. at presentation, he was agitated and showed increased muscular rigidity. he had taken tablets of "eve" (mdea, approx. g) and g of "smack" (heroin) by oral route approximately h before admission. because of rapidly progressive tachypnea and exhaustion, the patient was intubated and ventilated. the serum concentration of "eve" on admission was ng/ml (lethal range - ng/ml). trace amounts of cocaine and substantial amounts of heroin ( ngtml; mean value in heroin-related deaths: ng/ml) were also found in the serum. the patient was successfully weaned from the ventilator by day and recovered without persistent neurobehavioral disturbance. despite high serum levels of both drugs, the patient did not present with the classic signs and symptoms normally seen during intoxication with these drugs. amphetamines in general, and mdea in particular, have opposite clinical effects to heroin or diacetylmorphine. none of these were however present in the case presented despite the high ingested doses and the serum levels in the lethal range. conclusions: the fascinating fact that, apart from the respiratory depression, none of the clinical signs reported after massive overdose with these two drugs were present, might be attributed to the opposite pharmacological effects of mdea and heroin. we believe that the patient unwittingly saved his own life by the oral coingestion of both mdea and heroin. our clinical data raise an interesting point about the pharmacological treatment of acute poisoning with amphetaminederivatives. introduction: the acute attack of aip still carries a significant risk of mortality of around %. a succesful outcome depends on early diagnosis, removal of pricipitating factors and provision of intensive supportive therapy. objectives: twenty one patients ( females, male) with documented aip were seen over a -year period in the university hospital. patient was in clinical remission and were with the acute attack of aip, among them with respiratory paralysis were required artificial lung ventilation and -assistant ventilation with peee pathologic treatment during the attack was normosany, adenil, androgenes, glueosa, riboxin parenteral and enteral nutrition via nasogastric tube. symtomatic treatment -pethidine, propranoton, antibiotics, bronchoscopia. methods: intermittent phasmapheresis was performed on patients. the following measurements were peformed: level of porphobilinogen (pbg) in the wire and delta-aminolevulinic acid in the blood. hematological and routine chemical evaluations, hepatic, hemodynamic and respiratory function. results: after plasmapheresis the median pbg excretion (normal range - mkg per/ kgr creatinine) fill from mkg on admission . mkg, then on - day raise to mkg and then during treatment with normosong and prasmapheresis lowest level was . mgk. fatalities occured in two females during attacks with proforma cerebral involvement and patients attained clinical remission. conclusion: after therapy with plasmapheresis normosong we found that there was consistently reduce the urinary excretion of pbg and shortening the duration of the acute attack. objectives: pigs has been reported to present with a higher pulmonary arterial pressure (ppa) and stronger pulmonary vascular reactivity than many other species, including man. aim of the present study was to compare pulmonary vascular impedance (pvz) before and after embolisation in weight-matched adult dogs and minipigs. methods: we investigated pvz spectra in anaesthetized and ventilated (fio . ) minipigs and dogs. after baseline measurements the animals were embolised with autologous blood clots to reach a ppa above mmhg. results: flow ( and ppa matched pvz data (mean-+sem) are shown in the table. [zo = hz impedance (z; {dyn.sec_em- }); zl = first harmonic z; zc = characteristic z; z phase = first harmonic phase a@e {radians}; fmin = frequency of pvz the first m{n~mam; *, f p at least < . between dog and minipig, and before v~. after embolisation respectively]. before case report: a -yr-o]d woman affected by legs recurrent thmmbophlebitis, was admired in medmine department for tach.~pnea, chest pain, tachycardia and cyanosis. before starting two-dimensional transesophageal echocardiography (tee) to confirm the suspicion of pulmonary embolism, she suddenly had ventricular fibrillation. resuscitation and defibrillation were readily performed. when sinus rhythm was reinstituted she was in superficial coma with preserved corneal and light reflexes: right hemiplegia, poor perfusion and h~posphygrma of the left arm. tee showed dilation of rigth ventricle (rv), incomplete occlusion of pulmonary arter~ (pal at it~ hifurcation, severe tigth-to-left shunt through a patent foramen ovate, paradoxical embolism with incomplete occlusion of left subclavian artery mechanically ventilated with vt= ml, rr= /mm, fio =l, the patient had ph= . , pao = mmhg and paco = . systemic bp was / mmhg and hr= b/min with low dose epinephrine ( . g/kg/min) a thrombolytic infusion (rtpa: mg/ h) through a peripheral vein was started tee imaging and clinical status hours later were unmodified. a new rtpa infusion was performed through the pulmonary hole of a swan-ganz catheter with the tip close to the embolus. one hour later pa pressure decreased from / mmhg to / mmhg, etco increased from to mmhg and sao improved from % to % three days later the parietal, spontaneously breathing and with normalized tee scans of rv and pa, was transferred to rehabilitation service to perform physical therapy. conclusions: massive pulmonary embolism in a patient with patent foremen ovale, paradoxical embolism and refractory hypoxaemia was unaffected by systemic rtpa infusion, while intrapulmonary rtpa administration dramatically improved gas-exchange, hemodinamics and the general conditions of the patient. the presence of a large rigth-to-left _atrial shunt and the rapid rtpa metabolism could likely explain the effectiveness of its intrapulmonary administration in front of failure of systemic thrombolysis. introduction. cardiogenic shock during massive pulmonary embolism (blpe) is due to an acute increase of right ventricle (rv) afterload and possibly rv ischemia causing a failure of rv pump function. the rec~;mmended therapeutic strategies are: xoiume augmentation ~n ~rder m }ncrease rv pre-h~ad, adrenergic drugs to increase t'ontractillly and maybe coronary perfusion, fibrinolytic drugs to delermine clot lysis. there have been several reports of noradrenaline (na) as a useful drug in this setting for its sluing ~z, but also ~, properties. case report.an obese },ears old woman was transferred to our icu for tetanus. she was given the usual antibiotic and immunoglobuline therapy. l'wo thoracic epidural catheters were put in place at different levels and replenished with marcaine qid. a continous infusion of sedation (diazepam § was started together with mechanical ventilation. curarization ~,as given occasionally. fraxiparine . /die was used for prophylaxis of thrombotic disease, on day th at . a.m. she started to be hypoxic (sa %), tach ,tardic l l(i b/rain.), her blood pressure(rp) dropped frum norma~ values to r mm/hg, the central venous pressure (cvp) raised [rom lb to mm/hg and the end tidal co was mm/hg lower than one hour before. the physical examination of the chest revealed a clear bilateral ventilation and the chest x-ray was normal apart from an elevation of the :tiaphragm as compared to the previous. an e.c.g. showed sinus tachycardia, right bundle branch block and a possible inferior necrosis (which was already present on admission). a trans-thoracic echozardiography was performed which showed "an acute overload of the right centricle wilh remarkable dilatation. tricuspidal regurgitation ++. paradoxical movement of septum. small left ventricle with normal wall kinetics". the cardiac enzymes were later shown to be normal. an acute massive pulmonary embolization was assumed m be present.. a bolus of streptokinase x i(i u. was given fonowed by a continous infusion . two liters of colloids were also given in a sh~rt time, two hours later the patient was still deeply hypotensive, hypoxemic and anurir(bp / mm/hg, cvs mm/hg, spo %) despite a cominnus infusion of dobutamine fag/kg/min and adrenaline . ~tg/kg/min. at this stage a bolus of aoradrenaline ,g was given followed by a cnntinous infusion of . !*g/kg/min. an immediate improvement of the hemodynamics was noticed and one hour later the bp was / mmhg, the cvp mm/hg, the sao % and a brisk diuresis started. the hemodynamics kept stable and weaning from vasoactive drugs was achieved within two days. one month iater the patient was discharged home in good conditions.. con c i u sio n.ne administration may help to restore rv coronary flow and ;~ump function during mpe. aeute putmonary t~omboembo~sm [ffe) cou be mamfeslated with either respiratory or cardiovascular syndromes or both. the arm of the study was to establish leading respn'atory symptoms, frequency and form of the roendganographic (rig) changes as well as blood gas disturbance degree in acute pte with dommam respiratory disease appearance. the study includes retrospeotive analysis of i pte patients (pts), males (average age , yrs) and .q females (average age , yrs). they were admitted at university, olinie" with suspection ofpleuropnlmonary disease, including pte. final diagnosis of pte was based o~ evident risk factors in , % of the eases (deep venous thrombosis, surgery, trauma, imobilisation, malignancy ere), acceptable clinical, rtg, sdntigraphic and laboratory findings, as well as deep veins examination by dopple~-sonographie and radioisotopic -~enogmphy. respiratory symptoms appeared in all cases: sudden pleural pain ( %), dyspnea ( %), hemoptysis ( %), cough ( %) with association of two or more symptoms in %. chest xrays findings were abnormal in % with diaphragmal elevation ( , ~ lung opaeilies ( , %), atelectasis ( , %), plemal effusion ( , %), main pulmonary brancah asimetry ( , ~ oligemia ( %), heart shadow changes ( , %) and pulmonary arteries "cut off' ( , %). the association of two or more abnormalities was found in , % while normal chest x-rot was found in ~ of the cases. hypoxemia with pao < , kpa was found in , % followed with hypocapnia and respiratory alealosis in , % in , % of the gas exchage analysis were within normal limits. among cardiovascular symptoms short syn~cpa appeared in i , %, ecg changes-st q t type in "~ , %. results show high frequency of positive ~g findings in pte pts that is opposite to oppinion that chest x-ray in acute fie is the most ofran normal. leading symptoms are pleural pain and dyspnea, while hemoptysis were found in a half of the study group. blood gas changes were present in two thirds of the cases. kakkar, in his classic work ,clearly demonstrated the efficiency of low doses of heparin in prevention of deep vein thrombosis (lancet : , ) .after this first study the application of heparin prophylaxis became more and more diffused until to be considered a routine in many surgical departement.actually application of blood saving technique induces postoperative hemodilution effect. in that condition prophylaxis routinely applied seems a nonsense and can be at risk for postoperative hemorrhage. methods: to analize this problem we compared patients arrived in our intensive care unit (i.c.u.) in. : (group a) with arrived in : (group b) .every patient was operated for major abdominal surgery.in each one we considered the hemoglobin (hb) value,hematocrit(hct), and coagulation pattern (c.p.) at the arrive in i.c.u. and hours later. the patients was also divided in those receiving heparin prophylaxis (i) from not treated patients (ii) results:the application of blood saving technique clearly appears from the hb and hct level wich have a mean value of , +/- , (hb) and +/- (hct) in group a while in group b mean value are , -/- , (hb) and +/- (hct).patients of group a (ii) are the only one where a pathologycal c.p. with statistical significance has been demonstrated.in this goup we got four cases of evidence of venous thrombosis and one of pulmonary embolism.in patients of group b(i) we encontered the incidence of two cases of severe hemorrhage despite the absence of statistical significance in c.p.modifications. oxygen desaturation during broncho-alveolar lavage: role of oxygen saturation monitoring in prevention of acute respiratory insufficiency g. galluccio, b. valeri, s.batzella, m. di lazzaro*, servizio di endoscopia toracica, ospedale forlanini, rome, italy * servizio die anestesia a rianimazione, osp. forlanini the broncho-alveolar iavage is a diagnostic procedure employed in interstitial diseases of the lung. it requests the introduction through the working channel of a fiberoptic bronchoscope, after occlusion of a segmentary bronchus, of aliquots of saline solution at c, subsequently gently reaspired, in order to remove cells and proteins from elf (endoalveolar lining fluid), which is related to interstitial medium. bronchoalveolar lavage induces deep effects on pulmonary function: -lowering of the alveolar surface of exchange; -shunt effect, depending on the perfusion of non-ventilated districts; -increased pulmonary arterial pressure, due to hypoxic vasoconstriction; -decrease of lung compliance. in this report the authors present the result of oxygen saturation monitoring in a group of patients with interstitial lung disease, who underwent diagnostic broncho-alveolar lavage. in most patients with severe interstitial involvement, the lavage performed without supplement of oxygen induced a severe fall in the oxygen saturation during the late phase of the procedure. if supplementary oxygen was delivered during bronchoscopy, since its beginning, only slight modifications of the curve were detected. in patients without thickening of interstitium, in whom the lavage was performed in order to obtain material for bacterial or cytologic examination, no modification of oxygen saturation was observed in standard procedure. as conclusion the authors strongly reccomend monitoring oxygen saturation in patients with radiologic evidence of interstitial involvement also in patients with no evidence of dyspnoea. g. galluccio, b.valeri, s.batzella, m. di lazzaro*, servizio di endoscopia toracica, ospedale forlanini, rome, italy * servizio die anestesia a rianimazione, osp. forlanini the treatment of choice in patients with alveolar proteinosis consists of pulmonary lavage. this procedure requests the introduction, through the working channel of a fiberoptic bronchoscope, segment by segment, of aliquots of saline solution at c, subsequently gently reaspired, in order to remove the proteins deposited in the alveolar spaces. the method is very similar to that used in bronchoalveolar iavage, a diagnostic procedure used to obtain cells and substances from elf (endoalveolar lining fluid), which is related to interstitial medium. as known, bronchoalveolar lavage induces oxygen desaturation, because of shunt effect. understandably, one lung lavage has remarkably more deep effects on pulmonary function than bronchoalveolar lavage, for the amount of fluid introduced, the length of the procedure and the conditions of controlaterai lung. in this report the authors present the result of oxygen saturation monitoring in a patient who underwent pulmonary lavage for alveolar proteinosis. in the lavage performed without supplement of oxygen a severe fall in the oxygen saturation was observed during the late phase of the procedure. if supplementary oxygen was delivered during bronchoscopy, since its beginning, only slight modifications of the curve were detected. as conclusion the authors strongly reccomend the subministration of supplementary oxygen in pulmonary lavages, also in patients with excellent respiratory conditions. a. b. dublisky prof., m. r. isaakjan ass., v. a. zasukha, s. m. vinichuk prof., v. p. tserty ass. prof., chair of anaesthesiology, resuccitation and medicine of catastrophes, neurology of ukrainian state medical university, kiev, ukraine. objectives: detection of plasmophoresis's influence of results in treatment of ishemic insult. methods: we ve investigate patients with ishemic insult, treated with reverse plasmopheresis in complex treatment. after primary infusive therapy we took ml of patients' blood and separated it within min with rotation frequensy of /rain. after separation of erythrocytes from plasma, the latter has been returned to patients. we made - procedures during - days. hemoglobin, hematokrit, time of blood coagulation were determinated. the brain blood flow in internal carotid arteries, regional volum brain blood flow and total brain biood flow were evaluated with tetrapotar chest rheography and tetrapolar rheoencephalography. obtained date were comparised with control group after traditional treatment. results: it was found that after reverse plasmopheresis the hemoglobin and hematokrit levels decreased significantly in studied patients' plasma (from + . g/l to _+ . g/ and from + . % to _+ . % respectively). the time of blood coagulation by lee-white has increased by - . times (up to - rain). the level of brain blood flow has been increased significantly after reverse plasmopheresis in comparison with control group. the following tests of brain blood flow have been increased: a) the total volume brain blood flow from . + . ml/min to . _+ . ml/min (p < . ); b) the regional brain blood flow from . _+ . ml/min to . + . ml/min (p < . ); c) the brain blood flow in internal carotid arteries from . _+ . ml/min to . + . ml/min (p < . ). conclusions: the use of reverse plasmopheresis in complex treatment of patients with ishemic insult aiiows to improve rheological blood patterns, helps to increase volume brain blood flow. it results in quicer reparation of neurological functions. objectives: a prospective evaluation of the efficacy of continuous infusion of verapamil in reducing the incidence of postoperative atrial fibrillation after pulmonary surgery. methods: a total of consecutive patients, on verapamil, on placebo was included after lobectomy or pneumouectomy. a loading bolus of verapamil ( mg over minutes) was followed by a rapid loading infusion ( . mg/min) for minutes and finally a maintenance infusion ( . rag/rain) for hours. results: a mean plasma level of verapamil of ng/ml was obtained only after more than hours. atrial fibrillation occurred in five out of patients who tolerated the verapamil infusion, and in out of patients on placebo (p = . ). verapamil infusion was not tolerated in patients because of hypotension or a heart rate of less than /min, within hours of the start of the therapy. when atrial fibrillation occurred, the ventricular response, mean _+ sd, was not significantly slower during verapamil infusion ( + ) compared to placebo ( + ). conclusions: because of its frequent side effects and the only modest efficacy verapamil should not be considered for prophylactic therapy of atrial fibrillation after pulmonary surgery, and is probably not a good first choice for slowing the heart rate in case of rapid ventricular response once atrial fibrillation has occurred in these patients. results: study of haemostasis in these patients has showed deep disturbances of blood coagulation. fibrogen level has reduced to . + . g/l, fibrinogen and/or fibrine degradation products concentration have enhanced to . _+ . g/l, monofibrin soluble complex concentration to . -+ . g/l, blood plasmin level was enhanced to . + . mmol/ , plasminogen proactivator level was also enhanced to . + . ram, plateletes aggregation has decreased to %. after plasmopheresis aggregation was decreased in . times. it has been connected with decrease of fibrin and/or fibrinogen degradation products level and level plasmin in . times, and plasminogtnt activator level in . times. at the same time we have observed increase in total antifibrinalitic activity of blood in . times. activity of activators plasmine and plasminogene proactivators has decreased in . times and in the same time activity of activation inhibitors and antiplasmines has increased in times. conclusions: plasmapheresis leads to considerable improvement of a general condition and reduction of the haemorrhagic syndrom's sings (controlling of gastrointestinal haemorrage, reduction of intensity of subcutaneons haematoma). evaluation of continuous cardiac output (cc ) monitoring based on thermodilution technique in critically ill patients. methods: cardiac output (co) was monitored continuously using a modified pulmonary artery (pa) catheter, on which a heating filament is located and by which energy is transmitted to the circulating blood. a microprocessor calculated co by a new algorithm. standard bolus thermodilution technique ( ml of ice-cold saline solution) was used to compare cc with intermittent bolus cardiac output (ic ) measurements. the following subgroups were prospectively studied: i. heart rate (hr) > beats/min, . cardiac output > i/min . cardiac output < . i/min, . rectal temperature > . ~ and . pa catheter was inserted for more than days. results: a total of pairs of ic and cc measurements were obtained from the patients. bias (ico measurement minus cc measurement) of all measurements were . • i/min and the % confidence limits (mean difference• were - . / . i/min. also in the subgroups, cc measurement agreed closely with ico measurement (c > i/min: bias= . • i/min; co < . i/min: bias=- . • i/mln). elevated temperature and prolonged lay-days of the pa catheter did influence agreement of cc measurement with ic measurement neither (> ~ bias= . • i/min). conclusions: monitoring of cc using a modified pulmonary artery catheter with a heated filament has proven to be accurate and precise also in the critically ill when compared with "standard" intermittent bolus thermodilution technique. this method enhances our armamentarium for more intensive monitoring of these patients under various circumstances. background: the number of patients who need coronary artery surgery was) grows every year. most of these surgical operations are with extrar eircuiation (ecc). since january , this surgery is made without ecc in selected patients in our hospital. this technique is exceptional in spain. this type of surgery has proved useful in patients requiring revascularization of the left anterior descending, eireunflex or right coronary artery (not for grafting the pos~tefio~r descending branch}. blethods and results: since , patients aged to years (mean years) underwent cas without ecc. the mortality in programmed surgery was %. no patient was reexplored for hemorrhage. the mean values of some clinics parameters v~ere: a) blood requeriments: units per patient, b) need of mechanical ~entilation: i , hours, c) postoperative bleeding: cc, d) days at icui , . we used the student % t test or fisber~s exact test to compare these results with the mean values of surgery with ecc: a) blood requeriments per patient (p< , ), b) need of mechanical ventilation: hours (p< , ), c) postoperative bleeding: cc (p< , ), d) days at icu: (p< , ), e) programmed surgery mortality: % (p< , ). conclusion: our limited experience shows that this surgery is an alternative in the treatment of coronary disease, especially for aged patients with associated pathology and in jehova's witness. the need of mechanical ventilation, days at icu, blood requeriments and morbi-mortality were fewer than surgery with ecc. to study the hemodynamic and antiarrhythmic influence of ace-inhibitor enalapril in acute myocardial infarction (mi). methods: holter ecg monitoring, heart rate variability analysis, echocardiography ( and l days after beginning of the treatment), stress-echocardiography and stress ecg ( - -th day after the onset of mi). enalapril was included into the treatment of pts with mi (study group), with normal or increased blood pressure, from the -st day of the disease. the data were compared with pts treated without enalapril (control group). results: silent ischemia during stress-test was registered in pts of the study group and of control group, the arrhythmia episodes during stress test -in and pts and episodes of silent nocturnal isehemia -in and pts correspondingly. enalapril importantly attenuated the hypertensi~re re~aetioh % stress test. in pts of the study group the number of perifocal hypokinesis zones decreased; in the control group it didn't change. the quantity of ventricular extrasystoles in the patients of the study group decreased by %; the heart rate variability indices improved as well; in the control group the character of ventrieulir arrhythmias, heart rate and its va]~i~bili%y didn't change significantly. conclusions: the inclusion of enalapril into the treatment of mi is a useful t ol to improve hemodynamie parameters and decrease the incidence of ventricular arrhythmias. objectives: to study left ventricular (lv) systolic function in the patients with acute myocardial infarction (ami) before and after peroral captopril test. methods: the original echocardiographic parameter of lv contractility, "coefficient of effective systolic function" (cesf), was proposed in the study. cesf is calculated from lv stroke volume (sv), obtained from doppler aortic flow in lv outflow tract and lv end-diastolic diameter (edd): cesf =sv/edd. the study included patients with ami, who had local lv dyskinesia and global lv systolic dysfunction (ef< %). besides cesf, the ejection fraction was calculated before and after administration of mg eaptopril (on the fifth day of ami) by methods of bullet and simpson. results: the dynamics of these parameters, as well as heart rate (hr) and mean blood pressure (bp), is shown in the tabte. before cal~topril ef (bullet) . • . ef (simpson) . introduction: the cold system is a monitoring system for measurement of right (copa) and left (coart) ventricular cardiac output, cardiac function index (cfi), fight ventricular ejection fraction crvef), fight ventricular cnddiastolic volume (rvedv), intrathoracic blood volume (!tbv), global enddiastolic volume (gedv), lung water (etv) and excretory liver function (pdr). patients and methods: pts have been monitored by the cold system. above mentioned parameters are measured by thermal dye dilution and a fiheroptic femoral artery catheter. copa, rvef and rvedv measurements additionally were compared to measurements by the baxter explorer. :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ;;;k;;;;i cov (%) explorer ! ! [ gedv, itbv and pdr showed a significant decrease dufing the first - h after the operation, cfi and rvef si~canfly improved after k wheras etv showed a i~ in the early postoperative phase and fell to normal ranges at h. comparison of cold/explorer m~ements sb wed good correlations. discussion: concerning m ~toring of ri,ght ventric~ar function cold and explorer can he seen as equal. rvef gives an ar report about the performance of the right ventricle without use o f echocardiography. measuring itbv and gedv ~ improve ~gement and con~ol of th.e volume status, monitoring etv helps preventing lung edema. pdr shows good corre|ati n to liver blood chemistry and is bedside avai|ab|e. thus the cold system offers additional parameters for comprehensive m~nitofing of pts. ~e~ ~c surgery. obiectives: to evaluate the influence of an a!'~ered cardiac function on the cardiovascular response to the increase in oxygen demand induced by an increase in core temperature. methods: this preliminary study included adult critica!ly ill patients monitored by arterial and pulmonary artery catheters in whom thermodilution cardiac index {ci) and arteria! and mixed-vef)ous blood gases measurements could be obtained before and after an acute change in core temperature of at least . ~ (max rain apartl the patients were separated in two groups according to their cardiac function: patients had an impaired cardiac function as defined by a history of cardiac disease and an ejection fraction below % and patients had normal cardiac function. results: individual data are shown in the figure. in contrast to the control group (continuous line) in which c! increased without changes in oxygen extraction ( er), the q er in patients with impaired cardiac function (dottled line) increased without changes in ci. conclusions: the increase in oxygen demand associated with changes in temperature is met by an increase in c! in patients with unaltered cardiac function and in an increase in o er in patients with altered cardiac function. temperature should be taken into account in the assessment of the adequacy of cardiac output in patients with impaired cardiac function. objectives: to define the hemedynamic and metabolic response to physical therapy(pt) in relation to the type/level of sedation and the cardiac status in icu patients. methods: we studied mechanically ventilated icu patients ( • years) in stable hemodynamic status (no change in vasoactive treatment for at least hours), separated in groups: group = deep sedation, cardiac dysfunction required dobutamine (n= )r group = deep sedation (barbiturates), unaltered cardiac function (h=lo), group = moderate sedation, altered cardiac function (h= ) and group = moderate sedation, unaltered cardiac function (n= ). complete hemodynamic data, arterial and mixed venous blood gases, respiratory gas analysis (metabolic cart ccm, medgraphics) were obtained at baseline ( x) and twice (q. min) during leg mobilization. data were analyzed by anova. calcium channel blockers were used in complex preoperative preparation of hypertensive surgical patients. patients were allotted to groups based on their hemodynamic profile: hypokinetic: ejection fraction (ef)< . , patients; eukinetic (ef> . ),i patients and hyperkinetic (ef> . ),i patients. the most noticable change in hemodynamics was in the hypokinetic group: ef and cardiac output (co) were significantly decreased (p< . ) while systolic arterial pressure (sap) (p< . ) and peripheral resistance (pr) (p< . ) were elevated. the results showed that in hypokinetic patients on nifedipine ef (p< . t) stroke volume (sv) (p< . l) and co (p< . ) were increased while pr(p< . t), sap(p< . ) and diastolic arterial pressure(p< . ) were decreased. eukinetic type patients also showed an increase in ef,albiet to a lesser extent,than in the hypokinetic group. increased sv and co(p< . ) were observed in eukinetic patients though this was to a lesser extent than in the hyperkinetic group. in the hyperkinetic group of patients nifedipine had no effect on the aforementioned parameters except for a decrease in sap(p< . i). nifedipine increased ef in all hypokinetic patients. comparative results show that isoptin was less effective than nifedipine in decreasing peripl~eral vascular resistance and had a depressive effect on the myocardium. it can be concluded that the action of calcium channel blockers normalizing the circulation in the hypertensive surgical patient depends on: the condition of myocardium, the patients hemodynamic profile and their pharmacological properties. they were most effective in the hypokinetic group. zalo/nthinos e., daniil z. zakynthinos s., armaganidis a., kotanidou a., nikolaou ch..,roussos ch. critical care department, university of.athens, evangelismos hospital, athens, greece. introduction : surgical is the optimal treatrnent for ioculated effusions and the preferable procedure when multiple bands are seen in the pericardial sac by echo. patients : palients, post cardiac surgery, uremic ( men, women) with large pericardial effusion and clinical or echocardiographic findings of tamponade or both. these particular patients displayed numerous linear echo-dense bands and s~'ands crossing the pericardial space (in one of them a ioculated effusion compressed the left ventricule). one had aptt increased, four were mechanically ventilated. technklue : a fr polyurethane catheter with end and multiple side holes over ga needle was echo-guided to the ideal site (fluid abundant and closest to the transducer). the catheter was attached to a close system with a heimlich valve for continuous drainage (pneumothorax kit). subcostal entry was selected in one patient and chest wall in five. the patient's position was changed every hour at least. (we believe that the small changes in the position of the catheter and the mechanical breaking of the bands in relation with the movement of the heart assist the pericardial fluid to remove). results : in all cases only a small quantity of fluid was withdrawn in the first minutes( - ml) with some clinical and echo-findings improvement. the fluid was bloody or serosanuginous with high protein content (ht= % ,protein , gr/dl) in all cases. in first hours the mean volume of fluid removed was ml ( to ml). in that period echo showed no residual fluid. the catheter remained within the pericardium to days .. no complications are mentioned. conclusion : cardiac tamponade due to hemorrhagic high protein pericardial effusion in uremic and postcardiac surgery patients,, as it is revealed by echo dense bands, can be faced by -d echo guided perieardiocentesis. a -fr polyurethane catheter with multiple side holes, attached to a heimlich valve was effective to evacuate the pericardial fluid. no catheter was occluded though heparin infusions were not used. multiple changes of the patient's position may be fundamental. this -d echo guided pericardiocentesis performed in in~nsive care unit seems to be useful , safe and quick technique. determining the best inotropic drug represents a very serious problems. the use of more selective and potential inotropic and vasodilatative drugs does not always lead to improvement of hemodynamic parameters in patients with low cardiac output syndrome. this paper presents patients with acbp who need an inotropie support after extracorporeal circulation in first hours. the patients were divided into dobutamin et dopamine groups. the heart rate (hr). mean sistemic arterial pressure [map), central venous pressure (cvp). and termodilution cardiac index (ci) were measured. the measurements were without using inotropic drugs, and then using them after rain, min, and finally with one hour rate, within first hours. the statistical analysis shows that both drugs lead to an increase in hr in the first hour of the application. the final effect of dobutamine is no change in hr, whereas the effect of dopanime is very significant increase in hr. thus. an absence of taehyeardie response selects the dobutamine as a better choice. backeround: pulmonary vascular eadothelium possesses major metabolic functions, which when altered contribute to the development of serious pathologies such as ards. one such function is the conversion of angiotensin i to angiotensin ii, catalyzed by angiotensin converting enzyme (ace), located on the luminal surface of the endothelial cells. ace activity has been extensively studied in animals in vivo, by means of indicator-dilution techniques, providing: i) under toxic conditions, an early index of lung injury, and it) under normal conditions, estimations of dynamically perfused capillary surface area (pcsa). objectives: to validate the use of these techniques in matt: i) for pulmonary endothelial function assessment, and it) for pcsa estimation. methods: ace activity was estimated in ten adult haman volunteers, with no pulmonary medical history and normal pulmonary artery pressures, undergoing cardiac catheterization for coronary artery disease assessment. single-pass traspulmonary hydrolysis of the specific ace substrate hbenzoyl-phe-ala-pro (bpap; p.ci) was measured by means of indicatordilution techniques, and expressed as %metabolism (%m) and v=-hi( -m). bpap was injected as a bolus i) into a main pulmonary artery, and it) inside the right atrium, to assess ace activity in one and both lungs. we also calculated a,~,/i~, an index of pcsa. pulmonary plasma flow (fv) was determined by thermodilution. fp in one lung was estimated as . xf v. results: similar values of %m ( . + . vs . • and v ( . • vs . • were observed in both and one lung respectively. a~k~ decreased from • ml/min (both ltmgs) to :~ (one lung). conclusions: i) pulmonary endothelial ace activity and thus pulmonary endothelial function may be assessed in humans by means of indicator-dilution techniques, it) our data denote homogeneous pulmonary capillary ace coneentratious and capillary transit times in both haman lungs, iii) the % reduction of a=~/k~ in one lung suggests that this procedure can be used to quantify pcsa in man. (supported by the fonds de la recherche en saute du quebec and the national health system of greece). objective: verify whether antioxidant activity is higher in reperfused than in no-reflow myocardium after i.v. thrombolysis for acute myocardial infarction (ami). methods: patients with ami were included. blood for estimation of catalase (cat), glutathione peroxidase (gpx) and mn-superoxide dismutase (sod) was drawn before initiation of i. the mechanism of myocardial cell defence against free radicals is probably identical in both reperfusion and no-reflow phenomena. therefore, antioxidants cannot be used as reperfusion markers. objectives_ to evaluate the precipitating factors of hypothermic phrenic nerve injury following cabg with lima. methods: fifty two consecutive patients ( females), with a mean age of + (mean +sd) years were studied. during the ischemic arrest time topical hypothermia was obtained in al~ patients wffh ice slush and no cardiac insulation pad was used. all patients received a lima graft, with or whithout additional vein grafts. supramaximai, bilateral phrenic nerve stimulation was performed percutaneously preoperatively and whithin hours postoperatively. square wave stimuli of . msec duration were applied at the posterior border of the sternomastoid muscle. the compound muscle action potential of the diaphragm was recorded, using surface electrodes on the anterior chest wall. the time interval from the application of stimulus to the onset of diaphragmatic activity, phrenic nerve conduction time (pnct), was measured. values exceeding . msec were considered as abnormal. besults: preoperatively, all patients had normal (mean+sd) pnct, . • msec for the left nerve and . • mseo for the right nerve. on the first postoperative day, right pnct was normal in atl patients ( . • msec) , whereas left pnct was normal in patients ( . • msec) and abnormal in patients (incidence . %). in patients the left phrenic nerve was inexcitable and in patient left pnct was prolonged ( . msec). comparing patients with normal and abnormal pnct there was no difference in age, gender, number of grafts used, aortic cross-clamp and bypass time. however, patients with abnormal pnct had a lower preoperative ejection fraction ( • vs • p= . ). moreover, in all of them lima was dissected from its origin ligating all upper arterial branches, which provide the blood supply to the left phrenic nerve, whereas in those with normal pnct the small vessels originating from the upper to cm of lima were preserved (p= . ). conclusiojel~ a hypoperfused left phrenic nerve seems to be more susceptible to hypothermic injury during cabg with a lima conduit. objectives: to test if necessary interventions on systemic vascular resistance (svr) along with preset pump flew (q) during cpb could adversely affect autoregulatory response and cause vo shifts. methods: we studied males ( - yrs) who underwent cpb for cardiac surgery. at o oesophageal temperature - c we set pump flow at . i.m~ .min - . when map was higher than mmhg we calculated vo by using fick equation. then we infused sodium nitropruaside (sn) to control map at - mmhg for min and we calculated vq . without changing the sn infusion rate we set q at . i.m' .min " . ten min later we measured vo . we took vo changes into consideration if greater than %. statistical analysis using students-t-test for paired data and analysis of variance was used as appropriate. results: depending on the biphasic vo response to sn infusion during low and high q we classified pts in four groups (table). i. vo increases with sn and increases further during high q unmasking hypoperfusion and supply dependency. ii. vo increases with sn but the addition of high q results in systemic shunt. iii. vo increase during high q proves that vasodilatation can turn flow insufficient. iv. vo does not change with any intervention. the small number of pts and the wide standard deviation did not allow any statistical significance. conclusions: cpb is an interesting model for the behavior of microcirculation. intervention on svr and q can improve or impair effective regional oxygen delivery, resulting in either better perfusion or systemic shunt. vo monitoring seems necessary during cpb. preoperative cardiovascular optimization (opt) to ci > . l/min/m , _< paop < mm hg,and svri __< mmhg/ll/min/m decreases cardiac events (events) and mortality (mort) in peripheral vascular surgery patients (pvs). objectives: to determine if opt to the same endpeints decreases events in patients undergoing abdominal aortic aneurysm repair (aaar) and to study the r predictive value in pvs patients. methods: aaar patients and pvs patients were admitted to the s cu monitored with e pa and arterial catheters and treated to achieve opt. patients underwent surgery independent of success of opt data included demograph cs, incremental risk factors, laboratory and hemodynamic data pre, intra, a~nd postoperatively events, and mort. events included arrhythmias requiring treatment or prolonging the sicu stay > hours, a st depression > !mm or t wave inversion, an acute mr defined by a new q wave > . sec or cpk-mb > %. results are presented as means _ -. sd. opt was achieved in of ( %) and in of ( %) in the pvs and aaar group, respectively. events did nat differ between groups of ( , %) and of ( , %) in the pvs and aaar group, respectively (p>o. ). mort was of ( %) and of ( . %) in the pvs and aaar group, respectively (p > . ), while there was no difference in endpoints of opt between patients with and with.out events in the aaar group, there was a significant difference in ci between patients with and without events in the pvs group. of note, of ( %) patients who developed events in the pvs group had a ci < . in contrast to of ( %)in the aaar group. the positive and negative predictive value were % and % in the pvs and % and % in the aaar group. conciusione: f. the endpoints of opt used for pvs patients cannot be ~sed to reduce events in aaar patients; . pvs patients who have net achieved opt are at extraordinary risk of perioperative events; . preoperative card ovascu ar opt in aaar patients makes no difference in cardiac related events, background : comparison of the right and left filling pressures (cvp/pcwp ratio) is considered as a useful diagnostic clue : the normal ratio is _< . ; ratio >_ . may suggest right ventricul~ infarction while equalization of the cvp and pewp is a classic sign of tamponade ( ). however after cardiac surgery, many conditions (diastolic dysfunction, pulmonary hypertension, positive pressure ventilation) are susceptible to modify the '*normal" cvp/pcwp ratio. material and method : we determined cvp/pewp ratio in consecutive patients (pts) after uncomplicated cardiac surgery ( coronary artery bypass grafts; valvular replacements) measurements were made before and after tracheal axtubation. results :cardiac index : . _+ . /minlm~; laotate: + rag/i; cvp range : - rnmhg; pewp range : - mmhg. mean cvp/pcwp ratio before extubation is . ( % confidence imerval : . - . ) and after extubation, . ( % confidence interval : . -. . ), (ns, paired t-test). in % of the pts, cvp was higher than pewp. there are no correlation between the cvp/pcwp ratio and c! before (r = - . ) and after extubation (r = - . ) nor between the cvp/pcwp ratio and mean pulmonary arterial pressure (mpap), before (r = . ) and after extubation (r = - . ), discussion : cardiac performance is adequate according to ci and lactate. however the cvp/pcwp ratio is markedly higher than the "normal" (_< . ) ratio. this difference is not related to mechanical ventilation because the ratio is similar before and after extubation, nor to pulmonary hypetaension because of absence of any correlation with mpap, post-cpb diastolic dysfunction of the right ventricle could be an alternative explanation. in this group of pts, increased cvp/pewp is not associated with any impairment of cardiac performance (absence of correlation with ci), conclusions : cvp/pcwp ratio as high as within a large range of cvp ( - mmhg) and pcwp ( - mmhg) may still be considered as normal after cardiac surgery. this emphasizes the limitations of the hemodynamic monitoring after cardiac surgery (in comparison with echographic technics). careful analysis of the morphology of the cvp and right ventricular pressure curves (x descent, y descent, dip-plateau) is mandatory rather than relying on the quantitative assessment alone. reference : ( ) ntensive care.-university hospital -m~laga (spaink introduction. fibrinolitic treatment (ft) permits the treatment of acute myocardial infarction (ami) addressing the etiology, thereby eading to mproved ventncular function and a marked reduction m mortality. the main clinical oroblem is the reduced time of application. delay in hospitalization, which can be from to minutes, is potentially the most avoidable delay. method. to reduce delays in hospitalization, the following was carried out in two chases. audit: analysis of the time lapse from onset of symptoms to start of ft. showed that during "(he period june to december , patients with chest paros were treated within a eriod varying from minutes to hours from onset of symtoms. ages ranged from to (average , ), oelng males and females. they were glved initial ecgs to determine st mcreases suggesting ami. median t~me for this orocedure was l m.. potentia ami patients were then admitted to the coronary unit, [)atients, under age with no contraindications received ft the median time apse from admission to corona-y care and administration of ft was minutes ( . ), -he total median delay was minutes ~ -i h. min,~ delays n start of this procedure are grouped as follows: extra-hosdita delays (from onset of symtoms to arrival at hospital) diagnostic delays (from hospital arrival to ecg). treatment delays (from diagnosis to ft). objectives: protocol of procedure to implement a fast-track method. a protoco was drawn up with the object of reducing diagnostic delays to -i minutes and treatment delays to less than i minutes results. following rmplementatlon of this protocol in january , fts were glven, with an over all average delay of minutes. this fast-track method did not reveal any inappropnate ft or any increase m complications, conclusions: detailed study of the various times taken for diagnosis ane treatment of ami patients, showed up weaknesses in the system and improvements througn the protocol based on performence orocedures which led to a % reduction in the start of ft background: the importance of the early use of thrombo!ytic agents in acute myocardial infarction (ami) is based in the better remaining ventrictjlar function and smaller mortality rate because of the greater reperfusion and sma!ler infarction size, therefore, it is very impodant to apply this treatment to the maximum number of patients without thrombolytic contraindicati n, and within the minimun period of time. the "thrombolytic fast track" implementation allows to optimize the time to administrate thrombelytic agents avoiding multiple delays~ methodology: we anal!ze the application of thromboly c agents to patients with suspect of ami from the begin!ng of september until the end of february . in this time there are two different periods, during the first months thrombolytic agent were admin!strated at intensive care unit (icu), and during the second period we carried out a protocol of quick detection and thrombolysis therapy in susceptible patients at the emergency room in order to reduce the time to treatment. ma!n results are shown in the faffewins de ay h=hours m=minutes the implementation of the fast track does not need supplementary personal or equipment but a protocelized approach and training of the personal involved the main problem detected was the usual attendance overload of the emergency department that makes difficult to follow many structurated actions. conclusions: pratocqlized changes in the management of ami can significantly reduce the detay in the administration ef thrombolytic agents. it is not necessary to eomplet the procedure iq the emergency department, as the use of bolus schedules allows to begin the treatment in this area and to transfer the patient to icu afterwards. elective cardiac surgery. b calvet, f ryckwaert, p trinh duc, p colson. anesthesia -reanimation, hopital arnaud de villeneuve, montpellier, france. obhectives: the study was aimed at analysing the incidence of renal dysfunction following cardiac surgery and its prognosis (acute renal failure, post-operative morbidity and mortality). methods: two hundred and thirty seven patients (aged from to ) were consecutively operated on for elective cardiac surgery and retrospectively included in the study. patients with preoperative infections and operated on in emergency were excluded. each patient had preoperative invasive cardiac investigation with angiography and calculated ejection fraction (ef). anaesthesia, cardiopulmonary bypass (cpb) and cardiac arrest management were similar in all patients. general body temperature was reduced to - ~ c. renal dysfunction was defined as a % increase from baseline of serum creatinine. demographic data, asa, treatments, pre-operative creaunine level, cpb and clamping (axc) times, intra and postoperative use of inotrope, serum lactate level before surgery, at the end of cpb, at the time of admission in intensive care unit (icu) and on post operative day one and apache score were compared in patients with or without renal dysfunction using anova test for repeated mesures and x when appropriate. data are expressed as mean +__sd. p value less than . was considered statistically significant. results: thirtytwo patients ( , %) suffered from renal dysfunction. age, serum lactate level at the end of cpb, at admission in icu, at pod and apache level at admission in icu, intra-operative use of inotropes were statistically different in patients with or without renal dysfunction (p< , ). mortality rate was statistically different in patients with or without renal dysfunction(~, , % and %, respectively, p= , ). incidence of acute renal failure following renal dysfunction was , % ( patients required hemodialysis). conclusions: although our cdteria for defining renal dysfunction were very sensitive, the incidence of renal dysfunction following elective cardiac surgery was lower than communly accepted in the litterature ( ). however renal dysfunction appeared significantly associated with a poor prognosis. reference: -settergren g, ohqvist g current opinion in anaesthesiology , : - r ; , tzelepis, g. , , late complications were observed in % of cannulations: local infection in (i, %), catheter displacement by the patient in cases ( , %), catheter displacement during nursing care in ( , %) and malfunction in cases ( , %). conclusions: central venous catheterizations are followed by immediate and late complications in almost the same percentage acute poisoning with amphetamines (mdea) and heroin: antagonistic effects between the two drugs methods: after institutional approval and informed consent, selected patients ( _+ years) undergoing peripheral vascular surgery (n= ) or carotid endarterectomy (n= ) were investigated. patients included had either documented cad (n= ) or two or more (n= ) dsk factors (age > years, smoking, diabetes meltitus, hypertension, hypercholesterolaemia > mg/dl). -lead ecg recordings were carded out preoperatively, on ardval in the postanaesthetic care unit, and h, h, h, and h postoperatively. ecg recordings were analysed by an independent blinded cardiologist for signs of pmi (new st segment depression > . mv and/or new t inversion). in addition results: of the patients investigated developed ecg-documented pmi, % occurdng in the immediate postoperative phase. troponin i levels > . ng/ml were found in of these patients thus, comparing a cardiac troponin i cut-off level of ng/ml with intermittent -lead ecg recordings, we found a sensitivity of % and a specificity of % methods: demographic, clinical and ecg data were analyzed. . % of patients were male; . % female. cad was the most common underlying cardiac disease ( . %) and . % underwent open heart surgery. % received proeainamide for supraventricular and % for ven~cular arrhythmias. % received a loading dose. maintenance was provided by iv route in . % and by po in . % ( . %sr end . % ir). . % of patients were obese right ventricular function following cardiopulmonary bypass: is important the mode of myocardial protection we underwent this study in order to examine its safety and usefulness in pts with trustable coronary conditions (unstable angina ua the mean age for group a was • years, for group b • years, and for group c • years. a history of previous myocardial infarction was present in pts of group a, in of group b and in of group c. three pts in group a, in group b and in group c had previous coronary artery bypass grafting. the median time between the onset of symptoms and a was days ( - ) for group a we used a continuous fixed intravenous a infusion at a dose of the sn was % in groups a and b, % in c, and sp % for group a, (fixed defects included) and % for groups b and c. there was no difference of side effects among groups: chest pain (i pt -group a, pts -group b, and pts -group c), transient hypotension ( pt -group c), headache ( pts, group c), dyspnea ( pt -group a), while st depression was seen in pts of group b and in pts in group c. the rate of a infusion was decreased to /kgr/min in one group b pt due to development of chest pain s five year follow up of humoral immunity in paced patients athens polyclinic hospital, department of cardiology athens, greece author index a abiad ch bertschat, e betbes blanch, l del nogal saez e -meneza nolla, j. nolla-salas pilz~ u puig de la bellacasa e scarpa, n. van de wetering objectives: only % of patients suffering from acute guillain-barr@ syndrome (gbs) respond promptly to established therapies like plasma exchange or intravenous immunoglobulines. in contrast to serum, cerebrospinal fluid (csf) of gbs and ctdp patients contains enriched portions of antiexcitatory factors(i) and cytokines ( ) able to induce pronounced conduction block ( ). to reduce or remove such pathologic factors we introduced a technique with direct access to the subarachnoid space. methods: with informed consent we lumbally inserted g catheters in gbs-and cidp -patients under sterile conditions. some of them had not responded very well to established therapies. - ml of csf were withdrawn and retransfused by a bidirectional pump (flofors) after passing newly developed filters (pall). daily filtrations with several cycles were performed ( - ml) over one week. results: the gbs patients improved after days (median) for one grade (according to the gbs-scale from the gbs study group) . the ventilator dependent patients were weaned after days (median). patients not at all treated before ( / ) responded better than patients that had been pretreated ( / ) with plasmaexchange or intravenous immunoglobulines. / cidp patients drew benefit from treatment, stabilized iongterm. conclusions: csf-filtration is a relatively save and well tolerated additional procedure. the costs are considerably lower ( / ) than those for plasmaexchange or intravenous immunoglobulines. references:( )wsrz aet al: csf and serum from patients with inflammatory polyradiculopathy have opposite effects on sodium channels. muscle nerve ( ) . ( ) clinical observations were made in patients admitted to the clinic. they were in coma associated with acute alcohol intoxication.standard evaluations (ecg-monitoring, electrocardiography, neuromonitoring, studies of acid-alkali condition, biochemical and toxicologic investigation of blood and urine) prior to and following the treatment conducted were undertaken in all the patients.to correct irreversible impairement of functions twofold laser blood irradiation by means of alok- apparatus, the exposure within minutes, was carried out.the data obtained confirm more rapid coma withdrawal of the patients, reconstruction of the heart and central nervous system electrophysiologic indeces, reliable reduction in complications compared with the control group. objective: to know the actual incidence of the critical illness polyneuropathy(cip). setting: fourteen intensive/critical care unit beds, in bed university hospital, covering . inhabitants (majority rural area). the icu patients are medical, surgical and coronary, excluded the neurotrauma and neurosurgical. design: a conseculive and prospective study. all the patients admitted during three months, from january lth to march th , were eligible (patients with admittance diagnosis of polyneuropathy were excluded ). methods: patients with apache ii score > , at the admission and six days after admissions were included into the study protocol. diagnosis of sepsis, mof, and all the drugs administered days before were recorded. a complete neurological exam, by a neurologist, in absence of ssdatives and muscles reliant ( th, ~ and th days after icu admittance) was made. we evaluated the nerve and muscles function with and electromyography study in all patients, at same days. in some paeents with cip we performed a nerve biopsy. results: from patients ( apache ii score: . ) admitted in the icu, ( . %) enter the study protocol. seven ( , %) had an axonal polyneuropathy(cip), three very severe. only four of the patients with cip had pathologic clinical exam. apache ii score: cip vs non-cip was . vs . . the incidence of cip by diagnosis (cip/diagnosis) was: sepsis, / and mof, / . conclusions: . -we think that it is necessary to define the "critically ill" for some score, before designing a study to know the incidence of this syndrome. . -we think that the incidence of the cip is lower that the latest papers say. objectives:acute pancreatitis(ap)is becoming a more important problem among the elderly as the population ages. the increasing presence of gallstone disease,as well as the use of certain drugs,may also contribute to the occurrence of pancreatitis. methods:all patients(> years)admitted to our medical department over an eight year period were included.pancreatitis was confirmed by biochemical tests and imaging techniques.scores were developed using ranson's criteria and a multiple organ system failure(mosf)index . overall, patients were evaluated; ( %)had pancreatitis of unknown etiology . results:( )patients with pancreatitis of ~nlqnown etiology were sicker and had greater morbidity( % vs %),mortality( % vs %),and longer hospital stays than p~tierf~ with pancreatitis of known cause.( )the best predicto~of severity and outcome was the mosf index and not ranson's criteria;the higher the score,the greater the associated disease,the worse the outcome.( )curlously,no difference existed in associated medical conditions between patierts withknown and ur ~own causes of pancreatitis. conclusions:greater organ dysfunction exists in patients with pancreatitis of unknown etiology, even though age and associated medical conditions do not differ . the application of the total enteral nutrition in the burns disease has minimized the complication rate and consequently increased the survival rate of children and adults. time of initiation, composition, duration and way of administration are very important in obtaining the optimum beneficial effect from the treatment and diminishing the complication rate and side effects. the above features will be discussed in view of our experience in cases. ta buckle?,, ra freebalm, c gomersall g joynt, r young. tg short. department of anaesthesia and intensive cm+e, prince of wales hospital. the chinese university of hong kong, shatin, hong kong introduction: gastric mucosal ph (phi) monitoring has been proposed as a relatively noninvasive index of the adequacy of aerobic metabolism in the gut. to examine the accuracy of gastric intramucosal pit measurements as a function of time and as a function of the catheter itself to determine whether the measurement error between catheters is clinically acceptable. patients with a gastric tonometer (trip tm, tonometrics, worcester. ma) insitu for > days were studied. following informed consent two new tonometers were inserted equidistantly & correct position was confirmed radiographically. measurements of intramucosal gastric ph were then performed over a hr period. eight -ten measurements were made in each of ten critically ill patients.percent differences between the two new catheters were . % ie at ph . _+ . ( % limits) and between old & new catheters were . %, ie ph j _+ . ( % limits). conclusions: the results suggest that the function of the tonometer deteriorates over time and that the absolute values of phi m~ not ~ufficiently accurate. however as a trend monitor phi may be useful in the clinical setting. despite a continuous decline both in li'equency and severity of gastro-intestinal stress-lesion/-bleeding (gisb) due to both improvement in preclinical support and in intensive care medicine, patients with cerebral lesion are still considered at high risk for developing gis . therefore the question arises, whether m> specific (}lsb-prophylaxis besides general and neurological intensive care, specific pharlnaeothcrapy or even the combination of two specific drugs reveals any protective efli~ct on frequency and severity of gisb.this pntspcclive randomized study has been perfornted in patients snfrering t'rttna head-injury/cerebral lesion and with a glasgow-coma-scale on admission (gcs:,)of < . according to randomization the patients have been grouped as tbllows: h analgesia/sedation (n= ); ih analgesiajsedation plus pirenzepine mg/day (n= ); .[ih anatgcsia/sedalkm plus sncraltate x [ g/day (n= ); iv: analgesidsedatkm plus pirenzcpine mghlay plus sucralfate x e/day (n= ). slalislical analysis has been performed by chl:*tt~sl. rank correlatinn and unpaired t-test; statistical significance has been set with p < . . / patients ( . %) developed gisb. although the mean gcs~-value (x -+ sd) did not reach significance between patients with and without gisb ( . + . vs . -+ . ). a significant inverse correlation between gcs:, and the incidence of gtsb (rs~ = . ) has been shown. the frequency of gisb among the groups is as follows: h . %; lh . %; llh . %; iv: . % (ch -~ = . ; not signilicant). no gisb-induced blood translusion or mortality, respectively, could be demonstrated. survival rate between the groups did not differ significantly (chi-" = . ; p= . ) and reached an overall-value of . %.drug-specific glsb-prophylaxis -administered either as monotherapy (pirenzepine, sueralfate) or in combination of these two specific-drugs -reveals no additional significant influence on the incidence of gisb in patients with cerebral lesion compared to no specific prophylaxis besides the general trauma-/disease-specific intensive care measures. critical care dpt, evangelismos hospital, athens university scho~" of medicine objectives: the correlation of longterm presence of nasogastric tube (ngt) to gastroesophageal reflux (ger) is still in question. in case of positive correlation, peg should represent an alternative to tube feeding in patients unable to be fed orally. therefore, we investigated: i) the correlation between ng and ger and ii) the effect of peg on ger. methods: a -h esophageal ph-metry was performed in patients in recumbent position at ~ who had a ngt for more than days and were on sucralfate for gastric mucosal protection. the tip of the ph-probe was lied cm over the esophagogasttie junction, confirmed by x-rays. patients who presented a percentage of ger-total (i.e. with a ph less or more than ) (ger-t) more than %, underwent ~t peg. the presence of a creseent-notch on the esophagogastric junction persisting on inspiration and the grade os endoseopic and histologic esophagitis (scale= - ) was noted. two ph-metrles repeated on h and on days post-peg were compared to the pre-peg one, with the followin~ parameters taken in consideration: i) % ger-t, ii) number of ger-total per hour (no/h ger-t) and iii) the duration that ph was less than (tph< ). in case ot ger persistence at the ph-metry on ?th day post-peg (group ii) another endoscopy was performed, while patients with reduced ger (group i) were considered as esophagifis-free.results: out of patients presented a ger-t> %. eleven out of group i group (n= ) i ( objectives: the aim of the present study was to compare the performance of a specially modified version of a photo-and magnetoacoustic (pa/ma) gas analyzer (br~)el & kjaer, denmark) with a conventional quadrupole mass spectrometer (ms) (innovision, denmark) in inert gas rebreathing (rb) tests such as determination of functional residual capacity (frc), pulmonary capillary blood flow (pcbf) and lung tissue volume (vtc). methods : from simultaneous readings of inert gas concentrations with the ms and the pa/ma analyzer during rb experiments a comparison was made of the pcbf, vtc and frc values. the rb tests were performed during rest and exercise ( , and w) in ten healthy subjects. results: the differences (mean +/-sd) between simultaneous estimates of rebreathing parameters were the following (pa/ma -ms) for pooled data, pcbf: . +/- . i/min, vtc: - +/- ml and frc: . +/- . liters. conclusions: smell but significant differences were found between the estimates of pcbf, vtc and frc using the ms and pa/ma, respectively. reference: p. clemensen, p. christensen, p. norsk, and j. gr~nlund. a modified photo-and magnetoacoustic multigas analyzer aplied in gas exchange measurements. j appl physiol ; : - . objectives: because transcranial doppler (tcd) has been proposed to explore cerebral co vasoreactivity in brain injury (stroke ; : - ), we compared this technique with the kety-schmidt reference method to assess cerebral vasoreactivity in comatose patients. methods: mechanically ventilated patients (age - yrs, glasgow - ) in coma due to acute brain injury were investigated during stepwise changes in paco ( , , , and mmhg) by increasing inspired pco . middle cerebral artery velocity (vm) was measured by tcd. after insertion of a catheter in the ipsilateral jugular bulb, cerebral blood flow (cbf) was determined by the kety-schmidt method, using the inhalation of % n through the inspiratory line of the ventilator. for each patient a cerebral co~ vasoreactivity index was calculated as the slope of linear relationship between vm or cbf and paco . objectives: after cardiac surgery the fluid shill, between interstitial and intravasal space may be marked. this is due either to the intraoperative volume loading by the extracorporeal circulation or the increased postoperative diuresis. therefore, infusion of a large amount &fluids is necessary during the first postoperative hours. it still remains unclear which of the substances at disposal is the best for this purpose. aim of the present study was to compare the different fluids with special regard to postoperative bleeding and rheological behaviour. methods: patients undergoing cabg-surgery were investigated and randomizedly distributed to three different groups of postoperative volume replacement to stabilize the mean arterial pressure at mm hg. . ringer's solution, . . % gelatine solution, . % hydroxyaethylstarch (mean m.w. . ). we evaluated the following parameters within intervals of min: arterial and central venous pressure, heart rate, postoperative bleeding, urinary output, volume replacement. results: there was no statistically significant difference between the groups with regard to urinary output and bleeding. in spite of larger amounts of fluids necessary in the ringer treated group patients of this group showed symptoms of hypovolemia. hematocrit was increased in the ringer patients. this was statistically significant. introduction: pulmonary wedge pressure (pcwp) and central venous pressure (cvp) are frequently used as parameters for cardiac preload, although it is known that both are poorly correlated to the cardiac index (ci). it has been claimed that intrathoracic blood volume (itbv) measured with the thermal dye dilution method reflects cardiac preload better than pcwp and cvp. we studied the correlation between itbv and ci in a mixed population of critically ill patients. methods: in consecutive patients ( sepsis/sirs, acute heart failure, ards, transjugular intrahepatic portosystemic shunt) monitored with a pulmonary artery catheter, itbv was measured on regular intervals using the pulsion cold z- system (pulsion, munich, germany). ci, pcwp, and cvp were recorded simultaneously. results: a total of ol measurements was made. pcwp and cvp did not correlate to ci, nor did apcwp or acvp correlate to aci. itbv was correlated to ci in a non-linear fashion (f - , df = , p < . , (figure) ). aitbv was correlated to ac in a linear fashion (r = . , f = , df = , p < .o ). a rapid and efficient circulatory support system may save a patient in cardiogenic shock. left heart bypass with percutaneous and transseptal placement of the aspiration canuia simplifies the circuit and avoids the need for an oxygenator. we assessed this preclinical set-up in anaesthetized pigs using a centrifugal pump with a f arterial catheter and a f left atrial aspiration line. animals were supported for two hours at a mean flow of . liter ( ' rpm), a mean hematocrit of % and low heparinisetion (act double baseline). hemodynamic and laboratory samples were taken at baseline (a), minutes (b), one hour ( pulmonary hypertension (ph) usually involves obliteration and loss of functional pulmonary microvasculature. the microvaseular endothelium normally acts as a major metabolic organ, converting angiotensin i to angiotensin ii via the angiotensin-converting ectoenzyme (ace). it is unknown whether the loss of functional vasculature and altered pulmonary blood flow seen in ph will affect lung ace metabolic activity. we therefore estimated pulmonary vascular ace activity in patients with ph of various causes: primary; post atrial septal defect closure (asd); chronic thromboembolic (te); anorexigen; iv drugs; collagen disease. single-pass transpulmonary hydrolysis of the specific ace substrate h-benzoyl-pbe-ala-pro (bpap) was measured and expressed as % metabolism (%me . we also calculated an index of peffused functional capillary surface area (amax/km). all patients with ph had an abnormality of %met or amax/km, or both. as compared to control humans (mean %met = . % _+ . % s.d.), the mean %met in ph patients was . % _+ %. the %met in ph patients correlated inversely with cardiac output (r= . ), possibly reflecting more complete bpap hydrolysis with longer pulmonary transit times. amax/km was markedly decreased in ph ( + ml/min) as compared to controls ( _+ ml]min), consistent with a significant loss of functional capillary surface area. patients with collagen disease, asd and anorexigen-induced ph had the most marked abnormalities. in conclusion, patients with pulmonary hypertension have decreased pulmonary endothelial angiotensin converting enzyme activity, likely due to a loss of functional or perfused pulmonary microvaseulature. supported by the funds de la recherche en same du quebec and the national health system of greece. objective: to investigate adrenocortical function in patients with ruptured aneurysm of the abdominal aorta (raaa). studies investigating adrenocortical insufficiency in critically ill patients report an incidence ranging from % to less than %. this may in part be explained by difference in methods used (single cortisol measurement vs short acth stimulation test) and populations studied (heterogenous groups of patients with great individual variation in underlying disease as well as duration and severity of illness). methods: we investigated the adrenocortical function in patients with (raaa).a short acth stimulation test (synacthen test; ug - acth iv) was performed at hrs within hrs of admission. plasma cortisol was measured before (cort basal) and after stimulation (cort stim). a plasma cortisol level > . umol\l before or after stimulation was considered normal, severity of illness was assessed using apache ii. results: of the patients investigated died and survived. mean cort basal in nonsurvivors was significantly (p< .o ) higher than in survivors; . (range . - . ) vs . (range . - , ). this difference between nonsurvivors and survivors was also present for cort stim but lacked significance; . (range . - . ) vs . (range . - . ). while patients showed a cort basal < . , no cort stim < . was found. there was no significant difference in mean age or apache ii score between survivors and nonsurvivors; vs and vs . conclusions: single plasma cortisol levels were inadequate to assess the adrenocortical function in the patients studied, judged by a short acth stimulation test, our investigation in patients with raaa showed no adrenocortical insufficiency. mortality in raaa is associated with elevated plasma cortisol levels. obiectives: mortality in acute myocardial infarction (ami) prinicipally depends on hemedynamic impairment. thus, patients (pts) with elevated pulmonary wedge pressure (pwp) present high in-hospital mortality. however, the complete right heart catheterization is laborious, so the central venous pressure (cvp) alone is frequently used to assess the severity of ami. the accuracy of cvp in estimating pts with ami was tested in this retrospective study. methods: pts. aged + years, admitted to our ccu from to with their first ami, were inctuded in this study. all had undergone right heart catheterization because of overt or suspected heart failure. swan-ganz catheters ( f, cm, abbott, il, usa) had been used, every treatment had been temporarily interrupted l h before the calheferization. based on ecg findings the pts were retrospectively divided into groups. in group a we included pts with anterior ami, in group b, pts with inferior ami, and in group c, pts with inferior and right ventricular ami. the initial values of cvp and pwp were considered for the linear regression of the pwp variable on cvp and p< . was accepted as statistically significant.results: in g~oup a, the cvp and pwp vaiues were + mmhg and _+ mmhg respectively. despite the signifanf correlation (p< . ) between the two variables, it was not possible fo predict the exact value of pwp based on cvp value, pts ( %) presented cvp> mrnhg and of these ( %) had pwp_> mmhg. in group , the cvp was _+ mmhg and the pwp, _+ mmhg. significant correlation (p< . ) between the two variables also existed, however it was impossible to predict the pwp value. pts ( %) had cvp> mmhg but only of these ( %) had pwp> mmhg, similar was the relation between cvp and pwp in group c (p< . ). cvp averaged + mmhg, and pwp, _+ mmhg. pts ( %) had cvp> mmhg and from these ( %) presented pwp> mmhg,conclusions: a single measurement of cvp in ami does not ensure an accurate assessment of pwp. because every pt with ami needs optimal values of pwp in order to prevent pulmonary congestion or manifestations of low preload, the significance of complete right heart catheterization becomes apparent. in patients (pts) with advanced hf the need and the prognosis for heart transplantation (ht) can be predicted from vo= max. indirect measure of functional capacity with the six-minute walk test can also predict smvival in moderate hf. to predict vos max from indirect astinmtions of functional capadty such as - ~q~/, pulmonary and heart function tests, and to assess the prediddve value of the above parameters in hf pts survival. we evaluated pts (age + yeats nyha class: ii, hi, iv) with hf for pit. they underwent a pmgmmive exercise test on cycle ergometer for vo max determination, a -mw, a right heart catheterization and a spirometry and dlco estimation. introduction: brain death causes myocardial impairment by mechanisms that are not well understood yet. the aim of this work was to assess the echocardiographic features found in these patients from the clinical onset of brain death to somatic death, methods: seven brain dead patients were studied (patients" relatives refused to allow them to be used as donors). mean age was . ( - ) years old. four of the patients were female, none of the patients had any history of cardiac disease. transthoracic echocardiogram (echo) and electrocardiogram (ecg) were obtained at the onset of clinical brain death and were repeated every hours until somatic death. we we detected severe diffuse hypokinesia (ef< %) in patients and mild hypokinesia in others (ef - %). systolic function was strictly normal in only patients. corrected qt interval (qtc) in ecg was . _+ . msec (normal range - msec) just before somatic death (b). conclusion: in patients with brain death we observed a significant increase of left ventricular mass due mainly to ivs "hypertrophy" without any important change in the dimensions of the left ventricle. to our knowledge, this finding has never been reported before and its importantance in heart transplantations may be of particular interest. predict right ventricular outcome. l. jacquet, r. dion, p. noirhomme. m. van dijck. m. goenen cardiothoracic intensive care unit, st-luc univ. hospital(ucl) we have registred: heart rate (hr), blood pressure (bp), pulmonary artery pressures (pap), central venous pressure (cvp), pulmonary capillary wedge pressure (pcwp), pulmonary and systemic vascular resistances (pvr, svr), right ventricle end-diastolic end end-systolic volume (redv, resv), right ejection fraction (ref), right sistolyc ventricular work (rsvw) and cardiac output (co) using a thermodilution thechnique and a microprocessor (model ref- ; baxter-edwards laboratory); duration of cpb and aortic clamping, and the requirements of haemodynamic support after cpb.results: in the c group an increase post-cpb of the fc ( + . + . , p < . ) was produced without significantly changes in the redv, resv, ref, rsvw neither co. in the w group, hr increased from . + . to . + . (p < . ); redv was reduced from . -+ to . _+ . (p < . ); resv was reduced from • . to + . (p < . ). there were not changes in the other haemodynamyc parameters. there was a trend (no significantly) to an increase of ref in the w group ( . + . |• . ) compared with the c"group ( • . ($ . • . ) post-cpb. the need for haemodynamic support was similar in both groups.conclusions: the warm, continuous, anterograde-retrogade myocardial protection has obtained a decrease of preload, hr, and a trend to an increase in the ref, making an improvement in the right ventricular global performance when is compared with the classic form of cold myocardial protection. objective: to evaluate the effect of dobutamine on gastric mucosal ph (phi) after coronaly artery bypass surgery. design: prospective study in a university hospital intensive care unit (icu). subjects: elective cardiac surgery patients. interventions: dobutamine was infused at ug/kg/min for hours immediately after admission to the icu. hemodynamics were measured every minute periods until hours and again hours after stopping dobutamine. results: there were no significant differences in mean gastric phi between the groups but mean phi decreased in both groups during the study period. oxygen delivery and consumption both increased during dobutamine infusion but decreased to the control group level after stopping the dobutamine infusion. lactate levels did not change. baseline objectives: the aim of the study was to evaluate the usefulness of a low dobutamine dose in conjunction with intraaortic balloon pumping and mechanical ventilation in cardiogenic shock. we studied patients . -+ t . years of age suffered of post infarction cardiogenic shock characterized by a systolic arterial pressure< mmhg, urine output< ml/h and mental confusion or purpueral signs of low output, non responded to dobutamine infusion up to pg/kg/min. all patients underwent mechanical assistance by the intra-aortic balloon pump (iabp). five patients were additionally placed on mechanical ventilation due to blood gases disturbances. the end points in our study were: reversion of cardiogenic shock, improvement of patients survival or both on the th post infarction day and months later. results: three patients refused iabp treatment and / survived on the th day. on the th day / supported by the iabp and / that underwent mechanical ventilation plus iabp were alive (p < . ). on the th month / supported by the iabp and / that underwent mechanical ventilation plus iabp were alive (p< . ). conclusions: in conclusion, the combined use of mechanical ventilation and iabp assistance in severe cardiogenic shock might improve survival. obiectives: the study was aimed at analysing predictive factors of swan ganz pulmonary catheter (pc) requiremen t during elective cardiac surgery according to the need of sustained inotropic support after surgery. methods: three hundred patients (aged from to ; females and males)were consecutively operated on for elective coronary artery bypass surgery (cabg, n= ), valvular replacement (vr, n= ), combination of both (vr-cabg, n= ), or others (n= ) and retrospectively included in the study. each patient had preoperative invasive cardiac investigation with calculated ejection fraction (ee). anaesthesia, cardiopulmonary bypass (cpb) and cardiac arrest managements were similar in all patients. pc requirement was estimated from the need of either dobutamine, adrenaline, dopamine or enoximone use during the first hours after cardiac surgery. demographic data, asa and nyha classifications, preoperative ef and treatments, type of surgery, cpb and aortic cross clamping (axc) times, and postoperative incidence of complications were compared in patients with or without inotropic support using either student's t test or x with continuity correction when appropriate. results: seventy hree patients ( . %) required inotropic support after surgery. axc .and cpb times, mean stay in icu were significantly longer in patients with inotropie support (p< . ). type of surgery, preoperative ef, and nyha classification are the first significant factors related to inotropic support (p< . ). most patients operated on for double-vr or vr=cabg required inotropic support ( and %, respectively). postoperative mortality was higher in patients receiving inotropic support ( , % vs , % 'overall mortality, p= . ). conclusions: since pc insertion is most.often justified because inotropes are required, these results suggest that elective rather than routine systemic pc insertion could be helped by considering several but selected preoperative factors. background: cardiovascular depression due to anaesthesia, old age and major gastrointestinal surgery is becoming an increasingly frequent challenge .to the anaesthesia-surgory team. deliberate preoperative manipulation of haemodynamics and oxygen transport parametres towards prede~t~mined optimal values may prove to be effective "in reducing morbidity ~nd mortality in high risk surgical patients,. a new concept of using conlimaous perioperative measurement of cardiac'output to obtain and maintain supranormal oxygen delivery (do i) is presented. methods: continuous measurement of cardiac output is a relatively new form of on-line monitoring, in which trains of impulses are emitted from a thermal filament mounted on a pulmonary artery catheter. computer software recognizes patterns generated by minute changes in blood temperature and ealoalates cardiac output every - seconds. cardiac output and mixed venous blood oxygen saturation are displayed graphically on line. in tins tm study cardiac output was measured continuously by vigilance cardiac outpu t compl/ter (baxter). preoperative haemodynamic optimization was performed with the goal of increa- sing do i to at least ml/min/m accordfing to shoemaker's algorithm . this was.done by infusing colloids (albumin or hydroxy ethyl starch (haes-steril| until the desired do was reached. infusion was stopped if cardiac output ceased to increase with infusion, if there were signs of pulmonary oedema or if wedge pressure reached mmhg. vasoactive or inotropic drugs were infused if the desired do was not reached by infusion alone. anaesthetic technique included continuous thoracic epidural and isoflourane anaesthesia. expected mol:bidity and mortality rates were calculated by the "possum" score aasing preoperative clinical and paradinical estimates of organ function as well as surgery characteristics . materials: asa group ill-iv patients with a mean age of years (range - ) and a mean weight of kg (range - )) scheduled for major abdominal surgery were included. results: patients were excluded because do i could not be raised at all. mean do i was increased from ml/min/m (range - ) to ml/min/m (range - ). mean volume of preoperativdy infused colloid was ml (range - ). during surgery ml (range ) of colloid was infused. mean length of surgery was minutes (range - ). mean blood loss was ml (range ). expected mortality and morbidity rates ("possum") were % and %, respectively, whereas patient follow up upon discharge or at death revealed mortality and morbidity rates of % and %, respectively. conclusion: based on experience from the present study, continuous measurement of cardiac output has proved to be a valuable tool for perioperative optimization of do in asa group ili and iv patients during major surgery. however further studies including a greater number of patients are necessary to confirm the promising preliminary findings. we studied the hemodyn~c effects of three different combinations of positiv inotropic .agents, vasodilators, diuretics and av-filtration (av) in patients (pts) with severe left heart faille (left veutrieul x filling pressure (lvfp) > mmhg) due to acute myocardial infarction. hemodynamic measurements (intravascular pressures (lvfp), thermodilution (cardiac index (ci)) were made before (control) and after each therapy. in furosemide (f) + d butamin (d) + nitroglycerin (ni) reduced lvfp and a small increase of ci occurred. in of these pts :(group a) nitroprusside (hip) instead of ni increased ci significantly, in the other pts adding of amrinone (a) resulted in a pronounced increase of ci. group c (n= ): the combination of ni and av reduced lvfp but did not increase ci which was achieved by av+d+ni. in order to optimize the treatment of acute heart failure a combination of inotropic agents, vasodilators, diuretics and av-filtration should he used guided by hemodynamic monitoring. arias jr, miragaya d, sandard, san pedro dm ~, herndndez d, valenzuela . objectives: to evaluate the variation in nomdrenaline (na) plasma concentrations in patients with acute myocardial infarction (am ) after thrombolytic therapy with noniltvasive reperfusion criteria (clinical, electrocardiographic and enzymatic), in relation to infarct size and location.methods: consecutive patiens with ami, from october , to february , , admitted within hours alter onset of symptoms, undergone successfull systemic thrombolysis. of them were anterior (group a) and inferior (group b) . noradrenaline plasma levels at (na ), (na ) and (na ) minutes after admission were compared with ck-peak plasma levels by linear regression. differences were tested for significance by student-t-test for paired and unpaired values. na plasma concentration was measured by high-presssure liquid chromatography. p< ns . ns means -sem (normal limit for our laboratory: na < / pg/ml; ck < u/i ) conclusions: . the na plasma levels at admission (nai) are more increased in anterior than inferior amis, probably in relation to infarct size. . the decrease in na is more evidence in amis with anterior location. . this decrease is probably due to the major efficacy of thrombolytic therapy in amis with anterior location. arias jd, miragaya (group b) , probably due to certain degree of t~cg'rfueion. . there is not significant variation in na in conventional treated ami (group c). v.suchanov, a.levit, p.trofimov, icu, regional hospital, ekaterinburg, russiaobjectives: our task was to improve the technique of preservation of platelet rich plasma. methods: patients scheduled for multiple cardiac valve replacement in were divided into two groups: group i ( patients) -without pp; group ii ( patients) -pp was performed preoperatively. the first pp was made ten days and the second - days before the operation. prp was preserved by cryoconservation. our technique of cryoconservation is distinguished by the speed of freezing ( - ~ and absence of dmso. this made it possible to preserve % functionally active platelets during days. the prp was transfused back after heparin neutralization. the hospital ethics committee approved the investigation.results: the blood loss through the st p. o. d. was significantly greatest in the group i ( _+ ml) and all the patients required transfusion of the donor blood ( + ml) whereas the blood loss in group ii was +_ ml and olny patients required the donor blood. the number of platelets on the st p.o.d, was _+ . /l (group i) and + . /l (group ii), p < . .conclusions: our technique of prp cryoconservation makes it possible to avoid the crystallization phase during freezing of prr thus the infusion of prp may improve hemostasis after open heart surgery and limit the use of the donor blood. in-hospital outcome of women suffering an ami is generally considered worse than that of men, but it is still debated whether female sex is per sea negative prognostic factor or is merely associated with other negative determinants of prognosis. the purpose of the present study is to evaluate the independence of the association between female sex and mortality (in the patients of the swiss centers) and in the patients randomized in the isis- trail mortality rate in women was . % ( / ) compared to . % ( / ) in men; in switzerland: in-hospital mortality for women was . % ( / ), for men . % ( / ).the table shows the results of isis- in terms of odds ratios and their % confidence intervals either after unadjusted analysis or after adjustment for age, known to be the major confounding variable when prognosis of women after myocardial infarction is considered, and for all the available clinical and epidemiological characteristics collected at trial entry: these observations suggest that there is a small but independent effect of female sex on short-term mortality after acute myocardial infarction. ( ) and bubble ( ) oxygenators a, ere used. anaesthesia was balanced and pts were extubated to hrs after cpb. pts were monitored with swan-ganz catheters (sgc) for hrs after cpb. at that time qs/qt was calculate( according to )be standard shunt equation. after the sgc had been removed, an estimated shunt was calculated. measurements of qs/qt were performed: before induction of anaesthesia ( ), after induction of anaesthesia (i[), mins after cpb (iii) (iv) and (v) hrs afiter cpb, rains after extubation (vi), hrs after cpb (v[ ) and on the nd, rd, th, th and tb postoperative day (pd) (viii, x, x, xi, xi , respectively). analysis of data was performed by two-way analysis of variance, p < . being regard as significant.results: the figure shows the values for qs/qt expressed as means + sd. there was a significant increase in qs/qt above b~setine throughoul the whole investigated period except on the th pd. qs/qt reached maximum at rains after extubation (vi). objectives: many stndies have shown advantages of membrane oxygenalors over ubbie type oxygenators. the aim of this study was to evaluate the influence of x 'genator type on pulmonary shunt (as/at) after coronary surgery. methods: patients (pts) gave their informed consent to the study which was approved by the university ttuman research committee. pts were divided into two groups: a (n = ) with a membrane o~genator and a (n = ) with a bubble oxygenalor used during cardiopulmonary bypass (cpb). ths were monitored with swan-ganz catheters (sgc) for hrs after cpb. at that tfme os/ot was calculated according to the standard shunt equation. alter the sgc had been removed, an estimated shunt was calculated..measurements of os/qt were performed: betore induction of anaesthesia (i), mins after extubation ( ), hrs alter cpb ( ) and on the nd, rd, th, th and th postoperative day (iv, v, vi, vii> viii, respectively). analysis of data was performed by one-way analysis of variance, p < . being regarded as significant.results: the figure shows the values for qs/qt expressed as means _+ sd. os/qt was significantly greater at rains after extubation (ii) in a group. the difl'ereuce between the two groups was no more significant from hrs after cpb (iii) to the end of the investigated period. ! i * p < a. s betw~n ~o~ conclusions: membrane ox 'genation during cpb is accomplished by reduction in blood cellular destruction and less alteration in blood. the results of our study show the influence of oxygenator type on value of qs/ot only after extubation ( to hrs after cpb). the difference in qs/qt disappeared his after cpb and since that time the oxygenator type had no influence on qs/qt. it may be of particular importance in patients with severe forms of cardiopulmonary disease who are at risk of higher postoperative morbidity and mortality. objectives: hypomagnesemia has been reported with a variable prevalence ( to % ) in icu patients. magnesium deficiency can induce a number of climcal symptoms (primarily cardiovascular and neuropsychiatric) but can also be clinically silent ( - % are asymptomadc), methods: we measured whole blood ionized magnesium (lmg++) in patients on admission to the icu, using a nova electrolyte analyzer (nova biomedical), containing an img++ electrode. blood was collected in syringes with dry heparin (radiometer qs ). normal range of img++ was found between . - . mmot/l (healthy volunteers). results: for the entire population, we found a % prevalence ( / ) of hypomagnesemia (figure ) . among the surgical patients, the prevalence was highest after cardiac surgery ( %) and after thoracic surgery ( %) and was lowest after neurosurgery ( %). hypomagnesemia was also common in patients after liver transplantation (lvtx) or with hepatic failure ( % for both groups). conclusion: our findings confirm that hypomagnesemia is common in acutely ill patients, especially in those after cardiothoracic surgery or those with liver disease. nevertheless. it is difficult to define the associated factors with sufficient specificity, so that measurements of img++ are warranted to diagnose hypomagnesemia. hepariu influences platelet function and may lead to thrombocytopenia called heparin-associated thrombocytopenia (hat) regardless of the dose and route of administration. additinnal venous and/or arterial thrombosis may lead to life-threatening complications. the incidence of so-calied heparin-associated thrombocytopenia and thrombosis (hatt) ranges between i- %. hatt is confirmed by a heparin induced platelet activation assay (hipa). results: from / to / consecutive patients of our icu were reviewed retrospectively. all patients were treated with heparim the incidence of hatt was % ( ). in all cases diagnosis was proven by a positive hipa. / patients died. in / hatt could be confirmed before severe thromboembolic complications occured. / patients developed a deep vein thrombosis (dvt), / dvt and pulmonary embolism (pe), / dvt, pe and arterial thrombosis (at) and / a dvt, pe~ at and a sinus thrombosis. conclusion: the incidence of hatt in a r series of pts. is %. presence of thrombocytopenia and thrombosis of the great 'vessels is associated with a significant mortality ( / ). computed tom graphy (ct) and transthoracic/transesophageal echocardiography (tte/tee) are important tools in diagnosing and monitoring the extent of cenlrai venous and arterial thrombosis. a. cabral md, m. shahla md c. meneses-oliveira md and jl vincenl md.phd. department of intensive care. erasme university hospital, brussels, belgium objective: to determine extreme hemodynanuc patterns in cardiogenic shock. although ~.~xdiogenic shock is characterized by a low cardiac index (ci), high systemic w~,scular resistance index (svri), and high cardiac filling pressures, some patients may develop art atypical pattern. we reviewed the hemodyuamic pattern of patients with cardiogenic shock, as defined by an initial ct below . l/rain/m: in the presence of myocardial dysfimction attributed to ischemic heart disease (n= ), heart failure (n= ), valvulopathy (n= ) or recent cardiac surgery (n= ). after exclusion of patients with concurrently suspected/documented infection, this study included patients, of whom ( . %) survived. treatment of shock included dopamine (n= ), dobutamine (n= ), norepinephrine (n= ) and epinephrine (n= ). patients with arterial hypertension (ah) and initially law plasnla renin activity (pra) had been studied. in all patient changes of arterial pressure (ap) after single administration of enap was studied. nypotensive reaction wiht deereasin e of average ap about - mm hg ayter single drug administration observed only in patients. ezap monotherapy accomplished during one week with mg daily dose. hypotensive effect observed in patients including ones which were susceptible to single enap administration. after that first stage of therapy all patints began to combinate enap with hypothyazid in dose of mg per day~ after week of treatment such drugs combination lead to veritable ap lowering in addition patients. in the remaining resistant to such drug combination patients was add corinfar in daily dose of mg. this new drug combination permits to lower ap in patients. subsequent discontinuation of enap administration to such patients aid not connected with increasing of again.therefore the most of the patients with ah and law pra( , %)did not susceptible to enap therapy and enap and hypothyazid combination. on the contrary-combination of corinfar with hipothyazid was effective in % patients with ah and low pra. methods: in patients with cardiogenic shock due to ischemic heart disease (n= ), heart failure (n= ) and valvulopathy (n= ), hemod aamic data including measures of intravascular pressures, cardiac output and mixed venous gases were collected at regular times intervals, at least times a da?. all measurements were obtamed in a relative steady state and in the absence of severe anemia or hypoxemia. treatment of shock included dobutamine (n= ), dopamine (n= ), norepinephrine (n=i ) and epinephrine (n= objective: based on our previous studies of the function of isolated liver grafts, this experimental protocol aims at developing a novel extracorporeal liver support circuit, with an incorporated pig liver. methods:the graft liver was obtained from pigs weighing - kg. under general anesthesia the aqimals underwent total hepatectomy,following cannulation of the portal vein, the infrarenal aorta and the infrahapatic vena cava and peffusion wit h it of heparinised r/l solution at ~ the circuit consisted of the graft liver connected to a fluid reservoir and a centrifuge pump. ten healthy pigs weighing - kgr were connected to the circuit as follows: the rt carotid artery was connected to the portal vein of the graft and the rt jugular vein was connected to the fluid reservoir, through the centrifuge pump. the fluid reservoir collected the outflow from the graft's suprahepatic inferior vena cava. the cystic duct of the graft was ligated and the bile.duct cannulated for bile collection and measurement. bridges were adapted to the circuit to bypass the graft liver when necessary, in cases of by pass blood perfusing the graft was oxygenated through a bubble oxygenator. mean total priming volume of the circuit was ml. temperature was maintained at ~ and portal vein pressure at ( - ) mmhg. the flow was . - . ml/gr of graft liver mass per minute. observation period was hours (t ). results: results of the hemadynamic and metabolic monitoring of the recipients [map (t = mmhg , t = mmhg), hr (t = , t = ), rap (t = mmhg , t = mmhg), pap (t = mmhg, t = mmhg), pcwp (t = mmhg, t = ~mhg), svr (t = dyn'sec/cm ' , t = dyn'seclcm~ pvr (t = dyn.sec/cm o, t = dyn.sec/cm ,'~), co (t = . t/min, t = . t/min), do (t = ml/min, t = . ml/min), vo (t = ml/min, t = ml/min), o er (t = . %, t = . % ), ph (to= . , t = . ), po (t = mmhg, t = mmhg), pco (t = mmhg, t = mmhg), pvo (t = mmhg, t = mmhg), svo (t = %, t = %), be, na, k, ca ++, lactate, osmolality, ast, alt, pt, aptt, revealed hemodynamic and metabolic stability of the animal. consumption, co production and tissue oxygenation of the graft were also studied. conclusion; the described circuit proved to be safe and well tolerated by healthy animals but its value for temporary liver support is currently being estimated, in a surgically induced experimental fulminant hepatic failure modal. introduction: prosthetic materials like silikone, dacron, teflon e.tc. produce auto immune responses and may even trigger clinical syndromes like scleroderma, sjogren, sle el.c. in our study we followed the evolution of humorial immunity parametrs for up to five years in a cohort of paced pts with implanted metallic and silicone materials. method: paced pts (mean age +- yrs) without clinical or laboratory findings of malignancy or immune disorders were included. we measured the immunoglobulins, the complement, the auto antibodies and the proteins involved in inflammatory reactions every months. the initial and final mean values are shown in the obiectives: hsp, a systemic leucocytoclastic vasculitis and anaphylactoid purpura can be accompanied by abdominal pain and life-threatening intestinal bleeding. recently we could disclose, that these patients develop severe fxiii-deficiency and immense haemorrhagic oedema of the intestinal wall. by the following case report we will demonstrate and discuss the importance of fxiiideficiency for pathogenesis, therapy and outcome in hsp. case report: a year old man developed typical skin manifestations of hsp following an episode of severe (biliary ?) pancreatitis and percutaneous draining of a pancreatic pseudocyst. two days later he had a paralytic "ileus with immense hemorrhagic wall-oedema and massive dilatation of the small bowel. he got fever up to . ~ and developed severe gastrointestinal haemorrhage (blood transfusions necessary). the coagulation data disclosed a severe fxhi-deficiency (activity %), whereas quickvalues, platelet count and atiii-level were found to be within the normal range. elastase was markedly elevated. substitution of fxiii to normal levels leeds to the cessation of bleeding symptoms and abdominal pain, later resulting in a restitutio ad integrum. conclusions: hsp with intestinal involvement is a life-threatening vasculitis, in which careful and frequent examinations of the coagulation system, especially of fxiii are necessary. detailed analysis of the coagulation data suggest, that the severe fxiiideficiency is due to a specific degradation by proteolytic enzymes (like elastase) as well as consumption within the immense haemorrhagic oedema of the intestinal wall. knowing these facts, even most severe cases of hsp with intestinal involvement can be successfully treated by substitution of fxih. a -year-old woman presented a year history of occasional self-limited episodes of weakness, generalized edema and o!!~aria. the immunologic testing showed no~nnai levels of complements, clq inhibitor, and serum chemistry values, between or during a attack, she was not treated. she was a~mitted to the hospital with symptoms including nausea, vomiting, weakness and ol!guria. on examination, the patient presented facial and g~neralized edema. the systolic blood pressure was mm hg, pulse beats/mir~ute, hematocrit . , seln~n protein /i, and se~um albumin q/l. an leg-kappa pa[apfotein was demostrated ( . g/l) and urine was neaative for puotein. c~'stalloid and colloid don't increased the blaod pressure but resulted in anasarca, with a total of ii lit[as of in~ravenous fluids. therapy wink flozen plasma, . units of clq inhibitor, cortlcosteroids, annihistwnines and antifibrinolytic agents was uns~iccessfull. the a~minist~ation of dopamine, norepineph~ne and epinephrine was inefective. the patient died at the bores, only a few cases have been reported, all had igg paraprotein, the pathophysio!o~] is urd~no~n% but is possible that the paraprotein may be zesponsib!e for the increased capillary pe~leabilityo despite efforts to res~scinate the patients during an acute attack, the syndrome is often fatal. the variable course of systemic uapiliary leak syndrome and the unpredictability and self-limited nature of attacks cloud assessment of therapeutic inte~-vention. the purpose of the present work is to provide some information about the nursing care and results from our experience in continous arteriovenus hemofiltration (cavh).cavh is an extracorporeal technique, especially applicable in the critically ill patients, for disturbances, and for the control of azotemia.we used this method in critically ill patients men and women ages from - who had sepsis -arf congestive heart failure postoperative multiple organ failure and polytrauma .this method was applied to these patients from to hours. % of the patients recovered completely their kidney function, % improved their kidney function and % died.we concluded therefore that this method was very effective for the critically ill patients to whom it was applied, but it requires excellent and continuous nursing care; under the above mentioned circumstances the method works effectivelly. an animal model with rats undergoing a dialysis procedure was designed to test the hypothesis that recovery from ischemic acute renal failure (airf) may be affected by the type of membrane used in hemodialysis. male sprague dawley rats were allocated to groups: in group i, (n= ) airf was inducted by bilateral renal artery clamping for rain. group h (n= ) rats underwent a sham procedure. in each group, rats were dialyzed twice ( th and th day) with either a cuprophan (cupro), a hemophan (hemo) or a pan (an ) minidialyscr or stayed nondialyzed (no hi)). renal function was monitored daily by measuring urea and creatinine values and by two single shot inulin clearances on the days following dialysis. additionally hemolytical activity of complement was determined. inulin clearance on day was reduced significantly but there was no difference in the degree of decrement in glomular filtration rate (gfr) between dialyzed and undialyzed rats, nor between the dialyzed animals with different membranes (gfr: no hi): . _+ . ; cupro: . _+ . ; hemo: . _+ . ; an : . _+ . ). the evaluation of renal function by day nine revealed significant recovery for all airf-groups compared to day (p< . ), irrespective of wether they underwent dialysis or not, or the type of dialysis membrane. complement activation could be detected in all dialyzed groups but no statistical differences between the animal groups dialyzed with different membranes were noticed. our findings refute the hypothesis that in airf exposure to complement-activating cellulosic membranes impairs the recovery of renal function in rats. changes patients: patients who underwent first cadaver kidney transplantation in our unit between january and december in were involved. the recipients were divided into groups: group i." non functioning graft (n= ); group ii: delayed graft function (n= ), group ili: good graft function (n= ). the grouping criteria were: a/haemodialysis in the fii~t postoperative days, b/diuresis in the i st postoperative day, c,' scram crcatininc difference between the st postoperative day and the preoperative level. all of the parameters were involved into the exarainatio, which we measllre in our every, day practice. results: the preoperative haematocrit level differed significantly between group i. ( . ) and croup ii. and iii. ( . and . , p< . ). intmo! emtive significant differences were found between the different groups in systolic blood pressure (group i. hgrmn, group ii. hgnnn, group iii. hgmm, p< . ), mean arterial pressure (group i. hgmm, vs. group ii. hgnun p< . , vs. group iii. hgmm p< . ), and pulse-amplitude and rate-pressure product too. the second warm ishaemic time in group iii. was significantly shorter than in the other two groups (group iii. inin. vs. group ii. rain. p< . , vs. group i. rain. p< . !). the rejection rate was higher in the first days in the patients with non-functioning grafts (group i. % and group ii. % vs. group iii. %) . the other examined parameters have not differed significantly. conclusion: according to our results the success of the kidney transplantation is mnitifactorial. the most important factors of this relationship are: the perioperative fluid-balance, the maintenance of adequate perfusion blood pressure during the operation, good surgical technique and immunological problems. key: cord- -oecpqf j authors: nan title: aspho abstracts date: - - journal: pediatr blood cancer doi: . /pbc. sha: doc_id: cord_uid: oecpqf j nan myelodysplastic syndrome (mds) and frequently arise in the context of inherited bone marrow failure (bmf) syndromes, such as shwachman diamond syndrome (sds). monosomy /del( q) is associated with high grade mds and propensity to progress to acute myelogenous leukemia, a major cause of morbidity and mortality for patients with inherited bmf. development of non-transplant strategies to treat bone marrow failure without simultaneously stimulating outgrowth of malignant clones remains a major challenge. objectives: the aim of this study is to investigate the molecular consequences of del( q) in the context of bmf with the goal of developing more effective treatments. design/method: to study the biological and molecular consequences of monosomy/del( q) in bmf, induced pluripotent stem cells were generated from sds patients (sds-ipsc) . a deletion of the mds-associated region of the long arm of chromosome was then introduced using a previously published modified cre-lox approach. results: the sds ipsc phenocopied bone marrow failure with slow proliferation and impaired hematopoietic differentiation. we next explored whether deletion of q conferred a relative fitness advantage within the context of bone marrow failure. proliferation of the sds-del( q) ipscs was reduced below that of both the isogenic sds ipscs and normal controls without an increase in cell death. sds-del( q) demonstrated reduced hematopoietic differentiation compared with isogenic sds cells. these data demonstrate that deletion of q fails to confer a relative growth advantage relative to isogenic sds ipscs and results in further impairment of hematopoiesis. to gain insight into the mechanisms of del q-associated clonal evolution in sds, we performed rna sequencing (rnaseq) of sds+/-del( q) ipsc. expression of tgf pathways and their downstream targets were reduced in sds-del( q) ipscs compared to isogenic sds ipsc. single cell rnaseq analysis of primary sds bone marrow cells confirmed that the tgf pathway is hyperactivated in sds. western blot analysis showed increased phospho-smad levels in sds ipscs compared to sds-del( q) and normal controls, while total levels of smad were unchanged. pharmacological targeting of tfg with small molecule inhibitors resulted in selective improvement of sds hematopoietic colony formation and myeloid differentiation without stimulating outgrowth of the isogenic sds-del( q) cells or normal controls. these results demonstrate that del( q) reverses the tgf pathway hyperactivation of sds. furthermore, inhibition of tgf selectively rescues hematopoiesis in sds but not in isogenic del q cells, suggesting a potential strategy to treat bone marrow failure without stimulating del q clonal outgrowth. background: standard therapy of medulloblastoma consists of treatment with alkylating agents and radiation after surgical resection. although a statistically significant increase in survival is reported with this regimen, / rd recur and become resistant this class of agents ultimately leading to mortality. large numbers of somatic mutations were observed in recurrent medulloblastoma (rm) after alkylating agent and radiation treatment. high mutation rates in tumors can have twofold effect; ) a large number of non-synonymous mutations that have no role as drivers can still cause functional tumor antigens increasing the neoantigen burden and immunogenicity. moreover, ) such tumors can gain mutations in canonical or non-canonical dna repair pathways leading to a gain in the number of mutations as seen in case of glioblastoma, this can lead to even higher accelerated mutational rate. evidences suggest that high mutational load can cause higher neoantigen burden thereby making the tumor more susceptible to immune checkpoint inhibition. we propose that post therapy recurrent medulloblastoma gain mutational signature and immunophenotype of malignancies demonstrating clinical response to immune checkpoint therapy. objectives: ) rm has molecular signatures identical to tumors with high immunogenicity and clinical response to immune check point inhibition. ) rm has the immune inflammatory phenotype; harboring high percentage of tumor infiltrating lymphocytes (tils), macrophages and monocytes. design/method: to test our hypothesis, we downloaded the raw bam files of previously published data from international cancer genome consortium (icgc) . this set of about matched primaries and recurrent medulloblastoma cases forms our discovery cohort. we have called somatic variants using the gatk pipeline by the broad institute. to validate our key findings, we have procured human medulloblastoma specimens and are conducting whole exome sequencing. the primary assays utilized to assess immunogenicity are immunohistochemical (ihc) staining of formalin fixed and embedded recurrent medulloblastoma tissue to identify tils, tumor associated macrophages and other markers. mg/m had dlts of dyspnea (grade )/hypoxia (grade ) but no dlts were observed in any other cohort. adverse events were generally mild to moderate, consistent with the safety profile observed in adults. across the desc cohorts, plasma concentrations were dose-proportional and steady state concentrations were lower on day vs. day . mean systemic exposure in the mg/m cohort was ∼ -fold greater compared with the adult rp d of mg bid. a pk:pd relationship between tazemetostat exposure and h k me levels in peripheral blood monocytes and granulocytes was observed in the desc phase. consistent and significant post-dose reductions in h k me occurred at doses ≥ mg/m . further analysis of twelve patients treated at the rp d confirmed that h k me inhibition was maximally inhibited. doses - mg/m showed confirmed objective responses (cr/pr) per recist/rano in patients with es (n = ), chordoma (n = ), and atrt (n = ). background: previous studies established that the platelet/ fibrin(ogen) axis promotes metastatic potential by impeding the clearance of newly formed micrometastases by natural killer (nk) cells. however, multiple important questions remain, including the potential of fibrin(ogen) to promote metastasis through interactions with cells other than platelets (e.g., inflammatory cells), and the fundamental question of whether fibrin polymerization is required for metastasis. objectives: determine the role of fibrin polymerization and fibrin(ogen) engagement of integrins iib and m in metastasis. design/method: we performed experimental and spontaneous metastasis assays in immunocompetent mice carrying specific fibrinogen structure/function alterations. results: expression of a mutant fibrinogen lacking the binding motif for the leukocyte integrin m (fib - a) significantly decreased metastatic potential relative to wildtype fibrinogen, suggesting a role for fibrin(ogen)inflammatory cell interactions mediated by m in metastasis. to directly determine the importance of thrombinmediated fibrin polymerization in metastasis, we analyzed metastatic potential in fibaek mice, which carry a form of fibrinogen essentially "locked" in the soluble state due to a mutation in the a chain thrombin cleavage site. metastatic potential in fibaek mice was diminished relative to control mice, speaking to the importance of thrombin-mediated fibrin polymerization in the metastatic process. however, the fibaek mice retained significant metastatic potential relative to complete fibrinogen deficiency, indicating that fibrinogen monomer retains significant prometastatic properties. in order to better define the role of fibrin(ogen)-platelet interactions in metastasis, we compared metastatic potential in control and fib Δ mice, carrying a form of fibrinogen lacking the chain binding motif for the platelet integrin iib . surprisingly, this mutation had no impact on metastatic potential. together, these studies suggest fibrinogen plays a multifaceted role in metastasis. fibrin(ogen)-leukocyte interactions mediated by m appear to have a role in metastasis. previous studies showed that macrophages promote the metastatic potential of circulating tumor cells, which may represent at least one important m expressing cell type whose prometastatic behavior is influenced by fibrin(ogen) interactions. these studies show that thrombin-mediated fibrin polymerization promotes metastasis, but soluble fibrinogen retains some significant prometastatic capacity. surprisingly, loss of the fibrinogen chain iib binding motif had no impact on metastasis. given the established importance of platelets in metastasis, these findings suggest that fibrin (ogen) is capable of platelet stabilization through mechanism(s) independent of this iib binding motif. platelets may bind polymerized fibrin at other sites, and/or fibrin interactions with other matrix proteins capable of binding iib are sufficient to support platelet functions required for metastasis. the role of platelets in hemostasis and thrombosis is well defined, but it is becoming increasingly evident that platelets also assist in host defense and inflammation. platelets participate in the innate immune system through direct antimicrobial activity and interactions with effector cells (chapman , garlanda , kapur ). in the adaptive immune system, platelets recruit and costimulate t-cells, and promote b-cell differentiation and antibody class switching (kapur , morrell ). the question remains: which mechanisms influence platelet immune function and are they developmentally regulated? preliminary studies in the palis lab have revealed significant dif-ferences in embryonic versus adult platelet gene expression, including regulators of immune and inflammatory responses such as beta -microglobulin (b m) and major histocompatibility complex class i (mhc ). mhc is expressed on all cell surfaces except red blood cells and its molecular chaperone b m is a marker of inflammation highly expressed in platelet alpha granules (zufferey ). preliminary data from the morrell lab reveals a mass release of b m during platelet activation, which drives monocyte differentiation to an inflammatory phenotype through tgfb receptor signaling. we therefore sought to determine whether developmental changes in platelet b m expression mediate differences in platelet-mediated monocyte activation. with trilineage hematopoiesis with a predominance of early myeloid precursors, with full maturation. microarray, elane and sbds sequencing and deletion/duplication analyses were negative. immunologic evaluation was significant for agammaglobulinemia and an absence of memory (cd +cd +) b cells. a gene primary immunodeficiency panel revealed two variants of unknown significance-c. g>a and c. g>t in dnmt b; one previously reported in association with icf . parental testing demonstrated parental heterozygosity. centromeric instability was confirmed in mitogen stimulated lymphocytes showing characteristic, multibranched chromosomes containing at least arms of chromosome and joined near the centromere. decondensation of the qh and qh regions and triradial configuration of chromosome was noted, and a diagnosis of icf syndrome was made. the patient was started on monthly intravenous immunoglobulin (ivig). prophylaxis for pneumocystis jiroveci pneumonia and respiratory syncytial virus was initiated. a / matched sibling hsct is being planned. demonstrated the diagnosis of high grade osteosarcoma. the patient was started on multi-agent chemotherapy with planned a whole femur prosthesis at time of local control. cases of osteosarcoma have been described in the literature in patients with nf (median age; years, range - years) with slightly male predominance ( cases). the femur was the most common site of involvement ( cases). four patients died of metastatic disease despite surgery and multi-agent chemotherapy. conclusion: nf represents a major risk factor for development of malignancy and uncommonly osteosarcoma in adolescents and adults. we report a rare case of an extensive involvement of osteosarcoma of the left femur in a child with known diagnosis nf . this presentation should alert the pediatric oncologists to monitor for bone tumors in patients with nf by physical exam and detailed medical history. hasbro children's hospital, providence, rhode island, united states background: dysautonomia is a paraneoplastic syndrome most commonly described in adult malignancies. despite current therapies aimed at symptoms management, it is often debilitating. we present a case of a -year-old girl who initially presented with autonomic dysfunction and was subsequently found to have hodgkin lymphoma. objectives: describe hodgkin lymphoma presenting with dysautonomia and discuss symptom management with rituximab design/method: case report a year-old-girl presented with severe symptoms of orthostatic hypotension necessitating prone positioning to prevent syncopal episodes. additionally, she reported anhidrosis, xerostomia, urinary retention, and constipation. she had unmanageable peripheral neuropathic pain despite multiple analgesia medications. initially, it was suspected that her symptoms were caused by an atypical presentation of guillain-barre syndrome. she was treated with intravenous immunoglobulin g, without response. due to a suspicion of a paraneoplastic syndrome a positron emission test/cat scan (pet/ct) was performed and revealed widespread fdg-avid nodal and splenic disease. pathology from a thoracoscopic biopsy of a mediastinal lymph node demonstrated classical hodgkin lymphoma. she was classified as stage ivb. a paraneoplastic panel obtained during the first cycle of chemotherapy revealed elevated anti-amphiphysin antibodies and glutamic acid decarboxylase (gad) antibodies. therapy was initiated with abe-pc (doxorubicin, bleomycin, etoposide, prednisone, cyclophosphamide) ; vincristine was held given her significant neuropathy. due to persistence of autonomic symptoms following her first cycle and presence of antiamphiphysin and gad antibodies, rituximab was incorporated into her treatment. following two cycles abe-pc, she had a rapid early response by fdg-pet/ct. she completed an additional three cycles of abd-pc. end of therapy imaging demonstrated complete response with a single persistent mildly fdg-pet avid lymph node (deauville ) and her antibodies were negative. she continues treatment of maintenance rituximab with significant improvement, but not resolution, of her orthostatic hypotension. at this time, the patient can ambulate with assistance. constipation and urinary retention have fully resolved and, her peripheral neuropathy, xerostomia, anhidrosis have improved. conclusion: this is rare case of a pediatric hodgkin lymphoma patient developing dysautonomia associated with antiamphiphysin and glutamic acid decarboxylase antibodies and subsequently managed with chemotherapy and rituximab. clinicians should be suspicious of a paraneoplastic syndrome when a neurologic disorder fails to improve with standard treatment. results: labs obtained at an outside hospital one month prior to presentation showed absolute neutrophil count (anc) and hemoglobin . g/dl. she presented to our institution with days of fever, hepatomegaly cm below costal margin, a white plaque on her tongue, and circumferential perianal ulceration. labs were significant for anc and hemoglobin . g/dl. anti-granulocyte antibody testing was positive. bone marrow biopsy showed arrest of neutrophil maturation. after initiation of filgrastim ( . mcg/kg/day), her anc increased to > and repeat bone marrow biopsy demonstrated left shifted myelopoiesis. biopsy of her oral lesion demonstrated invasive actinomyces prompting a prolonged course of antibiotics. biopsies of her oral and anal lesions were reported as myeloid sarcoma without mll rearrangement. chemotherapy was not initiated due to complete resolution of both lesions within weeks of initiating filgrastim and appropriate antibiotic coverage. she has not developed any further lesions concerning for malignancy. testing for common genes associated with severe congenital neutropenia and autoimmune lymphoproliferative syndrome was negative. her immunoglobulin levels and the measurement of age-appropriate vaccine responses were normal. after her lymphocyte subpopulation analysis indicated a selective deficiency in cd positive t-lymphocytes (absolute cd cell count ), the severe combined immunodeficiency panel from genedx showed compound heterozygous mutations in results: a male infant was born with a large thigh mass. the child was clinically well aside from restricted movement of affected leg. mri showed mass expanding into pelvis without other lesions. an interventional-radiology guided core biopsy of the mass was reported as high-grade spindle cell sarcoma without etv rearrangement. surgery was deferred because of concern that it would result in excessive morbidity. the mass was treated with vincristine and dactinomycin per infantile fibrosarcoma protocols. after months of therapy, no significant change in size of the mass was noted on physical exam or imaging. repeat biopsy was obtained to confirm diagnosis and allow for expanded tumor testing. this biopsy showed triphasic distribution of adipose, fibrous and mesenchymal tissue consistent with fhi with rare sarcomatous foci. additional chemotherapy was deferred and the child was followed clinically. his tumor has remained approximately the same size and still unresectable. next generation sequencing of tumor utilizing panel based technology revealed braf-erc fusion consistent with braf activating mutation. this mutation was confirmed by fluorescent in situ hybridization (fish) probe for braf. braf and mek inhibitors have been pursued as treatments to decrease size of tumor and allow for resection. conclusion: braf mutations have been characterized in a variety of malignancies. inhibition of braf and downstream signaling components has produced promising results in a variety of patients. this is the first case report of a braf mutation in a fhi. although management of fhi is typically surgical, this does suggest a potential therapeutic target and may allow for improved surgical outcomes especially in cases where up-front surgery would result in unacceptable morbidity. genetic sequencing of fhi and other rare tumors is an important tool and has the potential to identify mutations amenable to targeted therapies. background: icf is a rare autosomal recessive disorder characterized by hypo-or agammaglobulinemia and often opportunistic infections suggesting t-cell dysfunction. it is further categorized into subtypes - based on mutations in dna methylation. mutations in the helicase-lymphoid specific (hells) gene, which is required for t-cell proliferation and participates in de novo dna methylation, are characteristic of icf type (icf ). of approximately reported cases of icf, less than percent are characterized as icf . while malignancy has been reported in icf (angiosarcoma, acute lymphoblastic leukemia), and icf (hodgkin lymphoma), here we describe the diagnosis and management of an icf patient with neuroblastoma and neutropenia, which has not been previously described. objectives: describe a novel phenotype and mutation of icf and its management to further expand our understanding of this disease. results: a month ex- week premature male with bronchopulmonary disease and failure to thrive presented with acute respiratory failure in the setting of recent viral bronchiolitis with associated chronic diarrhea. he was subsequently diagnosed with multiple infections including pjp pneumonia, norovirus, parainfluenza, rhinovirus, and pseudemonal cellulitis. he presented with profound neutropenia and agammaglobulinemia with presence of b and t cells on lymphocyte phenotyping. ct revealed a paraspinal mass that was mibg-avid on further study, strongly suggesting neuroblastoma. bone marrow was normocellular and negative for malignancy, however revealed marked granulocytic hypoplasia and maturation arrest concerning for severe congenital or, less likely, immune-mediated neutropenia. metastatic workup was negative. whole exome sequencing revealed a homozygous variant of unknown significance (c. t>c) in the hells gene, portending a working diagnosis of icf syndrome. immunoglobulin supplementation, pentamidine prophylaxis, and g-csf were initiated. he was able discontinue g-csf after months of treatment. his neuroblastoma, initially categorized as l , met criteria for observation. however, followup mri revealed interval growth nearing the spinal canal. he underwent tumor resection, confirming mycn non-amplified, favorable histology neuroblastoma. after infectious prophylaxis and immunologic support were initiated, he incurred two other hospitalizations, the first for g-tube cellulitis and the second for parainfluenza respiratory illness. he now has stable neutrophil counts off g-csf and remains in remission from neuroblastoma. current plan is to proceed with bone marrow transplantation for immunodeficiency. conclusion: icf has not previously been described with neutropenia or neuroblastoma. this report not only describes a novel mutation and phenotype of icf and the management thereof, but also reveals the potential curative role of bone marrow transplantation in such disease. staten island university hospital -northwell health, staten island, new york, united states background: desmoid tumors are rare tumors that arise from highly differentiated fibroblasts. they occur in isolation or as part of the disease spectrum of familial adenomatous polyposis (fap) . fap mutations between codons - typically correlate with increased extraintestinal disease such as desmoid tumors and upper gastrointestinal polyps. we describe a patient with a large intra-abdominal desmoid tumor who is heterozygous for a c. c>t (p.arg cys) apc gene mutation. we are not aware of any other patients reported with this germline apc mutation presenting with a desmoid tumor. objectives: to discuss a novel apc mutation and the presentation of a rare case. design/method: review of clinical presentation, genetic analysis and management of a rare tumor. a -year-old female with no significant medical history presented with abdominal asymmetry and intermittent pain. she reported urinary urgency, shortness of breath, early satiety, decreased appetite and a -pound weight loss over the course of months. ct scan of the abdomen demonstrated a × cm abdominal tumor abutting the local organs but no presence of bowel obstruction. a biopsy revealed a spindle cell neoplasm favoring fibromatosis. there was no known family history of fap, colon cancer, or desmoid tumors. apc gene mutation analysis demonstrated a c. c>t (p.arg cys) heterozygous gene variant. due to size and location of the tumor, it was initially deemed unresectable. the patient was started on a course of monthly liposomal doxorubicin. she tolerated the initial cycles well and interval ct after cycles of chemotherapy revealed a % decrease in tumor volume. variability exists in phenotypic presentation with regards to the location of the afp mutation locus. while fap mutations associated with desmoid tumors typically have changes in the - codon region, our patient presented with a heterozygous mutation resulting in a missense mutation at codon . due to the change in polarity and size, the mutation is not considered to be of conservative nature. we are only aware of one other report of this mutation, which occurred in an individual with a personal and family history of colon cancer. we are not aware of any patients with desmoid tumors who also have this germline apc gene mutation. our case report highlights an apc gene mutation that is not well-described; we are not aware of any other cases of this mutation reported in patients with desmoid tumors. future evaluation and tracking of this mutation may lead to the determination of further clinical significance. background: over time, advanced care planning for location of death has been associated with increased deaths at home rather than in the hospital. in some cases, however, complex management and symptom control can prevent families from achieving their goal of keeping their child out of the hospital and at home at the end of life. ascites is a sequelae of many conditions including malignancy that might lead to significant morbidity. increasingly, interventional procedures are being utilized. peritoneovenous "denver" shunts are placed internally with one end in the peritoneal space and the other buried within a major vessel such as the svc. a one-way valve and pump buried under the skin allows the patient to pump fluid from the peritoneal to the vascular space. the shunt is used frequently in adults, but has not seen much use in pediatric oncology patients. objectives: to describe a case of a terminally ill patient with refractory wilms tumor with ivc involvement who received symptomatic relief with denver shunt placement. results: an -year-old female was diagnosed with relapsed, refractory, metastatic wilms tumor with pulmonary and hepatic involvement, with tumor extension to the hepatic veins and ivc. multiple chemotherapeutic regimens and palliative radiation to the ivc were administered, but her disease continued to progress, leading to pressure on the portal vein and portal hypertension. the resulting ascites was causing the patient significant pain and was difficult to manage. the patient's code status was changed to dnr/dni after discussion with her mother, who identified a desire to have the child die at home as comfortably as possible. a peritoneovenous shunt was placed in order to control the patient's pain and avoid frequent medical procedures and therapies. despite initial anxiety, the patient was able to utilize the pump and achieve significant improvement in her ascites and pain. she was able to spend the remaining six weeks of her life at home. ascites is a common phenomenon of end stage disease. peritoneovenous shunts are a treatment modality that may be considered to allow for pain control at the end of life for pediatric oncology patients with ascites. the procedure is relatively low risk, allows for self-control of the pump to maintain comfort, and is easy enough to use by the patient or family. background: extraneural metastases (enm) from pediatric glioblastoma multiforme (gbm) are rare, with an estimated frequency of . %. etiologic factors include multiple neurosurgical procedures and sarcomatous dedifferentiation. their occurrence can seriously affect the patient's quality of life and survival. while enms have been well documented in adults, pediatric cases have not been previously summarized. a year old male with a cerebral gbm developed extension of disease outside of the neuraxis approximately months post initial presentation and at the time of disease progression. metastases included exracranial temporal lesions, cervical and mediastinal lymph nodes and s of s bilateral lung nodules. a large pleural-based soft tissue metastatic focus was identified on imaging when the patient presented with respiratory distress secondary to a right tension pneumothorax, which was recognized and managed promptly. we summarize the main reported cases in literature to better define risk factors for and evaluate the proposed mechanisms underlying these systemic metastases. design/method: we performed a literature review on the pubmed database using the terms gbm and enm. patients under years of age who met the weiss criteria for the diagnosis of enm from primary cns tumors were included. results: our patient fulfilled two of the three weiss criteria with confirmed gbm at the primary site with all enm in the temporal soft tissue and cervical lymph nodes displaying histopathologic features similar to the primary cns tumor. the intrathoracic adenopathy and lung nodules detected upon chest imaging during workup for respiratory distress were assumed to represent additional metastatic foci. our literature review identified pediatric patients with enm from gbm with a median age of years (range . - years) and a slight female predominance ( % females vs. % males). the most common sites of metastases reported were pleura/lungs, bones, lymph nodes and liver. in of patients, metastases were associated with csf shunting. conclusion: pediatric oncologists should have an increased index of suspicion when caring for patients with gbm, particularly those who have undergone shunting procedures and present with systemic symptoms including bony pain, respiratory changes, transaminitis or cytopenias which should prompt timely investigation for enm. although enm of cns tumors carry very poor prognosis, their diagnosis has potential therapeutic importance because treatment of metastatic lesions may alleviate symptoms and improve the quality of life. additional studies may be warranted to evaluate the incidence of enm that can provide valuable insight into the pathogenesis and biology of high-grade gliomas. nicklaus children's hospital, miami, florida, united states background: sinusoidal obstruction syndrome (sos) has been reported in patients undergoing intensive chemotherapy and as a complication post-hematopoietic stem cell transplan-tation. sos may be complicated by portal hypertension, hepatorenal disease or multi-organ failure. however, despite treatment, there may be further potential complications that can be anticipated in patients with history sos. we report two patients with history of sos presented with post-procedural bleeding after gastric tube placement. we believe that their presentations may be associated to their previous diagnosis of sos. design/method: pubmed search was done with search for terminology including "sinusoidal obstruction syndrome" "defibrotide", and "bleeding". papers relevant to our cases were selected for literature review. results: case : a year-old female with history of desmosplastic medulloblastoma status-post resection and intensive chemotherapy was diagnosed with sos one month after her second part of planned tandem transplant. she was managed with paracentesis and defibrotide. due to malnourishment, patient had a gastric tube placement months after she completed therapy and had an episode of upper gastrointestinal bleeding postoperatively from the g tube site. case : similarly, a year-old male diagnosed with anaplastic medulloblastoma status post resection and adjuvant multiagent chemotherapy. his treatment course was complicated with sos after the second cycle of induction chemotherapy which responded to -day course of defibrotide. likewise, the patient had a major bleeding event from the g-tube site approximately two months after sos diagnosis. defibrotide was discontinued in both cases before g-tube placement. both patients had no previous history of bleeding disorders or relevant family history. in addition, comprehensive laboratory evaluations were within normal limits before both procedures. in sos, there is blockage of fluid out of the liver that leads to congestion, ascites, ischemia of the liver, and post-sinusoidal portal hypertension. two related causes of sos should be considered as an explanation for g-tube bleeding. similar patients should have close monitoring postoperatively or if possible surgical intervention should be delayed until the sos process has been evolved. nicklaus children's hospital, miami, florida, united states background: the development of treatment related acute myeloid leukemia (t-aml) and myelodysplastic syndromes (t-mds) is a potential complication after cytotoxic chemotherapy or radiation therapy. the incidence of development of t-aml/t-mds varies from - % depending on the treatment regimen used. cutaneous myeloid sarcoma (ms) is a common presentation of extramedullary leukemia and usually occurs in the setting of aml. we report a rare case of cutaneous ms in an adolescent female after successful treatment for ovarian yolk sac tumor (yst) stage i with bep (bleomycin, etoposide and cisplatin) therapy. the ms was managed only with biopsy and close observation. design/method: a pubmed search was conducted for queries including t-aml/t-mds, cytotoxic agents, cutaneous myeloid sarcoma, regression. relevant papers were selected for literature review. a year-old female was diagnosed with a left ovarian yolk sac tumor, for which she underwent left salpingooophorectomy and successfully completed cycles of bep over months. during routine follow-up months after initiation of treatment for ovarian yst, she was noted to have a small, non-tender, indurated nodule on the left side of her upper back approximately cm in diameter. punch biopsy of the skin nodule was performed and pathology was positive for cutaneous myeloid sarcoma. at the time of next follow-up less than one month later, the skin lesion had resolved. two subsequent bone marrow aspirates were performed one month apart and were negative for leukemic involvement or mds. examinations and work-up including whole body pet with ct scan were negative for evidence of disease. although cutaneous ms can be regarded as the herald of systemic myeloid disease rather than a localized process, our patient was monitored periodically with physical exam and laboratory evaluations. she remains free of disease more than four years after the presentation of cutaneous ms without any further treatment. spontaneous regression ms has been previously reported. the authors would like to stress that a conservative approach with close observation could be an option in cutaneous ms even with history of chemotherapy exposure. nesreen ali, iman sidhom, sonia soliman, sherine salem national cancer institute, cairouniversity, egypt children cancer hospital egypt, egypt background: acute leukemia is the commonest malignancy in childhood. the coincidental occurrence of leukemia with hemophilia is extremely rare. hemophilia is a congenital rare x linked bleeding disorder. the main complication of the two diseases is bleeding diathesis which may be lifethreatening due to many factors, deficiency of coagulation factors in hemophilic patients, thrombocytopenia from disease and chemotherapy in leukemic patients, certain cytotoxic drugs such as asparaginase which may result in coagulation disorders and infection which may lead to disseminated intravascular coagulation. objectives: reporting such a case is imperative to set up treatment guidelines for prevention of bleeding and to optimize the therapeutic approach for these patients. design/method: seventeen years old boy, presented to children cancer hospital egypt in june with pallor and multiple ecchymoses.he was diagnosed with precursor b acute lymphoblastic leukemia, cerebrospinal fluid (csf) was free, the chromosomal analysis revealed hypodiploidy , xy. he had moderate type of hemophilia a since birth, factor viii level was . % at time of diagnosis, coagulation profile revealed prolonged partial thromboplastin time (normal - ), factor viii was low %, prothrombin concentration and prothrombin time were normal % and seconds, virology screening for hepatitis b core igg/igm, hbs ag, hiv and hc igg /igm were negative.the patient started induction total xv sjcrh protocol, factor viii unit/kg was given at presentation before doing bone marrow aspiration(bma), csf and as a prophylactic before intramuscular asparaginase injection, intrathecal and bma. it was given immediately within hours before the procedures and platelets transfusion was given regularly to maintain platelets count about , . the minimal residual disease by flow cytometry was . % and . % at d and d induction. results: our patient received his induction and reintensification chemotherapy without any major bleeding event which reveals the success of our guidelines for the prevention of bleeding. he developed very early relapse at w maintenance by the same clone. he received salvage chemotherapy but didn't achieve remission and died out of disease and resistant clone. the development of leukemia on top of hemophilia is a major problem. bleeding complication during chemotherapy can be prevented by regular prophylactic factor viii and platelets concentrate transfusion with good supportive care. life threating bleeding complication may be correlated with the severity of hemophilia. we need to collect data about the biology of leukemic cells, complications, and cause of death to optimize care for these patients. background: mucoepidermoid carcinoma (mec) is a rare malignancy that arises from exocrine glands in the upper aerodigestive tract and tracheobronchial tree. conventionally, mec diagnosis is based on histology, with prognosis based on the extent of resection and detection of metastases. mec is characterized by a translocation of chromosomes q and p resulting in a fusion between the mect and maml genes, that occurs in - % of cases. this fusion transcript has been recognized to have a favorable impact on disease features and prognosis of mec. however, recent studies indicate that high grade mec can have mect -maml fusion positivity and multiple other genomic imbalances that have not been studied in much detail. owing to the rarity of mec tumors, more definitive data related to the clinical and prognostic significance of these molecular markers are limited. objectives: . identify the presence or absence of mect -maml fusion in the tissue of our patient. . analyze the incidence of the fusion in mec cases in children and young adults retrieved from the iowa cancer registry. . determine if fusion status correlates with clinical, pathological and outcome data in our cohort. design/method: we describe the case of a year-old caucasian male who presented with recurrent pneumonia, persistent cough and radiographic evidence of right lobar collapse. bronchoscopy revealed an endobronchial lesion and the patient underwent right upper lobe sleeve resection. pathology report was consistent with low grade muco-epidermoid carcinoma. we retrieved archived formalin-fixed paraffinembedded (ffpe) specimens of pediatric and young adult mec cases (ages - ) reported in iowa from - using the iowa cancer registry. testing for the mect -maml fusion in the index case and ffpe specimens will be done using a custom-designed laboratory validated next generation sequencing (ngs) assay with the ability to detect novel fusion partners. clinical, pathological and outcome data (age, sex, tumor site, tumor size, nodal metastases, clinical stage, histologic grade, treatment and follow up) will be analyzed to correlate with fusion status. the mect -maml fusion tested positive in our index patient. we will obtain irb approval to test for the fusion in the archived ffpe specimens and correlate clinical, pathological and outcome data. conclusion: mect -maml fusion is a frequent event in mec that has prognostic and potential therapeutic applications in adults. the results of this study may enlighten the clinical management of mec in children and young adults. children 's mercy hospital, kansas city, missouri, united states background: mutations in the samd gene are associated with a rare syndrome comprising of myelodysplasia, infection, restriction of growth, adrenal hypoplasia, genital phenotypes and enteropathy (mirage syndrome). diagnosis is made through exome sequencing. in the largest reported case series, of eleven patients diagnosed with mirage syndrome, two developed loss of chromosome . given the potent growth restricting activity of samd mutants, the loss of chromosome is considered the first documentation of adaptation by aneuploidy mechanisms in humans and led to myelodysplastic syndrome (mds), with deaths occurring from related complications at and years of age. objectives: to report a case of mirage syndrome with congenital thrombocytopenia progressing to bone marrow failure, managed uniquely with bone marrow transplantation. results: male born at weeks gestation with prenatal diagnosis of iugr, two vessel cord, oligohydramnios was found to have ambiguous genitalia, adrenal insufficiency, partial panhypopituitarism and congenital thrombocytopenia with bone marrow showing absence of megakaryocytic precursors. severe thrombocytopenia was present from birth. bone marrow evaluation demonstrated a hypocellular marrow with markedly reduced megakaryocytic and myeloid precursors and no evidence of myelodysplasia. he required gastric tube placement for failure to thrive, had a laryngeal cleft repaired and developed focal segmental glomerulosclerosis. mpl gene testing for congenital amegakaryocytic thrombocytopenia was negative. testing for fanconi anemia, shwachman-diamond syndrome and dyskeratosis congenita was also negative. approximately % of cells had loss of heterozygosity on chromosome q. exome sequencing showed that he is heterozygous for a de novo gain of function variant, c. g>a (p.arg gln), identified in the samd gene, confirmed by sanger sequencing and consistent with a diagnosis of mirage syndrome. at years of age, he developed pancytopenia requiring frequent transfusions with platelets and packed red blood cells. he underwent a successful bone marrow transplant at years of age without significant complications, and remains transfusion independent without cytopenias greater than months from bone marrow transplantation. conclusion: it is imperative to pursue work up for persistent congenital thrombocytopenia in a stepwise multidisciplinary manner. to the best of our knowledge, this is the first case of mirage syndrome associated bone marrow failure treated with bone marrow transplant. due to the individual rarity of mirage syndrome and pediatric myelodysplastic syndrome, it is important to maintain an index of suspicion given their association and explore bone marrow transplant as a therapeutic option. results: the patient demonstrated disease regression, initially, and continued without disease progression for months. the regimen has been well tolerated with only minimal side effects of dry skin (ctcae grade ) and a transient episode of brief erythrodysesthesia (ctacae grade ) that resolved spontaneously. the combination of sorafenib and capecitabine was effective and well tolerated in this adolescent patient with fl-hcc. our observations, although in a single patient, lend support for further testing of this novel oral chemotherapy regimen in patients with fl-hcc, a disease for which there is no effective standard chemotherapy approach. background: epstein-barr virus (ebv) is a ubiquitous virus associated with a broad range of malignancies due to its oncogenic potential. history of organ or bone marrow transplantation, immunosuppressive therapy, and primary or acquired immunodeficiency syndromes increases the risk of ebvassociated tumors. epstein-barr virus associated smooth muscle tumors (ebv-smt) are unique and rare neoplasms typically discovered in immunocompromised patients. most information related to pathogenesis and therapeutic options is limited to case reports and case series of adult patients. there are several gene expression pathways that ebv utilizes, the most notable of which is the mammalian target of rapamycin (mtor) pathway. the mtor pathway performs a key role through integrating various cell growth signals and factors to regulate protein synthesis and metabolism related to smooth muscle proliferation. sirolimus is an immune modulating therapy that targets the mtor pathway to block activation of lymphocytes. objectives: several case reports have demonstrated shortterm clinical remission of ebv-smt in adult patients with the use of sirolimus. we report the first case of long-term background: bilateral neuroblastoma is characterized as neuroblastoma arising in both adrenal glands, a rare presentation with little data on its genetic make-up. a two-monthold patient was diagnosed with bilateral neuroblastoma in our clinic. her risk assignment was based on biopsy of the left adrenal lesion, which showed mycn amplification, an unfavorable genetic marker. treatment regimen was intensified accordingly and after courses of chemotherapy tumors were excised. patient went on to receive a stem cell transplant and immunotherapy. with no knowledge of genetic similarity between the two tumors it is unclear whether biopsy of the right lesion would have yielded similar results or whether bilateral biopsies are needed for risk assessment of bilateral neuroblastoma. objectives: utilize whole exome sequencing (wes) to characterize the genomic signature of bilateral adrenal neuroblastomas excised following chemotherapy treatment. design/method: paraffin-embedded samples from left (l) and right (r) tumors underwent wes at the broad institute. we analyzed resulting data including somatic variant calls, indel mutations, and copy number variants (cnvs) using ingenuity software to evaluate and compare differences between the two tumor samples. preliminary analysis of the data shows important descriptive information on the two tumor samples. out of somatic mutations in the r tumor cells and mutations in the l tumor cells, only two common somatic mutations were present. out of cnv calls in the r tumor and in the l tumor, cnvs were common between the two tumors, or % of each tumor's cnv calls. there was a fold higher frequency in gains versus losses. the median size of the common cnvs was , (range to , , bp). cancerrelated genes with increased copy numbers included transcription factors, receptors for signal transduction pathways, and histone methylation proteins. conclusion: preliminary analysis of the wes results of the two adrenal tumors show some genomic divergence. because the tumor tissue was exposed to chemotherapy prior to excision it is difficult to determine whether genomic divergence is a result of independently originated tumors or subsequent adaptation to chemotherapy of a clonal cell population. the high number of common cnvs in the two tumors points to a common cell of origin, however the low number of common somatic mutations does not fit that picture. a future study to help elucidate the question will be wes of the original biopsy tissue to provide information on tumor mutations prior to the effects of chemotherapy. baylor college of medicine, houston, texas, united states background: although there has been significant improvement in the overall survival rates of children with cancer many children will still die from their illness or complications secondary to treatment. research surrounding the deaths of children who succumb to their disease is warranted to ensure we are providing the best care possible for these patients. objectives: this case series aims to explore pediatric cancer deaths by focusing on perhaps the most extreme cases of high intensity end of life care. we explore those patients whom we know are dying or our very likely to die as evidence by their do not resuscitate (dnr) orders. in all of these cases despite the patients very grim prognosis, their great likelihood of death and limitations placed of resuscitation methods all patients continued end of life care in the pediatric intensive care unit (picu). the primary medical records of all children with a cancer diagnosis who died between february , and january , in the picu with a dnr order seven days or earlier prior to death. each medical history included disease-directed treatment history and response with particular attention to the events surrounding the terminal admission. results: eight patients met criteria for this study representing . % of all cancer patients who died during this time period and . % of those who died in the icu. the average time between dnr and death is . days ( days - days). the average length of terminal admission was . days ( day - days). the average time between diagnosis and dnr is . months ( months - months). the average time between diagnosis and death is . months ( months - months). conclusion: these cases highlight the journey that patients, families and providers endure leading up to death. medical care is complex, there are very few absolutes that are encountered when caring for patients and decisions around limiting or withdrawing medical care are made in a context of the prior journey. . these cases help to understand the complexity of death and how two seemingly opposite ideals can be congruent in the event of an anticipated death. most of these cases show the need for improved anticipatory guidance surrounding death and greater consideration for de-escalation of care when death is expected. the hospital for sick children, toronto, ontario, canada background: rhabdomyosarcoma (rms) is the most common soft tissue sarcoma in children, with embryonal (erms) and alveolar (arms) representing the most common subtypes. arms tumors are associated with inferior outcome when compared to erms, and they are characterized in about % of the cases by a t ( ; ) or t( ; ) chromosomal translocation with creation of a pax -foxo or pax -foxo fusion gene, respectively. it is increasingly clear that the pax-foxo fusion status is an important poor prognostic factor, thus the histological classification tends to be replaced by the fusion status, particularly in terms of risk stratifica-tion in contrast to arms, there are no recurrent chromosome alterations in erms; however, there are multiple numerical chromosome changes that are frequent in these tumours: gain of chromosome , , and have been found in to % of emrs karyotypes. moreover, erms tumors show frequently allelic loss, the .p . chromosomal region being the most frequently involved. recently, novel gene fusions have been described also in erms tumours. these fusions involved mainly the ncoa and or the vggl genes. the rearrangement partners are variable, and include, i.e. pax ( q ), srf ( q ) and tead ( p ). objectives: to present a patient who died as a consequence of brain metastases while on therapy in the setting of an foxo negative rms and the identification of a new translocation t( ; )(q ;q ). design/method: case report and retrospective review of the literature. we report a case of pelvic embryonal rhabdomyosarcoma in a -month old boy. he was treated as per cog arst intermediate risk group, but unfortunately was found to have a large cerebellar tumour during the course of his chemotherapy treatment and he subsequently passed away. a novel translocation between chromosomes and was observed in of metaphase cells by g-band analysis in the autopsy sample of the brain lesion. breakpoints of the translocation were estimated to be at q and q . there were no additional clonal chromosome abnormalities in the tumour cells. conclusion: erms tumors with fusion genes involved have been exclusively described in patients less than months of age; they seem to be associated with spindle cell histology and, a favorable outcome. in our patient, a novel ( ; ) translocation was found and clinically, the patient had a dismal outcome. further studies are indicated to inquire whether this finding is of significance in term of prognosis for these patients. children 's national medical center, washington, district of columbia, united states background: iatrogenic immunodeficiency-associated lymphoproliferative disorders (lpds) are a group of lymphoid s of s proliferations or lymphomas that are well known to be associated with an immunosuppressed state. these disorders most commonly occur following hematopoietic or solid organ transplantation (called post-transplant lymphoproliferative disorders or ptld), but cases have also been described during the treatment of autoimmune and rheumatologic disorders by immunosuppressive and immunomodulatory medications. these disorders are strongly associated with infection by the epstein-barr virus (ebv) as a result of impaired immune function in the immunosuppressed state. while this phenomenon has been well documented in autoimmune conditions, cases affecting pediatric patients while on antileukemia chemotherapy are lacking. background: atypical teratoid/rhabdoid tumor (at/rt) of the central nervous system (cns) in children younger than years old has a prevalence of % to % and accounts for . % of all pediatric cns tumors. only - % of patients have leptomeningeal dissemination. rhabdomyosarcoma is the most common soft tissue tumor in childhood, but represent only - % of all pediatric cancers. rarely, it can metastasize or even directly extend into the cns, but typically, cases of cns involvement arise either from parameningeal areas or other primary sites. primary spinal or meningeal rhabdomyosarcoma is extremely rare. objectives: our objective is to describe two unique cns malignancies presenting as rare, primary leptomeningeal disease. design/method: case a -month-old female presented with vomiting, fatigue and listlessness, despite a normal head ct and brain mri. csf showed hypoglycorrhachia and mild pleocytosis. ceftriaxone was started, but she developed nuchal rigidity and cranial nerve vii palsy. repeat brain mri showed evolving leptomeningeal enhancement concerning for meningitis. she gradually developed worsening opisthotonus and ultimately a brain biopsy of the temporal lobe was consistent with at/rt. case a -year-old male presented with new generalized tonic-clonic seizure activity and intermittent headaches with photophobia, phonophobia, and vomiting. brain mri was significant for enhancement of interpenducular and suprasellar cisterns extending to the optic nerves and chiasm most consistent with meningitis. neurosurgery ultimately placed a lumbar drain for hydrocephalus, and a tissue biopsy demonstrated primary meningeal rhabdomyosacroma. results: in case , our patient's temporal lobe biopsy demonstrated grade iv malignant tumor cells consistent with atypical teratoid/rhabdoid tumor. fish demonstrated a homozygous deletion of smarcb ( q . ). she was started on chemotherapy per the dana farber at/rt protocol but ultimately was discharged home on hospice. in case , our patient's lumbar arachnoid biopsy demonstrated cellular tumor consistent with group iiia embryonal rhabdomyosarcoma. immunostaining was positive for cd , desmin, myogenin, and myo-d with neural markers ema and gfap highlighting the meninges but without a neural component to the tumor. he completed craniospinal radiation to gy total with lumbar boost to . gy total. he is currently receiving chemotherapy per arst protocol. conclusion: these two cases are particularly instructive because of their similar initial presentations and neuroimaging, but with very different and unique diagnoses. university of iowa, iowa city, iowa, united states background: ebf -pdgfrb fusion causes ph-like b-cell acute lymphoblastic leukemia (b-all), which has a philadelphia positive phenotype without the bcr-abl translocation. this is one of several mutations associated with ph-like b-all and leads to downstream overexpression of tyrosine kinase. ebf -pdgfrb fusion accounts for about % of children with ph-like b-all. patients with ph-like b-all previously had poorer outcomes with conventional chemotherapy. the addition of tyrosine kinase inhibitors (tki), like imatinib, has improved the outcome for many patients predicted to have tki sensitive mutations. objectives: to review clinical characteristics and outcomes of two cases of ph-like b-all at the university of iowa stead family children's hospital and to compare these outcomes to similar cases reported in the literature. design/method: a retrospective chart review was performed for two cases of ph-like b-all diagnosed and treated at the university of iowa stead family children's hospital. results: both patients were males diagnosed at years of age with high wbc count ( , and , ) and positive for ebf -pdgfrb gene fusion. patient (pt ) was cns b at presentation while patient (pt ) was cns negative; neither had testicular involvement. both started treatment according to cog protocol aall . peripheral blasts cleared by induction day for pt and induction day for pt . at end of induction, pt had m bone marrow and pt had m bone marrow but mrd %. dasatinib was started induction day for pt and induction day for pt . pt was still not in remission at end of consolidation; bone marrow cell culture for tki resistance showed best response to dasatinib. pt proceeded to anti-cd car t-cell therapy followed by tbi-based matched unrelated donor bone marrow transplant. pt had negative mrd at the end of consolidation and continues chemotherapy according to aall , dasatinib arm. both patients are currently clinically well. our patients had the same tyrosine kinase gene fusion and similar initial clinical courses. while both patients had persistent disease at end of induction, pt had almost % blasts while pt had significant reduction of disease burden before starting tki. pt showed good response with the addition of dasatinib while pt did not. these findings suggest that response to conventional chemotherapy may potentiate the effect of tki and may predict overall outcome. there are likely additional factors which must be taken into account when determining response to tki for patients with ph-like b-all which have not yet been identified. background: medulloblastoma is the most common malignant brain tumor of childhood. classically, medulloblastoma presents as a well-defined mass lesion in the cerebellum, with a high rate of metastatic dissemination. primary leptomeningeal medulloblastoma (plmb) is an exceedingly rare type of medulloblastoma presentation with a dismal prognosis in which patients present with isolated leptomeningeal disease without an associated mass. to our knowledge, only three pediatric and three adult cases of plmb (ages - years) have been reported, all of which died within months of diagnosis. this is the first case of plmb to report a molecular classification. objectives: to report the case of a pediatric patient with plmb in which histopathologic and molecular characterization was performed and to describe the patient's treatment and clinical course. design/method: retrospective review of the patient's electronic medical record and review of the literature. a -year-old boy presented with headache, vomiting, diplopia, and fatigue. physical examination revealed upward gaze palsy, left-sided extremity and facial weakness, and ataxia. magnetic resonance imaging (mri) of the brain revealed diffuse cerebellar leptomeningeal enhancement and edema without an identifiable mass and moderate hydrocephalus. mri of the spine and cerebral spinal fluid analysis were normal. a diagnosis of cerebellitis was rendered, and the patient underwent placement of a ventriculoperitoneal shunt. an extensive infectious, neurologic, rheumatologic, and oncologic workup did not identify an etiology. empiric antibiotics, high-dose steroids, and intravenous immunoglobulin therapy yielded minimal improvement. two months later, repeat mri of the brain performed for declining mental status demonstrated progressive thickening of cerebellar leptomeningeal disease. a suboccipital craniectomy with decompression and cerebellar biopsy were performed. pathologic examination revealed a diagnosis of plmb, classic histology, non-wnt/non-shh, without gain/amplification of myc/mycn, and p wild type pattern. craniospinal radiation to cgy with a cgy boost to the posterior fossa was delivered with concurrent carboplatin/vincristine over six weeks. two months following chemoradiation, mri of s of s the brain demonstrates significantly reduced pathological leptomeningeal enhancement of the cerebellum, and the patient is awaiting initiation of systemic chemotherapy while recovering from a surgical wound infection. conclusion: plmb is extremely rare but should be considered in patients with cerebellitis and diffuse leptomeningeal involvement who are refractory to medical management or in whom an etiology has not been identified. cerebellar biopsy is recommended early to enable timely treatment and improved outcomes. molecular classification should be performed in cases of plmb to further characterize this disease, inform treatment decisions, and improve clinical outcomes. background: primary intracerebral osteosarcoma is extremely rare and limited to case reports. ptpn gain of function is associated with noonan syndrome, which has increased risk of multiple cancer types including brain tumors, but osteosarcoma has never been described. ptpn mutations have been reported in many cancers as both oncogenes and tumor suppressors, however no ptpn mutations have been described in osteosarcoma. pdgfr-a is a growth factor receptor whose activation is implicated in several malignancies. pdgfr-a and ptpn concurrent mutations are described in glioblastoma. there is no known link between holoprosencephaly, noonan syndrome, and osteosarcoma. we report a case of multifocal intracerebral osteosarcoma in a child with lobar holoprosencephaly and chronic subdural hemorrhage and discuss the genetic changes found in the tumor. design/method: a seven-year-old caucasian female, with a known diagnosis of lobar holoprosencephaly, chronic subdural hemorrhage and well controlled seizure disorder presented with status epilepticus shortly after completing antibiotic therapy for infection of subdural hematoma. mri showed diffuse dural thickening with mass lesions in the frontal lobe, temporal lobe, and the parasagittal region, the largest of which was contiguous with the subdural space but none of the lesions were associated with bone on mri or by direct neurosurgical visualization. tissue obtained for concern for recurrent infec-tion resulted in a diagnosis of high grade osteosarcoma. dna analysis was performed to help guide treatment choice. results: standard metastatic work-up was negative for skeletal primary tumor or metastatic lesions outside of the brain. she was treated with high dose methotrexate for two cycles per modified aost . despite maximal supportive care, she quickly developed rapid tumor growth as well as intratumoral hemorrhage with resultant herniation and death from respiratory failure just three months after diagnosis. tumor gene sequencing discovered three mutations with described roles in cancer: pdgfra d >vr, kdm a loss of exons - , and ptpn a v. conclusion: to our knowledge, primary multifocal extraosseus intracerebral osteosarcoma has not been previously described. despite known cns penetration of high dose methotrexate, this tumor proved resistant and aggressive. holoprosencephaly is associated with a multitude of known genetic drivers, but none are found in this case. furthermore, the genetic changes in this tumor are not typical for osteosarcoma. pdgfr-a over-expression is described in osteosarcoma, but is not clearly correlated with worse overall survival. further research is required to determine the role of ptpn in osteosarcoma. background: anaplastic lymphoma kinase (alk) encodes a receptor tyrosine kinase whose activation induces pathways associated with cell proliferation, angiogenesis, and cell survival. alk rearrangements are rare in neuroblastoma, while alk mutations and gene amplification occur more frequently. alk mutations have been found to be associated with increased alk protein expression that is associated with a worse prognosis. alk is commonly mutated in neuroblastoma at three hotspots (f , r , and f ). the eml -alk rearrangement has mostly been associated with lung adenocarcinomas, with only a few cases of non-lung cancers found. it has never been reported in neuroblastoma. multimodal therapy and to report the successful management of treatment related iron overload. results: a -year old male presented with abdominal swelling and ct showed a right kidney mass and bilateral lung nodules. he underwent right radical nephrectomy with lymph node sampling. pathology was reviewed centrally and revealed wilms tumor with diffuse anaplasia with rhabdomyosarcoma arising within the stromal component and of nodes positive. he received adjuvant intensive chemotherapy and radiation to the hemiabdomen and whole lungs. the -week chemotherapy regimen was vincristine, doxorubicin, cyclophosphamide (per cog arst ) alternating with carboplatin and etoposide (per cog aren revised uh- ). treatment was complicated by multiple episodes of fever and neutropenia and anorexia requiring g-tube placement. post-therapy, he had persistent neutropenia and thrombocytopenia without related complications. every months for evaluations he underwent a bone marrow which revealed normocellular marrow with maturing trilineage hematopoiesis. evaluation for a bone marrow failure syndrome was unrevealing. starting at months into therapy and all posttherapy imaging showed splenomegaly. he received units of packed red blood cells through the duration of therapy. he was diagnosed with iron overload based on serum ferritin and imaging, including t *mri. he received therapeutic phlebotomy for years with normalization of serum iron studies, t * of the heart, and liver iron concentration. he is more than years from completing therapy with no evidence of recurrent disease. asymptomatic cytopenias persist and he has no evidence of iron overload. conclusion: though a rare development, clonal sarcomatous transformation can occur in wilms tumor. our patient's tumor was successfully treated with intensive multimodal therapy targeting the diffusely anaplastic wilms and the rhabdomyosarcomatous component. treatment-related iron overload in a pediatric patient with a solid tumor was successfully treated with phlebotomy. consideration should be given to screen patients with solid tumors who receive multiple packed red cell transfusions for iron overload at the completion of cancer therapy. primary children's hospital, university of utah, salt lake city, utah, united states background: malignant solid tumors are less frequently encountered in infants. primitive myxoid mesenchymal tumors of infancy (pmmti) are a myofibroblastic malignancy and cases are rarely reported in the literature. cure is achieved in the majority of cases with surgical resection, however treatment for unresectable cases remains an enigma. recently published literature postulates that the newly discovered bcor duplication found in pmmti is tumorigenic via an epigenetic pathway. this molecular signature resembles that of clear cell sarcoma of the kidney (ccsk) and the growing number of bcor mutated sarcomas. a similar chemotherapeutic backbone and local control used for ccsk, has been proposed for the unresectable subset of pmmti. utilizing this approach a month-old with relapsed disease has remained disease free for months. however, given the rarity of this disease and the lack of published literature, there is no known standard of care treatment for unresectable and/or recurrent ppmti. we report a case of unresectable recurrent pmmti, a rare infant tumor, with less than cases reported. design/method: medical record, radiological studies, pathology and literature was reviewed. results: our patient is a now month-old female who presented with constipation and lower extremity weakness in the first weeks of life. an mri demonstrated a large lumbar epidural mass with spinal cord impingement. given prolonged (> days) neurological symptoms and location, emergent chemotherapy was initiated. biopsy showed a bcor positive, primitive myxoid mesenchymal tumor of infancy (pmmti). she was treated with ifosfamide, carboplatin and etoposide, and demonstrated clinical and radiographic response. we gave two additional cycles of cyclophosphamide, carboplatin and etoposide until surgical resection was feasible followed by two post-surgical cycles of chemotherapy. unfortunately, four month post-therapy mri demonstrated two new lesions; an unresectable paraspinal soft tissue mass and a left iliopsoas groove mass. given bcor association and reported successful therapy with vincristine, doxorubicin, cyclophosphamide alternating with ifosfamide and etoposide, we elected to incorporate vinca-alkaloid and anthracycline into her regimen. she is being treated with vdc/ie with plan for radiation consolidation. conclusion: pmmti is a locally aggressive tumor, for which surgical resection is curative. for those not amendable to resection, best care practices are still being determined. we report a case of pmmti initially responsive to chemotherapy, but not curative. this is the second case to conclusively demonstrate chemo-responsiveness. bcor mutation seems to be a common feature of this cancer; its role in the pathogenesis and as a target is an area of investigation. medical college of wisconsin, milwaukee, wisconsin, united states background: atypical teratoid/rhabdoid tumors (atrt) are central nervous system (cns) tumors that most commonly occur in very young children. there is no widely accepted standard of care for atrt patients, and while survival rates are improving they are historically poor. patients with metastatic disease to the spine at diagnosis have a worse prognosis, and for patients > years old, the presence of metastatic disease often results in the use of craniospinal radiation. the importance of correctly identifying metastatic disease at diagnosis aids in decision making and can have both prognostic and therapeutic implications. mr imaging at diagnosis is used to identify metastatic disease; however, here we present a case of diffuse leptomeningeal enhancement that spontaneously resolved after resection of a primary supratentorial atrt. objectives: to describe the resolution of diffuse leptomeningeal enhancement after resection of a primary atrt tumor in a -month-old prior to any adjuvant therapy. results: a -month-old male presented with a month history of vomiting and weight loss, regression of gross motor developmental milestones, and left hemiparesis. a brain mri demonstrated a × . × . cm solid and cystic right atrial mass with diffusion restriction and post-contrast enhancement. smooth diffuse enhancement was noted along the surface of the brainstem and within the interpeduncular fossa. a spine mri demonstrated diffuse circumferential post-contrast enhancement along the surface of the entire spinal cord. the patient underwent a successful near total surgical resection of the primary mass. pathology confirmed the loss of ini- staining in tumor cells, consistent with a diagnosis of atrt. no immediate adjuvant radiation or chemotherapy was given. repeat imaging was completed days after resection. brain mr demonstrated expected post-operative changes within the surgical cavity without definitive residual mass or leptomeningeal enhancement. spine mr demonstrated complete resolution of the previously seen circumferential enhance-ment along the entire spinal cord. csf evaluation at that time was negative for tumor cells. after recovery from surgery, chemotherapy treatment was initiated. conclusion: leptomeningeal enhancement at the time of diagnosis of atrt has historically been considered clear evidence of metastatic disease. this case raises questions about the previously accepted etiology of these imaging changes and suggests that widespread leptomeningeal enhancement should be carefully interpreted in future patients with similar imaging findings. in this setting, clinicians should consider repeat imaging following primary surgical resection in order to provide appropriate prognostic information and inform therapeutic decisions. poster # primary ewings sarcoma of cervical cord mimicking cauda equina syndrome sucharita bhaumik, joshua chan nyu winthrop hospital, mineola, new york, united states background: ewing's sarcoma (es) is a malignant primary bone tumor usually involving long bones. primary es of spine is quite uncommon ( . %) and its location in the cervical spine is even more rare. cauda equina syndrome (ces) is symptoms due to damage to the bundle of nerves below the end of the spinal cord known as the cauda equina (low back pain, radiating shooting pain down the legs, paraplegia, and loss of bowel or bladder control). it often occurs with lesions of lumbosacral spine. treatment with high-dose steroids may provide pain relief and improved neurologic function (by reducing edema) while awaiting diagnostic studies objectives: to demonstrate an unusual clinical presentation and emergent management of cervical es presenting with ces like symptoms. : year old male presented with a left sided posterior neck mass. soon after, he developed weakness of left arm, urinary and stool retention and inability to walk or bear weight in both legs. on physical exam a left tempero-occipital × cm fixed, non-tender, non-fluctuant mass was noted as well as motor and sensory impairment of left upper extremity, bilateral spastic paraplegia and loss of sphincter control. mri cervical spine showed a left cervical tumor with moth eaten appearance involving the vertebral bodies of c -c , adjacent muscles, displacing vital structures of the neck and compressing the cervical spinal cord. the thoracic and lumbosacral spine had no disease involvement. due to rapidly worsening spinal cord compression he was emergently treated with high dose steroids. he gained back all function in his extremities and regained bowel and bladder control. this eliminated need for urgent neurosurgical intervention. results: biopsy of the neck mass showed small blue round cells consistent with es with ewsr gene rearrangement. staging work up revealed no additional metastatic involvement. he then initiated treatment for localized es with systemic chemotherapy and radiotherapy and has had excellent response to treatment so far. conclusion: this is the first known case of non metastatic primary cervical es mimicking ces where an acutely enlarging mass presented with rapidly progressive neurologic deficits due to compression of anterior spinothalamic tract. in these unusual presentations of ces without lumbodorsal involvement it is important to consider cervical lesions. early rapid steroid initiation should be considered while awaiting biopsy results to prevent worsening cord compression followed by es focused treatments. this increases the chance of a successful outcome. the initial improvement with steroids may confuse the tumor with being a lymphoma children 's mercy hospital, kansas city, missouri, united states background: von willebrand disease (vwd) is a relatively common bleeding disorder with a high degree of genotypic and phenotypic variation. bleeding is usually mucocutaneous but can be severe and include muscle and joint bleeds especially in type vwd patients. most common bleeding management consists of desmopressin, anti-fibrinolytics, and/or plasma-derived antihemophilic factor/von willebrand factor (ahf/vwf) complex. a recombinant vwf has become available in the last few years. anaphylaxis and inhibitor development in vwd are rare. objectives: to describe the rare clinical manifestation of anaphylaxis to factor concentrate in a patient with severe type vwd. results: a -year-old female with severe type vwd [baseline vwag %, activity < %, factor viii (fviii) %] originally presented with heavy menstrual bleeding (hmb) leading to anemia requiring blood transfusion. she underwent placement of a levonorgestrel-releasing intrauterine device (lngiud) and began norethindrone. her hmb continued despite the lngiud and an increase in norethindrone dosing. plasma derived ahf/vwf complex was administered, which she had previously received. following the infusion, the patient developed anaphylaxis with hives, wheezing, tachycardia, and itching requiring doses of diphenhydramine and dose of hydrocortisone with resolution of symptoms. subsequently, she received recombinant vwf without incident. however, due to her low fviii level, she also required treatment with a full length recombinant fviii product. she again developed hives and itching after this infusion. she has since received recombinant vwf with recombinant fviii/fc fusion protein without further allergic reaction. there was no evidence of an inhibitor with her most recent post-infusion vwf level was %, factor viii %. conclusion: anaphylaxis to plasma derived factor products has been documented far less frequently within the vwd population compared to those with hemophilia and is typically seen in those with large gene deletions, usually with type disease. therefore, similar type vwd patients with severe disease may benefit from gene sequencing. it is unclear in this patient's case to which aspect of her treatment she is allergic, as she reacted to plasma-derived ahf/vwf and full length recombinant fviii, but not recombinant vwf or recombinant fviii/fc fusion protein. we hypothesize that she may be allergic to an epitope in the fviii b domain, or that the presence of fc fusion may have had a protective effect. further investigation including genetic analysis is planned. nodules. biopsies were consistent with neuroendocrine carcinoma, large cell type (g ). next generation sequencing revealed a khdrbs -braf fusion. he received conventional cytotoxic chemotherapy regimens both with cisplatin/doxorubicin, capecitabine/temozolomide, and doxorubicin/etoposide, but achieved a minimal response followed by rapid disease progression, massive ascites, and renal failure secondary to bilateral ureteral obstruction. results: based on his prior genomic testing, therapy with single agent mek inhibitor (trametinib) was initiated. this produced a rapid, dramatic response with greatly reduced disease burden at all sites, resolution of ascites and return to completely normal activity within months. this response lasted for approximately months before the tumor again progressed. further therapy with an erk inhibitor was ineffective, and the patient expired from progressive disease. located on the chromosome q , the braf oncogene, as part of the ras/mapk pathway, is involved in cellular proliferation, differentiation, migration, and apoptosis. braf mutations are recognized in a wide range of adult malignancies: thyroid cancers, non-small cell lung cancer, cholangiocarcinoma, ovarian cancers, and multiple myeloma. braf mutations have also been described in adult neuroendocrine carcinoma of the colon. trametinib is a highly specific inhibitor of mek /mek , a downstream mediator in the braf pathway. it has demonstrated activity in a number of tumors including advanced melanoma and gliomas. trametinib was chosen for this patient based on his atypical braf fusion. we believe this is the first documented case of its successful use in neuroendocrine carcinoma in the pediatric population. conclusion: this case demonstrates the presence of braf fusion in a case of pediatric neuroendocrine carcinoma and significant response to single agent mek inhibition in this context. this cases raises the question as to whether the combination of a targeted inhibitor, in addition to either conventional chemotherapy or other braf inhibitors, might offer a better approach to therapy than current treatment options. albany medical center, albany, new york, united states background: warm autoimmune hemolytic anemia (waiha) is characterized by autoantibody, and occasional complement binding of protein antigens, on the surface of red blood cells at temperatures ≥ oc resulting in targeted destruction. we describe the case of a year old male with a history of evan's syndrome, poor immune response to vaccines and lymphoid hyperplasia, presenting with altered mental status and severe anemia, found to have a warm igg pan agglutinin with evidence of both intra and extravascular hemolysis. his course was complicated by respiratory failure requiring intubation, pulmonary emboli, enterococcus bacteremia and hypertension. he received multiple transfusions with only transient increases in hemoglobin. the aiha was refractory to multiple rounds of treatment with high dose steroids, ivig, rituximab, cyclophosphamide, bortezomib, plasma exchange and mycophenolate mofetil (mmf). objectives: given the refractory nature of our patient's aiha the decision was made to trial eculizumab, a monoclonal antibody targeting c complement, preventing its cleavage and activation, and shown to be effective in treatment of atypical hemolytic uremic syndrome and hemolysis due to an igm cold agglutinin. prior to eculizumab infusion, ch and sc b- assays were significantly elevated. design/method: the patient was given two doses of eculizimab days apart. results: his hemoglobin steadily rose independent of red cell transfusions with a corresponding decrease in reticulocyte count, ldh and ch levels. the patient has remained stable with a normal hemoglobin ( - g/dl) on maintenance steroids and mmf. although we cannot definitively conclude that eculizumab directly caused his recovery, the clinical course post-eculizumab suggests this may be an efficacious treatment for aiha. genetic testing showed monoallelic frameshift mutation of the nfkb gene and monoallelic missense mutation of the dock gene. given the role of nfkb in both immunodeficiency and autoimmunity, it is thought that the patient's phenotype is due to nfkb haploinsufficiency and he is currently considering hematopoietic stem cell transplant. st. joseph's regional medical center, paterson, new jersey, united states background: heterozygous -thalassemia typically manifests as thalassemia minor, characterized by mild microcytic hypochromic anemia with minimal clinical ramifications. coinheritance of -globin gene triplication has been reported to exacerbate the clinical and hematological phenotype ofthalassemia trait, due to increase in the alpha/non-alpha-chain imbalance. reported phenotypes range from asymptomatic thalassemia minor to moderate thalassemia intermedia, usually diagnosed in adulthood without transfusion dependence. this combination has been described in mediterranean, european and asian populations, but rarely reported in hispanics. objectives: to report two cases of unusually severethalassemia intermedia in hispanic patients with heterozygosity for triplicated -globin gene and a ( )-thalassemia allele. results: case : sixteen-month-old male of mexican descent presented with persistent microcytic anemia and jaundice. peripheral smear showed nucleated rbcs with basophilic stippling and target cells. hemoglobin electrophoresis revealed: hba- %, hbf- %, hba - . %. -globin gene testing revealed heterozygosity for ( ) mutation (ivsi-i, g→a). given the unusually severe anemia, -gene testing was performed which showed -globin gene(anti . ) triplication ( / ). at four years, he had splenomegaly and bilateral maxillary prominence. head ct showed irregular contour of the parieto-occipital region due to medullary expansion. due to significant persistent anemia ( - g/dl) and progressive bony deformities of the skull, patient began chronic transfusions at age eight after family declined splenectomy.case : fifteen-year-old female, of peruvian and honduran descent, presented for evaluation prior to cholecystectomy for gallstones and recurrent ruq pain. father had known thalassemia trait. her hb was . g/dl with hypochromia, microcytosis, and target cells. electrophoresis indicated -thalassemia trait (hba- %, hba - . %, hbf- . %), confirmed by gene testing (heterozygous for a ( ) mutation in codon c>t). given jaundice and gallstones, -globin gene analysis was ordered showing triplication ( / ). ruq pain resolved post-cholecystectomy, but she developed persistent painful splenomegaly. she began hydroxyurea to increase gamma-globin production and decrease excess alpha chains, but it was discontinued due to hematological toxicity. due to recurrent luq pain and progressive splenomegaly, she underwent laparoscopic splenectomy at age with resolution of symptoms and improved hemoglobin. conclusion: -globin gene testing should be considered in -thalassemia carriers with an atypical clinical presentation including hispanic patients. the wide variability in the phenotypic expression of (anti . ) mutation andthalassemia trait suggest interplay of other genetic factors which remain undefined. the clinically significant presentation amongst certain subjects, as in our two cases, makes it imperative to identify these factors to aid in phenotype prediction and genetic counseling. ashley bonheur, shivakumar subramaniyam, jogarao vedula, sucharita bhaumik nyu winthrop hospital, mineola, new york, united states background: wilms tumor (wt) is one of the most common solid malignant neoplasms in children. a diverse range of genes and mechanisms are implicated in wt pathogenesis. predisposing syndromes result from a disruption of wt gene, crucial for renal and gonadal embryogenesis. another gene is wt gene locus at p , an area of imprinting. the p tumor suppressor gene on chromosome p . is seen in patients with anaplastic histology. in addition to these genes, whole and partial chromosome gains of q, , q, , , & and losses of p, p, q, q, as well as loss of heterozygosity (loh) are commonly seen. some genetic markers appear to be predictive of outcome and are now incorporated into the assigning of risk-directed therapy. patients with loh at chromosome p and q are treated with more intensive chemotherapy, as they have been associated with increased risk of relapse and mortality. objectives: to describe a new complex translocation involving chromosome , , and in a case of pediatric wt. design/method: a four-year old female presented with abdominal pain and emesis. on exam, patient had a firm and large abdominal mass. radiologic studies revealed a complex lobulated right renal mass. right radical nephrectomy was performed. histopathologic studies showed wt with triphasic histologic features with blastema predominance, invasion of the lymphovascular and perinephric adipose tissues, perinephric lymph node involvement and no anaplasia. chest ct scan showed bilateral lung metastases. tumor cytogenetics showed an abnormal karyotype, a complex translocation of , , and . the rearrangement occurred due to translocation between chromosomal bands q and q , with an insertion of q - on the q region. pcr based genotyping using microsatellite markers additionally identified loh for chromosome p and q . the patient was treated for high risk stage iv wilms tumor with favorable histology and received intensive chemotherapy and radiation therapy to the flank and the lungs. she is now in remission months after, with no evidence of recurrence on surveillance scans. complex translocations associated with wt have not been rigorously studied. a question for further study is whether there is any relationship between recurrence potential with a complex translocation compared to common chromosomal abnormalities. further knowledge of the molecular pathology and genetic changes in wt will help the development of new targeted therapies, as well as new biomarkers to aid diagnosis, risk stratification, and monitoring of treatment and relapse. results: a week-old girl was referred for evaluation of an abnormal newborn screen. mother was a known carrier of hb khartoum trait while father was a known carrier of thalassemia trait. patient's hemoglobin quantification performed by capillary zone electrophoresis showed hbf %, hb variant %, and no detectable hba. the hb variant ran in the d zone, a pattern consistent with mother's hb. alkaline agarose gel electrophoresis banding pattern showed f/s. acid agarose gel electrophoresis pattern showed v/f. later testing revealed abnormal isopropanol stability with + precipitation at minutes. this electrophoresis pattern is consistent with the pattern previously reported of hb khartoum. clinically, the patient is a healthy, active child whom we have followed for two years. she has not had any significant anemia outside of her physiologic nadir. she has not had any hemolytic episodes, and her bilirubin levels have always been within the normal range conclusion: to the best of our knowledge, this is the only reported case of hb khartoum/ thalassemia. the proline to arginine substitution of hb khartoum introduces a charged group on the chain at the site of contact. the resulting unstable chains can dissociate into monomers and favor the formation of methemoglobin, leading to hemoglobin instability. we had wondered if this unstable hemoglobin might result in clinical hemolysis when challenged with oxidative stress, such as in periods of infection. however, in the two years we have followed this patient, she has never had a hemolytic episode. at two years of age, she has hbf . %, hb khartoum . %, and hba . %. whether hbf elevation is protective from oxidative stress remains to be determined as we continue to follow this child. university of puerto rico -medical science campus, san juan, puerto rico, united states background: gm gangliosidosis is a lysosomal disorder caused by -galactosidase deficiency due to mutations in the glb gene. it is a rare autosomal recessive neurodegenerative disorder with an incidence of about : , - : , live births worldwide. this neurological disorder has three clinical forms. gm type , or infantile form is characterized by psychomotor regression by the age of months, visceromegaly (hepatosplenomegaly), macular cherry red spot, facial and skeletal abnormalities, seizures, and profound intellectual disability. we present a -year-old female with gm type and acute lymphocytic leukemia (all). design/method: she was diagnosed with gm type at the st months of age and family history was remarkable for an older sister with gm type . diagnostic studies reveal homozygous exon of the glb gene for a sequence variant defined as c. c>t, predicted to an amino acid substitution p.aarg cs. results: patient presented to our hospital with petechiae in lower extremities, pallor and intermittent tracheal bleeding. physical examination shows a hemodynamically stable girl that is chronically ill dependent of mechanical ventilation, severe mental retardation and scatter petechiae at upper and lower extremities. laboratory workup revealed severe normocytic anemia (hgb: . g/dl) with immature peripheral cells and thrombocytopenia ( × /l). serum chemistry revealed increase ldh ( u/l), increase hepatic enzymes (ast: u/l), normal uric acid level. there was no evidence coagulopathy. chest x ray was unremarkable except for evidence of chronic pulmonary illness. abdominal sonogram hepatosplenomegaly. during hospitalization, bone marrow aspirate and biopsy was performed which was diagnostic of b cell acute lymphoblastic leukemia (all) with . % lymphoblast and orderly myeloid/erythroid maturation. flow cytometry: % b lymphoblast with aberrant phenotype c/w b-acute lymphoblastic leukemia. karyotype revealed hyperdiploid female of favorable prognosis. cytogenetic by fish: hyperdiploid all with extra copies of runx and igh (no bcr-abl translocation). family was oriented about the new diagnosis and the dismal prognosis in conjunction to her primary condition. parents agree on no chemotherapy treatment for all with only supportive treatment. to this date, there is no evidence in literature that has previously described association of gm and leukemia. life expectancy of patient's primary condition is null therefore, correlation with leukemia might not be a coincidental finding. this patient opens the possibility of malignancy as part of gm type thus, malignancy diagnosis should be considered as part of their medical lifetime course. university of south florida, tampa, florida, united states background: hematological manifestations related to hiv infection are not uncommon, with thrombocytopenia having an estimated prevalence of - %. the pathophysiology is likely multifactorial. studies suggest that the primary mechanism may be immunologic resulting in accelerated platelet destruction. additional theories suggest that infection of megakaryocytes may also play a role causing inadequate platelet production. treatment of hiv-related thrombocytopenia is challenging. first-line treatments include initiation and optimization of antiretroviral therapies, immunoglobulin (ivig), and glucocorticoids. however, this approach is not effective in all patients and second line treatment options are less well studied, particularly in the pediatric population. objectives: we aim to present and discuss the case of a year old patient with perinatally acquired hiv- infection and persistent thrombocytopenia who, after failing first line therapies, showed normalization of platelet count on the novel thrombopoietin receptor agonist, eltrombopag. design/method: a retrospective chart review of the case patient's medical record was conducted. additionally, a thorough literature review was performed on this topic including the pathophysiology of hiv related thrombocytopenia and its treatment modalities. the patient required monthly ivig infusions for about year, but did not show a sustained response, often with platelet count dropping to less than , in between infusions. after initiation of mg eltrombopag daily the patient showed a sustained increase in platelet count (range , - , ). during a brief week lapse in eltrombopag treatment his platelet count dropped to , . upon re-initiation of therapy his count increased to , . the patient has remained asymptomatic, off of ivig for over one year, with undetectable hiv viral load and greater than cd t cell counts. no side effects or grade laboratory abnormalities were reported. conclusion: treatment of hiv-related thrombocytopenia can be challenging. first line therapies, including ivig and glucocorticoids, are not effective in all patients. several other treatment modalities have been utilized, including anti-d immunoglobulin, dapsone, danazol, interferon alfa, vincristine, thrombopoetic growth factors including romiplostim and eltrombopag, or splenectomy, but these are less well studied. this represents the first reported case of a pediatric patient with hiv who showed a positive response to eltrombopag with a sustained improvement in platelet count and no adverse effects from treatment. eltrombopag may be a safe alternative to first line therapies in those patients with hiv and refractory thrombocytopenia, however additional studies are needed. university of illinois college of medicine at peoria, peoria, illinois, united states background: achromobacter xylosoxidans is a gram negative rod with peritrichous flagella which causes rare opportunistic infections most commonly encountered by immunocompromised patients. it is primarily associated with uncomplicated bacteremia, cather-associated infections, and pneumonia. most reports of bacteremia associated with a. xylosoxidans are nosocomial, associated with neoplasm, and occurring mainly in adults. most reported infections with a. xylosoxidans in children are associated with cystic fibrosis. there are very few reported cases of septic shock from a. xylosoxidans bacteremia and pneumonia in the pediatric oncology population. objectives: to describe a rare case of a. xylosoxidans septic shock in a pediatric patient with relapsed neuroblastoma results: a -year old boy with history of stage iv highrisk neuroblastoma underwent standard frontline therapy with chemotherapy, hematopoietic stem cell transplant, radiation therapy, and immunotherapy, followed by a dfmo trial for maintenance. his -month follow-up scans demonstrated relapse and he was subsequently treated with additional chemotherapy, surgical resection, and mibg therapy, crizotinib for an eml -alk fusion and finally ifosfamide, carboplatin and etoposide (ice). he developed neutropenic fevers and was started on cefepime, vancomycin and fluconazole. blood cultures were initially negative. on the th day of fever, his previously scheduled pet scan was performed during hospitalization and showed new pulmonary opacities. he did not have respiratory symptoms, but therapy was escalated to meropenem, vancomycin and amphotericin. emergent bronchoscopy was performed the same day, with all bacterial and fungal cultures remaining negative. overnight, he developed tachypnea and saturations in the upper s, requiring nasal cannula. ir-guided lung biopsy was performed the next day, a flexible bronchoscopy was done to remove blood clots in the airway, the patient was placed on a ventilator, femoral lines were placed, granulocytes ordered and pressors were started for deterioration to presumed septic shock. arterial and femoral lines were placed but patient continued to have hemodynamic instability on multiple pressors. the following day, blood and respiratory cultures returned positive for results: at days after the start of iti, the inhibitor was < . bu and continued undetectable months after initiation of iti therapy. in this patient, iti with high-dose plasma-derived factor viii and von willebrand factor (vwf) complex was well tolerated and effective. genetic analysis confirmed a large factor viii gene duplication of exons to . we believe our patient developed inhibitor so quickly ( exposure days) due to the possibility of this mutation causing a frameshift that introduces a premature termination codon. this might be functionally similar to a deletion in the factor viii gene which poses the highest risk for inhibitor development in patients with severe hemophilia a. this variant has only been identified previously in two unrelated patients diagnosed with severe hemophilia a. this duplication is not listed in dbsnp variant database, nor observed in the general population database. our case proves the effectiveness of this method for patients with severe hemophilia a and an inhibitor. it also shows that more research is needed to identify patients at risk for inhibitor development. background: mercaptopurine ( -mp) is a prodrug that is a core component of maintenance chemotherapy for patients with a diagnosis of acute lymphoblastic leukemia (all). suppression of the neutrophil count is used to demonstrate adequate dosing of -mp during this phase of therapy. bone marrow suppression is mediated by the active metabolite -thioguanine ( -tgn), whereas the metabolite -methylmercaptopurine nucleotides ( -mmpn) has been shown to cause hepatotoxicity. allopurinol has been used infrequently in all maintenance therapy in the setting of skewed metabolism when adequate myelosuppression is difficult to achieve due to excessive hepatic toxicity. when given in combination with allopurinol a reduced dose of -mp may result in both increased -tgn levels and decreased -mmpn levels. objectives: describe the characteristics and clinical course of patients treated with allopurinol and reduced dose -mp during maintenance chemotherapy for all. we performed a retrospective chart review of patients at aflac cancer and blood disorders center of children's healthcare of atlanta with new diagnoses of b or t-cell all who received allopurinol during maintenance chemotherapy. we identified eleven patients with b-cell or tcell all who received allopurinol adjunctive therapy during maintenance chemotherapy at a single institution between - . these patients received adjunctive allopurinol for - weeks (median weeks) with reduced -mp ( - % of full dose). all ten patients with genetic testing for thiopurine s-methyltransferase (tpmt) had wildtype genotype associated with normal enzyme levels. indications for allopurinol use were most commonly unfavorable -mp metabolite levels, transaminitis (n = ), pancreatitis (n = ) and hyperbilirubinemia (n = ). favorable metabolite shift was achieved in all patients. liver enzymes improved in of patients with transaminitis after initiation of allopurinol/reduced -mp. three patients who experienced pancreatitis during maintenance did not have recurrence after initiation of allopurinol ( of these patients previously reported). six patients developed pancytopenia while on allopurinol, and two of those patients developed pancytopenia severe enough to require allopurinol cessation. four patients developed isolated anemia (hgb < . g/dl) without thrombocytopenia or severe neutropenia. no patient has experienced a recurrence of leukemia. overall, treatment with allopurinol and reduced dose -mp was successful in producing a favorable -mp metabolite distribution and reducing toxicity. therapy was generally tolerated; however a major and notable side effect was pancytopenia, in two cases severe enough to stop allopurinol treatment. anemia may be more prominent with allopurinol usage. allopurinol effect is variable among individual patients despite normal tpmt genotypes. baylor college of medicine, houston, texas, united states background: congenital sideroblastic anemia, b-cell immunodeficiency, periodic fevers and developmental delay syndrome (sifd) is a rare inherited sideroblastic anemia syndrome, first described in with clinically similar cases. genetic variations of trnt were identified as causative. objectives: to present an unusual presentation of a patient with sifd complicated by diagnosis of concomitant alpha thalassemia trait. design/method: retrospective chart review. a five month old male infant was referred to our hematology center for evaluation of elevated hemoglobin barts identified on newborn screen. despite numerous attempts, blood work was unable to be collected. at seven months of age he had microcytic anemia (hemoglobin . g/dl, mean corpuscular volume fl) more severe than what would be expected with alpha thalassemia trait. no variant hemoglobin was identified with isoelectric focusing or high performance liquid chromatography. by nine months of age he developed growth failure, intermittent emesis with fevers, developmental delays (predominantly gross motor), hearing loss, a disproportionally large head and coarse, thinning hair. over the next ten months, he was seen by numerous specialists for seemingly unconnected problems including sensorineural hearing loss, elevated liver enzymes and growth hormone deficiency. alpha globin analysis revealed deletion of two alpha globin genes. at months of age, he was admitted with one week of fevers, jaundice, and emesis. peripheral blood smear showed microcytic hypochromic anemia with marked anisopoikilocytosis including target cells, elliptocytes, tear drops, spherocytes, poikilocytes, marked polychromasia, and coarse basophilic stippling. given the inconsistency of his laboratory findings with the diagnosis of alpha thalassemia trait and clinical syndromic findings, bone marrow biopsy was performed which revealed rare ringed sideroblasts. one month later whole exome sequencing revealed trnt splicing variant c. - c>g and novel missense variant c. a>t consistent with sifd. hemoglobin barts on newborn screen with moderate to severe microcytic anemia directed initial diagnostic work-up towards variant alpha thalassemia. as additional medical conditions developed the focus shifted to a unifying syndrome. compared to previously described cases, our patient was diagnosed at an older age, presented with anemia rather than episodes of febrile illnesses, and had rare sideroblasts on bone marrow examination. diagnosis in this case led to identification of the novel c. a>t variant in his sister who had similar, but milder, features. sifd is a rare disease with variable phenotypic severity making diagnosis challenging without high index of suspicion which is crucial for appropriate management. wiseman, blood, . chakraborty, blood, background: cholelithiasis is uncommon in childhood. cholelithiasis is known to occur more frequently in children with predispositions, including female sex, obesity, parenteral nutrition, previous abdominal surgery, use of oral contraceptives, family history of gallstones, chronic hemolytic anemias, hepatobiliary disease, or exposure to specific drugs. although there have been occasional case reports linking cholelithiasis to childhood leukemia or leukemia therapy, the prevalence and risk factors of cholelithiasis in patients with childhood leukemia remain unclear. objectives: to estimate the prevalence of cholelithiasis in patients diagnosed with childhood acute lymphoblastic leukemia (all), and to evaluate possible risk factors for the development of cholelithiasis in patients with childhood all. we performed a computer-assisted review of the electronic medical records of patients diagnosed for b or t-cell all at children's healthcare of atlanta in the period from to . patients with diagnoses of cholelithiasis, cholecystitis or who had a cholecystectomy were identified. possible risk factors of age, sex, bmi, history of abdominal surgery and parenteral nutrition use were abstracted. patients with underlying chronic hemolytic anemia or pre-existing gallbladder disease were excluded. results: seventeen cases of cholelithiasis and cases of cholecystitis without documented cholelithiasis were identified. among patients with cholelithiasis, were female. median age at diagnosis of cholelithiasis was . (range . - . ) years. seven patients had no symptoms referable to cholelithiasis at the time of diagnosis. the median age of leukemia diagnosis among these patients was . (range . - . ) years. the median interval from diagnosis of leukemia to gallbladder disease was . years. four patients had bmi over the th percentile for age. two patients had a prior history of intraabdominal surgery. no patient received oral contraceptive pills. six patients received parenteral nutrition for more than days. there was no documented family history of cholelithiasis. seven patients did not receive any cholelithiasis directed therapy. two patients were managed with medical management only, with endoscopic retrograde cholangiopancreatogram with stone extraction, and with cholecystectomy. our study estimates the prevalence of cholelithiasis in childhood lymphoblastic leukemia to be . %, higher than the reported prevalence in the general pediatric population of . - . %. although our cohort size is small, it appears that all therapy and supportive care modalities associated with all are likely to play a larger role in the development of cholelithiasis than known predisposing factors in the general population. further studies are warranted. background: an uncommon side effect of intravenous immunoglobulin (ivig) administration is clinically apparent, sometimes severe hemolysis. we describe a severe case of coombs-positive hemolytic anemia secondary to ivig administration. ivig is a blood derivative manufactured from pools of , to , individual plasma donations. ivig is not abo-type restricted, so anti-a, anti-b and anti-a,b isoagglutinins are detectable. objectives: to describe a rare but serious type of transfusion reaction leading to gross hemolysis after ivig administration. results: a -year-old male with a past medical history of obstructive sleep apnea and obesity was admitted to the pediatric intensive care unit for adenoviral pneumonia and subsequent respiratory failure requiring mechanical ventilation. he had a complex hospital course with many complications including acute respiratory distress syndrome (ards), septic-shock, and coombs-positive hemolytic anemia. the patient was treated with commercial ivig (baxter/baxalta) -mg/kg daily for five days. he had two isolated episodes of severe hemolysis in relation to ivig administration requiring multiple transfusions of packed red blood cells (prbc). examination of pre-transfusion peripheral blood smear showed spherocytosis with rouleaux formation and large clumped rbc aggregates. the patient's blood type was classified as blood group a, rh-negative and his initial prbc transfusions were of this type. subsequently, the patient's coombs test was found to be positive using polyspecific and anti-igg typing sera. the patient's antibody screen against reagent group o screening cells was negative ruling out autoimmune hemolytic anemia. however, type specific anti-a antibodies were detected in his plasma as well as the acid eludate prepared from the coombs-positive red blood cells. it was concluded that the patient's hemolysis was due to anti-a antibodies presumed to arise from ivig. the patient's rbc transfusions were changed to o-negative blood and the hemolytic process resolved. the patient ultimately died due to complications of ards. although hemolysis is a known side effect of ivig, it is rarely considered when deciding to administer ivig. in addition, it has rarely been described in the pediatric population. ivig is used in the treatment of a growing number of medical conditions. due to the critical nature of many of these patients, hemolysis secondary to ivig may not be considered and continued blood transfusions with the patient's specific blood type may be used. it is crucial to remember that severe hemolysis can occur from ivig, and the importance of transfusing with blood group o, rh-negative blood when applicable. university of maryland medical center, children's hospital, baltimore, maryland, united states background: coagulopathy is a well-described complication of acute promyelocytic leukemia (apml), and remains a leading cause in induction failure. with treatment, coagulopathy associated with apml has been shown to rapidly improve. multiple organ dysfunction syndrome (mods) in apml, including acute respiratory distress syndrome (ards), has been associated with infection, traumatic injury, malignant infiltration, and cytokine release syndrome. when mechanical ventilation is no longer sufficient, extracorporeal membrane oxygenation (ecmo) can be considered; however, coagulopathy, severe end-organ damage, and malignancy are all relative contraindications to initiation of treatment. we report the case of a -year-old female presenting in respiratory failure, disseminated intravascular coagulopathy (dic), with intracranial hemorrhage, and mods, diagnosed with apml, successfully treated with ecmo therapy. design/method: retrospective case analysis and literature review. our patient, a -year-old female was admitted in respiratory failure and altered mental status, following a fall shortly prior to presentation. initial laboratory values were notable for pancytopenia, dic, and acute renal failure. a non-contrast head ct showed left temporal lobe intraparenchymal hemorrhage. she was diagnosed with apml by peripheral smear, later confirmed by fish for t( : ), and was started immediately on high-risk induction chemotherapy as per cog protocol aaml , including all-trans retinoic acid, arsenic trioxide, idarubicin, and dexamethasone. cvvhd was required for acute renal failure. despite maximal respiratory support, she remained hypoxemic, with oxygenation index of , pao /fio ratio of . ecmo was initiated hours after start of induction, hours after admission. coagulopathy resolved on day of induction, ecmo was discontinued after days, mechanical ventilation and cvvhd were stopped after days and she continued to improve, eventually achieving remission with few neurologic side effects. despite relative contraindications to ecmo, this patient was successfully treated with ecmo without significant neurologic side effects. the correction of her coagulopathy was multifactorial: ) restoration of adequate oxygen delivery via ecmo improving endothelial function; ) successful organ support to allow sufficient response to induction chemotherapy with atra leading to the terminal differentiation of leukemic blasts; ) complement and contact system activation through contact with ecmo circuitry. this case illustrates that ecmo can still be considered in patients despite coagulopathy and end organ damage. sinai hospital of baltimore, baltimore, maryland, united states background: primary polycythemia vera is an extremely rare diagnosis in the pediatric patient and is defined by a marked elevation of red blood cells due to erythropoietin-independent mechanisms. presentations of this disorder range from the asymptomatic person to severe thrombotic events, such as budd-chiari syndrome or cerebrovascular stroke. mutations in the jak gene are found in adult and pediatric patients with polycythemia vera; however, the jak v f mutation is less commonly identified in pediatric patients. we describe an otherwise healthy -year-old female who presented with a significantly elevated total erythrocyte count, hemoglobin, and platelets, incidentally discovered upon routine annual blood work obtained by her pediatrician. design/method: this is a report and discussion of a rare case. demonstrated cellular marrow with trilineage hematopoiesis and no dysplasia. cytogenetics were not assessed. his hemoglobin and platelet count recovered but leukopenia and neutropenia persisted. follow-up evaluation at three months revealed fevers, ongoing cytopenias, a one-month of a nodular skin rash on the trunk and extremities resembling erythema nodosum, and hepatitis (peak alt and ast of , and , , respectively). following clinical evaluation, a skin biopsy was performed and was remarkable for atypical lymphocytes within the subcutis with t-cell markers, a high ki- , and positive tia- , perforin, and -f immunoperoxidase stains. negative stains for cd , cd , and ebv were noted. these results are consistent with sptcl. additional evaluation did not support a diagnosis of hlh. a staging evaluation was performed. pet-ct showed widespread hypermetabolic subcutaneous activity in the legs, trunk and skull and diffuse marrow hyperplasia. bone marrow demonstrated involvement with precursor b-cell acute lymphoblastic leukemia, with a mll gene rearranagement. his skin biopsy was retrospectively stained with tdt, cd , pax- , cd a, and cd with negative results, and a blood smear taken at the time of the skin biopsy did not demonstrate leukemic cells. conclusion: this is the first report of a patient with sptcl having a synchronous malignancy. the patient is doing well, currently in the maintenance phase of treatment for his all, and his skin disease has resolved on pet-ct. while it is possible that his presentation was a function of chance, the possibility of an underlying immune dysfunction or cancer predisposition warrants further investigation. cincinnati children's hospital medical center, cincinnati, ohio, united states background: hereditary xerocytosis (hx) is a rare red blood cell (rbc) dehydration disorder, characterized by variable hemolysis and propensity to iron overload. hx is often misdiagnosed as hereditary spherocytosis (hs). while splenectomy is curative for hs, it is relatively contraindicated in hx due to a substantial thromboembolism risk, signifying the importance of delineating these diseases. blood smear abnormalities are variable and often insufficient to make an accurate diagnosis. osmotic-gradient ektacytometry and genetic confirmation are critical in distinguishing these overlapping disorders. objectives: describe a family with hx, initially misdiagnosed as hs. discuss the importance of distinguishing these disorders and the utility of ektacytometry in making this distinction. design/method: a -year-old caucasian male was diagnosed with hs after presenting with prolonged neonatal jaundice starting on the first day of life. he described mild scleral icterus and history of intermittent jaundice and dark urine, without need for transfusions. his father, paternal uncle and paternal grandmother were all diagnosed with hs during childhood and underwent cholecystectomy. additionally, his father underwent splenectomy for abdominal pain. the child's blood counts revealed compensated anemia (hb . gm/dl) and reticulocytosis (arc × /mcl) with increased mcv ( . fl) and mchc ( . gm/dl). blood smear showed increased polychromasia and poikilocytosis with rare spherocytes and few stomatocytes. while the child had normal ferritin, his father had iron overload (ferritin ng/ml) despite no prior transfusions. osmotic-gradient ektacytometry profile of the child and father's rbcs showed a characteristic left-shifted, bell-shaped curve with decreased omin and ohyp, diagnostic of hx. the family is currently undergoing genetic studies. despite clinical similarities between hs and hx, distinguishing these diseases has significant management implications. hx is a disorder of rbc permeability, causing shortened rbc survival. stomatocytes on blood smear can raise suspicion for hx, but are insufficient to make an accurate diagnosis. identifying characteristic biomechanical membrane properties using osmotic-gradient ektacytometry is the gold standard for clinical diagnosis, which can then be confirmed by molecular studies. hs and hx can be easily and reliably distinguished using ektacytometry, as both disorders have very distinctive curves representing different rbc deformability patterns. after hx diagnosis was made, we counseled the family against splenectomy, as the risk of thromboembolism is significantly increased in hx compared to hs, and the father was diagnosed with iron overload. conclusion: hx is commonly misdiagnosed as hs. this case highlights the importance of making this distinction, and the utility of osmotic-gradient ektacytometry in reliably distinguishing these conditions. penn state health children's hospital, hershey, pennsylvania, united states background: relapsed acute myeloid leukemia (aml) presenting as an isolated central nervous system myeloid sarcoma (cns ms) is very rare and its treatment is not well-defined. thiotepa, vinorelbine, topotecan and clofarabine (tvtc) has been successful for re-induction therapy to induce remission prior to hematopoietic stem cell transplant (hsct). objectives: to describe our experience in utilizing tvtc therapy in two children with no extramedullary disease at initial diagnosis who presented with relapsed aml as intracranial myeloid sarcomas. results: case : month-old female was diagnosed with flt negative aml and completed treatment per the children's oncology group (cog) aaml study on the low risk arm without bortezomib. cerebral spinal fluid (csf) negative at diagnosis. fish testing positive for tcf gene deletion of unknown significance. mrd was undetectable after induction i and remained undetectable after each cycle. nine months off therapy, recurrent headaches prompted mri imaging which revealed two posterior fossa masses. csf and bone marrow testing were negative. stereotactic biopsy of the larger mass confirmed recurrence of aml. patient underwent two cycles of tvtc with a total of seven doses of intrathecal cytarabine with almost near resolution of the cns ms. completed cranial radiation and proceeded to allogeneic stem cell transplant with unrelated cord marrow donor and is disease free at approximately day + .case : year-old female diagnosed with flt and mll negative aml and completed treatment per cog aaml study on the low risk arm without bortezomib. csf negative at diagnosis. mrd was undetectable after induction i and completed therapy without complications. two months off therapy, a retrospective analysis of her diagnostic bone marrow by the cytogenetic laboratory to test a new panel identifying novel q partners revealed a cryptic insertional : (mllt /mll(kmt a) translocation. at four months off therapy, acute mental status changes prompted mri imaging which revealed two intracranial ms and lumbar spine involvement. resection of the larger lesion for symptomatic relief confirmed the mllt /mll(kmt a) fusion. csf positive for blasts and marrow negative for relapsed disease. patient completed two cycles of tvtc with a total of seven doses of it cytarabine with near resolution of cns disease (only mm contrast enhancement in the medulla). she received craniospinal radiation and is awaiting improvement in her cardiac function before proceeding to hsct. conclusion: tvtc is a successful reinduction regimen for relapsed aml with cns ms prior to hsct. background: acute severe anemia can be a life-threatening medical condition. the differential is quite broad for possible etiologies of acute severe anemia, including autoimmune hemolytic anemia (aiha) and atypical hemolytic uremic syndrome (ahus). autoimmune hemolytic anemia is an antibody-mediated process that targets the protein antigens located on the surface of red blood cells. treatment options for aiha include corticosteroids, with up to % of patients being responsive, with some requiring splenectomy. atypical hemolytic uremic syndrome is a medical urgency, defined as the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. the etiology is usually due to genetic causes, or less commonly, due to autoantibodies or idiopathic reasons. prognosis is very poor. objectives: differentiating between autoimmune hemolytic anemia and atypical hemolytic uremic syndrome can be a time-sensitive diagnostic dilemma while the patient is in critical condition, but this important delineation can vastly alter therapeutic options. design/method: here we discuss two cases highlighting the diagnostic workup involved in differentiating between atypical hemolytic uremic syndrome and autoimmune hemolytic anemia. patient a is a -year-old male who presented in extremis with severe anemia, uremic encephalopathy, and severe acute renal injury requiring hemodialysis and multiple blood transfusions. patient b is a -month-old male, who also presented in extremis with respiratory failure secondary to adenovirus/rhinovirus/enterovirus, with acute progressive renal failure and microangiopathic hemolytic anemia, requiring hemodialysis and cardiorespiratory support. : patient a underwent a full hematologic and infectious disease workup. subsequent laboratory studies confirmed enteropathogenic e.coli (epec) in the patient's stool; blood cultures remained negative. renal biopsy results were consistent pigment nephropathy. bloodwork indicated positive direct coombs. patient a was ultimately treated with steroids mg/kg/day, with significant improvement. patient b also included a full hematologic work-up, including adamts activity and ahus genetic panel, as well as full infectious disease work-up. subsequent laboratory test-ing revealed blood cultures growing streptococcus pneumoniae, with adamts activity at % (adult ref range: >/ = %), and normal complement levels. imaging findings also supported diagnosis of ahus. the management of a critically ill patient with acute severe anemia requires a thorough hematologic and infectious disease work-up. while molecular and genetic are helpful in definitive diagnosis of ahus, the utility of such results is limited by time. overlapping clinical presentation of a patient in extremis due to acute severe hemolytic anemia with progressive renal failure presents a rather broad differential, with time-sensitive treatment and prognostic implications. the favorable response to steroids delineates aiha from hus. background: d- -hydroxyglutaric aciduria (d- -hga) is a rare metabolic disorder characterized by developmental delay, hypotonia, and bi-allelic mutations in d- hydroxyglutarate dehydrogenase (d hgdh) or isocitrate dehydrogenase (idh ). metaphyseal chondromatosis with d- -hydroxyglutaric aciduria (mc-hga) is a type of d- -hga that has been previously reported in seven patients (omim ; pmid ), three of whom had somatic mosaicism for r variants in isocitrate dehydrogenase (idh ). we describe a -year-old boy with mc-hga who subsequently developed acute myeloid leukemia (aml) and was found to have a r variant in idh in a leukemic bone marrow sample. we report the first case of aml with this metabolic disorder. design/method: a -year-old hispanic boy presented with short stature, developmental delay, abnormal skin pigmentation, and unilateral congenital cataract. workup revealed multiple skeletal enchondromatosis and elevated urine d- -hydroxyglutaric acid levels. he was diagnosed with mc-hga. no pathogenic variants in d hgdh, idh and idh were identified in peripheral blood. germline testing with biopsies of skin lesions was declined by the family. two years later, he presented with streptococcal sepsis and pancytopenia. blasts were noted on peripheral smear. bone marrow morphology was consistent with acute myelomonocytic leukemia (∼ % blasts). chromosome analysis showed normal xy, and molecular testing by pyrosequencing idh and idh revealed a r c variant in idh ( % mosaicism). the patient is being treated as per the cog study aaml . end of induction i bone marrow aspirate was hemodiluted, but there was no obvious residual disease by flow cytometry ( . - . % sensitivity) or morphology. the previously identified idh variant was no longer detectable (limit of detection < %). although targeted therapy for aml with idh mutation is currently in phase i clinical trials in adults, there is no safety or efficacy data for using idh inhibitors in children. treatment with ivosidenib is therefore not currently an option for our patient. conclusion: this is the first case of aml reported with this rare metabolic disorder. somatic r variants in idh have been identified in three other mc-hga cases. this same mutation leads to the accumulation of d- -hydroxyglutarate in gliomas and aml. without any confirmed germline mutation or somatic mosaicism testing of multiple specimen sources, we can only speculate that the patient has an underlying somatic idh mutation associated with mc-hga which subsequently led to leukemogenesis. we present the first case of this association, to increase index of suspicion for development of aml in children with metabolic disorders associated with variants in idh . background: congenital combined deficiency of the vitamin k-dependent coagulating factors (vkcfd) is a rare heterogeneous autosomal recessive bleeding disorder. vkcfd is caused by mutations in the genes of either gamma-glutamyl carboxylase (ggcx) or vitamin k epoxide reductase complex (vkorc), which are responsible for the gammacarboxylation of vitamin k dependent proteins (vkdps) allowing for their activation. the clinical presentation ranges from no bleeding to intracranial hemorrhage. to date, vkcfd has been reported in few patients worldwide. objectives: we report a case of a girl with novel homozygous mutation of the ggcx gene, highlighting her clinical and biochemical characteristics with a review of the literature. a -month-old girl of consanguineous emirati parents, presented to our hospital with a history of bleeding from puncture site after receiving her second-month vaccine. that was associated with episodes of mild mucosal bleeding. review of systems was negative for jaundice, steatorrhea and failure to thrive and physical exam was unremarkable. investigations revealed markedly prolonged pt and aptt with high inr. fibrinogen, hemoglobin and platelets were always normal. activities of vitamin k-dependent factors including fii, fvii, fix, fx, protein c and s were all low. a measurement of proteins induced by vitamin k absence (pivka-ii) was done and came very high. this was associated with a mild elevation in liver enzymes but normal liver function test. the picture was supporting vitamin k deficiency, and as a result, she was started on oral vitamin k supplements of mg/day. she responded partially to vitamin k and required higher doses to stabilize her inr. after excluding acquired causes and due to her requirement of high doses of vitamin k, a mutation in either ggcx or vkorc genes was suspected. genetic analysis was conducted for her which revealed a novel missense homozygous mutation in the ggcx gene (c. a>t) confirming the diagnosis of combined deficiency of vitamin k-dependent clotting factors type . the asymptomatic parents were both heterozygous for the same mutation. results: she is currently stable on mg/day of vitamin k supplements. conclusion: vkcfd is a rare bleeding disorder with an overall good prognosis due to the availability of several effective therapeutic options. the function of the mutated gene is unknown. our patient demonstrated a partial response to vitamin k supplements suggesting presence of a residual carboxylation capacity and a possible role of this gene in the enzymesubstrate interactions. university of alabama at birmingham, birmingham, alabama, united states s of s background: gata is a zinc finger transcription factor that plays a critical role in the regulation of hematopoiesis and lymphatic angiogenesis. mutations leading to gata deficiency (gd) have been linked to a variety of clinical conditions. patients with gd have a striking predisposition to develop myelodysplastic syndrome (mds), acute myeloid leukemia (aml), or chronic myelomonocytic leukemia (cmml). acute lymphoblastic leukemia (all) has not been associated with gd, although the association of bcell all and gd has been previously reported. objectives: to describe a unique association of gata deficiency and t-cell all in a young child. results: an -year-old female presented with a one-week history of fever and malaise. she had a significant past medical history of verruca plantaris and self-resolving leukopenia associated with febrile illnesses. significant family history included sister with neutropenia and human papilloma virus (hpv) infection, and mother with neutropenia, monocytopenia, atypical mycobacterial infections, and hpv infection. peripheral blood revealed hemoglobin . g/dl, hematocrit . %, platelets , /ul, and white blood cell , /ul (neutrophils /ul, lymphocytes /ul, monocytes /ul). patient underwent a bone marrow biopsy demonstrating lymphoblast infiltration. flow cytometry analysis demonstrated monoclonal lymphoid blast population that co-expressed cd , cd , cd , nuclear tdt, cd , however, lacked expression of cd , cd , cd , cd , hla-dr, or myeloperoxidase. findings were consistent with tcell all with aberrant myeloid markers. cytogenetics analysis revealed ,xx,dic( ; )(p . ;p . ). patient began treatment as per children's oncology group aall and achieved remission at the end of induction. course of therapy was complicated by episodes of fever, reciprocating junctional tachycardia, asparaginase-associated thrombosis, viral meningitis, recurrent episodes of verruca plantaris, and resistant streptococcus pneumoniae or haemophilus parainfluenza infections causing chronic cough. later, she was also found to have low igm levels; after completion of therapy, she developed monocytopenia. lymphocyte subset panel revealed absent b cells, decreased number of natural killer (nk) cells, and cd /cd inversion. further work-up included gata sequence analysis that showed heterozygous nonsense mutation (c. c > t/c; reference nm_ ) likely resulting in gata haploinsufficiency. patient continues to be in remission, is receiving monthly immunoglobulin replacement and is on azithromycin for atypical mycobacterial prophylaxis. surveillance bone marrow biopsies have shown no evidence of mds or leukemia, however, have demonstrated persistent hypocellularity. the possibility of undergoing an allogeneic bone marrow transplant is actively being discussed given its curative potential. clinicians should be aware that t-cell all may be associated with gata deficiency. cincinnati children's hospital medical center, cincinnati, ohio, united states background: treatment for severe hemophilia a is centered on factor viii (fviii) replacement therapy. development of an alloantibody (inhibitor) against fviii is a significant treatment complication occurring in as many as - % of patients. high titer inhibitors render treatment with factor viii ineffective, necessitating the use of bypass agents that may not achieve hemostasis with the same efficacy. considering the substantial ramifications of inhibitor development on treatment, eradication of inhibitors is of great importance to achieve adequate hemostasis in this patient population. desensitization by immune tolerance induction (iti) is the primary method of inhibitor elimination. however, not all patients respond to iti. immunomodulation may be considered as the next line of therapy, although controversy remains in regards to agent selection and use. objectives: there is incomplete data on the use of immunomodulation therapy for inhibitor eradication in severe hemophilia a. we present a case of a pediatric patient with severe hemophilia a and high titer inhibitor who failed initial iti therapy to better illustrate potential treatment options for the future. design/method: a retrospective chart review was performed on a patient with severe hemophilia a at cincinnati children's hospital medical center. results: an -year-old caucasian male with severe hemophilia a secondary to intron inversion, was initially diagnosed following extensive bleeding after circumcision at birth. he was identified as having an inhibitor ( bethesda units (bu)) at months of age after exposure days of treatment. he failed multiple attempts of iti, with recombinant and plasma-derived (pd) fviii. he was advanced to immunomodulation therapy in combination with pdfviii, however demonstrated anaphylaxis to rituximab and ofatumumab. he underwent tolerization to rituximab, and received a six month course with a partial response (nadir of . bu). months following last dose of rituximab, a rising inhibitor titer ( . bu) was found. mycophenolate mofetil (mmf) was initiated with subsequent inhibitor stabilization and a decreasing titer ( . bu) over the course of the following year. mmf has been well tolerated without major side effects or infection throughout therapy. conclusion: development of an inhibitor against fviii is a considerable complication in patients with severe hemophilia a. use of immunomodulatory therapies following iti failure remains controversial. mmf has not been well studied in this patient population. we report a case of a patient who is being successfully treated with mmf with minimal side effects. further prospective studies should be considered to further define the role of mmf immunomodulation therapy. background: down syndrome (ds) children with aml (ds aml) have higher cure rates than their non-ds counterparts. outcomes for refractory/relapsed cases, however, remain dismal. somatic mutations of the gene encoding the transcription factor gata in ds aml patients are responsible for the observed hypersensitivity of ds aml blasts to cytosine arabinoside (ara-c). in view of excellent survival rates (approaching %) of ds aml patients, the ongoing children's oncology group (cog) aaml study seeks to determine the feasibility of treating standard risk (minimal residual disease/mrd negative) ds aml patients using a reduced dose ( -fold decrease) ara-c backbone. although results from japanese trials with this approach are promising, north american and european data are conflicting. although chromosome rearrangements in ds aml do not appear to carry the same adverse prognostic significance as in non-ds aml, monosomy in ds aml patients has been associated with a moderately worse outcome. isochromosome q, however, is rare and has only been reported in previous cases of ds aml. objectives: to report our institutional experience of very early relapse involving cases of ds aml patients treated per the reduced dose ara-c arm ( . g/m ) of the aaml study. design/method: we hereby report the disease course and cytogenetics of the above ds aml patients. : patient is a month old caucasian female who had gata mutation negative aml. patient is a -year old caucasian male whose chromosomal analysis revealed isochromosome q ( copies of the long arm of chromosome ). both patients achieved negative mrd (< . %) after induction i chemotherapy with thioguanine, low-dose ara-c and daunorubicin and proceeded per the reduced dose ara-c arm of aaml . patient relapsed immediately after completion of chemotherapy. salvage chemotherapy with mitoxantrone/high dose ara-c (hidac) failed to induce a second remission and the patient subsequently died of disease. patient relapsed within months from end of therapy. the patient underwent salvage chemotherapy utilizing a hidac backbone and remains in disease remission. the noted very early relapse following a reduced dose ara-c regimen in our above ds aml children suggests that testing for gata mutation and chromosome rearrangements may play a useful role in the development of future risk-stratified treatment strategies for ds aml. university of rochester, rochester, new york, united states background: in developed countries in the st century, severe nutritional deficiency is not an often considered differential diagnosis of unexplained childhood anemia. aside from iron deficiency anemia, vitamin deficiency severe enough to impact hematopoiesis is uncommon in the general pediatric population. here we present the unique case of a -monthold infant who presented with intermittent emesis, failure to thrive (ftt), developmental delay, macrocytic anemia, and neutropenia which was initially concerning for a congenital bone marrow failure syndrome. instead, she was discovered to have an underlying, potentially familial deficiency of b . objectives: . to describe the unique case of an infant with b deficiency. . to outline the importance of including b deficiency in the differential diagnosis of unexplained megaloblastic anemia in children. a -month-old exclusively breastfed infant presented for gastroenterology evaluation due to persistent emesis and poor weight gain over the course of months. her history was notable for delayed developmental s of s milestones and hypoactivity. marked pallor prompted hematologic evaluation, which revealed concern for macrocytic anemia (hemoglobin . g/dl, mcv ), reticulocytopenia ( . × ^ / l), and neutropenia (anc . × ^ /l). an otherwise reassuring physical examination and laboratory evaluation was notable only for the discovery of an undetectable b level and marked hyperhomocysteinemia ( mol/l). her hemoglobin (hgb) continued to decline (to . g/dl) over the first few days after presentation, and she required red blood cell (rbc) transfusion. within only a few days of initiation, daily cyanocobalamin injections resulted in a robust reticulocytosis response, improved hgb, immediate normalization in the neutrophil count, and resolution of hyperhomocysteinemia. additional history and laboratory evaluation from the patient's mother revealed a concurrent, asymptomatic maternal b deficiency as well as a history of a need for b supplementation in the maternal grandfather, raising concern for an inherited etiology. despite the rarity of vitamin-deficient hematologic abnormalities in the general pediatric population, b deficiency should be considered as a potential cause of an otherwise unexplained megaloblastic anemia, especially in the setting of concurrent ftt and neurodevelopmental delay. a detailed family history should be obtained in such cases and may have helped to prevent this patient's clinical sequelae had the deficiency been discovered sooner. our patient has experienced a favorable clinical response to b supplementation, attesting to the importance of vitamin b in early childhood growth and development. background: peg-asparaginase is universally utilized in the treatment of pediatric acute lymphoblastic leukemia (all). despite its high efficacy in this disease, it is associated with hypersensitivity and allergy in - % of patients. protracted anaphylaxis has been described in circumstances such as severe food allergy with ongoing allergen exposure; however, it has not yet been described in relation to peg-asparaginase. we describe the first reported case of protracted anaphylaxis after peg-asparaginase administration, provide guidance as to time course and management of protracted anaphylaxis, as well as evidence that erwinia asparaginase may be safely administered even in this high risk population. objectives: to provide guidance regarding the duration, course and management of protracted, severe anaphylaxis after peg-asparaginase therapy. a year old male with very high risk all presented for consolidation therapy with peg-asparaginase (intramuscular) and vincristine. one hour after administration, he developed generalized hives and angioedema, for which he was given diphenhydramine. he then quickly developed progressive hives, angioedema, subjective throat and chest tightness, and wheezing. he was treated with diphenhydramine, epinephrine, albuterol, and methylprednisolone with resolution of symptoms. one hour later, symptoms recurred and the patient became hypotensive; he was retreated with methylprednisolone and epinephrine, and was transferred to the pediatric intensive care unit (picu). in the picu, he was placed on an epinephrine drip, and continued on methylprednisolone, diphenhydramine, cetirizine, albuterol, and ranitidine. the epinephrine drip was successfully discontinued after hours, and his other medications were gradually weaned over the course of two weeks. of note, the patient did have st segment changes in his electrocardiogram during the first hours of anaphylaxis. these were associated with normal ventricular function as per echocardiogram, and resolved within one week. this patient has subsequently tolerated multiple doses of erwinia asparaginase (intramuscular) without premedication. this patient was acutely managed in the pediatric intensive care unit with steroids, anti-histamines, and continuous infusion epinephrine. symptoms consistent with severe anaphylaxis including hives, angioedema, throat and chest tightness, wheezing, and hypotension persisted for a total of four days before finally resolving. he has thus far tolerated multiple doses of erwinia asparaginase without any symptoms of allergy, hypersensitivity, or anaphylaxis. protracted severe anaphylaxis after peg-asparaginase therapy can be successfully managed with multi-agent therapy, including antihistamines, steroids, and continuous infusion epinephrine. re-challenge with an alternate form of asparaginase may be tolerated, even in a patient with protracted anaphylaxis to peg-asparaginase. ucsf benioff children's hospital oakland, oakland, california, united states background: vincristine (vcr) is widely used in pediatric cancers. unlike most cytotoxic agents, hematopoietic toxicity is uncommon. vcr-induced anemia has been observed but its mechanism has not been well studied. vinca alkaloid-induced membrane changes were seen in early studies of hereditary spherocytosis (hs) and anecdotal cases suggest vcr may increase hemolysis in such patients. here we describe a case involving severe vcr-induced anemia in a patient with hs and an explanation as to the mechanism. objectives: to describe the mechanism of vcr-induced anemia in hs. design/method: case report. a year-old female with hs was diagnosed with t-lymphoblastic lymphoma. she had required packed red blood cell (prbc) transfusions as a neonate and thereafter had done well without episodes of acute hemolysis or aplasia. complete blood counts (cbc's) demonstrated a compensated hemolysis, and she did not require further transfusions until she commenced chemotherapy. by the start of maintenance she had received many more prbc transfusions than the average patient. intermittent drops in hemoglobin (hb) did not correlate with any particular agent, and she had stable, mild splenomegaly. a clear pattern emerged during maintenance. her hb was - g/dl at monthly clinic visits, when she received vcr, intermittent intrathecal methotrexate, and corticosteroids. within - days, her hb dropped to . ± . g/dl, and reticulocyte count decreased from . to . ± . %. transfusion at day corrected hb, and the reticulocytes and hb returned to baseline. white blood cell and platelet counts did not change after vcr. blood samples from pre, immediately post, and days post vcr were analyzed and rbc characteristics and markers of hemolysis were not significantly different. ektacytometry showed identical curves, indicating no change in rbc deformability. in vitro incubation of patient blood samples with vcr also did not affect the osmotic deformability, confirming that a change in rbc rigidity was unlikely the reason for the drop in hb. these data indicate that a dysregulation of erythropoiesis was responsible for the anemia after vcr, rather than damage of peripheral rbc's. in most patients, maintenance therapy for lymphoblastic lymphoma does not cause severe anemia, likely because a temporary reduction in erythropoiesis in patients with a normal rbc survival and low reticulocyte count is not noticed. however, in a patient with decreased rbc survival and a brisk reticulocytosis, a disruption in rbc generation is more apparent. in conclusion, vcr administration to patients with an rbc disorder warrants close observation for potentially severe vcr-induced anemia. background: the addition of tyrosine kinase inhibitors (tki) to conventional chemotherapy has improved outcomes for pediatric patients with philadelphia chromosome-positive (ph+) acute lymphoblastic leukemia (all), however there remains an increased risk of relapse compared to other types of childhood all. typically, in relapsed disease the philadelphia chromosome persists and several mechanisms of resistance involving acquired mutations of the bcr-abl chimeric oncoprotein have been reported. objectives: describe a unique case of a pediatric patient with ph+ b-precursor all relapsing with b-precursor all without the philadelphia chromosome. results: an -year-old boy was diagnosed with ph+ bprecursor all with the presence of the t( ; )/bcr-abl translocation by cytogenetics and fluorescence in situ hybridization (fish), respectively. additional abnormalities included gains of runx and loss of one copy of etv . a remission bone marrow with negative minimal residual disease (mrd) was achieved at the end of induction with dasatinib and the esphall chemotherapy backbone. duration of tki therapy was two years post diagnosis. nearly one year after the completion of therapy, cytopenias prompted a bone marrow investigation. relapsed b-precursor all was established by immunophenotyping, however fish analysis did not identify the bcr-abl rearrangement. moreover, quantitative reverse transcriptase pcr was negative for the bcr-abl fusion transcript. again fish analysis of the bone marrow revealed multiple additional copies of runx and mono-allelic loss of etv , similar to the initial diagnostic sample. the patient was re-induced per aall anticipating a ph+ all relapse. however, with confirmation of the loss of the ph+ clone, tki therapy was not re-initiated. due to positive mrd of . % at the end of re-induction therapy, the patient was salvaged with blinatumomab therapy and subsequently underwent an allogenic stem cell transplant with a sibling donor. conclusion: this is the first known report of a pediatric patient with ph+ b-precursor all who developed recurrent b-precursor all without the philadelphia chromosome. the persistent findings of gain of runx and loss of etv makes it unlikely that a second unrelated b-precursor all developed following successful treatment of the original disease. this case highlights the possibility of a genetically distinct subclone present at the onset of disease that shared abnormalities of runx and etv but did not contain the philadelphia chromosome. nevertheless, the subclone harbored leukemogenic potential in the absence bcr-abl expression. it is plausible that the predominant clone present at diagnosis was effectively treated with dasatinib and extinguished, but the bcr-abl -negative clone persisted in the face of tki therapy. background: ligneous conjunctivitis is a rare form of pseudomembranous conjunctivitis that develops specifically in patients with type plasminogen deficiency. lack of plasmin activity in those patients result in defective fibrinolysis and formation of fibrin-rich membranous material/ masses that develops on the palpebral conjunctiva as well as other sites in the body.current management involve surgical excision of the masses that is usually complicated by multiple recurrences. recently, use of topical plasminogen concentrates helped delaying recurrence, but currently, those concentrates are not commercially available. we report on a -year-old omani girl, with hypoplasminogenemia who required optimization of plasminogen level at the time of surgery to delay/ prevent recurrence. objectives: case report on the peri-operative use of ffp versus cryopricipitate transfusion as an alternative replacement of plasminogen during surgical excision of ligneous conjunctivitis. design/method: pharmacokinetic study was performed to assess plasminogen recovery after ffp ( ml/kg) and precipitate ( bag/ kg) transfusion results: plasminogen levels remained subnormal after either ffp or cryoprecipitate administration. with ffp, the maximum concentration reached was almost % of normal. although half-life of plasminogen is known to be - . days, the patient seemed to have a high catabolic rate after receiv-ing cryoprecipitate, with plasminogen levels reaching basal levels within hours. because of the better recovery profile with ffp, we opted to give ffp before and after surgery. peri-operative management included ffp transfusion at ml/kg/ hours one day before and for days post operatively, followed by ml/kg once daily from day - , then ml/kg on th post-operative day. topical treatment was initiated using antibiotic and steroids ed on the day of surgery, followed by heparin ed on the second day. on follow up, she used topical heparin, cyclosporine, prednisolone, and topical lubricant eye drops for variable duration. clinical picture remained stable for almost year post operatively, when she started to develop recurrence of ligneous lesions again. background: ponatinib (inclusig®, ariad pharmaceutical) is a rd generation multi-targeted tyrosine kinase inhibitor (tki) approved for treatment of adults with chronic myeloid leukemia (cml) and philadelphia chromosomepositive acute lymphoblastic leukemia (ph+ all) resistant to or intolerant of other tkis. ponatinib has numerous drug-drug interactions and a black box warning for associated serious adverse vascular events and hepatotoxicity. for this reason, ponatinib use has been confined to specific high-risk populations. however, in patients who prove refractory to other therapies, the potential benefits of ponatinib may outweigh risks. to date, ponatinib has not been studied in the pediatric/adolescent and young adult (aya) population. furthermore, literature describing the use of ponatinib alone or in combination with other agents in pediatric oncology patients is scarce. objectives: to describe a single institutional experience using ponatinib in the pediatric patients with ph+ all. design/method: two cases of ponatinib use in pediatric ph+ patients resistant to other tkis were identified at our institution and are described. peripheral blood samples obtained from both patients identified bcr-abl p fusion transcripts and sanger sequencing was used to identify resistant mutations. results: our first case is a -year-old female who received upfront multi-agent chemotherapy plus dasatinib for ph+ all. relapse was confirmed on end-of-therapy bone marrow evaluation, thus bcr-abl mutation testing was performed and revealed a t i mutation. ponatinib was initiated then discontinued after one week due to clinically significant fluid retention with peripheral edema and bilateral pleural/pericardial effusions. the second case is a lateadolescent female with ph+ all who relapsed -years after stem cell transplant (sct). following relapse, tki therapy included both imatinib and dasatinib. due to persistence of bcr-abl fusion transcript despite tki therapy she was switched to ponatinib. shortly following initiation of ponatinib she developed a diffuse, maculopapular rash, which persisted despite dose reduction, resulting in ultimate discontinuation of the drug. bcr-abl mutation testing identified f l and f v resistance-conferring mutations. to date, there is scant existing literature detailing the use of ponatinib in pediatric patients. appropriate dosing is undefined and side effect profile not well described, particularly when used concurrently with other chemotherapeutic agents. thus, this case series reporting the response to and toxicity of ponatinib in pediatric ph+ all patients has important clinical implications. additionally, this is the first report of a pediatric ph+ all patient with documented t i mutation underscoring the importance of bcr-abl mutational testing, particularly at the time of relapse. cooper university hospital, camden, new jersey, united states background: myh -related disorder is a rare autosomal dominant disease, encompassing several subtypes: may hegglin anomaly, epstein syndrome, fechtner's syndrome, and sebastian syndrome. heterozygous mutations are seen in the gene encoding non-muscle myosin heavy chain iia (nmmhc-iia) which is involved in cell motility as well as functions to maintain cellular shape and integrity. the presentation of myh -rd is mainly characterized by macrothrombocytopenia, but various related expressions exist: nephritis often leading to renal failure, cataracts and sensorineural deafness ( ). a -year-old girl with history of extensive dental caries, hyperactivity, and speech delay due to suspected hearing loss was incidentally found to have thrombocytopenia at the time of genetic evaluation. she did not have any bruising or excessive bleeding. she did not respond to observation, immunoglobulins, or steroid therapy. her platelet count remained persistently low ( - k/ul). she underwent extensive evaluation to rule out platelet disorder vs. coagulation defect. her peripheral smear showed enlarged platelets by giemsa stain but no inclusion bodies were noted in granulocytes. her platelet aggregation and platelet surface glycoprotein by flow cytometry were negative. her coagulation profile was also normal. objectives: this case report summarizes the complexity in diagnosing myh -rd in a pediatric patient. design/method: since a unifying diagnosis for her clinical presentation was not apparent, whole exome sequencing (wes) was undertaken. results: wes revealed the r c heterozygous pathogenic variant, located in exon in the myh gene. myh gene alteration explained the patient's clinical features of macrothrombocytopenia and hearing loss. this mutation was paternally inherited, and her father demonstrates mosaicism. he was asymptomatic with normal platelet count but his morphology showed enlarged platelets with no inclusion bodies in granulocytes. when dealing with patients who have mild or no symptoms of bleeding diathesis but evidence of persistent macrothrombocytopenia, considering a platelet disorder belonging to myh -rd can help delineate certain predisposing syndromes and guide clinical management. patients are likely to benefit from early genetic testing while receiving supportive therapy. wes can highlight syndromes and provide information on recurrence risk for families. the renal and hearing abnormalities are indistinguishable between epstein and fechtner's syndromes, but the pathogenic variants differ ( ). the genotype-phenotype correlation implies that our patient may have either syndrome, although clinical features compatible with nephritis have yet to manifest. patients should be monitored closely for long-term progression of myh disease, and treatments should be initiated accordingly. we present an -year old female evaluated by genetics at birth due to prenatal microcephaly. chromosomes and microarray were normal. at age she developed standard risk pre-b-cell acute lymphoblastic leukemia (all). she completed treatment in and has been doing well in the interim, remaining in complete clinical remission. during and after treatment she exhibited developmental delay and neurocognitive deficits. at age her height and weight were at or below the th centile and head circumference was below the nd centile (approximately standard deviations below the mean and corresponding to the th centile for a -month-old girl). bone age was appropriate. she had a distinctive triangular face with micrognathia and a pointed nose resembling a seckel-like syndrome. the patient also had clinodactyly of the th toes, zygodactylous triradius involving the nd and rd left toes, tendency to sydney line in the right palm and a radial loop in the left middle finger. the patient's unique clinical presentation prompted a more thorough genetic evaluation, which led to a novel finding we feel is clinically significant with regard to the development of malignancy. design/method: whole exome sequencing (wes) was performed on the patient as well as her biological parents (trio). a de novo heterozygous mutation in the gene pcdh with potential relation to the phenotype was discovered. this c. dupa variant causes a frameshift starting with codon asparagine , changing this amino acid to a lysine residue and creating a premature stop codon at position of the new reading frame denoted p.asn lysfsx . this variant is predicted to cause loss of normal protein function via protein truncation or nonsense-mediated mrna decay. conclusion: pcdh is a member of the protocadherins family which is important in cell-to-cell adhesion and synaptic function in the central nervous system and is highly expressed in areas of the brain involved in higher cortical function and speech. aberrant expression of protocadherins has been associated with the development of malignancies in many organ systems. with regards to leukemia, the methylation status of this gene at diagnosis has been implicated in the prognosis of all and could be used as a biomarker to predict relapse. this patient's de novo mutation and clinical presentation are unique to what has been previously presented in the literature. we feel that this mutation is a clinically significant finding that may shed light on the role of this gene in the development of hematopoeitic malignancies. background: acquired hemophilia a (aha) is an uncommon and potentially life-threatening hemorrhagic disease characterized by sudden onset of bleeding in patients with neither personal nor family history of bleeding dyscrasia. it is usually seen in adults with autoimmune diseases, solid tumors, lymphoproliferative diseases, pregnancy or during the postpartum period; occurrence in the pediatric population has rarely been reported. we report a case of an otherwise healthy teenager who was found to have aha when he presented with acute onset of atraumatic soft tissue hematoma. results: a -year old male of middle eastern descent with history of congenital absence of the right external ear, but otherwise in good general health, presented to our emergency department with a three day history of progressive worsening of right lower leg pain, swelling, and paresthesia, without preceding history of trauma. evaluation by the pediatric orthopedics service documented significantly elevated compartment pressures, necessitating immediate four-compartment fasciotomy. pre-operative labs were significant for prolonged activated partial thromboplastin time (aptt) of . ( . - . ) seconds with normal prothrombin time (pt) and international normalized ratio (inr). ptt did not correct on mixing studies, suggesting the presence of a circulating anticoagulant. factors xii and xi were in the normal range; factor ix was elevated, ( - ). factor viii level was % and fviii inhibitor level was . bethesda units (< . ), confirming the diagnosis of aha. work up for autoimmune disease was negative. his bleeding and surgical hemostasis were managed with recombinant factor vii (novoseven) mcg/kg every hours for hours post operatively, with gradual interval prolongation. factor viii antibody eradication was managed with prednisone mg/kg/day. factor viii and inhibitor levels normalized by day of hospitalization. recombinant factor vii was discontinued; steroids were gradually tapered and discontinued at discharge (hospital day ). conclusion: acquired hemophilia is likely an underdiagnosed condition in pediatrics. while it is typically seen in adults with underlying autoimmune disease, solid tumors, lymphoproliferative disease, or during pregnancy or the postpartum period, pediatric cases may have no identifiable etiology. this case highlights the importance of considering this diagnosis in any patient with unexplained bleeding regardless of their age, so as to intervene early and prevent adverse consequences. university of oklahoma, oklahoma city, oklahoma, united states background: myeloid neoplasms associated with eosinophilia is a rare subtype of chronic leukemia characterized by clonal eosinophilia. the true incidence is unknown due to its rarity and possible classification as idiopathic hypereosinophilia syndrome. the most common chromosomal aberrations involve platelet-derived growth factor receptors (pdgfrs). we report one such rare case in a pediatric patient. most of the pediatric management of this entity is derived from adult case reports and case series. objectives: to describe a case of chronic leukemia presenting as eosinophilia results: a previously healthy year old caucasian male presented with a several week history of migrating joint pain, splenomegaly, and abnormal blood counts with leukocytosis, thrombocytopenia and absolute eosinophilia. white blood cell differential showed myeloid precursors suggestive of chronic myeloid leukemia. bone marrow evaluation showed % blasts and % eosinophils. bcr-abl testing was negative, ruling out cml. fish analysis for eosinophilic clonality revealed deletion of chic gene, resulting in fip l /pdgfra fusion gene, diagnostic for myeloid neoplasm with eosinophilia associated with pdgfr abnormalities. treatment was started with tyrosine kinase inhibitor (tki), imatinib mg daily. within months, fish analysis for fusion gene was negative. after approximately months of daily imatinib, he was switched to maintenance dose of mg weekly. he is approximately months since diagnosis and doing well on maintenance imatinib. in , the who revised its classification of some chronic eosinophilic leukemias to myeloid and lymphoid neoplasms associated with eosinophilia and rearrangement of pdgfra, pdgfrb, fgfr . the most common abnormality is the fip l /pdgfra fusion gene. other less common abnormalities include fusion genes kif b-pdgfra and etv -pdgfrb and point mutations in pdgfra . some features of chronic eosinophilic leukemia include absolute eosinophilia, splenomegaly, elevated vitamin b and tryptase levels, and organ damage from eosinophil infiltrates and cytokine release. patients with rearrangements or mutations involving pdgfra are usually very responsive to imatinib. starting doses have not been well studied or established. experts recommend co-administration of corticosteroids during the first few days of imatinib therapy in patients with a history of cardiac involvement and/or elevated serum troponin levels to prevent myocardial necrosis, a rare complication of imatinib therapy in eosinophilic patients. fortunately our patient did not have cardiac involvement and to date has not exhibited signs of chronic tki toxicity. conclusion: myeloid neoplasms with eosinophilia constitute a rare form of chronic leukemias. they are often associated with pdgfr abnormalities and are usually very responsive to tyrosine kinase inhibitor therapy. walter reed national military medical center, bethesda, maryland, united states background: germline samd l mutation is a rare cause of constitutional bone marrow failure with a unique propensity for clonal evolution to monosomy and mds. objectives: previous case series have demonstrated diverse clinical outcomes in patients with a germline samd l mutation. our case presents a novel samd l mutation (p.val leu). additionally, the case highlights the challenges in clinical decision making for a patient with a gene mutation that is known for clonal evolution towards monosomy with risk of progression to myeloid malignancy, but also known for self-correction through uniparental disomy or inactivating mutations which results in disease remission. design/method: a retrospective chart review and review of the literature was performed. dna was isolated from peripheral blood and used for whole exome sequencing. a peripheral blood sample from the patient's mother and father showed no samd l mutation. skin biopsies of the patient and parents were evaluated for uniparental disomy or new mutations. to determine the pathogenicity of this novel mutation, the specific samd l mutant dna was transfected into the human embryonic kidney cell line to assess its role in inhibiting cell proliferation. our patient presented at months of age with pancytopenia and hypocellular bone marrow in the setting of s of s sepsis. he had evidence of dysfunctional immune activation with hemophagocytosis and elevated soluble il with simultaneous severe hypogammaglobulinemia. analysis of the peripheral blood showed no increase in chromosomal breakage, normal telomere length, and normal flow cytometry. gene testing for primary hemophagocytic lymphohistiocytosis and inherited bone marrow failure were negative. after the patient recovered from his presenting illness, a repeat bone marrow biopsy demonstrated improved cellularity with myelodysplasia and cytogenetics significant for monsomy .whole exome testing demonstrated a novel samd l mutation. the patient continued to require intermittent ivig and failed to demonstrate appropriate leukocytosis with intermittent infections. on repeat bone marrow evaluation over the course of months, the patient demonstrated no evidence of evolution towards self-correction and had a persistent monosomy clone. the patient is scheduled to undergo a matched unrelated donor bone marrow transplant. our case highlights the unique clinical picture associated with constitutional marrow failure and clonal evolution secondary to a novel samd l mutation which is thought to cause pancytopenia by inhibiting cellular proliferation and often results in the development of monosomy which rescues hematopoiesis but with a risk for malignancy. background: notable labs developed a flow cytometricbased assay with a custom robotic platform to test fdaapproved drugs for anti-cancer activity against individual patient's tumor cells. this personalized assay is a potential method for identifying novel agents and drug combinations to treat aml patients who have failed standard therapies. objectives: to present the case of a teen who underwent successful treatment of relapsed aml post-sct with bortezomib, panobinostat, and dexamethasone-a regimen selected based upon results of notable lab testing. results: a -year-old male with m -aml had an isolated bone marrow relapse months after completion of scheduled therapy. at relapse, his aml was flt -itd positive. he achieved a second remission with negative mrd and underwent matched sibling donor bmt after busulfan/cyclophosphamide conditioning. bma performed on day + was mrd positive ( . %). repeat bma done on day + showed . % mrd. he started sorafenib on day + . he received donor lymphocyte infusion (dli) on day + , then received cycles of azacitadine (aza) followed by dli. marrow mrd by flow after sorafenib alone, sorafenib with dli, and sorafenib with aza/dli were %, . %, and . %, respectively. treatment was complicated by varicella meningitis, grade i skin agvhd, febrile neutropenia and c. difficile colitis, and metapneumovirus pneumonia. despite extremely low levels of leukemia (marrow mrd . %), notable lab testing performed on the patient's leukemia cells from marrow collected after aza/dli/sorafenib revealed sensitivity of his leukemic blasts to a combination of bortezomib, panobinostat, and dexamethasone. because of prolonged cytopenias, multiple infectious complications, and persistently positive mrd, he discontinued aza/dli/sorafenib and on day + started bortezomib . mg/m iv on days , , , and ; panobinostat mg po on days , , , , , ; and dexamethasone mg po on days , , , , , , , and . chemotherapy cycle started days later. he tolerated treatment without side effects and with resolution of rash and cytopenias. he achieved full donor chimerism, negative flt -itd, and complete remission by morphology and flow after two cycles. notable lab testing is a powerful tool for evaluating the sensitivity of small populations of leukemic blasts to novel drug therapy. results from notable lab testing may serve as a useful guide for treatment selection after failure of standard aml therapy. this patient achieved morphologic and mrd remission post-sct with bortezomib, panobinostat, and dexamethasone-a regimen predicted to be efficacious based upon notable lab results. maria ahmad-nabi, christine knoll, sanjay shah, esteban gomez, lori wagner phoenix children's hospital, phoenix, arizona, united states background: development of inhibitors in patients with factor ix deficiency (fixd) is a well-recognized complication occurring in - % of patients. within this subset a small percentage can develop anaphylaxis to factor. desensitization with cyclophosphamide, an alkylating agent used in the management of various oncologic malignancies, and reported for use in factor viii desensitization has been previously unreported for use in desensitization in patients with fixd. rituximab, an anti-cd antibody, however has been used. objectives: to induce immune tolerance (it) in patients with inhibitors to factor ix with either novel or under reported methods using cyclophosphamide and/or rituximab. we report a case series of patients at phoenix children's hospital with fixd who achieved it with cyclophosphamide and/or rituximab. results: patient one was a year old male with severe fixd, who at the time of desensitization had inhibitor levels of bu. he was desensitized with cyclophosphamide, then admitted for infusion of recombinant factor ix. he experienced a few minor symptoms of intolerance including an urticarial rash which was self-limited, and hemarthrosis of the right elbow on day which responded to novo . he tolerated the remainder of his infusion without issues. he continued recombinant factor ix daily, and returned to clinic for monthly cyclophosphamide for months. he did develop urticaria with hemarthrosis and spontaneous muscle bleeds which were tempered with zantac, zyrtec, solumedrol, and benadryl. he remained without a recurrence of inhibitors, however did have intermittent hemarthrosis of his ankles thereafter requiring prophylactic twice daily dosing recombinant factor ix. patient two was a year old male with severe fixd and a family history of anaphylaxis to factor causing early death in all male relatives with the disease. he had never received factor ix and did not have a detectable inhibitor prior to desensitization. he successfully underwent desensitization to recombinant factor ix with rituximab in the icu, and returned to clinic for weekly infusions x . he experienced no adverse reactions concerning for anaphylaxis. he continued to tolerate factor ix products without evidence of intolerance, development of inhibitors, and continues on as prophylactic dosing of recombinant factor ix every other day. our experience at a single institution proves cyclophosphamide as a novel agent for inducing it in those with fixd and anaphylaxis. it also provides further evidence that rituximab can desensitize patients with severe fixd. differences include longer duration for cyclophosphamide therapy ( months vs month). background: cartilage-hair hypoplasia (chh) is an autosomal recessive chondrodysplasia associated with defective cell-mediated immunity caused by mutations in the ribonuclease mitochondrial rna processing (rmrp) gene. cancer incidence is -fold higher in patients with chh than in the general population, especially non-hodgkin lymphoma. the use of rituximab, an anti cd antibody, results in decreased host b-cell number and impaired humoral function for - months. the safety of rituximab in pediatric patients with cancer and immunodeficiency is not well documented. a diagnosis of underlying immunodeficiency may discourage physicians from using rituximab due to the risk of severe bacterial infection or viral re-activation. objectives: to report a case of burkitt lymphoma in a young adult female with chh and defective cellular immunity successfully treated with rituximab. results: an -year old amish female with disproportionate short stature presented to our center for management of stage iv biopsy proven burkitt lymphoma with myc rearrangement. she had presented a week earlier with cervical, occipital, and submandibular lymphadenopathy, splenomegaly; fevers, night sweats, and weight loss for - weeks. on exam, her height was three feet associated with brachydactyly, mild bowing of the legs, normal size head without frontal bossing, fine and sparse hair. she had normal intelligence. her pattern of dysmorphisms was suggestive of chh (genetic testing not performed at time of diagnosis). pet-ct scan showed stage iv disease with involvement of cervical lymph nodes, spleen, iliac bone and bone marrow. treatment with standardintensity fab/lmb therapy (group c) with the addition of rituximab was initiated. she had an incomplete response to cop (∼ % reduction of tumoral masses) but achieved complete remission after copadam . her course was complicated with severe varicella zoster but she completed therapy and remains in complete disease remission for months after treatment completion. genetic testing subsequently performed proved homozygosity for chh with a n. a>g variant. she had no other opportunistic infections during or after therapy. conclusion: the use of rituximab was both safe and beneficial in our patient despite defective cell mediated immunity secondary to chh suggesting that rituximab may be safe to use in patients with cellular immune deficiencies. background: hemophilia a and b are bleeding disorders characterized by deficiency in factor viii or ix, respectively. spontaneous or provoked hemarthrosis is a known complication of hemophilia. repetitive episodes of hemarthrosis can lead to debilitating hemophilic arthropathy. lyme disease is a tick-born infection which is endemic to increasing parts of the united states. chronic lyme disease, the phase in which lyme arthritis typically develops, occurs months to years after initial infection and is characterized by swelling of one or more large joints generally in the absence of systemic symptoms. objectives: review cases of hemophilia a and b patients with episodes of provoked hemarthrosis refractory to intensive recombinant factor replacement therapy found to have concurrent lyme arthritis. design/method: we report two clinical cases and review relevant literature. results: first, we report a year-old male with moderate hemophilia a with a provoked knee hemarthrosis which failed to improve despite months of intense factor replacement therapy requiring multiple hospitalizations. factor replacement regimens included twice daily standard half-life recombinant factor viii products or daily to every other day extended half-life recombinant factor viii products with trough levels aimed as high as - %. factor viii pk studies were obtained for dosing, to confirm adherence, and to evaluate for subclinical inhibitors (inhibitor testing was negative). given protracted symptoms additional workup for hemarthrosis was pursed. lyme titers were positive for ( )igg, though negative for igm. he was treated with days of doxycycline during which time hemarthrosis greatly improved on examination and imaging, and he was able to recover function through physical therapy. second, we report a year-old male with moderate hemophilia b who required multiple hospital admissions for a provoked knee hemarthro-sis with no improvement in symptoms despite weeks of daily or twice daily factor replacement with standard halflife recombinant factor ix products aiming for % correction. we performed inhibitor testing (which was negative) and pk studies to assess for non-detectable inhibitors, dosing and adherence. lyme testing was positive for ( )igg, though negative for igm. he was treated with amoxicillin for days during which time hemarthrosis significantly improved on examination and imaging. diagnosis and follow-up imaging studies for both patients included mri and serial bedside ultrasounds performed as per uc san diego school of medicine mskus guidelines. background: relapse/refractory aml following allogeneic hematopoietic stem cell transplant (hsct) holds a high mortality rate. current relapse/refractory therapy modalities for younger patients may include re-induction with a clofarabinebased regimen followed by second allogeneic hsct. even for patients who undergo second hsct, the five-year survival rate is dismal. new therapies, including small molecule inhibitors, are being studied in the post-hsct relapse setting or those unfit for hsct with promising results. venetoclax is a small molecule inhibitor that has received breakthrough designation for aml treatment in elderly patients objectives: to report a young adult aml patient with relapse post hsct who was successfully re-induced with topotecan, vinorelbine, thiotepa, clofarabine (tvtc) and has sustained remission with venetoclax maintenance therapy. this approach appears to be unique in terms of reported literature. results: our patient is now a -year-old female noted to have mll rearranged aml at initial diagnosis when she was years old. she underwent chemotherapy consisting of cytarabine/daunorubicin according to standard + . due to persistent disease, she was re-induced with g-csf, clofarabine, and high-dose cytarabine (gclac) which put her in cr. her course was complicated by sepsis, colitis, gastrointestinal bleed, deep venous thrombosis, and transfusionassociated circulatory overload. given her co-morbidities, she received another cycle of clofarabine/cytarabine, and then proceeded to reduced intensity allogeneic hsct, according to bmt ctn . the patient tolerated hsct well and experienced no transplant-related complications, including no acute or chronic gvhd. unfortunately, she relapsed about month's post-hsct. initial salvage therapy consisted of another course of g-clac, but due to persistent disease the decision was made to re-induce her with topotecan, vinorelbine, thiotepa, and clofarabine (tvtc). during this time however, she was found to have extensive infection with a fusarium species requiring a course of anti-fungal therapy. bone marrow evaluation showed no residual disease with an mrd of < . %. once the absolute neutrophil count recovered, the patient was started on single-agent venetoclax for maintenance therapy, which has been well-tolerated. she remains in morphologic remission for over months. we describe herein a young adult with multiply relapsed aml wherein tvtc re-induction, followed by maintenance with venetoclax were safely used in the post-hsct setting. venetoclax therapy in the relapsed aml setting warrants further study. background: vitamin b deficiency is uncommon in children in developed countries, especially in the absence of risk factors like malabsorption or inadequate dietary intake. it often presents with non-specific symptoms and signs and can elude diagnosis. the recognition and treatment of vitamin b deficiency is critical as it can lead to bone marrow failure as well as severe neurological and developmental problems in children. to increase index of suspicion of vitamin b deficiency anemia in children. we report a rare case of vita-min b deficiency anemia in a child who presented with a severe macrocytic anemia, with signs of hemolysis and concern of malignancy. design/method: an almost three-year-old previously healthy girl presented with a few day history of fever, emesis, fatigue and pallor. she had no dysmorphic features, hepatosplenomegaly or lymphadenopathy on exam, growth and development were normal. laboratory findings showed severe macrocytic anemia (hemoglobin . grams/dl; mcv . fl) with reticulocytopenia. signs of intravascular hemolysis were present with elevated lactate dehydrogenase ( , units/l) and haptoglobin below assay limit. immune-mediated hemolysis was ruled out. initial picture of a hemolytic anemia was compounded by other findings of moderate neutropenia, mild thrombocytopenia and peripheral smear showing occasional blasts. further workup was done with a broad differential diagnosis that included leukemias, hemolytic anemias, bone marrow failure syndromes, and specific deficiencies. results: workup revealed abnormally low vitamin b levels along with significantly elevated homocysteine and methylmalonic acid levels indicating functional vitamin b deficiency. bone marrow evaluation showed megaloblastic anemia and dyserythropoiesis consistent with vitamin b deficiency, and ruled out leukemia. vitamin b deficiency can cause a hemolytic anemia like picture secondary to intramedullary hemolysis due to ineffective erythropoiesis. myeloid precursors are also affected which can lead to neutropenia, thrombocytopenia, and abnormal peripheral blood cells. in our patient, initial symptomatic anemia was treated with blood transfusion, followed by intramuscular vitamin b injections with normalizing lab values. so far, workup for an etiology for vitamin b deficiency is negative except for an equivocal range of anti-parietal cell antibodies raising concerns for pernicious anemia; however it is rare in this age group. another rare condition is an inborn error of the cobalamin transporter. she is currently on oral vitamin b supplementation and further workup will be planned based on response. conclusion: this case highlights the importance of early consideration and thorough evaluation of vitamin b deficiency in children with unclear etiology of anemia, so that prompt treatment can be initiated. memorial hospital/ university of miami, miami, florida, united states background: despite great success in the treatment of acute lymphoblastic leukemia (all), the outcomes for patients with relapsed all remain poor. prognostic indicators include timing and site of relapse. blinatumomab, is the first agent in its class that simultaneously binds cd -positive cytotoxic t cells to cd -positive b cells resulting in lysis of malignant cells. however, mechanisms of leukemia resistance to blinatumomab are unclear. objectives: to describe a case with multiple sites of extramedullary (em) relapse during blinatumomab therapy. results: a -year-old hispanic male with philadelphia positive, cd -positive b-precursor cell all refractory to chemotherapy, had failed a bone marrow (bm) and was placed on blinatumomab and imatinib. he achieved minimal residual disease (mrd)-negative systemic remission, but during his fifth cycle developed bilateral periorbital masses. biopsies confirmed cd -negative isolated em relapsed disease, which was treated with radiation therapy (rt). there was notable resolution of em disease and he continued systemic therapy. subsequently, he presented with a painful left scapular swelling. imaging showed muscle and lung parenchymal em relapse with cd -positivity confirmed on histology. he continued on blinatumomab with localized rt while awaiting car-t cell therapy. his bm mrd remained negative until he developed systemic mrd-positivity with cd -positive blasts following the sixth cycle. primary resistance to blinatumomab is poorly understood. it is proposed that expansion of cd -negative clones or downregulation of cd following blinatumomab may play a role. this was observed in our patient's periorbital relapse; but subsequent em and systemic relapses were cd -positive, consistent with the co-existence of multiple clones in relapsed all. it has also been postulated that em relapse could be linked to the failure of blinatumomab or t cells to migrate to em sites of disease or drug inactivation by the microenvironment. the second em relapse in our patient, with cd -positive disease suggests this as a possible mechanism of relapse. this was reported in patients with cd positive non-hodgkin lymphoma (nhl), and higher doses of blinatumomab however, have shown promising results in this population. despite blinatumomab's effectiveness in inducing remissions in patients with refractory/relapsed all, it appears to have limitations in patients with em disease. these may arise either from the multiclonality associated with relapsed all or due to the emergence of resistance to blinatumomab, including failure to migrate to em sites. background: cyclic neutropenia is a rare hereditary disorder, characterized by recurrent neutropenia, cycling at about week intervals, with variable associated symptoms including oral ulcers and fever. there are reported cases of cyclic neutropenia associated with chronic inflammation leading to development of reactive aa amyloidosis. one patient also presented with amyloid goiter. we report a new case of cyclic neutropenia with associated renal and thyroid amyloid. design/method: a -year-old female presented with a month history of thyromegaly, and recurrent aphthous ulcers associated with fevers. laboratory workup showed severe neutropenia, anemia, azotemia, and abnormal thyroid function, with an absolute neutrophil count - / l, hemoglobin - . g/dl, serum creatinine - . mg/dl, and uric acid - . mg/dl. thyroid stimulating hormone was elevated - . iu/ml, and normal free t . urinalysis showed + protein, + blood, and - urine red blood cells/hpf. chest radiograph showed mild narrowing of the trachea from thyroid compression. bone marrow biopsy showed a hypocellular marrow, with tri-lineage hematopoiesis, left shifted myeloid maturation with very rare mature neutrophils. both renal biopsy and thyroid fine needle aspiration revealed abundant amyloid. of note, her father had aa amyloidosis, resulting in end-stage renal disease (esrd) requiring hemodialysis, and recurrent aphthous ulcers. the family history suggested a familial predisposition. genetic testing revealed a pathogenic elane c. a>t gene mutation with autosomal dominant inheritance confirming the diagnosis of cyclic neutropenia. we treated our patient with daily granulocyte colony stimulating factor to reduce the burden of chronic inflammation induced by cyclic neutropenia, and to preserve renal and other end organ function affected by further amyloid deposition. results: proband with elane gene mutation positive cyclic neutropenia, amyloidosis of thyroid and kidney, with a positive paternal history of aa amyloidosis resulting in esrd. cyclic neutropenia may result in chronic inflammatory states leading to secondary amyloidosis. university of kentucky, lexington, kentucky, united states background: overall survival of burkitt lymphoma (bl), regardless of stage, is greater than % in the pediatric population when treated with multi-agent chemotherapy. adenovirus is a common, usually self-limited infection within the pediatric population; however, findings can vary within an immunocompromised host. hepatitis is a rare complication, with very few reports of radiologic findings in this patient population. we discuss a three year old male with history of bl who presented with clinical and radiographic evidence of relapse but was found to have adenovirus hepatitis. design/method: a case report of a patient with bl in complete remission after completion of standard of care chemotherapy, who presented with return of high fever, elevated ldh, transaminitis and hepatic lesions. we describe the hepatic imaging and pathology consistent with adenovirus hepatitis in this immunocompromised host. our patient presented at three years old with a six week history of worsening abdominal pain and fevers. he was found to have a right sided pleural effusion, multiple lesions of the liver, and diffuse abdominal lymphadenopathy; biopsy of lymph tissue was consistent with bl. he completed therapy per anhl arm b and was in a complete remission at the end of planned therapy. one month after completion of therapy, he returned with high fever, abdominal pain and transaminitis, similar to his initial presentation. ct scan showed multiple hypodense discrete lesions throughout the liver and re-accumulation of right sided pleural effusion. ldh peaked at u/l (uln u/l). uric acid remained within normal limits. bilirubin peaked at . mg/dl, conjugated . mg/dl. liver biopsy was performed, showing smudgy nuclei with immunohistochemical staining positive for adenovirus. there was no evidence of lymphomatous involvement. resolution of hepatic lesions and transaminitis, with normalization of ldh and fever, occurred with symptomatic treatment alone. adenovirus is known to cause systemic disease in immunocompromised patients and rarely hepatitis. no pediatric patients with discrete hepatic lesions secondary to adenovirus have been reported in the literature. three cases of discrete hepatic lesions have been reported in adult immunocompromised patients, two with fatal fulminant liver failure and one who required cidofovir. this case demonstrates that a common pediatric viral infection can present with lesions concerning for metastatic disease in a pediatric lymphoma patient. prompt diagnosis is vital in the management of these patients when recurrent lymphoma is in the differential. background: heparin induced thrombocytopenia (hit) is an immunologic process in which antibodies bind a heparin complex and cause a paradoxical hypercoagulable state. ramifications of this process may include a multitude of thrombotic events and bleeding complications secondary to platelet consumption. in our patient, hit manifested as increased bruising, an acute decrease in platelet count, and continual clotting of her crrt circuit. hit, although rare in pediatrics, should be included in the differential for children with thrombocytopenia who have received heparin products. to present a unique case report of a critically ill pediatric patient who developed hit in the presence of multiorgan system failure and to discuss the challenges encountered with identification of an alternative anti-coagulant. results: a yo obese, caucasian female child presented to our facility with bilateral pulmonary emboli (of unclear etiology). initially, she was started on a continuous heparin infusion, but was transitioned to enoxaparin within days without issue. five days after enoxaparin was initiated, the patient developed acute kidney injury (evidenced by increasing creatinine) attributable to her biventricular heart failure. due to her need for continuous renal replacement therapy (crrt), she was transitioned back to a continuous heparin infusion. whereas her initial platelet count on transition was normal, she developed severe thrombocytopenia ( , ul) within hours. due to intermediate risk but low suspicion for hit, pf antibodies were sent which were positive. after much discussion, she was transitioned to an argatroban infusion which was titrated according to ptt levels. within hours, her platelet count normalized. at discharge, she was prescribed apixaban for anti-coagulant management. conclusion: hit is an uncommon presentation in the pediatric population. given its rarity, there is often a delay in diagnosis which increases risk of complications such as bleeding, stroke, and limb ischemia. even if the diagnosis is suspected or proven, there may be challenges in initiating alternative agents as limited data exists on pediatric options. as argatroban remains the treatment of choice for patients with hit, experience in pediatric patients is limited, and dosing recommendations have been extrapolated from adult studies. anecdotal data exists for use of bivalirudin in children, although studies, primarily, focus on use in specific cardiac cases. in our patient's case, choice was further complicated by renal failure. this case study highlights the need for further research regarding the identification of a secondary anti-coagulant agent for use in pediatric patients with hit. background: subcutaneous panniculitis-like t-cell lymphoma (sptl) is a rare form of non-hodgkin's lymphoma characterized by infiltration of cytotoxic t-cells into subcutaneous tissue. sptl occurs in both adults and children and can present in both patient populations as either alpha/beta or gamma/delta subtypes. patients with the gamma-delta phenotype have an overall poorer survival, although the exact etiology is unclear. interestingly, both subtypes of sptl can present with secondary hemophagocytic lymphohistiocytosis (hlh), and this is associated with a worse prognosis. currently, there are no standardized treatment protocols for sptl, and clinical management includes watchful waiting, corticosteroids/immunosuppression, chemotherapy, and stem cell transplant. the primary objective was to compare how two patients with the same diagnosis responded acutely to therapy. we performed a retrospective chart review of two pediatric patients at our institution who were diagnosed with alpha/beta sptl and secondary hlh. we examined each presentation, treatment course, and outcome. we then completed a brief review of the current literature describing treatment of and outcomes for sptl with secondary hlh. results: these two patients presented in a similar manner with signs and symptoms of hlh. each was then subse-quently diagnosed with alpha/beta sptl after biopsy of cutaneous nodules and each had diffuse disease, as measured by pet. however, they demonstrated vastly different acute responses to therapy. one patient was pre-treated with systemic glucocorticoids before receiving definitive chemotherapy and tolerated therapy well as an outpatient. the other patient started systemic chemotherapy without steroid pretreatment and developed severe cytokine storm characterized by hypotension, cardiac dysfunction, multi-organ failure and cytokine elevation. both patients achieved complete remission (cr) after treatment with chop chemotherapy and remain disease-free - months off therapy. in patients presenting with sptl and secondary hlh, we propose that initial treatment with antiinflammatory or anti-cytokine therapy can decrease, or even prevent, the possibility of life threatening cytokine release as a result of cytotoxic chemotherapy. background: congenital dyserythropoietic anemia type ii (cda ii) is a rare autosomal recessive disorder, rarely presenting in the neonatal period. iron overload often occurs as a late sequela of ineffective erythropoiesis and intramedullary hemolysis. objectives: to report the novel use of iron chelation in an infant with cda ii associated with severe iron overload. the patient is a -month-old, former -week infant with prenatal non-immune hydrops and transfusion-dependent fetal anemia who presented with persistent anemia, reticulocytopenia, hyperbilirubinemia, liver dysfunction, and hyperferritinemia. his initial ferritin was . ng/ml, tibc ug/dl, and transferrin mg/dl. his bone marrow biopsy showed trilineage hematopoiesis and erythroid dyspoiesis characterized by binucleation of late-stage precursors. genetic testing revealed a compound heterozygous missense mutation and splice site mutation in the sec b gene, confirming the diagnosis of cda ii. initial liver biopsy revealed mild portal fibrous expansion, and abundant hepatic iron deposition. his ferritin continued to increase, peaking at , ng/ml, along with liver enzymes peaking at an alanine aminotransferase (alt) of u/l and aspartate aminotransferase (ast) of u/l. ferriscan showed an elevated estimated liver concentration of . mg/g dry tissue. repeat liver biopsy months later showed giant cell hepatitis with worsening mild portal fibrosis and hemosiderosis. additionally, tissue liver iron concentration was mcg/g dry weight. cardiac t * mri revealed mild cardiac iron deposition. given his significant degree of iron overload, deferoxamine was used to reduce hemosiderosis and liver morbidity in preparation for bone marrow transplantation. the patient received deferoxamine mg/kg/day iv x days/week for three months, without any clinically significant adverse events. blood counts and hepatic and renal function were monitored weekly without any abnormalities. growth parameters and liver enzymes significantly improved while receiving chelation therapy. as a noninvasive, cost-effective method, serum ferritin levels were monitored monthly to gauge response to treatment. despite receiving blood transfusions every - weeks, serum ferritin decreased to ng/ml and liver enzymes decreased to alt u/l and ast u/l prior to bone marrow transplantation. we report the use of deferoxamine in a patient with cda ii less than years of age, for treatment of iron overload. our patient tolerated deferoxamine well without significant adverse events or organ toxicity. deferoxamine may be a well-tolerated method of reducing iron burden in young patients with iron-loading pathologies. background: low grade gliomas with kiaa- -braf fusions typically have a favorable prognosis with infrequent rates of high grade transformation, low rates of metastasis and even lower rates of extra cns metastasis. while highgrade transformation has been reported for tumors with braf v e mutations and cdkn a deletions, it has not been pre-viously reported in gliomas with kiaa- -braf fusions. while there are case reports of high-grade cns malignancies metastasizing through a ventriculo-peritoneal (vp) shunt, low-grade gliomas metastasizing in this manner are extremely rare. objectives: to describe a unique case of peritoneal tumor dissemination of a braf fusion positive high grade neuroepithelial tumor in a child with a vp shunt placed for multifocal braf fusion positive low grade astrocytomas results: an eight-year-old male was initially diagnosed with multifocal low-grade astrocytomas of the hypothalamus and c -c spinal cord. initial testing revealed the kiaa- -braf fusion, but no cdkn a or braf v e mutation. initial surgical management included a vp shunt and resection of the cervical spinal lesion. he received vincristine and carboplatin, followed by transition to vinblastine given new thoracic metastatic lesions after months of therapy. at months after diagnosis, scans were concerning for diffuse leptomeningeal progressive disease and new intracranial lesions, necessitating craniospinal radiation. following a near cr, he presented months later with acute onset of abdominal pain. a ct scan revealed peri-renal and perirectal soft tissue masses, confirmed by exploratory laparotomy to be peritoneal tumor dissemination of high grade neuroepithelial tumor. a kiaa -braf fusion was noted and confirmed by rt-pcr, identical to that seen in the original cns tumors. additional findings included deletion of chromosome p (without q loss) and heterozygous and homozygous deletion of cdkn a found by fish. brisk mitotic activity justified a high-grade designation. salvage chemotherapy consisted of cycles of ice with subsequent resolution of pet-avid disease and only minimal peri-nephric tissue remaining. given the favorable response, surgical resection and multiple tissue biopsies were performed which documented no residual active disease. the shunt was revised and he started trametinib for maintenance. we present a unique case of peritoneal dissemination of high grade neuroepitheial tumors with the same kiaa- -braf fusion as multifocal low grade astrocytomas in a child with a vp shunt. this raises suspicion for tumor metastasis and transformation to a higher grade malignancy versus two distinct diseases, which may be indicative of an underlying cancer predisposition. texas children's hospital, houston, texas, united states background: polycythemia is a common referral to hematology. it is important to evaluate for a high oxygen affinity hemoglobinopathy, ensuring appropriate testing is performed for early diagnosis and avoidance of additional tests and procedures. a year old mexican female presented with an elevated hemoglobin and hematocrit, symptoms of plethora of her hands and feet, chest pain, palpitations, and fatigue. further confounding the picture, she also had significant menorrhagia and iron deficiency. she was diagnosed with the rare high oxygen affinity hemoglobin new mexico variant, only previously described once in the literature in a year old black boy. objectives: the patient initially presented at age with a hemoglobin of . g/dl and a hematocrit of . %. initial work up consisted of a hemoglobin electrophoresis which diagnosed sickle cell trait, a co-oximetry panel which was normal, and erythropoietin level of mu/ml, also normal. she was then lost to follow up and re-referred at age . she is a competitive basketball athlete, and at that time, she presented with a hemoglobin of . g/dl, and hematocrit of %. erythropoietin level continued to be normal at mu/ml. design/method: cardiology was consulted regarding chest pain and palpitations with a normal evaluation. chest x-ray was also normal. a bone marrow aspirate and biopsy was performed with results significant for mild erythroid hyperplasia and mild reticulin fibrosis. jak mutation, von hippel lindau, bpgm, and hereditary erythrocytosis mutations including phd , hif a, and epor mutation analysis were sent, all of which were normal. testing to mayo clinic for p rbc oxygen dissociation returned low at mmhg ( - mmhg normal range) and subsequently a hemoglobin electrophoresis identified a hemoglobin variant leading to beta globin gene sequencing. results: patient found to be heterozygous for hemoglobin new mexico, with . % hb new mexico and . % hba, and . % hba . there was no evidence of hbs. when evaluating patients with polycythemia, maintaining a high index of suspicion for high affinity hemoglobinopathies may eliminate further unnecessary and invasive testing for patients. caution should be used when using hemoglobin electrophoresis testing since hb new mexico is known to migrate similarly to hbs on hplc with minimal change that may not be detected in regular laboratories. most high affinity hemoglobinopathies are reported to not have significant symptoms. in this case, our patient complains of fatigue, occasional palpitations and plethora of hands and feet. we will need to further follow this patient for possible attributable symptomatology. divya keerthy, simone chang, warren alperstein, patricia delgado, claudia rojas, ofelia alvarez, matteo trucco university of miami jackson memorial hospital, miami, florida, united states background: improved technology is enabling detection of previously unidentified translocations and mutations in otherwise unclassified sarcomas. one such mutation is the bcl- co-repressor -internal tandem duplication (bcor-itd) allowing for the new classification of bcor positive undifferentiated round cell sarcomas (urcs). this sarcoma has a similar appearance to clear cell sarcoma of the kidney (ccsk), potentially representing an extra-renal manifestation of this tumor, but their clinical pathologic features are not identical. objectives: this case highlights how recombinant polymerase chain reaction (rt-pcr) and bcor immunohistochemical staining can ease the diagnosis of this rare sarcoma. results: a month-old female presented for right sided pre-septal cellulitis and a temporal subcutaneous mass. the detection of multiple other subcutaneous nodules on exam raised the concern for malignancy and she was admitted for evaluation. she had two subcutaneous masses on her abdomen, with more cutaneous masses on her legs, back, shoulder, cheek and submandibular areas. she lacked spontaneous lower limb movement and had bilateral clonus. imaging confirmed multiple masses throughout the body including paravertebral area from t to l , bilateral adrenal glands, left kidney and muscles of upper and lower extremities. initial differential included neuroblastoma, infantile myofibromatosis, rhabdomyosarcoma or atypical presentation of a renal tumor. however, synaptophysin and chromogranin stains were negative. with standard immunohistochemistry, the tumor could be only broadly classified as "undifferentiated sarcoma" maintaining the diagnostic challenge. using rt-pcr in the setting of a morphologically primitive round cell neoplasm with strong bcor expression, two external institutes simultaneously diagnosed the tumor as bcor-urcs. the primary lesion is unknown but potentially may have arose from the kidney. bcor-urcs has a heterogeneous histology with tumor cells appearing monomorphic in nests of - cells separated by septa with uniform nuclei. there is frequently an "orphan annie eye" appearance and sparse cytoplasm to the cells. diagnosis cannot be made solely on evaluation of this nonspecific histology. rt-pcr uses the genetic abnormality in undifferentiated sarcomas to narrow the differential and bcor immunohistochemical staining provides further context. bcor has significant diagnostic value given its sensitivity and specificity in urcs. another potential marker includes ywhae-nutm b fusions, which occur in smaller subset of cases, but requires further study. rt-pcr has helped further classify tumors leading to the diagnosis of a rare undifferentiated sarcoma with bcor overexpression. while this technology is beneficial, its availability is limited. if accessibility improves, earlier identification and treatment may be possible maximizing the chance for a positive outcome. background: hematohidrosis is a rare condition that mimics bleeding disorders. cases present with oozing blood tinged fluid from various sites like eyes, ears, nose, skin, etc. reported causes of this condition were stress or fear, physical activity, psychological disorders. the condition is self-limited and don't affect the general condition of the patients, but it may contributes to psychosocial problems and may increases their stress and anxiety. so this condition needs to be promptly treated. to test the response of this disease and the associated headache to propranolol treatment. design/method: our case female patient years old st offspring of non consanguineous marriage, was admitted with recurrent episodes of oozing blood tinged fluid from eyes, ears and nose months before admission, about . - ml from each orifice, lasted - minutes and subsided spontaneously. it could involve the sites simultaneously or - sites. the number of attacks was - times per day then gradually increased to - times per day. later on the patient developed a bleeding attack from umbilicus. these attacks were aggravated by stress and physical activity and decreased with rest and sleep. the condition was associated with severe headache involving the whole head, throbbing in nature of gradual onset, increased by physical activity and relieved by analgesics. the condition was not associated with vomiting, blurring or diminution of vision, ocular pain, eye discoloration. no earache, tinnitus or diminution of hearing. there was no other form of discharge from eyes, ears or nose. no history of ecchymotic patches, bleeding from other orifices or blood product transfusion. no history of trauma, drug intake, fever or rash. no symptoms of other system affection. past history of recurrent attacks of epistaxis and two operations were done that passed without remarkable bleeding. no similar condition in the family physical examination was free, no evidence of psychological problems. complete blood count, coagulation profile, platelets function, factor and c.t brain were normal. oozing fluid from the patient was analyzed showed the same components as blood. results: our case started oral propranolol . mg/kg/day based on its use in similar cases in literature. the frequency of attacks and headache reduced then stopped after months of treatment and didn't recur after stoppage of propranolol. propranolol can treat this condition successfully. further investigations are needed to determine the link between this condition and severe headache our case was suffering from. background: wilms tumor is the most common renal solid tumors of childhood and is derived from primitive metanephric cells located in the kidney. primary extra-renal wilms tumors (erwt) are extremely rare, estimated to comprise . - % of all wilms tumors. despite similar histologic appearance intrarenal and erwts differ in embryologic tissues of origin. erwts arise from the more primitive mesonephric or pronephric origin and, therefore, can develop anywhere along the craniocaudal migration pathway of these primitive tissues, most often retroperitoneal, inguinal/genital, lumbosacral/pelvic and mediastinal. these tumors are typically staged and treated per national wilms tumor study (nwts) guidelines, and, by definition, are stage ii or greater due to location beyond the kidney borders. based on the cases reported in the literature, outcomes for erwt are comparable to renal wilms tumors with an % local recurrence rate and an % two-year event-free survival. we report the first case of a stage iii testicular extrarenal wilms tumor in an -month-old male with an intrabdominal undescended testis who underwent complete surgical excision followed by chemotherapy and inguinal radiation. results: a full term -month old male underwent orchipexy for an undescended left testicle. the testicle was noted to be grossly abnormal with a pea-sized thickened tissue adherent to the upper pole and a separate mass outside of the scrotum on the superior epididymis. both masses were removed, and s of s pathology demonstrated wilms tumor with favorable histology and negative margins. ct imaging of the chest, abdomen and pelvis were negative for a primary renal tumor, local residual disease, pathologic lymph node enlargement or distant metastases. the tumor was classified per nwts as stage iii due to tumor removal in multiple pieces. the patient completed dd- a treatment with vincristine, doxorubicin and dactinomycin per aren with cgy left inguinal radiation. he is currently months off therapy without clinical or radiographic evidence of recurrent disease. primary erwt is an extremely rare malignant neoplasm associated with challenges in diagnosis, staging and treatment. based on the cases reported in the literature, outcomes are similar to that of intrarenal wilms tumor. there are four pediatric paratesticular wilms tumors reported in the literature and, to the best of our knowledge, this is the first case of stage iii testicular wilms tumor successfully treated with dd- a chemotherapy and radiation. in erwt, nwts guidelines for staging and treatment should be applied with evaluation of both kidneys to exclude an intrarenal primary tumor. background: patient is a yo f, with esrd secondary to atypical hus versus ttp, who presented with thrombotic microangiopathy, aki, thrombocytopenia and anemia after a living unrelated donor kidney transplant. patient initially had downtrending creatinine. on post-op day , hematology was consulted for an increasing ldh and drop in platelets. peripheral smear was notable for an absence of schistocytes. yet, biopsy of the kidney revealed microthrombi. the patient was diagnosed with a thrombotic microangiopathy. plasmapharesis was initiated on day # , at which time ms r was noted to have significantly elevated creatinine. plasmapharesis did not yield any correction in labs and significant bruising developed. patient was started on eculizimab; plasmapharesis was stopped. shortly after, creatinine, anemia and thrombocytopenia corrected to levels at which she was discharged. overall, patient was found to have progressive anemia, thrombocytopenia, an increasing creatinine and ldh ( s) concerning for atypical hus, despite absence of schistocytes on peripheral smear. she responded well to eculizimab, with correction of hematologic changes during induction. she was discharged on eculizimab and continued to respond with normalizing platelet counts and hemoglobin. the differential in light of patient's thrombotic microangiopathy and thrombocytope-nia also included ttp. yet, adamts remained normal. dic was unlikely given normal fibrinogen level and d-dimer. objectives: presentations of atypical hus vs ttp. discuss eculizumab as a treatment of atypical hus. highlight atypical presentations of illness in transplant patients. results: despite absence of schistocytes by smear, pt was diagnosed with atypical hus based on presentation and after failing plasmapharesis, she responded well to eculizumab. though her presentation was abnormal, her response to this antibody that blocks the complement cascade suggests that she was experiencing a complement-mediated process. there are rare documented cases in the literature of atypical hus without schistocytes. hemolytic uremic syndrome (hus) is characterized by hemolytic anemia, thrombocytopenia and acute kidney injury. atypical hus is a diagnosis of exclusion, not due common etiologies such as shiga toxin. among atypical causes are complement-mediated forms, caused by an antibody to complement factor. in addition to plasmapharesis, renal transplant and supportive care, the mainstay of treatment for atypical hus is eculizumab (an antibody that blocks the complement terminal cascade). this case describes a patient unique in that, she was diagnosed with atypical hus without any schistocytes by smear. secondly, she responded to eculizumab, with unremarkable gene studies. finally, this case highlights that transplant patients often have unique presentations. nicklaus children's hospital, miami, florida, united states background: synovial sarcoma is a spindle cell tumor categorized as a soft tissue sarcoma. the chromosomal translocation t(x; ) leading to the ss -ssx fusion protein is unique to this sarcoma. it is a slow growing tumor with common recurrences and often, at presentation, with evidence of metastatic disease. if resection is not feasible, then neoadjuvant with adjuvant chemotherapy is recommended. metastasis carries an unfavorable prognosis given synovial sarcoma historically does not respond well to chemotherapy. trabectedin is a well-tolerated alkylating agent currently indicated for the treatment of liposarcoma and leiomyosarcoma. we present a -year-old male with metastatic synovial sarcoma to the lungs that progressed and was refractory to chemotherapy. he was administered trabectedin as a form of palliative chemotherapy, with significant clinical and radiographic response. design/method: pubmed search was done with search for terminology including "synovial sarcoma" and "trabectedin". papers relevant to our case were selected for literature review. a -year-old male patient presented with a large right axillary mass. initial imaging showed a heterogeneous multiseptated mass invading the subscapularis and teres major muscles along with innumerable lung nodules. biopsy confirmed diagnosis of monophasic synovial sarcoma. the patient was started on protocol arst with ifosfomide, mesna, doxorubicin. he completed cycles followed by radical resection and sessions of radiation. due to progression of disease multiple chemotherapy regimens were tried including topotecan and cyclophosphamide, protocol advl with lorvotuzumab, and pazopanib. imaging of the chest continued to show significant progression of metastasis. the patient's clinical status deteriorated with worsening respiratory status, requiring l of oxygen therapy, and inability to ambulate. he was started on trabectedin . mg/m for palliative care. after cycles of treatment patient was no longer requiring oxygen and was ambulating without assistance. radiological imaging showed significant reduction in number and size of lung nodules. trabectedin is a recently approved alkylating agent for the management of sarcomas resistant to first line treatment. response in synovial sarcoma is scarcely documented in the pediatric population. epidemiology places the most common age group in the young adults and children. our case opens the doors to further consideration of the use of trabectedin in the pediatric patient with metastatic synovial sarcoma. background: gata is an x-linked gene that plays critical role in hematopoiesis. mutations of gata gene can be associated to various blood disorders including diamond blackfan anemia, cytopenia, congenital dyserythropoietc anemia and acute megakaryoblastic leukemia. we report a patient with macrocytic anemia and platelet dysfunction who carries a novel gata mutation that has not been reported. results: a now -month-old male with complex medical history including prematurity at weeks, dysmorphic features, global developmental delay, hyperinsulinism, hypogonadotropic hypogonadism, growth hormone deficiency, micropenis, failure to thrive, patent ductus arteriosus status post ligation, and severe hypotonia, was referred to hematology at months old for resolved, transient thrombocytopenia and macrocytic anemia since month of age. chromosomal microarray showed chromosome deletion of q . , which is the rps gene. he doesn't have a family history of diamond blackfan anemia (dba), despite mom having the same rps mutation. he was then diagnosed with dba. his lab workup showed mild macrocytic anemia (hgb . g/dl, mcv fl), normal to inappropriately low reticulocyte count, normal white blood cell and platelet counts, hgf %, erythroid ada . eu/gm hgb (elevated). he has abnormal pfa- , with prolonged closure time of both adp and epinephrine. he had low von willebrand antigen and ristocetin cofactor activity. he has severe pancreatic insufficiency. bone marrow biopsy showed normocellular marrow with trilineage hematopoietic maturation, without ringed sideroblasts. since mother has the same rps gene mutation, maternal labs were done and showed no evidence of macroytosis or anemia. the diagnosis of dba was questioned. whole exome sequencing did not identify any pathogenic sequence changes in the coding regions of rps gene, but detected a gata mutation r w, which was reported variant of uncertain significance. his mother shares the same mutation and is asymptomatic, but she may not be affected since gata iis xlinked. his father doesn't harbor the gata mutation. conclusion: gata gene encodes zinc finger dna binding hematopoietic transcription factor, which is important during erythroid differentiation. gata mutation r w has not been reported in literature and is a novel variant of gata mutation, which might be contributing to this patient's clinical picture. further studies are warranted to confirm gata mutation r w to be a pathogenic sequence change. alexander boucher, tomoyuki mizuno, alexander vinks, greg tiao, stuart goldstein, james geller cincinnati children's hospital medical center, cincinnati, ohio, united states background: hepatoblastoma (hb), the most common pediatric primary hepatic malignancy, can be associated with specific congenital syndromes. recently, chronic kidney disease and genitourinary anomalies have been linked to hb. cisplatin is a key chemotherapeutic agent in treating hb but its renal clearance and toxicity profile can limit its use for those with end-stage renal disease (esrd). objectives: using an institutional case series, we present data using cisplatin for hb in dialysis-dependent esrd and define recommended dosing for future use. design/method: a chart review of patients with concurrent hb and esrd on dialysis treated with cisplatin at our institution was undertaken. demographic data, diagnostic history, tumor pathology, alpha fetoprotein (afp), hearing assessments, dosing schema, treatment outcomes, and therapyrelated toxicities were reviewed. total cisplatin levels were collected at time points within days after each infusion. free cisplatin levels were also collected for infusions, as were dialysate cisplatin levels. pk parameters were generated using bayesian estimation with a published population pk model as a priori information. results: three patients meeting these criteria were identified. each had "low risk" (non-metastatic resectable) disease at presentation and underwent upfront resections. all had congenital renal anomalies with esrd prior to their hb diagnosis. all cisplatin infusions were given over hours, followed hours later by hemodialysis. patients and received cisplatin at % of children's oncology group's ahep weight-based dosing ( . mg/kg). patient received % of ahep body surface area-based dosing ( mg/m ) during cycle but required a second dose reduction ( mg/m ) for cycle due to prolonged cisplatin exposure (total area under the curve mg⋅h/l; average for all seven evaluable cycles mg⋅h/l) and early sensorineural hearing loss at - hz. no other hearing loss in any patient was identified; mild toxicities also included grade - emesis and grade neutropenia and thrombocytopenia. the median (range) of clearance, volume of distribution at steady-state, and elimination half-life at terminal phase for total platinum were . ( . - . ) l/hour/ kg, . ( . - . ) l/ kg and ( - ) hours, respectively. patients and received cycles with rapid afp normalization. patient required an additional cycles, for a likely second primary hb year after initial therapy. cisplatin can be used successfully in pediatric patients with esrd on hemodialysis to treat hb with minimal morbidity using % standard mg/kg-based dosing ( . mg/kg), achieving pharmacologically appropriate cisplatin exposures. background: treatment for immune thrombocytopenia (itp) has been grouped into rescue and maintenance therapy and often is reserved for patients with bleeding, severe thrombocytopenia, or for improvement in quality of life. splenectomy is considered one of the more invasive but definitive treatments with success rates of - %. treatment of itp can be more difficult in the setting of previous treatment with immune modulation or when the patient is immunocompromised and not a candidate for splenectomy. objectives: present an interesting case of a patient with an autoimmune disease that presented with severe thrombocytopenia, un-responsive to rescue therapy, and requiring emergent splenectomy in the setting of acute intracranial hemorrhage (ich). a year old female with a history of juvenile dermatomyositis presented with a fine purpuric rash on her extremities, wet purpura, and a platelet count of k/ l. bone marrow evaluation at that time was consistent with itp. she was on cyclosporine and plaquenil for dermatomyositis. platelets failed to increase after three doses of intravenous immunoglobulin and high dose steroids. following a two week course of oral prednisone and eltrombopag, she presented with persistent severe thrombocytopenia of k/ l, anemia of . g/dl, and a lower gi bleed. she was started on amicar, novo-seven, rituximab, and given platelet transfusions with no improvement in bleeding. subsequently, she developed a subdural hematoma with midline shift. surgery performed an emergent open splenectomy with concurrent continuous platelet transfusion. results: she was monitored closely post operatively and, due to ich, transfused to maintain platelets greater than k/ l. by week post-op she had normal platelet counts off transfusions. all medications were stopped within three days of discharge. she represented eight days later with abdominal pain and thrombocytosis and was found to have a portal vein, splenic vein and mesenteric vein thrombosis. she was started on lovenox therapy and admitted for monitoring due to her history of ich. it is unknown whether our patient's underlying immune dysregulation and history of treatment with immunosuppressive medications may have contributed to her unresponsiveness to multiple therapeutic agents. in addition, her significant bleeding did not allow us to fully evaluate her response to second tier therapy. this adds to the scarcity of literature of itp response in pediatric patients with autoimmune disease, and may support more aggressive therapy upfront in these patients. background: multivisceral organ transplantation involves concurrent transplantation of the stomach, pancreas, liver, and intestine with splenectomy, and has been classically used in the pediatric population for infants with intestinal failure from disorders affecting foregut integrity. while there is some data demonstrating its efficacy in adults with low-grade abdominal malignancies, it has not been traditionally used for hepatocellular carcinoma treatment. to describe a unique pediatric case of multivisceral organ transplantation as definitive therapy for refractory fibrolamellar hepatocellular carcinoma in an adolescent male. a year old male presents with a history of fibrolamellar hepatocellular carcinoma, tumor invasion of the portal vein, severe portal hypertension complicated by bleeding esophageal varices and hypersplenism. he had two treatments with yttrium- radioembolization, without significant response. he completed six cycles of traditional chemotherapy in combination with sorafenib with resolution of petavidity, but minimal decrease in tumor size and continued portal hypertension. since his disease remained relatively stable for over years, he was evaluated and listed for multivisceral organ transplantation. at approximately years and months after diagnosis, he underwent en bloc liver, pancreas, stomach, small bowel, and colon transplant with splenectomy. a single lymph node was positive for malignancy at the time of resection. in addition to expected post-transplant complications, he also developed skin only acute graft versus host disease at weeks after transplant, treated successfully with a thymoglobulin course. he clinically improved and was back to his baseline activity level, on full oral feedings within months post-transplantation. at three and six month post-transplantation, there is no concern for relapsed hepatocellular carcinoma on comprehensive imaging and evaluation. he is maintained on protocol immunosuppression and posttransplant support. we present the first known case of successful multivisceral organ transplantation in the treatment of refractory pediatric fibrolamellar hepatocellular carcinoma. background: hematohidrosis is a rare disorder that presents with spontaneous excretion of whole blood from intact skin or mucosa. diagnosis is based on clinical observation of the occurrence with the proven presence of erythrocytes and other blood components, without other abnormalities to account for the phenomenon. the existing literature is scarce and consists of primarily case studies. most reports describe bleeding from facial sites around the eyes, ears, and nose. the available literature suggests anxiety and physical or emotional stress reactions as the most common inciting events. little evidence exists regarding the ideal therapeutic approach, however propranolol has been used successfully to reduce bleeding frequency and severity in multiple case reports. a specific genetic etiology has not been elucidated, and no familial cases have previously been reported. we present a pair of half-siblings, both of whom presented with spontaneous cutaneous and mucosal bleeding before two years of age, and report on preliminary results of propranolol therapy. tanzania. at months of age, he became ill and developed spontaneous bleeding from his ears, nose, and scalp. he continued to have frequent bleeding episodes, usually related to illness or physical distress. a bleeding diathesis work-up was unremarkable, however some episodes were severe enough to require transfusions. the patient was subsequently diagnosed with hiv and hepatitis b, presumably acquired via unscreened blood product transfusions. patient b is an infant female born to the same mother as patient a, with a different father. she was healthy until two months of age when she developed spontaneous bleeding from the hairline, eyelids, ears and genital/rectal area. bleeding episodes were nearly always associated with irritability and crying. extensive coagulation workup was unremarkable. results: propranolol therapy was started in both patients, titrated to a goal of mg/kg/day. in both patients, the frequency and duration of bleeding episodes significantly improved. patient b continues to have milder occasional bleeding episodes from her eyes, ears and scalp but has significantly less discomfort and irritability during the episodes. conclusion: to our knowledge, there are no prior reports involving two related patients with hematohidrosis. this case series suggests that there may be a genetic predisposition which has yet to be identified. propranolol has shown effectiveness in reducing symptom frequency and severity. background: gliomas are the most common central nervous system tumors in children. they are classified into different grades based on genotype (idh, braf, tsc, etc.). lowgrade gliomas such as oligodendrogliomas, astrocytomas, and mixed oligoastrocytomas are classified as grades i and ii. of the molecular level alterations this case report focuses on the braf v e mutation. braf is a member of the raf family of serine/threonine protein kinases and it plays an important role in cell survival, proliferation and terminal differentiation. objectives: here we discuss two cases where dabrafenib, a braf kinase inhibitor, was utilized in the management of gliomas. the cases focus on the use of dabrafenib late versus early in disease course. design/method: patient jl is a year old female who was diagnosed with a low-grade glioneuronal tumor (c -t with a metastatic lesion to the brain) in . jl was treated with chemotherapy, radiation, and surgical resection. despite treatment, the patient's disease progressed. she developed lower extremity dysfunction, urinary incontinence, poor truncal control, and hydrocephalus. dabrafenib was started after the braf v e mutation was confirmed. patient lg is a year old female who presented in november with left facial and upper extremity weakness. ct and mri scans demonstrated a mixed solid and cystic lesion extending from the optic chiasm and hypothalamus to the right thalamus and posterior basal ganglia with additional involvement of the right cerebral peduncle. neurosurgical intervention was undertaken and dabrafenib was started after the braf v e mutation was confirmed. results: patient jl's mri scans have demonstrated improvement of the spine with diminished areas of enhancement along thecal margins, decreased volume and enhancement within the trigeminal plate cistern and resolution of ependymal enhancement within the right ventricle. the patient's most recent mri exhibits no disease progression in head or spine. jl has shown improvement clinically since starting dabrafenib. patient lg has shown improvement in strength and recent mri of the brain has shown resolution of enhancement along surgical resection margins, decreased hyperintensity along the inferomedial aspect of the right basal ganglia and no new enhancements. conclusion: low grade gliomas can alter a person's quality of life and even lead to life threatening complications. often the standard chemotherapy, radiation and surgery don't prevent these complications. genetic analysis can help clinicians target therapy towards certain mutations such as braf v e. dabrafenib has shown to decrease tumor burden, early utilization as therapy can help prevent morbidity and mortality. children's hospital of pittsburgh of upmc, pittsburgh, pennsylvania, united states background: copper is an essential cofactor in enzymatic reactions essential to proper hematologic, skeletal, neurologic and vascular function. copper requirements in children over the age of are mg/day, which is readily acquired in a typical diet. copper deficiency is known to occur in patients with the rare x-linked mutation and in older individuals with gastrointestinal bypass surgery; however, it is rarely reported in other conditions. objectives: to highlight individuals with autism spectrum disorders or developmental delay with a limited dietary repertoire are at risk for copper deficiency, thus a high index of suspicion must exist in order to diagnose the disorder. design/method: a y/o boy with a prior diagnosis of global developmental delay and oral aversion presented with slowly progressive fatigue, weakness, gait instability, and weight loss. his longstanding feeding difficulties were refractory to intensive feeding programs. his daily diet consisted of - oz of milk and - individual servings of butterscotch pudding ( - calories/day, . mg iron/day). initial complete blood count demonstrated white blood cell count of . , absolute neutrophil count of , hemoglobin of . , mean corpuscular volume of < , reticulocyte count of . , platelet count of . review of his peripheral blood smear revealed microcytic, hypochromic red cells without marked fragmentation, anisopoikilocytosis and ringed sideroblasts; there were no morphologic abnormalities of his leukocytes or platelets. iron studies demonstrated ferritin of , total iron binding capacity of , and % iron saturation. he had no evidence of b , folate deficiency or blood loss. additional evaluation revealed a serum copper level of (range - ), and cerulosplasmin of . (range - ). results: once a diagnosis of copper deficiency was made, the patient promptly began a course of parenteral copper repletion. he received iv copper mcg/kg/day x days then weekly intravenous infusions. given his malnutrition, a gtube was placed to begin oral copper repletion and enteral nutrition. within weeks his copper level improved as well as his blood counts. unfortunately, although his blood counts and copper levels normalized, his neurologic status remains below his old baseline although, he has made gains in his gross and fine motor abilities. conclusion: acquired copper deficiency in the pediatric population is a rare event but given the hematologic and neurologic consequences, prompt recognition and treatment is important. this patient's clinical course demonstrates the need to have a high index of suspicion of concomitant nutritional deficiencies other than those routinely evaluated such as iron, b and folate. background: lymphoepithelioma-like thymic carcinoma (lelc) is a rare, aggressive neoplasm with a high rate of invasion, metastasis and recurrence. there are no known curative therapies for metastatic lelc. we report the case of a -year-old male who presented with metastatic ebv positive lelc. sites of disease included a large primary anterior mediastinal mass and metastases to hilar lymph nodes, lungs and liver. he was initially treated with cisplatin and fluorouracil followed by mediastinal radiation. he had a partial response to therapy but his end of therapy scans showed disease progression in lungs, liver, and hilar, supraclavicular and axillary lymph nodes. objectives: molecularly targeted therapies tailored to the patient's genetic profile offer a novel approach to obtain improved survival outcomes. design/method: the patient enrolled on a precision medicine trial, nmtrc : molecular-guided therapy for the treatment of patients with relapsed and refractory childhood cancer (nct ). in this study, tumor/normal whole exome sequencing and tumor rna sequencing were performed and a molecular report detailing the results of genomic and gene expression analysis was generated. a treatment plan was designed within a molecular tumor board comprising oncologists, pharmacists, genomicists, and molecular biologists with domain expertise. results: exome sequencing revealed somatic coding point mutations and no structural mutations (focal copy number changes or translocations). candidate somatic driver mutations included tp s x and r w as well as kit n k. both genes have been previously implicated in thymic carcinoma. rna expression analysis demonstrated aberrant activation of biological pathways, including overexpression of kit, hdac , and , tyms, and dhfr. the molecular tumor board selected the combination of pemetrexed ( mg/m ) on day of a day cycle, imatinib ( mg daily), and vorinostat ( mg days - , - , and - ) . on day of cycle , he was admitted with a herpes zoster infection and imatinib was discontinued in order to reduce risk of herpes zoster recurrence. imaging after cycles showed a complete metabolic response on f- fdg pet and a partial response by ct size criteria. as of december , the patient had received cycles of pemetrexed and vorinostat. scans in december showed an increase in the size and metabolic activity of two right lower lobe pulmonary nodules. there were no new sites of disease and imatinib was re-started. background: systemic lupus erythematosus (sle) is a chronic autoimmune disease that affects multiple organ systems and is associated with many different autoantibodies. patients can present with vague constitutional symptoms including fever, rash, fatigue, and weight loss. some of the various hematologic manifestations of sle include anemia of chronic disease, leukopenia, autoimmune hemolytic anemia (aiha), and idiopathic thrombocytopenic purpura (itp). these can be the presenting signs of sle. evans syndrome (es), a disease characterized by itp and aiha, is a rare hematologic manifestation of sle. neurofibromatosis (nf ) is a relatively common neurocutaneous disorder. these patients are at risk of developing benign and malignant tumors. its association with autoimmune disorders, including sle, remains rare. objectives: there are few cases in the literature that have patients with the combination of sle and nf . this is the only case that has a patient with sle, nf , and es. results: a -year-old caucasian female presents with two months of vaginal bleeding, weight loss and petechiae. her exam is remarkable for petechiae and café au lait macules. laboratory findings show severe anemia and thrombocytopenia. she receives blood and platelet transfusions during stabilization, and a bone marrow aspirate is performed to rule out a malignancy which is negative. based on the presence of thrombocytopenia and a positive coombs test, an autoimmune process such as es is considered. screening tests for sle reveal positive antinuclear and anti-double stranded dna antibodies as well as low complement. she receives intravenous immunoglobulin and methylprednisolone and eventually her vaginal bleeding slows and her counts recover. she begins sle therapy with hydroxychloroquine and azathioprine. due to the presence of café au lait macules on her exam, a genetics evaluation is performed and the patient is also diagnosed with nf . to date, there are seven cases of sle with nf reported in the literature, only two of which are pediatric cases. there are no reports of the combination of sle, nf , and es. conclusion: es is a rare hematologic manifestation of sle but can be the initial presentation of this disease. one large study estimates % of childhood-onset sle cases are observed to have es. screening for sle should be considered in all es patients even in the absence of typical clinical findings. association of nf and sle has been rarely described. whether this association reflects a causal relationship or is coincidental needs more investigation. (lube, ped blood & cancer, ) . university of california san diego, la jolla, california, united states background: high grade glioma (hgg) has poor outcomes in adults and children. extraneural metastases are very rare in hgg, and poorly characterized with only a few small case series in adults and only isolated case reports in pediatrics. no genomic data has previously been published for any children with hgg who develop extraneural metastases. objectives: our objective is to describe the natural history of two children with hgg and bony extraneural metastases, comparing their clinical characteristics as well as whole exome sequencing data for both tumors. this information would suggest similar patients should be monitored closely for extraneural metastasis and may benefit from more systemic therapy. design/method: we present a case series of two patients who presented with hgg and had development of bony metastases less than six months after initial diagnosis. both patients had molecular profiling with whole exome sequencing (wes). the first patient was an -year-old male with a tumor found in the left lateral ventricle invading into the fornices, hypothalamus, and left midbrain, who had subtotal resection. bony metastasis were found at . months after diagnosis, and he died months after diagnosis. he initially received radiation, followed by nivolimuab. the second was a -year-old female with a tectal/pineal tumor and multiple spinal cord metastases, who had subtotal resection. she developed bony metastasis at . months after diagnosis and died months after diagnosis. her histologic diagnosis was pineoblastoma, revised to hgg after whole exome sequencing. she received craniospinal radiation followed by chemotherapy per acns (cisplatin, vincristine, and cyclophosphamide) for cycles. when she failed to respond satisfactorily to this therapy, wes of tumor was performed and the findings were consistent with hgg. treatment was transitioned to temodar and lomustine after hgg diagnosis was given. she had ongoing progressive disease despite this therapy as well as trials of nivolumab, everolimus, and vorinostat. neither patient had extraneural metastasis at presentation. in both tumors, whole exome sequencing identified the h f a k m mutation. both tumors also had additional known mutations associated with hgg but no other overlapping mutations. this case series represents the first description of the genetic alterations of pediatric hgg patients who developed extraneural metastases. while h f a k m is a common mutation in pediatric midline hgg, especially dipg, and is associated with more aggressive disease, there has not been an association with extraneural metastasis prior to this series. background: deferiprone-induced agranulocytosis is a well -known albeit rare side effect of the drug. incidence of agranulocytosis varies from . - . %, while milder neutropenia is reported in . % of patients treated with deferiprone. deferasirox is unknown to cause such a complication. clinical trials and post marketing side effect monitoring studied possible correlations between different risk factors and development of agranulocytosis. unfortunately, no studies directly addressed a special risk in a community with background of ethnic neutropenia, like oman. objectives: to report on the incidence of neutropenia among omani children with b thalassemia using different iron chelators design/method: a retrospective study conducted on patients < year-old with b thalassemia treated with different iron chelators. electronic patients records were reviewed to detect episodes of neutropenia either mild (anc . -< . /cmm), moderate (anc . -< ), severe < . , or agranulocytosis anc = ). data were collected including sex, age, personal or family history of ethnic neutropenia, iron chelating agent, infective complications, management and outcome. detailed clinical, laboratory ± radiological information were reported for patients who developed life-threatening agranulocytosis. among young patients with b thalassemia, treated between - in squh, neutropenia, was reported in patients ( . %).severe neutropenia was encountered on occasions in patients ( / : . %) ( on deferiprone including episodes of agranulocytosis, on defersirox, on combined chelation, and off chelation). moderate neutropenia was encountered in patients ( / : . %), on occasions: deferiprone ( ), deferasirox ( ), combined chelation ( ), and episodes off chelation. mild neutropenia was more prevalent, encountered in patients ( . %) on occasions ( on deferiprone, on defersirox, on combined chelation, and off chelation) of patients exposed to deferiprone, patients had neutropenia ( %), higher than previously reported. deferiproneinduced agranulocytosis was encountered in patients ( / = . %). three of them had life threatening complications. one patient developed pneumonia complicated by rupture of pulmonary artery aneurysm-massive hemoptysis, who recovered fully after catheter embolization. the second had facial cellulitis and treatment with gcsf was complicated by frequent ventricular extrasystoles. the third had sepsis, disseminated herpes simplex and required admission to icu for inotropic support. in a community with background ethnic neutropenia, neutropenia is more common to be encountered among thalassemic patients, both on and off chelation therapy. careful monitoring of anc and rational choice/modification of chelating agents is required for optimal management of iron overload and to avoid life threatening complications. objectives: this case control study aimed to evaluate the systolic and diastolic cardiac function in groups of children with ti: non transfused group and a group that received early regular blood transfusion comparing them to healthy controls. design/method: thirteen regularly transfused patients with ti with a mean age of . + . years were compared with eight patients who are non-transfused or minimally transfused (< rbcs transfusion/year); mean age . + . years and healthy controls with a mean age of . ± . years. clinical parameters and standard echocardiographic and tissue doppler imaging (tdi) were compared. results: young non-transfused ti patients had a statistically significant higher peak late diastolic velocity of the left ventricular inflow doppler, a mitral valve a wave duration over the pulmonary vein a wave duration ratio and the pulmonary s of s vein s/d velocities ratio compared to the transfused group with p values of . , . , . respectively. in addition, they have a lower e/a ratio of the mitral valve inflow and a larger left atrial to aortic diameter ratio compared to the control group with p values of . and . respectively. the diameters of the right and left outflow tract were significantly larger in the non transfused group with a trend to have a higher cardiac index compare to the transfused group. systolic function was similar in the studied groups and none of the patients had evidence of pulmonary hypertension. young patients with ti who are receiving early regular blood transfusion have normal systolic function. diastolic function assessment revealed indicators of an abnormal relaxation of the left ventricle in the non transfused group which indicate diastolic dysfunction. the abnormalities affected multiple diastolic function parameters which give an indication that the changes are clinically significant. a statistically significant increase in the diameters of the outflow tracts are likely attributed to high cardiac output status in nontransfused ti patients as they had a trend to have a higher cardiac index. these findings support the early commencing of regular blood transfusion therapy for ti patients to prevent serious cardiac complications in adult life. background: in the -week sustain study, crizanlizumab . mg/kg significantly reduced the frequency of scpcs versus placebo ( . vs . , p = . ) and increased the time to first on-treatment scpc ( . vs . months, p = . ) in patients with sickle cell disease (scd). to evaluate time to first scpc in sustain study subgroups and the likelihood of not experiencing scpc for the duration of the trial using post hoc analyses. design/method: sustain was a randomized, double-blind, placebo-controlled, phase study (nct ). inclusion criteria were: scd patients aged - years; - scpcs in previous months; concomitant hydroxyurea use permitted if ≥ months and stable dose for ≥ months. patients were randomized : : to receive intravenous crizanlizumab . mg/kg, . mg/kg, or placebo. study treatments were administered on days and , then every weeks to week , with the final assessment at week . median time to first scpc after first dose was summarized for crizanlizumab . mg/kg or placebo in these subgroups: - or - scpcs in previous months; scd genotype; and hydroxyurea use at baseline. hazard ratios (hrs) for crizanlizumab . mg/kg versus placebo were calculated based on cox regression analysis, with treatment as a covariate. descriptive statistics were used to summarize the frequency of patients who were scpc event-free for the duration of the study by prior scpc events, scd genotype, and hydroxyurea use at baseline. : patients received crizanlizumab . mg/kg and received placebo. there was a meaningful delay in time to first scpc with crizanlizumab . mg/kg versus placebo observed in the entire study population. the effect was present in both scpc subgroups, and the largest treatment difference was observed in hbss scd versus other genotypes ( . vs . months; hr: . ). in patients taking hydroxyurea who experienced - scpcs in the previous year, time to first onstudy scpc was longer with crizanlizumab . mg/kg versus placebo ( . vs . months; hr: . ). a greater proportion of patients treated with crizanlizumab . mg/kg were scpc event-free versus placebo in each of the analyzed subgroups. one third of patients who were taking hydroxyurea and treated with crizanlizumab . mg/kg were scpc event-free during the study versus . % with placebo, possibly suggesting an additive effect. with crizanlizumab . mg/kg, there was a clinically meaningful delay in time to first scpc and an increased likelihood of being scpc-free versus placebo in all subgroups investigated. cincinnati children's hospital medical center, cincinnati, ohio, united states background: shwachman-diamond syndrome (sds) is an inherited marrow failure syndrome associated with increased risk of myelodysplasia (mds) and acute myeloid leukemia (aml). objectives: this multi-institutional retrospective study investigated clinical features, treatment, and outcomes of sds patients who developed mds or aml by central pathology review. design/method: nine individuals presented with aml ( male, female), mds-eb / ( males, females, with mds ( male and female), and one male with isolated persistent somatic tp mutation. one mds-eb and mds patient progressed to aml. median age (years) at diagnosis of mds was (range . - ), mds-eb / was (range . - ) and aml was . (range . - ). complex cytogenetics were noted in / aml cases, with one having normal cytogenetics. complex clonal cytogenetic abnormalities were noted in of mds-eb /eb patients and clonal abnormalities in of mds patients. follow up was available for aml patients; are deceased. received chemotherapy with intent to proceed to hematopoietic stem cell transplant (hsct). four failed to achieve remission and died with disease without proceeding to transplant. one patient proceeded to hsct without prior chemotherapy. four of six transplanted subjects died with relapsed disease. treatment related mortality was largely infectious or gvhd. the sole surviving aml patient had normal cytogenetics, achieved remission with chemotherapy and underwent hscts with separate stem cell infusions due to two primary graft failures. he remains alive in remission more than years after diagnosis. of the mds-eb / patients, underwent ric hsct, three of whom are alive, one died of infection. the fifth patient has stable disease on continued decitabine monotherapy for . years. of mds patients with treatment data, had upfront hsct therapy, upfront chemotherapy and had no therapy. three patients required ≥ hscts all due to graft failure. follow up is available for , of whom are deceased, with relapsed disease. treatment related mortality was largely infectious or graft failure. one individual died of hepatic failure unrelated to mds. seven mds patients are alive in remission. in summary, prognosis is poor for patients with sds who develop aml due to resistant disease and treatment-related complications. better markers for risk stratification are needed to identify patients who would benefit from early transplant. novel therapeutic strategies are urgently needed to improve outcomes of sds patients with mds or aml. background: unlike primary myelofibrosis (pmf) in adults, which is associated with somatic mutations in jak , mpl, or calr, myelofibrosis in children is rare and the underlying genetic mechanisms remain elusive. here we describe families with autosomal recessive congenital macrothrombocytopenia with focal myelofibrosis (cmtfm) due to germline mutations in the megakaryocyte-specific immune receptor tyrosine-based inhibitory motif (itim) receptor g b-b. objectives: to characterize the clinical phenotype, histological features and identify the causative gene for cmtfm. we performed affymetrix snp . genotyping on the index family to identify shared regions of homozygosity by descent. whole exome sequencing (ws) was performed on all three pedigrees to identify potentially causative mutations. we studied affected children from families, with macrothrombocytopenia, anemia, mild leukocytosis and a distinctive pattern of bone marrow (bm) fibrosis centered around clusters of atypical megakaryocytes. affected children had mild to moderate bleeding symptoms and required platelet and red cell transfusions. none showed evidence of extramedullary hematopoiesis, and all were negative for mutations in jak , mpl, and calr. snp genotyping identified multiple statistically non-significant genomic loci, including the region of the major histocompatibility locus (mhc) on chromosome p (lod = . ). we focused on this region because affected individuals in two families shared a common homozygous human leukocyte antigen (hla) type and had congenital adrenal hyperplasia (cah) due to -hydroxylase (cyp a ) mutation; the cyp a and hla loci are located at p . and p . - p . . wes revealed homozygous frameshift mutations in the megakaryocyte and platelet inhibitory receptor g b-b, encoded within the candidate linkage region. we identified two distinct g b-b frameshift mutations (c. _ + dup; p. fs and c. inst; p. fs) in individuals within these three families. no other mutations that segregated with the phenotype were identified. to validate g b-b as a potential disease-causing gene, we evaluated g b-b expression in bm biopsy specimens from affected patient and control samples by immunohistochemical staining using a monoclonal antibody. g b-b was strongly s of s and selectively expressed in megakaryocytes of control samples, but completely absent in clinically affected individuals. a murine knockout that lacks g b-b has a strikingly similar phenotype with macrothrombocytopenia, myelofibrosis and aberrant platelet production and function, further affirming the causality of g b-b mutations. we showed that autosomal recessive loss-offunction mutations in g b-b cause cmtfm, uncovering the molecular basis of this rare disease. loss of g b-b-dependent inhibition of megakaryocyte activation likely underlies the distinctive focal myelofibrotic phenotype and might be important in other forms of marrow fibrosis. cardinal glennon, saint louis, missouri, united states background: intrauterine transfusion is the method of choice for management of fetal anemia due to red blood cell alloimmunization. despite the decrease in prevalence of anemia due to rhesus d alloimmunization with prophylactic administration of anti-rhd immunoglobulin in rh d negative patients, maternal red red blood cell alloimmunization with other type of red blood cell antigens remains an important cause of fetal anemia. newborn who received intrauterine transfusion for hemolytic disease may have prolonged postnatal transfusion requirement. objectives: -to evaluate clinical outcome of fetuses and newborns who received intrauterine transfusions. -to determine the need of packed red blood cell transfusions until months of age. we conducted a retrospective case series study of all intrauterine transfusions due to anemia secondary to red blood cell alloimmunization performed in our regional center ssm in st louis missouri, between april and january . we evaluated the indications, diagnosis, gestational age, and frequency of intrauterine transfusions, along with the infant's gestational age at birth, duration of admission, timing of blood transfusion and monitoring of hemoglobin. results: intrauterine transfusions were performed in patients. the most common causes of alloimmunization were due to d antibodies (n = , %) and kell antibodies (n = , . %). the median gestational age of the first intrauterine transfusion was . weeks, and the median pre-transfusion hemoglobin was . g/dl. the gestational age at the first intrauterine transfusions was found to be significantly correlated with the number of postnatal transfusions (r = . . p = . ). the median gestational age at birth was found to be weeks ( . - . weeks), with a hemoglobin of . ( . - . ). in our population, patients ( %) received postnatal transfusions, of which were during the first weeks of life, and close monitoring follow up with a hematologist was established in patients at their discharge from the nursery/nicu. one neonatal death occurred and severe morbidity due to severe anemia occurred in one infant. despite the continuing risk factor for persistent anemia, only patients had follow up hemoglobin monitored by their primary care provider. conclusion: infants with anemia due to red blood cell alloimmunization treated with intrauterine transfusion should be monitored closely via regular complete blood count for persistent anemia due to suppression of fetal erythropoiesis. sebastian hesse, piotr grabowski, juri rappsilber, christoph klein dr. von hauner childen's hospital, lmu university hospital, munich, munich, germany background: neutrophil granulocytes are the most abundant leukocytes in the peripheral blood. validated diagnostic options for these cells are limited, leaving many patients with functional neutrophil defects without a defined diagnosis. objectives: here we evaluate proteomics as a new diagnostic tool to investigate defects of neutrophil granulocytes. we analyzed neutrophil granulocytes from children with severe congenital neutropenia (scn) associated with elane mutations, children with chronic granulomatous disease (cgd) with cyba ( ) or cybb ( ) mutations and children with leukocyte adhesion deficiency (lad) due to itgb mutations. in addition we collected samples of children with genetically undetermined neutrophil defects. neutrophils from healthy individuals served as controls. cells were isolated from fresh venous blood using negative selection (purity > %). whole cell proteome analysis was done by data-independent acquisition. showed a correlation coefficient of ∼ . . principal component analysis demonstrated unequivocal separation of the proteome of healthy and diseased cells. differential expression analysis showed minimal proteome aberrations in lad with deficiency in cell surface receptors and upregulation of alpl (total downregulated proteins: / total upregulated proteins: ). analysis of neutrophils from cgd patients also showed limited proteome aberration. cyba and cybb were both diminished independent of genotype, whereas protein clusters around a stat / centered network were increased (total down: / up: ). neutrophils with elane mutations showed the gravest proteome disturbance (total down: / up: ) with an upregulated translational apparatus (srpdependent ribosomes and protein folding complexes) and increased mitochondrial proteins. proteins of each granule subset were dysregulated and metabolic pathways upregulated. a detailed analysis of the proteome from patients with genetically undefined diseases is currently ongoing. one patient with clinical phenotype of cgd was found to have no mutations of nadph oxidase members in whole exome sequencing but critically low levels of ncf on protein level. heterozygosity mapping showed autozytocity in the ncf region warranting current efforts to sequence promoters and intronic regions of the gene. mass spectrometry based proteomics promises exciting new insights into monogenic disease of neutrophil granulocytes and may offer new diagnostic options, in particular in synergy with genome sequencing. by virtue of our international care-for-rare alliance, open to new partners, we hope that our proteome focus may lead to better delineation of as yet unknown disease of neutrophil granulocytes. background: warm autoimmune hemolytic anemia (aiha) is an igg mediated disease. although it can be post-viral, it is often idiopathic and can also be a forme fruste for malignancy or an autoimmune disease. initial management includes steroids. it often relapses on steroid wean and can be refractory to the use of second line treatment such as rituximab. objectives: abatacept (ctla- -ig fusion protein, ctla- mimetic) has been used to ameliorate autoimmune manifestation associated with ctla- haploinsufficiency. we used abatacept as a novel therapeutic agent to manage patients with refractory aiha. design/method: a retrospective case series of two patients at phoenix children's hospital with severe refractory aiha. results: patient , a previously healthy year old female, presented with weeks of icterus, fatigue, and hemoglobinuria. spleen was enlarged cm below the costal margin. laboratory evaluation demonstrated: hemoglobin . g/dl, mild leukopenia /microliter, platelets , /microliter, reticulocytosis . %, positive direct coombs' test, mycoplasma igm and igg positive. bone marrow evaluation showed a hypercellular marrow. she continued to need packed red blood cell (prbc) transfusions despite receiving high dose steroids, ivig and rituximab from may-july . in august, she started sirolimus decreasing her transfusion requirement. after starting abatacept ( mg/kg/dose bi-monthly for three doses and then monthly) in october, she maintained hemoglobin of - g/dl without transfusion. patient , a previously healthy month old male, presented with one week of progressive fatigue, jaundice, and poor feeding. splenomegaly was absent. laboratory evaluation revealed hemoglobin . g/dl, leukocytosis , /microliter, platelets , /microliter, reticulocytosis . %, negative direct coombs' test, and non-specific reactivity on antibody screen. evaluation for inherited hemolytic anemia including a next generation sequencing panel was negative. further evaluation by blood bank showed + positive coombs' for c d due to a warm antibody. cold agglutinin disease was ruled out. bone marrow evaluation was normal. he received high dose ivig as a steroid sparing agent but continued to require prbc transfusions weekly. when prednisone did not seem to slow down hemolysis, treatment with abatacept was initiated and he has not required transfusions for two months. steroids are being weaned. we present successful treatment of two refractory aiha cases with abatacept. patient is steroid and transfusion free and continues on monthly abatacept and sirolimus. patient is also transfusion free and continues on a steroid taper. ctla- is crucial for suppressive function of treg cells. abatacept by binding to cd / seems to enhance treg activity ameliorating autoimmune hemolysis. children's minnesota, minneapolis, minnesota, united states s of s background: transfusional iron overload is common in patients receiving chronic red cell transfusions. as a result, iron chelation is required to minimize toxicity from iron overload. chelation with a single agent can be inadequate at controlling or reducing iron burden. when combination therapy is required deferoxamine may be added to oral chelation. deferoxamine is generally given subcutaneous over - hours for - days a week at - mg/kg/day. many patients struggle to remain compliant with this schedule which has prompted trials of intravenous high-dose (hd) deferoxamine. prior reports of short-term hd deferoxamine have shown minimal side effects however, prolonged use of hd deferoxamine has known toxicity. when compliance is a concern, our center has used hd deferoxamine infusions at mg/kg/hr x hours every to weeks. objectives: evaluate the safety and efficacy of hd deferoxamine at our institution to help guide future therapy. design/method: a retrospective review was completed of patients previously treated with hd deferoxamine between april and september at children's minnesota. final sample included patients ages to years with underlying diagnosis of thalassemia ( ) and diamond-blackfan anemia ( ). deferoxamine infusions were given for hours every - days with a mean length of treatment of days. results: all patients were on combination therapy with deferasirox, however deferasirox was held during deferoxamine infusion. mean pre-deferoxamine liver iron concentration (lic) was . mg/g and mean post lic was . mg/g (p = . ). ferritin mean pre-deferoxamine was ng/ml compared with mean post ng/ml (p = . ). two patients had possible allergy, leading to deferoxamine discontinuation. one patient developed hives, eye swelling and cough while the other had emesis and cough. another patient experienced facial nerve palsy of unclear etiology, which did not recur with resumption of deferoxamine. no respiratory complications were seen. results showed significant decrease in iron burden following combination therapy with high dose deferoxamine and deferasirox. no significant pulmonary, liver, renal, vision, or hearing toxicities were observed. three patients reported reactions to deferoxamine infusions. however, one of these was able to successfully continue deferoxamine without further incident. short-term, hd deferoxamine was effective at reducing lic in combination with oral chelation but requires further evaluation to assess for potential increased risk of toxicity. short-term hd deferoxamine may be considered in the setting of poor compliance of subcutaneous administration or inadequate chelation with single agent therapy. further studies are needed to clarify ideal dosing, timing and risk of toxicity. background: immune thrombocytopenia (itp) is the most common cause of symptomatic thrombocytopenia in childhood but remains a diagnosis of exclusion warranting further evaluation if atypical findings are present. two male children ( months and years old) with newly diagnosed immune thrombocytopenia (itp) were found on initial evaluation to have persistent elevations of lactate dehydrogenase (ldh), alanine aminotransferase (alt), and aspartate aminotransferase (ast). these serum enzyme abnormalities cannot be attributed to itp. in the setting of thrombocytopenia, elevated transaminases and ldh create diagnostic complexity for the hematology/oncology provider as their elevation raises concern for malignancy, hemolytic disease, and other systemic diseases. to raise awareness about an unexpected pattern of duchenne muscular dystrophy in patients undergoing evaluation for itp. to expand the differential of a hematologist/oncologist when abnormal labs support a nonhematologic diagnosis design/method: this case-series of two patients with their clinical and laboratory findings were discovered with retrospective chart review. results: after a thorough evaluation for hemolytic anemias, liver disease and infectious etiologies was negative, bone marrow and liver biopsies were considered. eventually, both children were found to have severely elevated serum creatine kinase (ck). skeletal muscle has the highest concentration of ck of any tissue. thus, significant ck elevation is almost exclusively attributable to muscle injury and is the most sensitive and specific enzyme for diagnosis of muscle disease. referral to a neuromuscular specialist and further genetic testing confirmed the diagnosis of duchenne muscular dystrophy in both children allowing initiation of appropriate interventions. to date, there is no clear genetic predisposition to itp in patients with muscular dystrophy although further investigation may be needed. hematology/oncology providers should consider obtaining a serum ck to rule out muscle disease in any male child with unexplained elevations of serum ldh and/or aminotransferases, as it provides an easy and inexpensive, non-invasive approach to screening. additionally, clinical history and physical examination can aid in the diagnosis of muscular dystrophy, with gross motor delay, abnormal muscle bulk, gower's sign, and proximal muscle weakness all possible findings. objectives: to identify the range of cbcs in patients with ds without infections, hematologic or immune disorders and to create more accurate reference ranges for total white blood count; hemoglobin; hematocrit; mcv; platelet count and absolute neutrophils (anc), lymphocytes, monocytes, eosinophils, and basophils. design/method: a retrospective investigation of healthy pediatric patients with ds who received a cbc between and as part of their medical care at a single, large, pediatric teaching hospital. the study group consisted of children with ds (male = , . %; mean age = . years, sd = . ) at time of blood draw. initially children were reviewed for possible participation in the study; however, patients were excluded due to not meeting the study's inclusion criteria. descriptive statistics were performed on demographic and clinical characteristics. kruskal-wallis h tests, anova, and t-tests were run to determine the significant associations between independent means. results: a significant difference in absolute neutrophils between racial groups, f( , . ) = . , p = . , was observed. there was an increase in anc from . +/- . with african americans to . +/- . in the other racial groups and to . +/- . with caucasians. differences were also found in anc in hispanics/latinos versus non-hispanic/latinos. the results were higher in non-hispanics and latinos, a significant difference of -. ( % ci, -. to -. ), t( ) = . , p = . . preliminary kruskal-wallis h tests run determined that there were significant differences between age groups for total white blood cell, hemoglobin, hematocrit, platelets, lymphocytes and anc. further studies are being run to evaluate in which age groups these differences lie and create reference ranges by age, race and sex. conclusion: among patients with ds, there are differences between racial groups and age groups. this data has been compared to previously established reference ranges for cbcs, but we are currently establishing healthy cbc controls which we will use to validate the reference ranges. these ranges will be published to help guide providers in workup and management of patients with ds. background: transfusion is a critical part of the care provided in the neonatal intensive care unit, but it is not without risks. low birth weight and premature infants can become anaemic from an immature haematopoietic system and frequent phlebotomy. these infants often receive multiple red blood cell transfusions. identifying infants more likely to require such intervention is important in ensuring the appropriate usage of this scarce resource. to determine whether birth weight, gestational age, gender, length of stay and mode of delivery can predict red cell concentrate (rcc) transfusion, units required, donor exposure and time to exposure. design/method: a retrospective chart review of all infants born below weeks gestation and/or birth weight less than , g who received a red blood cell transfusion between july and july in the cork university maternity hospital neonatal unit. results: infants met the inclusion criteria, ( . %) received a rcc transfusion. our study showed lower gestational age (p< . ) and lower birth weight (p< . ) infants are more likely to be transfused. donor exposure increases with a lower birth weight (p = . ). multivariate analysis showed infants with a lower gestational age (or - . per day; p< . ); lower birth weight (or - . per g; p< . ) and a longer length of stay (or . per day; p< . ) are more likely to receive a higher number of rcc transfusions. the time to first rcc transfusion is shorter in those with lower birth weight (or . per g; p< . ) and lower gestational age (or . per day; p< . ). gender and mode of delivery were not found to be predictors of red blood cell transfusion in this study. conclusion: low birth weight and premature infants are more likely to receive a rcc transfusion during admission to the neonatal unit. our study highlights predictors of rcc transfusion, donor exposure and time to transfusion. these can be used in identifying at risk infants, counselling parents and in anticipating transfusion requirements. emily southard, r. grant rowe, david williams, akiko shimamura, taizo nakano children's hospital colorado, aurora, colorado, united states background: the mecom locus encodes transcription factors that regulate hematopoietic stem cell self-renewal and maintenance. overexpression of mecom has been noted in - % of acute myeloid leukemia, several solid tumors, and denotes a poor prognosis. mutations that reduce mecom expression or that disrupt protein function, however, have been implicated in the development of bone marrow failure (bmf) through undefined pathways. an association between mecom mutations and radioulnar synostosis with amegakaryocytic thrombocytopenia (rusat) syndrome has been reported, however further characterization of this phenotype has yet to be explored. to characterize the phenotypic spectrum of a cohort of pediatric patients with novel mecom mutations. we performed a retrospective review of five patients with mecom mutations who were referred to hematology at children's hospital colorado or boston children's hospital. clinical, laboratory, and genetic data was collected on subjects and available family members. results: four of subjects were identified in infancy presenting with congenital cytopenias or physical dysmorphisms that prompted broad genetic screening. platforms for genetic detection included microarray, targeted genetic panels, and whole exome sequencing. three of subjects with cytopenias presented with congenital thrombocytopenia, of whom rapidly progressed to severe aplastic anemia. four of subjects presented with congenital anomalies, of whom demonstrated radioulnar synostosis. additional dysmorphic features identified include craniofacial (low set ears x ), cardiac (pda x , vsd x , aortic root dilation x ), pulmonary (pulmonary hypertension x , arteriovenous malformations x ), and developmental delay. one subject presented at age years with acute pancytopenia, hypocellular marrow, no dysmorphisms, and a mecom variant of unknown signif-icance. the identified mecom mutations include one . mb deletion involving several genes including mecom, one variant affecting a splice acceptor consensus sequence predicted to disrupt splicing, and three novel missense mutations, tyr cys, arg thr, and tyr cys, all of which were absent from public databases and were predicted in silico to be deleterious. we describe the phenotypic spectrum of patients with novel mecom variants. a subset of patients lacked radio-ulnar synostosis and had presence of additional systemic anomalies, demonstrating a varied clinical phenotype that is not isolated to rusat syndrome. a centralized publically accessible database to share clinically annotated mecom variants, together with analysis by experts in mecom function would advance our understanding of the clinical interpretation of mecom variants. mecom should be considered in the differential diagnosis of bone marrow failure and we advocate for the inclusion of mecom in targeted sequencing panels. cairo university, cairo, egypt background: beta thalassemia is regarded as a serious public health problem in the mediterranean region, southeast asia, and the middle east. however, very few studies have been conducted to assess the quality of life (qol) among thalassemia major patients. objectives: to assess the quality of life among b-thalassemia major patients using short form (sf)- questionnaire and to determine the factors associated with their quality of life. design/method: a cross-sectional study was conducted among thalassemia major patients who were attending the hematology outpatient clinic at cairo university hospital, during the study period. data were collected between october and march . the quality of life was assessed for patients aged ≥ years. the mean age of the studied group was . ± . years. the majority ( . %) had one monthly blood transfusion. the mean total score of sf- was . ± . . general health perception domain was the most affected domain with mean score, while vitality was the least affected one. there was no statistically significant difference between males and females regarding different quality domains except for vitality where the mean score was significantly higher in males than females (p = . ). age at onset of disease, and at first blood transfusion were the most documented factors positively correlated with the quality of life among the enrolled thalassemia patients. conclusion: the quality of life in thalassemia major patient was found to be compromised. all thalassemia patients should undergo assessment of the quality of life so that interventions focusing on the affected domains can be implemented. background: international adoption of children with special needs has become more prevalent in recent years leading to tremendous growth in the number of u.s. thalassemia patients adopted from foreign countries. currently % of the , thalassemia patients registered in the cooley's anemia foundation (caf) patient database have been adopted from foreign countries, primarily china. as this population continues to grow, further information is needed in order to provide these families with best supportive care. the primary goal of this study is to characterize the socio-demographics and health statuses of adopted children with thalassemia and their families. a secondary goal is to describe adoptive families' motivations, experiences, challenges, and support resources. design/method: a redcap survey was accessed by families of adopted children with thalassemia through the caf website and caf social media from january to august . following a four-question screen, eligible subjects were directed to complete an adoption questionnaire. families who had at least one adopted child with thalassemia receiving care at a participating thalassemia treatment center or hematology office in the u.s. were considered eligible. descriptive statistics were analyzed using sas . . respondents who were ineligible or who provided incomplete data were removed from the dataset prior to analysis. of survey respondents, qualified and completed the survey. these households had adopted a total of children with thalassemia ( . % male), most from china ( . %), where they had been living in orphanages ( . %). legal guardians identified primarily as christian ( . %). the majority had completed post-secondary education ( . %) with reported household incomes greater than $ , ( . %). most adoptive families were connected to an adoption group or community including online groups, local support groups, and adoption networks ( . %). commonly cited challenges were: ) volume of frequent medical appointments, ) insufficient support from their local care centers, and ) financial burdens. the reality of care for the population of adopted patients with thalassemia in the u.s does not seem to match the expectations set by their providers. we are hopeful this data will be used to assist adoptive families navigating the complexities of thalassemia care. the findings suggest that this population would benefit from additional outreach, education, guidance, and advocacy resources -especially in the early stages of adoption and during initiation of post-adoption medical care. background: in many higher-income countries, thalassemia major has become a chronic disorder; many outcomes are different in emerging countries with more limited resources. most analyzes of health-related quality of life (qofl) in thalassemia have been conducted in high-income settings. objectives: to assess the impact of health status on qofl in thalassemia patients in an emerging country. we assessed qofl in randomly-selected patients ( thalassemia major; with hemoglobin e thalassemia; five thalassemia intermedia) at the national thalassemia center in kurunegala, sri lanka where approximately patients are managed. treatment is free, but compared to north america/europe, access to tertiary staff and other resources are limited. overall, control of body iron as estimated by serum ferritin concentration (mean± sem, ± g/l) was not optimal in many patients. to understand the impact of health status on qofl, we used the sf v health survey, analyzing scores of physical function, pain, general health, social functioning, emotional and mental health, to generate overall physical and mental component scores. results: compared to reports from higher-income countries (american journal of hematology ; : - ), physical function scores (mean±sd, . ± . ) were similar in sri lankan patients; indeed, in three categories (physical role, social function, emotional role), sri lankan scores were slightly higher. by contrast, compared to scores from higherincome settings, those estimating bodily pain, general health, and mental health were significantly lower, resulting overall in a significantly lower physical component score in sri lankan patients. male sri lankan patients reported higher scores than females, and somewhat surprisingly, in four categories (physical function, physical role, social function and emotional role) reported higher scores than those obtained in higher-income settings. lower scores in physical functioning, leading to an overall lower physical component score, were recorded by females. patients with hemoglobin e thalassemia reported generally poorer qofl than those with thalassemia major. the lack of differences in qofl in patients with "high" and "low" hemoglobins was likely related to low pre-transfusion hbs (mean±sem, . ± . g/dl) in nearly all patients. these early data in a small cohort of thalassemia patients in an emerging setting suggest that in many patients bodily pain, reduced mental health, and poorer views of general health affect overall qofl. prospective studies in larger cohorts including evaluation of adequacy of transfusions and chelation therapy, complications, and overall accessibility of care may guide approaches to improve qofl in lower-income settings of thalassemia care. geetanjali bora, anand prakash dubey, tarun sekhri, mammen puliyel, aparna roy maulana azad medical college, new delhi, delhi, india background: in the last two decades, the presence of osteopenia has been described in optimally treated patients with transfusion dependent thalassemia, the pathogenesis of which seems to differ from osteopenia in non-transfused patients. the prevalence rate of low bone mineral density (bmd) in pediatric population is highly variable amongst studies done worldwide. furthermore, the role of metabolic and endocrine factors in determining bone mass in this population is not well understood. objectives: to assess bmd in subjects with transfusion dependent beta thalassemia by dual-energy-x rayabsorptiometry and find its co-relation with clinical, biochemical and hematological parameters. design/method: this is a comparative cross-sectional study and includes patients with transfusion dependent beta thalassemia between ages to years enrolled from a thalassemia day care center in the year - . at the time of enrollment age, sex, bmi z scores, pubertal staging, duration and type of chelation therapy were noted. enrolled subjects were scanned for bmd at lumbar spine l - and left femoral neck using dexa scan. the bmd was expressed in mean values and z scores. age, bmi, ethnicity and gender matched historic controls were used to generate z scores. ml of pre transfusion fasting venous blood samples were obtained to test for serum calcium, phosphate, alkaline phosphatase, pth, thyroid function panel, serum ferritin and serum igf- levels. mean values for pretransfusion hemoglobin and serum ferritin over last months were calculated. results: total no of subjects , median age . years, male ( %), female ( %), ethnicity % asian, bmi < rd centile ( %), pre pubertal %, all receiving transfusion and chelation therapy. prevalence of low (z score < - sd) and very low (< - . sd) bmd was %, % at l -l respectively and %, % at left femoral neck respectively. there was trend of lower bmd z scores with advancing age. statistically significant co-relation (p value < . ) was found between low bmd and low mean pretransfusion hemoglobin, serum phosphate, igf - and vitamin d levels conclusion: a sizable proportion of children and adolescents with transfusion dependent thalassemia have suboptimal bone mineral density and this decline may start as early as - years of age despite being on transfusion regimen highlighting the importance of yearly dexa screening and optimization of pre-transfusion hemoglobin, vitamin d and igf levels. vanderbilt university medical center, nashville, tennessee, united states background: it is well described that iron deficiency anemia (ida) can co-present with thrombocytosis or thrombocytopenia, though cases of thrombocytopenia are less frequent than thrombocytosis. prior reports of thrombocytopenia have included adult and pediatric patients with menorrhagia ( - ), menorrhagia due to uterine fibroids ( ), or other gynecologic abnormalities ( ). our cases highlight the pattern of ida, thrombocytopenia, and menorrhagia in the setting of significant menstrual clotting without observed gynecologic abnormalities in african-american adolescents. objectives: to describe the clinical course of three adolescent females with severe ida, menorrhagia, and thrombocytopenia. results: our cases included three female african-american patients ages - who presented with severe anemia and concurrent thrombocytopenia in the setting of menorrhagia. all three patients reported heavy and prolonged menstrual cycle bleeding with significant clots. two of the three were admitted for transfusions at presentation and noted to have significant menstrual bleeding with continued blood loss requiring additional transfusions until bleeding was controlled with estrogen therapy. these two patients were evaluated with pelvic ultrasounds revealing a prominent endometrium in both patients and hyperechoic material consistent with a clot in one patient. average hemoglobin on presentation was . gm/dl ( . - . ), average platelet count was , /mcl ( , - , ), and average mcv was ( - ). all had severe iron deficiency with an average ferritin of ng/ml ( - ) subsequently treated with oral iron. one patient had a prior history of ida that required transfusion and had subsequent normalization of her complete blood count. two patients had subsequent thrombocytosis before normalization of their platelet counts. two patients received platelet transfusions: one due to recent neurosurgical intervention with a higher goal platelet count and the other to help control menstrual bleeding after a nadir platelet count of , . a review of the clinical history and red cell indices pointed to ida and ongoing blood loss from menorrhagia as the reason for the bicytopenias. the thrombocytopenia in these cases may have been exacerbated by consumption of platelets in the significant clots all three patients reported. it is reasonable to treat with iron supplementation and supportive care which may include transfusions or management of menorrhagia with oral contraceptives or other hormonal methods. background: sickle cell disease is one of the most common inherited red blood cell disorders, yet many are not aware of their carrier status. the american college of obstetricians and gynecologists' guidelines recommend that pregnant women of african, mediterranean and southeast asian descent be screened for hemoglobinopathies with a cbc and hemoglobin electrophoresis . however, adherence to this practice and frequency of improper screening with sickledex is unknown. proper screening and counseling can impact families' knowledge, allowing for establishing relationships with pediatric hematology providers earlier. objectives: we sought to assess prenatal hemoglobinopathy screening practice patterns and methods of obstetrics & gynecology (obgyn) and family medicine providers in the nyc regional area. design/method: a cross-sectional electronic survey was administered to obgyn and family medicine practitioners from four nyc institutions. questions focused on prenatal hemoglobinopathy screening practices using case scenarios with variations on parental trait status and ethnicities. chisquare analyses were used to compare the two provider groups on categorical variables. there were total responses; surveys were complete, of which were obgyn and family medicine providers. respondents were mainly from academic medical centers, with the majority being faculty ( % of the obgyns and % of family medicine). no significant difference was found in frequencies of screening patients with a positive family history of a hemoglobinopathy. when asked about screening practices for patients without a personal/family history of a hemoglobinopathy, % of obgyns versus % of family medicine providers "always" screened for hemoglobinpathies (p = . ). when analyzed by ethnic background, there were significant differences by group in screening patients of white ( % vs %), black ( % vs %), mediterranean ( % vs %), and asian descent ( % vs %) (p≤ . for all). however, in cases where the hemoglobinopathy carrier status of both parents was known, there was no difference in screening with a hemoglobin electrophoresis. furthermore, > % of all respondents use sickledex for screening in the case scenarios. conclusion: this pilot survey highlights a difference in the methods and likelihood of prenatal hemoglobinopathy screening based on the type of prenatal care provider. screening differences can lead to variations in prenatal guidance, diagnostic procedures, informed decision-making and knowledge of families referred to pediatric hematology clinics. this is the first study analyzing prenatal screening for hemoglobinopathies in obgyn and family medicine. improving prenatal screening practices by collaborating with hematologists may decrease health care disparities and allow for earlier relationship building with pediatric hematology. . acog, opinion# , poster # hermansky-pudlak syndrome: spectrum in oman background: hermansky-pudlak syndrome (hps) is a rare autosomal recessive disorder, characterized by the triad of oculocutaneous albinism, a hemorrhagic diathesis resulting from storage pool-deficient platelets, and accumulation of ceroid/lipofuscin-like material in various tissues. before , nine different types of hermansky-pudlak syndrome were identified, which can be distinguished by their signs and symptoms and underlying genetic cause. in , a tenth type was defined based on mutations in the ap d gene. hps type is characterized in addition by severe neutropenia and recurrent sinopulmonary infection. the disease is more common in puerto rico, and this is the first report from oman. to describe the clinical, laboratory and genetic characteristics of hps sub-types in oman, including the first cases of hps type . design/method: this is a retrospective study, including cases with hps that had been suspected clinically and confirmed through genetic mutation analysis. clinical data included sex, age at presentation, initial clinical presentation (skin, eyes, development, neurological involvement, bleeding tendency, recurrent infections) and course of disease. laboratory data (complete blood counts, platelet and absolute neutrophil counts, coagulation screening, platelet function tests by platelet function analyzer, and platelet aggregation studies using different agonist had been recorded. pcr and next generation sequencing for genetic confirmation by testing mutations in hps , ap b , hps , hps , hps , hps , dtnbp ,, bloc s , bloc s genes had been done. results: seven omani cases with hps have been identified ( males and females). their age ranged between (at birth) to years. two patients had hps type , patient had type , while the other cases had hps type . no other sub-types were encountered in oman. all patients were products of consanguineous marriage. one patient had adrenal hge, while the others had mild hemorrhagic phenotype, characterized by recurrent bruising and mild epistaxis. laboratory testing confirmed variable platelet aggregation defects with different platelet agonists. all patients had characteristic hypopigmentation, iris transillumination, nystagmus, and foveal hypoplasia. both patients with hps type had the same homozygous mutation in the ap b gene (c. _ delta), and presented with severe neutropenia. early diagnosis and initiation of gcsf on one of them improved outcome and prevented the development of complications. late diagnosis in the other patient resulted in the development of bronchiectasis as a result of recurrent sinopulmonary infections. background: sickle cell disease (scd), a genetic disorder characterized by defective sickle hemoglobin (hbs), triggers red blood cell sickling, hemolysis, vaso-occlusion, and inflammation. ischemic injury from scd starts in infancy and accumulates over a lifetime, causing pain, fatigue, and progressive end-organ damage that culminates in early mortality. voxelotor (gbt ) is an oral, once-daily therapy that modulates hemoglobin's oxygen affinity, thereby inhibiting hemoglobin polymerization. objectives: to assess the safety, pharmacokinetics, and efficacy of voxelotor in pediatric patients with scd. design/method: this ongoing study is being conducted in parts: part a: a single dose of voxelotor mg in pediatric and adolescent patients; part b: multiple doses of voxelotor mg/d or mg/d for weeks in adolescents. part b's primary objective is to assess the effect of voxelotor on modifying anemia. secondary objectives include measuring other markers of disease modification, such as hemolysis; daily scd symptoms, using a patient-reported outcome (pro) measure; and safety. results: as of november , , patients ( females) had received voxelotor mg and patients ( females) had received voxelotor for ≥ weeks. the median age for the patients was years, % were receiving hydroxyurea (hu), and % had ≥ painful crises in the past year. data for hemolysis measures are available for patients who received voxelotor for weeks. six of the patients achieved a hemoglobin (hb) response of > g/dl increase. laboratory markers of hemolysis improved concordantly; the median reductions in reticulocytes and indirect bilirubin were % and %, respectively. ten of patients showed reduction in total symptom scores (tss) at week , with a % median reduction in tss from baseline. there were no treatmentrelated serious adverse events (aes) or drug discontinuations due to aes. voxelotor mg for weeks in adolescents with scd, the majority receiving hu, demonstrated consistent, sustained efficacy on hb levels and measures of hemolysis; > % of patients showed a > g/dl improvement in hb. improvement in tss in mildly symptomatic patients suggests that the pro is sensitive to treatment effect and supports use in the ongoing hope phase study. voxelotor's reassuring safety profile is consistent with results in adults. these interim results support ongoing clinical evaluation of voxelotor as a potential disease-modifying therapy for adults and children with scd. supported by global blood therapeutics. background: acute kidney injury (aki) is a common complication in sickle cell disease (scd), and a potential risk factor for sickle nephropathy. aki is associated with acute decline in hemoglobin (hb) during vaso-occlusive pain crisis and acute chest syndrome (acs). it is unclear which pathologic factor plays a stronger role in aki development during hb drop: increase in free heme during vaso-occlusive events secondary to hemolysis or hb decline itself. objectives: to investigate if hb decline alone is associated with aki, we tested if the renal function of patients with scd worsened during parvovirus b -induced transient aplastic crisis (tac), in the absence of accentuated hemolysis. design/method: with irb approval, a retrospective study of patients who had laboratory confirmed parvovirus-b was conducted. serum creatinine (scr), both during and within months from the tac event, was collected. comparisons of the clinical and laboratory characteristics were analyzed using the wilcoxon test for continuous variables. aki was defined as an increase in scr by ≥ . mg/dl or a % increase in scr from baseline. to evaluate differences in change in hb on aki risk, changes in scr during tac were compared to those during pain crisis or acs admissions by fitting a generalized linear mixed model for binary outcome. a comparative sample of acs events and vaso-occlusive pain crisis were used to estimate rates of aki according to hb levels. results: three ( %) of the patients with scd developed aki during tac. no association was identified between change in hb from baseline to tac event (p = . ). no cases of aki were identified until hb decreased < . g/dl or the change in hb was ≥ . g/dl from baseline. next, we developed a model to evaluate the impact of change in hb from baseline for patients admitted with tac, pain crisis or acs on aki. with a g/dl decrease in admission hb from baseline, patients with tac had a % probability of developing aki, while acute chest syndrome and pain crisis would have a % and % probability, respectively. our data suggest that aki is still prevalent during parvovirus b -induced tac. however, the risk of aki during a tac event is and times lower than that from severe anemia induced by acute chest syndrome and vasoocclusive pain events, respectively. hemolysis-induced anemia during scd crisis appears to have a more significant role in the development of aki as compared to agenerative anemia. background: the natural history of hemoglobin e beta thalassemia (hbethal), the commonest form of severe beta thalassemia worldwide, has been examined in very few longterm studies. previously, we reported findings in hbethal patients in sri lanka. objectives: to evaluate longterm requirements for transfusion and splenectomy, complications and death in hbethal patients. design/method: all available patients were reviewed - times annually over years. results: patients ( %) died, aged (mean ± sem) . ± . years; the (known) causes commonly included iron overload ( ) and infection ( ); patients surviving patients are aged . ± . years. of patients originally classified by severity (group the mildest, and group the most severe, phenotypes), ( %) were assessed as mild (groups and ), of whom transfusions had been discontinued in . ultimately, / ( %) resumed transfusions, often following shifts to increasingly severe phenotypes including increasing intolerance to anemia. age at resumption of transfusions (following a transfusion-free interval of . ± . years) was . ± . years; in the more severe groups and , regular transfusions were stopped in / patients and resumed in / ( %), at younger ages ( . ± . years) and after shorter transfusion-free periods ( . ± . years) than in "milder" patients. mid-parental height (mph) was ultimately achieved in %. patients ( %) were splenectomized; updated analysis of responses to splenectomy (originally "group " patients), showed that splenectomy (at . ± . years) was followed by an extended, but impermanent, transfusion-free interval ( . ± . years); % patients resumed transfusions, usually related to exercise intolerance or poor growth. in groups and , complications of anemia and ineffective erythropoiesis, including leg ulcers (in % and %) and gallstones ( % and %), were more frequent than in groups and ; fractures were observed ( - %) across all groups, except for regularly-transfused group patients ( %). pulmonary artery pressures > mm were recorded in % patients. evaluation of patients with hbethal requires observations over years, without which definition of patients as "mild" or "severe" may be misleading. while in many patients transfusions may be withheld or reduced in frequency, troublesome complications may surface with advancing age even in "milder" patients. although individual consideration of transfusion requirements is critical, the availability of effective chelation, where this can be provided without prohibitive cost, may alter the balance of risks and benefits of regular transfusions in hbethal. (premawardhena a. lancet ). background: social determinants of health (sdh) are environmental and socioeconomic factors, such as access to food and housing that affect health outcomes. pediatricians are increasingly screening for sdh as part of primary care visits, however less is known about screening for sdh in pediatric hematology. evidence suggests that sdh play a role in disease severity for children with scd, who face significant socio-economic and racial disparities. the goal of our quality improvement (qi) project was to increase the percentage of patients with scd who were connected to community resources for unmet social needs. design/method: we based our intervention on the successful implementation of wecare in our institution's pediatric primary care clinic. eligible patients were identified at the start of each clinic session. on arrival the parent was given a self-reported screening tool for six sdh (childcare, education, employment, food, utilities and housing). results were entered in the electronic health record by the physician or social worker who then printed a pre-existing resource list for patients with a positive screen. we used a series of plan-do-study-act (pdsa) cycles to study tests of change. we tracked process measures (percentage of patients screened, percentage of patients with an unmet social need who received a resource sheet), outcome measures (percentage of patients with an unmet social need who connected with a community resource) and balancing measures (staff, patient and provider satisfaction). run charts were reviewed weekly and then monthly to inform further tests of change. examples of pdsa cycles include who gave the paper survey to patients (social worker or physician versus medical assistant) and length of time between surveys ( to months). results: between august and december screening rates improved from % to %. of the patients screened, % report at least one unmet social need; of those % received a targeted list of community resources in the first month of the project, and % in the fifth month. finally, % of patients reached by phone had connected with a community resource within weeks of the clinic visit. we have successfully implemented universal screening for sdh for patients with scd in our urban pediatric hematology clinic without requiring extra staff. next steps include further pdsa cycles to connect more patients to appropriate resources, and tracking improvement in health care utilization outcomes from addressing sdh in this vulnerable patient population. background: the clinical manifestations of sickle cell disease (scd), chronic hemolytic anemia, and vaso-occlusion occur as a direct result of sickle hemoglobin (hbs) polymerization. voxelotor (gbt ) is a first-in-class, oral, oncedaily investigational agent designed to modulate hemoglobin's oxygen affinity in a targeted approach to inhibit hbs polymerization. objectives: to examine the pharmacokinetics (pk), safety, and dosing of voxelotor in children (aged - years) and adolescents (aged - years) with scd from part a of the gbt - study. design/method: gbt - is an ongoing, open-label, phase a study in patients aged - years with scd (sickle cell anemia or sickle beta zero thalassemia). part a of this study (the focus of this abstract) is examining pk of singledose ( mg) voxelotor. pk samples to measure whole blood and plasma voxelotor concentrations were collected up to days following single-dose administration. separate population pk (ppk) models were developed to describe the concentration versus time profiles of voxelotor in whole blood and plasma using nonlinear mixed effects modeling (non-mem, version . ). ppk modeling and physiologically based pk (pbpk) modeling were used to simulate voxelotor pk parameters and support dose selection for future evaluation in younger children. : part a included adolescents ( females; median age years [range - ]) and children ( females; median age . years [range - ]). mean weight was . kg (range - kg) and . kg (range - kg) in adolescents and children, respectively. voxelotor was well tolerated with no drugrelated grade ≥ adverse events (ae) or serious aes. a compartment model with first-order absorption best described the pk of voxelotor (and was the same model structure used for adults with scd). voxelotor pk exposures in adolescents were comparable to those observed in adults, but higher exposures were observed in children. ppk and pbpk modeling support the use of a weight-based dosing strategy in younger children (aged < years) in future trials. adult voxelotor doses can be used in adolescents. however, based on higher pk exposures, a lower weight-based dosing strategy is recommended in children. ppk and pbpk modeling provides an innovative approach to minimize experimental dosing in children and accelerate dose selection of voxelotor in ongoing and future clinical studies. this abstract is supported by global blood therapeutics. background: hydroxyurea (hu) reduces rates of acute complications, and improves long term outcomes in patients with sickle cell disease (scd) and is now fda approved for children. through previous work we have increased the number of eligible patients on hu in our clinic, however accessing a compounding pharmacy remained a significant barrier to hu adherence for infants and children who cannot swallow capsules. objectives: the objective of our quality improvement project was to improve adherence to hu among pediatric patients with scd at our urban safety net hospital by addressing barriers to obtaining liquid hu. design/method: to begin we met with the leadership of our outpatient pharmacy which offers mail order delivery. however, like most retail pharmacies, they do not have the necessary protective equipment to compound liquid hu. through a series of discussions, we began a unique partnership with our institution's inpatient chemotherapy pharmacy who compounds the liquid hu and delivers it to the outpatient s of s pharmacy, who then dispenses liquid hu to families. using a series of plan-do-study-act (pdsa) cycles we tracked adherence by calculating the medication possession ratio (mpr), defined as the percentage of days in a given period of time that each patient had their medication on hand. the mpr for liquid hu mpr among enrolled patients was tracked by pharmacy staff and reviewed monthly. additional pdsa cycles included adding automatic refills and reminder calls by pharmacy staff and improving communication about delivery. we also tracked patient satisfaction. results: between march and december , a total of thirty pediatric patients were enrolled in our program for on-site compounding and free mail order delivery of liquid hu. mpr for liquid hu is currently . % among enrolled patients, significantly higher than the mpr of % reported in the literature, and has risen steadily since the beginning of the project. families are highly satisfied with the program, specifically appreciating the convenience of mail order delivery, saving on delivery fees, and reminder calls when refills were due. by compounding and dispensing liquid hu directly from our institution's outpatient pharmacy we have significantly improved adherence to this hu therapy in our high-risk population. next steps include analysis of change in clinical outcomes for patients enrolled in this program. as adherence to hydroxyurea is associated with decreased acute care utilization and cost, programs such as ours could play a crucial role in reducing the excessive costs and ed utilization among this patient population. background: experience with the iron-chelator deferasirox is reported widely in higher-income settings. by contrast, real-life experiences in emerging countries are infrequently reported. objectives: to evaluate, in a non-trial setting, the real-life response to deferasirox in an emerging country. design/method: in sri lanka's national thalassemia center which manages patients without tertiary staff, quantitative evaluations of body iron or estimates of extra-hepatic iron, the records of patients who began deferasirox in / were retrospectively reviewed. results: baseline assessments (mean±sem) indicated substantial iron loading [serum ferritin (sf) , ± ug/l; serum alt ± . u/l (normal ≤ u/l)]. deferasirox was introduced at low doses ( . ± . mg/kg/day); many patients started at < mg/kg and, after months, doses remained ≤ mg/kg/day in % patients. after months, sf in % patients remained > , ug/l; only by months had (mean) sf declined to < , ug/l ( ± ; p< . ). similarly, mean alt normalized (to ± u/l) only by months. death and complications were not systematically recorded by staff who had been charged, without provision of additional resources, with the introduction of this new drug in hundreds of patients. these results contrast to those in sri lanka's tertiary thalassemia center where, in patients following the introduction of deferasirox ± . mg/kg/day, sf declined rapidly, even in relatively less ironloaded patients (from , ± to , ± g/l after months; p = . ). these findings underscore the importance, during the implementation of new drug regimens in lowerincome centers with marginal resources, for investments in methods to quantitate body iron burden, hands-on educational initiatives to guide day-to-day management by competent but non-expert staff, and data systems to record efficacy, effectiveness, toxicity and compliance. such investment is critical to optimising therapy and improving complications in thalassemia patients worldwide: even in sri lanka, where resources directed to thalassemia management are greater than in most of asia, results in the oldest living cohort (born - ) indicate under-treatment [elevated iron burdens (sf , ± ug/l) and high prevalences of diabetes ( %) and hypothyroidism ( %)]. even in a younger cohort (born - ) which has benefitted from improved treatments, the prevalence of many complications exceeds those reported from high-income settings. over the next decade, and two decades after the who declaration that the impact of thalassemia on global mortality and morbidity is underrecognized, increased investments by governmental and nongovernmental sources will be necessary to improve outcomes for asian patients with thalassemia. background: a major barrier to success in hydroxyurea (hu) treatment of patients with sickle cell disease (scd) is non-adherence. objectives: to optimize hu adherence in patients with scd. design/method: a care model was designed by the sickle cell (qi) team at children's hospital to improve hu adherence among scd patients. the original model included bimonthly family phone contact, monthly dispensing pharmacy phone contact and lab monitoring. adherence measures included obtaining hu from pharmacy monthly, completion of monthly labs, hb f percentage and mcv, and mtd achievement. from / - / , several pdsa cycles refined our care model. a one-year follow-up survey gathered feedback on the care model. the first-year data involved ∼ patients. the biggest improvements resulted from making pharmacy calls before patient/family calls, shipping liquid hu to outlying patients, and tracking call time/content. the qi goal was % hu adherence by / . the % baseline adherence rate increased to % by / , and has remained in that range. the completion rate of patient/parent phone calls increased from % the first month to % at six months. pharmacy prescription pick-up has increased from % to % per month. lack of liquid hu availability was overcome by shipping the medication to the patient's home. parental hesitance to share information by phone, especially with qi team members with whom they had no established relationship, was overcome by having the longtime sickle cell nurse do many of the early calls. however, survey feedback showed families became comfortable with several clinic personnel calling. the calls gave families the opportunity to ask questions about their child and/or get additional information about scd. the calls also provided an opportunity for seasonal flu shot or tcd testing reminders. the surveys gave information on the optimal time of day to reach each family, providing individualization and further increasing the percentage of completed calls. two families surveyed said they no longer needed two calls a month because they were now able to remember to pick up hu, administer it, and get labs on their own. this qi project has not only improved hu adherence, but also fostered health education/counseling, increased patient/parent satisfaction, and enhanced service utilization. medical team member and patient/family comments demonstrate that it has helped build relationships and trust between families and the medical care system. based on survey feedback, we will further individualize care to increase adherence rate and sustain improvements. cincinnati children's hospital medical center, cincinnati, ohio, united states background: the thalassemias are a heterogeneous group of genetic blood disorders caused by mutations that decrease or eliminate the synthesis of the -and/or -globin subunits of hemoglobin. the phenotype of thalassemia depends on the interaction of the -and -globin gene clusters, because both loci determine the -/ -chain balance. for example, a -thalassemia phenotype can be more severe than expected when coinherited with -globin gene triplication (copy number gain), which exacerbates the -/ -globin imbalance. objectives: describe four individuals with an incorrect diagnosis of -thalassemia trait who were later properly diagnosed by comprehensive genetic testing to have -thalassemia intermedia caused by heterozygous -thalassemia mutations coinherited with triplicated -globin loci. design/method: sequence analysis of the -globin (hba /hba ) and -globin (hbb) genes, and copy number variation analysis of the -and -globin gene clusters by multiplex ligand-dependent probe amplification. results: four unrelated individuals of northern european ancestry were evaluated for signs and symptoms not explained by a diagnosis of -thalassemia trait (previously made by a pediatric hematologist), including growth delay, splenomegaly, moderate anemia, marked elevation of hemoglobin f, thalassemic facies, reticulocytosis, and/or indirect hyperbilirubinemia. genetic testing revealed that all were heterozygous ( / ) for the same, single -globin mutation [hbb.c. c>t (p.q *)] and also heterozygous for an -globin triplication ( / anti- . ). their previous diagnoses of thalassemia trait had been made by complete blood counts, hemoglobin electrophoresis, and/or sequence analysis of the -globin genes only. these individuals' phenotypes ranged from moderate anemia only to multiple stigmata of thalassemia, demonstrating the phenotypic variation of a thalassemia genotype. correct diagnosis was made at an average age of . years. a trial of chronic transfusions was initiated for one patient for growth failure. all were educated about the potential for exacerbations of anemia, gallstones, osteoporosis, and iron overload (even without transfusions). parental genetic testing was recommended to assess reproductive risk, because inheritance of this complex genotype can be apparently autosomal dominant. conclusion: heterozygosity for a -thalassemia mutation does not necessarily indicate -thalassemia minor or "trait". when coinherited with -globin gene triplication, a symptomatic form of -thalassemia can occur. correct and timely diagnosis of thalassemia requires careful consideration of the degree of anemia and examination for organomegaly, bony changes, and jaundice. sequence analysis and copy number variation analysis of both the -and -globin gene clusters is key. hematologists need to be aware of this diagnostic possibility and how to test for it to prevent inaccurate or delayed diagnosis. background: the burden of healthcare costs for sickle cell disease (scd) is nationally estimated at over $ billion. the major components of these costs are inpatient and emergency center (ec) visits, many of which are potentially avoidable. in several chronic conditions, a subset of patients account for most of the avoidable encounters. identifying these patients is the first step in targeted care delivery. objectives: to measure and analyze scd patient utilization patterns in the ec and inpatient at texas children's hospital (tch). we identified all individuals under years old with any encounter at tch associated with an international classification of disease (icd)- or code for scd, including hgb ss, hgb sc, and hgb s/beta thalassemia. for each patient, we identified all inpatient and ec encounters in the days prior to their most recent encounter. finally, each encounter was classified as associated with pain, acute chest syndrome (acs), or "other" using an algorithm of discharge diagnosis codes and pharmaceutical delivery. the total number of scd-associated ec and inpatient encounters over the prior year was calculated for each patient. we stratified each patient according to their utilization patterns: low ( - encounters), intermediate ( - encounters), and high (≥ encounters). we identified unique patients with scd that had at least one encounter from july until june . there were , scd-related encounters in the days prior to their most recent encounter. most ( %, n = ) patients exhibited low-utilization patterns and % (n = ) were intermediate. finally, a small subset ( %, n = ) demonstrated high-utilization patterns and accounted for % of all encounters. high-utilization was associated with older age and public payment mechanisms. pain encounters were predominantly in pre-adolescents and teenagers with high-and intermediate-utilization patterns. acs was most frequent in pre-teens and younger teens in the intermediate-utilization group. finally, the youngest-aged high and intermediate users presented for other reasons such as febrile episodes and splenic sequestration. our findings reflect national trends in that a significant portion of encounters are attributed to a small subset of patients exhibiting a high-or "super-" utilization pattern. at our institution, scd super-utilization is associated with older age and pain. we also identified a group of infants and toddlers with frequent encounters for fever. to comprehensively address this burden, it will be important to design interventions targeted toward age and specific medical needs. background: background: the rarity of diamond blackfan anemia (dba) has hindered describing the spectrum of disease, identifying predictive correlations, and guiding datadriven recommendations. long-term toxicities from steroid or transfusion therapy that start in childhood remain the major clinical problems in patients with dba who do not receive stem cell transplant. objectives: objective: to define the dba patient population at st. jude children's research hospital including treatment responses and toxicities to help inform recommendations on treatment and monitoring. design/method: method: medical records were reviewed for all patients with dba treated at st. jude between and for diagnostic testing, treatment types and regimens, and outcomes. two-sample t-test or wilcoxon rank sum test was used to compare continuous variables in two groups depending on the normality of the data tested by shapiro-wilk test. results: a total of patients with dba were identified with a median age of . years (range months - years) at last follow up. a ribosomal protein gene mutation was identified in / patients ( %) with an rps mutation / ( %). thirteen different congenital malformations were described in / patients ( %). fourteen of twenty ( %) patients treated with corticosteroids had an initial response and of those achieved full remission. three patients became steroid-refractory and were unable to wean to an acceptable dose. five of twenty patients continue on lower-dose steroids. five patients currently require no therapy. univariate analysis revealed no statistically significant genetic predictors of response or remission, however, / rpl patients responded to steroids with / ( %) in long-term remission. ten patients are maintained on chronic transfusions and have undergone successful hematopoietic stem cell transplant. nineteen of treated patients ( %) had a treatment-related toxicity. patients on steroids were more likely to have short stature than patients on transfusions or in remission (p = . ). severe bone mineral density deficit occurred in / ( %) patients, in before age years. eight patients had hepatic iron overload, in one documented by age years. other severe toxicities included restrictive cardiomyopathy from iron overload, pathologic fracture, diabetes mellitus, and premature ovarian failure in one patient each. this genotypically and phenotypically heterogeneous dba cohort had a high rate of treatment-related toxicities, notably growth retardation, bone density loss, and hepatic iron overload even in very young children. these findings underscore the need for early standardized monitoring. background: patients with sickle cell disease (scd) face worsening morbidity and mortality between ages and , when they must transition from pediatric to adult healthcare.( ) an effective curriculum addressing disease knowledge, educational and vocational skills, self-efficacy, and social supports is critical to a successful transition. traditional didactic approaches have not led to durable knowledge retention. ( ) technology-based methods have been attempted, but the best educational approach remains unknown. objectives: . to understand how adolescent and young adult (aya) patients with scd view existing transition education. . to include patient preferences in improving our transition curriculum. we developed a qualitative survey to assess patient views of existing approaches for learning about scd and their opinions about preferred transition topics. thirty patients with scd aged to years old were recruited between january and december . responses were managed using redcap electronic data tools hosted at the university of rochester.( , ) qualitative and quantitative data analyses were performed, including independent t-testing to compare responses between age groups. results: approximately % of subjects were under years of age, while % were or older. seventy-one percent had a computer, and . % had a cell phone, with most reporting daily use. subjects reported greatest satisfaction with learning from their doctor during clinic visits ( . % agree or strongly agree) and websites on a cell phone ( . % agree or strongly agree); the least popular methods were online chat rooms and microsoft® powerpoint presentations. satisfaction was similar across age groups. recommended transition topics were viewed positively, with subjects ranking highest understanding their bloodwork ( . % agree or strongly agree) and understanding laws protecting students with chronic disease ( . % agree or strongly agree). older subjects ( - years old) agreed more strongly with learning about opioid addiction and understanding differences between adult and pediatric doctors than did younger subjects ( - years old) (p < . ). this pilot study was successful in helping us to understand the educational needs of aya patients with scd. preliminary data underscore the importance of education provided by the pediatric hematologist. our results also suggest that the optimal use of technology-based methods requires further investigation and that tailoring transition education by age group may be useful. background: similar to patients with transfusion-dependent beta-thalassemias (tdt-beta), survivors of hemoglobin barts hydrops fetalis (homozygous alpha- -thalassemia, tdtalpha) will require lifelong transfusions of erythrocytes. we have previously shown that a transfusion strategy that is based on the guidelines developed for tdt-beta (conventional transfusion) is suboptimal for these patients owing to the differences in the pathophysiology of anemia in the two conditions: in tdt-alpha, conventional transfusion strategy will lead to a gradual increase in non-functional hbh with subsequent tissue hypoxia and hemolysis. an aggressive transfusion strategy that was based on reduction of hbh and increase in "functional" hemoglobin level resulted in improvement of tissue oxygenation and reduction of hemolysis but was associated with significant increase in transfusional iron burden [amid et al, blood ] . objectives: to define the optimal chronic blood transfusion targets for hbh% and functional hemoglobin in patients with tdt-alpha. design/method: following research ethics board approval, longitudinal data of patients with tdt-alpha ( males, median age . ( . - . ) were retrospectively collected. variables of interest included total pre-transfusion hemoglobin, hbh%, and "functional" hemoglobin [measured as total hemoglobin x ( -hbh/ )]. outcome variables were lactate dehydrogenase (ldh, marker of hemolysis), and soluble transferrin receptor (str, marker of erythropoiesis). hemoglobin analysis was done using high-performance liquid chromatography and capillary zone electrophoresis. we examined the association of "functional" hemoglobin with str, and hbh% with ldh, using repeated-measures anova to adjust for the effect of multiple testing. we constructed receiver operating characteristic curve and calculated the area under the curve to define the best cut-off values for variables of interests. there was a strong association between functional hb and str, as well as hbh and ldh. the optimal cut-off for "functional" hemoglobin that was associated with str < . mg/l was g/l (auc = . , sensitivity and specificity of . % and % respectively). the optimal cut-off for hbh to supress ldh to < u/l was % (auc = . , sensitivity and specificity of . % and % respectively). the optimal pre-transfusion hbh% for reduction of hemolysis was % and the optimal "functional" hemoglobin to adequately supress erythropoiesis was g/l. to meet these hbh% and functional hb targets by simple blood transfusions, patients with tdt-alpha would require a hypertransfusion regimen with a minimum pre-transfusion total hb of g/l and consequently high transfusional iron burden. an alternative approach using exchange transfusion to reduce hbh% and improve functional hemoglobin would be associated with less volume of transfusion and potentially better long-term outcome. hospital sacre coeur, milot, haiti background: initial results of work developing a pediatric sickle cell disease (scd) clinic at the hôpital sacré coeur (hsc) in milot, northern haiti were presented at aspho . the purpose of this clinic is for a pediatrician with a special interest in scd to provide scd care, advising on trait and managing disease with penicillin prophylaxis (pcn) and hydroxyurea therapy (hu) for select patients. this clinic was started in collaboration with a us based hematologist and support from yale-new haven hospital. objectives: to describe the success and challenges of providing pcn and hu in the scd clinic at hsc through a review of patient records. design/method: since this clinic's inception, a database of patients, with basic clinical information has been kept and made accessible, through 'drop-box', to the us hematologist. the records of those that presented to the clinic were reviewed. the hemoglobin diagnosis was made either by clinical history and sickle cell prep or by hemoglobin electrophoresis through alpha laboratory, port-au-prince, haiti. results: ninety-nine individuals were seen in the first years of the program. fifty-six underwent a hemoglobin electrophoresis. of these , are ≤ years old. thirty-two were started on pcn vk, of which / ( %) were ≤ years old. eleven patients were started hu therapy. all patients on hu have shown progressive increases in hemoglobin. there have been no clinical complications of hu therapy. none of the patients taking hu have required hospitalization or transfusion in . three patients (not on hu) were hospitalized in for complications of scd (osteomyelitis, pain). in , with less than half the numbers in the program, there were admissions for severe anemia, pain, stroke and splenic sequestration. with ongoing external support and a local reputation for excellence in sickle cell care, the clinic at hsc has been able to expand services and improve the health of a growing number of patients with scd. early data suggests that pcn and hu therapies are helping to reduce complications and improve quality of life. challenges to date have included lack of funding for transportation to clinics, for hospitalizations and to cover the cost of electrophoreses. at the same time as continuing providing excellent care and gathering data, it is crucial to explore opportunities for collaboration and cooperation in ways that will assure that the clinic can become independently sustainable while continuing to improve the quality of life for the individuals it serves. background: ykl- is an inflammatory glycoprotein expressed by infiltrating macrophages in various inflammatory conditions. it has been found to be elevated in patients with different pathological conditions like acute and chronic inflammations, increased remodeling of the extracellular matrix (ecm), development of fibrosis and cancer. several studies have found elevated ykl- concentrations in sera of patients with liver diseases such as hepatic fibrosis by hepatitis c virus. it has been suggested that ykl- concentrations reflect the degree of liver fibrosis. to evaluate serum ykl- levels in patients with -thalassemia and its relation to viral hepatitis, liver stiffness as assessed by transient elastography (fibroscan, fs) and hepatic iron concentration. design/method: a prospective study included patients with -tm ( males and females) with mean age . ± . years (range: - years). serum ferritin level, liver enzymes (alt and ast), hbs ag, anti hcv ab and serum ykl- using elisa kit were evaluated. all patients were subjected to liver mri t * to detect liver iron content by the sequence and transient elastography (fibroscan, fs) to assess degree of liver stiffness. results: mean fibroscan value was ( . ± . ) kpa with a median . (range . to ) kpa. ( %) patients were categorized as f - and ( %) were stage f - , ( %) patients had severe fibrosis. their median serum ferritin was ng∖ml, with ( %) patients had values exceeding g/l. median cardiac t * was . with patients had values below ms, and the median lic was . mg/g dw with patients showed readings above mg/g dw. nyl- was evaluated as a marker of inflammation and liver fibrosis and showed mean value . (± . ) pg/ml, and range from to pg/ml. mean ykl- was significantly higher among males (p = . ), patients on chelation therapy (p = . ), patients on dfs (p≤ . ), in those with abnormal liver enzymes, splenectomised patients, patients with hbv sero-positivity, those with moderate elevation of t * and patients with high grades of liver fibrosis (p< . ). ykl- showed positive correlation with the rate of transfusion, lic, ferritin, alt and ast but negative correlation with weight, height and t *. roc curve analysis revealed that the cutoff value of ykl- at pg/ml could differentiate -tm patients with and without viral hepatitis with . % sensitivity and specificity of . %, area under the curve (auc) . , positive predictive value . and negative predictive value . (p< . ). roc curve analysis revealed that the cutoff value of ykl- at pg/ml could detect -tm patients with liver cirrhosis with . % sensitivity and specificity of . %, area under the curve (auc) . , positive predictive value . and negative predictive value . (p< . ). conclusion: serum ykl- levels are elevated in patients with -thalassemia and can detect patients with active viral hepatitis and liver stiffness. background: the most common splenic complication in pediatric patients with sickle cell disease (scd) is acute splenic sequestration (ass), which has often been managed with splenectomy. although splenectomy has been a treatment of choice for years, long-term vascular complications have not been thoroughly evaluated. pulmonary hypertension (phtn) is a severe complication of scd. in adults with scd, phtn has been associated with a -month mortality rate of approximately %. it has been reported that splenectomized patients with hemolytic disorders are at even greater risk of phtn. several medications exist to treat phtn, but with few studies of their efficacy or toxicities in patients with scd. additionally, these patients are often treated with either chronic prbc transfusions or hydroxyurea (hu) to raise hemoglobin, reduce hemolysis, and prevent vaso-occlusive events. objectives: to evaluate effect of chronic prbc or hu vs. no intervention, on tricuspid regurgitant jet velocities (trv) in pediatric patients with scd and history of splenectomy. design/method: retrospective chart review of splenectomized patients with hbss followed at marian anderson center at st. christopher's hospital for children, philadelphia, between and . we analyzed trvs ( hu, prbc, and from control group receiving neither treatment) from patients ( hu, prbc, neither). mean age at echo was . +/- . . data was analyzed with linear correlations and analysis of variance (anova), including the post hoc test of least significant difference (lsd) for all pairs of treatment groups. results: trv was not significantly correlated with age at time of assessment or with time between splenectomy and trv. univariate anova among groups yielded trv means of: . +/- . cm/s (hu), . +/- . (prbc), . +/- . (neither). we found a notable difference as the mean of the hu group was almost cm/s lower than the others, but no overall statistically significant association for any of the groups exists. however, when we performed post hoc tests to adjust for multiple comparisons and looked at all pairings within the anova, we found that the lsd between the hu and the prbc groups was statistically significant (p = . ), and that a trend exists between the hu group and the neither treatment group (p = . ). our data suggests that treatment with hu is correlated with a reduction in trv in pediatric patients with scd who underwent splenectomy. given these promising results, we believe our data warrants further study with larger treatment groups. nancy olivieri, gaurav sharma, susmita nath, rajib de, tuphan kanti dolai, prakas kumar mandal, abhijit phukan, amir sabouhanian, robert yamashita, angela allen, david weatherall, prantar chakrabarti background: hemoglobin e thalassemia (hbethal), which accounts for % of all severe beta thalassemia worldwide, has an estimated prevalence of . / , in west bengal, from which little information about clinical findings has been reported. objectives: to document clinical and laboratory findings in patients with hbethal, ultimately to improve resources for clinical management. design/method: we reviewed records from: a database recording patient names; clinic charts; "special" charts containing additional details; and, in transfused patients, transfusion day-care records. additionally, because in india's public hospitals original lab/imaging reports are commonly retained at home, % of families were interviewed to provide additional information. we excluded records of patients aged < years and patients aged < years who had not been reviewed since . results: while at least one visit had been recorded in , hbethal patients at nrs hospital, most patients are not regularly reviewed there. we examined charts [ ( %) aged ≥ years; ( %) aged - years; % male], representing approximately % of regularly-reviewed patients. most families ( . %) reported monthly incomes (< , indian rupees), below the monthly cost of living ( , rupees) in kolkata. mean (±sem) hemoglobin was . ± . g/dl. % patients were receiving eight or more transfusions per year; from , % had been treated with deferasirox, . ± . mg/kg/day. iron control estimated by serum ferritin concentration ( . ± g/l) was highly variable. a total of % patients were splenectomized. a substantial obstacle to documenting complications was the lack of recording, in any of the five sources, of many relevant parameters: for example, the status of sexual maturation (normal, delayed, or absent) was documented in less than %, and measurements of fasting blood glucose in less than %, of records. where recorded, complication rates were high: delayed/abnormal sexual maturation was recorded in % patients aged > years; in the patients aged > years and those aged - years, respectively, hypothyroidism was recorded in % and %, and elevated serum alt in % and %. in most evaluable patients > years, height was measured between the rd- th percentiles. cardiac findings, rarely documented, included pulmonary hypertension and reduced left ventricular ejection fractions in a few patients. despite dedicated attention to many aspects of thalassemia care, insufficient documentation limited a clear understanding of the current morbidity in hbethal patients. investment in personnel and technology will be critical to record relevant information, ultimately to improve clinical management, over the next decade. children's hospital of richmond at vcu health, richmond, virginia, united states background: sepsis is a common cause of death in children with sickle cell disease (scd). recommendations for care of fever in children with scd include immediate medical evaluation including blood culture and initiation of broad-spectrum antibiotic therapy. the increasing availability of pcr-based respiratory pathogen panels (rpp) provide the opportunity to rapidly identify viral causes of fever. the role for rpps in identifying the source of fever in children with scd and how it affects provider practice is not well studied. ( ) to determine the epidemiology of respiratory virus-associated fever in children with scd and ( ) to determine whether a positive rpp is associated with reduced risk of bacteremia in this population. this was a single-center, retrospective cohort study. we identified and reviewed the medical records of all children with scd seen in our emergency department (ed) with temperature ≥ . oc at home or in the ed from january , , through september , , as well as, all febrile children for whom rpps were sent since the introduction of rpps april . we reviewed the results of blood cultures, rpps, chest radiographs, and ed notes and discharge summaries to identify sources of infections. independent t test and chi-square analysis were used as appropriate to compare results using spss©. overall, the rate of bacteremia was %. there were no cases of bacteremia among children with positive rpps. % of children with negative rpps had true bacteremia. a positive rpp did not reduce the likelihood of bacteremia (p . ). patients with bacteremia had higher presenting temperatures than those without bacteremia ( . oc vs . oc, p . ). the most common rpp findings were rhinovirus/enterovirus ( %), human metapneumovirus ( %), and influenza a ( %). sending an rpp did not affect admission rate ( % and % respectively, p . ); however, likelihood of admission was lower in patients with positive rpps ( % vs %, or . [ . - . ], p . ). length of stay (los) was shorter in patients for whom an rpp was not sent ( . vs . days, p . ). as previously reported, bacteremia in febrile children with scd is very low, but remains a serious concern, particularly in the setting of high fever (> oc). a positive rpp did not reduce the odds of bacteremia, but did have a sta-tistically significant impact on both admission rate and los. more work is needed to understand how rpp results impact provider decision-making and care for children with scd. cincinnati children's hospital medical center, cincinnati, ohio, united states background: diffuse myocardial fibrosis is a common, if not defining, feature of the heart in sickle cell anemia (sca) that is strongly associated with diastolic dysfunction. we found diffuse myocardial fibrosis in every patient in a sca cohort (n = ) ranging in age from to years (niss ). the treatment and prevention of this complication of sca has not been studied before. objectives: because diffuse myocardial fibrosis must begin in early childhood, we hypothesized that early initiation and uninterrupted use of disease-modifying therapy for sca can prevent it. design/method: we use cardiac magnetic resonance imaging (cmr) to measure the myocardial extracellular volume fraction (ecv) to quantify diffuse myocardial fibrosis in individuals with sca who have been treated, uninterrupted, with hydroxyurea or chronic transfusion therapy since ≤ years of age. two comparison groups were used: individuals with sca who have not been treated with disease-modifying therapy since ≤ years of age (n = ) and controls without sca (n = ). results: we studied individuals ( m/ f) with a mean age of . years (range - ). mean age at the start of diseasemodifying therapy was . ± . years (range - ). only had evidence of mild diffuse myocardial fibrosis (ecv . ); the other had no detectable diffuse fibrosis (all had ecv < . , the upper limit of normal). mean ecv was . ± . , which was significantly lower than the ecv of individuals with sca who have not received early uninterrupted therapy ( . ± . ; p = . ) and not statistically different from normal controls ( . ± . ; p = . ). none had macroscopic fibrosis by late gadolinium enhancement or evidence of myocardial hemosiderosis by t * imaging. no patient had diastolic dysfunction by echocardiographic classification, right heart catheterization, or both. disease-modifying therapy for sca can prevent diffuse myocardial fibrosis, and possibly diastolic dysfunction, if started in early childhood. prospective trials of disease-modifying and anti-fibrotic therapy are planned to prevent diffuse myocardial fibrosis, which can be monitored noninvasively by cmr, and improve outcomes in sca. (niss, blood, ) . background: a statewide sickle cell surveillance system (sscss) was developed with the goal of determining the prevalence of sickle cell disease (scd) in indiana and the level of care that patients receive throughout the state. persons with scd are at high risk of infection, especially with encapsulated organisms, as well as at increased complications from influenza. utilizing sscss data, the relationship between vaccination status and mortality was explored. to determine if vaccination status is associated with mortality in persons with scd. the project was granted a waiver of consent by the st. vincent irb. death certificates were obtained to identify cause of death. deceased patients (cases) were matched by age, gender, and sickle genotype to living patients (controls). vaccination data were collected from the medical record and the children and hoosier immunization registry program (chirp) through the date of death for each case. cases and controls were assigned a point for completion of the pneumococcus, meningococcus and haemophilus influenza type b (hib) vaccine series and one point if the influenza vaccine was given within a year prior to death of the cases [max vaccine status score (vss): ]. total points were compared between the cases and controls. two tailed t-tests to compare means of continuous data and wilcoxon signed-rank test to compare ordinal data. one thousand forty-eight individuals were included in the sscss. six hundred and seven ( . %) were seen at one institution and included in this analysis (mean age = years). thirty-three of the ( . %) were deceased at the time of analysis. six point one ( . )% of controls and . % of cases received a vss of . the mean vss for cases was . ± . and . ± . for controls. thirty point three ( . ) % of controls had a vss of one or more, compared to % of cases (p = . ). patients who died of infection [streptococ-cus (n = ), pseudomonas (n = ) and unidentified organisms (n = )] were not up to date on vaccination against encapsulated organisms, but two had received the influenza vaccine in the year prior to death. in this sample, mortality occurred exclusively among adult patients, which is consistent with current patterns in developed countries. among these adults, vss and mortality rates were not related. limitations to the study include small sample size and potential incompleteness of vaccine records. vaccination rates and other standard of care indicators should be explored in a larger cohort of patients to determine associations with mortality. background: sickle cell disease (scd) is a genetic disorder resulting in acute and chronic complications, including delayed puberty. delayed puberty can have adverse physical and psychosocial effects on affected children and families. there are no published reports from ghana on pubertal timing in children with scd. the aim of this cross-sectional study was to describe pubertal changes in children with scd at korle bu teaching hospital (kbth), accra, and compare these findings to those in a control group without scd. design/method: children with scd and children with hb aa, ages - years, were consecutively recruited and matched for age, sex and socioeconomic status. investigator-administered questionnaires were used to obtain demographic data for all participants and information on menarche (girls only). pubertal status was assessed by physical examination using tanner staging. testicular volumes were determined in boys using a prader orchidometer. body mass index (bmi) and socioeconomic status (ses) of participants were analyzed to determine if there were any associations with tanner stage. of the with scd, ( . %) were hb ss and ( . %) hb sc. females comprised . % (cases and controls). mean age at onset of breast development was significantly delayed in girls with scd ( . ± . years) compared to controls ( . ± . years) but there was no significant age difference at onset of pubic hair development. mean age at menarche was significantly delayed in girls with hb ss ( . ± . years) and hb sc ( . ± . years), compared to those with hb aa ( . ± . years). in boys, the mean ages at onset of puberty were significantly delayed in those with scd ( . ± . years, for genital development and . ± . years, for pubic hair development), compared to those without scd ( . ± . years and . ± . years, respectively). mean testicular volumes were significantly lower in cases compared to controls, across all age ranges (p< . ). mean bmi in both cases and controls were similar at onset of breast development in girls. however, in boys with and without scd, mean bmi values were significantly different at pubertal onset. in univariate analysis, ses was not associated with tanner stage for both genital and breast development. mean ages at pubertal onset were significantly delayed in children with scd. longitudinal studies are needed to further characterize any associations with bmi and determine potentially modifiable risk factors affecting pubertal onset in scd. background: sickle-cell disease (scd) is a life-threatening genetic disorder associated with multiple chronic and acute complications. specific monitoring and treatment for children is a major part of the medical focus, but there remains a lack of real-world evidence of the disease burden and practice patterns among the pediatric scd population. objectives: to examine the clinical burden and management of scd among pediatric patients. design/method: a retrospective claims study was conducted using the medicaid analytic extracts database from jan - dec . pediatric patients (aged < years) with scd were identified using icd- -cm diagnosis codes ( . - . , . - . ). the first observed scd diagnosis during the identification period was designated as the index date. patients were required to have continuous medical and pharmacy benefits for at least months pre-and months post-index period. patient data were assessed until the earliest occurrence of the following events: disenrollment, death, or the end of the study period. patient demographic and baseline clinical characteristics, clinical outcomes (mortality, incidence of pain crisis, complications), scd management, and healthcare utilization were examined. all variables were analyzed descriptively. results: a total of , patients met the study inclusion criteria, with a mean age of . years. most patients were black ( . %) and had a charlson comorbidity index score of ( . %). mortality during follow-up was . in personyears, and the event rate of pain crisis in the inpatient setting was . in person-years. the three most common complications after pain crisis (highest rates in person-years) were fever ( . ), infectious and parasitic diseases ( . ), and asthma ( . ). rates of life-threatening complications were also examined in person-years, including acute chest syndrome ( . ), stroke ( . ), splenic sequestration ( . ), pulmonary hypertension ( . ), and pulmonary embolism ( . ). . % of patients were prescribed antibiotics during the one-year post-index period. other frequent medications utilized among children were folic acid ( . %), nonsteroidal anti-inflammatory drugs ( . %), opioids ( . %), and hydroxyurea ( . %). . % of patients had a blood transfusion within one year post-index date. patients had frequent health care utilizations in the inpatient ( visit), emergency room ( visits), office ( visits), and pharmacy ( visits) settings during the one-year follow-up period. pediatric scd patients are burdened with a high rate of complications including pain crisis. in addition, patients utilized a substantial amount of health care resources including outpatient office care and acute care visits. background: novel use of hydroxyurea in an african region with malaria (noharm, nct ) is a randomized controlled trial of hydroxyurea for very young children with sickle cell anemia living in uganda. during year , study participants received blinded study treatment of hydroxyurea or placebo; those receiving hydroxyurea had no increased risk of malaria, but had both laboratory and clinical benefits. during year , all study participants received openlabel hydroxyurea treatment. to assess the effects of open-label hydroxyurea treatment in a very young population of children with sickle s of s cell anemia living in uganda. study endpoints included the rates and severity of malaria infections, clinical sickle-related events, and laboratory effects. design/method: all children in the noharm trial were enrolled at mulago hospital sickle cell clinic in kampala uganda. during year , all children received open-label fixeddose hydroxyurea ( mg/kg/day) for months, after previously receiving either hydroxyurea or placebo for months. results: a total of children entered year of the noharm trial and received fixed-dose hydroxyurea, including males and females, at an average age of . ± . years. among children previously on placebo, there were malaria events in children, including with severity grade ≥ , and three deaths (two acute chest syndrome, one sepsis). clinical adverse event rates dropped from . to . per patient year, and hospitalizations were reduced from to . expected hematological benefits of increased hemoglobin, mcv, and fetal hemoglobin, along with decreased neutrophils and reticulocytes, were rapidly achieved. laboratory adverse events were infrequent at . events per patient-year, and only half of those were dose-limiting hematological toxicities. among children previously on hydroxyurea, there were malaria events in children, including with severity grade ≥ , and two deaths (one acute chest syndrome, one sepsis). clinical adverse event rates and hospitalizations were maintained at low rates, the hematological benefits of hydroxyurea continued throughout the extended treatment period, and dose-limiting toxicities remained infrequent. fixed-dose hydroxyurea treatment of young children with sickle cell anemia living in uganda is associated with no increased risk for malaria. clinical and laboratory benefits occur, including children previously on placebo who crossed-over to hydroxyurea treatment. future studies should focus on the optimal dosing and monitoring strategies, in an effort to determine the overall feasibility and safety of introducing hydroxyurea therapy across sub-saharan africa. background: acute chest syndrome (acs) is the second most common cause of hospitalization in patients with sickle cell disease and is a leading cause of morbidity and mortality. in mid- , an algorithm was implemented at cohen children's medical center to initiate transfusions within four hours of diagnosis of acs in order to improve patient outcomes. objectives: the aim of this project was to analyze the effect of early blood transfusion on the outcomes of patients with acs. we focused on the number of total transfusions, need for exchange transfusion, need for intensive care unit (icu) stay, and length of hospitalization. design/method: a retrospective chart review was completed on patients admitted to ccmc with a primary diagnosis of sickle cell disease and a secondary diagnosis of either acs or pneumonia during the years of - . data from the three years directly prior to implementation of the algorithm was compared to data from the three years directly after implementation of the algorithm. a total of patients were analyzed, of which belonged to the pre-algorithm group and to the postalgorithm group. patients from the post-algorithm group had a higher incidence of transfusions ( % with a mean transfusion number of . pre versus % with a mean of . post) as well as exchange transfusion ( % pre versus % post). the post-algorithm group had a shorter overall length of stay (mean of . days pre versus . days post). while the overall percentage of patients requiring an icu admission was similar in each group ( % pre versus % post), the post-protocol group had a lower likelihood of requiring an icu admission for reasons outside of line placement for exchange transfusion, most commonly for icu-level respiratory support ( % pre versus % post). despite a higher total number of transfusions, early recognition and transfusion for acs can lead to decreased lengths of hospitalization as well as decreased need for icu-level respiratory support. further studies comparing different center's clinical practice guidelines are necessary to improve the standard of care. background: novel use of hydroxyurea in an african region with malaria (noharm) was the first placebocontrolled randomized clinical trial of hydroxyurea in sub-saharan africa. in noharm, young children with sca received either hydroxyurea or placebo during year , followed by open-label hydroxyurea for all study participants during year . an ancillary noharm project was designed to determine if hydroxyurea treatment lowers transcranial doppler (tcd) velocities and possibly reduces stroke risk in this very young cohort. objectives: to perform tcd screening on the noharm cohort, measuring the time-averaged mean velocity (tamv) at the end of both year and year . we hypothesized that the maximum tamv would be lower for noharm study participants receiving hydroxyurea compared to those receiving placebo, and that key clinical and laboratory parameters would also influence tcd velocities. design/method: all children enrolled in noharm were eligible to undergo tcd examination at two study time points: month - when they were completing the blinded treatment phase, and again at month - at the end of the open-label treatment phase. tcd measurements included tamv readings from the main intracranial arteries: middle cerebral artery, distal internal carotid artery, and bifurcation on tcd. all tcd examinations were scored and classified as normal (less than cm/sec), conditional ( - cm/sec) or abnormal (greater than or equal to cm/sec), with higher scores correlating to greater risk of stroke. results: at the end of year , tcd exams were conducted of which were suitable for analysis ( hydroxyurea, placebo). based on the maximum tamv, the median velocity was cm/sec (iqr - ) for children on hydroxyurea and cm/sec (iqr - ) on placebo, p = . . maximum tamv values had negative correlations with hemoglobin concentration (- . ), fetal hemoglobin (- . ), and oxygen saturation (- . ); positive correlations were noted with age ( . ) and absolute neutrophil count ( . ). at the end of year , tcd exams were conducted and all were suitable for analysis; the median velocity was cm/sec on open-label hydroxyurea treatment, regardless of previous blinded treatment. all correlations with tamv were maintained except for age. conclusion: compared to placebo, hydroxyurea treatment for young children with sca living in uganda was associated with lower tcd velocities, which have been correlated in other studies with lower risk of primary stroke. tcd velocities were correlated with hematological and clinical parameters that can be improved by hydroxyurea therapy. children's hospital of richmond at virginia commonwealth university, richmond, virginia, united states background: acute chest syndrome (acs), defined by respiratory symptoms and a new pulmonary infiltrate, is a serious complication of sickle cell disease (scd). acs can occur during hospitalization for non-pulmonary conditions, such as a vaso-occlusive crisis or after surgery. nih clinical practice guidelines encourage incentive spirometry (is) which decreases the incidence of acs. it is additionally widely accepted that early, frequent ambulation in post-operative and pneumonia patients decreases the length of stay (los). to decrease acs events in children with scd at our children's hospital, we aimed for is use in % of ageappropriate pediatric sickle cell admissions. design/method: a multidisciplinary team examined inpatient acs prevention practices, including is, at children's hospital of richmond. key drivers were identified, including educational awareness of patients and healthcare staff, order placement, and documentation. we aimed for all scd patients ≥ months of age hospitalized with any admission diagnosis to participate in is with the use of a traditional incentive spirometer or similar age-and ability-appropriate devices (e.g. positive expiratory pressure devices, bubbles, and pinwheels). we secondarily aimed to increase activity events, specifically ambulation and out of bed time. educational and outreach tools included patient informational brochure and incentive program, and staff informational sessions and reference materials at workstations. a disease-specific order set was implemented including desired is and activity orders. data were collected prospectively may through november , during which pdsa cycles were conducted. admissions during the corresponding months of the previous year were reviewed for comparison. independent t-test analysis was performed using graftpad prism statistical analysis software. results: improvements reaching statistical significance included increase in is order placement from % to % of admissions (p < . ), and admissions with documented is use increased from % to % (p < . ). los decreased from a mean of . days to . days (p . ). post-admission development of acs also decreased from % to % of admissions, but did not reach statistical significance (p . ). there was an additional increase in appropriate activity order placement and documentation of activity events. conclusion: improving education and outreach to patients and staff, including implementation of a disease-specific order set, can improve is use and activity events. the decline seen in incidence of acs development during hospitalization, though not statistically significant, and the decreased los are encouraging, and efforts continue to improve on these trends. background: painful vaso-occlusive crises (voc) are a frequent and debilitating complication of sickle cell disease (scd) and are thought to occur due to progressive blockage of the microvasculature with rigid sickle shaped red blood cells. any trigger that decreases the microvascular blood flow (mbf) can promote entrapment of sickled cells in the microvasculature and progression to voc. exposure to cold wind and changes in weather are common triggers of voc and are associated with increased frequency of hospitalizations for pain in patients with scd. there is limited experimental data on the physiologic effects of these factors on peripheral perfusion in scd. to study the effect of graded thermal stimuli on the peripheral mbf in scd. design/method: scd and control (healthy or sickle trait) subjects aging to years were exposed to their individual threshold temperatures for heat and cold detection, heat and cold pain via tsa-ii thermode that was placed on the thenar eminence. mbf was measured on the contralateral thumb using photo-plethysmography (ppg). the vasoconstriction response within the complex ppg signal was detected using cross-correlation technique. mean mbf was derived from the ppg amplitude during each of these stimuli and compared to baseline mbf. cross correlation analysis showed that cold pain caused significant vasoconstriction response in % of the subjects, followed by heat pain ( %), cold detection ( %) and heat detection ( %).there was a significant drop in the mbf during cold pain (p < . ), heat pain (p < . ), heat detection (p = . ) and cold detection (p = . ) when compared to baseline mbf, with cold pain causing the greatest drop in mbf. thermal sensitivity and mbf responses were comparable between scd and controls. conclusion: exposure to graded thermal stimuli causes a progressive drop in mbf with exposure to cold pain eliciting the strongest vasoconstriction response. vasoconstriction occurred in the contralateral hand at an average of seconds after the stimuli, suggesting a neurally mediated mechanism. although there was no significant difference in vasoconstriction responses between scd and controls, the drop in mbf in patients with sickle cell disease can increase the likelihood of entrapment of the sickled red blood cells, leading to vaso-occlusion. these findings are consistent with extensive reports in literature that exposure to cold weather is associated with a higher frequency of voc. this suggests that neurally mediated vasoconstriction is likely an important factor in the pathophysiology behind cold exposure leading to voc in scd. background: vaso-occlusive crisis (voc) is a major cause of hospital admissions in children with sickle cell disease (scd). although the use of clinical biomarkers in voc has been studied, especially with regards to acute chest syndrome (acs), there is less data regarding overall voc severity prediction. in addition new biomarkers such as platelet to lymphocyte ratio (plr), neutrophil to lymphocyte ratio (nlr), and lymphocyte to monocyte ratio (lmr) have been little studied with regards to scd. objectives: to identify whether admission laboratory values, changes from well baseline laboratory values, and new biomarkers such as plr, nlr, and lmr could predict severity of vaso-occlusive crisis in children with sickle cell disease admitted with voc. design/method: this was a retrospective single center observational study of admissions of voc in children aged - years with hbss or hbs-b thal from september to november excluding those on hyper-transfusion protocol or having an admission diagnosis of acs. univariate analysis was done using student's t-test, mann-whitney non parametric test, or fischer's exact test as appropriate depending on the distribution between admission laboratory data of complete blood count (cbc), reticulocyte count, comprehensive metabolic panel, lactate dehydrogenase (ldh), change from well baseline cbc values within months previously, plr, nlr, lmr, and the development of complicated voc. complicated voc was defined as the development of secondary acute chest syndrome, prolonged admission duration > days ( hours), requirement of blood transfusion, and readmission within days. results: a total of admissions were studied. fifty-nine ( . %) were female. of the , ( . %) were complicated with no significant differences in sex (p . ) or age (p . ). univariate analysis revealed significant elevations in total bilirubin (p . ), ldh (p . ), and platelet count (p . ) in those with complicated voc. there is also significant difference in the percentage change of platelet count from baseline with greater decline in uncomplicated voc (p . ). there were no significant differences in plr (p . ), nlr (p . ), or lmr (p . ). conclusion: elevations in total bilirubin, ldh, and platelet count in admission laboratory values are associated with developing complicated voc. in addition, those with complicated voc present with significantly less decline in platelet count from baseline well cbc. plr, nlr, and lmr do not seem to be useful predictive biomarkers for severity of voc. background: sickle cell disease (scd) causes health problems of varying frequency and severity. the only validated biomarker for children with scd is transcranial doppler. if reliable predictors existed for scd severity, children with scd could be treated according to risk category. many patients with scd face psychosocial or economic hardships, but these factors have not been evaluated as risk markers for medical or functional severity of scd. objectives: the goal of this project was to develop and stratify a preliminary list of psychosocial risk factors for health outcomes that could be used as scd severity predictors. st. vincent institutional review board. a list of potential psychosocial risk factors for adverse health outcomes was compiled based on assessment materials utilized by the sickle safe program (indiana's hemoglobinopathy newborn screening follow-up program). this list of items was distributed to child abuse prevention ( ) and scd ( ) experts, who ranked each item on a likert scale of (least important) to (most important). mean scores were calculated using spss version ; assessments were retrospectively analyzed to determine psychosocial risk factor frequency. risk factors occurring in ≥ % of homes were considered high frequency events. overall, there was high agreement among experts on the risk factors that were considered the most important predictors of severe scd outcomes. the risk factor with the highest frequency ( %) was eligibility for public assistance programs. fifteen risk factors were rated ≥ by the experts. four ( . %) were high frequency events occurring in ≥ % of homes: a child with hbss or hbs thalassemia not taking hydroxyurea ( %); parent report that they had treated a fever (> ®f) at home in the past months ( %); tobacco use by someone in the household ( %); and the family reporting significant psychosocial stressors in the past year ( %). tobacco use in the home was significantly correlated with several other risk factors (smoking during pregnancy [r = . ], other health concerns in the child [r = . ], and child having health insurance [r = - . ]), suggesting that it is part of a constellation of health risk. in general, the risk factors that were rated as most important for health outcomes occurred less frequently in the sample. this study represents important progress toward identifying a group of psychosocial risk factors for scd severity, which is a necessary first step for future investigation of empirical relationships between candidate risk factors and scd outcomes. unitversity of cartagena, cartagena, bolivar, colombia s of s background: sickle cell disease is an autosomal recessive disorder characterized by a mutation in the -globin chain, which produces hbs. acute and chronic complications as aplastic crisis, acute chest syndrome, priapism, stroke, leg ulcers and primary/secondary prevention of stroke can be treated with simple transfusion or exchange transfusion. the latter offers advantages as lower iron overload, post-treatment hbs goal control, lower viscosity and improved microvascular circulation. but it is not a widely-used option because is associated with technical difficulties. objectives: standardization of a new partial exchange transfusion protocol in a group of patients with sickle cell disease, within the framework of a chronic transfusion program. design/method: this is a prospective descriptive study, which included patients under years with sickle cell disease ( hbss, hbs-tal), with indication of partial exchange transfusion in a chronic transfusion program, according to the institutional protocol; patients who fulfilled the inclusion criteria were enrolled in the study between february and december . a registry of the medical and technical complications was made in each of the procedures. a database was constructed in excel, and the graph-pad prism® version oc software was used for statistical analysis. the sequence is as follows: isovolemic phlebotomy and transfusion of packed red cells. depending of the recent hemoglobin level ( hrs), we do the phlebotomy there: hb: - . : cc/kg, hb: - . : cc/kg, hb> : cc/kg; isovolemic solution (ns , %) there: hb: - . : cc/kg, hb: - . : cc/kg, hb> : cc/kg and packed red cell transfusion there: hb: - . : cc/kg, hb: - . : cc/kg, hb> : cc/kg. the safety of this exchange transfusion protocol was analyzed in patients with sickle cell disease ( procedures). there were no differences in the sex distribution, and the median age was years. % of the population was homozygous. the indication of transfusion was . %( / ) primary stroke prevention, . %( / ) secondary stroke prevention and . %( / ) was other reason. a low percentage of complications was found ( . %); of which, those of medical origin (hypotension and nausea/vomiting) were only presented in . % of the total procedures. the standardization of this protocol was safe and its use could be extended to other low-income centers that treat patients with sickle cell disease that need chronic transfusion program including patient with hemoglobin level until gr/dl. we suggest do studies for measure the security and efficacy of this protocol in patients with acute complications. background: clinical trials that aim to achieve pain reduction have challenges achieving clinical endpoints as pain has no quantifiable biomarkers and may be unrelated to scd. furthermore, the threshold of seeking medical care differs between patients and vocs that occur at home are missed. we present a non-interventional, longitudinal study to identify vocs in patients with scd. objectives: to examine the longitudinal relationship between pros and biomarkers in subjects with scd before, during, and after a self-reported voc event, in order to build a model of in-home and clinical voc and to collect longitudinal pros and biomarker data from subjects that span voc events in the home, clinic and the hospital. design/method: longitudinal measures of pain, fatigue, function, activity, and biomarkers from scd patients in steady state and voc were studied over a six month period. patients self-reported pain, fatigue, function, and medication use using a novel epro tool. voc was reported in real-time, triggering a mobile phlebotomy team. blood was collected sequentially after self-reported voc (at home or hospital). blood samples were drawn two days after resolution of voc, as reported by the patient. during non-voc periods, blood was drawn every weeks to establish a baseline. biomarkers included leukocyte-platelet aggregates and circulating microparticles, cell and soluble adhesion molecules, cytokines, inflammatory mediators and coagulation factors. patients wore an actigraphy device to track sleep and activity and rest. results: twenty-seven of thirty-five patients experienced a total of days with voc > hr, of which only days resulted in healthcare utilization. voc days had significantly higher pain and fatigue scores. voc days were associated with significantly decreased functional scores, with significantly greater decreases during vocs requiring medical contact compared to at-home vocs. different activity profiles were identified for non-voc, at-home voc and medical contact voc days by actigraphy monitoring. at-home voc days exhibited increased daytime resting compared to non-voc days. medical contact vocs had decreased average and peak activity, and increased daytime resting compared to non-voc days. a sleep fragmentation index trended up for both at-home ( %) and medical contact voc days ( %). significant changes during voc days were observed in: c-reactive protein ( % increase), nucleated rbc ( % increase), monocyte-platelet aggregates ( % increase) and neutrophil-platelet aggregates ( % increase), interleukin- ( % increase), interleukin- ( % increase) and tnfalpha ( % increase). the identification and assessment of at-home vocs through use of epros, actigraphy and biomarkers is feasible as demonstrated by this innovative at-home study design. background: risk-stratifying sickle cell disease (scd) patients and demonstrating response to disease-modifying therapies is challenging due to the phenotypical heterogeneity of scd. a pathogenic role for procoagulant von willebrand factor (vwf) via excess vwf high molecular weight multimers (hmwm) has been proposed, with variable reports of increased vwf and hmwm in crisis vs. steady-state in adults, but less so for vwf in children with scd. moreover, vwf and multimers have not been studied in sickle trait. objectives: our pilot study evaluated the potential for vwf antigen (vwf:ag) and hmwm on densitometric tracings to serve as biomarkers for disease severity or treatment response in children and young adults with scd compared to sickle trait (hbas) siblings. design/method: we evaluated vwf:ag, vwf multimers and retrospective clinical data from hbss, hbsc and hbas subjects at steady state. one hbsc subject also had a crisis sample. median scd age was years ( . - . years). % were female. scd severity was judged by annual vasoocclusive and acute chest events, or stroke/elevated tcd. eight of ( hbss and hbsc) took hydroxyurea. four hbss subjects had severe scd, all of whom were chronically transfused. results: mean vwf:ag (normal - iu/dl) was higher for hbss ( +/- . ) and severe hbss ( +/- . ) compared to hbsc ( +/- . , p = . and . , respectively); however, lacked statistical significance when compared to hbas ( +/- . , p = . and . , respectively). vwf:ag was elevated in / ( %) steady-state, including / ( %) with "severe" disease on chronic transfusion and / ( %) taking hydroxyurea, in hbsc crisis but no hbsc / ( %) at baseline. vwf:ag was high in / ( %) hbas siblings. four ( %) had increased hmwm at baseline: hbss/severe disease/chronic transfusion, hbss/hydroxyurea and hbsc untreated. hmwm were increased only during vaso-occlusive crisis in hydroxyureatreated hbsc subject. no ultra-large hmwm were observed. in this preliminary study, in young scd subjects, vwf:ag trended higher in hbss vs. hbsc and in severe hbss participants at a single time-point, but serial evaluations at baseline, in crisis and with optimized diseasemodifying therapy are needed to determine the potential of vwf:ag and hmwm as biomarkers for severity or treatment response. surprisingly, vwf:ag was high in some sickle trait subjects. since hbas is associated with some health challenges such as increased thrombosis risk, further examination of vwf and endothelial dysfunction in sickle trait may provide novel insights into its role as a biomarker. background: the national heart lung & blood institute(nhlbi) guidelines for acute management of voe recommends rapid evaluation and treatment of pain, including administration of a parenteral opioid within -minutes of triage or -minutes from registration, pain reassessment & repeat opioid delivery within - -minutes. inf use has been increasing in peds due to its rapid onset and ease of administration. objectives: to evaluate ped utilization of inf & its effect on intravenous (iv) opioid administration and pain control for the treatment of voe. design/method: a retrospective review of emr was performed on children with scd± years presenting to a ped with voe (pain scores on a - scale) from jan-june . variables studied were median time (iqr, %ci) from ped arrival to first-parenteral-opioid-administration, time-to-first-iv-opioid, first & final pain score, disposition and readmission rate. time-to-first-iv-opioid was also compared to historical data (jan-dec ,n = ) prior to inf protocol initiation. . additionally, % patients received iv opioids within minutes of ed arrival in the inf+iv opioid vs. % in the iv opioids alone group (p< . ). no differences in -hour-returnrates were found in any of the groups, including inf alone group. conclusion: use of inf in the ped for voe is an excellent strategy to shorten time-to-first-parenteral-opioidadministration, improve pain scores & improve adherence to the nhlbi guidelines. however we had distinct unexpected findings: ( ) delays in iv opioid delivery after inf use & ( ) inf alone appeared to provide sufficient pain control without iv opioids for disposition home in % of voe patients. whether the latter reflects insufficient pain management or that there is a milder subgroup for whom inf alone is sufficient, requires further investigation. this study illustrates our experience with a ped-based inf protocol in terms of unanticipated delays in iv opioids and also discharges after inf alone. efforts are underway to further improve use of inf in voe management. st. christopher's hospital for children, philadelphia, pennsylvania, united states background: folate supplementation is commonly included as standard management in patients with sickle cell disease. however, clear evidence supporting the clinical benefits of this practice is lacking. a single study demonstrated improvement on the occurrence of repeat dactylitis at a higher dose of folic acid. to compare clinical outcomes in pediatric patients with sickle cell disease treated with folate supplementation versus those who were not. design/method: this study was a retrospective chart review that included patients to years old with sickle cell disease type ss and s followed at st. christopher's hospital for children. data collected included information about folate supplementation, red cell indices and the presence or absence of clinical outcomes including vaso-occlusive crisis requiring hospitalization in the last six months, acute chest syndrome, infections, asthma, sleep apnea, nephropathy, cerebral vascular disease, stroke and avascular necrosis. analysis of variance (anova) was used to evaluate mean differences between age, number of infections, number of voc events, hemoglobin, reticulocyte count, and mean corpuscular volumes. additionally, chi square analysis was implemented to evaluate differences in folate and non-folate groups for left ventricular remodeling (lvr), sickle cell nephropathy, asthma, obstructive sleep apnea (osa), nocturnal hypoxia, and avascular necrosis (avn). mean differences between the folate and non-folate groups were compared for patients on and off hydroxyurea therapy. one hundred and seven patients met inclusion criteria following review of clinical data. of the patients included in the study, patients were found to be taking folate ( %), while patients were not ( %). statistical analysis showed that there were no significant differences in the incidence of clinical outcomes between patients on folate versus those who were not on folate. of the patients who were not on hydroxyurea, hemoglobin levels were significantly higher in patients on folate versus those who were not (p = . ), but not significantly different for the patients on hydroxyurea. this study suggests that folate supplementation makes no significant impact on the red blood cell indices of anemia nor on the incidence of adverse clinical outcomes in children with sickle cell disease. however, a larger prospective study is needed to guide future considerations for folate supplementation in sickle cell patients in the clinical setting. background: tanzania ranks rd globally for the number of infants born annually with sickle cell disease (scd) but lacks a national newborn screening program. the prevalence of sickle cell trait (sct) and scd is highest in the northwestern regions around lake victoria served by bugando medical centre (bmc) a teaching and consultancy hospital in mwanza. bmc also houses the hiv early infant diagnosis (eid) laboratory that tests dried blood spots (dbs) from hivexposed infants. dbs can be tested for hiv and then retested for sickle cell trait and disease. to determine the prevalence of sickle trait and disease by region and district in northwestern tanzania using existing public health infrastructure. secondary objectives explored associations between sct, scd, malaria and hiv. design/method: the tanzania sickle surveillance study (ts ) is a prospective year-long cross-sectional study of hivexposed infants born in northwestern tanzania, whose dbs collected by the eid program are tested at bmc and available for further testing of sct and scd. samples from children ≤ months of age were tested by isoelectric focusing (ief) and scored independently by two tanzanian staff as normal, sct, scd, variant, or uninterpretable. dbs samples scored as disease or variant were repeated. over the course of months, ief gels have been run. a total of , dbs samples have been scored, including , from children less than -months old. the overall prevalence of sct is . % and the prevalence of scd is . %, along with . % hemoglobin variants. quality of the laboratory results is extremely high, with only . % dbs samples yielding an uninterpretable result. geospatial mapping of the first , samples revealed a regional scd prevalence ranging from . % up to . % among the regions served by bmc. the prevalence of sct and scd is very high in northwestern tanzania. geospatial mapping will identify high prevalence areas where targeted newborn screening can be started using existing public health infrastructure with minimal start-up cost and training. further data will enhance the accuracy of the map to the district level. background: pediatric patients with sickle cell disease (scd) could develop obstructive, restrictive or mixed abnormalities of pulmonary function (pf). several publications report progressive worsening of pf over time, which could lead to severe morbidity in adult patients with sickle cell disease. in adults with sickle cell anemia up to - % of mortality is related to lung disease. early intervention aimed at improvement of lung function could significantly decrease morbidity and possibly improve life expectancy. among disease modifying approaches commonly used in scd are hydroxyurea (hu) and chronic prbc transfusions. both interventions lead to increase of hemoglobin, decrease of hbs fraction, leading to decreased hemolysis. reports of effect of hu on pulmonary function are conflicting with some suggesting no effect and others proposing a slower decline of pulmonary function. the goal of our study is to evaluate effect of disease modifying therapies, like hu and chronic prbc on change of pulmonary function in pediatric patients with sickle cell disease. design/method: this study utilized a retrospective chart review of children with scd who had multiple pfts. we analyzed pfts from patients done during clinic visits. scd patients were divided into three treatment groups: hydroxyurea, chronic transfusions or neither. data was analyzed with linear correlations and analysis of variance (anova). comparison were made between the three groups specifically observing the changes in absolute numbers on pfts over time using the first and last pft the patient had. results: there were a total of patients with multiple pfts (ranging from - ); control ( ), hydroxyurea ( ) and chronic transfusion ( ). the mean changes of the control, and hydroxyurea for the pft parameters fev (- . the chronic transfusion group demonstrated a small improvement in pfts over time for fev ( . ), fvc ( . ), fef - ( . ), however there was a decline in fev /fvc (- . ). however, there was no statistically significant (p-value < . ) in the difference in any pfts parameters between any of the groups. in children with scd there is a decline of pf parameters over time. although no significant differences were seen between the three groups it appears chronic transfusion may improve or limit the decline in pfts. larger studies need to be done to evaluate difference in pf decline in patients with scd patients. background: the use of mobile technology in health care has been a growing trend. patients with chronic diseases such as sickle cell disease (scd) require close monitoring to provide appropriate treatment recommendations and avoid complications. we conducted a feasibility study for patients with scd hospitalized for pain using our self-developed mobile application (tru-pain: technology resources to better understand pain) and a wearable activity tracker. subjective symptoms such as pain and objective data such as heart rate (hr) were measured. we aimed to ) correlate nursing recordings with mobile technology recordings; ) get feedback from patients about usability. design/method: we enrolled patients with scd > years old and < hours from admission for uncomplicated vasoocclusive crisis, excluding patients admitted to icu. patients were given an ipad and a wearable device. they were instructed to record in the application at least once per day and to keep the wearable on, removing only to charge. prior to discharge, patients completed a feasibility questionnaire. we enrolled patients, % females, median age . (range to ) who were admitted for a median days (range to ) for uncomplicated pain crisis. patients used the application throughout hospitalization and made one entry/day (range to ). pain scores recorded via tru-pain correlated well (r = . , p< . ) with pain scores recorded in emr. there was an average of , data points recorded per day, by the wearable, with a maximum of , data points/day. the median amount of hours of wearable data per day was . (maximum of . ). the hr recorded via the wearable correlated significantly with the hr recorded in emr (r = . , p-value < . ). as for usability, % of patients indicated never having a problem with the technology, % found tru-pain 'very easy' or 'somewhat easy' to use, and % were 'very satisfied' with their participation in the study, indicating that it helped them track their pain. our pilot study during hospitalization shows strong potential for using tru-pain for patients with scd. pain data from application and hr from wearable correlated well to the emr data. according to the feedback received, our application was easy to use and helped patients track their pain. despite limitations of battery life, the use of wearable technology is feasible, providing additional data such as activity. we are optimistic that we can continue to improve our tru-pain system to help improve care in patients with scd. background: hydroxyurea, chronic blood transfusion, and bone marrow transplantation can reduce complications, and improve survival in sickle cell disease (scd), but are associated with a significant decisional dilemma because of the inherent risk-benefit tradeoffs, and the lack of comparative studies. these treatments are underutilized leading to avoidable morbidity and premature mortality. there is a need for tools to provide patients high-quality information about their treatment options, the associated risks, and benefits, help them clarify their values, and allow them to share in the process of informed medical decision making. objectives: to develop a health literacy sensitive, web-based, decision aid (ptda) to help patients with scd make informed choices about treatments, and to estimate in a randomized clinical trial the acceptability and effectiveness of the ptda in improving patient knowledge, involvement in decisionmaking and decision-making quality. design/method: we conducted qualitative interviews of scd patients, caregivers, stakeholders, and healthcare providers for a decisional needs assessment to identify decisional conflict, knowledge, expectations, values, support, resources, decision types, timing, stages, and learning, and personal clinical characteristics, and to guide the development of a ptda. transcripts were coded using qsr nvivo . stakeholders completed alpha and beta testing of ptda. we conducted a randomized clinical trial of adults, and of caregivers of pediatric patients to evaluate the comparative efficacy of the ptda, vs. standard of care. results: ptda (www.sickleoptions.org) was developed per decisional needs described by stakeholders and finalized following alpha testing, and beta testing by and stakeholders respectively. in a randomized trial of subjects considering various treatment options, qualitative interviews revealed a high level of usability, acceptability, and utility in education, values clarification, and preparedness for decision making of the ptda. a median % rated the acceptability of ptda as good or excellent and provided narrative comments endorsing the acceptability, ease of use, and utility in preparation for decision making. the ptda met international standards for content, development process, and efficacy with the exception of having a full range of positive and negative experiences in patient stories. compared to baseline ptda group had statistically significant improvement in preparedness for decision making (p = . ) and informed subscale of decisional conflict (p = . ) but not for decisional self-efficacy, knowledge, choice predisposition, or stages of decision-making. a ptda for patients with scd developed following extensive engagement of key stakeholders was found to be acceptable, useful, easy to use, to improve preparedness for decision making, and decrease decisional conflict. background: painful vaso-occlusive crisis (voc) accounts for the majority of emergency department (ed) visits and hos-pitalizations in sickle cell disease (scd). we are interested in studying mental stress and associated autonomic nervous system (ans) imbalance that cause vaso-constriction as possible triggers of scd pain. to this end, we developed a mobile phone application (app) to record daily pain frequency and intensity as clinical endpoints that might be predicted by ans parameters measured in the laboratory. in particular, we think that the aura may represent ans instability that precedes or even triggers change in blood flow and voc. objectives: to assess the feasibility of using an app to evaluate frequency and severity of voc and its potential association with mental stress and presence of aura. design/method: an app was developed for both ios and android systems to allow patients to track pain, stress, and aura. the idea was to create an app that was easy to use with the intent to only capture pain episodes, rather than detailed description of the pain. all scd patients were eligible and a parent version was available for younger children. de-identified data was automatically transferred to a hipaa compliant database via a cloud-based server interfaced to the main research project database. a feedback questionnaire was implemented after at least a month of utilization to assess usability. of the scd patients enrolled, participants utilized the app and of the participants that provided feedback indicated the app was easy to navigate. the mean pain scale was out of (standard deviation . ) for those that entered they had pain that day. although the mean stress level was out of , there was a statistically significant correlation between increasing stress levels and increasing pain scores (p < . ). aura was reported by patients, with patients reporting more than episodes. moreover, on days aura was present there was greater incidence that pain was present as well (p < . ). however, there was no statistically significant association between pain intensity and presence of an aura (p = . ). conclusion: consistent with prior research, reported pain intensity is significantly associated with reported stress intensity. although there was an association between presence of aura and pain, it did not seem to correlate with pain intensity. this uniquely designed app can monitor scd pain clinically and help understand the role of sickle dysautonomia in the genesis of scd pain. university of florida college of medicine, gainesville, florida, united states background: evidenced-based guidelines recommend the emergent evaluation of fever in children with sickle cell disease (scd). as the prevalence of bacteremia has decreased, outpatient management has become more common. however, fever can sometimes herald other complications of scd, such as acute chest syndrome, vaso-occlusive pain crisis, splenic sequestration, or aplastic crisis. institutional practices regarding fever management in scd remain variable, and little is known about the clinical outcomes of children hospitalized for uncomplicated fever. objectives: the primary objective was to determine the rate of bacteremia or scd-related complications per febrile episode in children with scd admitted to a single institution between january and june for uncomplicated fever. this was a retrospective cohort study of febrile patients up to years of age with scd, any genotype, admitted to the university of florida during the defined study period. eligible patients were identified by a database search using admitting diagnosis codes for scd and fever based on the international classification of diseases th and th revisions. encounters were manually reviewed to confirm eligibility. patients were excluded if they had other indications for hospitalization apparent at the time of admission, such as an acute vaso-occlusive episode requiring parental narcotics, asthma exacerbation, or additional complications of scd. the database search identified encounters, of which were excluded based on confounding indications for hospitalization. sixty-three eligible patients accounted for hospitalizations. the median age was years (range weeks- years); . % were male. mean duration of hospitalization was . days (range - days). eight positive blood cultures were identified; six of these were classified as contaminants. bacteremia or the development of a scd-related complication was identified in ( . %) admissions. these included acute chest syndrome (n = ), bacteremia (n = ), splenic sequestration (n = ), and red cell transfusion (n = ). exploratory analyses of potential predictors of bacteremia or scd-related complications showed no association with the presenting white blood cell count or degree of fever (p = . ). of the patients classified as having a scd-related complication, % had hemoglobin ss disease and % had at least one prior documented complication. % of the patients transfused had at least one prior transfusion. conclusion: while improvements in preventative care have substantially lowered rates of bacteremia in children with scd, fever warrants careful evaluation for other acute scdrelated complications. providers should consider inpatient observation in select cases. additional studies are warranted to define subsets of patients suitable for outpatient fever management. background: children with sickle cell disease (scd) exhibit lower neurocognitive functioning than healthy peers, even in the absence of stroke. among the domains commonly affected, working memory (wm) seems particularly affected by disease processes and wm deficits have significant implications for academic achievement and disease selfmanagement. few interventions to improve working memory in pediatric scd have been evaluated. to determine the effects of cogmed, a homebased computerized wm training intervention, in children with scd using a randomized controlled trial design. design/method: participants (ages - ) with scd completed a baseline neuropsychological assessment and those with wm deficits were randomized to either begin cogmed immediately or enter an -week waitlist. cogmed is a homebased intervention completed on an ipad that consists of increasingly challenging exercises targeting visual-spatial and verbal wm, practiced over sessions. at the end of training, participants completed a post-intervention neuropsychological assessment, including tests of visual-spatial and verbal wm from the wechsler intelligence scale for children-fifth edition (wisc-v). results: ninety-one participants (m age = . , sd = . ; % female; % hbss) enrolled in the study; % (n = ) exhibited wm deficits and were randomized to either begin cogmed immediately or wait - weeks before starting cogmed. among those that have received the intervention and reached the end of their training period (n = ), participants ( %) completed at least cogmed sessions, ( %) finished at least sessions, and finished at least sessions ( %). the mean number of completed cogmed sessions was . (sd = . ). paired samples t-tests revealed significant improvements on the working memory index (t[ ] = - . , p = . ) and on the digit span (t[ ] = - . , p = . ), and spatial span-backward (t[ ] = - . , p = . ) subtests. improvements were especially pronounced for participants completing at least sessions. partial correlations controlling for respective baseline scores indicated that the number of cogmed sessions completed was positively correlated with post-test scores on digit span (r = . , p = . ) and spatial span-backward (r = . , p = . ) subtests. among participants who completed at least cogmed sessions, % scored in the average range or higher on the working memory index at the post-intervention assessment, compared to % at baseline. results support the efficacy of cogmed in producing significant improvements in wm. a dose-effect was observed such that participants who completed more cogmed sessions had greater improvements in wm. home-based cognitive training programs may ameliorate scd-related wm deficits but methods for motivating and supporting patients as they complete home-based interventions are needed to enhance adherence and effectiveness. background: sickle cell disease is associated with myriad complications that lead to significant morbidity and early mortality. hydroxyurea has been used successfully to reduce the incidence of these complications and has led to significant improvements in quality and duration of life. at children's minnesota we recommend hydroxyurea in all patients with hb ss/s thalassemia as early as months of age with a goal of starting all patients before months of age. objectives: the purpose of this study was to evaluate the use of hydroxyurea therapy in young patients with sickle cell disease, with particular attention to those children less than one year of age. design/method: a retrospective chart review was conducted on patients less than years of age with sickle cell disease who began hydroxyurea therapy between january , and december , . the study population was divided into three cohorts based upon age at hydroxyurea initiation: cohort ( - year), cohort ( - years), and cohort ( - years). outcomes included laboratory data, clinical events (hospitalization, dactylitis, pain crisis, transfusion, splenic sequestration, acute chest syndrome), and toxicity occurring in the first years of life. results: a total of patients were included in cohorts (n = , mean age . months), (n = , mean age . months), and (n = , mean age . months). patients in cohort had higher hemoglobin (p = . ) and mcv (p = . ) and lower absolute reticulocyte count (p = . ) when compared to cohort . the wbc (p = . , < . ) and anc (p = . , . ) were significantly lower compared to both older cohorts. however, no patient had therapy held because of neutropenia. the mean baseline hemoglobin f in cohort was . % compared to . % and . % in cohorts and respectively (p = . , p< . ). the mean duration of therapy in cohort was . months, compared to . months in cohort (p = . ) and . months in cohort (p = . ). during this time, hb f levels remained higher in cohort (mean . %) compared to cohorts and (mean . %, p = . and mean . %, p = . ). patients in cohort experienced fewer hospitalizations (p = . ), pain crises (p = . ), and transfusions (p = . ). there was no difference in toxicity between groups. hydroxyurea was used safely in infants to months of age and resulted in more robust hematologic responses and a decrease in sickle-related complications when compared with patients starting hydroxyurea later in life. children's national health system, washington, district of columbia, united states background: children with sickle cell disease (scd) have a significantly greater risk of silent or overt cerebral infarction than the general population. infarcts are associated with declines in cognitive functioning and academic achievement. while infarcts are reliably identified using mri, scans are expensive and occasionally necessitate sedation. moreover, mri's are not recommended for routine monitoring of cerebral infarcts. additional tools are needed for discriminating the presence of a cerebral infarct that are brief, noninvasive, inexpensive, and repeatable. objectives: to evaluate differences in performance on cogstate, a computerized neurocognitive assessment, in patients with scd with and without history of cerebral infarct. design/method: participants included children with scd ages - (m = . , sd = . ; % female; % s of s hbss) enrolled in a cognitive intervention trial. participants completed the cogstate pediatric battery, which measures processing speed, sustained attention, verbal learning, working memory, and executive functioning. history of silent or overt infarct was determined via health record review. participants also completed measures of intelligence (iq) and math fluency. results: participants' standard scores across most neurocognitive measures were lower than expected compared to the standardization sample (mean iq = . , sd = . ). thirty percent of participants (n = ) had a documented history of cerebral infarct. participants with a history of cerebral infarct scored lower on cogstate tasks measuring sustained attention (t[ ] = . , p = . ) and executive functioning (t[ ] = . , p = . ), as well as on a measure of math fluency (t[ ] = . , p = . ). receiver operating characteristic (roc) analyses demonstrated that the cogstate task measuring sustained attention was a fair discriminant of patients with and without a history of infarct (auc = . , ci = . - . , p = . ), whereas iq score was not (auc = . , ci = . - . , p = . ). cogstate processing speed and sustained attention tasks fairly discriminated between patients with at least average or below average intelligence (auc = . , ci = . - . , p = . and auc = . , ci = . - . , p = . , respectively). finally, the cogstate processing speed task was good at discriminating between at least average or below average math fluency (auc = . , ci = . - . , p< . ). multiple tasks in the cogstate pediatric battery appear to adequately identify patients with a history of cerebral infarcts. in addition, cogstate tasks appear to be fair predictors of impairments in iq and academic achievement outcomes. cogstate is inexpensive and can be easily administered in a medical setting with minimal training in approximately minutes. results support the potential for cogstate to be used as a screening tool for medical and neuropsychological abnormalities in children with scd. st. christopher's hospital for children, philadelphia, pennsylvania, united states background: cardiovascular disease contributes to the morbidity and mortality of patients with sickle cell disease (scd). hydroxyurea therapy in scd has known clinical efficacy including improving anemia, decreasing episodes of vasoocclusive crisis and acute chest syndrome, and decreasing mortality. effect of hydroxyurea on cardiac function in children with scd is not well studied. an earlier study suggested the protective effect of hydroxyurea on left ventricular (lv) hypertrophy in scd. we hypothesized that hydroxyurea use would be associated with decreased lv remodeling and improved cardiac function. we aimed to evaluate the association between hydroxyurea use and lv remodeling and cardiac dysfunction in children with scd. design/method: we completed a retrospective study of patients with scd who were to years old, followed at st. christopher's hospital for children and had an echocardiogram completed in the past months. data collected included gender, bmi, scd genotype, hydroxyurea use, chronic transfusion use, and d and doppler echocardiographic parameters. cardiac structure, geometry, systolic function, and diastolic function echocardiogram parameters were included. analysis of variance (anova) tests were performed to assess for statistical significance of differences in cardiac parameters between patients with and without hydroxyurea use. analysis of covariance (ancova) tests were performed to control for age. results: demographic and echocardiogram data was collected on all patients who met inclusion criteria. of the patients included, ( %) were on hydroxyurea therapy. patients on hydroxyurea had significantly lower mean relative wall thickness (p = . ) and significantly higher mean peak early lv filling velocities (p = . ) and peak early lv filling/septal annuli early peak (e/ea) velocities (p = . ); however, only the e/ea velocities remained significant when controlling for age (p = . ). mean peak early lv filling velocities approached significance when controlling for age (p = . ). hydroxyurea therapy resulted in a significantly higher e/ea velocity, suggesting that these patients had worse diastolic function. it is possible that the patients initiated on hydroxyurea already had worse disease manifestations than those not on hydroxyurea, possibly accounting for the decreased diastolic function. when controlling for age, hydroxyurea use did not result in significant differences in cardiac structure parameters, systolic function parameters or cardiac geometry. prospective studies and larger sample size are needed to validate our findings, examine for additional statistically significant differences, and develop preventive strategies for cardiovascular disease in children with scd. background: acute chest syndrome (acs) is now the leading cause of death in children with sickle cell disease; mortality in the u.s. is reported to be - % and is mostly due to respiratory failure. early transfusion improves clinical outcomes. although patients with concurrent asthma are considered at increased risk for poor outcomes, risk factors for respiratory failure in pediatric acs have not been well-defined. to determine whether specific epidemiological and clinical features of children hospitalized with acs are predictive of the need for mechanical ventilation. design/method: data from the kids' inpatient database were reviewed to identify patients age < years with a discharge diagnosis of acs for the years , , , and . outcomes were defined by the international classification of diseases, ninth revision, clinical modification code. data were weighted to estimate total annual hospitalizations according to hospital characteristics in the united states. trends in healthcare costs, length of hospital stay, transfusion, and mechanical ventilation use were analyzed using multivariable linear regression. in addition, multivariable logistic regression was used to ascertain specific clinical or epidemiologic factors associated with mechanical ventilation use after adjusting for patient and hospital characteristics. the total hospitalizations for acs were , in ; , in ; , in ; and , in . reported use of mechanical ventilation ranged from . % to . % and was associated with non-black compared to black children (or, . ; %ci, . to . ) and the fall season (or, . ; %ci, . to . ), but not with age, preexisting asthma or hb-genotype. comorbidities of obesity (or, . ; %ci, . to . ), obstructive sleep apnea (or, . ; %ci, . to . ) and heart disease (or, . ; %ci, . to . ) were associated with mechanical ventilation use. the use of simple and exchange transfusion during all acs admissions ranged from . % to . % and . % to . %, respectively. among pediatric acs patients, those with obesity, obstructive sleep apnea or heart disease were at increased risk for respiratory failure and might benefit from early intervention (e.g., transfusion). surprisingly, asthma in children with acs does not appear to be a distinct risk factor for respiratory failure, and further studies are needed to clarify whether differences in treatment approach (e.g., addition of corticosteroids, bronchodilators) might impact on acs progression and/or severity even in high risk patients without asthma. objectives: to compare pulmonary functions between aa and k children with scd and to assess if a high hb f level contributes to better function. design/method: a cross sectional study was done on children with scd (hb ss disease) followed in comprehensive sickle cell programs. aa patients were followed at brookdale hospital, ny and k patients were followed in mubarak hospital, kuwait. children between the ages of and years who had pulmonary function tests (pft) done as a routine screening were enrolled. pft was done using spirometer and plethysmography. patients with congenital or anatomical lung abnormality, heart disease, pulmonary disease such as acute chest syndrome, acute asthma or pneumonia within weeks were excluded. results: there were children ( in each group) with scd,. restrictive pattern on pft was seen in / ( %) of aa vs. / ( %) of k (p> . ). obstructive pattern was seen in / ( %) of aa vs. / ( %) of the k group (p> . ). in both groups, children ( %) had normal pft. three/ ( %) in the aa group had a hb f> % as compared to / ( %) in the k group (p< . ). abnormal pft was noted in / children ( %) in each group. hbf was > % in / ( %) in the aa group vs. / ( %) in the s of s k group (p< . ). in patients with abnormal pft, mean hbf was . ± . in aa group, compared to . ± in k group (p< . ). conclusion: abnormal pft is highly prevalent among children with scd in both groups. aa children are more likely to have restrictive disease and k to have an obstructive pattern. level of hbf did not seem to protect k patients from abnormalities on pft. this finding should emphasize the importance of performing pft as part of the initial evaluation of all children with scd. background: sickle cell disease (scd) is a life-threatening disease with varied clinical spectrum and severity leading to premature death. there is a lack of validated prognostic marker in scd. recent evidence suggests that inflammation and platelet adhesion plays a critical role in the pathophysiology of vaso-occlusion in scd. elevated mean platelet volume(mpv) values are associated with a higher degree of inflammation in many disease states but it's effect on sickle cell disease or it's severity is unknown. objectives: to analyze the role of mpv in predicting disease severity/mortality in pediatric patients with scd. design/method: this is a single center retrospective study and included patients with sickle cell disease between months and years of age during a -year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . demographic information, lab data and clinical information including acute chest syndrome (acs), priapism, transfusions, sepsis, pain crisis, avascular necrosis were collected. all laboratory data were collected in steady state with no crisis in the recent past months. the disease severity score/probability of death was calculated using a validated model to predict risk of death in sickle cell disease (sebastiani et al. blood ) . pearson test was used to analyze correlation between mpv and probability of death. results: total no. of patients = ; male ( . %); female ( . %). median age is . years. all patients were of african-american origin. disease severity, hb ss - ( %); hb sc - ( . %) and sickle-beta thalassemia ( . %). patients on hydroxyurea has significantly lower mpv, p = . and this is independent of hb f levels. mpv has a significant positive correlation with the probability of death, p = . and correlation coefficient, r = . . on subgroup analysis, the correlation is even more significant in the age group between and years, p = . , r = . . using linear regression model, with probability of death as a dependent variable and hydroxyurea, mpv as independent variables, mpv maintains a significant association with probability of death (p = . ). conclusion: mpv is an independent biomarker predicting disease severity and probability of death in pediatric patients with sickle cell disease. hydroxyurea a known disease ameliorating agent is associated with lower mpv values. this effect is independent of the levels of fetal hemoglobin and may be due to anti-inflammatory effect of hydroxyurea or effect on the platelets. background: major success with initial qi projects by the sickle cell care team at children's hospital has precipitated ongoing inclusion of the qi approach to many other aspects of patient care. objectives: to optimize scd patient care utilizing qi processes. design/method: success of the scd qi team's initial project on transcranial doppler studies (tcds) and a second more complex project on hydroxyurea (hu) adherence, led to additional projects on completion of key immunizations, rbc phenotyping, and vitamin d level testing. using similar processes and principles from the hu adherence project, plan-do-study-act (pdsa) cycles were used to conduct smallscale tests of change. patient chart prep sheets, created for bi-monthly pre-appointment chart prep meetings, were significantly modified to include these focused care qi objectives. because of difficulty with emr database capability, data collected from the emr was tracked in excel spreadsheets or other unique tracking vehicles for the various parameters. for example, due to the clinic's diffuse, geographically scattered population, many separate non-shared primary care emrs, and lack of a mandatory state immunization registry; immunization records needed to be retrieved from pcps, outlying hospitals, public health departments, and fqhcs, and added to the emr and excel database. starting in / , all such data was collected and updated monthly. in one year's time ( - ) , the average immunization completion rate for seven key immunizations (pcv , pcv , hepatitis a, hepatitis b, meningococcal a, meningococcal b, and hpv) has increased by %. the biggest improvements were a % and % increase in completion for meningococcal a and meningococcal b, respectively. completion rate for rbc phenotyping rose from . % to . %. patients with at least one vitamin d lab test increased from . % to . %. since starting the tcd project in , the percent of patients who have completed their annual tcd has gone from a baseline of % to a sustained value of > %. conclusion: these qi projects have not only increased adherence to national recommendations for care of scd patients, they have helped establish a scd clinic methodology to create and implement sustainable processes. having the focused care initiatives prominently displayed on the patients' chart prep sheet serve as a reminder to medical team members to check the status of that item. this methodology is currently being used to formulate additional qi projects on annual renal function parameters and specialty visits, such as annual eye and dental exams. background: dominican republic has a high burden of sickle cell disease, and - % of children with homozygous hbss (sickle cell anemia, sca) will develop primary stroke. transcranial doppler (tcd) ultrasonography is an effective screening tool for primary stroke risk, but is not routinely available in dominican republic. hydroxyurea and blood transfusions are available, but no prospective screening and treatment program for stroke prevention has been implemented to date. ( ) to screen a large cohort of children with sca living in dominican republic, using tcd to identify elevated stroke risk; ( ) to determine the effects of treatments for stroke prevention (hydroxyurea for conditional velocities and transfusions for abnormal velocities). we hypothesized that both hydroxyurea and blood transfusions will decrease elevated tcd velocities and help prevent primary stroke. design/method: stroke avoidance for children with república dominicana (sacred, nct ) features a research partnership between cincinnati children's hospital and robert reid cabral children's hospital in dominican republic. the protocol, consent forms, and redcap database were prepared collaboratively and translated into spanish, and then irb approval was obtained at both institutions. in the initial prospective phase, children receive tcd screening over a -month period; those with conditional tcd velocities (maximum time-averaged velocity - cm/sec) receive fixed-dose hydroxyurea at mg/kg/day, followed by dose escalation to maximum tolerated dose, while those with abnormal tcd velocities (≥ cm/sec) receive monthly transfusions for stroke prevention. results: a total of children were enrolled in sacred, with an average age of . ± . years. initial tcd screening revealed ( . %) normal, ( . %) conditional, ( . %) abnormal, and ( . %) inadequate velocities. among children ( males, females, average age . ± . years) who initiated hydroxyurea at mg/kg/day for conditional tcd velocities, completed six months of treatment with expected hematological benefits including significant increases in hemoglobin concentration ( . to . g/dl) and fetal hemoglobin ( . to . %). no clinical strokes have occurred in the treatment group. repeat tcd examination after -months of hydroxyurea treatment revealed % ( / ) with previous conditional velocities had normal tcd velocities. the prevalence of conditional tcd velocities in the dominican republic is high, indicating an elevated stroke risk among children with sca. hydroxyurea treatment is associated with improved hematological parameters, lower tcd velocities, and probable decreased stroke risk. sacred is an important prospective and collaborative research trial providing epidemiological data regarding tcd screening, stroke risk, and hydroxyurea effects among children with sca. background: red blood cell aggregation is a rheologic property that explains the shear-thinning behavior of blood. at lower shear rate blood flow, red cells tend to aggregate, s of s whereas in higher shear rate blood flow, these aggregates are dispersed. this property is especially important in the venous system, where low shear rate blood flow predominates. there is inconsistent data in the literature concerning aggregation and aggregability in sickle cell disease (scd). objectives: because the lorrca and myrenne instruments have been shown to be similarly effective methodologies in red cell aggregation measurements, we aimed to determine whether the measurement of aggregation indices in scd, by myrenne and by lorrca, is consistent in our lab. design/method: we measured aggregation in blood samples corrected to % hematocrit. aggregability was measured using kda dextran in the myrenne but not the lor-rca. aggregation index using lorrca was measured in patients with scd and healthy subjects enrolled in a study of blood flow between and . aggregation and aggregability using the myrenne was measured in patients with scd and healthy subjects enrolled in a separate study of blood flow between and . results: using lorrca, we found that aggregation index in patients with scd was less than that of healthy subjects (p< . ). in the myrenne, aggregation at stasis was slightly higher in patients with scd compared to healthy subjects (p = . ) but aggregation at low shear rotation was not different. aggregability was higher in the patients with scd compared to healthy subjects at both stasis and low shear rotation (p< . ). red cell aggregation is an important determinant of low shear blood flow. deoxygenated venous blood is particularly important to low shear blood flow in patients with sickle cell disease. we found that two different aggregometers predict different aggregation results for scd. it is unclear why there is a systematic difference between the two methods, but there are some possibilities. first, the syllectogram in the lorrca is generated by the backscatter of light from the laser, while the myrenne measures transmitted light. second, the distance between the bob and cup in the lorrca is microns, while the gap between plates in the myrenne is microns, which might affect the disaggregation of red cells. further work is needed to understand the differences in red cell aggregation and aggregability when using these instruments, particularly when using aggregation as a predictor of blood flow and tissue perfusion. background: children with sickle cell disease (scd) are at risk of acute splenic sequestration crisis (assc). assc is a life-threatening complication characterized by splenomegaly, pain and severe anemia. assc most often occurs in young children with the most severe forms of scd and one-third of patients will have more than one episode. treatment is based primarily on expert opinion and includes blood transfusion and surgical splenectomy. objectives: we plan to assess the clinical practice patterns of physicians treating children with assc. design/method: a survey study was performed. the survey included six scenarios of severe scd with variation in age, hydroxyurea-use, and episode number of assc; questions focused on the acute and chronic management of assc. the survey was disseminated on three occasions over a six-month period, using an online survey tool, surveymonkey, to pediatric hematologist-oncologists participating in the american society of pediatric hematology-oncology hemoglobinopathy special interest group. the survey had a response rate of % ( / ). most respondents were recent graduates ( %; / ) practicing in academic urban centers with greater than sickle-cell patients. seventy-nine percent ( / ) recommended hydroxyurea initiation in - m/o with severe scd. prophylactic penicillin after surgical splenectomy was continued by % ( / ) after years. for the acute management of assc results did not vary despite patient age, hydroxyurea use, and the number of previous assc episodes. simple transfusion was preferred by % ( / ), with % ( / ) recommending slow transfusion and % ( / ) recommending routine simple transfusion. for the chronic management of assc, results varied based on patient age and the number of previous assc episodes. for a m/o after the first episode, % ( / ) recommended observation and % ( / ) hydroxyurea initiation. for a m/o with any prior episode of assc, % ( / ) recommended chronic transfusion therapy and % ( / ) surgical referral for splenectomy. for a y/o after the first episode, % ( / ) recommended surgical splenectomy and % ( / ) increasing hydroxyurea dose. for a y/o with any prior assc episode, % ( / ) recommended referral for surgical splenectomy. in this survey, we found most providers continue to recommend simple transfusions for assc and surgical splenectomy after two episodes. the majority of providers continue to delay referral for surgical splenectomy until age two, but earlier referral in children under two and use of chronic transfusion therapy were also reported. variability in chronic management highlights the need for further research of splenic sequestration. background: developing therapies for sickle cell disease (scd) is challenging in part because the accepted endpoint, vaso-occlusive crisis (voc), occurs infrequently, does not measure full disease burden, and is a measure of healthcare utilization. in phase / studies of patients with scd, voxelotor (gbt ) has demonstrated increased hemoglobin (hb) levels and reduced hemolysis and has been safe and welltolerated. voxelotor is being evaluated in the ongoing hope phase trial. objectives: to report the innovative phase / hope trial design with novel primary and secondary outcomes to accelerate drug development. design/method: hope (nct ) is a phase , randomized, placebo-controlled, multicenter study of oral voxelotor in patients with scd (aged - years) with baseline hb . - . g/dl and - episodes of voc in the prior year. to accelerate clinical trials to support drug development, the study combines a phase exploratory, dose-selection phase (group ) with a pivotal phase (groups / ). patients in group will be randomized : : to voxelotor or mg/day or placebo. analysis for dose selection will occur when the final patient has received weeks of treatment. group will continue enrollment with randomization : : until dose selection based on analysis of the group cohort. group will allow for a seamless transition into group , which will randomize patients : to the selected dose or placebo. the final data analysis set will include group patients who received placebo or the selected dose and all group patients. the primary endpoint is an objective laboratory measure and surrogate of clinical benefit, increase in hb > g/dl, from baseline to weeks based on voxelotor mechanism of action (inhibition of hb polymerization). this trial is the first to use a patient-reported outcome (pro), the -item sickle cell disease severity measure, as a secondary endpoint. this novel electronic pro, developed specifically for the hope study following fda guidance, will evaluate changes in scd symptom exacerbation and total symptom score from baseline to weeks. additional secondary endpoints include measures of hemolysis, rates of voc, transfusions, and opioid use. the study was designed to enable selection of pro-defined symptom exacerbations or traditionally defined voc as the key secondary endpoint after the group analysis. results: this study is ongoing. the hope trial, expected to complete enrollment by late , will evaluate the efficacy and safety of voxelotor compared with placebo in patients with scd. supported by global blood therapeutics. background: inflammation, coagulation activation, oxidative stress and blood cell adhesion are elements of sickle cell disease (scd) pathophysiology. patients with scd have low levels of the omega- fatty docosahexaenoic acid (dha) and eicosatetraenoic acid (epa) in plasma and blood cell membranes. dha is a bioactive fatty acid with anti-inflammatory, anti-blood cell adhesion and anti-oxidant properties. altemi-atm is a novel dha ethyl ester formulation with a proprietary delivery platform (advanced lipid technology® (alt®)) that enhances oral dha bioavailability. the scot trial investigated the effects of altemiatm in children with scd. objectives: to demonstrate the effects of altemiatm on blood cell membrane omega- index and selected biomarkers of inflammation, coagulation, adhesion and haemolysis associated with scd. s of s design/method: children with scd, aged - years (n = ), were enrolled. subjects were randomized to receive either placebo or one of three daily oral doses of altemiatm ( - , - or - mg/kg/day dha) for two months. the effects of altemiatm on red blood cell (rbc), white blood cell and platelet membrane omega- fatty acids index (total dha + epa levels) were assessed after four weeks of treatment. the effects of altemiatm on markers of inflammation, adhesion, coagulation, and hemolysis were assessed after eight weeks of treatment. cell membrane dha and epa concentration was determined by using lc-ms/ms method. the percent changes from baseline on blood cell membrane omega- index and select scd biomarkers were compared between the three dose groups and placebo using a mixed-model repeatedmeasures (mmrm) analysis with baseline blood cell membrane omega- index, hydroxyurea use, and treatment as fixed effects and patient as a random effect. after four weeks of treatment, blood cell membrane dha and epa levels were significantly increased in all altemiatm doses (p< . ). after eight weeks of treatment, significant reductions were observed in se-selectin (p = . ), and d-dimer (p = . ) in patients exposed to altemiatm dose level vs. placebo. hemoglobin was significantly increased at altemiatm dose level versus placebo. plasma high-sensitivity c-reactive protein, lactate dehydrogenase, soluble vascular cell adhesion molecule- and white blood cell count showed improvement after weeks of treatment in all three altemiatm doses levels but did not reach significance. conclusion: treatment with altemiatm enriches dha and epa in blood cell membranes of patients with scd and improves select sickle cell disease biomarkers of blood cell adhesion and thrombin generation. these findings provide insight into the mechanisms of action of altemiatm in sickle cell disease. brown university -hasbro children's hospital, providence, rhode island, united states background: despite clinical advances in the treatment of sickle cell disease (scd) in pediatric and young adult patients, pain remains a significant source of disease-related morbidity. physical therapy has been shown to be useful for the treatment of pain in children and young adults with various chronic illnesses of which pain is a significant component, however no data exists regarding potential benefits of physical therapy in pediatric and young adult patients with scd. objectives: to query healthcare providers and others involved in the care of pediatric and young adult scd patients regarding possible benefits of and barriers to physical therapy as a potential treatment modality. design/method: we conducted a web-based survey of healthcare providers within the new england pediatric sickle cell consortium (nepscc) in an attempt to identify potential benefits of and barriers to outpatient physical therapy in this patient population. results: nearly % of survey participants felt that physical therapy had the potential to be "somewhat beneficial" or "very beneficial" in pediatric and young adult patients with scd. a majority of physicians reported having referred patients with scd for physical therapy in the past. the most frequently identified perceived potential benefits included improved functional mobility, improvement of chronic pain symptoms, decreased use of opiates, improved mood symptoms, improved acute pain symptoms, and improved adherence with medications and clinic visits. significant perceived barriers identified included lack of transportation, time constraints, patient lack of understanding, and difficulty with insurance coverage. our study indicates that healthcare providers have an overwhelmingly positive view of the use of physical therapy in the management of pediatric and young adult patients with scd. significant barriers exist which need to be addressed. future research should focus on patient and parent perspectives regarding physical therapy, as well as a randomized controlled trial of a physical therapy intervention in this patient population. background: vitamin-d deficiency is fast becoming increasingly recognized in patients with sickle cell disease (scd). while it is estimated that these patients are five times more likely to develop vitamin-d deficiency, the exact clinical significance of this is largely unknown. given that this deficiency can be inexpensively and easily treated, our study sought to establish the prevalence of vitamin-d deficiency in our patient population and its relationship with disease severity. objectives: to estimate the prevalence of vitamin-d deficiency in patients with scd in our institution and to analyze their disease severity in relation to their vitamin-d level. design/method: through retrospective chart review we analyzed subjects that represent a cohort of patients followed at the adult and pediatric hematology services at university of miami with known diagnosis of scd that had a vitamin-d level drawn between january st, and august st, . we conducted a cross-sectional study and recorded the first vitamin-d level during this period. patient demographics, medical and social history information were collected along with laboratory data. the number of admissions for vaso-occlusive crisis (voc) and acute chest syndrome within one year preceding the collection the vitamin-d level was also recorded. results: a total of charts were reviewed, adult charts and pediatric charts. after exclusion, patients were enrolled. subclinical vitamin-d deficiency is only evident on laboratory blood testing of vitamin-d ( -hydroxy) and according to this laboratory result patients were classified as sufficient (≥ ng/ml), insufficient (< to ng/ml) and deficient (< ng/ml). out of the cases, . % ( / ) were deficient, . % ( / ) were insufficient and . % ( / ) were optimal. after statistical analysis two negative correlations were identified, increasing vitamin-d levels with decreasing white blood cell count (ci %- . (- . , - . )and decreasing incidence voc (ci %- . (- . , - . ). conclusion: this study confirms that there is a significant prevalence of vitamin-d deficiency in patients with scd. furthermore, the results of this investigation proved that vitamin-d deficiency is associated with acute pain and leukocytosis in patients with scd. given the multitude of confounding factors that affect vitamin-d absorption and intake, multivariate analyses are required to truly further investigate this relationship. texas children's hospital, houston, texas, united states background: hemophagocytic lymphohistiocytosis (hlh) is a rare but life-threatening condition of hyper-inflammation that is characterized by splenomegaly, cytopenias, hyperferritinemia, hypertriglyceridemia, hemophagocytosis and coagulopathy. although timely diagnosis is imperative, it is often challenging as these individual signs and symptoms may occur in a variety of clinical conditions. to report a case of undiagnosed sickle cell anemia presenting with severe ebv viremia and associated hemophagocytic lymphohistiocytosis results: a -month-old previously healthy male presented with respiratory distress, increased fatigue, and a focal seizure following a two-week history of cough and lowgrade fevers. physical exam was consistent with hypovolemic shock and revealed significant splenomegaly. laboratory testing revealed severe hypoglycemia, acidosis and electrolyte disturbances including hyperkalemia, hyperphosphatemia, and hyperuricemia. labs showed a leukocytosis (wbc , ), severely low hemoglobin ( . ), and platelets of , . coagulation testing revealed prolonged pt/inr and ptt, hypofibrinogenemia and a highly elevated d-dimer. additional workup was completed to determine etiology of acute presentation, given broad differential diagnosis. infectious studies were consistent with an acute ebv infection (plasma ebv pcr > , ). elevated levels of soluble il- and ferritin completed / criteria for the diagnosis of hlh. bone marrow evaluation showed trilineage hematopoiesis with no abnormal blast population or hemophagocytosis. results from hemoglobin electrophoresis sent from the initial cbc sample were notable for hbs . %, hbf . %, and hba of %, confirming the diagnosis of sickle cell disease. the patient was started on hydroxyurea and penicillin and splenomegaly resolved. with supportive care, he demonstrated gradual improvement in symptoms and laboratory abnormalities, including normalization of soluble il- , ferritin, cd , il- levels, immunoglobulins, and declining ebv titers. nk cell function has remained abnormally low, not eliminating the possibility of acquired hlh despite spontaneous improvement. conclusion: splenic sequestration associated with sickle cell disease in combination with acute infectious mononucleosis could have explained many of the presenting symptoms including anemia, thrombocytopenia, and splenomegaly. however, it does not explain the unusually high ebv titer and degree of inflammation meeting diagnostic criteria for hlh, which raises concern for an underlying immunologic abnormality such as x-linked lymphoproliferative disorder (xlp). although testing for xlp was negative, he will require s of s continued monitoring in the future for signs of relapse. this case illustrates the complexity of diagnosing lymphohistiocytic disorders and the significant overlap in presentation between these disorders and other medical conditions. background: vaso-occlusive crisis (voc) is one of the most distressing occurrences in patients with sickle cell disease (scd). patient controlled analgesia (pca) is recommended by nih and expert opinions favor its early use. we aim to review the use of pca in patients with voc and to evaluate if its early use is associated with faster pain control and reduced length of stay (los). design/method: this retrospective single center study included all pediatric patients admitted and treated with pca for a severe voc from to . "early" use was defined as start of pca within hours of arrival in the emergency department (ed) and "late" use after hours. time to reach adequate analgesia was defined as oucher, verbal scale or faces pain scale < / obtained twice consecutively in a -hours interval. time to reach adequate analgesia and los were compared between early-pca and late-pca groups. results: a total of patients presented episodes of voc treated with pca during the study. sixty-one episodes ( %) were treated with early-pca and ( %) with late-pca. both groups were comparable in terms of age ( . vs . years old), gender ( . % female vs . %), hemoglobin phenotype ( . % hbss vs . %), but median pain score at admission was higher in early-pca than in late-pca ( / vs / , median difference ( % ci , ). early-pca was associated with a median reduction in los of . days ( % ci . , . ) (median early-pca los . vs late-pca . days). time to reach analgesia could be evaluated only in a subset of patients ( in early-pca and in late-pca group). although time to reach adequate analgesia tended to be shorter in the early-pca group, it was not statistically different: median . hours vs . hours, difference of . ( % ci - . , . ). side effects were observed during ( . %) pca treatments ( / ( . %) episodes in early-pca, / ( . %) in late-pca group) among which ( . %) were significant adverse events. these were observed in patients who required interventions: desaturations requiring oxygen without intubation, neurologic abnormalities (hallucinations, visual abnormalities, no stroke), urinary retentions. conclusion: early use of pca for severe voc was associated with a reduced length of hospital stay despite that these patients had higher pain score on admission. prospective studies are needed to support these positive outcomes. background: acute chest syndrome is one of the leading causes of death in children with sickle cell disease - . while the cause of acute chest syndrome most commonly is not identified, fat embolism and infectious causes are believed to be most common. with an extremely high mortality rate, rapid identification and initiation of therapy is essential for survival. case presentation: we describe the case of an -year-old female with sickle cell sc disease who was admitted for vasoocclusive pain crisis and quickly progressed to multi-system organ failure due to fat embolism syndrome and parvovirus b infection objectives: the case highlights the presentation and diagnosis so other providers can optimize outcomes for those with this under-recognized syndrome design/method: her parvovirus studies returned after days which showed: parvovirus b dna pcr detected; parvo igg . (positive > . ); and igm . (positive > . ). the patient experienced an approximately . g/dl drop in hemoglobin( . to . g/dl/ hrs) with progressive thrombocytopenia (from , to , /ul) and a peripheral smear showed microcytic,normochromic red cells with nucleated rbcs and occasional nuclear budding, slight polychromasia, schistocytes, and polymorphic cells with toxic granules that suggested leukoerythroblastosis. she was emergently transferred to the regional quaternary care hospital for ongoing ecmo therapy where she experienced a change in her pupillary exam prompting a stat ct scan that showed severe, diffuse cerebral edema with transtentorial herniation. the decision was made to withdraw life-sustaining therapies and her family refused a post-mortem autopsy examination. fat embolism syndrome is a severe and uncommonly recognized complication of sickle cell disease, seen most commonly in those with a non-ss phenotype and previous mild disease course who present with severe, unrelenting vaso-occlusive pain episode and/or acute chest syndrome that progresses to respiratory distress with altered mental status and cutaneous changes. rapid identification and initiation of exchange transfusion therapy should be initiated with clinical suspicion because of the extremely high mortality rate. although previously considered rare, it needs to be considered in the differential diagnosis of more commonly encountered complications of sickle cell disease. background: patients with sickle cell disease (scd) experience vaso-occlusive crisis (voc), which results in extreme pain, often requiring opioids and admission. genetic and environmental factors affect the frequency and severity of these episodes. previous research has born conflicting evidence on whether environmental temperature is contributory. edmonton, alberta is the northern most city with a population over a million in north america. there is an increasing sickle cell population which is exposed to extreme winter conditions. this provides a suitable population and atmosphere to study the influence on cold external temperatures in scd. this study sought to identify if pediatric patients with scd, experience greater morbidity in cold external temperatures. board approved retrospective case control series. patients were identified through a clinical database, and emergency visit, phone call and admission data was collected over a fiveyear period. the average, minimum and change in temperature on day of presentation, and hours prior, was collected from the government of alberta, and was statistically analyzed using descriptive statistics, to determine the relation to vaso-occlusive events. results: one-hundred and eighteen patients were identified, and voc events reviewed. the mean patient age was . years of age with a range from . - years old. the female to male ratio was equivalent with female ( . %) and male ( . %) voc events. eight records ( %) had docu-mented cold exposures. the analysis between the temperature and the frequency of events did not yield significant correlation. average and minimum temperature on day of admission had the largest percentage of voc events occur at mild temperatures, from - . to • c and - . to respectively. change in temperature on day of admission, and hours had the largest percentage of voc events at a mild to moderate change in temperature of - degrees. data at & hours prior to admission showed similar results. secondary data analysis accounting for the lower proportion of extreme weather days in comparison to moderate temperate days showed no significant impact. there was no correlation of average, minimum or change in temperature on day of admission, or hours prior. multiple cofounding factors likely contribute to these results. as it was a retrospective study many confounding and precipitant factors may not be recorded or identified. a prospective study to better record specific cold exposure is warranted. children's national health system, washington, district of columbia, united states background: achieving optimal anticoagulation with unfractionated heparin (ufh) in pediatric patients receiving extracorporeal membrane oxygenation (ecmo) is often challenging due to antithrombin (at)-mediated heparin resistance (hr). intermittent at dosing during pediatric ecmo support does not maintain adequate at levels. continuous at infusion (cati) presents an alternative strategy to achieving consistent goal at levels and optimizing heparinization. however, cati during pediatric ecmo has not been adequately studied. objectives: to describe our center's experience with an ecmo cati protocol. design/method: in , we modified our ecmo anticoagulation protocols to include ufh titration according to anti-factor xa (anti-fxa) levels and cati in patients with at-mediated hr. the cati rate was calculated using baseline and goal at levels while accounting for the circuit volume. cati was administered with ufh into the circuit via a s of s y-infusion set. at and anti-fxa levels were monitored every hours. recombinant at (r-at) concentrate was used at our center until with subsequent transition to a plasmaderived at (pd-at) concentrate. due to the longer half-life of pd-at concentrate, the protocol was modified so cati is stopped once target at and anti-fxa levels are achieved. we conducted a retrospective study of all patients who received cati during ecmo support at our center. data are reported as median and interquartile range and compared using the mann-whitney u test. two-tailed p-value < . was considered statistically significant. since , patients [ males, age month ( . - )] on ecmo support received catis ( rat, pd-at) per our protocol ( patients received pd-at infusions during one ecmo run). the duration of cati was hours ( - ). cati administration led to significant increases in at and anti-fxa levels from baseline of % ( - ) and . units/ml ( . - . ) to the first level within goal of % ( - ) and . units/ml ( . - . ), respectively (p< . ). the respective times to achieve goal at and anti-fxa levels were hours ( - ) and hours ( - ). the respective peak at and anti-fxa levels were % ( - ) and . units/ml ( . - . ). during cati, no patient required circuit change, patient developed cannula thrombosis and patients experienced non-fatal major bleeding. conclusion: cati in pediatric patients receiving ecmo support with close monitoring of at and anti-fxa levels was associated with significant rapid increase in at, optimization of heparin effect, and reduction in thrombotic complications without increase in major bleeding compared to prior reports. a prospective study of this at dosing strategy is warranted. children's hospital of orange county, orange, california, united states background: inherited factor xiii (f ) deficiency is a rare bleeding disorder with wide heterogeneity in clinical manifestations ranging from mild bruising, and mucosal and umbilical stump bleeding to spontaneous, severe intracranial bleeding. the bleeding phenotype is influenced not just by zygosity of the fxiii mutation alone, but also by co-inheritance of variants in other clotting protein genes that also play a major role in clot formation and stability. we present a series of three siblings found with f a gene variant and platelet dysfunction linked to bleeding phenotype. design/method: retrospective chart review of the index case, coagulation studies and whole gene sequencing. the index patient presented at two years of age with a subdural hematoma after a fall, requiring emergent craniotomy. a week after initial evacuation, she re-bled, prompting an extensive work-up for potential bleeding disorders, including f activity, von willebrand profile, comprehensive fibrinolysis panel, pai- antigen level, platelet mapping thromboelastogram (plt-teg), and f genetic analysis. the patient's identical twin and older sibling, who had symptoms of bruising, underwent a similar evaluation. the index patient demonstrated consistently low f activity ( - %), and platelet function testing revealed decreased response to adp agonists. the twin and older sibling had normal f levels, and only slightly decreased response to adp in platelet studies. whole gene analysis of f and other genes on our next generation panel, revealed several intronic deletions in the index patient that were not shared by her siblings, which likely account for her decrease in circulating f levels. her symptoms have responded well to monthly treatment with factor concentrate. all three children shared the f variant, pro leu, previously described as a risk factor for intracranial hemorrhage. the f mutation, pro leu, has been associated with intracranial hemorrhage in young women, but the presence of the variant alone may not be enough to cause a severe bleeding phenotype. family studies identified novel deletions in the index patient which may account for her decreased f levels, which would have been overlooked with standard sequencing. future studies, including evaluation of 'platelet' f levels, should be performed when platelet dysfunction is detected. further laboratory and clinical evaluation is required to delineate the long term implications of the interaction of even mild f deficiency if present with additional clotting disorders such as the platelet function defect in these siblings. background: acquired hemolytic anemia can occur due to mechanical shearing of red blood cells and is classically seen in patients with prosthetic heart valves. there are reports of this same traumatic effect with other repairs, including annuloplasty. following valvular procedures flow disturbances can exist across the valve that lead to shear stress and hemolysis. although von willebrand disease (vwd) is typically seen due to an inherited disorder in the pediatric population, flow disturbances in the setting of valve abnormalities can lead to acquired von willebrand syndrome (avws). von willebrand factor multimers become unfolded and elongated in the setting of shear stress resulting in increased susceptibility to cleavage by adamsts- . specifically, loss of high molecular weight multimers (hmwms) can lead to a syndrome akin to type a vwd. objectives: to describe a case of mechanical hemolysis with acquired type a vwd design/method: a -month-old girl with history of hypoplastic left heart syndrome and severe tricuspid valve insufficiency underwent norwood procedure, blalok-taussig shunt placement and subsequently a bidirectional glenn and tricuspid valve annuloplasty. during the following month she requires weekly red blood cell (rbc) transfusions due to intermittent anemia. she also experienced bloody stools and dark urine. laboratory evaluation was notable for normocytic anemia, reticulocytosis, elevated lactate dehydrogenase, and low haptoglobin consistent with hemolytic process. immune-mediated hemolysis from transfusion reaction or presence of autoimmune or alloimmune antibodies testing was negative. to investigate gi bleeding, work up for vwd revealed normal vw activity and antigen but with loss of high molecular weight multimers consistent with acquired type a vwd. in consultation with cardiology, it was felt her tricuspid valve insufficiency jet could be leading to mechanical hemolysis and avws. a repeat echo showed persistent moderate tricuspid insufficiency but no other significant changes. due to the patient's continued need for weekly rbc transfusions she was subsequently trialed on pentoxifylline which is used in adult patients to decrease blood viscosity and increase erythrocyte flexibility in patients with mechanical hemolysis. her transfusion needs remained the same and the medication was discontinued after two weeks. she required one transfusion a week later but no transfusions since that time. although not commonly seen in pediatric patients, the diagnosis of mechanical hemolysis accompanied by avws should be pursued in a patient with congenital heart disease with significant anemia and/or bleeding. the work up in these patients is difficult as echocardiograms can be inconclusive thus an extensive hematologic evaluation is usually necessary. objectives: our aim was to assess incidence of and potential risk factors for central line-related dvt at our institution between - . additionally, our goal was to analyze if that incidence differed between the three central line types and identification of line-specific risks. design/method: a retrospective chart review of central line placements in pediatric patients at cleveland clinic between - was conducted. data included demographics, potential risk factors, line characteristics and any related thrombotic events. the study cohort consisted of lines in pediatric patients aged - years of age. there were . thrombi ( % ci . - . ) per , line days. statistically significant risk factors for thrombus include diagnosis group (liquid tumor highest rate of %, solid tumor lowest at %), type of line (picc %, broviac %, and mediport %), location of line, greater number of lines per patient, peg asparaginase ( % vs %), sepsis, and history of procoagulant state. line characteristics such as lumen size and number of lumens were not identified as a significant risk. there was a significantly higher rate of thrombus in than in the previous years when pooled ( % in vs . % from - , p = . ). the incidence of dvt in pediatric patients at our institution was highest with broviac lines, and significant risk factors in our patient population included liquid tumor, femoral vein location, peg asparaginase, sepsis, and history of a procoagulant state. the incidence of thrombi was highest in , and therefore highlights the urgent need for improvement in nationwide hospital practices to minimize risk of thrombi formation and early detection in the higher-risk s of s populations. there is still much to be learned regarding the characteristics specific to different central lines, which would influence thrombi formation. nyu winthrop hospital, mineola, new york, united states background: pediatric immune thrombocytopenic purpura (itp) is an autoimmune disorder with platelet counts < causing increased risk for significant hemorrhage. there is increased immunologic platelet destruction due to production of specific autoantibodies along with inhibition of platelet production. few randomized trials exist to guide management and ultimately each patient requires an individualized treatment plan. itp may be acute (diagnosis to m) or chronic (> months). one of the treatments of chronic itp is laparoscopic splenectomy (ls), which is very well tolerated. a rare complication of ls is splenosis, an autotransplantation or implantation of ectopic splenic tissue within the abdominal cavity or in any other unusual body compartment. splenosis is sometimes associated with relapsed itp due to preserved immune activity. the usual management of symptomatic splenosis is surgical resection. objectives: to describe medical management in a young patient with itp relapsed due to extensive unresectable splenosis following ls design/method: our patient was originally diagnosed at years with itp and was treated with ls at years of age for chronic severe thrombocytopenia and persistent bleeding not responding to first line therapies. she tolerated it well and had a complete response (cr) defined as a platelet count of > measured on occasions > days apart and absence of bleeding. she maintained a normal platelet count for twelve years after which she relapsed (loss of response after cr) with severe thrombocytopenia and hematuria necessitating high dose steroids. ct scans showed multiple wellcircumscribed soft tissue masses in the left lower quadrant adjacent to uterus and left ovary, involving left omentum and the anterior abdominal wall partly. findings were confirmed by damaged rbc nuclear scan to be splenosis. during laparoscopy the splenosis lesions were deemed too extensive and were not resected completely to avoid postoperative morbidity. she was started on sirolimus around the same time for treatment of her relapsed itp and steroids were weaned off. results: eight months since beginning sirolimus with therapeutic levels she remains in cr with no bleeding and has not required any steroids, immunoglobulins or anti d immunoglobulin. conclusion: sirolimus is a safe and effective steroid-sparing agent in treatment of chronic itp. this is the first instance of a patient with poorly resectable splenosis responding well to medications for itp. more data is needed regarding the longterm efficacy of such an intervention and whether it will eliminate the need for a second surgery in relapsed itp patients with extensive splenosis. background: storage pool disorders affecting platelets result in bleeding symptoms related to a deficiency or defect in alpha granules or delta granules. in delta-storage pool disorders (dspd,) there is a deficiency of the delta granules and their constituents, which results in the inability of platelets to properly activate as well as lack of proper constriction of blood vessels during bleeding episodes. amongst patients with dspd, females most commonly present with menorrhagia, while males tend to present with epistaxis and easy bruising. the international society on thrombosis and hemostasis (isth) developed a screening bleeding assessment tool (bat) for mild bleeding disorders, shown to be a validated tool in children. diagnosis of dspd is classically made with a platelet electron microscopy (pem) value < . delta granules per platelet (dg/pl), but recently lower diagnostic thresholds of dg/pl or even . dg/pl have been suggested. objectives: evaluate the correlation between pem and bleeding scores, and also examine various cut-off values used to diagnose and risk stratify patients with dspd. design/method: retrospective chart review of pediatric patients followed by hematology with a diagnosis of dspd was performed. clinicians obtained bleeding scores for each patient as standard of care in the hemostasis clinic. quartile ranges were established to appropriate three stages of severity based upon bleeding scores. statistical analysis was performed using software r and exploratory data analysis to evaluate for a correlation. results: amongst all patients, the average bat score was . and pem was . dg/pl. the average bleeding score for pem between . dg/pl and dg/pl was . , while the average bleeding score for pem below dg/pl was . . the correlation coefficient between pem and bleeding scores is . . using a threshold of dg/pl, % of patients would have met diagnostic criteria. quartile ranges for the bleeding scores are as follows: st quartile was - , nd quartile was - , and rd quartile was > . conclusion: patients with a more marked granule deficiency do not exhibit a more severe bleeding phenotype, suggesting proper platelet function is not solely determined by granule quantity in these patients. bleeding severity may be more appropriately assessed with bleeding scores rather than pem values, and using quartile ranges may aide in risk stratification and therapeutic interventions for dspd patients. further work remains to determine the optimal diagnostic threshold of pem dspd in pediatric populations. texas children's hospital, houston, texas, united states background: warfarin management has many challenging aspects including pharmacogenomics, food and drug interactions, lack of standardized dosing, patient compliance, tracking lab results from multiple lab locations, and the potential for significant bleeding or thrombotic complications. a literature review revealed limited data highlighting anticoagulation monitoring workflow and emr documentation and specifically, no data in the pediatric population. historically, the texas children's hospital cardiology and hematology centers were each documenting anticoagulation data within the epic tm system differently. epic's tm original design for anticoagulation documenting resulted in the necessity to duplicate documentation in order to see at-a-glance critical anticoagulation monitoring information. objectives: the objective of this project was to standardize inr documentation across departments to reduce the risk of patient safety events and improve workflow. design/method: a workgroup assembled consisting of nurses from the cardiology and hematology departments, along with staff members from the epic tm is support group. the workgroup identified current documentation practices, available epic tm tools, and brainstormed ideas to streamline and improve both documentation with the current epic tm tools. physician partners were identified in cardiology, hematology and coagulation laboratory to gain their input. a new anti-coag (ac) encounter was developed and first made available in an epic tm practice environment, then once approved, epic tm written education and training session were completed by both departments' staff. results: surveys were sent to health care providers in the cardiology and hematology centers prior to the new ac encounter, and also to health care providers six months after implementing the ac encounter. six responses were received for each survey. the pre-implementation survey showed the most problematic part of the documentation system for anticoagulation was no single place in the emr to find a complete anticoagulation picture. post ac encounter implementation survey results revealed more health care providers using the epic tm inr reminder pool, less time needed to compile a report of three months of anticoagulation information, less time needed to document individual encounters, less locations needed to document ac information and decreased amount of types of documentation used. standardized ac encounters improves workflow with less time needed to document and compile information, less types of documentation utilized and easier access to patients ac information. next steps include retrospective review of patients' inr time in therapeutic range to determine if there was an impact on patient compliance and continue to evaluate and modify the ac encounter to enhance user friendliness. caitlin tydings, jennifer meldau, christine guelcher, carole hennessey, eena kapoor, michael guerrera, yaser diab s of s children's national health system, washington, district of columbia, united states background: venous anatomic abnormalities (vaas) are considered a risk factor for developing deep vein thromboses (dvts) that occur as a result of significant alterations in venous blood flow. identification of predisposing vaas can be challenging. hence, diagnosis can be delayed or overlooked especially in pediatric patients. dvts in children or adolescents with predisposing vaas have been only described in sporadic case reports and small case series. objectives: to describe characteristics and outcomes of dvts in pediatric patients with underlying vaa treated at our center. design/method: we conducted a retrospective chart review of all pediatric patients with objectively confirmed extremity dvt treated at our institution over a -year period from to and identified all patients with underlying vaas. patients were managed according to standardized institutional protocols based on published guidelines. post-thrombotic syndrome (pts) was assessed at our center using the manco-johnson instrument. relevant data were collected and summarized using descriptive statistics. during the study period, of pediatric patients ( %) [ females, median age years (range - )] diagnosed with extremity dvt at our center were found to have an underlying vaa. vaas included may-thurner anomaly ( patients), venous thoracic outlet obstruction ( patients) and inferior vena cava (ivc) atresia ( patients). additional provoking factors were identified in patients at time of presentation. dvt locations included upper extremity veins ( patients), lower extremity veins ( patients) and lower extremity veins and ivc ( patients). the majority of dvts [ patients, ( %)] were completely occlusive. high risk thrombophilia (defined as inherited deficiency of antithrombin, protein c, or protein s, or antiphospholipid antibody syndrome) was present in patients ( %). all patients were treated with therapeutic anticoagulation with patients continuing indefinite anticoagulation. endovascular interventions were performed in patients and included percutaneous pharmacomechanical thrombectomy and/or catheter-directed thrombolysis ( patients), balloon angioplasty ( patients) and stent angioplasty ( patients). surgical interventions included thoracic decompressive surgery ( patients) and surgical thrombectomy ( patient vvas represent an important risk factor for developing extensive extremity dvt in adolescents. this special population is at risk for short-term and long-term com-plications. early identification and correction of vaas may improve outcomes. however, multicenter, prospective studies are needed for developing optimal evidence-based treatment approaches. alexander glaros, roland chu, sureyya savasan, meera chitlur, madhvi rajpurkar, yaddanapudi ravindranath children's hospital of michigan, detroit, michigan, united states background: acute budd-chiari syndrome (bcs) is a rare thrombotic emergency in children, and etiologies/treatment are less well-defined than in adults. in adults, a systematic approach including anticoagulation, relief of venous obstruction, and treatment of the underlying cause has proven successful. more recently treatment has tilted towards aggressive surgical interventions, which carry significant risk and are often not feasible. objectives: review our experience with three different patients with bcs and suggest a mechanistic based approach to treatment. the records of three patients with bcs were reviewed and their presentations, etiologies, treatment, and outcomes were reported. results: patient a was a -year-old female with paroxysmal nocturnal hemoglobinuria who presented with recurrent worsening abdominal pain over several months. narrowing of inferior vena cava (ivc) and hepatic veins was noted on imaging. liver transplant was not considered surgically feasible. she was treated with eculizumab, steroids, and anticoagulation with restoration of hepatic venous flow in weeks. patient b was a -year-old male with several weeks of right upper quadrant pain, fatigue, and pre-syncopal episodes, with a history of blunt abdominal trauma from football scrimmage weeks earlier. he was found to have near complete occlusion of the ivc and hepatic veins. liver transplant was not considered feasible. he was successfully treated with anticoagulation alone. patient c was a -yearold male with acute myeloid leukemia in induction cycle who developed severe pancytopenia; typhlitis was diagnosed and managed medically. days later he acutely decompensated, arrested, and was placed on extra corporeal membrane oxygenation, and imaging showed complete occlusion of the portal vein, hepatic veins, and ivc to the level of the atrium, with bilateral pulmonary emboli. emergency liver transplant or catheter based interventions was deemed not feasible. treatment with eculizumab was considered for presumed inflammation induced complement activation (c mg/dl [normal - ]; ch was u/ml [normal - ]) as a trigger for thrombosis, but the patient progressed quickly and died before it could be initiated. our experience with bcs shows that invasive interventional options and liver transplant may not be feasible in most patients for multiple reasons. rapid diagnosis and aggressive etiology-based medical management are paramount to successful treatment of this rare complication. eculizumab may be considered in treating bcs with complement activation not only due to innate disorders, but also secondary to acute inflammation when proper laboratory evidence is present. background: platelet aggregation studies are the gold standard for the diagnosis of platelet function defects during the evaluation of a patient with bleeding problems. the platelet aggregation test measures how well platelets clot in response to different concentrations of epinephrine, adenosine diphosphate (adp), collagen, arachidonic acid and ristocetin. because platelet function defects are often under-recognized and under-diagnosed in the pediatric patient, the true incidence is unknown. we report our experience in the diagnosis of platelet defects at our institution over a -year period in order to add some clarity to the limited pediatric data available. objectives: our primary objective is to document correlations/trends between less well-known platelet function abnormalities and clinically significant bleeding at our institution over a -year period. design/method: after appropriate irb approval obtained, we performed a retrospective chart review of all children who had platelet aggregation testing done from to . data collected included demographics (age, sex, race), personal and family history of bleeding, screening for coagulation defects and platelet aggregation test results. symptoms examined in our data were limited to epistaxis and heavy menstrual periods. for each of these symptoms, results were further analyzed to those with abnormal responses to adp and epinephrine. patients with existing bleeding diagnoses and those with incomplete medical records were excluded. we identified patients. of the patients with epistaxis, % had abnormal platelet aggregation testing while only % of those with heavy menstrual periods had abnormal results. within our population, abnormal platelet function assay (pfa- ) results or race did not appear to correlate with abnormal platelet aggregation testing. in the cases of epistaxis, sex was also noncontributory. our preliminary results suggest that platelet aggregation testing was more useful in predicting platelet defects in those with a clinical bleeding history of epistaxis as opposed to heavy menstrual periods. for other presenting symptoms, platelet aggregation testing did not offer diagnostic benefit. abnormal response to adp in the platelet aggregation test was the most common finding in our population; the clinical significance of which is not well understood. going forward, we plan to document whether abnormal results correlated significantly with the subsequent final diagnoses of our patients. background: decision making for severe hemophilia a in previously untreated patients (pups) has recently become a significant ethical debate. recombinant factor viii (rfviii) products previously were recommended to avoid transmission of blood borne pathogens associated with plasma-derived fviii (pdfviii) products. however, the increased incidence of fviii alloantibody inhibitors with rfviii products compared to pdfviii products has challenged this former standard of care. despite the support of the medical and scientific advisory council, recommendations considering pdfviii products for a pup remains controversial. design/method: we used a modified utilitarian approach involving clinical, public health, and research ethics. shared decision making permeates the framework to maximize understanding, minimize bias, respect informed consent or dissent, and provide care that aligns with patient and family values when medically and practically feasible. the framework has three tiers. first, it evaluates whether resources are scarce or abundant for equitable resource allocation. if fviii products are scarce, we s of s recommend developing a central supply for emergency use and then evaluating the needs of the severe hemophilia a patients. prioritization of who receives the factor products would be decided by a designated team based on the availability of the factor products and clinical scenarios, with no preference given to those on research trials. however, if resources are abundant, treatment for acute bleeding and standard of care prophylaxis measures, including primary prophylaxis, could continue. the second tier accounts for whether there is a new infectious epidemic or concern where a pathogen cannot be eliminated. if there is, healthcare and public health workers may limit the use of pdfviii products. if not, pdfviii and rfviii products are to be equally considered. the third tier evaluates whether the clinical scenario is emergent or not. if there is acute, emergent bleeding, the immediately available resource should be used, along with bypassing and/or adjuvant resources as needed until the bleeding has resolved or improved. to align with patient and family preferences, attempts to have both pdfviii and rfviii products available at similar costs in institutions would be ideal. this ethical framework endeavors to balance autonomy, beneficence, nonmaleficence and justice in helping guide discussions among providers, pups with severe hemophilia a, and their families. disclaimer: findings and conclusions are those of the author(s) and do not necessarily represent the official position of the centers for disease control and prevention, emory university, or children's healthcare of atlanta. background: von willebrand disease (vwd) is a common bleeding disorder which affects up to % of the population without gender predilection. bleeding associated with this condition results from a deficiency or abnormality in von willebrand factor interfering with formation of primary hemostasis. ehlers-danlos syndrome (eds) is a group of rare inherited connective tissue disorders which may have an associated bleeding manifestation without abnormalities in coagulation testing. bleeding symptoms reported in eds result from capillary and tissue fragility. joint hypermobility syndrome (jhs) is an inherited condition which is nearly indistinguishable from eds iii. reports of coinheritance of vwd and eds or jhs are infrequent. the objective of this retrospective study was to review patients with coexisting vwd and eds or jhs at the indiana hemophilia and thrombosis center in order to describe the type and severity of bleeding symptoms, physical examination findings, and pertinent laboratory data. design/method: the electronic medical record database of the indiana hemophilia and thrombosis center was queried for patients with a diagnosis of vwd and one of the following descriptors: hypermobility syndrome, hypermobility, hypermobile joints, or ehlers-danlos syndrome. the records of identified patients were reviewed for demographics, type and severity of bleeding symptoms, beighton scores (bs), vwd antigen, ristocetin cofactor, factor viii levels, vwd multimer pattern, vwd subtype, genetic testing for eds, and family history of eds. results: a total of patients with dual diagnoses of vwd and eds and patients with vwd and hypermobility were identified with this query. two patients had completed genetic testing for eds, and one had a col a gene mutation identified. significant bleeding symptoms in the vwd and eds group included hematuria and postoperative hemorrhage. two of these patients had delayed wound healing postoperatively. seven of the patients identified to have type i vwd and jhs had moderately severe and somewhat unusual bleeding episodes reported including hematuria, hematemesis, and hemoptysis; of these patients had significant perioperative bleeding. females composed % of the vwd and eds group and % of the vwd and jhs group. conclusion: coinheritance of vwd and eds is an uncommon phenomenon. patients with vwd and eds or jhs may have atypical and moderately severe bleeding, especially with procedural intervention. incorporation of bs into the assessment of patients with bleeding disorders is useful to identify potential inherited collagen disorders, as diagnosis of these conditions may impact clinical management. in the year-long phase ii study (ro fd ), / khe patients responded. patients were followed for years after study completion, collecting data on growth and development, complications of therapy, unexpected toxicities, and need for continuing sirolimus. objectives: after study therapy treatment of one year, objectives include: . assess long term toxicity over the - year period after study therapy completion . assess unexpected toxicity . assess overall condition of the patient . assess need for restart or continuation of sirolimus therapy design/method: prospective follow-up of patients with a diagnosis of khe from institutions. inclusion criteria: follow-up for - years post-study. results: follow-up included data at year (n = ) and - . year (n = ) time points. average age at the start of treatment was months. of patients were available for follow up. four patients are no longer on sirolimus: one patient completed study therapy and remains off treatment (ot) ( years), required years of treatment and is now . years ot and required an additional treatment course prior to successful discontinuation now and months ot. of the patients still on sirolimus, all restarted medication for symptoms of pain, swelling and/or edema interfering with quality of life and have made an average of . attempts to discontinue sirolimus. no patient had reoccurrence of kmp. all patients had improvement in clinical and radiologic appearance of khe but all have residual lesions noted on imaging and/or clinical exam. no unexpected toxicity, growth delay, developmental issues or other long term toxicity of sirolimus was noted. conclusion: this is the first prospective data on long-term follow up of khe patients treated with sirolimus. although numbers are small, sirolimus is well tolerated; however, over half the patients were still on medication at - year follow up. this stresses the need for continued long term follow up in these young patients and investigation of the mechanism of sirolimus effect. nationwide children's hospital, columbus, ohio, united states background: recent studies have identified that adult persons with hemophilia (pwh) have a higher prevalence of hypertension and renal disease than the general population. while hematuria is a known complication of hemophilia a and b (ha, hb), its long-term impact on pwh is not currently known. by annually screening our patients with urinalysis, our pediatric center identified that just under half of our patients demonstrated hematuria over a four-year period. motivated by a desire to identify early markers of hypertension and renal disease, we sought to determine if this finding is reflected in the pediatric hemophilia population as a whole. objectives: establish the population-wide prevalence of hematuria in pediatric pwh. design/method: we used the pediatric health information system (phis) database, which contains clinical and resource utilization data for inpatients from hospitals nationwide, to analyze the prevalence of hematuria, hypertension, renal disease and related diagnosis codes in pediatric pwh who were admitted from january to september . results: during the five-year period, , unique pediatric pwh accounted for , admissions. while the majority of admissions were for bleeding or infectious concerns, ( . %) patients had an affiliated admission code for hematuria. for admissions as a whole, the median age was years with % of those admitted being infants, % toddlers, % children, % adolescents, % older than . we identified % of admissions were for ha with the remaining % were for hb. there were ( %) admits in which a bypassing agent was administered. the median length of stay for persons with hematuria was days compared to days for nonhematuria/other bleeding. there were ( . %) admissions with hypertension reported; though, only patients received an antihypertensive medication during that admission. additionally, only ( . %) admissions reported a diagnosis code of renal disease. our study demonstrated that pediatric pwh are experiencing hematuria. in general, only patients with persistent hematuria require hospital admission so we suspect this data underrepresents the numbers of pwh experiencing hematuria that is managed in the outpatient setting. we also suspect that hypertension is grossly underreported and undertreated in pediatric pwh. additionally, there are a low number of patients experiencing renal disease requiring hospital admission among this cohort. given that there is little research into the long-term impact of hematuria in hemophilia, we feel these findings support the need for further vigilance of our pediatric pwh. background: gla and gsd can aggressively destroy bone, with significant impact on morbidity and mortality. the mtor inhibitor, sirolimus has been shown to be effective in the treatment of these diseases. based on the addition of mtor inhibition to bisphosphonate therapy in metastatic cancer therapy, regimens have been used for refractory or high risk gla and gsd but there is heterogeneity of diagnosis, and variability of drug regimens and assessment of effectiveness. objectives: . assess the variability of clinical features of gla and gsd . assess the heterogeneity of diagnosis . assess drug regimens and response assessment across multiple institutions design/method: we conducted a retrospective review from institutions of cases of gla and gsd treated with sirolimus and a bisphosphonate for at least months with assessment of clinical features, treatment protocols, response regimens and side effects. results: patients included gla (n = ) and gsd (n = ). the average age at diagnosis was years. clinical features included effusions: gla (n = ), soft tissue lymphatic malformations: gla (n = ), gsd (n = ), multiple splenic lesions: gla (n = ), and soft tissue swelling at the site of bony lesion: gsd (n = ). the presenting symptom in patients was pain with patients (gla) presenting with shortness of breath. fracture was noted in patients: gla ( ), gsd ( ). diagnostic and/or response imaging included mri, ct, bone scan, skeletal survey and dexa scan. treatment consisted of: initial sirolimus use with the addition of bisphosphonate secondary to worsening disease (n = ), initial therapy with other agents (interferon, chemotherapeutic agents, radiation) and change to sirolimus and bisphosphonate secondary to toxicity (n = ), sirolimus and bisphosphonates (n = ) and sirolimus, bisphosphonates and interferon (n = ). seventeen patients had stable disease and patients had improvement of disease. sirolimus protocol was standard; however, bisphosphonate protocol varied in dosing and frequency. side effects were tolerable and expected with no grade iii or iv toxicity. sirolimus and bisphosphonates are a safe and effective therapy for gsd and gla. a consistent medication regimen, redefined response and an improved radiologic classification will be important for the development of a prospective clinical trial. background: hemophilia a is a bleeding disorder from the deficiency of clotting factor viii. the most significant sequelae of hemophilia a is the tendency to develop hemarthrosis that incites joint destruction. the prevalence of overweight and obesity has been increasing in the general and hemophilia population and leads to several morbidities including arthropathy. this is a particular concern for hemophilia a as arthropathy is a consequence of joint bleeding. objectives: the purpose of this study was to detect the relation between body mass index (bmi) and joint health endpoints in a pediatric hemophilia population. design/method: participants in this study included patients from the hemostasis and thrombosis center at children's hospital los angeles. participants were pre-screened and approached for this study during routine follow-up appointments. patients aged - years old who have been diagnosed with hemophilia a, including mild, moderate, and severe, qualified for the study. informed consent was obtained from the patients or parents before enrollment. joint health was objectively measured by physical therapists from children's hospital los angeles using the hemophilia joint health score (hjhs). an hjhs total score is calculated by assessing: swelling, duration of swelling, muscle atrophy, crepitus on motion, flexion loss, extension loss, joint pain, and muscle strength in major joints. subjective data was also obtained by patients recording their annual bleed rate within the past year. of the patients, ( %) were normal weight, ( %) overweight, and ( %) obese. we used chi-square analysis to compare joint scores across bmi classifications (chi square = . , df = , p-value = . ). although, this did not approach statistical significance, the average hjhs score in patients who had a hjhs > shows an increasing trend among bmi classifications: . in normal bmi patients, . in overweight bmi patients, and . in obese bmi patients. the average number of annual bleeds in those with positive values show: in normal bmi patients, in overweight bmi patients, and in obese bmi patients. although a positive effect of adiposity was found in the joints of hemophilia a pediatric patients, the effect shows there was not enough evidence to conclude a difference. future studies are needed to address whether obesity has an effect on hemophilia and to determine whether overweight/obesity can lead to further complications in hemophilic joints. background: stagnant blood flow in slow-flow vascular malformations (vm), particularly in their venous components, can lead to localized intravascular coagulation (lic) that is characterized by elevated d-dimer levels, low fibrinogen and decreased platelet count this coagulation derangement can lead to localized thrombosis or bleeding which can result in pain, functional limitations, and possible progression to disseminated intravascular coagulopathy (dic). the treatment of vm and their associated coagulopathy has proven difficult. patients with complex vm are frequently managed with sirolimus, an mtor inhibitor, and have clinical benefits, including reduction of pain and improvement in functional impairment. it is possible that some of these improvements from sirolimus could be secondary to improvement in the coexisting lic. objectives: this study assessed the use of sirolimus to manage the coagulopathy seen in slow-flow vm. design/method: we reviewed charts of patients with vm who are followed in the vascular anomalies center at arkansas children's hospital and were started on sirolimus. efficacy was objectively assessed through improvement of ddimer, fibrinogen and platelet count. three sets of lab values (pre-sirolimus, - months post-sirolimus, and most recent) were obtained for each patient when available. we identified a total of patients who had been prescribed sirolimus. eighteen were excluded based on underlying condition other than slow-flow vascular malformation and for inadequate medical records. a total of patients ( combined vascular, venous) were included in the study. all had elevated d-dimer levels (mean . mcg/ml feu, median . mcg/ml feu, range ( . - . )) prior to treatment. two patients had an associated low fibrinogen (below mg/dl), indicating severe lic. with treatment, ( . %) patients showed an overall decrease in d-dimer levels with an average decrease of . mcg/ml feu between pre-and post-sirolimus labs, and an average decrease of . mcg/ml feu between pre-sirolimus and most recent values. the two patients with low fibrinogen prior to treatment showed a decrease in d-dimer levels (mean decrease of . mcg/ml feu) and an increase and normalization in fibrinogen (mean increase . mg/dl) after beginning sirolimus. no patient had thrombocytopenia. we report that treatment with sirolimus was effective in improving coagulopathy associated with slowflow vm as evidenced by decreased d-dimer levels and increased fibrinogen and/or platelets. long-term use of this medication in this population may decrease the bleeding and thrombotic complications that these patients experience, especially following invasive vascular procedures. background: safety and efficacy of bay - , a sitespecifically pegylated b-domain-deleted recombinant factor viii, in previously treated adolescents and adults aged - years with severe hemophilia a was demonstrated in the phase / protect viii study and ongoing extension. objectives: this subanalysis examines the efficacy and safety of bay - in adolescents in protect viii and the ongoing extension study (data cutoff, january ). design/method: in protect viii, patients (including adolescents) received bay - on demand or as prophylaxis for weeks. prophylaxis regimens for weeks - were twice-weekly ( - iu/kg), every- -days ( - iu/kg), or once-weekly ( iu/kg) infusions based on bleeding during a -week run-in period of iu/kg twice-weekly prophylaxis. patients continued their prophylaxis regimens in the extension or changed regimens at any time. results: twelve patients aged - years were included in the protect viii intent-to-treat population; s of s additional patient discontinued after dose (included in safety population). for patients receiving prophylaxis before study enrollment, median (range) number of total and joint bleeds in the months before study entry was . ( - ) and . ( - ), respectively. ten patients ( . %) had target joints at baseline (median [range], [ - ] per patient). during weeks - of protect viii for the entire time patients remained on their designated prophylaxis dosing frequency, the median (quartile [q] ; q ) annualized bleeding rate (abr) for patients receiving twice-weekly (n = ), every- -days (n = ), and once-weekly prophylaxis (n = ) was ( ; . ), . ( ; . ), and . ( ; . ), respectively (overall prophylaxis [n = ], . [ . ; . ]). two patients switched from once-weekly to twice-weekly (n = ) or every- -days prophylaxis (n = ), and number of bleeds decreased from to in one patient and to in the other. all patients from the main study continued in the extension; mean abr in the extension was . and varied by dosing regimen (twice weekly [n = ], . ; every days [n = ], . ; once weekly [n = ], . ). two patients changed from every- -days to once-weekly prophylaxis during extension (mean abr, . ). one patient had a nonneutralizing antibody to bay - at baseline; end-of-study titers were negative. no patient developed anti-peg antibodies or factor viii inhibitors or experienced a serious adverse event related to bay - during the main study or extension. in previously treated adolescents with severe hemophilia a, bay - prophylaxis was effective in prevention of bleeds, with less bleeding overall versus prestudy, and was generally well tolerated. funded by bayer. cincinnati children's hospital medical center, cincinnati, ohio, united states background: vascular malformations (vms) consist of a heterogeneous group of congenital disorders characterized by the abnormal development of blood and/or lymphatic vessels, which cause a broad spectrum of clinical manifestations. although considered benign, vms are frequently associated with cutaneous complications that can cause significant morbidity such as nodular overgrowth, skin thickening, pruritus, oozing or bleeding of lymphatic blebs and secondary infection. oral sirolimus has shown to be effective in the treatment of complicated vascular malformations but has known side effects and need for frequent laboratory monitoring. currently, there are limited studies on the use of topical sirolimus for the treatment of cutaneous manifestations of vascular malformations. objectives: to evaluate the efficacy and safety of topical sirolimus in vms with cutaneous complications and propose indications for use. design/method: this is a retrospective review of medical records of patients with vascular malformations treated with topical sirolimus from january to december . response was determined by subjective and objective improvement. results: twenty-four patients, ( %) females and ( %) males, with vascular malformations and cutaneous manifestations were treated with topical sirolimus. age ranged from - years. indications for treatment were: blebs ( %, n = ) causing either leaking, bleeding, pain, pruritus, swelling or recurrent infection; nodular overgrowth % (n = ); pyogenic granuloma % (n = ); bleeding % (n = ) and cosmetic % (n = ). treatment course ranged from - months. no major side effects were reported. one patient reported burning and itching sensation. regarding clinical response: % (n = ) patients had improvement in cutaneous lesions; % (n = ) had a stable lesions; and % (n = ) stopped treatment due to side effects. for prior/concomitant treatment: % (n = ) had prior surgery, laser or sclerotherapy; % (n = ) had concomitant oral sirolimus. of the patients not receiving concomitant systemic sirolimus, only % (n = / ) had been on oral sirolimus. of these patients, % (n = / ) had a very good response to topical treatment. : topical sirolimus appears to be beneficial and well-tolerated with a minimal side effect profile for the treatment of cutaneous manifestations of vascular malformations as a single agent or as adjuvant therapy with systemic sirolimus when symptoms are not adequately controlled. further studies are needed to prospectively analyze efficacy and safety of topical sirolimus in this patient population. objectives: to evaluate the safety and efficacy of long-term romiplostim in children with itp. design/method: all patients received weekly sc romiplostim from - g/kg to target platelet counts of - × ( )/l. median (min-max) treatment for the patients was ( - ) weeks for a total of patient-years, or . years per patient. at baseline, median (min-max) age was ( - ) years; % were female; . % had prior splenectomy. median (min-max) average weekly dose was . ( . - . ) g/kg, including escalation to a stable dose; patients started on g/kg. reasons for discontinuing romiplostim (n = , %) included consent withdrawn (n = ), required other therapy (n = ), and ae (n = ) (asthenia, headache, dehydration, and vomiting in one patient and anxiety in the other; none treatment related). fifty four serious aes occurred in patients but were treatment related in one (concurrent grade thrombocytopenia, grade epistaxis, and grade anemia). anti-romiplostim neutralizing antibodies were detected in one patient who discontinued to receive other therapy; antibodies were absent on retesting. from week on, median platelet counts remained > × ( )/l; median platelet counts were > × ( )/l from weeks - . nearly all ( %, / ) patients had ≥ platelet response (platelet counts ≥ × ( )/l, excluding ≤ weeks after rescue medication). most ( %, / ) patients had a platelet response ≥ % of the time and % ( / ) did ≥ % of the time. sixty ( %) patients (or caregivers) self-administered romiplostim. fifteen ( %) patients had treatment-free periods of platelet counts ≥ × ( )/l for ≥ weeks (ie, remission); these patients ( girls, boys) had had itp for a median (min-max) of . ( . - ) years, none had prior splenectomy, and had received romiplostim for . ( . - ) years. all had platelet counts > × ( )/l for ≥ months and / for ≥ months; the median (min-max) duration of being ≥ × ( )/l was ( - ) weeks. of baseline characteristics such as sex, platelet counts, itp duration, and number of past itp treatments ( , , , > ), only age < years was predictive of developing treatment-free periods ≥ weeks (p = . ). in this seven-year open-label extension, > % of children with itp achieved a platelet response and romiplostim was well tolerated. importantly, % of patients were able to discontinue all itp medications for ≥ months. funded by amgen inc. background: sirolimus is an immunosuppressive drug that is widely used in solid organ and bone marrow transplantation, and more recently for the treatment of vascular and lymphatic anomalies. sirolimus has been associated with decreased immunity in the transplant setting in patients that have received other immunosuppressive drugs or were immunosuppressed from previous chemotherapy. the effects of sirolimus on the immune system in chemotherapy naïve children who have not received other immunosuppressive agents are not well understood, and there is variability in the approach to fever and pcp prophylaxis. to understand the effects of sirolimus on the immune system of patients with non-complicated vascular or lymphatic anomalies by evaluating anc, alc prior to and after sirolimus therapy. design/method: multi-institutional retrospective review was done to include patients with non-complicated vascular or lymphatic anomalies. those with effusions/ascites, multiorgan involvement, or history of vascular-anomaly-related infections prior to treatment were excluded. results: twenty patients with kaposiform hemangioendothelioma (n = ), generalized lymphatic anomaly (n = ), cloves syndrome ( ), and simple vascular malformation (n = ) were included. age at initiation of sirolimus treatment ranged from . - years. male to female ratio was : . sirolimus was initiated due to extensive disease, lack of response to steroids or bisphosphonates, pain, dment, lymphatic drainage, and prevention of ongoing overgrowth. prior to the start of sirolimus (sir- ) the mean anc was and alc was . the target level of sirolimus varied by indication and patient, and ranged from to . after the st steady state level, month after sirolimus (sir- ) the mean anc decreased to and alc was . at months after sirolimus (sir- ) the mean anc was and alc was . the first sirolimus levels (sir- ) mean was . ; and sir- level was . . nine patients were placed on pcp prophylaxis at the start of sirolimus. none of these patients had an infectious complication while on sirolimus at a median f/u of months. one patient had mild neutropenia (anc > ) which normalized after discontinuation of pjp prophylaxis. conclusion: in this small cohort of patients we found that the anc and alc level in patients with non-complicated vascular or lymphatic anomalies at sir- was not different from the sir- or sir- . prospective studies that specifically track anc, alc, igg, and lymphocyte function should be conducted to better understand the effects of sirolimus in the immune system. this data will allow for uniform recommendations regarding prophylaxis and management of febrile episodes. background: acute infections and the associated systemic inflammation can increase the risk of venous thromboembolism (vte) and in certain well-defined clinical scenarios may be the primary trigger of vte in pediatric patients. pediatric data on vte in the setting of acute infection are sparse. objectives: to describe characteristics and outcomes of vte in pediatric patients with acute infections. we conducted a retrospective chart review of all pediatric patients with objectively confirmed vte treated at our institution since and identified all patients in whom an acute infection was identified as a vte trigger. patients were managed according to standardized institutional protocols based on published guidelines. relevant demographic, clinical and laboratory data were collected and summarized using descriptive statistics. since , acute infection was identified as a trigger in of vtes ( %) diagnosed at our center. the median age at time of vte diagnosis in this group was . years (interquartile range . - ). males were more commonly affected than females, representing % of cases. neonatal vte events accounted for % of cases. sepsis was the most common acute infection to be identified as a vte trigger [ / cases ( %)]. most vte events ( %) associated with acute infections were considered hospital-associated vtes. at time of vte diagnosis, % of patients were critically ill. extensive vte (defined as completely occlusive thrombosis involving > venous segment) occurred in % of patients. acute infection was deemed to be the primary trigger for vte in / patients ( %). infection-associated vtes in this cohort included cerebral sinus venous thrombosis due to sinus or cns infection ( patients, %), septic throm-bophlebitis ( patients, %), lemierre's or lemierre's-like syndrome ( patients, %) and osteomyelitis-associated deep vein thrombosis ( patients, %). systemic anticoagulation was prescribed in / patients ( %). anticoagulationrelated major bleeding occurred in / patients ( %). vte complications included vte recurrence ( patients, %), vte progression ( patient), acute pulmonary embolism ( patients) and arterial ischemic stroke ( patients). our study indicates that acute infection is a common risk factor for pediatric vte, especially in critically ill children, and can be the primary trigger in a significant proportion of vte cases associated with acute infections. anticoagulation appeared to be overall safe in this population and was associated with low rates of serious vte-related acute complications. however, our study also suggests that this population may be at increased risk for vte recurrence and anticoagulation-related major bleeding. background: epithelioid hemangiomas (eh) are rare benign vascular tumors that occur in soft tissues and bone and present between the third and sixth decades of life. a subset ( %) of eh harbor fos rearrangement. eh has been described in children, but little is known about the long-term outcomes of pediatric eh. the main objective is to obtain data to be used for improved understanding of this rare disease in order to provide standardization of care and development of future research studies. board-approved retrospective review of clinical, pathologic, and radiographic characteristics, and treatment outcomes in patients diagnosed with eh between and . results: eight patients were male; mean age at diagnosis was . years (range: - ). lesions involved the lower extremities (n = ), cranium (n = ), pelvis (n = ), and spine (n = ). multifocal disease was identified in five patients. the most common presentations involved significant localized pain and neurologic symptoms: headache, cranial nerve injury, loss of consciousness. radiographic studies identified variable features, such as multifocal lytic bony lesions with sclerotic margins, enhancing soft tissue component, and surrounding inflammatory edema. histologically, all specimens were composed of vascular channels lined by epithelioid endothelial cells without significant cytologic atypia; solid cellular areas (n = ). endothelial cells were positive for cd and egr, and negative for camta . fos rearrangement was assessed in only one specimen and detected. mean follow-up time was days (range: - ). patients were treated with surgical resection, intravascular embolization, bisphosphonates, propranolol, interferon, and sirolimus. one patient treated with interferon and one with sirolimus exhibited partial response for mean follow-up of . days. although eh is a benign neoplasm, it is difficult to manage without standard protocols and portends considerable morbidity. our findings suggest medical management, particularly sirolimus, may benefit these patients; however, long-term follow-up is needed in treated children. novel fos inhibitors are in development and may benefit patients with fos rearrangement. penn state health children's hospital, hershey, pennsylvania, united states background: central venous catheters (cvc) are often required in critical care settings in order to provide a secure point of access for life sustaining care. clinical studies identify cvc presence as the single most important risk factor for deep vein thrombosis (dvt) in children. venous thromboembolic event (vte) incidence rates in critically ill children with a cvc range from . - % and . - . per catheter days depending on the population studied. per institutional protocol, the penn state health children's hospital picu (hershey, pa) utilizes a low dose continuous infusion of unfractionated heparin (ldufh) at units/kg/hr as prophylaxis against cvc-related vte and to maintain line patency. the efficacy of this approach has never been evaluated. to determine if ldufh for prophylaxis results in lower incidence of cvc-related vte, catheter dysfunction and central line associated blood stream infection (clabsi) without increasing morbidities. to determine if the incidence of catheter related vte is lower than historical published data, a retrospective chart review was conducted utilizing the institutional electronic medical record for all patients in , aged - . years, who had a cvc during a picu admission. secondary objectives such as the incidence of catheter dysfunction, clabsi, and any associated bleeding complications are also being analyzed. results: interim data analysis revealed cvcs ( nontunneled cvc, totally implantable devices, tunneled lines, peripherally inserted central catheters [picc] ) in total patients with a median age of . years. overall vte incidence was . % ( / ) with vtes associated with non-tunneled cvc and with piccs. sixty one percent of non-tunneled cvcs received ldufh and % ( / ) of the patients with vtes associated with non-tunneled cvcs did receive ldufh prophylaxis. vte incidence rate of nontunneled cvcs with ldufh was . % ( / ) and . per picu catheter days. the only other vte events identified within our study cohort were in the picc group where two patients experienced vte, one of which was receiving ldufh. clabsi incidence was . % ( non-tunneled cvc, tunnel cvc, picc). no major bleeding complications were associated with ldufh. preliminary data demonstrates ldufh is efficacious in preventing cvc-related vte in comparison to published reports. further analysis will compare another similar sized and acuity level picu which does not practice the same method. background: fibroadipose vascular anomaly (fava) is a rare, challenging disorder associated with pik ca mutations. fava often causes painful replacement of muscle and soft tissues with fibrotic and adipose tissue and is associated with ectatic draining veins. treatments for focal lesions are surgical excision, cryoablation or sclerotherapy and the role of medical therapy is unclear. some fava lesions are too extensive or directly involve neurovascular structure, resulting in refractory pain. objectives: to retrospectively evaluate the efficacy of sirolimus in patient with residual symptoms after procedural therapies for fava design/method: retrospective review of individual cases from institutions of fava refractory to other therapies treated with sirolimus for at least months. cases were s of s identified by polling member of the aspho vascular anomalies special interest group. results: all seven patients report improvement on sirolimus therapy. all patients had received prior procedures, including sclerotherapy ( patients), cryoablation ( patients) and/or resection ( patients). mean age at sirolimus initiation was y (range - y). mean length of therapy is . months (range - months). six patients were treated with bid dosing and one adult received daily dosing. goals of sirolimus were improvement in pain or musculoskeletal dysfunction. pain and function improved in all patients, including discontinuation of narcotic use and resumption of participation in sports. time to symptom improvement ranged from - weeks. in four patients for whom dose was lowered, pain recurred in all four and responded to restarting or increasing sirolimus dose. while all patients do not have pre-and postsirolimus imaging, decrease in fava lesion size is seen in cases with available imaging. sirolimus side effects are similar to prior reports, most commonly mouth sores, elevated lipids and acne. we report the first known data supporting a role of sirolimus in refractory fava cases. sirolimus is welltolerated and initial improvement is rapid, within weeks of initiation. whether sirolimus has a role in upfront therapy to reduce lesion size prior to procedures deserves further study. objectives: to assess platelet responses in children with itp receiving romiplostim. design/method: eligible children had itp for ≥ months, ≥ prior therapy, and screening platelet counts ≤ × ( )/l or uncontrolled bleeding. weekly dosing was from - g/kg to target platelet counts of - × ( )/l. bone marrow biopsies were evaluated in europe at baseline and after or years (cohorts and ). as of mar , patients received ≥ dose. at baseline, median (min-max) age was ( - ) years, itp duration was . ( . - . ) years, and platelet count was ( - ) × ( )/l; patients ( %) had had prior splenectomy. the median (q , q ) % time with a platelet response (platelet count ≥ × ( )/l, no rescue medications past weeks) in months - was % ( %, %) (primary endpoint). over the course of the study, % ( / ) of patients had a platelet response. four patients maintained platelet counts ≥ × ( )/l with no itp medications for ≥ weeks. median (min-max) treatment duration was ( - ) weeks for patient-years in total. median (min-max) average weekly romiplostim dose over the course of the study was . ( . - . ) g/kg; the median dose was g/kg at year (n = ) and g/kg at years (n = ). most ( %) patients initiated self-administration. sixty-four patients ( %) discontinued treatment, most frequently for lack of efficacy (n = ), patient request (n = ), and adverse event (ae) (n = ). fortyone ( %) patients had serious aes (saes) including epistaxis ( %) and decreased platelet count ( %). five patients had treatment-related saes: headaches, abdominal pain, and each of presyncope and neutralizing antibodies (ab). there were cases of neutralizing ab to romiplostim (of patients tested), but none to tpo; / had continued elevated platelet counts and in / cases ab were not found on retesting. for cohort , of patients with baseline bone marrow biopsies, had evaluable on-study biopsies scheduled for year; patient had an increase from grade to . there were no findings of collagen or abnormalities. in this interim datacut of a romiplostim openlabel study in children with itp, % of children had a platelet response. overall, the median dose was . g/kg; the median romiplostim dose over time reached g/kg. no new safety signals were observed over patient-years. funded by amgen inc. background: hepatic hemangiomas are benign vascular tumors without a medical home, managed by multiple specialties. the diagnosis has been assigned historically to various vascular lesions affecting the liver with completely different clinical presentations, resulting in difficult standardized management. objectives: the consensus steering committee identified an acute need of clear definitions and evaluation guidelines using the updated international society for the study of vascular anomalies (issva) classification. the goal was to formulate recommendations that will be adopted by all specialties involved in the care of children with hepatic hemangiomas. design/method: we used a rigorous, transparent consensus protocol, with input from multiple pediatric experts in vascular anomalies from hematology-oncology, surgery, pathology, radiology and gastroenterology. in the first section, we precisely define the subtypes of hepatic hemangiomas seen in children (congenital and infantile) using clinical course, histology and radiologic characteristics. inclusion and exclusion limits to the diagnosis are noted. the following two sections describe these subtypes in further detail, including complications to be considered during monitoring and respectively recommended screening evaluations. conclusion: while institutional variations may exist for specific clinical details, a clear understanding of the diagnosis of hepatic hemangiomas affecting the pediatric population and the possible complications that require screening during the monitoring period should be standard. as patients with hepatic hemangiomas are managed by different medical and surgical specialties, a multidisciplinary consensus based on current literature, on the data extracted from the liver hemangioma registry and on expert opinion was required and was accomplished by this manuscript. objectives: to investigate the association between routine prophylaxis with bay - and bleeding outcomes after adjusting for key patient and pharmacokinetic (pk) characteristics. design/method: the leopold kids study evaluated safety and efficacy of bay - prophylaxis in previously treated boys aged ≤ years with severe hemophilia a. patients received bay - - iu/kg x/wk (n = ) or > x/wk (n = ) and were followed up for - months. prophylaxis dose and frequency were assigned by investigators. pk parameters, including area under the curve (auc), half-life, and clearance, were derived from a population pk model and reflect predicted pk values with a -iu/kg dose. patient characteristics were compared between the x/wk and > x/wk groups using wilcoxon rank sum or chi-square tests. negative binomial regression was used to model the association between prophylaxis frequency and annualized bleeding rate (abr) for total bleeds, first without adjustment and then adjusting for age, pk parameters, and bleed history. results: mean ± sd age for patients in this analysis was . ± . years. patients receiving prophylaxis x/wk had more bleeding episodes in the months before study entry (mean ± sd, . ± . [median, . ] for x/wk vs . ± . [ . ] for > x/wk; p = . ) and were more likely to have been treated on demand ( % vs %; p = . ). pk parameters were similar between the x/wk and > x/wk groups. without adjustments, abr during the study was % higher in the x/wk group compared with the > x/wk group (rate ratio [rr], . ; % ci, . - . ; p = . ). abr was % lower in the x/wk group (rr, . ; % ci, . - . ; p = . ) after adjusting for age, auc, and number of bleeds in the prior months. conclusion: abr was numerically lower but not significantly different between the x/wk and > x/wk groups after adjusting for age and pk parameters. these findings suggest that even among patient groups that are homogeneous with respect to age, pk, and bleed history, further individualization of bay - prophylaxis based on other characteristics may help reduce bleeding episodes even at a lower treatment frequency. larger real-world studies are needed to verify these findings. funded by bayer. stanford, palo alto, california, united states s of s background: vascular malformations may be of lymphatic, arterial, venous or capillary endothelial origin. they may be simple or complex, with complex malformations being a combination soft tissue and skeletal overgrowth. although likely present at birth, these malformations often become symptomatic with puberty or infection, and range from little or no clinical impact to life threatening symptoms. in malformations primarily of venous origin, pain may be significant and hypothesized to be caused by phlebolith development (intra-malformation thrombi), inflammation, consumptive coagulopathy, vascular engorgement, and endothelial proliferation. anti-angiogenic and anti-platelet therapies have been reported to relieve pain. however, the use of anticoagulation for pain is not well described. objectives: to report clinical features and outcomes of patients with vascular malformations of venous origin treated with anticoagulation for pain. we performed a retrospective review of patients with vascular malformations followed by the hematology service between january and december who were treated for pain with anticoagulation. pain relief was determined both by wong-baker pain scales and patient report. clinical data were extracted from electronic medical records. we identified five patients with venous malformations (vm) who had received anticoagulation for pain. four patients were female and median age was years old (range to years old) at time of initiation of anticoagulation. all five patients had vm of the extremity, two with vm of the lower extremity, and three patients had vm of the upper extremity. two patients had concomitant coagulopathy and demonstrated decreased d-dimer after initiation of anticoagulation. four patients received enoxaparin, and one adult patient received rivaroxaban. all patients reported improvement in pain after administration of anticoagulation. one patient exhibited mild epistaxis and bruising at the injection site. there was no significant bleeding or other complications. pain is a significant complication in patients with venous malformations. our case series suggests that anticoagulation is a safe and effective therapy for pain relief in this population. further investigation is indicated to compare the effect of anticoagulation to other therapeutic interventions such sclerotherapy, surgery, and sirolimus in the treatment of pain associated with venous malformation. maria ahmad-nabi, christine knoll, sanjay shah, lucia mirea phoenix children's hospital, phoenix, arizona, united states background: estimates of the incidence of dvt in patients with osteomyelitis range widely from %- %, however risk factors and outcomes of dvt in this cohort have not been thoroughly established. objectives: this study aims to estimate the incidence of dvt in patients with osteomyelitis, and to assess risk factors and outcomes of dvt in this cohort. design/method: after irb approval, a retrospective chart review was conducted for patients aged - years seen at phoenix children's hospital between - with icd / codes for osteomyelitis. exclusion criteria included chronic recurrent multifocal osteomyelitis, and chronic dvt. demographics, clinical factors and outcomes were compared between osteomyelitis patients with and without dvt using the fisher-exact and wilcoxon-rank sum tests, as appropriate for the data distribution. results: a total of study subjects with osteomyelitis had a mean (standard deviation) age of . ( . ) years. dvt was present in ( % of ) patients, and ( %), ( %) and ( %) patients received anticoagulation for < , - and ≥ weeks, respectively. patients with vs without dvt were more likely to be male ( % vs %; p-value = . ), and had significantly higher rates of bacteremia ( % vs %; p-value = . ). rates of central lines were comparable between dvt and non-dvt patients ( % vs %; p-value = . ); however patients with dvt vs without dvt had significantly longer mean length of stay ( vs days; p-value < . ) and higher rates of icu admission ( % vs %; p-value < . ). the incidence of dvt among osteomyelitis pediatric patients was estimated at %, with risk increased by male sex and bacteremia. patients with dvt had significantly higher rates of icu admission and longer length of hospital stay. many of these patients had standard practice management of their dvt with - weeks of anticoagulation. our data highlights the need for recognition of high risk patients, and the need for future efforts targeting dvt prophylaxis. baylor college of medicine, houston, texas, united states background: lymphatic malformations (lm) frequently occur in the head and neck and can often be disfiguring and even life-threatening. management options include observation, surgery, sclerotherapy, and sirolimus. the optimal sequence of therapeutic interventions has not been determined due to the lack of comparative clinical trials or established guidelines. thus, prenatal planning with a multidisciplinary team is beneficial. we present a case series of ten children with head and neck lms evaluated in at our multidisciplinary vascular anomalies center. a chart review was performed to assess treatment modalities and recent trends. results: seven of patients ( %) with head and neck lms were diagnosed prenatally. six patients required an ex utero intrapartum treatment procedure. all patients were started on sirolimus at a median age of . months (range days - years). four patients most recently started on sirolimus were less than months of age at the time of initiation. six patients underwent partial excision of lm during the first year of life; none of whom received sirolimus prior to surgery. sirolimus was discontinued in one patient given chronic clostridium difficile infections, and non-compliance in another patient. five patients received sclerotherapy. tracheostomy was necessary in six patients; one patient was de-cannulated after months on sirolimus. all patients have had radiographic and clinical improvement of lm with varying treatment modalities. current clinical observations show improved response with sirolimus and demonstrate tolerability of sirolimus at a young age. conclusion: treatment of pediatric head and neck lms is challenging and a multidisciplinary approach is necessary. as the majority of patients are diagnosed prenatally, prenatal planning and discussion of potential use of sirolimus is beneficial. availability of vascular anomalies experts in the prenatal/neonatal period offers the best management results, and early initiation of sirolimus should be considered for complex lesions. long-term follow up is warranted to investigate the efficacy and timing of treatment options. yale school of medicine, new haven, connecticut, united states background: to mitigate transfusion of pathogencontaminated platelets, amotosalen, a synthetic psoralen compound, is added to sdp components. exposure to uv-a light activates amotosalen and crosslinks dna/rna base pairs, preventing replication of a broad spectrum of viral, bacterial, and other pathogens that may contaminate platelets. pr-sdps were fda approved for clinical use with no age restrictions in . we initiated use of pr-sdps in november of for all patients. we retrospectively analyzed usage of pr-sdp vs conventional (non-pr) platelets (cp) in neonatal and pediatric patients with thrombocytopenia to compare hemostatic efficacy and the incidence of transfusion reactions (tr) for these products, after one year of a dual platelet inventory. design/method: since pr-sdp were fda-licensed, no irb approval was required; pr-sdp and cp were both considered standard of care. we evaluated transfusions for all pediatric patients age - years who received any platelet transfusion between november and november . we determined the volume (mean ml ± sd) of each type of platelet component transfused, the number of platelet transfusion episodes, and reported trs based on cdc hemovigilance guidelines. a subgroup analysis was performed for thrombocytopenic neonates ( - months). results: patients - years who received only cps (n = ) received a total of , ml of platelets ( ± ml/patient) over transfusions ( . ± . episodes/patient). for comparison, in patients who received only pr-sdp, a total of , ml of platelets ( ± ml/patient, p = . ) were infused over transfusions ( . ± . episodes/patient, p = . ). for neonates ( - months, n = ) who received only cps, , ml of cps ( ± ml/ patient) were transfused over episodes ( . ± . episodes/patient). for comparison, those who received only pr-sdp (n = ), received , ml of pr-sdp ( ± ml/patient, p = . ), transfused over episodes ( . ± . episodes/patient, p = . ). for all recipients - years (n = ), including additional patients who received both cp and pr-sdp, there were three reported allergic trs over transfusion episodes, while no allergic reactions were reported with pr-sdp transfusions. one febrile tr was reported to cp transfusion, while three were reported for pr-sdp. in conclusion, pr-sdps, in our pediatric population age - years, were comparable to cp products in regards to volume and episodes of platelet transfusions, and incidence/type of transfusion reactions. pr-sdp were safe and effective for use in this pediatric patient population. background: vascular anomalies are classified as either vascular tumors or vascular malformations. fibro-adipose vascular anomaly (fava) is a newly described entity which presents with distinct clinical, radiographic and histopathologic findings. we present a case in which the diagnosis of fava was complicated by a persistent low platelet count secondary to immune thrombocytopenia (itp). to describe a challenging diagnosis of a novel vascular anomaly (fava) complicated by severe thrombocytopenia. a year old male presented to hospital with bruising and left thigh pain related to a remote sports injury. blood work revealed a platelet count of × /l, but with an otherwise normal complete blood count. the following were also normal: aptt and fibrinogen; d dimer levels were slightly increased. he was treated with one dose of ivig ( . mg/kg) for presumed itp and responded well with his platelet count increasing to × /l. he returned to hospital weeks later with recurrent thrombocytopenia and worsening leg pain. an ultrasound of the left thigh revealed a . cm x . cm x . cm lesion within the vastus medialis. the diagnosis of an intramuscular hematoma secondary to persistent thrombocytopenia was made. the patient presented with multiple episodes of thrombocytopenia over the next several months. his itp did not respond to oral prednisone ( mg/day for days). he continued to have short-lived responses to ivig requiring infusions every other week as his platelet count would fall below × /l. his leg pain progressed, restricting him to a wheelchair. further imaging by mri brought into question the diagnosis of a hematoma and a biopsy of the thigh lesion was performed. the results were consistent with a diagnosis of fava; this was subsequently excised. conclusion: this is a unique case where a vascular anomaly was misdiagnosed as a hematoma due to a patient's persistent thrombocytopenia and history of an injury. fava is a newer entity which, unlike other vascular anomalies, has not been linked to thrombocytopenia or a localized consumptive coagulopathy. after excision of the fava, the patient's chronic pain, and mobility resolved, though his itp persisted. objectives: this preliminary, exploratory analysis of realworld administrative data was conducted to determine units dispensed and factor replacement product-related direct expenditures associated with a currently marketed shl or ehl rfix product. design/method: de-identified claims data from the commercially available truven health marketscan® research u.s. claims database were used to identify direct expenditures and number of international units (ius) dispensed for all patients aged - years with a diagnosis code of icd- . /icd- d who used nonacog alfa or eftrenonacog alfa during the study period (june , to july , ). reference weight measurements from the centers for disease control and prevention national center for health statistics' (cdc nchs) anthropometric data were used to estimate product dispensation on an iu per kg basis. the nonacog alfa and eftrenonacog groups comprised and patients, respectively. the median [iqr] age in the two groups was . [ . ] and . [ . ] years, respectively. while of the patients in the eftrenonacog alfa group had > calendar quarter of available data, only of the patients in the nonacog alfa group had > available quarter. the median rfix product dispensation per quarter was , ius (iqr, , ius) in the nonacog alfa group and , ius (iqr, , ius) in the eftrenonacog alfa group. incorporating attributed weight values, the median rfix product iu dispensation per kg per week was . iu/kg/wk (iqr, . iu/kg/wk- . iu/kg/wk) in the nonacog alfa group, and . iu/kg/wk (iqr, . - . iu/kg/wk) in the eftrenonacog alfa group. applying wac prices (eftrenonacog alfa = $ . /iu; nonacog alfa = $ . /iu), the calculated estimates of $/kg/week were $ and $ in the nonacog alfa and eftranonacog alfa groups, respectively. conclusion: preliminary real-world data derived from a large u.s. claims database revealed differences in product dispensation and factor product-related expenditures among pediatric patients with any severity of hemophilia b to whom an shl or ehl rfix product was prescribed. refinements of these data, potentially to exclude instances of sporadic usage, may shed light on real-world dispensation of rfix products among pediatric hemophilia b patients. background: vascular malformations can be classified as simple (including capillary, venous, lymphatic, arteriovenous), combined, malformations of major named vessels or associated with other anomalies. multiple modalities including laser treatments, sclerotherapy, embolization, surgery and pharmacological intervention (with mtor inhibitors like sirolimus) have been used for treatment of vascular malformations. these interventions have been used alone or in combination with varied outcomes. we present our institution's experience with a multimodal approach to simple and combined vascular malformations. design/method: we performed a retrospective chart review of patients with vascular malformations who were referred to our center for an interventional radiology evaluation from june -july . we included patients (age at presentation: months - years), referred initially for interventional radiology procedures (irp) for vascular malformations. all patients had symptoms of pain and/or swelling/deformity. diagnosis of was based on vascular imaging (doppler ultrasound, mri/a/v). nine patients had venous malformations (vm), five had macrocystic lymphatic malformations (lm), six had lymphatic-venous malformations (lvm), and two arteriovenous malformations (avm). patients initially underwent interventional radiology procedures. all the vm patients responded to sclerotherapy alone. three patients with lm responded to sclerotherapy alone, remainder required surgical intervention. one avm patient responded well to embolization, the other needed surgical resection after embolization. four lvm patients underwent irp with minimal improvement in symptoms ( - procedures attempted), surgical resection was attempted in patients with poor response and patients were started on sirolimus ( . mg/m /dose twice a day). all lvm patients started on sirolimus have responded well (decreased pain and swelling); time to initial symptom response ranged from weeks - month from starting medication. in this case series, patients with simple vm responded well to sclerotherapy alone, avm and lm patients needed irp and/or surgery for complete response. complex lvm did not respond well to surgery or irp; . % had improvement in clinical symptoms with addition of sirolimus to the treatment regimen. response to various modalities of treatment varied based on the type of vascular malformation. a multidisciplinary approach to management of vascular malformations is essential to provide multimodal therapeutic options for rapid symptom relief and improve the quality of life of these fragile patients, especially those with complex malformations. background: von willebrand disease (vwd) is the most common bleeding disorder in humans, affecting ∼ % of the united states' population. desmopressin (ddavp) is a longacting vasopressin analog that induces vasoconstriction and release of vwf. ddavp is used in patients with vwd and as a surgical prophylaxis, but carries anti-diuretic properties. to avoid electrolyte imbalance and hyponatremia, fluid restrictions are recommended in the hours post-ddavp administration. objectives: this study sought to examine perioperative practices and outcomes following ddavp administration and a fluid restriction protocol in a population of pediatric patients with von willebrand disease. design/method: a retrospective chart review was conducted for patients with von willebrand disease who underwent surgical procedures at children's hospital of pittsburgh of upmc between january , and december , . patient age, sex, weight, diagnosis, surgical procedure, total fluids administered, and post-operative sodium level were recorded. the primary outcomes noted were the proportion of patients exceeding % of the recommended fluid consumption for the -and -hour periods post-ddavp s of s administration, as defined by local guidelines. secondary outcomes were the presence of any bleeding requiring an er visit or readmission or hyponatremic seizures within hours of ddavp administration. results: data was compiled for patients ( females, males). the mean age was . years (sd . years), median age was years (range to years). procedures included dental ( ), otolaryngology ( ), orthopedics ( ), gastrointestinal ( ), plastics ( ), neurosurgery ( ), ophthalmology ( ), dermatology ( ), general surgery ( ) and gynecology ( ). % of patients exceeded % of the fluid volume recommended for the first -hour period post-ddavp administration while still in the surgical setting. no patients exceeded % of the fluid volume recommended for the total -hour period post-ddavp administration. post-operative sodium levels were obtained in only of patients. no patients returned to the er or were admitted for bleeding in the hours post-ddavp administration. no patients returned to the er or were admitted for hyponatremia or seizures in the hours post-ddavp administration. maintenance of a fluid restriction protocol effectively deterred negative outcomes in this cohort. however, a significant fluid volume was administered in nearly a third of patients despite the restrictions. given the risk of hyponatremia, and limited compliance with fluid restrictions, postoperative sodium levels should be recorded in following ddavp administration to assess the possibility of a hyponatremia and to reinforce the importance of fluid restrictions and their communication. results: a male fetus required in utero insertion of a pleuroamniotic shunt for bilateral pleural effusions diagnosed antenatally by ultrasound. shortly after delivery at term, he developed respiratory distress and was found to have reaccumulation of the pleural effusions. blood work on day of life showed a platelet count of , / l, which then decreased precipitously. he demonstrated schistocytes on blood-smear, signs of consumptive coagulopathy with hypofibrinogenemia and high d-dimers, and compensatory reticulocytosis. he required multiple transfusions and admissions to the intensive care unit for respiratory support. investigations ruled out congenital ttp, neonatal alloimmune thrombocytopenia, and noonan syndrome. given high clinical suspicion for an underlying vascular lesion causing kmp, a full body mri without contrast was undertaken. this showed a focal area of suspicious signal intensity in the upper paraspinal musculature. an ultrasound and mri with contrast demonstrated an extensive infiltrative vascular lesion involving the paraspinal musculature, prevertebral space, posterior extrapleural space, mediastinum, and neck. the child was commenced on prednisone ( mg/kg/day) and rapamycin ( . mg/m twice/day). there was no clinical or laboratory improvement after one month. a biopsy was performed which confirmed khe. in the second month of rapamycin therapy, the platelet count gradually normalized and the patient was discharged from hospital at . -months of life. prednisone was weaned off at . months of life. a repeat mri at months showed significant reduction in the khe. he is now almost years into therapy and doing well. conclusion: this is a unique case of khe with kmp that initially presented with extensive and recurrent pleural and pericardial effusions. this case demonstrates the importance of suspecting an underlying vascular malformation in the presence of kmp. our patient had a delayed but overall good response to rapamycin. further studies investigating duration of rapamycin therapy is key for the optimal management of these patients. rosa diaz, donald mahoney, lakshmi srivaths, donald yee texas children's hospital, houston, texas, united states background: since von willebrand disease (vwd) is the most common inherited bleeding disorder, it must co-exist with other less common bleeding disorders in some dually affected patients. however, reports of combined deficiencies in factor viii (fviii) and von willebrand factor (vwf) are rare. objectives: to study the prevalence and bleeding phenotype of combined deficiencies of fviii and vwf in males with hemophilia a in a hemophilia treatment center. design/method: we retrospectively reviewed the electronic medical records of males with hemophilia a followed at our institution during the past years. the primary and secondary outcomes for the study were ( ) the prevalence of combined fviii and vwf deficiencies and ( ) the bleeding phenotype of these patients. we identified vwf deficiencies in % (n = ) of the patients with hemophilia a. most (n = , %) patients were tested for vwf deficiency as part of the initial hemostatic evaluation, but one-third were tested due to clinical concern for inadequate response to fviii concentrate. the median duration of follow up was . years (range . to . ). patients were referred to our clinic at a median age of months (range to years) for evaluation of easy bruising (n = , %), mucosal (n = , %) and surgical bleeding (n = , %). primary diagnoses included with severe, moderate and mild discrepant hemophilia a. secondary diagnoses included with low vwf activity, type vwd and with type unclassified. patients experienced episodes of musculoskeletal (n = , %), mucocutaneous (n = , %) and cns bleeding (n = , %). a total of patients received factor prophylaxis. half of the patients were initially treated with fviii concentrates but subsequently changed to combined fviii/vwf products due to the frequency of breakthrough bleeding despite good compliance. all patients are on combined fviii/vwf products at the time of this review. a total of ( %) of this cohort developed chronic joint disease manifest as decreased range of motion and/or abnormal mri findings. combined deficiencies of fviii and vwf were present in % of our center's hemophilia patients. these patients exhibited a severe bleeding phenotype as evidenced by the high frequency of hemarthrosis, need for prophylaxis and high prevalence of chronic joint disease. while the optimal treatment strategy remains to be elucidated, early recognition of a combined deficiency may have important clinical implications, particularly in patients who demonstrate a suboptimal response to fviii concentrate alone. background: childhood neutropenia is heterogeneous and may be congenital or acquired. cerebral cavernous malformation (ccm ) is a neurovascular malformation disorder where lesions consist of low flow, dilated capillary endothelial channels with increased permeability, predisposing to hemorrhage and thrombosis. programmed cell death protein (pdcd ) activity has been implicated in glia and neuron migration, and recently linked to the dysregulation of the actin and microtubule cytoskeleton, thereby affecting cellular morphology and migration. variants of pdcd encoding pdcd have been associated with ccm . ccm causes a greater and earlier disease burden than other ccms, with % presenting younger than years. some patients have associated extra-neuronal manifestations, suggesting that pdcd plays a role in other tissues. we describe a patient with significant blood cytopenias associated with ccm . design/method: retrospective chart review to obtain patient data. results: an -month old female presented with seizure and was found to have multiple intracranial cystic lesions and abscesses due to s. pneumonia serotype f. during her treatment, she developed anemia (hemoglobin . - . g/dl), thrombocytopenia (platelets , - , cells/l), and profound neutropenia (absolute neutrophil counts of zero). initial bone marrow evaluation revealed a normocellular marrow but with marked granulocytic hypoplasia and % hematogones on flow cytometry. florescent in situ hybridization excluded cytogenetic changes characteristic of myelodysplastic syndrome. further evaluation included testing for neutrophil antibodies, chromosome breakage, and telomere length and results were normal. whole exome sequencing excluded mutations affecting congenital neutropenia genes, but detected a de novo pdcd variant (c. + g>a), thereby diagnosing ccm . the neutropenia has responded well to granulocyte colony stimulation factor (gcsf), which is still needed at months of age. moreover, the thrombocytopenia has progressed, requiring periodic platelet transfusions. over time, the bone marrow hematogone population has decreased to % at months of age, though the granulocytic hypoplasia persists. conclusion: our case describes the first patient with neutropenia and thrombocytopenia associated with ccm . we hypothesize the pdcd variant is the etiology of bone marrow dysfunction due to its role in actin and microtubule cytoskeleton formation, akin to the pathophysiology of xlinked neutropenia. supportive features of an underlying genetic cause of marrow dysfunction include the persistence of cytopenias beyond infection resolution as well as presence of hematogones. hematogones were previously reported to occur in patients with other congenital neutropenia disorders, indicating they could be a feature of congenital neutropenia and may be reactive to surrounding cell apoptosis. further testing of pdcd role in hematopoiesis should be explored. background: - % of adult women will suffer from heavy menstrual bleeding (hmb) during their lifetime. % of women with inherited bleeding disorders suffer from hmb. there is a paucity of data about hmb among adolescents and young adults (aya), a population in which hmb may have large social and educational effects. objectives: to study the social and academic implications of hmb in an aya population. design/method: this is a questionnaire based survey conducted in a medium-sized city in california. we recruited females - years of age from one high school and from local university. the questionnaire was set up in research electronic data capture (redcap) at our institute which allowed us to obtain objective data about the respondents' menstrual cycles. a link was sent to the high school students via their online portal schoolloop and to the university students via social media and word of mouth. data was collected over weeks from may to august . we received replies, some were not complete. using regression analysis, data was analyzed from respondents in the age group of - (with a mean age of ) years. we developed a composite score for hmb based on factors including saturation levels, number of pads, duration of bleeding, soaking of a pad within two hours, passage of clots, size and number of clots, and gushing sensation. we conducted statistical analysis of the drivers and implications of hmb based on the composite score. results indicate that having a relative with hmb, having other bleeding problems, and having anemia are drivers of higher hmb score. the results also indicate that hmb adversely affects quality of life as measured by participation in sports, social activities, after-school activities, tiredness, absenteeism, and gpa. hmb is also associated with increased rates of anemia and use of anti-depressants. hmb-driven anemia further adversely affects gpa. under-represented minorities are more likely to have a higher hmb score, as well as an increased adverse effect of hmb on gpa. the results suggest that the social costs of hmb are pervasive in the aya population, and especially pronounced among minorities. a relative with hmb is a significant driver of heavy menstrual bleeding. a hemostatic screen should be included when assessing the aya population with hmb. johns hopkins all children 's hospital, st. petersburg, florida, united states background: propranolol is a non-cardioselective beta blocker medication frequently prescribed for hemangiomas and hyperthyroidism. propranolol inhibits types i and ii iodothyronine deiodinases, enzymes that convert bioinactive thyroxine (t ) into bioactive triiodothyronine (t ). hypothyroidism is a well-recognized complication of diffuse hepatic hemangiomas that produce type iii deiodinase, an enzyme that converts t into bioinactive reverse t and t into diiodothyronine. thyroxine is typically selected for replacement in this population, even though doses up to % above physiologic may be necessary. we hypothesized that low dose, nearly physiologic t would be safer and equally effective because it bypasses propranolol's impact on the pituitarythyroid axis. we report an infant with diffuse hepatic hemangiomatosis and acquired hypothyroidism successfully treated with propranolol, prednisone, and triiodothyronine. design/method: a mo healthy female presented with abdominal distension, poor oral intake, and hepatomegaly. mri confirmed diffuse hepatic hemangiomatosis, the largest lesion measuring . cm by . cm. thyrotropin (tsh) was elevated at . (reference range* . - mcgiu/ml), total t # (rr - ng/dl), and total t ^ . (rr - mcg/dl). treatment was started with prednisone ( mg/kg/day) for three weeks, propranolol ( mg/kg/day) and t ( . mcg/kg/day). the t dose was slowly titrated to a maximum of . mcg/kg/day. thyroid hormone levels rapidly improved on t replacement. after two weeks, the tsh was . , tt , and tt . . after eight months, the tsh was . , tt , and tt . . at twelve months, the tsh dropped to . , tt , and tt . , suggesting decreased tumor production of type iii iodothyronine deiodinase. liver mri confirmed fewer hemangiomas, largest being . cm by . cm. the patient's t dose was reduced. both propranolol and t were discontinued after twenty-four months of treatment. one year off all therapy, this child has normal growth and development, only two < . cm hepatic hemangiomas and no evidence of hypothyroidism (tsh . ; tt ; tt . ). conclusion: t at near physiologic doses corrects the consumptive hypothyroidism associated with diffuse hepatic hemangiomas. t replacement is preferable to thyroxine due to its lower risk of rebound hyperthyroidism as the hemangiomas involute and type iii deiodinase production declines. there are two prior case reports describing t use without t , one employing propranolol and the other utilizing steroids for hemangioma management. this is the first case report with long term follow-up of a child treated with multimodal therapy including propranolol, prednisone, and triiodothyronine. *rr = reference range; #tt = total t ;^tt = total t background: multifocal lymphangioendotheliomatosis with thrombocytopenia (mlt) is a rare congenital disorder first described in that is characterized by multiple vascular abnormalities commonly involving the skin and gastrointestinal tract as well as consumptive coagulopathy often resulting in gi bleeding in infancy( ). to describe an unusual presentation and successful management of mlt in a neonate. design/method: baby h was born at full term after a pregnancy complicated by maternal sinus venous thrombosis requiring anticoagulation beginning at weeks. at birth, she was diagnosed with multiple hemangiomas based on clinical exam. at two weeks of age, she developed melena and hematemesis. cbc revealed platelet count of and she was referred to the ed. abdominal ultrasound was concerning for abnormal hepatic waveform; cxr showed multiple pulmonary nodules. workup revealed no other lesions and no further hematologic abnormalities. biopsy of presumed hemangioma ultimately revealed a smooth muscle-lined vascular proliferation without glut- immunoreactivity, consistent with mlt. her early course was complicated by an acute hemodynamically significant gi bleed; esophagogastroduodenoscopy identified six bleeding vascular malformations within the stomach that were injected with epinephrine and sclerosed with successful hemostasis. she received multiple prbc and platelet transfusions. central access was obtained and she was started on oral sirolimus based on previous reports of successful use in management of vascular malformations given its antiangiogenic and immunosuppressive effects ( ). she has tolerated it well with no evidence of toxicity and has achieved a partial response with stable of hemoglobin > and platelet count > . cutaneous lesions have diminished in intensity and she has had no further signs of gi bleeding. she receives pentamidine for pcp prophylaxis. she continues to have appropriate growth and development. we describe here an unusual presentation of an already rare disease. while cutaneous and gi lesions are typical of mlt, pulmonary involvement is not well-described in the literature. early identification of tissue-based diagnosis enabled timely stabilization and treatment of the patient. five months later, she continues to tolerate sirolimus and has shown significant response with diminished coloration of cutaneous lesions, stable blood counts, and no further bleeding. mlt is a relatively newly-recognized disorder with significant phenotypic variability. given that bleeding secondary to a kasabach-merritt-type consumptive thrombocytopenia is the major cause of morbidity and mortality in the first year of life in children with mlt, it is essential to recognize the diagnosis and initiate appropriate treatment as early as possible. north, arch background: patients with generalized joint hypermobility (jhm) may experience easy bruising or bleeding given the association between these symptoms and abnormalities in collagen, a required component of primary hemostasis. heavy menstrual bleeding (hmb) is a common initial presentation for females with underlying hemostatic defects and may be the sole manifestation of a bleeding disorder. however, limited reports describe jhm as a cause of hmb, leading to under recognition. objectives: to describe the clinical characteristics and management of young women presenting with hmb in the setting of jhm. design/method: this study utilized our hmb research registry. we included subjects - years, seen in the nationwide children's young women's hematology clinic between february and november with both hmb and jhm. medical records were retrospectively reviewed for history of presentation, menorrhagia impact questionnaire (miq): a validated quality-of-life tool for females with hmb, medication profiles and relevant laboratory studies. results: twenty-five patients met inclusion criteria (median age years, range - ) with an average beighton score of . (range to ). participants presented an average of . years (range months to years) after menarche despite % of patients reporting heavy to very heavy menses since menarche. according to the miq responses, most participants expressed hmb-associated limitations in physical activities ( %), social activities ( %), and work or school activities ( %). of the participants, % reported bleeding symptoms in addition to hmb, most commonly easy bruising ( %), epistaxis ( %) and cutaneous bleeding ( %). forty percent of young women presented with anemia due to chronic blood loss. results of hemostatic testing were unremarkable, with the exception of one patient who was also found to have type von willebrand disease. additionally, % of females reported arthralgia, with knees and ankles the most commonly affected joints. at time of presentation, % of participants reported failure of initial therapies and most patients ( %) were managed long-term with oral hormone therapy. in a small population of young women found to have jhm who initially presented with hmb, patients were likely to have prior bleeding symptoms as well as substantial delays from menarche to timing of presentation at our young women's hematology clinic despite limitations in activities of daily life. greater awareness of the associations between bleeding symptoms and jhm, despite typically normal hemostatic laboratory results, is necessary so that patients can more easily be identified and receive appropriate therapy. the objective is to determine the impact of cl care practices involving the home environment on ambulatory clabsi rates. design/method: information for the pi was collected through a comprehensive survey that was completed annually by the ccbdn member hospitals. responses to the questions about cl care practices involving the home environment were selected from the pi for . ambulatory clabsi rates and ambulatory total bloodstream infection (bsi) rates were obtained from another ccbdn database. the proportion of hospitals that did or did not employ a particular cl care practice was tallied. the mean ambulatory clabsi rate and mean ambulatory total bsi rate of the hospitals that did or did not employ a particular cl care practice were compared using generalized linear model techniques assuming an underlying negative binomial distribution. results: twenty-five hospitals submitted responses to the questions about cl care practices involving the home environment. one hospital was excluded for lack of bsi data. sixty-three percent of the hospitals programmatically educated parents about all aspects of the cl care bundle. the mean ambulatory clabsi rate for the hospitals that educated parents was significantly lower than that of the hospitals that did not ( . infections/ cl days vs. . infections/ cl days; p = . ). the mean ambulatory total bsi rate was also significantly lower ( . infections/ cl days vs. . infections/ cl days; p = . ). the mean ambulatory clabsi rates and mean ambulatory total bsi rates were not significantly different for the other cl care practices. conclusion: an analysis of cl care practices involving the home environment reveals that parental education of all aspects of the cl care bundle is associated with a lower ambulatory clabsi rate and lower ambulatory total bsi rate. this finding highlights the importance of systematically teaching family members the proper method of handling cl. background: children undergoing chemotherapy are at a high risk for developing nausea. dr. amy baxter in collaboration with pediatric oncology patients and nurses, developed and validated a pictorial nausea rating scale for children aged - years, called the baxter retching faces (barf) nausea scale. staff nurses at a large, academic, pediatric hospital located within washington, d.c., have identified variability in nursing assessment and documentation of chemotherapy induced nausea and vomiting (cinv) in pediatric oncology patients. the purpose of this quality improvement project was to utilize the barf scale to standardize assessment and documentation of nausea in pediatric oncology patients receiving chemotherapy. the primary aims of this project were to: assess feasibility of the barf scale in clinical practice; increase nursing knowledge about cinv through education sessions; increase documentation of nausea assessments through the use of the scale. the secondary aim of this project was to: increase the recognition of nausea through the use of a standardized assessment tool. design/method: the pdsa model was used to guide the design and implementation plan. in the first phase of the project data was collected to identify the prevalence of nausea in patients admitted for chemotherapy in the prior three months. education sessions discussing cinv and the utilization of the barf scale were conducted. pre and post assessment of nurses' knowledge of cinv and documentation were assessed. in the second phase the barf scale was implemented into practice. nurses were asked to utilize the barf scale to assess and document nausea scores in patients, aged to years, receiving chemotherapy. at the end of the implementation period nurses were surveyed about the feasibility of the scale. post data was collected to identify the prevalence of nausea documented in the electronic health record. this project was undertaken as a quality improvement initiative at children's national and it does not constitute as human subjects research. as such it was not under the oversight of the institutional review board. results: all data has been collected; however complete data analysis will be conducted in the upcoming weeks. background: sickle cell disease (scd) is the most common inherited blood disorder in the united states (us); however, there are few quality measurements to evaluate scd practice. in , the nhlbi published guidelines that include two key interventions for children with sickle cell anemia (sca): the use of transcranial doppler (tcd) screening for stroke prevention and hydroxyurea (hu) to prevent scd pain crisis. we conducted a national survey of scd management sent to providers in over institutions in the us to better assess knowledge of the guidelines and barriers to hu counseling and tcd screening guideline implementation. it was hypothesized that the barriers to tcd screening are different than barriers to hu counseling and prescribing. a -question anonymous survey was sent to providers by mail (follow-up by email). survey themes included nhlbi guidelines knowledge and comfort with understanding and implementing both tcd screening and hu use. the response rate was % ( / ) however one survey was incomplete. thus, were analyzed in the final data set. all of the respondents are in active practice, % s of s in academics and all care for children with scd. the majority of providers ( %) felt "very" or "extremely" confident in their knowledge of tcd screening and interpretation. similarly, % of providers felt "very" or "extremely" familiar with hu dosing and management. for tcd screening, % of providers estimated their screening rates were > % and % providers felt their annual screening rates were - %. the two biggest barriers to tcd screening noted by providers (of moderate to extreme significance) included: lack of support staff ( %) and lack of time during a patient visit ( %). regarding hu prescribing practices, % of providers offered hu to at least % of children with sca over nine months of age. the biggest barrier to hu prescribing noted by % of providers was concerns about patient adherence or access to the medication. only % providers felt that lack of support staff was a moderately significant barrier to hu prescribing. the pediatric scd providers surveyed all have access to the nhlbi guidelines. despite widespread guideline knowledge, there are different barriers for tcd screening versus hu prescribing, which prevent optimal implementation. as a result, although both recommendations are from the same nhlbi guideline, they likely will require different implementation strategies (systems-based interventions for tcd screening; interventions to improve patient adherence for hu counseling) to improve outcomes. background: invasive fungal disease (ifd) is a major cause of mortality and morbidity among pediatric immunocompromised patients such as those who receive chemotherapy or hematopoietic stem cell transplantation. the current diagnostic 'gold standard' of ifd remains culture of infected tissue obtained by biopsy. noninvasive biomarker testing for galactomannan or , -beta-d-glucan (bg) can have low sensitivity and does not provide species-level identification. nextgeneration sequencing (ngs) of cell-free plasma is a promis-ing noninvasive approach to providing species-level identification of ifd via a blood test and can further guide specific treatment. objectives: describe the incidence of positivity for fungal specific pathogens on ngs analysis in a high-risk immunocompromised pediatric population and correlate results with other 'standard' infectious studies if performed. design/method: immunocompromised pediatric patients with suspected ifd were enrolled and plasma was collected at time of enrollment. ngs was performed on extracted dna in cell-free plasma (karius, redwood city, ca). after removing human reads, remaining sequences were aligned to a curated database including pathogens. organisms present at a significance-level above a predefined threshold were reported. results: twenty-seven samples from enrolled patients have been processed thus far. of these subjects, were enrolled for prolonged febrile neutropenia (≥ hours) despite broad-spectrum antibiotics, for recrudescent febrile neutropenia, for abnormal imaging, and with other findings. after evaluation of routine studies performed, patients met criteria for proven ifd, for probable ifd, and for possible ifd using eortc/msg guidelines. the ngs plasma test identified the same pathogen as cultured from infected tissue or blood in % ( / ) of the proven cases. in the probable cases, pneumocystis jirovecii was identified in a patient with a positive bg ( pg/ml) and pneumonia. among the possible cases, toxoplasma gondii was detected in a patient with prolonged febrile neutropenia and lung imaging suggestive of ifd. additionally, candida glabrata was isolated in a patient with prolonged febrile neutropenia but no other criteria for ifd. numerous pathogens were also identified that could explain the above clinical parameters, including hsv , cmv, vzv, hhv , ebv, bk polyoma virus, and ureaplasma parvum. the cell-free plasma ngs test can detect invasive fungal infections from blood. the test identified fungi from proven ifd, detected pathogens in both probable and possible ifd cases, and is a useful diagnostic tool in the evaluation of ifd. supplies and sample shipment and processing supported by karius, inc. baylor college of medicine, texas children's hospital, houston, texas, united states background: practicing medicine is a lifelong learning process. as noted in the institute of medicine's seminal report, 'to err is human,' adverse outcomes do not typically result from individual recklessness; rather, they result from faulty systems, processes, or conditions that provide an environment conducive to making a mistake, or failing to prevent one. learning to systematically review errors and translate lessons learned into quality improvement (qi) initiatives is a critical component of practice-based learning and improvement for practitioners at all career levels. objectives: to develop a methodical, self-reflective and nonthreatening approach to incident analysis and translation of lessons learned into qi initiatives. design/method: we used a validated, structured case audit approach, modified from szostek et al: ) review all documentation relating to the case and identify all health care providers involved; ) interview stakeholders, including those who directly provided and supported care; ) use a qi tool to conduct a root-cause analysis; ) identify a systems issue that contributed to the outcome; and ) propose systems-level interventions and prioritize initiatives based on effort-yield projections. results: pdsa cycle : plan: establish a committee to ) identify potential cases, ) triage cases for conference presentation, ) determine timing and frequency of conferences, ) develop a training manual, ) record identified qi initiatives. do: we established a quarterly section-wide meeting to which all members of the pediatric hematology/oncology service are invited, including administrative and nursing leadership. we developed a training manual and structured presentation template. prioritized cases were discussed in advance during multidisciplinary case review sessions, and presented by senior fellows who were instructed to focus discussion on potential opportunities for qi. study: we identified cases, meeting criteria for mmi presentation. qi initiatives identified from this conference resulted in a number of systemic practice changes; however, we encountered challenges to sustaining these changes over time. act: objectives for the next pdsa cycle are to ) establish a method for tracking the adherence to recommended changes in practice, ) maximize sustainability by integrating qi initiatives into institutional qi leadership and practice standardization committees. we have successfully implemented an mmi conference that meets out of institute of medicine quality domains: safety, effectiveness, patient-centeredness, timeliness, and efficiency. a standardized, consistent approach to mmi presentations that includes identification of contributing factors and specific qi implications has the potential for improving both provider education and patient care/safety. johns hopkins university, baltimore, maryland, united states background: receiving a cancer diagnosis is a life-changing event for patients and caregivers, although little is known about the experience. while some oncologists receive dedicated training in delivering this bad news, the initial conversation is often with a primary pediatrician, and these providers often feel they do not receive adequate training in the communication of a cancer diagnosis. objectives: our objectives were two-fold: first, to better define the experiences of caregivers/patients when told of a cancer diagnosis, and to query how caregivers/patients believe providers can improve the disclosure of this bad news. secondly, to assess what, if any, training primary pediatricians received in this skill, and to assess how comfortable providers in various settings and stages of training are with communicating cancer diagnoses. design/method: from november - , semistructured, in-depth interviews were conducted with pediatric oncology patients and caregivers of patients (n = ) diagnosed in the past year regarding their experiences receiving the diagnosis at our institution. in addition, pediatric residents (n = ), outpatient pediatric primary care physicians and pediatric emergency medicine physicians (n = ) were interviewed regarding their experiences delivering cancer diagnoses. interviews were analyzed following principles of thematic analysis. interviewers with patients and caregivers had two common themes: ) all emphasized their wish for direct and thorough information; ) both patients and caregivers emphasized the gratitude they felt for physicians who gave them hope by emphasizing the good prognosis of their child's cancer. lack of training in this area, as well as lack of comfort delivering this news was common will all providers. additionally, providers report variable approaches to giving bad news, including ) whether to tell caregivers separately or tell the child and parents together, and ) whether to give favorable prognostic information. additionally, attending physicians also differed significantly in their approaches to teaching residents. while some believed residents should give the news to gain experience, others felt that this is not appropriate if residents are inexperienced. only one resident reported ever receiving feedback on his communication skills in this type of discussion. conclusion: we plan to build on these interviews to develop a national survey of patients, caregivers, and providers to better understand the issues surrounding this discussion. we will use the findings to develop a communication curriculum for pediatric residents, focusing on the discussions that occur in the outpatient setting by primary pediatricians. background: human papilloma virus (hpv), common in both females and males, is responsible for pathologies ranging from benign genital warts to cervical and penile cancer. hpv strains and are responsible for , malignancies each year in the united states, and one third of them arise in men. pharmaceutical companies have now developed a vaccine that will help prevent the virus-associated malignancies. the cdc initially recommended that females ages - years receive the vaccine series, then starting in they expanded the eligibility to males ages - years. despite being widely available and highly publicized, only % of eligible females receive the full vaccine series. objectives: this study aims to assess the knowledge of hpv, the attitudes towards the hpv vaccine, and identify barriers preventing its full utilization. once identified, we aim to overcome the barrier(s) in order to improve vaccination rates in eligible adolescents. we distributed a standardized questionnaire to the parents of eligible female and male patients in our pediatric hematology-oncology clinic. it assessed the parents' knowledge of hpv and the vaccine, their views of the vaccine, and reasons why they may oppose it. results: approximately % of parents claim they have been educated about hpv, mostly by their primary care physician. however, % did not know what disorders hpv caused; % felt the vaccine should not be added to the typical vaccine schedule; % of parents do not intend to vaccinate their child. of those that opposed the vaccine, one-third were concerned about potential side effects and nearly % feel they do not have enough information. additionally, % of parents are not aware that the vaccine is available at their child's doctor and only % of parents have discussed the hpv vaccine with their child's doctor. the largest barrier to the utilization of the hpv vaccine that we have identified appears to be lack of educa-tion. as a result, we have begun distributing the cdc's hpv and vaccine patient guide to our patients' families as an intervention. we are currently in the process of re-administering our survey to these families after implementing the intervention to assess its success in increasing both knowledge and utilization of the hpv vaccine. cancer institute, chennai, chennai, tamilnadu, india background: rasburicase is a recombinant urate oxidase enzyme approved for use in tumor lysis syndrome (tls) and it acts by reducing serum uric acid levels. using rasburicase at the recommended dose of . mg/kg/day for days is expensive and it is not known whether this extended schedule is clinically beneficial compared to a single fixed dose of . mg. the aim of the present study was to evaluate the efficacy of single dose rasburicase . mg in prevention and management of tls. design/method: rasburicase is available as single use . mg vial. at our institution a single dose of rasburicase . mg irrespective of bodyweight has been used in adults and in children a dose of . mg/kg (maximum . mg) has been used since for prevention and management of tls and subsequent doses are given based on biochemical response and clinical condition. we retrospectively analysed the case records of patients who had received rasburicase from january to january . the study included patients with hematological malignancies who received rasburicase. children accounted for . % (n = ) patients and males comprised % (n = ). rasburicase was used prophylactically in ( . %) patients, for laboratory tls in patients ( . %) and for clinical tls in ( . %) patients. single fixed dose rasburicase prevented laboratory/clinical tls in % of the prophylactic group and prevented clinical tls in % of the laboratory tls group. none of the patients in prophylactic and laboratory tls group developed clinical tls. however, majority of the patients with clinical tls required more than one dose rasburicase. single dose of . mg ( vial) rasburicase is efficient in preventing and managing laboratory tls and is economically viable in resource constrained settings. nicole wood, lauren amos, nicholas clark, chris klockau, karen lewing, alan gamis children's mercy kansas city, kansas city, missouri, united states background: medication reconciliation for newly diagnosed oncology patients is complicated and cumbersome. these patients are often admitted on no medications, and leave on multiple. chemotherapy and supportive medications are crucial. despite numerous individuals overseeing this process, prescribing errors or omissions still occur. when reviewing the literature, improvement occurs when there is an interprofessional and standardized process to medication reconciliation. objectives: this project's aim was to improve the accuracy of the discharge medication reconciliation process from % to % from february -august . the process measure was the percentage of patients discharged with an accurate checklist. additional time for staff spent in completing the checklist and avoiding an increased error rate by changing the prescribing process were followed as balancing measures. we created a discharge medication checklist which included a list of required home medications prescribed by the resident, ideally hours prior to discharge. it required fellow or attending review and pharmacy to review the list and educate the family. checklists were collected monthly and reviewed against the electronic medical record (emr) for accuracy. results: six pdsa cycles were completed. there were errors during the data collection time frame. in pdsa cycle , a patient received acetaminophen for pain control which is avoided at home. in addition, this patient received diphenhydramine instead of ondansetron, which is preferred as an antiemetic. in pdsa cycle , a patient with a pending diagnosis was sent home with acetaminophen. of note, this patient did not have a checklist completed upon discharge. this project provides a novel and important method to standardize the discharge medication reconciliation process in a complex patient population. it clarifies which types of medications these patients need, provides pharmacy teaching to families which was not done previously, and prescribes discharge medications to families sooner. after the first medication reconciliation error, the checklist was revised. no further errors were made following revision, with the exception of one patient without a completed checklist at dis-charge. our accuracy rate increased from % at baseline to % following implementation. we are in the process of making the checklist electronic and accessible in the emr. in the interim between the end of data collection and implementation into the emr, a leukemia patient was sent home without an epinephrine pen, further demonstrating the importance of this standardized discharge process. for this reason, we have re-instituted the checklist until the electronic version is available. background: survivors of pediatric cancer are at risk of losing pre-existing protective antibodies to vaccine preventable diseases. in a prior study, % of children < years lost humoral immunity to measles as a result of chemotherapy induced alterations in immune system. measles in recipients of immunosuppressive chemotherapy has mortality rates up to %. because of volitional vaccine refusal, there has been a dramatic increase in measles infection from cases in to in , including several statewide outbreaks. small pediatric oncology practices frequently share floor/clinic space with the general pediatric patients putting them at risk for measles since virulence starts hours prior to symptoms. there is no standard protocol for revaccinating post-chemotherapy patients. to assess measles risk based on serial humoral immune status in a cohort of pediatric oncology patients receiving intensive chemotherapy design/method: patients < years age with known vaccination status receiving intensive chemotherapy between july -june at our institution's pediatric oncology practice were included in this prospective study. serial measles igg antibodies were measured at diagnosis, months and months after initiation of chemotherapy using elisa. measles immunity was defined per lab standards. a comparison of pre-chemotherapy and serial post-chemotherapy immunization titers was made for all patients by diagnosis. the study population consisted of children ( male); patients had all, non-hodgkin lymphoma, sarcoma and other solid tumors. two patients ( . %), both unvaccinated had non-protective measles antibody levels at s of s baseline. of the remaining patients, . % patients ( leukemia, lymphoma and sarcoma) lost protective antibody titers at months after initiation of chemotherapy and . % ( leukemia, lymphoma and sarcoma) at months after initiation of therapy. % of the remaining patients who retained measles antibody titers within protective range at months also demonstrated a steady decline in antibody titers at and months from therapy initiation. the loss of protective measles humoral immunity occurred significantly more often in patients with leukemia compared to other malignancies. oncology patients in our practice undergoing intensive chemotherapy demonstrated progressive waning of protective measles igg titers. our data suggests that it should be standard practice to check all patients for measles humoral immunity prior to starting chemotherapy and at completion. larger studies need to be performed to establish guidelines for revaccinating post-chemotherapy pediatric patients, an intervention that is easily applicable and of low cost. background: the accurate determination of glomerular filtration rate (gfr) is important to screen for acute kidney injury, to dose chemo-therapy, and to identify risk for chronic kidney disease.being correlated with inulin clearance, measured gfr by iohexol plasma disappearance (igfr) is a new gold standard for measurement of gfr in pediatric cohort studies. igfr is based on the clearance of an exogenous marker and is unaffected by endogenous compounds or a patient's muscle mass. we compared igfr with -hour urine creatinine clearance ( crcl) and gfr estimating equations using serum creatinine (scr) and serum cystatin c (cystc) in pediatric patients with cancer. we recruited participants who were ages to yrs, continent of urine, and diagnosed with a malignancy in the past years. eligible subjects had stable kidney function for at least two weeks prior to the assessment of igfr. consented subjects had baseline assessments including height, weight and vital signs. blood samples were obtained for serum chemistry, and time zero iohexol. igfr determined by ml iohexol solution infused over - minutes followed by ml of sterile saline. blood was drawn at , , and minutes.at the same time of igfr, the crcl was collected. igfr was calculated using a two-compartment model and area under the curve. we compared igfr to published gfr equations (schwartz et al, kidney int ). results: ten subjects ( female/ male) agreed to participate. the distribution of diagnoses for the subjects: all = , lymphoma = , brain tumors = and hepatocellular carcinoma = . six patients were off therapy. the lower gfrs are noted in patients who had malignancies other than leukemia, likely due to the use of cisplatin based therapy. the average igfr was ml/min/ . m^ whereas crcl was . ml/min/ . m^ ; demonstrating the crcl overestimates gfr compared to igfr. comparing igfr to univariate equations using scr, cystc, and the multivariate equation with both, the univariate cystc equation correlated well with igfr; the others overestimated igfr. we found that crcl overestimated igfr. the univariate cystc equation better correlated to igfr than equations with scr. the poor performance of scr based methods to assess gfr might be due to decreased muscle mass and inadequate nutritional status. creatinine-based determinations of gfr alone, may not be accurate in this population. further study is needed to determine if igfr should be a standard of care to assess gfr in children with cancer particularly who are receiving nephrotoxic medications and incontinent of urine. background: pediatric oncology patients undergoing chemotherapy through indwelling venous catheters are at increased risk for severe sepsis especially when neutropenic due to chemotherapy. rapid triage and early recognition are essential because delayed initiation of antibiotics and fluids in these patients or delayed transfer to higher level of care after initial stabilization is associated with poor clinical outcome. our pediatric oncology out-patient clinic is designated as an article unit whereby the providers can initiate and give treatment such as intravenous fluid, antibiotics, chemotherapy and blood products. objectives: global aim-optimize management of early sepsis and decreased morbidity, mortality and hospital length of stay in the high risk pediatric oncology patients. smart aim-improve timely management with initiation of fluids and antibiotics and transfer of septic patients to higher levels of care by % in months in above patients design/method: multidisciplinary team with physicians and nurses was created. retropective chart review of sepsis patients treated at the clinic from april to october was done using an audit sheet to identify the barriers in the delivery of care. three patients were identified and data analyzed prior to intervention; two were analyzed post interventions. a key driver diagram was created by the group to drive intervention. a process map was designed to identify the different steps in the care of these patients to pinpoint areas needing improvement. different timed data points were used starting from time of arrival to clinic, time to antibiotics and fluids and time to transfer to higher level of care. rapid pdsa cycles were done to improve the processes and delivery of care. run charts were created. there was an improvement close to the goal of % for all data points used. pdsa cycles for improvement included conducting frequent mock codes with appropriate feedback real time coaching and process planning with nursing staff. we partnered with pharmacy for close loop communication with clinic staff and we improved communication between physicans at different levels. conclusion: sepsis in neutropenic pediatric oncology patients is deadly and can be reversed with timely management at different levels. given the promising results of the above project, we want re-inforcement of the processes to be a part of the daily practice of first line clinical staff. eventually we will extend the principles learnt in management and triage of sepsis to other outpatient emergencies chemotherapy related anaphylaxis background: chemotherapy-induced nausea and vomiting (cinv) is a common side effect in children receiving antineoplastic chemotherapy. recommended prophylactic antiemetic medications are based on the classification of chemotherapy emetogenicity. however, despite appropriate use of these antiemetic agents, some patients will still experience nausea and/or vomiting. children's oncology group clinical practice guidelines recommend the addition of olanzapine to prophylactic regimens for management of breakthrough cinv. objectives: our pediatric hematology oncology center implemented a quality improvement (qi) project aimed to increase the use of olanzapine in pediatric cancer patients years of age and older receiving moderately or highly emetogenic chemotherapy and experiencing breakthrough cinv over a month period. design/method: this qi project was conducted utilizing plan-do-study-act (pdsa) cycles. for the first pdsa cycle, baseline data was collected through chart review to determine the rate of olanzapine use for breakthrough cinv over a month period from july to december . breakthrough cinv was defined as use of or more doses of antiemetic agents other than those given for cinv prophylaxis. guidelines for treatment of breakthrough cinv were reviewed with pediatric hematology/oncology attending physicians and fellows. flyers were created that listed chemotherapy regimens considered moderately and highly emetogenic. if a patient experienced breakthrough cinv, a flyer was to be placed in the patient's roadmap binder to signal olanzapine should be added to the next chemotherapy block. data was collected over a month period in september following this first intervention. the second pdsa cycle consisted of didactic education and training of pediatric oncology nurses as well as pediatric residents regarding the addition of olanzapine for breakthrough cinv. rates of olanzapine use were then collected from october through november . results: olanzapine use increased from . % at baseline to . % after the first pdsa cycle ( = . , p = . ). after the second pdsa cycle, olanzapine use increased another . % to . % ( = . , p = . ). the administration of olanzapine was successfully increased by modifying patients' roadmaps after patients experienced breakthrough cinv as well as with education and training of pediatric oncology staff, fellows, residents, and nurses. background: venous thromboembolism (vte) is increasingly affecting children. according to an administrative database study, there was a % increase in the incidence of vte among children admitted to free-standing children's hospitals in the united states from to . risk factors for hospital-acquired vte are well-known and well-studied in adults, with evidence-based preventative measures available. similar guidelines are lacking for children. objectives: there is an ongoing national-initiative to develop and institute methods for screening and preventing hospitalacquired vte in children. in / , nationwide children's hospital instituted an electronic screening form required for all patients admitted ≥ hours. patients were scored and riskstratified based on eight risk-categories. a summated score was used to determine the vte risk level, and used to make prophylaxis recommendations for patients ≥ years; as well as patients ≥ years who were admitted to an intensive care (icu), surgical, or trauma unit. the purpose of this irb exempt, quality improvement initiative was to retrospectively review our experience with this risk-stratification tool. results: hospital-acquired vte events occurred in unique subjects. median age at vte diagnosis was years. only ( %) vte occurred in children ≥ years of age. ( %) vte were deep vein thrombosis (dvt), and ( . %) involved pulmonary embolism. vte was most common in subspecialty units including the pediatric and cardiac icus ( . %); neonatal icu, ( . %); and hematologyoncology, ( . %). ( %) vte were associated with central venous catheters (cvc) and events ( %) were associated with altered mobility. congenital heart disease/heart failure was the most common chronic medical condition associated with vte ( ( . %) events); whereas infection and trauma/surgery were the most common acute medical conditions associated with vte ( ( . %) and ( %) events, respectively). during ( %) events, subjects scored a summated score ≥ . in summary, in this single institution, prospectively maintained database, cvc remains the most common risk factor for vte, followed by cardiac disease, infection and trauma/surgery. most subjects who developed vte scored high (score ≥ ) on our screening tool. only a small proportion of vte occurred in patients older than years and thus eligible for thromboprophylaxis. our results indicate that future vte prevention endeavors should include these age groups in addition to exploring more aggressive prophylactic modalities including pharmacological prophylaxis. background: pediatric fellows are required to have active engagement in quality improvement (qi) activities, and yet a national acgme review found most trainees had "limited knowledge of qi methods" and "limited participation in interprofessional qi teams". the twenty fellows in our pediatric hematology/oncology training program identified blood culture utilization as their qi priority. our institution recently introduced a hospital-wide decision algorithm to guide providers regarding when to obtain blood cultures. there is often a low threshold to obtain blood cultures in immunocompromised pediatric oncology patients, but these are often low-yield or result in falsepositives. our fellows spearheaded a project to implement the algorithm in the inpatient pediatric oncology population and improve the proportion of appropriately drawn blood cultures. we investigated how appropriately the algorithm was being utilized on the inpatient pediatric oncology floor prior to and after several educational steps aimed at disseminating the algorithm to members of the care team. our primary endpoint was to quantify the proportion of culture episodes drawn "inappropriately", with a goal of reducing inappropriate episodes to ≤ %. the algorithm was initially introduced to the nursing staff and residents covering the twenty-bed inpatient unit in september . qi project planning took place with upper level fellows in january . fellows and faculty received intensive training on the algorithm in july-august . we then conducted a retrospective chart review of blood culture episodes drawn between august and november . upper level fellows scored ∼ culture episodes as to whether the decision to culture and number of cultures drawn were "appropriate" or "inappropriate", and catalogued the indications for culture episodes and if applicable, why the episode was found to be inappropriate. additionally, fellows discussed inappropriate culture episodes with the team onservice, to provide direct feedback on where the algorithm failed. results: between august -december on average cultures/ patient-days were drawn. forty-nine percent of culture episodes were inappropriate. from january -october , following targeted education on the algorithm, the rate of blood cultures drawn decreased to cultures/ patient-days. the average proportion of inappropriate culture episodes fell to . %, representing a % decrease in inappropriate culture utilization. correct application of a decision algorithm for blood culture utilization can reduce total cultures drawn on an inpatient pediatric oncology unit. fellow-led education of the multi-disciplinary team decreases the rate of inappropriate culture episodes as well as provides active engagement in qi. background: inadequate understanding of sickle cell disease (scd) is common and can affect patients' compliance and therefore their morbidity and mortality, especially after transition to adult care. optimal clinical care for scd includes disease education, which can be difficult given the breadth of possible topics and limited time in clinic. it is unclear how best to provide personalized, efficient education for adolescents with scd. this quality improvement (qi) study aimed to implement a questionnaire-based system to improve patients' knowledge of their scd and documentation of education by the nurse or physician. the study objective was to improve provider documentation and patient knowledge about their scd by identifying patients' gaps in comprehension. by january , the study aimed to increase education documentation from % to %. by april , the study aimed to increase use of a smart phrase for education documentation from % to %. by june , the study aimed to increase patients' knowledge about their disease by %. design/method: twenty-one scd patients enrolled on an irb approved qi study, with twenty active patients. our comprehensive team generated a questionnaire with knowledgebased questions for two age groups: - and - years old. at each comprehensive visit, a questionnaire was distributed, with at least -month intervals. the provider scored questionnaires and reviewed two educational topics, with wrong answers taking priority. plan-do-study-act (pdsa) cycles included pdsa# : patients completed questionnaire. pdsa# : a smart phrase addressing questionnaire topics was created and shared with providers. pdsa# : patients received education handouts during clinic education. documentation in clinic notes was the process measure and questionnaire scores was the outcome measure. results: pdsa# is complete, pdsa# has four patients remaining, and pdsa# is ongoing. due to variable visit frequency, there are multiple concurrent cycles. after pdsa# , free text documentation was completed an average of % over the course of months. after pdsa # documentation increased to % within months and questionnaire scores increased from an average of % to %. of the questions that patients got wrong on their first visit, they were significantly more likely to improve on retesting if the topic was taught to them than if it was not addressed ( % vs. %, p = . ). we are currently completing pdsa# and collection of post pdsa# data. questionnaire-based scd education coupled with standardized smart phrases improves patients' scd knowledge and documentation by providers. further improvement in knowledge is expected with the addition of handouts. background: exposure to suffering can have a profound impact on the wellness of caregivers, often referred to as the "cost of caring". this cost is especially high in pediatric hematology/oncology. repeated exposure to suffering has the potential to negatively impact resilience and increases the risk of burnout, thus impacting quality of care and patient satisfaction. we have developed a peer support team utilizing the critical incident stress management (cism) model. this model has been successfully used in other professions that frequently face traumatic events such as fire fighters, police and emergency medical technicians. the h.o.p.e.s. team (helping our peers endure stress) consists of volunteer multidisciplinary staff members who have received training to provide both group and peer support following any 'critical incident' that may impact one or more staff members. we hypothesize that implementation of the h.o.p.e.s. team will improve staff resilience, decrease overall rates of burnout and improve compassion satisfaction. s of s design/method: we are using both empiric metrics and anecdotal reports to assess the impact of the h.o.p.e.s. team. prior to the activation of the team, all pediatric hematology/oncology clinical staff members were surveyed using validated tools to assess their levels of resilience, burnout, secondary trauma and compassion satisfaction (proqolv and brief resilience scale). they were also asked to rate the number of times they had experienced critical incidents, as well as their perceived level of distress after dealing with traumatic events. after the h.o.p.e.s. team has been functional for months, we will send the same survey to staff members to measure changes, paying special attention to resilience and rates of burnout and compassion satisfaction. results: enthusiasm for development of the team has been high. of people approached to volunteer their time to participate in the multidisciplinary team agreed, including attending physicians, fellows, nurses, nurse practitioners, child life specialists, social workers, clergy and psychologists. all volunteers participated in a -day training conducted by an instructor from the international critical incident stress foundation. engagement in the first staff survey has been high, with of responding to date. data collection is ongoing. clinical staff in pediatric hematology/oncology may be particularly vulnerable to burnout and decreased resilience by repeatedly witnessing suffering and trauma. peer support interventions following critical incidents may lead to increased resilience and compassion satisfaction while decreasing rates of burnout. enthusiasm for the development of a peer support team has been high. background: monthly blood transfusions are an indicated therapy for pediatric patients with sickle cell disease with certain complications. maximizing transfusion efficiency in a busy infusion clinic requires: ensuring that appropriate blood units are available in the hospital blood bank; laboratory specimens are obtained from patients in advance; and coordination of clinic appointment and nursing availability. we sought to improve clinic efficiency through identifying ways to better communicate with patients/families regarding upcoming laboratory and transfusion appointments, and to assess the efficacy of implementing a web-based personalized text reminder (pinger.com). we measured the baseline frequency with which transfusion appointments were missed by families, moved to later within the week, or delayed due to late labs. a convenience sample of patients receiving monthly transfusions received a questionnaire about patient/parent preferences for appointment reminders and barriers to keeping appointments. those patients/parents who did not opt-out of an additional text reminder received personalized texts from their care team reminding them of lab and transfusion appointments. rates of missed/moved/delayed appointments were compared between the group receiving the additional text messages and the group only receiving standard, hospitalgenerated appointment reminders (telephone call). results: forty-one families ( patients) responded to the survey, capturing information on % of patients receiving chronic transfusion therapy. thirteen families ( %) declined the additional text reminders. families reported a preference for text reminders ( %), more often than email ( %) or telephone ( %), and % of families wanted to receive reminders for both transfusion and laboratory appointments. the majority ( %) of families reported competing work/life priorities as the reason for missed/late appointments. other families noted transportation/travel ( %), fear/illness/pain ( %), and lack of reminders ( %) as the reason for missed appointments. at baseline (twelve weeks), . % of appointments were missed on a weekly basis (range - of available per week), . % were moved, and % of appointments were delayed. during our intervention period (twelve weeks), % were missed, . % were moved, and . % were delayed (combined, both groups). there was no difference in missed ( . % texted vs . % standard), moved ( . % texted vs . % standard) or delayed ( . % text vs . % standard) appointments. though families at our center reported a preference for a text-based reminder, personalized text reminders for appointments did not improve clinic efficiency as measured by missed, moved or delayed transfusion appointments. there was no improvement in appointment adherence in the group receiving personalized texts in addition to standard hospital reminders. university of utah, salt lake city, utah, united states background: childhood cancer outcomes have improved significantly, in large part due to multi-institution collaborative clinical trials run by the children's oncology group (cog). approximately half of eligible children with cancer will enroll on a therapeutic trial, but little is known about the factors affecting caregiver decision-making regarding enrollment or how well the required elements of informed consent are conveyed during the consent process. objectives: . assess coverage of ten of the required elements of informed consent for cog therapeutic trials. . describe factors affecting caregiver decision-making regarding therapeutic trial enrollment. we surveyed families of children who were offered enrollment onto a phase cog therapeutic study for an initial cancer diagnosis in the previous months. fisher's exact or wilcoxon rank-sum tests were utilized to compare demographic and other motivating factors related to enrollment decision-making. results: seventy participants were surveyed. regarding of the basic required elements of informed consent, % knew the trial involved research, % knew consent was required, % knew the enrollment length for the trial, % knew they could continue care independent of enrollment, % knew who to contact with questions, % knew there were options besides enrollment, % knew they could withdraw at any time, % knew the information was confidential, % knew there were risks associated with the trial, and % knew there were benefits. of all participants, % (n = / ) enrolled onto a therapeutic study. among enrollees, % (n = / ) of the primary caregivers had completed college compared to % (n = / ) of those not enrolled (p = . ). when asked about factors impacting their decision, % (n = / ) of those enrolled said they felt there were no risks or did not know if there were risks associated with the study compared to % (n = / ) of those choosing not to enroll (p = . ). of those enrolled, % (n = / ) reported the physician recommendation "somewhat" or "strongly" affected their decision to enroll compared to % (n = / ) of those not enrolling (p = . ). of those who enrolled, % (n = / ) reported feeling pressured to enroll while % (n = / ) of those not enrolled reported pressure (p = . ). of enrollees, % (n = / ) reported they did not have enough time to decide compared to % (n = / ) of those not enrolled (p = . ). failure to convey all required elements of informed consent highlights possible deficiencies in the consent process for cog therapeutic trials. caregivers' perception of being pressured and lack of time to make an informed decision may impact clinical trial enrollment. background: abnormal uterine bleeding (aub) is a frequent adolescent gynecologic complaint. however, limited research exists to guide management, and acute care varies. we sought to improve emergency care for adolescents with aub by developing a clinical effectiveness guideline (ceg) and assessing its impact on quality of care. design/method: a stakeholder engagement group consisting of members from the departments of hematology/oncology, adolescent medicine, general pediatrics, and emergency medicine designed a ceg algorithm for emergency aub management. pediatric residents received ceg training and their knowledge and attitudes were assessed using pre and post intervention surveys. icd- and codes identified electronic health record data for patients presenting to the pediatric emergency department (ed) for aub months before and after ceg implementation. pre-pubertal patients and those with vaginal bleeding from trauma were excluded. a weighted, -point scoring system consisting of prioritized aspects of history, laboratory studies and management was developed to quantify the quality of care provided. t-test, chi square test, wilcoxon rank sum test, and a run chart were used for analysis. of the patients identified, met inclusion criteria. there were % of patients currently using some form of contraception, while . % had bleeding related to a current or recent pregnancy. median aub quality care scores were pre-and post-intervention (p = . ). run chart data showed no shifts or trends (overall median score, -points). both pre and post-implementation, points were deducted most frequently for not assessing personal/family clotting disorder history and inappropriate use/dosing of oral contraceptives. we successfully designed and implemented a ceg and educational intervention for aub management in a pediatric ed. these data suggest our ceg may be an effective tool to improve emergency aub care for adolescents, though additional cycles are needed. background: high-dose methotrexate (hd-mtx) is a common chemotherapy administered inpatient at most centers. its administration is particularly susceptible to error due to the need for frequent drug levels with resulting changes in supportive care. errors can prolong patient stay and cause patient harm. objectives: global aim-to reduce the length of stay (los) of hd-mtx admissions. smart aims-to increase the percentage of patients whose pre-hydration fluids are started by am from % to % by / / , and to increase the percentage of patients who receive hd-mtx by pm from % to % by / / . we used rapid process improvement methods to target earlier methotrexate administration. a key driver of prolonged los was hypothesized to be drug levels returning overnight rather than in the day time due to delayed hd-mtx start. changes implemented have included scheduling hd-mtx patients as the first patients of the day for their exam in clinic and scheduling labs to pass for hd-mtx on the day prior to admission. there are ongoing pdsa cycles to change the location of pre-hydration start from the inpatient room to the clinic exam room in order to meet hd-mtx administration time goals. we are piloting two different education materials to improve patient experience. one explains hd-mtx levels in a red/yellow/green stoplight format and the other reminds patients how to prepare for the admission. other interventions regarding how we test urine ph and safety checks in the ordering process for history of delayed clearance are in the planning stage. the project is ongoing, but as of / / , we start methotrexate by pm % of the time which is improved from a baseline of %. when the project was started, pre-hydration was never started before am. now, fluids are started by am % of the time. pdsa cycles are ongoing and we have yet to sustain reductions in los, but some months have shown decreased los by as much as hours from baseline measurements. rapid cycle improvement can be utilized to decrease los hd-mtx admissions. this has important financial implications as well as the potential to reduce secondary harm from unnecessary time in the hospital. pediatric cancer centers should schedule hd-mtx admissions first thing in the morning so that data regarding kidney injury and drug clearance can be interpreted by the day team and children are not cleared for discharge in the middle of the night. background: education and training for interdisciplinary pediatric oncology providers requires training in principles of palliative and end-of-life (eol) care. the experiences of bereaved parents can inform and enhance palliative care educational curricula in uniquely powerful and valuable ways. the objective of this study is to present an innovative palliative care educational program for oncology providers facilitated by trained bereaved parents who serve as volunteer educators in local and national palliative care educational forums and to describe how incorporation of bereaved parents in these educational forums affects participant comfort with communication and management of children at the eol. design/method: survey tools were adapted to determine how bereaved parent educators affected participant experiences in different educational forums: institutional seminars on pediatric palliative and eol care, role-play based communication training sessions, and an international symposium on pediatric palliative oncology. pre-and post-session surveys with incorporation of retrospective pre-program assessment item to control for response shift were used in the evaluation of institutional seminars and communication training sessions. results from feedback surveys sent to all attendees were used to appraise the participants experience in the international oncology symposium. results: involvement of trained parent educators across diverse, interdisciplinary educational forums improved attendee comfort in communicating with, and caring for, patients and families with serious illness. importantly, parent educators also derive benefit from educational with interdisciplinary clinicians. integration of bereaved parents into palliative and eol care education is an innovative and effective model that benefits both interdisciplinary clinicians and bereaved parents. background: poorly controlled chemotherapy-induced nausea and vomiting (cinv) significantly impairs patients' quality of life and contributes to ongoing medical costs through increased length of stay in the hospital or readmissions and outpatient visits for control of nausea, vomiting or dehydration. lack of adherence to national evidenced-based guidelines that dictate antiemetic prescribing for variably emetogenic chemotherapy leaves patients vulnerable to increased cinv and its ensuing complications. objectives: to review our institution's antiemetic prescribing practices and their consistency with the antiemesis guidelines from the national comprehensive cancer network (nccn) and children's oncology group (cog)-endorsed supportive care guidelines and to further develop tools to increase adherence to these national-based guidelines to improve control of cinv. we performed a retrospective chart review of inpatient chemotherapy encounters. we evaluated emetogenicty of chemotherapy (high, medium, low), initial antiemetic regimen ordered, number of as needed medications required and adherence to national evidenced based guidelines tailored to each level of emetogenicity in the prescription of antiemetics. results: fifty-five total inpatient chemotherapy encounters were reviewed over months. eighteen of these encounters were considered to have been highly emetogenic chemotherapy (hec) with the remaining of these considered to be moderately emetogenic. only out of hec encounters completely included all guideline-recommended agents. there was a demonstrable lack of consistency across providers with dosing of aprepitant and most as needed medications. there was significant variation in order of first, second and third line anti-emetics ordered -with lorazepam and promethazine being used most frequently. with an aim of improving antiemetic prescribing practices for our patients, we are currently rebuilding chemotherapy treatment plans in our electronic medical record to incorporate antiemetic drug order sets that follow evidenced-based guidelines for variably emetogenic chemotherapy. this will be used in conjunction with an education initiative about best practices in supportive care for all prescribers of antiemetics. review of our department's recent inpatient chemotherapy encounters show we are falling short in following nationally recommended standards for appropriate antiemetic coverage during chemotherapy. identification of these deficiencies allows for implementation of quality initiatives to improve prescriber adherence to evidenced-based guidelines for better control of cinv. background: there are currently no consensus guidelines for the management of pediatric oncology patients presenting with fever without neutropenia. historically, these patients had been treated similarly to neutropenic patients with empiric antibiotics. while there has been a shift towards reducing unnecessary empiric treatment, there has been limited research into the outcomes associated with withholding empiric iv antibiotics in this patient population. we assessed the safety and efficacy of our institution's current protocol of observing well-appearing patients who present with fever without neutropenia and compared the outcomes of the patients who did and did not receive empiric iv antibiotics. design/method: this was a prospective, single-institution cohort study. patients were included if they were currently undergoing chemotherapy for an oncologic diagnosis and presented initially as an outpatient with fever and nonneutropenia (defined as anc ≥ cells/mm ). for each episode we recorded lab and blood culture results, signs and symptoms of initial presentation, and clinical outcomes, including antibiotic administration and hospital admission. results: a total of episodes of well-appearing patients with fever without neutropenia were identified. compliance with the institutional protocol was high; . % of patients were observed without receiving empiric iv antibiotics. the majority of patients were discharged home and there were no serious complications or infectious deaths. the incidence of positive blood cultures was low ( . % including several likely contaminants), despite the presence of central venous catheters in the majority ( . %) of patients. there were no significant differences in age, oncologic diagnosis, central s of s line access, anc value, or incidence of bacteremia between patients who did and did not receive empiric iv antibiotics. patients who were admitted to the hospital were significantly more likely to have received iv antibiotics (p < . ) despite documentation of a reassuring exam. however, admitted patients who initially received iv antibiotics were just as likely to discharge within hours compared to patients who were observed. we propose that empiric iv antibiotic administration in febrile, non-neutropenic, otherwise well-appearing patients is unnecessary. our study demonstrated no adverse consequences of observation and no significant differences in clinical outcomes between patients who did and did not receive iv antibiotics aside from rate of hospitalization. this supports the practice of observation without empiric antibiotics for such patients. background: children with hepatoblastoma (hb) undergo repetitive computed tomography (ct) scans to determine response to treatment and assess for relapse. this imaging exposes children to radiation, anesthesia, and imposes financial and emotional burden. objectives: review our institutional experience to determine if afp measurements are sufficient to assess response to treatment and detect relapse. we conducted a retrospective chart review of all patients diagnosed with hb at our institution between - . data collected included serum afp, total number and type of imaging studies during and post treatment, and how relapse or progressive disease was detected. results: thirty-one patients were diagnosed with afp positive hb. during therapy, ct scans were performed: to assess for response to therapy or surgical planning (average scans/patient) and due to concern for progression with rising afp. off therapy, surveillance ct scans were performed (average of . scans/patient) and ( %) included the chest in patients with no lung metastasis at diagnosis. relapsed patients averaged . surveillance scans, . of which were done before relapse was noted on imaging. there were no cases of radiographic evidence of relapse without a prior increase in afp. during treatment, response to therapy based on imaging correlated with a decline in afp in all patients, arguing that repetitive scans are not needed in this setting unless required for surgical planning. only of scans performed during off therapy surveillance displayed evidence of relapse, all of which were preceded by rise in afp. our study represents the largest cohort of hb patients. prior studies suggest similar results, but included fewer patients, lower stage of disease and less than years of surveillance monitoring. at our institution, the cost of a ct c/a/p is $ , with reimbursement varying from - %. in comparison, the cost of an afp measurement is $ . . many scans also require anesthesia and result in emotional toil for families concerned about this procedure as well as the results. thus, afp demonstrates greater sensitivity, with significant cost savings and decreased emotional burden, and should be used for monitoring both during and off therapy, replacing routine serial imaging. background: we observed that our practice of drawing daily blood cultures in hospitalized patients with fever and neutropenia was wasteful; it resulted in excessive negative cultures that did not add to patient care. the smart aim of this quality improvement project was to reduce the number of negative blood cultures drawn on hospitalized patients with fever and neutropenia by % in months. design/method: after reviewing published evidence suggesting drawing daily blood cultures in febrile neutropenic patients was unnecessary, a new blood culture guideline was implemented: cultures were drawn at presentation for fever with neutropenia and, if negative at hours, repeat cultures were not drawn except for clinical change, new fever after being afebrile > hours, or antimicrobials were being changed/broadened. to impact key drivers, we educated staff and changed blood culture order sets to require providers to select a reason for ordering the culture and to eliminate a nursing order to draw daily cultures with fever. we compared the number of blood cultures drawn per central linedays (/ -cld) and the proportion of positive versus negative cultures pre-guideline (july -may ) and postguideline (june -december ). we calculated the cost savings from reducing cultures. to assess patient safety, potential septic events without a corresponding positive blood culture were reviewed. data were analyzed by service (oncology and stem cell transplant). a chi-square test was used to compare rates. in stem cell transplant patients, pre vs. postguideline, there were vs. total cultures drawn/ -cld; vs. positive ( % decrease, p = . ) and vs. negative cultures/ -cld ( % decrease, p< . ). in oncology patients, pre vs. post-guideline, there were vs. total cultures drawn/ -cld; vs. positive ( % decrease, p = . ) and vs. negative cultures/ -cld ( % decrease, p< . ). the decreased positive culture rate among oncology patients may be due to decreased culture contaminants and/or the effect of a concurrent initiative to decrease clabsi in that group. there were safety concerns; however, chart review concluded that the guideline did not lead to missed infections in these patients. for the first months of the guideline, the total cost savings in blood cultures was $ , . . the implementation of our new blood culture guideline successfully led to a substantial reduction in the collection of negative cultures and a cost savings without compromising the detection of bacteremia in hospitalized pediatric patients with fever and neutropenia. background: there are various evidence-based guidelines for treatment of adult cancers, such as the nccn guidelines. previously, care was standardized for most new diagnosis pediatric cancer patients through enrollment on a clinical trial. with decreasing clinical trial availability and enrollment and few, if any, evidence-based guidelines for pediatric cancer, care standardization is challenging for pediatric cancers. objectives: to assess consistency of care, as determined by plan of treatment by diagnosis, for pediatric patients receiving chemotherapy for newly diagnosed cancer at a single center. design/method: patients with a new cancer diagnosis at a large, tertiary care pediatric oncology center in calendar year were identified through reports from the chemotherapy order entry (coe) system. reports included diagnosis (recorded through standardized options) and the plan of treatment. chart review was used to exclude patients who started treatment elsewhere and patients being treated for relapse, to clarify diagnosis if the standardized options in coe were unclear, and to clarify treatment plan if needed. data was entered and analyzed in a redcap database. specific diagnoses were clustered into higher level disease groups and the distribution of treatment plans for patients within each was determined. this project was deemed exempt from irb approval for human subject research as a qualifying quality improvement project. of the patients with a first chemotherapy order in , were excluded due to one or more reasons: stem cell transplant ( ), transfer of care ( ), relapse ( ), and other ( ). an additional patients were excluded because < patients/year/diagnosis. there was no cns tumor disease group with > patients. thus, patients with hematologic malignancies or non-cns solid tumors are the focus of this analysis. for patients with intermediate risk rhabdomyosarcoma, the plan of treatment was the standard arm of a cog protocol, arst for patients and arst for subsequent patient after protocol activation. for all other diseases including lymphoblastic leukemia/lymphoma (excluding infants), classical hodgkin lymphoma, aml (excluding trisomy and apml), stage iii/iv burkitt lymphoma/diffuse large b-cell lymphoma, posttransplant lymphoproliferative disease, wilms tumor, rhabdomyosarcoma, ewings sarcoma, osteosarcoma, neuroblastoma, and retinoblastoma, only one treatment plan per risk category was used. conclusion: this analysis demonstrates highly consistent chemotherapy treatment at a single center for patients with hematologic malignancies and non-cns solid tumors. next steps include exploring strategies to group diagnoses for cns tumors and assessing the quality of evidence supporting the treatments given. background: rapid initiation of empiric antibiotics in patients with fever and neutropenia has been shown to reduce morbidity and mortality. current practice guidelines call for the initiation of antibiotics in these patients within sixty minutes and time-to-antibiotic (tta) has been suggested as a quality-of-care measure. many institutions, including our own, face barriers to meeting this time limit. objectives: utilizing a quality improvement model, determine barriers and implement an intervention to reduce the time-to-antibiotics for pediatric febrile patients with suspected neutropenia who present to the emergency department (ed) at our institution. we have identified and implemented an intervention utilizing the plan-do-study-act model for quality improvement. a twelve-month retrospective review was conducted to evaluate the efficacy of the current practice algorithm at our large, academic tertiary-care hospital. subjects identified were pediatric oncology patients undergoing active chemotherapy who presented to the ed with febrile neutropenia. we identified two specific barriers, triage level assignments and delay in ordering antibiotics. to address these barriers, we have created a wallet sized "fever card" that patients were instructed to show upon arrive to the ed. in collaboration with the ed staff, efforts were also made to educate all pediatric staff on the use of the fever card. post-intervention data collection is currently underway and pre-and post-intervention antibiotic delivery times will be compared. the pre-intervention cohort consisted of thirty-three encounters with a mean time-to-antibiotic delivery of minutes, or seventy-five minutes greater than the accepted standard of care. only one patient received antibiotics within sixty minutes of arrival. post-intervention data collection is currently underway. since identifying two barriers to meeting the standard of care at our institution, we have implemented a quality improvement measure that empowers patient families to direct appropriate triage in the ed as well as simplifying the treatment protocol for ed providers. we expect to identify an improvement in time-to-antibiotics from the pre-intervention to the post-intervention period. background: sickle cell disease (scd) is a genetic disorder in which sickle hemoglobin (hbs) triggers multiple downstream effects, including red cell sickling, hemolysis, vaso-occlusion, and inflammation. scd, a lifelong disease initiated at birth with injury that accumulates over time, causes significant end-organ damage and clinical complications that are undertreated and associated with early death. homozygous mutation (hbss) causes the severe form of scd. individuals with scd are at increased risk of infection, stroke, and retinopathy. clinical guidelines for pediatric patients with scd recommend prophylactic penicillin use (ages - ), annual screening for stroke with transcranial doppler (tcd) imaging (ages - ), and annual ophthalmology exams to assess for retinopathy (ages ≥ ). there are limited real-world data on implementation of these nhlbi-based recommendations. objectives: to describe utilization of penicillin, tcd screening, and ophthalmology care in children with hbss disease. medicaid administrative claims databases were used to identify us patients aged - years at first indication of hbss recorded in each calendar year from to . patients were required to have medical and pharmacy benefits for the calendar year in which they were identified and for months prior to their first recorded hbss indication. prior year utilization of penicillin, tcds, and ophthalmologist visits was measured for each annual cohort. annual cohorts included - commercial (mean age . years, % female) and - medicaid (mean age . years, % female) patients with hbss disease. fewer than half of all patients had received a tcd scan in the previous year, with similar rates seen across all age groups for both payers. ophthalmologist visits increased as patients aged, and while patients aged - years had the highest proportion with an ophthalmologist visit in both payer populations, the overall implementation remained low. in contrast to the low use of tcd and ophthalmology visits, penicillin use was highest in the - year age group: > % use in any given year for both payers. conclusion: although our data demonstrated high penicillin use in the - year age group, consistent with guidelines there is an opportunity to improve implementation of other guidelines-based recommended screening. for example, tcd screening can identify children at risk of scd-related stroke in order to initiate preventive therapies. further research to understand potential barriers to proper screening and to evaluate strategies to improve awareness, adherence, and implementation of recommended screenings in children with scd is warranted. supported by global blood therapeutics. background: childhood cancer therapy has improved where there are many long-term survivors. while psychosocial difficulties in pediatric cancer survivors are recognized, the prevalence of these problems at initial survivorship presentation is unclear. objectives: to examine the prevalence of overall internalizing symptoms (e.g., depression/anxiety) in pediatric cancer survivors presenting to a survivorship clinic and to examine how this is mitigated by receiving psychological services and by evidence of parental depression/anxiety. design/method: pediatric cancer survivors attending their first visit at the reach for survivorship clinic at vanderbilt (ages - ) were included. survivors' parents ( % female) completed the child behavior checklist (cbcl), beck depression inventory-ii, and beck anxiety inventory. survivors > years completed a self-report. the wilcoxon rank-sum and pearson's test were used for univariate analyses. the effect size and % confidence intervals (ci) estimated from the multivariable linear regressions were reported. results: childhood cancer survivors a median of years old and . years off therapy were included. thirty one survivors ( %) showed at least borderline clinical internalizing problems (t score > ) on the cbcl, but only of these patients ( %) reported receiving psychological services. nine other survivors with normal t score ≤ also reported receiving psychological services. parental depressive and anxiety symptoms were correlated to the parental report of survivor overall internalizing symptoms (spearman = . , p = < . and = . , p = < . respectively), however they were not correlated to survivor selfreports. furthermore, parents with mild to severe depressive symptoms or mild to severe anxiety symptoms were more likely to rate their child as having higher overall internalizing symptoms (p = . ; p = . , respectively). multivariable linear regression showed that when adjusted for age, gender, cancer diagnosis and time off treatment, reported utilization of psychological services ( = . , % ci [ . , . ],p = . ), and parent depressive symptoms ( = . , [. , . ],p< . ) were significantly associated with child overall internalizing symptoms. in an otherwise identical alternate model substituting parental anxiety for parental depression, parental anxiety was also a significant risk factor ( = . , [. , . ], p< . ). alternatively, parent anxiety/depressive symptoms were not significantly associated with child self-report of internalizing symptoms. childhood cancer survivors have an elevated prevalence of experiencing internalizing symptoms but seldom report receiving psychological services. childhood cancer survivors' parents with anxious/depressed symptoms are more likely to rate their children as having more internalizing problems, compared to patient self-reports. ongoing longitudinal analyses will help clarify the best timing for potential interventions. background: life expectancy for adults with sickle cell disease (scd) has remained unchanged over the past years despite improvements in pediatric scd survival. at greatest risk are the adolescents and young adults (ayas) transitioning from pediatric to adult care. allen county ranks rd in scd incidence among the counties in indiana, and has board certified pediatric hematologist-oncologists. when children "age out" of the pediatric system, there are few providers knowledgeable about managing adults with scd in the region. a novel partnership between hematologists and the family medicine residency program in allen county was initiated to educate family medicine residents (fps) about scd, hydroxyurea (hu), and management of scd-related complications with the goal to increase the number of knowledgeable providers to care for adults with scd. to determine the effectiveness of online learning modules in educating fps about hu, best practices for aya scd care and transition. three online learning modules about scd (comprehensive care of ayas with scd, hu, best practices in aya transition) were developed and cme-accredited. electronic pre-and post-tests were distributed to fps with five questions for each module covering: contraception; screening tests; hu indications, dosing and monitoring; developmental milestones and scd knowledge assessments. the st vincent irb reviewed the protocol and granted a waiver of consent. results: twenty-six fps ( %) completed the pre-and posttests. over two-thirds correctly identified the clinical benefits of hu on both assessments. knowledge about the rationale for hu therapy increased after the completion of the hu module ( % correct on pre-test vs. % on post-test, p = . ). the proportion of correct responses increased for all comprehensive aya scd care post-test questions, but only the leading cause of death and the priapism-related questions reached statistical significance ( % vs. %, p = . ; % vs. %, p = . , respectively). the proportion of correct responses for of the transition-focused questions was unchanged ( % for both), while the proportion of correct post-test responses on the self-care assessment question significantly increased ( % vs. %, p = . ). after module completion, fps were able to correctly identify common scd complications and why hu is an effective treatment for individuals with scd. the best practices of transition clinic module may need modification to improve physician understanding of the intricacies in establishing and maintaining a scd transition clinic. overall, online training is effective at educating fps and could be used to increase the number of providers knowledgeable about scd care. background: survival rates for pediatric hodgkin lymphoma (hl) exceed % with contemporary therapy. studies of pediatric hl survivors treated in the s- s have shown increased risk for treatment-related chronic health conditions. risk-adapted therapy, including tailored radiotherapy, has been developed to reduce long-term morbidity while maintaining excellent survival. little is known about chronic conditions associated with contemporary therapy presenting during the first years from therapy completion (early outcomes). objectives: to analyze survival and early outcomes of pediatric hl patients treated with contemporary therapy. we conducted a retrospective review of hl patients diagnosed < years of age at our institution from - . three-year overall (os) and event-free (efs) survival were calculated with kaplan meier statistics using sas . . results of standardized screening for targeted toxicities that developed between - years from therapy completion were identified and graded per ctcae criteria. censoring occurred at date of death, years from therapy completion, or december , . data from the last collection point were used for prevalence calculations in cases with multiple evaluations. we identified patients ( % male; % non-hispanic white; mean age at diagnosis . ± . years) with a median time since therapy completion of . years (range . - . ). initial treatment included: ( %) chemotherapy only and ( %) multimodality treatment. all patients received anthracyclines (median dose mg/m ) and % received alkylating agents (median cyclophosphamide equivalent dose [ced] mg/m ). the -year os was % with an efs of % ( % chemotherapy only, % multimodality treatment; p = . ). patients with relapsed/refractory disease received salvage treatment including chemotherapy only (n = ), multimodality therapy (n = ), or multimodality treatment including stem cell transplant (autologous n = ; autologous+allogeneic n = ). no patients developed thyroid dysfunction, cardiac dysfunction, subsequent neoplasm, or male gonadal dysfunction during the study period. pulmonary dysfunction was limited to ctcae grade . anti-mullerian hormone (amh) below the normal range was found in / pubertal females who received ced ≥ mg/m compared to / females who received ced < mg/m . two of the females with low amh also had follicle stimulating hormone > iu/ml. this study is the first to evaluate early outcomes in pediatric hl survivors. the results indicate contemporary chemotherapy and a lower rate of radiotherapy utilization lead to excellent -year survival rates with minimal early toxicities. females exposed to ced ≥ mg/m are at increased risk for gonadal dysfunction and should be prioritized for fertility preservation approaches prior to initiation of cancer therapy. background: cancer is one of the leading disease-related causes of death among individuals aged < years in the united states. recent evaluations of national trends of pediatric cancer used data from before , or covered ≤ % of the us population. objectives: this study describes pediatric cancer incidence rates and trends by using the most recent and comprehensive cancer registry data available in the us. design/method: data from us cancer statistics were used to evaluate cancer incidence rates and trends among individuals aged < years during - . data were from states and covered % of the us population. we assessed trends by calculating average annual percent change (aapc) in rates using joinpoint regression. rates and trends were stratified by sex, age, race/ethnicity, us census region, county-based economic status, and county-based rural/urban classification, and cancer type, as grouped by the international classification of childhood cancer (iccc). we identified , cases of pediatric cancer during - . the overall cancer incidence rate was . per million; incidence rates were highest for leukemia ( . ), brain tumors ( . ), and lymphoma ( . ). rates were highest among males, aged - years, non-hispanic whites, the northeast us census region, the top % of counties by economic status, and metropolitan counties. the overall pediatric cancer incidence rate increased (aapc = . , % ci, . - . ) during - and contained no joinpoints. rates increased in each stratum of sex, age, race/ethnicity (except non-hispanic american indian/alaska native), region, economic status, and rural/urban classification. rates were stable for most individual cancer types, but increased for non-hodgkin lymphomas except burkitt lymphoma (iccc group ii(b), aapc = . , % ci, . - . ), central nervous system neoplasms (group iii, aapc = . , % ci, . - . ), renal tumors (group vi, aapc = . , % ci, . - . ), hepatic tumors (group vii, aapc = . , % ci, . - . ), and thyroid carcinomas (group xi(b), aapc = . , % ci, . - . ). rates of malignant melanoma decreased (group xi(d), aapc = - . , % ci, - . -- . ). this study documents increased rates of pediatric cancer during - , in each of the demographic variables examined. increased overall rates of hepatic cancer and decreased rates of melanoma are novel findings using data since . next steps in addressing changing rates could include investigation of diagnostic and reporting standards, host biologic factors, environmental exposures, or potential interventions for reducing cancer risk. increasing pediatric cancer incidence rates may necessitate changes related to treatment and survivorship care capacity. background: while childhood cancer treatment modalities have improved, the delayed effects of cancer treatment continue to compromise the quality of life in survivors. metabolic syndrome (ms) is diagnosed based on the presence of three of the following findings -obesity, dyslipidemia, hypertension and insulin resistance per the world health organization (who) criteria. the increased risk of ms among childhood cancer survivors was first reported in the 's and is known to increase the incidence of cardiovascular disease in these individuals. objectives: assess the frequency of ms in childhood cancer survivors at our institution. . we conducted a retrospective chart review on pediatric cancer survivors, - years of age, who had been treated at sri ramachandra medical institute and research foundation between august and august . patients who received at least one year of treatment with s of s chemotherapy and/or radiation and surgery were included. medical history, family history of diabetes, cardiovascular diseases, and hypercholesterolemia, tanner staging, weight for height (< y per who criteria), bmi (> y per indian academy of pediatrics iap), blood pressure (nhlbi criteria), fasting blood sugar levels and lipid profile were obtained from the charts. statistical analysis of the data was done using ibm spss statistical software (version ). results: patients were studied, . % were male. . % were under years of age, . % between - years and . % above years. leukemia survivors comprised . % of the sample and non-leukemic's were . %. . % were treated with chemotherapy alone, . % with radiotherapy and chemotherapy, and . % underwent surgery with radiotherapy and chemotherapy. hypertension was found in . % of the study group, dyslipidemia in %, impaired fasting blood glucose in . % and . % were found to be obese. % of the study group was diagnosed with ms based on who criteria. conclusion: % of our study population was found to have ms per who criteria. individual metabolic complications were detected in % of the population. acute lymphoblastic leukemia (all) survivors appeared to be at high risk in our population. ms has been known to increase cardiovascular complications in cancer survivors. a multidisciplinary team approach to management of these patients is important to closely monitor and manage the long-term complications related to ms such as type diabetes and atherosclerosis. such an approach is essential to decrease long term morbidity and mortality from ms in this vulnerable population. background: the -year survival rate for childhood cancer exceeds %. however, up to % of these children require admission to the pediatric intensive care unit (picu) within three years of diagnosis. these children account for approximately % of all picu deaths, with mortality being higher for those post-hematopoietic stem cell transplant (hsct). national guidelines recommend that providers share informa-tion regarding prognosis and treatment options within the first hours of icu admission. these prognostic goals of care conversations (pgocc) are critical to the care of children with malignancies, a subpopulation at risk for increased mortality. to determine the frequency of pgocc as well as describe differences in patient characteristics and critical care therapies by pgocc status. design/method: a retrospective cohort study was conducted using the university of michigan virtual picu system database. picu admissions lasting longer than hours for patients ages to years between july , and june , with an oncologic diagnosis and/or hsct were identified. data on pgocc, patient demographics, diagnoses, picu interventions, and outcomes were recorded and compared between children with pgocc and those without using chi square test for categorical variables and kruskal-wallis test for continuous data. of picu admissions, % were male; the mean age was . years. the leading diagnoses were acute lymphoblastic leukemia ( %), acute myeloid leukemia ( %), lymphoma ( %), neuroblastoma ( %), and brain tumors ( %), and % of patients were post-hsct. pgocc was documented in ( %) patients. in comparison with patients who did not have a pgocc, children with a pgocc were more likely to be readmitted to the picu ( % vs. %, p < . ) and more likely to have had relapse of disease ( % vs. %, p< . ). patients with a pgocc had higher severity of illness scores (p = . ), higher use of non-invasive ( . % vs. . %, p = . ) and invasive conventional ventilation ( . % vs. . %, p< . ), and high frequency ventilation ( . % vs. . %, p < . ). also, patients with pgocc were more likely to receive continuous renal replacement therapy ( . % vs. . %, p< . ), arterial catheterization ( . % vs. . %, p< . ), and cardiopulmonary resuscitation ( . % vs. . %, p< . ). in only in critically ill children with hematologic-oncologic disease is pgocc held. children with pgocc were sicker and received more critical care interventions. future research is needed to evaluate the content of pgocc. background: central nervous system (cns) tumors and autism spectrum disorder (asd) represent significant disease cohorts in the pediatric population. asd diagnoses in children have a prevalence of %, in every children in the united states. additionally, more than , cns tumors are reported in children age to years in the united states with brain tumors being the most common solid tumor and the leading cause of death among all childhood cancers. the genetic etiology of autism and cns tumors is complex. specific gene alterations present in certain cancers have similarly been described and suspected to play a role in asd subtypes. targeted therapy panels, like foundation one (fo), have been beneficial in guiding treatment for some cancers based on distinct gene alterations. given the genetic overlap, the potential for therapeutic benefit and crossover from such actionable gene target panels merit further exploration in asd and cns tumors. we aim to identify and describe genetic alterations with known actionable targets in cancer therapy from fo as potential diagnostic, therapeutic and research targets for neurodevelopmental diseases. we plan to discuss the common genetic alterations between our cancers and neurodevelopmental diseases described in the literature. fo data was extracted and compared to the literature. each reported gene alteration from fo plus the keywords "autism", "psych" were used on pubmed to search for a suspected association if any with a neurodevelopmental disorder. results: twenty-one patients representing a cohort of six unique (astrocytoma-five, ependymoma-six, gbm-four, glioma-three, nerve sheath tumor-one, etmr-two) cns tumors were investigated. fo produced eighty total with sixty unique gene alterations. thirty-one ( %) of these yielded at least one published, suspected association to a neurodevelopmental disorder. the most common gene alterations were tp -four, cdkn a/b-five and braf-four. the main functional categories were cellular: proliferation, structure, differentiation and degradation; chromatin modeling; histone transcriptional modification; dna methylation and repair; strna; and neural signaling. sixty unique gene alterations were found in our cns tumor set using foundation one. thirty-one ( %) of these discrete alterations paired with at least one description in the literature as having been similarly altered in an asd subtype. many of these alterations have actionable targeted therapies presented through foundation one for our cns tumors and may be a relevant guide in the future of targeted therapy and research in asd subtypes. monoclonal antibody therapy usage is associated with significantly improved survival in b-cell nhl aya patients. although the usage has increased in the aya population from to , the magnitude of the increase is low. factors that affect the use of mab include race and insurance s of s type. further research is warranted to identify why privately insured patients are less likely to receive these drugs. background: prevention of chemotherapy-induced nausea and vomiting (cinv) remains a challenge despite advances in pharmacotherapy and the development of cinv clinical practice guidelines by the pediatric oncology group of ontario (pogo) that have been endorsed by the children's oncology group. achieving control of cinv in pediatrics further is complicated by the difficulty young children have vocalizing their symptoms. use of a validated nausea-assessment tool in conjunction with improved adherence to evidence-based guidelines may result in better quantification of symptoms and reduction of both nausea severity and vomiting frequency for pediatric patients undergoing chemotherapy. the pediatric nausea assessment tool (penat) has been validated for children ages - , and its integration into clinical practice may help optimize cinv control. objectives: this single-institution study sought to improve control of cinv in patients admitted for chemotherapy by standardizing the antiemetic regimens prescribed by all providers according to an institutional cinv algorithm developed from the pogo guidelines. we hypothesized that treatment using a standardized guideline would improve cinv control in patients admitted for chemotherapy. a baseline cohort of admissions for chemotherapy completed penat assessments and cinv diaries prior to receiving chemotherapy, four times daily during each admission, and daily for days following completion of chemotherapy from may , to january , . providers then were provided an institutional cinv treatment algorithm based on the pogo guidelines and received education at departmental meetings on appropriate implementation of this algorithm. a second cohort of admissions completed penat assessments and cinv diaries in a similar fashion from july , to december , . results: complete control of vomiting markedly improved following cinv guideline implementation ( % vs %, p <. ) with treatment failure also significantly reduced ( % vs %, p <. ). after controlling for the degree of emetogenicity of chemotherapy received, a patient was . times more likely to vomit prior to guideline implementation (or . , ci . - . ). there was no difference in nausea control, even after adjusting for the emetogenicity of chemotherapy. conclusion: control of chemotherapy-induced vomiting (civ) improved following widespread implementation of an institutional cinv treatment algorithm at a single institution. the severity of nausea reported remained unchanged which may reflect the difficulty of assessing nausea or an inadequate sample size. future research may focus on cinv treatment management through the use of guidelines specifically for breakthrough cinv and delayed cinv. background: aspho's professional development committee (pdc) recognized pediatric hematologists-oncologists (phos) serving in the united states (us) military have unique professional development needs that may not be addressed by aspho or a similar professional society. these individuals may also encounter challenges when transitioning to a civilian career. however, barriers to professional development have not been systematically characterized. the objectives were to characterize the number of phos with current or prior military service (mphos) and to identify any unmet professional development needs. design/method: a working group consisting of pdc members and both senior and early career mphos was formed. initial comments were solicited by email from known mphos regarding potential gaps in professional development and interest in working with aspho to improve support of mphos. a survey was developed and piloted with four members of the advisory group, questions were revised based on their feedback, and a final version was distributed via the aspho website and online community forum. targeted emails were sent to mphos identified through aspho and military databases. eligibility to complete the survey included ) completion of a fellowship in pediatric hematologyoncology, and ) current or prior service as an active duty military provider. quantitative and qualitative information were collected, including demographic data and perceived barriers to professional development. responses were summarized using descriptive statistics. results: sixty-five mphos were identified and surveys were completed for a % response rate. respondents were engaged in a variety of professional activities; % were male, % were serving active duty commitments, and % felt there were professional development gaps. areas of concern were categorized into nine themes with the most concerning being ) limited civilian knowledge of mpho practices ( % of participants), ) inability to attend professional society meetings ( %), and possibility of deployment ( %). participants expressed a desire for educational products to meet their specific needs and for networking opportunities with civilian colleagues. qualitative analyses identified concerns about low patient numbers and practice size. a subset of mphos perceive significant gaps in professional development. additional research is needed to better define areas for intervention, but many of the concerns align with those of similarly sized civilian programs and may be addressed through professional society networking opportunities, such as an aspho special interest group. background: infertility is an established cause of distress and has a negative impact on quality of life among childhood cancer survivors. the american society of clinical oncology has established guidelines on fertility counseling for individuals of reproductive age diagnosed with cancer, with the goal of improving reproductive and psychosocial outcomes. studies have shown that instituting a fertility team that can provide counseling and discuss fertility preservation (fp) options results in improved patient satisfaction in patients with cancer. objectives: the goal of this study was to examine predictors of referrals to the multidisciplinary fertility team, and documented fp interventions among these patients. design/method: an irb-approved retrospective medical record review was performed at a large pediatric academic center. all patients with new cancer diagnoses receiving chemotherapy were included from january (when the fertility team was established) to present. a standardized abstraction form was used to collect information about: age at diagnosis, gender, cancer type, whether a fertility consult was placed, and documented fp interventions. data were summarized descriptively and comparisons were made using nonparametric statistical methods. results: patients met inclusion criteria, of which ( %) were male. cancer types were as follows: leukemia/lymphoma, cns tumors, sarcomas, embryonal tumors, and langerhan's cell histiocytosis (lch). the mean age was . years, (range < - years). overall, % of all patients had a consultation with the fertility team. patients were significantly less likely to have a fertility consult if they were younger (p< . ). further, there were differences in the consultation rate between diagnoses, with % of sarcoma patients completing a consult, compared to % of those with cns tumors, % of those with embryonal tumor, % of those with leukemia/lymphoma and none of the patients with lch. our findings show that many children, adolescents, and young adults newly diagnosed with cancer are still not receiving fertility counseling despite: ) an expanding body of literature supporting the need to provide this counseling, ) guidelines published by several organizations recommending discussions about infertility risk and fp options, and ) presence of a multidisciplinary fertility team. specific strategies need to be developed to improve access for younger children, and for disease groups in whom fertility consults are underutilized, such as youth with cns tumors, embryonal tumors, and leukemia/lymphoma. background: socioeconomic status (ses) has on impact on overall survival in the pediatric oncology population. unfortunately, data are insufficiently detailed to explain the mechanism behind this phenomenon. how parents handle the health management demands placed on them at the time of a child's cancer diagnosis may represent a point of differentiation in health outcomes. objectives: determine the association between socioeconomic factors, cancer literacy, and parents' understanding of home emergency management and their responses to instances of pain, nausea, and fever. in a prospective observational study of parents whose children were newly diagnosed with cancer, we obtained demographic information and, using a validated instrument, (dumenci, ) we evaluated cancer literacy. we tested understanding of the education parents received about home emergency management with a -item multiple-choice vignette-based questionnaire focused on actions needed in home scenarios. we then followed parents' actual behavior through periodic phone calls assessing instances of nausea, pain, and fever and their responses to these episodes. results: preliminary analysis of participants showed an average score of on the -item parental understanding questionnaire (range - ). variables associated with increased score were college-level education by . points ( % ci [. to . ]), private insurance by . points [. to . ] and adequate cancer literacy by . points [. to . ]. actual behavior reported by families indicated that married parents and those with income above $ , were less likely to treat instances of pain by % ( % ci [ to ]) and % [ . to ], respectively. white parents, those with college-level education, and those with adequate cancer literacy were less likely to treat instances of nausea by % [ to ], % [ to ] and % [ to ], respectively. no associations were found between socioeconomic markers and parental responses to instances of fever. our findings suggest an association between demographic and socioeconomic markers and improved parental understanding of home emergency management. paradoxically, the same markers show a decrease in treatment response to pain and nausea. larger prospective studies are needed to link this behavior pattern to health outcomes, and help inform the extent of ses impact on home emergency management. emory university/children's heathcare of atlanta, atlanta, georgia, united states background: cardiovascular disease is a leading cause of morbidity and mortality in childhood cancer survivors (ccs). previous research showed wide practice variation in referral patterns to cardiology from the survivor clinic and in recommendations from cardiologists about the need for further testing or exercise restrictions. to develop a cardio-oncology algorithm in order to standardize referrals to cardiology and provide guidelines for cardiologists evaluating pediatric ccs. design/method: survivorship and cardiology experts developed a weighted scoring system for pediatric ccs who received cardiotoxic therapy based on time since treatment and risk factors identified by the children's oncology group (cog) and american heart association (aha). the cardiooncology algorithm assigned a score of - . the score range was categorized to guide cardiology referral: screening echo only ( - ), consider cardiology referral ( - ), recommend cardiology referral ( - ), and regular cardiology follow-up (≥ ). the algorithm also provides recommendations to cardiologists for screening and exercise modifications based on the score. after establishment of the algorithm, a convenience sample of institutional survivor clinic patient charts were retrospectively reviewed from the first month of each quarter from april -march to validate the algorithm, evaluate referral patterns to cardiology, and assess cardiology recommendations. the retrospective chart review evaluated patients ( % male; % non-hispanic white; % leukemia survivors; median age at diagnosis . years [range - . ]; median time off-therapy . years [range . - . ]). patients ( %) received anthracyclines (median dose mg/m , range - ) and ( %) received cardiac radiation. assigned cardio-oncology scores resulted in: % echo only, % consider cardiology referral, % recommend cardiology referral, and % regular cardiology followup. when evaluating detection rates of late effects by cardiooncology score, survivors ( %) had an abnormal echo: / echo only, / consider referral, / recommend referral, and / regular cardiology follow-up. assessing referral patterns prior to initiation of the algorithm revealed forty-two survivors ( %) referred to cardiology: / echo only, / consider referral, / recommend referral, and / regular cardiology follow-up. of the patients seen by a cardiologist at our institution, had further diagnostic testing ordered (i.e., stress test) and received exercise restrictions. a cardio-oncology algorithm and guidelines will standardize cardiac care for survivors by assigning a score to guide referral and cardiology practice after referral. prospective clinical use has begun and review will occur in one year to determine changes in detection rates of cardiac late effects, referrals, and recommendations from cardiologists. oregon health and science university, portland, oregon, united states background: delirium affects - % of patients (pts) in pediatric intensive care units (picu) and is associated with increased length of stay, decreased attention in school, and post-traumatic stress disorder. the diagnostic and statistical manual of mental disorders (dsm v) defines delirium as a "disturbance of consciousness […] with reduced ability to focus, sustain or shift attention" due to an underlying medical condition. despite the medical complexity of the hospitalized pho population, there are no published prospective studies looking at delirium in these pts. hypothesizing that delirium is under recognized in the pho population, we designed a year-long prospective study using a validated screening tool to determine the frequency of delirium in hospitalized pho pts and to identify associated clinical factors. design/method: baseline frequency of pts with symptoms suggestive of delirium was determined through retrospective chart review using a data mining program of electronic medical records (emr). for the prospective study, pho and picu nurses were trained to use the cornell assessment for pediatric delirium and to record scores within the emr on all pho pts once every -hour shift. predetermined demographic and clinical variables were entered daily into a red-cap database on all hospitalized pho pts. results: baseline frequency of delirium, without active screening, was determined to be . % of hospitalized pho pts. in the first months of the prospective study, consecutive admissions occurred among unique pho pts: oncology, hematology, and stem cell transplant pts. pts had at least positive delirium screen, for a prevalence per admission of . %. statistically significant variables associated with delirium, at p < . by univariate logistical regression, included prolonged length of stay, pt location (picu vs pho unit), and fever. adjusting for length of stay, administration of benzodiazepines and opiates were also significantly associated with delirium, p = . and . , respectively. on average, nurses completed delirium screening in % of each pts' -hour shifts. study accrual ends in jan and final data analyses will be reported in the abstract presentation. conclusion: delirium does occur in the pho hospitalized population and screening by trained nursing staff is feasible. pts at highest risk appear to be pts with prolonged hospital stays, picu admissions, or frequent use of benzodiazepines/opioids. routine screening should improve our recognition of delirium and allow us to promptly intervene, or prevent delirium in an effort to avoid potential acute and long term consequences. background: with high survival rates for children and adolescents with hodgkin lymphoma (hl), treatment regimens are now designed to maximize cure while decreasing risk of long-term health outcomes associated with chemotherapy and radiation therapy. within contemporary treatment regimens, the comparison of toxicities experienced by patients receiving chemotherapy plus radiotherapy (crt) versus only chemotherapy (co) has not been studied extensively. objectives: this study examines select self-reported adverse health outcomes in survivors of contemporarily-treated pediatric hl to better understand the balance between efficacy and toxicity associated with chemotherapy and radiation therapy. (cog) ahod that evaluated a response-based treatment paradigm in pediatric hl. patient who received initial chemotherapy were randomized based on early response to continued chemotherapy, chemotherapy plus radiotherapy or augmented chemotherapy plus radiotherapy. patients completed self-report questionnaires on health problems at , , , and years following therapy. we examined selected patient-reported pulmonary, gastrointestinal (gi), cardiac and endocrine outcomes. kaplan-meier survival curves were used to determine probability of survival without the selected adverse health outcome. log-rank tests were used to compare the co versus the crt group. results: a total of , enrolled patients, patients in the co group and patients in the crt group, completed , questionnaires at a median of . years after s of s completion of therapy (q , q : . , . ) which were analyzed. the cumulative -year incidence of endocrine dysfunction was significantly greater in the crt group versus those in the co group ( % versus %; p< . ), driven by the incidence of hypothyroidism ( % versus %; p< . ). there were no significant differences in cardiac ( % versus %; p = . ), pulmonary ( % versus % p = . ), and gastrointestinal dysfunction ( % versus %; p = . ) between the co and crt patients. conclusion: this study demonstrates low cumulative incidence overall of organ dysfunction early post completion of contemporary therapy for hl. the addition of radiation therapy significantly increased risk for hypothyroidism, but with no higher risk noted for cardiac, pulmonary or gi dysfunction. limitations include self-report status, potential selection bias, and relatively short latency period following end of therapy. longer follow-up is needed to determine more delayed risks for organ dysfunction in order to best define the balance between therapeutic efficacy and long-term adverse health outcomes related to chemotherapy and/or radiation therapy. background: identification of an organism via bronchoalveolar lavage (bal) or respiratory tract biopsy (rtb) has historically been considered the gold standard for diagnosis of invasive fungal infection (ifi); however, data previously published by our group showed that these procedures infrequently lead to a change in management in children with an oncological diagnosis or undergoing hematopoietic stem cell transplant (hsct). there is also a paucity of data on the cost of ifi in this population. to compare the costs of work-up and management of pulmonary ifi diagnosed based on ct scan alone versus ct scan or chest x-ray prompting a bal or rtb. design/method: we collected cost data on patients at ann & robert h. lurie children's hospital of chicago undergoing chemotherapy or within months of hsct who were suspected of having an ifi between and . in order to include sufficient time to account for post-procedure compli-cations but avoid including costs unrelated to ifi, data were included for days from the day of their diagnostic scan or procedure. cost data was available for of the patients previously studied. thirty-six of these patients were diagnosed with suspected ifi based on ct only and patients underwent bal or rtb. when evaluating specific costs, inpatient beds costs were higher in the bal and rtb group (median $ , versus $ , , p = . ), yet there was only a trend towards higher costs for antifungal agents (median $ , versus $ , , p = . ) and respiratory support (median $ versus $ , p = . ). many of the initial ct scans were not captured in the -day evaluation period for the bal or rtb group based on the study design; however, even when accounting for ct scans up to a week prior these procedures, the total cost of ct scans was higher in the ct only group (median $ versus $ , p = . ), as they had more scans. despite this, total costs were significantly higher for patients who underwent bal or rtb versus ct scan only (median $ , versus $ , , p < . ). combined with our previous data that bal and rtb infrequently leads to a change in management in children with an oncological diagnosis or undergoing hsct suspected to have an ifi, the significantly higher costs associated with these procedures makes these invasive diagnostic techniques even less desirable. batra, pediatr blood cancer, . background: while infants > months of age with acute lymphoblastic leukemia (all) have a poor prognosis, infants with acute myeloid leukemia (aml) fare better despite more intensive therapy. there are limited data on this difference, particularly differences in supportive care requirements during induction therapy for infants. objectives: to compare induction mortality and resource utilization in infants relative to non-infants aged < years, separately for all and aml. design/method: we used previously established cohorts of children treated for new onset all or aml at children's hospitals in the us contributing to the pediatric health information system. patients with down syndrome were excluded. follow-up started on the first day of induction chemotherapy and continued until the earliest of: days after commencement of chemotherapy, start of the subsequent course, or death. high acuity of presentation, defined as icu requirements involving or more organ systems within the first hours following initial admission were compared using log binomial regression. -day inpatient mortality was compared using cox regression. resource utilization rates (days of use per inpatient days) were compared using poisson regression. results: a total of all ( infants, non-infants) and aml ( infants, non-infants) were included in the analyses. infants were more likely to present with high acuity compared to non-infants for both all ( % and %, rr = . , % ci: . , . ; p< . ) and aml ( % vs %; rr = . , % ci: . , . ; p = . ). infants with all had higher inpatient mortality compared to non-infants even after accounting for differences in acuity of presentation ( . % vs . %, adjusted hr = . % ci: . , . ; p = . ). in contrast, inpatient mortality was more similar for infants and noninfants with aml ( . % vs . %, adjusted hr = . % ci: . , . ; p = . ) and comparable to rates among infants with all. infants with all and aml had higher rates of utilization of fresh frozen plasma, cryoprecipitate, diuretics, supplemental oxygen, and ventilation relative to non-infants. infants with all also had higher rates of total parenteral nutrition, ecmo, and patient controlled analgesics compared to noninfants. infants with all experienced significantly higher induction mortality compared to noninfants, a difference not entirely explained by acuity at presentation. differences in ru among infants may reflect higher presentation acuity and greater treatment related toxicity. further work is needed to elucidate the contribution of treatment related toxicity to early mortality in infants with all. background: fever in a child with cancer is a medical emergency due to the significant risk of a serious bacterial infection. many attempts have been made to risk stratify these patients. the respiratory pathogen panel (rpp) is a panel of polymerase chain reaction tests that identify seventeen common respiratory viruses and three bacterial infections. samples are taken via nasopharyngeal swab. rpps are frequently sent, but we do not have data to determine whether a positive result can lead to stratification to a lower risk of bacterial infection. ( ) to determine the epidemiology of respiratory virus-associated fever in pediatric oncology patients ( ) to determine whether a positive rpp is associated with reduced risk of bacteremia in this population. this was a single-center, retrospective cohort study. we identified and reviewed the medical records of all pediatric oncology patients seen in our emergency department (ed) with fever from the introduction of the rpp in april to september , . we reviewed the results of blood cultures, rpp, chest radiographs, and discharge summaries to identify sources of infection. we also identified the patients' cancer diagnosis, age, absolute neutrophil count (anc), and absolute lymphocyte count (alc). results: positive rpps were found among pediatric oncology patients who presented to the ed with fever. the most common positive rpp findings were rhinovirus/enterovirus (rev) ( %), parainfluenza ( %), influenza ( %), coronavirus ( %), and polyviral ( %). among patients with a positive rpp, % had bacteremia compared to % bacteremia among all pediatric oncology patients with fever (or . [ . - . ], p . ). all cases of bacteremia were associated with rev. there was no bacteremia identified in patients with rpps positive for other viruses (or . [ . - . ], p . ). rev positivity did not confer a lower risk of bacteremia than rpp negative patients ], p . ). anc (p = . ) and alc (p = . ) less than , and number of patients with severe neutropenia (p = . ) were not statistically different between the rev and non-rev positive rpp groups. rpps positive for viruses other than rev reduced the likelihood of bacteremia in febrile pediatric oncology patients in the ed setting. patients with bacteremia may have concurrent infection with rev. a larger study is warranted to determine if positive rpp results can inform clinical management of a child with febrile neutropenia. emily mueller, anneli cochrane, seethal jacob, aaron carroll s of s background: the usage of mobile health (mhealth), which refers to the application of mobile or wireless communication technologies to health and healthcare, has grown exponentially in recent years. mhealth tools have been used by caregivers of other vulnerable populations, but little has been focused on caregivers of children with cancer. objectives: to conduct a survey to understand the mobile technology usage, barriers, and desired mhealth tools by caregivers of children with cancer. we conducted a mailed cross-sectional paper survey of caregivers of all children who were diagnosed with cancer at riley hospital for children between june, and june, . the survey contained questions, both fixed and open-ended, in both english and spanish. up to three rounds of surveys were sent to those who did not respond. of the respondents, they were primarily parents ( . %), median age was . years (range - ), and most were white ( . %) and non-hispanic/latino ( . %). the top three annual household income brackets included $ , to $ , ( . %), $ , to $ , ( . %) and under $ , ( . %). the majority had an education: . % college graduates, % graduate degree, and . % high school education or ged. nearly all respondents owned a smart phone ( . %) and . % owned a tablet. the majority used an ios operating system ( . %), while . % reported use of a device with an android operating system. all caregivers reported use of at least one mobile website/app regularly for their personal use. while . % of respondents reported no barriers to mobile technology use, the top barrier selected was "data limitations" ( . %). overall, . % wanted at least one medical managementrelated website/app: medical knowledge ( . %), healthcare symptom tracking/management ( . %), and medication reminders ( %). healthcare system-related desires were high, as . % wanted access to their child's medical record and . % wanted a website/app to facilitate better communication with medical providers. there were no significant associations between socioeconomic status (income or education) with barriers or types of websites/apps desired by caregivers. since the vast majority of caregivers use mobile technology with minimal barriers, future research should focus on designing an mhealth tool to address the medical management needs by caregivers of children with cancer. by supporting caregivers through this type of mhealth tool, it could positively impact patient clinical outcomes through greater adherence to medications and treatment protocols. background: in children with fever and neutropenia, early initiation of targeted antibiotic therapy improves outcomes, yet there are no standards for choice of empiric antibiotics. in our institution implemented an early empiric ceftriaxone (eec) protocol to reduce time to antibiotic administration in febrile hematology-oncology patients who are potentially neutropenic when the absolute neutrophil count is not yet know. ceftriaxone is given immediately after obtaining blood for culture and lab studies. in patients found to be neutropenic, ceftriaxone is discontinued and cefepime is initiated. the purpose of this retrospective study was to evaluate our eec protocol in neutropenic patients by assessing ceftriaxone sensitivity of positive blood cultures and comparing rates of adverse outcomes with a cohort of patients treated prior to implementation of the protocol. we are now conducting a prospective study to more thoroughly investigate antibiotic sensitivities of organisms isolated from blood cultures of neutropenic patients. design/method: hematology-oncology patients with at least one positive blood culture between january and december were identified. patient demographics, neutrophil count, antibiotic treatment, isolated organisms and sensitivities, and adverse outcomes (increased respiratory support, hypotension requiring intervention, and icu admission) were obtained by retrospective chart review. fisher exact test was used to compare dichotomous variables between patient groups. we are now prospectively identifying febrile neutropenic patients with positive blood cultures and performing antibiotic sensitivity testing to several antibiotics commonly used as empiric therapy for febrile neutropenia. results: retrospectively, we identified neutropenic patients with a total of bacterial isolates from blood cultures. of organisms isolated, were tested for sensitivity to ceftriaxone and ( %) were not sensitive, / ( %) of gram-positive cultures and / ( %) of gram-negative cultures. ten of ( %) eec patients had an adverse outcome versus / ( %) of non-eec patients (p = . ). notably, % of eec patients required icu admission versus % of non-eec patients (p = . ). thus far our data obtained prospectively is revealing similar rates of ceftriaxone resistance with / cultures not sensitive to ceftriaxone ( %, ci . %- . %). in our retrospective study, no statistically significant difference was seen in overall adverse outcome rate between the two cohorts, though icu admission rates were significantly higher in eec patients. ceftriaxone resistance rates were high in tested isolates, which is further supported by preliminary data from our ongoing prospective study. given these data, eec may not be effective at improving outcomes in febrile neutropenic pediatric hematology-oncology patients. background: approximately in children diagnosed with cancer will die of their disease, despite advances in treatment. results: two focus groups of six parents each met in june . the parents were predominantly female ( female, male) and had lost their children an average of . years prior (range - . years). two parents were in the same family. nearly all patients were offered palliative care ( / ), all were offered hospice and most died at home ( at home, in the icu). parent discussion uncovered six broad themes: beneficial provider qualities, optimal communication, helpful systematic supports, struggles to feel like a good parent, struggles with a loss of control and unmet needs. parents appreciated providers who were consistent, reliable and honest. parents desired communication that was sensitive to the needs of the patient and family with a balance of hope and realism. parents appreciated the tangible supports pro-vided by social work and the emotional support of child life both for the patient and their siblings. some parents struggled to define and advocate for their child's quality of life, especially when it led to disagreeing with the medical team. several parents expressed frustration with unfamiliar caregivers in the hospital, especially trainees. they expressed a strong desire for more anticipatory guidance about the end of life including how to discuss it with their children. they also wished for a cancer-specific support group for bereaved parents. conclusion: bereaved parents of pediatric oncology patients in our focus groups appreciated consistent, reliable providers who communicated with a balance of realism and hope. they appreciated the tangible and emotional support they received and wanted more anticipatory guidance at the end of their child's life. these results can help guide clinical care, especially in communities without strong palliative care support. further research is needed to develop interventions to improve end of life care. background: clinical trials involving human subjects depend on informed consent (ic) to ensure ethical protections for participants. parents of children with cancer often lack full understanding of the basic elements of ic for clinical trials. additionally, the stress of their child's cancer diagnosis may affect their decision-making capabilities. this is especially problematic as these children rely on parents to fully comprehend clinical trials and weigh their benefits and risks. physician communication is critical for effective family-centered care. the acgme mandates that training programs teach and assess trainees' communication skills. however, there are currently no published curricula aimed at training pediatric hematology/oncology fellows to deliver ic effectively for cancer clinical trials. to develop and pilot-test a simulation-based curriculum to enhance communication skills of pediatric s of s hematology/oncology fellows in the delivery of ic for cancer clinical trials. we developed, tested, and implemented the curriculum from to in two phases. in phase- , we reviewed literature on simulation-based curricula and completed a needs assessment to create a clinical scenario and full curriculum using standardized patients. using miller's pyramid model, fellows' assessments included: immediate de-brief, surveys to assess pre/post confidence and knowledge of the basic ic elements ("knows" and "knows how"), and -degree summative assessments compiled from fellow self-assessments, faculty, and standardized patients ("shows how"). after initial testing and refinements done with fellow, in phase- , we implemented the curriculum with our fellows. likert scale ( strongly disagree- strongly agree) and basic p values are reported. results: fellows gave high mean ratings for training relevance ( . ) and standardized patients' preparedness ( ). almost all ( . ) reported they have used the knowledge gained in their clinical practice. increase in self-reported confidence (pre/post) was noted in all domains: general -describing possible benefits of the clinical trial . / vs. . / (p = . ), risks and potential side effects . / vs. . / (p = . ), and explaining alternatives . / vs. . / (p = . ); research -discussing purpose of the clinical trial . / vs. . / (p = . ), and randomization . / vs. . / (p = . ); and family-centered -addressing emotions during ic . / vs. . / (p = . ), and delivering bad news . / vs. . / (p = . ). summative evaluation mean ratings for all fellows were . (range . - . ). our novel simulated-based ic curriculum, significantly increased fellows' self-reported confidence and skills during ic delivery. importantly, our ic curriculum addressed not just research-related content but also management of parental emotional needs during the ic discussion. next phase includes kirkpatrick model program evaluation and dissemination across other training programs in our institution. national kaohsiung normal university, kaohsiung, taiwan, province of china background: taiwan's childhood cancer foundation reported in that the -year survival rate of childhood cancer was %. as a result, many childhood cancer survivors were back in school after treatment. however, childhood cancer survivors' educational outcomes suffered because of their long-term absence from school and late effects of cancer and cancer treatment. a few school reentry protocols have been developed by the nursing professionals in taiwan to facilitate students' return to school but remained experimental in nature and hardly accessible. parents, students, and teachers were left to their own devices to make individual school reentry plans. objectives: this study aimed to examine and uncover the commonalities among three middle school students' successful school reentry experiences from their teachers' perspectives and to analyze the factors contributing to their success. design/method: this is a qualitative interview study. indepth semi-structured interviews were conducted with three middle school teachers in december about their perceptions, observations, and experiences working with adolescent childhood cancer survivors. the students were two boys with leukemia and one girl with bone cancer. they were diagnosed in the first year of middle school when they were - years old and returned to school for the third and the final year. these students met the following criteria for successful school reentry: regular school attendance, average/above average academic performance, friendship maintenance, and high school diploma. the theme -bring the class to the hospital was found to be the key to the adolescents' successful return to school. without a prescribed school reentry protocol and in the face of limited bedside education services, the homeroom teachers, as links between school, home, and hospital, brought the class to their hospitalized students. they doubled as bedside teachers conducting lessons at the hospital or students' homes, became friends with the parents, witnessed firsthand the students' pain and triumph during treatment, brought the students back to school for visits and celebrations, delivered the classmates' wishes and news to the students, encouraged and welcomed classmates' visits to the hospital, and, together with parents and other teachers, developed flexible school reentry schedules for the students. this on-going study demonstrated the critical roles and functions of homeroom teachers in successfully bringing the students back to school during and/or after cancer treatment. further analysis will be focused on how and why these three homeroom teachers were able to carry out this unexpected task on top of their already full workload. jennifer kesselheim, shicheng weng, victoria allen, collaborative group fellowship program directors dana-farber/boston children's cancer and blood disorders center, boston, massachusetts, united states background: a novel, -module, case-based curriculum entitled "humanism and professionalism for pediatric hematology-oncology" (hp-pho) aims to foster pho fellows' reflection on grief and loss, competing demands of fellowship, difficult relationships with patients and families, and physician well-being and burnout. in small group facilitated sessions, fellows work to identify coping strategies and explore how the challenges of fellowship influence both their own doctoring and the patient experience. objectives: to administer the hp-pho curriculum in a prospective, cluster-randomized trial, measuring whether exposure to this educational intervention, compared to standard conditions, fosters humanism and professionalism and improves satisfaction with training. design/method: pho fellowship programs (n = ) were cluster-randomized to deliver usual training in humanism and professionalism (control) or the novel curriculum (intervention) during the - academic year. the primary outcome measure was the pediatric hematology-oncology self-assessment in humanism (phosah). secondary measures included a -point satisfaction scale, the maslach burnout inventory (mbi), the patient-provider orientation scale, and the empowerment at work scale. participating fellows were pre-tested in summer and post-tested in spring . a change score was calculated for each study instrument. we compared each outcome between arms using mixed effect models adjusted for pre-test score as a fixed effect and site as a random effect. results: randomization yielded intervention and control fellows. the two arms did not significantly differ in distribution of fellow age, gender, or post-graduate year. the intervention sites successfully administered of ( %) modules. change scores on the phosah were not significantly different between the control and intervention arms (adjusted mean difference = . ; % confidence interval [ci] - . , . ; p = . ). compared to the control arm, fellows' exposed to the curriculum gave significantly higher ratings on several items within the satisfaction scale including satisfaction with their training on "physician burnout" (adjusted mean difference = . ; % ci . , . ; p< . ), "physician depression" (adjusted mean difference = . ; % ci . , . ; p< . ), "balancing professional duties and personal life" (adjusted mean difference = . ; % ci . , . ; p = . ), and "humanism overall" (adjusted mean difference = . ; % ci . , . ; p = . ). change scores on other secondary measures were not significantly different between study arms. conclusion: exposure to the hp-pho curriculum did not alter fellows' self-assessed humanism and professionalism. however, the curriculum proved feasible to administer and intervention fellows expressed higher levels of satisfaction in their humanism training, indicating the curriculum's positive impact both for fellows and their learning environment. background: recent work has documented significant levels of unmet needs among adolescents and young adults with cancer, particularly psychosocial challenges during the transition to adulthood, (e.g., abrupt disruption to school and social life, and social isolation). given that adolescents and young adults drive mobile app use, a mobile-phone may be an ideal way to deliver a psychosocial intervention to adolescents and young adults with cancer. to use a patient-centered approach to inform a mobile-based mindfulness and social support intervention for adolescent and young adult patients with cancer. design/method: participants were ten aya with sarcoma ( % female; % adolescents); parents of the five adolescents, and six healthcare providers (n = ). formative research involved three steps: ( ) in-depth interviews were conducted with ten aya with sarcoma; parents of the five adolescents, and six healthcare providers (n = ). ( ) adaptations were made to an existing mindfulness app which offers a program for youth. modifications included creating a -week "mindfulness for resilience in illness" program, with relaxation exercises, and the addition of videos featuring two sarcoma survivors as program hosts. content was informed by the mindfulness curriculum for adolescents, learning to breathe. ( ) a private facebook usability group was organized to (i) elicit beliefs about the mindfulness app and potential future enhancements, and (ii) promote social support. results of the in-depth interviews revealed themes around adolescents' functioning and coping, including body image concerns; recurrence-related anxiety; anger over loss; and being overwhelmed by medical information. themes from the interviews were incorporated into a demonstration version of the mobile app. a patient-centered approach is widely recommended in the development of mobile-based health behavior change interventions and may be a useful way to inform development of a mobile-based mindfulness and social support intervention for adolescents and young adults with cancer. background: medical trainees consistently report suboptimal instruction and poor self-confidence in communication skills. despite these deficits, few training programs provide comprehensive pediatric-specific communication education, particularly in the provision of "bad news." an in-depth survey to examine the historical experience and communication needs of pediatric fellows was conducted at a large academic pediatric center as the first step towards the development of a comprehensive communication curriculum. to determine the previous educational and clinical experiences of pediatric subspecialty fellows, assess their levels of comfort in the context of various communication topics, and query potential modalities and topics for future communication training. design/method: the needs assessment survey was developed using previously developed and validated questions and review of the literature. the survey was reviewed by internal and external pediatric oncology and palliative experts and pre-tested with a subset of trainees to enhance content validity. results: thirty-two out of a total of fellows completed the survey ( % completion rate), of which % were pediatric hematology-oncology or subspecialty fellows. most fellows had participated in previous teaching sessions ( %), including those involving role play or simulation ( %). however, few fellows had received feedback from senior clinicians on their communication skills ( % of fellows had received feedback ≤ times). on a scale of -x, with indicating "not well prepared," the mean score for of communication items was < . fellows felt least prepared to lead discussions around informed consent for experimental therapies, end of life care, and autopsy. fellows indicated that didactic educational sessions and additional coursework were less useful strategies for improving their communication skills, whereas small group role play sessions with faculty and/or bereaved parent educators were most useful. fellows' overall communication preparedness score was not correlated with post-graduate year but was positively associated with the number of times they previously had delivered bad news to patients and families. fellows requested additional training on many topics, with greatest interest in learning skills to optimize communication with an angry patient or family. additional topic requests included placing limitations on resuscitation, withdrawing/withholding further therapy, and ageappropriate inclusion of patients in difficult discussions. despite self-report of prior communication skills training, pediatric subspecialty fellows felt underprepared to participate in difficult discussions with patients and families. learners identified role-playing and coaching with real-time feedback from other physicians and bereaved parents as more useful training strategies as compared to didactic sessions. background: when children die of cancer, parents must adjust to their child's absence amidst the lingering turmoil of what preceded their death: witnessing their child undergo painful treatments, making difficult decisions, and anticipating a devastating loss, all the while hoping for a recovery. adjustment to a child's death, as depicted by current bereavement literature, necessitates making meaning of one's loss. professional care staff can help parents make sense of their child's illness, and in turn, of their own parental experience during treatment. however, the extent to which relationships with professional care team members influence parents' ability to make sense of, and successfully cope with, their loss has not been examined. objectives: to examine how bereaved parents' interactions with their deceased child's pediatric oncology professional care team have impacted their grief symptoms design/method: to better understand how interactions with professional care staff relate to parents' grief outcomes, we conducted a mixed-methods study examining staff impact on parental grief. thirty participants whose children died of cancer one to three years ago completed an in-depth interview and psychometrically validated surveys measuring meaningmaking, depression, and grief symptoms. results: correlational analyses of the measures found that an increase in meaning making was associated with lower depressive and grief symptoms. a content analysis of the interviews found that many participants regarded staff "like family," had on-going relationships with staff after their child died, and described various ways staff interactions during treatment and after the child's death helped them make sense of their loss. in particular, participants described how interactions with staff have helped them find benefits in their loss and learn to create a new relationship with their child despite their physical absence. quantifying the interview data and statistically analyzing it along with the measures found that participants' increased frequency of describing staff's positive impact on their grief correlated with higher meaning-making scores and lower grief symptom scores. our study found that bereaved parents who lost their children to cancer were articulate in sharing their experiences of staff engagement and communication during treatment, offering numerous examples of how staff aided them in making meaning of their loss that were reliably associated with their subsequent grief. we hope the results of this mixed methods research encourage further study of the importance of staff interaction with families during the critical period of their children's care, and the lasting impact this can have regardless of the treatment outcome. memorial sloan kettering cancer center, new york, new york, united states background: although resiliency has been recognized as necessary for healthcare professionals, trainees feel unprepared for the emotional challenges inherent in caring for sick and dying patients. compounded by long hours, challenging work environments, and lack of formal training on handling emotionally difficult situations, many institutions are recognizing the need for interventions to reduce trainee distress. the goals of this fellow-led quality improvement initiative were: ) to determine whether there is a need for emotional support amongst pediatric hematology and oncology fellows, ) to provide formal resiliency and debriefing sessions, and ) to measure feasibility, acceptability and effectiveness of implemented curriculum. design/method: an anonymous survey to determine need for resiliency and debriefing sessions following a traumatic event was distributed to active pediatric hematology & oncology fellows at memorial sloan kettering cancer center in january . once need was established, an intervention consisting of a formal curriculum was developed and initiated in june , involving: ) scheduled and ad hoc debriefing sessions in response to traumatic events (including patient death, codes, interpersonal conflicts, end-of-life care); led by a psychiatrist and social worker with fellows and a pediatric oncologist mentor in attendance, and ) a resiliency didactic curriculum, led by a palliative medicine specialist, focused on skills such as contesting cognitive distortions and mindfulness. the effectiveness of these sessions will be measured using follow-up anonymous surveys at months (currently underway) and months post-initiation of intervention. the initial survey demonstrated most trainees ( / ) were present at or more deaths during their training, while less than half of respondents had attended a post-event debriefing session. % of respondents felt there was not sufficient emotional support from the institution for physicians caring for dying patients. a separate pre-intervention survey found all respondents ( / ) expressed a need for regular debriefings, and nearly all anticipated that they would benefit from such debriefings. concerns identified by trainees that would preclude participation in the curriculum included preference to deal with emotional situations privately and time constraints. trainees identified a need for formal debriefings and resiliency skill development. the program was easily implemented, and is both feasible and acceptable with good attendance. feedback received at the -month mark will determine deficits and possible improvements to the curriculum. the -month survey will measure effectiveness of the program and whether it should be continued. background: acute kidney injury (aki) is a common but under-recognized complication among patients with leukemia. it is associated with prolonged hospital stays, increased mortality, progression to chronic kidney disease, and delays or changes in cancer therapy which may affect a patient's prognosis. however, data on aki in pediatric patients with cancer is still lacking overall. we investigated the incidence of aki in patients who were newly diagnosed with all at our center from january to september . we performed a retrospective chart review of all patients who were newly diagnosed with all from neonate to years in our facility. we determined the incidence of aki in our population using the kidney disease: improving global outcomes (kdigo) diagnostic criteria. we also assessed for nephrotoxic exposures, nci all risk stratification and risk of aki, and tumor lysis syndrome (tls). we identified patients diagnosed during the study period who met inclusion criteria. median follow-up time was . months (range . - . ). the cohort was predominantly male ( . %) and hispanic ( . %). our analysis showed . % had aki by kdigo criteria ( % grade , . % grade , and % grade ), . % had aki on presentation, and % had multiple aki episodes during the study period. older age and longer length of hospitalization were associated with aki (p = . and p = . , respectively). there was no association between aki and nci all risk classification, contrast exposure, hyponatremia, elevated white blood cell count, uric acid levels, antimicrobial therapy, or diuretic use in this study. conclusion: aki was a common finding in our study population. the majority had grade aki by kdigo criteria. however, aki was associated with older age and a longer length of stay. further study is needed to determine the short-and long-term impact of aki on pediatric patients with all. st. jude children's research hospital, memphis, tennessee, united states background: in some regions, the availability of trained pediatric oncologists is a limiting barrier for the care of children with cancer. in , the unidad nacional de oncología pediátrica (unop) and the universidad francisco marroquín school of medicine in guatemala established a pediatric hematology/oncology fellowship program sponsored by st jude children's research hospital to provide central america and the caribbean with well-trained specialists. a systematic analysis of the impact of fellowship programs in pediatric oncology has never been done, especially in the context of a regional education program. objectives: this study sought to analyze the impact of the unop fellowship program based on the regional number of providers, pediatric cancer centers and patient volume. in addition, it sought to characterize the jobs and scientific output of the graduates. the impact will be evaluated in the context of a cost analysis. to define the volume of providers, pediatric cancer centers and patients, the directors of pediatric cancer centers in central america were sent an online survey to obtain these data. all the centers contacted maintain an updated hospital-based patient registry. in addition, the graduates of the fellowship program were also sent an online survey, asking about their job at graduation, current role and scientific productivity. the cost analysis will include assessment of direct costs including salaries and stipends for away rotations, as well as the indirect costs of faculty time spent teaching. since the establishment of the unop fellowship program, the region has more providers for pediatric cancer (p< . ) and centers treat a larger volume of patients (p< . ). two new centers have opened with graduates of the program. all but one graduate practice pediatric oncology ( / ) and the majority do it in their country of origin ( / ). no graduate practices outside of this region. almost half of the graduates ( %) hold a leadership role at their institution. the majority of their time is spent in the public sector (> %). the majority of graduates participate in clinical research ( %) and have participated in the creation or implementation of therapeutic protocols ( %). on average, the graduates have published peer-reviewed articles since completion of training. the unop fellowship program has had a favorable impact on pediatric cancer care in the region, contributing to the capacity to treat a larger volume of patients. graduates practice pediatric oncology in the region in the public sector, frequently hold leadership roles and are scientifically productive. background: abandonment of treatment is a major cause of treatment failure and poor survival in children with cancer in low-and middle-income countries. the incidence of abandonment in peru has not been reported. objectives: the aim of this study was to examine the prevalence and associated factors of treatment abandonment in pediatric patients with cancer of peru. we retrospectively reviewed the sociodemographic and clinical data of children referred between january and december to the two main tertiary centers for childhood cancer, located in lima, peru. definition of treatment abandonment was used from the siop (international society of paediatric oncology) podc (paediatric oncology in developing countries) abandonment of treatment working group recommendation. results: data of children diagnosed with malignant solid tumors and lymphomas were analyzed, of which ( . %) abandoned treatment. univariate logistic regression analysis showed significant higher abandonment rates in children living outside the capital city, lima (p< . ); prolonged travel time to a tertiary center (> hours; or . , p = . ); living in a rural setting (or . ; p< . ) and lack of parental formal job (or . ; p = . ). according to cancer diagnosis, children with retinoblastoma were more likely to abandon compared with other solid tumors. in multivariate regression analyses, rural origin and lack of formal parental employment were independently predictive of abandonment. conclusion: treatment abandonment prevalence in our country is high and closely related to socio-demographical factors. treatment outcomes could be substantially improved by strategies that help prevent abandonment of therapy based on these results. st. jude children's research hospital, memphis, tennessee, united states background: to improve the quality of a pediatric hematology/oncology fellowship program, a systematic assessment must be performed that can evaluate its current state and identify areas of opportunity, as well as modifications over time. unfortunately, widely agreed-upon metrics of quality for pediatric hematology/oncology fellowship programs currently do not exist. this is particularly important in this field due to the global shortage of specialists. for this reason, an assessment instrument that is applicable throughout the world must be created. objectives: the st. jude global education program assessment tool (epat) is a novel instrument that seeks to evaluate pediatric hematology/oncology fellowship programs around the world in systematic and objective way. epat will help determine key performance indexes that are relevant for quality education in pediatric hematology/oncology fellowship programs and establish the framework for improvement. design/method: firstly, key domains to be evaluated for program assessment were identified a priori based on the continuum of pediatric hematology/oncology fellowship programs in the context of geography and educational structure. subsequently, questions were formulated to evaluate these key domains, seeking to assess elements involved in ensuring competence in clinical practice, academic productivity and regional impact. due to the novelty of this tool and the lack of defined metrics of quality, epat relies on expert opinion in a two-step process: internally in the department of global pediatric medicine at st. jude children's research hospital and, subsequently, from a panel of experts in global pediatric oncology and medical education from around the world. ten key domains were identified to evaluate all aspects relevant to training programs around the world, regardless of educational and geographic context. questions have been created to assess these domains and, to make epat quantitative, these have assigned weights with a value reflective of their relative importance. this grading system allows for a score in each key domain, permitting monitoring of changes over time. epat is currently at the stage of external expert review, and subsequently will be piloted in five fellowship programs around the world to provide different geographical and patient care contexts for its validation. once epat is finalized, it will be distributed to pediatric hematology/oncology fellowship programs around the world to be applied. epat proposes a novel strategy to assess training programs in a systematic way that includes all aspects relevant for a training program in a global context. this tool will help guide improvements in pediatric hematology/oncology fellowship programs and assure a well-trained workforce. background: with the improvement in pediatric oncology patient survival and outcomes in the past several decades, monitoring for recurrence and long-term effects of therapy has become even more important. the utilization of personalized treatment summaries and survivorship care plans (scps) is one way to communicate this information with patients and families. the american college of surgeons commission on cancer (coc) created a standard regarding provision of scps to % of eligible patients by december , as a metric for accreditation of all cancer centers. the standard applies to all patients with stage i, ii, and iii cancer diagnoses and requires creation of the scp within one year of diagnosis or six months of completing treatment. during implementation at our pediatric cancer center, we identified barriers to use of the guidelines in the childhood cancer setting. objectives: define eligibility for an scp for pediatric oncology patients to include all patients with curative intent and to deliver scps within six months of finishing therapy. design/method: using chart review and a cancer center registry query, we identified childhood cancer patients potentially eligible for an scp by collecting stage, goal of therapy, and dates of treatment. all patients with curative intent were deemed eligible for an scp regardless of stage i-iv. patients being followed in the oncology clinic for posttreatment surveillance and care were included even if they had received an scp in the survivorship program or were greater than six months off therapy at time of implementation. as expected in the pediatric oncology population, acute lymphoblastic leukemia (all) was the most common diagnosis comprising . % of patients. all is stratified into risk groups instead of surgical staging categories, and treatment duration is greater than one year, unlike many adult-onset malignancies. these differences required interpretation of the guidelines to apply to our pediatric population for all and other pediatric diagnoses with non-surgically based staging. our pediatric oncology clinic has to date provided scps to of eligible patients by adapting the guidelines to focus on patients with curative intent to receive an scp by six months off therapy. cancer staging guidelines and goals for curative intent as well as lengths of treatment vary between the pediatric and adult populations. the coc guidelines require adaptation for optimal applicability to the pediatric oncology population. background: education in communication for fellows in fields that require difficult discussions with families are few in nature. adult learning pedagogies such as role play are under-utilized in medical education, and have been shown to be as effective as traditional teaching methods such as lecture. an -module course for fellows in hematology/oncology, hospice and palliative medicine, radiation oncology, and pediatric hematology/oncology was implemented in january/february . fellows participated in the program. topics covered including fundamentals of communication, coping and spirituality, delivery of bad news, communicating with families, sexual dysfunction during treatment, palliative care/death and dying, and burnout. objectives: overall goal of this course is to foster holistic physicians who views their patients as people with cancer, not cancer patients, and physicians that can communicate effectively with their patients throughout the disease continuum. by the end of the course, learners should be able to practice the fundamental principles of good communication. design/method: fellows initially participated in a pre-course osce to establish baseline skills. osce was facilitated by the center for learning and innovation at northwell, and included actors portraying a pediatric patient and family member to whom the fellow had to break bad news. two months later, the course was carried out over the span of eight weeks and included didactic sessions followed by minutes of role play scenarios. five of the eight modules included role play, with faculty members serving as simulated patients. after the course, a second breaking bad news osce was held. both osces were filmed, and feedback was given by the on-site actors. additionally, faculty members were given access to the videos in an on-line format and were given an evaluation tool to assess the fellows' performance pre-and post-intervention. fellows were given subjective surveys pre-and post-course as well. results: subjective data from participants showed a noticeable increase in comfort level in all areas on the pre-and post-course survey. data obtained from osce videos showed improvement in communication skills as assessed by sps and faculty members using a new evaluation tool developed by faculty. initial first-run data shows that this course is successful in improving communication skills as well as increasing fellows' comfort level across several domains of communication. future directions for our course include improving and validating our assessment tool, expanding our topic base to include more aya and pediatric scenarios, faculty development for improved role play, and investigating impact on practice after course completion. background: acute lymphoblastic leukemia (all) is the most common form of childhood cancer with approximately children diagnosed each year. survival rates have improved significantly over the past several years. children with all are at risk for developing musculoskeletal complications during and after completion of treatment, which can contribute to impaired activity, elevated body mass index (bmi), and risk for complications. interventions involving physical activity could improve musculoskeletal strength as well as overall health in these children. the aims of this study are to examine the feasibility of a directed physical activity program for children with newly diagnosed all during the initial intensive phase of therapy and to evaluate the overall health and quality of life of children participating in the directed physical activity program. design/method: all subjects will receive education materials about the importance and safety of physical activity and a nutrition handout. all subjects will also participate in the directed physical activity program under the supervision of a trained physical therapist for at least minutes every week for weeks. the program will entail four stations including a cardiovascular, balance/proprioception, strength and flexibility, and coordination and cardio. feasibility will be assessed by tracking the participation rate throughout the study period. other assessments will be made at study entry, at the end of weeks of physical activity initiative and months after completion of the intervention. assessments include overall strength and flexibility, weight, height, bmi, blood pressure and performance scores. descriptive statistics will be used for this study. results: a total of patients, male and female, enrolled in the study over a . month period. patient ages ranged from - years. half of the patients enrolled have completed the week program and all patients had stability or improvement of their physical functioning scores. further data collection and analysis is ongoing. patients in the early intensive phase of all therapy are at risk for complications that can affect their physical functioning. a directed physical activity protocol may improve their overall physical functioning. patients may not need specific physical therapy; however a directed physical activity program appears to be beneficial for these patients. the main roadblocks to successful completion of the program were difficulty with scheduling, strain on the parents and patient from treatment, unplanned admissions for fever, as well as nausea and fatigue at time of visit. albany medical center, albany, new york, united states background: communication skills are a core competency highlighted by the acgme. increasing resident confidence in delivering difficult news has been shown to lead to more s of s effective communication. currently, the majority of residency programs lack formal training in communication skills. our objective was to demonstrate feasibility and efficacy of integrating a standardized-patient based training program for communication skills into the curriculum of pediatric residents design/method: to date, pediatric and medicine/pediatric residents have participated in the program during the intern year. the program consists of three, two-hour long sessions, in which each resident is given several opportunities to act out case scenarios with a standardized patient. scenarios included informing a parent of their child's new cancer diagnosis and disclosure of a positive hiv test to a teenager. residents received post hoc peer to peer, and preceptor to learner feedback. pre and post-program surveys were completed by residents. results: following course completion residents reported an increase in confidence in multiple areas of communication including giving a difficult diagnosis (p< . ), discussing a poor prognosis (p< . ), responding to different patient/family member emotional responses i.e. crying or anger (p< . ), and organizing vital information to be relayed (p< . ). in conclusion, communication skills training of pediatric residents is feasible and provides a platform for developing valuable skills not taught elsewhere within the curriculum. background: for children with cancer, transitioning back to school during or after treatment can be challenging. literature supports the need for school re-entry programs to ease this transition. however, these programs vary widely among pediatric cancer institutions with little data addressing their program components. data from this study provides information on current school re-entry programs across these institutions. objectives: one objective of this study was to assess for correlation between the presence of a school re-entry program and other factors, such as geographic location and institution size. a second objective was to establish a list of differences between institutions' school re-entry program components. finally, we aimed to describe current school reentry practices, as well as program benefits and perceived areas for improvement. states with membership in the children's oncology group were offered enrollment in this study. a member of each institution was invited to participate in a survey established by the research team. this person was closely associated with the institution's school re-entry practices. each interview queried institution demographics, as well as program components (e.g., participants, target audience, resources). comment was also collected on program benefits and potential for improvements. analysis of transcripts was performed using pearson's correlation to assess for relationships between institution size, geographic location, and program presence. grounded theory was used for analysis of benefits and improvements. results: thirty-nine of forty-one pediatric institutions who were offered enrollment participated in this study. twentynine institutions ( %) indicated the presence of a school reentry program, and ten ( %) stated they had none. no correlation was found between institution size and the presence of a school re-entry program (p = . , ns). there was also no correlation found between institution location and the presence of a school re-entry program (p = . , ns). a major theme surrounding the benefits of having a program included education for the returning student's peers. for those with programs, perceived improvements included increasing staffing and the ability to offer more services. the results do not support the hypothesis that the presence of a school re-entry program is influenced by the size and geographic location of the treating institution. however, data seem to suggest that available staffing may influence the presence of a program. future studies are needed to address other potential influences, as well as to take an evidence-based approach to determine the effectiveness of the interventions present in these programs. cohen children's medical center/ zucker school of medicine at hofstra-northwell, new hyde park, new york, united states background: genetics/genomics is evolving at an extremely rapid pace. current advances lead to individual algorithms toward disease treatment for each disease with multiple branch points. fellows learn only a fraction of the knowledge and there is no formal approach to teaching critical analysis of information and application algorithms toward disease. additionally, as knowledge evolves extremely rapidly, any approach must teach self-acquisition and application of evolving discoveries. objectives: to create, implement and evaluate a novel curriculum for genetics/genomics targeted toward pediatric hematology/oncology fellows design/method: the curriculum includes four components: ) genetic and genomic medical knowledge, with one initial team-based learning session and weekly online multiple choice questions; ) essential pathways, which will teach molecular pathways common in oncogenesis and relevant to targeted therapy in microteaching sessions with using auditory, visual and tactile learning; ) knowledge acquisition and clinical judgment, to allow learners to gain experience into researching data available, then developing and prioritizing potential treatment plans using problem-based learning sessions in which they will stage a patient, research treatment options, prioritize and present findings; and ) synthesis to demonstrate independent ability to research and recommend therapy through an independent project in which the learner, given a case, will present the case and research findings, genetics/genomics, molecular pathways and make recommendations for therapy in molecular tumor board for faculty and fellows. to evaluate, we plan to recruit to institutions, match for size of programs and implement in half and evaluate nd and rd year fellows in both groups by mcq exam and satisfaction surveys. the creation of a multi-module, adult-learning based curriculum for genetics and genomics in pediatric oncology is feasible. implementation and evaluation are necessary to demonstrate efficacy. background: neuroblastoma is the most common extracranial solid tumor in children. chimeric anti-gd antibody ch . (dinutuximab) therapy has improved the survival of children with newly diagnosed high-risk, neuroblastoma patients as well at the time of first relapse/progression. acute neuropathic pain is a well-documented side effect of dinutuximab administration. however, additional adverse effects including sensorimotor neuropathy, ocular symptoms, and behavioral changes have been described. the incidence and severity of these effects are currently not well-documented in pediatric patients. with improved long term survival of patients receiving this modality, it is important to look for the potential late effects of dinutuximab. objectives: to determine the incidence and severity of neurologic, ophthalmologic, or behavioral changes after dinutuximab administration at our institution. we performed a retrospective chart review using our electronic medical record. we included all patients with high-risk neuroblastoma between the ages of and years at our institution diagnosed between and who received dinutuximab. patients with history of opsoclonus-myoclonus syndrome or gross sensorimotor neuropathy prior to receiving dinutuximab were excluded. we examined clinical documentation for subjective reports and objective exam findings of neurologic, ophthalmologic, or behavioral changes. we also looked for referrals made to neurology, ophthalmology, physical medicine & rehabilitation (pm&r), and psychology. : twenty-two patients met inclusion criteria. at the time of chart review, patients were alive and were deceased. eighteen patients received dinutuximab per anbl ; patients received dinutuximab per anbl . of these patients, patients reported symptoms of interest and reported multiple symptoms. six patients reported symptoms that began at least months after completing dinutuximab. nine patients had objective findings on exam, including decreased deep tendon reflexes, abnormal pupils, and nearsightedness. for patients, referrals were made to ophthalmology, pm&r for neuropsychologic testing, or neurology. two patients who reported symptoms of interest were not referred to a specialist. conclusion: neurologic, ophthalmologic, and behavioral symptoms were commonly reported and demonstrated on exam among pediatric patients with high-risk neuroblastoma who received dinutuximab. it is important to identify these effects so that appropriate specialist referrals can be placed for adequate management of these changes. we recognize that these symptoms may not be solely due to dinutuximab as these patients receive other agents including opioids, so a prospective trial is needed to further evaluate the long-term effects of dinutuximab and to determine how best to screen for these effects. akron children's hospital, akron, ohio, united states background: pediatric cancer is the leading cause of diseaserelated death in children in the united states (u.s.). in , over fifteen thousand children were diagnosed with cancer in the u.s. this population is at high risk for malnutrition due to the multimodal therapies they receive: surgery, chemotherapy, radiation therapy, antibody therapy, and/or bone marrow transplant. adverse effects of these therapies include taste changes, loss of appetite, diarrhea, vomiting, and/or mucositis, making it difficult for the children to be able to consume adequate amounts of nutrition during therapy. there is no "gold standard" measurement tool for identifying patients at risk for malnutrition. nutritional status is not frequently evaluated as a component of clinical trials. assessment of anthropometric measurements (weight, height, z-scores) at diagnosis, as well as over the duration of treatment, can assist in the early identification of malnutrition. the incidence and prevalence of malnutrition in this population is unknown at akron children's hospital. the purpose of this study is to describe the nutritional status and provision of nutritional support therapies in pediatric patients during their first year post new oncologic diagnosis. objectives: identify the incidence and prevalence of malnutrition across oncologic diagnostic categories over the first twelve months post diagnosis. we performed a retrospective records review of all patients newly diagnosed with cancer in at akron children's hospital. demographic and anthropometric data was collected at time of diagnosis and nutritional status categorized by z score. anthropometric and nutrition support data was then collected every two months for the first year after diagnosis along with incidence of unplanned inpatient admissions. results: a total of patients were included in the analysis, with . % malnourished at time of diagnosis; . % developed malnutrition the first year. patients with solid tumors represented % of patients with pre-existing or acquired malnutrition. overall, % of patients received at least one nutritional support modality. patients with pre-existing or acquired malnutrition had a non-significant increase in unplanned admissions (p = . ). our study demonstrated that patients with solid tumors were found to be at increased risk of pre-existing and acquired malnutrition, followed by leukemias, and experienced higher incidence of unplanned admissions in the time period observed. prospective, multi-center replication of this study, including detailed collection of nutrition therapies is recommended to guide development of diagnosis specific nutrition support guidelines. background: pediatric and young adult oncology patients treated with intense chemotherapy have a high incidence of transfusional iron overload. iron deposition can lead to heart failure/arrhythmias, liver abnormalities, endocrine dysfunction, ineffective erythropoiesis, and increased cancer and mortality risk. however, there is a paucity of data regarding recommendations for management of transfusional iron overload in these cancer survivors. consequently, long-term complications of transfusional iron overload specific to these patients have not been assessed. objectives: to assess screening and phlebotomy-based treatment algorithms for this population. design/method: a retrospective chart review of pediatric and young adults who completed oncology management, had iron overload, and initiated phlebotomy treatment was conducted. tiered screening occurred in patients that received at least packed red blood cell (prbc) transfusions. patients were recommended for evaluation and possible phlebotomy if: ( ) liver iron concentration (lic) > mg of iron/gram dry weight liver tissue by ferriscan and/or ( ) cardiac mri t * < ms. during phlebotomy, iron status was assessed quarterly and phlebotomy discontinued with lic < or normalization of ferritin/imaging lic verification. descriptive statistics were employed to report the characteristics of the study population. spearman correlations were utilized to describe associations between transfusions, lic, ferritin, iron saturation and number of phlebotomy sessions. results: twenty five survivors underwent phlebotomy. the mean age was . years (sd . ) and ( %) were female. oncologic diagnoses: all ( %), aml ( %), nhl ( %), ewing sarcoma ( %), osteosarcoma ( %), neuroblastoma ( %) and cns ( %). patients received a median of . (iqr - ) transfusions. median number of phlebotomy sessions was (iqr - ) over . years (iqr . - . ). prior to phlebotomy, median lic was . mg/g (iqr . - . ) and ferritin was . ng/ml (iqr - ) . no patients demonstrated abnormal cardiac t * mri (n = ). ( %) patients completed phlebotomy. one discontinued due to poor vascular access. no patients developed iron deficiency. lic was reduced by a median of . mg/g (iqr . - . ) and ferritin by ng/ml . correlation between number of transfusions and phlebotomy sessions was poor (r = . ). conclusion: management guidelines are lacking for transfusional iron overload in pediatric and young adult survivors of cancer. we demonstrate a phlebotomy algorithm that is effective and tolerated. correlation between number of transfusions received and phlebotomy treatments was poor, necessitating serial assessments. using this management algorithm, prospective studies can evaluate the effect of iron removal on iron overload complications in this patient population. penn state children's hospital, hershey, pennsylvania, united states background: cancer therapy leads to an impaired immune system that takes time to recover. it is important to ensure that these survivors have adequate immunity to prevent common yet potentially severe childhood illnesses. no validated guidelines currently exist for surveillance testing or re-immunization in this population. retrospective analysis involving a small cohort of pediatric cancer patients treated at penn state children's hospital showed % of patients screened for varicella immunity after therapy completion did not have adequate disease titers. to determine the proportion of pediatric cancer survivors who have lost humoral immunity to previously received vaccines; to determine the rate of response to single dose boosters or full vaccine series in seronegative subjects after one booster. design/method: pediatric cancer survivors treated at the children's hospital who are at least months from completion of cancer therapy are prospectively tested for antibody levels to hepatitis b, tetanus, varicella, measles, and strains of pneumococcus ( , b, v, c, f, and f). samples are analyzed by the cdc for measles and varicella avidity. seronegative subjects by commercial studies, are eligible to receive booster vaccines. titers are rechecked at least weeks after boosters to re-evaluate immunity; if still seronegative, subjects will receive the entire vaccine series. titers are finally tested at least weeks after the final dose of the vaccine series. immunity analyzed after therapy, after boosters, and after vaccine series. results: of pediatric cancers survivors who completed therapy, % were non-immune to hepatitis b, % nonimmune to > % of pneumococcal strains tested, % nonimmune to measles, % non-immune to varicella, and % non-immune to tetanus. of subjects who received mmr vaccine after therapy and prior to study enrollment did not have protective antibodies to measles. of the subjects who received varicella vaccine after end of therapy and prior to study enrollment, did not maintain protective antibody levels. cdc results for measles and varicella are pending, as well as repeat studies after vaccine boosters and series. conclusion: a significant percentage of pediatric cancer survivors do not retain immunity to hepatitis b, pneumococcus, measles, and varicella. after one booster, a high percentage of subjects did not develop protective immunity to varicella. only subject did not have immunity to tetanus, which is consistent with the high immunogenicity of tetanus toxoid. formal guidelines are needed to protect this population from vaccine-preventable illness post-therapy. children's hospital of richmond at virginia commonwealth university health system, richmond, virginia, united states background: childhood cancer survivors are at risk for being overweight. diet and physical exercise are important in maintaining a healthy lifestyle and weight; however, it has been reported that cancer survivors are less active than their peers. one reason for this may be that there are no clearly established risk-based exercise recommendations for cancer survivors. another reason may be that providers tend to focus s of s recommendations for exercise more towards patients who are overweight. objectives: to describe changes in physical fitness of childhood cancer survivors who exercise. design/method: 'moving forward' is a wellness and physical fitness program that the center for care beyond the cure at chor offers in partnership with the ask childhood cancer foundation and the ymca. the program is available for any childhood cancer survivor between y and y age, being seen at our center. survivors define their fitness or wellness goals and then work with a trainer once a week (at least) for min sessions throughout the year to achieve these goals. baseline and ongoing measurements for core strength, endurance, overall strength and balance were collected. the average of each of the parameters of all participants were compared from the beginning to the end of the program. over the year, there was a % increase in endurance as measured by the average of the miles walked in minutes, % increase in core strength as measured by the average number of sit-ups in secs, an % and % increase in overall strength as measured by the average weight lifted by leg press and the average weight lifted by chest press, and a % increase in balance as measured by the average number of seconds balancing on a single leg. in addition, each child had actually gained weight in the process with an approximately % increase in the average of the weights of all children. there are benefits to regular exercise beyond weight control, and improvements in physical fitness can be seen even without weight loss. regular physical exercise results in improved physical fitness and should be universally advocated to all patients. determining insulin resistance, measuring changes in fatigue and wellness perception following exercise are future directions that we intend to explore. dana-farber cancer institute, boston, massachusetts, united states background: improvements in adolescent and young adult cancer patient (aya) survival rates and quality of life outcomes have lagged behind those of children and older adults, highlighting a need for research targeting this unique population. current literature supports the value of strong ayaclinician communication, notably in facilitating therapeutic alliance, however little is known about aya communication priorities during cancer care and barriers to optimal ayaclinician communication. objectives: to explore aya and oncology clinician communication priorities and to identify barriers and facilitators to aya-oncology clinician communication. design/method: semi-structured interviews were held with aya cancer patients and survivors (ages - years) from a single large academic institution and oncology clinicians (physicians and nurse practitioners) from academic institutions in the northeastern united states. interviews were conducted in english by phone or in person. all interviews were audio-recorded and transcribed verbatim. analyses were aided by nvivo software. ayas identified a wide range of topics as important to discuss with clinicians. the most frequently identified topics were ) side effects of treatment (with an emphasis on physical appearance and function, n = ), ) social issues (including friendship, family, and school, n = ), ) looking ahead to the future (n = ), and ) sexual & reproductive health (including future fertility, contraception, and romantic relationships, n = ). clinicians prioritized ) cancer treatment and side effects (n = ), ) emotional and psychological health (n = ), and ) sexual and reproductive health with a focus on fertility risk and fertility preservation (n = ). aya reported facilitators to good communication including an open and long-established relationship with the clinician (n = ) and clinician engagement in age-appropriate and patient-directed conversations (n = ). barriers included parental presence during visits (n = ). clinicians reported barriers including ) clinician discomfort (not feeling wellequipped to discuss psychosocial topics such as sexual health, spirituality, and relationships with peers, n = ), ) presence of parents/family (n = ), and ) perceived patient discomfort discussing specific topics (such as sexual health, n = ). clinicians acknowledged the need for collaborative efforts with additional team members (i.e. nurses, psychosocial providers) to assist in meeting aya communication needs. conclusion: aya and clinician-reported communication priorities are largely aligned. however, ayas emphasize some topics, such as social function, appearance, and sexual health that are not highly prioritized by clinicians, which may result in gaps in care for ayas in treatment and in survivorship. these data identify opportunities for intervention, including clinician education, patient and family education, clinic-based intervention, and systems-based changes that can be developed and tested. background: primary care physicians (pcps) cite lack of knowledge and inadequate communication with the oncology team as major barriers to providing recommended surveillance for late effects of treatment to childhood cancer survivors. a standardized telephone handoff to pcps posttherapy is a potential strategy to increase survivorship care by pcps through interactive communication. to determine the feasibility of a structured telephone communication using the situation, background, assessment, and recommendation (sbar) communication tool delivered by a trained oncology nurse to increase pcp knowledge and willingness to provide survivorship care. design/method: from / / to / / , a registered nurse expert in childhood cancer survivorship attempted to contact by telephone the pcps of the most recent patients attending yale's childhood cancer survivorship clinic that were < years old, english-speaking, and ≥ years posttreatment. all pcps had been previously sent an individualized survivorship care plan (scp) that listed the patient's previous treatment history and recommended surveillance tests. upon successful contact and after confirming receipt of the scp, the nurse explained the definition of late effects, description of patient's diagnosis and treatment history, and associated potential late complications and schedule of recommended surveillance tests. the pcp was also asked about his/her ability and willingness to provide needed surveillance for late effects in the future. overall, of pcps were successfully contacted with a median of phone call (range: - ) that lasted a median of minutes (range: - ) after a median of business day (range: - ). no pcps ended the call mid-conversation. all pcps were receptive and expressed appreciation for the call. twenty-five of ( %) pcps expressed an understand-ing of the material discussed and endorsed belief in their ability and willingness to provide late effects surveillance for their patients. no pcps questioned discussing their patient's care with a nurse versus a physician. interactive, structured communications between nurses and pcps by telephone are feasible and are associated with high-levels of pcp confidence in providing survivorship care. background: childhood cancer (cc) admissions account for % of non-newborn pediatric hospitalizations. these hospitalizations are longer and more expensive than other hospitalizations. admission payer (medicaid or commercial) reflects both health policy and sociodemographic status. the objective of this study was to determine if length of stay (los) or cost of cc admissions differed by payer. we used the kids inpatient database, a sampling of all pediatric hospital discharges in the united states. analysis for this study was limited to admissions containing a cancer diagnosis in any discharge icd- codes. admissions were further subcategorized by discharge codes according to diagnosis (leukemia, lymphoma, solid tumor and brain tumor) and reason for admission (chemotherapy, procedure, infection, non-infectious toxicity or "other"). charges were converted to costs using cost-to-charge ratios. multivariable linear regression models were performed to control for age, gender, race, reason for admission, and diagnosis. results: there were , weighted admissions for children with a cancer diagnosis in . of these admissions, . % had medicaid, . % had commercial insurance, and less than % had other payers. the mean los for medicaid admissions was . days ( % ci . - . ), compared with . days ( % ci . - . ) for commercial insurance. surgical admissions accounted for the largest difference in length of stay with medicaid admissions being . days longer than those covered by commercial insurance ( . days vs . days), however, the difference was significantly different for all reasons for admission. in multivariable analysis admissions associated with commercial insurance were % shorter s of s (p< . ), accounting for approximately one hospital day, than admissions associated with medicaid after controlling for other variables including race. the mean overall cost for medicaid admissions was $ , ( % ci - ), compared with $ , ( % ci - ) for commercial insurance. in the multivariable model, cost was collinear with race. conclusion: los and cost of admissions associated with medicaid differed from those associate with commercial payers. medicaid admissions were % longer on average than commercial insurance, accounting for a difference in length of stay of approximately one day although the difference varied with the reason for hospitalization (chemotherapy, surgical procedure, infection, other toxicity, other). costs of admissions were not independent of race. further investigation into potential explanations for this difference including differential access to home care needs, outpatient reimbursement differences, social indications for prolonged hospitalization, and provider biases, is warranted. background: pediatric cancer is a major cause of morbidity and mortality among children surpassed only by accidents. despite improved outcomes in high income countries (hic) survival rates remain poor in the developing word. there are various diagnostic and therapeutic limitations contributing significantly for the survival gap. the main objective of the study is to to evaluate the outcomes of pediatric cancer in armenia and identify diagnostic and therapeutic limitations in the country. we conducted a retrospective study among (≤ years old) children with cancer (solid tumors and hematological malignancies), who were diagnosed and treated at the clinic of chemotherapy of muratsan hospital complex of yerevan state medical university between and . those patients, who didn't receive chemotherapy for any reason were not included in the study cohort. epidemiological, social, medical information was collected through the patient charts review. this included patient age at diagnosis, sex, place of residence (city vs village), the educational level and employment status of parents, type of cancer, stage, presentation of symptoms, first medical specialty consulted and the time consulted, initial work-up, the type of treatment received, information on the diagnosis/treatment received abroad. results: at our clinic during the mentioned period of time the majority of patients presented with hematologic malignancies- %. ( . %) patients had information on diagnosis delay. average delay in diagnosis was about days. in % of cases the first contact with "healthcare system" was through pediatrician, and in % with surgeon. out of relapsed patients received salvage treatment in armenia and abroad. from those who stayed for treatment in armenia patients survived. majority of relapsed patients had acute lymphoblastic leukemia. from leukemia patients immunophenotyping and cytogenetics were available for ( . %) patients; the majority of missing cases were between and , when these diagnostic modalities were not available or affordable in the country. ( %) patients received part of diagnosis and/or treatment abroad. the most frequent reason for going abroad was bone marrow transplantation, otherwise none available in armenia. out of patients were lost to follow-up, patients had a fatal outcome. patients were in remission at a median follow up of . years. conclusion: unavailability of cancer registry and several essential diagnostic/treatment modalities, luck of multidisciplinary care and palliative support, high rate of out-of-pocket expenses were among the main challenges of pediatric cancer care in armenia. background: adverse drug reactions (adrs) are increasingly recognized as important and sometimes irreversible complications of cancer treatment. anthracyclines and cisplatin are effective chemotherapeutic agents, but their use can be limited by cardiotoxicity (anthracyclines) and ototoxicity (cisplatin) in up to % of patients. genetic variants that can be used to predict who is most at risk of developing these adrs have been discovered and replicated. objectives: to create pharmacogenetic risk prediction models for anthracycline and cisplatin toxicities and discuss results with oncologists to facilitate incorporation into treatment decision-making when appropriate. design/method: risk prediction models were developed from the linear regression of strongly-predictive genomic variants (odds ratios ≥ ) discovered and replicated in at least three patient populations. these models were used to assess an individual patient's genomic risk of developing cardiotoxicity from anthracyclines or hearing loss from cisplatin. risk results were returned to oncologists showing where the specific patient's genetic risk of toxicity lies on a continuum between the lowest and highest risk groups across all studied patients using a multi-gene model. interviews were conducted with patients, families, and oncologists to determine how results were valued and utilized. results: patients have been genotyped and had their genetic risk results returned to their oncologists. the first patients have been characterized to determine the impact these test results have had on their clinical care. results were described as being useful in decision-making by patients and/or oncologists in % of cases. additionally, for patients in the most extreme risk groups (highest and lowest risk), a change in treatment plan was ordered % of the time for cisplatin patients and % of the time for anthracycline patients. this included increased cardiac and audiological monitoring, the addition of a protective agent, or choosing an alternative treatment protocol if the risk outweighed the benefits of remaining on the current treatment plan. in interviews, patients indicated that they felt more involved in decision making, and felt reassured by understanding their genetic risk of toxicities. genetic risk prediction models for anthracycline cardiotoxicity and cisplatin ototoxicity were highly utilized by patients and oncologists in decision-making. results were found to be an important tool for informing patients of the risk of adrs during cancer treatment, and resulted in patients and their families feeling more involved in decision-making. background: childhood cancer survivors are at increased risk of developing executive dysfunction, and low socioe-conomic status (ses) has been identified as one of the mediators of executive functioning. previous studies have used traditional measures of ses, such as parents' education level, family annual income and occupation. but more recently, area based socioeconomic measures like block group poverty status are deemed to be more useful in monitoring of social inequalities in health in the united states. block groups are statistical divisions of census tracts and generally contain between and , people. the current study aims to understand the association of block group poverty status (percentage of households in family's block group of residence living below the federal poverty level) with executive functioning among cancer survivor children. design/method: we used a retrospective cohort of childhood cancer survivors. relevant information was collected from the medical record, administrative data sets and parent-filled surveys. address information was geocoded using arcgis . to obtain data on the block group poverty status. a priori cut-points were set to represent block groups with families living below poverty level at %, . % to . %, and ≥ . %. executive functioning were assessed through a parent-rated instrument, the behavior rating inventory of executive functions (brief). multiple linear regressions were used to determine the relationship between block group poverty status and the brief scores. results: data was examined from families of childhood cancer survivors, ranging in age from to years. in this sample, . % families reported an annual income <$ , , . % reported income between $ , and $ , while . % reported annual income ≥$ , . primary care giver of . % of cancer survivors had more than more high school education, and . %, . % and . %, of families were living in a block groups with %, . - . % and ≥ % poor households respectively. block group poverty level was not significantly associated with annual income levels (spearman's rho = . , p = . ), or parental education level (spearman's rho = - . , p = . ). in a step-wise multiple linear regression, there was no statistically significant association seen between block group poverty status and executive functioning after adjusting for co-variables in the final model. future prospective study with a bigger sample size, longer follow up period and more robust measures of the executive functioning like a clinician administered test are needed to understand the effect of block group poverty status on executive functioning. to d completion was . days (range - ). all parents strongly agreed/agreed that d was helpful and would recommend d participation to another family. ten parents ( %) reported time spent on d was "just right." no parent felt more worried due to the intervention, though parent found d participation stressful. this interim analysis suggests that parents have a favorable d experience and recommend the intervention. to date, < % of enrolled parents fail to participate. d shows promise as an acceptable interdisciplinary communication intervention targeted to the early treatment period for childhood cancer. children 's hospital and research center oakland, oakland, california, united states background: screening echocardiograms are recommended by children's oncology group (cog) guidelines to assess for anthracycline-induced left ventricular (lv) systolic dysfunction. the yield of screening echocardiograms during chemotherapy and in the immediate post-therapy period is uncertain. objectives: to assess the incidence of lv dysfunction detected by screening echocardiograms during chemotherapy and in the immediate post-therapy period, defined as - months off-therapy. design/method: children diagnosed with cancer between january -march who received anthracycline chemotherapy were identified. echocardiograms were performed as per protocol, institutional and cog guidelines, and were reviewed retrospectively. lv dysfunction was defined as fractional shortening (fs) < % or ejection fraction (ef) < % ( ) results: in this cohort (n = , median age years), the most common diagnosis was all ( . %), followed by aml ( . %). of echocardiograms, ( . %) were performed during treatment and in the immediate posttreatment period. thirty-eight ( . %) patients had a > % decrease in fs compared to their pre-treatment echocardiograms. none of these patients required any treatment modification or cardiac medications. only patient ( . %) had echocardiogram-proven lv dysfunction discovered on a screening echocardiogram during her treatment course. she eventually died due to multi-organ failure following septic shock. this patient was receiving treatment for aml and had received mg/m of doxorubicin-equivalent anthracyclines at the time of the abnormal echocardiogram. one patient with metastatic ewing sarcoma had borderline lv dysfunction with a fs of % detected a month before completion of therapy. she had received mg/m of doxorubicin equivalent anthracyclines at the time of the abnormal echocardiogram. she did not require any therapy modification or additional cardiac medications. serial echocardiograms done on this patient have shown stable ventricular function. no off-therapy screening echocardiograms identified lv dysfunction. in our experience, the yield of echocardiograms to detect anthracycline-related cardiac dysfunction during treatment and in the immediate post-therapy period is very low. one patient developed lv dysfunction during treatment and one had borderline fs, while no lv dysfunction was identified within months of completing chemotherapy. though fs decreased in % of patients, none required intervention. further study is needed to optimize the use of echocardiography screening in children treated with anthracyclines. references: . landier w et al. jco . background: platinum-based chemotherapy increases the risk of sensorineural hearing loss in children with cancer. little is known about the impact of hearing loss on cognitive and emotional functioning in survivors. to determine the association of severe/profound hearing loss after platinum-based chemotherapy with ) cognitive impairment and ) emotional distress (i.e. anxiety and/or depression). cross-sectional study of all patients attending yale's childhood cancer survivorship clinic ≥ years off therapy for cancer diagnosed at < years and treated with cisplatin and/or carboplatin, but with no history of cns tumor, cranial radiation, congenital hearing loss, or developmental delay. hearing loss severity and hearing aid data were abstracted from audiograms and detailed clinical history. cognitive impairment was defined as behavior rating inventory of executive function t score ≥ , assessment by neuropsychologist, and/or history of special education. emotional distress was determined by brief symptom inventory t score ≥ (global or two subscales) or behavioral and emotional screening system t score ≥ , psychologist interview, and/or history of psychotropic medication/psychotherapy. the most recent available patient data were used. logistic regression with sas software, version . was performed. results: overall, patients ( % female, % white) met eligibility criteria with a median age of . years (iqr = . ) at diagnosis and . years at evaluation (iqr = . ) after a diagnosis of sarcoma ( %), neuroblastoma ( %), or other ( %) for which % received cisplatin and % received carboplatin. fifteen patients ( %) had severe/profound hearing loss in at least one ear. patients with severe/profound hearing loss had a significantly increased risk of cognitive impairment (or = . ; % ci = . - . ), but not emotional distress, compared to patients without severe/profound hearing loss. there was no significant association between age at diagnosis, current age, time since diagnosis, sex, race, ethnicity, or diagnosis with either cognitive impairment or emotional distress. similarly, there was no significant interaction between ) age at diagnosis and hearing loss or ) sex and hearing loss with either cognitive impairment or emotional distress. ten of the ( %) patients with severe/profound hearing loss in at least one ear were recommended hearing aids, of which ( %) reported compliance most of the time. we conclude that severe/profound hearing loss is significantly associated with cognitive impairment, but not emotional distress, in childhood cancer survivors. our data supports the need for interventions to improve hearing in these patients, including compliance with hearing aids. background: who grade anaplastic astrocytoma is a high grade glioma dependent on vascular endothelial s of s growth factor (vegf) mediated angiogenesis for its growth and infiltration. bevacizumab is a recombinant humanized monoclonal antibody which binds vegf-a and inhibits angiogenesis. common adverse effects of bevacizumab are hypertension, proteinuria, thrombosis and bleeding. while animal model based studies have shown that bevacizumab may impair ovarian function the effects of bevacizumab therapy on human fertility are not clear. since the physiology of pregnancy involves neovascularization/angiogenesis it is recommended that conception be avoided for at least months following exposure to bevacizumab. to describe the course of a young adult who became pregnant after receiving bevacizumab and radiation therapy for treatment of an anaplastic astrocytoma. a year old woman diagnosed with a localized hemispheric who anaplastic astrocytoma was treated with chemotherapy and radiation (temozolomide/ . gy) followed by cycles of bi-weekly bevacizumab/temozolomide. patient opted not to pursue fertility preservation prior to initiation treatment. she experienced bevacizumab-associated proteinuria and hypertension during treatment but received all protocol mandated doses (cumulative doses: bevacizumab = mg/kg; temozolomide = . gm/m ). she had a spontaneous unassisted pregnancy months after completing treatment. her pregnancy was uneventful and she was normotensive throughout. fetal ultrasonography at , , , weeks revealed no abnormality of the brain, heart, great vessels, kidney, extremities, placenta and umbilical cord. at weeks she delivered a female infant via cesarean section (birth weight: grams, apgars: and ) excessive post-partum hemorrhage was not reported. placenta was bi-lobed and weighed g. histological analysis revealed normal placental villous development and maturation and two small infarcts. conclusion: exposure to bevacizumab in our patient had no detrimental effect on fertility and on placental/fetal vascular development. we hope this report will add to the existing data on the effects of bevacizumab therapy on fertility. children's healthcare of atlanta, emory university school of medicine, atlanta, georgia, united states background: reports of malnutrition incidence and prevalence in young cancer patients are variable and not well established. previous research suggests children, especially less than years old, treated with intensive cancer-directed therapy are at higher risk for malnutrition. however, no standardized assessment has been used to evaluate risk in this population. objectives: we aim to assess the trends of weight-for-age for patients following cancer diagnosis. this study will be the first to use a standardized measure of treatment intensity (intensity treatment rating scale, itr- ) and will assist in targeting interventions for identification and treatment of malnutrition. design/method: this observational, retrospective study obtained data through the center's pediatric cancer registry and electronic medical record. patients were classified by tumor type (brain or non-brain tumor) and treatment intensity (itr- ). itr- incorporates diagnosis, chemotherapy, radiation, and surgery, beginning with lowest intensity ( ) to highest intensity ( ). inclusion criteria included new cancer diagnosis - at less than years old, with weight obtained and available within days of therapy start date. incomplete data, alternate growth charts, or treatment intensity of , were excluded. weight was obtained at start of therapy and through years after treatment initiation (approximately days) and converted to z-scores adjusted for age and sex. weight trajectories were modeled using generalized linear mixed models with subject-specific random intercepts and spline functions. separate functions were constructed for subgroups of interest (tumor type and itr). results: there were patients included: patients with brain tumors ( . %) and with non-brain tumors ( . %). of included patients, had treatment intensity of ( . %), of ( . %) and of ( . %). over the observation period, , valid weights were recorded. at initiation of treatment, no difference existed between z-score by tumor type (p = . ) or by intensity ( vs. , p = . ; vs. , p = . ; vs. , p = . ). tumor type did not affect z-score through the follow up period. z-scores were higher for intensity rating vs. and vs. (p = < . and p = . respectively) at days after the start of treatment and persisted through days (p = . and p< . respectively). higher treatment intensity is associated with decline in z-score and failure to return to baseline. future directions include further analysis on specific risk factors and timing of weight loss, longer-term follow-up of weight trends, and targeted interventions for identification, prevention, and treatment of malnutrition. objectives: asses the pt requirements for bleeding episodes in a prospective cohort of pcp using a < × e threshold compared to a < × e /l threshold in a historical cohort. we collected pt data in all pcps treated at our center between january/ through december/ . diagnosis, prescription for pt (prophylaxis vs bleeding disorder), plt count and transfused units were assessed for each pt. pcps treated from january/ through june received prophylactic pt with a < × e threshold (cohort a), and pts treated from july/ through december/ received prophylactic pt with a < × e threshold. pts done for procedures and pts with concomitant hemorrhagic pathology were excluded. we compared the number of pts prescribed as prophylaxis vs bleeding episode between cohorts. data analyzed: graphpad prims . ®. statistical analysis: percentages with confidence interval (ci); t-student test (parametric variables) and mann-whitney test (nonparametric variables). statistical significance: p< . . we reviewed pts ( in cohort a, cohort b) in patients. % had acute leukemia, % received and auto or allo hsct. diagnoses and the proportion of patients undergoing hsct was comparable in both cohorts. the average number of pts per patient was , in cohort a and , in cohort b (p = ns), but a significant difference was found when hsct patients were excluded from this comparison ( , pt per patient in cohort a vs , in cohort b, p = , ), which resulted in an estimated , % reduction in pts prescription. furthermore ( , %) pts were prescribed for bleeding episodes in cohort a versus ( , %) in cohort b (p = ns). patients receiving hsct in the entire group ver-sus those not receiving hsct had similar pt requirements for bleeding episodes ( % vs , % p = ns) conclusion: a < × e plt count threshold for prophylactic pts is safe in pcp in chemotherapy and hsct. it can result in a significant reduction in pt usage. key words: platelets, transfusions, prophylaxis, cancer, childhood. ucsf benioff children's hospital oakland, oakland, california, united states background: transition of care for adolescent and young adult (aya) survivors of childhood cancer from pediatric to adult-oriented long-term follow-up (ltfu) is complex. loss to follow-up is common, and little is known about the success rates among different models. the survivors of childhood cancer program (sccp) at ucsf benioff children's hospital oakland employs a community-based model for transitional care. our multidisciplinary team provides aya survivors a comprehensive treatment summary and recommendations, then facilitates transition to primary care or adult oncology ltfu programs. evaluate the success rate for transition of care among aya survivors of childhood cancer in our ltfu program, and identify barriers to successful transition. design/method: aya patients seen from november to august in the sccp with intent to transition were asked by email or telephone if they had followed up with their designated provider. the primary outcome was successful transition, defined as establishing care within months of their visit. patients were also asked about barriers to transition and to rate the new provider's familiarity with their cancer history and ltfu needs. results: transition was intended for patients. eightyseven were contacted and responded. of these, ( %) successfully transitioned, while ( %) were lost to followup. ages ranged from to years, at to years since completion of therapy. ten ( %) transitioned to a primary care provider, ( %) to an adult oncology ltfu program, and ( %) to a pediatrician. patients rated their new provider's knowledge above average ( . ) on a -point scale from poor ( ) to excellent ( ). survivors lost to follow up indicated the following barriers to transition: loss/change of insurance ( ), inability to find a provider ( ), too busy/forgot ( ), problems with transportation ( ), concerns about cost/copay ( ), and s of s other ( ). twelve patients requested further assistance with transition. conclusion: two-thirds of responding patients successfully transitioned. more work is needed to overcome various barriers to transition for one third of aya survivors. albany medical center, albany, new york, united states background: the transition from active treatment, to offtherapy follow-up, is a stressful event for parents of children with cancer. the psychosocial needs of parents after therapy have received limited attention in the united states with only published quantitative studies, the largest with parents. we have secured funding for and recruited a transition care coordinator (tcc) to investigate this further. objectives: our objective is to assess and screen parents at the end of their child's treatment, and to develop interventions to support parents during this time and thereafter. design/method: after informed consent, a standardized questionnaire, the psychosocial assessment tool (pat . ), was administered to parents at end of therapy (t ), months later (t ) and year later (t ). the tcc provided "universal" intervention to all families with an end of therapy binder containing a treatment summary, follow-up roadmaps, information on late effects, and survivor scholarships. based on their pat . scores, some parents were provided intervention specific to symptoms (targeted intervention for scores - . ) or referred to a behavioral health specialist through the clinic social worker for counseling (for scores > ). results: analysis of pat data showed that % of parents (n = ) scored in the targeted or clinical ranges; % of parents scored in those ranges at pat . significant gender differences were revealed with the mean score for men of . and for women of . . this was confirmed by showing statistical significance (p = . ) when analysis was conducted for only a subgroup of data composed of couples (n = ). analysis of pat data by couples (n = ) showed the mean score for men was . and for women was . (p = . ). gender differences were most apparent in caregiver stress reaction questions that focused on ptsd symptoms. when the subgroup of couples' scores (n = ) for caregiver stress reaction at pat was analyzed, there was a significant difference (p = . ) in caregiver stress reaction with a mean of . for men versus . for women. [note: subcategory scores range from to ]. this study was initiated in october using a tcc and the pat . screening tool. the results suggest greater stress on mothers after therapy, with a substantial proportion of parents having symptoms of ptsd after therapy. background: hodgkin lymphoma (hl) is a common childhood cancer characterized by an inflammatory microenvironment. chemotherapy and radiation may exacerbate this inflammation and contribute to the development of late effects (pneumonitis or pulmonary fibrosis). in a heterogeneous cohort of childhood cancer survivors exposed to pulmonarytoxic therapy, no association between pro-inflammatory cytokines and late pulmonary dysfunction was observed. our objective was to test this association in a relatively uniform cohort of survivors of hl, given the well-recognized proinflammatory background of this disease. objectives: to characterize off-therapy pulmonary function in survivors of hl treated with contemporary therapy, and to investigate its association with persistent systemic inflammation. design/method: blood samples, clinical data, and pulmonary function tests were obtained from survivors of hl ≥ months off therapy. lung function score (lfs), a validated method for assessing degree of pulmonary dysfunction on a scale of i to iv, was determined from diffusion capacity and forced expiratory volume in one second (fev ). for a control group, blood samples from patients with benign, noninflammatory hematologic conditions were used. plasma concentrations of inflammatory cytokines were measured on a luminex platform (emd millipore). associations between clinical features or cytokine levels and lfs i (normal) vs. ii-iv were evaluated using logistic regression or wilcoxon rank sum tests, respectively. results: of survivors (mean age at diagnosis: years, range: - ; mean time off therapy: . years, range: . - ), % were categorized as lfs ii (mild dysfunction), % as lfs iii (moderate dysfunction), and no survivors as lfs iv (severe dysfunction). higher lfs was associated with female sex (p = . ) but not other demographic, disease, or treatment factors. forty-eight survivors had blood samples collected at a mean age of . years (range: - ) with a mean time since treatment completion of . years (range: . - . ). of controls, the mean age at time of blood collection was years (range: - ). survivors did not have significantly elevated cytokine levels compared to controls. female survivors of hl ≥ months off therapy are at increased risk of pulmonary dysfunction. neither evidence for pulmonary dysfunction, as measured by lfs, nor duration of time off therapy were related to systemic inflammation in this study. pulmonary function deterioration and clinical pulmonary symptoms are rarely observed immediately following therapy but increase over time. future studies may consider exploring the contribution of systemic inflammation to pulmonary late effects in survivors farther off therapy, when risk for this late effect is greater. background: thyroid carcinoma is a very rare tumor in pediatrics, accounting for . - % of childhood carcinomas in the united states and europe. we aim to detect the risk of second malignancies among pediatric thyroid cancer survivors. the cohort analysis consisted of pediatric cancer patients aged less than years diagnosed with a primary thyroid cancer and identified by site code icd- - : c , reported to a seer database between and . they were followed up by death or the end of the study period (december , ) . out of patients diagnosed primarily with thyroid carcinoma, there were patients who had incidences of subsequent malignancies. the mean age of patients at initial diagnosis of thyroid cancer was years. females ( . %) had significantly higher incidence of second malignancies (sm) than males ( . %). the overall standardized incidence ratio (sir) of sm in thyroid pediatric patients was higher than expected (sir = . ). some specific sites showed significantly higher incidences: salivary gland (sir = . ), gum and other mouth (sir = . ) and kidney (sir = . ). the overall risk of sm in patients received radioactive iodine was higher than expected (sir = . ). the cumulative inci-dence of sms from the initial diagnosis of thyroid cancer was calculated with the survival methodology of competing risk, death treated as a competing event. cumulative incidence of sm was . % [ % ci ( . , . %)] at years and substantially expanded after years, reaching . % [ % ci ( . , . %)] at years. the cumulative incidence of each tumor type at years was . % [ % ci ( . , . %)] for breast cancer, . % [ % ci ( . , . %)] for salivary gland, . % [ % ci ( . , . %)] for each one of kidney and cervix uteri and . % [ % ci ( , . %)] for each one of ovary and melanoma of the skin. cumulative incidence of sm was stratified based on race, gender and radiotherapy exposure, but there was no statistical difference in each of them. conclusion: race, gender, histological subtypes, and radioactive iodine may play an important role as prognostic factors for developing sm among pediatric thyroid cancer survivors. identification of underlying mechanisms that raise the risk of sm is important for both treatment and follow-up strategy. background: the ethical practice of informed consent requires it be both voluntary and understood by the research participant. in pediatric oncology, parents must undergo informed consent to enroll their child with cancer into clinical trials, but often it can be difficult to understand especially for parents with low english proficiency. previous research has shown that parents of children with cancer have difficulty understanding voluntariness, and that parental satisfaction with informed consent does not always correlate with adequate comprehension. objectives: to examine socio-demographic and contextual correlates of comprehension of informed consent, voluntariness, and satisfaction in parents who consented to participation of their child in a cancer clinical trial. we focused on characterizing differences between non-hispanics and hispanics, the fastest growing ethnic group in the u.s. design/method: parents/guardians (n = ) of children aged - years with newly diagnosed cancer, who had consented to participation of their child in a clinical trial for cancer treatment at rady children's hospital-san diego were s of s prospectively recruited. parents completed questionnaires assessing comprehension, voluntariness, satisfaction, health literacy, socio-demographics, and acculturation level, if hispanic. comprehension was surveyed at baseline and longitudinally at months. comprehension, voluntariness and satisfaction outcomes were analyzed by socio-demographics, health literacy, and acculturation level using logistic regression. results: of the participants surveyed, ( . %) were hispanic and ( . %) were non-hispanic. we found that higher health literacy was associated with greater objective comprehension (p< . ), voluntariness (p< . ), socioeconomic status (p< . ), and acculturation (p< . ). hispanics reported lower objective comprehension (p = . ), voluntariness (p = . ), health literacy (p< . ) and ses (p = . ) compared to non-hispanics. spanish-speakers reported lower voluntariness (p = . ), health literacy (p< . ), and acculturation (p< . ) compared to englishspeakers. at the -month follow-up, comprehension in hispanics significantly improved (p = . ) compared to their baseline comprehension. satisfaction was moderately high across all subgroups and was not significantly impacted by socio-demographics, health literacy, or acculturation. in this study, with equivalent numbers of hispanic and non-hispanic participants, we found that hispanic and spanish-speaking parents of children with newly diagnosed cancer had inadequate informed consent comprehension, voluntariness and health literacy despite high satisfaction. our study suggests that hispanics and individuals with limited english proficiency are not making truly informed decisions for their child with cancer. to ensure the ethical practice of research in pediatric oncology, the informed consent and decision-making process must be improved with culturally and linguistically interventions for these underserved populations. memorial sloan kettering cancer center, new york, new york, united states background: pediatric oncology patients undergo repeated bone marrow aspirations and biopsies (bma/bx). these potentially painful procedures can exacerbate anxiety and distress. standard practice at memorial sloan kettering (msk) department of pediatrics is to use propofol, which has amnestic but no analgesic properties. we sought to evaluate whether the addition of local anesthetic would improve patient experience with bma/bx. the purpose of reppair: reducing procedural pain and improving recovery of quality of life (qol) (nct ) is to evaluate the efficacy of local anesthesia with ropivacaine in reducing procedural pain and improving post-procedure qol in pediatric neuroblastoma patients undergoing bma/bx with general anesthesia. reppair is a prospective, randomized, crossover clinical trial that opened for enrollment october . eligible patients were - years old with neuroblastoma. participants were observed on trial for two sequential bm procedures; one procedure with intervention a: propofol alone (pa), and the other with intervention b: propofol plus ropivacaine (p+r). participants were randomized to intervention sequence ab or ba and were blinded to the order of interventions. participants and recovery room (rr) nurses, who were also blinded, followed a standardized postprocedure pain management algorithm. the primary endpoint was percentage of participants requiring opioid analgesia in the hours post-procedure. secondary endpoints included total opioid in hours, non-opioid analgesia use, pain scores, time to first opioid, and short-term qol. qol was assessed by a parent-proxy metric that evaluated pain interference with sleep, physical, emotional, and social recovery. as of january , patients were assessed for eligibility and patients were randomized ( have completed both procedures). for the primary endpoint, a slightly higher proportion of participants required opioid for pa than p+r ( % versus %, p = . ). pain scores in the rr were significantly higher for pa than p+r (median [ th, th percentile]: [ , ] versus [ , ], p = . ). there were no statistically significant differences in total opioid or non-opioid analgesia, -and -hour pain scores, median time to first opioid, or pain interference scores. there were no adverse events. conclusion: preliminary findings of the reppair trial suggest that local anesthesia does not reduce the need for opioid analgesia or improve short-term qol in pediatric patients undergoing bma/bx with general anesthesia. local anesthesia did improve pain scores in the immediate recovery period. final results of this study will help establish evidence-based guidelines and optimize the experience of pediatric patients with bone marrow procedures at our center. background: children with advanced cancer experience a range of symptoms throughout treatment or at end of life, some of which are poorly controlled. minimizing suffering, including effective symptom management, in children with advanced cancer is a central value for pediatric oncology clinicians. patient-reported outcomes have been used in symptomrelated research in pediatric oncology patients; however the majority of literature specific to symptoms during palliative care and end of life for children and adolescents with advanced cancer is based primarily upon medical record reviews and to a lesser extent, patient self-report. the purpose of this study was to prospectively describe symptom frequency, severity, and level of distress in children/adolescents with advanced cancer using patient selfreport and parent proxy. design/method: a prospective cohort design was used for this study. five pediatric oncology institutions from across the united states participated. children and adolescents were eligible to participate if they were - years of age, englishspeaking, and had a diagnosis of advanced cancer, defined as a -week history of progressive, recurrent, or non-responsive disease or a decision not to pursue curative-focused therapy. a modified version of the memorial symptom assessment scale (msas) was used to measure symptom frequency, severity, and level of distress and was administered to child/parent dyads electronically via smartphones every two weeks. information regarding disease status and cancer treatment was collected concurrently. data was analyzed using descriptive statistics and univariate logistic regression analysis. results: a total of children and adolescents and parents participated in the study. the median age of child participants was years, with half being male. the median age of parents was years. the child participants had a variety of primary diagnosis, including: leukemia/lymphoma (n = , %), solid tumor (n = , %), and brain tumor (n = , %). the most frequently reported symptoms by children with advanced cancer and parents were pain (n = / , . %), lack of energy (n = / , . %), and nausea (n = / , . %). presence of disease (p = < . ), recent disease progression (p = . ), and receiving cancer therapy (p = . ) were significant factors on the presence of pain. high intensity cancer therapy was a significant factor on pain frequency (p = . ) and level of distress (p = . ). it is feasible to collect data prospectively in children with advanced cancer regarding symptom frequency, severity, and level distress. clinicians' increased understanding of the symptom experience may promote communication with children and adolescents and timely intervention. more research is needed to understand symptom clusters in children with advanced cancer. vanderbilt children's hospital, nashville, tennessee, united states background: febrile neutropenia (fn) is a frequent occurrence in children undergoing chemotherapy. though guidelines recommend adding a second antibiotic to broad-spectrum antipseudomonal coverage in specific scenarios, augmenting empiric therapy with a second antibiotic is common practice. additional empiric antibiotic (aea) use increases the risk of antibiotic toxicity and future antimicrobial resistance. data clarifying the indications for aea are limited in pediatric patients. objectives: to identify risk factors for gram-positive (gp) and gram-negative (gn) bacteremia in patients presenting with fn to determine situations in which aea use is warranted. design/method: a retrospective chart review was conducted of pediatric severe fn with absolute neutrophil count < / l occurring at a single institution between and . potential a priori risk factors based on clinical reasons for antibiotic expansion were chills, hypotension, mucositis, skin or soft tissue infections (sstis), recent administration of highdose cytarabine (hdac), and a diagnosis of acute myeloid leukemia (aml). potential factors for gn bacteremia were chills, hypotension, mucositis, and abdominal pain. the association between each potential risk factor and gp or gn s of s bacteremia was identified. logistic regression was used for multi-variable analysis. the review yielded episodes. gp bacteremia was isolated in cases ( . %) and gn bacteremia in episodes ( . %). in multivariable analysis, hypotension (or . ( % ci . , . ), p = . ) and sstis (or . ( . , . ) , p = . ) were independently associated with increased risk of gp bacteremia, while mucositis (p = . ), recent administration of hdac (p = . ) and chills (p = . ) were not. ten patients with aml didn't receive hdac, thus the association between aml and gp bacteremia could not be reliably estimated. hypotension (or . ( . , . ), p< . ) and chills (or . ( . , . ), p< . ) were independently associated with a higher risk of gn bacteremia, while mucositis (p = . ) and abdominal pain (p = . ) were not. of the gn infections, ( %) were resistant to cefepime, the empiric agent of choice at our institution. patients with fn with sstis, hypotension, or recent hdac had increased risk of gp bacteremia indicating potential benefit of empiric vancomycin in these settings, while mucositis and chills were not associated with gp bacteremia. hypotension and chills were associated with gn bacteremia, potentially warranting empiric antibiotic expansion, while mucositis and abdominal pain were not. identifying specific indications for aea use in pediatric severe fn use may improve antimicrobial utilization, decrease unnecessary antibiotic use, and improve patient outcomes. background: for children/young adults with incurable high grade gliomas (hggs), like diffuse intrinsic pontine glioma (dipg) or glioblastoma multiforme (gbm), oncologists endeavor to align therapy with patient/family goals of care, but may be influenced by providers' preferences or limited resources. ethical challenges can arise around the perceived purpose, risks and benefits of therapy options, provider conflicts of interest, access to care, deciding decisional priority between patients and families, and conflicts around end-oflife care. objectives: evaluate factors that play into longitudinal decision making for children and young adults with hggs, their families and oncologists using a qualitative approach with ethnographic elements. design/method: eligible patients were aged - with dipg, gbm, or secondary hgg. patient exclusions included: non-english speaking, in state custody, death prior to diagnosis, seen by oncology once, or an oncologist declined participation. key decision making visits (e.g. mri reviews) were serially audio-recorded, along with subsequent : semistructured interviews with patients and/or parents about the decision making process. field notes from clinician meetings, chart notes, and oncologist questionnaires were obtained. discussions and interviews were transcribed and independently coded by three investigators. inter-rater reliability was assessed during code book development. discrepancies were discussed until consensus met. constant comparison analysis with maxqda software continued until thematic saturation. results: twenty-two of eligible patients were approached; agreed to participate. one withdrew upon transferring care. mean age was . years (sd . ); % male, % caucasian, % african american, % hispanic, and % asian. four encounters, ( . hours), were recorded on average per patient. parent/patient interview themes included: ) hope (for a cure, prolonged life, and quality of life), ) importance of physician recommendations, ) importance of support systems (family, community, social media), ) food (as cancer etiology, intervention) ) finances (personal, research funding), ) communication (with medical providers, family, community), ) death, and ) god (beliefs, prayer, existential questions). oncologists desired prolonged quality of life, while patients/families transitioned to that hope from hope for a cure. decisions made in the setting of hggs are multi-factorial, ultimately reflecting the competing values of decision makers. optimism about treatment efficacy is held in tension with poor prognosis, allowing for functional hope. acknowledging patients' and families' shifting hopes allows for changes in goals of care and shared decision making. future work is needed to ) develop preference tools for pediatric patients and families to inform medical providers and ) provide training in communication and shared decision making with oncologists. emory university, atlanta, georgia, united states background: bone marrow transplantation (bmt) is a potentially curative but underutilized treatment for scd. our previous work has shown that there is variation in physician philosophy and practice in considering bmt as a treatment option for patients with scd, and physicians may not discuss this with patients and families as a potential treatment option. in a randomized clinical trial to test the effectiveness of a decision aid for disease modifying therapies for sickle cell disease, adult patients with scd as well as caregivers of adult/pediatric patients were interviewed about how they seek or have sought information related to scd, made decisions about treatments for scd, and identified a treatment option they were interested in learning more about using the decision aid tool. we performed a secondary analysis of these baseline data to understand patient information needs and attitudes regarding bmt as a treatment option for scd. the goals of this analyses was to understand patient and caregivers' attitudes and perceived information needs regarding bmt as a treatment option for scd. we performed an analysis of baseline interviews from caregivers of patients with scd or adult patients from a randomized control trial for a decision aid tool for scd. of the interviews belonged to caregivers of patients with scd. in addition to reviewing interviews for discussion of bmt, we interrogated for mention of terms such as 'bone marrow transplant' or 'cure' or 'stem cell transplant'. interviews were coded using nvivo and analyzed for emerging themes. results: of the baseline interviews, interviews met selection criteria. thirteen of the interviews were with caregivers of pediatric patients, and the remainder were with adult patients, including young adult patients with scd. the majority of participants want to learn about bmt or curative options. in many participants, this was expressed despite knowledge that they were not a likely candidate for transplant. desired information about bmt included eligibility, benefits, risks, long-term effects, quality of life and financial aspects related to bmt. of the patients who discussed how they learnt about bmt, approximately half mentioned that their healthcare provider had not previously mentioned this to them. we then examined knowledge of bmt and attitudes with demographic and clinical variables. patients and caregivers of pediatric patients with scd want to learn about bmt as a treatment option. healthcare providers should consider discussing bmt with their patients with scd. natasha frederick, anna revette, alexis michaud, jennifer mack, sharon bober dana-farber cancer institute, boston, massachusetts, united states background: adolescents and young adults (ayas) consistently identify the need for improved patient-clinician communication on sexual and reproductive health (srh) issues. however, oncology clinicians do not routinely integrate srh conversations with ayas through disease treatment and survivorship. little is known about why these conversations do not take place. objectives: explore aya perceptions of and receptiveness to srh communication with oncology clinicians and to identify barriers and facilitators to these conversations. design/method: semi-structured interviews were held with aya cancer patients and survivors (ages - years, men, women). twelve participants were on active treatment and were within years of treatment completion. interviews were conducted in english by phone or in person. the interview transcript underwent pre-testing with ayas. all interviews were audio-recorded and transcribed verbatim. transcripts were analyzed and summarized by two trained qualitative researchers according to standard comprehensive thematic qualitative analysis methods. analyses were aided by nvivo software. results: ayas perceived existing srh communication between ayas and oncology providers as inadequate. all ayas reported a need for improved srh communication with oncology providers, and three key areas of need emerged: ) general education; ) addressing specific srh issues experienced during treatment and survivorship; and ) understanding the long-term impact of cancer and treatment on srh. ayas felt that current srh discussions are limited and too narrow in scope and scale. ayas reported that most srh conversations focus exclusively on fertility (n = ), usually taking place at the start of treatment. other additional yet limited communication reported was about sexual activity (n = ), contraception (n = ), sexual function (n = ). no ayas reported conversations about potential treatment complications related to sexuality other than infertility. key barriers to srh conversations include patient discomfort initiating conversation (n = ) and presence of family members (n = ), with additional reported barriers including perceived provider discomfort (n = ), lack of rapport with provider (n = ), and age/gender differences (n = ). ayas felt that s of s communication tools such as handouts, brochures, and websites would be helpful facilitators to direct communication from the oncology clinician, and wanted conversations to start before treatment initiation and to continue through treatment and survivorship conclusion: ayas identify a key role for pediatric oncology providers in srh care from diagnosis through survivorship, however multiple barriers interfere with discussions about srh on a regular basis. identified barriers suggest that future efforts should focus on provider education and training in srh and srh-related communication in order to optimize care provided to this unique patient population. background: peripherally inserted central venous catheters (picc) provide secure vascular access in pediatric patients for the delivery of necessary therapies. the ease of placement in the inpatient and outpatient settings has expanded their utilization. however, recent data analyses show a significant increase in venous thromboembolism (vte) risk with the use of picc lines. with its rising use, modifiable risk factors need to be understood for preventative measures. objectives: in this study we aim to understand patient and catheter specific characteristics in relation to the development of vte. design/method: with irb approval, a retrospective interrogation of the electronic medical record and a picc database, at rainbow babies and children's hospital, was completed. the study cohort contained patients < years of age who had a picc line placed between january of and december of . data collected included indication for line placement, line dwell time, location of insertion including blood vessel and extremity, number of attempts at line placement, lumen size and indwelling line length. in addition, we collected number of days to vte formation, associated symptoms and location of vte. chi-squared analyses and fischer's exact test were used where appropriate for statistical analysis. we analyzed ( neonatal) newly placed picc lines. fifty line-associated vte events were found, for an incidence of . %. all vte occurred with the placement of the first picc line. intravenous therapies were the most common reason for line placement. no statistical significance was found between various indications for placement. the most common symptom of vte manifestation was extremity swelling, follow by extremity pain. right extremity picc was found to have a higher incidence of vte. larger catheter lumen sizes (> french) had a higher incidence of vte. we found a mean time of . days to vte detection. we were unable to find any clinical, patient or line specific factors leading to increased vte formation after statistical analysis. special consideration should be given to the duration of picc line use as this may reduce the incidence and comorbities associated with vte. there is still much to be understood about catheter associated vte formation as our analyses indicates the need for prospective data collection on a larger scale in hopes to create guidelines related to catheter use in pediatrics. background: the decision to transfuse a patient is a complex one and is never based solely on a number; however, certain hemoglobin or platelet count thresholds have been proposed in aiding physicians make transfusion decisions. in our hospital, the thresholds for packed red blood cell (prbc) and platelet transfusion in pediatric oncology patients are hemoglobin levels below . g/dl and platelet counts below , /mm (< , for brain tumors), respectively. recently, these thresholds have been questioned and we were asked whether we could safely lower the thresholds to < . g/dl of hemoglobin and < , /mm platelet count objectives: to investigate platelet and hemoglobin transfusion thresholds for oncology patients at children hospital of michigan design/method: retrospective chart review over a -month period, examining platelet and hemoglobin pretransfusion levels for each prbc and platelet transfusion given to oncology patients results: over the course of months, eligible oncology patients (median age years) received transfusions ( prbc transfusions and platelet transfusions). the mean pretransfusion hemoglobin level was . ± . g/dl (range . - . ) (n = ) for total prbc transfusions and this was not different among disease categories (p = . ). patients who had anemia symptoms and signs (n = ) had a slightly lower hemoglobin level compared to those who did not (n = ): . ± . vs . ± . g/dl (p = . ). the mean pretransfusion platelet count was , ± , /mm (range , - , ) for total platelet transfusions (n = ); , ± , /mm in patients with brain tumors (n = ); , ± , in patients with leukemia (n = ); and , ± , in patients with solid tumors (n = ). the mean pretransfusion platelet count was significantly higher in transfusions for brain tumors compared to that in the other disease groups (p< . for both). the mean pretransfusion platelet count was not different among those patients who had bleeding/bruising symptoms ( , ± , , n = ) versus those who did not ( , ± , , n = ) (p = . ). the bleeding/bruising rate was slightly but insignificantly higher in those who had platelet counts < , vs those who had ≥ , ( . % vs . %, p = . ). since most patients develop symptoms of anemia at hemoglobin above g/dl and about / of patients develop bleeding/bruising symptoms at platelet counts above , /mm , our current policy so far reflects a safe threshold for transfusion, and further lowering of the thresholds should be investigated in prospective studies. background: renal impairment is an important complication of childhood cancer and its treatment. serum creatinine level is frequently used as a screening test to monitor renal function; however, patients can have significantly decreased glomerular filtration rate (gfr) with normal serum creatinine. to determine the prevalence of chronic kidney disease (ckd) among children with cancer diagnosis, based on calculated gfr. to compare the difference between using serum creatinine value alone versus gfr in detecting ckd. design/method: retrospective review of medical records of patients, age - years, diagnosed between / - / with solid tumors were analyzed. serum creatinine and calculated gfr using schwartz formula were recorded. ckd as classified by the foundation of kidney disease and outcome quality initiative was used: ckd stage : gfr ( to ml/min per . m ) ckd stage : gfr ( to ml/min per . m ) statistical analysis using spss software v. . chi-squared test for proportions within group, and pearson chi-squared and fisher exact tests for statistical differences between groups. p-value < . was considered to indicate significance results: out of the records reviewed, ( %) were males and ( %) females, with mean age of . ± . years. ( . %) patients received one or more of nephrotoxic chemotherapy drugs; cisplatinum, carboplatinum, or ifosphamide mainly in the non-wilms solid tumors group ( . %) compared to ( . %) in the wilms tumor (wt) group. based on calculated gfr (by schwartz formula) ckd stage /or was diagnosed in ( %) patients with overwhelming majority ( %) were in the mild stage ckd, only ( . %) of those patients had abnormally high serum creatinine levels (p = . ). . % of patients who received nephrotoxic chemotherapy developed ckd, compared to . % in those who did not receive it, (p = . ). despite that only / ( %) of wt group patients received nephrotoxic chemotherapy, yet this group had higher percentage of ckd ( . %) compared to non-wt group ( . %) p = . . significantly lower mean gfr . ± was noticed in the wt group compared to . ± in non-wt group (p = . ) conclusion: high prevalence of mild ckd was found among solid tumor patients. using serum creatinine alone as measure of renal function significantly under estimates renal impairment in those patients. early identification of ckd is easily achieved by using calculated gfr, which can helps providers and care givers to avoid potential nephrotoxic antibiotics, contrast media, nsaids and dehydration that may further deteriorate renal function the university of texas southwestern medical center, dallas, texas, united states background: children with down syndrome (ds) have increased risk of developing leukemia. pediatric patients with ds-associated acute lymphoblastic leukemia (ds-all) are known to have significant toxicities with reinduction chemotherapy and historically poor outcomes with stem cell transplant (sct). anti-cd chimeric antigen receptor (car) t-cell therapy, tisagenlecleucel, demonstrated high rates of durable complete remission (cr) and a manageable safety profile in children with r/r b-cell acute lymphoblastic leukemia (b-all). objectives: characterize the efficacy and safety of tisagenlecleucel in pediatric/young adults with ds-all. design/method: pooled data from single-arm, multicenter, phase trials of tisagenlecleucel in pediatric/young-adult patients with r/r b-all (eliana, nct ; ensign, nct ) were analyzed. eight patients with ds-all were enrolled (data cutoff: eliana, november ; ensign, february ). seven were infused with tisagenlecleucel; patient died from all progression and intracranial hemorrhage before infusion. no manufacturing issues occurred during production. / infused patients were male, / had prior sct (age range, - years). / patients achieved cr or cr with incomplete blood count recovery (cri) by day (d) (cr+cri, %); died before d and was not evaluable. analysis of minimal residual disease was negative in bone marrow in responding patients. two patients had cd negative relapses at and months. ongoing remissions in patients without relapse ranged from to months. the safety profile (n = ) appears similar to that in patients without ds in the same trials (n = ). grade (g) / cytokine release syndrome occurred in % ( / ) of patients with ds and in % without ds. rates of other g / adverse events of special interest did not appear to favor a consistent trend between patients with/without ds (febrile neutropenia: % vs %; neurological events: % vs %; tumor lysis syndrome: % vs %). g / infections were not observed in patients with ds ( % vs %). one patient died after infusion due to intracranial parenchymal hemorrhage on d associated with ongoing coagulopathy. time and extent of tisagenlecleucel expansion and long-term persistence were similar between groups. conclusion: this is the first analysis of car t-cell therapy in pediatric patients with r/r b-all and ds. these data suggest that toxicities appear similar to those in patients with b-all without ds, remission rates in ds-all are high, and longterm outcomes with sustained persistence appear promising. further exploration of tisagenlecleucel as an alternative to sct in children with r/r ds-all is warranted. sponsored by novartis. background: hispanic adolescence and young adults are twice as likely to develop acute lymphoblastic leukemia (all) with high risk features as non-hispanic whites. they also have poor prognosis and % higher death rate. b-all with crlf overexpression caused by genetic alteration of the cytokine receptor, crlf is five times more common in this subgroup. approximately % of crlf b-all cases also have ikzf genetic alterations. ikaros is involved in transcriptional regulation of several important genes involved in leukemogenesis. overexpressed casein kinase ii (ck ) impairs functions of ikaros. objectives: understand the molecular mechanisms that regulate crlf expression in crlf b-all. here we present evidence that ikaros-mediated repression of crlf transcription in b-all in hispanic children is regulated by ck . design/method: primary b-all patient samples from hispanic children were used. ikaros retroviral transduction, ikaros shrna transfection, real time-pcr, luciferace assay, quantitative chromatin immunoprecipitation (qchip) coupled with the next-generation sequencing (chip-seq), cytotoxicity assay and western blot. results: ikaros binding to promoter of crlf was confirmed using quantitative chip. functional experiments such as overexpression of ikaros in b-all primary cells results in transcriptional repression of crlf whereas ikaros silencing using shrna resulted in increased transcription. these results suggest that ikaros negatively regulates crlf expression. molecular inhibition of ck with shrna targeting the ck catalytic subunit, as well as pharmacological targeting of ck with cx resulted in transcriptional repression of crlf . ck inhibition was associated with increased ikaros dnabinding to the promoter of crlf . however, the ability of cx to repress crlf is lost or severely reduced, in cells with shrna silencing of ikaros, as compared to cells with intact ikaros. moreover, similar results were noted following treatment with cx in leukemia cells obtained from high risk b-all patients with deletion of one ikzf allele. ikaros binds poorly to promoters of crlf gene in these cells. treatment with cx restores ikaros dnabinding to the promoters of crlf , which is associated with its strong repression. serial qchip analysis of the epigenetic signature at the crlf promoter showed that increased ikaros binding to the crlf promoter, following ck inhibition, is associated with enrichment for the h k me histone modification, which is a marker of repressive chromatin. results demonstrate that crlf expression is epigenetically regulated by the ck -ikaros axis .cx show antileukemic effect via restoration of ikaros tumor suppressor function, resulting in crlf repression suggesting advantage of using ck inhibitors as potential therapeutic approach in crlf altered b-all. results: hypodiploid all (modal chromosome number < and/or di < . ) was identified in patients ( . % of all patients; . % of nci standard risk (sr) and . % of nci high risk (hr)), who were removed from frontline protocol therapy post-induction. overall -year efs and os were . %± . % and . %± . %. transplant status was retrospectively available for / ( %), of whom underwent hsct in cr . five-year efs with hsct was . %± . % vs. . %± . % without (p = . ). -year os with and without hsct was . %± . % vs. . %± . % (p = . ). when corrected for the median time to hsct ( days), there were no significant differences in -year efs or os rates with and without hsct: . %± . % and . %± . % vs. . %± . % and . %± . %. no nci risk group or mrd subset benefitted significantly from cr hsct. sr patients (n = ) had -year efs and os of . ± . % and . %± . % with hsct (n = ) vs. . %± . % and . %± . % without. hr patients (n = ) had -year efs and os of . %± . % and . %± . % with hsct (n = ) vs. . %± . % and . %± . % without. for those with end-induction mrd < . % (n = ), -year efs and os were . %± . % and . %± . % with hsct (n = ) vs. . %± . % and . %± . % without. end-induction mrd-positive patients (n = ) fared poorly with both year efs and os of . %± . % with hsct (n = ) vs. . %± . % and . %± . % without. multivariate regression analysis including nci risk group, mrd, and cr hsct, showed only mrd negativity was significantly associated with efs (hr . , p< . ) and os (hr . , p< . ). patients with hypodiploid all fare poorly, particularly those with end-induction mrd ≥ . %. while cr hsct is a standard treatment approach, it does not confer significant benefit. we were unable to assess bridging therapy prior to hsct, and comparator groups are small. taken together, however, new strategies are urgently needed for these patients. background: ras-pathway mutations are known to play a pivotal role in a significant proportion of myeloid malignancies, including upwards of % of pediatric aml cases. ras-pathway mutations in myeloid malignancy commonly co-occur with mutations of epigenetic regulators, suggesting cooperative leukemogenesis. among the epigenetic modifiers most frequently mutated in myeloid malignancy are regulators of dna methylation. this indicates that the alteration of dna methylation contributes to leukemogenesis. the ten-eleven translocation (tet ) is an epigenetic regulator that plays an important role in regulation of dna methylation through its action of hydroxylation of -methylcytosine, which ultimately leads to passive de-methylation of dna cytosines. in myeloid malignancy, loss of function tet mutation is one of the most frequently co-occurring lesions in ras mutated malignancy. how specifically the altered methylation patterns in ras-pathway driven diseases promotes leukemogenesis is unclear. objectives: we hypothesize in mice with a ras-pathway mutation, that when an epigenetic modifier co-occurs, such as loss of function of tet , this primes stem cells and/or early differentiating progenitors for transformation by preventing the repression of stem cell self-renewal genes, inhibiting differentiation, enhancing ras signaling and leading to leukemogenesis. we have generated a novel murine model with constitutive deletion of tet (tet -/-) combined with an inducible activating krasg d mutation (krasg d/wt). mice have been tracked for evidence of hematologic malignancies and compared to mice with corresponding single genetic lesions. cooperative leukemogenesis will be demonstrated by decreased latency to disease onset, impact on malignancy lineage, in addition to investigating mechanistically through which pathways leukemogenesis may be promoted. results: krasg d/wt/ tet -/-mice demonstrate statistically significant differences in peripheral white blood cell count, hemoglobin, and platelet levels as early as -weeks post ras-pathway activation. peripheral cell lineage analysis demonstrates early skewing toward myeloid differentiation and marked splenomegaly in mice harboring both genetic lesions compared to wild type or mice with single genetic lesions. phospho-flow cytometric analysis reveals increased perk and ps activation in krasg d/wt/ tet -/-sca- enriched bone marrow cells compared to either genetic lesion alone. our study utilizing a murine model to examine how in ras-pathway mutations the addition of a co-occurring epigenetic lesion demonstrates that these lesions appear to cooperate to promote early myeloid differentiation with attendant changes in signaling pathways. this exploration to elucidate the mechanics of ras-pathway mediated disease lay the foundation for identification of patients who may benefit from existing therapies, such as dmtis, or identify new signaling targets for therapeutic exploration. background: the humoral immunogenicity of car , a chimeric antigen receptor (car) with a murine scfv domain developed for treatment with tisagenlecleucel in relapsed/refractory (r/r) pediatric/young-adult acute lymphoblastic leukemia (all), was evaluated in studies. little is known about the presence/impact of preexisting/treatmentinduced anti-murine car (mcar ) antibodies in patients treated with car therapy. objectives: patients from eliana (nct ; n = ) and ensign (nct ; n = ) were evaluated before and after tisagenlecleucel infusion to determine the impact of anti-mcar antibodies on cellular kinetics, efficacy, and safety. design/method: anti-mcar antibodies were determined by flow cytometry and reported as median fluorescence intensity. assay validation included evaluation of the interferences of intravenous immunoglobulin (ivig) treatment with the anti-mcar antibody assay. impact of preexisting and treatment-induced immunogenicity on cellular kinetics, efficacy, and safety was determined. treatment-induced immunogenicity was defined by a positive increase in anti-mcar antibody levels over baseline and was assessed by calculating the fold-change between preexisting (ie, baseline) and postinfusion levels. results: % of patients displayed preexisting anti-mcar antibodies; a similar incidence was detected in healthy volunteer samples during method validation. % of patients developed treatment-induced anti-mcar antibodies. no relationship was identified between tisagenlecleucel expansion (auc - d) and preexisting/treatment-induced anti-mcar antibodies (r < . and r = . , respectively); similar results were seen for cmax. presence of treatment-induced anti-mcar antibodies did not appear to impact transgene persistence or response. kaplan-meier estimates showed that preexisting/treatment-induced anti-mcar antibodies did not appear to impact duration of response or event-free survival. strip plots showed consistent levels of preexisting/treatment-induced anti-mcar antibodies across patients with safety events, including cytokine release syndrome, neutropenia, thrombocytopenia, and neurological events. there was no apparent relationship between treatment-induced anti-mcar antibodies and b-cell recovery categories (≤ months, > and ≤ months, > months, and ongoing sustained aplasia). no association existed between time of b-cell recovery and presence of treatment-induced anti-mcar antibodies. b-cell aplasia requiring ivig occurred following tisagenlecleucel in the majority of patients. the tisagenlecleucel concentration-time profiles in patients with treatment-induced anti-mcar antibodies were categorized by time following ivig administration. time of ivig administration had no impact on in vivo transgene expansion and persistence. we report the first comprehensive assessment of the impact of anti-mcar antibodies on clinical endpoints with car therapy. pediatric/young-adult patients with r/r all had a high frequency of baseline anti-mcar antibodies, and preexisting/treatment-induced anti-mcar antibodies did not impact the cellular kinetics, safety, and efficacy of tisagenlecleucel. cell-mediated immunity studies are ongoing. sponsored by novartis. background: adoptive immunotherapy, using cd engager (cd -eng) t-cells, has shown success in preclinical studies, recognizing and killing acute myeloid leukemia (aml) blasts in vitro and in vivo. cd -eng t-cells secrete bispecific molecules that recognize cd (t-cells) and cd (aml blasts), and are able to direct transduced t-cells and recruit bystander t-cells to kill cd -positive blasts. however, cd -engs do not provide costimulation and have not shown the capability for sequential killing of targets in vitro. we are seeking to improve the expansion, persistence and sequential killing capabilities of cd -engs by genetically modifying these cells with an inducible costimulatory molecule, which can be activated by a chemical inducer of dimerization (cid). we generated a retroviral vector encoding cd -eng and the inducible costimulatory molecule myd .cd linked by a a sequence (cd -eng. a.imc). cd -eng and cd -eng.imc t-cells were generated by retroviral transduction, and their effector function was compared with and without cid. we used flow cytometric analysis to assess transduction efficiency, chromium release assays to evaluate cytolytic activity, and elisa to determine cytokine production. we successfully generated cd -eng.imc tcells and achieved a mean initial transduction efficiency of % that was maintained above % throughout our study period. cd -eng.imc t-cells +/-cid and cd -eng t-cells readily killed cd -positive aml blasts (molm and kg a) in cytotoxicity assays when compared to the cd -negative control (k ). in co-culture assays, cd -eng.imc t-cells secreted increased il- and ifn-gamma in the presence of cid and cd -positive targets (kg a and molm ) when compared to co-culture with cd -positive targets in the absence of cid. in addition, cd -eng.imc t-cells displayed enhanced sequential killing capabilities and ifn-gamma secretion when stimulated weekly with cid and tumor cells at a : ratio when compared to cd -eng t-cells. conclusion: cd -eng.imc t-cells are able to recognize and kill cd -positive aml blasts in an antigen dependent manner. cd -eng.imc t-cells have improved effector function in the presence of cid as judged by cytokine production and their ability to sequentially kill cd -positive target cells. thus, inducible myd and cd costimulation is a promising strategy to improve the effector function of cd -eng t-cells, and warrants further active exploration in preclinical studies. background: eliana (nct ; n = ) is a pivotal multicenter study testing the efficacy of tisagenlecleucel, anti-cd car-t, in children/young adults with r/r b-all. tocilizumab (toci) has been used for management of moderate/severe (grade / ) crs in ≈ % of patients treated with tisagenlecleucel at equivalent doses used in approved nononcological pediatric indications (< kg received mg/kg; ≥ kg received mg/kg [ mg max dose]).( ) crs onset, as graded by the penn grading scale, generally occurred at a median of days (range, - ) after infusion, requiring administration of - toci doses in some patients via a protocol-specific treatment algorithm. toci is a humanized monoclonal antibody that inhibits il- receptor (il- r) signaling. the pharmacokinetics (pk) and pharmacodynamics (pd) of toci in pediatric patients with b-all with carassociated crs have not previously been described. objectives: characterize toci pk/pd for crs management following tisagenlecleucel infusion and describe its impact on cellular kinetics. design/method: toci pk and levels of soluble il- r (sil- r) were determined from serum and quantified using validated assays. maximum toci concentration (cmax) was derived using noncompartmental methods. sil- r, proinflammatory cytokines, and crs resolution time were characterized to describe toci pd. summary statistics and graphical analyses of tisagenlecleucel exposure by number of doses were performed to describe the impact of toci on tisagenlecleucel kinetics in patients responding to tisagenlecleucel infusion. : / patients with crs received the first toci dose at a median of days (range, - ) after crs onset. seventeen patients received dose (range, . - mg/kg); received doses ( - mg/kg); received doses ( - mg/kg), per the crs treatment algorithm. first-dose mean cmax (sd) was ≈ ( . ) g/ml; second dose, ≈ ( ) g/ml. individual patient pd concentration-time profiles showed increased sil- r levels after the first toci dose which remained elevated following the second dose. following toci administration, median time to crs resolution (including fever resolution) was days (range, - ). crs onset coincided with tisagenlecleucel expansion, followed by a peak in serum cytokines, including il- . the geometric mean auc - day and cmax of tisagenlecleucel transgene (by pcr) were % and % higher in tisagenlecleucel-responding toci-treated patients. conclusion: crs symptoms resolved within a median of days after toci administration. toci levels achieved in patients with b-all were similar to reported pediatric nononcological indications (tocilizumab label) and resulted in concentration/time-dependent sil- r increases. transgene continued to expand and persist following toci administration. these data support treatment with toci for crs management. ( ) buechner, eha, . sponsored by novartis. background: in acute myeloid leukemia (aml), mesenchymal stem and stromal cells (mscs) in the bone marrow microenvironment contribute to extrinsically mediated chemo-resistance and are therefore important potential therapeutic targets. the study of patient-derived mscs is at a competitive disadvantage, however, because traditional means of isolating mscs from a bone marrow aspirate interferes with isolating the more highly prioritized leukemic cells. many opportunities to study mscs are therefore missed. objectives: to develop a novel method of isolating mscs using the otherwise discarded portion of a bone marrow aspirate, thereby de-coupling the isolation of primary mscs from the isolation of leukemia cells. design/method: aml patient bone marrow aspirates were obtained prospectively from the children's oncology group. healthy patient marrow was purchased. experimental mscs were isolated from the bottom-most layer (rbc-layer) produced by density-gradient separation of a bone marrow aspirate, which is typically discarded. control mscs were isolated from the buffy coat (mnc layer). non-adherent cells were removed after hours, and adherent cells were cultured at % co with mem-alpha containing % fbs. growth curves were obtained by seeding -well plates with , cells per well. cells were stained using oil red o to observe adipocyte differentiation. results: rbc-layer mscs grow successfully following overnight shipment of the aspirate. identical to mnc-layer mscs, rbc-layer mscs exhibit a fibroblastic morphology and are adherent to plastic. rbc-layer mscs persist in culture up to passages before senescence. they exhibit a slower growth curve relative to mnc-layer mscs, but their overall doubling time is similar at approximately hours. surprisingly, mscs from the rbc-layer exhibit adipocyte differentiation on stimulation, revealing their stem-cell like qualities. we present a method of isolating mscs from the discarded portion of a bone marrow aspirate that does not interfere with the isolation of leukemia cells from the same patient. this portion of the aspirate can be shipped, or can sit for at least hours, without sacrificing its mscs. rbclayer mscs are nearly identical to mscs obtained conventionally. perhaps most importantly, rbc-layer mscs retain a stem-cell like capacity, showing them to be a highly valuable cell population in aml research. future plans include investigating potential selective enrichment of stem-cell mscs in the rbc-layer, which could explain the unexpected difference in growth kinetics. aml researchers now have the opportunity to study this exciting component of the bone marrow microenvironment without sacrificing valuable leukemic cells in the process. background: neutropenia is one of the most frequent side effect of chemotherapy associated with an increase in the risk of infection, especially in the cases when the depth and duration of neutropenia are extended. some genes, as variations of darc, gsdma and cxcl are known to influence white blood cell and neutrophil counts. our previous study conducted in children with acute lymphoblastic leukemia (all), showed that polymorphisms in these genes might play a role in the onset of chemotherapy complications during consolidation and maintenance treatment. objectives: in order to support our previous finding, we have expanded the study to the induction period in a cohort of all children treated at the sainte-justine university health center between july and july . design/method: previous associated single nucleotide polymorphisms (snps) in darc, gsdma and cxcl genes were analyzed for an association with the complications occurring during induction including the duration of low neutrophil count (pnn) and low absolute phagocyte count (apc), proven infections and delay between induction and consolidation phases. results: significant effect was found for all studied polymorphims. minor alleles of darc rs , cxcl rs and gsdma rs were all associated with higher risk of complications during induction treatment, whereas that of darc rs (particularly gg genotype) had a protective effect. the gg genotype of rs was associated with a lower risk of post-induction delay (p = . or = . , %ci . - . ), less frequent febrile episodes (p = . ) and lower number of days with apc/pnn count reduction (p = . for apc< . and p = . for pnn< . ). in contrast, the minor t allele of another darc polymorphism (rs ), was associated with longer apc/pnn count reduction (p = . for apc< . and p = . for pnn < . ), as it was the tt genotype of gsdma rs (p = . for apc< . and p = . for pnn< . ). the patients with the gsdma rs had also a higher risk of documented febrile episodes (p = . or = . %ci - . ). the aa genotype of rs cxcl was associated with a higher risk of post-induction delay due to infection (p = . , or = . , % ci . - . ). conclusion: this complementary study confirmed our previous results, showing overall that variations in darc, gsdma and cxcl genes influence the onset of chemotherapy complications in pediatric all, regardless of treatment phases. these polymorphisms might be useful pharmacogenetics markers possibly guiding an adjustment of chemotherapy intensity. background: pediatric acute myeloid leukemia (aml) has a poor survival rate of about % and there is an urgent need for newer targeted therapies. car t-cell based therapies are effective against all but similar therapies against aml are still under development. recent clinical trials have highlighted the concerns about toxicity and therapy related deaths from car t-cells. antigen selection is the key factor determining the specificity, efficacy and toxicity of car t-cells. while contemporary adoptive t-cell therapies use monoclonal antibodies against tumor associated antigens we employed the naturally occurring flt ligand (fl) to target aml cells expressing flt receptors. flt receptor is expressed on multipotent and myelomonocytic progenitors as well as myeloid leukemia cells. to generate fl containing chimeric tlymphocytes designated flcar t-cells and to evaluate their efficacy against aml cells. design/method: flcar was constructed by fusing the coding sequences of the human fl, cd costimulatory domain, and cd -zeta chain (intracellular region) in series. it was then cloned into the phiv-egfp lentiviral vector for expression in cell lines and primary t cells obtained from healthy donors. the empty phiv-egfp vector was used as a negative control. flcar was expressed on both cd + and cd + t-lymphocytes, confirmed by western blot. cell cytoxicity was evaluated by co-culturing flcar t-cells and aml cells followed by flow cytometric analyses. cytokine production was assessed by analyzing expression of interleukin- using quantitative rt-pcr. results: flcar t-cells were generated from cd + jurkat and cd + tk- cell lines with up to % lentiviral transduction efficiency. the efficiency for primary t cells was lower ( - %). flcar was expressed as a ∼ kda protein in cells and was partially phosphorylated on tyrosine. the expression of flcar on lymphocytes lead to increased basal il- expression in the cells. this was further augmented (by > folds) upon co-incubating flcar t-cells with flt expressing target cells. jurkat cells, tk- cells and primary human t cells expressing flcar suppressed the growth of flt -expressing aml cell lines and primary aml cells in vitro. notably, flcar t-cells generated from healthy donors caused strong inhibition of aml cells even at a lower transduction efficiency. in vivo experiments using nsg-sgm mice xenografted with human aml cells are underway. our data demonstrate that flcar can be effectively expressed on t-lymphocytes and mediate potent cytotoxicity against flt -expressing aml cells in vitro. being a completely human derived chimeric protein, it represents a promising candidate for further therapeutic development. holly pacenta, kelly sullivan, ahwan pandey, kelly maloney, joaquin espinosa children's hospital colorado, denver, colorado, united states background: individuals with down syndrome (ds) have a -fold higher risk of developing acute lymphoblastic leukemia (all) than the typical population. there are several important differences between all in individuals with ds (ds-all) and all in individuals without ds (nds-all): first, patients with ds-all have a lower percentage of favorable cytogenetic features compared to nds-all. second, patients with ds-all are more likely to have activating mutations in jak , crlf overexpression, and ikzf deletions. despite these clear genotypic differences, this knowledge has not yet been exploited for therapeutic purposes in ds-all. when outcomes for ds-all are compared to nds-all with similar cytogenetic features, the survival rates are similar. however, individuals with ds-all have an increased risk of treatment-related mortality (trm). current therapy for ds-all is similar to that for nds-all, with the exception of small changes to decrease toxicities that are more prevalent in ds-all. it was recently identified that interferon signaling is constitutively activated in healthy individuals with t . we hypothesize that aberrant interferon signaling could play a role in the unique leukemias observed in ds patients. objectives: to identify differences in gene expression and intracellular signaling cascades that are unique to individuals with ds-all, relative to both nds-all and healthy individuals with ds that can be exploited for therapeutic use. design/method: bone marrow samples were obtained from ds-all patients and matched nds-all patients based on clinical characteristics and genetic features. rna sequencing of these samples was performed and a total of samples were used for the transcriptome analysis ( ds-all vs. nds-all). the differential expression data was generated by deseq and analyzed using ingenuity pathway analysis. the analysis revealed that the chromosome genes that have been implicated in leukemogenesis are not differentially expressed in the ds-all samples, relative to nds-all. an inflammatory signature was identified, which included interferon gamma as an upstream regulator with predicted activation in ds-all. this finding is consistent with prior observations from healthy individuals with ds. other examples of results with potentially actionable targets include the upregulation of several genes in the ras pathway and genes involved in histone methylation. the increased interferon signaling seen in healthy individuals with ds was also identified in ds-all. this may contribute to the development of mutations in inflammatory pathways such as jak and crlf in ds-all. targeting these common pathways with small molecule inhibitors may have a therapeutic benefit in ds-all. cincinnati children's hospital medical center, cincinnati, ohio, united states background: next-generation sequencing (ngs) guides precision medicine approaches in oncology using therapies targeting molecular alterations found within an individual cancer. increased availability of ngs coupled with a proliferation of targeted drugs in development heightens the need for reliable pre-clinical animal models. here we report a patientderived xenograft (pdx) system with integrated molecular profiling for pre-clinical testing of conventional cytotoxic and novel targeted agents. objectives: to utilize ngs from patients with pediatric leukemia to guide rational pre-clinical trials in pdx leukemia avatars, and to determine pdx mice tolerance of and response to cytotoxic and targeted therapies. pediatric acute lymphoblastic leukemia (all) samples were obtained in adherence to an irb-approved protocol and xenografted into nod/rag/interleukin- (il- )rg (nrg) mice. ngs was performed clinically using the foundationone® heme panel. a de novo all sample bearing mutations involving jak , crlf , ntrk , cdkn a/b, ptpn and wt was used for pre-clinical testing. thirty-seven nrg mice were transplanted with million patient cells/mouse via iv injection. standard -drug induction chemotherapy was administered consisting of vincristine, dexamethasone, pegaspargase, and daunorubicin [vxpd, n = mice], in comparison to vehicle control [n = ]. parallel pdx cohorts were treated with single agent targeted therapies based on ngs findings, including ruxolitinib [n = ], crizotinib [n = ] and loxo- [n = ]. the four-week treatment period began on day + from transplant after confirmation of engraftment. following completion of therapy, residual disease burden was analyzed by flow cytometry (hcd +, mcd -cells) in the bone marrow [bm] . to date, pdx models have been established using over thirty ngs-profiled pediatric all samples, including six samples bearing philadelphia (ph) chromosome or phlike mutations. pre-clinical testing was performed in a repre- conclusion: ngs reveals concomitant mutations in ph-like all that may represent additional targets for therapy, or predict tyrosine kinase inhibitor (tki) resistance. we show that all xenograft nrg mice can tolerate a -week multi-agent cytotoxic chemotherapy induction regimen, as well as rational targeted agents, and serve as a robust pre-clinical model for precision medicine trials. background: osteonecrosis is a well-characterized all therapeutic toxicity attributed to glucocorticoids, asparaginase, and methotrexate that disproportionately affects adolescents. in ccg- , alternate-week dexamethasone during double delayed intensification (di) reduced osteonecrosis vs continuous dexamethasone with single di in rapid early responders (rer) ≥ y. to compare efs and os between hr-all patients with vs without osteonecrosis. design/method: hr-all patients - y on aall ( - ) received cog augmented therapy with a × randomization to: ( ) induction dexamethasone ( mg/m d - ) vs prednisone ( mg/m d - ), and ( ) interim maintenance (im) high-dose methotrexate (hdm) vs escalating-dose methotrexate/pegaspargase (ema). rer received single, and slow early responders (ser) double, im/di. initially, all received monthly dexamethasone maintenance pulses, patients ≥ y received di alternate-week dexamethasone, and patients ≤ y received di continuous s of s dexamethasone. there were osteonecrosis-related amendments: after / all patients ≥ y received di alternateweek dexamethasone; after / all patients ≥ y were assigned to induction prednisone, and all patients received di alternate-week dexamethasone and maintenance prednisone pulses. results: osteonecrosis was confirmed in / patients. the y cumulative incidence (ci) was . % overall and increased with age: - y . %, - y . % (alternateweek dexamethasone . % vs continuous dexamethasone . %; p< . ), ≥ y . % (p< . ). among randomized rer patients ≥ y, ci differed by glucocorticoid (dexamethasone . % vs prednisone . %; p = . ) but not methotrexate assignment (hdm . % vs ema . %; p = . ). among randomized ser patients ≥ y, ci was . % with no difference by regimen. results were similar for patients ≥ y. in the entire study population, patients with osteonecrosis had superior y efs ( . % vs . %; p< . ) and os ( . % vs . %; p< . ) than those without osteonecrosis. y efs was significantly higher among randomized patients ≥ y with vs without osteonecrosis ( . % vs . %; p< . ); this finding was present in different age ranges (≥ y, ≥ y, ≥ y) and rer/ser subsets within each, especially in the ≥ y rer ( . % vs . %; p = . ) and ser ( . % vs . %; p< . ) cohorts. across groups, asparaginase allergy was significantly associated with reduced osteonecrosis risk (≥ y: hr . ; p = . ). patients who develop osteonecrosis have significantly increased efs and os, suggesting host differences that increase sensitivity to develop osteonecrosis and render all cells more chemo-responsive. pennsylvania state university, hershey, pennsylvania, united states background: cdc (cell division cycle protein ) belongs to rho family of small gtpases in ras-oncogene superfamily. pro-oncogenic role of overexpressed cdc in ras driven solid tumors are well known. however, role of cdc in leukemia is yet to be established. ikzf encodes ikaros protein which has important role in regulation of lymphoid development and tumor suppression in leukemia. casein kinase ii (ck ) oncogene is overexpressed in leukemia. ck impairs ikaros function which can be restored by using ck inhibitors. objectives: to investigate role of cdc in leukemia and regulation of cdc by ikaros and ck in b-cell acute lymphoblastic leukemia (b-all). shrna transfection, real time-pcr, luciferace assay, quantitative chromatin immunoprecipitation (qchip) coupled with the next-generation sequencing (chip-seq), cytotoxicity assay and western blot. results: cdc is identified as one of the ikaros target genes by analysis of genome-wide dna binding of ikaros using chip-seq and qchip in b-all primary cells. expression of cdc was also noted to be higher in all patient samples compared to normal bone marrow. functional experiments showed that ikaros overexpression via retroviral transduction results in transcriptional repression of cdc . ikaros silencing using shrna resulted in increased expression of cdc . these data suggest that ikaros negatively regulates transcription and expression of cdc . ck directly phosphorylates ikaros and impairs its function as transcription factor. we noted that molecular inhibition of ck via sirna as well as treatment with specific ck inhibitor, cx also decreases expression of cdc . treatment with cx of primary b-all with ikaros haploinsufficiency restores ikaros binding to cdc promoter and represses cdc expression. however, this effect is evident only in presence of ikaros. treatment with cx in ikaros silenced (ikaros shrna) cells showed no change in expression of cdc . these results emphasizes the importance of ikaros in regulating cdc expression. furthermore, we analyzed the changes in epigenetic signature at the cdc promoter following treatment with cx . results show that loss of histone marker of open chromatin (h k ac) and increased histone marker for repressive chromatin (h k me ), at the cdc promoter. these data suggest that ikaros transcriptionally represses cdc via chromatin remodeling. a specific cdc inhibitor, ml showed cytotoxic effects on primary b-all cells. conclusion: cdc may have important role in hematologic malignancies. expression of cdc in b cell all is regulated by ikaros and ck . these results suggest that targeting cdc could be a potential therapeutic strategy in leukemia. caitlyn duffy, laura hall, justin godown, koyama tatsuki, scott borinstein monroe carell jr. children's hospital at vanderbilt, nashville, tennessee, united states background: systemic corticosteroids are widely used as treatment of acute lymphoblastic leukemia (all) and lymphoblastic lymphoma. there are anecdotal reports of bradycardia in pediatric patients receiving corticosteroids, but a more extensive analysis of this effect is needed. objectives: the aim of this study was to describe the incidence, severity, and timing of steroid-induced bradycardia and document any adverse events associated with bradycardia. design/method: we performed a retrospective review of all newly diagnosed patients at our center ( - ) with all/lymphoblastic lymphoma who received corticosteroids (dexamethasone - mg/m /dose or prednisone mg/m /dose) during induction chemotherapy. patients were excluded if they had a pre-existing cardiac abnormality or if they received prior corticosteroids. the average hour heart rate (hr) was assessed for the period prior to initiating steroid therapy and for the hour period surrounding the nadir following steroid administration. the degree and time of steroid induced bradycardia was assessed. adverse patient events and concomitant medication use was documented to identify other contributing factors to bradycardia. a total of children ( females, males, months- years) were included in the analysis with demonstrating a decrease in mean hr following steroid administration. median hr decrease was . beats per minute (quartiles . - ) from prior to initiating steroids to surrounding nadir. sixty one percent developed bradycardia less than or equal to the st percentile for their age range. nadir occurred doses (range - ) into treatment, which corresponded to hours ( - ) after initiation of therapy. of patients who experienced bradycardia, % were associated with dexamethasone rather than prednisone. hr nadir was not associated with other vital sign abnormalities. after completion of induction chemotherapy, % of patients had documented resolution of bradycardia with hr greater than the th percentile for age. it was observed that the children who continued to have relatively low hr were often younger ( months- years old). examination of nadir hr during subsequent hospitalizations in which steroids were not being administered (excluding hr during procedural sedation) did not demonstrate a significant incidence of bradycardia. concomitant opioid, beta-blocker, or other medication exposure did not contribute to the incidence of bradycardia. corticosteroid-induced bradycardia is extremely common in children, teenagers, and young adults with all receiving induction chemotherapy. bradycardia was not associated with clinical adverse events and resolved after completion of corticosteroid treatment. therefore, further cardiac assessment may not be warranted in the presence of bradycardia suspected to be secondary to steroid administration. baylor college of medicine, houston, texas, united states background: survival in newly diagnosed pediatric acute myeloid leukemia (aml) is approximately %; however survival falls dramatically if a patient relapses. currently, approximately one-third of patients with pediatric aml relapse on standard chemotherapy regimens. aml cells are exposed to proteotoxic stress at baseline due to their rapid and inefficient metabolism; proteotoxic stress increases after chemotherapy due to accumulation of reactive oxygen species resulting in misfolded proteins. this leads to activation of cell stress pathways, such as the unfolded protein response (upr) in the endoplasmic reticulum. because an activated upr can make cells more sensitive to proteotoxic stress, we hypothesize that upr activation correlates with response to chemotherapy. objectives: determine the status of upr in pediatric aml and its correlation with chemosensitivity; design/method: peripheral blood samples from pediatric patients with aml were collected at the start of induction chemotherapy, - hours (h) and h post initiation of systemic chemotherapy. tumor cells were sorted from peripheral blood mononuclear cells. expression of upr proteins was determined by chemiluminescence using an automated capillary electrophoresis system. clinical correlations were performed using an annotated database. we measured five upr proteins: grp (glucose regulated protein kda), phospho-eif , inositol-requiring enzyme (ire ) and activating transcription factor (atf ). patients with aml had - times higher expression of upr proteins (except atf ) at baseline than normal controls. grp -the key upr driver-had the highest level of protein expression in myeloid blasts. there was a wide variability in the level of baseline upr expression. eight out of samples expressed > fold increase in grp above those with the lowest grp levels. similarly, and patients respectively, had a > fold increase in peif and ire , compared to patients with low basal expression of these upr proteins. in our limited sample set, there was a trend towards lower overall survival (os) and event-free survival in patients with low baseline grp and ire . conclusion: upr has a variable expression at baseline in pediatric aml, with a trend towards lower os in patients with a low basal grp and low ire expression, suggesting less chemosensitivity in this subgroup. conversely, it is possible that blasts with an upregulated upr prior to chemotherapy manage proteotoxic stress less effectively, having faster apoptosis and hence a better response to chemotherapy in patients with a high basal upr. we are currently expanding our findings in a larger cohort of patients enrolled in the children's oncology group aaml protocol. background: children with newly diagnosed acute lymphoblastic leukemia (all) undergo chest x-ray (cxr) evaluation during initial diagnostic workup to ensure safe airway management. however, to our knowledge, no systematic assessment of cxr findings has been reported. objectives: to evaluate cxr findings at diagnosis of all and their associations with clinical characteristics. we reviewed the cxr findings at diagnosis of all in patients treated on the total xv and xvi protocols at st. jude children's research hospital. findings were evaluated for associations with clinical characteristics at presentation, and the clinical management of mediastinal masses was reviewed. mediastinal masses were seen in ( . %) of patients evaluated and were more common in older patients (mean age, . years) than in younger patients (mean age, . years) (p = . ), in males than in females (p = . ), and in patients with t-all than in those with b-all (p< . ). also associated with mediastinal masses were a higher white blood cell count (wbc) at diagnosis (mean, . × /l) (vs. a lower wbc; mean, . × /l) (p< . ), cns involvement (vs. no involvement) (p = . ), and standard/high-risk disease (vs. low-risk disease) (p< . ). other cxr findings included pulmonary opacity ( patients [ . %]), bronchial/perihilar thickening ( patients [ . %]), cardiomegaly ( patients [ . %]), and osteopenia/fracture/periosteal lesions ( patients [ . %]). pulmonary opacity was more common in younger patients (mean age, . years) than in older patients (mean age, . years) (p = . ) and in those with t-all (vs. b-all) (p = . ). bronchial/perihilar thickening, cardiomegaly, and osteopenia/fracture/periosteal lesions were also more common in younger patients than in older ones (p< . , p = . , and p< . , respectively) and in those with low-risk disease (versus standard/high-risk disease) (p< . , p = . , and p = . , respectively). of the patients with a mediastinal mass on cxr, underwent a confirmatory chest ct scan, and ( . %) were confirmed to have a mediastinal mass. notably, patients ( . %) had airway compression, and compression of venous structures was identified in of patients ( . %) who received iv contrast. the clinical course was evaluated for patients with mediastinal masses detected by cxr. fifty patients ( . %) required icu admission (mean stay, . days). general anesthesia was used for only patients ( . %), and patients ( . %) had a less invasive peripherally inserted central catheter. no deaths occurred in the acute phase. conclusion: cxr at the time of all diagnosis can detect various intrathoracic lesions and is helpful in planning initial diagnostic workup and management. background: mertk is a receptor tyrosine kinase that is aberrantly expressed in % of pediatric primary aml samples. mertk inhibition with the small molecule tyrosine kinase inhibitor (tki) mrx- decreases tumor burden and prolongs survival in aml xenografts. while treatment with mrx- reduces leukemia in the peripheral blood, it is less effective in the bone marrow, suggesting a role for the marrow microenvironment in therapeutic resistance. the jak/stat pathway has been implicated as a mediator of bone marrow derived resistance to tkis and inhibitors of this pathway are in clinical development for the treatment of aml. to determine the role of the bone marrow stromal niche in mediating resistance to mertk inhibition and to evaluate the efficacy of combined mertk and jak/stat inhibition. design/method: aml cell lines were cultured with or without the hs stromal cell line or hs conditioned medium, then treated with mrx- +/-the jak/stat inhibitor ruxolitinib, or control. induction of apoptosis and cell cycle arrest in aml cells was measured by flow cytometry. expression of h ax and total and phosphorylated stat were determined by immunoblot. results: co-culture with stromal cells significantly reduced aml cell death and g /m phase arrest in response to treatment with nm mrx- compared to no co-culture (cell death: . % versus . %, p< . ; g /m arrest: . % versus . %, p< . ). g /m arrest was accompanied by an increase in h ax expression which was similarly abrogated in co-culture. conditioned medium did not provide protection from mrx- induced apoptosis, g /m arrest, or h ax induction. mrx- inhibited stat phosphorylation but direct co-culture and conditioned medium potently increased basal stat phosphorylation which was not inhibited by mrx- . to determine whether the observed induction of stat phosphorylation was functionally relevant, cocultures were treated with both mrx- and ruxolitinib. while ruxolitinib potently inhibited the phosphorylation of stat in the presence of co-culture, combination treatment did not overcome stromal mediated protection from mrx- induced apoptosis. similarly, the addition of exogenous gm-csf induced stat phosphorylation but did not yield protection from mrx- functional effects in the absence of co-culture. together these data support a model whereby direct cell-cell contact with stromal cells in the bone marrow niche protects leukemia cells from mrx- induced apoptosis, cell cycle alterations, and dna damage. while co-culture potently induces phosphorylation of stat in leukemia cells, this is neither necessary nor sufficient for stromal-cell mediated protection from mertk inhibition and combined treatment with jak/stat inhibitors is unlikely to be therapeutically efficacious. background: mercaptopurine ( -mp) is an immunosuppressive thiopurine drug that is a key component of acute lymphoblastic leukemia (all) treatment. -mp is metabolized into -thioguanine ( -tgn), which is responsible for anti-leukemic effects, as well as -methylmercaptopurine nucleotides ( -mmpn/ -mmp), which are associated with hepatotoxicity. some patients preferentially metabolize -mp to -mmpn/ -mmp, increasing their risk for hepatotoxicity and potentially reducing anti-leukemic effects. hepatotoxicity can cause interruptions or delays in therapy that may jeopardize cure rates. allopurinol has been increasingly used in patients with inflammatory bowel disease (ibd) to shunt -mp metabolism toward -tgn and away from -mmpn to minimize hepatotoxicity and preserve therapeutic effects. objectives: this retrospective chart review expands upon our previously published case series of three patients with all in whom allopurinol was successfully used to redirect -mp metabolism. twelve additional patients have subsequently received allopurinol and -mp combination therapy at texas children's hospital. data from this larger patient sample, with longer follow up, is being analyzed to increase knowledge of the effectiveness and longitudinal effects of adding allopurinol to -mp to reduce risk of hepatotoxicity. design/method: data were abstracted from the electronic medical records of patients with all treated at texas children's hospital from to present, who had been found to have evidence of altered -mp metabolism and in whom allopurinol was added to -mp therapy due to concern for risk or recurrence of hepatotoxicity. metabolite levels, -mp dose, and alanine transaminase (alt) prior to initiation of allopurinol and approximately weeks later were compared. wilcoxon signed-rank test was applied for statistical analysis. : after the addition of allopurinol, patients experienced a significant decrease in mean levels of -mmpn (p = . ), correlating with a significant decrease in mean alt (p = . ). with the initiation of allopurinol, the mean -mp dose was decreased from to mg/m /day over an -week period. mean -tgn levels increased (p = . ). in follow up beyond weeks, no patients had further holds in -mp due to hepatotoxicity. addition of allopurinol appears to shift metabolism from -mmpn toward -tgn, with increases in mean -tgn levels despite a decrease in mean -mp dose. this may limit negative side effects, thus resulting in fewer gaps in therapy and possible improved outcomes. further analysis of -mp dose titration and effects on anc over time as well as effects on overall survival is ongoing. prospective background: alterations in epigenetic patterning are a fundamental feature in acute myeloid leukemia (aml). treatment with dna methyltransferase inhibitors (dnmti) yields responses in aml, but the molecular mechanisms underlying this effect are poorly understood. in prior work, we demonstrated induction of genes involved in the pirna rna (piwi) silencing pathway as a common gene feature of aml cell lines treated with decitabine. the piwi pathway is an rna silencing system, distinct from classical small rna transcriptional silencing, responsible for transposon-silencing in gametogenesis; emerging data suggest a role for this system in somatic cells. based on these data, we postulate that piwi induction plays a crucial role in aml recovery following demethylation and that disruption of this pathway would modulate response and/or recovery from decitabine treatment. to assess the effect contribution of the pirna pathway response following dnmti treatment in aml. design/method: to choose target genes in the pirna pathway for disruption, molm cells were first treated with escalating doses of decitabine. using quantitative rt-pcr, the dose-dependent expression of several pirna-associated genes were analyzed. two genes, mael and piwil , were selected for disruption experiments based on preliminary data suggesting decitabine dose-dependent responses. molm cells were transduced with shrna targeting these genes using a lentivirus delivery system with selection in puromycin. knockdown efficiency was assessed by rt-qpcr. to determine how gene disruption affected cell growth, knockdown cells were treated with decitabine nm. proliferation was assessed by celltiter glo assay following decitabine treatment. clonogenic potential was assessed by colony forming assays of transduced cells after treatment with decitabine at nm and nm. results: following decitabine exposure in molm , there was a markedly increased expression of mael and piwil compared to untreated cells ( : and : , respectively) . thus, these were the candidate genes chosen for disruption. of mael shrna constructs, two resulted in a % relative expression of mael compared to controls. of the piwil shrna constructs, the best knockdown showed % relative expression. there were no significant differences in proliferation or clonogenicity of stably selected mael or piwil knock-down molm cells following decitabine treatment. using gene knockdown procedures, mael and piwl do not appear to have a marked effect on growth and response to decitabine treatment in molm . however, these results may be limited by inefficient knockdown using shrna targeting methods. further work using a cas /crispr based inactivation of these genes is ongoing. children cancer hospital cairo, egypt background: hypodiploidy < chromosomes is very uncommon and have particularly poor outcomes in childhood acute lymphoblastic leukemia (all). it is subdivided into: near-haploid ( - chromosomes), lowhypodiploid ( - chromosomes) and high-hypodiploid ( - chromosomes). to determine if minimal residual disease (mrd) can identify a group of patients with better prognosis in the hypodploid population who can be treated with intensive chemotherapy alone. design/method: a retrospective study that included all patients under age of diagnosed as hypodiploid b-precursor all during the period between january -december and treated at children's cancer hospital egypt on sjcrh total study-xv for ir/hr all. sixteen patients had < chromosomes ( nearhaploid and low-hypodiploid), constituting % of all pediatric patients with b-precursor all during the study period. patients with near-haploid all had a median age of years (range - ), initial leukocyte count (wbc) median of . × /l (range . - . ), ( . %) were males and / ( . %) had hr-nci criteria. four patients ( . %) are alive in complete remission(cr) (range - months, median ), one died in induction and ( . %) had hematological relapse (range . - months, median ). patients with low-hypodiploid all had significantly older age (median years, range - ), median wbc . × /l (range . - . ), / ( . %) were males. one patient ( . %) is alive in cr, one died in induction, one failed to achieve cr post-induction and patients( %) had hematological relapse (range . - . months, median . ). mrd< . % by flow-cytometry on day- and end of induction was achieved in / ( . %) and / patients( %) with near-haploid, compared with / ( . %) and / patients( %) with low-hypodiploid; respectively (p = . , p = . ;respectively). allogeneic transplantation was performed during initial remission only in mrd negative patients (one relapsed and one is in cr) and in the patient with induction failure (relapsed post-transplant). five of the total six patients who had negative mrd on day- and end of induction are alive in cr ( / with chemotherapy alone). all patients with negative mrd at end of induction but with mrd levels≥ . % on day- (range . - . %) relapsed as well as all patients with detectable mrd at the end of induction. the difference in relapse was statistically significant in relation to negative-mrd on day- (p = . ), but not at end of induction(p = . ). conclusion: children with hypodiploid all and negative mrd on day- of induction are highly curable with intensive chemotherapy alone, while patients with negative mrd at the end of induction and detectable mrd on day- had dismal outcome. background: overall survival in pediatric acute myeloid leukemia (aml) has plateaued between - %, with death during induction chemotherapy seen in - % of patients. respiratory complications contribute to morbidity and mortality in pediatric aml induction, however the incidence, patterns, and predictors of respiratory adverse events (aes) during this period are unknown. to estimate the incidence of respiratory aes during induction therapy for de novo pediatric aml, to characterize and grade these respiratory aes, and to identify predictors of respiratory ae development. we conducted a retrospective longitudinal study from presentation to day in institutional de novo pediatric aml patients (≤ years) between march and december . outcomes included any nci ctcae grade - respiratory ae or death from another cause. demographic, disease, and treatment-related data were abstracted. the most specific, best-fitting ctcae category and grade for each ae was determined. descriptive statistics, survival analysis, multivariable logistic regression analysis, and time-toevent distributions were performed (sas v . , cary, nc) . among eligible patients, . % (n = ) experienced discrete respiratory aes. incidence of grade - aes was . % (n = ). a bimodal time-to-event distribution demonstrated peaks at treatment days and . induction death occurred in . % (n = ) including deaths from respiratory failure associated with disseminated fungal disease. in univariate analysis, those experiencing aes differed significantly in regards to older age at diagnosis (p< . ), higher initial wbc (p = . ), higher initial peripheral blast percentage (p = . ), coagulopathy at diagnosis (pt (p = . ), d-dimer (p = . )), fluid overload status (p< . ), occurrence of infection (p = . ), and occurrence of tumor lysis syndrome (tls) (p = . ). patients with hyperleukocytosis (p = . ), fluid overload (p< . ), and fab m morphology (p = . ) each had a significantly decreased probability of completing the follow up period without experiencing a respiratory ae. on multivariable analysis, fluid overload (aor . [ % ci: . - . ) and older age (aor . [ % ci: . - . ) were significantly associated with ae occurrence when gender, hyperleukocytosis, tls, and infection status were held constant. we describe a high incidence of respiratory aes during pediatric aml induction. fluid overload and older age at diagnosis are independently associated with ae development when controlling for other proposed risk factors. interventions focused on conservative fluid management and offset of fluid overload should be explored in newly diagnosed pediatric aml in an effort to reduce respiratory complications during induction. overall, all survival rates are outstanding and have continued to improve with risk-adapted therapy. the most striking improvement occurred in t-all where -year os rates now exceed % and parallel b-all. survival improvements, however, have not been observed uniformly across all subgroups. while the gap in outcome differences narrowed among blacks, outcomes for hispanics have remained static. further, no improvements in survival were observed in infants or ayas and new treatment approaches have been implemented for these populations. background: acute myeloid leukemia (aml) accounts for approximately % of new childhood leukemia cases. chest x-ray (cxr) is performed in all newly diagnosed aml cases to evaluate the safety of airway management for anesthesia during diagnostic procedures; however, cxr results in pediatric patients with aml have not been described. objectives: the primary objective was to evaluate cxr findings at diagnosis in patients with aml. the secondary objectives included assessing associations between cxr findings and clinical characteristics, with the overall goal of aiding in the evaluation of the use of cxrs as an initial diagnostic study in pediatric patients with aml. design/method: cxr findings and clinical characteristics were evaluated in patients with newly diagnosed aml who were enrolled in one of three protocols at st. jude children's research hospital (aml , aml , and aml ). the findings were categorized based on radiologic reports. further, the associations of these findings and clinical characteristics were evaluated. we evaluated cxr findings in a total of patients: from aml ; from aml ; and from aml . common cxr findings were pulmonary opacity (n = , . %), bronchial/perihilar thickening (n = , . %), splenomegaly (n = , . %), mediastinal mass and lymph nodes (n = , . %), pleural effusion/thickening (n = , . %), demineralization/fracture/periosteal lesions (n = , . %), scoliosis (n = , . %), and granulomatous disease (n = , . %). three cxr findings were associated with younger age at diagnosis: pulmonary opacity (median age, . years in patients with positive findings vs. . years in those with negative findings, p< . ), bronchial/perihilar thickening (median age, . years vs. . years, p< . ), and demineralization/fracture/periosteal lesions (median age; . years vs. . years, p = . ). two cxr findings were associated with older age at diagnosis: scoliosis (median age, . years vs. . years, p< . ) and granulomatous disease (median age, . years vs. . years, p = . ). higher white blood cell counts (wbcs) at diagnosis were associated with cxrs showing pulmonary opacity (median wbc; . × ^ /l vs. . × ^ /l, p = . ) or splenomegaly (median wbc; . × ^ /l vs. . × ^ /l, p = . ). french-american-british (fab) m /m subtypes were more frequently associated with pulmonary opacity compared with others (p< . ). we did not find significant differences between female and male patients. conclusion: cxr in patients with newly diagnosed aml showed a variety of thoracic, abdominal, and bony lesions that are important for the initial evaluation and management. pulmonary opacity was the most common finding and was frequently seen in patients who were younger or had higher wbcs at diagnosis or fab m /m . background: children diagnosed with acute lymphoblastic leukemia (all) require a central venous catheter (cvc) to administer chemotherapy safely. both external and internal cvcs carry risks of complications including thrombosis, infection, and possible replacement. internal catheters, such as a port, are generally used for the majority of patients for the duration of treatment since therapy lasts for several years. many institutions place a port at the time of diagnosis. other institutions prefer to start induction therapy via placement of a peripherally inserted central catheter (picc) and defer port placement until the completion of induction therapy due to concerns of increased risk of infectious complications with port placement. objectives: to compare rates of common cvc associated complications by type of cvc placed at start of induction therapy in children treated for newly diagnosed all at the jimmy everest center (jec) at the university of oklahoma health sciences center. design/method: a retrospective chart review analyzed data from newly diagnosed all patients treated at the jec between - . data was collected on complications including thrombosis, bacteremia, insertion site infection, cvc malfunction and need for removal. data collection began at the start of induction and was completed at the end of induction therapy. statistical analysis used a univariate and multivariate logistic regression model to compare complication rates between those who had a port versus those who had a picc placed at start of induction. results: data was collected on patients. fifty-six patients had a port placed at start of therapy while had a picc placed. fourteen percent of patients had a cvc associated complication. univariate analysis showed no statistically significant difference in rates of cvc associated complications between the groups (port %, picc . % p = . ). the rates of hospitalization for cvc associated complications were similar between both groups (port %, picc % p = . ). rates of cvc removal were also similar between both groups (port %, picc % p = . ). multivariate model that included baseline patient characteristics including type of all, patient body surface area, gender, ethnicity and age continued to demonstrate no significant difference in cvc associated complications between both groups. conclusion: this single institution study showed that there was no significant difference in cvc associated complications between port and picc line placement at the start of childhood all induction therapy. port placement can be considered as a safe option at the start of induction therapy. complete remission [cr] or cr with incomplete blood count recovery [cri]) within treatment cycles - . interim data are reported (nct ). results: seventeen patients were enrolled and received ≥ dose of lenalidomide; median age was years (range - ); patients were female. patients received median prior regimens (range - ). nine patients had previously undergone bone marrow transplantation (bmt). four patients had relapsed aml and were refractory to immediate prior treatment. median duration of study treatment was weeks (range - ); patients completed a median of treatment cycle (range - ). all patients were evaluable for primary outcome; achieved morphologic cri after cycles (no patients achieved cr). the responder was a -year-old male with history of r/r aml after first-and second-line treatment, bmt, and salvage chemotherapy. at baseline, he had a complex cytogenetic karyotype (monoallelic − q . , − q, − q . , − p ) with no identifiable molecular mutation; he was also positive for del( q) (− q , − q ). his post-treatment karyotype showed no abnormalities. sixteen patients experienced treatment failure; due to resistant disease, of indeterminate cause, and had treatment failure before a post-baseline assessment was performed. all patients experienced ≥ grade - treatment-emergent adverse event (teae). the most commonly reported were thrombocytopenia (n = ), anemia (n = ), febrile neutropenia (n = ), and hypokalemia (n = ). fifteen patients experienced ≥ teae related to lenalidomide. all patients discontinued treatment; remain in follow-up. the study is now closed to enrollment. ten patients died on study: during treatment, during follow-up. all deaths were attributed to aml or complications due to aml. conclusion: third-line lenalidomide monotherapy was associated with clinical response in of pediatric patients with r/r aml; however, treatment exposure was limited. safety data are consistent with the known profile of lenalidomide. lenalidomide was not an efficacious treatment for r/r pediatric aml. funding: celgene corporation, summit, nj, usa. cook children's medical center, fort worth, texas, united states background: it is well documented that pediatric patients with acute lymphoblastic leukemia (all) often experience significant weight gain during induction therapy and later struggle with obesity. however, some patients experience unintended weight loss during induction therapy; since this issue is not well reported, it often goes undertreated. although malnutrition is reported to be associated with decreased survival, increased risk of infection, and loss of lean body mass, there remains a scarcity of in-depth analysis of prevalence and risk factors that contribute to this problem. our study attempts to address this critical yet unmet need. objectives: our aim was to identify the clinical risk factors and outcomes associated with weight loss during induction therapy for pediatric all. design/method: this was a retrospective chart review of patients between and years of age diagnosed with all at cook children's medical center from / / to / / . for each patient, we collected height, weight, age, body mass index (bmi) z-scores at diagnosis and end of induction therapy, risk stratification, and whether consolidation was delayed. patients with a bmi > th percentile at diagnosis were categorized as being overweight or obese. using logistic regression analyses, we examined which variables predicted whether the patient had an increase or decrease in bmi z-score throughout induction. a critical alpha level of . indicated statistical significance. results: ninety-six patients met our inclusion criteria. of these, % experienced a decrease in bmi during induction therapy. compared to patients whose bmi increased during induction, patients with a decrease in bmi were more likely to be overweight or obese at diagnosis ( % vs. %; p< . ), to be ≥ years of age ( % vs. %; p< . ), to have a high-or very-high-risk stratification ( % vs. %; p< . ), and to experience a delay in the start of consolidation therapy ( % vs. %; p< . ). conclusion: this research highlights a risk not previously identified in the literature that may impact outcomes. patients treated on high-or very-high-risk protocols, who are overweight or obese at diagnosis, and who are ≥ years of age at diagnosis should be monitored closely for weight loss during induction therapy. patients who experience weight loss should receive prompt intervention. it is our hope that this information can be used for future prospective studies and to help develop evidence-based guidelines. background: p abnormalities have been observed in some patients with hematologic malignancies. loss of p function as a tumor suppressor gene in the chromosome plays an important role for development of leukemia. these patients usually have poor outcome due to the chemotherapy and are associated with poor prognosis. objectives: this study aimed to identify frequency of p abnormalities between iranian children and adult patients with aml (acute myeloid leukemia) malignancy. design/method: the p abnormalities were analyzed via bone marrow karyotyping and fish method in acute myeloid leukemia patients. in this study, p abnormalities were observed in ( %) patients out of diagnosed cases. a significant strong correlation between p abnormalities and other high risk factors (poor risk cytogenetic) were observed. from patients with aml malignancy ( p abnormalities), ( %) patients have complex karyotype, ( %) patients monosomal karyotype and ( %) patients have monosomal karyotype accompanied with a complex karyotype. overall, p abnormalities are independent risk factor in acute myeloid leukemia and evaluation of these abnormalities by fish or other complementary techniques prior to treatment, might help for better risk stratification of high risk aml patients. background: hepatotoxicity in treatment of acute lymphoblastic leukemia (all) is well studied and transiently affects most patients receiving antimetabolite therapy. rarely, patients develop liver injury severe or prolonged enough to undergo a liver biopsy. little is known about how these patients differ from patients that develop transient hepatotoxicity. we sought to describe disease and treatment characteristics for all patients that developed hepatotoxicity severe enough to undergo liver biopsy. we also looked for pre-dictive factors for liver biopsy, including signs of early hepatic injury from the initial treatment protocol. design/method: pathology reports of all patients from the liver biopsy database at children's healthcare of atlanta were collected. controls were matched : for age, all subtype, and treatment protocol. demographics, treatment protocols, and overall outcomes were collected through the electronic health record. hepatic lab results for transaminases, coagulation, and albumin were collected for induction, consolidation, interim maintenance, delayed intensification, and maintenance. results: sixteen patients diagnosed between - (median age at diagnosis years, range - ; % male; % pre-b all) were included in the case series. the median time from diagnosis to liver biopsy was . years (range - ). eight patients ( %) were in maintenance at the time of biopsy; none had active disease. eight ( %) were postbone marrow transplant. biopsy results included: steatosis ( ), acute inflammatory/infectious ( ), liver infiltration ( ), fibrosis ( ) and graft-vs-host disease (gvhd) ( ). six patients were deceased; -year all-cause mortality from diagnosis was %. thiopurine methyltransferase (tpmt) status was known in % cases and % controls. all cases had intermediate or wildtype status, which did not differ from controls (p > . ). patients requiring liver biopsy did not have evidence of acute hepatotoxicity (ast/alt > × normal values) during their initial treatment protocol. hepatotoxicity requiring liver biopsy is a rare outcome of all treatment. these patients had elevated rates of relapse, bmt, and -year all-cause mortality, suggestive of a more severe disease process. however, it is difficult to sort out the temporality of relapse, bmt, and hepatoxicity requiring biopsy in this limited sample. additionally, patients with bmt preceding liver biopsy have other confounding factors that makes them difficult to include in the analysis. finally, our limited descriptive data show no notable correlation between early hepatotoxicity and later indication for liver biopsy. future cohort or case-control studies with larger sample sizes are required to further explore early predictive factors for severe hepatotoxicity requiring liver biopsy. nathan gossai, joanna perkins, michael richards, yoav messinger, bruce bostrom background: the majority of chemotherapeutic agents used to treat hodgkin lymphoma are teratogenic. pregnancy screening prior to the start of chemotherapy is supported by clinical guidelines and baseline testing is a standard component in therapeutic trials. there is limited data available on the incidence of pregnancy screening prior to the start of hodgkin therapy but previous studies suggest that pregnancy screening, especially at pediatric institutions, is not consistently completed. objectives: the objective of this study is to evaluate the incidence of pregnancy screening and contraceptive counseling prior to the start of therapy in females diagnosed with hodgkin lymphoma. design/method: a retrospective chart review was performed for all female patients newly diagnosed with hodgkin lymphoma from to at the hospital for sick children in toronto, ontario. all patients who were intended to receive multi-agent chemotherapy were included, regardless of age. data collected included demographic and disease information, chemotherapy regimen and enrollment on clinical trial. all pregnancy testing within two weeks prior to the start of therapy was captured, as well as type of pregnancy test performed, documentation of menstrual status, contraceptive counseling and contraceptive provision. univariate and multivariate analyses were used to describe factors influencing the incidence of pregnancy testing. results: a total of female patients with newly diagnosed hodgkin lymphoma between the ages of and years were identified. sixty patients ( %) had pregnancy testing done prior to the start of therapy. testing modalities included serum and urine screens as well as quantitative beta-hcg measures. older age (p = . ), documentation of menstrual status at diagnosis (p = . ) and diagnosis between and (p = . ) were associated with higher incidence of screening. enrollment on a therapeutic trial was not associated with a higher incidence of screening (p = . ). contraceptive counseling was documented for patients ( %) and patients ( %) were prescribed contraceptive medications during therapy. pre-chemotherapy pregnancy testing was completed on % of females with newly diagnosed hodgkin lymphoma. improvement is required and interventions, including clarification of institutional standards, modification of chemotherapy order sets and staff education, are planned. (rao et al., cancer, ) . university of louisville, louisville, kentucky, united states background: granulocytic sarcomas (also known as chloromas or leukemia cutis) were first described by a. burns in . they are solid tumors comprised of immature granulocytic cells and represent extramedullary manifestations of underlying leukemia. chloromas are most commonly associated with acute myeloid leukemia. they may arise in other myeloproliferative disorders but are rarely seen in b or t cell acute lymphoblastic leukemia (all). objectives: although patients with all rarely have chloromas, it should remain on the differential for patients with unusual swelling or masses. design/method: we present a case series of two patients from our institution diagnosed with b cell all who had a chloroma as the presenting symptom. the first patient is a yo who presented to his primary provider with nasal congestion and a one-week history of bilateral eye swelling and was referred to an allergist when the symptoms did not resolve with anti-histamines. his review of systems was otherwise negative. he was referred urgently to ent two months later for a × cm mass palpated along the medial border of the left eye. an mri showed a left facial mass surrounding the zygoma and extending into the anterior inferior left orbit. biopsy revealed b cell acute lymphoblastic lymphoma, and bone marrow aspirate and biopsy confirmed the diagnosis as b cell all. the second patient is a yo who presented to his primary doctor for rapid growth of a scalp nodule that had been present for about months. he was referred to dermatology and treated for a supposed kerion from tinea capitis. the lesion continued to grow and became more irritated with this treatment. punch biopsy revealed a complicated phenotype of lymphoblastic lymphoma. however, after a lymph node biopsy and bone marrow aspirate and biopsy, the diagnosis was confirmed as b all. his only other positive point on review of systems was a questionably pathologic -pound weight loss and an area of matted cervical lymph nodes. for both of our patients, the chloromas completely disappeared during induction therapy. it is worth noting that both of these patients presented with the chloroma as the only symptom of the underlying leukemia. this led to initial misdiagnosis and delay in identifying their leukemia. therefore, while it is very rare for a patient with b all to present with a chloroma, our experience shows that all should be on the differential for patients presenting with unusual swelling or masses. background: hodgkin lymphoma (hl) is a lymphoproliferative neoplasm that commonly presents with history of adenopathy and a predictable pattern of disease involvement with or without systemic symptoms of fever and/or weight loss. in the hands of an experienced oncologist the diagnosis of hl is usually not a challenge. occasionally a diagnostic challenge is presented by a patient who has an atypical presentation which is suggestive of an alternative diagnosis. we describe a case series of patients diagnosed with hl whose initial clinical presentations lead to a diagnosis different form hl. honduras, nicaragua and the united states. results: six pediatric oncology centers from the american continent conducted a retrospective review of patients diagnosed with hl since . patients that had an initial presentation not suggestive of hl or who were initially diagnosed with a disease other that hl were included for a total of patients. argentina n = , guatemala n = , honduras n = , nicaragua n = , united states n = . five patients were female and male. patient's ages ranged from to years. most patients (n = ) were older than years. three patients ( %) presented with non-immune cytopenias without overt lymphadenopathy, of those one had active hemophagocytic syndrome. five patients ( %) were suspected to have localized solid tumors: ewing sarcoma n = , rhabdomyosarcoma n = , hepatocellular carcinoma n = , and soft tissue tumor of the cheek n = . two ( %) metastatic solid malignancy as they presented with disseminated pulmonary nodules. five ( %) with autoimmune disorders: hashimoto thyroiditis n = , autoimmune hemolytic anemia n = , nephrotic syndrome n = . ten ( %) with chronic infectious processes: brucella n = , tonsillar abscess n = , splenic abscess n = , and tuberculosis (tb) n = . patients with suspected tuberculosis were diagnosed outside of the united states. six of patients were ultimately diagnosed as having both tb and hl. seventeen patients had ann-arbor stage iii or iv, seven patient had stage ii with either b symptoms or bulky disease. patients were treated with various chemotherapy regimens according to the treating center: abvd, abve-pc oepa-copdac, avpc, beacopp. two patients had recurrent disease, one died of disease progression and one died from causes not related to hl conclusion: a small proportion of hl patients have atypical or unusual presentations. hl should be included in the differential diagnosis of solid tumors, autoimmune disorders, infections or cytopenias. the most common atypical presentation is an infectious process. background: acute lymphoblastic leukemia (all) represents the largest group of pediatric malignancies. the high cure rate of childhood all represents one of the most remarkable success stories in the war on cancer. in a lower middle income country (lmic) like the philippines, we reviewed the five year survival in a tertiary referral center. objectives: this retrospective cohort study aims to determine the survival of children - years old with all treated at a tertiary referral center for childhood cancer in the philippines from january to december . design/method: this is a retrospective cohort study that reviewed medical charts of newly diagnosed all ages to years old from january to december . a total of subjects were included in the study. the year overall survival (os) and event free survival (efs) were . % and . %, respectively. the year os for standard risk all was . % and for high risk patients was %. the year os for the patients on remission was . % and for those who relapsed was . %. univariate and multivariate by cox proportional hazards regression revealed wbc count at diagnosis, risk classification, immunophenotyping, and development of relapse showed significant prognostic impact for mortality. age and gender were reported with no prognostic significance. the -year os and efs were lower compared to developed countries but are comparable with other lmics. the prognostic factors for relapse and mortality were compatible with the literature. overall, the adopted treatment protocols for childhood all in this institution showed acceptable results. relapse has a significant prognostic impact for mortality. development of accessibility to care, increase awareness, early detection and resources at hand should be achieved. improvement in the follow up protocol to prevent delays in the treatment, patient education to prevent non-compliance and psychosocial support, to developed better supportive care, and expand facilities should be given emphasis to further improve survival and prevent relapse. objectives: here, we seek to further characterize this entity by describing the pathologic and clinical features of pediatric cases of burkitt-like lymphoma with q aberration. we collected pathologic and clinical data from the medical record on all pediatric high grade b-cell lymphoma (hgbcl) cases diagnosed at our institution over a -year period ( - ) . for those cases classified as neither burkitt lymphoma nor diffuse large b-cell lymphoma (dlbcl), fish for myc, bcl- and bcl- , as well as array comparative genomic hybridization (acgh), were performed. we identified cases of hgbcl, including cases of burkitt lymphoma presenting as purely leukemic phase. of the hgbcl cases, had burkitt lymphoma as defined by myc rearrangements, and had dlbcl. collectively, the majority of these patients had primary disease outside of the head/neck, and most patients presented with advanced stage (iii-iv) disease. of the remaining cases, q aberration was identified in cases using acgh. all cases histologically and immunophenotypically resembled burkitt lymphoma but lacked myc rearrangement, instead showing proximal gains in q -q and telomeric losses in q . qter. all cases involved primary disease in the cervical lymph node and/or tonsil. three of these cases were localized (stage ii), and the fourth case involved a few metabolically active but non-enlarged lymph nodes in the chest and abdomen (stage iii). all patients achieved complete remission with standard therapy for mature b-cell lymphoma, and were alive with no clinical evidence of disease at a median follow-up of months. although the number is small, our results suggest that the majority of non-burkitt, non-dlbcl cases of pediatric hgbcl carry q aberrations. in addition, patients with q aberrations appear to be more likely to present with lower stage disease, thus requiring less intensive therapy, and also tend to have primary disease in the head/neck. these findings further support the classification of burkitt-like lymphoma with q aberration as a distinct pathologic and clinical entity, and we propose that all pediatric non-burkitt, non-dlbcl cases of hgbcl regularly undergo further workup for possible q aberrations. marie claire milady auguste, joseph bernard st damien hospital, port-au-prince, port-au-prince, haiti background: hodgkin lymphoma (hl) and non-hodgkin lymphoma (nhl) account for % of cancers in the united states pediatric population ( , ). in central america and the caribbean, they are in second position among all types of pediatric cancers ( ). a previous study on pediatric cancers in haiti showed that the lymphomas were in fifth place after the leukemias, wilms tumor, retinoblastoma and the sarcomas ( ). the main objective of this study is to present the epidemiological profile of lymphomas managed at a haitian pediatric hospital. design/method: this is a retrospective study conducted on the cases of lymphoma diagnosed and managed at st damien hospital from january to december . key variables such as age, gender, stage at diagnosis, histopathological types and outcome were collected to present the characteristics of this retrospective cohort. of the cases of cancer diagnosed during the study period, ( . %) had the diagnosis of lymphoma. the sex ratio was . ( males for females) and the average age was . years [ - years]. there were cases of hl ( . %) and cases of nhl ( . %). . % of the patients were diagnosed at stages iii and iv. among the hl cases, ( . %) were nodular sclerosis lymphoma, ( . %) with mixed cellularity and ( . %) with lymphocytic predominance. for the nhl cases, ( . %) were burkitt's lymphoma and ( . %) lymphoblastic t-cell lymphoma. among the patients for who immunohistochemistry was found, the cases of hl were cd -positive and out of cases of nhl were cd -negative. only patient was hiv-positive, and patients had a confirmed exposure to epstein-barr virus. patients ( . %) were lost to follow-up, ( . %) were in remission, ( %) relapsed, ( . %) were still in treatment and ( %) were deceased. university of chicago, chicago, illinois, united states background: due to the adoption of risk-adapted therapy, pediatric and adolescent acute lymphoblastic leukemia (all) is associated with high cure rates. despite excellent outcomes in most children, patients with certain blast cytogenetic features do not fare as well. furthermore, african american, native american, and hispanic patients have worse outcomes than caucasian patients. while the outcome discrepancies are certainly multifactorial, and blast cytogenetics are related to age, it remains unclear whether ethnicity and blast cytogenetics correlate. the diverse patient population at the university of chicago provides an opportunity to evaluate for such a correlation. objectives: to describe cytogenetic findings in a racially and ethnically diverse population of patients of all age groups diagnosed with all at university of chicago from to and determine if there is a correlation between race/ethnicity and blast cytogenetics. results: a total of newly diagnosed patients with all between the ages of - from - were included in this study. of those, patients ( . %) had b-all, had t-all ( . %), one had early t-cell precursor all and one had mixed phenotype all (b/t). caucasians accounted for % of patients, african americans (aa) %, hispanics . %, asians . %, and % were of other races. age distribution had a bimodal pattern, with a peak in incidence at and another at years of age, consistent with published data. cytogenetic categories included: t( ; )(p ;q ), q rearrangements (kmt a), iamp , t( ; )(q ;p . ), t( ; ) (q ;q ), hypodiploidy, hyperdiploidy and double trisomy of chromosomes and . aa and hispanic patients with b-all presented more frequently between the ages of - years compared to caucasians (p = . and . , respectively). in aa patients, t( ; ) (q ;p . ) was overrepresented (p = . when compared to caucasians), and was mainly observed in patients between - years. caucasian patients were more likely than non-caucasians to have hyperdiploidy (p = . ), especially in patients aged - years. the rate of t( ; )(q ;p . ) was significantly higher in aa patients in our cohort, in particular in patients between the ages of - years. hyperdiploidy was more likely in caucasians aged - years. these findings may suggest that varying blast cytogenetics could contribute to outcome differences between races. ahmed elgammal, yasser elborai, mohamed fawzy, asmaa salama, eman d el-desouky, lobna shalaby national cancer institute, cairo, cairo, egypt background: hodgkin lymphoma (hl) in children is one of the malignancies that have a high chance of cure. stage iv hl remains a challenge for getting good clinical outcome as in other stages. many treatment protocols used to give combination chemotherapy while combined modality treatment is the mainstay in other treatment protocols. objectives: we aimed in to assess the outcome using consolidation radiotherapy to chemotherapy (combined modality treatment) versus combination chemotherapy alone in treatment of stage iv hl. design/method: we included patients with stage iv hl and whose data were retrieved from the medical records of the pediatric oncology department, national cancer institute, cairo university, egypt from till june and were followed till august . treatment was either to give cycles of abvd (adriamycin, bleomycin, vinblastine, dacarbazine) only or to give cycles of abvd followed by consolidation radiotherapy. the study included cases; were males and were females. mean age was . years ranging from to years. the histopathology subtype was nodular sclerosis in the majority of cases ( cases) followed by mixed cellularity ( cases) then only one case of lymphocyte rich. nine cases were initially bulky while cases were not. constitutional manifestations were present in cases while it was absent in cases. bone marrow was involved in only cases. radiotherapy was given after completion of chemotherapy to cases while cases received chemotherapy only. the -year overall survival for patients who received radiotherapy was superior to those who received chemotherapy alone; % versus . % respectively with statistical significance (p = . ). the -year progression free survival was also higher with radiotherapy than others; % versus . % (p = . ). patients with stage iv hl who received consolidation radiotherapy apparently had a better outcome than those who received chemotherapy only. this suggests that radiotherapy contributes significantly with chemotherapy to the cure rate for those patients. the feinstein institute for medical research, manhasset, new york, united states background: microrna (mirnas) are short non-coding rnas that play a decisive role in cancer biology, including leukemia. exosomes are microvesicles ( - nm) produced by most cells in biological fluids. exosomes represent the fingerprint of the parental tumor and are loaded with bioactive markers such as mirnas, which may regulate tumor growth. exosomal cargo can be transferred into target cells changing their biological properties. our study investigates a functional role for exosomal mir- a in pediatric acute lymphoid leukemia (p-all). objectives: / to demonstrate that p-all exosomes induce cell proliferation / to confirm that exosome-induced cell proliferation is disease-stage specific / to analyze exosomal mir- a expression profiles in p-all / to authenticate that inhibition of exosomal mir- a reduces leukemia proliferation design/method: exosomes were isolated by ultracentrifugation from healthy donors (hd) & p-all serum and conditioned medium (cm) of sup-b , jm , and cl- (control) human cell lines. cell lines were exposed to different sources of leukemia-derived exosomes in a paracrine or autocrine fashion for hrs in triplicates. proliferation was assessed by microscopic cell counting and confirmed by gene expression for proliferation, pro-survival and pro-apoptotic genes. mirna profiling was performed with the human cancer pathway finder microarray (qiagen). silencing of exosomal mir a was carried out by a mir- a inhibitor (qiagen), utilizing exo-fecttm exosome transfection reagent (sbi, system biosciences). further, exosomal mir- a silencing was confirmed by q-pcr. cellular uptake of texred-sirna (sbi, system biosciences) was confirmed by flow cytometry. transfer of exosomal mir a to the target cells was evaluated by q-pcr. we elucidated that cm-derived exosomes from sup-b and jm cell lines induce cell proliferation in sup-b , jm (autocrine and paracrine) and cl- cells (paracrine) (p< . ). serum p-all exosomes promote paracrine cell proliferation in all cell lines compared to hdderived exosomes (p< . ). heatmap analysis of mirna profiles of leukemia exosomes (all cell lines and p-all) identified mir- a significantly upregulated in leukemia exosomes compared to controls. mir- a was also upregulated in all cell lines after exposure to leukemia exosomes that induced proliferation. moreover, exosomal mir- a inhibition reduces leukemic proliferation in pediatric all. our data suggest that all exosomes induce cell proliferation of leukemic cell lines in both paracrine and autocrine fashion. exosomes regulate these phenomena in a highly orchestrated way, by transfer of functional exosomal mirnas such as mir- a. the results of this study suggest s of s that exosomal mir- a inhibition can act as a novel way for growth-suppression of pediatric leukemia. results: a total of disease sites were detected at pet/ct, while sites were detected at contrast-enhanced ct and bone marrow biopsy (bmb). pet/ct showed improved detection of nodal lesions (p < . ) (kappa value = . ), extranodal lesions (p < . ) (kappa value = . ) and bone marrow (p < . ) (kappa value = . ) compared to contrast enhanced ct and bmb. pet/ct had upstaged cases ( %) and down-staged cases ( . %) (p < . ) (kappa value = . ). among the upstaged cases, patients ( . %) were upstaged from stage ii to iii, based on residual in pet/ct not seen in contrast enhanced ct after abdominal mass excision. four patients ( . %) were upstaged from stage iii to iv based on bone marrow uptake in fdg-pet without positivity in bma or bmb.regarding response assessment, sensitivity was % for pet and % for contrastenhanced ct (p = . ). specificity was % for pet and % for ct (p< . ). positive predictive value for pet was %, while was % for ct scan (p< . ). negative predictive value for both pet and ct was % (p = . ). five patients had nd biopsy to confirm viability of the residual lesions, lesions were negative in pathological examination (all of them were metabolic negative in pet/ct; deauville score below ). one lesion was positive in pathological examination (was positive in pet/ct; deauville score of ). conclusion: pet/ct detected additional sites compared with contrast-enhanced ct and resulted in changing stage of disease. pet scan is significantly more specific than ct in the management of children with burkitt lymphoma. background: deep sequencing of the immunoglobulin heavy chain (igh) locus indicates that each b all is composed of innumerable subclones. in many cases, subclones exhibit differing phenotypic qualities. however, it remains unclear whether subclones demonstrate distinct tissue distribution within a patient. objectives: . to quantify the extent of clonal heterogeneity in diagnostic b all specimens; . to identify variability in clonal composition between bone marrow (bm) and peripheral blood (pb) disease sites. design/method: igh sequencing was performed on purified dna from pairs of matched bm and pb patient specimens. multiplex pcr was used to globally amplify the igh locus; next generation sequencing (ngs) was performed using illu-mina® miseq. index clones (defined as ≥ % of all sequence reads in a specimen) and their subclone progeny (defined by shared nucleotide bases immediately upstream of a common jh, or n_jx) were identified using igblast-determined vh and jh alignments (http://www.ncbi.nlm.nih.gov/igblast/) and an established in-house computational pipeline. results: up to index clones per specimen were discovered in of the samples. in the remaining ( bm/pb pairs), pair did not reveal a clonal igh and was eliminated from analysis; in the other, clone frequency did not reach the % index threshold, but predominant clonal precursors were inferred by the prevalence of their subclone progeny. subclone counts ranged from to , per index clone. a combined , subclones derived from pb index clones were observed; in contrast, bm index clones gave rise to only subclones. subclone heterogeneity was observed between all paired specimens. in bm/pb pairs, index clones existed in equivalent proportions between disease sites. in contrast, bm/pb pair demonstrated high-frequency index clones in the bm ( . % & . %) with limited representation of these clones in the pb ( . % & . %, respectively); in this case, the most prevalent clone in the pb ( . %) matched the least frequent index clone in the bm ( . %). similarly, another pair showed a predominant index clone in the pb ( . %) which was below index threshold ( . %) in the bm. in paired patient specimens, index clone predominance was discovered to be overtly distinct between bm and pb. among all pairs, the extent of subclone progeny derived from each index clone showed marked variability, with far higher subclone frequency in the pb than in the bm. our data indicate that b all clonal composition differs between disease sites. valley children's healthcare, madera, california, united states background: tuberculosis (tb) presenting with hodgkin lymphoma (hl) is rare. their coexistence could lead to delay in diagnosis of both tb and hodgkin lymphoma due to the similarities in signs and symptoms of presentation. most cases have been reported in the adult literature. we describe a case series of children that were suspected to have tb and were found to have coexisting tb and hl. results: a retrospective review of hl patients in guatemala and argentina over six years, uncovered patients with simultaneous diagnosis of tb and hl. eight patients were from guatemala (incidence of . %) and from argentina (incidence of . %). there were females and males. age ranged from - years (mean . years, media years). nine patients were suspected to have tb at presentation by the referring physician. two patients were found to have tb at the time of relapse through routine tissue culture. initial systemic symptoms included fever (n = ), weight loss (n = ), and night sweats (n = ). six patients had a second systemic symptom in addition to fever. time for referral to oncology center ranged from weeks to months. nine patients were diagnosed with tb and hl through a tissue cultures and with serum quantiferon. one patient was found to have hl without tb. two patients had no systemic symptoms and the diagnosis of tb came to light through routine tissue culture. five patients had stage iiib and ivb, two stage iia and one iib at diagnosis. hl treatment was given according to the insti-tutional standards depending on stage and risk with abvd, oepa/copdac +/-radiation therapy, and ice for relapse. five patients started anti tb treatment (isoniazid, rifampin, pyrazinamide +/-ethambutol for months followed by isoniazid and rifampin for - weeks) simultaneously with chemotherapy, and three others after completing cycles. the two relapsed patients started tb treatment after cycles of chemotherapy. seven patients are alive and have been followed for months - years. one patient died during therapy, another died for causes not related to tb or hl and one is currently receiving treatment. conclusion: tuberculosis can coexist with hl. in areas were the prevalence of tb is high, microbiology investigations of biopsy specimen should be strongly considered. therapy for tb can be given simultaneously with chemotherapy. coexistence of tb and hl does not appear to affect outcomes. the children's hospital affiliated to the capital institute of pediatrics, united states background: the pi k/akt signaling pathway plays a central role in cell growth, proliferation and survival in physiological conditions. this signal pathway is considered to be an innovative targeted therapy of cancer, and its abnormal activation has been proved to be related to t-cell acute lymphoblastic leukemia (t-all). despite improved treatment strategies, such as multi-drug combination, high-dose chemotherapy and all kinds of application and popularization of hematopoietic stem cell transplantation, children with drug resistance or relapse t-all are still rather worse and its overall outcome and prognosis are much poorer than the more common b-lineage all. objectives: to explore the relationship between the pi k/akt pathway and the pediatric t-all, so as to probe the exact molecular mechanisms of t-all and provide more directions for its treatment. design/method: cases of new or recurrent acute t lymphocyte leukemia children with clinical information were collected in the children's hospital affiliated to the capital institute of pediatrics from dec. to oct. , with age and gender matched healty children as control (all was informed consent). the expressions of key genes in pi k pathway were s of s analyzed by western blot rt-pcr analysis, the pi k enzyme activities were detected by elisa,and the ccrf -cem's proliferation and its apoptosis were tested by mtt and flow cytometry technology on t-all cell lines ccrf-cem in different treatment group. the results of t-all children in clinical showed that pi k protein and gene expression level were higher apparent than the control group (p< . ), and pi k enzyme activity increased as well (p< . ); pi k inhibitor ly made a significant inhibition of cell proliferation and promoted cell apoptosis. ly also enhanced the effectiveness of clinical commonly used chemotherapeutic drug dnr. in combination ly and dnr treatment group cell viability dramatically declined, apoptosis and the apoptosis relation protein casepase expression in t-all patients was obviously higher than the control and the single drug group; pi k/akt signaling pathway related proteins and gene expression level, pi k, akt, gsk transcription in ccrf-cem were significantly higher than the control (p< . ), while pten transcription was significantly lower than the control (p< . ). the abnormal activation of pi k/akt signaling pathway might play an important role in pediatric t-all patients, especially in the cell proliferation or apoptosis. the results might provide new train of thought and direction in targeted suppress this signal pathway or in combination with other chemotherapy drugs therapy in looking for the more effective and less cytotoxic treatment of pediatric t-all. cleveland clinic children's hospital, cleveland, ohio, united states background: non-hodgkin lymphomas (nhls) are a heterogeneous group of lymphoproliferative diseases which comprise % of all childhood malignancies. nhls can be divided in to b cell lymphomas and t cell/natural killer (nk) cell lymphomas depending on immunophenotype, molecular biology, and clinical response to treatment. although nk/t cell lymphomas occurring in childhood and adolescence comprise a small portion of all lymphomas, they present many diagnostic and therapeutic challenges. the role of angiogenesis in lymphoma pathogenesis is becoming more evident. high molecular weight kininogen (hk) is a central compo-nent of the kallikrein-kinin system. it has been previously reported that cleaved hk (hka) induces apoptosis of proliferating endothelial cells and inhibits angiogenesis in matrigel plug and corneal angiogenesis models. however, the role of endogenous kininogen in regulation of angiogenesis is in tumor microenvironment is unknown. objectives: to elaborate the role of hk in lymphoma angiogenesis, we used a murine t-cell lymphoma model and compared angiogenesis and tumor growth between wild-type and kininogen deficient (mkng -/-) mice. we also evaluated the effect of hka on lymphoma cell proliferation. design/method: el- murine t-cell lymphoma cells ( × ^ ) were implanted into wild-type and mkng -/-mice. tumor size was measured using calipers and tumor volume was calculated using the formula volume = length × width^ × . . seventeen days after cell implantation, tumors were harvested and processed by immunoblotting and immunofluorescent staining. cell proliferation assays (mts) were performed to investigate any possible inhibitory effect of hka on el- cell growth, with human umbilical vein endothelial cells (huvec) were used as a positive control. results: el- lymphomas grew more rapidly and to larger sizes in mkng -/-mice compared to wild-type mice, with significant differences apparent by day after tumor implantation (p< . ). by day , the volume of tumors in mkng -/-mice was approximately . -fold larger than in wild-type mice (mean volume ± standard deviation; ± vs. ± mm , respectively, p< . ). mts assays showed that hka does not directly inhibit the proliferation of el- cells in vitro, though it does significantly impair the viability of ecs studied simultaneously. conclusion: these findings suggest that hk is an important endogenous regulator of angiogenesis and tumor growth in this t-cell lymphoma model, and suggests that hka specifically modulates endothelial proliferation in tumor microenvironment. further work is needed to understand the mechanisms underlying these findings and provide future anti-angiogenic approaches to increase the therapeutic options for patients with nhl. bruce bostrom, jack knudson, nathan gossai, joanna perkins, michael richards, jawhar rawwas, susan sencer, julie chu, nancy mcallister, yoav messinger children's minnesota, minneapolis, minnesota, united states background: osteonecrosis causes significant pain and morbidity in older patients treated for acute lymphoblastic leukemia. besides altering the schedule of dexamethasone in delayed intensification there is no other intervention known to reduce the incidence of symptomatic osteonecrosis. pamidronate has been shown to reduce bone pain from osteonecrosis but not to prevent joint collapse when advanced. objectives: to compare the incidence of symptomatic osteonecrosis in patients who received prophylactic pamidronate compared with concurrent controls. to describe any increase in side effects from the use of pamidronate. design/method: patients age to years at time of all diagnosis were given intravenous pamidronate monthly for one year at the discretion of the primary oncologist starting in the first year of therapy. concurrent controls were patients age to who did not receive pamidronate. all patients were treated according to the concurrent cog protocols and received intermittent dexamethasone during delayed intensification. patients with bcr-abl all were excluded as the use of imatinib may increase the risk of osteonecrosis. imaging was only done if osteonecrosis was suspect based on clinical symptoms. patients were censored at the time of relapse. data were analyzed as of / / . this retrospective study was approved by the children's minnesota irb. of the patients evaluated % were male and % female, % had b-cell and % t-cell. the median followup is . years with a range of . to years. pamidronate was given to patients with developing symptomatic osteonecrosis. there were concurrent controls with developing osteonecrosis. there was no significant difference in the leukemia lineage, gender distribution or body mass index (bmi) at diagnosis between groups. for all patients the median bmi was with a range of to . the age at diagnosis was significantly higher in the pamidronate group with a median of . years vs. . in the controls (p = . ). by kaplan-meier analyses the incidence of symptomatic osteonecrosis was significantly lower in the pamidronate group at % vs. % in controls. the log-rank p-value was . and the breslow p-value, which is more sensitive to early events, was . . there were no untoward side-effects from pamidronate. pamidronate infusions significantly reduced the incidence of symptomatic osteonecrosis in patients over the age of compared to concurrent controls who did not receive pamidronate. arahana awasthi, dina edani, janet ayello, christian klein, mitchell cairo new york medical college, valhalla, new york, united states background: mature b-nhl, including bl and pmbl express cd +/cd b+ and have an excellent prognosis, however, subset of patients relapse secondary to chemoimmunotherapy resistant disease and have a dismal prognosis (≤ % yr. efs, cairo et al. blood. ; gerrard/cairo et al., blood, , goldman/cairo et al. leukemia, . pv has been demonstrated to possess significant preclinical activity against indolent cd b+nhl (polson et al. can. res. ). we previously observed that obinutuzumab (anti-cd mab) significantly enhanced cell death and increased overall survival against bl (awasthi/cairo et al., bjh ) in xenografted nsg mice. however, additive/synergistic effects of pv with obinutuzumab against mature pmbl/bl are unknown. to determine the efficacy of the pv or obinutuzumab/rtx alone or in combination against pmbl and rituximab (rtx) sensitive/resistant bl cell lines. design/method: raji rh (provided by m. barth, md, roswell park cancer institute) and raji/ karpas p (atcc, usa) were cultured in rpmi. tumor cells were incubated with pv, and/or anti-cd b, mmae (generously supplied by genentech inc.) with obinutuzumab /rituximab ( ug/ml) for hr with nk cells at : e: t ratio and cytotoxicity was determined by delfia cytotoxicity assay. six to week old female nsg (nod.cg-prkdcscid il rgtm wjl/szj), were divided into groups: pbs, isotype control, pv, anticd b mab and mmae ( mg/kg). mice were xenografted with intravenous injections of luc+ bl and pmbl cells and tumor burden was monitored by ivis spectrum system. results: os of mice receiving pv alone was significantly increased compared to anticd b ab or isotype control in raji ( . vs. vs. . our preliminary data indicates that pv significantly increased survival in bl and pmbl nsg xenografts compared to anti-cd b ab alone. furthermore, pv in combination with obinutuzumab significantly enhances in-vitro cytotoxicity in bl and pmbl compared to obinutuzumab or pv alone. results: maximal grades (g) / , , and crs occurred in , , and patients, respectively. median lowest fibrinogen levels were . , . , and . g/l in patients with maximal g - , , and crs, respectively. %, %, and % of patients with maximal g - , , and crs had lowest reported fibrinogen levels of ≥ to < . g/l. eight patients (all with g crs) had very low fibrinogen levels (< g/l), which occurred before (n = ) or during (n = ) maximal crs grade or at time of improvement (n = ). no patients with maximal g - crs had < g/l fibrinogen levels. at the onset of < g/l fibrinogen levels, patient had concurrent g , and had g - increased international normalized ratio and activated partial thromboplastin. cryoprecipitate was the primary treatment in the us, and fibrinogen concentrate (fc) guidelines for tisagenlecleucel-associated coagulopathy were developed for other countries because administration of fresh frozen plasma can be problematic. fc was available at / sites for infused patients: / (g crs) and / (g - crs). cryoprecipitate was available at / sites for infused patients: / (g crs), / (g crs), and / (g - crs). risk of bleeding increases in pediatric patients with comorbid thrombocytopenia and anticoagulant treatments. / patients had g / decreased platelets within day of < g/l fibrinogen levels. fatal case of intraparenchymal cranial hemorrhage occurred during resolving crs with g hypofibrinogenemia, ongoing thrombocytopenia, and continuous veno-venous hemofiltration with citrate. hypofibrinogenemia was observed more frequently in patients with higher crs grades during/when crs was improving or resolving. fc and cryoprecipitate treatment guidelines were developed. frequent monitoring and fibrinogen replacement are needed in patients with g / crs. sponsored by novartis. its prolonged cns half-life, may allow a reduction in the number of intrathecal injections. objectives: to safely reduce the burden of therapy by reducing the number of it injections and reducing the total dose of doxorubicin with the addition of liposomal cytarabine and rituximab. design/method: patients ( - years) with cd + b-nhl with fab group b good risk (=stage i/ii and stage iii with ldh < xuln), fab group b intermediate risk (=stage iii ldh ≥ xuln and stage iv {bm blasts < %}) and fab group c high risk were eligible. patients received fab backbone therapy with the addition of six rituximab ( mg/m ) doses; two doses prior to each of two induction courses and one dose prior to each of two consolidation courses. cumulative doxorubicin was reduced from to mg/m in gr patients. after systemic methotrexate clearance, patients received age based dosing of it liposomal cytarabine. it injections were reduced from nine to five. the primary outcome is safety and toxic deaths among evaluable patients with an estimated -year survival above %, monitored by an independent dsmb. results: to date, evaluable patients, fab group b and group c ( cns positive), median age years (range - ), males, burkitt/ dlbcl with gr, ir and hr have enrolled. there has been one grade anaphylactic reaction to rituximab and one grade facial nerve palsy. no other serious adverse events were attributable to protocol therapy. there has been death from progressive disease and relapse at a median follow up of months. efs and os are % and %, respectively. our initial results show excellent efs and os, consistent with published standard of care outcomes, with the addition of rituximab and intrathecal liposomal cytarabine despite the reductions in therapy. further enrollment is ongoing and continued long term outcomes are needed to confirm early results. future randomized studies are needed to examine both short term (mucositis, infections, hospitalization days) and long term (late cardiac toxicity) endpoints. . goldman etal, leukemia, . cairo etal, jco st. jude children's research hospital, memphis, tennessee, united states background: bereaved parents identify significant spiritual needs around time of death and throughout their bereavement journeys. spirituality has been identified as a primary means by which bereaved parents can find meaning in their losses, and this ability to find meaning is associated with lower maladaptive grief symptoms. the use of spiritual coping strategies has been associated with improved coping and mental health outcomes among bereaved parents. objectives: to better understand how bereaved parents' experiences with spirituality throughout bereavement effects objective measures of grief, depression, and meaning-making. design/method: thirty participants whose children died of progressive cancer or related complications one to three years prior to participation completed an in-depth semi-structured telephone interview about their experiences with grief. participants were prompted to describe the impact of their spirituality on their bereavement processes. additionally, participants completed surveys related to grief (prolonged grief disorder questionnaire, pg- ), depression (beck depression inventory, bdi), and meaning-making (integration of stressful life experiences scale, isles). results were analyzed using a mixed methods approach including semantic content analysis of qualitative content and kruskal-wallis h test and post-hoc analyses of quantitative data. results: correlation analyses demonstrated significant differences between participants with positive and negative spiritual experiences of bereavement. participants with negative experiences of bereavement had a statistically significant increase in scores on the pg- compared to those with positive spiritual experiences signifying greater symptoms of prolonged grief. participants with negative spiritual experiences with grief had significantly lower scores on the isles, suggesting a lesser degree of adaptive integration of their losses. there were no significant differences in depression scores between groups. conclusion: bereaved parents that have a negative spiritual experience of bereavement are at increased risk for prolonged grief symptoms and are less likely to find meaning in their children's deaths than bereaved parents that describe a positive spiritual experience of bereavement. providers should consider exploration of spiritual beliefs and provision of spiritual care for parents of children facing life-limiting illnesses during treatment and bereavement. background: langerhans cell histiocytosis (lch) is an inflammatory myeloid neoplasia characterized by frequent relapse, with treatment failure associated with higher risk of death and neurodegenerative disease (lch-nd). activating somatic mutations in mapk pathway genes have been identified in almost all cases, with braf-v e in approximately % of lesions. targeted therapies have been successful in treating other refractory cancers with braf v e mutations (such as melanoma). given the central role of mapk pathway activation in lch, mapk pathway inhibition may be an effective therapeutic strategy for children with lch. objectives: the purpose of this study was to report the efficacy and toxicity profile of a retrospective cohort of patients with lch treated with mapk pathway inhibitors. design/method: medical records from pediatric patients with lch (systemic and/or lch-associated neurodegeneration) who were treated with a mapk pathway inhibitor were retrospectively reviewed from five institutions. all patients had failed at least one prior systemic therapy and had a proven mapk pathway mutation. results: all patients in this series were less than years old (median = . years; range: - years) with a median of three prior treatments (range: - ). at the time of initial mapk inhibitor use, nine of the patients had lch-nd diagnosed clinically and/or by radiographic imaging; the remaining three patients had systemic disease. patients were treated for a median of months (range: - months) with various reasons for discontinuation. three patients received combination mapk inhibitor therapies and three patients received other concurrent lch-directed therapies. four of the twelve patients had a grade or toxicity reported and three of these patients required dose reduction in order to be able to successfully resume therapy. overall survival was % with median month follow-up (range: - months) with only one patient achieving transient complete response. the remaining ten patients had partial response or stable disease and four of these patients developed progressive disease while on therapy. conclusion: mapk pathway inhibitors may be a relatively safe salvage therapy for refractory systemic lch and lch-nd but the efficacy and durability of this strategy remains to be defined. combination with cytotoxic chemotherapies may be required in order to eradicate the disease-causing cell. future prospective trials of mapk pathway inhibitors for patients with refractory lch are needed in order to directly compare their efficacy and toxicity relative to other current salvage strategies. cincinnati children's hospital medical center, cincinnati, ohio, united states background: medication adherence during maintenance therapy has been shown to have a direct relationship with disease relapse in pediatric leukemia. previous research determined that patients who are ≤ % adherent to mercaptopurine ( mp) have a greater risk for relapse. the primary aim of the present study is to examine the relationship between metabolite profiles of mp with behavioral adherence rates obtained via electronic monitoring at , , and days. it is hypothesized that patients demonstrating low levels of thioguanine (tgn) and methylated mercaptopurine (mmp) will have lower behavioral adherence rates prior to the blood draw. design/method: in a multisite, prospective study of patients ages - years diagnosed with acute lymphoblastic leukemia (all) or lymphoblastic lymphoma (lbl), mp adherence was measured across months of maintenance therapy using behavioral adherence (electronic monitoring) and pharmacological (metabolites) measures of mp. mp is metabolized into mmp and tgn. cluster analysis was used to generate three mutually-exclusive profiles of mp adherence. behavioral adherence rates were calculated for , , and days prior to the blood draw. results: this study identified three metabolite profiles of mp across months. previous research indicated that low levels of both metabolites suggest nonadherence to medication. low levels of one metabolite with high levels of another metabolite indicate adherence to mp. in this study, . % of the low tgn-low mmp group had -day behavioral adherence rates ≥ % (mean = %); . % had adherence rates < % (mean = . %). in the high tgn-low mmp group, . % had a mean -day adherence of %; . % had adherence rates < % (mean = . %). the low tgn-high mmp group had % of patients with a mean -day adherence level of %; % had adherence rates < % (m = . %). at and -days, to % of patients in the low tgn-low mmp group had adherence rates < %. conclusion: these findings suggest that electronic monitoring and metabolite concentrations can be used to monitor mp medication adherence during maintenance therapy. it is notable that there is a sub-sample of pediatric patients who are identified as being nonadherent to mp based on electronic monitoring, however, metabolite levels indicate adherence to mp. similarly, a sub-sample of patients were identified as being adherent based on electronic monitoring, but metabolite profiles indicated sub-therapeutic levels of mp. our findings underscore the clinical significance of using both objective measures of medication adherence to inform clinical decision making. cincinnati children's hospital medical center, cincinnati, ohio, united states background: hemophagocytic lymphohistiocytosis (hlh) is a life-threatening hyperinflammatory syndrome characterized by non-remitting fevers, rash, hepatosplenomegaly, cytopenias, liver dysfunction and coagulopathy, and can include central nervous system involvement. several genetic diseases cause hlh by impairing normal lymphocyte or macrophage function. the hlh panel at the cincinnati children's genetics laboratories includes genes associated with hlh and other lymphoproliferative diseases, including the genes that cause primary hlh (prf , unc d, stxbp , stx , rab a), x-linked lymphoproliferative diseases (sh d a, xiap), itk deficiency (itk), hermansky-pudlak syndrome types and (ap b and bloc s ), chediak-higashi syndrome (lyst), cd deficiency (cd ), xmen syndrome (magt ) and lysinuric protein intolerance (slc a ). deletion/duplication analysis is available as a reflex test for all genes, as copy number variations (cnvs) are not directly assessed by sequencing. objectives: the prevalence of cnvs among large groups of patients with hlh in north america is unknown. we assessed the frequency of cnvs in the genes on the hlh panel through a retrospective review of orders for deletion/duplication analysis performed after next-generation or sanger sequencing: orders for all genes on the panel, and orders of - genes from the panel. deletion/duplication analysis was performed on a custom × k microarray annotated against ncbi build (ucsc hg , march ). deletion/duplication analysis resulted in a confirmatory diagnosis in of cases ( . %). pathogenic or likely pathogenic cnvs were most common in the three x-linked genes: sh d a ( deletions), xiap ( deletions, duplication), and magt ( deletions). hemizygous deletions in xlinked genes in male patients were typically suspected after amplification failure during previous sequencing. of the autosomal recessive genes, pathogenic cnvs were observed once in each of three genes: rab a (heterozygous), lyst (heterozygous), and stxbp (homozygous). in the two heterozygous cases, a second change was not identified by sequencing, so deletion/duplication analysis did not offer a confirmatory diagnosis. in patients, deletion/duplication analysis was performed after a pathogenic or likely pathogenic variant was identified in an autosomal recessive gene during sequencing; however, in no case was a second mutation uncovered by cnv analysis. we recommend that deletion/duplication analysis be routinely performed in all male patients with hlh who lack a genetic diagnosis after sequencing of hlh-associated genes, especially if any regions failed to amplify. deletion/duplication analysis may be performed in female patients after sequencing if a genetic form of hlh is highly suspected, but the yield is expected to be low. cleveland clinic children's hospital, cleveland, ohio, united states background: the development of post-transplant neoplasia, typically from lymphoproliferative disease (ptld), is a severe complication in transplant recipients and affects approximately % of pediatric solid organ recipients. rates of lymphoma in adult heart transplantation patients are comparatively low, at less two percent at ten years. there are few published reports of the long-term outcomes of neoplasia after pediatric heart transplantation. we aimed to identify the subsequent malignancies that occurred in pediatric heart transplantation patients in a large single institution, and describe their treatment and subsequent clinical course. we performed a retrospective chart review of all pediatric heart transplant recipients followed at the cleveland clinic children's hospital from january to october . we excluded patients who died within days of heart transplantation. we reviewed in depth the history and clinical course of subjects who developed neoplasms. results: between and , patients underwent heart transplantation and survived at least days post transplantation. nine patients ( . %) developed a subsequent malignancy. in this case series, the median age at heart transplant was years old and the median time to develop neoplasia was . months. primary neoplasia included monomorphic ptld ( ), polymorphic ptld ( ), burkitt lymphoma ( ), hodgkin's lymphoma ( ), plasmacytoma-like lymphoma ( ) and epstein-barr virus-associated smooth muscle tumor (ebv-smt) ( ). one patient with hodgkin lymphoma subsequently developed monomorphic ptld, one patient with polymorphic ptld subsequently developed ebv-smt and later, an undifferentiated gastric cancer. one patient with monomorphic ptld developed an ebv-smt. evidence of epstein-barr virus was present in six of nine patients at diagnosis of first malignancy. four of nine patients received reduction in immunosuppression as a primary intervention for the initial malignancy, with two complete responses (cr), one partial response, and one with progressive disease. five patients were treated with chemotherapy, with four cr and one with progressive disease. three patients died of malignancy (recurrent ebv-smt, undifferentiated gastric cancer, and monomorphic ptld post-hodgkin disease) and two patients died of other transplant related complications. conclusion: secondary malignancies represent a significant disease burden to survivors of cardiac transplantation. as expected, much of the malignancy burden is driven by ebv. despite aggressive histology, many malignancies can be successfully cured in this setting with a multidisciplinary approach. stanford university school of medicine, palo alto, california, united states background: current treatment of langerhans cell histiocytosis (lch) is based on extent of organ system involvement and if high risk systems are affected. gastrointestinal (gi) involvement is diagnosed in about % of lch patients, and classically presents in children under years of age with malabsorption, failure to thrive, bloody diarrhea and anemia. although the gi system is considered standard risk, a mortality rate over % occurring within years of diagnosis has been reported. this study was performed due to this discrepancy and the limited number of published cases. objectives: to review the clinical course and outcomes of patients diagnosed with gi lch. design/method: a retrospective chart review of patients with histologically confirmed gi lch diagnosed in the last years identified from the bass center histiocytosis clinical database was performed. two other pediatric hematology/oncology centers (ucsf benioff children's hospital oakland and san francisco) were queried for additional cases. results: four patients with biopsy proven gi lch [ subjects ( . %) from database records and l from center queries] were identified. failure to thrive, hypoalbuminemia, bloody diarrhea and rash were the most common presenting symptoms. lch of the skin was found in all patients. risk organ systems were involved in patients. of note, subjects were of african racial background. the median age at diagnosis was . months ( . months to years), mean albumin . g/dl ( . - . g/dl), mean esr of mm/hr ( - mm/hr). all patients initially received combination therapy per lchiii protocol (vinblastine, prednisone, and mercaptopurine). two patients had recurrent disease and received second line therapy (cytarabine, cda, and local radiation therapy). all patients are alive without active disease at last follow-up ( to months after completion of therapy). a systematic approach to evaluate gi involvement should be performed in children diagnosed with lch. from our experience, combination chemotherapy for patients with lch involving the gi tract is an effective intervention for active disease. cincinnati children's hospital medical center, cincinnati, ohio, united states background: bhatia indicated that rates of mp adherence ≥ % have better clinical outcomes. those with adherence rates ≤ % have an increased risk for disease relapse. the present study investigated patterns of mp medication adherence using group-based trajectory modeling in a large sample of pediatric patients. to describe patterns of behavioral adherence during the maintenance phase of therapy for a cohort of pediatric patients ages - years who were diagnosed with acute lymphoblastic leukemia or lymphoblastic lymphoma (n = ). previous research has documented the relationship between optimal levels of medication adherence with positive health outcomes. it was hypothesized that three groups would be identified: optimal adherence, deteriorating adherence, and chronic nonadherence. it was hypothesized that patients in the optimal adherence group would have adherence rates ≥ %. those with poor adherence would have adherence rates ≤ %. design/method: the present study was a longitudinal, multisite study investigating adherence to -mercaptopurine in a pediatric cohort of patients using electronic monitoring devices. daily adherence rates (electronic monitoring of mp) were examined across -months. health outcomes were measured at quarterly intervals through medical chart reviews. results: unconditional growth curve modeling indicated that the mean percentage of behavioral adherence was . % at baseline and declined to . % at -months. three trajectories of mp behavioral adherence were identified: ) optimal adherence ( % of patients): averaging % behavioral adherence across months; ) moderate adherence ( %): relatively stable nonadherence with rates of % across months; and, ) chronically nonadherent ( %): adherence decreased from % to %. with respect to patterns of medication adherence and relationship to clinically-relevant health outcomes, there were no significant differences in health outcomes between patients in the adherent versus nonadherent trajectories, including mean absolute neutrophil counts (anc), risk for infection as measured by anc, healthcare utilization, or risk for disease relapse. although longitudinal patterns of mp behavioral adherence were not related to health outcomes, it is notable that only % of the current sample had adherence rates ≥ %. in fact, % of the current sample demonstrated adherence rates ≤ %. our findings are important for development of future adherence promotion studies in pediatric cancer. our findings underscore the relative significance of tailoring adherence promotion interventions to subgroups of patients, including those with problematic patterns of adherence. patients who demonstrate adequate levels of adherence could still benefit from less intensive, preventative interventions to sustain and improve adherence. sophie gatineau-sailliant, pascale grimard, marie-claude miron, guy grimard, anne-sophie carret, jean-marie leclerc chu sainte-justine, montreal, quebec, canada background: vertebral involvement in langerhans cell histiocytosis (lch) is still a subject of interest, due to its low frequency and the absence of management's guidelines. objectives: to provide additional information on presentation, treatment and morbidity of pediatric lch vertebral lesions, we report cases of children with vertebral lesion of biopsy-proven lch, between january st and december st , at sainte-justine university health center (montreal, quebec, canada). we conducted a retrospective study by reviewing charts and imaging of vertebral lch in a population of children (median age of . years at lch diagnosis), followed for a median duration of months. symptoms at presentation, treatment modalities and morbidities were collected. results: vertebral lesions were present at lch diagnosis in of cases. they were usually diagnosed secondary to back pain in of cases and were asymptomatic in only one case. despite an epidural extension in of cases, no child developed neurological symptoms. lesions frequently involved vertebral body ( of cases) and were rarely unstable ( of cases). out of vertebral lesions, most of them had a dorsal localization ( of lesions) and of patients had lch in multiple vertebrae. at diagnosis, median vertebral height loss was . % compared to % at last imaging control. most used imaging modalities were pet-scan and plain x-rays. treatments were diverse and consisted in chemotherapy in all children but three and bisphosphonates in only cases. radiation therapy was not used in any patient. six out patients did benefit of an orthosis. a lch recurrence was observed in patients and involved vertebrae in cases. one patient with treatment-resistant lch disease had relapses, and required multiple lines of treatment. all children were alive and disease-free at their last follow-up, patients having radiological vertebral sequelae and only had clinical sequelae. our study is consistent with the epidemiological data described in larger cohorts of children with vertebral lesions of lch and the favorable prognosis associated with such lesions. nevertheless, aggressive treatment and long term follow-up seemed to be essential as recurrences are s of s not rare and spontaneous bone regeneration often incomplete. plain x-rays appears to be a good follow-up tool for vertebral lesions as it allows reliable measures, less exposure to radiation at lower cost. national cancer institue, giza, giza, egypt background: acute lymphoblastic leukemia (all) is the most common type of childhood cancer and also the most complicated in the treatment, so it requires many interventions for both treatment and to alleviate suffer form side effects. pancreatitis is one of the toxicities, which is more common in all as it appears in about % of the patients. it occurs in many drug combinations which induce pre-pancreatitis and even direct destruction of pancreatic tissues. pancreatitis can be induced by many drugs used in the treatment such as chemotherapeutic agents or supportive treatment. lasparaginase is the backbone drug of the treatment of all in which to doses are required to achieve complete remission status in the induction phase of treatment and to doses in the maintenance phase.it is an enzyme that destructs the l-asparagine amino acid into aspartic acid and ammonia thus deplete the asparagine from the extracellular matrix . many drugs are investigated for their effect on treatment of induced pancreatitis such as interleukin- , nsaid as antiinflammatory, glycerin tri nitrates as improvement of microcirculation, tnf-alpha antibody, paf inhibitor as specific anti-inflammatory and low molecular weight heparin .none of the drugs was investigated for their ability to prevent the occurrence of pancreatitis. objectives: this study was designed to evaluate the protective effect of enoxaparin and diclofenac against l-asparaginase induced pancreatitis design/method: acute pancreatitis was induced in rats by intra-muscular injection of l-asparaginase ( i.u/kg) given daily for five days. enoxaparin was given subcutaneous ( i.u/kg) and diclofenac was given intra-peritoneal ( mg/kg) daily for five days. then, markers of pancreatic injury, lipids, immune cell infiltration and oxidative stress were analyzed with histo-pathological examination of the pancreatic tissue results: during acute pancreatitis, oxidative stress markers were significantly changed as indicated by reduced tis-sue glutathione and increased malondialdehyde levels. this was accompanied with significant increase in immune cells infiltration as indicated by high levels of myeloperoxidase and pro-inflammatory cytokine tnf-alpha. triglyceride only showed increase level. treatment with enoxaparin and/or diclofenac restored levels of biochemical markers including serum alpha-amylase, reduced glutathione, malondialdehyde, pro-inflammatory cytokine tnf-alpha, myeloperoxidase and triglyceride. histological injuries of pancreatic tissues as vacuolation and necrosis of epithelial lining pancreatic acini, inflammatory cells infiltration and focal pancreatic hemorrhage were also reduced by treatment with enoxaparin and/or diclofenac. the present study emphasizes the potential protective effect of enoxaparin and diclofenac against l-asparaginase induced pancreatitis background: rosai dorfman disease (rdd), or sinus histiocytosis with massive lymphadenopathy (shml), is a rare condition of immune dysregulation of unknown etiology arising from the massive accumulation of non-langerhans type histiocytic cells inside lymph nodes. the disease classically presents as bulky, painless lymphadenopathy often associated with infection showing distension of lymph node sinuses by abundant histiocytic cells (cd a(-), s- (+)/cd (+)). in some cases, the disease can be self-limiting, but in cases with a prolonged chronic course of exacerbations and remissions, those with extranodal involvement, or disease that threatens vitals structures, treatment may be necessary. there is no treatment consensus. to describe a case of life-threatening, unresectable, recurrent rdd successfully treated with langerhans cell histiocytosis (lch) -inspired therapy. design/method: we compared this case to the current literature on chemotherapeutic treatments for rdd. we searched pubmed, ovid, and google scholar for similar cases. we believe this to be the first reported case of using lch therapy to successfully treat rdd. an -year-old male presented to an outside hospital with two years of massive neck swelling causing torticollis. biopsy confirmed rdd. he was intermittently treated with courses of antibiotics with partial response. surgical removal of the affected lymph nodes was unsuccessful due to proximity to the spinal cord. two years later, the patient presented to our institution. he was initially treated with prednisone with a fast tapering dose, but after a second relapse the decision was made to try chemotherapy following the lch- protocol of weekly vinblastine ( mg/m ), -mp ( mg/m ), and high dose steroid bursts. he experienced two additional relapses off therapy at ages and years old, including cmv(+) associated septic shock and cytokine storm requiring rapid response, picu admission, and ionotropic support. this last episode was treated with a more prolonged induction and maintenance therapy. an extended and slowly tapered maintenance therapy regimen of . years of daily -mp, monthly vinblastine and steroids with a slowly tapered dose during his fourth remission has resulted in -months of continuous complete remission-the longest stretch of his life. no similar cases were found. literature search demonstrated no consensus regarding the most effective treatment of rdd, with no previous cases being successfully treated following lch chemotherapy protocols. we hypothesize that the multi-agent relatively mild lch- therapy mitigates the immune dysregulation of rdd. this case suggests that lch- therapy can be used to treat cases of rdd that is not amendable to surgery or observation. nicklaus children's hospital, miami, florida, united states background: central venous catheters (cvc) are necessary in the management of patients with malignancies, especially children. patients with acute leukemia (al) have higher rates of central line associated complications such as bloodstream infections compared with other malignancies. objectives: to examine the choice of placement of cvc and the differences in outcome between peripherally inserted central catheters (picc) and ports in patients with leukemia during induction. design/method: retrospective chart review of patients with newly diagnosed leukemia at nicklaus children's hospital between and . results: ninety four patients with a new diagnosis of leukemia undergoing induction chemotherapy were identified. the average age was . years. overall, ( . %) patients had a port placed and ( . %) had a picc placed. the decision for picc or port was subjective and physician based. the main outcome measures were local inflammation/infection, bacteremia, thrombophlebitis, blocked catheter and premature removal. the most common complication was bacteremia ( . %). in a multiple logistic regression analysis for predicting whether patients had at least one complication, results showed that having at least one complication is . times the odds in patients with aml compared to patients with all (p = . ). when comparing picc vs. ports, patients with picc had more frequent episodes of blocked catheters ( . %) and premature removal ( . %) compared to the patients with ports ( . % and . %) (p = . and p = . respectively) during induction. local inflammation, bacteremia and thrombophlebitis were not statistically different (p = . , p = . and p = . respectively). the most common place for port placement was the right subclavian vein ( %). there was no significant association between port location and having at least one complication (p = . ). acute lymphocytic leukemia subgroup analysis: fourteen patients ( %) in the picc group had at least one complication and ( %) in the port group but that was not statistically significant (p = . ). our series showed a higher incidence of blocked catheters and premature removals with picc compared to ports in patients with leukemia during induction. the choice of placement of picc vs port was subjective and physician based. patients with all, despite receiving steroids and asparaginase during induction, did not show a statistically significant increase risk in thrombosis or infection but larger numbers may be needed in future studies. university of california, san francisco, san francisco, california, united states background: hemophagocytic lymphohistiocytosis (hlh) is classically a disorder of young children meeting systemic hyperinflammation criteria. presentation in late adolescence is uncommon. furthermore, though cns signs occur in - % of cases, initial isolated neurologic presentation is rare, frequently resembling encephalitis or demyelinating disorders. these cns signs can be isolated or precede systemic disease, delaying hlh diagnosis. hlh declaring in adolescence with predominant psychiatric features has not been well documented. objectives: to describe a case of cns hlh presenting with neuropsychiatric features in absence of classic hlh criteria. design/method: retrospective review of clinical, radiologic, histologic, immunophenotypic, and molecular features of a patient with cns hlh. a -year-old female presented with acute-onset headaches following nine months of progressive anxiety, short-term memory loss, emotional lability, perceptual disturbances, and hypomania. brain mri demonstrated numerous enhancing t hyperintense supratentorial and infratentorial white matter lesions in the left thalamus and caudate head. brain biopsy showed histiocyte-rich inflammation and associated demyelination. extensive evaluation including universal microbial pcr failed to reveal underlying infection or malignancy. past medical history was notable for presumptive pulmonary sarcoidosis diagnosed months prior with progressive respiratory failure with associated granulomatous pulmonary nodules which responded to systemic immunosuppression. at presentation of her neuropsychiatric symptoms, she had normal sil- r, ferritin, fibrinogen, and triglycerides. there was no pancytopenia, coagulopathy, bone marrow hemophagocytosis, fevers, or splenomegaly. given the possibility of partial immune suppression of systemic symptoms and the prominent neurologic symptoms, hlh screening labs were sent and notable for decreased natural killer and cytotoxic t lymphocyte function, normal granzyme expression and cd a mobilization, and absent perforin expression. genetic testing confirmed compound heterozygous mutations in prf (c. g>a, c. a>c) and familial hlh type . she was treated with low-dose dexamethasone and intrathecal chemotherapy per hlh- . due to lack of evidence of systemic inflammation, vp- and high-dose steroids were held. within one week of initiating therapy, she had decreased anxiety and improved cognition, with sustained, incremental neuropsychiatric improvement with additional intrathecal treatments. she tolerated dexamethasone tapering without symptom flare. mri also demonstrated parenchymal lesion improvement. for definitive treatment, she underwent unrelated allogeneic hematopoietic cell transplantation and remains at neurologic baseline as of eight months post-transplant with ongoing imaging improvement. conclusion: this case of familial hlh with compound heterozygous perforin mutations in an adolescent with isolated neuropsychiatric symptoms illustrates that cns hlh may be an underrecognized phenomenon in absence of systemic signs. standard hlh therapy may effectively reverse these symptoms with associated radiologic responses. rush university children's hospital, chicago, illinois, united states background: posterior reversible encephalopathy syndrome (pres), a recognized complication of pediatric leukemia treatment has been reported in up to % patients in various series. hypertension, chemotherapy and cortical spreading depression have been implicated in the pathophysiology. due to the combinations used, it is difficult to identify the offending drug, several have been implicated. since delay of chemotherapeutic treatment in children with high risk leukemia is unfavorable, it is important to recognize the characteristic radiologic findings, manage appropriately and reintroduce the treatment as soon as possible. pharmacoethnicity is now recognized as an important factor for variation in neurotoxicity in children with all. ethnic differences in reported pres events in pediatric patients with all has not been well described in literature. to describe the factors associated with pres in a cohort of high risk pediatric all patients at a single institution. design/method: a total of children with an average age of years ( - years) diagnosed with all between - were retrospectively reviewed for the occurrence of pres. various demographic factors, therapy received, clinical features, radiology related findings and management were reviewed. a search for all published articles on pres in leukemia was conducted using pubmed databases. results: five ( %) children (average age . years) developed pres during days - of induction. % of the patients that developed and % of those that did not develop pres were hispanic. all the patients that developed pres and % of those that did not were diagnosed with high risk all. all patients received vincristine, % received daunomycin and intrathecal methotrexate and % received asparaginase in the week prior to the event. mri findings confirmed pres in all patients with no evidence of methotrexate related leukoencephalopathy or leukemia. at the time of pres all patients were in remission based on mrd and spinal fluid cytology. two-thirds of the patients had seizures and hypertension at the time of the event with no prior history of either. all patients had complete recovery of normal mental status after resolution of pres. a higher incidence of pres than previously reported was noted in our series. hispanic ethnicity, high-risk all and exposure to vincristine, daunomycin and intrathecal methotrexate in induction were associated with pres in our cohort. a new association that emerged was that of hispanic ethnicity with pres .larger studies to understand the importance of pharmacoethnicity in pres may help in individualization of chemotherapy based on ethnic differences. children's hospital of illinois, peoria, illinois, united states background: hyper ige syndrome is a primary immunodeficiency characterized by susceptibility to skin and lung infections as well as increased propensity for malignancy. hemophagocytic lymphohistiocytosis (hlh) is a syndrome characterized by overwhelming activation of t lymphocytes and macrophages occurring as either primary hlh caused by genetic abnormalities or secondary hlh associated with infectious, malignant, metabolic, or immunodeficiency causes. we describe the first case to our knowledge of hlh in a patient with hyper ige syndrome. to describe a case of hlh in a pediatric patient with hyper ige syndrome. results: a -year old caucasian male with known autosomal dominant hyper ige syndrome (stat mutation) was transferred to the pediatric intensive care unit secondary to concern for septic shock. the patient had persistent slow bleeding from oral lesions and central catheter sites despite the addition of aminocaproic acid and recombinant factor viia. he also required numerous blood product transfusions sec-ondary to anemia and thrombocytopenia. clinical suspicion was high for hlh and the patient met criteria for diagnosis of hlh with the following: ferritin > , ng/ml, triglycerides mg/dl, decreased nk cell function with the sample only containing % nk cells, elevated soluble il- receptor at u/ml, splenomegaly, and fever. infectious workup was remarkable for a positive ebv qpcr with , copies/ml suggestive of ebv driven secondary hlh. familial hlh testing was unable to be completed. therapy was initiated based upon the hlh- study. the addition of ruxolitinib and anakinra were considered but the patient declined rapidly prior to treatment. ct of the head was concerning for a stroke with signs of edema and increased intracranial pressure likely leading to the development of symptoms consistent with brain stem herniation. the decision was then made to withdraw care. conclusion: to our knowledge, this is the first report of hlh in a patient with hyper ige syndrome. diagnosing hlh requires a high index of suspicion in critically ill patients, and prompt initiation of therapy is essential. this challenging case of hlh in a patient with hyper ige syndrome highlights the diagnostic challenge, variable presentation, and need for effective therapy in this vulnerable patient population. background: adolescents and young adults (ayas) with cancer are at risk for psycho-social as well as physical symptom burden during cancer therapy. the purpose of this study is to explore psychological and physical symptoms endorsed by aya while receiving therapy for cancer design/method: surveys were given in both inpatient and outpatient settings during cancer therapy. symptom screening in pediatrics tool (sspedi) and memorial symptom assessment scale (msas). symptoms severity was rated by teens on a point likert scale. spss , used for statistical analysis. results: : a total of aya on cancer therapy (age range - . years) % female, % male, . % acute leukemia, . % solid tumors, and . % diagnosis was not reported. % of aya on cancer therapy reported at least or more symptoms, % reported > symptoms cluster. of the physical symptoms that were reported as most distressing to the teens, mouth sores and headaches were the top causes. of the physical symptoms that were most frequently endorsed; fatigue was on the top ( %), followed by change in appetite %, vomiting %, and pain %., the least was bowel habit changes. aya rated sadness as the most frequent psychological symptom %, followed by feeling angry %, and scared %. statistically significant difference was noticed based on gender difference with more females reported symptoms (p = . ), while type of cancer (acute leukemia versus solid tumors) was not statistically different. conclusion: aya with cancer reported multiple physical and psychological symptoms with significant distress. females seem to report more symptoms compared to males. screening aya for cancer therapy related symptoms is feasible during routine visits and adds important information about the aya well-being. background: sinus histiocytosis with massive lymphadenopathy (shml), also known as rosai-dorfman disease, is a rare histiocytic proliferative disorder of unknown etiology. many treatment modalities have been employed; however, no uniform guidelines exist. objectives: literature review of treatment options for shml. design/method: chart review was performed on pediatric patients diagnosed with shml at the children's hospital at montefiore between and after irb approval. inclusion criteria included children between the ages of and years with shml. exclusion criteria included children with cutaneous shml. four cases of shml seen at montefiore are described. a comprehensive review of the literature identified additional cases published between and . manuscripts that did not include the treatment modality or outcome were excluded. results: many of the patients with shml responded to observation alone. of patients, patients were observed, with ( %) having resolution of disease, five having stable disease, and five being lost to follow-up. one patient received subsequent systemic therapy. surgical management was con-ducted upfront in patients. of those, ( %) had resolution of disease, one had stable disease, and one had recurrence with no further therapy noted. of the remaining nine patients, % were successfully treated with systemic therapy, consisting of either steroids ( ) or steroids and chemotherapy ( ). systemic therapy was used as first-line therapy in patients. steroids alone or in conjunction with chemotherapy resulted in resolution of disease in / and / patients ( / , %), respectively, with four patients having stable and three with progressive disease. chemotherapy without steroids resulted in resolution of or stable disease in / patients. radiation was ineffective. conclusion: shml is a rare disease with no published guidelines for treatment. from the results of the cases and a detailed review of the literature, it can be suggested that observation may be considered as first line management in patients providing there are no significant symptoms. for patients who are symptomatic or have significant progression, surgery may be considered. in patients with recurrence or refractory disease, steroids and/or chemotherapy may be used. the presence of nodal or extra-nodal disease did not seem to have a significant impact on the course of treatment. given the rarity of the disease, it is difficult to conduct a randomized control trial. further work, involving collaboration between centers and cooperation with the international rare histiocytic disorders registry would be helpful. boston children's hospital, boston, massechusettes, united states background: increasing census and intensified work compression on the inpatient oncology service at our institution was identified as leading to resident dissatisfaction, impaired resident learning and decreased perceived quality of patient care. objectives: to evaluate the impact of a redesign of a pediatric inpatient hematologic malignancy (ihm) service on resident perceptions of the educational value of the rotation and safety of patient care. design/method: during the - academic year, we initiated a bundled intervention on the ihm service. modifications included ) decreased patient volume: the ihm service was divided into two teams, utilizing an extra attending -a teaching service consisting of residents and fellows and a team comprised of nurse practitioners. ) intentional patient team assignment: patients were deliberately assigned to a care team based on educational opportunities and provider skill sets. ) intentional attending faculty selection: attending faculty with deeper clinical and teaching experience were selected to supervise on the teaching team. ) increased weekend staffing. after completing the service, junior residents completed an electronic survey to evaluate their perceptions of the educational value of the rotation, as well as their ability to deliver safe care while on the rotation. fisher's exact tests were used to compare responses from residents in who experienced the redesign to residents in , whose experience results: survey completion rates were % ( / ) in and % ( / ) in . intervention residents were significantly more likely than comparison group residents to choose the answers "very good" or "excellent" to describe both the overall quality of the rotation ( % intervention vs. % comparison, p< . ) and the educational experience on rounds ( % intervention vs. % comparison, p< . ). intervention residents also reported caring for fewer average primary patients daily on weekdays as compared to comparison residents ( . vs . patients, p< . , % ci - . to - . ). furthermore, intervention residents were more likely than comparison residents to "agree" or "strongly agree" that they could provide safe patient care on weekend days ( % intervention vs. % comparison, p< . ) and on nights ( % intervention vs. % comparison, p< . ) while on the oncology service. a redesign initiative of an oncology service with the development of a new teaching service led to improved resident perceptions of the educational value of the rotation and ability to provide safe care to patients. this approach could be useful to other services and institutions to promote similar outcomes in resident education and patient care. background: alk-positive histiocytosis is a rare histiocytic proliferative disorder that has been reported in three infants presenting primarily with hepatosplenomegaly, anemia, and thrombocytopenia. given the rarity of this disease, there are no standard treatment algorithms for this diagnosis and the disease course and outcomes remain largely unknown. the published series describes treatment ranging from monitoring alone to multi-drug chemotherapy regimens. there was ulti-mately resolution of presenting symptoms in all three cases despite varying treatment strategies. objectives: to report a newly diagnosed case of alkpositive histiocytosis that was treated with a novel approach using cytarabine monotherapy. results: a full term male infant presented at birth with difficulty feeding and hyperbilirubinemia. over the first few weeks of his life, he subsequently developed thrombocytopenia, transaminitis, and profound hypoalbuminemia. by six weeks of life, he was experiencing significant abdominal ascites requiring repeat paracenteses, massive hepatosplenomegaly, respiratory distress secondary to abdominal distension, anemia, and coagulopathy. he underwent numerous diagnostic tests, including a liver biopsy followed by a bone marrow biopsy that showed alk-positive histiocytic infiltrates in both sites. treatment was initiated with cytarabine mg/kg/day x days, repeating every weeks. throughout his course of five cycles of treatment, he experienced intermittent fevers and mild nausea with no other adverse events. by the end of five cycles, his hepatosplenomegaly resolved, his blood counts normalized, he demonstrated weight gain on oral feeds, and his liver enzymes normalized. he is currently months post completion of therapy and remains well with a normal physical exam and laboratory values. conclusion: treatment of alk-positive histiocytosis with lose dose cytarabine resulted in complete resolution of our patient's symptoms with minimal treatment related adverse effects, and few long-term treatment related risks. given the rarity of the diagnosis, the reporting of effective novel treatment options is important for future patient care. background: adult patients with melanoma or lung cancer harboring braf v e have benefitted from the development and subsequent approval of specific braf inhibitors. as such, delineating the subset of similarly targetable pediatric oncology patients may spur development and rational use of these inhibitors in children. importantly, other point mutations and fusions of braf may also be targetable in s of s children analogous to recent emerging data in adult cancer patients. objectives: to define the genomic landscape of known and novel braf alterations and raf fusions in pediatric malignancies and report index cases with clinical response to braf or mek inhibitors. design/method: dna was extracted from microns of ffpe sections of , tumors from pediatric (< years of age) oncology patients, and cgp was performed on hybridization-captured, adaptor ligation based libraries to a mean coverage depth of x for up to cancer-related genes plus introns from genes frequently rearranged in cancer. genomic alterations (ga) included base substitutions, indels, copy number alterations and fusions/rearrangements. a total of ( . %) braf-altered pediatric malignancies were identified. ( . %) harbored a single kinaseactivating braf short variant, indel, or fusion. an alteration resulting in reduced braf kinase activity was identified in ( . %) tumors while ( . %) tumors harbored multiple braf alterations, of which contained at least a single activating short variant. the remaining tumors ( . %) contained functionally uncharacterized variants. kinaseactivating braf alterations were identified in diverse tumor spectra comprised of brain tumors ( . %; subtypes), carcinomas ( . %; subtypes, with melanoma constituting % of cases), hematological malignancies ( . %; subtypes), sarcomas ( . %; subtypes), and extracranial embryonal tumors ( . %; subtypes). seventy-two ( . % of braf-altered cases) braf fusions were identified, ( . %) of which were kiaa -braf; involved the novel fusion partners: stard nl and khdrbs . seven ( . %) raf fusionpositive cases, predominantly brain tumors ( ), were identified; involved the novel fusion partners: tmf and sox . index cases of response to therapy of intracranial tumors will be presented. we describe a population of pediatric patients with targetable braf alterations predominantly enriched in primary intracranial tumors, but spanning diverse solid tumor types and hematologic malignancies. we additionally report a cohort of raf fusion-positive patients. an index case and multiple previous reports suggest raf or mek inhibitors may benefit pediatric patients with either intracranial or extracranial disease, and development of such drugs in pediatric indications is strongly warranted. background: diffuse midline gliomas (dmg) with h k m mutation, including diffuse intrinsic pontine glioma (dipg), are the leading cause of brain tumor-related deaths in children. there are no effective therapeutic strategies and the median survival remains dismal. genomic studies have identified a recurrent mutation in the majority of dmgs involving a lysine to methionine substitution (k m) in histones . and . , resulting in changes in the epigenetic landscape that dysregulate gene expression and promote gliomagenesis. panobinostat, a multiple histone deacetylase (hdac) inhibitor, was found to be one of the most effective agents against dipg patient-derived cell cultures and xenograft models in previous studies and is presently in clinical trial for dipg. hdac inhibition with panobinostat may also exhibit activity against h k m+ diffuse midline gliomas of the thalamus and spinal cord. to evaluate the effect of panobinostat as a single agent against patient-derived thalamic and spinal cord h k m+ diffuse midline glioma cell cultures and in an orthotopic xenograft murine model of h k m+ spinal cord glioma. design/method: patient-derived thalamic and spinal cord h k m+ diffuse midline glioma cell cultures were treated with single agent panobinostat at a range of concentrations. cell viability was evaluated using the celltiter-glo assay. panobinostat was systemically administered to orthotopic xenograft murine models of luciferase-expressing spinal cord h k m+ diffuse midline glioma. response to panobinostat was evaluated with ivis in vivo imaging. results: hdac inhibition with panobinostat significantly decreases cell proliferation with an ic of nm and nm in the spinal cord and thalamic glioma patient-derived cell cultures respectively. panobinostat slowed tumor growth in murine models of spinal cord glioma by . -fold in the brain (p = . , n = ) and -fold in the spinal cord (p = . , n = ) when compared to vehicle controls after week of administration. panobinostat is in clinical trials for dipg. this study suggests that hdac inhibition with panobinostat may also be beneficial for patients with thalamic and spinal cord diffuse midline glioma h k m mutants. background: brain tumors are the most common solid tumor of childhood and the leading cause of childhood cancer deaths. while medulloblastoma is the most common malignant brain tumor of childhood with a -year survival - %, children with high-grade gliomas (hggs) such as glioblastoma multiforme (gbm) fare much worse with a -year survival of - %. implicated in this poor outcome is the presence of treatment resistant brain tumor stem-like cells. gbm stem-like cells (gscs) have been implicated in tumor growth, treatment resistance and patient relapse, making them a key therapeutic priority. antipsychotic drugs (apds) have been used for decades in various psychiatric clinical settings and are associated with a lower incidence of cancer, including malignant brain tumors. currently, atypical apds are being evaluated for their potential to alleviate cancer and treatment induced side effects. furthermore these drugs may have direct anti-tumor effects, potentially via inhibition of dopamine d receptors (drd ). objectives: determine the anti-cancer effects of atypical apds on gbm stem-like cells design/method: the anti-cancer effects of apds (quetiapine and risperidone) were evaluated on gbm stem-like cell lines developed in our laboratory (glio and ) and the group medulloblastoma cell line hdmbo . cell proliferation/viability was determined using trypan blue exclusion and mts assays. the effect of apds on cancer stem cell self-renewal was determined by neurosphere assay. receptor expression and apds effect on cell cycle proteins were examined by western blot analysis. results: western blot analysis of gscs and hdmbo demonstrated robust drd expression indicating a viable therapeutic target. both apds induced dose dependent cell death of all cell lines tested. treatment with only um of either apd for days significantly reduced cell proliferation by % (hdmbo ) and - % (gscs). consistent with these findings, we observed an increase in cell cycle inhibitors p and p . furthermore at day both apds induced a robust increase in gsc death, approximately % compared to only % in non-treated controls. lastly, um apds significantly reduced gsc neurosphere formation compared to untreated controls by up to % suggesting inhibition of gbm stem cell self-renewal. our data indicates that clinically relevant concentrations (low micromolar) of these apds induce anticancer effects in both gscs, which are enriched with tumor initiation/propagation properties, and in the group (myc amplified) medulloblastoma cell line. these apds represent strong candidates as potential adjuvant therapies for the treatment of these brain tumors. background: while the poor prognosis for high risk neuroblastoma (hrnb) underscores the need for new treatment strategies, the elucidation of specific biologic subsets of neuroblastoma suggests a way to improve disease management. the identification of agents that target specific molecular pathways associated with the development or progression of diseases holds promise. dfmo, an inhibitor of odc, has been shown to decrease lin and mycn and target cancer stem cells in preclinical studies. currently % of patients undergoing immunotherapy relapse. dfmo is in studies to prevent relapse after immunotherapy and may be helpful during immunotherapy as well. the hypotheses for this study were that: ) the incorporation of a targeted therapy, selected based upon upfront tumor genomic interrogation, into standard induction chemotherapy for hrnb is safe, feasible and may increase the pr/cr/vgpr response rate at the end of induction therapy; and ) the addition of dfmo as maintenance during immunotherapy is safe and feasible and may decrease the relapse rate for hrnb. a multicenter feasibility pilot trial in subjects with newly diagnosed hrnb within the beat childhood cancer consortium. at diagnosis, patients' tumors underwent dna exome and rna sequencing which were analyzed within a molecular tumor board to identify the single best drug of targeted agents to be added to cycles - of induction chemotherapy. after consolidation with asct and radiation, the patients received dfmo along with standard dinutuximab and retinoic acid and dfmo for years after immunotherapy. patients were evaluated for additional toxicities with the addition of targeted agents and dfmo in addition to induction response. results: the pilot study of eligible patients has shown this process to be feasible. all patients have completed induction portions of the study. the combination of targeted agent with chemotherapy was shown to be safe without any unexpected toxicities. delays between induction cycles were < weeks and related to surgery, infection, or thrombocytopenia. the induction response demonstrated % cr/vgpr/pr rate, which suggests improvement over historical %. in addition, patients were eligible for the combination of dfmo with dinutuximab and retinoic acid was well tolerated and safe without additional toxicities due to dfmo. the pilot study of patients has shown the process of genomic sequencing and addition of a targeted agent to upfront chemotherapy and addition of dfmo to dinutuximab and retinoic acid maintenance therapy in newly diagnosed hrnb patients and is feasible and safe without any unexpected toxicities. background: identifying sub-populations of medulloblastoma tumors with stem cell-like properties holds promise for reducing disease recurrence, but there is no known unifying marker of medulloblastoma cancer stem cells. the granulocyte stimulating factor receptor (gcsf-r or cd ) is well understood in the context of hematopoiesis, but its role in solid tumor pathogenesis is less clear. neuroblastoma and melanoma subpopulations expressing gcsf-r have cancer stem cell properties of chemoresistance and increased tumorigenicity, and are enriched in tumors after chemotherapy. gcsf-r activation leads to signaling through the jak-stat pathway, suggesting a potential therapeutic target. we hypothesized that a subpopulation of medulloblastoma cells would express the gcsf-r and that this subpopulation would demonstrate chemoresistance and response to inhibitors of the jak/stat pathway. objectives: our objective was to identify a subpopulation of medulloblastoma cells expressing the gcsf-r and determine their relative growth rates, tumorigenicity, and responses to chemotherapy and jak/stat inhibition. design/method: medulloblastoma cell lines were sorted via flow cytometry for gcsf-r surface expression. subpopulations of gcsf-r-positive and -negative medulloblastoma cells were then monitored for growth by continuous live cell imaging. responses to chemotherapy were measured in subpopulations of gcsf-r-positive and -negative medulloblastoma cells using continuous live cell imaging to measure percent cell confluence and cell viability assays. ic values were calculated for each cell line and each agent. parental medulloblastoma cell lines and isolated gcsf-r-positive and -negative subpopulations were also treated with the jak / inhibitor ruxolitinib and growth rates, viability, and ic values were calculated. results: gcsf-r surface expression was identified on . - . % of medulloblastoma cell lines. isolated gcsf-r positive cells demonstrate a slower growth rate compared to gcsf-rnegative or parental unsorted medulloblastoma cells. gcsf-r positive cells are more resistant in vitro to vincristine, etoposide, and carboplatin, when compared to the gcsf-r negative population and an unsorted population of the same cell line. ruxolitinib is cytotoxic to medulloblastoma cells in vitro, with higher ic values noted in gcsf-r positive cells compared to unsorted and gcsf-r negative cells. we show that a subpopulation of gcsf-r positive cells are present in multiple medulloblastoma cell lines via flow cytometry, and that isolated gcsf-r-positive cells have a slower growth rate than gcsf-r-negative or unsorted populations. we also show that ruxolitinib has in vitro activity against medulloblastoma cell lines. we propose that jak inhibition may represent an adjunct therapy targeting overall tumor burden and specifically targeting the gcsf-r-positive subpopulation of medulloblastoma cells that may drive tumor recurrence. we investigated the efficacy of intensified adjuvant chemotherapy in osteosarcoma patients. design/method: we retrospectively analyzed the medical records of children with osteosarcoma treated at asan medical center between and . all patients received a -drug induction consisting of cycles of cisplatin and doxorubicin along with cycles of methotrexate (map), and proceeded to surgical resection. adjuvant ct was map or map with the additional ifosfamide and etoposide (mapie), and mapie was mainly considered for poor responders (tumor necrosis below %) or patients with metastases. results: among patients, patients had metastases at diagnosis. surgery was conducted in patients who responded to induction ct, and showed over % tumor necrosis. among patients who proceeded to adjuvant ct, and patients received to map and mapie protocols. with a median follow-up of months, the -year overall survival (os) and event-free survival (efs) rates of all patients were % and . %. of those patients, patients recurred, and of them died of disease progression. relapsed patients received salvage ct and/or surgery, and were rescued after autologous stem cell transplantation (sct). three patients developed treatment-related acute myeloid leukemia, and they are alive after allogeneic sct. according to the response to neoadjuvant ct, the os rates of good responders (n = ) and poor responders (n = ) were % and . % (p = . ), and efs rates were . % and . % (p = . ). of the poor responders, patients received map as adjuvant ct, and the other received mapie. the os rates of map and mapie group were . % and . % (p = . ), and efs rates were . % and . % (p = . ), respectively. when patients were classified into three groups: . localized disease & necrosis ≥ % (n = ), . localized disease & necrosis < % (n = ), . metastatic disease (n = ), survival rates were in the order of group > > (os = %: . %: . %, efs = . %: . %: %). in each group, intensified adjuvant ct by mapie did not improve survival outcomes. conclusion: initial metastatic disease and poor histological response to neoadjuvant ct were major risk factors for poor survival in osteosarcoma patients. we found that adding ifosfamide and etoposide to map did not improve survival outcomes of patients with adverse risk factors. more effective adjuvant therapy for these patients is needed. background: circulating cell-free dna (cfdna) that shed from tumors into circulation have been used for noninvasive molecular profiling in adult cancers but little is known about its utility in pediatric cancers. pediatric patients with metastatic and refractory solid tumors are known to have poor survival rates, and a key challenge in their management is obtaining biopsy samples especially at times when disease is widely spread or the patient is physically unfit for sampling. the development of a noninvasive profiling strategy is critical for optimizing molecularly guided therapy and assessing response to treatment. in this study, we want to determine the utility of cfdna to noninvasively analyze the molecular profiles of pediatric solid tumors such as neuroblastoma (nb), osteosarcoma (os), and wilms tumor (wt). design/method: tumor, plasma, and matched controls were collected from patients with nb, wt, and os, at diagnosis or time of disease progression. cfdna was extracted from the plasma and analyzed through multiple methodologies including a targeted next generation sequencing panels and shallow whole genome sequencing (swgs). results: fifteen nb patients, os patients, and wt patients had tumor molecular profiles known from different targeted next-generation sequencing platforms. in the cfdna of / nb patients, somatic mutations and copy number alterations previously reported in the tumors were detected, including recurrent nb drivers such as mycn amplification, alk, and atrx mutations. mutations not detected in the original tumor were also found in / nb patients including nras, mll , arid b, some of which are potentially actionable. in os, mutations known from the tumor were found in the cfdna of of patients, including atrx and notch mutations, as well as copy number alterations such as cdk amplification, which has targetable therapeutics available. of the two wt patients analyzed, cfdna revealed the same mutations as tumor in one patient, however in a cohort of patients where tumor was not available, cfdna revealed recurrent driver mutations such as amer , dicer . it is feasible to noninvasively identify somatic mutations and copy number alterations in cfdna of patients with pediatric solid tumors. establishing a platform using cfdna to identify molecular profiles of these tumors can serve as a powerful tool for guiding treatment and monitoring response to treatment. background: despite multi-modality therapy, the prognosis for patients with metastatic osteosarcoma remains poor necessitating development of novel targeted therapies. immunotherapy can be exploited to target osteosarcoma with exquisite specificity but remains limited by insufficient tumor specific targets. objectives: to overcome the dearth in tumor specific antigens, we have explored the use of tumor derived mrna (representing a tumor specific transcriptome) for development of personalized nanoparticle vaccines. design/method: rna-nanoparticles (rna-nps) can be amplified from limited amounts of biopsied tissue for induction of tumor specific t cells against osteosarcoma. since local vaccination strategies are mired by poor overall immunogenicity, we assessed the feasibility, immunogenicity and antitumor activity of intravenously administered rna-nps (tumor mrna complexed to dotap nanoliposomes) in pre-clinical murine and canine tumor models. we identified a clinically translatable np formulation for the delivery of rna to antigen presenting cells (apcs) that induces in vivo gene expression and preserves rna stability over time. tumor derived rna-nps induced antigen specific t cell immunity and mediated anti-tumor efficacy in several pre-clinical solid tumor models (i.e. b f , kr b). when administered intravenously, rna-nps increased expression of co-stimulatory molecules (i.e. cd , cd , cd , ccr ) and pd-l on cd c+ cells throughout reticuloendothelial organs (i.e. spleen, liver, bone marrow) and within the tumor microenvironment; this phenotype was strictly dependent on type i interferon. targeted inhibition of type i interferon signaling (via infar mabs) abrogated anti-tumor efficacy mediated by rna-nps. we enhanced the immunogenicity of this platform by simply combining mrnas encoding for immunomodulatory molecules (i.e. hcv-pamps, gm-csf) or by combining rna-nps with immune checkpoint inhibitors. addition of checkpoint inhibitors (pd-l mabs) to rna-nps increased tumor infiltrating lymphocytes, and intratumoral mhc class i/ii expression, and mediated synergistic anti-tumor activity in settings where pd- or pd-l inhibition alone did not confer therapeutic benefit. we then explored the feasibility of rna-nps in a large animal osteosarcoma model. in ongoing studies for canines with osteosarcomas, we have shown that sufficient amounts of rna can be extracted, amplified, and manufactured into personalized rna-np vaccines. conclusion: rna-nps reprogram systemic immunity and mediate anti-tumor activity providing near immediate immune induction without the complexity of cellular immunotherapy. the immune correlate of preclinical response to rna-nps is hallmarked by interferon dependent pd-l expression on activated apcs (cd c+ mhcii+ cd + cells). based on these findings, we are exploring the preclinical safety, efficacy and immunologic effects of rna-nps targeting canine osteosarcoma before first in-human evaluation. background: ewing sarcoma is an aggressive bone tumor affecting mainly adolescent and young adults. treatments are based on compressed schedule chemotherapy combined with local control (surgery and/or radiation). prognosis is poorer for patients with metastatic disease, older age and central primaries. survival when disease recurs within two years of diagnosis is < %. the ews-fli fusion gene t( ; ) (q ; q ) has been well characterized as a dominant ews driver-gene. the most common variation is ews exon with fli exon ( % of fusion positive patients). we designed a novel pbi-shrna tm ews/fli type lpx which has demonstrated, safety and efficacy in animal model (rao et all). the pbi-shrna strategy silences target gene expression by concurrently inducing translational repression and p-body sequestration as well as post-transcriptional mrna cleavage. to determine the safety and maximum tolerated dose of intravenous administration of pbi-shrna tm ews/fli type lipoplex in patients advanced ews. design/method: phase i study × escalation cohort. testing pbi-shrna tm ews/fli type lpx (starting iv dose of . mg/kg) on patients (≥ age ) with advanced ewing's sarcoma, all with a type translocation. intravenous infusion was given twice a week for weeks with the following escalation schema: % → % → % → % → %. required kps > % and adequate organ function. cytokines induction pre and post-infusion was analyzed (il- , il- , tnf-alpha, il ra). first cohort of patients has been enrolled (ages between - years). three relapsed patients had > lines of therapy and patient had refractory disease, patients received a complete cycle of pbi-shrna tm ews/fli type lpx with twice a week infusions. a total of doses were given. the most prominent related toxicity has been hematological, patient developed transient g neutropenia, another patient developed g anemia that required prbc transfusion, and of note this patient had significant bone and bone marrow involvement. one patient only received two lpx infusions; she developed a fatal rsv pneumonia. other reported grade toxicity includes fatigue and headache. evaluable patients (n ) had stable disease between and months before progression. one patient had sustained response for month before progression, two patients are still alive. our preliminary experience supports the safety and potential efficacy of pbi-shrna tm ews/fli type lpx as novel treatment for advanced ews with limited toxicity. il- increase correlates with higher bi-shrnai ews/fli lpx infusion rate and clinical symptoms. further clinical testing is indicated. background: as more children with cns malignancies (bt) are surviving, the late effects of the therapies they receive are better described. studies show that radiation therapy is particularly harmful to neurocognitive functioning, specifically processing speed, working memory, and attention span. these deficits have negative effects on quality of life, especially in academic and professional settings. a large proportion of s of s adult survivors of bt are unable to reach adult milestones such as living on their own, holding a steady job, and getting married. proton beam radiation therapy (pbrt), is touted for the potential to have fewer and less severe side effects than traditional photon radiation therapy (xrt). because of the properties of protons, the amount of damaging energy released in non-target healthy tissue is reduced when compared to xrt. although a study comparing iq testing between pbrt and xrt found no difference between the two therapies, no studies have compared the specific neurocognitive domains. it would be valuable to evaluate full neurocognitive testing scores (nct) since the specific domains, particularly processing speed (psi), appear to be most vulnerable to radiation therapy. objectives: our primary aim was to assess differences in psi for patients with bt who underwent pbrt versus xrt. a secondary aim was to assess differences in iq (fsiq) and working memory (wmi). we retrospectively evaluated all patients treated for bt at the jimmy everest cancer center within the past years who received rt and had nct post radiation. we examined the full nct results for both subsets of participants to evaluate differences in the specific domains of processing speed, working memory, and iq by measuring percentiles scored in these domains. objectives: we report our experience on imaging children with mm treated uniformly on an institutional melanoma trial. we retrospectively reviewed the clinical and imaging findings of patients with ajcc stage iic-iv cutaneous mm treated on our institutional mel protocol. brain mri/ct, pet/ct, ct chest, abdomen, and pelvis (ctcap) were performed at diagnosis in all patients. on treatment, stratum a patients (peg-interferon; ajcc iic, iiia, iiib) (n = ) had the same imaging repeated every months; stratum b (peg-interferon and temozolomide; unresectable measurable disease metastatic, or recurrent) (n = ) had pet scans every months and brain imaging every months; those in stratum b (peg-interferon and temozolomide; unresectable non-measurable, metastatic, or recurrent) (n = ) had the same imaging performed every months. off therapy all patients continued same imaging every months for years. results: there were patients ( female; median age years). eleven had spitzoid and conventional melanoma. primary sites included head/neck (n = ), trunk (n = ), and extremities (n = ). patients with spitzoid melanoma had imaging studies ( pet, ctcap, ct chest, ct brain, and mri brain) with a median of , , , and studies/patient respectively. median cost per patient was $ , . thirteen studies ( . %) showed suspicious lesions with additional scans and diagnostic biopsies of which one only was positive stratum a with tert promoter mutation and died from disease). for conventional mm, studies ( pet, ctcap, ct chest, ct brain, and mri brain) were performed with a median of , . , , , studies/patient respectively. median cost per patient was $ , . twenty ( %) showed suspicious lesions with additional scans and diagnostic biopsies; four were positive (two at diagnosis); both died of disease; the other two recurred locoregionally and were detected clinically; both are alive and disease free; one patient had diffuse metastases and died shortly after enrollment. after a median follow up of . years (range . - . ) patients are alive and disease free. children with spitzoid melanoma should have minimal imaging at diagnosis and follow-up given the low risk of recurrence and low yield and high cost of aggressive imaging protocols. patients with conventional mm should be imaged according to the adult guidelines. nationwide children's hospital, columbus, ohio, united states background: the role of infections in the long term outcome of patients with bone tumors is controversial. two retrospective studies have shown increased survival in osteosarcoma patients who had a post-operative wound infection, while another showed no changes in overall survival. to determine the relationship between wound infections and/or bloodstream infection (bsi) on survival in pediatric and young adult patients with osteosarcoma and ewing sarcoma treated at a tertiary children's hospital. design/method: a retrospective chart review was performed for patients with diagnosis of osteosarcoma or ewing sarcoma from - . patients received standard chemotherapy regimens for their disease type and stage. local control included surgical resection and/or radiation therapy. presence of infection was determined by bsi or wound cultures while receiving treatment for primary tumor. the median age of patients was (range - years) at diagnosis. % had a diagnosis of osteosarcoma and % had ewing sarcoma. of these, % of patients developed an infection during treatment; % had bsi, % had wound infections, and % had both. patients with bsi had a year os of . %, compared to % in those without bsi (p = . ). those with both bsi and wound infections had the poorest overall survival of %, compared to . % for patients without any infection. patients with wound infections alone had a year os of . %, compared to % of patients without a wound infection. our analysis revealed decreased os in patients with bsi; however, this could be due to other confounding factors in the presence of bsi. those with bsi or bsi and wound infections had the poorest survival. wound infections without bsi were associated with a slight increase in survival; however, this study was limited by the number of patients that had local wound infections. with the use of newer surgical techniques, availability of antimicrobials and routine use of prophylactic antibiotics, the incidence of infections while undergoing treatment is low. however, the importance of this clinical observation indicates a likely enhanced immune system associated with infection, supporting the role of immunotherapy for treatment of these aggressive tumors. background: hypoalbuminemia is a well-recognized effect of cancer and other chronic illnesses and is often regarded as a marker of malnutrition. in adults, hypoalbuminemia has been associated with adverse outcomes in patients with cancers of the lung, pelvis, head and neck, gastrointestinal tract, and bone marrow, as well as in some pediatric patients with ewing sarcoma and hodgkin lymphoma. hypoalbuminemia has not been well studied in children with cancer. to determine the incidence of hypoalbuminemia (using age-specific references) in children with cancer receiving chemotherapy at baseline (prior to starting chemotherapy) and to determine whether hypoalbuminemia is associated with inferior -year overall survival. design/method: we performed a single institution, irbapproved, retrospective review of pediatric oncology patients diagnosed between and . five-year survival was estimated using the kaplan-meier method; groups were compared using cox regression. we identified pediatric patients with a first diagnosis of cancer, brain tumor, or other condition possibly requiring chemotherapy. of these patients, were excluded for reasons including not receiving chemotherapy and missing data, leaving patients who had a serum albumin level within days prior to starting chemotherapy. the mean age was . years (sd . years); % were male; % were non-hispanic. the most common diagnosis was acute lymphoblastic leukemia ( of ; %). one hundred thirty nine of ( %) had hypoalbuminemia prior to starting chemotherapy. there was no statistically significant difference in -year overall survival between those with and without hypoalbuminemia ( % vs. %, respectively; hazard ratio . , % c.i. . - . ). conclusion: hypoalbuminemia at baseline in pediatric oncology patients requiring chemotherapy is common (one in five), and was not associated with inferior -year overall survival in this cohort. leptomeningeal metastases at diagnosis. standard treatment for completely resected, non-anaplastic supratentorial ependymomas is close observation. treatment for anaplastic or incompletely resected non-anaplastic ependymomas is maximal safe surgical resection followed by focal radiation. however, up to % of localized ependymomas recur. the role of chemotherapy in treating ependymomas is under investigation. extraneural metastases of anaplastic ependymomas have rarely been reported and the outcome is dismal. objectives: to report extraneural cervical node metastases of a non-anaplastic ependymoma and successful treatment with surgical resection, radiation, and systemic chemotherapy. design/method: retrospective review of patient medical records, including radiographic imaging and tumor tissue pathology, and comprehensive literature review. results: a previously healthy -year-old girl underwent gross total resection (gtr) of an isolated right parietal lobe ependymoma (who grade ii). at age years, magnetic resonance imaging (mri) revealed an isolated localized recurrence. she underwent gtr followed by observation. at age years, she again experienced isolated localized recurrence and underwent gtr followed by . gy focal conformal photon radiation. at each recurrence, pathology revealed a non-anaplastic ependymoma, and cerebral spinal fluid (csf) cytopathology and spine mri were negative. at age years, she developed an enlarged right posterior cervical chain lymph node. subsequent mri revealed a large rim-enhancing, t hyperintense lymph node and multiple abnormally enhancing regional nodes consistent with metastases. biopsy revealed a non-anaplastic ependymoma. mri of the brain and spine, computed tomography of the chest, abdomen, and pelvis, and csf and marrow evaluations were unremarkable. chemotherapy according to acns was initiated. mri after course demonstrated significant node size reduction. she underwent right neck node dissection. only one right level ii lymph node showed metastases. she was treated with . gy irradiation to the neck and additional courses of chemotherapy. she remains in remission months and months after diagnosis of metastatic disease and end of therapy, respectively. literature review reveals rare reports of extraneural metastatic disease of anaplastic ependymomas to bone, lung, or liver, and only involving lymph nodes, all associated with a poor outcome despite multimodal therapy. to our knowledge, this is the first report of extraneural metastases of a non-anaplastic ependymoma. extraneural metastases should be considered in children previously treated for non-anaplastic ependymomas who experience systemic symptoms, even in absence of cns relapse. multimodal treatment offers potential long-term disease control with acceptable toxicity. arun gurunathan, joel sorger, andrew trout, joseph pressey, rajaram nagarajan, brian turpin cincinnati children's hospital medical center, cincinnati, ohio, united states background: pigmented villonodular synovitis (pvns) is a benign neoplasm of the synovium. standard treatment is surgery, but post-operative recurrence rate is as high as %. radiation therapy can be used for local control, but is associated with late effects. while pvns is rarely fatal, aggressive disease and/or extensive surgery can result in substantial functional impairment. colony stimulating factor- (csf ) overexpression, often due to chromosomal translocation involving csf , drives pvns through recruitment of synovial-like mononuclear cells expressing the csf -receptor. tyrosine kinase inhibitors such as imatinib are active against the csf -receptor, and have shown benefit in the post-surgical relapse setting. however, questions remain regarding the broader application of imatinib and regarding optimal response assessment. to present three patients with pvns, each with different clinical scenarios, who demonstrate clinical response to imatinib monitored by changes in metabolic activity (maximum suv) on pet/ct. results: three patients with pvns demonstrate pet/ct response to imatinib, guiding management of their challenging clinical scenarios. patient is a year-old female with left hip pvns and high grade articular cartilage loss, with decrease in metabolic activity (suvmax . to . in months) on neoadjuvant imatinib, enabling total hip replacement surgery planning. patient is a year-old female with left knee pvns with recurrences after synovectomies, spared subsequent surgical control attempts after clinical improvement correlating with pet/ct response to imatinib (suvmax . to . in months). patient is a year-old male with right knee pvns that recurred after total knee replacement, now with clinical improvement correlating with pet/ct response to imatinib (suvmax . to . in months). all patients would have been characterized as stable disease by response evaluation criteria in solid tumors (recist). in each of these patients, imatinib has been tolerated well, with no therapy interruptions and absent or easily managed side effects (one patient takes dronabinol for decreased appetite, one patient takes prn immodium for diarrhea). all patients are currently still taking imatinib, with therapy length ranging from five to eleven months. in our series of three patients with pvns, imatinib shows promise for disease management in neoadjuvant and adjuvant settings with a tolerable side effect profile. imatinib should be considered in the treatment of pvns to spare surgical and radiotherapy related morbidity, and treatment effect can be monitored by pet/ct. background: metastatic rhabdomyosarcoma (rms) carries a poor prognosis with three-year event free survival rates ranging between %- % (depending on oberlin risk factors) due to the lack of significantly effective breakthroughs in the recent past. there is an urgent and unmet need for new treatment strategies against this disease. metastatic rms cell lines exhibit increased expression of the erm family membrane-cytoskeleton linker protein ezrin. knockdown of ezrin expression using sirnas decreases the metastatic potential of these cells, whereas forced expression of ezrin results in increased degree of metastasis. the activity of ezrin is controlled by its phosphorylation at the threonine (thr ) residue at the c-terminus of the protein, suggesting that alteration of ezrin phosphorylation may control rms growth and metastasis. our goal was to determine if pharmacological inhibition of thr phosphorylation in ezrin affects the growth, survival and metastasis in rms in vitro as well as in vivo. design/method: rms cell lines representative of the alveolar and embryonal histological subtypes were used. rms cells were treated with a small molecule inhibitor of ezrin, nsc , which specifically dephosphorylates ezrin at the thr residue. baseline expression of ezrin and perm levels as well as the effect of nsc on perm levels in the rms cell lines was determined by western blotting of cell lysates. viability of cells was assessed by trypan blue exclusion, and morphology visualized by bright field microscopy. the extent of apoptosis was detected by imaging caspase / activation using fluorescent microscopy. motility of rms cells was examined by performing a wound-healing assay. subcutaneous and orthotopic xenografts were established in nsg mice using rd cells (embryonal rms). mice harbor-ing xenografts were treated with intraperitoneal injections of nsc or dmso. results: ezrin is constitutively phosphorylated at the thr residue in a majority of the rms cell lines examined. nsc dephosphorylates ezrin at the thr residue in these cell lines. treatment with nsc inhibits growth, induces apoptosis and inhibits the migration of rms cell lines in vitro. further, treatment of nsg mice bearing subcutaneous or orthotopic embryonal rhabdomyosarcoma xenografts with nsc significantly impedes tumor progression without any obvious adverse effects. our findings suggest that dephosphorylation of ezrin at the threonine residue may have the potential to be a novel therapeutic strategy for rms patients. all india institute of medical sciences, new delhi, new delhi, delhi, india background: the role of laparoscopy in the management of pediatric intra-abdominal solid tumors is yet to be established. the safety of laparoscopic management of pediatric intra-abdominal tumors is still questionable. we study the results of the initial case series of pediatric intraabdominal tumors managed laparoscopically at our institute from july onwards. design/method: total children ( -males, females) who presented to us with pediatric intra-abdominal tumors were included. the tumors included wilms tumor (n = ), neuroblastoma(n = ), adrenal cortical tumor(n = ), ovarian teratoma(n = ).children were between months - years and received neo-adjuvant chemotherapy. a -port laparoscopic nephrectomy and lymph node sampling for wilms tumor and adrenalectomy for adrenal tumors was performed. the tumors were removed in-toto with no rupture (except in one). specimens were retrieved through a lumbar incision (n = ) or an inguinal incision(n = ). all the children are under regular follow up. two children with wilms tumor had recurrence. the neuroblastoma child underwent open surgery for recurrence later. conclusion: laparoscopy/laparoscopic assisted removal of pediatric intra abdominal tumor is a feasible and safe option. it has the advantage of less postoperative pain, shorter hospital stay and a better cosmetic result. proper patient selection, port placement and laparoscopic experience are contributory. background: targeting of proteins and cell surface antigens specific to cancer cells with monoclonal antibodies has proven to be an effective form of treatment in many forms of cancer. gd is a cell surface disialoganglioside that is expressed on the cell surface of some normal tissues including nerve cells, melanocytes, and mesenchymal stromal cells and is overexpressed in some pediatric cancers like neuroblastoma and osteosarcoma. dinutuiximab is a chimeric monoclonal antibody that is fda approved for the treatment of patients with high risk neuroblastoma and under investigation for the treatment of relapsed osteosarcoma. little is known about the patterns of gd expression in other pediatric malignancies. objectives: we sought to describe the patterns of gd expression in the following pediatric sarcomas: synovial sarcoma, rhabdomyosarcoma and ewing sarcoma. design/method: synovial sarcoma (n = ), rhabdomyosarcoma (n = ) and ewing's sarcomas (n = ) formalin fixed, paraffin embedded cores were obtained from the seattle children's research institute tissue microarray (tma) biorepository. tma blocks consisting of melanoma cores stained with and without gd antibody were used as positive and negative controls, respectively. slides were incubated with anti-ganglioside gd antibody clone q (ab from abcam) diluted : in % normal goat serum and % bsa in tbs overnight at ˚c. the negative control of human melanoma section was incubated in % normal goat serum and % bsa in tbs without primary antibody. the expression of gd was indicated by characteristic brown diaminobenzidine staining. the intensity and location of tissue staining were assessed and compared to positive and negative controls. staining was considered positive (+++) if the intensity of the staining was consistent with that of the positive control with - % of cells staining positive. classification of intermediate gd expression (++) was assigned to slides in which - % of cells stained positive. slides were classified as sporadic staining (+) if - % of cells stained positive. tissue was considered (-) if there was complete absence of staining, similar to the negative control. objectives: to evaluate the clinical presentation, management and treatment outcomes of children with malignant germ cell tumor at our institute design/method: a prospective study was conducted from june to dec in the department of pediatric surgery in a tertiary care institute in a developing country. all patients were evaluated for local disease and metastatic disease by imaging and tumor markers. risk stratified chemotherapy was used with low risk tumor receiving no chemotherapy, intermediate risk: courses of peb chemotherapy and high risk: courses of peb + courses of pe. upfront resection of the primary or the residual disease after neoadjuvant chemotherapy if feasible was performed. follow up was done with monthly tumor markers for months and imaging studies every - months for initial years. five year overall survival and disease free survival was calculated. results: during the study we treated children who formed the study group. of these ( %) were gonadal ( ; % testicular and ; % ovarian) and the remaining ( %) were extragonadal with sacrococcygeal (sct) being the most common site ( %). one hundred and thirteen children ( %) presented to us primarily while the remaining had received treatment elsewhere. stage or stage disease at presentation was present in ( %) children. recurrence was noted in ( %) patients. respectively. patients with testicular mgct and children with age - years and males had significantly poor rfs rates. conclusion: patients with mgct should be staged correctly and adjuvant chemotherapy is advisable to all patients except stage i endermal sinus tumor of testis. awareness regarding the same is still lacking in our country. meticulous follow up is needed as more than % of will recur. cure rates are dismal in children with recurrent mgct especially those who are not chemotherapy naïve. nemours children's specialty care, jacksonville, florida, united states background: radiotherapy for pediatric head and neck tumors often results in mucositis, limiting oral intake and compromising patients' nutritional status. this may be reduced through the improved conformality offered by proton therapy. despite widespread use of enteral tube feeding through a percutaneous gastrostomy (peg) or nasogastric tube (ngt), there is little data available regarding overall incidence of ngt/peg placement and perspectives of pediatric patients and caregivers. objectives: to (a) estimate the need for ngt/peg support and (b) characterize patient and caregiver perceptions surrounding enteral feeding in children with head and neck tumors undergoing proton therapy. design/method: dependent on development stage, patient (n = ) or parents (n = ) filled out a series of customized surveys according to a prospective irb approved study. seventythree percent of patients also received concurrent chemotherapy. questions addressed their current feeding route and perception, for example, "what aspect(s) of tube feedings are beneficial to you?" and "what aspect(s) of tube feeding worry or scare you?" fifty-five surveys were distributed before and after radiation, and with any change in feeding route. results: at the start of proton therapy, patient had a ngt and patients had peg. of these, patients ( %) had a ngt/peg in place exclusively for the administration of medication; only patient ( %) needed a ngt/peg for nutrition. in those patients without ngt/peg, % would "consider" enteral feeds. in patients without ngt/peg, the most commonly cited benefit was "maximizing my nutrition" ( %) and the most common negative aspect was "fear" of tube placement ( % of patients). all sub-populations ( % of patients) cited change in appearance as a negative aspect. in patients without ngt/peg at the start of proton therapy, % of patients/caregivers felt enteral feeding to be "unnecessary," and % of these patients would not "consider" ngt/peg even if their "physician advised it." over the course of proton therapy, the patients/caregivers who deemed enteral feeding "unnecessary" decreased from % to %. at completion of treatment, patients ( %) were using a ngt/peg tube for nutritional support but only one ( %) patient relied exclusively on their enteral feeds. two patients (without ngt/peg) ( %) required parenteral support. our data does not support prophylactic placement of ngt/peg in of children with head and neck tumors undergoing proton therapy. ongoing research is needed to identify which patients will need ngt or peg to supplement their diet. in this cohort, anticipatory counseling should focus on pain, cosmesis, and utility. children's national medical center, washington, district of columbia, united states background: ovarian sex cord-stromal tumors (osct) are rare neoplasms that typically present with signs/symptoms of an adnexal mass and signs of hormonal production approximately % of ovarian sex cord-stromal tumors in children are sertoli-leydig cell tumors (slct) with median age of presentation years overall. to our knowledge the youngest reported case in the literature describes a -month old female in china with a slct that was treated with oophorectomy alone. some studies have found an association in families between pleuopulmonary blastoma and osct with a germline mutation leading to dicer syndrome, which has been associated with a younger age at diagnosis. , objectives: to describe an unusual case presentation of slct in an infant results: -month old, twin female, ex- week premature infant presented to the emergency department on multiple occasions for abdominal distention and feeding intolerance initially thought to be related to previous omphalocele repair and umbilical hernia. an ultrasound demonstrated an × cm mass arising from the right ovary with large volume ascites. she required admission to the intensive care unit due to s of s respiratory distress from her significant ascites. serum tumor marker including hcg, afp and ldh were negative. patient underwent right oophorectomy with tumor capsule noted to be open at time of surgery. further imaging post operatively demonstrated no other sites of disease. the patient was classified as figo stage ic due to the presence of her significant abdominal ascites that was presumed to be malignant pre-operative tumor rupture. the pathological diagnosis was challenging and eventually resulted as a mixed germ cell sex cord stromal tumor with pattern of sertoli cell tumor with neuroendocrine differentiation. based on the staging of figo ic with pre-operative rupture, the decision was made to treat with a standard platinum based regimen as there is a higher incidence of relapse in stage ic patients when compared to ia treated with observation alone. our patient tolerated four cycles of chemotherapy well and end of therapy scans showed no evidence of disease. interestingly, her dicer mutation genetics performed by ion torrent tm next generation sequencing was negative in germline and tumor studies. to our knowledge, our patient is the youngest described with slct. she will continue to be followed with serial imaging alone as she had no evidence of elevated tumor markers at diagnosis. , due to young age and unusual diagnosis, she was referred to cancer genetics team. background: approximately % of patients with wilms tumor (wt) have metastatic disease at diagnosis and often have a grave prognosis. limited cell lines are available for the study of metastatic wt and long-term passaged cell lines do not always recapitulate the human condition. focal adhesion kinase (fak) is a non-receptor tyrosine kinase that controls cellular pathways involved in the tumorigenesis of pediatric renal tumors. using a novel patient-derived xenograft (pdx) model from a patient's primary wt (coa ) and matched isogenic metastatic wt (coa ), we previously demonstrated that fak is expressed and its inhibition led to decreased tumorigenicity of both the primary and metastatic pdxs. kinomic profiling is an innovative, high-throughput method used to investigate kinase signaling to identify potential therapeutic targets. to date, the kinomic profile of primary and metastatic wt has not been examined. objectives: investigate baseline kinomic differences between primary and metastatic wt and evaluate kinases upstream and downstream of fak as potential targetable therapies. design/method: cells from coa and coa were treated with pf- , (pf), a small molecule fak inhibitor. protein from cell lysates of treated and untreated coa and coa were combined with kinase buffer, atp, and fluorescently labeled antibodies and loaded into a phosphotyrosine kinase or serine-threonine kinase pam-chip® per the uab kinome core protocol. phosphopeptide substrate analysis with the pamstation® kinomics workstation (pamgene® international), pamchip® protocol using evolve software, and bionavigator v. . were used to analyze kinases upstream and downstream of fak. the primary wt had increased epha , ror sgk and decreased pdgfrb relative to the paired metastatic wt at baseline. treatment with pf increased ron, pdgfrb, p s kb, mak, camk g, vacamkl, camk d, ck a and pskh in the primary wt. treatment with pf decreased tnk , lmr , cck , epha , pdk , sgk , lkb and increased pskh in the paired metastatic wt. primary wt displayed a different kinomic profile compared to metastatic wt in a matched isogenic pdx model. these data reveal that alternative therapies to specifically target metastases are needed. furthermore, fak inhibition resulted in diverse kinomic alterations between primary and metastatic wt. inhibitors targeting many of these pathways, such as pdgfrb inhibitors, are currently available and potentially could be combined with fak inhibitors in the treatment of wt. the results of the current study indicate that kinases upstream and downstream of fak in primary and metastatic wt warrant further investigation. background: use of high-dose methotrexate (hd-mtx, g/m^ ) is a mainstay of standard therapy for pediatric osteosarcoma (os) in north america. in pediatric os, there is a narrow therapeutic window for hd-mtx, with decreased tumor response rate with mtx concentrations < m and decreased survival due to severe toxicity with concentrations > m. risk factors for hd-mtx toxicity have been defined in adults, including body mass index (bmi) and male gender, but such studies have not been conducted in children. we sought to examine the relationship between mtx levels and toxicities during hd-mtx infusion for pedi-atric os, thereby identifying risk factors for increased toxicity and providing a framework for therapeutic drug monitoring. design/method: this retrospective chart review included patients treated at texas children's hospital with hd-mtx as first-line therapy for os from - . data abstracted from electronic records included patient characteristics, bmi and body surface area (bsa), baseline and post-treatment laboratory values, mtx levels and hours after dose given ( h, h), hour mtx cleared (mtx < . um), grade / mucositis, myleosuppression, persistent lft elevation (ctace v . ), and % tumor necrosis. correlation between h mtx level and other covariates was summarized using descriptive statistics. we reviewed hd-mtx infusions corresponding to patients. bmi was found to significantly impact h mtx level (p< . ). female gender was also significantly associated with higher h mtx level (p< . ). percent necrosis (available in patients) was associated with h mtx levels at near-statistical significance (p = . ). h mtx level was not found to contribute to toxicities or associate significantly with mtx clearance. analysis in a larger cohort is ongoing. we have identified at least one patient factor (bmi) that significantly impacts h mtx levels and is of potential use for future modeling, as current models incorporate bsa only. our findings concord with studies in adult os in that bmi significantly impacts h mtx level but diverge in that female gender is associated with higher h levels. importantly, these data support targeting h mtx levels to ensure that minimum concentration for adequate tumor necrosis is reached. these results do not suggest that monitoring h levels would prevent toxicities, thus necessitating further characterization of any intrinsic patient factors that associate with toxicity. overall, our definition of the clinical factors that associate with h mtx levels contributes to a framework for therapeutic drug monitoring in pediatric os. children 's mercy hospital kansas city, kansas city, missouri, united states background: post consolidation immunotherapy with dinutuximab, aldesleukin (il- ), granulocyte macrophage colony stimulating factor (gmcsf) and isotretinoin is standard of care for children with high risk neuroblastoma. dinutuximab is combined in alternating cycles with s of s gmcsf or il , followed by a th cycle with isotretinoin alone. il- is administered as a hour continuous infusion on days - at miu/m /day followed by a higher infusion dose, . miu/m /day, in combination with dinutuximab on days - of cycles and . the miu/m /day dose may be administered inpatient or in the ambulatory setting. objectives: to retrospectively compare the incidence of inpatient and outpatient side effects and complications associated with low dose ( miu) il to provide the tolerability data necessary to evaluate these venues for future administration options. design/method: this study was a descriptive, singlecentered definitive study utilizing a retrospective convenience sample population of children with high risk neuroblastoma who received low dose il either as an inpatient or an outpatient without exclusion from may to june . subjects were identified by a tumor registry query post irb approval. electronic and paper medical records were reviewed for the dates and location of the infusions, the home health company used if applicable and all documentation regarding clinical status, side effects and toxicity. demographics was limited to age and gender. results: infusion venue was chosen by provider preference. twenty-six infusions, inpatient and outpatient via separate home health companies were all administered in entirety and without interruption. there were males and females ranging from - years of age. two children received a single outpatient infusion due to intolerance of il when combined with dinutuximab and received therapy in both settings. fever, inpatient and outpatient was the only common side effect. no source of infection was ever identified. there was one incidence of diarrhea and one patient with pruritus in both the outpatient and inpatient settings respectively. no planned outpatient infusions required subsequent admission however the outpatient fever did necessitate an er evaluation. conclusion: low dose il can successfully be administered outpatient. the medication has minimal side effects with fever occurring in %, none of which were associated with infection. no outpatient infusion required a subsequent admission. no patients who received cycle infusions outpatient opted to receive the next cycle inpatient. baylor college of medicine, houston, texas, united states background: metastatic ewing sarcoma (es) has an extremely poor overall survival, necessitating investigations into molecular mechanisms to identify novel targets and develop new therapies. we previously performed an in vivo study, using our mouse model, designed to provide insights into transcriptomic and proteomic signatures for metastatic es to identify potential therapeutic targets. comparing profiles of primary tumors to corresponding metastatic lesions, we identified aberrant expression of integrin ß (itgb ) and downstream activation of integrin-linked kinase (ilk) in metastatic lesions compared to primary tumors, implicating this pathway as a key regulator in the ability of es to establish and enhance metastasis. our hypothesis is that upregulation of itgb and its downstream signaling events play a key role in es metastasis and are viable therapeutic targets. objectives: to investigate the role of itgb and its downstream signaling pathways in driving the establishment and enhancement of metastasis in es and to investigate this pathway as a potential therapeutic target. to investigate the role of itgb and ilk in es metastasis, we used sirna to knock down itgb and ilk expression in established es cell lines and then performed functional assays in vitro, including cell proliferation and invasion/migration assays. we also tested inhibition of this itgb signaling pathway using available small molecule inhibitors targeting itgb , ilk and the downstream target ap- , using cilengitide, compound and sr , respectively. we are currently using these small molecule inhibitors as treatment in vivo and assessing rates of metastatic tumor formation. we generated stable itgb and ilk overexpression and knockdown cell lines, which we are using for similar in vitro and in vivo investigations. knockdown of itgb and ilk in our sirna cell lines resulted in decreased cell proliferation and decreased invasion and migration compared to controls. we also found significantly decreased cell proliferation using each of the small molecule inhibitors in vitro. our preliminary studies using compound in vivo established a safety profile and dose escalation is underway to assess the effectiveness of inhibiting es metastasis. these results support our hypothesis that itgb and its downstream signaling events play a key role in the ability of es to establish metastatic foci and may serve as a potential therapeutic target. we continue to investigate this pathway in vitro. we are also using our small molecule inhibitors and itgb and ilk overexpression and knockdown approaches to study these effects on metastatic tumor development in vivo using our mouse model. background: neuroblastoma (nbl) is characterized by phenotypic heterogeneity. outcome is excellent for patients with low-(lr) and intermediate-risk (ir) disease, whereas only % of high-risk (hr) patients will survive. -hydroxymethylcytosine ( hmc) is an epigenetic marker of active gene transcription, and hmc profiles are prognostic in many types of adult cancers. we hypothesized that hmc profiles will serve as robust biomarkers in children with nbl tumors, refining current risk stratification. objectives: analyze genome-wide hmc in nbl tumors and correlate hmc deposition with chromosomal copy number and gene expression. design/method: hmc was quantified by nano-hmc-seal-seq from the dna extracted from hr, ir and lr nbl tumors. read counts and clinical data were analyzed with deseq to identify genes with differential hmc patterns between risk groups. chromosomal copy number was assessed by chromosomal microarray analysis (cma) in a subset of samples ( lr and hr). expression of genes located on chromosome p was evaluated using publically available microarrays (e-mtab- ) of hr nbl tumors with known p loh status. results: globally, lr tumors had more hmc peaks ( , ) than ir ( , , p = . ) tumors, or hr tumors ( , , p = . ). , genes had different patterns of hmc deposition in hr versus lr tumors. ( %) of these genes mapped to chromosome p and had decreased hmc in hr versus lr tumors (padj < . ). in the cma analysis p deletion was detected in of the tumors tested. in the tumors with p loss, genes that map to p showed decreased hmc deposition compared to the hr tumors without p loss (p< . ). further, compared to the tumors without p loss, the expression of of the p genes was decreased (p< × - ), including chd , camta , and arid a, known and proposed tumor suppressor genes in nbl. conclusion: different patterns of hmc accumulation are associated with neuroblastoma risk classification. nano-hmc-seal-seq is sensitive to copy number variations and has the potential to identify these changes in patient tumors. our results suggest that hmc deposition contributes to the silencing of tumor suppressor genes in p and may also regulate the transcription of other genes that drive tumor phenotype. background: metastatic osteosarcoma has a -year survival rate of - %. pulmonary metastases remain a major treatment challenge in osteosarcoma. current treatment with conventional chemotherapy shows inadequate activity towards metastases and has toxic systemic side effects. chloroquine is a widely used anti-malarial drug and has been shown to have promising anti-cancer and anti-metastatic activity. polymeric drugs have been shown to have multiple advantages over their small molecular parent drugs, including enhancing the therapeutic efficacy, an improved pharmacokinetics profile and decreased systemic toxicity. we hypothesized that by developing chloroquine into a polymeric drug and combining it with conventional chemotherapy it will improve the treatment of metastatic osteosarcoma. objectives: to identify the optimal combination of polymeric chloroquine (pcq) with conventional chemotherapy active in osteosarcoma as a new means of treating metastatic disease in a murine osteosarcoma model. we synthesized and developed pcq and evaluated its anti-invasive activity using an osteosarcoma cell migration and invasion assay. we evaluated the efficacy of cell killing using combination drug therapies with pcq and a panel of conventional chemotherapy agents (doxorubicin, docetaxel, cisplatin and paclitaxel) using celltiter blue cell viability assay. to develop the murine osteosarcoma model, we intravenously injected luciferase-expressing human osteosarcoma cells b into nsg mice. we administered the drug combination that showed the strongest in vitro synergy to the mice and evaluated their anti-cancer and anti-metastatic effects in vivo. tumor growth and suppression were evaluated using whole body bioluminescence imaging. results: we successfully synthesized pcq that contains . % chloroquine with a molecular weight of . kd. pcq was also found to decrease the toxicity of the parent chloroquine. pcq showed strong inhibition of osteosarcoma cell migration with % inhibition compared to % by chloroquine. we screened the combination drug therapies and found the combination of pcq and doxorubicin to show the strongest synergism. the pcq/doxorubicin combination is currently being evaluated in the murine model. combination drug therapy using pcq and doxorubicin showed synergistic cell killing and inhibition of cell migration in vitro. the combination represents a promising treatment strategy for pulmonary metastatic osteosarcoma. emory university/children's healthcare of atlanta, atlanta, georgia, united states background: survival for relapsed high-risk neuroblastoma (rnb) is < %, underscoring the critical need for novel therapies. rnbs have increased ras/raf/mapk mutations and increased yes-associated protein (yap) transcriptional activity. yap is a transcriptional co-activator that binds with tea-domain (tead) transcription factors to regulate cellular proliferation, self-renewal, and survival. we found that shrna inhibition of yap decreases nb cell proliferation and sensitizes ras-mutated nbs to mek inhibitors, supporting yap as a tractable therapeutic target. verteporfin (vp), a photodynamic drug used for macular degeneration, is the only drug found to inhibit yap expression or yap:tead binding to kill tumor-derived cells. peptide is a mer yap peptidomimetic that also disrupts yap:tead interactions. we sought to determine whether these compounds are potent in nb via yap direct effects. design/method: yap expressing (nlf, sk-n-as) or yap null (ngp, lan , sk-n-as-shyap) human-derived nbs were incubated with vp, with and without direct light exposure, or with peptide . celltiter-glo and immunoblots were used to assess for cell death and yap-downstream protein expression, respectively. results: without direct light exposure, vp inhibits yap expression at nm dosing, yet no nb cell death was observed at equal or higher concentrations. egfr and erk / were inhibited along with yap, confirming yap/ras pathway coregulation. when vp was exposed to direct incandescent light for minutes, > % nb cell death occurred in all nbs tested, even those lacking yap. peptide caused no cell death or yap inhibition up to um. neuroblastomas are resistant to vp at doses sufficient to inhibit yap expression. in macular degeneration, light-activated vp produces reactive oxygen species, which we hypothesize is the off target mechanism killing nbs independent of yap. given the off target effects and the need for light activation, vp is not an ideal preclinical or clinical yap inhibitor. accordingly, peptide has poor cell permeability and low tead affinity, leading to its lack of efficacy. given the relevance of yap in rnb and other cancers, we are chemically optimizing a yap peptidomimetic with enhanced permeability, nuclear localization, and tead affinity to create a bonafide yap inhibitor for preclinical and clinical application. kayeleigh higgerson, aaron sugalski, rajiv rajani, josefine heim-hall, jaclyn hung, anne-marie langevin ut health san antonio, san antonio, texas, united states background: osteosarcoma is the most common bone malignancy in children, adolescents, and young adults. most study cohorts have to % hispanic patients that encompass many different hispanic backgrounds. the university of texas health science center at san antonio (uthscsa) sarcoma team serves a latino population that is predominantly mexican american, thus providing a unique opportunity for evaluation this population. this study expands on previous data collected from january to december from the same institution, providing increased insight into outcomes of mexican american children, adolescents, and young adults with osteosarcoma. objectives: to further understanding of osteosarcoma in latino children, adolescents and young adults. design/method: a retrospective analysis of demographics, tumor characteristics, response to treatment, and survival outcome of all localized osteosarcoma of the extremity patients below years of age diagnosed and treated by the uthscsa sarcoma team between january and june was performed. results: in our original cohort from january to december , we observed a significantly decreased -year eventfree survival (efs) in patients diagnosed before age (preadolescent) relative to patients diagnosed between ages and ( % vs. %, p< . ). patients had a -year overall survival (os) and event-free survival of % and % respectively. in our expanded cohort from january to june we evaluated sixty-six patients with a median age of (range, to y) with localized high-grade osteosarcoma of the extremity. the expanded cohort was % mexican american, with a median follow-up of months (range, to ). the analysis of our expanded cohort is ongoing and we postulate that the findings will hold true, as we increase the cohort size and length of follow-up. conclusion: analysis of our previous cohort, predominantly of mexican american ethnicity, showed that preadolescent patients had an increased rate of relapse when compared with previous large studies. we also showed a trend towards decreased efs for the entire cohort. we hypothesize that we will further validate these findings with this expanded cohort and this will support further investigation into potential causes of poor outcome in this vulnerable latino population. background: neuroblastoma in infants has the potential to regress or mature spontaneously. growing literature showed that some cases subjected to initial observation didn't show inferior outcome compared to actively treated similar categories. objectives: we investigated whether early active treatment can be safely avoided/deferred in selected favorable cases at the children's cancer hospital-egypt (cche). design/method: patients enrolled on the watch and see strategy (w&s) at cche had small primary tumor; inss stage - , uncomplicated stage s or stage infants (< days). tissue biopsy was not mandatory for infants below months of age with localized adrenal mass (stage - ). on progression, immediate intervention took place according to stage and risk of disease after biological characterization. results: thirty four nbl patients were enrolled on w&s strategy; m/f: . / . eighteen patients had stage s disease, patients had stage - and were stage . primary adrenal site was reported in patients ( . %), patients ( . %) had small mass measuring ≤ cm in its largest diameter. the -year os & efs were . ± . % and . ± %, respectively, with months median follow-up (range: - months). spontaneous total/near total resolution of mass occurred in / patients ( %). median time to eliciting regression was . months (range: . - . months), and . months (range: - months) till complete resolution. only / patients ( . %) witnessed progression ( local, distant and combined local and distant progression); median time to progression was months (range: - months) with / deaths after starting chemotherapy. watch and see strategy is a safe approach in localized and uncomplicated stage s neuroblastoma. progressive cases could be rescued. baylor college of medicine, houston, texas, united states background: ga- dotatate binds to somatostatin receptor expressed in neuroendocrine tumors (nets). it was approved by fda in for use with pet/ct scan for localization of somatostatin receptor positive nets in adult and pediatric patients. pediatric approval was based mainly on extrapolation of data from adults. objectives: to describe the use of ga- dotatate pet/ct scan in children with neuroendocrine tumors and compare with other imaging modalities. design/method: patients with nets enrolled in texas children's rare tumor registry between february and october were reviewed and those patients who underwent ga- scan were included. results: four patients with nets underwent ga- scans without any adverse reactions. first patient was a -yearold female with small bowel net with multiple liver metastases. mri abdomen and fdg pet at diagnosis showed s of s multiple liver metastases but could not identify the primary lesion. ga- scan was able to accurately identify the enlarged lymph nodes in the small bowel and was better than fdg pet in delineating the liver metastases. second patient was a -year-old female with recurrent small bowel net with liver, lung and paraspinal metastases. the lesions were initially detected by ct scan. octreotide scan failed to show any uptake in the identified lesions while ga- was taken up by the liver lesions, lung lesions > cm in size and the paraspinal lesion. third patient is an year-old male with pancreatic net with peripancreatic lymphadenopathy, multiple liver metastases and cardiophrenic lymph node involvement. the primary lesion in the pancreas could not be identified by ct scan, ct angiogram, mibg scan, or octreotide scan. in addition, there was uncertainty about involvement of the enlarged cardiophrenic lymph node. in addition to clearly identifying the primary lesion, ga- scan was able to detect multiple peripancreatic lymph nodes not detected by other scans and revealed uptake in the cardiophrenic lymph node confirming its involvement by the tumor. fourth patient is a -year-old female with malignant abdominal paraganglioma with solitary lung metastasis. both mibg scan and ga- scan were able to identify the primary lesion. ga- scan was performed after the lung metastasis was removed and thus its ability to detect it could not be confirmed. background: neuroblastoma is the most common extracranial solid tumor of childhood, with overall survival for high-risk patients (hrnbl) near %. the outcomes of hrnbl have improved with high dose chemotherapy followed by autologous stem cell rescue (abmt). data about factors influencing the rate of hematopoietic recovery following abmt in hrnbl is lacking in the literature. our objective was to identify factors influencing the rate of hematopoietic recovery following abmt in hrnbl. design/method: this was a retrospective chart review of patients with hrnbl treated at texas children's hospital from to . neutrophil engraftment was considered the first of three consecutive days with post-transplant neutrophil count greater than cells/ul. red blood cell and platelet engraftment were considered at a hemoglobin greater than g/dl and platelets greater than , /ul three days after the last transfusion. race and conditioning regimen were analyzed using one-way anova; amount of infused cells was analyzed using pearson correlation coefficients; chemotherapy delay and bone marrow (bm) involvement after cycle of induction chemotherapy were analyzed using independent sample t-tests. the study included males and females with a median age at diagnosis of . years. thirtyeight patients were caucasian, african-american, hispanic, asian, and did not have race documented. the mean dose of infused cd + cells was . × ^ cells/kg. forty-five patients received conditioning therapy with carboplatin/etoposide/melphalan (cem), received busulfan/melphalan (bu/mel), and received thiotepa/cyclophosphamide (thiotepa/cpm). the conditioning regimen administered was significant (p = . ) for time to engraftment of neutrophils, with bu/mel at . days, cem at . days, and thiotepa/cpm at days. a delay of chemotherapy during induction (n = ) was significant (p = . ) for time to platelet engraftment of greater than , /ul and trended towards significance (p = . ) for time to neutrophil engraftment. bm involvement at diagnosis and after cycle of induction was not significant for time to engraftment. dose of stem cells infused was the only variable significant for hemoglobin engraftment. background: osteosarcoma (os) is the most prevalent aggressive primary malignancy of the bone affecting children and young adults. approximately % to % of patients have metastatic disease at initial presentation, and % of those patients have isolated pulmonary metastases. although overall survival in patients with os has improved with advances in therapy, there have been no significant improvements in survival outcome in patients with metastatic disease. recent studies suggest that tumor-associated vascular cell adhesion molecule (tvcam- or cd ) plays a critical role in the metastatic progression of various tumors. indirect evidence from these studies suggest that vcam- / integrin signaling promotes tumor survival and metastatic progression by changing the tumor niche and associated immune response. to determine if interfering vcam- / signaling between pulmonary metastatic osteosarcoma (pos) and macrophages (macs) by down-regulating vcam- , depleting macs or blocking vcam- / signaling will reduce pos and improve overall disease-free survival. design/method: we used a pair of spontaneous, high-grade murine os cell lines from balb/c mouse (h- d), k and k m (derived from in vivo k metastasis). we used lentiviral shrnas to knockdown vcam- mrna and protein expression in k m (vcam- kd). we introduced luciferase into k , k m and various k m shrna cell lines to follow lung metastasis by bioluminescence (bli). we depleted macs by intranasal administration of liposomal clodronate formulation. we tested the ability of k and k m supernatants to polarize m macs into m or m phenotype in vitro. we also administered anti- monoclonal antibody (anti- mab) intranasally to assess the outcome of functional blockade of vcam- / signaling. results: k m over-expressed vcam- compared to k . mac depletion in k m -bearing animals exhibited reduced pos. weekly administration of anti- mab resulted in % tumor-free rescue among mice with established k m pos. interestingly, supernatant from k m but not k preferentially induced m -like macs, suggesting a novel integrin-mediated mechanism of m differentiation. validation data with additional os cell lines will be presented. despite aggressive multimodal therapy, overall outcome for patients with pos remains dismal at - %. for this reason, novel and directed therapy approaches are desperately needed. molecular targeted approaches for therapy are challenging, due to the complex genetic heterogeneity of os. immune-modifying therapy is a promising new alternative approach for pos. university of chicago, chicago, illinois, united states background: only half of all patients diagnosed with high-risk neuroblastoma achieve long-term survival. imetaiodobenzylguanidine (mibg) scans are routinely used to evaluate disease at diagnosis and following treatment, and the extent of disease is quantified using the curie scoring system. a previous study by yanik et al., has shown that for high-risk patients with mycn non-ampliified tumors, scores less than versus greater than following cycles chemotherapy are associated of superior survival, whereas scores less than versus greater than were prognostic in patients with mycn-amplified tumors. however, the prognostic significance of specific sites of metastatic disease at diagnosis is not known. to determine if site of metastatic disease determined by i-metaiodobenzylguanidine (mibg) imaging in high-risk patients at the time of diagnosis was associated with outcome design/method: we performed a retrospective chart review of high-risk neuroblastoma patients treated at comer children's hospital and lurie children's hospital in chicago between and with positive mibg scans at the time of diagnosis. we collected imaging data as well as other clinical data including bone marrow status. sites of disease were defined as curie regions with any positive value. kaplan-meier analysis was performed to evaluate the association with disease sites and survival. pearson correlation coefficients were calculated to compare bone marrow disease to sites of positivity on mibg scan. the cohort consisted of high-risk patients. had skull disease, and had pelvic disease. the presence of mibg positive disease in the skull and in the pelvis trended toward worse efs. efs at years for patients with disease in the skull at diagnosis was ± % and for patients without skull disease was ± % (p = . ). efs at years for patients with and without pelvic disease was ± % and ± % (p = . ). consistent with prior data, we found that the presence of bone marrow disease was associated with worse survival with year efs of ± % and ± % with and without marrow disease at diagnosis (p = . ). there is the highest correlation between pelvic disease on mibg scan and bone marrow disease with pearson coefficient . . pelvic disease noted on mibg scan likely reflects underlying bone marrow disease. in patients with high-risk neuroblastoma, skull disease and pelvic disease on mibg scan at diagnosis may predict worse event free survival. background: osteosarcoma is one of the deadliest cancers in the pediatric population with little progress in morbidity and recurrence rates since the 's. oncolytic herpes simplex- virus (ohsv) is an attenuated virus that has shown encouraging results against certain solid tumors. programmed cell death protein (pd)- -mediated t cell suppression via engagement of its ligand, pd-l , is also of particular interest due to recent successes in selected cancers, especially those with high genetic mutational loads. most pediatric cancers do not have a wide variety of mutations; however, osteosarcoma has a chaotic genome, prone to genetic mutations. it has been shown through numerous other studies that pd- inhibition alone is not sufficient to result in statistically significant tumor growth delays in osteosarcoma models and patients. we hypothesize the addition of ohsv therapy as an immunologic stimulus to pd- inhibition is efficacious for osteosarcoma. ( ) to determine whether ohsv therapy enhances response to pd- inhibition in immunocompetent murine models of osteosarcoma and ( ) to quantify and characterize the anti-tumor t-cells infiltration after treatment with ohsv and pd- inhibition individually and in combination. we utilized an immunocompetent transplantable murine model using a cell line derived from a spontaneous metastatic osteosarcoma (k m , balb/c background). we transplanted established tumor wedges subcutaneously and monitored tumor volume by caliper measurement. once tumors reached - mm , we administered intratumoral injections of hsv ( × plaque-forming units) every other day for a total of injections. we then gave intraperitoneal injections of ug anti-pd- or control antibody twice weekly, up to weeks, starting from the last dose of virus treatment. we monitored tumor growth via calipers twice weekly until tumors reached mm or cm diameter. we quantified and characterized innate and adaptive immune cell infiltrates in tumors using flow analysis. we found significantly prolonged survival with our combination therapy group compared to all other groups. we found that anti-pd- by itself had little impact on t cell recruitment while the combination group had higher influx of cd + cells with a reduced amount of t-regulatory cells (cd +foxp +cd +). we also found an increase in cd + effector memory cells. osteosarcoma is a deadly cancer with therapeutics remaining unchanged for the last years. here, we describe prolonged murine survival after treatment with combination of pd- inhibition and ohsv injection. the combination treatment changed the microenvironment to be more inflammatory. our data support further preclinical and clinical studies. background: neuroblastoma is the second most common cause of cancer related death in children. treatment for high-risk neuroblastoma has improved significantly over the past twenty years, however cure rates remain below %. immunotherapy has emerged as an effective therapy for neuroblastoma, however new modalities and targets are needed to improve outcomes. objectives: our lab has developed a chimeric antigen receptor (car) that targets b -h (cd ), an immune checkpoint molecule overexpressed on many cancers, including neuroblastoma. we hypothesized that b -h would be a good target for car based immunotherapy for neuroblastoma. design/method: neuroblastoma tissue microarrays of primary patient samples were screened for b -h expression by immunohistochemistry and cell lines were screened using flow cytometry. b -h car t cells were tested in vitro by measuring tumor cell killing and cytokine production after coculture with tumor cell lines and in vivo in an orthotopic model of neuroblastoma. results: b -h expression was detected by ihc on % of the screened neuroblastoma patient samples. b -h was expressed at high levels ( + or +) in more than half of these samples ( %). almost all cell lines screened were homogeneously positive for b -h by flow cytometry. retrovirally transduced b -h . - bb. car t cells were cocultured with three b -h positive neuroblastoma cell lines (sk-n-be , kcnr, and chla ) and robust tumor cell killing was demonstrated using an incucyte assay. supernatant from the co-cultures was harvested after hours and both interferon gamma and il- production were detected by elisa.in an orthotopic subrenal capsule xenograft model of neuroblastoma, mice treated with b -h car t cells show significant reductions in tumor growth and prolonged survival compared to those treated with untransduced control t cells. however, the treatment is not always curative.b -h car t cells express high levels of exhaustion markers (pd , tim , and lag ) when compared to cd car controls. in order to overcome inhibition from exhaustion, b -h car t cells were co-cultured with neuroblastoma cell lines and pd- blocking antibody. nivolumab significantly increased the production of il- and interferon-gamma by b -h car t cells. further studies are underway to determine if b -h car t cell activity is enhanced in vivo by treating animals with pd- blockade along with car t cells. conclusion: b -h is expressed on a majority of neuroblastoma samples and appears to be a promising candidate for car t cell therapy. b -h car t cells demonstrate activity against neuroblastoma xenografts that may be enhanced by the addition of pd inhibitors. helen devos children's hospital, michigan state university, grand rapids, michigan, united states background: osteosarcoma is the most common bone tumor in children. it is often metastatic at diagnosis and in this scenario less than % of children survive. polyamines, small molecules found in all cells, are involved in many cell processes including cell cycle regulation, immune modulation, cell signaling and apoptosis. they are also involved in tumor development, invasion and metastasis. in neuroblastoma, inhibition of the polyamine biosynthesis pathway with odc inhibitor alpha-difluoromethylornithine (dfmo) results in decreased cell proliferation and differentiation. these finding have led to multiple phase i and phase ii multicenter clinical trials in pediatric neuroblastoma patients. dfmo is an attractive drug as it is oral, well-tolerated, can be given for prolonged periods and is already used in pediatric patients. the polyamine pathway has not been evaluated in osteosarcoma. objectives: evaluate effect of inhibition of polyamine biosynthesis with dfmo on osteosarcoma proliferation and cell differentiation. design/method: up to three osteosarcoma cell lines were used: mg- , u- os and saos- . cells were exposed to mm dfmo for days with replacement of media and dfmo on day . intracellular polyamine levels were measured by high performance liquid chromatography (hplc). cell numbers were obtained with a hemocytometer using trypan blue. flow cytometry cell cycle distribution (facs) and propidium iodide were used to evaluate for cell cycle arrest. the protein expression of several osteosarcoma differentiation markers was measured by sds-page and western blot using differentiation specific antibodies. a bioluminescent cell viability assay was used to measure cell recovery over several days after dfmo was removed and replaced with standard media. results: dfmo exposure resulted in significantly decreased cell proliferation in all cell lines. after treatment, intracellular spermidine levels were nearly eliminated in all cells. cell cycle arrest at g was observed in u- os. cell differentiation was most pronounced in mg- and u- os cells as determined by increased osteopontin levels. remarkably, cell proliferation continued to be suppressed for several days after removal of dfmo. conclusion: based on our findings dfmo is a promising new adjunct to the current osteosarcoma therapy for high risk patients. it is a well-tolerated oral drug that is currently in phase ii clinical trials in pediatric neuroblastoma patients as a maintenance therapy. the same type of regimen may also improve outcomes in metastatic or recurrent osteosarcoma patients for whom there have been essentially no medical advances in the last years. background: recent studies demonstrate that lower levels of the ews-fli fusion oncoprotein are associated with enhanced metastatic capability in ewing sarcoma. the nf-kb transcription factor is a critical mediator of cxcr and cxcr -driven metastasis in multiple cancers, and increased cxcr and cxcr expression have each been associated with increased metastasis and poor prognosis in ewing sarcoma. we thus sought to investigate the impact of ews-fli on cxcr /cxcr -dependent nf-kb signaling in ewing sarcoma. objectives: the goals of this study are ) to determine the impact of cxcr /cxcr signaling on metastasis-associated nf-kb target gene expression in ewing sarcoma and then ) to investigate how the ews-fli fusion oncoprotein modulates this response . design/method: we utilized multiple ewing sarcoma cells lines including a , chla , chla , tc and tc . cxcr /cxcr cell surface expression was determined by flow cytometry. ews-fli level was modulated using sirna and expression levels were confirmed by western blot and rt-pcr. p dna binding was measured via elisa. nf-kb target gene expression was assessed via rt-pcr. results: consistent with ihc analysis of primary and metastatic patient tumor samples, the paired primary and metastatic ewing sarcoma cell lines chla and chla showed dramatic differences in cxcr and cxcr expression, with the metastatic chla line demonstrating much higher expression of both receptors. other cell lines (nonpaired) showed variable cxcr /cxcr expression. genetic knock-out of cxcr lead to significant decrease in expression of both cxcl /sdf- and il- , two nf-kb transcriptional targets known to play a key role in tumor metastasis. knock-out of cxcr did not alter endogenous ews-fli mrna levels. conversely, lowering the level of ews-fli using sirna lead to enhanced nf-kb signaling, indicated by an increase in p dna binding. consistent with this observation, treating ewing cell lines with ews-fli sirna also resulted in significantly increased nf-kb target gene expression compared to control cells and target gene expression was then further enhanced upon cxcr /cxcr receptor stimulation with the receptor ligand cxcl /sdf- . our findings indicate that the ews-fli oncoprotein negatively modulates cxcr /cxcr -dependent nf-kb signaling. this suggests that ews-fli low, cxcr /cxcr high cells, which are associated with enhanced metastasis and poor prognosis, would be anticipated to exhibit enhanced expression of key nf-kb target genes. importantly, the nf-kb pathway is a druggable target that could potentially serve as an "achilles heel" in this subset of high risk tumors. current work is evaluating nf-kb inhibition as an approach to treating metastatic and refractory ewing sarcoma. background: acute graft versus host disease (agvhd) is a major cause of morbidity and mortality following allogeneic bone marrow transplant (bmt) in pediatric patients. gastrointestinal (gi) agvhd is the most serious manifestation. recently, decreased paneth cell (pc) in a predominantly adult cohort was shown to correlate with agvhd clinical grading and response to treatment. we aim to demonstrate the relationship between pc counts and gi agvhd stage and response to therapy. design/method: charts of patients who underwent endoscopy following bmt between - were reviewed. for repeated biopsies during the course of agvhd, only the first was included for analysis. one pathologist retrospectively reviewed the biopsies and counted pcs in high powered fields; the average pc count was analyzed. twenty-six percent of biopsies were reviewed by a second blinded pathologist. statistical associations between pc counts and day (d ) response, agvhd stage, and other study covariates of interest were gauged using general linear regression. agreement in pathologist pc counts was quantified by intraclass correlation (icc). the research was approved by the children's healthcare of atlanta irb. results: seventy-eight biopsies were included in the analysis. mean age at transplant was . years ± . (range: months - years). most patients underwent transplant for hematologic malignancies ( , %). the majority of transplants used a matched unrelated donor graft -including cords ( , %) and myeloablative conditioning regimens ( , %) - % received total body irradiation. of these, % were diagnosed clinically with gi agvhd (stage , %; stage , %; stage , %; stage , %). icc showed good agreement ( . ) between the pathologists. mean pc was . for patients with no gut agvhd, . for stage , . for stage , . for stage and . for stage (p = . ). on multivariate analysis pc was strongly associated with gi agvhd stage (p< . ) after controlling for age, preparative regimen intensity, and diagnosis (malignant vs. non-malignant). mean pc counts were significantly lower in patients with no response to steroid therapy at d (complete response (mean . ) vs. persistent disease ( . ) vs. partial response ( . ) (p = . )). patients diagnosed with gi agvhd with pc counts less than had a higher risk of mortality (hr . , % ci: . , . ; p = . ). lower pc count correlated with stage gi agvhd, refractory disease at d , and mortality. incorporating pc count in pathology review during gi agvhd work-up may help in agvhd risk stratification. background: there have been increasing discussions pressuring health care teams and institutions for potentially bearing the cost of clostridium difficile infections (cdi) as a health care-associated infection in the recent years. the pediatric oncology patient population, though small, accounts for significant portion of all cdi with - -fold increased risk. hematopoietic stem cell transplant (hsct) recipients constitute a unique subset with distinct risk factors, such as severe immune deficiency state and graft versus host disease (gvhd). although there is ample data on cdi in adult hsct recipients, reports on pediatric experience are limited. objectives: to evaluate the incidence and patterns of cdi among pediatric hematology, oncology and hsct inpatients at our institution. a retrospective review of all clostridium difficile (cd) stool tests performed using toxin enzyme immunoassay and later, polymerase chain reaction targeting toxin genes between and in a large, urban academic children's hospital was performed. the data were analyzed for hematology, oncology, hsct inpatient population and all the other cases separately and statistical comparisons were performed. results: a total of samples were submitted to the microbiology laboratory for cd testing during the study period. while hematology patients constituted . %, oncology . %, hsct . % and others . % of the cases on whom cd testing was done; per patient average test number was . , . , . , and . , respectively. of all the cd tests per-formed, . % were positive. test positivity was higher in hsct ( . %) and oncology ( . %) cases tested compared with hematology ( . %) and other cases ( . %) with statistical significance (p< . ). overall recurrence rate was . %; hsct patients had the highest recurrence with a rate of % followed by oncology ( . %), hematology ( . %) and other ( . %) cases, again reaching statistical significance (p< . ). again, hsct patients had the highest average number of recurrences at . ( - ) followed by oncology . ( - ), general . ( - ) and hematology . ( - ) groups. there was no seasonal variability in the incidence of cdi among populations analyzed. prolonged hospital stay/antibiotic use and persistent diarrhea due to gvhd are the likely reasons for higher rate of cd testing in hsct as a result of increased monitoring and thus might have even caused underrepresentation of positive cd test frequency. higher incidence and frequencies of recurrence underscores the inevitable nature of cdi in hsct population as a consequence of the current therapies and may lead to future radical treatment approaches like fecal implantation. background: viral infections remain a challenge to treat post hct in children, and significantly contribute to morbidity and mortality. virus specific t cells (vsts) have shown tremendous clinical efficacy in treating viral infections post-hct, with minimal toxicity and long term efficacy. we have used donor-derived vsts in individual patients, however not all donors are agreeable to the process, and numerous patients may benefit from vsts who do not have an identified donor/have other disease indications objectives: we sought to actively build a third-party vst bank, for "off the shelf" use in eligible patients. design/method: vsts targeting cmv, adenovirus and ebv were manufactured using one of techniques. initially ebv transformed b cells were genetically modified with an ad f pp vector and used as antigen presenting cells (apc) to stimulate and expand ebv, ad and cmvpp specific t cells. more recently, vsts were expanded using s of s apc pulsed with commercially available peptide pools (pep-mixes) to expand ebv/cmv/ad specific t cells. products were entered into the "bank" via two mechanisms: a) left over products from our "donor-derived" protocol when patients no longer required vsts or were not at risk of developing viral infections, or b) by targeting regular blood donors based on their hla typing to ensure an appropriate mix of high frequency hla types for optimal patient matching and antigen presentation based on current knowledge of antigen presentation. results: a total of products are currently in the thirdparty vst bank ready for use. twenty seven of these are from our donor derived protocol, and three from targeted donors. all vst products met safety and in vitro efficacy testing. thirteen vst infusions have been given to patients. eleven infusions have been given for cmv and two for adenovirus. five out of seven patients responded to thirdparty vst infusions, with a median of vst infusions per patient (range - ). the median hla matching was out of per patient (range to ) no patients experienced adverse reactions, gvhd or other toxicity related to the vst infusion. a third-party vst bank is feasible and produces clinically appropriate vsts for use in patients with viral infections. hla typing and matching of vst products is essential to reduce toxicity and promote appropriate antigen presentation and expansion of vsts in vivo. further work is underway to further characterize the vsts using epitope mapping to better define the hla restriction and immunogenicity of each vst product. akron children's hospital, akron, ohio, united states background: acute graft-versus-host disease (agvhd) is a well-known complication of hematopoietic stem cell transplant (hsct) and a major cause of post-transplant related morbidity and mortality. first line therapy of agvhd involves corticosteroids and calcineurin inhibition. in patients with severe refractory gvhd, mortality can reach up to %. currently, there is no standard of care for the treatment of steroid refractory agvhd. many centers have looked at the use of antibody mediated control of agvhd to competitively inhibit the inflammatory cascade. basiliximab, a chimeric monoclonal antibody against the t-cell il- receptor, has been used in adults with steroid refractory agvhd. patients receiving this medication have demonstrated complete and partial responses to therapy with minimal toxicities. objectives: report the successful use of basiliximab in the treatment of agvhd in a -year-old following matched unrelated (mud) hsct. design/method: a -year-old male underwent mud transplant for high risk aml with monosomy . conditioning regimen included busulfan, fludarabine and equine atg. his clinical course was complicated by fever, mucositis and agvhd (stage skin; stage gi-biopsy proven). gvhd prophylaxis included tacrolimus and methotrexate, however with progressive skin rash, diarrhea, and early satiety, gvhd treatment with corticosteroids was initiated. as the patient continued to have worsening symptoms, basiliximab therapy was started. the patient received doses ( mg) iv basiliximab on two consecutive days and then received weekly therapy for a total of doses leading to initial improvement. the patient further developed acute on chronic gvhd on day + , and subsequently received a second course of basiliximab. after initial administration of basiliximab, the patient had near complete resolution of symptoms. however, with a small wean in his tacrolimus dose, the patient experienced another skin gvhd flare prompting the second basiliximab course. the patient was subsequently weaned off all immunosuppression by day + . the only acute complication the patient experienced while receiving basiliximab was right toe paronychia and asymptomatic low ebv titer. the patient is currently off all immunosuppression at the time of report without evidence of cgvhd. conclusion: this single case report, in a young pediatric patient, demonstrates the use of basiliximab may be a safe and efficacious treatment for pediatric patients with agvhd. university of california, san diego, la jolla, california, united states background: clinical outcomes after allogeneic hematopoietic stem cell transplantation (hsct) depend on restoration of t lymphocyte populations. association between recovery of cd +foxp + regulatory t cells (tregs) and protection from chronic graft versus host disease (cgvhd) has been described in adult hsct. in adults, t cell recovery is driven by expansion of donor t cells and treg reconstitution is hypothesized to result from peripheral conversion. restoration of t cells in pediatric patients has a larger contribution from thymopoiesis, however, the relationship between thymopoiesis and treg recovery is undefined. objectives: we hypothesized that effective thymopoiesis is important for restoration of treg populations and protection from cgvhd in pediatric hsct patients. design/method: we performed longitudinal flow cytometry of peripheral blood t cells from pediatric hsct patients and age-matched healthy donors. laboratory data were correlated with clinical outcomes to evaluate impact. recovery of tregs occurred in / ( . %) patients by post-transplant day . day treg frequency in patients that developed cgvhd ( . ± . % of cd + t cells) was reduced compared to cgvhd-free patients ( . ± . %). failure to restore tregs to > . % of cd + cells by day was associated with increased risk of cgvhd in the first year post-hsct (rr = . , p = . ). a majority ( . ± . %) of tregs from patients recovering the peripheral treg compartment expressed helios, a marker of thymic-derived tregs; only . ± . % of tregs expressed helios in patients failing to restore adequate tregs. this prompted examining the relationship between defects in thymopoiesis and inability to restore tregs. we evaluated thymic function by flow cytometry quantification of cd ra+cd +ptk + recent thymic emigrant (rte) cd + cells (confirmed by qpcr for trec content). most ( / , . %) hsct patients had detectable rtes by day post-hsct. thymic production of rtes was persistently absent in patients that developed cgvhd (< / ^ cd + cells in / patients), compared to cgvhd-free patients ( / patients > rte/ ^ cd + cells by day , average . ± . / ^ cd + cells). post-hsct thymic activity as measured by rte enumeration correlated with treg restoration; / ( %) rte+ patients restored tregs, compared to / ( %) of rte-patients. conclusion: failure to restore tregs after allogeneic hsct results in increased risk for cgvhd. in pediatric patients thymic generation of new t cells is an important contributor to restoration of the treg compartment. this data supports further investigation into mechanisms impairing post-hsct thymopoiesis and suggests peripheral blood tregs may be a prognostic biomarker for cgvhd. background: haploidentical stem cell transplantation (haplo sct) is riddled with unique challenges. objectives: we present our experience in the use of haplo sct with post-transplant cyclophosphamide (ptcy) and the adaptations required for each disorder for optimal outcome. design/method: we performed a retrospective study at the pediatric blood and marrow transplant unit, apollo cancer institutes, chennai, india. children up to years of age, diagnosed to have benign disorders and underwent haplo sct with ptcy from to july were included. results: ptcy was used in i.e. % haplo transplants for children with benign disorders. the underlying conditions included fanconi anemia , severe aplastic anemia , mds , jmml , hemoglobinopathy , prca , xld and primary immunedeficiency disorders (pid) . source of stem cells was peripheral blood in %, bone marrow in %. conditioning included fludarabine with treosulphan or cyclophosphamide for pids and aplastic anemia respectively. neutrophil engraftment by day+ - with a durable graft was noted in % transplants with graft versus host disease in %, cmv reactivation in %. mortality rate was % with infants less than months of age developing severe fatal cytokine release syndrome. the median follow up is year with years being the longest. no significant late effects have been noted with chronic skin gvhd in children. survival rate was superior among children with pids with survival of % in this group. haplo sct with ptcy is a feasible and costeffective option for cure in children with life-threatening benign disorders with no compatible family or matched unrelated donor. careful patient selection, reducing cyclophosphamide related free radical toxicity with the use of n acetylcysteine, limiting t cell numbers by capping cd at × /kg, post-transplant viral monitoring protocols are required to reduce morbidity and mortality. we have been working on universal access to care for children from s of s all socioeconomic background and incorporating innovations to reduce the cost of hsct without compromising outcomes. haploidentical hsct using tcr / depletion costs usd as compared to ptcy priced at usd. children with severe aplastic anemia and pids can be transplanted using reduced intensity conditioning and ptcy. in hemoglobinopathies, pretransplant immunosuppression is required to prevent graft rejection. graft versus host disease remains the main cause of mortality in children with fanconi anemia. mortality in infants less than months after ptcy has been high, tcr / depletion would be superior in this cohort. cincinnati children's hospital medical center, cincinnati, ohio, united states background: fanconi anemia (fa) is a congenital bone marrow failure syndrome with hsct the only curative option for associated bone marrow failure. patients with fa undergoing hsct may experience increased toxicity related to either their underlying disease, or the effects of medications, resulting in the inability to tolerate prophylactic medications or sideeffects from anti-microbial therapy. objectives: we postulated that increased cd cell dose would be associated with a rapid immune reconstitution and therefore early withdrawal of anti-infective prophylactic medications. design/method: patients with fa transplanted at cchmc from an unrelated donor had peripheral blood stem cell grafts collected and cd selection performed. where possible, patients had serial measurements of their immune system performed at varying intervals post hsct. we defined immune reconstitution as normalization of lymphocyte subsets-cd , cd , cd and cd cells, as well as a normal response to mitogen stimulation including phytohemagglutinin, concanavalin a and pokeweed. the first measurement of either normal cell number or mitogen response was recorded for each patient. results: a total of patients underwent hsct for fa at cchmc between and . patient demographics included a median age of years at hsct, the vast majority of patients having a fully matched or one anti-gen mismatched donor, and the majority of patients transplanted for bone marrow failure. there was a statistically significantly decreased time post-transplant to immune cell recovery in patients receiving > × /kg cd cells (median . ) compared to those receiving < × /kg cd cells (median . ). the median time to normalization of cd count was days (cd count > /kg) versus days (cd count < /kg), cd count days (cd count > /kg) versus days (cd count < /kg), cd count days (cd count > /kg) versus days (cd count < /kg) and cd count days (cd count > /kg) versus days (cd count < /kg). time to normalization of mitogen response was decreased posttransplant in those patients receiving increased cd cell dose at time of transplant, though this was not significant, reflecting low number of patients with evaluable responses. no patients in either group experienced gvhd or graft failure. patients with fa who are transplanted with higher cd cell doses have quicker immune reconstitution than those who receive lower cell doses. along with benefit to patients including less risk of infection and early termination of immune-prophylaxis medications, this supports the use of high dose cd selected grafts in this vulnerable population. background: parvovirus b (pvb ) infection after transplantation was first reported in . since then, numerous cases of pvb infections after hematopoietic stem cell transplantation (hsct) and solid organ transplantation (sot) have been reported. most report anemia as the predominant clinical manifestation. however, pvb has been associated with pancytopenia, hepatitis, myocarditis, and allograft rejection. we present a patient with acute lymphoblastic leukemia who developed bone pain and pancytopenia following hsct in the setting of pvb infection. to describe an unusual presentation of pvb in a patient with acute lymphoblastic leukemia following hsct. design/method: a search of the english-language medical literature was performed using pubmed and medline databases. a review of the patient's medical history was performed. a year old male with relapsed b-cell all and history of "fifth disease" in infancy presented four months after hsct with focal left arm pain and difficulties fully extending the arm. bone mri showed enhancement of the medullary space centered within incomplete transverse cortical fracture interpreted as pathologic fracture due to neoplastic involvement of the ulna with no history of inciting injury. subsequently, peripheral blood counts decreased from low normal values to wbc . k/microl, anc /microl, plt k/microl, and hemoglobin . g/dl. the patient's chimerism remained % donor. a bone marrow biopsy and aspirate were performed to assess for recurrent leukemia given persistence of bone pain and developing pancytopenia. marrow findings included morphologic cytopathic effects with erythroid precursors and strong parvovirus staining with no signs of red cell aplasia or recurrent b-cell disease by morphology or flow cytometry. pvb was detected in blood by pcr and immunoglobulins with resolution of cytopenia and bone pain. this case highlights an unusual constellation of symptoms following hsct in a child with all. unexplained bone pain and medullary infiltrates with pancytopenia suggestive of recurrent leukemia were likely triggered by pvb infection. the question remains if he had reactivation of pvb , a primary infection by a new strain, or the virus was aquired through stem cells. bone biopsy could not be justified in light of clinical improvement. so far, bone lesions have only been described with congenital pvb infection. pvb appears to be uncommon after hsct, with a review of literature yielding pediatric cases. however, it may be underestimated due to lack of routine screening. our patient's presentation supports that evaluating for pvb may be warranted in hsct patients presenting with symptoms suggestive of relapsed leukemia. background: cardiac injury may occur during hematopoietic stem cell transplant (hsct) in pediatric patients and can be asymptomatic for many years. recommendations for screening are available for patients who received anthracyclines or chest irradiation, but no guidelines exist for unexposed longterm survivors. we sought to define the prevalence of echocardiographic abnormalities in long-term survivors of pediatric hsct and determine the need for screening in asymptomatic patients. design/method: we analyzed echocardiograms performed on long-term survivors (≥ five years) who underwent hsct at cincinnati children's hospital between and . we analyzed echocardiograms for left ventricular ejection fraction (ef), end-diastolic dimension (lvedd), septal thickness, posterior wall thickness, and global longitudinal strain (gls). we normalized linear measurements for age and patient body surface area. we included for further analysis patients who had echocardiogram obtained for routine surveillance. results: a total of patients underwent hsct and were alive more than years after transplant in , with having an echocardiogram obtained ≥ five years postinfusion. those with an echocardiogram were transplanted more recently (median vs. ). however, no difference between screened and unscreened individuals was noted for age at transplant, sex, transplant indication, anthracycline exposure, chest irradiation, or cyclophosphamide based preparative regimen. indications for echocardiograms included: cardiac symptoms ( . %), congenital cardiac anomalies ( . %), hypertension ( . %), known cardiac or pulmonary disease ( . %), routine post-hsct surveillance ( . %), and unknown ( . %). the mean time post-hsct was . years. among routine surveillance echocardiograms, the mean ef z-score was - . . mean lvedd zscore was - . , mean septal thickness z-score - . , mean posterior wall thickness z-score - . , and mean gls - . %. for patients that had echocardiogram performed for routine surveillance, / patients ( . %) had ef measured, and / ( . %) had ef z-scores ≤ - . (abnormally low). patients exposed to anthracyclines had a mean z-score ef of - . vs. unexposed patients - . (p = . ). among individuals who received neither anthracyclines nor tbi only / ( . %) was found to have an abnormal ef, . % (z-score - . ) or gls (- . %). only one patient who had a normal ejection fraction (z-score - . , ef . %) had an abnormal gls, - . % (normal ≤ - . ). long-term survivors of pediatric hsct who are asymptomatic and did not receive radiation or anthracyclines likely do not require surveillance echocardiograms, unless indicated by clinical symptoms. patients exposed to anthracyclines or tbi require close echocardiographic s of s screening and clinical monitoring for the development of cardiac complications. duke children's hospital, durham, north carolina, united states background: children undergoing pediatric blood and marrow transplants (pbmt) experience significant symptom distress. mobile health (mhealth) technologies can be leveraged to collect and monitor patient generated health data, and subsequently enhance our understanding of pbmt symptom clusters, patterns, and trajectories. better understanding of symptom complexity can foster development of precision health strategies to improve patient outcomes. however, limited research exists in integrating mhealth technology into pbmt management. we aimed to explore the feasibility, acceptability, and usability of using a pbmt specific mobile application to collect and monitor symptoms and wearable technology (apple watch) to measure objective data such as heart rate (hr) and activity. design/method: an exploratory mixed method design began in october to monitor pbmt symptoms for patients using real-time data from: ) a self-developed mhealth application (app) to collect subjective symptom data; and ) apple watch to collect physiologic measures such as heart rate and number of daily steps. data is collected pre-transplant through days. acceptability will be assessed through satisfaction surveys at study completion. we have enrolled patients to date who are all currently using the app and watch. patients' average frequency of daily charting in the app %. the wearable average daily recorded measurements are for hr and for step count. most common symptoms recorded within the app include fatigue and pain. we have noted trends in data including a decrease in activity following transplant and gvhd and an increase following engraftment. patients have stated "the app is helpful to keep track of how my pain is doing day to day" and "i try to take more steps each day than the day before". patients often remove the watch for charging, then forget to put it back on, but consistently put it on upon reminder. finally, parents often were required to make app entries with patients too sick to record. we continue to enroll patients with enthusiasm from both patients and parents to use mhealth during pbmt. preliminary findings suggest feasibility of using the mhealth devices is strongly correlated to the patient's post-transplant stage and is facilitated by caregiver participation with device management (charging devices, reminders to wear watch and record in app). patients reported satisfaction and ease of use with devices, but found it difficult to keep up with charging and charting. these findings indicate using mobile devices may be useful methods to collect patient generated health data. cincinnati children's hospital medical center, cincinnati, ohio, united states background: bacterial bloodstream infections (bsi) are a common complication following hematopoietic stem cell transplantation (hsct) in both pediatric and adult populations, and are associated with poor outcomes. there is limited data describing the outcomes and characteristics of patients who develop three or more bsi after hsct. objectives: to describe the characteristics and outcomes of pediatric patients who develop three or more blood stream infections in the first-year post hsct. design/method: we performed a retrospective chart review of consecutive patients who underwent hsct at our institution from through to compile this case series. data were collected through the first year post-hsct including: patient demographics, underlying disease and therapy characteristics; and transplant complications such as thrombotic microangiopathy (tma), graft versus host disease (gvhd) and overall survival. bsis were classified according to current center of disease control guidelines. results: of patients, ( %) developed or more bsi in the first-year post transplant (total bsi cases = including all patients). of the cases, the majority underwent allogeneic hsct (n = / ; %). most cases were from unrelated donor (n = / , %). more than half of patients had grade - gvhd (n = / , %). sixteen ( %) had tma. of these cases, tma preceded the first bsi in n = / ( %). the majority of bsis were classified as central line-associated bloodstream infections (clabsis, n = / , %), followed by mucosal barrier injury laboratory-confirmed bloodstream infections (n = / , %) and secondary bsi (n = / , %). the majority of isolated organisms ( %) were associated with mucosal barrier injury pathogens. one-year overall survival in the cohort was % (n = / ). pediatric patients undergoing hsct who develop or more bsis in the first-year post transplant demonstrated an increased rate of tma compared to the overall institutional incidence of roughly %. tma diagnosis preceded the first bsi in over half of patients, suggesting that tma may predispose to recurrent bsi. improved strategies for early detection and treatment of tma as well as prevention of clabsis may help reduce the number of bsis ultimately leading to decreased morbidity and mortality in this patient population. background: in neutropenic pediatric patients, infection remains a significant cause of morbidity and mortality. while granulocyte transfusions have been utilized for decades to treat infections, including in the pediatric population, the efficacy of this intervention remains poorly described. previous guidelines have primarily utilized information from adult populations. furthermore, recruitment of donors typically involves friends or relatives of the patient with periodic involvement of community donors. the use of a readily available local donor population to improve availability has yet to be well described. as the immunocompromised population is particularly susceptible to worsening infection and clinical deterioration, the ability to rapidly harvest and deliver granulocytes warrants further investigation. to investigate the efficacy, safety, and outcomes of severely immunocompromised patients receiving granulocyte transfusions from a local altruistic granulocyte program in a pediatric tertiary care center. design/method: a retrospective review was performed to evaluate the context for receiving a transfusion as well as primary outcomes including infection clearance, survival to discharge, and overall mortality. the indiana blood bank assisted with timing the interval from initial order placement to onset of first granulocyte infusion. results: among the patient population reviewed, patients received separate granulocyte regimens. ages ranged from - years with a mean neutrophil count of at time of first transfusion. indications for transfusions included bacteremia (n = ), fungal pneumonia (n = ), and fungemia (n = ). primary outcomes included clearing infection ( %) and surviving to discharge ( %). the median time from initial order placement to infusion was hours, although there was no significant difference between responders who cleared the infection and non-responders who did not. however, additional investigation found that ward patients had a % chance of surviving to discharge while patients in the icu at time of initial transfusion had a % chance of survival to discharge. the readily available granulocyte transfusion program allows patients to quickly receive therapy in neutropenic settings. this is beneficial for patients as transfusion prior to clinical decompensation correlates with increased likelihood of infection clearance, and subsequently improved mortality. further investigation is needed, likely as a prospective study, to better explore circumstances that are beneficial for granulocyte transfusions. background: donor lymphocyte infusions (dli) are composed of immune cells to treat relapse after hematopoietic cell transplantation (hct). to date, data regarding its efficacy is limited in pediatric populations. furthermore, while outcomes related to cd content have been characterized, to our knowledge, the relationship between outcomes and other cellular content in dli has never been reported. objectives: determine whether the primary hematological malignancy, presence/absence of graft-versus-host disease s of s (gvhd), and unique phenotypic content of each dli impact overall survival (os) in pediatric patients with hematological malignancies. design/method: irb-approved, retrospective study investigating all consecutive dlis given to patients at the children's hospital of wisconsin. analyses were conducted using mann-whitney, fisher's exact, and chi-square. from from - patients ≤ years old with hematologic malignancies [myeloid (aml/ mds/cml/jmml),n = ; lymphoid (all),n = ] underwent dlis ( %% ≥ dlis). the median time between hct and dli was . (range, . - . ) years. there were significant differences between the lymphoid and myeloid groups, respectively, in regard to median age at hct ( . vs . yrs, p = . ) and at first dli ( vs years, p = . ). ultimately, there were no statistically significant differences in gvhd or os in products with either higher or lower cd , cd , cd , cd , or cd cellular content. however, the median cd /kg content was more than double in the patients who developed gvhd as compared to patients who exhibited no gvhd after dli ( . × vs . × , p = . ). patients receiving one dli had a -year os of ± % vs those receiving + dli of ± % (p = . ). with a median follow-up of . (range, . - . ) years, the year estimated os of patients in the lymphoid group was higher at ± % vs ± % in the myeloid group, although not significant (p = . ). our results indicate a survival benefit when using dli in a subset of patients who relapse after hct. unlike adult studies demonstrating little effect of dli in lymphoid diseases, many children with all achieved durable remission. while our analysis did not demonstrate that dli cellular content had a statistically significant effect on gvhd or os, it is possible that differences could be found if a larger population and more targeted cell doses were studied. more data will be needed to further define these relationships and identify patients who stand to benefit most. cincinnati children's hospital medical center, cincinnati, ohio, united states background: many arabic speaking muslim parents of children requiring bone marrow transplantation (bmt) receive medical care in the united states. providers may not understand the impact of islamic parents' religious beliefs and practices on their health care experience. objectives: to explore how islamic parents used religion in decision making and to understand the impact of their religious beliefs and practices on their overall health care experience. design/method: we used grounded theory, an inductive method gathering data from interviews and analyzing text, to identify core themes. ten caregivers of bmt children from middle eastern countries were interviewed by an arabicspeaking provider; interviews were coded by an interdisciplinary team. we identified key themes: . patience is a core belief in islam. patience results from the acceptance of allah's will. behaviors showing patience include praying rather than questioning and crying. . al qur'an provides comfort, healing, and protection. families listen to recitations of al qur'an in the patient's room because they feel that this practice not only comforts them but promotes healing as well. for some, certain portions of the qur'an were especially meaningful such as surat al-baqara, which explains that while we may think something is bad for us, allah will know it is good for us. . religious care in the medical center helped families feel respected. religious care in the medical center included interactions with chaplains, who were understood to be "religion experts," and provision of space for prayer and religious resources. . seeking religious consultation. religious consultation from imams or religious scholars (muftis or sheikhs) provides interpretations of the qur'an applied to the family's specific situation helps families make difficult decisions and follow allah's plan. . muslim beliefs guided decision making; muslim practices brought comfort, strength, and peace. drawn from the parents' understanding of islam. parents who addressed this topic said they would only do what islam allowed. they did indicate that most aspects of healthcare were understood to be allowed within islam. additionally, muslim practices of prayer, reading/listening to qur'an, and giving alms all provided comfort, strength and peace. we identified several recurring themes through our interviews that allowed us to understand how families use their muslim faith to deal with their children's illnesses and how it influences their decision making. we believe this better understanding will allow for more informed conversations about patients' health care and decision making, and shows respect for religious beliefs and practices. nemours/dupont hospital for children, wilmington, delaware, united states background: virtually all children will be infected with human herpesvirus (hhv- ) by the age of two. hhv- reactivation after stem cell transplantation causes multiorgan toxicities, including encephalitis, with inflammation and destruction of the temporal lobes and hippocampi, memory loss, and seizures. catatonia is characterized by posturing, immobility, mutism, and autonomic instability, and it's associated with various psychiatric and medical conditions. we describe a patient with hhv- encephalitis and unusual neurologic sequelae, including cognitive and neurobehavioral dysfunction and catatonia, which may impact our understanding of the pathophysiology of hhv- reactivation encephalitis. objectives: describe a case of hhv encephalitis with practice implications for stem cell transplantation. results: our patient was diagnosed with acute myeloid leukemia at age . within years, he relapsed and received two stem cell transplants. on the th day after his second transplant, he developed hyponatremia and refractory seizures. brain mri showed edema in the medial right temporal lobe with linear ischemic change. eeg showed diffuse encephalopathy. cerebrospinal fluid (csf) demonstrated white blood cells, red blood cells, and hhv- by pcr. his prophylactic antiviral was switched to foscarnet and ganciclovir. repeat mri showed abnormal signals in bilateral medial temporal lobes and the right insula. three months later he developed episodes of diaphoresis, hypothermia, agitation, mutism, and unusual posturing, recurring almost daily, recognized as catatonia. mri showed improvement of the abnormalities in the bilateral medial temporal lobes and hippocampi. eegs showed diffuse slowing. after months of antiviral therapy, csf was negative for hhv- . over the ensuing years, he had numerous episodes of diaphoresis, hypertension, hypothermia, pruritis, confusion, agitation, cogwheel rigidity, and bizarre posturing. dopamine blocking agents did not help. clonazepam helped reduce their frequency, and hot showers helped break acute episodes. further mris showed generalized cortical volume loss. he suffered from depression and severely impaired sleep and cognitive function. we describe a novel, debilitating outcome of hhv encephalitis which may provide diagnostic considerations as we continue to improve our understanding of the breadth of possible neurologic sequelae in transplant patients. hhv- is understood to infect and destroy the temporal lobes and hippocampi, but our patient's autonomic dysfunction indicate involvement of the hypothalamus and basal ganglia. antidopaminergic agents may worsen catatonia, and they were not effective for our patient. treatment of catatonia includes benzodiazepines; electroconvulsive therapy was not attempted in this case but may also be useful. background: epstein-barr virus (ebv)-related posttransplant lymphoproliferative disorder (ptld) is a lifethreatening complication in patients following hematopoietic stem cell transplantation, with a frequency estimated at . % and a cumulative incidence of mortality estimated as high as %. studies of ebv have hypothesized that the tonsils are critical for propagating this infection, as tonsillar epithelial cells have been shown to be the site of primary viral infection and continued viral shedding; however, to date no studies have been performed assessing the role of tonsillectomy in patients with ebv ptld. objectives: identify patients with localized ebv ptld treated with tonsillectomy to identify prognostic factors that may be able to help guide future treatment decisions. design/method: patients treated at memorial sloan kettering cancer center who had received hematopoietic stem cell transplantation and had billing codes for both ebv and tonsillectomy were eligible for inclusion in this study. a retrospective chart review was performed, assessing patient demographics, transplant characteristics, laboratory values, tonsillar pathology, and clinical course. any patient who did not have unilateral or bilateral tonsillectomy performed or who had non-localized disease (defined as disease involvement outside of the oropharynx and neck) was subsequently immunodeficiency; % (n = / ) fanconi anemia (fa); % (n = / ) hemoglobinopathy; % (n = / ) non-fa marrow failure and % (n = / ) a metabolic disorder. seventy one percent (n = / ) had normal amh for age pre-transplant, % (n = / ) had low amh for age pre-transplant; of these, % (n = / ) had an oncologic diagnosis; % (n = / ) had fa; % (n = / ) had previously treated hlh; % (n = / ) had non-fa marrow failure; one had a metabolic disorder and one a hemoglobinopathy. of the patients with post-transplant amh measurement % (n = / ) had low levels. of the patients with previously normal pre-transplant amh % (n = / ) underwent myeloablative conditioning (mac) regimen with a % (n = / ) having low amh levels post-transplant compared to %(n = / ) who underwent reduced intensity conditioning (ric) regimen with % (n = / ) having low amh levels post-transplant (p . ). fifteen percent (n = / ) had low levels pre-transplant and underwent mac regimen with % (n = / ) remaining low; % of these patients (n = / ) had fa. nine percent (n = / ) had low levels and underwent a ric regimen with % (n = / ) of amh levels remaining low; % (n = / ) of these patients had hlh treated prior to transplant. conclusion: amh levels can be used for detection of premature ovarian failure and fertility counseling. there is a higher risk of premature ovarian failure with mac regimens and prior chemotherapy vs ric regimens. follow up of this cohort will provide more information to understand the effects of hsct in ovarian function and the usefulness of amh as a predictor of fertility potential. background: there are no proven strategies to prevent blood stream infections (bsi) secondary to oral mucosal barrier injury after hematopoietic stem cell transplant (hsct). additionally, we recently reported progressive gingivitis and dental plaque accumulation in hsct recipients despite our current oral standard of care (three times daily oral rinse). xylitol is a non-fermentable sugar alcohol that reduces dental caries, plaque accumulation, and oral disease progression by inhibiting bacterial growth. we hypothesized that the addition of xylitol to standard oral care will decrease dental plaque accumulation, gingivitis and bacteremia from oral flora. objectives: identify a clinically effective strategy to improve oral health and prevent bsi secondary to bacterial translocation through the oral mucosa in patients undergoing hsct. we are conducting a prospective randomized control study to test our hypothesis. those in the intervention arm receive our current standard of care (three times daily oral rinse) in addition to daily xylitol wipes; controls receive oral standard of care alone. oral exams are performed at baseline and weekly for the first days post hsct. metagenomic shotgun sequencing (mss) of gingival samples is performed at all time points to evaluate microbiome diversity and pathogenic bacterial load. finally, we performed whole genome sequencing of pathogenic bacterial isolates causing bacteremia to assess for genetic relatedness to corresponding strains present within the patient's oral microbiome preceding the infection. : preliminary interim analysis of patients demonstrates improved oral health in patients receiving xylitol (n = ) over those receiving standard of care (n = ), measured by the oral hygiene index (p = . ) and gingivitis index (p = . ). in the nine patients having complete oral mss analysis, xylitol appeared to be associated with decreased streptococcus mitis/oralis domination in the oral microbiome. finally, patients receiving xylitol had no incidence of streptococcus mitis/oralis bacteremia through the first days compared to three patients ( %) in standard of care arm. interestingly, streptococcus mitis/oralis comprised % of the oral microbiome in one child who subsequently developed a streptococcus mitis/oralis bsi. we expect to complete this study in the next months (n = ). the addition of xylitol to oral standard care appears to decrease dental plaque and gingivitis in patients undergoing hsct. xylitol may also impede streptococcus mitis/oralis dominance in the oral microbiome with potential reduction in blood stream infections. (range: - days). twenty-one mdli ( %) were administered because of lymphopenia, fourteen of them ( %) in patients with concomitant viral/opportunistic infections. mixed chimerism/graft failure was the motive of % of the mdli (n = ) and six ( %) were administered to accelerate immune reconstitution. all infusions were well tolerated without appearance or worsening of gvhd. an increase in t-cell counts was observed following six mdli ( . %), although it was a transitory response ( - weeks) in five cases. viral/opportunistic infections were controlled in five cases ( . %), requiring a median of mdli to achieve this response. none of the mdli administered in cases of mixed chimerism/graft failure were effective in reverting this situation. our preliminary data suggests that mdli, is a safe adoptive immunotherapy strategy even with high dose of t-cells without infusion side effects or gvhd complications. some efficacy has been observed in patients with lymphopenia and opportunistic infections, with no positive results in patients with mixed chimerism/graft failure, up to date. however, to determine the real efficacy of this strategy, prospective studies are required. jun zhao, kristen beebe, lucia mirea, alexandra walsh, shane lipskind, alexander, ngwube phoenix children's hospital, phoenix, arizona, united states background: male adolescents undergoing myeloablative hematopoietic stem cell transplantation (hsct) develop infertility with impaired spermatogenesis with reported rates ranging from % to %. in nonmalignant diseases, myeloablative regimens have been replaced with reduced intensity conditioning (ric) with the hopes of better survival rate, less organ toxicity and improved quality of life. despite the increased use of ric regimens for hsct, the effects of ric on fertility remain unknown. objectives: to assess fertility following ric hsct in young adult males. we assessed gonadal function and semen characteristics in adolescent males (> years) who received a single ric hsct at phoenix children's hospital for nonmalignant diseases during - . male patients who were a minimum of year from ric hsct and had postpubertal development at tanner stage iii or above were eligible for this study. gonadal status was assessed by measuring fsh, lh, testosterone, and inhibin b levels, and semen anal-yses assessed fertility indicators (semen volume, sperm concentration, motility, viability, forward progression, morphology, and total count). results: hormone levels and semen analysis have been obtained for patients thus far. the median time between transplant and semen analysis was years. post hsct, ( %) patients showed abnormally elevated lh levels, but fsh, testosterone (total and free), and inhibin b levels were within normal range for all patients. sperm morphology and viability testing were not able to be performed due to low concentrations and volumes. as a result, the total motile sperm count, the most useful estimate for fertile potential, is essentially for all patients. conclusion: recruitment is ongoing, but so far our limited results suggest that ric hsct may have detrimental longterm effects on male fertility. a multi-institutional trial may be appropriate due to small patient numbers at each institution. we are currently exploring options to expand to other centers. further consideration is warranted regarding decisions made by providers, ways to improve anticipatory counseling provided to patients and their families prior to transplant, and how to augment the preventive care of these patients in longterm follow-up. currently all male patients being considered for ric transplant should be counseled to sperm bank prior to transplant. background: a previous systematic literature review identified all published studies of defibrotide treatment for patients of all ages with vod/sos. to assess day+ survival for defibrotidetreated pediatric patients (≤ or ≤ years, per study) all patients exhibited infectious complications with at least viral infection. four patients also had bacterial infections. of note, no patient developed evidence of fungal infections. conclusion: early institution of ecp in patients with high risk acute gvhd (grade - ) was very effective at treating agvhd, allowed for an aggressive steroid taper and contributed to excellent overall survival rates ( %). infectious complications were primarily viral and bacterial, with no fungal infections in this very high risk population. background: vod/sos is a life-threatening complication of hsct conditioning. vod/sos with multi-organ dysfunction (mod) may be associated with > % mortality. defibrotide is approved to treat hepatic vod/sos with renal/pulmonary dysfunction post-hsct in the us and severe hepatic vod/sos post-hsct patients aged > month in the eu. there are few published data on survival of neuroblastoma patients with vod/sos post-hsct. objectives: to report day+ survival and safety post hoc for patients with neuroblastoma and vod/sos post-hsct in the defibrotide t-ind trial. design/method: vod/sos was diagnosed by baltimore or modified seattle criteria or biopsy, with/without mod, after hsct or chemotherapy. defibrotide treatment ( mg/kg/day) was recommended for ≥ days. this post hoc analysis is based on adult and pediatric patients receiving ≥ dose of defibrotide, including with mod. results: among patients with neuroblastoma, developed vod/sos after hsct. for these post-hsct patients, . % were male and . % were female, median age was years (range - years): . % aged - months, . % - years, . % - years, and patient > years. day+ survival data were available for / of these neuroblastoma patients ( with mod and without mod); had autologous and had allogeneic transplants. kaplan-meier estimated day+ survival for the neuroblastoma group was . % ( % confidence interval [ci] , . %- . %). for the mod and no mod subgroups, kaplan-meier estimated day+ survival was . % ( % ci, . %- . %) and . % ( % ci, . %- . %), respectively. in the overall t-ind hsct population aged ≤ years (n = ) and pediatric autologous hsct subgroup (n = ), kaplan-meier estimated day+ survival was . % and . %, respectively. treatment emergent adverse events (teaes) occurred in . % (n = / ), with serious teaes in . % ( / ; most common: multi-organ failure, . % [ / ]). teaes lead to treatment discontinuation in . % (n = ; most common: pulmonary hemorrhage, n = ); death occurred in . % (n = ; > %: multi-organ failure, . %; vod/sos, . %). treatment-related adverse events, as assessed by investigators, occurred in . % (n = ; most common: pulmonary hemorrhage, . %). this post hoc analysis found kaplan-meier estimated day+ survival of . % in patients with neuroblastoma and vod/sos post-hsct, which was consistent with outcomes in pediatric patients after autologous hsct. the safety profile of defibrotide in neuroblastoma patients was consistent with the overall hsct population in this study and other defibrotide studies in pediatric patients. cincinnati children's hospital medical center, cincinnati, ohio, united states background: blood stream infections occur in nearly % of patients undergoing hematopoietic stem cell transplant (hsct) and fever is often the first symptom. timely administration of antibiotics is associated with improved outcomes, thus, early recognition of fever is paramount. current standard of care (soc) includes episodic monitoring of temperature in hospitalized patients, which may delay fever detection. therefore, continuous real-time body temperature measurement may detect fever prior to the current soc. temptraq is a food and drug administration cleared class ii medical device and consists of a soft, comfortable, disposable patch that results: of patients, were started on a pca in the days post hct. % were male with median age of y. % had all, and % aml. matched related donors were used in % and % received tbi. pca was initiated median d+ . oral mucositis alone was the most common indication ( %). a majority of patients were started on hydromorphone ( %); % started on morphine and % started on fentanyl. % started on continuous infusion. pca was used for a median of days (range - days). median pain score was highest d+ of pca use, however, there was inconsistency in charting of numerical pain scores. on d+ , patients had insufficient data to determine efficacy of pain control; of the remaining patients, % had good pain control while % had moderate and % had poor pain control using our devised scale. the most common toxicity observed was respiratory depression (∼ %), however, etiology was often multifactorial and not due to opiates alone. analysis is ongoing to assess variables predicting pca use as well as efficacy of pain control and correlation between current reporting scales and patient perception. conclusion: pca use is common in pediatric hct yet pain control remains inadequate. there's a need for better evaluation of pca management, especially uniform assessment of pain, thereby improving quality of life post hct. children's national health system, washington, district of columbia, united states background: actinomycosis is a rare invasive anaerobic gram-positive bacterial disease caused by actinomyces spp. that may colonize the oropathynx, gastrointestinal tract and urogenitial tract and can lead to abscesses. respiratory tract actinomycosis is characterized by pulmonary cavities, nodules, consolidations and pleural effusions. although actinomyces are nearly always sensitive to penicillin they are frequently resistant to cephalosporins and variable sensitives to fluoroquinolones. although rare in children, immunosuppressed patients are at increased risk for actinomycosis. to describe a case of next-generation sequencing identification of actinomycosis. a -year-old male with a history of very high risk b-cell acute lymphoblastic leukemia who was months status post a / matched unrelated donor bone marrow transplant complicated by prolonged fevers, persistent weight loss, and splenic lesions, treated with posaconazole and levofloxacin developed fever and cough in the setting of neutropenia. blood cultures demonstrated staphylococcus epidermidis. ct showed micronodules and effusion not consistent with s. epi, prompting bronchoscopy. all bacterial cultures were negative. patient was prescribed a three-week course of vancomycin with rapid improvement. design/method: s next generation sequencing (ngs) from bronchoalveolar levage sample was performed at the university of washington laboratory results: ngs assay from bronchoalveolar lavage showed major abundance of actinomyces most closely related to meyeri or oodontolyticus. demonstrated actinomyces. the patient was started on a six month course of amoxicillin with continued clinical improvement. in retrospect, the splenic nodules that were presumed fungal disease were likely actinomycosis, partially treated with levofloxacin. this case highlights the potential utility of ngs in the diagnosis of rare diseases in immunocompromised patients. actinomycosis was only demonstrated through ngs and led to a change in treatment regimen and durable clinical improvement. because actinomyces often mimics malignancy, tuberculosis or nocardiosis, the use of this novel test both targeted appropriate therapy and reduced the exposure to unnecessary medications to treat the differential diagnosis. finally, we highlight that actinomyces should be considered in patients who present with unexplained fevers, weight loss, and night sweats. haneen shalabi, cynthia delbrook, maryalice stetler-stevenson, constance yuan, bonnie yates, terry j. fry, nirali n. shah center for cancer research, national cancer institute, national institute of health, bethesda, maryland, united states background: car-t therapy, while effective, may not be durable for all, and antigen negative escape is a growing problem. hct, in relapsed/refractory all, can be curative, particularly for those in an mrd negative remission. we demonstrated that cd directed car-t therapy effectively rendered patients into mrd negative remissions (by flow cytometry) and the leukemia free survival post-hct was high . in pastorek, jesssica bruce, michael a. pulsipher, chloe anthias, peter bader, andre willasch, jennifer sees, jennifer hoag, wendy pelletier, brent logan, pintip chitphakdithai, lori wiener university of pittsburgh, pittsburgh, pennsylvania, united states background: more than , pediatric hscts are performed in north american and europe each year. the ethics of exposing a healthy child to donation procedures which have some risks and no direct medical benefits continue to be a topic of debate. pediatric donors may experience psychological distress and poorer quality-of-life during and after donation compared to healthy controls. although there are fact/jacie requirements related to the management of pediatric donors, it is unclear what standardized practices exist for psychosocial assessment/management of this group. objectives: to describe transplant center practices for psychosocial evaluation/ management of pediatric donors (< years) and to examine differences in practices by location (cibmtr/ebmt) and number of harvests (volume). design/method: data were collected via a single crosssectional survey distributed electronically to cibmtr and ebmt centers between / / and / / . : / ( %) of cibmtr and / ( %) of ebmt centers completed the survey. most centers had written eligibility guidelines for pediatric donors ( %). most also had a process for ensuring that donors were freely assenting to donate ( %), managed by a transplant physician ( %). a single physician often jointly managed donor/recipient care ( %). half of centers had a pediatric donor advocate ( %), who was most often a physician ( %) or social worker ( %). cost was the largest barrier to having a donor advocate ( %). most centers performed psychosocial screening of donors ( %) but rarely declined donors based on psychosocial concerns ( %). less than half of centers provided post-donation psychosocial follow-up ( %). comparisons by center location indicated that ebmt centers were more likely to have a physician doing joint donor/recipient care ( % vs. %; p = . ), less likely to have a psychosocial assessment policy ( % vs. %; p = . ), less likely to have a donor advocate ( % vs. %; p = . ), but marginally more likely to do post-donation psychosocial follow-up ( % vs. %; p = . ). large volume centers were more likely to have a psychosocial assessment policy than their medium/smaller counterparts ( % vs. %, %; p = . ) â€"there were no other differences on key psychosocial management variables by volume. although most centers have written guidelines for pediatric donor eligibility and mechanisms for ensuring assent, substantial numbers of donors do not undergo psychosocial assessment, are jointly managed with the recipient by a single physician without an assigned donor advocate, and do not receive psychosocial follow-up. the field would benefit from guideline development for the psychosocial management of pediatric donors. background: germline mutations in samd and samd l genes cause mirage (myelodysplasia, infection, restriction of growth, adrenal hypoplasia, genital phenotypes and enteropathy) and ataxia-pancytopenia syndromes, respectively, and are associated with chromosome deletions, mds and bone marrow failure (bmf). there are limited data on outcomes of hct in these patients. to describe outcomes of allogeneic hct in patients with hematologic disorders associated with samd /samd l mutations. results: seven patients underwent allogeneic hct for primary mds (n = ), congenital amegakaryocytic thrombocytopenia (camt)(n = ), and dyskeratosis congenita (n = ). retrospective exome sequencing revealed gain-of-function mutations in samd (n = ) or samd l (n = ) genes. constitutional mosaic monosomy was present in cases. two samd patients had features of mirage syndrome. unusual findings of panhypopituitarism, laryngeal cleft, and glomerulosclerosis were noted in one case. in another case with a samd mutation hypospadias & bifid scrotum were the only findings. the remaining patients had no phenotypic abnormalities. median age at hct was y (range: . - . ). patients received transplants from bone marrow (matched unrelated (n = ) & hla identical sibling (n = )), or unrelated cord blood (ucb) (n = ). five mds patients received myeloablative s of s conditioning (busulfan-based (n = ) or tbi-based (n = )); patients (mds (n = ); camt (n = )) received reducedintensity conditioning (ric) (fludarabine, cyclophosphamide, with ratg or alemtuzumab). syndrome-related comorbidities (diarrhea, infections, malnutrition, electrolyte imbalance, lung disease and hypoxia) were present in both patients with mirage syndrome. one patient with a familial samd l mutation, mds and morbid obesity failed to engraft following ric double ucbt. she died one year later from refractory aml. all other patients achieved neutrophil and platelet engraftment, at a median (range) of ( - ) and ( - ) days, respectively. posttransplant complications included severe hypertension (n = ), pericardial effusions (n = ), veno-occlusive disease of liver (n = ), and recurrent aspiration pneumonias (n = ). one patient developed grade iii agvhd which resolved with treatment. one patient developed mild skin cgvhd and suffers from chronic lung disease. all surviving patients had resolution of hematological disorder and sustained peripheral blood donor chimerism ( - %). overall survival was % with a median follow-up of years (range: . - . y). patients with hematological disorders associated with germline samd /samd l mutations tolerated transplant conditioning without unusual, or unexpectedly severe toxicities. allogeneic hct led to successful resolution of mds or bmf, with excellent overall survival. more data is needed to refine transplant approaches in samd /samd l patients with significant comorbidities, and develop guidelines for their long-term follow-up. shyamli singla, tiffany simms-waldrip, andrew y. koh, victor m. aquino background: steroid-refractory acute graft versus host disease (agvhd) is a potentially fatal complication of allogeneic hematopoietic stem cell transplantation (hsct). basiliximab (anti-il -r monoclonal antibody) as a single agent or in combination infliximab (anti-tnf-monoclonal antibody) has demonstrated efficacy in adult cohorts with steroid-refractory agvhd, but has not been well studied in the pediatric population. we adopted the use of basiliximab and infliximab as our institutional standard of care for steroid-refractory agvhd in pediatric hsct patients. to determine the response and survival of hsct children who received basiliximab and infliximab for the treatment of steroid-refractory agvhd. design/method: we retrospectively reviewed children who received basiliximab and infliximab for steroid-refractory agvhd refractory between september and december . complete response (cr) was defined as resolution of all clinical signs of agvhd. partial response (pr) was defined as at least one grade reduction in one target organ (e.g. skin, gut or liver) without increased grade in another target organ. no response was defined as either no improvement or progressive worsening of agvhd in at least one organ. baseline demographics, transplant details, laboratory findings, and treatment outcomes were also evaluated. results: of the evaluable hsct patients, children (median age yrs, range mo- yrs) with steroid-refractory agvhd received combination monoclonal antibody (mab) therapy. the median time from the start of steroid therapy to initiation of mab was days. the overall glucksberg grade of agvhd at the time of initiating mab therapy was grade i (n = , . %) ii (n = ; %), iii (n = ; %) or iv (n = ; %). the overall response rate was %, with ( %) patients achieving cr, ( . %) patients achieving pr, and ( . %) patients with no response at days following the start of mab therapy. the median overall survival was , , and days for patients who exhibited cr, pr, and no response, respectively. the overall survival at year following start of mab therapy was %. background: the role of high dose chemotherapy (hdc) and autologous stem cell rescue (ascr) in patients with high risk (advanced metastatic or relapsed) soft tissue sarcomas is controversial. despite multimodal chemotherapy, radiotherapy, and local control measure advancements, prognosis of patients with advanced metastatic or unresectable and relapsed sarcomas remains poor, with less than % years disease free survival. objectives: to determine if consolidation with myeloablative hdc and ascr improves relapse free (rfs) and overall survival (os) outcomes in a high risk patient subgroup. we performed retrospective review of all high risk soft tissue sarcoma patients who underwent hdc and ascr at the children's hospital at montefiore, bronx, ny between october and january . the protocol was approved by albert einstein college of medicine institutional review board. results: patients ( primary metastatic high risk disease, relapsed or recurrent disease) received hdc with ascr. primary diagnoses were rhabdomyosarcoma (rms) (n = , alveolar histology), primary site nasopharynx (n = ) and lower extremity (n = ). ewing's sarcoma (ews) (n = ), axial site (pelvic) in patients ( %). median age years (range - years), ( %) were male. all patients were in complete metabolic remission before transplant. median pre transplant comorbidity index was (range - ). patients ( rms and ews) received conditioning with carboplatin, etoposide and melphalan. remaining patients with ews received conditioning with busulfan, melphalan and topotecan. all patients received peripheral blood mobilized hematopoietic stem cell transplantation. stem cell mobilization achieved with high dose filgrastim in all patients except one who required addition of plerixafor. median cd +/kg s of s recipient body weight cell dose infused was . × ^ (range . - . × ^ ). median times to neutrophil and platelet (> , / l) engraftment were (range - ) and ( - ) days respectively. patients ( %) developed bk viuria (one with grade iii hemorrhagic cystitis); ( %) developed cmv viremia; and one patient ( %) had asymptomatic ebv viremia. there was no graft failure, sinusoidal obstruction syndrome or transplant related mortality. median follow up post-transplant was days (range - days). year probability of os and rfs were % and % respectively. hdc with ascr is a promising therapeutic strategy to consolidate remission and improve survival in select high risk soft tissue sarcoma patient subgroups. prospective clinical trials will inform the impact of disease status prior to hdc and ascr on outcome, optimal conditioning and long term relapse free and overall survival. background: absence of minimal residual disease is paramount for cure of pediatric acute lymphoblastic leukemia (all). the testis may harbor occult leukemia and this disease may result in treatment failure. objectives: the purpose of this study was to assess the longterm outcomes of boys with or without testicular leukemia pre-hematopoietic stem cell transplantation (hsct). design/method: retrospective analysis of boys with high-risk de novo ( with hypodiploidy all) or recurrent/refractory all was conducted. flow cytometry of bone marrow mononuclear cells was used to determine remission status. testicular evaluations were performed by physical examination and wedge biopsy pre-hsct. the median age at time of transplant was . years. all patients were in remission by flow cytometry of bone marrow mononuclear cells at the time of transplant and none had evidence of clinically apparent testicular disease. testicular leukemia was detected in patient and he underwent bilateral orchiectomy. he developed acute graft versus host disease (gvhd) of the duodenum and sigmoid colon which resolved, and the leukemia remains in second complete remission and he is free of hsct-related morbidity . months post-hsct. of the patients without testicular leukemia died a median of . months (range, . to . ) post-hsct ( with adenovirus infection and each with thrombotic microangiopathy and aspergillus pneumonia); experienced infection (staphylococcus species, corynebacterium, enterococcus, klebsiella, citrobacter, e. coli, epstein barr virus, adenovirus, bk virus, human herpesvirus- , candida albicans, fusarium, aspergillus, yeast, and other fungus); experienced gvhd ( of the gi tract, of the skin, of the liver, of the eyes, of the mouth, and of the lungs); and developed a second neoplasia (right lower leg leiomyosarcoma). one patient developed bone marrow minimal residual disease ( . % phenotypically abnormal cells detected months after / matched sibling hsct). reinduction therapy comprised weekly doses of rituxan, courses of blinatumomab and donor lymphocyte infusions with il- . two subsequent bone marrow evaluations were minimal residual disease negative. thirteen months post-hsct residual disease recurred ( . %) and he will receive inotumumab. overall median survival post-transplant of the boys is . months (range, . to . ) and of the surviving boys is . months (range, to . ). conclusion: testicular biopsy can detect occult leukemia pre-hsct. testicular leukemia pre-hsct does not appear to increase the risk of subsequent relapse or other hsct-related adverse events compared to those without it. yaya chu, nang kham su, sarah alter, emily k. jeng, peter r. rhode, mathew barth, dean a. lee, hing c. wong, mitchell s. cairo new york medical college, valhalla, new york, united states background: rituximab has been widely used in frontline treatment of b-nhl including burkitt lymphoma (bl), however, some patients retreated with rituximab relapse, which limit patient treatment options. novel therapies are desperately needed for relapsed/refractory b-nhl patients. several strategies for overcoming rituximab-resistance are currently being evaluated, including engineering immune cells with chimeric antigen receptors (car), as well as second-generation anti-cd antibodies. nature killer (nk) cells play important roles in the rejection of tumors. however, nk therapy is limited by small numbers of active nk cells in unmodified peripheral blood, lack of tumor targeting specificity, and multiple mechanisms of tumor escape of nk cell immunosurveillance. our group has successfully expanded functional and active peripheral blood nk cells (expbnk). b t m was generated by fusing alt- , an il- superagonist, to four single-chains of rituximab. b t m displayed tri-specific binding activity through its recognition of the cd molecule on tumor cells, activated nk cells to enhance adcc, and induced apoptosis of b-lymphoma cells. objectives: to examine if b t m significantly enhances the cytotoxicity of expbnk against rituximab-sensitive and -resistant bl cells. design/method: expbnks were expanded with lethally irradiated k -mbil - bbl and isolated using miltenyi nk cell isolation kit. alt- and b t m were generously provided by altor bioscience. nk receptors expression and cytotoxicity were examined as we previous described. ifng and granzyme b levels were examined by elisa assays. equal doses of rituximab, alt- , rituximab+alt- , obinutuzumab (obinu) were used for comparison. igg was used as controls. anti-cd car expbnk cells were generated as we previously described by mrna electroporation. rituximab-sensitive raji andresistant bl cells raji- r and raji- rh, were used as target cells. results: b t m significantly enhanced expbnk cytotoxicity against rituximab-sensitive raji cells, rituximab-resistant raji- r cells and resistant raji- rh cells compared to the controls igg, rituximab, alt- , rituximab+alt- , obinu (p< . , e:t = : ). furthermore, we confirmed the enhanced cytotoxicity by measuring ifn-g and granzyme b production. b t m significantly enhanced ifn-g and granzyme b production from expbnk against raji, raji- r and raji- rh compared to igg (p< . ), rituximab (p< . ), alt- (p< . ), rituximab+alt- (p< . ), and obinutuzumab (p< . ). when compared to anti-cd car expbnk cells, b t m + expbnk had the similar cytotoxicity against raji, raji- r and raji- rh as anti-cd car expbnk cells did (p> . ). conclusion: b t m significantly enhanced expbnk activating receptor expression and in vitro cytotoxicity against rituximab-sensitive and -resistant bl cells. the in vivo functions of b t m with expbnk against rituximab-sensitive and -resistant bl cells using humanized nsg models are under investigation. background: cardiac dysfunction, including left ventricular systolic dysfunction (lvsd), is a known complication in stem cell transplant (sct) survivors. while detection of lvsd by echocardiography is important in this population, there has been minimal research to determine if subclinical cardiac dysfunction exists in sct patients. cardiopulmonary exercise testing (cpet) is a valuable tool to assess cardiac function, and to determine how the heart responds to the stress of exercise. no studies have been performed to determine if sct patients with normal lvsd on standard echocardiography may have abnormal cpet. to determine the feasibility of cpet, as well as additional echocardiographic parameters, to detect dysfunction in sct patients with a normal ejection fraction on echocardiogram. design/method: we performed a cross-sectional analysis of sct survivors who were at least years post sct, years of age or older and with an ejection fraction > % (low end of normal range) on echocardiogram. we assessed the exercise capacity of all patients with cpet, and sub-clinical cardiac dysfunction through tissue doppler and strain analysis from the echocardiogram. results: seven patients ( male) have qualified and completed this study so far with an average age of . ± . years. the median time from transplant is . ± . years. all seven patients had a normal ejection fraction, however four patients had abnormalities on their cpet. these abnormalities included abnormal predicted peak oxygen consumption (vo ) ( %± . , normal > %) (the best predictor of functional capacity), predicted oxygen pulse ( %± . , normal > %) (measure of cardiac stroke volume) and ventilatory efficiency (ve/vco slope) ( ± . , normal < ). submaximal exercise data, used when patients are unable to complete a maximal effort test, demonstrated low-normal predicted vo at anaerobic threshold ( . %± . %, normal > % of was . days while patients who received autologous infusions had a mean number of days to engraftment of . . engraftment after hsct needs to be prompt to minimize duration of neutropenia and maximize survival rates . our data demonstrates that the infusion of hematopoietic stem cell products with a syringe or iv pump is an effective method of delivery for stem cell products and does not delay the time to engraftment. the median days to neutrophil engraftment was . days. this is comparable to data from the nmdp, which reports engraftment occurs within - days. the main limitation to this study was its small sample size due to the number of transplants done at our center. however, it does provide evidence to support that infusion of stem cell products via pump mechanism is a safe alternative to the infusion by gravity method in the process of the hematopoietic stem cell administration. johns hopkins all children 's hospital, st. petersburg, florida, united states background: leukemic relapse remains the most common cause of treatment failure after allogeneic hematopoietic cell transplant (allohct) for myeloid malignancies. most children who relapse post-allohct will die of their disease, making interventions to minimize this risk a high priority. objectives: to evaluate the safety and efficacy of posttransplant azacitidine for relapse prevention in children undergoing allohct for myeloid malignancy. design/method: we retrospectively reviewed the charts of children undergoing allohct for myeloid malignancies between february and november at johns hopkins all children's hospital. results: during the study period, children (ages to years, median ) underwent allohct for myeloid malignancies: de novo acute myeloid leukemia (aml), ; mixed phenotype acute leukemia, ; treatment-related aml, ; juvenile myelomonocytic leukemia with aml transformation, ; and myelodysplasia/aml, . thirteen were in first complete remission, were in cr or greater. most patients ( / ) received fludarabine/melphalan/thiotepa conditioning; received hla-identical related or unrelated donors, and received haploidentical bone marrow grafts with post-transplant cyclophosphamide. three patients never received planned azacitidine ( early relapse; early trm), leaving evaluable patients. azacitidine ( mg/m /dose for days, in -day cycles for up to cycles) was started at a median of days post-transplant (range - ). two-thirds ( / ) of patients received eight or more cycles. of five patients who stopped therapy early, only one was due to toxicity; other reasons included severe gvhd ( ), parental preference ( ), and relapse ( ). cycle delays occurred in patients, with a median cycles delayed per patient, mostly for mild myelosuppression with early cycles. no patient required blood product transfusion during therapy, but g-csf was used in three patients to maintain anc> / l. dose-modifications were made in patients (renal tubular acidosis, acute kidney injury, and myelosuppression). there were relapses ( %), two of which occurred in patients in cr , for a relapse incidence of % in patients in cr , with a median follow-up of months (range . to ). no patients who received azacitidine died of transplant-related mortality. conclusion: administration of azacitidine in children undergoing allohct for myeloid malignancies is safe and feasible, with most patients successfully receiving all planned cycles. toxicity was acceptable and there was no trm or secondary graft failure. despite the limitations of a small cohort, relapse incidence-particularly in patients transplanted in cr suggests a potential benefit in disease control that warrants investigation in follow-up studies. background: despite significant improvements in the success rate of hematopoietic cell transplantation (hct), graft failure remains an important complication in patients transplanted for severe aplastic anemia (saa). second allogeneic hct can salvage patients, but -year overall survival (os) rates have been reported as low as % . objectives: identify patients who developed dropping donor chimerism, graft rejection, and/or graft failure after first hct for saa, necessitating additional hcts or cellular boosts (defined as stem cell products infused without preceding chemotherapy), and evaluate treatment-related complications and os. with vod/sos with and without multi-organ dysfunction (mod) pubmed and embase databases were searched for "defibrotide and retrospective chart reviews; excluded publication types were: case reports (< cases); meta-analyses; reviews; animal, modeling, pharmacokinetic, chromatography, and adult-only studies; guidelines; articles; and letters. resulting reports were screened for exclusion criteria. full-text articles were then reviewed for eligibility. study characteristics of selected publications were summarized, and publications were categorized by patients' mod status. when necessary, additional data tables were requested. a random effects model was used for pooling data for efficacy. interstudy heterogeneity was assessed with cochran's q-test. percentage of total variation across studies due to heterogeneity (i ) was evaluated we quantified ∼ proteins in each sample. reproducibility for one donor at different time points children 's minnesota, minneapolis, minnesota, united states background: pediatric and young adult hodgkin lymphoma (hl) has five-year survival rates > %. chemotherapy required to achieve this rate is associated with a lifetime risk of cardiac deaths, second malignancies, pulmonary disease and infertility. as effective salvage therapy exists, outcomes may be improved by de-intensifying initial therapy to lessen toxicity.objectives: we piloted a regimen in low and intermediate risk hl patients using agents without known association to significant late effects. this retrospective chart review was approved by children's minnesota irb.design/method: the bvg(p) regimen incorporated bortezomib ( . mg/m day , , , ); vinorelbine ( mg/m day , ); gemcitabine ( mg/m day , ) every days and prednisone ( mg/m /dose bid x days). we treated newly diagnosed patients, ages - years, with non-bulk stage iia (n = ) or iib (n = ) hl. two patients received bvg and received bvgp with the addition of prednisone.results: newly diagnosed patients were all pet negative after the first or second cycle and remained pet negative at end of therapy, cycles. nausea was well controlled with -ht antagonists and scopolamine. pegfilgrastim was not necessary due to the high absolute neutrophil count nadir [median . and minimum . × /l]. there were no episodes of febrile neutropenia, infection or transfusion need. no patients experienced alopecia. one patient developed sensory neuropathy after the eighth dose of bortezomib that was controlled with gabapentin and a switch to subcutaneous bortezomib administration. of the five newly diagnosed patients, four remain in remission at , , , days; relapsed at previous disease sites at days and subsequently achieved remission with bvgp with the addition of brentuximab. this series provides early evidence to stimulate expansion of this pilot experience and subsequent multiinstitutional study leading to a randomized trial of bvgp and current chemotherapy for low and intermediate hl. st jude affiliate clinic at st francis hospital, tulsa, oklahoma, united states background: symptoms suggestive of morning hypoglycemia has been noticed in children receiving all chemotherapy. only few small studies looked at this therapy related complication. factors increase risk of hypoglycemia in all patients include accelerated starvation, steroid induced adrenal suppression, mercaptopurine therapy and prolonged fasting for procedures.objectives: to study the prevalence and risk factors for hypoglycemia during all therapy design/method: medical records of of children (up to years old) treated for all between - ( patients) were studied for evidence of morning hypoglycemia defined as blood sugar (bs) < mg/dl. statistical mean differences between the subgroups were analyzed with spss using a nonparametric mann-whitney u test.results: fifty two percent ( %) of patients developed hypoglycemia during all treatment, with an average of . episodes/patient. % were males and % females. almost / ( %) of patients with hypoglycemia were in maintenance phase of therapy. % of hypoglycemic episodes occurred in % of patients. majority of hypoglycemic episodes ( . %) occurred on the day of procedure when patients were fasting overnight. . % of hypoglycemic episodes occurred in children ≤ years, with . % in ≤ years. patients who developed hypoglycemia were significantly younger (mean age at time of diagnosis of all was . ± . at the hypoglycemia group versus the non-hypoglycemia ( . ± . ) p< . . no statistically significant difference was found regarding sex, or tpmt genotype. % of hypoglycemic children-all < years of age-presented with life threatening hypoglycemia symptoms including seizure and loss of consciousness. this study showed high prevalence of hypoglycemia during childhood all therapy. younger age, especially ≤ years, is associated with higher risk of hypoglycemia as well as life-threatening episodes. to decrease fasting hypoglycemia during therapy for childhood all, we recommend that children under the age of years receive bed time snack high in proteins and complex carbohydrates, and to get them up early the day of procedure to take clear sugary drink. hospital for sick children, toronto, ontario, canada ann & robert h. lurie children's hospital of chicago, chicago, illinois, united states background: childhood brain tumors are the most common solid malignancy and the leading cause of cancer-related mortality in children. the most aggressive type of pediatric central nervous system (cns) tumors is diffuse intrinsic pontine glioma (dipg). despite decades of clinical trials, there has been no substantial improvement with respect to therapeutic outcomes with most children eventually succumbing to the disease. research on adult high-grade gliomas has shown a targetable pathway through the inflammationinduced expression of indoleamine , dioxygenase (ido ) and its recognized ability to suppress the anti-tumor immune response. a limited understanding into the role of ido in pediatric central nervous system tumors serves as the foundation of this research project. furthermore, the integration of nanotechnology is a fundamental step for the investigation and targeting of ido . spherical nucleic acids (snas) composed of nanoparticles have been shown to transverse cellular membranes, exhibit stability in physiological environments, escape from degradation, and create precise targeting in brain tumors.objectives: the purpose of our project is to delineate the role of ido in pediatric dipg, and develop small inhibitory (si)rna oligonucleotides and snas aimed at therapeutically inhibiting the gene expression of immunosuppressive ido . our specific aims are to: ( ) confirm the gene expression ido in different human dipg cell lines; ( ) generate and characterize sirna oligonucleotides targeting human ido in vitro; and ( ) generate and characterize gold nanoparticles for targeted inhibition of ido .design/method: unique patient-derived dipg cell lines were grown in culture, stimulated with increasing concentrations of the proinflammatory cytokine, ifn , and analyzed for mrna levels. sirna specific to ido was transfected into cells. sna generation is in progress.results: ido is expressed in multiple human pediatric dipg cell lines. sirna targeting ido among exons and results in a significant decrease in overall ido expression by dipg cells. sna generation for targeting ido with improved penetration & stability is ongoing, with preliminary results demonstrating a robust ability to inhibit ido expression. the grim prognosis of children with dipg, the lack of effective therapies, and the expression of ido by human dipg cells emphasize the importance of developing the treatment capability to inhibit ido gene expression, as a excluded from this study. the remaining patients were analyzed using descriptive statistics.results: a total of patients meeting inclusion criteria were identified. of these, patients ( . %) received tonsillectomy alone, ( . %) underwent tonsillectomy and decreased immunosuppression, ( . %) received tonsillectomy and rituximab, and another ( . %) received tonsillectomy with additional therapy (including ebv-specific cytotoxic tlymphocytes, donor leukocyte infusion, and chemotherapy). of the patients who received tonsillectomy with or without a decrease in immunosuppression, all were diagnosed with high-grade lymphoma and achieved clinical remission following tonsillectomy with no evidence of relapse to date. on further analysis looking at ptld risk factors, all patients were under years of age, all received t-cell depleted grafts, and none had significant graft-versus-host disease (gvhd) at the time of ptld diagnosis. we have identified a population of patients with localized ebv ptld that achieved clinical remission with no evidence of recurrence following tonsillectomy, suggesting that tonsillectomy alone may be an adequate treatment for localized ebv ptld in a specific subgroup of patients. further analysis is needed to identify characteristics of this subgroup to determine which patients would be most likely to respond to this treatment. university of rochester, rochester, new york, united states background: malignant central nervous system (cns) tumors in young children have a poor prognosis and pose a significant therapeutic challenge. consolidation therapy with carboplatin and thiotepa was piloted in ccg- , cog acns , and cog acns with the goals of intensifying therapy and omitting or delaying radiation.objectives: to document outcomes for patients undergoing carboplatin/thiotepa consolidation with autologous stem cell rescue (ascr) and to demonstrate the feasibility and toxicity of this regimen.design/method: patients up to years old (median age: months) with malignant cns tumors treated at the university of rochester from - with at least one cycle of carboplatin ( mg/kg/day x days) and thiotepa ( mg/kg x days) followed by peripheral blood ascr were included in retrospective analysis. data were recorded on time to engraftment (defined by absolute neutrophil count (anc) recovery to > . × ^ /l), length of hospitalization, toxicity with each consolidation cycle, progression free survival (pfs) and overall survival (os). stem cell harvest data were also collected.results: eleven patients with malignant cns tumors ( atypical teratoid/rhabdoid tumor, primitive neuroectodermal tumor, glioblastoma multiforme, and pineoblastoma) received a total of cycles of carboplatin/thiotepa. of these, underwent stem cell harvest at our institution, with complications limited to procedure-related hypotension for patient with known autonomic instability, and catheter-associated deep vein thrombosis (dvt) for patient. four patients were in complete remission (cr) /status-post gross total resection, was in cr , and had residual tumor at the time of consolidation. nine patients received planned consolidation cycles, patient (of ) planned cycles, and patient of an anticipated cycles thus far. average time to engraftment for these cycles was . (+/- . ) days, with a mean hospital length of stay of (+/- . ) days. fever occurred in of cycles ( %); infectious toxicity included documented bacterial infection in cases (enterococcus faecalis bacteremia in , klebsiella pneumoniae in ). there were no regimenrelated deaths. with a mean follow-up of months, survivors have not yet completed all therapies, and patients have relapsed ( have died of disease). of the survivors, have been disease-free for > months. background: autologous hematopoietic stem cell transplantation (auto-hsct) has resulted in improved survival for patients with high-risk neuroblastoma. treatment intensification is however associated with greater complications. data on early infectious complications in low-and-middle income countries are limited.objectives: to review the early infectious complications following auto-hsct in patients with high-risk neuroblastoma.design/method: a retrospective chart review of pediatric patients with high-risk neuroblastoma who underwent auto-hsct at the american university of beirut medical center between and was conducted. infectious complications during the first days post-transplant were reviewed.results: forty-three patients ( males and females) with a median age at diagnosis of . years [range: . - . ] years underwent auto-hsct during the above-mentioned period. conditioning regimen consisted of melphalan, etoposide and carboplatin. all patients received antiviral and antifungal prophylaxis. median time for neutrophil engraftment was days [range: - ]. bacteremia and clostridium difficile infections occurred in ( %) and ( %) patients respectively. seven ( %) patients developed enterocolitis diagnosed by imaging, were adenovirus induced. cmv viremia was diagnosed in ( %) patients, of whom required treatment. varicella zoster reactivation, parvovirus viremia, toxoplasmosis encephalitis, bk virus cystitis ( patients) and central nervous system ebv related post-transplant lymphoproliferative disorder were diagnosed in different patients. there was no invasive fungal infection. sixteen ( %) patients have died, of whom died in the early post-transplant period, due to disease progression and ( . %) due to infectious complications. among the patients who died due to infection, developed toxoplasmosis encephalitis, developed severe enterocolitis, of which were adenovirus related. the mean igg level within one week post-transplant was lower in patients with clinically significant viral infection compared to others ( vs . mg/dl, p: . ). the mean igg level at the time of clinically significant bacterial infection was lower in infected patients compared to others ( . vs . mg/dl, p: . ). neither absolute lymphocyte count nor absolute neutrophil count at day post-transplant affected the incidence of clinically significant infections. our results show that the rate of infections during the early post auto-hsct period is higher than what has been described in developed countries and has a significant impact on mortality. prevention, early detection and improvement in the treatment is required to improve outcome. university of miami, miami, florida, united states background: allogeneic hematopoietic stem cell transplantation (allo-hsct) is a curative treatment for many malignant and non-malignant (bone marrow failure, immunodeficiency, or metabolic diseases) in pediatrics. despite advances in medicine, graft-versus-host-disease (gvhd) remains a significant cause of non-relapsed morbidity and mortality, specifically in those with malignant diseases.objectives: to highlight the complexity to acute gvhd management and seldom-described treatment approach. a year male with a history of high risk acute myeloid leukemia (aml) due to failed induction therapy. he received a matched ( / ) unrelated donor hsctmarrow product-conditioned with busulfan, fludarabine, and anti-thymoglobulin (atg). his post-transplant course was complicated by hhv- viremia, pres (prompting a change from prograf to cyclosporine), mucositis, and grade iii acute gvhd (skin s , gut s , liver s ) around post transplant day , which later morphed to ocular involvement by d+ . he was started on mg/kg steroids with good response but flared up with each attempt to taper steroid dose. a course of rituximab and later atg were tried without success in weaning off steroids. switching cyclosporine to sirolimus did not provide any additional benefit either. extracorporeal photopheresis (ecp) was started times a week. he initially responded well, yet was not able to wean off steroids. in addition, he developed a flare when ecp session was reduced to days per week. ecp was therefore increased to days per week, which appeared to stabilize skin lesions. a trial of weekly methotrexate was attempted to wean off steroids and photopheresis, which provided no response. finally, a trial of bortezomib on days , , , and of a day cycle as published in a case series of multiple myeloma patients who developed post hsct gvhd. skin lesions improved remarkably however dose had to be reduced due to related pancytopenia. given the response to therapy, he was continued on a weekly dose of bortezomib, receiving a total doses, which has permitted the slow taper of prednisone that has since been discontinued without a major flare. he however is currently maintained on ecp times per week, which is now been slowly withdrawn.conclusion: management of acute gvhd in pediatric patients after hsct can be challenging with no definite options for those who fail steroids or become steroid dependent after initial response. in these situations, bortezomib could be a valid therapeutic option. background: neuroblastoma (nbl) is the second most common solid tumor in children and despite recent treatment advances, overall survival for high risk nbl remains < %. the addition of immunotherapy has improved survival and includes anti-gd antibody therapy. the success of antibody therapy in neuroblastoma is primarily due to natural killer (nk) cell mediated antibody dependent cellular cytotoxicity. we previously demonstrated that nk cells from patients with high risk nbl can be successfully isolated and expanded to large numbers and exhibit potent anti-tumor effects against nbl ( ). thus, infusions of autologous expanded nk cells in high risk nbl in combination with anti-gd antibody are being studied in clinical trials. toll-like receptors (tlr) present on the surface of leukocytes are responsible for pathogen recognition, and activation of these receptors stimulate the production of cytokines that critically link innate and adaptive immune responses. the tlr agonist, poly(ic) is a synthetic analog of dsrna that has previously been shown to directly stimulate cytokine production and improve cytotoxicity in primary nk cells through activation of genes regulated by interferon-response elements (ire) ( ). we hypothesized that ex vivo activation of tlr pathways in nk cells during our normal -day expansion using k feeder cells expressing membrane bound il- would enhance their function.design/method: nk cells were isolated from peripheral blood mononuclear cells and expanded with our previously described expansion protocol in media containing il- and ug/ml poly(ic) ( ). at the end of the -day expansion, nk cells expanded with poly(ic) were compared to controls using a calcein cytotoxicity assay to measure cytotoxicity against high risk neuroblastoma and cytometric bead array to measure cytokine production. : surprisingly, the addition of poly(ic) during nk cell expansion did not improve proliferation, cytokine production or cytotoxicity compared to our standard expansion method. rnaseq demonstrated that our standard expansion method results in a modest decrease in tlr expression at the transcriptional level, but significant upregulation of several ireregulated genes. we conclude that either our standard approach interferes with tlr signaling or saturates the innate immune response pathway such that co-stimulation with poly ic does not produce an additive effect. we are performing expression analysis on nk cells receiving poly(ic) during expansion to further explore this hypothesis. background: gonadal dysfunction leading to infertility is a complication after hematopoietic stem cell transplant (hsct). anti-müllerian hormone (amh) is a marker of ovarian reserve; it is not controlled by gonadotropins and has minimal inter-cycle variations, therefore, it can be used as a marker of ovarian reserve and aid in fertility counseling.objectives: assess ovarian reserve in hsct patients utilizing amh levels. background: tgf beta is an immune suppressive cytokine frequently elevated in the tumor microenvironment causing tumor immune evasion. acute tgf beta treatment potently inhibits nk cell cytotoxicity, cytokine secretion, and proliferation. however, tumor infiltrating nk cells receive chronic inhibitory tgf beta signals in conjunction with activating signals from tumor cells. objectives: to this end, we hypothesized that long-term tgf beta-cultured nk cells would induce functional and phenotypical changes on nk cells that differ from short-term tgf beta treatment.design/method: to explore this, primary human nk cells were cultured with the leukemia cell line, k , alone or with exogenous tgf beta for weeks. : surprisingly, nk cells cultured in tgf beta proliferated faster, and upon challenge with a variety of cell line targets they secreted much greater quantities of ifnÎ ( -to -fold increase against / cell lines) and tnf ( -to -fold increase against / cell lines). further, the high cytokine secretion induced in these nk cells was no longer inhibited by adding additional tgf beta. degranulation was also increased ( / cell lines), however cytotoxicity was not enhanced in a -hour cytotoxicity assay. after resting in il- , the cytokine hypersecretion of tgf betacultured nk cells was maintained for several weeks suggesting this functional change might involve cellular reprogramming. we investigated the mechanism behind these functional changes and profiled genes involved in tgf beta signaling. we found significant reduction of smad transcription which corresponded to a striking decrease in smad chromatin accessibility. we also found significantly increased smad and decreased tgfbr expression. phenotypic analysis revealed that tgf beta also induced remodeling of the nk receptor repertoire with decreased nkp , cd , and klrg and upregulation of trail. the functional consequences of these tgf beta-induced changes on in vitro and in vivo nk cell function are currently under investigation. background: the use of t-cell depleted grafts in haploidentical stem cell transplantation (hsct) has been associated with a delay in early t-cell recovery which increases the risk of viral infections, relapse or graft rejection. conventional donor lymphocyte infusion (dli) after hsct transplantation is effective but conditioned because of a high prevalence of gvhd. the infusion of selected lymphocyte subpopulations with low aloreactivity is emerging as an effective strategy to rectify this issue. the depletion of cd ra+ naive lymphocytes, preserving cd ro+ memory t-cells, could provide a safe source of functional lymphocytes with anti-infection, antileukemic and anti-rejection properties, and lower rates of adverse effects. our objective is to present data of patients that have received cd ro+ memory t-cells dli (mdli) and assess its safety and outcome. we present data of mdli performed after hsct in cases of mixed chimerism, persistent lymphopenia, viral/opportunistic infections or as a strategy to accelerate immune reconstitution.results: fifteen patients with diagnosis of all (n = ), aml (n = ), mds (n = ), saa (n = ), sideroblastic anemia (n = ) and cgd (n = ), received mdli after hsct. a total of forty-three mdli were infused. the median dose of cd ro+ memory t-cells infused was . × /kg (range: . × - . × /kg), with a median dose of cd ra+ naive t-cells of . × /kg (range: - . × /kg). the mdli were infused at a median of seventy-seven days after hsct (range: - days), with a median interval between mdli of thirty-four days results: eight published studies reported survival outcomes for pediatric vod/sos patients (n = ), across all defibrotide doses. estimated day+ survival ( % confidence interval) was % ( %- %). for vod/sos with mod, studies were identified (n = ) with pooled estimated day+ survival of % ( %- %). only one openlabel expanded-access study, the treatment-ind, reported outcomes separately for pediatric vod/sos patients without mod (n = patients aged ≤ years). the day+ kaplan-meier estimated survival for those patients was % ( %- %). safety results were not pooled due to differences in reporting methodology; however, study results were consistent with the safety profile of the phase historicallycontrolled trial in vod/sos patients with mod ( % pediatric), in which / defibrotide-treated patients and all controls experienced ≥ ae. hypotension was the most frequent ae ( %, defibrotide; %, controls); common hemorrhagic aes (ie, pulmonary alveolar and gastrointestinal hemorrhage) occurred in % of defibrotide-treated patients and % of controls. in this pooled analysis of studies with defibrotide-treated pediatric patients with vod/sos, estimated day + survival was % (without mod, %; with mod, %). safety results in individual studies were generally consistent with the known safety profile of defibrotide. taken together, these results show a largely consistent defibrotide treatment effect in pediatric patients treated with defibrotide for vod/sos, with or without mod. results: six patients met inclusion/exclusion criteria. all patients were started on ecp while concurrently receiving . to mg/kg steroid therapy for agvhd plus a calcineurin inhibitor. patients had initiation of ecp within a maximum of weeks from initial diagnosis of agvhd (range - days). patients had grade - agvhd ( / patients with grade ) with skin, liver, and gi gvhd represented. patients received ei-ecp - times per week for the first weeks and then had ei-ecp frequency tapered based on initial response.after weeks of therapy patient had a decrease in overall gvhd grade by grade. all patients were able to have steroids tapered, with doses decreased by an average of % ( % - % decrease).at weeks of therapy, one patient with grade agvhd died of mof associated with infections. three patients had complete resolution of agvhd and patients decreased by grade. steroid doses were decreased by an average of % ( % - % decrease). continuously measures axillary temperature and wirelessly transmits real time-time data. the primary aim of the study was to evaluate the feasibility, safety and tolerability of continuous temperature monitoring in hsct patients using temptraq. we are performing a prospective observational study of pediatric patients ( - years of age) undergoing hsct at cincinnati children's hospital in cincinnati, ohio. enrolled patients wore a temptraq patch for days. a - rating scale survey was completed by the parent/guardian at the end of the study to determine tolerability, ease of use, satisfaction and desire for future use in the inpatient and outpatient setting. temperature data from the temptraq patch was compared to the standard episodic temperature monitoring to determine detection of febrile episodes. seven of ten patients have completed screening. we anticipate completion of the study in early february. the temptraq patch was well tolerated by study subjects (mean tolerability rating of . / ). one patient developed skin breakdown at the site of the temptraq patch attributed to recent thiotepa. the patch was easy to apply with an easy of application rating of . / . parents were overall satisfied (rating . / ) and would like to use the temptraq patches in future hospitalizations (rating . / ) and at home (rating . / ). temptraq patch identified fever (≥ . • f) in patients. the fever was never detected by episodic monitoring (soc) in patients and significantly delayed in the other patients (> hours). temptraq was well tolerated in pediatric hsct patients. timely fever detection was improved in temptraq over the current soc. background: serotherapy is commonly used in patients undergoing hematopoietic stem cell transplant (hsct) to reduce the incidences of engraftment failure and graft versus host disease. however, one well-known side effect is fever. as children undergoing hsct have compromised immune defenses, fever may also be an early indicator of bloodstream infection, which would warrant prompt use of broad-spectrum antibiotics. in a subset of patients with serotherapy-associated fever, antibiotics, which may induce antibiotic resistance and increase costs, may be unnecessary. we aimed to determine the incidence and characteristics of serotherapy-related fever, as well as the likelihood of concomitant bacteremia, in our institutional experience. a -year retrospective chart review was conducted of pediatric patients who received serotherapy as part of hsct conditioning at the university of minnesota. one-hundred sixty eight consecutive hsct patients who received serotherapy -either atg (n = ) or alentuzumab (n = ) -were identified. the median age at hsct was -years (range, . - years). a total of patients ( %) developed fever while on serotherapy (atg = , alentuzumab = ). one-hundred sixteen patients presented fever following the first infusion, and the median onset of fever was hours after commencing infusion (range, . - hours). fever resolved at a median hours (range, - hours). one hundred and fourteen patients ( %) underwent blood cultures. only seven patient were not started on ( %) empiric antibiotics, while % (n = ) were on antibiotic treatment prior to serotherapy for previously known or suspected infections. nine patients ( % of febrile patients, % of all patients) had positive blood cultures (atg = ; alentuzumab = ). no infection-associated deaths were observed.conclusion: while fever is common during serotherapy conditioning in children undergoing sct, episodes of concomitant bloodstream infection are rare. ongoing analysis identified potential risk factors for bacteremia as recent history of infection, first episode of fever following second or subsequent infusions, and previous central line placement. further analysis is being conducted to identify subgroups of patients for whom close monitoring alone may be safe. background: hsct is potentially curative for caya with high-risk leukemias; however, most lack an hla-matched aspho abstracts related donor. the risk of gvhd is increased with unrelated (urd) or partially matched related (pmrd) donors. selective t-cell depletion based on the elimination of t cells carrying and chains of the t-cell receptor may greatly reduce the gvhd risks, while allowing the maintenance of mature donor-derived alloreactive nk cells and / (+) t cells, which may augment the anti-leukemia effect.objectives: this is a prospective study of caya with acute leukemia who underwent hsct with mmrd or urds and tcr / /cd depletion. outcomes included engraftment, toxicities, viral reactivation, and relapse.design/method: this study included caya with acute leukemia transplanted between october and may . all received a myeloablative preparative regimen with targeted busulfan (n = ) or tbi ( cgy/ fractions) (n = ), with thiotepa ( mg/kg) and cyclophosphamide ( mg/kg). atg ( mg/kg x ) was given to those receiving haploidentical grafts and to the first who received urd grafts. immune suppression was not given post-hsct. the stem cell source was mobilized peripheral blood stem cells (pscs), which then underwent tcr / /cd depletion utilizing the clinimacs device under gmp conditions in the chop cellular immunotherapy lab.results: median age was (range . - . ). diagnoses included all ( -b-cell, -t-cell) and aml ( ; -secondary aml). urd were used for ; were / allele matched and were / matched. haploidentical donors were used for . median cd (+) dose - . × , / (+) cd (+) cells - . × , and b cells - . × . all patients achieved an anc at a median of d+ ( - ), and % had platelet engraftment at median d+ ( - ). nine patients ( %) developed acute gvhd (all skin, grades i-iv). five developed chronic gvhd (skin, gut, lung): limited in , extensive in . viral reactivations included: adenovirus ( , %), bk virus ( , %), cmv ( , %), and hhv ( , %). nine ( %) patients relapsed at a median of days (range - ) post-hsct, including aml patients ( . %) and all patients ( . %). transplant-related mortality was %; causes included sepsis ( ) and ards ( ). os was %; efs was % (gvhd-free efs %, lfs %). hsct with tcr / /cd depletion demonstrates excellent engraftment kinetics with limited gvhd without immune suppression. elimination of post-hsct immunosuppression may offer an excellent platform to augment anti-leukemic immune therapy or to enhance immune reconstitution. background: hematopoietic cell transplantation (hct) is the only curative treatment available for patients with sickle cell disease (scd). low bone mineral density (bmd) has been described in scd, but little is known about the impact of curative hct on this outcome. to determine the prevalence of low bmd and variables associated with low bmd in scd patients after hct. we conducted a retrospective chart review of scd patients who underwent hct at children's healthcare of atlanta (choa) between / and / and survived ≥ year post-hct. transplant characteristics, post-hct dual-energy x-ray absorptiometry (dexa) scan results, vitamin d levels, graft-versus-host-disease (gvhd) status, and fsh levels were reviewed. for patients - years of age, height corrected z-scores were calculated using a nihvalidated calculator, with t-scores used for older patients. bmd was categorized as low if between - and - sd below the mean and clinically significantly low if >- sd, in accordance with the children's oncology group long-term follow-up guidelines. vitamin d levels < ng/mol were considered deficient, and fsh levels > miu/ml suggestive of premature ovarian failure. fisher's exact test was used to compare variables in those with normal versus abnormal dexa scan results, with p< . considered significant.results: hct was performed on patients with scd, with surviving ≥ year post-hct. dexa scans were obtained in patients ( % female), with mean time from hct to dexa scan being years ( . - . years) and mean age at time of dexa . years ( . - . years). patients with and without dexa scans did not differ by sex, donor source, age at transplant, or vitamin d status. low bmd was noted in patients ( . %), with these patients more likely to be > years (pubertal; . versus . %, p = . ). acute gvhd was more common in patients with low bmd ( . versus . %), but not statistically significant (p = . ). clinically significant low bmd was noted in patients ( . % of those with dexa scans). these patients were older ( . years at testing), were more likely to be male ( . %), and all had acute and chronic gvhd, while none had evidence of gonadal failure.conclusion: clinically significant low bmd is uncommon after hsct for scd. patients at risk for low bmd include older patients and likely those with gvhd. this preliminary data suggests routine dexas may not be indicated for all patients who undergo hct for scd, but further data is needed. background: causes of renal dysfunction after hematopoietic cell transplantation (hct) include damage from radiation, nephrotoxic medications, graft vs. host disease (gvhd), hepatorenal syndrome, viral infections, or transplant associated microangiopathy. we sought to investigate the incidence of, and risk factors for, acute kidney injury in pediatric hct patients and associated risk with mortality.design/method: data from patients who underwent hct between and at a single institution were sequentially retrospectively captured on irb approved protocol. acute kidney injury (aki) was defined at multiple time points post-hct using the standardized criteria: kidney disease: improving global outcomes (kdigo). interval differences between values were analyzed using wilcoxon rank sum testing and categorical variables were analyzed using chi-square analysis.results: ninety-eight patients were included in the study: allogeneic (n = ) and autologous (n = ), mean age . years, of whom % were african american, % asian, % caucasian, % latino, and % mixed race. forty-seven percent of patients developed aki within the first years of hct. increased risk for aki was associated with a lower pre-transplant creatinine level (p = . ), abnormal pretransplant bun (p = . ) and an unrelated donor (p = . ) while preparative regimen intensity, race, or primary disease were not. twenty-six percent of patients developed aki within days of hct. of those with aki, % were exposed to either cidofovir, aminoglycosides, and/or ambisome for at least days versus % without aki and % were exposed to vancomycin compared to % without aki. evaluating outcomes at year after hct, of those with stage aki: % had reduced gfr and % died, while % had reduced gfr and % had died for patients with aki stage or . the absence of aki by day was associated with % reduced gfr and % death at -year after hct. overall, those with aki at any time in the first year post-hct had a . fold increased risk of death compared to those without. for patients who required renal replacement therapy (rrt, n = ), the risk of death was . fold greater compared to those who did not. in the % of patients who survived rrt, both recovered renal function within years.conclusion: acute kidney injury is common after pediatric hct, and may be associated with low creatinine, abnormal bun, unrelated donor pre-hct, and renal toxic medications. early-onset aki post hct is associated with an increased risk of mortality. these data should be validated in a larger prospective study but may offer opportunities to intervene and enhance outcomes. background: myeloablative hematopoietic stem cell transplant (hct) for pediatric malignant disease is associated with significant morbidity with % patients experiencing mucositis. patient controlled analgesia (pca) utilizing opioids is an effective strategy for pain management. we sought to describe and analyze pca use in d+ days post myeloablative hct for malignancies at lurie children's hospital of chicago from - .design/method: utilizing retrospective chart review, pca details were collected: indication, initiation day, pca duration, team managing pca (anesthesia or palliative), medication and dose in morphine equivalents, and pca toxicities. efficacy of pca was evaluated on pca day + , + , + , + using demands %, maximum pain score (rflacc, faces, vas) and subjective patient, parent and/or pain team perception of pain control. we devised a scale based on the above to designate pain control as good, moderate or poor. variables being analyzed include recipient age, sex, donor type, source, diagnosis, tbi use, gvhd/trm. this analysis, we analyze the depth of remission, car-t persistence, and post-transplant gvhd on our phase i anti-cd car-t protocol (nct ) to better understand the role of car-t in the peri-hct setting.design/method: children and young adults with relapsed/refractory cd + all treated on our phase i anti-cd car-t protocol were analyzed. mrd was assessed by flow cytometry (fc) in all, with pcr-based mrd analysis using igh or tcr testing assessed in select patients. hcts were performed at each patient's local institution based on standard of care and included varying conditioning regimens, donor types, stem cell source, and gvhd prophylaxis.results: on our cd car trial, patients were treated, the majority of patients (n = ) having relapsed following a prior hct. / patients ( %) attained a cr, of whom were mrd negative by fc. concurrent pcr based mrd analysis available in patients demonstrated that all patients achieved pcr based negativity. in , this was simultaneous with the month mrd negative fc, and in , pcr negativity was achieved over time (fc remained negative). patients proceeded to hct at a median time of days (range: - days) post-car-t, which was a first hct in . these two patients remain in an mrd negative cr, year post-car-t. no patients developed acute or chronic gvhd. car persistence was seen in patients who had detectable car-t cells on the pre-hct marrow suggesting the possibility of ongoing anti-leukemia surveillance prior to initiation of the conditioning regimen.conclusion: by inducing pcr negativity, car-t therapy may have a synergistic role with hct to improve leukemia free survival, prior to emergence of antigen negative leukemia, without an increased risk of gvhd. while the sample size is small, car-t therapy may offer an effective bridge to hct, particularly for those who are pcr negative, and those who have not had a previous transplant. given the underlying risk of hct related trm, pre-hct car may potentially allow for hct conditioning de-intensification as it may not be needed to eradicate residual disease. lee dw, ash abstract , background: post-transplant lymphoproliferative disease (ptld) is a complication after solid organ transplantation (sot) that is frequently due to epstein -barr virus (ebv) as a decrease in ebv-specific t cell immunity due to immune suppression allows for uncontrolled proliferation of ebv-infected b cells. outcomes for ptld are suboptimal with relapse rates approaching %. however, ebv-infected b cells in ptld express the ebv antigens lmp and lmp that can be targeted with immune therapy.objectives: we hypothesize that third party "off the shelf" lmp-specific t cell products may improve outcomes and decrease associated co-morbidities for patients with ptld by not only target the lymphoproliferating ebv-infected b cells but also restoring ebv-specific immunity.design/method: lmp-specific t cells (lmp-tcs) are manufactured from eligible donors with a broad range of hla types in our gmp facility to be used in a children's oncology group (cog) trial (anhl ) for patients with ptld after sot. lmp-tc products are manufactured from healthy donors using autologous monocytes and lymphoblastoid cell lines (lcl) transduced with an adenoviral vector expressing Δlmp and lmp as antigen presenting cells. lmp-tc products undergo comprehensive characterization by ifn-elispot assay to determine lmpspecific epitopes, class i and/or ii response, and hla restriction to guide selection of lmp-tc product for each patient.results: thus far, lmp-tc products have been manufactured. lmp-tcs were active against lmp (mean: sfu/ × ^ cells; range: - ), lmp ( ; - ), and lcl ( ; - ) as determined by ifn-elispot assay. at the time of cryopreservation, the lmp-tc products comprised a mean of % cd + t-cells, % cd + t-cells, and % nk cells. no b cells or monocytes were detected in the final products. thus far, we have identified novel lmp epitopes (lmp specific: n = ; lmp specific: n = ). approximately % of the lmp-tc products have lmp-specific activity through multiple hla alleles, and % have a mixed class i and class ii response. conclusion: thus, lmp-specific t cell products can be expanded from healthy donors to creat a third party bank, and identifying epitopes and hla alleles with lmp activity will facilitate selecting the most appropriate product for patients. while lmp-specific t cells have previously demonstrated safety and efficacy in phase i studies, anhl is the first trial using cellular therapy within a cooperative group setting. children's cancer hospital at the university of texas md anderson cancer center, houston, texas, united states background: in , the united states food and drug administration (fda) approved the first chimeric antigen receptor t cell (car-t) therapy; tisagenlecleucel. this cd -directed genetically modified autologous t cell immunotherapy has shown response rates of almost % among children and young adults with b-cell precursor acute lymphoblastic leukemia (all) that are refractory or in second or later relapse. cytokine release syndrome (crs) and car-t cell related encephalopathy syndrome (cres) are well described toxicities associated with car-t therapy. crs is a systemic inflammatory response and is typically characterized by fever, hypoxia, tachycardia, hypotension and multi-organ toxicity. cres may occur concurrently or following crs, or without any associated crs symptoms and is characterized by encephalopathy, delirium, seizures and rarely cerebral edema. almost half of patients who receive tisagenlecleucel may require pediatric intensive care unit (picu) support. crs and cres are generally reversible but may be associated with fatal outcomes. pediatric specific management guidelines, comprehensive training of multidisciplinary staff, effective communication and phased infrastructure ensure that adequate resources are available to facilitate early diagnosis and appropriate management of pediatric patients with crs and cres and allow for optimal patient outcomes and accreditation by the foundation for accreditation of cellular therapy (fact).objectives: develop a comprehensive program to ensure safe administration of immune effector cell (iec) therapy to pediatric patients.design/method: an inter-disciplinary pediatric cartox (car t cell therapy associated toxicity) committee consisting of cell therapy and picu physicians, neurologists, fellows, nursing leadership, advanced practice practitioners, pharmacists, registered nurses and social workers was created to monitor patient toxicity and establish specific clinical guidelines and diagnostic and treatments algorithms for pediatric patients receiving iec therapy. educational modules were developed as (i) live in-services and (ii) an online module with a competency based assessment. electronic medical record (emr) order sets and documentation and warning systems were also developed by the committee. the pediatric cartox committee developed a diagnostic and treatment algorithm for patients receiving iec therapy. emr orders and flowsheets were developed to support adherence to the algorithm. inter-disciplinary staff training and competency assessments were closely tracked. almost % of identified staff have completed training and achieved competency including, pediatric cell therapy staff, emergency center, picu, outpatient clinic/triage, neurology and sub-specialty staff and nocturnalists.conclusion: an inter-disciplinary approach can assist in institutional readiness for an iec program, promote quality assurance and perhaps fact iec accreditation. future directions include a program for ongoing staff competency assessments. predicted peak vo ) and abnormal oxygen uptake efficiency slope at the anaerobic threshold ( . ± . . , normal ± ). additionally, on echocardiogram three patients had evidence of diastolic dysfunction as evidenced by an elevated e/a ratio ( . ± . ) on tissue doppler. three patients demonstrated depressed longitudinal peak systolic strain (- . ± . ), indicating dysfunction not captured by ejection fraction. in this feasibility study, sct patients without evidence of lvsd on standard measures by resting echocardiogram can demonstrate abnormal exercise capacity. additionally, they can demonstrate systolic and diastolic dysfunction by measures not always included in standard echocardiography. these data suggest the need for a more thorough screening of survivors, and will be further validated as additional patients are recruited for this study. background: in hematopoietic transplantation, the t lymphocytes of the inoculum play a determining role in promoting hematopoiesis, transferring immunity to pathogens and acting as mediators of the graft-versus-leukemia effect (gvl). however, they are also responsible for graft-versus-host disease (gvhd), the main cause of post-transplant morbidity and mortality. the depletion of cd ra lymphocytes, by eliminating naive t lymphocytes from the inoculum, aims to conserve the gvl without producing gvhd.design/method: since april , patients ( boys and girls), with a median age of years, have undergone an allogeneic hematopoietic transplant from an hla donor identical with cd ra/cd depletion. the indication for transplant was: acute lymphoblastic leukemia ( ), acute myeloblastic leukemia ( ), myelodysplasia ( ) and medullary aplasia ( ). the donor was familiar in cases and unrelated in . the conditioning regimen was with fludarabine, busulfan and thiotepa. the median of cd + cells infused was . × / kg. on the day , + and + a programmed infusion of × / kg lymphocytes cd ra-was performed.results: all the patients grafted with a median leukocyte (> . × / l) and platelet (> × / l) engraftment time of and days, respectively. only one patient has developed acute gvhd grade i and no patient has developed chronic gvhd. immune reconstitution was early and rapid in all t cell subsets no patient has relapsed so far and only patient with myelodysplasia has developed an aml. she has received a nd transplant and has died of relapse. there was no case of toxic mortality. the event-free survival (sle) was ± % with a median follow-up of months. at present, patients are alive, out of immunosuppressive treatment and doing well. allogeneic transplantation with cd lymphocytes ra depletion resulted on very encouraging results, with a very low incidence of acute and chronic gvhd, but preserving the gvl effect by infusing cd ra-donor lymphocytes. miami children's health system, miami, florida, united states background: hematopoietic stem cell transplantation (hsct) using autologous or allogeneic progenitor cells is a potentially curative treatment for patients with high-risk malignancies and nonmalignant conditions. the american society for blood and marrow transplantation developed a task force to establish consensus guidelines for defining patient care in hsct and advocated for further studies to delineate safe procedural steps as an increasing amount of hsct are being offered to patients. there is limited evidence to support engraftment in recipients who receive their infusions via iv or syringe pump. we present novel data from patients who achieved neutrophil engraftment following hsct by a pump mechanism.objectives: to provide evidence supporting the use of pump (intravenous or syringe) infusion method in hematopoietic stem cell transplantations.design/method: a retrospective review was completed for patients who underwent hsct between and . inclusion criteria included patients who had received hematopoietic stem cell transplants between and and who were ages months to years old. the main outcome measure was days to neutrophil engraftment (defined as the first of three consecutive days with an anc > × /l).results: among patients who received infusion of hematopoietic stem cell products via pump mechanism, patients ( . %) received autologous products and ( . %) received stem cells from allogeneic donors. neutrophil engraftment (anc > × /l) occurred in a median of . days after stem cell infusion. the mean number of days to engraftment for patients who received allogeneic infusions s of s design/method: a retrospective chart review was performed at the children's hospital of wisconsin. statistical analyses included kaplan-meier estimate for os, mann-whitney test for comparing outcomes between subjects, and descriptive analyses.results: from - , patients with a median age of . ( . - . ) years at st hct were identified. patients were conditioned with cy/atg (n = ), cy/flu/atg (n = ), or cy/flu/atg/tbi (n = ) and received marrow (n = ) or cord blood (n = ) with median cd /kg dose of . ( . - . ) × . two patients developed grade i acute graftversus-host disease (gvhd); none developed chronic gvhd. due to dropping chimerism, graft rejection, or graft failure, nd hct (n = ) or boost (n = ) was offered. the median cd chimerism prior to hct/boost was ( - )%. median time between st hct and nd hct or boost was days ( days- . years). in patients receiving nd hct, used the same donor, of which used the same stem cell source (marrow) and switched to peripheral blood stem cells (pbsc). in patients who switched donors, used pbsc and used cord blood. most patients receiving nd hct underwent a uniform conditioning regimen of cy /flu /equine atg/ gy tli (n = ) or cy /flu /rabbit atg/ gy tbi (n = ); one received cy/atg. acute and chronic gvhd (limited seen in %) developed in % and % of patients, respectively. four patients required additional boosts and additional hct. after final intervention, cd and whole-blood chimerism at last follow-up was between - % (n = ) and - % (n = ), respectively. with a median follow-up of . ( . - . ) years, of patients are alive with an estimated -year os of . ± . %, having performance status ≥ % (n = ) or % (n = ). one patient developed chronic extensive gvhd and died of fungal infection . years after nd hct. our single-center experience demonstrates excellent ability to salvage patients who develop graft failure after initial hct. transplant-related complications such as gvhd and infections remain significant concerns. key: cord- -yknwveyz authors: nan title: abstracts_poster presentations date: - - journal: eur j nucl med mol imaging doi: . /s - - - sha: doc_id: cord_uid: yknwveyz nan t am and t / rv increasing. and vice versa in patients with t vm and t / rv decreasing residual pulmonary hypertension was diagnosed. it may be explained on the one hand by residual imbalance in vascular tonus regulation, on the other hand by morphological changing in vascular wall. in inoperable patients (because of high risk of postoperative acute right ventricle failure) t am and t / rv decreasing predominated. in inoperable patients and in children with residual pulmonary hypertension we discovered mottled lung perfusion pattern that pointed either to local or diffuse circulatory disturbances. the expression of these symptoms was directly proportional to pulmonary artery pressure. conclusion. the performing of perfusion lung scintigraphy and first pass radionuclide angiography with vasodilatators allows estimating right ventricle function and pulmonary microcirculation. it may be used for predicting of postoperative right ventricle function and pulmonary artery pressure normalization. one of the main goals of whole body scintigraphy with radioactive iodine, performed after total thyroidectomy for differentiated thyroid carcinoma of follicular origin (dtcfo), is to quantify the residual tissue left, thus identifying the patients who need to be reoperated. to avoid the stunning effect, one may administer a low activity of i (e.g., , mbq) or use other radiopharmaceuticals, in particular the i. aim to compare scintigraphic imaging and cervical uptake of i and mtc in patients submitted to total thyroidectomy for dtcfo, in order to evaluate the suitability of mtc for the identification of patients whose volume of residual thyroid tissue constitutes an indication for a second surgical intervention. materials and methods prospective study from / / to / / in patients submitted to total thyroidectomy for dtcfo: female and male, aged - years (mean , ± , years). after withdrawal of levothyroxine, we obtained scintigraphic images and determined the cervical uptake of i hours after oral administration of mbq ( μci) of the radionuclide. then, we proceeded to the i.v. administration of mbq ( mci) of mtc, and, minutes later, acquired scintigraphic images and calculated the cervical uptake of the radionuclide. we used a siemens e-cam dcr dual head gamma camera, with medium-energy and low-energy high-resolution collimators for i and mtc respectively. images of the activities to be administered as well as of the patient`s cervical region in anterior projection were acquired at cm from the detector. results all of the patients presented cervical uptake of i ranging from , to , %, mean , ± , . in patients, who presented a very low or absent cervical uptake of mtc , a median i uptake of , % ( , - , %) was found. in patients the cervical uptake of both radionuclides had a median value of , ± , for i and , ± , for mtc, with an high correlation (r = , ). all the patients with a cervical uptake of i exceeding % presented a mtc cervical uptake above %. conclusions a high correlation was found between the cervical uptake of mtc and i in patients submitted to total thyroidectomy for dtcfo. cervical scintigraphy with mtc was shown to be useful in the identification of patients requiring repeat surgery for voluminous residual thyroid tissue. imaging a breast cancer with tc m mdp scintigraphy s. i. mihajlovska, , n. kosturski, ; clinical hospital, bitola, the former yugoslav republic of macedonia. the aim of the study was to assess the value of tc m mdp scintimammography in the detection of breast carcinoma. fifty six patients ( - years, mean ) were included into the study. there were patients with diagnosed malignant lesions, patients with mastectomy and normal patients. all women were injected with - mbq of tc m mdp and double phase ( min. and h.) breast imaging was made. whole body scans and lateral views of both breast were obtained in prone position with elevated arms. focal accumulation of mdp uptake in tumor localization was considered positive. results: a clear uptake of tc m mdp was evident in of malignant lesions individuated (sensitivity . , specificity %). no false positive results were observed. out patients presenting lymph node metastases (sensitivity . %). radioactivity accumulations were detected on contralateral nonoperated gland in two of patients who had masteclomy . for detection malignancy mammography, ultrasonography and biopsy were performed but they were negative. definitive diagnosis were made base on the histopathologic results and showed malignant lesions. our study suggests that scintimammography with tc m mdp seems to be a highly sensitive and specific method in the differentiation of breast lesions. this method can be added to routine presurgical bone scintigraphy as a diagnostic tool. the aim of this study was to evaluate the results of early and late lymphoscintigraphy scan using medium sized particles of labeled human serum albumin (hsa) and to compare the results of preoperative imaging and intraoperative probe detector technique in localization and detection of slns in melanoma patients. material and methods: study enrolled patients ( male and female, mean age ± yr) with malignant skin melanoma. the localizations of the skin lesion were as follows: trunk , upper extremities , limbs and head . the patients were given a total of . ml ( - mbq) mtc-hsa with the particle size of - nm (sentiscint-mediradopharma, hungary) in four to six small portions, intradermally, around the melanoma or on both sides of the scar after the making diagnostic excision. dynamic lymphoscintigraphy was performed immediately after the tracer was injected, followed by early and late ( - h) static scintigraphy. at the time of the surgery, blue dye was injected around the tumor at two to four sites, minutes before surgery. during the surgery, a gamma probe (europrobe, france) was used to localize sentinel lymph nodes. results: a total of slns were detected in lymphatic basins in patients on dynamic, early static and late lymphoscintigraphy. ten patients were found to have sln, in patients slns were detected, while in one patient slns were detected in one lyphatic basin. no additional sln was detected on late static scintigraphy h after labelinig, and all slns localized preoperatively were found during the operation by collimated gamma probe detector, even h after labeling. vital blue dye failed to color sln in patients, and slns in patient in whom slns were found by lymphoscintigraphy. seven out of patients had metastatic spreading in the lyphatic basins. the slns were positive in all patients with metastatic disease and were the only site of metastases in out of patients. conclusion: the results of our study suggest that the use of medium sized colloidal particles should be preferred in a melanoma patient because slns could be detected early after radiopharmaceutical application but with prolonged selective concentration in the sln, giving the surgeon enough time to make a surgery plan either for the same day or for the day after lymphoscintigraphy. the results demonstrated lymphatic mapping using lymphoscintigraphy as highly accurate method for staging melanoma patients. conclusion: in our study, there was a significant correlation between the pattern of brain glucose metabolism and regional myocardial mibg uptake. in particular, decreased cardiac mibg uptake in inferior wall tends to correlate with hypometabolism in subcortical nucleus. key words: mibg, heart, spect, fdg, brain, pet the treatment options for patients with follicular lymphoma have substantially improved recently, due to the development of radioinmunotherapy, which combines radiation and antibodies. the most important example is y-ibritumomab tiuxetan (zevalin®), which is specially indicated in relapsed and/or refractory follicular b-cell non-hodgkin lymphoma (nhl). aim: show our experience in the use of zevalin® in those patients with follicular lymphoma, whose previous treatments have failed. material and methods: since april until february we have treated patients ( women and men) with ages between and years old. all patients had to follow these criteria: follicular lymphoma, previous treatment with rituximab, platelet counts x /l and bone marrow involvement %. the administered dose was . mbq/kg if platelet counts x /l, and of . mbq/kg if x /l. days post-treatment, the weekly clinical and analitical survey was done, until haematological recovery was confirmed. the evaluation of the therapeutic response was done after three months. results: from the patients studied, died ( . %), because of the progression of the disease, the other due to heart failure. had not yet been evaluated ( . %) and from the remaining , had a complete response ( . %), had a partial response ( . %) and had a stabilized status ( . %). toxicities were primarily haematologic and reversible, with non extrahaematologic toxicity observed. conclusions: based on our experience, the treatment of nhl with zevalin® is useful and secure, due to the minimal secondary effects. the use in early stages of the follicular lymphoma could improve the therapeutical results. aim: to evaluate the usefulness of mtc-ciprofloxacin scintigraphy (cp) in patients with hip or knee arthroplasty and suspect of infection. material and methods: fifteen patients ( women, men) with a mean age of ± years and clinical symptoms, haematological and/or mtc-hmpao leukocyte scan suggestive of prosthetic infection were included. cp was performed at h, h and h alter intravenous injection of mbq of mtc-ciprofloxacin. anterior and posterior views centred in the affected joint were performed in all patients. a conventional bone scan, mtc-hmpao leukocyte scan and mtc-colloid scan were performed in all cases. the final diagnostic of arthroplasty infection was established by positive microbiologic analysis, macroscopic evidence of purulent material, or after visualization of more than neutrophils in the periprosthetic tissue. results: diagnosis of arthroplasty infection was established in / cases (coagulase-negative staphylococcus ( ), aureus staphylococcus ( ), e. coli ( ) and polymicrobial agents in the remaining cases). cp was able to correctly diagnose all cases of infection. cp images at ' postinjection showed false positive cases, and at h false negative case was found. in one patient with knee prosthetic loosening without infection and intense inflammatory changes, cp was positive and then considered as a false positive case. on the other hand, mtc-hmpao leukocyte scan was non-diagnostic in / cases of infection.conclusions: cp is useful in the diagnosis of arthroplasty infection of the hip and knee. cp images obtained at h alter injection are recommended. presence of synovitis may cause false positive images with cp in knee prostheses. surgical removal of pgs is a difficult procedure especially when their localization is deeper than expected. the aim of the study was to evaluate the number of deeply situated pgs in relation to their right or left positioning. materials and methods. in this retrospective study consecutive patients who had a positive scan ( with primary and with secondary hyperparathyroidism) were included. a double phase sestamibi technique followed by a pertechnetate scan was used. early right and left degree oblique images were routinely obtained in order to evaluate the depth of the pgs. findings were classified in to two groups based on the degree of change of the relative position of pgs and the thyroid gland (tg) in the oblique compared with the anterior image. group i included pgs where the relative position of the pg and tg in the anterior an oblique images remained the same or changed only slightly. those pgs were characterized as not deeply located. group ii included pgs that in oblique images the pg to tg distance was significantly increased and were characterized as deeply situated. the localization of the pgs was confirmed by the available surgical data. results a total of pgs were identified ( upper right, upper left, lower right and lower left). group i included / upper right, / upper left, / lower right and / lower left ( of the total pgs). group ii included / upper right, / upper left, / lower right and / lower left ( of the total pgs). upper left and lower right pgs were significantly more frequently located at a significant depth compared with the upper right and lower left sites (p< . and p< . respectively). conclusion these results indicate that upper left and especially lower right pgs are more frequently deeply located; information which is useful for the procedure of surgical removal, mainly when preoperative imaging has not been performed. in recent years, picture archiving and communication systems (pacs) and electronic transfer of radiological images using the dicom file standard has become more widely employed in diagnostic radiology. it seems to be likely that nuclear medicine will be integrated within such systems. on the other hand, many departments possess older equipment without digital output facilities. there is an increasing tendency to display and archive evaluated images ('save-screens', printouts) on non-dedicated, inexpensive systems using file formats capable of data compression. this was the reason for examining the value of the jpeg format in this pilot study. fifty scanned planar bitmap images of the most frequent scintigraphic examinations (thyroid, bone, myocardium, lungs, and kidneys) were compared with jpeg format at different data compressions by two blinded observers. the visualization of details, e.g. pathologic findings, is described for all these images as the visual appearance of the images and the storage capacity required. relevant loss of clinical information did not occur up to compression factors of . . a major decrease of subjective image quality was seen at compression factors > . . compared to bitmap files, the use of these factors reduced the storage capacity required by % at a (jpeg-related) compression factor of . , and % at a compression factor of . . compared to the gif format, a reduction by . - . could be achieved. use of the jpeg format can therefore be recommended to save costs of image transfer or archiving of standard planar scans for nuclear medical evaluation. the evaluation of genotoxic effect of gamma radiation in nuclear medicine workers to be used [ ] . material and methods: in a previous work we recorded the personal whole-body dose values received by the workers over a period covering the starting of a pet unit (october, ) and the subsequent years until march, [ ] . then, we reported a substantial increase ( %) of the whole-body dose received by the technologists which was then related to the initial increasing number of pet exams. following a clear evidence of this initial increase of whole-body dose to be related with the technologists contact with the patient during preparation to exam, a wholebody lead shielding, with a thickness higher than the tenth-value-layer (tvl) for kev photons, was implemented for protection during patient handling and exam preparation. all the dosimetric measurements considered in this work were executed by the same personal dosimeter provider (nrpb, uk) . results: after shielding started to be used by the technologists during pet patient handling, we observed a clear reduction of whole-body doses back to levels close to the ones observed before the pet implementation. conclusion: the increased dose received by the technologists before shielding implementation can now be even more clearly related with the time needed to handle the pet patient at the exam and with the higher exposition rate constant of f- when compared with other isotopes used in nuclear medicine (namely tc- m). in conclusion, we can say that whole-body shielding is an affective way to reduce doses to the technologists during this stage of pet procedures. besides shielding during patient preparation image acquisition, a remote control similar to the ones existing in a common gamma-camera could be also useful in the reduction of the doses. [ ] j.a.m. santos et al. impact of fdg-pet in the occupational whole-body dose received by several professional groups in a nuclear medicine department, annual congress of the eanm, athens, (oral presentation, ) aim: the dose administered to the hands of nuclear technologists working with petnuclides is a problem of concern ever since the introduction of pet as a routine examination in nuclear medicine. the dose to the hands can be monitored using ring tld's. the aim of this study is to determine the accuracy and detection limits of extremity dosimetry using ring tld's. material and methods: two types of tld's with different thicknesses, , and , inch respectively, were used. the tld's were exposed to ionising radiation using a cs source. the tld's were exposed to various doses under several angles. the use of sets of tld's, each consisting of thick and thin tld, averaged out the effects of single tld's. to improve statistics each exposure was repeated times. a perspex rod with a diameter of mm was used to simulate a human finger. after each exposure the tld's were read out using a harshaw . uncertainty analysis was used to determine detection limits and uncertainty intervals for both types of tld's. results: analysis of the measured data shows that within the uncertainty intervals the measured dose matches the exposed dose. no significant angle dependence is found. the relative error in the measured dose is larger at smaller doses. this effect occurres in both types of tld's. the effect was more pronounced in the thin tld, yielding a higher detection limit for the thin tld then for the thick tld. the detection limits for the thin and thick tld are μ sv and μ sv respectively. the main contribution to the uncertainty at low doses is the effect that manipulating a tld induces an artificial dose during tld read out. this effect probably scales with the volume/surface ratio of the tld and the amount of manipulation, needed to get the tld out of the ring, into the tld reader. conclusion: due to its high detection limit, is the thin tld, in contrast with the thick tld, not suitable to be used for extremity dose monitoring in nuclear medicine. the detection limit of both tld's can be improved by reducing the amount of manipulation, needed to put the tld in the tld reader, and to improve the protection against mechanical impacts. both can be achieved by improving the construction of the ring. new experiments are conducted using an improved design of the ring. aim: despite international recommendations about the use of the si units system [ ] determined in by the cipm (comité international des poids et mesures), non-si units in radiation physics and other fields of science are still in use today and included in scientific publications. some of these, such as the roentgen (r), rad, rem and curie (ci) are called traditional units and still temporarily acceptable by the si system although its use has been discouraged and a cessation has already been proposed for the year by the cirrpc. in nuclear medicine, these units have also been thoroughly used through the years. nevertheless, si units are slowly taking their place in the current clinical nuclear medicine practice and there is a general tendency for homogeneity towards its universal acceptance. however special care should be taken in this process. discussion: although the rad, rem and roentgen have already been almost universally replaced by their si units, the curie is still widely used in parallel with the bequerel (bq). the consequences, although minimal, can not be disregarded. activity values tend still to be written as integer multiples of the milicurie (ex. mci, mci) in most of the nuclear medicine literature, even if a conversion is provided, resulting in awkward values of activity expressed in si units, altering the number of precision digits, as seen in the above example, and leading to erroneous appreciation of measurement errors. for example when writing " mci", it is implicit an error of . mci ( %) while writing " . mci", an error of . mci ( . %) is assumed. on the other hand, when writing " mbq" instead of " mci", we assume an error of . mbq, i.e. . % (which is much less than the actual precision of a clinical purpose activimeter). conclusion: supplementary effort, besides simple conversion of traditional units into si should be pursued. significant digits number and the errors associated with them should be considered. the calculation of other important nuclear medicine physical quantities, such as the suv in pet or activity per body mass, should also be written and thinked primarily in si and optionally converted to traditional units and not vice-versa (ex. . gbq/kg - mci/kg; mbq/kg - . mci/kg). [ ecnc, in guidelines for radionuclide imaging of cardiac function will be published by the same institutions. methods and results: authors from several different european countries are collaborating and have written a draft of the new guidelines including the following sections: ) radiopharmaceuticals and dosimetry, ) acquisition of radionuclide ventriculography (first pass and planar and tomographic equilibrium ventriculography) as well as gated perfusion imaging, ) right ventricular ef, ) left ventricular (lv) ef, ) lv volumes, ) lv diastolic function, ) lv regional function, ) physics and software, ) reference values, and ) clinical indications. discussion and conclusion: the paramount principle is to write evidencebased guidelines, referring to original, peer-reviewed papers from international journals. however, such evidence is not always available. in lack of evidence for the best choice of performance of a procedure or indication, we emphasize the lack of evidence by expressions like "there is general consensus" or "most centres use" etc. the guidelines will be published in the ejnm with direct links from eanm, ecnc, and esc, and they will be regularly updated. influence of radiation source geometry on determination of in and y activity of radiofarmaceuticals p. kolenc peitl, p. tomše, a. so an, m. krošelj, t. gmeiner stopar; university medical centre ljubljana, ljubljana, slovenia. aim: measuring of the radioactivity of radiopharmaceuticals before injection to patient is essential in nuclear medicine. measurements are performed by use of a dosecalibrator. to assure accurate readings quality control checks are performed and proper calibration factors used. calibration factors are not only dependent on the type of the radionuclide but also on a number of other factors, including nature of the container and volume of the solution in it. the aim of our study was therefore estimation of the impact of these factors on radioactivity readings for y and in in four different dose-calibrators before implementing radiotherapy with y based radiopharmaceutical into routine use. material and methods: ycl and incl solutions were gravimetrically dispensed in seven different containers ( , and ml vials and , , and ml syringes). in each container several dilutions of the parent solutions were performed. mass, activity and time for each source geometry were recorded for all dose-calibrators (two vdc- , capintec and ptw). measurements were background, time and mass corrected. aliquotes of both parent solutions were calibrated in national metrology laboratory, vienna, austria (bev). from our measurements and results from bev correction factors (cf) and volume correction curves were determined. results: in: accurate results with ± % precision for all source geometries in all vials were obtained using manufacturersupplied cf in both vdc- and capintec calibrators. for ptw the uniform cf ( , ) was determined for all geometries in all types of vials. the uniform cf for each type of syringe was determined in each dose-calibrator: readings have to be reduced for up to % for vdc- and up to % for capintec and ptw, depending on syringe. y: the uniform cf for each type of syringe was determined in each dosecalibrator: readings have to be reduced for up to % for vdc- , % for ptw and % for capintec. in the vials the volume correction curves have to be used to increase readings for up to % in % in capintec and to reduce readings to % in ptw. conclusion: our results show that manufacturer-supplied cf without ckecking the influence of radiation source geometry cannot be blindly trusted. ignoring this fact measurements can lead to errors reaching % in preparation and dispensing of in and y radiopharmaceuticals. aim: bone grafting is essential modality for reconstruction of congenital and acquired bone defects. our aim was to determine the viability of bone grafts by three phase bone scintigraphy with histopathological confirmation. method: two different grafting methods in new zealand rabbits were evaluated; autogenous bone grafting and demineralisation bone matrix (dbm) method, which has been developed to improve incorporation and formation of new bones. one centimeter square sized bone defects were made on the parietal bones of rabbits. the acquired bone defects on the left side were replaced by grafting the healthy parietal region from the right and the bone defects on the right side were replaced by using dbm grafts. at the second week; as early stage and in the sixth and twelfth weeks as late stages of the graft operation, dynamic three phase bone scans were performed. the rabbits had intravenous bolus injection of mci ( mbq) tc- m hdp under anesthesia and the images were acquired with a pinhole collimator. early and late stages of bilateral parietal regions were visually and quantitatively assessed with equal pixel region of interests (roi). visual assessments were scored from to (zero as no uptake, as mild, as moderate and as highest uptake). results: osteoblastic radioactivity uptake ratios were evaluated from to in all grafts and histopathologically those grafts were viable. perfusion and blood pool images were similar in both bone grafts in all rabbits at all stages. in the quantitative assessment right parietal to occipital roi and left parietal to occipital ratios were as follows; at the second week dbm . ± , , autogenous bone graft , ± , (p= , ); at the sixth week dbm . ± , , autogenous bone graft , ± , (p= , ) and at the twelfth week dbm . ± , , autogenous bone graft , ± , ( p= , ) . in all phases of bone scintigraphy there was no visual or quantitative difference in statistically by between grafting methods statistically (p< . ). conclusion: the determination of graft viability by three phase bone scintigraphy in both dbm and autogenous bone graft method is an in-vivo, sufficient, useful and cost-effective imaging modality. p -monday, oct. , , : aim: it is widely accepted that myocardial perfusion spect should be acquired with ecg-gating. with this technique additional information about the pump function of the left ventricle is gained. the purpose of this study was to evaluate the relationship between left ventricular stress and rest ejection fraction (ef) in myocardial perfusion spect and to analyse possible influencing factors. material and methods: in this study consecutive patients from our outpatient clinic with a -day stress/rest protocol were enclosed. the patients consisted of women and men, with a mean age ± s.d. of . ± . years. in patients a coronary heart illness was known. the stress was induced ergometric by bicycling in all patients. the spect acquisition was carried out min after i.v-injection of tc- m-mibi (stress-study) or after min (rest-study) with a double headed gamma camera e.cam (siemens). the reconstructed slices of the short heart axis were used for fully automatic determination of the left ventricular ejection fraction and assessment of semiquantitative segmental pathology scores through the software dm-spect (university of michigan). results: the matched ef-values of the stress and rest study showed a small, but significant difference in the paired t-test (p = . ). the average value for the stress ef ( . %) lay about . percent points below the value of the rest ef ( . %). in a regression analysis the decrease of the ef ( ef) between the stress and the rest study showed no dependency with age (p = . ), the summed stress pathology score (sss) (p = . ) or the summed rest pathology score (srs) (p = . ). however a significant increasing of the ef was found with the summed pathology difference scores (sds) (p = . ) and a growing rest ef (p = . ). conclusion: the stress ef was found to be significant lower then the rest ef. this indicates a stress induced injury of the heart still influencing the ef at the post stress acquisition time of the spect. higher ef values correlated positively with stress-induced ischemia, according to the sds score. in contrast a perfusion abnormality alone in rest (high srs score) or stress (high sss value) had no significant influence to the ef. the additional information gained with gated myocardial perfusion spect can contribute to the assessment of stress-induced stunning of the myocardial pump function. aim: in many institutions, the first line imaging modality for suspected pulmonary embolism is lung scintigraphy. the value of adding ventilation imaging and single photon emission computed tomography (spect) to the perfusion study is controversial. the prospective acute pulmonary embolism (ape ) trial is planned to include patients suspected of pulmonary embolism. the aim is to determine if ventilation imaging and spect, as an adjunct to planar perfusion imaging, improves the interpretation of lung scintigraphy. this is a report from an initial pilot study. consecutive patients clinically suspected of pulmonary embolism entered the study. within four hours we performed scintigraphic examinations and, if abnormal, pulmonary angiography which was considered the gold standard. readings were done by expert physicians blinded to clinical data and other imaging modalities except the chest x-ray. results: of the patients who entered the pilot study, two had normal scintigrams and in one case logistics failed. the results presented are from the remaining patients, of whom six had pulmonary embolism and eight did not. planar perfusion images correctly identified five patients with pulmonary embolism and five patients without, but failed to identify one patient with and three patients without pulmonary embolism. perfusion spect and combined perfusion and ventilation imaging (both planar and spect) correctly identified all patients with pulmonary embolism and four patients without, but failed to identify four patients without pulmonary embolism. in the table below, the corresponding sensitivities and specificities are presented. conclusion: the ape pilot study showed no clear benefit from either ventilation imaging or spect, suggesting that planar perfusion imaging alone may be sufficient in suspected pulmonary embolism. however, the number of patients in the pilot study was small and definitive conclusions cannot be drawn until the results from the ape trial become available. the aim of the study was to compare myocardial blood flow (mbf) and coronary flow reserve (cfr) measured by positron emission tomography (pet) and the severity of coronary artery stenosis on coronary angiography. methods: we studied patients with angiographically proven coronary heart disease (chd) with dynamic [ n]ammonia pet imaging at rest and after dipyridamole. mbf was calculated by firstpass extraction method. the coronary flow reserve (cfr) was defined as the ratio between the stress and the rest mbf. results: mbf at rest did not differ between the patients with coronary atherosclerosis and the controls ( , ± , ml/min/ g vs , ± , ml/min/ g ns) with the exception of infarct-related regions where mbf at rest was significantly low ( , ± , ml/min/ g, p< , ). during hyperemia mbf significantly decreased in the regions supplied by diseased coronary vessels in the patients ( , ± , ml/min/ g. vs , ± , ml/min/ g., p< , ). it was revealed a significant correlation between mbf during hyperemia and coronary artery stenosis degree (r= - , ; p % stenosis showed an attenuated response to dipyridamole (cfr = , ± , ) . cfr was significantly low in regions supplied by arteries without significant stenoses in the patients vs the controls ( , ± , vs , ± , ; p< , ) due to an influence of coronary heart disease risk factors: myocardial hypertrophy, smoking, diabetes mellitus. conclusion: [ n]-ammonia pet imaging provides the valuable information about functional severity of coronary atherosclerosis. cfr impairment in regions without significant stenosis can be explained by an influence of coronary heart disease risk factors. silent ischemia elicited on resting post-nitrate gated-spect by a coronary steal mechanism is associated with short term outcomes in prior myocardial infarction g. carboni, t. castiello; univ. campus bio-medico, roma, italy. the value of post-nitrate cardiac gated spect (g-spect) in patients (pts) with prior myocardial (m) infarction (i) is still uncertain .thirty-six such pts ,mean age +- years , % males , were thus studied by g-spect , at rest , after sublingual administration of mg isosorbide dinitrate (n) and at controlled conditions ( baseline ) . methods: in all pts , g-spect , ( % with thallium , with % mibi ) , was carried out on a dual-head gamma camera and ejection fraction (ef), extent and reversibility (r) of abnormal defects (ads) were analyzed with cedars-qgs-cequal softwares. extent of ads after n administration was calculated as a percentage (%) of total lv pixels ( p ) and r as a % of the ads . the ads were considered significant when > than % p and concordant with regional hypokinesia on echocardiograpy . all pts were followed-up for cardiovascular events (ce) . results: overall pts , only showed partial r of ads . on a cox regression model (chi-square = , p < . ) , only r ( b = . , p < . ) was associated with the hazard of ce ( in pts cardiac death , in pts major ce ) but not with age, ef, cad , prior cabg or ptca , ( p = ns for all ) . results did not change when data were adjusted for risk factors. on kaplan-meier curves , pts with r showed also lower event-free survival probability versus those without r ( % versus % at a months follow-up ) , log-rank test: p < . , hazard ratio = . , % ci = . to . ) . conclusions: in % ( / ) of pts under study , resting post-n g-spect elicited partial r of ads ( residual m ischemia in prior mi ) in absence of any increase in m demand. a n-induced " coronary steal " from low flow coronary territories (infarct-related coronary artery) to non ischemic territories cannot be thus excluded . such a paradoxical effect occurs silently and may identify m instability , predict short-term outcomes and imply concern for n chronic therapy in prior mi . the aim of this study was to compare the results of ejection fraction (ef) values and volumetric data derived from gated myocardial perfusion spect( g-spect) using both qgs (siemens icon) and d-mspect( d) algorithms and to determine normal limits in patients with normal cardiac perfusion and function. methods: one hundred and sixty-six consecutive patients ( men, m, female, fm, ± years old) referred for the evaluation of suspected coronary heart disease ( chd) using g-spect were included in the study. inclusion criteria: having normal cardiac perfusion and function; exclusion criteria: previous chd, left bundle branch block, ischemia finding, q or qs pattern in ecg and severe arrhythmia at rest .modified bruce protocol was performed in stress test. ef%, end-diastolic (edv;ml) and end-systolic volumes (esv; ml) and stress/ rest left ventricular cavity dilatation index (cdi) were calculated. results: the mean values of overall ef, edv and esv in s and r were as follows. qgs: r-ef%= . . in volume comparison, although there was high correlation (r= . - ) between the methods , the mean differences were significantly different (p< . ). conclusion: ejection fraction limits in normal patients obtained in this study were in concordance with those of previously reported in the literature. ef values derived from d were significantly higher than those of qgs both in s and r g-spect and the methods do not prove to be interchangeable for ef calculation in normal patients. key words: left ventricular ejection fraction, gated perfusion spect, normal limits aim: generator-produced rubidium- ( rb) is of interest for centers lacking access to a cylotron. quantitation of myocardial blood flow (mbf) has been performed with rb using compartment-based models. however, reproducibility of such mbf quantitation with rb is not known precisely. material and methods: fourteen individuals (mean age ± y range - y; w, m; including volunteers and patients with angiographically proved cad) underwent dynamic pet imaging studies ( frames) at rest and during adenosine stress ( . mg/kg/min for min) after injection of mbq of rb (discovery ls, gems). after waiting period of min, the rest-adenosine stress sequence was repeated. mbf was determined using a -compartment model including a correction for flow-dependent extraction fraction of rb (pmod . analysis software, www.pmod.ch). myocardial flow reserve (mfr) was defined by the ratio of stress/rest mbf. for comparison, paired t-test and bland-altman plots were used. results: there was no difference in hemodynamic parameters between baseline and repeat measurements (rate-pressure product: . e ± . e vs. . e ± . e mmhg/min, p= . ). one volunteer refused to undergo adenosine stress because of side effects. there was no significant difference between baseline and repeat studies regarding mbf at rest ( . ± . vs. . ± . ml/min/ml, p= . ), during adenosine stress ( . ± . vs. . ± . ml/min/ml, p= . ) or in mfr ( . ± . vs. . ± . , p= . ). the correlations between baseline and repeat studies were also excellent (rest: r = . y= . ·x; adenosine: r = . y= . ·x; mfr: r = . y= . ·x) . finally, overall agreement was very good on bland-altman plots with out of measurement pairs ( %) being within reference range for difference, without any systematic difference (p= . ). conclusion: these results demonstrate an excellent reproducibility of myocardial blood flow measurements with rb at rest and under adenosine challenge. aim: diabetic patients develop coronary artery disease (cad) more frequently and have a higher incidence myocardial infarction (mi) .cad is also an important cause of mortality in patients with diabetes. its early detection is fundamental to improve medical treatment. the aim of this work is to describe single-photon emission computed tomography myocardial perfusion imaging (spect mpi) findings in patients with diabetes mellitus type (dmii) with atypical chest pain and analyze whether the presence of others risk factors are reliable predictors of positive scyntigraphy. materials & methods: authors interviewed all patients with dmii that underwent spect myocardial-perfusion with mtcmibi from december to march that had read and accepted informed consent. method of inducing stress was infusion of dipyridamole in . % cases and exercise loading in the others ( . %). ejection fraction (ef) was assessed by ecg-gated technique. patients that had reported previous heart infarction with or without revascularization intervention were excluded. results: authors interviewed diabetic patients who underwent spect mpi during this period. . % were women, ages ranging from to years old (mean value= . ). it was found perfusion abnormalities in patients ( . %); exams showed reversible defects and of them had irreversible lesion. % of the abnormal exams showed only one lesion; % showed two compromised walls and % showed walls affected. ejection fraction ranged from to % (median= ). concerning to risk factors, patients ( . %) affirmed being sedentary, patients ( %) were overweight, patients ( . %) were smokers, patients ( , %) had hyperlipidemia and patients ( , %) reported positive family history of cvd. authors also assessed whether the presence of risk factors would be correlated to a positive exam. no statistical correlation was individually significant: smoking (p= , ) and sedentatariness (p= , ) both analized with exact fisher' test; and overweight (p= , ), hyperlipidemia (p= , ), and positive family history (p= , ) , assessed with qui-square test. conclusion: frequency of perfusion abnormalities in diabetic patients with atypical chest pain was high ( . %).this data suggests that occult cad is common among asymptomatic and poorly symptomatic patients with diabetes. perfusions abnormalities in these patients by means of spect mpi could provide incremental information about silent cad. individualy, risk factors for cad had not statiscaly significant correlation with a positive spect mpi in this study, probably due to the small population surveyed. early primary percutaneous coronary intervention (pci) is a very effective technique in the treatment of the acute myocardial infarction (ami), since it allows the recanalization of the affected coronary vessel. objective: the aim of the study was to evaluate the extension of saved myocardium defined as the difference of perfusion score pre and post pci. patients and methods: patients with ami and st segment elevation were studied prospectively ( women, mean-age: . ± . years) . two gated-spect detections were acquired after mtc-mibi injection in all cases. the first injection before pci and the other after it ( . ± . days), following the habitual methodology. the initial acquisition was carried out at the exit of the catheterization lab in patients ( . ± . minutes) and after seven hours of stay in the coronary unit in patient. the quantitative automatic valuation of the segments was performed by the software qps (cedars). pre and post pci (sss, srs) score, the difference of the score (sds) and the percentage of extension (ss%, sr% and sd%) was evaluated. according to the coronary angiography the dilated arteries were left anterior descending arteries (lad) and right coronary arteries (rc). in patients the revascularization was angiographycally effective. results: in patients there was not significant difference between pre and post spect quantification ( not effective revascularization and with large ami). in the rest of patients salvaged myocardium is showed. sss shows the pre-dilatation deffect, srs shows the residual deffect (ami) and sds shows the saved myocardium. conclusions: the myocardial perfusion quantification by gated-spect allows a precise valuation of the saved myocardium by primary pci in the ami. side effects in patients undergoing myocardial perfusion imaging in one centre. medicine, aarhus university hospital, skejby, aarhus, denmark. aim: to analyse the frequency of side effects in stress myocardial perfusion imaging (mpi) related to gender, age, referral diagnosis and type of stress. material and methods: we included consecutive patients referred for mpi in the period june -december ( ½ years). bicycle stress was first choice ( %). patients who could not perform the test or were treated with betablockade were stressed with adenosine in combination with a minor work load when possible ( %) otherwiseand in case of left bundle branch block -adenosine was injected at rest ( %). dobutamine was used in patients with severe chronic obstructive lung disease or atrioventricular block ( %). results: the investigation included men and women aged to years (mean of years). the women were on average . years older. the patients suffered from ischemic heart disease (ihd) ( %) or were suspect to ihd ( %). side effects: only patients ( . %) had side effects. the most frequent side effects were: atrioventricular blockade ( . %), bronchospasme ( . %) and "other unspecified side effects" ( %). rare side effects were arrhythmias ( . %), ami/unstable angina ( . %) and syncope ( . %). no patients died. uncomplicated angina and well-known subjective symptoms to pharmacological stress and work load were not registered. patients stressed with bicycle had seldom side effects ( . %), whereas frequency was about % after adenosine and dobutamine stress but with differences in type of side effects. there was a higher prevalence of side effects in women ( vs. %), especially for ami /unstable angina ( %) and other unspecified side effects ( %). only syncope was more frequent among men ( %). the frequency of side effects increased with age from . % in the thirties to . % in the eighties. patients referred with known or suspected ihd had the same frequency of side effects. conclusion: during a ½ year period patients were examined with stress mpi. no one died and only . % had side effects apart from angina and wellknown subjective symptoms to pharmacological stress and work load. less than % had arrhythmias, ami /unstable angina or syncope. the prevalence was higher during pharmacologic stress than work load. the prevalence was more frequent in women and increased with age. cardiovascular disease is the leading cause of death among patients with type diabetes, myocardial ischemia being frequently silent. coronary artery disease detection is challenging in women due to a variety of factors. aim our purpose is twofold: to investigate the association of silent ischemia and diabetes in women; and determine the sensitivity of myocardial perfusion gated spect in these patients. material and methods poststress and resting gated spect was performed in women ( with type diabetes and nondiabetic) with suspected coronary artery disease. of the diabetic patients underwent coronary angiography within . months. mean age was . years. a -day stress/rest protocol was used with mtctetrofosmin and pharmacologic stress (adenosine: , dobutamine: ). perfusion analysis was semiquantitative based on a segment model determining the summed stress store (sss) and the summed difference score (sds). the sss< was defined as a normal scan, sss: to as moderate and sss> as severe ischemia, respectively. the sds < was considered no ischemia, sds: to moderate and sds> severe ischemia, respectively. poststress lvef was considered normal if > %. results p< . sds detected ischemia more frequently is diabetic versus nondiabetic patients. results of coronary angiography were positive with good vessel-territory correspondence in patients. two patients had false negative myocardial gated spect yielding a sensitivity of . %. clinical presentation, age ( vs . ), stress agent and risk factores (arterial hypertension, dyslipemia and smoking) were not different between nondiabetic and diabetic patients. there is no statistically significant difference between both groups in age variable. conclusion female patients with type diabetes present more severe ischemia than nondiabetic patients of similar conditions and clearly benefit from early coronary angiography. diabetes is considered a coronary artery disease (cad) risk equivalent with the evidence of an increased mortality rate in diabetic patients. cad is often silent and when it becomes clinically manifest it is in an advanced state. however, there is a wide variation in prevalence of cad in diabetes, possibly related to the presence of additional risk factors. aim of the study was to prospectively assess the usefulness of myocardial perfusion spect (mps) in asymptomatic diabetic patients and occult cad in comparison with traditional risk factors. methodology: among patients, pts with diabetes mellitus ( type i; type ii) and high likelihood of cad underwent rest-stress mps with mtc-tetrofosmin and a -segments scoring model was used for spect analysis. a summed stress score (sss) > indicated abnormal mps, sss - a mild, sss > - a moderate and sss > a severe perfusion defect. multiple risk factors and clinical predictors like duration of diabetes, presence of peripheral vascular disease, dyslipidemia, hypertension, active smoke, family history of cad or diabetes and body mass index, were analysed. results: according to the spect results, patients were classified in: group a ( pts with normal mps), and group b ( pts with reversible, pts with mixed, with fixed perfusion defects). moderate or large stress defects occurred in and pts, respectively. the analysis of the presence of cad risk factors or the association of two of these was not statistically significant (table ) . conclusion: mps is effecting in detect occult cad and silent myocardial infarction in asymptomatic patients with diabetes mellitus while the usual risk factor analysis or the association of or more of these, are inadequate to predict the presence of cad in this population. effects of cardiac resynchronization therapy: evaluation by first-pass radionuclide angiography and multiple gated equilibrium blood pool scintigraphy s. minin, v. chernov, e. makarova, g. savenkova, y. lishmanov; institute of cardiology, tomsk, russian federation. background: cardiac resynchronization therapy (crt) reduces symptoms and improves left ventricular function in many patients with heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony. but changes of pulmonary and central haemodynamics after crt are not clear. aim: to evaluate of chronic crt effect on pulmonary and central haemodynamics as well as on left ventricular ejection fraction (lvef) in patients with severe heart failure. material and methods: the study involved patients (m/f: / , mean age: + . years). we studied scheduled for implantation of a crt device based on conventional criteria (nyha class iii or iv, lvef < %, left bundle-branch block and qrs duration > ms). two patients had ischemic and patients had idiopathic dilated cardiomyopathy. first-pass radionuclide angiography (fpra) and multiple gated equilibrium blood pool scintigraphy (muga) were performed before and month after crt. results: our data show a significant clinical benefit of crt (nyha class change from . + . to . + . ; p= . ). we found significant increase in cardiac output from . ± . to . ± . ml/min (p= . ), stroke volume from . ± . to . ± . ml (p= . ), cardiac index from . ± . to . ± . ml/min/m (p= . ) and stroke index from . ± . to . ± . ml/m (p= . ). also increase in lvef from . ± . to . ± . % (p= . ) was shown. all patients after crt had improvement in pulmonary haemodynamics: the time of radionuclide bolus transit thought arterial section of lung (tam) and time of radionuclide bolus transit from right to left ventricles (tlung) decrease from . ± . to . ± . sec (p= . ) and from . ± . to . ± . sec (p= . ), respectively. conclusion: our results suggest that crt improved of pulmonary and central haemodynamics as well as of left ventricular contractility in patients with severe heart failure. fpra and muga are useful methods fore monitoring of crt effect. aim the aim of this study was to investigate whether early myocardial tetrofosmin imaging (t , min after injection) provided additional information in detecting coronary artery disease with respect to standard delayed scan (t , - min). one-hundred and twenty patients ( male, female, mean age +/- yrs, range - ) with anginal symptoms underwent single or two-day stress-rest tetrofosmin gated spect. in all conditions, t an t were obtained after stress and at rest with the same gamma cameras and using the same acquisition parameters. combines myocardial perfusion/function analysis was performed on a segment model using qps/qgs software (cedar sinai). coronary angiography was obtained within one month in all patients and stenosis > % at quantitative analysis was considered significant. results among clinical and nuclear variables, univariate predictors of coronary artery disease included: gender; previous myocardial infarction; previous ptca/cabg; t and t summed stress, rest and difference scores, t and t post-stress and rest wall motion scores; t and t post-stress and rest ef, t and t ef. multivariate logistic analysis of the most predictive and not correlated variables revealed previous myocardial infarction, t summed difference score and t ef as the most important predictors of significant coronary artery disease (p< . ). according to roc curves analysis, the optimal cut-off to identify coronary artery disease was for t summed difference score providing a global diagnostic accuracy of . (sensitivity: . ; specificity: . ). moreover, roc analysis showed that a reduction in t ef after stress > % was the optimal cut-off to identify patients with coronary artery disease (sensitivity: . ; specificity: . ; accuracy: . ). the combination of t summed difference score and t ef resulted in a significant increase in the global chi-square for prediction of significant coronary artery disease ( . vs . ; p< . ). conclusions our data suggested that early minutes tetrofosmin gated spect is superior to standard delayed - minutes imaging providing indexes of both perfusion and function highly predictive of coronary artery disease. serum levels of crp, creatine kinase (ck), creatine kinase mb fraction (ck-mb) and troponin i of patients with acs of high-risk, were measured on admission and every hours for hours. patients were evaluated with stress/rest mtc-tetrofosmin gspect before discharge or up to one month after acs. patients have been divided in group . acute st elevation myocardial infarction (stemi) without history of prior myocardial infarction (pmi) ( , %), . stemi and pmi ( , %), . non-st-elevation acute myocardial infarction (nstemi) without pmi ( , %), . nstemi and pmi ( , %), . unstable angina (ua) without pmi ( , %) . ua and pmi ( , %) . infarct size was measured by myocardial perfusion defects in spect ("bull eye"); lvefr by gated spect and the left ventricular dysfunction in stress was evaluated by the ratio of ventricular volume stress/rest > , or when the stress lvef was significantly lower than the lvef at rest (more than percent). results: the serum levels of crp on admission were similar in all groups. the pcpr, ck, ck-mb and troponin i levels were significantly related to infarct size determined by spect in all the groups, except in the patients with ua without pmi. the pcrp levels were significantly related to mn size (p = , ), with a tendency to more infarct zone in the patients with pmi. higher pcrp (> mg/l) were related to infarct zone > % of left ventricular myocardium (p= , ). pcrp levels were not related to myocardial ischemia in either groups (p= , ). the maximum cpr levels were found in patients with lower lvefr (p= , ). left ventricular dysfunction was not related to pcrp levels (p= , ). conclusion: the high levels of c reactive protein are related to extension of myocardial necrosis and low left ventricular ejection fraction at rest, determined by gated spect irrespective of clinical form of acute coronary syndrome, but they are not related with stress-induced systolic left ventricular dysfunction of ischemic origin. the aim of the study was to assess ( ) diagnostic accuracy of myocardial perfusion spect (mps) with low-dose ct attenuation correction (ac), and ( ) the risk of concomitant correction artifacts (ca). methods: ac has been clinically validated in patients with coronary artery disease (cad) verified by coronarography (group a). ca were studied in patients with normal mps finding (group b). in both groups, gated stress mps has been performed with mtc-tetrofosmin using hybrid dual-head gamma camera with low-dose ct (ge infinia-hawkeye). rest mps was performed only in the group a. for data processing, d-mspect programme was used. ac was applied using ct attenuation maps. in both groups of patients, perfusion defects were compared in emission scans with and without ac. quality of spect/ct registration was assessed visually. results: in the group a without ac, perfusion defects on inferior wall were found in of patients. with ac, / ( %) of these defects completely disappeared. in comparison with coronarography, specificity of findings in the territory of the right coronary artery (acd) increased by % from to %. in the group b without ac, no perfusion defect was found in any of patients. with ac, perfusion defects appeared in the anterior wall and in the apex in / ( %) patients. in these patients, apparent spect/ct misregistration was found. in / patients without perfusion defects on ac scans, spect/ct registration was good. conclusions: considering perfusion defects in the teritory of acd, ac improved specificity of mps. in this area, no correction artifacts were found in any patient. in the anterior wall and in the apex, high frequency of correction artifacts reduced the value of ac unless the reality of the perfusion defect was supported by registration of emission and transmission scans. in order to optimise the diagnostic accuracy of ac mps, simultaneous assessment of emission scans with and without ac and inspection of the fused spect/ct images remains necessary. background: wbr is an iterative method for resolution recovery. it is designed to simultaneously suppress noise and improve image resolution and is optimised for short gated cardiac perfusion acquisitions. we have demonstrated in previous studies that the wbr technology applied to cardiac perfusion scans doesn't influence functional and perfusion parameters. considering that transient ischaemic dilation (tid) is believed to be also an important parameter for cad severity, the aim of this study is to compare the tid indexes obtained from the two reconstruction spect methods (fbp/wbr). methods: patients (pts) were studied: women and men. mean age: ± years old. with past ami. after pharmacological stress test, pts went through a double stress spect acquisition. the first acquisition used views, s/view with detectors at º and images were reconstructed by fbp. the second acquisition used views, s/view, and images were treated by wbr. the studies were analysed and processed with cedars-sinai software. perfusion scores (sss and sds) and functional parameters (lvef, edv, esv, sms, sts) were obtained. tid index resulted from the ungated lv stress and rest volumes ratio (usv and urv). we considered abnormal values of tid index >= . .for statistical analysis, we used paired student t-test to compare fbp and wbr tid indexes. we also determined the correlation coefficient (cc) between tid and lvef, edv, esv, scores and ungated volumes) results: global paired t test for wbr and fbp tid indexes showed p< . . there were only / high tid for wbr and / for fbp. from these high tid, only one had a normal perfusion scan. the others had necrotic and ischaemic lesions. although pts had perfusion scans showing cad lesions, only ( %) showed a high tid index on fbp and ( %) on wbr. conclusions: this study showed that tid index determination isn't influenced by the reconstruction method (fbp/wbr). in neither techniques (fbp or wbr), did tid index show a good correlation to lvef, edv, esv, to the ungated volumes or to any score (sss, sds, sms, sts).the low incidence of significant tid in patients with known cad is also of concern. p scintigraphic and hemodynamic pattern of diabetic patients with and without cardiac autonomic neuropathy undergoing adenosine stress myocardial perfusion scintigraphy p. keinrath , f. gürel , r. weitgasser , c. pirich ; nuklearmedizin und endokrinologie, salzburg, austria, innere medizin i, salzburg, austria. myocardial perfusion scintigraphy (mps) is recommend for cardiac risk assessment in diabetic patients. in many countries, however, there is no agreement on diabetic patient selection for mps. recent studies have demonstrated an attenuated heart rate response in diabetics during dypirdamole mps (lee et al. j nucl. cardiol. ) representing a subgroup with presumably increased cardiac risk. methods: we aimed to investigate whether this effect could be also found in adenosine stress mps in diabetics with or without cardiac autonomic neuropathy (can). can was diagnosed by the vagus programme ( beat to beat variation, valsalva test, : ratio and orthostasis test). patients with a mean age of ± years with diabetes underwent adenosine stress mps ( pts without and pts with can). patients were asymptomatic or had episodes of atypical chest pain, but a negative physical exercise test. results: mean ejection fraction was ± % in can positive and % ± in group can negative subjects. mps was classified as abnormal in % ( patients) without can and in % ( patients) with np, respectively (n.s.) mean stress defect scores were ± in patients with can and ± in patients without can (n.s.) . baseline heart rate (can negative pts: ± , can positive pts ± ) and maximum heart rate (can negative pts: ± , can positive pts ± ) as well as absolute or relative heart rate increase were not different in can negative or positive diabetics, either. conclusion: in this study in diabetics hemodynamic to response adenosine was not different between patients with and without can. there was not difference in scintigraphic outcome between subjects with or without can, either. our data suggest that the presence or absence of can does not yield information on cardiac risk stratification comparable to the well validated information given by scintigraphic parameters, alone. purpose of study: a reverse redistribution (rr) pattern is described with technetium (tc- m) myocardial perfusion stress (mps) imaging. the aim of this study was to determine if there was an angiographic correlation of the finding of a rr pattern on tc- -m mps imaging. method: we reviewed consecutive tc- m tetrofosmin spect stress studies over a year period. patients ( . %) were found to have a rr pattern, of which patients had undergone coronary angiography within months. correlation was sought between rr pattern and location of angiographic stenoses, the effect of reversible perfusion defect (rd) or a fixed defect (fd) in addition to rr pattern on angiographic findings was also determined. results: of patients, rr pattern occurred anterior in , lateral in , inferior in with having rr in more than territory. of the patients who had angiography / ( %) had normal coronary angiograms, / had vessel disease (vd), / had vd and / had vd. of the studies patients had rr pattern involving more than one coronary territory. stenosis location correlated poorly with rr pattern (lad/anterior / , cx/lateral / , and rca/inferior / ). in cases, there was a rr pattern without rd or fd, of which cases had normal angiographic findings, had angiographic disease not correlating with the rr pattern and had angiographic disease correlating with the rr pattern. in cases, there was a rr pattern together with rd or fd but normal angiography. in the remaining cases ( %), there was angiographic disease with evidence of rr pattern with rd and/ or a fd as well but correlation with coronary territory was poor (as given above). conclusion: ( ) rr pattern alone should not be used to make a decision to proceed to angiography. ( ) rr pattern does not reliably correlate with the location of significant coronary artery stenosis ( ) rr pattern in addition to rd or fd does not influence angiographic findings. correlation of myocardial perfusion single photon emission computed tomography with coronary artery calcium score in coronary artery disease -an indian perspective. s. simon, i. muthukrishnan, p. nagwani, h. r. kulkarni; apollo hospitals, chennai, india. objectives: the consequences of atherosclerosis can be detected by coronary artery calcium score (cacs) and stress induced myocardial ischemia on myocardial perfusion single photon emission computed tomography (mps). we assessed the relationship between stress induced myocardial ischemia on mps and magnitude by slice computed tomography (ct) in patients undergoing both tests. methods: our study included patients with no earlier history of coronary artery disease (cad) of both sexes ( males , females ) in age group of - years. our patients were referred by cardiologists after they underwent cacs. of these patients ( %) presented with symptoms which included chest pain (non anginal, anginal, atypical) presence or absence of shortness of breath, and rest ( %) were asymptomatic. for each patient coronary risk factors were noted. all these patients underwent cacs and rest and stress mps one day protocol with tc m sestamibi within days. according to the cacs patients were divided into groups a ( - cacs ), group b ( and above cacs ), group c ( group a with symptoms), group d (group b with symptoms). results: myocardial perfusion study was positive for inducible ischemia in % in group a ( n= ), % in group b (n= ), % in group c ( n= ), % in group d (n= ). from these we observe that the incidence of ischemic mps is more with increasing cacs (p= . ), in patients with symptoms (p= . ) which are statistically significant. and also it is noted that more frequency of inducible ischemia in patients who presented with symptoms irrespective of cacs who are at short term risk. in negative mps cacs may be useful in long term risk stratification in finding out subclinical atherosclerosis. conclusion: the general perception is that the cacs is a good tool for long term risk stratification but it may be applicable to those patients with no significant risk factors. when there are risk factors mps is a better indicator for risk stratification for cad irrespective of cacs. further studies incorporating prognostic follow up is required. objective: peripheral arterial disease (pad) is frequently associated with significant coronary artery disease (cad) and cardiovascular morbidity/mortality. however, there is a paucity of studies disclosing the prevalence of cad by stress tc m sestamibi myocardial perfusion imaging tomography (spect) and the effects of atherogenic risk factors (arf) on abnormal myocardial perfusion. we thus investigated the prevalence of silent cad and the impact of other arf in hypertensive (ht) patients (pts) with pad vs those without pad and no known cad. material and methods: we investigated treated ht pts without known cad; men, women aged . ± . years. all pts underwent stress and rest dipyridamole stress spect imaging that were analysed blindly by experienced observers. other arf were also evaluated. it is important to note that, of these pts, or . % had type diabetes mellitus. results: we found that pad was present in pts or . % of our studied population. moreover, overall silent myocardial ischemia was observed by spect in ( . %) of the ht pts. of note, the frequency of silent cad increased from . % to . % in pts with pad (p= . ;rr: . ). analysis of arf indicated that pts with pad were more closely associated with male gender (p< . ), hypercholesterolemia (p= . ) and smoking (p< . ) as compared with pts without pad. most importantly, silent cad was further increased in ht pts with pad affected by type diabetes mellitus (dm) (p< . ;rr: . ). indeed, the prevalence of silent cad increased from . % in ht pts to . % in ht pts with dm plus pad. conclusion: in this large scale population of high risk treated ht pts, the prevalence of silent myocardial ischemia is significantly greater in ht pts with pad. furthermore, the prevalence of silent cad increased significantly in dm pts. these findings should be clinically relevant in order to select ht pts who are the most suitable candidates for silent cad who require intensive medical or surgical intervention. objectives: coronary artery disease (cad) is a major complication of type diabetes mellitus. because cad is often asymptomatic and the disease can be controlled through screening programs, myocardial perfusion scintigraphy may be the best practical way to accomplish this on a larger scale. the aim of our study was to screen the silent coronary artery disease in type diabetic patients by perfusion myocardial scintigraphy. we also analyzed the risk factors that might be related to cad in type diabetes mellitus (t dm) patients with no classical cardiac ischemic symptoms. methods: gated single-photon emission computed tomography was performed using a same day stress/rest protocol with tc- m sestamibi. we screened a total of patients: diabetic patients without evidence of cad and diabetic patients with evidence of cad . gender, patients' age, known diabetes duration, smoking status, hba c, the presence of who-metabolic syndrome defined hypertension and level of cholesterol and triglycerides were examined in order to access relationship to cad in diabetic patients. results: a semi-quantitative visual interpretation was made using short axis, horizontal, and vertical long axis myocardial tomograms and a five grade ( - ) scoring system in -segmental model. a study was judged abnormal if the sum of stress scores (sss) was . two groups of patients were compared: group a ( patients) without clinical evidence of cardiac disease and group b ( patients) with clinical evidence of cardiac disease. compared with group b patients (we excluded patients with combination of reversible and fixed defects), group a patients tended to have fewer perfusion reversible changes by visual analysis (t- , , p< , ), as well as by sss test (p= . ). correlation coefficient has been sign among visual analysis and sum stress scores (c = . ) . thirty-eight asymptomatic patients with normal resting ecg (group a) were examined by stress/rest myocardial perfusion scinigraphy with tc- m sestamibi. fifteen patients ( %) considered to have positive test or significant myocardial ischemia. twenty-three showed no significant ischemic lesion (p < . ). diabetes duration of . years was associated with silent cad (ci: . ; . ), tryglicerides and hba c were significantly associated with asymptomatic cad as well. (p< . and p< . ). conclusions: a considerable proportion of t dm patients have silent cad ( %). the patients with diabetes duration seven years and more should be screened routinely for the presence of cad as well as the patients with high level of hba c. m. l. de rimini , m. catalano , s. comenale pinto , r. ancona , p. caso , r. merenda , a. scalzone , p. muto ; nuclear medicine aorn monaldi, naples, italy, non invasive cardiology, aorn monaldi, naples, italy. diastolic function (df) abnormalities can be an early sign of cardiomyopathy in diabetic (dm) patients (pts) with no coronary artery disease (cad) or systolic (sy) left ventricular (lv) dysfunction. echocardiography (echo) with doppler measurements of transmitral and transtricuspidal flow and myocardial (m) tissue doppler (dti), strain (s) and strain rate (sr) can evaluate df. aim: to evaluate early d dysfunction in dm pts without documented cad. methods: we studied male pts: non-dm and dm, mean age: ± . selection criteria were: no history of cad or hypertension and normal perfusion at stress/rest (str/r) m-gspect (sss/sds ). qgs quantified lv sy (ef; rwm; rwt) and d (pfr/edvs; ttpf) f. echo system seven ge, equipped with tvi function, calculated lv/rv sy and df, pulmonary artery wedge pressure (pcwp), by e/ea and left and right atrial (la/ra) peak sy tissue s and sr in and chambers view, at the level of the apical segment of the septal, lateral, anterior and inferior la walls, and ra free wall. pulsed doppler and dti studied early (e) and late (a) d wave velocity, ratio e/a, deceleration time (dect); l-r isovolumic relaxation time (ivrt) and pulsed doppler of pulmonary vein flow. results: at echo: significantly higher prevalence of abnormal d mitral (ratio e/a= , vs , ) and tricuspidal (ratio e/a= , vs , ) flow patterns and a longer mitral valve dect ( versus msec) was observed in dm vs non-dm pts. although no differences were found in la/ra diameters and volumes, the m atrial s and sr were found to be significantly (p= , ) lower for atrial septum, ra free wall and la anterior wall in dm pts in respect of controls. no differences were found in dm and non-dm pts for sy function: ef= % vs %, ivrt ( vs msec), propagation velocity of transmitral flow during early ventricular filling (vp= , vs , cm/sec) and pcwp ( , vs , mmhg) . similarly at gspect: str/r pfr/edvs mean value = . / . in dm and . / . in non-dm pts (p= , ); rest tpfr was longer in dm pts ( ± ms) than in non-dm pts ( ± ms), with preserved sy function (lvef= ± % / ± %) in all pts. conclusions: gspect can assess str/r df; impaired pfr/edvs, tpfr, la/ra s and sr in dm pts with no hypertension or cad and preserved lv-sy function can suggest an earlier functional effect of a specific dm cardiomyopathy independently of cad. würzburg, würzburg, germany, st. antonius ziekenhuis, nieuwegein, the netherlands, objectives: for quantitative comparison of myocardial perfusion spect scans (mps), the -segment model conventionally used for clinical analysis has an undesirably low resolution, resulting in numerical obfuscation of extreme differences in small areas. the objective of this study was to establish a segment model that allows for detailed quantitative comparisons of mps and compare this to the segment model. methods: a -segment model was defined by quartering each segment of the -segment model. both models were applied to tl- and tc- m repeated phantom mps, repeated tl- and repeated tc- m-sestamibi patient mps from an ethical board-approved study. mean segmental counts-per-pixel values for the -and -segment model were calculated based on data-points extracted from mps using the munichheart software. for each segment the difference between repeated scans was calculated. spiral profiles for the difference per segment between scans were then generated. results: tl- : the overall variation between repeated phantom mps was . % ( % ci: - . to . %) for the segment model. for the -segment model this was . % ( % ci: . to . %). for patient scans overall variation was - . % ( % ci: - . to - . %) for the -segment model and - . % ( % ci: - . to - . %) for the -segment model. tc- m: the overall variation between repeated phantom mps was . % ( % ci: - . to . %) for the segment model. for the -segment model this was . % ( % ci: - . to . %). for patient scans overall variation was - . % ( % ci: - . to . %) for the segment model and - . % ( % ci: - . to - . %). spiral profiles: comparing the spiral profiles for the -and -segment model showed that the -segment model showed higher extreme deviations than the -segment model. regions of variability could be identified in more detail than in the segment model. conclusion: the -segment model allows for more detailed analysis of differences than the -segment model when comparing mps quantitatively. research support: supported financially by tyco healthcare. würzburg, würzburg, germany, st. antonius ziekenhuis, nieuwegein, the netherlands, utrecht university, utrecht, the netherlands, tyco healthcare b.v., petten, the netherlands, umc utrecht, utrecht, the netherlands. objectives: simultaneous acquisition of a tl- rest myocardial perfusion spect (mps) and a tc- m-sestamibi labelled stress mps is a much sought-after procedure in nuclear cardiology. before this procedure can be applied clinically, tl- rest-mps before and after an exercise test need to be compared for equality. for interpretation of this comparison, the normal variation between two repeated mps needs to be known. the objective of this study was establishing a normal range for the variation between repeated rest tl- and repeated stress tc- m-sestamibi mps. methods: ethical board approval was obtained. in patients repeated tl- rest-mps and in patients repeated post-stress tc- m-sestamibi mps was performed. also repeated anthropomorphic thorax phantom mps were obtained for both isotopes. quantitative analysis of mean counts-per-pixel for each segment in a segment model was done using the munichheart program. subsequently, statistical methods were used to calculate a normal range of variation. visual analysis was performed by independent observers scoring each of the repeated segments for each patient on a scale of - . results: tl- : the overall variation between repeated phantom mps was . % ( % confidence interval (ci): - . to . %). for patient scans this was - . % ( % ci: - . to - . ). observer scored . % of segments differently between repeated scans; observer did so in . % of segments. the observers disagreed in . % of segments. the differences were not clinically significant. tc- m: the overall variation between repeated phantom mps was . % ( % ci: - . to . %). for patient scans this was - . % ( % ci: - . to . %). observer scored . % of segments differently between repeated scans; observer did so in . % of segments. the observers disagreed in . % of segments. the differences were not clinically significant. overall: the mean difference per segment for repeated phantom spect scans did not differ significantly between the tl- and tc- m tests (paired t-test, p= . ) , and were significantly correlated (pearsons' r = . , p = . ). the mean difference per segment for repeated patient spect scans differed significantly between the tl- and tc- m patients (paired t-test, p= . ) conclusion: on average, tl- and tc- m-sestamibi mps show only minor variation when repeated; a normal range of variation between scans was calculated. the difference between tl- phantom-and patient-mps indicates a biological source of variation in patients. research support: supported financially by tyco healthcare aim: to study the prevalence of ischemic heart disease (ihd) in patients with diabetes mellitus who are asymptomatic for ihd with myocardial perfusion study (mps) . materials and methods: this retrospective study included patients known for diabetes mellitus of more than years duration of both sexes with or without additional risk factors for ihd but without any clinical evidence of ihd. patients were selected from the group referred by the cardiologists for myocardial perfusion single photon emission computed tomography (spect). patients with known ihd were not included in this study. age matched asymptomatic non-diabetics [n = ] without risk factors for ihd were evaluated with myocardial perfusion spect as controls. these patients were subjected to a rest and stress technitium- m sestamibi myocardial perfusion spect. the images were interpreted as fixed perfusion defects, inducible ischemia or both. twenty-two patients with inducible ischemia underwent coronary angiography. these results were correlated with glycosylated hemoglobin {hba c}; duration of diabetes; and presence of additional risk factors for ihd -hypertension [bp> / ], hyperlipidemia [total cholesterol > mg/dl, ldl > mg/dl, hdl < mg/dl], obesity [body mass index > kg/ sq. m], smoking, and a family history of premature ihd. results: significant perfusion abnormalities were found in out of the patients [ %] and out of the [ %] controls. hence cad was [relative ratio] times more prevalent in diabetics than in controls. in patients, the extent of myocardial ischemia or perfusion defects increased with duration of diabetes and with poor glycemic control [elevated hba c] statistically significant with [p = . ]. nine out of patients [ %] who underwent angiography had significant perfusion abnormalities in mps but without significant coronary stenoses [< %]. the correlation of mps with coronary angiogram showed a sensitivity and specificity of % and % respectively. conclusion: due to autonomic dysfunction in diabetes mellitus, chest pain is uncommon in spite of the underlying "silent" myocardial ischemia, warranting a thorough cardiac evaluation. mps is a sensitive modality for screening of subclinical ihd in diabetics. . perfusion of . %, . % and . % in the segments with severe, moderate and mild perfusion defects respectively. pre-operative rest mps showed / hypo-perfused segments with ( . %) segments with severely decreased perfusion, ( . %) segments with moderately and ( . %) with mildly decreased perfusion. after revascularization, perfusion in these segments was improved in . %, . % and . % respectively. there was no change in . % of segments with severely decreased perfusion. conclusion: the positive effect of cabg surgery in the area of severely hypoperfused segments on rest mps was not observed in more than in % of segments. segments with severely decreased perfusion showed fixed defects normally associated with myocardial infarction. however the significant improvement in myocardial perfusion after cabg was demonstrated in segments of moderate and mild perfusion defects. myocardial perfusion scintigraphy with tc m sestamibi provides useful information for assessment of coronary artery bypass surgery and prognosis of revascularization in patients with ischemic heart disease. the role of captopril renal scintigraphy for the qualification to the pta of the stenosed renal artery. m. kostkiewicz , t. przewlocki , d. rzeznik , w. szot , a. kablak-ziembicka , w. jarosz , w. tracz ; john pauil ii hospital, dept of nuclear medicine, krakow, poland, john pauil ii hospital, dept of nulcear medicine, krakow, poland. stenosis of renal artery is the most common cause of secondary hypertension and renal insufficiency. renal perfusion imaging (rpi) with ace inhibitors is well acknowledged study in diagnosis of these diseases. percutaneous transluminal angioplasty (pta) of stenosed arteries is currently one of methods of treatment in this group of patients, however, there are no effective methods of noninvasive control in those subjects and indications for pta still remain unclear. methods the group of patient studied comprised of people ( males and females, mean age . _+ , ) with ischemic heart disease, referred for pta, in whom angiography revealed stenosis of one or both renal arteries. all the patients had rpi with ace inhibitors performed with -days protocol with minimum hours between the first and second study -initially and months after pta. the values of gfr, time to peak of renographic curve (tmax), renal perfusion images, value of renal inflow and shape of renographic curves were analyzed. two independent observers were evaluating data in aim to refer the patient for pta. -grade scale was used: -stenosis not significant or normal images, -borderline stenosis, -significant stenosis. the data obtained were compared with ultrasonographic studies. rpi was repeated after months to evaluate late outcome of treatment and probability of recurrent stenosis. results. in studied group of patients left renal artery stenosis was found in pts, right in pts and bilateral in pts. pta proved to be successfully performed in all those pts. in pts recurrent stenosis was found and subsequent pta was performed. in pts, despite successful pta, no improvement in renal function was found in control study. those pts had low gfr values (below ml/min.) together with nephrectomic type of renographic curve. scintigraphic image was consistent with angiographic localization of renal artery stenosis. in pts, despite the presence of significant stenosis the scintigraphic images were normal. conclusions rpi with ace inhibitor is substantially efficient study in referring pts for pta and evaluation of late results. in case of severely impaired renal function the rpi should be the reason for postponing the pta. kbn po bo aim: coronary revascularisation is effective in many patients with stable angina pectoris. however, in some patients symptoms may persist or even progress, probably because of persisting regional hypoperfusion. we examined the rates of unchanged or worsened perfusion two years after coronary revascularisation. material and methods: a prospective series of patients ( females) with a mean age of . ± . years underwent coronary revascularisation for stable angina pectoris. myocardial perfusion scintigraphy (mps) was performed before angiography and two years later. the decision of invasive management was based exclusively upon patient history and angiographic findings since the result of mps was kept secret. the mps studies were reviewed to determine if a change, e.g., from a reversible to a mixed defect or from a mixed to a fixed defect was due to improvement (i.e., smaller defect) or deterioration (i.e., larger defect or decreased reversibility at unchanged defect size). results: before revascularisation, the rates of normal perfusion or of reversible, mixed, or fixed defects were % ( / ), % ( / ), % ( / ), and % ( / ), respectively. two years following revascularisation, improvement in perfusion was noted in % ( / ), % ( / ), % ( / ), and % ( / ) of these groups, respectively, summing up to improvement in % of the entire study population ( / ). perfusion remained unchanged in % ( / ) corresponding to % ( / ), % ( / ), % ( / ), and % ( / ) of patients with initially normal perfusion, or reversible, mixed, or fixed defects, respectively. in the remaining % ( / ) of patients there was a worsening of perfusion. worsening of perfusion was deemed serious in only of the patients with a worsened perfusion. conclusion: two years following revascularisation, the relationship between improvement, no change, or a deterioration in myocardial perfusion was in stable angina pectoris patients approximately : : . serious deterioration was a seldom event. improvement was noted exclusively in the patients with reversible or fixed perfusion defects suggesting that preoperative mps might potentially improve the overall result of coronary revascularisation by straining off patients with normal perfusion or fixed perfusion defects. f. marranzano , m. caruso , c. privitera , g. privitera , g. rapisarda , a. la rosa , s. gusmano ; dip. immagini az.osp.un. ove, catania, italy, uoc cardiologia az.osp.un. ove, catania, italy. aim to determine the clinical features of myocardial perfusion imaging in a novel heart syndrome with transient left ventricular apical ballooning( ab) , but without coronary artery stenosis, that mimics acute myocardial infarction. several case studies of ab, so called takotsubo cardiomyopathy ( tm), have been reported. tm is characterized by angina-like precordial pain and st-segment elevation and limited release of cardiac enzymes. sometimes appears with dyspnea or syncope. the catheterization procedure shows normal coronary arteries, and apical dyskinesia is observed on contrast ventriculography. the incidence of this syndrome is not clear but it develops predominantly in elderly women. case report we present the case of a year-old woman arrived to the emergency department of our institution hour after emotional stress ; symptoms began with angina and dyspnea at rest . the electrocardiogram on admission showed small progression of the first vector and stsegment elevation in leads v to v , with a moderate increase in levels of cardiac serum markers (ck , ck-mb, and troponin i ). on physical examination, she had a pulse of beats/min and her blood pressure was / mm hg. two-dimensional echocardiography showed left ventricular dilatation with preserved systolic function in the basal segments; the midventricular segments and the apical segments were dyskinetic. the diagnosis of acute anterior myocardial infarction was established, and thrombolysis was performed by use of recombinant tissue plasminogen activator. partial signs of reperfusion were observed , with reduction of st-segment elevation. four hours after the initial symptoms appeared acute rest-sestamibi myocardial perfusion g -spect was perfomed. results acute rest-g-spect showed perfusion defects on the septal, anterior, and apical walls . by use of gated spect, it was possible to assess myocardial dyskinesia of the anterior wall and apex. coronary artery study revelead no significant stenosis of main epicardial vessels . one month later a stress-rest g-spect study ( two days maximal exercise protocols) showed no perfusion defects, and the wall motion abnormalities had disappeared, with completely normal heart function. conclusion we report a case of severe, reversible myocardial perfusion defects and left ventricular wall motion dysfunction , seen on gated spect , compatible with tm , in patient with normal coronary angiograms and dyskinesia on contrast ventriculography.g-spect is therefore a useful method for the diagnosis and follow-up of tm because it is a noninvasive imaging technique that shows the complete reversibility of this entity. clinical utility of myocardial stress-rest perfusion scintigraphy with adenosine in elderly patients with diabetes mellitus. g. p. gerasimou, t. aggelopoulou, a. revela, e. dedousi, g. liaros, e. papanastasiou, a. siountas, k. psarrakos, s. chatzimiltiadis, s. gavriilidis, a. psarrakou; ahepa university hospital, thessaloniki, greece. coronary artery disease (cad) in elderly patients with diabetes mellitus (dm) is often characterized by occult or absent symptoms. these patients are not able to achieve an acceptable level of ergometric exercise. this study has as purpose to assess the diagnostic value of stress/rest radionuclide myocardial perfusion scintigraphy (rms) with adenosine (adn) in patients with dm, older than years, with a low clinical prevalence of cad. materials and methods: fifty-six patients ( females) with dm (mean age . + . ), with equivocal symptoms of cad are enrolled in the study. all patients underwent pharmacological intervention with adn at a dose of μg/kg/min in min under ecg inspection and mbq of tc m-tetrofosmin (tf) were injected at the rd min of adn infusion and stress study was taking place min post tf injection. four hours after pharmacological test, rest study was performed min post iv injection of mbq of tf. coronary angiography (ca) has been performed to all patients. results: the left ventricle of the patients was divided into segments (apex and apical plus basal segment of the anterior, lateral, inferior wall and interventricular septum). a segment was considered as abnormal, if the counts revealed were less than % compared to the data of normal population. in ca, a stenosis was considered significant when it exceeded % of a vessel's lumen or accordingly to the fraction flow reserve. in of the patients stress/rest radionuclide tf test has been considered within normal limits. in these patients ca revealed a stenosis of the coronary vessels in one of the patients, in one of the coronary vessels. in the remaining patients, reversible myocardial ischemia has been mentioned to out of a total of segments, whilst findings compatible with myocardial infarction have been reported to of these patients, numbering additional segments of the left ventricle. ca has been considered as abnormal in of these patients, with total occlusion of the coronary arteries in both patients with myocardial infarction as mentioned to rms. according to these results, the sensitivity of rms has been considered as high as . %, whilst specificity was at the level of . %. conclusions: in elderly patients with dm, presenting silent myocardial ischemia, rms with adn challenge, is a sensitive tool in the diagnosis of cad. purpose: some authors reported that a reduced i- bmipp uptake in the myocardium in patients with hcm, and the reduction of i- bmipp related to the myocardial abnormalities. we hypothesized that the abnormality of fatty acid uptake and metabolism may occur before it can be visually recognized on spect images in patients with hcm. a distribution volume (vd) of i- bmipp could be useful for detecting such abnormality of myocardial fatty acid metabolism. the purpose of this study was to investigate vd of i- bmipp in myocardium through a compartment model analysis in patients with hcm. methods: twenty-eight normal controls and patients with hcm were studied. i- bmipp and tc- m tetrofosmin spect were performed. according to the literaturere, the uptake of tc- m tetrofosmin and i- bmipp are preserved in very early phase of hcm. in moderately advanced phase of hcm, the uptake of i- bmipp is reduced, but the uptake of tc- m tetrofosmin is preserved. in severely advanced phase, the uptake of tc- m tetrofosmin is also reduced. based on these results, we defined early hcm as normal uptake of tc- m tetrofosmin and i- bmipp, moderately advanced hcm as normal uptake of tc- m tetrofosmin and decreased uptake of i- bmipp, and severely advanced hcm as decreased tc- m tetrofosmin and i- bmipp. moreover, all the myocardium was divided into segments. finally, these segments of hcm were categorized into early, moderately and severely advanced hcm segments. by using the timeactivity curves, we analyzed bmipp pharmacokinetics through a -compartment model. we defined k and k as influx and outflux rate constant between blood and reversible component, k as specific uptake rate constant between reversible and irreversible compartments. additionally, we calculated k /k as vd. results: the results were summarized in the table. the vd of i- bmipp was gradually decreased with progression of hcm, and there was statistically significant difference between normal and each hcm group (p < . in each group). conclusion: vd of i- bmipp might be useful index to evaluate the progression of hcm. however, uptake of i- bmipp was not reduced in early hcm group at least with visual qualitative approach. these results indicated that a mathematical compartment model analysis might be useful to detect subtle change of fatty acid metabolism in patients with hcm, and not only for identification of hcm in very early stage, but also for evaluation of the progression of hcm. aim: mtc-sestamibi (mibi) shows good retention in normal myocardium after the initial uptake. but, the washout is sometimes observed in ischemic hearts. these suggest the possibility that the washout rate of mibi would be a useful indicator of myocardial damages or dysfunction. this experimental study evaluated the mibi washout by hypoxic myocardial damage using electrically paced isolated rat hearts. methods: isolated rat hearts were electrically paced at beat/min and were perfused with oxygen-saturated krebs-henseleit solution of constant flow of ml/min. heart rate and left ventricular pressure (lvp) were measured. after mibi ( to mbq) was infused for minutes, mibi washout was observed in the following two groups: the control group that was continuously perfused with oxygen saturated solution for minutes and the hypoxic group that was perfused with oxygensaturated solution for min followed by nitrogen-saturated solution including glucose. cases of irreversibly damaged hearts were excluded. radioactivity in the heart was continuously measured using a gamma camera equipped with pin-hole collimator. mibi washout rate was evaluated by the slope of time-activity curve (tac) for roi of whole heart. results: the mean mibi uptake in the isolated heart was . ± . %/added dose. in the control group, mibi showed good retention with a very gentle slope of tac (- . ± . %/min). in the hypoxic group, the slope of tac was significantly increased (- . ± . %/min). under hypoxic condition, lvp was reduced first, and then the diastolic pressure (dp) was elevated. the change of tac slope simultaneously occurred with the rise of dp, not at the initiation of the hypoxic condition. carbonyl cyanide-m-chloro phenylhydrazone (cccp), a mitochondrial uncoupler, induced similar increase of the slope of tac under the same condition, suggesting that the mibi washout induced by the reversible hypoxic damage observed here was implicated in mitochondrial function. conclusion: the myocardial washout rate of mibi can be a useful marker of myocardial viability. aim: initial clinical studies have shown that bone marrow progenitor cells had beneficial effect on the healing process after myocardial infarction. the aim of the present study was to evaluate the effects of intracoronary infused bone marrow derived progenitor cells (cd +) on regional myocardial viability and perfusion by [ f]fdg pet and [ mtc]mibi spect in patients with first episode of acute myocardial infarction. materials and methods: patients were treated by percutaneous revascularisation and stenting of the occluded artery; left anterior descending (lad), right coronary artery (rca). all patients received intracoronary infusion of autologous cd + bone marrow stem cells ± days after the revascularisation. all patients underwent fdg-pet and mibi-spect before transplantation and months afterwards during follow-up. for quantitative evaluation of myocardial [ f]fdg and [ mtc]mibi uptake a ventricular segmentation scheme ( segments) was applied. mean signal intensities (msi) of the segments assigned to the lad/rca distribution were callculated for each patient. results: pet studies showed a highly significant increase of the msi in the infarct area from . ± . % to . ± % (p= . ). no statistically significant differences were found in myocardial [ mtc]mibi uptake before ( . ± . %) and after ( . ± . %) stem cell translpantation(p= . ) conclusion: our results indicate that local intracoronary cd + progenitor cell therapy results in a significant increase in myocardial viability of the infarct zone. aim in patients with previous myocardial infarction, the relationship among viability, ischemia, volume overload and systolic dysfunction is still unclear. methods we studied patients (age ± yrs, male) with previous myocardial infarction ( anterior, inferior, lateral). all patients underwent a single day rest postnitrate/stress tetrofosmin g-spect study. g-spect analysis was performed using qgs/qps protocols. viability was scored according to a summed rest score (srs) < (mostly viable), - (partially viable), and > (mostly necrotic). in each category, summed difference score (sds) provided the presence (sds> , group ) or the absence (group ) of myocardial ischemia. results according to srs, patients showed mostly viable, partially viable and mostly necrotic myocardium. in patients with mostly viable myocardium, mean resting lvef resulted lower in g than in g patients ( ± % vs ± %, p< . ) and significantly changed following exercise only in g (from ± % to ± %, p= . ). mean resting edv was higher in g than in g (p< . ) and did not change following exercise in both groups (p=ns). delta sms (resting sms -exercise sms) resulted significantly lower in g than in g patients (- . ± . vs - . ± . , p< . ) , suggesting the presence of exercise induced regional stunning. in patients with partially viable myocardium, mean resting lvef was lower in g than in g patients ( ± % vs ± %, p< . ) and significantly changed following exercise only in the presence of myocardial ischemia (g , from ± % to ± %, p= . ). mean resting edv was higher in g than in g patients (p< . ) and did not change following exercise in both groups (p=ns). again, delta sms resulted significantly lower in g than in g patients (- . ± . vs . ± . , p< . ). in patients with mostly necrotic myocardium, mean resting lvef resulted similar between g and g ( ± % vs ± %, p=ns) and did not change following exercise (p=ns). similarly, mean resting edvs were ± ml and ± ml (p=ns) in g and g patients and did not change following exercise (p=ns). delta sms resulted similar between g and g patients (- . ± . vs - . ± . , p=ns) . conclusions in patients with previous mi, ef decreases and edv increases proportionally to the amount of scarred myocardium. at any level of tissue viability, transient ischemia has an additional role in determining the degree of resting systolic dysfunction and volume overload. repetitive episodes of ischemia during daily activity could modulate the extension of scar and the time course of lv dysfunction. several studies have indicated that contrast-enhanced magnetic resonance imaging (cmr) enables the visualization of infarction and reperfusion.so far there are only a few reports comparing cmr with spect early after ami.the aim was to compare tl- rest(r)-redistribution(rd) perfusion spect results with cmr in patients early after ami. methods:twenty-nine patients ( males, females; ± yrs) with recent ami were studied.within days after ami, the patients were performed tl- r-rd perfusion spect using mci activity.cmr was carried out - minutes after , mmol/kg of iv.gadobutrol injection.myocardial perfusion and contrast enhancement was analyzed using a segment model.myocardial perfusion was scored in tl- spect as follows: =normal ( %- % maximal myocardial activity(mma), = - % mma, = - % mma , = - % mma and =< % mma ;myocardial contrast enhancement on cmr images was graded as: =no contrast enhancement, =hyperenhancement of - % of the wall thickness(wt) =hyperenhancement of - % of the wt, =hyperenhancement of - % of wt and =hyperenhancement of - % of wt.in cmr the existence of microvascular obstruction(mo) was also evaluated.total segment scores(tss) in r,rd and cmr for each patient were calculated by summing of segment score values. results:the mean tts values were calculated as: r-tss= ± . ,rd-tss= . ± . and cmr-tss= . ± . .the mean differences between r-rd tl- and cmr were significant(p= . ); cmr-tss values > r and rd-tts in / patients. in / patients, mo was observed.in / patients with mo, perfusion was normal in r-rd tl- (r and rd-tts= , cmr-tss= ).in / patients without mo,r-rd tl- perfusion findings were normal (r and rd-tts= ; cmr-tts= and ), / patients had r-tts =o, rd-tts= and cmr-tts= .in the analysis of a total of segments, poor agreement was found between cmr versus r and rd results (kappa= . ve . ).according to coronary artery territories the agreement between the segments were: lad: cmr -r, rd (kappa= . and . ), rca:cmr-r,rd (kappa= . and . ), lcx: cmr-r, rd (kappa= . and . ). conclusion:a poor segmental agreement was observed between cmr and tl- r-rd study. the segments in rca territory showed the worst agreement comparing to lad and lcx. cmr detected infarcted areas larger in % of patients. this was compatible with related literature including histopathology. possible explanations for overestimation in cmr, early after ami include an altered washout characteristics of the contrast medium in the ischemically injured but viable myocardium. follow up studies after revascularization are needed to obtain reliable results in identifying accurate viable and necrotic tissues. in patients with previous myocardial infarction evaluation of myocardial viability and global left ventricular ejection fraction (ef) may provide clinically useful diagnostic and prognostic information. gated spect imaging allows simultaneous assessment of myocardial viability (according to extent of perfusion defect and preserved wall thickening) and function (left ventricular ef). the aim of the study was to compare myocardial perfusion and global ef in patients with previous myocardial infarction (mi) before and after angioplasty. materials and methods: study group consisted of patients (mean age ± year, male) with previous myocardial infarction (before . ± months) and single vessel coronary artery disease ( lad, lcx and rca). all patients underwent coronary angioplasty and stenting of infarct related coronary artery. to evaluate myocardial perfusion and function we performed rest ecg gated mibi acquisition after nitroglycerin administration. left ventricular ef was calculated from gated spect data by commercially available software d-mspect. myocardial perfusion abnormalities were expressed as defect extent in per cent of entire left ventricle. myocardial region was considered as viable when systolic wall thickening was present and mibi uptake was % of peak myocardial activity. perfusion and function were evaluated before and - months after stenting. results: according to myocardial perfusion and preserved systolic wall thickening the patients were divided in two groups: group i consisted of patients with viable segments after mi and group ii of patients with non-viable segments. the mean left ventricular ef in group i was higher than in group ii ( ± % vs. ± %, p< . ) and perfusion abnormalities were grater in group ii than in group i ( ± % vs. ± %, p< . ). after successful angioplasty and stent implantation in group i global lvef slightly increased ( ± vs ± %, p> . ) and perfusion abnormalities significantly decreased ( ± % vs. ± %, p< . ). on the contrary, in group ii there was no significant improvement of lvef ( ± % vs. ± %, p> . ). perfusion abnormalities were larger after angioplasty, although without statistically significance ( l± % vs. ± %, p> . age . ± years submitted for evaluation of viability with mtc-sestamibi using rest-nitrate protocol with gspect and rnv. eighteen pts. had repeated studies at six months for assessment of therapy, so a total of pairs of studies were obtained. gated spect was performed between and min after administration of mtcsestamibi ( mbq/k) at rest, using frames per cardiac cycle, x zoom factor and no beat rejection. rnv was performed hours later with labeled rbcs in left anterior oblique projection, frames per cardiac cycle, x zoom factor, and % window beat rejection. patients with complete arrhythmia or with ectopic beats > % of total beats were not included for analysis. edv, esv and lvef were determined using the qgs (cedars-sinai) software package for gspect aim coronary artery disease (cad) shows higher incidence in diabetics than in nondiabetic population and is more advanced at diagnosis. the prognosis of cad is less favorable in patients with diabetes than in nondiabetics. postinfarction mortality is higher in diabetics. the available data suggest that occult cad is a comon finding among asymptomatic diabetics. stress/rest myocardial perfusion imaging (mpi) could be a useful, noninvasive procedure with diagnostic and prognostic roles. methods study population of patients, of them presented diabetes mellitus. clinical follow-up of - months, for confirmed cardiac deaths, non-fatal myocardial infarction and others adverse cardiac events (ace) mpi was performed after administration of mbq tc m-tetrofosmine in stress and mbq in rest ( day protocol). some patients also underwent radionuclide ventriculography and coronary angiography. the obtained images were categorized as normal or abnormal: reversible, fixed or mixed myocardial perfusion defects, severity and anatomic location (right, descending and circumflex coronary artery). results aim: due to the aging of population and high frequency of obesity, the prevalence of type ii diabetes mellitus (dm) is increasing rapidly in western nations and the associated coronary artery disease (cad) is nowadays the leading cause of death in diabetic subjects. the purpose of this study was to evaluate the long-term prognostic value of gated-spect myocardial perfusion imaging (gmpi) for the occurrence of cardiovascular events in patients with dm. materials and methods: a cohort of consecutive patients ( women and men, mean age ± years), with at least a five-year history of dm were enrolled in this study. the population was clinically classified according to history of cad and chest pain into high-(n= ) and low-risk (n= ) groups. all subjects underwent clinically indicated rest/stress tc- m sestamibi gmpi with physical exercise (n= ) or dipyridamole (n= ). to determine the prognostic value of gmpi the first endpoint was major acute cardiac events (cardiac death or non-fatal myocardial infarction) and the second endpoint was the revascularization rate. patients data were analysed using both kaplan-meier event-free survival curves and cox multivariate analyses. results: follow-up was completed in all patients with a median period of . years ( . - . ). the prevalence of abnormal gmpi was % (n= ) with reversible defects occurring in % (n= ), fixed defects in % (n= ) and mixed defects in % (n= ). patients with a normal gmpi had neither cardiac death, nor myocardial infarction, independently of a history of cad or chest pain. among the independent predictors of cardiac death and myocardial infarction, the strongest was abnormal gmpi (p< . ), followed by history of cad (hazard ratio (hr)= . ; p= . ) and inability to exercise (hr= . ; p= . ). patients with normal gmpi had a revascularisation rate of . % during the follow-up period, significantly lower than subjects with abnormal gmpi ( . %). compared to normal gmpi, cardiovascular events increased . fold for reversible defects, . fold for fixed defects and . fold for the association of both defects. conclusion: dm patients with normal gmpi seem to have an excellent prognosis independently of history of cad. on the opposite, an abnormal gmpi led to a more than -fold increase in cardiovascular events. this study outlines the additional value of gmpi in predicting cardiovascular events and risk-stratifying dm patients even if larger prospective trials are mandatory to confirm these findings and to assess their potential impact in clinical settings. the detection of myocardial ischemia in patients with preexisting left bundle branch block (lbbb) remains problematic. myocardial perfusion scintigraphy (mps) with dipyridamole is the preferred non-invasive diagnostic modality for this group of patients. materials and methods: seventy six patients with preexisting lbbb underwent sestamibi perfusion imaging with dipyridamole infusion protocol ( . mg/kg). stress and rest spect studies were acquired using single head ecam (siemens) and double head toshiba gca- a gamma cameras. images were interpreted by consensus of two experienced observers and classified as, low risk group (normal mps, small reversible/small fixed defect) and high-risk group (a large severe fixed or reversible defect and dilated lv cavity). patients with mean age of ± years (range= - years) were included in the study. these patients were followed up for months ± months and occurrences of hard cardiac events (mi or cardiac death) were asked by telephones. results: out of patients had low-risk scans ( %) and had high-risk scans ( %). in low risk group cardiac deaths were observed in / ( . %) and non-fatal mis were seen in / ( . %). in high-risk scans, suffered cardiac death ( . %) and non-fatal mis in ( . %). over all survival rate was . % in the low-risk group compared with . % in the high-risk group with a significant difference (p= . ). conversely, the negative predictive value of a normal myocardial perfusion scintigraphy for the occurrence of death was %. conclusion: myocardial perfusion imaging with dipyridamole stress provides important prognostic information in patients with left bundle-branch block, which is incremental to clinical assessment. aim; revascularisation of occluded coronary arteries and bypass grafts with insertion of drug coated and non drug coated [bare metal] stents has become the preferred choice of treatment in recent years for patients with multivessel coronary artery disease [cad] .our aim was to evaluate the role of gated spect [gspect] in patients who underwent multivessel ptca /stents. materials and methods: we evaluated patients[ males, females, mean age yrs] referred with chest pain - months after ptca/stent procedure in multiple coronary vessels including bypass grafts.all patients underwent two day stress/rest technetium- m-tetrofosmin myocardial perfusion gated spect [gspect] [ ] [ ] [ ] [ ] [ ] .coronary angiography showed instent restenosis in patients and progressive cad in patients with patent stents. patients were treated with redo ptca/stent and had cabg .no myocardial event was seen at - months follow-up. [ %] patients were considered normal [sds - ] .coronary angiography showed partial instent restenosis in of these patients. no adverse myocardial events were seen in these patients at - months followup. [ %] patients had fixed defects and event free follow-up .conclusion:our study shows that technetium- m-tetrofosmin myocardial perfusion gspect can be used as a powerful prognostic tool in patients who were treated with multivessel ptca/ stents aim: extension and severity of myocardial scar may condition short and long term efficacy of autologous stem cell treatment. methods: five male patients (mean age ± yrs) with previous myocardial infarction, multivessel coronary artery disease underwent to intramyocardial , ml injections of autologous stem cell in scarred myocardium concomitant with off-pump coronary artery bypass grafting. after open heart surgery, stem area was mapped on a d heart model by a cardiologist and a cardiac surgeon and transferred to the -segment model used for scintigraphic analysis. delivery area was chosen according to: ) dominance of scar; ) akinesis; ) ungraftability of the tributary coronary artery. mtc tetrofosmin gated spect ( mbq, views in a degrees orbit, double head gamma camera) was performed at rest before, weeks and four years after treatment with the same camera and acquisition parameters. severity of scar was quantified as number of standard deviations below matched normals according to qps protocol (ge health care) in segments. in the same segments regional wall thickening was quantified by qgs protocol (ge health care). results: ten weeks after the implantation, gated spect showed an improved regional perfusion in stem area in patients in whom the reduction of scar was % and %, respectively. one patient showed a further reduction of % after four years. patients who did not improve regional perfusion both at short and long term follow-up showed a more extensive scar area and an impairment in regional wall motion before surgery. conclusion: in patients with previous myocardial infarction and multivessel coronary artery disease undergoing stem cell treatment in ungraftable areas, reperfusion was higher in those segments with more viability and less akinesis. results observed at weeks were confirmed by gated spect at long term follow-up. gated spect appears to be an optimal tool to assess short-and long term effect of stem cell treatment on regional blood flow and function. background: there is a lack of validation and standardization of acquisition parameters for myocardial i-metaiodobenzylguanidine (mibg). this lack of standardization hampers large scale implementation of i-mibg parameters in chronic heart failure (chf). methods and results: in a retrospective multi-center study i-mibg planar scintigrams obtained on chf patients ( % male; % dilated cardiomyopathy; nyha>i) were reanalyzed to determine the late heart-tomediastinum ratio (h/m). there was a large variation in acquisition parameters. multivariate forward stepwise regression showed that a significant proportion ( %, p< . ) of the variation in late h/m could be explained by a model containing patient related variables and acquisition parameters. left ventricular ejection fraction (p< . ), type of collimation (p< . ), acquisition duration (p= . ), nyha class (p= . ) and age (p= . ) were independent predictors of late h/m. conclusions: acquisitions parameters are independent contributors to semi-quantitative measurements of cardiac i-mibg uptake. improved standardization of cardiac i-mibg imaging parameters would contribute to increased clinical applicability for this procedure. objectives: for investigating the effects of suppression of myocardial sympathetic innervation on the myocardial adrenergic activity and norepinephrine transporter (net) density, the study undertaken i -metaiodobenzyl guanidine (mibg) myocardial imaging and and myocardial net immunohistochemistry in sprague-dawley (sd) rats following surgical sympathectomy (sx) at superior cervical ganglia. methods: twelve -wk-old male sd rats were included in this study, rats were subjected to right-sided surgical sx (rsx group), rats were subjected to left-sided surgical sx (lsx), and another rats were subjects to sham operation for control (c group) . all rats were undertaken myocardial imaging within hours following operation. i-mibg myocardial images were performed for the early and delayed imaging using a gamma camera (picker prism xp) equipped with a -mm pinhole collimator. the heart-to-mediastinum count ratios (h/m) of the -min initial imaging and the -h delayed imaging were determined, then the myocardial washout rate (mwo) was determined for being a marker of uptake- activity. following i-mibg myocardial imaging, the rats were sacrificed and the isolated hearts were collected for net immunohistochemistry. results: the results demonstrated the early mibg h/m of rsx rats were lower than that of control rats (h/m: . + . in rsx; . + . in control rats, p < . ), whereas h/m in lsx rats were similar to control rats (h/m: . + . in lsx; p= ns vs. control rats). the mwo of control rats were higher than that of sx rats; whereas the lsx rats were higher than that of rsx rats (control rats: . + . , vs. rsx: . + . ; p < . ; lsx . + . ,p < . vs. control rats). the myocardial net immunohistochemistry revealed the density in rsx rats were higher than in lsx rats, whereas the net density in lsx were higher than that of control rats. conclusion: based on the above findings, we suggest myocardial sympathetic dennervation will develop following right-sided sympathectomy, which will accompanied by compensated uptake- system on presynaptic nerve endings of postganglionic neuron, demonstrated by lowered mwo and increased net density. role of i -mibg cardiac scintigraphy in differential diagnosis between alzheimer's and lewy bodies dementia e. m. covelli, p. sullo, g. mazzarella, m. salzillo, g. vitale, g. belfiore; s. anna e s. sebastiano hospital, caserta, italy. purpose: lewy bodies are abnormal structures in the mid-brain: microscopic protein deposits found in nerve cells that disrupt the brain's normal functioning. lewy body disease (lbd) is the second cause of dementia in older adults caused by abnormal structures in the brain. lbd diagnosis can be difficult because many of the symptoms are similar to alzheimer's disease (ad), and cerebral perfusive tomography is always non conclusive. i -metaiodobenzylguanidine (i -mibg) is a radioiodinated analogue of noradrenaline. i -mibg scintigraphy is a non-invasive and safe diagnostic tool to assess and evaluate cardiac sympathetic innervation. the aim of this study is to evaluate the cardiac sympathetic innervation by i -mibg scintigraphy in patients with clinically demential symptoms and inconclusive tc m-ecd perfusive tomography in order to help the differential diagnosis between lbd and ad. methods: fourteen patients ( f, m; mean age ± years) with suggestive dementia symptoms underwent cerebral tc m-ecd tomography and cardiac i -mibg scintigraphy. cerebral perfusive tomography was performed one hour after tc m-ecd ( mbq) injection and qualitative analysis was used for diagnosis. cardiac i -mibg scintigraphy was carried out in all patients within one week and planar scintigraphic images were acquired hours after i -mibg ( mbq e.v.) administration. semiquantitative analysis was also performed calculating delayed ( hours) heart to mediastinum count-ratio (h/m) by drawing regions of interest (rois) over the upper mediastinum and whole heart to confirm diagnosis. results: all patients submitted to cerebral tc m-ecd tomography presented severely reduced tracer uptake suggestive to dementia but we observed a different cardiac innervation pattern between ad and lbd patients. in fact, cardiac i -mibg scintigraphy showed normal uptake (delayed h/m: . ± . ) in eight patients diagnosed as having ad and abnormal reduced cardiac tracer accumulation (delayed h/m: . ± . , p< . ) in remaining six lbd patients. conclusions: a significant decrease of cardiac mibg accumulation indicating a relevant degeneration of myocardial sympathetic neurons in lbd patients was detected. therefore, these preliminary data suggest that cardiac i -mibg scintigraphy may be useful in the differential diagnosis between ad and lbd especially when cerebral tc m-ecd tomography is not conclusive and it can be considered a suitable and helpful tool in the management of patients with dementia syndromes. a new iterative reconstruction algorithm (wbr™) has been recently proposed for cardiac spect. the wbr™ technology, based on accurate modelling of the emission-detection process, was designed to reduce noise improving lesion detectability without affecting the image resolution. few data exist on the comparison between filtered back-projection (fbp) and this new algorithm in a clinical setting. aim. the aim of this study was to compare the performance of fbp and wbr™ in the clinical arena. methods. a group of pts, with different cardiac pathology, scheduled for a stress-rest spect were studied. a two-day mtc-sestamibi protocol was used. all pts performed standard ecg-gated spect acquisitions with a dual-head@ ° camera, with a time/frame of sec. immediately after the conclusion of the acquisition, a second ecg-gated acquisition was performed at half-time/frame ( sec). standard-time spect was reconstructed with a conventional fbp (butterworth, . , ); half-time spect was reconstructed with wbr™. tracer uptake was blinded evaluated by two experienced observers in segments with a point scoring system (from =normal to =absent). discrepancies were resolved by consensus. summed stress scores (sss) and summed rest scores (srs) were calculated. lv ef were automatically calculated with qgs. results. no significant differences were observed in sss and srs between half-time wbr™ spect ( . and . , respectively) and standard-time fbp spect ( . , and . , respectively, ns) . lv ef on rest acquisitions was also comparable ( . % on half-time spect vs . % on standard-time spect, ns). lv ef on post-stress studies in half-time spect ( . %) was lower than standard-time spect ( . %), although not statistically significant. conclusions. visual analysis of half-time/frame spect reconstructed with the new algorithm wbr™, was comparable to that of a standard time/frame spect acquisition reconstructed with conventional fbp. differences in the time elapsed from the end of the stress test and the spect acquisition could be involved to explain the differences of lvef between the two post-stress studies. results from the present study do not necessarily apply to spect studies employing an reduced activity of injected tracer, and further studies are needed. aim: present devices used for gated spect mpi may be incapable to identify the r wave as a proper triggering signal in patients with a pacemaker, mainly with dualchamber stimulation. the aim of our study was to assess in how many such patients the use of r wave fail and to test the usefulness of pulse wave as an alternative. material and methods: we evaluated a group of pts with pacemaker referred to our department for stress mpi. there were m and f, mean age y ( - ). two data sets were acquired at rest, the first set synchronized with r wave and the second set with pulse wave. cequaltm and qgstm software were used for processing. we compared ejection fraction (ef), end-diastolic and end-systolic volumes (edv, esv). paired t-test and correlation were used for comparison. results: we were unable to get good data in / ( . %) pts using synchronization with the r wave. in all of them the data synchronized with the pulse wave were acceptable for processing. in the whole group, the mean ef, edv and esv calculated using the r wave for triggering were . ( . - . ), ( - ) and ( - ) respectively, using the pulse wave . ( . - . ), ( - ) and ( - ) respectively, p= . for ef, p= . for edv and p= . for esv. correlation for ef was . (p= . ), for edv . and for esv . (p = . for both correlations). conclusion: there is a significant number of pts with pacemaker in whom the use of the r wave does not allow to evaluate parameters of the heart function ( . % in our group). we believe that the use of the pulse wave is the only alternative in such pts. quantitative data correlate highly with the data calculated with ecg trigger. the relation between helicobacter pylori infection and cardiac syndrome x;a novel study objectives: cardiac syndrome x (csx) is characterized by an angina pectoris and/or presence of positive none-invasive test (exercise tolerance test or myocardial perfusion scan) accompanied with normal coronary angiogram. several mechanisms such as ischemia, inflammation and endothelial dysfunction have been suggested. this study was carried out to assess the possible role of helicobacter pylori (hp) in this syndrome. methods: hp infection was distinguished by urea breath test (ubt) in patients with csx, and compared with two sex-and age-matched control groups. ubt classified as; negative, intermediate, positive for h. pylori. statistical analysis was carried out using anova and t tests. a p-values of . or less were considered to be significant. results: each group consisted of patients with a mean age of . ± . [sd] years, . ± . years, and . ± . years in csx, cad and healthy control respectively. fifty percent ( ) of csx patients had positive result, while none of two control groups had the same results (p-value= . ). the negative and intermediate results were not statistically significant in three groups. conclusion: with respect to the high occurrence of hp infection and likely contributory effect of inflammation in subjects with csx, potential role of hp infection in the pathogenesis of csx is proposed. however well planned clinical trials are required to validate this initial result. the interpretation of medical images by inexperienced physicians would theoretically be improved with a second opinion of a more experienced colleague or by a decision support system. in the present study we evaluate the performance and interobserver variability between inexperienced as well as experienced physicians and a decision support system regarding classification of myocardial infarction and ischemia. method: seven physicians, all specialists in nuclear medicine but with varying experience, participated and were compared with the care decision support system. each of the physicians interpreted patients with gated myocardial perfusion scintigraphy (mps) first a preliminary interpretation was made without the advice from the decision support system. the image was then processed by the computer and within seconds the physician received the advice from the decision support system and the interpretation and report was finalized. result: the sensitivity regarding interpretation of ischemia increased with % (p< . ) for the whole group with the help of a decision support system, both for inexperienced, % (p< . ) and experienced physicians, % (p= . ). the increase in sensitivity was larger in the anterior and inferior areas of the heart. conclusion: in the present study a second opinion from a decision support system increased the precision of physicians interpreting nuclear images, both for inexperienced as well as experienced physicians. a decision support system based on artificial intelligence is always available and can give advice regarding presence of infarction or reversible ischemia with the same precision as an experienced physician. a new iterative reconstruction algorithm (wbr™) has been recently proposed for cardiac spect. the wbr™ technology, based on accurate modelling of the emission-detection process, was designed to reduce noise improving lesion detectability without affecting the image resolution. few data exist on the comparison between filtered back-projection (fbp) and this new algorithm. aim. the aim of this study was to compare the performance of fbp and wbr™. methods. an antropomorphic phantom was acquired with a dual head@ ° camera, equipped with a lehr collimator. a solution of mtco -was used to fill the different regions of the phantom: mbq for both right ventricles and heart cavity. two different activities were used to fill the heart wall: . mbq (comparable to the activity usually obtained in clinical setting; standard dose) and . mbq (half-dose). a cold lesion was simulated in anterior, septal, posterior, and lateral region with a cubic cm cold disk inserted in the cardiac wall. for each wall activity and the different lesions, two sets of acquisitions were recorded: one at sec/frames (standard time) and one at sec/frame (half time). each spect was reconstructed with conventional fbp (butterworth, . , ) and with wbr™; a circular roi was drawn on the short-axis slice better displaying the lesion. an activity-vs-angular position histogram (circumferential profile) was obtained and the fwhm was calculated for each lesion. results. the average fwhm in half-time/standard dose ( . degrees) and halfdose/standard time ( . degrees) wbr™ spect were comparable to that of standard time/standard dose fbp spect ( . degrees). however, the fwhm in half time/half dose wbr™ spect ( . degrees) was worst than standard time/standard dose fbp spect. conclusions. the new iterative reconstruction algorithm wbr™ compared well in respect to conventional fbp spect, allowing half-time or halfactivity studies. however, further studies are needed to verify the potential clinical application of this method. fanbeam reconstruction using an iterative algorithm including d-collimator modell s o. s. grosser , t. prautzsch , g. ebel , m. seemann , j. ricke ; radiology und nuclear medicine, universitaetsklinikum magdeburg, magdeburg, germany, scivis, goettingen, germany. aim: fanbeam geometry improves resolution and sensitivity imaging small volumes and small field-of-views. reconstruction of volume data from fanbeam projections is usually performed using filtered back-projection algorithm (fbp). this procedure considers the imaging geometry, but attenuation and collimator characteristics are ignored. to improve imaging quality we performed reconstruction using an d-itertiv reconstruction algorithm for fanbeam geometry. the algorithm incorporates the distance and location dependent point spread function of the collimator and attenuation of the object. material and methods: examinations were performed using an e.cam variable (siemens medical solutions) gamma camera with fanbeam collimators. for this system the location dependent point spread function for different distances to the collimator front and for different positions orthogonal to the focus line were estimated. a d-system model is derived. it is used for iterative reconstruction with gma (geometric mean algorithm). we performed spect with a jaszcsak-phantom with different count rates (high/low) and different numbers of projection angles (n= , and ). data were reconstructed using a clinical established fbp including chang's attenuation correction and with an iterative algorithm using a contour based attenuation correction. furthermore the reconstructed data were examined for image quality and artifacts. spect homogeneity and resolution of solid spheres with different diameters were estimated. additionally line profiles, resolution and contrast were examined. results: the visual image quality of gma reconstructed data is significant improved compared to images reconstructed by fbp. in addition iterative reconstructed images show an better signal-noise-ratio snr (gma: . ; fbp: . ; p= . ) and a significant higher contrast in small solid spheres. fbp shows typical extra corporal artefacts. these artefacts are not to notice in images reconstructed with gma. conclusion: utilization of iterative fanbeam reconstruction including a d-collimator model results compared to standard fbp to an improved image quality, significant higher snr and an increased contrast. using the iterative algorithm is connected with an acceptable time involved. the main obstacle of fbp is the noise otherwise it is the best technique of tomographic reconstruction. determining the best filter and the proper degree of smoothing can help to ensure the most accurate diagnosis. unfortunately there have been significant discrepancies in selection of proper filter and adjustment of the filter parameters to individual cases. the purpose of this study was to define an optimal parameter for the tomographic reconstruction procedure in routine single photon emission tomography (spect) studies. in this study hoffman brain phantom is modified in such a way that only software capability is evaluated. the phantom is composed of several independent slice that can be imaged individually (planar) or in -d composition (spect). method and materials: the designed phantom was filled with water containing mtc. dual head mediso gamma camera spect system, equipped lehr and legp parallel hole collimators was used. energy window was set at ± % of photo peak. planar image of the slices were acquired separately at - cm from the collimator face collecting counts. tomographic image was performed using the phantom in d position. a total of projection images with × matrix were acquired over °. the time per view was and sec. planar images were used as reference ideal image for each corresponding reconstructed slice images. all the spect images were reconstructed using different filtering conditions. the quality of reconstructed images was evaluated by comparing the reconstructed images with the reference image using the universal image quality index (uiqi). results: at all count density no significant difference observed between metz and wiener (), however the difference between these two and other filters was quite significant (p< . ). the optimum filtering condition was significantly related to the count density (signal to noise ration) of the data. the results of this study are summarized the tabel- . finally, all of the acquisition studies regardless of counts or collimator, that the mean of uiqi was the most for wiener filter in comparison with the other filters. discussion: the data from this study suggests that the hanning and hamming are the weakest of the seven filter types tested. this is due to response of hanning and hamming filters at the low frequencies. based on the results of this study, wiener filter provided best image quality. aim: gated myocardial perfusion scintigraphy is an efficient tool to simultaneously assess myocardial perfusion, wall motion, left ventricular volumes and ejection fraction (lvef). filtered back projection (fbp) is often used for tomographic reconstruction, as this method can efficiently determine the transaxial slices. in a previous study we have investigated the effects of the applied smoothing filters on the measured volumes and ejection fractions. it turned out that the smaller volumes were underestimated, also resulting in an overestimation of the lvef for small hearts. iterative reconstruction techniques like osem perform better in low signal-to-noise ratio studies. so, we can apply filters with a higher cut-off frequency, which in turn may result in better estimates of the smaller volumes. in this study we have investigated the differences in measured volumes after fbp and osem reconstruction. methods: studies (ex/re) from patients were selected. all studies were reconstructed with fbp using an order butterworth filter with fixed cut-off frequency equal to . . the first studies were also reconstructed using osem. by increasing the cut-off frequency of the filter from . to . , a single frequency for all studies was selected above which the lvef was not changing anymore. in a former study this method was also applied to select the optimum cut-off frequency for fbp reconstructed studies. next all studies were reconstructed using both, fbp and osem, each method with their optimum cut-off frequency. a standard software package (germano) was used to determine the left ventricular volumes. fbp and osem results were compared on a study by study basis. results: the optimum cutoff frequency for osem turned out to be equal to . ( . for fbp). the comparisons of the volume measurements as well as the lvef are shown in the table. a good correlation was found between the two reconstruction methods. both, esv and edv volumes determined after osem turned out to be somewhat larger than those calculated from the fbp reconstructed studies, especially for the smaller lv volumes. lvef in turn, was found to be lower for osem compared to fbp with differences ranging from - % to + %. aim: erdheim-chester disease (ecd) is a rare multisystem, non-langerhans form of histiocytosis of unknown origin. it involves multiple organs and typically causes symmetrical osteosclerosis of the long bones. we describe patients with histologically proven ecd whose pet/ct showed vascular lesions. materiel and methods: case is a -year-old man operated for aortic regurgitation with a bicuspid aortic valve. spumous histiocytes were found in samples collected during surgery. a thoraco-abdominal ct showed an infiltration of main thoracic and abdominal arteries, and a perisplenic and perirenal fibrosis. bone scintigraphy showed symmetrical increased uptake of the long bones. case is a -year-old woman who had a history of weight loss and a severe biologic inflammation. a thoraco-abdominal ct scan revealed infiltration of the mediastinum, subrenal abdominal aorta and the superior mesenteric artery. bone scintigraphy did not reveal any abnormalities. the patients underwent a f-fdg pet/ct for evaluation of the extent of the disease. results: case : fdg pet imaging showed a marked hypermetabolism within the vascular lesions seen on the ct scan, with a more important fdg activity on the thoracic vascular lesions. there was no abnormal fdg uptake on the long bones. on the other hand, increased fdg uptake was observed on two dorsal vertebrae which was proved to be an extra-medullary meningioma. pet imaging failed to depict perirenal and perisplenic fibrosis. case : fdg pet showed only hypermetabolic foci: one on the level of the left pulmonary artery and the others of the superior mesenteric artery and the subrenal abdominal aorta. there was no abnormal fdg uptake on the skeleton. conclusion: fdg pet can detect extra skeletal lesions such as vascular involvement. in our cases, skeletal lesions were not depicted. this could be explained by effective treatment, since fdg pet was performed under chemotherapy. in ecd, fdg pet may be used for evaluation of the extent of the disease and the assessment of the response to therapy, but more further studies are needed. the prevalence of coronary steal in dipyridamoleinduced myocardial perfusion scintigraphy: the philippine heart center experience r. b. matias; philippine heart center, quezon city, philippines. to determine the prevalence of coronary steal in patients undergoing dipyridamoleinduced myocardial perfusion scan (mps) in the nuclear medicine division of phc to identify the subsequent mps abnormality in patients who developed coronary steal during dipyridamole induction. to determine if there is an association between mps abnormality and coronary steal. coronary steal is caused by redistribution of flow away from collateral-dependent myocardium following coronary vasodilatation. although coronary steal has been well described in canine studies, there are more limited observations of the absolute magnitude of coronary steal in humans and its relationship to clinical signs of myocardial ischemia. there is controversy whether chest pain and ecg changes with coronary vasodilation represent true myocardial ischemia because of coronary steal. dipyridamole (dipy) is often used as an alternative to exercise in the detection of coronary artery disease by radionuclide techniques that produce selective vasodilatation of normal coronary arteries, predominantly in the small, resistance vessels of the coronary bed. method: patients from january , to december , who developed chest pain with respective ecg changes after induction of dipy during mps procedure were included in the study. ecg changes include st segment depression or elevation of > mv in or more leads. perfusion abnormalities include evidence of inducible ischemia (mild, moderate or severe), fibrosis or scar and infarcts. normal perfusion scan pertains to those with no definite evidence of ischemia and defects which are due to soft tissue attenuation. a. hughes; royal preston hospital, preston, united kingdom. aim gated spect is a well established technique that allows simultaneous assessment of the perfusion and function of the left ventricle (lv). both global and regional lv function can be assessed using this technique and analysis of regional wall motion and thickening can help to identify viable myocardium and eliminate attenuation artefacts. most centres use an acquisition protocol that divides the cardiac cycle into frames. temporal resolution can be improved by using frames per cycle, but there will be a loss in the signal-to-noise ratio if the duration of the study is not increased. the aim of this study was to compare regional wall motion and thickening scores derived from gated spect using and frames per cycle. thirty-four female patients with normal perfusion and function were imaged on a philips forte jetstream gamma camera. gated datasets with and frames per cycle were acquired simultaneously one hour after treadmill exercise. all data were filtered using a -dimensional butterworth filter and reconstructed using filtered backprojection. regional wall motion and thickening scores were computed for a -segment model of the lv using the cedars-sinai qgs software. results wall thickening scores for the -frame datasets were consistently higher by - % throughout the myocardium. additionally, there was a significant increase in circumferential variation in thickening in the mid and distal portions of the lv, with the anterior and antero-lateral segments exhibiting the largest differences. wall motion scores were ~ % higher for the -frame data except in the septal wall, where the scores were comparable. comparing motion and thickening scores of patients with known functional defects with data from the normal patient group did not reveal an increased sensitivity of one technique over the other. conclusion the acquisition and processing of gated spect studies using frames per cycle is feasible on modern imaging systems. although there is an increase in temporal resolution over data acquired using frames per cycle, resulting in differences to the normal ranges, there does not appear to be an improvement in the detection of functional abnormalities. aim: brain natriuretic peptide (bnp) is a neuro-hormone representing a marker of heart impairment. female patients undergoing radiotherapy for left breast cancer may develop cardiac impairment. to evaluate this potential heart damage, bnp was measured in women treated by left breast radiotherapy. methods: twenty-four women with left breast carcinoma undergoing breast conservative surgery and radiotherapy (single dose gy; total dose gy followed by boost of gy on tumour bed) underwent bnp measurement, echocardiography and electrocardiogram at baseline ( week before treatment) and ( nd evaluation), ( rd evaluation) and ( th evaluation) months after radiotherapy. four patients were also evaluated months after radiotherapy, because the study is still in progress. aim: the aim of the study was to compare lv dyssynchrony assessment by gated myocardial perfusion spect (gmps) and tissue doppler imaging (tdi). background: recently, it has been demonstrated that left ventricular (lv) dyssynchrony is an important predictor of response to cardiac resynchronization therapy (crt); dyssynchrony is predominantly assessed by tdi with echocardiography. information on lv dyssynchrony can also be provided by gmps with phase analysis of regional lv maximal count changes throughout the cardiac cycle which tracks the onset of lv thickening. methods: in patients with heart failure, depressed lv function and wide qrs complex, gmps and d echocardiography, including tdi, were performed as part of clinical screening for eligibility for crt. clinical status was evaluated using nyha classification, -minute walk distance and quality-of-life score. different parameters (histogram bandwidth, phase standard deviation (sd), histogram skewness and histogram kurtosis) of lv dyssynchrony were assessed from gmps and compared with lv dyssynchrony on tdi using pearson's correlation analyses. results: histogram bandwidth and phase sd correlated well with lv dyssynchrony assessed with tdi (r= . , p< . and r= . , p< . respectively). histogram skewness and kurtosis correlated less well with lv dyssynchrony on tdi (r=- . , p< . and r=- . , p< . respectively). conclusion: lv dyssynchrony assessed from gmps correlated well with dyssynchrony assessed by tdi; histogram bandwidth and phase sd showed the best correlation with lv dyssynchrony on tdi. these parameters appear most optimal for assessment of lv dyssynchrony with gmps. outcome studies after crt are needed to further validate the use of gmps for assessment of lv dyssynchrony. aim. using radionuclide methods to study the correlation between the disturbances of central hemodynamics and the renal functional activity in patients with heart failure. material and methods. thirty seven patients (median age was , ± , years) with coronary artery disease (cad) and heart failure (hf) of nyha class ii or iii were examined using radionuclide renoscintigraphy and radiocardiopulmonography. parameters of cardio-pulmonary hemodynamics and renal function were estimated. results. we observed the damage of most of cardio-pulmonary hemodynamics parameters in all patients. that indicated the reduction of contractive activity of the left and right heart ventricles with pulmonary hypertension development. the disturbances of renal function were note in % of pts with hf and included the decrease of glomerular filtration rate and/or the increase of parenchymal clearance of mtc-dtpa. using multiple linear regression analysis significant positive correlations were detected of the damages of renal filtration and evacuatory parameters with the decrease of cardiac minute volume, cardiac index and efficiency factor of circulation. therefore the decrease of cardiac output is one of the basic factors of renal dysfunction pathogenesis in patients with hf. furthermore were detected significant negative correlations between the disturbance of pulmonary circulation and the decrease of glomerular filtration rate. conclusion. the radionuclide methods are available for the evaluation of influence of hemodynamics disturbances on renal function in pts with hf. aim to explain our experience with gbps, the obtained measurements of right and left ventricular ejection fraction (rvef and lvef) from gbps and corresponding values determined by equilibrium imaging, due to erv is the standard technique used to evaluate ejection fraction. to assess the reproducibility and reliability, the advantages and limitations of both thechniques. materials and methods patients underwent gbps and erv. there were females and males, with a range age between to years, who had risk of cardiotoxicity induced by chemotherapy (this is the most frequent indication to evaluate fvef), except the younger patient, who presented congenital cardiopathy, and the two older men, who presented cardiac failure. imaging was performed min after administration of mbq m tclabelled blood cells, acquiring spect with ecg gating. next a planar image was acquired, about min after injection. the data were processed using qube algorithm on a segami workstation by a physician specialist in nuclear medicine and processed again to assess intraobserver reproducibility. a second operator reconstructed and processed the same studies, to assess interobserver reproducibility. bland-altman analysis was applied. results the mean of lvef's values obtained with gbps was . , versus . from erv. for rvef was . with gbps and . with erv. the intraobserver reproducibility of lvef and rvef was higher for erv than gbps in both observers (in the best of cases, the limits of agreement ± sd calculated using bland-altman analysis were - . ± . for gbps vs. . ± . for erv from lvef, and . ± . for gbps vs. . ± . for erv from rvef). the interobserver reproducibility presented less differences between both techniques. lvef and rvef obtained from gbps were compared with those from erv using bland-altman analysis. the mean difference was . with ds . from lvef and - . with ds . from rvef. processing of data obtained with erv for rvef was unsuccessful in patients, in this cases gbps was very useful to estimate rvef. conclusions gbps presented a intra-inter-observer reproducibility slightly lower than erv. this technique provides values of lvef higher than erv (approximately %), but rvef's values were very similar to obtained with erv. in cases that rvef is especially difficult to estimate with erv, gbps is very usefull. aim: the aim of the study was to identify myocardial viability by mtc-tetrofosmine (rest and nitrate) in patients with ischemic left ventricular aneurysm. material and methods: the study involved patients (men) aged - with stable angina of the ii-iv nyha classes, chronic left ventricular aneurysm, all of them had a history of - previous transmural myocardial infarction. all patients before operation were underwent mtc-tetrofosmine myocardial spect according to protocol "nitrate-test ( mg of sublingual isosorbide dinitrate) -rest". all patients underwent coronary artery bypass surgery (abs) and aneurysmectomy by dore. after operation patients in weeks were underwent mtc-tetrofosmine myocardial spect only rest. analyse was performed by dividing the left ventricle into segments for spect. result: segments of left ventricle were analyzed on mtc-tetrofosmine spect. after mtc-tetrofosmine nitrate-test the amount of aperfusion sectors decreased in % in comparison with rest. after the surgery, we found that the amount of aperfusion segments was %; the amount of normal perfusion segments was %. we analyzed perfusion scans and myocardium segments for assessment size of the perfusion defect. average the perfusion defect before operation in mtc-tetrofosmine spect rest was . ± . %. after mtc-tetrofosmine nitrate-test it decreased to , ± , % (p< . ). after the surgery it was . ± . %. we found significant difference in intensity of accumulation mtc-tetrofosmine in the perfusion defect on rest and nitrate-test (p< . ). conclusions: mtc-tetrofosmine spect by protocol rest -nitrate -rest is useful techniques for the identification of viable myocardium and to predict functional recovery after revascularisation in patients with ischemic left ventricular aneurysm. diagnostic value of gated spect myocardial perfusion imaging using thallium- in patients with latent coronary artery disease h. shi, y. gu, w. liu, w. zhu; zhongshan hospital, fudan university, shanghai, china. aims: to investigate the diagnostic value of spect myocardial perfusion imaging using thallium- for the patient likelihood of latent coronary artery disease. materials and methods: fifty-two asymptomatic aircrews with positive results of exercise treadmill test underwent dipyridamole pharmaceutical stress and rest spect myocardial perfusion imaging using thallium- . patients with myocardial perfusion imaging positive findings accepted coronary artery angiography. patients with myocardial perfusion imaging negative findings were followed up till five years. results: twenty-four patients showed positive results in myocardial perfusion imaging and twenty two of them detected coronary artery stenoses with more than % luminal narrowing by coronary artery angiography and two of them were negative results in coronary artery angiography. twenty eight patients showed normal in myocardial perfusion imaging and no cardiac events happened in the following five years after myocardial perfusion imaging performed. conclusion: spect myocardial perfusion imaging using thallium- is very useful method for detecting latent coronary artery disease, especially for negative predictive value. and its diagnostic accuracy is much higher than exercise treadmill test. association of left ventricular functional parameters measured by gated single photon emission tomography and by two-dimensional echocardiography c. groselj, , b. simonic, , b. groselj, ; university medical center, ljubljana, slovenia, medical faculty, ljubljana, slovenia. introduction lvef, edv and esv are good clinical indicators of left ventricular function and volumes, routinely measured by echocardiography (echoc). in former decade the emory cardiac tool box (ectb) was developed, a toll for assessing left ventricular function and volumes from gated spect myocardial perfusion scintigraphy (gspect). gspect myocardial function assessment provides an important incremental information. aim of the study the aim of the present study was to validate the accuracy of the ectb in assessing lvef, edv and esv from gspect using echoc as a reference values. patients and methods consecutive patients, males and females; mean age +/- y, range - y, with suspected or known coronary artery disease were examined using mtc-mibi gspect ( gates/cardiac cycle) min after tracer injection at stress. the gspet data were reconstructed using an automatic algorithm employing filtered back projection (fbp) and further analyzed by emory cardiac (ec) toolbox. all patients underwent two-dimensional ( d) m-mode echoc in the same diagnostic evaluation. the results of both methods were compared. aim to determine if an average residual activity could be assumed for stress and rest myoview administrations. method an audit of residual activity in the syringe following myoview administrations for myocardial perfusion imaging was conducted at guy's and st thomas' (gstt) and the royal free hospital (rfh). residual activities for both stress and rest administrations were measured. myoview was administered using ml terumo syringes and ml braun injekt syringes at gstt, and ml bd luer-lok syringes and a y-tap extension set at rfh. stress activities were administered via a -way tap (gstt) and y-tap extension set (rfh). rest activities were directly injected into a vein. results at gstt residuals for rest studies and residuals for stress studies were collected using terumo syringes. residuals for stress studies were collected during a trial of braun injekt syringes. at the rfh residuals for stress studies and residuals for rest studies were collected. the residual activities from gstt, using the terumo and injekt syringes follow a normal distribution for both stress and rest administrations, and there was no dependence of residual activity on time of injection. there was a statistically significant difference in residuals between technologists for stress injections but not rest injections. the mean stress residual using terumo syringes ( . mbq), is significantly higher (p = < . ) than the mean rest residual of . mbq. the mean stress residual for braun injekt syringes of . mbq was significantly lower than the mean for terumo syringes of . mbq (p=< . ). the mean stress residual using the y-tap extension of . mbq was significantly lower than the stress administration with terumo syringes (p= . ). there was no significant difference between the rest and stress residual activities at the rfh (p= . ). conclusion: the significant difference between stress and rest residual activities was attributed to increased difficulty flushing the syringe during the stressing procedure, compared to direct injection. the significant difference between the stress residuals using the terumo and y-tap extension set but not between the rest residuals demonstrates that the stressing method using a y-tap extension reduces the residual activity and is not due to technologist working practices. due to the overall large variation of residuals assuming a single average residual activity may not be good practice. however, residual activities were significantly reduced using the injekt syringes and the y-tap extension set. using injekt syringes would reduce the residual of rest injections as well as stress injections. the value of radionuclide methods in patients with suspicious chronic myocarditis. , -complained about chest pain and dyspnea, had myocardial conduction disorders. echocardiography showed abnormalities at patients: hypokinesia (total or local) at al cases, mitral valve prolapse -in cases. abnormalities of laboratory indexes were found at patients (increasing of erythrocyte sedimentation rate, levels of ast and kfk). all patients underwent spect with mtc-hmpao-leucocytes at hours post injection, following by gated-spect with mtc-mibi at the rest condition. both scintigrams were then combined, using fusion display application, to define more exactly the localization of mtc-hmpao-leucocytes uptake in the heart. the presence, character and magnitude of perfusion defects, ejection fraction (ef) of left ventricle (lv), motion and thickening extent were also estimated. results: perfusion defects were detected at cases, with average size - , ± , % (max - %), which localized in ventricular septum, anterior or inferior wall of the lv. ( ). the viability of labelled stem cells was tested by flow cytometry with propidium iodure (facscan® becton dickinson™). the proliferation capacity was tested by cell culture on specific media (rpmi-based cell media). after determination of optimal dose, we made an intramyocardial injection of labelled stem cells on a healthy rabbit. a spect scintigraphy was then performed with static acquisitions at and h after injection. results: the labelling efficiency was good for all samples with an average rate of % ( - %). the viability was . % of living cells (no significant difference with control groups). the labelling with . mbq did not interfere on the proliferation whereas the higher activities, . or . mbq, stopped proliferation. the lowest dose does not disturb the viability and proliferation of stem cells and allows spect scintigraphy until at least h after intramyocardial injection of labelled stem cells on animal. conclusion: the labelling of rabbit bone marrow stem cells was successfully performed with indium- oxine. thus, we can follow stem cell therapy by spect scintigraphy without affecting cell viability or proliferation. the usefulness of an f-fdg pet/ct image obtained at hours after intravenous f-fdg injection in detecting aortic f-fdg uptake compared to that obtained at hour after injection aim: atherosclerosis is an immune inflammatory disease. increased macrophage metabolism is seen in active atherosclerotic plaque inflammation. f-fdg concentrates in those lesions and many studies have reported clinically and experimentally regarding the f-fdg images of atherosclerotic plaque inflammation. most of the studies used pet or pet/ct images obtained at about hour after intravenous f-fdg injection (as an early image), but to our knowledge there have been no reports using pet or pet/ct images obtained at hours after injection (as a delayed image). therefore we investigated the usefulness of the delayed pet/ct images in detecting aortic f-fdg uptake comparing with the early images. forty-one patients were participated in this study who were referred for tumor staging or seeking recurrence or metastatic lesions using fdg-pet/ct. we reviewed the early and delayed images visually for the presence of aortic f-fdg uptake. aortic f-fdg uptake was evaluated visually by dividing into the following sections: ( ) ascending aorta, ( ) aortic arch, ( ) thoracic descending aorta, ( ) upper abdominal aorta and ( ) lower abdominal aorta. we also examined the degree of aortic blood-pool f-fdg activity. results: the delayed image showed decreased blood-pool f-fdg activity in all lesions of the aorta. the number of aortic f-fdg uptake seen in the early image, the number of uptakes seen in the delayed image and the number of obtained clear visualizations in the delayed image of each section were as follows: ( ); , and , ( ) ; , and , ( ); , and , ( ); , and , ( ); , and , respectively. conclusion: this presentation illustrates the change in the aortic f-fdg uptake over time and the usefulness of delayed pet/ct images. about half of the aortic f-fdg uptake lesions in the delayed image showed clear visualization compared to the early image. the reasons were thought to be not only decreasing the blood-pool f-fdg activity but also increasing the aortic f-fdg uptake itself in the delayed image. aim: to measure the equivalent doses of radiation to medical staff performing nh myocardial perfusion pet scan. methods: the study was conducted in during pet examinations. nine examinations were performed on patients with severe ischaemic heart disease and consisted of two pet scans (one rest and one dipyridamole pharmacological stress scan), and eight examinations were performed on asymptomatic hiv patients and consisted of three pet scans (one rest, one cold pressor stress and one dipyridamole pharmacological stress scan). an electronic dosimeter was placed on the chest, and highly sensitive thermoluminescent dosimeters (tld) were placed on the right index finger and the right wrist of the two technologists and the physician, performing the examinations. when examinations consisted of two scans ( s), the primary technologist (t ) withdrew nh from the production facility and performed injection of the tracer into the patient. the second technologist (t ) nursed and observed the patient during the whole scan, and the physician (p) monitored and observed the patient during the pharmacologic stress. when examinations consisted of three scans ( s), the roles were the same, but the physician additionally held the left leg of the patient in ºc water and coached the patient through the cold pressor testing. results: when performing two scans, the mean equivalent doses to the index finger were μsv, μsv and μsv, and the mean equivalent doses to the wrist were μsv, μsv and μsv for t , t and p respectively. when performing three scans, the mean equivalent doses to the index finger were μsv, μsv and μsv, and the mean equivalent doses to the wrist were μsv, μsv and μsv for t , t and p respectively. the mean equivalent doses to the chest when performing two scans measured by electronic dosimeter were ± . μsv for t (p= . vs. s and p< . vs. b and p), ± . μsv for t (p= . vs. p) and ± . μsv for p and when performing three scans, ± . μsv, ± . μsv and ± . μsv for t , t and p respectively. conclusion: mean equivalent dose is less than ‰ of the current one year dose limit for the most exposed member of the medical staff when performing a myocardial perfusion examination with three nh pet scans. equivalent dose is dependant on work function and scan regimen as well as patient morbidity. the role of f -fdg pet in the diagnosis of large vessel vasculitis purpose: physiological accumulation of fdg into salivary glands often causes false positive findings in diagnosing head and neck lesions. it has been reported that some amount of radioactivity were excreted into saliva, therefore gargling before pet scanning has been investigated for improving the image quality in this region, however the actual efficacy of it is still unknown. in this study, we assessed the efficacy of lemon stimulation for encourage secretion of radioactivity in saliva to obtain images with higher quality. methods and materials: thirty normal subjects were examined fdg pet before and after lemon stimulus. region of interests of salivary glands, oral cavity and soft tissue were determined according to anatomical margins of them using fusion image with ct, and suvs were measured. radioactivities in saliva before and after lemon stimulation were also measured by a curiemeter. results: the suvs of salivary glands were shown in table ( pg: parotid gland, smg: submandibular gland, slg: sublingual gland ). there were no significant differences between before and after lemon stimulation. in addition, radioactivity in saliva after lemon stimulation was . +/- . microci in ml of gargling water which was as low level of radioactivity as that of background ( . +/- . microci/ml). conclusions: although low level of radioactivity was present in saliva after injection of fdg, excretion of it was not influenced by lemon stimulation in normal subjects. therefore, alternative imaging methods need to be developed for reduction of physiological accumulation of fdg into salivary glands and for improving image quality in the area of oral cavity. aim. diffusion weighted mr imaging is a technique allowing to grade non-invasively the tumour cellularity, basing on the principle that molecules in living tissues routinely undergo random (brownian) motion. adc (apparent diffusion coefficient) is a value describing microscopic water diffusibility in presence of factors restricting diffusion within tissue (cell membranes, viscosity). our aim was to investigate the existence of a relationship between metabolic activity as measured by fdg pet and water diffusivity as evaluated by apparent diffusion coefficients (adc) in brain tumours. methods. gadolinium-enhanced fast spoiled gradient echo (gd-fspgr), diffusion weighted magnetic resonance imaging (dwi) with adc maps and fdg pet were performed in patients ( glioblastoma multiforme, astrocytoma, brain metastases) with tumour lesions. adc and fdg pet images were coregistered with enhanced fspgr images to identify tumour sites. spherical d tumour and contralateral control region of interest (rois) of the same geometric parameters were drawn on fspgr, adc and pet images, using gd-fspgr as target for statistical parametric mapping with fused localization of adc and pet (by using mricro). pet and adc ratios of the tumour and control roi were obtained and linear regression analysis was carried out. results. a significant correlation was not shown between pet and adc ratios in all lesions studied; plotting ratios, if pet values were greater than . , adc data were below , while if adc indices were greater than , pet ratios were below . . a significant correlation (r = . , p = . ) was found between pet and adc findings in lesions, having pet and adc ratios lower than . conclusions. our data, although preliminary, show that a relationship might exist if pet and adc present low ratios. this could be due to the fact that in high cellularity areas, structures and cell membranes could increase impedence to water diffusion, causing decreased adc values and increased fdg uptake, while areas with low cellularity, i.e. necrotic areas, present increased adc and reduced fdg uptake. aim: according to literature, f-fluoroethyl-l-tyrosine (fet) was found to be a new valuable pet tracer to image brain tumors. particularly, fet uptake was higher in recurrent gliomas than in radiation injuries, whereas ct and mri showed a limited specificity in differentiating between post-therapeutic unspecific changes and neoplastic lesions. in this study we evaluated the contribution of fet pet/ct in the diagnosis of tumor recurrence in patients with gliomas undergoing multimodal treatment or radiosurgery. methods: the study included patients with glioma (primary grading: =who grade iv, = grade iii, = grade ii) who showed neuroradiological findings suspected for tumor relapse after multimodal treatment ( patients) and gliasite radiation therapy using radioactive iodine -i-iotrex ( patients). brain pet/ct scans (discovery ls pet/ct scanner, ge healthcare, milwaukee, wi, usa) were performed min after injection of - mbq of ffluoroethyl-l-tyrosine (iason labormedizin gesmbh & co. kg graz-seisberg, austria) using d mode acquisitions in / cases and d acquisitions in / the fet uptake in the most active part of the lesion was quantified by the standardized uptake value (suvmax) and lesion-to-brain ratio (suvmax/bg). brain lesions with a suvmax/bg of at least . were interpreted as probable recurrent disease. previously undergone breast cancer surgery and sentinel node biopsy and, when indicated, axilla lymphadenectomy, were enrolled. a sct scan was already performed in these patients when they came to our institution for pet/ct scanning. we compared sites and number of sct-diagnosed relapses with pet/ct results. results. in / patients (pts) ( %) sct scanning showed relapses not observed by pet/ct; in of these pts metastases observed in sct scans were located in liver or lungs. in other pts metastases sites were axillary or mediastinal lymph node chains. in / pts ( %) pet/ct results were coparable to sct ones. / pts ( %) had negative sct scanning, while pet/ct revealed widespread bone or lymph nodes metastases. finally in / pts ( %) pet scans showed unclear meaning high metabolic activity bone and lymph nodes areas; while in the same pts sct imaging revealed different sites of relapses as in lungs. conclusion. pet/ct seems to have higher sensitivity and positive predictive value than sct in detecting lymph node and bone relapses; sct appears more reliable than pet/ct to reveal lung or liver metastases. comparison of m aim. breast carcinoma express the na+/i-symporter and may -albeit not a routine procedure -be imaged with iodide ( i) and mtechnetium-pertechnetate ( mtco -) scintigraphy. objective of our prospective study was the comparison of mtco --and i-spect with fdg-pet in patients suspicious for breast cancer. methods and patients. twenty-nine untreated patients suspicious for breast carcinoma were prospectively examined with thorax spect with mtco -(n= ) or i (n= ), respectively, and fdg-pet (n= ) prior to biopsy. tumor-to-background ratios (tbr) were calculated for spect findings. mean and maximum suv were calculated for pet findings. findings were compared in an intra-individual lesion-tolesion analysis. results. in / patients, malignancy was verified with histopathology. in imaging the primary tumor, sensitivities of mtco --spect, i-spect and fdg-pet were %, % and %, respectively. tbr mean was . ± . in mtco --spect and . ± . in i-spect. in fdg-pet, mean tumor suv was . ± and maximum tumor suv was . ± . . in contrast to fdg-pet, mtco --spect was not sufficient in imaging nodal and distant metastases in the thorax, and i-spect failed in imaging lymph node infiltrations. distant metastases were not present in patients of the i group, and the value of i-spect was not evaluated. conclusion. in contrast to fdg-pet, mtco --and i-spect are not sufficient in imaging breast carcinoma in clinical practice. showed an overall accuracy of %, with sensitivity and specificity of % and % respectively. conversely, dual-time point pet-ct showed an overall accuracy of %, for lesions with an suvmax . and/or with a positive suvmax, with sensitivity and specificity of % and %, respectively vs %, % (both, p< . ) and % (p=n.s.) of single-time point pet-ct. in addition, on pet-ct, malignant lesions showed an increase in fdg uptake between time point and , with a %suv of ± . conversely, benign lesions showed either no change or a decrease in suvmax between time point and , with a % suv max of ± (p < . ). discussion. mri shows higher sensitivity compared to pet-ct in disclosing breast malignancy. dual-time point improves pet-ct accuracy in patients with suspicious breast malignancy over single point pet-ct. on pet-ct examination there is increasing uptake of fdg over time in breast tumor, conversely, benign lesions show a decrease in fdg uptake over time. these changes in suvs over time might be considered a reliable parameter that can be used to differentiate benign from malignant lesions of the breast, on pet-ct examination. aim : to evaluate the significance of early and late delayed image in the lesion that suv is over . . material and methods : cases suspected malignancy obtained three-phase ( ± min, ± , ± after fdg injection) pet/ct scan. the maximum suv value in three phase were recorded as suv ,suv ,suv . retention index of each lesion in two delayed phase were calculated according to the following formula: ri =(suv -suv )/suv * %.ri =(suv -suv )/suv * %. the diagnostic value of two delayed images was compared through roc curve. the most proper cut-off value of ri in two different delayed phases was established. results : / lesions were malignancy, / lesions were benign, that were proven by pathology, clinical, laboratory and radiological examination. suv in each lesion was over . . ri ,ri in malignancy were . %± . %, . %± . %, the correlation coefficient was . (p= . ). ri ,ri in benign lesion were . %± . %, . %± . %, the correlation coefficient was . (p= . ). through analysis of roc curve, the area under roc curve in early delayed image was . ± . (null hypothesis: true area = . , p< . ), when ri = %, the maximum youden's index was . , the diagnostic sensitivity, specificity and accuracy was . %, . %, . %. the area under roc curve in late delayed image was . ± . (null hypothesis: true area = . ,p> . ), that suggest late delayed image has no diagnostic value. conclusions : the retention index of two delayed phase in benign and malignant lesion have good relativity. the diagnostic value of early delayed image is higher than late delayed image. when ri was % in early delayed image, it has maximum diagnostic efficiency. the aim of the study is to evaluate the use of pet-ct for detection of mediastinal lymph node (mln) metastases from preoperatory staging of non small cell lung cancer in order to avoid mediastinoscopy before surgery. material and method we studied patients (p), out of them were women, between - years old (medium of years). we used a ge discovery ls equipment to realize the pet-ct studies after the administration of mbq of f-fdg and multislide ct without iv contrast. we analized histologically the primary tumour and mediastinal lymph nodes in all patients by means of mediastinoscopy or thoracotomy. we determined tumour staging and the standard uptake value (suv) of the tumour and mediastinal lymph nodes with activity above vascular pool. results primary tumour location: hilium p, right lower lobe p, left lower lobe , lingula p, medium lobe p, right upper lobe and left upper lobe . hystological analyse of primary tumour: adenoesquamous carcinoma p, adenocarcinoma p, large cell carcinoma p , bronchioloalveolar p and others p. differentiation grades: indiferentiated , %, low , %, moderate %, high , % and non valuable %. suv t = , ( - , ) ; suv t = , ( - ); suv t = , ( - ); suv t = , ( - ). staging: ia p; ib p; iia p; s iib p; iiia p, iiib p and iv p. detection of mediastinal metastases: sensitivity: . , specificity: . , ppv: . ; npv: . and diagnostic accuracy: . . the false-positive pet-ct scan were carcinoma abcessed, fibrohistiocitosis and inespecific adenitis . false negative scan in p with subcarinal mediastinal station afectation milimetric nodal size. the hight npv of pet-ct can avoid mediastinoscopy. but it must be considered that a positive or negative pet-ct does not assess or exclude malignancy in mediastinal nodes. aim: pet is a useful technique in the staging of non small-cell lung cancer (nsclc). although there is a wide experience with fdg-pet and ct, the introduction of pet/ct deserves to investigate its role in the context of diagnostic ct as a routine technique for nsclc staging. the aim of this study was to compare the contribution of fdg-pet/ct and diagnostic ct in the staging of nsclc. material and methods: sixty-six patients with nsclc, male and female were studied, (average age of years). all patients underwent a fdg-pet/ct and a ct, in -month interval. the findings of both techniques were compared, and the final diagnosis was made by histological findings, clinical follow up, and response to therapy. results: fdg-pet/ct and ct findings were concordant in of the patients ( %). in of them, the same lesions were identified. in of the patients ( %), the results disagreed. thus, in of the discordant patients ( %), the fdg-pet/ct showed a greater involvement than ct, related to the extension of lymph node involvement in patients ( false positives) and to the number of metastasis in ( false positives). in of the discordant patients, the fdg-pet/ct showed a smaller involvement than ct: less lymph nodes in ( %) and less metastasis in ( %). therefore, in / patients fdg-pet/ct and ct showed differences in location of the involved lymph node region. staging was modified by fdg-pet/ct in / ( %): it was increased in ( %) ( false positives) and diminished in ( %). in patients ( %), fdg-pet/ct modified the therapeutic setting, avoiding surgery in ( %), discarding adrenal metastasis in ( . %), and diminishing the lymph node extension in ( , %) patients. objective: diffusion-weighted mri is known to provide images seemingly similar to those of fdg-pet. in the present study, we examined and compared lung cancer cases using fdg-pet/ct and dwibs (diffusion-weighted mri) on the same day. [subjects] we examined lesions that were confirmed to be lung cancer with lymph node metastasis based on biopsies in addition to one pulmonary hamartoma lesion in patients who underwent follow-ups longer than months. the mean lesion size was . ± . mm (range: - mm). materials and methods: after -hour fasting, fdg was intravenously injected at a dose of . mbq/kg and then its distribution was analyzed using discovery st elite system (ge) one hour later. dwibs was performed to the consented patients, immediately prior to pet analysis, by taking images (slice thickness = mm, b-factor = ) with a single shot epi method using a -ch body array coil with signa excite . t (ge). both images were visually evaluated. the tracer accumulation in the liver and the signals in the spinal cord were considered to be positive for pet, dwibs, respectively. results: twenty ( . %) of the malignant lesions were positive on fdg-pet/ct, whereas lesions ( . %) were positive on dwibs. there were no significant differences between the two modalities (p = . ). the benign pulmonary hamartoma was negative on pet, but positive on dwibs. pulmonary adenocarcinoma ( . mm) in the right upper lobe showed false-negative findings on pet, but ct scanning of this node indicated suspicious pulmonary adenocarcinoma. in addition, left pulmonary hilar lymph node metastasis ( mm) associated with left upper lobe cancer and pulmonary adenocarcinoma ( mm) in the right upper lobe showed false-negative findings on dwibs. conclusion: both pet and dwibs detected malignant lesions almost the same level. however, dwibs is less efficient in differentiating malignant lesions from benign lesions because dwibs showed benign lesions such as pulmonary hamartoma as positive. by-lesion analysis. the vertebrae were the most frequently involved bones ( / = . %), followed by ribs ( / = . %), and pelvic bones ( / = . %). suv values of the metastatic foci range from . to . (mean . ; median . ). the ct patterns were classified into four groups: osteolytic ( / = . %); osteoblastic ( / = . %), mixed ( / = . %) and invisible type ( / = . %). osteolytic and invisible skeletal metastases showed higher value of fdg uptake than osteoblastic (the difference were statistically significant, p < . ) and mixed lesions (the difference were statistically borderline, p = . ). conclusion: our preliminary data shows that [ f]fdg-pet/ct provides a powerful combination of functional and morphologic information allowing an accurate characterization of bone metastases in lung cancer in terms of both metabolism and structural changes. , suvmax, and suvmean were calculated for each adrenal lesion. moreover, fdg adrenal uptake was compared with radioactivity of aorta, liver, and spleen by calculating the adrenal lesion-to-aorta, the adrenal lesion-toliver, and the adrenal lesion-to-spleen suv ratio. standard of reference for confirming the definitive nature of the adrenal lesions was either histophatology or clinical/imaging follow-up data. the value of [ f]fdg-pet/ct imaging was assessed by using independent t tests and receiving operating characteristic analysis (roc). results: of the lesions, turned out to be malignant based on subsequent growth (n = ) or histophatology (n = ), while were benign based on stability for months (n = ) or histopathologic analysis (n = ). there was a statistically significant difference in hu and suv between benign and malignant masses (p < . ), while the difference in size was not statistically significant (p = . ). the cutoff values derived from roc analysis for best discriminating malignant from benign lesions were as follows: suvmax of . (auc = . , sensitivity = %, specificity = %, ppv = %, and npv of %), hu of (auc = . , sensitivity = %, specificity = . %, ppv = . %,and npv of %), and a adrenal lesion-liver suv ratio of . (auc = . , sensitivity = %, specificity = %, ppv = %,and npv of % purpose: positron emission tomography (pet) is a radioisotope imaging method for obtaining information of organs and metabolisms within the human body. one of the most important criteria for quality-pet images is a high contrast value. injection doses and scan durations have important effects on the contrast of pet images, especially for the overweight patients. in this study, we have investigated the impact of injection doses and scan durations on the spatial resolution of the pet images within the lung lesions with diameters . , . , . and . cm consecutively. material and method: for the study, a whole body phantom was designed considering a standard adult human body of average weight of kg. the lung-lesions were filled with different an activity-concentration as , and times more than that of lung-tissue background. seventy-two transaxial pet images were acquired with combinations of , , , , , mbq/kg injected doses and , , , min/bed scan durations using a siemens biograph hi-res pet/ct. results: it was found that the visibility and contrast value of lung lesions increased with the increasing of injection doses and scan duration. two minutes scan duration for a bed position is not sufficient to localize a lesion with . cm diameter with all injection doses. apart from this, all scan durations and injection doses used in this study are sufficient to detect the lesion of . cm diameter. conclusion: we concluded that minimum contrast value for the visibility of a lung tumor pet image is and min/bed scan duration and mbq/kg injection dose are sufficient to detect the lung lesion used in this study. objective: pulmonary nodules associated with low or absent flourodeoxyglucose (fdg) tracer activity on fdg pet can generally be managed conservatively after consideration of multiple clinical parameters and risk factors. in some instances, patients with such pulmonary nodules have hilar and mediastinal lymph nodes with definite abnormal fdg uptake, confounding study interpretation and patient management. we hypothesized that a high level of fdg uptake in hilar or mediastinal lymph nodes, in the setting of a pulmonary nodule with low or absent fdg uptake, is due to benign inflammatory processes. methods: a total of pet-ct reports were reviewed and twenty-seven studies with discordant pulmonary nodule and hilar or mediastinal lymph node metabolism were identified. discordance was defined by an suv ratio of lymph nodes to nodule of greater than . . the suv (standardized uptake) values (average values, not corrected for lean body mass, and measured at - minutes post fdg administration) were calculated from filtered back projection images, and ratios were then calculated based on those suv values. a retrospective chart review was performed on the cases that met the study criteria and the follow-up (biopsy or follow up imaging) was documented. patients with a known diagnosis of malignancy or sarcoidosis were not included in the study. results: the suv values for the nodules ranged from . - . , with a mean of . . the suv values for the lymph nodes ranged from . - . , with a mean of . . in of twenty-seven patients biopsy found histologic findings of necrotizing granulomas or histoplasmosis. in of the twenty-seven patients, follow-up imaging revealed the hilar or mediastinal lymph nodes had decreased in size or remained stable. the remaining nine patients have yet to be followed up. conclusion: in patients undergoing fdg pet for evaluation of a pulmonary nodule, a nodule with low or absent glucose metabolism can likely be managed conservatively, even when there is definite associated abnormal glucose metabolism in hilar or mediastinal lymph nodes. f-fdg uptake of n lymph nodes and primary tumor on pet: clinical significance in stage iiia n non-small-cell lung cancer purpose: this study evaluated the potential role of f-fluoro- -deoxy-glucose (fdg) uptake by primary tumors and n nodes on positron emission tomography (pet) in patients with stage iiia n non-small-cell lung cancer (nsclc). experimental design: we analyzed pet scans of nsclc patients who received surgical resection and proved pathologically to have stage iiia n disease between january and april . on each patient's pet scan, fdg uptake by the primary tumor and n nodes were evaluated using the maximum standardized uptake value (suv). the highest suv of the n nodes in each patient was used for analysis. the suv of the node was affected by histology (p = . ). whereas a different survival outcome was not observed according to the suv of the primary tumor (p = . ), the suv of the node ( median vs. > median) was associated with survival (p = . ). patients with a low ratio of the node suv to the primary tumor suv ( median) showed better survival than those with a high suv ratio (> median) (p = . ). in the multivariate analysis, the t stage (p = . ) and ratio of the node suv to the primary tumor suv (p = . ), adjusted for the size of the n node ( cm vs. > cm), remained significant prognostic factors. conclusion: these results suggest that fdg uptake by the n node, especially relative to the uptake by the primary tumor, may predict survival of patients with stage iiia n nsclc. accuracy of dual-phase fdg pet for diagnosis of pulmonary nodule with initial suv less than . c. chen, b. lee, w. yao, p. wu, c. chu, n. chiu; national cheng kung university medical center, tainan, taiwan. aim: f-fdg pet is a very useful tool for the evaluation of pulmonary lesions with high sensitivity and specificity when using cutoff standard uptake value (suv) of . . however, false results may occur, such as in bronchioalveolar carcinoma or inflammatory foci. studies indicated the usefulness of delayed pet images to improve accuracy. our study aimed to clarify the efficiency of delayed pet in pulmonary nodules with initial suv less than . . material and methods: we collected dualphase fdg pet studies, imaging at hr and hr post-injection, that showed pulmonary lesions with initial suv less than . . those with final pathological reports were recruited for further analysis. we analyzed the difference in suvs, retention index (ri) (%) (ie. subtracting the hr suv from the hr suv and dividing by the hr suv), and rate of further increase of suv between benign and malignant pulmonary lesions. results: totally lesions, in patients, were recruited. ten, including nine of granulomatous inflammation, were benign and were malignant. for the benign lesions, the average suv on hr and hr images were . (range: . to . ) and . (range: . to . ), respectively. for the malignant lesions, the average suv on hr and hr images were . (range: . to . ) and . (range: . to . ), respectively. further increases of suv on delayed hr images were observed in of the benign ( . %) and of the malignant lesions ( . %). no significant differences in suv, ri, rate of further increase of suv were found between the benign and malignant pulmonary lesions. conclusion: further increases of fdg uptake on delayed pet images occur not only in malignant lesions but also in benign lesions, such as granulomatous inflammation. therefore, delayed fdg pet is not useful for differentiating benign and malignant pulmonary nodules with initial suv less than . , especially in the epidemic area of granulomatous diseases. irmet spa, torino, italy, università di torino, dipartimento di scienze cliniche e biologiche, aso s. luigi, orbassano, torino, italy. introduction. the role of fdg pet/ct in the management of patients with non small cell lung cancer has been widely investigated in the recent years and its usefulness has been proved in the initial diagnosis, staging, restaging in case of suspected recurrence and radiotherapy planning. our aim was to evaluate the accuracy of pet/ct with fdg in the preoperative mediastinal nodal staging of nsclc with histological results as gold standard. materials and methods. patients ( men, women, mean age ) with early clinical stage nsclc were included. all of them were preoperatively studied with clinical evaluation, whole body c.e. ct, whole body fdg-pet/ct, fibrobronchoscopy. all patients underwent surgery. pet mediastinal nodal findings were compared with histo-pathological ones; these latter were used as the reference standard. statistical evaluation was performed on per-nodal-station. sensitivity, specificity, positive and negative predictive value and accuracy of pet were calculated. results. pet correctly classified out of the lymph nodes histologically evaluated, with an accuracy of . %. in particular, pet correctly evidenced malignant nodes out of , and non malignant nodes out of . so, sensitivity and specificity resulted . % and . %, respectively. in the remaining nodes, we had false positive (all reactive hyperplasia) and false negative nodes (in all cases, the node diameter was inferior to x mm), with positive and negative predictive value of . % and . %, respectively. conclusions. our study, in concordance with the literature data, demonstrate that fdg-pet/ct has high specificity, but low sensitivity in mediastinal nodal staging. in patients with non small cell lung cancer (nsclc), pre-operative assessment with fdg pet/ct provides accurate tnm staging resulting in improved management plans. assessment of the visceral pleura is important since visceral pleural disease changes tumour staging from t to t , hence from stage ia to ib, which reduces post operative year survival from to %. although orthogonal planes are available, attention is often focused on the axial and coronal planes when pet/ct data is analysed. the aim of the study was to assess the impact of additionally reviewing images in the sagittal plane to assess visceral pleural involvement. method consecutive patients who had pet/ct for nsclc staging were reviewed. we assessed the effect of analysis of the sagittal plane in determining extension of the tumour onto interlobar fissures, and so by implication involvement of visceral pleura. results pet/ct identified patients with t disease. in , t disease was diagnosed by size criteria, or extension onto the fissure on axial pet /ct. / patients ( . %) were upstaged from t to t by diagnosis of extension onto the fissure not diagnosed prior to sagittal plane review. in patient multiple lumbar vertebral collapses due to osteoporosis was diagnosed on sagittal plane images. conclusion review of the sagittal plane on pet/ct images especially when the primary tumour is in the vicinity of an interlobar fissure can improve accuracy of t staging, and thus provide important prognostic information. background: accurate staging of small-cell lung cancer (sclc) is critical for patient treatment and prognosis. the most common staging system adopted from the veterans affairs research service lung group includes two stages, limited-stage disease is defined as tumor confined to one hemithorax and the regional lymph nodes, whereas extensive-stage disease is defined as disease beyond these bounds. patients with limited-stage disease are offered combination chemotherapy and concurrent thoracic radiation therapy. patients with extensive-stage disease are offered combination chemotherapy without thoracic irradiation. [ f]fluoro- -deoxy-d-glucose (fdg) positron emission tomography (pet) scan is widely used for the staging evaluation of non small cell lung cancer, however, its use in small cell lung cancer (sclc) remains investigational. the aim of this study was to evaluate fdg pet for sclc staging and to determine the impact of pet on treatment planning. patients and methods: from february to march , we prospectively performed pretreatment fdg-pet on patients, with sclc who also underwent a conventional staging. tumor-nodemetastasis system staging was assigned for each patient, with and without pet information and modification of treatment planning was assessed. results: fdg-pet demonstrated findings consistent with extensive-stage sclc in fifteen of patients. fdg-pet correctly upstaged nine ( %) of patients to extensive-stage disease. pet correctly identified tumor in each sclc mass (primary or nodal) that was suspected on computed tomography (ct) imaging, thus giving a lesion-based sensitivity relative to ct of %. pet identified unsuspected bone metastasis for eleven patients, hepatic lesions for patients and in others sites. fdg-pet correctly downstaged one ( %) of patients to limited-stage disease who had a adrenal mass in ct and negative in pet confirmed by histology. treatment was modified for ten patients ( %), patients underwent only chemotherapy and one had both chemo and radiotherapy.conclusion: fdg-pet has high sensitivity for sclc and appears to be of value for initial staging and treatment planning. aim: non small cell lung cancer (nsclc) is the leading cause of cancer mortality in both females and males. some studies have linked tumor glucose metabolism as evidenced by f- fdg pet to survival but these study populations were heterogeneous. we aimed to assess whether tumor glucose metabolism is related to tumor size, disease stage and tumor histology in patients treated with radiation therapy and curative intent. material and methods: patients ( males and females, mean age: years) underwent d conformal radiation therapy. all patients underwent pre-treatment staging with f- fdg pet (pet-ct) and were evaluated by the assessment of tumor size in two dimensions, maximum suv (suvmax), and tumor histology. eighty-one patients were clinically staged by tnm (t n = , t n = , t n = and t n = ). in out of patients the tumor was histologically analysed (squamous cell carcinomas = , adenocarcinomas = , large cell carcinomas = , non-small-cell-lung-cancer = ). results: in non-parametric analysis tumor metabolism as measured by suvmax was associated with tumor stage( r = . , p < . ). suvmax was related to -d tumor size in patients with nsclc (r = . , p < . ). this relation was stronger in patients with adenocarcinoma (r = . , p < . ) than in patients with squamous cell cancer (r = . , p < . ). multivariate analysis indicated that up to % of suv variability could be explained by tumor size. conclusion: in nsclc some relation exists between disease stage, primary tumor size and suvmax as an indicator of glucose metabolism. however, it is notable that tumor histology has substantial impact on these relations. correlation between staging fdg-pet, some cell cycle markers and survival in lung cancer. a. sanchez-salmon , i. aim: a great part of the patients with lung cancer have spread disease at the diagnosis. fdg positron emission tomography ( fdg-pet) is recommended for staging these patients in order to avoid unnecessary surgery in advanced disease. we report the evaluation of the relation between the suvmax (" standardized uptake value ") of the pet, cell cycle markers and the patients' survival in lung cancer patients. material and methods: there were patients ( men and women) studied, with an average of years old and a range of - years old. in the histological evaluation cases were squamous, adenocarcinoma (including bronquioloalveolar), undifferentiated, oat cell, and neuroendocrine tumours. five patients were in stage ia, in ib, in iia, in iib, in iia, in iiib and in iv. the follow-up ranged between and months. the inmunohistochemical study was realized by blocks of tissue microarrays using the envision (dako) system. results: an association between the suv and the negativity for the d cyclin (p= . and p (p= . ) was found. there is also a positive correlation between the suv and the index of proliferation (mib- ) as well as between the suv and the a inducible factor inducible by hypoxia (hif- a) expression but both of them did not reach significance. the of the suv maximum values associated with the age and with the squamous histology. there was found no correlation of the suv neither with the tnm nor with the survival. conclusions: . fdg-pet is very useful method for staging lung cancer. . fdg-pet is associated with different biological characteristics of the tumours . in our experience, it does not seem to be a good survival marker . background: the diagnostic and therapeutic management of different lung nodules in a single patient is challenging. the nature can be benign, as hamartoma, or malignant, as primary cancer or metastases. despite a high number of researchers and proposal for diagnostic work-up have been published accurate differentiation of benign from malignant lesions remains unsolved. aim of our study is to assess whatever integration of morphologic and metabolic imaging can help in the differential diagnosis between malignant and benign lung nodules in patients bearing multiple lung nodules. aim: f-fdg pet is widely accepted for evaluating patients with lymphoma; the role of pet in paediatric patients is still debated. aim of our study was to assess the usefulness of f-fdg pet imaging in paediatric hodgkin (hd) and non-hodgkin (nhl) lymphoma. materials and methods: paediatric subjects ( males, females; mean age years, range - years) with malignant lymphoma ( hd, nhl) were enrolled in the study. f-fdg pet was performed following standard procedures ( , mbq/kg of fdg were injected iv in the hours fastened patient, image acquisition was performed after one hour uptake). overall pet scans were carried out, at lymphoma presentation and during follow-up. pet results were compared with conventional imaging (ci) information (mr and/or ct) and with clinical followup; in all cases at least one contemporary imaging method was available, as well as months follow-up. results: out of scans, pet findings were consistent with clinical follow-up and other ci data in cases ( true positive, true negative results) with an overall sensibility and sensitivity of % and % respectively. the remaining two cases resulted falsely positive, and in one subject this was due to prominent thymic uptake. considering all scans, pet was more accurate then conventional imaging in the assessment of children with lymphoma, identifying active disease in ci negative scans and in ci inconclusive cases and excluding the presence of lymphoma in ci inconclusive and ci positive scans. conclusions: our data show the usefulness of f-fdg pet to accurately evaluate children with lymphoma. the presence of hyperplastic thymus in one case may have accounted for inaccurate pet reading, although in other cases prominent thymic uptake did not affect pet reporting. a recent report has emphasized the number of false positive pet findings in children: our data do not support this observation. nonetheless particular care has to be paid when reporting pet scans carried out in paediatric patients. purpose: in this retrospective study we aimed to assess the clinical impact of pet/ct imaging on staging and management of both hodgkin disease (hd) and nonhodgkin lymphoma (nhl). the results are also compared with the ct imaging findings. materials and methods: a total of patients with newly diagnosed lymphoma were included in the study. there were hds and nhls. the age range was - with a mean age . years. each patient was undergone whole body pet/ct examination with low dose ct acquisition by administrating only oral contrast in addition to establish full diagnostic ct examinations of cervical, chest and abdominopelvic regions. pet/ct scanning from the skull base to the upper thigh was performed using a dedicated pet/ct scanner (siemens biograph hi-rez lso), only when the patient's blood glucose level did not exceed mg/dl. the interval of pet/ct and ct was weeks at maximum. the findings suggesting for disease involvement obtained from the both modalities were recorded on a data sheet according to their topographic localization. the diagnostic certainty of two modalities was made according to clinician's final decision mainly based on clinical follow-up status of the patients. results: a total of disease sites in patients were recorded according to final clinical decision. of these, sites were revealed by pet/ct, but only were shown by ct. two modalities were agreed in sites. thirtythree sites were demonstrated only by pet/ct, which caused upstaging in ( %) patients. whereas ct found sites despite of negative pet/ct, which did not caused upstaging of the disease in any patient. in of the patients in whom pet/ct upstaged disease, treatment strategy was changed to the more aggressive protocols. conclusion: fdg pet/ct has a very important contribution in the initial staging of lymphomas, by changing the treatment strategy in a considerable percentage of the patients. according to our opinion ct appears to have a minimal role in initial staging beyond of pet/ct scanning and can be omitted in routine clinical settings. high negative predictive value of midtreatment fdg-pet/ct in response assessment of malignant lymphoma. aim f-fdg-positron emission tomography/computed tomography (pet/ct) is currently used in staging/restaging and in the definitive evaluation of response to therapy of hodgkin disease (hd) and aggressive non-hodgkin lymphoma (nhl). in fact, this functional imaging modality allows an accurate evaluation of disease extension as well as a metabolic characterisation of residual masses after chemo and/or radiotherapy. the use of f-fdg pet/ct for response assessment during treatment is still under debate: midtreatment scan seems to be predictive of final response to therapy, however its role and prognostic value remains to be proved. in our study we evaluated the predictive value of interim pet/ct scan in patients with hd and aggressive nhl, compared to the final therapy response. materials and methods consecutive patients ( male, female; mean age±sd: ± ys) were staged by f-fdg-pet/ct (pet- ), whole body ct and bone marrow biopsy for hd (n= ) and aggressive nhl (n= ). all of them underwent interim pet/ct (pet- ) after - cycles of chemotherapy, and final restaging with whole body ct and pet scan (pet- ) at the end of the treatment. results hd: out of patients had a negative pet- scan. at the end of the treatment, of them ( %) presented complete response, while , partial response. the remaining patients were positive at pet- . at the end of the treatment, ( %) of them were in complete response, while ( %) had partial response. nhl: out of patients had a negative pet- scan. at the end of the treatment, all of them had complete response. the remaining patients presented a positive pet- scan. at the end of the treatment, ( %) of them were in complete response, while ( %) had partial response. conclusions our data confirm that interim pet/ct scan has a very high negative predictive value, both in hd and aggressive nhl ( % and %, respectively). further studies are needed to demonstrate how this information can affect patient management and patient outcome. aim we performed a systematic review of the literature to analyze positron emission tomography with f-fluorodeoxiglucose (fdg-pet) as a diagnostic tool in the evaluation of lymphomas response to chemotherapy or immunotherapy in terms of diagnostic accuracy and clinical usefulness. methods and material bibliographic search was performed between july-august , with a date limit consensus established in . we used medline, embase and cancergov, as bibliographic primary fonts adopting in each case the most convenient searching strategy, adopting free vocabulary to specific thesaurus. cochrane library and other health technology agencies data bases were also reviewed. the methodology quality assessment of every article was determined by the quadas questionnaire. the software tools use to manage all extracted data were reference manager . , spss . and epidat . . results the number of primary article localized was . two independent reviewers performed screening of all references, and the final number of articles selected to be analyzed was . despite of the differences among equipment, no difference in patient's preparation and studies acquisition were found. all studies consider visual qualitative analysis as part of the evaluation, and only four did semiquantitative analysis using standard uptake value (suv). six of ten studies performed fdg-pet scans in hodgkin lymphoma at the end of the treatment. global results of sensitivity, specificity, positive predictive value, negative predictive value and accuracy correspond . % [ %ci, , . - . ] . work in progress to evaluate the possibility of develops meta-analyses of diagnostic test. conclusion despite of the small number of studies and the heterogeneity of the different population, it is important to emphasized the global results of negative predictive value of the fdg-pet in both hodgkin and non-hodgkin lymphomas and also at the different early and late response evaluation. study supported by the quality plan of the spanish national health service. months after fdg-pet) despite of additional therapy. two patients were noted as false-positive. in four patients only slightly increased fdg uptake was observed (equivocal findings). conclusions: fdg pet enables reliable prognosis in short and long-term follow-up of patients with hd and nhl , especially in patients without pathological uptake of fdg. false positive fdg uptake seems to be a problem. no one of our fdg negative patients relapsed. our results show that fdg negative patients usually have good prognosis and stay in complete remission for a long time. therefore, results of pet are predictive of immediate success of therapy as well as of disease-free survival. negative pet scan is an important contribution in the management of these patients due to its prognostic value and may reassure patients and their doctors that disease is not active. the bone lesions (bl) in hodgkin's disease (hd) are rare ( to %) in the initial staging but have to be detected for a more aggressive treatment. bl are explored mainly by the invasive unilateral bone marrow biopsy (bmb), insufficient compared with the bilateral one. the aim of this study is to evaluate the agreement between bone positive fdg-pet, bone ct and mri for rachis bl detection in hd, before and during chemotherapy. material and methods: patients (mean age ± years, men) with hd histologically proven and with fdg-avid lesions in the bone were analysed. only one suffered from lumbar pain. all underwent unilateral bmb, bone ct, and then mri of axial skeleton at the time of first staging. all those imaging exams were repeated for early interim evaluation (after cycles of chemotherapy) and month after the end of treatment (after cycles). each lesion was defined by its localization, the intensity of its signal: t , t on mri, bone destruction with ct by a neuroradiologist, fdg uptake with maximum standardized uptake value by a nuclear physician. results: the bmb was positive only in cases. a total of lesions were visualized on initial staging fdg-pet (average suvmax , ± , ) and on mri. on bone ct, only of lesions were detected. for of lesions, fdg-pet presented a vertebra hypofixation corresponding to a massive infiltration on mri. the localization of bl on fdg-pet and mri was well correlated except for patient (kappa= , ; , ; , ; , respectively for patients to ). indeed for this patient, a mismatch was noted between a homogeneous intense uptake of the thoracic rachis without pathological signal on mri at the same level. we concluded to a falsepositive fdg-pet by bone marrow hyperplasia. at mid and end of treatment, the fdg-pet became relatively normal whereas mri showed healing pattern on several vertebrae. on the follow-up, one patient recurred on mediastinal lymph node without bl. conclusion: fdg-pet and mri were the most accurate imaging modalities for bl in this context, complementary, especially in the whole spine assessment. fdg-pet allowed a better wholebody analysis and was enough sensitive to detect bl, including vertebra hypofixation. during treatment, bone fdg-pet became negative earlier than mri. the mri remained more precise for the small bl individualization. objective: because of anatomic changes after operation, detecting recurrent tumor is difficult in post-operative stomach cancer patients, especially in patients with paucity of intra-abdominal fat tissues. this study aimed to compare fdg pet/ct and enhanced ct in the detection of recurrent tumor according to body mass index (bmi) and anatomic regions. materials and methods: total of patients who had pet/ct and enhanced ct within month of each other, and diagnosed with recurrence were included. cases were pathologically confirmed and diagnosed clinically. we classified the patients into groups according to the bmi (kg/m ): group i < . ; group ii . ~ . ; group iii . ~ . ; and group iv > . . we compared pet/ct and enhanced ct findings by the anatomical sites: anastomosis site or stump; lymph node (ln); seeding nodules; bowel wall; and solid organ. result: five patients had only extraperitoneal lesions, and one had diffuse ascites without a focal lesion. cases were false negative in both pet/ct and enhanced ct. excluding these cases, we compared the findings of pet/ct and enhanced ct. in group i (n= ), pet/ct found ln lesions, seeding nodules and foci of bowel wall thickening, while ct found ln lesions, seeding nodules, foci of bowel wall thickening. in group ii (n= ), ln lesions, and seeding nodules were discovered on pet/ct. and ln lesions, seeding nodules, and foci of bowel wall thickening were detected. conclusions: fdg pet/ct may be more useful than enhanced ct in detection of metastatic lymph nodes and seeding nodules in patients with low bmi (groups i and ii). however in cases with seeding metastasis presenting as bowel wall thickening, enhanced ct could be more useful. aim: gastrointestinal tumors can be detected incidentally by fdg-pet. even though measurement of standard uptake value (suv) has been proposed to determine the nature of these tumors, the method has been criticized. because dual-time point fdg imaging was reported to increase accuracy of fdg pet, we conducted this study to analyze the use of suv and delayed fdg imaging in the evaluation of gastrointestinal tumors. material and methods: gastrointestinal tumors with dual-time point fdg imaging were collected. images were acquired at hr and hr post-injection. those with final pathological results were enrolled. we recorded the hr and hr suv of the lesions for further analysis. results: there were ten benign and fourteen malignant gastrointestinal lesions enrolled in this study. average hr and hr suv of the benign lesions were . (sd: . ) and . (sd: . ), respectively. average hr and hr suv of the malignant lesions were . (sd: . ) and . (sd: . ), respectively. for differentiation of benign and malignant lesions, best accuracy (accuracy: . , sensitivity: . , specificity: . ) could be obtained by using criteria of initial suv higher than and further increase of delayed suv higher than %. conclusion: delayed imaging can improve the accuracy of fdg-pet in differentiating benign and malignant gastrointestinal lesions. however, the accuracy is not high. evaluation of liver metastases from colo-rectal cancer after chemotherapy: fdg pet seems not to improve ct sensitivity m. rodari, c. carnaghi, c. tronconi, l. rimassa, f. r. lutman, g. ciocia, a. chiti; istituto clinico humanitas, rozzano -milano, italy. aim: neoadjuvant chemotherapy has been successfully used to treat patients with colorectal liver metastases. selection of those patients who can benefit from surgical resection after chemotherapy still poses a significant clinical problem. fdg pet is a useful tool in the assessment of liver metastases from colo-rectal cancer, but few data are available on its sensitivity after chemotherapy. we aimed to assess fdg pet and ct in the pre surgical evaluation of patients bearing liver metastases. materials and methods: data from patients with liver metastases from colo-rectal cancer treated with chemotherapy, evaluated with fdg pet and contrast enhanced ct scan at the end of treatment were retrospectively reviewed. nineteen patients ( males, females; median age years; range - ) were evaluated. chemotherapy regimens were: folfox ( patients), folfiri ( patients), other ( patients). median time between end of chemotherapy and ct was . weeks, between end of chemotherapy and pet . weeks and between end of chemotherapy and surgery . weeks. all patients underwent surgery and had pathological confirmation of liver lesions. nine patients underwent segmentectomy, wedge resection, right hepatectomy and explorative laparotomy with liver biopsies. results: data from patients were evaluated and liver lesions were confirmed by pathology. results on a perlesion basis shown a sensitivity of % for pet and % for ct. a complete agreement between pet or ct and histology was documented in and patients, respectively. pet sensitivity increases for lesions larger than cm ( % vs %). conclusions: our results suggest that pet and ct scan have sub-optimal sensitivity in the evaluation of colo-rectal liver lesions after neo-adjuvant chemotherapy, particularly for lesions < cm. the combined use of the two imaging techniques seems not to significantly increase the sensitivity of ct alone. introduction: the basic of pet/ct by use of f-fluorodeoxyglucose (fdg) is significantly increased glucose metabolism in the malignant neoplasm cells. the fdg metabolism depends on many factors such as: histopathology and presence of other factors which increase fdg metabolism. knowledge about the fdg metabolism in the stomach cancer cells' is not clear and some types of cancer are not avid in this type of diagnostics. aim: the evaluation of the fdg metabolism of pathological lesions in gastric cancer patients according to its histopatological type. material & methods: retrospective analysis of the pet/ct results of patients ( women, men, mean age , ) suffered from stomach cancer. the study population consists of patients with the primary stomach cancer and patients with confirmed recurrence. there were tubular adenocarcinoma, mucinous adenocarcinoma and low differentiated stomach cancers. pet/ct studies were performed on the biograph lso min after iv. of mbq/kg fdg. standard uptake value -suv was calculated. pet/ct results and mean values of suv were calculated for the each histopathological type of stomach cancer. results: lesions with pathological increase of fdg metabolism were fund in patients ( , %) with tubular adenocarcinoma, (mean suv , ± , ), ( %) patients with mucinous adenocarcinoma (mean suv , ± , ) and ( , %) patients with low differenciated stomach cancer (mean suv , ± , ) false negative results were found in patients with mucionous adenocarcinoma, with tubular adenocarcinoma ( low differenciated -g ) and with low differentiated cancer. conclusions: . higher differentiated tubular adenocarcinomas and low differentiated stomach cancers are characterized by the highest fdg metabolism. . mucinous adenocarcinomas is characterized by the low level of fdg metabolism. . histopatological type of stomach cancer must be taken into consideration during setting of indication to the pet/ct study. polyps: a feasibility study p. mainenti , b. salvatore , c. sirignano , t. de falco , a. speranza , g. fiumara , f. ricci , l. evangelista , l. pace , m. salvatore ; ibb-cnr, naples, italy, aou "federico ii", naples, italy, department of diagnostic imaging, university "federico ii", naples, italy. aim: to evaluate: ) the feasibility of pet/ct colonography (pet/ctc) in patients with colo-rectal polyps; ) the impact of metabolic information on ctc findings and the added value of morphologic to functional information in the characterization of focal colorectal uptakes. materials and methods: ten patients with colo-rectal polyps underwent pet/ctc previous colo-rectal air insufflation and just after therapeutic conventional colonoscopy (cc). a radiologist and a nuclear medicine physician analysed the pet/ctc images. the grade of overlapping of morphologic and metabolic information in the colon-rectum was evaluated. sensitivity and specificity for colo-rectal polyps of pet, ct and pet/ct were calculated. results: polypoid lesions were identified at cc: < mm, between and mm, > mm ( hyperplastic polyps, tubular adenomas, adenocarcinoma and submucosal lipoma). the overlapping of morphologic and metabolic information was excellent in scans, good in and moderate in . pet/ctc showed a sensitivity of % for lesions > mm and a specificity of %. the metabolic information did not allow to disclose any further polyp missed on ctc. the morphologic information permitted to classify correctly all focal radiotracer uptakes. conclusions: pet/ctc is a feasible study. adding a colonographic protocol to pet/ct images seems to allow characterizing correctly all colo-rectal focal radiotracer uptakes. the metabolic information does not seems to increase the accuracy of ctc. aim. metastases of colon cancer are often diagnosed in an advanced stage. in patients with this kind of neoplasm, pet with [f- ] fluorodeoxyglucose (fdg) is more sensitive and specific than the ct for detection of metastases. the cea level is used for monitoring the cancer but without anatomical localization of the lesions. the aim of this study was the retrospective assessment of the value of the pet/ct and ct in the diagnostics of the group of patients with an increased cea level. material & methods in the time between march and april , studies were made to diagnose colon cancer . we selected patients referred to the pet-ct study with an increased cea marker level who were being diagnosed for colon cancer with complete information about ct with contrast media. pet studies were made by using the siemens biograf lso scanner according to typical pet protocol. we compared the results of the particular methods of diagnostics, performing patient to patient analysis. results: in cases ( , %)pet/ct and ct gave consistent results. there was patients ( , %)with negative results of pet/ct and ct . there were negative pet/ct results ( , %) and ct negative results( , %). in patients pet/ct positive results( , %) corresponded with the negative ct results. in patients ( , %)ct positive results corresponded with the negative pet/ct results. mean cea level in this group of patients was , ng/ml. conclusion: pet/ct was found to be the more valuable than ct tool for detecting colon cancer metastases in the group of patients with increased level of cea, additionally giving exact information about their localization. there is a need to conduct a prospective study to assess the value of the pet/ct in the diagnostics of colon cancer in connection with histopathology. introduction. although the fdg-pet is indispensable in the follow-up of colo-rectal carcinoma (crc) when recurrence suspicion exists (elevation of markers and/or findings in structural image), is not defined the role that can suppose its inclusion in the systematic follow-up of these patients. the aim of this work is to analyze the impact that can suppose the incorporation of the fdg-pet in the systematic management of crc patients without suspicion of tumour recurrence. population and methods. from a cohort of patients with crc, a total of (mean age , +/- , years; rectum, sigma, colon) were followed-up during two years by simultaneous use of fdg-pet and structural image (mainly us and ct) evaluated in blinded conditions. results. fdg-pet was considered negative in / patients, without findings in the structural image. in / ( , %) cases fdg-pet showed not suspected tumour recurrence, without findings in the structural images in of them ( / / ; %/ , %). dissemination of was determined as hepatic metastases ( ), pulmonary metastases ( ), retroperitoneal lymph node ( ) and mesenteric implants ( ) . that is, fdg-pet showed unsuspected tumour disease in , % of patients, % of them free of significant structural changes. conclusions. even though the little number of patients, our series suggests that the inclusion of the fdg-pet in the systematic follow-up of the treated crc patients can improve their clinical management. aim. primary carcinoma of the gallbladder is a rare malignancy which is very difficult to diagnose and characterizes an extremely poor prognosis,. using fdg pet/ct we can obtain functional and morphological images of the entire body the aim of the study is a retrospective evaluation of pet/ct in patients with gallbladder carcinoma incidentally detected during cholecystectomy. material and methods. between march and december pet/ct was performed on patients ( women, men; age , yrs ) with gallbladder carcinoma detected incidentally after cholecystectomy. the pet/ct was performed with a biograph lso minutes after an intravenous administration of mbq/kg fdg. results. pet/ct scanning presented lesions of increased fdg metabolisms in patients. in patients liver metastases, hilus of the liver , site of the gallbladder removal, postoperative scar metastases, metastases in lymph nodes of the abdominal cavity, lymph nodes of the retroperitoneal space metastases, omentum metastases were found. all were true positive. there were true negative results in the remaining patients. conclusions. . pet/ct by fdg is a useful method in gallbladder cancer patient diagnostics. . pet/ct enables the diagnostics of the residual tumors, recurrence and distant metastases of the gallbladder carcinoma.. background it is known that f- fdg pet has a low sensitivity in the detection of hepatocellular carcinoma (hcc). we prospectively compared c- acetate pet results to those of f- fdg pet in patients with hccs. methods we prospectively analysed four patients (m:f= : , age range: - ) with histopathologically or clinically confirmed hccs underwent c- acetate pet and f- fdg pet. whole body c- acetate pet was performed min after injection of mbq of c- acetate. f- fdg pet was done within day before or after c- acetate pet. results a total of hcc lesions were confirmed histopathologically or clinically. f- fdg pet detected only lesions of them whereas c- acetate pet detected lesions. two false positive lesions were found on both pets, respectively. conclusion although the number of patients was very small, c- acetate pet may be complementary to f- fdg pet and useful in imaging of hcc. further studies including more patients are needed. comparison of hepatic fdg uptake between japanese people with and without metabolic syndrome objectives: liver demonstrates heterogeneous fdg uptake pattern and sometimes shows abnormally increased uptake even though there is no malignant tissue. recently, fdg uptake in liver was correlated with fasting plasma glucose, reported. over the past decades, there has been a dramatic increase in the number of subjects with the metabolic syndrome in japan as well as in western countries. the international diabetes federation defines metabolic syndrome as the presence of central obesity plus any two of the following three factors (fasting plasma glucose, lipid deviation and blood pressure). therefore, we evaluated the significance of hepatic fdg uptake associated with metabolic syndrome and hepatic enzymes. methods: sixty one patients ( men and women; age range, - years; mean age, . years) underwent whole-body fdg-pet imaging for cancer screening. patients with sever hepatic disease had been excluded. all patients were instructed to fast for at least h before the intravenous injection of fdg. pet image was obtained hour after injection of . mbq/kg of f- fdg with pet camera. the fdg uptake in liver was analyzed semiquantitativly using roi on transaxial image at umbilical level and we compared mean standardized uptake value (suv) between normal and metabolic syndrome group, based on waist circumference, raised triglyceride level, reduced hdl cholesterol, raised blood pressure, and raised fasting plasma glucose. we also evaluated effects of fasting plasma glucose and hepatic enzymes, i.e., aspirate aminotransferase (ast), alanine aminotransferase (alt) and -glutamyl trasopeptidase ( -gt) on hepatic fdg uptake. results: the average of hepatic suv in abnormal groups of blood glucose level, lipid deviation and blood pressure was significantly higher than that of normal group, respectively (blood glucose level; . ± . vs . ± . (p< . ), lipid deviation; . ± . vs . ± . (p< . ), and blood pressure; . ± . vs . ± . (p< . ). there was much more significantly high hepatic fdg uptake in metabolic syndrome group than normal group ( . ± . vs . ± . , p< . ). on the other, hepatic fdg uptake of abnormal ast, alt and -gt groups showed no significant difference from normal groups. conclusions: there was significantly high hepatic fdg uptake in metabolic syndrome group than normal group. this result suggests that we need careful interpretation of the liver in a case of metabolic syndrome. aim: contrast materials with high iodine concentration have been found to improve parenchymal enhancement on ct imaging. however, intravenous contrast materials (cm) may cause artifacts on pet/ct when using the ct data for pet attenuation correction. the aim of this retrospective clinical study was to assess the feasibility to use a highly concentrated contrast material (hccm) containing mg iodine/ml in pet/ct imaging. intravascular and parenchymal enhancement, potential ct and pet artifacts, and the accuracy of pet tracer quantification were assessed and compared to a lower concentrated cm containing mg iodine/ml (lccm). material and methods: whole-body fdg-pet/ct-scans of oncologic patients were investigated: patients each with hypervascularized and non-hypervascularized tumors underwent fdg-pet/ct with either an application of hccm or lccm. ct enhancement (hounsfield units) and tracer uptake (maximal standardized uptake value, suvmax) were measured at defined positions in different vessels and parenchyma. the quality of ct enhancement, the extent of potential ct and pet artifacts as well as the quality of tumor delineation were defined on a -point-scale. the influence of pet artifacts on clinical interpretation was defined. mann-whitney-wilcoxon-test was performed to evaluate statistically significant differences (p< . ). results: in patients with hypervascularized tumors, hccm led to significantly higher ct enhancement in / positions compared with lccm. in patients with nonhypervascularized tumors, hccm provided significantly higher ct enhancement in / positions. no significant differences using hccm and lccm were found both for hypervascularized as for non hypervascularized tumors with regard to the quality of ct artifacts, to the suvmax, to the quality of pet artifacts, the quality of tumor delineation on ct, and the quality of tumor delineation on pet. no statistically significant difference was detected between hccm or lccm concerning the influence of pet artifacts on clinical image interpretation. conclusion: hccm leads to a stronger contrast enhancement on ct images than lccm without causing more artifacts on ct or pet. the application of hccm is feasible in hybrid pet/ct and should be considered in patients with hypervascularized tumors. aim: is to determine the clinical utility of -fdg pet/ct in follow-up of patients with malignant melanoma. materials and methods: we studied patients in followup after surgery, having ajcc stage iii melanoma and contrast-enhanced computed tomography (ct) total body negative. in all patients a whole body (legs included) pet/ct scan was performed after an intravenous injection of - mbq of f-fdg in normoglucemia conditions. images were evaluated by nuclear physicians. results: of the pet/ct scans showed sites of active disease: limph nodes ( axillary, parasternal, supraclavicular, external iliac, bronchopulmonary, paratracheal), suprarenal gland, bone, subcutaneous and skin. all pet/ct findings were confirmed by histology or clinical evolution; pet/ct caused changes of treatments. conclusion: in our study pet/ct is superior to ct scan in detecting lymph nodes, skin and subcutaneous metastases. as everybody knows: the early detection of resecable melanoma metastases with early treatment decreases the risk of recurrence and increases survival. aim. to value pet/ct scanning sensibility and specificity compared with those of standard ct (sct) in staging lymph nodes, liver, bone and other organs metastases in patients (pts) with malignant melanoma (mm). patients and methods. between september and march , pts, age - years, mean , were enrolled. all pts were previously submitted to surgery to remove mm, sentinel node and, when indicated, other regional lymph nodes. a sct scan was already performed in these pts when they came to our institution for pet/ct scanning. we compared sites and number of sct-diagnosed relapses with pet/ct results. results. in / ( %) pts sct scanning showed a cerebellar relapse not observed by pet/ct. in / ( %) pts pet/ct results were comparable to sct ones; of these pts had a lung relapse, hadn't metastases, had an ovarian mass which was described as an ovarian cyst by sct, while pet/ct wasn't able to define it as malignant or benignant lesion. / ( %) pts had negative sct scanning, while pet/ct revealed bone or lymph nodes metastases; in of these pts there were widespread metastases. finally in / ( %) pts pet scans showed high metabolic activity lymph nodes, while in the same pts sct imaging revealed different sites of relapses, above all liver. conclusion. pet/ct and sct seem to have, in staging or restaging of mm, the same sensibility in discovering lung metastases, while pet/ct sensibility is higher than sct one relative to bone or lymph nodes relapses. pet/ct sensibility appears lower in detecting liver involvement. sct shows more specificity than pet/ct in describing cerebellar and ovarian lesions. aim: ovarian cancer is the leading cause of death as concerns gynecological cancer in the western countries. the difficulty in the detection of recurrence and the bad prognosis of the disease is well known. this study was designed to determine the value of fdg pet/ct compared to mri and ct, in the evaluation of recurrence disease. material-methods: patients went through fdg pet/ct examinations (siemens biograph lso) from june -march . the injected radioactivity dose for all scans was between - mbq ( - mci). all of them had ovarian cancer and underwent the pet/ct for restaging. mean age was . ± . years. in women with ovarian cancer, were subjected to ct scans (group a) and to mri (group b) for disease reevaluation just before pet/ct evaluation. results: / patients had positive pet/ct scan (suv . ± . ), / patients had positive ct while / had positive mri. group a: / patients ( , %) had match findings in pet/ct and ct scans ( cases negative results and case positive result) pet/ct scan outbalanced ct in / patient cases ( . %) -(mainly in extra pelvic disease). in cases with negative ct, pet/ct was positive ( . %). in / patients with negative pet/ct, ct was positive and of them had non diagnostic ct. group b: in / patients ( %) we had match findings in pet/ct and mri as well. in / patients ( . %) we had mri (+) and pet/ct (-) while another one had mri (-) and pet/ct (+). the critical point is that in / patients with mri (+) and pet/ct (+), pet/ct outbalanced mri (mainly in extra pelvic disease).in patients with tumor markers, of them had elevated serum ca and had normal ca levels. in / women with elevated serum ca pet/ct was observed (+) and in / pet/ct was (-). in the cases with normal ca level we found pet/ct (+). conclusion: according to the results of this study pet/ct scan presents a plain superiority in effectiveness over the ct scan. -fdg pet/ct may detect recurrent ovarian cancer more accurate than mri. also -fdg pet/ct is a very promising technique compared to raising levels of tumor markers. introduction: only sporadic data support the use of labelled-choline as oncological probe to monitor the pca response to treatment in patients. aim: to evaluate early modifications of f-methyl-choline ( f-ch) uptake in an animal model of prostate cancer (lncap xenograft on balb-c nude mice). material and methods: hormonosensitive prostate cancer xenografts were obtained in the back legs of athymic nude mice by subcutaneous injection of - lncap cells suspended in a solution of rpmi medium and matrigel®. animals were kept in appropriate facilities until tumour size reached . - ml. mice were then treated twice a week by intra-peritoneal administration of docetaxel ( mg/kg). sequential f-ch animal pet acquisitions ( _to_ min after ip injection) were performed basically and in the course of treatment of eight mice, to observe tumour metabolic changes after - cures and cures of docetaxel. because some animals died after the fifth cure of docetaxel, not enough data were available to perform further statistical analysis. results: tumor xenograft volumes continued to rise during the first cures of chemotherapy but tumour growth significantly slowed down afterwards. before tumour growth stabilization, f-choline pet revealed a decrease in tumour metabolism characterized by a significant fall (p= . ) of both suvmean (- %) and suvmax (- %) in comparison with initial values. a transitory stabilization of tracer amount in tumours (%id/ml) was also noted. nevertheless, this observation was restricted to the induction phase, while later pet studies (after or more cures) demonstrated a slight increase of semi-quantitative parameters in parallel to a tumor size regrowth, suggesting a docetaxel failure in the tumour proliferation control. conclusion: these preliminary data show that docetaxel treatment inducted a rapid decrease of semiquantitative index of f-choline uptake in lncap xenograft tumours. nevertheless, these observations are limited in time due to the suboptimal control of tumour growth by chemotherapy in these small animal series. purpose: we studied dynamic pelvic imaging followed by whole body ffluorocholine pet/ct imaging for the assessment of salvage radiotherapy in prostate cancer patients presenting either biochemical recurrence or suspicion of residual disease. methods: we evaluated patients with a persistent > , ng/ml or elevating psa (median . ; range . - . ), after radical prostatectomy combined or not with radiotherapy and after radiotherapy commonly with additional hormonotherapy. systematically all patients underwent early dynamic pelvic imaging within the first minutes after intravenous injection of mbq f-fluorocholine, followed by total body pet/ct scan (siemens sensation or ). late pelvic imaging after minutes was performed in patients. fused pet/ct images were interpreted visually by observers. correlation was made with other imaging modalities including endorectal mri ( patients) and bone scintigraphy ( patients). first results: overall, of the patients showed positive pet/ct for local or distant recurrence, were equivocal and negative. when classified according to site, were positive for local recurrence, equivocal and negative. loco-regional lymph nodes were positive or equivocal in patients. of the patients with positive pet/ct findings for distant sites, were positive for lymph node, for bone and for adrenal metastases. when classified according to psa levels, patients were equivocal and negative in range ng/ml, positive and negatives in range > to ng/ml, and positive and ambiguous in range > ng/ml. subsequently patients underwent salvage radiotherapy with the radiation field centred according to pet/ct findings as well as other imaging modalities. conclusion: dynamic and late ffluorocholine pet/ct imaging was advantageous in assessing loco-regional recurrence of prostate cancer. / patients with psa > ng/ml had positive pet/ct findings. consequently, salvage radiotherapy field could be better defined. further evaluation of the accuracy of this technique in the detection of recurrence using quantitative criteria as well as long term follow-up is underway. aim: pet/ct using f-choline (fch) was found to be valuable in the detection of prostate cancer recurrence even at lower psa levels. we evaluated the possible use of fch pet/ct in early re-staging of prostate cancer relapse with regard to the degree of glandular differentiation of the primary prostate tumor [gleason score(gs)]. methods: patients who had well/moderately differentiated primary prostate tumors (gs </= ) and were at low-risk for recurrence, and more patients who had poorly differentiated primary prostate cancer (gs> ) and were at high-risk for recurrence underwent a whole body pet/ct scan at > min after injection of . mbq/kg of fch (iason labormedizin gesmbh & co. kg graz-seisberg, austria) because of rising psa (> . ng/ml) after initial therapy (prostatectomy n= , radiotherapy n= , hormone therapy alone n= ). ( %) patients with gs> and ( %) patients with gs </= were under adjuvant hormonal therapy at the time of examination. focal high uptake of fch was rated (visual interpretation) as probable recurrent disease. corresponding images of ct from pet/ct (discovery ls pet/ct scanner, ge healthcare, milwaukee, wi, usa) were also used to achieve the diagnosis. results: prostate cancer recurrence was confirmed in all but one fch positive case in the clinical course. no fch negative patient had prostate cancer relapse from the clinically available data during a month follow-up . fch pet/ct detected recurrent disease in / ( %) high-risk patients (local recurrences n= , distant recurrences n= ) and in / ( %) low-risk patients (local recurrences n= , distant recurrences n= ). among them, high-risk patients and low-risk patients were under hormonal therapy. median psa in fch positive cases was . and . ng/ml for high-risk and low-risk patients respectively; median psa in fch negative cases was . and . ng/ml for high-risk and low-risk, respectively. fch pet/ct obtained true positive findings even at lower psa levels (< . ng/ml) in many ( / ) cases with gs> (median psa . ng/ml, range . - . ) but in only few ( / ) cases with gs</= (median psa . ng/ml, range . - . ). ( %) high-risk patients as well as ( %) low-risk patients developed recurrence in the first years after therapy. all recurrences (local n= , distant n= ) were identified by fch pet/ct, and for patients pet/ct was the only test showing recurrent disease. conclusion: fch pet/ct is proven as feasible in early detection of prostate cancer relapse, especially in those with poorly differentiated primary prostate cancer. introduction: retroperitoneal (rp) lymph nodes represent the regional lymphatic drainage in germinative testicular tumors. these lymph nodes often remain enlarged even following chemotherapy (cht), while the histopathological findings in resected lymph nodes consist of fibrotic tissue ( %), teratoma ( %), or other viable tumor cells ( %). aim: evaluation of the benefit of f-fdg pet in prediction of the viability of the rp masses via comparison of pet positive or pet negative findings in patients following curative cht plus rp residue resection. patients and methods: from september through june ( months) a total of pet scans were performed in patients with germinative testicular tumors. the presented study group includes patients after cht, in which the rp masses were resected within an average of days following the pet scan. the patient age ranged from to years (average . years, median . ). the tumors included seminomas and non-seminomas. results: the pet scan results subdivided the rp masses into pet positive (n = , activity of the lesion higher than the referential activity of the liver), and pet negative (n = ). in the pet positive subgroup the resection confirmed persisting tumor tissue in cases, while false pet positive results were recorded in patients with inflammatory changes within fibrosis (in both seminoma and nonseminoma). fibrotic changes were correctly detected via pet in patients with seminomas. the negative pet scans in patients with non-seminoma proved problematic due to eventual histopathological findings of teratocarcinoma micrometastases ( x), mature teratoma ( x) as well as fibrotic changes ( x). conclusion: in case of seminomas the fibrotic residual masses were detected correctly. we have recorded false pet positivity due to inflammatory changes in fibrotic tissue in various histological tumor types. our data suggest limited capability of pet to differentiate residual fibrotic masses from mature teratoma in case of nonseminomas (both findings can appear as pet negative). support: iga mzcr grant nr - / . aim: the incidence of testicular cancer has increased three-fold over the last decades, with the highest incidence being in european countries. a relatively new method fdg pet/ct, might be useful to overcome the diagnostic problems in re-staging testicular carcinoma. this study was designed to determine the value of fdg pet/ct compared to mri and ct, in the evaluation of recurrence disease and postchemotherapy residual mass in testicular carcinoma. material -methods: we examined patients who underwent whole-body pet/ct (siemens biograph lso) scans with -deoxy - -[f f]fluoro-d-glucose (fdg). the injected radioactivity dose for all scans was between - mbq ( - mci). all of the patients had history of testicular carcinoma and underwent the pet/ct for re-staging. mean age , ± , years. in men with testicular carcinoma, were subjected to ct scans (group a) and to mri (group b) for disease reevaluation just before pet/ct reevaluation. results: / patients had positive pet/ct scan (suv , ± , ), / patients had positive ct while / had positive mri. group a: / patients ( , %) had match findings in pet/ct and ct scans ( cases negative results and cases positive results). in cases with positive ct, pet was negative ( , %) while in cases with negative ct, pet was positive ( , %). in / patients we had mismatch findings between pet/ct and ct (in patients, pet/ct scan outbalanced ct, while in cases we had the opposite result). group b: in / patients ( %) match findings observed between mri and pet/ct scan ( cases negative results and case positive result). / patients ( %) had mri (+) and pet/ct (-) while / patients ( %) had mri (-) and pet/ct (+). in / patients ( %) with mri (+) and pet/ct (+), pet/ct outbalanced mri. in men with tumor markers, of them had elevated blood levels. / patients with abnormal tumor markers had positive pet/ct scan, while / patients had negative pet/ct (all cases with elevated afp levels). on the other hand in patients with normal tumor markers of them had negative pet/ct and positive pet/ct scan. conclusion: these preliminary results demonstrate that fdg pet/ct was superior to conventional techniques in restaging patients with testicular carcinoma. fdg pet/ct was a sensitive and reliable modality for detection of residual viable tumor in these patients. aim: primary extragonadal germ cell tumors (exgcts) account for nearly % of all gcts and are characterized by a poor prognosis. radical post-chemotherapy surgery of residual masses represents the standard of care. in case of residual viable tumor or teratoma, complete resection may be curative. however, when only necrosis is found, patients will be exposed to surgery-related morbidity and mortality without any survival benefit. no reliable factors predictive of the presence of viable tumor or teratoma in residual masses are available yet. fdg-pet has been successfully used for staging primary gonadal gct, but its role in the management of residual masses form gcts has not yet defined. we aimed to assess fdg-pet as a tool to detect residual tumor after chemotherapy. materials and methods: we evaluated consecutive patients with exgcts (mean age years, range - ), who underwent residual surgery following standard platinum and etoposide based chemotherapy. four patients had primary mediastinal location, peritoneal. four patients had a non seminomatous tumor, had seminoma. three patients were metastatic at the time of first diagnosis. four out of patients were classified as poor prognosis (pp) according to the igcccg. the patients with good prognosis (gp) had cycles of chemotherapy, the others had cycles.. all patients had fdg-pet, following standard procedures, at the end of chemotherapy and before undergoing residual surgery. fdg-pet results were compared with pathological findings. results: after chemo the four pp patients were classified as in partial response, the gp as complete response. the mean tumor shrinkage on ct was %. a correlation between fdg-pet and pathological finding was found in all cases: two patients with positive pet had viable tumor in postsurgical specimen, while patients with negative pet had necrosis or fibrosis. conclusion: following chemotherapy for exgcts, complete surgery of residual masses remains the recommended standard of care since it may be curative in an approximately half of patients with residual viable tumor or teratoma. among other clinical factors a positive fdg-pet might help to identify patients at higher risk for residual disease. in these patients, complete surgery may be suggested even in centimetric residual disease. fdg-pet may also help to address surgery to active lesions in patients with thoracic and abdominal disease. introduction and aim: multiple myeloma (mm), malignant b cell and plasma cell disorder, involves the skeleton in more than % at diagnosis. conventional and radionuclide methods are routinely used to evaluate these lesions. recently, fdg pet/ct has been introduced to the field. in this study, our aim was evaluate the accuracy of fdg pet in detecting myeloma lesions and its influence on patient's management comparing with clinical, radiological and bone scintigraphic findings. materials and methods: pts ( f, m) were evaluated; group i had patients ( f, m; aged - years) with mm, group ii had pts ( f, m; aged - years) with solitary plasmocytoma and group iii had patients ( f, m; aged - years) with monoclonal gammopathy. mean follow up period was , ± , months. in group i, pts were referred for evaluation of extent of disease before bone marrow transplantation (bmt) and pt referred for assesment of bmt response, pts had pain and referred for assesment of the extent of disease, and other pts with no complaints referred for follow up. in group and , pet/ct was performed to evaluate the extention of disease. the results of whole body bone scintigraphy (wbs), radiographs, and mri or ct imaging modalities as well as the clinical course at the same period were used to compare with fdg pet/ct results. results: the results are summarized in this table. conclusion: pet/ct scan is helpful to evaluate mm pts. it appears to be more sensitive than other radiologic and scintigraphic examination for the detection of lytic bone lesions. however, it may not be sufficient for detection and differentiation of small lesions and diffuse marrow involvement. in this study, / pts had negative pet/ct and positive bone lesions. it was thought that the combination of pet/ct and other radiological and scintigraphical examination might be more succesfull than pet alone. since pet investigation was performed mostly during active disease evaluation of its impact on survival, response was not avalaible. it is also important to emphasize the disadvantages of pet/ct in myeloma treatment, steroid related hyperglycemia, early vertebrate operations the frequently performed cause false positivity. however, we took precautions to delay imaging untill months following surgery and avoding imaging during glucose intolerance. pet/ct has the applicability to whole body imaging which is hard to apply to mri and results with better resolution compared to whole body mri. , lymphoma (n= ),hepatoma(n= ), prostatic carcinoma(n= ), gastric cancer(n= ),esophageal carcinoma(n= ), multiple myeloma (n= ), thyroid cancer (n= ), osteosarcoma (n= ), renal carcinoma (n= ),unknown primary origin (n= ); nonmalignant cases ingcluding:osteoporosis(n= ),bone tuberculosis(n= ), inflammation (n= ), hyperparathyroidism (n= ).in of malignant cases f-fdg pet/ct showed tracer accumulations corresponding to etiologic diagnosis .the sensitivity of f-fdg pet/ct was / ( . %).the false negative rate of f-fdg pet/ct was / ( . %).in f nonmalignant cases f-fdg pet/ct showed abnormal tracer accumulations . the specificity was / ( . %).the false positive rate of f-fdg pet/ct was / ( . %). conclusion: whole body f-fdg pet/ct is a valuable tool in etiologic diagnosis of suspected bd,the diagnostic accuracy could be more improved combinding with ct ,mri appearance and clinical informations. aim: the aim of this retrospective study was to evaluate the potential additional diagnostic role of f-fdg pet/ct imaging for the detection of unknown primary origing cancer (cup). materials and methods: the study population consisted of consecutive patients ( men, mean age: ± . years old) with suspected cup, tumoral markers abnormalities and/or paraneoplasic syndromes. an f-fdg pet/ct was performed in all patients population. all acquired images were assesed by a nuclear medicine with experience in pet and pet/ct and a radiologist physician. results: the initial evaluation of patients showed two differents findings: . patients with macroscopic lesions: presence of masses and lymphoadenophatiesmostly supraclavicular -in patients ( %) and liver and bone metastases in patients ( %). . patients without macroscopic lesions: high serum levels of tumour markers in patients ( %) and paraneoplasic syndromes in cases ( %). pet-ct results were: normal test in patients, non-specific features in patients and hypermetabolic lesions sugestive of malignancy (suv > ) in patients. primary tumor was sugested in patients and re-stage of neoplasm was performed in %. pet/ct was abnormal in all patients of the group with macroscopic lesions, except in one case. in the second group, pet/ct was suggested of malignancy in only of % of patients. conclusion: pet/ct identified primary tumour in % of patients with suspected cup, showing a better accuracy than other imaging techniques. in our study the diagnostic accuracy of pet/ct was higher than previously described in literature ( - %). however, the main limitation of this technique is the low ability to detect metastatic occult primary tumors in patients without macroscopic lesions. objectives: to provide accurate preoperative localization of parathyroid adenomas (pa) and to facilitate minimally invasive surgical approach to pa, as opposed to open cervicotomy and bilateral neck exploration. methods: for the same patients spect and mri scans were acquired with fiducial skin markers (fsms) placed on patient's thorax and neck. spect scans were obtained using: (i) mci of tc- m pertechnetate; (ii) min. and (iii) min. after administration of mci of tc- m sestamibi. mri was acquired with a t magnet using t -weighted spin-echo sequences. a deformable finite element model (fem) has been implemented for accurate nonrigid registration and fusion of spect and mri images. in this model fsms are used to sample d image deformation between spect and mri. in this method the intermodality displacements of the corresponding fsms observed in spect and mri are determined, then fem is used to distribute the fsms displacements linearly over the entire volume, followed by creation of a warped mr image registered with the spect image and by mri and spect volume fusion. a commercial ansys fem software was used for fem calculations along with our own programs for d image warping and fusion. results: we verified correct anatomical intermodal registration of the fused spect/mri images using organs with known high uptake of radiopharmaceuticals. the target registration error not exceeded mm. conclusions: our nonrigid registration and fusion method allowed creation of a detailed anatomic map of the neck and thorax from mri accurately combined with a functional d map from spect for improved preoperative localization of the parathyroid adenomas. aim: we describe our experience with ga-dotatoc pet imaging in neuroendocrine and neuroectodermal tumours as compared to in-octreotide, i-mibg and cross sectional imaging over a two year period. material and method: thirty-three patients ( f, m) with a variety of neuroendocrine and neuroectodermal tumours underwent ga-dotatoc pet imaging. the mean administered activity was mbq. the number of lesions, intensity of uptake and overall quality of the images were compared with octreotide or mibg (performed within months in % of cases) and radiological investigations such as ct, mri and angiography (performed within months in % of cases). results: five patients ( %) had additional lesions on the ga-dotatoc scan compared with other nuclear medicine imaging. in two of these patients the ga-dotatoc scan showed the lesions more clearly than the in-octreotide scan due to better resolution. in / ( %) patients, in-octreotide or i-mibg demonstrated more lesions than the ga-dotatoc scan. of these cases, / were in patients with benign phaeochromocytomas. in / ( %) patients all scintigraphic tests were negative when radiological investigations including angiography demonstrated lesions. conclusion: ga-dotatoc pet has an emerging role in detecting a wide range of neuroendocrine and neuroectodermal tumours. it shows better resolution and demonstrates extra lesions compared to in-octreotide and i-mibg. in has lower sensitivity than i-mibg for benign phaeochromocytoma but higher sensitivity in malignant neuroectodermal tumours. the multi-modality approach remains essential as % of these tumours were only detected with anatomical imaging. the increasing use of pet-ct should improve the sensitivity of this technique. breast cancer is the most frequent tumour in women. it would be very useful to identify patients responders to neo-adjuvant treatment from not responders. aim: the aim of this study was to systematically review the literature regarding the value of fdg-pet and pet-ct in the assesment of treatement respond after neo-adjuvant theraphy. materials and methods: systematic review of the literature, searching relevant studies in medline and cancerlit. for the selection of the studies we applied inclusion and exclusion criteria that had been previously set. two independent reviewers assessed the methodological quality of each selected study (flynn criteria) and the eficacy diagnostic level (fryback). most relevant data and statistic results were obtained from each study. results: studies were found in the primary search. after aplying inclusion and exclusion criteria, four studies were selected. in three of these four studies the metodological quality was modarately low (c group) ; all the studies were in level ii of diagnostic eficacy. with a statistical analysis , . sensitivity, . specificity and . accuracy were obtained. most of the authors agree in the necessity of perform some pet studies during neoadjuvant treatment. most authors also agree that it would be suitable to use a semicuantitative analysis using "standardized uptake value" (suv) from assessment the response. the threshold value for differentiation responders and no-responders is different depending on the study. conclusions: recent studies suggest that fdg-pet may identify patients responders to neo-adjuvant therapy earlier then other conventional imaging modalities. it is still not clear when to perform pet studies or which is the appropriate threshold value for differentiation responders and not-responders. finally, further prospective investigations on a larger number of patients need to be performed. objectives: paragangliomas are usually slowly growing, somatostatin receptor (sstr)-expressing, benign tumours of the head and neck region. however, they can also be locally invasive and cause bone destruction and dysfunction of cranial nerves. up to % of paragangliomas are malignant and may metastasize, leading to distant lesions. therefore, accurate whole body tumour screening is important. the aim of this study was to assess the accuracy in detection of sstr-positive lesions derived from paragangliomas by ga-dota-tyr -octreotide (dota-toc) pet/ct or ga-dota-toc pet/mri fusion. methods/patients: in this study, the clinical value of sstr imaging with ga-dota-toc pet was assessed in patients ( male and female, age ranged from to ). seven patients underwent whole body imaging with ga-dota-toc pet, and in patients cerebral ga-dota-toc pet imaging was done. each patient received mbq ga-dota-toc, images were obtained - minutes post i.v.-injection. combination of morphologic and functional imaging was done by pet/ct or pet/mri, providing more accurate information in staging and restaging. the interpretation of ct and pet scans was done independently. results: of the investigated patients with paragangliomas patients showed true-negative and true-positive results. all known lesions were also shown by pet. additionally unknown bone lesions were detected in a patient with metastatic disease. because of the high sstr-expression in one patient with local recurrence of invasive paraganglioma, treatment with the sstr-analog lu-dota-tate was initiated, since no other therapeutic options were available. over one year six therapeutic cycles with an overall dose of , gbq were performed, without severe side effects. in the follow up one year after first treatment by ga-dota-toc pet/ct, minor response was observed. conclusion: ga-dota-toc pet provides accurate information concerning extension and localisation of paraganglioma lesions for initial diagnosis, for selection and for follow up after radionuclide-peptidetherapy. furthermore, our data indicate that whole body imaging with ga-dota-toc pet might be useful to delineate distant and small metastases of paragangliomas. . fourteen patients had more than one fdopa-pet examination (between to ). forty examinations were performed without combined ct and (since july ) with combined ct. the impact of fdopa pet was evaluated, on a per-patient basis, thanks to a questionnaire filled in by the referring physician and the pertinence of the induced decisions was assessed thanks to the follow-up data. results: -carcinoid tumour of the small bowel: of patients were evaluable. an impact of fdopa-pet was reported in of them (rate: %), corresponding to an adequate decision in all patients (major therapeutic changes in patients, minor therapeutic changes in patients and orientation of biopsies or complementary imaging in patients). among the examinations performed in these patients, examinations were true-negative (tn), were true-positive (tp) and only one was false-negative (fn) (residual tumour measuring mm, responsible for clinical symptoms). -non-carcinoid digestive tumours: of patients were evaluable. an impact of fdopa-pet was reported in of them (rate %), corresponding to an adequate decision in patients (decision of surgery and decision of medical therapy) and a non-pertinent decision in patients (inappropriate cancellation of surgery and futile complementary exploration of a questionable focus of fdopa uptake). the examinations performed in these patients corresponded to tp, tn, fp and fn results. conclusion: the overall rate of change in patient management was %, with a significant difference between the rate in carcinoid and in non-carcinoid tumours ( % vs. %, p < . ). fdopa-pet appeared to be a major tool for the management of carcinoid digestive tumours with excellent diagnostic performances and induced pertinent changes in the management of patients at a rate similar to that of fdg-pet in other malignancies. background: fdg pet has a role to evaluate the response to molecular targeting therapy with imatinib mesyilate against gastrointestinal stromal tumor. metabolic response assessed by fdg pet is earlier than morphological changes determined by ct or mri. the assessment of early response to the molecular targeting therapy has a clinical significance in terms of evaluating effectiveness and determining alternative therapy based on the possibility of ineffectiveness in the early stage of the expensive therapy. purpose: we have conducted preliminary study of fdg pet to assess early response to the chemotherapy with gefitinib to non-small cell lung cancer (nsclc). materials and methods: four patients with advanced nsclc who have measurable lesion and epidermal growth factor receptor mutation, and were scheduled for gefitinib therapy were evaluated. the study was approved by the institutional review board and all the patients gave informed consent. fdg pet was done prior to, days and - weeks after the commencement of the therapy. pet was performed after injection of - mbq/kg fdg by d acquisition using a dedicated whole-body pet scanner (set w, shimadzu, japan). transmission data was acquired simultaneously with emission data using the external source. uptake of fdg in the tumor was evaluated by the semiquantitative evaluation using standardized uptake value (suv). outcome of patients was correlated with the changes in the size of the tumor and the suv. results: conventional response evaluation with ct revealed that two of four patients showed partial response (pr) and the others showed stable disease (sd) with minor response. progression free survival (pfs) of the two pr patients was . and . months. pfs of two patients with sd was . and . months. fdg pet showed decrease in fdg uptake ( . % and . % of initial study) in sd patients as well as in pr patients. conclusion: fdg pet could represent early response to gefitinib and have a role to estimate prognosis even in patients with sd which is evaluated by conventional ct. aim: dynamic pet studies with f-fdg were performed in patients with advanced non-small cell lung cancer (nsclc) who received palliative chemotherapy to evaluate the impact of full kinetic analysis and assess its value with regard to short ot long survival. methods: the evaluation includes metastatic lesions in patients with nsclc. all patients received a combined chemotherapeutic protocol consisting of vinorelbin and oxaliplatin. the survival data served as reference for the pet data. all patients were examined prior to onset of chemotherapy and on day - after onset of the first cycle. the following parameters were retrieved from the dynamic pet studies: suv, fractal dimension (fd), two compartment model with computation of k , k , k , k (unit: /min), the fractional blood volume (vb) and the fdg-influx according to patlak was calculated using the formula (k x k ) / (k + k ). we used a two group classification, namely a short and long term survival group based on the median survival time ( days) as a cutoff. a support vector machines (svm) analysis was used for classification of the two a priori defined groups. results: the observed survival times varied from to days with a median survival time of days. most kinetic parameters demonstrated only small changes, mostly declining after one cycle. the change in all kinetic parameters did not correlate to the survival based classification.the change in suv was significant between the first and second study (p= . ) but without an impact on the prediction of short ot long survival. svm based analysis revealed the highest correct classification rate (ccr) between short and long survival for the combination of suv and influx of the first study and suv, influx, k , k of the second study with a ccr of . %. conclusion: the results demonstrate, that a full kinetic analysis of the f-fdg kinetics in nsclc is helpful for the classification into short or long survival and may be used to identify those patients who may benefit from this palliative chemotherapeutic protocol. aim: (a) to evaluate the efficacy of fdg pet in the early prediction of chemotherapy effect on human testicular cancer xenografts; (b) to determine the optimal delay between chemotherapy administration and fdg imaging. material and methods: animal model eight week-old male nude rats bearing subcutaneous human embryonal carcinoma xenografts (n= per animal) were treated with a single dose of cisplatin. a control animal received saline serum. pet imaging sa-pet imaging (phillips mosaic system) was performed . hours after injection of - mbq of fdg in the tail vein. fdg uptake was evaluated with tumour/background ratio (t/b ratio). animals were imaged at day (baseline examination), day , day and day . immunochemistry at each point, rats were sacrificed for immunochemistry studies which comprised cell proliferation (cyclin a), apoptosis (cleaved caspase ), and macrophagic infiltrate (anti-cd ). whole slice quantification (pixit® software) was used for comparison with sa-pet data. results: sa-pet imaging fdg uptake in rats who received cisplatin showed a biphasic evolution: initially, a peak was observed at day , with t/b ratios ( . +/- . ) higher than those observed at day ( . +/- . ), p< . . secondly, a decrease was seen from day to day , although t/b ratios at day were still higher than those at day . the decrease of fdg uptake became statistically significant at day (p< . ). in the untreated rat images, tumours demonstrated an increase of fdg uptake at day (far lower than that observed in treated animals) then remained stable. immunochemistry a significant increase of apoptosis was observed at day ( . +/- . ; p= . ) and day ( . +/- . ; p= . ) in comparison with day ( . +/- . ). a transient increase in cell proliferation was observed at day ( . +/- . ; p= . ) in comparison with day ( . +/- . ), and was followed by a decrease at day ( +/- . ; p= . ). macrophage infiltrate, a well known cause of false positive findings, remained low when fdg uptake was increased after chemotherapy. conclusion: fdg pet may be useful in the early evaluation of treatment in patients with testicular cancer. a very early increased fdg uptake precedes a transient increase in cell proliferation but does not reveal refractory disease. additional studies investigating the effect of chemotherapy type, dose and schedule are currently underway in our laboratory. purpose. the purpose of this study was to analyze the diagnostic accuracy of pet and pet/ct in the evaluation of treatment response, both analyzing early response to treatment (ert) after a few cycles of chemotherapy, and after having completed the treatment (ahct), in patients with hodgkin disease (hd) and non-hodgkin lymphomas (nhl). methods. we performed a systematic review of the literature, searching medline and embase databases for studies published until december . we included articles that evaluated pet and pet/ct in patients with lymphoma after treatment (ert and ahct). the eligibility was based in articles with sufficient data for calculate parameters of diagnostic accuracy, with separated analysis in hd and nhl. we calculated values of sensitivity (se), specificity (sp), positive probability rate (ppr) and diagnostic odds ratio (dor). results. we selected studies for analysis. the diagnostic parameters for ert in pet and pet/ct in patients with hd were: se of . ( recent studies have demonstrated the effective use of imatinib mesylate for the unresectable, metastatic or recurrent gist. the aim of this study was to evaluate the role of f fdg pet/ct in gist patients treated with imatinib mesylate. material and methods: eight consecutive patients with gist proven by surgery ( stomach, small bowel, small bowel and peritoneum, and rectum) underwent thirteen f fdg pet/ct imaging after the start of imatinib mesylate therapy ( mg/day or greater if disease progression). patients were overnight fasting and had normal blood glucose levels. pet/ct was acquired - minutes after the intravenous injection of - mbq of f fdg. iterative reconstruction algorithms were applied and pet images were corrected for attenuation on the basis of ct data. a visual analysis of images was performed. standardized uptake value (suv) was calculated for each lesion. in the patients who underwent serial fdg pet/ct imaging, the therapy response was assessed according to the recist criteria for ct and eortc recommendations for pet. results were confirmed by clinical follow-up, radiographic findings or histological analysis. results: five patients were therapy-responders. the response was complete in , of them had abdominal lymph nodes and the other, peritoneal implants. the remaining patients had a partial response showing persistent fdg uptake in lung ( ) and in liver metastases and lymph nodes ( ). this latter patient showed a complete response increasing the imatinib mesylate dosage to mg/day. one patient had a disease progression showing new hepatic lesions on fdg pet/ct; a partial response was documented (a decrease of suv in two liver lesions) after a left hepatectomy and an increase of dosage to mg/day. two patients were no-responders. one patient had an unresectable pelvic gist and the other multiple peritoneal implants. both patients died in a - months period after fdg pet/ct. conclusion: tumor response to imatinib mesylate should be assessed by fdg pet/ct. fdg pet/ct imaging identified the degree of therapy response with a clinical impact on the management of patients with gist. of doses that mimics maximum tolerated dose (mtd) used clinically. the body weight of each mouse and the size of tumor implants were monitored throughout the experiment. the mice were scanned with f-fdg on days , , , and post tumor inoculation using high-sensitivity projection imaging (ppis- , hamamatsu) with f-fdg for monitoring the anti-tumor effect of ctx. the results of ppis imaging was compared to those of micropet imaging (r , concorde). result: ctx treatment resulted in growth inhibition of the ct- tumor and a decreased of the body weight of the mice as compared to the untreated controls. both the highsensitivity projection and micropet f-fdg imaging modality are equally effective in monitoring the ctx-induced tumor growth changes. conclusion: our results demonstrated that ppis imaging modality is as effective as micropet in the monitoring of the tumor response to ctx chemotherapy. these results suggest that the high-throughout screening imaging system may be employed for evaluating new anticancer drug using murine tumor models. aim: aim of the study was to evaluate the usefulness of ffdg-pet/ct in patients (pts) with lower rectal cancer treated with neoadjuvant chemo-radiotherapy (crt). fifty-five pts were enrolled in the study. all patients had known rectal cancer located within cm from the anal verge. the pts characteristics were: men, women, mean age ( - ). stage: pts (ut n-m ), pts (ut n-m ), pts (ut n+m ), pts (ut nxm ), pts (ut n m ), pts (ut nxm ). chemotherapy consisted of a weekly schedule of oxaliplatin (oxa) and -fluorouracil ( fu) or fu alone. radiotherapy started the same day as cht and was delivered up to a dose of . gy in daily fractions of . gy. rectal surgery was performed - weeks after the end of neoadjuvant treatment. fdg-pet/ct was performed at staging and - weeks after the end of crt. pathological examination of surgical specimens included the tumor regression grade (trg) evaluation according to mandard. pts were followed up for - months. suvmax pre and post crt was measured in the site of the primary lesion. results: twenty-nine pts were considered as complete pathological responders (group : trg - trg ). twenty-six pts were classified as pathological non responders (group : trg - trg ). the mean suvmax decrease compared to the baseline was % (range - % to - %) in group and % in group (range - % to - %). the mean value of suvmax post crt in group and was respectively and . . in group pre therapy suvmax mean value was . , while in group was . . interestingly, pts with trg showed a pre therapy suvmax mean value of while pts with trg showed a pre therapy suvmax mean value of (p < . ). conclusion: in our series of patients no correlation was found between metabolic response (suvmax decrement) and pathological response (trg). however a correlation was found between pre-therapy suvmax value and pathological response (trg vs trg ). aim: to evaluate the fdg metabolism in patients (pts.) with high risk soft-tissue sarcomas receiving an induction or neoadjuvant chemotherapy. the treatment effect was assessed with regard to the prediction of therapy outcome. methods: the ongoing evaluation includes patients with high grade soft-tissue sarcoma with different histologies. pts. received an induction chemotherapy consisting of adriamycin mg/m /day and ifosfamide mg/m /day - (ai-g regimen, six cycles) prior to peripheral blood stem cell transplantation, and pts. were treated with pre-operative chemotherapy consisting of etoposide mg/m /day + , ifosfamide mg/m /day - and doxorubicin mg/m /day (eia regimen, cycles). pts. were examined prior to onset of therapy and after completion of the first cycle of ai-g and after two cycles of eia chemotherapy, respectively. the restaging data of patients ( pts with ai-g and patients with eia treatment) served for reference. restaging was performed using ct and/or mri after six cycles of ai-g or four cycles of eia chemotherapy. results: restaging data are available in pts. according to recist criteria, clinical outcome was as follows: pt. showed no evidence of disease (ned), partial remissions (pr), stable diseases (sd), and pts. progressive disease (pd). due to the small number of pts., we dichotomized the data in pts. with ned/pr (n = ) and pts. with sd/pd (n = ). median suv prior therapy was . suv in comparison to . suv after chemotherapy. median influx was . prior to chemotherapy in comparison to . following therapy. most kinetic parameters showed only small changes, only vb declined after one cycle. we used discriminant analysisto classify the patients into responders and non-responders. da revealed a correct classification rate of % using all kinetic data of the baseline study and % using all kinetic data of the second study. conclusions: on the basis of these results, kinetic fdg data are helpful for the prediction of chemo-sensitivity in patients with high risk sarcomas. f-fdg pet/ct monitoring of tumor response to chemotherapy: does f-fdg imaging can be used as a chemosensitivity testing method? s. song, g. huang; renji hospital, shanghai jiaotong university, shanghai, china. aim: the aim of this study was to determine if fdg-pet/ct can be used as an in vivo individual chemosensitivity testing method, especially in those who underwent chemotherapy at the begining. material and methods: fourteen vx xenografts bearing new zealand rabbits with total of tumors in axillary fossa close to anterior wall were randomly divided into control group(n= ) and cisplatin chemotherapy group(n= ). the tumors were - mm in size. in treatment group fdg-pet/ct images were obtained before administration cddp(pett ),during treatment ( min after administration cddp pett ), d(pett ), d(pett ) and d(pett ) after chemotherapy. in control group fdg-pet/ct were obtained every days from the first imaging to days of total pet/ct imaging since the rabbit were inoculation vx tumor. results: mean suvmax ( - min after injection )of the control group were increased steadily, which were . ± . (petc ), . ± . (petc ), . ± . (petc ), . ± . (petc ), . ± . (petc ) and . ± . (petc ) respectively. in cddp treatment group, according to the degree of suvmax decrease on pett and pett , we divided the xenografts into a responder group (partial response + stable disease, n = ) and a nonresponder group (progressive disease, n = ). we use the (pett -pett )/ pett degree> % as the criteria of response. the retention index and t/m ratios showed marked changes at the time point of pett in the responder group, although the tumors did not show any significant change in volume at that time. paraffin section stained with haematoxylin and eosin of sections showed that the number of viable tumor cells in the responder group decreased at days, and peaked at days. necrotic cells and fibrotic tissue were observed after cddp treatment of and days. the decrease of fdg uptake in responder group on pett was an early marker that the individual was sensitive to cddp, and correlated well to days pathology results. in non-responder group there were no significant changes in pathology results compared with control group. conclusions: early evaluation by fdg-pet/ct, especially during cddp administration is useful. the decrease of fdg uptake was an in vivo biomarker to predict later pathology result. the study included patients diagnosed and treated of nmlc. fdg-pet/ct was done and weeks after chemoteraphy and/or radioteraphy respectively. pre-treatment staging was done with the addition of fdg-pet/ct in patients, and only by ct in . the images were evaluated by visual and semiquantitative analysis and the results were compared with ct findings. final diagnosis was based on the information obtained from clinical records. a good therapeutic response (gr) was achieved in patients, no changes (nc) in , and progression of the disease (pr) in . results: fdg-pet/ct and ct findings agreed in of the patients ( %) and disagreed in ( %), with gr, with nc and with pr. in of the , fdg-pet/ct revealed more lesions than ct ( in gr, in nc and in pr), showing a more extensive nodal disease in , extra-nodal metastatic disease in and local growth in one. in of the patients with discordant findings ( %), all with gr, fdg-pet/ct rule out tumoral disease suspected by ct findings. in patients ct studies were non-diagnostic ( with gr and with pr), and in of them fdg-pet/ct rule out disease, in confirm it. overall, fdg-pet/ct was definitive to establish the final diagnosis in of the with gr ( %), in one of the with nc, and in of the with pr ( %). interestingly, regarding the employment of pet/ct at staging, of the in whom it was applied, showed gr; however of the in whom staging was based only in ct, only showed gr unlike who showed pr. conclusion: the results demonstrate the value of fdg-pet/ct and confirm that it must be included in the assessment of the response of treatment of nmlc. in addition to clarify non-diagnostic ct scans, revealed a considerable number of unsuspected tumoral lesions. moreover, when fdg-pet/ct is employed for the initial staging a better therapeutic response is obtained. . males and females. they were of post solid organ transplantation namely heart (n= ), lung (n= ), liver (n= ), and kidney(n= ) that were performed from september until october . they were for staging purposes (n= ), and as follow up assessment( n= ), post therapy. the biopsy procedure and tissue samples were obtained prior to the pet ct scan. the results of a total pet ct were compared with conventional imaging (us, ct, mr), both of which imaging were done about the same time. results: cases were confirmed ptld by histopathological diagnosis. patients developed ptld early(less than months)and patients developed late ( months and later) after transplant. the mean time to onset is . months. ptld histological subtypes revealed malignant lymphoma,(ml) in cases, polymorphic lymphoproliferative disorder (pld) in cases, multiple myeloma (mm) in cases. in patient, diagnostic histology type was not available. cases involved only the lymph nodes and cases involved extranodal. in / examination, pet ct and conventional imaging were concordant. in comparison to conventional imaging, the pet ct study results showed lower sensitivity ( . % vs %) but similar specificity( % vs %). the overall accuracy of pet in diagnosis and follow-up is almost similar to conventional imaging ( . % vs %). conclusion: this study suggest pet ct is an accurate diagnostic tool in staging and follow-up of ptld patients. however, reconfirmation with histology of all positive findings remains mandatory. it is also a useful modality in patients with impaired renal function as a result of chronic immunosuppressive treatment. as no contrast medium is necessary, contrast related nephrotoxicity in ptld patients is avoided. further study is recommended before implementing pet ct as a routine diagnostic tool in suspected cases of ptld following solid organ transplantation. keywords: aim: f-fdg pet is increasingly used in radiotherapy planning. the aim of this study was to evaluate from a retrospective study the feasibility of using f-fdg pet/ct to detect and delineate the target volumes in advanced nsclc. this implementation into radiation treatment planning has required strong collaboration between radiation oncologists and nuclear physicians. patients and methods: from april and october , were enrolled for radical radiation therapy staging patients with unresectable nsclc ( males and females; mean age . years), performance status > % (karnofsky), squamous cell carcinoma, adenocarcinoma and large cell carcinoma, stage iii (n= ), stage iv (n= ). whole body pet/ct (biograph sensation siemens) was performed after min from the injection i.v. of mbq f-fdg, followed by pet/tc scan of the roi on bed for radiotherapy. gtvs were determinated and based on the pet data. results: after fdg pet/tc, out of pts were judged to be potentially eligible for curative treatment; out of pts underwent concurrent chemotherapy, out of pts performed successive surgery (in one of these a focal thyroid uptake of fdg were investigated and malignant lesion were demonstrated by cytological analysis -papillary cancer-). out of pts fdg pet/tc detected distant metastases (controlateral lung, adrenal and bone); in this pts was given palliative therapy. mean rate of radiation was gy ( - ). gtv was changed in all pts (decreased in pts and increased in pts). out of pts had mild toxic effects ( oesophagitis, cough, dyspnoea); out of pts moderate toxic effects ( oesophagitis, dyspnoea). all pts were followed for at least months; pts presented relapse ( with local and with distant recurrences), pts were in stable disease and pts were in complete remission (median time of months: range - ). one patient died post-treatment. conclusion: our data, even if obtained in a short number of pts, seems to confirm that fdg pet/tc could add information to precisely identify the gtv in advanced nsclc so as to obtain a better local control of disease. the technique of tumor contour definition by fdg pet/ct lead to substantially different volumes, especially in pts with necrotic or colliquative areas in the tumor mass. as we know from literature pet significantly altered the gtv or ctv in %, therefore all patients underwent a whole-body pet scan after a ct scan. the ct images provided morphological volumetric information, and in a second step, the corresponding pet images were overlaid to define the effective target volume. the images were exported off-line via an internal network to an rt simulator. we consider definitive follow-up after two years from treatment or in case of patient death's. the dose range is ÷ gy, with a mean of , gy. five patients have a negative pet, so the rt field was the whole mediastinal area to prevent prospective micro metastases. in all the others cases we have considered the pet area as the gtv for rt. results: nine patient were excluded from the study owing to change in the disease stage subsequent to the pet/ct study, sclc and nsclc. among the remaining patients, we have definitive follow-up for pz ( %) and temporary follow-up for the others . we verified ( %) not evident disease, ( %) sistemic progression or diffused metastases, ( %) stationary disease and ( %) with relapses in the rt field or in the neighboring. conclusion: fdg-pet is a highly sensitive imaging modality that offers better visualisation of local and locoregional tumour extension. this study lead to the conclusion that the use of pet/ct in radiotherapy planning allows a better patient management and gives comforting results about relapses in field. the assessment of the radioimmunotheraphy with it is important to assess the therapeutic response in refractory or relapsing lymphoma patients before progression of disease. therefore, we intended to find out the optimal timing for assessing the treatment response of the i-rituximab in patients with refractory nhl using f-fdg-pet/ct (pet). methods: twenty-eight patients with nhl (dlbl in , mcl in , mzbcl in , fl in , malt in ) refractory to previous chemotherapy ( to cycle, median: cycle) were enrolled. pet was performed at pretreatment, and days, days, and - days after i-rituximab. we compared pre and post-treatment pet with parameters; mean suv, maximum suv (suvmax), volume of interest (voi) of lesions, total metabolic volume volsum) and adjusted metabolic volume (suv*volsum). we correlated the decrement (%) of individual pet parameters calculated by roc curves with the clinical assessment of the treatment of months after i-rituximab. results: clinical assessments for the i-rituximab were cr in , pr in , sd in and pd in . area under the curve of the calculated decrements of each pet at , , and - days after i-rituximab were . , . and . for suvmax, and . , . and . for suv*volsum. there were statistically significant differences in the pet parameter decrements on days after i-rituximab (p< . ). moreover, there was tendency of disease progression in the ~ days pet parameters. conclusion: the assessment for the treatment of i-rituximab in patients with refractory nhl using pet was recommended at days after treatment. second dose of irituximab was recommend within ~ days before progression of disease. aim: ct images provides additional anatomical information for pet/ct study. however, the role of contrast medium in pet/ct is still controversy. in this study, we demonstrate the results and our experience by using ct contrast medium enhancement in fdg pet/ct examination. material and methods: between dec. and apr. , fdg pet/ct studies were performed on patients. patients whose images had either insufficient anatomic information or equivocal findings in fdg pet/ct were included in the study. subsequently we performed delayed imaging without and with intravenous contrast medium. the impact of contrast medium was assigned a value on a -point probability scale. results: during this period, fdg pet/ct delayed studies with contrast medium enhancement in patients were recruited for the study. among these scans with contrast medium enhancement, malignancy of the digestive system ( / , %) is the most frequently required for this procedure, especially in colorectal cancer ( / , %). in fact, contrast medium technique was useful for delineating the boundary of tumor and its surround tissues, evaluating vascular invasion of the tumor, and determining the vascularity of suspected lesions. there was mild adverse effect occurred in patients with skin rash and patients with extravasating contrast medium. conclusion: an additional imaging with contrast medium enhancement in fdg pet/ct study may provide useful information in cases with insufficient anatomic information or equivocal findings. the relatively side effect for contrast medium is acceptable in this study. introduction: the accumulation in the stomach and colon often pesters nuclear medicine physicians with the interpretation as to whether " normal or not " because f-fdg frequently accumulates not only in the abnormal lesion like malignant tumor but also in the normal stomach and intestines. the purpose of this study is to assess the ability of scopolamine butylbromide that inhibits the periatalsis to reduce the physiologic uptakes in the stomach and colon. methods: we studied people who had a checkup for cancer using pet/ct. all people are less than fifty years old and mean age was . ± . ( to ). fifty-four people were female and ninety-four people were male. we administered an intravenous drip injection of isotonic sodium chloride solution including scopolamine butylbromide of mg to people in this study for minutes. the drip was started at five minutes before the injection of f-fdg. we categorized the degree of f-fdg uptake in the stomach and along the colon into four grades according to the following scale: grade : no visible uptake; grade : lower than in the liver; grade : similar to the liver; grade : higher than in the liver. also, we measured suv in the stomach (circle roi, mm in diameter) and counted the number of nodular uptakes in the colon that is higher than in the liver per man. results: the mean grade of stomach in the injection group ( . ± . sd) was significantly lower than that in the non-injection group ( . ± . sd) (p< . ). also, the mean grade of colon in the injection group ( . ± . sd) was significantly lower than that in the non-injection group ( . ± . sd) (p= . ). the suv in the stomach averaged . ± . sd in the injection group, and . ± . in the non drip injection group. the averaged suv in the drip injection group was significantly lower than that in the non drip injection group (p< . ).the number of nodular uptakes in the colon ( . ± . sd) in the injection group was lower than that in the noninjection group ( . ± . sd), but the significant difference was not found (p= . ). conclusion: our results indicate that the intravenous drip injection of scopolamine butylbromide can reduce the physiologic uptake in the gastrointestinal tract, especially in the stomach. aim: to detect malignant tumors pet images are usually obtained about hour after intravenous administration of fdg, but fdg uptake by malignancies is often greater in delayed scans than in early scans. we investigated malignancies that were only detected on delayed scans and showed no fdg uptake on early scans. materials: two pet specialists judged the fdg-pet images of lesions in patients ( men and women with a mean age of . ± . years), which showed no uptake on early scans and abnormal uptake on delayed scans. these lesions were shown to be malignant by histology in cases, by follow up in cases, and by other methods in cases. methods: pet images were obtained from to minutes (early scans) and from to minutes (delayed scans) after administration of fdg following hours of fasting. the roi was set on the sites of abnormal fdg uptake on delayed scans and the corresponding area on early scans, after which the suv max of each roi and the rate of increase were calculated. results: the lesions included metastatic liver tumors, metastatic lung tumors, metastatic mediastinal lymph nodes, abdominal lymph nodes, prostate cancers, cases of peritoneal dissemination, primary lung cancers, bladder cancers, esophageal cancer, mesothelioma, hepatoma, and cholangioma. the suv max values for the early scans and delayed scans were . ± . and . ± . , respectively, while the rate of increase was . ± . . discussion: among the lesions, the most common was metastatic liver tumors, presumably because fdg uptake by these lesions increased over time and normal liver uptake decreased. the second most frequent diagnosis was metastatic mediastinal lymph nodes, also presumably because fdg uptake by these lesions increased over time and mediastinal background uptake decreased. four prostate cancers and bladder cancers were detected on delayed scans because bladder uptake was markedly decreased on these scans. the other lesions were too small for abnormal uptake to be detected on early scans. conclusion: examination of a delayed scan is extremely useful for detecting malignant tumors that do not show fdg uptake on the early scan, especially lesions surrounded by high background activity, such as those in the liver, mediastinum and bladder. fdg uptake in cold and heat treated mcf- cells, comparison with cell viability, apoptosis, and tumor marker changes c. zhang, x. sun, j. liu, p. liu, g. huang; renji hospital, shanghai jiaotong university, shanghai, china. aim: to investigate the fdg uptake changes in cold and hyperthermia therapy and its correlation with cell viability, apoptosis and tumor marker changes. material and methods : an in vitro cultured breast adenocarcinoma cell line, mcf- , was divided into groups. hyperthermia group: cell was treated in degree centigrade min. hypothermia group: cell was treated in degree centigrade min. hypo-and hyperthermia group: cell was treated in degree centigrade min and degree centigrade min. chemotherapy group: cell was treated with microgram cisplatin for hours. and control group: cell was untreated. the levels f-labelled fdg uptake, a -( , -dimethylthiazol- -yl)- , -diphenyltetrazoliumbromide viability assay, flow cytometry assay and tumor markers (ca ,ca ) were detected at hour and hour. results : the change of f-fdg uptake is early than tumor marker (which came out at the h) under our study conditions. in treated mcf- cells, the levels of f-labelled fdg uptake were significantly lower than control group. the levels of f-fdg uptake depression were well correlated with cell viability and apoptosis data. conclusions : fdg uptake is sensitive and well correlated with cell viability and apoptosis assay, and can be used for early response monitoring in hypoand hyperthermia therapy. purpose: to prospectively analyse the relevance of pet/ct in the clinical management (benign disease/malignancy, initial staging, re-staging) of the primary pleural malignancy (ppm). methods: consecutive patients ( - y.o., median y.o.; m, f) with pleural disease were included. all of them underwent a wholebody pet/ct investigation (discovery ls, ge healthcare) with standard dose ( . mbq fdg/kg). studies were reviewed. pet/ct findings were assessed according to the tnm international mesothelioma interest group clasification. the clinical indications were: suspected ppm (group a: n= ); initial staging of primary malignant mesothelioma (pmm) (group b: n= ); re-staging following therapy (group c: n= ) and assessment of recurrence (group d: n= ). for clinical management and to establish prognosis the following subgroups were compared: t -t vs t , n -n vs n -n y m vs m . imaging findings were correlated with surgical and histopathologic staging in all patients. results: in group a (n= ) malignancy was excluded in / patients and confirmed in / cases, thus avoiding multiple invasive procedures and speeding up diagnosis. in group b (n= ) pmm was staged as: epithelioid (n= ), sarcomatoid (n= ) y (n= ) was unknown. it was located on the right-sided (n= ) and left-sided (n= ) pleura. eight studies diagnosed irresectable disease: t (toracic wall/mediastinum infiltration) in / ; n (mediastinal adenopathy) in / and m in / . globally pet/ct diagnosed / patients ( %) with extensive disease significantly modifying their clinical management. in group c studies were performed to assess response to therapy: chemotherapy (n= ): / with stable disease and / with disease progression, / with partial response and / had no previous study for comparison; surgery (n= ): to assess incomplete surgery (decortication) showed residual disease and without evidence of recurrence; surgery and chemotherapy (n= ) without evidence of recurrence. pet/ct showed unknown metastasis in two patients and a synchronic unknown malignancy (synchronic squamous cell carcinoma in the contralateral lung) which was confirmed by pathology. conclusions: pet/ct is a non-invasive multimodality imaging technique with significant relevance in the clinical management of the primary pleural malignancy. estimation of optimal kinetic model and prediction of pathological diagnosis of anterior mediastinal tumor using c-acetate dynamic pet study aim: recent studies indicated that c-acetate (ac) may be a complementary tracer in pet imaging of thymomas. but, kinetics of ac in tumor tissue is not completely elucidated, and it is unknown which kinetic model (km) is most optimal. the aim of this study is to evaluate which km is most optimal for analyzing ac dynamics in thymoma tissue, and whether dynamic ac-pet study can predict pathological diagnosis of mediastinal tumors using this "most optimal" km. methods: dynamic ac-pet studies were performed for suspected thymic tumor with anterior mediastinal mass on chest ct scan. (in addition, static ac-pet scans and fdg-pet studies were also performed just after dynamic ac-pet studies.) we assumed candidates of four kms as follows: we analyzed datasets of cases diagnosed pathologically ( thymomas of type a/ab, thymomas of type b /c, and thymic cysts) from august until december , applying to these (a)-(d) kms, and calculated akaike informational criterion (aic) of each km, and determined which km is most optimal, based on values of aic. furthermore, we analyzed datasets again using this "most optimal" km, and estimated parameters, and compared with pathological diagnoses. results: aics of (a) c- p km became smallest in all datasets, and it seemed to be "most optimal" among kms. using c- p km, we estimated rate constants (k , k ) and blood volume and calculated metabolic rate (mr) defined as k /k in thymomas of who type a/ab, mrs were more than . (k >k ), and in the remaining tumors, mrs were less than . (k < k ). cases with thymomas (type a/ab/b /c) were successfully detected by static ac-pet scan, but cases among thymomas were false negative by fdg-pet. cases with thymic cysts demonstrated neither ac nor fdg uptake. conclusion: this study indicated that c- p km may be "most optimal" for pharmacokinetic analysis of ac in anterior mediastinal tumors, and mr obtained by dynamic ac-pet studymay be useful for discriminating between type a/ab thymomas and thymic cysts, or type a/ab thymomas and more aggressive histology, as well as static ac-pet scan. objective: a potential false-positive fdg pet interpretation in oncologic imaging is fdg-uptake in brown adipose tissue. the purpose of this exhibit is to demonstrate the characteristic as well as the atypical locations and appearance of hypermetabolic brown adipose tissue in the neck, thorax, and abdomen. methods: twenty-one patients ( female, male; age range, - year-old) with brown adipose tissue on pet/ct studies were documented out of approximately scans. lesions were defined as brown adipose tissue by increased fdg metabolism corresponding to fat density tissue on ct scan. results: there were two cases of hibernoma, two cases of lipomatous hypertrophy of the interatrial septum and the reminder seventeen cases of brown fat were identified in neck, supraclavicular, superior mediastinal, perinephric and retroperitoneal regions. hibernoma is a benign neoplasm presenting as a focal lipomatous mass indistinguishable by conventional imaging from a lipoma with increased fdg metabolic activity of brown adipose tissue. lipomatous hypertrophy of the interatrial septum is characterized by excessive deposition of fatty tissue in the interatrial septum. the typical appearance of brown fat in the neck appeared as bilateral curvilinear areas of fdg activity with extension into the supraclavicular regions. mediastinal fat demonstrated focal activity in the mediastinum and mapped to the adipose tissue surrounding the large vessels. perinephric fat illustrated curvilinear or focal activity corresponding to the perinephric adipose tissue surrounding the upper pole of the kidneys. retroperitoneal fat demonstrated focal activity mapped to adipose tissue. conclusion: hypermetabolic brown adipose tissue can be misinterpreted as adenopathy or malignant mass in the setting of known primary malignancy. knowledge of this potential pitfall and precise localization with ct are important in preventing misinterpretation as malignancy. male), consecutive fdg whole-body scans were obtained with a pet/ct scanner. scanning was performed using the discovery ls pet/ct scanner (general electric medical systems). patients were fasted at least h before the pet acquisition. intravenous injection of . mbq/kg of f-fdg was followed by a tracer uptake phase of about min, during which the patients sat in a quiet room without talking. imaging parameters were as follows for an acquisition at - bed positions: kv, mas, . s per ct rotation, a pitch of , a table speed of . mm/s, . mm coverage, and a . s acquisition time. all pet/ct scans were examined retrospectively by observer on an interactive display using fusion software (xeleris; general electric medical systems). results: twenty-five patients ( male and female) of the scans ( . %) demonstrated brown fat uptake. the incidence rate was . % in scans of female patients and . % in scans of male patients. patients with brown fat uptake were younger than patients without ( . ± y vs. . ± y, p< . ). although there was no significant difference in bmi between patients with brown fat uptake, they tended to be thinner (bmi, . ± vs. . ± , p> . ). bmi was . ± for male patients and . ± for female patients with brown fat uptake (p> . ). when comparing the monthly incidence rate from april to october, the incidence was highest from november to march in the whole group of patients ( . % vs. . %, p< . ). conclusions: fdg uptake in brown fat occurs particularly in female, younger patients and those with lower bmi values. the incidence of brown fat is clearly increased during the cooler period of the year. aim:the aim of the study was to evaluate the feasibility as well as the agreement between tl- and tc- m mibi in brain spect for the differentiation of brain lymphoma and toxoplasma encephalitis -a distinction which is not always possible by routine ct or mri. methods:we studied female patients with acquired immunodeficiency syndrome during a -month period who had intracranial lesions on ct or mri. dual isotope tl- and tc- m mibi brain spect was performed in order to obtain simultaneous acquisition. we calculated uptake ratios by drawing roi around each lesion as well as in the opposite side. we compared our findings with pathologic data and clinical follow up. results:of the patients studied, had intense focal uptake in the lesion(s). / had either biopsy -or autopsy-proven lymphoma ( true positive). one patient with purulent infection had focal uptake ( false positive). patients with negative scans had toxoplasma encephalitis on clinical follow up ( true negative). tl- and tc- m mibi spect tally with each otherwith mibi slightly prevailing -as far as it concerns the lesion-to-normal tissue uptake ratios which were higher for sestamibi compared with those of tl- . conclusions: . patients with aids having intracranial mass on ct or mri may benefit from tl- or tc- m mibi spect in order to distinguish lymphoma and toxoplasmosis. . tl- and tc- m mibi may give similar results. meningiomas account for about % of all intracranial tumors. although grade i meningiomas have a benign clinical course, malignant ones are associated with - % recurrence rate and less than years median survival. evaluation of their proliferation rate is useful for assessing their biological behavior, with implications in patient prognosis. spect by various radiotracers can metabolically characterize intracranial tumors. we evaluated whether mtc-tetrofosmin (tf) uptake in meningiomas correlates with cellular proliferative activity and with tumor grade. materials & methods: consecutive cases with diagnosed meningioma ( males, females; mean age . years) were enrolled. brain spect by tf had been performed within a week prior to surgical excision. in the excised tumor specimens we assessed the ki- index by the mib- immunostaining method, reflecting cellular proliferation and aggressiveness. tf uptake was assessed visually and semiquantitatively, by calculating the lesion-to-normal (l/n) uptake ratio. pearson bivariate correlation analysis was performed between the level of tracer uptake (as expressed by the l/n ratio) and ki- expression and tumor grade. statistical significance was set at p < . . results: / patients were diagnosed with typical benign meningiomas and / had malignant meningiomas. intensity of tf uptake in the region corresponding to the ct/mri findings ranged from faint to profound. a significant correlation was found between both tf uptake and tumor grade (r = . , p < . ) and between tf uptake and ki- expression (r = . , p = . ). conclusion: this pilot study implies that tf brain spect could prove useful in differentiating benign from malignant meningiomas and is a potential indicator of their proliferative activity. comparison of brain spect with tc m-mibi and ctscan in discriminating of radiation necrosis and brain tumor recurrence s. dabiri oskouie , m. amiri ; tabriz university of medical scienses, tabriz, iran (islamic republic of), babol university of medical scienses, babol, iran (islamic republic of). aim: tc m-mibi has been proposed for use as an imaging agent for various tumors, including brain neoplastic lesions. in spite of many advances in diagnosis and therapy, brain tumors still represent a serious challenge for clinicians. after radiotherapy, deterioreting clinical status can be due to either radiation necrosis or recurrent tumor. computed tomography and magnetic resonance imaging offer imperfect discrimination of radiation necrosis and tumor recurrence. the aim of this study is to compare tc m-mibi scan and ct-scan results in this group of patients. material and methods: twenty six patients ( male, female, mean age of years) with primary brain tumors and deterioration of clinical status after radiotherapy were enrolled in this study. tc m-mibi brain spect was performed minutes and hours after iv injection of mbq ( mci) tc m-mibi. images were obtained with adac dual head camera. transverse, coronal, and sagital views were reconstructed. images were visually assessed. results: focal tc m-mibi was observed in patients. eight of these patients expired within months. biopsy of patients in this group confirmed tumor recurrence. ct-scan was positive in patients and the rest had equivocal or negative results. of patients with negative tc m-mibi scan, only patients died during months follow-up. six of these patients had positive, five had equivocal and one had negative ct-scan. ct-scan results didn't correlate with survival rate. conclusion: patients with negative mibi scan showed higher months survival rate ( . % ) compared to patients with positive mibi scan ( . % ). focal uptake on tc m-mibi scan is probably due to recurrent tumor. it can be concluded that brain spect with tc m-mibi is a useful method for discriminating radiation necrosis from tumor recurrence in patients following brain radiotherapy. aim: the differentiation between tumor recurrence and radiation necrosis remains a challenge. these entities have discrete treatment options and prognosis. radiation necrosis can occur between months to few years after irradiation, i.e. the same period during which recurrence is most frequent. in many cases morphologic brain imaging by ct/mri is unable to distinguish between these two pathological entities. although glioma cell line studies substantiated a plausible imaging superiority of mtc-tetrofosmin (tf) over other tumor-seeking radiopharmaceuticals, little has been reported on its in vivo imaging properties.we sought to evaluate the usefulness of tf brain tomography in distinguishing glioma recurrence from radiation necrosis. materials & methods: brain tumor patients ( males, females; mean age . years) were prospectivelly enrolled in the study. the initial diagnosis had been glioblastoma multiforme ( cases), anaplastic astrocytoma ( ), anaplastic oligodendroglioma ( ), grade ii astrocytoma ( ), and low-grade oligodendroglioma ( ) . all patients had been operated upon and then received adjuvant external-beam radiotherapy (total dose gy; no residual tumor on ct/mri), while of them also received temozolomide-based adjuvant chemotherapy. in all cases neurologic symptomatology relapsed in a mean period of months, arousing suspicion of tumor recurrence. ct/mri could not differentiate between recurrence and post-irradiation necrosis, so tf spect was performed. the level of tracer uptake (as expressed by the lesion-to-normal brain [l/n] uptake ratio) was compared between radionecrosis and recurrence by the two-sided mann whitney u non-parametric test. statistical significance was set at p < . . results: in / cases an abnormally increased tracer uptake appeared in the region that ct and/or mri indicated as suspicious; in half recurrence was confirmed histologically after surgery, while in the other by growth of the lesion over a -month follow-up period and clinical deterioration. the remaining / patients had faint uptake in the suspicious region, compatible with radiation injury; these lesions remained morphologically unaltered over a mean month follow-up period, with no clinical deterioration in patient's condition, a course most likely favoring the diagnosis of radiation injury. statistical analysis verified that tumor recurrence had significantly higher tf uptake, as compared to radionecrosis (p = . ). conclusion: metabolic brain imaging by tf could offer useful information in the workup of treated brain tumors, where radiomorphologic (ct/mri) findings are inconclusive between recurrence and radionecrosis. aim: distinquishing neoplastic from nonneoplastic intracerebral hemorrhage (ich) constitutes a common challenging problem since on standard neuroradiologic imaging neoplasms can be hidden behind an intracerebral hematoma, while some hemorrhagic nonneoplastic lesions may mimic neoplasms. ct and mri cannot always distinguish between neoplastic and nonneoplastic hemorrhage due to considerable overlap of findings. in contrast to neoplastic ichs, nonneoplastic ones display faint radiotracer uptake and only several days (> ) after the onset of the episode. accurate diagnosis is therefore critical in providing optimal patient care. we evaluated the usefulness of brain spect by the tumor-seeking tracer mtc-tetrofosmin (tf) in diagnosing hemorrhagic brain tumors among patients with nontraumatic intracerebral hematomas. materials & methods: ten patients ( males, females; mean age . years) diagnosed with spontaneous intracerebral hematoma on ct/mri were prospectively enrolled in the study. all underwent tf brain spect within a mean period of days after onset of symptoms. imaging was performed early ( min) post-injection. surgery was performed in / within a week; in the remaining / the diagnosis was based on a 'wait-and-see' policy of clinical and morphologic (ct/mri) follow-up. results: faint or absent tf uptake in the region corresponding to the ct/mri findings was found in cases, while only displayed significant tracer accumulation. the latter patient and of those with negative spect underwent surgery, which revealed an underlying tumor (glioblastoma) solely in the patient with positive spect. the hemorrhage cases lacking tf uptake that were not operated upon demonstrated a diminution in the lesion size on ct/mri follow-up and clinical improvement, thus considered as representing non-neoplastic intracerebral hematomas. conclusion: tf could prove useful in the early noninvasive assessment of nontraumatic brain hematomas, allowing differentiation between neoplastic and nonneoplastic intraparenchymal cerebral hemorrhage. # investigation of pediatric brain tumours using combined indium-octreotide / mtechnetium-dtpa brain scintigraphy g. dabasi , i. szilvási , p. hauser , m. garami , d. schuler , a. doros , j. járay ; semmelweis university transplantational and surgical clinic, budapest, hungary, semmelweis university department of nuclear medicine, budapest, hungary, semmelweis univ. .dept. of pediatrics, budapest, hungary. brain tumours are the most frequent pediatric solid tumours.some of them (especially medulloblastomas) express somatostatin receptors (ssr). in- -octreotide scintigraphy (os) can visualize ssr expression of various types of tumours. increased octreotide uptake might be non-specific due to impaired blood-brain-barrier (bbb). conventional brain scintigraphy (bs) with mtc-dtpa assess integrity of the bbb. aim of our study was to evaluate os for differential diagnosis of pediatric brain tumours using a double-tracer technique. patients and methods: children with brain tumours were studied. patients had medulloblastoma, patients had different types of brain tumours: glioblastoma, ependymoma, astrocytoma, primitive neuroectodermal tumour (pnet) and cerebral metastasis of ewing sarcoma. diagnosis was based on histopathology and conventional radiological investigations. all patients underwent cs using tc- m-dtpa and os with in- -octreotide on the next day.tumour to background ratios (t/bg) were measured at minutes of the dtpa and at hr of the octreotide scans. t/bg on os was compared to t/bg on bs. only tumours with t/bg on os higher than on bs were defined as ssr positive. results. cases ( , %) were ssr positive: medulloblastomas, ependymomas, astrocytomas, glioblastomas. patients had lower t/bg on os than on bs. in this group ( , %) patients had no uptake of octreotide in the tumour region defined by dtpa scan. diagnoses of these tumours were: astrocytoma, ependymomas and medulloblastomas and in pnet . in ( , %) patients moderate uptake of octreotide was seen, but t/bg on os was lower than t/bg on bs. diagnoses were: glioblastoma, astrocytoma, ependymomas, metastasis of ewing sarcoma, medulloblatomas and pnet. conclusions: os has not proved to be useful for differental diagnosis of pediatric brain tumours. ssr expression defined by higher t/bg ratio on os than on bs is not specific for medulloblastoma. in our opinion somatostatin analogue and/or targeted radiation therapy is indicated only in patients with specific octreotide uptake, i.e. with higher t/bg on os than on bs. this combined scintigraphic approach can be used to evaluate therapy of pediatric brain tumours with ssr expression. although magnetic resonance imaging (mri) is an excellent tool to diagnose brain tumors, the functional information is limited. on the other hand mtc-mibi brain spect is considered a useful tool in the management of brain tumors. aim: mtc-mibi tumor uptake is related to histological grading, cellular proliferation index and prognosis. our aim was to evaluate mtc-mibi brain spect and mri studies efficacy in the differential diagnosis between recurrence of malignant gliomas and glioblastomas and the local modification after radiotherapy. material and methods: eight patients with suspected recurrence after surgical removal of a glioma ( low grade and high grade), - months before study and treated with radiotherapy were investigated. for brain spect - mbq of mtc-mibi were i.v. injected to each patient minutes before image acquisition by a dual-head gamma camera. gd-dtpa enhanced t and t weighted mri studies were carried out in every patient within days before mtc-mibi spect. the ratio between the tumor roi on a slice with maximum uptake and a mirrored control roi was calculated and if > it was considered pathological. results: spect and mri studies well correlated being both positive for recurrence in patients as confirmed by biopsy, while both negative in patients, considered as having radiation effects (evaluate by clinical follow up). one patient with negative spect was operated being severely symptomatic and the biopsy was positive for low grade tumor. combined sensitivity was , %, specifity %, npv % and ppv % conclusion: mtc-mibi brain spect and mri studies provide high specifity of detection of relapses of gliomas and glioblastomas and also the most adequate anatomic depiction of extent of tumor process. clinical follow up of these patients is underway to assess correlation of metabolic response to clinical response. aim: the aim of this study was to assess the incremental diagnostic value of i spect/ct fusion imaging compared with conventional i planar scintigraphy in patients with thyroid carcinoma. materials and methods: seventy-nine patients with thyroid carcinoma underwent i spect/ct and i planar imaging - days after administration of either a therapeutic dose (n= ) or a diagnostic dose of i (n= ). reconstruction of fusion images were performed by using external markers placed at locations on each patient's skin to mark the same geometric plane and combining spect and ct images on a workstation. without knowing the clinical information of the patients, nuclear medicine physicians interpreted first i planar images and then i spect/ct fusion images. i spect/ct fusion imaging was considered to have an incremental diagnostic value when it demonstrated different but precise localisation from the i planar scintigraphy. results: as compared with the conventional i planar scintigraphy, i spect/ct fusion imaging had an overall incremental diagnostic value in . % ( / ) of patients, with more lesions detected in . % ( / ) of patients. the undetected activity at the thyroid bed was demonstrated in . % ( / ) of patients, of whom had markedly elevated serum thyroglobulin level. the percentage of the detection of unsuspected lung metastases, bone metastases, and lymph node metastases were . % ( / ), . % ( / ), and . % ( / ) of patients. the previously considered lymph node metastases were excluded in . % ( / ) of patients. conclusion: i spect/ct fusion imaging had an incremental diagnostic value over conventional i planar scintigraphy in patients with thyroid carcinoma for precise localisation of lesions and improved interpretation, which led to more appropriate patient management. optimal time for i post-treatment whole body scan: comparison between -day scan and -day scan after treatment c. somboonporn, k. roysri; nuclear medicine division, department of radiology, faculty of medicine, khon kaen university, khon kaen, thailand. objective: i post-treatment whole body scan (wbs) is a widely accepted test in identifying the presence of thyroid remnant and the extent of functioning metastases in well-differentiated thyroid carcinoma (wdtc) patients. sensitivity in detecting lesions depends on image quality and the amount of i taken up by the lesions. although the scan is conventionally performed - days after i administration, optimal scanning time, however, that gives the best detection rate has not been well established. therefore, we compare the sensitivity of lesion detection between the scan performed on the day of discharge from the hospital (day- scan) and that performed days after treatment (day- scan) on the same patient basis. material and method: i post-treatment wbs was prospectively studied in patients ( female and male, mean age . + . years) treated with high-dose i therapy from november until january in our nuclear medicine division. both day- scan and day- scan were performed in every patient and the scans were interpreted by two nuclear medicine physicians with consensus. the number, location and grading of uptake ( = no abnormal uptake, = minimally increased but abnormal uptake, = clearly seen abnormal uptake) by each lesion were compared between the two types of scan. results: three patients were negative by both scan types, whereas patients had at least one lesion seen in either day- or day- scan. the two scans were concordant in terms of the number of lesion detection in from the overall detected lesions ( %). day- scan found lesions ( in the neck, in the lung, in the mediastinum) not visualized in day- scan. day- scan revealed lesions not seen in day- scan of patients; both of them were in the mediastinum. eleven lesions in patients having abnormal uptake had increase in uptake grade in day- scan compared with day- scan. two patients with elevated serum thyroglobulin disclosed a cervical lesion that had not been seen in both pre-treatment scan and day- scan. two patients showed more metastatic lesions in bone and mediastinum in day- scan which were not seen in day- scan. conclusion: i post-treatment wbs performed days after treatment is better than the scan performed days after treatment because it yields higher lesion detection rate. hence, it provides more accurate staging, risk stratification and better management plan in wdtc patients. value of post-treatment i spect/low dose ct on the management of patients with thyroid cancer k. taborska, k. michalova, p. racek, p. vlcek; clinic of nuclear medicine and endocrinology, the ndmedical school of charles university and faculty hospital motol, prague, czech republic. accurate assessment of inconclusive foci on whole body i scan after radioiodine therapy is important for treatment planning. due to lack of anatomic landmarks it is not always to evaluate correct site involvement or sometimes distinguish metastatic spread from physiologic uptake without further examination such as ultrasound, ct or mri. aim of our work was to analyse usefulness of i spect/low dose ct after radioiodine therapy when unexpected or new unknown areas with accumulation of i were found on post-treatment whole body scans. material and methods: patients ( females, males, age - years) with thyroid cancer at various stage of their disease were examined between august and march . planar scintigrams were performed with sophy dstxi (ge ) within four to six days after administration of , - , gbq i, spect/low dose ct examination was acquired with symbia t (siemens) at the same or next day. results: precise localization was obtained in all evaluated regions. spect/low dose ct images improved characterization of equivocal foci of i uptake as definitely benign in patients. additional morphologic imaging was recommended in patients, patients were admitted to surgery due to solitary neck lymph nodes involvement and patients to ovarectomy due to i uptake (teratom was histologically proven). in patients subsequent radioiodine therapy was scheduled with tailoring of the administered dosage according to skeletal, lung or nodes involvement. conclusion: results of the post-treatment spect/low dose ct scans were finally implemented into the management of all patients, patients were spared further examination and findings in patients helped to direct additional follow-up. spect/low dose ct examination was found to be a valuable tool in management patients with thyroid cancer. v. valotasiou, s. gerali, c. zerva; "alexandra" university hospital, athens, greece. introduction: diffuse liver uptake (dlu) seen on i wbs of patients with operated thyroid cancer, represents liver metabolism of iodoproteins and may indicate either functional thyroid remnants, recurrence of the tumor or functioning metastases. aim: the aim of our study was to evaluate the frequency and clinical significance of dlu on i wbs in patients with thyroid cancer in the presence and absence of thyroid visualization (tv). materials-methods: we studied patients ( men, women) with operated thyroid cancer ( papillary, follicular, mixed papillaryfollicular, hürthle), mean age . years (age range: - years). two hundred thirty-three out of patients (group a) underwent post therapy wbs - days (mean . days) after the administration of - mci of i (mean . mci), while / patients (group b) had diagnostic wbs. dlu was graded by two nuclear medicine physicians from - ( =no uptake, =faint uptake, =moderate uptake and =intense uptake). results: group a: / patients had tv (group a ) and / patients (group a ) had no tv. in group a , / patients had dlu ( / had visible metastases on wbs) and / patients had no dlu ( / patient had visible metastases). in group a , / patients (group a a) had dlu and / patients (group a b) had no dlu. group a a: / patients had visible metastases on wbs ( / had dlu grade= ) and thyroxin-free thyroglobulin (tg) levels - ng/ml. the other / patients had thyroxin-free thyroglobulin (tg) levels . - ng/ml, findings which raised the suspicion of hidden metastases in these patients. group a b: thyroxin-free tg was - . ng/ml. group b: / patients had tv (group b ) and / (group b ) had no tv. in group b , / patients had dlu ( / had visible metastases on wbs with dlu grade= ) and / had no dlu ( / had visible metastases on wbs). in group b , / patient had dlu and / had no dlu. conclusion: dlu in the presence of tv may be due to functioning thyroid remnant although the possibility of recurrence or functioning metastases can not be excluded. nevertheless, dlu in the absence of tv on delayed post therapy wbs, may indicate hidden metastases and therefore could offer additional information in the management of patients with thyroid cancer. aim: to evaluate the role of the parathyroid hormone (pth) assay in patients with primary hyperparathyroidism (phpt). material and methods: we studied patients, mean age years, clinical and biochemical diagnosis of phpt, surgical complete exploration after the sestamibi scanning and anatomopathological confirmation of the removed glands. the pth values were obtained before surgery, by range of normality and pg/ml. results: the patients presented a mean average of pth pg/ml. . pth/histology: pth/hyperplasia: n= , mean= , , tip deviation= , , tip error= , pth/adenoma: n= , mean= , , tip deviation= , , tip error= , . pth/ mtc-sestamibi scintigraphy: pth/negative: n= , mean= , , tip deviation= , , tip error= , pth/positive: n= , mean= , , tip deviation= , , tip error= , . pth means: n= , minimum= , , maximum= , , mean= , , tip deviation= , . glandular weight means: n= , minimum= , maximum= , mean= , , tip deviation= , conclusion: we didn't observe significant relation between the scintigraphy and the pth. there was obtained a statistically significant difference (p= , ) between the averages of the weight of adenomas ( , mg) and hyperplasias ( , mg). the comparison of the pth values of both groups hadn't got statistical significance. the results of the sestamibi scanning didn't show statistical relation with the pth values. aim: several authors have reported false positive i- accumulations due to various clinical conditions in the absence of residual thyroid tissue or metastasis of differentiated thyroid carcinoma (dtc). in this report, we present a case with dtc having false positive i- accumulation due to a large hydatid cyst in the liver is presented. case report: a years old woman underwent bilateral near total thyroidectomy for . cm papillary thyroid carcinoma located right lobe. sonographic examination of the patient demonstrated an ovoid, complex cystic mass with dimensions of x cm in the right lobe of liver. the mass was well delineated, and contained septated cystic parts as well as solid appearing components. the appearance of the some solid parts was in favour of detached membranes. color doppler ultrasonographic evaluation yielded no vascular signal in the mass. these sonographic findings were found to be concordant with a type ce- hydatid cyst according to the world health organization classification. the immunoblot test was confirmed hydatid disease. surgical extirpation of the cyst suggested by interdisciplinary consultations was planned to be performed after the radioiodine therapy. two month later the thyroid surgery mci ( mbq) radioiodine therapy was performed for ablation of the thyroid remnant. the post-ablative whole body i- scan displayed minor uptake in the thyroid bed concordant with residual thyroid tissue and a focal, intense and homogeneous uptake of radioiodine in right lobe of the liver which was reported to be a hydatid-cyst lesion by usg. conclusion: while some cystic lesions of kidney and liver have been previously reported as causes of false positive radioiodine accumulation, this is the first reported case of uptake i- by a hepatic hydatid-cyst up to our knowledge. we therefore suggest that hydatid cystic lesions should be considered as false positive i- accumulating pathologies while interpreting wholebody i- scans. a. mestre, m. negre, g. obiols, j. mesa, f. porta, j. castell-conesa; hospital universitari vall hebron, barcelona, spain. purpose: to assess the role of i scintigraphy in the initial staging of differentiated thyroid cancer in comparison with i post-treatment imaging. methods: this prospective study included patients, male and female, age range - years. all of them were diagnosed of differentiated thyroid cancer ( papillary, follicular) and treated with total thyroidectomy. we compared i scans ( of them with spet) with their corresponding post-treatment i whole-body images with a maximum interval of months between them, evaluating the number of foci and localization in each exam. patients received a dose of mci of i. images were obtained to hours after administration. therapeutic dose of i ( - mci) after was used as the gold standard diagnostic scanning. patients were studied with rhtsh administration and one with thyroid hormone withdrawal. results: in out of patients i scan findings were completely concordant with those of corresponding post-treatment i images with a concordance rate of %. patients showed the same number of foci in cervical region (concordance %) while three patient showed an increased number of lesions in i image. three patients showed more intense uptake in i images than in the i ones. two out of patients presented metastatic disease in i and i scans. nevertheless, at least two additional foci were observed on post-treatment i images. conclusion i pretherapeutic scan is comparable to i post-therapeutic imaging in differentiated thyroid carcinoma patients with an acceptable concordance in cervical region and at distant site. although some lesions were missed on i images, no changes in therapeutic management of patients were observed. i versus mtc-sestamibi to detect thyroid cancer recurrence in cervical lymph nodes in cases with increased serum thyroglobulin s. gerali , p. valsamaki , j. koutsikos , s. tsiouris , e. pantazi , e. karga , s. luccetti , c. zerva ; "alexandra" university hospital, athens, greece, university general hospital of ioannina, ioannina, greece. aim: the detection of cervical node metastases from differentiated thyroid cancer (dtc), in the setting of increased serum thyroglobulin (tg), may be accomplished by the post-therapeutic i whole-body scan ( i-wbs). the method's effectiveness is directly dependent on the iodine-trapping ability of the cancer cells, under thyrotropin (tsh) stimulation (tsh> μiu/l). in this clinical setting, we used the non-specific tumor-seeking radiotracer mtc-sestamibi as an alternative diagnostic approach. scintigraphic findings were correlated with neck ultrasonography (us) and evaluated against the results of lymph node biopsy. materials & methods: we retrospectively studied dtc patients [ men, women, aged - years (mean ± sd = . ± . years). the histologic types were: papillary cell, follicular cell, and hürthle cell carcinomas. patients had undergone total thyroidectomy and i ablation therapy and eventually presented with elevated serum tg levels. we performed neck us and mtc-sestamibi wbs, min after iv injection of mbq tracer activity. repeat ablative dose of ( - mbq) was then administered and posttherapeutic i-wbs was performed - days later. the findings of the three imaging diagnostic modalities were correlated and compared with the lymph node biopsy histology that provided the definite diagnosis. results: mtc-sestamibi identified / cases of cervical lymph node metastases ( papillary, follicular, and all hürthle carcinomas). positive post-therapeutic -wbs was observed in / cases. detection of dtc recurrence in cervical lymph nodes by mtc-sestamibi scintigraphy and post-therapeutic i-wbs was accomplished with a sensitivity of % versus %, respectively. conclusion: the application of mtc-sestamibi in detecting dtc metastases in cervical lymph nodes seems rewarding, since it demonstrates higher sensitivity than i-wbs, probably due to additional recognition of dedifferentiated non-iodophilic lesions. also, no discontinuation of the thyroxine replacement / suppression therapy is required and the method offers high-quality imaging, with results available on the same day. we present our experience in the follow-up of these patients with serum calcitonin assays and dmsa (v) scans. a retrospective review of the hospital's medical records was performed. sixteen patients ( males, females, age; - yrs) with histologically proven medullary thyroid carcinoma, and who had basal serum calcitonin assays and dmsa (v) scans as part of their post-operative follow-up assessment, were included in the study. dmsa (v) scans were performed on these between - . all patients had prior total thyroidectomy. two patients had synchronous papillary carcinoma of the contralateral thyroid lobe and patient had men a syndrome. patients had serum calcitonin assays performed pre-operatively or within weeks of surgery. all patients had calcitonin levels greater than pg/ml. the lowest level was pg/ml. four out of patients showed normalisation of the serum calcitonin levels within months of surgery. of the patients with elevated serum calcitonin levels, patients showed an initial decline in calcitonin levels up to months post-surgery (but still above pg/ml) and a subsequent increase. both patients were found on subsequent dmsa (v) scans to have residual or recurrent foci of disease. the rd patient was lost to follow up. tc- m dmsa (v) scans and serum calcitonin levels performed within a month apart were analysed. findings were concordant in of instances ( . %) and discordant in of instances ( . %). sensitivity of dmsa (v) scans for detecting recurrence was . %, using calcitonin levels as the reference. there were no false positive scans. clinical follow-up periods ranged from - months. two patients had only one follow-up scan performed within months of surgery and were considered lost to follow-up. at the end of their follow-up periods, of patients ( . %) were disease -free, patients ( . %) had residual or recurrent disease; the other patients' ( . %) status had biochemical recurrence without detectable disease. in conclusion, calcitonin levels are a sensitive and specific indicator of disease recurrence in postoperative follow-up of patients with medullary thyroid carcinoma. calcitonin normalisation (< pg/ml) within months of curative surgery may be a strong predictor of disease-free status whereas a less than complete normalisation of calcitonin may predict eventual disease recurrence. in cases of elevated calcitonin, tc- m dmsa (v) is an affordable, readily available and sensitive imaging agent. objective: the objective of the study was to evaluate the usefulness and accuracy of intra-operative hand held gamma probes in minimally invasive radio-guided surgery (mirs) of parathyroid adenomas. material and methods: patients who were suspected as having parathyroid adenoma by virtue of a high serum pth and were subsequently diagnosed as having a solitary parathyroid adenoma on the basis of localization study with tc- m-sestamibi were included in the study. all these patients then further underwent minimally invasive parathyroid surgery by being injected with tc- m-sestamibi to hours before their planned surgeries. a hand held gamma probe was used intra-operatively to precisely localize the adenoma followed by the surgery. results: tc- m-sestamibi correctly identified and precisely localized the parathyroid adenoma in all cases. intra-operative gamma probe also was able to localize the parathyroid adenoma and hence facilitated in the mirs. all patients have been disease and symptom free on a month follow up. conclusion: gamma probe guided mirs is a very attractive surgical approach to treat patients with primary hyperparathyroidism due to a solitary parathyroid adenoma. the procedure is technically easy, safe, with a low morbidity rate and has better cosmetic results and lower overall costs than convention bilateral neck exploration. introduction: in primary hyperparathyroidism, the main diagnostic procedures for presurgical localization of parathyroid adenomas are ultrasound of the neck and radionuclide imaging. the sensitivity of the nuclear imaging has proven to be far superior to ultrasound as later is operator dependant. difficulties in radionuclide imaging arise when primary hyperparathyroidism presents with a multinodular goiter with an incidence ranging from % to % in endemic regions. case report: presented here is a case of a year old female who presented with bony aches and pains. on examination she was found to have a mng. her labs showed the hormonal assays of the thyroid to be in normal range, however, she was found to have a high serum pth. she was advised a parathyroid scan for the localization of adenoma which showed an area of increased tracer uptake at the lower pole of the left lobe of the thyroid. this area however corresponded with a palpable left sided thyroid nodule on clinical examination. to remove any controversy as to the true origin of this nodule she was advised a tc- m-pertechnetate scan. the pertechnetate scan showed an area of photon deficiency in the same area. the patient was then underwent an ultrasound which on doppler studied confirmed a parathyroid adenoma at the lower pole of the left lobe of the thyroid. the patient was then planned for a minimally invasive parathyroid surgery by injecting mibi hrs before the planned surgery. a successful surgical outcome was reported and a parathyroid adenoma confirmed on histopatholgy. at months follow up, her pth and calcium levels became normal and she had also shown remarkable recovery symptomatically. unusual metastatic localizations of differentiated thyroid carcinoma n. ben rais; ibn sina hospital, rabat, morocco. introduction: the majority of thyroid cancers have a slow evolution, a more often loco-regional extension, and a good forecast. remote metastases, when they exist, generally touch the osseous skeleton and/or pulmonary tissu. however, unusual metastatic localizations much more exceptional are possible. the authors report through this work two cases of atypical metastasis of differentiated thyroid carcinoma followed in nuclear medicine department of ibn sina hospital in rabat. material and methods: our two patients had initially underwent a total thyroidectomy for differentiated thyroid carcinoma histologically confirmed. they had profited weeks after the surgical gesture from a reference isotopic exploration ( iodine whole body scan and thyroglobulin dosage). the paraclinic assessment was supplemented by a computed tomography (ct). results: revealing symptomatology in the first years old patient was dominated by a blindness associated with an elective up-take of radioactive -iodine on the level of hypophyseal gland extending to the sphenoid bone. the second years old patient reported right basithoracic pains resisting to the usual antalgic treatment with a bulky mass driving back the kidney right to the bottom at ct with and important up-take -iodine at whole body scan; a surrenalectomy was thus carried out with conservation of the kidney. in the cases the rate of thyroglobulin was considerably high. an activity of , gbq -iodine was managed with the patients. the evolution was marked, in the short run, at the first patient by a recovery partial of the sight, the disappearance of pain in the second patient and a remarkable reduction of thyroglobulin rate at both. discussion: unusual metastasis of differentiated thyroid carcinoma constitute an exceptional entities in the evolution of the disease. their treatment and following up does not seem to be significantly different from that of the traditional metastatic forms, insofar as the -iodine therapy keeps all its value to improve or at least stabilize the evolution of this pathology. the diagnostic process and further therapeutic decisions in a case of the solitary pulmonary nodule (spn) pose a challenge in everyday medical practice. differentiation whether the spn is benign or malignant based on traditional methods, may be inconclusive and does not ensure prompt diagnosis and optimal medical management. in this context, evaluation of the usefulness of the receptor scintigraphy with somatostatin analogue mtc-depreotide in diagnosis of a spn seems to be essential and determines the aim of this study. material. examined group consisted of patients with the spn diagnosed radigraphicaly. computed tomography (ct), somatostatin receptor scintigraphy (srs), and fine needle aspiration biopsy (fna) or surgery with histopathological verification were performed in all the patients. in each case the surgery type was selected based on pathological result: in some cases an operation was more radical with excision of the local lymph nodes. method. ap and pa projections of the planar images and spect examination were carried out between the nd and th h after iv injection of mtc-depreotide. radiopharmaceutical activity was mbq. srs was performed using a dual-head gamma camera varicam (elscint, haifa, israel) equipped with high-resolution collimators. tomographic projections were acquired every ° in ° geometry, each of s duration. a matrix of × pixels was applied ( . mm/pixel). reconstruction of the images was performed by means of the iterative method. semiquantitative analysis of mtc-depreotide uptake in the pulmonary nodules and lymph nodes was based on the calculation of the tumor/ background ratio (tumor activity/ activity in a region located in the contralateral lung). results. in patients with radiotracer uptake visible in an area corresponding to the tumor location on ct, the diagnosis of pulmonary cancer was confirmed. false negative result was obtained in one case (no depreotide accumulation in a nodule which turned out to be a cancer). in cases uptake of somatostatin receptor analogue was seen in the non-cancerous lesions (carcinoid in patients and tuberculoma in person). there was no tracer accumulation in benign lesions. conclusion. obtained results suggest that srs performed with mtc-depreotide is clinically useful and may be recommended as a part of the diagnostic algorithm for the management of the spn. thallium- -scintigraphy in differential diagnostics of inflammatory and neoplastic processes of lungs and mediastinum purpose: to estimate the efficiency of tl-scintigraphy in differentiating the inflammation and tumor of the lungs and mediastinum. materials and methods: the tl-scintigraphy has been applied in the investigation of patients ( male and female of mean age of . ± . years) with affection localizations. the scintigraphy was carried out at early and at deferred phases (in and minutes after the intravenous introduction of mbq tl, respectively). the accumulation focus has been estimated visually, and the coefficients er, dr, and ri=dr/er have been evaluated. the tl-scintigraphy results have been compared with the data of clinical examinations and the results of treatment (n= ), radiography (n= ), and ct (n= ). the affection of the lungs and mediastinum have been confirmed in / cases ( / -inflammations, / -tumors), and rejected in / cases. results: the affections have been visualized in / ( . %) cases ( / -tumors, / inflammations). the absence of an tl-scintigraphy uptake has been found in / cases ( false-negative results). the found absence can be referred to a tumor type and/or tumor smallness (d < cm). the correlation between coefficients ri and er at inflammations (r=- . , p< . ) and tumors (r=- . , p< . ) is due to the delivery and removing tl from an accumulation focus by the blood-groove. we found that ri=- , er+ . at inflammations, and ri=- , er+ . at tumors. on this basis, we offer the formula ricrit.=- . er+ . to differentiate inflammations and tumors. thus, the quantitative criterium of an inflammation is ri<- . er+ . , while at a tumor -ri>- . ·er+ . . conclusion: the differential diagnostics of inflammations and tumors in lungs and mediastinum has been found to be correct in / cases. the sensitivity, specificity, and accuracy of the tumor diagnostics by tl-scintigraphy have been estimated as . %, % and . %, respectively, and as % for all three parameters (estimated on a sample of small amount) of the inflammation diagnostics. s p -monday, oct. , , : pm - : pm, poster area diagnostic oncology: planar scintigraphy and spect -breast cancer scintigraphy a. spanu , f. chessa , g. b. meloni , d. sanna , p. cottu , a. manca , s. nuvoli , g. madeddu ; dept. of nuclear medicine university of sassari, sassari, italy, dept. of radiology university of sassari, sassari, italy, dept. of surgery university of sassari, sassari, italy, dept. of pathology university of sassari, sassari, italy. aim: planar scintimammography (sm) acquired with a conventional gamma camera has proved a useful complementary tool to mammography (mx) in the diagnosis of bc, but with unsatisfactory sensitivity in small size carcinomas. in this study we assessed the role of planar sm with a high resolution dbc in the diagnosis of bc, comparing the results with those of mx. methods: a consecutive series of patients scheduled for biopsy for suspect bc at conventional procedures (clinical examination, mx, us) was studied. mtc-tetrofosmin planar sm was acquired in all patients using a new developed small field of view high spatial resolution ( . mm) dbc (lumagem s/ k) mounted on a modified mammography unit allowing the similar projections as mx as well as breast compression during acquisition. scintigraphic data were compared to mx findings and correlated to histological findings. results: patients had bc (unifocal in cases and multifocal in cases) and patients had benign disease; in total carcinomas ( mm and > mm) and benign lesions were ascertained. dbc planar sm was true positive in / ( . %) bc patients, detecting / carcinomas (overall sensitivity: . %), and was true negative in / ( . %) patients with benign disease, excluding malignancy in / lesions (overall specificity: . %). sm sensitivity was % in carcinomas > mm and . % in those mm. globally, sm was more accurate than mx in / ( . %) cases, detecting cancer in patients with mx indeterminate for dense breast ( / tumors were < mm), assessing additional tumor foci (all < mm) in pts with multifocal disease and correctly classifying patients as affected by cancer ( cases) or by benign disease ( cases), all of these with inconclusive mammographic findings. however, mx was more sensitive than sm in patients, in each of these detecting one bc < mm, false negative at sm. conclusion: dbc planar sm appears a highly sensitive diagnostic tool in the detection of primary bc, also when small in size at a very early stage and in the assessment of multifocal disease. a wider employment of this procedure is thus suggested, especially in indeterminate or inconclusive mammographic findings to improve sensitivity and specificity of mx. aim: preliminary studies have demonstrated the usefulness of planar scintimammography (sm) with dedicated breast camera (dbc) in the detection of unifocal primary bcs. in this study we evaluated the usefulness of this radioisotopic procedure in the diagnosis of multifocal/multicentric bc, comparing the results with those of mammography (mx). methods: a series of consecutive patients with suspected bc, imaged preoperatively from november to february with dbc planar sm in adjunct to standard procedures, including mx, was reviewed. following the i.v. injection of mtc-tetrofosmin, sm was acquired in all cases using a new developed small field of view high spatial resolution ( . mm) dbc (lumagem s/ k) mounted on a modified mammographic unit allowing the similar projections as mx as well as breast compression during acquisition. scintigraphic data were related to final surgical histopathological findings and compared to those obtained with mx. results: at surgery, / ( . %) patients had multifocal ( cases)/multicentric ( cases) bc, bilateral in one case, including patients with palpable multiple ipsilateral invasive bc and with non palpable multiple microscopic foci of carcinoma in situ. dbc planar sm was true positive for cancer in all cases, while mx was true positive in / cases and false negative in one who had distinct foci ( and mm in size) of invasive carcinoma. sm assessed multifocal/multicentric condition in / patients with multiple invasive bc, showing additional tumor foci than mx in cases, while in one patient missed a subcentimetric focus, also negative at mx. moreover, sm correctly defined tumor extension ascertained at surgery in all patients with carcinomas in situ, including with only microcalcifications without masses at mx. in no case mx was more accurate than sm. conclusion: high resolution dbc planar sm proved a very useful diagnostic tool in multifocal/multicentric bc detection correctly assessing local disease extension and demonstrating a better performance than conventional mx. a wider employment of this radiosotopic procedure is thus suggested as a complementary tool to conventional methods in planning the surgical treatment of multifocal/multicentric bc patients. correlation of mammographic density with the mode of scintimammographic mtc-(v)dmsa uptake in various breast pathologies v. papantoniou , e. sotiropoulou , s. tsiouris , n. ptohis , m. sotiropoulou , a. tsigris , a. stipsanelli , k. sirgiannnis , k. dimitrakakis , p. valsamaki , e. kounadi , n. makris , c. zerva , a. antsaklis ; "alexandra" university hospital, athens, greece, university general hospital of ioannina, ioannina, greece. aim: to investigate the mode of mmtc-(v)dmsa distribution in correlation with mammographic density, in women with dense breasts and various breast lesions. materials & methods: women (aged . ± . years) scheduled for breast surgery due to suspicious palpation and/or mammography, were submitted to doublephase (v)dmsa scintimammography ( and min after intravenous tracer administration), - days before surgery. dense breast (%) area on mammography ([dense breast area / whole breast area] × %) and tracer uptake (%) area on scintimammography ([tracer uptake area / whole breast area] × %) were calculated by computer-assisted means and were correlated with the histological findings. calculation of the lesion-to-background (l/b) ratios at and min was performed at the sites of maximal breast activity. retention ratio (rr = l/b min minus l/b min) and retention index (ri = [l/b min minus l/b min] / l/b min] × %) were calculated and compared (mann-whitney u test) between the various breast pathologies. continuous data are expressed as mean ± sd; significance level was set at p< . . results: histology revealed benign non-proliferating lesions (bnpl), benign proliferating lesions (bpl), carcinomas in situ (cis), and infiltrating carcinomas (ic). bpl were associated with the highest breast density values, followed by cis. breast density was . ± . in bnpl, . ± . in bpl, . ± . in cis, and . ± . in ic. significant density differences were found between bnpl-bpl (p= . ), bpl-ic (p= . ), and cis-ic (p= . ). likewise, bpl were found to have significantly higher (%) tracer uptake compared to the other histologies. scintimammographic (%) uptake was . ± . in bnpl, . ± . in bpl, . ± . in cis, and . ± . in ic. (v)dmsa retention over time was profound in bpl and cis. rr was . ± . for bnpl, . ± . for bpl, . ± . for cis, and . ± . for ic, while the ri was . ± . , . ± . , . ± . , and . ± . , respectively. significant differences in (v)dmsa rr were found between bnpl-bpl (p= . ), bnpl-cis (p= . ), bpl-cis (p= . ) and bpl-ic (p= . ), whereas significant ri differences were found between bnpl-bpl (p= . ), bnpl-cis (p= . ), and bpl-ic (p= . ). conclusion: (v)dmsa's kinetic behaviour is possibly related to the early onset of cell proliferation in the process of carcinogenesis, in women with dense breasts. furthermore, increased breast density is associated with benign proliferating lesions with potential of evolving into malignancy and also with cis. the combination of mammography and scintimammography may be helpful in selecting those women at risk, who could benefit from prophylactic treatment. a. spanu , a. farris , f. chessa , d. sanna , m. pittalis , s. nuvoli , g. madeddu ; dept. of nuclear medicine university of sassari, sassari, italy, dept. of oncology university of sassari, sassari, italy. aim: conventional imaging procedures proved of limited value in assessing tumor response to neoadjuvant chemotherapy in patients with lapbc. in the present study we evaluated and compared the usefulness of mtc-tetrofosmin planar scintimammography (sm) and spect in monitoring the response to neoadjuvant hormone or chemotherapy in patients with lapbc. methods: patients affected by lapbc were studied before and after completing hormone ( cases) or chemo ( cases) neoadjuvant therapy prior to surgery. in all cases, following mbq mtctetrofosmin i.v. injection, both conventional planar sm and spect were acquired using a dual-head gamma camera equipped with hr parallel hole collimators. in cases planar sm with a new developed small field of view high spatial resolution ( . mm) dbc (lumagem s/ k) mounted on a modified mammography unit allowing similar projections of mammography and breast compression during acquisition was also acquired. planar and spect findings were evaluated visually, mutually compared and correlated with definitive histopathological findings in all cases. results: four patients had a complete pathologic positive response, while residual tumor was ascertained at histology in patients. no uptake areas were detected at both conventional planar sm and spect, excluding residual tumor after therapy, in / ( %) cases, in accordance with histology. dbc planar sm was performed in of these cases resulting true negative. conventional planar sm detected residual tumor in / ( %) cases, resulting false negative in patients with a pt c tumor, including one mucinous bc, and in patients with multiple and scattered subcentimetric tumor foci. spect was true positive in / ( . %) cases, but missed the mucinous bc and the subcentimetric tumors which were also false negative at conventional planar sm. however, these latter carcinomas were identified only at dbc planar sm which was true positive also in the other patients with macroscopic residual tumor in whom the procedure was performed. conclusion: both conventional planar sm and spect proved useful diagnostic tools in monitoring the response to neoadjuvant hormone or chemotherapy in lapbc. spect appears more sensitive than conventional planar sm in detecting residual tumor; however, our preliminary data seem to suggest that sensitivity can further increase by high resolution dbc planar sm, especially in subcentimetric tumor foci. these data need to be confirmed in larger series of patients. the role of mtc-mibi gated spect for assessment of anthracycline cardiac effects in breast cancer patients a. tzonevska, k. timcheva, m. dimitrova; national oncology hospital, sofia, bulgaria. aim: evaluation of adverse cardiac effects from anthracycline breast cancer therapy may enable identification of patients of risk for cardiotoxicity. the aim of the study is to assess the possibilities of mtc-mibi gated spect for early evaluation of patients of risk after anthracycline therapy. material and method: the study included s patients with breast cancer (mean age years ) after anthracycline therapy ( total dose mg farmarubicine ), - months after treatment. all of the patients had clinically normal cardiac status and performed echocardiography (echocg). gated spect myocardial scintigraphy was performed at rest after i.v. injection of mbq of mtc-mibi. a spect gamma camera siemens diacam was used. data were acquired for s for each projection using x matrix over °. images were gated at frame per cardiac cycle with an r-wave trigger. myocardial perfusion in each segment was estimated and regional systolic wall thickening and ejection fraction (ef) were measured and compared to echocg. results: the results demonstrated normal myocardial perfusion, regional systolic wall thickening and ef in patients. in patients there was mean to moderate hypoperfusion affecting myocardial segments ( anterior segments in patients, inferior segments in patients ). among these patients, patients established normal ef ( %- %) and patients had slightly reduced ef ( %- %) and regional systolic wall thickening in the hypoprfused regions as these results matched the echocg findings. it is concluded that mtc-mibi can be of use for early detection of adverse effects of anthracycline cancer treatment, before positive echcg results. the role of mtc-mibi scintimammography in recurrent breast cancer z. rajkovaca , j. mijatovic , g. vuleta , a. matavulj , p. kovacevic , n. ponorac ; clinical centre, banja luka, bosnia and herzegovina, medical faculty, banja luka, bosnia and herzegovina. breast conservative surgery has now become commonplace as it is less mutilating than radical surgery. the probability of recurrent tumour in this form of surgery increases. post-surgery and radiotherapy changes as fibrosis, inflammation have reduced the accuracy of convectional method of breast imaging as x-ray mammography. the aim of this study is to asses the accuracy of mtc-mibi scintimammography in patients with suspected recurrent breast cancer in the breast or loco regional tissues. methods: nineteen ( ) women (median age years, range - years) with suspected recurrent breast cancer in the breast or loco regional tissues were investigated. after routine analyses (clinical examination, ultrasound, x-ray mammography and fine needle aspiration biopsy) they were examined by scintimammography ( minutes after iv injection of mbq of mtc-mibi). all patients with suspected recurrent cancer in the breast or loco regional tissues ( ) undergone surgery and the final diagnosis was determined by histopathological examination. another patients were followed - months. the scintigraphic studies were correlated with radiological findings and/or with histopathology. results: there were patients with recurrent cancer ( with loco-regional recurrent and in another breast). x-ray mammography identified seven of these cancers. mtc-mibi scintimammography identified ten of eleven recurrent breast cancers. the one cancer not seen on scintimammography was positive on x-ray mammography. in the five out of seven patients without cancer, scintimammography were reported as having no changes consistent with cancer. x-ray mammography showed suspected cancer lesions in three out of seven patients without cancer. there were two false-positive scintimammograms and one false negative. axillary lymph node recurrence occurred in two patients. bought of them were positive on scintimammography. mtc-mibi showed higher sensitivity, specificity and accuracy per patient than did x-ray mammography ( . % vs. . %, . % vs. . % and . % vs. . %, respectively). conclusions: mtc-mibi scintimammography has high sensitivity, specificity and accuracy in patients with suspected recurrence of cancer in the breast or loco-regional tissues. to identifying recurrent breast cancer disease is better to use scintimammorapfy than x-ray mammografphy. aim: to evaluate breast scintigraphy in the diagnosis of breast cancer by quantitative analysis and image enhancement to emerge suspected lesions. breast scintigraphy demonstrates better specificity of mammography in cases where mammography is proven to be non-diagnostic (dense breast, scar tissue).. method: patients with a suspicious breast lesion and an abnormal mammography completed a scintigraphic study of the breasts. - mbq of tc m-tetrofosmin is injected intravenously in the arm vein contralateral to the breast with the suspected abnormality. the patient was laid prone with a single breast dependent from the imaging table of a spect gcamera. the contra lateral breast was compressed against the table to prevent cross talk of activity. the images obtained, as an interfile , were transferred via procyon starlab program to a pc and processed by image pro plus, software for data analysis, visualization and application development that combines the tools necessary for interactive analysis and display. results: the visualization of the image improved significantly, by applying image-processing techniques. in the histograms of the image pixels, brightness/contrast deficiencies are illustrated. the image contrast is adjusted appropriately by applying spatial filters and gamma correction technique. highactivity chest and abdominal organs such as the myocardium and liver are masked out, in regions of interests rois, by count subtraction. a logarithmic scale is chosen so that low-count areas are enhanced. semi-quantitative parameters were determined to characterize and improve the sensitivity and specificity. the tumor to background ratio (t/b) was calculated by using regions of interest (roi) of standardized shape and size over the site of the greatest activity and the surrounding normal tissue and creating the corresponding profiles. focal, increased uptake relative to surrounding tissue is classified as a positive study through the profile index. in every case scintigraphic results are compared with histological findings. conclusion: breast scintigraphy seems to be a very promising alternative imaging technique, especially, where mammography proves to be non-diagnostic. image processing techniques improve both the specificity and the sensitivity of the technique. one of our near future goals is to classify the grade of malignancy through the technique of image processing in breast scintigraphy. tc m-depreotide scintigraphy: priliminary study l. iordanidou, a. georgakopoulos, n. bolanos, e. trivizaki, s. saranti, k. rethimniotakis, n. stefanakos, p. koutsiouba; metaxa cancer hospital, piraeus, greece. aim:. accurate staging of disease recurrence is critical on treatment decisions. findings from conventional imaging can often be inconclusive, especially in areas previously treated with surgery or radiation. the aim of this study was to determine the potential role of m tc depreotide scintigraphy in the evaluation of breast cancer recurrence , particularly to intrathoracic tumor sites after primary treatment. patients and methods m tc depreotide scintigraphy (whole body and thoracic spect) was performed in female patients (mean age , age range - years) who had previously treated for invasive breast cancer. the impact of m tc depreotide on defining the disease recurrence was determined by comparing tc m depreotide results at the time of the examination with findings from conventional imaging (ci) performed before(mean time interval of days, range, - days) the final diagnosis of recurrent or metastatic breast cancer was confirmed by histopathological findings or clinical and radiological follow up . results overall of the patients under study, patients had confirmed recurrent or metastatic breast cancer, and were free of disease recurrence. eight of female patients had equivocal findings on ci of the thorax, and had findings indicative for metastatic disease. . m tc depreotide spect correctly identified the nature of equivocal findings as detected by ci imaging in out of patients: patients were truth positive ( malignant) , patient was truth negative ( benigh) and patient false positive (infection). m tc depreotide scintigraphy detected in all patients the metastatic lesions that had already been shown by ci imaging and in comparison with ci findings showed extent of disease increased in (new metastatic lesions ) and no change in patients. conclusions these preliminary results suggests that m tc depreotide scintigraphy is useful for detecting recurrent breast cancer and it seems to provide a better understanding of the extent of disease as compared with conventional imaging modalities. objectives: it is important for clinical physician to stage, to evaluate effectiveness, to diagnose recurrent and survived tumor in routine clinical practice. the purpose of this study was to validate the clinical application value of f-fluorodeoxyglucose ( f-fdg) using single photon emission computed tomography with coincidence detecting imaging in staging of lymphoma and evaluating the therapeutic effective. methods: eighteen patients with nhl were performed with f-fdg metabolic imaging preand post-therapy using a vertex plus epic mcd/ac from adac company. the imaging was performed min postinjection of f-fdg . - . mbq using adac vertex plus mcd/ac (spect with coincidence detection). qualitative and semi-quantitative analyses were made during interpretation of f-fdg imaging. qualitative analysis is that malignant neoplastic lesions were identified if there were f-fdg concentrated area beyond normal tissues (brain, heart, gastricintestinal tract, kidney and bladder et al). semi-quantitative analysis, such as t/b (ratio of radioactive counts of tumor and normal tissue) was performed. when t/b > . the lesion are regarded as malignant lesions. f-fdg images were compared with synchronous routine images such as ultrasonography and ct. results: thirty studies were performed in patients with nhl in this study. there were true positives, true negatives, false positives and false negative. the accuracy, sensitivity, specificity, positive predictive value(ppv) and negative predictive value(npv) were %, . %, %, . %, . %, respectively. f-fdg imaging led to a change of . % in the clinical staging, and . % in the management. the ppv and npv of recurrence detected by f-fdg spect/pet were % and %, while ct's were % and % after therapy. four of five patients with negative entered clinical complete remission (cr), whereas all the patients with abnormal f-fdg uptake relapsed or reprogressed. progression-free survival (pfs) with negative f-fdg was - months (median: . months) and pfs with positive was - months (median: . months). conclusion: f-fdg metabolic imaging using spect with coincidence detection plays an important role on clinical application of the diagnosis and management of patients with nhl. key words: f-fdg; spect; coincidence imaging; lymphoma rituximab and . ml of an medronate kit, reconstituted in ml of . m pb was irradiated for min at nm. irradiated solution was aliquoted into nitrogen-filled vials and stored at - oc. each aliquot was labelled with mbq of mtcpertechnetate. radiolabelled antibody was sterilised by filtration under aseptic conditions using a . um filter. the effectiveness of the labelling method was evaluated by determination of the number of free thiol groups per photoreduced antibody using -iodoacetamidofluorscein reaction method, radiochemical purity determination of mtc-rituximab by tlc and size-exclusion hplc and testing of in-vitro stability of the preparation. immunoreactivity of mtc labelled rituximab was further explored on ramos cells using a direct binding assay. until now six patients (age - y) with cd + lymphoblastic b-cell nhl and one with cd -nhl as diagnosed by lymph node biopsy and planned for mabthera® or y-zevalin treatment, were injected with mbq of mtc-rituximab. whole body and spect images were taken h, h, h and h post injection. scintigrafic results were compared with ct findings. results in all cases high radiochemical purity over % was observed with preserved affinity of mtc radiolabelled rituximab for cd antigen, irf being above %. on average . fee thiol groups per photoreduced rituximab were determined. in all patients expected activity was seen in the blood pool, liver, spleen and kidneys. accumulation of mtc-rituximab in involved sites was clearly seen on the whole body and spect images performed as early as h p.i. in some patients and and h p.i images in all patients. pathological, moderately to markedly increased mtc-rituximab activity was seen in all ct confirmed nhl involved sites h and h p.i.. conclusion mtc-rituximab is a promising imaging agent suitable for assessing expression of cd in patients with nhl prior to (radio) immunotherapy. bone involvement in lymphoma:comparison of mtcmibi and mtcmdp scintigraphy d. vassileva , a. tzonevska , m. dimitrova ; national centre of haematology and transfusiology, sofia, bulgaria, national centre of oncology, sofia, bulgaria. bone lymphoma is uncommon and presents diagnostic and therapeutic difficulties. aim:the purpose of the study was to compare mtcmibi and mtcmdp scintigraphy in bone lymphoma, with an attemt to define the relevance of each modality with respect to disease detection and possibly the interrelationships of scan pattens with disease activity. material and methods: patients with malignant lymphoma (hodgkin's disease, non-hodgkin's lymphoma and myeloma) and suspected bone involvement were investigated. the bone scans were obtained at hours after intravenous injection of mbq mtc mdp and min and hours after i.v. injection of mbq mtcmibi. the scintigraphic results were compared with the data of conventional imiging methods and hystological results. results: the results from the both scintigraphies were devided in groups: i group-in patients with osteolytic lesions both mtc mibi and mtc mdp scintigraphy were true positive for the presence of active disease. the mdp scans depend on the osteoblastic activities around the lesions. the scans detected lesions, especially in the femur, humerus, ribs,sternum, thoracic and lumbar spine, pelvis. ii group-the m tc mibi scans were positive ( lesions) and mtc mdp negative in patients. mtcmibi accumulation attributed to bone marrow metastases may occur at an early stage, before the bone remodeling process can be detected on conventional bone scans. iii group-in patients, positive m tc mdp scans and negative mtc mibi scintigraphy were found. pathological fractures and persistent reactive bone formation after therapy ( lesions) were detected in patients by positive bone scintigraphy only. the m tc mibi image may become positive before the m tc mdp and may subsequently revert to normal in the presence of an abnormal mtc mdp scan. in one patient with positive mmdp scintigraphy demonstrated lesion in humerus, the bone biopsy showed osteomyelitis. iv group-no abnormal images on the both scintigraphy were found in patients, defined as a desease remission. conclusion: mtc mibi scintigraphy is helpful in early diagnosis , in detecting the extraosseous lesions and in early remission after therapy in lymphoma. mtc mdp scintigraphy is of limited value for the initial diagnosis of sceletal involvement but is a sensitive method for the detection of pathological fractures and osteblastic activity after chemotherapy.the combination of mtcmibi and mtcmdp scintigraphy gives an accurate diagnosis and helps to asses the extent of the disease in lymphoma with bone involvement. the purpose of this ongoing clinical study is to optimize the follow up as well as the primary diagnosis of patients with neuroendocrine tumors. different methods, like f-dopa-pet/ct and in- octreotid spect/ct, conventional imaging modalities and biochemical markers are performed individually in a comprehensive concept. methods: up to now patients with suspicion of recurrence of a neuroendocrine tumor or in a preoperative assessment have been examined in our department. in addition to conventional imaging studies (ct/mri or ultrasonography) f-dopa pet/ct, if demanded in -octreotid spect/ct, a complete patient history, physical examination and biochemical markers (including cga, a h urine collection for determination of -hiaa and the predominant pancreatic peptide) were performed. results: patients demonstrated pathological findings in the f-dopa pet/ct and/or in the in- octreotid spect/ct. the results from the two imaging modalities were helpful in deciding the primary treatment options, meaning adequate resection with curative or palliative intent for primary and regional lesions. the somatostatinreceptorscintigraphy allows additional information about the treatment option with somatostatin analoga. in one patient with recurrence of a carcinoid tumor (clinical symptoms, hies + cga elevated) f-dopa pet-ct demonstrated clearly the extent of the metastatic disease (multiple peritoneal and iliacal metastases). in- octreotid spect/ct, however, demonstrated only tracer uptake in the iliacal lymphnodes, the multiple peritoneal metastases showed no somatostatin receptor expression -showing the different tumor biology of the metastases in one single patient. conclusion: each of the performed modalities (mri,ct, ultrasonography, f-dopa pet/ct, in- octreotid spect/ct, patient history, physical examination and biochemical markers) are of great value and can contribute in the whole concept of treatment options, follow up and therapy monitoring in patients with neuroendocrine tumors. in-octreotide scintigraphy is a very important procedure for the staging and followup of somatostatine receptors expressing cancers. however, a major drawback of the technique is the lack of anatomical landmarks. the best solution to this problem is the fusion with radiological images obtained using spect/ct devices. since this kind of machines is not still widely available, we propose a simple way to improve the anatomic localisation of in-octreotide foci. patients and methods: inoctreotide images (after injection of mbq activity) have been recorded at , and, if necessary, hours. according to the findings on the images acquired at hours, planar and tomographic images at hours have been obtained with a simultaneous double isotope acquisition, after administration of a bone tracer ( mtc-hmdp, mbq) three different energetic windows have been centered respectively on the two in peaks ( and kev) and on the mtc peak ( kev) we validated this technique in consecutive patients. results: we show several images where the association between in-octreotide and bone scan provided useful information on the anatomical localization of the lesions visualized by the somatostaine scintigraphy. conclusion: double isotope tomography is a simple technique and it's easily feasible in every nuclear medicine department. this modality of image acquisition allows to improve the anatomical localization of in-octreotide scintigraphy. aim: pentetreotide is a dtpa conjugate of octreotide, a long-acting analog of the human hormone, somatostatin. in pentetreotide (octreoscan) binds to somatostatin receptors on cell surfaces, and can be used for scintigraphic localization of neuroendocrine tumors bearing corresponding receptors. the aim of the study is detection of primary and metastatic neuroendocrine tumors. patients and methods: the total of patients ( males and females, age ± years) patients were investigated. scintigraphy of the whole body, (and tomography o/ o if necessary) were performed h, h and h after i.v. administration of mbq -in pentetreotide. if needed, the study was supplemented with liver/spleen radiocolloid and/or bone diphosphonate scintigraphy. the study was performed with orbiter gamma camera and microdelta computer, using medium energy collimator and two photopeak activities ( . kev± % and . kev± %). results: in the group with seven neuroendocrine carcinomas of unknown origin, there were six true positive (tp) findings (two with liver metastases, two with liver, lung, and bone metastases, one with liver and mediastinal lymph node metastases and one with liver and retroperitoneal lymph node metastases), while one was false negative (fn) (poorly differentiated carcinoma with retroperitoneal metastases). in four patients scintigraphy influenced further patient management. from the group of nine pancreatic neuroendocrine tumors, in five neuroendocrine pancreatic carcinomas there were three tp (two with liver metastases) and one fn (poorly differentiated). in two patients with pancreatic gastrinomas both findings were tp, while in one patient with insulinoma it was tp and in the other tn. in four patients scintigraphy influenced further patient management while in two contributed. from the group of four neuroendocrine lung tumors there were two tp (two patients with bronchial carcinoid, one with liver metastases and the other with liver, lung and bone metastases), in one patients with atypical lung carcinoid after surgery, finding was tn, while in one with neuroendocrine lung tumor (acth secreting) it was fn (small mediastinal tumor. in one patient scintigraphy influenced further patient management while in one contributed. because of the the high uptake of radiopharmaceutical, and widespread metastases, six patients were indicated for radionuclide therapy with y-dota tate, and three of them received it. conclusion: preliminary results show that scintigraphy of neuroendocrine tumors is a useful method in diagnosis, staging and follow up of the patients suspected to have neuroendocrine tumors in the lungs. it is also helpful in the appropriate choice of therapy, including the radionuclide one. centre, we noticed an increasing number of referrals for octreotide studies in patients with mild symptoms or signs suspicious for a net and raised gi peptides but no history of a net and no suggestion of a net on other imaging. therefore, an audit was undertaken to assess the use of octreotide studies in this patient group. method a retrospective review was performed of all octreotide studies performed in to firstly detect what percentage of referrals were performed for this group of patients. secondly, within this group, the number of normal and abnormal studies was examined. results studies were performed in total in with of these falling the category of interest. of these were normal with the remaining raising the possibility of an abnormality, but further imaging appeared normal. discussion & conclusions we concluded that octreotide studies did not appear to be useful in investigating this subgroup of patients. aim. the aim of this study based upon a large series of consecutive patients evaluated by spect in-pentetreotide for a neuroendocrine tumor, was to evaluate the variability of reconstructing parameters used during spect study, in relation to the patient body weight and body district, looking for the possibility to standardize such parameters. materials and methods. patients underwent in-pentatreotide scintigraphy by -and -hr whole-body and planar scans, and -hr spect examination. all patients were injected with - mbq of in-pentetreotide at least week after somatostatin analogs discontinuation. spect was sitematically acquired at the level of the head, chest, and abdomen. spect parameters were selected as follows: acquisition, gamma-camera dual-head, medium energy collimators, step and shoot method, no circular orbit, matrix x , sec. per view for a total of views; reconstruction, two procedures were compared, iteractive method using iterations vs. filtered back projection using butterworth filter with different cut-off and order values. results. the results we obtained are summarized on table (see below) , where reconstructing parameters of in-pentetreotide spect were correlated to patient's boby weight (b.w.) and body discrict. patients with b.w. patients with b.w. part lower than kg greater than kg head cut-off order - cut-off order - , - , , - , thorax cut-off order - cut-off order - , - , , - , order - abdomen cut-off order - , - , order - , - , order - , - , order - conclusions. in our experience, the optimal spect images were obained by applying the butterworth filter. moreover, it was possible to standardize the reconstructing parameters for the body districts of the head and chest, while in the abdomen the choice of these parameters was more variable; this is probably due to the fact that in-pentatreotide is physiologically trapped in various abdominal areas, and in different manner as a function of time, especially the liver, the spleen, the bowel, and the urinary tract. aim: as spect/ct evolves, its applications, including ct parameters, need to be evaluated in order to improve diagnostic accuracy and to assure that radiation exposure is minimal. here, we evaluate the added value of an additional "diagnostic" ct-scan (centred on a solitary focus) in cancer patients referred for bone staging and, for whom, a conventional low-dose spect/ct acquisition was planned. material and methods: patients with a solitary focus observed on whole-body bone scintigraphy (wbs) and classified as indeterminate or suspicious, underwent a low dose spect/ct acquisition ( kv, mas, mm slice thickness); the ct-scanning area being similar to that obtained during the spect acquisition. in addition, a "diagnostic" ct-scan ( kv, mas, . mm slice thickness) centred on the focus obtained from the ct-topogram, was performed. nuclear physicians considered prospectively wbs, low-dose spect/ct and finally the centred spect/ct. radiation dose exposure was evaluated by means of a computed tomography dose index (ctdi). results: thirty-one consecutive patients (mean age: yrs +/- ) were included in the study. whole-body bone scintigraphy depicted solitary indeterminate or suspicious foci in and patients, respectively. after low-dose spect/ct, these foci turned out to be malignant, or benign, in and patients, respectively, and remained indeterminate in patients. low-dose spect/ct altered the interpretation of the wbs results in pts of the "indeterminate focus" group and pts of the "suspicious focus" group. an additional diagnostic ct-scan was accurately centred in all but one patient and altered low-dose spect/ct results in only patient, in whom a solitary indeterminate focus on wbs was classified as indeterminate on low-dose spect/ct and subsequently benign on diagnostic spect/ct. additional foci (not found by wbs) located outside the scanning area of the centred diagnostic ct-scan were found in patients. ctdi measurements were . +/- . mgy and . +/- . mgy in low-dose and "diagnostic" ct, respectively. conclusion: these preliminary results show that, ( ) a conventional low-dose spect/ct is adequate for patients presenting with a solitary focus on wbs, provides an acceptable radiation dose exposure and identifies / ( %) of foci; ( ) a ct volume session should not be limited to the area of the solitary focus since additional foci overlooked by wbs and located outside the centred ct-scan occurred in pts ( %) and thus required ct data acquired over the entire spect region of interest for thorough elucidation. tl-scintigraphy in differential diagnostics of inflammatory and malignant tumoral processes of the musculoskeletal system purpose: to estimate the efficiency of tl-scintigraphy in differentiating the inflammation and tumor. materials and methods: the tl-scintigraphy has been applied in investigation of patients suffering the inflammatory and neoplastic diseases of the musculoskeletal system. the scintigraphy was carried out at early and at deferred phases (in and minutes after the intravenous introduction of mbq -thallium, respectively). the intensity and contour's sharpness of the radiotracer accumulation focus have been estimated visually, and the coefficients er, dr, and ri=dr/er have been evaluated. the thallium- -scintigraphy results have been verified morphologically (n= ) and compared with the data of ultrasonic (n= ), -phase scintigraphy (n= ), mrt (n= ), wbc-scintigraphy (n= ), radiography, (n= ), ct (n= ), clinical examinations, and results of treatment (n= ). results: the affections have been visualized in / ( . %) cases ( / inflammations, / -tumors). the correlation between coefficients ri and er at inflammations (r=- . , p< . ) and tumors (r=- . , p< . ) is due to the delivery and removing -thallium from an accumulation focus because of blood-groove. we have found that ri=- . ·er+ . at inflammations, and ri=- . ·er+ . at tumors. on this basis, we offer the formula ricrit.=- . ·er+ . to differentiate inflammations and tumors. thus, the quantitative and qualitative criteria of an inflammation are: ( ) ri<- . ·er+ . ; ( ) at an early phase, the contour's sharpness of the radiotracer accumulation focus is better than at a deferred phase; ( ) a homogeneous accumulation of radiotracer at a deferred phase. at a tumor they are: ( ) ri>- . ·er+ . ; ) at an early phase, the contour's sharpness of the radiotracer accumulation focus is worse than at a deferred phase; ) a heterogeneity accumulation of radiotracer at a deferred phase. conclusion: the use of the above formulated criteria results in / ( . %) success in the differential diagnostics of inflammations and tumors. the sensitivity, specificity, and accuracy of the tlscintigraphy are estimated as . %, . % and . %, respectively in the diagnostics of inflammations, and as . %, . % and . % -in that of tumors. patients with lung cancer. furthermore,to quantify the octreotide uptake for the positive sr metastases in order to assess the potential benefit of somatostatin derivatives therapy. patients and methods: twelve patients ( males and females, aged from to years old) with histologically confirmed lung cancer were evaluated ( with sclc and with nsclc).final diagnosis of bone metastases was based on the combination of clinical findings, the results of imaging methods including x-ray, computed tomography(ct) and bone scintigraphy(bs).the octreotide scanning included anterior and posterior views at and hours tomographic images when it was necessary and quantification of sr regional uptake for detected bone metastases graded with score to ( ,no uptake; ,low uptake; ,moderate uptake; ,intense uptake;).the images of each patient were evaluated independently by at least two nuclear medicine physicians. considering the small patient population no statistical analysis was performed. results: sr scintigraphy visualized the primary tumour in all cases. sr scintigraphy showed skeletal involvement in patients ( with sclc and with nsclc). the detected bone lesions were fewer than in the bs (sensitivity on a lesion basis , %), although two patients demonstrated more widespread bone metastases than the bs . in the remaining patients sr scintigraphy showed no skeletal involvement (sensitivity on a patient basis , % ). in our series, % of skeletal metastases showed strong uptake, % showed moderate uptake ,while low uptake was demonstrated in %.thirty percent of skeletal metastases showed no uptake. conclusion: indium octreotide scintigraphy provides great potential for the visualization of receptor-positive metastases mainly in sclc patients. the patients with high sr uptake (grade and ) could benefit from the treatment with radiolabeled somatostatin analogues. aim: this study looked at the incidence of positive bone scans in patients with low prostate specific antigens levels and compared this with the published recommendations for bone scanning in prostate cancer. material & method: we looked at bone scans in patients with known prostate cancer undertaken at our institution in . these were all reported as clearly "negative" or "positive". scans which were in any way ambiguous were excluded from the study. we then looked at the prostate specific antigen (psa) levels in these patients and compared this to the published recommendations which state that bone scans can be confidently be excluded in cases where the psa< , should be omitted where psa< and can cautiously be omitted at psa< . results: we had no positive bone scans at psa< in agreement with the published data, however, there were positive scans at psa < ; positive scans at psa< and positive scans at psa < . this is an incidence of %, which is much higher than the published data would suggest. for those patients with high psa values > , / ( %) patients had a positive scan in agreement with published data. conclusion: patients with prostate cancer and psa< should not routinely have bone scan imaging but those with psa - have a % incidence of a positive scan and should be considered for bone scintigraphy. purpose: breast cancer is the most common form of malignant disease among women associated with metastases in bones. ca . and cea are two of the most widely used tests for monitoring breast cancer. mtc mdp bone scintigraphy is the most widely using imaging test for early detection of bone metastases. carbon anhydrite antigen (ca) . is a high molecular weight glycoprotein defined by two monoclonal antibodies (df and d ), of clinical relevance in the monitoring of treatment and detection of recurrence in breast cancer. this is a prospective study evaluating the efficacy of ca . and cea in monitoring breast cancer and early detection of metastases in bones. methods: |sixty two females with high-risk breast cancer were included in the study. response evaluation was based upon clinical examination, -rays or histology and elaborated marker criteria. results : elevated ca . were found in patients with breast cancer associated with bone metastases ( . %) and patients without bone metastases( %). the sensitivity of ca . tests was %, whereas specificity was %. elevated cea levels were found only in patients with breast cancer associated with bone metastases ( . %). cea sensitivity was only . % whereas specificity was %. the specificity of bone scintigraphy for early detection of bone metastases were % whereas specificity were %. the combination of cea and ca . increased the overall sensitivity by only . %. ca . was a significantly more powerful marker than cea for early detection of bone metastases, but clearly less favorable than bone scintigraphy. conclusions: ca . monitoring should be considered an expensive and inefficient method for early detection of bone metastases from breast cancer, and it provides no additional value when used in combination with cea. bone scintigraphy still continuous to be most efficient test for early detection of bone metastases. ( ) other malign disease (bladder ca, renal cell ca, colon ca, multiple myeloma, uterine ca, leukemia, lymphoma, malignant mesothelioma, thyroid ca, thymic ca, pancreatic ca, larynx ca, etc.). the most metastatic cancers for bone are prostate ca ( %), breast ca ( %), lung ca ( %), gastric ca ( %), respectively. for the other malignancy types, bone metastasis ratio is %. bone metastasis determined in % of the patients with malignancy. suspicious lesions were not evaluated as metastasis. we frequently find the metastatic locations at extremities, pelvic bones and vertebrates for prostate ca; vertebrates, ribs and pelvic bones for breast ca; ribs, vertebrates and pelvic bones for lung ca; vertebrates and pelvic bones for gastric ca; extremities and ribs for others. conclusion: visualisation of metastatic bony lesions in / of cancer patients indicated the importance of whole body bone scintigraphy for these patients. if we assume some of the suspicious lesions as metastasis, the ratio of metastasis is increase ( - %). the excess amount of the bone metastasis and the frequency of the metastatic extremity lesions are unexpected. comparison of bone scintigraphy and x-ray imaging in the patients after revisal endoprotesis operation of hip joint. p. korol, a. kosiakov, n. shincarenko, d. levinskiy; clinical city hospital # of kyiv, kyiv, ukraine. aim: the aim of the study to evaluate the level of disease after revisal endoprotesis operation of hip joint using of bone scintigraphy and x-ray imaging. material and method. patients after revisal endoprotesis operation of hip joint were imaged by a standard method of whole body bone scan. intestinal uptake was observed visually hours after the intravenous administration of mbq m tc mdp. a whole body bone scan; anterior, posterior, oblique spot views of the hip joint region were obtained. the data of bone scan were compared with x-ray imaging. results. total number of patients with bone scans and x-ray imaging was statistically evaluated. / pts ( %) with bone scans had in the field of hip joint inflammatory process that is indicative of instability of the hip joint endoprotesis. however, on x-ray imaging, inflammation in hip joint was identified in / pts ( %) events only. in total there were matching scans and statistical data showed overall good correlation r= , . within the group of different matching regions correlation varied: r= , for head of hip; r= , for broach of hip; r= , for cervical of hip. conclusion. bone scintigraphy is more sensitive and specific method of the determination to stabilities of the hip joint than x-ray imaging in the patients after revisal endoprotesis operation of hip joint. complex regional pain syndrome i (crps) previously known as reflex sympathetic dystrophy (rsd) is a disabling condition with annual incidence estimated at . / , general population. symptoms include intense, prolonged pain and burning of the extremity, change in limb temperature, sweating and swelling. proposed mechanism is an abnormal response to noxious stimuli resulting in dysfunctional interaction between sensory, motor, immune and autonomic nervous systems. crps could be related to prior fracture or sprain, significant physical stress (surgery, myocardial infarction) or thought to be idiopathic in up to % of cases. important associations of crps with other clinical conditions include hepatitis c, cirrhosis, aids, pancoast and pancreatic tumors. crps is believed to represent a paraneoplastic syndrome in these conditions. our exhibit focuses on the radiographic/scintigraphic features of crps; reviews the current literature regarding association of crps with malignancy and presents an illustrative case of a patient who developed crps affecting the hand in association with metastatic bone lesion in proximal forearm. crps was the first presenting symptom of osseous metastasis in this patient. the main goal of this exhibit is to increase interpreters' awareness of crps, its potential association with malignancy, and the need for imaging investigations to establish the diagnosis and associated pathology. imaging features: plain radiography is normal in the early stages; patchy subchondral and peri-articular osteopenia can develop later, occasionally in combination with soft tissue swelling. three phase m-technetium- to evaluate the relapse frequency of malignant melanoma (mm) in patients (p) diagnosed of mm, who underwent surgery and sentinel lymph node detection and biopsy (slnb) materials and methods: p (aged - ; mean , ) who underwent surgery and slnb during - were included. parameters studied were: absence/presence of disease, tumor relapse (local or spread to other organs) and number of deaths. these items were evaluated depending on: mm's localization ( head-neck -hn, chest -ch-, arms -a-or limbs -l-) and breslow index (bi). the survival was estimated by kaplan-meier method results: the slnb was positive in p and negative in p. % of p studied with slnb negative were free of disease during our evaluation ( years). depending on mm's localization: in p it was located in ch ( %). relapsed p of them ( %); (bi> mm in p and , >bi mm p and , >ib< mm p). in p it was located in l ( %). relapsed p of them ( %; ib> mm; slnb positive). local relapse in / p and metastasis in / p. none of the patients with mm located in a ( p; %) showed local relapse or metastasis. in the group of patient analysed the most frequent localization was ch, and the worst prognostic factors were: mm's localization (l and ch), ib> mm and slnb positive. these results lean upon de value of slnb as a good method to foresay de long term tumor's relapse. aim multiple radioactive lymph nodes are often detected by lymphoscintigraphy to identify sentinel lymph node(s) (sln) in breast cancer patients. it is not clear whether these additional lymph nodes are "true" sentinel nodes, or second-echelon lymph nodes that have received radiocolloid particles passing through the sln. various criteria based on the degree of radioactivity regarding the "hottest" node have been proposed to define which radioactive lymph nodes should be removed in order to minimize the false negative rate of the procedure. aims of this study were: to determine the frequency with which the most radioactive node "fails" to be pn+ when the less radioactive lymph nodes contain metastatic disease; to establish which lymphoscintigraphic criteria best define the radioactive lymph nodes to be removed. a total of patients referred to pisa university hospital with operable breast cancer underwent radiocolloid lymphatic mapping and radioguided sln biopsy. to determine how often a less radioactive sentinel node is positive for tumor when the most radioactive lymph node is not, we considered as slns both those with the highest counts and any additional radioactive lymph nodes counting % or more of the hottest node. we identified two groups of pn+ patients, the former in which the most radioactive node was positive for tumor and the latter in which the less radioactive lymph nodes contained metastatic disease when the "hottest" did not. results: a total of out of patients ( . %) were found to have sentinel node metastases detected by histology or immunohistochemistry. we identified positive axillary nodal basins from patients in whom at least one positive sentinel node was found and more than one sentinel node was harvested. in out of these nodal basins, a less radioactive lymph node was positive for tumor when the most radioactive sentinel node was negative. if only the most radioactive sentinel node in each basin had been removed, % of the nodal basins with positive sentinel nodes would have been missed. the "parallel" lymphoscintigraphic pattern (multiple lymphatic channels originating in the region of the primary tumor and running to different lymph nodes) was associated with increased likelihood of finding the "hottest" lymph node negative for tumor while another, less radioactive, sentinel node contained metastatic disease ( of out patients; %). conclusion: we suggest the intraoperative threshold of % for optimal detection of nodal metastases in breast cancer patients. aim: due to its ability to depict sentinel nodes (sn) in expected and unexpected sites of lymphatic drainage lymphoscintigraphy is an important part of the sentinel node procedure. however, in prostate cancer lymphoscintigraphy has limitations in indicating the anatomical localization of deep located sentinel nodes inside and outside the pelvis. for this purpose spect-ct was evaluated in addition to lymphoscintigraphy in patients scheduled for laparoscopic pelvic lymphadenectomy. methods: in patients (mean age . y, range - y) with prostate cancer of the intermediate prognostic group (inclusion criteria: t or psa> μg/l or gleason score > ) mtc-nanocolloid was injected peri/intratumorally in depots of . ml per lobe guided by transrectal ultrasound. images were performed at min and - h. delayed planar images were followed by spect-ct (spect: matrix x , x -sec frames, ct: kv, mas, b s kernel) with -min acquisition using a hybrid camera. after correction for attenuation and scatter spect images were fused with ct and analysed using d orthogonal reslicing. sn were anatomically identified according to the lymph node groups inside/outside the pelvis and evaluated in relation to laparoscopic extended pelvic lymphadenectomy (epl) which was performed in all patients in combination with laparoscopic gamma probe guided sn dissection. results: mean injected dose was mbq (range - mbq). sn were visualized in patients ( %). in all these patients drainage was bilateral. drainage to the lymphatic groups included in the epl area was seen in all patients and spect-ct enabled anatomical sn localization in all of them. in patients ( %) additional sn, appearing in early images of lymhoscintigraphy, were visualized outside the area of epl (para-aortic, aortic-iliac junction, pre-vesical, inguinal). all sn outside the epl area were found at laparoscopy. sn metastases were found in patients ( %). in two of these patients metastases were found in sn located outside the epl area. conclusion. in addition to the anatomical localization of pelvic sn in prostate cancer, spect-ct may lead to an accurate identification of sn outside the pelvis. the anatomical spect-ct information concerning the location of these sn may subsequently guide its resection using a laparoscopic gamma probe. aim: determine if the size of the metastases in the sentinel node (sn) of patients (p) affected of breast cancer smaller than cm has any relationship with the finding of metastases in other axillary lymph nodes (am conclusion: the detection of the sentinel node with the combination of the gamma probe and the blue dye is also possible in t> cm. in % of these patients axillary lymph node dissection can be avoided, and in % the sln is the only one affected. therefore we consider that these patients should be included as a general indication in breast cancer sentinel node detection. the usefulness of sentinel lymph node mapping in colon cancer staging: preliminary experience. aim the presence of regional nodal metastatic disease in colon cancer is an important prognostic factor. improving identification of lymph node disease would significantly better select patients who may benefit from adjuvant chemotherapy. our study aimed to determine the usefulness of sentinel lymph node (sln) mapping in detecting regional lymph node metastatic disease in patients with potentially curable colon cancer. materials and methods we prospectively studied patients ( men, mean age: +/- ) with left colon cancer with no evidence of metastatic disease or lymphnode involvement at abdominal ct. patients underwent surgical resection with standard colectomy confined to the affected segment. mtc-nanocoll® ( mci/ml x ) was injected submucosally at sites around the tumour by colonoscopy hours prior to surgery. lymphoscintigraphy was performed hours after injection to verify radio colloid migration to the sln. slns were harvested ex-vivo from the mesentery of the resected specimen using a gamma probe. all nodes were examined by haematoxylin & eosin (he) staining. in addition sln were multisectioned and examined by immunohistochemical (ihc) staining with cytokeratin. results at least one sln was identified in % of patients ( / ), with a mean of sln/patient (range= - ). the mean number of lymph nodes from the standard lymphadenectomy was (range= - ). sln examination with he adequately predicted the regional nodal status in of ( %) cases ( negative and positive). in patients ( % of all patients studied), ihc of sln was the only indicator of metastatic disease. sln failed to predict nodal metastatic disease in patients (false-negative rate %). conclusions lymph node mapping using radio colloid is feasible in colon cancer, yielding a high rate of sln identification. although the false-negative rate is high ( %), sln technique improves staging in colon cancer patients, upstaging % of patients, who may benefit from adjuvant chemotherapy. follow-up in primary breast cancer after sentinel lymph node biopsy. during the follow-up (fu) period, we analysed the appearance of axillary and/or locoregional metastases in both groups by performing an echography of the axilla twice a year and annually a mammography. we also considered the presence of systemic metastases in both groups. results: in group a, pts ( %) were followed-up for two to four years. one pt ( . %) experienced axillary metastases after two years from surgery (pt c, g , idc with a single negative sln removed); four pts had locoregional recurrences; one pt developed bone metastases and four pts showed systemic involvement (total recurrences: cases). in group b, pts had only one positive sln ( %), two positive sln were found in pts ( %), three positive sln were removed in pts ( %) and more or equal to six sln were carried away in cases ( %). among the pts in this group who had a complete fu ( %), there were two cases of systemic metastases.conclusion: the accuracy of sln method was %. the risk of developing axillary metastases in pts with t breast cancer seems to be very low in our follow-up. objective: indication of sentinel node biopsy (snb) has not been fully established for patients with dcis. our aim was to relate the conversion rate to invasive carcinoma with sn positivity in high risk dcis, and also to refine the clinical presentation analysis in order to achieve a better patient selection for snb. relation between conversion rate and invasive carcinoma with sn positivity in high risk dcis did not reach statistical significance, thus a subset of selected high risk patients could not be redefined. however , the relevance of snb positivity cannot be overlooked in high risk dcis patients, and more studies are still needed to refine its final indication. radioisotopic identification of sentinel lymph node in early stages of cervical cancer with tc- m nanocolloid (preliminary results) v. g. moschogiannis; "metaxa 's" cancer hospital, piraeus, greece. the aim of this study is to investigate the feasibility and the utility of the detection of sentinel lymph node in early stages of cervical cancer with radionuclide method. method: women (median age , years) with cervical carcinoma, stage ia (no ), stage ib (no ), stage ib (no ), underwent sln detection during primary operation. exclution criteria was stage iib or more advanced disease. one day before the surgery, patients were injected intracervical with a total dose of mbq tc- m nanocolloid, devided in four injections, and one hour after the injection a lymphoscintigraphy was performed. on the day of surgery, ml of patent blue dye was injected in the cervix, at the same sites as the radioactive isotope injections. using a laparoscopic gamma probe and visual detection of blue nodes, the sln were identified and removed for pathological assesment. results: lymphoscintigraphy identified one or more sentinel nodes in out of patients ( , %), while blue dye identified sln in pts ( , %). the combination of blue dye and radioactive tracer detected lymph nodes in pts ( . %). in one woman, where the lymph nodes were not identified with tc- m nanocolloid, the stage of the disease was ib . in pts, we had a bilateral visualisation of lymph nodes. the average number of sln per patient was , . metastatic disease to the lymph nodes was found in pts. in total, in pts. the sentinel nodes were located in the distal parametrium, in pt they were located paraaortic and in pts, in the area of the external and internal iliac artery. conclusion: our findings confirm that sentinel lymph node detection with radiocolloid, in combination with blue dye, is feasible and improves detection rate in patients with cervical carcinoma and also allows the identification of lymph nodes in areas that are not frequently sampled. this technique must be evaluated in larger studies, that may lead to better treatment selection of patients with early cervical cancer. the sentinel lymph node (sln) is the first node in a nodal basin that receives the direct lymphatic flow from malignant melanoma (mm). however, in some patients, their lymphoscintigraphic study reveals the presence of lymphatic nodes in the area between the primary mm and the regional basin. these nodes are called "in transit nodes" or "aberrant nodes" and, by definition, they are also slns. aim: to determine the percentage and location of "in transit" slns in our group of mm patients and assess if it is really necessary to harvest them. method: in this study a total of patients were included. the day before surgery a lymphoscintigraphy was performed by injecting - mbq of mtc-nanocolloid in four doses around the primary mm or the biopsy scar. blue dye was injected in the majority of patients a few minutes before surgical procedure. a hand-held gammaprobe was used to better localize the slns. results: lymphoscintigraphy showed "in transit" slns in / patients ( . %). during surgical procedure of them were harvested ( . %). sln identification and excision proved most difficult to achieve in the popliteal and epithroclear regions. metastatic cells deposits were subsequently identified in ( . %) of these "in transit" slns. conclusions: lymphoscintigraphy has a pivotal role in the identification of "in transit" slns. the incidence of these nodes is relatively low in mm patients. however, these slns present metastatic deposits in a significant percentage of cases and it warrants a surgical search for them. role of spect-ct in sentinel node identification and intraoperative lymphatic mapping. first results of a pilot study in patients with breast cancer in thailand. c. chotipanich, y. kongdan, k. sumboonnanonda, r. suvikapakornkul, p. lertsithichai, k. cheuamsamakkee, s. promma, k. poonak, p. chouplywech, c. sritara; ramathibodi hospital,faculty of medicine, mahidol university, bangkok, thailand. purpose: to retrospectively evaluate the clinical usefulness of the role of spec-ct in sentinel lymph node identification in patients with breast cancer which has not yet been established in thailand. material and methods: a retrospective study of women ranging from in the age of to years(median age year) who underwent spect-ct lymphoscintigraphy from january to december was analyzed. all of the patients underwent lymphoscintigraphy with subareolar injection of tc- m dextran with planar and spect-ct fusion imaging. planar and spect-ct fusion images were assessed separated by a nuclear medicine physician. sentinel lymph node biopsy guided by intraoperative injection of vital dye (blue patent) and hand held gamma probe was performed. results: the sentinel node was detected using two methods in all cases ( %) and positively metastatic in . %. there were concordance between lymphoscintigraphy findings and blue dye in %. of the total lymph nodes, planar imaging detected nodes ( %), while spect-ct fusion detected nodes ( %). spect-ct fusion detected nodes, which were missed by planar imaging ( were obscured by the scattered radiation from the injection site and were misinterpreted as a single node on planar). one of the patients ( %) had a non-nodal false positive on planar imaging, when further assessed in spect-ct data. in additional, spect-ct fusion imaging gave information on localization of sentinel lymph nodes ( at level i, at level ii, at level iii, more than one level), which could not be evaluated by planar imaging. conclusion: it can be concluded that spect-ct fusion is more feasible and useful for identification of sentinel lymph nodes in breast cancer and provides information on the anatomical localization. background: it is considered that previous excisional biopsy might affect the performance of the sentinel node localization in breast cancer, and it is the aim of this study to present our experience in the therapeutic approach of the sln biopsy in patients with previous excisional biopsy because of non-palpable breast cancer. methods: retrospective study of cases of breast cancer in the period - divided in group a ( patients) with prior diagnostic excisional biopsy and group b ( patients) with non-previous surgery. lymphoscintigraphy was performed after peritumoral injection of mtc-colloidal rhenium sulphide (nanocis); the sentinel node was located with a gamma ray detection probe (europrobe) and periareolar isosulfan blue dye (lymphazurin). axillary lymph node dissection (lnd) was completed only when the sln was positive for metastasis or not located. results: table . sentinel lymph node detection rates in previous excisional biopsy. number positive lympho-positive of patients scintigraphy gamma probe/blue dye a (previous ( %) ( %) excisional biopsy) in cases the sln was not detected and axillary lymph node dissection was performed ( positive and negative for metastasis). because non-palpable lessions are smaller (most of them are microcalcifications) the rate of metastasis in the sln is clearly smaller than in the conventional group of palpable breast cancer. conclusion: lymphatic mapping and the combination of the gamma probe with the blue dye in the detection of the sentinel node is also feasible in patients with previous excisional biopsy. aim our work was aimed to a retrospective evaluation of our series of sentinel lymph node scintigraphy in order to evaluate the relationships between breast tumour dimensions and frequency of positive results. patients and methods in the last years patients, in tnm stage or , all females, underwent sentinel lymph node scintigraphy for a breast cancer. the test was performed according to usual procedures (subcutaneous injection of mbq of mtc-nanocolloid followed by repeated breast scans until the first lymph node was scintigraphically evident allowing the record of its position with a marker on the skin. at surgery, (a quadrantectomy was usually performed), the sentinel lymph node was histologically extemporaneously examined in order to detect the possible tumoral involvement. according to tnm system the patients were grouped as t a ( cases), t b ( cases), t c ( cases) and t ( ) cases. due to the small number of subjects in class t a in our study these patients were grouped together with t b patients. statistical analysis of the differences of the positive case frequency between the groups was performed by chi square test. as expected, bigger tumour dimensions were associated with higher frequencies of positive cases. in fact, the frequency of positive extemporaneous studies resulted of cases in the t a-t b group ( / = . ); of cases in the t c group ( / = . ) and of cases in the t group ( / = . ). the frequency differences between group (t a+t b) and group t c (p< . ) and between group (t a+ t b) and group t (p< . ) resulted highly statistically significant. the frequency difference between group t c and t group did not reach statistical significance (p< . , ns) . conclusions the relationships between breast cancer dimensions and lymph node metastatic involvement are well known, thus our data could not appear to offer a new and original contribution to address this issue. however, our study discloses some additional quantitative insights in order to evaluate the specific phenomenon of sentinel lymph node metastatic involvement and can, consequently, be of interest in breast cancer care. larger series of patents (the work is in progress) will allow us to study the frequency of positive sentinel lymph node scintigraphy according also with the different histotypes of breast cancer. sentinel lymph node scintigraphy (snc) in the preand perioperative diagnosis of breast cancer e. schmidt, z. szabo, g. szalai, e. kalman, g. tizedes, g. pavlovics, k. zambo; university of pecs, pecs, hungary. the importance of snc in the perioperative diagnosis of breast cancer is well-known. using the method with further completitions, results useful additional informations. the aim of our study was to establish, how these informations influence the treatment and management of the patients. patients and methodes: women were observed whose breast cancer was proved by fine needle biopsy (fnb). snc was performed a day before the planned operation. the radiopharmaceutical ( mbq mtc-senti-scint) was injected peritumoral, in - portions, using us guide. anterior and lateral planar scans were performed and hours after the injections from the chest and axilla. the projections of the sn were marked on the skin. with help of this markers us guided fnb and cytology of sn was performed in cases. the operation was carried out the next day with removing of sn and low axillary blockdissection, or -in cases of metastatic laesions -total axillary blockdissection. in both group, dynamic lymphoscintigraphic images were recorded for minutes immediately after the injection. then, static images were taken until the sln was visualised. two-four hours after the radiopharmaceutical injection, patients were taken to the operating room. before the incision, blue dye solution was injected peritumorally to all cases. aided by blue dye and gamma probe, sln detection was carried out during the operation. then, histopathological confirmation was performed. results: there was not a significant statistical differance between group i and group ii in terms of patients characteristics. in group i, identification rate of sln was % ( / ) in both lymphoscintigraphy and intraoperative gamma probe application. in / cases of this group, only one sln was observed in the axillary region; however, in / patients, slns were found in both axillary and internal mammary regions. there was a positive correlation among lymphoscintigraphy, intraoperative gamma probe application, blue dye and histopathological examination in % of this group. in group ii, detection rate of sln was . % ( / ) in lymphoscintigraphy; however, this rate was . % ( / ) in the intraoperative gamma probe application. all slns, which were detected with nuclear medicine techniques, were in the axillary region in this group. there was a positive correlation among lymphoscintigraphy, intraoperative gamma probe application, blue dye and histopathological assesment in . % of group ii patients. however, this rate increased to . % when the results of lymphoscintigraphy were excluded. conclusion: tc- m hig, which appears to be more effective and successful than tc- m nanocolloid, may be a preferable agent on sln identification in both lymphoscintigraphy and intraoperative gamma probe application in patients with early-stage breast cancer. usefulness of lymphoscintigraphic imaging prior to surgical detection of sln in breast cancer aim: the sentinel lymph node (sln) radioisotopic detection is a well established method in the surgical management of invasive breast cancer. however the interest of lymphoscintigraphy (ls) before surgery remains questionable. methods: in a prospective study including patients with breast cancer, mbq of radiocolloid (nanocoll* health amersham) were subcutaneously injected in the peri-areolar breast bearing a less than cm tumor day before surgery. all patients had a planar anterior ls with a large field of view camera (helix elscint general electric*) of the thorax, axillary and basicervical region. the body contour was imaged with a transmission view of a co planar source in the back of the patient. women were operated by validated surgeons and divided into groups: in group i (n= ) the more radioactive node was marked on the skin and the ls and report were known by the surgeon; in group ii (n= ), no marker was drawn and the surgeon does not know ls results. intraoperative identification of the sns was based both on blue dye mapping and probe detection (gammed iib eurorad system) scar length, surgical duration time and number of removed sln were compared within both groups using mann-whitney test. results: ls showed axillary sln in %, mammary internal sln in . % and supra clavicular sln in %. the median scar length was not significantly different in both groups (p = . ): . mm [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in group i and . mm [ ] [ ] [ ] [ ] [ ] [ ] in group ii. the median duration time for surgery was not significantly different (p = . ) in group i ( mn [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) and in group ii ( mn [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ). the number of removed sln was not significantly different (p = . ) in both groups (group i: [ ] [ ] [ ] , group ii: [ ] [ ] objectives -to calculate the rate of detection of the sn in patients with bc subjected to n-c. -to establish the predictive value of the sn with respect to the axillary state. material and methods. we studied patients with locally advanced bc subjected to n-c; age - years (average years). the initial size oscillated between - cm (average ' ) , showing good answer ' %, partial ' % and bad %. they were administered between - mbq of mtc-nanocoloides in peritumoral intraparenchymatous location ( ) or combined (intradermal and intraparenchymatous) ( ). in nonpalpable cases the injection was guided by ultrasound or stereotaxy ( cases). static images were taken between minutes and hours postinjection, being made external cutaneous mark of the sn. the sn was extirpated separately, being followed by a complete axillary ganglionary dissection. the histological study of the sn included staining with haematoxylin-eosin and inmunohistochemical in negative cases. results in the linfoscintigraphy at least one sn was visualized in out of patients ( ' %), with drainage to internal mammary in cases ( ' %). the rate of intraoperating detection was ' % ( / ). two visible cases could not be localized in the operating room and nonvisible cases could be extirpated. out of cases ( %) not located had axillary ganglionary affectation. the histological study of the sn with haematosylin-eosin was negative in out of cases ( ' %) showing tumoral invasion of the rest of the chain in a single case (rate fn ' %). out of the negative cases were positive with inmunohistochemical ( %), being in the three cases the only positive node. this was the only positive case in ( ' %), of the cases with affectation of the gc. without axillary affectation a sensitivity for ganglionary affectation of ' % with a npv of ' % was obtained. conclusions. the technique of the sn is feasible in bc subjected to n-c with a rate of detection above %. the failure in the location of the sn seems to indicate bad prognosis due to the high incidence of ganglionary affectation. a negative gc or with micrometástasis can avoid the complete axillary node dissection due to the high npv for the rest of the chain. phytate lymphoscintigraphy (spect) and ct from december of to march of . lymphoscintigraphy was performed hours after subcutaneous injection under the nipple of tc- m phytate using a gamma camera (symbia; siemens, forchheim, germany, and hoffman estates, ill.). contrast-enhanced ct was performed using acuillion (toshiba medical systems, tokyo, japan). image fusion between spect data and ct volume data was performed using fusion soft (fused vision d) on siemens e.soft workstation. twenty-six patients were divided into groups. the first group patients ( patients) were examined without markers. the second group patients( patients) were examined by spect and ct with markers on the upper and lower ends of sternum ( markers). the third group patients ( patients) were examined with markers on the upper and lower ends of sternum and outside of the nipple of opposote side ( markers) . a small vessel containing tc- m was used as marker for spect and that containing beads of mm-diameter for ct. results: in the first group patients examined without markers, preparation of the fusion images of spect and d-ct were difficult. in the second group patients examined with markers (the upper and lower ends of sternum), preparation of the fusion images were sometime difficult. in the third group patients examined with markers (the upper and lower ends of sternum and outside the nipple of opposote side), the fusion images were easily prepared and the anatomical identification of sentinel lymph node of breast carcinoma could be easily performed. conclusion: the fusion images of spect and d-ct were easily prepared by placing markers at the upper lower ends of sternum and outside the nipple of opposote side. as a result, anatomical location of sentinel lymph nodes of breast carcinoma could be easily identified. resection of non-palpable breast lesions without needle-guide needs an intraoperative pathological examination to confirm lesion inclusion and healthy margins. in those hospitals without an intraoperative pathological resource, a second surgery may be needed. roll technique to guide surgeon is more extensive. the use of tracer inside the tumour allows the lesion resection with free margins and decreases the number of second procedures. moreover, an intraoperative image can be acquire intraoperatively with a portable gammacamera, which can predict if margins are involved. aim: to value the usefulness of an intraoperative gammacamera to assess non-palpable breast lesions resection. material and methods: patients: women with non-palpable breast lesions were included, mean age ± . years. injection: the day previous to surgery, an intratumoural injection of mtc-nanocolloid was performed guided by ultrasonography. lymphoscintigraphy: it was performed to know the lymphatic drainage and spread of radiotracer in the breast. surgery: the lesion was removed guided by a gamma-probe. an image of the surgical piece was acquired by the intraoperative gammacamera (sentinella s , gem imaging, valencia, spain) and a second image was performed using a technetium pointer to draw the outline. an image over surgical bed was done to confirm the absence of activity after resection. ap: lesion inclusion and healthy margins were evaluated intraoperatively. results: all lesions were removed. centred lesion was found by portable gammacamera in / , out of place in / and in contact in cases. a pathological exam detected free margins in / with centred lesion ( %), affected margins in of with lesion not centred. that means a concordance of % ( / ). conclusion: bearing in mind these issues, the use of an intraoperative gammacamera can avoid an extra surgery in those centres without pathological exam during sugery, without delay in the surgical act. some aspects can raise the rate of concordance: to increase the number of projections or to improve the way of injection. objectives: the purpose of this study is to evaluate the efficacy of sln biopsy using imaging and gamma probe in oral cancers. material and methods: patients (mean age = . yrs) with operable oral cancers with clinically negative lymph adenopathy were studied. standard neck dissection was performed in all. scintigraphy was performed a day before surgery by injecting tc- m labeled nannocolloid submucosally in the peri-tumoral area. first lymph node to appear on the scan was labeled sentinel lymph node and marked on the skin. this hot node was explored intraoperatively using gamma probe followed by block neck dissection. results: the sentinel lymph node (sometimes associated with additional nodes) was identified in patients ( . % success rate). in patient ( %) sln was not visualized on the scan (failed study). the gamma probe guided localization was successful in while in cases it failed. in out of ( %) cases sentinel lymph node stood in agreement with the result of histopathology of remaining lymph nodes ( benign and malignant). the remaining lymph nodes, however, showed a discordance with the final histopathological result. sln was negative in all cases with disease spread to other nodes (? skip lesion / varied drainage patterns). conclusions: early results of lymphoscintigraphy with gamma probe guided sln biopsy have been encouraging; however, a variable lymphatic drainage pattern may result in skip metastasis. therefore, we recommend that every hot lymph node should be biopsied to minimize the possibility of this discordance. further, studies should be undertaken to establish the operator learning curve in this technique. introduction: sentinel node biopsy quickly became standard of care in breast cancer, before consensus on the technique was reached and without randomised studies having shown a similar or decreased axillary recurrence rate. a review of twenty-six learningphase studies on sentinel node biopsy followed by routine axillary node dissection demonstrated a median false-negative rate of % (range of - %), which is more than the % that is generally considered acceptable. axillary clearance is no longer done in patients with a tumour-free sentinel node. long-term follow-up results of such patients have now been published and these prompted this literature review to determine the axillary recurrence rate of the sentinel node procedure in breast cancer patients. methods: we searched the current literature for studies concerning patients with breast cancer, a clinically node-negative axilla, no subsequent axillary node dissection in case of a sentinel lymph node without disease, and a median follow up duration of at least three years. the axillary recurrence rate was calculated in the patients with a tumour-negative sentinel node biopsy. results: fourteen studies were published between and describing a total patients with a median follow-up time of months. all papers describe the injection of a radiopharmaceutical and the use of lymphoscintigraphy. mtc-nanocolloid was the most common radiopharmaceutical, used in nine studies. ten investigators additionally injected blue dye intraoperatively and all surgeons used a gamma ray detection probe. twenty-four of the sentinel node-negative patients recurred in their axilla with a median time to recurrence of months (range of - months). the median recurrence rate was . % and calculated when corrected and weighed for the number of patients per study. conclusion. the sentinel node procedure was introduced to limit morbidity without exceeding the - . % axillary recurrence rate seen in the past after routine axillary clearance. it is gratifying that this review of studies with a long-term follow-up finds the recurrence rate in sentinel node-negative patients well within the desired range. ( %); mean age y ( - y). lymphoscintigrapy was performed h post peritumoral radiocolloid injection. a subdermal reinjected dosis was performed in cases of no lymphoscintigraphy sentinel node detection post peritumoral injection. a handled gammaprobe was used to radioguide sentinel node surgery. axillary lymph node dissection (alnd) was performed on p ( %), ( p from group a and p from group b). the following parameters were analysed in both groups: sentinel node lymphoscintigraphy detection rate (snld) and the subdermal reinjection requierements (sr), sentinel node surgical detection rate (snsd), number of sentinel node metastases as well as the presence of metastases in other axillary lymph nodes. in the non sentinel node surgical detection group the rate of positive nodes was also analysed. results: data of pelvic sln scintigraphy helped to determine the direction of lymph outflow from tumor-affected testis or the stump of spermatic cord and prostate to sentinel lymph nodes by normal or changed lymph collectors. thus, sln scintigraphy led to exact determination of local lymph node dissection or delineation of fields' size and configuration for local radiation therapy. conclusions: finding of the lymph outflow routs with mtc-colloid increases the validity of early lymphatic cancer spread detection, including or excluding cases of lymph nodes enlargement. determination of the lymph outflow routs gave an opportunity to configure the radiation fields within sites of mtc-colloid accumulation. the aim of this study was preoperative scintigraphic imaging and subsequent intraoperative detection with small hand-held gamma probe and blue dye in some malignant tumours to identify the sentinel node (sln) of breast cancer group i and colorectal cancer group ii. method: group i - female with histologically proven breast cancer in early stage t -t by palpable and non-palpable lesions. scans were performed in anterior, oblique and lateral view - hours after administration of mtc-colloid / mbq in total volume . ml / peritumourally. by patients with non-palpable lesions ( patients) injections were under sono-graphic guidance. the site of sentinel nodes was marked on the skin. the same method was used for patients with colorectal cancer group ii, with more scans and without skin markers. results: group i -sentinel node was found in / patients except nodes in the internal mammary chain and nodes located very close to tumour. the sensitivity in this group was %. all nodes were examined routinely and by immunohistochemical staining. histologically / sentinel nodes were positive (micrometastases in eleven). group ii involved patients with colorectal cancer. lymph-nodes were found in / cases. the sensitivity of the method in this group of patients was %. according to pathologist / had tumour positive lymph-node. the method of detection of the sentinel node in total mesorectal excision is not therapeutic but diagnostic method, and it has quite a high level of sensitivity. conclusion: this study has demonstrated feasibility of the proposed procedure. sentinel node biopsy requires a multidisciplinary approach (surgery, pathology and nuclear medicine) for reliable results. the association of blue dye (in breast cancer only) and intra-operative gamma probe has made the procedure more effective, less time-consuming and less invasive. lymphoscintigraphy and radioguided surgery can be very useful as a prognostic sign, whether it detects sentinel lymph-node (some with micrometastases that would otherwise be missed). this method is easy and safe. the histological examination of sln improves staging of the disease and can help in planning of the follow up treatment. initial experience of preoperative lymphocintigraphy and sentinel lymph node biopsy in thyroid cancer patient. c. chotipanich, y. kongdan, k. cheuamsamakee, s. amnuaywattakorn, c. sritara; ramathibodi hospital,faculty of medicine, mahidol university, bangkok, thailand. purpose: to evaluate the clinical usefulness of the lymphoscintigraphy and of hand held gamma probe procedure for slnb in well differentiated thyroid cancer which have not yet been established in thailand. material and methods: three female patients with thyroid nodule highly suspected for thyroid carcinoma by fine needle aspiration cytology ranges from the age of to years underwent preoperative lymphoscintigraphy. all of the patients underwent lymphoscintigraphy with intratumoral injection of tc- m dextran . mci under ultrasonography guidance. sentinel lymph nodes were identified using gamma probe. results: three patients had papillary carcinoma.the sentinel lymph node was detected in all cases ( %). one patient showed a lymph node metastasis in the sentinel lymph node in the jugular compartment. there were no intra or operative complications. conclusion: this is the first report of slnd in thyroid carcinoma in thailand. our preliminary findings indicate that the identification of sentinel lymph nodes in thyroid cancer is a practical and safe method. in order to improve this technique as a standard procedure for staging of thyroid cancer further studies with a larger number of patients in thailand have to be done. key words: sentinel lymph node, thyroid cancer, lymphoscintigraphy radioisotopic identification of sentinel lymph node in early stages of cervical cancer with tc- m nanocolloid (preliminary results) e. trivizaki , v. moschogiannis , s. saranti , l. iordanidou , p. zarganis , k. rethimniotakis , a. georgakopoulos , p. koutsiouba ; department of nuclear medicine, "metaxa' s" cancer hospital, piraeus, greece, department of gynecology, "metaxa' s" cancer hospital, piraeus, greece, piraeus, greece. the aim of this study is to investigate the feasibility and the utility of the detection of sentinel lymph node in early stages of cervical cancer with radionuclide method. method: women (median age , years) with cervical carcinoma, stage ia (no ), stage ib (no ), stage ib (no ), underwent sln detection during primary operation. exclution criteria was stage iib or more advanced disease. one day before the surgery, patients were injected intracervical with a total dose of mbq tc- m nanocolloid, devided in four injections, and one hour after the injection a lymphoscintigraphy was performed. on the day of surgery, ml of patent blue dye was injected in the cervix, at the same sites as the radioactive isotope injections. using a laparoscopic gamma probe and visual detection of blue nodes, the sln were identified and removed for pathological assesment. results: lymphoscintigraphy identified one or more sentinel nodes in out of patients ( , %), while blue dye identified sln in pts ( , %). the combination of blue dye and radioactive tracer detected lymph nodes in pts ( . %). in one woman, where the lymph nodes were not identified with tc- m nanocolloid, the stage of the disease was ib . in pts, we had a bilateral visualisation of lymph nodes. the average number of sln per patient was , . metastatic disease to the lymph nodes was found in pts. in total, in pts. the sentinel nodes were located in the distal parametrium, in pt they were located paraaortic and in pts, in the area of the external and internal iliac artery. conclusion: our findings confirm that sentinel lymph node detection with radiocolloid, in combination with blue dye, is feasible and improves detection rate in patients with cervical carcinoma and also allows the identification of lymph nodes in areas that are not frequently sampled. this technique must be evaluated in larger studies, that may lead to better treatment selection of patients with early cervical cancer. radionuclide study of sentinal lymph nodes in breast cancer patients n. voit; institute of oncology of amsu, kyiv, ukraine. background. dissemination of breast cancer (bc) to lymph nodes plays is essential not only for survival but also for choice of tactic of the treatment. in accordance with a concept of sentinel lymph nodes (sln) a study of them is aimed to the identification of first draining nodes respectively to nodes of primary tumor. specific feature of sln is enlargement of first lymph node and visualization of afferent lymph vessel from tumor to it. aim was to study status of sentinel lymph nodes during their intraoperation detection using manual gamma europrobe. materials and methods. bc patients were examined using lymphscintigraphy in combination with intraoperation detection of sln. a technique was performed using mtc-nanocole infused peritumoraly and intracutaneously ( mbk/kg body weight) and . - . ml of water. next step of study was performed using ofect "e cam" (siemens). early ( min) and late ( h after administration of rpp) images were obtained. a day after intraoperation detection of sln was performed by manual gamma-probe. results. in accordance with the obtained data it was revealed that in of patients lymph nodes of axillar pool on side of the lesion were visualized. in patients lymph nodes on contralateral side were detected. in patients with visualized lymph nodes histological examination revealed sln. in patients they appeared to be affected by metastases, in the remains -no malignancies. conclusion. examination of sln using manual gamma-probe can be used for estimation of pathways of metastatic spread and rate of malignant injury of lymph nodes in bc patients. using of lymphoscintigraphy in combination with gamma-detection and following biopsy of sln is a perspective direction in the development of organ-saving surgical interventions in breast cancer. aim of study: while investigating different kinds of tumours, the conception of sentinel node has been used in our hospital for many years. in our work we are trying to find out the usage of mapping of lymph node and its biopsy on those patients who suffer with carcinoma of colorectum. method: we examined a group of patients with carcinoma of colorectum. with the help of applied colloid mtc and patent blau we performed lymphatic mapping in a submucosly or subserosly circulatory way around tumor. the searched nodes were presrved and marked. marked nodes were later investigated in a histological and imunohistological way. conclusion: we are persuaded that in the foreseeable future with this method we will be able to specify staging and decide on an operation and actinotherapy extent, wich should be proved by an ongoing study with oncological and oncosurgical departments cooperation. in the future we can also see lymphatic mapping utilization on laparoscopic operationsin oncosurgery of colon and rectum. lymphatic mapping also brings a possibility to detect aberant lymph vessel and lymph nodes in tumour surroundings. aim: multi-drug resistance (mdr) is a major challenge in treatment of multiple myeloma (mm). mtc-mibi is washed out from malignant cells in the presence of p-glycoprotein (pgp) mdr . this phenomenon results in non-visualization of the lesions and low sensitivity of whole body scan (wbs) in detection of active mm. the objective of the present study was to assess the value of sestamibi wbs in prediction of response to treatment and mdr. materials and methods: thirty four patients with mm ( male, female, . ± . years) entered the study. thirteen patients had no previous history of treatment and had history of previous chemoradiotherapy. the diagnosis and staging of the disease were based upon the standard criteria. for each patient routine laboratory tests, pgp measurement and wbs with mtc-mibi were performed in the beginning of the study and the response to treatment was assessed during one year follow up. the baseline wbs was considered positive for detection of active lesion when at least one area of non-physiologic increased activity was noted while the result of wbs was positive for mdr when the patient had active disease but no abnormal activity was seen. the value of the baseline pgp tests and wbs for prediction of patient's outcome and response to therapy were assessed. results: the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of wbs for determining the active disease were . %, %, . %, . % and . %, respectively. in cases who were in active state, these values for diagnosis of mdr with wbs were . %, . %, %, . % and . %, respectively. also the above values for detection of mdr with pgp were %, %, . %, . % and %, respectively. the percentage of patients who were resistant to multiple course treatment during one-year follow up was . % in cases with active disease and positive baseline wbs ( / ) and % in those with active disease and negative baseline wbs ( / ), with no statistical difference. conclusion: neither the baseline scan nor pgp findings are of great value in detection of mdr. furthermore, no difference was noted between the sensitivity of baseline wbs for detection of active lesion in the group of the patients who showed drug resistance later in the course of treatment and in the group with complete response to therapy. so, the low sensitivity of wbs for detection of active mm lesions is not definitely related to drug resistance. purpose: the aim of this study was to evaluate mtc-dtpa-deoxyglucose ( mtc-dtpa-dg) for the assessment of chemotherapy effect and biodistrbution in breastbearing nude mice. mehtods: each animal was xenografted subcutaneously in the right fore-leg with × cells per . ml of the mcf- breast carcinoma cell line. on day postinoculation, mammary tumor-bearing mice ( - g, n= per each group) were administration a single i. v. injection of taxol ( . mg/kg) and doxorubicin ( . mg/kg) in group , taxol ( . mg/kg) and doxorubicin ( . mg/kg) in group respectively. mammary tumor-bearing mice were treated with cisplatin ( . mg/kg) in group and cisplatin ( . mg/kg) in group . . ml of saline was injected intravenously in control group. on day , , , , , post-therapy, tumor-bearing mice were imaged with mtc-dtpa-dg ( . mci/mice, i.v. ) at . - hours after administration. the radio of tumors to non-tumors (t/nt) was counted by roi technology. tumor volume and inhibition rate of each group were calculated. radioactivity in each sample tissue was calculated as the percentage of the injected dose per gram of tissue wet weight (%id/g). results: scintigraphy in tumor animal models demonstrated that tumor tissue could be clearly visualized with mtc-dtpa-dg. there was significance difference in the t/nt among group , group and control group (f= . , p= . ) on day post-therapy. there was significance difference in tumor volume between group and control group (p< . ) on day , , post-therapy. biodistrbution of mtc-dtpa-dg demonstrated tumor uptake was observed, at the same time less brain and heart uptake was observed. conclusions: mtc-dtpa-dg could assess the chemotherapeutic tumor response. the technique developed allows for mechanism-specific targeted assessment of cell nuclei activity using mtc-dtpa-dg. aim neuroendocrine gastroenteropancreatic tumors (negep) are relatively rare tumors arising from neuroendocrine cells. they are characterized by slow growth and by specific symptoms and syndromes. the location (foregut, midgut or hindgut) of the primary tumor affects the functionality, the clinical course, and the treatment of the disease. for inoperable, well-differentiated tumors, biotherapy with somatostain analogs (sa) or interferon alfa represents the treatment of choice with two purposes: to control symptoms and tumor proliferation. somatostatin receptor scintigraphy (octreoscan -o) has been proven to play an important role to plane the clinical management of patients (pts) with negep. aim of this work was to compare accuracy of o alone or in association with ct and chromogranin a (cga) serum level and to evaluate impact on quality of life of sa treatment. material and methods: we submitted pts with primary negep tumors originated from foregut in / ( % stomach, % pancreas), from midgut in / ( % ileum, % coecum) and from hindgut in / ( % rectum) to o, ct and serum cga levels assessment. then, six of them received long acting sa treatment for a mean of months and performance status was assessed by ecog criteria before and after therapy. / pts submitted to sa, followed by ct and serum cga, repeated o after at least year. all pts were intravenously injected with mbq of in-pentetreotide. , and hours whole body and abdomen o spect scan were obtained. results o diagnosed primary tumors or metastatic lesion in and was truly negative in pts. both the results were in agreement with ct and cga. o resulted false negative in pts when compared with ct and cga serum levels. similarly ct and cga were, in two other pts, false positive and false negative, respectively. pts treated with sa, especially whose with no metastases, showed performance status improvement, except one, who suspended biotherapy after month, because of side effects. its worth of note that in pts who after biotherapy had normal o and ct scan, also cga lowered within normal limits. conclusions in our limited series we showed a significant improvement of accuracy to detect negep by combining o, ct and serum cga and their association allows to select people to administrate somatostatin analogs, able to improve quality of life through a control of symptoms and tumor growth stabilization. aim: the aim of this study was to compare the efficacy of low dose tc- m methoxyisobutylisonitrile (mibi) administration to high dose tc- m mibi administration on intraoperative localization of parathyroid adenomas with gamma probe in patients with primary hyperparathyroidism (phpt). material and methods: twenty-seven patients with phpt were included in this study. these patients were divided into groups. group i consisted of cases ( women, men; mean age: . ± . years) to whom mbq of tc- m mibi was injected intravenously in the operating room minutes before the start of the surgery. group ii was composed of patients ( women, men; mean age: . ± . years) to whom mbq of tc- m mibi was administered hours before the operation.the minimally invasive parathyroidectomy was performed in all cases. intraoperative localization of the pathological gland was carried out by the use of gamma probe in all subjects. surgical resection of the parathyroid adenomas was carried out. then, the excised tissues were evaluated histopathologically. parathyroid hormone (pth) level was registrated prior to and after the surgery in all cases. results: significant statistical difference was not found between group i and group ii in terms of patients characteristics. the parathyroid adenomas were identified (total parathyroid adenomas) and excised in all group i ( %) and group ii ( %) patients. when the results of gamma probe application to the results of histopathological examination were compared, a positive correlation was found between them. in group i, the mean preoperative level of pth was ± pg/ml (reference range: - pg/ml); however, the mean value of pth after the operation was ± pg/ml. in group ii, these values were ± pg/ml, ± pg/ml, respectively. the mean operation time was ± minutes in group i and ± minutes in group ii. there was not a statistical difference in the operation time between two groups. conclusion: low dose tc- m mibi application may be prefered in the intraoperative identification of parathyroid adenomas with gamma probe in patients with phpt since this procedure appears to be as effective as high dose tc- m mibi application. moreover, unlike high dose administration, low dose tc- m mibi application does not require a long waiting period after the radiopharmaceutical injection and in this method the radiation exposure of the patient and operation team is much lower. aim: the aim of this study was to compare the effectiveness of low dose to high dose tc- m methoxyisobutylisonitrile (mibi) applications on intraoperative identification of parathyroid glands in chronic renal failure patients with secondary hyperparathyroidism. material and methods: nineteen patients with secondary hyperparathyroidism were included in the study. patients were divided into two groups. group i included patients ( men, women; mean age: . ± . years) to whom mbq of tc- m mibi was injected intravenously in the operating room minutes before the surgery. group ii consisted of patients ( men, women; mean age: . ± . years) to whom mbq of tc- m mibi was administered intravenously hours before the operation. aided by gamma probe, parathyroid gland localization was carried out during the operation in both group i and ii. all patients underwent surgical resection of the parathyroid glands which were then evaluated histopathologically. parathyroid hormone (pth) level was registrated prior to and after the parathyroidectomy in all subjects. results: regarding the patients characteristics, significant statistical difference was not observed between group i and group ii. the hyperplastic parathyroid glands were identified and excised (total parathyroid glands) in all group i ( %) and group ii ( %) patients. when the results of gamma probe application to the results of histopathological examination were compared, it was observed that they were correlated. in group i, the mean preoperative level of pth was ± pg/ml (reference range: - pg/ml); however, the mean value of pth after the operation was ± pg/ml. in group ii these values were ± pg/ml, ± pg/ml, respectively. the mean operation time was ± minutes in group i and ± minutes in group ii. a statistical difference was not found between two groups in the operation time. conclusion: the low dose tc- m mibi application may be prefered in the intraoperative identification of parathyroid glands with gamma probe in patients with secondary hyperparathyroidism because it appears to be as effective as high dose tc- m mibi application. additionally, in contrast to high dose, low dose tc- m mibi application does not require a long waiting period after the radiopharmaceutical injection and with this method radiation exposure of the patient and operation team is much lower. radioguided sentinel node biopsy after breast surgery p. santoro , c. mazzone , g. d'eredità , f. lauriero , a. niccoli asabella , g. rubini ; nuclear medicine, bari, italy, general surgery, bari, italy. aim. previous breast surgery is often considered a controindication for subsequent lymphoscintigraphy and radioguided sentinel node biopsy (rsnb) because of surgery deep lymphatic drainage changes. this study wants to measure rsnb feasibility and accuracy after breast nodulectomy. patients and methods. between march and february , women, who were previously submitted to breast nodulectomy were enrolled. in all these women sentinel node wasn't dissected because of false negative extemporary histopathological examination on breast surgery piece. all women were submitted to lymphoscintigraphy on the day before surgery with subdermic tracer injection. nanocoll was injected in four points around scar in pts undergone higher-external quadrantectomy. in pts undergone a different quadrantectomy tracer was injected in points around scar + in points in higherexternal quadrant or in retroareolar site only. on the day after lymphoscintigraphy lymph node identified as sentinel lymph node (slns) was dissected during surgery. the radioactivity of lymph node was detected in vivo and ex vivo by intraoperative of gamma-probe (scintiprobe mr- pol. hi tech.). all lymph nodes were examined histopathologically with hematoxilin and eosin staining. lymph nodes metastasisnegative were immunostained with anticytokeratin antibodies. results. in women, preoperative lymphoscintigraphy showed a sentinel lymph node; in one patient there wasn't tracer drainage (she was years hold and with voluminous breast). preoperative identification rate: %. lymphatic metastases were detected only in sentinel nodes of women; these patients were submitted to total axillary dissection. both node metastases were located in sentinel nodes and axillary non sentinel nodes were all negative at histopathological and anticytokeratin antibodies stainings. at a median follow-up of months, no axillary relapses were observed in patients who were not submitted to axillary lymphadenectomy (positive predictive value= %). ct and pet/ ct, performed at our institution, were main imaging follow-up surveys. conclusions. rslnb after previous limited breast surgery appear feasible and reliable for its high positive predictive value. it is necessary to analize a larger number of women and to follow them for a longer period. aims: liver regeneration after loss of hepatic tissue is a fundamental parameter of liver response to injury. recognized as a phenomenon from mythological times, it is now defined as an orchestrated response induced by specific external stimuli and involving sequential changes in gene expression, growth factors production, and morphologic structure. much of the investigation on the mechanisms and kinetic of hepatic growth has been done only in partially hepatectomized animals and in hepatocytes primary cultures. the study of the hepatic extraction fraction (hef) by radioisotopic methods gives information about physiological mechanism of uptake, transport and allows also the excretion quantification of the hepatobiliary system by using mtc-ida derivates. this prospective study aimed to estimate the interest of hef in the evaluation of human liver regeneration / function of patients with hepatic tumoral disease underwent partial hepatectomy. methods: patients with colorectal metastases (n= ), hepatocellular carcinoma (n= ) and others (n= ) were included. liver function was assessed after intravenous bolus injection of mtc-n-( -bromo- , , -trimethylphenylcarbamoilmethyl -iminodiacetic acid (mebrofenin) that was uptaked by the hepatocytes and eventually excreted via billiary pathway without any change to its chemical structure. the hef is calculated using deconvolution analysis of first pass curve coming from scintigraphic data. we evaluated the pre-operative hef and in the th day and one month after the hepatic resection. we considered the hef values of . ± . % (med ± sd) as normal. for statistical analysis, t-student test was used. results: the pre-operative, th day or one month after the partial hepatectomy hef (med±sd) was . ± . %, . ± . % and . ± . %, respectively. there was not statistically difference between the three evaluations of hef (ns). conclusion: these results allow us to say that the human liver regeneration is early enough to normalize the hef at day after partial hepatectomy, being this evaluation of undoubtedly interest to know the function kinetics and indirectly knowledge about human liver regeneration. additionally, this fast functional liver recovery has high clinical importance, once more aggressive adjuvant chemotherapy can start much early after surgical treatment. objectives: some studies have demonstrated that a newly developed body diffusionweighted (dw) mri is useful for differentiating benign or malignant lesions in patients with bone and soft tissue tumors. thallium- (tl) spect has been widely used for clinically same purpose. we compared dw-mri with tl-spect to clarify the characteristics of these two methods. methods: both mri and tl-spect were performed on bone and soft tissue tumors ( malignant lesions and benign lesions), whose final diagnosis was based on histology. dw-mri was performed with an echo planar imaging sequence. the apparent diffusion coefficient (adc) value (× <sup>- </sup> mm<sup> </sup>/sec) was calculated on the lesions. the early and delayed tl-spect were performed, and the uptake ratio of the lesion to the contralateral normal tissue was obtained on the early images (early ratio; er) as well as on the delayed images (delayed ratio; dr). the diagnostic accuracy of malignant lesions was evaluated by visual interpretation. the adc values as well as er and dr in the lesions were evaluated and compared for quantitative evaluation of dw imaging and tl-spect, respectively. results: high sensitivity was observed in both dw-mri and tl-spect in visual interpretation. low specificity was observed on dw-mri ( . %), suitable specificity was observed on tl-spect ( %). in quantitative assessment, the sensitivity, specificity were calculated when the cut-off value of adc was less than . on dw-mri, and the cut-off value of er was over . on tl-spect. specificity on adc was only . %, although high sensitivity % was observed. there were significant differences between the uptake ratio of the benign and that of the malignant lesions (er: . ± . vs . ± . , p < . ; dr: . ± . vs . ± . , p < . ). however, there was no significant difference between the adc values of the benign and that of the malignant lesions ( . ± . vs . ± . ), suggesting that the adc values might not be conclusive in distinguishing between the benign and malignant lesions. conclusions: the adc values of bone and soft tissue tumors overlapped and could not be used to differentiate between benign and malignant tumors. whereas the er values and delayed visual assessment of tl-spect has high diagnostic ability for bone and soft tissue tumors. therefore, tl-spect has a better diagnostic ability than dw-mri for evaluation of bone and soft tissue tumors. clinical usefulness of thallium- scintigraphy in diagnosis of desmoid-type fibromatoses: comparison of planar and spect images t. shinya , s. akaki , s. sato , s. kanazawa ; okayama kyokuto hospital, okayama-city, japan, okayama university medical school, okayama-city, japan. aim: it has been reported that delayed thallium- (tl- ) scintigraphy is useful for differentiating malignant soft-tissue tumor from benign lesions. physiological muscle accumulations increase on delayed images in most cases, which often make it difficult to evaluate tl- accumulation on planar images in patients with soft-tissue tumors. desmoid-type fibromatoses are relatively rare soft-tissue tumors of fibroblastic origin and are locally aggressive. they are classified within the intermediate spectrum of fibroblastic/myofibroblastic tumors in the who classification. there are several case reports that describe tl- accumulation in desmoid-type fibromatoses. currently, however, no detailed documentation exists which describes tl- accumulation in desmoid-type fibromatoses. the purpose of this study was to evaluate the usefulness of tl- accumulation on planar and spect images, and the pattern of change in patients with desmoid-type fibromatoses. material and methods: sixteen patients with desmoid-type fibromatoses underwent whole-body tl- scans preoperatively, and we studied desmoid-type fibromatoses retrospectively ( primary tumors, recurrent tumors). in all tumors, early and delayed images were acquired at - minutes and hours after injection. tl- images were visually interpreted for degree of tl- accumulation and pattern of change. we employed a three-grade system to evaluate degree of tl- accumulation: = no appreciable accumulation, = accumulation higher than that of normal muscle but lower than cardiac accumulation, = accumulation higher than cardiac accumulation. we employed a three-pattern system in evaluating pattern of change on planar and spect images: pattern of decrease= more accumulation on early images, constant pattern= equal accumulation on both early and delayed images, pattern of increase= more accumulation on delayed images. surgical resection with histopathological analysis confirmed the diagnosis. purpose: cardiac sympathetic dennervation is a common event in synucleinopathies and the basis for to use scintigraphy imaging using iodine-labelled metaiodobenzylguanidine ( i-mibg) with diagnoses purposes in these diseases. our purpose is to explore diagnostic accuracy of this technique in order to differentiate patients with lewy bodies disease (lbd) from others with cognitive and movement disorders not associated to synucleinopathies. material and methods: series of cases constituted by patients with lbd (mckeith revised criteria) and control patients [essential temblor ( ), parkinson's disease and dementia without sinucleinopaties ( )]. all the patients underwent scintigraphy imaging using i-mibg and early and late cordis/ mediastinum (c/m) rate was measured. c/m rates between groups were compared (mann-whitney u-test) and area under roc curve (aroc), sensitivity, specificity and proportion of correct classifications were calculated. results: there were not differences between groups in age and sex. early and late c/m rate were significant smaller in the group with synucleinopathies (u= ; p< . in both cases). late c/m rate had a greater discriminatory ability (aroc= . ) than early rate (aroc= . ). for the late c/m rate, value . shows a sensitivity . and a specificity . , with correct classification of % of the patients. conclusions: in this small series, scintigraphy imaging using i-mibg shows a good discriminatory ability to correct identification of lbd patients. we used the established criteria for the diagnosis of every disorder and the dsm-iv criteria for the diagnosis of dementia. the majority of the patients had an mri and the rest a brain ct scan. all the patients had a brain spet with m-tc hmpao (adult dose mbq, single-headed camera, uhr parallel-hole collimator, sec/image, images on a x matrix. we applied the neurogam software on the reconstracted data for the evaluation of rcbf alterations in specific brodmann(br) areas in the left(l) and right(r) brain hemispheres. results: from logistic regession analysis we found statistically sigificant correlation of a number of neuropsychiatric symptoms with alteration of rcbf in the following brodmann areas: ) delusions related to hypoperfusion in l bra )agitation related to hypoperfusion in r bra )depression related to hypoperfusion in l and l bra )anxiety related to hyperperfusion in l bra )apathy related to hypoperfusion in l bra )irritability related to hypoperfusion in l bra )disinhibition is associated to dysfunction in several regions, related to hypoperfusion in r, l, r bra. conclusion: the data support the involvement of multiple cortical regions in both hemispheres in mediating social and emotional behaviour and the subsequent neuropsychiatric symptoms resulting from rcbf alterations in degenerative dementias. the contribution of dopamine transporter imaging to the distinction between dementia with lewy bodies and alzheimer's disease (besides tc- m hmpao findings) x. geronikola-trapali , i. armeniakos , t. doskas , g. stampoulis , a. prentakis , a. stefanoyannis ; university general hospital "attikon", nuclear medicine department, athens, greece, university general hospital "attikon", neurological department, athens, greece. aim: distinguishing between dementia with lewy bodies (dlb) and alzheimer's disease (ad) is often very difficult because of the significant overlap between them. the pathological features of dlb include cerebral cortex loss, lewy body inclusions and loss of nigrostriatal dopaminergic neurons. on the other hand in ad there is no significant dopaminergic degeneration. the aim of this study was to evaluate the role of dopamine transporter imaging with i- ioflupane (datscan) in order to distinguish these two types of dementia in case of inconclusive tc- m hmpao brain perfusion findings. materials & methods: patients over the age of who fulfilled the dsm-iv criteria were studied. cognitive function was assessed using mmse, clock and verbal fluency test. neuroimaging data were obtained from mri scans and all diagnoses were made before and independent of the spect scans. applying these criteria patients with ad (possible) and patients dlb (possible) participated. ten controls, group matched for age and the same clinical assessments as dementia patients were recruited. our study included two different steps: st: we performed cerebral perfusion spect imaging min after i.v. injection of mbq tc- m hmpao (ceretec -amersham). interpretation of the data followed. nd: one group of the above patients (i.e. without the predominant cbf pattern) were further evaluated with i- ioflupane (datscan). spect imaging was performed - hours after i.v. injection of mbq i- ioflupane. results:the interpretation of tc- m hmpao images revealed significant perfusion deficits in temporoparietal regions in the / ad patients. parietoocciptal deficits were identified in / dlb patients. we found evidence of datscan results: seven patients with neuropathology consistent with ad had a normal striatal uptake. three patients fulfilling the criteria of dlb showed a marked reduction of the tracer uptake in the putamen bilaterally. one patient with clinical diagnosis of dlb revealed a generalized bilateral decrease of uptake with preservation of the striatal shape. conclusion:i- ioflupane (datscan) improves significantly the distinction between dlb and ad patients (in life) and it could be a useful tool towards this direction. objectives: long-term chronic alcohol consumption is associated with regional structural brain damage and cognitive deficit including memory impairment. neuroimaging research has commonly linked chronic alcohol abuse with generalized frontal hypoperfusion. the aim of our study was to evaluate rcbf in alcohol induced cognitive decline and effect of memantine on rcbf. methods: twenty-eight patients (m: , mean age: . ± . , age range: ~ ) who fulfilled dsm-iv criteria for alcoholic dementia were enrolled in the study. on resting state, we were studied with technetium- m ethyl cysteinate dimer single-photon emission computed tomography (tc- m ecd spect) before and after memantine treatment. these results were analyzed with spm (statistical parametric mapping version ). results: brain areas with increased rcbf after memantine treatment in alcohol dementia; uncus (ba ) of both limbic lobes, parahippocampal gyrus (ba ) of left limbic lobe, both superior frontal gyrus (ba ), right inferior parietal lobule (ba ), cuneus of left occipital lobe (ba ), and left superior temporal gyrus. brain areas with decrease rcbf after memantin treatment in alcohol dementia; left medial frontal gyrus (ba ), cingulate gyrus (ba ) of left limbic lobe, left claustrum, right brainstem, left superior temporal gyrus (ba ), fusiform gyrus (ba ) of right temporal lobe, culmen of left cerebellum, and fusiform gyrus (ba ) of right occipital lobe. conclusion: we demonstrated increased rcbf of cognitive-related areas (ba , ba ) of brain after memantine treatment in alchoholic dementia. in conclusion, we suggest that use of memantine will be a new possible treatment of alcohol induced cognitive decline. patients ( initially mci and normal at nt) clinical symptoms worsened; demtect became suggestive for d in the mci cases and in / patients initially normal and for mci in the remaining negative patient. mmse became positive for d in the former patients who were enrolled for therapy and persisted negative in the latter one, in all of whom spect worsened. the remaining / patients ( initially mci and demtect negative) did not show clinical/nt change, while spect further worsened in one mci patient persisting negative in depression case.conclusions: mtc hmpao spect may be a useful complementary tool to nt, in particular demtect, to identify and monitor mci and to early ascertain its progression to d. moreover, in our study, spect proved more sensitive than nt also preceding mci diagnosis in some cases. the purpose of the study is to demonstrate imaging features of pet brain in dementia and to determine whether the mri anatomic changes correlate with dementia. method: from january to december , patients with suspicion for dementia clinically performed fdg pet/ct ( women, men, age range from - y). pet/ct results were compared and correlated with most recent mri ( day to month). results: ten patients with alzheimer's disease diagnosed clinically were consistent with hypometabolism of the temporo-parietal cortices on pet-ct frequently in an asymmetric pattern, with increasing degrees of frontal cortex hypometabolism in relation to advanced disease. there was sparing of the occipital and cerebellar cortices and motor sensory strips. on pet-ct imaging, cases showed temporo-parietal defects similar to alzheimer's disease, but there also was additional hypometabolism of the occipital cortices. these imaging findings were congruent with the clinical findings of visual hallucinations, leading to a diagnosis of diffuse lewy body disease. in this study, both alzheimer's disease and lewy body dementia correlated with age-appropriate global atrophy in of total dementia patients; of medial temporal lobe atrophy on mri. two patients presented clinically with alzheimer's type dementia. pet-ct with mr correlation showed vascular dementia in one patient, with wedge shaped hypometabolism in right fronto-temporal distribution and left cerebellar diaschisis. the other patient had bilateral mesial temporal hypermetabolism on pet-ct and increased signal intensity in the bilateral temporal lobes on t wi of mri, representing limbic encephalitis. one patient had both normal pet/ct and mri. conclusion: pet is useful modality of illustrating metabolic distribution of dementia. medial temporal lobe atrophy and age-related brain atrophy are associated with dementia. mri can detect structural alteration and differentiate underlying non-dementia disease such as mesial temporal encephalitis. aim: dementia is the progressive decline in cognitive function due to damage or disease in the brain beyond what might be expected from normal ageing. particularly affected areas may be memory, attention, language, and problem solving. it`s a disease strongly associated with age; % of those aged - , % of those aged - , and % of those aged or older suffer from the disease. the most common cause is alzheimer's disease. positron emission tomography (pet/ct f-fdg) is a valuable tool for understanding functional changes in brain's patients (pts) with several causes of dementia. as such, it can provide valuable physiological alterations for diagnosis, management and research of dementia disorders. pet helps to identify dementia causes and makes a differential diagnostic with other illnesses. the aim of the present study was to evaluate the value of the pet/ct f-fdg metabolic patterns for the differential diagnosis and the cause of dementias. material and methods: between january and march , pts ( women, men; age: - years; mean: . years), with isolated cognitive deficit or dementia (using standard clinical criteria) underwent pet/ct f-fdg brain studies, after a reversible illness had been excluded. pet/ct was performed in fasting pts minutes after a mbq f-fdg intravenous administration. some days before pet/ct, single photon emission computed tomography (spect/ct) was done in of the patients. fdg-pet brain scans results were evaluated and compared to spect/ct. results: f-fdg pet/ct scans confirmed the presence of a bilateral temporo-parietal hypometabolism pattern associated with alzheimer`s disease in / pts ( %); / presented a frontal involvement and / a occipital involvement. in ( %) pts we can see fronto-temporal hypometabolism pattern suggesting a frontal lobe dementia and in ( %) pts a bilateral temporal hypometabolism is present that could imply a premature stage alzheimer's disease. only patient had a f-fdg-pet/ct pattern compatible with vascular dementia ( %). pet/ct and spect/ct are congruent positive results in all studies. conclusion: f-fdg pet/ct brain scan may provide clinician with additional information helpful to establish the cause of dementia after reversible illness has been ruled out. the purpose: is to demonstrate the imaging features of dementias on brain fdg pet and to determine whether visible anatomic changes on mri correlate with these findings. methods and material: fifteen patients ( women and men, age range - years) with clinically suspected dementia underwent fdg pet/ct from january to december . the results of pet/ct were retrospectively correlated with the findings from the most recent available brain mri ( to days from the date of the pet/ct). results: ten patients with clinically diagnosed alzheimer's exhibited temporo-parietal cortical hypometabolism on pet, frequently in an asymmetric pattern, with increasing degrees of frontal cortical hypometabolism seen in relation to severity of disease. there was sparing of the occipital and cerebellar cortices and motor sensory strips. on pet imaging, patients showed temporo-parietal defects similar to alzheimer's disease, but with additional occipital cortical hypometabolism. this additional abnormality was congruent with clinical findings of visual hallucinations, leading to a diagnosis of diffuse lewy body disease. of patients with alzheimer's disease and lewy body dementia, showed age-appropriate global atrophy, and showed medial temporal lobe atrophy on mri. two other patients presented with alzheimer's type dementia, however pet-ct with mr correlation showed multi-infarct dementia in one, with wedge shaped hypometabolism in a right fronto-temporal distribution and left cerebellar diaschisis, while the other patient showed bilateral mesial temporal hypermetabolism on pet and increased signal intensity in the bilateral mesial temporal lobes on t wi mri, consistent with limbic encephalitis. one patient had normal pet/ct and mri, despite clinical dementia. conclusions: pet is a useful modality for aiding in confirmation and differential diagnosis in dementias. medial temporal lobe atrophy and diffuse brain atrophy are seen with dementia but lack of specificity by mri. mri is a powerful tool for differentiating dementias from other underlying disease, such as mesial temporal encephalitis. cerebral spect with hypercapnia in the examination of cerebrovascular reserve capacity p. sirucek , o. kraft , t. hrbac ; clinic of nuclear medicine university hospital, ostrava-poruba, czech republic, clinic of neurosurgery university hospital, ostrava-poruba, czech republic. aim aim of this diagnostic examination is choice of suitable patients with neurological deficit the most often after cerebrovascular accident with demonstrated carotid artery or intracranial artery occlusion. these patients would have benefit from bypass surgery (anastomosis between arteria cerebri media and arteria temporalis superficialis). methods from to we examined patients ( women, men, average age . yrs. the oldest patient was yrs old, the youngest yrs old). scintigraphy was done by means of double-headed camera e.cam by siemens with convergent collimators fan beam (matrix size x , zoom . , degrees of rotation , number of views , time per view sec.). processing was done by means of software e.soft. we have used filtered back projection reconstruction, filter butterworth (cutoff . , order ). in all patients we have done brain spect in native conditions and then after stress -by inhalation of air enriched by co . after increase kpa of partial pressure of co in expired air we injected i.v. mbq radiopharmaceutical mtc bicisate (neurolite) and then we did brain spect. native (rest) and stress examinations were compared. visual evaluation divided findings in three-grade scale: cerebrovascular reserve capacity (cvrc) was normal in unchanged finding in stress and rest, cvrc was reduced or strongly lowered in worsening of finding in stress. results pts had normal cvrc, pts had cvrc decreased and pts strongly reduced. pts were operated: in pts ec-ic anastomosis, endarterectomy in pts. in ec-ic anastomosis a blood flow was controlled by means of ultrasonography. in pts anastomosis was functional and in pts non-functional. pts indicated improvement of neurological finding. pts had unchanged finding, but from these pts patients had normal finding in time of surgery. pts had pathological finding without change, but after surgery they were without another stroke. in these patients we expect risk decrease of another cerebrovascular ischemic accident. conclusion examination of cvrc by means of brain spect and hypercapnia is an easy method which is able to help with choice of patients with cerebrovascular occlusion for bypass neurosurgery and to determine patients in whom surgery will improve neurological finding. introduction: interictal f- fdg pet is frequently used in the identification of epileptogenic foci in patients with intractable partial seizure. we have observed increased metabolic activity in the posterior ocular bulb (pob) in some patients with intractable partial seizure undergoing pet scanning in our facility. the purpose of the current study was to further investigate this observation by evaluating and comparing increased fdg uptake in (pob) in patients with seizure and in normal volunteers. methods: brain fdg pet/ct images for fifteen normal volunteers and patients with intractable partial seizure referred for interictal cerebral were retrospectively evaluated. all studies were acquired on a dedicated pet/ct scanner (gemini, phillips) with low-dose, non-contrast ct. two nuclear medicine physicians, blinded to clinical data, indepedently analyzed the pob tracer activity. chi-square test and interrater reliability with kappa were used. brain mri was available in of the seizure patients. a radiologist reviewed brain mri studies for any possible pob pathology. results: of the normal volunteers, ( %) showed no significant fdg uptake in the pob. in the one volunteer with increased pob uptake, significant falx calcification of unknown significance was noted on the ct portion of the pet/ct exam. of the seizure patients, ( %) had increased fdg uptake in the pob: unilaterally in and bilaterally in cases. on a patient bases, statistical significance was present between the two studied groups (p = . ). on an individual eye basis ( x for normal volunteers + x for seizure patients = pob areas), a high interrater agreement (kappa . ) was present for most cases ( / ) demonstrating feasible delineation of normal from abnormal pob uptake. available brain mri of patients showed no abnormalities at the pob or orbits. conclusion: when present, visually increased fdg uptake along the pob is abnormal and may be associated with seizure. however, further studies are needed to investigate underlying pathophysiologic mechanism(s) for this phenomenon. a prospective study including ophthalmological and neurological examination is pending in our institution. aim: there is a continuous scale of preoperative fdg-pet findings (from normal to abnormal) in temporal lobe epilepsy (tle) patients. the discrimination between normal variability and pathology seems to be a clinical challenge in some cases. the aim of this work was to define the cut-off point for different methods of fdg-pet evaluation and to define their accuracy. materials & methods: patients with refractory tle were indicated to preoperative fdg-pet from three departments. all consecutive patients, in whom histopathology proved hippocampal sclerosis (hs), were included into this study. the control group consisted of oncologic patients without any clinical signs of brain involvement. roc analysis was utilized for the assessment of accuracy of semi-quantitative parameters of manual evaluation by two operators as well as automated brain analysis using two software applications: scenium (siemens; alpha v. . ) and brass (hermes medical solutions; v. . ) . results: the areas under the roc curves were calculated for the extent of asymmetry in hippocampus , (brass), , (scenium); for side difference of z-value in mesial temporal lobe , (scenium); for manual assessment of asymmetry , (operator ) and , (operator ) and didn't differ significantly between respective methods. a similar analysis in all other regions of interest gave worse results. the correlation coefficient of subjective evaluation between both operators was r= , (ci %: , - , ). the cut-off points for the best discrimination between hs and control groups were for asymmetry of hippocampus: , % (brass) and , % (scenium); for manual assessment of asymmetry: , % (operator ) and , % (operator ); for side difference of z-value in mesial temporal lobe: - , (scenium). the extent of asymmetry assessed by all methods was able to correctly predict the side of operation in % of patients with tle (ci %: , - , ). conclusion: fdg-pet is a reliable diagnostic tool for discrimination between patients with hs and control group. sensitivity and specificity is at the level of % approximately, regardless of the method of evaluation used. furthermore fdg-pet is capable to correctly predict the side of operation in % of patients with hs. completely automated analysis is less laborious and operator independent. it gives the same results as careful manual assessment. manual assessment requires meticulous compliance with standardized evaluation methods. objectives: to evaluate the diagnostic performance of our new d ordered subsets expectation maximization (osem) algorithm vs. conventional fbp (filtered back projection) reconstruction algorithm in the functional brain perfusion spect imaging with tc- m hmpao and ecd in investigation of cerebrovascular decease, dementia, seizure disorders, tumors and arteriovenous malformation. methods: the tc- m hmpao or ecd brain spect data for patients (n= ) acquired for clinical purpose as a standard-of-care for the deceases listed above were retrospectively reconstructed. the subjects with independently confirmed (e.g. by mri studies) presence of perfusion abnormalities were selected for this study. the patients were administered mci of tc- m hmpao or ecd minutes prior to imaging. prior to radiopharmaceutical administration, standard pre-injection protocol was applied including placing the patient in a dark, quiet room with minimal visual and auditory stimulation. the spect scans were acquired with a triple-head gamma camera (triad , trionix) equipped with low energy high-resolution fan-beam collimators ( x , degree, -degree stops for s). the reconstructed images for the same patients were obtained using the standard-of-care clinical fbp algorithm with hanning filter ( . ny) and our new d osem algorithms. the same radiologists in blinded studies independently read them. our d osem algorithm is a fully d reconstruction method with fan-volume system model and with total variation optimization. the clinical findings from images reconstructed by the two algorithms were compared with ground truth information provided by corresponding complementary studies including ct, mri, pet, clinical examination and follow-up studies. results: we established an increase in the specificity and sensitivity in locating the site and spatial extent of brain perfusion abnormalities while using our d osem, as compared to fbp algorithm. conclusions: our new d osem algorithm applied to hmpao and ecd spect brain studies instead of conventional fbp algorithm resulted in improved diagnostic performance. to obtain a good quality ictal spect, the determining factor is the time delay from ictal eeg onset to tracer injection. aim: the aim was to study which phase of the eeg is the determining factor for reporting the lateralization of the ictal spect using siscom. the key phases in eeg chosen for study are brain activity lateralization (bal) at the onset (bal_o), bal at the moment of tracer injection (bal_ti) and then again seconds postinjection (bal_ ) methods: the study consisted of patients ( males and females) of an average age of years, with drug resistant complex partial seizures. there were temporal and extratemporal seizures. the spects were ictal in cases and postictal in the remaining , with an average tracer injection time of seconds from seizure onset. brain spects were carried out after the injection oh hmpao-tc m using an ecam gammacamera (siemens) and following siscom methodology for an accurate identification of the maximum brain activity during ictal spect. analysis was used to establish which of these eeg phases showed most agreement with the bal seen in the siscom. results: siscom identified bal on one side in / patients while eeg in . all cases without bal using eeg, were lateralized using siscom. bal_o occurred in patients, bal_ti in and bal_ in only . in the agreement study between bal_o and siscom, of the cases with bal, were lateralized on the same side and in the contralateral side (p = . ). in the case of bal_ti, of the patients that were lateralized, of these patients were on the same side of the brain and only one in the contralateral side (p = . ). finally, in the case of bal_ , patients were lateralized, of these were on the same side and two on the contralateral brain hemisphere (p = . ). conclusions: the highest degree of agreement was between siscom and bal_ti. this suggests that the tracer injection time is the determinant in correct interpretation of ictal spect. purpose: i- iomazenil(imz) is a one of the benzodiazepine partial-inverse agonist and has been widely used to evaluate a distribution of central benzodiazepine receptors. some authors reported that d-ssp could be useful to detect subtle change of tracer distribution in brain. however, a result of d-ssp depends on the normal database. we hypothesized that a distribution of central benzodiazepine receptors may change with age. the purpose of this study was to evaluate an age-specific normal distribution of i- iomazenil(imz) spect imaging. method and materials: twenty-nine subjects who were hospitalized in our hospital were studied. imz brain spect and brain mri were performed within weeks period. they were suspected of having epilepsy on the basis of clinical findings, but no significant abnormality was seen in their imz spect and no major abnormality in their mri. these findings visually interpreted by radiologists. these subjects were classified into groups by their age; - years ( males, females), - years ( males, females), - years ( males, females), and years and older ( males, females). three hours after the intravenous injection of mbq of imz, spect data acquisition was performed using a triple head digital gamma camera system. unpaired student t tests were performed to compare the imz accumulation in each group using d-ssp, and z score maps were obtained. two radiologists visually and independently evaluated these z score maps, and compared the imz accumulation between each group. results: the imz accumulation of the - years group in the cerebellar hemisphere was higher than the other groups. it of the - and - years groups in the central sulcus were also higher than the other groups. on the other hands, it of these younger groups in the frontal lobe were lower than the other groups. furthermore, it in the posterior cingulate gyrus and the occipitotemporal lobe increased with age. coclusions: according to our result, the distribution of imz could be change with age, and to assemble an age-specific normal database might be important. aim: to assess the role of brain perfusion spect in the management of patients with spontaneous intracerebral hemorrhage (sich). method: sich pts were studied. all pts underwent same day ct and brain spect with mtchmpao, h- d from onset of stroke. results: / pts ( . %) showed a larger perfusion defect than expected after ct. in pts hematoma diameter was comparable on ct and spect; pt had quasinormal aspect of spect study. in pts with larger defects, spect revealed a large cold spot with similar size compared with ct, and a surrounding hypoperfused area. / pts revealed cortical hyperperfusion, adjacent to hypoperfused area and corresponding to a normal-appearing brain tissue on ct. in pts we found crossed cerebellar diaskisis. in pts we found cortical hypoperfused area in the contralateral cortex, with normal appearing brain tissue on ct. discution: many mechanisms and scenarios were proposed in order to identify the pathologic factors involved in the pathology of sich: edema, ischemia, inflammation, microglial activation, hemotoxicity, apoptosis... all of these factors are affecting brain tissue surrounding hematoma and are responsible of the progressive neurological deterioration; most of these damages are not revealed by anatomical imaging techniques. despite the latest advances in medical treatment and neurocritical care, patients suffering sich still have a very poor prognosis, with a greater mortality and larger neurological deficits at the survivors than for ischemic stroke. in a significant number of our patients ( . %!) brain perfusion spect revealed different types of perfusion changes in the brain tissue surrounding hematoma, corresponding to normal appearing brain tissue on the ct scans. further studies are definitely required to demonstrate prognostic significance of these changes, but we can assume that all these areas contain viable tissue that can be a target for neuroprotective strategies. conclusions: brain perfusion spect can play an important role in sich, by early demonstrating functional changes responsible of clinical deterioration, thus allowing prompt dedicated therapeutic intervention. aim: to evaluate influence of hypotensive treatment on cerebral perfusion and cognitive function in patients (pts) with arterial hypertension (ah). material and methods: the study involved patients ( males and females, mean age ± ) with moderate essential hypertension. perfusion brain spect with mtc-hmpao and comprehensive neuropsychological testing were performed before and after months of antaginist ca treatment. brain spect slices were divided into symmetrical (right and left) regions of interest per patients: inferior and superior frontal lobes, temporal, anterior and posterior parietal, occipital lobes and cerebellar hemispheres. regional cerebral blood flow (rcbf)(ml/ g/min) in these regions was calculated. results: hypoperfused regions were revealed in pts. all pts had no focal neurological symptoms. antihypertensive therapy within month led to the brain perfusion improvement and positive effect on cognitive function in pts with ah. medical treatment followed by the increase in rcbf relative to baseline in right and left anterior parietal regions ( . ± . vs . ± . , p= . ; . ± . vs . ± . , p= . , correspondingly), in left temporal cortex ( . ± . vs . ± . , p= . ), in left inferior frontal region ( . ± . vs . ± . , p= . ). also growth in cerebral perfusion in right and left superior frontal regions, in right inferior frontal cortex and right and left occipital regions was observed. measures of immediate verbal memory, delayed verbal memory and learning showed a significant increase theirs after treatment an average on % (p= . ), % (p= . ) and % (p= . ), correspondingly, as well as improvement in immediate and delayed visual memory, attention on % (p= . ), % (p= . ), and , % (p= . ), correspondingly. relationship between the changes of cerebral perfusion and dynamics of cognitive status was found. improvement of immediate verbal memory correlated well with increase in rcbf in left temporal region (r = . ; p= . ). betterment of delayed verbal memory related to growth in cerebral perfusion in left anterior parietal region (r = . ; p= . ) and left inferior frontal region (r = . ; p= . ). positive correlation was shown between dynamics of attention and changes rcbf in right and left anterior parietal regions (r = . ; p= . , r = . ; p= . , correspondingly). conclusion: our results suggest that brain spect is useful technique for evaluation of medical treatment dynamic and understanding of cognitive disorders mechanisms in patients with arterial hypertension. improvement of cognitive functions after treatment in patients with ah was connected with the increase in brain perfusion. efficacy assessment of encephalo-duro-arteriosynangiosis for childhood moyamoya disease using dimensional stereotactic roi template analysis of brain perfusion spect s. hyun, k. lee, s. lee, y. cho, e. lee, j. choi, y. choi, y. choe, b. kim; samsung medical center, seoul, republic of korea. objectives: we evaluated the efficacy of encephalo-duro-arterio-synangiosis (edas) for childhood moyamoya disease using -dimensional stereotactic roi template ( dsrt) analysis of brain perfusion spect. methods: eighteen patients (f: m = : , mean . ± . yr) with childhood moyamoya disease who underwent bilateral simple edas were included. resting and acetazolamide (acz) challenged cerebral perfusions were measured with mtc-ecd spect . ± . days before the one side operation and . ± . months after the other side operation. the spect images were anatomically standardized using spm followed by normalization of counts using proportional scaling with the mean value of cerebellum at . we calculated the cerebral vascular reserve index (cvri) image as follows: cvri (%) = [(acz image -resting image) / resting image] x . fully automated roi analysis with dsrt was performed on resting, acz, and cvri images. dsrt calculated the area-weighted mean value of segments by quantification of constant rois in each hemisphere. we compared the mean value of each segment between pre-and postoperative groups. wilcoxon matched-pairs signed-ranks test was used for statistical analysis. results: comparison between pre-and postoperative brain spect revealed no significant improvement in resting perfusion. after edas, there was significant acz challenged perfusion improvement in the central (pre . ± . vs. post . ± . , p= . ) and parietal region (pre . ± . vs. post . ± . , p= . ). cvri improved in the central region with a mean difference of . (pre - . ± . vs. post - . ± . , p= . ) and the parietal region with a mean difference of . (pre - . ± . vs. post - . ± . , p= . ). cvri in the lenticular nucleus region was significantly reduced (pre - . ± . vs. post - . ± . , p= . ). conclusions: pre-and postoperative cerebral perfusion and vascular reserve in childhood moyamoya disease can be effectively assessed by dsrt. our results provide objective evidence that simple edas improves cerebral perfusion in the middle cerebral artery territory without direct benefit in the anterior and posterior cerebral artery territories. segments: callosomarginal, precentral, central, parietal, angular, temporal, posterior cerebral, pericallosal, lenticular nucleus, thalamus, hippocampus, and cerebellum aim of the study: to evaluate metabolic activity using f-fdg ct-pet in order to establish both carotid vulnerability to rupture and asymptomatic progression linked to plaque inflammatory cells. methods: patients with symptomatic or asymptomatic unilateral carotid arteries were studied. all of them were scheduled for carotid endarterectomy (ce). f-fdg head and neck ct-pet was performed using a discovery st scanner (ge healthcare) prior to ce and days following surgery. two speciality-trained persons blinded to the vascular examinations results reviewed and quantified the scans. two-centimeter circular regions of interest were drawn on ct images around the area including carotids in each slice, and then transferred onto the corresponding coregistered pet image to enable f-fdg uptake values based on maximum standardized uptake value. the analysis included vascular region mm over and below the level of the carotid bifurcation, and slice-activity curves were calculated in order to visualize plaque and basal metabolism. results: carotid plaques with inflammatory infiltrates had a major f-fdg uptake (p< . ). no significant correlation was found between degree of f-fdg uptake and time from symptoms to ct-pet imaging, symptomatic or asymptomatic patients, degree if carotid stenosis and vascular risk factors. we found significant correlation between the degree of f-fdg accumulation in carotids scheduled for ce and contralateral carotids (p< . ). the f-fdg ratios in the contralateral arteries remained increased on the follow-up imaging at days. statines treatment was correlated with more pronounced decreased in f-fdg-uptake at days (p< . ). conclusions: this is the first in vivo study using f-fdg ct-pet imaging demonstrating that carotid atherosclerosis is a bilateral disease. identification of inflammatory regions in the contralateral carotids has the potential to offer early aggressive pharmacotherapy in these patients. aim. we report our clinical experience with m tc-hmpao spect imaging in patients with giant intracranial aneurysm in order to identify patients without a sufficient collateral perfusion during internal carotid artery (ica) temporary occlusion test (tot). material and methods. consecutive patients ( man, women; mean age years; range - years) affected by a giant intracranial aneurysm, who could potentially benefit from permanent ica occlusion, underwent a tot to evaluate the efficiency of cerebral collateral perfusion. one patient with sudden onset of intese headache during tot (absolute contraindication for permanent ica occlusion) was excluded from this series whereas patients were injected with twenty mci of m tc hmpao after a endovascular balloon had been blown up for ten minutes. images were obtained by a dual headed gamma camera using a circular orbit and a ° step and shoot technique. data were processed after a backprojection and an attenuation correction, by using a low pass filter. both a qualitative and a semiquantitative analysis of images were performed. results. in patients, no perfusion impairments were found and a permanent ica occlusion was made. the procedure resulted in aneurysm thrombosis and no signs of ischemic injures occurred in the follow-up period. four patients showed a reduced perfusion during tot. one of these patients underwent surgical revascularization by ec/ic bypass. a new tot, after surgical revascularization, revealed no perfusion alterations and the patient underwent permanent ica occlusion without any subsequent ischemic injury. conclusion. m tc hmpao is an effective tool in identifying patients who cannot undergo permanent ica occlusion. intracranial arteriovenous malformation (avm) is an abnormal collection of immature blood vessels within the brain. treatment of the brain avms includes three modalities: endovascular embolization, which reduces the size and vascularity of the lesion, standard microsurgery or radiosurgery. very little relevant literature concerning the role of spect in the evaluation of avm treatment through endovascular embolization encouraged us to study this problem. material. examined group included patients ( women and men) at the age of - years. all the patients had been previously diagnosed with intracranial avm and subsequently qualified for the endovascular embolization procedure. the patients were in good clinical condition and had no symptoms of recent intracranial haemorrhage. methods. brain scintigraphy was performed on the same day, prior to embolization and - days after treatment. administrated activity of mtc-ecd (polatom, poland) was to mbq. spect examination was carried through minutes after iv radiotracer injection with two-head gamma-camera varicam. acquisition was performed using high-resolution collimators, with one projection for each ° in a ° orbit. a matrix of × pixels was applied. filtered back projection with metz filter was used for reconstruction. regional cerebral blood flow (rcbf) was evaluated visually and semiquantitatively using voxel-based analysis with brain spect quantification software (compart, warsaw, poland). embolization procedure was performed under general anaesthesia. angiography was carried out using siemens equipment (multistar). partial or complete obliteration of avm was followed by postembolization angiography. results. no serious side effects were observed after embolization. in each patient, spect showed the nidus of avm as a region of decreased radiotracer accumulation. after embolization significant changes of perfusion (cut off cluster size- , ml, cut-off percentage- % in semiquantitative analysis) in an area adjacent to the avm nidus were found in pts: deterioration of perfusion in pts ( , ml- , ml mean , ± , ml, %- % mean , ± , %) and improvement in patient ( , ml, , %). significant perfusion changes in the areas remote to the nidus were seen in pts: areas of perfusion deterioration and regions of rcbf improvement after embolization. these areas were located in cerebral and cerebellar hemispheres both ipsilateral and contralateral to avm. conclusions. perfusion changes in patients with avm treated through endovascular embolization can be detected by means of m tc-ecd spect with voxel-based analysis. deterioration of perfusion after embolization seems to prevail over improvement. mean cerebral blood flow,response to paco and rcbf distribution in the patients with diabetic mellitus a. komatani; yamagata univ., yamagata, japan. aim: the diabetes mellitus (dm) is widely known as a risk factor of many diseases e.g. retinopathy, nephropathy, neuropathy and angiopathy, etc. to confirm the possibility of dm as a risk factor for the cerebral infarction and/or vascular dementia, we inspected mean cerebral blood flow (cbf), its distribution, and flow reserve in patients with dm. materials: fifty-one males aged . ± and forty seven female aged . ± with dm. ten males aged . ± and twelve females aged . ± . for healthy control. methods: mean cbf was measured using xe-spect with kanno-lassen's method, and the flow reserve was estimated as a response to paco by sodium bicarbonate (hco -) injection. the distribution of regional cerebral blood flow (rcbf) was estimated using statistical parametric mapping (spm) with m tc-ecd. results: the mean cbf was . ± . ml/ g/min in the group of dm patients, and . ± . ml/ g/min in the group of healthy control. no significant difference was seen between the both groups (p= . ). regional flow reduction in the white matter especially at the sub cortical region was observed in most of the dm patients. no significant difference in the mean cbf was seen between with and without complications of hypertension and/or hyperlipemia. the correlation between the mean cbf and the dilation of the disease tend to have negative correlation (p= . ). the percent increase with the sodium bicarbonate injection was . ± . % in dm patients and . ± . % in healthy controls. the flow reserve in dm patients was significantly poor compared with control group (p< . ). conclusion: the most obvious findings of dm patients were flow reserve reduction, and the reduced regional flow in the white matter especially at the sub cortical area. the reduction in mean cerebral blood flow was not so major characteristic of dm patients. dm should be a certain risk factor for the cerebral infarction and/or vascular dementia due to micro angiopathy with dm. brain metabolism in patients with unilateral carotid stenosis. regional changes evaluation after endarterectomy using ct-pet with f-fdg a. fernandez leon , j. krupinsky , m. font , r. de juan , p. pifarre , a. carvajal , f. rubio , a. domenech , c. gamez , j. gispert ; idibell. hospital de bellvitge. unitat pet., barcelona, spain, idibell. hospital de bellvitge, barcelona, sudan. aim of the work: atheroesclerosis is a chronic inflammatory disorder but it is still unclear whether patients with unilateral carotid disease are at higher risk of contralateral carotid artery progression. both carotid vulnerability to rupture and metabolic brain changes related to vascular disease may be linked to plaque inflammatory cells. imaging with f-fdg pet has been shown to be unique in detection of plaque inflammatory activity and secondary brain changes. methods: we studied patients with symptomatic or asymptomatic unilateral carotid arteries. all of them were scheduled for carotid endarterectomy (ce). all patients received an integrated fdg-pet/ct using a discovery st scanner (general electric healthcare) prior to ce and days following surgery. pet was performed with , mm slice thickness with no overlapping slices in d mode including brain and neck structures. a stiff cervical collar was worn to minimize patient movement. approximately mbq of fdg was administered intravenously as a bolus and static emission images were obtained min later. attenuation correction -slice ct helical scans (ctac) were obtained at , mm slice thickness, kv tube voltage and ma tube current. all images were pre-processed using the algorithms provided with the spm software package. images were normalized to the pet template and smoothed with a gaussian kernel of mm fwhm. then, images were masked so that all remaining voxels had an activity higher than % of the brain global value in all cases. relative intra-subject changes in brain metabolism were determined in a voxel-by-voxel manner by subtracting the post and pre images and expressing this difference in percentage units relative to the first image [ x(post-pre/pre)]. finally, these images were thresholded and the number of voxels showing changes over/under % were recorded, as well as the average relative metabolic change in them. results: in / patients significant increased metabolism in unilateral or bilateral carotidean territories were observed after endarterectomy. in half cases there was concordance between brain changes and affected carotid. in / we observed decreased bilateral metabolism after ca. no changes were observed in / patients, all of them with left arterial disease. no significant correlation was found between brain changes and time from symptoms to pet imaging, symptomatic or asymptomatic patients, degree of carotid stenosis and vascular risk factors. conclusions: f-fdg ct-pet imaging can demonstrate bilateral changes in brain metabolism after endarterectomy, mainly in carotidean territories. objective to evaluate the efficacy and the diagnostic value of cerebral perfusion quantification in patients (p) with carotide artery stenosis (cas) who underwent surgical endarterectomy. materials and methods p were studied. showed right and left carotide stenosis. most of them had bilateral cas and underwent surgery of the main affected artery. eco-doppler, basal and months after endarterectomy mtc-spect with mci of mtc-ecd scan (vg gems gamma camera, fan beam collimator) were performed in all p. the perfusion was analysed by spm comparing each patient's study (pre and post surgery) with a healthy control group. the changes in both the extension and intensity of the cerebral hypoperfusion before and after surgery were also evaluated. results a significant carotide artery flow improvement was found in all p by eco-doppler. in p the basal cerebral perfusion analysis by spm was normal. in p an increase of the intensity (mean , %) and extension (mean %) of the hypoperfused areas seen in the basal study was detected. in p a decrease of the intensity (mean , %) and extension (mean , %) was seen. conclusion spm is a useful method to analyse the post surgery cerebral perfusion changes in p with carotide stenosis, detecting a significative hypoperfusion decrease (intensity and area) in of p. a post surgery worsening was found in p. these results are uncertain and further long term studies would be needed to clarify these findings. aim: study of brain perfusion in patients with arterial hypertension (ah) and type ii diabetes mellitus (dm). material and methods: fifty seven patients with moderate essential hypertension (mean age , + , years) were investigated by brain spect scanning with m tc-hexamethylpropylene amine oxime ( m tc-hmpao). thirty three patients were found to have ah without carbohydrate metabolism disturbance (gr.i) and patients -ah with type ii dm (gr.ii) in stage of compensation and subcompensation. all patients had no focal neurological symptoms. spect was performed at baseline and during adenosine test. results: hypoperfused regions were revealed in all patients. the dercrease in radiopharmaceutical accumulation was found in of brain regions in patients of gr.i. the most significant cerebral blood decrease was marked in parietal brain region ( %). hypoperfused regions were observed less frequently in temporal ( %), occipital ( %) and frontal ( %) brain lobes. cerebral perfusion disorders in patients with ah and dm were more pronounced in comparison with patients of gr.i (p= , ). thus, of brain regions ( %) were hypoperfused in pts of gr.ii. microcirculation disorders of greater degree were found in occipital brain lobes, where hypoperfusion was revealed in of ( %) brain regions. the less pronounced decrease in accumulation of m tc-hmpao was observed in parietal ( %), temporal ( %) and frontal ( %) brain lobes. use of adenosine test in both patients groups did not affect cerebral perfusion in hemispheres (p= , and p= , , respectively). however, in some cases brain perfusion decrease in individual regions was observed. at the same time in frontal lobe almost double increase in hypoperfused regions quantity as compared with baseline was found. this fact may testify to cerebrovascular reserve decrease in frontal region in these patients. conclusion: our results suggest that the signs of brain hypoperfusion and the decrease in cerebrovascular reserve take place in patients with essential hypertension and diabetes mellitus as well as in ah patients without it even if they have no focal neurological symptoms. the most pronounced cerebral perfusion disorders are revealed in patients with ah and diabetes mellitus in comparison with ah patients without carbohydrate metabolism disturbance. [ i]fp-cit is suitable for the quantification of dopamine (da) transporters localized on the membrane of presynaptic dopaminergic neurons. the practical use of [ i]fp-cit spect has become a routine diagnostic tool to investigate the integrity of the nigrostriatal pathway in vivo and also to directly assess the progression of parkinsonism. previous studies applying roi methods for data analysis have evaluated the effect of medications on the striatal da transporter imaging, that is however still debated. aim of the study was to evaluate the effect of treatment with dopamine agonist drugs on da transporters in patients with parkinson's disease (pd) by means of a voxel-based analysis of [ i]fp-cit spect data. spect [ i]fp-cit binding to the da transporters was evaluated in patients both without any medication and during treatment with dopamine agonist drugs (ergot-derivatives and non-ergotderivatives) after reaching the maximal optimazed dose (mean days). a -head gamma camera equipped with lehr collimators was used for data acquisition ( x matrix, pixel size mm, projections, ° circular orbit) after the i.v. injection of mbq of [ i]fp-cit. filtered back projection with a butterworth prefilter ( . cycles/cm, order ) was used for reconstruction, applying uniform attenuation correction ( . cm- ). reconstructed data were realigned, spatially normalized to a [ i]fp-cit spect template and smoothed. individual voxels values were expressed as % of occipital mean counts. spm was then used for data analysis. both caudate and putamen [ i]fp-cit binding values were bilaterally not significantly different on baseline and during treatment (p< . ). no statistically differences were also observed when comparing patients treated with ergot-derivatives versus non-ergot-derivatives. in conclusion, the results of the voxel-based analysis, a less operator-dependent approach than roi methods, confirm that dopamine agonist medications do not affect the spect imaging with [ i]fp-cit and support the needless of withdrawing both ergot-derivative and non-ergot-derivative drugs to measure da transporter levels. the absence of effect of this treatment on spect measurements is particularly important when the neuroprotective effect of dopamine agonist drugs is going to be assessed by [ i]fp-cit imaging. the diagnosis of alzheimer's disease (ad) versus lewy-body dementia (lbd) and parkinson's disease (pd) with dementia is often problematic, especially in patients with both dementia and parkinsonism. aim of the study was to assess the usefulness of spect with [ i]fp-cit, a dopaminergic presynaptic ligand evaluating integrity of nigrostriatal pathways, combined with rcbf spect for differentiating in-vivo lbd, pd with dementia and ad, by means of a voxel-based approach. most previous spect studies have applied roi methods for analysis, which are subjective and operator-dependent. fifteen patients with probable lbd, with probable ad (nincds/adrda criteria) and patients with dementing pd underwent rcbf spect with mtc-ecd and a brain spect with [ i]fp-cit. patients were matched for age, sex and severity of cognitive impairment (mmse). spect was performed with a dual-head gamma-camera - hr after the i.v. injection of [ i]fp-cit ( mbq) and about hr after mtc-ecd ( mbq). comparison of the[ i]fp-cit striatal binding ratios and rcbf spect patterns among ad, lbd and pd was performed by means of the voxel-based spm analysis (spm , unpaired ttest for statistical analysis). the spm analysis showed a significant (p< . ) bilaterally reduced binding in caudate and putamen in lbd and pd patients compared to ad. striatal uptake was indistinguishable between patients with lbd and pd. ad patients had significantly (p< . ) reduced rcbf in the temporo-parietal and frontal areas versus both the lbd and pd groups. lbd and pd patients showed significantly reduced (p< . ) rcbf in the occipital regions versus the ad patients. whereas, no statistical differences in the rcbf patterns were found between lbd and pd patients. in conclusion, the spm voxel-based approach is a viable alternative to the method of roi analysis, and could be included in the routine clinical analysis. nigrostriatal impairment as evaluated by means of [ i]fp-cit spect allows to differentiate lbd or dementing pd from ad patients. the rcbf study adds further informations about the existence of a common or different neurobiological substrate underlying the clinical spectrum of parkinsonism-dementia. on the other hand, it appears that [ i]fp-cit and rcbf imaging cannot differentiate lbd from pd with dementia. background a differential diagnosis between idiopathic parkinson's disease (ipd) and multiple system atrophy (msa) is clinically difficult. we analyzed the difference in glucose metabolism between ipd and msa using spm (statistical parametric mapping). methods this study included ipd patients (age range: - yr), msa patients (age range: - yr) and healthy controls (age range: - yr) who underwent f- fdg pet. using spm (statistical parametric mapping , wellcome department of cognitive neurology, london, uk) software, all the images were spatially normalized into the standard template, smoothed with mm fwhm isotropic gaussian kernel. the count of each voxel was normalized versus the total count for the brain (proportional scaling in spm) to remove global cerebral blood flow differences between the individuals. images of ipd were compared with those of healthy controls and msa patients in a voxel wise manner using spm (uncorrected p < . ). the ipd patients were found to have a significant glucose hypermetabolism in comparison with the healthy controls in both basal ganglia, thalami, cerebellar areas and decreased metabolism in motor cortical areas. the msa patients demonstrated diffusely decreased cerebral glucose metabolism in both both cerebellar areas compared to the ipd patients. conclusion although the number of patients studied is small, spm analysis may be useful in differential diagnosis of patients with idiopathic parkinson's disease and multi-system atrophy. further studies including more patients may be warranted . normal or aspecific findings at ct/mr. brain spect was performed - hrs after mbq i fp-cit (datscan, amersham health) i.v. injection by a dual head gamma camera with fan beam collimators. spect images were analyzed qualitatively and quantitatively calculating conventional putamen/occipital (p/o) and caudate/occipital (c/o) ratios normalized with phantom and compared to age matched normal controls (c) provided by the data processing software (normal values: p/o= . ± . ; c/o= . ± . ). when the two analysis data were controversial the binding potentials were determined by another software (neurotrans d, mirage) that corrects the partial volume effect applying the talairach atlas as anatomical d reference. results: i-fp-cit spect was normal at qualitative analysis in / ( . %) patients without difference in both p/o and c/o ratio in respect of c, thus classifying these cases as affected by et. spect was pathological in / ( . %) cases; in of these, monolateral putamen uptake defects were ascertained in concordance with clinically evidenced site and p/o ratios ( . ± . ) in all involved putamen were significantly lower than in controlateral ones ( . ± . ; p< . ) and c (p< . ). bilateral defects were detected in the remaining / pathological cases, clinically classified as monolateral; however, p/o ratio was bilaterally low only in / cases with mean values significantly lower (p< . ) than c in both putamen (left: . ± . ; right: . ± . ) while, it was low monolaterally in the remaining / . however, in these latter, at d analysis, binding potentials were low bilaterally. all patients classified as pd underwent l-dopa therapy. conclusions: i-fp-cit brain spect may be useful in patients with clinically suspected resting tremor of recent appearance to clarify uncertain differential diagnosis between pd and et, thus permitting the most appropriate treatment. moreover, spect also gave more information on disease extension in respect of clinical data utilizing both qualitative and semiquantitative analyses, with d binding potentials evaluation obtaining higher performance in our cases. ) the placement of rois in basal ganglia not uniquely defined. these issues are most prominent in patients with low tracer uptake in the basal ganglia (advanced pd, candidates for surgery etc.), but also of importance in longitudinal studies. we propose an automated method relying on histogram analysis that does not involve operator interaction. materials and methods the algorithm exploits the pharmacokinetic feature of high target-to-background ratios of the ligands. simple histogram analysis of the image slices containing the basal ganglia and occipital cortex can reveal estimates for specific and unspecific uptake. the histogram analysis consists of parts: ) thresholding for extraction of brain pixels, ) calculation of the median pixel value in the brain as an estimate of unspecific uptake, ) calculation of the median of the pixels with the highest tracer uptake corresponding to the size of the basal ganglia. the algorithm was tested on fp-cit images from patients and compared to the manual "crescent roi" analysis. the parameter of interest was the ratio of uptake in the basal ganglia compared to the background. results in / datasets the agreement of the ratios was within . , in / datasets within . . datasets with "patchy" tracer uptake with areas of low uptake in the background region exhibited the largest differences. in one dataset, the algorithm failed to identify the slice with the basal ganglia. this dataset was excluded. conclusion despite its simplicity, the algorithm reproduces clinically reported results in most cases with good correspondence. deviations are prominent in cases with patchy unspecific uptake. in longitudinal studies the algorithm may provide valuable information as both inter-and intra-operator variance are removed. white matter normalization -a novel analysis method with improved sensitivity in pet perfusion studies of neurodegenerative diseases. p. borghammer , k. y. jonsdottir , a. gjedde ; pet center, aarhus university hospital, aarhus, denmark, center for integrative functional neuroscience, aarhus university, aarhus, denmark. aim: in pet studies of cerebral blood flow (cbf) and glucose consumption, the data analysis is complicated by the very large inter-subject variability. to overcome this problem, data normalization is often carried out by dividing each voxel in a subject scan with the global mean (gm). it is an often overlooked fact, that even subtle differences in global mean between the groups introduce bias into the analysis. we suggest, that normalization to white matter mean (wm) might improve analysis sensitivity and diminish the risk of creating artifacts. materials & methods: earlystage parkinson’s disease (pd) patients and healthy age-matched controls underwent cbf pet scans while resting. we employed both region-of-interest (roi) and voxel-based statistics. the analysis was carried out on non-normalized data and after normalization to gm and wm mean, respectively. the findings of these three analyses were compared. results: roi: no significant differences were found in absolute values of cbf in whole brain or any of the major lobes. after normalization to gm, pd patients had decreased cbf in parieto-occipital lobes, and in whole grey matter (all p< . ). after wm normalization, we found significant differences in the same areas and additionally in the frontal lobe (all p< . ). voxel-based: gm normalization yielded a single small voxel-cluster of significant decrease in the medial occipital lobe and a cluster of significant increase in left primary motor area (mostly white matter). wm normalized data disclosed much larger significant clusters of decreases cbf in occipital lobe and lateral parietal lobe bilaterally (p< . for all clusters), but no increases. conclusion: following wm normalization, significantly larger areas of cortical cbf decreases were detected than after gm normalization. conversely, only in gm normalized data, we detected increased cbf in pd. wm hyperactivity has been reported numerous times before in studies of pd patients. there is no basis or prior evidence for wm hyperactivity in animal models of pd. we propose, that the wm hyperactivity, reported in numerous pet studies of human pd, is an artifact created by wrongful normalization to gm, since gm is most likely decreased in pd, although this is rarely detected in the absolute data due to insufficient subject sample sizes. the wm normalization method seems to be more sensitive to detect expected (true) decreases and less prone to create artifacts such as wm hyperactivity. aim. i-fp-cit is a neuroreceptor tracer successfully used in diagnosing dopaminergic deficit in parkinsons' disease (pd) at an early stage due to the loss of dopamine transporter (dat). this study evaluates the possibility of making a more extensive and larger early diagnosis of the dopaminergic damage using semiquantitative analysis of i-fp-cit spect in patients with suspected parkinson's disease compared to only qualitative tests. methods. the study was carried out on patients with suspected pd. another people were involved as a control group, they were similar age-wise to the pd group and at follow-up months later essential tremor was evidenced and not pd. spect was carried out hours after the dat tracer had been administered. both qualitative and semi-quantitative analyses were performed in the region of the striatum in the patients studied. the semiquantitative analysis was made out and the patients with results superior to the standard deviation of the established range were selected. result. in patients out of ( %) a reduction of dat activity in at least one region of striatum was evident. visual analysis of the images diagnosed dopaminergic damage to the putamen controlaterally to the side where the symptoms were present in . %; to adjacent caudate nucleus in . % and damage to the base nuclei isolaterally to the symptoms in . %. while the semi-quantitative analysis gave the following results: . %, . % and . % respectively.conclusions. the results indicate that i-fp-cit spect allows a more accurate characterisation of the dopaminergic damage in patients with suspected parkinson's disease. g. p. sechi , s. nuvoli , v. agnetti , k. paulus , f. chessa , g. cocco , a. spanu , g. madeddu ; neurology dpt, university of sassari, sassari, italy, nuclear medicine dpt, university of sassari, sassari, italy. aim: in parkinson's disease (pd) patients we used i-fp-cit spect to investigate whether the tripeptide gsh may have an effect on dat, gsh ability to cross the blood-brain barrier (bbb) being still debated. material and methods: twenty consecutive pd patients (h-y stage - ) were studied, never been treated (group ) and on chronic carbidopa/levodopa and/or dopamine agonist therapy (group ). in all pd patients and in healthy subjects were performed: updrs motor battery and webster step-second test, and spect - hrs after mbq i-fp-cit (datscan, amersham ge) i.v. injection. spect images were evaluated both qualitatively and semiquantitatively calculating putamen/occipital (p/o) and caudate/occipital (c/o) ratios, normalized with phantom and compared to age matched normal controls (c) provided by processing software data. both group and group patients were treated for weeks with i.m. gsh therapy, μg twice daily, group maintaining basal treatment. after gsh, pd patients repeated spect and neurological tests comparing data to basal values. results: at the first observation, in involved putamen of group patients and in of group , p/o was low (< . ), with mean values, in the putamen, significantly (< . ) lower ( . ± . ) than the not involved putamen ( . ± . ), and those of healthy subjects ( . ± . ) and c ( . ± . ) ; no difference was ascertained between the latter groups. in all cases c/o was normal. after gsh therapy, there was p/o increase in / involved putamen with an increment percentage > in % of cases, mean values ( . ± . ) being significantly (p< . ) higher than basal values ( . ± . ); in / putamen p/o had no change and in the remaining / further decreased, but not significantly. in particular, an increment percentage > % there was in % of group putamen and in % of group . the not involved putamen had no significant change. updrs slightly improved in patients. conclusions: i-fp-cit spect proved useful to evidence that gsh therapy may increase putamen dat binding, particularly in never treated pd patients in our series, thus indicating bbb penetration of this tripeptide. a potential therapeutic role of parenteral gsh might be suggested in pd patients. objectives: many studies show changes of serotonin transporter (sert) in various neuropsychiatric diseases. sert is also the primary target for selective serotonin reuptake inhibitors (ssris), widely prescribed for the treatment of major depressive disorder and other mood and anxiety disorders. so, in vivo measurement of sert function is useful tool for studying pathophysiology of neuropsychiatric diseases. recently, as most valuable candidate for measurement of sert function, c- amino- -( -dimethylaminomethylphenylsulfanyl)benzonitrile ( c-dasb) was developed and showed its potential for evaluation of sert. use of c-dasb thought to be able to investigate various neuropsychiatric diseases, but age-related change of sert density is reported in normal cases. in this study, we tried to measure the density of sert with c-dasb in healthy volunteers, and evaluate the age-related change of sert density. methods: we studied sert activity in male subjects ( - y old) using c-dasb and pet brain imaging. pet examination was performed min after intravenous injection of c-dasb. regions of interest (rois) were drawn on mr images and pasted to corresponding pet slices. all subjects had also spect perfusion studies with m tc-ecd. three analytical methods without arterial blood sampling (the transient equilibrium, the linear graphical analysis, and the ratio of target to reference region) were used to estimate binding potentials (bps). cerebellum was used as the reference region in each method. results: bps obtained from each method had almost same values. test-retest reproducibility showed the verification of this study. a significant negative correlation was observed between c-dasb sert binding and age (thalamus: r = - . ; p = . , striatum: r = - . ; p = . ). decrease of c-dasb binding was approximately % per decade in thalamus. conclusion: in this study, we showed the age-related decline of sert in thalamus and striatum with c-dasb in normal subjects. these results indicate that c-dasb can apply for clinical studies on treatment of neuropsychiatric diseases using age-matched controls. background: the prevalence of depression in parkinson's disease (pd) is about % and the rate of depression is twice that seen in other disabling diseases. however, the pathophysiology of depression in pd remains obscure. regional brain changes have been demonstrated in non-pd patients with depression with the core perfusion deficit in bilateral parietal regions. objective: to determine whether pd patients with major depression exhibit differential brain perfusion compared to non-depressed pd patients. methods: we studied right-handed pd patients who fulfilled dsm-iv criteria for depression (dpd: females, mean age ± years, mean disease duration ± years) and right-handed non-depressed pd patients (ndpd: females, mean age ± years, mean disease duration ± years). diagnosis of pd was made according to the uk parkinson's disease brain bank criteria. all dpd and ndpd patients were in hoehn and yahr stage or and matched for age, disease duration and severity (updrs-iii). we excluded patients with dementia, cognitive and/or executive function deficits assessed by the mini mental state examination, the frontal assessment battery and the wisconsin card sorting test. the beck depression inventory (bdi) was used to quantify the severity of depressive symptoms. all subjects underwent resting state m tc-ethylcysteine dimer brain perfusion spect. statistical parametric mapping (spm ) was used for data analysis (p< . uncorrected). results: we observed hypoperfused regions in the left and right inferior frontal gyrus and in the left middle frontal gyrus; furthermore we found two areas of hyperfusion: the first one in the right thalamus and right hyppocampus and the other in the posterior cingulum, cerebellar tonsil and posterior lobe of left cerebellum. bdi mean score was ± for dpd and ± for ndpd (p< . , mann-whitney test); updrs-iii mean score did not differ between pd subgroups (dpd: ± , ndpd: ± ). conclusion: our analysis outlined that major depression in pd is associated with hypoperfusion of inferior and middle frontal gyri. the findings suggest that loss of dopaminergic innervation in pd might cause impairment of fronto-striatal circuits and which plays a key role in the manifestation of depression in pd. introduction obsessive-compulsive disorder (ocd) has been suggested to be a neurobiological disorder arising from abnormalities in the serotonergic system. despite the therapeutic efficacy of serotonin uptake inhibitors, evidence from neurobiological studies does not provide consistent evidence for serotonergic abnormality. converging lines of evidence suggest a role for dopamine in ocd. objectives to investigate the binding potential change of [ c]-sch to dopamine d receptors in patients with ocd. methods seven patients fulfilling the dsmiv criteria for ocd and seven age and gender matched ( +/- years) volunteers underwent a single minute dynamic positron emission tomography (pet) scan with [ c]sch ( +/- mbq) with a specific activity of +/- ci/mm. pet scans were co-registered to individual mri and regions of interest compared. from the individuals mri, a cerebellar grey-tissue was defined as the reference region. logan graphical analyses was performed and distribution volume ratios (dvr's) defined for caudate, putamen, anterior cingulate, orbito-frontal-cortex and thalamus. results significant reductions (p = . ) in d binding potential were found in the caudate nuclei of patients in comparison to controls. conclusion this study is the first demonstration of a dopamine d abnormality in ocd. the findings implicate dopamine in the neurobiology of ocd and may help explain neuropsychological and neuroimaging findings associated with the disorder. background: cerebral activity patterns are distinctly modified by clozapine and typical neuroleptics. however, no study has directly compared to date the brain activity patterns while treatment with clozapine and other atypical antipsychotics. this comparison could contribute to a better comprehension of its respective mechanisms of action. the aims of this study were to compare the regional cerebral blood flow (rcbf) patterns of a group of schizophrenic patients who were switched from risperidone to clozapine due to lack of efficiency and to assess the corrrelation between the improvement in symptoms and the perfusion changes. material and methods: we have studied patients ( males; paranoid and undifferentiated patients, according to dsm-iv criteria) with m tc-hmpao-spect imaging at baseline (after a chronic treatment with risperidone) and after a month of treatment with clozapine. patients were performing a stroop test paradigm minutes before and minutes after a bolus intravenous inyection of mbq of m tc-hmpao. spect images were analyzed with the spm (from the welcome dept. of cognitive neurology, london, uk) software package comparing baseline and after clozapine conditions. one-tailed significant threshold was set to p= . with a minimum extent of voxels. the correlation between the clinical improvement and the changes in rcbf was assessed with a spm general linear model using rank-transformed symptom scores and checking separately for direct and inverse associations. results: in comparison to the risperidone condition, brain perfusion with clozapina was significantly lower on the posterior orbital gyrus in the right side and on the ipsilateral parahippocampal gyrus. in addition, patients showed a higher perfusion as compared to risperidone on the inferior prefrontal cortex as well as on parieto-occipital region. positive symptom improved was directly correlated with the increase of activity in two frontal areas, left prefrontal and left premotor and the improvement in negative symptoms was directly related to the increase of perfusion on cerebellum and on visual association areas. however, no association was found between decreases in perfusion and clinical changes. conclusion: these data suggest that the effects of clozapine and risperidone on rcbf patterns during the perfomance of a cognitive test were quite distinct. the clinical changes correlated with the higher perfusion areas produced by clozapine. this may be consistent with the effectiveness of clozapine in patients that failed to respond to risperidone. hungary, department of nuclear medicine university of szeged, szeged, hungary. several data suggest the role of the dopaminergic system in depression, but the results with functional imaging are contradictory. the selective serotonin reuptake inhibitor (ssri) antidepressants are believed to mainly act by selectively binding to the serotonin, but some of the ssris also exhibit other neuropharmacologic effects. the aim of this study was to evaluate the dat activity of untreated patients with unipolar depression and compared to healthy volunteers. we also studied the effect of sertraline on dopamin transporter activity in depression. materials and methods: we performed overall i-fp-beta-cit-spect examinations in healthy controls (mini) and in depressed patients (dsm-iv), the inclusion criteria was a score of at least on the hamilton depression scale (ham-d, items). in age-matched healthy subjects and in patients baseline i-fp-beta-cit-spect investigations were done, in the depressed patient group the dat spect was repeated after weeks sertraline treatment. on the transversal reconstructed spect slices at the level of the basal ganglia, regions of interest were fixed by self-developed semiautomatic technique. the binding potential was estimated by the ratio of the specific to non-specific activity ({mean striatal activity-mean occipital activity}/mean occipital activity.) results: in the patients group, the median baseline binding potential was . (range: . - . ), in the control group, this value was . (range: . - . ). a mann-whitney u-test revealed that this difference was not statistically significant (z=- . , p= . ). in the patient group, the median binding potential after sertraline administration was . (range: . - . ), which indicates a decrease of % of fp-cit binding. ham-d scores showed % decrease after sertraline treatment. spearman's correlation indicated no significant relationship among binding potentials, ham-d scores, age, and education (p> . ). conclusion: we didn't find any significant difference in the baseline values of dat activity between control and untreated depressed subjects. the ham-d score showed decrease after treatment, which prove effectiveness of therapy. sertraline treatment decreased the dat occupancy ( %) but further investigations are needed to support this finding. aim: dopamine d receptor (d r) availability appears to be important in addictive behavior. for example, low striatal d r binding predicts high rates of intravenous cocaine self-administration in animals. the study of striatal d r availability in mouse models of cocaine addiction may therefore be important to unravel the role of the d r in addiction. additionally, endogenous dopamine release, induced by psychostimulants, may differ in drug-addiction. we recently developed a highresolution single-pinhole spect system to perform studies in small laboratory animals. in this study, we evaluated the feasibility to image d r and to assess dopamine release in mice using the d r antagonist [ i]ibzm and our pinhole spect system. materials and methods: male c bl/ j mice were scanned on our single-pinhole spect system [habraken et al. jnm ] . in this system, the mouse is tightly fitted in a cylinder which is positioned directly and horizontally above the pinhole aperture, and rotates during data acquisition. the pinhole collimator is connected to an adac arc © scintillation camera. a -mm pinhole aperture was used. all experiments were acquired, step and shoot, with a % energy window around kev in a x matrix, ror of mm, field of view . mm. reconstruction was performed using the feldkamp algoritm. images were analyzed with fixed rois for the striatum and cerebellum. in a first study, mice were injected intravenously with up to mbq [ i]ibzm and scanned continuously up to h p.i. ( frames of min.) to study the pharmacokinetics of the radiotracer ( studies in mice). in a second experiment, the feasibility to assess dopamine release was evaluated. nine mice were injected min. before ibzm injection ( mbq) with saline i.p., and acquisition was started min. ( timeframe of min.) after bolus injection of ibzm. approximately week later, the same group of mice was rescanned, but now the mice received . mg per kg body weight amphetamine i.p. min. prior to the injection of ibzm. results: injection of [ i]ibzm resulted in clear specific binding in the striatum, with highest specific to non-specific binding ratios min. after injection. in the second experiment, amphetamine induced a significant decrease in striatal ibzm binding ratios. conclusion: this study shows the unique possibility to image striatal d r and to assess endogenous dopamine release in the mouse brain. aim: quantitative assessment of functional pet data is attractive since it can lower variability across institutions and may enhance the consistency of image interpretation independent of reader experience. various quantitative indices have been suggested for functional brain imaging of the dopaminergic system including advanced kinetic models and simplified semi-quantitative measures such as the specific binding index (sbi) computed as the ratio of uptake in a region with specific receptor binding to a reference region. a common problem with these indices is their dependence on the reference region of interest (roi) and the spatial resolution of the imaging system. therefore, partial volume effect results in underestimates of this index compared to the true value. materials and method: a new index named the specific uptake size index (susi), which considers total uptake in the object not just activity concentration, was recently proposed and claimed to be independent of roi size and system resolution. the validity of this index is assessed in this work using pet images acquired from an anthropomorphic striatal phantom study and f-dopa studies of patients potentially suffering from parkinson's disease. for the latter, the external brain contour was drawn manually using the patient's coregistered mri to exclude the bony skull and cerebral border thus avoiding partial volume effect. the influence of roi size was assessed by drawing non-overlapping rois of different size around the striatum not necessarily covering the whole striatum. results: phantom studies showed that sbi measures based on maximum counts were . and . for right and left striatum, respectively, and proved to deviate considerably from the true value ( . ). the susi estimate is nearly constant in the striatum for rois greater than cm . below this volume, the susi estimates are not reliable. the clinical studies seem to report that the sbi derived from susi is always greater than the sbi derived from maximum counts in the rois. the sbi derived from susi that uses total uptake instead of maximum uptake is likely to be more accurate for small objects. conclusion: we have demonstrated using phantom and clinical data that the susi is approximately independent of the roi size allowing to guarantee good reproducibility of quantitative parameters estimates. significant increases and decreases of regional uptake were obtained using t-statistics at every voxel from patients and normal control groups. clusters consisting of a minimum of contiguous voxels with an uncorrected p< . were considered to be significantly different. results: the gmfcs scales of the spastic diplegia type cp patients were level in patients, level in two and level in one patient.the pyramidal tracts in the patients were grossly normal in terms of connectivity and white matter volume. [ f]-ffmz binding was increased in the motor and premotor areas and bilateral visual cortices. conclusion; altered gaba a receptor binding in the motor cortices might play a important role in the pathogenesis of motor dysfunction in spastic type cp as the gabaergic signaling in the motor and visual cortices plays an important role in the development of peri-lesional or use-dependent plasticity after brain damage. msa is a neurodegenerative disease that manifests itself with clinical symptoms of parkinsonism combined with cerebellar ataxia, autonomic failure and pyramidal signs. the form with predominant parkinsonism (msa-p) accounts for % cases and its differentiation from parkinson's disease (pd) is often difficult. the aim was to examine potential role of scintigraphy in differerential diagnosis of msa-p and pd using binding potential of the striatum for i-fp-cit (datscan) and i-ibzm to reveal complex dysregulations in dopaminergic transporter/receptor system. methods: the study has been performed in patients suspected for diagnosis of msa-p based on clinical criteria including mri and poor response to dopaminergic therapy (n = ), patients with verified pd (n = ), and age-matched healthy controls in order to obtain normal values of diagnostic indices with fp-cit (n = ) and ibzm (n = ). inclusion of individuals and their informed consent has been approved by ethical committee of the hospital. in patients, both fp-cit and ibzm examinations have been performed with the same administered activity ( mbq). control subjects underwent only one study, either fp-cit or ibzm. spect data have been recorded by triple-head gamma camera picker prism and dual-head gamma camera ge infinia-hawkeye. striatal binding capacity has been assessed visually and semiquantitatively as binding ratios striatal/occipital (sor) for fp-cit and striatal/frontal (sfr) for ibzm. results: in comparison with healthy controls, significantly reduced sor has been found in both msa-p and pd patients (p= . ) in nucleus caudatus and in putamen. however, no difference has been found between the two groups of patients. in patients with msa-p, there was no difference in density of presynaptic dtransporters between nucleus caudatus and putamen. in contrast, sfr has been significantly reduced in nucleus caudatus and in putamen in patients with msa-p with respect to healthy controls (p= . ) while no such difference was found in patients with pd. in of patients suspected for msa-p, diagnosis has been changed to pd due to normal density of d receptors in the striatum. in patients with msa-p, binding capacity for postsynaptic d receptors was reduced more in putamen than in nucleus caudatus (p= . ). conclusion: assessment of dopaminergic transporter density in striatum using only fp-cit is not sufficient to differentiate msa-p from pd. instead, complex information is required on the dysfunction of dopaminergic transporter/receptor system in the striatum that can be obtained by comparison of fp-cit and ibzm scans. aim: to evaluate the usefulness of calculating an specific uptake index (sui) and the i-ioflupane spect (datsp) cut-off points as a supporting tool to diagnosis. material and methods: we included patients ( men and women with an average age of ) who had a diagnosis of suspected essential tremor (et) vs parkinsonian syndrome (ps). all patients received datsp four hours after a dose of mbq loflupane -i . using a visual appraisal method, we clasified the patients into normal ( ), minor( ), moderate ( ) and severe ( ) . the quantification was made on two consecutive central transaxial views, drawing irregular and/or geometric regions of interest (rois) in striatum (str), caudate nuclei (c), anterior putamen (ap), posterior putamen (pp) and occipital. we calculated the sui using the following formula: counts in roi-counts in occipital/counts in occipital. we drew cor curves to determine discrimination cut-off points of pathological trouble. all data was captured and recorded in microsoft excel format, with analysis carried out using the statistical package, spss. results: the results from the visual appraisal method were normal, minor, moderate and severe patients. we calculated two discrimination cut-off points for the sui str of pathologic ( + + ) and severe ( ) with values < , (s %, e %) and < , (s %, e %) respectively. we also calculated two discrimination cut-off points for the sui pp of moderatesevere ( + ) and severe ( ) with values of < (s %, e %) and < (s %, e %) respectively. we related the sui in str, c, ap and pp and the differents pathological groups. we obtained statistically significant difference between the suiof the group and the rest. conclusion: quantification of the sui is statistically significant to differenciate the severe group from the rest. the calculation of the sui pp is more useful given its highest sensitivity and especificity. regarding to gender and age , there were no significant statistical differences found. the visual appraisal method continues to be, in our case, the best tool for diagnosis to differenciate between these type of patients than obtaining quantitative values. aim it has been demonstrated that [ i]fp-cit single photon emission computed tomography (spect) might be useful to characterize dopamine transporters (dat) loss in basal ganglia in parkinson's disease (pd), progressive sopranuclear palsy (psp) and lewy body disease (lbd) patients, but it is not capable to distinguish between these diseases. the aim of our study was to quantify serotonin transporters (sert) availability in the mesencephalic region of pd, psp and lbd patients by [ i]fp-cit spect. materials and methods patients ( age-matched pd, age-matched psp, age-matched lbd and age-matched healthy controls) were enrolled in this study. spect was performed in all cases after i.v. injection of mbq of [ i]fp-cit, using a double head gamma camera (infinia-ge). software coregistration of functional and morphological (mr) imaging data were then used to define regions of interest (roi) including mesencephal and the occipital lobe. the ratio of specific (mesencephal -occipital lobe) to non specific (occipital lobe) binding was calculated. results by semiquantitative analysis, the ratio of mesencephaloccipital lobe (specific) to occipital lobe (non specific) were different between pd (mean= . , range= . - . ), psp (mean= . , range= . - . ), lbd (mean= . , range= . - . ). when compared to controls (mean= . , range . - . ), were not different for pd. as compared with control values, the psp and lbd patients had a significant reduction of specific [ i]fp-cit binding in the mesencephalic region. conclusions our results suggest that sert in mesencephalic region can be used in diagnostic differentiation between pd, psp and lbd. our findings need to be confirmed in larger number of patients. objective: it is necessary to obtain an arterial blood sample to calibrate and individualize the standard arterial input function for regional cerebral blood flow mapping with iodine- -imp (imp) autoradiographic (arg) method (j nucl med ; : ) . the objective of this study was to propose an alternative method without blood sampling to estimate individual calibration coefficients for arg method. methods: if the individual difference in the brain distribution volume (vd) of imp is small enough, the calibration coefficients for the standard input function (cf: (kbq/ml) / (cps/g blood)) can be estimated from a product of cf and vd that can be obtained by -compartment model analysis of brain time-activity data using the uncalibrated standard arterial input function. to validate this method, consecutive patients with various cerebral diseases ( ± years old, m/f= / ) were studied with imp dynamic spect. imp ( mbq) was infused intravenously over min. immediately after starting the infusion, dynamic spect data acquisition ( rotations/ min) was performed. seven to ten minutes after starting the infusion, onepoint arterial blood sampling was performed to measure cf. by threshold percentages ( , , , %) to the maximum, the mean+ . sd and the mean+ sd of voxel count in the brain, twelve whole brain time-activity curves (tacs) normalized by the volume of interest given in kbq/ml were generated. each tac was fitted to compartment model using the uncalibrated standard arterial input function to obtain a product of influx rate constant (k : ml/min) and cf (cfk ), and efflux rate constant (k : /min). dividing cfk by k , the quotient (cfk /k ) gave a product of cf and vd (cfvd). the correlation between estimated cfvd from -compartment model analysis and measured cf from arterial blood sampling was investigated in a set of brain tacs. results: measured cf ranged from . to . ( . ± . ). in every compartment model fitting, cfk , k , and cfvd could be determined with small error of estimate. among the eight conditions for determining the brain border, the best correlation between estimated cfvd and measured cf was noted in the set of tacs determined by the threshold of % to the mean+ . sd of voxel count (cf= . cfvd + . , r = . , n= , rmse= . , p < . ). conclusion: in arg method, the calibration coefficients for the standard arterial input function could be estimated without arterial blood sampling, using proposed linear regression equation. brain death is present when all functions of brain stem have irreversibly ceased. before discontinuation of artificial ventilation and organ harvesting the instrumental confirmation is necessary in addition to neurological findings. authors present own experiences with brain perfusion scintigraphy in the diagnosis of brain death. patients and method: brain scintigraphies for confirmation of clinical diagnosis of brain death in patients ( male, female, in age - years) were performed in the years [ ] [ ] [ ] [ ] . patients were examined as potential donors of organs, seven from other reasons. about mbq of mtc-hmpao was injected as bolus to central vein. dual-head spect gamma cameras with lehr collimators for acquisition of the date were used. flow images ( s per frame) were acquired from the time of tracer injection to one minute. planar images in four projections or spect of the head were obtained subsequently. in brain death flow images show completely absent of the blood flow superior to the circle of willis circulation and planar images or spect demonstrate no radiopharmaceutical uptake in the whole brain. results: in patients the brain death was unambiguously confirmed. in two patients (a female after cerebellar hemorrhage and a male after suicide of hanging with repeated scintigraphy after h) had brain perfusion partly preserved and brain death was not confirmed. we did not find mismatch between dynamic and static images. no side effects were observed. conclusions: cerebral perfusion scintigraphy is simple, reliable, safe and cost-effectives method for confirmation of irreversibility of clinical signs of brain death. the great advantage against x-ray angiography is exactness of findings also in cases of head injury and after craniotomy. other advantage of perfusion scintigraphy is non-invasivity and there is no fear of damage of organs for transplantation due to injected x-ray contrast substances. aim: to determine whether age-matched normal database (ndb) is necessary for the detection of alzheimer's disease (ad) using brian fdg pet and automatic image analysis. material and methods: we generated age-specific ndb sets ranging in age from yr to yr; each consisted of males and females. in order to assess the diagnostic performance using these ndbs to distinguish ad patients from normals, patients ( males, females; mean age, . ± . yr) with probable ad and normal subjects ( males, females; mean age, . ± . yr) were recruited. the image analysis was performed using neurostat. the changes of relative fdg activity with age were measured for the posterior cingulate gyri and precunei (pcgp). a receiver-operating characteristic (roc) analysis was performed for comparison of the diagnostic accuracy using these ndbs. results: there was no significant difference in area under the roc curves (az) for the discrimination of ad patients from normals (table) . furthermore, there was no significant correlation between the relative fdg activity in pcgp and age. conclusions: our results indicate that age-specific normal database for fdg pet may not be necessary for the detection of ad. this could be explained by the lack of significant correlation between relative fdg activity in pcgp and age. aims: anatomical imaging methods, especially computerized tomography (ct) and magnetic resonance imaging (mri) are helpful in diagnosis of acute traumatic brain injuries (atbi) however, they are not as efficient as single photon emission computed tomography (spect) for the diagnosis of traumatic brain injury with chronic symptoms (tbics). our aim was to compare brain perfusion spect and ct or mri findings in patients with a history of thics being followed for more than one year. material and methods: ninety two patients fulfilled the criteria to enter our study. sixty-two of these patients had a history of a mild brain disease (group a) while the remaining cases had a history of moderate to severe brain disease (group b) .the age of our patients ranged between - y, with mean age . ± . y. the mean post-traumatic period was . ± . y. these patients presented with various neurological signs and symptoms especially due to hypofrontality and hypotemporalism. brain perfusion spect with m tc-ecd and ct or mri were obtained in all patients with a maximum interval of one month between each procedure. in our study, the brain was divided into ten areas five regions in each hemisphere. the spect, ct and mri images were interpreted separately by two nuclear medicine physicians and two radiologists who were blinded to all study results. results: out of a total of brain regions, brain perfusion spect revealed lesions ( %) while, anatomic modalities ct or mri detected significantly less lesions ( . %) (p< . ). conclusion: brain perfusion spect may be more useful than anatomic imaging procedures in identifying tbics, especially in patients presenting with symptoms of hypofrontality or hypotemporalism. brain perfusion spect can be effectively used to identify the chronic complications of remote traumatic brain injuries. effect of aerobic training on tc m-sestamibi uptake by rat brain: evidence for exercise augmentation of the blood-brain barrier (bbb) function ? introduction-aim: bbb effectively contributes to brain homeostasis maintenance. tc m-sestamibi does not enter normal brain and its uptake is very low. cerebral capillary endothelium, a major bbb component, is characterized by a five-fold mitochondrial content compared to capillaries of systematic circulation. high mitochondrial density is potentially related to increased pumping energy demands of the bbb. mitochondria are also a known subcellular target of tc m-sestamibi. moreover, p-glycoprotein, a membrane efflux pump, using tc m-sestamibi as substrate is abundant on bbb. this study investigates the impact of the aerobic trainning on brain uptake of tc m-sestamibi and a possible explanation is discussed animals and methods: twenty-four adult male wistar rats were allocated to a trained (n= ) and an untrained (n= ) group. endurance exercise on a motor-driven treadmill had the following characteristics: speed m/min for min, days/wk for weeks. on completion of the training program, tc -sestamibi ( . mbq/kg body weight) was administered i.v. to all animals. two hours after injection, heart, brain, blood and various skeletal muscles of the hindlimbs were removed. tc m-sestamibi uptake was calculated, after activity measurement in a well-type counter, as % of injected dose (id) per tissue gram. differences between trained and untrained rats were assessed for significance at p< . level by the independent student's t test. results: tc sestamibi uptake in both myocardium and skeletal muscles of trained animals was significantly higher than that of untrained, thus evidencing the effectiveness of the exercise scheme.tc -sestamibi uptake was very low in brain, comparable to blood levels. however, uptake in trained rats was about double than in untrained: . vs . %id/g, p< . . conclusion: despite being low, tc -sestamibi uptake in rat brain is increased after a period of aerobic training. both accelerated fuel transportation and increased prohibitive activity against various exercise-related metabolic products by the bbb during repeated exercise bursts, may induce mitochondriogenesis in bbb endothelium, thus explaining increased tc -sestamibi uptake in trained animals. the purpose of this study was to investigate the neurological variables associated with chronic traumatic brain injury in amateur boxers. material and methods: cerebral perfusion changes were evaluated using technetium- m hexamethylpropyleneaamineoxime single photon emission computed tomography (tc- m hmpao spect). spect were performed in boxers and healthy volunteers. images were acquired using a dual-headed gamma camera equipped with high resolution parallel-hole collimators. quantitative analyses were done using brain spect assessment tool in general electric xeleris work station (neurogam). results: analysis of tc- m hmpao spect images showed that the boxers had more cerebral perfusion changes than healthy volunteers. all cortical areas showed decreased blood flow especially in frontal and temporal areas in boxers. conclusion: in conclusion, the results showed that tc- m hmpao spect could be helpful to investigate cerebral blood flow abnormalities in amateur boxers and differences from healthy volunteers. cerebral perfusion changes should be taken into consideration in evaluating boxers having any neurological symptoms. the difference of brain fdg uptake pattern between health adults and cancer patients m. si, j. liu, g. huang, x. sun; renji hospital, shanghai jiaotong university, shanghai, china. aim: to determine the difference of brain fdg uptake pattern between health adults and cancer patients. material and method: the brain fdg uptake patterns of patients who performed pet/ct scan in our center from aug. to dec. .were retrospectively studied. the inclusion criteria is: ( ) absence of clear focal brain lesions (epilepsy, cerebrovascular diseases etc). ( ) absence of metabolic diseases, such as hyperthyroidism, hypothyroidism and diabetes. ( ) absence of psychiatric disorders and abuse of drugs and alcohol. ( )cancer patients were diagnosed definitely of variable cancers except brain cancer or brain metastasis. the normal group consists of subjects for tumor screen and got negative results. the age is ranging from to yr. the cancer group consists of various cancer patients. the age is ranging from to yr. both groups were sub grouped into six starting from years old with the interval of years old, and the gender, educational background and serum glucose were matched. all subgroups were compared to the subgroup of normal - years old called control subgroup ( subjects). the t-statistic analysis was applied to all brain images using the spm software. results: with the increasing of age, similar hypometabolic brain areas are detected in both normal group and cancer group ,they are mainly in the cortical structures such as bilateral prefrontal cortex, superior temporal gyrus(ba ),parietal cortex (inferior parietal lobule and precuneus(ba ),insula(ba )),parahippocampal gyrus and amygdala(p< . )and are especially apparent in the prefrontal cortex(ba )and sensory-motor cortex(ba , )(p< . ). but characteristic hypometabolism in cingulate gyrus and bilateral cerebellum are only seen in cancer group.compared to the same age interval of normal subgroup, each cancer subgroup shows significant hypo-metabolism in cingulate gyrus (p< . ),as well as bilateral cerebellum and basal ganglia(lentiform nucleus and thalamus)(p< . ). conclusions: relative hypometabolism in limbic system such as cingulate gyrus and basal. fahr's disaese is a rare of unknown aetiology disorder characterised by massive symmetrical calcifications of the basal ganglia, dentate nuclei and subcortical white matter. although the clinical pattern of fahr's disease is variable; neurobehavioural, cognitive, extrapyramidal-cerebellar symptoms, dementia, seizures and speech disorders are most common clinical features. clinical and ct scan examination is enough for diagnosis. in the literature there is no study performed to evaluate the value of hmpao brain perfusion spect in fahr's disease to the best of our knowledge. the clinical, ct scan and hmpao brain spect findings of a years-old woman with fahr's disease is reported. the patient presented to a neurologist with difficulty to use the upper limbs bilaterally (more prominent of the left side) and reduced movement ability six years ago. on neuropsychiatric examination; a mild deterioration of frontal functions was mentioned and computed tomography showed no abnormality. when symptoms progressed she was reevaluated and a non-enhanced ct scan revealed extensive, symmetrical intracranial calcifications involving the dentate nuclei and white matter of cerebellum, globus pallidus, putamen, caudate nucleus, internal capsule, thalami and centrum semiovale. serum levels of ionised calcium, phosphorus and parathyroid hormones were within normal range. she had no family history and was diagnosed as idiopathic sporadic fahr's diasease. spect images did not demonstrate perfusion abnormalities in all calcification foci visualised bilaterally on ct scan. hmpao brain perfusion spect images showed hypoperfusion in the left visual centre compared to that of right side and perfusion defect in the right basal ganglion. spect images did not demostrate perfusion abnormalities in all calcification foci visualised bilaterally on ct images. spect findings were not only congruent with the coresponding ct scan abnormalities but also correlated more specifically with the clinical findings. this case suggests that hmpao brain perfusion spect is useful in the clinical approach of fahr's disease providing more specific and clinically relevant information as compared to anatomical imaging. chronic fatigue syndrome (cfs) is an heterogeneous disease: disabling fatigue lasting at least months and accompanied by numerous rheumatological, infectious and neuropsychiatric symptoms. nowadays there is not a test with enough sensitivity or specificity to constitute a reliable diagnostic tool. aim: to describe the usefulness of brain perfusion spect in the evaluation of patients with chronic fatigue syndrome (cfs), comparing the basal brain perfusion pattern with the cortical changes after physical exercise and a mental test. material and methods: thirty-five patients ( female, mean age years) with clinical criteria of cfs (holmes and fukuda) were included. all of them underwent a m tc-ecd brain perfusion spect ( mbq, double-headed gammacamera) in basal condition and after a stress test. the study consisted in physical exercise in the morning and injecting the tracer at the middle of a neurocognitive test (wais modified) in the afternoon. all the brain spect were blindly evaluated by experts, using a semiquantitative score: normal uptake (score ), slight hypoperfusion (score ), mild hypoperfusion (score ) or severe hypoperfusion (score ). cortical areas: frontal, temporal, parietal and occipital. results: patients showed a normal brain spect in basal and stress condition and patients ( . %) showed decreased perfusion in both studies, without changes in the intensity and localization of perfusion deficits. in patients ( . %) changes in perfusion were appraised: eighteen ( . %) showed decreased perfusion after psychological test with regard to basal condition (p= . ). frontal and temporal lobes were predominantly involved. eight patients ( . %) showed improvement in brain perfusion after the neurocognitive test (p= . ). conclusion: our results showed a high percentage of blood flow impairment in cfs patients, which worsened after a combination of physical and stress-mental test. brain perfusion spect might be a useful tool to improve diagnostic approach to an elusive illness such as cfs. the use of an objective neuroimaging method may help in the characterization and monitoring of brain perfusion abnormalities in cfs. the intoxication has adverse effects on health: digestive, endocrinologic and neurologic symptoms. these symptoms are unspecific (dizziness, asthenia, itchy sensation..) and often difficult to distinguish from a functional disorder. the aim of this work was to evaluate the brain perfusion changes in patients exposed to organophosphorate compounds. material and methods: nine patients (p) ( women; aged - years; mean age: ) with chronic exposure to organophosphorates were included. brain perfusion spect ( mci m tc-ecd) was performed in all p using gems vg, hawkeye gamma camera and fan beam collimator. brain perfusion was analysed in all patients using spm program and comparing each patient with a healthy control group. in all cases neuropsychological test, electroencephalogram, ct scan were also obtained. results: in p the brain perfusion was normal. the remaining showed hypoperfusion in different brain areas: p (parietal lobe - right; left-); p (posterior frontal); p (right mesial temporal); p (posterior temporal, anterior and temporo-parietal). conclusions: in of the patients exposed to organophosphorates spm detected significant brain hypoperfusion. the cerebral lobe involved was variable. further studies are necessary to confirm these results. recently, the physikalisch-technische bundesanstalt (ptb) and the company aea technology (now: qsa global) organized a joint national comparison of m tc solutions in order to obtain information on the quality of routine activity measurements in nuclear medicine in germany. the participants were asked to measure the activity in p -type glass ampoules and in syringes. the results and supplementary information on the instrument characteristics, uncertainties, radionuclidic impurities and steps for quality control had to be stated in a questionnaire prepared by the organizers. in this contribution, the m tc comparison results for two different geometries are presented and compared with results of previous comparisons. in particular the distribution of the deviations (a i -a i, ref )/a i, ref with the activity a i stated by the participants and the ptb reference activity a i, ref were analyzed. about % of the results fulfil the limitations prescribed by the european pharmacopoeia [ ] , i.e. the deviation to the reference value is less than ± %. the data clearly indicate a considerable reduction of the deviations compared to results obtained in previous comparisons [ , ] . in spite of this improvement there is still a considerable number of results which do not comply with the ± % criteria. these data were carefully analysed to detect potential causes for discrepancies and to find steps for further improvements of the quality in nuclear medicine. after a period in which the results of all participants were collected, all of them obtained a calibration certificate stating the reference activity value from the ptb. this document can be used as an important tool for quality control in the respective institute. [ (t) time from the elution to the labeling. test anova (p = . < . ) indicates significant differences and test of bonferroni specifies that these occur between group with respect to and , and do not occur between groups and . conclusions the increase of the rcp in groups and indicates that can be used eluents with a time over to hours, unlike at the specified in the technical leaflet of the ceretec®. this radiochemical can be used in the leukocytes labeling without decrease in its efficiency. aim the development of m tc-labeled infection imaging agents will contribute in the differential diagnosis of infection versus aseptic inflammation. currently, there are several formulations for the labeling of fluoroquinolones with tc- m that show contradictory data. our aim was the development of tc- m analogs of fluoroquinolones (norfloxacin and ciprofloxacin) of well-defined structure as well as their biological evaluation in vitro and in vivo. materials and methods fluoroquinolones, fq (norfloxacin and ciprofloxacin) have been functionalized at the n atom of the piperazine ring, by conjugation on suitable bifuctional chelators, n, n-( -picolyl)amino-diacetic acid (pada) and l-cysteine to form o-c h n-ch n(ch cooh)ch co-fq (fq-pada) and hoocch(nh )ch sch ch ch -fq (fq-cys) respectively. fq-pada and fq-cys reacted with [ m tc(co) (h o) ] + ( . ml, - mci) and produced two types of neutral m tc complexes, fac-[ m tc(co) (fq-pada)] and fac-[ m tc(co) (fq-cys)]. in vitro studies were performed, by incubating these m tc complexes with x cfus of s. aureus and e. coli. in vivo studies were performed by injecting μci of the m tc complexes via the tail vain in mice. results and conclusions the m tc complexes synthesized were analyzed by hplc and showed, in all cases, the formation of one radioactive species. in vitro studies of the m tc complexes resulted in - % binding in s. aureus, while the binding to e. coli was found to be lower for all the compounds tested ( - %). in vivo biodistribution studies in mice ( and min p.i.) showed that all the compounds present fast blood and soft tissue clearance. preliminary studies showed that only small percentage of activity accumulates in muscles with induced aseptic inflammation (turpentine oil, negative control) resulting in an inflammation to normal tissue ratio . . further in vitro and in vivo evaluation is in progress, in order to prove the potential radiopharmaceutical use of these novel technetium- m compounds as specific infection imaging agents. aim: the application of the heart-lung machine in human medicine implies the sideeffect of activated granulocytes which may cause inflammatory processes in the human organs. for this reason tc- m hmpao labeled granulocytes were used to localize the inflammatory process in pigs. imaging was performed to determine the distribution of tc- m hmpao labeled granulocytes in the organs and thereby the state of inflammation. material and methods: domestic pigs aged about month weighing - kg were examined. after gradient centrifugation of ml venous blood from the animal to isolate the granulocytes for labelling with - mbq tc-hmpao, the labeled granulocytes were then reinjected into the pig following thoracotomy. imaging was performed after at least hours of incubation time with a dst-xli gamma camera (ge). in each case a whole body scan (ap; scan speed cm/min) was carried out and in some cases spect imaging ( projections; acquisition time s/step). for quantification the geometric mean of the corresponding roi's over the liver, spleen, lung and brain of the anterior and posterior view of the whole body scan were obtained. the count rate was correlated to the administered activity and the weight of the animal. as reference organ the liver was selected. e.coli lps induced inflammations were generated as a positive control. results: the main part of the activity is located in the liver ( %). the activity in the spleen is decreased by a factor , and the activity in the brain is reduced by a factor in comparison to the liver. partly found unexpected high count rates in the lung were related to pneumonia of the animals. artificially generated inflammations were well displayed. conclusion: this method is basically suitable for inflammatory process imaging in pigs. the presented model is herewith suitable to answer questions concerning inflammatory process imaging in human medicine. the animals should be pre-treated with antibiotics in individual cases to preclude unspecific activity enhancement if applicable. introduction: the recommended method (meth ) to determine the radiochemical purity (rcp) of tc- m tetrofosmin (tfos) involves developing an itlc-sg strip in dichloromethane:acetone ( : ). in this system, colloids and hydrophilic impurities remain at near origin, free pertechnetate (tco ) runs near the front, and tfos migrates with an rf of ~ . . the disadvantages of this method include the need to prepare a fresh mixture of volatile solvents daily, sensitivity to spot size, and slight variations in the rf of tfos which result in falsely low rcp values using the cut and count technique. an alternative method (meth ) developed for rcp testing of tc- m sestamibi (proulx et al, appl radiat isot ; : - ) has now been validated for tfos. methods: meth uses two strips of itlc-sg developed in -butanone and saline, respectively. in -butanone, insoluble impurities and tc- m gluconate intermediate (gluc) remain at the origin while tfos and tco migrate near the front, whereas in saline the impurities tco and gluc migrate with the front and the remainder stays at the origin. rcp is calculated as % minus the two impurity measurements (note that gluc is double counted, however it is a very minor component). meth was compared with meth on samples of tfos and impure mixtures with free tco , colloid, and/or gluc added. a preparation at high radioactivity concentration without oxygen venting was used to produce an additional impurity. results: with clinical preparations of tfos there was no significant difference in rcp measurements: meth . ± . %, meth . ± . % bound, n= ; paired t-test p=ns. with impure mixtures ( . - . %) the regression line had the equation: rcp(meth ) = . rcp(meth ) + . , n= , r = . . most importantly, in the critical region around the % cutoff, the meth produced results ~ % lower than meth . in the period during which meth has been in routine use, it has detected one product failure and the result was confirmed by meth . during this period the mean rcp was . ± . % (n= ). conclusions: this report presents validation of a new method for rcp testing of tfos which is rapid, uses standard solvents and media, does not require daily preparation of a mixture of volatile solvents, provides clear and reproducible separation between impurities, and can also be used with sestamibi. aim: quality controls on renal scintigraphic agent m tc-mag prepared following procedures recommended by manufacturer, in our experimental conditions, gave poorly reproducible radiochemical purity results and often below the minimum acceptable. for this reason we investigated if modification of physical and chemical variables involved in preparation and storage could enhance m tc-mag radiochemical purity. material and methods: parameters involved in this study were the following: time elapsed between elution and labelling, age of the technetium generator column, opposite sequence of dilution and heating steps, activity/volume ratio for labelling, duration of heating and storage temperature of labelled drug. moreover, we aimed to study m tc-mag stability beyond four hours from labelling. quality controls were performed immediately after labelling, at minutes, at , , , , hours and in some experiments till to hours. as analytical technique a double paper chromatography (whatman n. ) was choosen, eluted with acetone to separate free pertechnetate and with acetonitrile: water ( : ) mixture to separate reduced hydrolyzed technetium. results: dilution after labelling is not recommended. storage at °c did not prolong stability, so it is also not recommended. the following parameters did not influence labelling yield and stability of m tc-mag : time elapsed between elution and labelling, age of technetium generator column, prolonged heating. labelling with innovative activity/volume ratio ( . gbq in . ml) constantly gave higher radiochemical purity results compared to recommended ratio ( gbq in ml). beyond, it was demonstrated for both labelling procedures a prolonged stability of m tc-mag till to hours after labelling. conclusion: m tc-mag chelation complex demonstrated an high physical chemical stability significatively influenced only by activity and volume used in labelling procedure. labelling with . gbq in . ml allows preparation of an higher number of doses from the same kit and the execution of diagnostic procedures requiring higher activities than conventional. finally, if evidences emerged from this study about m tc-mag prolonged stability will be confirmed by other experiments, it would be possible to administrate it till to hours after labelling, a double time compared to hours time interval recommended by manufacturer. aim: sodium iodide- is well known as a radioisotope that is used for studies of the thyroid and its metastases. i labelled compounds are used for kidney, heart and brain studies.since demand for i- is increasing a serious effort for production of i- has performed. material and methods: for production of i, a home made target was designed. the main part of the target contained; conical target vessel that was mounted in an aluminium cylinder of length cm and diameter . cm for water cooling during bombardment. front and rear target windows made by titanium foil and cooling system. in addition, some other part such as a cold finger, decay vessel, vacuum pump and four fingers also designed and installed on the system. i was produced from the reaction of mev protons with . % enriched xe with cyclon- . bombarded xenon was transferred to the vessel and stored there up to about hours to allow cs decay to i with the maximum efficiency. the remaining xenon gas was then transferred into the reservoir capsule using a cryogenic technique. the produced, i which is deposited on the wall of the decay vessel, was rinsed out by dissolution in . μs water at ºc. nitrogen gas pressure was used for the transfer the i solution to the chemical hot lab. the ph, and adjusted with sodium hydroxide. results and discussion: a sample of production was send to quality control. quality control results were in good accordance with the united states pharmacopoeia conclusion: using this system with the above specification, the production yield could be increased by increasing the current. the results shows no chmical or radionuclide impurity, and enable to produce i- withouht any more purification step. aims: in order to overcome the limitations of the reported methods, a short and simple method for the preparation of radioiodinated n-succinimidyl- -iodobenzoate that is widely used for radioiodination of antibodies is described. material and methods: the method involves the reaction of in situe generated trimethylsilyl radioiodide from trimethylsilyl chloride with n-succinimidyl- -[ , ( , -butanediyl)-triazene]benzoate available from the condensation of n-hydroxysuccinimide and -( -carboxyphenyl)- , -( , -butanediyl)triazene in the presence of dicyclohehyl carbodiimide. the recent triazene was prepared by precipitating the diazonium ion of -aminobenzoic acid with pyrrolidine. a microwave-mediated rate acceleration was observed during the radioiodination step. results: activation of radioiodination reaction by exposure to microwave irradiation (in a domestic oven at mhz for minutes) afforded the radioiodinated product in % radiochemical yield. conclusion: when compared with alternative methods, the present approach, which reduced the reaction sequence until steps was faster and the method required less expensive reagents and purification was easier. aim: transarterial chemoembolisation (tace) is a promising approach in the therapy of malignant, hypervascularized liver tumors. developing and optimizing radioiodination reactions and adding the labelled product to an original drug-deliveryembolisation-system was the main goal of this present investigation. this may help to determine an individual, pharmakokinetical parameter and possibly will increase therapeutical effects in prospective animal and human studies. material and methods: in a first step iodogen ® as radioiodination agent was used for labelling anthracycline analogs (doxo-, epi-. dauno-, iododoxorubicin). the labelled products were characterized and separated by hplc (radio-and diodenarray-detektor) and tlc. in a next step another direct electrophilic radiolabelling [iodine monochloride (icl) methode] with c.a. i- -nai and i- -nai ( °, min) has been performed. the subsequent hplc-isolating was changed by spe (sep-pak c -cartrigde). after removing the solvent the product was solubilised in . % saline solution. results: the radiochemical yield (rcy) with iodogen-method was ± %. in comparison to that the iodine monochloride method achieved higher rcy's for doxo-( ± %), epi-( ± %), dauno-( ± %) and iododoxorubicin ( ± %). in vitro stability of all products was controlled after h. specific activity lay around mbq/μmol. conclusions: the direct iodination method with icl was proved to be a viable labelling possibility of anthracycline analogs. specific activities are very low, but these results are sufficiently working in case of use in combination with unlabelled therapeuticals in a chemoembolisation system. higher rcy's of iododoxorubicin can be explained by isotopic exchange. after validation of radiolabelling conditions and results the chemoemolisation system with radiolabelled anthracycline and the sterilisation of the used materials needs further investigation. this could lead to a proved method for nuclear medical imaging of a radio-chemoembolisat for locoregional application. the development of new pet radiopharmaceuticals demands strategies for the identification of dedicated targets. following the identification of a target, the "in silico" search for substrates is a promising approach to achieve specific drugs. methods: the search for targets for new radiopharmaceuticals demands the use of large scale gene expression data, usually obtained by gene array techniques. we used gene array data, obtained from tissue specimen ( human tumors, reference tissue samples) to search for differencially enhanced genes, in order to identify possible targets for new radiopharmaceuticals. furthermore, ten samples from a human colorectal cell culture line were evaluated. gene expression data were obtained using the u a and u plus . gene chip (affymetrix inc., santa clara, ca, usa). gene expression values were converted to relative expression values (rev): rev = * (gene expression value -minimum expression value) / (reference gene expression -minimum expression value). the genepet module of the pmod software (pmod technologies ltd., adliswil, switzerland) was used for data evaluation. the fast rigid exhaustive docking (fred) software (openeye scientific software, santa fe, nm, usa) was used to assess receptor/ligand properties. results: the gene expression data comprised (u a) or (u plus . ) probe values for each tissue sample. following normalization, matrices were calculated for the ratios tumor/reference tissue as well as for the mann-whitney test variable of each gene. search strings were applied to select those genes related to receptors and cell membrane proteins. furthermore, discriminant analysis based on the support vector machines method (svm) was used to select those genes from the subgroup which provide the best discrimination between tumor and normal tissue. the final svm analysis provided genes related to cell receptors, mainly belonging to the group of g protein-coupled receptors. following the identification of targets, the fred software was used to assess possible substrates for these receptors. conclusions: molecular biological data, obtained by gene array analysis, provide a promising approach for the development of new pet radiopharmaceuticals. the combination with computational drug software helps to select a subgroup of substrates for receptors and membrane structures, which are then further evaluated using conventional lab procedures. aim several radiolabelled amino acids have proven to be useful as a radiopharmaceutical substance for pet imaging of tumors. o-( -[ f]fluoroethyl)-ltyrosine (fet) seems to be one of these promising compounds. this f-labelled amino acid can be synthesized with high radiochemical yield. large production and distribution is allowed by using f. fet provides excellent quality for pet imaging of solid gliomas in brain. from these points of view fet is the right choice for our interest. the synthesis of fet is known, however, modification of the method for our facilities was necessary. the aim of this study was to adapt synthesis method in order to start production of fet as a commercial pet imaging tracer. materials and methods the synthesis was performed with tracerlab mx system (coincidence), which is originally designated for production of [ f]fdg. therefore, some modifications in method had to be done. synthesis is based on phase transfer mediated nucleophilic f-fluorination of o-( -tosyloxyethyl)-n-trityl-l-tyrosine tert.butylester with subsequent hydrolysis by mixture trifluoroacetic acid / , -dichloroethane. subsequently, purification of reaction mixture was completed by reversed phased hplc. quality control was done with hplc for radiochemical and enantiomeric purity. results because the production automat did not resist the mixture trifluoroacetic acid / , -dichloroethane, we changed the deprotection step and applied m hcl. the fluorination yield ranged from to % and overall yield was - % (uncorrected for decay). radiochemical purity was over % and enantiomeric purity was %. conclusion we successfully developed and tested the synthesis of [ f]fet in our production conditions. nowadays we are providing biodistribution and preclinical studies with animals. finally, we are intended to distribute fet to medical facilities. acknowledgement this work is supported by the project no aim: evaluation of a ge/ ga generator to produce carrier free ga radionuclide and optimization of a synthesis method to obtain ga-dotatoc for clinical purpose. materials and methods: imaging of sstr expressing tumours, such as neuroendocrine, lymphomas, meningiomas and breast cancers, has been greatly improved by utilization of ga-dotatoc radiopharmaceutical and positron emission tomography. in this study ga-dotatoc was synthesized from a mci ge/ ga generator (cyclotronco., obninsk, russia) carrying out the following steps: i) ga in cationic form ga + was eluted from the generator by a . m hcl solution and trapped in a cation exchange cartridge. ii) metallic and radionuclidic impurities, such as fe (iii) and zn (ii) were washed to waste by rinsing the cartridge with a % acetone / . m hcl solution. iii) ga + was eluted to the reactor with a % acetone / . m hcl solution and reacted with nmol of dotatoc in a no buffered water solution. ge (iv) breakthrough and ti (iv) impurities remained in the cartridge and were subsequently eluted to waste by m hcl and water iv) after labelling, in order to eliminate not reacted ga + , the crude solution was passed in a apolar c cartridge where ga-dotatoc was trapped. v) final product was eluted by ethanol and diluted with an appropriate amount of saline solution for the final formulation. during the validation of the method a complete set of quality controls including radiochemical purity by radio-tlc and radionuclidic purity by -spectrometry was performed; sterility of the preparations was also assessed. results: about syntheses were carried out during six months of activity and an amount ranging between to mbq (depending on the ge/ ga generator life) of ga-dotatoc was obtained. mean synthesis yield was computed to be ± % (not corrected for decay) in a synthesis time of about minutes. radiochemical purity was about % and highest radiochemical impurity resulted in free ga + not reacted ( ga-dotatoc: r f = . free ga + rf = . ). radionuclidic purity was observed to be greater than . % and final solution resulted sterile. conclusion: after elution in cationic form and the purification steps described, ge/ ga generator can be considered a safe source of pure ga for high yielding labelling of peptide or other molecules. ga-dotatoc produced with this method can be efficiently utilized in nuclear medicine department for clinical evaluations. synthesis and biological evaluation of c-labeled acyclic-and furo[ , -d]pyrimidine derivative of bicyclic nucleoside analogs (bcnas) for structure-brain uptake relationship study of bcna tracers s. k. chitneni, j. balzarini, a. verbruggen, g. bormans; katholieke universiteit, leuven, belgium. we recently synthesized and evaluated several bcnas labeled with c- , f- or i- as potential pet or spect tracers for non-invasive imaging of varicella-zoster virus thymidine kinase (vzv-tk) gene. these studies resulted in a new reporter gene/probe system but none of these tracers were taken up in the brain in biodistribution studies despite fulfilling the theoretical requirements for passive diffusion of such molecules through bbb. we have now synthesized and evaluated a c-labeled bcna ([ c]-( )) with a hydroxyethoxymethyl side chain instead of a deoxy ribose sugar for bcnas, and a bcna without sugar moiety ([ c]-( )). methods: the precursor compounds ( ) and ( ) were synthesized by sonogashira coupling of -iodo- -[( -hydroxyethoxy)methyl]uracil and -iodouracil, respectively, with -hydroxyphenyl acetylene, followed by cyclization in situ. they were converted to non-radioactive ( ) and ( ) by methylation of the phenol for ( ) and at the n- of the pyrimidine ring for ( ) using ch i in the presence of k co in dmf. the radiolabeling was achieved using [ c]methyl triflate. the methylation products were purified using c- semi-prep hplc. the affinity (ic ) of the non-radioactive compounds for vzv-tk was determined in vitro in competition with [[ h]-ch ]dthd. the logp of [ c]-( ) and [ c]-( ) was determined and their biodistribution was evaluated in normal mice at and min pi. results: synthesis yields were % for ( ), % for ( ), % for ( ) and % for ( ). the rcy for [ c]-( ) and [ c]-( ) was % and %, respectively, and the rcp was > % for both tracers. the identity of the tracers was confirmed by co-injection with the authentic ( ) or ( ). logp . value of both tracers was . . ic values of ( ), ( ), ( ) and ( ) for vzv-tk were , , and μm, respectively. similar to the previously synthesized bcna tracers, negligible brain uptake was seen at min and min pi for both [ c]-( ) and [ c]-( ), which were cleared mainly by the hepatobiliary system and to a lesser extent to the urine at min pi. blood clearance was rapid for both tracers (< . % id in blood at min pi). conclusions: lack of uptake in brain for [ c]-( ) and [ c]-( ) confirms that bcna tracers do not cross bbb despite their lipophilic character. in general, this observation can be extended to other uridine-or uracil-based nucleoside analogues also. this study was funded by the ec- aim: fluoromisonidazole [ f]fmiso, has been used with pet in humans for the identification of hypoxic tissue in stroke. however, [ f]fmiso suffers from low cellular uptake into hypoxic tissue and slow clearance from normal cells, requiring long periods between iv-injection and imaging. in we have reported the radiolabelling of another class of compounds (sulfoxide containing nitrogen mustards) that have great affinity for hypoxic tissue. in this study, we have performed in vivo analysis to evaluate these compounds ([ f]so and [ f]so ) as potential imaging agents. method and materials: to determine the uptake of the tracers in the ischemic penumbra, mcao stroke-induced rats were injected with the desired tracer immediately after stroke. uptake times of . , and h post injection were assessed and autoradiography performed. a delayed injection study (injection hrs post stroke, sacrificed hrs post injection) was also performed to determine if the tracer is binding to the infarct tissue. autoradiography and histology was used to correlate infarct regions with uptake of the tracer. a pet/ct scan of so was also investigated. all data was compared to the current gold standard [ f]fmiso. results: at h post injection, the density ratios and the hemispheric area of uptake of the three tracers ([ ( , ) carried out by distillation of the intermediate f-fluorobromomethane (fbrme) and subsequent alkylation of dimethylaminoethanol (dmae) or by gas phase conversation of fbrme to f-fluoromethyltriflate followed by dmae alkylation. the aim of this study was the investigation of a one pot synthesis without distillation on an automatic synthesis module for production of high radioactivity amounts of fmc. materials and methods: trapping the target water on an anion exchanger, elution with kryptofix® . . /potassium carbonate and azeotropic drying was performed according to a standard procedure. the nucleophilic substitution with dibromomethane as precursor was optimized with respect to time and temperature. the second reaction step was carried out by addition of dmae in acetone to the intermediate fbrme and also optimized with respect to time and temperature. subsequently the solvents were evaporated and a sodium hydroxide solution was added to the residue and heated for additional min. by transferring the product solution over a cation exchange the fmc was trapped on the cartridge. after washing with ethanol and water, fmc was eluted with saline. the qc was performed by hplc and tlc. results: the strategy for the synthesis of fmc (according to ( ) ) was transferred to an automatic, remote controlled synthesis unit. the optimization of the nucleophilic substitution results in a radiochemical yield of - % in min at °c. the alkylation reaction in the same reaction vessel proceeded with radiochemical yields of - % in min at °c. this result in an overall radiochemical yield of ± %, which only slightly differs from the non automatic synthesis ( - % ( )). destroying the byproduct bromomethylcholine by basic hydrolysis was nearly quantitatively. total synthesis time was approximately min. the radiochemical purity was > %. conclusions: the two step one pot synthesis of fmc was successfully adapted to an automatic, remote controlled synthesis unit. this process allows the efficient and reliable production of fmc with high radioactivity amounts in less than one hour. references: ( ) introduction: there is an increasing need for pet radiotracers to be produced at high specific radioactivity (sa) to delineate low population binding sites in man or for imaging studies on small animals. these studies often require radioligands with very high binding affinities, which also imposes the need for producing the radioligand at high sa. an example of these tracers is the high affinity dopamine d / radioligand [ f]fallypride which we are using for human and micropet studies. to perform these studies successfully and in particular to enable us to perform two pet studies consecutively from one radiochemical preparation we have investigated means to improve the sa of the final product. method and results: based on analysis of the various components of the radioligand synthesis, including the precursor's chemical purity, the key determinate of the sa of [ f]fallypride was identified to be the cyclotron-generated [ f]fluoride, prepared by the o(p,n) f method. using our standard [ f]fluoride production protocol based on μa for min which produced - gbq, we obtained - gbq of [ f]fallypride at end-of-synthesis (eos). the sa was determined, using a calibrated radio-hplc-uv system, to average gbq/μmol (range - gbq/μmol, n= ). we then modified our [ f]-fluoride production method to perform an irradiation consisting of μa for min in which the target product was then emptied unused. this was followed by a second [ f]fluoride production ( μa for min) to be used for the radiosynthesis process. the amount of [ f]fluoride ( - gbq) and the radiochemical product of [ f]fallypride ( - gbq) did no change significantly. however the sa of [ f]fallypride at eos was found to increase significantly to average gbq/μmol ( - gbq/μmol, n = ). with these sa we are able to perform two consecutive human studies within hrs from eos while keeping to our imaging protocol criteria of mbq dose and a maximum limit of nmol of co-injected mass of fallypride. conclusion: using a two stage irradiation protocol we have been able to double the sa of our [ f]fallypride product. as well as being at the required level for performing micropet studies these sa allows us to perform multiply pet studies from one preparation enabling more efficient use of our regular productions of this tracer. using this protocol has also enabled us to reduce the required activity of [ f]fallypride to be produced while still obtaining the required sa's for our studies, therefore reducing radiation dose to the production staff. u. choudhry , r. paul , p. blower , s. biagini ; university of kent, canterbury, united kingdom, king's college london, london, united kingdom. background: current methods for f labelling of peptides for pet imaging are timeconsuming and complex. more efficient (preferably single step) methods, analogous to m tc kits, are required because of the short half-life ( min). we have previously shown that the reaction of fluoride with alkoxytrialkylsilanes is fast and that the product is stable to hydrolysis up to ph . when bulky alkyl groups are used. we therefore selected the tert-butyldiphenylalkoxysilane group for evaluation with nocarrier-added f. aims: to demonstrate radiolabelling of a tertbutyldiphenylalkoxysilane with f and establish appropriate conditions. material & methods: f in k. . . /ch cn/k co was prepared by a conventional procedure: ml of aqueous f- ( mbq) was passed through the qma cartridge (conditioned with ml of m sodium bicarbonate and ml water) and eluted in ml k. . . /ch cn/k co solution. no azeotropic drying was performed. to this solution was added . ml tert-butyldiphenylmethoxysilane ( mg/ml in ch cn) and μl trifluoroacetic acid (tfa). rp-hplc (water/acetonitrile/ . % tfa) and tlc (silica/hexane) were performed after min incubation at room temperature. results: both hplc and tlc showed the presence of a single radioactive, hydrophobic species corresponding to a bona fide cold sample of the tert-butyldiphenylfluorosilane (rt min, rf . ) and no significant residual free f (rf ). conclusion: the alkoxytrialkylsilane prosthetic group reacts very efficiently at room temperature with f in the presence of kryptofix without the need for drying by azeoptropic distillation, offering the basis of a very convenient route to radiolabelling biomolecules for f pet. objectives: intra-arterial administration of particles containing beta-emitting radionuclides appears to be a useful alternative of liver tumour therapy. particles of a well-defined size are trapped in the vascular bed of the tumour and remain there while delivering a high dose of radiation in order to destroy both primary and metastatic liver tumours. methods: ho-pla-ms were prepared using the solvent evaporation technique. ho-acetylacetone complex and polylactic acid (pla) was dissolved in chloroform and consequently added to % polyvinyl alcohol. this mixture was stirred s for at least hours until chloroform was evaporated. the precipitated microspheres were centrifuged, washed with distilled water and . m hcl and finally collected on a cellulose nitrate filter. microspheres were placed in the screwed titanium ampoules and irradiated in the channel providing lower neutron flux in order to avoid radiation degradation of prepared microspheres. results: generally, mg of microspheres were irradiated at the neutron flux cm - s - and the radioactivity reached after minutes neutron irradiation ranged from - mbq. the particle size distribution highly depended on the speed of the stirrer and on pla molecular weight. microspheres of the ideal size - mm and the mean diameter of mm were obtained after stirring at rpm and microsieving using mm and mm pore size sieves. holmium as a paramagnetic lanthanide was visualized using mri. study was performed using the polyacrilic glass phantom. non-radioactive microspheres containing holmium in % agar was used. the amount of microspheres used for visualisation ranged from to mg and and this amount corresponds with the amount intended for the future aplication. discussion: microspheres of the size of - mm is considered to be an ideal size for immobilisation inside the tumour tissue. granulometric analysis proved minimally % prepared particles conform to this dimension. mri study on holmium loaded microspheres provided image of sufficient signal strength within the all studied concentration range and seems to be promissing for possible imaging of microspheres after decreasing radioactivity owing to decay. . interest of ytracis ® radiochromatographic control prior to zevalin ® radiolabelling. aim: the zevalin ® (ibritumomab tiuxétan) radiolabelling with ytracis ® ( yttrium) fails in about per cent of cases despite following a rigorous and well tried procedure. the origin of the failures remains unclear in most cases. after experiencing a labelling failure in our department we performed a chromatic control of the ytracis ® marker solution. materials & methods: one patient who presented a recurrence from a refractory follicular lymphoma was referred to our department for a y-zevalin therapy. the radiochromatographic purity (rcp) of the labelled zevalin ® was controlled by thin layer chromatography (tlc) using strips of itlc-sg paper and . % nacl solvent. in the present case the strip scanning performed with a radiochromatograph showed a rcp value of . ± . % (m ± sd) (normal > %), and an impurity peak with a migration front (rf) of . ± . . for this reason, the treatment was cancelled. the analysis of the critical procedure steps (registration, storage, labelling, rcp control) and the manufacturer inquiry did not permit to identify the non conformity source. therefore the present ytracis ® lot has been controlled by tlc as well as successfully used lots with the same procedure as performed for the zevalin ® rcp test. results: the tlc strip readings of the control ytracis ® lots gave a single migration peak (rf: . ± . ). the tlc strip readings of the tested ytracis ® lot showed a first migration peak (rf: . ) corresponding to . ± . % of the deposited activity. a second migration peak with a rf: . ± . not present on the control lots was detected corresponding to . ± . % of the deposited activity. the impurity nature could not be identified due to the lack of product. conclusion: considering the possible failures of zevalin ® radiolabelling with ytracis ® we suggest to include a simplified and systematic rcp control of the ytracis ® solution during the source registration procedure. the rcp control is a main step before the zevalin ® labelling and the patient convocation. at present, no useful data is available concerning the efficiency and the safety of sm-edtmp (quadramet®) therapy in patients with renal function impairment, especially in chronic renal failure treated with dialysis. we report the case of a years-old woman who suffered from painful bone metastases. her medical history consisted of untreated asthma, hypertension, left breast adenocarcinoma and chronic renal failure for which she benefited from haemodialysis times a week. the patient was referred by the geriatric department to perform bone scintigraphy for the initial evaluation of skeletal metastases because of her hypercalcemia and bone symptoms. the bone scan revealed multiple secondary lesions. pain evaluation by visual analogic scale (vas) was expressed as and the recorded motor score was / . these findings were diagnosed as extensive metastases of her breast cancer. this patient was given the opportunity to benefit from internal radiotherapy with quadramet®. considering her renal failure and urinary excretion of sm-edtmp after intravenous administration, nuclear physician decided that careful and cost-effective treatment could only be achieved by performing % of the conventional activity, i.e. . mbq/kg ( . mci/kg) instead of mbq/kg ( mci/kg), hours before haemodialysis. her haematological status recorded hours before, made feasible the radionuclide therapy. the administration was performed in the nuclear medicine department without any problem. the clinical follow up included adequate monitoring of bone pain response, haematological status and supportive medication. treatment efficacy was assessed according to vas, motor score, analgesics consumption and performance status. painful osteoblastic lesions were significantly alleviated after internal irradiation (vas, ; motor score, / ). onset of pain improvement took place weeks after internal radiotherapy. there was an obvious decrease in opioid analgesics use in the active phase of the treatment.. no relevant haematological toxicity occurred. however, a temporally recoverable mild anaemia was observed. this finding was likely related to arterio-venous fistula inflammation. conclusion: in this case, management of painful bone metastases with sm- edtmp in a dialysis patient was successfully performed. our observation demonstrates that such therapy is feasible in patients under chronic haemodialysis. radionuclide production for biomedical applications has been studied in recent years at infn-lasa laboratory, in co-operation with the cyclotron laboratory of the joint research centre (jrc ispra, italy), taking advantage of extensive experience in the experimental nuclear physics and nuclear chemistry fields. several research aspects concerning radiation detection and the relevant instruments, the measurements of excitation functions of the involved nuclear reactions and the required radiochemistry methods have been investigated. the latest studies on high specific activity, accelerator-produced radionuclides in no-carrier-added (nca) form, for use in therapeutic applications and in related spet/pet diagnoses investigated, are: . nca cu, produced by nat zn(d, xn), nat zn(d, pxn) and zn(d, p) reactions for simultaneous + /metabolic radiotherapy, with intrinsic pet imaging, including the short-lived radionuclide cu; . g re, produced by w(p,n) and w(d, n) reactions, for bone metastases pain palliation by beta ( . mev) metabolic radiotherapy, including spect imaging; . nca at/ g po, produced by the bi( , n) reaction, with internal spike of the emitter at from the bi( , n) reaction (leading to very small amount of po as radiotoxic long-lived impurity), for high-let metabolic radio-and immuno-radiotherapy; targets are irradiated at the scanditronix mc- cyclotron (k= ) of the jrc with proton or alpha beams up to mev, he + particle beam up to mev or deuteron beams up to . mev. activity measurements are performed either at jrc ispra or at lasa laboratory: , x spectra are measured with hpge detectors, spectra with pips detectors with a resolution of kev (fwhm), and spectra with a conventional liquid scintillation counting lsc and spectrometry system with horrocks number capability for quenching correction, and a higher-resolution liquid scintillation portable spectrometer with / pulse shape analysis (psa) discriminator. in order to produce nca radionuclides suitable radiochemical separation processes for the radionuclides of interest, together with quality control checks must be developed. the radiochemical separations adopted are presented for each radionuclide produced. in order to evaluate production feasibility or to confirm the cross sections experimentally obtained, calculations for the involved nuclear reactions are carried out with the empire-ii code, taking into accounting the major nuclear reaction channels. objectives: due to the more favourable physical characteristics of re, re-lipiodol is an interesting alternative for i-lipiodol in the treatment of hepatocellular carcinoma (hcc). a water-in-oil emulsion (w/o) was prepared as carrier system using lipiodol as oil phase, containing m tco -/ reo in the inner aqueous phase. the aim of present study was to optimize the formulation of the w/o emulsion based on a plackett-burman -run statistical design. methods: types of emulsions were prepared according to the orthogonal plackett-burman design. to optimize the formulation, the influence of causal factors such as rpm, rotation time, aqueous phase, oily phase, volume ratio, type and concentration of emulsifier was evaluated. for each run the cumulative percentage of administered activity released from each formulation (cpa), was calculated in vitro. the latter quantity will be an important indicator for the whole body irradiation of the patient. in vitro release rate characteristics were measured using a dialysis system. results: plackett-burman analysis showed a significant influence (p< , ) on cpa for volume ratio (p = , ), rotation time (p = , ), emulsifier concentration (p = , ) and oil phase (p = , ) with volume ratio as most important factor. no significant influence was found for the aqueous phase (p = , ), type of emulsifier (p = , ) and rotation rate(p = , ). conclusion: stable lipiodolized w/o emulsions could be prepared according to the plackett-burman experimental design. based on our statistical screening design, volume ratio, rotation time, emulsifier concentration and oil phase could be identified as factors affecting the release characteristics of the formulation significantly (p< , ). in further optimization steps, these factors should be taken into account. such conjugates were achieved when the ratios of rhil :hynic reactions were set from : to : (ca. % efficiency of the substitution), and the purification step was performed on pd- column. the next most essential parameter of radiolabelling reaction was the ph of the reaction medium, which should be kept in the range of - . . gf-hplc analysis indicated that two radioactive species of m tc-hynic-il (monomer and dimmer) are formed during radiolabelling, although dimmer could be selectively removed by purification on tc column. the optimized conditions of the wet-radiolabelling ( μg of rhil :hynic, - mg of tricine, - μg of sncl , ph - . , min in rt) enabled to achieve m tc-hynic-il monomer (radiochemical purity > %, specific activity ca. mbq/μg il- ) with overall yield of ca. %. the two vial freeze-dried kit was prepared: first vial with μg hynic-il , second vial with mg tricine and μg sncl . unfortunately, radiochemical purities of the m tc-hynic-il preparations obtained using the dry kit were unsatisfied and did not allow giving the purification step up. conclusions: our study showed that rhil- can be efficiently radiolabelled with tc- m via bifunctional chelator -hynic, and tricine as coligand. however, investigation are still ongoing to receive one-step preparation of ready to use m tc-hynic-il radiopharmaceutical. aim: the purpose of this study was to compare biodistribution profiles and elimination pathways of dota-tyr( )-octreotate (dota-tate) and dota-l-nal( )-octreotide (dota-noc) labelled with in- in rats. whereas clinically used radiolabelled dota-tate shows high affinity to somatostatin receptor subtype sstr and low or absent affinity towards the other somatostatin receptor subtypes, dota-noc exhibits high affinity to somatostatin receptor subtypes sstr , and . materials and methods: for the cell experiments, rat pancreatic carcinoma ar j cells expressing sstr receptors were employed. for biological experiments, male wistar rats ( - g) were used. the peptides were administered to rats intravenously in the dose of . μg per animal. the kinetics of the peptide uptake in the kidney was also studied on the proximal tubule-derived opossum kidney (ok) cell line. results: in-dota-tate and in-dota-noc showed high and comparable rates of internalization into ar j rat pancreatic carcinoma cells in agreement with their similar affinity to somatostatin receptor subtype sstr . both peptides under study exhibited similar distribution profiles in rats. radioactivity was rapidly eliminated from the blood and most organs and tissues. high radioactivity uptake in somatostatin receptor-rich organs and in the main elimination organ (the kidney) was determined. due to higher lipophilicity of in-dota-noc its plasma protein binding was higher, the blood radioactivity decrease was slightly slower and liver accumulation was significantly higher in comparison with in-dota-tate. the physiological internalization of radioactivity into somatostatin receptor-rich organs (the pancreas and adrenals) was for in-dota-noc about twice of that for in-dota-tate. no significant differences in the renal radioactivity uptake were found. these results were confirmed also in the study of the peptide uptake by the ok cells. elimination pathways were comparable for both peptides under study. conclusion: radiolabelled dota-noc represents promising somatostatin receptor-specific peptide for diagnosis and radiotherapy of some neuroendocrine tumours due to its very high uptake in tissues with high density of somatostatin receptors. the study was supported by the grant agency of the czech republic -grant no. / / . whereas the peptides labelled with radiometals were eliminated into urine mostly in the parent form and only traces of metabolites were detected, a significant portion of metabolites of iodinated compounds (especially in the longer time intervals after dosing) in rat urine were found. in time intervals up to hour after dosing, the distribution profiles of all peptides under study were similar. high radioactivity uptake in organs with high density of somatostatin receptors (the pancreas and adrenals) and also in the kidney was determined. whereas high radioactivity accumulation in the above-mentioned organs continued for a long time for the peptides labelled with radiometals, this uptake significantly decreased with time for iodinated derivatives. the physiological internalization of radioactivity in somatostatin receptor-rich organs is mediated by their somatostatin receptors. renal uptake and retention of the peptides involves glomerular filtration and subsequent partial reabsorption in the proximal tubular cells by endocytosis. the peptides could be consequently transferred to lysosomes and digested by proteolytic enzymes. resulting breakdown products remained in the lysosomes for a long post-injection period for the agents labelled with radiometals. on the other hand radioiodinated break-down products could cross biological membranes from the sites of metabolism to the central distribution compartment and finally be eliminated by urine. conclusion: the reason of different metabolites proportion of the peptides under study in rat urine was in different rates of externalization of brake-down products from the sites of biotransformation. k. durkan, f. yurt lambrecht, p. Ünak; institute of nuclear science, izmir, turkey. aim: bombesin-like peptides are neurotransmitters and cancer growth factors. bombesin-like peptides express several human cancer, including small cell lung, prostate, breast, colon and pancreatic cancer receptors. litorin is a peptide derivative as amphibian bombesin. in this study, a new m tc labeled bn-like peptide (litorin) was prepared and biodistribution studies in normal rats were investigated. materials & methods: litorin was labeled with tc- m by using μg stannous chloride at ph . . after the labeling procedure, the radiochemical analysis of radiolabeled peptide was determined by radio thin layer chromatography (rtlc) and radio high performance chromatography (rhplc). in vivo biodistribution studies were performed in normal male albino wistar rats with blocked and non-blocked receptors. the stability was investigated in human serum. results: labeling yield was . ± . %. serum stability results showed that in vitro stability of the radiolabeled peptide was quite high. the radiolabeling efficiency was . ± . at h during incubation. significant uptake in bombesin/gastrin releasing peptide (bn/grp) receptor rich tissues such as the pancreas ( . ± . %id/g, min post injection) was observed. the uptake in the pancreas could be blocked by cold litorin ( . ± . %id/g at min). m tc-litorin exhibited very hydrophilic and eliminated via renal filtration and urinary excretion. conclusion: m tc-litorin showed high uptake in the gastrin-releasing peptide receptor-rich pancreas and might be useful radiopharmaceutical in the detection of bombesine receptor-expressing cancers in vivo. introduction: in the process of sm production, the eu (t / , years, kev, kev, kev) is generated like main radionucleidic impurity. however, the low proportion of this radionucleid in the final product, inferior to . %, assures its harmless. objective: to quantify the amount of eu present in the waste generated by sm-edtmp use and to evaluate its incidence in the waste management. material and methods: the remaining liquids of quadramet ® vials of different lots and patients' urine collected during h p.i were analysed. the emission espectrum's analysis of each sample and the estimation of the eu specific activity were performed with a nai(tl) detector. results: the average eu ratio in vials versus the sm nominal activity was . %, which agreed with manufacturer indication. the mean eu ratio in vials and in urine were of · bq/l y · bq/l respectively. in both cases exceeded the valid limit for drinking water ( bq/l). eu / sm-edtmp ratio in urine, was approximately of . %. conclusions: the waste management program of sm must consider current eu ratio, establishing the suitable dilutions, in agreement with the characteristics of each center, as the final concentration must not exceed the valid limit for drinking water. biodistribution of the chemical species containing eu and sm seems to be differents. the potential of the - kda fraction of the water-soluble polymer polyethyleneimine, functionalised with methylene phosphonate groups (pei-mp) and labelled with mtc ( hr half-life and kev gamma), msn ( . d half-life, conversion electrons) and re ( . d half-life, . mev beta-) has been described elsewhere. distinct differences in the biodistribution in animal models were found for the different radionuclides. mtc-pei-mp had high bladder and kidney uptake. msn-pei-mp had moderate reticuloendothelial uptake, reasonable bone-uptake and considerable uptake in the bladder wall. re-pei-mp showed rapid clearance of all organs as well as considerable and early excretion in the urine and little bone uptake. it is postulated that the size of the polymer complex changes with the different metal ions which is the reason for this difference in biodistribution. methods: nonradioactive sn(ii)-pei-mp and re-pei-mp were prepared according to the labelling procedures. parallel radiolabelled equivalents were used to prove the labelling was successful. as mtc is no-carrier-included, the mass of this metal ion is negligible and will not influence the result. therefore the kit formulation (a mixture of pei-mp, sn(ii), sn(iv) and buffer) was used to simulate mtc-pei-mp. all solutions were kept under ar and were analysed for size by conventional gpc using an agilent isocratic pump. results: the average gpc size results showed that the size of the polymer fraction is . kda, and . kda for the tc- m kit formulation ( mtc-pei-mp), . kda for sn(ii)-pei-mp and . kda for re-pei-mp. conclusions: it seems that the polymer contracts upon complexation with sn(iv) due to ml complexes but expands with sn(ii) which prefers m l complexes. as low specific activity re was used in earlier experiments, it was expected that the size of re-pei-mp would be considerably higher. y is a widely used radionuclide in therapeutical nuclear medicine applications. to be safely administered to patients, y solution must fulfill specific quality requirements; it must be at correct ph, endotoxin free, metal free, and it should have only minute amounts of long-lived parent nuclide sr. the aim of this work is to develop a fast, efficient and reliable method to determine sr content in y solution. the separation of y and sr is performed by using highly selective extractive chromatographic sr resin. y sample is loaded to the column in diluted nitric acid. yttrium under this condition does not retain on the column so it is first washed out and collected. yttrium fraction is measured with a dose calibrator. strontium is eluted from the column with water. the strontium fraction is evaporated to near dryness and dissolved in scintillation cocktail. finally the sample is measured with liquid scintillation counting (lsc). the problem in using lsc in sr determination lies with the ingrowth of y in the sample. high energetic y spectrum (max. kev) overlaps sr spectrum (max. kev), hence obtaining a 'pure' sr spectrum is impossible. an indirect mathematical model that utilizes counts of the beta spectra originating from each nuclide is a convenient method for subtracting y from the sr y spectrum. a pure y spectrum is measured and a window in the high energy area of the spectrum is selected. the window area is normalized with the yttrium- counts in the sr y spectrum. the two spectra are subtracted from each other resulting in a pure sr spectrum. the developed method allows a rapid sr content determination with sr/ y ratio as low as - . the time needed for the entire quality control procedure is in the range of one hour. same mathematical method can be used to determine tungsten- content in rhenium- solution from w/ re -generator. ( ). only the patients with normal globular volume (vg) and vp (vg exp< % vg theoretical; vp exp< % vp theoretical) have been studied. calculation formulas were: vg(hts/( -hts)) for vp calc, , * age + x body surface (bs) for female vg th, * bs - for male vg th, * bs for female vp th, * bs for male vp th. data were analyzed for means. a student test and regression analysis were performed using the excel program of microsoft, inc. results: the student test has shown that it existed a significant difference between vp exp and vp calc for males (p< . ) and females (p< . ). however, the regression analysis has shown a correlation of vp exp versus vp calc for males (r= . for minutes blood sample) and females (r= . for minutes blood sample). when the equations of correlation lines have been used to find vp exp from vp calc on a patient's sample, a significant difference was remained between the two vp. discussion and conclusion: according to these results, the use of i-has seems to be indispensable to obtain a good estimation of vp. as it has been shown by morin, et al. in (ouest-médical, è année n° , mai ), the use of hts to calculate the vp calc. explains this result. hts is obtained from the formula: venous ht * x where x estimation is . . in reality, x depends on the person. so to limit the viral risk linking to the use of i-has, only red cell mass measurement by cr will be done in research of myeloproliferative syndrome (vaquez disease, ) and cr and i-has will be used in other cases. to optimize the choice of the technique (single or double isotopes), we are developing a prescription medium in order to obtain all necessary informations to choose the best technique. aim activity measurement of i radiopharmaceuticals, may be affected by several factors such as recipient shape and its nature (kind of glass, plastic, etc); as well as, the own attenuation produced by liquid volume in which radiopharmaceutical is dissolved. the aim of this study is the assessment of variation between measured activity and reference activity, using two different dose calibrators. as well as, the calculation of corresponding correction factors necessary to obtain the most exactly dose with each dose calibrator. material and methods we have used two dose calibrator for activity measurement: capintec crc ® - r (dc ) and capintec crc ® - (dc ). activity measurement of i was performed using the corresponding channel of each dose calibrator. measurements of i activity were performed to the radiopharmaceuticals into manufacturer vial, and others after withdraw the whole radiopharmaceutical activity into a ml syringe. those measurements were performed in both dose calibrators. the measured activity in each case was compared with reference activity. also, we have calculated the medium variation percentage (mvp) of measurements performed versus reference activity, as well as, the medium correction factor (mcf) for each measurement. results the mvp of measurements performed versus reference activity in case of dc was . ± . in syringe and in manufacturer vial - . ± . . in case of dc mvp in syringe was . ± . and in manufacturer vial - . ± . . mcf were calculated in each case. for dc : syringe, . ± . ; manufacturer vial, . ± . ; and for dc : syringe, . ± . and manufacturer vial, - . ± . . conclusions our results showed than measured activity for i using manufacturer vial was significantly lower than reference activity, in both dose calibrators; while, on the contrary, when the radiopharmaceuticals was measured in syringe, the activity resulted higher than reference activity, and moreover, higher in case of dc . in consequence, to get the most exact activity measurement of i radiopharmaceuticals, it is necessary the calculation and use of the correction factor corresponding to the dose calibrate used to the measurement, both for manufacturer vial activity and syringe activity. introduction: dextrans are glucose polymers, whose versatility has led to their application in numerous fields. m tc-labelled dextrans have been proposed as possible substitutes for human albumin and labelled red blood cells in angiography and cardiac pool studies. objective: to assess the pharmacokinetics of a m tc-labelled dextran- preparation in rats. material and methods: eight wistar male rats with an average weight of g were administered with mbq of m tc-dextran- in a volume of μl via cannula in jugular vein. blood samples of ml were taken at , , , , and min post-injection and kept in a flask with anti-coagulant; . ml of each sample was centrifuged to obtain plasma. aliquots of . ml of total blood and plasma were measured in a well counter for minutes. the activity of each sample was determined as a function of time and the following pharmacokinetic parameters were determined: plasma concentration, apparent distribution volume and plasma clearance of the radiopharmaceutical. results: tc-labelled dextran- shows the characteristic kinetics of a vascular tracer. in every case le was tested: in vivo/in vitro method: . - . ml m tc-rbc aliquots were added to ml of nacl . % solution into sterile vacuum blood collection tubes. the tubes were centrifugated at xg for minutes and supernatant (cell-free plasma) was transferred into plastic test tubes. le was calculated by measurement, both cell-free plasma and rbcs packed, activities using a dose calibrator (capintec crc ® - r). in vivo method: ml whole-blood was withdrawn from a peripheral vein using a ml heparinnized syringe. it was centrifuged at xg for min and supernatant was transferred into plastic test tubes. le was calculated by measurement, both cell-free plasma and rbcs packed, activities using a well counter. le was expressed as percentage and the mean value and the standard deviation were calculated for each method. the gammacamera used was a double headed variable tangential philips axis. results average le of m tc-rcbs by in vivo/in vitro method was . ± . % (low le . % and high le= %), on the other hand, the m tc-rcbs by in vivo method yielded an average le of . ± . %, in a range of . to . percent. in each case, gammagraphics images were tested by two different independent testers, neither of them detected any undesirable uptake because of low quality of m tc-rcbs, or by any in vivo unlabelling. conclusions according to our results, the le using in vivo methods was slightly lower than le by in vivo/in vitro method. perhaps, both of them were into an acceptable range to be used for lvef studies. moreover, lvef studies performed have not shown any significant difference, so both methods are useful to get m tc-rbcs in fact, we think that the use of m tc-rbcs by in vivo method is preferable, because it is a simple system, easy to perform, safe and efficient to assess lvef getting good results and image quality. introduction: insulin-like growth factor (igf- ) and its binding proteins, mainly igfbp , have a very important role in the regulation of fetal growth. the synthesis of igf- and igfbp is regulated to diverse hormonal factors, such thyroid hormones. the purpose of this study is to determine the possible association between the hypothyroidism status of pregnant women and the levels of igf- and igfbp respectively. objective: assessment the relationship between thyroid hormone levels and igf- and igfbp serum levels in pregnant women. aim: the polyazaligands such as dtpa or dota are suitable for transitionmetal and lanthanide ions, and their complexes have found important use in the radioimmunotherapy and radioimmunodiagnosis. a key parameter for these applications is a fast and efficient complexation of a convenient radioisotope. acyclic dtpa forms complexes immediately; complexation with macrocyclic dota is much slower. however, the macrocycles are better from all other aspects (e.g. kinetic and thermodynamic stability). in general, the most suitable central ions for dota-like ligands are trivalent lanthanides and indium. the in isotope was chosen for this study, because it has convenient radio-properties. we present here an investigation of two new bifunctional monophosphinic acid h dota derivatives having distant paminobenzyl (do a-p abn ) or carboxylic groups (h do ap pra ) suitable for a further conjugation. material and methods: do a-p abn and h do ap pra were prepared according to the published procedures. incl was purchased from amersham plc.. the reactions were followed with radio-tlc on silikagel plates or rp-hplc on lichrocart c column (merck). biodistribution and elimination studies were carried out using male wistar rats. results: the studied ligands exhibit a fast complex formation at optimized conditions (ligand:metal ratio : , ph . , °c, min). as expected, higher ph and temperature accelerate the complex formation reactions. however, ph where precipitation of colloid metal hydroxides can occur (>~ ) is not suitable. biodistribution studies showed a rapid clearance from most organs including blood and muscle. the main elimination pathway was urine excretion mostly by the mechanism of glomerular filtration. conclusion: the resultes indicate that do a-p abn and h do ap pra are promising for radiolabelling of target-specific biomolecules. initial the relationship between proinflammatory cytokines, il- and tnf-, and hyperthyroisdim is not well known. serum levels of cytokines may indicate activity levels of immune functions. on the other hand some hyperthyroisdim variant have a immune component. objective: to measure and compare serum concentrations of proinflammatory cytokines, interleukin- and tnf-, in patients with different hyperthyroid diseases. material and methods: analyses were conducted in sera samples drawn from patients with graves-basedow disease, patients with multinodular goitre, patients with thyroiditis and euthyroid controls. serum tsh, ft , ft , il- and tnf-concentrations were measured by irma or ria assays. statistical analysis: a one-factor anova and subsequent bonferroni test were performed. results: in-dota-tate in μl is required. under these conditions the radiolabelled peptide is vulnerable to radiolysis and oxidation, which results in loss of biological activity. labelling conditions were investigated to obtain a chemically stable product with intact high and specific receptor-binding. moreover, high sa can only be achieved when the ingrowth of non-radioactive competing cd is low. cd is the decay product of in. incl is produced and delivered every week, thus the radiolabelled peptide should preferably be stable for week. in-dota-tate was therefore tested chemically and biologically. materials and methods: labelling conditions like time of labelling, temperature during the labelling, specific activity and the addition of several quenchers (ethanol, ascorbic acid and gentisic acid) in different combinations and concentrations were tested. radiochemical purity (rcp) was determined by using a hplc c column at t= up to week after labelling biological stability of in-dota-tate was tested (at - m) by performing uptake and internalisation experiments using the somatostatin receptor expressing rat pancreatic cell line ca . parallel in vitro autoradiography was performed on rat brain sections, both with * - m and - m of in-dota-tate. results: mbq/nmol in-dota-tate was prepared. use of quenchers was inevitable to maintain rcp and prevent loss of receptor affinity. conditions were optimal in the presence of ethanol, ascorbic acid and gentisic acid. at t= rcp was ± %, whereas after week the rcp was ± %. uptake of in-dota-tate ( - m) to ca cells was % [dose/mg protein] of which % was internalised. similar results were found in experiments throughout the week. receptor-binding of in-dota-tate was confirmed on brain sections, and could be blocked in the presence of an excess ( - m) of octreotide analogue. corrected for decay and exposure time the specific receptor-binding of in-dota-tate to brain also remained constant. conclusion: optimised labelling conditions of in-dota-tate and the presence of a combination of quenchers enables the production of this radiopharmaceutical with a high and intact rcp for a week. since the chemical status, and the intact high and specific receptor affinity are maintained, centralised production and shipment of "hot liquids" are now possible. aim in order to satisfy the good preparation norms in nuclear medicine all radiopharmaceuticals employed for diagnostic and therapy have to be tested by quality control (qc) by determining radiochemical purity (rp) the purpose of this study was to validate a simplified qc method for gamma and beta radiopharmaceuticals using storage phosphor screen technology and adapting the complexity of the optiquant software of cyclone perkin elmer to common usage. material and methods: gamma and beta radiopharmaceuticals habitually used in our laboratory (diluted : in normal saline) were tested by instant thin-layer chromatography (itlc). all the chromatographic strips were tested exposing phosphor screen (multi-sensitive medium ms) at progressively increasing times (from to seconds) to establish the better time of exposure (for the average of our strips: seconds). then we have performed itlc for each radiopharmaceutical to calculate the average of distribution areas of radiopharmaceutical and its impurities in order to find the background area. since cyclone can simultaneously measure different chromatographic strips, we have estimated a minimal distance ( . cm) between the various strips avoiding images superimpositions. we have compared itlc results measured by cyclone and by gamma-counter and the agreement was excellent (correlation coefficient . ). then by the optiquant software we have saved in a scheme of lanes -templates-the exact dimensions of the chromatographic strips well as the distribution areas from the origin (o) to the solvent front line (f) and the background area of each radiopharmaceutical. results this simplified method is easy for user at all levels of computer expertise, moreover consent to scan a screen, display and analyze the image, report the data of various chromatographic strips at the same time with high sensibility and resolution, clearly visualizing the distribution of the radiopharmaceutical and its impurities. the scheme of lanes (templates) saved in the software optiquant allows a rapid, automatic and exact measure of rp (less than minutes for different strips at the same time) providing a profile for a graphical representation of data. conclusion this simplified method for the measurement of radiochemical purity is easy, rapid, optimized and standardized no matter who the users are. introduction: hidroxyethyl starch is the most used agent in the sedimentation of the erythrocytes during the radiolabelling procedure for leukocytes. colloid dextran- , a plasma expander, have been proposed as possible alternative to hidroxyethyl starch in this process. objective: to assess the usefulness of the plasma volume expander colloid dextran- as an alternative to hydroxyethyl starch in the sedimentation of the erythrocytes in leukocytes radiolabelling by m tc-hmpao. material and methods: two identical samples of ml of blood in ml of acd were obtained from patients referred to our department for labelled leukocytes scintigraphy. leukocyte concentrations were obtained by using a hes solution, following the established protocol. simultaneously, another leukocyte concentration was obtained using a % dextran- solution in saline solution of . %. concentrations of leukocytes, platelets and red blood cells were determined in the plasma obtained. the efficiency of the labelling was estimated, the cell viability was calculated by means of the trypan blue method, and the in vitro leukocyte recovery and erythrocyte:leukocyte ratio in final suspension of labelled cells were determined. results are expressed as arithmetic means ± standard deviation. the student's t test for related samples was used to compare means, considering p < . as significant. results: aim: to assess the effect of scatter coincidences, partial volume, positron range and non-colinearity on the ratio of the specific striatal uptake to non specific uptake (sur) in fdopa pet studies. materials and methods: the simset monte carlo code was employed to simulate acquisitions of the pet/ct siemens biograph scanner. the study was performed by using a numerical model obtained from a ct-image of a striatal phantom. theoretical sur values of . , , . , , . and were simulated. neither axial nor angular compression were considered. as a consequence, sinograms with transaxial bins (bin size of . mm) and angular positions were obtained. simulations were carried out with/without positron range and noncolinearity effects. true and scatter coincidences were stored separately so that an ideal scatter correction (isc) could be performed. a d iterative algorithm kept in the stir library (http://stir.sourceforge.net) was used to reconstruct the d pet data. the reconstruction parameters were: iterations, subsets and a reconstruction grid of x x (x-y pixel size of . mm and z pixel size of . mm). different reconstruction strategies were employed in order to evaluate the effect of degradations: a) osem d, reconstruction of the sinograms with total coincidences, b) osem d+isc, reconstruction of the sinograms with only true coincidences, equivalent to an ideal scatter correction, c) osem d+isc+pvc, reconstruction of the sinograms using the isc and including a partial volume effect correction and d) osem d+isc+pvc+prc+ncc, reconstruction of the sinograms using isc, including a pvc and without positron range and non-collinearity effects. a linear regression analysis was carried out between calculated and theoretical surs. the slope of the linear fit was considered to be the recovered sur (rsur). in all cases, the correlation coefficients were also calculated. results: for all reconstruction strategies, the correlation coefficients were higher than . . the slope of the linear fit was: a) osem d: . , b) osem d+isc: . , c) osem d+isc+pvc: . and d aim recent developments in pet d scanners have enabled the spatial resolution to achieve - mm fwhm range. with such an optimization, even small patient movements during data acquisition can lead to severe image quality degradation. frequently, patients who undergo pet brain scans suffer from movement disorders. if a head cushion is used, the probability of involuntary movements is still high. monte carlo simulator codes may assume a relevant role in understanding the image implication of these occurrences. the aim of this work is to show the potentiality of the geant application for tomographic emission (gate) to simulate the results of head movements during a realistic static pet study in image quality. materials and methods we used gate platform to model the ecat exact hr+ scanner. an attractive feature of gate is its capacity to simulate the behaviour of the scanner's detectors and the signal processing chain. to achieve this, we have defined a resolution of % and energy blurring between %- % at kev, a global sensitivity for each crystal of %, and an energy window of - kev. we have applied a paralyzable dead-time model. a coincidence time window and a delayed window were simulated. the hoffman brain phantom was used as an emission map to map f-fdg activity in ventricles, white and grey matter. a mbq f-fdg administered activity d pet minutes static hoffman simulation was performed. fiducial markers were simulated to allow the identification of movement occurrence directly in the brain sinograms. results we obtained d sinograms with radial bins and azimuthal bins for seconds time frames. a total of . e+ f decays were acquired for each static aquisition. a c language programme was conceived in order to obtain a sinogram representing the whole of simulated data. through an exploratory analysis we verify that a : relation between fiducial markers' activity and f-fdg brain activity allows clear visual identification of these markers on the sinogram containing the whole data. conclusions the preliminary results suggest that is possible to obtain realistic brain pet sinograms under realistic simulation conditions. we are currently simulating translation movements with different ranges of magnitude and to couple this information with marker activity v.s. marker dimension. rotation movements of different magnitudes will also be simulated. simulated sinograms will be used to develop a correction method suitable for correcting intra-frame movements. wall motion and thickening estimation in myocardial gated spect: a comparison between two commercially available programs l. s. maffioli, a. vignati, f. cammelli, c. songini; ospedale civile di legnano, legnano, italy. routinary interpretation of gated spect is based on a visual evaluation of the rest/stress perfusion images of the left ventricle, an analysis of global function expressed as ejection fraction (ef) and left ventricular volumes and an assessment of the regional wall motion and thickening in the gated spect images. in order to calculate left ventricular ejection fraction (lvef), end-diastolic volume (edv), wall motion (wm) and thickening (wt), various types of programs are commercially available. aim of the study: we evaluated the reproducibility of ef, edv, wm and wt results obtained from two commercially available software packages in a clinical model. methodology: fifty consecutive male patients with suspected or known cad were evaluated with rest myocardial gated-spect. each study was reconstructed using a standard filtered back-projection on the same processing workstation (odyssey philips). in order to avoid influences, pixel size and reconstruction parameters were maintained constant in all patients. two programs were compared to evaluate functional parameters: cedars-sinai quantitative gspect (qgs) and d-mspect (michigan university). so, on the same reconstructed slices, lvef, edv, wm (in mm) and wt (%) were computed in a segment model (apex, anterior, septal, inferior and lateral wall), representing the whole left ventricle. statistical analysis was performed. results: a good correlation between the programs was found only for the estimation of lvef and edv (r = . and . respectively), while a poor correlation was found for wt and wm. the r values for wt and wm are summarized in table . qgs provided bad bull's eye images in patients, and d-mspect, in patients. conclusions: cedars-sinai quantitative gspect (qgs) and the d-mspect programs provide reproducible results for the estimation of lvef and edv. in spite of these favourable results, we noted that the estimation of wt and wm only moderately correlate between qgs and d-mspect. for these parameters, the poor correlation suggests caution for the clinical use of polar maps and values of wt and wm. aim various computer algorithms are available to segment the myocardium in gated myocardial perfusion scintigraphy, to calculate functional parameters such as left ventricular ejection fraction (lvef). the ability of these algorithms to reproducibly detect the myocardium will depend on how well defined the wall is in the images of the heart, and hence on the size of any myocardial defects and the count in the heart. this study was carried out to measure the inter-operator variability of lvef calculated with the cedars-sinai and stanford methods, and to determine how this varied with count and defect size. materials and methods consecutive gated myocardial perfusion studies carried out at the bristol royal infirmary were included. a circular region of interest was drawn over the lao image of the heart and the count in the region was recorded; patients were grouped into upper quartile, lower quartile, and intermediate counts. the defect size was determined using the perfusion quantification package myoquant, and patients were grouped into no defect ( / ), defect size - % ( / ) and defect size > % ( / ). data was processed to determine lvef using multidim (stanford) and qgs (cedars-sinai). results lvef was on average . % (sd . %) lower with multidim than qgs. inter-operator variability for lvef was . % for multidim and . % for qgs. lvef decreased with increasing defect size for both multidim and qgs. the difference in lvef between qgs and multidim decreased significantly, from . % to . %, as defect size increased from zero to > % of myocardium. inter-operator variability of lvef increased with perfusion defect size for multidim, but not for qgs. lvef, and the difference between qgs and multidim, did not change with count. the inter-operator variability was greater for lvef with lower count, for both multidim and qgs, but this was only significant for multidim. conclusion the inter-operator variability of lvef measurements in gated mps may be affected by algorithm, count and defect size. overall, qgs and multidim had very similar average inter-operator variability for lvef, but multidim was more affected by count -worse with low count -and defect size -worse with large defects -than was qgs. aim: imaging from the source that striking the whole crystal area with a uniform flux of photon, is the main method for calculation of non-uniformity in gamma camera systems. in such condition a perfect system produces images of uniform count density. however noise is a major problem in evaluation of non-uniformity in low count test images. noise causes random fluctuation in count density that is hard to distinguish from real non-uniformity in the image. in this study we used statistical methods in fourier domain for calculation of non-uniformity in simulation nuclear medicine images. methods and materials: using the monte carol method, uniform and nonuniform flood images of different matrix sizes and counts density were generated. the uniformity of the images was calculated using the conventional method (integral and differential uniformity) and proposed (fourier transformation) method. results: the value of integral and differential uniformity shows that these parameters are suitable for calculation non-uniformity only in small matrix size image (high count density). however fourier transformation could perfectly reflect the non-uniformity even at very low counts almost in all matrix size. discussion: in daily uniformity test (low count density image) it is not possible to quantify the non-uniformity of test image accurately. however if data is transformed into the frequency domain, non-uniformity may be better be distinguished from random noise in data. aim:simulation is the first step for improving the imaging tests and developing the imaging systems. simset is a routine powerful simulation software for simulating nuclear medicine systems specially pet and spect. it is necessary that the parameters of these simulation software be accuracy and according to standards in real systems. in this study we considered the simset software with intrinsic quality control tests.material and methods: we perform four routine intrinsic quality control tests(uniformity , spatial resolution , spatial linearity , energy resolution) in a virtual spect system that was simulated by simset. we also used the ncat softwares to produce the phantoms of quality control. these tests were performed according to the nema methods. the calculations were done in mathlab and for more accuracy all the procedures were repeated times.result: we acquired integral and differential uniformity less than % for counts per pixel , spatial resolution less than cm , spatial linearity less than . % and energy resolution was exactly the same as the default value that be set. conclusion:all the parameters that we calculated were according nema standards. but the calculated values were ideally less than the parameters in real spect systems. it shows that it needs more study to extend the result of simulating to real condition. background: the discovery that the use of herceptin® (trastuzumab) in breast cancer may cause cardiotoxicity in some patients has led to calls for rigorous cardiac monitoring of patients, both to ensure that they are eligible for the drug and at regular intervals once therapy has begun. one of the techniques indicated for this cardiac monitoring is the gated blood pool study (muga scan). patients can only be accepted for therapy if their ejection fraction (ef) is within the normal range of the centre performing the study. it is therefore important that centres have a robust and reproducible method for measuring ef. the aim of this study was to assess the reliability of muga processing carried out at our centre. method: gated blood pool studies are performed following the administration of mbq tc m in vivo labelled red blood cells. the studies were performed on a siemens ecam gamma camera with a high resolution collimator. the data was processed using nud hermes fuga software. we selected the most recently reported muga studies which had been routinely processed by different operators. these scans were retrospectively reprocessed by two experienced operators independently. the ef results initially reported were compared with those obtained by these investigators. results: for the studies assessed, the mean (± sd) reported ef was . ± . %. the mean ef obtained by investigator was . ± . % and the mean ef obtained by investigator was . ± . %. using the paired t-test, there was found to be a significant difference between the reported efs and those obtained by both investigators (p< . ). however, there was no significant difference found between the efs obtained by the two investigators (p> . ). review of the original data processing, showed that the selection of the background region was not consistent, with regions of high activity (e.g. gut) included in a number cases. conclusion: in this preliminary review of our working practices, significant differences were found in the ef results reported when compared with subsequent re-processing by single operators carefully selecting the background region. further work is intended to ascertain other possible reasons for these differences and assess whether further training and regular review of practice is needed to ensure reliable results are reported. objectives: to enhance signal-to-noise ratio in a selected volume-of-interest (voi) centered on the heart and to improve diagnostic performance of nuclear spect studies. methods: the new method of simultaneous spect acquisition and reconstruction using a cone-beam and a parallel beam collimator has been introduced and evaluated. we simulated nuclear spect scans with tc- m sestamibi using monte carlo method (simset). we also acquired spect data using physical phantoms on a two-head gamma camera (e.cam, siemens). the normal hearts, as well as hearts with various size defects were imaged. for tomographic reconstruction we used our new fully d ordered subsets expectation maximization (osem) algorithm with cone-volume system model combined with parallel-volume system model. total variation optimization regularization was also implemented in this approach. we evaluated signal-to-noise ratio improvement in the selected voi and accuracy of determination of the extent and location of the defects in the heart using our combined cone-beam/parallel-beam acquisition and reconstruction method, as compared to conventional parallel-beam only approach. results: we established an increase in the accuracy in locating the site and the spatial extent of heart abnormalities while using our combined cone-beam/parallel-beam acquisition and reconstruction method, as compared to parallel-beam only approach. conclusions: application of our new combined cone/parallel-beam method might results in improved accuracy in nuclear cardiology spect studies. i- mibg is a radiopharmaceutical used for evaluation of cardiac symphahetic function based on the heart to mediastinum count ratio (h/m ratio) in myocardial scintigraphy. images are acquired by detecting the photons within ± % energy window centered on the kev photopeak. the radioactivity contains a considerable scatter fraction due to high energy gamma-rays with kev ( . %) and others emitted from i- . scattering and penetration of these high energy photons thrausk the lead the collimator are the prime cause of deteriorating image quality. the aim of this study is to evaluate validity of a monte carlo code for estimating the fraction of scattered photons for various types of collimators on i- mibg myocardial study. materials and methods: calculations were carried out using a monte carlo simulator which consists of the hexagon code modelled the collimator and the nai code modelled the nai detector system including the back-compartment. the code provides the energy spectrum for every pixel identifying the unscattered, the scattered and the penetrated photons. the simulated image was formed using these energy spectra. the phantom used in the measurement was made from the breast-shaped sheets of paper soaked with the i- solution. the organs such as chest wall, left-and right-lungs and heart, were simulated by the overlapped sheets having the different activity densities, respectively. the mix-dp plastic was used as the scattering medium. experimental data were acquired using the prism irix (philips) gamma-camera attached with various collimators such as the legap, the lehr and the megap. comparisons of the energy spectrum, the count profile and the planar image between the measurement and the simulation were made under the conditions with and without the scattering medium. results: the simulated count profiles along a line agreed well with the measurements. the simulated and the experimental planar images were compared with each other using the method of power spectrum analysis. the characteristics of the images obtained on the frequency domain and the subtracted images agreed between the simulation and the measurement. conclusion: monte carlo simulation of the scintillation camera system using i- enabled to reproduce the experimental images with a high accuracy. the present study is useful for the improvement of the quantitative evaluation on i- myocardial imaging. effect of administered dose level on image quality of brain perfusion imaging with m tc-hmpao: a quantitative analysis a. p. stefanoyiannis, x. geronikola-trapali, i. armeniakos, s. n. chatziioannou, a. prentakis, e. efstathopoulos, a. gouliamos; second department of radiology, nuclear medicine division, school of medicine, university of athens, athens, greece. aim: brain perfusion imaging by means of m tc-labeled hexamethyl propylene amine oxime (hmpao) is a well-established diagnostic procedure. the administered dose range recommended by the supplying company and reported in bibliography is rather wide (approximately . - mci). in this study, a quantitative evaluation of the radiopharmaceutical performance for different values of administered dose ( , , mci) was carried out, based on computer-generated indicators of image quality. subsequently, a generic image quality index was correlated with the administered dose, to produce an overall performance indicator. by means of this analysis, the necessity of higher dose administration was examined, taking into consideration patient absorbed dose. materials & methods: a sample of patients ( administered with mci, with mci and with mci) was utilised. some patients were classified as normal, while others presented various forms of pathology. evaluation of image quality was based on contrast, noise and contrast-to-noise ratio indicators, denoted ci, ni and cnr respectively. calculation of all indicators was based on wavelet transform. an overall performance indicator (denoted pi), produced by the ratio of cnr by administered dose, was also calculated. results: the results of quantitative evaluation are presented in table , where the % differences of estimated indicators for mci and mci subsamples versus the control subsample of mci are reported. calculation of skewness parameter revealed the normality of ci, ni and non-normality of cnr, pi populations. application of appropriate statistical tests (analysis of variance for normal and kruskal-wallis test for non-normal populations) showed that there is a statistically significant difference in ci (p< . ), ni (p< . ) and cnr (p< . ), but not for pi (p> . ) values. application of tukey test for normal populations ci, ni led to the conclusion that ci( mci) = ci( mci)<ci( (mci) and ni( mci)>ni( mci), while ni( mci) can not be characterised. finally, application of non-parametric multiple comparisons showed that cnr( mci)>cnr( mci), while cnr( mci) can not be characterised. the discovery ste is a dedicated brain and whole body pet scanner, with design features that enable high image spatial resolution combined with high sensitivity. the scanner combines eight multislice helical ct scanner with a pet tomography which consists of bgo crystals arranged in rings. the crystal sizes are . × . × mm in the axial, transaxial, and radial dimensions, respectively. the pet detector ring diameter is . cm with axial and transaxial fields of view (fovs) of . and cm, respectively. the ct scanner is a -slice lightspeed. this study evaluated the nema performance of the scanner. performance measurements of spatial resolution, sensitivity, image quality, scatter fraction and counting rate performance for d and d were made using the nema procedures. the low energy thresholds of -dimensional and -dimensional are set to and kev, respectively, and the both high energy is kev. the coincidence time window of d and d are set to . ns and . ns, respectively. in addition, images from the d hoffman brain phantom acquired in d modes is shown to demonstrate the image quality obtained from the scanner. the average transaxial (axial) fwhm resolution measured . ( . ) at r = cm and . ( . ) at r= . the system sensitivity in the center for d and d was measured as . kcps/mbq and . kcps/mbq, respectively. the scatter fraction was . % and . % in d and d. the peak noise equivalent count rate (necr) was . kcps at kbq/ml in d and . kcps at kbq/ml in d for a noise-free estimation of randoms. the contrast of the , , and mm hot spheres in the image quality phantom in d ( d) were . % ( . %), . %( . %), . % ( . %) and . % ( . %), respectively. the results show good system resolution and sensitivity in both d and d, making this scanner highly suitable for brain and whole body studies. the choice of two-dimensional ( d) compared with three-dimensional ( d) imaging and the effect of reducing the scan time duration in bgo based positron emission tomography computed tomography (pet ct) scanners remains a matter of discussion. in our study of patients with known or suspected head and neck cancer ( lesions total) we used a d and d acquisition protocol utilising min, min and min scan time durations on an axial single-field-of-view (sfov). the scan sequence was d min, d min, d min, d min, d min and d min to minimise redistribution and decay bias in results. semi-quantitative analysis was achieved by drawing regions-of-interest (roi) around each tumour maximum fdg uptake (suvmax) and associated uniform background mean uptake (b) in all scans to calculate suvmax, lesion signal / background ratio (i.e. suvmax/b) and image noise as the % coefficient of variation in the background (i.e. %cv in b). for suvmax in all paired scans d > d at min, min and min; differences were highly statistically significant (p< . ) with mean % differences of approximately , , and respectively favouring d. lesion signal / background ratio differences between paired d and d scans were highly statistically significant at min, min and min (p< . ) with mean % differences of approximately , , and respectively favouring d. noise differences between paired d and d scans were statistically significant at min, min and min (p< . ; p< . , p< . respectively) with mean % differences of approximately , and respectively favouring d. all lesions were seen irrespective of acquisition mode or scan time duration. we conclude that scan time durations of min may be implemented in d without significant loss of semi-quantitative information when applying our acquisition protocols and reconstruction algorithms in head and neck cancer patients on a bgo based pet ct scanner. aims: modern petct systems have detector configurations and reconstruction algorithms optimised for maximising patient throughput for whole-body fdg oncology studies. the aim of this observer study is to determine the optimum scanning time for such studies and to assess how bmi can affect this time. to understand more about perceived image quality, the relationship between image quality and image noise is also assessed. material and methods: twenty-five randomly selected patient studies were acquired in d mode on a ge dst petct scanner using list mode acquisitions, to allow the reframing of studies into imaging times of two, three, and four minutes per bed position. data was then randomised and presented to three observers in three sessions. in each session three datasets of variable quality were presented as a training set before the observer was asked to rate image quality of the study patients using a five-point scale. image noise was also characterised at several locations throughout each dataset. results: reduced imaging time led to lower image quality scores, with paired comparisons showing the largest difference in scores (mean: . %ci: . - . ) between and minutes per bed position. using our imaging protocol, minutes per bed position is necessary for an adequate (score > ) scan in the majority of studies ( / ). the relationship between score and bmi for each scanning time is shown in table . for bmi's less than , minutes per bed position were adequate in ( / ) studies. for ( / ) studies with bmi > a scan time greater than minutes was required. image noise also decreased with imaging time in similar manner to image quality, and there was also a significant association between image noise and image quality (p < . ). however, no significant difference in noise was seen between adequate and inadequate scans, and no significant association was found between noise and bmi. conclusions: using our modern petct system and protocol, minutes per bed position is adequate for most patients, although scanning time should be extended for obese patients, and could be reduced for those not overweight. furthermore our data shows a strong relationship between image quality and image noise. and mm) and by a torso background (fillable compartments), whose volume is equal to ml, was used. the tank and the spheres were filled with a set of known f-fdg concentrations in multiple experiments. in every setup, the six spheres were filled with equal concentrations of f-fdg in a fixed standard background concentration of . μci/ml, simulating clinical situation. background activity concentration was calculated from the analysis of fdg-pet studies. the experiments was repeated times; in each measurement the contrast of the spheres was % inferior in comparison to the previous one; we obtained contrast value ranging from about % to %. the emission scans were performed in d mode, acquiring a single bed centred upon the spheres. the transmission scans were performed in spiral mode, kv, ma, slice thickness . mm, pitch . . a d iterative algorithm (osem, subsets, iterations) was used for image reconstructions. a ge xeleris workstation and an advantage windows workstation were employed for image analysis. for each measurement, contrast was estimated as a function of the diameter of the spheres. a contrast-detail curve was obtained, and contrast-detail threshold was estimated. to estimate volume of small lesions, we used a threshold at % of the maximum voxel intensity value of the lesion. results lesion nominal contrast is well correlated with lesion measured contrast (r = . ). the tcdd (threshold contrast detail detectability) for the mm diameter sphere is about %, for mm diameter sphere is about %, for the mm diameter sphere is about %, for the mm diameter sphere is about %, for the mm diameter sphere is about %. conclusionswe investigated the performances of our pet/ct scanner used in d modality for lesion detectability. next step will be the investigation of the effect of acquisition and reconstruction on lesion detectability. pet has a reputation in the quantification of brain perfusion and metabolism. recent advance of pet/ct brought a new era in oncology pet. most of newly shipped pet instruments are pet/ct scanners, all of which are designed to use mainly in d mode and ct based attenuation correction. although d acquisition and ct attenuation correction have many advantages, there are remaining problems in terms of quantitative accuracy. in this paper, we focus on the effect of direct photons from radioactivity outside the fov, and the accuracy of ct based attenuation correction. the lack of interplane septa of d scanner results in an increase of random events of direct photons from outside the fov. it may badly affect the accuracy of image. in particular, oxygen- gas inhalation study for brain, high radioactivity outside the fov exists throughout the scan. we performed an o- co gas inhalation pet scan in a healthy subject using d-lso pet/ct, under the steady state condition. thanks to the lso detector, better quality images were obtained than expected prior to the scan. however, random events were % of true events. a high fraction of random must be derived from activity outside fov, especially from lung. in an experiment with external activities placing cm apart from a phantom, image deterioration was observed with increase of the external radioactivity. to estimate the accuracy of ct based attenuation correction, we performed an experiment with high attenuation objects. a phantom with multiple rod inserts was used. six inserts were filled with same amount of radioactivity, and of the were also filled with contrast material of different density. with the increase of density, measured events tend to increase, even the same activities exists. it might affect the quantitative accuracy in the region with high attenuation. our goal is to establish a method to obtain highly quantitative brain pet images, using d pet/ct designed mainly for whole body scan. aim: contrast-to noise ratio (cnr), was studied as a function of emission scan duration (esd) and activity at the start of acquisition (a acq ) for different target sizes and target-to-background (t/b) ratios using a multivariate approach in a wide range of conditions approaching the ones that can be encountered in the clinical practice, using a d-lso based pet/ct scanner. material and methods: an annular ring of water bags of cm thickness was fitted over an iec phantom in order to obtain counting rates similar to those found in average patients. a supplemental set of micro-hollow spheres was positioned inside the phantom. the phantom was filled with a solution of water and f ( kbq/ml) and the spheres with various t/b ratios of . , . and . . sequential imaging was performed to acquire pet images with varying background concentrations of about , , . , . and . kbq/ml. the esd was set to , , , and min/bed. lesion detectability was visually and quantitatively assessed. results: with t/b ratios of . , . and . the . , . and . mm spheres were detectable for the whole ranges of background activity concentration and esd, respectively. the regression equation that best summarizes the results obtained in a multiple regression model with cnr as predicted variable and t/b ratio, activity at the start of acquisition (a acq ), sphere area and esd as predictor variables may be written as: cnr=- . + . x( - /t/b)+ . x(aacq) / + . x sphere a + . x (esd) / the multiple r of model fitting equals . . all of the variables were statistically significant predictors of cnr, whose variance can be accounted for, in order of increasing weight, by esd ( = . ), t/b ratio ( = . ), sphere a ( = . ) and a acq ( = . ). conclusion: cnr depends only slightly on a acq : the weight of a acq in explaining cnr is more than halved with respect to the contribution of esd. cnr values exhibited an essentially flat response for a acq in the wide range explored . (from . to . mbq). as cnr is closely related to lesion detection, this finding suggests that also lesion detectability might not strongly depend on the injected activity, in this range. if confirmed by further studies on lesion detectability on anthropomorphic phantoms, these findings would suggest using lower fdg activities, which could be a gain both from a radiation protection and economical point of view. aim: the respiratory gating system varian rpm (real-time position management) was implemented on a ge discovery ste pet-ct scanner to reduce artifacts and drawbacks due to breathing. analyses of a moving phantom and patient acquisitions were performed to estimate the potential benefit of such a system in clinical practice. material and methods: a phantom containing spheres of different size (volume ranging from . to ml, filled with f, lesion-to-background ratio of about : ) was acquired with a ge discovery ste pet-ct coupled to a varian rpm system. breathing motion was simulated with the standard imaging gating respiratory platform (period s, amplitude mm). two series of pet-ct acquisitions were performed: i) without taking into account the motion tracking (non-gated mode) ii) by dividing the breathing period in bins and reconstructing pet-ct images for each bin (gated mode). then patients showing uptaking lesions in lungs or liver were acquired. the maximum of the weight body standard uptake value (suv bw max ) was compared for gated and non-gated acquisitions for lesions. the motion amplitude of each lesion was evaluated. results: in the phantom trial the images acquired in gated mode showed better recovery coefficients: for the smallest spheres the enhancement ranges from % to %. for the largest one the relative increase is %. in patient acquistions in gated mode lesions showed an increase less than % in suv bw max or a small decrease, an increase from % to %. lesions had motion amplitude less than mm, showing an average enhancement of suv bw max in gated mode of %. lesions with motion amplitude higher than mm (up to mm) showed an average increase in suv bw max of %. conclusions: when a periodic movement due to breathing is present in pet-ct exams, the varian rpm system provides a general improvement in the image quality, reduced motion artifacts in ct, higher suv in pet, more precise match of ct and pet, more accurate volume delineation for radiotherapeutic purposes. a high variability in the advantages of a gated acquisition was observed, depending on lesion features such as the motion amplitude. aim: f- -dopa pet is a well-established method to image dopamine transporter system in human brain. in pet/ct scanners, ac is performed with a ct-based method (ct-ac) as compared to ge- /ga- source transmission scan (s-ac) of pet only scanners. the influence of ct-ac on the determination of the influx constant (ki) to measure dopamine transporter expression is unknown. methods: ten volunteers and parkinson disease patients ( ± y) underwent a -frame -min or -frame -min acquisition after the injection of mbq of f- -fdopa, performed after ac acquisitions (ct-ac: kev, ma; s-ac: -min transmission scan; discovery ls, ge). striatal and occipital rois were drawn and time-activity curves (tac) were generated summing the central slices encompassing the striatum. ki was computed using the occipital cortex tac as input function. differences in striatal and occipital tac were characterized, and differences in ki derived using voxel-based kinetic analysis (pmod software). comparisons were performed with pearson's correlation and bland-altman plots. results: absolute differences in striatal and occipital tac between ct-ac and s-ac were < . kbq/ml ( %) in all studies (mean - . ± . kbq/ml [- ± %]). absolute difference in ki was < . e- /min ( . %) in any striatal voxel (mean - . e- ± . e- /min [ . ± . %]). correlation of ki between both ac methods was excellent (y= . x+ . , r= . , p< . ) without systematic error (p> . ). all measurement pairs were within bland-altman's reference range (- e- to + e- /min). the largest variations were observed around the skull's outline and at the interface between air and bone, in relation to differences in ac maps resolution or minor patient motion (n= ). conclusion: ct-based ac introduces a difference < % in tac and < % in voxel-based striatal ki estimates as compared to source ac. average differences of ± %, an excellent correlation between ac methods and absence of systematic differences allows using both ac method or norms interchangeably when comparing patient groups. however, in follow-up studies aiming at assessing individual disease progression or response to treatment, the same ac method should be used to avoid introducing additional variability. v. schulz , j. zeintl , a. szikszai , j. hornegger , t. kuwert ; clinic of nuclear medicine, university of erlangen/nürnberg, erlangen, germany, chair of pattern recognition, university of erlangen/nürnberg, erlangen, germany. aim: this study investigates the influence of ct-based attenuation correction on the quantification of uptake of i- . methods: data sets acquired using a hybrid spect/ spiral-ct system (symbia t , siemens, hoffman estates, il) in patients with thyroid cancer were retrospectively analyzed. the whole group of patients was divided into a subgroup exhibiting i- uptake in the thyroid bed (n = ; tg) and another one with foci located elsewhere (n = ; ntg). using regions of interest (rois), ratios were determined between the counts in the focus and those determined in the whole transversal slice. roi measurements were performed in uncorrected tomograms (nac) as well as in images corrected for attenuation using the registered ct images (ac). the minimal distance of the focus to the surface of the body (dist) was correlated to the ratio between the values determined for ac and nac (ac/nac ratio). furthermore, the roi measurements were also performed in ac scans in which spect and ct images had been misaligned by cm in one dimension beforehand (acx, acy, acz). results: the mean differences of i- uptake ratios between ac and nac were . % in tg and . % in ntg. both differences were, however, not significant due to their large standard deviations (p > . ). no significant correlation could be found between dist and the ac/nac ratio. ac using misaligned pairs of patient data sets led to a significant change of whole-slice uptake ratios for acx and acy in tg and for acz in ntg, the differences ranging between . to . % (p < . ). conclusions: ac did not affect i- uptake ratios significantly in our study, probably due to the fairly high energy of i- or also heterogeneities of the investigated group of patients with regard to the location of the foci of i- uptake. in i- -spect scans, ct-based attenuation correction should be performed with particular attention to artefacts caused by misalignment between spect and ct. objective: in nuclear oncology, ga- spect studies can still play a useful clinical role. recently, hybrid spect/ct system provided nonuniform attenuation correction with the spatial distribution of attenuation coefficients using a ct data. the purpose of this study was to verify the effects of nonuniform attenuation correction on the hot spot lesion detectability in thoracic spect images with ga- . methods: we evaluated hot spot lesions from patients with ga- thoracic spect. using our combined spect/ct system (millennium vg, ge), all patients underwent ga- spect and ct examinations. spect images were reconstructed with and without nonuniform attenuation correction. to assess the impact of attenuation correction, we compared the values of legion to normal tissue contrast. furthermore, we performed simulation study with numeric digital phantom consisted of lung and soft tissue attenuation coefficients. the phantom imitated a human thorax, in which several lung hot lesions were located in the lung field with homogeneous activity. after generating projection data from the phantom with taking attenuation into account, reconstruction was performed with and without attenuation correction. as with patients study, we compared the values of legion to normal tissue contrast. this simulation study was calculated using the software "prominence processor" developed by maeda. results: in the patients study, the average values of contrast increased from . to . with nonuniform attenuation correction. the contrast of hot spot lesions was also improved by nonuniform attenuation correction in the simulation study. on the other hand, without attenuation correction, legion to lung contrast was decreased significantly depending on the background activity in the lung. conclusion: nonuniform attenuation correction using spect/ct improves the lesion contrast in ga- thoracic spect imaging. ( ), control study in men ii ( ) and primary pheochromocytoma ( ). the scintigraphic result was correlated with those obtained in morphologic imaging techniques and follow up during a mean time of months. results: in patients the scintigraphy was negative: in of them the planar study was doubtful and spect-ct was negative and in cases both of them were negative, showing the absence of uptake in the radiological lesions visualized in of them (size of lesion < mm). the scintigraphy was positive in cases: were positive in the planar imaging (in one of them, spect-ct localized higher number of metastases) and were doubtful, contributing the spect-ct to the confirmation of pathological functionality and its location. the positivity of the i-mibg scintigraphy confirmed the clinical diagnosis of pheochromocytoma and the consequent indication of surgical treatment in all cases ( ), except in one with diseminated disease. the diagnosis in the negative cases was essential hypertension or non-hipersecretory lesions. the performance of the spect-ct represented an increase of the specificity ( % vs % for planar imaging). conclusion: in % ( / ) of cases the spect-ct helped to establish the final scintigraphic diagnosis contributing to a better diagnostic and therapeutic management accuracy. aim audit new low dose ct protocols used for localisation imaging on the philips precedence spect/ct system. method low dose protocols for localisation ct (l-ct) have been created. all are helical with identical pitch and use the doseright-dom auto ma feature: • l-ct abdo: a body protocol for viewing conventional axial ct images ( mas, kv, collimation x . , slice width mm, rotation time . s, ctdi v . mgy). • l-ct abdo mpr: a modified version of l-ct abdo with thinner reconstructed slices (collimation x . , slice . mm) making it more suitable for multi planar reconstruction (mpr). the mas was doubled ( mas, ctdi v . mgy) to maintain the same noise level. • l-ct neck: a protocol for scanning the neck using the head filter ( mas, kv, collimation x . , slice width mm, rotation time . s, ctdi v . mgy). over months, a range of spect/ct scans were performed of the body, neck or feet. an audit questionnaire was designed and completed by the reporting consultant radiologist to find out how l-cts were viewed, the amount of detail required in the image, an acceptable level of noise and if the overall image quality was acceptable. results spect/ct scans were included in the audit, using l-ct abdo (mean dlp mgy.cm), using l-ct abdo mpr (mean dlp mgy.cm) and using l-ct neck (mean dlp mgy.cm). scans were viewed in mpr mode, including of the l-ct abdo scans. image detail of < mm, - mm and - mm were required in ( %), ( %) and scans ( %) respectively. ( %) l-cts were considered to have poor image quality, of which were due to patient related artefacts. the other unacceptable scans were of feet. feet l-cts were audited, were considered acceptable but comments were made on of these indicating that a higher resolution ct would have been preferred. conclusion despite the subjective nature of these results, we now have an insight into some of the imaging requirements of l-ct. the majority of viewing and reporting was done in mpr mode requiring the thinner slices of the l-ct abdo mpr protocol. the low dose l-ct protocols are acceptable for most of our scans, except feet, where high resolution is critical (and more important than low noise). a new anthropomorphic phantom will be used to further develop these protocols and create new ones tailored to specific exam types. the audit will then be repeated. morphological image processing for automatic arm removal in spect-ct images. objectives: image fusion of longitudinal spect-ct and ct to ct studies is frequently required to detect significant changes with time. but accurate image registration is hampered by the presence of the patients arms in the field of view which may take radically different positions or even not be present in some imaging sessions. the objective of this study is to investigate the feasibility of automatic arm detection and removal even in the difficult case when the arms are touching the body. methods: the process of arm detection and removal consists of a: an automatic thresholding step is applied to each ct section to segment the data into foreground with value representing the thorax , abdomen and arms if distinct from the body and background with value zero. b:holes frequently occur within the thorax and abdomen from air , gas etc, to remove these areas the morphological image operation of opening using structured elements is applied to smooth out the resulting sections. c:connected components are identified within each section and from the number and respective sizes of the detected regions the arms may be automatically detected and removed when distinct from the abdomen. d: should the number of regions detected not reflect the presence of the arms then the morphological operation of watershed segmentation is applied . this operation automatically separates or cuts apart objects that touch. it starts with our segmented binary image and calculates a distance map to find the fattest parts of the object, the peaks or local maxima of the distance map. purpose: the aim of this study was to control the inflammatory process and evaluate the volume of the inflamed synovium of the knee during the radiation synovectomy (rs) treatment of chronic synovitis. gadolinium-dtpa contrast-enhanced t weighted images are useful in identification of pannus tissue, which can be seen as areas of increased signal intensity adjacent to low signal intensity of joint fluid. the fusion of ho-fhma (holmium ferric hydroxide macroaggregates) spet images and mri images is often inaccurate. to avoid this problem, we aimed this volume procedure to facilitate fusion of mri and spet images. methods and material: the patients with rheumatoid arthritis were treated with ho-fhma. the spet images were taken after hours of rs. the mri images were taken three times. the first mri imaged before rs and study was used as a reference to the later imaged mri studies. the second mri was taken after one week and third mri after three months after rs. all mri control images are taken in the same manner. the images are processed with region growing method to separate inflamed synovium of the knee. the region of interests (rois) masked in every slices of the study. all rois were checked by two independent radiologists. the volume calculation was confirmed by the ml filled syringe in the same manner like patient studies. volume evaluation was possible and accurate with this procedure. result: this volume evaluation procedure shows clearly the effect of the therapy. comparing these volumes of the same patient we can see how inflamed synovium volume decreases. also the changes of the joint fluid volume can be evaluated. decreasing of the relative synovium volume after one week of rs and after three months of rs was average , % / , %. conclusion: mri is an accurate procedure to estimate the volume of acute synovitis. the volume quantification of the inflamed pannus and synovial fluid was made possible by this procedure and the effect of the therapy is accurately determined. the volume evaluation of the treated knee with rois make possible to increase accuracy of spet and mri image fusion. objectives: reconstruction of pet images from projections is a problem which from a clinical perspective seems like a chapter completed in the mid eighties; in particularly replacing already established algorithms like fbp and osem are not easily accepted. this is well justified by lack of stability of the new algorithms, the often edgy looks of the resulting images, and in general by too complex ways of obtaining the results. methods: for obtaining quantitatively correct results for use in s multi-subject region-of-interest(roi) studies, it is also well known how crucial correct delineation of the roi's for the individual subjects are, making it possible to compare binding potentials for specific roi's between subjects. when delineating the roi's, it is essential not to include tissue outside the respective region while at the same time, it is beneficial to include as much tissue as possible to lower the noise in data. this leads to the well known trade-off between bias and variance, where the size of the region is the parameter that can be optimized. results: for a number of simulated tracer distributions, we demonstrate the effect that resizing the regions have on the mean activity within a region. segmented mr images are used for simulating the tracer a possible tracer distribution in the brain and the mean activity in the insula and putamen are set to known values. knowing the true mean activity, we visualize how a scaling of the regions minimizes the error on the mean activity. it is further shown how this scaling depends on the algorithm used for reconstruction and any filtering applied to the reconstructed images. among the reconstruction algorithms, we show how an edge-preserving algorithm allows us to defining larger regions in the sense that the size that minimizes bias+variance is closer to the size of the anatomical region. conclusion: for our simulations, we conclude that for obtaining quantitatively correct measures for the mean activities in the regions, we should define our regions smaller than the regions derived from the anatomical information and for a typical case, we can reduce our bias by half by choosing either penalized least squares or an edgepreserving algorithm instead of fbp. the pet-fdg dynamic acquisitions are usually used with compartmental methods which suppose a modeling stage. these techniques are not widely used in clinical routines because of their complexity. we propose a simple and direct non invasive approach without modeling stage. the aim of this work is the definition of the cerebral physiological kinetic curves activity of fdg since its injection. material and methods: control subjects without cerebral diseases are evaluated for this study. all acquisitions are made on a biograph tm pet/ct (siemens medical solutions) with minutes total acquisition duration; an intravenous bolus of f-fdg is done during acquisition. to determine the beginning of the volume reconstructions, the arrival time of the tracer in the brain is evaluated using list-mode files. the number and duration of the reconstructed volumes (aw-osem) are respectively: x seconds; x seconds; x seconds; x seconds; x seconds; x seconds. in-house idl software (itt industries inc.) was developed to construct and analyze the fdg time activity curves of grey and white matter, arteries and veins. regions of interest (rois) for cerebral regions ( rois for each matter and rois for each vascular region) are drawn on the ct volume and then reported on pet volumes. normalization of the curves of each subject is done either by using the accumulated true events during each interval of reconstruction or by using the accumulated activity of fdg in the venous region. the standard deviations (std) are calculated at each temporal sample of the "characteristic cerebral curves" (ccc) that we define as the mean subjects' curves. results: vascular fdg curves are constructed with good temporal sampling of the few seconds after the injection showing the fdg bolus arrival at early stage. the dispersion of the ccc is evaluated for normalized and unnormalized subjects' curves at late stage (between seconds and minutes). the maximum std to mean ratio of the grey matter is . for unnormalized curves, . for the true events based normalization and . for venous based normalization; for white matter the values are respectively . , . and . . conclusion: we have defined a direct approach describing the physiological normalized curves of fdg kinetics in the cerebral regions with good temporal sampling and low dispersion. this allows the definition of key parameters of the curves. the comparison of ccc with pathological cerebral curves could be done in diseases as alzheimer. the use of normal brain spect databases that are not age-matched to the subject(s) under investigation: a feasibility study l. barnden; the queen elizabeth hospital, adelaide, australia. voxel-based statistical analysis of brain spect with the spm package offers adjustment for nuisance effects that may produce false positive results or introduce regional nuisance variance that degrades the sensitivity for detecting effects of interest. for each voxel, the software essentially performs a linear regression of the nuisance parameter versus counts and removes (adjusts out) any effect before reporting results for the effect of interest. this 'analysis of covariance' can be used to adjust for age effects provided the ages of each subject are input to spm and, in principle, should permit use of non age-matched normal databases. this approach was assessed by dividing a subject normal database into four age groups - ( subjects), - ( ) , - ( ) and - ( ) and running spm to detect significant regional differences between the - age group and each of the three other age groups with and without adjustment for age. without adjustment for age, significant regional differences were detected for all three age groups with spatial distributions that resembled the ageing effects for the whole database. after adjustment for age, there was no significant difference between the elderly and any of the other three subgroups except for one location for the - to - comparison. the coefficient of variation in gray matter suggested that using the youngest group of normals may confer a slight statistical advantage. this work demonstrates that, provided extreme age differences are avoided, it is acceptable to use a normal database that is not agematched to the patient(s) under investigation. introduction during the last years, siscom (substracted ictal spect coregistred to mri) analysis of multimodality images realised in the assessment of medically refractory partial epilepsy has been widely used. however, other methods can be explored like fractal analysis. indeed, this mathematical tool is known for its ability to characterize heterogeneities into a structure. the aim of this work was to present the preliminary results of an application based of this tool for the characterization of observable anomalies in ictal and inter ictal spect. methods we have developed an algorithm to evaluate the d fractal dimension (fd) of d images of spect. the fd is estimated by a differential box-counting approach which consists in iteratively subdividing the image on boxes with increasing size and to evaluate the df as the slope of the regression line binding sizes of the boxes and the mean of maximum deviations of gray levels in each box. as a first assessment of the algorithm, we used simulated data with a well defined fd. then we tested the algorithm on a database containing patients with ictal and interictal exams and a control group of volunteers distributed by age: between and years, between to and more than . finally, as application we used the method on an imagebase of patients with partial epilepsy. tc- m hmpao brain perfusion ictal and interictal images were acquired on a brain dedidated system: the tomomatic (medimatic). the procedure was to subdivide the images into subimages and to compare the fd of the paired subimages of ictal and interictal. results for the comparison of healthy groups and pathologic group, we found a significant difference (mann-whitney test, p< . ) whereas no difference was observed between the different healthy groups. as for the final application, we found a significant difference between the subimage where hyper-fixation focus were detected. conclusion in consideration with these promising preliminary results, we are working on a method to perform a multidimensional fractal analysis (multifractal) of the images. this method will lead us to fine characterization of local heterogeneities and thus a better localisation of epileptic focus. nevertheless, routine application of ml techniques to large scale biomedical data set is still a relatively new occurrence. otherwise, complex configuration and datapreprocess is an obstacle for physicians. this study proposes an innovative and userfriendly machine learning software for large-scale molecular and clinical data. we choose the excel file with customized header as the data standard. we use support vector machine (svm) as our machine learning algorithm in the platform. svms are a set of related supervised learning methods used for classification and regression. for handling large-scaled molecular data, some feature selections methods like recursive feature elimination are introduced in the system. the platform is a module of the pmod software (pmod technologies ltd., adlisvil, switzerland). results: on the machine learning platform, we developed some applications and did some researches related to molecular and clinical data. some examples are illustrated as follows: ( ) we developed a machine learning based tool for parameter imaging and kinetic modeling of dynamic pet study. we collected studies of kinetic modeling as training samples and built different regression models for different pet parameters. using the models, we can predict the quantitative pet parameters of vois or pixels according to the tac. ( ) classification study for gene expression data. the study addresses the problem to find a small subset of genes which provides the best discrimination for a specified classification, for instance to discriminate between normal and tumor tissues. this subset can then potentially be used for genetic diagnosis, or for drug discovery. ( ) we did a prediction study of short-term survival in patients with advanced non-small cell lung cancer following chemotherapy based on fdg-pet. the study demonstrates that a full kinetic analysis of the f-fdg kinetics is helpful for the classification into short or long survival and may helpful to identify those patients who may benefit from this palliative chemotherapeutic protocol. conclusion: the new machine learning platform provided a very unique tool for the classification and regression analysis of molecular and clinical data. the studies on the platform show that it can be widely used in the medical and biological fields. coronary artery disease (cad) is one of the world's most premier causes of early mortality, so any improvement of diagnostic process is highly appreciated. in the clinical setting, cad diagnostic is performed in a sequential manner. the four diagnostic levels consist of evaluation of ( ) signs and symptoms and ecg at rest, ( ) ecg testing during the controlled exercise, ( ) stress myocardial perfusion scintigraphy, and ( ) coronary angiography, which is considered as the reference method. in our study we focus on improving diagnostic performance of stress myocardial perfusion scintigraphy. this method bases on series of medical images. in clinical practice, these images are manually described (parameterized) and subsequently evaluated by expert physicians. we present an innovative alternative to manual image evaluation -an automatic image parametrization of multiple resolutions, based on texture description with specialized association rules, and image evaluation with machine learning methods. our results show that multi-resolution image parameterizations equals the physicians in terms of quality of image parameters. however, by using both manual and automatic image description parameters at the same time, diagnostic performance can be significantly improved with respect to the results of clinical practice. our experiments with artex image parameterization algorithm in conjunction with bayesian machine learning (naive bayesian classifier) produced highly significant results, improving diagnostic accuracy, specificity and sensitvity by more . - . %. while these values contribute to more accurate clinical diagnostics, the improvement of sepecificity by almost % also suggests that % of negative patients (no cad present) may be reliably diagnosed without resorting to coronary angiography. background: recently, it has been recommended that nhs clinical biochemistry laboratories routinely provide a measure of renal function, egfr (estimated glomerular filtration rate), based on the modification of diet in renal disease (mdrd) formula which uses serum creatinine concentration, age, ethnic origin and gender. in our centre, a further modification is applied to the formula to account for the method of serum creatinine analysis. the aim of this study was to evaluate the accuracy of egfr in our centre by comparing with the "gold standard" cr-edta gfr method. method: we measure cr-edta gfr using a sample technique following the recommendations in the british nuclear medicine society guidelines. patients were included in this retrospective study of which were male and were female, with mean age years (range - years). only patients who had cr-edta gfr measurements within two weeks of a reported egfr were included. where egfr exceeds ml/min/ . m², it is reported as "> " rather than an exact figure due to the decrease in accuracy with increasing gfr. results: for the patients, mean (± sd) measured gfr was . ± . ml/min/ . m² and mean egfr was . ± . ml/min/ . m². the mean difference between measured gfr and egfr was found to be . ml/min/ . m². the correlation coefficient was . and a paired t-test showed there was a significant difference between the two methods (p< . ). limiting the analysis to patient's with egfr< ml/min/ . m² led to a similar correlation ( . ) and again significant differences were found using the paired t-test (p< . ). for these patients, mean measured gfr was . ± . ml/min/ . m² and mean egfr was . ± . ml/min/ . m². the mean difference between measured gfr and egfr was found to be . ml/min/ . m². conclusion: in this preliminary study, absolute values of gfr and egfr were found to be significantly different. in general, egfr was found to overestimate compared with measured gfr. our findings agree with previous work suggesting that egfr becomes less accurate as gfr increases. however, egfr may be a useful indicator of the intrapatient changes in gfr as qgs and ectb behave differently and produce variable results from one another, they should not be used interchangeably. introduction estimation of reliable cardiac ejection fraction for oncology patients is of great importance in the therapy follow-up procedure. aim the development of automatic processing algorithm for the determination of left ventricle and background regions. methods multiparametric method was applied for the lv roi determination in every sequential image of the representative cycle. from amplitude, phase and temporary dc images of fourier time analysis segmentation of both ventricle and atrium structures was performed in the phase histogram, the lv spatial structure was separated from the other heart components by the size condition and the local minimum counts in the dc component between lv and rv and la. backround region was computed from the definite number of pixels with minimum counts in the lv close vicinity. for quality control of segmentation the visual inspection during the analysis is provided for every frame and the manual lv delineation with manual or automatic background selection is used as an alternative method. results completely automatic computational algorithm is fast enough (less than minute for frames' study and x matrix) and gives highly comparable ejection fraction value to the standard roi method (r > . ; n= ) for well separated lv from rv and lv from la studies. visual inspection of the computation procedure is provided for the lv edge delineation by the cine display mode and the time sequence of parametric images for ejection and filling rates. conclusions the new multiparametric pattern recognition method with the controlling visual tools was developed for the completely automatic processing of muga studies. for patient studies with careful positioning it can safely replaces the standard "manual" methods. aim: to investigate the effect of crystal thickness on the spatial resolution of pet detectors which use artificial neural network (ann) based positioning algorithms. finding this relationship is important in determining the best trade-off between spatial resolution and sensitivity for the optimal design of a pet detector. studies have been made to investigate this trade-off for the anger based positioning algorithms but not for the ann based algorithms. materials and methods: we took the approach of conducting monte carlo simulation studies due to the complex nature of this relationship. we chose parameter values for a continuous lso based positron emission mammography (pem) system. we used the builder, grit and detect software programs for the simulations. the detector consisted of a continuous lso scintillation crystal with an area of x mm and varying thickness levels of - mm. the hamamatsu h multi-anode ( x ) flat-panel pspmt is assumed to be mounted on the crystal. monoenergetic kev photons have been sent perpendicular to the crystal surface. training sets were constructed from simulated data on a x uniform grid with mm for each interval with photon incidences at each point for the first quadrant of the crystal. an energy threshold of kev was set in order to reduce the influence of weak events, namely compton scatters. tests were performed on sets of simulated data on a x uniform grid with mm for each interval taking photons at each point with the same energy discrimination. the inputs of the neural network, namely pspmt-anode outputs were reduced to four as x+, x-, y+ and y-, one from each corner of the resistor network. results and discussion: initial results show that nonlinearity is considerably reduced and spatial resolution improved by the ann method at different thickness values, thus rising also the question of whether the more expensive and less light efficient but more sensitive lso should be prefered to nai. a look-up- aim: the continuous crystal concept for pet offers a number of advantages such as low cost but suffers from edge effects, distortions and low spatial resolution when used with anger logic. in particular, resolution degrades rapidly with increasing crystal thickness. in this study, we aimed to develop and evaluate a new positioning and depth of interaction algorithm to be used with a continuous crystal small organ pet system in order to overcome these deficiencies. materials and methods: the algorithm we present uses a lookup table, which is constructed by using the pmt outputs of scintillation events, simulated at each sample point of a three dimensional grid covering the entire crystal volume using the detect monte carlo simulation package. scintillation point estimation is done by matching the pmt outputs of an event with the data inside the lookup table. the nearest neighbor algorithm is used during matching. during the process, we apply a first threshold for each pmt output to eliminate low energy events and then a second threshold to the nn algorithm in order to remove probable compton scatterings inside the crystal which reduce resolution. the performance of anger logic and the new algorithms are compared over a limited region for a detector configuration consisting of x x mm continuous nai crystal coupled to square pmts with dimensions x mm each. the grid consists of . mm spaced points over the entire crystal volume. kev rays are sent along a line perpendicular to the crystal face midway between the center and the edge of the crystal. results: the anger logic results in resolution loss due to uncertain depth of interaction along any line perpendicular to the crystal face. we obtained an average resolution of . mm with the new algorithm as opposed to nearly mm with the anger logic. this reflects the reduction of the positional uncertainty caused by crystal thickness as well as the elimination of most compton scattered rays. furthermore, edge effects and nonlinearities are totally eliminated. simulation results show that the new algorithm implemented for a small organ pet can provide with acceptable performance in terms of resolution and distortion while offering a low cost alternative. this algorithm can also be used in the doi determination. availability of a shielding system for brain studies in d thorax scan aim to examine the potential availability of a shielding system for brain studies in d thorax scan using fdg. material and methods a pet scanner (ge advance nxi), a shielding system for brain studies (ipl neuroshield), a cylinder phantom ( cm × cm), iec body and nema scatter phantoms were used in this study. the cylinder phantom was filled with mbq of f to simulate the brain. the background region of the body phantom was filled with an activity of . kbq/ml. the four hot spheres were filled with an activity concentration of times that of the background. the largest two spheres were filled with water only. the lung insert filled with foam pellets and water was placed in the center of the phantom. the line source of the scatter phantom was filled with mbq. emission and transmission scans were performed in three conditions. in condition , the body and scatter phantoms were used according to the nema nu - image quality measurement protocol. in condition , the cylinder phantom was used in addition to two phantoms used in condition and placed on opposite side of the scatter phantom. in condition , the shielding system was used in addition to all phantoms and located between the cylinder and body phantoms. in every condition, emission data was acquired in d mode and for min, which was performed three times. transmission scan time was min. after compensated by randoms correction, model-based scatter correction and segmented attenuation correction, the acquired data were reconstructed using fore- d iterative reconstruction with ~ iterations and subsets. according to the nema protocol, the pixel values on each image were examined. results with the % contrast and the accuracy of attenuation and scatter correction, there was not much difference among the results in three conditions. however, the % background variability for , , , , and mm spheres in condition were about . , . , . , . , . and . times those of condition , respectively. those of condition were about . , . , . , . , . and . times those of condition , respectively. these results show that the random events from the cylinder phantom were reduced by the shielding system. conclusion in d thorax study with fdg, our preliminary results show that the shielding system is potentially useful to reduce the random events from brain. aim. to describe and quantitatively assess the influence of a malfunctioning block detector on reconstructed pet images for a full ring block designed scanner. methods. by using raw data acquired with fully calibrated and perfectly functioning ecat hr+ pet scanner (cti-siemens) in d (span ) and in d (span ) mode, one block detector with % loss of efficiency was simulated. the effect of defective block was studied with: -the cm diameter ge uniform phantom scanned at high counting statistics and reconstructed with fbp ramp filter and awosem i/ s ( iterations, subsets); -the anthropomorphic alderson phantom filled with f and acquired at clinical counting statistics and reconstructed with awosem i/ s, as routinely used in wb-pet fdg studies, and i/ s. defective block was simulated also on d transmission and blank scan data to separately study the effect on μ-maps. taking as reference the original images, defective images were evaluated qualitatively and quantitatively by assessing % difference of suv ( suv % .). results. defective block severely affects measured μ-map: overestimated coefficients can be generated along the correspondent fan angle. a considerable reduction of such artefacts can be obtained by segmenting transmissive data. visually and quantitatively, defective block slightly influences reconstructed images of d or d emission data when segmented attenuation coefficients are used. as shown by reconstructed high counting statistics uniform images defective block generates different artefact shapes on d and d data: -in d mode with ramp fbp or i/ s awosem they appear as cold stripes along the fan angle covered by the defective detector; -in dmode a very slight distortion on the edge tangential to the fan is visible only with awosem. on the uniform and alderson phantom images, in regions where artefacts were visible suv% was less than %. conclusions.this study showed that for hr+ scanner, even a % loss of efficiency of a block, in spite of the evident defect on sinograms, does not substantially affect qualitatively and quantitatively d/ d mode reconstructed images ( suv% variations less than %) when segmented or non altered attenuation coefficients are used. simulations on patient studies are under evaluation to confirm results obtained with phantoms. it is worth noting that the clinical use of a scanner with a defective block is to help temporary patient management and not to change maintenance scheduler or lower the quality standards. contrast and sensitivity performances of elscint, general electric, siemens and smv multi-heads cameras. mbq tc- m. a cm-diameter cylindrical phantom with home made hot ( - mm) and cold ( - mm) rods inserts was filled with about mbq tc- m. a tomography of or steps over ° was recorded in h-mode with a circular trajectory. using a * matrix and a hardware zoom, projection pixel size was adjusted to . mm for the vg, to . mm for the dst and to . - . mm for the other cameras. reconstructed slices were obtained by ramp filtered backprojection and chang attenuation correction using a ge vision . powerstation. hot and cold contrasts were determined using in-house developed software. from the known shape of the phantom and the pixel size, this software automatically proposed a template of regions of interest (roi) of predefined sizes. for each rod, two circular rois were used: one having the rod diameter and a smaller one. for each roi, the software computed the contrast using the roi mean pixel value and the roi minimum (cold) or maximum (hot) pixel value. the user was allowed to shift and rotate the template in order to coregister the rois with the rods and the background areas. results. the cold contrasts were very similar although the multispect- , the dst and, to a lesser extend, the magicam delivered somewhat lower contrasts. the smv cameras, the multispect- and the magicam, but again to a lower extend, generated lower hot contrasts than the other cameras. among the cameras that presented the highest contrasts, the sensitivity of the e-cam was to % higher. conclusions. recent multi-heads cameras from ge and siemens perform equally well from the point of view of contrast in tomography but with differences in sensitivity amounting to - %. monte carlo simulation for in- imaging using a scintillation camera with a low-energy general purpose collimator indium- (in- ) emits gamma rays with two different energies, kev ( %) and kev ( %). for in- imaging, the use of a medium-energy (me) collimator is preferable to a low energy (le) collimator. the me collimator, however, has poorer spatial resolution than the le collimator. we reported the improvement in spatial resolution of in- imaging with the combination of the low-energy general purpose (legp) collimator and the collimator-penetration correction (cpc) by a blurring filter in eanm' athens. the aim of this study is to validate a monte carle simulator developed for investigating the cpc method on in- imaging using the legp collimator. material and methods: in order to simulate a commercially available scintillation camera, we modified the in-house monte carlo program (mcep code) that our coauthor has previously developed for the transport of photons and electrons in matter. in this modified mcep code, interactions of photons in the scattering medium, the camera collimator, the nai crystal, and the back-compartment (including the light guide, photomultipliers, and electronics located behind the nai crystal) were accounted for. furtermore, special attention was paid to collimator penetration. simulations were carried out for some in- sources in air and in water, and energy spectra in the energy range - kev and images with two % energy windows set at the kev and kev photopeaks were calculated. images were separately obtained for unscattered, scattered and penetrated photons. in order to validate the modified mcep program, data acquisitions were performed using the gamma camera (gca a/di, toshiba, japan) equipped with the legp or megp collimators under the same condition as the calculations. results: the energy spectra calculated for both the legp and megp collimators were in good agreement with the measured ones. the simulated planar images for the in- source also agreed well with the experimental measurements in spatial resolution and the count profiles. the images simulated for the legp collimator's septal penetration of the kev gamma rays were very similar to the acquired images. conclusion: the modified mcep program for the in- source was validated through comparison with experimental data measured on the real scintillation camera. since this program allows for an accurate septal penetration of the kev gamma rays on the legp collimator, it is very useful for studying and optimizing the cpc method. as nuclear medicine imaging has been widely used in diagnostic and treatment, improving the image quality is so important which is not performed by conventional collimators. slit-slat collimator has been proposed for this purpose although the optimization of such collimators has not been performed yet. in order to compare the system with slit-slat and hexagonal collimator this work is performed, in which the gamma camera system with both slit-slat collimator and hexagonal collimator was simulated by monte carlo method. the simulation of hexagonal system was compared with practical results and a good correlation was found between them so in this way the validity of our simulation code was confirmed. the nai(tl) crystal thickness for simulated gamma camera systems with both slit slat and hexagonal collimator for detection of kev photons was set to be / in .since in our case we compare slit slat and hexagonal system ,collimator parameters were chosen the same as legp collimator. the simulated ss collimators consisted of lead plates and the imaging was performed by rotating the ss collimator from to in steps of . each. spatial resolution, detection efficiency, geometric efficiency and modulation transfer function (mtf) of this system for both hexagonal and ss systems were evaluated and compared. moreover the mtf of ss system was confirmed by the fourier transform of point spread function. based on the mtf value, our result showed that the spatial resolution of mentioned systems are the same whereas the relative detection efficiency of the ss system was about . times more than efficiency of hexagonal system as well as the geometric efficiency of slit slat system, which is . times more than hexagonal. the results of this study show that the ss collimators have great advantages over than hexagonal collimators by providing much higher detection efficiency, besides higher geometric efficiency while maintaining a comparable spatial resolution. as a result using this collimator makes it possible to have a better image quality in nuclear medicine imaging systems. a. kamali asl , s. sarkar , s. star artifact is one of the conventional artifacts in nuclear medicine imaging which is produced by gamma penetration in collimator septa. this effect is more profound for high energy photons. thick collimator septa reduce septal penetration but lead to formation of hole pattern in detection area and consequently degrading the quality of images, (dark area under collimator surface). one of the most important issues in collimator design is to how to reduce contribution of photon penetration and hole pattern artifact in acquired images. a gamma camera system with both hexagonal parallel hole (hex) and slit-slat (ss) collimators was simulated by monte-carlo method. the validity of simulation was done with practical data for kev photons and a good correlation was found between them. point spread function (psf), modulation transfer function (mtf), spatial resolution, efficiency, star artifact, hole pattern artifact and optimum geometry for ss collimator were evaluated for high energy photons ( up to kev ) and were compared with those of a conventional hex collimator. the efficiency of the system with ss collimator after background subtraction was measured to be times higher than hexagonal collimator and spatial resolution was . mm and . mm with % statistical error for ss and hex collimators respectively. based on our ss collimator optimum geometry, septal penetration was reduced while star artifact was remained unchanged.. by increasing the number of step rotation of ss collimator, a free star artifact imaging is achievable. the contribution of septal penetration of an optimum ss collimator was reduced more than % in comparison with hex collimator. consequently our simulation data showed that with ideal collimator material, contrast has been improved about - % . our results showed that using ss collimator has a profound effect on increasing efficiency while the spatial resolution was comparable with the system using the conventional hex collimator. in addition to increasing efficiency, star artifact was removed and contrast was improved using high attenuation material such as depleted uranium or high density material. modelling of system response with depth-dependent resolution as part of iterative reconstruction has been proposed as a resolution recovery technique in spect. recently, such schemes have become commercially available by manufacturers within routine reconstruction software implemented at clinically practical processing times. as well as improving on reconstructed spatial resolution such schemes may offer improvements in terms of signal-to-noise by supporting a more accurate detection model. we have assessed the performance of one such scheme, the philips astonish, available as part of osem reconstruction for clinical spect data. on the basis of point spread function measurements in a thorax and neck phantom the algorithm demonstrated substantial improvements in fwhm and fwtm for the parameters tested both with m tc and i spect data without affecting conservation of counts. an additional feature of precise modelling of the acquisition process appears to be an improvement in the statistical properties of the images with lower dependency on acquisition times. as convergence of statistical schemes is generally dependent on activity distribution the performance of the algorithm was assessed with more complex objects and with patient data. patient data were acquired with 'concurrent imaging' allowing multiples of seconds i.e. , , and sec per projection recorded from the same scan in order to assess the effect of counting statistics. on the basis of test objects, depth-dependent resolution modelling shows encouraging results for recovering resolution in data acquired with wider collimation and higher sensitivity. preliminary results with m tc-mdp and post-therapy i spect studies demonstrate improvements in signal-to-noise levels and reconstructed resolution. introduction: the cyclone storage phosphor imager is a digital film-less autoradiography system for qualitative and quantitative imaging of radioactivity. reusable storage phosphor screens capture and store the activity and are then scanned to create a high resolution digitized image. the phosphor-imager is a versatile tool in nuclear medicine for a broad range of applications. aim: to demonstrate the versatility of the phosphor-imager in common nuclear medicine techniques including in-vivo imaging, histology, quality control of protein radio-labeling and radionuclide uptake in cultured cells. methods: tissue from mice treated with i pr a was exposed to storage phosphor screens. histological tissue sections of rat with in and tc labeled octreotide were exposed to storage phosphor screens. thin layer chromatography (tlc) plates spotted with lu octreotate and developed with solvent were exposed to storage phosphor screens. in cultured cells in multi-well plates and collimators were exposed to storage phosphor screens. conclusion: the storage phosphor-imager is a versatile tool in nuclear medicine. it offers high resolution and quantitative analyses with a linear dynamic range of orders of magnitude. it detects activity with a better efficiency than film and can significantly reduce exposure times compared to film. the storage phosphor-imager is a useful and relatively inexpensive autoradiography device for gels, chromatograms, tissues and multi-well plates. determination of internal contamination is one of the important task in radiation accident management program. cs is one of the important radioisotopes in radiological and nuclear accident. possibility for using routine gamma camera system for this situation could be of great value. an adult bottle mannequin absorption (bomab) phantom has been used for calculations. a gamma camera with low energy general purpose (legp) and high energy general purpose (hegp) collimators has been simulated with monte-carlo method and evaluated with practical data. the simulated bomab phantom has standard dimensions. minimum detectable activity (mda) and counting efficiencies for cs and i were simulated individually. also the members of bomab phantom with different contamination of cs and i have been studied. the result of benchmarking showed a good correlation between simulation results and practical data. for the first time our new data regarding mixed cs- i source reveals strategies will exist for evaluation. the mda for cs with gamma camera is several times higher than mda's whole body counter but availability and logistically using the gamma camera in large accidents will be appreciated for primary triage and response. in other way our results showed that using a thicker or higher density of crystal can to improve the quality of results. also background contribution has important rule in accuracy of mda. determination of the weights of downscatter windows in i- spect studies r. de nijs, c. svarer; copenhagen university hospital, copenhagen, denmark. aim iodine- emits photons of kev which are detected in an imaging window. downscatter of high energy photons contributes significantly to this window, primarily by penetration of the collimator and backscattering into the crystal. for determining the weights in the triple energy window (tew) approach it is assumed that the count energy density varies linearly inside the imaging window. since the peak value of the backscattering is positioned at kev close to the energy of the imaging photons this is not the case, and the correct weight might be significantly different. for low count (e.g. dynamic) studies broader energy windows are preferred and a method of determining the weights is needed, since the ratio of the downscattered photons in the imaging window and the downscatter correction window is not known. methods if it is assumed that there are no primary and scattered photons detected in the background of the projection data, the weight for a downscatter correction window can be determined by minimizing the background outside the object. as an illustration the dual energy window (dew) scatter correction was extended with a broad downscatter correction window d ( - kev). in the dew approach a scatter window s ( - kev) is subtracted from the imaging window i ( - kev). both the scatter and the imaging window were corrected for downscatter by subtracting the weighted downscatter window. final images were reconstructed from i-k *d-k *c=i-(k -k *k )*d-k *s, where c denotes compton scattering, k and k are downscatter weights for i and s, and the weight k is the empirical dew scatter multiplier which was assumed to be . . measurements were performed on a -headed irix camera (philips medical) with legp collimators. reconstruction was performed with and without (down)scatter corrections in x matrices ( . mm pixel size) using fbp, a low pass th order butterworth filter at . nyquist and uniform attenuation correction. results human studies of both the serotonin (i- -adam) and dopamine (pe i- ) transport system were analyzed. the downscatter weights k and k were measured to be . - . and . - . for both studies. for a flat energy spectrum these values would be . (same window width) and . (= / ), respectively. conclusions the weight of a downscatter window can be determined by minimizing the background in the projection data. this makes an extension of the dew approach with a broad downscatter window possible. objectives: we devised a new correction method that combined attenuation correction using a difference of intrinsic dual-energy between lower energy emissions ( kev) and higher energy emissions ( or kev) without transmission scan and compton scatter correction using triple-energy window (tew) method for kev because of enhancing a difference of intrinsic dual-energy in ga citrate ( ga), and applied to jis phantom and tumor phantom spect studies. methods: attenuation coefficients ratio and counts ratio for kev/ kev or kev/ kev were calculated from spect data acquired by energy window of kev, kev and kev, respectively. the jis phantom for concentration linearity and resolution measurements was used. in phantom study, size of tumor simulated sphere types with . , . , . , . and . cm in diameter, and tumor types were created with tumor to non-tumor (t/nt) activity ratios of . : , . : and . : . the images reconstructed by non-attenuation-scatter (a(-)s(-)) as a conventional method, only scatter (a(-)s(+)) and attenuation-scatter (a(+)s(+)) correction were compared by visual and quantitative analysis, respectively. results: the adequate attenuation coefficients ratio and counts ratio for kev/ kev were . and , respectively. for jis phantom, concentration linearity was kept, and then fwhm was shown improvement. in the tumor phantom, the t/nt ratio was improved by attenuationscatter (a(+)s(+)) correction, and approached the real value. the quality of image for attenuation-scatter (a(+)s(+)) was higher than that for non-attenuation-scatter (a(-)s(-)). conclusions: it is suggested that a new correction method that combined attenuation correction using a difference of intrinsic dual-energy and compton scatter correction using triple-energy window (tew) method for kev is useful in ga tumor spect studies. background and aim: in vivo neuroimaging techniques in correlation with mri imaging, offers a potential which can reliably assess early clinical and pre-clinical diagnosis in parkinson's disease. the aim of this study was to compare striatal's volume from mri volumetric measurements with the specific binding index (sbi) from regional datscans results method: in thirty five patients both dopaminergic imaging using i -fp-cit spect and mri scanning were performed. specific binding index (sbi) has been calculated from regional datscan both for left and right striatum respectively, by applying the formulas: sbi left=( cv left/ cb-vv)/vs and sbi right=( cv right/ cb-vv)/vs where: cv left: total counts in left striatum roi, cv right: total counts in right striatum roi cb: total counts in background region divided by volume of the background region. vv: volume of roi, vs: volume of standard striatum (set to . ml) mri imaging has been evaluated by employing high spatial resolution t -weighted sequence such as t -weighted/ gradient-spinecho followed by a contiguous echo planar imaging sequence at the mid-brain striatal level in sagital projection. multi-planar reconstruction images have been analysed and volumetric measuerements created in order to compare volume in relation to the sbi results. statistical significance of these results was assessed using the mann-whitney test. results: the overall results show a significant relation between the two imaging modalities for discriminating normal, parkinsonian syndromes ( ps) and essential tremor (et) patients . aim: patients with carcinoma of the breast undergoing sentinel lymph node (sln) imaging in nuclear medicine may also undergo ultrasound guided wire localisation when the primary tumour is non-palpable. the wire localisation is performed by radiologists shortly after sentinel node imaging using m tc colloid. due to operational restrictions the wire localisations can only be undertaken after sentinel lymph node imaging. therefore, it was felt necessary to carry out a study to assess radiation dose to staff performing the wire localisation procedure. method: in our centre there are two regimes for patients undergoing sentinel lymph node localisation; patients injected with mbq of m tc colloid are sent for surgery on the same day whilst patients injected with mbq undergo surgery the following day. a number of dose measurements were performed including extremity, whole body and instantaneous dose rate readings during the procedures. chest and ring monitor badges were worn by the two radiologists whilst performing the wire localisations. in this study patients were included of which were injected with mbq and injected with mbq. results: for the patients the mean delay between injection and the wire localisation procedure was . hours ( mbq) and . hours ( mbq). the mean duration of all procedures was minutes.. all doses measured using the body and ring monitor badges were below the minimum detectable limits of μsv (whole body badge) and μsv (ring). a mean instantaneous dose rate of μsv hr - was measured at the minimum observed source-radiologist separation ( cm) for patients injected with mbq. based on this, body and finger dose estimates per procedure were calculated as . μsv and . μsv for the mbq patients and . μsv and . μsv for the mbq patients. conclusions: the measured dose estimates from our study show that doses received by radiologists performing ultrasound guided wire localisation procedures following patients injected with m tc colloid are insignificant. for comparison, in order to receive the annual public dose limit of msv any one radiologist would need to perform approximately procedures per year. aim: radioguided surgery and sentinel lymph-node biopsy has become standard of care in patients with breast cancer. these procedures are usually done in operating room working in close proximity to an electrosurgical unit (esu) that is known to produce high levels of electromagnetic (em) fields. this study analyses the risks deriving from the interference of esu with the operation of a gamma-probe (gp) and suggests some practical recommendations intended to minimize them. methods: we investigated the function of hand-held gps of different manufacturers (csi(tl) scintillator) evaluating their change in operations and malfunctions in the presence of strong em fields. while the tests were under way both esu and gamma probe have been set as for routine clinical use simulating a typical operating-room environment (esu's output power ranging from to w -full, ± % and ± % photopeak energy window). results: all devices tested were affected by electromagnetic interferences (emi) especially when the hand held gp was used in close proximity (< cm) of the electrosurgical return-plate and the surgeon was coagulating tissues. the interferences recorded range from a simple buzzing noise to an erroneous data displayed. in the worst case the device emitted a continuous audio signal also there were no radioactive isotopes nearby. conclusions: our study demonstrates that gamma probes are particularly sensitive to electromagnetic disturbances that can be radiated during electrosurgery activities. based on the previous results the overall suggestions and recommendations intended to avoid these unwanted effects can be summarized as follows: • do not allow electrosurgery cables to lay over or contact the cables of gp; • do not place the esu's return-plate near the lymph-node excision region; • whenever possible, use the narrower energy windows setting for the intended purpose; • all sources of rf energy should be kept at a sufficient distance from gp. considering that electromagnetic radiation it's governed by the inverse square law we suggest to place the esu and all other accessories at least . meter away from gp. aim: we aimed to analyze the different steps involved in the maintenance procedures required to run a medical cyclotron. we are operating an iba cyclone / , which is dedicated to clinical pet radionuclides production. cyclone / is a fixed energy cyclotron that accelerates hions until mev and dions until mev; our machine has eight exit ports equipped with five targets: one titanium liquid target "large volume" for f production, one niobium liquid target "large volume" for f production, one silver liquid target "small volume" for f production, one aluminum gas target for c production and one aluminum liquid target for n production. materials and methods: eight scheduled maintenance interventions are required every year, operated by iba field engineers and by the hospital staff; the complexity of the maintenance interventions changes depending on which cyclotron part has to be checked. target maintenance: no need to open the cyclotron (no vacuum shut-down); targets must be disconnected from the cooling lines; mean execution time: min/target source maintenance: cyclotron must be opened (vacuum shut-down); ion source must be disconnected from the cooling lines; mean execution time: hour stripper-foils maintenance: cyclotron must be opened (vacuum shut-down); mean execution time: min after every interventions a short beam is made on each target to verify the cyclotron yield. results: since the cyclotron started to produce radionuclides, in may , we made twenty-eight maintenance interventions, operated in part by iba field engineers and in part by the hospital staff; intervention time varied from few hours to a maximum of two days. from the radiation protection point of view, the operator total body absorbed dose is mainly dependent on the time between the last radionuclide production and the intervention. for this reason maintenance intervention are scheduled on monday, after days of cyclotron stop. up to now, from the collected data we measured a mean total body absorbed dose of μsv (range - μsv) for hospital workers, with a mean time of stay inside the bunker of min (range - min). conclusion: after three years of experience we can state maintenance interventions (i.e. routine target, ion source and stripper foils maintenance) can be performed by hospital staff without particular problems. on the other hand, for more technical demanding problems, field engineers has to be called on-site to perform the required procedures. background: phantoms using printed radioactive paper sheets from an ink-jet printer may be used to provide test objects with a close approximation to the d activity distribution in organs. however, these phantoms do not necessarily accurately represent the attenuation properties of soft tissue since they are made of a composite of paper and perspex. we propose that a stack phantom constructed of paper and sheets of spacing material can be produced with a close approximation to the attenuation properties of soft tissue, provided the correct ratio of paper to spacing material is used. aims: to measure the effective linear attenuation coefficient of paper, and to use this information to calculate the composition of a paper and spacing material stack phantom to have soft tissue (water) attenuation characteristics. the effective linear attenuation coefficients of paper and water were measured for m tc using a gamma camera (siemens e.cam) with an leap collimator in broad beam geometry. the paper was a standard office printer paper, g/m . the measured values were used to select a spacing material from published attenuation values. perspex was selected since it has a higher attenuation coefficient than water, to balance the lower attenuation coefficient of paper in the composite phantom, and because of its availability, low cost and ease of machining. the effective linear attenuation coefficient of perspex was measured, and the correct proportions of paper and perspex for use in the phantom were calculated. a stack phantom with these proportions was constructed and the linear attenuation coefficient of the paper-perspex composite was measured. results: the measured effective linear attenuation coefficients were . cm - for water, . cm - for paper and . cm - for perspex. this gives a required paper to perspex ratio of . : for water equivalence. the linear attenuation coefficient of this composition was found to be . cm - (difference to water: . cm - ). in a cm thick phantom this difference in attenuation represents a small ( . %) increase in gamma ray penetration between soft tissue and the phantom. conclusions: paper-perspex composite stack phantoms can be constructed to have attenuation properties very similar to soft tissue, enabling pseudo-anatomical soft tissue equivalent phantoms to be produced. production of radioactive quality assurance phantoms using a standard inkjet printer. j. a. van staden, h. du raan, m. g. lötter, a. van aswegen, c. p. herbst; univ. of the free state, bloemfontein, south africa. aim: the use of a standard inkjet printer is proposed to produce radioactive phantoms that can be used for the routine quality control of gamma cameras. the purpose of this study was to evaluate the printed radioactive phantoms and demonstrate their use by the determination of the camera resolution. material and methods: the ink used to print the phantoms was obtained by adding a well mixed solution of black ink and m tc pertechnetate to the cartridge of a hewlett-packard inkjet printer. ms powerpoint software was used to create an image that is representative of the radioactive distribution required. the distribution was then printed on paper using the radioactive ink. imaging was performed with a ge at starcam camera fitted with a low energy all purpose collimator and alfanuclear acquisition software. the amount of activity to be deposited on paper per unit area was predicted and compared to the measured activity. the uniformity of the printouts was compared to the uniformity obtained with a standard co flood source. joining two a size printed phantoms to create larger sources was evaluated. the spatial resolution obtained with printed sources was compared to that obtained using standard line source techniques. a resolution image was also obtained from a m tc printed bar quadrant phantom and compared to an image obtained with the lead bar pattern using a co flood source. results: the results indicated that the uniformity of the printed phantoms compared well with those obtained with the co flood source [integral uniformity . % (printed source) and . % ( co flood source)], and the accuracy of the activity predicted to be deposited was better than %. there was no difference in the resolution measurements obtained with the printed sources and those obtained with the standard methods. conclusion: this study demonstrates that affordable phantoms can easily be created to evaluate system uniformity and resolution in any department where a standard pc and inkjet printer are available. aim: a lot of sophisticated models are available for the quantitative interpretation of dynamic pet data. parameters in these models are used to define quantities, such as metabolic rate, blood volume and flow, etc., characterizing the functional physiological and/or biochemical status of tissue in vivo. normally, these models are so sophisticated that the physicians cannot easily handle them without much experience. this study proposes an innovative machine learning method for parameter imaging and kinetic modeling of pet data, which can automatically predict the values of quantitative pet parameters using learned regression models from accumulated training studies of kinetic modeling. materials and methods: the support vector machine (svm) approach was used as machine learning algorithm in the tool. svms are a set of related supervised learning methods used for classification and regression. we used the cross-validation and grid-search for automatically choosing the kernels parameters. we choose the spreadsheet file with customized header as the data standard. based on the java implementation, the software is currently offered for different operating systems. by now, we collected studies of quantitative pet parameters as training samples from -tissue compartments modeling. each training sample comprises the value of pet parameter as y value and input data as well as model data as x values. then different regression models are built for different pet parameters. using the models, we can predict the values of quantitative pet parameters of vois or pixels according to the tac of them. the tool is integrated to the pmod software (pmod technologies ltd., adlisvil, switzerland). results: squared correlation coefficient was calculated from cross-validation. the highest correlation coefficient was obtained for k for . . two correlation coefficients were also very high: vb = . , inf= . . other three correlation coefficients were below . : k = . , k = . , k = . . parametric images were also calculated for these parameters using the trained models. conclusion: the initial results show that machine learning based calculation of quantitative pet parameters is helpful for parameter imaging and kinetic modeling of pet data. it can be applied to any kinetic model based on the training studies of specific model from modeling expert. specially, the machine learning based method can be integrated with other kinetic models and be used as initialization technique for the models to decrease the number of iteration of the iterative-based kinetic methods. densitometry by dual-energy x-ray absorptiometry (dxa)is the gold standard for osteoporosis diagnosis and pharmacological treatment monitoring. the hologic qdr-discoverya densitometer offers a positioning scan mode and three different measurement scan modes: "fast-array", "array" and "high-definition", which differ in image definition, scan time and patient radiation dose. aim of this study was to assess a possible significant differences, between in-vivo bone mineral density (bmd) result measured by different scan mode and if this differences are clinically significant. patients enrolment started just after annually routine maintenance and calibration procedures by hologic inc. all acquisitions were performed by the same skilled operator. repeated acquisitions were performed for each skeletal site through the three different scan modes without repositioning of the patient between scans. analysis on whole patients and on a obese subgroup (body mass index > ) was carry out. bmd was expressed as g/cm and as t-score (sds from normal reference population database) for instrumental diagnosis (t-score > - sd for normal; t-score ranging between - and - . sd for osteopenia and t-score < - . sd for osteoporosis). patients ( man) for lumbar spine and ( men) for femoral neck were enrolled. we found a significant differences between bmd measurement in fast array/array mode and high definition mode ( , g/cm p< , anova, bonferroni's multiple comparison test). moreover, bmd differences were correlated with bone mineral content (bmc) values for fast array vs high definition (r= , ; p< , ) and for array vs high definition (r= , ; p= , ). the difference between different scan modes were statistically significant, but seem too small to be relevant in order to achieve a correct clinical diagnosis; . % of lumbar spine instrumental diagnosis based on array mode measure was different from those calculated on high definition and . % of total hip on fast array from high definition. our data suggest that for correct clinical diagnosis a physician evaluation of dxa results is needed. aim: renal volume measurement is an essential part of split renal function assessment in mr urography. the aim of this study was to assess the accuracy and repeatability of a three-dimensional segmentation algorithm based on the belief functions theory in calculating renal volumes from mr images. materials and methods: the true volume of various sized animal kidneys was obtained by fluid displacement. each kidney was examined using two different mr units. d proton-density weightedacquisitions with incremental slice thickness were obtained. the mr volume was then measured with a segmentation algorithm based on the belief functions theory. two independent observers performed all segmentations twice. accuracy, intra-and interobserver variability were evaluated by the bland-altman method. the number and type of manual corrections were recorded, as well as the whole processing time. the mean renal volume estimated by fluid displacement was ml (range, - ml). the maximal standard deviations of the difference were: . ml (accuracy), . ml and . ml (respectively intra-and inter-observer variability). segmentation of axial slices provided better accuracy and reproducibility as compared with coronal ones. overlapped coronal slices yielded poor results due to the partial volume effect. the mean processing time, including optional manual modifications, was shorter than seconds. conclusion: the belief functions theory is an accurate and reproducible mathematic method to assess renal volume from mr adjacent images. in the s the discovery of expression of somatostatin receptors on net cells made the use of somatostatin analogues in diagnosis and therapy possible. the aim of the study was to assess response of targeted radio-nuclide therapy with radio-labeled somatostatin analogue y [dota , d-phe , tyr ] octreotate (dotatate) and mixed y/ lu-dotatate in treatment of disseminated nets. materials and methods: patients with diffuse nets were enrolled, divided into two randomization group by pts. one group was treated by y dotatate: men, women, aged , +/- , . second group was treated by y/ lu dotatate: men, women, aged , +/- , . before therapy blood tests for hematology, kidney and liver function, cga were done. all patients underwent ct and scintigraphy with m tc-hynic-tate. treatments of y -or mixed y/ dotatate were repeated - weeks apart up to total calculated doses - mci /m ; per one course we usually used mci. mixed amino acids infusion was used for kidney protection. results: y dotatate: . regression of disease (pr -decrease of size and number of metastases, decrease of cga level, good clinical response) was observed in pts . stable disease (sd-stable size and number of metastases, decrease of cga) was observed in pts . patients died no nephrotoxity was observed. wbc and plt levels were stable during therapy in pts. in pts leucopenia was observed (wbc level < x / mm ); serious neutropenia < x / mm , was observed in pts. plt level decreased in pts, but thrombopenia was observed only in patient . y/ lu dotatate . pr was observed in pts, . sd in pts. . patients had progression of disease during the therapy, of them died. in pts increase of ceratinine level was observed (abnormal creatinine level from the beginning of therapy). liver tests were stable.wbc level was decreasing during therapy in all patients; we observed no serious neutropenia. plt decreased in / pts. conclusions: . it seems that y dotatate or mixed y/ lu dotatate come to the same results in treatment of patients with diffuse neuroendocrine tumors in month observation. . higher decrease of plt was observed in group treated by y dotatate than y/ lu dotatate. . lower decrease of wbc was observed in group treated by y dotatate than y/ lu dotatate, however in that group serious neutropenia < x / mm was observed p results y-dota tate therapy in patients with neuroendocrine tumors -own experience of years therapy j. kunikowska , l. krolicki , a. hubalewska-dydejczyk , a. sowa-staszczak , r. mikolajczak , d. pawlak , m. kobylecka , j. maczewska ; med.univ. of warsaw, nm dept., warsaw, poland, collegium medicum cracow, cracow, poland, obri polatom, swierk, poland. the aim of the study was to assess response of targeted radio-nuclide therapy with radio-labelled somatostatin analogue y-[dota , d-phe , tyr ]-octreotate (dotatate) in the treatment of disseminated nets. material and methods: patients (aged , +/- , ): carcinoid- pts, insulinoma- pt, gastrinoma- pts, pancreatic net- pts, neuroendocrine cancer without primary tumor- , stomach net- pt were enrolled in the study. before the therapy, blood tests for hematology, kidney and liver function and cga were performed. all patients underwent ct scans and m tc-hynic/edda-octreotate srs. . scintigraphy examinations were made with two-head elscint gammacamera, using m tc labelled somatostatine analogueoctreotate, with - mbq activity; using planar and single photon emission computed tomography (spect) techniques. and hours after injection the data was acquired in x s mode, matrix x . ct scans were performed on ge light speed . images were acquired before iv injection of contrast media mm slices thickness and in the arterial - , mm, and portal venous phase- , mm.pmod software was used for fusion imaging. treatment with y-dotatate was repeated every - weeks up to the total of mci/m . mixed amino acids infusion was used for kidney protection. results: one year observation: regression of disease (prdecrease of size and number of metastases, decrease of cga level, good clinical response) was observed in pts, stable disease (sd-stable size and number of metastases, decrease of cga) in pts. patients died. no nephrotoxicity was observed. wbc and plt levels were stable during therapy in pts (without chemotherapy). in pt with previous chemotherapy (last course a month before radiotherapy), plt level decreased ( x /mm to x /mm after the first course); the patient died two months after the beginning of the therapy. in pts leucopoenia was observed (< x /mm ) but serious neutropenia (< x /mm ) was found in pts with previous chemotherapy. thrombocytopenia (plt < x /mm ) was observed in patients with previous chemotherapy. two years observation: prolonged pr - pts; sd- pts, progression of disease in pts: with gastrinoma and stomach net without hormonal activity ( and months after radiotherapy). blood tests stable. conclusion: pr and sd were observed in / patients with disseminated net. severe haematologic toxicity was mainly observed in patients after prior chemotherapy -the question of optimizing the time between chemotherapy and radiotherapy is still open. this study was supported in part by a research grant for scientific research ( /p. - / ) from the ministry of health and ministry of education. o. solodyannikova, g. sukach, v. tratsevsky; institute of oncology of amsu, kyiv, ukraine. background. limitations of possibilities of radio-and chemotherapeutical methods for medullary thyroid cancer (mtc) resulted in use of radionuclide pharmaceuticals (rp) for its treatment. the most frequently used is i-meta-iodinebenzilguanidin ( i-mbg). problematic is monitoring of mtc patients and estimation of treatment efficacy. aim was the analysis of treatment results of mtc patients using i-mbg and m tc-carbomec for the follow-up and estimation of the treatment effectiveness. materials and methods. patients received intravenous i-mbg ( mbk). there were no complications or side effects during day stay at a clinic. three patients received repeated therapy with an interval of one year. the follow-up included scintigraphy (sg) of thyroid gland with m tc-carbomec, estimation of blood calcitonin level, ultrasonic examination and in some cases computed tomography. the repeatedly treated patients were under the follow-up during two years. during this period the whole-body scanning on residual dose of i-mbg and three times with m tc-carbomec was performed. in seven patients, who received single i-mbg treatment, diagnostic scanning was performed three times (follow-up - . years). in eight patients, treated with i-mgb, term of the follow-up -a year, diagnostic examinations with i-mgb and m tc-carbomec were performed twice. in patients diagnostic scanning with m tc-carbomec was performed after surgery, in of them -once, in -twice (follow-up - . - . years). results. during observation various reactions for i-mgb treatment have been detected. in of patients ultrasonography, sg and calcitonin level , , months after the treatment didn't detect prolongation of the pathologic process. after first course of therapy in one patient increase of calcitonin level months after resulted in appearance of hyperfixed lymph nodes on sg with m tc-carbomec. in one patient with metastatic foci in liver i-mgb therapy and control with m tc-carbomec months after didn't detect negative dynamics. in two patients with men syndrome and mtc sg with i-mgb, performed on residual therapeutic dose, revealed rp decrease but sg with m tccarbomec performed months after treatment and calcitonin level didn't reveal signs of disease progression. in patients, who didn't receive i-mgb, basing on diagnostic scanning with m tc-carbomec dissection of neck lymph nodes was carried out and sg with m tc-carbomec half a year after didn't detect prolongation of the process. conclusion. use of radionuclide therapy and diagnostics significantly increase outcomes of mtc patients' complex treatment and monitoring. p -monday, oct. , , : pm - : pm, poster area radionuclide therapy/dosimetry -clinical thyroid, bone pain palliation and miscellaneous a. k. sinha, male; national university hospital, singapore, singapore. paper describing therapeutic uses of radium was published; in , {sup } na was administered as a therapy to a leukemia patient. three years later, uptake of {sup } sr was noted in bone metastases. during the s, there was increasing use of iodine therapy for thyroid diseases, including thyroid cancer. radiolabeled antibodies targeting human tumors in animals were reported in ; antibody tumor imaging in humans was reported in . since then development of new radioisotopes and new radiopharmaceuticals, coupled with improvements in technology, make therapeutic nuclear oncology an area of growth for nuclear medicine. our aim is to project the role of therapeutic nuclear medicine in different cancer and its related complication in poster presentation. these radionuclide therapy done at national university hospital, and singapore general hospital, singapore with i- ,receptor based antibodies, peptides and bone-seeking radionuclides. methods: it involved a retrospective review on the treatment of different type of the cancer and its related complications (thyroid cancer, non-hodgkin's b-cell lymphoma, neuroendocrine tumor, liver tumor and bone pain from metastatic disease) with radionuclides, performed at national university hospital and singapore general hospital, from to in the dept of nuclear medicine. results: results are encouraging and it will be presented in the poster. conclusions: globally increasing numbers of the cancer patients, including those with thyroid cancer, lymphoma, different form of neuroendocrine tumors, liver cancer, metastatic bone involvement with prostate and breast cancer, radionuclide therapy has already become an important component of modern medical practice. new drugs application (nda) is promising form of therapy on the new horizon in the field of targeted peptides and antibodies therapy. mapping of human genome is the greatest scientific achievement of this era. molecular methodologies that were developed during human genome project, led directly to the discovery of improved molecular targets for targeted therapy. the current era moving toward increasing sophistication of radiopharmaceutical formulation, including antibodies, peptides, nano particles, fusion proteins and small organic molecules which will lead to better agents and better patterns of practice for established practice. aim: the most widely accepted protocol for the treatment of painful bone metastases suggests to administer a weight-based activity of sm-edtmp (sm) ( mbq/kg). this procedure is obviously inadequate for over weighted patients, with the risk to deliver more than gy to bone-marrow. in order to easily approach to a pre-therapy dosimetric evaluation, we tried to estimate the sm uptake by a dual mdp bone scan semiquantitative study. patients and methods: the bone uptake of ( f/ m) pts with painful skeletal metastases was studied. the week before the treatment each pt underwent mdp bone scan with a double acquisition ( min and - hrs p.i.) under the same conditions, in order to evaluate the skeletal uptake and personalize the radioactive amount of sm for the treatment. prior to inject mdp the patients were invited to void. mins after i.v. injection the patients underwent total body scan (wb) with a double-head gamma camera, with particular attention to include the whole body in the field of view. a post-micturition acquisition was repeated - hrs later, under the same conditions. identical acquisitions were performed mins and hrs after sm injection. methods: rois were drawn in order to calculate the counts for each wb. the counts were decay corrected and the geometric means for opposite views were calculated. the uptake was estimated as: u= xcnts(delayed)/cnts(early). statistical analysis was performed. results: mdp skeletal retention ranged from % to % (mean= , sd= ). sm retention ranged from % and % (mean= , sd= ). a good correlation was found between sm and mdp retention (linear regression coefficient r = . ; y= . x+ . ). if two cases (who received zolendronate the day before the study) are excluded from the study (due to a markedly interference of bisphosphonate uptake), the correlation improves (linear regression coefficient r = . ; y= . x+ . ). conclusions: the dual mdp bone scan methodology is useful to predict the retention of sm in patients with painful bone metastases. this approach can lead to a personalized dosimetry in planning radiometabolic treatment to administer the highest activity of sm, respecting the constraint of gy to the bone marrow. recent zolendronate infusion could impair bisphosphonate uptake. aim: to investigate haematological safety after multiple doses of rhenium -hedp, a betta-emmiting factor used in the palliative therapy of painful bone metastases. patients and methods: aiming to that, we evaluated patients with painful osseous metastases ( men with prostate cancer, women with breast cancer), mean age= . +/- years, who received fixed doses ( mbq) of rhenium -hedp, far off other therapeutic manipulations. of these, patients (group a, mean age= +/- years, men) underwent multiple ( - ) radioanalgetic therapies (mean= . +/- . ) and the rest patients (group b, mean age= . +/- . years, men) underwent only one therapy. haematological status (hgb, wbc and plt count) and karnofsky pain scale (ks, estimated by an established numeric rating scale, values - ) of all patients were followed up every days for months after last therapy. results: respective pretherapeutic blood count absolute values (+/-sd) of groups a and b: hgb= . +/- . and . +/- . , wbc= +/- and +/- , plt= +/- and +/- thousand. maximum percentile decrease of blood counts during the three month follow up period in groups a and b: hgb= % and %, wbc= % and %, plt= % and . %. paired t-test analysis did not show statistical difference in hgb values between pre-and post any radioisotopic therapy in both groups, while significant decrease in wbc count was seen only in group a (p= . ). the plt count was clearly decreased after therapy in both groups (p= . and . respectively), but significant myelosupression was evolved only in three patients of group a (one with grade and two with grade myelotoxicity). finally, patients with good pretherapeutic clinical status (ks>/= , mean= +/- , n= ) had less decrease in plt count after therapy compared to those with ks< (mean= +/- , n= ) (respective decrease= . +/- . % versus . +/- . %, p= . ), irrespectively of patients' age, pre-therapeutic plt count or the number of radioisotopic therapies received. conclusion: rhenium -hedp is safe enough to be readministered several times if an acceptable haematological baseline status exists, especially in those patients who present with a more favourable pretherapeutic karnofsky pain index. a. tsaroucha, g. meristoudis, t. liotsou, v. giannakopoulos, c. batsakis, a. balomenos, j. christacopoulou; dept of nuclear medicine,''sotiria'' hospital, athens, greece. introduction:the role of radionuclide bone palliation therapy in patients with prostate cancer as well as breast cancer is well established. aim: the aim of the study was to evaluate the efficacy and toxicity of radionuclide palliative treatment in patients with lung cancer. method: fourteen patients with lung cancer were included in this study. they were randomized in two groups. the first group a n = patients received mbq/kgr sm-edtmp and the other group b n= received mbq re-hedp. all of them had a positive bone scan demonstrating a multifocal spread of osseous disease. blood cell counts and renal function tests were in all patients within safe limits. two of the patients were on non steroid anti-inflammatory drugs, two on weak opioids and ten on strong opioids analgesic therapy. pain was scored by an eight-point-rating-scale. pain response as well as possible myelotoxicity were checked , , and weeks after radionuclide administration. the treatment was deemed effective if the pain retreated by at least two points. results: four of the patients of group a and three of group b experienced obvious reduction of pain. however no patient demonstrated complete pain relief. the overall pain response was %. the onset of the palliative effect was between to weeks in both groups, and its duration ranged from to weeks. two of the responded patients reduced the strong opioids consumption and these two were retreated after weeks . however retreatments were less effective than initial ones. flare phenomenon occurred in two patients, one of each group. one of them eventually responded to the therapy. mild transient myelotoxicity, concerning white blood cells and platelets, occurred in three patients, two of group a and one of group b. conclusions: patients with lung cancer and metastatic bone pain can benefit from radionuclide palliative therapy. although our sample was small, radionuclide analgesic therapy in patients with lung cancer seems to be less effective than in patients with prostate or breast cancer. the two radiopharmaceuticals did not show any difference in palliative efficacy or toxicity. radionuclide treatment for painful bone metastases in patients with hormone-refractory prostate cancer j. dolezal; teaching hospital, hradec kralové, czech republic. aim: to assess the efficacy of the sm-edtmp treatment in patients with disseminated prostate cancer with bone metastases and pain. materials and methods: thirty-eight men (aged - , mean years) with bone disseminated hormonerefractory prostate cancer and bone pain received samarium-edtmp. mean applied dosage was mbq per kg of patient's body weight. karnofsky performance status, pain score (numerical rating scale), analgesic score (who) and blood count were evaluated before and and months after the treatment. results: significant pain relief was observed in % and % of patients, mild relief in % and % and no effect in % and % of patients one and three months after administration, respectively. the pain palliation was accompanied by an improvement in mobility and a decrease in necessary dosage of analgetics. mild and transient bone marrow suppression was observed as a side effect of sm-edtmp treatment. none of the patients showed haematological toxicity grade , and only patients showed grade (nci ctc). the majority of patients had haematological toxicity grade or . conclusion: after administration of sm-edtmp bone pain palliation was observed in % of patients for three months. the haematological toxicity after sm-edtmp treatment was mild and transient. values for group ii: +/- , +/- , . +/- . % and . +/- . %. with the exception of only one patient of group i who deteriorated scintigraphically, the ssi of the rest patients was unchanged. paired t-test analysis did not show statistical difference in bsi pre-and post any radioisotopic therapy in both groups, while only in group i was seen a significant improvement in ks after the completion of therapies (p= . ). furthermore, patients of group a (pretherapeutic bsi= . +/- . ) had insignificant ks change (from +/- to +/- ), while those of group b, who set out with mean bsi= +/- , resulted in an interestingly better clinical outcome (ks from +/- to +/- , p= . ), although no difference in age, number of therapies or blood counts were observed. conclusion: in spite of a minimum scintigraphic deterioration in most patients throughout the follow up period, the post-therapeutical karnofsky scores might suggest an unexpectedly favourable clinical outcome, at least in a short-term follow up period, specifically in patients who present with a more adverse pretherapeutic bone scan and who would receive multiple rather single doses of rhenium -hedp. introduction and aims: samarium-edtmp has proved to be effective as palliative treatment in patients with difosfonate fixing bone metastases (as breast, lung, prostate cancer). its utility has also been demonstrated in patients with osteosarcoma bone metastases, when administered at high doses (from to mci/kg). prognosis of patients with osteosarcoma presenting bone metastases at diagnosis or with disease relapse or progression is generally very poor. aim of this study was to evaluate the feasibility of treatment with samarium-edtmp at the doses of mci/kg in cases of osteosarcoma with multiple bone metastases, followed by re-infusion of peripheral blood progenitor cells (pbpg) gathered after administration of cycles of ciclofosfamide and etoposide (ce). patients and methods: six patients with osteosarcoma were enrolled in the study: were affected by osteoblastic forms and grading iv, had condroblastic form -grade iii and with a round cells form. two patients had metastases at onset (vertebral, pelvic, femoral and pulmonary) and went immediately treated with samarium-edtmp, patient was treated following the second disease recurrence (at femoral and pelvic levels), patient underwent treatment after the the first recurrence (at femoral and pulmonary levels). samarium-edtmp was administered via slow e.v. injection in a single dose of mci/kg, followed days later by re-infusion of pbpc ( . x /kg cellule cd +, range . - ). all patients underwent pet-ct. results: treatment was well tolerated by all patients and no cases of severe extra-haematological toxicity occurred. white blood cell and platelet nadir took place respectively at days (range - ) and ( - ) from administration of samarium-edtmp. thirty days after the administration of samarium-edtmp one of the patients at second recurrence showed bone and pulmonary progression, the patient at first recurrence showed stable disease, on the other hand, the two patient treated at onset showed partial response (with meaningful improvement of pet scan and bone scintigraphy). approximately five months after the radiometabolic treatment three patients are died and one of patients affected by osteosarcoma with bone metastases at onset is well (partial response) conclusions: although results are still preliminary, high dose radio-metabolic treatment with samarium-edtmp appears to be well tolerated and pbpc infusion allows to control haematological toxicity. aim: to assess the outcome results at months follow up of patients with painful knee oa treated with single y- rs and factors that influence the results. methods: the rs treatment response was assessed retrospectively for painful at exercise knees of patients. the duration of oa symptoms was ± months with / knee joints presented also pain during the night and / knees abnormal knee flexibility. knee joints were assigned according the steinbrocker radiological grading system ( grade_ , grade_i, grade_ii, grade_iii and grade_iv). rs was performed with intra-articular knee injection of mbq y- silicate according eanm guidelines. rs response was assessed at months in terms of a -point visual-analog-scale (vas) pain improvement from baseline values, of the improvement of knee flexibility and pain remission during the night. rs success rate results were classified as poor (vas < ), fair (vas >= - ), good (vas >= - ) and excellent (vas > ), with excellent and good results considered as success, while fair and poor results as failure. results: the percentage of vas knee joint pain improvement from baseline values was . ± . %. there was a significant difference of the vas pain improvement in patients with the duration of disease symptoms less or more than years (p= . ), with the patient's age of less or more than years (p= . ) and with radiographic changes (p< . ). with radiographic changes adjustment it was found that knees with no or mineral oa radiographic changes (steinbrocker-grade -i) respond better than those with more advanced changes (steinbrocker-grade iii-iv) in terms of vas improvement ( . % versus . %). the overall success rate for rs (vas ), was . %. failure response was . %, with no response at all found on / knees. complete response as a complete remission and a % vas improvement was found on / knees. success rate was % for knees with no or mineral oa radiographic changes and % with steinbrocker-grade ii, while the success rate of knees with more advanced changes was . %. after rs treatment, pain during the night was improved on . % and knee flexibility was totally improved on . %. these response values were significant different from the baseline values before rs treatment (p< . ). conclusions: rs in patients with oa seems to be safe, without significant side effects and short time effective. our findings implicate rs might be more beneficial in the early stages of oa. study objectives: examination of anti-inflammatory effect of -holmium-phytate injection. methods: phases i-ii, randomized, simple-blind, placebo-controlled comparative study using increasing dosage. patients suffering from chronic synovitis, rheumatoid arthritis and seronegative spondylarthritis were examined. the protocol commenced with screening. patients were randomly distributed into four treatment arms: group i. holmium phytate injectable suspension marked by mbq ho + mg of ml triamcinolone acetonide/ta/ + ml of % lidocaine injection./lid.inj./ group ii. mbq ho. + mg of ml ta + ml lid.inj. group iii. mbq ho + mg ml ta + ml of % lid.inj. group iv. solely mg of ml ta + ml of % lid.inj. inflammatory activity of the affected knee-joint was tested prior to treatment, and the th and th days, and , , , , , , and months after treatment. testing was done based on the following parameters: measurement of swelling of knee-joint [cm]; flexion -heal buttocks distance [cm]; degree of knee-joint pain. visual analogue scale /vas- - /; patient's opinion on inflammation of knee-joint /vas- - /; doctor's opinion on given inflammation of knee-joint /vas- - / results: even after year period . % of the findings were rated as excellent or good. . % of the patients do not need another punction even after a years period. we found no deviations in either haematological or chemical parameters during the study period. administration of holmium- phytate is a safe procedure. we did not detect symptoms of radiation sickness. during the study period, inflammation decreased in the group receiving and mbq. conclusion: ho- isotope is an effective radiopharmacy treating synovitis. due its adventageous features it produces less radioactive damage on the organism than the traditionally used isotopes ( -y, -er, -re). due to its physical parameters it is optimal to treat large joints, and medium size joints. -holmium-phytate has a: radiation type beta energy maximum: . mev; and radiation type gamma, energy maximum: . mev; soft tissue penetration: maximum . mm; /average: . mm /; half-life: . hours; particle size: . - μm study objectives: measur the synovial thickness after -holmium radiosynoviorthesis by sonography. methods: phase i-iia, randomized, simple-blind, placebo-controlled comparative study using increasing dosage. patients suffering from chronic synovitis, rheumatoid arthritis, or seronegative spondylarthritis were examined. patients: gender (male/female): - ; diagnosis (ra / snsa): / ; stage of knee joint x-ray (i / ii): / ; duration of synovitis (years): . ; duration of disease (years): . ; number of punctures before the ho- treatment: . ; number of steroid injections before the treatment: . . the protocol commenced with screening. the patients were selected according to inclusion and exclusion criteria. patients were randomly distributed into four treatment arms: group i. mbq holmium phytate / -ho/ injectable suspension and mg of ml triamcinolone acetonide /ta/, and ml of lidocaine injection % group ii. mbq ho injectable suspension, and mg of ml ta and ml of lidocaine % group iii. mbq ho injectable suspension and mg of ml ta and ml of lidocaine %. group iv. solely mg of ml ta and ml of lidocaine injection %. there were month follow-up period after the administration of the isotope. we measured the quantity of the synovial fluid and the thickness of the synovia before the treatment, and the th , th days and , , , , , , and months after the treatment. we measured the synovial thickness the following locations: in the midline, lateral and medial, by the condylus of femur medial and lateral. results: the thickness of the synovia decreased significantly in the group ii. ( mbq) and iii. ( mbq). after a transient improve (the steroid effect) the thickness of the synovia began to rise in the group i. ( mbq) and in the control group. we find a significant correlation between the synovial thickness and the clinical improvenes. conclusions: the -holmium-phytate is an effective new radiopharmacon in the treatment of synovitis. we detect the clinical improvement by sonography. the effective dose is - mbq. ultrasound monitoring of the synovial thickness after -homium-phytate radiosynoviorthesis. two years results phase iii prospectiv study m. szentesi , z. farbaky , i. buday ; semmelweis univ., chair of introduction there is no consensus whether a fixed or a calculated activity of i should be used for treatment of graves' hyperthyroidism. there is no evidence that precise dosimetry leads to an improved clinical outcome. a fixed activity designed to treat the majority of patients without attempting to ablate the thyroid gland, is a simple compromise strategy. aim the aim was to examine the quality of a method developed at our institution decades ago, based on estimating the i activity one should use for treatment of graves´ disease. this method was compared with administation of a fixed activity of mbq i. material and methods our estimation method is based on the thyroid uptake of m tc-pertechnetate and the size of the thyroid gland, estimated by palpation. sixty consecutive patients with graves´ disease were randomised to receive either an individually estimated activity or a fixed activity of mbq. in average, mbq (range - mbq) was administered to patients, and patients received mbq. three patients did not, after all, want radioiodine treatment. the patients were followed until they had started thyroxin substitution or, if still euthyroid, typically for one year. each time tsh, free t and free t were measured, and side effects were noted. results among the patients who received an estimated activity, ( %) were still hyperthyroid and needed further treatment. thyroxin substitution was started in patients ( %) after an average period of . months (range . - ) . five patients were euthyroid after the treatment. of the patients given a fixed activity of mbq, ( %) were still hyperthyroid. thyroxin substitution was started in patients ( %) after an average of . months (range . - ). one year after treatment ( %) patients were still euthyroid. in summarize, the success rate of the treatment was % and % in the estimated and mbq group, respectively. this difference is not significant (p= , ), but our findings are in accordance with other published studies. conclusion the study indicates that a fixed dose of mbq as well as an estimated activity in the range of - mbq give a reasonable outcome and at the same time are in compliance with the alara principle. however, % of the patients given an estimated activity needed more than one treatment of radioiodine compared to % in the fixed activity group. this is a case of v.c., a years old, female, from las pinas city, philippines, diagnosed as a case of graves' disease. during the course of therapy, the patient had allergy to antithyroid drugs (atds) and beta blocker (propanolol). she developed rashes all over the body sparing the face the day after taking her atds as well as propanolol, thus all medications were discontinued. other options, such as rai therapy and surgery, with their respective advantages and disadvantages were fully explained to the patient who then opted to undergo rai therapy. in our institution, we usually compute the dose based on the size of the gland and radioactive iodine- uptake measurements (raiu) rather than using fixed doses. thyroid scintigraphy and raiu were done which revealed poorly visualized thyroid gland and markedly diminished -hour uptake but normal -hour uptake [raiu - hour uptake: % (nv= - %); hour uptake: % (nv= - %)]. * note: variations in normal uptake values compared to us are due to iodine deficiency still existing in some regions. because of the very low -hour uptake, we reviewed the probable causes, which can result in low uptake values. all causes were ruled out and the patient was advised to undergo two weeks of strict low-iodine diet prior to repeat thyroid scintigraphy and raiu. thereafter the result of repeat study showed diffuse thyromegaly with elevated uptake values indicating rapid trapping and organification processes [raiu - hour uptake: % (nv= - %); hour uptake: % (nv= - %)]. the day after the study, the patient was given mci i- based on the estimated weight of the gland, rapid thyroid iodine turnover ("small pool") and hour uptake. this was considered to be the highest allowable dose of rai to decrease the probability of relapse and the need for re-treatment. currently, approximately weeks after the therapy, the patient is noted to have responded satisfactorily to therapy with resolution of symptoms. aim: the aim of the study was to analyze the outcome i- therapy for autonomous thyroid adenomas in patients observed during years. materials and method: we investigated patients with plummer's disease (m/f ratio : , ; mean age , ± , years). , % of these patients had an unifocal nodule, while , % had multifocal toxic autonomous nodules. the patients always stopped for weeks before administration of radioiodine therapy. we administered i- activity of ± , mci. the mean duration of follow up was , years results: in patients ( %) a single dose was administered and the other ( patients - %) needed - doses. after four years , % of the patients who received a single dose were euthyroid with scenografic normalization. the percentage of euthyroidism was the same after ten years. the recurrent hyperthyroidism was , % - . in these patients the mean nodular weight was , gr, the mean administered dose per gram was , ± , μci. the incidence of hypothyroidism was , % within , - , years. in these patients the mean administered dose per gram nodular tissue was , ± , μci and the mean nodular weight was , ± , gr. the nodular weight was statisticaly higher in patients who had recurrent hyperthyroidism vs hypothyroidism (p= , ) and vs euthyroidism (p= , ). no differences were observed in the outcome between unifocal and multifocal nodules. conclusion: i- therapy is a simple, safe, effective and economical treatment of plummer's disease. euthyroidism can be achieved by determination of individual dose related to nodular weight and radioiodine uptake, also by preventing extranodular uptake and by evaluating more accurately the nodular weight the use of radioiodine for treatment of hyperthyroidism is based upon the radiationinduced cell changes resulting from the highly energetic beta-rays emitted by i. the magnitude of such effect appears directly proportional to the radiation dose. aim: monitoring the effect of radioiodine treatment in patients with nodular toxic goiter. material and methods: definitive radioiodine treatment is performed in patients with nodular toxic goiter, female, mean age , and male mean age , .the disease duration is , months in female and , months in male. before treatment all of the patients passed sonography, if necessary fine needle biopsy, hormonal status, radioiodine uptake test and scintigrsphy. antithyroid drug treatment was withdrawn days before radionuclide examinations. the radioiodine uptake is measured at , and hour, administered activity is , mbq. the scintigraphy was performed at hour. the patients monitoring was performed at rd month after treatment with clinical examination and hormonal measurements, at th , th and th month with clinical examination, hormonal status, radioiodine uptake and scintigraphy. radioiodine treatment was performed with dose of - mbq. results: from treated patients are female with conservative treatment duration , months and this represents twice longer duration in comparison to the male.in definitively cured patients the radioiodine uptake decreased to values , %, months after treatment and the trend retained in the follow up controls and reaches to , % compared to the initial values. in no effectively cured patients there is no significant variety in the test. the thyroid weight in the follow up period decreased with - % in comparison to the initial values. definitive treatment is determined in , % at month, in , % at month and in , % at month after treatment and this trend is observed in follow up tests. all of the patients received antithyroid drug therapy for to months followed by hormonal control and clinical examination. conclusions:for the assessment of the treatment effectiveness and due establishment of disease relapse, the follow up period for months after treatment is required.hypothyroid status after radioiodine treatment is an indicator for definitive treatment.the variety of the radioiodine uptake and the thyroid weigh are indicators for assessment of therapy effectiveness.the absorbed radioiodine dose in the thyroid gland is - gy . key words: hyperthyroidism, nodular toxic goiter, i diagnostics, i therapy, absorbed dose. the effect of radioiodine therapy on some parameters of oxidant/antioxidant balance in patients with subclinical hyperthyroidism s. s. abdelrazek, f. rogowski, a. zonenberg, m. szelachowska, a. niko ajuk, a. parfie czyk, p. szumowski, b. telejko, k. siewko; medical university of bialystok, bialystok, poland. oxidative stress plays an important role in hyperthyroidism-induced tissue damage. increased oxidative stress, with elevated levels of free radicals, together with diminished antioxidant have been described previously in patients with hyperthyroidism. aim: we aimed to determine whether patients with subclinical hyperthyroidism are subject to oxidative stress and whether radioiodine therapy has benefit effect on the oxidant and antioxidant status in subclinical hyperthyroidism. material and methods: we studied patients with untreated subclinical hyperthyroidism, ( female, male), aged - years; patients with multinodular goitre (mng), and patients with solitary autonomous nodule (atn). normal adult volunteers (age-and sex-matched) were studied as control group. qualification of these patients was based on clinical features and characteristic appearance on thyroid scintigraphy and ultrasongraphy. all the patients had normal levels of serum ft and ft , serum tsh levels was less than . mu/l and effective half-life measured by the use of t and t was more than days at the time of treatment. malignant changes were excluded in all nodules by fine needle aspiration biopsy. in the investigated groups, we evaluate malondialdehyde (mda) as a marker of oxidative stress, glutathione (gsh) and glutathione peroxidase (gpx) activity as a parameters of antioxidant system before and months after treatment with radioiodine. the serum ft ft and tsh were evaluated before and monthly up to months after rit, thyroid ultrasound, and thyroid scan were done again after months of i therapy to assess the volume of thyroid gland and thyroid nodules. the activity dose was calculated by the use of marinelli's formula and ranged between and mbq. the absorbed dose ranged between - gy, and was proportional to thyroid volume. follow up control was done every weeks. results: subclinical hyperthyroidism caused a significant increase in mda level (p < . ) as well as a significant decrease in gpx activities (p < . ) and gsh level (p < . ) compared to euthyroidism controls subject. achievement of euthyroidism after months of radioiodine administration resulted in a significant decrease of mda level, significant increase of gsh level and non significant increase in gpx activities. thyroid volume reduced to about % (average), repeated rit given to one patient. conclusions: our results confirm the imbalance of the antioxidant/oxidant status in subclinical hyperthyroid patients. radioiodine therapy was more effective to improve these balances. aim: the aim of this study is to evaluate the effectiveness of the fixed dose ( mbq) of radioiodine treatment on the function and the size of toxic adenoma (ta) and multinodular toxic goiter (mntg). patients' population: thirty patients ( m, f, age range - , mean age . ) with ta and mntg were included in the study. twenty six patients had ta and patients had mntg. fifteen patients had subclinical hyperthyroidism and patients had overt hyperthyroidism. eight patients were previously treated with antithyroid drugs. method: thyroid scan were performed, volumes of nodules were measured sonographically, thyroid hormones, tsh level and h iodine uptake were determined in all patients. all of them received fixed dose of radioiodine ( mbq). every three months (min. and max. months) thyroid hormones, tsh and the volume of the nodules were measured. results: the initial mean volume of nodules was . ml ( . - . ml). after (n= ), (n= ) and (n= ) months the volume decreased to mean . ml ( . - . ml) (p< . ), mean . ml ( . - . ml) (p< . ) and . ml ( . - . ml) (p< . ) respectively. subclinic hypothyroidism was developed in five patients during the follow-up period of nine months. only two patients were received the second dose of radioiodine after six months because of the persistent hyperthyroidism. overt hypothyroidism was not developed in any patient. the rest of the patients found to be euthyroid during the follow up after the initial treatment. conclusion: our data indicate that fixed dose ( mbq) of radioiodine was effective in both functions and volumes of ta and mntg in a short time of period. aim: rai therapy has been used for over half-a-century for the treatment of hyperthyroidism. it is extremely effective option but there are no definite methods or tests to assess the final outcome of treatment as the response varies according to a number of factors. this study was carried out to assess pulse rate at six weeks post rai therapy as an initial clinical predictor of final outcome as documented at six months on follow up. materials & methods: fifty consecutive patients referred to the department of nuclear medicine, diagnosed as having hyperthyroidism from july to december were included in the study. ( %) males and ( %) females with an age range of - years (mean age . ) were given single dose ranging from mci( mbq)- mci( mbq); mean dose . mci( . mbq). the baseline pulse rate for every patient was recorded twice; taken by the staff nurse and nuclear medicine physician and average of the two documented. the patients were followed for at least six months post rai therapy on an out-patient basis and assessed both clinically and biochemically (t , t and tsh). at six weeks the follow up pulse rate was again assessed and correlated with the tsh levels at six months. results: the baseline pulse rate per minute ranged from - with the mean pulse rate of . pre-therapy. the follow up pulse rate ranged from - per minute with the mean pulse rate . post rai therapy. it was observed that if the pulse rate was > per minute at six months post therapy, this was related with an adverse outcome at six months post treatment. when correlated with the tsh levels this was statistically significant applying fisher exact test and chi-square test with p-value of . and . respectively. conclusion: assessment of pulse rate at six weeks post rai therapy can be used as an initial clinical predictor of final outcome at six months, however, more studies with a larger cohort of patients would help confirm this in due course. purpose: in view of the euratom / regulations, a study was performed in two greek centers, in order to evaluate radiation dose to family members of patients treated with radioiodine ( i) for ablation (group i), follow-up treatment (group ii) and hyperthyroidism (group iii), provided that they followed hospital guidelines for days. the annual dose limit for the public is msv/year. however, relatives helping in the support and comfort of patients are considered volunteers and dose constraints are established for them. this constraint for adult relatives (< y) is msv during the patient's treatment. method: the radiation doses received by adult family members ( adults) of patients treated with i were measured using thermoluminescent dosimeters (tld) mounted on wrist bands, for days. the administered activity was . gbq ( mci), . gbq ( mci) and - . mbq ( - , mci) for groups i, ii and iii respectively patient's exposure rates were also measured by a survey meter for distances , and meters during the same period of days. radiation safety instructions were the same for all groups. results: radiation doses to all family members were below the recommended dose constraints, for the measurement period of days. the estimated doses to infinity were also calculated and found to be below the recommended dose constraints. the patient's exposure rates at m, at the time of their release from the hospital ranged between - μsv/h, . - μsv/h and , - μsv/h for groups i, ii and iii respectively. conclusion: the radiation dose to family members of all groups is well below recommended dose constraints, provided that they comply with hospital guidelines. according to our results, days of hospitalization is sufficient for groups i and ii. papillary carcinoma of the thyroid is usually an indolent tumor with a good survival prognosis especially when small and limited to the thyroid gland. the annual incidence of thyroid cancer per million individuals in the czech republic is approximately - new cases, thyroid cancer is rare in children below years of age -we have in our group % of children cancers and about % of microcarcinomas. thyroid cancer is five times more frequent in females than in males, the incidence increases with age. the median age at diagnosis is between - years. the authors followed since to a cohort of the patients suffering from differentiated thyroid carcinoma and detect microcarciomas since to (n= total patients). we studied this phenomenon and discovered that this change was limited to females and to the less advanced cancers t . the number of papillary cancers in women with more advanced stages did not change as well as any differentiated cancers in men. this unexpected finding cannot be explained by differences in radioactive fallout, and other factors should be looked for, as age, better evaluation of thyroid morphology in women. the increase of t cancers is remarkable, as during the years to a total of new t cancers were diagnosed in females compared to new t cancers between and , than more than six fold increase. in patients with a thyroid carcinoma of less than . cm in diameter, which represent % (n= ) of all of our patients (n= ) form - , the prognosis is excellent and routine rj ablation is not indicated. however, we still prefer total thyroidectomy in these patients. recurrent disease was detected in % of these patients, usually in the form of lung metastases or recurrent disease, typically during the first five years at the diagnosis. we found lung metastases after years after diagnosis in one patient! the fifths version of tnm classification classified tumours into the categories t ( - mm), t ( - mm). the new sixth version of tnm classification changes that clasiffication by shifting the categories into t ( - mm) and t ( - mm). this new version thus does not allow to distinguish the patients with significantly different probability of the metastasis occurrence in the - mm category. this research was supported by av cr et and by msmt cr m . v. voliotopoulos , i. valais , m. margaritaki , v. gianakopoulos ; iatropolis magnitiki tomografia, athens, greece, sotiria general hospital, athens, greece. the association between thyroid cancer and hypothyroidism is considered a rare event. in the international bibliography the incidence of coexistence of thyroid cancer and hyperthyroidism is between , % and , %. materials and methods: in our clinic since now, we treated patients with thyroid cancer and of them was operated at firs time for thyrotoxocosis and the malignancy was detected incidentally. %of them were men and %women.among them had moltinodular goiter and the rest % had graves'disease.the histological examination revealed papillary, follicular and hurthle cells carcinoma. results: all patients received radioiodine therapy and in one patient because a high radioiodine uptake ( , %) and after days of withdraw of t and a tsh level of , ngr/ml we used the recombinant tsh (thyrogen).in the wbs days after therapy in this patient the uptake was very intense in the thyroid bed. conclusion: the rate of incidence thyroid carcinoma in these subjects with thyrotoxocosis was similar to previous studies reported from other european countries. the ablation therapy year after therapy was very successful and with no need for a new therapeutic session. despite many years of experience in thyroid cancer treatment the optimal dose of iodine- necessary for successful ablation is not established. the aim of the study was to compare the rate of ablation with different doses of radioiodine. the rate of ablation was compared in four groups of patients. statistical differences were evaluated with mann-whitney u-test, kruskal-wallis test or pearson's chi-square exact test and a p value less than . was considered to indicate statistical significance. consecutive patients with papillary thyroid cancer ( women, median age years; range - years), who have undergone total thyroidectomy were retrospectively studied. ablative doses of i- were applied - weeks after the surgery. patients were hypothyroid, with tsh more than miu/l. patients were randomized into four groups according to i administered activity, starting at mci ( patients), then mci ( patients), mci ( patients), until mci ( patients). the outcome of thyroid ablation was assessed by conventional mci whole body-scan, performed in hypothyroid state - months after ablation (first control study), and finally months after (second control study). successful ablation has been defined as the absence of residual thyroid uptake in thyroid bed. the rate of successful ablation was similar in the group of patients received and mci ( % and . % respectively). the higher rate of ablation ( . % and . %) was achieved in the groups treated with and mci of radioiodine. in conclusion, our study indicates that a mci dose of radioiodine is a sufficient for a satisfactory thyroid ablation rate. use of low effectively and mci dose for initial ablation is justified by the convenience of administration, the lower expence and the lower whole-body radiation dose, and in our opinion this modality is convenient for group of patients with low risk of recurrent disease. introduction: although the differentiation thyroid cancer (dtc) has proven to be a good prognosis with significant decrease in mortality rates, many countries recently witnessed an increase incidence of this pathology. in this respect,this study aims at assessing years of dtc management in national cancer centre, through a population survey. materials &methods: patients were referred to the department of endocrinology and nuclear medicine, for dtc management between and .all patients have undergone a surgery with total thyroidectomy even for papillary microcarcinoma followed by an iodine ablation. results: this study confirms that the dtc incidence increased through the years essentially from (between to times).the female sex is times more frequent than in male ( %vs %) with a median age at diagnosis stage between to years in % of patients. in % of the cases ( % for solitary nodule), the multinodular goiter is the principal reason for the first consultation. even though the fine needle aspiration biopsy (fna) was performed only in % of patients, % were malignant. the papillary histology type is times more frequent than follicular type ( % vs %). % of patients have received an activity of . gbq of i- , while % have received . gbq , % more than . gbq as cumulative activity. after a minimum follow up of one year % of patients have had an undetectabletg. conclusion: although the increase incidence of dtc has been observed since , the reasons according to our understanding are due to the early stage diagnosis using fna, the frequent availability of neck ultrasonography and the multidisciplinary approach, rather than the fallout atmosphere of radioactive iodine or the population's exposure to thyroid radiation. as for the rest of the results, it is noticed that a patient is generally a female sex in % of the cases, aged between to years in %.they present a multinodular goiter in % with papillary histology type in % aim: well differentiated thyroid carcinoma of the ectopic thyroid tissue is a very rare entity. our aim in this study is to determine the frequency of this clinical condition and to present the clinical experience obtained in the management of our patients with thyroid carcinoma of the ectopic thyroid tissue. material and method: the clinical records of well differentiated thyroid carcinoma patients treated and followed in our institution between the years and were retrospectively evaluated. the carcinoma focus was found in an ectopic thyroid tissue in cases. the localization of the ectopic thyroid tissue was thyroglossal duct in patients, parapharengeal region in one patient, submandibular region in one patient and submental region in one patient. results: mean age of the patients ( f; m) is , years. histopathological examination of ectopic tissue specimen revealed that of the patients had papillary carcinoma and one of them had follicular carcinoma. near total thyroidectomy was performed in all of the patients. seven of patients had a focus of well differentiated carcinoma in thyroid tissue also. the size of the thyroid tumor was between - mm in cases and below mm. (papillary microcarcinoma) in cases, of them being multifocal. two patients had regional lymph node metastasis; there was hyoid bone and regional muscle tissue invasion in another patient. only sub-total/near-total thyroidectomy was performed for two patients of the patients whose thyroid gland was normal. for the other patients with advanced disease and patients who had carcinoma of the thyroid gland also; radioiodine ablation therapy was performed after thyroidectomy. two patients were lost to follow-up. mean remission time was . ( - ) months for the other patients who are currently under follow-up (for - months) by sonographic examination and thyroglobulin level measurement at intervals. conclusion: the occurrence of ectopic thyroid tissue carcinoma is uncommon in regard to all thyroid carcinomas. the evaluation of thyroid gland for concomitant carcinoma in the thyroid tissue leads to the incidental detection of papillary microcarcinoma in majority of these patients. however, the clinical course of the disease is favorable with a management protocol similar to well differentiated thyroid carcinoma. if we hypothesize that stunning effect arose from either the ablative action of the diagnostic i- dose or the early effects of the therapeutic i- dose , this like stunning phenomenon should concern any thyroid remnants independently to the time interval between the above iodine doses. aim: the goal of this study was to investigate the presence of like stunning phenomenon in patients who received both diagnostic and ablative i- dose with a delayed time interval (> months) between them. material and methods: the study included patients ( men, women, mean age years) with a histology of differentiated thyroid carcinoma , disease limited into the thyroid bed and uptake . ± . . a therapeutic i- dose of - mci was given - months after the mci i- diagnostic whole body scanning. all patients had a whole-body scan on the th posttherapy day while of them had it also on the rd day. a quantitative estimation of the thyroid remnants was considered on the rd day (dx) for the diagnostic wbs, on the rd (rx ) and th (rx ) day for the posttherapy wbs. the ratio therapeutic/diagnostic (rx /dx) concentration of i- in residual thyroid remnants was calculated for all patients and stunning was considered when rx /dx was lesser than . the ratio rx /rx and rx /dx were also calculated for the / patients. results: of the patients, ( %) exhibited rx /dx < (likestunning effect). the like-stunning population included / ( %) patients with uptake > %, / ( %) patients with uptake between % and % and / ( %) patients with uptake < %. among the patients with posttherapy evaluation on the rd and th day, patients had rx /rx > and rx /dx> , indicating a clear early curative action of the therapeutic i- dose and patients had ratio rx /dx< and rx /dx< indicating a clear curative action of the diagnostic i- dose. conclusion: our results support the hypothesis that thyroid like-stunning phenomenon can be observed in patients with a diagnostic and a delayed consecutively therapeutic i- dose. this like-stunning effect could be the consequence of destructive effects from either the diagnostic or the therapeutic i- dose, mostly when the thyroid remnants are major. objective: studies have suggested that i- whole body scans (wbss) can underestimate the extent of well differentiated thyroid cancer. we wanted to find out if i- wbs images provide an accurate foundation for deciding the therapeutic dose of i- . method: three hundred and thirty three i- wbss of consecutive patients from january to march were retrospectively reviewed. all patients received total thyroidectomy for well differentiated thyroid cancer, and were on low iodine diet for at least weeks, and reached tsh greater than miu/l prior to the i- wbs. i- wbss were obtained after the patients were given high dose of i- (> mci) for remnant thyroid tissue, local recurrence, or metastasis. the i- wbs and post-therapeutic i- wbs were performed less than weeks apart, the images were reviewed for abnormal radioiodine uptakes. results: in cases, i- wbs and post-therapeutic i- wbs agreed on the extent of the thyroid cancer. however, in cases, post-therapeutic i- wbss detected additional lesions such as further metastatic lymphadenopathy of the mediastinum or distant metastasis to the lungs. in of these i- wbs and i- wbs discrepant cases, the therapeutic dose of i- may have been increased had the physician known about the presence of additional lesions. conclusion: i- wbs performed prior to high dose radioiodine therapy underestimated the extent of well differentiated thyroid cancer in . % of the cases, and may have lead to suboptimal therapeutic dose in . % of the cases. therefore, i- wbs images alone may not be accurate basis for determining the dose of radioiodine therapy. aim of the study: to determine the recurrences and disease related deaths in patients (pts) with differentiated thyroid carcinoma (dtc) treated by surgery and by radioactive iodine ( i) as initial therapy. patients and methods: two hundred eighty dtc pts were operated and after that treated by i once or several times. all pts received life-long hormonal therapy. duration of follow-up: mean . + . years, median . years, range months- . years. probabilities of the recurrences and disease related deaths were calculated by kaplan-meier's method and the significance of differences was determined by log-rank test. results: two hundred fifty eight pts were in the remission after initial therapy; the recurrences appeared in ( . %) of them during follow-up period. the probabilities of recurrences after , and years were %, % and %, respectively. the significant influence on the appearance of recurrences had: the absence of i accumulation in tumor, incomplete remission, initial tnm stage iii and iv, pts' age > years and nodal metastases. the disease related deaths occurred in pts ( . % of all treated pts) during follow-up period; deaths occurred after recurrences in pts ( . % of pts with recurrences). the probabilities of disease related deaths after , and years were %, % and %, respectively. the significant influence on the deaths had: the initial tnm stage iii and iv, pts' age > years, distant metastases, absence of i accumulation in tumor, masculine gender and nodal metastases. conclusion: all followed pts were initially treated surgically and by radioiodine. the appearance of recurrences progressively increased with years after initial therapy, so it is necessarily to follow-up pts till the end of their life. it is very important to treat pts until complete remission of disease is reached, to decrease the frequency of recurrences. disease related deaths occurred more frequently after onset of recurrences; it is indispensably to treat relapses to achieve the stable complete remission, if this is possible. the retrospective evaluation of metastatic bone disease in differentiated thyroid carcinoma Ö. küçük, e. Özkan, e. tokmak, p. tarı, g. aras; ankara university medical faculty, ankara, turkey. aim: bone metastases(bm) are seen clinically in %- % of patients (pts) with differentiated thyroid carcinoma(dtc).due to difficult treatment, the prognosis is poor. we evaluated metastatic bone disease in our dtc group, retrospectively. material-method: bm were detected in pts out of with dtc who were treated and follow-up in our clinic between - (age range - years; f, m). papillary carcinoma was diagnosed in / pts and follicular carcinoma in / . a total of . - . gbq ( - mci) i- was given to each patient. the duration of follow-up ranged from to months. i- whole-body scan(wbs), tc- m mdp whole-body bone scan, the determination of tg and antitg levels and/or a ct scan were carried out in the assessment of a diagnosis and follow-up of pts with bm. results: the frequency of bm were found . % in our analysis. classification was performed according to detection time of bm. group ; pts diagnosed with primary bm, group ; pts with bm detected in post-ablative wbs, group ; bm diagnosed in the follow-up period in pts. in group , / pts had only bm, / pt had bone and brain metastases, / pts had lymph node and/or lung metastases also. in group ; pt had only bm, pt had bone and lung metastases. in group ; pts had bone, lymph node and/or lung metastases, pt had bone, lymph node, lung and brain metastases. in the follow-up period, pts from group and pt from group were died. the bm were seen in - months after the diagnosis for group . bm were persistent after the therapy on the other hand, additional new lesions were observed. tg level was high in all pts remarkably except pts (tg-max: ng/ml). one of these pts with normal tg level had high anti-tg level ( iu/ml), the other one had normal anti-tg level (< iu/ml). pts had anti-tg levels higher than tg levels. bm were persistent after the therapy on the other hand, additional new lesions were observed, especially in group . discussion: the frequency of bm has been reported %- %. this ratio were found . % in our analysis. we observed higher ratio of diagnosed dtc with primary bm ( %) (grup ). its prognosis was worst than other groups. conclusion: tg is more important parameter than anti-tg and the prevalence of the other organ metastases is high in dtc pts with bm. aims: based on the icrp recommendations, the policy for releasing patients with differentiated thyroid carcinoma (dtc) who underwent thyroidectomy and received ablation doses of i- , from the nuclear medicine departments should be based both on general national rules and specific regional conditions. the aim of this research was to study the kinetic, urinary excretion pattern and dosimetric characteristics i- to estimate the radiation doses to the public, and to check the policy for the release of these patients. materials and methods: twenty-nine patients with dtc who referred to our department were selected for this study. the mean radioactivity doses administrated was ± . gbq (range . - . ). the instantaneous dose rates were measured immediately after the administration of therapeutic radioiodine with patients in the upright position at distance of meters and just before they left the department at distances of . , and meters using a survey meter. also, urine samples from each patient were collected every - hours for up to days after radioiodine administration. results: the maximum dose received by the nursing staff was . msv/week, less than the dose recommended by the icrp. the dose rate and remaining activity values of out of patients were higher than those of the others and this contributed to a high standard deviation. only one of these six patients had metastases. it was noteworthy that other patients with metastases showed a moderate dose rate exposure or moderate remaining radioiodine activity in the body. on average sixty hours post administration of radioiodine, % of the administrated dose was excreted through the urine, % remained in the body and % decayed or excreted through other routes. conclusion: these results indicate that family members should take into consideration the duration and the distance of being in close contact with the above patients. the time-rate curve of urinary excretion of radioactivity in all patients showed multiple peaks due to the retention and redistribution of radioiodine within the body and the enterohepatic cycle of radioiodinated thyroid hormones. based on the study results, at least in countries as ours we strongly recommend changing the policy for release of all patients receiving radioiodine therapy except those who are capable to keep instructions properly. patients should be discharged when radioiodine body retention and instantaneous dose rate are less than mbq and msv/h at a distance of m, respectively. aim: radioiodine therapy (rit) after a total thyroidectomy is the standard treatment of differentiated thyroid cancer (dtc). since more than % of the incorporated iodine in healthy patients is cleared by the kidneys, the rit of renal failure patients (rfp) affords high requirements concerning dosimetry. aim of this study was to determine the progression of activity in rfp and to compare the results to renal healthy patients with dtc ( patients). material and methods: in the recent years we treated rfp with dtc. one of them was treated times ( x rit + diagnostic scan (ds)), twice and one patient once. consequently the activity progresses of collectively rits were documented and assessed dosimetrically. applicated activities were between and mbq ( mbq for ds). the remaining activity was measured twice a day and immediately before respectively after the haemodialysis with an individual calibrated gamma probe. hence the mean halflife was determined with an exponential fit on the one hand, and the integrals between the single measured values on the other hand for calculating the mean whole body dose (wbd). haemodialysis was done on the first and third day after application. results: the calculated halflife averages . days ( . - . ). the wbd per patient averages mgy ( - ) corresponding to a mean wbd of . mgy/mbq. in comparison, the effective halflife for non-rfp averages . days ( . - . ) and the wbd averages mgy ( - ) corresponding to a mean wbd of . mgy/mbq. the mean elimination of radioiodine per haemodialysis averages % (+/- %). conclusion: about % of the remaining activity is eliminated per haemodialysis. the effective halflife during the time interval between two haemodialysis in one patient varies depending on the grade of renal failure and should therefore be observed. the mean effective halflife for the total rit of rfp is increased times compared to healthy patients. the dose per applicated mbq is enhanced correspondingly . times. therefore, we suggest to decrease the activity for rfp with dtc to an amount of % of the activity, administered in non-rfp. retrospective analysis of patients with differentiated thyroid carcinoma (dtc) e. urbanova, j. vizda; nuclear medicine university hospital, hradec kralove, czech republic. nuclear medicine has had a major impact on the management of dtc, especially in post-operative ablation, detection and therapy of recurrence or metastases. aim of this study was long term follow-up patients ranged from to yrs after radioiodine therapy. method: during the period lasting from february till december radioiodine therapy was performed for pts after thyroidectomy due to dtc. papillary carcinoma was diagnosed in / pts and follicular in / an in one pts histologically mixed type was found. thyroid hormones treatment was done to compensate the lack of endogenous hormones and to stop tsh secretion. follow up for all pts consisted from the wbs (whole body scintigraphy) performed after thyroid remnant ablation with i. further clinical, plain x-ray of the chest, vocal cord and us (ultrasound) of thyroid gland and neck examination and periodic serum tg (thyreoglobulin) measurements and later wbs with m tc-mibi and rarely ct were performed. results: despite early detection and adequate initial treatment we observed after mean follow-up of ten yrs, three neck lymph-nodes recurrences and two pulmonary, one bone and one vocal manifestation of disease. so seven pts were retreat with radioiodine therapy. after yrs seven pts showed recurrence due to pulmonary and bone metastases and five pts were follow-up for second carcinoma. two pts died due to cardiovascular disease and one after generalisation of the disease. completely free of disease after years were pts but lot of other complications were present (e.g. haematuria, hypertension, nephrolithiasis). two patients showed one side decrease in salivary function. maximum total administered activity of i for one patient with repeated therapy for pulmonary, bone and brain metastatic process during years was about mci. conclusion: the demonstration of distant metastases can be present after long period after beginning of the disease. for the evaluation of lung metastases in dtc, determination of tg levels and the i wbs were the most important procedures. computed tomography is a useful addition, because m tc-mibi imaging alone may not be enough to detect lung metastases from dtc. short and long complications of i treatment should be taken into the careful consideration with the benefit for the patient with long survival. our first experience with low dose radioiodine ablation therapy in low risk patients with differentiated thyroid carcinoma z. rajkovaca , j. mijatovic , m. skrobic , g. mikac , g. vuleta , a. matavulj , p. kovacevic , n. ponorac ; clinical centre, banja luka, bosnia and herzegovina, medical faculty, banja luka, bosnia and herzegovina. the optimal dose of iodine- for ablation of functioning residual thyroid tissue after (near)total thyreidectomy is controversial. the aim of this study is to present our experience with low ( . gbq) dose i- in ablation of differentiated thyroid cancer remnants in low risk patients. material and methods: a total of patients (mean ages of . years, range - years) with papillary and follicular carcinoma were treated first time in our department with i- for ablation of a postoperative thyroid remnant after (near)total thyreidectomy. patients with stage pt or pt n m were including in the study. patients were divided into two groups according to size of postoperative residual thyroid tissue, level of thyroglobulin and age. group a, patients received . gbq i- , group b, patients received . gbq i- . six months after treatment, all patients were reassessed after withdrawing l-thyroxin for to weeks with i- whole body scan and serum thyreoglobulin measurement. a successful ablation was defined as the absence of thyroid bed activity in mbq i- neck scan, the neck uptake of < . % of the administered activity and the thyroglobulin value of < ng/ml. results: in group a successful ablative therapy was seen in ( . %) of patients. of these . % had papillary carcinoma on histopathology and . % had follicular carcinoma. in group b successful ablative therapy was seen in . % of patients. of these . % had follicular carcinoma on histopathology and . % had papillary carcinoma. there were no statistically significant differences between these two groups in relation to thyroid ablation. also, there were no statistically significant differences in thyroglobulin serum level months after i- treatment. the remaining ones, . % and . % respectively, received the second course of i- for remnant ablation. / patients required therapy in group a and / in group b. response to low dose i- was same in patients with papillary and follicular type of carcinoma. conclusion: our evaluation of early efficacy of adjuvant radioiodine treatment in low risk patients with differentiated thyroid carcinoma shows no differences between two radioiodine activities - . gbq and . gbq in relation to thyroid ablation. we recommend the activity of . gmbq in low risk patients. thyroid stunning phenomenon is the impairment of therapeutic i uptake by normal or metastatic thyroid tissue, as a result of previous administration of a diagnostic activity of the same radionuclide. it has been demonstrated after the administration of diagnostic activities of - mbq ( - mci) of i. we can avoid it using i in the whole-body scintigraphy. however, even the ablative therapeutic activity itself may cause stunning, because of the high radiation dose absorbed by the thyroid remnant in the first hours of the iodine accumulation (self-stunning). aim to evaluate the occurrence of self-stunning in residual thyroid tissue after total thyroidectomy for differentiated thyroid cancer followed by i therapeutic ablation. materials and methods a prospective study was conducted from / / to / / in patients submitted to total thyroidectomy for differentiated thyroid carcinoma of follicular origin ( female and male, aged from to , mean , ± , years). withdrawal of levothyroxine intake, low iodine diet throughout the foregoing week and analytical studies including iodinuria were required before undertaking both diagnostic and therapeutic procedures. cervical uptake was determinated hours after oral administration of mbq ( μci) of i. ablative therapeutic was performed days later, with i activities ranging from to mbq ( to mci), mean mbq ( mci). cervical uptake of the radionuclide was determined hours later. we used a siemens e-cam dcr dual head gamma camera, equipped with medium and high-energy collimators for i and i respectively, to obtain segmentary images of the patient`s cervical anterior region, as well as the i capsule to be administered and a known activity of i, cm from the detector. results in the diagnostic study, the cervical i uptake varied between , % and , % (mean , %). the post therapeutic uptake of i oscillated between , % and , % (mean , %). in all of the patients, a reduction in the cervical uptake of iodine ranging from - , % to - % (mean - , %) was observed in the post therapeutic study, as compared with the diagnostic one. this reduction was found to be statistically significant (t = , ; p < , ). conclusions we verified the occurrence of selfstunning in all of the patients subjected to ablative therapeutic with i. a. georgakopoulos, s. saranti, l. iordanidou, e. trivizaki, k. rethymniotakis, e. matselas, p. koutsiouba; metaxa's cancer hospital piraeus greece, piraeus, greece. if we accept the hypothesis that stunning phenomenon could be related to the curative radiation dose of iodine - , either the diagnostic or the early therapeutic iodine- (i- ) action could contribute to a stunning effect production. aim: the aim of this study was to investigate whether the diagnostic or the early therapeutic i- radiation dose provoke a partial ablation, giving thus the stunned appearance of the thyroid remnants. material and methods: patients with total/near total thyroidectomy (uptake . ± . ) for differentiated thyroid carcinoma received the first ablative iodine dose ( - mci) within months from the diagnostic mci i- dose. the patients were evaluated with diagnostic wbs hours after the administration of mci i- and with posttherapy wbs days after the ablative i- dose. furthermore of the above patients were evaluated with onemore posttherapy wbs on the rd day of the ablation. serum tsh, tg and anti-tg were considered in hypothyroid state. the patients were divided into groups according to the uptake value. group a(uptake > %) consisted of patients, group b (uptake %- %) of and group c (uptake < %) of patients. a quantitative estimation of the thyroid bed activity was performed for the diagnostic, the rd day posttherapy and the th day posttherapy wbs. the ratio therapeutic/diagnostic (rx /dx) concentration of i- in thyroid remnants was calculated and stunning was considered when the ratio rx /dx< . the ratios rx /rx and rx /dx were calculated for the patients with the additional rd posttherapy day wbs. results: of the patients ( %) demonstrated stunning phenomenon (rx /dx < ). between them / ( %) had a days interval between the diagnostic and the therapeutic dose, / ( %) had a - days interval and the rest ( %) patients had a - days interval. the stunned population consisted of / ( %) patients of group a, / ( %) of group b and / ( %) of group c. among the patients with the rd and th day posttherapy wbs, had rx /rx > and rx /dx> indicating a clear early curative action of the therapeutic i- dose and other patients had ratio rx /dx< and rx /dx< indicating a clear curative action of the diagnostic i- dose. conclusion: a partial ablation could be generated by either the diagnostic or the early curative therapeutical i- . the density of this phenomenon seems to be directly proportional to the extent of the residual thyroid tissue. radioiodine treatment is contraindicated in pregnancy. still, inadvertent therapy does occur. radioiodine was given to two pregnant women with graves' disease and thyroid cancer respectively, both in their th gestational week. routine pregnancy tests based on urinary -hcg had failed to indicate pregnancy in both cases. methods: estimation of doses to the foetuses and foetal thyroids. scrutiny of pregnancy testing. results: doses to foetal thyroids were ablative ( - gy). total foetal dose in the graves' patient was mgy and compatible with survival, whereas a foetal dose of approximately mgy together with induced hypothyroidism was fatal for the foetus of the cancer patient. conclusions: routine pregnancy tests (urine -hcg) may not only fail early and but also later in pregnancy.the -hcg level can be low from mid term, especially in case of a male foetus. the possibility of pregnancy should be considered in all fertile women before therapy with radionuclides or cytostatic regimens, and a clinical investigation undertaken on wide indications with determination of serum -hcg, preferably together with an ultrasound examination. more than two decades ago, the radiation absorbed dose thresholds for successful radioiodine- (i- ) treatment of residual thyroid tissue and lymph node metastases ( gy, n= , p< . and gy, n= , p< . , respectively) were established by maxon hr et al. n engl j med . [ ] . until today, these thresholds have been frequently cited in dosimetric context related to postsurgical thyroid cancer patients. the aim of this study was to review some quantitative dosimetric works published so far, in order to explore if the initially proposed thresholds [ ] ). the data were adopted from available works exactly in the form in which they had been published or presented and were statistically analyzed using x tables. three-hundred gy has been not statistically proven absorbed dose threshold for successful ablation of remnant thyroid with i- [ , , , , ] . suggested absorbed dose-rate threshold of gy/h for successful thyroid remnant ablation [ ] was not proven too. the lowest study-specific thresholds for successful thyroid remnant ablation were derived as follows: gy (n= , p< . ) [ ], gy (n= , p< . ) [ ] , gy (n= , p< . ) [ ], . gy/h .and. gy (n= , p< . ) [ ] . further support of the latter values is the mean absorbed doses of therapeutic i- delivered for successful ( ± gy) and unsuccessful ( ± gy) thyroid remnant ablation (n= , p< . ), as presented in abstract by haq m et al. eur j nucl med mol imaging . quantitative in-vivo data published to date does not support a widely-accepted dosimetric approach to thyroid remnant ablation based on the threshold absorbed dose of gy. in contrast, intrathyroidal doses of i- in the range of - gy appear to be evidence based cut-off values required for significantly higher success-rate of thyroid remnant ablation in postsurgical thyroid cancer patients. aim: this study evaluates the incidence of radiation thyroiditis and its relationship with i- thyroid remnant uptake following i- adminstration for post surgical completion ablation therapy for thyroid cancer. methods: patients having an initial post surgical administration of either mbq or mbq i- between jan -dec were retrospectively reviewed. the activity of thyroid remnant i- on the hour post administration scan was measured and correlated with neck symptoms experienced. following review of medical records, patients were classified as having insignificant, mild or severe thyroiditis based on no treatment, nsaids, or steroids respectively. statistical analysis was performed using ordinal and regular logistic regression for thyroiditis (yes/no). results: patients were included ( f, m; - years). patients received mbq and patients received mbq.the mean i- thyroid uptake was . mbq (range - mbq). / ( %) patients developed symptomatic radiation thyroiditis. incidence and severity of thyroiditis increased with increasing i- thyroid remnant activity (p=< . ). the risk of developing any degree of thyroiditis increased by % for every mbq increase in activity (or= . ( % ci , - . ). severe thyroiditis was not seen with remnant uptake < mbq while / ( %) of patients with remnant uptake > mbq experienced severe thyroiditis. for patients treated with mbq and mbq, thyroid remnant ablation success rate was % and % (p=ns), incidence of any thyroiditis was % and % and incidence of severe thyroiditis was % and % (p=< . ) respectively. conclusions: initial post surgical i- thyroid remnant uptake of > mbq often produces significant thyroiditis. lower initial administered i- activities may be desirable for low risk disease, particularly when a larger thyroid remnant is suspected. this lower initial administered dose does not appear to significantly compromise success rate of thyroid remnant ablation. ) . after oral administration of -i the external whole-body dose rates were measured at a distance of meter in each hospitalization day until the dose rates fall bellow the release dose rate level of μsv/hr. results: the dose rate decay was biexponential for all four groups. by considering the dose rate limit of μsv/h at m for releasing patients, % . of patients satisfied this limit after days , % . after days and % . after days. there was total of three cases with hospitalization times more than days because of functional thyroid reminants and widespread metastasis. the cumulated dose received by the nursing staff was μsv/week, less than the dose recommended by the international committee for radiation protection (icrp). discussion: our data clearly showed that suitable guidelines can be derived to limit the annual dose to less than msv for children, members of the public and staff who may come into contact with cancer patient treated with radioiodine . aims: negative diagnostic i whole body scan with elevated serum tg levels are found in % of patients with differentiated thyroid cancer (dtc). empirical radioiodine treatment has also been advocated by some researchers with controversial outcomes. we performed an anterospective study to aim the answer to abovementioned dilemma and also determine the capability of tl- scintigraphy in these patients. materials and methods: we studied patients with a mean age of ± . years who had a history of follicular cell derived thyroid cancer (fcdtc) and elevated serum tg levels with a negative i diagnostic wbs and also were treated with radioiodine. in patients also whole body scan with tl- was carried out. paired t test and correlation tests were carried out. a p-values of . or less were considered to be significant. results: the mean pretreatment and posttreatment tg were . ± . ng/ml and . ± . ng/ml respectively. there was statistically significant difference between pre and posttreatment tg (p value< . ). eleven cases showed at least % decreased in tg value (remission group), patients revealed less than % decreased in tg value (stable group) while subjects demonstrated tg increment in posttreatment tg relative to pretreatment tg value (progression group).there was no significant correlation between cumulative and also last i- doses in three groups (remission, stable and progression groups) [p value> . ]. in the posttreatment wbs, patients showed abnormal findings in their images. in follow up scan with tl- , out of cases had positive scan. in our study at least % of subjects demonstrated the reduction or normalization of serum tg occurred in the first post-treatment follow up. thus, our study support benefits of empiric rai therapy of diagnostic rai scan-negative and tg-positive fcdtc patients .in addition, for the management of fcdtc patients who do not have rai accumulation and have elevated tg, other imaging modalities such as tl- scan are helpful. conclusion: we recommend rai therapy in dtc patients with elevated tg and negative wbs .in addition, at hospitals without access to pet, we can expect improvements in the detection of recurrence and metastasis to make a logical management after total thyroidectomy using i- and t - as complements to each other. objectives: for radioimmunotherapy (rit) with y- -labelled monoclonal antibodies, a surrogate nuclide for assessing biokinetics is necessary as y- is not appropriate for imaging. due to similar half-life, coordination chemistry and metabolic handling in- is used. however, differences in biodistribution of these nuclides have been reported. here we present a method for an intraindividual comparison of blood biokinetics of in- -and y- -labelled anti-cd antibody for rit. methods: for five patients ( male and female, age: median years, range - years) with aml or all blood serum activity data were collected during dosimetry (in- ) and therapy (y- ). the median and range of the applied activities for in- and y- were mbq ( - mbq) and mbq ( - mbq), respectively. a set of models (sums of to exponentials, with various combinations of shared or non-shared parameters) was chosen and fitted to the data of each patient. non-shared parameters means fitting the in- and y- data with extra parameters, while shared means using a common parameter for both nuclides. all parameters, which describe later parts of the serum time activity curve were fitted non-shared, as the treatment could affect serum time activity curve. the fit parameters were calculated using a minimum sum of squares algorithm. the model which supported the data best was selected using the corrected akaike information criterion. the models were ranked according to the akaike weights. results: the model when sharing the parameters of the first exponential between the in- -and y- -labelled time activity curves is ranked best in four out of five patients. one patient's data were best described sharing only the half-life, but not the prefactor of the exponential. all best models were substantially supported (wi = . - . ) by the data and r as a measure of goodness of fit was higher than . . the areas under the curves from to h p.i. of the best fit model of in- and y- had a ratio of . ± . . conclusions: the introduced method is a powerful and straightforward approach for intraindividually quantifying similarities or equality of blood serum biokinetics. this is a pivotal step in the surrogate nuclide selection process, since equality or high similarity is a necessary, although not sufficient, condition for extrapolating from a pretherapeutical dosimetry on the therapeutic radiation absorbed dose. introduction a dosimetric study involves many different specialists and many different steps. it starts with the labelled of the radiopharmaceutical (in cl -dotatoc) and proceeds with the administration, the collection of biological samples, the scintigraphic exams and the physic and mathematical analysis of all data collected. aim we want to evaluate the contribution of different specialists involved in the collection data for dosimetric study before y cl -dotatoc therapy, the mantime and instrumentation-time for all steps. materials and methods the biologist of nuclear medicine department label the in cl -dotatoc with the help of a medical physicist for radioprotection. meanwhile a nurse make the infusion of the aminoacid to the patient. then a physician administer the radiopharmaceutical to the patient. immediately the collection of blood samples starts (nurse). the patient makes the complete urinary collection using dedicated containers that the biologist (who directs all steps) provides to change at established time intervals. the biologist divides all samples in test-tubes containing the same volume of liquid and then the physicist measures them by a spectrometric system. the tecnologist of nuclear medicine units performs five whole-body scans at the patient at difference times and days. the physicist performs the spect and ct applying appropriate reperies to the patients to carry out images fusion. using compartimental models and dosimetric software the physicist calculates residence-times and dosimetric data for critical organs and lesions. the result of all these work is delivered to the physicians who compiles therapeutic plane. results the patient is busy for four days. the biologist, as director of the entire procedure, is busy for all first day and for two hours in next days. the physicist is busy for four hours in first day, two hours in second day (for spect/ct) and for about three hours when all samples are collected for the data analyse. the nurse in busy in the first and second days (when he can work in routine too). the phisicians is busy for a few minutes the first day for administration and then for about two hours for the compiling of the therapeutic plane basing on the dosimetric data. conclusions all the procedure is time-expensive, but the dosimetric study is an important step of the therapy with y cl -dotatoc. to optimise the work is very important that all specialists involved are in harmony and organized. we already have performed dosimetric study and we now have a consolidated organization. aim: peptide receptor radionuclide therapy (prrt) with lu- dota-tate is used for the treatment of patients with neuroendocrine tumors. the aim of our study was to determine the organ and tumor kinetics for dosimetric calculations. material and methods: patients (aged +/- years; m, f) with metastasized neuroendocrine tumors (somatostatin expression verified before by ga- dota-noc pet/ct) were treated with activities of . - . gbq lu- dota-tate ( - cycles). on the basis of conjugated planar whole-body scintigraphies . h, h, h, h and h p.i. the time-dependent whole-body, organ and tumor activities were determined and dosimetric calculations were performed according to the mird scheme using olinda software. blood samples were drawn from patients to estimate the absorbed dose to the red marrow. to describe the kinetics we used the withdrawn s following parameters: mean half-life and uptake (fraction of injected activity/dose, id) which were calculated using the fit of the time-dependent activity curve to a mono-or bi-exponential function. results: the renal uptake decreased for the first - hours p.i. with a mean half-life of . +/- . h, followed by a second phase with a longer half-life of +/- h. the maximum kidney uptake was +/- %. the uptake in the spleen was with +/- . % id stable until hours p.i. and then showed a decline with a half-life of +/- h. the tumor uptake showed an increase until h p.i. to a maximum of . +/- . % id per unit mass and then slowly decreased with a half-life of +/- h. liver metastases showed a higher maximal uptake ( . +/- . %) as compared to lymph node metastases ( . +/- . %). the blood kinetics were fitted to a tri-exponential function with large variation: half-life : . +/- . h; half-life : +/- . h and half-life : +/- h. the following organ absorbed doses were calculated: kidneys: +/- sv; spleen: +/- sv; metastases: +/- sv ( +/- sv for lymph node, and +/- sv for liver metastases). the resulting dose to the red marrow was . +/- . sv. conclusions: the relatively low organ doses compared to y- labelled peptides for prrt correlate with the low clinical toxicity of the radiopharmaceutical. the effective treatment of patients with neuroendocrine tumors using lu- dota-tate is confirmed by the mean absorbed tumor doses. individual patient dosimetry should be performed due to the large interindividual variations concerning the organ and tumor doses. aim: an individualized quantitative method to calculate activity distribution and kinetics is needed for accurate, patient-specific dosimetry for optimized internal radiotherapy treatment. our objective is to design a clinically viable, simple procedure that will provide patient specific, quantitative and -dimensional ( d + time) estimate of the dose-rate absorbed from an internally delivered radiopharmaceutical. methods: the elements of the procedure are as follows: • quantitative reconstruction of spect data using patient-specific transmission or ct-based attenuation maps. our qspect method includes attenuation and scatter corrections, and accounts for system resolution, and cross-talk and septal penetration when needed. • quantitative data reconstructed from a spect scan are being combined with the information obtained from a series of - whole body scans (wb) in order to determine quantitative biokinetics of the tracer in tumours and critical organs. • estimation of dose delivered to organs of interest using three complementary elements: (a) voxelized d quantitative activity concentrations, (b) temporal information about biodistribution of this activity, and (c) analytical calculation of the delivered dose. this calculation will be based on the known physics of photon and particle interactions and will use our analytical photon distribution (apd) method. • for repeated radiotherapy treatments, d dose-rate maps may prove to be particularly useful, as the final goal of this project is the determination of the reliable dose-response relationship. materials: simulations and phantom experiments were performed in order to evaluate the accuracy of quantitation for different isotopes relevant for oncology and to design new acquisition protocols that would provide quantitative biodistribution information in clinical setting. investigated isotopes included tc- m, in- , i- , and i- . experiments used siemens e-cam + profile transmission system and ge infinia + hawkeye ct. activity in "tumour"-like containers placed in air and active background was measured using planar, wb, tomographic and a combination of two spect and five wb acquisitions. results: the results of our studies show that in planar and wb studies the quantitation errors vary from about - % to - % depending on the activity distribution and the method of data processing. our qspect technique results in activity estimation with errors in the order of - %. similar accuracy levels were achieved in quantitatition of activity kinetics from a combination of spect+wb studies. conclusions: improved accuracy of biodistribution quantitation obtained from a combined protocol of spect+wb offers new promise for patient specific dosimetry. incorporated into our apd calculation these data will provide -d voxelized dose maps. dose assessment of salivary glands in radioiodine therapy d. shahbazi-gahrouei, z. shahi, k. ziaei; dept. of medical physics, isfahan uni. of medical sciences, isfahan, iran (islamic republic of). the use of radioactive iodine ( i) has become an important adjunct to the treatment of thyroid cancer and hyperthyroidism. salivary gland has the ability to concentrate radioactive iodine under normal circumstances. salivary gland dysfunction and dry mouth are the common side effects of high-dose radioiodine therapy. the purpose of this study was to determine the absorbed dose of salivary glands. materials and methods: twenty patients who were divided into two groups of were studied (a group without pilocarpine and the b group received pilocarpine during treatment). the absorbed dose of parotid glands and the submandibular glands of patients was measured using thermoluminescent dosimeter (tld) at three different times ( hours, days and months after treatment). the attenuation coefficient of patients and the effects of pilocarpine were also determined. results: in group a total attenuation coefficient was . , . , and . for parotid glands and the right and left submandibular glands, respectively. in group b total attenuation coefficient was . , . , and . for parotid glands and the right and left submandibular glands, respectively. the results also showed the dose decreases to cgy after and half life for a and b group, respectively. conclusions: the findings showed that the dose decreases to cgy after half life of iodine therapy. the exponential coefficient attenuation of salivary glands varied between % to %. pilocarpine should be effective to increase excretion of radioactive iodine and increases . to times coefficient attenuation. aim: commercially available radiopharmaceuticals for radiosynovectomy (rso) are expensive and not always accessible for developing countries. cost effective and safe agents are therefore needed. herein we present the biokinetic data of rhenium- -tin colloid (re-col) and phosphorus- colloid (p-col) in patients undergoing rso of the knee. methods: in patients (pts) treated with ± mbq re- ( ) in knee serial blood samples at , , , , , , , , h and urine up to h were collected. additional, in pts treated with ± mbq p- blood measurement at , , , h and urine sampling up to h were studied. median particle size range for re-col μm (range: - ) and for p- . μm ( . - . ), respectively. results: in rabbit animal model, retention of radioactivity in the synovium for re-col at and h were . ± . % and . ± . % of id respectively. in patients undergoing rso of the knee with re-col, average %id in blood at , , and h were . ± . %, . ± . %, . ± . % and . ± . % respectively. total excreted activity in urine at h was . ± . %id (range: - . ). for p-col %id in blood at , , and h p.i. were . ± . ; . ± . , . ± . , . ± . respectively, and . ± . %id in h-collected urine. percent id in blood at h and the area under the curve up to hs were significantly lower for re-col compared to p-col, p< . and p< . respectively. discussion and conclusion: p-col showed a longer retention in blood and a higher urine excretion than re- tin colloid indicating a lower in-vivo stability for p-col formulation. data suggest that blood radiation exposure is lower for re-col than for p-col. both radiopharmaceuticals are however, suitable for radiosynovectomy. as a generator product, re- provide excellent availability and can be cost effective which is however dependent on the frequency of use. p- as a cheep reactor product provide a good and cost effective alternative. reference: . jeong jm et al. appl radiat isot , : - results of an iaea led crp e . . objectives : the objective of this work was to determine normal organ mean absorbed dose and effective dose equivalent and effective dose for c-pib dosimetry in humans. methods : patients ( female, male, mean age . y) were administered with a bolus infusion of c-pib (dose range . - . mbq) and immediately scanned on a gemini pet/ct camera. sequential wholebody pet images, which extended from head to upper thigh, were acquired, representing time points over a period of minutes. resultant images were reconstructed using an iterative single scatter simulation algorithm. using in-house developed software, voi analysis for each time point was performed to obtain activity concentration in normal tissue. organs considered as source organs were brain, lung, liver, kidney, spleen, gallbladder contents and bladder contents. using reference man (icrp ) values for organ volumes, the total activity was calculated per organ for each time point and the cumulated activity was determined from the area under curve of a bi-exponential fit to the resultant time activity curves. the cumulated activities were used as input to olinda. results : large accumulation of c-pib was visualised in gallbladder, liver and urinary bladder. accordingly, the organs with the greatest mean absorbed dose (mean ± sd) were gallbladder wall ( . ± . μgy/mbq), urinary bladder wall ( . ± . μgy/mbq), liver ( . ± . μgy/mbq) and kidneys ( . ± . μgy/mbq). effective dose equivalent (ede) was . ± . μsv/mbq and effective dose (ed) was . ± . μsv/mbq. of note, due to its high absorbed dose, gallbladder wall has a large contribution towards ede, whilst not being considered in the calculation of ed. conclusions : organ dose estimates for c-pib are comparable to other reported c ligands. analyzed and used to determinate the red-marrow-dose. the residence-time in lesions, with s-factors (mird), are used to calculate lesions-dose. data are elaborated by compartimental-models to write the therapeutic plan. patients treated with y cl dotatoc have been followed for appraising the course of disease. results we collected these average and range dose-data (mgy/mbq): red-marrow ( . , . to . ); kidneys ( . , . to . ); spleen ( . , . to . ); liver ( . , . to . ); urinary-bladder ( . , . to . ); total-body ( . , . to . ) . the dose to principal lesion has been calculated for patients (average . , . to . ) . patients had kidneys-dose less than lesion-dose and patients had liver-dose less than lesion-dose. / patients had lesion-dose greater then red-marrow-dose, liverdose and kidney-dose. we followed patients ( patients not treated, patients in progress of treatment). patients had a positive results to the treatment (complete or partial result or disease stabilization) and patients a negative one (progression of disease). among patients with positive results, had lesion-dose greater than critical organs-dose (reached gy to lesion), for patients the lesion-dose has not been calculated. only patient who reached gy in lesion had a negative responce. conclusions the variability of the dosimetric results shows the importance to perform a personalized dosimetric-study. follow-up showed that the patients treated till gy to the lesion had a positive result to the therapy (only one exception). among the patients treated till the reaching of the dose-limit to the critical organs (lesion-dose less then gy), had a positive result. in conclusion, the therapeutic plan wrote on the base of dosimetric-study has a real utility. aim: the pharmacokinetics and dosimetric profile of y-dotatoc is well known, being the kidney the critical organ. however, in end-stage renal failure, biodistribution could be altered and organs such as red marrow (rm) could be critical. the aim of this study was to evaluate the biodistribution and dosimetry of y-dotatoc in a patient with end-stage renal failure undergoing dialysis. methods: a female patient affected by abdominal lymphnode metastases from endocrine carcinoma, asked to eradicate her disease with y-dotatoc in order to be enclosed in the waiting list for renal transplant. the patient suffered from renal failure since the age of . at years old she was operated for lymphnode metastases from gastrin secreting endocrine carcinoma of unknown origin. a subsequent octreoscan showed persistence of abdominal lymphnodes ( mm). gastrin: pg/ml. mbq in-dotatoc were administered for dosimetry. blood samples and planar images were obtained up to h p.i. patient-specific dosimetry was evaluated by imaging analysis and actual organ masses (ct). the blood-derived method was used for rm dosimetry, considering the rm specific activity equal to that in blood. the number of disintegrations (nd) was obtained for all source organs; for rm, the rm specific activity equal to that in blood. the olinda/exm code was used to calculate absorbed doses. results: nds (h) in source organs were: . (rm); . (spleen); . (liver); . (remainder of body-rb). absorbed doses (gy/gbq) were significantly higher than published results (mean±sd): . (vs. . ± . ), spleen; . ( . ± . ), liver; . (vs. . ± . ), rm, . (vs. . ± . ), total body. this confirmed a redistribution of the activity usually eliminated through kidneys, with fast and higher uptake in liver and spleen. tumour dose was gy/gbq. the treatment was considered feasible, with rm critical organ, liver second limiting organ, spleen irradiation of some concern. the patient conservatively received . gbq. therapy was well tolerated. only reversible grade toxicity on wbc and plt, and grade on hb, occurred. six months after octreoscan and mri showed disappearance of the lesions. gastrin: pg/ml. conclusions: in patients undergoing dialysis, rm is the critical organ. these results showed the feasibility of y-dotatoc therapy even in patients who would be logically excluded. in such cases, a deep analysis of the tumour dose and risk-benefit balance should guide, addressing y-dotatoc to cases without other options. assessment of absorbed dose and therapeutic response of tumor in repeated high-dose i- anti-cd monoclonal antibody (rituximab) radioimmunotherapy for non-hodgkin's lymphoma nearby tumor. the shape of d-roi of tumor was determined from the mip pet image. the volume of tumor was measured from the ct image, the % change of tumor volume before and after rit was used to evaluate the therapeutic response. the value of ct-based tumor volume was compared with that measured by pet image at the cut-off suv of . . in tumor dose estimation, the time-activity curve (tac) of tumor region was used, and the both absorbed fractions of beta-and gamma-ray were considered together. results: bi-exponential decrease was observed in fitting of tac of tumor. the values of ct-and pet-based tumor volume were . ± . cc and . ± . cc, respectively, and showed the linear relationship(r= . ). the values of absorbed dose for tumor and the %changes of tumor volume before and after rit were . ± . rad, were . ± . %, respectively, and did not show the linear relationship(r=- . ). the values of absorbed dose for tumor and the % changes of tumor volume did not show the linear relationship with the number of repeated administration(r= . and - . , respectively). conclusion: aligning pet and planar images could estimate the quantitative values of absorbed dose to tumor. the data suggest that potentially equal absorbed dose and therapeutic response of tumor could be expected in repeated rit with i- rituximab for nhl. purpose: gastric cancer is one of the most common cancers, and is the second most common cause of cancer related mortality in the world. the a antigen is a glycoprotein which is homogenously expressed by more than % of colorectal cancers and % of gastric cancer and in the normal intestinal mucosa, but not in other epithelial tissues including gastric epithelium. in order to determine the in vivo characteristics of hua , a cdr grafted humanized monoclonal antibody against the a antigen, a clinical trial was conducted in patients with gastric carcinoma. patients and methods: thirteen patients were entered into the study. they were assigned serially onto one of four dose levels ( . , . , . , . mg/m ) of hua . patients with early gastric carcinoma received a single infusion of i-hua one week prior to surgery. biodistribution of i-hua was evaluated by the imaging at least occasions including on the day of administration and on upto days. adverse events were assessed. ex vivo imaging and immunohistochemical analysis were performed on the samples of biopsy and surgical specimens. results: no dose-limiting toxicity was observed and the maximum tolerated dose was not reached. although cancer tissues with low expression of a by immunostaining in biopsied frozen sections did not show positive imaging with i-hua , cancers with high expression of a by frozen and paraffin sections in the biopsied specimen showed positive ex-vivo imaging and positive antigen expression in resected gastric cancer specimen, and the biodistribution analysis also showed tumor uptake of i-hua . conclusions: humanized monoclonal antibody hua demonstrated selective localization to gastric cancer that strongly expresses a antigen. these targeting characteristics of the hua indicate potential for the targeted therapy of advanced gastric cancer that is refractory to cytotoxic chemotherapy or recurrence after surgery, and could also be exploitable for the adjuvant therapy after curative resection of early gastric cancer. metabolic radiation therapy is mediated by emitter labelled radiopharmaceuticals allowing lethal target radiation. unfortunately, such medical practices using emitter radioisotopes is associated with an increase of medical staff radiation exposure in nuclear medicine department. this gives us reasons to quantify medical staff radiation in our department during -i lipiodol, -y-colloid and -sm edtm treatments of hepatocellular carcinoma, arthritis (radiosynovectomy) and bone metastases respectively. methods: injections of i-lipiodol, -y-colloid radiosynovectomy sessions and -sm-edtm treatments were studied. whole body doses (wbd) and right and left finger doses (rfd, lfd) for radiopharmacists (rp), nurses (n), radiologists (rd) and rheumatologists (rm) were evaluated by cylindric lif-thermoluminescent dosimeters (tld) placed on the waist or on the inward second finger. results: wbd for medical staff during . ± . gbq -i lipiodol injections were . ± . , . ± . and . ± . μsv for respectively rp, n and rd. rfd and lfd were respectively . ± and . ± μsv for rp, . ± . and . ± . μsv for rd. the use of angioseal ® hemostatic puncture closure device deployed for haemostasis after -i lipiodol injections afforded a two fold decrease in rds' exposure compared to manual compression. during the -y colloid syringe filling sessions (mean activity per session: . ± . mbq, n= ), the wbd for rp was . ± . μsv, rfd was . ± and lfd was ± μsv. wbd for rm and n performing intra-articular infusions were respectively . ± . and . ± . μsv per mbq injected. fd, normalized to mbq injected, were . ± μsv (rfd) and . ± μsv (lfd) for rm and . ± . (rfd) and . ± . μsv (lfd) for n. during -sm edtm syringe filling ( . ± . gbq) rp wbd was . ± . μsv rfd was . ± . and lfd was . ± μsv. n exposure during -sm-edtm administration was . ± . (wbd) and . ± . μsv (rfd) conclusion: fortunately, annual extrapolated wbd and fd doses remain under legal limits but observed values are not negligible and have to be added to those relative to -iodine treatment of thyroid disorders for example. such considerations may confirm the interest of protocol optimization, personal information and studies focusing on radioprotection. evaluation of factors affecting the accuracy and precision of a technique for quantification of volume and acticity with in spect. m. s. kotzassarlidou, c. tziaka, t. kalathas, a. raptou, n. salem, a. makridou; theagenion cancer hospital, thessaloniki, greece. aim: accurate in vivo volume and activity determination is essential in clinical research, especially for estimating organ absorbed dose during radionuclide therapy. in this study volume and activity concentration were estimated using single photon emission computed tomography (spect) for volume and activity concentrations of -in sources between . - . ml and - mbq/ml. all sources were of regular geometry. the influence of voxel size, source size and shape was studied. materials and methods: spect acquisitions have been carried out by sopha dst xli -head gamma camera over o, elliptical orbit and step and shoot mode, according to the following protocols: - x , frames, sec/frame, - x , frames, sec/frame. pixel size [cm] and system sensitivity, [cps/mbq] of both matrix sizes for -in spect have been determined in advance. processing was performed on vision workstation using a butterworth reconstruction filter (order , nyquist . ). attenuation correction was applied and transaxial images of one pixel thickness were obtained. the segmentation algorithm used for volume quantification was the autothresholding method. pixel value with the maximum counts in all slices was selected and percentage ( - %) of it was determined. pixels of all slices with a value equal or greater than the predetermined value belonged to the source. volume estimation was obtained by summing the number of voxels within the source contour in each slice and multiplying their total by voxel volume. activity estimation was obtained by summing the counts of the above regions and dividing their total by acquisition time and the system sensitivity. results: the best correlation between nominal and measured volumes by -in spect images was obtained with threshold percentage of % and % for x and x matrix size respectively. error increases as nominal volume decreases (r=- . , p= . ) for x whereas for x it increases proportionally to the threshold (r= , , p< . ). activity estimation was best obtained for threshold percentage of % for x . conclusions: autothreshold technique is effective for in vivo volume and activity quantitation of lesions with volumes greater than the system spatial resolution (i.e. volmeas> . ml). in case of smaller lesions ct is preferable for volume quantitation. where d k is the mean absorbed dose to region k (gy); a is the administered activity (bq); s (r k r j ) is the mean absorbed dose in target region k irradiated by source region j; j is the residence time in source region j (s), which is j = t t a j (t)dt / a = t t a j (t) / a dt = t t %id dt. where a j is the activity of source region j at the time of t. we calculated the mean absorbed dose of critic organ by mirdose . software (internal dose information center at oak ridge institute for science and education, oak ridge, tn), using the dynamic bladder model ( h void) . we summed up the resident time of lungs and tumor as the "lungs" resident time. corrections were made for lungs masses. for the mass of tumor tissue ( m t ) we assumed unit density and employed the ct volume ( v t ) : m t = × v t . tumor background subtraction was attempted using ct scans to estimate true background thickness. absorbed doses to tumor tissues (d t ) were estimated using the same approach taken for normal organs. s-factors for tumors were estimated by comparison with lungs. according to equation d t =m lungs ×(d " lungs" -d lungs )/ m t and d t =m lungs ×(d " lungs" -d lungs )/ m t , where d " lungs" , the mean absorbed dose of mixed lungs and tumor. by equation, we can easy to calculate the d t and d lungs . results: the absorbed dose of red marrow ranged from . to . gy; thyroid, from . to . gy; ovaries, from . to . gy; testes, from . to . gy; kidneys, from . ~ . gy; liver, from . to . gy; lungs, from . to . gy; and effective dose equivalent from . to . gy. the results shows tumors with highest uptake of ( . ± . )%id of i-chtnt at h. the mean absorbed dose of tumors (within a) was [( . ± . ), from . to . ]gy, d reached ( ± )%, d reached ( ± )%, and the tumor-to-nontumor ratio (t/nt) was . ± . (from . to . ). conclusion: repeated intravenous i-chtnt is needed because single intravenous dose of i-chtnt could hardly depress the growth of tumor masses. objective: to study tgf- and bfgf expression in normal prostate and bph and inhibitory effects of specially designed sr /y applicator radiation on the expression in hyperplasic prostatic diseases. method: bph patients were divided into two groups, the intracavitary exposure group and the hyperplasia group. all patients in exposure group were treated with sr /y applicator. patients were practiced operation days after the exposure, another patients were practiced operation days after the exposure, and the rest patients were practiced operation days after the exposure. patients in hyperplasia group were not treated with intracavitary exposure. expression of tgf- and bfgf were detected through immunohistochemical staining technique. results: tgf- positive expression rates of np and bph epithelial cells were higher than those in correspondent stromal cells (p< . ). no statistically significant association was found between tgf- positive expression of epithelium and stroma in bph tissues and the correspondent expression in np (p> . ). compared with the hyperplasia group, tgf- positive cell rates in bph epithelial and stromal cells were significantly increased , and days after sr /y applicator exposure (p< . ). expression of bfgf existed not only in epithelial and stromal cells of bph, but also in normal prostatic tissues. the bfgf positive expression rates in bph epithelial and stromal cells were higher than those in np epithelial and stromal cells (p< . ). bfgf positive expression rates in bph and np stromal cells were higher than those in corresponding bph and np epithelial cells (p< . ). bfgf levels in bph epithelial and stromal cells descent sharply , and days after sr /y applicator exposure (p< . ).conclusion: exposure of -rays from sr /y applicator had noticeable effects to enhance tgf- expression and inhibit bfgf expression in bph tissues. objective: to investigate expressions of bcl- and bax in benign prostatic hyperplasia (bph) tissues and influence of radiation from specially designed sr /y applicator on bcl- and bax expressions. method: bph patients were divided into two groups, the intracavitary exposure group and the hyperplasia group. all patients in exposure group were treated with sr /y applicator. patients were practiced operation days after the exposure, another patients were practiced operation days after the exposure, and the rest patients were practiced operation days after the exposure. patients in hyperplasia group were not treated with intracavitary exposure. expression of bcl- and bax were detected through immunohistochemical staining technique. results: the bcl- positive expressions in both normal prostate(np) and bph epithelial cells were higher than those in corresponsive stromal cells(p< . ),while the bcl- positive expressions in epithelial and stromal in bph tissues were higher than those in np(p< . ).meanwhile, the bax expression in np epithelial cells was higher than that in bph(p< . ),and the bcl- expressions of epithelia and stroma in bph were higher than the corresponsive bax expressions(p< . ). no statistically significant association was found between the bcl- expressions of epithelia and stroma in np and the correspondent bax expressions(p> . ).compared with the hyperplasia group, bcl- in bph epithelial and stromal cells reduced sharply, and bax positive cell rates increased distinctly , or days after the intracavitary exposure by sr /y applicator radiation(p< . ). conclusion: bcl- and bax play an important role in regulation of prostatic apoptosis and the treatment of radiation with sr /y applicator before surgery can accelerate apoptosis in prostatic tissues. the purpose of this study was the quantitative analysis of the internal contamination with four uranium isotopes in the population living near the uranium conversion facility in port hope, ontario, canada; the oldest operating uranium processing plant in the world. the urine samples of symptomatic patients presenting with symptoms of musculo-skeletal, cns, immune system, and neoplastic disease were obtained from among a large population. control samples were also analyzed. the urine samples were analyzed in a specialized radiochemistry laboratory by mass spectrometry, including pre-concentration of urine by co-precipitation, oxidation of organic matter, uranium purification by ion-exchange chromatography, and icp-ms double-focusing thermo finnigan neptune multi-collector. natural uranium has a u/ u ratio of . and does not contain u. background total uranium concentration in the urine of humans is ng/l (usa nceh). our results show of samples containing uranium of non-natural origin. one sample was highly positive for depleted uranium (du) with a u/ u of . ± . and a relatively normal abundance of total uranium. this sample contained a concentration of u with a u/ u ratio of . x - ± . x - indicating its reactor origin. three samples contained detectable amounts of u, one being paradoxically high with a u/ u ratio of . x - ± . x - . one of these three samples contained a higher than normal concentration of total uranium ( . ng/l). the u in these samples indicates its origin as contamination with non-natural uranium. the remaining five samples were negative for both depleted uranium and uranium- . the history of uranium contamination of the vicinity of port hope has been verified in objective scientific literature . our results suggest long-term contamination and possible adverse effects on the body burden of the current population of port hope. these preliminary results warrant additional multidisciplinary studies. aim: standard treatment of differentiated thyroid carcinoma (dtc) is total thyreoidectomy followed by radioiodine therapy (rit) and diagnostical i- -whole body scan (d-wbs). radioiodine (ri) is eliminated via kidneys. in patients with dtc and end stage renal failure (esrf) doses between and mbq were administered orally. the aim of this study was to evaluate the therapeutical effectiveness of rit using reduced amounts of ri. material and methods: during the last seven years esrf patients suffering from dtc were treated with rit. one patient received four ri treatments . one patient got two rits and d-wbs and one patient received two rits. the activity doses administered ranged between and mbq for rit and between and mbq for d-wbs, respectively. hemodialysis was done on the st and rd day after ri administration. serum thyroglobulin (tg) was measured prior to and after ri applications using tg-sria( brahms, sensitivity , ng/ml) during tsh stimulation indium oxinate is a radiopharmaceutical that decays by electron capture with a half life of hours, emitting gamma radiation with energies of kev and kev as well as low energy auger electrons. indium oxinate is used in nuclear medicine for the in-vitro labelling of separated blood cells, which are then administered to patients to investigate inflammation at the sites of infection and abscesses. because of the potential toxicity of its auger emissions indium has also been evaluated recently as a potential tumour therapy, where indium has been conjugated to somatostatin receptor analogues or to tumour-specific antibodies. aims: the aim of this investigation was to study the dna-damaging effects and cytotoxicity associated with cellular exposure to indium and to evaluate the intracellular and intranuclear doses of indium required to elicit cytotoxic effects. methods: we have investigated cellular toxicity of indium oxinate in ht fibrosarcoma cells and mcf- breast epithelial cells using the colorimetric mtt assay and the clonogenic survival assay. the results were compared with data obtained from similar experiments in which cells were treated with equimolar amounts of indium oxinate that had been subjected to several weeks of decay, in order to determine the degree of cytotoxicity attributable to radioactive emissions. the single cell gel electrophoresis (comet) assay was also used to determine dna damage associated with exposure to indium oxinate. cellular and nuclear uptake were measured using a phophorimager or a gamma counter. results: ht cells that were subjected to mbq/ml indium oxinate exhibited . % cellular survival in the clonogenic survival assay compared to untreated control, while treatment with a molar equivalent of the decayed indium oxinate exhibited % survival compared with the same control. mcf- cells exhibited zero cellular survival when subjected to treatment with mbq/ml compared to untreated control, while treatment with decayed indium oxinate exhibited % survival compared with the same control. the comet assay showed dna damage only at doses where cell toxicity was observed. cellular and nuclear uptake showed that % of indium taken up by the cell was contained in the nucleus. the results demonstrate that radioactive emissions associated with mbq/ml indium oxinate elicit significant dna damage and cytotoxicity in ht and mcf- cells. these data will allow correlation of intracellular dosage and nuclear proximity with cytotoxicity and dna damage. auger electrons and it effect on cell viability. in vitro preliminary results m. laranjo , a. m. abrantes , i. carreira , m. f. botelho ; biophysics/biomathematics institute, ibili-faculty of medicine, coimbra, portugal, biology institute, faculty of medicine, coimbra, portugal. aim: because auger electrons cause a high energy deposition limited to the area of the decay site the ensuing biological effects may represent an alternative in cancer radiation therapy. mtc is the most used radionuclide in nuclear medicine. besides its energetic gamma emission, its hours half-life makes it the preferred radioisotope for patient administration. as mtc is also an auger emitter, the possibility to use it not only in diagnosis but also in treatment should be investigated. in order to examine the effects of mtc auger electrons in cancer cells, we investigated the survival and proliferation after exposure to mtc-pertechnetate. material and methods: adenocarcinoma colon cells (atcc -widr) developed in dulbelcco's medium with % of fetal bovine serum and incubated in ºc, % co atmosphere were used. mtc-perchnetate ( mbq) was added to the medium during different exposure times ( , , and minutes) which resulted in absorbed doses of . , . , . , gy, respectively. after the incubations, mtc-perchnetate uptake was calculated. the cell viability and proliferation were evaluated , and hours after exposure. cell viability was evaluated by trypan blue exclusion test. this vital stain does not pass trough the membrane of living cells however, traverses the membrane at a death cell. with this method it is possible to estimate the ratio between living cells and death cells. to access cell proliferation we used mtt ( -[ , -dimethylthiazol- - yl]- , -diphenyltetrazolium bromide), an yellow tetrazolium salt that is reduced in metabolically active cells to form insoluble purple formazan crystals. these are solubilized by the addiction of a detergent and then quantified by spectrophotometric means. results: regarding uptake of mtc-pertechnetate it increases proportionately to the incubation time ( % for . gy; % for . gy; % for . gy and % for gy). the viability indicates an increase of proliferation on the first hours after irradiation, but after this time it decrease progressively with the time. h after treatment the proliferation values were % for . gy; % for . gy; % for . gy and % for gy. h after treatment the proliferation values were % for . gy; % for . gy; % for . gy and % for gy. conclusions: these preliminary results indicate that there are time dependent effects on proliferation and cell death. y. lin , w. chang , w. lin ; chunghsing university, taichung, taiwan, taichung veteran general hospital, taichung, taiwan. the aim of this study was to investigate of various basic amino acid solutions and other compounds in order to assess their safety and their capacity to inhibit the renal uptake of in- -dotatoc. materials and methods: male spraque-dawley rats ( - g) , in the presence of reuptake blocker, were injected with in- -dotatoc. at hours after injection, rats were sacrificed and organs were isolated and counted for radioactivity. results: lysine ( mg/kg) were resulted in more than % inhibition of kidney uptake, but it may induce hyperkalacmia and metabolic changes. combination of arginine and histidine were also resulted more than % inhibition, nevertheless it have less side effect than lysine. maleate ( mg/kg) were more effective to reduce renal uptake about over %. further, coinjection of colchicines ( mg/kg), vincristine ( . mg/kg), noscapine ( mg/kg), nocodazole ( mg/kg) hours before injection of in- -dotatoc were significantly reduced kidney uptake (respective inhibitions of %, %, % and %). conclusions: administration of these compounds effectively reduce kidney radioactivity in order to allow the administration of higher doses of radiolabelled somatostatin analogues for scintigraphy and peptide receptor radionuclide therapy. introduction hyperthyroidism is a common disease in old cats and is preferably treated with radioactive iodine. treatment results are good, with - % of the cats becoming euthyroid. concurrent subclinical kidney disease is not uncommon in this patient group and close monitoring of kidney function is mandatory. a recent research protocol at our institution necessitated the use of iohexol as a gfr marker to investigate kidney disease immediately prior to treatment with radioactive iodine. since it is generally known that iohexol reduces (radio)iodine uptake in the thyroid, this study was set up to evaluate its effect on absorbed dose in the thyroid and to investigate whether this procedure influenced long term outcome of treatment. materials and methods hyperthyroid cats, presented for i -treament, participated in this study. gfr measurement using iohexol was performed in patients one day before injection of i . cats received only i and functioned as control-group. the iohexol-group received an average activity of mbq i (sd ± mbq); the control-group received on average mbq i (sd ± mbq). scintigraphic scans were performed , and h post-therapy. a syringe with known reference activity was scanned using the same parameters. roi's were drawn over the thyroid region, background and reference activity for all time points. cumulative activity was calculated. a factor was obtained using mirdose . software converting the cumulative activity into absorbed dose, taking into account the thyroid volume. results the mean estimated absorbed thyroid dose in the iohexol-group was gy (sd ± gy), which was significantly different from the control group: gy (sd = gy) (p< . ). of the cats that received iohexol, a higher percentage remained hyperthyroid ( %) months after treatment compared to the control group ( %). these results however did not reach significance. (p> . , -test) . conclusion the administration of iohexol to evaluate kidney function reduces absorbed thyroid dose of i in this small group of cats but does not seem to influence long-term outcome of feline hyperthyroidism. p -monday, oct. , , : pm - : tc-mibi were . μsv.h - ± . and . μsv.h - ± . respectively, at cm from the patients. for tl, the average dose rates at the distances of , and cm from patients hours after administration were . , . and . μsv.h - respectively. these values were in close agreement to the mean corresponding value of . , . and . μsv.h - obtained by munford et al . the maximum departure dose rates at these distances were . , . and . μsv.h - .mbq - respectively. external doses rate of tl fell gradually, until three days after administration. after injection of m tc-mibi a rising of the external dose within - hours was seen. the maximum departure rate per unit activity at the distances of , , and cm were . μsv - .mbq - , . μsv - .mbq - , . μsv - .mbq - and . μsv - .mbq - respectively. significant exposure from patients after injection of m tc-mibi was limited on the few hours after administration. maximum and average absorbed dose of nuclear medicine staff from tl were . and . μsv.h - , and for m tc-mibi were . and . μsv.h - in each scan. conclusion: significant exposure from m tc-mibi for cardiac investigations has limited to a few hours after administration. in case of administration tl the dose rates from the patients continues to decrease until three days after injection. these data could be considered as a base for calculative exposure dose in close contact during working hours of nuclear medicine staff. . one of the most effective treatments for thyroid carcinoma is the use of iodine- . in recent months a number of patients with end stage renal failure have been referred to our hospital for thyroid ablation therapy. this has presented a number of challenges from a radiation protection perspective, for both the patient and the staff involved. in establishing this procedure we aim to provide an effective combination of treatments for these patients. in addition the radiation dose to all staff involved in this therapy must be considered. to date two patients in end stage renal failure, both requiring regular haemodialysis sessions, have been treated at our hospital. a multidisciplinary team was involved in establishing this procedure and helped to identify the risks involved. a dialysis facility was provided in one of our dedicated treatment rooms to enable the best possible arrangement for radiation protection purposes. all staff involved were given radiation safety training before the therapy was conducted. a member of the radiation safety team was also on hand for the duration of each dialysis session. each patient received mbq of i- in capsule form with dialysis sessions conducted immediately prior to the therapy and and hours after administration of the capsule. each patient was successfully dialysed on all three occasions, with no unexpected complications being noted. dose rate measurements were performed on a daily basis, which is a routine occurrence for all our patients. dose rates were also measured immediately prior to and after the completion of each dialysis session. all staff involved were provided with radiation monitoring in the form of whole body tld monitors, extremity monitors and electronic personal dose meters. our dose rate measurements show slower clearance rates, by approximately %, in these two patients when compared to 'standard' cases. however, this is to be expected as the main excretion route for i- is via the kidney. by implementing appropriate radiation safety training and methods staff doses were also able to be kept to a minimum. maintaining the regular dialysis schedule for both these patients also allowed us to deliver an effective therapy without compromising the patient's welfare. skin cancer is the most common cancer in humans. many different treatments are currently used in the management of this kind of tumours, and include surgical techniques, topical therapy and radiotherapy. the healing percentage usually range from to % by using the best therapeutic treatments. in the present paper a new therapeutic option for the treatment of squamous cell carcinoma (scc) and of basal cell carcinoma (bcc) proposed. it consists in a superficial radiotherapy with beta emitters isotopes, characterized by the use of a synthetic resin incorporating radioactive re, that is able to perform a selective irradiation treatment of the cancer lesion. patients with histologically confirmed diagnosis of bcc and of scc were enrolled for the treatment, by choosing the cases in which a relapse of the tumour was present, or in which a surgical operation would have been impossible or aesthetically unacceptable. all treatments were performed in the nuclear medicine dept. of s.eugenio hospital, rome. in all treated cases, an apparent clinical remission occurred in approximately months; a complete healing was obtained in % of the treated cases, in % of the cases after a single application. neither unaesthetic scars, nor side effects, were observed. after a follow up of - months, no signs of clinical relapses were present in any of the treated patients; when a histological examination was performed, a complete tumour regression was observed. treatment of verruca plantaris with microwave and p application therapy y. ma, y. liu, p. lu, g. huang; renji hospital, shanghai jiaotong university, shanghai, china. aim: to study the clinical curative effect of verruca plantaris with microwave and p application and its application value. material and methods: patients with extremity verruca plantaris were chosen by random from outpatient, out of them, the patients is male and is female, their average age is . ± . s ( ±sd) years old, randomly divided them into two groups: ( ) microwave treatment group have ,the wart bodies were eliminated by microwave under local anaesthetize. ( ) individuals were treated with p application therapy ,the liquid of radionuclide p were dropped in gauze, drying them and then fixing them in corresponding focus surface for application therapy, randomly divided patients into three groups with hours, hours, hours application each time, a group has patients average. about - times. and once a week until the lesion recovered. the clinical reaction and curative effect were observed. results: the clinical cure rate, recurrence rate, side effective occurrence rate and complication occurrence rate are . %, . %, . % and . % respectively in microwave treatment group and they are . %, . %, . % and . % respectively in the group of p application therapy. conclusions: the characteristics of treatment of verruca plantaris, with p application therapy are simple method , convenient, safety , little pain, notable curative effect, it is a kind of successful effective treatment method. using ligandtracer® to quantify protein-cell interactions in real-time l. vennstrom , h. bjorke , k. andersson ; ridgeview instruments ab, uppsala, sweden, uppsala university, uppsala, sweden. aim: validate a novel biosensor (ligandtracer®) designed to detect how radiolabelled proteins bind to cell surface receptors in real-time and explore new possibilities with the biosensor. material and methods: different cell lines (e.g. a and skov- ) and radiolabelled proteins (e.g. egf and trastuzumab) known to bind to the receptors egfr or her were used in this study. cells and reagents were placed in ligandtracer grey and binding traces of the protein-cell interactions were recorded in real-time without user intervention. the results were compared to data obtained from classical protocols. results: the results obtained with ligandtracer grey agreed with classical protocols and was highly repeatable. the time resolution in ligandtracer data was superior to the classical protocols used. furthermore, the novel biosensor required less disposables and manual workload. conclusion: the automated, real-time binding traces obtained with ligandtracer relieve researchers from manual workload and provides data with higher time-resolution. apart from replacing manual protocols in protein-cell interaction measurements, this novel method opens up many new possibilities in the field of cell-based assays. p -monday, oct. , , : pm - despite of progress in pediatric oncology, metastatic neuroblastoma in children over year of age still remains great challenge. nearly % of children in this group present bone marrow involevement. in staging of neuroblastoma , the assessment of tumoral infiltration of bone marrow is an important indicator of prognosis. for detection of bone marrow metastasis traditional staging includes bone marrow aspiration biopsy. another method, scintigraphy with radiolabeled metaiodobenzylguanidine (mibg), specifically taken up for cells of sympathetic origin, is now considered as the first line method for the staging and follow-up of neuroblastoma. the aim of this study was to assess the respective values of these two methods: mibg scintygraphy and bone marrow aspiration biopsy in determination of the extent of neuroblastoma. materials and methods: i-mibg scans and bone marrow aspiration biopsy were performed at a time of diagnosis and were repeated at interval of mean months (from months to months) during at least two years. retrospectively there were evaluated i-mibg scans of children ( stage iv, stage iii and stage ii) and were compared with the results of bone marrow aspiration biopsy. mibg scan was divided into three groups: -no tracer uptake in the skeleton, -diffuse uptake in the skeleton with or without focal lesion, -focal lesion in one or more bones. results: there was no tracer uptake in mibg scans, all of them had negative bone marrow aspiration biopsy. focally increased uptake was seen in mibg scans but only in of those scans bone marrow biopsy was positive. diffuse uptake in the skeleton with or without focal lesion was detected in mibg scans and bone marrow aspiration biopsy was positive in . conclusion: mibg scintigraphy has very high sensitivity and specificity for detection of bone marrow metastasis. to assess bone marrow involvement mibg scintigraphy is more sensitive than bone marrow aspiration biopsy. mibg scan seems to be very good method for staging of neuroblastoma even when bone marrow aspiration biopsy is negative. the study aimed to determine if the fetal anteroposterior renal pelvic diameter (rpd) is predictive of obstruction as determined by scintigraphy. methods: neonatal lasix augmented(f+ ) mag studies conducted over months for the clinical indication of sonographically detected antenatal hydronephrosis (rpd> mm in mid trimester, mt, and > mm in the third trimester, tt) were retrospectively analysed. the sonographic mt, tt and postnatal (pn) rpd were noted. pnrpd> mm on the postnatal ultrasound was defined as postnatal hydronephrosis. this was based on scott and renwick's findings of % of the postnatal population falling in the - mm range (br j urol : - ). two blinded nuclear physicians classified the scintigraphic studies as 'obstruction' or 'no obstruction' based on the half time drainage (t / ) and frusemide washout curves. results: a total of patients ( hydronephrotic kidneys) were identified with measurements at mt in n= , at tt in n= and at pn in n= . antenatal hydronephrosis detected in / tt kidneys had resolved on the postnatal ultrasound. a series of one-way anova's were performed separately for the right and left kidneys to compare the means of the trimester measurements for those that were obstructed on scintigraphy. though the probability of obstruction was greater at higher rpd, in all groups, there was no statistically significant difference for the mt and tt mean rpd measurements in the obstructed versus non-obstructed group (p>. ). the mean pnrpd was found the most reliable predictor of obstruction on scintigraphy (p=. rt and p=. lt). the ppv for prediction of obstruction with rpd> mm is % and the npv for prediction of nonobstruction at rpd < mm is %. the findings were also correlated with results of the micturarting cystourethrogram(mcu) when it was available. mcu was available in / patients and / kidneys. vesico-ureteric reflux(vur) was identified in / ( . %) patients and / ( %) kidneys. there was no statistically significant relationship between the rpd and presence of vur. conclusion: antenatal hydronephrosis is more prevalent in the male fetus. the pn-rpd has a higher predictive value for diagnosis of obstruction compared to the mt and tt measurements, with higher likelihood of obstruction at higher diameters. the negative predictive value is % to s exclude obstruction if pn-rpd< mm.this group of patients can hence be observed with follow-up sonography rather than subjecting them to have renogram studies. objective: clinical presentation of myocarditis (myo) varies from asymptomatic cases to acute heart failure. endomyocardial biopsy (emb) is an invasive method, therefore another procedure would be advisable, especially in children. the aim of study was to investigate of the scintigraphy with m tc-anty-granulocyte antibody ( m tcaga) usefulness in pediatric cases with suspected myo. methods: between between to aged , - , yrs) with the symptoms of myo were evaluated at initial presentation and month later. all pts underwent heart scintigraphy with m tcaga; - mci the tracer activity was administered iv and acquisition in ap projection was performed and hours later. the estimation of m tcaga uptake was evaluated by calculation of the heart-to-lung ratio (hlr), value of , or more was considered as a positive result. m tcaga scintigraphy was performed in control group of children with suspected enterocolitis (hlr , ) . emb was performed with immunohistchemical method in pts (no consent in one case). the results of heart scintigraphy were compared with emb. results: the mean time from onset of symptoms of myo which included fatigue, heart failure (n= ), ventricular arrhythmias (n= ), chest pain (n= ) to diagnosis of myo was , ± mo. positive m tcaga uptake was observed in pts (mean hlr , ± , ), in cases intense (hlr> ), in moderate (hlr< ) and in pt borderline (hlr , ) . higher hlr (mean , ± , ) was found in the pts who presented within mo of the onset of symptoms than in those who presented in later phase (mean hlr , ± , ). emb results showed evidence of myo in pts, no evidence in one case. all pts with hlr> showed evidence of active myocarditis in emb. follow up m tcaga scintigraphy was performed in pts (mean hrl , ± , ); follow up emb in pts showed evidence of persistent inflammatory process in myocardium. conclusion: . , % of the pts with positive heart scintigraphy showed evidence of myocarditis in emb. . intense myocardial uptake of antigranulocyte antibodies with hlr> strongly indicates active myocarditis. . although further studies are necessary to establish its sensitivity and specificity, scintigraphy with m tcaga seems to be an advisable diagnostic method in pediatric cases with myocarditis. dynamic renal scintigraphy in patients with hydronephrosis e. urbanova , i. novak , j. vizda ; university hospital, nuclear medicine, hradec kralove, czech republic, university hospital, pediatric urology, hradec kralove, czech republic. the aim of this study is to evaluate the kidney function before and after operation for hydronephrosis. stenosis of proximal ureter is the most common anomaly, causing dilatation of the renal pelvis and thus hydronephrosis. in all children in our study ureteropelvic obstruction was suspected and hydronephrosis with dilatation of renal pelvis was detected by ultrasound. for functional relevance of urinary tract obstruction dynamic renal scintigraphy (drs) was used. material and methods: during the past months children in age - years without clinical sign of infection were included in our study. preoperative data, early and late complications and outcome were recorded. imaging studies included urinary tract sonography and drs, which were compared pre and postoperatively. patients were hydrated before scintigraphy and were advised to empty urinary bladder before investigation. for drs as radiopharmaceutical technetium m labeled mag was used. frusemide was administered intravenously minutes after the start of examination at dosage of . mg/kg body weight to achieve forced diuresis. scintigrams were recorded in posterior view. the zoom factor was chosen . - , matrix x . total time of examination was minutes. the definition of the region of interest (roi) for each kidney was either semiautomatic, using a roi drown around the kidney, or fully automated. it was routine to obtain post-void images for gravity-assisted drainage. quantitative functional parameters were interpreted in conjunction with image review and perfusion, parenchymal and excretory phases were described. an attempt was made to define the approximate limits of reversibility of stasis in affected kidney after operation, so drs was repeated in children from our study - months after the operation. results: drs in comparison pre and post-operation in the children showed marked improvement of washout (wo). in addition the six children with wo = about % also showed months later small improvement at scintigraphy. conclusion: sonography is suited to documenting the anatomical situation and can be repeated without radiation burden, but drs can be used to assess the functional relevance of urinary tract obstruction before and after the operation. the careful attention to the technique of the examination is necessary, because there are still many controversies surrounding the physiology and interpretation of the renogram. early diagnosis and suitable therapy of functionally relevant urinary tract obstruction are very important to avoid chronic renal damage. aim: glomerular filtration rate (gfr) is generally considered the best functional measure among several important functions of kidney. cystatin c is a nonglycosylated basic protein produced at a constant rate by all nucleated cells and eliminated by glomerular filtration. serum cystatin c reflects renal function in children independent of age, gender, height, and body composition. recently, cystatin c has been studied as an alternative marker of gfr and more accuracy than serum creatinine.the aim of this study was to compare measured gfr by two-plasma sample method (tpsm) with serum cystatin c level in paediatric population. materials and methods: the study population comprised consecutive patients ( boys, girls, mean age . ± . ), included thalassemia (n= ), acute lymphoblastic leukemia (all) (n= ) and fanconi anemia (n= ). blood samples were taken at and min post-injection of - mbq of tc- m dtpa from the contralateral arm. slope-intercept method was used for tpsm gfr measurements. serum cystatin c level was also measured on all patients. results: tpsm gfr values varied between - ml/min/ . m (mean: , ± ml/min/ . m ). serum cystatin c levels ranged from . to . mg/l with a mean of , ± . mg/l. there were found statistically significant negative correlation between tpsm gfr and serum cystatin c level (r = - . , p< . ) . regression analysis showed the curve equation formula as follow:gfr (ml/min/ . m ) = -( x serum cystatin c )ninetyfive % confidence interval is: . -( . x cystatin c) to . -( x cystatin c); p< . . conclusion: this study showed that there was statistically significant negative correlation between gfr value in tpsm and serum cystatin c level. cystatin c may reflect the quantitative renal function in the paediatric population. further studies are needed to validate this conclusion in paediatric population. there is increasing evidence that botulinum a toxin (boa) might have a powerful role in the management of children with functional voiding problems. the aim of this study was to analyze radionuclide uroflowmetry evidence of effectiveness of boa injection in treatment of dysfunctional voiding in children. patients and methods: study enrolled female children, - year old, with dysfunctional voiding and recurrent urinary tract infection, in whom pharmacological and biofeedback treatment failed. a dose of units of botulinum-a toxin (dysport) was injected intrasphincterically at sites in all children. urodynamic and radionuclide uroflowmetry was performed in all children before, and months after the treatment. radionuclide uroflowmetry was performed using mtc-dtpa or mtc-mag and the following parameters were analyzed: functional bladder capacity measured as voided volume plus residual urine volume, presented as a percent of predicted bladder capacity (fbc, %), residual urine volume presented as a percent of fbc (ru,%), voided time (vt,s), average flow rate expressed as voided volume divided by voiding time(afr, ml/s), peak flow rate expressed as afr multiplied by peak bladder emptying rate (pfr, ml/) and ejection fraction calculated as ratio of counts between peak bladder emptying rate minus minimal bladder emptying rate, and mean bladder emptying rate (ef,%). all children have been tested before and six month after the treatment using empirically designed international reflux study modified questionnaire, regarding daytime and nighttime symptoms, voiding and bowel habits and quality of life. results: the relative changes-each in comparison with the value before dysport injection therapy were as follows: fbc increased by % versus % (ns), ru decreased by % versus % (p< . ), afr increased by ml/s versus ml/s (p< . ), pfr increased by ml/s versus ml/s (p< . ), ef increased by % versus % (p< . ) and vt decreased by s versus s (p< . ). significant symptom score improvement was detected six months after the treatment, being decreased by versus . no major side effects occurred. conclusions: although we surveyed only a few patients, the efficacy after boa injections in difficult-to-treat children with bladder dysfunction seems promising. only slight improvement of bladder function parameters detected by means of radionuclide uroflowmetry with the significant improvement of urinary tract symptoms six month after the treatment could be addressed to improvement in voiding dynamics and significant reduction of postvoid residual urine volume. these results raise hope of keeping high-risk children with bladder dysfunction under conservative control longer. before and after the furosemid provocation was , /min and , /min respectively. in cases the number of waves actually increased, and there was no change in the remaining cases. in cases we compared the change in ureteral function before and after reconstructive surgery. the mean peristaltic wave number before the operation was , /min, and decreased to , /min afterwards. conclusion: according to previous studies, the ureter adapts to increased urine flow by increasing the transported bolus volume. in our study, megaureters adapted to the same challange by increasing the frequency, which is an indication of impaired renal drainage. the decrease in frequency following surgery may be the result of a succesful operation. b. ajdinovic , l. jaukovic , z. jankovic , a. peco-antic ; military medical academy, belgrade, serbia, university pediatric clinic, belgrade, serbia. objective: urinary tract infection (uti) is a common condition in children with vesicoureteral reflux (vur), and may lead to renal damage. the aim of this study was to determine the incidence and the pattern of abnormal dmsa findings in children with hystory of bacteriologically proven uti. materials and methods: standard m tc-dmsa renal scintigraphy was performed in children ( boys and girls, aged from seven months to seven years ), six months after the initial infection. findings were classified according to the image appearance and relative kidney uptake (rku) and related to the grade of vur, sex and child's age. results: micturating cystourethrography (mcu) revealed vur ( uni and bilateral) of grades i, ii, iii, iv and v in , , , and patients respectively. dmsa images were normal with rku within normal limits in patients and equivocal in pts findings were interpreted as abnormal in cases due to scarring, and in pts with decreased rku. bilateral scarring was shown exclusively in children with bilateral vur. scarring rate was significantly associated with vur of higher degree (p< . ) and male gender ( p< . ). no significant difference was found between renal scarring and child's age in same gender group. poor kidney function (rku less than %) was shown in / patients. conclusion: renal damage on dmsa scintigraphy highly correlated with grade of vur. a strategy to perform mcu in only patients with abnormal dmsa finding is proposed. disordered gastric emptying is frequent and clinically important complication of diabetes mellitus (dm). the aim of this study was to determine gastric emptying rate(ger) in children and adolescents with type dm, and to investigate relationship between ger and microalbuminuria in these patients. subjects and methods: ger with solid meals was assessed by a radionuclide method using solid meal in diabetic children and adolescents and age matched healthy controls. the patients were divided into two groups according to duration of diabetes as less than years (group a) and longer than years (group b). the patients ingested scrambled egg bound to mci of tc- m sulphur colloid bound to a scrambled egg. images were obtained from anterior and posterior projection in a x matrix with . zoom factor. the period of data collection began as soon as the subjects finished the meal. the data were acquired for s per frame, for a total of min. a region of interest corresponding to the stomach was outlined to the determine the gastric counts for each image. a power exponential fit was used to analyse the time-activity curve over the stomach and to calculate the half-time of gastric emptying. delay was recognized if ger was longer than minutes. three consecutive timed overnight urine collections were used to calculate microalbuminuria. increased microalbuminuria was defined as a median value is greater than or equal to . μg/min. data were evaluated using mann whitney u analysis, kruskall wallis analysis and pearson's correlation tests. results: the mean values of ger were . ± . minutes for diabetic patients and . ± . minutes for control group; and the difference was not statistically significant (p= . ). ger didn't differ significantly between group a and group b and control group (p> . ). there was no significant difference of ger among in patients who have higher and lower microalbuminuria level (p> . ). there was no correlation between ger and duration of diabetes and microalbuminuria (p> . ). conclusion: we did not detect any significant changes of ger in children and adolescents with type dm. no relationship could be found between microalbuminuria and ger. aim: scintigraphy with tc- m dmsa is considered a reference method for assessment of renal parenchymal lesions and estimation of differential renal function (drf). however, comparisons with tc- m mag indicated certain disadvantages of dmsa such as relatively higher radiation exposure to kidney and time consumption. tc- m mag with high tubular secretion suggests that it may be useful in infants. the aim of this study was to evaluate the performance of tc- m mag dynamic renal scintigraphy in the detection of renal parenchymal defects and in the estimation of drf comparing to tc- m dmsa scintigraphy. materials & methods: a retrospective review of the records between april -january indicated that a total of infants ( boys and girls) aged under years, underwent both tc- m dmsa and tc- m mag scintigraphies within weeks of each other. parenchymal phase of mag scintigraphy were compared to dmsa images for right and left kidneys, separately. the renal cortical analysis of mag scintigraphy was performed on the summed image obtained from dynamic images. and also, differential function was calculated in mag and dmsa studies and then compared. results: findings corresponded completely in % of patients. there was no statistically significant difference between calculated drf on dmsa and mag images. however, in the left kidney, mean mag value ( . %) tend to be higher than that of dmsa ( . %). there is a high correlation between the drf (r= . and r= . ; for the left and right kidney, respectively; p< . ). accepting dmsa is a gold standard method to assess renal cortical lesions, the sensitivity and specificity of the mag cortical scintigraphy were calculated as % and %, respectively. compared with dmsa, mag was as sensitive as dmsa however lower specific than dmsa. the results showed that most of renal parenchymal lesions detected on dmsa scans can be identified on mag parenchymal scans. both studies can be equally used for the calculation of drf. tc- m mag may be acquired for evaluating of renal parenchyma especially in infants because it is a feasible, useful, rapid ( min) functional imaging method and lower radiation dose. because of low specificity of tc- m mag cortical analysis, tc- m dmsa scintigraphy have to be acquired in the definite diagnosis and management of renal cortical lesion therapy. aim: congenital diaphragmatic hernia (cdh) is often combined with primary hypoplasia of the pulmonary vascular bed, which is one of the most significant prognostic factors in patients with cdh. in this study, the values of lung perfusion and ventilation scintigraphies were investigated to assess the lung regarding pulmonary vascular hypoplasia in the pediatric patients with cdh. material and methods: patients ( boys, girls) were included in the study. all patients had respiratory distress within the first hours of life due to cdh. six patients had left-sided and patients had right-sided cdh. all cases underwent a surgical repair of cdh in the newborn period (mean age: . days). the mean ± days after the operation, lung perfusion scintigraphy was carried out with . mbq/kg of tc- m maa. the perfusion images were evaluated quantitatively. for quantitative analysis, the regional distribution of each lung was expressed in a percentage of total lung perfusion. next day, lung ventilation scintigraphy was performed with . mbq/kg of tc- m dtpa by placing a see-through mask over the child's mouth and nose allowing them to be able to breathe as if via a nubulizer. ventilaton images were evaluated quantitatively in a similar manner as to the perfusion study. results: in one patient, the perfusion rate of the side of cdh was % and the ventilation rate of the same lung was %. because of the combination of the good ventilation and restricted perfusion, it was thought that primary pulmonary vascular hypoplasia might exist in this patient. in other / cases, the mean perfusion rate was . ± . % and the mean ventilation rate was . ± . % in the side of the cdh. in these patients, a statistical difference was not observed between perfusion and ventilation results (p> . ). having been considered that ventilation disorder with secondary perfusion disorder might develop, the pulmonary vascular hypoplasia could not be eliminated in these cases. conclusion: this study reveals that the combination of lung perfusion and ventilation scintigraphies, which are objective, quantitative, non-invasive, and easily performed methods, may helpful in determining the pulmonary vascular hypoplasia in pediatric patients with cdh. additionally, it can be suggested that these methods may be useful to evaluate the growth and development of lung affected by cdh especially during the first year of life when respratory function studies are difficult to obtain. using the same site for tracer injections and blood sampling makes edta clearances more acceptable to patients and ensures that blood samples will be successfully obtained. but there are predicted problems from tracer contaminating the samples or saline diluting the samples. in practical terms the two important questions are (a) whether same site sampling (sss) produces an increased rate of recognisable poor test results, and (b) whether it produces undetected bias or errors in the results. since february -sample edta clearance studies have been performed, of which had separate sites for injection and sampling, and the remainder used the same venous access for injection and blood sampling. in addition, studies from another hospital (w) that used different sites were included. a review of the results produced the following:-recognised problems: were noted as follows:-venous access not obtained ( ) ward lost samples ( ) patient fainted ( ) vein "blew" during tracer injection ( ) tracer contamination of first sample ( ) . unrecognised problems: were looked for by using the following quality assurance factors:-( ) the r value of the log-plot fit to the data points. ( ) the ratio v d / weight. ( ) the first point position relative to a line drawn only through the second and third points. the different groups studied were group n= hospital w and group n= hospital a . both of these first two groups used separate sites for the tracer injection and sampling. groups to used the same site for injection and sampling, as follows:-group n= sss (antecubital fossa luer) group n= sss (pic line) group n= sss (luer in hand vein) group n= any method but gfr< ml/min. results: with one exception, none of the qa factors showed any difference between the groups studied. the exception was group (low gfrs), and this group showed a lower r value than the others. conclusion: the one case of sample contamination was detected by looking at the data and the routine qa values. assessment of the qa values in the remaining data did not suggest any undetected bias in the group results. objective: ureteropelvic junction stenosis and vesicoureteral reflux are the most frequent entities identified by antenatal hydronephrosis. aim: to determine the incidence and pattern of abnormal renal scintigraphy findings in postnatal investigation of children with antenatal hydronephrosis. patients and methods: twenty four infants ( boys and five girls) who presented with antenatal hydronephrosis and mild to moderate hydronephrosis on ultrasound in newborn period were referred for renal scintigraphy. ten patients with vesicoureteral reflux documented on micturating cystoureterography received dmsa renal scintigraphy and patients received dtpa scintigraphy. results: antero posterior pelvic diameter on ultrasound ranged from to mm. dmsa renal scans identified congenital scars in two boys with bilateral reflux of grade v and unilateral reflux of grade iii. global hypoplasia (relative kidney uptake (rku) less than %) was found in three, and poor kidney function (rku less than %) in two patients. significant obstruction was shown on dtpa diuretic renal scintigraphy in near the half of patients ( / ). some slowing in drainage (t / greater than minutes) with no reduction in differential renal function was identified in three patients. differential renal function less than % was obtained in one case. conclusion: high proportion of abnormal renal scintigraphy findings was obtained ( %). renal scintigraphy was useful in determination of underlying cause of antenatally detected hydronephrosis. pediatric urolithiasis is very important because of its effects on the growing kidney, the significant recurrence rate, the association with urinary tract infections (uti) and the long term outcome. in this study we aimed to determine the renal cortical state by dmsa in children with urolithiasis who had experienced uti during follow up. patients with urinary tract abnormalities were not included to the study. a series of patients ( boys, girls) with a mean age of . ± . months and a mean follow up period of . ± . months were studied by dmsa. dmsa scar grading was performed for each subject according to imperiale et al. number of utis, the localization of the stones were noted. uti was treated with proper antimicrobial therapy. stone patients were treated medically according to their stone analysis or urinary metabolic analysis. uti attacks were recognized during follow up. only patients ( %) showed scars on dmsa. scar grading was in two patients and in two patients. of these four patients children with single uti showed score on dmsa and children with or more uti showed score on dmsa. the localization and the side of the stones were the same in all subjects. we conclude that urolithiasis often coexists with uti and the risk of renal injury is not low . dmsa scan evaluation is important during the follow up of these patients. introduction -aim: gfr is the best measure of kidney function and is accurately measured by cr-edta, which follows bi-exponential kinetics. as the widely applied multiple sample technique assumes a monoexponential pattern of tracer elimination, gfr is overestimated and corrections for the missing, initial, fast component of tracer clearance have been incorporated in current european guidelines. these are the linear chantler's (ch) and the quadratic brochner-mortensen's (bm) corrections, diverging, however, at different gfr levels. the aim of the present study was to analyse the agreement between gfr measurements after applying the two correction methods at various gfr levels in a mixed adult population. patients and methods: four hundred ninety six pts ( women), aged . ± . yrs were enrolled in the study. pts were referred for gfr measurement for chronic kidney disease or as kidney donor candidates, renal transplant recipients and renal transplant donors. gfr was measured with the slope-intercept, two-sample technique after i.v. administration of cr-edta . values were normalized for body surface area calculated according to haycock's formula and were expressed as ml/min/ . m . bland-altman analysis was applied for assessment of agreement. results: patients were allocated in low (< , pts), intermediate ( - , pts) and high (> ml/min/ . m , pts) uncorrected gfr groups. mean (sd) uncorrected gfr values were . ( . ), . ( . ) and . ( . ) ml/min/ . m for the three groups, respectively. after ch / bm corrections, gfr values were . ( . ) / . ( . ), . ( . ) / . ( . ) and . ( . ) / . ( . ) ml/min/ . m for the three groups, respectively. mean gfr differences (ch -bm) were - . ( . ), . ( . ) and . ( . ) with % confidence limits - . - . , - . - . and . - . ml/min/ . m for the three groups, respectively. - ) and gamma camera equipped with a low energy high resolution collimator interfaced with a computer. regions of interest (roi) were drawn over the whole kidneys. radioactivity-time curves were generated from the roi. time to peak activity (t max ), time from peak to % activity (t ½ ) and the uptake slope of each kidney were calculated from the renograms. the same protocol was repeated for the same animal times at days intervals at , and °c higher temperature. blood pressure was measured using a catheter inserted into the femoral artery connected to a recorder and renal blood flow was also measured through renal artery using an electromagnetic blood flow sensor connected to a flowmeter. creatinine and urea in blood were measured in control and hyperthermic rabbits. results: during hyperthermia the experimental curves shifted to the right of the control curves indicating that there was a delayed renal uptake of mtc-mag- and clearance of radioactivity. this delay was proportional to body temperature. from body weight and height. linear regression analysis was applied to assess association between variables. results: all patients were overweight or obese, with bmi . ± . (range . - . ) kg/m . gfr was . ± . ml/min. gfr was moderately correlated to bsa ( . , p< . ), lbm (r= . , p< . ) and tbw (r= . , p< . ) . prediction equations were: gfr = - . + . x bsa, gfr = . + . x lbm and gfr = . + . x tbw. no statistically significant difference was detected between the slope coefficients ( . vs . ) conclusion: despite the common beliefe, tbw is equally good to bsa or lbm as a gfr predictor in overweight or obese patients with normal renal function, thus questioning the importance of bsa normalization. as we see at these results, no significant difference was found between group i and group ii, regarding the number of patients with skeletal metastases. conclusion: low levels (< ng/ml) of serum prostaticspecific antigen can not eliminate the possibility of existance of skeletal metastases, as was expected. even more, as the difference of the pathological bone scans between group i and group ii was not significant, values of psa ng/ml cannot be considered as a safe threshold for the exclusion of the indication of bone scan. background: the rutland-patlak plot is used in renography for determining relative kidney function and for separating blood background in the measured renogram. in the uptake phase the plot is a straight line, but the duration of this phase may differ from patient to patient. a good method for drawing the line in the patlak-rutland plot should be accurate and precise, while taking into account that data may show unusual behaviour or be noisy. aim: this work compares three methods for drawing the line with the aim of finding a method that gives reliable results on all groups of data. materials and methods: data were collected from consecutive m tc-dtpa renographies routinely made in the department ( kidneys). independent of this collection, renographies were selected where at least one of the kidneys has a renogram with irregular behaviour early in the renogram, such as decrease in the renogram about minute p.i., or unusually noisy data ( kidneys with "problematic" renograms). from each renogram points for the rutland-patlak plot was calculated and three methods were used independently to draw the line: .) manual drawing on hardcopies by three independent observers. slope and intercept were determined afterwards. .) linear regression on the first points measured after minute p.i. (from to about minutes p.i.). .) points for linear regression were selected by an algorithm developed for the purpose, based on possible exclusion of early points and possible inclusion of points later than minutes p.i., to reduce weighted residual variance. results: in the group of consecutive patients ( kidneys) friedmann test showed significant differences among methods (p < . ). pairwise comparison showed no significant difference between method and , whereas method yielded slightly lower values of slope and slightly higher values of intercept than the other two methods. estimates on uncertainty gave similar results: no significant difference between method and , significantly higher uncertainty estimates in method than the other two methods. for the group of selected "problematic" renograms ( kidneys) method was used as reference method. method failed in a number of cases compared to the reference method, whereas method showed good results. see table. conclusion: method gives results that are accurate and precise on normal and "problematic" renograms. the method is operator-independent. method fails in a number of cases. results: among patients that underwent each of the three studies, no statistically differences were observed regarding age, sex, disease duration and type of lesion. / renograms ( %) were interpreted as abnormal ( ou, on). / dmsa renal scintigraphies ( %) were abnormal and / gfr measurements ( %) were also abnormal. conclusions: in patients with spinal cord lesion and neuropathic bladder, "functional" obstructions and parenchymal scars seem to be the most common nephrourological complications, while nephropathy detected by renogram and/or gfr measurement is found in a smaller number of patients. it is suggested that diuretic renogram and dmsa renal scintigraphy should be performed as part of the diagnostic and therapeutic management of all these patients. patients who were booked for dtpa renograms and edta clearances on the same day had those injections given at the same time, and the plasma samples were counted on a collimated gamma camera at the end of the day. an excel program was used to calculate the m tc-dtpa results (using times that had been recorded to correct for tc-decay during the day). after hours to allow the technetium to decay, the cr-edta was counted in a sample counter, and the results compared. it is sometimes difficult to differentiate peripelvical cysts / ppc / and hydronephrosis / hn /, based only on the symptoms of the patients / pts / and the data from the ultrasonography. the aim of the study was, using dynamic renal scintigraphy, to differentiate these two entities.we have investigated pts, using - mbq mtc-ec. in all of them, the ultrasonographic data showed hypoechogenic area in the region of the kidneys' pelvis and it was difficult to differentiate ppc from hn. after performing renography, in of the pts, there was an "accumulation" type of the curve, in -a "retention" type, in -the curve was with a delayed excretion and in normal. in all of the pts with an "accumulation" or "retention" type of the curves, additionally a diuretic renography was performed / using . mg/kg furosemid , injected on min. p.i. of mtc-ec /, to differentiate obstructive from nonobstructive hydronephrosis. in the latter pts there was a quick outflow of the radioactivity from the pelvicaliceal system after the injection of the diuretic / t ½ min./. using additional imaging methods and follow up of the pts, of them with a normal or delayed excretion, finally were diagnosed as having only ppc, and from those with an "accumulation" or "retention' type - were with a non-obstructive hydronephrosis and -with an obstructive hydronephrosis, due to different reasons. only patient with ppc had non-obstructive hydronephrosis. divided renal function of the kidneys with hn was lower - . % than that of the kidneys with ppc- . % / p< . /. we consider, that using dynamic renal scintigraphy without or with diuretic, further elucidating of the diagnosis could be made and the appropriate therapy of the patient could be planed. conclusion: the renography is a reliable tool for differentiation of the ppc from hn. using additionally diuretic renography, not only differentiation of the obstructive and non-obstructive hydronephrosis could be made, but according to the obtained results, the following therapy could be chosen. excretory function. aim of the study was investigation whether clearance parametric images of kidneys widen the diagnostic capacity of traditional procedures. materials and methods: individuals were studied in whom diabetes type i (insulin dependent) was diagnosed. a second group of healthy volunteers served as controls. individual kidneys were studied and their images and renoscintigraphic curves evaluated. in all individuals a dynamic kidney study was performed after administration of the m tc-ethylenodicysteine (ec) and erpf determined. after processing of aquired data conventional images were created by summation of scintigrams received in the phase of secretion of rf. from the same images the clearance images were created. both types of obtained images served for the evaluation of defects of kidney parenchyma. for both types of images a level score scale was used to provide semiquantitative measure of observed pathology. renographic curves were evaluated by analyzing their shape, taking into account relative contribution of each kidney to total uptake (or erpf). elimination of urine from the pelvic and ureteral space was evaluated on basis of phase iii of the renogram. mean renal transit time (mtt) and mean parenchymal transit time (ptt) of the tracer were also calculated. results: analysis of clearance parametric images revealed that regional defects in function of renal parenchyma were more frequent in kidneys of patients with diabetes than in the controls ( , % vs , %). in conventional summation images there were no significant differences in defect frequency noted between the groups ( , % vs. , %) . there were no differences between ptt and erpf between the groups (p= , and , resp). relative uptake of ec in both groups did not differ and was within the normal range of values. there were a larger mean value of mtt and more frequent flattening of the curve in phase iii in patients with diabetes than in control group (p= , and p= , , resp.) , what could be due to the functional uropathy, seen in diabetic patients. conclusions: . clearance parametric images reveal additional information on regional function of kidneys even if other values characterizing global function of kidneys are still within the normal range. . parametric clearance images should be included as a component of dynamic kidney studies. s. inanir, g. ege aktas, t. erdil, h. turoglu; marmara university, istanbul, turkey. aim: tc- m dmsa renal cortical scan is a reference method in determining relative renal function (rrf). tc- m mag- is also recommended for the estimation of rrf, particularly in young children. the aim of this study was to compare mag- and dmsa rrf estimations, and, to assess reproducibility of these estimations in children with unilateral hydronephrosis. methods: we reviewed mag- and dmsa scans in children with unilateral hydronephrosis and a normal contralateral unit. all were imaged with agents within months. mag- rrf was calculated using different time intervals ( - minutes and - minutes) and perirenal c-type region of background activity. no background correction method was used in the calculation of dmsa rrf. all data were processed twice by two independent operators. results: in the repeated estimates of mag- rrf, the maximum mean differences were . % (sd: . %) within observer and . % (sd: . %) between the observers. intra-method analysis showed statistically significant agreement between repeated measures of rrf for agents as well as for operators (intraclass correlation coefficients of early and later phase of mag- and dmsa rrf values were . , . , . for operator and . , , . for operator , respectively, p< . ). there were significant correlations between the mag- and dmsa rrf estimations (r= . / . at - min, . / . at - min for the repeated measures of rrf for operator i, and . / . , . / . for operator , respectively, p< . , pearson). when each scan was classified as normal or abnormal according to rrf values, inter-method analysis showed statistically significant agreement between mag- and dmsa rrf estimations (kappa statistic). however, a disagreement was revealed between the methods when borderline and supranormal estimates of rrf were taken into consideration. conclusion: in children with unilateral hydronephrosis, our results indicated a close correlation between dmsa and mag- rrf estimations with a good reproducibility. renal perfusion scintigraphy using technitium- m is commonly performed after renal transplant to assess vascular flow to the transplanted kidney. this allows cases of vascular compromise to be detected early to minimize damage to the transplanted kidney. this retrospective study evaluates the outcomes of a series of renal perfusion scans performed in a tertiary care hospital in the post-operative management of renal transplantation. in addition, we define a renal transplant perfusion index (rtpi) as the ratio of the cumulative counts in the renal transplant to the cumulative counts in the aorta from start of the renal perfusion scan to time of peak aortic curve, and attempted to correlate the values in each patient with the eventual outcome. over a month period, all recipients of a kidney transplant and who subsequently underwent renal perfusion scan within the same admission were recruited into the study. the medical notes were analyzed for scan results and patient outcome. a scan was deemed normal if no evidence of major vascular compromise was detected, abnormal if there is a perfusion defect seen and/or there is delay in perfusion to the transplanted kidney. a patient's outcome was deemed uneventful if there were no transplant-related complications prior to discharge (i.e. vascular compromise, biopsy-proven transplant rejection or acute tubular necrosis), and eventful if complications arose. a total of patients were included. scans were normal, of which patient had an eventful outcome (transplant rejection). another scans were abnormal, of which patients had eventful outcomes ( with vascular obstruction, with transplant rejection or acute tubular necrosis). the sensitivity of this study in detecting a transplant-related complication was %, and the specificity was . % (thus giving the likelihood ratio for a positive test as . ). the positive predictive value was . % and the negative predictive value was . %. the mean rtpi in patients with uneventful outcomes was . ± . , compared to . ± . in patients with eventful outcomes. a tc- m renal perfusion study has become a mainstay of management after renal transplant. this study quantifies its utility in predicting outcome after renal transplantation when done in the post-operative period. it also suggests that an elevated rtpi is associated with patients who develop acute post-transplant complications. the ectopic kidneys belong to the inherited abnormalities of the kidneys. the aim of the present study was to evaluate the function of the ectopic kidney with renal dynamic scintigraphy with mtc -dtpa. materials and methods: a retrospective study of the renal dynamic scintigraphies done between to year was done. out of renal scintigraphic examinations patients with an ectopic kidney were found- men and women with age from to years. in all of them diagnosis an ectopic kidney was put for the first time due to the scintigraphic examination. the scintigraphy was done on a gamma -camera siemens according to a predefined protocol with quantitative measurements in two phases: perfusion and secretionexcretion. mbq/ kg / mtc -dtpa was injected as bolus at the very beginning a quality assessment and quantitative determinations of t max, t ½, relative function of each kidney and glomerular filtration rate /gfr/ were done. results: in all patients the ectopic kidney was found in the pelvis above the urinary bladder. in patients the right kidney was ectopic and in the rest the left one has an ectopic position. in patients the ectopic kidney was hypoplastic. preserved kidney function with spastic drainage were found in patients. reduced secretion, excretion and drainage were found in patients. afunction of the ectopic kidney was seen in patients. conclusion: we consider that renal dynamic scintigraphy with mtc -dtpa can be helpful either for diagnosis or for evaluation of the function of the ectopic kidneys aim: to evaluate if renal pelvic dilatation is associated with dysregulation of the rennin-angiotensin system (ras) in foetuses in the second trimester of pregnancy that could represent an early predictor of arterial hypertension development after birth. the study consisted of non-diabetic heterozygousthalassemia pregnant women aged between and years, on their second trimester of pregnancy ( st to rd week of gestation). the foetuses had normal development and no obvious congenital abnormalities on ultrasound. maternal and foetal blood was collected and total rennin and active rennin were measured by an immuno-radiological (irma) method; inactive rennin (prorennin) concentration was calculated by subtraction of the active rennin from the total rennin concentration. foetal renal pelvis was evaluated by ultrasound. the mann-whitney u test was used to compare active rennin, prorennin, and the prorennin-to-active rennin ratio between maternal and foetal blood. the same comparison was performed between foetuses with and without pelvic dilatation, as well as between their mothers. continuous data are expressed as mean ± sd; significance was set at p< . . results: a significant difference as regards prorennin, active rennin, and their ratio was observed between pregnant women and their foetuses (p< . ). furthermore, a significant difference was found in the prorennin-to-active rennin ratios between foetuses bearing renal pelvic dilatation and those without (p= . ), while no significant ratio difference was found between their mothers (p= . ). conclusion: dilatation of renal pelvis in the nd trimester of pregnancy seems to upregulate the ras system, with all the possible consequences of renal dysfunction and arterial hypertension after delivery; thus ultrasonographic evaluation of the foetal renal pelvis and measurements of foetal rennin should be considered. foetuses prorennin (μu/ml) . ± . . ± . active renin (μu/ml) . ± . . correlation with urodynamics and classification by american spinal injury association (asia) impairment scale refluxes (vur) and recurrent urinary tract infection. these situations can lead to scar formation in the renal parenchyma and renal failure that have serious impact on the quality of life and long term survival in this group of patients. the aim of this study was the detection by diuretic renogram of urological and/or nephrological complications in the special group of patients with spinal cord injury and neuropathic bladder. materials and methods: forty-six diuretic renograms were performed in patients with normal renal function (males/females= / , mean age , ± , years, mean disease duration , ± , years) that were referred by the neuropathic bladder unit of the national rehabilitation center. all patients were classified according to asia impairment scale and underwent urodynamics. the different types of neuropathic bladder were defined according to international continence society (ics) terminology. one week after the urodynamics, the diuretic renogram was performed (i.v. injections of mbq tc- m mag- and mgr furosemide at zero timeprotocol f ). our studies were classified as normal (n), ou and obstructive nephropathy (on). results: according to the asia impairment scale, patients were distributed as: a= patients, b= patients, c= patients, d= patients and e= patient and according to ics, detrusor and sphincteric mechanism overactivity was revealed in patients, detrusor overactivity and sphincteric mechanism underactivity in patient and detrusor and sphincteric mechanism underactivity in patients. twenty-eight/ renograms ( %) were interpreted as abnormal ( ou, on). on was detected in males with disease duration of and years. no correlation was found between renogram results and asia impairment scale and type of neuropathic bladder dysfunction. conclusions: diuretic renogram revealed a great number of "functional" obstructions in patients with spinal cord injury and neuropathic bladder. the obstruction is independent of the type of neuropathic bladder. nephropathy is the future threat. the aim of this study was to established the alleles distributions of vdr fok i polymorphism and how one influence on intact parathyroid hormone /pth/ level and some biochemical markers of bone turnover -serum osteocalcin /oc/ and bone alkaline phosphatase /bap/ in predialysis patients with chronic renal failure /crf/. material and methods. forty patients - men and women with crf were investigated. vdr polymorphism was detected about polymerase chain reaction. the serum oc was analyzed using an original kit elsa-osteo and an automatic minigamma counter /abbott, usa/. the bap was measured with special kit "alkphase-b" of metra biosystems. the level of pth was determined with an immunoenzymetric assay. the serum and urine creatinine, total calcium, phosphorus, total alkaline phosphatase were measured according to standard methods, recommended by ifcc. the results. the distribution of allelic variation of vdr fok i in predialysis patients were follow: / . %/ with "ff" alleles, / . %/ with "ff" and / . %/ with "ff" alleles. the level of creatinine clearance were similar in three groups. no significant difference in serum calcium, phosphorus, alkaline phosphatase existed among groups. the intact pth was highest in patients with "ff" alleles - . ± . pg/ml versus . ± . pg/ml in patient with "ff" alleles and . ± . pg/ml in "ff" group /p < . /. the bap in patients with "ff" alleles was higher then bap in patient with "ff" - . ± . u/l versus . ± . u/l but the difference was not significantly. significantly higher serum oc levels were registered in predialysis patients compared to the healthy controls - . ± . ng/ml versus . ± . ng/ml / p < . /. the serum oc was highest in predialysis patients with "ff" alleles - . ± . ng/ml but the difference was not significantly compare to patients with "ff' and "ff" alleles. conclusions: / we detected the follow distribution of fok i allelic variation in our patients: / . %/ with "ff" alleles, / . %/ with "ff" and / . %/ with "ff". / the intact pth was highest in patients with "ff" alleles and this is not due to difference of serum calcium and phosphorus. / the serum oc and bap in patients with "ff" alleles were highest but compare to patients with "ff' and "ff" alleles the difference was not significantly continuous ambulatory peritoneal dialysis (capd) is an effective mode of management for end-stage renal disease. dialysate leakage represents a major noninfectious complication of this procedure. this technique may caused increased intraabdominal pressure resulting in hydrothorax and hernia with reported incidence of % to % and % to %, respectively. a -year-old male who was undergoing continuous ambulatory peritoneal dialysis (capd) for diabetes mellitus nephropathy had scrotal swelling on the first day of initiation of the procedure. peritoneoscrotal scintigraphy was requested in which tc- m sulfur colloid ( mbq; mci) was mixed into a -liter dialysate bag under aseptic technique and instilled into the peritoneal cavity thru an indwelling catheter. sequential scintigraphy revealed gradual advancement of radiotracer via the right inguinal canal and reaching the right scrotum by hour post-instillation. patient underwent right herniorapphy. one month postsurgery, peritoneal dialysis was resumed and scrotal swelling did not recur. p -monday, oct. , , : introduction: dysphagia is a common and disabling symptom, often associated with tracheo-aspiration phenomenon, characterising different neurological and neuromuscular disorders. amyotrophic lateral sclerosis (als) is the most common degenerative motor neuron disease in adults and dysphagia is the most frequent symptom. aim: to evaluate the role of oro-pharyngo-oesophageal scintigraphy (opes) in the diagnostic approach to patients with als. materials and methods: patients divided into two groups underwent opes: group a (control group) included healthy volunteers (female/male / ; mean age ± yrs); group b patients (female/male / ; mean age ± yrs) with als. opes is based on the rapid sequential acquisition of images ( frames/sec. for a total " examination); ml of water containing mbq of m tc-sulfur-colloid are administered by a straw to patients standing in an ° right anterior oblique position in front of a gamma-camera with a large field-high-resolution-low energy collimator. the evaluation of sequential scintigraphic images and a/t curves allows a qualitative (bolus fragmentation with multiple swallowing, naso-pharyngeal or pharyngo-oral refluxes, premature ingestion of the bolus, laryngo-tracheal aspiration) and a quantitative analysis of swallowing disorders [oral, pharyngeal and oesophageal transit times (ott, ptt, ett) as well as retention indexes (ori, pri, eri), and tracheal aspiration percentage ( conclusions: opes appears to be a sensitive test in characterising different swallowing disorders that affect patients with als: propulsion defect (documented by increased oral and pharyngeal transit times, and retention indexes) and incoordinate swallowing (with tracheo-aspiration). opes is a simple, non-invasive and welltolerated test which can provide qualitative and quantitative information of the swallowing phases, useful for rehabilitative and therapeutic purposes. juice as sialogogue j. hsieh; chi mei medical center, yungkang city, taiwan. purpose: to assess the feasibility of using the locally popular and widely available dried sour plum as a substitute for the frequently used lemon juice in stimulated salivary gland scintigraphy (ssgs) and to evaluate the utility of parotid gland stimulated salivary excretion fraction (ssef) as a semi-quantitative functional parameter in pre-radiotherapy and post-radiotherapy head and neck cancer (hnc) patients. methods eighty patients with hnc underwent ssgs and ssef of parotid glands were determined. patients were classified into two groups: twenty in preradiotherapy group (pr) and in post-radiotherapy group (po). each half of the group pr and group po were further subdivided into two groups using different gustatory stimulus: lemon group (l) and dried sour plum group (d). in group pr, those with subjective or objective xerostomia were excluded. in group po, patients underwent ssgs at least three months post-radiotherapy and includes only those who had completed the course of curative radiotherapy and had not received adjuvant or neo-adjuvant treatment. results the ssef of parotid glands greater than % was able to distinguish normal from abnormal salivary function in hnc patients. there is no difference between two different kinds of sialogogues l and d in both group pr and group po using % as a cut-off reference for a normal ssef. conclusions the use of dried sour plum as substitute for lemon juice is feasible in ssgs and the finding of using % as a cut-off reference for a normal ssef was able to distinguish normal from abnormal salivary function in hnc patients. the relationship between helicobacter pylori infection and obesity enteroclysis and xray angiography were negative too. results: twenty-three patients had positive scintigraphy with in vivo tagged rbcs and patients had negative scintigraphy. gi bleeding stopped spontaneously in these patients with negative scintigraphy and these patients did not undergo push-enteroscopy, intra-operative enteroscopy or surgery. final diagnosis of our patients with positive scintigraphy was determined in patients (push-enteroscopy - patients, intra-operative enteroscopy - patients or by surgery - patients). these patients had following final diagnoses: bleeding small bowel arteriovenous malformation ( patients), uraemic enteritis with bleeding erosions in ileum and jejunum ( patients aim: the vanishing bile duct syndrome (vbds), is an acquired and pathologic process that occurs in the biliary tree and is recognizable as an absence of bile duct in an individual portal tract. the underlying processes responsible for bile duct loss include immunological, infectious, ischemic, metabolic, and toxic processes. the purpose of this study was to investigate the potential role of dynamic mtc-hida hepatobiliary scintigraphy (dhbs) in the evaluation of patients affected by chronic liver disease with histological liver involvement characterized by small bile duct injury. material and methods: the study comprised consecutive patients ( males, female), aged between - years. at diagnosis, showed chronic hepatitis c virus (hcv) infection, wilson's disease. all patients underwent standard biochemical liver function tests including parameters of cholestasis gammagt (ggt) and alkaline phosphatase (af) and liver biopsy. dhbs was performed after i.v. injection of mbq m tc-iminodiacetic acid. acquisition of images started at the moment of injection and time/frame acquisition was sec for min. time-activity curves were recorded from regions of interest placed over hepatic parenchyma and main intra-hepatic biliary ducts. quantitative analysis of the curves was performed using deconvolutional analysis and non-linear regression, measuring parenchimal and ductal time point at maximum peak counts (t max ) and t ½ of excretion. results: a liver biopsy revealed in all patients marked ductopenia consistent with vbds. laboratory parameters showed ggt elevation in hcv patiens with concomitant increase of af in one of these. the analysis of quantitative data obtained by dhbs showed in all patients a slow blood clearance and excretion of hida documented by delayed time of parenchimal and biliary t max and abnormal parenchimal and ductal excretion t ½ . no correlation was found between hida t ½ ductal excretion and parameters of cholestasis. however, positive correlation between liver parenchimal/ductal t ½ and histologic scores was observed. conclusion: the dhbs is able to assess the different aspects of hepatic function in vbds. although the present study includes a small number of patients, we believe that this method may be of clinical value in revealing the real hepatic and biliary function showed by correlation with histologic data. its clinical use may be crucial in follow-up and in prognostic evaluation of vbds patients. aim meckel's diverticulum is the most frequent congenital anomaly of the gastrointestinal tract, with an incidence of about % of the population. it is a sacculation attached to the ileum due to the failure of the vitelline duct to disappear. the mucosal lining of meckel's diverticulum containes island of heterotopic mucosa, which may give cause to serious complications such as peptic ulcer, hemorrhage and perforation. the aim of our study was to compare scintigraphy with ultrasonography (us) in the detection of meckel's diverticulum. materials and methods we recruited children, younger than years of age, with painless rectal bleeding. all the patients underwent first scintigraphy and then ultrasound. for the scintigraphic evaluation mbq ( mci) of mtc-pertechnetate (tco -) were administered intravenously. the initial scan was made min to hr after the radiopharmaceutical administration. anterior abdominal images were obtained at a frame rate of one images every - sec over the course of to minutes. acquisition parameters were: single head gamma camera, parallel hr collimator, matrix x , frames. activity in the ectopic gastric mucosa should appear simultaneously than that of normal gastric mucosa. activity in the urinary tract, most often confused with for a meckel's diverticulum, usually first appears after activity is seen in the normal gastric mucosa. for the abdominal sonography a mhz convex-array probe was used. sonographic demonstration of noncompressible, tubular, aperistaltic structure with a double-layered wall, located far from the cecum suggested for meckel's diverticulum. all us scans were reviewed by one of the authors blinded to the scintigraphic results. results out of patients showed abnormal scintigraphic findings with suggestive for meckel's diverticulum. ultrasound confirmed these results in patients of the seen by scintigraphy and was negative in cases. conclusion ultrasound imaging is one of the most widely utilized medical imaging modality that will continue to improve the quality of healthcare in diagnostic application. however scintigraphy is easier to perform, is less operator dependent and has a better sensitivity compared to ultrasound. also scintigraphy is noninvasive, painless, relatively inexpensive. it can be concluded that scintigraphy is still of value in the diagnosis of patients affected by meckel's diverticulum. making of patient with hcv related hepatopathy. our results confirm that both, painless thyroiditis and graves disease, may occur during the treatment with ifn . in this connection, non immunogenic hyperthyroidism may be related to the acute release of hormones circulation (painless thyroiditis). a simple imaging method as pertechnetate thyroid scintigraphy allows to make a differential diagnosis between graves disease and painless thyroiditis and is essential to address the patients towards an appropriate treatment of hyperthyroidism. uptake ( . - %) ft ( - pmol/l) ft ( - year old (mean . ± . ) ( f, m) multinodular goiter patients were included to the study. after taking blood and urine samples, tcpu tests and thyroid scintigraphies were done and the patients were evaluated with thyroid ultrasound. by performing i- uptake measurements . and . hour uptake levels were calculated. results: in this study, of patients (% ) had urinary iodine level above μg/gr cre that indicates sufficient iodine intake. there was a significant negative correlation between tcpu levels and urine iodine levels as indicated in the literature. according to tsh levels, while patients were euthyroid, were hyperthyroid ( subclinical, overt clinic). tcpu levels were found to be higher in hyperthyroid patients than euthyroid ones, but this difference was not statistically significant. in euthyroid patients there were hyperactive nodules. there was a significant positive correlation between patients' tcpu and i- . and . hour uptake values. conclusion: in conclusion, our patients' median urinary iodine level was μg/gr cre which was sufficient. after iodinisation, high percentage (% ) of patients were hyperthyroid. we found that half of euthyroid patients had hyperactive nodules which showed the importance of thyroid scintigraphy in the evaluation of multinodular goiter patients. correlation of tcpu and i- uptake levels suggest that tcpu can be used instead of i- uptake levels. our preliminary results suggest that it would be important to evaluate the relationship between urinary iodine and tcpu levels in larger series of mng patients after mandatory iodinization. abnormal thyroid function and/or with thyroid antibodies an important problem in nuclear endocrinology is the "blocking" of thyroid gland, which necessitates to postpone investigation, to experience adverse clinical effects of stopping medications and a delay of making diagnosis. the aim of the study was to introduce and to determine the clinical value of the scintigraphy with mtc-mibi in patients / pts / with a "blocked" thyroid. in pts / aged - years /, indicated for a thyroid scintigraphy after proper preparation, an investigation was performed with mbq mtc-pertechnetate, min. p.i. in of them ( . %), the thyroid was "blocked" and additional scintigraphy was done with - mbq mtc-mibi, and min.p.i. it was estimated that in all pts there was a visualization of thyroid. in of them, a large "hot" nodule was visualized in the early and late image. later on a differentiated thyroid carcinoma was proved histologically. in another patients "cold" nodules on the early and late scans were detected and benign cysts were proved. therefore according to the type of the nodule, visualized with mtc-mibi and its kynetics, we could help in differentiation of the diseases, to chose the treatment option and to deretmine the prognosis of the patient. as a conclusion we consider, that a scintigraphy with mtc-mibi is a useful tool in pts with "blocked" thyroid. in addition -in patients with nodules, the investigation could help in their differentiation and therefore-a recommendation for therapy. purpose: the aim of this study was to determine an optimal radioiodine treatment by comparing the clinical and biochemical outcome of patients with graves disease treated with estimate doses of radioiodine to those treated with fixed doses. material and methods: a total of consecutive patients of thyrotoxicosis treated with j- were divided into two groups according to the amount of j- administered:i group- patients who received estimated dose of - mbq(mean mbq), ii group- patients who received fixed dose of mbq.all patients were pretreated with antithyroid drugs and were stopped one week before using radioiodine therapy.in , %( / ) patients with recurrent disease were given an additional dose(total dose mbq).the outcome were followed from months to years(median , years). results: at six months after single dose of radioiodine therapy, euthyroid state was achieved in % patients in the fixed dose group and % patients in estimated dose group. there was significant difference in the rate of development of euthyroid state in respect to the given dose of j- (p< , ). % patients in the fixed dose group became hypothyroid,compared to % patients in estimated dose group.the median time to hypothyroidism was weeks. % patients in fixed dose group remained hyperthyroidism six months after radioiodine therapy,compared with % patients in the estimated group.in that group significantly more patients who received low( - mbq) doses remained hyperthyroid,compared to those who received high(< mbq) doses.the thyroid volume reduction was significantly (p < , ) higher in successfully tred patients( %) than in those that remained hyperthyroid( %). conclusion: there was significant difference in outcome between the two treatment regimes.better control of thyroid states can be achieved by estimated j- dose,while fixed radioiodine offers an affective treatment option where is required rapid control of thyrotoxicosis and long term hypothyroidism is a recognized outcome. evaluated by visual examination (grading "high", "moderate" uptake and "no uptake") and by calculation of background radiouptake ratio (rur) was evaluated. results: patients had a intense mibi retention and underwent surgery: (histology revealed papillary carcinoma and folliculary folliculary carcinoma in one pat. folliculary adenoma, pts. had a moderate uptake and underwent surgery too- pat. have benign nodule in another two thyroiditis). using the / -minute thyroid lesion to background radiouptake ratio (rur), malignant and benign thyroid nodules could be separated with a sensitivity, specificity, and negative predictive value of . %, . %, and . %, respectively. the mean rur for malignant thyroid lesions was . +/- . , whereas for benign lesions, the ratio was significantly lower, . +/- . (p= . ). conclusions: in patients, in whom a needle aspiration cytology is not possible (hampered by antigoagulation therapy), the tc- m mibi scintigraphy appears to be a useful additional diagnostic tool in the preoperative assessment of suspected thyroid nodules differential diagnosis of the main types of hyperthyroidism is performed with the help of thyroid scan m tc- m, which brings out the size, the shape, the nodularity and the functional state of the gland. a second scintigraphy, this one with i, is necessary to estimate the therapeutic activity of i in hyperthyroidic patients. both radionuclides are trapped by thyroid gland in a similar manner, however, m tc is not organified. hence, the results of both types of scans are not expected to be identical in all the circumstances. aim the aim of this study is to evaluate and compare the correlation between the uptake of m tc and i in graves disease, toxic multinodular goiter and toxic autonomous nodule, in order to ponder, in these three situations, the performance of the m tc scan only, which exposes the patient to a lower radiation dose. materials and methods this is a retrospective study, based on a population of patients, divided into groups: a) patients with graves disease; b) with toxic multinodular goiter; c) and with toxic autonomous nodule. all of them underwent a thyroid scintigraphy h after administration of , mbq ( μci ) of i and a thyroid scan minutes after the administration of mbq ( mci) of m tc pertechnetate. we used a siemens ecam dcr dual head gamma camera, with the same acquisition conditions ( x matrix), and the uptake of each radionuclide was calculated. the results in each of the groups were correlationed and compared. results in plotting the m tc uptake against the uptake of i, the best fit was a linear regression model for the three studied groups. the calculated coefficient of determination (r ) was , for patients with graves disease; , for patients with toxic multinodular goiter; and , for patients with toxic autonomous nodule. conclusions our results demonstrated a poor relationship between the uptake of m tc and i in graves disease, toxic multinodular goiter and toxic autonomous nodule, especially in the former. thus, it will not be feasible to rely solely on the m tc thyroid scan and exclude the i thyroid scintigraphy as part of the protocol in none of these situations. purpose: higher levels of urokinase-type plasminogen activator (upa) and its inhibitor (pai- ) are linked to the poor prognosis in a variety of malignances. upa and pai- were expressed in most thyroid carcinomas, as had been measured immunohistochemically. however, no relationship between their expression and clinicopathological parameters were described. aim of the present study was to investigate the expression and clinical relevance of upa and pai- in thyroid cancer. patients and methods: upa and pai- in paired cytosol samples of thyroid tumor and normal tissue were determined in patients using enzyme-linked immunosorbent assay and correlated to the known prognostic features. results: both upa and pai- concentrations were significantly higher in malignant thyroid tumors (upa= . ± . and pai- = . ± . ng/mg protein) than in normal tissue (upa= . ± . , p= , and pai- = . ± . ng/mg protein, p= , ) with positive correlation of the two proteins in the tumors. upa and pai- were significantly higher in anaplastic vs. well-differentiated cancers (upa p= . and pai- p= . ), if extrathyroidal invasion (upa p= . and pai- p= . ) or distant metastases (upa p= . and pai- p= . ) had been present, and in tumors whose size exceeded cm in diameter (upa p= . and pai- p= . ). only pai- , but not upa was significantly higher in multicentric vs. solitary tumors (p= . ) and lymph node positive compared to lymph node negative patients (p= . ). the differences of upa and pai- did not reach the significant level when patients with well-differentiated tumors below and above years of age had been compared. survival analysis revealed the significant impact of both upa and pai- on the progression-free survival (pfs) ( . vs. . months for patients with low and high upa, respectively, p< . ; . vs. months for patients with low and high pai- , respectively, p= . ). conclusions: the correlation of high upa and pai- with the known prognostic factors of poorer outcome and with lower pfs rate in patients with thyroid cancers proved that these proteins could be an additional prognostic parameter. aim: to evaluate the changes of myocardial parameters in patients with confirmed primary hyperparathyroidism, asymptomatic for coronary artery disease (cad). a total of patients (mean age . ± , years) with suspected primary hyperparathyroidism and no-cardiac related major symptoms (myocardial infarction, pectoris angina) were examined using cervical planar, spect and dynamic, and gated rest-cardiac spect acquisitions. we analyzed the myocardial-rest parameters including myocardial perfusion, left regional ventricular ejection fraction (lvef), regional motility and thickening. acquisition was performed by obtaining early dynamic study, planar cervical images at min, min and - h after iv administration of mbq of m-tc-tetrofosmin (myoview); cardiac gated spect acquisition at min post-injection. results: patients ( , %) were positive for parathyroid adenoma ( m-tc-tetrofosmin scintigraphy), and confirmed through ct/mri and surgical exeresis with histological exam. / patients ( , %) had myocardial parameters changes including perfusion defects, decreased leftventricular regional ejection fraction, systolic thickening and motility disorders. patients ( , %) had normal myocardial perfusion scintigraphy result. out of patients with unconfirmed parathyroid adenoma had normal mps result. patient have moderate perfusion defects. all the results were correlated with parathyroid hormone, calcium and phosphorus plasma and urinary levels. conclusion: among patients with primary hyperparathyroidism, a high percent was affected by important changes of myocardial perfusion and systolic function ( , %). we have to underline that all these patients were asymptomatic for cad. we can therefore conclude that gated-spect is definitely a useful tool for management of patients with primary hyperparathyroidism. negative predictive value of undetectable tg level in tsh suppression during the early follow-up of low-risk differentiated thyroid carcinoma a. piccardo, s. morbelli, p. bianchi, f. barbera, g. villavecchia, m. cabria; ospedali galliera, genoa, italy. aim: is noted that tsh stimulated thyroglobulin(tsh-tg) alone is sufficient for early follow-up of low-risk differentiated thyroid cancer(dtc) patients with no clinical evidence of disease after thyroidectomy and thyroid i ablation. recent data indicate that serum thyroglobulin at the time of remnant ablation( ablation-tg) can be correlated with tsh-tg measured months later and can predict persistent or recurrent disease in postoperative period. there is also consensus that, during long term follow-up, tg measurement during thyroid hormone suppression(thst-tg) are sufficiently sensitive to forgo further testing in a low-risk patient who is clinically free of disease and has had undetectable tg after recombinant human tsh(rhtsh) or thyroid hormone withdrawal(thw). however only a small fraction of relapsing dtc patients, at month follow-up, show undetectable tg under t treatment(< . ng/ml). the aim of this study is to evaluate, in low risk dtc patients early follow-up, the negative predictive value(npv) of undetectable thst-tg measurement and undetectable thst measurement + ablationtg compared with rhtsh-tg. materials and methods: we enrolled patients with histologically proven dtc treated by total thyroidectomy and radioidine. in all patients we measured ablation-tg levels. inclusion criteria were: tumor grater than cm, smaller than cm, limited to the thyroid, not of virulent subtype, which were completely resected with or without nodal metastases but without distant metastases, negative anti-tg antibodies. all patients present undetectable thst-tg at month follow-up. at year after radioiodine treatment, all patient underwent on rhtsh stimulated tg assay. results: based on rhtsh-tg assay(> ng/ml), histology, clinical data and long term follow-up persistent/ relapsing disease was proven in patients. tg positive( . - . ng/ml) after rhtsh, with no evidence of disease was observed in patients. patients showed undetectable rhtsh-tg. the negative predictive value of undetectable thst-tg and rhtsh-tg were respectively . % and %. the ablation-tg levels were < ng/ml in patients. in this group the npv of undetectable thst-tg was %. conclusion: these data seem to indicate that undetectable thst-tg assay, evaluated by high sensitive methods combined with low ablation-tg levels may avoid a significant number of high cost rhtsh-tg. further confirmation on a larger group of patients are needed. the results sensitivity and specificity of % and % respectively, however with fna combination, the specificity of the combined procedure increased to %. serum tg measurement was detectable ( ng/ml) in tumor patients with a sensitivity of % but gave no localization information, which was important for surgical intervention. as a non-invasive imaging modality, fdg pet had a sensitivity, specificity, positive predictive value and accuracy of %, % and % and %. conclusion: ultrasonography of the neck is a practical modality that can be employed as first line investigation in papillary thyroid carcinoma patients with a clinical suspicion of loco-regional recurrent disease. it can be combined with radioiodine and pet findings and lead the patients to surgical intervention for a promising complete cure. retrobulbar mtc-diethylenetriamine-pentaacetic-acid uptake predicts the effectiveness of immunosuppressive therapy in graves' ophthalmopathy l. galuska , b. Újhelyi , j. varga , l. szabados , a. erdei , i. garai , e. v. nagy ; university of debrecen, debrecen, hungary, university of debrecen, pet-ct medical diagnostic ltd., debrecen, hungary. aim of study: in graves' ophthalmopathy, only patients with immunologically active disease respond to immunosuppressive therapy, while those in the fibrotic stage do not. in the present series we aimed to show if m tc-ethylenetriamine-pentaacetic-acid (dtpa) spet is able to predict the success of imunosuppressive treatment. patients and methods: orbits of patients with graves' ophthalmopathy ( women and men) were studied. patients with graves' disease and eye signs suggestive of activity of the orbital autoimmune process (cas ) were entered in the study. all received corticosteroid treatment and were additionally treated with orbital irradiation. dtpa spet was performed before, and to months after the initiation of immunosuppressive treatment. orbital dtpa uptakes were numerically quantified and compared before and after treatment. the calculations were performed for the entire orbit voi as well as the anterior and posterior segments separately. the control group consisted of orbits of patients who had no thyroid disease. results: in the control group, the dtpa uptake of the orbit as a whole, the anterior, and posterior segments were . ± . , . ± . and . ± . bq/cm (mean±sd) respectively. the upper normal reference limit of posterior segment dtpa uptake was set to the % percentile of the control group, . bq/cm . the mean dtpa uptake of the orbits of go patients was higher before immunosuppressive treatment than after therapy ( . ± . bq/cm and . ± . bq/cm , respectively, p= . ). the anterior and posterior segment values correlated with those of the entire orbit. of the orbits with an initial dtpa uptake . bq/cm in the posterior segment, % has improved, while of those orbits with an initial dtpa uptake above . bq/cm , % has improved. conclusions: for a favourable treatment outcome, the positive predictive value of an initial dtpa uptake > . was . %, while a negative predictive value of a dtpa uptake . was . %. patients with dtpa uptake above . may be predicted as responders, while those with a dtpa uptake below this value have only low chance of benefit from immunosuppressive treatment. aim: marine-lenhart syndome (mls) was defined as graves`disease with autonomously functioning nodules. currently there exist no data about the actual incidence of this desease and the results of radioiodine therapy. methods: in a prospective trial patients with initial diagnosed hyperthyreoidism were evaluated. physical examination, interview, ultrasound, scintigraphy and determination of t , t , tsh and antibodies were carried out in all patients. all patients were followed up at least one year after radioiodine treatment. results: mls was diagnosed in patients (incience . %). following treatment with radioioidine patients had normal serum tsh levels. hypothyreoidism was present in patients and hyperthyreoidism persisted in patients. a newly diagnosed orbitopathy was not observed after radioiodine treatment. conclusion: the actual incidence of mls was . % in patients with newly diagnosed hyperthyreoidism. treatment with radioiodine offers the chance for euthyreodism but includes a significant probability for a second therapy. the optimal method to determine iodine- treatment doses is to obtain time-activity curves from serial measures, after administration of a trace dose. a simplified method is based on a -hours i- uptake. it's still unclear the potential usefulness of tc- m scan (routinary performed during the diagnostic work-up) to estimate the iodine uptake. aim of the study. we evaluated the possibility to use the -minute tc uptake computed during standard tc scintigraphy to reliably estimate the maximum thyroid radioiodine uptake. methodology. we consecutively evaluated patients: with uni-or multinodular goiter (ng) and with graves' disease (gd). each patient underwent both tc scintigraphy and i- uptake. tc scan was acquired with a gamma camera equipped with a lehr-p collimator, ± minutes after the i.v. injection of mbq of the tracer. tc uptake was computed by measuring the syringe before and after injection under the same geometrical conditions. i- time/activity curve was obtained acquiring planar images with a gamma camera equipped with a hegp collimator at several times ( hrs, hrs, > hrs) after oral administration of . ± . mbq. thyroid uptake at any time was calculated according to standard methods. statistical analysis was performed. results. our data demonstrate different kinetics between ng and gd. mean iodine maximum uptake per mass of thyroid tissue (umax) resulted similar between groups: . ± . (ng) and . ± . (gd) . mean time to reach max iodine uptake (tmax) resulted statistically different: . ± . (ng) and . ± . (gd) (p< . ). tc uptake mean values and standard deviation (s.d.) were . ( . )% for ng and . ( . )% for gd. the best fitting demonstrated a natural logarithmic correlation between tc uptake and umax for both ng and gd. a strong correlation was found between umax vs. the natural log of tc uptake. regression coefficients r were: introduction: interferons (ifn) are a family of naturally occurring proteins with antiviral and immunomodulatory activities. there is a wide range of thyroid abnormalities related to ifn administration. thyroid autoimmunity has been widely reported as a side effect of ifn treatment as well as hypothyroidism and thyrotoxicosis. methods: a retrospective analysis of radionuclide thyroid studies of patients who had thyroid scans and were on interferons was done. all patients had thyroid scans obtained after iv injection of mci of tc m pertechnetate as well as thyroid uptake after oral administration of uci of i- . results: there were six thyroid studies of five patients , four on alpha ifn for hepatitis c viremia and one patient on beta ifn for multiple sclerosis were identified. patients included females and males ranging in age from to . patients had no history of thyroid disease prior to interferon therapy. scintigraphic diagnoses included one patient with simple goiter, one with subacute thyroiditis, one with diffuse toxic goiter and two with nodular toxic goiter. one patient developed first the nodularity then the hyperactivity in the intervening tissue later as seen on the follow up scan.conclusion: thyroid scintigraphy shows different interferon induced scintigraphic patterns and is valuable to differentiate hyperthyroidism due to graves' like pattern from ifn -induced thyroidits. adrenal or retroperitoneal masses preoperatively was beneficial. the number of positive cases continued to grow, indicating a more judicious referral in the recent years. conclusion: the experience of with in-house preparation of mibg was rewarding. the impact on clinical endocrine practice was so significant that mibg scintigraphy had become a routine investigation for all neuroendocrine tumours in our institution. the aim. data on the thyroid blood flow in healthy subjects without thyroid disease are scarce. the aim of our work was to evaluate the influence of thyrotropin (tsh) concentration on the peak systolic velocity (psv) in a group of healthy persons. patients and methods. we included euthyroid subjects, females, males, aged to (mean, . ± . years). all subjects were negative for thyroid peroxidase antibodies (tpoab) and thyroglobulin antibodies (tgab). colour flow doppler sonography (cfds) was performed using a . mhz linear transducer. psv was measured at the level of intrathyroid arteries with a sampling volume of mm. in each subject psv was expressed as a mean of five measurements. results. mean tsh concentration in all subjects was . ± . mu/l, (min. . , max. . mu/l, reference value: . - . mu/l). according to their tsh concentration, subjects were divided into groups: first group with tsh between . and mu/l (n = ) had mean psv . ± . cm/s, second group with tsh between . and . mu/l (n = ) had mean psv . ± . cm/s, third group with tsh between . and . mu/l (n = ) had mean psv . ± . cm/s, and fourth group with tsh between . and . mu/l (n = ) had mean psv . ± . cm/s. when compared with group one, psv was significantly higher in group four (p = . ). additionally, in all subjects a significant correlation between tsh concentration and psv (r = . , p = . ) was found. conclusion. we established a significant positive correlation between tsh concentration and psv in euthyroid subjects without autoimmune thyroid disease. the results are in accordance with the data on the stimulative influence of tsh on angiogenesis. radioiodine and m tc-peretechnetate uptakes are currently used for the assessment of thyroid function. i has the disadvantages of high radiation dose due to itsemission, high energy rays and longer half life. i is cyclotron produced agent and is costly. m tco has the advantages of quick assessments, low radiation dose and better image quality. however, both studies need preparation of patient with low iodine diet and cessation of anti-thyroid /thyroid replacement therapy. m tc-sestamibi has been recently evaluated by various investigators for the assessment of thyroid function with an advantage that there is no need of such preparation. the current study was done to assess the m tc-sestamibi thyroid uptake and t max . for this purpose, nine euthyroid volunteers (group i), patients with grave's disease (group ii), patients with hypertrophic hashimoto's thyroiditis (group iii) and patients with atrophic hashimoto's thyroiditis (group iv) underwent m tc-sestamibi thyroid scintigraphy. dynamic images of thyroid were acquired for minutes along with static syringe images (pre & post injection) for two seconds. maximum uptake of m tc-sestamibi was seen at minutes post injection in volunteers as well as in patients in various groups. images at , , , , minutes revealed gradual tracer clearance from thyroid. in ev, minutes m tc-sestamibi uptake was (mean±sd; . ± . %). in gd and hht patients minutes m tc-sestamibi uptake (mean ±sd; . ± . % and . ± . % respectively) was greater than in ev (p< . and p= . respectively). aht patients revealed minutes m tc-sestamibi uptake (mean±sd; . ± . %) lower than in ev and hht (p= . and p= . respectively). mean minutes m tc-sestamibi uptake showed strong correlation with mean minutes m tc-pertechnetate uptake in gd patients (r= . ) and with tsh levels in hht patients (r= . ). it is concluded that minutes is optimal time interval between m tc-sestamibi injection and calculation of thyroid uptake. minutes m tc-sestamibi uptake can differentiate euthyroid individuals from gd patients. no preparation with low iodine diet and cessation of anti-thyroid drugs before m tc-sestamibi uptake is a great advantages which possess its role as possible alternative radiopharmaceutical for thyroid uptake calculation. possible use of thyroid us and thyroid abexaminations in follow up in detecting high risk patients or early and subclinical hashimoto thyroiditis k. zaplatnikov , w. wiedemann , m. plotkin , f. grünwald ; nuclear medicine clinic nürnberg, nürnberg, germany, nuclear medicine department university hospital charite berlin, berlin, germany, nuclear medicine department university, frankfurt, germany. aim patients with hashimoto thyroiditis (hit) show typically decreased echogenicity of the thyroid ultrasonography (us). in this study, we investigated the association between the us pattern, tsh values and level of thyroid antibodies (anti-tpo,tg-ab) in order to evaluate the usefulness of us for hit screening. method included were consecutive pts with suspected hit ( f, m, mean age ± yrs) and control group with pts ( f, m, mean age ± yrs). blood samples were analysed for thyroid-ab, tsh and periphere thyroid hormones. us or scintigraphy of the thyroid was performed in follow up ( and mo). results pat. with decreased echogenicity and high level of thyroid autoantibodes (n= , gr.i) had a higher mean tsh ( . miu/l) compared with pts. with normal echogenicity and thyroid autoantibodes (n= , gr. ii) ( . mu/l, p< . ). pts. with normal echogenicity had thyroid autoantibodies too (n= , gr. iii) with mean tpo-ab ( ± ng/ml) and tg-ab ( ± ng/ml). pts. with decreased echogenicity (gr. i) had a higher level of thyroid autoantibodies (anti-tpo,tg-ab) than subjects from gr. iii (p< . ). conclusion we found a strong association between hypoechogenicity at thyroid us and higher levels of serum tsh/thyroid abs in pts suffering on hit. our results suggest that a decreased echogenicity represents a reliable sign of hit. however, a normal echo pattern cannot exclude a hit. this indicates a possible use of thyroid us and thyroid ab-examinations in follow up in detecting high risk pts or early and subclinical hit. application of somatostatin receptor scintigraphy in patients with thyroid associated ophthalmopathy j. deng; xijing hospital, fourth military med. univ., xi'an, china. the study aims at investigating the effectiveness of the orbital somatostatin receptor scintigraphy (srs) with m tc-oct in curing patients with active graves' ophthalmopathy disease and their response to the corticosteroid therapy. method: a somatostatin analog, oct, was labeled with m tc by a direct method. the compound's labeling efficiency was confirmed by paper chromatography. the subjects of the experiment were patients with graves' ophthalmopathy (go) and four volunteers without eye disease or graves' disease (gd) as the control group (cg). during the study, single photon emission computed tomography (spect), computed tomography (ct) and the left and right lateral position planar imaging of the heads of the subjects were obtained four hours after the iv injection of mbq m tc-oct. corticosteroid therapy (methylprednisolone, mg po tid for month) was then given to all patients in the next day and lasted for one month, after that the srs was repeated to all patients. radioligand uptake within each orbit (o) and occipital (oc) was measured using the region of interest (roi) method and the o-to-oc ratio was determined before and after corticosteroid treatment. clinical activity of graves' ophthalmopathy was evaluated before and after the treatment by calculating the ophthalmopathy index (oi). key results: comparing to the o/oc ratio of the control group at the scintigraphy ( . ± . , p< . ), a significant change in the o/oc ratio was observed in patients with active go between pretreatment and post-treatment ( . ± . vs. . ± . , p< . ). no significant change in the o/oc ratio was found between the cg and the go patients after post-treatment ( . ± . vs. . ± . ,p> . ). there was no significant change in the o/oc ratio in patients with inactive go (p> . ) in both pre-treatment and post-treatment periods and in the cg (p> . ). conclusions: in those patients with active graves' ophthalmopathy, somatostatin receptor scintigraphy showed markedly increased orbital uptake of m tc-oct. the study demonstrates that m tc-oct scitigraphy is a good indicator and able to predict the clinical response to the corticosteroid therapy in patients with go. this method should be considered as an objective and safe method to select proper treatment therapy. the use of real-time quantitative polymerase chain reaction (quantitative real time pcr) amplification of the human epidermal growth factor receptor (egfr) in lung cancer patients and cases of benign pulmonary disease and healthy controls. results median concentration of free circulating dna in serum of lung cancer patients, benign pulmonary disease and healthy controls was . ng/ml, . ng/ml and . ng/ml, respectively. the diagnostic sensitivity, specificity and accuracy of free circulating dna for lung cancer was . %, % and . %, same as the diagnostic value of combinations for detecting lung cancer was . %, % and %, respectively. conclusion the free circulating dna in the serum at diagnosis in lung cancer patients may be a new better tumor marker. sialoscintigraphy with m tc-pertechnetate in evaluation of salivary gland function in patients after radiotherapy with head and neck carcinoma j. niewiadomska, g. lapinska, d. kolataj, m. benke, i. kozlowicz-gudzinska, d. kiprian, a. sackiewicz; institute of oncology, warsaw, poland. radiotherapy in patients with head and neck carcinoma can result in temporary or permanent damage of the salivary glands. xerostomia can exert negative effects on the patients quality of life. aim: the aim of study was to evaluate salivary glands function in patients receiving radiotherapy due to head and neck cancer. materials and methods: patients ( men, women, aged - years) with larynx and pharynx carcinoma were enrolled in this study and underwent scintigraphy prior to radiation therapy as well as in the th and in the th month of follow-up. the patients were divided in two groups. first group consisted of patients with the area of parotid glands irradiated in %- %. second group included patients with the area of parotid glands irradiated in %- %. in both groups % mass of submandibular glands was irradiated. each patient received total irradiation dose of - cgy. dynamic salivary scintigraphy was performed with single-head gamma camera spx after injection of mbq tc m-petrechnetate. gland function was stimulated with lemon juice at min of the study. up (uptake ratio), t max (time at the max count), ms (maximum secretion) and ma (maximum accumulation) were calculated and analyzed. results: in both groups complete dysfunction of submandibular glands was observed in the majority of patients during months after rt. in comparison with the first group, in the second the parotid glands damage was less and reversible. among patients with retained salivary glands function, higher values of ma, ms, up parameters were observed in cases with parotid glands irradiated in - %. conclusions: sialoscinigraphy is a valuable non-invasive method for assessing salivary glands function in total and for each gland separately. in patients with head and neck carcinoma, radiotherapy leads to salivary glands damage which may last up to months after irradiation. degree of dysfunction is correlated with the area of irradiation. peritoneal dialysis and hydrothorax e. urbanova; nuclear medicine university hospital, hradec kralove, czech republic. continuous ambulatory chronic peritoneal dialysis (capd) is an affective renal replacement therapy for patients with end stage of renal disease. development of hydrothorax is serious but relatively less common complication. plain radiograph shows presence of hydrothorax but cannot establish its association with peritoneal dialysis and assessing the outcome of pleurodesis procedure. aim of this study was to show two patients (pts). with hydrothorax and capd. method both pts were undergoing caps for five monts. they were admitted to the hospital for breathlessness and right side chest pain. plain radiographs showed presence of hydrothorax. cytological examination of pleural fluid was negative for malignant cells. in view of transudative nature of pleural aspirate, a peritoneo-pleural communication was suspected. patients were subjected to peritoneal scintigraphy to establish the communication between peritoneal and pleural cavity. radiopharmaceutical m tc-colloid (administered activity mci) was injected into dialysate bag and infused through catheter into peritoneal cavity. to reach homogenous mixing of activity within peritoneal cavity the patient was asked to roll into bed. static scans incorporating thoraco-abdominal region were acquired at frequent time intervals with dual head gamma camera equipped with leap collimators. results by one hour some radioactivity was noted in right pleural space, but after two hours scintigrams were much better with ascent of activity up to apex of pleural space on the right side. hydrothorax was present in both pts on right side due to transit of dialysate fluid through peritoneo-pleural communication. conclusion peritoneal scintigraphy is simple, non invasive procedure with diagnostic value in evaluating connection between capd and hydrothorax. introduction. recently, a somatic point mutation of the b-raf gene (v e) has been identified like the most common genetic event in papillary thyroid carcinoma (ptc), with a variable prevalence between the different series ( - %). its detection can be made on thyroid biopsys as well as in cytological samples obtained by fine needle aspiration biopsy (fnab). for these reasons, it has proposed like a molecular marker in the early diagnosis of the ptc. objectives. to know the frequency of b-raft a in operated patients of thyroid cancer. to value the utility of the detection of this mutation in the ptc diagnosis. material and methods. the detection of mutation b-raft a was made in patients with thyroid cancer diagnosis. for the test were used fixed paraffin-embedded thyroid tissue sections coming from the surgery. patients had a thyroid fnab previous to the surgery in which also the presence of the mutation was analyzed. the techniques used for the detection of b-raft a were: dna extraction, pcr/rflp and mutation confirmation by sequentiation. results. of the analyzed biopsies ( ptc, follicular carcinomas, hurthle carcinomas, anaplastic carcinomas and high degree sarcoma), b-raft a mutation was positive in , % of tumors ( / ). according to the histologycal type, the mutation was detected in , % of ptcs ( / ): , % of classic variant, , % of micropapillaries ( / ), , % of follicular or mixed variants ( / ) and % of the variant of high cells ( / ). the mutation was not detected in any of the histologycal types different from ptc. of the patients who in the last had a previous paaf year, the mutation was positive in % of the patients ( / ) with a fnab previous to the surgery in the last year. conclusions. the presence of braft a mutation is specific of ptc and displays an elevated frequency in this group of patients. in of the patients with a previous fnab in last year, a precocious and definitive diagnosis of cpt could have been given by detecting braft a mutation in the cytology. waist circumference predicts silent myocardial ischemia in patients with diabetes mellitus: a myocardial perfusion study g. p. carboni, s. manfrini; università campus bio-medico, roma, italy. silent myocardial ischemia (smi) is a frequent condition in patients (pts) with diabetes mellitus but its mechanism and clinical relevance are still uncertain. aim:we screened for smi consecutive such pts , mean age +- years , % males , by rest/stress gated single photon emission computed tomography ( g-spect). methods: imaging was carried out on a dual-head gamma camera with thallium or sestamibi .extent of abnormal defects ads was considered significant when > than % of total lv pixels ( p ) and reversibility (myocardial ischemia) as a % of the ads p . visual images were analyzed with a score from to . relationship between imaging results and clinical parameters such first-degree family history of diabetes ( % of pts) , waist circumference ( +- cm ) , mass body index ( +- ), duration of diabetes ( +- years ) , type of diabetes ( % of pts with type , % with type ) ,total cholesterol ( +- mg/dl ) , ldl-cholesterol ( +- mg/dl) hdl-cholesterol ( +- mg/dl ) ,triglycerides ( +- mg/dl ) , hypertension ( % of pts ) , glycosylated haemoglobin ( +- % ) , c-reactive protein ( . +- . mg/l ) , current therapy ( insulin:in % of pts ; ace-inhibitors: in % of pts ; calciumantagonists: in % ; of pts ; statins: in % of pts ) were then analyzed for study . all pts were also followed-up for cardiac events ( ce ) for an average time of +- months. results: overall pts , % ( / ) revealed clear-cut smi on g-spect but only subject of these had a major ce after month follow-up. on a logistic regression model ( chi-square = , p < . ) , smi was significantly associated only with waist circumference but not with the rest of clinical parameters. when data were adjusted for established risk factors and current therapy, results did not change ( p = ns for all). conclusions: this study suggest that pts with diabetes mellitus , abnormal waist circumference indicates predisposition to an accelerate development of smi . stress myocardial perfusion imaging may thus indicate early appropriate prevention and treatment. the aim of this study was to evaluate the possible application of bone mineral density measurement using dual energy x-ray absorbtometry (dexa) in the diagnosis of transient osteoporosis of the femur. methods: fourteen patients were included this study ( males and females), with age range - years. all patients presented with hip pain, diagnosed by bone isotope scan and confirmed by mri as transient osteoporosis of the proximal femur. all patients underwent dexa scan for bilateral proximal femurs. bone mineral density values and t-score values were recorded. bone density was considered normal if t-score >- , consistent with osteopenia if tscore was (- ) -(- . ) and consistent with osteoporosis if t-score was < - . . t test was used in statistical analysis and p< . was considered significant. results: tscores in the affected femurs were ranging from (- . ) and (- . ) with a mean value of (- . ). t-scores were consistent with osteoporosis in patients, osteopenia in and normal bone density in one. t-scores in the controlateral femurs were ranging between ( . ) and (- . ) with a mean value of (- . ), with significant difference compared to affected side (p< . ). t-scores were consistent with normal bone density in , osteopenia in and osteoporosis in patients. t-score difference between the affected and the normal side was ranging between - . , and twelve patients ( %) had a tscore deficit in the affected side with more than sd compared to the controlateral side. conclusion: dexa scan can detect significant drop in bone density in patients with transient osteoporosis of the femur. although most cases didn't show t-score values of osteoporosis, still using the t-score difference compared to the controlateral femur as cutoff value may have application in establishing the diagnosis. aim: spondylodiscitis still remains a diagnostical problem. the aim of the study was to assess the sensitivity and diagnostic value of bone scintigraphy and leukocyte scintigraphy in spondylodiscitis detection. material and methods: the documentation of patients with clinically confirmed spondylodiscitis, who were treated at the department of infectious diseases between and , was reviewed. according to algorithms valid in our hospital bone scintigraphy has to be done in patients with suspected spondylodiscitis if spine on plain x-ray is inconclusive. leukocyte scintigraphy is mainly used for detection of infective foci and in patients with fever of unknown origin. m tc dpd, activity mbq, was used for bone scintigraphy. whole body scintigrams in ap and pa projections were done between two and four hours after radiopharmaceutical injection. if scintigrams were inconclusive, spect of suspected part of body was done. m tc hmpao labelled leukocytes, activity to mbq, were used for leukocyte scintigraphy. scintigrams of the whole body were performed minutes and two hours after radiopharmaceutical injection. results: bone scintigraphy was done just before or during hospitalization in ( %) patients. at the time of bone scintigraphy patients had working diagnosis of spondylodiscitis or were suspected of having spondylodiscitis. patients had different working diagnosis. radiopharmaceutical accumulation in the region with spondylodiscitis was: -increased in ( %) out of cases, -normal in ( %) out of cases. leukocyte scintigraphy was performed just before or during hospitalization in ( %) patients. of them had working diagnosis of spondylodiscitis or were suspected of having spondylodiscitis. radiopharmaceutical accumulation in the region with spondylodiscitis was:increased in ( %) out of cases, -normal in ( %) out of cases, -decreased in ( %) out of cases (absent activity in vertebral body), -irregular in ( %) out of cases (increased and decreased). the activity in the region with spondylodiscitis was normal in out of patients with working diagnosis of spondylodiscitis and decreased (absent) in of them. conclusions: -bone scintigraphy is important investigation in diagnostic process in patients suffering for spondylodiscitis due to its very high sensitivity. -leukocyte scintigraphy is without diagnostic value in patients with spondylodiscitis. the spect technique was confirmed to be more sensitive than the conventional planar bone scanning for the detection of reactive bony lesions in patients with back pain ( ) . the newly developed hybrid spect/ct device can provide enhanced anatomical localization of the lesions detected on spect. the aim of this study was to investigate the value of spect/ct bone scanning in the evaluation of patients with back pain, which has not been clearly examined yet. methods: we retrospectively evaluated bone scans of patients with back pain (age ± years, men) that had both planar and spect/ct images performed. planar, spect & spect/ct scans were separately reviewed by observers for bony lesion presence, location, & specific diagnosis based on each scan. the confidence in each of these assessments was categorized as uncertain, probable or certain. the final diagnosis was confirmed by surgical/pathological, radiological correlation, or follow-up for up to months. results: there were lesions detected in patients with final diagnosis of arthritis, degenerative disease, fracture, and normal scans. spect/ct findings were more accurate in predicting the final diagnosis (lambda value . , uncertainty coefficient error reduction %) than spect alone (lambda value . , uncertainty coefficient error reduction %). the localization certainty was significantly higher in spect/ct than spect alone (p < . ). as to lesion presence, spect significantly improved lesion certainty, without additional significant improvement by spect/ct. the diagnostic confidence in the determination of the underlying bony abnormality by spect/ct was significantly higher than spect alone (p < . ). conclusions: while the detection of bone scan lesion is significantly enhanced by spect, the hybrid spect/ct can additionally clarify the exact location of these lesions and visualize the associated ct changes. the improved certainty of these factors is the likely reason behind the superior confidence in spect/ct specific diagnosis of the bone abnormality in patient with back pain. aim of the study: stress fractures (sf) have been considered a hazard of strenuous physical activities, such as the military training of army recruits. the aim of our study was to demonstrate the association between the findings of bone scanning and some clinical parameters of physical strain that result in bone injury in this specific group of young people. patients and methods: ninety four male recruits, - years old (mean= ± years), under a similar training program and with suspected sf of the lower extremities underwent three-phase bone scanning after injection of mbq mtc-mdp. they were divided into various groups according to: a) body mass index (bmi): (< =normal, - =overweight and > =obese), b) duration of military service ( - months = recruits, and > months = post-trained soldiers), c) location of the primary symptoms (knees-tibiae, or feet), d) duration of pain symptoms (</= days or > days), e) pain intensity, in a - scale, where = pain free and = very intense pain, f) results of plain radiography (positive/negative) and g) results of bone scintigraphy (grade = negative in all phases, grade = positive only in the rd phase, and grade = positive in all phases). paired chi-square statistical tests were applied for all parameters. results: seventy two patients ( % of the sum) had scintigraphically positive bone pathology ( on the leg and on the feet), while the rest / ( %) had negative bone scans. sf were found at patients ( %), more commonly in the feet rather than the legs (x = . , p= . ) and in recruits rather than post-trained soldiers (x = . , p= . ). positive scintigraphic results also correlated to pain intensity (x = . , p= . ), although the former were not correlated to bmi, duration of pain, or the results of plain radiography. plain radiography had sensitivity= %, specificity= %, ppv= %, npv= % and accuracy= % in the detection of sf, taken bone scintigraphy as "gold standard", with no correlation to any of the aforementioned clinical parameters of bone injury. conclusions: army recruits under the basic training program seem to suffer more severe bone lessions, located mainly in the feet, regardless of overweight or the duration of pain symptoms. regarding bone scanning as the "gold standard" diagnostic method, pain intensity is a strong predictor of an adverse clinical condition (bone fracture rather than a milder lession) bone scintigraphy and xray in detection of active osteoarthritis.their relation to type of knee pain. a roc analysis. aim: bone scintigraphy is a valuable method for detecting synovitis in knee joints with severe osteoarthritis. both clinical symptoms and proven hyperperfusion set the indication for radionuclide synovectomy (rs). the aim of our study was to evaluate the clinical usefulness of blood pool (bp) and static scan (ss) in respect with joint pain, clinical and x-ray findings. materials and methods: knee joints of patients ( ± . years old) referred for setting indication for rs were clinically evaluated and classified by x-ray steinboecker system and type of pain (only under stress/ both under stress and rest). two-phase bone scintigraphy was performed according to the procedure guidelines of our department and intensity of tracer accumulation in joints was scored. to check scintigraphy or simple xrays' ability to evaluate dolorous active synovitis complete statistical receiver operating characteristic (roc) curves were analyzed. results: of all knee joints studied . % were painful at exercise while % were continuously dolorous. in general bp was positive in . % and ss in . %. osteoarthritic joints were x-ray graded . % as , . % as i, . % as ii, . % as iii and . % as grade iv. bp had a sensitivity of . , specificity of . , ppv of . and npv of . at exercise pain and . , . , . and . at continuous pain respectively. all values were critically better than these of ss and xray. area under roc curve for bp was larger than this for ss and for xray (the smallest) in painful joints ( . , . and . respectively) with statistically significant differences. conclusion: bb scintigraphy is a useful technique for detecting active synovitis in knee joints with oa better than ss or simple xray. tracer accumulation is strongly related to the type of pain. introduction condylar hyperplasia is a common cause of crossbite malocclusion and facial asymmetry. treatment often includes surgery and it's necessary to know the growth activity of the hyperplastic condyles for treatment assessment. nuclear methods are beginning very useful in this pathology. objetives the aim of our study is evaluate the correlation between histopathologic findings and uptake intensity in spect in patients with condylar hyperplasia. patients and methods prospective study in patients with clinical suspect of condylar hyperplasia and positive m tc mdp spect. the patients with increased uptake of m tc mdp in any tmj were considered positives and were classificated in three grades of uptake. all patients were referred to surgery (condylectomy or condylar shave). an hystologic study classified the samples in three activity grades. a stadystical analysis of spect and hystopatological finding was done. results condylar hyperplasia was confirmed by hystological findings in all cases. a strong correlationship was confirmed between the uptake intensity and anatomopatologycal findings. conclusions condilar spect with m tc mdp is an easy diagnostic method with high sensitivity for the diagnosis of condylar hyperplasia and is very useful to evaluate the grade of hyperplasia. progressive condition and early surgical intervention may prevent further deformity of the hip join. although the prognosis and treatment of these conditions differ greatly, in the early stages the radiographic appearance of toh my be confused with avn. we will attempt to define radiologic characteristics that distinguish toh from avn. patients and method: in years , patients ( f, m) were referred with acute hip pain; male with bilateral hip pain in the third trimester of pregnancy ( hips). in all patients radiographs, bone scan and mri was performed. the diagnosis of toh was confirmed by complete clinical recovery and normal mri in the follow up with conservatively treatment.. results: no patients had radiographic changes. bone scanning showed uniformly increased uptake at the affected femoral head extending down into the femoral head in all patients. the changes on mri were a pattern of diffuse edema without focal defects, and intact articular surface, but patient with focal defect which diagnosis was avn. conclusion: diffuse edema pattern on mri without focal defects and bone scanning with homogeneously increased uptake in the femoral head and neck is highly suggestive of toh. introduction: reflex sympathetic dystrophy (rsd) or complex regional pain syndrome is a condition of burning pain, stiffness, swelling and discoloration of the affected limb (commonly hands and feet). females are affected more commonly than male ( : ) . only one in five affected patients is able to return to a normal level of functioning. bone scan is highly sensitive ( %) and specific ( %). it is also a useful guide to prognosis. about % of patients with positive bone scan experienced a favorable response to steroid as oppose to % of those with negative scintigrams. case report: this is a years old male presented with weeks h/o severe burning sensation and pain in the left hand. he has had a laminectomy over c -c about weeks back. follow up mri revealed no nerve compression. x-rays of left hand was unremarkable. a three phase bone scan was performed with mbq of tc- m mdp. results: dynamic and blood pool images revealed abnormally increased blood flow over left forearm, wrist and hand. delayed images revealed diffusely increased tracer uptake over the left wrist, carpal, metacarpo-phalangeal and inter-phalangeal joints. a diagnosis of reflex sympathetic dystrophy was made. he was started on oral steroid therapy with analgesic for months and responded well to the treatment. conclusion: it is concluded that three phase bone scan is a safe, non-invasive, cost effective, highly sensitive and specific modality for the diagnosis of reflex sympathetic dystrophy and also a good predictor of response to treatment. aim: fdg pet can assess the activity of several inflammatory diseases. idiopathic retroperitoneal fibrosis (irf) is a rare disease characterised by a fibro-inflammatory mass which surrounds the abdominal aorta and the iliac arteries and often causes obstructive uropathy. we explored the ability of fdg-pet to predict response to therapy and post-treatment relapse in irf patients (pts). methods: twenty-four consecutive irf pts (m/f: / ; median age yrs, range - ). the treatment was oral prednisone for month and then prednisone+methotrexate or tamoxifen for months. ct or mri were performed at diagnosis, after months of treatment and at the end of treatment. pet was performed in all pts before treatment, and in / pts also after the end of therapy. the treatment-induced reduction in size of irf, as assessed by ct/mri, was defined as absent if < %, mild if - %, and marked if > %. fdg uptake was graded from to +. the pts were compared with controls. results: at diagnosis, ( %) pts showed a pathologic fgd uptake with main patterns: diffuse ( / pts, %), and focal ( / pts, %). diffuse pattern: had grade +, had + and had + uptake; the reduction in size of irf was marked in / ( %) pts with grade + and of pts with grade + and absent in with +, with + and with +. focal pattern: had grade +, had + and had + uptake. a marked response was observed in only / pts with grade +; mild responses in / pts with grade +; no response in / patients with grade +, / with grade + and / with grade +. both pts without pathologic uptake showed no reduction. after the end of treatment, / pts had a residual pathological uptake whereas had no uptake. posttreatment relapses were observed in / pts with a residual uptake, and in only / pts without. conclusions: the distribution and intensity of vascular fdg uptake may predict response to treatment in irf patients; a post-treatment residual uptake heralds disease relapse. spect/ct may provide an incremental value to routine indium- labeled wbc scintigraphy, as suggested by a recent report with a limited number of patients ( ) . in this study, we verify this finding in a larger group of patients and also evaluate the different possible contributory factors to the diagnostic confidence of spect and spect/ct scans. methods: we retrospectively evaluated indium- wbc planar scans of patients (age ± years, men) with known or suspected infection that also had spect/ct performed. planar, spect and spect/ct scans were separately reviewed by observers in respect to infection presence, location, and the specific diagnosis based on each scan. the confidence in each of these assessments was categorized as uncertain, probable and certain. the final diagnosis was confirmed by surgical/pathological correlation; follow up scan/radiological examination or up to months clinical follow-up. results: in planar images with uncertain infection location, spect improved locations to probable sites that were further improved to definite and probable sites by spect/ct. correspondingly, in probable location sites on planar images, spect improved locations to definite sites compared with definite sites improvement by spect/ct. conversely, spect significantly improved infection presence certainty in uncertain and probable planar subcategories, without significant additional improvement by spect/ct. in spect/ct, the specific diagnosis confidence was significantly higher when both infection presence and location site were certain, which was more frequently attained than with spect scans alone ( vs , p < . ). final diagnosis was categorized as non-specific/abscess, specific soft tissue infection, osteomyelitis, combined osteomyelitis/soft tissue infection, and normal/physiological uptake. spect/ct findings were more accurate in predicting the final diagnosis (lambda value . , uncertainty coefficient error reduction %) than spect alone (lambda value . , uncertainty coefficient error reduction %). conclusions: in indium- wbc scintigraphy, the infection presence recognition is improved by both spect and spect/ct, while the use of spect/ct leads to considerable enhancement in infection localization as well. the significant improvement in both these factors is the likely reason for the high confidence in the spect/ct specific diagnosis of infection. . bar-shalom r, et al. j nucl med ; : - objectives: in aortic aneurysm (an) tissues, chronic aortic wall inflammation is mediated by macrophage infiltration, which is playing important role for tissue degeneration. some studies have shown that weakening of the mechanical properties of the degenerated tissues may progress the expansion of the aneurysm. especially, saccular ans often expand rapidly and are suspicious for an infected aneurysm. in the present study, we hypothesized that fdg accumulated in saccular an walls because these lesions had strong inflammatory reaction with macrophage infiltration and investigated whether fdg accumulated in saccular ans. methods: a retrospective survey was conducted on patients with an who underwent fdg-pet. after at least h fasting, the study subjects received an intravenous administration of fdg. one hour after fdg injection, pet imaging was carried out. fdg images were visually evaluated for the presence of increased fdg uptake in the carotid arteries. we divided the ans in patients into two groups (saccular-type or fusiform-type) according to the morphologic characteristics. we assessed inflammatory marker (crp) and pathologic characteristics (atherosclerotic or inflamated) in two groups. results: of ans were divided into saccular-type and fusiform-type ans. of saccular-type ans were pet-positive, whereas only one of fusiform-type ans was pet-positive. there was no significant difference in the values of crp and aneurysmal size in two groups. ans proven pathologically were divided into saccular-type ( infected, atherosclerotic ans) and fusiform-type (all atherosclerotic ans). fdg accumulated in all of saccular-type ans. conclusion: fdg frequently accumulated in saccular-type ans. ans in which fdg accumulates may have a high risk of rapid expansion and rapture because these lesions are suspected to have inflammatory reaction with macrophage infiltration. aim aim of this study was that of confirming additional clinical effectiveness using spect/ct with mtc hmpao-labelled leucocyte in infection and inflammation . materials and methods we studied ninety-seven patients (pts) ( females and males; mean age . ± . years); all patients underwent labelled leucocyte scintigraphy for known or suspected infectious or inflammation processes: pts with orthopedic implants, pts with suspected osteomyelitis , pts with spondylodiscitis, pts with fever of unknown origin (fuo), pts with inflammatory bowel disease (ibd), pts with suspected septic arthritis and pt with suspected vascular graft. in addition with planar and whole body protocol images spect /ct was performed using dual head gamma camera equipped with a low-power x ray system (infinia hawkeye -g.e.healthcare ). after injection of - mbq of mtc hmpao-labelled leucocyte spect/ct images of the interesting area were obtained in all cases at h or h according with the clinical query. final diagnosis of infection and inflammation was made on the base of bacteriologic, surgical data or clinical followup. results spect/ct results proved on the whole cases true-negative and true -positive, false -negative and false-positive results. in orthopedic implants and osteomyelitis cases spect /ct permitted to distinguish between soft -tissue infection and bone involvement and allowed to change clinical and surgical management in % cases; spect/ct detected precise localization in ileal and ileocolonic tract in positive ibd cases. additional value of spect/ct was in fuo cases since it permitted a diagnosis of renal abscess in pt with polycystic kidney who previously underwent renal transplant, in another pt, abnormal focal uptake in catheter for haemodialysis and in cases with liver , lung and sub-diaphragmatic abscess respectively. the overall sensitivity and specificity of spect/ct mtc-hmpao labelled-leucocyte was % and % respectively. conclusion spect/ct with mtc hmpao-labelled leucocyte is a useful tool for infection and inflammation detection that provides a precise anatomy localization, expansion and tissues differentiation mainly between soft tissue infections and osteomyelitis. furhermore, it underlines the role of mtc hmpao-labelled leucocyte in cases of suspected abdominal-pelvic or thoracic sites of infections increasing the diagnostic accuracy of positive findings. objective: hemodialysis (hd) activates neutrophils and causes increased lung retention. m tc fanolesomab is a monoclonal antibody that radiolabels white blood cells and myeloid precursors in vivo. it reacts with cd , expressed on the surface of polymorphonuclear neutrophils, eosinophils and monocytes. serious complications occurring < min. after injection was reported in patients (pts) with compromised cardiopulmonary reserves. lung retention of this agent has not been addressed yet. we hypothesized that there might be an excess transient retention of these invivo labeled and probably activated wbcs in the lung capillaries post hd, which may contribute to pulmonary compromise. methods: we retrospectively and semi-quantitatively determined the degree of invivo labeled m tc wbc activity on anterior (a) and posterior (p) whole body images of the consecutive pts. a and p rois were drawn in the upper (u), middle (m) and lower (l) lung zones and over the chest wall soft tissue background and used to calculate the geometric means of conjugate rois (lung uptake ratio). pts without esrd and not on hd were used as controls. elapsed times from the last hd to imaging times were determined. result: mean± sd injection to imaging time: ± min ( - ). of the pts with esrd on hd, had hd < hr before the imaging (group i), pts had hd - before the imaging (group ii). geometric mean lung uptake ratios for right (r) u, rm, rl, left (l) u, lm, ll in group i were . ± . , . ± . , . ± . , . ± . , . ± . and . ± . , respectively. those values for group ii were . ± . , . ± . , . ± . , . ± . , . ± . and . ± . , respectively. control ratios were . ± . , . ± . , . ± . , . ± . , . ± . and . ± . , respectively. a trend of subtle increase in lung uptake ratios was noted for group i, especially in left lung. however, differences weren't statistically significant. conclusion: a recent hd done < hrs might play a role in the activation of the invivo labeled m tcwbcs causing prolonged lung retention in esrd pts, which is not present > hrs. despite the strong trend, lack of statistical significance in group i pts might be due to relatively long ( - min) injection to imaging time and small pt population. purpose:in this study, we aimed to investigate the role of tc- m hmpao white blood cell (tc- m wbc) spect in the evaluation of bone infections in addition to tc- m mdp -phase bone (tc- m -p) scans and planar tc- m wbc scans. materials and methods: the patients who had tc- m -p and tc- m wbc scans between january and march for the investigation of suspected bone infections were evaluated retrospectively. from these, patients whose pathological, bacteriological, surgical data, and clinical onset showed infection were included to our study. for every patient, tc- m -p, planar and spect tc- m wbc scans were performed within one week. our patient group consisted ( %) males and ( %) females whose ages were - (mean age was . ) and who had bone infections in various localizations: patients ( %) had infections of foot, patients ( %) had infections of knee ( of them had knee prosthesis), patients ( %) had infections of hand, and patient ( %) had infection of leg. results: the images of tc- m -p and planar tc- m wbc scans were evaluated together and tc- m wbc spect images alone. the results were as followings: were enrolled the study. the patients were suspected of bacterial infection due to travmatic injury ( pts), diabetic foot ( pts) and prosthetic surgery ( pts). whole-body images at , and hours after iv slow injection of mci ciprofloxacin labelled with technetium- m in-house were obtained. threephase bone scintigraphy was also performed in patients in a period of to days. final diagnosis was obtained by microbiological and patological examinations and clinical follow-up for a period of to years. results there were positive findings on tc- m ciprofloxacin images and of them were proved to be true-positive. staphilococci was the most common agent isolated by microbiological analysis. in one of the patients with false-positive finding, intensive bone repair was noted on bone scan images. ciprofloxacin imaging was true-negative in patients and failed to show bacterial infection in patients (chronic osteomyelitis in , hip and knee posthesis in and diabetic foot in patients). the overall sensitivity, spesificity, negative/ positive predictive value and accuracy of tc- m ciprofloxacin imaging were % % %/ % and % respectively. conclusion tc- m ciprofloxacin is a sensitive and practical procedure that can be used in detecting musculoskeletal infection. it also contrubutes to discriminate aseptic loosening and prosthetic infection and avoids unnecessary orthopaedic surgery. along with three-phase bone scanning false-positive results can be reduced where excessive new bone formation might be the potential cause of false-positive results. objectives: infection of hd vascular access site is a frequent cause of mortality morbidity in hd patients. the incidence is lowest in patients with avf. although the prosthetic hd access (avg and/or catheters) has been acceptable alternative to the native avf, the patients are often plagued by more complications (i.e., infection, thrombosis). aim of the study was to determine the accuracy of infection detection using invivo labeled tc- m wbc imaging in patients with avf as hd access as compared to those with prosthetic hd vascular access (avg, catheter). methods: consecutive patients with end stage renal disease being treated with hd and who had suspected infections were retrospectively analyzed. two nuclear medicine physicians evaluated the tc- m wbc images in a blinded fashion. vascular access infection was diagnosed if radiotracer uptake at the site was focal fashion and more prominent than the surrounding blood vessels. the scan results were correlated with clinical/laboratory information, cultures and outcome. results: in patients a total of vascular access sites were evaluated. there were avg, avf, and hd catheters. none of the avf was infected but % showed collateral formation. invivo labeled tc- m wbc scan showed evidence of infection in / avg (% ) of the avgs, compare to / ( %) of the hd catheters (p: . ). when compared, avf versus prosthetic hd access (avg + catheters), the incidence of detected infection was % versus % (p: . ). the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for the detection of infection with the tc- m-wbc scan in avgs were: %, %, %, %, and %. the values for the hd catheter were %, %, %, % and, %, respectively. conclusions: a properly formed arteriovenous fistula is less likely than other types of vascular access to become infected. hemodialysis catheters and arterio venous grafts had similar rates of infection. the tc- m wbc scan has an accuracy rate of - % in detecting infection in arterio venous grafts and hemodialysis catheters i.e., prosthetic hemodialysis access. objectives: this was an intraindividual analysis of the utility of currently available radionuclide imaging techniques: phase bone ( pbo), bone (bo), gallium (ga), bone/gallium (boga), labeled leukocyte (wbc), leukocyte/bone (wbc/bo), and leukocyte/marrow (wbc/ma), to determine the most accurate radionuclide technique for diagnosing the infected hip prosthesis. methods: patients, females, males, - years old, with failed hip replacements, total arthroplasty, hemiarthroplasty, weeks- years old, who completed all radionuclide imaging tests and who subsequently underwent surgery formed the basis of this retrospective study. one experienced nuclear physician reviewed all images. diagnostic criteria for infection were as follows: pbo= triad of periprosthetic hyperperfusion, hyperemia, & increased periprosthetic activity on delayed, bone, images; bo= increased activity around the shaft of the femoral component, ga= any increased periprosthetic activity except focal activity at the tip or trochanters, bo/ga= spatially incongruent distribution of activity or, if congruent, ga activity >bo activity, wbc= increased periprosthetic activity relative to contralateral limb or surrounding normal activity, wbc/bo= spatially incongruent distribution of activity or, if congruent, wbc activity >bo activity, wbc/ma= spatially incongruent distribution of activity. imaging results were compared with surgical, histopathological and microbiological results for all prostheses. results: there were infected prostheses. final diagnoses in the remaining cases include aseptic loosening ( ), failed acetabular liner ( ) , and component malposition ( ) . imaging results are summarized in the for all prostheses the pbo scan demonstrated only moderate sensitivity and low specificity. for reasons that are as yet unknown, the test was not sensitive, but moderately specific, for diagnosing prosthetic hip infection, while in contrast, it was very sensitive, but not at all specific, for diagnosing prosthetic knee infection. conclusions: the phase bone scan is of limited utility for diagnosing infection of lower extremity joint prostheses. the test is not sensitive for prosthetic hip infection and too nonspecific to serve as a screening test for knee prostheses. malignant otitis externa is a rare infectious disease of the external auditory canal commonly caused by pseudomonas aeruginosa. the disease may have a protracted course with extension to other bony and soft tissues structures of the skull base. evaluation of disease extent is crucial for initial management with further evaluation required to document resolution during treatment. ct will delineate bone and gross soft tissue involvement but may be normal in early disease. mri is useful to assess soft tissue extent of disease but assessment of resolution is difficult with both modalities. bone scintigraphy will detect early bone involvement but remains abnormal for some time therefore is unreliable for assessment of resolution or detecting early recurrence. gallium- citrate can be used to assess disease extent but like bone scintigraphy is non-specific and partly reflects bone activity. there is less published data on the use of in- white cell imaging which has been said to become negative before complete resolution. it is possible that this drawback relates to the imaging properties of in- and the difficulty of localising small low intensity foci of white cell accumulation on planar views. in three recent cases of suspected skull base osteomyelitis low intensity foci of white cell accumulation were identified on planar imaging with in- labelled white cells. use of spect combined with 'hawkeye' (low power ct: ge-millenium vg) allowed accurate localisation of these foci. dual isotope acquisition with combined in- and tc- m mdp assisted in this process as the more intense and extensive uptake by the bone agent helps to identify the initial extent of disease and which transverse slices to examine in detail on the lower count data acquired with the in- spect. in each case imaging was repeated during the clinical course of the disease to document resolution with scintigraphic findings mirroring the clinical course. conclusion use of in- combined with tc- m mdp spect and 'hawkeye' can be useful to assess extent of disease in suspected skull base osteomyelitis on initial presentation, to monitor response to treatment and to assist in determining when to discontinue antibiotics. it is possible that this may be more specific and may present a viable alternative to ga- citrate in such cases. careful attention to imaging parameters is required to avoid acquisition of meaningless data in view of the low counts obtained with in- spect particularly as disease resolution occurs. the utility of m- ; conclusion: many common diseases manifest themselves with no specific sign or symptoms, but with fuo associated to an increase of no specific marker of inflammation. our data show that, even if, most of patients with fuo had negative scintigraphy with leukoscan, it can help clinician to identify the cause of fuo and to decide the best therapeutic treatment. the main etiologies of fever of unknown origin (fuo) are infections, cancers, and noninfectious inflammatory preocesses. in this prospective study, we aimed to evaluate the diagnostic role of f-fluorodeoxyglucose (fdg)-pet in fuo, since this substance has an increased uptake by neoplastic and inflammatory cells. methods: the study included patients ( male, female, mean age . ± . years, range - years) referred to our unit for fdg-pet study between march and december . siemens lso hirez pet-ct camera was used for the record of the imaging. one hour after injecting - mci fdg, a whole body pet-ct from vertex to toe was obtained. results: among patients studied by pet-ct, ( . %) had foci with increased fdg uptake. the remaining had normal findings. among those patients with increased fdg; malignant neoplastic process, inflammatory process, and infection were diagnosed in , , and patients respectively. modern combination chemo-and radiotherapy have raised long-term survival of hodgkin lymphoma (hl) to more than %. however, the longer follow-up has shown serious long-term adverse effects related to the treatment, including heart and lung diseases, and secondary malignancies. in order to reduce these long-term side effects, alternative therapeuties are becoming more tailored to the individual patient's prognosis. in this regard, an important predictor of outcome is the early establishment of treatment response. conventional methods as ct scan have proven to be poorly accurate to this purpose. recently, early interim fdg pet/ct has been reported as a strong and independent predictor of progression-free survival in hl. in particular, a positive early interim fdg pet/ct is highly predictive of progression in patients with advanced stage or extranodal disease. in the present prospective study, we collected consecutive patients with newly diagnosed hl since . all patients underwent initial staging with fdg pet/ct (it was positive in all patients) along with standard staging procedures, including ct. fdg pet/ct was repeated after (fdg pet ) and cycles of chemotherapy, and after completion of chemotherapy (abvd schedule). evaluation of this last fdg pet/ct was discriminant to decide for radiotherapy in bulky disease. the follow-up range was of - months. all the fdg pet negative patients are in complete disease remission, except for one case (patient /see table) who experienced early relapse, resistant to autologous bone marrow transplantation. she is now in disease progression and a shift in lymphocyte depletion histo-type has been documented. results are shown in the subtotal splenectomy is effective in decreasing both the hematologic complications of hs and infectious complications of total splenectomy. the objective of this retrospective study on patients was to identify clinical and/or biological factors which could predict the rate of regrowth of the splenic remnant and influence the beneficial effect of subtotal splenectomy on red cell life span. material and methods : sixty one patients (m= ; f= ) with hs who underwent subtotal splenectomy between february and march were included in this analysis. for each patient, preoperative and postoperative clinical and biological data were collected: date of first symptoms, the clinical and biological indications for subtotal splenectomy (propensity for fatigue , number of transfusions, associated cholelithiasis, mean values of haemoglobin and reticulocyte counts), patient's age at the date of surgery. postoperative growth and functional value of the splenic remnant were assessed by abdominal single photon emission computed tomography (spect). acquisitions were performed after injection of autologous heat damaged red blood cells labelled with technetium m. splenic volume was calculated on reconstructed axial slices by means of a threshold algorithm previously validated on a phantom study. results & conclusion: statistical analysis was done with r software. mean values of haemoglobin, reticulocyte counts and clinical scores were compared between preoperative and postoperative follow-up periods. median delay between subtotal splenectomy and splenic scintigraphy was days (range - ). three patients developed splenic necrosis postoperatively and were dropped from the statistical analysis of predictive factors. the mean splenic volume measured by spect was ml (range ml - ml ; median= ml). the mean haemoglobin values increased from . g/dl before surgery to . g/dl after surgery. univariate and multivariate analyses were performed to identify the predictive variables of splenic regrowth. we describe a case of hairy cell leukemia (hcl) coexistent with non-hodgkin's lymphoma (nhd). this combination is reported to be extremely rare with no clear demonstration of the clonal relationship between the two condition. after a previous failure of purine analogs therapy, our patient was successfully treated with rituximab resulting in normalisation of blood cell count cessation of blood transfusion and negative iliac crest biopsy. unfortunately, the patient developed intense and persistent bone pain during the st line treatment for hcl. skeletal x-rays, whole-body ct scan and bone mri were unremarkable and bone scintigraphy showed non-specific changes. laboratory examinations were normal. to better evaluate these non-specific findings, a fdg-pet/ct was performed, followed by a guided bone marrow biopsy of the left femoral diaphysis. this demonstrated an aggressive high grade lymphoma, characterized by immunoblasts and polymorphous centroblasts in a diffuse pattern, expressing cd , cd a, cd , ig k for a %, nuclear and cytoplasmic bcl- antigen, a high proliferative index (mib- > %), and alk negative. these parameters, along with the absence of a low-grade component, were consistent with the diagnosis of primary bone marrow diffuse large b-cell lymphoma (lbcl). shortly afterwards, ldh rapidly increased to u/l and hb levels decreased to g/dl; esr was mm, ferritin was ng/ml, fibrinogen mg/dl, -m mg/l. an attempt was made to assess and compare b cell clonality of both disorders using a seminested pcr approach, as previously described ( ); unfortunately no major ig h gene rearrangements could be detected in both disorders with the primer pairs used for the assay. in may the patient was started on weekly chemotherapy scheme (vacop-b). diffuse bone pain rapidly resolved and hb concentration, esr, -m and ldh normalized. unfortunately in july, six weeks after chemotherapy, she became sleepy and developed loss of memory, and central nervous system involvement with lbcl was confirmed with csf cytology and immunophenotyping. brain mri showed diffuse subependimal disease. therefore, the patient was given both intrathecal and systemic rd line chemotherapy with progressive neurological improvement. however, her clinical condition showed rapid deterioration culmibnating in cessation of chemotherapy. the patient eventually died of progression of her disease in august . it can be recommended the early performance of fdg-pet/ct in poorly understood bone pain to identify bone and bone marrow localization of nhd. objective: the aim of our retrospective study is to compare the recurrence (local, regional node or distant metastasis) after sentinel lymph node biopsy (slnb) with and without axillary lymph node dissection (alnd) in patients with breast cancer. patients and methods : between may and september , patients with early-stage invasive breast cancer (<ct , cn , cm ), underwent slnb in our institution. patients were treated with alnd after slnb and patients without. all patients were classified pn+ or pn based upon presence or absence of metastatic lymph node by pathologic analysis. a total of patients ( . %) were pn+. the median follow-up period is months (range - ). the site of first recurrence was classified as local, regional node or distant metastasis. results : recurrence occurred in / patients ( . %). the median interval to recurrence was months. local, regional node and distant metastasis recurrence occurred respectively in . %, % and . % of pn patients treated with slnb alone (n= ), and in . %, . % and . % of pn patients treated by slnb with alnd (n= ). in patients with positive nodes (n= ), regional node recurrence and distant metastasis are sensibly more frequent (respectively . % and . %), while local recurrence is comparable ( . %). conclusions : as reported by several others teams, our study demonstrates that local, regional node and distant recurrence rate in patients treated by slnb without alnd, providing sln is negative, is not greater than after alnd. this remains true after a long time follow-up (over years). our results support that slnb alone in sln-negative patients is a safe method to assess axillary lymph node status in early-stage breast cancer. ( ) ( ) ( ) ( ) - ( ) ( ) ( ) ( . ) - ( ) ( ) ( ) ( . ) > ( ) ( ) ( ) ( . ) median follow-up months months months months median interval to months months months recurrence recurrence ( . ) ( . ) ( ) ( . ) local ( . ) ( . ) ( ) ( . ) regional node ( ) ( . ) ( ) ( . ) distant metastasis ( . ) ( . ) ( ) ( . ) alnd, axillary lymph node dissection; sln, sentinel lymph node; aln, axillary lymph node aim: although it is well documented that previous excisional biopsy is not a contraindication in sentinel lymph node biopsy (slnb), there are studies reporting problems caused by previous surgical applications. in this study we aimed to review retrospectively if there is a relation between problems encountered and presence of previous excisional biopsy during snlb. material and method: a total of female patients were included in the study. seventy two of them were patients having previous excisional biopsies. mci of tin colloid was injected at quadrant around areola intra/subdermally hr before surgery. patients were imaged at anterior and lateral projections and during operation slns were excised with the guidance of gamma probe. results: application difficulties were analysed in main topics and were seen in patients. dilated lymphatic channels showing activity stasis caused problem in patients. leakage of the activity in a localization other than injection site was the case in patients (into the biopsy cavity in and in an intradermal pouche in patients). non-vizualization of sln at first injection was the problem in patients. when occurence of this problems and presence and localization of previous biopsies were compared no correlation was detected between dilated lymphatics and biopsies. presence of dilated lymphatic channels were more often in non-biopsied patients ( / ) than biopsied patients ( / ) . although dilated lymphatics increased operation time did not prevent detection of slns. all patients showing activity leakage have had biopsies within weeks with periareolar insicions. leakages formed focal activity accumulation areas mimicking sln appearences. the real sln could not be visualized in patient having leakage into the biopsy cavity. in other patients having leakage into dermal pouch slns are succesfully identified. all patients with nonvisualized slns at first injection were patients having previous biopsies. in of them with a second intraparenchimal injection done just before the operation slns could be detected. in the rd patient who had additionally morbid obesity sln could not be identified. conclusion: although previous excisional biopsies do not compromise the effectiveness of the technique, especially when done with periareolar insicions it may cause problems in periareolar injection technique. detection of sentinel lymph nodes in breast cancer: every day practice and pitfalls g. moulin-romsee , e. d'hondt , f. persyn , b. van calster , s. ceyssens , p. neven , s. stroobants ; ku leuven, leuven, belgium, uza, antwerp, belgium. the sln technique has radically changed the management of breast cancer by reducing the need for axillary lymph node dissection. controversy and variety in every day practice however exists. we investigated the effect of different methodologies as part of an internal iso audit. methods: initially, mbq tc-nannocolloid was injected peritumoral and images were acquired after - min and hours (group i, april-september ). because a decreased visualisation on scintigraphy was noted (group ii, january-april ), the procedure was adapted (group iii, may-september ). the tracer was injected subdermal and for the -day protocol, the dose was increased to mbq. if lymphoscintigraphy was negative after hours another mbq was injected periareolar. differences in patients characteristics, visualisation and identification rate between the patients groups were statistically analysed. results: scintigraphic visualisation and surgical identification rate was % and % for group i, % and % for group ii and % and % for group iii. except for age, patients' characteristics were similar (bmi, hooked wire). the odds of finding a preoperative sln is significantly higher in group iii compared to both other groups (or= . ) which is explained by the higher count rate of the resected sln (p= . ). other factors that are associated with a decreased detection rate are hooked wire (or= . ), bmi (or= . ) and age (or= . ) discussion: we advocate the use of a single subdermal deposit since it drains more rapidly and is easier to perform. failure to detect a sln is more frequently in association with hooked wire, higher age and patient overweight. when a -day protocol is used, sufficient dosage should be used to ensure strong signal perioperatively. aim axillary treatment for breast cancer can increase resistance to lymph outflow from the arm. lymphatic collector vessels may have to pump against a chronically raised afterload, leading to lymphatic collector pump (lcp) failure and breast cancerrelated lymphoedema (bcrl). a new lymphoscintigraphic technique was used to measure lcp function in normal and bcrl arms. materials and methods in an ethics committee approved study we first measured hand to axillary lymph node transit time (t transit ) using intradermal injection of m tc-human igg ( m tc-hig, mbq) using -camera imaging. lcp force was assessed by placing a sphygmomanometer cuff at mmhg around the upper arm before injection and retention of m tc-hig distal to the cuff and absence of axillary counts at >t transit indicated inhibition of lcp function. after t transit max cuff pressure was lowered by mmhg steps until m tc-hig passed under the cuff and reached the axilla, indicating the pressure (p pump ) lymphatics could overcome. results t transit was ± [sd]min ( min for t transit max) in healthy subjects ( ± years). lcp force (p pump ) was assessed in healthy controls ( ± years) and women with bcrl ( ± years, - % forearm swelling). p pump was ± mmhg in controls, and lower at ± mmhg, in bcrl subjects with swollen forearms (p= . , unpaired t-test). background and aim based on our previous experience with radioguided occult lesion localisation (roll) in the breast, we have recently introduced similar roll method for the detection of clinically non-palpable lesions in the neck with mtclabelled macroagregates ( mtc-maa). patients and methods radioguided biopsy was performed in patients ( males and females, age - years) who had ultrasonographically proven non-palpable lesions in the neck. in these were clinically suspected to be lymphoma, in / patients with papillary thyroid carcinoma (ptc) who already had total thyroidectomy and radioiodine ablation or therapy these were suspected to be ptc lymph node metastases and in / a relaps in the thyroid bed. in patient repeated supraclavicular lymph-node biopsies were inconclusive, in another a primary ptc was cytologically suspected to be located in a thyroglossal duct cyst. the radiotracer ( mtc-maa . mbq in . ml volume) was injected intratumorally under the us guidance. all the patients underwent planar scintigraphy of the neck imediately after radiotracer application - - hours before surgery. the location of the injected radiopharmaceutical in the neck was marked on the patient's skin with a point -co source and indellible ink. injected activity, taken up by the neck lesions, was intraoperativelly detected and located with a gamma probe. in all patients scintigraphy revealed intense focal uptake in the neck. all the marked lesions were intraoperativelly easily detected with gamma probe. histopathological findings confirmed lymphoma in (follicular b-cell in , anaplastic large cell in and hodgkin's lymphoma in patient) and ptc metastases in patients. in a patient with thyroglossal cyst histopathology excluded any neoplastic infiltration. in a patient in whom repeated supraclavicular lymph node biopsies were inconclusive, a radioguided biopsy revealed a metastasis of a poorly-differentiated pancreatic adenocarcinoma. in one patient with ptc and elevated tg levels after total thyroidectomy and repeated radioiodine therapies, suspected to have a relaps in the thyroid bed, histology of a scintigraphically and intraoperativelly »hot« paratracheal lesion was negative, probably due to the fibrosis as a consequence of surgical and radioiodine therapy. conclusion our work suggests that intraoperative radioguided detection of nonpalpable lesions in the neck after mtc-maa under the us guidance is simple and accurate method. the aim of the study was to determine the reliability of the diagnostic procedure of radioguided occult lesion localization (roll) and to detect sentinel lymph nodes in occult lesion localization (snoll) using two kinds of radiopharmaceuticals. a total of female patients (mean age ), in whom mammography, breast ultrasound, and fine needle aspiration cytology detected high risk occult lesions, were enrolled in the study. material and methods: the day before surgery ( hrs) under ultrasound guidance mbq mtc-maa (from . mbq to . mbq) in a volume of . ml was injected into the center of the lesion. usually about ten minutes after radiotracer was injected, anterior and oblique scintigrafic images were acquired. the breast contour was outlined with flexible marker co and the nipples marked with point source ( am). on the day of surgery mbq of m tc-nanocolloid in a volume of . ml was subdermally injected above the marked localized breast lesion. images made twenty minutes later in anterior and anterior-oblique projection revealed a sentinel lymph node. results: in all patients scintigraphy uncovered activity in the lesions and sentinel lymph nodes. the average lesion size of . mm was detected mammographically, and of . mm with ultrasound. cytological findings confirmed invasive ductal malignant tumors in ( . %) and suspect in ( . %) patients. puncture of the suspect lesion was not performed in ( . %) patients and only one patient ( . %) had normal findings. tumerectomy was performed in all patients. patohistological findings confirmed malignant breast cancer in ( . %) patients, of which metastases in sln were detected in five ( . %). conclusion: the obtained results show that a method of choice for a safe and quick localization of the occult breast lesion and sln is the combination of simultaneous detection of the occult localized breast lesion with m tc-maa under ultrasound guidance and the detection of sln with a lymphoscintigraphic subdermal injection of mtc-nanocolloid. introduction: chyluria may present as chylous clot, chylous clot retention, hematuria, flank pain, dysuria, weakness, fever and weight loss. it is a late manifestation of filariasis, a parasitic infestation endemic in south east asia. other associated conditions include repeated retroperitoneal infection, especially tuberculosis, trauma, genitourinary or gastrointestinal tumors, malignancy of the thoracic duct and thyroid, ureteric stone, hydrocele, inguinal hernia and pregnancy. lymphangiography has been the main imaging modality in investigating chyluria, chyloperitoneum and chylothorax. however, it requires tedious cannulation of lymphatics, is invasive and is not readily reproducible. lymphoscintigraphy using m tc labeled colloid delineates the pattern of lymphatic drainage, is fast, non-traumatic and has no known side effects. we are reporting a case of chyluria developed after a spinal surgery in which lymhoscintigraphy was used to localize the lymphorenal fistula. case history: years old male who had a history of laminectomy over l -l level and after months he presented with complaint of chyluria and repeated urinary retention. on examination his vitals were normal and his cbc, lfts and serum creatinine were within normal limits. his urine reported milky in color with enormous fat and cellular component. his ultrasound abdomen revealed right renal cyst and mild prostatic enlargement. lymphoscintigram was performed with mbq ( . cc volume) of m tc labeled nannocolloid injected subcutaneously as . cc aliquot in nd and rd interdigital spaces of both feet. hr delayed whole body images revealed reduced traveling and relatively less outlined left inguinal lymph nodes, a normal flow and well outlined inguinal lymph nodes were seen in the right lower limb. there was evidence of visualization of tracer in the left kidney with appearance of para-aortic lymph nodes consistent with left sided lymphorenal fistula. a follow up cystography confirmed the appearance of chylous urine from the left ureter. patient refused surgery. discussion: chyluria is a relatively common condition is south east asia. lymphangiography has been the main imaging modality but it is invasive and requires expertise for canulation and significant radiation exposure. lymphoscintigraphy using tc- m labeled colloid is safe, non-invasive and reproducible technique and gives less radiation exposure. it is invaluable in detection of site of lymphorenal fistula and cystoscopy during active chyluria helps to determine relative severity of the involved site of urinary tract. thus these two investigations together help determine the site of operation. granulocyte-colony stimulating factor (g-csf), a hematopoietic growth factor, is widely used to accelerate recovery from neutropenia after severe chemotherapy, both decreasing the risk of infection and mobilizing peripheral blood stem cells. g-csf is commonly administrated to healthy donors to mobilize peripheral blood stem cells for allogeneic hematopoietic stem cell transplantation. adverse events from g-csf use in healthy donors been described in approximately % of cases, and are comprised predominantly of bone pain, headache, and general fatigue. pulmonary complications caused by g-csf include cough, dyspnea, and interstitial or alveolar pulmonary edema with mild-to-severe deterioration of blood oxygen level. few cases of acute respiratory distress syndrome (ards) following g-csf administration have been reported. the present study was designed to determine the pulmonary clearance rate of tc- m diethylenetriaminepentaacetic acid (tc- m dtpa) in healthy donors for allogeneic hematopoietic stem cell transplantation and the role of tc- m dtpa aerosol scintigraphy in the early detection of lung involvement. material and methods: five healthy donors ( female, male; aged ± years) were studied. tc- m dtpa aerosol inhalation scintigraphy and pulmonary function tests (pft) were performed before and after days g-csf administrations. on the basis of the scintigrams the percentage decline in activity per minute (kep) was evaluated, which represented an accurate parameter of lung membrane permeability. results: increased lung epithelial permeability was observed in all of the donors after days g-csf administrations. there was statistically significant difference between two studies ( . ± . and . ± . for left lung; . ± . and . ± . for right lung, p< . , paired t test). but no significant change was observed in pft (p> . ). conclusion: our preliminary results show that subclinical alveolitis may be present in healthy donors after g-csf administrations since it is known that an increase in the epithelial permeability of the lung is an early manifestation of interstitial disease. assessment of mean transit time in the engrafted lung with xe- lung ventilation scintigraphy improves diagnosis of bronchiolitis obliterans syndrome in living-donor lobar lung transplant recipients t. shinya , s. sato , k. kato , s. akaki , h. date , s. kanazawa ; okayama kyokuto hospital, okayama-city, japan, okayama university medical school, okayama-city, japan. aim: staging of bronchiolitis obliterans syndrome (bos) after lung transplantation is based on declines in forced expiratory volume in s (fev ). use of computed tomography (ct) has been described for early detection of bos. the aim of this study was to evaluate the usefulness of xe ventilation scintigraphy in early detection of bos after living-donor lobar lung transplantation (ldllt) and to compare xe wahout imaging with ct finging for early detection of bos after ldllt. material and methods: subjects comprised double-lung recipients and single-lung recipient, who had undergone ldllt at our institution and survived > year. clinically diagnosed bos developed in recipients. declines in graft function were evaluated using a combination of methods: dynamic spirometry; computed tomography; and xe ventilation scintigraphy. findings for all transplanted lungs were compared between ct and xe washout imaging. assessment of xe washout was assessed using mean transit time (mtt) of bi-and unilateral lungs. correlations between mtt of bilateral lungs and fev % were evaluated. differences between mtt of bos and non-bos lungs and between mtt of non-bos and donor lungs were also evaluated on bi-and unilateral lungs, respectively. an appropriate cut-off value for mtt of bi-and unilateral lungs was set for the diagnosis of bos. results: in all bos cases, prolonged-washout images of engrafted lungs revealed early-phase bos with declines from baseline fev , while only bos case could be detected using ct. a significant correlation was identified between mtt and fev % (r=- . , p< . ). mtt of bi-and unilateral lungs was significantly longer in bos lungs than in non-bos lungs (p< . ). the cut-off mtt for bi-and unilateral lungs for diagnosis of bos were set at . s and . s.conclusion: our data show that xe washout imaging offers excellent potential for early detection of bos compared to early ct findings. using xe washout imaging and mtt with radioactive tracer offers a non-invasive indication of selective ventilatory function in grafted lungs after ldllt. mtt appears useful for identifying bos after ldllt and allows evaluation of graft function in bi-and unilateral lungs. pet and ct evaluate of pulmonary nodules in an integrated pet/ct system w. s. huang , c. y. cheng , c. y. chang , c. s. liu , c. h. ku , j. k. lee ; department of nuclear medicine, tri-service general hospital, taipei, taiwan;, taipei, taiwan, department of radiology, tri-service general hospital, taipei, taiwan;, taipei, taiwan, school of public health, national defense medical center, taipei, taiwan., taipei, taiwan, dept. of nm, chung shan med. univ. hosp., taichung, taiwan., taichung, taiwan. aim: the fdg pet and ct have proved useful in evaluating pulmonary lesions. this study was performed to compare the respectively diagnostic power of pet and ct in the evaluation of single pulmonary nodules (spn). material and methods: a total of patients with spn and without previous history of malignancy were analyzed. of them, with known spn, the other were accidentally found from a physical check-up. both pet and ct images were independently interpreted and were graded by the -point scales as described (radiology ; : ) . equivocal pet and ct image (grade ) were dealt with conditions: ) dropped, ) regrouped in to positive results or ) regrouped into negative results. malignant diagnosis was based on histological findings or a clinical/ radiological follow-up at least m. four comparisons were applied to assess the performance including ) ct; ) pet; ) test in parallel (ct or pet positive); and ) test in series (ct and pet positive). we used student's t test for univariate continuous variables and the test for categorical variables and fisher's exact test whenever the expected value for at least one cell was < (sas version . , cary, nc). receiver operating characteristic curves were applied to calculate the areas under the curves of interest and for comparisons (medcalc version , mariakerke, belgium). results: pet yields equivocal results, of them had negative ct that turned out to be benign lesions. the other patients had both equivocal pet and ct and two of them proved to be malignant. ct revealed equivocal results, were confirmed by pet as malignancy, the other were benign. out of the ct equivocal lesions turned out to be malignant. conclusion: pet and ct play synergic role in the combined pet/ct scanner. fdg pet produced less equivocal lesions. combining interpretation of both pet and ct information helps resolve more than half of equivocal lesions. key words: f-fdg; pet/ct; single pulmonary nodules running title: pet/ct in pulmonary nodules aim: to evaluate the situation of the work-up of patients with suspected pulmonary embolism at the national level especially in relation to the use of new diagnostic methods. method: we used a questionnaire send to all nuclear medicine departments in the czech republic. questions were selected to evaluate the methodology of the lung scintigraphy from the aspect of performance, results description, use of criteria and several time and quantitative parameters. we also asked about some concomitant and concurrent examinations. results: / ( %) departments filled in and returned the questionnaire. as to methodology, the planar images ( or to views) are mostly used; only departments perform only spect. lung perfusion scintigraphy is available only during working hours on working days; only in department also on weekends. ventilation scintigraphy is performed only selectively. in the assessment of images, mostly standardized criteria in combination with any own are used (predominantly modified pioped). radionuclide venography is performed on all but departments, thrombi imaging is not available at all. the number of perfusion scans declined yearly about %, ventilation scans increased about % and venography declined about % between years and . ct scanners with less than slices are mostly available for ct angiography. conclusion: the main drawback of lung scintigraphy is its time unavailability and predominance of planar imaging. the increase of ventilation scintigraphy could be done by the effort to increase specificity. the decline of perfusion scans is not significant, although it could be done by the low quality of ct scanners. long lasting exposure to toluene that is commonly used in automobile and spray paints, may cause in occupational asthma. in this study, we aimed to investigate the effect of toluene on tc- m clearance rate of alveolar epithelium and on spirometric lung function tests in auto painters who exposed to toluene at least for ten years. twenty-eight autopainters with a mean age of . ± . years and a healthy group with a mean age . ± . were included in the study. tc- m dtpa aerosol inhalation scintigraphy, and spirometric lung function test was administered to all subjects. clearance half time (t½) and penetration index (pi) on the first minute image after tc- m dtpa scintigraphy were calculated. t½ and pi values were ( . ± . and . ± . ) for painters, and ( . ± . and . ± . ) for healthy group, respectively (p= . , p= . ). there was a negative correlation between mean t½ and %fvc, %fev values (p= . , p= . , respectively). whereas, a positive correlation was observed between mean pi and fev /fvc, %fef - (p= . , p= . ). comparison of pef values between painters ( . ± . ) and healthy subjects ( . ± . ) yielded significantly different results (p= . ). however, t / and pi did not correlate with pef. in painters group, t½ and pi significantly differed when painters with obstruction ( . ± . , . ± . ; respectively) compared with painters who did not have obstruction ( . ± . , and . ± . ; respectively) (p= . , p= . , respectively). toluene exposure duration did not show a relationship with t½, pi and sft. our results indicate that toluene exposure affects bronco alveolar permeability and may cause obstructive changes that might be demonstrated by sft. however, we could not detect any relationship of toluene exposure duration with any parameter. to show if toluene exposure duration has any affect on occupational asthma development further studies are needed. technetium labeled human polyclonal immunoglobulin g ( mtc-hig) scintigraphy in the early detection of pulmonary involvement in connective tissue diseases (ctd) considering analgesics as the first option. if these fail, other therapeutic options can be considered, including metabolic radiotherapy with sm as the greatest exponent. aim: evaluate sm treatment response in patients with painful bone metastases. material and methods: we studied patients ( men; women) with ages between and years old (with a mean age of . years) with painful bone metastases resistant to analgesic therapy. mbq/kg of sm were administrated intravenously. each patient remained hospitalized for hours in our nuclear medicine unit in a room, conditioned for metabolic radiotherapy treatments. pain was evaluated following a visual scale before and after treatment (considering: total response: improvement > points; partial response: improvement - points; no response: improvement points). results: in out of patients ( %) an effective therapeutical response was observed. of these effective responses ( %) showed a total pain disappearance, while in the remaining ( %) the pain was partially soothed. the therapy was repeated in patients, obtaining an efficient response, similar to the previous one. treatment was effective for to weeks (average: . weeks). no response was observed in out of patients ( %), including patients who suffered sudden-deaths in where the response could not be evaluated. conclusions: treatment using sm may result effective in painful bone metastases resistant to analgesic therapy. if the symptoms reappear, a new dose would achieve equally satisfying results. accurate interpretation of fdg-pet images requires optimal knowledge of the normal distribution of the tracer in various anatomical structures. this distribution may change due to age, gender, and physiologic conditions. our aim was to assess cervical spinal cord fdg-pet uptake as a function of age and gender. methods: head and neck fdg-pet images of subjects were retrospectively assessed ( male, female; age: - years). the subjects had undergone head and neck fdg-pet imaging for a variety of reasons. the subjects did not have any evidence of fdg uptake which could interfere with measurement of spinal cord uptake. the subjects had no previous history of chemotherapy and radiation therapy. fdg uptake in the cervical spinal cord was visually evaluated. mean and maximum standardized uptake values (suvs) of cervical spinal cord were calculated for all subjects with visible spinal cord uptake. subjects were separated into three age groups, each consisting of two decades, and into two groups based on gender. one way anova and t tests were used for statistical analysis to calculate the differences of mean and maximum values for age groups and for gender. results: amongst subjects, had visible cervical spinal cord fdg uptake. three did not have visible cervical spinal cord uptake. the mean suv ranged from . - . , the maximum suv ranged from . - . . averages and standard deviations (sd) of the mean and maximum suvs for age groups from the youngest to the oldest were . ± . , . ± . , . ± . , and . ± . , . ± . , and . ± . , respectively . averages and sd of the mean and maximum suvs for men were . ± . and . ± . , respectively, and . ± . and . ± . , respectively, for women. there were no statistically significant differences between the mean and maximum suvs amongst age groups or between genders. conclusion: these preliminary data show that fdg uptake within the normal cervical spinal cord is not affected due to aging or gender. further studies are required to confirm our results and to determine the significance of this observation in normal and pathological states. fusion of near-isotropic spiral ct to d nuclear medicine data to improve the accuracy of roi delineation in hepatobiliary and renal imaging b. corcoran, m. carroll, m. buxton-thomas; king's college hospital, london, united kingdom. objective in dynamic planar hepatobiliary imaging of auxiliary liver transplants and both dynamic and static renal imaging, regions of interest (roi) are used to generate time activity curves (tac) and to calculate the relative function of two organs. on the hepatobiliary image it is often difficult to differentiate the native and transplant livers. in both static and dynamic renal imaging, the edges of poorly functioning kidneys are often difficult to identify. the advent of high resolution spiral ct, available through pacs connectivity, now allows near-isotropic quality orthogonal images to be reconstructed. we use the coronal anatomical data to improve the delineation of the organs. fusing the coronal data to nuclear medicine imaging allows the more accurate rois to be applied in generating the tac and the calculation of physiological divided function. method for calculation of divided function from the dynamic data a composite image of the uptake phase is created. on a hermes workstation, orthogonal coronal sections are generated from high resolution spiral ct (transverse slice width = . mm, slice separation = . mm). a coronal section through the liver is chosen which clearly shows the division between the native and transplant. the summed ct image is fused, using mutual information rigid transformations, to the composite nm image. accurate rois drawn on the ct image are then applied to the nm image and divided function is calculated from the relative regional counts. result the method was applied to several patients undergoing sequential post-transplant hepatobiliary imaging ( mtc-ida) where spiral ct of the liver was available. the ct data provided greater confidence in differentiating the two functional regions of native and transplant liver. the method has also been applied to the deconvolution analysis of renograms ( mtc-mag ) and static renal scans ( mtc-dmsa). conclusion in hepatobiliary investigations for monitoring liver transplants, coronal images generated from spiral ct can be used to improve roi delineation in the calculation of relative function between native and auxiliary liver regions. the method has also been shown to have a useful application in the renal imaging of poorly functioning kidneys. with promising results from ongoing clinical trials, alpharadin™ (ra- ) looks destined to become commonplace in nuclear medicine. this paper aims to introduce the radiation protection requirements with ra- to those less familiar in working with short-lived alpha emitters and dispel some common misconceptions. traditional teaching of radiation protection has focussed on beta-and gamma-emitting radiation due to their more common application, ease of detection and less stringent regulations for handling open radioactive sources in the laboratory. as such, alpha-emitting radionuclides have traditionally been confined to research or use in sealed sources. in some countries, alpha emitters have developed an unwarranted reputation as a dangerous form of radiation. it is important to emphasise that alpha radiation only poses a radiation risk when long-lived alpha-emitting radionuclides become incorporated into the body and irradiate a small area of tissue for a long period. outside of the body, there is a much lower risk when working with alpha radiation compared to beta radiation and working procedures are often simpler. alpharadin™ is an alpha-emitting radiopharmaceutical in clinical development for tumour therapy and pain palliation in patients with skeletal bone metastasis. the alpha emitter ra- does not have inherent properties that make it a dangerous radionuclide. on the contrary, radiation protection parameters for alpharadin™ offer some significant advantages when compared to traditional beta emitters (table ). comparison of radiation protection parameters for ra- , sm- and sr- aim the purpose of this study was to analyse the radiation emergency triage, treatment and hospital protection procedures in london after the contamination of alexander v. litvinenko with the polonium in london . identifying strengths and weaknesses allowed us to draw conclusions for improved future radiation emergency management (rem) strategies particularily for hospitals. materials we researched numerous public documents and conducted interviews with medical professionals at various hospitals involved in the case. methods we reconstructed the sequence of emergency management procedures such as triage and the treatment of the patient as well as radiation protection measurements taken. we then identified key characteristics and compared them with typical hospital rem procedures for radiation victims. furthermore, we then analysed the results in the light of radiation mass casualties to detect the weaknesses of current disaster management concepts. results the medical effects of internal contamination with the radioactive isotope polonium was not immediately diagnosed. a treatment plan was applied rather late. the single case allowed an intensive care with technical resources and a number of medical professionals to diagnose the patient which would have been impossible if the number of casualties was higher. the psychological effects of the radiological contamination remained rather unclear. the patient died a few weeks later. the received dose and exact cause of his death (radiation vs. toxicity in particular) are still disputed. conclusion our research shows that the contamination with radioactive isotopes in general still remains a very unusual challenge for medical professionals. even specialist hospitals confronted with cases of radiation poisoning are quickly taken to the limits of their diagnostic and treatment capacity. only the concentration of medical specialists and the intense usage of resources could eventually help to diagnose the illness. we can conclude that other non-specialist hospitals would perform rather inadequately if confronted with the same case and much worse if there were more casualties of that kind. future improved emergency management strategies will strongly rely on adequate, continuous and specialised training of hospital staff, appropriate equipment as well as communication and triage among hospitals. aim: the aim of this study is to evaluate the efficiency of the radiation protection program of a department of nuclear medicine equipped with a pet and therapy units. material and method: the department has a workplace monitoring system. we calculate the mean dose of the radiation exposure levels that the workers were submitted in each part of the department and compare with the whole body dosimetry, during one year. the workplace monitoring system is a tam radiation meter system from tema sinergy, italy and consists on eight geiger-muller detectors with a dose rate range between , μsv/h and , sv/h and an energy sensitivity from kev to mev. the whole-body dosimeters are tld. the eight detectors are installed in: radiopharmacy, waiting room for accompanying persons, waiting room for injected patients (at two points), room for injected patients, pet radiopharmacy, pet command room, and waiting room for pts injected with f-fdg. the monitoring data of each main area is compiled in a hour database. results: the monitoring results, in each area per year were: conclusions: when compared with each other, we conclude that the results match: the mean dose in the main areas where the workers usually are and the whole body values. the mean dose for the area monitoring system was , msv/year and the mean dose for the whole body dosimetry was , msv/year. these results are in the scope of the national legislation and the european regulation of radiation protection and are demonstrative that we are working in good conditions of radiation protection. since several years, our department of nuclear medicine works with the department of haematology in the field of radioimmunotherapy of non hodgkin lymphomas using antibodies (anti cd zevalin® schering-bayer, anti cd immunomedics) labelled with high activities of yttrium (y ) (cis bio international and nordion). the manipulation of such activities of a ß-emitter can induce a great exposure of the hands of the personnel when appropriate radioprotection procedures are not applied. at the beginning, we used the radioprotection material present in our laboratory, but with increasing experience we added some improvements in our practice: -use of a shielded suit -use of an electric infusion pump for zevalin® administration -use of radiation attenuating gloves for ß-emitters -use of a radioprotection kit in polymethyl-methacrylate (pmma) supplying by schering-bayer -local production of a pmma protection box for the perfusion of the anti cd . material and methods: *in , an electronic dosimeter was placed under the gloves at the palm of one hand of the radiopharmacist during these steps. *in , more precise studies were made with tld chips placed at the palm and at the extremities of the thumb and the index. day, and is a minimally necessary criterion of agencies that accredit nuclear medicine laboratories. tracking trends in daily qc on a monthly basis is helpful in detecting developing camera problems, which if addressed in a timely manner, will avoid unnecessary unscheduled camera downtime and maintain image quality. increasingly, the environment in which hospitals and clinics operate is through consortiums, which, by virtue of their design, necessitate the development of standardized, uniform means of detecting and documenting problems and methods of solving these problems. we have implemented algorithms written in a version of visual basic on commercial nuclear medicine computers to analyze intrinsic and extrinsic flood uniformity values for a wide range of gamma camera models from various manufacturers. these algorithms use data transmitted via ethernet among sites using the dicom standard. computed parameters include integral and differential uniformity values for full field of view and central field of view regions of interest, which are generated automatically and are tailored to each detector type. output values are stored automatically in ascii files, which are updated each time the analysis programs are run. the display format of flood fields is adjusted automatically for as few as up to as many as simultaneously displayed individually normalized flood fields for flexibility of recording floods on film. algorithms written in mathcad (mathsoft, inc.) further analyze the resultant ascii files, segregating uniformity values for each detector of each camera in groups of monthly values, deleting duplicate records, plotting uniformity versus date curves, identifying values that exceed predetermined action levels and tabulating the number of times a detector does not meet standard criteria, prompting required attention for uniformity problems. a microsoft word file is generated automatically as a permanent record. these sets of algorithms have been instrumental in providing an ongoing method of guaranteeing standardized high quality imaging at different sites and facilitating certification by accreditation organizations. aim: to fully implement alternative services that internet offers to the easy transfer of complete patients' examinations. prosperity of easy interchange in every day practice of nuclear medicine found its application through the internet media. we use a simple and safe way to interchange images and diagnostic information between the scintigraphic acquisition and processing location and the clinical department in order to improve patient's health care and young doctors' education. we present our experience in transferring patient data, spect slices, d spect images in video (movies) form and animation display to medical specialists. materials and method: images and patient reports are transferred and saved through dedicated software to a workstation that transform gamma-camera scintigraphic images in a pc readable format. the data are transferred to the local server pc via a local area network -in which the medical system computer is also included-and are modified by procyon starlab ge software to bmp type image files. spect slices and/or d processed spect images as well as dynamic or gated studies can be send to the connected pc. medical record data are combined with the images and movies in a hypertext file that can be sent as an attachment via an e-mailer functioning under windows environment. the receiver side should be equipped with a similar e-mailer and can view or print patient's set of images and data through a suitable browser. the mailed series of images are characterised by diagnostic quality analogous to that of the original sets that someone can see as simple series or in a cine form of tomographic slices, dynamic studies and d images in a gamma camera. results:transfer via e-mail has been used in our center for the exchange of complete studies including data, images and movies to and from our colleagues when particular patients are concerned. furthermore, both patients' files and educational files can be downloaded, from our department ftp location, by a unique password. conclusion: a full patient template transfer enables the archiving of particular files from the authors' institute database ensuring the security desired and it has been proven to be a quick and safe mean of exchange of dynamic set of nuclear medicine information between physicians and scientific centers. usual www connection gives the possibility of patients' data transfer as well as interchange of relative comments towards both directions. cost effective solution has been achieved using standard hard-and software. picture archiving and communications system: a convenient connecting point between nuclear medicine and radiology for higher specifity k. f. wurm, m. zobel, b. clewing; department of radiology and nuclear medicine, göppingen, germany. aim: picture archiving and communication system (pacs) has become an important component of many radiological departments. the major benefit of pacs based on its ability to communicate images and reports to different physicians in a short and common modality. the aim of our study was to create the benefit for nuclear medicine results using pacs as the connecting point to additional radiological images. material and methods: in a period of months we investigated patients with different bone lesions, metastases and inflammatory deseases. all patients underwent bone scintigraphy with mtc-hdp. all images were evaluated and adjudged. in a second view the additional informations of radiological issues using pacs were documented. results: / patients presented an area with increased focal activity in bone scintigraphy. using the early pictures after min. additional pathological results could be detected. in correlation with radiological images using pacs cases are documented as an unambiguous benign lesion, previously adjudged as a suspected area. / cases were adjudged as a benign lesion, however using pacs pathological lesion were documented. conclusion: the progressive spread of picture archiving and communication system (pacs) in medical imaging constitutes some of the most common changes in the radiological and hospital activities during the last decade. using pacs as the connection point between radiological and nuclear medicine images both department have a benefit and the numbers of false positive/false negative results are reduced. pacs creates a synergy that will be otherwise only realized using spect/spiral-ct hyprid imaging. uptake of technetium- mdimercaptosuccinic acid in cats e. vandermeulen , a. dobbeleir , h. ham , a. piepsz , t. waelbers , s. vermeire , k. peremans ; department of medical imaging of domestic animals, faculty of veterinary medicine, ghent university, ghent, belgium, department of nuclear medicine, university hospital, ghent, belgium, saint-pierre hospital, brussels, belgium, department of medicine and clinical biology of small animals, faculty of veterinary medicine, ghent university, ghent, belgium. aim: the purpose of this study was to calculate the fractional uptake (fu) of technetium- m dimercaptosuccinic acid (tc m -dmsa) in cats at , and hours and to test the influence of prone compared to supine positioning on the fu due to flexible kidney position in cats. material and methods: a total of cats were injected with a mean dose of , mbq tc m-dmsa. the cats were anesthetized (induction with propofol, maintenance with isoflurane on oxygen) and anterior and posterior images were acquired in prone position at , and hours after injection. rois were placed over the kidneys and the geometric mean kidney activities calculated. additionally, a second anterior and posterior view was acquired with a calibrated source positioned between the kidneys. the calibrated source activity was obtained by substraction of the activities in a large roi on both anterior views. this was repeated for the posterior views, and the geometric mean of the calibrated source was calculated. from the posterior and geometric mean activity, the attenuation correction value can be calculated. the kidney uptake was calculated from the geometric mean of kidney counts and the attenuation value. after decay correction the uptake was expressed as a fraction of the injected dose (fu). in cats these tests were repeated in the supine position. results: the mean values of fu in cats scanned in prone position were . ± . for the left kidney and . ± . for the right kidney at hours. fu values at and hours were respectively . ± . , . ± . for the left kidney, . ± . and . ± . for the right. in supine compared to prone position, a small but systematic lower fu was observed: the difference being . at hours, . at hours and . at hours. conclusion: fractional uptake of mtc-dmsa can be calculated up to hours. a small uptake increase is observed over time. using the method of geometric mean minor differences were obtained in prone and supine position. this difference decreases at h, which might indicate a higher background contribution in prone position. organotypic slice cultures (osc) of human brain specimens represent an intriguing experi-mental model for translational studies addressing, e.g., stem cell transplantation in neurodegenerative diseases or targeting invasion by malignant glioma ex vivo. however, long-term viability and phenomena of structural reorganization of human osc remain to be further characterized. here, we report the use of the positron emission tomographic radiopharmaceutical f- -deoxyglucose (fdg) for evaluating the viability of brain slice preparations obtained either from postnatal rats or human hippocampal specimens. anatomically well preserved human hippocampi obtained from epilepsy surgery (n = ) and rat hippocampus slice cultures obtained from six day old wistar rats (n = ) were dissected into μm horizontal slices using a vibratome. all slices where placed onto interphase nylon culture plate inserts, subsequently transferred into six-well culture dishes containing . ml of culture medium and kept in a humidified atmosphere at °c and % co for at least days. the slices were incubated with - mbq fdg in phosphate buffered saline up to h, either with or without supplementation of glucose at a concentration of . mg/ml. radioactivity within the medium or slice cultures was measured using a gamma-counter. in addition, distribution of radioactivity was autoradiographically visualized and quantified as counts per mm tissue per mbq fdg (cd) for the whole slice. all experiments were carried out at least in triplicate. in rat hip-pocampal slices, fdg accumulated over minutes with a doubling time of approximately minutes and reached , , ± , counts/mm , whereas the incorporation of the radioactive label in human slices was in the order of , , ± , counts/ mm . the elevation of glucose concentration within the medium led to a significant three-fold decrease of fdg accumulation in rat slices and to a . -fold decrease in human specimens. in conclusion, fdg specifically accumulated in organotypic brain cultures of human or rodent origin. fdg is thus suited to investigate the viability of osc. furthermore, these preparations open new avenues to study the factors governing cerebral fdg uptake in normal and diseased brain tissue ex vivo. changes in metabolism and gene expression in hepatomas expressing antiangiogenic genes u. haberkorn , j. hoffend , a. altmann , k. schmidt , a. dimitrakopoulou-strauss , l. strauss , m. eisenhut , r. kinscherf ; purpose: human troponin i (trop), the soluble receptor for vascular endothelial growth factor (sflt) and angiostatin (astat) are potent inhibitors of endothelial cell proliferation, angiogenesis and tumor growth in vivo. transfer of these genes into tumors may induce changes not only in perfusion, but also more general ones such as changes in metabolism. experimental design: after generation of morris hepatoma (mh a) cell lines expressing trop, sflt or astat we quantified ffluorodeoxyglucose ( fdg) uptake by dynamic positron emission tomography (pet) after tumor inoculation in aci rats. furthermore, expression of glucose transporter- and (glut- ; glut- ) as well as hexokinase- and - were investigated by rt-pcr and immunohistomorphometry. in addition, changes in gene expression were measured using gene arrays. results: fdg uptake, vascular fraction and distribution volume were significantly higher in all genetically modified tumors. immunohistomorphometry showed an increased percentage of hexokinase- and - as well as glut- and - immunoreactive (ir) cells. using gene arrays and comparing all three groups of genetically modified tumors, we found changes in expression of genes related to apoptosis, signal transduction, stress or metabolism. conclusions: trop, sflt or astat expressing mh a tumors show enhanced influx of fdg, which is caused to several factors: enhanced exchange of nutrients between blood and tumor, increased amounts of glucose transporters and hexokinases and increased expression of genes related to apoptosis, matrix and stress which induce an increased demand for glucose. a. altmann , k. schmidt , j. hoffend , a. dimitrakopoulou-strauss , l. strauss , m. eisenhut , r. kinscherf , u. haberkorn ; university hospital, heidelberg, germany, dkfz, heidelberg, germany. purpose: growth of malignant tumors is dependent on sufficient blood supply. thus, inhibition of tumor angiogenesis is emerging as promising target in treatment of malignancies. human calreticulin (hcret) is a potent inhibitor of basic fibroblast growth factor (bfgf)-induced endothelial cell proliferation in vitro and bfgf-induced angiogenesis and tumor growth in vivo. experimental design: to obtain more information about functional changes in the angiogenic process we established morris hepatoma (mh a) cell lines expressing hcret (hcret-mh a). the effects of hcret expression on proliferation and apoptosis of human umbilical vein endothelial cells (huvecs) were measured in co-culture experiments in vitro. to evaluate changes in tumor perfusion h o was used for positron emission tomography studies in vivo. additionally, immunohistological quantification of vascularization, apoptosis and proliferation as well as gene array analyses were performed. results: the in vitro experiments demonstrate reduced proliferation and increased apoptosis in huvecs when being co-cultured with mhhcret cells. in support, tumor growth of mhhcret is diminished in vivo together with a reduction in pcna staining and an increase in apoptosis as determined by immunohistology. however, tumor perfusion and blood volume are increased in hcret-mh a corresponding to an increased microvessel density. furthermore, hcret-transfected tumors show changes in expression of genes related to angiogenesis, apoptosis, stress, signal-transduction and metabolism. conclusions: hcret expression leads to inhibition of tumor growth, increased apoptosis and changes in the expression of multiple genes involved in angiogenesis, stress reactions, signal transduction and apoptosis which indicates a multifactorial reaction of tumors. an enhanced microvessel density is seen as part of these reactions and is associated with increased perfusion as measured by pet. aims progressive improvement in the noninvasive imaging of different tumor associated antigens has lead to study a series of pancarcinoma radioligands. among them, monoclonal (radio) antibodies for cell adhesion molecule integrin v occurring on both the tumor and endothelial cells that line tumor infiltrating blood vessels has recently gained widespread support from preclinical trials in our laboratories. in this study, this effort continues by applying iodine ( i)-labeled monoclonal antibody to visualize and quantify the subunit of integrin v in three histologically different types of murine tumors. material and methods monoclonal antibody anti-cd ( c .g ) against the subunit of the integrin v was directly labeled with i using a standard iodogen method. the radiochemical purity of the resulting mab- i of % was achieved in a reaction time just after the iodination, and . and . %, respectively after and hr post-labeling. the diagnostic value of the mab- i radiotracer was elucidated by planar scintigraphic imaging followed by quantification of the tumor integrin subunit level in male c bl/ , c h and balb/c mice wk after s.c. inoculation of the syngeneic lewis lung (llc), breast or sarcoma (l ) murine cancers, respectively. the imaging and biodistribution studies of the mab- i radiotracer were done hr after a single intravenous injection of to μg mab- i in tumor-bearing mice. results the transplanted tumors expressing the subunit of the integrin v were visualized on the scintigraphic images of all the examined murine tumor experimental models. on the images the liver and kidneys and the bladder were also the organs with the highest activity levels, illuminating the renal excretion pattern of the radiolabeled tracer. muscle, brain and skin tissues had relatively low activity uptake. biodistribution analysis, studied hr after μg mab- i injection, revealed a quite similar profile of the tumor-to-muscle count ratio (t/m) of . ; . and . for llc, breast and l tumors, respectively. the tumor-to-non tumor ratio (t/nt) for selected organs was increased with increasing the radiotracer dose up to μg. the binding potential extrapolated from the graphical analysis of scintigraphic data correlated well with the biodistribution studies. conclusion the present study showed that the radiolabeled monoclonal antibody, mab- i that binds to the subunit of the v integrin, is able to target and image murine tumor tissues independently of their histological origin. phage display for the identification of a hepatoma binding peptide t. prenzel , a. altmann , w. mier , s. krämer , m. eisenhut , u. haberkorn ; university hospital, heidelberg, germany, dkfz, heidelberg, germany. hepatocellular carcinoma (hcc) is usually diagnosed at a late stage and has a high recurrence rate after resection. increasing the concentration of chemotherapeutics in a carcinoma and thus lowering the side effects for the organism is a problem in the diagnosis and therapy of hcc. a prerequisite for a specific accumulation in the tumour are molecules with a high binding affinity for tumour cells. due to their small size peptides are very useful tracers showing easy penetration into tumor tissues. the aim of this work was the identification of peptides with high affinity for hepatoma cells using different selection conditions. methods: we used a amino acid phage display library to identify hepatoma specific peptides. this libraray was exposed to hepg cells. six peptides with the selected amino acid sequences were synthesized by solid phase peptide synthesis and radiolabelled with radioactive iodine. the properties of these peptides were evaluated by in vitro binding experiments. furthermore, a biodistribution study was performed in tumor bearing mice. results: five of the six peptides showed low binding to hcc cells. the linear peptide e with positive binding was investigated by further studies. in in vitro binding experiments these cells showed the highest peptide binding rate after ten minutes with no evidence of internalization. competition experiments demonstrated that binding of i- -e was reduced by the addition of unlabeled peptide. e binds weakly to huh cells and primary human hepatocytes. the half life determined in human serum was more than one hour. peptide degradation products were isolated and characterized by mass spectrometry. we assume a a rapid deiodation and breakage of ammonium early after incubation start. biodistribution studies of e in balb/c nu/nu mice carrying hepg tumours revealed a two-fold higher e accumulation in the tumour as compared to the liver. conclusions: the peptide e showed some properties that make it a possible carrier for liver cancer imaging or the delivery of isotopes or drugs to hepatocellular carcinomas. further investigations will be necessary in order to characterise the value of e and its derivatives. purpose: histone deacetylase (hdac) inhibitors trigger differentiation, decrease cell proliferation and induce apoptosis in tumor cells. furthermore, they seem to act selectively to alter transcription of fewer than % of expressed genes. suberoylanilide hydroxamic acid (saha) is a new hdac inhibitor used in phase i/ii clinical trials. in order to determine whether there is preferential tumor accumulation of saha we studied the uptake of the drug in sensitive tumor cell lines. experimental design: after labelling of saha with iodide a mtt assay was done to assess the effects of iodination on therapeutic efficacy in different tumor cell lines (thyroid carcinoma, hepatoma, colon carcinoma). therefafter, uptake, competition and efflux studies were done using i- labeled saha. finally, a biodistribution study was performed in tumor bearing mice. results: iodinated saha analogs showed equal toxicity as compared to unmodified saha. the uptake of i- -saha was time dependent with a plateau at h and was inhibited by the presence of unlabeled saha with ic values around nm. furthermore, a rapid efflux was observed with a % decrease of intracellular activity after minutes. the biodistribution study showed high accumulation in liver and kidney and a moderate accumulation in the tumor. also a rapid washout was seen with . %id/g and . %id/g in the tumor at h and h after tracer administration, respectively. the tumor to organ ratios were highest for brain and for for h and h) and muscle ( . and . for h and h). conclusions: iodinated saha showed rapid efflux and no preferential tumor accumulation. for therapeutic activity tumor selective uptake may be not a necessary condition. rather low amounts of the drug seem to be sufficient to change the balance between acetylated and non-acetylated histones in a manner that leads to differentiation, inhibition of proliferation and apoptosis. radiolabeling and biodistribution of pkf - , an inhibitor of the wnt signalling pathway u. haberkorn , w. mier , m. eisenhut , b. beijer , a. altmann ; univ.hosp., heidelberg, germany, dkfz, heidelberg, germany. the wnt signalling pathway plays key roles in cell fate specification, cns patterning and control of asymmetric cell division. constitutive wnt signalling is observed in many tumors including colorectal carcinoma where > % have an activating mutation of the wnt canonical pathway leading to an accumulation of beta-catenin. the binding of beta-catenin to tcf represents a promising target for therapy and could be used for imaging of the wnt signalling pathway. methods: after labeling of pkf - , a small molecule interfering with the beta-catenin/tcf interaction, with i- we performed uptake studies in vitro using two human anaplastic thyroid carcinoma (c and sw ) and two human colon carcinoma (hct and caco ) cell lines. efflux experiments were done with sw and hct cells. finally a biodistribution study with i- -pkf - was performed in tumor bearing mice. results: we observed a time dependent uptake with a plateau after h incubation with a higher uptake in the thyroid carcinoma cell lines as compared to the colorectal carcinoma cells. no significant efflux was seen during the first minutes after incubation of the tumor cells. the biodistribution study revealed different values with %id/g for sw tumors and . %id/g for hct tumors at h after tracer administration. this uptake was followed by a decrease in activity with %id/g and . %id/g at h and h for sw and . %id/g and . %id/g at h and h for hct . tumor-to blood ratios at h were for brain, . for muscle and . for liver at h for sw tumors. these remained stable until h. similar data were obtained for hct tumors. conclusions: iodinated pkf - may be used as a tracer for the visualization of wnt signalling. however, at present its exact binding site -beta-catenin, tcf or the complex of both -remains to be elucidated. preparation and in vitro evaluation of mtc-hyniclactadherin as a potential radioligand for apoptosis detection studied. they were divided into three groups randomly: ason, son and asonblocked group. pcna ason and son were both radiolabeled with m tc after being coupled with hynic and were injected to the former groups respectively, and the latter were given unlabeled ason before the injection of m tc -hynic-pcna ason as control. then scintigraphy experiments were performed on all the objects. after the last imaging session, the animals in the first group were sacrificed and their aortic arteries were removed for ex-vivo scan. moreover, the arteries were dissected into segments for well counting, pathological examinations and pcna staining. results: abdominal aortas of all the rabbits could be seen soon after the injection. however, accumulated radioactivity was observed only in the rabbits in the first group hours later, and the count ratios of the lesion to the background of the abdomen were . ± . while . ± . for vessels of the son group (p < . ) and . ± . for the blocked group (p < . ). the ex-vivo scan of the arteries revealed good correlation of tracer accumulation. the atherosclerotic lesions were predominantly of american heart association class ii. the percentages of injected dose for the plaque and non-plaque vessels were . ± . and . ± . , respectively (p < . ). the pcna index was ( . ± . ) % and ( . ± . ) %, respectively (p < . ). there is a significant correlation between these two sets of data by regression analysis(r= . , p< . ). conclusion: m tc-pcna ason scintigraphy can reveal the abnormally increased radioactivity of the lesions of the atherosclerotic arteries in rabbit model and it has potential to be used to diagnose the atherosclerosis noninvasively. objective: the aim of the study was to determine the location and range of fdg uptake in knee joint and to detect the influence of aging on fdg uptake. methods: thirty seven patients (age range - years, m and f) who had fdg pet which included lower extremities and who had no known disease of the knee joints were included. maximum standardized uptake value (suv max) was measured by placing regions of interest (roi) around the medial, lateral synovia, joint space, entire knee and patello-femoral joint in all the subjects. several roi's were placed on adjacent axial slices in the above mentioned regions of interest and average suvmax for each region of interest for both knees was calculated for all subjects. analysis of suvmax was carried out for the effects of age. the correlation of knee fdg uptake with aging was also determined. results: there is positive correlation between suvmax measurements in all knee compartments and age where the r (pearson correlation) measured . for all regions of the knee (p< . ). the most affected part of the knee by age was the medial synovium where the p value was less than . . the average suvmax ± standard deviation (sd) for medial, lateral synovia, joint space, entire knee and patello-femoral joint was . ± . , . ± . , . ± . , . ± . and . ± . respectively. conclusion: there is significant correlation between age and metabolic activity in different regions in the knee and effects of aging was noted most in the medial synovium. the increased fdg uptake in the knees with aging may be secondary to cumulative effect of weight bearing on knee joints with increasing age. the increased metabolic activity can also be secondary to inflammation associated with degenerative joint disease, the incidence of which also increases with normal aging. further studies to investigate the role of fdg-pet in aging and related disorders such as degenerative joint disease would be of further value in clarifying the nature of our finding. to increased metabolic activity. brown fat occurs often in the supra-clavicular region and the increased fdg uptake can complicate the interpretation of the pet-studies. materials and methods: a thin, -year-old girl with the diagnosis of malignant melanoma was pet/ct scanned with mbq f-fdg (intravenous injection while supine). after injection, she continued resting supine for min and was scanned min post injection. the scan showed an extremely high uptake in the brown fat. the scan was performed during the winter months where the patient was exposed to cold temperatures and a new scan was requested. three months later, a new scan was performed where a more envolved pre-scan preparation was prescribed for the day of the examination. the patient was instructed to keep warm from the time she woke up and during transportation to our pet centre. after arrival, she was kept warm, mg oral diazepam was given, and she rested supine min prior to injection of mbq f-fdg and min after. the last min she was allowed to sit, but still kept warm and the scan was performed min post injection. results: the first pet scan demonstrated a very high uptake of fdg in brown fat in the chest and neck area and the scanning could not be optimally reported. the second scan was without brown fat uptake and was clinically relevant in following the patient's illness. conclusion: planning and simple preparatory procedures like keeping warm prior and throughout the whole injection/uptake process and a comfortable room temperature are important to avoid increased fdg uptake in the brown fat. muscle relaxing medication like diazepam can be useful if the patient is nervous or agitated. fused pet/ct images aids in image interpretation and it is often possible on axial slices to differentiate between brown fat, muscle and lymph nodes. however, it is important to prevent uptake in brown fat as much as possible to avoid confusion between pathologic and physiologic activity. the -iodine whole body scintigraphy has high sensitivity for the detention of bone, lymph nodes, and pulmonary metastasis of differentiated thyroid carcinoma, in particular when acquired after the administration of therapeutical activities. but if this scintigraphic images supplies functional information, sensible and precocious, possesses, on the other hand, slight anatomic detail, not allowing to locate the source of the pathological alteration. to get an anatomic reliable reference of areas of hyperfixation of i detected in the whole body scintigraphy after therapy, it might be an advantage to have a simultaneous acquisition of bone scan with mtc-mdp and i. aim we intend to describe the technical procedure and to present some images resultant from the application of this protocol to patients with thyroidectomy, for differentiated thyroid carcinoma, for localization of focal hyperfixations detected in the i whole body scintigraphy after ablation therapy. materials and methods in the whole body scintigraphys acquired days after the administration of the therapeutical activities of i, were detected focal hyperfixations of i in the thorax that, for its localizations, could involve pulmonary or bone structures. after hours of the administration of mtc-mdp, were acquired, simultaneously in the peak of energy of the two radioisotopes, whole body scan, segmentary images of the thorax and, in some cases, thorax spect. it was used a gamma camera siemens e-cam dcr dual-head, equipped with high energy collimators. before the reconstruction of the tomographic studies, we added the corresponding plans of each isotopes. the visual analysis of the segmentary images was facilitated by the use of a software that allows to overlap the images of the two isotopes and to individually vary the brightness and contrast scales of each one of them. results the analysis of the acquired images allowed to verify that the i focal hyperfixations found in the studied patients were secondary lesions in the bone. conclusion the simultaneous acquisition of bone scintigraphy with mtc-mdp and i whole body scintigraphy, in double window of energy, with the help of a processing commercial software, allowed the anatomic localization of areas of focal hyperfixation of i, contributing for the orientation of the patients later imagiologic studies. in- labelled octreotride and spect/ct image fusion from two seoarated equipments -clinical case i. paula, t. coutinho, a. fonseca, l. pereira, l. bastos; instituto portugues oncologia, porto, portugal. aim: in- labelled octreotride (octeroscan tm ) is used for imaging somatostatin receptor expression in tumours and their metastases. precise location of the lesions is quite difficult and the spect/ct image fusion can improve accuracy and provide additional information on the anatomic location of increased uptake of octeroscan tm . this clinical case illustrates that the registration and fusion of images from independent acquisitions by spect and ct can be useful in the location of increased uptake of octeroscan tm , and shows the benefit of the resultant images when compared with the conventional whole-body spect. material and methods: we show the case of a years old female patient with suspected neuroendocrine tumour. a whole-body scan with mibg i- plus a whole body spect octeroscan tm scan (e-cam siemens) and ct images (biograph pet/ct by siemens) were acquired. the spect and ct scan were performed sequentially with perforated pmma markers with approximately mm with to mbq of tc- m, which can be seen both in transmission and emission tomographic images, attached to the skin over the bilateral iliac crests and the sternal furcula. the reconstruction of the spect and ct raw data as well as the manual registration and fusion of both sets of images was made with the syngo siemens software based in invariability of the position of the tc m markers relative to the patient body. results: whole-body scans with mibg i- were negative. first octeroscan tm whole-body scan showed only two small lesions in the upper abdomen and in the bowel. the second octeroscan tm whole-body scan and spect images showed abnormal uptake sites but only spect/ct fusion images showed the exact location of the metastases in the upper abdomen, bowel, liver, upper mediastine and a small lesion on the right breast (suspicious of breast cancer). conclusion: this case illustrates the benefit of spect/ct octeroscan tm and the usefulness of combining spect and ct images from two separated devices without a dedicated spect/ct device. we show that spect/ct fusion images has a clear advantage over conventional whole-body scan and can lead to a more precise lesion location in the case of octeroscan tm somatostatin receptor expression. the effect of activity outside the field of view in estimation of human neuroreceptor binding with pet. t. shiraishi, m. shidahara, k. tanimoto, a. ando, t. miyamoto, r. koganezawa, h. fukuda, k. watanabe; national institute of radiological sciences, chiba, japan. objectives: to estimate the binding of radioligands for neuroreceptors, quantitative analysis using dynamic pet scan data of target regions with a reference region in the brain is the traditional strategy to estimate the binding of radio-ligands for neuroreceptors. in the study estimating the binding potential (bp) of dopamine d receptor, high activities were sometimes observed in lung, liver, gallbladder, intestine and urinary bladder, as well as in the brain. those activities accumulated in the tissues outside of field of view (fov) have effect on quantification of pet scanner as noise, especially on the reference region owing to non-existence of dopamine d receptor. in this study, we analyze the effect of the activities outside of fov on bp value using d and d acquisitions. methods: pet scanning was carried out using cti-simens ecat exact hr+. we prepared the high activity ( kbq/ml) phantom used as the activity of target region and the low activity ( kbq/ml) phantom used as the activity of reference region. both of them were filled with ge- ga source, and another phantom filled with f solution ( mbq) was fixed outside of fov as the noise. after min pre-injection transmission scan, pet scans were performed with d and d modes under decaying the radio-activity outside of fov. the pet scan at decaying radio-activity outside of fov to a background was used as ideal scan. rois were placed on target and reference region, bp values were calculated with the roi values. results: the radio-activity of reference region was + . % higher compared to that of ideal scan in d mode. in d mode, by the contrast, the increase of radioactivity of reference region were + . %. as for the bp value, the decrease of bp value compared to that of ideal scan was - . % in d mode, while that of d was - . %. the coefficient of variation (cv) of bp values in d mode was obviously higher than that of d due to the radio-activity outside of fov. conclusion: based on our analysis, it is clear that the bp values were underestimated due to increase of the radio-activity outside of fov, especially in d mode. furthermore, because of radioactivity outside of fov, the bp values of d mode were varied widely, while bp value of d was stable. these results indicate that human neuroreceptor pet studies estimating bp values should use d acquisition mode to suppress the effect of radioactivity outside of fov. abstract datscan is a diagnostic tool used routinely to differentiate patients with parkinson's disease from those with essential tremor. by using iodine labelled dopamine active transporter proteins to image the pre-synaptic striatal uptake in the basal ganglia region of the brain. data suggests datscan has . % sensitivity in differentiating between parkinson's disease and essential tremor aim to investigate whether the clinical diagnosis of patients whom present with parkinson's syndromes would be affected depending on if the images were analysed using a qualitative or quantitative method. to assess the difference in the image interpretation of separate health care professionals. methods a blinded anonymous retrospective analysis of patient studies was interpreted by; . consultant radiologist . experienced clinical technologist . trainee clinical technologist the results were compared with the original clinical report by a different radiologist. each study was interpreted twice at different times, using; a) qualitative analyses of image b) quantitative analyses using proprietary software. results table n/a software references to a normal range so there is no equivocal range. a mismatch was when operators report disagreed with the original report. the qualitative data shows that of the operators are fairly comparable with the original clinical report. the radiologist had mismatched the report with original report in ( %), technologist ( %) and trainee ( %). the quantitative and qualitative results for the technologist show a large difference and are possibly due to the operators rois. the radiologist and trainee appear to have good agreement between qualitative and quantitative results. further analysis comparing the studies original report with an abnormal quantification result hence mismatch with the original report indicated radiologist ( %), technologist ( %) and trainee ( %). conclusion qualitative assessment results indicate less variability between each grade of operator and the current gold standard original report. there is a wide variability in quantification between operators and original report that is likely to represent the difference in patient roi's. this may be due to the complexity of the software but could be improved by further training. the clinical data, we studied the current situation on the exposure to fingers and efficacious measures to decrease and monitor the exposure. methods: with ned (nuclear educated dosimeter: unfors, sweden) as a semiconductor dosimeter, first, we measured energy response and direction response as sensor characteristics and then the each medical staff in the five different clinical workplaces put the dosimeter on the index finger of their dominant hands to measure the dose. the staff's details are as follows: physician who injects ri drugs into the patients, radiological technologists who extract technetium from the mo-tc generator and handle ri drugs, physician who injects f-fdg-pet drugs, pharmacists who test the fdg and radiological technologist who position the patients. results: as the energy becomes higher, the response tends to be lower. it is because the energy response is a semiconductor element. based on the result, we set a calibration constant. the direction response ended in good result except sensor-cable junction part. the finger dose of the physician who injected ri drugs was . μsv, radiological technologists handling m tc . μsv per day (consultation period days), physician who injected f-fdg-pet drugs . μsv ( cases, right finger . μsv, left finger . μsv), pharmacists who tested the fdg . μsv, and radiological technologist who positioned the patients . μsv. this dosimeter can measure a real-time finger dose easily and its high sensitivity helped us to know the exposure situation effectively. (table and ). conclusion: this dosimeter provides a simple and effective solution to radiation protection procedures and follow-up. we measured the finger doses of nuclear medicine staff in our institute this time and found that the value ended in less than the annual limit ( msv per year). but, workers who use f-fdg pet showed high exposure compared with no-pet case, and it should be considerd reduction of radiation exposure methods. introduction: the dynamic renal scintigraphy used dtpa-tc m and captopril test constitutes a process of noninvasive functional exploration for the diagnosis of rénovascular hypertension. it permits to distinguish the hypertension induced by renal arterial stenosis from the stenosis of meeting associated with a primitive arterial hypertension. case report: a years old girl, without notable pathological antecedent, developed two months before the first consultation, a severe arterial hypertension with cephalgias and buzzing in the ears. the clinical examination objectified a breath in the left lumbar pit to the auscultation. the renal angiography objectified a stenosis of infrarenal aorta due to circumferential parietal thickening associated to renal arteries stenosis more marked in the left side. the dynamic renal scintigraphy after administration of captopril highlighted a marked collapse of the rate of tracer collecting exceeding % on the left side with an increase in the time of collecting on the right side testifying to a frankly positive test prevailing on the left. a transluminal angioplasty of the left renal artery and a revascularisation surgery on the right side were carried out. the evolution was marked by an improvement of blood pressure figures, which contributed to a considerable reduction of posology of the antihypertensive treatments. discussion: the dynamic renal scintigraphy using dtpa-tc m with captopril test constitutes a noninvasive process, little irradiant for patients. its principal goal is to affirm the incrimination of the renovascular stenosis in the arterial hypertension genesis and to determine which hypertensive patients, with a renal arterial stenosis, could be treated successfully by the surgical or endoscopic revascularisation of the kidney. usefulness of oro-pharyngo-esophageal scintigraphy in the evaluation of inhalation into the tracheobronchial branch: a case report acquired image by count setting( kcnt), that scan time of mm pin hole collimator was longer than mm pin hole collimator about . times(mean time- mm: . sec, mm: . sec). thyroid images by the mm pin hole collimator was acquired within about minute except in the case of low level thyroid uptake like hypothyroidsm. we confirmed that the region of nodule was discriminated by mm hole better than mm hole through image of patient who has nodule. even if detected count value in the mm pin hole collimator was % of mm pin hole collimator in the image of patient who has nodule, nodule portion of thyroid was certainly discriminated in the mm pin hole collimator's image. we confirmed that scan time of each diseases were needed better in mm hole.(hyperthyroidism - . times, hypothyroidism - . times, goiter - . times, thyroidal nodule - . times) . conclusion although scan time is longer by using mm pin hole collimator if we adjust time and count, mm pin hole collimator image is more useful than mm pin hole collimator image. especially, it provide useful diagnostic information in pantient who has nodule. racial variations in bone scintigraphy: an original investigation r. allie, q. siraj; royal hospital haslar, portsmouth nhs trust, gosport, united kingdom. by merit of its high sensitivity for early detection of bone pathology, bone scintigraphy remains the modality of choice for investigating sports injuries. this department regularly performs bone scans on military patients referred for musculoskeletal problems for the early detection of stress fractures and other musculoskeletal pathologies. for some time we have noticed that there appears to be a difference in the bone-to-soft-tissue uptake between caucasians (whites) to afro-caribbeans (blacks). bone scans of military recruits ( males, % blacks and females, % blacks) were analysed. all subjects were injected and imaged according to departmental protocol using the same gamma camera. regions of interest were plotted over the bone and soft tissue to obtain bone-to-soft-tissue ratios. these were compared for each ethnic group. the results showed a significant statistical difference (p = . ) between the two groups. these findings were independent of gender, dose and waiting times. there was also a significant difference in respect to acquisition times (p = . ) for k counts. though many options were explored, no obvious cause could be determined for this phenomenon. more research is required to shed further light on the matter; however, the various plausible hypotheses will be discussed. aim: to learn about acute osteomyelitis as a complication in varicella and about imaging findings at different points in the course of the disease. background: acute osteomyelitis is a rare complication in varicella. to our knowledge only cases have been reported in the litterature. materials and methods: the clinical symptoms, findings and course of the disease are illustrated by patients, a boy ( months) and a girl ( years) admitted to our hospital. bone scintigraphy ( m tcmethylenediphosphonate) and radiography were performed on the first or second day after admission in both patients. mr imaging was performed in the girl the . day. radiograms and scintigrams were performed later in both patients. results: the first scintigrams showed increased activity in the distal part and slightly reduced activity in the proximal part of the right humerus in the boy, and increased activity in the left tibia metaphysis in the girl. scintigrams after days in the boy showed further increased activity in the right humerus, now affecting the whole diaphysis.scintigrams after weeks were normal in the girl. the first radiograms were negative in both patients. radiograms after days showed irregular osteolytic lesions and periostal reactions in the proximal humerus diaphysis in the boy. later radiograms showed slowly normalizing conditions. radiograms in the girl after month were normal. the mr images in the girl showed bone marrow edema in the left lateral tibia metaphysis and medial femur condyle. both patients recovered completely after adequate treatment with antibiotics. discussion: the scintigraphic findings in the boy could represent reactive hyperemia in the distal part of the humerus diaphysis and a transient reduced perfusion, before activity accumulation in the proximal diaphysis, where the infection was localized. bone scintigraphy, preferably a multiphase study, is positive in osteomyelitis within - hours after onset of symptoms, with - % sensitivity. radiographs do not show significant changes the first days, even weeks, but are necessary in the follow-up. . mr imaging allows early detection of osteomyelitis, bone marrow edema appears during the first days of infection. the sensitivity is ~ %. conclusion: acute osteomyelitis is a serious complication in varicella and should be considered in any child with pain in a limb or joint after an episode of varicella. successful treatment depends on early detection. bone scintigraphy and mr imaging are sensitive methods showing pathological changes within the first days of osteomyelitis. background/aims. circulatory and pulmonary complications are common in patients with cirrhosis and portal hypertension and some patients have gas exchange abnormalities that may progress to the hepatopulmonary syndrome (hps). the prevalence of hps is, however, variably reported from to %, but its precise relation to the liver function is poorly understood. the aims of the present study were by means of lung perfusion scintigraphy (lps) to assess the prevalence of hps in consecutive portal hypertensive cirrhotic patients in relation to patient characteristics and during a % oxygen test. methods.forty-one patients ( . ± . yrs, women and men) with alcoholic cirrhosis (child class a/b/c: / / ) entered the study. all underwent a haemodynamic investigation with the determination of splanchnic and systemic haemodynamics. all had a contrast-enhanced echocardiography (cee) and a lps performed to diagnose extrapulmonary shunt fraction (epsf) and hps. in addition, measurement of pa,o , alveolar-arterial oxygen gradient (pa-a,o ), lung diffusing capacity (dl,co) and a % oxygen test were performed. results. all patients had portal hypertension (hvpg: . ± . mmhg). five patients had a positive cee and epsf above %. three of these patients had a pa,o below . kpa giving a frequency of hps of %. the dl,co was reduced in % of the patients and correlated significantly with metabolic liver function (gec: r= . , p= . ), splanchnic haemodynamics (post-sinusoidal resistance: r=- . ,p= . ; hepatic blood flow: r= . ,p= . ), and systemic haemodynamics (central blood volume: . ,p= . ; plasma volume: . ,p= . ; blood volume: r= . ,p= . ). pa,o was reduced below . kpa in % and pa-a,o was above . kpa in % patients. pa-a,o was significantly higher in patients with positive cee, . ± . vs . ± . kpa than in those with a negative cee (p< . ). the change in pa-a,o after % oxygen inhalation was significantly reduced in child class c patients,- . ± . kpa, compared with child class a and b patients( p< . ). moreover, the change in paa,o correlated with the epsf fraction in the total patient population (r=- . , p< . ). conclusions. whereas pulmonary dysfunction in cirrhosis is frequent and relates complexly to metabolic, splanchnic and central systemic haemodynamic complications, the prevalence of patients fulfilling the criteria of hps is below % even in patients with advanced disease. lps is considered a useful contribution in the evaluation of pulmonary dysfunction in cirrhosis. aim: emboli cause ventilation/perfusion (v/p) mismatches, usually with typical triangular character. however, in the area of middle lobe and lingula they might differ in form on sagittal tomographic images. mismatches are sometimes observed only in these areas and they may cause dilemma in interpretation. we wanted to validate if these type of changes are caused by emboli or movement of lung position during first minutes, known otherwise in cardiology as "upward creep" of the heart. materials and method: before perfusion spect, consecutive patient performed two ventilation (v) spect. first and second ventilation studies were then compared with each other and v /v quotient was calculated in order to estimate changes in lung position during the first minutes. images were validated visually and quantitatively. change index was expressed as the fraction of the lung volume that had a quotient (v /v ) below . or above . . results: visual and quantitative analysis did not show significant changes in lung position due to "upward creep" that can influence false interpretation of mismatches caused by pulmonary embolism. conclusion: v/p mismatches identified in middle lobe and lingula by spect are reliable for interpretation for pulmonary embolism. correlation between ctpa and v/q scintigraphy in the diagnosis of pulmonary embolism s. rep, j. fettich; nuk.med.department, ljubljana, slovenia. introduction: a pulmonary embolism (pe) is a blockage of a pulmonary artery caused usually by an embolus. this can be diagnosed using v/q scintigraphy showing absent perfusion and normal ventilation of the affected lung segment or using ct pulmonary angiography (ctpa). in this case iodinated contrast medium is injected i.v. and pe is shown as filling defect of the affected pulmonary artery. aim: the goal of our study was to detect relationship between absent perfusion showing with v/q scintigraphy and defect of the affected pulmonary artery showing with ctpa. patients and methods: our study includes patients with ctpa positive results for pe. ctpa and v/q planar scintigraphy was performed within hours all patients. for v/q scintigraphy we used xe ( mbq) for ventilation and mtc-maa ( mbq) for perfusion in four projections. lungs were divided into anatomical lobes (upper lobes, lower lobes, middle lobe and intermediate lobe). each lobe was evaluated as having normal perfusion, ventilation/perfusion defect mismatch or match on v/q scan, and partial or total occlusion of a segmental pulmonary artery on ctpa. the results of v/q planar scintigraphy and of ctpa were compared. results: analysis of ctpa perfusion showed normal perfusion in . % lobes, partial occlusion in . % lobes and total occlusion of pulmonary artery in . % of lobes. ventilation was not successfully performed in patient ( %). in % of segments ventilation was affected. perfusion results showed absent perfusion in %, decreased perfusion in . % and in . % of lung segments the perfusion was normal. results of both methods corresponded in % and did not in %. conclusion: according to our results abnormalities corresponded in the % of segments with both methods. in % of segments disparity of the results was due to the fact that pe can be caused not only by complete but also by partial occlusion of the pulmonary artery. in % of segments the results were false positive on v/q mainly due to ventilatory changes (indeterminate v/q results). in % of segments v/q results were false negative most probably due to better resolution of ctpa as compared with scintigraphy. asynchronous appearance of double parathyroid adenomas in a patient with primary hyperparathyroidism t. athanasoulis, a. fothiadaki, t. karianos, a. tsakmakli, v. makripoulias, f. athanasouli, c. zerva; "alexandra" university hospital athens, greece, athens, greece. during work up of a male patient years old with a discovered raised calcium level who demonstrated primary hyperparathyroidism (pth= pg/ml and serum calcium ca= mg/dl), a double phase parathyroid scintigraphy with mibi was performed. a large area of hyperactive parathyroid gland localized at the lower left lobe of the thyroid gland. the patient was operated and a giant parathyroid adenoma was removed at the indicated location of the study which was confirmed histologically. the patient was followed up for the following two years during which his calcium and parathyroid hormone levels were normal. during a normal check up seven years later an elevated serum calcium level was found (ca= , mg/dl). at that time a cervical ultrasound was performed and pth was measured. the value of pth was pg/ml confirming a mild hyperparathyroidism. a double phase sestamibi technique followed by a pertechnetate scan was used for further evaluation. an enlarged area of hyperactive parathyroid gland localized below and directly opposite of the lower right thyroid lobe extending to the upper mediastinum was discovered. an mri was performed which confirmed the appearance of a mass ( , cm x cm x , in dimensions) localized in the upper mediastinal area at the tracheo-esophageal groove with its lower border in contact with the aortic arch. a surgical removal was performed and the histological study confirmed that the removed mass was a huge parathyroid adenoma. this case report indicates that despite the fact that a parathyroid adenoma is discovered and removed, this does not exclude the possibility of asynchronous appearance of a second adenoma. bonescintigraphy -adjustment of administrated activity a. eriksson, centralhospital, karlstad, sweden background: diagnostic reference levels (drl) for nuclear medicine is established in sweden by the swedish radiation protection authority, ssi. drl is the given level of specific activity that shall not be exceeded. currently all patients that undergoe a bonescintigraphy in karlstad receive the same activity irrespective of weight and age. question: is it possible to individually adjust administrated activity by combination of age and bodyweight without loss of quality? method and material: adjustment of activity is done by creating an index of age divided by bodyweight. relation of activity to index is given by a prestudy of patients injected with mbq or mbq hdp-tc. results: patients received standard activity mbq and patients got individually adjusted activity. mean counts per image was , mcts respective , mcts. the decrease in administrated activity was , % for the adjusted group. variance of counts per image decreased from , to , . conclusion: individually adjusted activity by this model yields same quality in the image as a standard activity. the decrease in administered activity is positive both for the staff and the patient. radiation protection during two decades in a nuclear medicine department s. kristiansen, a. nielsen; department of nuclear medicine, aalborg hospital, aalborg, denmark. aim: the aim of this study was to follow the yearly radiation doses during two decades to staff working in department of nuclear medicine, aalborg hospital. we focused on the development in procedures, the number of examinations, and the physical working environment. this includes radiation protection in general nuclear medicine and pet/ct. materials and methods: data has been taken from list of examinations sent to the ministry of health since and measuring results of personal dosimetry from the same ministry since . until the department had very old and narrow quarters. when moving to new facilities in and when establishing pet procedures in december , our primary goal was to increase distance between the radiation source (the patient) and the technologists in order to reduce occupational exposure. the following was taken into consideration: •large, simple but functional rooms. •a new laboratory section with a direct hatch to the injection room. •a special waiting area for patients confined to bed. •improved shielding in preparation settings. •electronic personal dosimeters. •introduction program for new staff where the main topics are: radiation protection, personal dosimeter, receiving and registration of radioactive sources and pharmaceuticals, circumstances for pregnant and breastfeeding staff and handling of radioactive waste. •radiation protection is taken into consideration whenever changes are made or new procedures are implemented. •dosimeter measuring results are discussed at staff meeting. results: among the examinations giving the highest radiation dose to the staff are bone scintigraphy, myocardial scintigraphy and pet scannings. the number of bone scintigraphies has been almost stable since . the number of myocardial scans has increased from scans in to scans in . the department started pet/ct scans in and made scannings the first year. evaluating technologists working since in nuclear medicine the average occupational radiation dose has not increased. conclusion: we found that it is very important to develop the physical working environment currently while having focus on its functionality. furthermore the electronic personal dosimeter, updated guidelines for procedures and introduction of new staff is significance to keep radiation dose low. this has been introduced in our department, and despite an increase in the number of scannings, the radiation dose to the staff has not increased. cyclotrons are commonly used for production of radioactive isotopes for nuclear medicine purposes. as part of the site safety system, the nuclear process requires installation of a stack radiation monitoring system (srms) to determine the released activity during routine operation. this srms requires determination of a conversion factor for converting the radiation detector readings into concentration unit. defining the conversion factor is done mainly by calibration process of releasing a known amount of activity. it is important to have a precise estimation of the converting factor in order to enable the design of an optimal duct that shall provide maximum detection sensitivity. a computer program was developed for determining the stack conversion factor based on simulating the positron emitter isotopes free mean pass in the duct and the motion direction of the kev energy photons created by positron annihilation. the obtained conversion factor (by the software) is based on the radiation detector sensitivity for kev energy photons, the user definitions for the stack dimensions and the cross section of the duct. this algorithm is acceptable since all pet isotopes produce kev photons. a local calibration factor is designated to adjust the software conversion factor to the self-characteristics of the specified detector. adjustment is done by locating a calibrated radiation source in a pre-determined location and comparing between the expected reading calculated by software and the detector actual reading. the detector readings, converted into activity concentration along with the air flow data, are used to accumulate the total activity release through the duct. the software simulation has been performed on few square and round ducts of different dimensions and the results were compared to the actual calibration releases. results show a very high correlation between the software simulation and the actual releases. the conversion factors found to be in the range of cps per nci/m for duct with cross section of cm . due to the high correlation between the simulation and the calibration releases, the simulation may now be used to estimate the design ventilation system sensitivity in order to improve the minimum detectable activity and to be compatible with the restrict regulation of detecting concentration level as low as nci/m . this high correlation can reduce the amount of activity releases that are accumulated during the calibration process as part of the annual release activity under the site license and reduce the allowed released activity derived from the site routine operation. introduction: the nuclear medicine technologist(nmt) is the healthcare professional who is able to cover the whole range of nm procedures in the clinical routine. the period of education is a fundamental part of the educational process and for this purpose considerable resources investment is dedicated to it. the possibility of knowing how to confront the most varied situations in italy(i), in european(eu) and mediterranean nations, determines a professional growth in the sector. aim: the nmt is an important part of a team of healthcare specialists; the aim of this work is to identify nmt formative processes, working situations and economical capacities. in i, education and training is quite similar than in eu: during the initial months of the university course(average years), nmts acquire the basic theoretical elements, follow the courses which help to develop didactic, then anatomy, pathology, equipment in the radiology area( %); at the end, nmt deals with other fields of application of the ionizing radiations. the range of tasks permitted of nmt varies from country to country, and there is considerable overlap with other professional groups. results: according to several published reports, there are approximately radiological+nm technologist in the world; of them in europe ( %men+ %women). there are nmts operating throughout italian nm-pet departments. in addition to historical/cultural traditions, differences in teaching and the characteristics of university course programming create different technical procedures in nmt routine (diagnostic imaging, radiation protection, etc.); legislation is relative flexible in all countries, with - working hours per week with additional extramural nmt activity; the duties of chief-nmt are always dedicated to management of logistic problems( %) and financial resources( %). credit points must be collected by the exam for ce sessions in every countries. italian nmt salary is . times lower than % of eu. professional benefits (extra days off or special bonus) are taken into account only in the mediterranean area or intercontinental countries. conclusions: the training and the professional qualification of nmt represents a first step towards a governance of healthcare working activities; it's important to underline main nmt goal: one high standard of work for nmt in countries. fundamental for the changeover of nmts is the ability to acquire/process spet&pet-ct images, in addition to performing quality control of nm technologies. it's in the interest of healthcare quality that nmts take responsibility for providing of high quality service and performance in clinical routine, with professional competence and global competition. introduction: assuming that the modern concept of a nuclear medicine department should ideally include a positron emitting tracers (pet) production facility, there is a need to optimize the design of an integrated facility (here considered as the opportunity to build from the beginning) in order to allow the distinct patterns of functioning and circulation (patients, public, professionals, products, ) to occur in an harmonious and most efficient way. the purpose of this study is to integrate the ultimate concepts concerning aspects so crucial as radiation protection, ergonomics and the practicability and efficiency of the unit, considered as a whole. material and methods: starting with a bibliographic review, done according to the most recent developments on regulations and legislation, essentially at international level but also regarding eventual national particularities and following with practical knowledge, obtained from recent (real) implementation of similar units -and information shared by the responsible entities -we aim to build a complete and structured project, with an objective planning (blueprints), able to serve as basis for real implementation of an unit with an updated and optimized integrated vision of the current production and diagnostic processes. results and conclusions: the final blueprints of the unit are based on studies concerning not only the previous research on current legislation, but also the current assumption of best practices and fundamental principles related to radioprotection (as the alara principle), production (as the cgmp rules) and diagnosis (international guidelines). these blueprints demonstrated the practical result of that research and consist, briefly, on the obtained optimal structuring of the diagnostic side of the unit (as well as the production side) combined together in order to facilitate the necessary interaction, even if maintaining its respective independence and individual protection (compulsory condition to assure best practices) even in case of simultaneous operation. results: in the first patient tg level decreased from . ng/ml to . , . and . ng/ml after st and nd and rd ri application, respectively conclusion: there is a significant reduction of tg levels in esrf patients with dtc during the course of therapies using reduced activity doses. tg levels in all patients were lower then ng/ml after the nd therapy same-patient perfusion spect data were acquired by alternating between nr and bh every seconds. the ct protocol was standard breath hold. these data were transferred to the lungguide (nihon advanced biologic, japan) workstation via dicom where non-rigid spect/ct image co-registration and fusion were performed using lg-ifm. due to the small difference in displacements, bh-spect/bh-ct registration was taken to be the "gold standard" to which nr-spect/bh-ct registration was compared. the differences in the position of the the diaphragm and the bottom of the lungs and in bh ct and nr spect, respectively, were measured. after lg-ifm registration with, we evaluated the difference of bh-spect/bh-ct and nr-spect/bh-ct fusion images in the lung lower field. results: lg-ifm mis-registration was observed in of cases ( . ± . %) in nr spect/bh ct fusion images czech republic -the result of the questionnaire rd medical faculty rehling ; clinical physiology and nuclear medicine positive cd /weak glut- ( . ± . , n= ), negative cd /strong glut- ( . ± . , n= ) were significantly higher than those of negative cd /negativeglut- ( . ± . , n= ) using kruskal wallis test (p= . ), suggesting that fdg uptake variation is related not only glut- but also cd (thus muc ) we present synthesis, radiochemical synthesis, and preclinical data on a series of novel radiofluorinated alkyne agents as potential pet agents for the detection of amyloid plaques. one such pet agent, av- binds avidly to abeta (a ) with a ki = . ± . nm (vs. i-impy) and localizes specifically to a in ad brain tissue máthé , i. foldes ; nat is it possible, from stress images only, to decide if a myocardial perfusion rest study is needed? present our experience about the unwished effects that appear during the administration of i-ioflupano/fp-cit in patient with movement disorder. material and methods. a total of consecutives patients ( % male; mean age . y) were men are studied between xii/' to i/' . the patients were grouped according to the clinical prescription in / ( . %) patients were reported pain during the injection, red flush and irritation in the zone of puncture in spite of its reinjection in another vein assuring a correct canalization. in / ( , %) was observed slight headache with slight reddening face. three of these patients were referred for reevaluation in a follow-up protocol ( / ; , %) presenting similar reactions to the first time when the exploration was repeated. comments. the administration of i-ioflupano/fp-cit is a procedure of limited adverse reactions and if appear, are of slight intensity spect are inaccurate for both algoritims, and that degree spet recontructed with osem can offer an acceptable alternative. however, degree spect recontructed with fbp is superior for this purpose parisella , a. lenza , f. scopinaro ; ospedale sant'andrea the main component of paint thinner used in industry is toluene. toluene can diffuse into many body fluids and tissues; and causes formation of reactive oxygen species (ros) which are the main agents responsible for cellular damage. antioxidant enzymes such as sod, gsh-px and cat are part of the natural cell defense system against ros mediated injuries. matrix metalloproteinases (mmps) play an important role in physiologic and pathologic processes, including extracellular matrix turnover, tissue degradation and repair, cell migration and inflammation. an imbalance between the expression of mmps and tissue inhibitor of metalloproteinases (timps) is believed to cause some pulmonary inflammatory diseases. especially, the imbalance between mmp- and timp- expression may play an important role in airway inflammation. we aimed to investigate the alveolar clearance by tc- m dtpa radioaerosol inhalation scintigraphy in auto painters, to assess effects of exposure to toluene on clearance rate of alveolar epithelium and to determine the correlation between tc- m dtpa radioaerosol lung scintigraphy findings and mda, antioxidant enzymes, mmp- , mmp- , timp- levels. twenty eight auto painters, and control group were included in the study. tc- m dtpa radioaerosol inhalation scintigraphy was performed in all subjects. clearance half time (t½) and penetration index (pi) on the first minute image were calculated. the mean t½ values and pi of toluene exposed workers were significantly higher than those of control group (p= . , p= . respectively). the sod and gsh-px levels of auto painters were significantly higher than those of the control group (p= . , p= . , respectively). conversely, cat and mda levels was not significantly different between groups (p> . ). we observed a statistically significant increase (p= . ) in mmp- levels of toluene exposed workers compared with the control group, whereas the mmp- and timp- levels of painters were less than those of control group that not reached to statistical significance (p> . ). a positive correlation was observed between pi and gsh-px levels (p< . ) in the painters. there were no correlation between scintigraphic findings and other parameters in any subjects. our findings indicate that occupational exposure to toluene in auto painters has effect on bronco alveolar epithelial permeability, which is supported by prolonged tc- m clearance half time and increased penetration index. we also found increase in antioxidant enzymes and mmp- levels. in the light of these findings, it might be concluded that long lasting toluene exposure may lead into occupational lung diseases. study objectives: measur the synovial thickness after -holmium radiosynoviorthesis by sonography. methods: phases iii, prospectiv study. patients suffering from chronic synovitis, rheumatoid arthritis were examined. the protocol commenced with screening. the patients were selected according to inclusion and exclusion criteria. holmium phytate injectable suspension marked by mbq holmium phytate injectable suspension, and mg of ml triamcinolone acetonide and ml of lidocaine %. there were month follow-up period after the administration of the isotope. inflammatory activity of the affected knee-joint was tested prior to treatment, and the th and , , , and months after treatment. we measured the synovial thickness the following locations: in the midline, lateral and medial, by the condylus of femur medial and lateral. results: during the study period, inflammation decreased. in the first two years excellent and good results were recorded in . %. two years after radiosynoviorthesis . % of patients did not need another punction. the thickness of the synovia decreased significantly. we find a significant correlation between the synovial thickness and the clinical improvenes. conclusion: the -holmium-phytate is an effective new radiopharmacon in the treatment of synovitis. we detect the clinical improvement by sonography. the effective dose is - mbq. references: margit szentesi: radiosynoviorthesis with ho- phytate. first clinical results eanm post-congress scintific meeting. radionuclide therapy in theory and practice. györ, hungary. . szept. . szentesi m., környei j., antalffy m., törkö j. tóth gy., jánoki gy., balogh l., : study of intraarticular application of -holmium ihpp in rabbits. world journal of nucl. med. . suppl. . s . sept. . szentesi m., takács s., farbaki zs., nagy e., környei j., antalffy m., törkö j., tóth gy., jánoki gy., balogh l. géher p., comparitive study of applying increasing doses of ho-phytate injectable suspension in chronic synovitis. (comparative, randomized, single-blind, placebocontrolled study with increasing dosage). eur. j. nucl. med. suppl. . . . szentesi m., takács s., farbaky zs., nagy e., környei j., antalffy m., törkö j. tóth gy., jánoki gy., the first article on radiosynoviorthesis was published in by fellinger. the traditional isotopes cause whole body radiation of rad. isotope specialists have aspired to produce an isotope incurring lower radiation loads. (pirick, russel, sledge, junsing song) -holmium-phytate produced by us: radiation type beta energy maximum: , mev; radiation type gamma energy maximum: , mev; soft tissue penetration: maximum , mm; average: , mm; half-life: , hours; particle size: , - μm study objectives: examination of anti-inflammatory effect of -holmium-phytate injection. methods: phases iii, prospectiv study. patients suffering from chronic synovitis, rheumatoid arthritis were examined. the protocol commenced with screening. the patients were selected according to inclusion and exclusion criteria. holmium phytate injectable suspension marked by mbq holmium phytate injectable suspension, and mg of ml triamcinolone acetonide and ml of lidocaine %. there were month follow-up period after the administration of the isotope. inflammatory activity of the affected knee-joint was tested prior to treatment, and the th and , , , , and months after treatment. evaulation was based on the criteria as described by müller, rau and scütte the score system was developed by the authors. results: during the study period, inflammation decreased. in the first three years excellent and good results were recorded in . %. three years after radiosynoviorthesis . % of patients did not need another punction. administration of holmium- phytate is a safe procedure. we did not detect any symptoms of radiation sickness. we found no deviations in either haematological or chemical parameters during the study period. conclusion: holmium- phytate isotope is an effective radiopharmacy treating synovitis. due its adventageous features it produces less radioactive damage on the organism than the traditionally used isotopes . due to its physical parameters it is optimal to treat large joints (knee) and medium size joints (hips, shoulder, elbow, wrist, ankle) . effective dosage is - mbq. references: margit szentesi: radiosynoviorthesis with ho- phytate. first clinical results. eanm post-congress scintific meeting. radionuclide therapy in theory and practice. györ, hungary. . szept. . szentesi m., takács s., farbaki zs., nagy e., környei j., antalffy m., törkö j. tóth gy., jánoki gy., background: early and continuous prophylaxis in haemophilia is of paramount importance due to the susceptibility of the young and immature skeleton to repeated joint bleedings. in developing countries, financial aspects of clotting factor a or b replacement play a major role in patients' management. radiosynovectomy (rso) offers an alternative treatment option to surgical or chemical synovectomy and may reduce the need for clotting factor substitution. a. . . methods: in a multicenter effort patients from centers underwent rso of the knee following repeated bleeding episodes. rso was performed applying three radiocolloid formulations (y- -silicate, re- tin and p- chromic phosphate). average age was . (range - years). standard injected activities were mbq for y- , mbq for re- and mbq for p . the injected activity was tailored to patients' age; - one third, - one half and - years three quarters of adult dose. patients were referred by the haematological outpatient clinic. the frequency of bleeding episodes was documented. prior to the rso the frequency of knee joint bleeding was reported from patients' records. results: with exception of one case with circumscribed and reversible skin necrosis along the injection tract or reversible swelling of the knee joint, there were no other serious side effects. within the one month period prior to rso, all patients had at least bleeding episodes per month. following the rso, number of bleeding episodes dropped significantly (a total of bleeding episodes during the one month prior to rso dropping to at one month, at months and at months following the rso, x < . ). during a months follow-up period, % of the patients had no bleeding episodes ( % reduction), % had an % reduction and % had a % reduction. based on the feedback by the children and their guardians, there was a significant improvement of the life quality attributed to improved mobility and lesser drop-out days from school. conclusions: our results indicate that rso is effective in preventing joint bleeding in the paediatric population. in addition there is a significant cost benefit attributed to reducing the need for clotting factor substitution (medication cost to treat one bleeding episode - us$ vs. - usd for rso using p- or re- ). following an initial period of scepticism, the acceptance of the procedure improved significantly. results of an iaea led crp: e . . radiation synovectomy may be indicated for the treatment of chronic synovitis. a number of factors may affect its current use, including availability, limited evidense for its efficacy compared to intra-glucocorticoid, and concerns regarding the potential long term effects of radiation exposure, particularly in younger patients. specific chromosome-type abnormalities in peripherial lymphocytes can be useful indicators of whole-body radiation exposure. the frequency of these aberrations has been shown to increase in patients who have had radiation synovectomy using yttrium- /y- / by up to five times compared to baseline levers. -holmium-phytate / -ho/ is a new radiopharmaceutical currently on trial which appears to have less extra-articular leakage than y- compounds. the aim of this study was to indentify any increase in specific chromosome-type abnormalities, using published criteria, in patients following -ho synovectomy of the knee. patients / men, women/ in whom the analyses were performed had a mean age yr range / - yr./ results: there was no increase in scored chromosome-type abnormalities after -ho synovectomy. conclusion: this study further supporth the relative safety of -ho compared to oder radiopharmaceuticals. p -monday, oct. , , : aim: use of rhtsh aided rai therapy for differentiated thyroid cancers has increased over past few years. this study has been done to assess the clinical usefulness of rhtsh aided rai therapy for patients of differentiated thyroid cancers administered rai for either residual remnant ablation (rra) or irresectable and metastatic disease. materials and methods: patients ( females; males) - years (mean age . ); of differentiated carcinoma of thyroid given rhtsh aided rai therapy for either rra or irresectable and metastatic disease from october to february were included in the study. patients had papillary carcinoma while had follicular carcinoma. patients had stage i, stage ii, stage iii while had stage iv disease. patients were given rhtsh aided rai therapy for rra while had either irresectable or metastatic disease. patient's tsh did not rise adequately after surgery or due to functioning metastatic disease while opted for rhtsh aided therapy because of the problems associated with thyroxine withdrawal. rai given ranged from mci( mbq)- mci( mbq); mean dose . mci( . mbq). all the patient's baseline tsh, thyroglobulin (tg) and anti-thyroglobulin (anti-tg) levels were recorded. . mg i/m injections of rhtsh were given at day & and tsh levels recorded hours post injection. rai therapy was given if tsh level was > μiu/ml. all patients underwent whole body scan prior to discharge. patients were followed at months interval on outpatient basis. the mean follow up was . months. if the valid tg levels came down to negligible levels at months complete response (cr) was documented; if tg levels reduced significantly but not negligible, was termed as partial response (pr), if no significant difference noted; stable disease (sd) and if increased progressive disease (pd). results: patients had valid tg levels. the baseline tg levels ranged from . -> ng/ml. the baseline tsh levels ranged from . - . μiu/ml. after the rhtsh injection the tsh levels rose to ( . - . ) after first injection and ( . -> ) after the second injection. all patients are alive; patients had cr, had pr while had sd. patients were too soon to assess at the time of review. the overall response rate was %. conclusion: rhtsh aided rai therapy yields good results with an appreciable response rate, therefore it can be used for effective therapeutic administration of rai for both rra and in cases of irresectable or metastatic disease. detection of ectopic gastric mucosa in meckel´s diverticulum by m tc-pertechnetate disodium scintigraphy in patients with the lower gastrointestinal bleeding, retrospective study j. dolezal; teaching hospital, hradec kralové, czech republic.aim and background: to present our twelve-years experience with the perfusion m tc-pertechnetate disodium scintigraphy of meckel's diverticulum in patients with lower gastrointestinal bleeding. gastric mucosa may be presented in meckel´s diverticulum and associated with the peptic ulcer disease and the lower gastrointestinal (gi) bleeding and the m tc-pertechnetate scintigraphy can help to make diagnosis of ectopic gastric mucosa. material and method: one hundred patients - adults ( males, females, aged - , mean years) and children ( boys, girls, aged - , mean years) underwent m tc-pertechnetate scintigraphy. all patients had melaena or hematochezia with anaemia. the morphology imaging and the endoscopy were negative in all patients. the dynamic scintigraphy of the abdomen was started immediately after i.v. administration of mtc-pertechnetate. the static image of the abdomen was done after it. as necessary the spect was added to improve sensitivity, specificity and better spatial specification. results: four patients (two boys -two-and ten-years-old, one girl -four-years-old and -years-old male) had positive scintigraphy. all patients underwent surgery and meckel diverticulum with ectopic gastric mucosa (by histology) was detected. gi bleeding stopped spontaneously in patients with negative scintigraphy. these patients did not undergo intra-operative enteroscopy or surgery. conclusion: m tc-pertechnetate scintigraphy can help to detect ectopic gastric mucosa in the abdomen and improve a management of patients with lower gastrointestinal bleeding. aim: rapid detection and localization of the bleeding sites are important factors for the clinical management of patients with active hemorrhage. the aim of this study was to assess the accuracy of technetium- m (tc- m) labeled red blood cell (rbc) scintigraphy in patients with suspected gastrointestinal bleeding. material and methods: between december and august , we selected patients ( women and men, age range - years) with clinical suspect of gastrointestinal bleeding consecutively referred for tc- m rbc scintigraphy. the results of tc- m rbc scintigraphy were compared with those of oesophagus gastro duodenoscopy and angiography. results: tc- m rbc scintigraphy was positive for active gastrointestinal bleeding in ( %) patients and negative in ( %) patients. gastrointestinal bleeding was confirmed by other procedures in of the patients ( % true positive rate) with positive rbc scintigraphy (by oesophagus gastro duodenoscopy in patients and by angiography in patients). in ( %) of the true positive patients, rbc scintigraphy demonstrated active bleeding already in the early (within min) phase of the study. in the remaining patients ( %), rbc scintigraphy resulted positive only after delayed (between - hours) acquisition. therefore, the acquisition of delayed images increased the sensitivity of the method. in of patients with positive rbc scintigraphy, gastrointestinal bleeding was not confirmed by other procedures ( % false positive rate). among the patients with negative rbc scintigraphy, the lack of gastrointestinal bleeding was confirmed by oesophagus gastro duodenoscopy and/or angiography in patients ( % true negative rate). among the remaining patients with negative rbc scintigraphy, patients had gastrointestinal bleeding by oesophagus gastro duodenoscopy and by angiography. rbc scintigraphy had a sensitivity of %, specificity of %, positive and negative predictive values of % and %, respectively. conclusion: tc- m rbc scintigraphy is a useful and safe non-invasive test for the diagnosis and the management of patients with suspected gastrointestinal bleeding. in particular, the possibility to re-image patients over an extended period is helpful in identifying intermittent bleeding sites. radionuclide assessment of gastric emptying in relapsing-remitting multiple sclerosis b. g. chaushev, a. klisarova, p. bochev, n. deleva, b. ivanov; mbal st.marina -varna,bulgaria, varna, bulgaria. aim assessment of gastric motility disorderders in relapsing-remitting multiple sclerosis (ms) using dynamic scintigraphy of gastric emptying by mtc. material and method evolution of gastric emptying was performed in patients with ms ( males and females), aged , ± , years, with , ± , years of disease duration. the diagnosis ms was defined according to mcdonald's criteria. the clinical impairment was rated according to the expanded disability rating scale (edss). none of the patients have subjective complaints, suggestive of gastroparesis. at the time of the study all patients were in remission and free of corticosteroid treatment. dynamic gastroscintigraphy was carried out in the morning after evening fast, with - hours abstention of tobacco, drinks and medication influencing gastric motility function. the patients was took breakfast consisting of semi-solid food, labeled with mci / mbq / tc- m sc. parameters of the protocol included frames. the first image was achieved at minute and the next ones were achieved after minutes interval during two hours or until stomach evacuation goes above %. the time needed for semi-emptying of stomach was determined from all received images. we were drawing region of interest, which includes the whole stomach from all projections. time-activity curve that represents the movement of radioactivity in region of interest was generated and half emptying time was calculated (with up to minute's normal range). results our results demonstrate delayed gastric emptying in more than half of the patients ( %) with values ranging from , % to , %. we found gastric motility disorders in patients with more pronounced functional deficit, as assessed by edss. sex, age and disease duration have not a significant impact on gastric emptying. conclusion autonomic dysfunction is an integral part of the pathological process in ms with involvement of almost all somatic systems. dynamic scintigraphy of the gastric emptying in ms provides possibilities to evaluate the gastric motility. the evacuatory disturbances are an essential factor, impacting on the health status and on the quality of life. they appear even in patients without subjective complaints and with relatively mild neurological deficit. key words: multiple sclerosis, gastric emptying, dynamic scintigraphy introduction: tc- m mibi which is widely used in nuclear cardiology, is excreted via the hepatobiliary system thus enabling to make comments concerning this system of elimination. the nonalcoholic fatty liver disease (nafld) which is associated with mitochondrial dysfunction and has the potential to progress to cirrhosis has recently been drawing attention with its increased incidence due to predisposing factors such as obesity and diabetes (dm) . aim: in this retrospective study, mibi findings in normal and obese patients (pts) groups and the influence of accompanying risk factors on these findings were investigated using the rest images of myocardial perfusion scintigraphy (mps). method: regions of interest (rois) of the liver (l) and right lung (rl) were drawn in the anterior projection using the rest mps images of the pts referred to our department for coronary artery disease (cad) work up. the liver index (l/rl) was calculated using the ratios of average counts obtained from the related rois. the body mass index (bmi) was calculated with the help of the medical records at the time of the mps. the presence of dm and hyperlipidemia (hl) was investigated from the pts' medical records and history. the pts who had a known liver and/or lung disease, those who smoked or drank alcohol, with a low lvef or perfusion defects on rest mps images were excluded from the study. finding: the data of a total pts ( females, males, average age: , ± years, height: . ± . m, weight: , ± kg) were analysed. no significant change was observed in the l index with respect to an increase in bmi in the overall assessment of the study group (r: . , p: . ). the cases with bmi> and dm (n: , l index . ± . ) showed a significant degree of decrease in their l index (p: . ); while in the cases with bmi> and had only hl (n: , l index: . ± . ) a significant change was not detected (p: . ). conclusion: in the study group the liver uptake ratio of mibi was significantly decreased in the presence of both obesity and dm as compared to normal individuals. however, similar findings were not observed in the presence of only obesity or obesity and hl. although histopathological verification is a must, these findings suggest hepatocyte dysfunction in pts with nafld who has similar pts characteristics. the present findings need to be confirmed in prospective studies that enable kinetic analysis of hepatic function with simultaneous histopathologic analysis. p -monday, oct. , , : pm - the aim of this work has been to evaluate the results obtained by radioguided parathyroid surgery in patients diagnosed of primary hyperparathyroidism due to parathyroid adenoma (pa). methods. inclusion criteria: patients diagnosed of primary hyperparathyroidism, a previous positive mtc-mibi scan (including spect or spect/ct), pathological diagnosis and clinical/biochemical follow-up > months.according with these criteria we have included in our study patients. radioguided parathyroidectomy was performed between february and july . the day of surgery, a low dose ( - mbq) of mtc-mibi was injected and a planar scan was performed in order to draw a cutaneous mark in the localization of the pa. the interval between tracer injection and surgery was determined on the basis of the previous scan, ranged between m. and h. on surgical theatre an intraoperative hand-held gamma probe was used. in all cases we determined intraoperatively pth levels and performed a pathological diagnosis. a radioguided removal of the pa, reduction of intraoperative pth levels > % and a pathological diagnosis of pa were used as criterions for successful excision of the abnormal gland. results. in patients ( %) radioguided removal of the pa was achieved. in patients the pa was eutopic ( double adenoma) and in ectopic. scintigraphic localization of the pa was concordant with surgical localization in patients, in two was nonconcordant ( eutopic adenoma), and in the pa was non detected on surgery. radioguided surgical technique was minimally invasive in patients, unilateral or bilateral cervicotomy in ( previous cervical surgery, nodular goiter, double adenoma, four glands revision and non surgical detection) and sternotomy in (ectopic mediastinal adenoma). biochemical follow-up revealed normocalcemia in patients and persistent hyperparathyroidism in ( %). conclusions. radioguided parathyroid surgery is a safe and effective method in the surgical treatment of primary hyperparathyroidism due to pa. we achieved a % of surgical detection with a % rate of hyperparathyroidism persistence/recurrence. aim: although total thyroidectomy is accepted to be the main component of the therapy in differentiated thyroid carcinoma (dtc), completion thyroidectomy (ct) is a controversial issue due to its morbidity potential. the aim of this study is to evaluate the efficacy of ct with the aid of gamma probe, using i- . materials and methods: patients ( female, male; mean age: , range: - ) who had undergone ct, between april -january , with the help of gamma probe, after labelling with i- were enrolled in this study. the patients have undergone the primary operation with the diagnosis of either benign multinodular or solitary nodular goitre, and dtc was diagnosed in the operation specimen. the patients, while not under thyroid hormone replacement therapy in the th week or later after the operation and with tsh< mu/l, remnant thyroid tissue grams and/or suspicious malignant findings in the remnant tissue due to ultrasonographic examination, were evaluated by the council of thyroideal diseases of our hospital, and ct was decided. . - . mci. i- was given orally to the patients - hours prior to surgery, and thyroid scintigraphy were obtained on the operation day. ct were performed with the guidence of gamma probe. patients underwent bilateral, and unilateral remnant thyroid tissue resection. results: preoperative mean remnant thyroid tissue mass was measured ultrasonographically to be , ± , grams. intraoperative mean ratio of thyroid activity to background activity(t/bg) was detected to be , ± , and the mean ratio of thyroid bed activity to background activity after the excision (tb/bg), , ± , . (p< . ). mean operative time was ± minutes. tsh levels were > mu/l in all patients after the th week and no remnant thyroid tissue was detected in patients either by ultrasonography or scintigraphy. while the mean tsh level of the patients was , ± , mu/l preoperatively, it was , ± , mu/l postoperatively (p< . ). malignancy in the remnant tissue was detected in ( , %) patients. ( , %) patients had transient hypoparathyroidism and ( , %) had transient recurrent laryngeal nerve palsy postoperatively. none of the patients had persistent hypoparathyroidism and recurrent laryngeal nerve palsy.conclusion: in patients with dtc who had undergone subtotal thyroidectomy or lobectomy in the primary operation, ct with the guidence of gamma probe after labelling with i- , is a safe procedure with minimal complications. i- adam spet in athyreotic patients with and without suppressive thyroxine therapy. aim: to evaluate the added diagnostic value of spect imaging over planar imaging of parathyroid scintigraphy performed in primary and secondary hyperparathyroid (hpt) patients. materials and methods: patients with primary hpt (no. ) or secondary hpt (no. ) underwent pararathyroid localising imaging in our centre, and then were operated on by the same surgical equipe. parathyroid scintigraphy consistsed of a double-tracer m tc-pertecnetate ( mbq)/ m tc-sestamibi ( mbq) subtraction scintigraphy plus perchlorate per os ( mg) accordingly to rubello's protocol (ejnmmi, ; ( ) : - ); spect imaging was obtained immediately after planar imaging using the following parameters: acquisistion, elliptical orbit, x steps, sec./step, x matrix, processing, filtered back projection and butterworth filter using different cut-off levels and order calues depending on the location, depth and uptake of the parathyroid enlargement. high resolution - mhz -ultrasonography (us) was also routinely associated. results: sensitivity in localising parathyroid enlargements using double-tracer subtraction scintigraphy, spect alone, and us were: %, %, and % in primary hpt, and %, %, and % in secondary hpt. interestingly, combining double-tracer scintigraphy and spect information sensitivity rose up to % in primary hpt (instead, in this series, us did not improve sensitivity, even if allowed a better location of the parathyroid enlargement in some cases). on the other hand, us allowed a mild increase of sensitivity in patients with secondary hpt. this was related to the fac that us was able to detect some very small parathyroid enlargements which were not seen at scintigraphy. however, it has to be underlined that us gave % false positive results in comparison to % of scintigraphy, especially in secondary hpt patients. conclusions: on the basis of our data, it seems reasonable to argue that the combination of planar double-tracer subtraction scintigraphy and spect is an optimal pre-operative localising procedure in primary hpt patients. conversely, in secondary hpt patients, neither scintigraphy nor us showed a very high accuracy: a combination of all these methods in secondary hpt could be recommended. tc- m radio-guided completion thyroidectomy in patients with differentiated thyroid carcinoma aim: completion thyroidectomy (ct) is crucial in patients with differentiated thyroid carcinoma (dtc) who had either subtotal thyroidectomy or lobectomy as the initial operation. whether ct is associated with an increased complication risk is controversial. the aim of this study is to evaluate the efficacy of tc- m radio-guided surgery with gamma probe in performing ct. materials-methods: patients with the histopathological diagnosis of dtc after the initial operation, with the tumor diameter cm, tsh < mu/l, remnant tissue > g. in ultrasonographic examination and/or suspicious malignant foci in the remnant thyroid tissue, and undergone ct with the aid of gamma probe using tc- m were enrolled in this study retrospectively. on the operation day, - mci, . ml tc- m pertecnetate was injected through the forearm minutes prior to the incision, and bilateral remnant tissue resection was performed with the guidence of gamma probe. results: intraoperative mean ratio of thyroid activity to background activity(t/bg) was detected to be . ± . and the mean ratio of thyroid bed activity to background activity after the excision (tb/bg), . ± . . (p< . ). mean operation time was ± minutes. tsh levels of all patients one month after the surgery were > mu/l and no remnant thyroid tissue was detected either by ultrasonography or thyroid scintigraphy, except in two patients. preoperative mean tsh level of the patients was . ± . mu/l, while it was ± . mu/l postoperatively, (p< . ). malignancy in the remnant tissue was detected in ( . %) of the patients. transient hypoparathyroidism occured in ( . %) patient postoperatively. persistent hypoparathyroidism or recurrent laryngeal nerve damage occured in none of the patients. conclusion: in patients with dtc who had undergone subtotal thyroidectomy or lobectomy in the primary operation,tc- m radio-guided ct is a safe procedure with minimal complications. the diagnostic value of tc- m mibi gated myocard perfusion spect in detection of silent myocardial ischemia in asymptomatic patients with type ii diabetes mellitus aim: in this study, we aimed to evaluate the diagnostic value of tc- m mibi gated myocard perfusion spect (mps) in the detection of coronary artery disease (cad) and silent myocardial ischemia (smi) in the patients with asymptomatic type- diabetes mellitus (dm). material and methods: for this purpose, patients with type- dm and volunteers without any cardiac symptom as a control group were included in this study. exercise tolerance test (ett), echocardiography and tc- m mibi gated mps were performed to the patients and volunteers. computed tomography coronary angiography (ctca) was performed in the patients with coronary ischemia or infarct detected in tc- m mibi gated mps. biochemical analyses lipid profile of the patients and the volunteers were evaluated for the risk of cad. the results were analyzed and compared visually and statistically. results: the data of the present study revealed that silent myocardial ischemia was found at a high rate ( . %, n= ) in patients with type- dm. severe cad in ctca was detected in four of nine patients with ischemia or infarct in tc- m mibi gated mps ( . %). left ventricular diastolic dysfunction in echocardiography, ischemic pattern in ett and high risk of cad according to biochemical analysis were detected in the same four patients. at the end of statistical evaluation, we found that tc- m mibi gated mps showed significant correlations with ctca, echocardiography, ett, hba c, risk of cad and diabetic age in diabetic patients with cad. conclusion: in conclusion, we propose that tc- m mibi gated mps is a reliable and non-invasive method, which can be used to detect silent myocardial ischemia and cad in the patients with type- dm. were subjected to pet studies. all patients were treated previously with total thyroidectomy and i treatment. the routine protocol during the follow-up included i whole-body scan (wbs). thyroxin treatment was withdrawn (four weeks) and patients were on an iodine-free diet before wbs. tg, anti-tg antibodies, ft , ft and tsh were determined. patients with negative wbs and elevated tg or with suspicion of recurrence were subjected one week later to a pet study. pet findings were verified by pathology report or other imaging techniques (ct, mri, ultrasound) . results: at the time of the pet study, mean thyroglobulin values were ng/ml ( - ng/ml). in three cases, the value was < ng/ml but there was suspicion of recurrence based on clinical examination. tsh values were always > μui/ml and antithyroglobulin antibodies were negative. pet detected disease in / studies ( %), localized as follows: cervical lymph nodes, mediastinal lymph nodes, one lung metastasis and one bone metastasis. pet findings were verified by ct scan in cases and by ultrasound and mri in cases. in all cases, presence of disease was confirmed by postoperative pathology report. pet was negative in studies; four patients remained disease-free in the follow-up, and lymphatic metastasis was confirmed intra-operatively in one patient. conclusion fdg-pet localized the metastasis in / ( %) of the studies performed in patients of dtc variants with poor prognosis (tall cell or hürthle cell carcinoma), modifying the subsequent therapeutic approach to these patients. the role of mtc-pertechnetate thyroid scintigraphy in hyperthyroid hcv positive patients treated with interferon (ifn ) background: the occurrence of thyrotoxycosis in the course of therapy with ifn for hcv related chronic hepatitis is well known. however, a differential diagnosis between painless thyroiditis and graves disease is needed to provide a proper clinical management of patients with thyroid disfunction and liver disease. aim: to determine the value of pertechnetate uptake in the thyroid gland of patients with low tsh serum levels found in the course of treatment with ifn or within one months from drug withdrawal. patients and methods: thyroid scintigraphies of patients ( f; mean age yrs) treated with ifn and with low tsh values (mean tsh serum value: . ± . mu/l; normal range: . - . mu/l) were retrospectively evaluated. thyroid images were obtained at minutes after intravenous injection of mbq of m tc-pertechnetate and the tracer uptake value was calculated as percentage of injected activity (normal range: . - %). results: pertechnetate uptake values were out of normal range in / patients; of them had a low uptake value (a) and had an uptake over the normal upper limit (b). a normal uptake value was seen in the remaining patients (c) whose circulating hormone levels were into a normal range (see table) . discussion and conclusion: although hypothyroidism is considered the most frequent thyroid disease in the course of ifn therapy, the differential diagnosis of different forms of thyrotoxicosis has an important role in the clinical decision the aim of this study was to compare the effectiveness of fixed and calculated dose i- treatment efficiency in patients with graves disease. materials and methods: we retrospectively analysed patients with graves disease who treated with radioiodine in a manner of calculated or fixed dose approach between the years of - . study group consisted of male and female patients (range: - , mean age: ± , years old). mean follow-up interval was ± months. twenty four patients excluded from the study due to failure in follow-up. one hundred and fifteen patients received single dose i- . sixteen of these patients received i- via calculated dose and fixed dose approach. mean doses for both groups were as follows: ± . mci for calculated dose group (range - mci); ± . mci for fixed dose group (range - mci). the criteria for successful therapy was defined as euthyroidism or hypothyroidism after radioiodine therapy and, the existence of hyperthyroidism six months after therapy was considered as unsuccessful therapy. results: for patients who recieved calculated doses success ratio was % [hipothyroid (% ), euthyroid (% )] after treatment. success ratio was % [hipothyroid (% ), euthyroid (% )] for patients who recieved fixed doses. hipothyroidism occured - months (mean: ± , ) after treatment. patients recieved second doses and success ratio in this group was % [(hipothyroid (% ), euthyroid (% )]. one patient whose thyroid volume was g, recieved third dose and after total mci rai- finally patient was euthyroid. although the difference in success ratios and frequency of hipothyroidism weren't statistically significant, success rates and frequency of hypothyroidism was higer in fixed dose group. this statistical problem may be related to small number of patients in calculated dose group. low success ratio in the calculated group can be a consequence of low dose/gr factor ( mikrocurie per gram). conclusion: our results were in agreement with literature with respect to success rate and frequency of hipothyroidism in graves' disease with fixed dose of radioiodine. success rates can be improven by using higher dose/gr factors in calculated group. aim: i-mibg scintigraphy is shown to be useful in imaging of neuroendocrine tumours. a technique of in-house iodination of mibg, developed in our department in was found to be very cost-effective. our experience in i-mibg scintigraphy with the tracer prepared in-house was analyzed. materials and methods: records of i-mibg scintigraphy, carried out in our department between and were reviewed. results: a total of studies were performed during this period. there was a significant increase in the number of scintigraphy studies in the latter half of this period - during to , and during to . the clinical indications were pheochromocytoma and paragangliomas ( cases), carcinoid tumours ( ), neuroblastoma ( ), medullary thyroid carcinoma ( ) and others ( ), with more of neuroendocrine tumours in the latter half of study period. evaluation of aim: hiv patients receiving haart may develop body fat changes and low mineral density (bd), but whether these conditions are related is unclear. we further investigated whether a relationship exists between osteopenia/osteoporosis and lipodystrophy (ld)/lipoatrophy (la) in hiv patients on haart. methods: sixtyfive male patients, aged to yrs, with hiv infection haart (treatment duration: . ± . mths) were consecutively studied; all cases had normal bmi (range: to ); patients had ld, la while had no fat changes (nfc). there was no percentage difference between the groups in hiv infection and haart duration and in cdc stage, while the percentage of ld which included protease inhibitors (pi) in their haart regimen was significantly higher than both la and nfc patients. in all cases we measured by dexa (hologic qdr - a) bd (g/cm ) in lumbar spine, with t-score calculation according who criteria, and fat mass (fm; g) both in trunk (t) and appendicular (a) regions with t/a ratio calculation. results: globally, / ( . %) patients had low bd values, with osteoporosis in ( . %) cases and osteopenia in ( . %); the frequency of osteoporosis was higher in ld patients ( %), than in la ( %) and nfc ( . %), but with significant (p< . ) difference only between ld and nfc. bd was lower in ld than in la and nfc, but not significantly. t-fm was significantly (p< . ) higher in ld than in la and nfc, and a-fm was significantly lower in la than in ld (p< . ) and nfc (p< . ) with no difference between the latter two. t/a was significantly higher in ld ( . ± . ) than in la ( . ± . ) and nfc ( . ± . ) as well as it was in la than in nfc. t-fm correlated negatively with bd and t/a positively with pi therapy duration. conclusion: bone mass loss, even osteoporosis, may occur in hiv patients on haart with significantly higher frequency in pi treated patients who had lipodystrophy with t fat accumulation, in our cases. an inverse correlation seems to exist between t-fm and bd in haart patients, but it is unclear whether the pathogenetic mechanism leading to t fat accumulation and bone mass loss is common. aim: body fat changes are common in hiv infected patients receiving haart, mainly if protease inhibitors (pi) are present in their regimen, but the pathogenetic mechanism is still unclear. we evaluated quantitatively body fat composition in hiv patients treated with haart to ascertain both fat loss and fat distribution changes in order to identify possible therapeutic and host related associated risk factors. methods: we enrolled hiv patients receiving haart, m and f; according cdc stage, patients were stage a, stage b and stage c. at clinical examination, fat changes were present in / patients (fc) and absent in the remaining / cases (nfc). in all patients we measured by dexa (hologic qdr - a) fat mass (fm; g) in whole body (w), trunk (t), peripheral regions (p), arms (a), legs (l) and calculated t/p ratio and total weight (tw). we also measured bmi, cd counts and hiv rna and determined cd count nadir and rise from nadir and haart duration, including pi, nrti and nnrti. results: we found significantly lower values of wfm (p< . ), pfm and lfm (p< . ) in fc than in nfc; afm was also lower in fc, but not significantly. moreover, tfm and t/p were higher in fc than in nfc, but significantly (p< . ) only for t/p. no significant difference was ascertained in tw, bmi and in cdc stage between the groups of patients. fc patients had significantly (p< . ) longer haart duration in respect of nfc ( . ± . vs . ± . mths), in particular pi and nrti duration; significantly higher current cd count (p< . ) and cd rise from nadir (p< . ) were also ascertained in fc than in fnc, while nadir showed no difference. wfm, pfm and lfm negatively and t/p positively correlated to pi and nrti therapy duration. conclusion: in hiv patients on haart fat loss with distribution changes, mainly involving peripheral regions, may occur, significantly higher in fc and in nfc. the pi and nrti longer exposure and the better immune recovery, both conditions affecting adipocite metabolism, could represent probable risk factors for fat loss in our fc cases, to be considered in haart patient follow up. aim the glomerular filtration rate (gfr) is measured frequently in cancer patient receiving cytostatics, because some of the pharmaceuticals are excreted by filtration in the kidney and some may also be nephrotoxic. the treatment dose of a few specific drugs is adjusted and calculated in relation to gfr and may be discontinued if gfr decreases severely. in denmark, gfr is assessed by plasma clearance of cr-edta ( cr-labelled ethylenediaminetetra-acetic acid), which is a highly reliable method, but indeed also time consuming. due to the frequent need of gfr-estimation it appears relevant to look for a more simple method for estimating gfr. in this study we therefore explored the possibility of replacing cr-edta (gfr) by an estimate (egfr) from plasma creatinine, sex and age of the patients according to . material and methods cancer patients having a least four cr-edta measurements performed in were included in the study. information concerning gender, age, weight, diagnosis, chemotherapy, plasma creatinine and gfr were obtained from the files and egfr was calculated using the cockroft-gault formula. results in , patients ( women and men) were subjects to at least four gfr measurements. mean age was years (range - years) and the diagnostic profiles included: sarcoma ( %), cancer of the bladder ( %), germ cell tumors ( %), cervical cancer ( %), lung cancer ( %), unknown primary ( %) and various ( %). all patients were treated with nephrotoxic chemotherapy such as cisplatin, carboplatin and ifosfamide. on average, gfr decreased continuously from the first to the last measurement: , , and ml/min ( %). egfr, however, first increased and then decreased with no difference between the first and last values: , , and ml/min. as a consequence, the ratio gfr/egfr decreased significantly from . to . . conclusion: in patients receiving nephrotoxic cytostatics gfr and egfr agreeded at the first examination but a % fall in gfr was not detected by the egfr. consequently, plasma clearance of cr-edta can not be replaced by egfr from plasma creatinine and the cockroft-gault formula in these patients if the aim is to calculate the specific dose as accurate as possible in order to monitor the toxicity of the various treatment strategies and to ensure the highest efficacy. [ ] the variation in age, body habitus, glycemia level, duration of uptake period and partial volume effects are important factors that influence the suv level. the purpose of this study was to quantitavely assess the differences of suvbw (suv measurement based on body weight) in normal tissues (blood, hepatic parenchyma, spleen, kidney, bone marrow, muscle, stomach, brain) and to evaluated the degree of correlation with body weight and age. materials and methods consecutive patients having fdg-pet/ct studies were evaluated retrospectively ( m and f mean: ± . y.o. and body weights ranged from to mean: ± ). approximately h after injection of mbq/kg of f-fdg, whole-body ct images were acquired without contrast media. a whole-body emission pet scan was performed with min acquisition per each bed position (pet/ct: discovery ste, ge). roi were placed at the same level with no know abnormality. mean suvbw were compared, and the correlation between fdg uptake and body weight, patient age was assessed by using the pearson correlation coefficient test. results the mean suvbw values for cerebellum, kidney, stomach, liver, bone marrow, spleen, blood and muscle were . ± . , . ± . , . ± . , . ± . , . ± . , . ± . , . ± . and . ± . . body weight correlated well with mean suvbw (blood r = . , p < . ; kidney r = . , p< . ; spleen r = . , p = . ; stomach r = . , p = . ; bone marrow r = . , p = . ; liver r = . , p = . ; muscle r = . , p = . ; cerebellum r = . , p = . ) the suvbw showed no significant and very weak correlation with age ranged from r = - . , p = . (kidney) to r = . , p = . (spleen). discussion although there was a wide variance in the suvbw, it showed a strong significant positive correlation with body weight in blood, kidney, spleen, stomach and bone marrow. the best correlation between glucose consumption and body weight was observed when the suvbw was > . ( blood) with exception of cerebellum. the suv bw showed no significant correlation with age. conclusion suvbw are weight-dependent indice for fdg uptake in tissues. there are however some notable differences between the r correlation coefficient with regard to the selection of normal tissues. aim: to investigate the diagnostic potential of a new semiquantitative sacroiliac index in bone scintigraphy, as a method to distinguish chronic, non-infectious, inflammatory sacroiliac disease (cilbp) from low back pain of mechanical/non-inflammatory origin (mlbp) in young males. patients and methods: we studied a relative homogenous population sample of young males, aged - years, including the age when many sacroiliac diseases emerge. of these people, (group a) had cilbp, verified by clinicolaboratory and other imaging procedures, (group b) had mlbp similarly verified, and the rest (group c) had been scintiscanned for reasons irrelevant to sacrospinal disease. all of them were also subgrouped by age criteria. after planar static bone scanning, two rectangular and symmetrical regions of interest (rois) were drawn onto the bottom third of the sacroiliacs, as well as a third one which encompassed the whole l vertebra. finally a non-dimensional numerical value called "r" was created for all patients, by the equation r = total counts/total pixels of the "hottest" of the two sacroiliac rois divided by the counts/pixels corresponding to the l values (r = si/l ). results: the statistical analysis showed negative correlation of r with age in all three groups (p= . for group , . for group and . for group c). regardless of age, the mean value of r of group's b patients ( . +/- . ) appeared significantly lower (p= . ) than group's a ( . +/- . ) and unsignificantly higher (p= . ) than group's c ( . +/- . ), while group's a mean value of r also appeared significantly higher than group's c (p< . ). conclusions: the si/l ratio seems to decrease with ageing -at least in the young ages-, irrespectively of the presence of cilbp, and its clinical potential seems to be helpful in the distinction of patients with cilbp from both the normal people and from patients with mlbp. to our knowledge, there is no other study of this semiquantitative index in young male adults with cilbp using the above methodology, but a larger population sample would still be necessary so to accurately standardize the normal value range of si/l ratio. f. marafi, a. syed, a. esmail, a. elgazzar; mubarak al-kabeer hospital, jabriyah, kuwait.aim: post-polio syndrome causes new weakening in muscles previously affected by the polio infection and in muscles that seemingly were unaffected. patients present with musculoskeletal pain, weakness, and fatigue that probably result from overuse and misuse of muscles and joints. the objective of this study is to review patterns of poliomyelitis on bone scintigraphy. material and methods: bone scans of adult patients, five females and one male, aged to years, known to have paralytic poliomyelitis were studied. five patients had unilateral while one has bilateral disease. patients' complains included knee, shoulder, neck and/or back pain. all the patients underwent three-phase bone scan acquired minutes (blood pool) and hours (delayed) post-intravenous injection of mci of tc m mdp. studies were reviewed by two nuclear medicine specialists and findings were recorded. results:the following patterns were recognized: ( ) markedly decreased blood pool activity in all affected limbs particularly distal to the knee (both limbs in the patient with bilateral disease), ( ) deformed ipsilateral hemipelvis with relatively reduced radiotracer uptake in all patients with unilateral disease with minor degree of asymmetry in the patient with bilateral disease, ( ) stress changes in the contralateral lower extremity illustrated by relatively increased radiotracer uptake diffusely in the bones of the lower extremity and ( ) degenerative changes of multiple joints (shoulders, knees, ankle and spine). significant scoliosis was only noted in the patient with bilateral disease. conclusion: bone scintigraphy shows several poliomyelitis related findings predominantly due to skeletal asymmetry with unilateral disease. awareness of the characteristic scintigraphic findings is important to avoid misdiagnosis on bone scan which can help also in the follow up of post poliomyelitis changes. purpose: to examine the observer variation for bone scintigraphy in the detection of occult scaphoid fractures in daily practice, using only the early bone scanning images. methods: one hundred subsequent bone scans of patients with a suspected scaphoid fracture but negative initial radiographs were prospectively included to calculate the inter-and intra-observer variation. three nuclear medicine physicians independently evaluated all bone scans at two different points in time with a three months interval. the observers filled out a blinded scoring sheet for each patient. they scored if a scaphoid fracture was present or not. in addition they scored the presence or absence of another fracture. the inter-and intra-observer variation was analysed using the kappa statistic. results: the inter-observer variation showed substantial agreement for a scaphoid fracture and almost perfect agreement for another fracture. the intraobserver variation showed almost perfect agreement for both a scaphoid fracture and another fracture. conclusions: in the present study early static images of bone scintigraphy for suspected scaphoid fractures showed very little inter-and intraobserver variation. in addition, expertise does not seem to have a negative influence on the results. this enhances the possibility of using bone scintigraphy in daily practice. aim: to determine normal limits for quantitative m tc-hdp three phase bone scintigraphy regarding flow distribution at ankle and mid foot level. materials and methods: consecutive patients referred to bone scintigraphy and without known pathology in the legs or hips were included. patients were eligible, females and males. the population was divided into three groups according to age; less than years (n= ), between and years (n= ) and older than years (n= ). quantitative three-phase bone scintigraphy was performed in all patients. first phase consisted of a dynamic planar uptake in anterior projection immediately after a bolus injection of mbq m tc-hdp with a matrix size of by pixels with a legp collimator, dorsal view, and recording of frames at two frames per second. a processing protocol with standardised size rois was used to quantify flow distribution at ankle level and in the mid foot using the area under the curve for each roi during the first ten seconds of initial bolus passage. results: blood flow distribution at ankle and mid foot level for the three age groups is presented in table . conclusion: we suggest the normal range for distribution of blood flow at ankle level determined by quantitative three phase bone scintigraphy to be / (i.e. mean + sd). since variation in blood flow at ankle and mid foot level increases with age most probably because of uneven development of arteriosclerosis and various joint diseases, normal ranges for blood flow distribution at ankle level is wider among people older than years. at mid foot level the normal range for blood flow is as wide as / . the reference levels presented have been produced with the intention to quantify blood flow distribution at ankle and mid foot level among patients with various pathological conditions in particular charcot foot. aim: the aim of this study was to determine whether there is a difference between the left and the right proximal femur bone mineral densities (bmds) and, therefore, whether it is necessary to measure bmd of the femur bilaterally in determining bone loss. material and methods: this study was performed on subjects ( women, mean age ± years; and men, mean age . ± years). bmds of both hips (femoral neck, trochanter, intertrochanter and ward's area) were measured using dual energy x-ray absorptiometry (dexa) (qdr_ -hologic densitometer). the statistical software spss version for windows (spss, inc, chicago, il) was used for statistical analysis. a paired t-test was used to assess the right versus left (r-l) differences in bmds of the said regions. the results of bmd measurements were expressed in units of grams per square centimeter (g/cm²) as means (m) and standard deviations (sd). the -tailed pearson correlation was used for correlation analyses between r-l bmds. results: the mean femoral neck and trochanter bmds in total subjects were higher in the right leg than the left ( . ± . vs. , ± . , p< . ; and . ± . vs. . ± . , p< . , respectively). similar results were also obtained in females ( . ± . vs. , ± . , p< . ; and . ± . vs. . ± . , p< . , respectively). in males, a significant right versus left bmd difference was found only in femoral neck ( . ± . vs. , ± . , p< . ). there were significant correlations of bmd between all the right and the left femoral regions (p< . ). conclusion: although bmds of the right and the left femoral regions were strongly correlated, there were significant r-l differences of bmd in femoral neck (in males and females) and trochanter (in females). therefore, bilateral femur bmd should be taken into consideration in evaluating a possible bone loss.aim: the purpose of this series of cases was to describe clinical findings and patterns of the triple phase bone scans in young patients with clinical examination suggesting medial tibia stress syndrome (mtss) or "shin splint", term frequently used synonymously with this disorder. material and methods: this study included seven patients ( limbs) selected retrospectively with clinical examination suggesting mtss that underwent plain radiographs and triple phase bone scintigraphy (tpbs) with technetium- methylene diphosphonate dimmer (mdp) during the period from june/ to february/ . patients generally reported diffuse tenderness along the posteromedial edge of the tibia and complained of exercise-induced pain after starting physical activity. results: five patients had bilateral symptoms and two had unilateral pain. mean duration of symptoms was about . weeks. there were male and female. age ranged from to years old (mean value= . ). patients included runners ( military recruits and recreational runners), professional basketball player, recreational soccer player and recreational gymnast. all the patients related exercise-induced pain in the beginning of activity. one recreational runner related an unbearably pain when he continued the activity. radiographs were normal in all patients. perfusion and blood pool images of isotope bone scans were normal in all cases. delayed bone scintigraphy showed characteristic longitudinal linear uptake in limbs ( patients) and focal uptake (longitudinally spindle-shaped uptake) in limbs ( patients). conclusion: in this study, all patients with clinical examination suggesting mtss had scintigraphic abnormalities. most of them had focal uptake (longitudinally spindle-shaped uptake) in the bone scan. it was an unexpected finding once mtss pattern most usually found in other studies is longitudinal diffuse uptake (double stripe sign, tubular pattern or longitudinal linear uptake), more related to bone remodeling. in the current study, most patients were recreational athletes. this fact suggests that many of these problems result from poor or misguided training regimens. bone scintigraphy was an important tool to confirm the clinical diagnosis of mtss and exclude other causes of lower leg pain such as stress fracture, nerve compression syndrome and extertional compartment syndrome. accurate diagnosis is essential in early phase after the onset of pain to establish specific treatment and ensure return to sports activity. transiet osteoporosis of the hip (toh) is an uncommon condition. it presents with progressively worsening hip pain gradually increasing without history of trauma. there is a characteristic discrepancy between substantial clinical disability and minimal physical findings. this condition is characterized by a predictable bening course, with complete clinical recovery. unlike toh, avascular necrosis (avn) is a introduction-aim: early diagnosis of osteomyelitis (om) in the diabetic foot reduces the need for amputation, but detection is difficult. coexisting disorders such as soft tissue infection and charcot arthropathy (ca) may obscure the clinical and radiological manifestations of om and bone biopsy is not routinely performed. the aim of this prospective study was to evaluate the efficacy of tc m-hmpao-labelled leucocyte scan (hmpao-ls) for the diagnosis of om in the complicated diabetic foot, in comparison with other commonly used diagnostic modalities. patients and methods: forty five diabetic patients with clinical suspicion of om in pedal sites were enrolled in the study. all patients had pre-existing pedal abnormalities including pedal ulcers (n= ), ca (n= ), and toe or foot amputation (n= ). c-reactive protein levels (crp), esr and white blood cell count (wbc) were measured at inclusion. all patients underwent plain radiography, three-phase tc m-mdp-bone scan (mdp) and hmpao-ls. tc- m-sulfur colloid bone marrow scan (bms) was additionally performed in patients to interpret abnormal leucocyte uptake in ca. spatially congruent bone/leucocyte findings were interpreted as positive for om. incongruent hmpao-ls /bms indicated om superimposed on ca. diagnosis was confirmed by long-term clinical and radiological follow-up or bone biopsy. results: among the pedal sites investigated, foci of om, cases with acute charcot arthropathy (aca) and sites with simple soft tissue infection (sti) were diagnosed. patients with om had higher crp compared with those with aca or sti ( . vs . and . mg/l , p< , ). wbc and esr were not significantly different among the three groups of patients. plain radiography was insensitive ( . %), but very specific ( . %) while three-phase bone scan was extremely sensitive ( %), but not specific ( . %) for the diagnosis of diabetic foot om. the sensitivity, specificity and accuracy of hmpao-ls were %, % and . %, improved to %, % and . % respectively with the addition of bms. conclusion:among laboratory tests, elevated crp is better marker of om in the diabetic foot compared with leucocytocis or elevated esr. plain radiography is the least sensitive imaging method for early diagnosis of om and bone scan is the least specific method for detecting om in patients with pre-existing pedal abnormalities. tc m-hmpao-labelled leucocyte scan is the most accurate radionuclide method for the diagnosis of om in the diabetic foot. the addition of bone marrow scan improves the specificity of leucocyte scan for diagnosing om superimposed on ca. aim: in the large-vessel vasculitis, in particular takayasu arteritis (ta), clinical signs and laboratory tests are not good markers for evaluating the vascular disease activity. aim of this study is to evaluate if fdg-pet can have a role in assessing the inflammatory activity and the extent of the disease in patients (pts) with ta by a correlation between f-fdg uptake, acute-phase reactants and the clinical outcome. material and methods: we studied consecutive pts with large-vessel vasculitis in steroid treatment (m/f / ; age ± yrs; ta and giant cell arteritis). a total number of pet studies was acquired. fdg uptake was evaluated using a visual score ( - - - ), in different vascular areas and a total vascular score was calculated.pet was performed at the same time of the evaluation of acute-phase reactants [erythrocyte sedimentation rate (esr), c-reactive protein (crp) and interleukin- (il- )] and assessment of disease activity according to the kerr criteria. results: the frequency of elevated esr was higher (p . ) in presence of vascular fdg uptake ( %) than in absence of uptake ( %). esr was higher (p . ) in pts with vascular fdg uptake ( ± ) than in pts with no uptake ( ± ). the pet score was significantly (p . ) higher in pts with high esr ( . ± . ) than in pts with normal hsr ( . ± . ). the correlation of pet score was significant with ers (r=+ . p . ) and il- (r=+ . p . ) and not with crp (r=+ . ns). the pet score was significantly higher (p . ) in pts with active disease ( . ± . ) than in pts with inactive disease ( , colon carcinoma= , kaposi sarcoma= , lung tumors= , anal carcinoma= , myeloma= , cervical carcinoma= , hcc= , brain tumor= ) underwent fdg pet/ct studies to identify areas of hiv replication and/or tumor increase. all hiv-positive patients had a combined pet and ct body scan (discovery ls pet ct, ge healthcare, milwaukee, wi, usa) from the base of the skull to the pelvis with [ f]fluorodeoxyglucose (fdg) and patients also had brain studies with fdg. fdg accumulations (visual and quantitative) were rated, on a per patient basis, as true positive(tp) or true negative(tn), and false positive(fp) or false negative(fn), based on final clinical data. results: / ( %) hiv-positive patients had proven malignancies (nhl= , hl= , lung cancer= , anal cancer= , brain tumor= , hcc= ) in cytology/histology and conventional diagnostic imaging procedures (ct, mri, abdominal us, thorax x-ray). in this context, overall sensitivity (tp/tp+fn), specificity (tn/tn+fp) and accuracy (tp+tn/tp+tn+fp+fn) of pet/ct scanning with fdg was: %, %, % respectively for diagnosis of nhl diseases; %, %, % respectively for diagnosis of hl and %, % and % respectively for diagnosis of other neoplastic diseases. moreover, nodal fdg uptake showing active hiv replication areas was well identified in / hiv-positive subjects, and lung infections were correctly diagnosed in six more hiv-positive cases. the standardized uptake values (suvmax) over nodal lesions from lymphoma (nhl plus hl) were in the range of . - and in active hiv replication were in the range of . - . . conclusion: in our patient series, fdg pet/ct scan misjudged in the separation of malignancy from infection in some cases. however, pet/ct provided accurate localization of malignant and infective disease allowing biopsy of specific sites. even if abnormal fdg uptake occurs in subjects' nodes with detectable viral load, evaluating active lymphoid tissues during hiv infection from malignant lymphomas was possible. the effect of recent hemodialysis on invivo labeled m tc wbc lung retention in patients with end stage renal disease (esrd)aim: several clinical studies are evaluating the therapeutic potential of delivery of various progenitor cells (pcs) for treatment of injured hearts. the only noninvasive in vivo imaging method for evaluation of homing of transplanted haematopoietic pcs (hpcs) used so far was labelling the cells with in-oxine. the aim of our study was to evaluate radiolabelling of cd + haematopoietic pcs with mtc-exametazime and to examine use of radiolabelled cells to monitor myocardial homing. materials and methods: human hpcs were mobilized with granulocyte-colony stimulating factor and collected by aphaeresis. cd + cells were enriched with an immunomagnetic separation device (isolex i). amount of collected cd + cells per patient varied between to million. a fraction of of the cells ( - %) was radiolabelled with mbq of mtc-exsametazime and incubated for min at room temperature. to remove unbound radioactivity, the cells were washed with cell free media. cell viability was assessed by trypan blue exclusion assay before radiolabelling and and min after labelling. labelling stability of hpcs was assessed min after cell labelling. - mbq of radiolabelled cells was injected into open coronary vessel through a micro catheter. spect images were obtained and hours after hpc injection. results: labelling efficiency of hpcs was up to . % depending on the amount of cells available for radiolabelling. according to trypan-blue staining, viability of radiolabelled hpcs before and immediately after the labelling was . % and . % respectively, whereas viability min after labelling was %. labelling stability of hpcs min after cell labelling was . %. spect images obtained and hours after hpcs injection enabled us to evaluate the arrangement and percentage of transplanted hpcs accumulated in the heart muscle. additionally it was possible to evaluate their migration and accumulation in the reticuloendothelial system of the liver, spleen and bone marrow. conclusion: we can conclude that mtcexametazime labelling of hpcs is feasible, and in vivo imaging with spect provides a non-invasive method for sequentially monitoring cell trafficking with good spatial resolution. red cell mass, plasma volume, blood volume and their deviations from expected normal values in patients with end stage chronic renal disease. results: pvk was correlated (r : . p< . ) with pcv and bmi in all patients especially in men (r : . ). rcvk in all patients was also strongly correlated (r : . p< . ) with pcv and bmi. rcvk in men is affected only by bmi (r : . p< . ), while in females both pcv and bmi's influence reach statistical significance. in general, drcv and dpv are strongly related to bmi and pcv (r : . and . respectively). in men pcv and w predict drcv and dpv (r : . and . respectively) whereas in female subjects only drcv is strongly correlated (r : . p< . ) with pcv and w. serum fe seems to have a predictive role in drcv and dpv estimation. no other significant correlation among biochemical parameters (urea, creatinine, pth), total duration of dialysis and blood volumes was found. conclusion: not only radionuclide measurement of blood volumes but their promt estimation as well from the above equations has an important role in decision making in patients at esrd providing a applicable estimation of their anaemia. aim: to assess the contribution of an integrated spect-ct (infinia-hawekeye , ge healthcare) in patients undergoing m tc-radiolabelled blood cell imaging. material and methods: consecutive patients underwent m tc-radiolabelled blood cells imaging. among them, patients had m tc-red blood cell imaging (rbc) for suspicion of liver or spleen hemangiomas (n= ), and for suspicion of splenosis (n= ); additionally, patients had m tc-hmpao-white blood cell imaging (wbc) for detection of active crohn's disease (n= ), and for suspicion of infection (n= ). following the routine protocol, a low-dose unenhanced spect-ct study ( . ma, kv, eff.d msv) was performed. spect-ct findings were compared to planar and spect results. final reports were correlated to morphological imaging, clinical and surgical reports. results: in the rbc group, / patients had a positive study suggestive of liver or spleen hemangiomas (n= ) and splenosis (n= ). spect-ct was particularly useful for appropriate differentiation between physiological uptakes and pathological uptakes (vessel hot spots vs. liver lesions), as well as for precise anatomic localization of functional splenic remnants. all liver lesions > . cm were assessable on the low-grade ct, but liver or spleen lesions < cm were not always distinctly detected. in some patients, respiratory motion artifacts also impaired the ct quality. in the wbc group, patients had a positive study suggestive of infection on planar imaging. spect-ct was particularly helpful for a more accurate diagnosis of osteomyelitis vs. soft tissue infection (n= ), or for confidently ruling out a liver abscess (n= ). in patients with crohn's disease (cd), spect-ct allowed better anatomic localization of disease extent, and exclusion of intra-luminal bowel activities. in patient, spect-ct helped identify an entero-cutaneous fistula from ileostomy; in patients with active cd, the low-dose ct showed a colon wall thickening with a lumen narrowing matching a hot spot on the spect part. conclusion: in m tc-radiolabelled blood cell imaging, a low-dose multi-slice spect-ct, the infinia-hawkeye - , was found useful for improving the interpretation confidence, and thus, the diagnostic accuracy. aim: behcet's disease (bd) is a multisystem disorder characterized by vasculitis, and consists of a triad of recurrent ulcers of the oral and genital mucosa with relapsing uveitis. the prevalance of pulmonary involvement varies in the range of % - in various studies and its complications are severe and life threatening. we aimed in this study to investigate the changes of pulmonary epithelial permeability of patients with bd using m tc-dtpa aerosol scintigraphy. material and methods: twenty-one non-smoking patients with bd ( females, males; mean age: . ± . years) and healthy voluntary non-smoking controls ( females, males; mean age: . ± . years) underwent m tc-dtpa aerosol inhalation scintigraphy and pulmonary function tests. subjects inhaled mbq of m tc-dtpa for minutes in supine position. scintigraphic data were recorded dynamically ( frame/min) in posterior projection on a x matrix for a min period using with a double headed gamma camera (infinia, ge, tirat hacermel, israel) equipped with a low-energy all purpose parallel hole colimator. half time of m tc-dtpa clearance (t / ) were calculated by placing a mono-exponential fit on the curves. penetration index (pi) was also calculated by dividing the peripheral total counts by the sum of the peripheral and central total counts on the first minute image, in order to quantify the distribution of the inhaled aerosol. results: the clearance half time of m tc-dtpa radioaerosols in bd's patients ( . ± . min) were faster than in normal control group ( . ± . min) (p= . ). there was also a significant difference between pi of patients with bd ( . ± . ) and that of controls ( . ± . ) (p= . ). no correlation was found between the mean t / values of m tc-dtpa clearance and the spirometric measurements except fev in bd patients (r= . ; p= . ). pi were correlated with fev in bd patients (r=- . ; p= . ). conclusion: lung epithelial permeability of the patients with bd was found significantly lower than that of normal subjects. the result of this study demonstrated that the assessment of lung epithelial permeability using m tc-dtpa aerosol scintigraphy could predict the presence of lung involvement in patients with bd. . detect of pulmonary emobolism in patients with deep venous thrombosis using m tc -technegas/ m tc-maa lung scan s. l. chen, b. l. li, w. liu, y. gu; institution of nuclear medicine,zhongshan hospital,fudan university, shanghai, china. the existence and severity of pulmonary thromboembolism(pte) was still one of the major clinical concerns. the aim of this study was to assess the use of lung ventilation/perfusion (v/q ) scan in the investigation of pte, and compared the results of lung ventilation/perfusion (v/q ) scan with ct angiography (cta) or mr angiography (mra). methods: a total of patients with deep venous thrombosis (dvt) underwent v/q planar scan and chest x-ray , cta or mra were performed also. the modified prospective investigation of pulmonary embolism diagnosis(pioped) diagnostic criterion was used for interpretation of lung scintigraphy. according to the data of perfusion-ventilation scintigraphy, the patients was consider with a high pretest probability of pulmonary embolism, intermediate probability of pulmonary embolism, low probability of pulmonary embolism, lower clinical probability of pulmonary embolism or normal. the patients with a high pretest probability, intermediate probability and low probability were positive, lower probability and normal patients were negative. results: among the patients, patients with a high clinical probability of pulmonary embolism ( . %) by mtc -technegas/ mtc-maa lung scan, patients with a intermediate clinical probability of pulmonary embolism ( . %), patients with a low clinical probability of pulmonary embolism( . %), patients with a lower clinical probability of pulmonary embolism ( . %), another patients were normal( . %). pulmonary embolism was detected in of the patients ( . percent). compared with the data of lung v/q scan detect and cta or mra examination in the patients with clinical probability of pulmonary embolism, % patients showed different blood vessel abnormality findings between lung v/q scan defect and cta or mra. we found that in patients with partly pulmonary embolism, the blood flood could pass away the stricture artery. so the perfusion scan of the patients maybe was normal, the perfusionventilation scintigraphy couldn't found pathological vascular disease. moreover, when the small pulmonary embolism was in the laterale or outboard segment of the lung, cta or mra maybe mistake diagnosis and the perfusion-ventilation scintigraphy could found pathological vascular disease. conclusions: lung v/q scan was a considerably effective technique to detect pte. the combination of v/q scan and cta (or mra) could provide more comprehensive and accurate diagnosis information. and a larger outcome study is needed. comparison of ventilation-perfusion scintigraphy and contrast enhanced computed tomography in patients with pulmonary embolism k. f. wurm, t. zelesny, u. wacker, a. hentz, f. dammann; department of radiology and nuc. med., göppingen, germany.aim: ventilation-perfusion scintigraphy has been the main imaging modality used in the evaluation of patients with suspected acute pulmonary embolism. since the introduction of multi-slice devices computed tomography has been used as an equivalent imaging method. the aim of our study was to correlate the results of ventilation-perfusion scintigraphy with spiral ct pulmonary angiography. material and methods: we evaluated patients ( women, men, mean age years) with suspected acute pulmonary embolism (symptomatic patients and increased d-dimer blood test). all patients underwent computed tomography and ventilation-perfusion scan. scintigraphic examinations were obtained with two head gamma camera, using tc- m labelled human albumin microspheres. spiral ct scans were performed with the use of radiological contrast and multi-slice device. we compared the results of these three investigations. the sensitivity and specificity were evaluated. results: the ventilation-perfusion scintigraphy presented matching results in of cases. of them presented an identical issue in computed tomography. in of cases we found a mismatch of ventilation-perfusion study. in cases computed tomography could confirm a positive acute lung embolism. the sensitivity and specificity of lung perfusion scan in detecting lung embolism was % and %. computed tomography revealed a sensitivity and specificity of and %. conclusion: the results of ventilation-perfusion scintigraphy confirm a high sensitivity for diagnosis of lung embolism. in correlation computed tomography presented a similar sensitivity with additional specific informations. both modalities shall be accepted further on as an important diagnostic tool for patients with suspected lung embolism. pfeifer, n. millman, j.mortensen; rigshospital, universityhospital of copenhagen, københavn Ø, denmark.a -year old woman, suffering from stridor and dyspnoe was diagnosed with tracheobronchial amyloidosis of transthyretin type (attr). pulmonary involvement in attr is uncommon. according to the patient's symptoms and for prognostic reasons it was important to rule out cardiac amyloidosis as frequently seen in attr. the usefulness of m tc -aprotinine scintigraphy in detecting extra abdominal lesions of amyloidosis and especially early cardiac involvement has previous been shown ( ) . thus, the patient was evaluated with m tc -aprotinine whole body scintigraphy supplemented with single photon emission tomography (spect) and computer tomography of the chest using the vg hawkeye ge hybrid system. there was a close correlation between a) the scintigraphic findings of amyloid deposits in the central airways and b) the wall changes of the right upper bronchus as seen on the low quality ct (hawkeye) and c) the right upper lobe atelectasis shown on chest x-ray. no extra pulmonary amyloid deposits were found. conclusion: m tc -aprotinine scintigraphy with spect/ct detected amyloidosis in the central airways that correlated closely to the clinical and histological findings. reference: ( ) objectives: the purpose of this study was to evaluate the usefulness of tl- chloride/tc- m mibi, for the investigation of lung lesions, after comparison with ct and histological findings. methods: scintigraphy with tl- chloride and tc- m-mibi was performed in patients [ men, aged - years and women aged - years] with radiographic findings lung nodules, suspicious for malignancy. factors of the early and delayed static scans (hot, warm or cold uptake), the early and delayed retention indexes, the blood flow and the tumour retention index were obtained from tl- /tc- m-mibi scintigraphy. tumour retention indexes were classified into three grades; slightly (> . ), moderately ( . - . ) and severely (< . ) decreased. grade of tissue differentiation of tumour (well, moderately or poorly differentiated) and tumour size (t t ) were examined. scintigraphic indexes and tumour characteristics were compared. results: the early static scan and tumour size showed a correlation with the blood flow index. however, the delayed static scan did not show any relationship with blood flow index and tumour size. the tumour retention index with tc- m-mibi had a tendency to decrease in malignant tumours, and showed a significant correlation with the grade of tissue differentiation of the tumour. regarding tl- chloride we obtained a . % sensitivity, % specificity, % accuracy, a . % positive prognostic value and a . % negative prognostic value. conclusions: the tendency of the tumour retention index to decrease in tc- m-mibi scintigraphy might imply the malignancy of the nodule investigated and would be an additional useful parameter for the accuracy of the diagnosis. introduction: in patients with ctd, the early detection of the pulmonary involvement is mandatory. pulmonary function tests (pfts) are considered to be valuable noninvasive diagnostic modalities. among them, carbon monoxide lung diffusion (dlco) reduction that is consistent with pulmonary fibrosis and microvascular damage is widely considered as the earliest and most sensitive index for the evaluation of pulmonary involvement. in previous studies we proposed the usefulness of hig scintigraphy in the evaluation of lung involvement in ctd. the aim of our study was the evaluation of hig lung scintigraphy, in the early detection of the pulmonary involvement in ctd patients. methods: fifty-two non-smoking patients suffering from scleroderma, rheumatoid arthritis or systemic lupus erythematosus (males/females / , mean age . years, mean duration of disease . years) and referred to our institution for detection of possible pulmonary involvement were included in this study. patients were submitted to pfts (dlco, forced vital capacity [fvc] and total lung capacity [tlc]) and hig scintigraphy within a week. for semiquantitative interpretation of hig scintigraphy, a region of interest (roi) analysis was performed on the posterior view (sum of the mean activity for each lung divided by mean left ventricular activity / = average score). the average score was correlated with pfts. pearson's correlation coefficient r was calculated. a probability p< . (two-tailed) was considered to indicate statistical significance. results: pfts abnormalities were detected in patients (dlco reduction in , fvc reduction in and tlc reduction in patients). a statistically significant negative correlation was detected between hig scores and each one of the pfts [dlco (r=- . , p< . ), fvc (r=- . , p= . ) and tlc (r=- . , p= . )]. in patients isolated dlco reduction (normal fvc and tlc) was detected. hig scores were greater in these patients comparing to them with dlco within normal range ( . vs. . , p< . ). discussion and conclusion: dlco reduction was the commonest pulmonary function abnormality in our patients. the isolated dlco reduction might be attributed to pulmonary microvascular damage and increased membrane permeability, which constitutes one of the possible mtc-hig uptake mechanisms. by this pathway, hig lung scintigraphy seems to be useful in the early detection of the pulmonary involvement in ctd patients. aim: the aim of the study is to documentate intraoperative gamma probe applications in neck surgery in our hospital. material and method: between january -march with the guidance of intraoperative gamma probe patients underwent parathyroidectomy, well differentiated thyroid cancer patients; complementary thyroidectomy, medullary thyroid carcinoma patients; recurrent tumor exicion and carcinoid patient; tumor excision. before parathyroidectomy mci of tc m-mibi was injected and during hours static images were obtained every minute in order to detect maximum parathyroid/thyroid uptake. at the operation day according to this optimal timing mci tc m-mibi was injected. for complementary thyroidectomy μci i - was given per orally hours before the surgery and patients were imaged at - th hour following i- injestion. in medullary thyroid carcinoma patients mci of tc -dmsa(v) and in carcinoid patients mci tc m-mibi was injected minutes before the operation. results: in parathyroidectomy patients during operation except , ideal timing for peak parathyroid/thyroid uptake ratio was reached. obtained parathyroid/thyroid ratios were quite variable and changed between; . - . in complementary thyroidectomies thyroid/background ratios were between; - . tumor/background ratio was - . in medullary carcinoma and . in carcinoid. conclusion: optimization of injection time before surgery is very important in radioguided parathyroidectomy. this can be reached with the cooperation of departments of surgery and nuclear medicine. in parathyroidectomies, complementary thyroidectomies and in various tumor excisions beside a guidance potential, gamma probe help surgeons to instantly verify accurate removal of the targeted tissues. graft-versus-host disease (gvhd) is common compication of allogeneic bone marrow transplantation (bmt) in which functional immune cells in the transplanted marrow recognize the recipient as "foreign" and mount an immunologic attack. the chronic form of graft-versus-host disease (cgvhd) is defined as that which occurs after days. chronic gvhd demages liver, skin and mucosa, and the gastrointestinal tract like in acute gvhd (agvhd), but also causes changes to the connective tissue of the skin and exocrine glands. function of salivary glands, as exocrine glands, is very often observed in patients suffering from cgvhd. aim:the aim of this study was to evaluate the function of major salivary glands with dynamic salivary gland scintigraphy (dsgs) in hematologic patients suffering of cgvhd after allogenic bmt. methods: dsgs was performed after iv. injection of mbq tc mpertechnetate, with gamma cammera above parotid (pg), submandibular salivary glands (sg) and oral cavity (oc). dsgs lasted minutes (one frame-one minute), with per os stimulation in . minute with ascorbic acid tablete. time-activity curves (tac) were generated over pg, sg and oc as regions of interest. activity in oc was estimated on static scintigram . minutes after iv. injection.using tac and scintigrams, dsgs findings were graded from to according to shall at all. ( sct grade -normal finding, sct grade -moderate function damage, sct grade serious function damage, sct grade -very serious function damage). dsgs was performed in five patients, seven to ten months after allogenic bmt. two pts. were male and three female, aged from ninetheen to thirty nine years. three patients suffered from acute leucaemia and two from mielodisplastic syndrome. results: three pts. suffered from agvhd and all pts. were diagnosed as having cgvhd in skin, mucosa and liver. four pts. had feeling of dry mouth (xerostomia). all pts. with xerostomia had patological scintigraphic finding: two pts. had sct grade and the other two sct grade . in pts. without xerostomia scintigraphic finding was negative. conclusion: this preliminary results sugests that dsgs, as objective test, can detect disfunction of salivary glands in patients suspected of chronic graft-versus-host disease, improving diagnosis and forehand therapy of cgvhd. bone metastases are a frequent complication in oncological patients, and can deteriorate their quality of life by the appearance of bone pain, and, to a less degree, fractures or medular compression. bone pain treatment is multidisciplinary, aim: objective of this study is the evaluation of the staff radiation extremity exposure from preparation and application of y-zevalin (activity/patient< . mbq) in our hospital. material and methods: data from the first therapeutic administrations were considered. the chemists performed the radiolabelling at a high protection standard in a dedicated hot cell, using shieldings in plexiglas for vials and syringes, tele-tongs and an automatic dispensing system. technicians were involved in activity dose preparation only before buying the current dispensing system. physicians administered the radiopharmaceutical through slow activity infusion (duration nearly min). all operators wore both latex and anti-x gloves. thin-layer tlds (lif:mg,cu,p) were fixed to the fingertips to measure the local skin dose, hp( . ), at the position with the highest risk of exposure to adequately protect the hands. tlds were given to the chemist and the technician, while to the physician. results: as for the chemist fingertips, the th percentile of the dose distribution (hp( . )) is . msv/gbq, while the th is . msv/gbq. for each radiolabelling the sum of all fingertips adsorbed doses was performed. the mean of these values is . +/- . msv/gbq. the medians of the radiolabelling fingertips doses range from . to . msv/gbq, while the means range from . to . msv/gbq. the ratio between the highest and the lowest absorbed dose to the fingertips is extremely variable per radiolabelling, observing values from . to . . technician doses are lower than the chemist ones, ranging from . % to . % compared to the latter. as for the physician the medians of the fingertips doses range from . to . msv/gbq/administration, while the means range from . to . msv/gbq/administration. conclusion: when working at low radioprotection level, the exposure of the staff might exceed the annual skin dose limit of msv. it is due to carry out an extremity monitoring with fingertips dosimeters suitable to betaradiation, stated the high risk of the method. aim: radionuclides have been used worldwide for diagnosis and treatment. their use in brasil have started in and have been increasing progressively, benefiting thousands. scintigraphic methods have significant role in brazilian physicians practice. despite its great importance, nuclear medicine's image was tarnished by nuclear disasters as chernobil ( ) and goiania ( -brazilian disaster linked to radiotherapy). those events boosted fear in public opinion concerning the use of radiation in medical procedures, even those that utilize small amounts of it like nuclear medicine. this work aims to evaluate how widely spread is knowledge about nuclear medicine among its patients, to find out their personal view and fears about procedures and specially if fear of radiation is usual. materials & methods: after reading and accepting informed consent, adult patients underwent a multiple choice questionnaire. research took place in a private service of nm in teresina, brazil during january-march . results: patients were interviewed, women and men, ages ranging from to years old. most patients ( . %) have never undergone a nuclear medicine procedure before; ( . %) had never even heard about this medical field. from the ( . %) that already knew something about nuclear medicine, ( %) received information from relatives or friends. patients under years old were not asked to answer the questionnaire. a great majority ( . %) believe that the exam will be useful in solving their health problem. besides, % think it is a very advanced procedure and . % declared insecure due to their lack of information. only ( . %) patients reported to have some kind of fear; ( . %) from them said to be afraid of bad result; ( . %) feared it could be painful and only ( . %) were afraid of exam's radiation. others kinds of fears, as allergic reactions, injection, suffocation, distressed ( . %) of the patients. conclusion: although many had already heard about this kind of procedure, lack of information is still usual among them. therefore, greater efforts for public diffusion of social benefits of nuclear medicine are needed. fear of bad result is the most frequently mentioned, probably because it may represent life-threatening situations as bone metastasis and coronary insufficiency. twenty years after brazilian main nuclear accident (goiania), fears of radiation seem not to be very important among patients. m. gerhardt, t. pulawska, s. b. søndergaard, b. zerahn; herlev hospital, copenhagen county, herlev, denmark. to evaluate the effect of music composed with the purpose of being calming, on heart rate and motion artefacts during image acquisition in rest and stress myocardial perfusion scintigraphy. material and methods: patients referred for myocardial perfusion imaging on the suspicion of ischemic heart disease were included in a randomised cross over study. only studies with successful gating during both rest and stress image acquisition were included. patients listened to music during acquisition of rest images and not during stress image acquisition and patients did vice versa. the study comprised women and men. the music played is named musicure and composed with the purpose of creating a relaxed atmosphere. the music is non vocal, slow in tempo and performed with acoustic and electric instruments and nature sounds. heart rate was registered before and after each image acquisition. motion artefacts were evaluated by two independent specialists in nuclear medicine using a semiquantitative four point scoring system. after each image acquisition the patients filled in a questionnaire with their evaluation of the calming effect of music/no music, whether they liked the music played or if they would prefer to select the style of music played, and if they would prefer to listen to music during the acquisition or not. results: during stress image acquisition there was a significant decline in heart rate of - . (± . ) bpm, (p= . ) among patients who did not listen to music. this decline in heart rate was significant for women alone; - . (± . ) bpm, (p= . ) but not for men; - . (± . ) bpm, (p= . ). regardless of music being played or not there was no significant effect on heart rate during rest acquisition and there was no difference in the frequency or severity of motion artefacts. % of the patients preferred to listen to music during image acquisition, and % would prefer to select music of their own choice. % of the patients declared that the music had a calming effect, % no effect, and % found it to be distressing. conclusion: listening to music during acquisition for myocardial perfusion imaging after stress prevents a decline in heart rate in particular among women and has not any adverse effects on the frequency and severity of motion artefacts. a vast majority of patients preferred to listen to music during image acquisition, although half of the patients preferred to select the music style themselves. flood field uniformity quality control (qc) is an essential function that must be performed daily before a gamma camera can be placed into clinical service for that purpose. clinical audit (ec directive / /euratom): systematic examination or review of medical radiological procedures which seeks to improve the quality and the outcome of patient care through structured review whereby radiological practices, procedures and results are examined against agreed standards for good medical radiological procedures, with modification of practices where indicatedand the application of new standards if necessary. implementation of med directive. clinical audit shall be arranged to supplement the self-evaluation of practices. objective must be that clinical audit be carried out every years to cover all essential radiological practices in health care. ten points of interest to be covered by clinical audits are defined in the degree. introduction in any medical investigation the result standards in terms of sensitivity, specificity and accuracy are expressed. for stress myocardial perfusion scintigraphy (smps) in ideal non-selected population these values are all around . according to the references they can be much lower in compromised group of patients. to assure appropriate work quality every diagnostic laboratory should periodically perform the quality control of the whole laboratory as well as of every individual results interpreter . aim aim of the study was to control the quality of smps results reading in our nuclear medicine laboratory in a compromised group of patients. the whole laboratory as well as every individual interpreter was controlled. patients retrospectively the smps readings of pts, ( %) men, ( %) women, mean age of ± y ( - ), were compared to the results of coronary angiography. ( %) pts suffered recent mi, in ( %) pts cabg and in ( %) ptca was performed. methods the smps results, denoted as positive or negative, were compared to the results of coronary angiography. by their comparing, sensitivity, specificity and accuracy of smps were expressed for the whole group as well as for the individual readers of scintigrams. results conclusion: the great difference in diagnostic accuracy among the readers of scintigrams was found. these results were a good reminder of the whole group and especially of certain individuals for approving the quality of their work. advantages and problems of digital documentation and reporting in nuclear medicine o. nickel, a. helisch, m. schreckenberger; klinikum der j. gutenberg-universitaet, mainz, germany.aim: archiving and online reporting with digital documentation (without hardcopy) requires certain technical prerequisites and an adapted workflow. as well the image display on the workstations used for reporting as the image archive are to be optimised for easy and fast access, a good report quality and a safe long-term availability of the archived data. material and methods: all the image data from our modalities ( gamma cameras, pet scanner, ultrasound) are sent by dicom transfer immediately after acquisition to the department pacs system "tomomagine"(bs industrieelektronik, germany). the reporting physicians use windows workstations with two monitors for text and images. quality control of the image monitors is done by test images (e.g. smpte). all images can be displayed with the tomomagine viewer, which was developed especially for nuclear medicine: spect and pet slice data can be viewed interactively with d navigation in planes and mip projections; overlays of pet/ct or spect/ct can be displayed as well. all image data of a patient can be loaded online in a short time by using the archive database. hours after acquisition the images are sent automatically to the central pacs system of the hospital; this system distributes the patient studies to the department servers of the referring physicians. results: the image management of a digital archive has some problems compared to a conventional archive with film or paper hardcopies: the monitor and graphics mode for image display must be able to display all relevant levels of grey. some lcd monitors that we tested were bad or even useless in this respect. a document on paper or film can be easily removed, an electronic document, which has been sent to a ris/pacs, may have already been copied to several places; therefore its elimination can take very much effort. by the temporary storage of images in a local image archive and delayed transfer to a central pacs this problem can be minimized. the use of a local image archive improves the speed of access to the image data compared with a central pacs, the redundant archiving (local and central) increases the long term data security. conclusion: the use of a local image archive in nuclear medicine, together with a centralized pacs can improve the workflow during reporting and image archiving.aim: lactadherin binds with high affinity to phosphatidylserine exposed on the surface of apoptotic cells. it is the aim of this project to synthesize mtc-hyniclactadherin and to measure its ability to bind to apoptotic hl leukemia cells. materials and methods: bovine lactadherin was isolated from milk, conjugated with hynic and labelled with mtc using tricine as the coligand. the conjugate was separated on a biosep-sec-s hplc column and stability studies with and without bsa carrier was carried out by tlc. hl cells (human leukaemia cell line) were made apoptotic using etoposide. multiple cell aliquots were added different amounts of mtc-hynic-lactadherin. the procedure was repeated with untreated hl cells to evaluate mtc-hynic-lactadherin binding to non-apoptotic cells.results: the amount of conjugated hynic per protein molecule was determined spectrophotometrically to be . the relatively low yield of the hplc purification ( ± %, n= ) relates to the fact that lactadherin most likely adhered to the column. the stability tests showed that in the presence of bsa the rcp only decreased from % to % during a five hours period. the non-stabilized solution plunges from % to % rcp during the same period. a significant difference in binding activity between apoptotic and control cells ( ± . %) was achieved with a mtc-hyniclactadherin concentration as low as . nm. furthermore, the difference in binding to apoptotic and normal hl cells reached a plateau at . nm label resulting in an ± . % increase. when native lactadherin was added in excess the radioactivity in the pelleted apoptotic cells dropped to ± . %. this strongly suggests that the binding of mtc-hynic-lactadherin to apoptotic cells is mediated by the same mechanisms as for unlabeled lactadherin. conclusion: mtc-hynic-lactadherin has been synthesized, tested for stability and in vitro biological binding activity. the data clearly show that the compound is a potential imaging agent for apoptosis recognition. aim: annexin v is known to bind to phosphatidylserine which is exposed on the outer surface of the cell membrane of cells undergoing apoptosis. it has been shown that bovine lactadherin a milk fat protein isolated from milk has affinity to phosphatidylserine and apoptotic cells as well. in vitro binding studies of mtc-hynic-lactadherin indicate that it binds to apoptotic cells. we want to present the results of the biodistribution studies in mice and tracer kinetic studies in pigs of mtc-hynic-lactadherin and mtc-hynic-annexin v. materials and methods: normal mice were injected with approximately mbq in ul of mtc-hyniclactadherin or mtc-hynic-annexin v and sacrificed after min, h or h. the animals were dissected and major organs were collected in counting tubes and the distribution of radioactivity was measured. tracer kinetic studies in pigs were done by a combination of non-invasive scintigraphy and katheterisation. results: the biodistribution studies in mice showed a relatively fast blood clearance. the relative uptake of mtc-hynic-lactadherin (n = )/ mtc-hynic-annexin v (n = ) h post injection was . ± . / . ± . in blood, . ± . / . ± . in the liver, . ± . / . ± . in the spleen and . ± . / . ± . in the kidneys. accordingly, scintigraphy in pigs showed high liver uptake of mtc-hynic-lactadherin (n = ) and high uptake of mtc-hynic-annexin v (n = ) in the kidneys. renal extraction of mtc-hynic-lactadherin was about % whereas the extraction of mtc-hynic-annexin v fell from - % - min p.i. conclusion: these tracer kinetic studies in mice and pigs showed that mtc-hynic-lactadherin is mainly taken up by the liver in contrast to mtc-hynic-annexin v which is mainly taken up by the kidneys. these results combined to the apoptosis recognition ability of mtc-hynic-lactadherin makes this radiotracer a potential new imaging agent for apoptosis in different organs with an advantage to mtc-hynic-annexin v for imaging apoptosis in the kidneys. transport and phosphorylation of f- -deoxyglucose (fdg) in the tumor cells determine the kinetics of the tracer and the accumulation. however, experimental data gave evidence that other processes like angiogenesis may have an impact on the tracer kinetics. this study is focussed on the combined evaluation of pet and angiogenesis related gene expression. methods: dynamic pet fdg studies were performed in patients with colorectal tumors within two days prior to surgery. volumes-of-interest (voi) were used to obtain time-dependent tracer concentrations from the tumor region and a reference area. vois over the descending aorta were used to retrieve fdg total blood concentration data. a two-tissue-compartment model was fitted to the data and the transport constants k -k as well as the fracional blood volume (vessel density, vb) were calculated using the evaluation software pmod (pmod technologies ltd., adliswil, switzerland). tumor specimen as well as specimen from a reference area(normal colon) were obtained by surgery and quantitative gene expression data were obtained by gene array analysis using the u a gene chip (affymetrix inc., santa clara,ca,usa). pet and gene array data were evaluated with the genepet module of pmod. results: a quantiative data evaluation was performed in patients, comprising specimen of tumors and normal colon tissue. suvs were highly variable between . and . suv for this collective. angiogenesis related genes were enhanced by a factor of . , when tumors and normal colon were compared. classification analysis demonstrated that angiogenesis related genes provided the best discrimination between malignancies and reference tissue. the correlation/regression analysis demonstrated significant correlations (p< %) for the suv, fractal dimension (heterogenity of the tracer), k , k , and the fdg influx. summary: angiogenesis has a significant impact primarily on the kinetic data (k , k ), but also on the global fdg uptake. a detailed analysis of the fdg kinetics can help to classify the grade of angiogensis in primary colorectal tumors. fifteen patients between ages and years of age (mean yrs), with stage iia-iii recurrent cervical carcinoma treated with radiation therapy or chemotherapy and radiation therapy were enrolled. mr was performed on a . tesla scanner (ge scanner), the ct and pet was performed in a pet/ct scanner, (ge discovery st). mr scans were performed for radiation planning tumor delineation and pet ct's were performed for ruling out nodular metastasis. mr and pet/ct scans were done with a time interval less than days. pet and ct were coregistered during acquisition in the pet/ct scanner. mr volumes were co-registered with the ct part of the pet/ct using - internal anatomical fix points. the gtv were retrospectively delineated on transverse sections of ct (center hu; width, hu and tumor consistent criteria like contrast enhancement) and mr (t weighted) scans independently by two physicians with training in radiology and nuclear medicine, working in a blind fashion. gtv's were evaluated with different modalities on a single integrated eclipse planning system (varian medical systems). gtv was autosegmented on pet scans using a lower activity level defined as % of maximum activity corrected for regional background results: the preliminary results demonstrated that on average gtv defined in pet smaller than in both ct and mr.the final result will be demonstrated at the meeting. conclusion: the combined pet/ct scan demonstrates an easy and observer independent definition of gtv for radiotherapy. the size of gtv was found smaller compared to determination by mr and ct. aim: cd /neutral endopeptidase (cd ) and intestinal-type mucin (muc ) are known to associate with colorectal carcinogenesis and local invasion. the purpose of this study is to investigate the relationship between clinicopathological factors and fdg uptake in pet-ct in colon cancer, focusing on the expression of cd and muc . methods: in this study, patients ( . ± . year old women, . ± . year old men) with colon cancer were contiguously selected from april to september . preoperative pet-ct was performed in all of them. to determine the relationship between clinicopathological factors and standardized uptake values (suvs) in colon cancer, we analyzed the tumor differentiation, tumor size, lymph node metastasis, vascular invasion, lymphatic invasion, and the expression of muc and cd , in paraffinated tissue using immunohistochemial stain. in addition, the expression of hexokinase (hk-ii) and glucose transport (glut- ), and cell proliferating activity using ki- were evaluated. results: all of the cases studied were positive for glut- , specifically of glut- weak positive and of glut- strong positive. there were cases of cd positive, cases of muc positive. cd showed negative correlation with muc (rho=- . , p< . ). muc expression exhibited the positive correlation with ki- (rho= . , p= . ). there was no statistical significance among suvs and various clinicopathological factors such as tumor differentiation, size, lymphatic or vessel invasion, lymph node metastasis, ki- , and hk-ii. furthermore, no clear correlation was found between a very simple animal model of liver infection consists of the intraperitoneal injection of clamidia pneumoniae, which results in an activation of hepatic kupffer cells in % of the animals. this kupffer cells dis-regulation can be associated to primary biliary cirrhosis. aim of this study was to assess the predictivity of fdg small animal pet for the early identification of reactive animals, possibly identifying not only the peritoneal inflammation caused by the injection but also the liver kupffer cells activation and behaviour (are they originated from the peritoneum or from the liver itself?). we used adults balb/c mice ( - weeks) which were intraperitoneally injected with purified c. pneumoniae elementary body suspension (the inoculum preparation contained . x ^ inclusion forming units). , , and days after, the animals underwent a fdg small animal pet (ge, explore vista). we administrated mbq of fdg via the tail vein. uptake time was min, acquisition time min. images were reconstructed with osem d iterative reconstruction. animals were considered positive if a visual abnormal fdg uptake was present in the abdomen and/or in the liver. we found that / animals had a positive pet scan days after inoculum within the peritoneum. days after inoculum all these animals presented an increased peritoneal fdg uptake, which disappeared an days after inoculum. the other animals had negative scans , , and days after inoculum. no hepatic signs of inflammation were detected in any of the animals. these results reflect the biological behaviour of this animal model previously reported in literature (world j gastroenterol, oct ; ( ) ) which shows an inflammatory response in about % of the subjects. this inflammation, probably connected with the liver reaction, could be very early detected by fdg pet (those that were positive intraperitoneally). however, this imaging method was never able to identify the liver kupffer cells activation. these preliminary data indicates that, although predictive for reactive animals, fdg small animal pet is not the most appropriate technique to in vivo evaluate kupffer cells movements and behaviour. a reporter gene-reporter probe method or a in vitro cell labelling tracking method may be more accurate to fully in vivo understand the kupffer cells behaviour.aim: differentiation between cancerous growth and inflammatory reaction may be sometimes difficult. the glucose analogue, - f-fluoro- -deoxy-d-glucose ( f-fdg) accumulates in the areas of high glucose metabolism, such as rapidly growing tumours or active inflammatory foci. however, f-fdg is specific neither for cancerous growth nor inflammation, thus causing false-positive findings. vascular adhesion protein (vap- ) is a human endothelial protein whose cell surface expression is induced under inflammatory conditions, thus making it a highly promising target molecule for studying inflammatory processes in vivo. we hypothesized that positron emission tomography (pet) with gallium- -labeled , , , -tetraazacyclododecane-n',n'',n''',n''''-tetraacetic acid conjugated synthetic peptide targeted to vap- ( ga-dotavap-p ) could be feasible for differentiating tumours and inflammatory foci. we compared the biodistribution of ga-dotavap-p , f-fdg, c-choline and ga using experimental rat model. c-choline is a marker for cellular proliferation and it has been extensively used for pet imaging of prostate cancer. free ga also accumulates in both the tumours and inflammatory foci. to establish an in vivo model, athymic rats were s.c. implanted with human bxpc- pancreatic adenocarcinoma cells and sterile skin/muscle inflammation was caused by turpentine oil. dynamic h pet imaging and ex vivo organ distribution measures were performed h after induction of inflammation. results: our results revealed that the ga-dotavap-p was able to visualize inflammation better than tumour and it was more inflammation-selective than other tested tracers. the difference between ga-dotavap-p vs. ga and vs. c-choline was statistically significant (p< . ). the most tumour-selective tracer was c-choline. the difference between c-choline vs. ga and vs. ga-dotavap-p was statistically significant (p< . ). however, f-fdg showed the highest target-to-background ratios (table) . conclusion: our results indicate that ga-dotavap-p targeting vap- was capable of differentiating tumour from inflammatory foci in our animal model and it was almost as sensitive as f-fdg for inflammation imaging. a minority of tracers developed for scintigraphic detection of infection and inflammation could theroretically discriminate bacterial infection from sterile inflammation. however, for some of these tracers these claims could not be confirmed. recently, the radiolabeled thymidine kinase (tk) substrate -( '-deoxy- 'fluoro-beta-d-arabinofuranosyl)- -iodouracil (fiau) has been proposed as an agent to image bacterial infections, based on presence of endogenous tk in bacteria. in the present study, we investigated [i- ]fiau targeting in rats with bacterial and sterile inflammation. to prove that fiau uptake was tk-mediated, e. coli tk-negative bacteria were generated and inoculated intramuscularly (im) in rats and fiau uptake was studied. methods. fiau was labeled with i- using the trimethyl tin precursor. aim: angiogenesis is a prominent feature of rheumatoid synovitis. v integrin is expressed at high levels on the synovial formation of new blood vessels in rheumatoid arthritis. synovitis in rabbits could be suppressed by blocking this integrin with cyclic rgd peptide based v antagonists injected directly into the joint. the multi-pinhole (mph) single-photon emission computed tomography (spect) technique and in- labelled cyclic rgd peptide ( in-dota-e-[c(rgdfk)] ) allows to detect vascular joint alterations in arthritis-mouse-models. methods: mph-spect-measurements were performed under short general anaesthesia in collagen-induced-arthritis (cia) mice, which had arthritis of front and back paws. all mice were independently scored macroscopically before starting the studies. control mice were compared with the mph-analysis of arthritis-mouse-models. spect data was acquired with a conventional gamma camera (prism s, philips) which was outfitted with a new constructed mph-collimator ( pinholes with a diameter of . mm). after the injection of . ± . mbq (mean±sd) in- labelled rgd peptide, a dynamic measurement between and minutes p.i. was performed. results: the high sensitivity of the mph-technique allowed the dynamic visualisation in the uptake of rgd peptide in the ankles and other organs of the mice. mph-spect allows to detect all arthritic lesions (n= ) and a quantitative analysis. the regional evaluation showed that after minutes, the percentual accumulation h p.i. in the inflamed paws was . %± . % while in healthy control mice (n= ) a significant lower uptake of . %± . % was measured (p( )= . , mann-whitney). no significant difference was observable in the knee joints between healthy and arthritic mice. conclusion: the results of our studies suggest a correlation between arthritic inflammation and accumulation of cyclic rgd peptides in cia animals in vivo. the mph-spect technique in combination with a cyclic rgd peptide can be used as a diagnostic instrument for imaging joint pathologies and for an accurate and quantitatively precise monitoring of therapy studies. aim: image quality using the specific serotonin a-receptor radioligand i-r- is variable in dogs. since the p-glycoprotein is expressed in the blood-brain barrier, amongst many other organs, we wanted to evaluate the effect of ketoconazole, a pglycoprotein modulator, on the brain uptake of this radioligand in dogs. materials & methods: three -year-old healthy female beagle dogs were included. two spect scans were performed; one baseline scan and one scan after administration of ketoconazole. ketoconazole was administered orally during successive days; two days before scanning at a dose of mg/kg, one day before scanning and the day of scanning at a dose of mg/kg. the radioligand i- -i-r was injected (mean mbq) intravenously minutes prior to acquisition. acquisitions were performed under general anaesthesia (premedication with medetomidine, induction with propofol and maintenance with isoflurane in oxygen). acquisitions were performed with a triple head gamma camera (triad, trionix), equipped with lehr hole collimators. images were reconstructed with hosem iterative reconstruction and application of a butterworth-postfilter (cut-off, , cycles/cm, order ). roi's were drawn over eight cortical regions (left and right fronto-, temporo-, parieto-, and occipito-cortical area) and one global subcortical region. the uptake in the cerebellum (area void of serotonin a-receptors) was used as a reference for non-specific binding in addition to free ligand. radioactivity measured in the cortical areas was assumed to represent the total activity. the binding index was operationally estimated as (mean counts/pixel in regional cortex)/ (mean counts/pixel in cerebellum). results: on visual inspection a clear improvement was noted after administration of ketoconazole. the mean counts/pixel in the total brain was , ± , . after administration of ketoconazole the mean counts/pixel in the total brain was , ± , . the mean serotonin- a binding index of the baseline scan in the frontal cortex was , ± , . after administration of ketoconazole, the mean serotonin- a binding index increased to , ± , . this is a mean increase of , %. conclusion: the results of this study demonstrate a trend towards an increased brain uptake of serotonin a-receptor radioligand i-r- after use of ketoconazole. despite clear improvement of image quality, no statistic conclusions can be taken due to a low number included subjects. further investigations are necessary to confirm these preliminary findings. aim. to determine possibilities of quantitative imaging of the mouse thyroids using the nanospect/ct small animal imaging system. materials and methods. phantom and in vivo measurements were made with the nanospect/ct device. phantoms of two point sources distributed in homogenous flood source of cylindrical for were created. mtc and i isotopes were used to fill in radioactivity. mtc activities ranged from mbq in points to mbq, i activities ranged from . mbq to mbq. flood activities were between - mbq. in vivo imaging of - mice with the respective isotope was performed using activities of mtc of - mbq injected iv. or - mbq of i.imaging was done - minutes post inj. thyroids were then removed from mice and measured in a welltype counter and compared to standard activities to determine real activity. results. roi-quantified voxel activities were the same in the measured phantoms and the calculations of two digits post zero. in vivo results were the same with an error of % with mtc, with i the error depended on the signal intesity and count-noise ratio. conclusions. nanospect/ct allows the correct absolute quantification of activity located in voxels both in vitro and in vivo if a good signal-noise ratio can be obtained. objective: poor in vitro and in vivo delivery is limiting the use of oligomers for imaging and therapy. streptavidin (sa) may be used as a convenient link between biotinylated antisense radiolabeled oligomers and transmembrane carriers added to improve delivery provided that antisense and carrier function is not compromised thereby. methods: nanoparticles with mer uniform phosphodiester (po) or phosphorothioate (ps) dnas against the mdr mrna or a mer phosphorodiamidate morpholino (morf) against the survivin mrna were linked to sa along with cholesterol, a mer tat or mer polyarginine carrier. the m tc radiolabel was always on the oligomer. results: as evidence of unimpeded carrier function, the morf/sa/tat and morf/sa/polyarginine nanoparticles accumulated fold more than the morf/sa and the naked morf controls after h in survivin+ mcf cells while all po nanoparticles showed increased accumulations at all times with compared to without carriers in three mdr + cells but not so the ps dna nanoparticles because of its high protein affinity. evidence of antisense targeting were the statistically higher cellular accumulations of the antisense morf nanoparticle than the sense morf nanoparticle control and statistically higher accumulations of the po dna nanoparticle in the three cell types in order of their mdr expression levels. in xenografted mice, the ps dna/sa/tat and ps dna/sa/cholesterol nanoparticles were accumulated in all tissues including tumor much higher than the po nanoparticles. these results show that the high protein binding affinity of the ps dna was expressed despite the presence of the sa. conclusions: the preparation of oligomer carrier constructs was greatly simplified over covalent conjugations by using sa as a linker. the sa linker had no apparent detrimental influence on the function of the carriers or antisense oligomers. these observations suggest that sa provides a convenient means of linking oligomers, carriers and, eventually, antitumor antibodies without compromising properties. the aim of this study was to investigate the effect of food and time on intestinal activity in technetium m tetrofosmin stress myocardial perfusion scintigraphy. based on a pre-study sample size calculation, we estimate the study population to comprise a total of patients. patients were recruited at a single center and underwent a two day exercise-rest tc- m tetrofosmin single photon emission computed tomography (spect) imaging. patients were randomized to food or no food ( ml of water and two slices of white bread with butter versus no drink or food) versus early or late spect (within min from injection of tracer versus - min after injection of tracer) in a x factorial design. patients with abnormalities on their stress test also had a rest spect. the food/time allocation used for the stress test was used for the rest as well. rest data will be reported separately. patients were randomized in blocks of four. most patients received adenosine pharmacological testing with moderate ( w) bicycle exercise. frequency of intestinal activity was assessed visually on spect images on different planar projections. inferior myocardial wall and abdominal activity adjacent to the myocardium was evaluated visually on a -point semi-quantitative scale, ranging from no to severe intestinal overlay and a final accept/repeat spect decision. evaluation was performed by a trained observer blinded to the pre-spect details. the primary endpoint is the percentage of accepted first time spect in each cohort in the intention to treat population. secondary endpoints include proportion of approved first time scans in each cohort as per actual time and food (per protocol analysis), intestinal activity according to method of exercise testing, and time from injection to final acceptance of the scan (including repeat scans). an interim analysis has been planned at patients (estimated to be late april, ). the final results will be presented at the meeting. the aim of study was to explore the possibilities of the use of dicom standard (digital imaging and communications in medicine) in our department. we used it in comparison of new commercial software package ( dm spect) with the existing (qgs) for the quantification of left ventricular ejection fraction (lvef). lvef values obtained with dm spect, and frames/cycle were also compared. material and methods: twenty patients ( male, female, mean age ys) referred to stress and/or rest gspect study with mtc mibi, were enrolled. studies were performed with two detector camera system (ecam), first with frames/cycle, and immediately after that with frames/cycle for each patient, according to the recently published eanm/esc procedural guidelines for myocardial perfusion imaging (gspect, high count study), with total duration of minutes ( minutes for each study). after the reconstruction, the and frames/cycle data were processed with dm spect program. original frames studies were also copied from esoft to icon working station, using the dicom key, where reconstruction and qgs processing was performed. mean lvef values were compared, and statistical significances were checked with paired t test. results: dm spect- fr dm spect- fr qgs - fr mean lvef % (range%) % ( - %) * ** % ( - %) % ( - %) * p< . between and fr dm spect **p< . between fr dm spect and qgs mean lvef values obtained with frames dm spect were % higher than with frames qgs program. difference between and frame mean lvef values in dm spect was smaller, but both results turned to be statistically significant (p< . ). conclusions: dicom transfer from one to another working station was successful in all cases. significant differences between and frame dm spect study were found, and between frames studies obtained with two software programs. since more prominent differences were found with different programs, it can be concluded that lvef values should always be processed with the same software package, especially when follow up of patient is needed. the dicom successfully enabled the comparison of the two software packages. aim: both stress and rest examinations are usually performed to diagnose ischemia or infarction in the left ventricle. if the stress study is performed first and the images show normal findings, it might be unnecessary to perform the rest study. the aim of this study was to evaluate if it is possible to avoid rest studies in some patients without making false negative interpretations. material and method: the gated-spect studies performed using a two-day nongated stress/gated rest m tc-sestamibi protocol from consecutive patients were investigated. the patients had a mean age of ± years, and % were men. myocardial perfusion scan was performed for the diagnosis of cad in patients and for management of known cad in patients, previous myocardial infarction in patients and previous revascularisation in . visual interpretation by one experienced physician at the time of clinical reporting was used as the gold standard for the scintigraphic presence of myocardial infarction or ischaemia. rest, stress and gated images as well as clinical information were available for this interpretation. only the stress images (slice images and polar plots) were examined independently by physicians and technologists regarding the question if a rest study was needed or not. results: the clinical evaluation of the rest and stress images by the experienced physician showed normal findings, i.e. no signs of infarction and ischaemia, in cases. the five observers decided that rest was unnecessary in , , , and of these studies respectively. a false negative classification, i.e. rest study not necessary in a case were the gold standard interpretation was infarct or ischaemia, was found in , , , and cases respectively. conclusion: the results show that it is possible to avoid rest studies in a significant number of patients with no or only few false negative interpretations.technologists and physicians did not differ substantially in the interpretations. h. lehtinen, a. sonkki; university hospital of turku, pet centre, turku, finland.the aim of this poster is our practical experiences of cardiac cta and perfusion studies performed at turku pet centre, finland. coronary cta combined with the cardiac perfusion study is one of the best and most reliable non-invasic tests in diagnosis of cad. the study provides seamless team work with many occupational groups like medical laboratory technologists, physicians and the physicists. the radiographer's role is to prepare patients, inform them of the study and do the scan. materials and methods. at first we prepare the patient for the cardiac study. the patient fills an interview form where we will see his current medications, possible former reactions to contrast agents, allergies, diabetes and kidney diseases. while the patient lies down we observe heart rate, check blood pressure and set an intravenous cannula. optimal heart rate is stable and under bpm. if it's above bpm the physician gives beta-blockers intravenously. oral nitrate spray is given to each patient before the scan. cta demands breath holds so it's good to exercise this with the patient before the study. the scanner used is ge vct -slice pet-ct scanner. cardiac cta consists of a calcium score scan and a coronary scan with contrast media. we use an automatic dual head injector system for injecting contrast media and nacl bolus chaser. the cta scan is then followed by the perfusion studies with olabelled radio water, first basal perfusion and then adenosine stress perfusion. during the perfusion studies we monitor ecg and the blood pressure according to our protocol. after the study we observe the patient for awhile and advise him to drink a lot because of the possibility a nephrotoxic reaction due to iodine-containing contrast. conclusion. cardiac cta combined with pet perfusion is an excellent example of a multimodalitystudy, as the anatomic information of ct images is combined with the functional information of pet. it has been very challenging, exciting and rewarding to do these studies. standard indicator of sestamibi regional washout in the myocardium purpose: in recent years, it has been shown that washout of mibi is observed in myocardial ischemia lesions, and a method for its evaluation is discussed. we obtained the standard indicator for regional washout from early and delayed mibi images and evaluated its usefulness. method: in healthy volunteers without abnormalities, such as cardiac diseases, hypertension or electrocardiographic abnormalities, spect images were acquired one hour after intravenous administration of mbq of mibi of (early image), and subsequently, three times, up to five hours (delayed image , delayed image and delayed image ). to draw a polar map from each sequential spect image, the regional washout rate obtained from the mean count in three areas of the myocardium was plotted, and the gradient was calculated with the approximate equation. results: comparison of gradients in the linear approximation and exponential approximation from the early image to delayed image in each area showed no significant differences ( and rca=- . ± . , showed significant difference (p< . ) for the lad and lcx, but not for the other vessels (p=ns). the respective r were . , . and . , with no significant differences among the three (p=ns). as for correlation between the linear approximation and exponential approximation, the linear approximation approached more closely than the curve approximation, however, no significant difference was observed. conclusion:it was suggested that the regional washout of mibi in healthy myocardium would decrease with a gradient of linear or curve approximation. since there was no significant difference between the approximated line and curve, evaluation of the gradient with the linear approximate expression may provide a constant gradient, and therefore, it can be used as an indicator of the washout rate. t. iimori, t. fujibuchi, h. sato, k. sawada, y. uchida, t. kawata, m. fujita, s. shindo, y. kuwabara; chiba university hospital, chiba, japan.background and purpose: by m tc -mibi scintigraphy, a myocardial morphologic assessment (hypertrophy or enlargement) and functional assessment are also enabled as well as myocardial perfusion evaluation, and they contribute to the assessment of myocardial viability. recently, there are some reports that accumulation and clearance of mibi are related to severity of heart failure. therefore, we evaluated the utility of scatter correction for precise energy count in calculating h/m (heart/mediastinum) value of mibi in the planar image. method: ) phantom simulation study: in the phantom, myocardial region was filled by . mbq/ml with mibi, liver region was filled with . mbq/ml of mibi, and mediastinum was filled by water. we imaged the phantom with static collection (preset time; , counts, matrix; * ), and repeated with the different main window widths and sub window widths in order to determine the appropriate window width for scatter correction by tew. we used nmse (normalized mean square error) for their evaluation. ) clinical evaluation: with the appropriate windows determined by the phantom, we measured h/m value of mibi in patients with heart failure ( male, femail, mean age . ± . years), and compared with raw data for the relation with the clinical data such as ejection fraction (ef). since i-mibg imaging is well-established as a gauge of chf, effect of scatter correction by tew in mibi was also evaluated for the correlation with i-mibg. result: main window width with kev± % and sub window width with kev± . % were appropriate in scatter correction by tew by the phantom study, respectively. )correlation coefficient between h/m value and ef in patients with chf was r= . without scatter correction, and it improved to r= . with scatter correction. correlation coefficient with h/m value and i-mibg h/m value were r= . without scatter correction, however, it increased to r= . with scatter correction. conclusion: we proposed appropriate windows for the scatter correction in cardiac imaging by m tc-mibi by phantom study, and proved its utility by applying to the clinical cases. background: stem cells represent one of the new therapeutic possibilities for severe co ronarydisease, the effect being tested in many trials. most centers use intracoronary injections, but some recommend intramyocardial injection, to obtain maximal homing and retention of the cells in the ischaemic myocardium. details about differences between these administration techniques are completely unknown. the purpose of the present study was to examine the retention of in- labelled human stem cells injected into porcine, left ventricular (lv) myocardium. methods: in-labelling was performed as previously described by our group (ejnm (ejnm , : (ejnm - . the labelled cells ( ) ( ) ( ) were injected into the pigs ( - kg) via a cardiac catheter into the lv walls in small depots (total volume injected = cc). subsequent static gamma camera images were obtained ( and kev dual window, megp collimator) over the next days to monitor the clearance of the labelled cells from the myocardium. on the second day mbq sestamibi was given iv. after the planar image and cardiac spect performed min later. the energy windows for spect were % around and kev. results: it was easy to localize, in the homogenous sestamibi visualization of the lv myocardium, the remainder of - mbq in- , distributed in - hot spots, in the apex, posterior wall, septum etc. by the daily planar "pure" in- images the retention of the indium could easily be calculated after correction for physical decay: (day , , , ). discussion and conclusion: this technique with a lower energy window centered around kev during spect, permitting only part of the general myocardial activity uptake to be visualized as a background. it nicely demonstrated the myocardial localization of < mbq in- activity accumulations from labelled stem cells injected into the heart of - kg pigs. introduction lvef, edv and esv are good clinical indicators of left ventricular function and volumes, routinely measured by echocardiography (echoc). in former decade the emory cardiac tool box (ectb) was developed, a toll for assessing left ventricular function and volumes from gated spect myocardial perfusion scintigraphy (gspect). gspect myocardial function assessment provides an important incremental information. aim of the study the aim of the present study was to validate the accuracy of the ectb in assessing lvef, edv and esv from gspect using echoc as a reference values. patients and methods consecutive patients, males and females; mean age +/- y, range - y, with suspected or known coronary artery disease were examined using mtc-mibi gspect ( gates/cardiac cycle) min after tracer injection at stress. the gspet data were reconstructed using an automatic algorithm employing filtered back projection (fbp) and further analyzed by emory cardiac (ec) toolbox. all patients underwent two-dimensional ( d) m-mode echoc in the same diagnostic evaluation. optimization of myocardial fdg-uptake in f -fdg pet-ct by a standardised hyperinsulinemiceuglycemic clamp protocol and acipimox k. krommes, g. pleschberger, v. meyer, h. kässmann, c. pirich; salzburger landeskliniken, nuklearmedizin, salzburg, austria. the assessment of myocardial viability by f- fdg pet has become a standard procedure in nuclear cardiology. metabolic imaging of the heart requires designated protocols that reflect alterations in substrate metabolism under ischemic conditions. it was the aim of the study to analyse the efficacy and practicability of a standardised hyperinsulinemic-euglycemic clamp protocol in clinical routine. method: cardiac f- fdg imaging was studied in patients from till february . patients were non-diabetic ( %) and patients were diabetic (insulin and non-insulin dependent; %). every patient was given a dosage of mg acipimox on the study day. the hyperinsulinemic-euglycemic clamp protocol differentiates between non-diabetic, diabetic non-insulin-dependent and diabetic insulin-dependent patients. for each patient group, there is a predefined pattern for application of oral glucose or/and insulin (maximum single insulin dose iu) according to the blood glucose level. results: according to our protocol the following procedure was necessary in our patients: • no insulin / no glucose: patient • no insulin / glucose: patients • insulin / glucose: patients • insulin / no glucose: patients patients needed glucose, of whom patients ( %) got g glucose and patients ( %) got , g glucose. after glucose application, patients ( %) required no insulin, and patients ( %) needed insulin to lower the blood glucose level. of patients were given insulin, of them after glucose application and patients without glucose. in detail, , and patients received respective dosages of , and i.u. insulin. one patient was given i.u. insulin. diagnostically adequate imaging quality was achieved in cases ( %) and even in of diabetics ( %). cardiac fdg-pet imaging of patients was not successful due to vomiting of the oral glucose drink. conclusion: for metabolic imaging of cardiac glucose consumption by means of f -fdg pet-ct a strategy combining the use of acipimox and the hyperinsulinemic-euglycemic clamp protocol is feasible and results in adequate imaging quality in the vast majority of patients. the protocol is even successful in a diabetic population. aim: in our department, myocardial perfusion scintigraphy (mps) is usually performed using a -day rest-stress m-tc-sestemibi protocol. with more referrals and wishes of additional procedures for routine and research purposes there is a growing pressure on the staff and a waiting list seems inevitable. we examined if resource utilization could be improved by applying the lean concept originally introduced by toyota for optimizing automobile production. material and methods: implementations of lean has as its core five concepts: . specify value in the eyes of the customer; . identify the value stream and eliminate waste; . make value flow at the pull of the customer; . involve and empower employees; . continuously improve in the pursuit of perfection. in terms of mps, concepts - were applied. first, we established an "as-is" flow diagram, which required a) an interview guide, b) interviews of secretaries, booking, laboratory technicians, and physicians, c) sketching of a so-called swimming lane diagram, and d) the "as-is" flow diagram. from the "as-is" diagram it was easily seen which activities could be combined, reduced, or eliminated. based on these observations a "to-be" diagram eliminating all "waste" could be established in a process involving and empowering all relevant employees. results: the "as-is" diagram identified the following pre-scan steps as candidates for a change: i) non-appearance of patients, ii) measurement of body weight and height, calculation of body mass index and sestamibi dose, iii) preparations and check of patient dose, iv) positioning of intravenous cannula and dose injection, v) check of medication and withdrawal of relevant drugs before stress acquisition, and vi) entering of informations into a working sheet and the patient protocol. similarly, the following post-scan steps were candidates for a change: vii) information to the patient of preparations for the succeeding stress examination, viii) precautions on day- in case these instructions had not been followed. conclusion: these and other simple changes, which could eliminate or streamline the many extra procedures, lightened the pressure on the personnel, made the working rhythm more fluent and stable, and yielded extra time for patient care as well as the conductance, processessing, and finalizing of each single mps study. in this way, the "low hanging fruits" were collected. in addition, a further gain could be obtained in at least ¼ of the patients by converting the sequence rest-stress to stress-rest and leaving the rest study undone in case the stress study was normal. aim: gated myocardial spect provides an estimate of left ventricular ejection fraction (lvef). most commonly gating is performed with frames per cardiac cycle although frames per cycle may provide more accurate estimates of left ventricular function. the aim of this study was to compare same day repeatability of left ventricular ejection fraction using -frame or -frame gated spect. method and materials: in patients referred for routine myocardial spect a -frame gated spect study (study a) was performed hour after injection of mbq mtc -mibi. a second -frame gated spect study (study b) was performed immediately after without the patient leaving the gamma camera. frame studies were constructed from frame studies. gated studies were processed with qgs software. repeatability is reported as the mean difference (study a -study b) ± . sd. results: repeated studies ( stress and rest studies) were performed in patients. in study a, frame studies produced significantly higher lvef than -frame studies (mean lvef . %, vs . %, p < . ). repeatability of lvef in -frame and -frame studies were . ± . % and . ± . % respectively. the difference in lvef was not statistically significant in neither -frame nor -frame studies. in stress studies lvef was significantly lower in study b than in study a (repeatability . ± . % [p = . ] in -frame studies and . ± . % [p= . ] in -frame studies). in rest studies no change in lvef was observed (repeatability . ± . % in -frame studies and . ± . % in -frame studies). no correlation between difference of lvef and change of heart rate, perfusion defect size, edv or esv was observed conclusion: there is significant variability of same day left ventricular ejection fraction measured with gated spect. repeatability seems not to be affected by frame rate, but appears to be poorer in stress studies than in rest studies. these observations should be taken into account in serial evaluation of left ventricular function with gated spect studies. . recently there has been an increase in the number of acute chest pain and pre-surgical patients (pts) with cardiac risk factors treated at community hospitals in the u.s. many of these pts require immediate cardiac care which has significantly added to hospital stays and health care costs. yet both federal and state reimbursements for institutions seeing these patients have decreased. aim: to develop a patient care pathway and pacs ( picture archiving and communication system ) to maximize immediate care for cardiac and pre-surgical patients while reducing the patient's hospital stay when possible. length of hospital stay was recorded for all uncomplicated cases. method: this project was a cooperative effort among the cardiology department, hospital administration, stress laboratory, cardiac care floor and nuclear medicine. a tc- m gated myocardial perfusion imaging (mpi) was performed on all low and intermediate risk chest pain and pre-surgical patients within hours of admission and preliminary results were provided to the attending physician within hours of completion of the test. patients ( females, males) with an age range of to years (mean = ) underwent a one day rest and stress (exercise or pharmacologic stress with adenosine or dobutamine) gated spect mpi. a rest/stress dose of mbq/ . gbq ( / mci) of tc - m tetrafosmine was used. a siemens e-cam gamma camera with d ms spect software was used to reconstruct orthogonal views. results: pts ( %) had negative mpi findings and were discharged with hours of the exam. pts ( %) had positive mpi findings and were immediately sent to coronary angiography and discharged within to days post mpi. pre-surgical pts ( %) with negative mpi findings went to surgery within hours. pts ( %) with positive mpi results went on to have cabg. conclusions: all low and intermediate risk chest pain pts were discharged within hours of mpi which represents an improvement over past hospital stays for these pts. pre-surgical pts with negative mpi results were immediately sent to surgery. these data suggest a significant reduction in hospital costs and stays. introduction: even if filtered backprojection (fbp) methodology still has a very well established role in routine image processing in nuclear cardiology, actually, with the general improvement of computational power available, an increasing number of nuclear medicine departments worldwide tend/is interested on the use of iterative methods (im). with this paper, it is intended to expose some main considerations, always with clear practical purposes, sharing our own studies and experiences. material and methods: the first part of the study consisted on the analysis of the different possibilities available within the current software options brought widely available by the furnishers of equipment. once concluded, sessions of practical tests started: the main goal was to establish the relative practicability of the options predefined on the first part of the study. hence, we used one group of different myocardium perfusion scintigraphic studies, which had been processed with the distinct methodologies previously defined. we have compare data related with the processing operation itself for each case, with main focus on parameters as the time spent (from the operators as well as the system's immobilization, for instance) and complexity (here considered as essentially related with the degree of operator's intervention). in order to establish the clinical value of each methodological option, the resultant images were evaluated by independent physicians, according to different criteria, always based on its clinical value. conclusions: it had been clarified and justified what seems to be the best option for the use im in routine image processing, in the specific case of mpi. introduction: it is worldwide very common that patients who will undergo a myocardium perfusion scintigraphy are requested to be in fasting condition. even if this idea is generally accepted, the scientific evidence underlying this requirement seems to be far from objective and/or consensual. the main goal of this work is to contribute for the study of in vivo biodistribution and pharmacokinetics of mtcsestamibi with and without fasting. material and methods: the same normal volunteer was imaged twice under different physiological conditions: the first study was done without fasting and the second one in fasting condition. anterior projections of thoracic and abdominal regions were acquired during minutes, starting immediately after intravenous injection of the tracer. regions of interest in myocardium, liver, gallbladder and proximal intestine were drawn and a related timeactivity curve was then obtained. data was compared and correlated with the normal gastrointestinal tract physiology. results and conclusions: biodistribution and pharmacokinetics of mtc-sestamibi under those distinct physiological conditions had appeared slightly different, particularly in the case of organs such as the liver and the gallbladder. based on the obtained results, the authors assume first, the need to study further this subject and, secondly, maybe there is a need to review patient preparation procedures in the specific context of myocardium perfusion imaging. objectives: fdg-pet has suboptimal sensitivity in the diagnosis of brain metastases (bm). the presence of such metastases may result in cerebellar asymmetry (ca) of fdg uptake or crossed cerebellar diaschisis (ccd). previously, ccd has been studied qualitatively to describe the neuronal dysfunction of the cortico-pontocerebellar-system caused by supratentorial bm. we aimed to evaluate the potential added value of semiquantitative analysis of ca in the diagnosis of bm by comparing cerebellar uptake in patients (pts) with and without bm as well as in normal volunteers (nv) methods: a total of subjects studied: nv and cancer pts including without bm (g ) by mri and with bm (g ) as confirmed by mri, pet or histopathology. pet/ct scans of all subjects were retrospectively reviewed and one symmetric roi in bilateral cerebellar (cbl) cortex was drawn. differential values were calculated as -(suv /suv ), whereby suv /suv corresponds to the cerebllar hemisphere with the lower/higher suvmean, respectively. differential values of groups nv and g were used to determine the cut-off for ca determined as mean - x standard deviation. mann-whitney and t-tests were used for statistical analysis. results : differential values of nv and g showed no significant difference (mean . +/- . vs. . +/- . , p = . ) with values ranging from - . %. cut-off for ca was determined as differential values . %. / pts ( %) in g were found to have ca suggesting affection due to bm. / pts ( %) with unilateral supratentorial (st) metastasis showed contralateral ca consistent with ccd (frontal, parietal, occipital) which is compatible with published data. three pts demonstrated ca ipsilaterally to st foci (frontal, temporal/parietal occipital). despite bilateral st foci, / pts developed ca. / patients with cbl metastasis revealed ca caused by ipsilateral foci whereas pts with bilateral cbl foci showed no ca. bm could be identified by pet/ct in / pts ( %) as increased or decreased fdg-avidity. pet/ct failed to identify bm in / patients ( %) which however could have be decreased to ( %) if evaluation of ca was used. conclusions: detection of ca in fdg pet may indicate the presence of bm, and thus may have an added value in the diagnosis of bm, particularly if semiqunatitative measurement is used instead of subjective visual assessment. prospective validation of our findings is needed. measurement of suv as a means to evaluate glucose metabolism in solid tumours may aid in defining response to treatment. aim: we have evaluated fdg-suv changes during neoadjuvant chemo-radiotherapy in larc patients, in comparison with pathological response determined at surgery performed at the end of treatment. methods: thirty-three patients undergoing a novel treatment regimen have been evaluated with fdg pet during treatment. baseline pet studies were obtained from neck to pelvis for staging purposes. scans obtained after days of treatment and presurgically were carried out only on the pelvis. suv corrected for body weight was obtained for each study. maximum suv values and average suv values were obtained by drawing an irregular three-dimensional region of interest which semiautomatically defined the tumor area based on preset threshold values. values were recorded for the three studies and changes compared to treatment outcome which was defined on pathologic evaluation of surgical specimens at the end of treatment and scored on a five level tumor regression grade scale (trg). results: in % of tumours a complete or near-complete regression was observed at the end of treatment. in the remaining patients considered non-responders only partial or no regression was observed. baseline suv showed no correlation with the overall outcome. conversely, a strong correlation was observed between suv values measured days after the start of treatment and the pathological response (trg). the most important factor in predicting tumor response was found to be the early suv change (variation between the baseline and the day scan). the suv values measured on the pre-surgery scan were not as predictive of the overall outcome. we could define a cutoff value of the early average suv change that predicted treatment response in % of patients, whereas for early maximum suv change this was correct only in / patients. conclusions: fdg-pet is an effiecient and powerful tool for monitoring changes of tumour activity during the course of treatment. in particular, the early changes occurring shortly after beginning of treatment allow a very efficient evaluation of response which is more accurate for average suv compared to maximum suv. evaluation of dispersion of suv obtained by different pet system; preliminary cylinder phantom study h. otake , y. takahashi purpose: suv (standardized uptake value) is a useful tool for the evaluation of the uptake of fdg in tumor lesion, however, reliability of its accuracy in different condition such as different camera or institution has not been evaluated enough. in our study, suvs obtained by five pet systems with different acquisition condition and reconstruction method were compared by phantom study. materials and methods: five cameras, set- (shimadzu), acquiduo(toshiba), biograph lso(siemens), discovery (ge) and gemni (philips) were used. the same amount of radioactivity of f- was filled in a cylinder phantom with the size of mm tall and mm in diameter (type- , anzai-sogyo, tokyo, japan ). in phantom filled with same concentration of f- , different sized round spots ( , , , , , mm) filled with f- solution containing activity corresponding to suv . were placed in equal interval. suv of different spots were measured and compared with background. suv were calculated using formula by kubota et al. max suv obtained by roi methods was used as a representative value. d acquisition method and image reconstruction by fore-osem method was applied. results: minimum detectable size were different in each pet system. suvs by ct attenuation correction pet system were higher than those by external radiation source. in routine condition, maximum difference of suv was . %, whereas, . % in condition under image reconstruction. conclusion: for the early detection or follow up of cancer patients, contribution of fdg-pet is recently recognized and the number of study are increasing rapidly. however, we should pay attention about the follow up pet study by different pet camera, which may show different suv value. as shown in our study, maximum difference of suvs by different camera was . %, therefore, precise information of each pet study such as name of pet camera, acquisition condition and reconstruction method is recommended to be added to each results. aim: it is now a well know fact that the interpretation of abdomino-pelvic images in pet/ct can be altered by normal tracer fixation or accumulation in different organs and anatomic structures, such as the bowel, the ureters or the bladder. the purpose of this presentation is to show the advantages of the administration of furosemide and laxatives to the patient, as part of the preparation for a late second image acquisition when in presence of equivocal findings in first acquisition. methods: we present six examples of pet/ct (siemens biograph hirez) whole-body image acquisitions performed minutes after the i.v. administration of approximately mbq of f-fdg, adjusted according to the patient body weight. images were visually analysed after iterative reconstruction using the common parameters for these patients. when equivocal f-fdg foci were found along the course of urinary or intestinal tract, a second late abdomino-pelvic image acquisition (approximately h later) was performed after administration of furosemide ( - mg) and/or laxatives (sodium citrate and sodium laurilsulfoacetate). the second late images were then compared visually with the correspondent first acquisition ones. results: we show a comparative study of the images acquired before and after administration of furosemide and laxatives to remove equivocal f-fdg activity. as can be seen, the late images acquired post-furosemide and post-laxative administration, show enhanced information when compared with the first abdomino-pelvic pet/ct evaluation. this clearly allowed a more accurate distinction between physiologic and pathological f-fdg uptake, improving the diagnostic accuracy.conclusions: the administration of furosemide and laxatives and late image acquisition in pet/ct, after equivocal first diagnosis, due to retention of f-fdg along the intestinal and urinary tracts, proved to be of great utility in the above mentioned examples. in conclusion, this presentation shows the usefulness of this simple, non-invasive interventional procedures in ruling out suspected tracer fixation that is otherwise difficult to evaluate. objectives: to assess the value of a image fusion and change protocol for early detection of disease progression or recurrence. each patient underwent pre-surgery imaging with in- octreotide , i mibg and spiral ct and post surgery imaging with in- octreotide , i mibg and spiral ct at approximately monthly intervals post surgery. spect and whole body imaging (wbi) with in- octreotide is carried out at and hours pi . i mibg spect and wbi is performed at hrs and further wbi at hours pi. methods: a composite data set comprising the hr, hr octreotide, hr mibg and ct transaxial images is created by mutual information based image fusion for each patient's follow up imaging sessions. change detection is carried out between the octreotide spect hr and hr image sets to detect and eliminate significant changes corresponding to normal physiological excretion e.g. in the gut. remaining areas of stable, significant uptake are reviewed in the context of the co-registered hr mibg spect and ct data. pre -surgery and any previous post-surgery composite data sets are fused and compared to the current data to detect areas of significant change and potential areas of tumour recurrence or progression. results: of the patients included to date, exhibited stable disease, demonstrated disease progression and disease recurrence . conclusion: the advent of accurate image fusion software and ready availability of ct through pacs has enabled the development of comprehensive image protocols for follow up imaging in patients with neuroendocrine tumours. this image fusion and change detection protocol is also directly applicable to patient data acquired with new hybrid spect-ct systems. with the improvement of gamma cameras systems and software, spect has become a usual practice in most nuclear medicine departments. however, the development of other techniques in nuclear medicine conditioned the impact of new advances in spect methodology. spect provides significant technical challenges for the nuclear medicine technologist, concerning to data acquisition and image processing and reconstruction. many new advances in spect methodology are becoming available, such as whole body spect acquisition and iterative d reconstruction ( d osem). whole body spect acquisition is a new technique of image acquisition, allowing the d visualization of whole body. the application of this method is especially important in bone studies, excluding additional planar views, and improving the recognition and identification of lesions. the aims of this study are to describe the benefits of spect imaging based on whole body acquisition in bone studies and iterative d reconstruction (in relation to backprojection and the most widely used iterative reconstruction method, d osem) and analyse the impact, advantages and limitations of this methodologies, essentials to produce highest quality scans and reduce some image artefacts. material and methods: the acquisition of whole body spect was performed on a dual-head camera (siemens e.cam signature), using low-energy and high resolution collimators. a % energy window centered on kev was used for data acquisition. imaging was performed with the patient in supine position. images were acquired as × matrices with use of a º arc. for each of the positions considered, projections were acquired, each seconds in duration with a non-circular orbit, step and shoot mode. tomographic images were lately submitted to different reconstruction methodologies. results and conclusions: the whole body spect acquisition applied to bone studies is an effective, relatively cheap and easy to apply technique, that consume a short period of time ( minutes), allowing the d visualization of whole body, advantages that guarantees its superiority by themselves in relation to conventional whole body bone scan. in concern to reconstruction of the data, iterative d reconstruction algorithm provides significant improvements in image quality due to higher spatial resolution, lower noise, reduction of distortions and artefacts, improved image contrast and more accurate and easier to interpret images compared to backprojection and conventional iterative d reconstruction method. aim: oblique projections have been suggested to enhance sentinel node (sn) detection in breast cancer by supplementing anterior projection (ap) and lateral projection (lp). sn close to tracer depots can be especially difficult to detect. this may be remedied by moving the breast before acquiring ap or lp to increase distance between injection site and axilla. however, in some patients movement of the breast may be inadvisable, e.g. to avoid hook-wire displacement in patients with nonpalpable tumours. we wanted to compare a ° anterior oblique projection (ao- ) with ap and lp to investigate if this improved scintigraphic detection of sn in patients, where the breast could not be moved due to a hook-wire. furthermore, we wished to test the influence on observer confidence. material and methods: all women with non-palpable breast cancer scheduled for sn procedure and hook-wire implantation in were eligible (n= ). fifteen were excluded: reinjection of tracer s (n= ), contamination artefacts (n= ), bilateral tumours (n= ), non-available images (n= ), non-available surgery results (n= ) and multiple wire-implantations (n= ). mtc-nanocoll ( x mbq) was administered using both a peritumoral and a periareolar injection. scintigraphic images were obtained using a single-headed gamma camera (mediso, hungary) equipped with a low energy high resolution collimator. dynamic images in ao- were obtained for minutes after injection and a summed image from - minutes comprised the early ao- . following dynamic acquisi-tion, successive -minutes planar images were acquired in ap and lp. late images in ao- and ap were obtained successively starting minutes after injection. for each patient, the five images were reviewed randomly and independently without knowledge of other projections or the number reported and confirmed by surgery. results: in all patients, one or more sn were identified, in patients ( %), one or more were positive for metastases. in patients ( %), ap was sufficient. we found additional sn in ao- alone in of patients ( %); one was positive for metastasis. in another patients ( %), ao- also showed additional sn, but these were also visualized in lp. in the former patients, ao- improved observer confidence in ( %) and in the latter , observer confidence was improved with ao- in ( %). conclusion: adding oblique projections to standard ap and lp for sn detection in non-palpable breast cancer demonstrated a few more detected sn, and improved observer confidence in one third of the patients. to ascertain whether imaging patients at hours post injection will demonstrate sln(s) if the initial hour image is negative. method: sentinel lymph node (sln) images are usually acquired the day before surgery. four injections of mbq m tc nano-colloid in . ml are injected peri-areolar. the nipple area is then massaged for minutes. hours post injection anterior, lateral and oblique images are acquired on matrix with lehr collimator. a cobalt flood source is used to outline the patient. if no nodes are seen on the hour image a further minute oblique image is acquired at hours, again on matrix with lehr collimator. at surgery, ml of blue dye is also injected peri-areolar. results: out of patients (< %) demonstrated no nodes at three hours. patients went to surgery before delayed images could be acquired. of the remaining , ( %) images indicated nodes at hours. of the patients, with negative images at hours, had low activity nodes found at surgery using a gamma probe and in patient the nodes were detected with blue dye only. conclusion: imaging at hours post injection can improve the sln localisation if the hour image is negative. interdisciplinary databases for evaluation of nuclear medicine procedures m. móldrup , w. vach , p. hóilund-carlsen ; odense universitetshospital, odense c, denmark, university of southern denmark, odense c, denmark. we have established interdisciplinary databases the stem of which are nuclear medicine procedures in heart disease and cancer. using our database for breast cancer as an example we present its important characteristics and our experiences with it. material and methods: the database includes prospective and chronological data from mammography, nuclear medicine, surgery, pathology, oncology, and clinical genetics. its purpose is to ensure that all patients are included, check the quality of the sentinel lymph node (sln) procedure, evaluate its usefulness in terms of a constantly high identification rate, reliable detection, and treatment of extra-axillary slns, and long term follow-up with regard to axillary and distant recurrences. all parties agreed upon purpose, rules, and which data should be recorded for each patient. we created the questionnaire sheets with a common lay-out suited for typing of data, e.g., yes or no. all questions must be clear and unequivocal allowing simple answers only. each panel must have blanks for crosses or numbers, not text. spaces for "unknown" or "not done" are mandatory to ensure all questions are considered. in each department a contact person collects and controls data before submission to us, where they are checked once again by a controller before typing. in collaboration with the statistical research unit we have established an organization ensuring creation of proper webbased databases, relevant questionnaires, control of submitted data sheets, typing (twice) of data, error correction, etc. patient id is converted to a serial number to ensure anonymity. a set of basic data are available to all parties at all times. all can have their own data within a fortnight. interdisciplinary data are provided after application. an updated set of all data is available twice a year. results: the database has created a positive and unique collaboration between departments. all parties can check the entire patient course, including waiting and procedure times. it has become clear what is good and less good, if there are patterns of non-visibility of slns, reoperation, rates and appearance times of lymphedema, effects of treatment, new procedures, etc. conclusion: interdisciplinary databases yield closer collaboration and better understanding between parties. the fact that each department has its own questions means that data are much more comprehensive, detailed, correct, and up-todate than in nationwide cancer databases. datasheets and controllers are still necessary to ensure data reliability. nucl. med. , - ( ) ]. we use computer-controlled modules in connection with an automatic dose dispenser. the modules are installed in pharmaceutical class b cells surrounded by a class c laboratory. materials & methods: all the batches were analyzed according to the european pharmacopoeia (ep) to verify: •radiochemical purity (hplc, tlc); •ph (ph indicator strips); •sterility (all the batches has been sent to an external gmp compliance laboratory); •bacterial endotoxins (turbidimetric method); •chemical purity (hplc); •radionuclide purity (nai detector); •half-life (measuring the activity at different times in a dose calibrator); •residual solvents (gc-based method for measurement of residual methanol, acetone, ethanol and acetonitrile. detections limit was μg/ml for all solvents); • kryptofix . . (method developed by mock et al [nucl. med. biol. ; : - , ( ) ]; •bubble point of sterilization filters. depending on the requested amount of activity for in-house scheduled scans and of external costumers requests, we usually bombarded . ml of [ o] h o for to minutes at - μa beam current with a pettrace cyclotron and using alternatively two targets. [ f] fobtained by (p,n) reaction is transferred to the automated synthesis modules, which synthesise [ f] fdg within minutes. furthermore minutes are required to empty the target and additional minutes are necessary for the automatic dispensing unit to dispense activity in vials for qc, back-up and sterility in addition to vials for a variable number of costumers. all the samples are filtered (at . μm) into sterile evacuated collecting vials in pharmaceutical class a environment. results:the number of rejected batches over was and was due either to mechanical problems as leakage of fittings, tubes and valves or to solvent-/radiochemical impurities exceeding the ep limits. none of the batches was positive to sterility or pyrogenicity tests or presented problems due to the radiochemical purity or half life. conclusion: based on our experience we conclude that solvents impurities represent a crucial point in fdg production and great attention must be focused on an accurate method for residual solvents detection. background: immunoscintigraphy is an attractive tool for tumor and other imaging purposes, with iodine ( i / i) and indium(in) as popular isotopes for radiolabelling. i-labelling may be obtained by the iodogen and other methods, in needs some chelator, e.g. dtpa. the aim of this study was to produce and evaluate, in an experimental mouse model, a good labelling technique for in vivo use of a specific monoclonal antibodies (moab) against a human breast cancer (bc) antigen, muc- . materials and method: i and i labelled anti-muc- (muc) moab were synthesized by the iodogen method. after one sephadex purification step free i or i were < %. the i-muc was then injected into bc xenograft tumors in mice. as control a nonsense i-labelled moab, anti-tnp, was injected into other mice with the same bc tumors. by gamma camera monitoring and well counting of the tumors the retention of the moab were compared. in labelling of polyclonal igg ab modified with dtpa-anhydride were done times, before labelling muc. dtpa-anhydride was suspended in dichloro-methane (dcm) to avoid hydrolysis. just before adding the igg solution, dcm was evaporated with nitrogen. igg-dtpa was then separated from dtpa-anhydride by gel chromatography before adding in-citrate. results: iodine-: in the first series of bc xenografts i labelled muc was retained longer than anti-tnp (p< . ), both according to imaging and well counting. however, in the following identical mouse tumor series, radio-iodine was rapidly removed from muc anti-tnp in the xenografts, and high iodine uptake was noted in the thyroid gland. indium: labelling efficiency of igg-dtpa varied from to % (mean ). generally, but not always, purification with one sephadex column increased purity to > %. the in-muc has not yet been tested in an in vivo mouse model. conclusion: in vitro labelling with iodine is generally simple, but in vivo stability of i-labelled antibody must be carefully evaluated since de-iodination in vivo often occurs. inlabelled antibodies are, according to literature, usually stable in vivo, but chelatorbased in-labelling procedures may be a greater challenge for a reproducible production of a highly purified, radiolabelled antibody. aim: a radiation detection system for target monitoring was designed, developed and optimized for its use as a diagnostic tool for cyclotron startup, maintenance and operational needs. the system was installed for monitoring the radiation levels next to the cyclotron target during and after bombardment. the system permits a rapid assessment of the quality of any particular run in which isotopes are produced as radionuclides for pharmaceutical labeling. cyclotrons are produce short-lived positron-emitting isotopes that are used as research tools in identifying physiological mechanisms and in diagnostic procedures for numerous medical problems with the positron emission tomography (pet) instrument. the short half-lives characterizing the positron-emitting isotopes necessitate that they be produced at the desired activity, as rapidly as possible, so that they will be available for the scheduled procedure. this raises a need for automated control sensors that can monitor the production process. method: a computerized radiation detection system was developed for monitoring the radiation levels next to the cyclotron target, during and after the isotope bombardment in an attempt to show that a particular cyclotron run might be faulty. the system utilized a bgo scintillation detector focusing on measuring the photons at the energy window of kev; and a geiger muller detectors design for measuring the gross gamma radiation. the system monitored the radiation levels throughout the production run as well as the activity before and after the transfer procedure, when the measurement of isotope activity takes place. the installed system input on-line the results into computerized software, and used as part of an overall diagnostic and control tool of the bombardment run. results: the target radiation detectors provided an early warning of a malfunction or an irregular run. this information could lead to operational decisions in order to prevent delay in the production and availability of the isotope. the system predicted and quantified accurately the actual amount of radioactivity being produced, thus it assured quality control during isotope production. the system also helped in troubleshooting target problems immediately after their occurrence and identified the stage at which the malfunctioning took place. conclusion: the results obtained from the developed system indicated that such a measurement tool can serve as a powerful instrument for sensing various target conditions. this can be translated to an awareness of problems in the early stage during isotope production, and provide early notification to the cyclotron operator that a particular run is malfunctioning. aim at present, most nuclear medical departments have instrumentation that allows them to perform tommographic studies in a continuous circular method. with the present work, we aimed to compare quality of images obtained by simple photon emission tomography with two approaches, continuous circular and step-and-shoot circular acquisitions. material and methods for both methods, continuous circular acquisition and step-and-shoot circular acquisition, we tried to establish associations between acquisition parameters (independent variables) -number of projections for each detector, time for each projection; and measurements of image quality (dependent variables) -noise, contrast, resolution and sensitivity. the experimental series was defined using a non probabilistic method by convenience, with sixteen studies of a jaszczak fantom, model ecat/dlx/p, in which eight studies were acquired in a continuous circular mode and the other eight in circular step-and-shoot mode. the statistical analysis was performed with package spss version . results the percentage of noise was inferior in studies in continuous circular mode, the contrast measured with the spheres gave identical results in the two acquisition methods, the resolution was higher in step-and-shoot mode and the detection sensitivity was higher in continuous circular mode. conclusion we conclude that the tommographic acquisition in continuous circular mode presents identical image quality to the one in step-and-shoot circular mode. the quantification of low activity in plasma of a positron emission tomography tracer is performed in pet research to derive a kinetic model for a particular biochemical process. to define the kinetic model, the concentration of radioactivity in the parent compound present in the plasma must be measured at several time points. a radio-hplc is used to measure low levels of radioactivity in a compound throughout rapid sequential experiments with the nearby presence of another compound causing a high background level. both the measured compound and the background level are caused by compounds labeled by a positron emitter isotope. the time separation between the parent compound and the metabolite one is limited, therefore optimization of the measured volume and its geometrical configuration can improve the minimum detectable activity. improving of the mda is important for achieving a better reliability and validity in measuring biochemical processes with pet. the research was based on an analytical study, followed by software simulation and feasibility experiments for increasing the measuring sensitivity of an hplc metabolite radiation detector. as a first analytical step a mathematical model for the coincidence measurement probability from a pet tracer radioactive compound was developed. by using this model, an estimation of the number of coincidence counts was made, and its influence on detection sensitivity from the system configuration parameters was assessed. results of the mathematical model were compared to those obtained by software simulation.. finally an experiment was performed under similar conditions those in the mathematical modeling and software simulation. a high correlation between the mathematical modeling and the software simulation was found. the results indicated that an optimum for the measured volume and its geometrical configuration can be found. a curve representing the measured coincidence counts as a function of volume was obtained from the experimental results. the experiment validated the analytical study, showing that optimization can be achieved for each case based on the time separation between the parent compound and the metabolite one. a new method for improving the mda for the data acquisition during kinetic modeling, based on optimizing the measured volume seen by coincidence detection configuration is suggested. the mda is defined by both the signal and the background levels. the s reduction in the sensitivity for the signal measurement is negligible compared to the reduction in the background level, and is achieved by increasing the distance between the measured parent compound and the metabolite one. we have developed a simple image registration method for m tc-mdp planar bone scintigraphy and x-ray images in patients with suspected scaphoid fracture. this method is based on immobilisation of the wrist in a vacuum pillow equipped with three multi-modality fiducial markers ( co-source collimated by a punched coin, . cm) during image acquisition followed by computer assisted semi automatic image registration (casair). the aims of this study were to investigate the feasibility of the vacuum pillow to immobilize the wrist and to evaluate the accuracy of casair. materials & methods: wrist movement between two examinations was assessed in five healthy individuals. a small metal disk ( . cm) was taped radially to the volar side of the carpus. two x-ray images were acquired with the wrist immobilized in a vacuum pillow equipped with three fiducial markers. between the two acquisitions the subject walked around for about minutes. the two images were registered with casair and the distance between the centres of the metal disc on the carpus in the two images picture was measured. accuracy of multi-modality image registration with casair was estimated from clinical fusion images. the distance between the centres of each fiducial marker on the x-ray image and scintigraphic image was measured. results: mean wrist movement as evaluated by consecutive xrays was . mm (range mm to . mm ). accuracy of casair was . mm (range . to . mm). conclusion: the vacuum pillow provides a feasible and accurate method of immobilisation of the wrist and image registration with casair provides very accurate image registration of nuclear medicine and x-ray images. in consideration of the size of the scaphoid bone the magnitude of misregistration with the proposed method has no clinical impact. introduction:in routine practice of spect acqusition,the image acquisition time per projection is a cause of concern eventually leading to increased overall acquisition time of a clical study.the present study was therefore undertaken to optimize the overall aquisition time irespective of whether fbp or osem reconstruction technique is used.the objective of the study also included comparative evaluation of the images obtained by either reconstruction techniques. materials and methods:the raw image data were retreived from dst-xl sopha gamma camera work station and were then subjected reconstruction using both fbp and osem technique on xeleries work station.the aquisition time was also manipulated to seconds per view from seconds per view/projection.the reconstructed images were obtaine for reduced acquisition time keeping all other parameters identical nad by using both reconstruction techniques.the reconstructed images were blinded for independent evaluation by two nuclear medicine physicians in the nuclear medicine department of the institute. results and conclusions:the overall image information and quality remained unchanged even after reducing the acquisition time from seconds to seconds per projection irrespective of whether fbp or osem reconstruction method was used for skeletal images.in addition the intercomparison of fbp and osem reconstructed images revealed that the image information was better delineated in osem reconstructed images as compared to fbp reconstructed images. the image optimization in terms of reduction in acquisition time without any loss of image information would help reducing overall study time in spect aquisition.in addition use of osem reconstruction technique appears to be the order of the day in image processing and would provide improved image information delineation. the generally used filtered back projection(fbp)method is likely to be influenced by high accumulation, especially in the liver and biliary system, and it is often difficult to reduce the waiting time for imaging with a tc preparation. in this study, reduction of artifacts using the projection mask method was studied. method: a model was prepared to generate artifacts from the liver using a cardiohepatic phantom. mask processing of counts was applied to spect images acquired over degrees at intervals of degrees and the obtained projection data of slices other than the myocardium. a similar mask processing was also applied to clinical cases after ami and compared. for analysis, decreases and variations of the counts were measured with a polar map and a circumferential profile curve (cpr) on a short axial image. results: in the phantom, a significant difference in the count was observed (p< . ) between normal processing and mask processing, that is, the average count was . for normal processing and . for mask processing. variances in the area with visually observed artifacts with the cpr were . for normal processing and . for mask processing, indicating smaller variations with the mask processing. the counts and variances in an area with visually observed artifacts in clinical cases were . and . respectively, which were significantly reduced to . and . by mask processing (p< . ). conclusion: the projection mask processing method is an effective means for removing artifacts from the liver and the gallbladder, and imaging may be available from the early period after myocardial injection of the mtc tracer. aim: in pet study, the coincidence count rate (cr) in the imaging of standard image quality phantom (iq phantom) is different from that of the actual clinical data. therefore, clinically optimal injection dose cannot be estimated using the data of iq phantom. in this study, we made an anthropomorphic pelvis phantom (pelvis phantom) which can provide the cr equivalent to clinical data and investigated whether the optimal injection dose could be estimated using this pelvic phantom. materials and methods: the pelvic phantom was made by putting high radioactivity area imitating the urinary bladder in the iq phantom and by using bone-equivalent material for pelvic bone model. at first, the images of the pelvic phantom were acquired changing its radioactivity using both d and d acquisition modes. obtained crs were compared to those of pelvic images of actual patients. then, single photon ratio (spr) indicating the maximal necr was determined in the pelvic phantom imaging. using this spr, the spr obtained from patients' data was normalized. the optimal injection dose of fdg per kg of body weight was calculated according to the relationship between spr and the injected dose. results: the good correspondence was shown between cr of pelvic phantom data and that of clinical data when sprs were . to . mcps for d imaging, and . to . mcps for d imaging. the spr at the maximal necr in the pelvic phantom imaging was . mcps in d acquisition whereas no peak was found in d mode. the optimal injection doses calculated using spr in d imaging were mbq and mbq for the body weight of kg and kg, respectively. these results were empirically acceptable. conclusion: the imaging of pelvic phantom showed the cr similar to human bodies, indicating that the statistical quality of the obtained data in human studies can be estimated by this phantom. and, using spr of this phantom, the optimal injection dose per body weight could be simulated in d imaging. introduction: phantoms for the determination of the size of pixels should be big, rectangular, homogeneous and easily available. however, they must not "jut out". the nema homogeneity phantom can meet these requirements if its position is adjusted to whole body scanning. material and methods: the nema phantom was filled with gbq of m-tco and placed on the examination table with its long edges parallel to the examination table. a square tile of . cm was put on top of the phantom and was aligned to one of the short edges of the nema phantom to facilitate a comparison of the resulting defect with that of a static image. pixel numbers were determined by applying rectangular roi to the edges of the phantom and of the tile. by this, the numbers of pixels of the x-and y-axis could be determined and compared with the length and width of the phantoms. we compared the data of a prism camera with those of an lfov camera that had not been approved yet by our hospital at the time when we did the exams. we did a static scan and two whole body scans ( and cm) with both cameras. results tile the accuracy of osem and fbp reconstruction algorithm for the determination of the thyroid volume: a fantom study a. ergulen, g. durmus-altun, f. ustun, s. erol, s. cıldavil, s. berkarda; trakya university, edirne, turkey.background_individualised dosage models are frequently applied for radioiodine therapy in patients with graves' hyperthyroidism. in these dosage schemes the thyroid volume (tv) is an important parameter. iterative reconstruction algorithms produce accurate images without streak artifacts as in filtered backprojection. they allow improved incorporation of important corrections for image degrading effects, such as attenuation, scatter and depth-dependent resolution. the aim of this study was to compare the accuracy of osem and fbp reconstruction algorithm for the determination of the tv in fantom study, and to comparing estimted tv and anterior degree spect acquisition methods and results_the osem (it: , sbs: ) and fbp (bw cut-off: . , order ) algorithm was employed in reconstruction. at quantitative analysis and anterior degree -i thyroid spect , the volume of thyroid were calculated for %- %- % uptake levels of wather-filled thyroid fantom. for estimation of tv, linear regresion analysis was eployed and final regresion equations were generated for each acqusitions and filters. the thyroid images were filtered, and after applying a threshold method an automatic segmentation algorithm was used for the volume determinations. the best estimation of tv was observed on degree spect acquisition and fbp algoritims. estimated tv(ml)= +( . * calculated tv)-( . * average count of thyroid); r: . , r : . , p: . , se of estimation: . ). th predicted tv was . +/- . ml (min: . , max: . ) and see of ptv was . +/- . ml. conclusions_the comparisons with osem and fbp indicate that thyroid volume estimations with aim high resolution scintigraphy ( hrs) can be useful in radio-guided surgery (rgs) and small animal imaging. devices are generally based on arrays of sensible elements: room temperature semiconductor arrays or scintillating crystals arrays that can be coupled with position sensitive photomultipliers (pspmt). here we describe a small field of view (fov) portable cameras based on and inches pspmt. materials & methods these cameras show a peculiar crystal-collimator-pspmt matching that allows the exact positioning of all the scintillating elements inserted in the square holes of a parallel tungsten collimator. this arrangement ensures no crosstalk of rays or light among crystals. the scintillation light emerging from each crystal is revealed by a pspmt (h or r - -c ). the anodes allow event positioning through the reconstruction of the maximum of the multiplied charge distribution by the centroid algorithm. data are then selected with an appropriate energy window and transferred to a workstation. we studied the spatial resolution and the homogeneity of two cameras both equipped with . x . x mm csi (tl) crystals and a mm long collimator. a thin plexiglas container filled with m tc was used to check homogeneity and pixel identification. a derenzo phantoms with the diameter of the holes ranging from to mm was positioned at contact, at , , cm distance from the collimator and filled with m tc to assess the camera spatial resolution. results the energy resolution was . % fwhm of the m tc peak over the whole fov area. both cameras showed homogeneity within ± % between max and min pixel counts. pixel identification showed average peak to valley ratio of : . spatial resolution was . mm at cm, . mm at cm, . mm at cm and . mm at cm distance. conclusion measurement of resolution were performed to foresee the working conditions of hr cameras. actually when nuclear physicians show to surgeons sentinel nodes or parathyroid glands, they are on contact with the source or at few cm distance. both detectors were used for rgs and showed hot nodes less than mm large and distant . mm each other. in several instances a spot detected as single node by anger camera showed the presence of two near nodes. aim the aim of our study is to evaluate the correlation between the bone density measured with quantitative us technique (qus) and with dual x-ray absorbiometry (dxa). material and methods we studied patients ( - years; mean: ). bone status was assessed by quantitative ultrasound, using dbm sonic (igea, italy), which measures amplitude-dependent speed of sound (ad-sos [m/s]) and bone densitometry by the use of unigamma plus/compact (l'acn, italy), which measures bone mineral density. we correlated the t-score parameters obtained in qus e in dxa scan. "t-score" compares the patient's bmd with the young-normal mean bmd and expresses the difference as a standard deviation (sd) score. the qus was performed in menopausal ambulatory in gynaecology department, measuring the bone tissue at the metaphysic of the proximal phalanges of the last four fingers of the non-dominant hand. after the ultrasound bone densitometry, the women underwent the dxa scan of lumbar spine (l -l ). the bmd is calculated in g/cm . we had exposed t-score as diagnosis of normality, osteopenia and osteoporosis according to world healt organization normal range. results according the who definitions, osteopenia was found in patients and normal bone density in patients with quantitative us technique . with dxa method, osteopenia was found in patients, normal in patients and osteoporosis in patient . conclusions concordance was found between the bone density measured with qus and with dxa in patients, while patients results were discordant. some studies in literature showed an agreement of . - . between qus methods and dxa in our study the agreement between the diagnosis in qus and in dxa is . . it agree the literature data. our intention is to continue this study, extending the case study. aim: neuroendocrine tumors may be treated by peptide receptor radionuclide therapy. in order to target somatostatin expressing tumors dotatoc was coupled to a ßemitter yttrium- (y- ) or lutetium- (lu- ) which results in a high radiation dose in the tumor tissue. the elimination of the peptide occurs via the kidneys. y- -dotatoc shows tubular reabsorbtion and accumulates in the kidneys. therefore, a major complication of y- -dotatoc-therapy is the radiation-induced nephrotoxicity. in this study we determined the effects of y- -dotatoc-therapy on renal function with tc- m-mag- scintigraphy. methods: patients ( m; f) between and years (average: , years; median: years) have been examined. all patients received a minimum of three dotatoc-therapies in combination with a nephro-protective amino acid infusion according to the heidelberger standard protocoll. the dynamic scintigraphy was carried out from dorsal position (multispect , fa. siemens) with a weight dependent application of tc- m-mag . between the st. and th. minute p.i. a blood sample was taken at the opposite arm. the blood was centrifuged and ml serum was measured in a gammacounter using repeat determination. the evaluation of the tubular excretion rate (ter) was done on a xeleris workstation. the ter of any examination was normalized using a specific patient standard. the average after the second, third and forth therapy was verified with the t-test procedure and deviations from average were analysed. results: after the second and third therapy there was no significant change in renal function with a probability of p= , (n= ) after the second therapy and p= , (n= ) after the third therapy. a significant aggravation of the renal function was shown in patients p= , (n= ) after the fourth therapy. in of patients the ter was pathological. conclusions: three cycles of y- -dotatoc therapy are well tolerated by the kidneys, and a significant reduction of renal functions were not observed. however a significant reduction of the ter was found after the th cycle in some patients. however, the renal function dropped into the pathological range in . % of these patients. we conclude that the risk of a nephro-toxicity by a y- -dotatoc-therapy is negligible during the first cycles. after the th cycle of y- -dotatoc therapy, a reduction of renal function may occur, but the clinical relevance is low. this presentation will outline some of the additional duties that may be encountered by a nuclear medicine technologist (nmt) working in the field of rit research. radioimmunotherapy is being increasingly used, particularly in the treatment of haematological malignancies. a stem cell transplant with prior rit involves input from a range of specialities such as oncology, haematology, nursing, radiopharmacy, physics, imaging, and laboratory services. it is vital that the multidisciplinary team works in harmony to deliver this service. the large number of staff members involved adds complication to making patient appointments and has led to some overlapping of roles in order to offer a continuous service. rit is a complex and evolving technique and many procedures will be new to a nuclear medicine technologist entering the field. the additional duties performed by a nmt at southampton include coordination of patient appointments for rit clinical trials, performance of elisa assays, quality control of radio labeled antibodies by hplc and itlc, administration of dosimetric and therapeutic infusions, assistance with dosimetry calculations and bremstrahlung imaging. these duties will be illustrated with reference to a clinical rit trial currently being undertaken at this institution. aim the aim of this study was to determine the radiation dosimetry of no-carrieradded (nca) i-metaiodobenzylguanidine (mibg) compared to carrier-added (ca) i mibg, in the same subjects. materials and methods nine healthy subjects were injected with mbq nca i mibg and on a separate occasion with ca i mibg. anterior and posterior whole body (wb) scans were made with a dual-head camera at min, . , . , . , , and h post injection to obtain organ timeactivity data. blood samples were collected at the same time points in order to determine activity in the total blood volume. urine was collected in five portions up to h in order to monitor the excretion. one set of regions of interest (rois) was drawn for ten source organs and different background regions on the wb scans, and then applied to each wb scan. the counts in the rois were corrected for background. the geometric mean net counts were calculated, and corrected for attenuation, efficiency, decay, and expressed as a percentage of injected activity. curve fitting was applied to the time-activity data to obtain the total number of disintegrations in each source organ, from which the absorbed doses to all organs was calculated (olinda/exm software). the effective dose (msv/mbq) and effective dose equivalent (msv/mbq) were then determined. results the effective dose of nca i mibg was equal to ca i mibg ( . ± . msv/mbq vs. . ± . msv/mbq, respectively; p= . ). the effective dose equivalent of nca i mibg corresponded with that of ca i mibg ( . ± . msv/mbq vs. . ± . msv/mbq, respectively; p= . ). the myocardial wall showed % more uptake for nca i mibg compared to ca i mibg. the radiation dose to the myocardium was thus higher for nca i mibg compared to ca i mibg ( . ± . msv/mbq vs. . ± . msv/mbq, respectively). conclusion no essential differences were found in absorbed dose between nca and ca. the higher myocardial uptake of nca favours the use of nca over ca for the assessment of myocardial imaging. characteristic evaluation of a real-time semiconductor dosimeter and measuring finger dose in nuclear medicine departments t. fujibuchi , t. isobe , t. iimori , y. uchida ; chiba university hospital, chiba-shi, japan, kitasato university, sagamihara-shi, japan.background and purpose: workers who use radiation sources in the nuclear medicine field have the highest risk of exposures to their fingers. until now, tlds have been the only reliable dosimeter to measure finger doses. however, the usage of tlds is complicated, its procedure is time-consuming and it is used in other fields as well. in this study, we measured finger doses by using a semiconductor dosimeter for the nuclear medicine examination and evaluated its sensor characteristic. after having aim: the tracheo-bronchial inhalation is the most invalidating symptom shown by patients with neurological disease and it is the most frequent cause of death. oro-pharyngo-esophageal scintigraphy (ofes) allows both functional and semiquantitative study of the various stages of swallowing. material and methods: we studied with ofes a woman who underwent to high dosage radiotherapy treatment for rhinopharyngeal carcinoma. the patient developed progressive and ingravescent dysphagia, with ipomobility of the right arm. the patient, placed in a ° right anterior oblique upright position, in front of a large-field-of view gamma-camera, was given a single cc bolus o water labelled with mbq of m tc-nanocolloid. eight images/sec are acquired ( . sec/frame) for one minute, with dynamic acquisitions using a x matrix and zoom of the visual field from oral cavity down to epigastric area. two second after the beginning the patient is invited to swallow the liquid in a single time and a static image lasting seconds is then acquired at the end of examination, to evaluate the presence of tracheo-bronchial aspirate. for the presence of massive inhalation the study was completed with a spet-tc. the parameters analysed were: oral, pharyngeal and esophageal transit time, oro-pharyngeal and esophageal retention index, percentage of tracheo-bronchial aspirate. the study was performed at the time of diagnosis, after the treatment by positioning the low pressure cuffied tracheostomy tube and finally after functional laryngectomy. results: ofes shows a massive tracheo-bronchial inhalation at first study with ritention of bolus in the both lungs and a lengthier oral and pharyngeal transit times and an increase in the oro-pharyngeal retention index. a spet-tc confirms the pulmonary aspiration and shows a sovra-elevation of the right lung as consequence of inhalation. the ofes performed after positioning of the cuffied tracheostomy tube shows absence of inhalation in tracheo-bronchial tract after oropharyngo-esophageal transit of liquid bolus with a presence of small aspiration in the right lung in tardive acquisition. the cuffied tracheostomy tube was changed with a standard tracheostomy tube and the ofes shows again massive tracheo-bronchial inhalation. then the patient was submitted to functional laryngectomy. a scintigraphic study performed subsequentely shows absence of tracheo-bronchial inhalation. conclusion: ofes in neurological patient is a simple, inexpensive, non invasive and reliable technique that shows the presence of bolus inhaled and quantifies tracheobronchial aspirate. ofes is a useful and accurate tool to monitoring the response to medical and/or surgery therapy. ger on children with recidive bronchitis(rb) m. hudournik; general hospital celje, celje, slovenia.aim: in this examination we are finding how frequent ger as a cause for rb. materials and methods: in this examination have been included children ( men, women) in an age from mounts to years. doctor's notes for these children have: rb ( children), vomiting ( ), cough ( ) and allergy ( ). the images of these children has been taken in lying position after a normal meal. radiofarmac was tc- m-lyomaa (dose upon , mbq - mbq), which has been to apply through the nasogastric tube or to drink up. gamma camera was set up behind the patient. the field of view includes the mouth, sternum and abdomen. images are generated every s for h on x matrix. after - hours we have taken delay images of lungs to find out the aspiration tc- m-lyomma in to the lungs. results: from all ( ) in this examination included children has had ( , %) ger and from this has ha dan aspiration in the lungs. in examination has confirmed with diagnosis, rb %, vomiting %, allergy % and cough % ger. children average age with rb diagnosis has been , years . most children ( ) with rb has been - years old, % of them has had a ger. conclusion: frequency of ger on children with rb is %, especially with children at approximate age ( %). introduction: the collaboration problems that arise from the observation and care of patients could be codified to nursing interventions classification (nic), to obtain finally results codified agreed to nursing outcomes classification (noc). these collaboration problems, interventions (nic) and results (noc) applied to patients referred for treatment of hipertiroidism could identify and develop interventions to optimize ant obtain the wished results so the patient feels more comfortable in the visit to our service. methodology: since the nursing in our service are explore these aspects in the daily care of patients (approximately patients weekly), and have been identified the collaboration problems that usually presents this type of patients. the most frequent were: administration of radionuclides, informed consent, radioprotection advices, nursing registry, discard pregnancy in women in fertile age. once identified these collaborations problems an interventions, codified according the nic criteria are applied: administration of oral medication ( ), agreement with the patient ( ), support in making decisions ( ), identification of risks ( ), documentation ( ), advise before conception ( ). all patients fulfilled a report (survey form) about the satisfaction for the care received in the service. this form was complimented at % of patients. all patients facilitated a satisfaction survey when they left our service, which was answered for the % of them. results: after application the interventions we had a satisfactory results in % of patients. these results codified agreed the noc were: behaviour of fulfillment ( ), well-being ( ) , knowledge: prescribed activity ( ), knowledge: preconception ( ). conclusions: the use of the methodology according nanda criteria could diminish the collaboration problems in patients referred to treatment with i- . we acquired image that used orbiter gamma camera with pin hole collimator. also we acquired the thyroid phantom and the -q bar phantom image to compare resolution. the patient image aquired by sec or kcnts. and phantom image acquired by kcnts. we calculated thyroid/bkg ratio from the image that is setted with sec. and then compared scan time from the image that is setted with kcnts. additionally, we investigated that the time required of each diseases(hyperthyroidism, hypothyroidism, goiter, nodule). when we acquired image by time setting( sec), using mm pin hole collimator and mm pin hole collimator, that result of thyroid/bkg ratio was as low as . times in mm pin hole collimator(ratio - mm: . , mm: . ). and we the relative high number of persons who daily attend to nuclear medicine departments is an important factor regarding disease transmission. although the permanence of these people in the facilities is usually quite short in time, there is always the possibility to transmit or receive infectious agents (both through organic material or airborne transmission). the goal of this work is, firstly, to "make the diagnosis" of the present situation, identifying what kind of infectious agents are present at nuclear medicine departments (and if different nm departments present different profiles, according to their characteristic turnover of patients), and, secondly, to suggest appropriated technical solutions for their control/elimination, when possible (otherwise, at least, to obtain their minimization). this abstract relates with the first part of the work (as it is still on progress). material and methods: as a first step, it was performed the characterization of the present situation, via an adequate analysis/detection of the main pathological agents (focusing only on bacteria and fungi) present in the diagnostic equipment, as well as in other important "hot spots" in a nuclear medicine department, where the spreading of these agents was believed to be more prone to happen (such as keyboards). it had been collected and microbiologically analysed bacteriological samples from those pre-established spots in several distinct nuclear medicine departments. the information collected is actually being related to the different kind of scintigraphic studies that are performed in those departments (and/or the different "specific profiles" of the departments itselves). the cleaning methodology (agents used and respective frequency) used in these departments is being taken into account and related with the results obtained. results and conclusions: according to the results obtained, it had been possible to identify the main infectious agents and to make the "point of the situation" in distinct profiles of nm departments, being believed that this should be the starting point to further studies, now aiming to identify methodologies able to control the incidence of nosocomial infections related with nm departments. ben-gurion university of the negev, beer-sheva, israel. the o oxygen isotope is widely used in cyclotron targets for the production of the f positron emitting isotope. the latter's rapidly increasing use in medical imaging generated a need to improve the diagnostic tools for controlling the cyclotron production of f and o during the enrichment process. a highly reliable measurement of o concentration is important for the o manufacturer to validate its purity, and for the f producer, to assure that that it is produced with the required activity and quantity at the end of the cyclotron run. this work describes a process that can validate the concentration of these isotopes and that should prove useful to both parties. the manufacturing of o water involves several stages to obtain the final required concentration of o ( . %). by carrying out isotopic analysis repeatedly throughout these stages, the concentration of each isotope can be validated. a radiation detector was used to measure the gamma field for different levels of o enrichment during the production of f. the gamma radiation dose rate and the accumulated dose were measured for a target loaded with recycled water, or % enriched o water, or o water. the detector readings from the nuclear interaction in the cyclotron target were compared to the measured beam current, the existing indicator for the bombardment. the variations in the radiation level were calculated and compared to the different levels of o activity in the water, obtained repeatedly throughout the enrichment process, to establish a relationship. the isotope analysis test during enrichment enabled the manufacturer to maintain the o enriched water concentration level in the short run, and the o production quantity rate in the long run. the water enrichment was not reflected by the accumulated beam current when measuring cyclotron protons; however the calculated ratio between the radiation level and the accumulated beam current gave a factor of up to . during the target water bombardment at the various stages. this study presents a comprehensive solution for monitoring and validating o enrichment during the manufacturing stage, as well as the production of f. the isotopic analytical test enabled malfunction identification at the early stages of the o manufacturing process which assured quality and quantity. during the bombardment, the beam current did not indicate any difference in the level of enrichment. however, the radiation monitoring system provided a useful tool for distinguishing between different enrichment levels during the production runs. calibration of i- in dose calibrators routinely used in nuclear medicine departments s. tastan , n. kucuk , e. ibis , e. turkoglu , k. kir , a. soylu ; ankara university, ankara, turkey, monrol a.s, ankara, turkey.introduction: a dose calibrator is one of the most important instruments in a nuclear medicine center since it is crucial to give the right amount of activity to the patient. the calibrator is a well-type ionisation chamber, which has long term stability and can measure activity to the desired level of accuracy. however, it is sensitive to even small changes in geometry, container type, density and volume of samples. material & method: in this study ,which is part of a project supported by the iaea as a crp,performance tests of biodex atomlab- dose calibrator were performed according to " iaea technical report series no: " . the calibration was done by using an i- standard solution provided by the iaea to all participants of the project in various countries. the solution was mbq/ ml in a r schott vial with teflon-coated stoper and aluminium uncrimped seal,uncertainity ( %, k= ) . correction factors were calculated for the r vial, ml syringe and the vial which is routinely used in our laboratory . during the transfer to syringe/vial, necessary amount of carrier solution was added to bring final solution to original mass. results: calibration factors were . , . , . respectively r vial, ml syringe and routine vial. gum ( iso guide to the expression of uncertainty in measurement) were used to analyse all uncertainty components. the table demonstrates correction factors with the calculated uncertainities. conclusion: this study demonstrated that dose calibrator measurements are sensitive to small changes in container type and geometry altough total mass is the same. in many countries don't have national measurement laboratories. therefore, it is important that performance tests, calibrations and audits of radioactivity measurements in radiopharmacies and clinic so that measurement errors can be avoided.correction factor with uncertainities r vial . x activity ± , k= routine vial , x activity ± , k= ml syringe , x activity ± , k= introduction. usually the patients coming for the first time to our diagnosis unit for a pet study show a high degree of unknown about details of that. this fact induces a high degree of anxiety that could be assessed in nursing diagnosis according nanda classification. on basis this diagnosis could be planned nursing interventions (nic). objective: to evaluate nursing diagnosis of anxiety and the effectiveness of the application of interventions (nic) according to noc criteria in patients who are going to perform a pet study. material and methods: from i/' to vi/' patients have been studied for first time using pet, under suspicion of malignant disease. for this purpose, patients with alteration of conscience level are excluded. the degree of anxiety is evaluated by means a numerical scale likert type, before and after the application of the plan of care. results: after the application of the nursing care plan a % of patients reduce in points the anxiety level, in % this reduction is of points and in a % in point according likert scale. conclusions: the application of the nursing plan of care in patients, who first perform a study pet, diminished the level of anxiety in a significant proportion. high performance liquid chromatography evaluated the stability of levofloxacin and stannous chloride for injection x. q. zhou, g. x. cao, r. j. zhang, x. f. qin; jiangsu institute of nuclear medicine, wuxi, jiangsu province, china.aim: levofloxacin is a sort of broadspectrum antibiotic which is often used to treat infectious diseases at present. the method about determination content of levofloxacin tablet using spectrophotography was reported. m tc-levofloxacin is a new specific infect imaging. we prepared levofloxacin and stannous chloride for injection by freeze-dry. it is most important for radiopharmaceutical. we determined the concentration and evaluated the stability of levofloxacin in levofloxacin and stannous chloride for injection for the first time. methods:the concentration of levofloxacin and the concerned substance in levofloxacin and stannous chloride for injection were determined by reverse high performance liquid chromatography (hplc). the stability of levofloxacin and stannous chloride for injection and the radiochemical purity were examined under the different conditions of light, temperature, humidity. we used citric acid and acetonitrile ( : ) as mobile phase, adjusted ph to . using triethylamine. the mobile phase was pumped at ml/min through the lichrospher c ( . × mm, μm) at room temperature. the detective wavelength was nm and the sensitivity was . aufs .the number of theoretical plates was exceed using the model high performance liquid chromatograph and uv detection (waters aim: to guarantee presentation of all studies from pacs to a particular examination on a given imaging modality (in our case pet) after a query from his. material: pet ecat accel (siemens, erlangen, germany), dicom modality tool kit (the offis computer science institute, oldenburg, germany). method: his is interconnected with pacs via unique identifier (on pacs side with the seek key "accession number") for selecting all image data for particular examination on given imaging modality. the imaging modalities without the possibility to write down this unique identifier to a corresponding data item (most often if native image format is used -e.g. ecat for pet ecat accel) can usually use the data item only for a unique "study id". now there arises a problem if it was necessary to make additional studies for a particular examination, as the previous image study would be unwantedly overwritten. the only possible solution is simulated modification of "study id" for additional studies. for the purposes of proper archiving and selecting all the studies appertaining to a given examination on pacs it is necessary, after the conversion of the native image format to dicom, to write down backwards in the blank data item "accession number" the original unmodified value. on the basis of the above mentioned was for simulated "study id" generation modified before now designed dicom modality worklist in the form of an intranet application. after the conversion of the native image format ecat to dicom on the evaluating workstation esoft siemens are the image data going to pacs received by a temporally pacs running on hospital intranet server. here is reconstructed backwards the original value of the "accession number" from data item with simulated "study id" and is at once written into the corresponding blank data item in the format dicom. the data repaired in this way are resent to target pacs and after their successful archiving deleted from temporally pacs. results: such solution allows medical staff to make very simply additional studies on scheduled imaging modality for a given examination such that all of them could always be presented after a query from his. conclusion: the methods with the usage of free software tools may not always be easy to perform but sometimes are the only possible. moreover, they are in some cases the cheapest option. aim: vaccination using dendritic cells is a new therapeutic approach for patients with disseminated malignant melanoma. this phase i-study examines safety and migration of alpha-type i dendritic cells versus pge dendritic cells in patients with malignant melanoma. methods: the treatment consist of vaccination with the patients own dendritic cells, which are injected intradermally or directly into the lymph nodes. at the onset of treatment we are looking for the migration comportment of radiolabeled dendritic cells generated by differently preparation processes. at present six patients with malignant melanoma in stages iii and iv (ajcc, ) were included. alpha-type i dendritic cells and pge dendritic cells were radiolabeled with approximately . mbq in-oxin. thereafter, a minimum of x alpha-type i dendritic cells were injected intradermally of the right upper leg, and the same amount of pge dendritic cells into the left upper leg. migration was investigated by dynamic examination during min. furthermore, static scans were performed inguinal for another min. with and without shielding of the injection area. additionally, whole body scan, including radioactive standards (activities . mbq - . mbq) were performed with a scan speed of cm/min. late scans were acquired hours and hours after injection. results: scintigraphically, lymph nodes were visualized at and hours after injection. positive lesions were semi-quantitatively analysed by drawing regions of interest (roi) above the injection area, inguinal lymph nodes and radioactive standards. after correction for half-life, (± )% after h and (± )% after h of the initial activity was found in the injection area of both cell types. mean of ratios (counts in lymph nodes/ counts in injection area) of alpha-type i dendritic cells were . after hours and . after hours. for peg dendritic cells, the ratios were . after hours and . after hours. in all patients, differences in migration of both cell types were not significant (p= . ). conclusion: alpha-type i dc have a lower tendency to migrate than pge -dc in vivo, but the differences observed are not significant. our data do not provide information about the stimulating behaviour of dendritic cells for an antitumor tumor reaction. up to now, the optimal type of dendritic cells is not synthesized. however, the cells used in this study show potential for further clinical studies. key: cord- -kt gt t authors: nan title: poster session abstracts date: - - journal: pediatr pulmonol doi: . /ppul. sha: doc_id: cord_uid: kt gt t nan causing mutation is ∆f , making studies of nbd essential in understanding cftr function. crystal structures have been solved of wild-type (wt) and mutant cftr nbd , including variants containing ∆f (lewis et al. embo j. ; lewis et al. j. biol. chem. ; thibodeau et al. nat. struct. mol. biol. ) . cftr nbd contains a regulatory insertion (ri) and a regulatory extension (re) that contain pka phosphorylation sites. although the nbd core is very similar in the various structures, the ri and re in some structures of human wt nbd differ by °rotations, indicating that they are mobile. we have used nmr spectroscopy to study wt and ∆f nbd in the phosphorylated (phospho) and non-phosphorylated (non-phospho) states, and bound to different regions of cftr. despite their similar structures, differences are observed in the nmr spectra of wt and ∆f nbd . these changes, possibly due to altered dynamics or interactions of the ri and re with the nbd core, will be discussed. the inherent stability and function of nbd could be affected by these changes, accounting for part of the ∆f defect. different interactions between wt and ∆f nbd with the icls could also affect channel function. to identify residues comprising the icls, we generated a homology model of cftr based on the crystal structure of sav in which nbd and nbd form a productive dimer (dawson and locher. nature. ) . our data on a peptide corresponding to the first intracellular loop (icl ) indicate that binding to nbd requires phosphorylation of the ri. our homology model shows that the icl binding site is buried when the ri is bound to the nbd core. nmr data comparing phospho and non-phospho nbd indicates that phosphorylation of the ri and re disrupts their interactions with the nbd core, likely exposing the site for icl binding. the structure of the molybdate transporter modb c , with the nbds in an open conformation, shows icl binding is cognate nbd at a different interface (hollenstein et al. nature. ) . icl in modb c interacts with the nbd near y , the analogous residue to f in cftr. we will show binding data of icl with wt and ∆f nbd in different states and also present resonance assignments of nbd to map the icl interaction sites. since the sav and modb c structures were solved in different states, the different icl interactions may represent structural changes during the reaction cycle. the ∆f mutation may thus affect intramolecular associations in certain conformations, which would account for another part of the ∆f defect. probing differences in interactions of wt and ∆f nbd is critical for understanding the molecular basis of normal cftr function and of the altered cftr function in cystic fibrosis. shsps target ∆f cftr for erad via the sumo pathway ahner, a. ; brodsky, j.l. ; frizzell, r.a. . cell biology and physiology, university of pittsburgh, pittsburgh, pa, usa; . biological sciences, university of pittsburgh, pittsburgh, pa, usa the most frequent disease-causing mutation in cystic fibrosis (cf) is a deletion of phenylalanine at position (df ) in the first nucleotide binding domain of cftr. essentially all of the mutant protein, as well as % of wild type (wt) cftr, is retained in the er and targeted for erassociated degradation (erad) by the s proteasome. key mediators of cftr folding and degradation are molecular chaperones, which help protein substrates fold, but can target them for degradation if folding efficiency is compromised. to identify factors modulating erad of cftr we performed a microarray analysis, screening for transcription profile differences between yeast expressing cftr and control strains, and identified enhanced transcript levels for the small heat shock protein hsp in yeast expressing cftr. we then demonstrated that cftr degradation was blocked in strains lacking the genes encoding the two yeast shsps, hsp and hsp ( ) . to examine whether shsps regulate cftr biogenesis in mammalian cells, we asked which of the human shsp homologues are endogenously co-expressed with cftr using rt-pcr and western blot analysis. we detected shsps, including alphaa-crystallin and hsp , in calu- and primary hbe cells. co-expression of alphaacrystallin or hsp together with wt or df -cftr in hek cells selectively decreased the steady state levels of df -cftr. pulse-chase experiments showed that the rate of df -cftr degradation was enhanced when either shsp was over-expressed, but wt cftr biogenesis was unchanged. co-immuno-precipitation experiments in hek cells revealed that alphaa-crystallin and hsp interacted preferentially with df -cftr. thus far, our results suggest that shsps selectively increase df -cftr's accessibility to proteasome-mediated degradation pathways. previously, hsp was reported to interact with ubc , the sumo (small ubiquitin-like modifier) conjugating enzyme ( ) . sumo is covalently linked to its substrates, often at sumoylation consensus sites; similarly to ubiquitin, this occurs through a series of thiol transfer reactions. we confirmed this interaction by co-immuno-precipitation and found that ubc as well as the sumo specific protease, senp , are expressed in airway epithelial cells. over-expression of ubc decreased, while over-expression of senp increased df -cftr protein levels. pulse-chase experiments indicated that these enzymes regulate selectively the degradation of df -cftr, similarly to the shsps. preliminary studies in vitro and in vivo indicate that cftr, and particularly purified nbd , is sumoylated and that hsp facilitates this process. mutational analysis of the sumoylation consensus sites within cftr suggests a cycle of sumo modification that facilitates wt cftr biosynthesis but targets df -cftr for degradation, probably because the balance between sumo addition and removal is impaired by an excessive interaction of shsps with the mutant protein. [supported by grants from the nih and the cystic young, a. physiology and biophysics, chicago medical school, north chicago, il, usa efficient retrieval of wtcftr from the cell surface is mediated by components of the clathrin mediated endocytic pathway; however many aspects of cftr endocytosis remain to be elucidated. we have previously shown that endocytosis of wtcftr is dependent upon recognition of a tyrosinebased motif in the carboxyl tail of cftr by the ap endocytic adaptor complex. in contrast to wtcftr, less is known about the mechanisms whereby mutant cftr undergoes internalization. according to one model, df cftr undergoes accelerated endocytosis compared to wtcftr, whereas others have argued that endocytic rates of df cftr are comparable to those of wild-type cftr. to further define the function of proteins involved in the initial steps of wt and mutant cftr endocytosis, we investigated the role of the gtpase dynamin. dynamin has been proposed to play a key role in endocytosis by facilitating the scission of nascent clathrin coated vesicles from the cell surface. until recently, very few tools were available to modulate clathrin mediated events. we took advantage of dynasore, a newly discovered small molecule, non-competitive inhibitor of the gtpase dynamin. dynasore acts as a potent, rapid and reversible inhibitor of endocytic pathways known to depend upon dynamin, by blocking coated vesicle formation within seconds of dynasore addition. endocytosis of wtcftr was inhibited rapidly and efficiently upon addition of dynasore. furthermore, within minutes of dynasore washout, endocytosis of wtcftr resumed completely. also upon dynamin washout, normal trafficking and recycling of wtcftr was also observed. temperature correction of df causes expression of cftr at the cell surface, however such 'rescued' df cftr is not stabilized upon returning cells to c. application of dynasore prevented such rapid loss of mutant cftr from the cell surface. since maintenance of mutant cftr at the cell surface is critical for effective therapeutic intervention in patients with cf, our results provide insight into additional potential targets for pharmacological manipulation for the treatment of cf. richardson, j.m.; thibodeau, p.h.; watson, j.; thomas, p.j. physiology, ut southwestern medical center, dallas, tx, usa protein misfolding is the basis for a multitude of human diseases; however, the mechanisms underlying misfolding are not well understood. most cases of cystic fibrosis are associated with mutations-including the most common, deletion of phenylalanine (∆f ) in nbd -that interfere with the folding of the cystic fibrosis transmembrane conductance regulator (cftr). the resulting loss of functional cftr causes the disease. thus, elucidating how ∆f , affects the folding of cftr is critical to understanding the pathology of the disease. cftr is composed of five domains: two integral membrane transmembrane domains (tmds), a regulatory domain (r), and two nucleotide binding domains (nbds). ∆f occurs in the n-terminal nbd . both the murine wildtype and ∆f nbd can be expressed in bacteria and purified to near homogeneity. while the soluble expression yield of ∆f is lower than the wild type under identical conditions, ∆f achieves a native conformation similar to wild type as monitored by a variety of hydrodynamic and spectroscopic characteristics such as analytical size exclusion chromatography, circular dichroism, and fluorescence. recently, a non-native, but folded, species has been detected under mildly denaturing conditions. far-uv cd reveals a time and temperature dependent conversion from a mixed alpha/beta native conformation to a less helical non-native conformation, while fluorescence measurements reveal a parallel blue shift in the peak emission intensity from to nm. this non-native species is in a more open conformation as determined by both limited proteolysis and the change in retention time on analytical size exclusion chromatography. the conversion to this state is inhibited by the native state ligand (atp) and by the presence of the second site suppressors (g e, r m, and r k). notably, the ∆f nbd protein populates the non-native state under milder conditions than the wild type nbd . these studies reveal the properties of the native state and its conversion to a partially folded state that is affected by the ∆f mutation. this data highlight the proximal affect of the disease causing mutation and provide a means of assessing strategies designed to correct the defect. this work is supported by the cystic fibrosis foundation through a postdoctoral training grant and by the nih we have previously demonstrated that the stability of cftr is negatively modulated by the cftr interacting protein, cal. cal competes with nherf in binding to the pdz motif at the c-terminus of cftr and directs cftr trafficking to the lysosome. recently, silencing of cal or overexpression of nherf has been shown to restore chloride transport activity in ∆f -cftr cell lines. to identify the molecular machineries involved in cal dependent degradation of cftr, we investigated the role of the cal interacting snare protein syntaxin (stx ). stx protein expression and function were manipulated by sirna silencing, over-expression, and a dominant-negative mutant. we also performed a functional study of chloride transport activity in cystic fibrosis bronchial epithelial cell line cfbe o-stably expressing either wt-cftr or ∆f -cftr. the endogenous stx and cal protein expressions were knocked down by sirna techniques in multiple human cell lines including hek , hela cell stably expressing ∆f -cftr and cfbe o-stably expressing either wt-cftr or ∆f -cftr. in hek cells, knockdown of either stx or cal augments the expression of transfected gfp-tagged cftr (gfp-cftr), which is consistent with the observation that overexpression of either stx or cal enhances the degradation of cftr. stx interaction with cal was confirmed by a co-immunoprecipitation assay. because of this interaction, we hypothesize that stx negatively regulates cftr protein stability by interacting with cal which in turn binds to the c-ter-minal pdz motif of cftr. consistent with his hypothesis, stx knockdown has no effect on protein levels of a cftr mutant lacking the pdz motif (gfp-cftr∆trl). more importantly, cal knockdown eliminates the inhibitory effect of stx overexpression on gfp-cftr. a cell surface biotinylation assay and confocal microscopy showed significant increases in plasma membrane expression of cftr in stx knockdown cells without gross changes in the expression pattern. furthermore, consistent with its trans-golgi localization, stx knockdown has no effect on gfp-∆f -cftr expression. however, ∆f -cftr increases significantly in stx knockdown, temperature-rescued cells. to assess the effect of stx in bronchial epithelial cells, stx was knocked down in cfbe o-stably expressing wt-cftr. consistent with the observations in hek and hela cells, the expression of untagged wt-cftr is also augmented. knockdown of stx increases cftr expression in a does-dependent manner, reciprocal to the expression level of stx , without changing the level of expression of cal or gapdh. furthermore, stx knockdown lead to a does-dependent increase in cftr mediated short-circuit current that is stimulated by forskolin and inhibited by cftr chloride channel inhibitor cftrinh- . more importantly, in temperaturerescued cfbe o-stably expressing ∆f -cftr, stx knockdown tripled the cftr mediated short-circuit chloride current. these results not only delineate the effect of stx on post-golgi trafficking of cftr and its dependence on cal-mediated pdz-based interaction, but also points to it as a potential therapeutic target in conjunction with the er-quality control based rescue of ∆f -cftr. supported by the cystic fibrosis foundation and the national institutes of health. seavilleklein, g. ; evagelidis, a. ; amer, n. ; chappe, f. ; hanrahan, j. ; chappe, v. . physiology & biophysics, dalhousie university, halifax, ns, canada; . physiology, mcgill university, montreal, qc, canada cftr channel activity is regulated by phosphorylation and de-phosphorylation of the r-domain. direct pkc phosphorylation at specific sites in the r domain and nbd is essential and modulates cftr activation by pka. however, the molecular mechanism by which phosphorylation of the r domain induces channel activity remains unknown. we have reported biochemical evidence for the role of phosphorylation in domain-domain association using a deltar-split construct encoding the front (tmd -nbd ) and back (nbd -tmd ) halves of cftr as separate polypeptides ( ) . in agreement with the inhibitory role of the r domain, iodide effluxes and patch-clamp experiments confirmed that deltar-split channels were functional and constitutively active without camp stimulation. co-transfecting a plasmid that directs expression of the r domain restored the pka-dependence of re-assembled channels. co-immunoprecipitations of the halves of the deltar-split with a gst-r domain fusion protein in vitro or with the cotransfected r domain in bhk cells revealed that pka phosphorylation enhances the r domain binding to the rest of the channel. we have now investigated the effect of pkc phosphorylation on the r domain binding. our data demonstrate that pkc phosphorylation also induces a strong binding of gst-r domain in vitro or co-transfected r domain in vivo when bhk cells are stimulated with pma. interestingly, the combination of pkc+pka phosphorylation induced a stronger binding than pka alone. mutation of all consensus pkc sites on the r domain to alanine ( ca) eliminated specific pkc phosphorylation but did not alter pka phosphorylation in gst-rd. western blotting and confocal microscopy experiments confirmed that expression levels of all domains of the split- ca/rd are unchanged compared to split-rd and co-localize at the plasma membrane of bhk cells. basal activity of the split- ca/rd was similar to that of the split-rd in iodide efflux experiments. however, activation by camp+ibmx was delayed and significantly reduced ( . % of split-rd and . % of wt-cftr activation). these results confirm the functional re-assembly of the ca-rd with the front and back halves of the channel and the inhibitory role of the r domain. in co-immunoprecipitation experiments, the same level of interaction was observed between the ca/rd and rd with the split halves suggesting that basal, inhibitory interaction of the r domain is independent of pkc phosphorylation. however, ca/rd binding with the split channel was not increased by pkc or pka stimulation. we conclude that pkc phosphorylation is essential for pka-dependent binding of the r domain to the rest of the channel, and that the combined effect of these kinases further strengthens the r domain interaction. these structural changes are consistent with the essential role of pkc sites for cftr activation by pka as previously reported ( ) . supported by cihr, nshrf, dmrf & ccff. g.seavilleklein was supported by nserc. ( ) the in vivo folding mechanism of multidomain membrane proteins, including the cystic fibrosis transmembrane conductance regulator (cftr), is poorly understood. cftr, a member of the abc transporter superfamily, contains two symmetrical halves, each consisting of a membrane spanning domain (msd and msd ) and a cytosolic nucleotide binding domains (nbd and nbd ), connected by the regulatory (r) domain. to address whether cftr follows the archetypical domain-wise folding of multidomain soluble polypeptides and/or the cooperative domain folding mechanism, first we determined domain combinations that are necessary and sufficient to escape the endoplasmic reticulum (er) quality control. one-, twoor three-domain assemblies failed to be processed efficiently in cells, measured by biochemical and morphological assays. the smallest folding unit that escaped the er quality control was composed of a four-domain assembly, containing msd , nbd , r or msd as linear or split polypeptide. as a second approach we showed that cf-causing point mutations in the msd , nbd or msd provoked the er retention of the full-length cftr with severe conformational defect in the nbd , measured by limited proteolysis and immunoblotting, using domain spacific antibodies. the posttranslational folding kinetics of the four-domain folding unit was comparable to that of cftr, suggesting that cooperative domain assembly is essential for the channel biogenesis. this mechanism provides an explanation for the processing defect caused by numerous cf mutations and outlines a possible paradigm for cftr folding in living cells. cftr in post-golgi compartments. our results, jointly, uncover the role of n-glycans as a critical structural determinant of cftr conformational maturation/stability in a chaperone-independent manner. karamyshev, a.l. ; patrick, a.e. ; johnson, a.e. ; thomas, p.j. . ut southwestern medical center at dallas, dallas, tx, usa; . texas a&m university, college station, tx, usa cystic fibrosis (cf) is caused by mutations in cftr (cystic fibrosis transmembrane conductance regulator). cftr, a member of the abc transporter family, is a multispanning membrane protein critical to chloride and water movement in secretory epithelia. over one thousand mutations, in all parts of the cftr sequence, have been identified, many of which disrupt the function of the protein to cause the disease. some of the disease-associated mutations in the n-terminal portion of cftr were predicted to alter cotranslational interactions with factors involved in the membrane integration of cftr required for its proper function. to test this hypothesis, a photoreactive probe was incorporated into different positions of the n-terminal portion of cftr by introducing amber stop codons and translating these messages in vitro in the presence of the amber suppressor trna n ε -( -azido- nitrobenzoyl)-lys-trna amb . ribosome-associated nascent chains of a specific length containing the modified amino acid at a defined position were produced using truncated mrnas. some of these cftr nascent chains photocrosslinked with proteins of approximately and kda molecular mass. crosslinking to the ~ kda protein was observed only after the tm span had emerged from the ribosomal tunnel. moreover, truncation analysis demonstrated that tm is necessary for this interaction. in evaluating a range of nascent chains, the extents of photocrosslinking to the ~ kda and kda proteins often varied inversely. immunochemical and knockdown/depletion studies indicate the ~ kda protein is srp , a subunit of the signal recognition particle involved in targeting ribosome nascent chain complexes to the translocon in the endoplasmic reticulum membrane. highlighting the functional relevance of this interaction, in cells with reduced srp levels, nonglycosylated forms of cftr accumulate and total cftr levels decrease. notably, some cf-causing mutations in tm also reduce crosslinking to srp. these data reveal that mutational inhibition of nascent cftr association with srp likely contributes to or mediates some types of cf. aleksandrov, l.; aleksandrov, a.a.; riordan, j.r. the initial reversible steps of atp binding to the first (nbd ) and second (nbd ) nucleotide binding sites of cftr are divalent cation independent and dependent, respectively (aleksandrov et al, j biol chem , - , ) . subsequent to the initial binding, either mg or mn drive rapid hydrolysis at the second site while promoting trapping of the nucleotide at the first site. this occlusion at the first site of functional wildtype cftr is somewhat similar to that which occurs when the catalytic glutamates in both of the hydrolytic sites of p-glycoprotein are mutated. this occluded state has been proposed to be the result of dimerization of the two nbds and represent a transient intermediate formed during atp hydrolysis (tombline and senior, j bioenerg biomembr , - , ) . to test the possible relevance of this interpretation to cftr, we have now characterized the process by which nbd occludes [ p]- n atp and [ p]- n adp. we have now found that only n atp and not n adp can be bound initially at nbd in the absence of mg. consistent with this mg requirement for the ndp binding, n adp or adp is able to compete for the n atp binding site only when the divalent ion is present. despite the lack of a requirement for mg for atp binding, retention of the nucleotide triphosphate at the binding site at °c was dependent on the cation. however, at reduced temperature ( °c), n atp remains locked in the binding pocket with virtually no reduction over a hour period even in the absence of mg. these apparently paradoxical temperature effects hint that different molecular events can contribute to the occlusion of nucleotide at nbd . that the occlusion process occurs exclusively at nbd and does not depend on its interaction with nbd , was shown by experiments in which identical behavior was exhibited by ∆nbd constructs of cftr. thus, nucleotide trapping by wild-type cftr, unlike that by mutant p-glycoprotein, is accomplished by events at a single domain (nbd ), rather than by dimerization of the two nbds. (supported by the nih and cff). cftr consists of five domains or regions, two regions that span the cell membrane (the tmds), two cytoplasmic nucleotide-binding domains (the nbds), and a regulatory (r) domain. the r domain is unique to cftr: without phosphorylation of this domain, the cftr chloride channel does not open. the tmds and the nbds of cftr are similar to those found in many atp-binding cassette proteins, the majority of which are transporters. the domains are fused in a single polypeptide chain, linked in the sequence: tmd , nbd , r domain, tmd , nbd . the first nbd is the site of the location of the mutation that is responsible for the development of cystic fibrosis in the majority of human patients (loss of phenylalanine ). although there is a structure for nbd , we are still lacking a structure for the entire cftr protein. we have employed electron microscopy to provide low-to medium-resolution structures for the complete cftr protein which was expressed in bhk cells and purified by affinity chromatography. using single particle analysis combined with site-specific labelling using . nm diameter ni-nta nanogold, we have identified the locations of nbd and the region around residue of the r-domain within the low resolution d structure. by a process of elimination, this has also allowed the identification of nbd and the region occupied by the two tmds. these low resolution studies have now enabled us to interpret medium resolution d structural data obtained for cftr. progress in obtaining two-dimensional arrays (crystals a single molecule thick) should allow higher resolution structural data to be obtained for the entire cftr protein -sufficient for the identification of the transmembrane alpha helices. these data should allow a much clearer picture of the transmembrane channel formed by cftr and will inform molecular modelling approaches aimed at the development of novel drugs for the treatment of cystic fibrosis. we explored the gating process by introducing cysteines along the entire lengths of various transmembrane domains and extra-cellular loops, and studying their ability to chemically modified. we study the changes in their reactivity in closed and open channel states to characterize the changes in transmembrane domain conformations during gating. using membrane impermeant mts-reagents, we have characterized the conformational changes in tm -ecl , ecl -tm , ecl -tm , and ecl -tm of cftr. our results suggest that atp binding induces modest changes in the transmembrane domains and extracellular loops. channel opening involves a rearrangement of the tm helices leading to decreased hydration of residues near the extracellular end. this conformational change is either a part of, or allosterically coupled to the gating mechanism. physiological role of nherf in the regulation of cftr raghuram, v.; yang, y.; yaemsiri, s. laboratory of kidney and electrolyte metabolism, nhlbi/nih, bethesda, md, usa in the apical membrane of epithelial cells, cftr seems to exist within a multiprotein complex, in which its activity is regulated by interactions with other proteins. the c-terminus of cftr contains a pdz-binding motif, which binds to several pdz domain-containing proteins, including members of na+/h+ exchanger regulatory factor (nherf) family, nherf /ebp , nherf /e karp, cap /nherf , nherf , and cal/pist/gopc. pdz domain proteins act as scaffolds to assemble signaling proteins to form signaling complexes. these signaling complexes are central to achieve specificity and efficiency of signal transduction. nherf and nherf have a c-terminal erm domain, which interacts with cytoskeleton-associated erm proteins. this interaction may anchor cftr to the actin-cytoskeleton and restrict its movement within the membrane. in addition, several functional roles have been proposed for cftr-pdz domain interactions, including as an adapter to promote efficient pka phosphorylation of cftr, apical targeting and recycling of cftr, regulation of single-channel activity, organization of β-adrenergic, and lysophosphatidic acid- receptor signaling complex, and trafficking of romk channels. our current understandings of the role of cftr-pdz interactions are mostly obtained from heterologous expression studies. very few studies have addressed the role of pdz domain proteins in native epithelial cells or in organ physiology. we have used rna interference techniques to produce a knockout or knockdown (kd) calu- cell lines using a lenti-viral vector for stable suppression. using four different shrnas, we have generated four stable nherf -kd cell lines with varying levels of nherf suppression. in these cells, nherf expression ranged from - % of calu- nt cells (control cells). in nherf -kd cells, steady-state cftr protein level was greatly reduced, whereas its apical localization was unaffected. we also found structural defects in the apical microvilli. in polarized nherf -kd epithelia, membrane-permeable camp analogs were unable to stimulate cftr mediated short-circuit currents. however, forskolin induced response was nearly normal despite reduced cftr expression. examinations of βadrenergic-, and adenosine-receptor signaling pathways suggest that nherf plays a unique role in organizing the adenosine receptor signaling pathway. abnormal retention of the df cftr mutated protein in lung epithelial cells underlies the pathology in a large proportion of individuals with cystic fibrosis. a drug discovery alliance between cfft and biofocus dpi was initiated with the aim to identify novel genes which upon shrna-mediated knockdown were able to efficiently restore df cftr activity. a high-throughput assay based on an yfp halide reporter was developed in a human cystic fibrosis bronchial epithelial cell line (cfbe o-), whereby the rate of halide influx directly correlated to df cftr activity. biofocus dpi's proprietary adenoviral shrna libraries totalling , viruses were screened in this functional assay and yielded hits. these hits were repropogated to generate new adenoviral stocks and rescreened at three concentrations on the yfp halide reporter assay. genes were eliminated due to potential cytotoxic effects, and hit calling was performed on the remaining hits. a total of duplicate hits were confirmed ( %). of the confirmed hits had more than one shrnas which targeted the respective gene. confirmed hits were stronger in restoring df cftr function than the most potent positive control: syntaxin- . in order to elucidate which of these hits induce halide influx via direct rescue and activation of df cftr, the yfp halide reporter assay was performed in the presence or absence of the cftrinh . these cftr dependent hits will move forward into subsequent validation experiments whereby hits will be categorised into potentiators and correctors. the final goal of this program is to prioritize targets for entry into drug discovery. restoring expression and/or function of mutated cftr provides a means to treat cystic fibrosis. biofocus dpi -a galapagos company -in collaboration with the cystic fibrosis foundation therapeutics (cfft) has established a drug target discovery project that will enable the selection of proteins that rescue mutated cftr. by screening biofocus dpi's proprietary adenoviral shrna libraries in a high-throughput primary functional assay for cftr activity in human cells, we have identified and confirmed hits out of , that entered the primary screen. to further validate these proteins as potential drug targets, we have set up a series of experiments and assays focused on the rescue of cftr expression and its maturation by knock-down of specific targets. ) in order to establish whether the knock-down of a specific target was able to promote df -cftr plasma membrane localization, we performed immunofluorescence stainings of df -cftr in a patient-derived human cell line carrying the df -cftr mutation (cfbe o-) grown in air-liquid interface culture. a transduction protocol to deliver shrna adenovirus to this polarized airway cell model system has been optimized and preliminary results showed increased levels of expression of df -cftr at the plasma membrane level upon knock-down of syntaxin- , our positive control. experiments performed at οc also demonstrated redistribution of df -cftr to the apical plasma membrane at low temperature. we will show the results of all the shrna hits in this assay. ) changes in the post-translational maturation levels of df -cftr upon knock-down of specific proteins were evaluated by determining the accumulation of band b and c by using a western blot approach. in this way, we can select targets able to promote post-translational maturation of df -cftr and/or its escape from er in the cfbe o-cell line. accumulation of band b and c indicates maturation of cftr and will be considered as a beneficial effect. preliminary results show increased accumulation of band b upon knock-down of specific targets and overexpression of wild-type cftr induces band c accumulation. experiments performed at οc also demonstrated increased band b expression. we will show the effect of all the shrna hits in this assay on band b and c expression. we believe that the results obtained by the combination of those two approaches will guide us in obtaining very strong drug targets for entry into a drug discovery phase. because gene therapy as a corrective measure for cf is possible in the foreseeable future, it is important to understand whether the global effects of gene introduction will have significant detrimental impact on cell function. to address this question, global gene mrna expression profiles were created with the affymetrix u a & b chip sets. wild type cftr (n= ), ∆f (n= ) and g d (n= ) were transfected in separate ib cell cultures using lipofectamine ™. control expression profiles were generated from untreated ib cells; one from this experimental set and five from previous control experiments. differential gene expression was determined by anova using a % false discovery rate threshold. genespring was used for data analysis and visualization. genego was used to determine which functional categories were over represented in the list and further assisted in interpretation of the results. rt-pcr was used to confirm differential expression of selected genes and examine the response in more detail. all transfected constructs produced very similar gene expression profiles quite distinct from the untransfected cells. probe sets representing uniquely named genes were significantly different between transfected and untransfected cells. cftr mrna expression in all forms was increased an average of -fold. transfection of ib - cells resulted in upregulation of a variety of genes involved in several basic processes: inflammation, protein folding and cytoskeleton framework regulation. genego canonical pathways with a significantly enriched number of genes from the data set involved glucocorticoid signaling and regulation, cytoskeleton remodeling and adhesion plus a variety of other signaling pathways including il , chemokines, g-protein and mapk cascades. cell processes overrepresented in the list were predominately associated with protein folding, inflammatory responses and cytoskeleton regulation. geneontology categories over represented in the list were regulation of signal transduction, receptor mediated endocytosis and protein folding. the proinflammatory interleukins il and il were upregulated . fold and fold respectively. the genes most upregulated, samd ( -fold) and oasl ( fold), are not well annotated. as controls, rt-pcr analysis of cells treated with either lipofectamine ™ alone or any form of cftr dna alone did not show upregulation of il , il , samd or oasl. in cells transfected with lipofectamine containing dna, upregulation of il (n= ), oasl (n= ) and samd (n= ) was confirmed by rt-pcr. oasl is known to interact with methyl cpg-binding protein , a dna transcription repressor acting at methylated promoter regions. thus it is possible that the global effects noted here leading to dramatic upregulation of two novel genes oasl and smad could be previously unrecognized consequences of gene therapies. cystic fibrosis (cf) is a disease which is caused by mutations of the cf gene, which codes for the cftr chloride channel. the ∆f -cftr mutation results in a mutant protein that undergoes transcription but fails to localize to the apical membrane, where it normally functions as a camp-regulated clchannel. however, clchannel activity can be detected at the plasma membrane when ∆f -cftr is overexpressed, synthesized at a reduced temperature, or in the presence of chemical chaperones. thus, strategies that facilitate the translocation of ∆f -cftr to the plasma membrane by increasing cftr transcription may be beneficial for the treat-ment of cf. previous studies performed using fluorescence halide efflux measurements and short-circuit current voltage clamp have shown that treatment with pparγ (peroxisome proliferator activated receptor gamma) agonists, such as pioglitazone and fll (fmoc-l-leucine), resulted in an increased biosynthesis and trafficking of ∆f -cftr to the cell surface. this effect was at least partially due to increased ∆f -cftr expression. further studies were designed to investigate the effect of pparγ agonists on cftr promoter activity. two firefly luciferase-conjugated cftr promoter plasmids, containing either . kb or . kb fragments, were transfected together with a control plasmid containing a renilla luciferase in human alveolar basal epithelial (a ) cells. the ratio of the firefly to renilla luminescence was used to measure cftr promoter activity. pparγ agonists increased cftr expression acting both on . kb and . kb promoter fragments. these results were confirmed in quantitative rt-pcr studies. transcription factor binding site analysis using current online programs and matrices showed three putative ppre (peroxisome proliferator response element) consensus sequences in the cftr promoter. the interaction of these sites with pparγ was shown using emsa (electrophoretic mobility shift assay). interestingly, none of these consensus sequences appear in the . kb construct, which still maintained a significant pparγ activation response. therefore, we hypothesized that a novel pparγ agonist effector site(s) is involved in transcription activation of cftr. to characterize this novel site(s), a series of deletion constructs to the promoter region were created, using mutation-introduced restriction sites in the original promoter construct. the new constructs ranged from . kb to base pairs upstream of the transcription start site. in preliminary studies we found that at least one previously uncharacterized pparγ effector site was present in the . kb promoter fragment that regulated cftr expression. additional experiments were performed using emsa to determine the proteins and cofactors which controlled the optimal conditions for cftr expression. the results of this study show that pparγ agonists, currently prescribed to treat hyperglycemia and improve peripheral insulin resistance, may also have additional benefits for the treatment of cf. our studies also show that pioglitazone and other pparγ agonists, by increasing cftr expression, are potent activators of clflux in epithelial cells expressing ∆f -cftr. this work was supported by grant from the canadian cystic fibrosis foundation decreased by µm gsno. the effect of gsno on hop expression was post-transcriptional. in cfbe o-cells transfected with sirna duplex specific for hop ( hr), hop expression was modestly inhibited; however, gsno dramatically augmented the inhibition. we next showed that knockdown of endogenous hop by sirna increased the steady-state levels of immature and mature forms of cftr. though overexpression of hop did not significantly affect cftr expression (immature and mature forms increased . ± . and . ± . fold respectively), in the presence of µm gsno, expression of both immature and mature cftr forms significantly increased in the hop overexpressing cells ( . ± . and . ± . fold respectively). next, we treated cfbe o-cells with a pulse of gsno ( µm; hr); isolated cytosol, er and golgi fractions; immunoprecipitated cftr from these fractions; and studied whether hop, co-immunoprecipitated with cftr, was s-nitrosylated (using a biotin substitution technique followed by streptavadin isolation). we found that sno-modified hop coimmunoprecipitated with ∆f cftr in the cytosol and er at baseline; and that gsno decreased the association between sno-modified hop and ∆f cftr. we speculate that the effect of gsno to decrease hop-cftr association may ) result from increased hop s-nitrosylation; and ) be permissive for ∆f cftr maturation. these data may be of relevance to the development of no donor-based therapies for cf. supported by cf foundation and the nih. mouse models for cystic fibrosis (cf) provide new possibilities to study disease pathogenesis, to correlate genotype and phenotype, and to test novel cf therapies. we use the cftr tm eu mice homozygous for the f del mutation in a congenic fvb background as a tool in pre-clinical testing of therapeutic strategies aimed at the correction of the f del folding and trafficking defect. these mice show characteristic cf ion transport abnormalities such as reduced camp-and cgmp activated intestinal chloride secretion and an increase of the amiloride-sensitive sodium absorption in nasal epithelium. we developed an ex vivo assay for the rescue studies of the f del trafficking defect in murine intestine by proteasome inhibitors based on periodical measurements of camp-activated transepithlial chloride currents in the ussing chamber. muscle-stripped ileum was incubated at c in william's e glutamax medium supplemented with insulin ( µg/ml) and dexamethasone ( µg/ml), in the presence of vehicle or proteasome inhibitor. a partial gain of chloride secretory function was achieved by incubating the tissue for - h at c in the presence of the proteasome inhibitors (pi) epoxomicin ( µm), mg ( µm), nip-(leu) -vinyl and adalys(bio)ahx l vs (both µm) and bortezomib ( nm). exposure of the tissue for h at c to alln ( µm) revealed a functional recovery up to wt levels. immunohistochemical and western blot analysis of all pitreated tissues showed the appearance of cftr positive crypt cells and mature band c cftr protein. rescue by alln remained detectable following inhibition of the er to golgi transport by brefeldin a. our ex vivo experiments demonstrate that proteasome inhibitors can enhance the amount of mature, functionally active murine f cftr mutant protein in intact tissue by preventing proteolytic degradation and increasing its expression at the cell surface. in vivo treatment of homozygous f del mice with bortezomib at a dose of . mg/kg/day for days resulted in a high morbidity. administration of a lower dose ( . mg/kg/day ) was well tolerated and no mortality or significant weight loss could be observed. as outcome parameters for the in vivo treatment with pis we used a salivary secretion assay and bioelectric measurements of intestinal and nasal epithelium in the ussing chamber. there was no difference in isoproterenol-induced salivary gland secretion or and in cftr-mediated intestinal chloride currents between control -and bortezomib-treated animals. however we found a reduction ( . fold) of the amiloride-sensitive short circuit current (isc) in the nasal epithelium of bortezomib-treated mice, indicating a moderate correction of the enacmediated sodium hyper absorption, that was not paralleled by a gain of the forskolin-mediated transepithelial chloride secretion. current in vivo experiments focus on the effects of pis upon short term ( h- h) rather than chronic treatment, to allow a direct comparison with the ex vivo treatment data. supported by grants from the cf foundation, bethesda, the sophia foundation and the dutch stomach-liver-intestine foundation. rotterdam, netherlands; . physiology and biophysics, university of alabama birmingham, birmingham, al, usa; . physiology, school of medical sciences, university of bristol, bristol, united kingdom recent progress in the development of small molecule correctors and potentiators capable of restoring cftr function have increased the need for pre-clinical test models including cultured airway epithelial cells from human cf patients as well as cf mouse models. the validity of cf mice as a surrogate for human cf patients depends on the assumption that human and mouse cftr, despite their limited sequence homology ( %) and differences in open probability (p o ) and channel subconductance state, behave similarly in their response to pharmacological correctors and potentiators. to verify this assumption, we used the iodide efflux technique to compare the cftr chloride channel activity in (i) cho cells stably transfected with mouse f del-cftr, (ii) nih- t cells stably expressing human f del-cftr, and (iii) their wt-counterparts. forskolin ( µm)-stimulated iodide efflux was very low in both mouse and human f del cftr cells ( . respectively % of wt values) and was stimulated to a similar extent ( . and . fold) by the cftr potentiator genistein ( µm). preincubation for h at c, or at c in the presence of the vertex corrector cfcor- ( µm) caused a - fold increase in forskolin-activated i-efflux in both cell types that was further enhanced by . - fold upon addition of genistein. functional correction was paralleled by the appearance of mature, complex-glycosylated mouse or human cftr on western blots. surprisingly, two other, structurally unrelated compounds known to correct the gating defect in hcftr, i.e. the vertex potentiator cfpot- ( µm) and the uncharged nppb analogue nppb-am ( µm; cf. wang w et al. ; j biol chem : ) mimicked the effect of genistein on hf del-cftr but failed to potentiate mf del-cftr in the t cells. both cfpot- and nppb-am likewise failed to potentiate forskolin-stimulated, cftr-mediated transepithelial chloride currents ex vivo in muscle-stripped ileal mucosa from homozygous f del-cftr tm eu mice (congenic fvb) mounted in ussing chambers under conditions in which genistein ( µm) enhanced the current response by - fold. in contrast, preincubation of the tissue in william's e glutamax medium for h at c, or for h at c in the presence of cfcor- ( µm) enhanced the forskolin+genisteininduced transepithelial clsecretion up to - % of the response in cftr+/+ littermates, and was associated with the appearance of band c on western blots. these results indicate that mouse and human f del-cftr ( ) respond to low temperature incubation or to a small molecule corrector with a similar gain in surface expression and function, supporting the use of cf mouse models for in vivo tests of cftr correctors; ( ) respond differently to various classes of cftr potentiators, in line with their pronounced differences in gating behaviour, and emphasizing the specificity of cftr-potentiator interaction. further studies focussing on human/mouse cftr chimera and aimed to identify the domain(s) accounting for the differential response to the cftr potentiators are in progress. cell apoptosis is a highly regulated process which is central to the maintenance of pulmonary vascular homeostasis. recent investigations implicated cftr in the regulation of intracellular sphingolipid levels. our laboratory demonstrated that an imbalance in endothelial sphingolipid levels triggers apoptotic cell death. we therefore hypothesized that a dysregulated cftr function in human lung endothelial cells inhibits programmed cell death in response to stress. methods: patch clamp analysis was used to verify the expression of cftr on human lung endothelial cells and the effect of specific inhibitors. we inhibited cftr with dpc, cftr inh - , and nppb or specific sirna followed by treatment with prototypical stressors that induce endothelial cell apoptosis, staurosporine, h o , or tnf-α. apoptosis was quantified by caspase- activity or annexin/ propidium iodide staining. lipid extraction was performed by a modified bligh and dyer method and intracellular sphingolipids were measured by tandem mass spectrometry. results: patch clamp analysis confirmed functional cftr expression on endothelial cells and a complete inhibitory effect of dpc and nppb but no effect of dids. as expected, treatment with staurosporine, a general protein kinase inhibitor and h o , as an oxidative stress stimulus resulted in significant endothelial cell apoptosis. similarly, tnf-α treatment ( ng/ml) in combination with cycloheximide caused activation of caspase- associated with a significant upregulation of the pro-apoptotic sphingolipid ceramide. knock-down with specific cftr sirna was validated with western blot and whole cell patch clamp analysis. dpc, nppb, and cftr inh - consistently and significantly inhibited apoptosis in human lung and primary mouse lung endothelial cells. caspase- activity was decreased by - % (% decrease in caspase units/µg/min) in hlmvec treated with h o after pretreatment with dpc ( %), cftr inh - ( %), and nppb ( %). however, we observed that dids, a non-specific chloride channel inhibitor also inhibited staurosporine induced caspase- activation ( %), suggesting the possible involvement of other chloride channels. in conclusion, our data suggest a role of cftr in modulating endothelial cell apoptosis in response to various stresses. the absence of functional cftr impaired stress-induced apoptosis, a process which may be mediated via alterations in sphingolipid trafficking. this abnormal cftr function in cf leading to aberrant cellular responses to stress may perpetuate an activated, pro-inflammatory phenotype of the lung vasculature. in turn, aberrant vascular activation may have a significant impact to the abnormal airway remodeling and persistence of a chronic inflammatory state characteristic of cf. supported by: cystic fibrosis foundation clinical fellowship training grant hegedus, t. , ; serohijos, a.w. , ; dokholyan, n.v. ; he, l. , ; riordan, j.r. , . department of biochemistry and biophysics, unc at chapel hill, chapel hill, nc, usa; . cystic fibrosis treatment and research center, unc at chapel hill, chapel hill, nc, usa; . department of physics and astronomy, unc at chapel hill, chapel hill, nc, usa cftr (cystic fibrosis transmembrane conductance regulator) is a camp dependent chloride channel. the phosphorylation of its amino acid r domain by protein kinase a (pka) is obligatory for channel gating under normal conditions. r domain contains multiple pka phosphorylation sites, which participate in activation, but no specific site is essential for channel function. in spite of numerous studies of the role of r domain in cftr regulation, the mechanism is largely unknown. one reason for this is the lack of information on r domain structure and its interactions with other parts of cftr. it has been shown that r domain lacks well-defined secondary structural elements and is intrinsically disordered. in this study, we used computational methods to explore the structure and function of the disordered r domain. our results show a specific disorder-order pattern in r domain, which is conserved among species even though the primary structure is not conserved. this result implies a role of the disorder-order pattern in r domain function and provides a basis of a novel working model. to gain some insight into the three dimensional structure of r domain, we per-formed ab initio folding of r-domain using discrete molecular dynamics with an all-atom force field. as disordered domains can not be characterized with a single structure, an ensemble was generated by selection of structures with the lowest energy from a large number of folding simulations. these structures were clustered to determine the dominant r domain conformations. they reveal features of secondary and tertiary structure, the positions of phosphorylation sites in d, and residue contacts within the r region that might be important for structure and function. to computationally confirm the mechanism proposed in our working model, an ensemble of phosphorylated r domain structures was also produced and characterized. supported by nih (r dk ), cff (dokhol i ), and novartis ( ). physiology system that utilises the planar patch clamp technique (finkel et al ) . this format utilises perforated patch clamp recording of wells in parallel, permitting the generation of up to data points per day. we have employed this system to develop assays to detect modulators of mutant cftr. human cftr-g d and df , over expressed in bhk and cho cells respectively, were cultured to approximately % confluence before harvesting. df cells were temperature corrected at °c for hours prior to experimentation to facilitate channel trafficking to the plasma membrane. cells were placed on the quattro system and whole cell chloride currents measured using asymmetric chloride selective solutions such that the chloride reversal potential was significantly different from that of leak currents ( mv). currents were assessed using a voltage ramp from - to + mv applied prior and min subsequent to compound addition. to validate the assays we used the prototypical cftr potentiator, genistein, which was added simultaneously to cells under study with µm forskolin. after assessing the effects of genistein, the specific cftr inhibitor glyh , was added at µm to confirm the currents were mediated via activation of cftr. the ec values determined for genistein were . ± . µm (mean ± s.e.m, n= ) for df and . ± . µm (mean ± s.e.m, n= ) for g d. these values agree with literature values (bulteau-pignoux et al ) . two alternative potentiators, phenylglycine- (pg- ) and vrt- were also tested in the presence of µm forskolin and were active against both df and g d. the ec values for pg- were . ± . µm (mean ± s.e.m, n= ) for df and . ± . µm (mean ± s.e.m, n= ) for g d. the ec values for vrt- were . ± . µm (mean ± s.d, n= ) for df and . µm (mean, n= ) for g d. these values agree with published data from ion transport studies (pedemonte et al ; van goor et al ) . in summary the ionworks quattro can be used to identify compounds which modulate the activity of cftr. this assay has a number of advantages over other formats in that it is direct, sensitive and employs voltage control of the cells under study. these assays can be used for primary screening of small to medium compound sets or as a secondary screen to triage the output from higher throughput indirect formats such as membrane potential. references it is very well agreed that ∆f cftr is recognized as a misfolded protein by the er quality control and targeted for degradation by the proteasome. during the course of experiments for aav gene therapy for cf we created an aav / vector expressing a truncated cftr insert (∆ ) driven by a chicken beta actin promoter (raav-cb-∆ -cftr). ∆ -cftr contains the normal coding sequence of wt cftr except that it is missing the first amino acids. we observed that cos cells transiently transfected with raav-cb-∆ cftr express cftr at significantly lower levels as compared to cells similarly transfected with a wt-cftr construct. to examine why, cells were transfected with raav-cb-∆ -cftr and treated for hours with µm of proteasome inhibitor, mg . in the cells treated with mg , ∆ -cftr protein expression was significantly increased. because lysosomal inhibitors did not have a significant effect, the data suggest that a large frac-tion of ∆ -cftr protein is degraded in the proteasome. to evaluate the rate of degradation, cells were treated with cycloheximide. time course experiments showed that ∆ is more rapidly degraded than ∆f -cftr. importantly, in cos cells cotransfected with ∆f and ∆ -cftr, there was a significant increase in the mature c-band of ∆f cftr compared to cells transfected with ∆f alone. this suggests that ∆ -cftr enhanced the maturation of ∆f from b to c bands. enhanced maturation of cftr from b band to c band also occurred when ∆ -cftr was transfected into hela cells stably expressing ∆ cftr (hela ∆ ) and cfbe o-cells stably expressing ∆ (cfbe o-∆ ). a number of proteins participate in the er to determine the fate of cftr. ∆f -cftr is known to associate with retrograde translocation protein complex on the er membrane containing vcp (valosin-containing protein) and derlin . vcp is also found in aggresomes containing ∆f -cftr in association with cytosolic histone deacetylase, hdac . we hypothesized that since ∆ is more efficiently degraded as compared to ∆f -cftr it may have higher affinity with vcp protein complex. we verified that ∆ -cftr interacts more readily with vcp and also has a higher degree of association with hdac as compared to ∆f -cftr. our data suggest that ∆ is more readily degraded by the proteasome as compared to ∆f -cftr and lacks biosynthetic arrest in the er. ∆ -cftr binds more readily to vcp and associates avidly with hdac , two outcomes that are expected to enhance proteasomal degradation. by engaging key quality control proteins, ∆ -cftr allows more ∆f -cftr to mature. our data suggest that truncated forms of cftr (∆ ) may be useful for cf gene therapy by affecting the maturation of endogenous cftr. ∆f , the most common disease causing cftr mutation, has impaired conformational maturation during its biosynthesis, and thus is unable to exit the endoplasmic reticulum (er). a well-defined di-acidic er exit code has been identified within the first nucleotide binding domain (nbd ) of wildtype cftr (jcb : - , ) , the disruption of which prevents cftr from efficiently exiting the er. this is consistent with the role of the diacidic code in the copii-mediated cargo concentration process. however, it is not known whether other types of er-to-golgi trafficking signals play a role in cftr trafficking in the early secretory pathway. even less is known about the trafficking signal(s) that are responsible for the rescue of ∆f cftr by a number of means. to achieve a better understanding of the trafficking signals dictating the export of cftr from the er, we constructed a series of cftr mutants to probe the potential functional targeting signals within both wild-type and ∆f cftr. it has been shown that nbd is not required for the export of wild-type cftr from the er. we further found that an internal deletion mutant lacking membrane spanning domain (msd ) and nbd -r but retaining the n-terminal cytoplasmic region, msd and nbd does not have sufficient signal to allow er export, suggesting that the signal(s) that are responsible for cftr export largely reside within the nbd -r. unlike ∆f cftr, the di-acidic code mutants are not temperature-sensitive. dissecting the di-acidic code revealed that both acidic residues contribute to er export, and that simultaneous substitution of both leads to a much decreased export of cftr. we found that the temperature-dependent export of ∆f relies on the presence of the di-acidic code within the nbd , suggesting that this code has a functional role in the temperature-dependent rescue of ∆f cftr. in our effort to further examine the role of the di-acidic code in the rescue of ∆f cftr by second site mutations, we found that ∆f cftr rescue by the simultaneous disruption of two of the arginine-framed tripeptides (afts) is also dependent upon the di-acidic code. surprisingly, we found that while nbd is not necessary for the export of wild-type cftr, it is required for the aft-mediated rescue of ∆f cftr, suggesting a role for cytoplasmic inter-domain interactions in the aft-mediated rescue of ∆f cftr. a detailed biochemical analysis of these mutants provides valuable insights into the roles of different cftr "trafficking" motifs in the er-to-golgi transport of cftr, the specific conformational defects of ∆f cftr and the potential molecular mechanism underlying the rescue of ∆f cftr. supported by cff. sonawane, n.d. ; zhao, d. ; galietta, l. ; zegarra-moran, o. ; verkman, a. . medicine, university of california san francisco, san francisco, ca, usa; . genetica molecolare, istituto gianina gaslini, genova, italy cftr inhibitors are predicted to prevent intestinal fluid secretion in enterotoxin-mediated secretory diarrheas such as cholera. cftr inhibitors that are not absorbed across the intestinal wall are attractive for diarrhea therapy because they may provide safe oral therapy. we previously discovered low affinity glycine hydrazide (glyh, ic ~ µm) cftr inhibitors that block cftr at its external pore (muanprasat et al., j. gen. physiol. ; : - ) . in order to increase inhibitor potency and prevent washout during severe secretory diarrhea, we synthesized a series of glycocalyx interactive cftr inhibitors containing a malonic acid hydrazide (malh) cftr pore blocking moiety linked to a lectin (sonawane et al., gastroenterology ; : - . lectin conjugation improved cftr inhibitory potency by ~ -fold (ic to nm). high-affinity cftr inhibition was abolished by malh-lectin heat denaturation, protease digestion, or competition by mannose or unconjugated lectin. fluorescently labeled malh-lectin remained membrane-bound for > hours after washout, whereas washout occurred in a few minutes without the lectin. malh-lectins blocked cholera toxin-induced intestinal fluid secretion in closed intestinal loops in mice with ec - pmol, and greatly reduced mortality in a suckling mouse model of cholera. we recently synthesized mono-and divalent cftr inhibitors consisting of malh coupled via a disulfonic stilbene linker to flexible mono and bifunctional polyethyleneglycols (pegs) of molecular size . , . , , , , , , and kda, with calculated solution lengths of - nm, with the larger size pegs potentially spanning cftr dimers or inducing their formation. ic for inhibition of cftr chloride current was - µm for monovalent malh-pegs, but substantially lower and size-dependent for divalent malh-pegs, decreasing from . µm to nm with increasing peg size. the mechanisms responsible for the improved and size-dependent potency of divalent malh-pegs were studied by whole cell, single-channel patch-clamp and by functional analysis of multivalent malh-conjugated dextrans and asymmetric divalent pegs. whole-cell experiments revealed reversible voltage-dependent block of cftr currents, with outward (positive) currents being more strongly blocked. in outside-out patch-clamp experiments, inhibitors caused a reduction of the mean open time. for malh-peg kda-malh ( µm) , the mean open time decreased from ± to ± ms. the effect on currentvoltage relationship and channel kinetics are consistent with a mechanism involving occlusion of the cftr pore from the extracellular side. luminally added divalent malh-pegs blocked by > % cholera toxin-induced fluid secretion in mouse intestinal loops with ic s of < pmol/loop, and greatly reduced mortality in a suckling mouse model of cholera. nonabsorbable, multivalent cftr inhibitor-macromolecule conjugates may be useful as anti-secretory agents in the treatment of enterotoxin-mediated diarrheas. supported by cff and nih. activation of the cystic fibrosis transmembrane conductance regulator (cftr) clchannel is primarily controlled by pka-dependent phosphory-lation of the r domain. once the r domain is phosphorylated, atp binding and enzymatic activity at two nucleotide-binding domains (nbds) open and close the cftr clchannel. we hypothesized that r domain phosphorylation regulates cftr activity by modulating atp interactions within two nbds. to test this hypothesis, we studied the activity of wild-type cftr and five variants with deletions of portions of the r domain between residues and . to alter atp-dependent channel gating, we tested three cftr stimulators, pyrophosphate (pp i , mm), 'deoxy-atp ( 'datp, mm) and caatp ( mm) . consistent with previous studies, pp i , 'datp and caatp all increased current of wild-type cftr about two-fold. each stimulator produced a similar increase in the r domain variants. the similar effects of stimulators on the channel activities of wild-type cftr and r domain variants suggest that the r domain does not have a major role in regulating atp-dependent channel gating. the r domain deletions did not alter the single-channel current amplitude of the r domain variants. however, r domain variants missing the sequence between residues and markedly reduced the open state probability, suggesting that this region is required for normal gating. these data suggest that the r domain does not control cftr activity by modulating atp interactions with nbd binding sites. instead, we speculate that the c-terminal part of r domain might participate in the channel-gating machinery downstream of atp regulation. supported by the cystic fibrosis foundation and howard hughes medical institute. haggie, p.m.; verkman, a. medicine and physiology, cvri, u.c.s.f., san francisco, ca, usa it was recently reported that phagolysosomes of alveolar macrophages from cf mice acidify in a cftr-dependent manner and that defective phagolysosomal acidification impairs bactericidal activity (di et al., nat. cell biol. , : - ) . these findings suggested a unifying hypothesis for cf disease progression: defective phagolysosomal acidification in cf macrophages permits the initiation and promotes progression of bacterial infection in the lungs. to reassess the central finding of that study we measured phagolysosomal ph using a fluorescent ph indicator containing oregon green® (pka ~ . ) and tetramethylrhodamine covalently bound to zymosan. phagolysosomal ph was insensitive to cftr inhibition ( µm cftrinh- ) in j macrophages (ph . ± . vs. . ± . ), alveolar macrophages from mouse lung (ph . ± . vs. . ± . ), and alveolar macrophages from human lung (ph . ± . vs. . ± . ). phagolysosomal ph in alveolar macrophages from ∆f cf mice was not significantly different from that in alveolar macrophages from wild-type mice (ph . ± . vs. . ± . ). to account for their finding of defective phagolysosomal acidification in alveolar macrophages, di et al. reported that lysosomal acidification was cftr-dependent and that fusion of lysosomes to phagosomes (at ~ min after phagocytic uptake) was responsible for phagosomal acidification. we measured lysosomal acidification in j macrophages using a dextran-conjugate containing oregon green® and tetramethylrhodamine and found that acidification was not impaired by cftr inhibition (ph . ± . vs. . ± . ) . we also measured the kinetics of phagosomal acidification using a zymosan-conjugate containing -(and- )-carboxyfluorescein (pka ~ . ) and tetramethylrhodamine. phagosomal acidification in j macrophages and murine alveolar macrophages began within min of phagocytosis and reached steady-state by - min, in agreement with prior data in murine peritoneal and bone marrow-derived macrophages. acidification kinetics in j macrophages was not altered by cftr inhibition, nor was acidification kinetics different in wild-type vs. cf alveolar macrophages. our findings do not support the conclusion that phagolysosomal acidification in alveolar macrophages is cftr-dependent, nor that it is impaired in cf. the mechanism of phagosomal acidification proposed by di et al. is not in accord with our data or precedents in the literature. because phagolysosomal acidification is central to the proposed mechanism linking defective cftr chloride channel function with cf lung disease, our results do not support the involvement of cftr in defective macrophage function in the pathogenesis of cf lung disease. supported by cff and nih. pared to that of wild-type cftr. the hsp family of molecular chaperones play important roles in the protein quality control process within the er. hsp atpase activity is regulated by multiple co-chaperones such as hsp , bag- and hspbp . hsp , a high-molecular-weight member of the hsp family was recently shown to display nucleotide exchange activity for hsp s in vitro. furthermore, hsp was identified as a component of a cftr-associated multiple protein complex using a global proteomic approach (cell : - , ) . in an attempt to explore the role of hsp in cftr conformational maturation in the er, we over-expressed the co-chaperone in hek cells and quantitatively analyzed its effect on the maturation and degradation of cftr. consistent with its role as a nucleotide exchange factor for hsp s, over-expression of hsp inhibits the er export of wild-type cftr and promotes its degradation. however, in striking contrast, over-expressing hsp stabilizes ∆f cftr and promotes its er export at reduced temperature. this effect is less pronounced at physiological temperature. the apparently opposite effects of hsp on wild-type and ∆f cftr maturation and quality control, suggests distinct conformational maturation pathways for the two cftr molecules, and reveals a specific role for hsp in regulating ∆f cftr refolding. such conclusion is reinforced by rnai experiments and further supported by quantitative co-immunoprecipitation. rnai-mediated down-regulation of hsp expression destabilizes ∆f cftr and reduces its export at reduced temperature, and hsp shows more extensive association with the er form of ∆f cftr than that of wild-type cftr. further analysis revealed that hsp not only modulates the chaperone activities of hsp s but also alters their steady state levels within the cell, creating secondary effects on cftr maturation and quality control. further studies are necessary to achieve a better understanding of the machinery, pathway and mechanism of ∆f cftr conformational maturation at reduced as well as physiological temperatures, and this in turn will provide critical insights and key factors that are of potential value to the rescue of the trafficking defect of ∆f cftr. farinha, c.m. , ; pissarra, l.s. ; amaral, m.d. , . department of chemistry and biochemistry, faculty of sciences, university of lisboa, lisboa, portugal; . ctr hum genet, nat inst health, lisboa, portugal the most frequent mutation in the cystic fibrosis (cf) gene, f del, causes retention of its protein product, f del-cf transmembrane conductance regulator (cftr) in the endoplasmic reticulum (er) as a core-glycosylated intermediate that is rapidly degraded. therefore, most f del-cftr fails to traffic to the plasma membrane, where wild-type (wt) cftr normally functions as a chloride (cl-) channel. retention, however, is not due to lack of function, since the mutant still retains some function if it reaches the membrane. instead, it results from misfolding which is recognized by the er quality control (erqc) in which many intervenients, including molecular chaperones, participate. identification of molecular partners involved in the disposal of f del-cftr to the proteasome is therefore crutial. it was recently shown that casein kinase ii (ck ), a pleiotropic constitutively active protein kinase involved in several processes, such as neoplasia, cell survival and viral infections, binds wt-cftr near the f residue, phosphorylating its first nucleotide binding domain (nbd ) at s [ ] . interestingly, deletion of f abrogates this interaction, which is the first described f del-dependent protein-protein interaction. our aim here was to identify whether ck interaction affects the early steps of cftr biogenesis, turnover and processing. to this end, novel bhk cells were produced which stably express wt-or f del-cftr in which the consensus residue s was substituted by either a neutral (alanine -s a) or an acidic residue (aspartate -s d). initial biochemical analyses of these cell lines revealed that: ) cftr proteins bearing d or a at position are processed; ) despite producing equivalent levels of cftr transcripts, s a expressing lines consistently show lower levels of cftr protein. metabolic labelling and pulse-chase experiments followed by cftr immunoprecipitation were also performed in these lines. after quantification of bands b (immature form) and c (mature form) of cftr, these preliminary results show that substitution of s (by a or d) does not affect the turnover or processing of either wt-or f del-cftr. the effect of ck inhibition on the turnover and processing of cftr was also studied, by incubating cells with µm of the ck inhibitor tetrabromobenzotriazole (tbb) for min. pulse-chase experiments under these conditions show that: ) the steady-state levels of both wt-and f del-cftr are reduced; ) the turnover of wt-cftr (but not of f del-cftr) is increased; and ) processing of wt-cftr is decreased. such data are consistent with a putative stabilizing role for ck upon wt-cftr [ ] . however, in our preliminary results this effect does not appear to be dependent on residue (nor on the putative charge added by the kinase on this residue), thus suggesting that this effect may be indirect. further studies are underway to identify the mechanism by which ck affects the turnover and processing of cftr. . treharne et al ( ) pissarra, l.s. ; xu, z. ; farinha, c.m. , ; sheppard, d.n. ; amaral, m.d. , . department of chemistry and biochemistry, faculty of sciences, university of lisboa, lisboa, portugal; . dep physiology, univ bristol, school med sciences, bristol, united kingdom; . ctr hum genet, nat inst health, lisboa, portugal g e and rk (the simultaneous mutation of four arginine-framed tripeptides (afts): r k, r k, r k and r k) are second site mutations that rescue the processing and function of f del-cftr [ , ] . these revertant mutations rescue f del-cftr from retention within the endoplasmic reticulum by distinct mechanisms: g e likely alters the conformation of the first nucleotide-binding domain (nbd ), whereas rk plausibly allows f del-cftr to escape er retention/retrieval mediated by afts [ ] . both g e and one of the afts (r k) lie close to the residue g , where a common cf-causing mutation g d occurs, generating a correctly localized clchannel with a severe gating defect. our aim here was to assess whether the revertants g e and rk influence the folding, processing and gating behaviour of the g d mutation, by employing biochemical and functional approaches. to test this idea, we introduced the g d mutation into cftr cdnas containing either g e or rk in the pnut vector and stably expressed these constructs in bhk cells. preliminary results from biochemical studies indicate that the mature fully-glycosylated form of cftr protein (band c) of both g e-g d-cftr and rk-g d-cftr were present at similar levels to those of g d-cftr. analysis of cftr-mediated iodide efflux from these cells revealed that g e is unable to rescue the functional defect of g d. however, rk generated an efflux of iodide larger than that elicited by cells expressing g d, albeit smaller than that of cells expressing wild-type (wt) cftr. consistent with these data neither rk nor g e rescued the defective channel gating of g d-cftr. however, both revertants caused a small increase in g d-cftr activity by attenuating the prolonged interburst interval of g d. we conclude that f del and g d disrupt cftr channel gating by distinct mechanisms. altogether, our data suggest that at least when in cis with the g d mutation, the afts (together or individually) might have a direct effect on cftr channel gating. this raises the possibility that rk, in addition to its well-described effect on trafficking, may act on cftr structure and/or folding, as previously suggested for r k [ ] . work supported by grant pocti/sau/mmo/ / and pluriannual funding of cigmh (fct, portugal) and the uk cf trust. l. pissarra was a recipient of bd/ / doctoral fellowship (fct, portugal) . [ ] carvalho ac, gansheroff lj, teem jl ( ) j biol chem , - . [ ] chang xb, cui l, hou yx, jensen tj, aleksandrov aa, mengos a, riordan jr ( ) mol cell , [ ] [ ] [ ] [ ] [ ] [ ] [ ] roxo-rosa m, xu z, schmidt a, neto m, cai z, soares cm, sheppard dn, amaral md ( ) proc natl acad sci usa , - . [ ] teem jl, carson mr, welsh mj ( ) improves ∆f -cftr intracellular trafficking in cf epithelial cells, although the mechanism by which this occurs is not clear. to identify gene products with atlered abundance in response to pba, we performed a differential display rt-pcr screen on rna isolated from ib - cf epithelial cells treated with pba for - hours. we isolated a cdna encoding stip- , a putative human stat- (signal transducer and activator of transcription- ) interacting protein and confirmed that pba causes transiently increased stip- mrna and protein abundance after hours of exposure. stip- was originally described as a scaffold protein that is required for ligand-dependent activation of stat- . stip- is also identical to elongator protein (elp- ), a subunit of the multicomponent elongator complex that stimulates rna polymerase ii activity. interestingly, recent data suggests that elongator may also regulate polarized secretion (rahl, et al. ( ) , mol. cell, : - ). we therefore hypothesized that stip- /elp- would regulate ∆f -cftr intracellular trafficking. in ib - cells, stip- /elp- associates with ∆f -cftr in coimmunoprecipitation experiments after pba treatment. in ib - cells overexpressing stip- /elp- , immunofluorescence experiments suggested that ∆f -cftr trafficked to the plasma membrane even in the absence of pba treatment. stip- /elp co-localized with markers of the golgi ( kda golgi protein) and exocytic vesicles (snap- ) when overexpressed in these cells. in contrast, overexpression of a deletion mutant of stip- /elp- lacking the wd domain, or stat- binding region, blocks the improvement of ∆f -cftr trafficking in response to pba in immunofluorescence and surface biotinylation experiments. this stip- /elp- deletion mutant did not co-localize with golgi or exocytic vesicle markers. furthermore, immunofluorescence experiments also suggested that pba causes colocalization of stip- /elp- and elp- , another member of the elongator complex that is often defective in familial dysautonomia. these data are consistent with stip- /elp- regulating ∆f -cftr intracellular trafficking in response to pba. this regulation may occur in the context of pba stimulating assembly of elongator, which in turn may promote trafficking of exocytic vesicles carrying ∆f -cftr to the plasma membrane. supported by grants from niddk. fold [ , ] . however, functional studies demonstrate significant differences in the gating behaviour of hcftr and mcftr [ ] . a powerful approach to investigate cftr structure and function is to examine interspecies differences and identify regions of conservation and divergence. to understand the structural basis for the functional differences between hcftr and mcftr, we generated hmcftr chimeras containing mcftr domains on an hcftr backbone. for this purpose, we replaced all or part of nbd , nbd or the rdomain of hcftr with the equivalent regions of mcftr and investigated their biochemical and functional properties. the in vivo folding of these hmcftr chimeric proteins was indirectly evaluated from their maturation status, after their stable expression in novel bhk cell lines. like wt-hcftr, most chimeric proteins were processed within the cell. however, two chimeras failed to mature: clone b (mnbd , amino acid (aa) residues - ) and clone c (mnbd , aa - ). we compared the murine sequence of these two chimeras with that of hcftr to determine the respective physico-chemical distances (pcds) of their aa changes. changes with higher pcd values were selected and in vitro mutagenesis performed to introduce these aa alterations into hcftr cdna. for clone b the selected changes were: e q, e q (pcd = ); s t (pcd = ); k q (pcd = ), i t (pcd = ) and k e (pcd = ). for clone c the changes were: p t (pcd = ), k q (pcd = ), y n (pcd = ), s k (pcd = ), c y (pcd = ), d g (pcd = ) and e d (pcd = ). biochemical analyses of these mutants stably expressed in bhk cells revealed that for clone b, e q, s t, k q and i t were processed, whereas k e was not. for clone c, p t, k q, y n, d g and e d were processed. iodide efflux showed that s t, k q, i t, e d and d g were functional, but not k e. we consider that with additional functional analyses, our approach will identify critical residues responsible for conformational changes and hence, functional differences between hcftr and mcftr. work supported by the bbsrc and grant pocti/mgi/ / (fct, portugal) and pluriannual funding of cigmh (fct, portugal) . ac dapaula is a recipient of phd fellowship sfrh/ bd/ / (fct, portugal we recently reported that the upr decreases endogenous wild-type (wt) cftr expression. as a follow up of these studies, we investigated the role of the folding deficient, ∆f cftr on upr induction and identified a mechanism by which the upr decreases cftr expression. for these studies, we developed a cell line expressing recombinant ∆f cftr on the endogenous wt background (calu- ∆f) and established individual clones with different ratios of endogenous (wt) to recombinant (∆f cftr) expression. two clones which express : (calu- ∆fc ) and : (calu- ∆fc ) ratios of wt to ∆f cftr and cfpac- cells expressing endogenous ∆f cftr were tested as models. the upr was constitutively active in calu- ∆fc cells only. in calu- ∆fc induction of ∆f cftr expression resulted in upr activation, indicating that high expression of ∆f cftr is required for upr induction. furthermore, following pharmacological induction of the upr, endogenous cftr mrna decreased to undetectable amounts both in calu- ∆f and cfpac- cells. the decrease in cftr mrna levels was not the result of shortened mrna half-life. in contrast, using a human cftr promoter driven reporter (pcftr-pluc), we demonstrate suppression of the cftr promoter when the upr is activated. considering that correction of ∆f cftr is the main therapeutic approach for cf, it is important that ∆f cftr expressed at low levels, such as in vivo, does not activate the upr. however, our results also reveal that ∆f cftr correctors have to be tested for upr activation, since transcriptional inhibition in this setting may contribute to inefficient rescue in native cells or in vivo. genistein, a naturally occurring tryrosine kinase inhibitor, at low concentrations ( µm) stimulates wt -cftr-mediated chloride secretion in a variety of cell and tissue types by an adenosine ', '-cyclic monophosphate (camp)-independent pathway. genistein has been shown to potentiate the channel function of ∆f -cftr and g d-cftr channels by prolonging channel open time (hwanget al., am j physiol cell physiol : c -c , ; illeck et al. am j physiol cell physiol : c -c , ) patch clamp studies have provided indirect evidence that genistein may bind directly to cftr and potentiate channel open probability by modifying the function of the nucleotide binding domains (weinreich et al., pflügers arch : - , ) . the goal of the present study was to determine whether genistein activated purified and reconstituted cftr protein as an initial step toward defining its molecular mechanism of action. the effect of genistein on purified and reconstituted wt-cftr was first studied following its reconstitution into planar lipid bilayers. in the presence of µm atp, phosphorylated cftr exhibited a low open probability (po= . ). the addition of µm genistein, caused a significant increase to the open probability of cftr (po= . ). using an electrogenic flux assay on a population of purified and phosphorylated cftr molecules, we determined that µm genistein caused a potentiation ( % increase) of chloride channel activity in the presence of µm atp. these results suggest that this macroscopic assay of purified cftr function is sufficiently sensitive to detect the effect of this potentiator. currently, the consequences of genistein on the channel activity and atpase activity of purified reconstituted ∆f -cftr and g d-cftr are being assessed. preliminary results suggest that in the presence of low atp concentrations ( - µm), µm genistein inhibits the atpase activity of ∆f -cftr, suggesting that it interacts directly with the nucleotide binding domains to alter their function. previous studies indicated an acute coordination between the activities of cystic fibrosis transmembrane conductance regulator (cftr) chloride channel and the amiloride sensitive epithelial sodium channel (enac) so that both these channels are either activated or deactivated in a synchronous fashion in the human sweat duct (reddy et.al, ) . however, the mechanisms responsible for such cooperativity between these ion channels are unknown. previous studies indicated that: cytoplasmic ph controls cftr activity through effects on phosphorylation (reddy et.al. ) . at ph . , cftr chloride conductance was reduced to ± ms/cm , but incresed to ± ms/cm at ph . (n=number of ducts= ). enac channel activity is also a function of cytosolic ph in heterologous expression systems (chalfant et.al, ) . the objective of this study was to test the hypothesis that the cytosolic ph may mediate the cooperative effects that occur between cftr and enac. we used basolaterally a-toxin permeabilized apical membrane preparations of native human sweat duct which expresses enac and cftr robustly as an experimental system. we showed that while luminal ph had no effect, changes in cytosolic ph acutely affected enac activity. that is, acidic ph inhibited, while basic ph activated enac activity. alkalinizing cytosolic ph from . to . increased enac conductance (genac) by ± . ms/cm (n= ). ph regulation of enac activity appears to be independent of cftr and endogenous kinase activities because basic ph stimulated enac: a.) after deactivating cftr by removing camp and atp in normal ducts, b.) in the absence of cftr in cf ducts, and c.) after blocking endogenous kinase activity with the non-specific kinase inhibitor, staurosporine. na + /h + exchanger (nhe) may mediate changes in cytosolic ph as a function of intracellular na + activity. nhe mrna is expressed in the sweat duct and cytosolic ph responds to changes in na + gradients across the basolateral membrane. conceivably, when transport conditions are favorable and intracellular na + is low, alkaline ph would allow enac and cftr to cooperatively admit na + and clthrough the apical membrane. when conditions are unfavorable and intracellular na + is excessive, acid ph would limit na + and clentry to protect the cell from disruptive changes in cell volume. thus, changes in cytosolic ph may play a crucial role in coordinating the activities of enac and cftr during transepithelial salt transport. acknowledgements: kirk taylor and sucharitha madireddi for expert technical assistance. funded by nih-ro de , nih-ro hl and the nancy olmsted trust. the cystic fibrosis transmembrane conductance regulator (cftr) is an anion channel that is normally expressed in the plasma membrane but is mislocalized in cf. to monitor trafficking we inserted super ecliptic phluorin, a ph-sensitive variant of green fluorescent protein (gfp) (miesenbock g, de angelis da, rothman je ( ) nature , - ) into the fourth extracellular loop of cftr. this construct, which we call cftr-phluor, has weak fluorescence intracellularly that increases ~ -fold when it is inserted into the plasma membrane and the phlour becomes exposed to more alkaline extracellular ph . thus cftr-phluor should be less fluorescent than cftr with the normal gfp fused to the n or c termini when situated in intracellular vesicles. despite the insertion of an entire gfp in the middle of the channel protein, cftr-phluor trafficked to the membrane and patch clamp studies revealed little change in unitary conductance or open probability compared to wild-type cftr. cftr-phluor enabled visualization of vesicle insertion events at the plasma membrane by total internal reflection fluorescence (tirf) microscopy. faintly fluorescent vesicles containing cftr were observed under the plasma membrane and eventually fusing with it to generate a burst of fluorescence. phluorin inserted at the same position in ∆f -cftr, the predominant mutant in cf, was retained in the er where the phluor remained partially quenched. when the folding defect was corrected by culturing cells at °c or treating them with known correctors, ∆f -phluor trafficking was partially restored and total cell fluorescence increased. this enabled a quantitative analysis of ∆f -cftr correction based on the increase in fluorescence in individual cells by flow cytometry. cftr-phluor may be most useful for microscope-based high-content screening studies of cftr and ∆f -cftr trafficking. support: the breathe program, canadian cf foundation, canadian institutes of health research and cf foundation therapeutics (usa). tukaye, d.n.; guggino, w.b. physiology, johns hopkins university, baltimore, md, usa type iii secretion system (t ss) toxins of p. aeruginosa are important virulence factors in p. aeruginosa infections. one of the t ss toxins, exos, has been shown to facilitate uptake and invasion of p. aeruginosa at airway surface epithelium. in mouse models of pseudomonas pneumonia, infection with p. aeruginosa exos+ strains caused increased levels of fluid in lungs as determined at autopsy in contrast to infection with p. aeruginosa exosstrains. the exact molecular mechanism underlying these observations is not known. exos is a bifunctional protein with gtpase activating protein (gap) activity at the n terminal domain and adp ribosyl transferase (adprt) activity at the c terminal domain. we found that exos-gap activity increases total cellular levels of mature (c band) wild type (wt) cftr in cfbe o-cells as measured by western blot analysis. this increase was mediated by decreased delivery of wt cftr for lysosomal degradation. in contrast, exos-gap failed to increase total levels of ∆ cftr (b band). interestingly, exos-gap increased total levels of ∆ cftr, bands c and b, following rescue with -phenylbutyrate. this indicates that targets of exos-gap exist in cftr trafficking beyond the er degradation pathway. exos-gap also brought about a corresponding increase in surface levels of mature wt cftr as measured by surface biotinylation. in conclusion, we have shown that p. aeruginosa t ss exos-gap, upregulates total and surface levels of mature wt cftr by modulating cftr trafficking beyond er, most likely by decreasing lysosomal degradation. the decrease in lysosomal degradation could be occurring in part by inactivation of small molecular weight g-proteins involved in delivery of wt cftr to lysosomes. increases in total and hence surface levels of cftr could in part explain increased amounts of fluids seen in p. aeruginosa pneumonia mouse model treated with exos+ strains. the post-maturational trafficking and localization of cftr is regulated by a wide variety of proteins. among the most prominent are several pdz domain proteins that bind to the c-terminal residues of cftr. in particular, two of these proteins, nherf and cal, have been shown to mediate opposing effects on the apical membrane levels of the disease-associated ∆f -cftr mutant, by controlling the balance between endocytic recycling and lysosomal degradation. in particular, whereas overexpression of nherf rescues ∆f -cftr at the cell surface, overexpression of cal has the opposite effect on cftr. cal-mediated downregulation of cftr requires a functional pdz binding site. we have now shown that suppression of endogenous cal cooperates with temperature rescue to stabilize functional ∆f -cftr channels at the apical membrane in polarized bronchial epithelial cells. this work supports the hypothesis that the cal pdz binding site is a therapeutic target for treatment of cystic fibrosis. a more direct test of this hypothesis will require competitive inhibitors that can efficiently block the cal:cftr interaction. in addition, given the large-number of protein-protein interactions formed by both the cal pdz domain and the cftr c-terminus, these inhibitors should ideally exhibit bidirectional selectivity, neither disrupting the favorable nherf :cftr interaction, nor strongly displacing other membrane proteins that interact with cal. using a fluorescence polarization assay and peptide-array technology, we have now identified a high-affinity, cal-selective peptide inhibitor. compared to cftr, this sequence binds cal more tightly, but nherf more weakly. furthermore, we have shown that the cal:cftr interaction is the weakest among the known cal-binding proteins, and that cftr should thus be susceptible to selective displacement from the cal binding site. finally, we have designed cell-permeable peptides that allow us to test the hypotheses (a) that such compounds will specifically disrupt the cal:cftr interaction and (b) that such targeted stereochemical inhibition will stabilize the functional cell-surface expression of ∆f -cftr in airway epithelial cells. the pathways for the endoplasmic reticulum associated protein degradation (erad) of misfolded proteins in the mammalian cells are incompletely understood. we investigated the role of molecular chaperones in erad for the cystic fibrosis transmembrane conductance regulator (cftr) and its common folding mutant, ∆f cftr. we found that hsp and its cochaperone hdj- interacted significantly with ∆f cftr and wt-cftr in airway epithelial cells. hsp interacted with the immature form of cftr while hdj- associated with both immature form and ubiquitylated cftr. structure-function studies showed that hdj- recognized ubiquitylated cftr via its zn-binding domain. immunoprecipitation and gst-fusion protein pulldown experiments revealed that hdj- interacted with ubiquitin. in steady-state, over-expression of hdj- elicited increasing both immature and mature forms of wt-cftr, but it resulted in decreasing immature form of ∆f cftr. pulse-chase studies showed that co-expression of hdj- promoted ∆f cftr degradation, reducing its half-life from to min. in contrast, hdj- expression did not significantly affect wt-cftr biogenesis. these data are consistent with our finding that hdj- shows a selective physical interaction with ∆f cftr, which translates into a functional discrimination between the mutant and its wt counterpart. the hpd motif within the j-domain of hdj- , which is necessary for the co-chaperone to bind hsp and stimulate its atpase activity, was required for hdj- mediated ∆f cftr degradation. mutation of the hpd motif retarded the degradation of ∆f cftr and increased the steady-state levels of ∆f cftr -fold. a role for hsp in hdj- mediated ∆f cftr degradation was tested in which hsp knockdown increased ∆f cftr expression - fold. hjd- regulates ∆f cftr maturation and knockdown of endogenous hdj- promoted ∆f cftr and its camp-dependent anion conductance in airway epithelial cells. in contrast, we were unable to detect maturation of ∆f cftr in hsp knockdown experiments, indicating that the maturation of ∆f cftr mediated by reduced hdj- expression may be independent of hsp function. taken together, our data demonstrate that hdj- is a molecular sensor that can detect differences in the folding related to the ∆f cftr maturation. these data also highlight a novel pathway for hdj- linked, ubiquitin-dependent degradation of ∆f cftr. reduction of hdj- expression or its association with ∆f cftr promotes maturation of this mutant and therefore represents a potential therapeutic approach for cystic fibrosis. [supported by nih and cf foundation] how the loss of cftr function results in cholesterol accumulation within the cell is currently unknown. cftr activation is driven by the camp and we propose that cf cells respond to the loss of cftr activity by increasing the camp pathway in order to increase cftr expression. to test this hypothesis, epithelial cells were treated with the phosphodiesterase- (pde ) and pde inhibitors milrinone and rolipram, respectively. inhibition of pde function with rolipram in wildtype cells leads to peri-nuclear free cholesterol accumulation identical to what is observed in cf epithelial cells as viewed by filipin staining, strongly implicating a camp-dependent pathway in the regulation of cholesterol trafficking. the pde -selective inhibitor milrinone had no effect on cholesterol trafficking suggesting specificity for the pde pathway. our preliminary data support this hypothesis in that both cf-model hteo-pcepr cells and mouse nasal epithelium (mne) from cftr -/-mice exhibit reduced protein expression of the campspecific phosphodiesterases pde compared to wt controls. the proposed consequence of a chronic amplification in camp signaling is altered cholesterol transport regulation. to address this potential role of pde in cholesterol trafficking, free cholesterol was visualized using filipin staining in wild type cells that were treated with rolipram, a pde -specific inhibitor. conversely, treatment of cf-model pcepr cells with the pka inhibitor rp-camps significantly improves cholesterol processing, further pointing to the involvement of the camp pathway. we propose that the camp pathway influences cholesterol processing through the regulation of β-arrestin- (βarr ) according to the premise that chronic increase in the camp pathway would initiate an elevation in βarr expression. βarr is an important regulator of adrenergic receptor recycling and organelle trafficking. because βarr is pivotal in regulating endocytotic recycling pathways, it could also impact cholesterol processing. this predicted increase in βarr protein expression is observed in both cf-model pcepr cells and cftr -/-mne compared to respective controls. over expression of βarr in wt epithelial cells leads to cf-like peri-nuclear cholesterol accumulation further implicating a role for βarr in the development of this phenotype. altered cholesterol trafficking in cftr would lead one to expect different βarr localization throughout the cell. further understanding of the implications of altered camp signaling and its relationship to aberrant cholesterol accumu-rationale: we recently reported that vcp (valosin containing protein) physically interacts with gp /amfr (autocrine motility factor receptor) to couple retrograde translocation of ∆f -cftr to proteasomal degradation (vij et al. jbc ) . recent studies have revealed an alternative system to the proteasome for degradation of polyubiquitinated misfolded proteins termed the aggresome. histone deacetylase- (hdac ) is a unique cytoplasmic deacetylase capable of interacting with ubiquitin and mediating the accumulation of ∆f -cftr in aggresome bodies. hypothesis: vcp competes with hdac to dissociate ∆f -cftr perinuclear aggregates. methods: ib - (∆f /w x) cf bronchial epithelial cells were transiently transfected with ∆f -cftr and vcp-gfp constructs and treated with a hdac inhibitor (tubacin), proteasome inhibitor (ps- or mg- ), lysosome inhibitor (baflomycin a ) or nil-tubacin (control) for , or hrs. the effect of these inhibitors on ∆f -cftr and vcp:∆f -cftr interactions were quantified by immunoprecipitating these protein complexes followed by immunoblotting with vcp, hdac or clathrin antibody. ∆f -cftr levels were measured by metabolic labeling using tran- s-label ( µci/ml) for a min pulse and hrs chase. the subsequent effects of these inhibitors on vcp localization was detected by fluorescence microscopy of gfp moiety. results: the co-immunoprecipitation experiments showed that hdac inhibition by µm tubacin ( hrs) promotes vcp:∆f -cftr and prevents hdac :∆f -cftr interaction. the proteasome inhibition (mg µm) resulted in maximal hdac :∆f -cftr at hrs with minimal at hrs while vcp:∆f -cftr increased overtime ( to hrs). adding tubacin ( µm; hrs) reversed the proteasomal inhibitor effects. in pulse-chase experiments, mg- increased the accumulation of cftr bform and poly-ubiquitinated-∆f -cftr as compared to the untreated control. tubacin suppressed the levels of mg- induced poly-ubiquinated-∆f -cftr as well as ∆f -cftr b-form. the vcp localization by microscopy showed the accumulation of vcp-gfp in perinuclear aggregates in the presence of proteasome inhibitor (ps- µm). the µm tubacin blocked these ps- induced perinuclear aggregates. we observed that vcp is associated with endocytic protein-complexes containing clathrin in the presence of ps- indicating cytosolic re-localization of vcp. we further confirmed the cytosolic re-localization of vcp-gfp in the presence of lysosome inhibitor (bafilomycin a µm) by fluorescent microscopy. conclusion: we found that a small molecule inhibitor of aggresome function prevents hdac :∆f -cftr interaction, promotes vcp:∆f -cftr interaction, and suppresses the accumulation of poly-ubiquinated-∆f -cftr. wang, y. ; jiang, y. ; zhu, n. ; feng, x. ; yang, h. , ; ma, t. , . membrane channel research laboratory, northeast normal university, changchun, china; . biopharmaceutical center, liaoning normal university, dalian, china deletion of the codon encoding the phenylalanine residue at position (∆f ) in the cystic fibrosis transmembrane conductance regulator (cftr) is the most common mutation causing cystic fibrosis (cf). the ∆f mutation results in a cftr protein with impaired folding, trafficking and gating in human and rodents. the consequences of ∆f -cftr mutation in other species have not been studied. the purpose of the present study was to characterize the ∆f mutant of porcine cftr in cell culture model. cdna sequence encoding full-length porcine cftr (pcftr) was cloned from the lung by rt-pcr using primers designed according to porcine genomic sequences in two bac clones (genbank accession no. ac and ac ) containing all exons of the porcine cftr. pcftr encodes a -amino-acid protein that shows . % identity to human cftr. the phenylalanine residue at position is conserved in pcftr. functional analysis of pcftr stably expressed in fisher rat thyroid (frt) epithelial cells by short-circuit current assays indicated a campactivated cl-channel similar to human cftr except that the sensitivity of pcftr to the specific cftr inhibitor cftrinh- is -fold lower than that of human cftr. a ∆f mutation of porcine cftr was generated by site-directed mutagenesis. surprisingly, ∆f -pcftr expressed as a func-tional chloride channel activated by forskolin in stably transfected frt cells. western blot analysis of cos and bhk cells transiently transfected with cmyc-tagged ∆f -pcftr indicated a protein pattern identical to that of wildtype pcftr. immunofluorescence analysis of the transiently transfected cells demonstrated similar plasma membrane expression pattern of ∆f -pcftr and wildtype pcftr. these results clearly demonstrated unimpaired cellular processing of ∆f -pcftr. however, the sensitivity of ∆f -pcftr to forskolin activation (ic ~ . µm) was dramatically lower than that of wildtype pcftr (ic ~ . µm), indicating a defect of channel gating by pka phosphorylation. the present study provided the first evidence that the ∆f mutation in mammalian cftr does not result in impaired cellular processing that is closely associated with cf phenotype. we have optimized airway epithelial cell spheroid cultures for functional measurements of cftr chloride conductance in order to screen smallmolecule activators and inhibitors. spheroids, which are sealed spheroidal monolayers of airway surface epithelial cells with diameter - micron, were generated within to days after nasal brushing and suspension culture. yields of up to spheroids were obtained from nasal brushing of a non-cf or cf subject. approximately , spheroids could be prepared from one million freshly isolated human bronchial epithelial cells. we compared several electrophysiological and fluorescence methods to assay cftr function in spheroids. whole-cell current was measured in single spheroids following pipette immobilization and micropipette puncture of the solutionexposed apical cell membrane. large, forskolin-stimulated whole-cell chloride currents were measured in non-cf spheroids. as an independent approach, transepithelial potential difference was measured by micropipette insertion into the spheroid lumen. for fluorescence detection, cell cytoplasm was stained with the halide indicators mqae or lzq. fluorescently stained spheroids were immobilized on a coated coverglass or in a custom microfluidic chamber. halide flux across the apical surface was measured in response to chloride-nitrate or iodide-chloride solution exchange, in the absence and presence of camp activators. the fluorescence assay is suitable for medium-throughput screening of ∆f correctors and potentiators, with definitive verification of cftr chloride channel function by whole-cell current analysis. an airway spheroid cultures provide a powerful approach to prioritize the efficacy of ∆f correctors because of their rapid generation without prolonged culture, and their suitability for quantitative analysis of cftr function. supported by cff and nih. background and aims: cftr has been shown to be expressed and functional in ventricular cardiomyocytes. however, to date, no physiological role for cftr in the heart has been established. the aim of this study was to determine if cftr plays a role in the regulation of cardiomyocyte contraction rate. methods: cardiomyocyte contraction rate was assessed using the neonatal mouse beating assay. ventricular myocytes were isolated from neonatal mice and cultured for - days until they formed a functional in sitium. contraction rates were captured by video imaging and analyzed by metamorph in the presence and absence of beta-adrenergic receptor stimulation by isoproteronol ( µm). assessment of cftr activity was determined by pharmacological inhibition by glibenclamide ( µm), dpc ( µm), and cftr inh- ( and µm). the role of k atp channels was assessed by -hd ( µm). results: baseline contraction rate of vehicletreated (dmso or h o) cardiomyocytes was unchanged. addition of isoproteronol caused a significant increase in contraction rate, which was sustained for at least minutes. in contrast, application of glibenclamide to beating ventricular myocytes significantly, but transiently, inhibited cardiomyocyte contraction rate, with recovery occurring within minutes. glibenclamide did not affect the initial increase in contraction rate caused by isoproteronol stimulation, but inhibited sustained increases in isoproteronol-stimulated contraction rate. to determine if this was an effect of k atp channel inhibition we examined the effect of -hd on contraction rate. in contrast to glibenclamide, -hd had no inhibitory affect on basal or isoproteronol-stimulated contraction rate, indicating glibenclamide's inhibitory effect was due to its inhibition of cftr. to further verify this, we examined the effect of two other cftr inhibitors, dpc and cftr inh- on ventricular cardiomyocyte contraction rate. both dpc and cftr inh- elicited similar responses as glibenclamide, with a quick, but transient inhibition of baseline contraction rate and inhibition of sustained isoproteronol-stimulated increases in cardiomyocyte beating. summary and conclusions: using neonatal murine ventricular myocyte cultures inhibition of cftr leads to a significant, but transient inhibition of baseline ventricular cardiomyocyte contraction rate. additionally, while inhibition of cftr did not affect initial increases in beta-adrenergic receptor-stimulated contraction rate, cftr inhibition did prevent sustained increases in contraction rate. the data suggest that cftr plays a role in modulating ventricular cardiomyocyte contraction rate during resting and adrenergic-stimulated conditions. drevillon, l. , ; tanguy, g. , ; hinzpeter, a. , ; arous, n. , ; goossens, m. , ; fanen, p. , . génétique, inserm u. , créteil, france; . faculté de médecine, université paris , créteil, france cystic fibrosis is mainly caused by mutations that interfere with the biosynthetic folding of the cftr protein. the aim of this study was to find cellular proteins capable of interacting with cftr and modifying its processing or its trafficking. we have used a genetic screen in yeast to identify such proteins and identified commd that preferentially interacted with the third cytoplasmic loop of cftr. commd is a regulator of copper transporter atp b in hepatocyte and sodium epithelial channel enac, but its exact biochemical function and physiological relevance remain elusive. here, we report that first, commd interacted with wild-type and f del-cftr in epithelial cells and second, commd subcellular distribution was not only both nuclear and cytoplasmic, but also in cytoplasmic vesicular compartments. we wondered if commd was involved in the processing and/or the trafficking of cftr protein in epithelial cells. we demonstrated that commd was not involved in cftr processing but that cell surface expression of wild-type cftr at the plasma membrane was cut by half when commd expression was % reduced by rna interference. we drew the conclusion that commd is a major component of cftr trafficking and/or recycling at the plasma membrane, precise characterization of commd in these vesicular compartments is under process to decipher its function in cftr trafficking. commd has been labelled as the prototype of a newly described protein family that plays a role in inhibiting nf-kappab signalling. moreover, subcellular distribution of commd was different in cf and non cf cells, nuclear form of commd being increased in f del cells compared to wild-type cells. thus, this opens up a new area of investigation about commd nuclear function. finally, these data indicate that commd is involved in multiple cellular processes of outstanding interest in cf pathophysiology. understanding how its modulation modifies transepithelial transport and inflammation in cf versus non cf cells should give new therapeutic clues to reduce exaggerated inflammation and improve fluid secretion in cf patients. supported ; fanen, p. ; galietta, l.j. . lab. of molecular genetics, istituto giannina gaslini, genova, italy; . inserm u. , creteil, france class iii cystic fibrosis mutations cause reduced cltransport by impairing the process of cftr channel opening. typical class iii mutations include g d, g d, and f del, all of them affecting nucleotide binding domains. it has been reported that mutations residing in other regions of the cftr protein may also reduce channel activity. we investigated the extent of loss of function caused by such mutations, in particular by missense mutations localized in cftr intracellular loops, and the sensitivity to pharmacological stimulation with cftr potentiators. to determine cftr activity, plasmids carrying the coding sequence for wild type or mutant cftr were co-transfected in cos- cells together with the halide-sensitive yellow fluorescent protein yfp-h q/i l. the rate of cftr-dependent anion transport was measured after short-term stimulation with forskolin alone or in combination with potentiators (felodipine, phenylglycine pg- , or sulfonamide sf- ). processing of cftr protein was assessed by examining glycosylation status of cftr by immunoprecipitation experiments. when stimulated with forskolin alone, cftr mutants showed the following anion transport compared to the wild type protein: i t ( %), i v ( %), q k ( %), e k ( %), g r ( %), d h ( %). interestingly, all mutants having a reduced anion transport responded to stimulation with potentiators pg- , sf- , and felodipine ( µm) with an increase in anion transport that approached the level of normal cftr protein. the correction of defective cftr activity by potentiators was confirmed in frt cells expressing e k and d h mutants using short-circuit current measurements. our results indicate that some missense cf mutations, like e k and g r, really cause a severe reduction in cftr activity. others, like d h, cause only a partial loss of function which may explain their association with a milder form of the disease. conversely, some other amino acid changes (with the extreme example of i v that seems to cause a gain of function) do not impair cftr activity and therefore may represent polymorphisms and not cf-causing mutations. interestingly, all mutants having a mild or more severe anion transport defect were sensitive to potentiators. this finding indicates that cftr potentiators have a wide efficacy on many class iii mutants and therefore may represent a promising therapeutic strategy for a significant number of cf patients. supported by cfft and telethon-italy. cftr, a cl-channel membrane protein, is a member of the atp-binding cassette (abc) super-family. mutations in cftr result in a misfolded protein which fails to mature, leading to impaired flow of cl-ions across the membrane of the epithelial cells lining the airway, and to cf. the most common mutation leading to cf is df . currently available structural information relevant to cftr modeling includes low resolution structures of cftr ( Å) and p-gp ( Å) and high resolution structures of other abc transporters as well as nucleotide binding domains (nbd) . of particular relevance is the newly published structure of the bacterial multidrug abc transporter, sav , whose topology can serve as a starting point for cftr modeling. as a first step towards the development of cf therapeutics, epix has undertaken the modeling of the d structure of cftr (excluding the r domain) in its conducting (i.e., open-channel, nbd-dimer) state, using our proprietary membrane-protein modeling technology (predicttm) in combination with other modeling tools. to date, we have modeled the cytosolic part of the receptor, namely the nbds:icls construct and work is ongoing on modeling the transmembrane (msd :msd ) region. the now available partial model has been scanned for putative binding sites for df -cftr correctors/potentiators. several potential sites have been located, and epix has initiated its in silico screening technology in order to identify potential drug candidates. this work is supported by the cfft. the deletion of a phenylalanine residue at position (f del) in the first nucleotide-binding domain (nbd ) of cftr is the principal cause of cystic fibrosis (cf). the altered interaction of f del cftr with endoplasmic reticulum (er) quality control proteins, primarily chaperones, promotes its proteasomal degradation. however, it is believed that crucial cftr-interacting proteins (cips) remain unknown [ ] . moreover, there is little information currently available on the strength of cip-cftr interactions. our goals here are two-fold: ) to quantify cftr-cip interactions; and ) to isolate and characterise unidentified cips. to address our first goal, we used surface plasmon resonance (spr; biacore tm ) to quantify real-time binding of hsc (a well-known cip) to bacterially expressed wt-and f del-nbd . hsc /hsp was covalently immobilised onto the surface of carboxymethyl dextran (cm ) sensor chips ( µm) and the real-time binding of purified nbd and control proteins quantified. in control experiments, anti-hsc antibody b ( nm; against residues - ) bound specifically to immobilised hsc with high affinity (k d , . ± . nm; n = ) whereas bovine serum albumin ( µm) did not interact (n = ). given the difficulties associated with expression of hnbd carrying the f del mutation [ ] it was not used in our spr analyses. instead, we used purified murine (m) nbd to quantify the impact of f del on the strength of the hsc -nbd binding. in the presence of low concentrations of atp (≤ um), the affinity of nbd binding to immobilised hsc was strengthened when f was deleted (wt, k d app , . ± . µm; f del, k d app , . ± . µm; n = ; p < . ). interestingly, raising the concentration of mgatp weakened the binding of nbd ( . µm) to hsc (wt, k i , µm atp; n = ). furthermore, deletion of f dramatically increased the concentration of mgatp required to destabilise the nbd -hsc interaction (f del, k i , µm atp; n = ). in summary, we used spr to demonstrate that: (i) nbd of cftr binds specifically to hsc , and (ii) the f del mutation enhances the association of nbd with hsc . we are presently investigating the effect of co-chaperones and small molecules on the interaction of hsc/hsp with wt-and f del-nbd . to identify novel cips, purified nbd was immobilised onto metalaffinity resin and used to capture cips from epithelial cell lysates. by this approach, cips were captured from human respiratory cell (calu- ) lysates and analysed by d-electrophoresis. relevant protein spots so far identified by mass spectrometry include: ) raichu x (thr/ser kinase); ) profilin isoform b; ) annexin a ; ) ifapsoriasin (intermediate filament-associated ca + regulatory protein); ) mgc (member of the er reticulon family). current analyses are underway to determine their functional roles in cftr trafficking and function. [ ] amaral ( billet, a. ; melin, p. ; norez, c. ; bilan, f. ; vandebrouck, c. ; mettey, y. ; becq, f. . physiologie, cnrs umr , poitiers, france; . gmas umr , poitiers, france; . faculté medecine et pharmacie, poitiers, france in order to gain a better insight into the structure-activity relationship (sar) of cftr protein, we have functionally characterized a cystic fibrosis mutation: the cftr-g d, identified in patients with oligospermia (vankeerberghen et al., ) . we examined cftr chloride channel activity by patch-clamp analysis, in whole cell configuration, using cos- cells transiently transfected with gfp-cftr-wt or with the mutant gfp-cftr-g d. cftr channels were activated by µm forskolin (fsk), and, after stable activation µm cftrinh- was added. as gfp-cftr-wt, g d chloride channels elicit a time and voltage independent current in presence of µm fsk. gfp-cftr-g d current density at + mv ( . ± . pa/pf) is . fold less than gfp-cftr-wt current density at + mv ( . ± . pa/pf). g d mediated currents are blocked by µm of the specific cftr-inhibitor, cftrinh- (ma et al., ) . as expected, gfp-cftr-wt channels are stimulated by µm of the potent activator -butyl- -hydroxy- -chlorobenzo[c]quinolizinium chloride (mpb- , derand et al., ) with a current density at + mv of . ± . pa/pf. interestingly, no activation of g d channels is recorded in presence of mpb- : difference between currents recorded in basal condition or in presence of mpb- is not significant. using iodide efflux experiments, we showed that cftr-g d mutant does not respond to several benzo[c]quinolizinium derivatives. however, the mutant channel can be activated by forskolin, ibmx and genistein. thus, the mechanisms of activation by xanthine and isoflavone are not affected by the mutation. these results show that: ( ) cftr-g d channels are functional: activation by camp pathway, inhibition by cftrinh- . ( ) camp chloride currents elicited by cftr-g d protein are weaker than cftr-wt. ( ) cftr-g d channels are refractory to benzo[c]quinolizinium activation. the replacement of the glycine by a negative charged amino acid in position affects cftr chloride channel activity and prevents activation by benzo [c] quinolizinium. this amino acid g , localized in the interface of nbd and r domain between two β sheets (callebaut et al., ) seems to have a crucial role in pharmacological activation of cftr by mpbs. further experiments will be performed to evaluate the role of the charge and of the nature of the amino acid at position in cftr protein. supported by vaincre la mucoviscidose and cnrs. cysteine string protein (csp) is a j-domain containing protein that regulates the extent of wild type cftr maturation. over-expression of csp blocks the formation of mature, glycosylated (band c) cftr and increases the level of immature (band b) cftr, whereas knockdown of csp elicits a marked increase in cftr maturation (zhang et al., j. biol. chem. : , ) . thus, csp appears to block the exit of cftr from the er. when the er exit of cftr is blocked by a different mechanism, i.e. the expression of mutant sar -gtp (sar h g interferes with the formation of copii vesicles), the steady-state level of immature cftr is two-fold greater than that resulting from csp over-expression. this finding suggests that csp, in addition to blocking er exit of cftr, may facilitate the degradation of the immature protein. in agreement with this concept, csp expression increased cftr ubiquitylation. a mutation within the conserved hpd motif of the j-domain (h q) disrupts the ability of csp to interact with and stimulate the atpase activity of hsp . csp h q does not block cftr maturation (above ref); in addition, the level of immature cftr was ~ % higher when h q csp was over-expressed than the level observed with mutant sar . this finding suggests that the pro-degradative effect of csp on immature cftr requires hsp binding/activation. chip (carboxy terminus of hsp -interacting protein) is an e ubiquitin protein ligase that can target wt and ∆f cftr for proteasome-mediated degradation (meacham et al., nature cell biol. : , ) . we sought to determine weather chip was involved in the csp-mediated degradation of cftr. indeed, co-immunoprecipitation (co-ip) experiments showed that chip associated with csp. also, csp h q, which has reduced interaction with hsp , showed a similar level of chip interaction by co-ip, suggesting that their association did not depend on hsp as a linker between the two proteins. a csp mutant that is truncated after the cysteine string domain, which is its site of membrane attachment, blocked cftr maturation as did wt csp; however, this mutant did not decrease cftr band b levels like wt csp did. in addition, the csp mutant missing its cterminus did not associate with chip. these findings further implicate chip in the csp-mediated degradation of immature cftr, and they suggest that the c-terminus of csp is a chip binding domain. when a dominant-negative mutant of chip, which lacks the u-box needed for chip-mediated ubiquitylation (chip∆ub), was co-expressed with cftr, csp was no longer able to facilitate the degradation of cftr in the er. these data show that it is possible to separate the effect of csp on cftr maturation from its ability to mediate the degradation of immature cftr. thus, csp blocks the exit of cftr from the er, and this requires a j-domain mediated activation of hsp but not the csp c-terminus. the action of csp on cftr degradation requires both a functional j-domain and the csp c-terminus, and this may require a trimeric complex involving csp, hsp and chip. [ the cystic fibrosis transmembrane conductance regulator (cftr) represents the main clchannel in the apical membrane of epithelial cells for camp-dependent clsecretion. mutations of this channel causes cystic fibrosis disease ; thus discovery of pharmacological activators of cftr is crucial to design future medicament for protein therapy. recently, we reported on the synthesis and screening of a small library of -phenylpyrrolo [ , b] pyrazines (named rp derivatives) evaluated as activators of wild-type cftr, g d-cftr and f del-cftr clchannels (noël et al, ) . this preliminary structure-activity relationship study identified -hydroxyphenyl and -n-butyl as determinants required for activation of cftr (rp- and rp- ). here we studied structure-function relationship of more than compounds prepared by chemical synthesis, and the subsequent activation of cftr channels. within the -phenylpyrrolo [ , -b] pyrazines family, we observed by iodide efflux technique that rp- bearing a hydroxyphenyl substituant is more potent (ec = nm) than rp- having -hydroxyphenyl substituant (ec = nm). by whole-cell patch clamp recording analysis, we confirmed that nanomolar concentrations of rp- activate linear chloride current in cho cells stably transfected with human wild-type cftr. this current was inhibited by µm of cftr inh - . we also found significant stimulation of short circuit current (i sc ) by rp- (ec = nm) on colon of cftr +/+ but not of cftr -/mice mounted in ussing chamber. stimulation of i sc by rp derivatives was inhibited by glibenclamide. the structural analogue , was less potent (ec = nm). as for rp- compound, we found that the -nbutyl chain is crucial for rp- and rp- activity, and that the -hydroxyphenyl compounds without -n-butyl chain are unactive on cftr. in this study, we showed that the presence of an hydroxyl group at position , or of the pyrrolopyrazine cycle determined the highest activity on cftr. the most potent compound is the -n-butyl- -( -hydroxyphenyl) hpyrrolo [ , b] pyrazine . the potency of these agents indicates that compounds in this class may be of therapeutic benefit in cftr-related diseases, including cystic fibrosis. the most common mutation causing cystic fibrosis (cf) is the deletion of f in the cftr gene, which results in inefficient trafficking of the cftr protein from the endoplasmic reticulum to the plasma membrane. the surface expression of the cftr is usually quantified biochemically with western blot or functionally with electrophysiological assays. however, these methods are labor intensive. we explore using fluorescence-based techniques for monitoring cftr surface expression. wild-type cftr was tagged at the amino terminus with green fluorescent polypeptides (gfp-cftr). the gfp-cftr was either transiently or stably expressed in chinese hamster ovary (cho) cells. the cells were then treated with a red fluorophore that specifically labels plasma membranes. the fluorescent images were acquired with an olympus laser scanning confocal microscope. two image channels were taken simultaneously. the green channel was excited with a nm laser, and signals within - nm were collected. the red channel was excited with a nm laser, and signals within - nm were collected. for a single focal plane, each image was composed of * pixels. threshold values were given to both green and red channels. pixels with an intensity value above the threshold were marked as green/red pixels. the green pixels in the first channel represent the signal of gfp-cftr, and the red pixels in the second channel represent the location of the plasma membrane. thus, pixels that are both green in the first channel and red in the second channel are the cftr surface expression, and denoted as yellow pixels. the percentage of successfully trafficked cftr is thus quantitatively estimated by the ratio of yellow to green pixels in the single plane. alternatively, a stack of images from the same cell at different depth was collected and analyzed. the total amount and surface portion of cftr expression are then determined by summing the correspondent pixels. the percentage of cftr surface expression was then calculated and will be verified both biochemically and functionally. the approach is modified to study deltaf cftr trafficking. we anticipate that the method can be used to screen cftr correctors from a small or intermediate sized chemical database. supported by cfft and nih. the most common mutation of the cystic fibrosis transmembrane conductance regulator (cftr) gene (deletion of phe- (∆f ) in the first nucleotide binding domain (nbd )) causes retention of the ∆f protein in the endoplasmic reticulum (er). ∆f mutation prevents conformational maturation of cftr protein without altering profoundly the local structure of nbd , but possibly by disrupting the interaction between nbd and nbd . however, the individual role of nbd and nbd in biogenesis, folding, maturation and membrane stability of a full length cftr is still under debate. using splicing by overlap extension method (soe by pcr), we generated six recombinant cftr proteins with inverted or suppressed nbds. the native boundary domains of nbd and nbd were respected for all mutants (riordan j.r. et al. ) and their c-terminal tails preserved. the constructs were transiently or stably expressed in cos- and bhk cells respectively. immmunodetection and immunolocalization assays confirmed that deletion of nbd domain (n -cftr) did not alter the trafficking or the plasma membrane expression of cftr. both processes were abolished in the presence of ∆f mutation. however, using whole cell patch-clamp configuration, we did not detect any camp-stimulated clcurrent. pulse-chase experiments established that the turnover of n -cftr is - fold faster (t / ~ h) than its wild type counterpart (t / ~ h). when we replaced nbd with nbd ( n -cftr), we could detect a faint plasma membrane expression associated with a weak cl-channel activation. more surprisingly, the t / of n -cftr coreglycosylated form was around h. when nbd was deleted (n -cftr) or substituted with nbd domain ( n -cftr), the expression and functional pattern were similar to cftr ∆f . furthermore, we showed that the n -cftr folding was not attenuated as demonstrated by protease susceptibility and sdsresistant thermoaggregation tendency, supporting the notion that n -cftr membrane stability requires nbd -nbd interaction. altogether, our results suggest that nbd domain is essential to form a foldable cftr that satisfies er quality control (erqc) but correct inter-domain assembly is mandatory for its stability at plasma membrane. the results are also in agreement with previous suggestion that ∆f mutation alters the interactions between nbds and transmembrane domains of cftr. supported . inserm u , inserm, paris, france; . inserm u , inserm, paris, france; . inserm u , inserm, paris, france; . inserm u , inserm, paris, france; . inserm u , inserm, paris, france; . inserm u , inserm, paris, france; . inserm , inserm, paris, france; . inserm u , inserm, paris, france the physiological role of cftr in renal epithelium is not known. in the proximal tubule, cftr co-localizes with the sodium-phosphate cotransporter npt a, a protein involved in phosphate (pi) reabsorption. the aim of our work is to determine if there is a functional interaction between cftr and npt a. to this end, the arnm coding for cftr and the arn coding for npt a (bearing a myc tag in c-ter) were injected in xenopus laevis oocytes. electrophysiological or biochemical experiments were performed days after arns injection. currents induced by mm pi (ipi) were measured in voltage-clamped (- mv) oocytes that expressed npt a alone, or in oocytes co-expressing cftr + npt a. for immunoprecipitation experiments, - cftrab and myc ab were used. results ipi was significantly reduced in oocytes expressing cftr + npt a compared to that measured in oocytes expressing npt a alone. using a two-bath electrodes configuration during voltage-clamping did not change this observation. this result suggests that when expressed in oocytes, cftr is in functional interaction with npt a. kinetic analysis (ipi as a function of pi concentration) of npt a showed a reduction in vmax but not in phosphate km. this suggests that npt a membrane expression and/or activity is altered when cftr is co-expressed. co-immunoprecipitation experiments performed on protein lysate derived from oocytes co-expressing cftr and npt a suggested an interaction between the transporters. using a pka activating cocktail as a pkc activator induced cftr-mediated currents in cftr+npt a expressing oocytes. in these oocytes, ipi is decreased by pkc activation (as expected from npt a regulation) but is increased shortly after exposure to the pka activating cocktail. the increase of ipi observed under this condition is at variance to that expected from classical npt a regulation. in oocytes expressing npt a alone, both pka activation and pkc activation reduced ipi. these observations suggest that in oocytes, cftr expression modifies npt a regulation. our study suggests that, after expression in xenopus laevis oocytes, cftr interacts functionally with npt a, and modifies its regulation. an interaction is also suggested by the co-immunoprecipitation of cftr and npt a. these results cannot discriminate between a direct or an indirect (via a third protein) interaction. to determine if an intracellular chloride concentration change may participate to the functional interaction, we are now measuring in cftr+npt a expressing oocytes intracellular chloride activity (using chloride-sensitive microelectrodes) during the use of the pka activating cocktail, and measuring ipi when pka is stimulated in the presence of a specific cftr inhibitor. cystic fibrosis (cf), the most commonly inherited lethal pulmonary disorder in caucasians, is caused by mutations in the cystic fibrosis transmembrane conductance regulator gene (cftr). to date, more than mutations were identified in cftr and were associated with clinical disease. a phenylalanine deletion at position accounts for % of cf genotypes in caucasian populations, and determines cftr misfolding and degradation by proteasome. consequently, limited cftr abundance leads to multiorgan disease, affecting the lung, pancreas, gut, liver, sweat glands and the reproductive organs. the past several years have witnessed an explosion of information regarding the identification and elucidation of molecules and pathways that are regulated by cftr or that regulate cftr activity. genomics and proteomics technologies now offer the opportunity to examine global alterations in the mrna and protein expression patterns of cf cells and tissues to elucidate the pathways linking defective cftr to clinical disease. here we describe systems biology methods that integrate heterogeneous datasets, including protein-protein interaction networks, gene expression and mass-spectrometry profiles, and mutation and genetic variation information, in order to identify the regulatory circuits and active subnetworks that are responsible for the progression and the severity of cf disease. the study will focus on correlations that define the key events in the cftr folding and trafficking pathways that lead to pathogenesis and dysfunctions, and could provide insights and targets for intervention and therapy. the number of cftr cl-channels in the plasma membrane, and thus the transepithelial cl-secretion is controlled, in part, by the endocytic trafficking of cftr. rab gtpases regulate the endocytic trafficking by acting as molecular switches that cycle between the gdp-bound (i.e. inactive) and the gtp-bound (i.e. active) state, associate with target membranes, and recruit downstream effectors. rab facilitates cftr endocytosis and rab a facilitates the recycling of internalized cftr to the plasma membrane. furthermore, rab and rab facilitate cftr trafficking to the lysosome. the mechanism of sorting internalized cftr for either recycling to the plasma membrane or degradation in the lysosome is not well understood. recent evidence demonstrates that protein sorting occurs in rab specific sorting endosomes. presence of cftr in rab compartment has been previously demonstrated in human airway epithelial cells by electron microscopy. yet, the role of rab in cftr trafficking has not been determined in these cells. rab did not control cftr trafficking in fibroblasts (bhk cells). however, it negatively regulated the plasma membrane expression of cftr in the colorectal cells . the goal of this study was to elucidate the role of rab in the endocytic trafficking of cftr in polarized human airway epithelial cells (calu- cells and cfbe o-cells stably expressing wt-cftr or deltaf -cftr). endogenous rab coimmunoprecipitated with cftr in calu- cell and cfbe o-cells. to determine if rab plays a role in cftr trafficking, cfbe o-cells were transfected with either the flag-tagged, dominant negative (dn) rab mutant deficient in gtp binding (gdp-locked; flag-rab -n i) or with a non-specific cdna control (gfp). if rab sorts internalized cftr to the recycling pathway, the dn rab should inhibit recycling, and, thus, should decrease the plasma membrane expression of cftr. if, on the other hand, rab sorts internalized cftr for degradation the dn rab should inhibit cftr degradation, increase cftr recycling and thus, should increase the expression of cftr in the plasma membrane. the dn rab increased cftr expression in the plasma membrane as determined by cell surface biotinylation. these data are consistent with the role of rab in sorting internalized cftr for degradation. similar to overexpression of the dn rab , silencing endogenous rab with double stranded small interfering rna specific for the human rab sequence increased the plasma membrane expression of cftr and increased the cftr mediated cl-secretion across polarized cfbe o-cells in ussing chamber experiments. the plasma membrane half-life of deltaf -cftr is decreased compared to wt-cftr. however, after silencing rab , the plasma membrane half-life of deltaf -cftr was similar to that of wt-cftr, as determined by cftr disappearance from the plasma membrane following incubation with cycloheximide. our data are consistent with the role of rab in sorting the internalized cftr for degradation and are consistent with the changing paradigm for the role of rab in protein trafficking (supported by the nih grant p rr and the cff swiate qo). the conformational changes underlying activation of phosphorylated cftr by atp remain unclear. in the present study we assessed the utility of labeling endogenous cysteine(s) in cftr using an environmentally-sensitive fluorescent probe alexa- in monitoring such changes in structure. these studies were performed using purified and functionally reconstituted wild-type cftr. we labeled pka-phosphorylated cftr with µm alexa- maleimide prior to reconstitution in phospholipids liposomes. changes in fluorescence intensity were monitored in a suspension of proteoliposomes following addition of and mm mg-atp or mm mg-amp-pnp in order to evaluate nucleotide dependent changes in conformation. in order to identify the labeled cysteines, the protein was subjected trypsin-mediated proteolysis and analysis by mass spectrometry. we have shown that cftr is labeled using alexa- maleimide. a significant increase in fluorescence emission occurred in alexa- labeled cftr of ± (au) relative to empty liposomes one minute after the addition of activating nucleotide, mm mg-atp (n = ). the non-hydrolyzable analogue, mm mg-amp-pnp, failed to cause an increase in fluorescence of alexa- -labeled cftr. however, the higher concentration of mm mg-amp-pnp evoked an increase in fluorescence similar in magnitude to that of mm mg-atp suggesting that the fluorescence response reflects structural changes relating to atp binding to cftr. analysis by mass spectrometry identified the labeled residue as c . this cysteine resides at the junction between nbd and the "r" domain in a region which has been suggested to be highly dynamic on the basis of multiple crystal structures. our studies suggest that this flexible region around c of cftr undergoes conformational change upon mg-atp binding such that it moves the alexa fluorophore into a relatively more polar environment. this finding presents a first case where conformational changes in the cftr nbds induced by atp binding could lead to changes in the conformation of the r domain. further, these studies suggest that fluorescence methods can be used to probe dynamic conformational changes in purified reconstituted cftr. acknowledgements cystic fibrosis is caused by mutations in the apical chloride channel cftr with % of patients carrying at least one allele of the ∆f mutation. this mutant form of cftr is characterized by a trafficking defect in which it fails to exit the endoplasmic reticulum (er). we have previously reported that ∆f cftr is found in complex with hsp and its co-chaperones in cell extracts suggesting that either this mutant form of the protein accumulates in on-pathway folding intermediates which result in its accumulation in the er or that these intermediates include inhibitory factors leading to retention of ∆f cftr in this compartment. we have examined the role of one of these hsp co-chaperones, fk binding protein (fkbp ), in the life cycle of cftr. fkbp is a unique member of the immunophilin family of peptidyl-prolyl isomerases (ppiases) which mediate the cis/trans interconversion of peptidyl-prolyl bonds, which is thought to represent a rate limiting step in protein folding. in order to establish a functional role for fkbp in cftr stability and trafficking, we modulated the expression level of this protein in human bronchial epithelial cells endogenously expressing either wild type or ∆f cftr. a knockdown of fkbp by sirna resulted in a destabilization of both wild type and ∆f cftr as well as a concomitant loss in channel activity of wild type and temperature corrected ∆f cftr. conversely, over expression of fkbp resulted in a stabilization of the er glycoform of ∆f cftr in both mammalian and yeast systems. these data suggest that fkbp is an essential component of the hsp -mediated folding machinery for both wild type and ∆f cftr, which supports the hypothesis that ∆f cftr accumulates in the er in an on-pathway folding intermediate. dmh cftr folding involves a series of sequential, although potentially overlapping steps that involve i) formation, orientation and integration of (tms), ii) helical packing, iii) folding of cytosolic and extracytosolic domains, and iv) establishing proper domain-domain contacts. this process begins cotranslationally and is facilitated by the sec er translocation machinery and a diverse group of lumenal and cytosolic chaperones. the most common inherited cftr mutation, deltaf , disrupts one or more early steps along this folding pathway. a major obstacle in understanding how deltaf causes cf is that the native folding environment, comprised of lipids, cytosolic and er proteins, is not amenable to traditional biochemical and biophysical approaches. to overcome this problem we are developing a flu-orescence based analytical approach that enables one to directly access nascent ribosome-attached folding intermediates at virtually any stage of synthesis. the strategy requires incorporation of fluorescent probes into the substrate protein, which provide a highly selective means to monitor structural features at sub-nanomolar concentrations in highly complex biological mixtures. polypeptides are synthesized in vitro from truncated mrna templates to generate uniform cohorts of ribosome-bound nascent chains. progressive stages of folding can then be evaluated using mrna templates of different length. as proof-of-principle we have shown that fully synthesized gfp variants can be readily trapped in an unfolded state and complete their folding only after the entire nascent peptide has exited the large ribosomal subunit. this approach enabled us to measure real-time folding kinetics of extended peptide domains following synchronous ribosome release and compare fluorophore maturation of four fluorescent protein variants with different spectral properties cfp, gfp, venus and mcherry. to extend this approach to cftr and other general protein substrates, we are employing fluorescence resonance energy transfer (fret) using "donor" and "acceptor" probes incorporated simultaneously into the substrate protein. an in frame n-terminal fusion to cfp provides the "donor" fluorophore, while the "acceptor" fluorophore is incorporated at an engineered stop codon using a synthetic modified aminoacyl-suppressor trna. we are currently developing a 'molecular ruler' to correlate the efficiency of energy transfer with changes in the relative distance between probes in ribosome-bound and ribosome-released cftr folding intermediates. fret-based experiments are underway to evaluate folding of both n-terminal ( - aa) and nbd ( - aa) domains. these studies will provide new insight into the mechanism of cotranslational cftr domain folding and provide a potential means to identify agents that correct the deltaf folding defect. relationships between hypoxia, ado release, and prostenoid production in ariway cells are not defined. in the present studies, we examined mechanisms governing hypoxia-induced production of prostenoids in cfbe o-and calu- monolayers. using elisa-based detection of prostenoid and leukotriene production, both calu- and cfbe omonolayers treated with ado ( µm) or arachidonic acid (aa, µm, the parent molecule of prostenoids and leukotrienes) for hrs led to increases in pge levels ( - ± - pg/mg of total proteins vs controls ± pg/mg in calu- cells, - ± - pg/mg vs controls ± pg/mg in cfbe o-cells, p< . in both airway cell types compared with control). in contrast, ltb and ltc release were not stimulated by both maneuvers. we next used sirna techniques to knockdown a b adenosine receptor expression, and demonstrated durable knockdown of a b ar expression to~ % of scrambled sirna-treated controls following lipid-based transfection with sirna directed against the a b ar in cfbe o-cells. following sirna knockdown of a b ar expression, cells were exposed to hypoxic conditions (mucosal volume = ml in -well plate), normoxic conditions (mucosal volume = . ml, fio = . ), and ado ( µm). hypoxic stress led to high levels of mucosal pge production ( ± . pg/mg vs controls ± . pg/mg, p< . ) that was sensitive to a b ar knockdown ( ± . pg/mg, p< . ). exogenous ado also stimulated pge production, but this effect was small relative to hypoxia. we next examined basolateral effects of ado and aa on transmucosal clsecretion in cfbe o-and calu- cells grown as monolayers on permeable supports and conducted ussing chamber analysis under voltage clamp conditions. addition of ado and aa to the basolateral membrane ( µm) activated transmucosal clsecretion [ . ± . µa/cm (ado) and . ± . µa/cm (aa) for calu- cells; and . ± . µa/cm (ado) and . ± . µa/cm (aa) for cfbe o-cells expressing wtcftr] that was sensitive to basolateral blockade with barium cl -( mm). isc by either agonist was stimulat-ed in the presence and absence of apical glybenclamide ( µm), adenosine deaminase (ada - u/ml) and hexokinase (hexo - u/ml), confirming that the effects were specific for the basolateral membrane and could be accomplished with or without cftr activity. these results demonstrate that hypoxia is sufficient to stimulate pge production through a b ars, and that both ado and aa activate basolateral k + channels to promote transepithelial clsecretion. the findings further support a model in which ado (and prostenoids) regulate cltransport through effects on both the apical and the basolateral membrane, and elucidate molecules that couple the two membranes as part of the normal clsecretory response. hypoxia would be predicted to increase local prostenoid production through ado release and stimulation of a b ars, and further highlight a unifying model by which local hypoxia promotes inflammation in airway epithelia. supported by the nih and cff. low levels of tissue oxygen -observed in lung diseases such as cystic fibrosis -initiate a signaling cascade resulting in altered transcription of genes possessing a hypoxia response element (hre). we recently used gene chip mrna array, quantitative rt-pcr, protein analysis, and functional (short circuit current) assays to show that cftr expression is strongly repressed by hypoxia in vitro and in vivo. among several thousand human mrnas suppressed by low ambient oxygen, cftr was among the most strongly inhibited (by - fold) in a cell model system. however, cftr and the vast majority of other repressed genes lack a traditional hre. because hypoxia inducible factor (hif) acts primarily as a transcriptional activator, the mechanisms underlying hypoxia mediated suppression of mammalian genes are not well understood. we therefore tested the hypothesis that micrornas play a central role during transcriptional regulation of genes such as cftr. micrornas are evolutionarily conserved, short noncoding rna sequences believed important for repression of gene expression. some reports have estimated that at least % of protein-coding genes are regulated by micrornas. thousands of micrornas have been predicted in the human genome by available algorithms (e.g. palgrade, mirscan, and promir) and several hundred experimentally validated. the cftr gene contains predicted target sites for micrornas in the 'utr, including hsa-mir- (nucleotides - of the cftr 'utr), hsa-mir- (nt - ) and hsa-mir- (nt - ). however, no study to date has examined the effect of micrornas on cftr message levels, or the influence of micrornas during the cftr response to environmental perturbations such as hypoxia. we therefore performed a global, genome-wide analyses of both mrnas and micrornas expressed during hypoxia (using air/liquid or liquid/liquid interface culture systems) in ht (colonic epithelial) cells that robustly express cftr. we found that approximately % of micrornas were significantly altered by hypoxia, as judged by mirna profiling (ambion mirvana™ bioarray v , asuragen microrna expression profiling service). comparison of these hypoxia-related micrornas with expression profiles of their predicted targets indicated a much lower level of correlation than has been previously hypothesized by others. we show that none of the micrornas predicted to regulate cftr are altered in ht (in response to hypoxia). these findings are therefore consistent with the notion that highly expressed genes in a particular tissue type are not co-expressed with their predicted regulatory micrornas. our data also indicate that micrornas do not mediate the hypoxic repression of cftr via the ' utr. supported by nih and cff. . physiology, mcgill university, montreal, qc, canada; . biochemistry, mcgill university, montreal, qc, canada the ∆f mutation impairs cftr maturation and trafficking to the plasma membrane and results in a partially functional chloride channel that is retained in the endoplasmic reticulum and degraded. using our highthroughput trafficking assay, we previously showed that the quinoline km , a structural analogue of sildenafil, corrects the ∆f -cftr processing defect and leads to a significant increase in cftr surface expression after h treatment with µm and after h treatment with nm according to detection of mature cftr in western-blots. additional studies have now been carried out with other preparations to assess the functionality of ∆f -cftr following rescue by km treatment. different time and concentration exposures were tested on the cftr function using iodide efflux assays with both bhk and human bronchial epithelial cells over-expressing ∆f -cftr. exposure to µm km for h partially restored iodide efflux responses to µm forskolin + µm genistein in both cell line. after h incubation, rescue of the mutant protein in bhk cells still required µm, whereas nm was sufficient in the human cell line cfbe. iodide efflux assays were performed at different times following km wash out to functionally assess the stability of the rescued mutant protein. camp-stimulated iodide efflux was still detectable h after removing km , but responsiveness was lost after h in both cell types. electrophysiological studies were performed to examine the channel activity of ∆f -cftr rescued by km treatment. incubation with µm km for h increased camp-responsive ∆f -cftr current density in hek whole-cell patches ~ -fold. the conductance was time-and voltage-independent, anion selective, and strongly inhibited by glibenclamide. incubating polarized cfbe monolayers with µm km increased the forskolin + genistein-stimulated short-circuit current after h, and this response was inhibited by cftrinh ( µm). permeabilization of the basolateral membrane with nystatin confirmed the apical location of the forskolin + genistein-stimulation. ussing chamber experiments also revealed trafficking correction in ileum that had been excised from cftrtm eu mice homozygous for ∆f . when the ileum was pre-incubated with µm km for - h, the forskolin + genistein-stimulation of short-circuit current was significantly increased when compared to untreated intestine. these results confirm partial correction of ∆f -cftr by km in unpolarized cells and in human polarized epithelial cell monolayers and ex-vivo intestine isolated from ∆f -cftr mice. this work was supported by the breathe program funded by the ccff and cihr, cihr, cfft, and génome québec. primary sequence and overall structure of human cftr overlaps significantly with murine, rabbit and other homologues, a feature that has limited generation of conformation specific reagents to address cftr folding. because regions of ∆f cftr exposed extracellularly may exhibit aberrant topology (jbc : - ), probes that identify cftr from the extracellular surface could be useful to ) verify plasma membrane localization of ∆f cftr, ) discriminate wild-type from mutant protein, and ) provide a means of determining whether small molecule "correctors" of the ∆f processing lead to a native (wildtype) cftr configuration. our laboratories are investigating phage-display techniques suitable for detecting properly folded extracellular domains of cftr. two large phage libraries encoding or amino acid sequences (approximately phage per library) were panned against extracellular regions of cftr in hela cells. following incubation in blocking solution containing pbs and % bsa at °c, unbound fraction was incubated with recombinant helas expressing wild-type or temperature corrected ∆f cftr (protein expression verified biochemically and functionally). bound bacteriophage was dislodged after multiple washings by exposure to an acidic elution buffer and amplified to increase copy number (five rounds of antigen selection for each library, eur j biochem : - ). supernatants from microtiter wells expressing phage were analyzed for binding to parental (no cftr), wt or ∆f cftr expressing hela cells. using this method we obtained enrichment of phage at the surface of cells expressing wt or ∆f cftr. an example using a -amino acid sequence ( phage) with specificity for ∆f cftr (representative of four repeat experiments) is shown in a binding assay with hela cells/condition. reagents such as these can be further optimized by constructing second generation libraries using core recognition sequences (derived from the initial screen) and surrounding the core epitopes with random amino acid diversity. these experiments are intended to identify peptides with high binding affinity (nm binding constants) that recognize native cftr epitopes exposed extracellularly. because there is evidence that low temperature corrected ∆f cftr in the plasma membrane is misfolded, these probes may ultimately distinguish wild-type cftr from the surface targeted ∆f mutant and be useful as drug discovery reagents. supported by cff and nih. bridges, r.; nagubadi, s.; thakerar, a.; jia, y.; bradbury, n.a. physiology and biophysics, rosalind franklin university of medicine and science, north chicago, il, usa the goal of this project was to compare several reported correctors of ∆f -cftr biosynthesis for their efficacy on chloride channel activity under a standard set of experimental conditions. fisher rat thyroid (frt) cells were transfected with ∆f -cftr and a stable cell line selected with g . cells were grown on transwell filters and studied under short circuit current (i sc ) conditions in ussing chambers. i sc measurements were performed at °c. the basolateral membrane was permeabilized with α toxin and chloride currents were measured with a serosal to mucosal chloride gradient. atp ( mm) and gtp ( µm) were added to the serosal bath. cftr channel activity was stimulated with camp ( µm), ibmx ( µm) and genistein ( µm). cells were treated with correctors or vehicle (dmso) at and hours before the i sc measurements. a subgroup of cells were temperature corrected at °c for hours for comparison. because only modest currents were observed even in the temperature corrected cells ( - µa/cm ) cells were treated for hours with mm sodium butyrate and nm dexamethasone to enhance the observed currents. under these conditions temperature corrected cells displayed stimulated chloride currents of ~ µa/cm that were - -fold greater than cells maintained at °c. correctors c (n- ' ]bithiazolyl- '-yl]-benzamide) and c ( -( h-benzomidazol- -ylsulfanylmethyl)- -( -methoxy- -methyl-quinazolin- -ylamino)pyrimidin- -ol) caused a modest rescue of ∆f -cftr chloride currents compared to cells maintained at °c (c , . -fold; c , . -fold) but far below the effect of temperature correction. rescue by c was concentration dependent with a significant observable effect at nm and a maximum effect at µm. rescue by c was observed at only µm, lower concentrations had no effect and higher concentrations caused an inhibition of the stimulated chloride currents. compounds c -piperazin- -yl]-ethyl}- -piperidin- -yl-quinazoline) ( to µm), c ( -cyclohexyloxy- -{ - [ -( - methoxy-benzensulfonyl)-piperazin- yl]-ethyl}-quinazoline) ( to µm) and phenylbutyrate ( mm) did not significantly increase the stimulated chloride currents. all four compounds c -c caused significant decreases in the transepithelial resistances at the higher concentrations ( - µm) suggesting some degree of cytotoxicity. our results indicate only c and c demonstrate efficacy in frt cells and that these effects are modest compared to temperature correction. supported by the cystic fibrosis foundation. cftr contains two membrane-spanning domains (msd), two nucleotide-binding domains (nbd), and a regulatory domain that require proper assembly for chloride channel activity. the most prevalent disease causing mutation, cftr∆f , arises from deletion of phenylalanine in the nbd domain. the cftr∆f mutant is translated and inserted into the endoplasmic reticulum (er) membrane, but is unable to attain its native state and accumulates in a kinetically trapped conformation that is degraded by the ubiquitin proteasome system ( ) . the nature of the misfolded cftr∆f intermediate that is selected for premature degradation is not clear and is a topic of great interest ( ) . recent work in the cyr lab indicate that defects in cftr and cftr∆f folding are sensed by two different e ubiquitin ligase complexes that are located in the er membrane and cytosol ( ) . the membrane-associated derlin- /rma e complex appears to recognize early folding defects of cftr that may involve assembly of msd into a complex with the amino-terminal regions of cftr. in contrast, the cytosolic hsc /chip e complex appears to sense folding defects that occur after synthesis of the nbd domain. misfolded cftrs recognized at either checkpoint are retained and degraded via the proteasomal pathway. the presence of dual protein quality control (qc) checkpoints suggests a mechanism by which the folding status of cftrs membrane and cytosolic domains are sequentially monitored prior to its escape from the er. currently little is known about how these erqc complexes sense misfolded substrates. small-molecule chemical correctors have recently been identified which rescue the folding defect of cftr∆f in model cell culture systems. in the presence of these chemical correctors a subset of cftr∆f is able to localize to the cell surface and retain channel function. however, how the chemical correctors rescue cftr∆f folding is not clear. we have examined the extent to which the molecules correct folding defects that are recognized by the derlin- /rma or hsc /chip qc checkpoints. in addition, because it is unknown at what point of cftr biogenesis that the chemical correctors act to facilitate folding, we have determined how the chemical correctors affect the folding of different biogenic intermediates. our results indicate that the correctors act in a post-translational manner to influence assembly of cftr sub-domains. interactions with members of the qc pathway have also been used to monitor the folding and assembly process of cftr in the presence of chemical correctors. ultimately the results from these studies will enhance our knowledge of how chemical correctors permit passage of the cftr mutants past different erqc checkpoints. supported by -cystic fibrosis foundation combination therapy has proven successful in treating a wide variety of human diseases, including cancer, infectious disease, and diabetes. historically, combination treatments have been discovered through trial and error using drugs with proven disease modifying effects. we have developed a combination high-throughput screening (chts™) technology to systematically and efficiently find synergistic combinations that target multiple pathways underlying disease biology, and that may be developed into new therapeutics. we are applying chts technology to discover and develop combination therapeutics for the treatment of cystic fibrosis. we have optimized two high throughput screening assays for identifying correctors and potentiators of the cftr (cystic fibrosis transmembrane protein regulator) ∆f mutation. one assay uses the flipr membrane potential dye (fmp) and the other uses genetically modified yellow fluorescent protein yfp h q/i l to measure changes in halide flux through ∆f cftr. both assays were optimized and validated on the flipr tetra using the panel of cf correctors, potentiators and inhibitors provided by the cf foundation. using our automated chts, we systematically evaluate pairwise combinations of a library of ~ , approved drugs and other bioactive molecules to identify novel disease-relevant biological interactions. candidate single agents and combinations are tested in secondary assays and prioritized for testing in animal efficacy models. combination therapies can act on multiple pathways in a coordinated way. chts may prove to be a useful tool for identifying combination therapeutic candidates with novel multi-target mechanisms and a way to enhance co-therapy regimens for the treatment of cystic fibrosis. supported the highly variable clinical phenotypes of cf airway disease suggest that a number of genetic factors, other than cftr, play a role in its pathophysiology. some of these modifier genes are expected to play a role in the endoplasmic reticulum quality control (erqc), since the major defect caused by f del is misfolding, retention and degradation of the mutant protein by this cellular surveillance system. the nematode caenorhabditis elegans is an excellent multicellular genetic model, which has been successfully used in studies of human diseases. its ~ , -genes genome has been fully sequenced, it has short life-span ( - weeks) and life cycle (~ . days) and it is easily cultured and amenable for gene disruption, both by knockout or rnai. our goal is to generate a c. elegans model for the cftr folding defect, so as to take advantage of this model for the identification of genes involved in cftr folding and/or degradation. to this end, and because no cftr orthologue has been described in c. elegans, we constructed two previously described human p-gp-/cftr chimeras (p-gp/wt-cftr and p-gp/f del-cftr) [ , ] to be used as an in vivo folding substrate in this organism. the two chimeric cdnas and intact human p-gp cdna were cloned into the c. elegans ubiquitous expression vector ps and injected into mutant nematode strains for multidrug resistance genes [ ] . the effect on the nematodes phenotype was evaluated by an assay of heavy metal sensitivity ( . mm arsenite), as described [ ] . our quantitative results show that the p-gp/wt-cftr chimera increases the resistance to arsenite when injected into the pgp- /pgp- c. elegans double mutant, whereas p-gp/f del-cftr causes no effect. these preliminary results indicate it is possible to generate two distinct nematode phenotypes caused by each of the transgenic chimeras (p-gp/wt-cftr and pgp/f del-cftr). they also suggest that the same folding defect impairing f del-cftr function in cf may be responsible for the loss of heavy metal resistance function by the p-gp/f del-cftr chimera. these chimeras are currently under test in pgp- /pgp- double and in pgp- /pgp- /mrp- triple c. elegans mutants. analysis of these strains by rt-pcr showed that the mrnas from the two p-gp/cftr chimeras have low expression levels. this led us to produce more robust constructs, including: ) to test chimera expression under the c. elegans endogenous pgp- or intestinal-specific (potent) promoters; and ) to develop p-gp chimeras with a full cftr-nbd . these c. elegans models will be used in genome-wide rnai screens to identify genes involved in the erqc of the p-gp/cftr chimeras. work channel gating of cftr is regulated by atp binding and hydrolysis at the nbds and by pka phosphorylation at multiple sites, primarily within the intrinsically disordered regulatory (r) region. phosphorylation at multiple sites is required for full activation of channel function, but no one specific phosphorylation site is required. the phospho-regulation of r region interactions with nbd likely contributes to the regulation of cftr channel function by modulating r region interactions with nbd at the nbd /nbd dimerization interface, consistent with nbd crystal structures that include the regulatory extension (re) comprising the first residues of the r region ( ). this regulation likely occurs via a dynamic complex where multiple segments of nonphosphorylated r region with αhelical propensity transiently engage nbd and are released. pka phosphorylation disrupts r region α-helical propensity and decreases binding of each interacting segment ( ) . regulation of the ∆f cftr by pka is altered, with the rate of channel activation by pka -fold slower than for wild-type ( ). we hypothesize that the dynamic interactions between the r region and nbd are affected by the ∆f mutation. to characterize the differences in r region binding between wild-type and ∆f nbd at residue-level resolution, we use nuclear magnetic resonance (nmr) techniques. experiments are performed using either r region or nbd samples labeled with nmr-active nuclei and monitoring their structural changes upon the addition of unlabeled binding partner, allowing us to confirm r region binding to nbd at the nbd /nbd dimerization interface and to identify other potential interaction surfaces on both the r region and nbd . together, these experiments will allow us to characterize the dynamic associations between the r region and nbd in order to better understand the molecular basis for the pathogenesis associated with ∆f cftr. funded by the canadian institutes for health research, the canadian cystic fibrosis foundation, and the us cystic fibrosis foundation . lewis, h.a., et al, embo j. , - ( ) . . baker, j.m.r., hudson, r.p., kanelis, v., choy, w-y, thibodeau, p.h., thomas, p.j., and forman-kay, j.d. submitted. the ∆f -cftr mutation, the most common gene mutation in cystic fibrosis (cf), results in diminished plasma membrane expression of cftr, leading to loss of functional cftr and altered mucociliary clearance. this impairment promotes chronic infection of cf patients by the opportunistic pathogen, pseudomonas aeruginosa. we previously reported that a secreted protein from p. aeruginosa (cftr inhibitory factor (cif)) reduces the wt-cftr and ∆f -cftr-mediated chloride secretion and the plasma membrane expression of cftr by decreasing endocytic recycling of cftr. the aim of the current study was to investigate the mechanism by which cif is secreted by p. aeruginosa and delivered to human airway epithelial cells (cfbe o-). in this study, we show that cif is packaged in outer membrane vesicles (omv) for secretion from p. aeruginosa. interestingly, cif secretion via omv was increased when the bacteria were exposed to airway epithelial cells. changes in cif protein level or bacterial growth did not account for the increase in cif secretion. purification and application of p. aeruginosa omv to airway epithelial cells caused a decrease in plasma membrane expression of cftr. the decreased plasma membrane cftr expression was followed by increased ubiquitination and lysosomal degradation of cftr. cif delivery to the airway epithelial cells via omv showed a more robust decrease in plasma membrane cftr expression, in comparison with cif delivery as purified protein. to investigate the mechanisms whereby cif enters epithelial cells, optiprep gradient fractionation experiments were conducted in polarized airway epithelial cells. in airway epithelial cells treated with p. aeruginosa omv, cif was associated with airway cell lipid rafts. pharmacological inhibition of lipid raft formation with filipin iii blocked the decrease in cftr plasma membrane expression upon treatment with omv. these studies demonstrate that cif is released by p. aeruginosa via omv and enters the airway epithelial cells through lipid rafts. upon entry into the epithelial cell, cif increases the ubiquitination and degradation of cftr and redirects cftr trafficking from the recycling pathway to the lysosomal-degradative pathway. these data suggest that chronic infection of p. aeruginosa in the cf lung may reduce the efficacy of therapeutics developed to increase plasma membrane expression of the mutant ∆f -cftr (supported by the nih ro hl - and t -dk - ). . physiology, dartmouth medical school, hanover, nh, usa; . microbiology and immunology, dartmouth medical school, hanover, nh, usa we have identified and cloned a secreted protein from pseudomonas aeruginosa (p. aeruginosa pa and clinical isolates), designated cftr inhibitory factor (cif). cif reduces the apical membrane expression of cftr and inhibits the cftr-mediated chloride ion secretion by human airway epithelial cells expressing wt-cftr and df -cftr. cif does not have general effects on protein trafficking, as the localization and expression of gp , na + -k + -atpase, and the transferrin receptor were not affected. cftr is a member of the atp-binding cassette (abc) transporter superfamily. abc proteins are atp-dependent transporters involved in exporting a wide variety of cytotoxic agents across the plasma membrane. p-glycoprotein (pgp; abcb , mdr gene product), also an abc transporter, is one of the major drug-efflux pumps expressed in normal tissues, as well as in many human cancers. over-expression of pgp results in reduced intracellular drug concentration and reduced cytotoxicity, conferring multi-drug resistance (mdr) to cancer cells. the aim of the current study was to examine whether cif also affects pgp expression in the plasma membrane, which could be exploited as a potential therapeutic strategy for restoring the sensitivity to pgp-transported drugs in cancer chemotherapy. cif significantly reduced the apical expression of pgp in mdck cells stably transfected with gfp-tagged pgp (mdck-gfp-mdr cells) and in caco- and calu- cells, which express endogenous pgp in the apical plasma membrane. the drug sensitivity of mdck-gfp-mdr cells to doxorubicin, a pgp substrate, was evaluated in the absence and presence of cif by measuring the ec . cif reduced the cytotoxicity of doxorubicin by -fold. neither cif nor vehicle alone had a cytotoxic effect. the drug sensitivity of the parental cell line, mdck-c , that expresses -fold less pgp than the transfected mdck cells, to doxorubicin was also increased by -fold. by contrast, cif had no effect on the ec values of cisplatin (a substrate of mrp ) and etoposide (a substrate of mrp ), suggesting that the alteration of the sensitivity to doxorubicin was due to decreased apical expression of pgp, but not other abc transporters. these results suggest that although cif may be an obstacle to therapeutic attempts to restore the apical expression of cftr in the cf lung, it could be useful for the development of a novel class of inhibitors of pgp aimed at increasing the sensitivity of tumors to chemotherapeutic drugs (supported by the nih ( ro hl )). hamai, h. ; keyserman, f. ; worgall, t.s. , . pathology, columbia university, new york, ny, usa; . pediatrics, columbia university, new york, ny, usa cystic fibrosis (cf) is characterized by an inflammatory state and susceptibility to chronic lung infections. a common clinical finding is dyslipidemia characterized by altered plasma free fatty acid patterns, low plasma hdl levels and increased phospholipase a (pla ) activity. it is not clear how cftr mutations relate to lipid abnormalities. it was shown that defective cftr is associated with decreased uptake of sphingolipids (sl). sl homeostasis is tightly regulated and metabolites are relevant to lipid metabolism and cf. sl synthesis (sls) correlates with activity of srebp, a key transcription factor of lipid metabolism; ceramide- -phosphate, a sl metabolite, is a regulator of pla that is highly activated in cf. we investigated the hypothesis that sls is increased in cf. experiments were carried out in airway epithelial cell lines that express defective cftr (c / ib ), no cftr ( hbe sense / antisense) and overexpress cftr (a cells infected with adcftr or adcontrol). sls was assessed using radioactive tracers h-serine (de-novo sls) and h-sphinganine (recycling pathways). ceramide and sphingomyelin mass were determined enzymatically. neutral and alkaline sphingomyelinase activity was assessed using h-sphingomyelin as substrate. srebp mediated gene transcription was assessed using sre-promoter assays. cholesterol synthesis was evaluated by incorporation of h-acetic and h-mevalonic acid. cholesterol mass was determined by gas-chromatography. abca- expression was determined by western blot analysis. pla activity was measured using fluorescent phospholipid substrates. sls was post-transcriptionally increased in cells expressing defective or no cftr through the de-novo pathway ( % ± % for ib ; %± % for hbe-antisense; p< . ) and the recycling pathways ( % ± % or ib ; % ± % for hbe-antisense; p< . ). ceramide mass was increased by % (± %) in hbe antisense, % ± % in ib cells. sphingomyelin mass was increased -fold in ib , up to -fold in hbe antisense cells. neutral and alkaline sphingomyelinase activity was increased up to -fold in both cell lines. sre-mediated gene expression was increased up to -fold in ib and by % in hbe-antisense cells. overexpression of cftr in a decreased sls and srebp activity up to %. free cholesterol synthesis was increased by % in ib and by % in hbe antisense. expression of the cholesterol efflux receptor abca- was decreased in ib and hbe antisense compared to controls. sl mass, sre-mediated gene transcription and pla activity were decreased following incubation with inhibitors of sls in ib and hbe antisense cells. conclusion: defective cftr or lack of cftr expression correlates with ) increased sls synthesis and sl mass; ) increased sremediated gene transcription and free cholesterol synthesis; ) decreased expression of the abca- cholesterol efflux receptor. inhibition of sls decreases sre-mediated gene transcription and pla activity. dysfunctional sls is a newly recognized pathway associated with defective cftr and a possible therapeutic target in cf. the ability to make accurate, reproducible measures of mucociliary and cough clearance (mcc/cc) in cf patients is critical to assessment of new therapies designed to improve mcc/cc function, and thus decrease pulmonary infections and decline in lung function. for example, using mcc/cc methods developed in our laboratory, we showed that -week treatment with aerosolized hypertonic ( %) saline (hs) led to a sustained increase in mcc and improved lung function in cf patients (donaldson et al, n eng j med ; : ) . the mcc/cc technique involves patient inhalation of radiolabeled particles followed by gamma camera scanning to determine the rate of particle movement from the lungs. while a few cf centers have shown the capability to measure mcc/cc, the techniques across these centers are not standardized, making comparison of results difficult. it is vital to develop standard, simplified techniques for these measures to make larger cf patient populations available for such studies. to standardize a radiolabeled particle inhalation technique that can be easily used by other cf centers, we have compared three protocols in healthy and cf subjects. protocol # was identical to that used in recent studies, and incorporates a devilbiss jet nebulizer to generate µm mmad (gsd = . ), aqueous droplets containing suspended tc m-sulfur colloid particles. tidal volume and inhaled/exhaled flow rates were guided by a volume signal displayed on an oscilloscope. protocol # was further standardized and simplified to allow use at other centers. this protocol utilized the same nebulizer, but triggered by a commercial dosimeter (spira electro , finland) during inhalation as the subject breathed in time to a metronome ( breaths/min) at flow rate of . l/sec. subjects controlled inspiratory flow rate by feedback from a digital flow readout on the dosimeter. repeat measurements of mcc/cc were made in healthy subjects and mild cf patients to compare mcc/cc variables following radioaerosol inhalation using protocols # and # . there were no differences in particle deposition (i.e. central to peripheral ratio, or "c/p"), or clearance of particles through minutes and hours in either subject group. these data suggest that the new methodology (protocol # ) will be useful and easily employed by other cf centers to test effectiveness of new therapies for cf. the third protocol (# ) was then tested in five of the healthy subjects. this protocol used a nebulizer that generated very large droplets ( . um mmad, gsd = . ) and subjects inhaled at very slow flow rates (~ ml/sec). it was designed to provide greater bronchial airway deposition and thus an "improved signal" for mcc/cc evaluation. indeed, this methodology produced a larger average c/p and significantly greater particle clearance from the lung compared to the other standardized methodology (protocol # ) (c/p = . vs. . ; min clearance = % vs. %; hr clearance = % vs. %, respectively). interestingly, the greater fraction of clearance between min and hr may also reflect heightened ability to assess clearance from smaller airways, which could be particularly important in cf. protocol # will be tested further in cf patients. supported by cf foundation. previous clinical trials in cystic fibrosis (cf) indicate that anti-inflammatory therapy probably will not result in improvement in lung function, but will slow the rate of decline. this imposes constraints on study design for new anti-inflammatory agents, requiring that they use many patients over long periods. it is highly desirable to design a strategy for evaluation of antiinflammatory agents that will allow for the selection of only the most promising agents for phase iii trials. sputum induction (si) samples lower respiratory tract secretions and permits measurement of inflammatory markers. the purpose of this study was to assess the measurement of inflammatory markers in induced sputum as one such strategy by using ibuprofen as the test agent because it has demonstrated clinical benefit in cf. if changes in inflammatory markers are detectable in ibuprofen treated patients, then si might serve as a quick, noninvasive method by which to select the most promising anti-inflammatory agents for further study. methods: in this twoarm (ibuprofen and no treatment), open-label, parallel group study, cf patients >/= years of age with mild to moderate lung disease were screened at sites. si was performed on days , , and . patients in the ibuprofen group received drug on days - . subjects met eligibility criteria. were randomized to ibuprofen and to no treatment. subjects ( ibuprofen and no treatment) completed the study through day and comprise the intent-to-treat efficacy population. a maximum of subjects ( ibuprofen and no treatment) and a minimum of subjects ( ibuprofen and no treatment) across all markers had acceptable inflammatory marker values at both days and . within group and between group comparisons were made. results: with respect to the within group comparisons (before and after ibuprofen), most inflammatory markers slightly decreased in the ibuprofen group and increased in the no treatment group. for ibuprofen patients, mean changes were most apparent for il- (- . log pg/ml, p= . ) and % neutrophils (pmns) (- %, p= . ). with respect to the between group comparisons (ibuprofen vs. no treatment), differences were strongest for il- ( . log pg/ml, p= . ), percent pmns ( %, p= . ), and absolute pmn count ( . cells/ml, p= . ). fourteen days after discontinuing ibuprofen, inflammatory mediators tended to increase. there was no difference in aes between the two groups, and si was generally safe. conclusions: . overall, si is well-tolerated in patients >/= years, . a -week treatment period may not be long enough to study anti-inflammatory drugs, . with respect to changes in inflammatory markers associated with anti-inflammatory therapy, the effect size is small and the variance of the effect is small in clinically stable patients. . measuring inflammatory markers in induced sputum has potential as a screening tool for studying anti-inflammatory drugs in cf, . further studies of si in cf are warranted. supported by cystic fibrosis foundation therapeutics, inc. in preparation for our gene therapy clinical trial programme we are currently assessing a number of sputum biomarkers including viscosity and elasticity, total solids and dna content and hr sputum weight. we tracked and correlated these biomarkers in cf patients ( years and over) during a course of iv antibiotics (ab) by collecting samples on several occasions [visit (v) : at the start of ab treatment, v : at the end of ab treatment (generally after weeks) and interim periods]. to ensure adequate reproducibility of the results viscosity/elasticity measurements were carried out in triplicate using a csl rheometer which required a comparatively large volume ( mls) of spontaneously expectorated sputum. because of this requirement paired samples could only be obtained from approximately % of the patients. there was no change in viscosity/elasticity (n= ), solid or dna (n= ) content when comparing samples at the beginning and end of iv ab. in contrast, hr sputum weight was significantly (p< . ) lower at the end of the ab treatment (visit : . ± . g, visit : . ± . g, n= ). there was a strong and significant correlation between solid content and viscosity/elasticity (r= . , p< . ) and a modest correlation between hr sputum weight and % predicted fev (r=- . , p< . ) and hr sputum weight and patient scored symptom severity (r= . , p< . ). surprisingly, sputum dna content did not correlate with viscosity/elasticity, despite being generally thought of as a contributor to viscosity, which may in part be related to the assay not being able to discriminate between free and cell-enclosed genomic dna.in summary, after a course of iv antibiotics which lead to significant subjective and objective (fev ) improvement the overall quantity of expectorated sputum was significantly reduced but, based on analysis available to date, none of the other parameters (viscosity, elasticity, solid and dna content) changed significantly. considering the difficulties we encountered in collecting sufficient sputum during this period of an exacerbation, sputum viscosity/elasticity measurements may not be feasible parameters to measure in a gene therapy trial to which stable patients re likely to be recruited. this study was funded by the cf trust. chronic neutrophilic inflammation is a feature of cystic fibrotic (cf)related inflammation and serves as a significant contributor to morbidity and mortality associated with the condition. recently, our group has described a novel collagen-derived neutrophil chemoattractant, proline-glycine-proline (pgp), in a murine model of lipopolysaccharide-induced inflammation. the purpose of this study was to explore both the presence of this peptide in sputum from cf patients and the determination of a proteolytic system involved in pgp generation. we show that lower airway secretions from cf subjects have -fold increase in pgp levels compared to normal controls and that cf sputum (p< . ) is able to generate pgp from intact type i and ii collagen -fold above that seen from normal control sputum ex vivo (p< . ). we further demonstrate that production of pgp is dependent on two specific matrix metalloproteases (mmps), mmp- and mmp- . finally, we show that the generation of pgp can be significantly inhibited ( - % inhibition) by the use of either mmp- or mmp- specific inhibitors (p< . versus no inhibitor); a nonspecific mmp inhibitor (doxycycline) also demonstrates significant attenuation of pgp production. the determination of the requirements of these proteases in pgp generation allows for the identification of logical targets for disease-modifying therapeutics in cf. . cfrc, uab, birmingham, al, usa; . cfrc, university of north carolina, chapel hill, nc, usa cystic fibrosis (cf) lung disease is characterized by chronic neutrophilic inflammation. the discrete collagen breakdown product prolineglycine-proline (pgp) is a potent neutrophil chemoattractant thought to be generated by a specific proteolytic cascade present during cf pulmonary exacerbation (nat med ( ): , ) . high-mobility group box (hmgb ) is a potent inflammatory mediator found in sepsis, rheumatoid arthritis, and other inflammatory diseases characterized by neutrophilic inflammation. the role of pgp and hmgb as pmn attractants in cf is unknown. in this study we utilized specimens derived both from humans and scnn b-transgenic mice (βenac mice) in which overexpression of the βenac subunit in the airways leads to sodium hyperabsorption and airway surface liquid depletion, mimicking the cf muco-obstructive phenotype. pgp was quantified using tandem ms. neutrophil chemotaxis was measured in vitro following preincuabtion of sputum or balf with anti-hmgb neutralizing antibody. murine balf was assayed for hmgb by western blot and elisa. human sputum was similarly evaluated after normalizing for total protein concentration. in vivo hmgb activity was measured after intratracheal instillation in wt mice. βenac mice had % higher cell counts and a greater percentage of pmns ( . % vs. . %) in bal samples than wild-type (wt) littermates (p< . , n= /genotype). pgp was elevated in balf of scnn b animals ( . vs. below limits of detection in wt controls, p< . , n= ), increased in serum from cf subjects ( vs. pg/ml normal controls, p< . , n= ), and detected at high levels in cf sputum ( , pg/ml). balf screened for hmgb by western blot revealed elevated levels in βenac mice (p< . by densitometry, n= /genotype); elisa confirmed % greater hmgb concentration ( . vs. . ng/ml, p< . ). hmgb was also detected by western blot in human cf sputum ( of ) and at higher levels than secretions from normal subjects (p< . by densitometry; n= cf, control). purified hmgb induced dose-dependent pmn chemotaxis in vitro (peak - ng/ml, p< . , n= ) and cf sputum caused potent chemotaxis ( -fold over control, p< . , n= ) that was inhibited by preincubation with hmgb antibody (p< . ). balf from βenac mice (but not wt controls) was also chemotactic ( -fold greater than media control, p< . , n= ) and inhibited by anti-hmgb antibody (p< . ). exogenous hmgb ( ng) administered intratracheally to lps resistant mice (c hej, toll- receptor mutant) and balb/c mice caused pmn influx in balf at hours (c hej: . x pmns after hmgb vs. . x after vehicle, p< . ; balb/c: . x vs. . x , p< . ), and generation of pgp ( . vs. . pg/ml in c hej, p< . , n= ) . in summary, pgp and hmgb are elevated in balf of βenac mice that present with cf-like lung pathology; in cf airway secretions, hmgb is present in vivo at concentrations that induce neutrophil chemotaxis in vitro and pgp production in vivo, and is inhibited by blocking antibody. the role of pgp and hmgb in cf deserve further evaluation as they may be potential therapeutic targets of dysregulated inflammation. esther, c.r. ; jasin, h.m. ; collins, l.p. ; boysen, g. ; boucher, r.c. . pediatric pulmonology, university of north carolina at chapel hill, chapel hill, nc, usa; . cf research center, univeristy of north carolina at chapel hill, chapel hill, nc, usa; . center for environmental health and susecptibility, univeristy of north carolina at chapel hill, chapel hill, nc, usa biomarkers of airway inflammation are needed in cystic fibrosis (cf) to aid clinical management and assess the efficacy of novel therapies. we describe a simple and non-invasive method to measure airway purines, signaling molecules previously shown to be biomarkers of neutrophilic airway inflammation. airway secretions were obtained using exhaled breath condensate (ebc) collection, a technique that was easily performed in the outpatient setting on children as young as three years. the purines adenosine and amp in ebc were measured using ultra-sensitive liquid chromatography/tandem mass spectrometry (lc/ms/ms). in addition, we used lc/ms/ms to simultaneously measure urea as a dilution marker to control for the known dilutional variability of airway secretions within ebc. detection of adenonosine, amp, and urea was optimized using positive mode ms with selected reaction monitoring, and stable isotope dilution was utilized to improve quantification. detection was linear with concentration over four orders of magnitude, with coefficients of variation < %. the method was sensitive, with limits of detection for adenosine and amp (~ . nm) and urea (~ . µm), below expected ebc concentrations. applying the methods to ebc demonstrated that detection of purines and urea was reliable, with intraclass correlation coefficients greater than . between duplicate measures (n= ). we also measured purines and urea in ebc samples collected prospectively from children with cf (n= ) and healthy controls (n= ) during regular clinic visits. all samples were lyophilized and reconstituted to increase concentration -fold. adenosine, amp, and urea were detected in all samples. neither adenosine nor amp levels differed between groups, but urea was significantly lower in cf ( . ± . µm) versus healthy control ( . ± . µm, p= . ), suggesting that airway secretions were more dilute in cf samples. when dilutional variability was controlled using purine to urea ratios, the amp to urea ratio was found to be elevated in subjects with cf ( . ± . ) compared to healthy controls ( . ± . , p= . ), consistent with previous findings. the amp to adenosine ratio was also elevated in cf ( . ± . ) compared to control ( . ± . ), although the difference did not reach statistical significance in this small sample set (p= . ). experiments are ongoing to increase sample size and assess ebc purine levels before and after treatment of a cf exacerbation. these results demonstrate that lc/ms/ms analysis of ebc provides a non-invasive method to measure purine biomarkers of cf airway inflammation. given the flexibility of ms, this methodology could also prove applicable for study of other small molecule biomarkers. importantly, we also show that dilution of airway secretions in ebc may be altered in cf, and lc/ms/ms can be used to control for this variability through measurement of urea as a dilution marker. introduction: mucociliary clearance and antimicrobial peptide activity may be affected by airway surface liquid (asl) ph, which is regulated by epithelial ion transport. asl ph is abnormal in disease states in which il- a is elevated, including cystic fibrosis (cf), and the il- a receptor is expressed at the basolateral surface of bronchial epithelium. therefore, we investigated the effects of il- a on vectorial ion transport in well-differentiated hbe cells. methods: hbe cells were grown with an apical air interface and incubated with il- a at or ng/ml in the basolateral medium for hours prior to being studied with standard short-circuit current (isc) techniques. results: il- a treated cells had a minimal increase in resting and amiloride-sensitive isc compared to control cells, and had a dosedependent, statistically significant increase in forskolin-stimulated isc. at a dose of ng/ml, il- a doubled forskolin-stimulated isc ( . ± . µa/cm for control vs. . µa/cm for il- a). the increased isc was not bumetanide-sensitive, but was sensitive to acetazolamide and dnds, and was not present in hco --free solutions, suggesting it was due to hco secretion. to investigate whether this hco secretion was cl --dependent, we studied hbe cells in cl --free solutions, and there was no difference between untreated and il- a treated hbe cells. to test the hypothesis that il- a promoted cl -/hco exchange, we performed experiments in hbe cells mounted in cl --free solutions, and after addition of amiloride and forskolin, mm nacl was added to the mucosal bath and mm nagluconate was added to the serosal bath. under these conditions, one would predict a decrease in isc due to mucosal to serosal clmovement down its electrochemical gradient. in untreated hbe cells, we saw a decrease in isc followed by a recovery. in il- a treated cells there was a sustained increase in isc, suggesting that movement of cldown its electrochemical gradient resulted in exchange of clfor an anion at the apical membrane. in the absence of hco -, both untreated and il- a treated cells responded to claddition to the mucosal bath with decreases in isc. to assess the cftr dependence of the il- a-induced isc, we stimulated primary cf hbe cells treated with il- a. in cf cells, there was a minimal increase in amiloride-sensitive isc ( . ± . µa/cm for control vs. ± . µa/cm for il- a ) and in forskolin-stimulated isc ( . ± . µa/cm for control vs. . ± . µa/cm for il- a ). conclusion: the proinflammatory cytokine il- a induces cl -/hco exchange in hbe cells. notably, the observed cl -/hco exchange appears to be cftr-independent. however, cftr activation is required for maximum cl -/hco exchange as demonstrated by the smaller isc generated in cf cells. these data suggest that the cytokine milieu of the airway epithelium can alter ion transport and potentially asl physiology. furthermore, they suggest that cftr may interact with or regulate novel proteins in the presence of inflammation. supported by cff and nih periciliary fluid balance is maintained by the coordination of sodium and chloride (cl-) channels in the apical membranes of the respiratory epithelia. in the absence of the cystic fibrosis transmembrane conductance regulator (cftr), cl-secretion is diminished and sodium reabsorption becomes exaggerated. activation of non-cftr-dependent cl-channels can provide an alternate pathway for cl-secretion in the airways and gastrointestinal tract. the ph and voltage-dependent type- cl-channel (clc- ) is expressed in airway epithelial cell luminal membranes. we hypothesize that topically applied clc- agonists may restore cl-secretion in cystic fibrosis (cf) murine airways. using in vivo nasal potential difference measurements, we quantified clc- -mediated cl-transport in both cf and wild-type mice during nasal perfusion with lubiprostone (a prostone compound and specific clc- agonist; sucampo, pharmaceuticals, inc., bethesda md) or vehicle control. wild-type (c bl , n = ) and cf knock-out (cfko; n= (jax stock# )(jackson laboratories, bar harbor, me) mice were sedated and intubated to protect the lower airways from aspiration of perfusate. nasal and subcutaneous bridges were connected to fluid-filled silver chloride electrodes. baseline (in ringer's), amiloride-inhibited, low cl-(cl-free, gluconate-substituted ringer's with amiloride), and low cl-plus lubiprostone (with increasing concentrations of lubiprostone or vehicle) mice were perfused and potential differences were measured with a high impedance voltmeter (world precision instruments, sarasota fl) and continuously recorded. a clear dose-response relationship was detected in both wild-type and cf mice. at µm lubiprostone, wild-type mice showed hyperpolarization of - . ± . mv and cf mice responded with - . ± . mv hyperpolarization. a paired t-test of low cl-perfusion and lubiprostone perfusions revealed significant (p< . ) differences in both genotypes. five clc- cfko mice were similarly tested and showed no response to lubiprostone (+ . ± / mv). cftr inhibitor- ( µmol) (calbiochem, san diego ca) added to the low cl-perfusion in additional wild-type mice eliminated the low cl-response but did not abolish the lubiprostone response, confirming that clc- is present and independent of cftr regulation. we conclude that direct application of a clc- agonist in the cf murine upper airways restores near normal levels of cl-secretion. cftr is an apical membrane chloride channel whose activity is required to maintain airway surface liquid (asl) volume and efficient mucociliary clearance. cftr is activated by camp dependent stimulation of protein kinase a. however, studies have suggested that the actin cytoskeleton may also be required for regulation of cftr, by acting as a structural element in second messenger compartmentalization ( ) . to determine whether an intact cytoskeleton is required for asl volume homeostasis, adenosine (ado), atp, or isoproterenol (iso) (all at µm) were added apically to human bronchial epithelial cultures (hbec's) before or after the cytoskeleton had been disrupted by cytochalasin d exposure ( µm for h). in control cultures ado, atp and iso all resulted in a significant increase in asl height (∆asl) within min (∆asl; ado, . ± . µm; atp, . ± . µm; iso, . ± . µm). however, in cytochalasin d exposed cultures ado was without effect while atp and iso were still able to evoke an increase in height (∆asl; ado, - . ± . µm; atp, . ± . µm; iso, . ± . µm). however, we showed that a b receptor function was not compromised by cytoskeleton disruption as camp levels were seen to increase both after addition of adenosine and adenosine in the presence of cytochalasin d. thus, the effect of cytochalasin d on asl height appeared specific for adenosine-mediated cl-secretion. to further test the effect of cytochalasin d on the relationship between adenosine and cftr, we designed a fluorescent resonance energy transfer (fret) pair of cfp-cftr (labeled at the n-terminus) and yfp-a b receptor (labeled at the c-terminus). addition of adenosine ( µm) increased fret by . times (% efficiency; control, . ± . %, ado, . ± . %) compared to the vehicle control (n= ). cytochalasin d exposure ( µm for h) completely inhibited the increase in fret that was observed after adenosine addition (p< . ). in contrast, cytochalasin d had no effect on fret between cftr and the β adrenoceptor. to determine whether cytochalasin d treatment ( µm for h) had any direct effect on cftr protein levels and localization we used a cell line stably expressed with an exotope-tagged cftr (hb cells) ( ) . cftr protein levels were found to be significantly reduced as compared to nontreated controls by both western blot analysis and chemiluminescence detection (n= ). cells were also stained with an antibody against the external cftr exotope and imaged by confocal microscopy and a significant decrease in staining at the plasma membrane was observed after cytochalasin d treatment (n= ). we conclude that cytochalasin d exposure decreases cftr protein levels and specifically inhibits adenosine-mediated regulation of cftr activity in the airways, leading to disruption of asl homeostasis and inhibition of mucociliary clearance. numerous studies have reported evidence that cftr is expressed in the apical membrane of serous cells in the airway submucosal glands. thus, it has been reasoned that ( ) cftr plays some role in normal anion and fluid secretion by airway glands and ( ) loss of this channel's function in cystic fibrosis (cf) airways plays some role in the etiology of cf lung disease. a recent study by joo et al. (jbc : - , ) indicates that cf airway glands lose the ability to secrete fluid when treated with forskolin or vip but maintain the ability to secrete when treated with muscarinic agonists. this result suggests that vip and muscarinic agonists mediate secretion by cftr-dependent and cftr-independent pathways, respectively. the present study was undertaken to explore the dynamics of fluid secretion by individual submucosal glands to determine if further differences in their responses to these two agonists could be distinguished. pig tracheas were obtained from a local slaughterhouse. after removal of the cartilage, tissues were mounted in a warm ( °c) observation chamber that permitted exposure of the submucosa to krebs solution. the mucosal surfaces of the airways were dried with a stream of warm dry air and then layered with mineral oil. liquid secreted from the gland duct openings formed spherical aqueous droplets within the oil layer, and their volumes were estimated from spatial dimensions taken from sequential digital images. liquid secretion rates were estimated for individual glands present within a . mm region of interest. rates were determined for two experimental protocols. for one group of tissues, secretion rates were determined for a control period, followed by a period of exposure to µm vip, and then a period of exposure to both vip and µm acetylcholine (ach). in the second group, the order of vip and ach treatment was reversed. these agonist concentrations were expected to produce near maximum rates of secretion. when the agonists were applied first, secretion rates were significantly (p< . ) increased from the control period by both ach ( . ± . nl/min to . ± . nl/min) and vip ( . ± . nl/min to . ± . nl/min). the secretion rates for individual glands were highly variable with both agonists (ach: . - . nl/min; vip: . - . nl/min). when ach application followed vip treatment, the mean secretion rate was significantly increased further to . ± . nl/min; however, when vip application followed ach treatment, the secretion rate was only marginally and insignificantly increased to . ± . nl/min. we conclude that both ach and vip are efficacious secretagogues for porcine airway glands and that the rate of secretion from individual glands to either agonist is very heterogenous. because vip has no effect following stimulation by ach, we speculate that ach induces secretion by activating all transporters relevant to vip-induced secretion including cftr. however, ach must also activate channels and/or transporters not induced by vip since its effects are additive to vip. this most likely includes activation of a non-cftr anion channel. ( serous cells are thought to serve as the principal anion and fluidsecreting cells of airway submucosal glands. mucous cells primarily secrete gel-forming mucins. these respective physiological roles for these two cell types imply that the mucous cells, which secrete the thick mucus gel, should lie downstream of the serous cells so that their watery secretions can flush the mucins out of the ducts and onto the airway surface. early studies indicated that such arrangements existed within glands but reports of cell distributions have been descriptive rather than quantitative. because of resurgent interest in serous cell function, we revisited this issue to formally document the distribution of these cell types within the secretory tubules of the submucosal glands as well as at the surfaces of the glands, where serous cells are most accessible for study. a piece of porcine lung, containing a mm diameter bronchus, was treated with formalin fixative, and consecutive µm sections were taken. the apices of virtually all gland epithelial cells, except the cells lining the collecting and ciliated ducts, stain positive for pas indicating that these cells are either serous or mucous cells. however, pas staining does not allow distinctions to be made between these two cell types. consequently, all slide sections were stained with hematoxylin and eosin. with these stains, mucous cells were identified as cells containing lucent granules in their apices whereas serous cells were considered to be cells where the apical cytoplasm stained a uniform dark reddish color. first, the distribution of serous and mucous cells in the secretory tubules were determined. the acini of individual tubules were located in the slide sections, and cells were identified and counted in consecutive sections that approached the collecting ducts until the tubules were no longer distinguishable as discrete tubes. secretory tubules from individual glands were studied. in the acini, serous cells accounted for . ± . % of total cells whereas mucous cells accounted for . ± . % of total cells (remaining cells were not distinguishable as either cell type). there was a significant (p<. ) negative correlation of serous cell numbers with distance from the acini so that at µm from the acinus serous cells accounted for only . ± . % of total cells. there was a coincident significant positive correlation with mucous cell numbers so that at µm from the acini mucous cells accounted for . ± . % of total cells. next, we examined the cell distribution at the adventitial and mucosal surfaces and at the lateral margins of the glands. serous cells accounted for . %, . %, and . % of the total cells at these respective locales. mucous cells represented . %, . %, and . % of total cells in these same respective regions. we conclude that serous cells are by far the dominant cell type in secretory tubules of porcine submucosal glands. mucous cells are rare in acini but increase in frequency with distance from the acini. the outer surfaces of the glands are dominated by serous cells as well. at the lateral margin of the glands, serous cells outnumber mucous cells by -to- . (supported by nih hl ) . many of the membrane transporters that participate in this process have been identified; however, the identity of the class of kchannels that maintains resting membrane potential and/or cell membrane polarization during the secretion process remains poorly characterized. liquid secretion by porcine submucosal glands is insensitive to numerous k + channel blockers including ba + , tetraethylammonium, apamin, charybdotoxin, iberiotoxin, clotrimazole, penitrem a, -aminopyridine, and quinidine. recently, a new class of k + channels, the "tandem-pore" or k p channels, have been described. potassium channels of this class are insensitive to many traditional k + channel inhibitors but are blocked by local anesthetics, such as lidocaine and bupivacaine. additionally, many k p channels are sensitive to changes in extracellular ph. in the present study, we considered whether k p channels might participate in the liquid secretion response to acetylcholine (ach). intrapulmonary bronchi, excised intact from the lungs of pigs, were cleared of accessible luminal liquid, cannulated, and treated with µm ach to induce secretion. paired airways were pretreated for h with mm bupivacaine. bupivacaine blocked . ± . % of the liquid secretion response to ach. the ic for the bupivacaine inhibition was approximately µm. the inhibitory effect of bupivacaine was not due to nonspecific toxicity since tissues exposed to bupivacaine for h and then washed with fresh inhibitor-free buffer recovered to % the control achinduced secretory rate. the bupivacaine effect was not due to inhibition of voltage-gated na + channels in intrinsic neurons since µm tetrodotoxin did not inhibit ach-induced secretion. no significant effect was seen in the secretion rate when the extracellular solution ph was lowered from . ± . (normal hco --buffered krebs gassed with % co ) to . ± . by gassing with % co gas (balance o ). while we recognize the relative nonspecificity of this agent, the inhibitory effects of bupivacaine on liquid secretion by porcine bronchi are consistent with k p channel participation in this secretory response. the failure to demonstrate inhibition with acidification of extracellular solution could signify a k p channel subtype that is insensitive to low extracellular ph. ( . novartis, horsham, united kingdom; . rosalind franklin university, chicago, il, usa; . mount sinai medical center, miami, fl, usa; . genomics institute of the novartis foundation, la jolla, ca, usa enac activity in the human airway epithelium has been reported to be partially-sensitive to the broad spectrum trypsin-like protease inhibitors aprotinin and placental bikunin (bridges et al., am j physiol :l - ; donaldson et al., jbc : - ) . a low molecular weight inhibitor of the airway channel activating protease (cap) would represent a potential therapeutic approach to attenuating enac function in cystic fibrosis (cf) lung disease. the aims of the current study were to: ( ) further characterise the in vitro efficacy of cap inhibitors in human bronchial epithelial cells (hbes), ( ) to evaluate the relevance of a cap mechanism to the regulation of enac function in vivo, and ( ) to establish whether the inhibition of the airway cap can modulate mucociliary clearance in vivo. primary cultures of hbes (normal and cf), cultured under air-liquid interface conditions, demonstrated an amiloride-sensitive short circuit current (isc), that was sensitive to aprotinin but that was insensitive to inhibition by sbti, α -anti-trypsin and α -pdx. the amiloride sensitive isc was also attenuated by the low molecular weight cap inhibitor nvp-qau (hbc ) with an ic value of approximately nm. nvp-qau caused a time dependent inhibition of the isc with a t ⁄ of approximately min and this effect could be reversed by the addition of excess trypsin. in vivo, aprotinin attenuated the guinea pig tracheal potential difference (tpd) from - . ± . mv to - . ± . mv (n= - ) with an ed value of pmoles/kg, measured at hours following intra-tracheal instillation. the tpd was unaffected by either sbti or α -anti-trypsin at doses up to pmoles/kg. the combination dosing of an enac blocker with aprotinin did not attenuate the tpd beyond the effect observed with either agent alone, consistent with aprotinin attenuating enac function in this model system. intra-tracheal instillation of nvp-qau attenuated the tpd from - . ± . mv to - . mv with an ed value of µg/kg (n= - ). in the sheep, the administration of nvp-qau into the airways by aerosolisation of a mg/ml solution resulted in a - fold enhancement of the rate of clearance of mtc sulfur colloid from the lungs compared with the vehicle control. these studies indicate that the cap mechanism of enac regulation can translate through in vitro human assays, into in vivo models. cap inhibitors can attenuate tpd in the guinea pig in vivo and enhance the rate of mucociliary clearance in the sheep, thereby representing an approach to the therapeutic regulation of enac function in cf lung disease. cotton, c. pediatrics, physiology and biophysics, case western reserve university, cleveland, oh, usa cystic fibrosis is caused by mutations in the gene that encodes cftr, a camp-activated apical membrane anion channel. loss of cftr-mediated anion conductance is a primary defect in cf but secondary defects such a sodium hyperabsorption are also implicated in cf pathophysiology. it is generally accepted that mucociliary clearance is compromised in cf airways due to reduced fluid secretion and/or increased fluid absorption. the recent generation of a transgenic mouse model with enac overexpression that exhibits cf-like lung disease highlights the importance of sodium hyperabsorption. therapies designed to reduce mucus production and viscosity, increase lumenal water content, stimulate fluid secretion, and inhibit fluid absorption are under development for treatment of cf airways. although controversial, several recent studies have demonstrated that serca pump inhibitors partially correct the trafficking defect associated with delta f mutant cftr. the goal of this work is to determine if serca pump inhibitors affect enac-mediated sodium absorption. a renal collecting duct epithelial cell line and primary cultures of well-differentiated human tracheal epithelial cells (air/liquid interface culture) were used for these studies. amiloride-sensitive short circuit current was determined as a measure of enac-mediated sodium absorption. quantitative rt-pcr was used to evaluate expression levels for each of the subunits of enac (alpha, beta, and gamma). epithelial monolayers were treated for - hours with serca pump inhibitors (thapsigargin, - nm; dbhq, - um; and curcumin, - um). treatment with serca pump inhibitors decreased amiloride-sensitive short circuit current by - %. in contrast, campstimulated short circuit current was not reduced by treatment with serca pump inhibitors. the steady-state levels of alpha, beta, and gamma enac were reduced by - % in renal epithelial monolayers treated with thapsigargin whereas beta and gamma enac were reduced by - % with no significant change in alpha enac in airway epithelial cells. the results of these studies demonstrate that sustained depletion of endoplasmic reticulum calcium stores and/or elevation of intracellular calcium by inhibition of serca pump activity reduces enac mrna expression and enac-mediated sodium absorption. thus, inhibition of serca pump activity in airway epithelial cells of cf patients that carry the delta f mutation may provide dual benefit by promoting delivery of mutant cftr to the membrane . pediatrics, national jewish medical and research center, denver, co, usa; . integrated department of immunology, national jewish medical and research center, denver, co, usa; . department of medicine, cystic fibrosis/pulmonary research and treatment center, the university of north carolina at chapel hill, chapel hill, nc, usa increased cytosolic calcium ([ca + ] i ) initiated by the release of stored ca + from the endoplasmic reticulum (er) is a key signal to elicit a wide range of essential cellular responses, including secretory functions of the respiratory epithelium that are modified in cf. serca pumps are responsible for (re)filling the er ca + stores, and serca blockers such as thapsigargin are very potent and commonly used pharmacological triggers of ca + -signals. modulation of the activity of sercas can profoundly affect ca + homeostasis. although defective calcium homeostasis is a characteristic of several pulmonary diseases including cf, the role of serca is unknown. lung tissue samples (bronchus and distal lungs) from normal (n= ) and cf subjects (n= ) were evaluated by immunohistochemistry. serca expression was decreased in the bronchial and bronchiolar epithelia of cf. non-cf and cf bronchial epithelial cell line pairs including calu- and jme/cf , c- and ib - , hbe o-( hbe), cfbe o-(cf o-) and cfbe o-(cf o-) were also probed. given certain limitations of such cells, several consistent findings still emerged. a % and % decrease in serca expression was observed in cf o-and cf ocells as compared to hbe cells. immunocytochemical studies in these cells confirmed that the serca was localized in the er and that the decreased serca expression was not associated with decreased er content. reduced serca expression and activity ( . ± . vs . ± . and . ± . pmol/min/mg protein in hbe vs. cf o-and cf ocells respectively) was observed in the purified er membranes from cf cell lines. northern blot analysis revealed a parallel reduced mrna expression as well. decreased serca was accompanied by increase in the low affinity isoform serca ( . ± . vs. . ± . and . ± . arbitrary serca intensity/b-actin in respectively) . we have also evaluated a limited number of primary airway epithelial cells isolated from lung samples of normal and cf subjects for serca expression. serca expression in polarized tracheobronchial epithelial cell lysates from cf subjects was decreased by about % as compared to those from normal subjects ( . ± . vs. . ± . arbitrary serca intensity/b-actin units in cf and normal respectively, n= ). expression of serca could also be suppressed by inhibiting cftr with cftr inh in normal human bronchial epithelial cells ( various studies indicate that the airway surface fluid possess an antibacterial system based on the combined action of lactoperoxidase, h o , and scn -(thiocyanate). the enzyme lactoperoxidase (secreted by submucosal glands) utilizes h o and scnto generate oscn -(hypothiocyanite) a molecule with antimicrobial activity. h o is produced by dual oxidases expressed on the apical membrane of airway epithelial cells whereas scnis transported across the epithelium through anion transporters and channels. in particular, scntransport seems to occur through cftr and other ca +dependent clchannels. therefore, reduced scntransport in the airways of cystic fibrosis patients may contribute to impaired antimicrobial activity. in a recent study, we have found that cytokines, in particular il- , cause a strong increase in the ability of cultured bronchial epithelia to transport scnfrom the basolateral to the apical membrane. this effect is mediated by upregulation of ca + -dependent clchannels and of the slc a (pendrin) anion transporter. these findings suggest that under proinflammatory conditions the activity of the scn -/h o /lactoperoxidase system is potentiated. we evaluated the antimicrobial activity of airway surface by seeding bacteria on the apical membrane of human bronchial epithelia grown with an air liquid interface on a porous membrane. an inoculum corresponding to , cfu of s. aureus was added to the cells in µl of saline solution with and without lactoperoxidase ( . µg/ml). experiments were performed in the presence or absence of scn -( µm) in the basolateral solution. bacteria were recovered after four hours and plated on agar plates for colony counting. our preliminary results show that simple addition of lactoperoxidase to the apical surface decreases bacterial survival. in addition, bacterial killing is strongly enhanced by prestimulation of cells for hours with il- ( ng/ml). the effect of lactoperoxidase is dependent on h o as it is prevented by addition of catalase and is absent in cell-free experiments when h o is omitted from the reaction mixture. surprisingly, the presence of scnin the basolateral compartment did not increase bacterial killing and, in some cases, appeared to generate a protective effect. our results suggest that lactoperoxidase, in the presence of h o , is an effective antimicrobial molecule. the contribution of scnand the mechanism of the potentiation caused by cytokines is less clear and requires further investigation. a possibility is that, in the absence of scn -, lactoperoxidase generates an oxidant molecule that is more toxic to bacteria than oscn -. elucidation of this mechanism and comparison between cf and non-cf epithelia is in progress to assess the role of cftr and of other anion channels. supported by cfft and telethon-italy. cf patients become infected with pseudomonas aeruginosa, which release flagellin into the airway surface liquid to activate toll-like receptor and proinflammatory signaling. flagellin has been shown to inhibit na absorption by airway epithelia. we tested flagellin on cl secretion and proinflammatory signaling (nf-κb activation) by calu cells, a cftrexpressing, serous-like airway gland cell line. calu cells were grown on filters and either mounted in ussing chambers (clamped to zero mv) in the presence of a serosa-to-mucosa gradient of [cl] for measurements of transepithelial cl secretion (i cl ) or treated with an adenovirus expressing nf-κb-controlled luciferase to assay nf-κb activation. flagellin ( - g/ml) on either the apical or basolateral surface of cells increased apparent anion secretion that began in - mins and increased over - mins by - µa/cm . this i cl was blocked by glibenclamide and glyh , indicating that it resulted at least in part from activation of cftr. flagellin also stimulated fluid secretion by intact human tracheal glands. flagellin activated nf-κb (luciferase assays) in both calu- cells and in the cf cell line cf , while i cl was stimulated in calu but not in cf cells. flagellin-stimulated i cl in calu- cells was blocked % by sb (a p mapk blocker) and by a similar amount by wortmannin (pi kinase blocker). interleukin β and the tlr -agonist pam cys also activated i cl . the effect of flagellin was not due to increases in cytosolic [ca + ] (ca i ) because flagellin did not alter ca i . in contrast to the slow effects of flagellin, pam cys and il β, atp rapidly increased i cl (within secs, up to µa/cm ) followed by slower decrease to steady i cl = - µa/cm that had a similar time signature as the increases in ca i . forskolin (to increase cytosolic [cyclic amp]) increased i cl within mins to a steady value = - µa/cm . flagellin had small or no effects on i cl following maximal stimulation with either atp or forskolin. atp and forskolin on their own had no effect on nf-κb. flagellin increased phosphorylation of p mapk and of akt (down-stream kinase phosphorylated by pi k) with a time course similar to the increase in i cl . flagellin-activated nf-κb was reduced by roughly % by either wortmannin or sb . these results indicated that tlr agonists and inflammatory cytokines stimulate both nf-κb and proinflammatory processes and also cftr-dependent cl and fluid secretion by airway gland cells. these responses are mediated in part by activation of both p mapk and pi kinase. flagellin-tlr -activated increases in cftr-mediated cl secretion and reduction in enac-mediated na absorption will increase fluid secretion into the airways, which may facilitate bacterial removal by the mucociliary escalator and thereby reduce the proinflammatory stimulus. in cf it is expected that bacteria will activate tlr signaling to trigger innate immune responses, but cl and water secretion and the resulting "bacterial flush," will be missing, leading to sustained inflammation. ( , ) . treatment with hs improved several measures of lung function including mucociliary clearance. in one study amiloride was seen to have a negative impact on the benefit of hs ( ) . the long duration of action of hs and the paradoxical effect of amiloride are surprising and require further investigation. aims: our goal was to study the effect of exposure to a hypertonic challenge (hc) on amiloride sensitive na+ transport (ina) in primary cultures of human bronchial epithelial (hbe) cells from non-cf and cf patients. methods: hbe cells were grown at an air liquid interface and studied under short circuit current conditions. cells were challenged with hs by exchange of the apical or basolateral baths. in some experiments the timedependent effect of a small ( µl) isosmotic or hs volume at the airway surface was tested on ina and apical osmolality. results: application of hypertonic nacl and mannitol solutions from either the mucosal or serosal sides of the epithelium inhibited ina. the degree of inhibition was a saturable function of the imposed hypertonicity with an ic of (mannitol) and (nacl) mosmol/kg h o and a maximal inhibition of %. the inclusion of amiloride ( - µm) did not affect the hc-induced reduction in ina. the inhibition in ina by hc was rapid in onset and accompanied by a fall in the transepithelial resistance and the total transepithelial capacitance as expected for cell shrinkage. the inhibition in ina was only partially reversible (~ %) after returning to isotonic solutions for min. exposure of the airway surface to hypertonicity ( mosmol/kg h o) inhibited ina by - % at min of exposure. as osmotically-driven water moved from the serosal to the mucosal side, the apical volume increased concomitant with a decrease in its osmolality and a recovery of ina. the osmolality declined exponentially and reached the isosmotic value after ~ hrs. the recovery of ina lagged behind the recovery of apical osmolality by , and % at . , and hrs of incubation, respectively. after hrs of airway hc exposure, the osmolality and ina recovered completely. our results demonstrate that hc causes a rapid, dramatic and prolonged decrease in na+ absorption and that continuous presence of amiloride had no effect on the inhibition of ina or the recovery of apical osmolality. hc also causes the epithelium to shrink. no appreciable differences were observed between cf and non-cf hbe cells. conclusions: we propose cell shrinkage together with the continued influx of na+ increases intracellular na+ ([na]i) and lead to an inhibition of na+ transport. elevated [na] i is a known inhibitor of epithelial na+ channels ( ). the sustained nature of the inhibition in na+ transport to a hc may help explain the longer than expected duration of action of hs in the clinical trials ( , ) . explanation of the paradoxical effects of amiloride observed in a clinical trial ( ) requires further investigation. references: . n engl j med : - , ; . n engl j med : - , ; . physiol rev : - , reduced airway surface liquid (asl) volume resulting from enac mediated na+ hyperabsorption and cftr-mediated hyposecretion plays a critical role in cf lung disease pathogenesis. however, the mechanisms involved in enac/cftr regulation are poorly understood. using human bronchial epithelial cultures (hbecs) under thick film conditions, i.e. in the ussing chamber with the asl washed away, adenosine (ado) directly stimulates cl-secretion. however, in a cl-free environment, ado has no effect on the amiloride-sensitive current, which is mediated by enac. mean change in i sc following µm ado to the apical chamber was . µa/cm from baseline compared to vehicle alone (- . µa/cm ;ns;n= ) in hbecs. mean delta amiloride ( µm) was - . and - . µa/cm respectively (ns; n= each). in contrast, under thin film conditions we have previously shown that ado stimulates sustained asl secretion via activation of cftr in the presence of the protease-inhibitor aprotinin, whereas trypsin pre-treatment abolished this secretion, likely by activating enac and abolishing the electrical driving force for cl-secretion . further, ado-mediated asl secretion is significantly increased if hbecs (thin film conditions) are left with intact asl for h, an action that is abolished by acutely washing the apical surface . thus, we hypothesised that a soluble enac inhibitor was secreted into the asl under thin film conditions, which could accumulate sufficiently to inhibit enac and provide the necessary driving force for cftr-mediated cl-secretion after ado-addition. to search for such an inhibitor, we incubated asl with trypsin-coated beads and identified bound proteins by mass spectrometry (albumin-coated beads were used as a control to exclude non-specific binding). the major identified protein was plunc, a protein that is secreted into the asl both in vivo and in vitro which has no current known function. secretion of plunc into hbec asl was confirmed by western blot. to test whether plunc could alter asl volume homeostasis, we made an anti-plunc shrna retroviral construct which we used to infect hbecs. unlike the control anti-luciferase shrna infected hbecs, anti-plunc shrna-infected hbecs exhibited > % knockdown of plunc and a failure to regulate asl volume (ctrl, . ± . µm; ± . µm; n= ) . when co-expressed with enac in oocytes, plunc inhibited enac currents by % (n= ). cftr function in contrast was unaffected by plunc expression (n= ). thus,it is likely that ado stimulates cftr mediated cl-secretion but is not involved in enac regulation. however, experiments were performed in a very simplified environment i.e. static cultures with little mucosal atp or mucus and these findings will need to be expanded and further evaluated in native tissues. we conclude that plunc, rather than ado may be the soluble mediator in the asl which regulates enac function by reducing its activity. . tarran, r. et al., j. gen. physiol., . ( ) airway surface liquid (asl) absorption is mediated by epithelial na + channels (enac), which establish an osmotic gradient that drives fluid absorption. we and others have recently reported that a protease / anti-protease balance regulates enac in normal human bronchial epithelial cells (hbe) and provides a mechanism for auto-regulation of asl volume. in cf, this balance is disturbed, leading to constitutive proteolytic activation of enac and the pathological na + hyper-absorption characteristic of the disease. to determine if channel activating protease expression is regulated by changes in asl volume and is altered in cf, we examined prostasin expression in control and cf hbe under basal and asl volume expansion conditions using western blotting. prostasin migrates as kda and kda bands in apically biotinylated proteins, apical secretions, and whole cell lysates of primary hbe. following apical aprotinin exposure, only the kda prostasin molecular species was present in the biotinylated proteins, suggesting that the proteolytic conversion of prostasin zymogen to active enzyme occurs on the cell surface. following asl volume expansion, cell surface prostasin expression increased by > % (p= . , n= tissue donors, > cultures from each). as our recent studies indicated that increased proteolytic activation of enac occurs in cf airway epithelia, we next compared prostasin expression in cf and control hbe cells. prostasin expression in the apical biotinylate of cf hbe was . fold greater than in control hbe (p= . , n= tissue donors). furthermore, the ratio of the kda (active enzyme) to kda (zymogen) prostasin molecular species was . fold greater in cf (p= . ), indicating that increased activation of prostasin occurs in cf airway epithelium. we next determined whether increased prostasin activation in cf may reflect the deficiency of a protease inhibitor. serpin e , also known as protease nexin- (pn- ), forms an ~ kda complex with prostasin and permanently inactivates its protease activity. while no significant difference in pn- expression was observed between control and cf hbe, pn- was found to contribute to prostasin regulation by (i) forming an inactive prostasin complex, (ii) inhibiting the amiloride-sensitive short-circuit current across hbe, and (iii) preventing conversion of prostasin zymogen to active enzyme. these findings demonstrate that cellular mechanisms coordinate prostasin expression and activity with asl volume. accordingly, at times when the asl volume is high, prostasin expression increases, and this presumably augments na + and asl absorption to absorb the excess luminal fluid. these regulatory mechanisms govern the apical membrane expression and processing of zymogen to active enzyme. because prostasin is incapable of autocatalysis, these findings support the existence of a proteolytic cascade that controls enac activity during asl volume homeostasis, perhaps reflecting the recently reported matriptase-prostasin cascade. furthermore, the increased expression of prostasin in cf suggests that abnormal regulation of prostasin contributes to na + hyper-absorption in cf airways. supported by the nih, cff, and ala. we report that annexin (anx )-s a forms a functional camp/pka/calcineurin (can)-dependent complex with cftr. cell stimulation with forskolin/ibmx significantly increases the amount of anx -s a that reciprocally co-immunoprecipitates with cell surface cftr and can a. pre-inhibition of the cells with pka or can inhibitors attenuates the interaction. furthermore, we find that the acetylated peptide (stvheilcklsleg, ac - ), but not the non-acetylated equivalent n - , corresponding to the s a binding site on anx , disrupts the anx -s a /cftr complex. analysis of dids and cftr inh -sensitive currents, taken as indication of the outwardly rectifying cl-channels (orcc) and cftr-mediated currents, respectively, showed that ac - , but not n - , inhibits both the camp/pka-dependent orcc and cftr activities. can inhibitors (cypermethrin, cyclosporin a) discriminated between orcc/cftr by inhibiting the cftr inh , but not the dids, sensitive currents, by more than %. furthermore, peptide ac - inhibited acetylcholine-induced short-circuit current measured across a sheet of intact intestinal biopsy. our data suggests that the anx -s a /cftr complex is important for cftr function across epithelia. the content and water (h o) mobility in airway epithelium is tighly coupled to airway function. in cystic fibrosis (cf), h o epithelial permeability is reduced in airways. the demand of noninvasively imaging techniques with high spatial resolution potential is rising because such imaging tools would expedite anatomical and functional phenotyping in the genetically altered mice. magnetic resonance microscopy (mrm) is a noninvasive, inherently three-dimensional ( d) imaging technique capable of visualizing anatomical structures in the mouse and allows for interpretation of complex spatial relationships between substructures and h o. in this study, we explore different mr contrast parameters and signal-to-noise ratios at a µm pixel size to characterize microstructure and h o mobility in ex vivo trachea of cf transmembrane conductance regulator (cftr)-deficient (cftr knockout, cftr tm unc ) mice and their aged-matched wt littermates. this study is performed using a bruker mrm system at . tesla. we demonstrate for the first time the ability of d-mrm to map the h o content and mobility in trachea epithelium. from the d-mrm videoimages, differential h o content was visualized in different levels of trachea in wt and cf mice. t mrm images depicting the h o rotational mobility which is related to environmental viscosity of trachea epithelium will be also shown. finally, this d-mrm imaging method is a valuable method for measuring h o content and permeability in airways and can serve for assessing the effects of drugs on h o mobility in cf airways. supported by grants from inserm, upmc-paris , cnrs, and the french cystic fibrosis association (vlm). cystic fibrosis (cf) is a lethal inherited disorder caused by mutations in a single gene encoding the cystic fibrosis transmembrane conductance regulator (cftr) protein resulting in progressive lung oxidative damage. in this study, we evaluated the role of cftr in the control of ubiquitin-proteasome activity (ups system) and the nf-κb / iκb-αsignaling after lung oxidative stress. we exposed cftr deficient (cftr-/-) and wild type mice for h to hyperoxia-mediated oxidative stress. cftr deficient mice exhibited significantly higher lung proteasomal activity than cftr+/+ animals after oxidative stress. this was accompagnied by a strong reduction of lung caspase- activity and an absence of degradation of nf-κb inhibitor iκb-α. in vitro, human cftr-deficient lung cells also exhibited higher proteasomal activity and a lack of increased nf-κbdependent transcriptional activity compared to cftr-sufficient lung cells after oxidative stress. furthermore, inhibition of the proteasomal activity by mg in cftr-deficient lung cells restored the nf-κb/iκb-α signaling to that of cftr-sufficient lung cells. inhibition of caspase- by z-dqmd in cftr-sufficient lung cells mimicked the response profile of increased proteasomal degradation and lowered nf-κb transcriptional activity of cftr-deficient lung cells when exposed to oxidative stress. all together, these results suggest that cftr is a crucial molecule in regulating proteasomal degradation and nf-κb activity in lung epithelium under oxidative stress. staphylococcus aureus, one of the major pathogen involved in airway infections, releases in the airway lumen virulence factors that may impair the airway epithelial functionality. to date, the effect of s. aureus virulence factors on the loss of electrolyte homeostasis of the airway epithelium has not been investigated. we have previously shown that the combination of a corticosteroid and a long-acting beta agonist attenuated the airway epithelial cell inflammatory response induced by s. aureus virulence factors. the aim of the present work was to investigate the effect of s. aureus virulence factors on the airway epithelial tightness and on the chloride efflux of airway epithelial cells incubated or not with salmeterol hydroxynaphthoate × - m and fluticasone propionate × - m (sm/fp). the airway epithelial tightness was assessed by immunocytochemistry, western blotting and transepithelial resistance measurement. the chloride efflux was evaluated by dynamic imaging using the -methoxy-n-( -sulfopropyl) quinolinium (spq) fluorescent probe. s. aureus (strain - ) virulence factors were obtained by growing bacteria at × cfu/ml for h at °c. the bacteria supernatant containing s. aureus soluble virulence factors was then centrifuged, filtered and diluted at % in cell culture medium (a concentration that did not alter cell viability). human airway epithelial cells (mm ) were incubated with % s. aureus virulence factors for h and then co-incubated or not with sm/fp for h. we observed that the incubation with % s. aureus virulence factors alone did not significantly alter the epithelial integrity assessed by the expression of tight junction proteins and transepithelial resistance measurement. however, when the cells were incubated with sm/fp alone or with % s. aureus virulence factors plus sm/fp, the expression of tight junction proteins was significantly increased (p< . ) as compared to cells incubated with s. aureus virulence factors. interestingly, the chloride efflux in airway epithelial cells was significantly decreased in a time-dependent way by s. aureus virulence factors ( fold decrease after a h incubation). the co-incubation of airway epithelial cells with s. aureus virulence factors and sm/fp prevented the s. aureus virulence factorsdependent chloride efflux decrease. our results demonstrate that bacterial virulence factors induce the loss of the electrolyte homeostasis and suggest that the treatment by the combination of a corticosteroid and a long-acting beta agonist may preserve the airway epithelial functionality. supported by association vaincre la mucoviscidose and glaxo-smithkline nilsson, h.e. ; dragomir, a. ; ahlander, a. ; johannesson, m. ; roomans, g.m. . medical cell biology, uppsala university, uppsala, sweden; . women's and children's health, uppsala university, uppsala, sweden inhalation of hyperosmotic solutions (salt, mannitol) has been used in the treatment of patients with cystic fibrosis or asthma, but the mechanism behind the effect of hyperosmotic solutions on mucociliary clearance (mcc) is unclear. one explanation has been suggested, namely that hypertonic solutions open tight junctions, which may lead to increased water transport followed by an increased airway surface liquid (asl) volume. furthermore, the role in cftr-mediated hco -conductance in regulating asl ph has led us to investigate if ph changes may have an effect on the tightness of tight junctions. the effect of osmolarity was investigated on the hbe o-cell line by the addition of nacl, nabr, licl, mannitol or xylitol ( - mosm). the effect of ph was investigated on the hbe o-, calu- and t cell lines as well as the cystic fibrosis cell line cfbe o-. transepithelial resistance was measured as indicator of the tightness of the cultures. cell-cell contacts and morphology were investigated by immuno-fluorescence and by transmission electron microscopy, with lanthanum nitrate added to the luminal side of the epithelium to investigate tight junction permeability. the electrolyte solutions caused a significant decrease in transepithelial resistance from mosm on, when the hyperosmolar exposure was gradually increased from to mosm, whereas the non-electrolyte solutions caused a decrease in transepithelial resistance from mosm on. immunofluorescence micrographs showed weaker staining for the proteins zo- , claudin- in treated samples compared to the control. the ultrastructure revealed an increased number of open tight junctions as well as a disturbed morphology with increasing osmolarity, and with electrolyte solutions opening a larger proportion of tight junctions than non-electrolyte solutions. it was noted that during the exposure of the cultured cells to the hyperosmolar solutions, the ph of the medium increased from . to . . hbe o-cells exposed to both a rise in ph and hyperosmotic stress showed an overall lower teer and a significantly reduced ability to recover from stress compared to cultures at a ph hold constant at . . without exposure to hyperosmolar solutions, a rise in ph caused a significant decrease in transepithelial resistance in hbe o-cells, calu- and t cell lines but not in the cfbe o-cell lines, where the reaction was significantly less and delayed. in conclusion, hyperosmolar solutions caused a reversible opening of the tj in hbe o-cell cultures with electrolytes having stronger effects than non-electrolytes, where one of the effects on mcc may be due to increased water transport across the leaky paracellular space. an increase in ph caused a significant decrease in teer in the healthy cell lines compared to the cfbe o-cell line. we speculated that an impaired alkalinisation of the apical fluid due to a defective cftr also will cause the tight junctions to react different to other external stimuli, such as osmolarity, compared to healthy cells, which is also indicated by preliminary experiments on the effect of nacl on teer in cfbe o-cultures. extracellular nucleotides regulate surfactant secretion in alveoli and mucociliary clearance in airway epithelia, but the mechanism(s) of their release and their regulatory pathways remain incompletely understood. previously, we showed that hypotonic swelling of a epithelial cells induces ca + -dependent secretion of several adenosine and uridine nucleotides, implicating regulated exocytosis. in this study, we examined sources of intracellular ca + ([ca + ] i ) elevation evoked by acute % hypotonic stress and the role of autocrine purinergic signaling in ca + -dependent atp release. we found that atp release does not directly involve ca + influx from extracellular spaces, but depends entirely on ca + mobilization from intracellular stores. the [ca + ] i response consisted of slowly-rising elevation representing mobilization from thapsigargin (tg)-insensitive stores and a superimposed rapid spike due to ca + release from tg-sensitive endoplasmic reticulum (er) stores. the latter could be abolished by hydrolysis of extracellular tri-and di-nucleotides with apyrase; blocking p y /p y receptors of a cells with suramin; blocking udp receptors (p y ) by ppads; emptying tg-sensitive stores downstream with µm tg or mm caffeine in ca + -free extracellular solution; or blocking the ca + -release inositol , , -triphosphate (ip ) receptor channel of the er with µm aminoethyl diphenylborinate. these results demonstrate that the rapid [ca + ] i spike results from the autocrine stimulation of ip )/ca + -coupled p y /p y receptors, which accounts for ~ % of total ca + -dependent atp release evoked by hypotonic shock. our study reveals a novel paradigm in which atp release is amplified by the synergistic autocrine/paracrine action of co-released uridine and adenosine nucleotides. we suggest that a similar mechanism of purinergic signal propagation operates in other cell types. (this study was supported in part by the canadian institutes of health research and the canadian cystic fibrosis foundation (ccff). s.t. was the recipient of a ccff studentship). the maintenance of a thin liquid layer on the airways and alveoli surfaces is essential for normal lung physiology.yet, the mechanism sensing the height of the layer remains obscure. in this study, we examined atp secretion from human lung a epithelial cell monolayers mounted in a closed, flowthrough chamber ( . mm height) and found that passage of an air bubble over the monolayer caused transient (< . min) but significant atp release ( to , pmoles/ cells). air bubble-induced atp release was reduced by~ % from cells loaded with the intracellular ca + chelator bapta-am, and was completely abolished in n-methylmalemide-treated ( mm) cells, suggesting the involvement of ca + -dependent exocytosis. fura- intracellular ca + ([ca + ] i ) imaging experiments revealed transient [ca + ] i elevation during the passage of an air bubble over the cell monolayer, but the [ca + ] i response did not involve non-specific ca + influx from the extracellular space, e.g. due to cell damage, since similar responses were observed in ca + -free extracellular solution. ethidium bromide staining did not disclose any cell damage in these experiments. confocal fluorescence microscopy study showed reversible cell deformation (flattening) of % to % in height in the monolayer part in contact with the air bubble and confirmed that cell integrity was entirely preserved. these experiments demonstrate that in close proximity to the air-liquid interface (i.e. between the air bubble and the wet cell surface), surface tension forces are transmitted directly on cells, causing their mechanical deformation, elevation of [ca + ] i and subsequent atp release. we propose that a similar mechanism may operate in vivo in the airways, where surface tension forces acting directly on exposed epithelial cell surfaces may provide a fail-proof mechanism to protect proper airway surface liquid volume via mechanosensitive, ca + -dependent atp release and purinergic modulation of fluid secretion. this mechanism may be defective in cystic fibrosis due to excessive mucus layer covering the airways. introduction : cystic fibrosis is a genetic disease that reflects the consequences of mutations in the cystic fibrosis transmembrane conductance reg-ulator (cftr) gene, affecting anionic transport in epithelia. slc family members are anionic transporters involved in cl-and hco -absorption or secretion in epithelia. in addition, the activation of some slc family members by cftr has been demonstrated (nature cell biology, , : - ) . slc a is a poorly characterized member of this family, being the solely expressed in lung. putative interaction domains with cftr are also present in the slc a protein. in this study, we have investigated the transport properties of slc a (human) to determine the functional and pharmacological characteristics of this transporter. methods : to this aim, electrophysiological studies (two-electrode voltage clamp or current clamp methods and intracellular ph measurements using ph sensitive microelectrode) were performed in xenopus laevis oocytes expressing slc a proteins. complementary ( cl) transport studies were also undertaken. results : the protein expression results in the appearance of an anionic current showing a linear current/voltage relationship. cl influxes experiments confirmed the induced cl-permeability following slc a protein expression. the sequences of conductivity, cl->i-> no -≥ gluconate > so -and selectivity (px/pcl), i-> cl-= no -> gluconate > so -are found. the hco -conductance mediated by the slc a protein expression is low. using co /hco -containing ringer solutions, no intracellular phi changes were detectable in conditions (low chloride in external medium) favoring the cl-/hco -exchange whereas phi changes (alkalinization) were observed with the expression of the ae exchanger. however, phi changes could be detected in conditions largely favoring the driving force for hco -entry. dids and ns inhibited slc a associated currents. the specific cftr inhibitor (cftrinh ) or glybenclamide had little effect. elevation of intracellular camp (a cftr activator) was also ineffective while maneuvers increasing intracellular calcium blocked the slc a associated currents. conclusions : our study demonstrates that slc a presents an electrogenic anion conductance (characteristics of an anionic channel) when expressed in xenopus oocytes (however a transporter functioning as a ncl-/hco -exchanger can not be excluded). this function (channel) has also been described for another member of this family, slc a (j biol. chem, , : - ) . the physiological role of slc a , present in the bronchial cells of airway epithelia and its potential interaction with cftr has to be precised in situ or in oocytes and in mammal expression systems. medicine, women's & children's hospital, nth adelaide, sa, australia; . cf research & treatment center, university of nth carolina at chapel hill, chapel hill, nc, usa; [ ] [ ] [ ] [ ] [ ] [ ] jasri, hyogo, japan; . physics and synchrotron science, monash university, clayton, vic, australia; . paediatrics, university of adelaide, adelaide, sa, australia non-invasive imaging of lung (e.g. hrct, mri, pet) is a valuable modality for detection and monitoring of the effects of cf in human airways, but resolution is limited; e.g. airway hrct detects airways no smaller than ~ . mm dia. detection of wall or lumen changes in smaller airways, or the detection and monitoring of induced airway disease in live rodent models, demands significantly greater resolution coupled with rapid image capture. we report substantially increased airway resolution is achievable using synchrotron phase-contrast x-ray and can produce three-dimensional reconstructions encompassing the smallest mouse lung airways. nembutal-anaesthetised c bl/ mice (~ gm) were imaged at the spring- synchrotron in hyogo, japan. -d phase-contrast airway images were obtained on ccd detectors ( . µm pixels) with a cm phase-contrast propagation distance at kev; nose and trachea were imaged at or sec intervals ( - ms exposures) over mins. mice killed with nembutal overdose were imaged in axially aligned segments to obtain dimensional ct data voume of approximately x x mm with x x um voxels of nose, trachea, and lung (hammamatsu ccd detector). volume renderings were produced using volview or osirix software. live, -d nasal or tracheal imaging revealed airway-surface activity in some live mice consistent with dynamic mucociliary clearance activity. individual ct slices revealed the fine detail in the mouse lung, with dynamic ("fly through") sequences of lung ct slices permitting visual identification and tracking of lung tree branching from trachea (~ mm dia) into small airways (approx um dia). adjustment of x-ray contrast, opacity, and range in these volume reconstructions permitted selective display of the mouse lung conducting-airway tree and airway surfaces. selected regions of the lung could be examined statically, or in rotation through different orientations in high-resolution -d. synchrotron phase contrast x-ray provides a new option for non-invasive imaging of intact mouse lung, at a resolution that permits examination of small conducting airways in mice. combined with volume-reconstruction software these ultract images can provide a powerful option for understanding the structure-function relationships produced by airway disease. ultra-ct -d studies are underway to compare lung airways at high resoltuion in normal and transgenic mice having altered airway pathophysiology. the epithelial sodium channel, enac, has a vital role in the function of the pulmonary epithelia and significantly contributes to the pathophysiology of the cf airway. thus, strategies to repair mutant cftr dysfunction must also consider the influence of such repair on enac functional expression. the ∆f trafficking repair agent -phenylbutyrate modulates the expression of the kda molecular chaperones hsc and hsp in cf epithelial cells. we therefore assessed the role of these chaperones in the regulation of enac trafficking. in xenopus oocytes, we previously observed that overexpression of hsc inhibits murine enac (menac) functional and surface expression. in contrast, hsp can either enhance or inhibit menac functional and surface expression depending on the extent of overexpression [goldfarb et al. ( ), proc. natl. acad. sci. : - ]. here, we tested the hypothesis that these differential effects of hsc and hsp on menac expression also occur in epithelial cells. mdck cell lines with stable expression of α-ha, β-v , γ-myc-menac and tetracyclineinducible expression of either hsc , atpase-deficient hsc , hsp or atpase-deficient hsp containing myc/his epitope-tags were selected. all epitopes were fused to the respective c-termini. these cells were grown as high-resistance (> Ω/cm ) monolayers on permeable supports. doxycycline-induced overexpression of hsc decreased amiloride-sensitive i sc and the whole cell content of α-haand β-v -menac. in contrast, lower amounts of tetracycline-induced hsp overexpression increased amiloridesensitive i sc and whole cell α-haand β-v -menac expression; these effects were absent at higher levels of hsp overexpression. these data are consistent with our previous data in xenopus oocytes. interestingly, the atpase-deficient chaperones had the opposite effect on menac functional expression. modest doxycycline-induced expression of atpase-deficient hsc increased amiloride-sensitive i sc in these cells, while modest overexpression of atpase-deficient hsp decreased amiloride-sensitive i sc . these effects may result from "dominant negative" interference with hsc and hsp function, respectively. these data are consistent with hsc and hsp having different effects on menac functional expression in epithelial cells, and that these effects are dependent upon the atpase activity of the respective chaperones. supported by grants from niddk. we have studied survival, airway epithelia bioelectrics and lung pathology of mice over-expressing various combinations of the epithelial na + channel (enac) subunits (α, β and γ, genes scnn a, scnn b and scnn g). we generated double-transgenic mice and crossed them with single-transgenic mice to obtain litters comprising all possible genotypes. survival analysis revealed that overexpression of βenac in combination with either αenac or γenac significantly reduced survival in comparison to wild-type (wt) littermates. strikingly, at days of age, all genotypes were represented according to the expected mendelian proportion, except for the triple transgenic αβγenac, which was significantly under represented. in utero studies are ongoing to understand if over-expression of αβγ affects the fetuses or the newborn pups during the first hours post-partum. due to the high mortality of mice over-expressing βenac subunit combinations, we studied tracheas from pups at days of age. as previously reported, mice overexpressing β, but not the α or γ enac subunits, exhibit airways hyperabsorption of na + and lung pathology (mall et all ) . the βenac tracheas exhibited na + absorption [as measured by the change in short circuit current (isc) in response to amiloride in the ussing chamber] that was ~ . fold greater (∆isc . ± . µa×cm - , n= , means±sem) than wt ( . ± . µa×cm - , n= ). over-expressing αβ or αγ enac subunits resulted in rates of na + absorption that did not differ significantly from those of βenac or γenac subunit alone, respectively. however over-expressing the β and γ enac subunits together resulted in an amiloride sensitive isc that was ~ . fold greater (∆isc . ± . µa×cm - , n= ) than wt. we also studied the tracheal bioelectrics of the few day-old αβγenac pups available. tracheas from the αbγ pups exhibited na + absorption that was ~ . fold greater (∆isc ± . µa×cm - , n= ) than wt. due to the small sample size, we cannot determine if this response is significantly different from the response of the βγenac pups. analysis of lung pathology in day-old pups revealed that all the combinations that exhibited increased airway na + absorption and decreased survival in comparison to wt littermates, e.g. αβ, βγ and αβγ, also presented with alveolar space enlargement, maybe due to postobstructive air trapping, and airway epithelia necrotic degeneration associated with ab-pas negative bronchial obstruction. from these data, it appears that the rate of airway na + absorption negatively correlates with the survival of the pups. thus, it is likely that the mucus and airway surface liquid is more dehydrated as a function of the rates of na + absorption (aβγ > βγ > αβ, β > wt) which produces gradual failure to survive due to asphyxia secondary to airway obstruction. supported by nih scor p hl choi, j. , ; joo, n. ; wu, j. ; krouse, m. ; wine, j.j. . cystic fibrosis research laboratory, , stanford, ca, usa; . otorhinolaryngology, yonsei university, seoul, south korea submucosal glands, which produce most airway mucus, are mainly controlled by parasympathetic pathways that stimulate glands via airway intrinsic neurons distributed along the airway walls. the intrinsic neurons can be stimulated via axon reflexes from receptors in the mucosa. in previous experiments, it was shown that capsaicin applied to the mucosa stimulated gland secretion in the upper tracheas of wt but not cftr -/-mice (ianowski et al., j physiol, , , ) . it seemed important to assess a possible role of capsaicin-sensitive pathways in pigs and humans. we obtained pig tracheas following acute experiments carried out for other reasons, and human airways following lung transplants from donor tracheas and from the excised lungs of the transplant recipients. secretion from individual submucosal glands was quantified optically by time-lapse digital imaging of the growth of spherical bubbles of mucus in an oil layer in humans, commercial chili oil ( µm dispersed in µm mineral oil) stimulated mucus secretion from submucosal glands from both donors (n = glands from subjects, . ± . nl/min/gland) and disease control subjects (n = glands from subjects, . ± . nl/min/gland). however, there were no responses to chili oil in submucosal glands from cf subjects (n = glands from subjects, . ± . nl/min/gland). in pigs, we determined concentrationresponse relations for gland secretion in response to purified capsaicin (sigma). the threshold was ~ µm and the ec was . ± . µm. the response to µm capsaicin was partially blocked by high dose ttx (> µm). as in humans, the capsaicin response required cftr, because it was blocked ~ % by cftrinh- , (n = glands, from pigs, p < . ). cftrinh- is presently the most specific inhibitor of cftr that can be used with glands, where we do not have access to the apical membrane. in ferrets, intrinsic airway neurons express acetylcholine, vip and sp, often colocalized within the same neurons (dey et al., am j respir cell mol biol, , , ) . in pigs, all three of these transmitter systems appear to be involved in gland secretion to capsaicin, because the response was partially blocked by the nk- receptor blocker l (oxalate salt, µm), the vip receptor inhibitor l k ( µm), and the muscarinic receptor blocker atropine ( µm); each of these blocked to % of the response (n = to glands from to pigs). indeed, most of the local pathways are probably damaged, which may account for the relatively small responses to strong stimulation. relatively few experiments have been carried out in intact airways with uninterrupted innervation and circulation, but in those experiments the glands were highly responsive to modest mucosal stimuli (reviewed in wine, auto neurosci, , , ) . hence, we hypothesize that ( ) reflex stimulation of glands plays an important role in lung innate defenses; ( ) defects in these responses is an important reason that cf airways are prone to infection, and ( ) local reflexes may assume greater importance for maintaining the mucosal defenses of transplanted lungs. supported by niddk ro - (jjw), cff and cfri. most airway mucus arises from submucosal glands, which express cftr in their ciliated ducts and in serous cells. the airway glands secrete to agonists that either increase intracellular ca + (e.g. acetylcholine) or camp (e.g. vip).substance p(sp) also stimulates airway gland liquid secretion in pig (trout l et al., am j physiol lung cell mol physiol. , ,:l ) , suggesting that sensory afferents or local neurons that express sp play a role in stimulating submucosal glands. we used pharmacological methods to dissect the secretory mechanism of sp-induced gland secretion in comparison with responses to carbachol. tracheas were obtained from pigs after acute surgeries carried out for other reasons. the ventral mucosa with underlying glands was dissected from the cartilage, pinned mucosal side up at the gas/bath interface of a physiological chamber, and covered with oil. secretions from individual glands could be visualized as spherical bubbles in the oil, and secretion rates determined by optical monitoring of bubble diameters. concentration-response relations for gland secretion were determined for sp ( - bubbles at each concentration from pigs). the threshold was ~ nm for sp and the ec was . ± . µm. the maximum secretion rate to sp was . ± . nl/min.gland, which is only ~ / of the maximal secretion rate to carbachol ( . ± . nl/min.gland). the inhibition profile for responses to sp ( µm) was quite different from those to carbachol ( nm, a value chose to mimic the secretion rate to µm sp). gland secretory responses to µm sp ( . ± . nl/min.gland, glands from pigs) were strongly inhibited by µm cftrinh- ( . ± . nl/min.gland, glands from pigs, p< . ), and by µm clotrimazole ( . ± . nl/min.gland, glands from pigs), whereas µm niflumic acid did not inhibit ( . ± . nl/min.gland, glands from pigs). in contrast, secretory response to nm carbachol ( . ± . nl/min.gland, glands from pigs) were only weakly inhibited by cftrinh- ( . ± . nl/min.gland, glands from pigs, p< . ), and by clotrimazole ( . ± . nl/min.gland, glands from pigs, p> . ), but niflumic acid, which was ineffective with sp, inhibited the carbachol response ( . ± . nl/min.gland, glands from pigs, p< . ). gland secretion to sp depends at least partially on intracellular ca + release, because the response was partially inhibited by µm bapta-am ( . ± . nl/min.gland, glands from pigs, p< . ). there was no additional effect of sp on top of µm carbachol, but a subthreshold level of sp ( nm) showed synergic response ( . ± . nl/min.gland, glands from pigs) with subthreshold level of vip ( nm). we are presently testing how sp activates cftr-dependent mucus secretion. in initial experiments to determine if pkc was being recruited, however the pkc inhibitor (gf , sigma) did not suppress sp-induced mucus secretion. in contrast, the nkcc inhibitor bumetanide ( µm) markedly suppressed secretion to sp ( . ± . nl/min.gland, glands from pigs, p< . ). supported by niddk ro - (jjw), cff and cfri. mucus obstruction of airways is considered the most vicious agent of morbidity and mortality in cystic fibrosis (cf). to provide optimal defense of the small airways the volume/thickness of airway surface fluid must be controlled according to physiological demand. to date we have no clear understandings of how these fluids are maintained in a steady state between two pathological extremes (too little or too much) in native small airways. earlier studies have attempted to measure the ion transport properties of small airways of sheep (al-bazzaz et. al. ) and pigs (ballard et. al. ), but the complicated branching structure of small airways may have compromised electrical signals. to avoid dissection trauma wang et. al. ( ) examined the electrophysiological properties of undissected intact small airways from pigs in vitro by microperfusing bronchioles (diam. - mm) embedded in the lung parenchyma; however, these studies were limited to luminal manipulations and transbronchiolar electrical potentials only. to more rigorously define small airway properties, we designed a special micro ussing chamber ( area ≈ mm ). we excised and opened small airways (diam. - mm) of pig lung that we mounted as a flat sheet over a pvc supporting filter ( - µm holes). both sides of the tissue could then be bathed with different solutions at °c. the luminal side was isolated by pressing a pipette (≈ mm diam., tip fire polished) on to the apical surface of the tissue until it sealed electrically. constant current pulses ( . - . µa) were passed across the tissue. transepithelial potential (tep) and resistance in bilateral mm nacl ringers were, - . ± . mv and . ± . Ω.cm (mean ± se) respectively. when mm naglu ringers replaced the luminal solution, tep increased significantly to - . ± . mv (n= , p< . ) and resistance increased to . ± . Ω.cm (n= , p< . . adding forkskolin (fsk, µm) plus ibmx ( . mm) hyperpolarized the tep to - . ± . mv (n= , p< . ), but decreased the resistance to . ± . Ω.cm (n= , p< . ). luminal amiloride ( µm) depolarized the tep to - . ± . mv (n= , p< . ) but significantly increased resistance to . ± . Ω.cm (n= , p< . ). these results show that this system supports measurements of ion transport properties of airways smaller than mm diameter where cf lung pathology is thought to originate. these airway epithelia express a very high constitutively active clconductance and are apparently capable of secretory as well as absorptive functions. amiloride sensitive na + conductance (≈ ms/cm ) was not significantly affected by fsk added to activate secretion. the observation that stimulation with fsk did not significantly suppress na + conductance (≈ ms/cm ) (p= . ) may suggest that separate groups of reabsorptive and secretory cells comprise small airway epithelia. mucins are class of proteins uniquely characterized by large glycosylated domains. these proteins likely play a key role in cystic fibrosis (cf) lung disease as major constituents of mucus. in airways of both humans and mice, the gel-forming secreted mucins are represented by muc ac and muc b, and the transmembrane mucins are represented primarily by muc , muc , and muc . we have been interested in the role of the transmembrane mucins in airways and have previously demonstrated that lack of muc in a knock-out mouse model (provided by s. gendler) shows increased susceptibility to adenoviral-mediated gene transfer (stonebraker, j. virology, ) . to expand upon these findings, mice deficient for muc were developed using embryonic stem cell technology by deleting exon of the mouse muc gene, which contains the atg start codon and signal peptide. rna analysis reveals loss of exon in homozygous mutant mice and immunohistochemistry using a vntr antibody indicated a loss of full length muc protein. muc homozygous mice are viable and do not develop any spontaneous, readily detectable disease phenotype. although the muc deficient mice do have reduced fertility consisting of both reduced litter size and number, all major tissue systems where the muc protein is easily detected, including the eye, respiratory tract, intestine, and reproductive tracts, appear normal in year old mice after histological analyses. in contrast to the results we reported in the muc mice, the muc deficient mice do not show an increase in adenoviral mediated gene transfer, suggesting that muc is not involved in the barrier aspect of the airway glycocalxy, at least for adenoviral infection. interestingly, quantitative real-time pcr analysis revealed up-regulation of muc protein in the trachea of the muc deficient mice, suggesting that muc may be able to compensate for loss of muc . the expression of muc in human ciliated cells as revealed by recent antibody studies prompted us to evaluate the potential role of muc in ciliary function. ciliary beat frequency (cbf) was monitored in a shear chamber using microscopy image analysis. cbf under baseline conditions for this study (low shear stress) from muc deficient trachea (c bl/ j congenic n ) was significantly lower than that for littermate controls ( . vs. . , sem ± . , p = . ). application of shear resulted in increased cbf in both groups, although the wt response to shear was smaller in magnitude. thus, muc may have a role in supporting basal cbf and may make cbf less vulnerable to stimulation by shear, perhaps by reducing the inherent friction of ciliary motion. this finding underscores the usefulness of this model for dissecting out the normal roles that the transmembrane mucins play in airway biology. supported by nih (hl ) and cff (r -cr ). enac (joo et al. jbc , and jbc , ) . in a search for a model to test the hypothesis we found that ussing chamber short-circuit current(i sc ) measurements with freshly obtained airway mucosa provided useful information about enac activity in response to various drug treatments. in these studies we observed an as yet unidentified pathway that regulates surface enac activity. airway mucosa from sheep tracheas displays a large, amiloride/benzamil-sensitive i sc prior to stimulation. when stimulated with basolateral carbachol, the enac i sc was almost abolished, as indicated by a sustained decrease ( . ± . %, n= ) in i sc after an initial increase and left a small effect to subsequent amiloride or benzamil. in contrast, when carbachol was given after benzamil, it again produced a peak response followed by a sustained increase (~ %, n= ) in the i sc . enac inhibition by carbachol was dose dependent with a minimal sensitivity between . ~ µm and was slowly reversible. apical µm atp also inhibited enac i sc by . ± . % (n= ) and carbachol on top of atp further reduced the enac i sc by . ± . % (n= ). however, u/ml of apyrase pretreatment, in attempt to breakdown atp, failed to inhibit carbachol-induced enac inhibition, indicating that atp release is not on obligatory component of carbachol inhibition of enac. carbachol inhibition of enac could result from a direct action of carbachol on the surface epithelia, by activation of airway intrinsic neurons, or by activation of the glands, which were intact in these preparations and are strongly stimulated by carbachol. rabbit tracheas, which lack airway submucosal glands, displayed large enac currents and these were not inhibited by cholinergic stimulation (n= ). carbachol-induced enac inhibition, like gland stimulation but unlike stimulation of neurons, was mediated by muscarinic receptors since it was eliminated by atropine but not by the nicotinic receptor antagonist, hexomethonium bromide (n= ). however, inhibition of gland secretion with hepes/bumetanide did not eliminate the ability of carbachol to inhibit enac. the effects of carbachol on surface na + transport in our study are consistent with previous observations in microperfused sheep bronchiole preparations (al-bazzaz, ajp-lung , ). although we do not yet know the mechanism, it would be physiologically efficient if parasympathetic, cholinergic activation of airway gland secretion was accompanied by enac inhibition, which would minimize the fluid absorption by surface epithelia and increase clearance. it will be important to determine if cholinergic inhibition of enac is present in human tissues, and if so, if it is defective in cf. supported by cff and nih. introduction: lung disease accounts for more than % of the current morbidity and mortality associated with cf. the majority of research aiming to elucidate the reason(s) of severe lung disease has focused on airway surface liquid (asl) layer homeostasis or composition. the cftr gene encodes a camp-regulated clchannel located on the apical side of the epithelium and is instrumental in maintaining a hydrated asl layer and promoting effective mucociliary clearance (mcc). in patients with class i or class ii cftr genetic mutations, normal cftr clchannel activity in the epithelium is impaired resulting in na + hyperabsorption and consequently in the generation of a thick and static overlaying asl layer creating an environment that favors progressively worsening bacterial infections. in this study we investigated the potential contributory role of altered respiratory cilia function to inefficient mcc in cf airways allowing for bacterial infestations. our ex vivo model system was the nasal airways of the cftr gene knockout (cftr tm unc ) mouse in which key aspects of the phenotype of human cf lung disease, such as dehydrated asl layer and goblet hyperplasia, are observed. methods and results: ciliary beat frequency (cbf) was measured using a dual temperature controlled perfusion chamber, differential interference contrast microscopy and high speed digital video analysis system. we evaluated the cbf of nasal septa explants from homozygote cf (affected) and non-affected littermate wild type (wt) and heterozygote mice congenic on the c bl/ background. the basal cbf of homozygote cf mice ( ± hz, n= ) was significantly lower than that of wt mice ( ± hz, n= ) and also heterozygote mice ( ± hz, n= ) (p< . , anova, snk test). to determine whether the dehydrated asl layer was still present on the surface of the cf mouse nasal airway epithelium and as such impeding normal cilial beating, we fixed nasal septa (n= ) of cf and wt mice immediately following isolation using the pfc/oso fixation method to preserve the fragile asl layer and compared the height of the asl layer to nasal septa (n= ) from cf and wt mice fixed with pfc/oso immediately following cbf analysis. electron microscopy analysis revealed that although the asl layer was present at the time of isolation, there was no asl layer following the perfusion of solutions necessary for the cbf measurements. this finding demonstrated that the activity of cilia was not impaired in the cf nasal airway epithelium due to the presence of a dehydrated asl layer. cbf frequency was also significantly reduced in three different codes of mouse ciliated nasal airway epithelial cultures derived from affected cf mice compared to those derived from non-affected wt mice. conclusion: we show that the absence of the cftr gene product in the cf knockout mouse nasal airway epithelium is associated with significantly decreased basal cbf compared to the non-affected wt and heterozygote mice. this observation potentially provides an additional mechanism as to why lung disease persists in human cf lungs. ml and mba contributed equally. clinical studies have linked increased sputum and peripheral blood neutrophil mpo activity with increased airflow obstruction in cystic fibrosis (cf) patients of the same age, gender, airway bacterial flora, and cftr genotype. variations in the tgf-β gene associated with increased tgf-β production have been linked to worse airflow obstruction in cf patients of similar age, gender and cftr genotype. we hypothesized that in the presence of mpo, tgf-β production would increase in airway epithelial cells. we obtained normal human airway epithelial cells (hae) and cultured them in trans-wells. tgf-β mrna was measured by pcr. tgf-β protein was detected by immunofluorescence staining and immunoprecipitation. we found increased tgf-β mrna after hae were exposed to mpo (at activities found in cf sputum) normalized to mrna of constitutive beta actin. under identical conditions, tgf-β protein expression was increased in hae. we conclude that neutrophil mpo present on the apical surface of cultured hae induces transcription and protein synthesis of tgf-β . these results suggest that mpo induction of airway epithelial tgf-β is one molecular system linking the chronic neutrophilic endobronchitis seen in cf and subsequent airway wall fibrosis. are more oxidatively stressed than normal. as oxidative stress (os) is a potent activator of nf-κb, these data supported our hypothesis that cftr dysfunction causes alterations in the expression and/or modification of redox related proteins thereby enhancing activation of nf-κb. delineation of this interaction will produce good therapeutic targets. in this report we examine the role of os in cf inflammation. methods: to address our hypothesis, we used both in vitro and in vivo models of cf. our airway epithelial cell models are the hteo-pcep and pcep-r cell pair; and the hbeo-sense (s) and antisense (as) cell pair. additionally, we examined whole lungs from - week old b . s -cftr tm mrc mice (r h mutants back-crossed into the c bl j background). proteins were prepared from homogenates of whole samples, run on -d gels, and their densities compared. the gel spots of differentially expressed proteins were excised, subjected to in-gel trypsin digestion, and identified by lc ms/ms. for biochemical analysis, we tested for the levels of h o , glutathione, and lipid peroxidation. we correlated these data with measurements of nf-κb activity (elisa and cytokine production), and the activity of nrf- , an antioxidant (ao) response pathway transcription factor. we studied cultured cells in the presence and absence of inflammatory stimulation (tnf-α/il- β), and compared non-stimulated cf mouse lungs to lungs from normal litter mates. results: our proteomic analysis revealed that in the absence of inflammatory stimulation, a paradoxical decrease in ao proteins exists in cf cells by or more fold compared to matched pairs. this is despite a significant increase in intracellular os, which we confirmed by different biochemical measures. activity of nrf- was decreased by ~ % in cf cells vs. normal. the data predict an increase in h o , which is a potent activator of nf-κb, and we confirmed both a significant elevation in h o (up - fold in cf) and a related significant increase in nf-κb activity, as assessed by elisa for nuclear p , and il- and il- production. when we analyzed whole lungs from cf mice for antioxidant protein levels, we similarly observed decreases vs. normal littermates. when cells were stimulated, differences in protein expression and oxidative stress between cf and normal were further enhanced, corresponding to an excessive activation of nf-κb and increased production of il- and il- . treatment with the antioxidants nac or selenium decreased the activation of nf-κb to normal levels. members of the clc family of proteins form either voltage-gated chloride channels or cl -/h + exchangers; nine subtypes are found in mammals. among these, clc- is one of the most ubiquitous variants, which is expressed in several of the types of epithelial cells that also express the cystic fibrosis transmembrane conductance regulator (cftr). it has been postulated that clc- may be a suitable alternative chloride pathway in these cells; however the contribution of clc- to chloride transport in these cells is poorly understood. this is partly due to the lack of appropriate pharmacological tools that are capable of specifically inhibiting clc- . we describe here the isolation, from venom of the scorpion leiurus quinquestriatus hebraeus, of the first peptide inhibitor of any clc channel. this toxin, which we have named gatx , specifically inhibits the clc- channel. gatx bears primary sequence identical to that of a toxin thought to serve as a k + channel inhibitor, although no molecular target for this toxin was previously known. a homology model of gatx reveals that it adopts a similar fold to other scorpion toxins. gatx was prepared via solid-phase chemical synthesis, and the synthetic toxin inhibits clc- with higher affinity than any other inhibitor of clc- or any other chloride channel. the k d for gatx mediated inhibition of clc- in multichannel patches is only pm at v m = - mv, and pm at - mv. single channel experiments show that gatx does not alter single channel amplitude, but may alter channel gating. these experiments provide the basis for developing gatx into a useful tool that can be used to define the role of clc- in airway and intestinal epithelial cells. furthermore, the high affinity and specificity of inhibition suggest that gatx interacts intimately with the channel, and thus may the exploitation of alternative chloride channels to bypass the defect in cftr-mediated chloride secretion is an established therapeutic strategy in cf. in search of such potential therapeutic targets, we assessed camp/pkadependent chloride secretion across excised nasal epithelium of cftr null mice and wildtype controls, by measuring short-circuit currents (isc) in an ussing chamber set-up. all experiments were performed in the presence of amiloride to block the contribution of epithelial sodium channels to the isc. in cftr null mice of mixed background (c bl/ ; ), the camp agonist forskolin activated a bumetanide-sensitive rise in isc that was comparable in magnitude to the cftr-mediated isc response of littermate controls ( ± vs. ± µa/cm , respectively). the forskolin-induced isc in these null mice was inhibited by the general chloride channel inhibitor dpc, but appeared insensitive to the cftr inhibitors cftrinh- and glibenclamide, the orcc and calcium-activated chloride channel inhibitor dids, and the clc- inhibitors cadmium and pre-activated omeprazol. moreover, the isc response to forskolin greatly exceeded the response to the calciumlinked agonists ionomycin and carbachol. intriguingly, in nasal epithelium of cftr null mice with a different genetic background (fvb), no such forskolin-inducible secretory pathway was evident (cftr-/-: ± vs. cftr+/+: ± µa/cm ). when, in nasal epithelium of cftr null mice (c bl/ ; ), the basolateral membrane electrical resistance was negated by nystatin treatment, and in the presence of a transepithelial chloride gradient, forskolin failed to elicit a rise in isc, suggesting that camp/pka signaling targets a basolaterally located ion transport system. indeed, in intact epithelium, addition of chromanol b, a selective inhibitor of camp/pka-activated potassium channels, to the serosal bath, blocked the forskolin-induced rise in isc. we tentatively conclude that the hyperpolarization of nasal epithelial cells, which ensues from camp/pka-induced potassium efflux across the basolateral membrane, drives chloride exit across the apical membrane via a constitutively active anion conductive pathway that is absent from fvb cftr null mice. rt-pcr and immunostaining demonstrated that, among the candidate anion channels that fit the above pharmacological profile, clc-ka, but not clc-kb, was expressed in nasal epithelium of both cftr null mice and controls (c bl/ ; ), together with the accessory protein barttin. importantly, immunostaining suggested a strong increase in clc-k protein abundance in the cftr null mice, as compared to wildtype animals. on the basis of these findings, we postulate that clc-ka channels may serve as cftr bypass channels in nasal epithelium of cftr null mice that, albeit indirectly, are responsive to camp/pka signaling. future studies aim to characterize clc-ka and barttin in the airways from cf patients and controls, and to identify the post-transcriptional mechanism resulting in the up-regulation of clc-ka protein in cftr null mice. in the disease cystic fibrosis (cf), the most common mutation f del results in endoplasmic reticulum retention of misfolded cf gene proteins (cftr). the endoplasmic reticulum (er) f del-cftr protein retention is dependent upon chaperone proteins, many of which require ca + for optimal activity. an increase in cytosolic free ca + concentration is dependent on the activity of ion channels in the membrane of er and on extracellular ca + influx. this influx, named capacitative ca + entry (cce), induced by calcium store depletion, represents the major ca + influx mechanism in cells (putney et al., ) . during the cce, ca + influx can be mediated by one or several of the isoforms of transient receptor potential canonical channels (trpc) (putney et al., ) . aims & methods: in the present work, we studied the cce in human cf tracheal gland serous cfkm cells compared to non cf human tracheal mm cells. for this, we characterized the molecular identity of trpc channels responsible of cce by rt pcr technique and we compared global ca + influx in cf and non cf cells by using fluo -am probes. moreover, we measured the single channel activity of plasma membrane trpc channels by cellattached patch-clamp configuration in cf and non cf cells. we also studied the cce in cf cells after correction of the abnormal f del-cftr trafficking by miglustat ( h at µm of n-butyldeoxynojirimycin, nb-dnj) (norez et al., ) and low temperature ( h at °c) (denning et al., ) . results: we detected by rt-pcr technique the presence of trpc and trpc in both cell lines and we observed that cce was increased -fold in cf-km cells compare to non-cf mm cells. following stimulation by histamine, we recorded elementary ca + currents with similar amplitude ( . pa at - mv) and conductance ( ps) whatever the cells tested (cf-km or mm cells). however, we observed a -fold increase of the npo (number of channels in each patch × open probability of single channel) in cf cells compare to non-cf cells. in f del-cftr corrected-cf cells, the ca + influx stimulated by the ca + stores depletion was reduced to a similar level to non cf mm cells. the permanent contact of the airway epithelium with the external milieu induces frequent injuries caused by inhaled pathogens and particles. regeneration of the wounded airway epithelium needs to respect its prior structure in order to restore its defence functions. the underlying molecular mechanisms associated with the regeneration of the human airway epithelium are poorly described. the aim of our study was to determine, using a global expression approach, the transcriptional profile of human airway cells during the epithelial regeneration process. human airway epithelial cells collected from nasal polyps were seeded on type iv collagen-coated porous membranes, cultured up to confluence in liquid-liquid(ll) conditions, then put at the air-liquid interface (ali) allowing epithelial mucociliary differentiation. rna were extracted from epithelial cells at % confluence in ll conditions (epithelial cell proliferation and migration stage, step i), after days in ali conditions (beginning of epithelial cell differentiation, step ii), when first ciliated cells appeared (step iii) and when cultures were completely differentiated (step iv). our results demonstrated that between step i and step ii, genes were significantly modulated (ratio r<- or r> , p< . ), among them were activated and were repressed. between step ii and step iii, transcripts were up-regulated (tubulin, dynein, stath, microtubule associated proteins…) and only one gene (fatty acid desaturase- ) was repressed. finally, between step iii and step iv, except stath which was~ -fold down-regulated, we observed only few genes differentially and slightly modulated. all along the regeneration process, between step i and step iv, genes were significantly modulated with % of activated and % of repressed genes, among them a family of genes encoding proteins involved in the ciliary differentiation (foxj , tektin, dynein, tubulin, …), extracellular matrix proteins (collagen, laminin, …) and inflammatory-related genes like cytokines, growth factors and their receptors (ccl , vegfc, csf , il , il ra …). by elucidating the specific transcriptome involved in each step of the human airway epithelium regeneration, our study could allow to better understand the different cellular and molecular mechanisms, as well as the chronological events involved in these processes, and will further be applied to the study of the regeneration process in cystic fibrosis airway epithelium. supported by french association vaincre la mucoviscidose. electrolytes may be transported either through cells, the transcellular pathway, or between cells, the paracellular pathway. most research has focused on the channels and transporters of the transcellular pathway, while much less is known about paracellular transport. paracellular transport is regulated by tight junctions. claudins, the main component of tight junctions, are necessary and sufficient for tight junction formation and are important in establishing ion selectivity. the goal of this study was to further investigate the role of tight junctions in human airway epithelia. real-time pcr identified claudins , , , , , and in primary human airway epithelia. immunocytochemistry localized claudins , , , and to tight junctions. to measure the relative ion selectivity of tight junctions, we studied well-differentiated human airway epithelia in ussing chambers. to minimize transcellular transport, we used cf epithelia, which lack cftr and blocked enac with amiloride. we found the pna/pcl is . ± . , suggesting tight juctions are more permeable to cations than anions. the relative cation selectivity was na+ > k+ > cs+ > tma+ > mg + and the relative anion selectivity was cl-> br-≥ i-> no -> gluconate-. we compared these in vitro results to in vivo studies in people with cf and measured nasal voltage in the presence of amiloride. we found the pna/pcl is . ± . . tight junctions were slightly more selective for cations than anions in vitro and in vivo. to determine the effect of specific claudins on the selectivity of the paracellular pathway, primary human airway epithelia were infected with adenovirus expressing claudin or gfp. epithelia overexpressing claudin had a higher transepithelial resistance (ter) and the pna/pcl was . . however, infection efficiency was only %. this lead us to investigate if transformed human airway epithelial cells lines may be a better model to study permeability. cufi cells also express claudins , , , , , and . furthermore, like the primary human airway, cufi cells are more selective for cations; pna/pcl = . ± . . future studies will investigate the effect of claudin expression on the paracellular permeability of these cells. the results will help identify the properties of a pathway critical to epithelial transport and barrier functions. altered adenosine (ado) signaling is associated with chronic lung disease and increased asl ado levels are thought to drive inflammation by stimulation of a b receptors (a b-r) in airway epithelia, which can activate nfκb. when measured by lavage, asl ado is ≤ nm. due to its relatively low affinity to ado, a b-r are thought to be inactive under normal conditions (ec is ~ . µm), and only stimulated during chronic lung disease. however, we have previously demonstrated that the ado-receptor (ado-r) antagonist -spt inhibits asl volume regulation, and that a b-r is in close proximity to cftr. thus, we hypothesized that the asl ado concentration close to the apical membrane is higher than measured by asl lavage in bulk solution. we tested this hypothesis by looking for ado-r expression and function in well-differentiated human bronchial epithelia cultures (hbecs) and in vivo. by pcr analysis, we found that a b-r was the only ado-r expressed in hbecs. we then measured asl height over h ± ado-r antagonists by xz confocal microcopy when asl height was preset to ~ µm at t= . at µm, caffeine is a non-specific ado-r antagonist, which inhibited asl volume regulation ( h asl height was . µm vs. . µm for controls, n= ). similar inhibition was observed with alloxazine, which is relatively specific for a b-r (n= ). in contrast, dpcpx, zm & mrs , which inhibit a , a a & a -r respectively had no effect on asl volume regulation. asl height regulation was also ablated by the addition of adenosine deaminase (ada) to the asl (n = ). we next attempted to recapitulate the changes in asl height seen under control conditions, i.e. increase from to µm over the initial h followed by a plateau (the remainder of the h) by adding the non-hydrolyzable ado analogue neca to the asl in the presence of ada. nm neca was insufficient to regulate asl volume and height remained at µm over h. in contrast, addition of µm neca to the asl resulted asl volume regulation that was indistinguishable from control conditions (n= ), suggesting that near-membrane asl is much higher than has been measured by lavage. to confirm that a b-r stimulates cftr chloride secretion, we measured transepithelial potential differences of hbecs mounted in ussing chambers. a dose-dependent increase in cl-secretion was observed by ado addition with an ec of . +/- . µm, similar to the concentration of neca required to regulate asl height. to demonstrate which ado-r are expressed in human airways in vivo, we used laser capture to obtain ciliated cells from frozen tissue sections of excised donor bronchi. relative expression of a b-r by qpcr was found to be . +/- . fold higher than the a , a a-r, or a receptors (n= ). to confirm that ado-r activate cftr in vivo, we measured nasal potential differences. we found that ado activated chloride secretion at similar levels to isoproterenol. the effect of ado was inhibited by pre-exposure to µm caffeine (ado, . +/- . mv; ado + caffeine, . +/- . mv). we conclude that a b-r has an important role in asl homeostasis through regulation of cftr and it is active in human airway epithelia under normal physiological conditions. through osmotic forces, hypertonic saline (hs) may increase the volume of cf airway surface liquid, restore mucus clearance, and improve lung function. the na + channel antagonist amiloride is predicted to increase the duration of action of hs. however, patients taking amiloride with hs showed less clinical benefits than patients taking placebo with hs. in vitro data suggested that amiloride inhibits transepithelial water flux (pf) in cystic fibrosis airway epithelia. we have extended this study by looking at the effects of amiloride on aquaporins in a heterologous expression system (mdck cells) and have used immunofluorescence to determine which aquaporins are expressed in human airways in vivo and in vitro. inhibition of enac by aprotinin pretreatment had no effect on hs-induced pf (n= ), suggesting that amiloride did not exert its actions on pf by inhibiting enac. however, since hs-induced pf was also inhibited with hgcl , we speculated that amiloride directly blocked an aquaporin. to test this hypothesis, we measured the rate of cell shrinkage of wild-type mdck cells, and those stably-expressing aqp or , or expressing aqp (after h exposure to a mildly hypertonic media; mosm). following mucosal exposure to a mosm hypertonic ringer solution, mdck cultures grown to confluency on permeable filters shrunk by % after s (n = ), as measured by xz confocal microscopy following staining with calcein-am. in contrast mdck/aqp or mdck/aqp cultures shrunk by % over the same period and mdck/aqp cultures shrunk by % (all n= ). a min pretreatment with µm amiloride abolished hypertonic ringer-induced cell shrinkage in mdck/aqp cultures ( % at s; n= ) but had no affect on cell shrinkage in aqp or aqp expressing cultures. amiloride is fluorescent and can be imaged in epithelia by xz confocal scanning under uv excitation. amiloride was not internalized immediately (< s) before hypertonic ringer addition and did not block aqp -mediated cell shrinkage ( % at s; n = ). however, a min pretreatment with amiloride caused it be internalized and at this time aqp -induced cell shrinkage was blocked, suggesting that amiloride blocks aqp intracellularly. to confirm that aqp is present in airway epithelia, we performed immunostaining with an aqp antibody and found that aqp is highly expressed at the apical membrane of ciliated cells in human bronchial tissue and well-differentiated bronchial cultures. we conclude that amiloride blocks aqp , which is abundantly expressed in the superficial airway epithelia. supported we have previously observed that cftr, annexin (a ) and cytosolic phospholipase a (cpla ) are partially recruited in detergent insoluble microdomains (dim) upon proinflammatory stimulation. this is prevented by specific inhibition of cftr. a participates in the regulation of inflammation by inhibiting cpla activity. we have also shown that a expression is decreased in cftr-/-mouse tissues. we postulate that cftr, a and cpla participate in the regulation of inflammation by their dynamic interaction within dim. in this study we aimed to (i) demonstrate and characterize this interaction, and (ii) identify other potential partners of this complex in dim. by coimmunoprecipitation, we examined the interaction between cftr, a and cpla in human pulmonary epithelial cells calu . to search for additional partners we developed a new proteomic approach based on double sds-page (dsds-page), which is compatible with membrane protein analysis. calu cells and human epithelial bronchial cfbe cells (expressing either wt or f delcftr) were subjected or not to proinflammatory conditions (tnfα). dim were isolated by density gradient and analyzed by dsds-page. cftr immunoprecipitated with a and cpla in calu cells. dsds-page analyses showed significant differential expression of cytokeratin , actin and protein disulfide isomerase (pdi, involved in protein folding) in dim between control and proinflammatory conditions in calu cells, and between wt and f del cfbe cells, as determined by mass spectrometry. in conclusion, cftr, a and cpla interact in basal conditions. proinflammatory treatment causes differential expression of cytoskeletal proteins and pdi depending on the expression of normal and mutated cftr. this work suggests that cftr could participate in the regulation of inflammation within a complex with a and cpla . cytoskeletal proteins and pdi could be involved in the dynamics of this complex. this could be related to the abnormal inflammatory response characteristic of cf. we acute and chronic inflammation, common features of cf airways disease, have been linked to higher atp release and changes in atp metabolic patterns in vivo, e.g., in induced sputum and exhaled breath condensate from cf patients and bronchoalveolar lavage fluid from inflamed lobes (esther, ped pulm sppl , ) . we, therefore, investigated the contribution of airway epithelia per se to the raised atp concentrations on cf airway surface during inflammation. when exposed to supernatant of mucopurulent material (smm) from cf airways for h, or infected with respiratory syncytial virus (rsv) h prior to the study, basal atp release from well-differentiated primary human bronchial epithelial (hbe) cultures did not differ from that of control cultures. however, basal atp release was increased weeks after rsv infection when inflammation had waned (as indexed by il- secretion). the increase in basal atp release correlated with increased basal udp-glucose and mucin release, and goblet cell metaplasia. these data indicate that the increased basal atp release following rsv infection reflected increased goblet cell secretion. a different pattern was observed for stimulated atp release. hbes exposed to smm for h, or infected with rsv h prior, released - times more atp following hypotonic challenge than control cultures (okada, ped pulm sppl, ) . the increase in peak atp concentrations correlated with the degree of inflammation as indexed by il- secretion and the increase in intracellular calcium (ca + i ) mobilization in response to hypotonic challenge, but not with the goblet cell number. ca + i mobilization in response to hypotonic challenge in control hbes was almost completely due to extracellular ca + i influx which was inhibited by antagonists of a transient receptor potential v (trpv ) ca + channel. in contrast, an additional component of atp-induced ca + i release from endoplasmic reticulum (er) was observed in smm-treated hbes. the increase in hypotonicity-induced atp release in smm-treated hbes compared to control hbes was almost completely sensitive to chelation of ca + i by bapta ( µm; h), or inhibition of exocytosis by brefeldin a ( µm; . h), monensin ( µm; h) or n-ethylmaleimide ( mm; min), whereas these reagents were ineffective against hypotonicity-induced atp release from control hbes. these data suggest a positive feedback loop between the increased atp release linked to ca + i -dependent exocytosis and the increase in atp-induced ca + i mobolization linked to increased er ca + i stores (ribeiro, jbc , ) in inflamed hbes. in conclusion, we propose that basal and hypotonicity-induced atp release from hbes are regulated in distinct mechanisms during inflammation. basal atp release reflects continuous exocytosis processes independent of ca + i mobilization and differs as a function of cell type (ciliated vs goblet cell), whereas acute inflammation upregulates hypotonicity-induced atp release via increased ca + i mobilization and ca + i -dependent exocytosis. we conclude that airway epithelia exhibit multiple mechanisms of increasing atp release into the lumen in response to inflammation. supported by cff grant okada i to sfo and grants from nih. the main biological role of vitamin d is in control of bone and mineral metabolism, but it has also been discovered to have many immune system functions. vitamin d, a fat soluble vitamin, is poorly absorbed in cf leading to low serum levels. we sought to investigate the involvement of vitamin d in the control of inflammation in a cf model. methods cf tracheal epithelial cells (cfte) were pretreated with vitamin d ( , [oh] d ) or control and exposed to p aeruginosa lipopolysaccharide (lps) for hrs before collecting the cell supernatants. cytokine levels in the supernatants were assessed by cytokine array and subsequent elisas specific for il- , il- and mcp- . vitamin d was measured in the plasma of children with cystic fibrosis aged months to years. neutrophil numbers, neutrophil elastase (ne) activity and il- concentrations were measured in the bronchoalveolar lavage (bal) of these children. children with cystic fibrosis were deemed to be non-colonised, intermittently colonised or chronically colonised with p aeruginosa on the basis of the leeds criteria. pretreatment with vitamin d significantly reduced secretion of il- , il- and mcp- from cftes after challenge with p aeruginosa lps in a dose dependant manner. plasma vitamin d levels were highest in the noncolonised group and lowest in the chronically colonised group with intermediate levels in the intermittently colonised group. bal neutrophil counts, ne activity and il- concentration showed a reciprocal pattern. conclusions vitamin d acts on cf lung epithelial cells to protect against excessive cytokine production in response to lps. levels of vitamin d are inversely related to both p aeruginosa colonisation status and bal markers of inflammation. low levels of vitamin d may contribute to advancing lung disease in children with cystic fibrosis. more aggressive correction of vitamin d deficiency may have a role in protecting against excessive inflammatory response to infection. sleeping in a mist tent has been used as a treatment for cystic fibrosis (cf) patients, in order to hydrate the viscous mucus and make it easier to be removed by coughing (matthews et al., ) . however, the efficiency of the method has been questioned, and its use was largely discontinued. with a new method to measure the ion content of human nasal fluid the effect of sleeping in a moisture tent on the ion content of nasal airway surface liquid (asl) in cf-patients and healthy controls was determined. the cf-patients and healthy controls spent a night ( h) in a mist tent, and samples of the nasal asl were taken before the experiment, after the period in the tent, and then at each hour during h after the persons had left the tent. samples of nasal fluid were collected on sephadex g- beads that had been mounted on strips of filter paper, which were then put into the nasal cavity of the cf patients or controls for - min. the strips were removed, and the beads were isolated, dried, and analyzed by x-ray microanalysis (vanthanouvong et al., ) . the concentration of na, cl, and k in the nasal fluid of cf patients was , , and mm, respectively, before the patient entered the tent, significantly higher than the levels in the nasal fluid of the controls (na mm, cl mm, and k mm). during the period in the tent, the ion content decreased, to levels of na mm, cl mm, and k mm (cfpatients) and na mm, cl mm, and k mm (controls) immediately after leaving the tent. after leaving the mist tent the ion levels in the nasal fluid increased, reaching after h values of na mm, cl mm, and k mm (cf-patients) and na mm, cl mm and k mm (controls), which was for both groups higher than before entering the tent. no major changes in the ion content of the asl occurred after h. the salt content of the asl may be relevant in cf, since the asl is known to contain anti-bacterial proteins, defensins, which are sensitive to the salt concentration (bals et al., ) . hence, the higher salt concentra-tions in the asl of cf-patients may have negative consequences for the anti-bacterial defense system in the lungs, and conversely, the decrease in ion concentrations, caused by spending time in a mist tent, may have positive effects. (we have previously shown that none of our patients was chronically colonized with pseudomonas aeruginosa while regularly sleeping in mist tents.) however, with currently used procedures, the effect of sleeping in a mist tent on the ion content of the nasal asl is short-lived. bals background: antibody microarrays for clinical applications have been anticipated for more than a decade but the technology has only recently become sufficiently mature for reproducible, robust detection of low abundance proteins. the advantage of this new technology is the high throughput, parallel detection of identified, known, low abundance proteins. antibody microarray results are usually given in terms of ratios between two samples (e.g., "experiment" and "control"). however, given the printing and calibration issues inherent with antibody microarrays, this ratio'ing approach precludes statistically valid inter-array comparisons of the individual protein concentrations. we have therefore developed and implemented a different calibration strategy using a benchmark mixture that is applied to every array as an internal standard, thus controlling for any differences in antibody activities as well as printing imperfections. the amount of protein bound to each spot is determined relative to the respective protein in the internal standard. since all samples in the study are compared to the same internal standard, this semi-quantitative approach permits the comparison of multiple samples. all data for the same antibody on multiple arrays can then be used to calculate the average and standard deviation for a given population (such as patients or control groups) in a parallel fashion. methods: cf lung epithelial cultured cells ib - and the cftrrepaired ib - /s were biosynthetically labeled with a hour pulse of [s]methionine, and then chased with cold methionine for , or hours. we then isolated total protein from each sample, and labeled the proteins with cy . labeled proteins were applied to clontech® antibody arrays ( antibodies printed in duplicates) according to the manufacturer's protocols. the internal standard, consisting of a mixture of cell cultures and tissue extracts known to contain the cognate protein for each antibody on the array, was labeled with cy . the data were then used to compare the cf and the corrected cells in terms of amount, biosynthesis rate and degradation half-life (t / ) for each one of the features on the array. data analysis: for each spot on the array the ratio of cy /cy (after background subtraction) was calculated, normalized and stored for further analysis. for "pulse-chase" experiments the ratio of [s] counts to cy at each time point gives a measure of the fraction of newly synthesized (radiolabeled) to total protein (dye labeled) bound to each given antibody on the array. the addition of the cy labeled internal standard enables the calibration of these totals, allowing the comparison all the spots for any given antibody on multiple arrays. furthermore, the internal standard calibration makes it possible to compare not only t / values but also to calculate the relative degradation rates in different cell lines even when the amounts of that protein are different in the "control" and "experiment" cells. the new approach quantitatively identifies and subjects to analysis the effect of the cftr mutation on protein biosynthesis and degradation of the cellular signaling proteome. supported by nih no -hv- (hbp) and ro - (hbp) in cf patients, defective apical chloride secretion, due to lack of functional cftr, leads to dehydration of airway surface liquid (asl) and mucus plugging. this defect is likely ameliorated, in part, by an alternative route of chloride conductance, the calcium activated chloride channel (cacc) . female gender appears to be associated with more rapid decline of lung function and earlier death in cf. this suggests that gender differences in hormonal environments might influence asl height regulation, thus modifying the pulmonary phenotype. we hypothesized that changes in estrogen concentrations might alter asl hydration by affecting cacc. consistent with this, we have shown that estrogen attenuates increases in intracellular calcium and asl height that follow purinergic receptor activation in primary cultures of human bronchial epithelial cells (hbecs, see accompanying abstract by hengrui sun et al). here, we report correlations between estrogen levels and nasal ion transport in vivo and further probe hormonal effects on ion transport and asl height regulation in vitro. in vivo studies: in healthy, spontaneously menstruating females, nasal potential difference (npd) was measured (both nostrils) on two occasions during a single monthly cycle. based on a history of the most recent menstrual cycles, we measured npd on a day when estrogen levels were predicted to be low (generally - days following onset of menses) and subsequently on the day when the pre-ovulatory estrogen surge was predicted. the recording electrode was positioned at the location where maximal stable basal pd was detected and changes in pd recorded continuously during sequential perfusion with ] ringer's solution, ] ringer's solution containing amiloride (to inhibit sodium absorption via enac), ] modified (low chloride) ringer's containing amiloride and finally ] a similar solution also containing utp (to activate cacc). as predicted, blood estrogen levels were higher on the "pre-ovulatory" day ( . ± . vs . ± . nm, p< . ). utp-stimulated change in pd was significantly lower on the study day when estrogen levels were elevated ( . ± . vs . ± . mvs, p< . ). further, the amiloride-sensitive component of basal pd was higher on this day ( . ± . vs . ± . mvs, p< . ). the change in pd in response to perfusion with a low chloride solution was not different. in vitro studies: expression of estrogen receptor (er) α (but not β) was confirmed in non-cf and cf hbecs by real time pcr. erα was detected in hbecs from males and female donors. in cf and non-cf hbecs mounted in modified ussing chambers, exposure to nm e was associated with a significant (~ %) reduction in utp-stimulated short circuit current. e inhibited the atp-stimulated increase in asl height in male and female hbecs and this asl regulatory phenotype was not reproduced by testosterone or progesterone. in conclusion, estrogen inhibits utp-activated chloride secretion in vivo and in vitro suggesting that elevated pre-ovulatory estrogen levels may further impair mucociliary clearance in females with cf. all data mean±sem. supported by cff leroy matthews award [ ] . data demonstrating an upregulation of caccs when cftr is absent or defective [ , ] have triggered further studies of these channels and prompted further elucidation of the functional (and possibly also physical) interactions between these two channels. although searched for long, the molecular identity of caccs is still under debate. the role of bestrophin family proteins as putative candidates for caccs is discussed controversially. bestrophin (best- ) has been proposed to form ca + activated clchannels in epithelial cells. moreover, caccs have been shown to support cell proliferation, namely in the development of cancer [ ] . here, our goal is two-fold: ) to investigate the correlation between expression levels of best- and epithelial cell proliferation; and ) to pursue a search for interacting protein partners of best- to better understand the role and function of bestrophin(s) in epithelial cells. to study the correlation between best- expression and cell proliferation, we analyzed two populations of the t colonic carcinoma cell line with very different proliferation rates: the original (t -slow) and the spontaneously transformed t cells (t -fast). we observed that t -slow cells have a small proliferation rate and express low amounts of best- , while t -fast cells express high levels of this protein. best- is spontaneously active in t -fast cells. best- -rnai inhibited ca + activated clconductance and cell proliferation, therefore establishing a novel role of bestrophins in cell proliferation, which may be of relevance for the regeneration of the epithelia in cf and also for alternative therapies for cf. for the second objective, two putative cytoplasmic domains of best , polyhistidine -tagged (phis) n-term (aa - , best -n) and c-term (aa - , best -c), were cloned into the pet-sumo bacterial expression vector. these domains were then immobilized onto metal-affinity resin to capture interacting proteins from human t whole cell and sub-cellular lysates. protein-containing fractions recovered from best -n/c-coated and blank resins were subjected to d-gel and protein identification. it is expected that functional characterization of the interaction between the captured proteins and best- will give new insights into the biological role, plausibly of relevance to cf. work supported by dfg-sfb -a grant (germany) and pluriannual funding of cigmh (feder-eu and fct, portugal extracellular nucleotides acting on epithelial cell surface purinergic receptors regulate the mucociliary clearance process that removes noxious materials from the lung. however, how epithelial cells release nucleotides into the airways remains largely unknown. cftr has been suggested to mediate atp release in airway epithelia, but conclusive demonstration remains elusive. calu- is a human airway derived cell line often described as a model of airway gland serous cells. at least % of cells in a monolayer expressed high levels of cftr protein and activity at the apical membrane. atp, adenosine, and udp-glucose, the naturally occurring agonists for the p y , a b, and p y receptors, respectively, were quantified in airway surface liquid with nanomolar sensitivity using radiolabeling and fluorescence hplc-based techniques, and real-time atp measurements. atp (and udp-glucose) was found to be released constitutively and selectively onto the mucosal surface of calu- cells. however, the specific cftr inhibitor ( µm, - min) failed to decrease atp concentration in the mucosal bath of resting calu- cells. forskolin ( µm, min) stimulated cftr channel activity, but did not affect basal levels of atp (or udpglucose) release. in contrast, elevation of intracellular calcium using ionomycin ( - µm, - min) significantly increased atp (and udp-glucose) release into the mucosal (but not serosal) bath of calu- cells. calciummediated nucleotide release enhancement was not abolished by cftr inhibitor . maneuvers like pre-incubation in nominally free-calcium solution, bapta ( µm, min), or cytochalasin d ( µm, min) to disrupt actin cytoskeleton, which inhibited regulated exocytosis in calu- cells, also reduced calcium-mediated increase in nucleotide release. calu- monolayers presented a fraction of cells (< %) exhibiting negligible cftr immunostaining signal, but displaying airway goblet cell mucin granules. remarkably, stimulation of atp and udp-sugar release with ionomycin resulted in concomitant enhanced exocytotic secretion of muc ac. these results suggest that cftr is not involved in regulation of atp release in airway epithelial cells. more likely, nucleotides and nucleotide-sugars residing in the biosynthetic pathway involved in modification of apically targeted glycoconjugates (e.g. mucins) are released to the extracellular environment via calcium-triggered exocytosis. supported although the regulation of na+ transport is relatively well described in normal and cf airway epithelial cells, the impact of inflammation and infection, two major components of cf lung disease, on na+ transport has not been studied extensively. significant amounts of evidence suggest that bacterial by-products may influence na+ transport in airway epithelium. furthermore, the secretion of exoenzyme s by pseudomonas aeruginosa is enhanced during an exacerbation of lung disease in cystic fibrosis. in the past few years, our laboratory has shown that exposition of lung epithelial cells to p. aeruginosa lps leads to a rapid decrease in activity and expression of enac channel. the aim of our study was to evaluate the mechanism involved in the modulation of enac expression and activity by lps. primary culture of lung epithelial cells grown on filters were treated with lps ( µg/ml) for different time ( min, , , h). at each time point, the total and amiloride-sensitive short circuit current (isc) was determined in ussing chamber. in parallel, the cell proteins were collected to investigate by western blot the signalling pathways involved in this response to lps. a hours lps treatment leads to a significant decrease in alpha and gamma enac mrna to % and % of control respectively. similarly, the amiloridesensitive current was decreased by % of the current in untreated cells after a min exposure to lps. by western blot, we demonstrated the strong implication of the pi k/akt pathway in response to lps in the regulation enac mrna and the potential implication of tyrosine/kinase receptors signalling pathway through mtor in the regulation of enac channel activity. in conclusion, we demonstrate that inflammatory molecules can modulate the expression and function of the na+ transport mechanism in lung epithelial cells and could contribute to the modulation of airway surface fluid in the chronic infectious process associated with cf. serous acinar cells are thought to be crucial for secretion of airway surface liquid by submucosal glands in large airways, but the molecular mechanisms of serous cell ion and fluid transport are not well understood. to address this, we isolated murine nasal serous acinar cells and studied them using simultaneous dic and quantitative fluorescence microscopy to track changes in cell volume and intracellular concentrations of ions involved in fluid secretion ([cl -] i ; spq) and its regulation ([ca + ] i ; fura- ). previous results indicated that serous acinar cell volume changes were indicative of solute efflux (shrinking) and solute influx (swelling), reflecting the secretory state of the cell. acinar cells stimulated with µm carbachol (cch) exhibited a rapid increase in [ca + ] i and subsequent ~ % cell shrinkage due to efflux of ~ % of cell clcontent and parallel loss of k + and osmotically obliged h o. because murine serous cells are sites of apical cftr expression in the airway, we tested the requirement for cftr in cch/ca +activated shrinkage/clefflux. acinar cells isolated from either cftr tm unc-/mice or wt cells pre-treated with cftr inh exhibited identical rates and magnitudes of ca + -induced cell shrinkage and clloss compared to wt control cells. resting [cl -] i was also identical in wt and cftr tm unc-/serous acinar cells ( ± and ± mm, respectively), suggesting similar levels of resting clconductance. thus, murine serous acinar cells can secrete kcl/h o by ca + -dependent mechanisms in the absence of functional cftr, in agreement with studies of intact glands suggesting cch-induced glandular fluid secretion is cftr-independent. wt serous acinar cells were stimulated with camp-agonists, including µm forskolin, µm isoproterenol, µm adenosine, and µm vip. however, no camp-induced shrinkage was observed, even in the presence of a cocktail of inhibitors to block solute uptake. to determine if cftr activation could enhance cch/ca + -induced cell shrinkage at a sub-optimal [cch], serous acinar cells were pre-treated with forskolin followed by stimulation with µm cch in the continued presence of forskolin. however, similar rates and magnitudes of cell shrinkage were observed in forskolin-treated and control cells. these results suggest that the magnitude of the cftr clconductance in murine serous acinar cells is much smaller than the ca + -activated clconductance, below the resolution of these optical assays. more sensitive electrophysiological approaches are being used to determine the molecular identity of the non-cftr clconductance(s) and the role of cftr in murine serous acinar cell ion transport. females with cf exhibit more rapid decline in fev than males, which reduces their life span. normal airway epithelia regulate airway surface liquid (asl) volume and mucus transport by secretion through both cftr and the ca +-activated cl-channel (cacc), and inhibition of either of these pathways in isolation does not abolish mucus transport. however, a loss of both pathways is predicted to result in mucus plugging which contributes to lung disease. despite a loss of cftr, cacc is functional in cf airways due to mechanical stimulation of atp release and activation of the p y pathway which serves to raise intracellular ca +. we hypothesized that e may inhibit cacc, leaving females with cf more prone to lung disease than males due to a greater depletion of asl volume. using confocal microscopy, we found that acute pre-exposure with e inhibited atp induced asl secretion in normal and cf human bronchial epithelial cultures (hbecs) from both male and female donors. the ic for e -inhibition of atp-induced asl secretion was . nm. to better understand how estrogen receptors (ers) interact with the p y pathway, we transiently transfected er-α or er-β linked to an orange fluorescent protein in an er null bhk cell line. with the co-transfection of ha tagged p y -r, we observed that e addition did not induce internalization of p y -r, neither did it alter the internalization induced by atp. we then measured total cell inositol phosphates (ip) in cf airway cells +/-e pretreatment. cell ip levels were not different between groups (n= ), suggesting that the effect of e is downstream of ip production. the investigation of the changes of the intracellular ca + (ca +i) by recording fura- emission ratio over time in er-α or er-β expressed cells provided clues. after nm e exposure, the fura- emission ratio in untransfected cells (n= ) or er-β transfected cells (n= ) increased by . following um atp addition. this increase was significantly inhibited by~ % in er-α transfected cells (n= ), providing good evidence that er-α is respon-sible for inhibiting the p y pathway. we next measured ca +i in normal hbecs. while acute nm e addition had no affect on basal ca +i levels, which were around nm, this maneuver reduced the ca +i response to nm following atp addition (both n= ), suggesting that e addition altered ca + signaling in response to atp. thapsigargin induces ca +i release from the endoplasmic reticulum, but the magnitude of ca +i release after thapsigargin addition was not altered by e pretreatment, indicating that e works further up stream to affect the p y signaling pathway. together, these results suggest that e directly interacts with the p y signaling pathway through er-α by altering ca +i. we propose that this interaction leaves females more vulnerable to infections due to a reduced asl volume during periods of high e , such as occur prior to ovulation. the nasal potential difference (or npd) is a sensitive, real time bioelectric assay of cftr-dependent and independent ion transport that is a commonly used study endpoint in early clinical stages of drug development. technical limitations of the assay must be controlled to facilitate its use in multicenter trials and limited intra-site variability. two forms of equipment are commonly employed to evaluate nasal potential difference in humans: silver-silver chloride electrodes (agcl) with saline bridges or calomel electrodes with agar bridges; however, these techniques have never been directly compared. we repeatedly evaluated (within days) the basal potential difference of five normal subjects using the two available techniques, then compared variance and repeatability of the measures. basal pd was measured during perfusion of ringer's solution, and measured at . , . , . , . , and . cm within the inferior meatus, as indicated in the cf-tdn standard operating procedures. mean basal pd were within . mv using the two techniques, with very similar coefficients of variation (cvar; . vs. . in agcl vs. calomel, respectively). maximum basal pds were also similar between the two methodologies (mean difference . mv; cvar . and . , respectively). the correlation between first and second measures of mean pd was highly reproducible, and similar between the two techniques (r= . vs. . in agcl vs. calomel, respectively); however, when each individual basal pd measure was compared, correlation between first and second pd using the agcl device appeared superior (r= . vs. . respectively; n= measures per device). comparison of values obtained in cf subjects are currently in progress and will also be reported. next, we examined diagnostic npd tracings in cf subjects for whether the effect of amiloride might influence values obtained in the contralateral nare. an effect of cross-contamination by amiloride or other agent (gene therapy vectors or other nasal administered compounds, for example) could influence accurate measure of npd values. when basal pds were performed in both nostrils prior to amiloride exposure in either nostril, mean basal pd between nares remained stable (< mv, p=ns for change). however, if the basal pd in one nostril was measured after amiloride exposure in the contralateral side, mean pd depolarized by mv (from - to - mv; p< . ), indicating the presence of a 'cross-nostril' amiloride effect that might potentially affect interpretation of this endpoint if not performed in a sequence designed to avoid amiloride exposure. in summary, we show that calomel and agcl electrodes perform similarly in repeated measures from the same normal subjects, and that improper npd sequence can adversely affect basal pd measures. other potential impediments to the pd measurement (e.g. solution temperature, tonicity, ionic content, and sources of electrical offset) will also be discussed. these findings are relevant to the optimizing the use of the npd assay in clinical trials. supported by nih, cff, and cfft. the gene defective in patients with cystic fibrosis (cf) is the cystic fibrosis transmembrane conductance regulator (cftr), a camp-activated chloride channel in the apical membrane of epithelia, but alteration of expression and function of many genes undoubtedly contributes to the pleiotropic manifestations of cf. a hallmark of cf in airway epithelia is the hyperabsorption of sodium through the epithelial sodium channel (enac) in the apical membrane followed by extrusion through the na,k-atpase in the basolateral membrane. this results in airway surface liquid (asl) dehydration, mucus buildup and bacterial infection characteristically observed in the lungs of cf patients. previous studies have shown that the na,k-atpase is increased in cf airway epithelia, consistent with increased sodium transport along the enac/na,k-atpase axis. we have previously demonstrated that fxyd , a member of a small family of proteins known to regulate the na,k-atpase, is increased in s x cf mouse lung and nasal epithelia and in primary human tracheal epithelial cells (hte) after treatment with an inhibitor of cftr ( ). recent evidence has indicated that enac activation occurs through modification of the serine protease-protease inhibitor balance in asl. thus, we hypothesized that enac-mediated increases in sodium absorption may be partially responsible for the increase in fxyd expression observed in cf airway epithelia. we now report that increasing asl volume on hte cells upregulated fxyd expression (p< . ) after hours, an effect that was further increased after trypsin addition and abrogated by the serine-protease inhibitor aprotinin. treatment of hte cells with nystatin also increased fxyd expression measured by quantitative rt-pcr (p< . ). based on these results and the observation that mice overexpressing enac beta-subunit exhibit cystic fibrosis-like lung pathophysiology, we examined fxyd expression in the lungs of mice overexpressing the scnn b-transgene. contrary to our expectations, fxyd lung expression was decreased as assessed by quantitative rt-pcr and immunoblot analysis (p< . ), indicating fxyd may be alternatively regulated in epithelia under conditions of acute versus chronic sodium hyperabsorption. therefore, we measured fxyd expression in an epithelial cell culture model using an inducible, tri-cistronic vector capable of expressing enac alpha, beta and gamma subunits. we determined that fxyd expression is decreased after chronic enac induction. we conclude that fxyd expression is coordinately regulated based on acute versus chronic enac-mediated sodium absorption and suggest that fxyd is increased in cystic fibrosis airway epithelia as a result of an imbalance between increased inflammatory signaling and altered ion transport. picher, m.; van heusden, c. cystic fibrosis center, university of north carolina, chapel hill, nc, usa airway infection by the respiratory syncytial virus (rsv) is considered an important cause of pulmonary exacerbation and hospitalization in cystic fibrosis (cf) children. this disease is characterized by functional mutations in the cf transmembrane regulator (cftr). the inability of cftr -/-mice to clear rsv is associated with exaggerated inflammatory responses. a relationship was recently established between airway inflammation and chronically-elevated airway adenosine. this signaling molecule regulates key aspects of lung defenses, including bacterial clearance and inflammatory cells. high adenosine levels measured in bronchoalveolar lavage fluid of asthmatic or cf patients cause airway inflammation, remodeling and fibrosis in animal models. the objective of this study was to investigate the longterm effects of rsv infection on adenosine regulation and inflammatory responses in human airway epithelia. methods. polarized primary cultures of bronchial epithelial cells from healthy subjects and cf patients were exposed to vehicle, uv-inactivated or active green fluorescent protein (gfp)-rsv. the cultures were monitored days for infection (fluorescence microscopy), adenosine levels (fluorescence chromatography), the release of cytokines regulating adenosine tnfα) and enzyme activities (ecto '-nucleotidase [ecto '-nt: amp Ç adenosine] and adenosine deaminase [ada : adenosine Ç inosine]). results. (a) both normal and cf cultures exhibited detectable rsv infection over days, with peak density on day - . (b) we demonstrate that rsv enhances the release of all five cytokines from normal cultures over days. in contrast, cf cultures responded to rsv by a transient decrease in il- β, il- and tnfα (peak on day ), but a sustained decrease in il- , and a sustained increase in il- , secretion. (c) on normal epithelia, rsv transiently stimulated ecto '-nt (peak on day ) but caused a sustained increase in ada activity, resulting in chronically-low adenosine levels. in cf, rsv raised adenosine levels by the combined effects of a sustained increase in ecto '-nt activity and the lack ada response. (d) chronically-elevated adenosine generated by ada inhibition [erythro -( -hydroxy- -nonyl)adenine] stimulated the secretion of all cytokines, except il- . conclusion. these data support a complex relationship between adenosine and cytokine regulation in human airway epithelia. the il- -adenosine amplification pathways identified in rsv-infected cf epithelia are in agreement with animal models and their key role in chronic airway inflammation/remodeling. on the other hand, the data also suggest that ada activity is influenced by il- , known to stimulate the expression of a major protein anchoring soluble ada to epithelial surfaces: cd . altogether, this study suggests that an rsv infection in cf children may accelerate the progression of the disease by setting the stage for airway adenosine-cytokine amplification pathways. supported by the cystic fibrosis foundation (picher g ). cystic fibrosis (cf) airway submucosal glands are defective in mucus secretion rate (jayaraman, pnas, , , ; joo, j biol chem, , , ; joo, pediatr. pulmonol., , suppl. , ; wine, proc ats, , , ; thiagarajah, faseb j, , , ; song, ajp cell, ; salinas, faseb j, , , ) . one hypothesis is that loss of cftr results in reduced secretion of electrolytes leading to underhydration of mucins, thereby altering the mucus properties. it has been generally believed that the cf mucus in response to cholinergic agonists is thicker and more viscous. however, comparisons of pure gland mucus are difficult because of variability in gland secretion rates and a decline in mucus solids with repeated stimulations (wu, pediatr. pulmonol. , suppl. , ) . in the present study, we directly compared the solid content of airway submucosal gland mucus between control and cf individuals. human donor tracheas (hn) or disease control bronchi (dc) were dissected and mounted as previously described but without mineral oil. tissue was kept warmed and humidified in a chamber with two layers of saturated degree c / % co /o water vapor. the mucosal surface was blotted dry and coated with a thin layer of dimethylpolysiloxane to prevent re-absorption by the surface epithelium. the tissue surface was covered with a cover slip, leaving minimal air space between it and the surface to further reduce evaporation. a µl droplet of % nacl was placed at the side of every tissue as a standard to assess evaporation and measurement error. any basal secretions were removed prior to stimulation with µm carbachol. mucus secretion from individual glands was pooled using forceps and then drawn into a constant bore microcapillary (drummond) that had been alcohol-cleaned, dried, and weighed. stimulation time was allowed to vary so that at least µl of mucus was collected. after mucus collection, both the standard and the bath solution were refreshed. mucus filled capillaries were weighed with a mettler microbalance before and after overnight degree c oven drying to obtain nonvolatile solid content. the average solids measured in six repeated measures of % salt solutions was ± . % with no trend over time. results for hn (n= ) and dc (n= ) did not differ and were pooled as 'control'. the initial control secretion yielded . ± . % solids (mean ± sem, n= subjects) and required ± min to produce adequate mucus. the initial cf secretion gave . ± . % solids (n= ) in ± min. the second control secretion yielded . ± . % solids (n= ) and required ± min, whereas the second cf secretion gave . ± . % solids (n= ) and required ± min. in summary, cf gland mucus solids content was % higher than control following the first stimulation (p = . ). after the second stimulation, cf solids content was % higher than the control (p = . ). solids contents of controls observed in our experiment are much higher than was found for mucus collected from airway lumens after hr stimulation (c. %, trout, am j physiol, , , l ) . supported by niddk ro - (jjw) and cff. in patients with cystic fibrosis (cf) as well as in some animal models of cf lung disease, higher levels of prostaglandin e (pge ) have been detected compared to control subjects. it is not clear whether this excess of pge contributes to the airway pathology of cf, or whether it may serve a protective function against airway constriction. inhaled pge has been tried in asthma and may be of benefit as a bronchodilator. interestingly, pge has shown benefit in aspirin-sensitive asthmatics, a population that shares some features with the cf airway phenotype including nasal polyposis. the mechanism of airway relaxation to pge is mediated primarily by ep receptors signaling through camp. in cf, beta-adrenergic bronchodilators are commonly used, but are often only partially effective at reversing bronchospasm. beta-agonists and pge both signal through g-proteins coupled to camp and pka signaling, thus pge may offer another treatment when beta-agonists are ineffective at reversing bronchospasm in cf. in mouse tracheas, the beta-agonist isoproterenol (iso) will partially relax a pre-contracted airway, but ± % of contractile force remains (n= ). in contrast to the limited relaxation with iso, constricted mouse airways demonstrate significantly greater relaxation to pge , with only ± % of force remaining (n= , p< . compared to iso). this difference in relaxation responses suggests different intracellular signals are activated by each agonist despite both signaling through pka. to investigate phosphorylation events in response to iso or pge , we developed a new method for perfusing isolated mouse lungs. using this technique, tissues were perfused with buffered solution containing p for radiolabeling. lungs were then stimulated with either iso or pge , and phosphoproteins were compared from each condition. radiolabeling was effective under all three conditions. targets were chosen from each group (unstimulated, iso, or pge treated) that showed phosphorylation or dephosphorylation, and proteins were identified by mass spectrometry. over differentially phosphorylated proteins were identified, and two of these (rho gdi and inositol-requiring protein ) were selected as candidates to be tested in the context of relaxation to pge compared to iso. by identifying signaling targets involved in airway relaxation to pge , it may be possible to activate beneficial airway relaxation responses without the limitations seen in iso relaxation and without activating pge responses other than relaxation that may link pge to the airway pathology seen in cf. the parental ∆f /∆f cf bronchial epithelial cell line (cfbe o-) was compared to clones of cfbe o-complemented with . kb wild type (wt) or . kb ∆f cftr cdna in terms of their ion transport characteristics. the transepithelial resistance (rt) (~ (cm ) observed in the parental cfbe o-was maintained in the complemented cells. two clones complemented with wt cftr cdna (c - . wt and c - . wt) demonstrated rt ~ Ωcm , while another clone (c - . ∆f) complemented with the ∆f cftr cdna showed an rt of ~ Ωcm . two stable clones expressing wt cftr were selected based on electrophysiological characteristics and stability of cftr expression. forskolin-stimulated cl secretion in clone c - . wt was on average . ± . µa/cm and . ± . µa/cm in clone c - . wt. furthermore small camp-stimulated transepithelial current of . ± . µa/cm was observed in clone c - . ∆f indicating that ∆f cftr can traffic to the plasma membrane if present at high enough levels at physiological temperatures. the role that cftr plays in ca-activated cl conductance was investigated following treatment of the cells with atp in parental cfbe o-and wtcftr . -cfbe o-monolayers. in symmetrical cl-containing solutions, mucosal application of atp ( µm) elicited a small, transient cl secretory response in the parental cfbe ocells ( . ± . µa/cm ), while the magnitude of the atp-stimulated cl current was markedly enhanced in cftr-corrected cfbe o-cells with peak currents at . ± . µa/cm . recordings done in presence of a serosal-tomucosal cl gradient to increase the driving force for cl secretion showed a transient atp-dependent activation of cl currents in parental cfbe ocells with peak cl currents of . ± . µa/cm (n= ). cftr corrected cfbe o-cells showed a sustained activation of cl currents of similar magnitude ( . ± . µa/cm ; n= ). atp-stimulated cl currents were effectively blocked by the cftr inhibitor glyh ( µm). histochemical analysis showed prominent epithelial characteristics in all clones. these observations indicate that i) the apical driving force is limiting for atp-stimulated cl secretion and that ii) cftr participates in the cl secretory response to atp. furthermore, the findings suggest that these novel clonal isolates of the cfbe o-bronchial epithelial cell line can be useful for the investigation of cf therapies. this work was supported by grants from the cff, cfri, nih, elizabeth nash foundation, and pacfi. the lactoperoxidase (lpo) system functions in normal airways to prevent infection and may be compromised in cystic fibrosis (cf) due to defective transport of its substrate thiocyanate. a computational model of normal airway surface liquid suggests that hydrogen peroxide levels regulate lpo system activity and that the lower thiocyanate in cf airways may result in elevated levels of hydrogen peroxide that is likely produced by duox the major nadph oxidase in airway epithelial cells. to investigate the regulation of duox by bacterial products, passage normal human airway epithelial cells were grown and redifferentiated at the air liquid interface and treated for , or h with either pseudomonas aeruginosa flagellin or lps, applied apically. treated and mock treated cultures were analyzed for levels of duox and lpo mrna and protein, and for hydrogen peroxide production. quantitative pcr was performed using taqman kits, protein was measured by western blots, and hydrogen peroxide was quantified using amplex red-hrp coupled fluorescence. the data showed the duox and lpo mrna but not duox mrna, were significantly upregulated at all measured time points following apical treatment of the cultures with purified flagellin compared to mock treated. at h duox was increased . +/- . fold and lpo was increased . +/- . fold (means +/-s.e.m., n = lungs, - cultures of each lung). muc ac mrna was also upregulated by flagellin treatment ( . +/- . fold, n = lungs, - cultures of each lung). apical treatment with lps had no effect on any tested mrna and induced minimal il- secretion in these cultures. western blots using anti-duox antibodies (courtesy of f. miot, brussels, belgium) showed corresponding increases in duox protein following flagellin treatments. hydrogen peroxide production by flagellin treated cultures was increased in proportion to increases in duox mrna. application of flagellin alone to the apical surface of previously untreated cultures did not increase hydrogen peroxide production. thus, pseudomonas flagellin up-regulates duox and results in higher activity in normal human airway epithelial cells perhaps serving to increase innate host defense activity of the lpo system. chloride ion in phagolysosomes is an essential substrate for neutrophils to produce hypochlorous acid (hocl), an important bactericidal agent. we have previously shown that cftr was present in the phagolysosomal membrane of neutrophils and the cftr defect led to deficient chlorination of ingested pseudomonas aeruginosa (pa) (painter et al, biochemistry, : - , ) . these results suggested that chloride accessibility to the phagolysosomal lumen might be impaired in cf neutrophils thereby affecting neutrophil-mediated bacterial killing. to understand the role of chloride ion in the process, we first assessed the effect of extracellular chloride concentration on pa killing by normal neutrophils under iso-osmotic conditions. surprisingly, bacterial killing was strongly dependent on extracellular chloride concentration. the initial rate of killing of pa was~ fold less in a chloride-free medium than a physiological chloride medium. killing efficiency increased as the chloride concentration was raised in a dosedependent fashion and plateaued at~ mm chloride concentration. to determine what percent of the chloride-dependent killing was oxidantdependent, we applied the cftr inhibitor glyh- , the myeloperoxidase (mpo) inhibitor aminobenzoic acid hydrazide (abah) and the nadph-oxidase inhibitor diphenylene iodium chloride (dpi), respectively to bacterial killing assays. the results showed that the killing of pa could be divided into three discernible components: ( ) a component accounting for about - % of the total killing rate that was inhibited by glyh- , abah or dpi; ( ) a second component amounting to~ - % that was chloride-dependent and partially sensitive to glyh- and; ( ) a third accounting for~ % of the total killing activity that was not sensitive to oxidant inhibitors, or extracellular chloride concentration. dpi and abah had no effect on killing of pa in the absence of extracellular chloride suggesting that most of the oxidant-mediated killing activity toward pa was due to hocl. none of the inhibitors had any significant effect on phagocytosis. finally, the rate of pa killing by cf neutrophils was found to be significantly lower ( - %) than that seen for normal neutrophils and was comparable to the effect of glyh- on killing of pa by normal neutrophils. the data suggest that cftr plays a significant role in killing of pa by normal neutrophils and, when defective as in cf, may compromise the ability of neutrophils to efficiently kill pa. this research was supported by a cff grant to gw. %. the cf group demonstrated a significantly higher frequency of pseudomonas respiratory infections than the non-cf group. interestingly, no significant differences were detected in any infections from other systems including blood, sinuses, skin, wounds, oral cavity, bowel, eyes, peritoneal cavity, and urinary tract. moreover, the cf lung-transplant patients had significantly less time free from pseudomonas infections in the transplanted lungs. conclusion normal lungs transplanted into cf patients had significantly higher susceptibility to pseudomonas infections than those transplanted into non-cf patients, which strongly suggests that defective host defense mechanism(s) beyond the respiratory system contribute to cf lung pathogenesis. pyocyanin (n-methyl- -hydroxyphenazine, pcn) is produced by pseudomonas aeruginosa and is found in pulmonary secretions of infected cf patients at concentrations up to µm. pcn is a redox-active compound that generates superoxide and hydrogen peroxide in the presence of cellular reductants. since cftr was reported to be modulated by h o , we hypothesized that pcn, through its ability to redox cycle and to produce h o , would affect cftr-mediated cl transport. we therefore tested pcn and h o for effects on cltransport (transepithelial short-circuit currents in ussing chambers measured with serosal-to-mucosal clgradient) and cytosolic redox potential (imaging microscopy on cells transfected with a redox sensitive gfp, rogfp ) using cftr-corrected cf bronchial epithelial cells (wtcftr . . under resting conditions, acute exposure of the apical epithelial surface to µm pcn elicited a small clsecretory response ( . ± . µa/cm , n= ) that was completely blocked by the cftr inhibitor glyh ( µm). in contrast, in presence of the camp-elevating agonist forskolin, pcn caused a time-dependent decline of forskolin-stimulated cftr clcurrents by %. exposure to h o ( µm) elicited a more pronounced clsecretory response than pcn in resting cells and h o -stimulated clcurrents peaked at . ± . µa/cm (n= ). h o was less effective than pcn at inhibiting forskolin-stimulated cftr clcurrents and currents declined by %. both pcn and h o oxidized the cytosolic redox potential from a resting value of - mv by similar amounts ( ± mv for pcn vs. ± mv for h o ), but rates of oxidation were faster for h o ( . ± . mv/min) than for pcn ( . ± . mv/min). inhibition of camp-stimulated cftr clcurrents by oxidation was a linear function of the cytosolic redox potential, but pcn ( µa×cm - ×mv - ) was more potent than h o ( . µa×cm - ×mv - ). cf bronchial epithelial cells homozygous for ∆f -cftr did not show a clsecretory response to pcn or h o . these data suggest that cftr-corrected cf bronchial epithelial cells respond acutely to oxidative stress by turning on cftr activity probably as part of the innate host defense response and this mechanism is absent in cf airways. furthermore, prolonged exposure to pcn and h o is detrimental for the proper function of the camp-regulated cftr clconductance. we conclude that oxidative stress in p. aeruginosa-infected airways is a key factor that needs to be considered for successfully correcting cftr function in cf airways. supported by nih (nccam p at ), cff (fischer g ) the lung is continually exposed to environmental agents and pathogens. the lung epithelial lining fluid (elf) is first to encounter these agents and gsh is a major antioxidant found in this apical fluid. the cystic fibrosis transmembrane conductance regulator protein (cftr) is the only known gsh transporter that maintains lung elf gsh levels. cystic fibrosis (cf) patient have low levels of gsh in their elf and have copious and viscous mucus. hypertonic saline is used in cf patient to help clear mucous and improve lung function however the mechanism(s) by which it does so are poorly understood. the purpose of these studies was to examine whether hypertonic ( . %) saline can modulate apical gsh levels and protect lung epithelial cells against the oxidant, t-butyl hydroperoxide (t-booh). we used human lung epithelial cell lines sufficient (c ) and deficient (ib ) in cftr. the cftr deficient ib cells have % lower basal levels of apical gsh as compare to cftr sufficient c cells. cells were exposed separately and in combination to % saline, and t-booh ( um) for hours. the cftr deficient ib cells were much more sensitive to t-booh-mediated oxidative injury as measured by lactate dehydrogenase (ldh) release. hypertonic saline exposure was associated with an increase in apical gsh levels in both cftr sufficient and deficient cells and decreased t-boohmediated oxidative injury in both cells lines. hypertonic saline increased gsh in the apical compartment, which appeared to be largely cftr mediated. we examined this issue in mice given a clinically used dosing regimen of % hypertonic saline nebulized twice daily and examined changes in elf gsh levels hours after last treatment. mice receiving the hypertonic saline treatment had significantly higher gsh levels in their elf than untreated controls. this data suggests that cftr and gsh adaptive responses play an important role in lung's reaction to oxidants. we propose that factors, which interfere with the lung's capability to mount and maintain an adequate adaptive apical gsh response, may compromise and sensitize the lung to oxidative injury. (supported in part from nih grant hl ). the absence of functional cftr in airway epithelia of cf patients leads to abnormal airway surface liquid, which favors chronic bacterial infection. this chronic infection in cf lungs is associated with an exaggerated inflammatory response characterized by abnormal cytokines secretion and massive lung neutrophils infiltration. we have previous recapitulated the abnormal inflammatory response in cftr-/-(cf) mice by repeated administration of pseudomonas aeruginosa lipopolysaccharide (lps) (ped. pulmonology, supp. , ) . we demonstrated that the bronchoalveolar lavage (bal) fluid of cf and heterozygous (het, cftr+/-) littermate control mice when compared to the bal from wt mice shows ) higher numbers of neutrophils and ) higher concentrations of cytokines (il- alpha, il- , kc, mcp- , gm-csf, m-csf) as assessed using multiplex analysis of selected cytokines. of note, airway epithelial cells from cf patients are known to have elevated secretion of some of these cytokines. however to date, the contribution of immune cells to these abnormal cytokine levels has not been well characterized. this study aims to investigate the contribution of cf macrophages in this altered cytokine profile/response. we examined cytokine secretion from two different macrophage populations: alveolar macrophages (am) obtained from the bal fluid and bone marrow (bm)-derived macrophages differentiated in presence of m-csf. both macrophage populations were cultured in the presence or absence of lps, and the supernatants were tested for the concentration of the cytokines that we had shown to be abnormal in vivo. these macrophage populations were examined from cf, het and wt mice. in absence of lps exposure, bm-derived macrophages from cf mice have lower levels of il- and kc compared to wt and het mice. in contrast, am of cf mice have higher levels of il- and kc than am of wt mice. this difference may be due to am's prior exposure to antigens in vivo whereas the bm-derived macrophages are a truly naïve population. interestingly, after lps stimulation, il- a, il- , mcp- , kc, g-csf and gm-csf are higher in cf macrophages compare to wt and het mice suggesting that cf affected macrophages display an altered inflammatory response when compared to wt and het. the abnormal production of these cytokines was also detected at the transcriptional level using quantitative rt-pcr analysis. in conclusion, our data support the hypothesis that cftr-null macrophages may have an impaired cytokine profile at baseline as well as after stimulation. furthermore, cftr deficient macrophages may contribute directly to the abnormal inflammatory response in cf. (supported by cff, nih, niddk) cystic fibrosis lung disease is associated with an excess of free neutrophil elastase (ne) in the airway arising from persistent neutrophil inflammation. dx- is a potent small protein inhibitor of neutrophil elastase that could be a useful therapy for diseases involving neutrophilic inflammation such as cystic fibrosis and copd. dx- effectively inhibits ne activity in cf sputum sol (ic = pm). however the physical barriers posed by cf whole sputum may prevent dx- accessing and inhibiting ne ensconced within the mucus. the mucolytic dnase acts by cleaving extracellular dna in mucus thereby reducing viscosity. however dna binds and inactivates ne and therefore dnase treatment of mucus results in an acute increase in active ne. the lipid portion of pulmonary surfactant acts as a lubricant and our group has previously shown that bovine lung extract surfactant (bles) increases the fluidity of whole sputum. ( aim we aimed to show that, by reducing the surface tension of sputum, bles would enhance the anti-elastase effect of dx- in whole sputum. methods whole sputum ( . g per well in a -well plate) was pre-incubated with µl saline as control, µl dnase ( µg/ml) or µl bovine lung extract surfactant (bles, µg/ml) for minutes at °c followed by addition of µl dx- ( µm or µm) for h at °c. the contents of each well were aspirated, added to ml nacl ( . %) and centrifuged at , g for min. the resulting sputum sol was assayed for ne activity using the colorimetric substrate n-meosuc-aapv-pna. results ne activity in whole sputum was significantly inhibited by µm dx- (p= . ) and µm dx- (p= . ). µm dx- inhibited significantly more ne when sputum was pre-treated with bles (p= . ) treatment of sputum with dnase caused a significant increase in ne activity compared to untreated sputum (p= . ) whereas treatment of sputum with bles did not have this effect. conclusion dx- effectively inhibits elastase in cf sol. pre-treatment of cf whole sputum with bles enhanced the anti-elastase effect of dx- and treatment of sputum with bles alone did not cause an increase in ne activity in contrast to treatment with dnase. dx- inhibitory capacity in whole sputum could be improved by co-treatment with surfactant which increases fluidity of sputum and could allow greater access of drugs to sputum components. bovine lung extract surfactant, bles™ was a kind gift from bles biochemicals inc., on, canada. dx- was a kind gift from dyax corp, ma who also funded part of this research. table : results are summarised as neutrophil elastase activity µg/ml and show the mean and sem of n= experiments. cystic fibrosis lung disease is associated with an excess of free neutrophil elastase (ne) in the airway arising from persistent neutrophil inflammation. dx- is a potent small protein inhibitor of neutrophil elastase that could be a useful therapy for diseases involving neutrophilic inflammation such as cystic fibrosis and copd. dx- effectively inhibits ne activity in cf sputum sol (ic = pm). however the physical barriers posed by cf whole sputum may prevent dx- accessing and inhibiting ne ensconced within the mucus. the mucolytic dnase acts by cleaving extracellular dna in mucus thereby reducing viscosity. however dna binds and inactivates ne and therefore dnase treatment of mucus results in an acute increase in active ne. pulmonary surfactant acts as a lubricant and our group has previously shown that bovine lung extract surfactant (bles™) increases the fluidity of whole sputum. ( we aimed to show that, by reducing the surface tension of sputum, bles™ would enhance the anti-elastase effect of dx- in whole sputum. methods whole sputum ( . g per well in a -well plate) was pre-incubated with µl saline as control, µl dnase ( µg/ml) or µl bovine lung extract surfactant (bles™, µg/ml) for minutes at °c followed by addition of µl dx- ( µm or µm) for h at °c. the contents of each well were aspirated, added to ml nacl ( . %) and centrifuged at , g for min. the resulting sputum sol was assayed for ne activity using the colorimetric substrate n-meosuc-aapv-pna. results ne activity in whole sputum was significantly inhibited by µm dx- (p= . ) and µm dx- (p= . ). µm dx- inhibited significantly more ne when sputum was pre-treated with bles™ (p= . ) treatment of sputum with dnase caused a significant increase in ne activity compared to untreated sputum (p= . ) whereas treatment of sputum with bles did not have this effect. conclusion dx- effectively inhibits elastase in cf sol. pre-treatment of cf whole sputum with bles™ enhanced the anti-elastase effect of dx- and treatment of sputum with bles alone did not cause an increase in ne activity in contrast to treatment with dnase. dx- inhibitory capacity in whole sputum could be improved by co-treatment with surfactant which increases fluidity of sputum and could allow greater access of drugs to sputum components. we would like to thank prof. f. possmayer, on, canada and bles biochemicals inc., on, canada for the bovine lung extract surfactant, bles™. dx- was a kind gift from dyax corp, ma who also funded part of this research. table results are summarised as neutrophil elastase activity µg/ml and show the mean and sem of n= experiments. cf patients infected with p. aeruginosa (pa) have increased levels of proinflammatory cytokines, such as tnf-α, il- β, il- , and il- ; but have low levels of the anti-inflammatory cytokine, il- in their airways. the proinflammatory mediators in the cf airway recruit a large number of polymorphonuclear neukocytes (pmns), which release high levels of neutrophil elastase and human neutrophil peptides and damage the lungs. the intense neutrophil-dominated inflammatory response associated with chronic pa infection results in progressive airway obstruction, the cause of death of over three-quarters of cf patients. recent studies highlight the significance of sphingolipid metabolism in cell growth, differentiation, membrane traffic, apoptosis, senescence, and immune regulation. acid sphingomyelinase (asm) plays a critical role in sphingolipid metabolism by hydrolyzing sphingomyelin to ceramide. ceramide self-associates to form ceramide-enriched membrane platforms(also called lipid rafts). these platforms have been shown to be involved in the internalization of pa; induction of apoptosis and immune regulation. our in vitro and in vivo studies of asm confirm that there is a loss of induction of asm after pa infection in both cf bronchial epithelial cells and cftr knock out mice as compared with controls. in vitro, we examined the asm activity in human bronchial epithelial cells with normal cftr expression (s cells) and with mutant cftr expression (ib cells ) after pa infection at , , , , , and min. asm activity was up-regulated in s cells following pa infection after min and kept increasing until min, while asm induction was lost in ib cells. asm protein and ceramide levels also increased in s cells following pa infection compared with ib cells. in our in vivo studies, cftr knock out mice and control c bl/ mice were both administered various doses of pa orally ( x cfu to x cfu) . six hours after pa infection, lung homogenates from the c bl/ mice indicated increasing asm protein and ceramide production, which corresponded to the dose of pa given. in contrast, asm protein and total ceramide production remained at baseline levels in the lung homogenates of cf mice regardless of the dose of pa given. rna interference (sirna) assays were performed by transfecting a bp pre-designed sirna specific for human asm in s cells. these cells were then infected with pa for hrs to see if they had similar il- level compared with infected ib cells. we demonstrated a significantly elevated il- expression in s cells tranfected with asm sirna compare with s cells transfected with a scramble sirna (p< . ). our results suggest that the loss of asm induction, caused by mutant cftr, is involved in pa clearance and contributes to the exaggerated proinflammatory cytokine response in cf airway. we are conducting research on defining the roles of asm and the sphingolipids in pa infection; cell signaling; as well as cytokine induction, we are also looking at the therapeutic potential of aav.asm vectors in pa-infected cf bronchial epithelial cells and cftr knock out mice. work supported by nhlbi introduction: new therapies are critically needed to treat cystic fibrosis (cf) lung disease, which is characterized by chronic infection and inflammation. novel therapies to target airway inflammation are likely to improve the clinical outcome in cf. as yet there is no consensus regarding the molecular pathway(s) mediating inflammation in the cf lung. objective: to establish whether toll-like receptor (tlr) signalling is the key molecular pathway responsible for the inflammation seen in cf lung disease and to determine whether inhibitors of tlr signalling can reduce this damaging inflammatory response. methods and results: to quantify the airway inflammatory response, we used established cf and cf-corrected lung epithelial cells (ib - and c ). since artefacts may alter the inflammatory phenotype of cell lines, we validated all findings with fresh peripheral blood mononuclear cells (pbmcs) from cf patients (n= ) and healthy controls. we measured the inflammatory response (il , il , tnfα) of these cells following stimulation with: (i) cf pathogens (p. aeurginosa, b. multivorans, b. cenocepacia); (ii) purified tlr ligands. both cf respiratory epithelial cells and cf pbmcs had a greatly increased inflammatory response compared to matched controls when stimulated with whole bacteria and purified tlr ligands (p< . ). interestingly, the cf airway cells responded most vigorously to the tlr ligand, flagellin (p< . ). to investigate tlr as a potential anti-inflammatory target, we found that tlr mrna (p< . ) and protein (p< . ) were expressed at a higher level in cf compared to cf-corrected lung epithelial cells. finally, to determine the contribution of tlr activation to cf lung inflammation we exposed the airway cells to wild-type (pak & pao ) and isogenic flagellin-deficient strains of p. aeruginosa (pak∆flic, pao ∆flic, pao ∆flge & pao ∆flim) . strikingly, the absence of the tlr -flagellin interaction significantly reduced the proinflammatory response of cf respiratory epithelial cells to p. aeruginosa (p< . ). we show that tlr-mediated innate immune responsiveness is increased in both cf respiratory epithelial cells and fresh blood cells from cf patients. moreover, inhibition of the tlr -flagellin interaction markedly reduced proinflammatory response of cf respiratory epithelial cells following exposure to predominant cf pathogen p. aeruginosa. these data suggest that tlr activation may represent a novel anti-inflammatory target for improving cf lung disease. supported by the canadian cf foundation. cf airway cells (ib - ) were stimulated with wild-type (pak) and flagellin-deficient p. aeruginosa (pak∆flic). introduction: genetic polymorphisms for tgf-β have recently been identified as a significant modifier of cf lung disease severity. however, at present little is known about protein measurements of tgf-β in bronchoalveolar lavage fluid (balf) or serum obtained from pediatric cf patients during an acute respiratory exacerbation. hypothesis: tgf-β in cf balf and serum is increased in association with markers of cf lung disease severity, and is decreased after completion of iv antibiotic (iv abx) therapy. study design and methods: in a descriptive, prospective study of children with cf presenting for hospital admission to treat a pulmonary exacerbation, balf specimens were obtained from patients undergoing clinically-indicated flexible bronchoscopy on admission. balf was immediately analyzed for total and differential cell counts with the cell-free balf supernatant stored at - °c. serum specimens were obtained at the initiation and conclusion of iv abx and similarly stored at - °c. measurement of total tgf-β utilized a commercial elisa kit. t-test statistical analysis assumed significance at p<. . results: balf was obtained from cf patients with a mean age of . ± . years (range - years). three balf cultures were pseudomonas aeruginosa positive (psa+). balf tgf-β levels ranged from - pg/ml (mean ± . pg/ml) with the highest tgf-β measured in a patient with abpa and culture positive for m. abscessus. in balf, higher neutrophil counts (greater than the median, . x pmn/ml) were associated with increased balf tgf-β ( ± . pg/ml vs. ± . pg/ml, p<. ). serum tgf-β was collected in cf patients with a mean age of . ± . years (range - years), four of whom were psa+. serum tgf-β ranged from . - . ng/ml (mean . ± . ng/ml). in both balf and serum, neither patient age nor psa culture status was associated with increased tgf-β at admission. however, previous hospitalization in the last months was significantly associated with an elevated admission tgf-β in both balf ( ± . pg/ml vs. ± . pg/ml, p<. ) and serum ( . ± . ng/ml vs. . ± . ng/ml, p<. ). after completing the clinically-indicated course of iv abx, / psa-cf patients had a reduction in serum tgf-β (mean . ± . ng/ml to . ± . ng/ml, p=ns). in contrast, / psa+ cf patients had an increase in serum tgf-β (mean . ± . ng/ml to . ± . ng/ml, p=ns) after completing iv abx therapy. conclusions: tgf-β is measurable in balf and serum from pediatric cf patients and varies in association with clinical parameters. these preliminary results support our hypothesis that increased tgf-β may be associated with more severe lung disease as evidenced by ) association of increased tgf-β in balf and serum obtained from cf patients with previous hospitalization in the last months, and ) association of increased tgf-β in balf with increased cellular inflammation. the direction of change in serum tgf-β after iv abx therapy may be influenced by the presence or absence of pseudomonas infection. acknowledgments: supported by cff (harris ao). paula murphy and cassidy henegar provided technical support. background: cystic fibrosis is one of the leading genetic causes of end stage lung disease for which the treatment is lung transplantation. however, mortality due to chronic rejection known as obliterative bronchiolitis (ob) remains high due to small airway obliteration. ob is associated with increased levels of matrix metalloproteinase- (mmp- ), an interstitial collagenase, expressed by polymorphonuclear cells (pmns). pmns are among the first inflammatory cells to be detected in ob but very little is known about the role of pmn mmp- or the mechanisms used by pmns to migrate through extracellular collagen matrices. objective: to identify the molecular mechanism for neutrophil recruitment into the airway. we hypothesize that mmp- promotes accumulation of pmns in ob lesions by promoting their migration through the extracellular matrix protein barriers by its pericellular collagenase activity. method: the heterotopic airway transplant model was used to study the role of neutrophil mmp- in promoting pmn migration through extracellular matrices. mhc-disparate balb/c tracheas were subcutaneously transplanted into c bl/ wild-type (wt) or mmp- deficient (mmp- -/-) mice. to further dissect the mechanism of pmn migration in vitro their migration through collagen gels was studied. collagen gels were made in transwells using rat-tail collagen providing a highly cross-linked thick collagen barrier. bone marrow derived pmns from wt or mmp -/-mice were fluorescently labeled and stimulated to induce the surface expression of mmp- . pmns were placed on thick collagen gels in traswells. the transwells had polycarbonate membranes at the bottom of the gels. the pore size of the membranes did not allow pmns to pass through into the lower chambers that had flmp a chemo attractant. at hours and hours the gels were fixed and the polycarbonate membrane at the bottom of the collagen gel was gently peeled off. pmns on the membrane were counted under a fluorescent microscope. results: significantly decreased migration of pmns into the airway lumen was noted in the mmp- deficient mice (p< . ) weeks post-transplantation compared to wt mice in the heterotopic airway transplant model. in addition there was more than a three-fold increase in the pmns outside the lumen in the extracellular collagen matix (p< . ). wt-pmns were able to penetrate collagen barriers in greater numbers both at and hours compared to mmp -/-pmns in vitro (p < . for hours and . for hours). in addition, mmp inhibitor gm -treated wt cells demonstrated decreased migration through collagen gels ( hours p< . and hours p< . ). conclusions: mmp- -/-mice has significantly less pmns in the airway lumen due to decreased migration through collagen matrices providing protection against ob. this has great significance for conditions such as cystic fibrosis, lung transplant rejection (obliterative bronchiolitis) and other inflammatory diseases mediated by pmns. mmp- blockade can potentially be a novel therapeutic target to decrease neutrophil efflux into the airways and thus reduce airway inflammation. background: our laboratory has demonstrated alterations in cf-related regulation of cholesterol processing. hydroxycholesterols (oxysterols) are oxygenated derivatives of cholesterol formed from autoxidation of cholesterol and from de novo synthesis. oxysterols are known to be key regulators of cholesterol metabolism and cellular signaling. the role of oxysterols in the cellular pathways involved in cholesterol processing in cystic fibrosis has not been elucidated. based on our previous findings of increased de novo cholesterol synthesis in cf tissues, we hypothesize that oxysterol production in cf would be positively impacted. increased oxysterol production may lead to abnormalities in cellular signaling associated with oxidative stress and may influence the inflammatory response in cf. the goals of this research are to investigate the effect of oxysterols on inflammation in cf and to determine if there is a difference in oxysterol production in cf compared to wild type controls. results: the goal of these studies is to determine if cf cells respond uniquely to oxysterols compared to control cells. initial studies demonstrate that cf-model /hteo-pcepr cells failed to respond to -oh cholesterol ( -oh) with regards to nfκb activation. control /hteo-pcep cells, however, exhibited a significant -fold increase in nfκb activity upon -oh stimulation ( . -fold +/- . increase from il- , tnf alpha alone). however, il- promoter activation in response to -oh was not significantly altered in either cf or wt cells ( . -fold +/- . (cf) increase from il- , tnf alpha alone, . -fold +/- . (wt) increase from il- , tnf alpha alone). in order to verify il- promoter results, il- protein production was measured directly in response to pseudomonas aeruginosa. il- protein level in response to -oh was increased in cf cells ( . -fold) and decreased in wt cells ( . -fold), although not significantly in either group. oxysterol content and de novo synthesis are currently being examined in vivo in cf and wild type mouse models. mice lacking cftr on a c bl/ background and wild type controls were obtained from our animal core and the amount of oxysterol present in these mouse models is currently being studied. conclusion: these findings suggest that endogenous oxysterol production or other components of oxidative stress are pre-stimulating nfκb activation via the oxysterol-sensitive pathway. interestingly, although oxysterols robustly activate nfκb in wt cells, oxysterol-dependent pathways are not involved in il- production. these data suggest that il- is not a primary cause for increased oxysterol mediated inflammation. elucidating the role of oxysterols in cf will be an important contribution to our understanding of the inflammatory pathways in cf and will contribute to the growing body of evidence for aberrant cholesterol regulation in cf. this work is supported by grants from the cff and the nhlbi. cystic fibrosis (cf) is a common genetic disorder caused by a mutation in the cftr, a chloride transporter of the abc transporter family. innate immunity, the first line in host defense against infectious agents, is abnormal in cf patients. cf patients are commonly colonized with bacterial pathogens, which is the major clinical problem of this disease. despite a marked difference in the clinical outcome amongst cf patients infected with pseudomonas aeruginosa and burkholderia cepacia, the mechanisms under-lying these differences remain unclear. understanding the innate immune response, specifically the role of cftr, in p. aeruginosa and b. cepacia infections will lead to new insights into mechanisms that limit these infections. our objective is to develop a cf model in the simple organism, the worm, c.elegans, and to test the role of the cftr orthologue, mrp- , in host defense. using this model, we have compared the survival of c. elegans between virulent p.aeruginosa (pa ) and b.cepacia (bc). our experiments have demonstrated that, when compared to growth on their natural food source, e.coli op , worms fed on pa and bc die prematurely. specifically, worms survive up to hours on op , whereas pa fed worms die with in hours. death on pa also requires active infection, as heat inactivation of these bacteria destroys their killing capacity. two bc strains have been tested, a virulent strain ( ) and an avirulent strain ( ). worms infected with bc show an intermediate phenotype, surviving approximately hours. our future work will define whether synergy occurs during coinfection with p.aeruginosa and b.cepacia, as would be suggested by clinical data. in addition, we will define the transcriptional changes induced in c.elegans fed on pa and bc, and use these data to identify common and pathogen specific responses to these infections. finally, mrp- knock-down worms will be generated using rna interference, and the role of the cftr orthologue in infection will be tested. in conclusion, c.elegans offers a genetically tractable model organism in which the innate immune response to pseudomonas aeruginosa and burkholderia cepacia can be studied. in addition, this simple model system will allow us to define the role of the cftr orthologue in host defense. supported serine proteases released from neutrophils are considered central to the pathogenesis of cf lung disease, and have been obvious therapeutic targets. although intracellular serine proteases are important in host defense and bacterial killing, extracellular enzymes may contribute to bacterial persistence and promote airway inflammation. neutrophil elastase (ne) digests key opsonins present in the lung and has been shown to disrupt phagocytosis, allowing the bacteria to persist in the face of established pulmonary inflammation. in addition we have found that other proteases, like cathepsin g (cg), an abundant serine protease found in human and murine neutrophils, may also have other, critical roles in development of cf lung disease. indeed, using murine models of endobronchial inflammation, cg inhibits airway defenses and interferes with the host's ability to clear pseudomonas aeruginosa from the lung with effects quite distinct from ne. to test the hypothesis that differences in bacterial killing are due to defects in innate defenses created by excess, unopposed cg at the apical surface of the airway epithelium, we have examined profiles of proteins secreted into the airway lumen by epithelial cells, which are necessary for p. aeruginosa clearance and susceptible to cg proteolysis. analysis of lavage fluid utilizing -d page indicated a total of spots which were increased in pooled lavage fluid from infected cg-deficient mice as compared to wild-type littermates. tandem mass spectrometry analysis identified several novel proteins that were cleaved by cg, including inter-alpha inhibitor protein, selenium-binding protein, sec -like protein, beta- -glycoprotein, and annexin a . another protein candidate, serum amyloid p component (sap), is a novel opsonin and may be involved in airway defenses. immunoblot analy-sis demonstrates that cg cleaves sap. these results suggest that cg, like ne, plays an important role in the pathogenesis of lung diseases. we have previously demonstrated in ∆f -cf mice that in vivo treatment with azithromycin (azm) attenuates cellular infiltration in baseline and lipopolysaccharide (lps)-induced inflammation, and inhibits proinflammatory cytokine release in induced inflammatory condition (legssyer et al, ) . this study aimed at investigating macrophages isolated from wild type (wt) or ∆f -cf mice (van doorninck et al, ) and the effect of azm on these cells. purified peritoneal and alveolar macrophages were stimulated with lps (p. aeruginosa, . µg/ml) plus ifnγ ( . µg/ml), with or without azm ( µg/ml). macrophage inflammatory status was investigated by assessing different pro-and anti-inflammatory mediators at mrna level h after stimulation. pro and anti-inflammatory markers seemed to be reduced in naive alveolar cf macrophages. by contrast, a trend to overexpression of these markers was seen in naive peritoneal cf cells. pro-inflammatory status, as assessed by il- β, was induced in stimulated alveolar and peritoneal cf macrophages and in naive peritoneal cf cells. moreover, nos- was found to be overexpressed in stimulated alveolar cf macrophages while il- was downregulated. azm significantly reduced il- β expression in stimulated alveolar macrophages. in conclusion, peritoneal and alveolar macrophages exhibit distinct phenotype. a pro-inflammatory status was more prominent in stimulated cf alveolar and peritoneal cells. interestingly, azm modulates il- β overexpression only in cf stimulated alveolar macrophages, supporting the antiinflammatory activity of this macrolide and identifying, at least partly, alveolar macrophages as possible target cells for its effects. supported it has been recently reported by perez and coll. that the inhibition of function of w/t cftr produces an inflammatory profile that resembles that observed in cf patients [am j physiol lung cell mol physiol, ] , whereas we demonstrated that correction of f del cftr function with mpb- down modulates the pseudomonas aeruginosa (p.aeruginosa) dependent expression of the pro-inflammatory mediators il- and icam- in cf bronchial cells [am. j. resp. cell. mol biology, ] . since both evidence support a direct link between cftr function and inflammatory response in respiratory epithelial cells, we extended our investigation to other f del cftr correctors, such as miglustat [norez et al, febs letters, ] , which is an approved drug for gaucher disease, in comparison with an isomer without any correcting effect, namely nb-dgj. human bronchial ib - (cftr f del/w x), cufi- (cftr f del/f del) and nuli- (cftr w/t) cells were exposed to the laboratory strain of p.aeruginosa (pao ) or tnf-alpha or il- beta and the transcription of icam- and il- were quantitated by real time rt pcr. cftr function was assayed by single-cell fluorescence imaging, using the potential-sensitive probe disbac [renier et al, hum. gene ther. ]. analysis of binding of nf-kb and ap- transcription factors to labelled dna target was performed with electrophoretic mobility shift assay (emsa) [borgatti et al, j. biol. chem. ]. miglustat significantly reduced the expression of il- by % in ib - and by % in cufi- cells and of icam- by % in ib - and by % in cufi- cells, upon infection by pao . in parallel, correction of f del cftr function was observed after miglustat treatment in both ib - and cufi- cells. miglustat had no major effects on overall binding activity of transcription factors nf-kb and ap- , activated by pao in ib - cells. the inflammatory response induced by tnf-alpha or il- beta was also significantly reduced in ib - and cufi- cells treated with miglustat. nb-dgj, which is not a corrector of function of f del cftr, down modulated the induction of il- and icam- in ib - and cufi- cells. in addition, both miglustat and nb-dgj reduced the inflammatory response to pao in non cf nuli- cells. in conclusion, miglustat and nb-dgj have an anti-inflammatory effect in bronchial cells independently of the correction of f del cftr, by interfering with the pro-inflammatory signaling downstream the receptors for pathogens and pro-inflammatory cytokines. since miglustat is already approved for the treatment of gaucher disease and other glycosphingolipidoses, it may be an interesting candidate to ameliorate lung inflammation in cf patients. background: the primary cause of mortality and morbidity in cystic fibrosis (cf) is lung disease, which is characterized as a chronic cycle of infection and inflammation dominated by a neutrophilic infiltrate and increased levels of circulating mediators such as il- . a wide variation in the rate of progression of lung disease is observed in cf. hypothesis: we postulate the presence of a brisk systemic inflammatory response in cf patients and that this systemic response reflects the magnitude and progression of lung disease. methods: lung function and clinical data were obtained from cf patients treated and followed in the adult cf clinic, st paul's hospital. forced expiratory volume at s (fev ) and forced vital capacity (fvc) values dating back to were used in regression equations to group patients into quartiles based on their decline in predicted fev %. rate of decline in lung function was compared with clinical characteristics and various systemic inflammatory biomarkers, including wbc, band cell count, crp, il- β, il- , il- , mcp- , and gm-csf results: the quartiles exemplified significantly different rates of decline in fev /fvc% values. subjects with a rapid decline in lung function were younger and were colonized/infected more commonly with methicillinresistant staphylococcus aureus (mrsa) (p< . ). in addition, altered calcium, magnesium, and albumin levels were found in subjects with increased rates of decline in lung function (p< . ). preliminary results show that patients with cf have significantly elevated levels of wbc ( . e /l), crp ( . e ng/ml), and il- ( . pg/ml) in serum when compared to control subjects (p< . ). there were trends in relationships between levels of il- , il- and mcp- and rates of decline in lung function, however none reached statistical significance. conclusion: there is a variable rate in the decline in lung function among cf patients and one factor may be a heterogeneous systemic inflammatory response. circulating pro-inflammatory mediators may not only impact progression of lung disease, but could also be novel biomarkers to monitor and assess disease severity in cystic fibrosis. nutritional status in addition effects the rate of decline in lung function perhaps by modifying the inflammatory response. this research is supported by the bc lung association. overexpression of the epithelial na + channel β subunit (protein = βenac, gene = scnn b) in transgenic mice results in cf-like lung pathology, characterized by neonatal mortality, mucus obstruction and airway inflammation (mall et al., nat. med. ) . breeding βenac mice into gene-deleted mice enables quick and efficient determination of the specific pathways relevant to the development of lung pathology. tnfα is a pleiotropic pro-inflammatory cytokine released by many different cell types, including t cells, macrophages, granulocytes, and epithelial cells. tnfα levels are significantly elevated in bronchoalveolar lavage (bal) from βenac mice in comparison to wild-type (wt) littermates. we crossbred βenac mice (heterozygous, inbred line c - ) with tnfα knockout mice, generating four types of mice: wt, tnfα +/-; wt, tnfα -/-; βenac, tnfα +/-; and βenac, tnfα -/-. all mice had comparable, high survival, ranging between - %. the lack of tnfα did not prevent neutrophil and eosinophil infiltration and did not significantly modify the lung pathology characteristic of βenac mice, namely mucus plugs, mucous secretory cell hyperplasia, airway inflammation and emphysema. the absence of tnfα in bal from βenac, tnfα -/-mice, in comparison to βenac, tnfα +/mice, was confirmed by luminex cytokine assay. the levels of kc, a potent neutrophil chemoattractant, were significantly elevated in bal fluid from βenac mice, regardless of the presence or absence of tnfα. in wt mice, no granulocytic infiltrate or morphologic changes were observed and tnfα and kc were undetectable. similarly, the pathologic changes in βenac mice were not mitigated by crossbreeding to knockout mice for tnfα receptor (tnfαr ), the major mediator of biologic responses classically attributed to tnfα. these results suggest that tnfα per se does not have a critical pro-inflammatory role in the development of inflammation in the βenac mouse model. the production of alternative cytokines may compensate for the loss of tnfα bioactivity in the tnfα and tnfαr -/-mice. since tnfα has been suggested to play a role in the regulation of enac, ussing chamber studies are underway to test whether the bioelectric features of tracheobronchial epithelia from βenac mice are altered by the absence of tnfα in vivo. these data suggest that a tnfα-independent signaling cascade links airway surface dehydration to airway inflammation in the βenac mouse model. innovative pharmacological approaches to control the excessive neutrophil infiltrates into the bronchial lumen of cf patients are thought to be beneficial to reduce the extensive airway tissue damage. the activation of expression of proinflammatory genes by p.aeruginosa with bronchial epithelial cells is a central mechanism to be targeted with novel therapies. medicinal plants from the socalled traditional asian medicine are attracting a growing interest because of their potential safety, already tested in large scale applications in human diseases. however, due to the presence of different active principles in each plant extract, whose multifunctional effects may even result contradictory, understanding the effect of each component is mandatory to pursue selective and reproducible applications. a panel of medicinal plant extracts have been firstly screened for their capacity to interfere in the binding of nuclear transcription factor proteins (tf) with dna consensus sequences identified in the promoters of the pro-inflammatory genes, thus for their potential inhibitory action on gene expression. extracts from several medicinal plants have been screened for their ability to interfere with the tf nf-kb, ap- and creb, which are induced by p.aeruginosa, and some of them, such as emblica officinalis (eo), aegle marmelos (am), polyalthia longifolia (pl), have been shown to inhibit tf/dna interactions, opening the possibility of potential applications to downregulate expression of pro-inflammatory genes. extracts from eo, am, pl were tested in ib - cf bronchial cells exposed to the p.aeruginosa laboratory strain pao . eo, am and pl strongly inhibited the pao -dependent transcription of il- in ib - cells. pyrogallol, one active principle of eo, was tested in ib - cells, where it inhibited the transcription of the neutrophil chemokines il- , gro-alpha and gamma, of the intercellular adhesion molecule icam- and the pro-inflammatory cytokine interleukin , similarly to the whole eo extract, whereas a second active principle from eo, namely hydroxy-isoquinoline, had no effect. similar results were obtained with eo and pyrogallol in the monocyte-derived macrophage cell line thp- exposed to pao . in conclusion, extracts from plants of the traditional medicine can inhibit expression of pro-inflammatory genes and screening active principles purified from medicinal plants could result useful to identify safe and innovative pharmaceutical molecules to control lung inflammation in the lung of cf patients. supported by italian cystic fibrosis research foundation and by fondazione cariverona -bando -malattie rare e della povertà. massive infiltrates of neutrophils in the mucosal wall and lumen of the conductive airways of cf patients contribute to the progressive lung func-tion decline by releasing different proteases responsible for the progressive airway tissue damage. bacterial products and pathogens themselves within the mucopurulent material of the airway surface fluid induce the activation of transcription factors such as nf-kappab, ap- , sp , nf-il , nf-at, elk- , creb resulting in expression of chemo/cytokine genes driving the recruitment of leukocytes inside the bronchial lumen. to find new treatment options focused on the reduction of neutrophil chemotaxis, without abolishing the immune response against pathogens, we are exploring the transcription factor (tf) "decoy" strategy, in which oligodeoxynucleotides (odn) mimicking the consensus sequences for the tfs proteins identified in the promoters of different chemo/cytokines are delivered inside the cell in order to interfere with gene transcription. cf bronchial epithelial cells ib - have been exposed to the (i)p.aeruginosa(/i) strain pao . a clear pao -dependent activation of tfs such as nf-κb, sp , ap- , nf-at, nf-il was confirmed by electrophoretic mobility shift assay (emsa). in parallel, transcription of genes involved in innate immune response has been quantified by real-time rt pcr. transcription factor "decoy" odns directed against the consensus sequences identified in the promoters of different genes have been designed and validated by testing their interference in tf protein/dna binding assays. transfection of ib - cells with hiv- ltr and igk chain nf-κb odn "decoys" complexed with lipofectamine, performed hrs before challenge with pao , was shown previously to inhibit strongly pao -dependent transcription of il- but not gro, il- β, il- and icam- . therefore other tf "decoy" odns have been also tested: a) odn for nf-κb from il- promoter inhibited il- , gro-gamma and il- by %, b) odn for sp from hiv- genome inhibited il- by %, c) odn for ap- from il- promoter inhibited both il- and gro-gamma by %. a tf "decoy" molecule designed as peptide-dna chimera mimicking the consensus sequence of hiv ltr nf-κb strongly and selectively inhibited il- transcription. in conclusion, transcription of chemo/cytokines induced by (i)p.aeruginosa(/i) in cf bronchial epithelial cells (i)in vitro(/i) can be inhibited with different efficiency and selectivity by tf "decoy" molecules. these results provide useful hints for a gene-targeted anti-inflammatory approach and add further information on the regulation of expression of pro-inflammatory genes induced by (i)p.aeruginosa(/i) in bronchial epithelial cells. supported by italian cystic fibrosis research foundation and by fondazione cariverona -bando -malattie rare e della povertà. background: cf is characterized by hypersecretion of the pro-inflammatory cytokine il- from airway epithelial cells. however the mechanism by which il- gene expression is dysregulated in cf is not known. the expression of cytokine and chemokine genes is known to be regulated at multiple mechanistic steps including transcription, mrna decay, translation, and various post-translational steps. sequence-specific mrna degradation is now recognized to be an important site controlling the expression of several chemokine mrnas. this selective behavior is conferred by cisacting elements in the mrna composed of au-rich sequences (ares). the regulatory function of ares is thought to be mediated via rna-binding proteins that specifically recognize the are motifs. the steps required for mrna decay is comprised of deadenylation, decapping and body decay. deadenylation or removal of the poly (a) tail by poly(a)-specific ribonuclease (parn) appears to be the first and perhaps the rate-limiting step. this is accompanied by decapping or enzymatic removal of the ' methylate guanosine cap. subsequently, exonuclease activities in the ' to ' or ' to ' direction predominate to degrade the remaining mrna. hypothesis: we have hypothesized that defects in transcription as well as modulation of the post-transcriptional stability of il- mrna might contribute to hyper-production of il- protein in the cystic fibrosis. methods: il- mrna stability was assessed in cystic fibrosis ib - lung epithelial cells and in aav-cftr-repaired ib - /s cells, by measuring residual il- mrna levels at various intervals of time after addition of actinomycin-d to the culture. protein s extracts, prepared from the cf cell line as well as the cftr-corrected cell line, were analyzed by western blot. the expression levels of the various factors known to participate in are-mediated mrna decay, including ttp (an are-binding protein), parn and the exosome were compared in the two sets of s extracts. results: we find that the levels of il- mrna in the cf cells are greater than the levels found in the cftr-repaired cells. in addition, we found that the rate of decay of il- mrna in cf cells was significantly less than that in the repaired cell line. the levels of ttp, parn and exosome proteins were significantly reduced in the cf cells compared to the cftrrepaired controls. however, expression of ttp in ib - cells causes significant destabilization of il- mrna. conclusion: we conclude that the high levels of il- protein expression in cf lung epithelial cells can be partly due to enhanced stability of the il- mrna. consistently, the actual levels of il- mrna are higher in the cf cells compared to controls. understanding the mechanism by which ttp promotes enhanced destabilization of il- mrna in cf cells may be important for developing novel therapeutic targets to alleviate the pulmonary pathophysiology of this disease manifested by hyper-secretion of il- protein. understanding the mechanism of airway remodeling could lead to the identification of novel therapeutic targets for the prevention of irreversible lung damage in cf. we have investigated transcriptional responses to epithelial injury in a mouse model of cf that was developed in our laboratory (f del, cftr tm eur fvb backcross f ). to induce transient epithelial lung injury, homozygous normal and mutant age matched littermates were treated in parallel with naphthalene ( mg/kg ip) or carrier (corn oil) as control (n= x ). naphthalene causes an almost complete selective ablation of clara cells overnight, followed by migration of resistant ciliated cells and rapid proliferation of undifferentiated progenitor cells. two and seven days after treatment, lungs were collected for histological and transcriptome analysis. based on a previous affymetrix microarray analysis (n= ), a quantitative pcr array was designed containing genes differentially expressed after naphthalene injury. as expected, naphthalene injury results in a transient increase of cell proliferation markers (mki , cdc , cdc a etc), and a strong ( %) reduction of clara cell markers (cc /scgb a ; claudin /cldn ; cyp f ). in addition, we have now identified twenty-five genes that are increased (p< . ) two-to fifty-fold after naphthalene injury in both normal and mutant mice. this includes known and novel markers of epithelial tissue injury such as timp , retlna, mmp , serpin n, and lipocalin. in particular, a group of egf receptor agonists is strongly induced: amphiregulin (areg, fold), epiregulin (ereg fold) and heparin binding egf ( fold). amphiregulin mrna can be detected by in situ hybridization only in airway epithelial cells after injury. these egfr agonists are involved in stimulating epithelial repair, but can also activate cells in the underlying mesenchyma. indeed, we observe a substantial increase of major extracellular matrix mrna's two days after injury (co a : -fold, col a : -fold, elastin: -fold). whereas expression levels were substantially reduced in normal animals seven days after injury, in cf mutant animals two to three fold higher levels were observed for these three genes at day seven (p< . ). conclusions. we have designed and validated a gene array that can be used to study distal lung injury and repair. egfr agonists produced by epithelial cells are the most prominent growth factors after injury, involved in both epithelial repair and extracellular matrix production by mesenchymal cells. ecm production in cf mouse lung is sustained compared to normal mice, suggesting an inherent tendency towards fibrosis in cf lungs. our data suggest that the mesenchymal egf receptor and regulation of its agonists are important future targets of novel therapeutic strategies. supported by eec th fw projects eurocarecf, improved precision the mucosa of the proximal airways defends itself and the lower airways from inhaled irritants, allergens, and microbial and viral infections by several mechanisms. sensory nerves monitor the luminal microenvironment and trigger reflexes in the central nervous system (cns) that alter breathing, induce cough and stimulate mucus secretion when challenged with noxious stimuli. sensory nerves also release the tachykinins substance p (sp), neurokinin a and calcitonin gene-related peptide through axon reflexes in neighboring tissues, and these locally released tachykinins stimulate mucus secretion by binding to neurokinin receptors on submucosal glands. recently we reported that local fluid secretory responses to noxious stimuli are dependent on the clchannel cftr in mouse airway submucosal glands and are defective in glands from cftr knockout mice (ianowski et al., j physiol, , , ) . we have now tested the effects of sp directly and examined the possible role of cftr in mediating these responses using tracheas from congenic wild-type and cftr knockout mice (cftr m unc /cftr m unc ) that had been bred onto c bl/ j or balb/c genetic backgrounds. we compared single gland secretion rates using optical methods as described previously. the cftr genotype of each mouse was assessed by using pcr to amplify genomic dna from tail clippings obtained at age days. after the cftr knockout mice were weaned, intestinal obstruction was minimized by supplementing their water with peglite. capsaicinoids (chili pepper oil) increased fluid secretion from glands of wild-type mice from ± pl/min (n= tracheas, glands) to ± pl/min (n= tracheas, glands, anova p< . , tukey-kramer multiple comparison test p< . ). this response was abolished by exposing the basolateral surface of the tracheas to l- , ( µmol/l), a known sp (nk- ) receptor antagonist ( ± pl/min, not different from control, tukey-kramer multiple comparison test p> . ). secretion was stimulated from ± pl/min to ± pl/min (n= tracheas, glands, student's t-test p< . ) by the direct application of sp, and this response was strongly inhibited by pre-incubation with the cftr inhibitor cftrinh (saturating concentration, nominal µmol/l; n= tracheas, glands). finally, submucosal glands from cftr knockout mice failed to secrete when exposed to sp ( µmol/l) whereas wild-type littermates were responsive. these results indicate that sp mediates local responses to capsaicinoids through a cftr-dependent mechanism. loss of this local regulation in cf may contribute to the susceptibility of cf airways. support: canadian cf foundation, canadian institutes of health research, nih (dk ), and the cff (usa). chronically infected/inflamed cf human bronchial epithelia (hbe), or normal hbe exposed to supernatant from mucopurulent material (smm) from human cf airways, exhibit expansion of the endoplasmic reticulum (er) ca + stores and amplification of ca + -mediated inflammatory responses. we have shown that infection/inflammation of hbe triggers an unfolded protein response (upr) coupled to mrna splicing of x-box binding protein- (xbp- ). spliced xbp- (xbp- s) is a transcription factor that promotes er expansion to augment the protein folding capacity during increased protein synthesis. because we have shown that hbe inflammation couples to increases in protein synthesis, we hypothesized that hbe infection/inflammation-induced er ca + store expansion is mediated by xbp- s. to test this hypothesis, we constructed four retrovirally-tranduced stable hbe o-cell lines containing empty vector (ev), xbp- unspliced (xbp- u), xbp- s, or dominant negative xbp- (dn-xbp- ). cells were grown to confluence under an air-liquid interface and er ca + store expansion and il- secretion studied in the absence or following hr mucosal pbs or smm exposure. consistent with our hypothesis, expression of xbp- s in the absence of stimulation induced er expansion and increased mucosal utp-sensitive er ca + stores ( to confirm that these effects were mediated by upr activation, cells were transfected with a upr response element luciferase reporter plasmid, and luciferase activity was measured in the absence or presence of the upr inducer tunicamycin (tm). cells expressing xbp- s exhibited higher baseline luciferase activity than cells expressing ev or xbp- u, whereas luciferase activity was decreased in the dn-xbp- expressing cells. furthermore, while tm increased luciferase activity in cultures expressing ev or xbp- u, its effect was blocked in dn-xbp- expressing cells. these findings suggest that xbp- s is the major trigger of er ca + store expansion, which mediates the amplified ca + -dependent inflammatory response in infected/inflamed airway epithelia. although it remains to be established whether upr-dependent xbp- s is a beneficial or a maladaptive response in infected/inflamed airways, therapies aimed at manipulating this upr pathway may be beneficial for patients with chronic inflammatory lung diseases. luminal exposure of well-differentiated normal human bronchial epithelia (hbe) to supernatant from mucopurulent material (smm) from human cf airways increases the secretion of inflammatory mediators and triggers an unfolded protein response (upr) mediated by the mrna splicing of the x-box binding protein- (xbp- ). spliced xbp- (xbp- s) is a transcription factor that expands the endoplasmic reticulum (er) and protein secretory pathway during er stress induced by accumulation of unfolded proteins due to increases in protein synthesis. our previous studies in primary cultures of hbe and hbe o-cells stably expressing empty vector, inactive unspliced xbp- (xbp- u), xbp- s or a dominant negative xbp- (dn-xbp- ) suggest that induction of xbp- s by smm exposure promotes er ca + store expansion, which mediates a ca + -dependent hyperinflammatory response. the present studies were designed to determine if pseudomonas aeruginosa pak strain (p.a.) would reproduce the effects of smm in both in vitro and, importantly, in vivo models. for in vitro studies, hbe were exposed to broth (tsb) or to a % p.a. extract for hr, and inflammation, xbp- s, and er ca + store expansion investigated by il- secretion, southern blots and calreticulin expression, respectively. similar to smm, p.a. induced a . fold increase in il- secretion coupled to a fold increase in xbp- s and larger er ca + stores as compared with tsbexposed hbe. these data demonstrate the link between p.a. infection, upr activation and xbp- s in vitro. we next tested the relevance of these findings in vivo. wild-type mice airways were challenged with pbs or cfu of p.a., and airway epithelial er density was assessed by calreticulin staining hr later. in comparison with pbs challenges, p.a.-challenged mice exhibited airway epithelial er expansion, which correlated with the degree of airway inflammation, based on the presence of inflammatory cells. to test whether this p.a.-induced er expansion was linked to xbp- s, we utilized "er stress activated indicator" (erai) mice expressing a fusion protein consisting of xbp- u and the fluorescent protein venus. in erai mice, upr activation-dependent xbp- splicing leads to venus expression; hence, venus fluorescence is an index of xbp- s. consistent with our hypothesis that p.a. infection-triggered inflammation would induce upr-dependent xbp- s, venus fluorescence, after hr challenge with cfu of p.a., was increased in inflamed as compared with non-inflamed airways. these findings suggest that ) airway epithelia respond to bacterial infection-induced inflammation by up-regulating the er ca + stores and ) activation of the xbp- s pathway by bacterial infection may be relevant to airway inflammatory responses in vivo. funded by the cff. we have shown that luminal exposure of well-differentiated primary cultures of normal human bronchial epithelia (hbe) to supernatant from mucopurulent material (smm) from human cf airways increases total cellular protein synthesis, which reflects the increased secretion of inflammatory factors induced by the infectious and inflammatory process. in the present studies, we first investigated whether these hbe responses to smm were linked with an increased metabolic rate by measuring lactate accumulation into the serosal media. smm increased lactate production, and this effect was maximal within hrs ( . + . vs. . + . , and . + . vs. . + . mmol/l in and hr pbs vs. smm, respectively; n= - ), suggesting that the increase in protein synthesis couples to a hyper-metabolic state in infected/inflamed hbe. in agreement with this notion, or hr smm, as compared with pbs exposure, induced the expression of genes associated with amino acid transport and metabolism (n= ). in addition, or hr smm exposure up-regulated genes involved in oxidative stress (n= ). we hypothesized that these hbe responses were linked to an unfolded protein response (upr) mediated by activation of the pkr-like er kinase/pancreatic eif α kinase (perk)-induced activating transcription factor (atf ), since this pathway has been shown to confer protection against amino acid loss and oxidative stress in other cells. we first tested whether smm induced activation of perk/atf in hbe by performing western blot analyzes of the components of this pathway. twenty-four hr smm exposure induced perk activation, as indexed by phosphorylation of perk, in comparison with pbs-exposed hbe. on the other hand, total perk protein levels were unchanged in smm-treated hbe. phosphorylation of eif α, the downstream effector of perk, and increased atf protein levels, which depend on the phosphorylated status of eif α, provided additional evidence that the perk/atf pathway was activated by smm. these data are consistent with the hypothesis that induction of atf is triggered by upr activation resulting from increased synthesis of inflammatory factors. we next utilized rna microarrays to test whether atf target genes were induced by smm. six or hr smm exposure induced atf target genes (e.g., ero , an oxido-reductase that provides protection against the accumulation of endogenous peroxides during er stress; stanniocalcin , whose expression is associated with anti-apoptotic functions; and heme oxygenase ). these findings suggest that ) activation of the upr-dependent atf pathway is a compensatory component of the airway epithelial adaptive response to luminal infection/inflammation, and ) activation of the atf pathway protects against inflammation-induced amino acid loss and oxidative stress by up-regulating genes involved in amino acid transport/metabolism and oxidative stress responses. unraveling the functions of atf should help determine if therapies targeted to manipulate pathway activity would be likely to improve lung function in patients with cf or other chronic inflammatory airway diseases. funded by the cff. miller, t.j.; perez, a.; qian, y.; davis, p. pediatrics, case western reserve university, cleveland, oh, usa fxyd is a cell surface protein originally identified in a screen for molecular markers of tumorigenesis. increased fxyd expression was found in tumors from stomach, thyroid, colon, pancreatic, breast and lung cancers and correlated with down-regulation of e-cadherin and poor patient prognosis. recent studies have shown that overexpression of fxyd promotes cell motility, decreases cell-cell attachment and increases tumor metastasis. fxyd , also known as dysadherin, is a member of small family of proteins known to regulate the na,k-atpase. we now report that fxyd is upregulated in cystic fibrosis (cf) airway epithelia and modulates wound healing. we show by immunohistochemistry and immunoblot analyses that fxyd is increased in the lungs of s x cf mice, and demonstrate an almost -fold increase in fxyd expression in the nasal epithelia of cf mice compared to wild-type littermates (p< . ). furthermore, we show that fxyd is upregulated in nasal scrapings from human cf patients compared to controls (p< . ). immunofluorescence data show that flag-tagged fxyd co-localizes with the na,k-atpase in epithelial cells, suggesting that fxyd , similar to other members of the fxyd family, may regulate na,k-atpase function. it has previously been shown that expression and localization of the na,k-atpase is required for efficient polarization and suppression of cell motility in epithelial cells. the recurrent remodeling of pulmonary epithelium as a result of bacterial infection in cf requires that airway epithelial cells polarize and migrate to wound sites in order to maintain lung integrity. thus we hypothesized that fxyd may be involved in wound healing after infection. laser-capture microdissection and microarray analysis of murine lung epithelia after hours treatment with p. aeruginosa indicated a significant, -fold increase in expression of fxyd that was confirmed by immunoblot analysis. others have shown that fxyd may mediate expression of mcp- , a critical determinant in monocyte recruitment, through activation of the nf-kb pathway. treatment of human tracheal epithelial (hte) cells with a cftr inhibitor ( ) confirmed that loss of cftr function correlated with increased fxyd expression by quantitative rt-pcr (p< . ), an effect that was abrogated with treatment of pdtc, an inhibitor of nf-kb (p< . ). we speculated that fxyd -induced increases in cell motility may be due in part to phosphorylation at serine . in a murine airway epithelial cell wound healing model, serine to alanine (s a) mutations at serine inhibited wound healing compared to wild type fxyd overexpression, whereas aspartic acid (s d) mutations increased wound healing (p< . ). immunoblot and immunofluorescence analyses of these mutants suggest phosphorylation at ser regulates membrane localization. we conclude that fxyd is increased in cystic fibrosis epithelia due to increased inflammatory mediators and suggest that fxyd may modulate airway epithelia wound healing after infection with p. aeruginosa through phosphorylation at ser . the inflammatory response to bacterial infection in the cf airway is exaggerated compared to normal, leading to the accumulation of millions of necrotic neutrophils. extracellular neutrophil elastase (ne) activity in the cf airway not only compromises innate defences by cleaving opsonins and reducing ciliary activity, but amplifies the inflammatory response by stimulating expression of the neutrophil chemoattractant il- and increases mucus production, in addition to degrading the tissue matrix leading to fatal bronchiectasis. ne therefore represents an important target for the development of new therapies. however, this strategy requires consideration of the normal physiological function of this enzyme, since previous studies in knock-out mice indicated an essential role for ne in cell migration, bacterial phagocytosis and killing. our approach was to use the intracellular neutrophil elastase inhibitor gw a to 'knock-out' ne activity in neutrophils in normal human blood and test the function of isolated cells in chemotaxis, bacterial phagocytosis and killing assays. whole normal human blood was incubated with gw a, or pbs control, for h at °c. neutrophils were isolated by sedimentation of red blood cells (rbc) on dextran , purification on lymphoprep and hypotonic lysis to remove contaminating rbc. chemotaxis towards il- was measured using a modified micro-boyden chamber. phagocytosis was assayed by the depletion of staphylococcus aureus (sa), pseudomonas aeruginosa (pa) and e. coli (ec) in supernatants following culture in a : ratio with pmn for h at °c. supernatants were diluted and remaining organisms were plated on agar and grown overnight to count viable colonies. bacterial killing was assayed by incubating bacteria and cells in a : ratio for minutes to allow phagocytosis, washing off remaining organisms, and incubating for h at °c. neutrophils were lysed with water and lysates plated on agar to test for bacterial growth overnight. results; gw a inhibited intracellular ne dose-dependently and at µm . ± . % ne activity remained (n= ). there was no significant effect of µm gw a on neutrophil chemotaxis, bacterial phagocytosis or killing of any organism compared to pbs-treated controls. phagocytosis data is shown in the table. thus, in the absence of ne activity, human neutrophils remain wellequipped with other defence molecules including myeloperoxidase and defensins to successfully maintain the role of the neutrophil in innate immunity. however, mouse neutrophils which lack defensins require ne activity for optimal intracellular bacterial killing, and mice are not a perfect model for studies of human infection. the development of novel inhibitors of ne to treat lung disease in cf therefore remains an important goal. supported by the cf trust of great britain. background: sphingolipid signalling may differ between individuals with cf and healthy controls. the response to bacterial inflammation is different, and uptake and inactivation of sphingosine- -phosphate, an intracel-lular pro-inflammatory mediator, is reduced in cf cells. it may therefore continue to act on g-protein coupled receptors in the plasma membrane. (boujaoude et al, j biol chem ) . furthermore, ceramide originating from basolateral sphingomyelin hinders augmentation of cftr-mediated anion conductance across the apical membrane, resulting in reduction of transepithelial airway anion secretion (ito et al, bbrc ) . aim of study: to determine if there is a difference in the levels of alkaline, neutral or acid sphingomyelinase (smase), or in the levels of neutral or acid ceramidase, in the intestinal or bronchial mucosa and some other tissues, between wildtype, homozygous (+/+) and heterozygous (+/-) delta-f cftr mice. methods: enzyme activities (duan and nilsson meth enzymol ) were determined in intestine (and content) divided into four regions, liver, lungs, kidney and spleen from deltaf -cftr mice (+/+) and controls (wildtype, +/-). results: there was an increased amount of neutral ceramidase in spleens from deltaf -cftr mice (+/+) in comparison to control mice (p= . ). no other significant differences were seen. conclusion: delta-f mutation did not influence the levels of alkaline smase and neutral ceramidase acting as ectoenzymes, or the levels of intracellular smases and ceramidases, which may all generate bioactive sphingolipid metabolites in intestine and lungs. the implications of the increased level of neutral ceramidase in spleen are not known. in children with cystic fibrosis (cf) there is a clear correlation between the development of chronic p aeruginosa infection and acceleration in the decline of lung function. when chronically present, p aeruginosa takes on a mucoid phenotype and is impossible to eradicate. prior to this, when colonisation is intermittent, it is possible to eradicate it with aggressive antibiotic regimes. we sought to examine the degree of inflammation and innate defence status in the lungs of children with cystic fibrosis in various stages of colonisation by looking at a range of proteases, innate defence proteins and markers of inflammation in broncho alveolar lavage (bal). children with cf were allocated to one of three groups in relation to p aeruginosa infection; chronically colonised, intermittently colonised and non-colonised, on the basis of the leeds criteria. bal was collected as per ers guidelines as part of each patient's routine clinical care. bal was collected from control patients undergoing elective non-pulmonary surgical procedures. differential cell counts in bal were performed manually. secretory leukocyte protease inhibitor (slpi), elafin, alpha- antitrypsin (a at) and lactoferrin concentrations were measured by elisa. neutrophil elastase activity and cathepsin activity were assayed by colorometric activity assays. fifty two patients were included in the study ranging in age from months to years ( chronic, intermittent, non colonised and controls). neutrophil counts, neutrophil elastase activity and cathepsin activity were markedly increased in children chronically colonised with p aeruginosa compared to those in the intermittent and non colonised groups. in contrast, levels of the antiproteases slpi and a at and the antimicrobial peptides elafin and lactoferrin were highest in the control group and decreased as colonisation progressed, with levels in the chronically colonised group markedly lower than those with intermittent colonisation. this study demonstrates that in children with chronic p aeruginosa colonisation, there is a marked decrease in antiproteases and antimicrobial factors and a marked increase in protease activity and neutrophil influx in comparison with those who are non-colonised or intermittently colonised. these findings underline the importance of careful microbiological surveillance and early aggressive treatment of p aeruginosa infection in children with cf in order to avoid chronic colonisation. background : abnormal bronchial angiogenesis is responsible for hemoptysis in cystic fibrosis (cf). expression of vegf-a in airway epithelium induces bronchial angiogenesis in animal models. we have recently found that vegf-a and egf receptors (egfr) are increased in the airway epithelium of subjects with advanced cf lung disease. aims: to examine the effects of pa bacterial products and egfr inhibition on vegf synthesis in airway epithelium. methods: culture of non cf (nci-h ) and cf (cfte o-) human airway epithelial cell lines. stimulation with pa lipopolysaccharide (lps). assessment of vegf mrna and protein by rt-pcr and elisa. use of chemical inhibitors, blocking antibodies and sirna. results: pa lps increased vegf gene expression and protein production time-and dose-dependently in both cells lines. using chemical inhibitors, we show that egfr and erk / activation are required for lpsinduced vegf production. using blocking antibodies to egfr and its ligands, we show that tgf-alpha-dependent egfr activation mediates pa lps-induced vegf gene and protein synthesis. using pharmacological inhibitors (an ros scavenger and an nadph oxidase inhibitor) and using small interfering rna of dual oxidase (duox) and tnf-alpha converting enzyme (tace),we show that lps-induced vegf upregulation is dependent on duox -mediated ros release and tace activation. thus, pa products induce vegf synthesis in airway epithelium via a duox -ros-tace-tgf-alpha-egfr-erk / cascade. conclusions: these results describe a novel pathway by which bacterial products induce angiogenic signaling in cf and non cf airway epithelium. background: unlike bronchoalveolar lavage (bal), the airway mucosa has been under-investigated in cystic fibrosis (cf), despite the fact that irreversible airway wall changes (bronchiectasis) are a feature of endstage disease. cf is characterized by a neutrophil-dominated inflammation in bal, but little is known about the pattern of inflammation in the airway mucosa, especially in children with relatively early stage disease. we aimed to assess whether the pattern of inflammation seen in cf bal was also found in the airway mucosa in cf children. methods: to date, endobronchial biopsies and bal from children ( - years) with cf and control children ( - years) without lower respiratory disease have been assessed. bal cell differential was assessed on may-grünwald-stained cytospins. endobronchial biopsies were stained for neutrophils (neutrophil elastase, ne), t-(cd ) and b-(cd ) lymphocytes, eosinophils (eg ), and macrophages (cd ). area profile counts of immunopositive cells in subepithelial tissue were performed by investigators blinded to disease group. results: all cell types were increased in cf bal compared to controls. cf bal was characterized by an abundance of neutrophils ( x /ml vs. x /ml in controls, p< . ) with moderate numbers of lymphocytes ( x /ml vs. x /ml in controls, p< . ). in contrast, cf subepithelial tissue was characterized by a lymphocytic infiltrate ( cells/mm vs. cells/mm , p< . ) with only very few neutrophils ( cells/mm vs. cell/mm , p< . ). the lymphocytic infiltrate in cf consisted mainly of t lymphocytes ( %). eosinophil counts in subepithelial tissue did not differ between cf and controls. for all cell types, there was no correlation between counts in bal and counts in subepithelial tissue. conclusions: in contrast to the neutrophil-dominated inflammation in the airway lumen, cf is characterized by a lymphocytic inflammation in the airway mucosa. the lymphocytic infiltrate consists mainly of t lymphocytes, the pathophysiological function of which may be important and is being investigated in future work. support: ers long-term fellowship and swiss national foundation grant to nr the epithelium serves as a barrier to the penetration of foreign antigens, particles, and infectious agents across the airway. the integrity of this barrier is dependent, in part, upon the apical junctional complex consisting of the tight junction (tj) and the adherens junction. alterations in tj permeability have been linked to the pathogenesis of inflammatory bowel disease and this increased intestinal permeability may actually precede the onset of chronic inflammation. in cystic fibrosis (cf), the airway lumen is filled with high concentrations of inflammatory cells, bacteria, and inflammatory mediators. since tj barrier function can be significantly reduced by inflammatory mediators, we hypothesized that measures that enhance airway tj barrier function will decrease airway responses to the continuous presence of inflammatory mediators in the lumen. to test this hypothesis, we examined the relationship between lung inflammation and epithelial permeability in vivo using a lipopolysaccharide (lps) model of lung inflammation. pseudomonas aeruginosa lps was instilled intratracheally into the lungs of c bl/ mice which were then euthanized at , and hrs. lung inflammation was assessed by total cell counts using a hemacytometer and differential counts by wrights staining of cytospin preparations of the bronchoalveolar lavage fluid (balf). lps increased total cell counts and neutrophil concentrations that peaked at hours after lps administration, compared to saline controls. measurements of the proinflammatory murine cytokine kc in balf, by a cytokine antibody bead technique, showed an increase in murine kc at hr following lps administration, which correlated with the substantial increase in neutrophil concentration. changes in lung permeability with inflammation were assessed by elisa measurements of the levels of serum protein murine albumin in balf. correlating with changes in cellular inflammation and murine kc levels, albumin concentration peaked at hr after lps administration. this increase was subsequently resolved, consistent with the restoration of barrier function. an examination of frozen sections of lung from lps-treated animals showed a redistribution of the tight junction protein zo- consistent with the disruption of barrier function. since the p map kinase signaling pathway has been implicated in lps-induced airway inflammation, and an inhibitor of this kinase, sb has been shown to reduce this inflammation, the effect of this inhibitor on barrier function is being investigated. in initial studies, sb appears to reduce total and neutrophil cell counts by % in vivo. the effect of sb on murine albumin concentrations in balf and on tj protein localization is currently being evaluated. a reduction in these parameters will be used as indices of improved barrier function with sb . these studies will determine whether a reduction in lung inflammation correlates with a restoration of barrier function. the degree of protection provided by the p map kinase inhibitor sb could have important implications for inflammatory lung diseases such as cf. background: chronic pulmonary inflammation in cf is characterized by a robust neutrophil response associated with airway damage and failure to eliminate the pathogen, p. aeruginosa (pa). pa is a highly adaptable opportunist which quickly develops resistance to antimicrobials. thus, the development of specific immunotherapy targeting the neutrophil recruitment without ablating the host's immune response to infection or promoting pathogen resistance would be ideal. our group has identified il- as a prime target for the development of immunotherapy due to the central role that the il- /il- proinflammatory axis plays in neutrophil recruitment. however il- does not mediate the early neutrophil recruitment seen in response to infection. hypothesis: il- , acting synergistically with il- , is critical to early neutrophil recruitment during pulmonary pa infection. the primary effector cells are the il- -producing antigen presenting cells: alveolar macrophages (ams) and myeloid dendritic cells (dcs). methods: wt and il- -deficient mice were infected with pa at x cfu/ ul by intratracheal (it) inoculation for hours. bal inflammatory cell counts, and cytokines and chemokines were measured. am and dc cultures were infected for hours in vitro and supernatant cytokines/chemokines were measured by luminex and elisa; il- levels were measured by taqman. these studies were designed to elucidate the role of il- in the early neutrophil peak and define am-and dc-mediated cytokine/chemokine production. recombinant murine il- , il- , and il- + il- were instilled via it into wt and il- -deficient mice. bal inflammatory cell counts and cytokines/chemokines were measured at hours. these studies were designed to elucidate the role of il- and il- in the early neutrophil peak and define am-and dc-mediated cytokine and chemokine production. results: at hours post-infection, il- deficient mice had significantly lower percent neutrophils (p< . ) and lower mip α, kc, and il- (p< . ) in the bal. il- was undetectable. there was no significant difference in bacterial load that could account for these cytokine/chemokine differences. infected wt ams elaborated significantly more mip a, gm-csf, mcp- , il- , g-csf, ip- , kc and il- than the il- -deficient ams (p< . ) and the response was inoculum-dependent (p< . ). dcs elaborated no il- and exhibited il- -dependent differences in mip- α and mcp- production (p< . ). in vivo studies of il- and il- effect demonstrated a synergistic increase in bal neutrophil recruitment (p< . ) and cytokine and chemokine induction (p< . ). conclusion: the first wave of neutrophil recruitment seen during pa infection is il- -dependent and il- -independent. ams and dcs are critical to il- and il- indcution of this neutrophil recruitment. these studies identify il- as a key mediator of neutrophil recruitment in the early stages of infection as well as the proximate mediator in the il- /il- pro-inflammatory axis and suggest il- as a potential target for anti-inflammatory therapy in the treatment of pa pulmonary infection. supported by the cystic fibrosis foundation, american lung association and the nih the airways are under constant assault from air-borne pathogenic material. despite the intake of up to , bacteria per hour, the airways are sterile below the larynx in healthy individuals. the task of maintaining this sterility falls to the airway surface liquid layer (asl), the protective twophased system consisting of the viscoelastic mucus layer and the periciliary layer (pcl) through which cilia beat, sweeping the mucus layer away from the lungs. the mucus layer, which is responsible for trapping pathogenic material, is comprised of mucins (high molecular weight glycoproteins), cellular debris, dna, neurtifils, and more than other proteins. this chemically heterogeneous mixture forms a viscoelastic gel that is thick enough to trap pathogens of various sizes and surface chemistries, while not sticking to the underling cellular / cilia layer, allowing the transport of trapped pathogenic materials away from the lungs. the performance of this trapping / transportation system is defined by the rheological properties of the mucus layer and the force imparted on the mucus. therefore, understanding how mucins and other chemical components of the mucus layer interact with each other to form a successful mucus gel (i.e. one that is cleared from the airways) is crucial to understanding airway defense. here we present the results of physical and chemical composition studies of sputum samples collected from patients with chronic obstructive pulmonary disease (copd) and cystic fibrosis (cf). the rheological properties of each sample was assayed using parallel plate rheolometry, probing the materials non-linear viscoelastic properties such as viscosity, elasticity, and yield stress. the physical properties of the sample are then correlated to the sample's chemical properties such as percents solids (divided between salts, proteins, and mucins), as well as the relative concentrations of the key airway mucins muc b and muc ac. our results indicate that the physical properties of sputum are not well predicted from the total amount of biosolids in a given sputum sample, but by the relative concentrations of muc b and muc ac and the interactions of these molecules with themselves and the other proteins present. further, we establish that the heterogeneous physical properties within a given sputum sample correlate to differences in the muc b and muc ac concentrations. the gene modifier study (gms) was established as an effort to identify potential genetic modifiers of cystic fibrosis pulmonary disease and survival. during the course of this study over delta f homozygous cf patients classified as having mild lung disease, severe lung disease, or increased survival, have submitted both clinical data and blood samples for single nucleotide polymorphism (snp) analysis. the original snp analyses have shown a significant association between variants in the endothelin receptor a (ednra) gene, and cf survival, most markedly in female cf patients. sixteen additional snps within and around the ednra gene have now been genotyped, and have implicated the ' and ' untranslated regions of the gene as having the most significant association with pulmonary disease in females (p< . ), suggesting quantitative differences as a possible mechanism for the association with pulmonary phenotype. we are in the process of saturating the ' and ' regions of ednra with an additional snps to further delineate the genetic association. ednra binds endothelin- (et- ) in airway smooth muscle cells, causing increased cell proliferation, smooth muscle contraction, and stimulation of inflammatory molecules. because each of these effects is known to be deleterious to the cf lung, we hypothesize that the ednra variants found more commonly in "severe" cf females ("severe" alleles) are marking increased ednra expression compared to alleles found more commonly in "mild" cf females ("mild" allelels). because the genetic association was strongest in cf females, we used the matinspector software to analyze kb of ednra promoter sequence and found several putative binding sites for both estrogen and progesterone. we then used a brdu assay to measure cell proliferation after stimulation with both estrogen and progesterone. these experiments showed that the asm cells with the "severe" ' ednra genotype proliferated at levels approximately twice that of the asm cells with the "mild" ' ednra genotype following stimulation with either estrogen or progesterone. using a single base extension protocol and quantitative pcr on human airway smooth muscle cells, we were also able to compare ednra expression from the "severe" allele, and the "mild" allele. these comparisons of ednra expression demonstrate that expression levels appear to be approximately % higher from alleles found more frequently in the "severe" cf females. in addition, preliminary data suggest that stimulating the asm cells with estrogen increases ednra expression by approximately fold, and like the cell proliferation experiments, these increases are most pronounced in cell lines with the "severe" genotypes. these data suggest that the "severe" genotypes are marking alleles with increased expression, perhaps due to estrogen binding, that leads to increased et- functional effects that over time are deleterious to the cf lung. cf patients do present with variable spectra of lung disease, of which infections are most life-threatening. β-defensins have an antimicrobial activity against a broad spectrum of microorganisms and are chemotactic agents for cells of the adaptive immune system, and therefore assist in combating these infections. β-defensins - are part of a repeat region. this repeat region is polymorphic between individuals and therefore the dosage of these defensin genes/proteins varies. we developed a real time pcr assay to quantify the number of βdefensin repeats in this region. appropriate controls are needed for an accurate quantitative assay. therefore we made concatemeric constructs with copy of defb and a particular number of defb copies, which ranged from to copies. using these controls as standards, the number of defensin repeats could be accurately determined in dna samples. we then tested f del homozygous cf patients from belgian ( patients), czech ( patients) and south-italian ( patients) origin. the diploid number of repeats varied between and . for each patient group, a higher number of repeats was found in the group of patients with milder disease (fev > %) compared to the group of patients with more severe disease (fev < %) (student t test, p-values of . , . and . respectively). moreover, in our cohort of belgian cf patients, cf patients of years or older have a significant higher number of repeats than the cf patient group below (p-value . ). to evaluate this at the functional level, we cultured nasal epithelial cells from individuals with a low number of repeats (i.e. or repeats) and individuals with a high number of repeats (i.e. repeats). the cells where grown in air liquid interface cultures. after differentiation, the cells were stimulated with ng tnfα. in cells with a high number of repeats, defb expression, as measured by the extent of transcription, was strongly upregulated by tnfα. in cells with a low number of repeats, defb was not upregulated (p-value = . ). we also tested the antimicrobial activity of epithelial cells. we challenged epithelial cells from individuals ( repeats) with a laboratory strain (pa ) of pseudomonas aeruginosa and a clinical isolate ( - cfu), either in combination with tnfα or without tnfα. after h, surviving bacteria were counted by a plating out method. cells that were stimulated with tnfα h prior to the bacterial challenges were more bactericidal. the clinical strain was more vulnerable to the surface liquid than the laboratory strain. in epithelial cells from individuals having a low number of repeats, these effects were very variable from individual to individual. in summary, the β-defensin region is a modulator of cystic fibrosis lung disease. the pro-inflammatory response in cultured epithelium cells strongly correlates with the number of β-defensin repeats. cells with a higher number of repeats respond to tnfα treatment, which in turn results in a better antimicrobial activity of the surface liquid. rationale: studies of affected twins and siblings demonstrate that modifier genes are major contributors to variation in cystic fibrosis (cf) lung disease severity. we performed genome wide linkage analysis to identify regions likely to contain modifier genes affecting severity of cf lung disease. methods: individuals with cf from families were analyzed. pulmonary function data were collected from patient chart review and were supplemented with data from the us cystic fibrosis foundation patient registry. to minimize environmental variation, only data obtained while subjects were living with an affected twin or sibling were analyzed. the pulmonary phenotypes were defined using the best cf-specific percentile for fev (kulich, et al) within the last year of available pft data as a crosssectional measure (maxfev cf%) and using two longitudinal measures: the lifetime average cf-specific % for fev (avgfev cf%) and the estimated percent-predicted fev at age (estfev %pred@ yrs, schluchter, et al). longitudinal measures were derived from a minimum of years of pft data. short tandem repeat markers (strs) were typed in all affected individuals and their parents (marshfield genotyping center: markers or decode genotyping center: markers). two-point and multipoint linkage analyses were performed using sequential oligogenic linkage analysis routines (solar). results: patients represented the spectrum of lung disease severity, with maxfev cf%'s ranging from to , mean . ± . and avgfev cf% ranging from . to . , mean . ± . . the maxfev cf% was predictive of avgfev cf% (r= . , p< . ) for the individuals for whom both measures were available. the two longitudinal measures were also highly correlated (r= . , p< . ). linkage was found at chromosome for all three phenotype definitions. peak multipoint lod scores on chromosome occurred at cm for maxfev cf% and avgfev cf% (lod . and lod . , respectively) and at cm for estfev %pred@ yrs (lod . ). single point lod scores on chromosome peaked at marker aaat ( . for maxfev cf%, . for avgfev cf%, and . for est-fev %pred@ yrs). the region of linkage encompasses approximately megabases near the telomere of chromosome q. conclusions: chromosome appears to contain one or more genetic modifiers of cf lung disease severity. supported by the nhlbi, cff and genome canada through the ogi. cystic fibrosis-related diabetes (cfrd) is the most common extrapulmonary complication of cf and is an increasingly important contributor to morbidity and mortality as cf patients live longer. while pancreatic fibrosis and loss of exocrine and endocrine tissue are common in cf, - % of cf adults develop defects in insulin secretion and accumulation of islet amyloid polypeptide, features typical of type diabetes (t dm) in the general population. to test whether modifier genes play a role in cfrd, we compared concordance rates for cfrd in pairs of monozygous (mz) twins, sets of dizygous (dz) twins, and sets of or more siblings ( individuals with cf). criteria for defining cfrd included physician diagnosis, treatment with insulin/oral agent, and episodes of glucose ≥ mg/dl. mz twins were highly concordant for cfrd ( of pairs, %). the young age of dz twin recruits precluded analysis of this group in isolation ( of pairs were concordant). twelve of ( %) sibling pairs were concordant for cfrd. with heritability defined as: h = *(mz concordance -dz concordance), and including siblings as a proxy for dz twins, heritability is estimated as ~ . . the same results were obtained considering only same-sex dz twins and siblings, correcting for differences in age and duration of clinical follow-up, or restricting analysis to ∆f homozygotes. these data support a significant role for one or more modifier genes in development of cfrd. we then tested whether cfrd correlated with a strong family history of adult-onset diabetes (at least first-degree or second-degree relatives on the same side of the family). of those reporting family history of diabetes, of had cfrd, compared to of with no family history (or= . [ . - . ]; p= . ). this correlation persisted after adjusting for age, sex, and pancreatic insufficiency (or= . ; p= . ). thus, family history of diabetes correlated with increased risk of cfrd. we then tested whether variants in tcf l , a transcription factor in the wnt signaling pathway, that have been reproducibly associated with t dm in the general population were associated with cfrd in our study subjects. genotyping of four single nucleotide polymorphisms associated with t dm (rs , rs , rs , rs , here termed snpa-d) and transmission disequilibrium testing (tdt) of parent-parent-child trios revealed significant overtransmission for snpb ( : , p= . ) and snpc ( : , p= . ), and possible overtransmission for snpa ( : , p= . ) and snpd ( : , p= . ). in every case, the tcf l allele overtransmitted to patients with cfrd is the same allele that confers increased risk for t dm. furthermore, individuals with cfrd who were homozygous for risk alleles were diagnosed at a significantly earlier age (average . vs. . ; p= . ). these data support a key role for modifier genes in development of cf-related diabetes, and demonstrate that cfrd and type diabetes may share disease mechanisms such as alterations in wnt signaling. supported by nih dk , hd , dk and hl , and cf foundation grant cuttin p . cystic fibrosis (cf) phenotypes and survival are highly variable among df homozygous patients, pointing to the existence of modifier genes and/or environmental factors that contribute to this disease. studies to identify genetic modifiers of cf are being carried out using dna from homozygous df cf patients. important clinical features, such as severity of lung disease, liver disease and meconium ileus (mi) status, are well defined. tgfβ has been previously identified as a modifier of cf lung disease (drumm et al., nejm, ( ) : [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) , but it does not explain all of the genetic heterogeneity in this population. current evidence suggests that mucus is involved in the progression of cf, making the muc genes prime candidates as modifiers of lung disease and/or other phenotypes. methods: our approach to evaluate muc genes utilizes both variable number tandem repeat (vntr) polymorphisms and single nucleotide polymorphisms (snps). vntr polymorphisms in the muc and muc ac genes (n= and n= patients, respectively) were detected by southern blotting under conditions fully optimized to maximize the allele size resolution. to minimize gel to gel variation, a genomic dna mixture with the most common muc and muc ac alleles was used as internal markers. accuracy and reproducibility were evaluated by duplicating the southern on the critical dna samples for muc and muc ac genes (n= and n= patients, respectively). fifty snps in muc ac, muc b, muc , muc and muc genes are being tested using illumina technology in cf patients. results: preliminary analysis suggests there are significant differences between cf patients with "severe" and "mild" lung disease for both muc and muc ac allele distribution, which is mainly driven by the male population; exhaustive statistical data analysis still is underway. the vntr data also suggest significant association between the larger muc allele size and cf patients with mi. the ongoing vntr analysis will be complemented by muc gene snps being genotyped. conclusions: initial results indicate that we can reproducibly characterize muc and muc ac vntr alleles. additional characterization of muc and muc ac vntr alleles, coupled to snp data, will allow us to better define the significance of muc gene variations as modifiers of different cf phenotypes. supported by cff perezv g (jpv), cff knowle a (mk), cff r -cr (wko), nih rr , r hl , and cff drumm a . reporting for the gene modifier study group (mrk). we have previously reported that βenac transgenic mice, which overexpress the beta subunit of the amiloride sensitive sodium channel (scnn b) specifically in the airways, share common features with cf, including increased enac activity, reduced airway surface liquid, mucus accumulation and obstruction, inflammation, and death. interestingly, analysis of this model also suggested the existence of potential genetic modifiers of phenotype severity, and we speculated that identification of these modifiers would provide novel insights into disease phenotype. to establish a set of reagents that could be used to uncover genetic modifiers, we have bred βenac transgenic mice from two independent founder lines ( and , b :c background) onto several strains of inbred mice, including c bl/ n, c h/hen, balb/cj, fvb/j, and /svj. these studies revealed dramatic phenotypic differences as measured by survival ( to %) among strains and between lines. all lines thus far tested show ~ - fold increases in amiloride sensitive short-circuit current as measured by ussing chambers in the trachea. complete phenotypic characterization of c bl/ n line at backcross generation reveals high survival ( ± % in comparison to ± % of the mixed b :c background), yet the mice maintain the pulmonary features of the originally reported mice, including increased mucus plugging, mucous cell hyperplasia, neutrophilic and eosinophilic inflammation peaking at early timepoints ( days - weeks). lymphocytic nodules, which are not commonly seen in - weeks-old animals with mixed strain background, are a common feature in the c bl/ n congenic line. emphysema and early airway epithelial cell necrosis, two phenotypes initially not strongly associated with transgene expression, are also observed. line on balb/cj and c h/hen backgrounds has reduced survival compared to the c bl/ n background, and generation backcross lines are now being evaluated in these two strains for other phenotypic characteristics. analysis of backcross data from line , which has low survival on all genetic backgrounds tested to date, including c bl/ n, suggested that the transgene may have integrated onto a c h locus with a dominant negative effect on survival. genetic analysis using genome-wide snp genotyping revealed a region of chromosome linked to the transgene in line (lod score > . ). further analysis of this region is underway. in summary, backcrossing onto different genetic backgrounds is revealing genetic modifiers for phenotypes in the βenac overexpressing model. characterization of these phenotypic and genetic differences should provide clues about the mechanisms relevant to disease development. furthermore, inbred lines with variable phenotype will likely be an important reagent for the cf community as the utility of this model is evaluated in future studies. supported by nih (scor p hl ) and cff (mall go, oneal go). introduction: new york state screens newborns with immunoreactive trypsinogen levels within the top % of all infants, for common cf gene mutations. infants found to be heterozygote carriers are referred to a cf center to determine sweat chloride concentration. the proposed abnormal sweat chloride value for this group of newborns is ≥ mmol/l, ≥ standard deviation (sd) above the mean (farrell, ) . this retrospective study reports on the mean sweat chloride value + sd in cf heterozygote newborns who have been referred for evaluation to suny upstate medical university cystic fibrosis center, and regarding the genotype of these infants with abnormal sweat chloride levels. method: from october, to december, , infants were referred for positive cf screening, and of these ( %) were identified as heterozygote carriers by the screening program. at our center, these patients underwent pilocarpine iontophoresis, followed by collection of sweat (≥ µl) in macroduct ® coils. sweat testing was performed successfully in of the ( %) patients. the patients' age (mean ± sd) at the time of sweat testing was . ± . days. for infants with an initial sweat chloride level ≥ mmol/l, the sweat test was repeated within a week and a complete gene sequencing was requested (quest laboratory, ca). results: the sweat chloride level (mean ± sd) in newborns who were heterozygous for a cf mutation (excluding those who were found to have an additional mutation or deletion) was . ± . mmol/l (n = ). the mean + sd was mmol/l, which defined our minimal value for an abnormal test. eleven infants had sweat chloride values of - mmol/l (table) ; of them ( %) were subsequently diagnosed with cf by complete gene sequencing. four of the remaining patients ( %) had ∆f mutation coupled to the t variant on the opposite chromosome (sweat chloride levels, - mmol/l). conclusions: the reference range for sweat chloride in cf heterozygote infants appears to be significantly lower for some centers than previously reported. thus, each cf center should consider evaluating the cutoff values for the test at their site. moreover, the t polymorphism may account for sweat chloride elevations in heterozygote infants. method: we reviewed the charts of all patients with cf who were referred as a result of the new york state newborn screening program to the suny upstate medical university cf center from october, through april, . we included the patients who were identified by the state as heterozygote carriers of one of common cf gene mutations, and whose second mutation was identified only after complete cf gene sequencing. results: seven of the patients ( %) met inclusion criteria. six of the patients ( %) were compound heterozygous for a novel or a rare cf gene mutation. one patient was compound heterozygous for a large deletion in the cf gene. the genotype and clinical status of the patients are shown in table. all patients have been pancreatic sufficient to date. conclusions:the clinical effect of compound heterozygosity as a result of novel or rare cf gene mutations appears to be mild in early childhood. prior to newborn screening (with the exception of the patient with cftr deletion), these patients may not have been diagnosed with cf in the first few years of life. these patients may have subclinical airway inflammation and thus benefit from early treatment. patients with cf manifest symptoms in the pancreas, respiratory tract, male reproductive tract and sweat gland due to mutations in cftr. patients with non-classic cf have disease in a subset of these organ systems. most non-classic cf patients have two disease-causing mutations in cftr and at least one mutation permits residual cftr function. a subset of non-classic cf patients have only one cf-causing mutation after screening for a panel of common cf-causing mutations or following mutation scanning of the coding region of cftr. these patients present a diagnostic dilemma and a challenge for genetic counseling. we evaluated cf patients with only one cf-causing mutation identified after a screen of cftr mutations ( patients) or scanning of the coding region of cftr ( patients). nine of these patients, including one set of siblings, have non-classic cf with borderline or elevated sweat [cl -] plus lung disease (table) . one patient is pancreatic insufficient and has classic cf. many of these patients have features which are consistent with cftr dysfunction including a cf-like nasal potential difference (npd),p. aeruginosa infection, or congenital bilateral absence of the vas deferens (cbavd), suggesting that they have a second cftr mutation. mutations that are not detected by screening methods include insertions or deletions, mutations outside of the cftr coding region that affect rna splicing or expression, or mutations in the coding region of cftr that were missed by screening methods. to exclude the third possiblity, dna sequencing of the exons and flanking introns of cftr was performed. a second mutation was identified in the coding region of cftr in of the patients; had screening for known cftr mutations (genzyme), while the remaining had comprehensive scanning of the coding region of cftr by modified tgge (ambry). each of the mutations identified by sequencing has been previously described in patients with cf and is predicted to cause cftr dysfunction. these results reaffirm that patients with one cftr mutation who have biochemical and clinical features of cf are likely to have a second mutation in the coding region of cftr. thus, we suggest sequencing cftr in patients with only one mutation after mutation screening before employing other more complex genotyping methods (insertion/deletion or rna analysis). diagnostic criteria for confirming cf in symptomatic individuals includes two positive sweat tests or two known disease-causing cftr mutations. accurate sweat testing is performed at accredited cf centers, while cftr testing is available through national and specialty genetic labs. most labs offer analysis of a basic panel of cftr mutations as recommended by the american college of medical genetics (acmg), while specialty laboratories may offer an expanded panel or full sequencing/scanning. we report on one center's use of these methodologies to confirm the diagnosis of cf presenting in adulthood. the charts of patients diagnosed with cf at 〉 years of age were reviewed. were sweat tested. all were genotyped. results: twelve ( %) pts had two positive sweat tests (> mmol/l). an additional five ( %) had at least one borderline result ( - mmol/l). two pts had negative results ( - mmol/l). one refused sweat testing because dna analysis through the acmg panel had confirmed the diagnosis prior to initial consultation. genotyping results for the pts are summarized in the table below. rare mutations identifiable only through gene sequencing accounted for / alleles ( %) in our population. importantly, among this group, only one pt had a negative sweat test, a suggestive mmol/l. two pts with positive sweat tests and clinical symptoms failed to reveal any cf mutations after sequencing. we continue to follow pts without genotypic confirmation, based on their clinical presentation and sweat chloride levels, and have recommended additional evaluation, including nasal potential difference studies in our series of adult-diagnosed patients, sweat test results were positive, borderline, or suggestive in all cases tested. sweat testing costs $ -$ and results are ready in a day. genotyping costs $ -$ and takes several weeks. we acknowledge that circumstances may arise where reliable sweat testing is not conveniently available; but in our series, genotyping with the acmg panel would have diagnosed % of pts; using an expanded panel would have diagnosed %. genotyping is an important tool for genetic counseling, determination of eligibility for research studies, furthering knowledge of cftr dysfunction and cf pathophysiology, and for confirming a cf diagnosis after borderline or suggestive sweat test results. based on our findings and the dramatic difference in cost, we conclude that sweat testing should remain the first approach in the diagnostic workup of adult patients with a clinical presentation suggestive of cf. in colorado, infants with cf (non-meconium ileus) have been diagnosed with cf by a two tiered immunoreactive trypsinogen (irt/irt) based newborn screening approach. the irt/irt algorithm has been recently adopted by other screening programs with two mandatory screening tests. while most infants in colorado have been successfully identified, the program has had a missed case rate of approximately %. the more common approach to cf newborn screening is the irt/dna method in which the blood spot of infants with an initial elevated irt is tested for the most common cf mutations. the initial irt cutoff is lower in the irt/dna programs than in the irt/irt programs, resulting in a lower missed case rate. the considerable number of carriers identified through the irt/dna approach puts a significant burden on the genetic counseling community, as carriers are identified at a rate of / - / of positive irts we propose an irt/irt/dna newborn screening algorithm that will maximize sensitivity and specificity while minimizing the number of identified carriers. using new database technologies in the newborn screening lab we will be able to identify those infants with an elevated first irt (> ng/ml, approximately th percentile). all infants with an irt > ng/ml will have a repeat irt on their second state mandated blood-spot. if the second screen is also elevated (> ng/ml), the blood spot will be tested using a panel of mutations, including mutations specific to the hispanic community. infants with one or two cftr mutations will have a sweat test to confirm the diagnosis, or rule out cf. we compared the projected statistics of our current method irt/irt to the new irt/irt/dna method, and to irt/dna is presented in the table, based on , births per year in colorado. four infants ( . %) identified under the current irt/irt protocol would not have been identified by the mutation panel proposed in the new algorithm, out of genotyped, non-meconium ileus infants. three of these missed cases are hispanic. two would be identified using an extreme irt cutoff of the . th percentile ( ng/ml). the projected missed case rate would be < . % ( . - . %, % ci), using the irt/irt/dna algorithm, with carriers identified, maximizing both sensitivity and specificity. this algorithm may provide a better alternative to the irt/irt screening methods in states with two mandatory screening tests, and has advantages over both the irt/irt and irt/dna methods. newborn screening for cystic fibrosis (cf) is rapidly expanding and has been implemented in at least states. although most newborn screening assays are done using biochemical testing, many laboratories screening for cf include both biochemical and molecular testing of multiple alleles in the cystic fibrosis transmembrane conductance regulator gene. in response to the growing need for proficiency testing (pt) materials for molecular testing, the centers for disease control's newborn screening quality assurance program (nsqap) in collaboration with the university of wisconsin school of medicine and public health, the johns hopkins hospital, and case western reserve university, created a repository of dried-blood spot specimens with known mutations in the cftr gene to be used in a pt program. twenty milliliters of blood was collected voluntarily from adult donors with cf and sent to the nsqap laboratory. each specimen was adjusted to a hematocrit of % before being spotted onto whatman paper ( µl per spot), dried, and stored at - °c with desiccant. proficiency testing (pt) panels consisted of to blind-coded specimens from adult donors. the panels were sent quarterly to laboratories worldwide that test specimens for cf using molecular methods. laboratories were asked to report the genotype, method used, and the presumptive clinical assessment of each specimen. twenty-two laboratories participated during both quarters and , . the laboratories used different methods ranging from in-house assays to commercially available kits. most reporting laboratories tested the following alleles -∆f , g x, and g d. another twelve alleles were detected by most participants. nine more alleles were common among commercially available kits. laboratories were evaluated based on the clinical assessments. mutations that were not detected by a particular method were not evaluated. overall, the laboratories performed well. data compiled from both quarters demonstrated that there was incorrect clinical assessment and amplification failures. developing a pt program for dna-based testing is complicated by the number of methods and different alleles each laboratory chooses to test. though molecular testing for cf may be complex, pt monitors the laboratory's ability to test multiple alleles, including uncommon alleles, the limitations of various assays, and the different algorithms used for screening. the repository will also allow storage and access to rare specimens that may be useful for future research but are not readily available. who did could not reproduce. genetic counseling focused on a patient's parents, who were counseled about their recurrence risk at the time of the child's diagnosis. today, cf is a disease of adulthood. in , > % of cf patients in the us were > ; by it will be > %. together with advances in assisted reproductive technology (art), reproduction and recurrence risk are now important issues for adolescent and young adult cf patients. methods: a item questionnaire was developed from the results of prior semi-structured interviews with cf patients age - years. knowledge based questions (medical issues, inheritance, and reproductive options/risks) as well as communication patterns (preferred resources for learning about cf and preferred people with whom to talk about reproductive issues) were addressed. recruited from the uab cf clinic population, patients age - (mean ), male ( %), female ( %), completed the questionnaire. results: regarding autosomal recessive inheritance of cf, only % knew that two carriers have a % chance of having a child with cf, and % knew that two carriers have a % chance of having a child who is a carrier. however, % knew that two carriers could have a child who did not have cf, and % knew that two carriers could have a child who did not carry cf. on their own reproductive risks, % knew that a cf patient had a % chance of having a child with cf if their partner was not a carrier, but only % knew that all their children would be carriers even if their partner was not a carrier. in the scenario of a cf patient with a cf carrier partner, % knew that a child had a % chance of having cf, and % knew that a child had a % chance of being a cf carrier. most patients knew about their reproductive potential, as % responded that cf patients are able to have children. however, when asked about whether the chance for having children was different for males and females with cf, % answered that it was more difficult for males, % that it was more difficult for females, and % answered "not sure." while % reported that they knew that there were options for male cf patients who wanted to have children, only % knew of art. conclusions: despite widespread availability, the lack of knowledge of adolescents and young adults with cf about the genetics of their disease continues. furthermore, these patients are unaware of both modern technologies that could enable them to have biological children and the risk of those children having cf. this study illustrates the changing needs of patient education as medical knowledge progresses. cf patients would benefit from further genetic knowledge and counseling to enable them to make informed decisions about reproduction as they mature into adulthood. center at the university of minnesota is one of three sites in the state providing confirmatory testing and follow up services for newborns identified by screening. while cf nbs identifies children with cf, most of the infants with positive screening results are carriers. our goal is to provide genetic counseling to every cf nbs patient seen at our center, and we believe that a protocol incorporating genetic counseling in the initial care plan for infants both with and without cf is imperative. the literature has shown that families who obtain genetic counseling through the cf nbs process recall genetic information more easily and accurately and are more likely to have testing to determine parental carrier status. for parents of a child that is determined to be a cf carrier, it is especially important to find the optimal method and timing of genetic counseling as many of these families are from several hours away and therefore less likely to return to clinic. to provide genetic information and emotional support for the families of infants screening positive on cf nbs, our center has a genetic counselor who serves as the cf nbs coordinator and clinical contact for the family. this allows many opportunities to speak with the genetic counselor and ask questions, as well as learn about their child's diagnosis or carrier status and the subsequent carrier testing recommendations for the infant's parents and families. to assess the success and impact of the minnesota cystic fibrosis center's nbs follow-up program and the incorporation of genetic counseling, an anonymous questionnaire was developed for parents of infants who were seen at our center due to a positive cf nbs result. questionnaires were mailed to parents of all infants seen at our center for a sweat test and genetic counseling due to a positive cystic fibrosis newborn screening result. as of the last mailing, this totals families. two questionnaires were returned due to incorrect address and questionnaires were returned answered, indicating a response rate of % ( / ). responses overwhelmingly indicated that parents were satisfied with our center's algorithm for the cf nbs follow-up program and found the information and support provided through genetic counseling to be a useful and recommended portion of the program. as cf nbs continues, it is critical that we learn about the patient's experience with genetic counseling and the nbs program, as well as identify areas needing improvement. genetic counseling is vital to the comprehensive success of our center's program, and we will report on the responses gathered from the families identified through cf nbs this first year, as well as discuss the lessons learned from setting up such projects on a state-wide basis. background & aims: aberrant splicing and nonsense mediated decay (nmd) lead to dysfunctional mrnas by skipping exons and to a reduced number of functional mrna respectively. both mechanisms have a strong quantitative aspect and may determine whether a cf patient develops a classic or atypical disease phenotype. in order to approach these highly important questions we wanted to establish a new quantitative real-time pcr based assay which allows allele specific quantification on cdna level. using this assay we like to determine the exact proportions of the f del and non-f del cftr mrna in cf patients compound heterozygous for the f del mutation (for example in cf patients carrying the f del and a nonsense mutation such as the r x). material & methods: materials: we used genomic dna (gdna) and total rna (extracted from white blood cells and nasal epithelial cells respectively) from cf patients with compound heterozygosity for the f del mutation, homozygosity for f del mutation and from healthy individuals (controls). methods: the lasq (ligation dependent allele specific quantification) assay comprises reactions: . reverse transcription of cftr mrna into cdna using gene specific primers (all rna specific). . overnight hybridization ( - h) of the cftr cdna with either the f del specific or the wt specific oligo probe pair provided by jan schouten (mrc holland). . ligation of the hybridized oligo pairs using the ligase enzyme from mrc holland. . quantitative real-time pcr of the allele specific ligation products on the lightcycler (roche). results: in order to establish the lasq assay we first validated it using gdna instead of cdna as template. mixing experiments were performed to verify the accuracy of the assay. in brief, gdna (c= mg/l) of a f del homozygous and a f del compound heterozygous cf patient were mixed in such a manner that . , . amplification products of the f del and the wt allele (both bp long) were analyzed by gel electrophoresis (page) and direct sequencing (abi ) to control specificity. our results using gdna and cdna showed that there occurs unspecific hybridization/ ligation for both probe pairs. the proportion of unspecific amplification products varies between . and . and increases the lower the initial number of templates is. however, the specificity of this assay can be significantly improved by increasing the hybridization temperature and/or decreasing the ligation time. conclusion: although some minor limitations concerning allele specificity the lasq assay has been proven to be an accurate, reliable and reproducible method for allele specific quantification and may be applied for several important questions in cystic fibrosis such as the exact determination of the amount of nmd of cftr mrna containing a premature termination codon (ptc) or the allele specific determination of aberrant splicing of cftr mrna . background & aims: as clinical presentation varies significantly among cf patients with the same genotype, e.g. in the f del homozygous, it is evident that factors in addition to the cftr genotype such as modifier genes, are involved in determining disease severity. however, only one of several previously postulated modifier genes, the tgfβ gene, could recently be confirmed in a large association study. hence the identification of new modifier genes is a very important task in order to find new explanations for the heterogeneity of pulmonary disease in cf patients. we decided to search for new potential modifier genes applying a quantitative proteomic approach comparing the proteomes of a wild type ( hbe o-) and a f del homozygous bronchial epithelial cell line (cfbe o-). the main goal of this study is the identification of up or down regulated proteins in the cfbe cell line which may act as modifiers of cf disease. material & methods: materials: we used two bronchial epithelial cell lines, e.g. a wild type ( hbe o-) and a f del homozygous (cfbe o-) cell line which we obtained from dr. gruenert (california, usa). additionally, we also used nasal cells from f del homozygous cf patients obtained either from nasal brushings or nasal polyps. methods: proteome analysis was performed by making d-gels using high sensitive staining protocols (ruthenium and deep purple). quantitative analysis was accomplished applying the powerful dige (difference in gel electrophoresis) method. for each dige experiment we made gels whereby each cell line was twice labelled with cy and cy (= technical replicates). finally, identification of the protein spots was done by the use of a maldi-tof mass spectrometer. results: in a first step we established the proteomes of the two bronchial epithelial cell lines. we were able to optimize protein extraction and d gel electrophoresis in such a manner that the proteomes of the two cell-lines looked very similarly and the assignment of spots could easily be done. protein spots from both cell lines were analyzed using our mass spectrometry (maldi-tof ms) and allowed the identification of more than different proteins so far. in a next step we quantitatively compared the proteome of the two cell lines using the d-dige method leading to the identification of proteins which are down regulated and proteins which are up regulated at least twofold in the cfbe cell line. out of the aforementioned differently expressed proteins could already be identified because they were among the previously determined proteins. while glutathione s-transferase p and protein s -a (s calcium binding protein) were down regulated ( . and . -fold respectively), superoxide dismutase was up regulated ( . -fold) in the cfbe cell line. conclusion: comparative quantitative proteomics using the dige method is a promising tool in search of potential new modifier genes which may unravel one of the key problems in cf: the large heterogeneity of pulmonary disease in f del homozygous patients. background: cystic fibrosis is one of the most common autosomal recessive disorders among caucasians, and manifests a wide range of disease severity. although this range of disease expression can be attributed, in part, to specific mutations within the cftr gene, much of this variability has not been adequately explained. from the gene modifier study (gms-a multicenter study of , cf patients), ten genes were tested as potential modifiers of cf, and the tgfβ codon cc genotype was associated with lung disease severity. objective: to test whether the adverse codon cc genotype is associated with higher circulating levels of tgfβ , compared to the tt genotype in cf patients and healthy controls. if true, then a link will be established between genotype, disease severity, and circulating levels of tgfβ , and have implications for novel treatment of cf patients. methods: the study includes clinically stable cf patients and healthy control subjects equally distributed between the cc and tt genotypes. the cf patients enrolled are age and older, of both genders, and all ethnicities that fulfilled the standard diagnostic criteria for cf, using the genetic information from the gms. healthy controls are age and older, caucasian males and females, obtained from the environmental polymorphism registry (epr), a dna registry of , self-reported normal volunteers. we genotyped blood samples from the epr to define healthy control subjects for each of the cc and tt cohorts. subjects have a blood draw of ml. blood is divided into tubes and each tube is used to measure a different parameter: cbc with differential; tgfβ levels in platelet poor plasma by quantikine human tgfβ elisa kit; tgfβ levels in the buffy coatwhich includes platelets; and tgfβ mrna levels in lymphocytes from the buffy coat, using real-time pcr roche light cycler. cbc with differential is performed to quantitate lymphocytes and platelets in order to reference tgfβ protein and rna levels to the number of circulating blood cells. analyses will include graphical comparisons between the two groups, chi square analysis, student's two-sample t test, and one way analysis of variance (anova). results: pilot studies show that elisa tgfβ measurements are reproducible and mrna levels can be quantified. we have currently enrolled cc genotype and tt genotype of the cf subjects and cc genotype and tt genotype of the healthy controls. blood samples have been collected and processed. conclusion: genetic variants that predispose to more severe cf disease are potential targets for new therapies. we are testing the hypothesis that the adverse (codon ) cc genotype is likely to reflect increased transcription and/ or tgfβ protein synthesis/ secretion. if true, "anti-tgfβ " therapies could provide a novel therapy in cf. *reporting for the gene modifier study group. supported by cff knowle a , cff drumm a , gcrc rr , nih r hl . aim: centralized periodic evaluations of data from the screening laboratories and cf centers by afdphe (french association for screening and prevention of infant handicaps), were analysed to optimize the efficiency of the program. methods: the strategy combined d irt assay/dna analysis (kit elucigen cf- arms) /d -fail-safe irt. revised irt-cut off levels were decided in order to maintain the percentage of positive screens around a . % target. a questionnaire yearly sent to the cf centers collected the cf false negative cases. results: from to december, , cf cases were detected through nbs ( screened infants). the i period (p) (n= ); d -irt: µg/l and d -irt: µg/l showed a) . % infant above the d cut-off, generating an excess of costly dna tests b) % had a d -irt above the cut-off leading to a very high number of st (n= ) with an extremely low rate of cf (n= ). by increasing slightly both d /d irt cutoff levels ( µg/l, µg/l) during the ii p (n= ) a) the number of positive screens decreased to . % b) . % of infants with elevated d -irt had to be referred for st (n= ) with cf diagnosis. since the risk to had true cf remained very low among infants with no detected mutations, during the iii p (n= ), d -irt concerned only the ones with d -irt> µg/l and the percentage of infants requiring a st was reduced to . % (n= , cf). the incidence of cf detected during these p did not vary significantly ( / - / - / ). another point of concern was the false negative cohort; with a follow-up period over months, cf were detected on clinical symptoms ( . %) at a mean age of months. only were directly related to the modifications of the strategy. conclusion: centralisation of data made possible changes in the flow charts of the screening strategy to limit the number of false positive cases without significant alteration of the global performance of the program. there were three infants of mixed aa/caucasian origin diagnosed with cf, all had ∆ /genotype on screening. mutation data on the additional aa cf patients followed at the cf centers in new york was collected. six patients have not been genotyped. there were patients who were homozygous for ∆ , patients had only one mutation identified and were not found to have any cf mutations. ∆ ( %) and + g>a( %) were the most common mutations. there are five cf patients (including infants diagnosed by nbs) with mixed racial origin who are not included in this analysis. mutations results: the median (range) mbl plasma level was . ( . - . ) µg/ml in cf patients, compared to . ( . - . ) µg/ml in controls. mbl genotype frequencies were similar in patients and controls. lung function level was not correlated with mbl genotype or plasma level. the frequency of colonization with pseudomonas aeruginosa was % in mbldeficient (xa/o and o/o genotype) children with cf and % in mbl-sufficient (a/a and ya/o genotypes) children (p= . ). we found a trend of a decreased age of first onset of colonization with staphylococcus aureus, haemophilus influenza and pseudomonas aeruginosa in mbl-deficient cf patients (p= . , p= . , and p= . , respectively). conclusions: mbl-deficiency was associated with an increased frequency of pseudomonas aeruginosa colonization in children. mbl deficiency was not associated with lung function deterioration. in a larger cohort we hope to confirm that mbl deficiency influences age at onset of bacterial colonization in cf patients. acknowledgments although there is some evidence that cftr gene mutations may be associated with respiratory diseases, little is known about the relationship between cftr gene mutations and idiopathic bronchiectasis (ngiam et al. ) . we have recently showed that a rare allele (- g>a) in the minimal cftr promoter, previously reported in patients with idiopathic bronchiectasis ( using supershift assays, we demonstrated that these transcription factors bind cftr promoter in vitro. a functional analysis, by using co-transfection assays with expression vectors of each transcription factor in pulmonary epithelial cells, showed that nrf , irf significantly decrease cftr expression, whereas irf and sp increase it. in an attempt to further elucidate the mechanisms involving these factors in the cftr transcriptional regulation, for instance, to determine whether these factors could interact together in order to regulate cftr transcription, we started several experiments such as co-immnoprecipitation, multiple co-transfection and rnai. taken together, these data evidence that the variant - a in cftr promoter should be considered as an important risk factor in bronchiectasis pathogenesis. furthermore, we have identified a novel regulatory complex on the minimal cftr promoter, which will enlighten the understanding of the transcriptional regulation of the cftr gene. a better knowledge of cftr cis-and trans-acting elements will allow to consider new approaches to modulate and/or control more specifically cftr expression. this work is supported in part by the association vaincre la mucoviscidose. (nat genet, ) . a recent study reports strong genetic influences for mi (blackman et al., gastroenterology, ) , but it did not replicate the modifier locus on chr. q . inconsistency of results may reflect the variability of data reporting and different classifications of mi (i.e. surgically or medically treated). we tested the accuracy of reporting of mi on case report forms (crfs), as compared to primary source documents. methods: the crf for the gms has a checklist for past medical history. for example, we requested "yes" or "no" for mi (an obstruction of the terminal ileum at birth), but did not require source documents or identification of the type of treatment. to evaluate crf reporting of mi, we requested source documents for patients with reported mi, including a surgical or medical treatment report. if a written report from the time of birth was unavailable, a clinic note, detailing mi at birth, treatment, and evidence of a surgical, abdominal scar (if applicable), was required. verbal confirmation by the patient and evidence of a surgical scar was also accepted, if no written documentation was available. results: on crfs, of patients ( %) were initially reported to have mi. to date, source documentation has been obtained for patients, and of those ( %) have been confirmed to have mi ( % by written report, % by verbal report). of the with confirmed mi, ( %) had surgery, and ( %) had medical treatment. there were false reports of mi ( . %). mi could not be confirmed or refuted for patients ( . %) because of insufficient information (n= ) or confounding circumstances (n= ). to date, documentation for patients who were reported to have no mi has been obtained, and no false negatives have been found. additional documentation for mi from other sites is expected. conclusion: at least %, and perhaps as many as %, of the reports of mi on crfs were inaccurate. gene modifier studies must include rigorous documentation of mi to ensure an accurate correlation between phenotype and genotype. studies should also characterize different classifications (i.e. surgical vs. medical treatment) to assist the detection of gene modifiers of mi. reporting for the gene modifier study group (mrk); supported by cff knowle a , cff drumm a , nih r dk , nih r hl , and gcrc rr . any mutation that disrupts or diminishes the efficiency of the splicing process will have an impact on disease manifestation. in the cystic fibrosis (cf) transmembrane conductance regulator (cftr) gene more than , mutations were identified, most of them being disease-causing [ ] . among these,~ % are classified as missense and about % are classified as splicing mutations, given that they disrupt the consensus splice sites [ ] . however, the splicing mutation concept is evolving, as it nowadays also includes mutations other than just those within or close to the consensus splice sites, rendering prediction of mutation consequences a hard task. nevertheless, it is still very important for the clinical settings to determine the functional effect of gene mutations. our aim here was to study the effect of i v, a rare cftr missense mutation in nbd (exon ), directly in native tissues of a cf patient bearing f del in the other allele, so as to gain insight on how it influence the disease outcome. to look for a possible effect at the rna level, total rna was extracted from native nasal cells and colonic tissue, and cdna producd using random primers. rt-pcr amplification was performed in the region spanning exons - , being one of the primers fluorescently labelled. the products were analysed as described before [ ] . the i v( a>g) mutation which creates both a novel acceptor and a novel donor, was found here to cause alternative spliced cftr transcripts lacking the last nucleotides of exon , thus showing that only the novel donor is used in vivo. moreover, our data show that no normal (only alternatively spliced) transcripts result from this allele. we have also analysed the i v mutation at the protein level by producing a stable bhk cell line expressing the i v-cftr, after generating the respective mutant cdna construct by site-direct mutagenesis. protein expression and function was determined by immunoblot and iodide efflux assay, respectively. results show that i v-cftr protein is processed and functional. however, given the above-described absence of normally spliced mrna coding for this cftr variant, we have to conclude that this protein is not produced in vivo. indeed, since only the mrna coding for cftr lacking the last six aminoacids of exon was detected, we are currently characterizing in vitro the proprerties of this truncated protein. altogether, our data clearly demonstrate that the functional effect of this mutation is not due to the amino acid change but to abnormal splicing. in conclusion, characterization of the consequences of mutations in native affected tissues is important, not just because this provides unexpected information about the mechanisms underlying the basic defect but also for disease diagnosis and prognosis. (darrah et al, nacfc ) . the purpose of this study was to examine the influence of common genetic variation in the endothelin pathway on the cf phenotype. methods: patients were recruited from the cf clinics in dublin, belfast and seattle. serial clinical data were abstracted from medical charts and local clinical databases. studentized residuals of maximum fev , after adjusting for age, gender and height, was the phenotype of interest. twentyone maximally informative tagsnps were identified in the edn , edn , ednra and ednrb genes using the niehs environmental genome project and were genotyped using the illumina beadarray system. genotype and haplotype analysis were carried out using helixtree genetic analysis software. results: clinical and genetic data were available on cf patients ( from seattle and from dublin/belfast). in the combined cohorts, tagsnps in the ednra gene were significantly associated with differences in cf lung disease severity (p= . ). this was observed in both the irish cohort (p= . ) and the seattle cohort (p= . ). the effects were independent of gender and cftr genotype. four common haplotypes (haplotype frequency> %) were identified in the ednra gene. there was significant association between ednra haplotypes and cf lung disease severity (table ). there was no association between genetic variants in ednrb, edn and edn and cf lung disease severity. conclusions: the ednra gene is a genetic modifier of the cf phenotype. our findings were seen in two independent cohorts and verify existing associations found in other populations. the endothelin pathway may be a novel therapeutic target for the treatment of cf lung disease. background: cystic fibrosis (cf) is a recessive "monogenetic" disorder, but there is heterogeneity of lung disease severity and survival reflecting environment and non-cftr genetic modifiers. the unc/cwru multisite gene modifier study (gms) identified patients who were "severe" or "mild" as teenagers or young adults and pertinent cross-sectional data was collected; however, we did not collect all pertinent information about early (age < years) clinical features. objective: we sought to retrospectively evaluate the early clinical features of "severe" and "young mild" patients enrolled in the gms. methods: we obtained all cff registry data available on patients. there were "severe" (worst th percentile of birth cohort, age range - ) and "mild" (best th percentile, age range - ). initial analyses focused on cross-sectional plots of patient age versus multiple clinical features, including age at diagnosis, hospitalizations, cdc height and weight percentiles, presence/absence of ps. aeruginosa from respiratory cultures, and fev (% pred). results: there were . and . years of cff registry data per patient for "severes" and "milds," respectively. preliminary results indicate "severe" patients were diagnosed earlier in life than "mild" patients (mean: . vs. . years, p= . ). this difference is greater after omitting patients who had meconium ileus (diagnosis: . vs . years, "severes" and "milds" respectively, p= . ). between and years of age, "severe" patients were hospitalized more frequently than "mild" patients and, from age onwards, the disparity in frequency of hospitalization increased. "severes" and "milds" had similar cdc height percentiles (~ th percentile) until age , at which point percentiles increased more for "mild" versus "severe" patients. by age , "severe" patients already had lower cdc weight percentiles than "milds" ( nd versus st percentile) and this disparity increased throughout adolescence. from age to , "severe" patients had a - fold higher prevalence of ps. aeruginosa than "mild" patients. as early as years of age, fev (% pred) was ~ points lower in "severes" as compared to "milds." however, some "severe" patients had normal lung function at ages - and overlapped with mild patients; thus phenotyping of lung severity for young patients is not optimal. all of these results were similar for males and females. summary: retrospective analysis of the cff registry data indicates that patients classified later in life as being "severe" experience a worse course of disease from early in life. understanding the early clinical course may prove helpful in defining surrogate phenotypes for modifier studies, and help define appropriate therapeutic targets. cystic fibrosis is mainly caused by small molecular defects of the cftr gene; despite the genotype is defined in the majority of patients, a number of cf cases still remain uncharacterised. the cf mutation database lists more than large rearrangements that may escape detection using pcrbase techniques. the innogenetics assay, the dhplc and sequencing screening showed a mutation detection rate of . % in our population. we report here the results of mlpa screening for ctfr gene rearrangements, performed on the unidentified alleles of our cf patients. our sample population consists of unrelated italian cf patients (for a total of alleles), followed at cf centres of lombardia region. mlpa analysis was performed in patients who still had one or two unidentified alleles after extensive analysis of cftr gene. all patients studied had classical clinical cf symptoms. subjects presented with persistent or recurrent respiratory symptoms, failure to thrive, salt loss syndrome and gastro-intestinal findings. we characterized different deletions and a new duplication (dup promoter-ex. ). thus, . % ( / ) tested alleles had a large gene rearrangement. the deletion of exons - ( / ) was the most frequent in our cohort. all patients had positive sweat chloride values (above meq/l), except the patient carrying duplication who has borderline sweat chloride value. out of patients, ( %) had fecal elastase levels consistent with a preserved pancreatic function: of these patients, had mild mutation, had severe, and had unknown mutation. six patients present liver involvement. the results of the present study could indicate that compound heterozygosity for large rearrangements in cftr gene, is strongly associated with severe pancreatic disease as mutations in classes i, ii, and/or iii. l f is a missense substitution which changes from leucine to phenylalanine at position , resulting from a g/c transition at position in exon a of the cftr gene. it has been described in patients with disseminated bronchiectasis, recurrent idiopathic pancreatitis, sarcoidosis, newborns with hypertripsinemia,. recently derichs et al. reported one healthy -year-old girl homozygous for l f; therefore the pathogenic role of the variant is still unclear. in this study we present subjects compound heterozygotes with l f. no other mutations have been identified after molecular analysis performed using sequencing analysis of the whole coding region of cftr gene and mlpa technique in order to search for gene rearrangements.none of them presented ivs t allele. three of them had a severe mutation in trans (r x, aa>g, and n k), while the other three had a mild mutation on the complementary allele (d h, r q, and r w). individuals with a severe mutation in trans presented a remarkably different clinical picture compared to those with a mild mutation in trans. the formers were diagnosed at a mean age of . years, had an average sweat chloride of . meq/l; besides, all of them have respiratory symptoms, staphilococcus aureus in sputum cultures (one had pseudomonas aeruginosa as well), and in two the chest x-rays was abnormal. the three l f/ps mutation individuals were diagnosed at a mean age of . years, had an average sweat chloride of . meq/l; besides none of them had respiratory symptoms, abnormal chest-xrays, or positive sputum cultures, but two had a history of pancreatitis. these data seem to suggest that l f cannot in any case be considered a neutral polymorphism. the variability of its clinical expression seems to be influenced by the mutation in trans. further studies are needed in order to support our results. expression of the cystic fibrosis transmembrane conductance regulator (cftr) is tightly regulated both spatially and temporally, yet the molecular mechanism of this regulation is not well understood. because no tissue-specific regulatory elements were recognized in the basal cftr promoter, the crucial cis-regulatory elements are likely to be located elsewhere within the cftr locus. a number of the non-coding regions of the cftr gene were found by our laboratory to contain dnase i hypersensitive sites (dhs), suggesting the presence of regulatory elements at these sites. studies presented here investigate the role of an intron dhs (dhs ) in the tissue-specific regulation of cftr gene transcription. the elucidation of molecular mechanisms underlying the temporal and spatial expression of cftr may aid in developing more specific targeted therapies for cystic fibrosis (cf). footprinting analysis of cftr intron revealed a protected region within the core of dhs at + kb. in silico analysis of this sequence uncovered a number of transcription factors binding motifs, including a consensus binding sequence for hepatocyte nuclear factor (hnf ). we have previously identified a role for this factor in the regulation of cftr expression. results of electrophoretic mobility shift assays (emsa) demonstrate that hnf α specifically binds to the motif in cftr intron in vitro. in addition, chromatin immunoprecipitation (chip) analysis of cells expressing both cftr and hnf α factor shows that this factor binds to the intron site in vivo. when cloned as an enhancer, the dhs element was found to augment minimal cftr promoter activity in a luciferase reporter based assay. this increase in luciferase activity was abolished when two nucleotides within the core hnf binding site were mutated, suggesting a functional role for hnf α in cftr gene transcription. further experiments are underway to determine whether additional transcription factors can be recruited to the core of the intron dhs regulatory element and can interact with hnf and the cftr basal promoter to modulate tissue-specific cftr gene expression. the promoter of the cftr (cystic fibrosis transmembrane conductance regulator) gene is not solely responsible for its complex pattern of expression. to identify potential regulatory elements for cftr we previously mapped dnase i hypersensitive sites (dhs) across kb spanning the locus. in addition to intronic dhs, a number of sites were observed that flank the cftr gene. we hypothesized that these may include insulator elements that establish the chromatin expression domain, within which the cftr gene is regulated. insulators are elements that shield against the effects of regulatory elements from adjacent genes, and they may also block silencing of integrated transgenes. using a well-established insulator assay, in which dna regions of interest are assayed for their ability to interfere with communication between a chicken β-globin enhancer and a neomycin resistance gene, we demonstrated that two dhs, at - . kb from the cftr translational start site, and at + . kb from the ' end of the gene, exhibit enhancer blocking activity comparable to known insulator elements. electrophoretic mobility shift assays (emsa), demonstrated in vitro binding of the well-characterized insulator protein ctcf (ccctc-binding factor) at the - . kb dhs. this was confirmed in vivo in both cftr-expressing and non-expressing cell types using chromatin immunoprecipitation (chip). in contrast, although the + . kb dhs did not bind ctcf, we obtained in vitro evidence for the interaction of other factors that may be involved in insulator activity. furthermore, chip analysis of histone modifications across the cftr locus revealed striking differences between the - . kb and + . kb dhs, again suggesting mechanistic differences between these elements. the characterization of insulator elements flanking the cftr locus may be of direct practical relevance in the design of vectors for effective cf gene therapy. one of the problems encountered in gene therapy protocols is the relatively rapid loss of expression from the cftr cdna once it is introduced into mammalian cells. incorporation of the - . kb and + . aminoglycosides, particularly tobramycin, are primary antibiotics used to treat the airway infections in cystic fibrosis patients. lifetime, systemic exposure to these antibiotics is significant and can be associated with significant nephro-and ototoxicity. these toxicities have the potential to significantly reduce the quality of life in the aging adult cf population. we previously reported an incidence of aminoglycoside ototoxicity of greater than % with sensitive audiometric studies (i.e. pure tone audiometry and distortion product otoacoustic emissions). these studies indicated considerable variability in ototoxicity in patients with similar systemic aminoglycoside exposure. the literature suggests that genetic variability in mitochondrial dna can partially explain these differences. single nucleotide polymorphisms (snps) in the mitochondrial srrna gene are associated with aminoglycoside ototoxicity. we genotyped unselected adult cf patients for four of the mitochondrial s-rrna polymorphisms associated with aminoglycoside ototoxicity by direct sequencing of dna harvested from peripheral blood. four patients exhibited polymorphisms in this gene. two patients possessed the a g transition, while another patient each revealed a polymorphism at a g and c t transitions. the patient with the a g polymorphism died prior to audiometric testing. both patients with the a g had audiometric studies consistent with moderate to severe ototoxicity. while the patient with the c t had mild aminoglycoside ototoxicity. all four patients had severe airway obstruction and at least one full course of parenteral tobramycin at mg/kg/d. there was no history of toxic serum levels aminoglycosides during this therapy. both patients with the a g polymorphism had a family history consistent with the expected maternal inheritance pattern associated with the mitochondrial s-rrna gene. we found no evidence of the delt polymorphism in this population. these studies indicate a higher than expected frequency ( %) of mitochondrial s rrna polymorphisms associated with aminoglycoside ototoxicity. these studies demonstrate that genetic screen-ing provides valuable susceptibility information and may change clinical decision-making. support: rising hope foundation/national cf foundation. cystic fibrosis is a genetic autosomal recessive disease that is caused by deleterious mutations in the cftr gene. in its most severe form, cf results in abnormal sweat electrolytes, sino-pulmonary disease, male infertility, and pancreatic exocrine insufficiency. in fact, cf is the most frequent cause of pancreatic insufficiency in humans. carriers of cf (i.e., heterozygotes) do not express any of these classic symptoms. recent studies indicate that significant numbers of non-cf patients diagnosed with congenital bilateral absence of the vas deferens (cbavd) or idiopathic chronic pancreatitis (icp) are compound heterozygotes and carry two cftr mutations of varying severity. in dogs, especially german shepherds and rough-coated collies, exocrine pancreatic insufficiency (epi) has been observed with symptoms similar to those seen in human patients. epi in dogs is most often caused by pancreatic acinar atrophy (paa), a degenerative disease of the exocrine pancreas that has been shown to be inherited as an autosomal recessive trait. the locus responsible for canine paa has not been identified to date. we considered the possibility that cftr mutations might be responsible for this disease. a dog that had been diagnosed with paa and one that was a known carrier of paa were screened for cftr mutations. our samples also included dogs diagnosed with idiopathic pancreatitis as well as healthy dogs. we have established protocols for detecting putative mutations in the canine cftr gene using temporal temperature gradient gel electrophoresis (ttge). in the dog with paa and in the carrier of paa, our screening methodology identified mutations in of the amplicons that span the exons of the cftr gene. dna sequencing revealed silent mutations in exons , and . in exons (l ) and (l ), single nucleotide polymorphisms converted ctt codons into ctc codons, both leucine codons. in exon (p ) another single nucleotide polymorphism converted a ccc proline codon into a cct proline codon. the other identified mutations (amplicons , and , , , , , and ) were found in intronic sequences and have no predicted effect on cftr expression or function. based on these findings, we conclude that cftr mutations are not responsible for paa and the epi that it causes in dogs. hypothesis: specific polymorphisms in genes of the innate immunity may modify the severity and progression of cf pulmonary disease and influence pseudomonas aeruginosa colonisation. methods: single nucleotide polymorphisms (snps) analysis of multiple genes contributing to the innate immunity ( (mbl ), masp (mbl associated serine protease) Ç , fcn (ficolin) Ç , lbp (lipopolysaccharide -binding protein), cd , tlr (toll-like receptor Ç ) ) was performed in cf patients (age - years). spirometric data and bacterial colonisation status with pseudomonas aeruginosa were collected retrospectively. a decline in fev of % over a years period and a percent predicted fev value of % were used to discriminate mild from more severe affected adult cf patients (≥ years). the frequency of single and combined snps in well-defined subgroups of the cf population was compared. results: in adult cf patients with a mean fev lower than %, the combinations of snps of cd (promoter) with tlr (promoter), fcn with tlr (exon ), and masp with tlr (promoter) were more common than in adult cf patients with mean fev > % (odds ratio (or) , ( % confidential interval (ci) : , - , ) , or , ( % ci: , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) and or , ( % ci: , - , ) respectively). the frequency of combination snps of masp with tlr and masp with tlr was significantly higher in cf adults with more than % decline in fev compared to cf adults with less than % decline in fev (or , ( % ci: , - , ) and or , ( % ci: , - , ) respectively). however, the single snps of masp , tlr , tlr were not more frequently found. in pseudomonas aeruginosa colonised cf patients, an increased frequency of combined snps of tlr (exon ) with tlr (exon ), lbp (exon ) with tlr (exon ) and mbl with tlr (exon ) (or , ( % ci: , - , ), or , ( % ci: , - , ), or , ( % ci: , - , ) respectively) was found. in contrast, for single snp tlr (exon ) no statistically significant differences were found between the groups (or : , ( % ci: , - , )). in general, the odds ratios for the combined snps were higher than for the single snps and remained significant when the different groups were subdivided according to cftr genotype. conclusion: certain combinations of snps of genes of the innate immunity are more frequently found in cf patients with a lower fev , a stronger decline in pulmonary function and pseudomonas aeruginosa colonisation. however, for the single snps this trend was less pronounced or absent. congenital bilateral absence of the vas deferens (cbavd) is a rare condition associated with mutations in cftr. cbavd lacks extra-genital organ system abnormalities; it has been viewed as a mild (variant) form of cf. the disease serves as an excellent model for studying the clinical and experimental ramifications of marginal cftr activity, and the functional thresholds necessary to confer a cf-related phenotype. recently, drumm et al. (nejm, ) found that the codon cc genotype of tgfβ- is associated with more severe pulmonary disease, particularly in individuals homozygous for ∆f cftr. tgfβ is also known to play a critical role during normal development and differentiation of the human vas deferens (han-nema et al., horm res, ) . because % of cbavd subjects carry at least one defective cftr allele (but millions of males worldwide are heterozygous for cftr mutations without developing cbavd), the present study was designed to test whether tgfβ polymorphism might serve as a genetic modifier underlying isolated vas deferens loss in the setting of cbavd. we sequenced the ' end of the tgfβ gene in eighty cbavd individuals possessing at least one cftr mutation, and compared genotype frequency with results previously published from demographically similar controls. when cc frequency in cbavd subjects was compared to pooled estimates from earlier trials, no significant differences were seen using a non-dominant model. compared to frequencies reported by arkwright et al. and garrote et al., a greater number of homozygous cc subjects ( . % vs. . %, p< . ) was observed. our preliminary results therefore indicate that if tgfβ- codon polymorphism is associated with cbavd penetrance, it does not represent the major modifier of disease phenotype. in order to evaluate this possibility further, we plan analysis of a larger (matched) control set of cbavd and non-cbavd individuals, studies of tgfβ- activity in vas deferens epithelial cells with and without cftr, and experiments to investigate the effects of tgfβ on cftr biogenesis and function. supported by nih and cff. newborn screening (nbs) for cf has been successful in identifying cf infants, particularly those who have positive sweat tests immediately following the positive screening result. tracking by personnel at the central nbs program facilitates resolution of diagnostic status because cf nbs presents a challenge to cf center (cfc) systems and primary care providers when apparently asymptomatic infants have inadequate (quantity not sufficient (qns)), borderline or indeterminate sweat tests. short-term follow up is more problematic when the screening algorithm requests earlier sweat tests and defines a lower cutoff for indeterminate sweat test results than is used for older infants, children and adults. the massachusetts (ma) cf nbs workgroup chose a low cutoff for indeterminate results of meq/l up to months of age, reverting to the accepted meq/l cutoff thereafter. follow up by the central nbs program identified infants whose diagnostic status remained unresolved more than weeks after a qns or borderline sweat test and eliminated the need for individual cfcs to follow infants tested at more than one cfc. the program sent informational letters and a reminder recommendation to finalize the diagnosis to primary care providers of infants with unresolved diagnoses. of the cf infants identified by ma cf nbs, had an initial sweat result that was indeterminate and another had an initial result that was qns. the central screening program has the capacity to track infant and child outcomes across cfcs; for example, we have been tracking growth outcomes of all cf infants identified by ma cf nbs, despite of the cf infants having moved from one cfc to another during their first years of life. tracking and outcomes data will be presented. when more than one cfc operates within a screening program, centralized tracking ensures capture of quality data. despite several educational campaigns cf is often not diagnosed in early infancy in poland (the mean age of diagnosis months, median is months). after several years of discussions,in september a neonatal screening for cf supported by the ministery of health was started as the third obligatory neonatal screening in poland. more than , neonates were screened in the first seven months using the existing screening infrastructure and spare blood spots after pku and congenital hypothyreosis screening. the protocol was two stage irt/dna (covering the most common mutations in the polish population). the final diagnosis was based on sweat tests (conventional pilocarpine-iontophoresis and conductometric nanoduct) as well as clinical examination. values of chloride in sweat > mmol/l and nacl > mmol/l were considered diagnostic for cf. children were confirmed as cf. although delta f is the most common mutation in the polish population, only two infants were delta f homozygotes, six were delta f heterozygotes and the remaining had different mutations ( children had + kbc>). half of the diagnosed group was still pancreatic sufficient. the children had confirmed cf diagnosis at the mean age of weeks. only children were free from any radiological changes in lungs. the most common pathogen in this group was staphylococcus aureus. at the first visit information for parents about cf was given along with physiotherapy and dietary education. anthropometric measurements, airways bacteriology and elastase - in stool were performed. psychologist consultations were available. neonatal screening for cf enabled earlier diagnosis and the introduction of complex therapy in comparision with symptomatic screening. objectives: the clinical course of cystic fibrosis (cf) varies widely among patients carrying the same cftr gene mutations supporting that additional genetic modifiers could affect the cf phenotype. as inflammation is a central contributor to the pathogenesis of cf lung disease, genes involved in the inflammatory response are potential modifier candidate genes. methods: we examined the influence of polymorphisms in genes involved in the inflammatory response (tnf, il- β, il- receptor antagonist (rn), il- , il- , il- and tgf-β ), on disease progression in a group of caucasian children with cf. the genotypes were tested for an association with changes in lung function tests, pseudomonas aeruginosa colonization and nutritional status by multivariable analysis. results: we found a significant association between tgf-β + t/c variants and decline in lung function measured as the forced expiratory volume in one second (fev ) and the forced vital capacity (fvc) (p= . and . respectively). il- gene polymorphisms (- a/t, + g/t and + t/c) were associated with the occurrence of pseudomonas aeruginosa colonization (p< . ). conclusions: this study suggest that il- variants may influence pseudomonas aeruginosa colonization in cf, however this need further confirmation. moreover, we provide additional support to the results of other trials and strongly suggest an association between tgf-β variants and lung disease phenotype in cf. if such a role of tgf-β is confirmed by functional studies, it may have important clinical impact for the identification of patients at risk to develop more severe respiratory manifestations and for the development of new therapeutic strategies aimed at adequately balancing tgf-β production and action introduction: cystic fibrosis (cf) is the most common monogenic disease in caucasian population, its frequency is about one in live born. the estimated frequency in hispanic population is about one in , with differences in mutation frequency especially for low frequent alleles. heterogeneity in pulmonary manifestations cannot be explained by the cftr mutation genotype. recent studies are focused in the study of modifier genes. these are genes different from the primary cftr gene that could influence the fq phenotype, acting trough mechanisms like inflammation, repair and remodeling, protease-anti protease balance, innate immune response, etc. this work shows some advances in cf diagnosis and modifier genes analysis in mexican population. methods: we tested the effectiveness of innolipa cftr kit (innogenetics) in clinically diagnosed cf patients. thirty six frequent mutations in cftr gene were analyzed by pcr and reverse hybridization with allele specific oligonucleotides probes in dna samples extracted from blood or oral swabs. for frequency analysis of modifier genes we tested about seventy dna samples from a dna bank of patients previously tested positive for cftr mutation. the polymorphism analysis of modifier genes was made by pcr-rflp. for alpha antitrypsin (aat), z and s alleles were analyzed according stanford and cols. ( ) . for tumor necrosis factor alpha (tnfα) - polymorphism in the promoter region was analyzed according chen and cols. ( ) . results: mutation was detected in in of patients ( % of effectiveness). df allele frequency was % (caucasian - %) followed by + g-a, s n, g x, g e and delt ( %). % of the mutant alleles remain undetected. preliminary results in modifier genes show low frequency for aat mutant alleles ( . % for aat s and z alelle respectively) and . % for tnf- . conclusions: df alelle frequency was %, and we found the low fequency alleles s n and + g-a. frequency of modifier genes mutant alleles in cf patients are low. this work is in progress of selection and recruitment of patients and controls, as well as standardization of the other genes modifiers, along with some other biomarkers that will allow to understand the physiopathology of cf and to define a possible genetic risk profile of severe pulmonary disease. over putative cystic fibrosis (cf)-causing mutations have been reported to the cf mutation database and almost half (~ ) are rare missense mutations that are predicted to substitute a single amino acid. to determine if any of these rare missense mutations cause cf by altering localiza-tion of cftr, we examined mutations in the cytosolic loops of cftr since localization signals have been identified in cytosolic loops of other ion channels. amino acids alignments comparing human cftr sequence to that of species revealed that cytosolic loop (cl ) was the most conserved loop by identity. furthermore, cl had the most naturally observed mutations: of the amino acids were found to be mutated in cf patients and sites had multiple missense mutations at the same amino acid. in addition, different substitutions of the same cl amino acid have been associated with different disease consequences, such as the missense mutations in the arginine at codon . patients with the r p mutation have pancreatic insufficient (pi)-cf, those with r w mutation have pancreatic sufficient (ps)-cf or cbavd, while patients with r q primarily had pi-cf. to determine whether the r mutations cause disease by affecting cftr localization, we used the flp-in system to create stable polarized mdck-gfp-cftr cells to produce isogenic clones with cftr expressed from the same integration site. confocal microscopy studies of stable mdck-frt-gfp-cftr-r mutant cell lines revealed that cftr-r p was cytoplasmic, cftr-r w was apical and cytoplasmic, and cftr-r q was apical. to confirm these observations, quantitative biotinylation studies were performed. biotinylation assays of mdck cells stably expressing cftr-r p confirmed that this mutant was absent from the apical surface, cftr-r w had a low level of fully glycosylated protein at the apical membrane, while cftr-r q had fully glycosylated protein at the apical membrane comparable to wild-type cftr. thus, cftr-r p and cftr-r w displayed properties in polarized cells that were distinctly different from wild-type cftr consistent with their associated cf phenotypes. however, the profile of cftr-r q (apical localization and cl-channel function (seibert et al. , mickle et al. ) appears inconsistent with a pi-cf phenotype. indeed, re-analysis of cftr genes bearing r q revealed that of carried a second mutation in cis (s x). in nine of these patients in whom cftr genotype and pancreatic status is known, presence of the nonsense mutation s x is associated with the pi-cf phenotype. since nonsense mutations are known to cause severe gene dysfunction by promoting decay of their rna transcript, we concluded that the s x mutation rather than r q is responsible for the pi-cf phenotype. the finding of s x explained the otherwise enigmatic functional studies of r q and clinical observations in patients bearing this mutation. this study also demonstrates that stable expression of cftr mutants in polarized mdck cells using the flp-in system provides a useful screen for evaluating the disease potential of rare missense mutations. the clinical course of cf is characterized by recurrent pulmonary infections and chronic inflammation. in cf patients, up-regulation of toll-like receptor- (tlr ) gene in airway epithelial cells is believed to enhance proinflammatory responses towards bacterial tlr ligands. we have recently shown that decreased methylation (demethylation) of the tlr promoter is responsible for cf-related up-regulation of tlr in bronchial epithelial cells (shuto. t. et al., faseb j, ) . however, the molecular mechanisms responsible for dna demethylation-dependent tlr gene upregulation in cf cells remain unknown. here, we identified minimum region of the tlr promoter critical for its expression at - /+ , which contains one putative binding site for sp . sp inhibitor mithramycin a treatment reduced tlr promoter activity and its expression in cf bronchial epithelial cells (cfbe o-), suggesting the importance of this sp site for the tlr gene regulation. moreover, bisulfite sequence analysis revealed the hypomethylation of adjacent this sp binding motif within tlr promoter in cfbe o-cells, implying the cf-specific demethylation of adjacent sp binding motif. although mithramycin a rarely affected basal expression of tlr gene in hbe o-cells (non-cf bronchial epithelial cells), mithramycin a inhibited tlr expression in -azacytidine (dna-demethylating agent)-treated hbe o-cells. taken together, our results suggest that sp is crucial for dna demethylation-induced gene upregulation of tlr in cf bronchial epithelial cells. mucus hypersecretion due to goblet cell metaplasia is a critical feature of cf lung disease, affecting both mucociliary clearance and drug delivery. various studies in cf lungs and cf primary cultures have shown increased expression of muc ac, the main gel-forming mucin produced by goblet cells; however, little is known about the role of muc ac in the progression of lung disease. to determine whether overexpression of muc ac alone is sufficient to induce lung pathology, we generated a mouse model overexpressing muc ac. the entire muc ac cdna (minus % of the predicted vntr sequence, final size ~ kb) was cloned and tagged with an internal gfp epitope at a site close to the vntr to preserve the integrity of mucin domains. gfp-muc ac was linked to the rat ccsp promoter to drive specific airway expression, primarily in clara cells since these cells are capable of secreting mucins. blastocyst injections were used to generate transgenic founder lines in c bl/ background. although muc ac-gfp mrnas were expressed in transgenic mice, lung histology did not show significant increases in inflammation, ab/pas-positive cells, or luminal secretion compared to wild-type littermates. gfp fluorescence from freshly excised lung was weak but immunohistochemistry showed that the distribution of gfp correlated with the expected expression pattern, with the majority of positive cells localized to the airways and few positive cells in the alveolar space. at higher magnification, gfp-positive granules were observed in dome-shaped cells that were also positive with cc antibody, suggesting proper muc ac-gfp packaging in clara cells. bronchoalveolar lavage samples separated by agarose gel western blots and probed with gfp antibody confirmed that each line secreted muc ac-gfp, with a migration pattern comparable to a mucin. to further characterize the secreted transgenic mucin, a pool of lavage samples was separated into supernatant and pellet. the pellet was resolubilized in m guanidine. both elements were passed through a s size-exclusion column. analysis by light scattering and refractometry to determine molecular weight and concentration revealed that the solubilized pellet contained an enormous but compact complex ( x g/mol and nm radius of gyration). gfp-rich fractions were pas-positive, indicating proper glycosylation of the transgenic muc ac-gfp. cscl density gradient studies revealed that the gfp-rich fractions had a high molecular weight but did not appear to be a prominent part of the megacomplex retrieved in lavages, unlike other tested mucins. in conclusion, we showed that the overexpressed muc ac-gfp was a high-molecular-weight protein that was glycosylated, packaged in clara cells and formed multimers. lack of discernable phenotype in the transgenic lungs suggests that mucin overproduction alone is not sufficient to trigger goblet cell metaplasia and mucus accumulation, supporting the protective role of mucins. currently we are crossing the muc ac-gfp with the scnn b mouse model to study muc ac-gfp under dehydrated conditions and we are conducting allergen-challenges in the transgenic mice. results of such studies will provide novel insights into the role of secreted muc ac in development of lung disease in these models. supported by grants from the cf foundation. the major characteristic in cystic fibrosis (cf) is acquirement of chronic lung infections with p. aeruginosa. once established the chronic infection can only be suppressed, not eliminated. the cf patients harbour one single strain of p. aeruginosa which only rarely is replaced by other strains. during the chronic lung infection there is a year long mutual impact of the bactaria on the host, and of the host response and antibiotics on the bacteria, resulting in a continous adaptation of the bactaria in the lungs of the cf patients with selection for different clones. in contrast, mouse models of the lung infection in cf is limited to two weeks! therefore, we introduced a new strategy infecting different groups of balb/c mice with pulsed field gel electrophoresis-(pfge) identical clones isolated from one cf patient during -years of p. aeruginosa lung infection. ) infecting the mice with non-mucoid isolate showed that the early isolates were significantly better in establishing an infection with reduced clearance of the bacteria from the lungs (p< . ), increased dissimination of the macroscopic pathology (p< . ) and a more acute type and a higher degree of inflammation (p< . ) as compared to mice infected with a late isolate. in addition, the pulmonary cytokine response was comparable with observations in cf where gm-csf and il- correlated to a milder disease, whereas g-csf, mip- (il- analog), and il- b correlated to severe disease. ) infecting the mice with the mucoid pfge-identical isolates from the same cf patient revealed a signicantly higher mortality in mice infected with the late isolates (p< . ). in addition, the pulmonary g-csf and mip- response increased in the groups of mice that were infected with the late isolates as compared to the early isolate (p< . ). moreover, the g-csf and mip- increased during the first three days of infection with the late mucoid isolates (p< . ), indicating an impairment of the host response in controlling the lung infection. ) when tobramycin treatment was initiated h after infection of mice with a mucoid isolate, the number of bacteria were cleared or reduced to a significantly lower level (p< . ), and a significant decrease of both g-csf and mip- at day one, two and three was observed (p< . ). in contrast, when treatment was initiated after h the number of bacteria did not change significantly, and the reduction in inflammatory cytokine response became significant for both late isolates only at day three of treatment (p< . ). moreover, cytokine levels were significantly lower in the h as compared to the h group (p< . ) confirming the importance of early and aggressive antibiotic treatment in cf. non-mucoid isolates were reduced during the first three days of infection independent of treatment. in conclusion, we have implemented a clinical important cf-time perspective (years) in experimental p. aeruginosa lung infection, useful for patho-physiological and treatment studies. cystic fibrosis (cf) is a complex disease that affects multiple organs and results in a wide range of phenotypes in humans. mouse models of cf display many of the phenotypes observed in human patients and provide necessary tools to dissect this multifaceted disease. however, due to the involvement of cftr in various organ systems, the ability to discern the contribution of each organ system to each phenotype of cf is unknown. for example, we have found that mouse growth is dramatically reduced compared to wildtype, and mechanisms ranging from neuroendocrine disruption, intestinal malabsorption and cacchexia have been proposed. we have found that cf mice consume more calories per gram body weight than non-cf mice and intestinal absorption of dietary lipids is similar between the two. cf animals absorb % and non-cf % (p > . ). to identify the source of the growth deficit, it would be advantageous to restrict expression of cftr in specific tissues to determine each tissue's contribution to the phenotype. to accomplish this, we have created a conditional, null murine cftr allele. a conditional null allele is one in which the gene of interest is induced to be non-functional in either a specific tissue or cell type, or at a specific developmental time. examination of cftr absence on a tissue-by-tissue basis will greatly facilitate our understanding of the disease. the conditional cftr allele was created by "floxing" exon of cftr, known to be critical for function, with flanking loxp sites that allow for the deletion of exon when bacterial recombinase cre is present. to date, mice stably transmitting the floxed allele have been created. these founder mice have been crossed with mice expressing cre from the promoter of the villin gene, which restricts transcription of cre to intestinal epithelium. first generation animals show appropriate recombination and deletion of exon in the gut. however, these first generation animals are heterozygous for the floxed allele. we are currently backcrossing these animals with the founders to generate animals with homozygous deletion of cftr in the intestinal epithelium. similar crosses are planned to target other tissues. this new animal model of cf will be available to the cf research community to further our understanding of cf pathophysiology. this work was supported by a grant from the cf foundation increased enac-mediated na+ absorption is a hallmark of cystic fibrosis (cf) airways. we demonstrated that mimicking na+ hyperabsorption by overexpression of βenac in mouse airways results in airway surface liquid (asl) depletion and reduced mucus clearance causing a spontaneous cflike lung disease with high pulmonary mortality, and airway mucus obstruction, mucous cell metaplasia and chronic airway inflammation in adult survivors (mall et al., nature med. : , ) . the aim of this study was to identify the initiating lesions and investigate the natural history of lung disease caused by asl depletion in βenac overexpressing (βenac-tg) mice. to achieve this goal, we performed longitudinal studies on lung morphology, airway mucus obstruction, bronchoalveolar lavage inflammatory cell counts, expression levels of mucins (muc ac, muc b, muc ) and proinflammatory cytokines (tnfα, kc, ifnγ, il- , eotaxin- ), lung volume, lung mechanics, and airway na+ transport in neonatal to adult βenac-tg mice and wild-type littermate controls. we show that airway mucus obstruction in βenac-tg mice originated in the trachea in the absence of mucous cell metaplasia in the first days of life, and was associated with hypoxic degeneration and necrosis of airway epithelium, and death. in surviving βenac-tg mice, mucus obstruction extended into the lungs and was accompanied by secondary mucous cell metaplasia, increased expression of muc ac, muc b and muc , and airway inflammation with transient increases in macrophages and tnfα, in eosinophils and il- , and persistent increases in neutrophils and kc in the lung. βenac-tg mice also developed emphysema with increased lung volumes, distal airspace enlargement, and increased lung compliance. several disease surrogate markers waned in parallel with βenac transcript levels and airway na+ absorption in adult βenac-tg mice indicating that the level of enac overexpression was critical in determining disease severity. in summary, our results provide several novel insights into the in vivo pathogenesis of lung disease caused by asl depletion. we show that (i) asl depletion is sufficient to initiate severe airway mucus obstruction in the absence of mucous cell metaplasia and/or mucus hypersecretion; and (ii) airway na+ hyperabsorption and mucus plugging-induced hypoxia is associated with airway epithelial necrosis constituting a mechanism that initiates airway inflammation in the absence of infection. further, our results point to a novel link between airway na+ hyperabsorption, eosinophilic inflammation, and emphysema. the high frequency of allergic airway inflammation and emphysema in cf patients warrants further studies of the mechanisms that link asl depletion with these associated pathologies. the balance of airway surface liquid (asl) at a height compatible with efficient clearance of mucus is a process regulated by two main pathways: the secretion of clvia cftr, and absorption of na + via the epithelial na + channel (enac). to study this interplay, an immortal cell line capable of growing at an air liquid interface and having properties of human bronchiolar epithelium would be desirable for its simplicity in preparation and ease of molecular manipulation. an immortal human bronchial adenocarcinoma cell line (hbac) was infected with a lcfsn retrovirus carrying either cftr cdna (hbac cftr ) or the blank vector (hbac mock ). - day monolayers, grown on transwell clear membranes, were mounted in ussing chambers and studied under open-circuit conditions. to study regulation of clsecretion, the equivalent short circuit current was calculated in the presence of amiloride (apical, µm). in hbac mock cells, forskolin ( µm, basolateral) had no effect upon i sc . in contrast, hbac cftr cells demonstrated a robust increase in i sc ; a rapid increase to a peak (∆~ µa cm ), followed by relaxation to a stable and sustained plateau. genistein ( µm) also stimulated i sc in hbac cftr (∆i sc µa cm ) but not hbac mock cells. amiloride resistant basal current was consistently higher, by - µa cm , in hbac cftr versus hbac mock cells, presumably reflecting low basal cftr activity. we next examined the ability of endogenous receptors present in hbacs to regulate transfected cftr. stimulation of i sc in response to apical adenosine ( µm) in hbac cftr was qualitatively and quantatively similar to the forskolin response. while the above experiments provided evidence to suggest that hbac cftr cells possess the bioelectric capability of sustaining anion transport via nucleoside-stimulated cftr activity, it does not guarantee a resultant vectorial flow of fluid. in the final series of experiments, we examined whether adenosine was indeed able to stimulate secretion across the hbac-cftr monolayer by assaying asl height. monolayers were loaded apically with fitc-labeled dextran ( µl), and the majority of dye was then aspirated. monolayers were then allowed to equilibrate over a hour period, and asl measured by xz scanning on a leica confocal microscope. ~ µm adenosine and ~ µm benzamil was then added apically in pfc and asl height measured after and minutes. in both hbac mock and hbac-cftr cells, the basal asl height was ~ µm. over minutes asl height of hbac mock cells did not change in response to adenosine. in contrast, adenosine stimulated hbac cftr cells demonstrated a doubling of asl height (to µm) over the same period. this response is consistent with the prolonged increase in i sc observed upon stimulation with adenosine. in summary, the hbac model which displays only absorptive currents endogenously, can be transformed into a cell line in which cftr-mediated secretion can be stimulated and sustained by endogenous receptor systems present in the apical membrane. this new model will allow us to study cftr-mediated fluid transport in a defined manipulatable system. despite the identification of the cftr channel more than years ago, many questions remain about its regulation and in vivo function. in order to better understand how cftr functions in vivo, numerous studies have searched for and identified potential interacting partners but to date, there is little evidence linking any of the known cftr interactors to its activity. during a forward genetic screen in zebrafish, aiming to identify genes regulating endodermal organ development, we identified a mutant, which we named baobab (bao), after the african tree that accumulates water during the wet season, which exhibits a dramatically enlarged fluid-filled gut tube. most interestingly, we have shown that various cftr inhibitors reduced the appearance of enlarged guts in bao mutant embryos, suggesting that the fluid accumulation phenotype resulted from an increase in cftr activity. to test whether increased cftr activity resulted from changes in cftr protein levels or localization we raised antibodies against zebrafish cftr. western-blot and immunolocalization studies revealed that the channel was expressed and localized as in wild type in bao mutant embryos indicating that the increased cftr function most likely resulted from the activation of the channel. these data, together with the recessive character of the mutation, suggest that the bao protein is a negative regulator of cftr activity. we have positionally cloned the bao locus and isolated the affected gene. bao encodes a cytosolic protein that has not been previously shown to regulate cftr. in agreement with the pharmacological data pointing to a gut-specific function of bao, in situ hybridization studies showed that bao is higly expressed in gut. we are currently investigating how the bao protein regulates cftr function. in addition, we are also investigating the function of cftr during zebrafish development. these studies lay the groundwork to take advantage of the zebrafish system to further investigate cftr biology. we establish a genetic model system for studying the regulation of the cftr channel that will contribute to the understanding of the pathophysiology of cystic fibrosis and several intestinal secretory conditions. acknowledegements: this work was supported by an embo long-term postdoctoral fellowship to mb and by nih grants to d.y.r.s.. we thank a. verkman for providing cftr inhibitors and k. brand for technical assistance. the trachea of the adult cf mouse (cftr tm unc or cftr tm kth ) expresses little cftr and exhibits neither a defect in camp-mediated clsecretion nor hyperabsorption of na + , both signature abnormalities in human cf airways. we generated a mouse exhibiting hyperabsorption of na + in the airways by over-expressing the β subunit of the epithelial na + channel (βenac, gene scnn b). βenac mice exhibit airway pathology (decreased mucociliary transport, mucus plugging, and airway inflammation) similar to human cf airways. to determine whether inactivation of cftr in βenac mice results in a more severe phenotype, we generated a cf/βenac mouse by crossing the ∆f (c bl/ n) mouse (cf mouse) with the βenac mouse (c bl/ n). survival analysis showed a drastic reduction in survival for cf/βenac mice in comparison to cf mice or βenac mice. we studied the airway bioelectrics of day-old pups of each genotype. the basal short circuit current (i sc ) was ~ fold greater in wild-type (wt) ( ± µa . cm - ; mean ± sem, n= ) vs. cf ( . µa . cm - , n= ) neonatal tracheas. as previously reported, the basal i sc in βenac preps was significantly elevated ( . ± µa . cm - , n= ) vs. wt tracheas. however, the basal i sc in the cf/βenac tracheas ( . ± µa . cm - , n= ) was intermediate between the cf and the βenac tracheas. the amiloride-sensitive i sc was elevated similarly in the tracheas of the βenac and cf/βenac pups and was ~ x greater than that exhibited by the wt or cf tracheas. the post-amiloride i sc was strikingly reduced in both cf and cf/βenac tracheas compared to the wt and βenac tracheas. we suggest that the post-amiloride i sc reflects constitutive cftr-mediated clsecretion, which may help hydrate airways in the neonate. unlike the tracheas of adult cf mice, neonatal cf tracheas exhibited the classic defect in camp-mediated clsecretion, with the forskolin response in the cf and cf/βenac tracheas being reduced ~ fold compared to the response in the wt or βenac preps. the response to utp (ca ++ -mediated clsecretion) was similar in the four genotypes. absence of cftr-mediated clsecretion does not appear to cause airway pathology in neonatal cf mice, but when this defect is coupled with na + hyperabsorption, it results in a significant increase in neonatal mortality. due to lack of cftr-mediated clsecretion, cf/βenac mice appear to experience greater mucus adhesion, producing death due to asphyxiation. in addition, the tracheas of cf mice (especially congenic c bl/ n) often appear constricted or collapsed due to a cartilaginous defect resulting in increased compliance. this anatomical defect does not appear to be detrimental to the cf mouse. however, in cf/βenac pups, that accumulate thick, sticky mucus in their tracheas, this tracheal constriction may contribute to their asphyxiation. these results demonstrate the importance of both abnormal na + absorption and decreased clsecretion in the pathogenesis of cf lung disease. supported by nih scor p hl . recently, we reported that species-specific differences in the airway biology of raav transduction exist between mice and human (am j respir cell mol biol, , : - ) . these differences significantly interfere with the use of mice as surrogate models for human lung gene therapy with certain raav serotypes. to survey which species might be an optimal animal model for raav preclinical testing, we utilized differentiated airway epithelia grown at an air-liquid interface (ali) from five species (human, non-human primate [nhp] , pig, ferret, and mouse) to test the efficiency of transduction with three serotypes of raav (type , , and ). our results demonstrated significant species-specific differences in raav transduction biology in airway epithelia. the serotype preferences of raav transduction from the apical membrane in human, ferret, and pig epithelia was raav >raav ≈raav , different from that seen in mouse epithelia (raav >>raav >>raav ). surprisingly, the profile of raav transduction with these three serotypes in nhp rhesus monkey airway epithelia (raav ≈raav >>raav ) was less similar to human than pig and ferret. additionally, raav lacked a bias in polarity of transduction in human airway epithelia, however, in nhp epithelia, raav transduced the basolateral membrane -fold more effectively than the apical membrane. furthermore, differences in the properties of raav receptors between these species was also seen. using neuraminidase treatment of the apical surface of ali cultures, we tested whether n-linked sialic acids were potential receptors for raav binding and/or transduction. these studies demonstrated removal of n-linked sialic acids inhibited raav transduction of human, nhp, and mouse airway epithelia, but not ferret and pig. however, raav binding in this setting did not correlate with changes in transduction; neuraminidase treatment dramatically reduced raav binding to nhp epithelia, but enhanced binding to human epithelia (~ fold). these findings suggest viral binding to airway epithelial cells may not be a major barrier for raav transduction. evidence that proteasome-modulating agents enhancing raav transduction - logs for all serotypes and species tested, suggest that the ubiquitin/proteasome pathway represents a common intracellular block in raav transduction of airway epithelia. these findings support the notion that viral interactions at the surface of airway epithelial cells (with co-receptors and receptors) influence intracellular processing aav virions that can alter the efficiency of productive transduction. enac surface density in cortical collecting duct (ccd) epithelial cells is established by camp/pka regulated insertion and retrieval of the channel at the apical membrane, together with the recycling of internalized enac back to the apical surface (butterworth et al. ( ) journal of general physiology : - ). ubiquitination by the nedd - ligase elicits endocytosis of surface enac, which may lead to its degradation. however, enac recycling to the apical surface requires ubiquitin removal by a deubiquitinating enzyme (dub). using a chemical probe approach, we identified ubiquitin carboxy-terminal hydrolase (uch-l ) as the predominant dub in vesicular endocytic and recycling compartments in mouse ccd epithelia. specific inhibition of uch-l ( µm of , , , -tetrachloroindan- , -dione) in filter-cultured ccd cells resulted in a rapid decline in enac currents, which was accelerated by forskolin stimulation, suggesting that uch is responsible for recycling enac to the apical surface. knockdown of uch-l significantly reduced both basal and camp-stimulated enac currents (from . ± . µa/cm in control sirna treated to . ± . µa/cm in uch-l knockdown cells). to determine whether the same dub was responsible for the regulation of enac in human bronchial epithelial (hbe) airway cells, differentiated cultures derived from cf and non-cf lung tissue were treated with the uch inhibitor. to address the possibility that protease cleaved enac may be regulated differently from unprocessed channels, differentiated hbe cultures were either maintained at air/liquid interface or were submerged under liquid/liquid conditions to alter the cleavage state of enac, as we have previously described (myerburg et al. ( ) journal of biological chemistry : - ). in all cases, no significant difference in enac-mediated na+ transport was observed between control and uch-l inhibited conditions. these data are in sharp contrast with the mechanisms of enac regulation observed in the ccd model system, and they support our previous findings that enac turnover and mode of regulation in hbe are distinct from the recycling mechanisms defined in the ccd epithelia (butterworth et al. primary human tracheobronchial epithelial (htbe) cells cultured at an air-liquid interface (ali) regulate ion transport, mucin secretion, and cilia beating to recapitulate directional mucus clearance, a key innate defense mechanism that fails in cystic fibrosis (cf). thus, ali htbe cell cultures are crucial for studying cf pathogenesis and for developing/validating novel therapies. different research centers use alternative protocols that enable reproducible creation of ali htbe cell cultures. however, limited primary htbe cell availability has driven the creation of cognate cell lines, accomplished mainly by the introduction of viral oncogenes. viral oncogenes disrupt normal cell physiology causing cellular hyperplasia, abundant apoptosis, genomic instability and, sometimes, poor polarization/differentiation, rendering the cells less useful than primary cells for assessing cftr function. furthermore, genetically unstable cell lines will continuously acquire changes independent of cftr genotype. bmi- is a polycomb group protein that controls cell cycle and cell identity via epigenetic regulation of chromatin, maintaining stem cells by suppressing expression of p , an inhibitor of cyclin dependent kinases. bmi- expression has been used to create cell lines that recapitulate normal cell structure and function better than viral oncogene-immortalized cell lines. using hiv lentiviral vectors, we introduced bmi- and the catalytic subunit of telomerase to enhance the growth of different ∆f homozygous cf and non-cf primary human airway epithelial cell preparations. all new cell lines grew for at least population doublings, while their normal counterparts senesced prior to a maximum of doublings. at passage - , the new cell lines had a diploid karyotype compared to grossly abnormal chromosomes in cells immortalized by viral oncogenes. ussing chamber analysis of ali cultures at passage (p) - revealed variable transepithelial resistances among the cell lines ranging from -> Ω*cm , but short circuit current (isc) responses stimulated by forskolin and inhibited by cftr were true to the cell's genotype and comparable to early passage primary cells, except for one non-cf cell line with relatively low cftr isc's at p . amiloride sensitive and utp-stimulated isc's were present but were more variable in magnitude in comparison to the currents observed in low passage primary cells. ali cultures exhibited a pseudostratified morphology with prominent apical membrane polarization, few apoptotic bodies, numerous mucous secretory cells and occasional ciliated cells. all cf and non-cf cell lines in culture produced similar levels of il- at baseline and cf and non-cf cells equally increased il- secretion in response to il- β, tnfα and the tolllike receptor agonist, pam cys. these novel cell lines will help fill gaps currently hindering cf research and therapeutic development. supported by cystic fibrosis foundation grant randel g . we recently considered that domestic dogs could represent a large natural reservoir to search for cftr mutations and, ultimately, to identify and breed animals with cf traits. the canine genome has been completely sequenced, and the canine cftr gene, found on chromosome , consists of exons spread over kb. an animal model that faithfully expresses human cf lung pathology is critical for the development of effective treatments for this most lethal aspect of cf disease. while transgenic mouse models of cf replicate numerous aspects of cf disease, they unfortunately do not develop the characteristic lung pathology including mucus plugging of airways, chronic bacterial infections, and bronchiectasis. the reason for this is not completely understood but it is likely related to significant differences in lung morphology between these species. to date, no non-murine genetic model of cf has been developed, and naturally-occurring, cf-causing mutations have not been identified in any non-human animal species. temporal temperature gradient gel electrophoresis (ttge), developed as a screening tool to identify sequence variations and mutations in the human cftr gene, was used to screen dogs for cftr mutations. dna was purified from whole blood received from veterinary clinics treating dogs for a variety of ailments. we have performed ttge analysis on dna from dogs, which includes dogs with pancreatitis and dogs with bronchiec-tasis, and have found hundreds of potential mutations amongst the thousands of amplicons tested. ttge can detect single base pair changes within a fragment of dna. as the temperature increases, the migrating dna becomes partially melted, creating single stranded regions (internal bubbles and branched ends) that decrease its mobility through the gel. the dna fragments have distinct melting profiles that are sequence dependent; therefore, changes in sequence of even a point mutation can alter the profile and result in a change in the rate of migration through the gel that can distinguish wild type from even a homozygous mutant. thus far exonic mutations have been sequenced but none have caused changes to cftr at the amino acid level (i.e., the mutations have all been silent). we conclude that ttge is a sensitive and effective method for screening large canine populations for cftr mutations. ( introduction: the search for "correctors" of defective protein processing of ∆f cftr has led to the development of high throughput screening assays to find compounds that promote the surface activity of the mutant protein. by necessity, primary screening assays typically use cell lines expressing recombinant ∆f cftr. however, "hits" identified in primary screening require scrutiny for false positives whose activity is either dependent on the ∆f cftr expression system or insufficiently robust to correct processing in the complex physiological setting of a native epithelium. to this end, we have developed a secondary functional assay that measures the shortcircuit current (isc) responses in organ cultures of gallbladder mucosa from ∆f cftr mice (cftr tm kth ). previous studies have shown that murine ∆f cftr recapitulates the protein processing defect including the capability to increase processing when mucosa is incubated at reduced temperature ( °c) (j. clin. invest. : invest. : , . gallbladder mucosa was chosen for this assay because the murine gallbladder can be removed aseptically for organ culture, the epithelium is essentially a monolayer, and the mucosal wall is transparent which facilitates morphological assessment. methods: using either wild-type (wt), ∆f cftr (df) mutant or cftr knockout (cftr ko) mice, excised gallbladders were opened longitudinally, rinsed and positioned on loose nylon mesh. the preparation was mounted between two halves of a polycarbonate culture cup with . mm aperture and placed in submersion culture for - days at either °c or °c using supplemented ham's f medium mixed : with nih t fibroblast-conditioned dmem containing % calf serum. after incubation, the culture cups were placed in custom designed ussing chambers for measurement of isc responses to a cocktail of µm forskolin and µm ibmx (camp isc) at °c. contribution of calcium-activated clchannels to the camp isc was eliminated by addition of the distilbene dids ( µm) to the luminal bath. results: the mean ∆camp isc responses (in µa/cm ) after two days incubation were as follows: wt at °c = . ± . (n = ); df at °c = . ± . (n = ); df at °c = . ± . (n = ); and cftr ko at °c = . ± . (n = ). in a pairwise comparison, the wt ( °c) was significantly greater than the df ( °c) and cftr ko ( °c) but not significantly different from df ( °c). conclusions: incubation of ∆f cftr mutant murine gallbladder mucosa at °c for two days in organ culture restored approximately % of the cftr-dependent isc responses to camp stimulation. the temperature-dependent effect is consistent with correction of murine ∆f cftr processing, indicating a physiological screening assay that is useful for preclinical testing of candidate drugs targeted at correcting the protein processing defect of ∆f cftr. supported by cfft and nih. the lack of a large animal model that replicates the lung disease found in humans with cystic fibrosis is a major impediment to understanding disease pathogenesis and the development of effective therapies. although cystic fibrosis is a multi-system disease, airway infection and inflammation currently cause most of the morbidity and mortality in patients. several homozygote null and missense cftr mutations have been developed in mice, but they do not exhibit the lung phenotype observed in humans. in contrast to mice, the structure and physiology of porcine lung and airways closely resemble those of humans. therefore, the goal of this project is to develop a swine model for cystic fibrosis by combining gene targeting and nuclear transfer to produce a pig with a cftr null genotype. we employed homologous recombination to disrupt exon of pig cftr with a neomycin resistance cassette. we generated primary male fetal fibroblasts that were positive for cftr-targeting at one allele as detected by multiple pcr screens. genomic southern blot analysis confirmed proper gene targeting and revealed most clones were free of random integration events. these cells were used for somatic cell nuclear transfer that resulted in the birth of ten cftr null heterozygote piglets. subsequent breeding of these male pigs to wild-type females has yielded at least female cftr null heterozygotes. breeding male and female heterozygotes will provide cftrnull homozygotes. our recent published and preliminary studies demonstrate that mouse slc a , a newly discovered member of slc family of anion exchangers, is expressed on the apical membrane of tracheal epithelial cells and gastric surface epithelial cells and in the tubulovesicle membranes of gastric parietal cells. the functional properties of mouse slc a were examined in xenopus oocytes and in stably transfected cultured cells. in xenopus oocytes injected with the slc a crna and studied with the voltage and/or ph sensitive microelectrodes, the rank order for anion selectivity at + mv was cl->i-> no ->gluconate > sulfate, and that of the selectivity (px/pcl) was i-> cl-> no -= gluconate > sulfate. inhibitor profile studies demonstrated that nppb at µm inhibited the current at min by % (p< . compared to control period, n= ). the effect of nppb was partly reversible. dids at µm had no significant effect on the slc a -mediated current (p> . compared to control period, n= ). niflumic acid at µm inhibited the current at min by ~ % (p< . compared to control period, n= ) which was partly reversible. cftr inh at µm inhibited the current at min by ~ % (p< . compared to control period, n= ) which was reversible. clamping currents in a mm k-gluconate medium and using mm k-cl or k-bicarbonate revealed very low bicarbonate conductance for slc a compared to that of cl-. no significant phi changes were observed in oocytes when favoring cl-exit by substituting perfusate cl-with gluconate in the presence of co /hco -. conversely we observed significant alkalinization in ae -expressing oocytes in the same experimental solutions. interestingly, in hek cells stably transfected with the mouse slc a , a significant intracellular alkalinization was observed upon switching to a chloride-free perfusate. the alkalization in slc a -expressing cells was inhibited by ~ % in the presence of µm dids. baseline intracellular ph was significantly increased in slc a expressing hek cells vs. non transfected cells. however, baseline phi was comparable in control and slc a -expressing cells in the presence of µm eipa, indicating the activation of endogenous nhe by slc a . in conclusion, slc a displays characteristics of an anionic channel in xenopus oocytes, with low bicarbonate permeability. in mammalian expression systems, slc a can also function in cl-/hco -exchange mode with moderate sensitivity to inhibition by dids. we propose that slc a plays an important role in anion (chloride) secretion and/or ph regulation in tracheal and gastric epithelial cells. no cell lines exist at present that robustly express endogenous wt and ∆f cftr on the same genetic background. zinc finger nucleases (zfns) allow the introduction of specific genetic changes at loci within the human genome (nature : [ ] [ ] [ ] [ ] [ ] [ ] ) . we have been using this technology in an attempt to generate human cells carrying the major cf-causing genotype -∆f -at the endogenous cftr locus. such lines could be expected to provide better understanding of the ∆f maturational processing defect, as well as new model systems for cell based assays of ∆f repair. we performed a bioinformatic analysis of cftr exon , and designed multiple distinct zfns against the ∆f dna sequence. all of these nucleases were assembled, cloned into mammalian expression vectors, and assayed for dna binding affinity and specificity. the zfns were then assayed for endogenous cftr locus editing in calu- and ht- cells using a novel, massively parallel methodology applied for the detection of genome editing events. the effort demonstrated that specific zfn pairs successfully bind to, and cleave, within exon of the endogenous cftr locus in both cell types. we will describe experiments that yielded optimized zfns for the cftr locus, and a robust viral platform to transiently deliver genome editing reagents to the human pulmonary cell line, calu- . supported by cff. the localization of slc anion transporters, as well as their function vary among members. some (slc a , slc a , slc a , slc a ) are widespread, implying specific physiological function in diverse tissues. others are expressed only in a single epithelia, e.g., slc a (prestin) in the inner ear. we have previously found that slc a is a highly electrogenic cl --hco exchanger with a large anion conductance. to determine the possible physiologic roles of slc a , we developed a chicken antibody (designed against sulfate transporter and anti-sigma domain, stas, of slc a ) to localize the protein. to test the antibody specificity for functional protein, we inject xenopus oocytes with crna for slc a , slc a or slc a and documented appropriate ph and membrane potential changes. only oocytes functionally expressing slc a were stained using our primary slc a antibody. further, specific staining was eliminated when either pre-immune serum or blocking peptide was used. slc a was only found in epithelia. in the respiratory system, slc a was in the apical membrane of nasal epithelial cells and tracheal submucosal glands. membranes of calu- cells, derived from human tracheal submucosal glands, stained indicating that our antibody also recognizes the human slc a protein. slc a is found in the proximal parts of the gastrointestinal tract (esophagus, stomach), with lesser amounts in the small intestine and colon. however, slc a is not present in liver. slc a is present in ducts of secretory epithelia such as salivary glands and pancreas. in the urinary tract, slc a is localized to the renal proximal tubule apical membrane but not in urinary bladder. in the reproductive system, we found slc a in epithelia of the uterus and seminal vesicles but not the vas deference or the prostate. finally, slc a is found on the eye surface, i.e., corneal epithelial cells. together, these results and the varied slc a physiology suggest that several epithelial function models will need to be re-evaluated to incorporate an electrogenic cl --hco exchanger and/or another apical anion channel. (support: romero- g , sindic- f ). a tgfβ- polymorphism modifies severity of cystic fibrosis lung disease in the setting of ∆f cftr homozygosity (drumm et al., nejm, ) . the mechanism(s) underlying this observation, and whether elevated or repressed tgfβ are responsible, are not known. in addition, the pathogenic role of tgfβ in other cf organs and in murine models of the disease has not been well studied. because the tgfβ codon cc genotype is associated with worsened cf pulmonary prognosis, and since high levels of tgfβ are also known to suppress cftr mrna expression and apical cftr protein expression in colonic epithelia (howe et al., exp cell res, ) , we developed a mouse model to test tgfβ/cftr interactions that may directly influence cf phenotype. we bred ∆f heterozygous mice (cftr tm kth , ∆f cftr) against the tgfβ receptor-deficient murine strain (mtrii ). mtrii mice express a dominant-negative mutant form of the tgfβ type ii receptor which lacks the intracellular (kinase) receptor domain. the receptor binds tgfβ, but fails to transmit a tgfβ dependent signal. the tgfβ receptor transgene was inserted downstream of a metallothionein-derived promoter and expressed in numerous murine tissues following induction with mm znso in drinking water. an antibody raised against active tgfβ (lc- - - , gift of dr. kathy flanders, national cancer institute) was used to establish tgfβ in murine tissues including lung and intestinal tract of the mtrii strain. rt-pcr confirmed high level transgene expression similar to gapdh internal control. nasal potential difference measurements in cftr +/+ mice expressing the tgfβ transgene indicated intact camp dependent cltransport following induction of the dominant-negative receptor. homozygous cf animals deficient for tgfβ signaling have recently been obtained and exhibit the expected litter sizes and distribution of the ∆f allele. studies of cf homozygous mice following induction with znso are in progress, and will be used to determine whether a failure to signal through tgfβ in vivo ) influences the severity of cf intestinal disease, ) alters airway or intestinal bioelectric findings characteristic of cf, or ) changes survival, histopathology or other features of the disease. these experiments are intended to provide an in vivo means of investigating tgfβ signaling and resultant cf modifier effects in vivo. supported by nih and cff. objective: to determine if the abpa phenotype observed in cftr mice was preventable by corrective gene replacement, we delivered aav cftr to the lung. in addition to further assess whether cftr-/-lymphocytes alone where responsible for the phenotype, we performed adoptive transfers of cftr-/-lymphocytes into cftr+/+ mice and proceeded to expose the mice to the abpa model. design/methods: cftr-/-mice underwent it administration of raav cftr or raav gfp. all mice were then sensitized with ug of crude af antigen via intraperitoneal route. non-injected mice were sensitized without prior virus exposure. challenges were performed on all mice, using an af solution delivered by aerosol inhalation in a closed chamber on consecutive days. serum ige levels were then obtained, as well as bronchoalveolar lavage fluid for differential cell counts, histologic and cytokine analysis. adoptive transfer experiments were done using spleens cells isolated from af sensitized delaf -/-and f +/+ mice and transfer into c /bl _rag-/-mice. after weeks post transfer c /bl _rag-/-mice with f -/-and f +/+ lymphocytes were then challenged with af. results: following challenge with af, raav -cftr mice had significantly lower total serum ige levels ( , ) as compared to raav -gfp controls ( , ) (p= . ). analysis of af-specific ige also revealed a two-fold reduction in the mice receiving the corrective gene therapy. curiously, gene transfer to the lung lowered the secretion of inflammatory cytokines from activated splenocytes of raav -cftr when compared to raav -gfp controls. these results suggest that correction of immune cells in the lung that traffic to the spleen may be partially responsible for the attenuation of the phenotype. in addition the transfer experiments showed that the hyper-ige syndrome can be partially transferred into b rag-/-by f -/-splenocytes. conclusions: correction of cftr deficiency by aav lung transfer attenuates the inflammatory phenotype associated with abpa. epithelial cells lining the vas deferens express cyclooxygenase (cox) when exposed to testosterone in vivo, although no functional link to ion transport has been established. we hypothesized that testosterone modulates cftr-mediated anion secretion across vas deferens epithelia that is stimulated via cox-dependent pathways. vas deferens epithelial cells were isolated from human and porcine tissues and cultured as monolayers on permeable supports until assayed in modified ussing chambers. rna was isolated concurrently for semi-quantitative gene expression analysis. bradykinin (bk) caused an increase in anion secretion (measured as short circuit current) and this effect was inhibited by indomethacin, which indicates cox dependency. testosterone treated monolayers exhibited a bkinduced response that is % greater than paired vehicle treated monolayers. qrt-pcr revealed that cox- mrna is times more abundant than cox- mrna in cultured vas deferens epithelial cells. the effects of bk on ion transport are inhibited by the b receptor antagonist hoe while the b receptor agonist des-arg -bk produced no effect. prostaglandin e and selective agonists of the ep ( -oh-pge ) and ep (butaprost) receptors produced concentration dependent increases in short circuit current whereas sulprostone, an agonist of ep and ep receptors, had no effect. taken together, these results suggest that testosterone plays a key permissive role for bk-stimulated anion secretion by inducing cox- expression. bradykinin acts at the b receptor to increase cox- activity and the synthesis of prostaglandins that ultimately bind to ep receptors to promote cftr-dependent hco -and cl-secretion that would be expected to modify the environment for sperm. the results further suggest that developmentally associated increases in testosterone levels during gestation and puberty will produce physiological changes in vas deferens luminal environment that are likely compromised in cystic fibrosis patients. supported by cystic fibrosis foundation schult po and ksu cobre nih rr- . background: recent studies in cystic fibrosis (cf) suggest a prominent t h profile; a facet that may interfere with normal bacterial clearance. this phenotype appears to increase secondary to infection with aspergillus fumigatus or pseudomonas aeruginosa and also, may interfere with macrophage activation. these same characteristics are present in cftr-deficient mice (cftr s x -/-fabp-hcftr (+/+), hereafter designated cf mice). as a study of pathogenesis of cf related diabetes (cfrd), we previously observed increased il- and splenocyte proliferation in cf mice subject to streptozotocin-induced hyperglycemia. herein, we hypothesized that differences in glucose concentration would increase t h profiles of splenocytes in vitro. methods: cf mice and c bl/ j mice (b mice; n= /group) were sacrificed at wk of age. splenocytes were collected and cultured at the following glucose concentrations: , , and mm. each mouse and glucose concentration was stimulated with cona, lps and cd /cd . supernatants were collected at hr and measured by luminex analysis. statistical analysis was performed by a one-way anova. results: stimulation by cona produced increased levels of il- , il- , tnf-a, gm-csf and il- in splenocytes of cf mice (p< . for all). stimulation by lps produced decreased concentrations of il- in cf mice(p< . ). stimulation of cf mice by cd /cd produced decreased concentrations of il- (p< . ). interestingly, no difference was observed in cytokine elaboration as a function of glucose concentration. data are presented in table as fold increase of cytokine concentration for cf mice compared to b mice. discussion: profound differences in cytokine production were measured in stimulated splenocyte responses of cf in comparison to b mice. the profiles did support the notion for a prominent t h response, with the potential to interference of normal macrophage activation. in addition, differences in cytokine production profiles appear related to the nature of adaptive and innate stimuli provided (cona vs. lps). the absence of influence by glucose concentration in vitro suggests that local/immediate concentration of glucose is not relevant to prolonged expression of cytokine responses to stimuli. further studies on the impact of chronic hyperglycemia and its relation to immune response are necessary. an improved understanding of these mechanisms holds hope for a better overall outcome in patients with cf and cfrd. studies from different laboratories to characterize ∆f cftr clchannel activity have yielded disparate results, likely due to variations in technique, cell type, or method of analysis. in the present study, we compared ∆f cftr activation in two well characterized polarizing cell models. fisher rat thyroid (frt) cells have been used in high-throughput drug screening to identify ∆f cftr active agents, whereas cfbe ocells have been transduced to provide robust ∆f cftr expression in an airway epithelial background. ∆f cftr biogenesis following low temperature correction was compared, indicating qualitatively similar levels of cftr transcripts and band b and c cftr. in paired studies in ussing chambers, distinct differences in isc were seen following exposure to cftr activating stimuli. in frt cell monolayers grown at °c, forskolin ( µm) or genistein ( µm) were strong stimuli of isc, producing mean isc of . +/- . (forskolin) and . +/- . (genistein) µa/cm . regardless of exposure sequence, both agents induced equivalent changes in maximal current ( % of . µa/cm by forskolin when administered prior to genistein; % of . µa/cm by forskolin in converse order). growth at °c for hours increased currents approximately . fold, but relative contributions of the two stimuli were similar to cells grown at °c ( % of total current stimulated by forskolin). in cfbe o -∆f cells grown at °c, forskolin-dependant currents were minimal and genistein-stimulated currents small ( . +/- . µa/cm , compared to zero current in parental, nontransduced cfbe ocells, p< . ). in temperature-corrected ∆f cfbe ocells, forskolin was a poor stimulus of cl-transport relative to genistein, contributing % to the total current produced by both agents (p< . ). genistein-stimulated currents did not require pre-treatment with forskolin to produce maximal effects ( . µa/cm with genistein alone vs. . µa/cm after forskolin and genistein), and forskolin did not cause further isc when added after genistein ( µa/cm ). levels of camp did not account for these differences, since forskolin markedly increased camp in both models. to determine whether excessive phosphodiesterase (pde) or phosphatase (pp) activity limited ∆f cftr activation by forskolin in the cfbe o -∆f cells, monolayers were pretreated with the nonspecific pde inhibitor papaverine ( µm) or the pp inhibitor endothall ( µm), each sufficient to activate isc in cfbe oexpressing wtcftr (papverine: . vs. . µa/cm with vehicle, p< . ; endothal: . vs. . ua/cm , p= . ). neither agent restored isc in ∆f cfbe oby forskolin ( . mv difference, p=ns). these results indicate that activity of ∆f cftr in polarizing monolayers is exquisitely dependant on the model chosen for study. substantial differences in ∆f cftr behavior in two commonly used cell models, and suggest that the failure of camp to activate ∆f cftr in cfbe ocells is due to cell-specific factors that may ) influence ∆f cftr folding and tertiary structure, or ) favor interactions of ∆f cftr with inhibitory binding partners that limit activation by camp. adverse immune responses to viral vectors or vector-encoded proteins may hinder the practical application of gene therapy. to date, little effort has been devoted to determining the immunological consequences of topically delivered lentiviral vectors to respiratory epithelia. previously, we demonstrated that an integrating feline immunodeficiency virus-based lentiviral vector pseudotyped with a baculoviral envelope glycoprotein (gp -fiv) readily transduced differentiated airway epithelia in vitro when applied to the apical surface. furthermore, using a luciferase reporter gene and bioluminescence imaging, we observed in vivo gene transfer to murine nasal epithelia following a single application of gp -fiv. longitudinal bioluminescence analysis documented persistent expression in nasal epithelia for greater than months without significant decline. by histological analysis, surface epithelial cells were transduced following a single nasal application of gp -fiv expressing beta-galactosidase. importantly, we observed that consecutive doses of gp -fiv delivered over consecutive days greatly increased the number of beta-galactosidase positive epithelial cells. using quantitative bioluminescent imaging, we observed that repeated doses given over consecutive days resulted in a linear additive increase in gene expression. in addition, we performed studies investigating gene transfer efficacy and immune responses following lentiviral vector readministration with greater intervening time periods. in control mice, we observed that giving nasally instilled doses ( weeks apart) of an e /e deleted ad vector resulted in significantly attenuated expression after the second dose. the attenuated expression correlated to the production of neutralizing antibodies. in contrast, using the same delivery protocol, doses of gp -fiv resulted in gene transfer without loss of expression of the forth dose. no significant production of neutralizing antibodies was observed following the lentiviral delivery protocol. we further report the additive increase in reporter gene expression following doses of lentiviral vector delivered over consecutive weeks ( dose/week), as well as the lack of production of systemic and local neutralizing antibodies. gp -fiv efficiently transduces and persistently expresses a transgene in respiratory epithelia and has the potential for repeat administration without eliciting adverse immune responses. these data have important implications for the application of lentiviral gene therapy to pulmonary diseases. uniform delivery of gene therapy vectors to all lung lobes is important for cf gene therapy. however, this important objective has not been achieved in large animals. to address this obstacle, we have developed an approach to specifically deliver vector into all lung lobes. in this strategy, an intracorporeal nebulizing catheter (aero-probe) is inserted into a bronchoscope to permit visual targeted aerosolization of vector specifically into each lung lobe. using this approach, ml of . % lpc (to transiently open tight junctions) containing x vp of hdad-k lacz was sequentially aerosolized into each of the six major lung lobes of a baboon. aerosolization was triggered by the ventilator upon inspiration at . ml/pulse at a rate of to pulses/min. halfway through the procedure a very slight, transient and fluctuating decrease in oxygen saturation of no more than % was noted that did not warrant supplemental oxygen. the entire procedure was otherwise uneventful and well tolerated with no clinical manifestations of toxicity. no changes in chest x-rays taken at h, h and at necropsy h post-vector were observed compared to baseline. x-gal staining of the lungs at h revealed extensive transduction of the epithelium in the large and small airways in all six major targeted lung lobes. x-gal histochemistry revealed substantial transduction that was exclusively restricted to the airway epithelial cells and submucosal glands, the target cells for cf gene therapy. assessment of the proximal major bronchi from each lung lobe revealed that~ % of the airway epithelial cells were transduced in the left upper lobe (lul), ≥ % were transduced in the lml, lll, rul, rml and rll, and~ % were transduced in the accessory lobe. approximately % of the airway epithelial cells in the tracheal sections examined were transduced. we also investigated the duration of pulmonary transgene expression. in these studies, we aerosolized a hdad expressing the baboon α-fetoprotein from the k promoter into the lungs of baboons. by measuring serum bafp levels, we found that pulmonary transgene expression from transduced airway epithelial cells can be detected for at least days post-vector. these results demonstrate for the first time that exceedingly high levels of transduction of the airway epithelial cells and submucosal glands throughout all lung lobes in a large animal can be achieved with negligible toxicity resulting in long term trangene expression and should pave the way towards successful clinical cf gene therapy. inefficient gene transfer after repeat administration of most viral vectors has limited their suitability for cf gene therapy. however, lentiviral vectors are reported to be less immunogenic. this property combined with their capacity to integrate into the genome of transduced cells and, therefore, allowing gene expression for the life-time of the cell (approximately months for airway epithelial cells and theoretically unlimited for stem cells) justify further investigation of these vectors for cf gene therapy. to ensure high transduction efficiency in the lung without the need for any pre-conditioning strategies we pseudotyped a simian immunodeficiency virus (sivagm)-based vector with the sendai virus f and hn proteins (f/hn-siv-gfp) and transduced mouse nasal epithelium ( x e tu/mouse). at this titre transduction efficiency along the nasal septum was up to % when measured and days after transduction (n= /time-point). the vast majority (approx. %) of gfp positive cells across all time-points were respiratory epithelial cells followed by neuronal and sustenticular cells (approx. %) in the olfactory epithelium. interestingly, we observed two types of duration patterns of gfp expression in mouse nose. in some mice the number of gfp positive cells decreased over time (day : ± cells/section, n= , day : ± cells/section, n= ). however, in other mice strong gfp expression persisted for up to days (day : ± cells/section, n= ), significantly longer than the proposed life-span of airway epithelial cells. in order to support the idea of f/hn-siv integration into nasal respiratory stem/progenitor cells we artificially induced cell division after siv vector transduction by damaging the nasal tissue with the detergent (polidocanol), which strips of the epithelium within a few hours, while retaining the basal cell layer. the epithelium completely regenerates over the course of a few days. seven and days after the vector transduction ( x e tu/mouse, n= ) the nasal tissue was perfused with % polidocanol ( µl/mouse) and gene expression was analyzed weeks after the last detergent treatment. gfp expression was detectable in various cell types of the regenerating epithelium including ciliated and basal cells. importantly, gfp-expressing cells were more clustered after polidocanol treatment, possibly indicating origination from a common progenitor. these data suggest that, f/hn-siv integration may have occurred into differentiated airway epithelial cells as well as into stem/progenitor cells involved in the regeneration of the airway epithelium. introduction: hypersecretion of mucus is a major cause of airway obstruction in cystic fibrosis, asthma and chronic bronchitis. though mucus is a complex, non-homogeneous mixture of secretions, one group of its constituents, the mucous glycoproteins or mucins, contributes greatly to the obstruction associated with airway diseases. currently, there are a limited number of therapeutic agents available for controlling mucin overproduction and hypersecretion. the objective of this study is to develop a sensitive, cost-effective technique for reliably quantifying total mucin concentration in a robust mucin-secreting cell line for use in high throughput screening of small molecule compounds with potential to inhibit mucin secretion. methods: an enzyme-linked lectin assay (ella) was adapted using a lectin from helix pomatia (hpa), which binds specifically to n-acetylgalactosamine residues. bovine sub-maxillary mucin was used for test development and later, as a mucin standard. the test sample was "sandwiched" between hpa pre-coated onto -well microtiter plates and biotinylated hpa lectin. the plate was developed with a fluorescent hrp substrate, and measured at nm using a standard fluorescence plate reader. using the ella, a number of carcinoma (hm , a , ls , nci-h ) and immortalized lung epithelial ( hbe, cfsme) cell lines were tested to determine their responsiveness to various secretagogues. preliminary experiments indicated that the nci-h cells, derived from a human mucoepidermoid lung carcinoma, were most suitable for adaptation to high throughput studies. nci-h cells were seeded into -plates at a density sufficient to produce confluence in approximately hours. then, individual wells were incubated for hour in either control or secretagogue-containing media. supernatants were collected and mucin concentration of individual wells was determined using the ella. results: optimization of the ella provided a sensitive calibration curve from ng/ml to . mg/ml. mucin secretory ratios (sr) were calculated by comparing mucin release from test and control wells. significant (p ≤ . ) secretory ratios were obtained following incubation with utp at µm ( . ± . ), vip at nm ( . ± . ), carbachol at . mm ( . ± . ), interleukin- β at ng/ml ( . ± . ) and heparin-binding egf-like growth factor at ng/ml ( . ± . ); all data expressed as sr ± sem, n = . histamine at µm did not result in significant mucin secretion. conclusion: a relatively simple and economical assay has been developed for high throughput screening of small molecules for detecting their effects on mucin secretion. cystic fibrosis (cf) is the most common lethal genetic disease in north america, where it occurs with a frequency of one in ~ live births. it is caused by mutations in the cystic fibrosis transmembrane conductance regulator (cftr) gene, the most common being the deletion of phenylalanine (delf ). the delf mutation causes a folding defect that inhibits maturation and trafficking to the plasma membrane, however the mutant still functions as a chloride ion channel when delivered to the plasma membrane, and partial rescue ( - %) may be sufficient to alleviate disease symptoms. thus cftr is an attractive target for the development of pharmaceutical therapies. we recently described a novel, cell-based assay for protein trafficking which directly monitors expression of delf cftr on the surface of baby hamster kidney (bhk) cells and is suitable for high throughput screening of small molecule libraries. in this study we have extended the approach to natural products by studying extracts derived from marine sponges that were collected from the coasts of indonesia and papua new guinea. sponges are a particularly rich source of novel bioactives and secondary metabolites. iterative use of our high throughput assay and chemical deconvolution of active fractions yielded four alkaloids jmcg , jmcg , jmcg and jmcg . these compounds caused a detectable increase in delf cftr trafficking to the plasma membrane within h, and after exposure to pm for h all four increased surface delf cftr expression - % and enhanced camp-stimulated halide conductance. we tested a series of analogues of the alkaloids and found three others jmcg , jmcg and jmcg that also caused trafficking correction and functional ion channels in the plasma membrane. these results were confirmed in functional studies of the human bronchial epithelial cell-line cfbe stably overexpressing delf cftr. these compounds increased surface delf cftr by - % within h when treated with nm. these results identify a promising group of delf cftr trafficking correctors that are now being actively pursued as potential pharmacotherapeutics for cystic fibrosis along with other hits from compound library screening campaigns. work supported as part of the breathe program jointly funded by the ccff and cihr, and grants from cystic fibrosis foundation therapeutics, (cfft). kim chiaw, p. , ; bear, c.e. background/rationale: biosynthetic misprocessing of the major cf mutant ∆f -cftr has been proposed to result from the disruption in domain-domain interactions (du et al. nature struct and mol biol, ) that may lead to the exposure of di-arginine (rxr) retention/retrieval motifs. simultaneous site directed mutagenesis of all four rxr motifs to rxk or kxr motifs overcame retention and promoted cell surface expression of ∆f -cftr (chang et al. mol cell, ) . we hypothesize that it is possible to compete inhibitory interactions with rxr motifs exposed in ∆f -cftr by delivering synthetically derived cftr peptides bearing one or a combination of rxr motifs (cf-rxr), each conjugated to cell penetrating peptides (cpp) to permit intracellular delivery. results: confocal immunofluorescence microscopy confirms that alexa- -tagged cpp-cf-rxr peptides can be taken up rapidly (within min) by bhk cells stably expressing recombinant human ∆f -cftr. fluorophore-conjugated peptides appear to be concentrated in vesicular compartments, consistent with the current hypothesis that cpp-peptides enter cells into endosomal vesicles via macropinocytosis from which efflux into the cytosol occurs (wadia et al. nature med, ) . we determined that treatment of cell cultures with cpp-cf-rxr peptide at a final concentration [ µm] for minutes is effective in inducing cell surface functional expression of human ∆f -cftr in bhk cells as observed by a . -fold increase in cyclic amp-mediated iodide efflux over control ∆f -cftr (n= ; p < . ). this rescue is specific to the cf-rxr peptide as controls (cpp alone or peptides bearing a kxk motif in place of rxr) show no functional rescue of ∆f -cftr (n= ; p > . ). preliminary cyclic ampmediated iodide efflux results also indicate that ∆f -cftr functional rescue by cpp-cf-rxr peptide is as effective as temperature ( o c) rescue. although we hypothesize that the peptide acts to facilitate trafficking of the major mutant to the cell surface, immunoblotting studies fail to show a clear conversion of the er-form (band b) to the fully processed, band c form of the protein. currently, we are developing more sensitive assays of cell surface expression as well as evaluating the possible efficacy of this peptide in potentiating function of ∆f -cftr. discussion: future efforts include investigating the relative efficacy of peptides corresponding to the four different rxr motifs in rescuing ∆f -cftr trafficking. the promising candidate described above is currently being evaluated with respect to functional rescue of the major mutant in primary human bronchial epithelial cells obtained from patients homozygous for ∆f -cftr (joseph zabner and phil karp, university of iowa) and in cftr-∆f mice. these studies may provide the basis for future pre-clinical studies of peptide based therapies of cystic fibrosis (supported by ccff (breathe program grant) and cihr -(strategic training program in the structural biology of membrane proteins linked to disease)). several promising methods of promoting ∆f cftr escape from er degradation increase cftr chloride channel activity at the cell surface. however, increasing data from a number of laboratories indicate that in both epithelial and non-epithelial cell lines expressing ∆f cftr, the rescued chloride channel is unstable at the cell surface compared to wild-type cftr. small molecule correctors have therefore become a widely used approach to enhance ∆f cftr function at the cell surface. in most cases, the exact mechanism of these promising compounds has not been established. in the present study, we use stably transfected, polarized cfbe o-cells to elucidate the effect of two of these compounds, cfcor- and corr- a, on the surface stability of wild type and low temperature rescued ∆f cftr. specifically, we cultured cells expressing ∆f cftr at c for hours to establish a large pool of surface-expressed ∆f cftr; we then monitored cftr internalization rates and half-life with and without small molecule treatment using surface biotinylation-based assays, performed as described previously (jurkuvenaite et al. j. biol. chem. : , ) . as a control, internalization and half-life of transferrin receptor was also followed. our results indicate that both cfcor- and corr- a slow ∆f cftr endocytosis from ~ %/ . min to ~ %/ . min, and this is similar to wild type cftr internalization rates. neither wild type cftr nor transferrin receptor internalization rates were affected by corrector treatment, suggesting that the effects of the correctors were specific for ∆f cftr. in the surface half-life studies, both correctors doubled ∆f cftr halflife from to hours, but they did not correct the half-life to wild type levels (~ h). again, the correctors had no effect on either wild type cftr or transferrin receptor surface half-lives. our results suggest that small molecule correctors may not only rescue cftr from erad during biogenesis, but can contribute to the stabilization of ∆f cftr at the cell surface, and this effect seems to be ∆f cftr-specific. the ∆f mutation in cftr causes defects in chloride channel gating and cellular processing. cell cultures models suggest the need for both a potentiator and corrector to restore ∆f -cftr channel function and processing, respectively. previously, we identified several classes of potentiators, including 'phenylglycines', which probably bind to cftr at the cell surface and restore normal channel gating (pedemonte et al., mol. pharm. ; : - . we also identified several classes of correctors, including 'bisaminomethylbithiazoles', which may bind to ∆f -cftr in the er and partially restore its folding and plasma membrane targeting (pedemonte, et al., j. clin. invest. ; : - . these compounds were identified from screening a diverse collection of , small molecules; the most active potentiator was phenylglycine pg { -[( - h-indol- -ylacetyl)-methyl-amino]-n-( -isopropylphenyl)- -phenyl-acetamide} and the most potent corrector was the bisaminomethylbithiazole corr- a {n- ( -[ -chloro- -methoxyphenylamino]- '-methyl- , '-bithiazol- 'yl) benzamide}. here we synthesized and characterized a hybrid molecule (corr- a-linker-pg ) containing both corrector and potentiator fragments. based on sar data of potentiators and correctors, a hybrid molecule was designed that incorporated an enzymatically hydrolysable linker to generate and deliver the potentiator and corrector-linker fragments. using synthetic organic chemistry we synthesized a hybrid molecule containing a pg -oh moiety and a corr- a-linker-cooh moiety, linked with an ethylene glycol spacer through an ester bond. the potentiator and corrector fragments (after cleavage) had low micromolar potency or better. however, the intact hybrid molecule was inactive, likely because of its large size ( daltons) and hence poor cell penetration. as proof-of-principle evidence that the hybrid molecule can be hydrolyzed to the active fragments, treatment with carbonic anhydrase or rodent stool specimens gave the appropriate potentiator and corrector-linker fragments identified by lcms. smallmolecule corrector-potentiator hybrids have potential utility as single drug therapy for cf caused by the ∆f mutation. supported by cff and nih. cftr is a chloride channel gated by atp binding and hydrolysis at its two nucleotide binding domains (nbd and nbd ). the two nbds may dimerize in a head-to-tail configuration, as observed in other abc transporters, forming two atp binding pockets (abp and abp ), with the atp molecules buried at the dimer interface. abp , formed by the walker a and b motifs of nbd and the signature sequence of nbd , was proposed as the site critical for the atp-dependent opening of the cftr channel, while abp (consisting of the walker a and b motifs of nbd and the signature sequence of nbd ) may contribute to the stabilization of the open channel conformation. g d, the third most common cf-associated mutation, is characterized by a very low open probability, and patients carrying this mutation present a severe phenotype. this mutation is located in the signature sequence of nbd (and thus in abp ). we have recently characterized this mutant channel and found that its low activity is atp-independent. this behavior corroborates with the idea that the occupancy of abp by atp is crucial for catalyzing the opening of the channel. interestingly, we now found that a high affinity atp analog, n -( -phenylethyl)-atp (p-atp), increases g d currents primarily by increasing the open time of the channel. this effect of p-atp is reduced when p-atp was applied together with atp, suggesting a competition between atp and p-atp for a common binding site. introducing the mutation y g (located at abp ), which reduces by more than -fold the atp-binding affinity in wild-type channels, does not alter the effect of p-atp in the g d/y g mutant. in contrast, when we introduce the mutation w g (located at abp ) in the g d background, the effect of p-atp is reduced remarkably, suggesting that abp is the binding site where p-atp binds to increase the activity of g d channels. these new results further confirm the idea that nucleotide binding at abp could stabilize the open channel conformation. since the competition experiments show that atp and p-atp are readily exchanged in the binding site, we conclude that the atp molecule is not occluded in abp , at least under the g d background. our observation that p-atp enhances the g d activity by binding at abp implicates that abp can potentially be a target for drugs to bind and increase the channel activity. supported by cff grant to s. bompadre and nih grants to t.-c. hwang (hl r , dk r ) and s. bompadre (dk k ). van goor, f.; hadida, s.; grootenhuis, p. vertex pharmaceuticals, san diego, ca, usa several cf-causing mutations, including ∆f , g d, and r h, cause gating defects in cftr that decrease the open probability (po) of the channel, resulting in decreased cl-secretion across epithelia of multiple organs, including the lung. a therapeutic strategy for the treatment of cf is to develop pharmacological potentiators that increase po leading to increased fluid transport in affected tissues. vx- was identified through cell-based screening and chemistry optimization as a potent potentiator of cftr, including ∆f -, g d-, and r h-cftr. in single-channel recordings of cftr expressed in fisher rat thyroid cells, vx- increased the po of ∆f -cftr from . ± . to . ± . . the po of g d increased from . ± . - . ± . . these levels are similar to the po of wild-type cftr, indicating that vx- restores normal gating at the single channel level. to assess the potency and efficacy of vx- in native airway cells, cl-secretion was monitored in ussing chamber studies using human bronchial epithelia (hbe) cultured from the bronchi of cf and non-cf donors. in the absence of the potentiator vx- , cftr-mediated clsecretion in ∆f /∆f or g d/∆f -hbe reached a maximum amplitude of . ± . and . ± . ua/cm , respectively. this is ~ % of that observed in wild-type-hbe ( ± ua/cm ) and consistent with the low level of residual cftr activity reported in some individuals with severe cf disease. in ∆f /∆f -hbe, vx- caused a -fold increase (peak response; . ± . ua/cm ) in cftr mediated cl-secretion with an ec of ± nm, whereas in g d/∆f -hbe, cl-secretion increased fold (peak response; ± ua/cm ) with an ec of ± nm. the improved efficacy observed in g d/∆f -hbe is consistent with a higher cell surface density of g d-cftr compared to ∆f -cftr, which has defective trafficking to the cell membrane. vx- was found to be highly selective for cftr and to have good oral bioavailability in multiple species with a half-life of - hours. the biological and pharmacokinetic data support the clinical development of vx- for the treatment of cystic fibrosis. we would like to acknowledge the cfft for their support and dr. joseph pilewski for providing cf hbe. the pari eflow ® rapid nebulizer is a member of the "soft mist" inhaler class for the administration of aerosolized antibiotics that eliminates the need for a compressor. objectives: to compare the pharmacokinetics and safety of tobramycin inhalation solution (tobi ® ) delivered via the pari eflow ® rapid electronic nebulizer vs the pari lc ® plus jet nebulizer with compressor. methods: we compared tobramycin levels in sputum and serum, incidence of bronchospasm and frequency of adverse events (ae) of mg tobi, administered twice-daily for weeks from these two delivery systems in a randomized, crossover study in cystic fibrosis patients. blood and sputum samples were collected over a dosing interval after the first and last dose on each device (days and ). tobramycin serum and sputum area under the concentration-time curves (auc) were derived and the therapeutic ratio (mean sputum auc / mean serum auc) calculated. pulmonary function tests were performed before and min after nebulization on days and , and ae were recorded. results: the total nebulization time was reduced by half for the pari eflow rapid vs pari lc plus ( . ± . min vs . ± . min [p< . ] on day , and . ± . vs . ± . [p< . ] on day , respectively). tobramycin predose serum levels > µg/ml or cmax > µg/ml, predefined as a potential for increased risk of systemic toxicity, were not exceeded in any patient during use of either nebulizer. as tabulated below, mean systemic exposure to tobramycin from the pari eflow rapid on day was slightly lower, by %, whereas mean sputum exposure was higher, by %, compared with the pari lc plus. consequently, the therapeutic ratio was nearly -fold higher for the pari eflow rapid due mainly to higher sputum concentrations. adverse events occurred in patients using the pari lc plus nebulizer (primarily headache and abdominal pain) and in patients using the pari eflow rapid nebulizer (primarily headache, cough, dyspnea). on day , no clinically relevant bronchospasm (defined as ≥ % decrease in fev ) was observed for either treatment. the mean percentage change in fev at mins from predose on day was - . % for the lc plus and - . % for the eflow rapid. conclusions: tobi delivered via the pari eflow rapid electronic nebulizer required shorter delivery times with similar safety and a higher therapeutic ratio (sputum/serum exposure) compared with the pari lc plus jet nebulizer. sponsored by novartis pharma ag which acknowledges support from pari gmbh introduction alpha- antitrypsin (aat) is a protein protecting lung tissues by inhibition of neutrophil elastase. the function of neutrophil elastase is to digest bacteria and other foreign objects in the lungs. in a person deficient of aat, the neutrophil elastase acts uncontrolled, destroying healthy tissue. the result of the damage is emphysema, which progresses if not treated. patients show a specific impaired breathing pattern of short inhalation followed by prolonged exhalation. current therapy consists of weekly i.v. infusion of aat of about - mg/kg body weight. by this method only about % of the administered dose is estimated to reach the lungs. since aat can currently be derived only from human blood serum by an expensive purification process, the worldwide supplies are limited and do not allow to treat all patients. an improvement of the delivery efficiency is highly desirable. inhaled treatment would offer a targeted therapy by delivering aat directly to the lungs and allow for a better use of the limited drug. the eflow ® , a novel electronic nebulizer, is more efficient than conventional nebulizers. it operates by means of a perforated vibrating membrane, applying no or only little stress to the nebulized substances. hence it is well suited for the pulmonary delivery of proteins. it has been shown previously, that a % aat solution can be nebulized by eflow ® without a loss of biological activity. we investigated two eflow ® configurations comparing the in-vitro delivered dose for different breathing patterns. method a highly purified % aat preparation (kamada ltd, rehovot, israel) was aerosolized with the eflow ® electronic nebulizer. initial studies were conducted using the l configuration of eflow ® . delivery performance is compared to a specially designed xl configuration, with increased aerosol chamber volume. aerosol delivery efficiency was determined by breath simulation using an emphysema breathing pattern (tidal volume ml, breaths/min, inh:exh ratio = : . ) generated by a pari compas™ breath simulator. as reference, a standardized regular breathing pattern (tidal volume ml, breaths/min, inh:exh = : ) was also investigated. the respirable fraction (drug in droplets < and . µm) was determined using the andersen cascade impactor at . l/min. samples were analysed for aat activity by an elastase inhibition assay. when the eflow ® l configuration was investigated for the standardized breathing pattern, a delivered dose (dd) of ± % of the loaded dose ( mg) was found. this value was reduced to ± % when the emphysema pattern was applied. with the new eflow ® xl configuration an improved dd of ± % was obtained. furthermore, when the emphysema pattern was applied, the dd did not drop strongly, but remained at values above %. with % of aerosol droplets in the respirable size range (< µm) and % < . µm, a high % of aat can be expected to reach both, the central and peripheral lungs of patients. conclusion inhaled aat has the potential to significantly improve the efficiency of aat replacement therapy. a customized eflow ® electronic nebulizer produced delivered doses > % even when breathing patterns of patients with impaired breathing capabilities were mimicked. the formulation is optimized for rapid aerosol administration through use of higher drug concentrations and is taste-masked. this study was conducted to evaluate the aerosol performance of novel higher dosed levofloxacin inhalation solutions in a customized eflow ® electronic nebulizer. methods two concentrations of mp- ( mg/ml and mg/ml of levofloxacin) were nebulized at fill volumes of and ml using the eflow ® l nebulizer configuration. the in-vitro delivered dose (dd) was determined by breath simulation using a standardized breathing pattern (tidal volume ml, breaths/min, inh:exh ratio = : ) generated by a pari compas™ breath simulator. the geometric droplet size distribution was determined by laser diffraction (ld). the aerodynamic droplet size distribution was determined using the andersen cascade impactor (aci). the invitro respirable dose (rd) was calculated by multiplying the respirable fraction (rf, %droplets < µm) derived from the cascade impaction experiment and the dd derived from breath simulation. nebulization time was determined by the electronic shut-off of the eflow ® control unit. all tests were conducted for three devices in duplicate, each (n= ). the eflow ® electronic nebulizer delivered mp- at both concentrations and fill volumes with equal efficiency, obtaining in-vitro dds of around ± %. the average nebulization times were between and minutes for the ml fill volume and between and minutes for the ml fill volume and were also independent of the concentration in the investigated range. determination of the mass median diameter (mmd) by ld resulted in values between . and . µm. values of the mass median aerodynamic diameter (mmad) obtained by cascade impaction were similar (between . and . µm). the average respirable fraction was in the range between % and % for both experimental methods. conclusion the eflow ® electronic nebulizer can be customized to deliver high doses of mp- . the short nebulization times achieved are patient friendly and should support high patient compliance. mp- , with the potential for once daily administration, provides significant advantages over currently avail-able aerosol antibiotics. clinical evaluation of mp- delivered by the eflow ® nebulizer in cf patients is in progress. lavange, l. ; engels, j. ; accurso, f.j. . university of north carolina, chapel hill, nc, usa; . inspire pharmaceuticals, inc., durham, nc, usa; . university of colorado, denver, co, usa introduction: percent change from baseline in a continuous outcome variable, such as lung function, is a useful descriptive measure in therapeutic clinical trials. while often favored by clinicians as the primary efficacy measure, the use of percent change as the basis for statistical comparisons raises a number of issues. defined as *(post-pre)/pre, where pre and post represent baseline and follow-up values, respectively, percent change is a ratio of random variables and as such, does not follow a normal distribution. analyzing percent change with standard methods can result in inefficiences and may be inappropriate without a suitable transformation (e.g., logarithmic). furthermore, the treatment effect estimated on the transformed scale is difficult to interpret. the purpose of this abstract is to describe an alternative method for analyzing percent change and illustrate its utility in cf clinical trials. methods: probability plots are generated to compare the distributions of percent change in fev from baseline to study endpoint among treatment groups. the plots are similar to kaplan-meier curves, with percent change on the horizontal axis in lieu of survival time. the percentage of patients on the vertical axis depicts the cumulative percentage of patients who had a percent change at least as great as the corresponding value on the horizontal axis. a log-rank test statistic provides an overall test for any difference in distributions among treatment groups. the methods are illustrated using data from a -day, phase , multicenter, randomized, double-blind, placebo-controlled clinical trial of denufosol in cf patients with a screening fev ≥ % predicted. results: a probability plot of denufosol (active doses combined, n= ) vs. placebo (n= ) is shown below. more denufosol patients ( %) experienced improvement compared to placebo ( %). the log rank test, adjusted for study site, showed that the overall distributions of percent change in fev between denufosol and placebo were significantly different (p-value= . ). conclusions: the proposed methods provide a convenient means for assessing differences in percent change and may be useful in cf clinical trials. comparisons of both a descriptive and inferential nature can be made with minimal assumptions, thereby avoiding the pitfalls in analyzing percent change with standard techniques. the methods are easy to implement with existing software packages (e.g., sas). trial supported by inspire pharmaceuticals, inc. and cf foundation therapeutics, inc. chen, x. , ; davis, p. compacted dna nanoparticles formulated with pegylated polylysine and plasmid dna transfect airway cells in vivo at high efficiency, so they have great potential for gene therapy. the mechanism by which dna nanoparticles enter the cell and get expressed is not well understood. we previously showed that rhodamine labeled dna nanoparticles enter primary human tracheal epithelial (hte) cells within min, and accumulate in the nucleus in hr, where the transgene can be expressed. dna nanoparticles do not enter via clathrin-mediated endocytosis (cme), which leads to the degradation of internalized material in lysosomes. further characterization of the kinetics and trafficking pathway may allow us to improve the formulation of the nanoparticles and facilitate its gene delivery. as they do in hte cells, rhodamine labeled dna nanoparticles enter hela and hbeo-, an immortalized human bronchial epithelial cell line, within min, and by - hr accumulate in the nucleus, especially the nucleolus, where they colocalize with nucleolin. expression of the gfp reporter gene in the nanoparticles was observed at hr, which confirms the functionality of the labeled dna nanoparticles. cellular entry is energy dependent, as little or no intracellular rhodamine was observed at °c by hr. we also applied rhodamine labeled nanoparticles and biotin-conjugated transferrin, a marker for cme, simultaneously. little colocalization was observed during a min to hr time course, so the nanoparticles do not follow this pathway. we then found a direct and strong relationship of cell surface nucleolin and the ability of the cells to take up and express dna nanoparticles. nucleolin directly binds to dna nanoparticles with kd= . nm. manipulations of cell surface nucleolin in hela cells affect transfection of dna nanoparticles with a positive correlation. we therefore costained nucleolin in both hela and hbeo-cells treated with the rhodamine labeled dna nanoparticle. the rhodamine fluorescence colocalizes with nucleolin both in the cytoplasm at early time points and in the nucleus/nucleolus at hr and hr, which further supports that nucleolin might be associated with the nanoparticles during their trafficking. to confirm this association, we performed uptake experiments with ms- , a mouse monoclonal antibody against nucleolin, alone or with rhodamine labeled nanoparticles over a min to hr time course. the ms- antibody enters hela cells at similar kinetics to the nanoparticles. at min, we observed substantial amount of cytoplasmic staining, while nuclear staining tends to increase by time until hr. it has little or no colocalization with transferrin in the cytoplasm, which suggests that this antibody also enters the cell via a pathway other than cme. in contrast, it showed extensive colocalization with dna nanoparticles in both cytoplasm and nucleus at all time points, which suggests that cell surface nucleolin and dna nanoparticles are associated or at least in close vicinity during their trafficking inside the cell. therefore, we suggest that dna nanoparticles enter the cell by binding to cell surface nucleolin and enter the cell via the same pathway as nucleolin antibody. chen, x. , ; davis, p. dna nanoparticles are non-viral gene delivery vectors in clinical trial for treating genetic disorders including cystic fibrosis. we previously discovered that cell surface nucleolin serves as a receptor for the dna nanoparticles, and is important for their gene delivery efficiency. as nucleolin has no signal sequence or membrane-spanning domain, it is not clear how nucleolin are expressed on the outer surface of plasma membrane or what signals increase its surface delivery. we initially observed that the transfection efficiency of dna nanoparticles in hela cell decreases by . % following hr serum-free medium treatment, which reduces cell surface nucleolin by . % as determined by cell surface biotinylation and streptavidin bead pulldown. since serum depletion inhibits cell proliferation and affects cell cycle progression, we examined the level of cell surface nucleolin at different stages of cell cycle. hela cells were arrested at s phase by high concentration of thymidine, and allowed to progress synchronously through cell cycle after removing this block. surprisingly, we observed substantial increase of cell surface nucleolin at the onset of m phase, about hours after release of thymidine block. it has been reported that nucleolin is phosphorylated by a cell cycle dependent kinase (cdk) cdc , and has eight consecutive cdk phosphorylation sites. therefore it is appealing to speculate that phosphorylation by cdc might increase the targeting of nucleolin to the cell surface. we then determined the potential export signal in nucleolin by serial deletions. deletion of c-terminal aa of nucleolin, including the c-terminal glycine/arginine rich (gar) domain and the four rna recognition motifs (rrm) does not affect its arrival at the cell surface. the n-terminal aa of nucleolin is sufficient to target a gfp protein to the cell surface. in contrast, when we further delete the cdk phosphorylation sites from aa to , cell surface expression of nucleolin is significantly diminished. furthermore, nucleolin lacking the n-terminal aa is not present on the cell surface. therefore, phosphorylation on the cdk sites may serve as a signal to enhance the cell surface expression of nucleolin. there has been recent interest in dry powder inhaled mannitol as a therapeutic agent in patients with cystic fibrosis (cf). it is has been shown to increase mucociliary clearance (mcc) by airway rehydration. whilst there has been one short term clinical trial of mannitol in adult subjects [ ] , to date no studies have been conducted looking at its potential as a therapy in children with cf. it could be argued that children may have the potential to benefit most from a therapeutic agent that acts relatively proximally in the cf pathogenic pathway. the aim of this study was to determine acute tolerability of inhaled mannitol in children with cf. we recruited children (aged to years) with cf. inclusion criteria were either rhdnase treatment or an fev > % and < % of mean predicted normal value. bronchial provocation challenges with incrementally increasing doses ( , , , , , , mg) of dry powder mannitol were carried out. subjects were pre-treated with bronchodilator minutes prior to the challenge ( mcg of salbutamol or mg of terbutaline). fev was measured following each dose increase up to a maximum cumulative dose of mg. oxygen saturation monitoring was carried out throughout. a positive challenge was defined by a drop in fev of > % from baseline. these subjects received bronchodilator treatment and had spirometry repeated at minute intervals until fev returned to within % of baseline. those children with a negative challenge had spirometry repeated minutes post-completion of the challenge results mean baseline fev was % predicted ( - , sd . ). / subjects ( %) had a positive challenge. mean pd (dose of mannitol required to cause a % reduction in fev ) was mg ( - , sd ). the mean time to complete the challenge was minutes ( - , sd . ) for negative challenges and minutes ( - , sd . ) to pd for those subjects with a positive challenge. we found no association between a positive challenge and age, sex, weight, height, baseline fev , pseudomonas aeruginosa colonization, bronchodilator reversibility, previous aspergillus fumigatus sen-sitization, atopy or corticosteroid use. there was a non-significant trend for lower fef - (means . versus . ; p= . ) and higher prevalence of aspergillus fumigatus cultured in sputum at baseline ( / versus / children; p= . ) amongst those children who went on to have a positive challenge. there was no significant drop in oxygen saturation in either group. although cough was common during the challenge, other adverse events were infrequent. we find that % of children with cf could not tolerate inhaled mannitol as compared with % of adult subjects as reported in the previous study [ ] . we could not identify factors predictive of a positive mannitol challenge in these patients. the most common cause of cystic fibrosis (cf) is the deletion of phenylalanine (∆f ) in the cf transmembrane conductance regulator (cftr) chloride channel [ ] . a major problem with ∆f cftr is that the protein is defective in folding so that little mature protein is delivered to the cell surface [ ] . expression of ∆f cftr in the presence of small molecules known as correctors or pharmacological chaperones can increase the level of mature protein [ ] [ ] [ ] [ ] . unfortunately, the efficiency of correctorinduced maturation of ∆f cftr is low and other approaches are needed to increase the therapeutic value of correctors. we postulated that expression of ∆f cftr in the presence of multiple correctors that bound to different sites in the protein may have an additive effect on maturation. in support of this mechanism, we found that expression of p-glycoprotein processing mutants (cftr's sister protein) in the presence of two compounds that bind to different sites (rhodamine b and hoechst ) had an additive effect on maturation. therefore we tested whether expression of ∆f cftr in the presence of combinations of three different classes of corrector molecules would increase its maturation efficiency. it was found that the combination of the quinazoline vrt- together with the thiazole corr- b or bisaminomethylbithiazole corr- a doubled the steady-state maturation efficiency of ∆f cftr (about % of total cftr was mature protein) compared to expression in the presence of a single compound. the additive effect of the correctors on ∆f cftr maturation suggests that they may directly interact at different sites of the protein. the use of multiple correctors has the potential to increase the therapeutic value of pharmacological chaperones. pharmacol. , - . the cftr protein is expressed at the surface of the airway epithelium, where it plays a critical role in maintaining airway hydration by secretion of chloride. for gene therapy of cf lung disease to be successful, it is critical that the endogenous transgene be expressed in the correct cell type and at levels sufficient to restore normal function. the expression of high levels of cftr has resulted in cftr mediated chloride secretion in a wide range of experimental systems. however, the cell type or types that need to be corrected and the level of cftr expression required to ameliorate the pulmonary manifestations of cf are not yet clear. because cftr has been localized to the ciliated cells of human airway epithelial cells, we have been investigating the use of ciliated cell-specific promoters to improve the efficiency and safety of gene therapy for cf and other airway diseases. in previous studies a fragment of the human foxj promoter was shown to target transgene expression specifically to ciliated cells. however, expression of cftr from this promoter in transgenic cf mice did not significantly improve the cf phenotype, as measured by the nasal potential difference (pd) technique (ostrowski et al, ) . this may be due to the inability of this promoter to correct the olfactory epithelium, which comprises approximately % of the mouse nasal cavity. in cf mice, the olfactory epithelium exhibits sodium hyperabsorption and an absence of cftr mediated chloride secretion, similar to the respiratory epithelium (grubb et al, ) . in this work, we used a fragment of the ciliated cell-specific promoter foxj to drive cftr expression specifically in human ciliated cells. replication deficient adenovirus expressing either egfp or cftr from the foxj promoter were used to transduce well-differentiated cultures of human cf cells following treatment with c to disrupt tight-junctions. cultures were studied hours after treatment, and those treated with ad-foxj /egfp showed strong expression of egfp that was dependant on ciliated cell differentiation. rna analysis demonstrated strong expression of cftr from the foxj promoter, and western blotting demonstrated levels of protein that were much greater than the level in normal airway cells (> -fold). immuno-localization of cftr with specific antibodies resulted in a strong signal at the apical membrane of ciliated cells. cultures treated with ad-foxj /cftr demonstrated a significant increase in forskolin-stimulated short circuit current (isc; . +/- . µa/cm , mean +/-sem, n= ), that was approximately -fold greater than the response in ad-foxj /egfp treated cultures ( . +/- . µa/cm , n= ). the increase in isc was blocked by inh , an inhibitor of cftr mediated secretion. under these conditions, ad-foxj /cftr restored approximately % of the forskolin response of normal human airway cells ( . +/- . µa/cm , n= ). because patients expressing low levels of normal cftr mrna ( - %) have mild disease symptoms, these studies demonstrate that the incorporation of the ciliated cell-specific foxj promoter into gene therapy vectors may be useful for treatment of cf. supported by nhlbi ro hl and the cff. there is a compelling need for safe and effective ai therapy for cf lung disease. low-dose methotrexate (mtx) has been used to treat inflammatory diseases and its use has been reported in cf. encouraging results previously described regarding mtx in cf prompted this study. the study objective was to determine if mtx safely reduces inflammation in the airways of cf patients. methods: this was a single-center, open label study of mtx in stable cf patients with mild to moderate lung disease. baseline levels of neutrophils, free elastase, pro-inflammatory cytokines, and bacteria were determined from an induced sputum specimen. subjects received mg/m /week of oral mtx (single dose). after weeks of treatment, a second induced sputum specimen was obtained for the same inflammatory indices. within subject comparisons (end of treatment vs baseline) were performed for the following primary endpoints: total white cell and neutrophil counts, percent neutrophils, and concentrations of free elastase, il- , il- , tnf-α, and il- β. sputum quantitative microbiology was obtained at baseline and end of therapy. routine laboratories and spirometry were performed monthly. pharmacokinetic testing was performed on the final day of treatment. results: thirteen subjects were screened with started on mtx. six completed the protocol and withdrew early secondary to adverse events (gastrointestinal [gi] complaints and pulmonary exacerbation). five of subjects completing the protocol had declines in pulmonary function: mean change in fvc was - . l (range - . to - . ); mean change in fev was - . l (range - . to - . ); change in fef - was . l (range - . to . ). mean change in weight was - . pounds (range - to . ). mean change in free elastase was . µg/ml (range - . to . ; sd . ). mean change in il- was pg/ml (range - to ; sd ). similar results were obtained for the other cytokines. analysis of cytology specimens is pending. esr and crp did not show significant changes. two subjects completing the protocol had significant gi side effects, including requiring admission for severe abdominal discomfort. quantitative microbiology specimens revealed an increase in colony counts in subjects, decreases in , and mixed results in the th. other safety laboratories were not remarkable. pharmacokinetic studies are pending. complete statistical analysis and safety assessment are also underway. conclusions: the small sample size of this study precludes definitive conclusions regarding the safety or efficacy of mtx. however, the data suggest that ) induced sputum inflammatory indices can be used to assess an ai in clinically stable patients, and ) mtx therapy may not be beneficial, and may be difficult to tolerate as along-term ai therapy for cf lung disease. additional analyses of cell counts and microbiology from this study are ongoing, and may provide additional insight into the effect of mtx in the cf lung. sponsored by the cf foundation , a cellular component of many gram negative bacteria (e.g. pseudomonas aeruginosa), is a common airway stimulus. dampening the inflammatory response in cf reduces the progressive decline in lung function, so anti-inflammatory agents have become both a cornerstone of cf clinical care and a focus of therapeutics research development. reactive oxygen species [ros] can play a role in proinflammatory signaling, including the activation of nuclear factor κb [nfκb] . research has demonstrated increased oxidative stress in cf epithelial cells, potentially highlighting one of the mechanisms responsible for the exuberant inflammation observed. we have previously shown that cddo, a novel anti-inflammatory agent, significantly limits nfκb activation in cftr deficient cell culture models at nanomolar concentrations. using cf mice, we have also shown that intra-tracheal cddo limits neutrophil accumulation and the concentrations of proinflammatory cytokines and chemokines in bronchoalveolar lavage [bal] fluid in response to lps. the synthetic triterpenoids have been shown to activate the nrf transcription factor, thereby inducing several genes involved in redox balance. we now present data demonstrating that cddo may inhibit inflammation in models of cf pulmonary disease by reducing the oxidative stress within cells. methods: b . s -cftr tm mrc cf mice received µl of µm cddo in pbs with %dmso or vehicle (control) daily. drug was administered intratracheally with an atomizer (penncentury) for three days before stimulation. in separate experiments, all mice received µg lps or free pseudomonas aeruginosa intratracheally. mice were sacrificed by co asphyxiation and cardiac puncture hours after stimulation and bal, serum and lung tissue were obtained. the lungs were incubated in lysis buffer containing protease inhibitors and immediately frozen. upon thawing, the tissue was homogenized and whole lung protein extracted. one mg of lung protein from each experimental animal was separated by two dimensional gel electrophoresis. gels were then imaged and analyzed with pdquest to identify protein spots that were differentially expressed in drugtreated mice compared with controls. spots of interest were excised from the gels, trypsin digested and analyzed by liquid chromatography/tandem mass spectroscopy. results: over proteins with greater than -fold differences in expression were identified. we categorized proteins appearing in repeated analyses and identified several affecting intracellular redox regulation; including glutathione s-transferase mu and , peroxiredoxin and , enolase (alpha non-neuron), contrapsin, alpha- antiproteinase and cu/zn superoxide dismutase. these proteins were expressed at significantly greater concentration in the lungs of mice treated with cddo rather than vehicle. conclusion: cddo exhibits anti-inflammatory effects in mouse models of cf pulmonary disease and one potential mechanism for this effect may be the upregulation of reducing proteins to combat oxidative stress. methods: lpc ( ul of . %, . % or . % (w/v) in pbs) was administered (trans-orally via a cannula) to trachea of c l/b mice. in sheep ( of completed) we targeted delivery of . ml of . % lpc dissolved in pbs to the main bronchus of the right lung at branch in a month old sheep (bronchoscope, via tracheostomy). one hour later ul (mice) or . ml (sheep) of a lv-lacz vector ( . x tu/ml) was administered in the same manner. one week post-exposure lungs were inflation-fixed in situ, removed, stained using x-gal, sectioned, and counterstained with saf-o or h/e. results: no lacz gene expression (blue cells) was found in lungs of control (pbs-treated) mice or in the left (untreated side) of sheep lung. blue cells were found in scattered punctuate groups, or in lines of stained cells in mice and sheep. mice given the highest lpc dose ( . %) had extensive gene transfer in larynx, trachea, carina, and in large, middle and small airways of most lobes of the lung, reaching % airway perimeter cell transduction in one animal. with decreasing lpc dose the distribution and number of blues cells was reduced, but transduced epithelial cells including nonciliated columnar cells, ciliated cells, and basal cells were seen in all cases. in sheep, blue cells appeared in the right main bronchus between branch and branch , and in the branch airway, and with highest expression found near branch and . cross-sections revealed that primarily ciliated columnar cells and basal cells (and no goblet cells or macrophages) were transduced. conclusions: lv gene transfer into mouse or sheep lung can be enhanced by pretreatment with lpc. in mice this early data suggests an lpc dose-dependency. for sheep, we await further results to confirm the encouraging finding in this first study; however, it does confirm that gene transfer into the airways of large animals with a lung size similar to humans can also be achieved using lpc pre-treatment and a vsv-g pseudotyped lentivirus. the transduction of both ciliated and basal lung epithelial cells in-vivo in both models is an encouraging funding for the development and understanding of our continuing efforts to produce life-long airway gene transfer suitable for a cf airway gene therapy. supported by: nh&mrc, usa cff, sa channel crf, philanthropic donations. increased airway na+ absorption is a characteristic abnormality in cystic fibrosis (cf), and is thought to play a key role in the pathogenesis of cf lung disease. we have previously demonstrated that mimicking na+ hyperabsorption by overexpression of βenac in mouse airways results in airway surface liquid (asl) volume depletion and reduced mucus clearance causing a spontaneous cf-like lung disease with high pulmonary mortality, and airway mucus plugging, mucous cell metaplasia and chronic airway inflammation in surviving βenac-transgenic (βenac-tg) mice (mall et al., nature med. : , ). in the present study, we used βenac-tg mice to test if inhibition of increased airway na+ absorption by the classic enac blocker amiloride has therapeutic effects on cf-like lung disease in vivo. specifically, we determined the effects of 'early' and 'late' enac blocker intervention on mortality, airway mucus obstruction and inflammation by starting intrapulmonary amiloride therapy in βenac-tg mice either at birth, i.e. prior to the onset of lung disease, or after mucus obstruction and inflammation had established. to achieve this goal, newborn, day, or week old βenac-tg mice and wild-type littermate controls were treated by intranasal instillation of amiloride ( mmol/l; µl/g body weight, tid) or vehicle (h o) alone for a period of days. initial deposition studies showed that this treatment protocol resulted in pulmonary amiloride concentrations sufficient for inhibition of enac. during amiloride therapy, growth and survival were monitored, and any loss in body volume due to diuretic side effects was substituted by subcutaneous injection of isotonic saline (nacl . %). after the day treatment period, mice were euthanized, bronchoalveolar lavage (bal) was performed to determine inflammatory cell counts, and lungs were processed for histology and morphometry to quantitate airway mucus obstruction and mucous cell metaplasia. we show that amiloride significantly reduced pulmonary mortality by~ % (p < . ), when therapy was started in newborn βenac-tg mice. further, early amiloride treatment significantly reduced airway mucus content (p < . ), mucous cell numbers (p < . ), and bal eosinophils (p < . ) compared to vehicle treated βenac-tg mice. in contrast, amiloride therapy had no benefits on airway mucus obstruction, mucous cell metaplasia or inflammation, if treatment was started in day, or week old βenac-tg mice with established lung disease. taken together, our results are consistent with previous human studies where amiloride lacked therapeutic benefits in cf patients with established lung disease, and demonstrate for the first time that early inhibition of na+ hyperabsorption is an effective therapy for cf-like lung disease in vivo. these results warrant an evaluation of more potent and longer acting amiloride derivatives in chronic lung disease in mice, and a clinical evaluation of preventive enac blocker therapy in human trials. supported by cff (mall g ) and ec (mext- - objective: hypertonic saline aerosol delivered intranasally is currently being studied to enhance mucociliary clearance. there is evidence of patients' reluctance to use concentrations above % due to potential discomfort. our study was performed to determine the short term tolerance of . % and % hypertonic saline versus normal saline delivered intranasally via a nebulizer/compressor system (pari sinustartm, pari respiratory equipment, midlothian, va). methods: using the sinustartm nasal aerosol delivery system, we administered concentrations of saline solution, ( . %, . %, %) to healthy, adult volunteers for minutes each. a washout period of minutes between treatments allowed volunteers to wipe their nose and cleanse their mouth with water. a question self-administered questionnaire was completed following each treatment using a point scale ( =high tolerability; =low tolerability). burning sensation, cold, cough, throat irritation, runny nose, and overall comfort were measured. the order of treatments was randomized and volunteers were blinded to the concentration. data: for all measurements . % and % were equally well tolerated compared to normal saline with burning, cough, and throat irritation measuring . or below. no variable measured more than . . out of volunteers stated they would continue this treatment on a regular basis. conclusions: our study indicates that during the time of treatment nasal aerosol delivery of hypertonic saline up to % is well tolerated in healthy adults. there appears to be no issue of discomfort associated with hypertonic saline that would prevent nasal aerosol treatment compliance. our overall research goal is to discover new drugs for clinical treatment of cystic fibrosis (cf) that will correct the biochemical defect in the predominant cf mutation, the ∆f form of the cystic fibrosis transmembrane conductance regulator (cftr) protein, which accounts for over % of all cf cases. this mutation leads to a misfolded protein which is rapidly degraded as well as changes in its function and half-life at the cell surface. however, it has been proposed that only a fraction of the normal surface expression level is needed to provide a clinically significant impact on the disease. thus, from a pharmacological standpoint, strategies that can partially but effectively correct these defects would be expected to have a clear clinical benefit to these cf patients, and these strategies may also be applicable to other cftr mutations. we previously demonstrated that several members of a particular class of related drugs, the anthracyclines, anthraquinones, and anthracenediones, significantly increased cftr cell surface expression and function in cell culture. in particular, we demonstrated that a non-cytotoxic concentration of doxorubicin (dox), a model anthracycline drug, significantly increased total cellular and membrane-associated cftr protein levels and cftr-associated chloride currents in human colon cancer t cells, and also caused a two-fold increase in ∆f cftr-associated chloride current in a canine mdck-c -derived cell line that expresses a stably transfected copy of human ∆f cftr. our previous studies also demonstrated that dox is able to impart structural integrity to ∆f cftr, increasing its half-life and decreasing its proteolytic sensitivity, which is indicative of efficient folding. additionally, two other structurally related drugs, i.e., the anthracycline, daunorubicin, and the anthraquinone, mitoxantrone, were shown to have similar effects on ∆f cftr expression. in the current work, we have extended these effects to two other related aza-anthracenedione molecules, bbr (pixantrone) which is a cancer chemotherapy drug with lower non-target toxicity than dox and which is in phase iii clinical trials, and a structurally related analog, bbr , which is essentially non-cytotoxic with a -fold lower cytotoxic potency than bbr . both compounds increased cftr-associated chloride currents to a similar extent as dox in cfbe human airway epithelial cells expressing ∆f cftr, as measured by ussing chamber experiments. the ability of the non-cytotoxic analog bbr to do so is particularly important, since it indicates that correction of the ∆f cftr defect is not directly tied to the toxicity of this class of compounds per se but rather is a result of other structural features. thus, it is likely that this and/or other non-toxic analogs in this chemical class can be developed that have potential as clinically useful agents for treatment of cf in patients. supported by a cystic fibrosis foundation (cff) grant to jwh and rm, and by the cff-supported dartmouth cf program. cystic fibrosis (cf) is caused by mutations in cystic fibrosis transmembrane conductance regulator (cftr). cftr is not only an epithelial chloride channel, but it also regulates other transporter and ion channels, including epithelial sodium channels (enac) and aquaporin water channels. in patients with cf, absent or dysfunctional cftr results in abnormal electrolyte and fluid content on the epithelial surface. treatments intended to normalize ion transport in cf airways through non-cftr dependent pathways represent attractive approaches to alleviate the underlying pathologic defect. calcium (ca +)-activated cl-channels have been proposed as rescue channel for the cyclic amp-dependent cftr cl-channels, offering a target for cf pharmacotherapy. increases in cytosolic ca + concentration activate epithelial cl-channels, but inhibit epithelial na+ channels, which is also beneficial in correcting the hyperabsorption of na+ in cf. herein we developed a high throughput screening (hts) assay for screening compound libraries with the intention of finding compounds which can increase intracellular ca +. in the pilot primary screening, we screened a mssp library which contains known bioactive compounds and natural products. compounds were classified as the real hits after the secondary screening validation with the hit percentage . %. we have found that the ec of these compounds are less than um in dose-response studies and none of those compounds were toxic to the cells. we have further discovered that those compounds stimulate cl-secretion through activating ca + dependent cl-channels in cf and non-cf human airway epithelial cells in short-circuit current experiments. in summary, our data suggest that modulation of intracellular ca + is a target for cf therapy. the compounds identified by our study will provide possible therapeutic leads in the treatment of cf. non-viral gene delivery particles with various synthetic polymer coatings have been developed for cystic fibrosis (cf). intracellular trafficking and in vivo tissue distribution of these particles must be carefully monitored to guide rational design of efficient delivery system. fluorescent semiconductor quantum dots (qds) allow sensitive, long-term and multi-target imaging in cellular environment, and so are a promising tool in tracing gene delivery materials in vitro and in vivo. however, application has been limited by the lack of efficient and reproducible techniques of qd bioconjugation. here, we describe a method of labeling dna nanoparticles with tunable qds that may enable us to study gene delivery in vitro and in vivo. highly fluorescent zns-coated cdse qds were first synthesized and encapsulated in amine-containing phospholipid micelles. the non-viral vector system we used is based on a polymer backbone consisting of lysines with a cysteine on the n-terminus (ck ) which is conjugated to polyethylene glycol (peg). this polymer vector condenses dna plasmids into stable nanoparticles that efficiently transfect airway epithelial cells in vivo. to introduce the aminecontaining qds, we utilized a hetero-bifunctional peg with an nhs ester at one end, which was first reacted with the amine groups of the qds and a maleimide group at the other end which was subsequently reacted with the thiol group in ck . excess reagents were removed from the final conjugates qd-peg-ck by filtration. conjugation was first confirmed by . % agarose gel electrophoresis. free qds were positively charged and migrated toward the cathode. pegylated qds migrated significantly slower than free qds, and qd-peg-ck conjugates migrated at still a different rate. to further demonstrate conjugation, we biotin-labeled the ck and assessed the binding of qd-peg-ck -biotin to avidin coated agarose beads by monitoring the yield of fluorescent beads. qds, pegylated qds, and physical mixture of qds and ck -biotin were also incubated with the agarose beads as controls. fluorescent beads were detected only when qd-peg-ck -biotin was present. to directly evaluate the ability of qd-peg-ck to bind double stranded dna, we also immobilized double stranded dna fragments to agarose beads. qd-peg-ck , but not unconjugated qd bound to the immobilized dna fragments as determined by the yield of fluorescent beads. qd-peg-ck was then used to compact luciferase reporter plasmids. electron microscopy images of the compacted dna showed that qds were integrated into some dna nanoparticles. we transfected hela cells with qd-labeled and unlabeled dna nanoparticles. luciferase assay and toxicity assay indicated that qd-labeled dna nanoparticles transfected hela cells, though with less reporter gene expression than unlabeled nanoparticles and more toxicity than uncompacted qd. in conclusion, we have developed a method to conjugate qd to dna nanoparticles. improvement of the quality and biocompatibility of the qd may be required for further in vitro and in vivo studies. this system is also versatile. other less toxic optical makers can be readily tested. this study was supported by dk and the cff. in cystic fibrosis (cf) the epithelial sodium channel (enac) hyperactivity plays a role in the pathogenesis of chronic lung disease. the missing enac regulation by the cf transmembrane conductance regulator (cftr) causes increased absorption of sodium ions and fluid across airway epithelia leading to the depletion of the perciliary liquid layer and to the consequent inhibition of mucus clearance. we developed a hiv-based lentiviral (lv) vector containing a sirna cassette to efficiently knockdown the expression and activity of enac in human respiratory cells. background: sildenafil has been implicated in the relocation of cystic fibrosis transmembrane conductance regulator (cftr) protein. the effect was observed in vitro and in the presence of doses roughly times larger than those commonly used for treating erectile dysfunction. aim: to evaluate in vivo therapeutic efficiency of clinical doses of sildenafil and vardenafil, two approved type v phosphodiesterase inhibitors, for correcting chloride transport defect in ∆f mice. methods: we measured transepithelial potential difference in vivo across the nasal mucosa as a readout for sodium and chloride conductance. the effect of a single intraperitoneal injection of sildenafil ( . mg/kg) or vardenafil ( . mg/kg) was investigated in df /df and normal homozygous mice. results: in df /df mice, chloride conductance, evaluated by perfusing the nasal mucosa with a chloride-free solution in the presence of amiloride and with forskolin, was corrected h after sildenafil administration. a more prolonged effect, persisting at least for h, was observed with vardenafil. the forskolin response was increased after sildenafil and vardenafil in both normal and df mutant animals. no effect on sodium conductance was detected in any group of animals. conclusion: our results provide preclinical evidence of effectiveness of both drugs for correcting chloride transport defects in the cf. acknowledgments: this work was supported by grants from the french cf association, vaincre la mucoviscidose and by an educational grant from pfizer belgium. there is a strong interest in developing small molecules able to correct the phenotypic effects of cystic fibrosis (cf) mutations. many mutations (e.g. ∆f ) impair the function of cftr protein, by altering the protein targeting to the plasma membrane and/or by causing an abnormally low open channel probability. drug-like organic compounds may restore the correct membrane localization ("correctors") or increase channel activity ("potentiators") of mutant cftr. in the last years, various research teams have identified molecules with activity as correctors (corr- a, vrt- , miglustat, curcumin) or as potentiators (tetrahydrobenzothiophenes, phenylglycines, sulfonamides, vrt- , , -dihydropyridines). however, these compounds have been tested using different assays and the results are sometimes controversial, with marked differences in declared efficacy and potency of compounds. we have tested a panel of correctors and potentiators to directly compare their effects under the same experimental conditions. for this purpose, we have used the functional assay based on the halide-sensitive eyfp-h q/i l to measure ∆f -cftr activity in frt and a cells. the assay for potentiators consisted in stimulation with the test compound ( . - µm) plus forskolin (on cells previously incubated at °c for hours). the assay for correctors consisted in hours incubation of ∆f cells with test compounds and then determination of cftr activity in the presence of forskolin plus genistein ( µm). our results indicate that all potentiators are active in our assay with a comparable maximal effect but with values of potency that vary significantly among compounds. the potency order measured in frt cells was: dhp- = pg- (ka~ nm) > sf- (ka = nm) > dhp- = dhp- (ka~ nm) > act- b (ka = nm) > felodipine (ka = nm) > vrt- (ka = . µm) > genistein (ka = . µm). a similar order of potency was found also in a cells expressing ∆f . the activity of correctors showed a more marked dependence on cell line. while the potency was comparable between frt and a cells, the maximal effects showed clear differences. in frt cells, corr- a, corr- b and corr- c generated a maximal effect that was . - -fold higher than that obtained by incubating the cells at low temperature. conversely, vrt- and vrt- were less effective (maximal correction equivalent to - % of low temperature rescue). in a cells, all compounds were instead less effective than low temperature, with vrt- being the molecule eliciting the highest activity ( - % of low temperature). our results indicate the , -dihydropyridine dhp- and the phenylglycine pg- among the most potent activators of the mutant cftr channel. the similar behavior of potentiators in two different cell lines is consistent with the assumption that all potentiators act with a similar mechanism, by interacting with the cftr protein itself. in contrast, the cell line dependence of correctors suggests that they act with indirect mechanisms, possibly by interacting with proteins involved in cftr biosynthesis and trafficking. supported by cfft and telethon-italy. we also thank cfft and rfums for providing chemical compounds. lung damage in cystic fibrosis (cf) patients is determined by mucus accumulation, pseudomonas aeruginosa infection and chronic inflammation. extracellular gsh is a scavenger of free radicals produced by neutrophils in inflamed tissues. glutathione transferases (gst) are a superfamily of dimeric proteins which conjugate glutathione to a wide range of substrates including oxidants and are involved the synthesis of leukotriens. clinical beneficial effects have been reported in cf patients following treatment with the macrolide azythromicin (azm); anti-inflammatory properties have been proposed as possible mechanism. the aim of this study is to investigate the regulation of the gstt and gstm activity and expression by azm. reductions of about % and % on gst enzymatic activity were detected in ib - and cfsmeo-cells respectively. gsts mrna expression in cf airway epithelial cell lines was analysed by quantitative pcr (qpcr). the level of gstt and gstm basal expression in cf cells ib - was significantly higher than in isogenic non-cf cells c . we found statistically significant decreases of gstt and gstm mrna of about % and % respectively in ib - cells after treatment with azm for hours, restoring the levels observed in c cells. in cfsmeo-cells after exposure to azm we observed % and % reductions in gstt and gstm mrna respectively. the macrolide jm, known to lack clinical anti-inflammatory properties, had no significant effects on gstt and gstm mrna expression in all cell lines. furthermore, azm did not alter the mrna expression levels of gstp , a glutathione-s-transferase not differentially expressed in cf and isogenic non-cf cells. decreased expression of % and % of gstt protein has been detected by immunoblotting in ib - and cfsmeo-cells, respectively, following treatment with azm. in the same conditions we found a drastic reduction of protein level of gstm in both cf cell lines. finally, gsts activity and the expression of gstt and gstm proteins in cf cells, were reduced approximately to the same level detected after treatment with interleukin (il- ), an anti-inflammatory cytokine, shedding light on a possible correlation between gsts inhibition and antiinflammatory properties of azm. the effects of azm described in this study suggest that downregulation of gstt and gstm expression may result in increased availability of intracellular gsh making cf cells less susceptible to oxidative stress induced by chronic inflammation. inhibition of gstt and gstm might provide a therapeutic approach for limiting the effects of inflammation critical for lung damage in cf patients. this study is supported by italian cf research foundation; comitato di vicenza-associazione veneta per la lotta contro la fibrosi cistica; azienda ospedaliera verona, italy. tradtrantip, l.; padmawar, p.; yangthara, b.; verkman, a. activation of cftr chloride conductance by gpcrs involves camp elevation and pka-mediated cftr phosphorylation. we developed a 'pathway screen' in which cftr-mediated iodide influx is used as a read-out of gpcr activation. the cell-based fluorescence assay utilizes multiply transfected epithelial cells expressing wildtype cftr, yfp-h q/i l and a specified gpcr. we recently used this assay to identify a new class of nanomolar-affinity, -aryl- -benzoyl- hydroxy- -( -arylethyl)- h-pyrrol- -one vasopressin- receptor antagonists (yangthara et al., mol. pharm. , in press ). additional screening of , diverse small molecules yielded novel chemical classes of inhibitors of cftr activation. the potential molecular targets of pathway inhibitors include the gpcr, gs or gi proteins, adenylyl cyclase, phosphodiesterase, pka and cftr. a series of target identification studies was done to classify the new pathway inhibitors, which involved the use of agonists acting at different sites in the activation pathway, and specific site-of-action assays. the pathway screen yielded new small-molecule cftr inhibitors that are unrelated to thiazolidinone and glycine hydrazide inhibitors. one interesting class of pathway inhibitors, thiophenecarboxylates, represent the first small-molecule phosphodiesterase activators, which strongly reduce camp and cgmp concentration in many cell types. the best thiophenecarboxylate greatly reduced intestinal fluid secretion in closed loop mouse models of cholera and travelers' diarrhea, and slowed cyst growth in a model of polycystic kidney disease. other pathway inhibitors, which are potential effectors of g-proteins and pka, are under evaluation. the gpcr-linked cftr pathway screen developed here is useful for high-throughput parallel identification of small-molecule inhibitors of multiple targets in the cftr activation pathway. potential uses of the inhibitors identified here include therapy of secretory diarrheas, polycystic kidney disease, and cyclic nucleotide-dependent tumor growth, as well as pharmacological creation of cf-phenotype in ex vivo human tissues and animal models. supported by cff and nih. inhibitors of intestinal caccs are predicted to have anti-secretory effects in certain diarrheas, and activators of airway and intestinal caccs are of potential use in cystic fibrosis therapy (activation of 'alternative' chloride channels). the purpose of this study was to identify small-molecule cacc inhibitors and activators that target caccs directly, rather than ubiquitous upstream processes such as calcium signaling. we screened a collection of , chemically diverse small molecules using a novel high-throughput screening assay involving lentiviral introduction of a yfp-based halide sensor in cacc-natively expressing human epithelial cells. cacc inhibitors were identified from iodide influx following cacc simulation by carbachol/atp. we identified five classes of cacc inhibitors with micromolar potency, including tetrahydro-cyclopentaquinolines, and -aryl- -(trifluoromethyl)-pyrazoles each of which was unrelated to known transport modulators. two classes of compounds inhibited calcium-activated halide flux following stimulation by multiple types of agonists, including thapsigargin and calcium ionophores, and by patch-clamp analysis appear to target cacc directly. structure-activity analysis of analogs of 'hits' yielded compounds with improved potency, which have been resynthesized and characterized for use in assays of antidiarrheal effiacy in rodent models of viral and drug-induced secretory diarrheas. screening for caccselective activators that act in a sustained manner (non-transiently) was accomplished using a similar cell-based fluorescence assay, but instead testing for increased halide influx. several classes of putative cacc activators with micromolar-potency were identified in screening of , small molecules, whose mechanism-of-action and specificity are under investigation. small-molecule modulators of cacc function that target caccs directly have potential clinical applications, and may be useful in defining the physiological roles and molecular identity of caccs. supported by cff and nih. introduction: inhaled hypertonic saline 〈hs〉improves lung function and decreases pulmonary exacerbations in older children and adults with cf. initiating therapeutic interventions in the youngest patients, particularly those that target the underlying cf defect of airway surface liquid volume depletion, has potential to preserve lung function and improve prognosis. subbarao et al performed baseline, post-albuterol and post-hs lung function testing in infants using the raised volume rapid thoracoabdominal compression technique 〈rvrtc〉and demonstrated no significant drop in lung function 〈 pediatric pulmonology, 〉. however, performing three sets of rvrtc maneuvers under the same sedation could prove difficult. before conducting a therapeutic trial of hs in this population, a simplified protocol must be possible at multiple centers. we sought to evaluate a simplified approach as well as to analyze changes in lung function and clinical findings after acute administration of hs. methods: in this ongoing study, clinically stable children with cf between the ages of months and years inhale . mg of albuterol prior to sedation with chloral hydrate. rvrtc and plethysmography are then performed before and after inhalation of ml of ‰ hs. fvc, forced expiratory volume in . seconds 〈fev . 〉, fef - , frc, rv/tlc ratio, respiratory rate, oxygen saturation, and chest exam findings are recorded. predefined stopping criteria include a % drop in fev . or in oxygen saturation to below ‰. results: six subjects 〈mean age . ± . years〉 have completed the protocol with ‰ hs. comparison of post-albuterol lung function to that obtained minutes after ‰ hs revealed no changes in mean fvc 〈 vs ml; p= . 〉, mean fev . 〈 vs ml; p= . 〉, mean fef - 〈 vs ml/sec; p= . 〉, frc 〈measured after each inhaled therapy in of subjects; vs ml; p= . 〉, or rv/tlc 〈measured after each inhaled therapy in of subjects; . vs . ; p= . 〉. respiratory rate, oxygen saturation and chest exam were unchanged. conclusions: results from this study demonstrate that a two-step protocol may used to evaluate the safety of hs. based on these findings, acute administration of ‰ hs is safe in children ages months to years with cf. despite the known improvement in mucociliary clearance, preliminary findings demonstrate a lack of an immediate response in lung volume measures. given the demonstrated benefits in older children and adults, a multicenter therapeutic trial of hs is warranted. supported by the cystic fibrosis foundation. methods and results: we have characterized aav serotypes - in addition to twenty novel vectors isolated from human or macaque tissues to transduce the murine airway epithelium in vivo. vectors [ e+ genome copies (gc)/mouse] expressing α- -antitrypsin (aat) and βgalactosidase (β-gal) were co-instilled into the mouse lung or nose. transgene expression levels were monitored by assaying aat concentration in serum as well as the number and cell-types positive for (β-gal) expression in lung and nasal airways. of all vectors tested aav and aav were the two most efficient vectors in conducting airways. when these aav vectors ( e+ gc) were subsequently evaluated on human ciliated airway epithelial cultures (haec), in contrast to our findings in mouse airways, aav failed to transduce haec, whereas aav resulted in~ % of the haec expressing transgene. since aav was the most efficient vector in mouse and human airway epithelium we performed structure-function analyses of the aav vector capsid and found two atypical capsid residues that were unique in otherwise conserved positions (f , k ). to generate a potentially fitter vector, residue f was mutated to its conserved state. residue k was found to confer lung tropism and was left unchanged. the resulting vector, aav . , transduced mouse lung and nasal airway with greater efficiency than all aav vectors tested. the increased transduction efficiency of this vector was also observed (~ %) in haec derived from six different human subjects. to continue our preclinical studies in a more relevant model, aav / . expressing egfp was tested in ciliated cultures derived from macaque airways and showed - % of cells expressing egfp one week after inoculation with e+ gc. confocal microscopy revealed that aav . targeted a significant number of ciliated cells: the airway cell-types that likely require cftr expression in cf patients. aav . expressing rhesus α-fetoprotein (rhafp) was then inoculated in the nasal airways of a rhesus macaque and transduction evaluated by monitoring concentration of rhafp in the nasal lavage fluid. we have found that rhafp expression remained high (~ ng/mg) and stable for at least days. conclusion: the enhanced transduction efficiency of aav / . vector in human and macaque airway cultures and its ability to stably transduce the nasal airway of a rhesus macaque in vivo demonstrates that aav / . is a good candidate gene transfer agent for the efficient expression of cftr in human cf airway epithelium. submitted for presentation at the american society of gene therapy. supported by gsk, cff, cfpo , p , mtcc. pharmacological correction of ∆f cftr cellular processing is a potential therapeutic strategy for cystic fibrosis. recent high-throughput screening has identified synthetic small molecules, such as bisaminomethylbithiazoles (corr- ), which partially restore chloride permeability in ∆f mutant cells. the purpose of this study was to examine the utility of natural compounds (chinese medicinal herbs) as ∆f correctors. a herbal compound fraction library was constructed from herbs most frequently used in traditional chinese medicine (tcm) that are believed to contain therapeutic compounds for a broad spectrum of human diseases including lung disease. for construction of the tcm fraction library, crude herbal extracts were first prepared by % ethanol extraction on soxhlet reflux apparatus followed by automated fractionation by preparative hplc. eighty fractions were collected from each of the herbs. each fraction contained to (average . ) individual compounds as determined by analytical hplc. collected fractions were dried and milligram of the material was dissolved in µl dmso to generate mg/ml solutions in -well plates. each -well plate contained fractions from one herb. high-throughout screening was done using the frt cell-based fluorescence assay developed previously (j. clin. invest. : - , . of , fractions screened, active fractions from herbs were identified, with positive fractions verified in secondary screening. the positive fraction did not increase halide transport in control non-transfected cells, and halide transport in ∆f -corrected cells was fully abolished by cftrinh- . we have fractionated some of the most active fractions by preparative hplc to identify which compound(s) conferred activity. for example, in one fraction there were single compounds, of which conferred corrector activity with ic s < µm and efficacy comparable to that of low temperature rescue. these results demonstrate the feasibility of ∆f -cftr corrector discovery from natural compounds. further fractionation, characterization and structure determination are in progress. the unexpectedly high 'hit'rate for the natural compounds suggests their further exploration in cf therapy. cystic fibrosis (cf) is the most common genetic disease affecting the caucasian population, with an incidence of approximately one in three thousand births. cf transpires as a result from a mutation in the cystic fibrosis transmembrane conductance regulator protein (cftr), which regulates ion transport across epithelial membranes. subsequently, patients afflicted with cf have an abnormally excessive incidence of chronic lung infection, with organisms such as pseudomonas aeruginosa. because cystic fibrosis is characterized by chronic bacterial infections, excessive neutrophil recruitment to the lungs, and a coinciding increase in pro-inflammatory cytokine production and nuclear factor-kappa b (nf-κb) activation, we hypothesized that exogenous addition of the nf-κb inhibitor iκbα might ameliorate this phenotype. we cloned the human iκbα gene as well as a mutated iκbα gene into plasmids with chicken-beta actin hybrid promoters. we then tested the new plasmids, paav .cb-hiκbα and paav .cb-hiκbαm, in vitro in the presence and absence of pseudomonas aeruginosa infection in the ib - and s cell lines. both plasmids produce iκbα at high levels as shown by enzyme linked immunosorbant assays (elisas). we also show that paav .cb-hiκbα transfected ib - cells, after infection with pseudomonas aeruginosa, express significantly reduced levels of interleukin (il)- β ( fold, p< . ), il- ( fold, p< . ), and tnf ( fold, p= . ) as well as nf-κb activation ( fold, p< . ) compared to p. aeruginosa-infected ib - controls as determined by human cytokine and nf-κb phosphoprotein bio-plex assays; cytokine expression and nf-κb activation levels in infected paav .cb-hiκbα transfected ib - cells were between levels found in infected ib - and s- cells, excluding il- levels which were below s- levels of expression. flavonoids are among the most potent cftr modulators known. equol [ hydroxy- -( '-hydroxyphenyl)-chroman] is a product of intestinal metabolism of dietary isoflavones such as daidzein, and has been of recent interest in studies of cancer, cardiovascular risk, and neurologic disease. equol is metabolically stable, and % circulates in the free (non-protein bound) form, which is considerably greater than the proportion of free daidzein ( %). structural differences such as modification of ring c (e.g. saturation at c- / , and absence of carbonyl group at c- ) and an absent hydroxyl at position c- distinguish equol from compounds previously reported to modulate cftr activity. in prior work by our center, we showed that equol activates wt and ∆f cftr in membrane patches excised from bhk cells and in cfbe o-monolayers studied in ussing chambers. activation by equol occurred only after r-domain phosphorylation in wt and ∆f cftr constructs, but was independent of rdomain phosphorylation in ∆r cftr, indicating activity may be related to dimerization of the nbds or other domain-domain interaction. because a molecule that alters nbd interactions might have effects on the aberrant processing of ∆f cftr, we screened equol and other flavonoids by preincubating compounds with cfbe o-cells expressing ∆f cftr for hours, and then tested for rescue of cftr dependent cl-channel activity after exchange of media solution. we found that preincubation with equol ( - µm) induced rescue of short-circuit current compared to vehicle treated cells ( vs. µa/cm , p< . , n= ). we then evaluated hour preincubation with equol ( um) for biochemical evidence of cftr processing correction in ∆f cfbe o-cells grown in polarizing conditions. immunoprecipitation and in vitro phosphorylation demonstrated minimal formation of band c compared to vehicle treated cells, but adaptation of a more sensitive avidin label/biotinylation assay specific for surface localized cftr revealed clear evidence that equol preincubation led to cftr at the plasma membrane. next, we examined equol in hela cells stably transduced with ∆f cftr. preincubation of equol led to dose-dependent increases in halide transport measured by fluorescence-based halide efflux (spq) after stimulation by genistein ( . and . fluorescence slope (∆%/sec) with equol and µm respectively, compared to . ∆%/sec in cells pretreated with vehicle alone; p< . , n= - cells/condition). immunohistochemical staining of ∆f hela cells for cftr with - c-terminus antibody showed rescue of surface localized protein with equol ( µm) preincubation for hours, while vehicle treated cells showed only perinuclear staining. in summary, we show functional, biochemical, and immunohistochemical evidence that the naturally occurring flavonoid equol corrects the ∆f processing defect in two model systems. a naturally occurring agent that both activates and corrects ∆f cftr deserves further exploration as a potential cf therapeutic, and may lead to new insights regarding domain-domain interactions that influence the activation and biogenesis of the mutant channel. supported by nih and cff. mote ∆f cftr maturation has been identified. although several small molecule agents have been described that overcome ∆f cftr processing defects in specific cellular models, few studies have directly compared the activity of temperature corrected and chemically corrected ∆f cftr in polarized cell systems. in the present study, we examined chemical and temperature corrected activity of ∆f cftr. correctors included all members of the cfft modulator library (c , c , c , and c ; rosalind franklin university, chicago, il). in a screen using ∆f cfbe omonolayers, maximal corrector activity across the two model systems exhibited a rank order of c >> c > c = c , using forskolin ( µm) and genistein ( µm) stimulated isc as a sensitive test for ∆f cftr activity at the plasma membrane. no change in isc was observed in matched control (parental) cells lacking ∆f cftr expression. based on these results, we further defined the activity of c in ∆f cfbe oand frt model systems, including dose/response and time dependence for peak isc rescue. in cfbe o-cells, exposure to µm c for hrs produced maximal reproducible correction of ∆f cftr processing, with loss of activity following prolonged or high concentration exposure; in frt cells, peak effects were seen at hours. ∆f cftr activity following small molecule treatment qualitatively mirrored temperature correction ( °c growth for - hrs) in both cell types. maximal currents produced by stimulation with forskolin ( um) and genistein ( µm) in ∆f frt monolayers following c pretreatment were % of that produced by temperature correction (p< . ). forskolin was responsible for % of maximal current in frt ∆f cells following chemical correction and % of maximal currents following temperature correction. in ∆f cfbe o-cells, maximal currents following chemical correction were % of that produced by temperature correction (p< . ). forskolin was responsible for . % of maximal currents in cfbe o -∆f cells following chemical correction and . % of maximal currents following temperature correction. these results illustrate dose and time response with a small molecule corrector in two polarizing epithelial model systems, and provide reassurance that observations based upon ∆f cftr following low temperature incubation are relevant to functional analysis after chemical correction. similarity in activation properties between chemical and low temperature correction suggest it is unlikely that the two maneuvers result in ∆f cftr with significantly different structural properties. the studies also indicate fundamental differences in ∆f cftr behavior in frt compared to cfbe ocells, and emphasize the importance of identifying an agent that can restore camp dependent regulation to bronchial epithelial cell types. supported by the nih, cff and cfft. participants: n= patients ( randomised to azm and to placebo) who had successfully completed a course of intravenous antipseudomonal antibiotics immediately before the trial (mean age: . years; mean fev : % of predicted). measurements and results: after treatment (mean dose of . mg/kg body weight once a week) pulmonary function declined in both groups compared to baseline (i.e. after cessation of iv antibiotics). the azithromycin group had signifcantly better results regarding the mean changes in serum crp (azm: + . mg/l, placebo: + . mg/l, p= . ), lipopolysaccharide binding protein in serum, lbp (azm: + . µg/ml, placebo: + . µg/ml, p= . ), serum interleukin- (azm: - . pg/ml, placebo: + . pg/ml, p= . ) and alginate in sputum (azm: + µg/ml, placebo: + µg/ml, p= . ). quality of life (german version of the cfq) showed significantly better results after azm in adolescents and adults. azithromycin was well tolerated with no increase in treatment-related adverse events. conclusion: once-weekly azithromycin ameliorated inflammatory reactions and improved quality of life. a decline of pulmonary function after cessation of intravenous antibiotics could not be prevented, however. this study has been sponsored pfizer gmbh, germany this open-label, multicenter study was conducted in the usa and australia to evaluate the clinical responsiveness of a patient-reported outcome measure, the cfq-r respiratory scale, by determining the minimal clinically important difference (mcid) following a -day course of tobramycin inhalation solution (tis). cf patients (n= [≥ to < yrs, n= ; ≥ yrs, n= ]) with pseudomonas aeruginosa and clinical symptoms predictive of a pulmonary exacerbation (increased cough, increased sputum /chest congestion, decreased exercise tolerance or decreased appetite) were enrolled. three efficacy measures were included: )change in forced expiratory volume in second (fev ) from baseline (day ) to end of treatment (day ) or end of study (day ); )one question about change in respiratory function (days and ; global rating of change questionnaire, respiratory domain, grcq rd; =no change; =maximal improvement or worsening);and )change in cfq r-respiratory scale (day , ). average change from baseline fev (mean [standard deviation, sd]) was . % ( . ) at day and . % ( . ) at day . based on grcq-rd at day , patients ( %) reported no change in respiratory symptoms (score < . ), ( %) a minimal change (≥ . to < . ), ( %) a moderate change (≥ . to < . ), and ( %) a large change (≥ . ). mean (sd) change from baseline cfq-r respiratory was . ( . ) at day and . ( . ) at day . at day , change in cfq-r was moderately correlated with change in fev and with grcq-rd; the correlation was stronger for patients with baseline fev < % of predicted fev values (see table) . mean change from baseline on the cfq-r respiratory scale was . at day for patients with grcq-rd scores indicating minimal change in symptoms (≥ . to < . ; n= ); this provided an estimate of the mcid for the cfq-r respiratory scale for those in exacerbation. this mcid value was consistent with estimates from distribution-based methods( ⁄ sd and standard error of measurement). the cfq-r was responsive to changes in pulmonary symptoms in patients in mild exacerbation following tis treatment; the mcid in this population was . points. responses on the cfq-r-respiratory scale were moderately correlated with changes in fev . funded by gilead sciences, inc. this was an open-label, multicenter study conducted in the usa. we determined the minimal clinically important difference (mcid) for the cfq-r, respiratory scale following a -day course of tobramycin inhalation solution (tis) in patients with cf and chronic pa infection (n= , children [< yrs]). patients had received ≥ courses of tis (mean = . ) within the previous year, however their respiratory symptoms were stable at study entry, with forced expiratory volume in second (fev ) between % to % of predicted values. efficacy measures included: ) percent change in fev (l) from baseline (day ) to treatment end (day ); ) a single question about change in respiratory function (day ; global rating of change questionnaire; respiratory domain, grcq-rd; =no change, =maximal improvement or worsening); ) change in cfq-r-respiratory scale (day to ); and ) change in log pa colony-forming unit (cfu) density in sputum (day to ). the mcid for cfq-r was estimated using three methods: ) change in cfq-r (day to ) for the patient subset with minimal change in respiratory function, as determined by the grcq-rd at day ; ) cfq-r standard error of measurement (sem) from a validation sample), and ) ⁄ standard deviation (sd) of the cfq-r respiratory scale scores. at day , change from baseline fev (mean [sd]) was . % ( . ), change from baseline cfq-r was - . ( . ), and change in log pa cfus was - . ( . ) . based on the grcq-rd at day , patients ( %) reported no change in respiratory symptoms (score < . ), ( %) a minimal change (≥ . to < . ), ( %) a moderate change (≥ . to < . ), and ( %) a large change (≥ . ). pearson r-values for the correlation of change in the cfq-r-respiratory scale and change in fev , log cfus and grcq-rd were . , . , and . , respectively. estimates of the mcid for cfq-r-rd ranged from . to . for adults/adolescent patients (table) . in patients with cf who had no immediate need for antipseudomonal therapy at study entry, the cfq-r-respiratory scale appeared responsive to changes in patient disease perception following days of tis treatment; the mcid for cfq-r was approximately points for the adolescent/adult patient population. funded by gilead sciences, inc. ex vivo chloride secretion measurements (intestinal current measurement, icm) in cf patients have been established over the past years to study the cftr-basic defect in more functional detail. modified micro-ussingchambers are used to registrate the transepithelial short-circuit current (isc) in freshly obtained human rectal suction biopsies as a measure of ion transport after stimulation with secretagogues. hereby, the cftr clchannel, its amount of residual function in cf and alternative cl-channels can be investigated by a standardised protocol.in the course of the development of cftr pharmacotherapeutics as well as agents activating alternative cl-channels, icm may function as an useful outcome parameter in preclinical and clinical trials. it is easy to perform repeatedly at all patients ages and comprises the safety advantages of an ex vivo method which is relevant especially for early study phases. aim of this study was to describe reference values and quantify the intraindividual variability of different icm parameters. methods: a total of n= rectal biopsies from n= individuals; with pancreatic insufficient (pi)-cf (n= ; mean age . years), pancreatic sufficient (ps)-cf (n= ; . years), excluded cf by icm diagnostics (n= ; . years) and healthy control (n= ; . years) were included into analysis. for calculation of intraindividual variability, - biopsies/patient were compared with respect to basal tissue resistance (rt basal), basal open circuit potential difference (pd basal), basal short circuit current (isc basal) and the isc responses to stimulation with carbachol ( - mol/l, serosal), -bromocyclic monophosphate (camp) ( - mol/l, mucosal+serosal) + forskoline ( - mol/l, serosal) and histamine ( x - mol/l, serosal).results:we determined icm reference values for the groups of pi-cf (isc basal . ± . µa/cm , ∆isc carbachol . ± . µa/cm ,∆isc camp/forskoline . ± . µa/cm ,∆isc histamine - . ± . µa/cm );ps-cf (isc basal . ± . µa/cm ,∆isc carbachol . ± . µa/cm ,∆isc camp/forskoline . ± . µa/cm ,∆isc histamine . ± . µa/cm ),and healthy control (isc basal . ± . µa/cm , ∆isc carbachol . ± . µa/cm , ∆isc camp/forskoline . ± . µa/cm , ∆isc histamine . ± . µa/cm ). for the total cohort, mean coefficients of variation were: rt basal %, pd basal %, isc basal %, ∆isc carbachol %, ∆isc camp/forskoline %, ∆isc histamine %. conclusion:this first comprehensive analysis of the intraindividual variability of icm basal tissue and cl-secretion parameters provides the basis for the method as an useful outcome measure for future clinical trials aiming to rescue the cftr basic defect. possible effects of pharmacological therapeutics in cf relevant human epithelia have to be adequately interpreted with respect to subject variability and laboratories reference data. ex vivo cl-secretion measurements have the potential of being an essential step in the evaluation process of cftr-correcting/potentiating agents on their way from laboratory screening to the application in human cf tissue without any risk of toxicity. center, placebo-controlled, double-blinded pilot study we assessed safety and tolerability of . mg/d moli versus placebo (normal saline) administered by inhalation (pari lc plus) once daily for days. patients included were ≥ years of age in phase i and ≥ years of age in phase ii, with a fev > % predicted and stable lung disease. overall, subjects received moli and placebo. exclusion criteria included abpa, b. cepacia infection and severe liver disease. the study involved clinic visits over a period of weeks to assess adverse events, spirometry, pulse oximetry and quality of life. a total of adverse events (aes) were observed in subjects ( ae in subjects receiving moli ), with only (productive cough) in the moli group being of severe intensity. the most frequent aes related to the study medication were (productive) cough ( x) and dry throat/throat irritation ( x), and most of these resolved within hour after inhalation. in the moli group no significant ae, defined as a decline of fev ≥ % from baseline accompanied by symptoms, a decrease in oxygen saturation to < % or a fall of % from baseline requiring therapeutic intervention, or a change in safety parameters judged to be clinically significant was observed. this trial was not primarily designed to show efficacy; however, the median change in fev from day to day was - % in the placebo group, and + % in the moli group, and this difference was significant (wilcoxon test, p= . ). similarly, there was a significant difference between the median change in fef - % from day to day in the placebo group as compared to the moli group (- % vs. + %, p= . ). no significant changes were observed for the other study days or for fvc and pulse oximetry. moli was well tolerated in this trial, with the observed aes generally being mild and of short duration. these encouraging explorative results are currently being further evaluated in explorative and confirmatory trials. introduction: results from published data elucidate that microbes found in the upper respiratory tract are similar or the same as those found in the lower airways of cf patients. inhaled, aerosolized drug delivery to the lower respiratory tract is an established treatment route. however, drug delivery systems capable of depositing drug to the paranasal cavities are not yet established and require evidence of deposition and efficacy. pari developed the vibrent™ paranasal drug delivery system to enable the aerosol and drug to penetrate into the nose and sinuses. objectives: this study was conducted to demonstrate that the pari vibrent™ pulsating drug delivery system is capable of ventilating the human paranasal sinuses of healthy volunteers. methods: mkr-gas was continuously ventilated through the nasal tract of three healthy non-smokers in front of a single-head gamma camera (diacam, siemens, germany), using the pari vibent™ pulsating drug delivery system. the nebulizer was coupled to the right nostril and a flow resistor to an output tube was inserted into the left nostril. during ventilation with the krgas (about sec) the subject closed their soft palate to transmit the pulsation and to prevent penetration into the lower respiratory tract. the gas supply of the vibrent™ was directly taken from the mkr-gas generator output channel. kr-gas ventilation imaging was performed with and without pulsation. serial images were recorded with anterior and lateral views. additionally, mri (magnetic resonance imaging) lateral slices of the subjects' head were recorded. the gamma camera images were superimposed to the mri images by adjusting the spatial resolution. with no pulsation from the vibrent™ no ventilation of sinus cavity was visualized by gamma camera images and radioactivity was detected in the nose only. when pulsation was added the maxillary sinuses can be visualized in the gamma camera images of all volunteers. conclusions: without pulsation no ventilation was observed. gas penetration to the paranasal sinuses can be demonstrated using the pulsating action of the pari vibrent™, potentially enabling drug delivery via aerosols. this confirms results of in vitro studies using a cast model. mkr-gas ventilation of the nasal cavities during sec breath holding in front of a planar gamma camera head (anterior) using the pari vibrent without (w/o, left image) and with (w, right image) the pulsation system. the delivery and the exhaust tubing of the kr-gas are shown together with the outline of the head, obtained from mri pictures. introduction: pediatric patients with cf were previously studied in clinical trial studies of denufosol, a novel selective p y agonist that enhances ciliary beat frequency and activates chloride secretion to hydrate the airways in the lung. pediatric patients are often discouraged from participation in clinical trials until later stages of drug development. aims: in order to evaluate the safety experience with denufosol in this population, we have retrospectively examined integrated data for pediatric cf patients with mild to moderate pulmonary disease that participated in three phase studies. demographic and baseline characteristics in addition to safety and tolerability results for cf patients aged - years old are reported. methods: three phase , multicenter, randomized, double-blind, placebo-controlled, parallel group studies were conducted. patients were randomized to receive either denufosol ( , or mg) or placebo (normal saline) tid for days by inhalation. only study included denufosol mg, while all studies included denufosol mg and mg. the fev predicted normal required to be eligible was > % (study ); %- %, inclusive (study ); > % (study ). all three studies included a one-week pre-randomization period during which reproducibility of fev (l) ± % was required in order to be randomized to double-blind study medication. patients were allowed to use bronchodilators, dornase alfa and corticosteroids in studies , and . patients were allowed to use oral antibiotics including macrolides and inhaled tobramycin solution in studies and . results: a total of cf patients - years old were randomized and dosed in three -day studies. eighty-one received denufosol (active doses combined) and received placebo. demographics were similar for all treatment groups -denufosol pediatric patients had a mean (sd) age of . (± . ) years old compared to placebo pediatric patients who had a mean (sd) age of . (± . ) years. denufosoltreated patients were % male and placebo-treated patients were % male. the mean (sd) percent predicted fev at baseline was similar between treatment groups [ . % (± . ) and . % (± . ) for denufosol and placebo, respectively]. the overall incidence of treatment emergent adverse events (ae) was similar between treatment groups ( % denufosol, % placebo). the most common ae was cough, reported by % and % of patients that received denufosol and placebo, respectively. seven percent of denufosol and % of placebo patients prematurely discontinued from the study due to aes. there were no differences in compliance with administration of study drug ( % in patients given denufosol and % in patients given placebo). conclusion: doses of denufosol up to mg given tid for days were well tolerated in pediatric cf patients - years old. these data demonstrate that inclusion of patients - years old is feasible regardless of administration of denufosol or placebo. a longer term phase study of denufosol in cf patients > years old in north america is currently ongoing. acknowledgements: this research was funded by inspire and the cystic fibrosis foundation. objective: pulmonary delivery of anti-infectives provides the potential to attain pk-pd indices exceeding those which can be achieved with systemic dosing. mp- is a novel formulation of levofloxacin that enables delivery of high concentrations over a short period, and provides taste masking. the objective of this study was to: i) determine the safety of aerosol doses of mp- and, ii) determine pharmacokinetics of levofloxacin in serum, urine, and sputum following aerosol doses of mp- using the pari eflow nebulizer in normal healthy volunteers (nhv) and patients with cystic fibrosis (cf). methods: nhv and patients with stable cf were enrolled in a single within-subject ascending dose study of dose levels (loaded doses of , , and mg) of inhalational mp- (levofloxacin solution for inhalation) or placebo. study participants were monitored for safety and changes in pulmonary function. serum, urine, and sputum (cf patients only) samples were collected at various times following the dose and assayed for levofloxacin concentration using hplc. in addition, each participant received a single iv dose of levofloxacin to determine the systemic bioavailability following aerosol mp- . noncompartmental and compartmental methods were used to determine serum, sputum and urinary pharmacokinetic parameters. pharmacokinetic deconvolution methods were used to determine the amount of the dose remaining in the lung over time. results: this study is ongoing. dosing in nhvs ( active mp- , placebo) has been completed. there were no serious adverse effects, and no significant changes in pulmonary function were noted. preliminary pharmacokinetic data from nhvs show a proportional increase in serum levofloxacin concentrations with increasing aerosol mp- dose; serum aucs were . , . , . , and . mg-h/l for the iv dose, low, mid, and high aerosol doses, respectively. deconvolution of the serum levofloxacin concentrations from aerosol mp- and iv dosing shows absorption of drug from lung over time. conclusion: preliminary results show that mp- is well tolerated following aerosol administration in normal volunteers. serum concentration data following aerosol dosing suggests that absorption of levofloxacin into the systemic circulation is a major route of elimination from the lung. studies in cf patients are in progress and will be presented. methods: a mg/kg aerosol dose of mp- was given using a microspray aerosol generation device. when placed just above the tracheal bifurcation, and activated, it delivers a bolus aerosol dose to the lung. a mg/kg intravenous (iv) dose of lvx was given as a slow bolus into the lateral tail vein. plasma lvx was determined in all rats up to sacrifice at , , , or hours, at which time rats were humanely euthanized and bronchialalveolar lavage (bal) performed. fluids were analyzed for lvx concentration using an hplc/ms method. results: the plasma lvx versus time profiles of both iv and aerosol doses were best described by a two compartment model. the plasma auc after an iv dose of levofloxacin and an aerosol dose mp- were similar ( . mg᭹hr/l vs. . mg᭹hr/l, respectively) suggesting near % bioavailability from the lung. after an aerosol dose, the mean residence time (mrt) was prolonged when compared to the intravenous dose ( . vs. . hours). this delay in absorption was associated with an increase in bal lvx auc - h in bal ( . mg᭹hr/l vs. . mg᭹hr/l for iv vs. aerosol dosing, respectively). conclusion: these data show that levofloxacin is highly available to plasma following a single microspray aerosol dose of mp- . the aerosol dose does produce a slightly longer mean residence time in plasma, suggesting delayed, but complete absorption from the lung; this delay in absorption was associated with increase in bal aucs. these data suggest that high concentrations of lvx can be attained in lung fluids following an aerosol dose of mp- . auc: area under the time-concentration curve; cl: clearance; cmax: maximum concentration; f: bioavailability; mrt: mean residence time. methods: animals were assigned to one of five exposure groups for all studies. for the -day toxicology studies, animals were exposed for up to four hours daily for twenty-eight consecutive days, followed by a -day recovery period. respiratory function and cardiovascular safety were conducted on the first and last day of the -day study in dogs. rats were exposed to , , or mg/kg/day, and dogs were exposed to , , or mg/kg/day. at the conclusion of the study, necropsy was performed and all respiratory tissues were harvested, weighed, and underwent gross and microscopic examination. a separate dog respiratory safety study was conducted in which dogs were exposed to , , or mg/kg. results: four week repeat dose inhalational exposure of mp- at target doses up to mg/kg/day in dogs and mg/kg/day in rats was not associated with any test article-related changes in any respiratory tissues. aerosol administration of mp- at doses of up to mg/kg in dogs was found to have no acute effects on minute volume, tidal volume, respiratory rate, or ecg. conclusion: local effects due to the inhalational administration of levofloxacin formulated as mp- were not observed in either rats or dogs. these data suggest that the risk of respiratory toxicity from nebulized doses of mp- is low. methods: bacteria were grown overnight in mueller-hinton broth (mhb) at °c and then sub-cultured into fresh mhb and allowed to reach log phase ( hours). female swiss mice were infected under anesthesia by intratracheal instillation of . ml of a x cfu/ml bacterial suspension. ip doses were selected to provide lvx exposures (as auc) comparable to that obtained with systemic dosing regimens. for the p. aeruginosa infection, treatment was initiated by either the ip or aerosol route hours post-infection. mice were euthanized and hours after the start of treatment, lungs harvested, and bacterial counts in lung determined. results: lvx plasma pharmacokinetic profiles were nearly identical following intraperitoneal or aerosol dosing. the geometric mean log cfu/lung pair (sd) for the p. aeruginosa are shown in the table below: in both the k. pneumoniae and p. aeruginosa lung infection studies, aerosol administration was more effective than systemic administration; for k. pneumoniae, the extent of bacterial killing at hrs was ca. . log cfu greater with aerosol mp- than with systemic lvx. conclusion: aerosol administration of mp- produces a greater extent of bacterial killing than systemic dosing of lvx in mouse models of pneumonia due to k. pneumoniae and p. aeruginosa. the majority of morbidity and mortality in cystic fibrosis patients is caused by chronic and persistent lung infections especially with pseudomonas aeruginosa. since galactosyl ceramide had been previously shown to be involved in pseudomonas internalization, ceramide levels in the plasma of cf patients were assessed and compared to healthy volunteers using hplc followed by mass spectrometry. the results demonstrated that cf patients displayed significantly lower levels of several ceramide species. also, cftr-knockout mice displayed diminished ceramide levels in cf related organs (lung, pancreas, and ileum) and plasma compared to wildtype controls. treatment with a semi-synthetic retinoid (fenretinide), which was previously reported to induce ceramide in neuroblastoma cell lines, was able to increase ceramide concentrations in cf related organs in cftr-knockout mice to the levels of wildtype mice. treatment also dramatically improved the ability of cftr-knockout mice to control pseudomonas infection. following infection with pseudomonas-impregnated agar beads, fenretinide treated cftr-knockout mice were able to clear bacterial infection as efficiently as wildtype mice. overall, these findings not only documented a novel deficiency of ceramide in cf patients but also demonstrated a pharmacological means to correct this defect in cftr-knockout mice. our data provides a strong rationale for clinical intervention that may benefit cystic fibrosis patients suffering from cf lung disease. recent reports show that adult bone marrow-derived stem cells can localize to and acquire phenotypic and functional markers of lung epithelium. these findings raise the novel possibility of stem cell therapy for multitude of lung diseases. however, only small numbers of adult marrowderived stem cells localize to lung and it is not clear whether these cells will be clinically useful. we investigated whether mesenchymal stem cells (mscs) obtained from human cord blood might have increased potential to participate in structural lung remodeling. cord blood was obtained from normal deliveries at the university of vermont. mononuclear cells were isolated and plastic adherent cells were expanded and characterized as mscs according to international society for stem cells research (isscr) criteria. following systemic ( x cells/mouse by tail vein) administration to sublethally irradiated ( . gy) immunodeficient (nod/scid) mice, lungs harvested day, weeks, or months later demonstrated small numbers of human b -microglobulin positive cells in the airway epithelium at all time points. small number of cells was found also stain positive for pancytokeratin (pan-ck) and rarely, we identified cells of b -microglobulin+/pan-ck+ in the airway epithelium of these mice after weeks. we are currently characterizing the phenotype of these cells with ccsp and cftr but these data suggest that cb-mscs may be a potential alternative source of stem cells for use in lung remodeling. high-throughput screening (hts) and other drug development programs have identified cftr activators and potentiators that require secondary evaluation and mechanistic confirmation. we recently evaluated the cfft modulator library (rosalind franklin university, chicago, il) and found some, but not all, cftr potentiators induced potent phosphorylation of the regulatory-domain (r-d), conventionally viewed as the first step in cftr activation. to assess whether this observation has functional significance regarding ion channel activation by these agents, we evaluated cftr potentiators in cfbe o-and fisher rat thyroid (frt) cells stabily transduced with ∆f cftr. cells were studied in modified ussing chambers under control conditions and after correction of ∆f cftr misprocessing using either low temperature ( οc x hrs) or pre-incubation with the chemical corrector c . total currents were determined following potentiator (at reported ec ), forskolin ( µm), and genistein ( µm) stimulation. in temperature corrected ∆f cfbe ocells, potentiator (p , cfpot- ), an agent that does not induce r-d phosphyorylation, caused modest activation when acutely administered ( µm) ( . vs . µa/cm in vehicle treated cells, p < . ). importantly, this agent potentiated forskolin mediated short-circuit current (isc: . vs . µa/cm , p < . ). forskolin accounted for % (vs. % with vehicle) of total current, demonstrating potent rescue of camp dependent cftr activity, an effect not previously reported in this cell type (p< . ). in contrast, two cftr potentiators that induce r-d phosphorylation, p (uccf- , a benzoflavone intermediate, µm) and p (uccf- , an isoxazole, µm) induced modest direct activation of cftr ( . and . µa/cm respectively, p= . and p< . ), but no evidence of forskolin potentiation (p : . µa/cm , % of total stimulated current p=ns; p : . µa/cm , %, p=ns). in ∆f frt cells grown at low temperate, p elicited strong potentiation of forskolin mediated currents ( . vs. . µa/cm with vehicle, p < . ), and modest direct cftr activation ( . vs. . µa/cm , p < . ). p and p were limited to minimal (not significant) activation and no evidence of forskolin potentiation. in cfbe oand frt cells pretreated with c (to chemically correct ∆f cftr processing), p again potentiated forskolin mediated current ( . vs. . µa/cm with vehicle, p< . in the frt model) but did not directly activate i sc . findings with p and p were otherwise as seen with low temperature corrected cells. in summary, in ∆f cftr polarized epithelia, p both activates and potentiates cftr activity (with potentiation being the predominant effect, a unique observation in cfbe ocells), while p and p confer activation of cftr without forskolin potentiation. given that p and p induce r-d phosphorylation while p does not, our findings suggest that agents that do not confer phosphorylation of the r-d may be better suited to rescue the endogenous camp mediated component of i sc . screening of potential therapeutic agents for effects on r-d phosphorylation may help predict utility at restoring ∆f chloride channel activity. supported by nih and cff. activation of cftr is conventionally viewed as a two step process: pka-regulated phosphorylation of multiple sites within the regulatory domain (r-domain), followed by atp dependent gating mediated by binding sites at the interface of the two nucleotide binding domains (nbds). cftr 'potentiators', small organic molecules that overcome mutant cftr gating defects at the cell surface, have been proposed as therapies for cf. although a number of these agents are advancing to the clinical testing phase, their mechanism(s) of action are not well understood. as a step towards better characterizing cftr potentiators available through the cfft modulator library or other resources, we are developing standardized biochemical and functional assays to evaluate the r-domain during cftr activation in living cells. we have previously described a gel-shift method by which phosphorylation of isolated r-domain (residues - ) can be monitored. using this method, we have confirmed that one potentiator, p (cfpot- ), does not induce phosphorylation of the r-domain ( % of forskolin response, n= , p = ns). unexpectedly, two potentiators, p (uccf- , a benzoflavone intermediate) and p (uccf- , an isoxazole), robustly confer phosphorylation of the r-domain (p : % of forskolin response, n= , p = . , p : % of forskolin response, n= , p = . ). we found the phosphorylation conferred by either p or p could be inhibited with the pka inhibitor h ( µm). maximal stimulation of phosphorylation occurs within minutes, indicating time dependence similar to forskolin. importantly, neither p nor p increased total cellular camp, a finding confirmed by a number of other laboratories. the results may therefore implicate compartmental inhibition of cftr-associated phosphotases (eg. pp a) or phosphodiestereases (eg. pde ) as an underlying mechanism by which isoxazole or certain flavone-derivative compounds stimulate cftr. to further test this hypothesis, p , p and p are being examined for effects on ∆r-cftr chloride channel activity. these studies provide a means by which novel cftr potentiators can be biochemically categorized based on r-domain phosphorylation, a measure of the first step of cftr activation. compounds working through distinct mechanisms may have particular relevance to certain cftr mutations, and could provide synergy in the clinical setting. supported by nih and cff. mucociliary clearance (mcc) is an innate defense mechanism that protects the lungs from bacteria and viruses. mcc requires maintenance of a thin layer of airway surface liquid (asl) to eliminate inhaled particles. the asl volume is tightly regulated by a balance of ion and water transport across the airway epithelia. in cf, the loss of cftr clsecretion coupled with unregulated na + absorption via enac results in asl volume depletion and impaired mcc. although significant progress has been made in the identification of the basic disease mechanism in cf, therapeutic approaches that address abnormal cftr biogenesis are not currently available. the extracellular nucleotides atp and utp are important mediators of asl volume and mcc. in the airways, secreted atp acts on the g-protein coupled p y receptors to fine-tune mcc via the regulation of apical ion transport, ciliary beating, and mucin secretion. we have previously demonstrated that atp controls asl volume by inhibiting absorption through enac and increasing secretion through apical membrane chloride channels. p y receptor agonists are good candidates to treat cf. however, the rapid hydrolysis of atp and utp on the airway surface of cf patients limits the effectiveness of this approach. consequently, inspire pharmaceuticals has developed di-nucleotide molecules which retain the ability to activate p y receptors, but are more resistant to hydrolysis by ectonucleotidases. denufosol, inspire's lead compound for cf treatment, potently activates p y receptors to stimulate cl -/water secretion, ciliary beating, and mucin release in epithelial tissues. however, the stability and potency of denufosol has not been determined using human bronchial epithelial (hbe) cells. in primary cultures of hbes, denufosol was significantly more stable than utp. under thin-film conditions, the initial hydrolysis rate of a therapeutic concentration of denufosol ( mm) was . nmol × min - × cm - with a half-life of approximately hour. by comparison, denufosol is more than times more stable than utp on the mucosal surface of hbes. importantly, the increased stability of denufosol translated into an increase in efficacy for this compound in vitro. equipotent concentrations of denufosol and utp significantly increased asl height. however, denufosol produced maximum asl height increases that were both greater ( . % versus . % maximum increase over basal asl for denufosol and utp, respectively) and longer-lasting ( . % versus . % increase over basal asl following a minute application of denufosol and utp, respectively) compared to utp. furthermore, the asl height increases are specific for denufosol as the addition of apyrase blunts the response to utp, but not denufosol. our data demonstrate that denufosol is more stable than utp on the mucosal surface of human airway epithelia, which results in larger and more sustained increases in asl volume. recent phase ii clinical trials show that administration of denufosol over days was well tolerated and associated with improved lung function in mild cf patients. taken together, these data suggest that denufosol is a promising candidate molecule for cf therapeutics. mucociliary clearance (mcc) is the primary airway host defense against chronic exposure to infectious and noxious agents. mcc is dependent upon ciliary beating and the volume and composition of the airway surface liquid (asl). asl volume is regulated via isotonic fluid transport which is dominated by na + absorption in the superficial epithelium. in cf, unregulated na + absorption through enac drives asl volume depletion and a subsequent decline in mcc. the accumulation of mucus in the airways of cf patients supports persistent and life-threatening bacterial infection. increasing airway surface hydration represents a promising therapeutic approach for treating cf. in vivo, aerosolized osmotic agents such as hypertonic saline (hs) improve mcc and lung function in cf patients. however, the benefits derived from hs treatments are transient, as nacl is relatively rapidly absorbed by airway epithelia. previously, donaldson et al. (nejm ) tested the hypothesis that blocking na + absorption with the enac inhibitor amiloride would increase the efficacy and extend the benefit of hs. surprisingly, amiloride blunted the response to hs, which resulted from a previously unrecognized property of amiloride to inhibit aquaporin-mediated water transport. while potent inhibitors of enac would likely be of great benefit to the cf treatment milieu, the compounds then available were not adequate for this purpose. parion sciences has developed novel -substituted pyrazinoylguanidine compounds that selectively inhibit enac and are > -fold more potent than amiloride. in the present study, we evaluated the ability of two compounds, - and , to increase asl volume under thin film conditions. in primary cultures of human bronchial epithelial cells (hbes), - alone produced a small, but significant increase in asl height. in cf cultures exposed to phasic motion that simulates the shear stress generated by normal tidal breathing, - alone increased asl heights by . %. additionally, we tested the effects of - pre-addition in combination with % hs. as expected, hs alone produced a rapid and substantial increase in asl height ( . % by minutes) which declined to % bỹ hour post-treatment. pre-treatment of cultures with - prior to hs was both more potent ( . % by minutes) and longer-lasting ( % initial response at ~ hours) than hs alone. on normal hbes cultures, the compound alone increased the basal asl height by . % following a hour exposure. similar to - , in combination with hs likewise extended the longevity of the hs effect (t / ~ h versus ~ h for + hs and hs, respectively). by blocking na + absorption, the parion compounds alone increased asl volume in both normal and cf hbes. strikingly, when used in combination with hs, the parion compounds enhance and sustain the increase in asl volume associated with hs alone. our data demonstrate that the parion compounds alone are sufficient to increase basal asl volume. furthermore, these data provide a proof-of-concept that combinational therapies utilizing osmotic agents and compounds that regulate ion transport will provide therapeutic benefits to cf patients. methods: a total of patients (with fev ≥ % of predicted) received mg of arikace by inhalation for days. drug was administered using the pari lc star nebulizer. laboratory parameters, adverse events and pulmonary function tests were collected for all study subjects in order to determine safety and tolerability of arikace™. sputum samples were collected to determine changes in bacterial density, and amikacin pharmacokinetic parameters were assessed at selected time points in urine, serum and sputum specimens. change in fev , fev % predicted, fef - % and fvc relative to baseline and change in log cfu on days and were assessed. results: on day , and , the observed change for fef - % was . (p < . ), . (p = . ) and . l/sec (p = . ), respectively. on day and , the observed change for fev was . (p = . ) and . l (p = . ), respectively, and was . (p < . ) and . l/sec (p = . ) for fev % predicted. significant relationships (p ≤ . ) between log cfu and serum auc:mic ratio, and between changes in log cfu and fev , fev % predicted and fvc were identified. treatment was safe and well tolerated with the most frequent adverse events being dyspnea and headache of mild to moderate severity. conclusion: inhaled arikace™ mg/ml was well tolerated and in select patients improved pulmonary function. together these clinically relevant changes from baseline likely represent drug effect and warrant further development of liposomal amikacin for inhalation in patients with cf. allergic bronchopulmonary aspergillosis (abpa) is a disease caused by hypersensitivity to aspergillus fumigatus (af). the prevalence of abpa is approximately %- % of patients with cf and can contribute to worsening of their pulmonary disease. the treatment of abpa consists of high-dose oral corticosteroids for many months and may include also antifungal antibiotic such as itraconazole. the clinical effectiveness of corticosteroids is usually shown by an improvement in clinical symptoms and radiological parameters, as well as a reduction in total ige. the prolonged period of systemic steroids may cause significant side effects such as cushingoid appearance, hypertension, glucose intolerance and more. over the past years, we have used pulse high-dose methylprednisolone in patients with cf. method:all patients were diagnosed as suffering from abpa by the standard criteria as the may have mucoid impaction or central bronchiectasis on chest radiography, an elevated ige (> iu/ml), the presence of specific ige anti af and an elevated eosinophil count. the patient may have a positive skin prick test to af allergen. they were treated once a month with iv pulse high-dose methylprednisolone ( mg/kg/a day) for days once a month for several months until the total ige decreased to normal values. three patients were treated also with itraconazole. in patients itraconazole was discontinues due to side effects. results: we treated patients age - years old ( m/ f). four patient are pancreatic insufficient and pancreatic sufficient. ige was +/- ( - ) at the time of diagnosis and decrease to +/- ( - ). fev increased from +/- to +/- . the patients also gained weight and improved their chest x-ray finding. side effect were minor and mainly during the treatment days and resolved - days after each treatment and included malaise during the infusions, glucose intolerance on infusion days in one case, and hypertension in another case. conclusion: iv pulse steroid treatment should be considered in abpa as it was found effective with fewer side effects that should be expected from prolonged oral corticosteroid treatment. lung pathology in individuals with cystic fibrosis (cf) is linked to sodium hyper-absorption. the defective regulation of the epithelial sodium channel enac is thought to be a major contributor to reduced airway surface liquid (asl) volume and impaired mucociliary clearance of the airways. thus, strategies designed to inhibit enac function may result in clinical benefit. rna interference (rnai), mediated by short, double-stranded rna molecules, can be used to target complementary rna sequences for degradation via the rna induced silencing complex (risc). we investigated the possibility of using rnai to reduce expression of enac in the mouse lung, as proof of principle for a strategy to reduce sodium hyperabsorption in the cf lung. potent sirna molecules capable of efficient knockdown of enac alpha, beta and gamma subunits were identified in an optimised cell culture system utilising mouse kidney m cells ( , cells per -well; pmol sirna complexed with lipofectamine ; hour harvest) in which enac expression was quantified using real-time rt-pcr. approximately % knockdown of each enac subunit was observed with the most potent sirna molecules in this system. subsequently, sirna molecules were delivered to the lungs of female balb/c mice via hydrodynamic tail vein injection ( µg naked sirna, n= - ). after hours, lungs were harvested, rna extracted and enac mrna measured using real-time taqman pcr. whereas, enac subunit mrna levels in mice treated with a negative control sirna were not different from untreated mice (p < . ), delivery of enac alpha and beta-specific sirna molecules resulted in a reduction to . ± . % or . ± . % of the expression levels observed in untreated mice, respectively (p < . , mann-whitney u). interestingly, despite efficient knockdown in cell culture, in vivo treatment with the most potent enac gamma-specific sirna molecule led to no reduction in enac gamma expression compared with untreated controls (p > . ). these data show proof of principle that enac expression can be reduced in the lung using sirna. further work is needed to assess the functional consequences of inhibiting enac in the lung. gene therapy for cystic fibrosis lung disease will likely require longterm transgene expression; however, in the lung, many gene transfer agents have resulted in only transient gene expression. previously we have shown that the choice of enhancer/promoter elements has a strong influence on the duration of reporter gene expression following delivery of non-viral vectors to the mouse lung (gill et al., , gene ther, , . however, it is also possible that other elements of plasmid vector design play an important role. using a clinically relevant mouse lung aerosol model, we have studied the effect of varying the plasmid cpg-dinucleotide content on the duration of expression from plasmids that had an identical enhancer/promoter sequence. firstly we constructed a cpg-free plasmid vector containing a synthetic cpg-free luciferase gene under the transcriptional control of the human cmv enhancer/ef α promoter. secondly, we constructed a similar vector containing an identical enhancer and promoter but with a small number of cpg motifs, in the luciferase gene ( cpgs) and in the backbone sequence ( cpgs). we then investigated the level and duration of transgene expression following aerosol delivery of these plasmids complexed with the genzyme lipid gl to the lungs of balb/c mice ( . mg/ml pdna, mm gl , ml, pari lc+ nebuliser). total lung extracts were assayed for luciferase activity at days , , , & (n= per time-point). the cpgcontaining plasmid initially directed approximately -fold higher levels of reporter gene expression than the cpg-free plasmid (p< . both days and post-delivery). however, while expression from the cpg-containing plasmid subsequently fell slowly to background levels, expression from the cpg-free plasmid increased -fold to day , and remained at the peak levels observed with the cpg-containing plasmid until the end of the experiment at day (cpg-free plasmid -fold, -fold and -fold higher expression at days , and post-delivery respectively; p< . for each). these data suggest that the ability of a promoter/enhancer sequence to direct long-term expression in the mouse lung is dependent by the sequence of the plasmid backbone. one explanation for this observation is that a specific, but as yet unidentified, sequence exists in the cpg containing backbone that triggers transcriptional silencing. alternatively, the well-described host inflammatory response to cpg-containing dna, may be involved and the cpg content of the vector could be responsible for these differences. we are currently evaluating the potency and duration of effect of cftr expressing, cpgfree, plasmids in late-stage pre-clinical studies prior to the initiation of a further round of clinical studies of non-viral gene transfer in cf patients. background: novel approaches to cf therapy by improving/restoring cftr chloride channel function using gene therapeutic tools or small molecules are currently undergoing phase i and phase ii clinical trials. there remains a great need for accurate and practical methods of measuring cftr function in vivo to act as primary outcome measures of efficacy. we propose that an in vivo assay measuring cftr function in sweat glands offers several potential advantages over the nasal potential difference test. objective: to develop a reliable test of sweat gland function that is capable of measuring the range of cftr function in vivo. methods: we are performing repeated measures of sweat gland function in healthy controls (n= ), obligate heterozygotes (n= ), pancreatic sufficient (cfps, n= ) and insufficient cf patients (cfpi, n= ). sweat secretion is stimulated by iontophoresis ( µa/cm ) with % pilocarpine. to elucidate the most sensitive and discriminatory parameter of sweat gland function within this study group we are performing simultaneous measurements of: a) the transglandular potential difference of a stimulated skin area using an ecg electrode (espd) and b) single sweat gland potential differences in single sweat glands (spd). using a wescor® collector cup we also measure: c) sweat secretion rate and (d) sweat chloride concentration (sweat cl-). results: we report interim results of our ongoing study (table) . sweat rate was not different between the groups, but a gender difference was observed (mean±sd; male: . ± . µl/min/cm ; female: . ± . µl/min/cm , p< . ) as previously described. our preliminary data show that espd as well as sweat cl-allow good discrimination among healthy controls, cfps and cfpi (p< . and p< . respectively). spd show similar trends to espd but with greater overlap (differences not significant). conclusion: these encouraging preliminary results, particularly the espd method and sweat cl-following stimulation with a lower iontophoretic current, justify further efforts to complete enrolment of subjects and to further refine technical challenges such as minimizing the effect liquid junction potentials across the ecg electrode. results will also be compared to the classical sweat test using higher iontophoresis current and npd measurements in these patients. this study is supported by the ccff and genome canada. ino- , a prodrug, has been demonstrated to inhibit nasal potential difference (pd)in human cf nasal airway epithelia and cf mice and this effect is more potent with repeated dosing. as such it is being developed as potential therapeutic for cystic fibrosis. ino- cell entry is facilitated by its hydrophobic propionoxy(methyl)ester protecting groups which can be hydrolyzed by intracellular carboxyesterases after the prodrug enters the cell. once the protecting groups are removed, the drug (ino- ) with the ether-linked octyl group is expected to be more slowly metabolized. however, the precise kinetics of the uptake of ino- , its conversion to its active metabolite, and methods. confluent cultures of hela or t cells were incubated for varying periods of time ranging from min to hrs with medium containing [ h] ino- ( x cpm/ml) and µm ino- cold carrier to ascertain the rate of uptake. in pulse chase experiments after cultures were incubated for hours, they were washed and incubated with media without radiolabel for varying periods of time. after the indicated times, the media was removed and the cells were washed, harvested, extracted and the aqueous and organic extracts subjected to sax and reversed phase hplc respectively. results ino- , a prodrug, has been demonstrated to inhibit nasal pd in human cf nasal airway epithelia and cf mice and this effect is more potent with repeated dosing. ino- cell entry is facilitated by its hydrophobic propionoxy(methyl)ester protecting groups which can be hydrolyzed by intracellular carboxyesterases after the prodrug enters the cell. once the protecting groups are removed, the drug (ino- ) with the ether-linked octyl group is expected to be more slowly metabolized. however, it is not known whether the mucus present in cf airways could impede its access to airway epithelia or whether ino- would cross the epithelial layer to enter the bloodstream. here, in order to address these issues we measured its uptake into human tracheal epithelial sheets in the presence and absence of mucus and compared its transepithelial permeation to mannitol. we studied the uptake and transepithelial fluxes of [ h]ino- in primary cultures of human tracheal epithelium with transepithelial resistance of from to ohms.cm . the mucosal surface of some tissues was rinsed three times with pbs to remove mucus for comparison with control cells which were not rinsed. elisa for human airway mucins performed on the rinsings confirmed that three rinses sufficed to remove the mucosal mucous blanket. the development of long-term, safe and efficacious gene therapies for lung disease will require efficient gene delivery to stem cells which produce the differentiated progeny of affected epithelial tissues. recombinant lentiviral vectors are being considered for gene therapy applications for the lung because they can efficiently transduce a wide variety of stem and progenitor cell types. however, it is of concern that strong constitutive viral promoters have produced oncogenesis in x-scid patient recipients of retroviral vectors in part due to the disregulation of proto-oncogenes by the strong viral promoter/enhancer located near the integration site. we propose that regulation of transgene expression to the tissue or cell type of interest will enhance the safety of gene therapy for respiratory disease. in this study we have investigated the potential for respiratory specific transgene expression from integrated lentiproviruses in cell lines in vitro and in mice in vivo. the lentiviral vectors constructed for this study contained regulatory elements predicted to produce lung specific transgene expression: the surfactant protein c promoter (spc) for alveolar epithelial type ii cell (aecii) expression, the clara cell kd protein (cc ) for clara cell expression in the airway, and the jaagskiete sheep retrovirus (jsrv) promoter for expression in both cell types. transgene expression from the spc and cc vectors was restricted to aecii and clara cell lines respectively, while expression from the jsrv vector was observed in multiple respiratory and non-respiratory cell types. following intra-tracheal delivery of lentivector supernatant to mice, transgene expression was observed in aecii from the spc lentivector (n= mice), and in clara cells from the cc promoted lentivector (n= mice). transgene expression was not detected in non-respiratory tissues following intravenous delivery of cc and spc lentiviral vectors to neonatal murine recipients (n= and n= respectively). in summary, incorporation of genomic regulatory elements from the spc and cc genes resulted in respiratory specific transgene expression in vitro and in vivo. these vectors will provide a useful tool for the study of lung biology and the development of gene therapies for lung disorders such as cf. cystic fibrosis (cf) is associated with chronic pulmonary inflammation and progressive lung dysfunction, associated with the formation of oxidants derived from neutrophil myeloperoxidase (mpo). indeed, respiratory tract levels of mpo are extensive, and have been found to correlate with decreases in respiratory parameters or disease severity in cf. mpo-derived oxidants thus may play a role in perpetuating the progressive lung dysfunction associated with cf. based upon these premises, we reasoned that mpo could represent a novel therapeutic target for the treatment of inflammatory diseases such as cf. herein we report that substituted urea and thiourea compounds are potent inhibitors of mpo. utilizing tetramethylbenzidine (tmb) as a classical heme peroxidase substrate, we screened a large number of structurally varied urea and thiourea derivatives. alkyl, cycloalkyl, and aromatic ureas and thioureas all proved to be effective mpo inhibitors, however, with a high degree of variability in potency. of those compounds examined, substituted phenylthioureas proved to be the most potent mpo inhibitors. various ortho-, meta-, and para-substituted phenylthioureas (ptus) were then assessed for inhibitor potency. the most potent inhibitor of mpo was -chlorophenylthiourea (ic = nm, ki = nm). the potency of ortho-ptus as mpo inhibitors showed a linear relationship with ortho sigma substituent constants (reflecting resonance, steric and inductive effects). moreover, cyclic voltametry experiments with ortho-substituted ptu compounds revealed a linear relationship between inhibitor potency and thiourea oxidation potential. this correlation is indicative of a substituent effect on the relative ease of sulfur oxidation within the thiourea moiety. this finding suggests that the redox-active sulfur plays a crucial role in mpo inhibition, perhaps via a direct interaction with the heme of mpo. thioureas proved to also inhibit the chlorinating activity of mpo, whereas sustituted ureas were not effective in this regard. both ureas and thioureas were also effective inhibitors of dityrosine formation by mpo. these findings will help facilitate the rational design and optimization of mpo inhibitors with even greater potency, which could serve as novel therapeutic agents for the treatment of cf. gene therapy is the transfer of a normal copy of the cftr gene and should, in theory, provide a long-term cure for cf. the development of prenatal screening programs for cystic fibrosis has provided an opportunity to identify cf patients in utero, and may provide an opportunity to treat the disease before birth, prior to the onset of disease symptoms. the long-term goal of our study is to investigate the therapeutic potential of delivering the normal cftr gene to epithelial stem cells in fetal cf mice by in utero administration of recombinant lentiviral vectors carrying the normal cftr gene. this would provide us with the unique opportunity to "correct" the chloride channel defect in the epithelial stem cells, which give rise to the epithelial cells in the tissues affected by cf at a very early stage. the aim of the current study is to optimize the in utero gene delivery of recombinant lentiviral vectors, carrying an egfp reporter gene to epithelial stem cells in fetal mice. mice have been used for these studies, as mouse strains with a variety of cf mutations are available. in all studies, the uterus was exteriorized following a mid-line laparotomy, and the injections were made directly into the amniotic fluid of individual fetuses. in the first studies, the survival of pregnant females and pups following saline injection at e . (n= ) and e . (n= ) was evaluated. all five females survived the procedure and an average of % ( / ) of the pups present at the time of injection were born alive. this experiment demonstrated that the surgical procedures were reasonably safe. in the next experiments, we injected . ul lentiviral supernatant (~ . x iu/pup) into the amniotic fluid of each pup and evaluated the effect of the gestational age pups on transduction efficiency. the pregnant mice were allowed to carry the fetuses to term. at p , p and p , - pups of each litter were sacrificed and skin, trachea, lung, stomach and intestines were harvested for analysis of gene transfer and egfp transgene expression. all but one pup ( / ) from the e . time point aborted prior to parturition. from the e . and e . injections, / and / pups were born naturally, respectively. at e . and e . , proviral sequences were observed in the skin, trachea and stomach, although the level of transduction varied among individual fetuses and tissues. immunofluorescence analysis on the skin of one mouse with a high proviral copy number demonstrated that some of the egfp positive cells were also positive for vimentin or f / , markers of mesenchymal cells and macrophages, respectively but negative for pancytokeratin. our preliminary studies suggest that in utero gene therapy with lentiviral gene delivery may be safe, however ongoing studies will provide more in depth analysis on safety and feasibility of delivering the normal cftr cdna to epithelial stem cells in the tissues affected by cf in utero. future studies will investigate the therapeutic potential of delivering a lentiviral vector containing the cftr gene to fetal pups in a murine model of cf. supported background & objectives: cystic fibrosis is characterized by progressive loss of lung function resulting from chronic bacterial infection and concomitant airway inflammation. while a number of bacteria are known pathogens in cf, mounting evidence suggests that the lungs of cf patients harbor numerous bacterial species, and that interactions within this ecosystem may affect outcomes. however, the composition of this community is not well characterized. we therefore initiated work to profile the bacterial diversity of the lungs of cf patients with end-stage disease by s rrna gene sequencing. methods: genomic dna was purified from snap-frozen explanted lung tissue of randomly selected cf patients undergoing transplantation in toronto between and . bacterial s rrna genes were amplified from each sample using broad-spectrum pcr primers, and pcr products used to generate s rdna libraries for each patient. s rdna profiles for each patient were generated by automated dna sequencing of up to randomly selected clones per library, and tentative species assignments made by comparison to known s rrna gene sequences using phylogenetically-based analyses. results: sequence analysis of s rdna sequences from this preliminary set of patients (avg. = sequences/patient; range = - ) demonstrates a range of complexity of the microflora in cf lungs, with some patients showing a single dominant organism and others showing multiple co-existing species. in total, over species have been identified to date in this set of patients. these include species identified previously by clinical microbiology, including pseudomonas aeruginosa (detected in / patients), and burkholderia species (detected in / patients known clinically to be infected). numerous organisms not previously reported in the lung were also identified, including several from the taxonomic order burkholderiales. interestingly, while organisms commonly associated with cf were detected in patients transplanted throughout the year, a cluster of four plant-associated species demonstrated striking seasonal variation in rates of detection. conclusions: the lungs of cf lung transplant patients harbor a diverse bacterial community. sequencing of s rrna genes is a powerful method to profile this diversity. correlation of these profiles with clinical information may help identify new patterns of infection and important interactions between species in this community. introduction and aims: pulmonary infection, primarily with pseudomonas aeruginosa, is the leading cause of morbidity and mortality in cystic fibrosis (cf) patients. we have demonstrated that anaerobic bacteria, belonging primarily to the genera prevotella, veillonella, propionibacterium and actinomyces, can be cultured from the sputum of cf patients. the aim of this study was to determine the antibiotic susceptibility of these anaerobic isolates grown planktonically and as biofilms. methods: the planktonic susceptibility of anaerobic isolates to antibiotics used in the treatment of cf (meropenem, piperacillin/tazobactam) as well as to antibiotics traditionally used to treat anaerobic infection (clindamycin, metronidazole and ampicillin) was examined using e-test® strips. selected anaerobic isolates were grown as biofilms for or hours in well trays prior to challenge with antibiotic. bacterial biofilm formation was determined using crystal violet. results: the planktonic susceptibility of anaerobic isolates ( prevotella, veillonella, propionibacterium, actinomyces and additional isolates) comprising different genera was determined. although all of the anaerobic isolates examined were sensitive to meropenem when grown planktonically, high levels of resistance to the anti-anaerobic drugs, metronidazole and clindamycin were observed. examining susceptibility by genera, the veillonella were the most resistant to piperacillin/tazobactam and the propionibacterium the most resistant to metronidazole. furthermore, several isolates, including of the prevotella isolates examined, were found to be resistant to multiple antibiotics. the susceptibility of anaerobic biofilms to antibiotics was found to be isolate and antibiotic dependent. generally antibiotic treatment of hour old biofilms was often able to eradicate biomass and prevent biofilm formation; however, antibiotic treatment after hours of biofilm formation with up to x the mic of an antibiotic often failed to eradicate the biofilm. conclusion: these results suggest that alternative antibiotic treatment regimes may be necessary to treat cf pulmonary infection if anaerobes are present. these results also suggest, based on in vitro susceptibility, that meropenem and not metronidazole or clindamycin would be the most effective antibiotic in treating any anaerobes present in cf pulmonary infection. early eradication protocols for the first appearance of pseudomonas aeruginosa (psa) have become standard practice in many cystic fibrosis (cf) clinics. the details of such protocols often vary significantly between clinics, making it important to compare efficacy from one approach to another. however, comparison of reported results is currently very difficult. this is not only because of variations in completeness of reporting, but especially because calculation of average time to regrowth cannot by definition include patients who remain free of psa regrowth at the time the "average" is calculated (nor those in whom a re-appearance of psa is found to be due to a different strain). such results would be better expressed using "time to event" (tte) statistics (analogous to "life tables") and different protocols can be better compared using this methodology. we report for the first time, results from our psa early aggressive eradication protocol for the period - , expressed using tte statistical analysis. children are seen in clinic on average times yearly for full assessment, and at each clinic visit sputum or pharyngeal cultures obtained by the physiotherapist. standard treatment for "first growth" pseudomonas aeruginosa consists of weeks of intravenous antibiotics (piperacillin mg/kg/day plus tobramycin mg/kg/day) followed by weeks of oral ciprofloxacin ( - mg/kg/day) and inhaled colymycin ( mg bid) for months. a total of treatment courses have been completed for the period - with a % clearance rate, defined as or more consecutive negative cultures for pseudomonas aeruginosa over months. since the initiation of this protocol, the percentage of patients colonized with psa in our cf pediatric clinic has declined from % in , down to % in . subsequent regrowth of psa occurred in / of patients. treatment courses may then be repeated a second, third, or fourth time. to determine whether these repeat psa isolates are newly acquired or identical to the previous isolate, rapd typing of these isolates is routinely assessed. a total of isolates have been rapd tested and have identified the same strain as the previous isolate in ( %) and a different strain in ( %)treatment courses. the average time to regrowth for those who had a recurrence of psa following this treatment protocol was months, but this does not include those patients who have had no further growth of psa for periods up to years. to reflect the results for all patients, including those who have not as yet had further regrowth of psa, we have constructed tte curves. these measures can be used to compare results using our protocol with results from other approaches to clearing pseudomonas aeruginosa in cf. retsch-bogart, g.z. inhaled antibiotics have been part of the therapeutic armamentarium for patients with cf for decades. we studied the effect of inhaled aztreonam on respiratory symptoms in cf in a phase , double blind, placebo (pl) controlled trial of azli, a novel formulation of aztreonam, which enrolled patients with cf from centers in the us, canada, australia, and new zealand. all patients have completed study participation. inclusion criteria included age ≥ years, pa in sputum or throat swab, fev ≥ % to ≤ % predicted, and no use of anti-pseudomonal antibiotics in the previous days. following a day screening period, patients were treated for days with either azli mg or pl. study drug was administered tid using the pari eflow® electronic nebulizer after pre-treatment with bronchodilator. concomitant standard cf therapies were allowed, with the exception of anti-pseudomonal antibiotics, azithromycin and hypertonic saline. the primary endpoint was change from baseline to day in scores from the cystic fibrosis questionnaire-revised (cfq-r) respiratory domain, a validated patient-reported measure of respiratory symptoms. other efficacy measures included change in pulmonary function (fev , fvc, and fef - ), number of hospital days and number of courses of iv, oral or inhaled anti-pseudomonal antibiotics. microbiological endpoints included change in pa bacterial density in sputum, change in susceptibility of pa to aztreonam, and emergence or disappearance of other pathogens. safety evaluations included adverse events, airway reactivity (defined as acute decrease in fev ≥ % at minutes after dosing) and clinical chemistry and hematology. complete efficacy and safety results from this trial will be presented. salam, a.p.; orchard, c.; wee, a.; hodson, m. introduction: oral ciprofloxacin is often used for pseudomonas aeruginosa (psa) infections in patients with cystic fibrosis (cf) not requiring intravenous antibiotics. oral chloramphenicol is commonly used at the royal brompton hospital (rbh) as an alternative to ciprofloxacin, but less so in other cf centres due to concerns about aplastic anaemia and uncertainty regarding effectiveness. this study aimed to address three questions: ) what proportion of psa is sensitive to ciprofloxacin and/or chloramphenicol? ) were there any adverse haematological effects with the use of oral chloramphenicol at rbh? ) how effective is chloramphenicol in comparison to ciprofloxacin? study design: we carried out a retrospective review from the rbh cf database ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) together with analysis of patients' notes. methods: ) psa sensitivities to ciprofloxacin and chloramphenicol were recorded from sputum samples taken in late . ) all blood dyscrasias in patients who had received chloramphenicol from to were reviewed. ) the database was searched for patients who had received a course of either oral chloramphenicol or ciprofloxacin from to . patients from each group were randomly selected. fev , fvc and oxygen saturations pre and post treatment completion were analysed, as were markers of symptom improvement. results: ) sputum samples from patients grew psa. some were sensitive to only one antibiotic, and there were some cross-sensitivities, but in total . % were sensitive to chloramphenicol and . % to ciprofloxacin. ) patients received oral chloramphenicol and oral ciprofloxacin from - . multiple courses were often given, but usually no more frequent than monthly with chloramphenicol. over years, cases of blood dyscrasia were recorded, none due to chloramphenicol, and all recovered. ) in the ciprofloxacin group: the mean oxygen saturations improved by . % (p . ), the mean fev improved by . % (p . ), and the mean fvc by . % (p . ). in the chloramphenicol group: the mean oxygen saturations improved by . % (p . ). ), the mean fev improved by % (p . ) and the mean fvc improved by . % (p . ). % of patients in the chloramphenicol group and % of patients in the ciprofloxacin group reported symptom improvement. a significant proportion of psa is sensitive to chloramphenicol and in over years there have been no documented cases of related aplastic anaemia. clinical improvements with choramphenicol comparable to ciprofloxacin were also recorded. our data shows chloramphenicol is safe and may be the oral antibiotic of choice in ciprofloxacin allergy or psa resistance to ciprofloxacin. a randomised prospective study is needed to further evaluate the efficacy of chloramphenicol in comparison to ciprofloxacin. pseudomonas aeruginosa lung infections are one of the main factors causing disease in cf patients. at present the generally recommended treatment is repeated courses of antibiotics. this has resulted in fewer infections and a markedly improved prognosis for the patients. but it has also severe drawbacks such as antibiotic resistance, disturbed normal flora and allergenicity. antibiotic resistance is an emerging problem world wide and alternatives are urgently needed. specific chicken antibodies, anti-pseudomonas igy, have potential both as an alternative and a complement to antibiotics (pediatr pulmonol ; : ) . anti-pseudomonas igy prevents p. aeruginosa from adhesion to epithelial cells and has affinity for flagellin in vitro. humans do not produce anti-igy antibodies and oral administration of igy is generally regarded as safe. the risk that bacteria should develop resistance to igy is extremely low. in total, cf patients have received antipseudomonas igy for up to years. since november, the drug is given to a group of cf patients (at present patients) on individual permissions granted by the swedish mpa and reimbursed by the swedish government. in our first study about the effect of igy there were . positive cultures/ months, compared to . / months in a control group. up to december , , nearly five years later, the effect is maintained with . / months for the whole study period. we are at present compiling the data from the control group during the same period. only two siblings in the igy-treated group have been chronically colonized (with an identical p. aeruginosa strain), which still is non-mucoid after . and . years. during the whole treatment period there have been no cultures positive for mucoid p. aeruginosa or b. cepacia and other pathogens (s. maltophilia, a. xyloxidans, atypical mycobacteria and a. fumigatus) have only appeared sporadically -possibly due to the relatively low use of antibiotics. all patients have preserved pulmonary functions and nutritional status. there have been no adverse events. thus treatment with anti-pseudomonas igy has diminished the number of positive cultures and delayed the onset of chronic infection. the need for antibiotics is reduced as well as their adverse side effects. in conclusion, igy is an important complement to antibiotics for prevention of p. aeruginosa infections in cf. introduction and aims: we have previously shown by culture that the lungs of clinically stable cystic fibrosis (cf) patients are not only colonised by commonly recognised aerobic bacteria, such as pseudomonas aeruginosa, but also by a range of potentially pathogenic anaerobic species. the aim of this study was to determine whether anaerobes are also present in the sputum of cf patients with an acute exacerbation of pulmonary infection. methods: sputum samples were collected and processed using strict anaerobic bacteriological techniques, prior to commencing and at the end of antibiotic therapy, from adult cf patients admitted for treatment of an acute exacerbation of pulmonary infection. bacteria within the samples were detected by plating on selective agars, quantified by total viable count and identified by pcr and sequencing of s ribosomal rna genes. as a control induced sputum samples were collected, using hypertonic saline, from healthy volunteers who did not have cf and processed using similar methods. results: anaerobes from a range of species including prevotella, veillonella, propionibacterium, actinomyces and gemella were detected in high numbers (up to x cfu/g of sputum) from all patients prior to commencing antibiotic therapy with the predominant primary pathogens (p. aeruginosa or b. cepacia complex) detected in similar numbers. anaerobic bacteria were also detected in sputum samples at the end of antibiotic treatment and for / ( %) patients they were present in lower numbers than detected before antibiotic treatment. moreover, in / ( %) patients there was greater than a one log reduction in the total viable count of anaerobes. similar data for detection of the predominant aerobic pathogens was also collected for of these patients. p. aeruginosa or b. cepacia complex was present in lower numbers following antibiotic treatment in / ( %) patients and in / ( %) patients there was more than a one log reduction in the total viable count. anaerobes were not detected in the induced sputum samples from volunteers and in the remaining samples they were present in much smaller numbers, ranging from to cfu/g of induced sputum, than detected in cf sputum. the most commonly isolated bacteria from the induced sputum samples were the actinomyces and streptococcus, with prevotella cultured from only samples. no veillonella and propionibacterium species were isolated from the induced sputum samples and combined with the low frequency of isolation of prevotella species, these results strongly suggests that the prevotella, veillonella and propionibacterium species recovered from cf sputum samples are not oral contaminants. conclusion: these results indicate that anaerobes are present in large numbers within the cf lung during an acute exacerbation of pulmonary infection. their presence could be of important clinical relevance to cf patients as they may contribute significantly to the inflammatory process. airway infection and inflammation cause the majority of morbidity and mortality in cystic fibrosis (cf). the microbiology of cf is complex. not only are the routinely identified pathogenic bacteria present, increasingly a number of other bacteria are associated with pulmonary disease. in addition, the normal microbiota likely contribute to airway disease in cf via intracellular signaling, but remains largely unstudied. the application of culture independent methods for bacterial identification in cf airway secretions provides for the first time the ability to characterize the bacterial communities in the cf airway comprehensively and efficiently. here we present the results of a two-year study of cf airway samples to describe the bacterial communities present by ribosomal rna sequences. we have examined airway specimens from subjects ( cf, controls). these results provide a unique perspective on cf airway microbiology. bacterial communities identified in sputum were more complex than communities identified in bronchoalveolar lavage fluid (balf). however, pulmonary status determined the level of complexity, with higher complexity observed during stable pulmonary function. we identified a collection of anaerobic bacteria that were present at high levels during pulmonary exacerbation in a subset of cf subjects. detection rates ranged from - % of cf subjects examined depending on the specific organism (table ). these organisms of interest are suspected to be involved in pulmonary exacerbation especially when cultures for standard cf pathogens are negative (~ % in our center). preliminary data will be presented from quantitative real-time pcr experiments to track these organisms. we also will present the application of new meth-ods for community comparisons. this analysis provides the ability to look at how clinical information from individuals with cf corresponds to the microbial communities that occur in the airway. overall, the results point to a much richer bacterial community associated with the cf airway than previously thought. the results also point to new opportunities to understand the differences within the cf population, and thus potentially improve individual patient outcomes. cystic fibrosis (cf) patients are characterized by persistent microbial colonization of the airways and recurrent pulmonary infection. however, due to the domination of bacterial communities present in cf sputum by a small number of species (typically pseudomonas aeruginosa), culture-independent approaches to characterize the depth of bacterial diversity in cf sputum have yielded limited information. here we describe application of a novel microarray, the s rrna phylochip to comprehensively describe the bacterial diversity present in temporal sputum samples of cf patients who experienced periods of exacerbation (defined as hospitalization) and remission. in addition, these samples permitted assessment of bacterial community dynamism during periods of antimicrobial administration in these patients. phylochip analysis identified bacterial taxa present across these patient samples, including a large number of known human pathogens. antimicrobial administration caused a profound decrease in bacterial diversity in all patients examined. despite this, a sizeable fraction of each community remained stable or proliferated during the period of antimicrobial administration, suggesting many of the bacterial taxa present were resistant to the antimicrobials administered. taxa exhibiting this behavior included p. aeruginosa, arcobacter cryaerophilus, streptococcus constellatus and burkholderia mallei amongst other pathogens. these results suggest that complex polymicrobial communities exist in cf sputum that exhibit significant antimicrobial driven dynamism and consist of multiple antimicrobial resistant pathogens. future studies will focus on whole community gene expression to determine which virulence systems are activated in response to bacterial community perturbations and contribute to pathogenic processes in cf airways. the lungs of chronically infected cystic fibrosis (cf) patients have been intensively studied. it is well documented that pseudomonas aeruginosa is the predominant pathogen in cf (høiby , baurnfeind et al. , koch , and that p. aeruginosa accumulates in heaps (aggregates), detected in cf sputum (høiby ) and intraluminal in the lung (baltimore et al. ) . the bacterial density is highest in the bronchi (potts et al ) and these p. aeruginosa microcolonies are embedded in a matrix (lam et al. ) . the morbidity of the infection is due to an extensive and ongoing pmn response which apparently does not eradicate the bacteria, instead leading to slow degradation of the lung. in addition, even highest deliverable doses of antibiotics fail to clear the bacteria completely, though survival has significantly increased the last years due to aggressive anti p. aeruginosa therapy (koch and høiby ) the present study was performed to investigate the significance of the aggressive therapy for the distribution of p. aeruginosa and how p. aeruginosa is organized and persists in the cf lung. the material used was: autopsies from dead short term colonized cf patients (n= ) obtained before today's aggressive antibiotic treatment , and explanted lungs from long term p. aeruginosa infected cf patients (n= ) (i.v. antibiotics every rd month since + inhalation of colistin daily since . histological sections of the lungs were investigated using he stain, gram stain, alcian blue, antibodies against alginate and p. aeruginosa specific pna-fish combined with bacuni pna-fish and with dapi as counter stains. due to the high specificity of the pna-fish probes employed in this study, our results provide strong evidence for that before the aggressive antibiotic therapy, p. aeruginosa infected and destroyed the cf lung due to fast spreading into the respiratory zone. today antibiotics suppress but can not eradicate the bacteria from the conductive zone, whereas the remaining respiratory zone is protected from massive biofilm infection for prolonged time. the conductive zone serves as a reservoir; here the bacteria are organized in microcolonies embedded in puss, a trait which is independent on the time course of the infection and amounts of antibiotics. these microcolonies consisted solely of p. aeruginosa. in addition, we found no bacteria adhering to the epithelial tissue. the pus consisted mainly of leukocytes, surrounding the microcolonies. a smear of dna and dead leukocytes were detected just around the microcolonies, possible due to the quorum sensing dependent rhamnolipid killing recently described by us (jensen et al. ) . we conclude that p. aeruginosa persists in the cf lung due to its ability to create microcolonies i.e. biofilms. within these biofilms the bacteria are protected against antibiotics and the host defence. respiratory viral infections, including influenza (flu) and respiratory syncytial virus (rsv) contribute to the morbidity of children with cf. additional human respiratory viruses have been identified in children such as human metapneumovirus (hmpv) and coronavirus (cov), but these have not been examined in cf patients. in our laboratory, pcr assays have been developed to identify both traditional and newer respiratory viruses in healthy and immunocompromised children. these assays are usually performed on nasal swabs or nasal wash samples. however, oropharyngeal (op) and sputum samples are routinely obtained in cf for bacterial culture. the goals of this trial are to determine whether these available samples can be used for viral pcr studies and to examine the epidemiology of respiratory viruses in cf. for this single center observational trial, cf patients, ages . to . yrs (mean . yrs), have been recruited. subjects provide op and nasopharyngeal (np) samples at quarterly clinic visits and with acute pulmonary exacerbations requiring hospitalization; sputum is also collected if patients can expectorate. np and op samples are pooled when both are available. viruses assayed are flu a and b, rsv, parainfluenza (piv) , , and , hmpv, cov, adenovirus (adv), and rhinovirus (rhv). subjects are being followed for two respiratory viral seasons. we report here the methodology of viral pcr detection in cf sputum, as well as the results of viral detection during the first respiratory viral season in the seattle community. the mean length of time subjects were followed was . yrs (median: . yrs, range: . - . yrs). overall, samples ( % of the samples analyzed) were positive. twenty-four subjects ( . %) had at least one viral infection detected and ( . %) had two viruses at different visits. both sputum and pooled op/np samples were available at visits and were concordant in % of cases. among the discordant cases, it was more common for sputum to be positive and op/np to be negative ( . %) than the converse ( . %). the most frequently identified viruses were rhv ( isolations); piv and cov were the next most prevalent with and isolations, respectively. in conclusion, sputum viral pcr shows promise for the diagnosis of both traditional and novel viral infections in cf. as part of ongoing clinical trials in cf, non-fermenting gram negative bacilli (nfgnr) identified at site laboratories are often sent to the tdn core microbiology laboratory for confirmation of identification. among nfgnr from cf patients, p. aeruginosa are the most frequently isolated and also are acknowledged to be the easiest to identify. however, in a survey of "p. aeruginosa" isolates sent to the laboratory in the past year, pcr identified ( %) as alternate species. these included: non-aeruginosa pseudomonads, stenotrophomonas maltophilia, achromobacter xylosoxidans, ralstonia spp., alcaligenes spp., brevidimonas spp., and bordetella bronchiseptica. identification of these nfgnr can be difficult; however, p. aeruginosa is an important isolate for the clinical microbiology laboratories in all cf centers to be able to identify. many methods are available including conventional biochemical testing and rapid identification kits. in the tdn core laboratory we previously demonstrated the importance of combining phenotypic identification (morphology plus a short set of biochemical tests) and genotypic identification ( s rdna sequencing of v and/or pcr using three primer sets) and developed an algorithm for testing. in this study, we examined all of the cf cultures performed in the clinical microbiology laboratory at chrmc over the past two years to determine the number of isolates for which it was necessary to perform genotypic identification in nfgnr. among this collection of nfgnr from clinical cultures sent to the microbiology laboratory from the seattle children's hospital cf center, pcr identified isolates as burkholderia cepacia complex. next most commonly identified were a. xylosoxidans ( ), p. aeruginosa ( ) and non-aeruginosa pseudomonas spp. ( ). three isolates remained unidentified, even with pcr sequencing of the v determinant. the clinical microbiology laboratory at chrmc has served as the core microbiology laboratory for tdn clinical trials for years and thousands of cf samples are processed annually. the result is that there is increased experience with cf isolates among the laboratory personnel. however, even with experienced technologists, a significant number of nfgnr required genotypic identification in the past two years. thus, it is important for clinical microbiology laboratories with less experience in the identification of cf nfgnr to utilize additional molecular techniques or send problematic isolates to a reference laboratory. based on these results we propose an algorithm for the most efficient means of identifying nfgnr from cf samples using a combination of tests including phenotypic (colony morphology, biochemical testing) and genotypic identification (pcr, sequencing). background: the epidemiology of s. aureus has been changing in both cf and non-cf patients. in non-cf patients, methicillin-resistant s. aureus (mrsa) has traditionally caused infections in patients with risk factors such as hospitalization, surgery, and anterior nares colonization. recently, community-acquired (ca-) mrsa infections have increased among patients without known risks. in cf, colonization of the anterior nares with methicillin-susceptible s. aureus (mssa) is associated with transmission between patients and household members. the prevalence of respiratory tract colonization/ infection with mrsa has increased in cf, but little is known about risk factors for mrsa, including possible transmission among families, and if strains are ca-or healthcare-acquired. methods: this is a case-control, multicenter study to investigate potential risk factors for mrsa among children with cf - years of age. subjects are enrolled from cf centers in the new york metropolitan area that have a mrsa prevalence ranging from % to %. cases are children with a positive respiratory tract culture for mrsa within the past years. controls ( age and center matched per case) are negative for mrsa. the aims of the study are: [ ] to determine the point prevalence of anterior nares colonization with s. aureus in children with cf and their household members; [ ] to assess potential risk factors for mrsa by administering a survey to the parents of subjects inquiring about factors such as crowding, pets, and participation in contact sports and by reviewing the medical record for antibiotic use, hospitalization, and surgery; [ ] to determine potential transmission of s. aureus within families and centers by assessing the molecular epidemiology of strains using pulsed field gel electrophoresis and meca type of mrsa isolates. results: to date, cf subjects ( cases, controls), mean age . years, and household members ( to per subject) have been enrolled. preliminary data demonstrate positive anterior nares cultures among cases, controls, and household members to be / ( %), / ( %), and / ( %), respectively. of the s. aureus isolates, were mssa and were mrsa ( cases, household members of cases, and household members of controls). during the past months, household members have been hospitalized and one has stayed overnight in a nursing home; had staphylococcal infections and had skin infections. data collection and molecular analysis are ongoing. conclusions: we expect this study to provide insight into risk factors for respiratory tract colonization/ infection with mrsa, the role of ca-mrsa in cf, and potential strategies to prevent mrsa. aims: . revise infection control guidelines for the institution . establish outpatient infection control policies consistent with those used for hospital inpatients . cohort young and recently diagnosed cf patients without pseudomonas or mrsa to clinic days separate from colonized patients . establish a protocol for eradication of mrsa in newly colonized patients. methods: working with representatives from hospital epidemiology, the cf center, inpatient units, outpatient clinics, respiratory therapy, and cf families, a uniform infection control policy for cf patients in all settings (inpatient, outpatient, home care) was drafted and revised. arrangements were made to cohort newly diagnosed patients and children < years free of pseudomonas and mrsa to separate clinic days from colonized patients. review of the mrsa positive patients in our pediatric population, for whom data was available, showed median age of acquisition of years (range mo to yrs). for patients the first culture obtained at diagnosis or transfer from another center was mrsa positive ( mo, yr, yr). an eradication protocol for newly acquired mrsa has been developed involving treatment with oral and topical antibiotics and phisohex or clorox washes for days, plus changing disposable respiratory care equipment at the beginning and end of the treatment period. surveillance cultures of nose, groin, and airway or sputum are done after completion of the treatment protocol and re-treatment initiated if still positive for mrsa. conclusion: using a three-tiered approach of infection control guidelines, cohorting, and mrsa eradication protocol we expect to decrease our overall rate of mrsa and protect our newly diagnosed and young cf patients from acquisition. objective: studies have shown that respiratory pathogens can be transmitted within cf centers. in a recent cross-sectional study at cf centers, we assessed the rate of bacterial shedding by cf patients during office visits and noted that % of patients carried respiratory flora on their hands. the current study was performed to assess the effectiveness of alcohol-based rubs on hand carriage of respiratory pathogens by patients during the course of office visits. methods: four bacterial organisms were chosen for study: pseudomonas aeruginosa (pa), staphylococcus aureus (sa) [including methicillin-resistant (mrsa) strains], stenotrophomonas maltophilia (sm) and burkholderia cepacia complex (bcc). at the beginning of clinic visits, hands of study patients were cultured using the "glove-juice" technique (gjt) [ ] . hand hygiene was then performed using an alcohol-based rub. at the end of the visit, hands were again sampled using the gjt. samples were sent to the microbiology laboratory at dartmouth-hitchcock medical center for culture and identification of study organisms. hand and respiratory tract isolates were compared using pulsed field gel electrophoresis (pfge). recovery experiments were also performed to assess the sensitivity of the gjt. results: samples were collected from encounters ( adult; pediatric). median encounter time was min (range . - . min). recovery experiments determined that the level of detection for each study organism using the gjt was ~ colony forming units. confirmation of matches between hand and respiratory isolates was determined by pfge. the number of patients with study organisms recovered from the respiratory tract was: pa, sa, mrsa, sm, and bcc. the overall hand contamination rate with a matched respiratory tract isolate at either culturing time was % ( % ci, . - . %). before use of the alcohol rub, hand contamination was . % ( % ci, . - . %). in those patients with hand contamination by respiratory pathogens prior to alcohol rub, . % ( % ci, - %) had negative cultures at the end of the clinic visit. however, there was strong evidence of hand contamination during the encounter, despite hand hygiene, as the overall rate at the end of visits was . % ( % ci, . - . %). there was a trend toward increased hand contamination in those suffering from pulmonary exacerbations versus clinically stable patients ( . % [ % ci, . - %] vs. . % [ % ci, . - %], p= . ). conclusions: contamination of patient hands by respiratory tract pathogens is observed in the outpatient setting in approximately % of patients. a single application of an alcohol-based hand rub, while safe and inexpensive, has limited antiseptic effectiveness during the full course of a typical cf clinic visit. repeated use of alcohol-based hand rubs during outpatient encounters would likely be more effective. these data support recent recommendations in the cf foundation consensus guidelines for infection control [ ] (nthi) is the most common initial bacterium infecting the airways in cystic fibrosis (cf). nthi infection usually precedes pseudomonas aeruginosa infection in many chronic lung diseases, including cf, emphysema, diffuse panbronchiolitis, and immotile cilia syndrome. it is hypothesized that nthi acts as a gateway organism paving the way for subsequent infection with p. aeruginosa, however, the mechanism by which this occurs remains poorly understood. we used a novel co-culture model of persistent nthi biofilm infection on airway epithelial cultures to study epithelial immune responses following nthi biofilm infections. objective: we hypothesized that prolonged exposure to nthi biofilms causes airway epithelia to become tolerant to inflammatory stimuli and show subsequent decreased innate immune responses. methods: nthi were inoculated onto the apical surface of calu air-liquid interface epithelia and grown in co-culture. rna from sets of paired airway epithelial cultures at , , and hours both with and without nthi inoculation was isolated and hybridized on custom affymetrix chips. data were normalized with rma and data biases were removed using the mixed model anova method. differentially expressed gene analyses were performed using anova, and pathways analyses were performed using gene set enrichment analysis (gsea). to test the hypothesis that prolonged nthi infection induces tolerance, epithelial cultures were pre-treated with either days of nthi or days of pbs before stimulation with pbs, il β ( ng/ml) or th cfus of live p. aeruginosa before subsequent measurement of epithelial responses. results: both rma and gsea analyses of microarray data showed many innate immune and pro-inflammatory responses at early timepoints that largely returned to baseline after days of co-culture, despite an increasing apical nthi biofilm infection. stimulation with il β or p. aeruginosa after days of nthi infection resulted in significantly decreased il production compared to uninfected controls. nthi treated cultures subsequently infected with p. aeruginosa also displayed increased tight junction integrity and resistance to cell culture death. conclusions: persistent nthi infections on airway epithelia resulted in increased tolerance to bacteria and inflammatory stimuli and increased resistance to bacterial toxicity. airway epithelial tolerance may contribute to a failure to clear subsequent bacterial infections. these phenomena would help to explain how early infections with nthi may promote chronic bacterial infections and p. aeruginosa acquisition in cf and other nthi related airway diseases. the colonization of cf airways by p. aeruginosa leads to intractable and persistent lung infections that resist permanent eradication by antibiotics. the lack of efficacy of current therapies is believed to be due to the formation of p. aeruginosa antibiotic resistant biofilms in the cf airways. however, little is known about biofilm formation on human airway epithelial cells. thus, we designed a continuous flow, live cell imaging system to grow p. aeruginosa biofilms on glass or on the apical surface of polarized human cells. cfbe ohuman airway epithelial cells homozygous for the ∆f mutation (cfbe), and cfbe o-cells complemented with wt-cftr (cfbe+wt-cftr) were grown as polarized monolayers at an air-liquid interface and gfp-labeled p. aeruginosa were applied to the apical surface of the cells. after hours biofilms did not form on glass but large bacterial macrocolonies developed on cfbe cells. surprisingly, biofilms also developed on cfbe+wt-cftr cells: however, p. aeruginosa biomass on cfbe+wt-cftr cells was significantly reduced compared to cfbe cells ( . ± . µm /µm vs . ± . µm /µm ). the minimal bactericidal concentration for tobramycin was > , µg/ml for p. aeruginosa grown on cfbe and cfbe+wt-cftr cells. these results explain why tobramycin given clinically, which is~ , µg/ml in bronchoalveolar fluid collected from cf patients, fails to eradicate the persistent infection by p. aeruginosa. p. aeruginosa also formed biofilms on human bronchial epithelial cells, which produce mucus. indeed, biomass was similar on cfbe+wt-cftr cells, which do not produce mucus, and human bronchial epithelial cells. to determine if human airway epithelial cells secrete factors that facilitate biofilm formation, conditioned medium was collected from cfbe and cfbe+wt-cftr cells and applied to p. aeruginosa grown on glass. under these conditions, biofilm formation was dramatically facilitated, with a biomass of . ± . µm /µm when p. aeruginosa was grown in conditioned medium collected from cfbe+wt-cftr cells and . ± . µm /µm when grown in conditioned medium collected from cfbe cells. the secreted factor(s) were greater than kda, as assessed by size exclusion. our results suggest that human airway epithelial cells secrete factor(s) that facilitate biofilm formation by p. aeruginosa, in the presence and absence of mucus, and that secretions from cf cells are more effective in promoting biofilms than secretions from non-cf cells. the ability of non-cf cells to facilitate biofilm formation appears to contradict the observation that non-cf lungs do not harbor p. aeruginosa. we propose that the innate immune response in the non-cf lung effectively eliminates p. aeruginosa from the lung, thus, biofilms do not form even thought the airway epithelial cells secrete factors that have the potential to facilitate biofilm formation. however, in cf when mucociliary clearance is compromised, p. aeruginosa accumulates in the lung and secretions by cf airway epithelial cells greatly enhances the formation of drug resistant biofilms (supported by the nih (ro ai , ro -hl- , p -rr , t -dk- ), and the cff (stanto ro, anders fo). ma, l. ; parsek, m.r. ; wozniak, d.j. . microbiology and immunology, wake forest university health science, winstonsalem, nc, usa; . university of washington, seattle, nc, usa bacteria in natural, industrial and clinical settings live in surface-associated communities termed biofilms, which are the source of persistent infection and resistance to antimicrobial treatment. biofilm development is initiated by the attachment of planktonic cells to a surface, followed by formation of microcolnies, and finally disperses swimming cells from microcolnies to occupy a new surface. to maintain the community structure, bacteria in a biofilm are usually enmeshed in an extracellular polymeric matrix, which consists of nucleic acids, proteins, and polysaccharides. exopolysaccharides (eps) have been known as a component of the biofilm matrix for years. however, little is know about how the eps matrix forms and develops and whether an eps can form a matrix independently. in the present report, we use lectins that specifically detect the mannose or galactose structure in pseudomonas aeruginosa psl eps. this technique allows us to visualize psl eps on the bacteria cell surface and in the biofilm matrix. our results indicate that psl eps is likely anchored on the cell surface in a helical pattern and clearly forms a matrix, which holds bacteria in the biofilm and on the surface. in a flat multiple-layer biofilm, psl eps is equally distributed in the entire biofilm. however, microcolonies reveal peripheral staining of psl eps with minimal staining of matrix in the center of the microcolonies. instead, this region has swimming cells indicating a biofilm development stage prior to dispersion. more strikingly, this area also has concentrated dead cells and/or extracellular dna, which fills up the viod spaces in the lower center of microcolonies at the stage prior to dispersion. these data provides a plausible mechanism for how p. aeruginosa sacrifices a portion of cells to make void spaces and free another portion of cells for future dispersion. in addition, our data also show that psl eps matrix and dna matrix are not overlapping, which suggests that these two components of the matrix work coordinately to encase bacteria in the biofilm. finally we show that the psl eps matrix is present in biofilms formed by mucoid p. aeruginosa, and formation of the psl eps matrix is independent of the production of alginate and pel, two eps that also contribute to p. aeruginosa biofilm formation. overall, our data indicates that psl eps functions as a primary scaffold, holding biofilm cells together in the matrix. moreover, our data along with published literature suggest a possible model for how p. aeruginosa biofilms persist in cystic fibrosis patients. . clinical microbiology, rigshospitalet, copenhagen, denmark; . biocentrum, technical university of denmark, kgs. lyngby, denmark; . department of paediatrics, copenhagen cystic fibrosis centre, rigshospitalet, copenhagen, denmark pseudomonas aeruginosa predominates chronic lung infections in patients with cystic fibrosis (cf). a hallmark of chronic p. aeruginosa lung infections in cf patients is the presence of mucoid p. aeruginosa biofilms surrounded by numerous polymorphonuclear leukocytes (pmns) in the lower airways. how p. aeruginosa escapes the bactericidal pmns is not fully understood. several virulence factors of p. aeruginosa is controlled by quorum sensing (qs); a density dependent mode of inter-bacterial communication based on signal transmitter molecules. active qs is present during chronic p. aeruginosa lung infections in cf patients and we have previously demonstrated a qs-regulated tolerance of biofilm bacteria to the antimicrobial properties of the pmns. the precise qs-regulated effect on the pmns is, however, unknown. in the present study, further elaboration using flow cytometry and microscopy revealed that qs-competent p. aeruginosa (pao and ∆rhli lasi complemented with c -hsl and -oxo-c -hsl) induces rapid necrosis of the pmns. this mechanism was also observed in in vitro biofilms and in mouse lungs infected with p. aeruginosa embedded in alginate. by using hplc fractionation the toxicity could be ascribed to a single substance. using lc-ms and d nmr this substance was identified as rhamnolipid b. in accordance, concentrations of rhamnolipid exceeding µg/ml were found in the toxic supernatants from wild-type p. aeruginosa (pao ) whereas non-toxic supernatants from qs-deficient knock-out mutants (∆rhlr lasr and ∆rhli lasi) and from ∆rhla mutants contained low amounts of rhamnolipids approaching µg/ml. our results demonstrate the potential of the qs system to facilitate infections with p. aeruginosa by utilizing rhamnolipid to disable a major first line of defense of the host -the pmns. furthermore, our study emphasizes the inhibition of qs as a target for the treatment of infections with p. aeruginosa. carlsson, m. , ; pettersson, a. ; andersson, c. ; wieslander, j. ; eriksson, l. ; segelmark, m. ; hellmark, t. . dept of microbiology, immunology, and glycobiology, university of lund, lund, sweden; . department of nephrology, lund university, lund, sweden; . heart lung division, the cystic fibrosis center, lund university hospital, lund, sweden; . wieslab analys ab, lund, sweden the clinical consequence of chronic pseudomonas (p) aeruginosa colonization in cystic fibrosis (cf) varies between individuals for unknown reasons. auto-antibodies against bactericidal/ permeability increasing protein (bpi-anca) are associated with poor prognosis in cf. we hypothesize that there is a correlation between the presence of bpi-anca, the biological properties of the colonizing bacteria and the clinical conditions of the hosts. we have compared isolates of p aeruginosa from two groups of cf patients: one with positive serum levels of bpi-anca and deteriorating lung disease, and one with negative bpi-anca levels and stable clinical conditions. epithelial cells (a ) and isolated polymorphonuclear granulocytes (pmns) were stimulated with the clinical isolates and cell death was analyzed with flow cytometry. interleukin- (il- ) released into the supernatant was measured by elisa. we found that the anca associated strains in most cases showed a pyocyanin negative phenotype. these strains also induced less inflammatory response than the non-anca associated strains as shown by the number of necrotic cells and il- release, yet elevated compared to control. we conclude that colonization with strains of p aeruginosa that induce a weak inflammatory response is associated with unfavourable outcome in cf. we speculate that inadequate control of pathogen proliferation through an insufficient inflammatory response results in a slowly increasing number of bacteria and accumulation of dying pmns in the airways, contributing to the progressive lung disease seen in many cf patients. . pulmonary critical care, northwestern university, chicago, il, usa; . microbiology/immunology, northwestern university, chicago, il, usa; . pulmonary medicine, children's memorial hospital, chicago, il, usa; . pediatrics, children's memorial hospital, chicago, il, usa purpose: most cystic fibrosis (cf) patients are infected with pseudomonas aeruginosa (pa) and have progressive loss of lung function. among individual patients, however, there are marked differences in rates of lung function deterioration. although the reasons for this variability are not completely understood, it is likely that microbiological factors play a role. type iii secretion in pseudomonas aeruginosa (pa) isolates from non-cf patients have been associated with poorer outcome. the aim of this study was to determine whether there is an association between type iii secretion properties and deterioration in lung function in cf. methods: we prospectively enrolled cf children and adults over years. demographics, clinical characteristics, spirometry and a respiratory culture were obtained at the first visit. the age at time of first postive pa culture was also determined. subsequently, spirometry and respiratory cultures were obtained and clinical characteristics recorded every months until december . from each sputum culture individual isolates were selected for evaluation and type iii secretion was evaluated for each isolate by western blot analysis. the children were subcohorted into those newly infected ( st positive pa culture) or those chronically infected (minimum sputum pa (+) > year duration). results: there were patients evaluated, of which were adults and were children. ninety percent of our population cohort was caucasian and % were female. overall % of the patients were on tobi and % on macrolides chronically. the mean age at time of a first pa positive culture was years for the chronically infected subjects(adults and children) and years for the st time infected subcohort. a total of sputum samples were collected for the current study. the prevalence of type iii secretion properties for the overall population was . %. foe adults, of ( . %) pa isolates were type iii secretion positive compared to of isolates ( . %) in chronically infected children and of isolates( . %) from newly infected children. at study entry the mean fev % predicted was +/- for the whole cohort. for the adult subcohort the fev % predicted was % +/- %, for chronically infected children it was % +/- % and newly infected children is was %+/- %. the average annual rate of fev % change was - . % for adults, - . % for chronically infected children and + . for newly infected children. analysis on the relationship between type iii secretion pa isolates and fev % decline is ongoing and will be presented at nacf. conclusion: prevalence of type iii secretion in pa isolates from cf patients decreases with age. there is a slower decline in fev % in chronically pa infected adults compared to chronically pa infected children. the relationship of type iii secretion to fev % change and pulmonary exacerbations will be presented at nacf. a limited number of bacterial species -in example pseudomonas aeruginosa, staphylococcus aureus, burkholderia cepacia complex, stenotrophomonas maltophilia -is typically found in the cf lung. these facultative anaerobic bacteria exhibit the capability to switch from aerobic to anaerobic metabolism, which enables them to survive in the hypoxic environment in the cf lung [ ] . absence of oxygen would also favour the growth of fastidious anaerobes and, indeed, sequencing of s rrna resulted in the detection of strict anaerobic species in cf sputum [ ] . thus, we identified and quantified strict anaerobes in cf sputum using conventional anaerobic microbiological methods, examined the recovery rate of identical species in sputum samples from the same patients, and determined the antibiotic susceptibilities. sputum samples were collected from cf children and cf adults (mean age . ± . yrs). samples were incubated aerobically on columbia agar, supplemented with % sheep blood, and anaerobically on brain heart infusion agar and schaedler agar supplemented with % mutton blood, for up to days. bacteria were identified (rapid ana ii identification system, remel, lenexa, ks) and cfu's were determined by dilution plate counting. fastidious anaerobes ( strains) were submitted to e-test ® susceptibility testing (ab biodisk, solna, sweden) using the anaerobically active antibiotics ceftazidime, clindamycin, meropenem, metronidazole, and piperacillin/tazobactam. in . % of the patients, the following strict anaerobes were detected with a mean of . x cfu/ml (range . x to . x cfu/ml): peptostreptococcus spp., clostridium spp., actinomyces spp., prevotella spp., wolinella spp., propionibacterium spp., streptococcus spp., lactobacillus spp., gemella spp., bacteroides spp. and eubacterium spp., whereas p. aeruginosa, s. aureus and b. cepacia revealed . x cfu/ml (range . x to . x cfu/ml). in sputum samples contaminated with p. aeruginosa together with strict anaerobes . x ± . x cfu/ml p. aeruginosa were counted, whereas in samples with p. aeruginosa without strict anaerobes only . x ± . x cfu/ml were found (p= . ). for s. aureus, no significant difference was observed. identical strict anaerobic species were detected in out of patients with two or more repeated sputum samples ( %). e-test® sensitivity testing for strict anaerobes yielded high sensitivity for meropenem (only . % resistant strains), piperacillin/tazobactam ( . %), and clindamycin ( . %), but not ceftazidime ( . %) or metronidazole ( . %). high numbers of strict anaerobes are present in the majority of cf patients. possibly, strict anaerobes promote growth of p. aeruginosa but not s. aureus. the high persistence of identical anaerobic strains reflects chronic lung infection and may be caused by their increased resistence against standard antibiotics such as ceftazidime. [ in sputum in the cf lungs bacteria such as pseudomonas aeruginosa have to metabolize anaerobically [ ] . for anaerobic energy generation, p. aeruginosa can use nitrate and arginine, but also pyruvate which is produced from glucose via anaerobic glycolysis [ ] and can be metabolized to lactate and vice versa. in order to investigate if p. aeruginosa may benefit from externally produced lactate, we measured the concentration of lactate in p. aeruginosa, staphylococcus aureus, burkholderia cenocepacia and polymorphonuclear neutrophils in vitro and in cf sputum. in sputum samples of cf patients and in neutrophils ( x /ml) from healthy donors lactate concentrations were determined. in addition, p. aeruginosa (starting with x cfu/ml in tryptone soy broth), s. aureus ( x cfu/ml), and b. cenocepacia ( x cfu/ml)were grown aerobically ( through hrs) and anaerobically ( through days). l-lactate was measured spectrophotometrically (detection limit: . mmol/l), and total lactate gaschromatographically. aerobic and anaerobic gene expression of p. aeruginosa strain pao was determined using affymetrix® microarrays. lactate concentrations in cf sputum amounted to . ± . mmol/l (range . to . mmol/l). concentrations were similar in sputum samples colonized with p. aeruginosa, s. aureus ( . ± . vs. . ± . mmol/l, p= . ) and b. cenocepacia ( . mmol/l). neutrophils produced . mmol/l. in all samples exclusively l-lactate was found. during in vitro experiments, p. aeruginosa did not generate any lactate at all, neither aerobically nor anaerobically. in contrast, anaerobically grown s. aureus produced up to . mmol/l lactate, and b. cenocepacia up to . mmol/l. a p. aeruginosa suspension [ x cfu/ml] spiked with mmol/l l-lactate did not change its concentration, indicating that p. aeruginosa does not metabolize lactate. similar results were obtained in our gene chip experiments: after three days of anaerobic growth, the genes encoding for the lactate dehydrogenases were downregulated (pa ldha - . fold, pa llda - . fold) or unchanged (pa lldd . fold). in contrast, the genes encoding for pyruvate decomposition to acetyl coa (pa and pa , both encoding for pyruvate dehygrogenase e components) were upregulated by and fold, respectively. we could demonstrate that p. aeruginosa does not benefit from externally produced lactate. we confirmed the important role of pyruvate metabolism for anaerobic p. aeruginosa energy generation. whether lactate production of neutrophils, s. aureus or b. cenocepacia contributes to cf lung pathophysiology still remains to be investigated. references: [ ] macleod, d. ; barker, l. ; gurgel, j. ; kenney, t. ; burns, j. ; baker, w. . gilead sciences, inc., seattle, wa, usa; . university of washington, seattle, wa, usa antibiotic resistance may severely limit therapeutic options in individuals with cystic fibrosis (cf) or bronchiectasis. because of frequent antibiotic treatment courses, resistance continues to emerge, even to newer agents. treatment with multiple antibiotics in a single aerosol formulation may be a promising approach to slow development of resistance. fosfomycin is a phosphonic acid antibiotic that is bactericidal against both gram positive and gram negative organisms. fosfomycin inhibits the first committed step in the synthesis of peptidoglycan, suggesting cross resistance to other cell wall acting antibiotics will not occur. the aminoglycoside tobramycin is one of the most commonly used antimicrobials in cf, with potent activity against gram negative bacteria and the majority of staphylococcus aureus isolates. a : (wt/wt) fixed combination of fosfomycin:tobramycin (gs- / ) was used to determine the in vitro susceptibilities of a panel of respiratory pathogens: cf pseudomonas aeruginosa ( ), s. aureus ( ), haemophilus influenzae ( ), stenotrophomonas maltophilia ( ) and burkholderia cepacia complex ( ), including minimal inhibitory concentration (mic) and time-kill experiments in the absence and presence of % porcine mucin. synergy was evaluated using the checkerboard method, and spontaneous resistance mutation frequencies were determined in antibiotic-containing agar ( x, x and x mic). in vivo drug efficacy was examined using a rat agar bead pneumonia model of either p. aeruginosa or s. aureus. all experiments compared gs- / to fosfomycin and tobramycin as single agents. gs- / had a lower mic than tobramycin for the s. aureus strains, % of which were methicillin resistant (mrsa). for p. aeruginosa, gs- / had a lower mic and mic than fosfomycin alone, but tobramycin was more active than either. for h. influenzae and s. maltophilia, gs- / , fosfomycin and tobramycin had similar mic and mic . b. cepacia complex were resistant to all three drugs. results in the presence of mucin were similar. time-kill studies showed a more rapid and prolonged killing of s. aureus and p. aeruginosa by gs- / compared with either agent alone at the same drug concentrations. gs- / was bactericidal and exhibited concentration-dependent killing. synergy studies showed no antagonism between fosfomycin and tobramycin, and the majority of p. aeruginosa and all of the s. aureus tested demonstrated indifference for the combination. at x mic concentrations the mutation frequency of gs- / was at least - logs lower than tobramycin and - logs lower than fosfomycin alone for s. aureus. for p. aeruginosa the mutation frequency of gs- / was - logs lower than fosfomycin and - logs lower than tobramycin. in the rat pneumonia model, gs- / and tobramycin alone demonstrated bactericidal killing of p. aeruginosa; both were more active than fosfomycin alone. in vivo killing of s. aureus by gs- / was also demonstrated. gs- / appears to have advantages over single agents for the treatment of both gram positive and gram negative bacterial lung infections in cf and bronchiectasis. britton, l.j. antibiotic resistance is becoming a major problem in the treatment of pulmonary exacerbations in cystic fibrosis (cf). organ-isms that are resistant to multiple antibiotics infect the airways of an estimated - % of adults with cf. as a result of the growing resistance in cf patients, many centers have been performing synergy testing of sputum cultures in addition to the conventional culture and sensitivity testing. the purpose of our investigation was to determine if antibiotic synergy studies and the use of synergistic combinations of antibiotics improve therapeutic outcomes in cystic fibrosis patients with acute pulmonary exacerbations. methods: this study is a retrospective chart review of cf patients who had antibiotic synergy testing performed while hospitalized for respiratory tract infections. eligibility criteria included cf patients hospitalized with respiratory tract infections from to . laboratory data from each hospital admission was reviewed for synergy among those antibiotics commonly used against pseudomonas aeruginosa. a review of medical charts ascertained each patient's pulmonary function (determined by fev before and after antibiotic therapy), weight z-score, organism cultured from sputum sample, time to next hospital admission, and the antibiotic(s) actually prescribed. primary endpoints were determined to be the change in fev and the time to next admission. results: four hundred seventy-five hospital admissions were analyzed. a total of cystic fibrosis patients, age birth to years, were included in the study. patients receiving antibiotic synergy experienced a significant decrease in mean time to next admission ( days with synergy vs. days without synergy, p= . ). no significant difference was found in the change in fev before or after antibiotic therapy, with an increase of . % with synergy vs. . % without synergy (p= . ). patients infected with non-mucoid p. aeruginosa experienced days to the next hospital admission, while patients infected with mucoid p. aeruginosa experienced days to the next hospital admission (p = . ). no statistically significant difference was observed between the synergy and non-synergy groups in regards to nutritional status and lung function prior to antibiotic therapy. speculations: antibiotic resistance in cystic fibrosis patients increases the morbidity and mortality caused by this disorder with each exacerbation the patient experiences. synergistic antibiotic therapies should improve patient outcomes through more efficient bacterial eradication and increased time to next hospital admission; however, we were unable to substantiate this assumption based on the results from this study. synergistic antibiotics did not show an improvement in the therapeutic outcomes of days to next admission or change in fev . background: expectorated sputum (es) technique is currently the most frequently used method for routine assessment of lower airway infection in patients with cystic fibrosis (cf). induced sputum (is) using hypertonic saline (hs) has been successfully used in cf patients unable to produce sputum spontaneously, but only limited data are available comparing the diagnostic yield of expectorated versus induced sputum in cf patients. while ultrasonic nebuliser have been used in the majority of studies, new high output jet nebulisers may offer a suitable alternative technique to induce sputum expectoration. aim: to assess the feasibility of sputum induction using a pari e-flow nebulizer and to compare the diagnostic yield of is and es in children with cf . methods: this is a preliminary report of an ongoing study in routine clinical care in sputum producing children with cf. es is being obtained before sputum induction. subsequently, sputum induction is performed using stepwise inhalation of nebulized ml of %, % and % hypertonic saline with an e-flow nebulizer (pari, starnberg, germany). lung function is assessed by portable spirometry before the procedure and after inhalation of each saline concentration. results: so far cf patients ( females) with a mean age of . years (range to years) and fev between - % predicted (mean %) have been included in the study. all subjects provided es samples and all produced sputum after induction. discrepancies in cultures between es and is samples were seen in cases ( . %). in cases additional cf pathogens were found in is samples, whereas in cases es yielded additional organisms compared to is. the number of distinct pathogens was similar in the remaining patient, but different bacteria were found with the techniques. in cases p. aeruginosa was detected only with one of the techniques ( es versus is). the spectrum of side effects was similar to previous reports using other nebulizer systems, with throat irritation being the most common adverse event of the is technique. all patients who had symptoms during the procedure became asymptomatic at the time of discharge from the clinic - minutes after the procedure. patients did not finish all cycles of sputum induction procedure due to symptoms of shortness of breath and/or drop in fev > % from baseline (in patients); all reversed after salbutamol inhalation. vomiting occurred in one patient. patients refused to complete the procedure due to unpleasant taste and/or throat irritation. conclusion: these preliminary results show discrepancies between expectorated sputum and induced sputum cultures in a significant proportion of cf patients. this may be explained by the previously described regional differences in lower airway infection in cf airways rather than by a higher diagnostic yield of one of the techniques. the results also demonstrate that the e-flow system is an efficient and safe device for sputum induction in sputum producing children with cf. seidler, m.j.; salvenmoser, s.; müller, f.c. dept. pediatrics iii, university heidelberg, pediatric pulmonology, cystic fibrosis centre & infectious diseases, heidelberg, germany background: the preferred growth form of bacteria is a biofilm. s. aureus, h. influenzae, and p. aeruginosa can produce an extracellular matrix (ecm) with implications in cystic fibrosis (cf) lung disease. the biofilm can protect against host defenses and antimicrobials. a. fumigatus is a frequent colonizer of the cf respiratory tract and can cause allergic bronchopulmonary aspergillosis (abpa). while antifungals in vitro are active against a. fumigatus, in vivo antifungal therapy is often complicated or resistance is observable. the aim of this study was to investigate the ability of a. fumigatus to form a biofilm-like matrix in vitro on polystyrene (ps), human bronchial epithelia cells ( hbe) and human bronchial epithelia cells with f del/f del (cfbe o-). methods: a. fumigatus atcc # was incubated in rpmi at different ph and concentrations of fbs. temperature, production time and different flow conditions were varied on ps, hbe and cfbe o-. dry weight measurement and antifungal drug susceptibility testing was performed. scanning electron microscopy (sem) and confocal scanning laser microscopy (cslm) images were analyzed. results: the thickest biofilm was produced on ps with rpmi (+ % fbs, ph= . ) at °c for h slightly rocking. biofilm dry weight on ps was . mg after h and . mg after h. the dry weight of produced biofilm exceeded . mg on hbe and . mg on cfbe o-cells after h of biofilm production. there was no significant difference in dry weight increase between the cell lines and ps. planktonic a. fumigatus was susceptible to itraconazole ( . µg/ml), voriconazole ( . µg/ml) and amphotericin b ( µg/ml). aspergillus in biofilm was resistant against all drugs (> µg/ml). the sem pictures displayed a network of hyphal structures and matrix at h. characteristic flow channels were observed at h. cslm images displayed conidia and hyphal structures embedded in matrix formations. a-alexafluor dyed polysaccharides of the cell wall and of the ecm in the biofilm. three dimensional constructs of the cslm pictures displayed biofilm on hbe and proofed viability of the cells after h co-incubation. differences in biofilm production between hbe and cfbe o-were not significant. conclusions: a. fumigatus is able to form a biofilm structure in vitro on ps, hbe and cfbe o-. a biofilm-like matrix produced by a. fumigatus was evidenced by dry weight measurement, sem, cslm and antifungal drug resist-ance in comparison to planktonic cells. potential clinical implications of a. fumigatus biofilm formation in vivo require further attention and investigations. etherington, c. ; peckham, d. ; conway, s. ; hall, m. ; denton, m. . seacroft hospital, regional adult cf unit, leeds, united kingdom; . microbiology department, leeds teaching hospitals, leeds, united kingdom susceptibility testing results are not predictive of clinical response to antibiotic therapy in chronic pseudomonas aeruginosa infections in cystic fibrosis. we assessed the impact of reducing the number of routine susceptibility tests performed on clinical outcome in these cases. in june we introduced a protocol of limiting susceptibility tests to p. aeruginosa isolates obtained from respiratory samples taken at the commencement of antibiotic therapy, when there was evidence of clinical failure, or routinely if not tested in the previous three months. at all other times, isolates were identified and reported as normal but p. aeruginosa isolates were not subjected to susceptibility tests. between st june and th november p. aeruginosa, was isolated on at least one occasion from patients attending our adult cf unit. in this six month period we reduced the number of susceptibility tests by % (from a projected , tests on samples to an actual tests on samples). this resulted in projected savings of $ , in consumables and hours (costed at $ , ) of laboratory staff time per annum, a total saving of $ , (£ , ) per annum. we assessed the response to intravenous antibiotic treatment between the study period in and the same period in . no significant differences in median change of fev , fvc, crp, white cell count, weight, or duration of intravenous antibiotics were observed. for cf units sending regular, routine sputum samples, a reduction in the number of susceptibility tests performed in cases of chronic p. aeruginosa can be carried out without impacting on clinical outcomes. we report our preliminary results for a total of strains obtained from patients ( patients harbored more than strains). these patients were classified in groups of respiratory insufficiency according to their fev : severe in patients (fev < %), moderate in patients (fev : - %) and mild in patients (fev > %). the clonal distribution was analyzed for the different strains of sa ( to ) isolated from patients sputum. these strains were analyzed for their antibiotic susceptibility and typed by pulsed-field electrophoresis gel (pfge) after smai digestion of chromosomal dna. thirty seven patients ( %) were colonized with mrsa. nine patients were both colonized with mrsa and mssa. among mrsa strains, / ( %) were also resistant to more than three other antibiotic family. strains harboring minor differences in the banding pattern (> % similarity as assessed by the dice coefficient) were considered clonal. our results show that % of the patients were colonized with a single persistent strain during the year of follow-up. consecutive isolates with different pfge profiles were obtained from only / patients ( %). pfge analysis revealed that mrsa isolated from patients were grouped in clusters. these results revealed a possible clonal relationship between mrsa isolated from different patients with cf. we did not find any difference in the distribution of sa strains in our cf patients among the groups of respiratory insufficiency. the study is ongoing in our adult cf population and in necker pediatric cf centre in paris. giusti, r. ; furfaro, s. . pediatrics, long island college hospital, brooklyn, ny, usa; . research, lumina fund, new york, ny, usa palivizumab(synagis) is a humanized monoclonal antibody to rsv. the redbook acknowledges that some patients with cystic fibrosis may be at increased risk of rsv infection but that there is insufficient data to determine the effectiveness of this therapy. the objective of this study was to assess: )practice patterns of cf physicians in the us and canada )the severity of rsv disease in cf infants during the past rsv season. )if there is a standard of care concerning the use of synagis for cf infants. methods a questionnaire was developed using a web-based commercial vendor. an embedded web link was distributed via an e-mail sent to all us and canadian pediatric cf center directors. respondents clicked on a link to respond to the survey and results were automatically tabulated in real-time. completed responses were received from center directors ( us and canadian) for a response rate of % in us and % in canada. most responders ( %) have prescribed synagis for infants with cf in the first rsv season, however only % routinely prescribed synagis for all infants with cf. only % expressed having had difficulty in obtaining insurance approval for this medication. many physicians indicated that synagis was frequently prescribed by the general pediatrician and that infants living at long distances from a cf center may be hospitalized at local hospitals. these issues may affect the accuracy of the data and result in an underestimate of actual synagis prescription and hospitalization rates. there were infants diagnosed with cf in the past year and of these infants were reported as symptomatic. there were cf infants ( %) reported as having a documented rsv infection and ( %) of these infants had received synagis. there were infants ( %) with documented rsv infection who responded to outpatient management.there were no deaths but patients were hospitalized and of these had received synagis. of the infants that required admission to an icu had received synagis. of the patients who were noted as having persistent chest x-ray changes had received treatment with synagis. there were infants with persistent wheezing and of these infants had been treated with synagis. conclusions despite the limitations of a retrospective survey, this data demonstrates that rsv can cause significant and prolonged pulmonary disease and is a significant precipitating factor resulting in hospitalization of cf infants. the data also notes that many cf infants infected during the past rsv season have a mild illness and respond to outpatient management. a surprising finding of this survey is that infants at cf care centers where synagis was prescribed for all cf infants continued to have significant rsv related hospitalizations, persistent wheezing or prolonged chest x-ray abnormalities. there are different opinions among cf physicians concerning the routine use of synagis and currently the data suggests that there is not a standard of care concerning the prophylaxis of cf infants with synagis. this results of this survey should encourage physicians to prospectively study the efficacy of synagis prophylaxis in preventing hospitalization, persistent wheezing and chest x-ray abnormalities in cf infants. milani, a. ; cisbani, g. ; macchi, r. ; vidal-aroca, f. ; bertoni, g. . biomolecular sciences and biotechnology, university of milan, milano, italy; . basilea pharmaceutica ltd., basel, switzerland with ever increasing frequency, we now observe several examples of bacteria being resistant to every clinically available drug. therefore this urgently calls for the development of novel and improved antibiotics that may escape the extant mechanisms of bacterial resistance. one recent and promising development of the genome-wide search for target functions for antibiotics led to the identification of essential genes of pathogens by interfering antisense rnas. the first step is the construction of shotgun antisense libraries (sals) as follows. genomic dna is extracted from the bacterial strain of interest, fragmented by shearing into short pieces of dna, blunt-ended and cloned in an expression vector under the control of a regulatable promoter. the library is then reintroduced into the cognate bacterial strain and screened by replica plating colonies both in the presence and the absence of an inducer of the vector promoter. by this method, insert sequencing of clones showing conditional growth phenotypes is expected to lead to the identification of essential genes that can be silenced via antisense rna activity. we adopted this technology in order to generate a panel of essential functions of the cystic fibrosis-related opportunistic pathogen pseudomonas aeruginosa. so far, we tuned the protocol for sal generation in p. aeruginosa and identified a number of sequences conferring different levels of growth inhibition we are now characterizing these putative antisense rnas in order to define the minimal sequence able to cause the toxic effect and, on the other hand, to understand the cellular role of their targets. pseudomonas aeruginosa (pa) is an extremely versatile microbe with a vast array of pathogenic and metabolic mechanisms that allow it to form persistent infections in select patient populations, especially patients with cystic fibrosis. an ineffective immune response is considered partially to blame for failure of pa eradication. we have discovered that some strains of pa express peptidylarginine deiminase (padi) activity. padi is an enzyme that post-translationally modifies peptidylarginine to peptidylcitrulline with ammonia as a byproduct. our lab has shown that human padi can modulate the immune system through downregulation of tlr and ikk-gamma signaling. characterization of the pa padi will offer insights into a completely novel method of immune modulation by pseudomonas aeruginosa. using a widely published colorimetric assay for padi activity we have found the specific activity of crude pa cell lysates is very low. however this is similar to the only other known prokaryotic padi described in porphyromonas gingivalis. a protein homology search with the porphyromonas padi has revealed the likely genetic locus of pseudomonas padi in a . kb operon that appears in the genome of the pathogenic pseudomonas isolate pa . this operon appears to contain two candidate genes for padi activity based on conserved motif searches (padi and padi ). both have been cloned into expression vectors, partially purified by affinity tag technology and tested in the colorimetric padi assay. curiously padi autocitrullinates itself while padi has not shown activity. reaction conditions and substrate specificities for pa-padi are not like either the human or porphyromonas padi. furthermore analysis of up to clinically diverse strains has demonstrated % carry the gene for padi . this work is only the second description of padi activity in any prokaryote. pa padi could clearly have a dramatic impact on the local inflammatory milieu if it can access the same targets as human padi. the description of this activity in pseudomonas will advance our knowledge of the human-pathogen relationship and give insight into new therapies. which functions by translocating toxins into the cytoplasm of host cells. these toxins cause disease by damaging the surrounding host tissue, promoting dissemination of the organism and paralyzing the phagocytic mechanism of macrophages. pcrv is a factor required for the translocation of the toxins. the bases of these studies were to evaluate pcrv as a protective antigen in "p. aeruginosa" pneumonia and cldc as a vaccine adjuvant. methods: mice were vaccinated , , or times with the pcrv antigen combined with either aluminum hydroxide (alum) or cldc by various routes of administration. efficacy of vaccination was evaluated by challenge with "p. aeruginosa" and evaluation of survival and/or measurement of various parameters associated with lung injury. results: increase in median survival time was highly significant when cldc/pcrv was compared with cldc or pcrv alone. following subcutaneous administrations cldc/pcrv showed an increase in median survival time ( hours versus hours) and overall survival benefit following intraperitoneal administrations ( % versus %). mice with anti-pcrv antibody levels above µg/ml were significantly protected. conclusion: the investigators establish the efficacy of cldc/pcrv vaccines via several parenteral routes of administration compared to no treatment as well as cldc and pcrv-only controls. differences were demonstrated between performance of cldc/pcrv and alum/pcrv in measures of lung injury, median survival, and overall survival. the results correlated with antibody levels and histological examination of the lung tissues. importantly, these studies indicate that protection can be achieved against "p. aeruginosa" infection by targeting an antigen associated with the type iii secretion system. background: there has been a recent increase in the number of reported cases of acute renal failure (arf) in cystic fibrosis (cf). our group have undertaken a national survey, which measured the incidence risk of arf in cf patients at between . and . cases / , cf patients / year. we have now conducted a case control study to determine which factors which are associated with an increased risk of arf. methods: in our initial survey we confirmed cases of arf, in cf patients from uk cf centres, presenting between & . using the uk cf database, we identified sex and age (within months) matched controls. informed consent was sought from the control patients, or their parents, for access to the case notes and clinical data were extracted. analysis of risk factors was by conditional logistic regression, using stata (version ) and by fisher's exact test. results: there were cases of arf ( male, median age y, range m- y) and controls ( male, y, m- y). in the group of patients with arf, / had received an aminoglycoside at the time of their episode of arf or in the preceding week, compared with only of the controls for the same time period (p< . ). the median number of days of aminoglycoside in the year prior to the index case developing acute renal failure was ( - ) for cases and ( - ) for controls. conditional logistic regression showed that the odds ratio for arf per each day of aminoglycoside was . ( % ci . to . , p= . it is well-known that pa senses the environment and changes its phenotype. for instance, it produces greater amounts of the extracellular polysaccharide alginate in the cf lung, characterized by a microaerobic environment. little is known about the changes in protein secretion induced by oxygen limitation in pao , the proto-typical pa laboratory strain. no data are available on this regard about pa clinical strains. our work was aimed to study the differential regulation of proteins secreted by pa strains grown in microaerobic or aerobic conditions. a pa clinical isolate and pao were grown overnight in aerobiosis and in microaerophilic conditions. the supernatants were collected and proteomic analysis was carried over by two-dimensional capillary chromatography -tandem mass spectrometry (mauri et al., faseb j ) to evaluate the differential protein expression. in the pa clinical isolate, we identified proteins down-regulated and proteins upregulated in aerobic conditions in comparison with microaerophilic culture while in pao proteins were down-regulated and were up-regulated. proteins were down-regulated and up-regulated both in the clinical and in the laboratory strain. these proteins can mediate different biological functions since they are enzymes, heat shock proteins, chaperones, proteins involved in adaptation, motility and in the transport of small molecules. among all these proteins, as the alkaline metalloproteinase is associated with tissue invasion not only by causing rupture of epithelial tight-junctions but also by degrading several chemokines, we decided to validate its up-regulation observed in aerobic conditions by zymography. we found that the proteolytic activity of the supernatants of pa grown in aerobic conditions was higher than in microaerophilic culture both for the laboratory and clinical strain, indicating the functional relevance of data obtained by proteomic analysis. the identification of proteins differentially regulated in aerobiosis and oxygen limitated conditions in pa laboratory and clinical strains might be helpful for the knowledge of the mechanisms of colonization and lung damage due to pa in cf patients. for instance, the validation of the upregulation of the alkaline metalloproteinase in aerobic condition may shed light on these mechanisms of cf lung disease. further studies are in progress to evaluate the function of other bacterial exoproducts regulated in this model and to extend the analysis to other clinical strains. supported by the italian cystic fibrosis research foundation (ffc-grant# / ), comitato di vicenza dell'associazione veneta per la lotta contro la fibrosi cistica and azienda ospedaliera di verona, italy. cystic fibrosis (cf) sufferers are subject to repeated lung infections most commonly with the bacterium pseudomonas aeruginosa. in spite of antibiotic treatment p. aeruginosa tends to become established giving rise to persistent chronic infection. in the lung environment, the bacterium grows as a highly structured biofilm consisting of a complex community of cells embedded within a self-secreted polysaccharide matrix. investigations of p. aeruginosa biofilm growth using model strains have elucidated mechanisms which appear to govern the biofilm life-cycle. our research aims to test whether observation of these mechanisms in planktonic culture can be related to the efficiency of biofilm formation. biofilm initiation has been linked to cell motility and in particular to the presence of flagella and pili, which are thought to be important for cell attachment and the formation of microcolonies. on testing a large, genetically diverse group of clinical p. aeruginosa isolates retrieved from the lungs of cf patients we found no definitive correlation between the degree of motility of an isolate in planktonic culture and its ability to form a biofilm in vitro. the development of biofilm architecture has been demonstrated in model systems to be coordinated by the production and secretion of n-acylhomoserine lactone (ahl) quorum sensing molecules. however among the clinical isolates tested we observed no obvious correlation between the amount of ahls produced in planktonic culture and the extent of biofilm formation. overall we have found observation of phenotypic characteristics in planktonic culture to be poor predictors of efficient biofilm formation. a proteomics approach was adopted to provide further insight into the physiology of biofilm growth of p. aeruginosa isolates by comparison with planktonic growth of the same isolates. two genetically unrelated clinical isolates, demonstrated as being capable of efficient in vitro biofilm formation, were selected from our culture collection on the basis of their diverse phenotypic characteristics when cultured planktonically. one displays both twitching and swimming motilities, is mucoid and expresses ahls, while the other is non-motile, non-mucoid and no ahls have been detected in planktonic culture. we have developed a simple flow-through bioreactor to provide sufficient quantities of biofilm for proteomic analysis. gel-based and gel-free techniques were employed to study protein expression patterns for both biofilm and planktonic cultures of each isolate by mass spectrometry. proteins specific for each growth phase could be detected and may prove suitable biomarkers for monitoring the physiological status of biofilm forming strains when a larger bank of clinical isolates are examined. liposomal amikacin (arikace tm ) is a liposome-encapsulated form of amikacin that is formulated to treat chronic p. aeruginosa infections in cystic fibrosis patients. these liposomes carry a zwitterionic surface charge and are composed of lipids found naturally within the lung. a key aspect of the activity of the formulation is the ability to penetrate to the sites of pseudomonas biofilm-like growth in the lung. experiments were designed to investigate the penetration of liposomes into p. aeruginosa biofilms and in vitro activity. methods and results: model liposomes of the same size and lipid composition as liposomal amikacin (arikace tm ) were prepared with membrane-associated or encapsulated fluorescent labels, a hydrophobic carbocyanine dye and calcein, respectively. a mucoid strain of pseudomonas aeruginosa (pa ) was used to establish biofilms in rectangular optical grade glass flow cells. biofilms were observed after four days of growth by confocal laser scanning microscopy using a focal plane set to view within the biofilm cluster or outside as a control. time dependent accumulation of fluorescent liposomes within the biofilms was measured by the spatial distribution of fluorescence intensity in regions within or outside of the biofilm. images indicated significant penetration of liposomes into the interior of biofilms under these conditions. the rate of penetration was considerably slower than typical rates for small molecules, consistent with the size of the liposomes. liposome concentrations were higher near the periphery than the interior. however, even the interior concentration was at least as high as the concentration of liposomes in the fluid outside of the biofilm, suggesting some binding or trapping of the liposomes within the biofilm. penetration of liposomes was observed under flow or static conditions. in a "washout" experiment, where medium is passed through the biofilms previously treated with liposomes, a significant portion of the liposomes remained associated with the biofilms for an extended period of time. the penetration of liposomes was reflected in the observation of killing of bacteria in colonies in the interior of agar beads. exposure of these cultures to liposomal amikacin resulted in a large reduction of viable bacteria throughout the beads as monitored by a fluorescent dna content assay. similar colony forming unit reductions in animal models (to be shown in other poster presentations) suggest that these principles also operate in vivo. liposomes similar to liposomal amikacin (arikace tm ) readily penetrate into biofilms of pseudomonas aeruginosa and may even have enhanced binding to biofilms. this binding along with localized release can explain the substantial efficacy observed in animal models. coates, a.l. adherence to recommended therapy in cf has always been a challenge, in part, due to the time demands of the daily therapy. while twice daily inhaled tobramycin for those infected with pseudomonas aeruginosa (pa) has become an accepted standard of care, as much as minutes a day may be consumed inhaling mg in ml of tobramycin (tobi ® ) from the pari lc plus ® breath enhanced jet nebulizer. the purpose of this study was to determine if equivalent levels of pulmonary deposition could be achieved in a much shorter time period using . ml of a more concentrated ( mg/ml) tobramycin solution delivered by a perforated vibrating membrane nebulizer (eflow ® membrane configuration l) both, developed by pari pharma; germany. methods with a goal to study children and adults, to date, the subjects are children years and older and adult males, all with an fev > % predicted, with stable cf. all were receiving inhaled tobramycin for positive sputum cultures of pa. following pretreatment with albuterol, they inhaled both preparations on two occasions with m tc-dtpa added to the tobramycin in the nuclear medicine facility. in vitro preliminary work demonstrated that the radiolabel tracked with both formulations of tobramycin. deposition was measured by a gamma camera taking both tissue attenuation and mucociliary clearance during nebulization into account (pediatric pulmonol suppl : a ; ) . in order to have a continuous rate of deposition, the pari lc plus ® was run for a timed minutes and then both the total deposition and time of nebulization "scaled up" from in vitro testing when the nebulizer was run to dryness. this was done by multiplying the deposition by the total output when run to dryness divided by the total output in minutes. (blood samples were taken for quantification of tobramycin in the serum but not yet analysed). the rate of output per minute was calculated from the minute run and the total time was total output from in vitro testing divided by the rate of output. the eflow ® pro-vides a continuous output and stops automatically at dryness. quality assurance was the agreement between total radioactivity pre nebulization (in the nebulizer) and post which included the subject, the nebulizer, the connectors and the expiratory filter. the pari lc plus ® delivered . ± . mg in . ± . minutes compared to . ± . mg in . ± . minutes for the eflow ® . only the time of delivery was significantly different with p< . (paired t-test). tolerability of the treatment was comparable for both inhalation regimes, but the shorter treatment was preferred by all patients. these results demonstrate the possibility of delivering equivalent levels of tobramycin in much shorter periods of time into the lungs of cf patients when using eflow ® , a very efficient electronic nebulizer. this time saving may improve adherence to recommended therapy. (pediatrics ; : ) . in order to properly interpret op cultures from nbs infants, especially those with non-classic cf mutations, we need to know the op flora of non-cf infants. we obtained op cultures from healthy infants under yr of age. op specimens were plated on standard cf culture media. exclusion criteria included a first degree relative with cf, respiratory illness at the time of culture, or positive newborn screen for cf. data on cigarette smoke exposure, animal exposure, and exposure to hot tubs/swimming pools was collected. samples have been collected to date. in healthy, non-cf infants, the most common finding is non-specific mixed gram negative and positive growth. however, infants have grown pa (ages months, months, and months). many infants have grown multiple organisms. the following bacteria have been found in (n) number of infants: s. aureus ( ), e. coli ( ), e. cloacae ( ) , h. flu ( ), klebsiella ( ), pseudomonas aeruginosa ( ), h. parainflu ( ), unidentified non-lactose fermenting ( ), other ( ). data on infants including correlation to environmental factors will be presented. conclusion: non-cf infants commonly have s. aureus and many gram negative organisms including pa in their oropharynx. these results may have some bearing on interpetting colonization and clearance of pa in infants identified through nbs and in epic study participants. # ) ). identification of smg by sputum cultivation represents a significant challenge because the organisms are phenotypically diverse, grow poorly on routine culture media, and are very difficult to discriminate from other members of the oropharyngeal flora. we have developed a solid media for the selective isolation of smg from sputum. the value of the media is highlighted by the identification of smg as the quantitatively dominant organism in sputum samples of three cf patients admitted to hospital for an acute pulmonary exacerbation. in all three, the smg species failed to be identified on routine or selective media currently described for the culture of cf-specific sputum pathogens. antibiotic treatment directed against the smg correlated with clinical resolution of acute symptoms as well the reduction of smg on daily serial sputum cultures during hospitalization. this novel selective media makes use of antibiotics (colistin, sulfadiazine and oxolinic acid) inhibitory to the growth of principal cf pathogens and much of the usual oropharyngeal flora. smg agar utilizes a colorimetric indicator to uniquely identify smg colonies. the sensitivity and specificity of the selective media has been evaluated by molecular methods using terminal restriction fragment length polymorphism analysis. smg organisms do not respond well to anti-pseudomonal therapy, therefore proper detection and culture-directed antibiotic therapy is paramount. we believe that smg represent significant respiratory pathogens in cf, and because of the inability to effectively culture and identify smg they have largely gone unrecognized. pseudomonas aeruginosa releases substantial amounts of the blue antibiotic pigment pyocyanin. in presence of a reductant (such as nadph), pyocyanin redox-cycles and generates superoxide and h o . in infected cf airways, pyocyanin concentrations can reach high micromolar levels and contribute to oxidative stress of the airways. the structural basis of the pyocyanin molecule that underlies the redox-cycling with reductants of the airways is not clear. we therefore investigated i) the ability of physiologically or pharmacologically relevant reductants of the airways to support the redox-cycle activity of pyocyanin, and ii) the molecular features of pyocyanin that support redox cycling. dose-and time-dependent h o production by pyocyanin was measured by amplex red oxidation in presence of horseradish peroxidase. rates of h o production by µm pyocyanin in presence of µm reductant were: nadph ( pmole/min) > l-ascorbate ( pmole/min) > reduced glutathione ( pmole/min) > α-tocopherol ( pmole/min). in contrast, lipoic acid, genistein, or resveratrol did not significantly support pyocyanin-mediated h o production. in absence of a reductant, pyocyanin showed no measurable formation of h o . to identify the structural characteristics of the pyocyanin molecule that allow for its redox-cycling activity we synthesized a number of new pyocyanins containing electron-donating or electron-withdrawing substituents. functional assays were performed in presence of l-ascorbate as reductant. molecular substituents that donated electrons to the positively charged core of pyocyanin, either by hyperconjugative or resonance effects, reduced the h o output of the corresponding pyocyanin. in contrast, a closely related analog ( -hydroxyphenazine- , dioxide) showed significantly increased activity ( . x compared to pyocyanin) suggesting that the electron-withdrawing effect of the n-oxide functionality led to an increase in the redox-cycle activity. these data indicate that the functional characteristics of pyocyanin as a redox-cycling compound are governed by its positively charged core. in the airways, pyocyanin is predicted to utilize several reductants that are present in the airway surface liquid or intracellularly, thus contributing to cf airway disease. because pyocyanin utilizes a variety of reductants, it appears prudent to test whether inhaled small-molecular cf therapeutics support pyocyanin function. supported by nih (hl- , p at ), cfri, philip morris usa inc and philip morris international, and cff (fischer g ). taccetti, g.; braggion, c.; ravenni, n.; zavataro, l.; neri, a.; festini, f.; campana, s. meyer hospital, university of florence, cf center of tuscany, florence, italy for practical purposes, after early eradication treatment, at least three consecutive negative respiratory cultures over a -month period would indicate that the organism has been eradicated (cf trust guidelines). this recommendation is based on opinion/clinical experience of respected authorities in the absence of directly applicable studies of good quality. aims: using molecular biological techniques, we evaluated whether this -month interval is really trustworthy for distinguishing between regrowth of the same strain, suppressed but not eradicated by treatment, and new pseudomonas aeruginosa (pa) colonization. patients and methods: cystic fibrosis (cf) patients were treated with oral ciprofloxacin and nebulized colistin at detection of pa. all pa colonization episodes were recorded in an appropriate database. molecular study of each bacterial isolate from each colonization episode was performed with the rapd-pcr. results: between between - of patients in follow-up in our center had repeated pa colonization. the patients' mean age at first pa colonization was ± . months. a total of episodes was observed (mean of . episodes per patient, median of , range - ). molecular typing on strains indicated that ( . %) were a different genotype from later colonization episodes while ( . %) isolates had the same genotype as those of the preceding episode. the same genotype as preceding colonization was observed in ( . %) of isolates from patients in which a successive colonization was verified in less than months, and was verified in ( . %) of strains in patients having a successive colonization in over months (or= . ). colonization was due to a genotypically diverse strain in % of cases where colonization occurred within months of eradication. during the observation period ( %) of patients acquired chronic pa infection. conclusion: re-colonization by pa following eradication therapy is mostly ( %) caused by strains with a different genotype, suggesting acquisition from an external source. a short pa-free period is mainly due to transient suppression of pa growth, and true eradication followed by acquisition of a new pa genotype occurred in most cases only after a pa-free period longer than months. those patients with a pa-free interval of less than months had a six-times higher chance that the pa was not eradicated compared to those with a germ-free interval of over months. this evidence demonstrates that the definition of successful eradication should be reconsidered, taking into account additional parameters such as molecular analysis. cystic fibrosis (cf) patients appear to have an increased risk of urolithiasis. while a number of possible explanations for this have been proposed and investigated, no definitive mechanism has yet been demonstrated. as cf patients frequently get respiratory tract infections they regularly receive ciprofloxacin treatment, often given in doses well in excess of conventional prescription regimes. there are occasional reports of ciprofloxacin crystals urine and stones in the urinary tract. here we investigate the hypothesis that ciprofloxacin excreted in urine might act as a promoter of crystallisation of calcium or magnesium salts and thereby increase the risk of kidney stone disease. the effect of ciprofloxacin was tested in artificial urine (au). in vitro crystallisation was tested using a well plate turbidity method, to identify a metastable limit of oxalate concentration (ml) and a growth and nucleation parameter, the turbidity rate index (tri). the nucleation ph of urine was examined by tritrating oxalate free au through a ph range of . to . and monitoring the solution/suspension turbidity. in au at ph . , ciprofloxacin, at , , or mg/l, had no detectable effect on initiation of calcium oxalate crystallisation (ml) or its progress (tri) (n= for each concentration). when au with mm ca, mm mg and mm po was titrated there were two distinct nucleation points; a slow event starting at about ph . and a much faster event at about ph . . omitting ca or mg confirmed that the first event was due to calcium phosphate precipitation and the second to struvite. including ciprofloxacin at , or mg/l did not alter these nucleation ph values, but the magnitude of the turbidity rise showed that the ciprofloxacin co-precipitated with the struvite. ciprofloxacin at mg/l and without ca or mg began to precipitate at ph . and could be held in solution until ph . when ca and mg were included. even at high concentrations, ciprofloxacin does not influence calcium oxalate crystallisation. nor does it promote calcium phosphate or struvite precipitation; on the contrary, while the calcium and magnesium remain in solution, they help to prevent precipitation of the ciprofloxacin itself. urinary ciprofloxacin does not appear to act as a stone or crystal promoter. pseudomonas aeruginosa is a significant cause of mortality in cystic fibrosis (cf) sufferers. cf patients were thought to acquire p. aeruginosa from the environment; however genotyping over recent years has revealed clonal strains in sputa from cf patients in the uk, australia, and canada that are transmitted person to person or from a common source. one clonal strain, australian epidemic strain- (aes- ), (formerly melbourne epidemic strain, m or pi) currently infects up to % of patients in five cf clinics on the eastern seaboard of australia. most cf clonal strains have been associated with increased virulence not fully explained by greater antibiotic resistance. both genotypic and phenotypic differences have been postulated as important in enabling transmission of clonal strains. in order to compare the expression profile of aes- to the type strain p. aeruginosa pao , the cf research group at the university of sydney compared the genome expression data of four clonal aes- isolates and pao , when grown as planktonic and as -hr biofilm cultures. in aes- , a set of significantly differentially expressed genes (all downregulated) were identified, including the quorum sensing genes lasa, lasb and rhll. in contrast, both upregulated and downregulated genes were differentially expressed in pao biofilm compared to pao planktonic culture. expression data was validated using quantitative real-time pcr. to compare biofilm growth at the phenotypic level, the four clonal strains and pao were grown as -hr biofilms in a double-blind study, and the size of ten randomly selected biofilms per isolate, stained with syto® green fluorescent stain was measured. at hr, the biofilms formed by aes- isolates were significantly larger (ca. -fold) than pao (average size: ± µm vs ± µm )(p< . ). the average thickness of three biofilms per isolate, measured by confocal microscopy, showed aes- biofilms to be approximately . -fold thicker than those formed by pao ( . ± . µm vs . ± . µm). the general gene downregulation observed in aes- biofilms suggests an adaptation to the cf host, while a larger biofilm would provide for more effective bacterial dispersal. thus the transmissibility of aes- may be linked to enhanced biofilm formation upon colonisation. background -objective: whilst influence induced by bacterial colonization in cystic fibrosis (cf) is established, risk induced by fungal colonization is less defined. prevalence of other species than aspergillus sp. or candida sp., and factors associated with fungal presence are also poorly documented. our preliminary study aimed to determine which fungal species were present in sputum collected from adult cf patients, and which factors were associated with fungal presence. methods: in a monocenter, transversal prospective study, cf adult patients were included to determine fungal presence in sputum using semi selective growing media. clinical parameters (shwachman score, respiratory function, nutritional status, gastro-oesophageal reflux, pancreatic insufficiency and diabetes); therapeutics used (including oral or intravenous antibiotics, systemic or inhaled corticosteroids or bronchodilatators, antifungal treatments); microbiological data of bacterial colonization and environmental parameters (potted plants or domestic animals presence) were determined for each patient. correlation between fungal, clinical, environmental, therapeutic or microbiological data was evaluated by mann-whitney non parametric u test. results: patients ( %) presented with fungal presence in sputum. % presented with yeasts species, % with moulds. aspergillus fumigatus and candida albicans were the predominant species in moulds and yeasts respectively, but less common mould species such as exophiala dermatidis or paecilomyces variotii were also recovered. factors associated with fungal presence were pancreatic insufficiency (p= , ); malnutrition (p= , ), bacterial colonization and inhaled corticosteroids. candida albicans was correlated with more severe shwachman score (p= , ), bacterial colonization (p= , ), notably with pseudomonas aeruginosa (p= , ) , and intravenous antibiotics use (p= , ). moulds species were significantly associated with inhaled corticosteroids (p= , ). antifungal use was associated with frequent resistance to azoles treatments ( resistant isolates out of patients treated). conclusion: fungal presence in cf appears frequent. some species could have been previously overlooked due to diagnosis difficulties. the effect of corticosteroids on moulds species, already found in other pathologies, appears important in cf. influence of fungal presence on cf course needs prospective studies, in order to establish if patients could benefit from antifungal treatments or preventive measures. dren on a ventilator without a previous diagnosis of cystic fibrosis is unknown. the aim of our study was to investigate the prevalence of these microorganisms in routine sputum cultures in young children on a ventilator in a pediatric intensive care unit (picu). methods: from all ventilated children aged - years admitted from - , sputum culture results obtained from tracheal aspirates within the first week of admission were retrospectively analysed. three patient subgroups were identified: respiratory failure due to pulmonary disease (group ), ventilation after elective surgical procedures (group ) and other ventilated children (group ). children with a previous intensive care admission or cf were excluded. the cf database was checked ( ) to identify any children with a new diagnosis of cf that were included in the study. results: . % of all ventilated children had a positive sputum culture with one of the "cf-bacteria" s. aureus, h. influenzae and p. aeruginosa these were found mainly in group (see table) . / of these children were admitted for treatment of respiratory syncytial virus (rsv) bronchiolitis. a sweat test was performed in children, all admitted with pulmonary disease and because of co-existing clinical signs or symptoms. one sweat test was positive and subsequently cf was diagnosed in this child. no other children out of the study group have since then been diagnosed with cf. as the population in the northern part of the netherlands is very stable, it is unlikely a diagnosis of cf has been missed. conclusion: s. aureus and h. influenzae are cultured frequently in ventilated children without cf, especially when ventilated because of pulmonary disease. the opportunistic pathogen p. aeruginosa causes both acute and chronic human infections. the balance between systemic infection and mortality or chronic persistence and morbidity depends on complex relationships in which the immunological status and genetic potential of the host but also the bacterial biodiversity are determinant factors. p. aeruginosa extensive genetic adaptation and microevolution have been repeatedly observed in chronic infections of cf patients in contrast to what it is documented in acute infections. whether these p. aeruginosa clonal variants differ in their pathogenic potential is not yet known. a total of clinical p. aeruginosa isolates from six cf patients which carried unique clonal lineage from the onset of colonization over - years were selected (bragonzi et al, ; montanari et al, ) . five p. aeruginosa environmental strains, which represent the source of acquisition for cf patients, and two laboratory strains pao and pa were also used as references. multiple genotypic analysis of sequential p. aeruginosa isolates which included pfge, atchip and multilocus snps showed intraclonal diversity with genome rearrangements, variations in pathogenic islands and acquisition of prothoadaptive mutations in the muc genes. the largest divergence was observed between the completely sequenced reference strains pao and pa , the latter represented in our panel by three cf isolates. p. aeruginosa virulence has been assessed by monitoring its capacity to induce bacteremia and to establish chronic infection in a murine model (bragonzi et al, ) . overall, p. aeruginosa environmental strains increased five times the risk of bacteremia when compared to clinical strains (test of proportion: p< . ). the high risk of mortality was also evidenced for p. aeruginosa cf strains isolated at the onset of the infection when compared with those isolated after years of colonization (p= . ) indicating that environmental strains or newly acquired strains were similar in their virulence. p. aeruginosa clinical strains isolated after years of colonization increased chronic persistence and reduced the risk of bacteremia (p= . ) when compared to strains isolated at the onset of the infection. the strain pa was found to be lethal in contrast to p. aeruginosa clonal strains of clinical origin that established chronic persistent infection in the murine lung. furthermore, our data showed that adaptive traits commonly associated with the chronic p. aeruginosa infections in cf patients, such as transition to the mucoid phenotype, did not confer a selective advantage to bacterial cells in colonizing the murine lung (p= . ). these results suggest that p. aeruginosa pathogenicity is independent of the strain's genotype but rather genetic adaptation to the cf airways plays an important role in the development of persistence and in the resistance to host defences. supported by telethon and italian cf research foundation. beringer, p. the combination of antipseudomonal beta-lactam and aminoglycoside antibiotics is frequently prescribed during acute pulmonary exacerbations. since the introduction of the beta-lactam compounds there has been numerous reports citing altered pharmacokinetics of several compounds (but not all) within the beta-lactam class. recently it has been suggested that substrate specificity for the renal transporter pgp may explain the variability in renal drug clearance observed in patients with cf. pgp is structurally related to cftr and evidence suggests it serves a complementary role in modulating alternative chloride channel function. in a cftr knockout model mdr expression was reported to be increased nearly four-fold. in an effort to elucidate the potential contribution of pgp to the renal clearance of drugs in patients with cf, we conducted a controlled clinical trial comparing the pharmacokinetics of fexofenadine (fx) in patients with cf and age matched healthy volunteers (hv). fexofenadine is not significantly metabolized and is a relatively specific substrate for the membrane transporters pgp and oatp. probenecid (pb) is a selective inhibitor of oatp and was used pharmacologically to block the activity of this transporter in-vivo. our hypothesis is that if pgp is upregulated within the renal tubules of patients with cf we would expect to see an enhanced renal clearance of fexofenadine in these patients when compared with control subjects. methods: (n= cf, hv) subjects underwent this prospective controlled study which fx was received alone or in combination with probenecid (pb). iothalamate was given each day to measure glomerular filtration rate (gfr). blood and urine samples were obtained at specified times over hours each study day for determination of fexofenadine and iothalamate concentrations. fexofenadine and iothalamate concentrations were assayed using liquid chromatography-tandem mass spectrometry and hplc-uv respectively. pharmacokinetic analysis was performed using a -compartment cumulative urinary excretion model with the adapt ii software. differences between groups were determined using a paired t-test or mann whitney-u. results: patients were included, cf patients were slightly older and had lower body mass index when compared to hv, (mean±sd, ± . vs. . ± years p= . , . ± . vs. . ± . p= . respectively) but did not differ in gfr ( ± . vs. ± ml/min- . m p= . respectively). no significant differences were found between cf and hv in clr of fx alone and fx in combination with pb clr ( . ± vs. . ± . ml/min- . m p= . and . ± vs . ± . ml/min- . m p= . respectively). conclusion: the results of this study indicate the enhanced clearance of certain antibiotics previously reported in patients with cf do not appear to be due to upregulation of renal tubular pgp or increased gfr. maceachran, d.p. department of microbiology and immunology, dartmouth medical school, hanover, nh, usa p. aeruginosa is the leading cause of morbidity and mortality in cystic fibrosis (cf) patients. shortly after birth cf patients are colonized by p. aeruginosa, which leads to a lifelong chronic infection. the mechanisms behind p. aeruginosa colonization of the cf lung are still poorly understood, however several secreted toxins have been associated with this phenomenon. cf is characterized by a loss of mucocilliary clearance, a key component of innate immunity in the lung, and an increase in sputum viscosity as a result of mutations in the gene encoding the cystic fibrosis transmembrane conductance regulator (cftr). we have previously shown that the novel p. aeruginosa secreted protein cif is capable of reducing apical membrane expression of cftr. we have begun to characterize cif expression and have identified a key regulator of cif transcription. mutations affecting the divergently transcribed putative tetr family repressor encoded by the pa gene result in a significant increase in cif expression. furthermore, we have demonstrated that the pa gene product is capable of binding the promoter region located immediately upstream of the cif-containing operon. this work has been supported by the nih t -dk - . ryall, b. ; davies, j.c. , ; wilson, r. ; shoemark, a. ; williams, h.d. . division of biology, imperial college london, london, united kingdom; . department of gene therapy, imperial college london, london, united kingdom; . host defence unit, royal brompton hospital, london, united kingdom; . paediatric respiratory medicine, royal brompton hospital, london, united kingdom pseudomonas aeruginosa is the most important respiratory pathogen in patients with cystic fibrosis (cf) and non-cf bronchiectasis. the factors which enable p. aeruginosa to establish chronic, debilitating respiratory infections are unclear. however p. aeruginosa is one of a limited number of bacteria that is able to synthesise hydrogen cyanide, a potent inhibitor of cellular respiration. this study examined whether hydrogen cyanide is produced by p. aeruginosa in cf and non-cf bronchiectasis airway infection. cyanide concentration was measured in fresh sputum from cf and non-cf bronchiectasis patients with and without p. aeruginosa lung infection using a cyanide ion sensing electrode. cyanide was detected in sputum from / cf and non-cf bronchiectasis patients with current p. aeruginosa infection, whereas it was not detected in any of the patients without this organism (p< . ). maximum lev-els were µm (mean ±se: ± . µm), which compares with levels of above µm which would be considered toxic in blood. concurrent lung function data were available on all p. aeruginosainfected cf patients; the group with measurable sputum cyanide (n= ) was not different from those without (n= ) on the basis of age, gender or p. aeruginosa phenotype (mucoid/ non-mucoid). however, those with detectable cyanide had significantly poorer lung function than those without (fev % predicted: . ± . % versus . ± . %, p< . ; fvc% predicted: . ± . % versus . ± . , p< . ). we have shown that cyanide is detectable at clinically significant levels in sputum from cf and non-cf bronchiectasis patients infected with p. aeruginosa and is associated with significantly impaired lung function. we have recently reported a dose regimen for once-daily tobramycin dosing in patients with cystic fibrosis which was based on a retrospective study (lam w et al., j antimicrob chemother ) . we present here an interim analysis of an ongoing prospective study to evaluate the proposed dosing in paediatric patients with cystic fibrosis. as part of this protocol pharmacokinetic parameters were determined in cystic fibrosis (cf) patients receiving intravenous antibiotic therapy for a pulmonary exacerbation. serum creatinine, audiometric testing, respiratory cultures and fev were assessed at baseline and after a week treatment period. serum tobramycin concentrations were interpreted by clinical pharmacists performing therapeutic drug monitoring (tdm) to optimize dosing. serum tobramycin levels were drawn after the first dose, repeated with each dose adjustment and weekly thereafter. the proposed sample size of this study is patients; an interim analysis was performed to identify trends for pharmacokinetic and safety outcomes from patients admitted from november through april . seven ( . %) patients achieved the target c max of - mg/l, ( . %) patients remained under the target range and patient was above the target range with the st dose. with nd, rd, and th tdm performed for either routine weekly levels or dose adjustment levels, , , and patients met the target c max respectively. the percentage of patients who achieved target c max increased to . % with the rd set of tdm levels and . % with the th set of tdm levels (p-value< . ). there were no significant changes in k e , t / and v d /kg for each patient from st to nd set of tdm levels over time. compared to the previous retrospective study the mean v d /kg was significantly higher ( . l/kg versus . l/kg, p= . ) and the mean t / was significantly shorter ( . hrs versus . hrs; p< . ). none of the patients' serum creatinine increased ≥ % from baseline. baseline audiometric tests were within normal limits in ( . %) patients. p. aeruginosa was isolated from respiratory specimens of patients on initial culture. of the patients with follow-up cultures, patients grew p. aeruginosa sensitive to tobramycin, demonstrating no decrease in sensitivity. our preliminary results suggest the pharmacokinetic data differ from the expected profile suggested by the retrospective study. all study patients treated according to the guidelines were clinically well after their course of therapy and did not experience clinically significant toxicity from once-daily tobramycin dosing. the once-daily tobramycin dosing will continue to be evaluated until the proposed sample size is achieved for final analysis. anderson, g.g.; o'toole, g.a. dartmouth medical school, hanover, nh, usa pseudomonas aeruginosa chronically colonizes the lungs of individuals with cystic fibrosis (cf). evidence suggests that this infection progresses through distinct phases, wherein initial colonizing strains undergo a switch to mucoidy that corresponds to formation of bacterial microcolonies in the airways and life-long persistence. currently, the environmental signals and mechanisms regulating conversion from the acute, highly virulent form to a less virulent biofilm state remain obscure. to investigate these issues, we developed a tissue culture model system for growth of p. aeruginosa biofilms on cf-derived human airway epithelial cells in vitro. biofilms grown on these cells appear similar to those found in cf airways as well as to abiotic biofilms. eventually, epithelial cells were killed by the p. aeruginosa biofilms. however, we discovered that addition of the antibiotic tobramycin preserved the monolayer integrity for at least hours. bacteria were not completely eliminated by this treatment, suggesting that tobramycin influenced the virulence of the biofilm bacteria. microarray analysis of cf cell grown biofilms treated with tobramycin revealed marked alterations in transcriptional profiles compared to untreated controls. two tobramycin-induced genes were identified from this screen which, when deleted, exerted altered virulence phenotypes on airway epithelial cells in culture. quantification of cytotoxicity of these mutants revealed either increased or decreased ability to kill the epithelial cells. complementation with full-length copies of these genes restored wild-type function. these studies suggest a complex relationship between acute and chronic forms of p. aeruginosa, and that antibiotic treatment may influence transitions between these modes. it is this interplay that may determine the virulence status of the microorganism upon initial infection as well as during cf exacerbations. neville, m.; sardaryan, g.; ejaz, s.; scotto, a.w.; gupta, r. transave, inc., monmouth junction, nj, usa purpose: during the course of treatment, patients with cystic fibrosis and chronic pseudomonas aeruginosa infections in their lungs may be treated with nebulized tobramycin (tobi®). reduction in treatment times or dosing frequency may improve compliance and outcome. nebulized arikace™ may offer advantages to tobramycin by producing sustained lung levels of drug, reducing dosing frequency and increasing antimicrobial efficacy. herein are presented biodistribution data and efficacy data in a chronic rat model of p aeruginosa comparing arikace™, soluble amikacin and tobramycin. method: female rats (charles river) received (~ mg / kg) of arikace™, soluble amikacin and tobramycin by inhalation. test articles were aerosolized in a pari lc star nebulizer at psi using devilbiss compressors (sunrise medical) for min. - rats were euthanized at time and hr post inhalation by co asphyxiation. blood was collected by a cardiac puncture. serum was collected from coagulated blood by centrifugation and stored at oc until analysis for drug content. in addition lungs, kidneys, intestinal contents, urine and brains were harvested. tissues and biological samples were homogenized in saline and antibiotic concentrations determined by tdx analyzer (abbott). chronic lung infections were produced in rats by intratracheal instillation of agar beads containing p. aeruginosa. three days post instillation, rats (n= /group) were treated with aerosolized saline or once daily with arikace™, or twice daily with tobramycin (total daily dose = mg /kg) for days. rats were euthanized days post final dose and the pseudomonas cfu counts per lung were determined. results: the biodistribution and pharmacokinetics of aerosolized arikace™ was significantly different from that of amikacin and tobramycin. the primary difference was the amount of antibiotic retained in the lungs. rats that inhaled soluble amikacin cleared approximately % of the amikacin from the lungs after hr with concomitant % increase in drug levels in the urine. rats that inhaled arikace™ cleared only % of the deposited amikacin from the lungs after hrs. this initial clearance of drug most likely reflected the amikacin released during nebulization. extended clearance of arikace™ from the lungs was measured by recovery of amikacin in the urine at later time points. in a separate longer-term study comparing arikace™ and tobramycin, auc ( - hr)for arikace™ in the lung was ug*hr/g while only ug*hr/ g for tobramycin which demonstrates a -fold increase in retention of antibiotic in the lung with arikace™. eradication of p. aeruginosa from the lungs of rats with arikace™ was equal to tobramycin (given equivalent daily doses). however, arikace™ reduced the number of cfu in the lungs with a single daily exposure to the same degree as inhalation of tobramycin twice a day. conclusions: inhalation of arikace™ achieved higher concentrations and increased retention time of the antibiotic in the lungs of rats when compared to inhaled amikacin or tobramycin. it is expected that these properties of arikace™ will reduce dosing frequency and improve antimicrobial efficacy in patients. nielsen, x.c. ; johansen, u.r. ; nørregaard, l. ; vandamme, p. ; høiby, n. . clinical microbiology, rigshospitalet, copenhagen, denmark; . laboratory for microbiology, university of ghent, ghent, belgium background: the burhkolderia cepacia complex (bcc) is a diverse group of bacteria with at least genomovars (gv) or species. accurate species identification is necessary for better understanding of the epidemiology and pathogenesis of bcc. species identification based on phenotypic characters is difficult when it is based on few if any differences. crossed immunoelectrophoresis (cie) has been performed routinely to identify all burkholderia and other difficult isolates in our department (høiby et al.: "taxonomic application of crossed immunoelectrophoresis." int. j. syst. bact. ( ): - .) . in this study, we compared the results obtained by cie with those obtained by the standard molecular biological method using reca gene pcr and rflp to identify bcc at the species level (golden standard). methods: between and , burkholdreia isolates were recovered from patients in the two danish cystic fibrosis (cf) centres. . cie method: immunological cross-reactivity between antigens from the reference strains and the strains isolated from our cf patients were compared by employing cie and rabbit standard-antibodies (purified igg) raised against water-soluble antigens from reference strains of the bcc. species identification was made based on matching coefficient (mc). . reca gene-based identification: bcc specific primers were used to amplify reca gene. species-specific pcr is then performed using b. multivorans specific primers to identify the b. multivorans gv ii. rflp patterns were generated for those non-multivorans bcc by digesting the bcc-specific pcr products with haeiii. the patterns were then compared with the patterns generated from reference strains in the database. pulsed field gel electrophoresis (pfge) genotyping was performed for all strains to detect patient-topatient transmission. results: / isolates were bcc-specific pcr positive. species-specific pcr identified isolates as b. multivorans (gv ii). the other three isolates were identified as b. cenocepacia (gv iii) based on rflp patterns. two isolates with negative bcc-specific pcr reactions were identified as b. gladioli by cie (confirmed by reference laboratory in belgium). results from cie showed that strains from bcc were immunologically closely related with only a few non-cross-reactive antigens. compared with the standard reca gene-based method, cie method resulted in correct identifications in isolates ( . %), misidentifications in isolates ( . %) and uncertain identifications in isolates ( . %). genotyping by pfge showed unique patterns for all isolates except for those from two sisters. this suggested that patient-to-patient transmission of bcc among the danish cf patients has remained very rare. conclusions: reca gene-based pcr and rflp is a quick and reliable method for identification of bcc at the species level. cie proved useful in initial classification of bcc strains, but additional information is obtained by the reca gene-based species identification and pfge method. background: in childhood, the cystic fibrosis airway is characterized by persistent inflammation with high quantities of neutrophils. in this setting, recurrent exposure to low numbers of pseudomonas aeruginosa occurs routinely. chronic infection by p. aeruginosa is associated with a significant increase in morbidity and mortality in cf, and is believed to occur by formation of a biofilm in the cf airway. previously, we have shown a significant neutrophil dependent enhancement of p. aeruginosa biofilm density that is greatest for low initial concentrations of p. aeruginosa. biofilm enhancement is facilitated via neutrophil-derived dna and f-actin, which form a framework that p. aeruginosa can exploit for growth. dna and factin polymerize via positively charged molecules such as histones. p. aeruginosa then associates with these polymers, which results in increased early biofilm density, displaying an increase of over fold at hours compared to p. aeruginosa in the absence of neutrophils. hypothesis: compounds that disperse dna and/or f-actin can disrupt neutrophil-enhanced biofilms. methods: poly(aspartic acid), a negatively charged amino acid chain with the capacity to disrupt f-actin, was examined singly and in combination with dnase and/or antibiotics (ciprofloxacin and tobramycin). the nunc-tsp system was used to allow for high throughput assessment of the density of biofilm formation in the presence of neutrophils and the effect of various agents in disrupting the biofilm. the biofilm assay is independent of cellular settling, as the reactor is vertically suspended in the culture. p. aeruginosa strains tested were pao , and two isogenic cf isolates recovered from an initial infection (early), and following established infection ~ years later (late). biofilms were formed by incubation of p. aeruginosa with human neutrophils for to hours in rpmi with % heat inactivated platelet poor plasma. results: antibiotics were incapable of disrupting biofilms. poly(asp) significantly disrupted neutrophil-induced biofilms. in the presence of neutrophil products this action is sensitive to proteolytic degradation, but can be protected by the presence of protease inhibitors. dnase also disrupts a biofilm formed in the presence of human neutrophils. the combination of poly(asp) + dnase resulted in an increase in biofilm disruption for a hour biofilm. biofilms allowed to form for hours were more resistant to disruption by dnase and poly(asp) as single agents, but the combination of both demonstrated a synergistic effect. similar disruption of biofilms were observed when pao was compared to early and late cf strains. conclusions: pseudomonas aeruginosa biofilms formed in the presence of neutrophils in vitro can be disrupted by agents that disperse the f-actin and dna framework. support: cff, max and yetta karasik foundation cystic fibrosis (cf) patients may suffer increased morbidity and mortality through colonisation, allergy and invasive infection from fungi. the black yeast, exophiala dermatitidis (synonym wangiella dermatitidis) has been found with increasing frequency in sputum specimens of cf patients, with reported isolation rates ranging from between . and . %. at present, no species-specific diagnostic pcr exists to aid with the clinical laboratory detection and identification of this organism. a novel species-specific pcr-based assay was developed for the detection of e. dermatitidis, based on employment of rdna operons and interspacer (its) regions between these rdna operons. two novel primers, (designated exdf & exdr) were designed in silico with the aid of computer-aided alignment software and with the alignment of multiple species of exophiala, as well as with other commonly described yeasts and filamentous fungi within cf sputum, including candida, aspergillus and scedosporium. pcr employing exdf (forward primer [ -,mer], '-ccg cct att cag gtc c- ') and exdr (reverse primer [ -mer], '-tct ctc cca ctc ccg c- '), was employed and optimized on extracted genomic dna from a well characterized culture of e. dermatitidis, as well as with high quality genomic dna template from a further unrelated fungi, including candida albicans, c. dubliniensis, c. parapsilosis, c. glabrata, scedosporium apiospermum, penicillium sp., aspergillus fumigatus, aspergillus versicolor, pichia guilliermondii, rhodotorula sp., trichosporon sp., aureobasidium pullulans, fusarium sp., mucor hiemalis, bionectria ochroleuca, gibberella pulicaris. results demonstrated that only dna from e. dermatitidis gave an amplification product of the expected size, whilst none of the other fungi were amplifiable. subsequent direct employment of this primer pair detected this yeast in the sputum of / ( %) adult cf patients, employing a nested pcr approach with panfungal outer flanking primers of the its -its region. these two patients were the only patients who were previously shown to have a cultural history of e. dermititidis from their sputum. e. dermatitidis is a slow-growing fungus, which usually takes up to two weeks to culture in the microbiology laboratory and therefore is slow to detect conventionally, with the risk of bacterial overgrowth from common co-habiting pan-and multiresistant bacterial pathogens from sputum, namely pseudomonas aeruginosa and burkholderia cepacia complex organisms, hence this species-specific pcr assay may help detect this organism from cf sputum more specifically and rapidly. overall, employment of this novel assay may help in the understanding of the occurrence, aetiology and epidemiology of exophiala dermatitidis, as an emerging fungal agent in patients with cf. cystic fibrosis patients are particularly susceptible to infection by strains of pseudomonas aeruginosa and burkholderia cepacia complex. since , the pseudomonas genome database has been a resource for peer-reviewed, continually-updated annotations for the pseudomonas aeruginosa pao reference strain's genome and, more recently, comparative analyses to several closely-related pseudomonas species. in order to facilitate better cross-strain and cross-species genome comparisons, we have developed or are incorporating methods to improve the identification of orthologs (genes diverged due to speciation) and identify genes undergoing unusual selection. our analysis of several completely sequenced pseudomonas genomes has revealed that approximately % of ortholog predictions by the classic "reciprocal best blast hit method" are likely incorrect. we have also performed an analysis of unusually large intergenic regions in p. aeruginosa pao that appear to be essential (according to saturation transposon mutagenesis) or involved in virulence (according to signature tagged mutagenesis). we identified at least new putative protein-coding regions and non-coding rnas that were not previously annotated and may play critical roles in microbial pathogenesis or viability. we are also focusing our attention on facilitating better cross-strain comparisons between recently sequenced burkholderia cepacia complex genomes through development of a new online burkholderia genome database. in addition to improved ortholog prediction, this new database will provide access to a very flexible boolean search feature that allows researchers to search and compare annotations within or between the genomes of burkholderia strains, returning annotations from multiple genomes suitable for simultaneous viewing and downstream analyses. we have also included new, very accurate protein subcellular localization predictions for the deduced proteome from each of these genomes -predictions that can aid the identification of new cell surface or secreted therapeutic targets or vaccine candidates. further comparative analyses with other newly-sequenced, related strains should provide insight into strain-specific features that may be exploited to better understand virulence and antimicrobial resistance exhibited by cf-relevant pathogens. funding provided by cystic fibrosis foundation, therapeutics (usa). popova, a.p.; verma, r.; zanni, r.l.; sembrano, e. pediatrics, monmouth medical center, long brnach, nj, usa background: cystic fibrosis (cf) is a chronic, progressive, genetic disease leading to poor lung function, chronic bronchial infection with certain bacteria and recurrent pulmonary exacerbations. despite evidence of inflammation within the airway, it is unclear which circulating inflammatory biomarker best reflects the airway inflammation and lung function in cf. objective: to determine the utility of c-reactive protein (crp) value in evaluating patients with cystic fibrosis pulmonary exacerbation. design: a retrospective chart review was carried out on patients followed at the cystic fibrosis center at the children's hospital. information about serum crp values, pulmonary function test results(pft), presence of pulmonary exacerbation as documented in the chart, sputum culture results, current medications, as well as demographic data, genetic compositions and weight percentiles between january and march was collected from the charts and was analyzed. results: of patients whose charts were reviewed, were excluded because they underwent lung transplant, were excluded because they had other mild infection, not diagnosed as pulmonary exacerbation. for patients crp was not measured and they were also excluded from the analysis. total of patients were included in the study. for patients information about crp was obtained on more than one occasion. the patients were divided into groups based on the presence of pulmonary exacerbation and elevation of crp values -in the group with pulmonary exacerbation, patients had elevated crp and had normal crp and in the nonexacerbation group had elevated crp and had normal. fisher's exact test (two -tail) was applied (p= . ) and confirmed statistically significant elevation of crp in patients with pulmonary exacerbation of cystic fibrosis. the means and standard deviations of the crp values for the patients without pulmonary exacerbation and the patients with pulmonary exacerbation were calculated and analyzed using independent group t-test (two tail). mean crp value for the exacerbation group was . with standard deviation of . and mean crp value for the non-exacerbation group of . with a standard deviation of . . statistically significant difference between the two means was noted (p= . ). conclusion: serum crp values in patients with cf pulmonary exacerbation were significantly higher than in patients without pulmonary exacerbation. serum crp may be a useful marker of pulmonary exacerbation in children. in the absence of pulmonary exacerbation, cf is not associated with elevated crp values in children. the findings of this study could aid in identifying patients with pulmonary exacerbation earlier and initiate appropriate therapy sooner. further studies are needed to determine whether crp values are associated with the severity of the underlying disease, to what extent the pft are affected, the age of the patient, the type of bacterial pathogen, and genetic factors. background pulmonary infections with nontuberculous mycobacteria (ntm) are commonly associated with structural lung diseases or airways clearance disorders such as cystic fibrosis and primary ciliary dyskinesia. we follow approximately individuals with ntm pulmonary disease who share common clinical features but have no identifiable systemic immune defect or clearly defined predisposing conditions. the pulmonary disease and clinical presentation suggest these individuals may have disorders of ion transport or ciliary function. while some cftr mutations and ciliary abnormalities are difficult to detect through standard genetic and ultrastructural analyses, in vivo physiologic tests of ion transport and measures of ciliary function may allow us to identify ion transport abnormalities in subjects with no identified cftr abnormalities, determine the functional significance of novel cftr mutations, and distinguish disorders of ciliary function from other airways clearance disorders. methods we evaluated the medical and family histories, chest and sinus ct's, sputum cultures, cftr genotypes, and sweat chloride levels of individuals with nontuberculous mycobacterial pulmonary disease and individuals with chronic airways disease and bronchiectasis. we systematically tested the pulmonary function (pft), nasal nitric oxide production (nno), and nasal potential difference (npd) of each subject. nasal mucosal scrape biopsies were performed and sent to unc-chapel hill for assessment of ciliary ultrastructure as part of the genetic diseases of mucociliary clearance consortium. pulmonary function, nno, and npd were measured on healthy controls. results all subjects had sino-pulmonary symptoms consistent with those associated with cf and pcd. subjects had low nno ( . ± . nl/min) consistent with levels reported in subjects with pcd (< nl/min, noone ). one subject with variant cf (∆f /r h) displayed low basal pd (- . mv), elevated na+ absorption ( . mv), and no cftrmediated cl-conductance (- . mv). subjects with cftr mutations, subject with isolated elevated sweat chloride ( mmol/l), and subject with isolated borderline sweat chloride ( mmol/l) displayed normal basal potential difference (- . ± . mv) and na+ absorption ( . ± . mv) but decreased cftr-mediated cl-conductance (- . ± . mv) relative to controls (- . ± . mv). conclusions ntm patients heterozygous for cftr-mutations or with elevated sweat chloride (and no identified mutations with coding region sequencing of cftr) may have detectable subtle differences in cftr clconductance, while measurement of nno may identify disease associated with ciliary abnormalities. these findings suggest subtle abnormalities in airways clearance may predispose to airway infection with environmental organisms such as ntm. support: intramural funds, national institute of allergy and infectious diseases muhlebach, m. ; goodrich, j. ; sutton-shields, t.n. ; wedd, j.p. ; henegar, c. ; miller, m.b. ; gilligan, p.h. . dept. of pediatrics, unc chapel hill, chapel hill, nc, usa; . university of north carolina hospitals, chapel hill, nc, usa; . school of public health, university of north carolina hospitals, chapel hill, nc, usa; . dept. pathology and laboratory medicine, university of north carolina hospitals, chapel hill, nc, usa introduction: proportion of methicillin resistant (mrsa) vs. susceptible sa infections increased from % in to % in in us hospitals. similarly, the prevalence of mrsa in the community has risen in recent years. these community acquired (ca) mrsa isolates are genotypically different, have different antibiotic susceptibility, and often carry the pvl virulence gene. this virulence gene is associated with more invasive, mostly skin infections in healthy individuals. reports on impact of mrsa in cf show conflicting data. , . the aim of this study was to determine the prevalence of ca-mrsa strains at our pediatric and adult cf center and to assess the impact of these infections on clinical outcome. methods: all mrsa isolates recovered from routine clinical cultures, were prospectively collected and analyzed for months ( / - / ). using molecular assays to determine the pvl status and to identify the sccmec (staphylococcal cassette chromosome) type, the organisms were classified as ca or ha. classification as ca mrsa was based on presence of pvl and sccmec iv type. clinical outcomes included lung function measurements in patients reliably performing spirometry and nutritional parameters (bmi%). patients who had undergone lung transplant were excluded as their lung functions vary depending on transplant outcome. results: of the patients identified in this month period, % had ha and % ca mrsa. neither current age (mean . yrs. in ha vs. . years in ca) nor age at acquisition of mrsa ( . vs. years) was significantly different. sixty-eight % of all mrsa infected patients had chronic p. aeruginosa infection, ( % in the ha and % in ca, relative risk . of having ha in presence of chronic p. aeruginosa infection). crosssectional comparison of patients infected with ca vs. ha acquired strains showed no difference in nutritional status (bmi vs. %). lung function (fev and fef - ) was not different in ca vs. ha patients, neither when including all mrsa infected patients or those who had no concomitant infection with other organisms (n= ). we will present further comparisons to age and gender matched children with ossa infection in the final report. conclusion: comparison to ossa in matched patients will assess clinical outcomes of infections with mrsa. initial data collected at our center did not show a significant difference in outcomes between patients infected with ca vs. ha mrsa. a multicenter study would most efficiently assess the impact on clinical outcomes and determine regional differences of mrsa patterns (ca vs. ha) in different cf centers. ref : the stringent response is a global regulatory mechanism used by bacteria to adapt to nutrient limitation and other environmental stresses, and is mediated by the signaling molecules (p)ppgpp (phosphorylated guanosine nucleotides). increases in (p)ppgpp repress metabolic processes and growth, and regulate genes involved in long-term stress and starvation survival in several species ((i)e. coli, m. tuberculosis(i)), bacterial multicellular behavior ((i)myxococcus xanthus(i)), and pathogenesis ((i)p. aeruginosa(i)). while many studies have investigated bacterial functions (such as attachment and motility) involved in biofilm development, less is known about the physiological adaptation occurring in biofilm growth. when cells grow to high densities entrapped in a polymer matrix, they must adapt to heterogeneous micro-environments where gradients in nutrients, oxygen and metabolic waste exist. nutrient may thus become depleted as they are consumed by overlying cells, and some biofilm subpopulations are likely starved. we hypothesized that the stringent response mediates adaptation to nutrient starvation in (i)p. aeruginosa(i) and is important for biofilm formation. we tested a (i)rela(i) deletion mutant unable to synthesize (p)ppgpp in response to amino acid starvation, and its isogenic wildtype parent pao . we measured the starvation survival of planktonic bacteria in phosphate buffered saline and observed that the (i)rela(i) has a to fold greater loss in viability compared to wild type after h. we also tested biofilm formation in a static biofilm assay using polystyrene peg lids and estimated biomass accumulation by crystal violet staining. in this system, the (i)rela(i) accumulates times less biomass than wild type. in a flow-cell reactor system, the wildtype strain forms complex mushroom-like biofilm structures, but the (i)rela(i) mutant forms flat, thin biofilms. we determined cell attachment to polystyrene by crystal violet staining, and to glass surfaces by direct visualization under microscopy. the attachment to both surfaces is similar in the (i)rela(i) and wildtype strains, and the strains have identical planktonic growth rates. our findings suggest that the stringent response is involved in starvation survival, a physiological condition relevant to growth in biofilm. furthermore, (i)rela(i) inactivation impairs biofilm formation, suggesting that the stringent response may be an important stress adaptation in biofilm. belfast, united kingdom; . northern ireland public health laboratory, belfast city hospital, belfast, united kingdom; . northern ireland regional adult cf unit, belfast city hospital, belfast, united kingdom; . department of respiratory medicine, queen's university, belfast, united kingdom pseudomonas aeruginosa (pa) is a clinically significant bacterial pathogen responsible for increased morbidity and mortality in patients with cystic fibrosis. small non-coding micro(mi)rna species (generally ~ nts or less) in prokaryotes are involved in numerous cellular processes as is the case with eukaryotes. as in eukaryotes, these mirnas act by base pairing with target mrnas imposing translational and stability changes of mrnas and thus culminating in the control and regulation of target mrnas, crucial for bacterial stress responses and virulence to changing environments surrounding the infected zone or host cell (e.g. human airway epithelial cells). we recruited a commercial kit (biodynamics dynaexpress mirna cloning kit av, tokyo, japan) and isolated mirnas from a variety of pseudomonas pathogens from plant, soil / agricultural environment (pseudomonas syringae -ps), type strain (pseudomonas aeruginosa -pa) and a collection of clinical isolates of pseudomonas aeruginosa (cfpa) from adult cf patients, who were chronically infected with p. aeruginosa. the results on the mirna clones obtained exhibited a wide variation in the occurrence of mirnas in this bacterium. the putative mirnas obtained, cfpa in particular, yielded small non-coding rnas of sizes from as little as nts to well over nts. an initial search using the bioinformatic tool srnapredict (www.waldorlab/tufts.edu) has not as yet, fully revealed the genomic annotations for these novel srna sequences in the inter-generic regions of the pathogenic pseudomonad group of bacteria. we present our data on these unknown cellular mirnas cloned from cfpa isolates from cf patients and discuss their significance as novel regulators to bacterial stress responses and in the context of the bacterium's involvement as the predominant pulmonary pathogen, associated with cystic fibrosis. airway function is diminished in infants with cf diagnosed clinically but whether this is true for those identified by newborn screening remains unclear. we investigated whether lung function is diminished in infants with cf diagnosed by newborn screening and if this occurs in association with pulmonary infection. methods:lung function was measured in asymptomatic infants with cf following sedation with chloral hydrate ( - mg/kg) using the raised volume rapid thoracic compression technique at an inflation pressure of cmh . we measured forced vital capacity (fvc), forced expired volume after . seconds (fev . ) and forced expired flow at % expired fvc (fef ) which were then expressed as z scores. broncho-alveolar lavage (bal) was performed under general anesthesia within forty-eight hours following infant lung function testing. three separate aliquots of ml/kg sterile saline were instilled into the right middle lobe and a further aliquot in the left lingula and the bal fluid analyzed for bacterial, fungal and viral pathogens using routine culture techniques. results: bal was successful in all infants studied aged . to . yrs (median . yrs) and lung function in infants. median (range) z scores for fvc, fev . and fef were - . (- . to . ), - . (- . to . ) and - . (- . to . ) respectively. these decrements in lung function were all significant (p< . ). bal cultures were positive in ( %) infants of whom ( %) had evidence of infection with s. aureus and ( %) with p. aeruginosa. in infants there was no growth in bal or growth only of mixed oral flora. viruses were not identified in any infants. there was no association between any of the lung function parameters and pulmonary infection detected by bal. lung function was successful in a subgroup of of infants who were less than . yrs (median age . yrs) when tested. diminished airway function was identified in this younger subgroup even though only one infant had evidence of pulmonary infection with respiratory organisms in bal. in this younger subgroup median fev . z score was - . which was significantly below that predicted ( % ci: - . ,- . and p= . ). conclusions: airway function is diminished in infants with cf diagnosed by newborn screening and occurs irrespective of infection identified by bal. lung function is abnormal in very young infants before pulmonary symptoms develop and when no evidence of pulmonary infection can be detected in bal. inhaled high-dose tobramycin appears to transiently clear p. aeruginosa (pa) from airway secretions in young children with cf, though inflammation may not be markedly reduced (am j resp crit care med ; : ) . because inhaled antibiotics may not reach some areas of infection, we hypothesized that intravenous (i.v.) antibiotics may be more effective than inhaled high-dose tobramycin for reducing lower airways inflammation in cf children with early pa infection. study design: we initiated a single-center, randomized, prospective study comparing the effects of two antibiotic treatment regimens on bronchoalveolar lavage fluid (balf) inflammatory markers. clinically stable cf children with a recent isolate of pa from surveillance cultures are randomized to receive weeks of tobi® (group ) or weeks of i.v. ceftazidime and tobramycin (group ). balf is obtained just before treatment, and repeated - weeks after completion of treatment. the primary study outcome is change in balf % neutrophils (pmn). multiple secondary outcomes are assessed including quantitative bacterial cultures and cytokines in balf. this report summarizes interim analysis at the halfway point of the study. results: to date, subjects have enrolled. five subjects ( in group , in group ) dropped out after the initial bronchoscopy due to a decision by the primary cf physician to use other treatments based on balf culture results ( ) , or because of the development of a new respiratory illness before the second bronchoscopy ( ). a total of adverse events ( significant, unrelated to protocol) were reported in subjects, none resulting in a change of protocol request by the irb or data safety monitor. of the subjects completing the protocol to date, were in group , and were in group . the groups were well matched in terms of age, pa in initial balf, and initial balf %pmn. a majority of subjects in each group were children with their first isolation of pa on surveillance cultures. there was a tendency for group , but not group , to have mild reductions in balf %pmn (- ± %) after treatment. interim efficacy analysis did not suggest a significant difference between the treatment groups at this stage. similar changes were seen in group for pmn/ml (- ± x /ml) and several cytokines including gm-csf (- ± pg/ml) and mcp- (- ± pg/ml). two group subjects were unable to have stable i.v. access established and were treated with oral ciprofloxacin and inhaled tobi® for weeks as alternative systemic antibiotics, per protocol. dropping these subjects from group data did not change data trends. conclusions: the protocol appears to have adequate safety. parents of children with first-time pa infection may be more likely to consent to treatment randomization, than those with repeated pa infection. interim data analysis suggests that continuation of the study toward the original sample estimate is appropriate. acknowledgements: supported by cff(noah a ) and nih (gcrc r ). we thank tracy callahan rn, lupe haynes rrt, justin hubbard, paula murphy, cassidy henegar, nancy lee rn, benjamin butler rn, and sheree berckmans rn for logistical and technical support. methods: our local cf database was searched for patients born - . patients were included in the analysis if they were followed in our cf center before the age of . patients were separated into two birth cohorts, born - (cohort ) and - (cohort ). yearly peak fev % predicted from ages - were obtained using knudson reference equations. yearly peak bmi% and weight-for-age% at each age were also obtained. type tests of fixed effects and repeated measures analyses were used to assess mean peak bmi%, mean peak weight-for-age%, mean peak fev % predicted at first pft, mean peak fev % predicted from ages - , and mean rate of change (slope analysis) in peak fev % predicted from ages - . chi-square test for association was used to analyze differences in demographic parameters. wilcoxon rank-sum test was used to assess differences in age at diagnosis. wilcoxon non-parametric test was used to analyze differences in mean clinic visits per year. chi-square testing with a two sided alpha of p < . was used to determine significance. results: cf patients were included in the analysis. there were no significant differences between birth cohorts and for age of diagnosis (p= . ), sex (p= . ), race (p= . ), genotype (p= . ), pancreatic insufficiency (p= . ), or the mean number of clinic visits per year from ages of - (p= . ). there was a significant difference in the mean number of clinic visits per year from ages of - (p=. ; see table ) . birth cohort had a significant effect on the rate of decline in lung function from ages - . birth cohort and age had significant effects on the mean weight-for-age%, mean fev % predicted at first pft, and mean fev % predicted from ages - . sex had a trend for significant effects on lung function parameters. adjusted for age and sex, there were significant differences between birth cohorts and in mean bmi% and mean weight-for-age% at ages and , mean fev % predicted at first pft, mean fev % predicted from ages - , and in the mean rate of decline in fev % predicted (see table ). conclusions: improvements in lung function and nutritional outcomes in our cf center are associated with an increase in the mean number of clinical visits per year for cf patients ages - . the frequency of clinical follow-up is a marker of cf care that may have positive impacts on cf outcomes. background: current management of cf airway disease includes the use of key pharmacological therapies designed to combat the chronic cycle of obstruction, infection, and inflammation. randomized controlled trials have demonstrated that maintenance therapy with azithromycin (azm), dornase alfa (dnase), and tobramycin for inhalation (tob) each improves pulmonary function and reduces the frequency of exacerbations in patients with p. aeruginosa. the purpose of this study was to determine if cf patients in an uncontrolled environment (clinical setting), experience a reduced rate of pulmonary function decline when receiving azm + dnase + tob compared to those not on all three therapies. methods: adult cf patients were selected based on positive sputum cultures for p. aeruginosa, pulmonary function test results (fev % predicted) for the past year, and receiving one of the key pharmacological therapies. in addition data was collected on cfrd, depression, medication adherence, airway clearance, and nutritional status. patients were stratified according to baseline pulmonary function: mild (fev ), moderate (fev of - %), and severe (fev < %). patients were then sub-grouped as to whether they were receiving all or ≤ of the key therapies. the annual rate of decline in % predicted fev was determined using linear regression on non-exacerbation data and was categorized as stable (< . % decline), intermediate ( . - . %) , or rapidly declining (> . %). time to intermediate or rapid decline in pulmonary function was determined using cox proportional hazard modeling. results: patients ( males/ females, median age years) were included in this study; with mild, with moderate, and with severe pulmonary disease. overall, the mild and moderate groups experienced median declines of . % and . %, while the severe group experienced a . % improvement in fev % predicted respectively. the use of regimens containing azm therapy significantly delayed time to intermediate or rapid decline in lung function in the mild group (median days vs. . days, hr= . , p= . ). similarly, regimens containing dnase + azm + tob significantly delayed time to intermediate or rapid decline in lung function in the mild group (median days vs. days, hr= . , p= . ). no significant differences were seen in the moderate or severe group for patients receiving all or individual therapies. con-clusion: administration of pharmacological regimens containing dnase + azm + tob, or azm + tob or azm + dnase significantly delay progression of pulmonary disease in cf patients with mild lung disease. sawhney, v. ; arthur, b. ; seltzer, r. ; kraynack, n.c. . internal medicine, akron general medical center, akron, oh, usa; . pediatrics, akron children's hospital, akron, oh, usa; . biostatistics, neoucom, rootstown, oh, usa; . pulmonology, akron children's hospital, akron, oh, usa early and efficient diagnosis of pulmonary exacerbations (pex) in patients with cystic fibrosis (cf) is crucial in the management of cf. in oct , we implemented a pulmonary exacerbation scoring (pes) system to uniformly and consistently identify pex in cf patients as part of a quality improvement project at the cf center at akron children's hospital. we have previously reported improved pulmonary function outcomes in pediatric patients at our center after implementation of the pes. we now describe the impact of the pes on clinical practice in the management of pex and pulmonary function in our adult cf patients. the pes was developed by our multidisciplinary cf team after an extensive literature review and was implemented in oct . the pes has been previously described and consists of clinical questions divided into three domains: systemic and pulmonary symptoms and signs, and objective measurements. these elements are scored individually and a cumulative pes of ≥ (range - ) is considered a pex and treatment with antibiotics is recommended. the course and choice of antibiotic regimen is left to the physician's discretion. we examined median percent predicted fev decline from quarterly percent predicted fev measurements obtained from port cf. we calculated this for all the patients seen in our adult cf clinic (age> ) from oct till sep during which the pes was in use. we compared this rate of decline to median percent predicted fev decline for the same cohort of patients over the preceding two years (oct till sep , during which the pes was not in use. the percent utilization of the pes was calculated individually for all adult cf care providers. the influence of individual components of pes in decision to treat was also studied. we found no significant difference between the rates of decline in percent predicted fev during the pre-pes and post-pes periods (mean = -. , sd = . vs mean = -. , sd = . , p= . ) as measured by paired samples t-test. logistic regression analysis was done to evaluate the relative importance of each pes component in predicting decision to treat a pex. we found that changes in fev (or= . ), cough (or= . ), sputum (or= . ), and chest examination (or= . ) are most likely to affect the decision to treat where as dyspnea (or= . ) has the little effect on decision to treat. we found a high degree of correlation between adult provider use of the pes and an independent chart reviewer (correlation coefficient . - . ; p< . ). in contrast to cf patients ages - years, we found no significant effect of use of the pes on pulmonary function in our adult population, despite the high frequency of use by our adult providers. it is unclear why this is the case given the robust effect of the pes on our pediatric population. this study suggests that a simplified score that includes fev , cough, sputum, and chest exam may be useful in identifying a pex in adult cf patients. special thanks to tasha capozzi for her help with chart review. this project was supported by the akron children's hospital foundation. objective chronic pulmonary infection with pseudomonas aeruginosa is the main cause for morbidity and mortality in cystic fibrosis (cf) patients. tobramycin and colistin, widely used inhaled antibiotics in cf patients, were found to affect elastase activity in vitro. we showed recently that cxcr on neutrophils mediates bacterial killing, but is cleaved in cf airways by elastase. therefore, we examined the effects of inhalation with tobramycin and colistin on cxcr expression and antibacterial capacities by airway neutrophils in cf patients in vivo. methods cxcr expression was quantified by flow cytometry on neutrophils in peripheral blood and induced sputum of cf patients without inhalation therapy, cf patients with tobramycin and cf patients with colistin inhalation therapy. the longitudinal effect of a weeks tobramycin or colistin inhalation period on cxcr expression, free elastase levels and bacterial killing by airway neutrophils was assessed. results inhalation with tobramycin increased, while inhalation with colistin decreased cxcr expression on neutrophils in induced sputum of cf patients. neutrophils isolated from sputum of cf patients after tobramycin therapy had higher, whereas patients after colistin therapy had lower bacterial killing capacity and α-defensin release as compared to neutrophils before antibiotic inhalation therapy. conclusions tobramycin and colistin differentially modulate the pulmonary host defense in cf patients in vivo via cxcr on neutrophils. these findings may have clinical implications when considering antibiotic treatment in cf patients. sharp, j. ; sheehan, d. ; ren, c.l. . pediatrics, women & children's hospital, buffalo, ny, usa; . pediatrics, university of rochester, rochester, ny, usa background: airway infection and inflammation occur early in infants with cf. the raised volume/rapid thoracoabdominal (rv/rtc) technique is more sensitive than older infant pulmonary function test (ipft) methods in detecting airflow obstruction in these patients. however, there are limited data regarding lung function measured by rv/rtc in infants with cf nbs. we hypothesized that abnormalities of lung function measured by rv/rtc are present in cf nbs infants. to test this hypothesis, we reviewed the ipft data from cf nbs infants followed at our cf centers. methods: this study was a retrospective chart review. we identified infants with cf nbs followed at our cf centers who had had at least ipft performed in the first year of life. ipfts were performed using the collins ipl. forced expiratory flows were measured using rv/rtc as described by feher et al (j appl physiol : , and fractional lung volumes were measured by whole body plethysmography (bp) as described by castile, et al (ped pulm : , ) . data from the cf infants were compared to normal data reported by jones, et al (ajrccm : , ) for rv/rtc and castile, et al for bp. results: we reviewed data from infants. their mean age was . m (range= - ). pancreatic insufficiency was present in ( %) infants, and ( . %) had been treated for pseudomonas infection. their pft findings are summarized in the table. fvc and fev . were not significantly different from the normal predicted values. however, the mean fef and fef - z scores were significantly below the mean of normal infants (p= . and . respectively). gas trapping was present, as evidenced by significantly increased frc, rv, and rv/tlc (p< . for all measures). six infants ( %) had an fef z score of < - . , and ( %) had an frc > % predicted. conclusions: infants with cf nbs have abnormal lung function early in life. our results suggest that pfts in cf nbs infants can be useful in detecting early changes in lung function. we speculate that early therapeutic interventions may improve lung function in this group of patients. table. pft findings in infants with cf nbs. forced expiratory flows are reported as z scores, while fractional lung volumes are reported as % predicted. objective: clinicians use pfts to assess effectiveness of therapy in hospitalized cf patients. however, the variability of multiple pft efforts has not been described in this group of patients. previous study of within day variation of pfts has been reported in healthy adults and children (enright, , and nickerson, ) and clinically stable outpatients with cf (nickerson, , and cooper, ) . nickerson and cooper found coefficient of variations (cv) for fvc of . - %, fev of . - . %, and fef - of . - . % for adults and children with cf. no one has studied the within day variation of pfts in cf patients during pulmonary exacerbations. our objective was to determine the within day variation of pfts during hospitalizations for cf pulmonary exacerbations. we hypothesized that within day variation would improve during treatment. methods: we retrospectively reviewed pft data for all patients admitted to childrens' hospital and regional medical center for a cf pulmonary exacerbation in . patients performed pfts under the direction of experienced pulmonary function technicians. the test was complete when the patient performed efforts that met ats/ers criteria for acceptability. if the patient was unable to produce efforts because of coughing, efforts were accepted if the fvc and fev were within % or ml of each other. for analysis, we included only those pfts: ( ) with at least - flow-volume curves that fulfilled ats/ers criteria, and ( ) were performed within days of hospital admission or discharge. for patients with multiple admissions, we used pft data for their first admission only. for patients with admission and discharge pfts available, we compared the coefficient of variation (cv) for pfts (fvc, fev , ). there were at least days between admission and discharge pfts. the wilcoxon rank-order test was used to compare the cv for admission and discharge pfts. data: sixty-one patients were admitted times in . excluding repeat hospital admissions, patients had individual pft trials available at the time of admission and patients at the time of discharge. seven admission and discharge pfts included only trials. three patients at admission, and patients at discharge, were unable to produce pft curves that met ats/ers criteria, despite previously having done so when well. nine patients had paired admission and discharge pfts from the same hospitalization. the cv for fvc at discharge was significantly better than at admission, p = . (see table) . conclusions: within day variation of pfts during hospitalizations for cf pulmonary exacerbations is comparable to published outpatient data. cv for fvc improves significantly during exacerbation. changes in fvc > %, fev > %, and fef - > % can be considered a significant spirometric response to therapy in hospitalized cf patients. background: lung clearance index (lci), a measure of ventilation heterogeneity, can be calculated from multiple breath washouts of inert gas. in cross sectional studies it is a more sensitive measure of early airway dysfunction in cf than spirometry alone. in normal subjects, the technique is reproducible, with a narrow normal range of . - . . we hypothesized that it may be helpful in detecting change longitudinally, and may have value in assessing novel therapeutic interventions such as the upcoming gene therapy by the uk cfgt consortium. methods: patients aged years and over, presenting with an exacerbation requiring intravenous antibiotics, were recruited. lci was assessed in triplicate by multiple breath washout of . % sulphur hexafluoride (sf ), using a novel gas analyser (innocor, denmark) and custom-built software within the first hours of starting treatment. the test was repeated at the end of parenteral antibiotic therapy and again - weeks later when clinically stable. patients were recruited at three sites and assessed using standardised equipment and a data analysis protocol. results: paired lci measurements were available in patients, mean age (range - ) years, male. in a further patients, technically acceptable washouts could not be obtained at one or other time point. mean (sd) lci improved from . ( . ) to . ( . ), p< . . in / patients there was an improvement in lci of > % after antibiotics. patients showed a > % deterioration in lci. mean fev was significantly greater after treatment ( . v . l/s, p< . , n= ). there was a weak correlation between percent change in fev and lci (r = . , p< . ). patients also had lci measured at the follow up. mean (sd) lci at this visit was . ( . ), p< . vs visit , no significant difference vs visit . conclusions: lci can be used to demonstrate changes in the lung after antibiotic therapy. this is the first study in cf to demonstrate a lon-gitudinal improvement after intervention in a marker of ventilation heterogeneity, and offers different but complimentary information to spirometry. the higher sensitivity of lci may make possible measurement of improvement in mild patients after novel therapies such as gene therapy. this work was funded by the cystic fibrosis trust. aim: inhaled hypertonic saline positively affects sputum production in patients with cystic fibrosis (cf) by improving mucociliary clearance. this study was conducted to compare the aerosol delivery performance of various nebulizers upon aerosolization of hypertonic saline (hyper-sal™) . % and %, available as preservative-free, sterile ml solution in single dose, patient friendly blow-fill seal vials. method: ml hypertonic saline (hyper-sal™) % was nebulized by three jet nebulizers the pari lc plus®, lc star® and hudson rci micro mist as well as the eflow® for hypertonic saline (hs) generating aerosols via a perforated vibrating membrane. hs . % was characterized in the eflow®hs. droplet size distribution patterns were assessed by laser diffraction at a flow rate of l/min and aerosol delivery performance by breath simulation tests mimicking a sinusoidal breathing pattern. the delivered dose (dd) was determined by gravimetric analysis of the inhalation filters. inhalation and exhalation filters were changed after min and the drug delivery rate (ddr) was calculated as nacl found on inhalation filters per min. respirable drug delivery rate (rddr; ddr x respirable fraction < µm) indicates how much nacl can reach the lungs per minute. results: aerosol characteristics of the different nebulizers after aerosolization of ml hs % are summarized in the table. data for hs . % nebulized by the eflow®hs were as follows: dd= . %, ddr= . %, nebulization time = . min and comparable to data for hs %. the lower recoveries for the jet nebulizers are probably associated with increased evaporation and longer nebulization times. conclusion: about - % of the charged sodium chloride from ml hs was delivered and % - % of these droplets were in a respirable size range < µm resulting in vitro respirable doses of about % - % of the label claim. ddr and rddr are about -to -fold higher for eflow®hs indicating a much higher delivery efficiency compared to conventional jet nebulizers. further studies will be needed to demonstrate that about ml hs may be sufficient to deliver a comparable dose to the lungs using an eflow®hs compared with jet nebulizers. this bears the potential to further reduce nebulization time and increase acceptance by patients. objectives: individuals with cf frequently have complicated and time consuming treatment regimens consisting of inhaled antibiotics, mucolytics, and airway clearance. patients and clinicians may have difficulty determining which specific therapies are effective for any individual patient or whether a particular treatment is causing adverse effects. this study assessed the utility of home spirometry for providing an objective measure of pulmonary status in between scheduled clinic visits. methods: consecutive adults with cf were recruited at a single academic medical center and were asked to measure fev twice daily for six months using the piko- meter (nspire health™, llc). subjects agreed to participate and completed the study. subjects were given diaries to record changes in respiratory symptoms and changes in medications during the study period. subjects were evaluated in clinic at least every three months and fev values obtained in the pulmonary function lab were compared to home fev from the same day using linear regression and bland-altman analyses. graphical displays of home fev measures were visually inspected for changing trends and these were compared with medication changes. results: the mean fev measured at home was . ± . l. the mean fev in the pulmonary lab was . ± . l. the home fev was significantly correlated with the clinic value from the same day, r = . , p< . . fev measures fell within the limits of agreement (± sd) by bland-altman plot. in of subjects ( . %) there was at least one sustained change in fev that correlated with either stopping or starting a particular treatment. the figure shows two significant changes in fev in one patient related to medication changes. there is an increase in fev at the initiation of aerosolized % saline and a fall in fev that corresponded to inhaled tobramycin use. the improvement on hypertonic saline increased this patient's enthusiasm for this treatment. conclusions: home fev monitoring is feasible and appears to provide accurate measurement of pulmonary function. it can provide clinicians with objective data to tailor treatments without necessitating a clinic visit. feedback from home monitoring may improve medication adherence and may allow treatments to be individually tailored based on patient responses to the medications. . respiratory unit, royal hospital for sick children, glasgow, united kingdom; . diagnostic imaging, nhs greater glasgow & clyde, glasgow, united kingdom; . medical statistics, royal hospital for sick children, glasgow, united kingdom; . medical physics department, gartnavel hospital, glasgow, united kingdom background: there have been calls for caution regarding the suggested use of regular chest computed tomography (ct) scans for monitoring disease progression in cf . consideration of the associations of higher ionizing radiation exposure must be made before regular chest cts are performed on the wider cf population. aim: we tested the hypothesis that higher ionizing radiation exposure from chest radiographs (cxr) and chest cts would be associated with markers of severity including gender, genotype (class i/ii or iii-v), height sds, weight sds, bmi, fev sds, length of hospital admission (days), scottish index of multiple deprivation (simd) scores and pa/bc microbiological infection (chronic or intermittent colonisation with pseudomonas aeruginosa and/or burkholderia complex). methods: effective doses of ionizing radiation (msv) from cxrs and chest cts (including hr scans) were determined for all cf children at our centre between st january and th july ( weeks). the most recent anthropometric and lung function data to july were used. simd scores report a data zone that encompasses ~ individuals and comprises indicators in six domains (current income, employment, health, education, housing and access). results: cf patients ( male: female) underwent radiation exposure procedures (mean of . procedures per patient per year). the average effective doses were calculated for of the procedures ( . %) including cxrs and chest cts. lung function data were available on patients ( %). univariate analysis revealed that higher ionizing radiation exposure was significantly associated with fev sds (p< . ), length of stay (p< . ) and pa/bc infection (p< . ). the regression line indicates that for each drop of two fev sds, each child receives an extra msv in radiation exposure from cxrs and chest cts alone. similarly, each child receives an extra msv in radiation exposure from cxrs and chest cts for every days of hospital admission. multivariate analysis with backward selection demonstrated that length of hospital admission (p< . ) and pa/bc infection (p= . ) were associated with higher ionizing radiation exposure. discussion: in cf, higher ionizing radiation exposure from cxrs and chest cts in childhood are associated with poor lung function, pa/bc infection and length of hospital admission but not other indicators of severity such as gender, severe genotype, anthropometric measures or socio-economic status. using effective doses of ionizing radiation as an outcome marker in cf is an alternative means of assessing the impact of the disease and its management on the child. background: exhaled volatile compounds have attracted attention as potential non-invasive biomarkers of chronic lung disease. early sustained airway inflammation and bacterial infection are characteristic features of pulmonary involvement in cystic fibrosis (cf). the cellular response is dominated by neutrophils, which have been shown to generate oxygen-and halogen-derived radicals as part of their host defense armamentarium. aims: to gather pilot data on the pulmonary output or uptake of selected organic trace gases in cf patients and healthy controls; and to explore the impact of pulmonary exacerbations and antibiotic treatment. methods: samples of ambient air and exhaled breath were collected from children, adolescents and young adults with cf and from healthy controls. the patients' age ranged from - years and their fev between - % predicted, were pseudomonas positive. twelve patients were studied at the start of i.v. antibiotic treatment for a pulmonary exacerbation; repeated sampling after the course was performed in subjects. all samples were analyzed on a customized gas chromatography system with flame ionization and electron capture detectors. after determining the mixing ratios of a variety of volatile organic compounds, alveolar gradients were calculated from the corresponding exhaled and ambient values. results: compared to healthy control subjects, cf patients showed a significantly lower respiratory output of methanol, ethanol, acetaldehyde and dimethylsulfide but a higher net release of benzene, methylchloride, trichloromethane and trichloroethene. these differences were most pronounced in patients with acute exacerbations. a relevant scatter and overlap between groups was noted for ethane, pentane, acetone, isoprene, toluene, and tetrachloromethane. after antibiotic treatment, the output of benzene, methylchloride and trichloromethane decreased by - %. conclusion: although important pathways remain incompletely understood, the local biochemical milieu in cf lungs may be informative and accessible through non-invasive breath testing. in this context, the diagnostic potential of exhaled organic traces gases (especially oxygenated, halogenated and aromatic compounds) should be further explored. supported by: german research foundation (dfg ba / - ). toy, e. ; weiner, j. ; sacco, p. ; duh, m.s. . health economics, novartis pharmaceuticals, east hanover, nj, usa; . analysis group, inc., boston, ma, usa objective: to review up-to-date economic outcomes data in patients with cystic fibrosis (cf), and in particular, costs related to respiratory infection by pseudomonas aeruginosa (pa), which is the leading cause of morbidity and mortality in cf patients. methods: a systematic search of the medline database from - was conducted to identify major and review articles that contained the terms "cystic fibrosis" and "cost" and which were published in english language journals. selected conference abstracts were searched, and additional articles were identified through bibliographies of retrieved articles. recent articles that contained economic data on antibiotic and mucolytic therapies were selected for in-depth review. cost estimates were converted to us dollars for comparability. results: approximately articles fulfilled the initial search criteria, and were selected for in-depth review. articles were divided into four categories: economic impact of inhaled tobramycin ( articles), the effect of home-vs. hos-pital-based antibiotic therapies for pulmonary exacerbations ( articles), economic impact of recombinant human deoxyribonuclease (rhdnase) ( articles), and cost-of-illness for cf ( articles). inhaled tobramycin (actual or recommended dose of mg/ ml) has been associated with reductions in health care costs; these cost savings offset between % and % of the cost of this therapy. antibiotic therapy for pulmonary exacerbations generally resulted in lower health care costs when administered in a home setting rather than a hospital setting. use of rhdnase led to reduction in health care costs, with higher reductions observed in patients with higher levels of use; the cost savings offset between % and % of the drug cost. cost-of-illness studies have been conducted in different countries; the economic estimates varied widely across studies due to differences in treatment patterns, health systems, methodologies, and patient populations. most cost-of-illness studies were retrospective observational studies from the perspective of a hospital or third-party payer, and the cost of cf ranged from $ , to $ , per patient per year. the largest cost categories included hospitalizations, out-patient visits, rhdnase and antibiotics, while disease severity and presence of pa infection were common determinants of cost. cost-of-illness studies have underestimated societal costs because they have rarely considered patient time costs and none have considered indirect costs (e.g., burden on lost productivity or informal caregivers). conclusions: studies show that inhaled tobramycin and rhdnase can partially offset medical costs; home-based iv antibiotic therapy is likely to reduce costs; and direct costs associated with cf can be high but vary widely across countries and analytical methodologies. areas for future research include direct comparisons of inhaled antibiotic therapies, examination of the relationship between treatment adherence and economic outcomes, and estimation of societal cost-of illness. this study was sponsored by novartis pharmaceuticals corporation, east hanover, nj. background: sputum interleukin (il ) and myeloperoxidase (mpo) are advocated as markers for infective exacerbations in cf. we have previously shown that the neutrophil protein, calprotectin, is a sputum biomarker of disease activity in cross sectional and longitudinal studies. in the present study we evaluate longitudinal measurement of sputum and serum calprotectin during infective exacerbation. methods: sputum and venous blood samples were taken at the beginning (visit ) and end of a course of iv antibiotics (visit ), and at time of clinical stability following the infective episode (visit ). processed sputum supernatant was analysed by elisa for calprotectin, il and mpo. serum calprotectin was assayed by elisa. results: paired sputum samples samples were available for visits and and paired samples for visits and . all data are presented as mean(sem). sputum calprotectin decreased from ( ) to ( ) µg/ml, p< . , from visit to . there was a non-significant increase to ( ) µg/ml at visit . sputum il did not change from visit to [ . ( . ) ( . ) ]. serum calprotectin decreased from ( . ) to . ( . ) ng/ml, p< . (n= paired samples) from visit to . at visit there was an increase to ( ) ng/ml, p< . (n= ). discussion: calprotectin appears a valuable marker both in sputum and serum for tracking changes in lung inflammation during an exacerbation of cf and may be more sensitive to change than il or mpo. on stopping antibiotic therapy sputum and serum calprotectin increase implying that this marker may be sensitive to small sub-clinical changes in lung inflammation. these data suggest that sputum and serum calprotectin might be employed to assess responses to drug therapies in cf such as gene therapy. this research was funded by the cf trust uk. chronic lung disorders are usually associated with a hypoxia driven increase in red cell mass. however, patients with cystic fibrosis often have normal or decreased haemoglobin levels. the present prospective observational study in cystic fibrosis (cf) patients was performed to determine which factors were involved in alterations in the hematopoetic response to corresponding arterial oxygen pressure. sixty adult patients (age - ) with stable cf were included. they all had vitamin a, d, e and k but no vitamin b supplementation. patients were on oral fe + ( mg/day). resting arterial blood gases, lung function, complete blood counts, parameters of iron status, crp, sputum microbiology and serum erythropoietin were measured at recruitment and after and months. patients had varying degrees of pulmonary functional impairment and % were hypoxemic (arterial oxygen pressure < mm hg). low-grade systemic inflammation (crp > . mg/dl) was present in % of the patients, who all had bacterial colonization. none of the patient had erythrocytosis and patients had anemia . there was no significant difference in iron status between patients with or without chronic iron supplementation and erythropoietin levels were normal. during the months observation period no significant changes occurred. the patients exhibited an impaired erythropoietic response to hypoxemia with normal or low hematocrit in spite of chronic lung disease. linear multivariate regression analysis (table) revealed crp and iron levels but neither iron substitution, nor erythropoietin levels nor lung function parameters as independent determinant of haemoglobin levels. cf may be associated with anemia of variable severity as expression of the chronic inflammation present in these patients. the therapeutic consequences are to treat the underlying inflammation rather than to supplement iron. variables included in initial model: background improvement in the treatment and survival of females with cf has led to many leading a normal adult lifestyle, and some can now expect to raise a family. however, pregnancy can have a profound impact on wellbeing, and caring for a young child can affect compliance with cf treatment. to look at this further, we surveyed the experience of pregnancy and motherhood in cf women attending our large adult cf centre ( patients). methods we reviewed the records of cf women who chose to remain pregnant ( babies [ male] from pregnancies), looking at changes in lung function, bmi, respiratory exacerbations during pregnancy, clinic attendance, and oral and iv antibiotic therapy (home and inpatient care) during pregnancy and also in the first year post delivery. we devised a questionnaire to examine how patients coped with pregnancy and the demands of motherhood, focussing on changes in compliance with therapy, worries regarding the effect of cf treatments on the baby, and support given by the cf team. results at conception mean fev was % predicted (range to ) and mean bmi (range to ).there were no miscarriages or neonatal mortalities and all children remain well, but the sickest mother died at years. mean fev following pregnancy was % [range to ] (p= . ), with mother losing % by one year post delivery. at one year, bmi was unchanged (mean , range to ). rates of respiratory exacerbations and iv antibiotics were similar pre and during pregnancy, although during the first year post delivery mothers avoided hospital based treatment preferring home care. six mothers' clinic attendances increased during and post pregnancy ( attended outpatients times in the first year post delivery). nine mothers worried about the effects of cf medication on their unborn child: the remaining mother was in her nd pregnancy. all managed their health differently during pregnancy: whilst increased compliance, worked harder to stay healthy, and increased clinic attendances; avoided clinic, postponed treatment, avoided any medication in the first trimester, and reduced oral antibiotic use to prevent harm to their unborn child. following delivery, mothers spent less time on their own health due to motherhood demands, and missed treatments during the first year: missed all except iv antibiotics. seven mothers ceased chest clearance and nebuliser therapy, and whilst missed oral therapies only avoided iv therapy. one mother who returned to work early felt this had contributed to her post natal depression. nine mothers indicated that cf team support was adequate, but the remaining mother felt that she should have been offered more frequent home visits post delivery due to lack of family support. conclusions the experience of pregnancy in our centre has positive outcomes for most mothers. however, compliance with treatment was affected and a number of mothers lost significant pulmonary function due to pregnancy. our study has shown that the demands of motherhood especially in the first year challenge the management of their own health. we offer a proactive service to women considering pregnancy, with early participation of the multidisciplinary team, and have increased home visit frequency to during the first year post-delivery. geller, d.e.; kesser, k.c. research, nemours children's clinic, orlando, fl, usa background: alpha- antiprotease (α- ap) is being developed as an inhaled drug in cf to inactivate excess elastase in the lungs. it is estimated that tens of milligrams of α- ap need to be deposited in the lungs to be effective. delivering a high dose with conventional jet nebulizers may be too time-consuming. we speculated that slowing and prolonging inspiration could optimize α- ap delivery. the i-neb® adaptive aerosol delivery (aad® system, respironics) is a portable, electronic, battery-powered, mesh nebulizer that uses the aad algorithms to deliver drug in the first portion of inspiration. interchangeable mouthpieces allow the i-neb to be used in a conventional tidal breathing mode (tbm) or in the target inhalation mode (tim) that guides the patient to inhale very slowly. the low residual volume after nebulization reduces drug waste and optimizes efficiency. we compared delivery efficiency of α- ap in vitro with the i-neb in the tbm vs. tim modes. methods: we studied new i-neb devices using tbm (tidal volume [vt] . l, respiratory rate [rr]= , i-time= seconds), tim- (vt . l, rr= , i-time= sec), and tim- (vt . l, rr= , i-time= sec) using a breath simulator. nebulizers were filled with . ml α- ap ( mg/ml). nebulized drug was captured on a filter and measured via spectrophotometer (inhaled dose), and particle size was measured with an insitec laser system. results: median particle sizes for the modes were similar ( . - . µm) . the dose emitted from the i-neb was very high, and similar between modes ( - % of nominal dose). predicted lung doses for these experiments were calculated from a previous scintigraphy study (nikander ) that showed % of the emitted dose deposited with tbm and % with tim. predicted lung dose of α- ap (as % of nominal) and delivery times were tbm: . % in . min, tim- : . % in . min, and tim- : . % in . min. discussion: the i-neb has a very high predicted lung dose with both tbm and tim. however, tim reduces the time of administration to as little as / that of tidal breathing. if larger predicted lung dose is necessary to see a clinical effect, either the initial drug volume or drug concentration may be increased. we conclude that slow, deep, controlled inspirations using i-neb is a very efficient method to deliver α- ap, and is faster than tidal breathing. we also speculate that tim has the additional potential advantage of better distribution of drug in the lungs because of slower flow rate and particle velocity. objective: early inflammation was observed in infants with cf regardless the occurrence of bacterial infection. lung function (lf) is a tool to assess bronchial inflammation consequences. few data are available on the pronostic value of impaired lf in infancy. methods: in infants, airflow obstruction (t ptef/te , curve shapes, tidal volume, functional residual capacity (frc, nitrogen washout technique) were assessed with the sensor medics and interpreted with stocks reference values. at y, fev and pulmonary flows (spiro , nova medical sc, zapletal reference values) and frc he , were measured. symptomatic children were defined when cough, wheeze or rattle were recurrent. all symptomatic infants have been treated with inhaled steroids as any infantile wheezer. results: screened infants ( ∆f /∆f , ∆f /other, other/other) were investigated at mean age mo and years. ( %) had respiratory symptoms (rs); the mean tidal volume was normal ( . ml/kg), ( %) had a marked obstructive curve shape, ( %) a decreased t ptef/te , and ( %) hyperinflation. then, ( %) had normal lf, ( %) ao, ( %) hyperinflation and ( %) both. at age , % had rs, and lf with mild alteration as mean flows ≥ %, and frc he = . %. accurate analyses showed that ( %) had normal lf, ( %) ao and ( %) small airway diseases (only distal ao and/or hyperinflation). frc in infancy and at age were correlated (r= . ; p= . ). conversely, no correlation between ao parameters in infancy and at age was found. the lf alteration was independent of the genotype, bacterial colonization and recurrent symptoms at both ages. conclusion: ao in infancy is frequent as found in half of the screened cf infants. the lack of correlation with the ao observed at age suggested that ao in infants might be due to a non specific inflammation (i.e viral), transient and then relevant from a treatment. hyperinflation, although mild, is conversely an early marker of the cf disease as persistent between infancy and age . we describe the efficacy of a novel system using an electronic real-time distant home monitoring of symptoms and spirometry in cf patients with the aim of early detection of p exs patients and methods: this is a month prospective observational study. all patients were provided with a set consisted of a mobile phone-palm pc (the x daii, o -uk) and with a spirometer (vitalograph) with an attachment to the pc. the pc contained a purpose-built software on which cf symptoms and spirometric values were recorded once daily. these were then sent on a real time to a computer server where the data were plotted on a time-magnitude graph. the site was accessed by a password-permitted cf physicians. patients were asked to score four symptoms (cough, sputum, breathlessness and fatigue) once a day and to record at least three attempts of spirometry. these were accepted by the software only if they met the ats criteria. preset criteria for p exs were stipulated. when the recordings met the criteria for p exs patients were invited to come to the cf clinic for review and were managed by either watchful waiting, oral or iv antibiotics. a prodrome phase is deemed to be present when a patient had an increase in one or more symptom for one week prior to the p ex. twenty one evaluable patients were included in the study. in ( %) there were an increase in one or more than one recorded symptoms throughout the study. a total of p exs median . per patient were detected within the months study period. in ( %) p exs, symptom increase and/or decline in fev met the preset criteria for p ex and in cases patients presented despite that symptom changes were not sufficient to meet the pre-set definition of p ex. prodromal phase prior to p exs were seen in ( %) patients. adherence and technical issues were the main two problems throughout the study. distant daily monitoring of patients symptom is easy and sensitive. it can be used to monitor symptoms and early detect p exs. the vast majority of our patients have an increase in their symptoms even when they perceive their disease to be stable. a prodormal phase preceded p ex is seen in the majority of patients. the pre-set criteria for defining p ex may have been too stringent. the research was funded by o telecommunication, uk the monitoring system used in the study. a combination of a mobile phone-palm computer (x daii, o uk) and a spirometer (vitalograph uk) .. the aim of this research was to examine whether systemic inflammation is present in adult patients with cf during their stable status. patients and methods: blood samples were obtained from a total of cf patients female, mean age , range( - ) males mean . range - and from control subjects, female, mean age . , range( - ) males,mean age . yrs, range( - ) all cf patients were included when they were at least weeks away from any pulmonary exacerbations. all control subjects were not known to have any pulmonary or systemic disease. venous blood samples were taken and spun at rpm.separated sera was aliquted and frozen at - degrees c. they were analysed in batches for cytokines il- b,il- ,il- , il- , ilp ,and tnf-alpa using a cba human inflammatory kit(bd bioscience). whitney-u test was used to compare values of serum cytokines between stable cf patients and control subjects.. serum il- and il- were raised in cf patients compared to control subjects. the mean value for il- was . pg/ml (sd . ) for patients and . pg/ml (sd . ) for controls, p< . . similarly, the mean value of serum il was . pg/ml (sd . ) in cf patients compared to . pg/ml (sd . ) in the control group, p< . (figure below). there was no difference between cf patients and control with regards to serum il- b, il- and il- p . conclusion: serum il- and il- were raised in cf patients compared to an agematched control subjects. inflammatory markers were raised in the sera of cf patients even during disease stability. even during disease stability, the lungs remain an inflamed organ which could explain the decline in lung function tests and the countinued daily systemic symptoms experienced by patients with cf. serum il and il in cf patients with stable disease compared to the control group (please see abstract body) we have shown that even during disease stability, an increase in inflammatory markers are present in the sera of cf patients compared to an agematched control group. this longitudinal study examines changes in serum inflammatory markers during p exs. we investigated cf patients female, mean age , range - years. their mean baseline fev was . % of predicted (range . - %). a baseline venous blood sample was withdrawn and sera were stored at - degree c from patients during disease stability. out of those there experienced p exs. blood samples were obtained at the beginning and at the end of the p exs.the following inflammatory markers were analysed: white blood counts, c -reactive protein (crp), il- , il- , il- , il- b, il- p and tnf-α. patients recorded their symptoms and their fev on a daily basis on an electronic diary and the data were beamed daily to a research centre where data were analysed. p ex was defined as ). an increase in two symptoms for successive days, or ). an increase in symptoms and % reduced fev from baseline over successive days or ). % decline in fev over successive days or ).when a patient felt that he/she was going through a p ex. paired t tests were used to analyse changes in inflammatory markers. there was no change in the number of circulating neutrophils, lymphocytes or eosinophiles at the start compared with the end of p ex. there was an increase in mean crp values at the start of p ex and reduction at the end of p ex, but this did not attain statistical significance. mean (sd) of serum il increased from . pg/ml ( . ) at baseline to . pg/ml ( . ) at the start of p ex (p= . ) and returned to base line . pg/ml ( . ) at the end of p exs (p= . compared to values at the start of p ex). (figure ) there were no changes in the values of serum il- , il- , il- b, il p or tnf-α at the start and at the end of p exs. serum il increased at the start of p ex and returned at the baseline at the end of p ex. crp was the closest inflammatory marker to follow that pattern. none of the other inflammatory markers changed with the diagnosis of p ex's. this and other studies call for the price of analysis of il- to be reduced to become available in routine clinical practice. background. abpa can be a therapeutic challenge in children with cf. aim was to describe the tolerability of voriconazole and nebulised liposomal amphotericin in the treatment of abpa in children with cf. methods. we performed a retrospective case note review of voriconazole and nebulised liposomal amphotericin use, in the treatment of abpa in children with cf, at our centre. results. children diagnosed with abpa according to the current criteria, failed to improve despite previous treatment with itraconazole and steroids, and received voriconazole as a second line agent. the dose of voriconazole was as recommended by the manufacturer's summary of product characteristics and the duration of treatment was two weeks. significant side effects noted in children. observed side effects included visual hallucinations (n= ), photopsia (n= ), sleep disturbances (n= ), severe headache (n= ), influenza like symptoms (n= ), gastrointestinal side effects (n= ) and elevation of alkaline phosphatase (n= ). of these children, one child tolerated voriconazole when concomitant treatment with omeprazole was withdrawn. a second course of voriconazole, given at a lower dose and without the loading dose was tolerated by two children. voriconazole blood levels were not measured in any patient. we used nebulised liposomal amphotericin in of these children. one child received amphotericin as a second line agent when voriconazole had to be stopped because of significant side effects. children had active abpa despite treatment with first line (itraconazole and steroids) and second line (voriconazole) agents and received amphotericin as a third line agent. amphotericin was used at a starting dose of mg nebulised twice daily, with weekly increments as tolerated, up to a maximum dose of mg twice daily for four weeks. the starting dose and all subsequent increments in dose were supervised. all children received salbutamol immediately before nebulised amphotericin. the standard formulation available for intravenous infusion was made up into single doses for nebulisation by the pharmacy. this was stored at c and diluted with water for injection for use with the nebuliser. the only side effect, experienced by all children was a dry irritant cough at the start of nebulisation that settled soon without need for discontinuation of the medication. improvement in clinical symptoms, lung function and total serum ige was noted in all children. the improvement in fev and fvc, expressed as mean (range) of percentage predicted were and respectively. the mean (range) fall in serum total ige and aspergillus specific ige were ku/l ( - ) and mg/l ( - ) respectively. conclusion. voriconazole use was associated with significant side effects. avoidance of drugs that may potentially result in interaction is important. omitting a loading dose and using a lower maintenance dose may help selected patients tolerate voriconazole. nebulised liposomal amphotericin was tolerated by our children with cf and abpa who did not tolerate or responded poorly to voriconazole. recent studies have shown that high resolution computed tomography (hrct) is a more accurate method of evaluating early lung disease in cystic fibrosis (cf) than pulmonary function tests (pfts) or chest x-rays. since young children can not perform the breathing maneuvers required for high quality hrct, lung volume control is necessary. positive pressure facemask ventilation using chloral hydrate allows full inspiration and end exhalation images, but requires special expertise. controlled ventilation can also be produced with general anesthesia (ga). ga has not been reported in children undergoing hrct for cf research. the advantages of ga over sedation include rapid onset, faster recovery and reliability of scan completion. the undesirable effects of sedation are unpredictability and the higher failure rates. additionally, failed sedation contributed significantly to parental dissatisfaction. (malviya, et al., ) . the primary outcome of our study was to examine the safety of using ga for hrct scans and the quality of images obtained. a secondary outcome was parental satisfaction. methods: participants were recruited from a larger nih/cffti funded multi-site randomized clinical trial focusing on behavior and nutrition treatment to improve growth in preschoolers with cf. hrct in subjects to years old (mean age ± months) was performed with ga. parents accompanied the child during induction and left after the child was asleep prior to the intravenous (iv) being placed. after induction of anesthesia, a proseal®, specialized laryngeal mask airway (lma), was placed which allowed ventilation with higher pressures and the ability to suction the stomach. volumetric thin section ct scans were obtained. ga using inhalation (sevoflurane) and/or iv (propofol) agents was used and out of families who were eligible ( % recruitment rate) participated in the sub-study. results: the quality of the hrct scans in all subjects were optimal. there were no anesthetic complications upon emergence and none of the patients experienced any side effects after follow-up phone calls at hours. parents also expressed that the clinical interpretation of the hrct scan provided beneficial information about their child's current lung disease status. the mean time from completion of scan to discharge was . ± minutes. conclusions: the use of ga in radiology departments is becoming more common in pediatric centers. our initial findings of this study demonstrate that ga can be safely administered for children with cf. in addition to very good quality scans being obtained, parental satisfaction was also noted. the use of the proseal® lma for hrct may improve the image quality and aid in the diagnosis of early lung disease in preschoolers with cf. supported by nih grant r dk and a cf foundation clinical research grant. whey protein is rich in sulfhydryl (sh) groups and is recognized for its ability to increase glutathione and reduce oxidative stress. hyperbaric pressure treatment of whey protein increases its digestibility, promotes the release of novel peptides for absorption, increases intracellular glutathione in healthy subjects (zavorsky et al, int j vit nutr res, ) , and reduces in vitro production of il- (vilela et al, inter immnuopharmacol, ) . we present here the initial results of a pilot study of supplementation with pressurized whey in cf patients. children and adults with cf were supplemented with hyperbaric whey protein for month ( gm/day in patients less than years of age, gm/day in older patients). anthropometric measures, pulmonary function, serum c-reactive protein (crp) and plasma lipid peroxides were measured before and after supplementation. the results of the first patients to have completed the study are reported, with further data to be presented. in / subjects weight increased and in / subjects lean body mass increased. there were no significant changes in fev or fev/fvc ratio. in / patients the crp fell ( / by more than %) and in / the crp increased. in the remaining two patients, the crp was undetectable at baseline and did not change at follow-up. plasma lipid peroxides decreased in the three patients in whom it could be measured ( / to undetectable levels). these preliminary results suggest that supplementation with pressurized whey protein can reduce systemic inflammation in cf patients and has the potential to beneficially modulate the inflammatory response in cf patients. supported by the breathe initiative of the canadian cf foundation with pseudomonas aeruginosa. soon after its introduction, the mesh technology based pari eflow® nebulizer gained preference over jet nebulization in the cf community because of its short nebulization time, portability and noiseless operation. concerns were raised about the durability of the device due to expected vulnerability of the mesh. the aim of this study was to compare the particle size distributions in the aerosol, delivered doses and output rates from the eflow and the pari lc plus®(lc+)with paritur-boboy compressor before and after use in daily practice. lc+ nebulizers in use by the adult patients taking part in the study were taken in for testing and new eflows, cleaning instructions and a disinfection device were provided. after months use ( cycles of x doses tsi: mg/ ml), the eflows were collected by the local cf center. particle size distributions were measured at a constant flow rate of l/min with a laser diffraction apparatus. because of uncertainty regarding the cleaning procedure after last use, additional e-flows were collected from the same patients after another period of months use. conclusions: new eflows produce slightly larger droplets in a narrower size range than new lc+ nebulizers. after use in daily practice, droplet size distribution changes for both devices. output rate (delivered dose per minute) decreases for both devices. for used eflows delivered dose is lower than for used lc+ nebulizers, because the eflow is programmed to switch off after min, even when nebulization is still incomplete ( out of tested eflows). this may result in a considerable reduction of delivered dose. however, when a mesh is replaced, performance is the same as that of a new device, suggesting that the changes in performance originate in the vibrating mesh. for daily practice these results indicate: ( ) the performance of both nebulizers changes during use but the changes are smaller for eflow than for lc+ ( ) changes in droplet size distribution are relatively small for both devices;in contrast with output rate and delivered dose ( ) proper functioning of eflow can be improved by timely replacement of the mesh, ultimately when eflow switches off after minutes. without replacement, the delivered dose is unpredictable. mean values for size distribution, delivered dose, nebulization time and output rate (x is volume median diameter) backgrounds: lung surfactant protein a (sp-a) belongs to the family of collagen containing, c-type lectins, called collectins. sp-a plays a critical role in the innate immune defense of the lung. sp-a binds calcium dependent to carbohydrate structures on pathogens via its carbohydrate-binding domain (crd). cystic fibrosis (cf) lung disease is characterized by chronic inflammatory and proteolytic processes in the airways, leading to destruction of the lungs and early death. aims: we hypothesized that sp-a might have a reduced function in cf. this might result from sp-a degradation by neutrophil proteases, an altered macromolecular organization of sp-a, or inhibition of crd-binding by airway components. methods: we studied bronchoalveolar lavage fluid (balf) from clinically stable patients with cf and from children suffering from bronchitis. balf samples were purified by carbohydrate-binding assay on fucose attached to sepharose resin with and without calcium. in the absence of calcium sp-a cannot bind via its crd. each fraction was analysed for sp-a and igg by immunoblotting. macromolecular organization of sp-a was determined by gel chromatography. results: only % of total sp-a of cf balf bound to the fucose column, whereas % bound from the bronchitis balf. the structural organization of the sp-a oligomers did not differ between the non-binding and the binding fractions of both groups. of the cf balf had sp-a at kd that did not bind to fucose. these balfs had a high percentage of neutrophils (> %). in vitro human leucocyte elastase decreased sp-a to less than % of its initial levels and sp-a fragments at kd were detected. conclusions: neutrophil proteases degrade sp-a in cf lungs. the carbohydrate dependent binding of sp-a is diminished due to a reduced function of the crd. these alterations contribute to the reduced ability in cf to remove specific pathogens from the lungs. chiron, r. , ; murris-espin, m. , ; crampette, l. , ; varrin, m. ; didier, a. , ; wallaert, b. , ; chanez, p. , ; leroy, s. , . crcm, chu, montpellier, france; . crcm, chu, toulouse, france; . orl, chu, montpellier, france; . iurc, chu, montpellier, france; . crcm, chu, lille, france; montpellier, france in cystic fibrosis (cf) patients, upper airways involvement is frequent but its impact and relationships on the course and severity of the disease has been rarely investigated. objective: to relate upper airways involvement with lower airways parameters and quality of life in cf patients. methods: clinical and radiological prospective study of subjects with cf at french cf centres. clinical rhino-sinusitis (rs) was defined by the presence of more than episodes of nasal symptoms during the last year, current nasal obstruction or rhinorrhea. nasal investigations included: anterior rhinoscopy, sinus ct scan analysis and rs quality of life questionnaire. lower airways were assessed using a thoracic ct scan (bhalla score), spirometry and sputum culture and a cf quality of life questionnaire (cfq +). results: ( f/ m) patients aged . ( - ) years old were enrolled. endoscopy demonstrated polyposis in % and nasal hyper secretions in . % of the patients. spirometry, bhalla score, sputum colonization did not discriminate patients with (n= ) or without rs (n= ), and regardless the presence of polyps. cfq + was significantly lower in patients with of rs (p= . ). conclusions: rs involvement altered quality of life in cf patients, although, they do not have a more severe pulmonary disease. a specific attention and treatment to rs should be paid in cf patients. the impact on different outcomes deserves to be examined in longitudinal studies. as part of the uk cystic fibrosis gene therapy consortium "tracking study", ebc was measured (ecoscreen, jaeger) in adult and paediatric patients presenting with an infective exacerbation requiring iv antibiotics. exacerbation was defined by pre-determined criteria. ebc was repeated at the end of parenteral antibiotic therapy and again - weeks later. patients were recruited at three sites and assessed using standardised equipment. samples were obtained according to ers guidelines. exhaled breath ph was assayed (shindengen ph meter, camlab, uk) immediately after collection without a de-aeration step. results: paired ebc measurements at the start and end of antibiotic therapy were available in patients. mean age was yrs (range - ). data from patients were excluded because at least one ph measurement was > , suggesting salivary contamination. for the remaining patients mean ebc (sd) ph increased from . ( . ) to . ( . ), p< . . of these patients, also had measurements available at a third visit, - weeks after completion of antibiotics. were excluded because of salivary contamination. no difference in mean(sd) ebc ph was found ( . ( . ) vs. . ( . )) conclusions: ebc ph increases after treatment with antibiotics, and may offer a non-invasive means of assessing airways inflammation in chest exacerbations. further work is required to follow the longitudinal change in ebc ph and other inflammatory markers in clinically stable patients, as ebc may be a useful tool in assessing response to novel treatments, such as gene therapy. this work was funded by the cystic fibrosis trust. background: children with cystic fibrosis (cf) undergo multiple procedures exposing them to ionizing radiation in hospital. some specialist centres have advocated regular chest computed tomography (ct) as a means of better quantifying lung pathology. the clinical benefit of this approach is unproven and previous calculations of risk have failed to account for other ionizing radiation exposure procedures . aim: to quantify the exposure of ionizing radiation in the pediatric cf population of a tertiary level children's hospital. to determine the potential difference in exposure of introducing biannual chest ct scans. methods: effective doses of ionizing radiation from chest (cxr) and abdominal (axr) radiographs, fluoroscopy and cts (sinuses and chest including hr scans) were determined for cf children at our centre between st january and th july ( weeks). the maximal effect was tested i.e. introduction of biannual chest ct scans from age years abolishing the requirement for cxrs and the assumption was made that axrs, sinus cts and fluoroscopy rates were unchanged (median exposure values calculated for age groups -< year, -< year, -< year, -< year, -< year, > year) . results: cf patients (n= , gender ratio : ) underwent a mean of . ionizing radiation exposure procedures per patient over the study period (total of procedures). the average effective ionizing radiation doses (msv) were calculated for ( . %) procedures. each cf child received a mean (median) effective radiation dose of . ( . ) msv/year with a range of . - . msv/year. the reason for the skewed distribution was identified by analysing the proportions of the procedures to the total effective dose in this population: fluoroscopy . %, chest ct . %, sinus ct . %, cxrs . %, axrs . % and hrct . %. it was calculated that these patients undergo . cxrs per patient per year. we calculated that an average patient diagnosed by newborn screening could expect to receive . msv from ionizing radiation procedures between birth and age . biannual ct chest scans in addition to median exposures for each age group from axrs, sinus cts and fluoroscopy would potentially result in . msv by age , an fold increase. discussion: there is a in lifetime risk of developing a solid or haematological cancer with each exposure to msv of ionizing radiation . although fluoroscopy forms the most significant contribution to a pediatric cf patient's ionizing radiation exposure in our centre, introducing biannual chest cts would markedly increase exposure. as cf survival improves, cf physicians must be cognisant of the potential health cost of survival. references : previous studies have used generic measures of hrqol, which are not sensitive to important changes that may occur as a result of treatment. this study assesses the impact of iv antibiotic treatment for a pulmonary exacerbation on both generic and disease-specific hrqol of children and adolescents with cf. method: participants included patients (m age = . years) from the cincinnati children's hospital and university of florida cf centers. fiftyfour percent of the sample were male. patients completed two hrqol measures, the pedsql™ (generic) and cfq-r child or teen/adult version (cf-specific), which have excellent reliability and validity. these measures were completed within hours of hospital admission (pre) and hours of discontinuation of iv antibiotics (post). note that approximately % of patients went home on iv antibiotics and % remained in the hospital for approximately weeks. results: significant improvements were found in pulmonary functioning (fev % predicted) pre to post iv antibiotic treatment (paired t ( ) = - . , p < . ), with an average of % increase in fev % predicted. paired t-tests were conducted to examine changes in hrqol scores, using holm's procedure to correct for multiple comparisons. significant improvements were found on the cfq-r respiratory (paired t ( ) = - . , p < . ) and weight scales (paired t ( ) = - . , p < . ). trends were also noted for improved emotional functioning (paired t ( ) = - . , p = . ) and vitality (paired t ( ) = - . , p = . ), and worse treatment burden (paired t ( ) = . , p = . ). on the pedsql, only emotional functioning improved significantly (paired t ( ) = - . , p < . ). conclusions: results of this study confirm the effectiveness of iv antibiotics for the treatment of pulmonary exacerbations, with significant improvements found for both pulmonary functioning and hrqol. these results also highlighted the importance of using a disease-specific hrqol instrument, which proved to be more sensitive than the generic measure. on the cfq-r, significant improvements were observed in respiratory symptoms and weight, aspects of functioning that are not assessed on generic measures. fukushima, l.k.; hsu, e.; woo, m.s. division of pediatric pulmonology, childrens hospital los angeles, los angeles, ca, usa do hispanic and caucasian cf patients share the same frequency of pulmonary exacerbations? increased frequency of pulmonary exacerbations is linked to increased risk for cf morbidity and mortality. we have previously reported that pediatric hispanic cf patients have greater mortality than our caucasian cf patients who attend the same accredited cf center. we performed a retrospective review of cf pulmonary exacerbations (defined as physician prescription of intravenous or oral antibiotic therapy) in our cf patients who routinely attended the cf clinic during the period of january , through december , . data collected included demographics, number of intravenous antibiotic courses and number of oral antibiotic courses. unpaired student's t-test was used to compare age of the groups and chi-square was used to compare use of intravenous and oral antibiotics between hispanic and caucasian cf patients as well as between males and females. during the study period, there was a total of cf patients ( males: females; mean age . ± . years). of the patients, ( %) were classified as hispanic ( males: females; mean age . ± . years) and ( %)were classified as caucasian ( males: females; mean age . ± . years; p= . , ns). hispanic cf patients ( patients had episodes; males: females) had significantly greater number of pulmonary exacerbations (received treatment with intravenous and/or oral antibiotics) than caucasian cf patients ( patients had episodes; p = . ). hispanic cf patients who required intravenous antibiotic therapy were significantly younger ( . ± . years vs . ± . years; p< . ) than the caucasian cf patients who were treated with intravenous antibiotics. there was no significant difference in age between hispanic and caucasian cf patients who received oral antibiotic courses ( . ± . years vs . ± . years; p= . , ns). gender did not have a significant impact on pulmonary exacerbation risk in our population (hispanic iv use by gender p= . ; hispanic oral use by gender p= . ; caucasian iv use by gender p= . ; caucasian oral use by gender p= . ). we conclude that hispanic cf patients had increased incidence of pulmonary exacerbations than caucasian cf patients who attend the same cf clinic. hispanic patients who were treated with intravenous antibiotics were younger than the caucasian cf patients. we speculate that hispanic ethnicity has a major impact on the incidence of pulmonary exacerbations. other factors, such as modifier genes, environmental exposures, or inflammatory responses, may play a role in the increased risk of pulmonary exacerbations in the hispanic cf population. introduction: one of the main goals of the multidisciplinary team of the cf association of minas gerais, brazil is to find strategies to preserve lung tissue from the bacterial exacerbation in cystic fibrosis patients. objective: to investigate clues on onset of bacterial exacerbation. to our knowledge, no studies were found regarding the identification of the early warning signs of bacterial exacerbation with cf patients. we wanted to know whether cf patients present early warning signs before onset of fever and/or breathing difficulties. methods: telephone interviews were carried out with the cf patients registered in the association, by a physiotherapist academic who did not know the patients and just ask two questions. the first question was about the use of antibiotics during the year of and the second was related to early signs before the onset of fever. results: from the patients, only patients replied. patients who were using antibiotics therapy during and had fever: / patients who were using antibiotics and did not have fever: / patients who had fever and did not use antibiotics: / patients who did not have fever and did not use antibiotics: / the results revealed the following warning signs and also that some patients had more than one sign. tiredness, quietness, slowness ( / ); increased cough ( / ); lack of appetite ( / ); sticky sputum ( / ); sleepiness ( / ); headache ( / ); increased excitement, nervousness ( / ); crybaby ( / ); dry mouth ( / ); clammy ( / ); difficult to walk ( / ); gastric upset ( / ); itchy throat ( / ); abdominal pain ( / ) ; itchy eyes ( / ); breathing difficulties ( / ); tremulous ( / ); paleness ( / ); burning ear ( / ); chest pain ( / ); hissing ( / ) ; and syncope( / ). conclusions: it is helpful to know these early warning sings. we assume that the earlier the diagnosis of the exacerbation is made, the easier it is to resolve the problem and the less destruction of the lung tissues. reference: lung line, national jewish center for immunology and respiratory medicine . background: cystic fibrosis patients are experiencing increasing survival and are being treated with more chronic therapies. how these changes are reflected in day to day clinical symptoms has not been evaluated. objective: we examined data from the epidemiologic study of cystic fibrosis, a large longitudinal observational study, to characterize the change in respiratory symptoms over time. for each year between and data from patients with at least one visit recorded as occurring while clinically stable were included. data from all visits, including sick as well as stable, were used for each year in which at least one clinically stable visit was recorded. patients were separated into age groups less than , to , to , and or older. note that in data collection changed, potentially confounding the results. results: the average number of patients per year was . the percent of patients with no reported cough progressively increased over time (table) . results were similar for pateints with no reported sputum production at clinically stable visits. when sick visits were added there were similar results. the frequency of cough reported at greater than percent of visits progressively decreased over time (table) . again the results for sputum production were similar. these findings were seen in all age groups although older patients are more likely to experience these symptoms. conclusions: these data suggest that cf patients are experiencing fewer respiratory symptoms of cough and sputum production over the last decade. this improvement has occurred in patients with either intermittent or chronic symptoms. how clinical care has impacted on these symptoms has yet to be determined. also, more people are being diagnosed with cf at an earlier age or with milder disease, potentially resulting in the entire cf population having fewer symptoms. lung disease in children with cf begins in early childhood, with intermittent and then chronic infection, associated with an exaggerated inflammatory response. the extent to which inflammation contributes to bronchiectasis has not yet been identified. the aim of this study was examine relationships between inflammation and early lung damage methods: twenty eight children with cf were assessed at diagnosis and annually thereafter with a bronchoalveolar lavage (bal). bal fluid was used to assess micro-organisms and inflammation, including total and differential cell counts. a three slice hrct technique (inspiration and expiration) was performed under general anesthesia at age - y, immediately preceding the annual bal. hrct scans were scored by an independent and experienced radiologist using a modification of the brody score. results. twelve children ( %) had evidence of bronchiectasis on hrct. inflammation present in bal at months of age predicted bronchiectasis at - y. total cell count at mo, predominantly neutrophils, was higher in those who developed bronchiectasis compared to those who did not ( . vs . x cells/ml bal; p= . ). the total number of infections detected in bal was not related to bronchectasis. however, children with bronchiectasis had a higher incidence of pseudomonas aeruginosa within the first years of life ( % vs. %). conclusions: bronchiectasis is evident within the first five years of life and appears to be associated with an exaggerated inflammatory response and the early acquisition of pseudomonas aeruginosa. supported by: cystic fibrosis foundation (usa), national health and medical research council (australia). fortunately the survival of patients with cystic fibrosis has improved remarkably over the last few decades. many patients can life quite "normal". therefore family planning becomes more important. several reports docu-mented the good maternal and fetal outcome in pregnant women with cystic fibrosis. besides the data from the french cf registry no longterm data about the impact of paternity of male patients with cystic fibrosis are available until now. in a retrospective analysis we gathered data about all our male patients who became father while being followed-up in our cystic fibrosis center for adults. from male patients, patients became father between and . patient no. became father twice (second time father of twins); patients no. became also father of twins .we looked at fev % year prior to childbirth, perinatal and and years after the childbirth. for the fev % one year prior to birth as well as for fev % and years after birth, we calculated the difference to the fev % at time of birth. between and , male adult patients with cystic fibrosis became fathers of a total of children, all by the assistance of reproductive techniques. their fev % are shown in table . although the male patients are not directly influenced by a pregenancy (as the pregnant women are by growth of the uterus), there seems to be more than ususal differences in this lung function parameter. there were also more fluctuations in fev per year. the biggest differences in fev % were seen year after birth of their children. further investigations in a larger group (in cooperation with other centers) are planned; especially with a focus on the frequency of infections and quality of life compared to male patients without children. intravenous (i.v) aminoglycosides are widely used in cystic fibrosis (cf) patients as treatment for pulmonary exacerbations. in an effort to reduce undesiderable effects of these antibiotics it is recommended to measure drug serum levels. recent experience suggests that tobramycin (to) may be administered as a single daily dose with equal efficacy as multiple doses but less risk of nephrotoxicity. aim: we evaluated the efficacy of once-daily i.v to treatment to improve pulmonary function expressed as forced expiratory volume in one second (fev ) in cf patients with pulmonary exacerbations compared to the same group of patients who were previously treated with to in multiple daily i.v doses, as historic control. we evaluated baseline and peak drug serum levels of to administered once daily compared to multiple dose levels. methods: all patients were treated with i.v to in combination with a beta-lactam antibiotic for two weeks. respiratory exacerbation was defined according to cff criteria. all cf patients were colonized by non-fermentative gram-negative bacteria. serum concentrations of to were measured (fluorescent polarisation immunoassays) before the fifth infusion (basal) and minutes after the fifth infusion (peak). reference to blood levels were considered to be ≤ mg/l (basal) and < mg/l (peak) for multiple daily doses, and ≤ mg/l (basal) and - mg/l (peak) for single daily dose. treatment efficacy was evaluated on the basis of improved clinical condition and increased fev values compared to the beginning of therapy. results: patients with respiratory exacerbation were evaluated, with a mean (± ds) age of . years (± . ; median . , range . - . ) . out of patients were chronically colonized by pseudomonas aeruginosa. the total mean (± sd) daily dose of to administered in multiple doses was (± . ) mg whereas the mean single dose was . (± . ) mg. of those patients given multiple doses of to, only one patient ( . %) had basal to values outside the range and patients ( . %) had peak values outside the range. of those patients given a single daily dose, no patients had basal to values outside the range whereas out of ( %) had peak values of less than mg/l and patients out of ( %) had peaks between and mg/l. the mean (± sd) increase in fev was . % (± . ) in patients treated with a single dose and % (± . ) in those treated with multiple doses. the mean (± sd) period between fev measurements before and after exacerbation was . days (± . , median , range - ) in case of monodose therapy, and . (± . , median , range - ) in case of therapy with multiple doses. conclusions: both single and multiple-dose i.v to therapy caused a comparable fev increase and were effective in resolving the respiratory exacerbation. although clinical improvement was observed, the mean i.v to dose of mg/day in patients treated with once-daily i.v to determined peak values between and mg/l in % of subjects. intravenously administered aminoglycosides are efficacious for the treatment of pulmonary infections of cystic fibrosis (cf) patients, with the principal adverse effects of these molecules being acoustic nerve damage and nephropathy. damage to the eighth cranial nerve varies from . to % in cf patients treated with multiple daily doses of aminoglycosides. recent experience suggests that tobramycin can be administered as a single daily dose, resulting in less nephrotoxicity but equal efficacy. patients and methods: we evaluated the prevalence of oto-and nephrotoxicity due to aminoglycosides administered to cf patients followed at the tuscan regional center where we are currently following patients. cochlear damage was evaluated using tonal audiometry (amplifon amplaid s). renal damage was evaluated by measuring patients' creatinine clearance. results: ( %) patients ( males and females) between the ages of and (mean age . years, median , sd ) were tested with audiometry. all these patients had been repeatedly treated with multiple daily doses of intravenous aminoglycosides. ( . %) ( males and females) out of patients between and years (mean age . , median . , sd . ) had their creatinine clearance measured. we found that patients ( . %) had an abnormal audiometry, typically attributable to aminoglycoside ototoxicity (high frequency deficit). two patients required a hearing aid. one patient with normal cochlear function had labyrinth deficit. one out of patients tested had pathological creatinine clearance values. conclusions: our data indicate that ( . %) of our patients had damage to the eighth cranial nerve due to repeated multiple daily doses of aminoglycosides. we recommend that cf patients under aminoglycoside therapy be routinely given audiometric and creatinine clearance exams in an attempt to reduce the incidence of undesirable side effects of these drugs. davies, j. , ; voase, n. , ; dewar, m. , ; mullard, k. , ; gammie, f. , ; saunders, c. , ; horsley, a. , ; gray, r. , ; macleod, k. , ; somerton, l. , ; higgins, t. , ; donovan, j. , ; cornish, n. , ; hansell, d. , ; aziz, z. , ; ashby, d. ; geddes, d. , ; greening, a. , ; cunningham, s. , ; innes, a. , ; alton, e. , . gene therapy, imperial college, london, united kingdom; . western general hospital, edinburgh, united kingdom; . royal hospital for sick children, edinburgh, united kingdom; . royal brompton hospital, london, united kingdom; . queen mary, university of london, london, united kingdom; . uk cf gene therapy consortium, edinburgh, london, oxford, united kingdom the improving clinical status of patients with cf and the slow rate of decline of conventional outcome measures such as fev necessitate the development of clinically-relevant surrogate outcome assays for use in clinical trials. in our forthcoming clinical trial of cftr gene therapy, the uk cf gene therapy consortium will use both established, clinically-available assays and more novel measures designed specifically for this purpose. both groups of assays are being subjected to rigorous testing prior to use to establish their utility as disease biomarkers. in this study, we examined their performance in the context of an infective exacerbation treated with iv antibiotics. this abstract will report the response of established, clinically-available assays; available data from novel assays will be reported separately. children ( years and above) and adults with cf were recruited from three centres at the time of a clinician-defined infective exacerbation requiring iv antibiotic treatment. exclusion criteria included fev < % predicted and requirement for supplemental oxygen. a panel of assays was performed at the start and end of treatment, which was most commonly days. data are presented as mean (sd) or median (range) and differences compared with either parametric or non-parametric paired analysis as appropriate. clinical assays included spirometry, sputum microbiology, sputum cell count and differential, serum inflammatory markers (crp, white blood cell (wbc) count,) and chest ct. patients also completed a symptom score sheet. to date, patients (mean age . [ . ] years, male) have paired data available from the start and end of the course of ivs. at baseline, were infected with p. aeruginosa, with b. cepacia complex organisms and with s. aureus ( mrsa). significant changes from baseline were observed in fev ( . [ . ] the clinical response to any novel intervention, for example, cftr gene therapy is difficult to predict. prior testing of experimental assays in a study such as this provides data on the variability of the measurements within the disease population and the degree of change observed with an intervention known to lead to clinical benefit. this should aid the design of rational, powered clinical trials. funded by the cf trust influenza can worsen cf and lead to serious complications and mortality. influenza vaccine is safe and effective in cf patients. in france, annual influenza vaccination is recommended for all cf patients aged over months and for healthcare workers in regular and prolonged contact with high-risk patients. objective: to estimate the influenza vaccination coverage rate for - season in cf patients and healthcare workers in cf care centres of the great south region of france. methods: a multicentric observational study between february and september was conducted. healthcare workers were contacted by telephone and were questioned about their - influenza vaccination status, and the reason for not getting vaccinated. for patients aged over months whose vaccination booklet was available, the physician filled in a written questionnaire. results: a total of professionals were interviewed. the survey included . % of doctors, . % of nurses, . % of dieticians, . % of physiotherapists, . % of social workers and . % of psychologists. the overall influenza vc rate was . % and varied considerably according to profession: . % of doctors, . % of physiotherapists, . % of dieticians, % of psychologists, . % of nurses and . % of social workers. the overall influenza vc rate in cf patients was . % ( . % in children (age < years old) versus . % in adults; p< . ). receiving a voucher for free vaccination from the national insurance increased the influenza vc rate. for healthcare workers, the main reason for non vaccination was that flu was considered as a benign disease (useless vaccine); for patients, it was a lack of time. conclusion methods: adult patients with cf were studied. patients completed a standardised questionnaire. the questionnaire identified which changes and duration of symptoms would cause them to contact the cf team and/or change treatment. results: all patients would contact the cf team for haemoptysis but % would wait for more than hours and % would wait for more than hours before doing so. up to % of patients would wait a week or more before contacting the cf team because of sputum purulence. % of patients would not contact the cf team if they developed new chest pain. conclusion: there appears to be a disconnect between recognizing a change in symptoms and the length of time before acting on the change. this has major implications for the delivery of cf care. supported by cystic fibrosis association of ireland. aim: to determine the efficacy of standardized desensitization protocols in treating antibiotic allergies in adults with cystic fibrosis (cf). background: dependence on high dose and multiple combination intravenous (iv) antibiotics to treat pulmonary exacerbations in adult cf patients has resulted in an increased frequency of allergic reactions when compared with the general population. ( , ) strategies to address these allergies are essential to maintain effective antibiotic treatment in this population. antibiotic desensitization is the process by which one induces immune tolerance by incremental exposure to the antibiotic, which may induce stabilization of mast cells. the mechanism remains undetermined but may be mediated via ige or memory t-cells. prior to the study period, standardized antibiotic desensitization protocols were developed by an allergist/immunologist based on published reports and were approved through the hospital's pharmacy and therapeutics committee. methods: the toronto cf database was accessed to generate a list of hospital admissions for iv antibiotics during the -year study period ( ) ( ) ( ) ( ) ( ) ( ) . patients who underwent desensitization were identified and each of their case notes underwent retrospective analysis. data were collected with respect to age, organism requiring antibiotic therapy, antibiotic allergy requiring desensitization, reactions during desensitization, reactions post desensitization, treatments required to treat these reactions, and the completeness of antibiotic therapy post desensitization. statistical analyses were performed using graph pad prism®. results: during the study period the cf unit dispensed and initiated approximately courses of iv antibiotics. a total of desensitizations were performed in patients ( female). although some patients were desensitized to only one drug or to the same drug more than once, there were patient-drug combinations with a median of (+/= . ) unique combinations per patient. of the desensitizations protocols initiated, patients developed documented reaction to the antibiotic during desensitization however only desensitization protocol was not completed due to an adverse event. there were no episodes of anaphylaxis either during or after desensitization. a total of patients developed documented reactions during the subsequent antibiotic course - required termination of the antibiotic and completed the course of iv antibiotics with management of allergic type reactions with antihistamines. conclusions: standardized desensitization protocols were initiated in patients during the study period. the success rate for desensitizations in these patients was % however when the data is analyzed for true allergic phenomenon, the success rate rises to %. this demonstrates the efficacy of these standardized protocols in the treatment of ige-mediated allergic reactions to antibiotics in the adult cf patient. references: . burrows, j., toon, m., bell, s., ( ) . antibiotic desensitization in adults with cystic fibrosis. respirology, : - . . ramesh, s. ( ) . antibiotic hypersensitivity in patients with cf. clin rev allerg immun, : - . surgery for symptomatic disease. there is a long-held suspicion that poorly-controlled chronic sinusitis negatively impacts the respiratory status of cf patients, but whether sinus surgery improves the clinical course of cf lung disease is unclear. aim: assess the impact of functional endoscopic sinus surgery (fess) on respiratory exacerbation rate and lung function in adult cf patients methods: this is a single-center, retrospective study based on chart review. during the study period, - , adult patients underwent separate fess procedures. this abstract contains results so far from the analysis of patients that underwent a total of surgeries. primary outcomes were -year change pre to post fess in pulmonary function parameters and pulmonary exacerbation rate. results: at the time of surgery, the mean fev was % of predicted (ppd), the mean fvc . ppd, and the median age was . years (range . - . ). . % of patients were female. the median number of iv antibiotic courses for respiratory exacerbations in the months prior to fess was (range - ) compared to (range - ) in the year after surgery (p = . ). further,there were fewer days on intravenous (iv) antibiotics for respiratory exacerbations in the months prior to fess than in the month post-operative period (median vs. days), but this difference was not statistically significant (p = . ). the use of oral antibiotics for respiratory flares was comparable in the months before and after fess (median vs. days, respectively, p = . ). the median number of hospital admissions and median number of days hospitalized for respiratory exacerbations did not differ in the months pre vs. post-fess (p = . and p = . , respectively). the mean fev and fvc in the months pre and post surgery did not differ significantly ( . vs. . ppd, p = . , and . vs. . ppd, p = . ). the linear rate of change in fev and fvc did not differ significantly in the months prior to and following fess (-. l/month vs. +. l/month, p = . and -. l/month vs. +. l/month, p = . , respectively). there were no significant differences (p > . ) for any of the above comparisons when the analysis was limited to months before and after fess. there were no significant differences (p > . ) in antibiotic use and hospitalizations when the analysis was limited to the surgeries in which patients were experiencing both respiratory and sinus symptoms. this latter group had lower fev and fvc ppd in the month post-fess period ( . vs. . ppd, p = . , and . vs. . ppd, p = . , respectively). however, the rate of decline in fev and fvc in the months before and after surgery did not differ significantly ( p = . and p = . , respectively). conclusion: fess did not significantly affect the rate of respiratory exacerbations or rate of decline in pulmonary function in adults with cystic fibrosis. cumulative decline in lung function as measured by fev in cystic fibrosis (cf) pulmonary exacerbation is a major cause of cf-related morbidity and mortality. high-dose extended interval aminoglycoside (hdei ag) use may be more effective in improving lung function than traditional multiple daily dosing in cf-related pulmonary exacerbation. intermittent dosing of beta-lactam antibiotics are often used with hdei ag in patients with cf pulmonary exacerbation, which does not optimize betalactam pharmacodynamics. the primary purpose of this study is to determine the effect of hdei ag plus continuous infusion beta-lactam (cibl) on patients' return to best baseline fev from the previous months. this study was conducted at university of kentucky healthcare. this was a concurrent observational trial with patients serving as their own historic controls via review of the medical record. all pediatric and adult patients with cf respiratory disease hospitalized with an acute pulmonary exacerbation between november , and may , , with pseudomonas aeruginosa in their respiratory culture and were followed for at least one year were included. excluded were patients with known hearing disability or renal insufficiency or an inability to reliably perform spirometry (ie.less than six years old). patients served as their own historic controls via conventional treatment (control) versus hdei ag plus cibl (treatment). the primary endpoint was to determine the percent of patient courses that return to best baseline fev in the last twelve months after treatment with hdei ag plus cibl. secondary endpoints included determination of patient courses that returned to mean baseline fev in the last twelve months after study treatments, and description of beta-lactam dosing characteristics. thirteen patients were included in the pilot analysis which totaled patient courses (mean . courses per patient). average patient age was ± . years with a mean fev of %; . % were female. after hdei ag plus cibl no patients showed a return to their best baseline fev in the previous months with the exception of one patient whose value was unchanged. average overall percent change in best baseline fev group was - . ± . at follow up. % of patient courses exhibited a return to their mean baseline fev . average overall percent change in mean fev baseline was . ± . at follow up. five of the ( . %) study patients who had serum beta-lactam concentrations obtained were able to achieve at least four times the mic of the target organism. more data will be collected on subsequent courses and follow up lung function. our preliminary data suggest that our patients lost % of their best fev with an acute exacerbation and returned to % above mean baseline after treatment with hdei ag and cibl therapy. this evidence suggests that this might be an alternative to intermittent beta-lactam therapy. follow up data on remaining patients may provide sufficient evidence to validate this hypothesis. respiratory exacerbation in cystic fibrosis patients is characterized by increased sputum that may become more purulent. the detection of the exacerbation is based mainly on clinical subjective parameters. fev measurements are accepted as gold standard to be used for the life-time of the patient but do not adapt fast enough after resolution of an exacerbation. we compared parameters that are affected by the uneven distribution of ventilation in the lung due to increase sputum. methods: a zen body plethysmograph was used to measure tlc, fev and dlco (co/ch mixture). tlc was also calculated by the volume of ch , the angle of the slope of phase iii was calculated in cf patients at the beginning of the respiratory exacerbation and after weeks of antibiotic treatment. patients were - years old ( m/ f). results: fev changed by . + . % at the end of the antibiotic treatment, the tlc(pleth) however was stable and changed by only . + . %. the rv/tlc decreased by . + . % and the tlc(gas) was increased by + . %. the difference between tlc (pleth) and tlc (gas) before and after the antibiotic treatment decreased from . + . % to . + . %. conclusion: the changes in the parameters affected by the unevenness of distribution of ventilation (m/p reflecting the increased sputum in the airway) are more pronounced than fev and may be used as a more sensitive parameter for assessing the course of respiratory exacerbation. fibreoptic bronchoscopy was performed in children aged - years: with cf, with non-cf bronchiectasis (bx), with asthma, and control children without lower respiratory disease. endobronchial biopsies were taken and stained with haematoxylin and eosin. asm content, myocyte number and size were quantified using stereology. results: the volume fraction of asm in subepithelial tissue (median; iqr) was . ( . - . ) in controls. by comparison, it was . ( . - . , p< . ) in cf, . ( . - . , p< . ) in bx, and . ( . - . , p< . ) in asthma. myocyte number (cells per mm of reticular basement membrane) was ( - ) in controls, ( - , ns) in cf, ( - , ns) in bx, and ( - , p< . ) in asthma. myocyte size (um , mean; sd) was ( ) in controls, ( , p< . ) in cf, ( , p< . ) in bx, and ( , p< . ) in asthma. in cf, the volume fraction of asm in subepithelial tissue was related to myocyte number (r= . , p= . ), but not to myocyte size. conclusions: asm remodeling occurs in cf children. this, however, is not disease-specific and is also found in non-cf bronchiectasis and in asthma. both myocyte hypertrophy and hyperplasia contribute to increase in asm in cf. support: ers long-term fellowship and swiss national foundation grant to nr purpose: ct scans are increasingly being ordered on a routine basis in patients with cystic fibrosis. while prior studies have investigated their clinical utility in children, there is limited and conflicting information on their utility in adults. the purpose of this study was to determine the relationship between clinical disease severity as assessed by spirometry and ct findings as well as initial ct score ability to predict change in lung function in a nonselected group of adult cf patients. methods: a retrospective review of cf patients (mean age . +/- . , male %) who had undergone a routine chest ct was performed. the ct scans were scored using the brody method by a blinded reader with the degree of bronchiectasis, mucous plugging, peribronchial thickening, parenchymal disease, and air trapping assessed individually and a composite score generated. the ct metrics were first compared with spirometric test that were temporally related to the date of the ct scan, and then with future spirometric tests. results: for the cohort the patients had a wide range of severity of disease with the average fev % . +/- . , and the average fvc% was . +/- . . no significant correlation was found between initial fev % and total ct score ( . p value . ), or initial fvc% and total ct score (- . p value . ). for ct metrics and future spirometry, the average time from ct to pft's was days +/- with median of days. predictors for a significant decline in pft's were a decreasing bmi and male sex (p-values . and . respectively). further, for patients with a low fev % (< % at baseline), the fvc% change over time was associated with total ct score, male gender, and bmi (p-values . , . , and . respectively) conclusions: in adult cf patients, ct scan findings did not correlate with lung function. however in longitudinal analysis, bmi and gender had an effect on fvc change. for patients with low lung function, total ct score did have an association with change in fvc along with bmi and gender. pulmonary exacerbations (pes) are episodes of worsening of respiratory symptoms that commonly occur in patients with cystic fibrosis (cf). in clinical trials of new therapies in cf, pulmonary exacerbation is widely used as a primary or secondary endpoint. despite its importance, no single clearly agreed upon definition exists. some are based on patient reported symptoms while others require hospitalization or antibiotic prescription. use of different definitions makes it difficult to compare the results across studies and also to plan future studies. moreover, the rate of pes (proportion of patients with at least one exacerbation over a given time-period) is affected by baseline patient characteristics such as age, fev and medication use at the start of the clinical trial; factors which also contribute to the difficulty in comparing trials. using data from the cf therapeutics development network (tdn) data bank, we examined several pe definitions and baseline characteristics for their effect on pe rates. we find that pulmonary exacerbation rates vary substantially depending on both the pe definition and the baseline characteristics. for example, in one study, the proportion of subjects hospitalized and/or prescribed antibiotics during the month treatment period was %, while the proportion who met a symptoms based criteria for pe during the same period was %. we also examined the implications of varying control group exacerbation rates on sample size requirements for clinical trials and find that the control group pe rate has a large impact. for illustration, we assume a two group study with two-sided significance level . and % power. if the control group rate is %, then approximately subjects per group are required to detect a relative rate reduction of % (corresponding to a treatment group rate of %). however, if the control group rate is %, then only approximately subjects per group are required to detect the same relative rate reduction of % (corresponding to a treatment group rate of %). thus, a pe definition that selects for a greater pe rate in the control group will require fewer study subjects to detect the same relative rate reduction given that all other variables remain equal. sample size requirements can be further reduced by analyzing the number of events or the time to first event instead of the proportion of subjects who have at least one pe during a given time period. supported by cystic fibrosis foundation therapeutics, inc. (ram-sey y ), the national center for research resources (ncrr mo -rr ) and csl behring. briglia, h.; hilliard, j.; chmiel, j.f.; krenicky, j.; konstan, m.w. pediatrics, case western reserve university, cleveland, oh, usa cystic fibrosis (cf) is characterized by a vicious cycle of obstruction, infection and inflammation. the inflammatory response, which is profound and excessive relative to the burden of bacteria, is characterized by a massive neutrophil (pmn) influx. cf patients often experience intermittent declines in lung function associated with increases in both bacterial burden and pmn influx. these pulmonary exacerbations require treatment with antibiotics. there are substantive issues in the identification of pulmonary exacerbations and the assessment of therapies. a marker which indicates the inflammatory state of the lung would be useful to identify infective/inflammatory exacerbations, as opposed to worsening due to pulmonary vascular disease, or simply upper airway infection (cold), and might guide therapy for intensity and duration. g-csf and gro-α are cytokines produced in the lung by a variety of cells, including macrophages and epithelial cells. g-csf is involved in the proliferation, differentiation and activation of pmn precursors, while gro-α has known chemotactic and activating effects on pmns. transfer of these cytokines through the basolateral membrane into the bloodstream results in increased pmn production and activation in the bone marrow. the plasma concentrations of g-csf and gro-α might serve as potential biomarkers for a pulmonary exacerbation. in this pilot study we measured g-csf and gro-α in the plasma of healthy volunteers (n= ), clinically stable cf patients (n= ) and cf patients experiencing a pulmonary exacerbation, both before (n= ) and following (n= ) - days of antibiotic (abx) therapy. cytokines were measured using commercially available elisa kits (r&d systems, minneapolis, mn) . t-tests were performed on natural log transformed cytokine data (sigmastat v . , systat software inc., san jose, ca). ᭹ the lack of a significant difference between g-csf and gro-α plasma levels in healthy and clinically stable cf patients suggests that these cytokines are not indicators of chronic inflammation. ᭹ both cytokines are increased during pulmonary exacerbations in patients with cf and decrease to baseline values following antibiotic therapy, suggesting that these cytokines might serve as potential biomarkers for cf pulmonary exacerbations. ᭹ although not statistically significant, there was a trend towards an inverse correlation between both cytokines and fev during pulmonary exacerbations in this small study (data not shown). ᭹ further studies are warranted to increase our understanding of g-csf and gro-α as potential biomarkers of pulmonary exacerbation in cystic fibrosis. this work was supported in part by the cystic fibrosis foundation through an institutional research development grant. pletcher, s.d. ; koff, j.l. ; kleinhenz, m. . otolaryngology, university of california, san francisco, san francisco, ca, usa; . medicine, university of california, san francisco, san francisco, ca, usa introduction: while sinus disease is common in adult patients with cystic fibrosis (cf), the severity of sinus symptoms and relationship of sinus disease to other manifestations of cf are relatively unknown. objectives: to evaluate the severity of sinus symptoms in adult patients with cf and correlate these findings with other cf manifestations. methods: twenty-six consecutive adult patients with cystic fibrosis were surveyed during routine clinic visits for sinus specific and overall quality of life outcomes using both the sino-nasal outcome test (snot- ) and the cystic fibrosis questionaire (cfqr). analysis of snot- and cfqr scores were compared to %fev and sputum culture growth of pseudomonas for all patients. results: snot- scores ranged from . to . with a mean of . on a - point scale. for the purpose of data analysis, the patients were divided into two patient cohorts: group with minimal sinus symptoms (snot- < . ) and group with mild to moderate sinus symptoms (snot- > . ). the mean %fev for group was significantly higher than the mean %fev for group ( . % vs. . % respectively, p< . ). patients in group were more likely to have sputum culture growth of pseudomonas although this trend did not reach statistical significance ( % vs %, p= . ). cfqr scores differed significantly among the two groups with group patients reporting more disability in the physical, role, vitality, body, eating, health, respiratory, weight, and digestion domains but not in the emotion, social, and treatment domains. conclusions: this cohort of adult cf patients show minimal to moderate symptoms of sinonasal disability. those patients with mild to moderate sinonasal symptoms have decreased pulmonary function and decreased overall quality of life compared to cf patients with minimal sinus symptoms. , . internal medicine, university of iowa hospital and clinics, iowa city, ia, usa; . translational lung imaging program, university of iowa hospitals and clinics, iowa city, ia, usa; . pulmonary and critical care medicine, mount sinai medical center, miami beach, fl, usa mucociliary transport is an important component of airway host defense against inhaled particles and microbial pathogens. mucociliary clearance is hypothesized to be defective in cystic fibrosis allowing for airway colonization and infection. current methods for measuring mucociliary transport and clearance lack the ability to measure mucociliary transport in specific proximal and distal airway segments. using a -slice high resolution ct scanner (somatom , siemens), we are developing a method to track radiopaque particle movement in the swine airway. swine were induced with ketamine/acepromazine, intubated, and then anesthesia maintained with propofol infusions. animals spontaneously breathed humidified air with the endotracheal tube cuff deflated. radiopaque teflon/bismuth trioxide disks ( mm diameter, . mm thick) were instilled via a catheter into the airways. serial ct images ( . mm slice thickness and slice increment of . mm) were obtained every minutes for a total of minutes. airway tree segmentation was performed using pulmonary workstation . (vida diagnostics, iowa city, ia). this program allows for fully automated airway tree segmentation. baseline mucociliary transport rates ( -dimensional) were . ± . mm/min. following aerosol delivery of human sputum leukocyte elastase ( mu), mucociliary transport was markedly diminished ( . ± . mm/min) at minutes. thus far, we are able to measure mucociliary transport down to the rd generation airways. future studies include more distal deposition and measurement of particle movement. in summary, this novel method measures mucociliary transport in defined airways and will allow us to examine the effect of altered airway epithelial function on mucociliary transport. lung transplant. purpose: to design a ct scoring system to quantify structural abnormalities on ct scans from cf patients with severe advanced lung disease (sald) and to investigate the correlation between ct scores and survival. materials and methods: ct scans of cf patients screened for lung transplant between and were collected from transplant centres. all scans were scored with the brody ii scoring system. to design a new scoring system sensitive for the specific changes in sald, a panel of experts reviewed a random set of ct scans on eligible items to be used in a pilot analysis. the resulting sald scoring system consisted of four items: bulla/cysts; areas with consolidation/mucous; areas with hypo perfusion/air trapping and hyper/normal perfusion. in each ct slice ( mm spacing) and for each of the items the surface area of corresponding lung tissue involved was estimated on a - % scale. total surface area for the items and each slice added up to %. the final sald score was a mean volume estimate of abnormal and normal lung tissue. results: pilot analysis of a set of ct scans showed a a spectrum of abnormalities, ranging from predominantly bronchiectasis to predominantly mosaic perfusion. a moderate correlation was found between the sald components inflammation and hypo perfusion/ air trapping and brody score (p= . , r= . and p= . , r= . ). the inter-observer variability of both scoring systems was comparable. (ri ranging from . to . ) analysis of the complete cohort with the brody ii score showed a significant correlation with survival with a hazard ratio of . ( % ci of . to . ) for dying on the waiting list for every ten point increase in brody ii score. (p= . ). the brody component scores for bronchiectasis, airway wall thickening and parenchyma showed a similar correlation with hazard ratios ( % ci's) of respectively . ( . - . ), . ( . - . ) and . ( . - . ) for every ten point increase in score. (p= . , . and . ). the preliminary results with the brody score suggest that it is useful to include ct information in prediction models. it is likely that the predictive value of the ct can for survival can be further improved using the dedicated sald-ct score. scoring of the remaining scans according to the sald system is ongoing and will be completed shortly. snell, g. . physiotherapy, the alfred, melbourne, vic, australia; . allergy, immunology and respiratory medicine, the alfred, melbourne, vic, australia; . epidemiology and preventative medicine, monash university, melbourne, vic, australia; . radiology, the alfred, melbourne, vic, australia background despite the widespread use of airway clearance (ac) techniques to clear excessive secretions and improve lung function, little is known about their efficacy following lung transplant (lt). this study aimed to compare the effects of two ac strategies (proactive vs reactive) on a range of clinical outcomes following lt. methods a prospective randomized trial design with stratification for suppurative pre-lt disease was used. consecutive patients at month post lt were eligible for inclusion. subjects were excluded if medically unstable, ventilator dependent or had a contraindication to performing positive expiratory pressure (pep) therapy. patients performed ac using pep either twice daily (proactive strategy) or only in the presence chest infection (reactive strategy). lung function (fev and fvc), chest radiography (brasfield score), exercise capacity ( minute walk) and bronchoscopic airway characteristics (anastomotic healing, patency and secretions) were assessed at , and months post lt. patient adherence and satisfaction were measured. results of consecutive patients, ( in each group) were recruited and completed the study. both groups improved lung function (fev ± % to ± % p< . ; fvc ± % to ± % p< . ), brasfield scores ( . ± . to . ± . p< . ) and minute walk ( ± m to ± m p< . ) over the study period. no significant differences between groups for any outcome were found. the vast majority had fully healed, % patent anastomoses without secretions at months. there were no significant differences between airway characteristics and incidence of chest infection. adherence to both strategies was high ( % proactive, % reactive). conclusion in the absence of significant differences in outcomes, it is recommended that ac only be performed in the presence of chest infection based on greater treatment cost and treatment time required by a proactive strategy. further studies in those with reduced anastomotic patency and in those with recurrent chest infections later post-transplant are warranted. supported by an alfred trusts grant. munro, p.e. ; button, b. , ; bailey, m. ; holland, a. , ; snell, g. . physiotherapy, the alfred, prahran, vic, australia; . allergy, immunology and respiratory medicine, the alfred, melbourne, vic, australia; . epidemiology and preventative medicine, monash university, melbourne, vic, australia; . school of physiotherapy, la trobe university, melbourne, vic, australia background the optimal duration and structure of pulmonary rehabilitation (pr) for lung transplant (lt) recipients is not known. this study aimed to describe changes in functional outcomes in lt recipients who participated in a post lt pr program at the alfred, melbourne, australia. methods prospective, repeated measures design. functional exercise capacity (six minute walk test- mwt), lung function (fev , fvc) and quality of life (sf ) were assessed at , and months following lt. following discharge, all subjects attended a hour supervised outpatient exercise training class days per week until weeks post lt and education sessions. patients with post-operative complications were excluded. data were analysed using descriptive statistics and anova with repeated measures. results consecutive lt recipients from sept to mar were assessed for inclusion. ( % male) subjects, mean age ± yrs were recruited and completed the study. % had undergone bilateral lt. % had cystic fibrosis, % chronic obstructive pulmonary disease. significant improvements were demonstrated in mwt ( ± m to ± m, p< . ), fev ( ± % to ± %, p< . ), fvc ( ± % to ± %, p< . ) and all quality of life domains, p< . . the greatest changes in mwt and lung function were seen between and months. conclusion functional exercise capacity, lung function and quality of life improved significantly over the first months in lt recipients who participated in pr at our institution. these data will allow benchmarking with other centres and program structures. supported by an alfred trusts grant. does gender play a role in perception of cf quality of life domains before and after lung transplantation? the cf quality of life (cfq-r) for patients м years of age is a disease-specific instrument. previous studies using this instrument have reported that cf females have higher scores in weight and body perception than cf males. to determine the impact of lung transplantation on gender-based perception of quality of life, we reviewed the cfq-r on all cf patients м years of age and who underwent successful lung transplantation at our center. cfq-r was administered - months prior to transplant surgery and then months after lung transplantation while the patients were in the outpatient clinic setting. domains measured: physical, role, vitality, emotion, social, body image, eating, treatment burden, health status, weight, respiratory symptoms, and digestion. the cfq-r responses were computer-scored and domain scores were then generated (score - , =better). during the ⁄ year study period, cf patients underwent successful lung transplantation ( males: females; mean age . ± . years). prior to lung transplantation, female cf patients had lower physical domain scores but higher scores in health status perceptions than the male cf lung transplant candidates (see graph). all patients had marked improvement in all domains months after lung transplantation (see graph). after transplant surgery, cf males had higher scores than cf females in emotion and in eating domains. scores for body image domain were similar for both genders before and -months after lung transplantation. we conclude that although there were differences in physical and health domain perceptions prior to lung transplantation, both male and female pediatric cf patients had marked improvement in all domains after lung transplantation. however, female cf lung transplant recipients had lower emotion and eating domain scores after transplantation. we speculate that lower scores in these domains may reflect increased post-traumatic stress and depression in female lung transplant recipients. further study on cf quality of life in pediatric lung transplant recipients is on-going. background cf liver disease (cfld) with severe cirrhosis develops in - % of patients, usually within the first decades of life. most patients with cfld suffer from complications of portal hypertension but hepatocellular function usually remains intact for many years, even decades. patients with cfld referred for lung transplantation (tx) may be offered lung tx, lung-liver tx or be excluded from lung tx. however, variceal hemorrhage due to portal hypertension can be managed by banding, sclerotherapy or shunt procedures without liver tx. the aim of this study was to examine outcome of cfld patients who underwent lung tx and the subsequent progression of cfld, particularly with the use of potentially hepatotoxic immunosuppressive drugs. we conducted a retrospective cohort study to compare cf patients undergoing lung tx with and without cfld. b. cepacia-negative cf patients undergoing lung tx at toronto general hospital from - were eligible for inclusion. liver cirrhosis was defined by histology, esophageal varices on endoscopy or imaging evidence of splenomegaly. each patient with cfld was matched for age and year of tx with cf patients without cfld. demographic data, survival and liver function tests (lfts)(ast, alt, alp, inr, albumin, protein at week , month , , , , , , , , and post tx) were obtained by chart review. results of the groups were compared using unpaired t-test (parametric data) or mann-whitney u test (non-parametric data). results b. cepacia-negative cf patients underwent lung tx over this period, ( . %) having cfld with cirrhosis. data from the cfld patients vs. matched cf patients without cfld were analyzed. no significant difference was found between the groups in pre-tx age, gender, bmi, pi status, cfrd status, fev % predicted, -minute walk distance or lfts. in the cfld group albumin was lower week post-tx ( . + . g/l vs. . + . g/l, p< . ), alp was higher month post lung tx ( . vs. . , p< . ) and alt was higher months post-tx ( . + . u/l vs. . + . u/l, p< . ). there was no significant difference in the other blood tests. azathioprine was changed to mycophenolate mofetil in cfld patients due to liver test abnormalities. cfld patient developed hepatic encephalopathy and ascites years post lung tx and is being assessed for liver tx. no difference was seen in the number of episodes of acute rejection or post-tx survival ( . % vs. . % alive at years). discussion cfld patients undergoing lung tx did not have a worse prognosis than patients without cfld. transient elevation of lfts were seen in the immediate post-tx period but settled either spontaneously or after discontinuation of azathioprine. we conclude that selected patients with cirrhosis due to cfld may be safely offered lung tx without concomitant liver tx. infectious mononucleosis, commonly called mononucleosis, or "mono," is an illness caused by the epstein-barr virus. mononucleosis has been nicknamed the "kissing disease" because the epstein-barr virus commonly is transmitted in saliva during kissing. however, sneezes and coughs also can transmit the virus occasionally. the epstein-barr virus (ebv) permanently infects more than % of the people on earth, but it causes symptomatic mononucleosis only in a small number. in developed nations, such as the united states, mononucleosis most often occurs between the ages of and . unfortunately ebv can not only infect, but can also transform, b cells after transplant and may lead to lymphoma with a resulting ~ % mortality rate. the source of ebv is presumed to be passenger lymphocytes in the donor tissue and those at greatest risk are patients who are ebv naive before transplant. since most cf patients with endstage lung disease in the developed world are now being referred for transplant given the success of this intervention, we reviewed our entire lung transplant database to determine the nature of ebv infection and the likelihood of developing lymphoma following lung transplantation. of first-time lung transplants, ( %) had cf. ebv serology was not available in ( cf, others) before transplant. of ( %) cf patients were ebv seronegative before transplant as compared to of ( %) patients with other end stage lung diseases (composed mostly of copd and ipf) in the control population (chi square p < . ). the cf ebv seronegative cohort was (sd ) years old on average, an age when most seroconversion has already occurred in our society. of the cf ebv seronegatives, survived beyond months and were thus at risk for post transplant lymphoma. of these , developed lymphoma (incidence = %) in comparison to of the ebv seronegative controls (incidence = %, p = ns). all lymphomas were stage iv at presentation and the majority ( of ) arose in the first post transplant year. the cf ebv seronegatives who developed lymphoma did not differ from those who did not with regard to levels of immunosuppression (cyclosporine, methylprednisolone or prednisone) or doses of antiviral therapy (i.e., ganciclovir which is active against both cmv and ebv). in addition, the cessation of anti-lymphocyte antibody induction therapy in the summer of , somewhat surprisingly, had no impact on the development of lymphoma. two cases of lymphoma developed in cf ebv seropositives (incidence = . %) and no cases of lymphoma developed in the control ebv seropositives (p = ns). thus ebv seronegativity raises the lymphoma risk fold in cf patients (p < . ). two of the ( %) cases of lymphoma resulted in death (one cf and one other) and one cf patient probably died of complications related to chemotherapy even though he was tumor free at that time. lymphoma outcome was not stage or clonality dependent. in conclusion, cf lung transplant recipients are at an increased risk for lymphoma largely due to their lack of exposure to ebv before transplant. kissing more before transplant may lower the risk of lymphoma afterward. university hospital uzb, brussels, belgium; . chest medicine, erasme university hospital, brussels, belgium; . dermatology, erasme university hospital, brussels, belgium; . gynaecology, erasme university hospital, brussels, belgium; . gastroenterology, erasme university hospital, brussels, belgium; . pathology, erasme university hospital, brussels, belgium hpv infection is an underestimated phenomenon in organ transplantation (tx) recipients, being unable during immunosuppression (is) to mount an adequate anti-viral immune response and risking genital/anal warts (condylomata acuminata) as well as pre-cancerous/cancerous lesions. we retrospectively assessed the incidence/treatment of genital/anal hpv-associated lesions in cystic fibrosis (cf) lung tx recipients. the files of all tx patients transplanted in the ulb center between and / ( men/ women, median age ± . , range - yrs) were reviewed. maintenance is consisted in chronic triple therapy combining a calcineurin inhibitor, a cell cycle inhibitor and corticosteroids. median survival was . ± . months (range - ). ten of sexually active patients ( %) who survived ≥ months post-tx developed hpv-associated genital/anal lesions: men ( - yrs) and women ( - yrs). genital/anal hpv-pcr proven condylomata were diagnosed between - months in the men and between - months post-tx in the women. all underwent local treatment (cryotherapy ± laser ± topical imiquimod), / patients underwent multiple treatments under general anesthesia. recurrence of the condylomata was high. one male patient presented high-grade anal dysplasia and women moderate to high-grade cervical dysplasia; underwent conization and one complete hysterectomy after conizations. one of the females presented both condylomata and a high grade cervical dysplasia. these retrospective data in a cf population indicate that ) hpv infection may cause significant morbidity in young subjects with chronic disease needing organ tx. it may even compromise life expectancy after tx. ) data on the effectiveness of treatment strategies -including topical immunomodulators -have to be collected ) the potentially protective effects of the now available hpv vaccination in females and males? with chronic disease at risk for future organ tx, when administrated before sexual activity and before tx, should be rapidly evaluated in a multi-center effort. ballmann, m. ; pfister, e. ; schlueter, k. ; becker, t. ; melter, m. ; junge, s. . pediatric pulmonology and neonatology, medical school, hannover, germany; . pediatric nephrology and hepatology, medical school, hannover, germany; . visceral and transplant surgury, medical school, hannover, germany liver disease is an important comortality and comorbidity in cf patients even in the pediatric age group. liver transplantation (ltx) is an accepted option in end stage liver disease. nevertheless the clinical outcome in cf patients is still under discussion. here we reported the clinical outcome months after isolated liver tx in pediatric cf-patients.since n= ltx were performed in children (male n= , female n= ; age (mean±sd) , ± years) . immunosuppressive therapy was done with ciclosporin ± basilixumab and steroid. we followed pulmonary function, cn-score, nutritional status (bmi z-score) and body com-position, airway cultures and igg.results:all were still alive months after ltx. before ltx all patients had a mild to moderate pulmonary disease: fvc(%pred) , ± ( , %- ), fev (%pred) , ± , ( - ), mef (%pred) , ± , ( - ) , cn-score ± , points. nutritional status: bmi(mean) , ± , % (range: , %- , %, z-score: , ± , ), upper arm circumference(cm)(mean±sd) , ± , , triceps skin fat fold(cm) , ± , . body composition: , ± , % of bodyweight were fat. one year after ltx all patients were still in a stable pulmonary situation: fvc(%pred) , ± (range: , %- %), fev (%pred) , ± , (range: %- %), mef (%pred) , ± , (range: , %- %), cn-score , ± , points. there weren't any significant changes in the airway microbiology under immunosuppressive therapy (steroid, ciclosporin±basiliximab), the serum igg levels declined significant from , ± , g/l to , ± , /l(p< . ). the growth over the year was , ± cm and the increase of weight come to , ± , kg, while the bmi didn't increase in this first year after transplantation. certainly we found an increase of the body fat mass (to , ± , % of body weight), of the upper arm circumference (to ± , cm) und of the triceps skin fat fold (to , ± , cm) .conclusion:liver transplantation is an effective therapy even in children with cf related liver disease and stabilise pulmonary function and improves nutritional status in patients with cf and mild or moderate pulmonary involvement before ltx. (neglia jp et al., n engl j med ; : - ) , and colon cancer has been described in young adults with cf (chaun h et al., can j gastroenterol ; : - ) . three of lung transplant (ltx) recipients from our center developed colon cancer after successful bilateral lung transplant for end-stage lung disease. data from these individuals are given in table below . an additional recipients with cystic fibrosis were screened via colonoscopy. colonic polyps were detected in and included lesions up to cm in diameter. five years after a colonoscopy that had shown a mm polyp, one patient underwent a nd colonoscopy that revealed multiple polyps, including a cm diameter sessile polyp in the sigmoid colon. colonic malignancies appear to arise from mucosal polyps, and screening via colonoscopy can detect and remove premalignant lesions. lung transplant recipients have an increased risk of gi malignancies and tumor surveillance is impaired by post-transplant immunosuppression, colonoscopic screening should be considered for transplant recipients with cystic fibrosis. additionally, colonic malignancy should be considered as a potential cause of unexplained gastrointestinal symptoms such as constipation. nossent, g. ; kastelijn, e. ; teding van berkhout, f. ; zanen, p. ; van den bosch, j. ; van de graaf, e. . respiratory dis, university medical centre, utrecht, netherlands; . respiratory diseases, st. antonius hospital, nieuwegein, netherlands objective: in the netherlands lung allocation is based on waiting time. to prioritize patients with a poor prognosis and to reduce waiting list mortality the high urgency (hu) status was introduced in . to be considered for hu status there has to be a limited life expectancy on clinical judgement and all three transplantation centers have to audit this decision. the aim of this study is to analyze the potential effect of las on patients with cystic fibrosis (cf) who became hu or died on the waiting list. it would be expected that patients who became hu had a higher las. methods: from till in all cf patients placed on the hu waiting list, the median las ( th, th) was calculated at the moment of listing and at the moment the patients became hu. also for the cf patients who died on the waiting list the mean las (sd) was calculated at the moment of listing. results: from the patients on the waiting list patients had cf. of these patient were placed on hu list and died on the waiting list. in the cf patients that became hu the median las on the moment of listing was . ( . ; . ) . at the moment they were placed on the hu waiting list the median las was . ( . ; . )(p= . ) . the median las of the patients who died on the waitinglist was . ( . ) . this las did not differ significantly from the las of listing of the patients that became hu (p= . ). conclusion: the las does not detect the deterioration in patients with cf as diagnosed by clinical judgement. this may be due to the exclusion of specific prognostic factors of cf in the calculation of the las. besides that, the las does not differentiate cf patients on the waiting list with a high chance of mortality. introduction: lutx recipients have one of the highest rates of ia in solid organ transplantation causing high morbidity and mortality rates. nowadays antifungal prophylaxis is extensively used but clinical trials are rare. methods: all patients who received lutx in our hospital were included in this retrospective study. aspergillus airway colonization was defined as aspergillus cultured twice from airway specimens in the absence of ia or tracheobronchitis (tb). definition of ia and tb was according to literature. after the death of cf-patients due to ia, a prophylaxis protocol was introduced containing avoidance of use of the cell saver during the operation in pretx colonized patients to avoid hematological fungal spreading and targeted prophylaxis with itraconazole or voriconazole in all pre-and posttx colonized patients during months and inhaled amphotericin during hospital admission. results: a total of lutx were performed (in patients) ( % cf patients) from - - until - - . patients ( . %) were colonized with aspergillus pretx and patients posttx. only patients were colonized before and after tx. before introduction of the protocol patients ( / = . %) ( % cf patients) developed an aspergillus infection: ( . %) patients developed a. fumigatus tb and ( . %) patient suffered from ia: cerebral a. fumigatus infection (proven ia). two patients, both cf patients, ( / = %) died due toaspergillus infection (cerebral and tb).after introduction of the protocol only one a. fumigatus tb occurred ( / = . %) but no invasive fungal infection. conclusions: the rate of fungal infections in our lutx patients was comparable with data from literature. since introduction of azole prophylaxis protocol and avoidance of use of cellsaver no ia occurred. fischer, a. ; müllinger, b. ; arendt, t. ; bernhardt, t. ; hannah, k. ; scheuch, g. . activaero gmbh, gemuenden, germany; . biological products, bayer healthcare, leverkusen, germany; . activaero gmbh, gauting, germany; . talecris biotherapeutics, research triangle park, nc, usa background patient compliance during a study is an important factor in view of assessing the clinical effect of a treatment. this is especially true when patients administer the drug at home. usually, patient records, counting of returned doses or mechanical counters are used to track compliance, which may be biased by the study subjects. this report is about an aerosol study in cf which used a device for controlled breathing (akita® inhalation system, activaero, germany). the device works with a patient-individual smart card that records every single breath during a treatment including a date/time stamp in an encrypted manner. each patient's inhalation protocol can be displayed by loading the smart card into the proprietary "compliance manager" software. methods for this report, the data set of a recent controlled study (griese et al., ) was analyzed. cf-patients were instructed to inhale with the akita inhalation system at home for days. after the study, the smart cards were returned to activaero, and the inhalation records on the chip were analysed. we analysed the compliance of patients who participated at least days ( out of patients, others deemed to be drop-outs . most of the patients showed a dsc which is lower than the tdc, indicating that they had missing treatment days, which were compensated by additional inhalations on other days. we found patients with a dsc more than % lower than their tdc (max difference: . %). conclusion this aerosol study with home treatment demonstrated a high compliance rate for tdc and dsc. this information is more reliable for compliance than study participation in days alone. for future studies it is recommended to define in the protocol not only a minimum of study participation in days but also a minimum in tdc and dsc. in addition the compliance thresholds may be defined with regard to the drug's pharmacokinetic profile. in general, the inhalation record of the akita smart card provides an unbiased view of the inhalations treatments during a study especially when the subjects perform the inhalations at home. compliance calculations as shown above may be performed and linked to other outcomes of a study for validation. compliance data like these may also be used routinely by the treating physician in order to guide and supervise his patients. introduction: adaptive aerosol delivery (the i-neb ® aad ® system) has been developed to deliver precise, reproducible doses of aerosol into inhalation. i-neb utilizes a medication chamber, which incorporates a metering chamber to deliver a preset (metered) dose of aerosol. inhalation of hypertonic ( %) saline has been shown to aid mucociliary clearance in patients with cystic fibrosis. [ ] we performed an in vitro test to determine the emitted, delivered and residual doses of hypertonic saline from the i-neb aad system with . ml metering chamber, and a conventional jet nebulizer (lc plus ® ) with a ml fill. the results were then entered into a model to predict the likely lung dose from the in vitro tests, in order to determine the equivalent i-neb dose to the ml conventional jet nebulizer fill. methods:an i-neb device configured to operate at power level (of ) was fitted with a metering chamber designed to deliver a preset dose of . ml. the i-neb was weighed, loaded with ml of % saline and run on the cen simulated breathing pattern. this process was repeated using an lc plus nebulizer loaded with ml of % saline. aerosol was collected on a filter placed between a harvard pump and the device. emitted dose and residual dose were determined by gravimetric output, and delivered dose was determined by ion analysis. all tests were conducted in triplicate. results: as shown in table , the emitted dose approximated the delivered dose for i-neb, whereas for lc plus the emitted dose was approximately twice the delivered dose, due to the wastage of aerosol upon simulated exhalation. as i-neb has a delivered dose of mg, and i-neb has been shown to deposit . % of the dose in the lung, [ ] this would result in a lung dose of mg. the pari lc plus has a higher delivered dose, but the overall lung deposition is only % of the fill volume, i.e. mg. [ ] conclusion: the results of this test suggest that two treatments would be required in order to deliver an equivalent lung dose of hypertonic saline from an i-neb device fitted with a . ml metering chamber, compared with a ml fill in an lc plus jet nebulizer. references introduction: inhaled colistimethate sodium can be used for the eradication of pseudomonas aeruginosa in patients with cystic fibrosis. the tonicity of colistimethate sodium inhalation solution has been linked to the occurrence of bronchospasm in some patients. it has been suggested that this bronchospasm can be avoided by using an isotonic solution of colistimethate sodium. [ ] this can be complicated when using conventional jet nebulizers, since evaporation during nebulization tends to change the tonicity of the solution remaining in the nebulizer. however, because very little evaporation occurs within the i-neb medication chamber during nebulization, the tonicity of the loaded solution at the beginning and end of nebulization remains almost constant. aim: we investigated the effects of various saline concentrations upon the tonicity of two concentrations of colistimethate sodium solution ( . miu/ml and miu/ml). methods: diluent containing sodium chloride concentrations of: % (water for injection), . %, . %, . %, and . % (normal saline) were used to reconstitute vials of colistimethate sodium (promixin ® , profile pharma, uk). each vial was reconstituted with either or ml of diluent to make up miu/ml or . miu/ml colistimethate sodium solution, respectively. the tonicity of each diluent concentration/colistimethate sodium concentration combination was made up and tested in triplicate using an advanced micro osmometer (advanced instruments, norwood, usa). the results were plotted on a graph along with a line of best fit, to determine the diluent concentration that gave a mean tonicity closest to that of an isotonic solution. results: tonicity increased linearly with increasing concentrations of saline solution for both miu/ml and . miu/ml concentrations. the tonicity of the miu/ml solution was approximately mosm higher than the . miu/ml solution across the range of saline concentrations tested. the best fit line passed through the isotonic solution point ( mosm) closest to the . % saline concentration point. conclusions: the diluent that produces the closest approximation of isotonicity for the mean of . miu/ml and miu/ml colistimethate sodium concentrations was . % saline. references . transave, inc., monmouth junction, nj, usa; . activaero, gmbh, gauting, germany arikace™ is an inhalation formulation of a liposomal amikacin suspension that is designed to treat chronic pseudomonas aeruginosa infections in cystic fibrosis patients. liposome encapsulation of amikacin reduces nonspecific binding of this cationic aminoglycoside drug to the negatively charged mucus and biofilm surfaces and allows penetration and delivery of packets of highly concentrated drug to the otherwise protected bacteria. as nebulized and delivered to the lungs, arikace™ comprises % liposomal amikacin and % 'free' amikacin that is not entrapped by liposomes; free drug is produced by liposome leakage during nebulization. this profile provides an initial high peak concentration of amikacin followed by a sustained level as drug leaks from the liposomes. nebulized arikace™ with this profile was evaluated previously in human clinical studies using the lc star® nebulizer. although the . µm liposomes of arikace™ are efficiently loaded with drug, the expected effective dose in humans will require relatively large volumes of drug solution to be administered. to minimize treatment time and improve patient convenience we sought to find a nebulizer that would efficiently deposit drug and produce aerosol at a high output rate, while still producing the same level of free drug during nebulization. methods: nebulization of liposomal amikacin was compared using several nebulizers, including jet nebulizers: lc star® and lc sprint® (both from pari), and electronic mesh nebulizers: microair® ne u v (omron), aeronebgo® (nektar), and eflow® (pari). additionally, meshes of different pore sizes were examined for the microair® and eflow® devices. output rates were measured by gravimetric differences. droplet size distribution was assessed by a laser light scattering method and by cascade impaction; mass median aerodynamic diameters (mmad), geometric standard deviation (gsd), and fine particle fraction (fpf) (i.e., % droplet mass < µm). amikacin association with the liposomes was measured using a centrifugation-filtration assay. results: in terms of output rate, the order of performance was eflow® (~ . g/min) > lc sprint® > lc star® > aeronebgo® > microair®. while the aeronebgo® and microair® mesh nebulizers performed well with saline, their performance declined dramatically when nebulizing the liposomal amikacin solution, and, in fact, the microair device clogged. in additional studies with the eflow® where different meshes were compared, the l mesh was selected as it provided ideal aerosol properties (mmad = . µm, gsd = . , fpf > %) with a ratio of entrapped to free amikacin of approximately %/ %. importantly, from in vitro breath simulation studies it is estimated that about twice of the nominal drug dose is expected to deposit in the lungs compared to the lc star®. conclusions: for nebulization of liposomal amikacin, the eflow® configured with a l mesh provided optimum aerosol characteristics with a high output rate and ideal size for distribution throughout the lung. the eflow® reduces dose administration time not only because of its faster output rate but also because its higher deposition factor greatly reduces the amount of drug needed. zeman, k.l.; bennett, w.d. cemalb, university of north carolina, chapel hill, nc, usa many inhaled, therapeutic drugs have their site of action in the conducting airways, but may deposit elsewhere in the respiratory tract, resulting in unwanted side effects and waste. the quantity and location of particle deposition in the respiratory tract depends on both the particles' aerodynamic size and breathing pattern. in subjects with normal lung function, we evaluated three methodologies for their ability to deliver radiolabeled particles ( mtc-labeled sulfur colloid) to the conducting airways: . inhalation of µm mmad particles (devilbiss jet nebulizer) using a resting tidal volume and flow (mean . l and . lps); . inhalation from the same nebulizer using a very large inspiratory capacity volume and higher flow rate (mean . l and . lps); and . inhalation of larger . µm mmad (heart jet nebulizer) particles with a large tidal volume and very low flow rate (mean . l and . lps). gamma scintigraphy gave an estimate of % conducting airway deposition (%cad) by multiplying the percent of activity in the lungs immediately post-deposition relative to the total deposition (i.e. lung+mouth +esophagus+stomach) times the percent of activity cleared from the lungs over hours. %cad was %, %, and % for the three methods, respectively, significantly greater for the large particle, very slow inhalation technique when compared to the other two methods. the amount deposited in the mouth and larynx was %, and %. in addition, we evaluated protocols and above in a preliminary group of cf patients. for protocol , mean inhaled volume and rate was . l and . lps. mean inhaled volume and flow were . l and . lps for protocol . the %cad for the two protocols and were % and %, respectively. the amount deposited in the mouth and larynx was % and %. higher therapeutic value of a medication delivered to the airways where the primary defect is associated with cf disease, and with fewer losses to the extrathoracic airways, can be obtained by using a "very large particle/slow inhaled flow" routine when compared to normal or higher flow breathing associated with typical nebulizers. supported by cf foundation. positive effects of physical conditioning in cystic fibrosis (cf) have been reported for quality of life (qol) in addition to effectis on fitness and lung functions. the objective of this study was to identify the effects of different modes of training on qol in cf. cf-patients (age - yr., fev > %pred.) were randomized into groups: germany: unsupervised homebased training, hours per week, free choice of training mode and means (ut, n= ) and controls (con , n= ); switzerland: aerobic training (at, n= ) or weight training (wt, n= ) in a fitness center, x min per week, or controls (con , n= ). subjects in the training groups were asked to train for months. at study entry and after and months, qol was assessed by questionnaire and maximal physical working capacity (pwc, %pred) was determined during cycle ergometry (godfrey protocol). changes from baseline values were calculated and anova for repeated measures was used to test for differences among groups. weight training resulted in a significant decrease in qol (generic dimension) at and months compared with all other training modes including controls. there was no significant difference between at or ut and controls in qol during the program. however, there was a positive association between the change in pwc and the change in qol (r= . , p< . ) in the entire sample. in conclusion, physical training may not always result in an increase in ql in cf. possibly, the decrease in qol in the wt group may have resulted from tiredness induced by the training. thus, a different outcome might have been found with less intense training. positive effects may be achieved by improving aerobic fitness. supported introduction: exercise and exercise training programs are felt to be important to improve aerobic exercise capacity, muscle strength, lung function, and quality of life in cf-patients. recent studies in children and adults with cf have demonstrated an increase of motor performance after exercise training. less is known about trainability of motor performance in younger children with cf. the aim of this study was to assess the effects of a training program on motor performance in preschool children with cf. methods: preschool children with cf ( female and male patients, mean age . yrs; range - yrs, fev %pred. , ± . rage from . - . ) participated. at baseline (t ) and at the end of the training program (t ) the "motorik test (mot)" was used to assess motor performance and to evaluate training effects. components of motor performance tested with the mot are balance, agility and flexibility, strength, coordination, fine motor skills, reactivity, accuracy of movement). lung function in patients with cf was measured by spirometric techniques. the duration of training was - weeks ( times/week, minutes per session) with different kinds of sport activities. results: at t , strength and balance had increased significantly (p< . ). no other components of the mot increased, but the increases in strength and balance were enough to cause a significant (p< . ) increase overall motor performance, as indicated by an increase of . % in mq. the mq is the sum of all test-items of the mot. no correlation was found between lung function and motor performance. discussion: to our knowledge this was the first study that examined the effects of an exercise training program on motor performance in preschool children with cf. main findings of this study were that a training program of - week of duration improved some aspects of motor performance. the improvements may be explained by different kinds of sports activities during training when compared with activities before training. classification of motor performance of the tested children was normal (mq = . ± . ). this could be the reason that only some aspects of motor performance increased. parents of the children were asked about habitual physical activity at home. all children were physically active and some of the children participated in organized sports. a recent study showed that with an increase in age lower motor performance in children and adolescent with cf was seen compared to healthy children. we speculate that time spent in physical activity in preschool children with cf is comparable to healthy children. conclusion: an exercise program offered to preschool-children with cf may lead to an improvement in motor performance. pre-school children with cf have normal motor performance. to prevent a decline of motor performance, exercise programs should be available for preschool children. gruber, w. ; braumann, k.m. ; orenstein, d.m. ; huels, g. . dept. for sports and exercise, clinic sattelduene for children and adolescent, nebel/amrum, germany; . institute for sport and exercise medicine, university of hamburg, hamburg, germany; . school of medicine, university of pittsburgh, pittsburgh, pa, usa; . dept. of medicine, clinic sattelduene for children and adolescent, nebel/amrum, germany introduction: a decline in physical activity with age is one of the main problems in patients with cf. as a consequence, lower exercise capacity and a more rapid decline in lung function may be seen in those patients who are physical inactive. furthermore, motor performance is lower in children and adolescents with cf compared to healthy children of the same age. little attention has been paid to younger children with cf and motor performance. the aim of the study was to compare motor performance in preschool-children with cf with healthy children of the same age. methods: children with cf (mean age . yrs; range - yrs) and healthy children (mean age . yrs; range - yrs) participated. the "motorik test" (mot) was used to assess motor performance. the mot consisted of test-items which evaluated seven different components of motor performance (balance, agility and flexibility, strength, coordination, fine motor skills, reactivity, accuracy of movement). lung function in patients with cf was measured by spirometric techniques results: results of the mot showed no difference either for single testitems or for parameter "motorische quotient (mq)" (p> . ). this parameter classified motor performance of all aspects tested with the mot. classification of children with cf and of healthy children was normal. mean value for parameter mq (cf: . ± . vs. healthy . ± . ) was slight higher in patients with cf than in healthy children (p> . ). differences between healthy and cf for different components of motor performance were not significant (p< . ) discussion: the mot is a reliable and valid test method in germany to determine motor performance in younger children. to our knowledge this was the first study to examine motor performance in preschool-children with cf. furthermore, we compared patients with cf and healthy children. we observed no differences between groups for motor performance. in older children with cf, lower motor performance has previously been found compared to healthy children of the same age. we do not have any information about the level of habitual activity in tested healthy children. we therefore speculate that time spent in physical activity in cf is similar to that of healthy children at this age. a recent study showed a decline in physical activity in cf when age and problems during physical activity increased. we think that motor performance is normal in children with cf up to an age of yrs. when age increased, time spent in physical activity decreases (treatment, school) and therefore motor performance decreases. conclusion: motor performance is normal in preschool-children with cf compared to healthy children. to prevent a decline or to maintain motor performance it is recommended to motivate cf-children from early infancy to participate in sports activities or other physical activities to maintain or to increase their physical fitness. . respiratory medicine, the hospital for sick children, toronto, on, canada; . respirology, st. michael's hospital, toronto, on, canada; . respiratory medicine, montreal children's hospital, montreal, qc, canada purpose: the habitual activity estimation scale (haes) questionnaire has been shown to be a feasible tool to measure physical activity however the reliability has yet to be determined in cf populations. we therefore assessed the reliability and validity of the haes questionnaire in paediatric and adult cystic fibrosis (cf) populations. methods: fourteen ( male, female) patients aged . + . yrs with cystic fibrosis from the cf clinics at the hospital for sick children and st. michael's hospital participated in this study. participants were clinically stable at the time of the study (fev > % predicted) and participating in their 'habitual' physical activity. to assess test-retest reliability, patients completed each of the haes (schneiderman-walker et al., j pediatr. ; ( ): - .), and a validated -day activity diary (bratteby et al., eur j clin nutr. ; ( ) : - ), and wore an actigraphtm tri-axial accelerometer for two consecutive weeks. validity was assessed by comparing the activity results of each of the three instruments over a single week time period. results: intra-class correlation coefficient estimates of reliability for the haes, diary and accelerometer were . (p< . ), . (p< . ), . (p< . ), respectively. validity was estimated by comparing the results from each instrument using a one-way anova with block design. there were no overall differences among the participants' activity results as estimated by the haes, diary and accelerometer. furthermore, there were no significant differences between activity measures among the instruments when broken into morning, afternoon, or evening periods, or between measures from weekday or weekend days. while there were no significant differences among the instruments when recording 'very active' intensity levels, they did detect differences during the inactive / somewhat inactive (p = . ) and somewhat active (p = . ) intensity levels. conclusion: the findings of this study suggest that the haes questionnaire is a reliable and valid instrument that can be used to assess activity levels in patients with cystic fibrosis. in agreement with others, our patients found it easiest to recall and record accurately those periods in which they are participating in vigorous activity. acknowledgement: this research was supported by the canadian cystic fibrosis foundation. . respiratory medicine, hospital for sick children, toronto, on, canada; . respiratory medicine, montreal children's hospital, montreal, qc, canada; . respirology, st. michael's hospital, toronto, on, canada objective: previous work showed a relationship between habitual physical activity (hpa) and decline of lung function (fev ) in cf females (sneiderman-walker, j peds : , ) . this study only included a small number of patients and the follow-up period was limited to months. the purpose of this study was to evaluate daily activity levels and decline in fev in a larger cohort over a longer period of time. methods: a total of (n= female) patients with cf (age - yrs) were studied over a six year period at the hospital for sick children, st. michael's hospital and montreal children's hospital. at each quarterly cf clinic visit, patients performed pulmonary function tests to determine fev and completed the habitual activity estimation scale (haes). weekday total activity (wdta), expressed as hours/day (h/day), was calculated from the sum of 'very active' (wdva) and 'somewhat active' (wdsa) categories as previously described. a repeated measures linear regression was performed to evaluate the relationship of fev and hpa over time. results: at baseline, mean fev was % predicted (range - % pred). mean baseline wdta was . h/d (wdva = . h/d and wdsa = . h/d) similar to that previously reported. subjects were divided into high and low activity groups based on the group median wdta. those in the low activity group had a significantly (p= . ) steeper rate of decline (- . % predicted per year) compared to those in the high activity group (- . % predicted per year) . unlike in the in the previous study this difference was observed in males as well as females. conclusions: six year follow-up of this patient cohort has shown that higher activity levels are clearly associated with a slower rate of decline of fev . we are currently evaluating whether strategies aimed at increasing physical activity will have an impact on lung function decline in cf patients. background: knowledge of exercise principles, benefits, and techniques has not been assessed in children with cystic fibrosis (cf) or their parents. regular exercise is a recommended cf treatment regimen that is often not followed, but one which might improve cardiovascular fitness, lung function, sputum clearance, and health-related quality of life. further, aerobic fitness, measured as peak oxygen uptake (vo ), is positively related to survival in cf. construction of a reliable and valid measure of exercise knowledge is necessary to assess level of knowledge and study its relationship to exercise behavior. the aim of this study was to develop and test a measure of exercise knowledge for pediatric patients with cf and their parents. methods: we constructed a -item exercise knowledge test (ekt) and then examined its psychometric properties. a comprehensive review of the exercise literature guided the formulation of objectives and development of items. to establish content validity, a panel of experts (cf physician, two exercise physiologists, and a clinical cf nurse) evaluated the objectives and test items for relevance, clarity, and accuracy. after feedback from the panel, we revised the ekt through an iterative process. in consultation with a reading level expert, we wrote the ekt items so that the test could be administered to children and adults. a measurement and evaluation expert also reviewed the test, and additional revisions were made. during routine clinic visits, the ekt was administered to subjects with cf and parents. the cf subjects included boys and girls, age to years, fev range: - % predicted. the parents had an average age of years and most (n= ) were female. results: the ekt includes items, true-false and multiple choice. it is self-administered, yields a single summed score, and has a flesch-kincaid rd grade reading level. the means were . + . ( % correct) and . + . ( % correct) for the cf subjects and parents, respectively; % of the parents scored between and . internal consistency reliability estimates were . for the children and . for the parents, reflecting both the multidimensionality of the material and the lack of variability in the parent scores. item difficulty ranged from . to . for the cf subjects and from . to . for the parents. in both groups, the discrimination values were positive for all items with difficulty values less than . . conclusions: we were able to develop a measure of exercise knowledge with an acceptable reading level for children with cf and their parents. this sample of cf subjects and parents showed substantial exercise knowledge. the ekt can be a useful tool to identify gaps in exercise knowledge in cf patients and their parents, develop educational programs to increase knowledge, and examine how knowledge relates to exercise behavior in children with cf. supported by cystic fibrosis foundation therapeutics, inc. purpose: although physical activity is routinely recommended for adolescents with cystic fibrosis, past research suggests that many patients do not regularly participate in physical activity. there may be a variety of reasons, both related to disease and otherwise, for this inconsistent participation. in this study, qualitative methods were used to describe factors that facilitated or served as barriers to physical activity in adolescents with cf and compared these factors to those in a healthy peer group. methods: ten subjects with cf and ten subjects without cf aged - volunteered for this study. each subject participated in two, open-ended semi-structured interviews with - weeks between each interview. subjects were questioned about their current and past physical activity as well as the benefits and barriers to participation. the adolescents with cf were also asked about their perceptions of physical activity on their own health and other adolescents with cf. interviews were transcribed and coded by three investigator groups. analysis was conducted using the grounded theory approach at two points in the study, following each interview and again at the completion of all interviews. at the first point, individual interviews were coded using line-by-line coding, and similar information was grouped into categories. in the second interview, categories were confirmed and subjects were also asked to elaborate or clarify points from the first interview. interviews were continued until themes reached a saturation point. upon completion of all interviews, data for each group were organized by question. data categories appearing throughout the interviews became major themes describing facilitators and barriers to exercise. the major themes were identified by the three researcher groups and then through collaborative group analysis. results: the central theme for both groups was perceived importance of physical activity for health benefits. for the cf group, facilitators and barriers were both psychological and physical. physical benefits were categorized as either relating to their general health (such as feeling energized) or as benefiting their disease (such as improving breathing). in the non-cf group, facilitators included social factors in addition to general health-related and psychological benefits. in the non-cf group, barriers were categorized as either internal or external, with the internal barriers being similar to the cf group (physical and psychological), however, the non-cf participants also indicated external barriers (such as time) not articulated by the cf group. conclusions: in general, we found very similar facilitators and barriers to physical activity in adolescents with cf and those without. however, the adolescents with cf strongly indicated that physical activity would have positive effects on their physical health. further work is needed to determine ways to accentuate facilitators and remove barriers to improve physical activity levels in adolescents with cf. this project was supported by a research grant from the cardiovascular & pulmonary section, apta. lloyd, e. ; dodd, m. . paediatric cystic fibrosis service, central manchester and manchester children's university hospital, manchester, united kingdom; . adult cystic fibrosis centre, wythenshawe hospital, university hospital of south manchester nhs foundation trust, manchester, united kingdom background: training in the skills of communication and self care are considered important components of transitional care . physiotherapists work to involve families and young people to encourage this independence. the cf manager training programme (cfmtp) is a recognised tool for measuring age appropriate tasks in cf care. aim: the aim of the study was to survey the current levels of autonomy in all patients with cystic fibrosis in the north west of england from birth to years to provide a baseline measure for encouraging autonomy in preparation for transition. method: three areas of the cfmtp were selected for the survey: physiotherapy (p), inhalation therapy ( it) and communication (c) for the age groups: - . , . - , - , - , - , - , - , - , - ,and + years. physiotherapists from all the north west cf clinics were invited to assess all the patients under their care. data collected were age, gender and whether the patients skills fell "below", "same" or "above" the age appropriate self management tasks as described in the cfmtp. 'not applicable' was indicated where the skills did not apply. results: / clinics responded. out of a total of patients in the nw were assessed, three patients were excluded. population by clinic ranged from - . population by age category: ( - . years) ( . - years) ( - years) ( - years) ( - years) ( - years) ( - years) ( - years) ( - years and ( + years). / ( %) were male. for p (n= ), it (n= ), c (n= ), %, %, % = below, %, %, % = same, %, %, % = above respectively. there were no gender differences. conclusions: overall scores revealed that / rd of patients were gaining age appropriate independence in all areas. there was the least autonomy with it. it was rare for a child to be setting up and cleaning equipment regularly at - years, but this continued throughout the adolescent years. overall % were 'below' for p and it; this was highest after the age of years. autonomy with physiotherapy appeared slow to develop. some categories in cfmtp were different from our practice for e.g. patients are not invited to be seen alone in our clinics until years v - years and this may account for the lower scores in communication below this age. this study has highlighted that some of our patients are not fully independent in the time up to transfer. we need to encourage independence from an early age with all aspects of care and integrate the process into our routine clinical practice. refs mcdonagh and viner bmj ; : - , . parents' guide to the cf manager training programme. children's hospital of eastern ontario planner, s. ; morrison, l. . physiotherapy, gartnavel general hospital, glasgow, united kingdom; cystic fibrosis (cf) causes a deterioration in lung function and exercise tolerance. assessing exercise capacity is therefore essential in order to monitor changes in disease severity. the -minute walk test ( mwt) and minute step test ( mst) are validated and widely used outcome measures for identifying exercise capacity in patients with cf. exercise testing is part of annual review of all patients in the west of scotland. previous studies identified that the mst was a sensitive measure of exercise tolerance, but did not successfully challenge patients with mild or moderate lung disease as defined by fev(sub) (/sub)> % (morrison ) . further analysis of the mst, where step height was increased to inches did not show any difference in sao(sub) (/sub). decline or rate of perceived exertion (rpe) in patients with mild disease. the chester step test (cst) was developed to assess aerobic fitness which is used in the uk cardiac population for exercise prescription (sykes ) . it is a minute progressive, sub-maximal test with a variable step height ( - inches) , making it suitable for those with a wide range of exercise capacities. in addition, cst results extrapolate to a mets value (oxygen utilisation: met = rate of oxygen utilisation at rest) as an outcome measure which can facilitate exercise prescription based on established values for physical activities. we aim to determine whether the cst is a more sensitive measure of exercise capacity than the mwt or mst when considering decrease in sao(sub) (/sub) and rpe. patients ( aged - mean fev(sub) (/sub) . l) with mild-moderate cf performed the cst and mwt and results were correlated with fev(sub) (/sub). decrease in sao(sub) (/sub), increase in hr and rpe scores were also compared between the cst, mwt and recent mst data. patients were exercised to a symptom limited maximum which differed from the cardiac cst where patients are exercised to % of maximal hr. the cst appears to be more challenging as only patients completed it, all with an fev(sub) (/sub)of > % predicted, whereas in the mst and the mwt all patients completed the test. mets levels for the cst were weakly correlated with fev(sub) (/sub)(r= . ) and the mwt (r= . ) . this could be explained by the narrow range of mets data available or the size of the sample population. there were significantly greater rises in hr (p= . , p= . ), decrease in sao(sub) (/sub) (p= . , p= . ) and rpe (p= . , p= . ) , between the cst, mst and mwt respectively, suggesting that the cst is a more sensitive measure of cardiorespiratory effort. conclusions the cst appears to be a more challenging exercise test for those with mild to moderate disease and therefore may be a better reflection of exercise capabilities. cst results are useful for prescribing exercise and monitoring programmes appropriately for this patient group. further study could determine whether the cst is also suitable for those with severe disease. lee, a.l. ; button, b. ; holdsworth, m. ; holland, a. . physiotherapy, the alfred, melbourne, vic, australia; . latrobe university, melbourne, vic, australia musculoskeletal pain is prevalent in cystic fibrosis (cf). while the chest and back are frequently reported regions of acute or chronic pain, it is unclear if pain in these areas is related to disease severity or respiratory symptoms. manual therapy and postural advice has been shown to alleviate pain, but the effects of a combined approach of musculoskeletal physiotherapy and massage has not been studied. the aim of this study was to identify the primary regions of musculoskeletal pain, the relationship between pain severity and respiratory symptoms and to examine the effect of musculoskeletal physiotherapy techniques and soft tissue therapy, including remedial massage on pain and ease of breathing (eob) in adults with cf. one hundred and twenty-nine adults with cf ( with acute exacerbation, post lung transplant) aged ± years (mean ±sd) with fev(sub) (/sub) of ± % participated in this study. following assessment of primary pain regions, each subject underwent a single treatment session including spinal joint / intercostal mobilisation and soft tissue therapy. pain and eob on a visual analogue scale were measured before and after treatment. changes were compared using paired-samples t-tests. pain was frequently reported in the thoracic spine region ( % of subjects), followed by the shoulder region ( %), cervical spine region ( %) and chest wall region ( %). equivalent ratings of pain and eob prior to treatment were reported for all regions of pain. eob rating prior to treatment were worse in those with low bmi (r=- . , p= . ) and low fev(sub) (/sub) (r=- . , p= . ). a single treatment session was associated with reduction in pain ( %ci . to . , p< . ) and improvement in eob ( %ci . to . , p< . ), irrespective of clinical status. improvement in pain was equivalent for all primary pain regions. however, greater improvement in eob was evident in subjects with shoulder pain compared to other regions ( %ci - . to - . , p= . ). a combination of musculoskeletal physiotherapy techniques and soft tissue therapy reduces musculoskeletal pain and improves eob in adults with stable cf, during an acute exacerbation and post lung transplantation. service cystic fibrosis is characterized by an excessive production of airway secretions responsible for bronchial obstruction and recurrent infections of the respiratory tract. the transport by ciliary activity and cough may be dependent on the unsteady rheological properties of the respiratory mucus such as thixotropy and shear-thinning properties which correspond to a decrease of viscosity with time or flow rate, respectively. we have previously shown that respiratory mucus with high shear-thinning and thixotropic properties is better transported by the cough mechanism (zahm et al, eur. respir. j., ) . to promote mucus clearance and to finally expectorate the mucus by a cough manoeuvre, an innovative device, the airhelp, has been developed and aimed to improve chest physiotherapy effectiveness. during a prolonged expiratory manoeuvre, the airhelp delivers negative pressure variations (maximal amplitude: - kpa) at an oscillatory frequency of hz. the aim of the present work was to test the effect of the airhelp device on the in vitro clearance of mucus by airflow. a plexiglass tube of mm in diameter and mm in length has been connected by one part on the airhelp and by the other part on a l thank mimicking the lung compliance. a µl drop of mucus simulant at different concentrations (viscogum at . % or . % with actigum at . % to . %) or of respiratory mucus, was deposited within the plastic tube and the distance travelled by the sample under a sec-airflow was measured. twelve respiratory mucus samples collected from cf patients were analyzed and the viscosity of the samples was measured before and after the airhelp experiment. we observed a significant (p < . ) and negative relationship (r = - . ) between the viscosity of mucus simulants and oscillatory airflow transport: the lower the viscosity, the higher the mucus transport by oscillatory airflow. using cf respiratory mucus samples, we observed that without the oscillatory airflow, no transport occurred, whereas when the samples were submitted to the oscillatory airflow, a significant increase in mucus transportability was measured. in addition, the viscosity of the cf respiratory mucus samples was significantly decreased after oscillatory airflow treatment ( ± pa.s to ± pa.s, p < . ). these results demonstrate that the mucus transport efficiency by an oscillatory airflow is dependent on mucus viscosity and that the improvement in mucus transport is related to the thixotropic and shear thinning properties of the airway mucus. we conclude that the airhelp device may improve chest physiotherapy effectiveness. potter, e. ; nufer, j. ; cullina, j. , ; quinton, h. ; jain, m. , ; mccolley, s.a. , . northwestern university feinberg school of medicine, chicago, il, usa; . children's memorial hospital, chicago, il, usa; lebanon, nh, usa; . northwestern memorial hospital, chicago, il, usa socioeconomic status (ses) significantly impacts health outcomes in cystic fibrosis (cf). the cystic fibrosis foundation (cff) is currently using median income estimated by zip code from the us census of the population for ses risk adjustment of data reported publicly from the cff patient registry. median income estimated by zip code is an "ecologic" variable that may misclassify patient and family income. in order to more fully assess the impact of ses on cf health outcomes, the cff began to ask centers to collect data on household income directly from patients and families. these data were captured for . % of patients and families in and . % in in the national registry. we report a method of collecting ses data from children and adults implemented at the children's memorial hospital and northwestern university cystic fibrosis center, and compare directly collected income to income based on zip code. methods: a short survey with the questions on household composition, income, and education level from the cff patient registry was developed. a letter from the center director and adult program director was mailed to patients and families informing them of the survey's purpose and confidentiality measures, i.e. responses would be seen only by the individual entering the data and identified by cff id number. the survey was distributed to cf patients and families in clinic by clerical staff. completed surveys were placed in an envelope and sealed by the patient or family. both directly collected income and income from zip code was classified into groups (<$ k, - k, - k, - k, - k, - k, - k, - k, and > k) . percent concordance and spearman's rank correlation were calculated. data were used for patients who provided data in ; otherwise, data were used. each patient's data was used only once in the analysis. results: unique patients were identified, pediatric and adult patients. eighteen percent of pediatric and % of adult patients preferred not to answer income questions or did not complete the survey. the mean income by zip code was $ k for patients who did not report income data and $ k for the entire group. for the responses, reported income data was moderately correlated with income by zip code (rho= . , p< . ). concordance between the categories was %. the correlation was stronger for pediatric patients (rho= . , p< . ) than for adults (rho= . , p= . ). re-classifying income as "low", "medium" and "high" (<$ k, $ - k, >$ ) led to a concordance of %. conclusion: survey methods that protect patient and family confidentiality result in good return rates of full ses data from patients and families. zip code derived median income shows moderate concordance with reported income. comparing the associations of the forms of income data with important cf outcomes needs to be done in a larger data set. we acknowledge the cystic fibrosis foundation, gerald o'connor, kathryn sabadosa, and participating patients and families. the patient registry provided a unique opportunity to assess changes in the epidemiology of respiratory pathogens in cf. while the incidence of p. aeruginosa remained stable, the prevalence decreased, suggestive of the impact of antibiotic eradication strategies. in contrast, the increasing incidence and prevalence of s. aureus and mrsa may reflect improved microbiological surveillance and laboratory techniques. the trends noted for b. cepacia complex may reflect successful implementation of infection control strategies. future studies are needed to better define the association between these observed trends and improving care for cf patients. vanderwyden, a. , ; drumm, m.l. , ; schluchter, m. . pediatrics, case western reserve university, cleveland, oh, usa; . epidemiology and biostatistics, case western reserve university, cleveland, oh, usa; . genetics, case western reserve university, cleveland, oh, usa in the genetic modifier study (gms) of lung disease of cystic fibrosis (cf), patients, homozygous for the ∆f mutation, were classified as having either severe or mild lung disease, as defined by the lowest or highest quartile of forced expiratory volume in one second (fev ) and a linear model was fit from these patients' longitudinal data (drumm , schluchter . while these models successfully dichotomized patients for the association study, we assessed whether a single slope model could be improved. here we have begun to compare models with one, two and three slopes, each representing different age ranges, for their use in this type of association study. as an example, interleukin- (il- ), a neutrophil chemoattractant, associates with the severe lung inflammation seen in cf patients. we have observed the tt genotype of the il- snp rs , correlated with severe pulmonary function in the gms sample of patients, relative to the aa and at genotypes of this snp. in a replicate study of patients, with cftr genotypes associated with exocrine insuffiency, longitudinal linear mixed models were used to further characterize the decline in lung function over time as associated with the il- snp, rs . three linear regression models of fev % predicted of patients were fit over age and compared with likelihood ratio tests. the three models differed with respect to the number of nodes. the first model had a single slope while the second and the third were piecewise linear models, with nodes at age , and ages and , respectively. age was chosen as the first node, as by this age most cf patients have reached puberty, an event believed to coincide with changes in pulmonary function. the second node, age , was arbitrarily chosen as a point in the third decade, as survivor effect becomes a significant issue during this period. when compared to the single slope and two slope models, the three slope model with nodes at age and age better explained the pulmonary function of this study (p< . , - loglikelihood chi-squared tests). when the explanatory variable, il- rs genotype, was added, the single slope model and the three slope model were again compared. the three slope with nodes at age and age again resulted in a better fit of fev % predicted over age as correlated with rs genotype (p< . , - loglikelihood chi-squared test). estimates of fev % predicted at ages , , , and for each rs genotype (aa, at/ta, or tt) were determined using the three slope model (p< . for all estimates). other explanatory variables, like gender and survival (p< . ), were added to further elucidate the relation between il- genotype and lung disease phenotype. we propose to use this piecewise three slope model with nodes at age and age to look at the pulmonary function of patients in the cf foundation registry data to better explain the decline in fev % predicted over time seen in cf patients. (supported by hl- and grants from the cf foundation) stephenson, a.l. purpose: the purpose of this study is to determine the annual incidence of hospitalizations for individuals with cf living in ontario and to examine predictors of hospitalization, specifically gender. methods: this is a retrospective cohort study from to , using newly linked clinical and administrative databases. the canadian cf foundation patient data registry (cpdr), contains detailed clinical information on all cf patients receiving care at one of accredited cf centres across canada. the institute for clinical evaluative sciences (ices), holds linked administrative databases containing information on all publicly reimbursed health care services delivered in ontario. canadian institute for health information (cihi) discharge abstracts database (dad), ontario health insurance plan (ohip), and homecare databases were used for this study. the cpdr was probabilistically linked (automatch software) to the ices administrative database using name, gender and date of birth. all individuals were then linked to the cihi dad, ohip, and homecare databases using unique numeric identifiers. with these databases, longitudinal records for each individual were created. cihi-dad, ohip, and homecare claims data were used to calculate the number of hospitalizations per year for pulmonary infections. males and females were analyzed separately to elucidate any gender disparities. other predictor variables include age, geographical location, number of clinic visits, socioeconomic status (income quintile) as well as clinical variables such as pulmonary function tests, nutritional status, diabetes mellitus, sputum bacteriology and pancreatic status. results: the cpdr contained data on individuals with cf followed within canada between - . of those individuals, could be found within the ices administrative databases using probabilistic linkage. of those individuals matched to the administrative databases, ( . % female) had hospitalizations. a total of , ohip claims were made during this -year period which represents any encounter between an individual with cf and a physician in ontario. multivariable analysis of hospitalization predictors is in progress. zhang, z.; lai, h. uw-madison, madison, wi, usa the cff practice guidelines recommend adjusting for genetic potential when evaluating height status in children with cf. however, calculation of adjusted height percentile is not recommended due to the complexity of method involved in such calculation. instead, a simple method to estimate a target height based on mid parental height was recommended. however, this target height includes a -cm confidence interval, which spans most of the channels on the growth chart. therefore, a child's unadjusted height may be considerably below the target height, yet remains above the lower bound of the target height range. in addition, there is a paucity of data on the associations between adjusted height to lung disease outcomes to justify whether adjustment for genetic potential is necessary. the objective of this study is to compare two methods of incorporating genetic potential in identifying short stature, namely, the cff's target method and the method developed by himes et al (pediatr ; : - ) , which applies positive adjustments to children with short parents and negative adjustments to those with tall parents. data from - cff registry were utilized. a total of children born between - who had complete height data from age - years and their parental height data were analyzed. short stature was defined by unadjusted height < th percentile, unadjusted height below the lower bound of cff's target height, or himes' adjusted height < th percentile. our results showed that adjusted height percentiles are consistently lower than unadjusted height percentiles, with an average difference of . z-score unit between ages - years and . z-score unit between ages - . proportionately more children were classified as short stature based on himes method compared to unadjusted height ( % vs. %, p = . ). in contrast, proportionately fewer children were below the lower bound of cff's target height ( %) compared to unadjusted height < th percentile ( %), p < . . among children with average parents, unadjusted and adjusted height percentiles were similar. however, among children with short parents (< th percentile), the percentage children with of short stature decreased from % with unadjusted height to % with himes' adjusted height and % with cff's target height method. among children with tall parents (> th percentile), the percentage of short stature increased from % with unadjusted height to % with himes method and % with cff's target height method. taken together, these results demonstrate that, without incorporating genetic height potential, - times more cf children who have short parents would be classified as short stature, while times fewer cf children who have tall parents would be classified as short stature. further analyses show that, compared to unadjusted height percentile, himes adjusted height percentile is more sensitive to, and has stronger association with, percent predicted fev- . in conclusion, our findings provide evidence that genetic potential should be incorporated in evaluating short statue in cf children, particularly for children with short or tall parents. the cff's target height method and himes method differ significantly in identifying short stature in cf children with short parents. cohort study of individuals in the cff patient registry from - . all individuals years of age or older and diagnosed before age were included. the new, persistent mrsa infection cohort was defined by having at least two cultures negative for mrsa over a two-year lead-in period followed by at least two mrsa positive cultures. individuals with only one mrsa culture (transient infection) were excluded. we developed multiple linear regression models using generalized estimating equations to assess the effect of mrsa on fev %predicted (%fev ) and rate of change of %fev . results: during the study period , individuals cultured mrsa. of these, , ( %) cultured mrsa only once (transient infection) and were excluded from subsequent analysis. , individuals met the criteria for new and persistent mrsa infection. , met the criteria for never having mrsa resulting in a total study cohort of , . participants were followed for a median of years. the median time to first isolation of mrsa in the persistent mrsa cohort was . years and the mean number of positive mrsa cultures per patient was . . a comparison of baseline characteristics between the persistent mrsa and never mrsa cohorts revealed the mrsa cohort to be younger ( . vs . years p< . ), equivalent in lung function (%fev . % vs . % p=ns), and with higher likelihood of methicillin sensitive staph aureus colonization ( % vs. . % p< . ). . years into the study period (the median time of acquisition for new mrsa), the mrsa cohort had a lower %fev ( . % vs . % p< . ), and averaged twice as many hospital admissions per year ( . vs . p< . ) and home iv courses per year ( . vs . p< . ). in an unadjusted analysis, the presence of mrsa was associated with a mean %fev that was . % lower than the mrsa cohort ( %ci . %- . %). however, after adjusting for sex, age, pancreatic status, p. aeruginosa, and b. cenocepacia, the presence of mrsa was associated with a mean %fev . % lower ( %ci . %- . %). most importantly, an analysis investigating the interaction between mrsa and time, after adjusting for confounders, indicated no statistically nor clinically meaningful difference in the mean rate of lung function decline between the two groups. conclusions: approximately one-third of patients who culture mrsa do so only once and do not subsequently develop persistent mrsa infection. mrsa infection occurs in a group with more severe structural lung disease as measured by fev , and frequent hospitalizations and iv antibiotics are strongly associated with mrsa acquisition. after adjusting for confounders, mrsa infection is not statistically significantly associated with a more rapid decline in %fev over time. simmonds, n.j. , ; macneill, s. ; cullinan, p. , ; hodson, m.e. , . department of cystic fibrosis, royal brompton hospital, london, united kingdom; . national heart and lung institute, imperial college, london, united kingdom introduction: disentangling the influence different factors have on long-term survival in cf is complex. there are a myriad of influences (including environmental, healthcare-related, psychological and socioeconomic) which may be important, as there is generally a poor genotype-phenotype correlation. the aim of this case-control study was to identify these factors. the cf database at the royal brompton hospital was used to identify long-term survivors. they were classified as cases and were patients who had reached years of age (without transplantation). each case was agematched with at least one control who died of cf (or a cf-related condition) or was transplanted before reaching years of age. late diagnosis patients were excluded. conditional logistic regression models were used to identify potential influences on survival. results: cases and controls were analysed, producing matched pairs. % of the patients were pancreatic insufficient. of the many factors investigated, those resulting in increased probabilities of survival included: increased body mass index (or= . , % ci . - . ), fev (or per % increase= . , ) at transfer to the adult clinic (after adjusting for age and sex) and the use of oral antibiotics before attending the adult clinic (or= . , . - . ) after adjusting for age at first attendance. factors associated with a reduced probability of survival included: cf diagnosis < years old (or= . , . - . ); initial presentation of chest symptoms or malabsorption (or= . , . - . and or= . , . - . , respectively); referral from a paediatric clinic in a deprived area (or= . , . - . ); pneumothorax before transfer to the adult clinic (or= . , . - . ) after adjusting for age at first attendance; and s. aureus or p. aeruginosa colonisation before years of age (or= . , . - . and . , . - . , respectively). factors not influencing survival included: sex, h. influenzae colonisation before years of age, development of diabetes before years of age, major haemoptysis before transfer to the adult clinic, parents' occupation, number of siblings (cf and non-cf) and school achievements. in a very carefully matched study we failed to identify major non-clinical determinants of long-term survival in early diagnosis cf. findings suggest that the majority of significant factors were directly related to optimal physical parameters, the use of oral antibiotics, avoiding bacterial colonisation and a low pneumothorax rate. adler, a. , ; bilton, d. ; haworth, c. ; gunn, e. ; shine, b. . addenbrooke's cambridge university hospitals, cambridge, united kingdom; . papworth hospital, papworth everard, united kingdom; . oxford centre for diabetes and endocrinology, oxford, united kingdom background and aims: although the prevalence of diabetes in patients with cf (cfrd) is high, few prospective studies exist, and even for genet-ic factors, cross-sectional studies may bias the magnitude of associations. this study sought to identify risk factors for cfrd from a predominantly white cohort of individuals with cf in the united kingdom. methods: , individuals aged - were identified from the uk cf database, a registry of patients coordinated by the uk cystic fibrosis trust with data from over specialists centres from england, scotland and wales, countries which provide medical care free of charge. of the patients, , had no diabetes at baseline ( - ) , and also had at least one follow-up annual visit. diabetes was defined as either a physician diagnosis of diabetes, a blood glucose of > . mmol/l two hours following an oral glucose tolerance test, or treatment with insulin or oral hypoglycemic drugs. follow-up was calculated as time from baseline to the first detection of new diabetes or censoring. risk factors included clinical, genetic (functional classes i,ii,iii vs iv,v), and anthropometric characteristics measured at baseline. survival analyses were limited to patients with complete data. cox proportional hazards modeling was used to estimate the magnitude of the association between potential risk factors and incident diabetes. one-way interactions with sex were tested. results: the median age of entry into the cohort was years and bmi was . kg/m . % were male, and % were white. patients developed diabetes during , person-years of follow-up (mean . years); the incidence was . % per year. patients who developed diabetes were more likely in univariate analyses to be older, have a high body mass index (bmi), bacterial pulmonary infections, liver and pulmonary function abnormalities, poor oxygen saturation, a history of organ transplantation, supplemental feeds, and take pancreatic enzymes or bile acids. in addition, patients with class iv,v genotypes were less likely to develop diabetes relative to patients with other genotypes, as were patients screened for cf at birth. not associated with incident diabetes was age at diagnosis of cf and ethnicity. in multivariate analyses (n= , ) age (hazard ratio . per year, % ci . - . ), female sex ( . ( % ci . - . ), % predicted forced expiratory volume in second ( . , . - . per % decrement), dose of pancreatic enzyme replacement ( . , . - . ), above vs below median dosage, use of bile acid supplements ( . , . - . ) , and genotype class i,ii, iii ( . , . - . ) relative to class iv/v. these associations were not confounded by bmi or history of transplantation. there were no significant interactions between sex and other risk factors. conclusions: the study confirms the high incidence of cfrd, and shows that patients with class iv/v genotypes are less likely to develop diabetes independent of other cf-related complications. females are disproportionately at risk for diabetes which is not explained by a higher prevalence of known risk factors nor by effect modification. cystic fibrosis children are at increased risk for hearing disorders due aminoglycoside exposure, mucopurulent upper respiratory tract infections, and increased inflammatory responses. pure tone audiometry is the standard instrument used to determine hearing loss. however, it can be expensive and time-consuming to use audiometry for routine hearing screening. hearing questionnaires have been used as a screening tool to assess possible hearing loss in otherwise healthy populations. what are the results of hearing questionnaires administered to pediatric cf patients? does cf patient age or ethnicity increase the likelihood of hearing loss as determined by a hearing questionnaire? a hearing questionnaire (english and spanish versions) was administered to pediatric cf patients over a week period at our accredited cf center. data collected included demographic information. inclusion criteria: age м years and in baseline health status. possible hearing loss was defined as at least "yes" responses (> ) to the quesions administered to the patients. fisher's exact test was used to perform the analyses. a total of cf patients were seen in the cf clinic during the study period. cf patients completed the hearing questionnaire. mean age was . ± . years (median . years). there were males and females; were classified as hispanic and were classified as caucasian. patients were older than . years (the median age) and patients were less than . years. patients who were older than age . years had a score of > and patients < age . years had scores > (p= . , ns). thus, of cf patients ( %) were classified as having possible hearing loss as per their questionnaire scores. of hispanic cf patients had hearing scores > and of caucasian patients had hearing score > (p= . , ns) . we found that a significant proportion ( %) of our cf children may require formal hearing evaluation. we speculate that hearing questionnaires may be useful to screen for hearing loss in the cf patient population. hispanic cf patients have increased morbidity and mortality risks compared to caucasian cf patients who attend our accredited cystic fibrosis center in southern california. is the increased morbidity/mortality risk due to decreased access to outpatient cf care? we performed a retrospective review of all patient visits to our cf clinic between january , through december , . data collected included demographic information (age, ethnicity, gender) , and the number of clinic visits during the study period. data was analyzed by unpaired student's t-test as well as by chi-square. during the study period, a total of cf patients ( males: females; mean age . ± . years; range months to years) were routinely followed in our cf clinic. these patients had a total of outpatient visits to the cf clinic ( . clinic visits/patient over the year study period). there were hispanic cf patients ( males: females; mean age . ± . years) and caucasian cf patients ( males: females; mean age . ± . years; p= . , ns). there was no difference in gender distribution between the group (p= . , ns). hispanic patients had a greater number of cf clinic visits ( . visits/patient) as compared to caucasian patients ( . vists/patient; p= . ) during the same period. we conclude that the increased morbidity and mortality of hispanic cf patients in california cannot be attributed to barriers to outpatient care. in fact, hispanic cf patients were seen more frequently in cf clinic compared to caucasian cf patients who attend the same clinic. we speculate that hispanic cf patients are seen more frequently in cf clinic due to increased severity of cf disease manifestations. duguépéroux, i. ; scotet, v. ; audrézet, m. , ; blayau, m. ; parent, p. ; journel, h. ; boisseau, p. ; férec, c. , . inserm u , brest, france; . dep. of genetics, brest, france; . dep. of genetics, rennes, france; . unit of medical genetics, brest, france; . unit of medical genetics, vannes, france; . dep. of genetics, nantes, france aim: the aim of this study was to describe -year experience of prenatal diagnosis (pd) for cf in brittany (western france) and to assess its impact on incidence. method: we registered, by the genetic laboratories of our region, all the pds performed in women living in brittany over the period - . we described the number of pds made for each reason (way by which the one-in-four risk was identified: previous affected child, family testing, echogenic bowel, etc). we reported the proportion of cf-affected fetuses and of consecutive terminations, and assessed the incidence modification due to pd. results: over the -year period, a total of pds were performed in couples living in brittany. most of them were done in couples already having cf child(ren) (n= , . %). extended testing in families -a practice largely proposed in brittany -led to the identification of new onein-four risk couples among the relatives of cf patients who opted for pd times over the study period ( . %). the other pds were made in couples without previous history of cf. the one-in-four risk was mainly identified following the detection of an echogenic bowel during pregnancy ultrasound examination ( pds were done directly following the positive ultrasound ( . %), whereas others were done for subsequent pregnancies ( . %)). the other pds were consecutive to the detection of an heterozygote through newborn screening (n= , . %) or for an other reasons (n= , . %). over the study period, the number of pds per couple varied between one and five, the mean being . . overall, a total of cf fetuses were identified, among whom were terminated ( . %). the inclusion in the incidence calculation of these pregnancy terminations led that to an incidence modification of . % over the study period. conclusion: this study shows that pd for cf is commonly used in brittany and highlights the impact of family testing and of routine ultrasound examination of pregnancies in that region. supported context: hispanics with cystic fibrosis (cf) in the united states experience an % increased annual risk of death from cf compared to non-hispanic patients. when adjusted for socioeconomic status this disparity persists. studies characterizing this at-risk population do not exist. objective: to characterize the center-reported us hispanic population with cystic fibrosis through a cystic fibrosis foundation (cff) patient registry analysis and to elucidate factors present within this hispanic population that may affect outcomes. design: retrospective cross sectional study of the cff patient registry. patients: all , patients in the cff patient registry were included in the analysis. there were no exclusion criteria. the hispanic population is defined as those who were entered by their respective care center as hispanic ethnicity regardless of race. main study measures: prior to analysis, study measures were selected to demographically and genetically characterize the hispanic cf population. genotype, state of residence, mean age and mean age of diagnosis were obtained in the entire population. maternal education (for patients < years of age) and insurance status data were captured as indicators of socioeconomic status. complication rates, fev percent predicted (under years of age) and absolute fev (over years old of age) were obtained as measures of clinical status. t-tests and logistic regression analyses were used to compare measures between hispanic and non-hispanic groups. odds ratios (or) and % confidence intervals are reported. results: center-reported hispanic patients with cf were identified. over % of hispanic patients resided in california, florida, texas or new york. the most common genotype was delta f homozygous, accounting for % of the population. mean age was . years +/- . years for hispanic patients and . years +/- . years for non-hispanic patients. hispanic patients were diagnosed at an earlier age ( . years vs. . years, p= . ). they were more likely to have mothers with education at less than a high school level (or . ( . , . ) ) and have government insurance (or . ( . , . ) ). complication patterns differed between the two groups; non-hispanics were more likely to have complications reported that were related to depression (or . ( . , . ) ), bone health (or . ( . , . ) ) and cf related diabetes (or . ( . , . )) compared to hispanics. hispanics however, were more likely to have complications reported from cf liver disease (or . ( . , . ) ). pulmonary function, as measured by fev percent predicted in children (p< . ) and absolute fev for adults (p= . ) were lower for hispanic patients. conclusions: differences exist between hispanics and non-hispanics with cf with respect to maternal education, insurance status, complications rates and pulmonary function. the lower reported rates of depression, bone complications and cf related diabetes may represent ascertainment bias. further study is needed into the etiology of health outcome disparities in this population, and to design interventions for this high-risk population. mastella, g.; baldo, e.; forneris, m.; furnari, m.; lucidi, v.; manunza, d.; marinelli, i.; messore, b.; neri, a.; raia, v.; salvatore, d.; buzzetti, r.; cairo group, italian cf research foundation, verona, italy with our work we reviewed the international scientific literature coming from cf registries worldwide. our aims were: to verify what has been produced in scientific literature thanks to the material derived from fc registries and to see which clinical problems have been tackled and which clinical questions were answered correctly and exhaustively. a search in medline and embase produced articles (our strategy was "cystic fibrosis"[mesh] and ("registry"[mesh]) or registr$) updated to the / / ). out of these articles have been selected by two independent assessors on the basis of their pertinence (primary studies that used data taken from a formally established registry, at least national, to test some hypothesis of research). each article has been examined with the help of a pre-defined form that in particular evaluated skills of different registry data, selected clinical characteristics of the study populations and statistical methods. more than one half of cases data came from usa-cff foundation patient registry, the remaining coming from canadian, uk, french, italian, german, and other european registries. the main focuses of the articles were included in the following topics: ) incidence/prevalence of the disease and survival ( studies); ) neonatal screening, growth and nutrition ( ); ) genotype/phenotype correlation/ different ethnical groups and twin/brothers ( ); ) complications and outcomes (abpa, diabetes, nasal polyposis, pregnancy and paternity, etc) ( ); ) microbiology ( ). our assessment scores were good/excellent for / studies for the relevance of the problem addressed; / for the usefulness of the outcomes and / for the usefulness of the implications for research from the italian registry. thirty-two articles gave a significant contribution to the analysis of the studied problem, but of them left a partial uncertainty, while left complete uncertainty. cf registries are a very important source of data to provide a powerful tool for clinical and research questions. however, further comparable studies have to be planned to assess registry data as a platform for improvement in clinical practice. vandenbranden, s.l. ; mcmullen, a. ; konstan, m. ; morgan, w. ; wagener, j. ; schechter, m. ; watts, k. , ; mccolley, s. , . children's memorial medical center, chicago, il, usa; . emory university, atlanta, ga, usa; . university of arizona, tuscon, az, usa; . case western reserve university, cleveland, oh, usa; . northwestern university feinberg school of medicine, chicago, il, usa; . university of colorado, denver, co, usa; . university of rochester, rochester, ny, usa background: although life expectancy in cf has dramatically improved over the last years, most of the improvement is due to improved survival during early childhood. adolescence and young adulthood continue to be a time of worsening pulmonary disease and mortality. study objective: data from a large longitudinal observational study, the epidemiologic study of cystic fibrosis (escf), was examined to characterize lung function decline in subjects with cf during the periods preceding and after the age of . design: escf data from individuals with cf collected during the period of - were analyzed. inclusion criteria required individuals to have a minimum of encounters in each of the . year time periods before and after the age of . the cohort was strati-fied by disease severity based on the best fev at the th year (+/- months). one hundred thirty seven subjects had severe lung disease (fev < % predicted), had moderate-severe lung disease (fev -< % predicted), had mild lung disease (fev -< % predicted), and had very mild disease (fev > % predicted) the study compared the annualized rate of fev decline during the adolescent period, defined as ages - . years, and in the young adult period defined as . - years. results: in the entire cohort, the annualized rate of decline was less in the young adult period than in the adolescent period (p< . ). the most dramatic improvement in slope of decline was seen in the severe group, and significant improvements were also noted in the moderate group (p< . ). the mild group demonstrated insignificant change; the very mild group was the only group that demonstrated a more negative annualized rate of the decline in young adulthood than in adolescence (p= . ). conclusions: these data suggest that, overall, young adults have a slower rate of decline in fev in the period after age . this "stabilizing" of lung function is most prominent in those individuals with moderate-to-severe lung disease. only those with very mild lung disease have a slightly more rapid rate of decline between the ages of and . overall there is less variation in the rate of fev decline across disease strata after the th birthday. further analysis is underway to better understand the factors leading to these findings. . department of paediatrics, university of florence, cystic fibrosis centre, florence, italy; . italian cystic fibrosis microbiology group, florence, italy; . institute of medical microbiology and hygiene, tübingen, germany mrsa is now a worldwide public health problem, due to the increasing rate of infection in several settings as well as in cf patients. mrsa was first recognized as being acquired from hospitalized patients (ha-mrsa), but the onset of mrsa infection outside the hospital setting, in communityassociated strains (ca-mrsa), has recently been described with increasing frequency. ha-mrsa are known to be responsible for infections in hospitalized patients, although highly virulent ca-mrsa are increasingly reported worldwide as the cause of severe outbreaks, replacing ha-mrsa strains in nosocomial infections. little evidence is available about the characterization (sccmec type) and epidemiology of community-acquired mrsa (ca-mrsa) or hospital-acquired mrsa (ha-mrsa), transmissibility, antibiotic susceptibility and virulence in the cf population. the present multicenter study investigated the susceptibility pattern, epidemiology, and sccmec type of mrsa strains isolated from nine italian cf centers. the susceptibility pattern was determined by the disk diffusion method and pulsed field gel electrophoresis (pfge) was performed for epidemiological purposes. the sccmec type in order to identify hospital-and community-acquired mrsa strains (ha-mrsa and ca-mrsa respectively) was determined with molecular methods, and the presence of gene encoding panton-valentine leukocidin (pvl) was tested. during the study period, mrsa strains were isolated from out of ( . %) patients attending these cf centers. of the sccmec type representing ha-mrsa, our data showed an high prevalence of sccmec i ( . %) while the prevalence of sccmec ii, (reported as the most represented among ha-mrsa) was only . %. furthermore a high prevalence ( . %) was found of sccmec iv (suggestive of ca-mrsa strains). epidemiological analysis showed that ( . %) out of analyzed mrsa strains belong to the same pfge clone shared among six centers, belonging to the sccmec type iv, suggestive of ca-mrsa isolates. twenty-four ( . %) out of these strains were sccmec type iv, indicative of ca-mrsa, as suggested by the good susceptibility rate to trimethoprim-sulfamethoxazole and rifampin. surprisingly all the isolates belonging to this epidemic clone were negative for the pvl genes. these results show that ca-mrsa is now spreading in the cf population, documenting the first epidemic of ca-mrsa in cf patients who are considered at risk for ha-mrsa acquisition due to frequent hospitalizations. these data show a peculiar picture of mrsa epidemiology indicating that further studies are required to clarify the role of ca-mrsa in global epidemiology, their pathogenicity and clinical impact on cf patients. we thank the fondazione per la ricerca sulla fibrosi cistica-onlus for its grant (ffc# ) . there are concerns regarding an increased risk of cancer in patients with cystic fibrosis (cf). this study aimed to review the occurrence of malignant disease in a large population of adult patients with cf. the case notes of patients attending the leeds adult cf unit were reviewed. demographics and data regarding a diagnosis of malignant disease were recorded. a total of eight patients ( male, female) were diagnosed with a malignant condition over the year period. the median (range) age of diagnosis of a malignant condition was . years ( - years). five patients were diagnosed with malignancy post-transplantation. within this group of patients there were two cases of lymphoproliferative disease, one case of basal cell carcinoma, one case of liver cancer and one case of small cell lung cancer related to the donor lung. the median (range) time to diagnosis post-transplantation was two years ( - years) with a median (range) age of years ( - years). three patients were diagnosed with a malignant condition without solid organ transplantation. this group consisted of one case of pancreatic carcinoma, one case of oesophageal carcinoma and one case of bowel carcinoma. the median age of diagnosis in this group of patients was years ( - years) . prior to transplantation we found all malignant diagnoses were related to the gastrointestinal tract. post-transplantation we found a wider variety of malignant diagnoses, with lymphoproliferative disease being most common. awareness of the increased risk of malignant disease is important and appropriate investigations should be undertaken particularly in patients with atypical symptoms. background: patient outcomes can be improved by implementing evidence-based guidelines for initiating therapies. in our cf center, practitioners have traditionally prescribed medications without a centralized database to screen patients for evidence-based criteria. goals: the primary goal of this project was to increase cf practitioner, family and patient awareness of evidence-based medication guidelines to facilitate discussions regarding therapies. the secondary goal of this quality improvement (qi) project was to determine if cf practitioner prescribing patterns would be altered by increasing awareness. methods: the cf steering committee at cincinnati children's hospital medical center (cchmc) identified oral azithromycin, inhaled tobramycin, and dornase alpha as target medications for this qi project. an evidence-based medicine committee was formed, including a parent advocate, to direct the project. a consensus was reached among cf practitioners for when to initiate therapy discussions. dornase alpha was recommended for cf patients ages six and older. inhaled tobramycin was recommended for cf patients ages six and older with chronic pseudomonas (defined as positive cultures in past months). oral azithromycin was recommended for cf patients ages six and older, with chronic pseudomonas, and a weight of kilograms or more. the cf database was screened to determine each patient's medication eligibilities. eligibilities were reviewed weekly at our cf chart conference. medication specific family and patient handouts were developed, reviewed by the parent advocate, and given to eligible families and patients on arrival to clinic. data was collected to document the number of discussions facilitated at clinic visits, the decisions regarding medications, and the number of new treatment prescriptions that were facilitated. after seven weeks of the initiative, statistical analysis was conducted using mcnemar's test for differences. a chi-square test with a two sided alpha of p < . was used to determine significance. results: of the cf patients in our center were eligible for pulmonary medications using our evidence-based criteria. there were individual prescribing opportunities in these patients (taking each medication for each patient as a unique prescribing opportunity). at the start of the project, . % ( / ) of the prescribing opportunities were fulfilled. % ( / ) of patients were prescribed all of their recommended medications. during the first seven weeks of the project, cf practitioners discussed initiating new pulmonary medications with cf families and patients. the proportion of prescribing opportunities fulfilled increased from . % ( / ) to . % ( / ) (p value < . ; % ci . %- . %). the proportion of patients prescribed all of their recommended medications increased from % ( / ) to . % ( / ) (p value < . ; % ci . %- . %). conclusions: increasing awareness of evidence-based pulmonary medication recommendations with cf practitioners, families and patients facilitates therapy discussions, increases the proportion of therapies prescribed and increases the proportion of patients on all recommended therapies. purpose: our purpose was to optimize lung function (fev ) by consistently and aggressively diagnosing and treating pulmonary exacerbations (pex) in all cf patients at our center. it was important to work on this because our families wanted standardized care and we felt our patients' fev 's were suboptimal. methods: our core llc team included two parents of cf patients and one adult patient. we met weekly, received coaching every other week, and learned and applied quality improvement techniques. physicians began monthly meetings, and monthly meetings of the entire cf team continued. the fab met every other month. we identified our specific aims, and approached them systematically. the providers, starting with criteria used by several authors, agreed upon the definition of pex and created a pulmonary exacerbation score sheet (pexss). we selected a score of as the threshold for defining a pex. after using the pexss for three months, all providers reviewed the individual pexsss and validated our original choice of . run charts were produced and reviewed periodically to display each provider's percent of pexsss used. when the use of the pexss was not standardized after a year, it was reprinted on bright yellow paper to make it stand out. to educate the families and patients about the early symptoms of pex, a refrigerator magnet was designed and distributed that included all pex criteria. results: we standardized the use of our pexss by all providers on all patients seen in cf clinic with ongoing measurement of its use and regular feedback. many patients and families gained greater knowledge about what a pex was, and the importance of early recognition and treatment. the cf nurses note that ) many patients call with milder pex symptoms than they did before, ) providers treat pex earlier, ) many patients call with their pex score as well as their symptoms. we hospitalized more patients for pex after this project began, with an average of patients/year in the years prior, and in . the median fev % predicted of our - conclusions: participating in the llc changed the culture and functioning of our cf team. limitations to our study include: ) fev change may not have been due solely to this project, ) the groups who's fev 's were averaged over the various years are different. we will continue to optimize and standardize ) prevention of pex, ) inpatient care, ) care of pex in cf providers' private offices, and ) follow up of patients with pex. patient adherence to airway clearance techniques (act) in the treatment of cystic fibrosis is known to be sub-optimal resulting in deterioration of lung function. the global aim of our project was to improve median fev . the specific aim was to improve adherence to act. we believed that these goals could be acheived by implementing a program which included re-education of airway clearance techniques (react) for our cystic fibrosis patients. methods: the initial phase of this project began with the administration of an anonymous survey to patients/families. this survey was designed to assess act practices, knowledge of the rationale for performing act and barriers that prevent patients/families from adhereing to act. the next step included an in-clinic questionnaire and patient/family demonstration of current aerosol therapy and act. based on individual results patients were identified as: adherent with correct technique, adherent with incorrect technique or non-adherent. we defined adherent as correct performance of act one to two times daily as prescribed. then all patients entered the react program which included a standardized tutorial on proper act and correction of techniques if necessary. in the non-adherent group barriers to performing act were discussed and problem solving techniques were used to overcome barriers. the patients in the non-adherent group were re-evaluated in clinic monthly while the adherent patients returned on an every two month schedule. results: analysis of our initial survey revealed that while the majority of patients/families reported performing act daily, the duration of treatments was less then medically prescribed. many patients/families reported barriers which decreased adherence to therapy. to date % ( / ) of our patients have completed the in-clinic questionnaire and entered the react program. the results of these evaluations and patient demonstrations revealed: % ( / ) were adherent with correct technique, % ( / ) were adherent with incorrect technique and % ( / ) were non-adherent. in the six months since the implementation of the react program, patients/families are self-reporting an increased adherence to act and the median fev for our center has increased form . % ( cff registry data, ages - years) to . % (cff registry, first quarter, , ages - years). conclusion: while adherence to act in our center was poor, we were able to improve adherence and ultimately improve the median fev by implementing a program of re-education for act (react). we believe re-assessment of adherence to therapy and reviewing correct technique is necessary at every clinic visit. continuous quality improvement (cqi) techniques have recently been employed in medicine to improve quality of care. although there is evidence that cqi improves efficiency in hospitals, little is known about effects of cqi on improving patient outcomes. we have previously reported creation of a unique nutritional risk pathway (nrp) to care for cystic fibrosis (cf) patients who are at nutritional risk. the goal of this study is to assess perceived impact and objective clinical efficiency of our nrp. patient data was recorded from all children attending the cf clinic over an -month observation period (between sep and mar ). bmi percentiles were assessed and nutritional risk zones -green: acceptable (bmi > %ile), yellow: at risk (bmi - %ile) or red: at urgent risk (bmi < %ile) -assigned at each visit. the visit intervals were every to weeks based on severity of nutritional risk. patients that remained in the red zone for an average of to months with no improvement were considered for gastrostomy tube (gt) placement. the cf dietitian updated the data weekly and e-mailed quarterly to cf physicians for review of their patients' status. patient/family perceptions and understanding of the nrp was assessed by questionnaire. of the children in the study, ( %) were identified to be at nutritional risk and were enrolled into the nrp: in red and in yellow zones; ( %) male, ( %) female; ( %) age < yrs, ( %) age ≥ yrs. over the -month observation period, ( %) showed improvement ( moved from red to yellow, from red to green and from yellow to green zones). thirteen ( %) females improved, whereas ( %) males improved. in the under yrs age group, ( %) improved compared to ( %) in the ≥ yrs age group. as a result of participation in the nrp, ( %) children had gt placed: six of the showed improvement with four moving from the red to green zone. from the survey responders, % stated they understood the meaning of the cf nrp. all responders were extremely to somewhat motivated to focus on their child's nutrition when asked to return for growth monitoring or follow-up visits. having specific goals for weight gain, calorie requirements and bmi were considered extremely helpful by % of families. when gt placement for their child was recommended, % felt they lacked all the necessary information to make a decision. our new cf nutrition education booklet was not received by % of families. some of the physicians who received the quarterly nutritional patient data provided positive feedback and found this information beneficial for patient care. nutritional cqi in our cf center utilizing a specific nrp and monitoring of nutritional risk status resulted in improved patient outcomes. overall perceptions of our nrp were positive from both patients and cf physicians. these results suggest that this cqi strategy improved clinical outcomes in our patient population. patients with cf require frequent healthcare visits to optimize growth, initiate early interventions and delay progression of lung disease. the cff recommends evaluation at a cf center at least quarterly. as part of a llciv quality improvement (qi) initiative, our cf team set a goal to increase the percent of cf patients attending clinic or more times a year to % or greater by developing strategies to monitor and improve adherence rates. methods: we reviewed cf patients who attended clinic times or less in to determine patterns of non-adherence in regards to age, gender, distance from center, season, physician or insurer. a patient survey was used to assess clinic attendance barriers from a patient/family perspective. a brainstorming session identified other barriers. a fishbone diagram was drafted into barrier categories: external, internal, communication, and patient/family perceptions. after reviewing all barriers, we concluded the most effective improvements could be made to internal clinic barriers. clinic processes were then assessed including making of appointments, reminder letters/calls, a time cycle analysis, and number of cf appointments available per patient per physician. our family advisory board participated by focusing on the importance of or more clinic visits in their newsletter and by assignment of a member to the llciv team. we discovered a lack of a standardized process to follow-up (fu) patients who "did not keep appointments" (dnka). a spreadsheet was created to monitor physician dnka rates. a primary fu strategy was devised to identify patients who dnka through daily auto-emails to the cf office assistant and utilization of a rescheduling decision tree for reappointment of these patients by our appointment center. two secondary fu strategies were developed. the first involves the clinical coordinator printing a monthly report off port cf entitled "patients due a visit" then emailing this list to the cf team to contact and reappoint. the second involves the cf social worker tracking patients seen per quarter on a spreadsheet and emailing the spreadsheet quarterly to the cf team as well as posting on our datawall. results: in , and , %, %, and % of our patients attended clinic or more times, respectively. in in , and , %, %, and % of our patients were at nutritional risk, respectively. in and , mean fev % predicted was . % and . %, respectively. conclusion: the number of cf patients attending clinic quarterly at our center increased by implementing processes to track dnka patients and reappoint them to clinic promptly. however, some of the early improvement in clinic attendance was partially due to an increased awareness of our qi efforts by our clinic staff, cf team and patients/families. we speculate that improvements in nutritional status and lung function are at least partially related to more frequent clinic attendance by our patients. continued monitoring of the number of dnka patients and patients who attend clinic quarterly is required to sustain these gains in improved patient outcomes. data when we first measured patient/family satisfaction in , parents and children were given questionnaires to measure their satisfaction with services provided at the clinic. at that time, responses in our survey were very positive. with regards to our new model we received very positive feedback, encouraging us to continue with the model. parents and children liked the elimination of duplication in questions and they also like having the whole team involved in the meeting and problem-solving. final results for our second satisfaction questionnaire will not be available until june of this year as the questionnaires are being given at clinics over a month period this spring. the children complete a questionnaire with the help of their parents if needed and the parents also complete a survey. results to date are very positive for both the parents and the children. of the children who have completed the survey to date, all stated they would like to continue to meet with the group as a whole as opposed to meeting individually with team members. of the parents surveyed to date, all are either very satisfied or satisfied with the group format. conclusion: we have not yet completed the survey but results to date clearly show that both the patients and their families are happy with the round table model. results will be compiled early this summer and would be ready for the poster and/or presentation in the fall. the cff clinical care guidelines recommend routine clinic visits for assessments, interventions, monitoring, education and counseling every months or more often as indicated. adherence to these guidelines is important in ensuring better clinical outcomes. in reviewing our cf center data from the cff registry report, . % of pediatric patients ( - yrs.) and . % of adults ( yrs. and older) adhered to the guidelines. national goals were not provided then; instead data was given for the top ten cf centers ( . % and . % for pediatric and adult patients respectively) as well as the national rates ( . % and . % for pediatric and adult patients respectively). our cf care center acknowledged the need to improve adherence to these guidelines and at the beginning of the year , embarked on a quality improvement project to address this issue. following the pdsa (plan-do-study-act) steps, we agreed on the objective of increasing the percentage of pediatric and adult patients adhering to the guidelines by at least % and at the same time, to exceed the national average in year or by the end of the year . the physicians and social worker obtained feedback from patients and/or families during a clinic visit regarding barriers in complying with scheduled clinic visits. suggestions were elicited to overcome these barriers. the team members then identified barriers in meeting the guidelines and implemented measures to improve compliance with clinical care guidelines. among these measures were sharing the information about clinical care guidelines and importance of adherence through our cf newsletter and at every clinic visit, reminder calls to patients or caregivers at least days prior to the visit, appointments for the next visit given prior to discharge from the clinic, and same day calls to patients who failed to keep their appointment for rescheduling. our social worker identified patients with difficulties or problems in consistently keeping appointments and helped address these problems. progress made in this endeavor was shared with parents and caregivers during the "parents' night" held in the fall of . indeed, with consistent implementation of these measures, we have seen improvement in the percentage of patients adhering to guidelines. in our cf care center data, . % of pediatric patients and . % of adult patients adhered to recommended clinical care guidelines, approximating and in fact for the adults, exceeding, our target of % increase in the percentage ( % and % increase respectively for pediatric and adult patients). these data were better than the national average for ( . % and . % for pediatric and adult patients respectively) but for pediatric patients, still % below the national goal of %. adults approximated the national goal of %. we are committed to continually engage in the process of quality improvement in further improving adherence to clinical care guidelines and to hold on to the gains. weight z-scores and height z-scores were monitored prospectively for all infants, children, and adolescents at a pediatric outpatient cf clinic during an ongoing, multidisciplinary quality improvement (qi) initiative. all cf team members participated in this qi project which emphasized the importance of good nutrition and adequate growth for optimal lung health. specific strategies for improvement included education to families at each visit with a written nutrition action plan, increased emphasis on liquid supplements and enteral feeds as needed, and a consist message from all cf clinic staff in encouraging attention to nutrition. the study objective was to determine if multidisciplinary qi interventions to improve nutritional status had any effect on weight z-scores and/or height z-scores over a -year period. the null hypothesis was that z-scores for weight and height would either not improve or worsen. inclusion criterion for this study was attendance at cf oupatient clinic during the first months of the qi initiative (time ) with a subsequent clinic visit years later (time ). patients not attending clinic at both time and time were excluded. a cohort of patients ( male, female) met the inclusion criterion. the mean time to time interval was . ± . years (range . to . years) with mean patient age at time of . ± . years (range . to . years). pancreatic enzyme replacement therapy was used for ( . %) of the cohort. paired sample t-tests indicated significant improvements for weight z-score (p <. , t ( ) = . ) and height z-score (p <. , t ( ) = . ) after the -year intervention. at time , children ( . %) were underweight or less than th percentile while children ( . %) were normal-weight, at or more than th percentile for age. mean differences in both weight and height z-scores in the initially underweight patients were greater than those for the normal-weight patients over the year interval. no significant differences were found for the initially normal weight-for-age children between time and time for weight z-score ( p = . ) or height z-score (p =. ). children who were not underweight at time grew normally, without acceleration over the yr intervention. therefore, we conclude that a longterm multidisciplinary qi project to enhance nutritional status resulted in significantly improved weight z-scores and height z-scores for those individuals who were initially underweight for age. the most common cause of morbidity and mortality for patients with cystic fibrosis (cf) is pulmonary exacerbations. these exacerbations lead to hospital admissions and treatment with intravenous (iv) antibiotics. all cf patients at our facility are admitted to a teaching service which includes house officers and students. standardized order forms are used to improve accuracy and timeliness of medications and therapies. the efficiency of this process was brought into question in / , when several parents complained about a delay in the receipt of first dose iv antibiotics after hospital admission. the objectives of this study were to determine what were the actual delivery times of the iv antibiotics to the patients (both retrospectively and prospectively), and areas where improvements could be made. our predetermined target time was < hours. two analyses were performed in order to answer the objectives. the first analysis was done in a retrospective fashion. this analysis included cf patients admitted from / / - / / . a total of patients were included. total median time from admission to receipt of first dose of iv antibiotics was analyzed. a second collection of blinded prospective data was performed between / / - / / . only the pulmonologist, pharmacist collecting data, and pharmacy clinical manager were aware of the data collection. a total of patients were included in the prospective project. each part of the process model were recorded and analyzed so that areas of improvement could be realized. the median time from hospital admission to first dose of antibiotics was hours (range - hours) (retrospective cohort). the prospective cohort median time from hospital admission to first dose of antibiotics was hours (range min- hrs). the median time from admission to order entry by pharmacy: hrs, min (range min- hrs, min). the median time from the medication order being written by medical practitioner to order entry by pharmacy: minutes (range min- hrs, min). the median turn-around time by the hospital pharmacy of order entry until reaching the nursing unit: min (range min- min). the median time required by the nursing staff to administer the antibiotic: hrs, minutes (range min- hrs). this project was initiated in response to parental concerns. from the results of the retrospective and prospective analyses, it was determined that a delay is occurring in the receipt of iv antibiotics, which translates to hours in the hospital without therapy. this is both inconvenient and uncomfortable to the family, and wasteful of medical resources. the findings of this project were presented to the pharmacy and therapeutic committee of the hospital, to the nursing directors, and to the parents of cystic fibrosis patients. the delay is greater than expected before this project was initiated. as a result of these findings a "fast track" medication order set was developed to expedite initiation of inpatient therapy. four key areas included in this order set are sputum, iv access, diet, and iv antibiotics. we speculate that time to first drug delivery will decrease and patient satisfaction with improve. the pediatric intermountain cystic fibrosis center (imcfc) provides multidisciplinary cystic fibrosis (cf) care to pediatric patients from utah and parts of idaho, wyoming, and nevada. historically the imcfc has embraced early intervention. as new therapies have been added to the cf armamentarium it has become necessary to have a method of keeping track of which patients are candidates for various therapies and also which medications have been prescribed, utilized or even should be discontinued. in order to address this quality issue, the imcfc decided to develop and implement the use of a medication tracker (mt). the imcfc decided to focus on key therapies which were felt to be at risk for variability in prescriptive practice. the five therapies included were: pulmozyme<®>, tobi<™>, hypertonic saline(hs), azithromycin and asthma medications (inhaled corticosteroids and/or leukotriene receptor antagonists). ibuprofen was intially included and later removed from the mt. prior to implementing the mt, the imcfc met to review literature, medication trackers from other centers, and develop consensus among team members. six versions of the mt have been developed between / / - / / . each mt has been tested in a pdsa cycle and revised. since initating the mt, patients have been seen at least once. there have been mt encounters. the mt is used only after the first visit to the imcfc and reflects changes to established cf care. there have been a total of changes in prescribed therapies in different patients( % of patients seen). a minority of patients were receiving therapies that did not meet our pre-determined consensus for prescription. the most common therapies in this category were tobi™ and azithromycin. primary reasons cited for prescribing were: chronic suppressive antibiotic use, pseudomonas positive and < years old, and significant changes on chest imaging. reasons patients were not prescribed clinically indicated therapies were: patient refusal, participation in clinical trials, cost, and lack of compliance with other therapies. changes in asthma therapy included the discontinuation of medication in encounters and the initiation of therapy in . the use of a specific cf patient mt allows consistent practice in selection of therapies. it can be used by all team members and helps to identify discrepancies in therapy. assuring all patients receive information and are considered for new therapies is increasingly important as our treatment options expand. the mt also highlights the need to consider discontinuing therapies. we speculate the mt will become an increasingly valuable tool over time and improve patient care. rationale: recent reports document increasing prevalence of antimicrobial resistance across a range of pathogens in patients with cf. the increase in multidrug resistance of these organisms complicates the therapeutic management of these patients. objective: to describe patterns of antibiotic use among physicians treating cf patients. methods: for the original purpose of evaluating site characteristics that act as effect modifiers on the relative efficacy or cost of novel therapies, we administered a survey to acquire information on practice patterns and characteristics of physicians participating in a clinical study of an investigational drug for patients with cystic fibrosis. chi-square and spearman rank test were used to evaluate associations between physician characteristics and patterns of reported antibiotic use. results: fifty-nine physicians, representing study sites, completed the survey. ninety percent reported a medical specialty of pulmonology and % reported practicing at a teaching hospital. on average, respondents reported that about half of their practice consisted of patients with mild cf (defined by fev ≥ % of predicted normal.). forty-two percent of respondents reported prescribing oral antibiotics and % of respondents reported prescribing inhaled antibiotics for maintenance therapy for at least % of their mild cf patients. eight-five percent and % of respondents reported prescribing iv antibiotics for pulmonary exacerbation and pulmonary 'clean out', respectively, with about a third of these cases being prescribed for outpatient iv use. physicians that prescribed iv antibiotics for pulmonary clean out were more likely to pre-scribe oral (p= . ) and inhaled antibiotics (p=. ) for maintenance therapy than physicians that did not prescribe iv antibiotics for pulmonary clean out. conclusions: antibiotic use for maintenance therapy and iv antibiotic use for pulmonary exacerbation and pulmonary clean out acted as 'complements' rather than 'substitutes' as there was a group of physicians who reported less use of antibiotics. our findings warrant further research as well as additional exploratory analyses with a larger and broader sample to examine associations between physician characteristics and patterns of antibiotic use. understanding the relationship between physician characteristics and antibiotic use has the potential to influence the approach to management of cf patients in an environment of increasing antimicrobial resistance. introduction: hypertonic saline (hs) has been shown to increase mucus clearance and improve lung function in cf, and is now increasingly being used as part of routine therapy. one of the goals of our cf center quality improvement (qi) initiative is to increase use of hs among all eligible patients. objectives: to assess adherence to treatment with hs, parental opinions on treatment, perception of side effects, and the effect of initiating hs on the use of other nebulized medications in pediatric cf patients started on hs therapy during . methods: patients under years of age were identified as initiating hs therapy during . a telephone survey of their parents using a -item multiple-option questionnaire was administered in april as part of our cf center qi initiative. results: parents ( %) completed the survey: ( %) patients were still using hs. of those still reporting use of hs, ( %) were using it twice a day; ( %) once a day; and less often than daily. among the patients who discontinued hs, ( %) stopped following recommendations from their pulmonologist; ( %) stopped due to side effects; ( %) felt hs took too long to administer; and ( %) felt hs solution was too difficult to mix. the most common side effect reported was cough in patients ( %); ( %) reported no side effects. the majority of patients ( %) spent - minutes per day on hs therapy. thirteen ( %) patients discontinued another nebulized medication when they initiated hs; ( %) of those stopped pulmozyme. reasons for stopping pulmozyme included: time to nebulize both medications was too long ( %), perception that hs was working better for their symptoms ( %); and doctor's instructions ( %). overall, ( %) parents felt hs improved their child's symptoms; ( %) saw no difference; and ( %) believed hs made symptoms worse. there was a significant difference in the proportion of patients that reported improvement of their symptoms in the group using hs twice a day ( / , %) when compared to those using it once a day ( / , %) (p= . ). discussion: the majority of patients continued to report the use of hs therapy several months after our initial intervention, with the most parents reporting improvement in their child's symptoms. physician recommendation was the most common reason cited for discontinuation of hs therapy. further study of physician opinions on hs therapy, particularly the timing of initiation and discontinuation, is warranted. one-half of patients reported using hs only once a day; however those reporting twice daily use were more likely to report subjective improvement of symptoms. since treatment complexity in cf increasing, determining the effectiveness of once daily hs therapy, either alone, in place of, or in combination with other therapies such as pulmozyme is essential. long-term follow up of these hs-initiated patients will focus on effects on exacerbations, pulmonary function, and hospitalizations. the uab/children's hospital (chs) cf center participated in learning and leadership collaborative ii. as part of the qi journey, the chs cf qi team thoroughly evaluated the current system of care in an effort to identify areas of needed improvement. one area assessed was clinic attendance. it was discovered that % of patients failed to attend clinic appointments every week. according to cff care guidelines, patients with cf should be seen a minimum of times each year at the cf center. the cff has also found that those centers that see their patients more frequently have improved outcomes for fev and nutritional status. aim to decrease the number of missed appointments at the chs cf clinic. the chs cf center administered a qi survey to identify the reasons patients and families were missing appointments. this survey was a item questionnaire that evaluated: reasons for missed appointments, if the families rescheduled missed appointments, difficulties with rescheduling, the need for reminder calls, distance traveled to the cf center, and insurance status. results completed surveys were collected. % of the families reported medicaid as their insurance provider. % of families live more than miles away from the cf center. % of the families confirmed that they had missed an appointment in cf clinic over the last months. the reasons for the missed appointments were widely variable; however, . % of those who missed appointments reported that they did not have access to transportation to get to the appointment. overall, families did not report difficulties in rescheduling appointments. % of those that missed appointments identified medicaid as their insurance which can be correlated with lower income families and . % of those that missed lived greater than miles away from the cf center. % of families reported that a reminder call would be helpful for them. interventions after evaluation of the survey data, the center quickly initiated reminder calls for cf clinics. a student employed by the cf center made these telephone calls to the patients scheduled for clinic every week. the majority of the time the student caller left a message for the family. with the implementation of this simple intervention, missed appointments have decreased from % to % which is a % improvement rate. reminder calls are now a routine part of the cf center's system of care. other ongoing interventions include increased involvement of primary care doctors for patients lost to follow up for more than months and a system for quickly rescheduling patients. next steps in addition to reminder calls, the cf team will now determine where patients who routinely miss appointments live. if there are pockets of patients in common areas of the state, the team will attempt to maximize services for those patients such as linking them with community transportation resources, community health advocates, or providing satellite clinics. this will be accomplished through geomapping of the alabama cf population based on zip code. we designed a scoring system to uniformly identify patients experiencing a pulmonary exacerbation. the elements of this pul-monary exacerbation score (pes) have been previously described. at the time this project began the median fev % predicted of the cf patients at our center - years old was below the national average ( cf registry data). our hypothesis was that greater uniformity of identification of pulmonary exacerbations, would improve pulmonary function in the pediatric age group at our center. this abstract describes continued improvement in the pulmonary function of this age group at our center now that the pes has become standardized in our clinical practice. methods: beginning in october , a pes was calculated for all patients presenting to our center age - years of age. any patient with a pes of > was defined as having a pulmonary exacerbation, and treatment with antibiotics was recommended. the patient's cf physician dictated the ultimate decision for treatment and specific course of treatment. median fev of all patients age - years was calculated quarterly to determine the effect of the pes use on pulmonary function. in october the pes was incorporated into our cf clinic medical record and its use was standardized. the use of the pes, the adherence to the recommendation for treatment, and quarterly fev of the population has continued to be monitored. results: from / to / (the duration of the original qi project), patient visits occurred, with a pes calculated on (utilization of . %). patients were treated for a pulmonary exacerbation of the patients with a pes of > (adherence of . %). . % of exacerbations were treated with oral and/or inhaled antibiotics, and . % were treated with intravenous antibiotics. since standardization of the pes in / , visits have occured. use of the score has decreased slightly ( . % utilization), however adherence to the score has increased ( . % of pes > have been treated). use of oral vs. iv antibiotics has been similar ( . % oral vs. . % iv). the median fev of our patient population has improved from an average of . % predicted during the months before implementing the pes to an average of . % predicted during the ensuing months of the original qi project (a . % improvement). since standardization of the pes in / , the average median fev of the population has continued to increase to . % predicted (an . % increase from the baseline period). this improvement in median fev is reflected in our cf registry data. summary: implementation of a pulmonary exacerbation score, designed to encourage uniform identification of pulmonary exacerbations in patients with cf, is associated with an improvement in median fev in children - years of age. standardization of the pes has resulted in continued improvement in pulmonary function of this population at our cf center. this work has been supported in part by the cff and akron children's hospital. our cf family council parent and patient advisory group has been involved in the development and implementation of this project. utilizing data from the cff patient registry, we determined that our center has had nutritional outcomes consistently below the national average for pediatric and near the average for our adult patients. as a result, we developed the global aim to improve and maintain optimal growth and nutrition in all patients at our cf center. our specific aims included: )to record growth parameters at all outpatient visits; )to identify patients at nutrition risk, categorizing them based on anthropometric data; ) to develop and implement a specific nutrition plan based on nutritional category; and ) to educate staff, patients,and families on the benefits of normal growth and nutrition. we surveyed our patients to determine their overall attitudes toward nutrition and nutritional care received at our center. we discovered that many patients and families did not feel that nutrition was addressed at every cf visit nor that they had a nutritional plan at each encounter. this led to the development of an intake form/home-going sheet for our patients to complete that included data elements necessary for assessment of nutrition and that clearly outlined a nutrition action plan. a standardized nutritional assessment score (nas) was devised that incorporated weight, height/length, bmi and weight for length percentiles as well as weight loss, failure to gain or maintain, and failure to remain in the expected growth channel. the nas was developed after examining the medical literature, reviewing work done by other qi teams, and acquiring input from our pediatric gastroenterologist and endocrinologist. we then developed nutritional algorithms to address nutritional intake, malabsorption, evaluation for cfrd, and short stature. these four algorithms were used to develop a nutrition action plan for each individual. beginning in march , a nutritional category (optimal/acceptable, concerning, at risk or failure) was assigned to each patient at each visit based on their nas. an individualized nutrition action plan was developed with each patient. at the time of project implementation, patients age - at our center had a median bmi %ile of . % with . % of our patients with a bmi < th%ile. our patients > years had a median bmi of . with . % having a bmi< th%ile. after one month of implementation of the nas, % of our patients had been categorized with % of our patients having individual nutrition action plan developed. to track our progress, we will monitor median bmi, % of patients with bmi < %ile, and % of our patients in each nutritional category quarterly using portcf. our goal is to have all our patients assessed and a nutrition action plan implemented by the end of . we have developed a nutritional assessment score and nutrition treatment algorithms for pediatric and adult patients with cf as part of a qi initiative to improve nutritional status of patients at our center. the project has been supported, in part, by akron children's hospital. we are indebted to lori lundquist, a parent of two of our cf patients, who has been an integral part of our nutriton qi team. in germany there are about , cf patients who are usually treated in special centres by a team of trained and experienced health care professionals. the result of this structured approach to patient care, including frequent clinical assessments, monitoring, and aggressive interventions is an improved mean survival and a higher quality of life of pediatric and adult cf patients. however, a recent survey showed that german reimbursement schemes cover only about % of resources used within these centres. objective to assess and evaluate direct costs of outpatient treatment of cf patients in germany. a micro-costing approach was used to record resource use data directly within representative cf centres. results of the evaluation may be used to initiate and support discussions between health care providers and insurances about adequate reimbursement schemes in germany. outpatient care was evaluated in seven different centres for pediatric and adult cf patients. patient reported outcomes, clinical patient data, resource utilisation, and physician related time consumption for treatment was recorded for every patient during one representative month in . cost data for staff, materials, medical equipment, rooms, etc. were assessed within the respective centres. data for cf patients were collected. about half of them were children and adolescents, and half of them were adults. a comparison of the resource uses to the actual remuneration of these services indicates that only about % of the costs are covered by the reimbursement system. correlation analysis identified significant cost drivers like the age of the patient, comorbidities like pancreatic insufficiency and hepatobiliary complications, lung function (% fev ), and the presence of certain pathogens in the lungs. as the actual reimbursement covers only about % of the resource usage costs in germany, the existence of the cf centres and sufficient treatment for cf patients is uncertain in the future. in order to ensure the existence of the centres it would be necessary to agree to a cost-covering reimbursement at minimum. this may be based on a lump-sum payment that could be differentiated for pediatric and adult centres or according to comorbidities or clinical parameters. the data calculated in this study could be used to trigger and support discussions between health care providers and insurances about a new cost-covering reimbursement system for the out-patient treatment of cf patients in germany. the impact of the new us cystic fibrosis foundation (cff) nutrition practice guidelines, i.e., discontinuing the use of percentage of ideal body weight (%ibw) to define "nutritional failure" and setting body mass index (bmi) below the th percentile to define "nutritional risk", on evaluating nutritional care practices is unclear. methods: data from children reported to the cff patient registry were analyzed to compare the rates of malnutrition among cf centers. results: nationally, eliminating %ibw < % as a criterion for underweight resulted in a . % reduction (from . % to . %) in "nutritional failure" rate. misclassification of "nutritional failure" by %ibw < % ranged . - . % among centers and was greater for centers having a larger proportion of tall patients. one-third of centers switched to a different tertile ranking, after correcting for misclassification by %ibw. use of bmi < th percentile led to the classification of . % of patients as "nutritional risk". more than half of the centers had different tertile rankings on "nutritional risk" compared to "nutritional failure". a total of . % ( - . % among centers) of patients who had height < th percentile but bmi ≥ percentile were not considered at nutritional risk. the cystic fibrosis questionnaire-revised (cfqr) is a disease specific quality of life measure that is currently undergoing clinical validation and may prove to be a useful adjunct to provider assessments. we proposed the routine use of the cfqr in a busy adult cystic fibrosis (cf) clinic would assist in identifying patients in need of limited clinic resources. this performance improvement project focused on new and infrequently-seen patients (i.e. fewer than three outpatient clinic visits/year) to determine the frequency of patients with domain scores that fall more than one standard deviation below our clinic mean. methods: the cfqr is routinely self-administered to all adult cf patients in clinic at least once every year. these assessments occur after vital signs are obtained and prior to any other clinical assessments. patients were deemed to be at baseline if there were no changes made to their pharmacologic or chest physiotherapy regimens. the mean and standard deviation of each domain of baseline cfqr assessments were determined. the frequency of rarely seen and new patients with domain scores less than one standard deviation below the mean was determined. results ( ). of these baseline assessments, forty five were obtained from patients who were rarely seen or new to the clinic. . % (n= ) of these patients had one or more domain scores falling more than one standard deviation below the mean. . % (n= ) of these patients had two or more domain scores below these cutoffs. % (n= ) of the rarely evaluated patients had domain composite scores (i.e. the sum of the individual domains) that fell below the standard deviation cutoff. the most common outlying domains in these infrequently seen or new patients were body ( ), weight ( ), physical ( ), health perceptions ( ) and the composite domain ( ). conclusions: the cfqr is easy to administer and score during routine adult cf clinical visits. as many as % of our infrequently evaluated patients had multiple scores that were more than one standard deviation below our clinic mean. we conclude that the cfqr is a useful adjunctive measure to provider assessments and can help focus limited personnel resources. aminoglycoside antibiotics are known to be toxic to the inner ear. however, they continue to have a leading role in the treatment of certain infections and in the treatment of pulmonary exacerbations in patients having cystic fibrosis (cf). while there is ample evidence in the literature of ototoxicity, and there are established protocols for monitoring the effects of toxic agents on hearing, less is known about the prevalence of vestibular toxicity among patients who are exposed, and there are no commonly accepted protocols for monitoring vestibular system function. oscillopsia and unsteadiness when standing and walking are the two most commonly reported and disturbing symptoms associated with bilateral loss of vestibular system function. oscillopsia is the perception that viewed stationary objects or surroundings move coincident with head movement. when it is severe, oscillopsia can prevent an individual from having clear vision with even the slightest head movement. the unsteadiness that accompanies vestibular loss can range from mild to disabling. because of the referral of a number of patients to the vestibular testing center (vtc) at the university of michigan in whom severe bilateral vestibular loss was evident secondary to apparent aminoglycoside toxicity and our concern about quality of life issues, we initiated a quality improvement clinical protocol with our cf patients. vestibular system function and hearing are evaluated at the time of admission for pulmonary exacerbations and coincident with the three month follow-up visit with the pulmonologist. our goal is to understand the incidence of ototoxicity in this patient population, and to determine how best to measure incremental changes over time. the ultimate desired outcome is to investigate the efficacy of protective agents for limiting the toxic impact of these drugs on hearing and vestibular function. to date, we have completed vestibular testing on patients with cf ranging in age from - years, some of whom were referred prior to the initiation of this monitoring program. of the sample, individuals have completely normal vestibular test results, and of the had no prior aminoglycoside exposure. of the remaining patients, have bilateral vestibular loss ranging from mild to severe, two have evidence of a unilateral vestibular loss, and each of the others has non-lateralizing evidence of vestibular involvement. we have also documented change in the three individuals we have seen for repeat testing. specifically, repeat testing has shown incremental decline in vestibular function with repeated exposure to aminoglycosides. interestingly, only individuals in the group have documented hearing loss, and although most report that they do not and have never had any problems with dizziness or balance, many patients have evidence of oscillopsia or abnormal postural control test results. it is clear from our limited data that it is important to monitor vestibular system function whenever potentially toxic agents are used. while monitoring hearing is also warranted, our data suggest that a monitoring program that includes only hearing is insufficient. background: the correlation between bmi, lung function, and longterm outcomes in cystic fibrosis patients has been well documented. based on this data the cf foundation (cff) has established adult patient care guidelines for bmi of or greater for women and or greater for men. in our cf center implementation of nutrition therapies in cf adult patients has been difficult due to lack of acceptance of proposed interventions. due to the importance of optimal nutrition to attain the cff recommendation for bmi, university of cincinnati adult cf center implemented a weight management quality improvement protocol to improve the nutritional status of patients below the cff recommended bmi. our aim is to improve to the nutritional outcomes in our center through patients' acceptance of our nutrition interventions. strategies: as part of the weight management protocol we developed a nutrition action plan, nutrition algorithm, and weight management education record and learning log. the action plan took a systematic approach to weight management, classifying patients into different risk categories based on bmi. patients were categorized as mild nutritional insufficiency (bmi - ), moderate nutritional insufficiency , and severe nutritional insufficiency . each category required a specific action to address weight loss or inability to gain weight. areas of focus for the action plan include; intake assessment through computerized dietary analysis, assessment of pancreatic function, pancreatic enzyme replacement therapy (pert) regimen assessment, hour stool collection for malabsorption, assessment of glycemic control, assessment for gerd, and enteral/parental feeding. the dietitian completed a chart review and nutrition assessment with the patients and classified them into one of the three nutritional risk categories. eleven patients with a bmi below were initially identified. nine ( %) of the eleven patients with a bmi of or less have been approached with the protocol and algorithm. patients completed a three day food journal and oral intake was assessed via computerized dietary analysis. oral enteral supplements were recommended - times per day. g-tube placement was discussed and an educational material on tube feeding was distributed. the protocol and algorithm guided identification and assessment of contributing factors to weight loss. results: of eighty patients seen in the adult center since the beginning of october, thirty-seven of the patients ( %) have a bmi below and eleven patients ( %) have a bmi below . out of the nine patients approached with the protocol % (n= ) completed and returned the three day food journal. of the patients that completed their food journal % (n= ) agreed to a peg placement, one of the patients is still contemplating peg placement while sorting through some psychosocial issues, and the other patient has had a differential diagnosis that might negate the necessity for a peg placement. conclusion: we developed a systematic approach to weight management within our adult cf program. this systematic approach to weight management, which includes patient involvement and specific education, has improved the overall acceptance of nutrition interventions in our adult population. the inpatient care of adults with cystic fibrosis can be a challenging given complicated medical regimens, specialized respiratory care orders, and unique dietary requirements. a large proportion of these patients are admitted to academic centers with rotating house staff that may have never treated an adult with cystic fibrosis. to improve the quality of care of our adult patients we have implemented a standardized electronic order set, a recurring educational program, and a "pocket card" to help the house staff. the adult cystic fibrosis program at vanderbilt cares for over patients, with - inpatient admissions per month. vanderbilt's inpatient order system is completely electronic. we have devised an order set based on our agreed standard of care for inpatients with pneumonia. the order set guides the house staff through most aspects of inpatient care including culturing, antibiotic choice and dosing, dietary consultation, nutritional recommendations, and respiratory care orders. this order set not only educates the house staff on our standard of care but also provides direct access to each order they may wish to enter. we have reiterated this educational process with a pocket sized handout that guides them through the typical issues in adults with cf as well as provide phone numbers to members of the cf team. these resources are presented in short talk given at the beginning of each month to incoming house staff. a preliminary data analysis suggests that over % of all adults with cf are admitted using some component of this order set. an informal survey of the house staff also concludes that the pocket card and lectures have been helpful. all three aspects of this quality improvement have been implemented since december of . we plan to formally test the impact of this intervention when a meaningful number of house staff have been through the service. * background: malnutrition is a common complication of cystic fibrosis (cf). the median bmi percentile in cf patients between the ages of and years is . % but ranges between various centers from . to . percent. previous research has shown a trend toward improvement of pulmonary disease and a significant improvement in weight, height, and bmi z-scores after nutritional supplementation via a gastrostomy tube ; furthermore, fev is positively correlated with bmi percentile. higher weight at three years of age predicts better pulmonary function at six years of age. the effect of gastrostomy tube feedings on pulmonary exacerbation frequency has not been well defined. hypothesis: the incidence of pulmonary exacerbations in children will decrease after the initiation of supplemental gastrostomy feedings. methods: a retrospective chart review of all pediatric patients seen at the cmh cf center, and who received gastrostomy tubes between and was performed. data was evaluated in six month time intervals for two years prior and two years after gastrostomy tube placement. we assessed weight, height and bmi percentiles, fev percent predicted, number of courses of exacerbation therapy (intravenous and oral) and microbiologic data. results: we identified patients, females and males, with ages ranging from months to years of age ( . years mean) at time of gastrostomy tube insertion. all patients had increases in their weight-forage percentile (mean of all patients of . percentile pre to . percentile post, p< . ), height-for-age percentile ( . percentile pre to . percentile post, p< . ), and bmi percentiles ( . percentile pre to . percentile post, p< . ). the mean fev percent predicted declined overall from . % to . % ( . percent predicted per year) over four years in patients. there was a trend of exacerbation reduction after gastrostomy tube placement from to total courses (p= . ). this decline in exacerbations after gastrostomy tube placement was most dramatic in those patients growing pseudomonas aeruginosa without other organisms, with a decline from total courses to total courses in patients (p= . ). discussion: weight, height and bmi percentile improved after initiation of gastrostomy tube feedings. lung function (fev % predicted) decreased at the rate predicted in spite of gastrostomy feedings. there is a trend toward decrease in exacerbation frequency after improved nutrition with gastrostomy tube feedings, especially in patients infected with pseudomonas aeruginosa. limitations of this study include the small sample size, relatively short follow-up time, and the retrospective nature of the study which did not allow assessment of adherence. conclusion: improved nutrition through gastrostomy tube placement may decrease the frequency of pulmonary exacerbations. evidence of an association of improved pulmonary function with improved nutritional status has motivated aggressive nutritional intervention. percutaneous endoscopic gastrostomies (pegs) are employed increasingly in cystic fibrosis to optimize nutritional status. we reviewed our center data over the past years to assess changes in our peg practice and effects on nutritional and pulmonary outcomes. we hypothesized that our change in practice to earlier peg intervention improved patient's nutritional and pulmonary outcomes. we conducted a case controlled retrospective study of pediatric cf patients spanning the past years divided into two periods: p (peg placed before ) and p (peg placed or later) compared with their respective age/sex matched controls. we compared peg vs. control cf patients with respect to age, nutritional and pulmonary status. we compared weight, height and bmi directly preceding peg placement and at approximately one-year post peg. we compared available data for best yearly fev and fvc before peg and at , and -years post-peg. we then compared data between the two time periods. results: peg patients in p (n= ; mean age . + . yrs.) had lower bmi ( z = - . v. - . , p< . ) pre-peg placement compared to controls. by year post peg, the bmi normalized and equaled controls (z=- . v. - . , p= . ). peg patients' fev %ile prior to placement was lower than controls ( v. , p= . ) as was their fvc %ile ( v. , p= . ) and remained lower at year post-peg. following peg placement, absolute bmi increased ( . kg/m , p= . ), as did bmi z-score ( . , p= . ). we did not see significant changes in pulmonary function tests (pft). peg patients in p , (n= ; mean age . + . yrs.) also had lower bmi (z= - . v. - . , p= . ) pre-peg than controls. at year post-peg, the peg patients still had a significantly lower bmi (z = - . v. - . , p= . ). fev was lower in peg patients compared to controls in pre-, year, and -year post-peg data (p< . ). variability in pfts and small sample size limited our analysis. pre-peg weight, height, bmi, fev and fvc were lower in p patients compared to the younger p patients. at -year post-peg, similar bmi zscores (- . , p= . ) was obtained between the two periods. variability in pfts among the patients within each period prevented valid comparisons, although p tended to have better pft values. conclusions: peg placement was effective at improving nutritional status in patients with cystic fibrosis. placement in younger patients with better pre-peg nutritional and pulmonary status allowed more complete nutritional recovery. we speculate that improved height z-scores with apparently stable fev is consistent with increased pulmonary growth. demonstration of an attenuated rate of pft decline to correlate with this earlier intervention will require a larger population and longer observation period. a multi-center longitudinal outcome study would help determine optimal timing and criteria for peg intervention. . pediatric gastroenterology and hepatology, university medical center groningen, groningen, netherlands; . biochemistery, erasmus medical center, rotterdam, netherlands background: ursodeoxycholic acid (udca) treatment is frequently applied for cystic fibrosis-related liver disease (cfld). it has been hypothesized that udca is beneficial through its choleretic activity, i.e. its capacity to induce bile flow. the hepatic expression of the cftr protein is restricted to the cholangiocytes lining the bile ducts. cholangiocytic cftr is involved in the generation of ductular bile flow. it is not known to what extent the choleretic activity of bile salt treatment depends on expression of competent cftr protein, and whether or not udca differs in this respect from other bile salts. we evaluated the role of cftr in the acute and chronic choleretic effect of bile salt treatment, through comparative studies in cftr-null, homozygous f del, and corresponding wild type control (wt) mice. methods: bile flow was determined after gallbladder cannulation. bile flow during the first minutes after acute interruption of the enterohepatic circulation was regarded as basal bile flow. after min, taurocholic acid (tca) or tauroursodeoxycholic acid (tudca) were iv administered in stepwise increasing dosages, up to nmol/min/ g bw, to cftr-null mice and wt littermates fed a standard chow diet. other cftr-null, homozygous f del mice and their respective wt littermates were fed either the standard chow, or the same diet supplemented with cholic acid (ca, . wt%) for weeks. finally, cftr-null mice and wt littermates were fed the standard chow or the same diet supplemented with ursodeoxycholic acid (udca, . wt%) for weeks. : upon a regular chow diet, the basal bile flow was similar in cftr-null and homozygous f del mice, compared to their respective wt littermates (cftr-null, . ± . vs. . ± . ; and, f del(∆/∆), . ± . vs. . ± . µl/min. g bw, resp.; ns). iv administration of tca or tudca to cftr-null mice and wt littermates increased bile flow to similar extents. dietary ca treatment increased basal bile flow significantly less in cftr-null and homozygous f del mice than in their respective wt littermates (cftr-null, . ± . vs. . ± . , p< . ; and, f del(∆/∆), . ± . vs. . ± . µl/min. g bw, p= . ; resp.). interestingly, dietary udca treatment increased basal bile flow more profoundly than ca treatment, and to similar levels in cftr-null mice and wt littermates (+~ %, . ± . vs. . ± . µl/min/ g bw, resp.; ns). conclusion: upon chronic treatment, udca is highly choleretic in mice, independently of the presence of functional cftr. the independence of functional cftr is udca specific, since the choleretic activity of chronic ca treatment is diminished in cftr-null and homozygous f del mice. we speculate that this specific, cftr-independent choleretic effect of chronic udca treatment could be therapeutically important for cystic fibrosis. most cystic fibrosis (cf) patients have mild to moderate focal portal tract changes (ductal obstruction and cholangitis) and hepatosteatosis. etiology of severe liver disease (ld)with cirrhosis and portal hypertension which occurs in - % of cf patients is unknown. the c bl/ j congenic cf mice develop progressive cf-like ld. as a useful therapeutic model, we have shown that dietary addition of docosahexaenoic acid (dha) significantly ameliorates inflammation but has little effect on ductal obstruction (am j physiol gastrointest liver physiol : g -g , ) . we hypothesized that treatment with udca,a hydrophilic bile acid will ameliorate portal tract ductal obstruction and have an additive effect with dha in preventing ld. methods: thirty-day old wild-type and cf littermates are fed peptamen and either olive oil or dha, with and without . % udca ( groups, mice/group). mice are killed following days of treatment and bile salts, serum liver enzymes and serum and tissue lipids analyzed. h&e stained liver tissues are coded and assessed blindly by an expert hepatopathologist (jp) for evidence of hepatosteatosis, inflammation, bile duct obstruction, fibrosis and other signs of liver pathology. an arbitrary scale of to is used, with representing no pathology and being the most severe. we present interim statistical analysis performed for pathology results only for untreated mice (wt, n= ; cf, n= ); treated mice with dha, (wt, n= ; cf, n= ), treated mice with udca (wt, n= ; cf, n= ) and treated mice with udca and dha (wt, n= ; cf, n= ). results: mean pathology scores from groups of mice are pooled to examine the effects of genotype, treatment and diet (table) . at present,the bile,lipid and liver biochemical test data are insufficient to perform statistical analysis. udca-treated mice have significantly increased bile duct obstructed scores compared to the untreated mice which subanalyzed (not shown) reveals increased bile duct obstruction in the wild-type littermates and no effect in cf mice. hepatosteatosis and inflammatory scores in the untreated mice (fed olive oil) are increased compared to the mice treated with dha. summary: we anticipate completing and performing final analysis within six months. however, these preliminary data confirm that dha reduces inflammation in c bl/ j mice livers and suggest that udca therapy has an adverse effect in wt mice and is not effective in ameliorating liver disease in cf mice. udca with dha therapy does not appear to have an additive effect in ameliorating cfld in this mouse model. supported by axcan pharma inc. background the cf mouse intestine has an innate response associated with small intestinal bacterial overgrowth (sibo). a previous affymetrix genechip analysis of the cf mouse intestine showed altered expression of several eicosanoid metabolic genes. eicosanoids are biologically active arachidonic acid metabolites with a variety of pro-and anti-inflammatory actions as well as effects on mucus production, electrolyte transport, and gastrointestinal motility, all of which are of potential importance to the cf phenotype of the intestine. methods wild type (wt) and cf mouse (cftr tm unc ) littermates congenic on the c bl/ j background were fed an elemental liquid diet (peptamen). intestinal rna was isolated for quantitative rt-pcr of expression levels of genes involved in eicosanoid metabolism to confirm and extend the genechip analysis. various eicosanoids were measured in small intestinal lavage fluid using specific enzyme immunoassays. results we confirmed microarray results by qrt-pcr that the following genes were differentially expressed in the cf small intestine relative to wt: cyp a (cytochrome p a ; -hete synthesis; % of wt); ltb dh (leukotriene b dehydrogenase; metabolizes prostaglandins and leukotrienes; % of wt); cyp c (cytochrome p c ; -hete synthesis; % of wt); ltc s (leukotriene c synthase; ltc synthesis; % of wt); hpgd (hydroxyprostaglandin dehydrogenase ; metabolizes prostaglandins; % of wt); and pla g (group phospholipase a ; potentiates arachidonic acid generation; % of wt). non-significant or less than -fold changes in gene expression were measured for: cyclooxygenase (cox) genes, pge synthase, pgi synthase, and -and -lipoxygenases. as measured by their stable metabolic products, pge and pgf α were significantly increased in the cf mouse intestine ( % and % of wt, respectively). the following eicosanoids were significantly decreased in the cf mice: -hete ( % of wt), -hete ( % of wt) and -hete ( % of wt). there were not significant changes in the levels of pgi , pgd , ltb , cys-lts, or lxa . the changed levels of eicosanoids are generally consistent with the differential gene expression. conclusions there are significant changes in expression of eicosanoid metabolic genes and certain eicosanoids in the cf mouse small intestine. the increase in pla g and decrease in cyp expression levels are expected to make more arachidonic acid available for eicosanoids except hetes. decreases in degradative genes (hpgd, ltb dh) will prolong availability of prostaglandins. altered levels of eicosanoids are expected to play important roles in the pathophysiology of the cf intestine. elevated pge may contribute to increased mucus secretion which is characteristic of cf. pgf α and pge regulate intestinal motility and small intestinal transit is slower in cf patients and in cf mice. the hetes are mostly known for their effects on vascular tone and electrolyte transport in the kidney but are less-well characterized in the intestine. their dramatic decrease in the cf intestine may affect blood flow, electrolyte transport, intestinal motility, or other gi functions. the specific effects of the altered eicosanoid metabolism in cf remain to be explored. supported by cff grant delisl g . for the scandinavian study consortium. background: progressive pulmonary disease, correlating with igg levels, is a major cause of morbidity and mortality in cf patients. recently, immunosuppressive effects of vitamin d and a potential role of vitamin d deficiency in the pathophysiology of autoimmune diseases have been described. we investigated whether vitamin d deficiency could contribute to the chronic proinflammatory state characterizing cf and the higher occurrence of immune-hyperreactivity-related conditions in cf patients. methods: multiple linear regression analysis, taking the confounding factor of age into account, was used to evaluate the relationship between cross-sectionally determined vitamin d variables and: lung function parameters, inflammatory parameters and immune hyperreactivity markers in patients followed at the cf centers in sweden, norway and denmark. vitamin d intake was based on a -day precoded dietary food record, calculated in the national food databases. findings: in the population of all patients included in the study (n= ), blood vitamin d positively correlated with fev (p< , ) as well as with fvc (p< , ). negative correlation was found between blood vitamin d and igg (p< , ), supplemented vitamin d per kg bw and igg (p< , ), total vitamin d intake per kg bw and igg (p< , ). additionally, lower blood vitamin d levels were related to both presence of pathological ogtt (p< , ) and occurrence of cfrdm (p< , ). correspondingly, food vitamin d (p< , ), food vitamin d per kg bw (p< , ), supplemented vitamin d (p< , ), supplemented vitamin d per kg bw (p< , ), total vitamin d intake (p< , ) and total vitamin d intake per kg bw (p< , ) all correlated negatively with hba c values. most of the studied vitamin d variables were lower in patients with endomysial antibodies positivity (n= ) and higher in patients with abpa (n= ) than in the rest of cf population studied (ns). interestingly, in children (n= ) blood vitamin d correlated negatively with transglutaminase levels (p< , ) and there was also a significant negative correlation between hba c and vitamin d intake. surprisingly, in adult cf patients (n= ) iga positively correlated with total vitamin d intake (p< . ) and total vitamin d intake per kg bw (p< . ). in the population of stockholm cf-center patients (n= ), where it was possible to allow for the influence of both age and compliance, negative correlation between blood vitamin d and igg (p< . ) was found. after allowing for age, compliance showed significant correlation only with igg (p< . ) and esr (p< . ), and with none of the rest of the studied variables. conclusions: vitamin d deficiency might contribute to the continuous shift towards inflammation as well as to the higher prevalence of dm and celiac disease in cf patients. new recommendations for vitamin d supplementation and monitoring of blood vitamin d levels are needed, in order to improve immunological balance and decrease the need for anti-inflammatory therapy in cf patients. supported by swedish heart lung foundation, stiftelsen frimurare-barnhuset i stockholm, norwegian and swedish cystic fibrosis associations, and by an unrestricted grant from solvay pharma. von drygalski, a.; biller, j.a. medical college of wisconsin, milwaukee, wi, usa anemia is associated with increased morbidity and mortality in other chronic diseases, but little is known about anemia in cf. recognition and correction of anemia in cf might lead to better outcomes. chronic inflammation, iron deficiency and malabsorption may be important mechanisms contributing to the anemia in cf patients. we hypothesized that anemia might be correlated with poor lung function. methods: clinical charts and portcf.org visit logs of patients of all ages ( m to yrs) with cf were reviewed for as many years as charts permitted (range - yrs). the following data were extracted: cbc, iron studies, pulmonary function tests (pfts), vitamins a, d, and e levels, creatinine, pertinent medical history, and current medications. anemia was defined by age-and gender-specific world health organization (who) criteria. patients were considered anemic if low hemoglobin(hb) was present on two separate occasions at least two months apart, or average annual hb met who criteria. pfts in patients (all > yrs) included forced expiratory volume (fev ) and forced vital capacity (fvc) as percent predicted of normal and were considered a reflection of patient performance. the most representative annual pft from at least annual tests was chosen for analysis since acute infection adversely influences daily performance. results: of patients were anemic (prevalence %). prevalence of anemia increased with age from . % in patients < age to % in patients > age and was significantly higher in patients with vitamin deficiencies. % vitamin-deficient patients vs. . % non-vitamin deficient patients were anemic (p= . ). mean hb was . mg/dl (range . - . ). roughly two thirds of patients had moderate and severe anemia (hb < mg/dl) with no gender difference in regard to prevalence or severity identified. complete iron studies were available in / patients. were identified as iron deficiency anemia (ida), as anemia of chronic illness(aci), and as combined; others had renal failure. in patients, iron studies were incomplete, but renal failure, hemoptysis, hematochezia and solid organ transplants were contributing factors in half. pfts obtained in patients ≥ yrs were compared in anemic and non-anemic patients. mean fev and fvc at all ages were statistically significantly poorer in the anemic patients (p < . ). complete iron studies were also available in non-anemic patients with impaired lung function. / patients had ferritins < ng/ml suggesting relative iron deficiency. conclusions: the prevalence of anemia in cf patients is high and increases with age. in patients for whom iron studies were available, ida was the prominent underlying mechanism, followed by aci or a combination of both. in addition, a group of non-anemic patients with poor lung function had relative iron deficiency. the strikingly significant association between anemia and poor pulmonary function as well as the higher prevalence of anemia in vitamin deficient patients uncover anemia as significant co-morbidity in cf. identification of iron deficiency in anemic as well as in non-anemic patients with poor lung function could be important since iron supplementation might allow hb levels to increase as an appropriate response to hypoxia. oral administration of dha to a cf mouse model corrected the lipid imbalance and reversed certain pathological manifestations in tissues affected by cf. the aim of this study was to investigate the metabolism of la through the n- pathway, and to determine the effect of dha supplementation on la metabolism in cultured cells with a cf phenotype. methods: sense (wt) and antisense (cf) cftr hbe cells were cultured in mem containing % horse serum. cells were supplemented with various concentrations of la (ranging from to µm) and dha ( , , and µm) for one week. cellular lipids were extracted from confluent monolayers, and fatty acids were methylated and analyzed by gc-ms. metabolism through the n- pathway was studied by incubating the cells with . µm [ c] la for hours, and quantitating its downstream metabolites by hplc. results: the levels of la and dha were significantly decreased in cf cells compared to wt cells (la in wt: . ± . , cf: . ± . %, p< . ; dha in wt: . ± . , cf: . ± . %, p< . , mean ± sem for each). la supplementation resulted in an increase in la and aa levels in both wt and cf cells. at most la concentrations tested, la levels were significantly lower and aa levels were significantly higher in cf cells, indicating an increased production of aa from la in cf cells. the study of [ c] la metabolites showed an increased production of multiple downstream fatty acids including : n- ( . fold), aa ( . fold), and : n- ( . fold) in cf cells compared to wt cells, further substantiating an increased metabolism through the n- pathway. supplementing hbe cells with dha for week resulted in a significant increase in la levels and a corresponding decrease in aa levels in wt and cf cells. when supplemental dha was added in combination with la, dha inhibited the la-derived increase in aa levels in cf cells and normalized them to the wt values. the formation of [ c] la metabolites was inhibited after -hour supplementation with dha. this inhibitory effect of dha was greatest on aa production, and it was more prominent in cf than in wt cells (wt: . fold, cf: . fold decrease in aa production). conclusions: decreased la levels in cf are at least in part related to increased la metabolism through the n- pathway. the fact that dha supplementation decreased the flux from la to fatty acid metabolites in the n- pathway, especially to aa, may partially explain dha's mechanism of therapeutic benefit. these data would also suggest that dha combined with la in the diet may normalize fatty acid metabolism in cf patients. background: decreased levels of linoleic acid (la) and docosahexaenoic acid (dha) have been found in the blood and tissues of cf patients. studies on cultured cf cells and cftr-/-mice have indicated that decreased la levels in cf might be related to its increased metabolism through the n- pathway. other potential mechanisms of the observed decreased la and dha levels in cf could be related to altered cellular uptake of these two essential fatty acids. the goal of this study was to investigate the uptake of la and dha into cultured cf cells, and their distribution among the major lipid classes. methods: sense (wt) and antisense (cf) cftr hbe cells were cultured in mem containing % horse serum. the uptake of la and dha into the cells was studied by incubating the cells with . µm [ c] la or [ c] dha for hour and hours, followed by measurement of radioactivity in the supernatant and cell lysate. lipid fractions from the cells (total phospholipids, triglycerides, cholesteryl esters, and free fatty acids) were separated by thin layer chromatography (tlc), and the fatty acid composition was determined by gc-ms after methylation. incorporation of la and dha into cellular lipid fractions was determined by incubating the cells with . µm [ c] la or . µm [ c] dha for hour and hours, followed by tlc separation of lipids and measurement of radioactivity associated with the various fractions. (all data are mean±sem). results: the levels of la and dha were significantly decreased in cf cells compared to wt cells (la in wt: . ± . , cf: . ± . %, p< . ; dha in wt: . ± . , cf: . ± . %, p< . ). fatty acid composition analysis of lipid fractions indicated that la levels were significantly decreased in the phospholipid and triglyceride fractions of cf cells ( . % and . % of the wt values, respectively), and dha levels were significantly decreased in the phospholipid fraction of cf cells ( . % of the wt values). the uptake of la was significantly higher into cf cells compared to wt cells at hour (wt: . ± . , cf: . ± . dpm/µg protein, p< . ) and hours (wt: . ± . , cf: . ± . dpm/µg protein, p< . ). the uptake of dha was also significantly higher in cf cells compared to wt cells at hour (wt: . ± . , cf: . ± . dpm/µg protein, p< . ) and hours (wt: . ± . , cf: . ± . dpm/µg protein, p< . ). incorporation of la and dha was increased in the phospholipid, cholesteryl ester, and free fatty acid fractions of cf cells at hours. dha, but not la, incorporation was significantly increased in the triglyceride fraction of cf cells. conclusions: low la and dha levels in cf cells are associated with a decrease in cellular lipid fractions, the largest of which is in total phospholipids. there is an increased uptake of la and dha into cf cells, and into most lipid fractions of these cells. the decreased levels of la and dha in cf cells, despite their increased cellular uptake and esterification in lipid classes, indicate that there is increased mobilization of these fatty acids in cultured cf cells. perez, a.; issler, a.; davis, p.b. pediatrics, cwru, cleveland, oh, usa even though lung disease continues to be the primary cause of death in cystic fibrosis (cf), the considerable increase in life expectancy of the cf patient over the last decades, has made management of the diverse gastrointestinal and nutritional complications in the adult cf increasingly important. malnutrition and fatty acid deficiency has been a hallmark of cf and its impact in long-term lung health has been established. data obtained by us using affymetrix mg-u av arrays from ileum and liver of pristine -week-old male mice bearing the y x cf mutation and their normal littermates, indicates that there is a profound disturbance in genes associated with lipid metabolism, many of which are regulated by the peroxisome proliferator-activated receptor-gamma (pparγ), a ligand-regulated transcription factor that regulates lipid metabolism and possess anti-inflammatory properties. we hypothesize that lack of cftr function results in altered expression of pparγ regulated genes in the gut and liver, leading to the fatty acid metabolism abnormalities observed in cf. pparγ mrna and protein levels were measured in ileum, colon, liver, and fat of week old female mice bearing the cf mutation s x and its wt littermates (c bl/ j background), and fabpcftr mice (gut corrected, mixed background) after the administration of ethanol or pioglitazone (a pparγ agonist, mg/kg) by gavage every h for days, sacrificed h after last dose. highest pparγ mrna levels were found in fat, followed by colon, liver, and lowest in ileum. at basal state, mrna levels were higher only in fabp ileum vs. wt and fabp colon vs. cf. after treatment, higher expression was seen in cf and fabp ileums and cf liver vs. controls and wt treated mice. however, there were striking differences at the protein level, especially in the colon. at basal state, pparγ was localized, mainly at the surface of the epithelia in wt, in crypts in cf, and mainly in crypts but extending towards the surface in fabp mice. upon treatment, pparγ location in wt colon moved almost exclusively to the crypts, and in the cf and fabp mice, although expression remained mainly in crypts, pparγ could now be seen at the surface. changes in pparγ protein were also seen in ileum and especially liver, between wt and cf, at basal and upon treatment, but changes were subtle and will require more sensitive methods to further examine them. we also examined mrna and protein levels for several genes involved in fat processing that could be related directly or indirectly to pparγ. mrna and protein levels for aqp and cubilin, and protein levels for megalin, apoa- , and apob- were reduced in the ileum of cf mice compared to wt. our data indicates a pparγ dysfunction in the gastrointestinal system of cf mice, which could be responsible for the gastrointestinal manifestations observed in cf. understanding the association between pparγ, cftr, and fat processing may help us to develop new therapies directed towards improving the nutritional status of cf patients that, in the long run, will influence their lung health. cf is characterized by low linoleic acid (la) and docosahexaenoic acid (dha) levels. although this could be due to a primary abnormality in fatty acid biosynthesis, this could also be explained by alterations in phosphatidylcholine (pc) formation. pc are formed by two pathways. the most utilized is the de novo conversion of choline to pc via the cdp-choline pathway, which preferentially forms pc containing saturated and monounsaturated fatty acids. in the other pathway phosphatidylethanolamine (pe) is converted to pc through three methylation steps utilizing the enzyme phosphatidylethanolamine n-methyltransferase (pemt). this pathway preferentially forms pc containing polyunsaturated fatty acids. thus decreased pemt activity would be predicted to result in decreased dha and la levels. this is supported by results seen in pemt knockout mice (watkins et al, j nutrition, ) showing decreased dha and la levels, and variable to increased levels of arachidonic acid (aa). furthermore, innis et al have shown that cf patients have decreased choline levels making them more dependent on the pemt pathway. we hypothesized that alterations in fatty acid levels in cf may be due at least in part to decreased pemt activity. methods: cftr -/mice (cf) and wt littermates were fed with either a diet containing choline (control) or, in order to mimic choline status in humans, an otherwise matched choline deficient (cd) liquid diet for days. choline levels were measured using a kit. livers were perfused and microsomes prepared. to measure pemt activity, microsomes were incubated with radioactive s-adenosylmethionine in the presence of dimethyl pe. the pc product was extracted and radioactivity measured. fatty acids from liver and pancreas were analyzed by gc/ms. results: there was no difference in choline levels in serum or liver comparing wt and cf mice. there was no difference in pemt activity in livers from cf mice compared to wt on control diet. cf mice on cd diet had decreased pemt activity in the liver compared to wt mice on cd diet (wt: ± ; cf: ± cpm/mg protein/min; p< . conclusion: induction of choline deficiency in cf mice to mimic the situation in cf patients, leads to decreased pemt activity. this resulted in low la levels compared to wt mice in both the liver and pancreas and indicates that the fatty acid abnormality in cf is at least in part due to defective pc metabolism through the pemt pathway. ( ). urolithiasis appears to be more common in adult cystic fibrosis (cf) patients than in the general population. a variety of urinary findings have been observed which could account for this, including low volumes, raised oxalate and low citrate, but not all the reports are consistent. most cf patients have pancreatic insufficiency and a plausible explanation for an elevated oxalate excretion in these patients is malabsorbed fat in the intestinal tract sequestering calcium and permitting more oxalate to be absorbed from their food. if this were the mechanism for the elevated stone risk in cf patients then we would expect to observe differences in stone incidence and oxalate excretion between cf patients with exocrine pancreatic sufficiency (ps) and pancreatic insufficiency (pi). methods diagnosis of cf is by clinical and genetic criteria and ps or pi status is based on faecal elastase measurement. patients and healthy volunteers (hv) provided h urines for analysis of volume, ph, ca, mg, na, k, po , oxalate, citrate, creatinine, urea. supersaturations were calculated using equil . there is a history of renal stone disease in out of cf patients attending our unit. patients have pi and include of the stone formers. the remaining stone former is amongst the ps patients. no significant differences in urine chemistry or derived supersaturations were found between the cf patients without a history of stones that were ps (n= ) or pi (n= ). nor were any such differences found when stone forming cf patients were included (ps, n= ; pi, n= ) or when the healthy volunteers were included in the ps group (ps, n= ; pi, n= ). amongst the cf patients, only citrate and creatinine excretions were significantly different between stone formers (n= ) and non stone formers (n= ) (medians (mmol/ h), citrate, . vs. . , p= . ; creatinine, . vs. . , p= . ) . the difference in creatinine excretion can be accounted for by the difference in body mass of these two groups (median (kg) . vs. . , p= . ) compared to the hv, the cf patients with a history of stones had significantly lower citrate excretion and higher calcium oxalate supersaturation (medians, citrate (mmol/ h), . vs. . , p= . ; . vs. . , p= . ) conclusions there is no evidence to suggest that the prevalence of stones is different in the ps and pi groups nor could we detect any difference in excretion of oxalate or any other urine variable related to pancreatic sufficiency. comparing those with and without stones, the only consistent finding was a lower citrate excretion by stone formers. between the hv and stone formers this was also associated with a significantly reduced calcium oxalate supersaturation. our evidence does not support the hypothesis that fat malabsorption by the majority of cf patients contributes to an elevated risk of renal stone disease. we undertook assessment of the use of a hypopharyngeal sensor for detection of laryngopharyngeal reflux in infants and children. gastric reflux in the airway, or supraesophageal reflux, commonly takes a gaseous form that cannot easily be measured using conventional technology. the miniaturized ph sensor at the tip of the dx-ph probe is the only sensor able to measure ph in the airway. fifteen infants and children referred to the pediatric pulmonary center for assessment of chronic cough, hoarse voice, or uncontrolled asthma unresponsive to usual medical intervention underwent - hour to placement of the dx-ph probe in supplementation of radiologic assessment of gastresophageal reflux. the probe was placed transnasally and visualzed in the hypopharynx with the red light at the tip. drops in ph < were correlated with food and symptom diaries. positive results were found in / patients, leading to surgical intervention in three patients. one patient with cystic fibrosis age months with failure to thrive underwent study for symptoms of cough. upper gi demonstrated no gross gastroesophageal reflux or anatomic obstruction.gastric emptying scan was mildly prolonged. outpatient supraesophageal ph probe demonstrated drops to ph< associated with respiratory symptoms. patient underwent nissen and g tube placement with resolution at six week follow-up.the patient returned at age six months with onset cough and underwent repeat study. there were no drops in ph and the cough responded to oral steroid burst. the device was tolerated in / patients with early removal in one young adult with endstage neuromuscular disease and in an infant with "colic" due to a hysterical parental reaction.as a result of our experience we have incorporated the use of supraesophageal ph monitoring into our practice, with particular attention to infants with persistent asthma and children with histories suggestive of gastric asthma. we have now incorporated it into our vivometrics lifeshirt, an ambulatory physiologic monitoring device which will allow us to examine supraesophageal ph and its relationship to sleep apnea, cough, tachycardia, tachypnea, and hypoxemia. aim: monitoring and adjusting dose requirements of pancreatic enzyme replacement therapy (pert) are an integral part of the dietetic assessment of patients with cf. we investigated characteristics of enzyme use in our adult clinic population and determine the extent to which inappropriate enzyme use contributed to poor nutritional and clinical state. method: information was collected using an annonymous self-administered questionnaire developed to measure patient practice, knowledge and beliefs on pert. exclusion criteria included pancreatic sufficiency, < units lipase/kg/d, and fev < %. results: out of potential clinic population of patients completed the questionnaire ( - y, % male, fev - %). % of participants reported to never miss enzymes with meals; this was considerably lower for snacks ( %). those patients who omit enzymes with meals also missed enzymes with snacks (r = %, p< . ). a more appropriate use of pert was observed in patients with lower as opposed to higher bmi. despite intensive dietetic input % of patients missed pert with foods containing fat and % took pert inappropriately with food and drink that did not contain fat. the results identified potentially better practices for measuring pert behaviour and knowledge: ) taking pert with all meals, ) taking pert with majority of snacks ) swallowing capsules intact rather than splitting them open, ) carrying enzymes around with them and ) the ability to titrate pert in accordance to the fat content of food. patients were scored on the basis of the above criteria to differentiate between prudent enzyme users and those who are compromising therapy. in conjunction with their nutritional status score (bmi and gastrointestinal symptoms) risk for intervention can be assessed. discussion:underweight patients have more optimal enzyme use, suggesting greater dietetic involvement in these patients. schall et al also found this to be the case in children. the findings emphasised the need for targeted and effective input in patients where problems are less obvious. the questionnaire has been a useful research tool, and has been adapted as a screening tool for dietitians to gain a subjective perspective of patient's enzyme management and identify patients who need support. the combination of patient's pert usage and their nutritional status could help capture and identify risk objectively and quickly and allows resources to be allocated most effectively. schall . ), nutritional failure, measured as bmi< , (p> . ), or lung transplant status (p> . ) between patients with and without colonic wall redundancy. there was no significant difference in cftr function, per sweat chloride values, between groups (p> . ). conclusion: we report a previously undescribed colonic wall abnormality seen on ct in patients with cystic fibrosis: proximal colonic wall redundancy was found in % of adults with cystic fibrosis, but not in children, appeared to be chronic, and was associated with non-∆f cftr gene mutations, particularly the g x mutation. recognition of the ct appearances will prevent erroneous diagnosis of acute colonic disease in this patient population, and stimulate investigation of a biologic basis for this finding as a recognizable feature of adult cystic fibrosis. intro: infants and children with cystic fibrosis, both pancreatic sufficient and insufficient, are at risk for developing hyponatremia due to an excess loss of salt though skin during sweating. these children should receive daily supplemental sodium. children without cf require - meq/kg of sodium daily; and one could argue children with cf need more. a historical recommendation is / tsp table salt daily for infants; this contains to meq of sodium based on the density of the table salt. parents may measure the salt inaccurately, and it may be difficult logistically to distribute the salt throughout the day. if supplementation is given as sodium chloride solutions distributed through pharmacies, as suggested in a recent consensus conference, co-pays or full payments may be required. our aim is to provide a simple, inexpensive, and more accessible method for accurately giving sodium supplementation. do pre-packaged salt packets contain a precise amount of sodium and thus could be recommended to fulfill the daily requirement of sodium in patients with cf? method: pre-packaged table salt packets were collected with permission from four national fast food restaurants and one commercial salt producer. contents (sodium chloride) of ten packets from each source were weighed individually. measurements were made using a scientific scale with the ability to measure up to / , of a gram. weights of sodium chloride from individual packets were converted to meq sodium. means, ranges and standard deviations were calculated for the data using microsoft office excel ™ program. see table conclusions: there is some variability in the content of pre-packaged salt packets, both between and within brands, though some brands have less variance than others. measurements showed that packages contained mean values of approximately to meq of sodium. there is a range in the sodium dose recommendations, and spot urine sodium can be used to determine if patients are sodium depleted. pre-packaged salt packets lack the precision of pharmacological dosing but are inexpensive, practical, and supply a reasonably predictable dose of sodium. background: ten to forty percent of people with cf have vitamin d deficiency secondary to pancreatic insufficiency. obtaining optimal vitamin d levels ( -ohd) has been a challenge. for vitamin d deficient individuals, current supplementation strategies ( , iu weekly for months) have been mostly unsuccessful. objectives: to identify individuals at risk for vitamin d deficiency and to evaluate the efficacy of a week repletion course of high dose ergocalciferol in children and young adults with cf. methods: as part of a quality improvement initiative, a prospective cohort study was performed from january to april . phase i included querying our cf practice database to identify patients who were due for annual routine blood tests or who had recently documented levels of -ohd less than ng/ml. in phase ii, , iu of daily ergocalciferol was prescribed for a day period as part of routine inpatient or outpatient care. during phase iii, a post treatment -ohd level was obtained. baseline subject characteristics were obtained at entry and included age, gender, pubertal status, pancreatic status, and fev %. post -ohd levels were classified as sub therapeutic (< ng/ml), therapeutic ( - ), high therapeutic ( - ), or potentially toxic (> ). a paired t test was performed to evaluate pre and post intervention differences. the impact of age, gender, and lung function on the response to vitamin d supplementation were also analyzed. all values are expressed as mean ± standard deviation. results: eighteen individuals with cf participated in the study. the mean age was years with a range of to years. . % were male, and % were pancreatic insufficient requiring pancreatic enzyme replacement. fev % was . ± . %. all participants had -ohd levels less than ng/dl pre-treatment. -ohd levels increased from . ± . to . ± . (p< . ). of the participants ( . %) became therapeutic over the two week interval. an increase of . ± . (ng/ml) or % was seen in the two week period. no correlation was seen on the extent of increase in -ohd and baseline lung function. pre and peri pubertal individuals had a greater increase in -ohd levels than post pubertal individuals ( . ± . vs . ± . , p< . ) although the magnitude of change did not reach significance. the degree of response also appeared related to age (r=- . ). no impact of gender was seen. seven individuals achieved normal therapeutic values while were in the high therapeutic range. no participants had toxic levels. conclusions: the results of this study demonstrate that high dosing of ergocalciferol over a day period is an effective strategy in achieving therapeutic levels of vitamin d. it is unclear whether a pubertal effect on the degree of response exists or if this response is merely age related. further research is needed to evaluate whether this strategy is able to maintain therapeutic levels after completion of the intervention. additional studies that monitor compliance and evaluate responders and non-responders are needed. foundation consensus committee established guidelines for optimizing bone health in individuals with cf, including screening for vitamin d insufficiency and a treatment protocol for achieving and maintaining normal serum vitamin d concentrations. however, since the guidelines were published, there has been additional research assessing various vitamin d treatment regimens and their effect on serum vitamin d concentrations. in addition, vitamin d assay variability has recently been well documented. the objective of this study was to evaluate variability of vitamin d surveillance methods as well as treatment protocols used to treat low vitamin d concentrations at cf centers. methods: a survey was created via survey monkey, and was sent to the cf nutrition listserv, which includes over cf healthcare providers. spss version . was used for statistical analysis. results: fifty-nine listserv members responded to the survey. the majority ( %) of respondents measured oh vitamin d concentrations, and % considered patients to be vitamin d deficient when serum concentrations were below ng/ml. however, % were monitoring only , oh vitamin d or a combination of both concentrations. there was considerable variability in vitamin d supplementation protocols for treating low oh vitamin d concentrations. only % were following the consensus guidelines of , units of ergocalciferol once/week for ages through adults. one third indicated that they followed consensus guidelines for patients less than age ; however nearly half of the remaining two thirds were not sure what is prescribed or have not observed low vitamin d concentrations in this age group. fifty-two percent of respondents were aware of vitamin d assay variability. despite this knowledge, the majority were unaware of the type of vitamin d assay used to measure serum vitamin d concentrations at their institution. conclusions: there is considerable variability in the measurement and treatment of vitamin d concentrations across cf centers despite guidelines provided via a cff consensus report. the consensus guidelines for measuring vitamin d concentrations and treatment of vitamin d insufficiency should be revisited based on recent studies and expert opinion. children with cystic fibrosis (cf) who suffer from sub-optimal growth are offered overnight enteral feeding via gastrostomy tube. this study aimed to assess the nutritional impact of overnight feeding over a year period using a retrospective study design. data, including height, weight, fev , pancreatic function were collated for all patients with cf who had a gastrostomy tube placed in the past years. data were collected at baseline and then every months for years post-gastrostomy insertion. data for height, weight and body mass index (bmi) were converted into z scores using centre for disease control reference ranges and the lms method ( , ) . a total of patients ( . % of the clinic population) were identified as having a gastrostomy tube. two were no longer receiving feeds and there were incomplete data for subjects. on placement of the tubes, there were substantial deficits in nutritional status with mean z scores for height - . (sd . ), weight - . (sd . ) and bmi - . (sd . ), with compromised lung function (mean fev %, range - ). using a repeated measures anova with fev as a co-variate, there were no significant differences in weight, height or bmi from baseline to years (at years post placement: mean z scores for height - . (sd . ), weight - . (sd . ) and bmi - . (sd . ). fev remained stable over time. these results indicate that gastrostomy feeding can potentially halt the decline in nutritional status that is a feature of cf. however, patient expectations that over night enteral feeding will lead to an increase in nutritional status need to be sensitively managed. background : cystic fibrosis (cf) is the most common life threatening autosomal recessive disorder in caucasians.following a landmark paper by corrie et al a high fat,high calorie diet has promoted a normal growth pattern.improved nutritional status together with prevention and early treatment of respiratory infections has contributed to improved survival. objective: the aim of this study was to assess the relationship between lean body mass and disease severity in children with cf. methods: the nutritional status and body composition of children with cf was measured using a harpenden stadiometer, calibrated electronic scales and a ge lunar prodigy densitometer. the following indices were calculated; body mass index (bmi), fat mass (expressed as logarithm % total body fat (ln%tbf) and fat free mass (ffm). body composition data were expressed as z-scores using dutch reference values. correlations were performed between indices of nutrition (bmi, height, ffm, tbf) z scores and markers of disease severity (percent predicted fev and shwachman kulczycki (sk) scores).the nutritional status of these children was also compared with healthy controls. statistical analyses were performed using microsoft excel . results: there was a weak but significant correlation between sk scores and height z score and ffm (r = . , p< . & r = . , p= < . respectively). there was also a weak but significant correlation between % predicted fev and bmi and ffm (r= . , p < . , r= . , p< . ). height and weight z scores were significantly lower in children with cf (- . and - . respectively) than in control subjects ( . and . respectively) with p < . in both groups. conclusion: this study demonstrates that there is an association between indices of nutrition and disease severity in children with cystic fibrosis. muscle mass (ffm), assessed by dual energy x-ray absorptiometry (dxa) correlates with lung function and with sk scores. the strongest correlation between markers of disease severity (sk scores and % predicted fev ) was with ffm. ffm may be expected to be associated with respiratory function tests.however,sk scores are a more general assessment of well being and less obviously directly related to muscle mass. ffm and growth may reflect long term nutrition and health in contrast to bmi and ln%tbf which may reflect acute deterioration or short term nutritional intervention. therefore ffm may prove to be a useful tool to assess quality of nutrition and may be predictive of respiratory and general decline. body composition assessment has an important role in chronic conditions such as cystic fibrosis, in order to identify nutritional depletion and evaluate nutritional interventions. it is important that reliable and accurate methods are used. the usefulness of non-invasive methods, such as skinfold thickness measurements (sft) to measure change in body composition has not been evaluated in cf. this study aimed to compare changes in fat-free mass (ffm) and fat mass measured using sft and dual-energy x-ray absorptiometry (dxa) in adults with cf. methods: adults with cf ( % male, % pancreatic insufficient, mean age at baseline . (sd . ) years, mean fev at baseline . (sd . ) % predicted) were studied. they underwent body composition assessment using dxa and sft, at baseline and a mean of . (sd . ) years later. durnin and womersley equations were used to estimate ffm and fat mass from sft. estimates of change in ffm and fat mass obtained using sft were compared with dxa using paired t-tests, univariate analysis and bland and altman analysis. results: at baseline, mean ffm was . (sd . ) kg; mean fat mass was . (sd . ) kg and mean bmi was . (sd . ) kg/m . mean ffm, fat mass and bmi were not significantly different at follow-up, indicating no change in nutritional status for the population overall. individual change in ffm ranged from - . to + . kg, while change in fat mass ranged from - . to + . kg. the table shows mean change (∆) in ffm and fat mass by each method, correlations (r ) between sft and dxa, and the % limits of agreements (loa) between sft and dxa for change in ffm and fat mass. mean change in ffm and fat mass estimated using sft did not differ significantly from dxa. mean bias between the methods was small, and overall correlations between sft and dxa were strong for changes in both ffm, suggesting good agreement for the overall population. however the % loa between the two methods were wide for change in both ffm and fat mass. this suggests that sft will not accurately predict changes in body composition in all cf patients. conclusion: sft measurements do not accurately estimate change in ffm or fat mass over time in individual adult cf patients compared with dxa. body composition changes measured using sft tended to more closely reflect changes detected by dxa in male patients compared with females. caution should be exercised when interpreting the results of serial measurements of body composition using sft in individuals with cf. analysed were significantly correlated with age-cml or srage levels (age, gender, bmi, presence of cf-related diabetes mellitus (cfrd) or hba c level). conclusions: serum levels of ages are elevated in adults with cf. elevation is not restricted to those with cfrd. the levels of srage reflect ability to respond to this pathway and are associated with poorer lung function. modification of the diet in cf may reduce this mediator and may have the potential to modify lung and renal injury. mouse models of cf generated by expression of improperly processed cftr (∆f ) or lacking cftr expression (ko) demonstrate selective induction of sult e in the liver (falany et al., biochem. j. : , ) . sult e is responsible for the sulfation and inactivation of β-estradiol (e ) at physiological concentrations. the increase in sult e expression is specific to the hepatocyte, whereas cftr is selectively expressed in cholangiocytes. the induction of sult e activity is associated with changes in levels of e regulated proteins in cftr (-/-) liver (li and falany, j cystic fibrosis : , ) . increased sult e activity is correlated with low body weight and decreased igf- message levels in livers of cftr(-/-). the mechanism for the induction of sult e in hepatocytes by cholanigiocytes lacking cftr expression, and the mechanism for the inhibition of igf- expression by increasing sult e expression was investigated in human cells. human mmnk- cholangiocytes in which cftr expression was inhibited by short interfering rna (sirna) induced sult e expression in human hepg hepatocytes when cocultured in a permeable membrane separated system. sult a expression was not altered in this model. the data suggests that loss of cftr function in cholangiocytes is capable of selectively modulating sult e expression in hepatocytes. to investigate the ability of increased sult e activity to modulate expression of igf- , hepg cells were stably transformed with sult e /pcdna to activity levels intermediate to the levels observed in cftr(-/-) mice. the increased sult e activity was associated with decreased igf- message expression in the hepg cells. since a major pathway for igf- regulation involves growth hormone (gh) stimulation of stat b phosphorylation, the effects of e and increased sult e activity on gh stimulated stat b phosphorylation were examined. stat b activation was identified using immunoblot analysis with a rabbit anti-tyrosine phosphorylated-stat b antibody. treatment of control hepg with nm e prior to the addition of gh increases stat b phosphorylation. in hepg cells expressing increased sult e activity, the stimulation of stat b phosphorylation by nm e was significantly decreased. e had an apparent rapid action on stat b phosphorylation that is not attenuated by the estrogen receptor antagonist, ici , . e was effective at increasing stat b phosphorylation when applied to hepg cells - min before gh. increased stat b phosphorylation was observed in control hepg cells at nm e although -fold higher e concentrations were required in the sult e -hepg cells consistent with the increased e sulfation. no differences were observed in total stat b in any of the studies. this study demonstrates that human cholangiocytes with low levels of functional cftr are capable of inducing sult e expression in human hepatocytes and the increase in e sulfation inhibits the gh stimulation of igf- expression via a decrease in stat b phosphorylation. supported by grants from the cystic fibrosis research, inc. and nih (gm ). williams, j.e. ; benden, c. ; jaffe, a. ; suri, r. ; wells, j.c. ; fewtrell, m.s. . mrc childhood nutrition unit, institute of child health, london, united kingdom; . portex respiratory medicine unit, great ormond street hospital, london, united kingdom background: patients with cystic fibrosis (cf) are at high risk of malnutrition. to our knowledge, no study so far has employed a reference fourcomponent model(sup) (/sup)( cm) to assess body composition (bc) in cf children, which allows accurate evaluation of both fat mass (fm) and the components of fat-free mass (ffm; mineral, protein, water) and most studies have been cross sectional. methods: cf subjects, aged - yrs, were compared with age-and sex-matched healthy controls for assessment of bc using a reference cm. comparison between groups was performed using paired t-tests and general linear models to adjust for age, height and pubertal status. in addition fm index (fmi; fm/height ) and ffmi (ffm/height ) standard deviation scores (sds) were calculated using measurements performed in a reference population of healthy children aged to yrs. repeat measurements were made in children with cf ( boys) after yrs and the change in fmi sds and ffmi sds investigated. results: for the initial measurement at baseline, boys with cf (n= ) were significantly shorter (mean (se) height sds: - . ( . , p< . ) compared to uk reference data; girls with cf were lighter, bmi sds (- . ( . ), p< . ). at baseline, comparison of cf children with pair-matched controls indicated that there was no difference in the boys but cf girls had less fm (cf minus control) (- . ( . )kg, p< . ) and mineral mass (- . ( . )kg, p< . ) after adjustment for age, height and puberty. fmi sds adjusted for age and puberty was also significantly lower in girls with cf (- . ( . ), p< . ) whereas ffmi sds was not. for comparison with the large reference population there was no difference in the boys at either time point for fmi sds and ffmi sds (paired t-test). for girls however, there was a significant difference at both baseline fmi sds (- . ( . ), p< . ), ffmi sds (- . ( . ), p< . ) and yrs fmi sds (- . ( . ), p< . ) and ffmi sds (- . ( . ), p< . ). paired t-test analysis between baseline and yr followup measurements indicated that fmi sds and ffmi sds were not significantly different at each point in time in either boys and girls. conclusion: at baseline, the bc of cf boys appears to be within normal range, but the cf girls already have lower fm and mineral than their healthy pair matched controls, even when adjustment for size and puberty is made. follow-up measures in cf children indicated that these descriptions of nutritional status of cf boys and girls remained consistent over the following years, with no evidence of any further deterioration in girls. however, nutritional surveillance is important in both sexes in cf at around puberty to address potential deterioration and this study suggests that the cm is a useful tool for this purpose. fuller background: although lung function (lf) in children with cystic fibrosis (cf) has been reported to be related to their nutritional status, particularly body fat, the latter has usually been assumed from anthropometric measurements and not measured using an appropriate reference method. habal, h. ; al-turkmani, m. ; freedman, s. ; laposata, m. . pathology, massachusetts general hospital and harvard medical school, boston, ma, usa; . medicine, bidmc and harvard medical school, boston, ma, usa background: increased dietary intake of fatty acids is recommended for cf patients. it is unknown if this results in increased incorporation of all fatty acids-saturated, monounsaturated, and polyunsaturated-into cells with a cf phenotype to a greater extent than into non-cf cells. docosahexaenoic acid (dha) supplementation of cftr-/-mice has been shown to reverse the pathologic cf phenotype. aim: to investigate whether the uptake of multiple predominant fatty acids and the release of membrane-bound arachidonic acid (aa) are altered in cultured epithelial cells with a cf phenotype; in addition, to determine whether fatty acid uptake is selectively inhibited by dha supplementation. methods: sense (wt) and antisense (cf) cftr hbe cells were cultured in mem containing % horse serum. aa release from membrane phospholipids (pls) was studied by incubating the cells with µm [ c] aa for min, and then with serum free medium containing . % fatty acid free human serum albumin in the presence or absence of µm adenosine for min, followed by measurement of radioactivity in the supernatant. the uptake of fatty acids into the cells was studied by incubating the cells for different time points with . µm [ c] linoleic acid (la), [ c] aa, [ c] dha, [ c] palmitic acid or [ c] oleic acid, in the presence and absence of µm or µm dha, followed by measurement of radioactivity in the cell lysate. results: basal and adenosine-stimulated aa release from membrane pls was significantly higher in cf cells compared to wt cells (basal wt: . ± . , cf: . ± . dpm/ cells, p< . ; stimulated wt: . ± . , cf: . ± . dpm/ cells, p< . ; mean±sem for each). the uptake of la, aa, dha, palmitic acid and oleic acid were significantly higher into cf cells compared to wt cells. dha significantly decreased the elevated uptake of these fatty acids into cf cells, but not into wt cells. data are shown in the table below. conclusion: in this cell culture model, these data demonstrate that aa uptake and release are increased in cf cells, which may suggest elevated mobilization of this fatty acid by cf cells. our data also show that cftr dysfunction leads to increased uptake of all tested fatty acids into the cells. downregulation of this increased uptake may be one mechanism by which dha exerts its therapeutic benefits. low bmi in cf correlates directly with worsening lung function and is an independent risk factor for mortality. the causes for this decreased bmi are incompletely understood but could be related to levels of the orexigenic peptide ghrelin, and to levels of leptin, an anorexigen. studies assessing plasma levels of leptin in cf have shown contradictory results, while the data on ghrelin in cf are scarce. we assessed both leptin and ghrelin plasma levels in mild (fev > % predicted), moderate (fev % to % predicted), and severe (fev < % predicted) adult cf patients. we compared these levels in cf subjects to age matched controls with normal bmi (range . to . kg/m ). we conclude that leptin levels are decreased, while ghrelin levels are increased only in cf patients with severe disease and low bmi. plasma levels of ghrelin and leptin did not differ from normals in those with mild and moderate disease. gastroesophageal reflux (ger) is common in cf before and after lung transplant (ltx). laparascopic fundoplication (lapf) is used when patients fail on conservative medical therapy. aims: to review longer term clinical outcomes of lapf in patients with cf in terms of lung function, body mass index (bmi), reflux symptoms, patient satisfaction with surgery and complications. method: retrospective review of patient records and patient questionnaire to gather relevant information. results:thirty-two patients with cf underwent lap.f recently; transplanted (ltxgroup), female (mean age [ - ]) years, and not transplanted (cf group), female ( ). the median time between ltx & lapf was ( ; ) days, range - . endoscopy was undertaken in patients prior to surgery and all underwent hr ph monitoring. complete (nissen) lapf was undertaken in % patients and a partial (toupet) in the other %. total median time in the operating theatre was ( - ) minutes. the average length of stay in hospital (in days) in the ltxgroup: pre-op. was . ; post-op. was . days; and in the cf group was: . and . respectively. lung function (fev and fvc in percent predicted) and bmi were measured at minus(-) , plus (+) , + and + days from lapf. patient satisfaction with lapf was a mean of % in the ltx group and % in the cf group and improvement in reflux symptoms of % in both groups. nocturnal cough reduced markedly in the cf group and there was an overall improvement in quality of life in both groups. complications consisted of port site hernias, failed lapf with re-operation months later; esophageal dilatations and patient with lower esophageal sphincter hypotonia. there were deaths on day , and post fundoplication. one was in a non-transplanted patient with recurrent episodes of hemoptysis. she succumbed to a catastrophic hemoptysis episode not related to lapf. the other were in transplanted patients. conclusions: in this relatively small series of patients there was a small but significant drop in fev in the ltx group days after lapf, but not in the cf group who remained stable throughout the review period. there was a significant drop in bmi in both groups after lapf, but the cf group returned to pre lapf values at + days. patient satisfaction with the procedure was high. fundoplication is an expensibe complicated procedure not without risk. a long term prospective study is warranted. historically this phenomenon has been attributed to intestinal malabsorption and cachexia as a consequence of chronic lung infection. however, cf mice exhibit similar growth and weight deficits but are not afflicted with malabsorption or lung infection, suggesting other mechanisms are participating as well. we hypothesize that small size is in part a result of increased β-oxidation in adipose stores. to test this we utilized a mouse model to study lipid metabolism. our study includes female cf mice with a null mutation in the cftr gene. these mice are congenic on the c bl/ j background as well as age matched with their controls (wt) to - days. liver, adipose and skeletal muscle (calf) were dissected from wt and cf mice in a fed state. tissues were immediately flash frozen in liquid nitrogen and used for rna and protein lysate harvest. quantitative pcr (qpcr) was performed using primers for the lipogenic isoform of acetyl-coa carboxylase α (acc α) in the liver and adipocytes, whereas the non-lipogenic isoform acc β was assessed in the skeletal muscle. primers for acyl coa oxidase (aox), carnitine palmitoyltransferase (cpt ) and long acyl-coa dehydrogenase (lcad) were used as gene markers for β-oxidation steps in the peroxisome, carnitine shuttle and mitochondrion, respectively. western blots were performed to detect acc (active) and phospho-acc (inactive) forms. the results show that there is a decrease in the total amount of acc protein in the fat as well as the skeletal muscle of the cf mice and the ratio of acc:phospho-acc is substantially lower in the cf tissues. phosphorylation and/or decreased expression of acc results in decreased expression of malonyl coa, leading to a cascade of events that increase β-oxidation. in addition, increased expression of aox and lcad, two downstream β-oxidation genes, is also observed. hyperactivity of the β-oxidation pathway could account for the decreased adipose stores seen in cf mice compared to the wt. such patterns of expression are reminiscent of starvation. caloric intake and intestinal absorption of dietary lipid were measured and cf animals consumed approximately % the calories of wt animals (per gram body weight) and lipid absorption was not significantly different ( % for cf, % for wt), indicating the cf animals have sufficient access to nutrition. we will continue to investigate fatty acid synthesis and degradation pathways during both the fed and fasted states to delineate the mechanism. this research was supported by grant hl . effect of gender on dha levels in p and rbc with lower values for male cf patients. acknowledgments: this work was supported by the belgian cf association (ablm), the french cf association (vlm) and by a grant from frs (ucl). data are expressed as means ± sd. * and indicate a significant difference with controls and cf ps patients respectively, p< . . background: deficit of antioxidant systems and increased oxidative stress have been demonstrated in cf patients with respect to healthy controls. the origin of this imbalance is known to be multifactorial. objective: the aim of our study was to assess changes in antioxidant systems and oxidative stress parameters in cf pediatric patients in presence or absence of pancreatic insufficiency material and methods: we recruited patients ( with pancreatic insufficiency pi and with pancreatic sufficiency ps) attending the cystic fibrosis centre of turin ( ) ( ) . during the annual routine control visit were performed antropometric measurements, pulmonary function tests (fev ), and were collected fasting blood samples and last days food record. vitamin e, a, c, selenium, glutathione (gsh, gshpx, gssg), dehydroascorbic acid, pcr were assessed. data were analysed using the two sample t-test with equal variances. results: there are not statistically significant differences between two groups for sex, age and fev . / of pi patients and / of ps patients took oral vitamin supplementation. serum levels of alpha-tocopherol and beta-carotene resulted within the local reference range either in pi or ps patients showing no significative differences. the mean serum levels were respectively suboptimal and optimal for vitamin e and a (biesalsky ' ). pi and ps patients did not show significant intergroup differences of water soluble and enzymatic antioxidants levels as well. serum levels of vitamin c, selenium, erythrocyte reduced glutathione (gsh) and glutathione peroxidase activity (gshpx) resulted within the local reference range. plasma vitamin c concentrations resulted slightly inferior to the optimal values (biesalsky ' ) in both groups. oxidative stress parameters (erythrocyte glutathione disulfide-gssg, dehydroascorbic acid) and inflammatory parameters (pcr) did not differ significantly, presenting values within the local reference range, in both groups. nutritional data revealed significantly reduced zscore for weight (p< . ) and height (p< . ) in pi patients vs ps patients. our data did not evidence significant differences in total energy (kcal/kg) and macronutrients (% of total kcal) intake in both pi and ps patients. dietary intake of antioxidant vitamins resulted slightly superior the rda (larn- ) presenting no significant intergroup differences. conclusions: this study shows that pancreatic insufficiency do not influence oxidant/antioxidant balance in cf patients at least in paediatric age. until innovative supplementation guidelines will be proposed for application, nutritional education and monitoring and correct dietary habits are useful to optimize antioxidant status in cf patients. there are more than cf mutations that are responsible for the spectrum of disease severity in cystic fibrosis (cf). the most common, f del mutation, is associated with pancreatic insufficiency (pi), and a classic phenotype. . yet even within a group of f del homozygotes, there is a small minority of patients ( . %) who are not taking pancreatic supplements, and are therefore presumably pancreatic sufficient (ps) (data from * cff registry). this observation prompted us to look more closely at enzyme use in cf patients with non-f del homozygous genotype. we reviewed enzyme use in cf patients who were fully genotyped and whose enzyme use was documented in the * cf registry. heterozygotes with one or two non-f del mutations were included in this analysis. using the assumption that the milder mutation is dominant, if the patient was ps and heterozygous with one f del mutation, the second mutation was classified as ps; if the person was pi, the second mutation was classified as pi. we also reviewed the pancreatic status and genotype of patients participating in the wisconsin newborn screening study. in this randomized control trial (rct), pancreatic status was determined by hour fecal fat analysis. enzyme use was extracted from the database for the year . there were patients in the cff registry with a total of different mutations. twenty-one of these mutations were associated with pi. this finding correlated well with the per cent of patients who were on enzyme supplements (range of per cent patients on enzymes by mutation - %). however when we looked at the six mutations associated with ps, the distribution of patients on enzymes vs. not, was much closer. see table below. possible reasons for enzyme supplement use by patients with ps mutations include a) treatment for recurrent pancreatitis, b)the fact that this is a cross-sectional analysis and patient may be on enzymes temporarily, c) patient may truly be pi, d) overuse of enzymes due to unreliable test to measure pancreatic status in patient, e) patients who are on enzymes are older, and have changed from ps to pi phenotype. this analysis suggests a need for better assessment of pancreatic status in patients with cf. * this analysis was originally done by request for the ecfs conference at garda on cftr genetics, and focused on the suggested " main mutations", and will be updated with the cff registry data. (supported by nih grants dk , dk , mo rr , mo rr ) number of patients in rct with each mutation: , , , , , respectively. dutta, a. ; woo, k. ; fitz, j.g. ; feranchak, a.p. . department of pediatrics, ut southwestern medical center/children's medical center, dallas, tx, usa; . medicine, ut southwestern, dallas, tx, usa extracellular atp is an important signaling molecule contributing to bile formation by the liver through binding biliary epithelial cell (cholangiocyte) membrane p receptors and stimulating cl-efflux. importantly, atp appears to work through cl-channels unrelated to cftr, suggesting it may be a potential way to modulate bile flow in cf liver disease. however, the signaling pathways linking receptor binding to channel activation in cholangiocytes are unknown. consequently, the aim of the present study was to identify the pathways responsible for atp-stimulated increases in [ca +]i and membrane clpermeability in a human biliary epithelial cell model. studies were performed in mz-cha- human biliary cells; [ca +]i was measured by fura- and membrane cl-currents by patch-clamp techniques. results: exposure of cells to atp ( µm) resulted in a rapid increase in [ca +]i to . ± . nm (n= ) which was abolished by prior depletion of intracellular ca + by thapsigargin ( . ± . nm; n= ), but unaffected by removal of extracellular ca + (egta, . ± . nm; n= ). in parallel studies, atp ( µm) increased current density from - . ± pa/pf to - . ± . pa/pf (n= ) . currents reversed at mv (ecl-), were outwardly rectifying, and were inhibited by the cl-channel inhibitor nppb (- . ± . pa/pf, n= ), but not the cftr inhibitor cftrinh . atp failed to activate currents after depletion of intracellular ca + stores by bapta-am (- . ± . pa/pf, n= ). the p y receptor antagonist suramin inhibited atp-stimulated increases in [ca +]i ( . ± . nm; n= ) and cl-channel activity (- . ± . pa/pf; n= ). however, the p x receptor antagonist brilliant blue g did not affect the magnitude of atp-stimulated cl-currents (- . ± . pa/pf, n= ). together these findings suggest that atp activates cl-currents primarily through p y, but not p x, receptors in human biliary cells. since p y are g-proteincoupled receptors and modulate [ca +]i by phospholipase c (plc) generation of inositol , , -trisphosphate (ip ), a series of experiments were designed to directly assess the effects of ip receptor inhibition or stimulation on atpstimulated cl-currents. first, the plc inhibitor, u blocked atp-stimulated cl-currents ( . ± . pa/pf; n= ). second, the specific ip receptor blocker -apb, inhibited both the atp-stimulated increase in [ca +]i ( . ± . nm, n= ) as well as membrane cl-currents (- . ± . pa/pf, n= ). lastly, intracellular dialysis with purified ip during whole-cell patch clamp activated cl-currents with identical properties to those activated by atp (- . ± . pa/pf, n= ). together these studies demonstrate that extracellular atp stimulates ca +-activated cl-channels in cholangiocytes primarily through p y receptor binding and plc/ip -dependent release of intracellular ca + stores. thus, the p y-ip receptor signaling complex represents a potential target to increase cholangiocyte secretion, and hence augment bile flow, in the treatment of the cholestatic liver disease associated with cf. supported by grants from the nih niddk and the cff to a. feranchak. background: supplemental pep therapy is used to treat cf patients with epi to assist with digestion, food absorption. this open-label, multipledose, single-treatment, multicenter study evaluated efficacy and safety of eur- for malabsorption treatment in young patients with cf and epi. eur- is a novel, zero-overfill, highly-stable formulation of porcinederived pancreatic enzymes, and was specifically developed for use in very young children allowing the product to be sprinkled on food. methods: eligible patients were < years with cf and epi, in acceptable nutritional status, needing peps and clinically stable. patients consumed a standard cf recommended diet, could not take drugs affecting gastric ph or motility. the trial involved a -day dose stabilization period and a -day treatment period. patients switched from their baseline enzyme treatment without washout. the optimal dose of eur- , determined during dose stabilization, was used during treatment. primary endpoint compared malabsorption of fat after eur- vs. previous treatment. clinical symptoms were also evaluated, as was physicians' and parents' judgment on the control of malabsorption signs and symptoms. safety measures included aes, physical exams, vital signs and changes in clinical laboratory findings, including cholesterol levels and fat-soluble vitamins. results: nineteen patients ( male) enrolled and completed all study phases. mean age was . years (range - ). percentage of responders (patients without steatorrhea (< % fecal fat content) and without signs and symptoms of malabsorption after and weeks of treatment) was . at baseline, . (p= . vs. base) after stabilization and . (p = . vs. base) at study end. frequency and oily stools showed a significant decrease vs. baseline at study end. the mean number of stools per day was . stools at screening and . stools during treatment (p< . ). the mean proportion of stool samples with visible oil or grease at screening was . % and . % during treatment (p= . ). a statistically significant improvement was seen in the incidence of moderate bloating. physicians characterized % of patients as "improved" in the control of epi signs and symptoms vs. previous therapies and % as "unchanged" at the end of the treatment phase, while parent assessments were % "improved" and % "unchanged." vitamin k absorption (measured through pivka) improved with eur- treatment over prior pep treatment measured at baseline. eur- was safe and well tolerated, with minimal aes. no aes led to discontinuation of study drug interruption. no incidences of uric acid toxicity or fibrosing colonopathy following eur- treatment. no trends were seen in lab parameters, physical examination, or vital signs. conclusion: eur- is effective, safe, well-tolerated in the treatment of epi in young cf patients. treatment controlled malabsorption and clinical symptoms of epi in young patients with cf. safety and efficacy of eur- in this trial is consistent with the pivotal phase iii trial. there is an association between the presence of cf and alterations in fatty acid metabolism, consisting of a decrease in linoleate ( : n- ). more recently, a deficiency of docosahexaenoate ( : n- , dha) has arisen as a prominent fatty acid abnormality in cf. an established breeding colony of exon cftr knockout (cftr-/-, cf, n= ) and wild type (wt, n= ) mice was used for this study. all mice were weaned at days of age and then raised on peptamen and water until days of age, and then continued for days with ml/day of peptamen to homogenize the nutritional status. after this period, some mice (n= per group) were subjected to dha treatment ( mg/day) for one week. after sacrifice, pancreatic tissue was collected, homogenized and extracted. lipid classes were separated by sequential elution in aminopropyl columns. the eluted fractions were transmethylated and injected into a hewlett-packard a gas chromatograph with a flame ionization detector for quantitative analysis. the vast majority of fatty acids were mainly distributed in phospholipids, except those with -carbons. wt and cf mice were studied a gender gap in the survival of cystic fibrosis (cf) is well-documented. however, little is known whether there is a gender différence in pubertal growth pattern in cf children. delayed and attenuated pubertal growth are commonly observed in adolescents with cf. however, characterizing height velocity (hv) pattern is very challenging because of errors associated with calculating hv, e.g. interpolation and extrapolation between heights measured in irregular intervals, as well as difficulties in determining the location and the magnitude of peak height velocity (phv). in this study, we applied a new statistical method, namely, the semi-parametric shape-invariant model, to characterize the hv pattern of cf children. this method is based on the assumption that all individuals' growth curves have a common shape. therefore, this method attempts to shift and stretch (squeeze) individual's growth data until they can be modeled by the common shape curve. the semi-parametric shape-invariant model has the advantage of fitting measured heights directly, thereby eliminating the errors associated with calculating hv. the study population included cf children who had height measurements between ages to years documented in the - cff registry. because fitting each individual height curve is computing-intensive, boys and girls were randomly chosen for this preliminary analysis. our results showed that girls exhibited a typical growth deceleration during late preadolescence, followed by accelerated hv and a single phv during adolescence (figure) . unexpectedly, cf boys exhibited a notable hv peak during late preadolescence in addition to the typical adolescent phv (figure) . overall, the mean magnitude and age of phv was . cm at . years for boys and . cm at . years for girls. when compared to phv of non-cf children based on tanner's reference (pediatr. , : ) , cf boys showed a greater delay in the age of phv while cf girls showed a greater attenuation in the magnitude of phv. further analyses are being performed to characterize the hv patterns of all children to confirm these results. (supported by nih-dk ). anelli, m.; foresti, r.; peloso, l.; ortenzi, g. medical affairs, eurand, pessano con bo, italy background: given their inherent instability, the dose units of all pancreatic enzyme preparations (peps) have always been "overfilled" to compensate for enzyme degradation over time and assure at least % of the label lipase content at the end of their shelf life. this overfill issue was first examined by whitehead who reported overfills ranging from to % after analyzing several commercially available peps (whitehead am. pharm weekbl sci. ) . the usp presently allows for pep overfills up to %. thus, the actual active lipase content of a pep capsule labelled at , iu might vary from , to , units according to its "freshness." as a result, patients taking peps receive a product with variable potency, which can lead to efficacy issues, increased pill burden, unnecessary drug interactions, and product switching. the fda has also noted the potential safety risk posed by overfilling and, in a recently published guidance, it imposed a zero overfill requirement for all peps to be marketed in the usa after april . methods: over a period of two years, we ran a series of tests similar to those conducted by whitehead to evaluate overfill on commercial peps currently available in the u.s. and europe. results: no finished product was formulated to % of the labelclaimed lipase enzyme activity. overfill on commercially available peps ranged from % to %, with a median value of %. the peps analyzed were to months old on average; therefore, the actual amount of overfill is likely underestimated. conclusion: our findings confirm those reported earlier by whitehead and demonstrate that none of the currently available peps complies with the zero overfill requirement of the fda guidance. these findings highlight a potential cause of suboptimal therapy with currently available peps. references: -whitehead am. study to compare the enzyme activity, acid resistance and dissolution characteristics of currently available pancreatic enzyme preparations. pharm weekbl sci. feb ; ( ): - . -food and drug administration. guidance for industry: exocrine pancreatic insufficiency drug products -submitting ndas. april . heubi, j. ; boas, s.r. ; blake, k. ; nasr, s.z. ; woo, m.s. ; graff, g.r. ; hardy, k.a. ; amaro-galvez, r. ; latino, m. ; lee, c. . children 's hospital medical center, cincinnati, oh, usa; . chicago cf care, glenview, il, usa; . nemours, jacksonville, fl, usa; . michigan u, ann arbor, mi, usa; . children's h, los angeles, ca, usa; . penn state h, hershey, pa, usa; . children's h, oakland, ca, usa; . texas u, tyler, tx, usa; . eurand, milan, italy; . eurand, vandalia, oh, usa background: supplemental pep therapy helps prevent maldigestion and malabsorption in cf patients. eur- is a novel, zero-overfill, highly-stable formulation of porcine-derived pancreatic enzymes developed to treat epi in cf patients. this phase iii, randomized, doubleblind, placebo-controlled, two-treatment, crossover, multicenter trial evaluated the efficacy and safety of eur- to treat epi in cf patients. methods: patients with confirmed cf and epi, age ≥ years, good nutritional status and weight ≤ kg were enrolled. no drugs affecting gastric ph or motility were allowed. after open-label dose titration, patients were randomized to receive eur- or placebo over a week-long period. following another open-label normalization, all patients were crossed over to the alternative treatment arm. primary endpoint was change in coefficient of fat absorption (cfa) following oral administration of eur- vs. placebo. secondary endpoints were change in coefficient of nitrogen absorption (cna), cholesterol, fat soluble vitamins, body weight, bmi and epi symptoms following oral administration of eur- vs. placebo. safety endpoints included aes, clinical laboratory parameters, physical exams and vital signs. results: thirty-four patients were enrolled ( female); were evaluated. mean age was . years (range - ). eur- treatment was associated with statistically significant (p< . ) increases in both cfa and cna vs. placebo. eur- treatment was associated with decreases in pivka ii (an indicator of vitamin k status). epi symptoms consistently improved during eur- treatment, including a statistically significant reduction in stool frequency and fewer soft and watery stools. treatment with eur- improved the signs and symptoms of malabsorption even in the small subset of patients with cfa values greater than % under placebo treatment. there were no notable changes in serum lipids, vitamin a and e values, mean weight or bmi in patients who received eur- . eur- was safe and well-tolerated. there were no unexpected or significant differences in the frequency or type of aes between eur- and placebo, and no trends were seen in lab parameters or vital signs. no patient discontinued from the study due to an ae. two serious aes were considered unrelated to the study drug and both resolved. conclusion: in this randomized, double blind, placebo-controlled study, eur- was safe, well tolerated and effective in the treatment of cf patients with epi, with clinically and statistically significant improvements in cfa, cna, and epi signs and symptoms in the absence of any concomitant treatment affecting gastrointestinal motility and ph. the therapeutic benefit of eur- was seen even in patients with very high cfa values (> %). the relative infrequency of cystic fibrosis related diabetes (cfrd), until recently, means little is known about hypoglycaemia ('hypos') associated with its treatment. insulin is frequently taken by those who have cfrd, for whom the risk of hypoglycaemia may be high due to dramatic changes in insulin sensitivity that can occur with pulmonary exacerbations and a decreased ability to secrete glucagon. a number of studies involving people with type diabetes mellitus (t dm) have reported on their experiences of hypoglycaemia, but whether results from such investigations apply to cfrd is unclear. an exploratory investigation was conducted to compare the type, frequency and severity of hypoglycaemic symptoms experienced by patients who had cfrd with patients who had t dm. method a cross sectional study was conducted, involving adults ( - years) with t dm or cfrd, recruited from two hospitals in england. a questionnaire, sent to patients with t dm and with cfrd, included investigator-developed items about knowledge and frequency of hypoglycaemia and the edinburgh hypoglycaemia scale (ehs), a standardised measure that assesses autonomic (e.g. sweating, hunger) and neuroglycopenic (e.g. confusion, poor co-ordination) symptoms associated with hypoglycaemia. questionnaire data were entered into spss for analysis. comparisons were conducted using t-tests, mann whitney tests or chi square tests as appropriate. results questionnaires were returned by patients with t dm and with cfrd. five of those with t dm were over years of age and, therefore, excluded from analysis. almost all participants had experienced a 'hypo' ( %). comparisons between the two groups are reported in table . conclusion patients with cfrd reported fewer and tended to have less severe episodes of hypoglycaemia compared to those with t dm. fewer neuroglycopenic symptoms in the former could be related to their shorter duration of diabetes or to how cfrd was managed; patients with cfrd were given shorter acting insulin, making them less prone to 'hypos' during the night, and had a high sugar diet to ensure weight maintenance. differences between the groups could also be related to specific characteristics of these two forms of diabetes. table : data from questionnaire insulin resistance. the purpose of this study was to investigate the relationship between pem and the risk of developing glucose intolerance and/or cfrd and the effect on lung function in children ≤ years of age whose history suggests pem. patients whose diagnosis of cf was suggested by failure to thrive(ftt) and whose growth parameters remain < % for weight and height for age were identified as having incurred pem. a retrospective analysis of our cf registry database was performed. cf patients ≤ years old were identified. of patients( . %) had cfrd. ( . %) of these plotted < % for weight and height (pem)and ( . %) were diagnosed with cfrd. further review of the patients showed whose diagnosis of cf was suggested by ftt and ( . %) of those had cfrd. statistical analysis did not show a clinical significance, but a strong relationship is implied. pulmonary function, fev %, was significantly lower in the pem/cfrd patients (mean fev . % ± . %) than the pem only group, (mean fev . % ± . %)(p= . ). this review provides further support that patients who have pem are at increased risk of developing cfrd. a significant risk was not established; however a strong association is suggested. assessment of a larger cohort of patients may show a stronger relationship. findings from this study would suggest that further research into the physiological relationship between pem and cfrd should be initiated. cfrd screening should be considered at a younger age than the current cff recommended age of > years. diagnosing cfrd/glucose intolerance early may contribute to improve growth parameters, preserve lung function, and improve survival. based on this review, our center is initiating cfrd screening for all patients ≥ years, and considers screening for all pem patients ≥ years. background: patients with cf are thought to have a rapid postprandial rise in plasma glucose which may be followed by a delayed and prolonged insulin response and hypoglycemia. we sought to estimate the prevalance, cumulative one year incidence, and factors associated with hypoglycemia during oral glucose tolerance testing in non-diabetic adults with cf. we also compared the prevalence of hypoglycemia to a geographically matched cohort of young adults without cf. methods: we performed a prospective study of individuals aged over years with cf followed in clinic providing population-based, specialized care in cambridgeshire, england. we excluded patients with previously-diagnosed diabetes or taking anti-diabetic medications. we evaluated individuals who underwent g hour oral glucose tolerance testing (ogtt) in . of these, individuals had neither new diabetes nor hypoglycemia in and were retested using ogtt in . we testing the association between biochemical and anthropometric factors measured in with the prevalence of hypoglycemia in , and incident hypoglycemia in . biochemical hypoglycemia was defined as a blood glucose between < . mmol/l ( mg/dl), but greater or equal to . mmol/l ( mg/dl) and severe hypoglycemia as a value lower than . mmol/l on either the fasting or post glucose challenge value. for comparison, we used data from the cambridgeshire-based young ely study of individuals age - years who underwent g ogtt testing in - . results: in , in patients with cf, the prevalence of fasting hypoglycemia was . %. no patients had fasting severe hypoglycemia. following glucose challenge, . % and . % of patients had glucose values consistent with hypoglycemia and severe hypoglycemia respectively. there were no diferrences in age, hepatic, pulmonary or renal function, but patients with hypoglycemia at two hours were five times more like to be male (odds ratio . , % ci . - . ) and more likely to have a higher bmi. the prevalence of a hours value of < . mmol/l in patients with cf at . % ( / ) was not different than in controls . % ( / ). of patients who did not have hypoglycemic readings in , at one year, patient developed fasting hypoglycemia and individuals developed post-challenge hypoglycemic for a cumulative incidence . %. of these . % ( ) had values in the range of severe hypoglycemia. there were no differences between age, sex, bmi, liver, renal, or pulmonary function in those who did and did not develop hypoglycemia. conclusions: hypoglycemia appears common in patients with cf but is also common in a healthy population. male sex and bmi were associated with post load hypoglycemia in patients with cf in cross-sectional analyses only. further research needs to assess whether these low blood glucose values are associated with symptoms. it is well recognised that cystic fibrosis related diabetes (cfrd) is a poor prognostic indicator in cf, and therefore early recognition is imperative to allow effective treatment in an attempt to prevent the associated decline in pulmonary function and nutritional status. although the oral glucose tolerance test (ogtt) is the accepted method of detecting diabetes mellitus in non cf individuals, glucose intolerance and lack of insulin can be variable in cf patients such that the reliability of ogtt in the diagnosis of cfrd has been questioned. under these circumstances, other methods of monitoring glucose intolerance, such as serial post prandial glucose monitoring (sgm), may be more appropriate. to look at this further, we prospectively compared ogtt with sgm in a group of adult cf patients. fourteen patients with no previous history of cfrd ( ], df homozygous, male) admitted for acute pulmonary exacerbations were evaluated. all were exocrine pancreatic insufficient, and was on long term oral steroids. eleven patients received mg/day oral prednisolone in addition to iv antibiotic therapy for the duration of their admission. ogtt was performed in the standard fashion (ingestion of . g glucose/kg body weight [maximum g] within minutes, after an overnight fast). sgm was performed hours post prandially and before bedtime over the period of the admission. the local ethics committee approved the study and informed consent was obtained from all patients. results sgm revealed elevated postprandial blood glucose values in all patients. there were episodes (mean per patient [ to ]) with glucose > . mmol/l (frank diabetes, who criteria) and episodes (mean per patient [ to ] ) with glucose . to . mmol/l (impaired glucose tolerance, who criteria). however, ogtt revealed impaired glucose tolerance in only one patient ( hour glucose value . mmol/l). in the remaining patients, ogtt revealed normal hour glucose values (mean . mmol/l [range . to . ]). fasting plasma glucose values were also normal (mean . mmol/l [ . to . ]) in all patients. we have shown a high prevalence of hyperglycaemia in our adult patients admitted for pulmonary exacerbations that was only detected using serial glucose monitoring. this study suggests that sgm may be more sensitive at detecting early cfrd than the ogtt. further work needs to be carried out to look at the best methods of diagnosing cfrd, to facilitate early treatment and thereby improve the prognosis. the diagnosis of cystic fibrosis related diabetes (cfrd) is associated with a decline in pulmonary function and nutritional state and is a poor prognostic indicator: the risk of its development increases with age. furthermore, the development of cfrd is due to a gradual loss of insulin production, and the disease may therefore be preceded by a period of glucose intolerance. despite this, the incidence of hyperglycaemia in cf patients is unknown. to study this further, we monitored the blood glucose profiles of adult cf patients admitted for the treatment of a pulmonary exacerbation. we looked at consecutive cf patient admissions for iv antibiotic therapy to our large adult unit. of these, had established cfrd and were excluded. the remaining patients (mean age years [range to ], male) formed the study population. none were on long term oral steroids, but received mg/day prednisolone as part of their routine exacerbation treatment. all patients underwent blood glucose measurement hours after each meal and before bedtime as part of a standard assessment protocol in our clinic. thirty patients ( %, / on steroids) demonstrated post prandial hyperglycaemia: exhibited values between . and . mmol/l (impaired glucose tolerance, who criteria) and > . mmol/l (frank diabetes, who criteria). there were no significant differences in age, genotype, fev , fvc, bmi, or duration of hospital stay between the two groups. of the hyperglycaemic patients, ( %) had abnormal glucose levels detected before bed time, significantly more than hours post breakfast ( %, p< . ), post lunch ( %, p< . ), but not post dinner ( %, p= . ). this study has shown a high prevalence of hyperglycaemia in adult cf patients treated for a pulmonary exacerbation who were not otherwise known to suffer from cfrd. nearly all our patients demonstrated glucose intolerance later in the day, when the recommended screening test for cfrd (the fasting oral glucose tolerance challenge) cannot be used. post prandial glucose monitoring of such patients during times of stress may therefore be advisable, allowing the introduction of insulin treatment at an earlier stage in the disease process. whittaker, l.a.; tilluckdharry, l.; christian, r. medicine, university of vermont, burlington, vt, usa objective: bone disease is a recognized complication of cystic fibrosis (cf). there are currently no guidelines for bone mineral density (bmd) testing or tools for fracture risk assessment in cf adults. we piloted a survey designed to identify cf-specific risk factors for low bone density and fracture. methods: a question survey was completed by patients prior to measurement of bmd at the hip, spine and radius by densitometry (dxa). the survey was comprised of questions on calcium and vitamin d intake, exercise, family history, medications, reproductive health, ultraviolet exposure, cf related diabetes (cfrd), weight loss, severity of cf lung disease and quality of life. z scores (bmd adjusted for age and gender) were used so that male and female data could be analyzed collectively. patient perceived health (pph) was rated by four questions and totaled for the pph score, which ranged from - with the highest score indicating the best health. functional status (fs) was rated by three questions that reflect the degree to which cf interferes with school, work or play. the total fs score ranged from - , with the highest score representing the least interference with life. questions on pph and fs were derived from a validated clinical assessment tool, the cf questionnaire (cfq) ( ) . results: all cf adult patients (n= , age and older) were offered participation in the study. dxa of total hip and lumbar spine was performed on patients ( %); ( %) of these patients also completed the survey. % of patients had low bone density on dxa (z score <- ). % of male cf adults had low bone density vs % of females. fracture was reported by % of patients who completed the survey ( % female and % male). lower pph score was associated with lower z score at the hip and spine. lower fs score was associated with lower z score at the hip and spine. low body mass index was associated with low z scores at both hip and spine. patients with bmi below kg/m were most likely to have osteopenia. conclusions: osteopenia and history of fracture were common in our adult cf population regardless of gender. bmi, pph and fs predicted bone density. risk stratification by a cf-specific bone health survey may guide bone density screening strategies for cf adults. prospective studies in cf adults are needed to determine whether a cf-specific survey can predict fracture risk as well as bone density. references : as life expectancy in cystic fibrosis (cf) increase, osteoporosis has become more prevalent. vitamin d status is one of many factors that contribute to optimal bone health. previous data has shown, the majority of cf patients are deficient in vitamin d despite being prescribed daily cf specific vitamin therapy. previous research has also shown that the current recommendations for vitamin d supplementation and repletion provided by the cystic fibrosis foundation bone health consensus ( ) are not sufficient to achieve optimal vitamin d levels in the majority of patients. moreover, the recommendations fail to sustain levels in the optimal range for bone health. purpose: we demonstrate a successful supplementation algorithm for individualized high dose vitamin d with continued high dose maintenance therapy which achieves and sustains appropriate levels. methods: all patients followed at the pediatric center are prescribed routine cf vitamin supplementation. vitamin d levels are obtained as part of routine clinical care via mass spectroscopy. if serum vitamin d level is < ng/dl, vitamin d therapy with ergocalciferol is initiated one time per week. patients < years of age receive iu/ dose and > years of age receive iu/dose. at the next routine quarterly visit, vitamin d levels are re-assessed via mass spectroscopy to determine efficacy of once weekly supplementation. if levels are > ng/dl, patients continue high dose supplementation time a week as maintenance therapy. however, if levels remain < ng/dl, the ergocalciferol is increased by time a week in month increments until adequate levels are obtained. once adequate serum vitamin d levels are obtained, patients remain on the level of supplementation needed to achieve levels > ng/dl as maintenance therapy. all patients are instructed to take vitamin d and their cf vitamins with enzymes and food to optimize absorption. results: after implementation of the algorithm, . % of patients, with varying levels of supplementation, had vitamin d levels > ng/dl (mean= . ng/dl). of the patients that achieved goal vitamin d levels, % were able to achieve and sustain adequate vitamin d levels without additional vitamin d supplementation while on standard cf vitamins (mean vitamin d level = . ng/dl). the remaining patients required chronic maintenance vitamin d: % required vitamin d supplementation once per week with a resulting mean vitamin d level of . ng/dl, . % required maintenance vitamin d supplementation twice per week with a resulting mean vitamin d level of . ng/dl, and, . % required vitamin d supplementation or more times per week with a resulting mean vitamin d level of . ng/dl. another % of patients take vitamin d supplements other than ergocalciferol and were not included in this study. conclusions: individualized vitamin d repletion and maintenance therapy as outlined in our algorithm is a successful mechanism to obtain optimal vitamin d levels in patients with cf. inhaled tobramycin ( %). sixty-two percent reported using at least different types of oral medications on that day including pancreatic enzymes ( %), oral antibiotics ( %), anti-reflux medication ( %), azithromycin ( %), anti-histamine ( %), and a decongestant ( %). twenty percent reported taking at least one medication for pain. forty-nine percent reported performing airway clearance at least twice during the day with % using a vest, % performing standard chest physiotherapy, and % using a flutter or acapella device. there was no difference in the reported number of medications or the reported time needed to complete therapies based on respondent age. although respondents with severe lung disease (fev < % predicted) reported a higher median number of therapies ( vs. , p= . ), the reported time for completing therapies was not associated with fev (p= . ). conclusion: daily treatment burden and complexity in all adults with cf is high, and is only marginally increased in those with worse pulmonary function. given this already high load of daily therapies, efforts to assess the treatment burden of new cf therapies are warranted. the impact of this high treatment burden on overall health related quality of life for adults with cf needs to be assessed. objective: the cystic fibrosis foundation (cff) has a network of over accredited care centers throughout the united states. data is collected from these care centers to help better understand the disease and describe changes in survival, standards of care, and health outcomes. when the cff was founded in few children survived to school age. now the predicted survival extends beyond the mid 's (cff, ) . with this change has come the need for age appropriate care in many areas including reproduction. the adult cystic fibrosis center at morristown memorial hospital presently follows adults. of those, women( %) with cf have had children affected with cystic fibrosis. each woman was diagnosed after her child. the cf data registry does not have any means of identifying if a patient has an affected child. as the average age of survival of cf patients has increased, so has the likelihood of cf patients having cf offspring. what is the estimated incidence of cf patients having cf affected children attending accredited cf centers in the united states? method: questionnaires were sent to care centers and satellite centers via standard mail or facsimile based on information from the cff directory. one month after the last questionnaire was mailed, the cf foundation sent out a reminder email to the nurse coordinators. questions asked were as follows: ) name of center ) do you presently care for any patients with cf who have given birth to, or fathered a cf affected child? ) how many patients at your center have had cf affected children? ) was the parent diagnosed before or after pregnancy was confirmed? ) if parent's diagnosis came after conception, was this after child was diagnosed? ) was the parent's diagnosis a result of prenatal testing? results: a total of questionnaires were mailed or faxed. this netted a result of responses. after email reminder, an additional questionnaires were returned for a total of responses, an % response rate. name of center was checked to remove duplicate information. the number of parents with cystic fibrosis who have had children with cf numbered . of those, ( %) were diagnosed before pregnancy; ( %) were diagnosed after pregnancy. of those diagnosed after pregnancy, the majority ( %) were diagnosed as a result of their child's diagnosis. only ( %) were diagnosed as a result of prenatal testing. conclusion: based on the responses from accredited cf care centers, patients with cf have children also affected with this disorder. prior to conceiving their child, % knew that they had cf. having cf did not appear to be a deterrent to delivering cf offspring. this study did not look at the age of the parent or child; they may have conceived their child before genetic screening was common for spouses. as the median survival of this population increases, the incidence of cf adults with cf children may also increase. the cff may choose to add a question to the cf data registry, identifying cf patients with cf offspring. the potential physical and psychosocial impact can then be tracked. anderson, a.; popli, k.; stewart, j.; heslop, k.; gascoigne, a.; bourke, s. adult cystic fibrosis centre and fertility centre, royal victoria infirmary, newcastle upon tyne, united kingdom as the outcome of patients with cf improves fertility issues become increasingly important. almost all men with cf are infertile because of azoospermia due to congenital absence of the vas deferens. these men can attain genetic paternity by sperm aspiration from the epididymis or testis with intracytoplasmic sperm injection (icsi), but few men with cf seek fertility treatment to assess their knowledge and attitude towards fertility issues a questionnaire was sent to men with cf: ( %) responded; ( %) declined to give information and ( %) replied in full. overall % thought that nearly all men with cf were infertile, % did not know how many were affected, and % could describe the exact nature of infertility. only % knew that treatment for infertility was available: % of these thought it was rarely successful and % were unsure of success rates. although % had thought of having children at some stage, only % had sought investigation of infertility. two men had children, one by icsi and one by donor insemination. overall % feared that the child could have cf and % worried that their health would affect their ability to function as a parent. in terms of receiving advice % thought that this should be given by a fertility specialist, % by a cf physician and % by a primary care physician. with regard to fertility treatment % thought that decisions should be made by the patients and their partners, % by the patient alone, and % by a doctor. the reluctance of men with cf to seek fertility treatment appears to be due to many factors including lack of knowledge of available treatments, fears about the child inheriting cf, and concerns that their health would adversely affect their role as a parent. in addiition to information provided by the cf team advice from a specialist in fertility treatment may help to improve the provision of reproductive counselling to these patients. nash, e.f. , ; coonar, a.s. ; stephenson, a.l. , ; delgado, d.h. ; singer, l.g. , ; tullis, e. , ; chaparro-mutis, c. studies have shown varying degrees of right ventricular (rv) dysfunction in adult cf patients with severe lung disease. left ventricular (lv) dysfunction is much less common with conflicting reports as to its prevalence. pulmonary hypertension (ph) is commonly seen, the severity correlating with fev . one group reported that ph was more prevalent in b. cepaciacolonized patients, albeit in a small sample. the aim of this study was to determine the true prevalence of ph and cardiac dysfunction in cf patients with severe lung disease. we carried out a retrospective cohort study of all adult cf patients referred to the lung transplant program at toronto general hospital from - . adult patients referred with non-cf bronchiectasis were included for comparison. demographic data, lung function, -minute walk, micro-biology, doppler echocardiography and resting and stress radionuclide ventriculography (muga) results were analyzed by students t-test (parametric) or mann whitney u test (non-parametric). results adult cf patients ( % non-b. cepacia, % b. cepacia) and non-cf bronchiectasis patients were included. data from these groups are summarized in the table. we found higher minute walk and bmi values and a higher percentage of males in the b. cepacia compared to non-b. cepacia group. ph was present in % of the cf patients in whom pasp could be obtained. b. cepacia patients had lower first pass rvef compared to non-b. cepacia patients. % of the b. cepacia patients had an abnormal lvef response to exercise (defined as < % increase on exercise) compared to % of the non-b. cepacia patients. we found a high prevalence of ph as well as rv and lv dysfunction in cf patients with severe lung disease. b. cepacia-colonized patients had worse rv function compared to non-b. cepacia-colonized patients on first pass radionuclide ventriculography. *non-cf bronchiectasis group older than cf groups (p< . ) b. cepacia cf group higher than non-b. cepacia cf group (p< . ) b. cepacia cf group lower than non-b. cepacia cf group (p<. ) perobelli, s. ; dorazio, c. ; assael, b. ; tamanini, a. ; castellani, c. . cystic fibrosis center, verona, italy; . molecular biology laboratory, verona, italy cf neonatal screeening (nbs) can identify neonates with elevated irt, normal or borderline sweat chloride concentrations, and one cf mutation plus an additional cftr sequence variant, or, alternatively, two cftr sequence variants. the combination of hypertrypsinogenemia and two cftr gene defects is consistent with the presence of a cftr-related disorder (cftr-rd). although these neonates are usually healthy at diagnosis, the long-term phenotypical consequences may be highly variable. such variability makes impossible to predict the clinical outcome, and provide satisfactory genetic counselling for the family. the diagnosis of such a vague condition could potentially cause considerable family stress. this study aimed at assessing how parents of infants diagnosed with a cftr-rd through nbs perceive their children's health. a questionnaire for parents was designed, consisting of three sections. the first section asked about information given to the family in the neonatal period, and about emotional reactions to the cftr-rd communication of diagnosis. the second section investigated the present perception of the child's health, and the parents level of anxiety/concern. the third section focused on the impact of the diagnosis on family planning, on relationships inside the couple and with the child, and on emotional distress; this section was concerned also with the use of carrier testing in relatives. parents were also asked to fill in a standardized form on child behaviour (achenbach child behaviour check-list). the questionnaire was distributed to two populations, the parents of children diagnosed with cftr-rd through nbs (group a), and the parents of children diagnosed with cf through nbs as the life expectancy of children with cf increases new issues arise that have not been dealt with in the past. in the past,issues related to the support and care of a young adult with cf were rarely raised because only small numbers of children with cf lived into adulthood. however, with an increasing young adult population, young adults without family support have surfaced in significant numbers and their needs should be identified and understood by the cf center care team. these young adults face the same range of issues others with cf face related to health insurance, government benefits, housing, education and employment. however, they do not have a family to help them wiht support, health insurance benefits and care needs. method in october , the cf legal information hotline ("hotline") began to provide free and confidential information to people with cf, family members and healthcare providers in the u.s. the hotline is staffed by attorneys, beth sufian and james passamano(bs and jp) and is accessed by dialing a toll free number or by e-mail. information about the hotline is available at cf care centers, in cf publications and on the web. information regarding the content of each call is recorded on an intake form and includes caller name, address, phone number, age of person with cf, cf center attended, and information related to the caller's question, attempts made to access legal information prior to calling the hotline, relation of access to information to access to care. calls and e-mails are tracked by seven major categories which are divided into subcategories. if a caller has more than one question, the call is tracked using the caller's primary issue. results from november to april the cf legal information hotline has received calls from young adults with cf who do not have family support and have issues related to obtaining health insur-ance, government benefits, educational oppornties or employment opportunities. as well as issues related to lack of support for care. the hotline has also received calls from cf care centers team members with questions related to the needs of young adults without family support. over an eight year period the cf hotline received _______calls. the categories for the calls were: social security benefits ( , ) , health insurance ( , ) , educational ( ), employment ( ), long term disability benefits ( ), family law ( ) and miscellaneous legal issues ( ). discussion people with cf face obstacles to care if they are unaware of their legal rights especially in the areas of health insurance and government benefits. healthcare providers are busy addressing the medical needs of patients and are often not well equipped to provide detailed information about the legal rights of their patients. the hotline provides important information to both patients and healthcare providers that can optimize both patient care and outcomes. access to legal information can result in individuals obtaining health insurance, medicaid, medicare or other state coverage that in turn results in better access to treatment. legal information can also lead to important modifications in the educational or employment environment for the individual with cf. these modifications can be critical in allowing those individuals access to important care and treatments. providing information that can help individuals obtain social security or long term disability benefits can result in a monthly benefit and health insurance that then allows the individual to devote more time to their healthcare. many people with cf and healthcare providers lack information about the legal rights of individuals with cf. understanding the legal rights of people with cf can reduce obstacles to obtaining care, optimize education and employment, and increase access to retirement benefits. further work needs to be done to identify ways to make individuals with cf and healthcare providers aware of the hotline. the cf hotline provides a unique service to cf patients and healthcare providers by providing information regarding the legal rights of people with cf. identification of ways to assist young adults without family support should be identified and cf center xcare teams shoudl be given the tools to allow them to help their patients access government assistance and other programs that can help make sure that the young adults have acces to care and support they need to live with cf. the dvd gives healthcare staff, patients and families a rare glimpse of ten couples with cystic fibrosis (cf) interacting at a cf care center-sponsored 'couples support group'. they discuss the impact this forum has in their daily lives for gainingo information about how cf affects their lives as individuals, and as couples, and how the 'non-cf partner' learns from others. o skills at networking and personal coping strategies. o reflections on 'family life and cf', and o observations on ways cf care centers can join them in greater health partnership. lastly, this dvd provides a 'starter kit' for ways to establish such a group. one of the realities of a life-threatening illness can be that of social isolation, and of separation from others who share the same disease. having the opportunity of participate in a support group can significantly reduce that sense of isolation and give the participants an ability to share experiences and give support to others with this disease. cystic fibrosis as an illness has growing ranks of 'survivors' who live longer, fuller lives, thanks to the advances made on multiple-research fronts. historically, adults with cystic fibrosis have not had much occasion to share person-to-person experiences within the structure of their cf care centers. justifiably, with the potential for cross-infection, the cystic fibrosis foundation has urged caution for the cf population in having face-to-face interactions. in , our cf care center recognized this need and sponsoredwith guidance from staff facilitators-an on-going adult support group. prior to the formation of the group pre-and on-site group ic protocols were developed. at the pre-group stage, the physician initially certifies that the patient is free from aggressive pathogens. each time the patient rsvp's permission to attend a group session, the physician must 'recertify' this status. on-site protocols emphasize a number of ic precautions to minimize crossinfection. the center recognized that by developing such a support group, 'patient and family centered care' could be enhanced. a goal in the group's formation was to create 'mutually beneficial partnerships among patients, families, and healthcare providers'. group structure/successes to date: the group is limited to participants. two cf care center staff act as facilitators. this is a support, not a therapy group. compliance with therapies is reported to have increased as one outcome of this forum. formal topics are purposefully not predetermined; the group's success is predicated on the personal responsibility of each participant to bring topics/issues from their daily life experiences. the group has gained identity and trust and has evolved over three years into two separate groups: an individual cf group and a couples cf group. ownership of these groups by those who attend is apparent. both the care center and the couples support group are forums for learning 'how to live with cf'. future goals will call for using identified quality of life tools to measure psychosocial and emotional growth in individuals through their participation over time in the group. sawicki, g. ; asher, d. ; dill, e. ; sellers, d. ; robinson, w. . children's hospital, boston, ma, usa; . education development center, newton, ma, usa background: advance care planning (acp) is an important tool to promote alignment of the patient's care with his or her needs, goals and values, and is particularly useful if the patient's ability to make decision becomes compromised. the purpose of acp is to develop a treatment plan promoting a high quality of life for those near the end of life. such planning is especially appropriate in persons with life limiting disease. minimal research exists on the advance care planning process of adults with cf.<p>methods: in the fifth survey wave of the project on adult care in cystic fibrosis (pac-cf), an ongoing longitudinal panel study of cf adults from cf centers in the us, participants were asked to report on their opinions and experiences with advance care planning. the survey asked about opinions on advance care planning documents, communication about advance care planning with family and clinicians and whether a directive had been completed. clinical data were obtained from the participating centers. preliminary bivariate analyses were conducted to examine factors associated with completing an advance care directive.<p>results: / ( %) surveys were completed. the mean age was ± years, % were female, and the mean fev (% predicted) was ± . % reported that they had spoken to someone about the care they would want if they became too ill to make their own decisions in the future, % had thought about whom they would want as their healthcare proxy, and % reported having specific wishes about the types of medical treatment they want or would not want if they became too ill to make decisions for themselves in the future. however, only % reported completing a healthcare proxy form, living will or any other type of written instructions concerning advance care directives. % of respondents reported feeling comfortable talking to their clinician about acp. % of subjects said that their cf clinicians have asked them about acp, and only % reported that they have discussed acp with their cf clinician. the following characteristics were significantly related (p<. ) to completion of an advance care directive: female gender ( % vs. %), age (mean years vs. years), having a college degree ( % vs. %), being married currently or in the past ( % vs. %), having children ( % vs. %), having diabetes ( % vs. %), having specific wishes about treatment decisions ( % vs. %), and reporting that a clinician had discussed acp with them ( % vs. %).<p>discussion: though the majority of cf adults report thinking about, communicating with family and deciding on their advance care wishes, only a minority report completing any legal documentation supporting their decision. additionally, very few cf adults report being asked about acp by their clinicians and even fewer report discussing acp with them. formulating specific wishes and discussing acp with a clinician are strongly associated with completing an advance care directive, suggesting that if clinicians were more active in talking to their patients about acp, patients are much more likely to complete advance care directives. efforts to improve clinician communication with cf adults around the issues of advance care planning are needed. objectives: caregiver involvement in children's cf treatments fosters better adherence and improved health outcomes. several studies have suggested that parents of children with cf report elevated symptoms of depression (quittner et al., ) , however, there is no data on the effects of caregiver depression on adherence. adherence to treatment is difficult to measure in patients with cf, and prior research has relied primarily on self-report, which is likely to be inflated. the purpose of this study was to examine the effects of caregiver depression on adherence to enzymes using both parent-reported and electronically monitored enzyme adherence over a three-month period. in addition, we examined the relationship between depression, rates of enzyme adherence and short-term changes in weight. methods: as part of a larger intervention study at cf centers, children with cf ages to and their parents were recruited. parents completed a standardized measure of depression (cesd) at enrollment and were provided with mems caps that recorded the date and time of each bottle opening. three months later, the electronic data from the pill caps was downloaded and parents completed a structured interview reporting their child's adherence to all components of the cf treatment regimen. only the section addressing enzyme adherence was included in this analysis. standard health outcomes, such as weight and height, were also assessed at enrollment and months later. results: preliminary analyses indicated that caregivers reported elevated levels of depression, with % scoring in the clinical range. rates of adherence to enzymes were poor ( % at home and % at school). caregiver depression was negatively associated with adherence, with depressed caregivers demonstrating lower rates of adherence ( percentage points). adherence to enzymes was associated with changes in weight, with a % adherence translating into percentile points of weight gain. final analyses will also include parent-reported adherence to enzymes. conclusions: a substantial number of parents scored in the clinical range on a depression screening measure. in addition, depression was associated with poorer adherence. rates of adherence to enzymes were surprisingly low, both at home and at school. furthermore, poor adherence was associated with a decrease in weight three months later. caregiver depression appears to be under-diagnosed and these results suggest that screening and intervention may be warranted. adherence to enzymes should also be targeted in clinical interventions. funding was provided by nih grant #hl of non-compliance with medical treatment and greater behavioral and emotional distress. adherence is particularly problematic during adolescence, however, few family-based interventions have been developed to target adherence behaviors in this population. the goal of this study was to compare the effects of behavioral-family systems therapy (bfst), an empirically-supported treatment, to both family education (fe) and standard care (sc). methods: as part of a larger intervention study, adolescents with cf ages to and their parents completed the conflict behavior questionnaire (cbq) and the parent-adolescent relationship questionnaire (parq) developed by robin and foster ( ) . adolescents completed these measures for each parent and both parents, if available, completed them with respect to their teen. the problem-solving, communication, and beliefs subscales from the parq were administered. participants were then randomly assigned to one of three treatment arms: bfst, fe or sc. families in the bfst group received ten -minute sessions over a month period, including family problem-solving, communication skills training, and cognitive restructuring. families assigned to the fe group received ten minute psychoeducational sessions over months aimed at increasing knowledge about cf and its management. those in the sc group received their usual care at the cf center. the cbq and parq were completed pre, post and , and months following the intervention. results: adolescents reported that the bfst intervention, relative to the other two, improved their communication with their primary caregivers (p < . ) and caregivers improved their communication with their adolescents (p < . ). in addition, caregivers reported improved problem-solving with their adolescents (p < . ). on the cbq, bfst reduced both adolescent and primary caregiver conflict and fe reduced caregiver conflict. no significant improvements were found for those in sc. conclusions: preliminary findings suggest that bfst is effective in improving communication skills and reducing conflict in adolescents with cf and their caregivers. future analyses will evaluate the effectiveness of bfst and fe on adherence and other family functioning measures over the course of the study. funding was provided by nih (hl # ) background: cases of diabetes among people with cystic fibrosis (cf) have increased as life expectancy for these patients improves, yet the impact of this additional illness on daily functioning is under-researched. to explore this issue, a study was conducted comparing the views of patients with either cystic fibrosis related diabetes (cfrd) or type diabetes mellitus (t dm) about being diagnosed and living with diabetes. methods: qualitative research was used because the study was concerned with understanding diabetes from patients' perspectives. purposive sampling was employed to achieve maximum variation in terms of duration and type of diabetes experienced by participants. data were collected via semi-structured interviews, all of which were taped and transcribed verbatim. recruitment continued until no new ideas or insights emerged from additional participants. a framework approach to analysis was adopted. this involved coding and summarising interview data into charts to explore and develop main themes. initial analysis was undertaken by two researchers (st and cd) and amended after comments from the remaining authors. results: interviews, carried out with cfrd and similarly aged t dm patients, lasted for an average of minutes (range - minutes). the following themes were derived from the data collected: evolving vs fracturing identity; diabetes in context; self-management motivators. for patients with cfrd, diagnosis represented a progression in their health status, which called on them to adapt existing treatment regimens to accommodate this additional condition. in contrast, interviewees with t dm had to re-evaluate their previous sense of self as 'healthy' and adjust to manag-ing a long-term complaint. these individuals were more likely to talk about diabetes in relation to a range of competing commitments (e.g. work or family related) and to describe feeling psychologically low due to diabetes compared to patients with cfrd, the latter depicting demands from their primary illness (cf) as a major obstacle to caring for diabetes. participants with cfrd recalled feeling lucky when told they would not face strict dietary restraints, which they associated with other forms of diabetes, and seemed less concerned about diabetic complications than those with t dm. for interviewees with t dm, a desire to reduce future health risks motivated their self-management efforts, whilst those with cfrd were driven by the negative effect poor control of diabetes had on their chest and weight. conclusions: both sets of interviewees found diabetes time consuming and, on occasions, frustrating to accommodate into daily life. findings from the study act as a reminder that patients manage their condition in the real world, against a plethora of other demands on their time and energy. in the narratives of participants with cfrd, these demands were often related to the existence of their primary illness. ing the course of development. the purpose of this study is to examine rates of medication adherence across a wide age span using an objective measure of adherence and to compare adherence to health outcomes. methods: patients with cf age years or older who are prescribed azithromycin, colistin, hypertonic saline, pulmozyme, and/or tobi for at least one year are eligible. recruitment is ongoing. the previous year's medication refill records were requested from participant-identified pharmacies. a medication possession ratio (mpr) was calculated for each drug and was defined as the sum of all days of medication supply received during the months divided by the number of days the medication was prescribed. values were truncated to % and averaged across all medications to obtain a composite score. medical records were abstracted to identify the prescribed drug regimen and health outcomes (e.g., lung function, exacerbations, bmi) over the same time period. results: thus far, patients have joined the study ( % participation rate), resulting in pharmacy records requested ( unique pharmacies). of the first participants with complete pharmacy data, the mean age was . years (sd= . ; range= - ) and % were female. the table presents mpr data for each drug and composite score overall and stratified by child, adolescent, and adult participants. the complexity of the drug regimen and age were significantly correlated with the composite score (rho= -. and rho= -. respectively; p<. ). future analyses will compare the composite score and each drug's mpr with health outcomes. con-clusions: participants had suboptimal medication adherence similar to that reported in the literature. as mpr provides the maximal possible level of adherence, actual adherence may be even lower. poor adherence spanned the age groups and was associated with regimen complexity. children had the highest adherence, but also the least complicated drug regimen. these results suggest that obtaining pharmacy records is a viable means to objectively assessing medication adherence. moreover, results suggest that interventions targeting medication adherence may be a strategy for improving health outcomes, particularly for adolescents and adults. * fewer than participants within this cell (cf) whose exchange capacities for oxygen and carbon dioxide are already diminished. lack of rem and delta sleep have significant implications for the daytime functioning of pediatric patients with cf, potentially leading to impaired memory and attention which would reduce their ability to complete typical activities, such as school work and disease-specific tasks related to self care and adherence. based on these clinic findings, the authors are beginning a prospective study on the effects of sleep on neuropsychological functioning, well-being and compliance in pediatric patients with cf. future research should examine the relationship between decreased slow wave, rem sleep and psychosocial outcomes, including attention, memory, and health-related quality of life. there are diagnostic challenges related to non-classic cf (knowles and durie, ) particularly patients presenting in adolescence or adulthood with obstructive azoospermia, chronic sinopulmonary disease and chronic or acute, recurrent pancreatitis. practitioners are often unable to provide clarity to patients about diagnosis, disease course, and prognosis. potential harms and benefits of relaying a clear or unclear diagnosis may be psychological rather than physical and have long-term implications for mental and social well-being. the aim of the current study is to assess the psychological impact of diagnostic information for adults presenting with a cf phenotype, be it confirmatory (cf or most likely not cf) or unclear. method: we administered self report measures pertaining to psychological state, cognitive appraisal and uncertainty in a welldefined cohort of adult patients. presenting symptoms of patients include chronic sinopulmonary disease, obstructive azoospermia, pancreatitis, and those presenting with more than more cf phenotype. patients completed the self-report measures on two occasions: at the time of diagnostic testing and months after being counseled and notified of the diagnostic results. at the time of the initial assessment, the subjects were unaware of the test results and had not been seen by a cf physician. results: we provide interim observations on patients (sinopulmonary (n= ), obstructive azoospermia (n= ), pancreatitis (n= ), and multiple phenotypes (n= ) who completed the initial assessment. at the time of diagnostic testing, the level of depression, hostility, anxiety and interpersonal sensitivity were elevated in each group (t score > ); male patients reported significantly greater depression, anxiety and interpersonal sensitivity than female patients. compared to published normative data of patients with mixed chronic illnesses, patients presenting with sinopulmonary or pancreatic disorders reported significantly more uncertainty(p < . ). to date, of these patients have completed the measures months after receiving the diagnostic information. preliminary review of results shows that the level of depression, hostility, anxiety and interpersonal sensitivity remained elevated while the degree of uncertainty decreased. among the patients who completed assessment at months, patients were told that it was unlikely that they had cf, were told that they had mild cf, while were given an unclear diagnosis. those who were told that they did not have cf reported more uncertainty than those who were told they had cf (p < . ). detailed analyses related to outcome diagnosis will be conducted at the time of study completion (october ) . when this study is complete, the information will assist in our understanding of the psychological impact of a genetic diagnosis at an older age, identify issues confronting those individuals and help to establish appropriate paradigms for delivering complex information about genetic diseases. supported by grants from niddk [scor] and the canadian cf foundation. ( ). in accordance with these guidelines, we report our experience in using our nutrition action plan (nap) in patients with suboptimal nutrition. objective: to determine if implementing our nap would improve the bmi of these patients. methods: our nap is a written contract between the patient, caregiver and cf team. for clarity of nutritional goals, the nap is based on the colors of a traffic light. the red zone indicates a bmi less than the th percentile and poor nutritional status. the yellow zone indicates a bmi between the th and th percentile and fair nutritional status. the green zone indicates a bmi greater or equal to the th percentile and desired nutritional status. within each color zone, specific recommendations to improve nutritional status are listed. the ultimate goal for each patient is reaching the green zone. the caregiver, patient and nutritionist review the current nutritional status and a mutually accepted weight gain goal is established. the goal is recorded on the nap which is then signed by the nutritionist and patient. this contract establishes a commitment to achieve the goal by the next clinic visit. a reward system is implemented in conjunction with the nap. for patients reaching their goal, a previously agreed upon prize is given. patients achieving some weight gain but falling short of their goal receive a gift such as candy or small toys that serve as an incentive for continued weight gain. patients chosen for inclusion into this study demonstrated a bmi less than the th percentile; those on growth hormone, appetite stimulants or chronic systemic steroids were excluded. results: twenty-one patients, male and female, with a mean age of . years (range to years) were included in this study. fifteen patients demonstrated an improvement in their bmi with use of the nap: improved by - %; improved by - %; improved by - %; improved by - %; improved by - %. six participants had a negative change in bmi which we attribute to family upheaval, missed appointments with the cf team, exacerbations of disease and non-adherence. conclusion: we intervened in patients with a bmi less than the th percentile using a nap and a reward system. the results of this pilot study suggest that our nap and reward system may be of benefit in achieving positive gains in bmi. reference: ( ) previously it was rare for women with severe cf to undertake pregnancy and doctors tended to advise against pregnancy if the forced expiratory volume in one second (fev ) was less than %. the attitudes of doctors and patients are changing and many women living their lives with cf nowadays chose to undertake pregnancy despite the severity of their health problems. over the last years females (age range - years) have attended the newcastle adult cf centre. there have been a total of pregnancies involving women with live births ( ectopic). a further women had termination of unwanted pregnancy. mean age at the time of pregnancy was years. we compared an age-matched cohort of never pregnant women to see if there were differences in key variables making successful pregnancy more likely. the mean fev was % (range - %) and % (range - %) of predicted in the pregnant and non-pregnant group respectively (p= . ); rates of chronic pseudomonas aeuriginosa infection were ( %) and ( %) respectively (p= . ). cases of burkholderia cenocepacia were identified in the non pregnant group. there were no cases in the pregnant group (p= . ); ( %) had diabetes with patients having cf related diabetes prior to pregnancy and patients developing gestational diabetes; this compared with ( %) of non pregnant women (p= . ); there was impaired nutritional status within both groups with a mean bmi of . pre pregnancy (range - ) and . in the non pregnant group (range - ) (p= . ); ( %) and ( %) patients had had previous gastrostomy feeding (p= . ). pancreatic insufficiency was present in ( %) and ( %) patients in respective groups (p= . ). no child had cf but one child had complex congenital heart disease. there were no maternal deaths but patients subsequently underwent lung transplantation and patients died leaving young children (ages and years). patients in the non-pregnant group have also died. conclusion the profile of women with cf undertaking pregnancy is now similar to the overall cf population. the woman's decision to undertake pregnancy is often not directly related to the severity of her disease. amongst those who successfully completed pregnancy maternal and fetal outcomes are generally favorable. objectives: health-related quality of life (hrqol) instruments provide important information on disease progression and are increasingly used as patient-reported outcomes (pros) for behavioral and pharmacological trials (goss & quittner, in press) . recent advances in medical care have improved the long-term stability of pulmonary functioning, which has made it more difficult to detect small improvements in fev % predicted. new outcome measures are needed; the cystic fibrosis questionnaire-revised (cfq-r; quittner et al., ) , a disease-specific hrqol measure, has shown promise in this regard. the purpose of this study was to examine the longitudinal relationships between fev % predicted, weight percentiles, and cfq-r scores for adolescents with cf. methods: as part of a larger study evaluating adherence interventions, adolescents with cf, ages to , and their parents were enrolled at six centers. parents reported on their adolescents using the cfq-parent version, and adolescents completed the cfq-teen/adult version as a selfreport. measures were completed pre and post treatment and at , , and month follow-up visits. spirometry and weight data were collected at these same time points. results: empirical bayes estimates were used to examine change over time. preliminary results indicated that adolescents' scores on the cfq-r respiratory scale were significantly and positively correlated with changes in pulmonary functioning. parents' scores on the cfq-r vitality scale were also correlated with changes in pulmonary functioning, with higher cfq-r vitality scores associated with better lung function. in addition, parents' scores on the cfq-r weight scale were significantly and positively correlated with changes in adolescents' weight. conclusions: these results support the validity and sensitivity of the cfq-r to changes in both pulmonary functioning and weight for adolescents with cf. additional analyses will be conducted to determine the relative stability of hrqol scores over time and to examine other cfq-r scales that may reflect positive changes in adolescent functioning (e.g., reduced treatment burden background: development of cf specific patient symptom tools as outcome measures is a critical step toward the development of potential new therapies for cf. we have developed a novel instrument to assess respiratory symptoms in cf patients. methods: we conducted in-depth qualitative interviews using the day reconstruction method and cognitive debriefing interviews ( adults, youth, and parents) at two cf programs, the university of washington and children's hospital and regional medical center. interviews were conducted until no new symptoms were mentioned by interviewees (i.e., data saturation). the interviews were audio-recorded, transcribed, coded and analyzed for themes. results: six pulmonary symptoms were identified in the interviews: cough, sputum production, wheeze, chest tightness, difficulty breathing/shortness of breath and fever. in addition, the most commonly cited activity and emotional impacts identified in the interviews were also included on the questionnaire. these emotions included: frustration, sadness/depression, irritability, worry, difficulty sleeping, and activities included time spent sitting or lying down, reduction of usual activities, and missing school or work. in all, eight symptom items were selected for inclusion on the self-administered questionnaire (see table) . as a result of the cognitive debriefing interviews, we changed initial language and adjusted the response options on some of the items in order to create greater distinctions between them. no important issues were felt to be omitted by patients who were interviewed. conclusions: using qualitative inductive methodology, we have created a novel patient reported outcome measure for cf. further study will be required to assess validation of the instrument. or more signs and symptoms occurred for more than two days, antibiotics were ordered with physician input and phone follow-up in days. if symptoms occurred less than two days, chest clearance was increased with phone follow-up in hours. the initial algorithm (ia) was piloted by nurses on patient calls on the emr and reviewed for adherence. subsequently, the cf phone note was revised, expanding the symptoms to include gi issues, last visit date and last hospitalization. the revised algorithm (ra) was used for a one month trial period with the entire nursing staff. a total of patient calls relating to pulmonary exacerbation were again reviewed for adherence to the algorithm. results: the review of phone notes following the ia found ( %) of the phone notes to be adherent to the assessment and treatment plan on the algorithm. several exceptions included calls received for gi issues, medications, complaints of general pediatric symptoms, and lab results. the phone follow-up within - hrs was also difficult to accomplish secondary to nursing responsibilities and difficulty locating the patient. the review of calls following the ra found ( %) notes were adherent to the algorithm. discussion: the revised algorithm and cf phone note for pulmonary exacerbation improved consistency in nursing assessment of signs and symptoms, evaluation of the current plan of care, and triggered appropriate interventions based on symptoms and length of illness. this improvement was particularly pronounced among the part-time rns who found it easier to obtain a more accurate history of patient's illnesses without asking for assistance from other cf team members. since the algorithm and cf phone note are newly implemented, tracking for consistency with the cf phone note will continue, revisions will be made as needed, and phone notes for conditions other than pulmonary exacerbation may be developed. methods: in , helen devos children's hospital integrated research coordinators (rc) from the spectrum health research department into the cf care team. this model incorporates two key aspects: . a shared resource of experienced, centrally educated and trained research coordinators (rc) with three rc's having a primary cf focus . incorporation of rc's into helen devos cf care centers' multidisciplinary team for weekly contact with patients. using the cf registry consent as a starting point of research discussion with the patients and families, the rc's present new and upcoming opportunities and answer questions about research. with attendance at local and national cf meetings, rc's have expanded their cf knowledge, networked with other rc's and explored new research trials. our site also integrated education about various aspects of research into both the clinical staff and cf family education meetings. a review of the research database was completed to assess our cf center's research program. results: over the years reviewed, participation in clinical research trials has seen significant growth and patient participation has exceeded patients enrolled into clinical studies. conclusion: utilizing a team of dedicated rc's from the research department has proven to be effective in advancing our cf center's clinical research program. discussion: to meet the growing demand of patients needed to participate in clinical trials, cf centers will need to provide research education to both the patients and families and the clinical team, improve on skills needed to identify and enroll our patients into clinical trials and include the rc's into the multi-disciplinary cf patient care team. centralized research represents an excellent model for cf centers that want to excel in clinical research. integration of rc's into the cf care team, along with education initiatives for both clinical staff and patients and families has led to successful participation and enrollment in clinical trials. further studies need to be done to better identify barriers that patients and families have with participation in research. the goal of "cystic fibrosis transition care" is to ensure that youth with cystic fibrosis (cf) are adequately prepared to participate in the management of their health condition into adulthood and as they graduate to the adult health care system. in canada, it is unknown if, or to what extent, cf transition care is practiced in individual clinics. we therefore surveyed all canadian pediatric cf clinic coordinators (n= )using a brief standardized questionnaire; surveys ( %) were completed and returned for analysis. findings: all responding clinics transfer their pediatric patients to a distinct adult cf clinic, however almost half of these share one or more team members between the two clinics. transition care is recognized and practiced by % of responding clinics: % follow a formal transition program, and % follow an "informal program". "informal" practices vary widely from one clinic to another. formal programs were created by individual clinics, and share the common properties of being based on current research, having set goals, and utilizing a tool to document the process. the average age of transfer to the adult clinic is years. most clinics have "rare exceptions only" to delaying the age of transfer, the most commonly cited reason being "very ill/palliative patient". a small number of clinics also cited "intellectually challenged patient" and "reluctant patient" as reasons to delay transfer. only % of pediatric clinics hold a formal "transition" or "graduation" clinic, which allows adult team members to be introduced to youth before the actual transfer of care takes place. conclusions: although sharing team members between pediatric and adult clinics may ease the change from pediatric to adult care, it can also create barriers to the transition process. therefore, it is encouraging to learn that the majority of canadian pediatric cf clinics view adult care as distinct from pediatric care, and that there is a consistent age of transfer across the country. transition preparedness is also recognized as an important component of care, as evidenced by the number of clinics following a formal or informal transition process. it remains undetermined, however, whether in general there is adequate preparation for adult care. with only % of clinics following a formal transition process (and % not following any type of transition program), further assessment seems warranted and may reveal inadequacies requiring remediation. future direction: to strengthen cf transition care in canada, a "patient readiness to transition" questionnaire has been developed and will be administered to canadian cf patients transferring to adult cf clinics in . analysis of this questionnaire will provide insight into how well canadian cf clinics are preparing their youth for transfer to adult life, and may provide directions for further improvement. nearly all females with cf now survive into adulthood, and advice regarding pregnancy and contraception is becoming increasingly important as part of their sexual health education. we set out to identify the level of knowledge of these issues in patients attending our large adult cf unit. using a structured questionnaire, we surveyed consecutive cf females (age range to years) attending routine cf clinics. we asked about knowledge and usage of contraception, and issues relating to pregnancy and its possible effect in cf, ensuring the opportunity for a one to one discussion with the individual on completion of the questionnaire. only ( %) claimed to have had previous advice relating to contraception and ( %) pregnancy education. of these, ( %) stated that this was from adult cf nurse specialists, ( %) from adult cf physicians and the remainder from other sources (general medical practitioners, written literature, and the internet). only patients ( %) recalled that they had been given information in the paediatric sector before transition. the majority of all advice was given verbally. of the ( %) who were using some form of contraception ( [ %] condoms, [ %] combined pill, [ %] depot injection, [ %] a coil, and [ %] the mini pill); ( %) had experienced problems, and in some cases patients had been misinformed about the reliability of their contraceptive choice. as regards pregnancy, ( %) had undergone previous termination and ( %) already had children. thirty six ( %) had considered becoming pregnant but ( %) said they would discuss this with a member of the cf team beforehand: ( %) were aware this might impact on their health. of these, ( %) believed a reduction in lung capacity to be the biggest possible problem. other problems identified were alteration of medication, tiredness, and weight loss or gain. overall, ( %) felt they did not have enough information regarding pregnancy in cf and ( %) that insufficient contraceptive advice was given, expressing a wish for further knowledge. conclusion this survey has shown that a significant number of adult females with cf require further education about contraception and pregnancy. in some cases the advice they had already been given may not have been appropriate for patients with cf. furthermore, few patients appeared to have had effective counselling in the paediatric sector, despite the risk of pregnancy. we are working with patients and paediatric colleagues to improve the education in this important area for our women with cf. the state of minnesota added cystic fibrosis to the newborn screening panel on march , . one-year follow-up to date reveals infants have screened positive, of the screen positive, have been diagnosed with cystic fibrosis, infants are pending sweat chloride tests and evaluation. of this population infants are being followed by the minnesota cf center. the university has a comprehensive, interdisciplinary team available to provide care to infants, children and adults with cystic fibrosis. in response to newborn screening for cystic fibrosis, the center has implemented a prophylactic care program to include clinical care through early intervention and education within the first two weeks of life. benefits of collaborative care have been previously identified in the literature, showing improved quality of care with increased patient satisfaction, lower mortality, and improved outcomes. infants who are identified by newborn screening and receive earlier treatment have the potential for improved physical health and development. the inclusion of comprehensive genetic consultation as an integral component of cf education, allows for informed reproductive decisions. the newborn screening intervention plan is supervised by a nurse practitioner and consists of initial evaluation, initial therapy implementation, and a teaching/consultation schedule, which covers a minimum of four appointments scheduled over weeks. follow-up visits are scheduled within hours of referral and then at one week, days and weeks post referral. the schedule is adjusted based on infant acuity and family needs. initial evaluation consists of the confirmatory sweat chloride testing and/or genetic mutation analysis, serum laboratories, chest x-ray, stool for fecal elastase, and nasopharyngeal culture. general, supportive teaching with evidence from the literature is provided. preliminary results to date demonstrate that our infants have had no pulmonary exacerbations, no pulmonary hospitalizations with pulmonary functions obtained in over half of the infants. nasopharyngeal cultures obtained at the time of ascertainment demonstrate newborn screening patients have positive cultures for staphylococcus aureus, haemophilus influenzae, escherichia coli, streptococcus pneumoniae, klebsiella pneumoniae, acinetobacter junii and alcaligenes faecalis. one infant was culture positive for pseudomonas aeruginosa at the first out-patient clinic visit. this demonstrates colonization of organisms prior to clinic exposure. through minnesota's early intervention and education plan, the families will be more adherent to prescribed care, which will result in improved cf infant outcomes as monitored by number of exacerbations, pulmonary functions and potential complications. a detailed outline of medical intervention, education, and outcomes will be presented. cf-pediatric centre we developed a malabsorption blood test (mbt) using odd-chain length fatty acids, pentadecanoic acid (pa) and heptadecanoic acid (ha), to assess fat absorption in subjects with cf. pa is a free fatty acid, while ha requires hydrolysis of triheptadecanoic acid (tha) by pancreatic enzymes for absorption. objective: to determine the mbt reproducibility in healthy subjects and subjects with cf. methods: subjects with cf ingested a liquid test meal including fats (pa and tha) on occasions at least days apart. for each subject, a standard dose of pert ( , lipase units) or the subject's usual dose (if higher) was given with each test meal. serum was analyzed for pa and ha levels at baseline and then hourly for hours. a non-compartmental pharmacokinetic analysis was performed using pa and ha concentration-time data from subjects with cf. c max was directly observed from the individual subject profiles, and auc was calculated using the linear trapezoid rule. summary statistics (mean±s.d.) were calculated for all parameters. reproducibility of the mbt was also assessed in healthy adult controls tested on occasions. between subject (bsv, %) and within subject variability (wsv, %) was calculated for pa, ha and the ha/pa ratio. results: bsv (%) and wsv (%) of pa and ha absorption are presented in the table for subjects with cf (age . ± . y, females) and healthy adult subjects (age . ± . y, females). as expected, the mbt had greater reproducibility in healthy controls than in subjects with cf. in healthy controls, the reproducibility for pa and ha absorption was comparable; there is less wsv than bsv, and the ha/pa ratio has the best reproducibility. in subjects with cf, pa and the ha/pa ratio show less wsv than ha. conclusion: wider variability in fat absorption in subjects with cf reflects the complex interactions of the biliary, pancreatic and intestinal factors background: the international, multi-center gene modifier study of cystic fibrosis liver disease (cfld) initially enrolled patients with severe liver disease (i.e. cirrhosis and portal hypertension). for the initial population despite severe liver disease with portal hypertension, many of these patients had normal liver biochemical function tests and/or inr ( - %), depending on the test. the mean age of enrollment into the study was years, with the mean age of cfld diagnosis of years. candidate gene testing revealed an increased prevalence of the alpha- antitrypsin z allele in cfld patients, particularly in females, as compared to cf patients (> yrs.) without cfld, and an association with tgfβ variants (- and codon ) in males smoothing reference centile curves: the lms method and penalized likelihood hepb) and inactivated hepatitis a (hepa) vaccines in cystic fibrosis (cf) patients chronic liver disease (cld) remains the second mortality cause in cf. we evaluated the immunogenicity of hepa-and hepb-vaccines in cf-patients because it is described lower in patients with cld. patients and methods: blood samples of cf-patients aged . - . y (mean . y) were tested twice (time interval y) by chemiluminescent microparticle immunoassay to asses the presence of hbs-ab and ha-igg, and their vaccination status was recorded. seronegative patients for hbs-ab and/or ha-igg were vaccinated in between tests with engerix®, havrix® or twinrix®. results: / ( . %) patients tested positive for hbs-ab. / cld ( steatosis and cirrhosis). / tested positive at first but negative at present data are incomplete for hbs-ab and ha-igg for and patients. conclusions: . immunogenicity of hepa-and hepb-vaccines is comparable in cf-patients and healthy subjects. . cf-patients are at risk for cld and seroconversion must be checked after vaccination. . vaccination records are important as numbers of antibodies may decline beneath the detection limit in time methods: lf was assessed in children with cf, aged - yrs, using forced expiratory volume (fev(sub) (/sub)% predicted). body composition was measured using a reference four-component model(sup) (/sup) ( cm) allowing accurate evaluation of both fat mass (fm) and the components of fat-free mass dual-energy xray absorptiometry (dxa; lunar prodigy, g.e. medical systems) was used to measure fat, lean (non mineral) and bone mass and skin-fold thicknesses (bicep, tricep, sub-scapular) were measured. strength of relationship was assessed using pearson's correlation coefficient (r) and significant body composition components were fitted into a regression model. difference in fev(sub) (/sub) between the sexes was assessed with an independent t test. results: boys with cf did not differ from the reference population conclusion: our results confirm that body fat, but not ffm or bone mass, are related to the severity of impaired lf in children with cf. it is likely that the significant association between fev(sub) (/sub)and fat in girls but not boys reflects the poor body composition of the girls with cf. longitudinal follow-up of these children should indicate whether this sex difference persists after puberty. given the fact that prognosis is worse in girls the sex difference we've identified merits more attention. fuller nj et al. four-component model for the assessment of body composition in humans: comparison with alternative methods and evaluation of the density and hydration of fat-free mass conclusions: these results show that pancreatic status plays an important role in relation with pufa status in cf patients and particularly in (the initial fatty acids in the n- and n- pathways) in neutral lipids, nonesterified fatty acids, and phospholipids this may, in some way, account for the fact that : n- is more readily metabolized, and therefore depleted, in cf animals than in wt mice. conclusion: dha supplementation increased the localization does an integrated clinical and nutritional approach prevent this case control study examines the impact of clinical approach on pre and post-cfrd clinical course. patients with cfrd (mean age . + . yrs) matched to cf controls ( . + . yrs) for age, sex and pseudomonal status had parameters of clinical status and nutritional intervention recorded annually from six years pre diagnosis of cfrd to two years post. weight and body mass index (bmi) were lower at all time points to diagnosis of cfrd (ns) but were stable as a % of control values intravenous antibiotic treatment intensified, peaking at one year post diagnosis . days/yr (cfrd) v . (cf) ns but there was no difference in nebulised antibiotic use. an aggressive clinical approach prevents nutritional decline and delays respiratory decline until the year preceding diagnosis of cfrd data show mean (sd) or % , ; battezzati with advancing age insulin secretory defects and insulin resistance cause glucose intolerance and diabetes in an increasing proportion of cystic fibrosis (cf) patients. prediction of diabetes development in cf is made difficult by unique features: many patients are normoglycemic or even hypoglycemic after overnight fast, and there are repeated changes of glucose tolerance status from normal to diabetes and vice-versa, for many years and for unclear reasons. aim of the study was to detect predictive factors of definitive cf related diabetes (cfrd) development in patients undergoing oral glucose tolerance test (ogtt) evaluations routinarily. methods. starting from , all patients followed at the cf center in milan aged > years and without established cfrd undergo ogtt yearly. among those who received their first ogtt between and , had developed definitive diabetes by µu/ml, and . ± . vs . ± . ng/ml). glucose (p= . ) and insulin aucs (p= . ) were the most important predictive variables, respectively directly and inversely related to cfrd development (pseudo r for the model: . , p< . ). glycated hemoglobin and baseline glucose concentrations were directly related with outcome at univariate analysis whereas c-peptide concentrations were inversely related. in contrast, no relationship emerged between insulin-sensitivity indexes and outcome. anthropometric (weight, height z scores, bmi) and pulmonary function indexes were also unrelated. conclusions. insulin secretory defects are an important determinant of subsequent cfrd developement response rate was / in group a and / in group b. group a included males and females, mean age was months, sd . ; group b included males and females, mean age months, sd . . followgroup b parents do ("poor-very poor" health % vs %, p< . ), but over time health perception in parents of children with cf improves, and the gap vanishes ("poor-very poor" health in last year % in group b). post-diagnosis anxiety, depressive symptoms, sleep disturbances, mood changes, and nervousness are less frequently reported in group a ( % vs % p< . ), and the diagnosis was considered to affect the parent-child relationship more in group b than in a (p< . ). the two groups did not differ in the assessment scores of internalizing, externalizing and total behavioural/emotional problems. however, group b performed worse than the general control population average (mean . sd . vs mean sd . , p< . ). thirty-five% of parents in group a and % in group b changed their family planning projects following the diagnosis physical health and anxiety symptoms: does monitoring mediate the relation? results: physical health, monitoring, and anxiety symptoms were related. children who perceived themselves to be relatively healthy were less likely to have an information processing style characterized by high levels of monitoring (r = -. , p < . ), and they reported fewer trait anxiety symptoms (r = -. , p < . ). monitoring, as hypothesized, was associated with increased trait anxiety (r = . , p = . ). low bmi, a potential indicator of poor nutritional status and physical health among youth with cf, also was related to higher monitoring (r = -. , p = . ) and trait anxiety (r = -. , p = . ). tests of mediation indicate that monitoring partially mediated the relation between poor health and trait anxiety for both child report of physical health (goodman test: z = . , p = . ) and for bmi (goodman test: z = . , p = . ), but not when parental report or fev were used to assess youth's physical health, or when parental report of youth's internalizing symptoms was used as the outcome. conclusion: youth who tend to generally scan for and are attentive to changes in their environment, which may include their internal physical environment, were found to report more anxiety. moreover, this monitoring style appears to partially mediate the relation between physical health and anxiety among youth with cf. if monitoring is found to be a risk factor leading to an increase in future anxiety symptoms among youth with cf data was analysed using a thematic analysis: "framework" results: young people say that befriending is fun, offers opportunities for new experiences, a confidant outside the family, and gives them a boost psychologically. carers see befriending as confidence building for their children, providing time out for themselves, and helping with the big questions. befrienders see their role as mentoring, broadening young people's horizons and providing a safe place physically and emotionally. challenges include: forming and ending relationships, having multiple befrienders, ongoing support and training for befrienders, maintaining boundaries, sibling rivalry, and cost. conclusions: befriending is a new innovation in cf, and has the potential to make a difference to young people's lives. careful planning at the outset, ongoing support for befrienders and regular evaluation are essential factors in ensuring its success good practice in befriending services for people with learning disabilities qualitative research practice sage london ଙ in addition, there was high use of non-cf vitamins (n= ) and protein shakes (n= ) which were not included as a cam therapies. when prayer was excluded (which was used by % of respondents), . % of the patients are still using some form of cam. the most commonly used cam therapies in cf were relaxation therapies (n= ), massage therapy (n= ), chiropractor care (n= ), herb/plant product therapies (n= ), homeopathy (n= ), and yoga (n= ). an analysis of the relaxation therapies revealed that deep breathing exercises (n= ) were the most common and frequently combined with other relaxation techniques: meditation (n= ), progressive relaxation (n= ) and guided imagery (n= ). the most common herb/plant products used were: echinacea (n= ), garlic (n= ), selenium (n= ), ragweed or chamomile (n= ) and ginseng (n= ). the use of possible cf specific cam therapies were fish oils/omega fatty acids (n= ), glutathione (n= ), docosahexaenoic acid (n= ) and curcumin (n= ). in conclusion, cam is widely used by the cf population with "prayer for health" being the most common modality, however, many patients are utilizing multiple cam therapies (data not presented) within the framework of a weighted satisfaction model of quality of life, we investigated the importance ratings of adolescent and adult patients regarding disease-specific aspects of living with cf. method: outpatients (aged - years, m= . , sd= . ; fev - %, m= . , sd= . ) repeatedly filled in the cf-specific module of the questions on life satisfaction (flz-cf) to measure satisfaction with nine cf-specific aspects of life in relation to the subjective importance of each life domain. a ranking list of the most important life domains across the study group was determined, and intra-individual changes of the importance scores were analysed. associations of importance ratings with changes of pulmonary functioning (fev %) were examined. results: the most important aspects (% of "very important" or "extremely important" answers) are sleep ( . %), integration of therapy into daily routine ( . %), breathing ( . %), gastrointestinal functioning ( . %), and eating ( . %), less important is understanding by others ( %) , ; durieu, i. , . département d'information médicale, hospices civils de lyon dr. von hauner children`s hospital helios hospital, e.v. behring, berlin, germany supported by the cystic fibrosis foundation leroy matthews physician scientist award, the national heart, lung, and blood institute cystic fibrosis foundation therapeutics inc. symptoms patient-reported respiratory symptoms in cystic fibrosis: initial validation children's hospital and regional medical center the first author is supported by a second year clinical fellowship from razvi, s. ; quittell, l.m. ; sewall, a. ; marshall, b.c. ; saiman, l. . pediatric pulmonary medicine, columbia university, new york, ny, usa; . cystic fibrosis foundation, bethesda, md, usa significance: significant improvements have been made in diagnostic and therapeutic strategies for cf patients in recent decades. we hypothesized that these changes could potentially impact cf respiratory microbiology. thus, we examined longitudinal trends in the annual incidence and prevalence of cf respiratory pathogens from to .methods: cf foundation patient registry data, estimated to include % of the cf population in the u.s., was utilized in this analysis. patients were included if results from at least one respiratory culture were in the registry from january to december . patients were excluded after organ transplantation. to avoid misclassification of incident cases, a retrospective review of registry data from to was performed to establish the culture status of included patients prior to . thus, incident cases were subjects with first detection of a given pathogen in a given year. prevalent cases were defined as subjects with at least one positive respiratory culture for a given pathogen in a given year. all submitted culture results were included.results: the number of cf patients submitting registry data increased from , in to , in . the proportion of subjects meeting inclusion criteria remained relatively constant ( % to % per year). the median age of the study cohort increased from . years in to . years in . during the study period, the incidence of hemophilus influenzae remained stable ( . % to . %) as did the prevalence ( . % to . %). the incidence of pseudomonas aeruginosa ranged from . % in to a peak of . % in . the prevalence of p. aeruginosa declined from . % in to . % in . there is a trend for both an increasing incidence and prevalence of staphylococcus aureus; the incidence increased from . % in to . % in and the prevalence increased from . % in to . % in . the age specific prevalence of s. aureus remained highest in children aged - years. the incidence of methicillin-resistant s. aureus (mrsa) increased from . % in to . % in , with a parallel increase in prevalence from . % to . %. the highest prevalence of mrsa was noted in subjects years of age and older. the incidence of burkholderia cepacia complex decreased from . % in to . % in , while the prevalence remained relatively stable (range . % to . %). both the incidence and prevalence of stenotrophomonas maltophilia increased (incidence: . % to . %, prevalence: . % to . %).this retrospective study aims at assessing the respiratory function and the cystic fibrosis (cf) co-morbid conditions according to the patients' nutritional status.method: data were collected from the french observatory (onm) (n= ) (vlm, ined). the last year data for weight (w), height (h), fev , fvc were extracted from the database (exclusion criteria: transplan-tation); were also analysed the genotype, pancreatic enzymes consumption, pseudomonas aeruginosa (pa) colonization, cirrhosis, diabetes, pulmonary transplantation and mortality (sas . ). we used international age-adjusted standards for bmi z-score for children (c) and bmi for adults (over years) (a) (cole tj bmj ) to define underw (uw), normal w (nw), overw (ow) and obesity (ob) .results: data are available for patients in the c cohort and for patients in the a cohort ( %). nutritional status subgroups prevalence (%) is: . , . , . and . in c and . , . , . and . in a for respectively uw, nw, ow and ob. mean age in a is significantly increasing with bmi (p<. ). frequency of del/ del in c and a is lower in ow/ob (p<. ) as well as the use of pancreatic enzymes (p<. ). ow/ob patients have the best fev and fvc values whatever the gender and the age, with significantly less pa colonization in a (p<. ). we could identify a positive correlation between the pulmonary function and bmi. the cf co-morbid conditions demonstrated a lower prevalence of diabetes ( / ) and cirrhosis ( / ) in ow/ob. none of the ow/ob c or a are on a transplant waiting list versus . % in uw/nw (n= / ) and none died versus % in uw/nw (n= / ).conclusion: the observed prevalence of ow and ob in cf is respectively . and % whereas the french obepi study collected and %. our results suggest that increased bmi is associated with better fev , fvc, lower prevalence of pa, cirrhosis and diabetes. the potential risks of chronically high bmi have not been studied in this population yet, but justify further investigations in this longer life expectancy cohort. materials and methods: we retrospectively identified abdominal ct scans of consecutive patients ( females, males, mean age of years) with cystic fibrosis and a control group of consecutive patients ( females, males, mean age of years) scanned as potential renal donors. three readers reviewed all scans and recorded the presence and location of colonic wall redundancy, and the wall thickness of the ascending, transverse, and descending colon. clinical information on cystic fibrosis patients, including cftr gene mutations, was queried from our cystic fibrosis patient registry database. additionally, medical records of all cystic fibrosis patients were reviewed to determine the indication for abdominal ct. results: colonic wall redundancy was seen exclusively in patients with cystic fibrosis, and was noted in of patients each for reviewers , , and (p< . ). colonic wall redundancy was seen in of adult patients with cystic fibrosis ( %), but was not seen in any children age or younger (p< . ). excellent agreement was found for the ct identification of colonic wall redundancy among readers (kappa= . , p< . ). cystic fibrosis patients with colonic wall redundancy had significantly thicker ascending colonic walls (mean . mm) vs. those without wall redundancy (mean . mm) or controls (mean . mm), (p= . ). three patients with colonic wall redundancy had follow-up ct, and all showed temporal stability (mean of months). among adult cystic fibrosis patients, cftr gene mutations were available for of patients with and of without colonic wall redundancy. while the common ∆f mutation was the predominant mutant allele among patients with normal colons at ct (only of patients, or %, had an identified mutation other than ∆f on either allele), a higher prevalence of less common non-∆f mutations was seen patients with colonic wall redundancy ( of patients, or %, p< . ). the g x mutation was seen exclusively in patients with colonic wall redundancy ( of patients, or %, p= . ). there was no significant difference in the proportion of patients with abdominal pain (> . ), pancreatic insufficiency (p> . ), diabetes mellitus (p> . ), history of meconium ileus background: airway inflammation in cf is associated with marked remodelling and bronchiectasis. pro-inflammatory mediators such as advanced glycation end-products (ages) and the soluble receptor for age (srage) may perpetuate this response in the lung and in other organs such as the kidney . the total body burden of ages reflects exogenous sources from the diet, endogenous production by the body, tissue degradation and renal clearance, which may be reduced in renal impairment. the accumulation of endogenous age is accelerated in conditions of high oxidative stress and inflammation, and ages have been implicated in the pathogenesis of diabetic nephropathy. the burden and significance of ages in cf has not been determined, but if elevated, dietary modification of ages may represent a novel anti-inflammatory approach for cf. the aim of this study was to determine serum levels of age and srage, and identify clinical correlates of age and srage levels.methods: adults with cf (n= , males, % pancreatic insufficient, mean age . ± . years (range to years), mean fev %predicted . ± . %predicted (range - )) and healthy adults (n= , male, mean age . ± . years (range - years)) were studied. cf participants provided - serum samples each over a six month period, while healthy controls provided a single sample. serum was analysed for levels of advanced glycation end-product (age-cml) and soluble receptor for age (srage) (elisa). for each cf participant, levels in the multiple samples were averaged, and the median for the study sample reported. clinical data, including bmi, presence of cf-related diabetes mellitus (cfrd) and serum hba c level were collected from the medical record. mann-whitney tests were used to compare cf and control levels, while spearman rank correlations were used to identify clinical correlates of age and srage.results: prevalence of cfrd was . %. mean bmi was . ± . kg/m and mean hba c level was . ± . %. median (iqr) levels for age-cml were ( , ) background: osteopenia is diagnosed in cystic fibrosis (cf) using dual-energy x-ray absorptiometry (dxa). areal bmd from dxa is subject to error when bones are smaller in volume than reference standards (t-scores). normalization of bone size by use of zscores in cf is controversial and not widely utilized, thus comparing to larger bone areas. reports in cftr-deficient mice (cf mice) reveal osteopenia when measured by dxa. we hypothesized that use of pqct, which eliminates bias of size, would more accurately analyze bmd.methods: femurs were collected at necropsy from cf mice and c bl/ j (b ) mice at wks, and cf mice and b mice at wks (all female) for pqct. time points were chosen to coincide with pre-pubertal and adult ages for comparison to human disease. total mineral, trabecular and cortical densities were measured. student's t-test was used to detect significant differences (p< . ).results: femur measurements from both cf mice and b mice are listed as mean ± sd in the table (below). length was greater in b mice compared to cf mice at and wks. total area at the metaphysis and diaphysis were greater in b mice at and wks. data are consistent with larger bones in b mice. total mineral density , trabecular density and cortical density , however, were greater in cf mice compared to b ( & wks, wks, wks).discussion: our study demonstrates greater bmd in cf mice when volumetric data are analyzed and size differences are accounted for by use of pqct. these findings persisted at adult age, suggesting a normal deposition of bone. in clinical management, dxa imaging is readily available compared to pqct, and can be used as a predictor of bmd and fracture risk. correct reference ranges must be utilized to minimize erroneous values secondary to size. z-scores allow correction for differences in bone area and size, even in adults. more studies into understanding bone mineral deficit and tools of measurement are needed in cf. meanwhile, bone measurements by radiographic imaging must be taken in context of overall health, pubertal progression, and size of individuals. gainesville, fl, usa; . nemours children's clinic, orlando, fl, usa; . suny upstate medical university, syracuse, ny, usa; . case western reserve university, cleveland, oh, usa; . genentech, san fancisco, ca, usa background: greater growth rates, bmi and fat-free mass are associated with improved lung function in individuals with cf (pedreira, et al. pediatr pulmonol. ) . current treatments for weight gain have focused on nutritional supplements and appetite stimulation, and not underlying issues of catabolism or chronic disease. we hypothesized that anabolic effects of gh would not only improve weight and height, but lbm as well.methods: sixty-seven prepubertal children with cf and height less than or equal to the th percentile were randomized to daily gh (n= ) or observation (n= ) for a period of year, followed by an off-treatment observation period of months. children randomized to gh received somatropin injections daily at . mg/kg/wk. height and weight were measured every three months. height was evaluated as height standard deviation score (sds) to control for differences in age and sex. lbm was measured by dexa scan at time zero, at and months, and at the end of the -month observation period. in addition, for lbm, change from baseline was calculated for subjects for whom the same dexa equipment was used at both time points. the preliminary results of the first months of the study are presented here.results: data for subjects in the observation arm and subjects in the gh arm, who completed months, are available. as shown in the table below (listed as mean ± sd), gain in height, weight and lbm were significantly greater in the gh treated group than in the observation group over the month period.discussion: gh improves growth in prepubertal children with cf as measured by height sds. in addition, gh significantly improves weight gain and this gain is, in part a result of the significantly greater increase in lbm in the gh-treated group than in the observation group. the relationship between the improvement in lbm and other outcomes in cf deserves further exploration. the national cystic fibrosis(cf) registry database notes cystic fibrosis related diabetes mellitus(cfrd) as a complication in . % of cf patients at all ages. cfrd is associated with poorer nutrition and increased pulmonary morbidity. the cause of cfrd is not completely known but insulin resistance may be associated with fibrotic damage to pancreatic islet cells due to chronic inflammation. other studies suggest protein energy malnutrition(pem) in early life leads to impairment of insulin secretion and cystic fibrosis-related diabetes (cfrd) accounts for increased morbidity and mortality in patients with cf and occurs in approximately % of patients by the age of years. cfrd net (network for epidemiology and trials) is a consortium of four large uk cf centres caring for adult patients with cf. the aim of this group is to undertake research into the diagnosis, investigation and management of cfrd. in this abstract, we estimate the prevalence of diabetes in a screened population of adults with cf. methods annual review data were collected on attending patients with cf aged and above during . g ogtts were performed after fasting for at least hours on patients without known diabetes. each ogtt was categorised as either normal ( hour glucose . - . mmol/l), impaired ( hour glucose ≥ . mmol/l and < . mmol/l) or diabetic ( hour glucose ≥ . mmol/l). all patients with a diabetic ogtt were followed up with serial bm monitoring to determine whether or not they had cfrd. fasting plasma glucose (fpg) was considered to be elevated ≥ . mmol/l, isolated impaired fasting glucose (igf) was defined as a value between . mmol/l and . mmol/l and hypoglycaemia was defined as a blood glucose < . mmol/l. in addition, we obtained information on age, sex and prescription of anti-diabetic medications subsequent to ogtt. in three of four centres, hba c was routinely performed on all patients. of patients (median age years, % male), ( %) had established diabetes and were therefore excluded from further screening. of the remaining patients, ( %) underwent formal ogtt testing. in this latter group ( %) had a diabetic ogtt, ( %) an impaired ogtt and ( %) had evidence of reactive hypoglycaemia at hours. of the patients with a diabetic ogtt, ( %) only had an abnormal hour value, ( %) only had an elevated fpg and (< %) had both. all patients with diabetic ogtts underwent blood glucose monitoring and ( %) went on to treatment with hypoglycaemic agents in the calendar year. none of the patients with an isolated elevated fpg had diabetes.hba cs were available in of newly diagnosed patients with diabetes (in the centres which performed hba c). in this group median hba c was . %. this study confirms the high prevalence of diabetes among screened patients and the growing burden of diabetes management in adult cystic fibrosis clinics. it further highlights the importance of performing screening for diabetes in this population; the majority of patients were identified on the basis of abnormal hour values. despite this only half of all suitable patients underwent ogtts in the four centres committed to screening. these patients merit further study, as previous work suggests that the decline in clinical status occurs several years before diabetes becomes apparent. cystic fibrosis related diabetes (cfrd) occurs in up to % of patients with cystic fibrosis (cf), the incidence rising with increasing age. the likelihood of developing long-term complications secondary to diabetes increases with poor glycaemic control and duration of diabetes. as survival has improved for people with cf those who develop cfrd may live with diabetes for several years. aim: to establish the frequency of diabetic complications in patients with cystic fibrosis related diabetes.method : patients with cfrd attending the adult cf service at the royal brompton hospital between april -march were screened for diabetic complications and cardiovascular risk factors. a total of patients (male/female: / ) including post transplant patients were screened. mean age was . years ( - ), mean hba c . % ( . - . % ) and average duration of diabetes was . years (< - years).as immunosuppressive therapy can also cause many of the complications associated with diabetes the results are presented separately for nontransplant and post transplant patients (table ) . patients in total had retinopathy: background retinopathy, proliferative retinopathy undergoing laser therapy and maculopathy. the average duration of diabetes in those with background retinopathy was . years with only patient having diabetes for > years. the patient with proliferative retinopathy (non-transplant) had been diabetic for years. a raised creatinine level was identified in all transplanted patients with microalbuminuria but none of the non-transplanted patients. patient (nontransplant) had macroalbuminuria. post transplant patients were on treatment for hypertension and a further patients ( post transplant and nontransplant) had elevated blood pressure (> / ) at screening requiring follow-up. none of the patients had evidence of cardiovascular disease or stroke.conclusion: macrovascular complications were not seen. microvascular complications occurred but were less common than the reported incidence in type and type diabetes. this may reflect the relatively short duration of diabetes (mean . years) of patients in this study. a further study comparing cfrd patients with a non-cf diabetic control group of similar duration of diabetes is warranted. cystic fibrosis (cf) is a disease that leads to serious disturbances in nutritional status and bone calcification. comparison of two methods for assessment of bone mineralization: dexa and hand radiograms in diagnosing osteopenia or osteoporosis. study was performed in a group of cf patients ( f, m), aged - yrs. nutritional status was assessed using bmi, cole's index and bmc. radiograms of non-dominant hand were assessed according to normalized optical density comparing to aluminum standard. bone density was also assessed using dexa. for statistical analysis, backward stepwise binary logistic regression (wald's test) was used. analysis of data revealed that using bmc, cole's index and hand radiograms markers we can diagnose bone mass disturbances (z score < sd) with precision up to . % comparing to dexa. sensitivity and specificity of this method was respectively . % and . %. false negative results were obtained in patients and false positive were also in patients. hand radiograms method could be an alternative for dexa in screening of bone density disturbances in cf patients. the study was partly supported by grant of ministry of science and higher education no p e .in a very recent publication( ) a high rate of fasting ( %) and reactive hypoglycaemia ( %) was described in a group of n= cf patients older than years who received an oral glucose tolerance test. reactive hypoglycaemia was related to the minute glucose concentration in the ogt test. we were surprised by the high percentage of asymptomatic hypoglycaemic situations in cf patients. as a part of a prospective intervention study in cf patients with cfrd, we screened more than patients years or older with cf for cfrd. in this multi-centres population ogt was performed in the morning after overnight fasting according to who standards. using the same definition for fasting hypoglycaemia (glucose < mg/dl; . mmol/l) and reactive hypoglycaemia (glucose < mg/dl; . mmol/l at minute during ogt test)as in the other study we calculated the percentage of cf patients with fasting or reactive hypoglycaemia in our cohort. results: ogt were done in patients with cf. age(mean±sd) , ± , years; bmi z-score - . ± , ;height z-score - , ± , and weight z-score - , ± , . ogt was categorised according to ada criteria. normal ogt (n= all ; fasting hypoglycaemia (fh) n= ( , %), reactive hypoglycaemia (rh)n= ( , %),ifg (n= all, fh n= , rh n= ( , %), igt(n= ,fh n= ( , %), rh n= ),fgt (n= all, fh n= ,rh n= ) and diabetes mellitus (n= all, fh n= ( , %)). fh was observed in ( , %) and rh in ( , %) out of ogt tests. there were no difference related to age, bmi z-score, height z-score and weight z-score comparing those patients with fh or rh to those without fh or rh in all categories of ogt tests.in this large multi-centres cohort of cf patients we were neither able to confirm the high percentage of fasting nor of reactive asymptomatic hypoglycaemia which was reported recently on a small group of cf patients. nutritional status measured by bmi z-scores, height and weight z-scores were unaffected by hypoglycaemia in our cohort as noticed also in the small group. as the ogt tests in the other study were done in a single centre it might by that a centre specific situation influenced the frequency of hypoglycaemia in that small group. we conclude that large numbers of investigations might be needed to come up with firm conclusions related to frequency of specific aspects of glucose disturbance in cf patients.fh does not exclude diabetes mellitus or igt. as survival from cf improves, surveillance to identify and treat complications associated with longevity is an important component of management. renal disease has been reported in adults with cf. risk factors may include cf-related diabetes mellitus (cfrd) and use of nephrotoxic medications. diabetic nephropathy has been observed in the absence of cfrd , highlighting the need for screening for renal impairment. this study aimed to measure renal function in a sample of adults with cf, and to compare estimated glomerular filtration rate (egfr) and urinary creatinine clearance (urcrcl) as markers of renal function.methods: adults with cf aged years or over (n= , % male, % pancreatic insufficient, mean age . ± . years) underwent screening for renal impairment. of these patients, ( males) had cfrd, and ( males) had no history or clinical features of cfrd. hour urine collections were analysed for urcrcl, with renal impairment being defined as < ml/min. serum creatinine level was used to calculate egfr (mdrd formula), which was classified renal function as normal or mildly impaired (> ml/min); moderately impaired ( - ml/min) or severely impaired (< ml/min). sensitivity of egfr for identification of renal function was calculated using urinary creatinine clearance as the reference method. unpaired t-tests were used to compared cfrd with non-cfrd patients.results: mean urcrcl was ± ml/min, and eight patients ( . %) had renal impairment (< ml/min). of these, only had egfr suggestive of renal impairment. the sensitivity of egfr for identifying renal impairment in this sample was %. a further patients had moderately impaired egfr, but normal urcrcl. five of the patients with impaired urcrcl had cfrd. age, gender, cfrd, fev %predicted and hba c level did not correlate with urcrcl. the table compares cfrd patients with non-cfrd patients. hba c level was higher in cfrd patients. there were no other significant differences in clinical or renal function parameters.conclusion: renal impairment, is common in the adult cf population and is not confined to patients with cfrd. screening using egfr is poorly predictive of impaired urcrcl in this population. these results suggest that surveillance to monitor renal function is indicated in the adult cf population, including in patients without cfrd, and that determination of urcrcl should be included in the screening process. cystic fibrosis (cf) patients suffer from pancreatic insufficiency resulting in malabsorption of fat soluble vitamins including vitamin d. many fac-tors contribute to low bone mass and fractures in patients with cf; however, chronic vitamin d deficiency plays a major role. the prevalence of vitamin d deficiency has been reported as high as % in some specialized care centers. in addition, reports of occult vertebral fractures have been reported as high as %. we sought to determine the prevalence of vitamin d deficiency (defined as -hydroxyvitamin d ( (oh)d) < ng/ml) and of vertebral fractures at our cf center. we obtained irb approval to review the records of all patients seen at our cf center during [ ] [ ] . we collected information related to bone health including (oh)d, bone mineral density and lateral spine or chest x-rays to examine for the presence of a vertebral fracture. we reviewed the records of subjects who were seen at our center during the study period. the mean age of the subjects was ± years. subjects had a mean bmi of . ± and an fev % predicted of . ± %. the percentage of subjects having an annual (oh)d level checked was only % and % in and , respectively. the mean (oh)d was . ± and . ± ng/ml in and . the prevalence of vitamin deficiency was % and % in and . about one quarter of the subjects had bone mineral density testing with half of the tests showing osteopenia or osteoporosis. twenty-seven percent of subjects had vertebral abnormalites detected on lateral chest x-ray. we sought to determine whether any factors were associated with vitamin d deficiency. we found that taking a multivitamin did not significantly protect against vitamin d deficiency. however, not taking a supplement containing vitamin d other than a multivitamin was associated with a % risk of vitamin d deficiency (p= . ). subjects having (oh)d levels determined in the winter or spring was associated with a % risk of vitamin d deficiency (p= . ). in summary, we found annual testing for vitamin d status was inadequate in our cf center and that when (oh)d level was determined, over % of subjects were vitamin d deficient. nearly one quarter of our adult patients already had evidence of vertebral compression fracture seen in lateral chest x-ray. we urge greater screening for vitamin d deficiency in the cf population. effective protocols to prevent and/or treat vitamin d deficiency are urgently needed in the cf population. improved vitamin d status in cf patients is one factor that may reduce the high prevalence of vetebral fractures. support for this study was provided by proctor and gamble pharmaceuticals background: more cf patients are surviving into adulthood, in part due to the increasing use of new therapies and more aggressive management of chronic respiratory and gi disease. as a result, the recommended daily treatment regimens for most cf adults are both complex and time consuming. objective: to assess the self-reported daily treatment burden of cf therapies in a cohort of adults with cf. methods: in the sixth survey wave of the project on adult care in cf (pac-cf), an ongoing longitudinal panel study of adults with cf from us cf centers, respondents were asked to report the type of medications, inhaled therapies, and airway clearance therapies they used during the day prior to completing the survey, as well as estimate the time generally required to complete each type of therapy.results: of the respondents (response rate %), the median number of therapies reported was (iqr - ) and the median reported amount of time usually spent on treatments was minutes per day (iqr - minutes). forty-eight percent reported using or more different inhaled therapies or using inhaled therapies or more times during that one day. the most commonly reported inhaled therapies were a bronchodilator ( %), pulmozyme ( %), an inhaled steroid ( %), hypertonic saline ( %), and objective: caring for a child with cf is stressful and often leads to adverse effects for both children and caregivers. support from family and friends can help reduce the adverse effects of chronic stress, however, there is little research documenting types of support provision as well as sources of support. moreover, social support may be related to important health outcomes. this study described the types of support provided to caregivers of children with cf and examined relationships between support and health outcomes.method: as part of a larger intervention study to improve adherence to medical regimens, children with cf ages to and their caregivers were enrolled across cf centers in florida: university of florida, nemours children's clinic, and all children's hospital. caregivers completed the norbeck social support questionnaire (nssq; norbeck, ) in addition to other measures at baseline and follow up. this questionnaire provides information about the number and type of people providing support, as well as its type and quality.results: caregivers received the majority of support from their families, spouses and friends and characterized these relationships as longer in duration, with more frequent provision of support. other individuals who provided support included the cf team, religious leaders, counselors or psychologists, and work associates. overall, caregivers rated family members and spouses as providing the greatest amount (i.e., "quite a bit") of emotional support. spouses received the highest ratings for tangible support; they were perceived as providing "quite a bit" of support in comparison to families (i.e., moderate) and friends (i.e., a little). in terms of size of the support network, caregivers in this study had similar networks to those of a normative sample of healthy adults. in addition, there was no difference in amount of emotional or tangible support received by these caregivers. preliminary baseline results indicated that social support was positively related to both adherence, children's growth (i.e., height and weight percentile), and family income.discussion: caregivers of young children with cf reported similar support networks as other healthy adults. however, there was variability in the amount of support provided by source, with spouses providing the greatest amount. social support appeared to be a protective factor, and lack of support was related to negative health consequences for their children. more attention should be focused on the potentially beneficial effects of social support.funding was provided by nih grant # befriending is reported to be valued by those who have been befriended, offering opportunities for social activities and new experiences and can impact positively on self confidence and self esteem . whilst government policy supports befriending, few schemes collect evidence to demonstrate the effectiveness of these services . young people with cf may suffer social isolation due to chronic illness and treatment demands and a befriend-ing service was offered to those considered socially vulnerable in the edinburgh area.this project aims to evaluate the effectiveness of this befriending service on young people with cf and their carers. methods liverpool, united kingdom; . child mental health, university of liverpool, liverpool, united kingdom; . child health, university of liverpool, liverpool, united kingdom; . psychology, university of miami, miami, fl, usa; . psychology, birkbeck college, university of london, london, united kingdom; . mathematics and statistics, university of lancaster, lancaster, united kingdom; . psychiatry, university of manchester, manchester, united kingdom introduction: existing treatments for cystic fibrosis (cf) are time-consuming and labour intensive and biomedical advances are likely to lead to further novel interventions. there is concern amongst clinicians that a high care burden associated with these interventions may compromise the wellbeing of caregivers, reduce adherence to the treatment protocol and increase the likelihood of inadvertent errors in the delivery of interventions. at present, there is no measure of 'treatment burden' and therefore no way to assess the impact of new and increasingly more complex interventions conducted by lay caregivers at home. furthermore, trials are hampered by the lack of measurable patient-reported outcomes beyond a broad quality of life assessment. to address this gap we have developed a measure of treatment burden for cf using qualitative methods (focus groups, action research, in-depth interviews) with participating parents and a working group of cf team professional staff. this measure addresses the time, effort, meaning and ease of management for caregivers of children with cf up to years and post the first year following a diagnosis. methods: we report here the pilot phase of the validation of this instrument, which involved (i) cognitive interviewing with n= caregivers; and, (ii) n= caregivers completing the clcf instrument together with a quality of life measure at time points. this yielded data for stability, reliability and coherence of the hypothesized constructs. results: the clcf takes minutes to complete. face validity and acceptability are established. for the first pilot sample the age of the child ranged from . - . years. treatments took, on average minutes per day to complete and an average of minutes of this was devoted to administering enzymes particularly for carers of infants. a prominent concern amongst these parents was their child's height and weight and their efforts were directed at optimising growth. for the child however, management of nebulised medications and physiotherapy were more frequently flagged as a concern. these data suggest this is a reliable, coherent and useful, although complex tool. conclusion: the caregiver challenge for cf cannot be understood simply in terms of time and effort involved in delivery of treatments. it also involves contextualising interventions for their meaning at multiple levels of explanation for the individual concerned. structural equation modelling would be an appropriate way to proceed with the main validation when such complex relationships occur between latent variables and would serve as a confirmatory factor analysis for the hypothesised relationships. sponsored by: royal liverpool children's nhs trust and university of liverpool. funded by: national institute for health research (nihr) research for patient benefit programme.introduction: the french cf practice recommendations, published at the end of in parallel with the creation of cf reference centres, advise that each patient should be seen at least every months at a cystic fibrosis reference centre.objective: to investigate the impact of these recommendations on the effectiveness of the follow-up of patients at the four reference centres in the rhône-alpes region.methods: all patients with cystic fibrosis attending one of the four cf centres between and were retrospectively included. the total number of visits was recorded for each patient and each year of the study period. to determine the evolution slope for each patient followed for at least years, a negative binomial regression of number of visits versus time was carried out (confirmed with a repeated model). to estimate the impact of the recommendations, the analysis was restricted to patients with at least two visits before and after and a second model was adjusted with a new intercept in to estimate the change in slope as of this point.results: a total of patients were included in the cohort. the average number of visits per patient rose from . in to . in (p< . ). the proportion of patients with at least visits per year increased from % to %. the negative binomial regression for the patients having had at least years follow-up confirmed this trend with an average slope of + . (sd= . ). a total of patients were evaluable for the change in slope. no significant change in trend was observed in : only % of patients had a higher rate of growth (this change was significant for only subjects). at the last follow-up visit, patients with increasing rates of number of visits were older ( yrs vs. yrs, p< . ), had lower %fev ( vs. , p= . ), had a similar average number of visits before ( . vs. . , p= . ), and a similar weight-for-age z-score (- . vs. - . , p= . ) .conclusion: the number of visits per patient is regularly increasing. since the publication of the practice recommendations in , the growth has tended to slow down: clinicians were already convinced by the need for closer follow-up and had begun to increase the rate of visits. methods: patients > years who presented for routine healthcare voluntarily completed four surveys: ) the revised eating attitudes test (eat), validated for cf patients by abbott and colleagues, where higher scores reflect worse attitudes towards eating; ) the rosenberg self-esteem scale (rse), where higher scores reflect better self-esteem; ) the body image scale (bis), developed for cf patients by wenninger and colleagues, where higher scores reflect better body image; ) the cystic fibrosis questionnaire (cfq), developed by quittner and colleagues, where higher scores reflect better hrqol. also, fev %, body mass index (bmi), and pancreatic sufficiency or insufficiency (based on the need for pancreatic enzymes) was recorded. regression analyses controlling for age, gender and bmi were used to examine the associations between the surveys. results: this study included patients with % males and a mean age of years. the eat was negatively associated with the rse (p= . , adjusted r = . ), bis (p= . , adjusted r = . ) and cfq (p= . , adjusted r = . ). the rse was positively associated with the cfq (p= . , adjusted r = . ). the bis was positively associated with the rse (p= . , adjusted r = . ) and cfq (p= . , adjusted r = . ). neither bmi nor pancreatic function was associated with the surveys (p=ns). fev % was positively associated with the cfq (p= . , adjusted r = . ) but was not associated with the other surveys.conclusions: more negative attitudes towards eating predict worse selfesteem and body image, while more positive body image predicts better self-esteem. also, attitudes towards eating, self-esteem and body image are significant predictors of hrqol with body image being the most important predictor.clinical importance: hrqol is an important clinical outcome measure in cf. clinicians need to be sensitive to attitudes towards eating, self-esteem and body image in cf patients, because they are important predictors of hrqol. riekert, k.a. ; mogayzel, p.j. ; bilderback, a. ; hale, w. ; boyle, m.p. . medicine, johns hopkins university, baltimore, md, usa; . pediatrics, johns hopkins university, baltimore, md, usa background: existing research suggests that self-reported adherence to all aspects of the regimen is likely suboptimal and objective measures suggest even poorer adherence. there is little empirical data on how much adherence is necessary to achieve desired health outcomes. moreover, there is limited data on how adherence changes dur-objective: cf may be associated with pain attributed to several etiologies. this study evaluates the prevalence of pain symptoms in adult cf patients and the influence on patients` lives.methods: patients of adult cf centers in germany completed a validated, self report questionnaire during a routine clinic visit assessing characteristics of chronic pain (prevalence, duration, location, quality and intensity of pain symptoms). furthermore, the impact of pain on different aspects of life was explored using a numeric scale from to with being the worst. every-day-life was divided into categories: duties at home, recreation, social activities, occupation, sexual life, autonomy, vital activities and cf-therapy. the average intensity of pain within the last weeks was correlated to fev , bmi and age.results: patients ( male) completed the questionnaire. the age was - years (mean . ± . ). patients ( %) aged - years (mean . ± . )reported pain within the last months. bmi was . - . kg/m (mean . ± . ), fev - % (mean . ± . ). if asked for pain within the last weeks ( %) reported painful episodes lasting from - days with a mean of . days (± . ). most patients described pain occurring at more than one site with the head being the most localized site, followed by chest and abdomen. concerning the quality of pain . % characterized their pain episodes as attacks whereas . % reported them as continious, . % had continious pain combined with pain attacks. patients desribed the intensity of pain as . (± . ) on a scale from to with being the most severe pain. the category of life negatively influenced most of all by pain episodes was recreation, followed by occupation and duties at home. female patients were more limited in their acitivites by pain symptoms than male patients with the highest difference being reported in sexual life. there was no correlation of the average intensity of pain within the last weeks to fev , bmi or age.conclusion: the prelevance of pain in cf is often underestimated. painful episodes can be the cause of worsening the quality of life for adult cf patients. assessment of pain should be routinely performed as part of care in cf centers. objective. sleep has been examined in a number of pediatric conditions, with impaired sleep resulting in worse neurobehavioral functioning (beebe, ) . recent research has shown that slow wave sleep is critical for memory (marshall, helgadottir, molle, & born, ) . to the authors' knowledge, no studies have examined slow wave and rapid-eye-movement (rem) sleep in pediatric patients with cystic fibrosis. methods. retrospective medical record review revealed two patients who underwent clinically indicated polysomnography (psg) who reported feeling tired and lacking energy. patients were females with cystic fibrosis, ages and years. results. psg revealed an increase in stage sleep for both patients, resulting in increased risk and observed hypopneic episodes. patient -a experienced . % in stage , . % in stage , and % in stages and combined. this patient also had no rem sleep. patient -b experienced % in stage , . % in stage , and % in delta wave sleep, with no rem sleep. respiratory disturbance index (rdi) for patients a and b were calculated at . and . , respectively. respiratory effort related arousal (rera) contributed to rdi by . and . points in patients a and b, respectively. in addition, endtidal co for patient a and b were maxed at mm hg and mmhg, respectively. their epworth sleepiness scales were scored at and for patients a and b, respectively. conclusions. structure of sleep was abnormal in both patients with decreased slow wave (delta) sleep in patient b and lack of delta sleep in patient a. neither patient experienced rem sleep. compensatory increased stage (nrem) sleep could cause respiratory related abnormalities, such as hypopnea and apnea in patients with cystic fibrosis background: understanding and advancing the application of tools to measure patients' symptoms is critical to advancing our evaluation of potential new therapies used to treat cf. we performed initial evaluation of the measurement properties of a cf-specific respiratory symptom daily questionnaire. methods: we planned to enroll cf subjects, stratified by age, at three cf programs, the university of washington medical center and children's hospital and regional medical center in seattle and mary bridge children's hospital in tacoma in a prospective assessment of a novel cf specific respiratory questionnaire. cf subjects years and older were eligible for enrollment. patients (parents for children under the age of ) completed a daily symptom questionnaire during two -day periods of clinical stability and one -day period when patients were ill for a total of days. the ill state began when patients/parents sought medical attention for respiratory symptoms. the questionnaires were completed using a secure web-based application or via paper for those patients without access to the internet. two health related quality of life measures (generic and cf specific) were completed by the subjects at the end of each -day period to assess the relationship between the novel questionnaire and health related quality of life. patients also used pedometers during the well and ill states to assess relationship between symptoms and activity level.results: cf subjects have been enrolled to date. at the time of this interim analysis, patients had completed questionnaires. of this total, only individual questionnaire entries have been missed in patients (< % of possible questionnaires). interim review of cross-sectional data suggests clear differences in symptom reporting between the ill and well periods. examples include % ( / ) noted difficulty breathing and % ( / ) noted tightness in the chest in the preceding hours during the initial well period compared to % ( / ) noting difficulty breathing and % ( / ) noting tightness in the chest during the ill period.conclusions: interim evaluation of this novel instrument demonstrates feasibility of deploying this instrument via the internet with an extremely high completion rate. using a cross-sectional analysis, the instrument can discriminate between the ill and well state. further data will be presented regarding within patient variability and discrimination of the instrument.supported by the cystic fibrosis foundation leroy matthews physician scientist award, the national heart, lung, and blood institute (hl - ), national institute of health (rr- - ), cystic fibrosis foundation therapeutics inc. background: improved communication in today's health care delivery system is a critically important aspect of patient care. nurses are in an effective position to improve communication due to their close interaction with patients. as a result, they are able to identify potential problems, communicate them to the healthcare team and improve patient care and satisfaction.hypothesis: improving communication between the patient/family and the health care team will improve patient/family satisfaction.method: as a member hospital partnering with the institute for healthcare improvement's (ihi) initiative, transforming care at the bedside (tcab), the children's hospital of philadelphia (chop) introduced the use of daily patient goal sheets (dpgs) as a vehicle to improve communication between members of the healthcare team, patients and families and the dpgs was refined to meet the needs of an inpatient medical unit to which cf patients are admitted. using rapid plan-do-study-act (pdsa) cycles, a multidisciplinary team engaged in small tests of change in different stages. initially, patient goals and discharge criteria generated in daily rounds were posted in each room on easel paper. then large "whiteboards" were placed in each patient room for documenting patient goals, discharge criteria, names of the care team members and questions from patients and families. as a final step in the process, we shifted the health care team rounds to the patient's bedside and implemented bedside shift to shift nurse report and safety checks. patient satisfaction was continuously monitored over this process using the press ganey survey.results: over an eight month period, the press ganey survey results for the unit showed an average increase of %. we attribute this increase to better information sharing among patient, family and hospital staff regarding the plan of care for the patient's hospitalization. the health care team also had an improved dialog with the patients/families. conclusion: patient/family and healthcare team communication and satisfaction were improved using an organized and stepwise pdsa process to develop daily patient goal sheets on a medical unit. background: the uab/chs pediatric cf center provides care for approximately patients. the pulmonary division has full-time rns and part-time rns who rotate phone triage for all calls (including cf) of patients seen by the faculty physicians. historically, patient calls received during office hours are taken by the receptionist and put into the emr, then returned by the rn on call. the rn contacts one of the staff md's, gives report of the patient's condition,treatment orders are received, and the patient notified. there are several issues with this phone triage system, which include inconsistencies in rn and md response as well as differences in documentation. global aim: to improve the consistency among rns in phone triage of sick cf patients.method: an algorithm for pulmonary exacerbation phone triage was developed by the cf center director and lead rns to improve consistency in symptom assessment and treatment plan. a specific list of systemic and pulmonary signs and symptoms was formed including length of illness. if three objective: patients with cf often require intravenous antibiotics for treatment of pulmonary exacerbations. patients often receive peripherally inserted central catheter (picc) lines or totally implantable venous access devices (tivads) for venous access. few studies have examined complications of tivad implantation and little published data exists concerning picc line complications in cf patients. this study sought to assess the complication rates of both tivad and picc lines as well as to identify possible risk factors for developing complications.methods: this retrospective study included patients from cf centers in northern new england. data was obtained from each patient's local medical record, port cf, and patient interviews. demographic data was recorded for all cf patients between / / - / / . for each tivad or picc line, the following information was recorded: type of line placed, history of prior line placement during the study period, patient age, history of use for blood draws, method of line flushing, and status of the line at the end of the study (if still in use). complications were defined as catheter occlusion, vascular thrombosis/stenosis, infection, or other local inflammatory reactions.results: data was collected for pediatric and adult cf patients during the defined study period. seventy-three tivads and picc lines were placed during the study period in patients. the tivad and picc line complication rates were % ( / ) and . % ( / ), respectively. in pediatric patients, % ( of ) tivads and . % ( / ) picc lines had a complication. of the tivad complications, three were systemic infections and three were catheter occlusions. of the picc line complications, there were two venous thromboses, one line occlusion, two systemic infections, and nine minor incidents of localized phlebitis. in adults, complications were recorded in % ( / ) of tivads and . % ( / ) of picc lines. of the tivad complications, there were five systemic infections, seven catheter occlusions, and four venous thromboses. of the picc line complications, there were three venous thromboses, three line occlusions, and four minor incidents of localized phlebitis. all adult patients who developed a deep venous thrombosis(dvt) associated with tivad implantation were homozygous for the deltaf mutation. the presence of diabetes or burkholderia cepacia complex(bcc) lung infection was associated with dvt with odds ratios of . ( % ci . - . ) and . ( %ci . - . ), respectively. conclusions: complications of picc lines were uncommon and usually minor. the rate of tivad complication observed was more common over the lifetime of the catheter and was similar to previously published reports. we identified potential risk factors for the development of dvt associated with tivads and picc lines, specifically cf related diabetes, bcc infection, and homozygous deltaf genotype. the mechanism by which these factors are associated with catheter complications is unclear and warrants further investigation. key: cord- -y sfr c authors: nan title: scientific programme date: - - journal: pediatr nephrol doi: . /s - - - sha: doc_id: cord_uid: y sfr c nan the kidney plays an important role in ion homeostasis in the human body. several hereditary disorders characterized by perturbations of renal magnesium reabsorption leading to hypomagnesemia were described over the past years. only recently, mutations in renal ion channels and transporters have been identified in several of these diseases, following positional cloning strategies in families with these disorders. muations in the slc a gene have been identified in patients with gitelman syndrome, an autosomal recessive disorders characterized by hypokalemia, hypomagnesemia and hypocalciuria. slc a encodes the thiazide-sensitive na + , cl-cotransporter (ncc) in the distal convoluted tubule (dct), the nephron site of active renal magnesium reabsorption. the hypomagnesemia in gitelman syndrome has been shown to be secondary to the primary defect in ncc. mutations in the fxyd gene have been found in patients with autosomal dominant renal hypomagnesemia associated with hypocalciuria (idh). fxyd encodes the gamma-subunit of the na + , k + -atpase, which is expressed primarily in the kidney with the highest expression levels in dct and tal. hypomagnesemia in patients with idh can be severe (< . mm) and cause generalized convulsions. the molecular mechanism for renal mg + loss in this autosomal dominant type of primary hypomagnesemia remains to be elucidated. in patients with autosomal recessive hypomagnesemia with hypercalciuria and nephrocalcinosis (fhhnc) mutations in the cldn gene, and very recently also in the cldn gene, have been identified. these genes encode claudin and claudin respectively, which are essential components of the paracellular pathway for magnesium at the level of the thick ascending limb of henle's loop. mutations in trpm , encoding the epithelial mg + channel trpm in the apical membrane of dct cells, have been identified in patients with mg + wasting and secondary hypocalcemia (hsh). this autosomal recessive disease is due to defective intestinal and renal mg + (re)absorption, and affected individuals show neurologic symptoms of hypomagnesemic hypocalcemia, including seizures and muscle spasms during infancy. in my lecture, i will give an update on the proteins involved in magnesium reabsorption and the emerging pathophysiological understanding of hereditary disorders in which renal handling of this divalent ion is disturbed. transcriptional control of genes that regulate tissue patterning and the cell cycle is fundamental to normal renal development. the mammalian kidney arises from reciprocal inductive tissue interactions between the ureteric bud and the metanephric mesenchyme. these interactions result in growth and branching of the ureteric bud and its daughter collecting ducts, a process termed, renal branching morphogenesis, and formation of nephrogenic progenitors and mature nephrons. expression and activity of transcription factors in ureteric and metanephric mesenchyme cells determines the patterning of ureteric bud and metanephric mesenchyme derived tissue elements. this lecture will highlight transcription factors critical to renal branching morphogenesis and nephrogenesis, with particular emphasis on those factors that are mutated in humans with renal malformation. the regulation of transcription factor activity will be discussed in the context of growth factor signaling pathways downstream of wnts, bone morphogenetic proteins and sonic hedgehog and pathways such as notch that control cell differentiation. the complexity of transcriptional signaling will be highlighted in the normal and malformed kidney at the level of transcriptional factor interactions and target gene promoters that can be targeted by mutiple signaling pathways. t. benzing diseases of the glomerular filter of the kidney are a leading cause of end-stage renal failure. recent studies have emphasized the critical role of the slit diaphragm of podocytes for the size-selective filtration barrier of the kidney and revealed novel aspects of the mechanisms leading to proteinuria, both in inherited and acquired diseases. several critical structural protein components of the slit diaphragm have been identified. recently, it has been shown that slit diaphragm proteins, in addition to their structural functions, participate in common signaling pathways. this talk will focus on what is known about the importance of the podocyte for the function of the glomerular filter of the kidney. it will provide a snapshot of our current understanding of the signaling properties of slit diaphragm proteins and project a framework for further studies necessary to delineate the function and dynamics of the slit diaphragm protein complex and the pathogenesis of nephrotic syndrome. long-term survival of children with end-stage renal disease (esrd) has increased in the last years but the mortality rate remains high. cardiovascular disease accounts for to % of all deaths, infectious disease about %. a prolonged period of dialysis versus having a renal graft and persistent hypertension are mortality risk factors. the prevalence of all sorts of morbidities is high among those who have reached adulthood. nearly % of all these patients suffer from left ventricular hypertrophy and life threatening vascular changes; nearly one third has clinical signs of metabolic bone disease. this accounts for both dialysis and transplanted patients. the chance of getting cancer is times increased as compared to the general population; skin cancer and non-hodgkin lymphomas are most reported. a long period of dialysis at childhood is associated with impairment of both cognitive and educational attainment in adulthood. yet, despite all these negative outcomes, the health perception of young adults with childhood onset esrd is good. unemployment under young adults on chronic dialysis with pediatric onset of disease is higher than among healthy age related peers, but much lower than among dialysis patients of the same age with adult onset of disease. an impaired social development in childhood is associated with an impaired mental health perception at adult age. research and therapy in children with esrd should focus not only on prevention of graft failure but also on prevention of co-morbidity, especially cardiovascular disease, life threatening infections and malignancies. early transplantation, more extended forms of frequent hemodialysis in those who can not be transplanted, a more rigorous treatment of hypertension, avoidance of calcium-containing phosphate binders, reduction of the chronic inflammatory state, and tailor made anti-rejection therapy after transplantation may all be targets to improve outcome in future patients. psychosocial care should be more focused on attainment of independency and preparation for adult life, i. e. schooling and job career. applying regenerative medicine to combat organ shortage laboratory of regenerative nephrology, edmond and lili safra children's hospital, sheba medical center, tel hashomer, sackler school of medicine, tel aviv university, tel aviv, israel organ transplantation has been one of the major medical advances of the past years; however, it is becoming increasingly apparent that the supply of organs is limited and will not improve with current medical practice. regenerative medicine is focused on the development of cells and tissues for the purpose of restoring function through transplantation. when facing late stages of esrd, which necessitate whole kidney transplantation, organogenesis represents an alternative to combat organ shortage. indeed, previous data pinpoints a window of time in human and pig kidney organogenesis that may be optimal for transplantation into mature recipients. "window" transplants are defined by their remarkable ability to grow, differentiate and undergo vascularization, achieving successful organogenesis of urine-producing miniature kidneys with no evidence of trans-differentiation into non-renal cell types, lack of tumorigenicity and reduced immunogenicity compared to adult counterparts. in contrast, when dealing with earlier stages of esrd or acute renal disease, which allow for individual cell replacement, both bonemarrow derived and kidney specific stem cells, might be applicable. accordingly, we show in proof-of-principle experiments that a novel population of multi-potential stem cells derived from the adult murine kidney are capable of re-populating ischemically injured tubular cells, while hematopoietic stem cells (cd +cd +) or hemangioblastic progenitor cells can give rise to peritubular endothelial cells. thus, different types of biological materials (embryonic kidney, adult kidney, adult bone marrow) offer new and powerful strategies for future tissue development and regeneration in renal medicine. k. tory, É. kis, a. szabó, g. reusz st department of pediatrics, semmelweis university, budapest, hungary it is well known that chronic renal failure significantly increases the risk of cardiovascular mortality in adults. transplantation decreases this risk; however, it still exceeds that of the normal population. as the number of children on renal replacement therapy (including transplantation) has significantly increased in recent years, there has been a growing amount of evidence regarding the increased cardiovascular vulnerability of this specific patient group. one important factor of cardiovascular mortality in adults is the dysfunction of the autonomic nervous system, previously designated as autonomic neuropathy. in a series of studies using the conventional ewing tests as well as heart rate variability (hrv) monitoring we were able to show altered sympathovagal balance in children on peritoneal-and hemodialysis, that was at least partly reversible following renal transplantation. according to our data sympathetic overactivity plays a major role in the sympathovagal disequilibrium observed. correspondingly, beta-adrenergic blockade improves the decreased hrv in the young. early, accelerated arteriosclerosis is another important, recently recognized consequence of crf in children. arterial calcification leads to increased arterial stiffness deteriorating the cushioning function of the aorta. arterial stiffness can be assessed by the reproducible and non-invasive measurement of the pulse wave velocity (pwv). in adults, it was found to be a strong, independent predictor of cardiovascular mortality. hypertension, hyperphosphatemia/elevated serum calciumphosphate product and vitamin d deficiency are the principal factors associated with pwv. recently, pwv was also shown to be increased in children on dialysis. however, the difference to the normal population may only be apparent if a control group matched for body dimensions is used, because of the dependence of pwv on body dimensions and uremic children's significant growth deficit. furthermore, increased pwv could also be shown in children following renal transplantation (tx) indicating the persistence of these lesions even following successful tx. the data on the autonomic nervous system and arterial dysfunction in young patients point to the necessity of early prevention in order to avoid the cardiovascular complications of crf. this study was supported by grants otka-t -f -f and ett / . nitric oxide (no) production is reduced in ckd due to decreased renal and widespread decreases in endothelial no production. possible causes of no deficiency are: ). substrate (l-arginine) limitation; ). increased levels of circulating endogenous inhibitors of nitric oxide synthase (particularly asymmetric dimethylarginine [adma]); ). decreased nos protein abundance/activity. decreased l-arginine availability in ckd is likely due to perturbed renal biosynthesis secondary to damage to the renal parenchyma. in addition, inhibition of transport of larginine into endothelial cells and shunting of l-arginine into other metabolic pathways (e. g. arginase) will also decrease availability. elevated plasma and tissue levels of adma in ckd are functions of reduced renal excretion (minor), reduced catabolism by dimethylarginine dimethylamino-hydrolase (ddah) and possibly increased protein methylation. an increase in adma has emerged as a major independent risk factor in many forms of cardiovascular disease as well as end-stage renal disease (and probably ckd). decreased renal nos protein abundance and activity have been reported by us in multiple models of ckd in the rat. the neuronal (nos ) isoform is always reduced in the presence of injury, and is preserved in settings where there is protection from damage (female; wistar furth rat vs. sprague dawley). generalized and nnos specific inhibition accelerates underlying renal injury and in vulnerable animals will cause injury in the absence of underlying renal disease. we also find that relaxin (rlx) mediated prevention and repair of damaged kidneys requires an intact no system in order to function. in summary, no deficiency can cause cardiovascular and renal disease, and ckd results in no deficiency, contributing to a vicious cycle that promotes progression. an intact no system is required for rlxmediated repair of kidney damage. no deficiency in ckd is likely due to many causes: decreased arginine synthesis/availability and transport; increased endogenous adma functioning as competitive inhibitor; decreased enzyme abundance and activity will all lead to reduction in no generation. in addition, the oxidative stress of ckd will further reduce nos activity, switch the nos to become oxidant generators and will scavenge no to form the harmful peroxynitrite. selected glomerulopathies due to single gene defects such as finnish type nephropathy, diffuse mesangial sclerosis alport/thin membrane disease and inherited lipid disorders and will be discussed. finnish nephropathy is due to mutations of nephrin, a major structural component of the slit diaphragm. over nephrin mutations are known associated with variably absent slit diaphragms, originally thought to be specific for constitutional nephrin mutations. however, sporadic minimal change disease and membranous glomerulonephritis may have absent slit diaphragms suggesting that nephrin may participate in the nephrotic syndrome in nonhereditary diseases. dms is one cause of congenital nephrotic syndrome, characterized by podocyte proliferationis shared by wt (denys-drash syndrome), laminin α (pierson syndrome) and galloway-mowat syndrome mutations. alport nephritis is a paradigm in which only a subset of mutations may predict disease severity (col ivα )). heterozygous alport is similar to thin membrane disease (tmd), but % of tmd harbor col (iv) α mutations and a subset has col ivα . nail patella syndrome due to heterozygous loss of lmx b gene which regulates col ivα - expression during kidney development. in classic nail-patella pathology fibrillar collagen bundles within the gbm are identical in severe and mild disease. thus the mutation does not correlate with prognosis. a mutation overlap in factor h gene in lipid disorders such as dense deposit disease (ddd) and lcat underscores glomerular pathologies that ranges from classic ribbon-like deposits in ddd, to lucent gbm deposits characteristic of lcat, or subendothelial lipid pools in lipoprotein glomerulopathy. the importance of genetics underscoring the pathology is amply demonstrated but mutations may not determine prognosis. background genes, post-translational modification and or protein/protein interactions in podocytes or the gbm may act as phenotypic modifiers. acute renal failure (arf) has many different definitions. rifle criteria distinguish "risk, injury, failure, loss and end-stage renal disease" features of this event. classic forms include pathophysiological cases of renal hypoperfusion and direct parenchymal injury, as well as postrenal anatomical obstruction. microvascular mechanism is in general the effect of disturbed balance between vasoconstriction (in response to endothelin, angiotensin ii, thromboxane a , leukotrienes and increased sympathetic nerve activity) and vasodilatation (in response to nitric oxide, pge and bradykinin). endothelial and vascular smooth muscles cells may undergo structural damage and increased leukocytes-endothelial adhesion is a cause of inflammation. cytoskeletal breakdown, loss of polarity, apoptosis, necrosis, desquamation of viable and necrotic cells with tubular obstruction are underlying mechanisms of acute tubular necrosis. ischemic and direct tubular injury dominate as causes of arf, however specific epidemiology is strictly age-related. sepsis and major surgeryrelated events are the most common causes of arf in hospitalized patients. data on genetic background of certain genes polymorphisms and susceptibility to specific risk factors in newborns and infants are conflicting. several prophylactic and therapeutic techniques are available, however not of universal value. appropriate fluid management is crucial in ischemic arf, classic hemolyticuremic syndrome and rhabdomyolysis, however fluid overload is the one of major predictors of poor outcome in children admitted to icu. neither "renal dose" of dopamine, nor loop diuretics change the outcome. involvement of extrarenal organs worsens the overall outcome, which is the poorest in patients with multi-organ failure. early introduced renal replacement therapy is one of the key modalities in icu-treated patients. continuous techniques are of major value. in specific cases, such as hepato-renal syndrome, albumin ("liver") dialysis serves as an effective bridge to liver transplantation. hyperostosis-hyperphosphatemia syndrome (hhs) is a rare recessively inherited disease, manifested by persistent severe hyperphosphatemia and self-remitting episodic bone pain with radiologic findings of periosteal reaction and cortical hyperostosis. hyperphosphatemia in this patient population is not counter-balanced by pth or vitamin d, posing a mirror image of two hypophosphatemic states which result from increased activity of fibroblast growth factor (fgf ). the two hypophosphatemic disorders which result from enhanced urinary phosphate leak are: dominantly inherited hypophosphatemic rickets and tumor induced osteomalacia. this observation was the impetus to study the role of fgf in hhs. affected individuals were found to have low levels of the full length, biologically active fgf , but markedly augmented amounts of the cleaved inactive fragments. patients were found to be homozygous for a mutation in the galnt gene encoding a peptide involved in mucin-type o-glycosylation. decreasing the expression of the galnt gene by rna interference resulted in augmenting processing of the intact fgf . our research indicates that the primary defect in hhs is a state of underglycosylation of fgf- resulting from reduced expression of ppgantase-t , due to mutations in galnt , and leading to augmented processing at the cleavage site. these changes in fgf- would abolish its phosphaturic effect and lead to severe persistent hyperphosphatemia. this study provides the pathogenetic mechanism of the first mucin-type o-glycosylation defect identified. our observation lends further credence to the primary and essential role of fgf in phosphate homeostasis through a pth-independent pathway. this was substantiated most recently by several reports which showed that mutations in the fgf gene are responsible for familial hyperphosphatemic tumoral calcinosis (fhtc) . a further study showed that hhs and familial hyperphosphatemic tumoral calcinosis are allelic disorders with a founder mutation in our region. immune responses govern the outcome of many forms of chronic kidney disease. gene therapy offers the potential to modify immune genes to improve outcome. we will discuss the potential use of gene transduction as a therapy for chronic kidney disease. background: chronic proteinuric renal disease is a major cause of end stage renal disease in man. adriamycin nephropathy is a murine model of chronic proteinuric renal disease where initial chemical injury is followed by immune and structural changes that mimic human disease. foxp is a gene specifically expressed by regulatory t (treg) cells. forced expression of the gene foxp causes transduced t cells to develop a regulatory phenotype. we hypothesised that foxp transduced regulatory t cells could protect against renal injury in adriamycin nephropathy. methods: the retroviral vectors expressing foxp and green fluorescent protein (gfp) (foxp /migr) and gfp alone (migr) were transfected into package cell lines ecopack - , which produced the two retroviruses. cd + t cells were isolated from spleen of balb/c mice and stimulated by anti-cd mab and il- for hours and then were infected with either retrovirus. expression was confirmed and phenotypic and in vitro functional assays demonstrated a regulatory phenotype. one week after infection, the gfp+ positive cells were sorted. foxp and control vector (migr) transduced t cells were administered to adriamycin (adr)-induced progressive renal nephropathy in mice. results: adoptive transfer of the foxp transduced t cells protected against renal injury. urinary protein excretion was reduced; there was less renal injury as measured by glomerulosclerosis, and interstitial infiltrates. serum creatinine, glomerular sclerosis and tubulointerstitial alterations were significantly lower in adr-foxp group, compared to those without treatment (adr) and treated with control vector (migr) transduced group (adr+migr). the foxp transduced cd t cells also showed suppressive activity in vitro. we conclude that foxp induced t reg cells may have a therapeutic role in protecting against immune injury and disease progression in chronic proteinuric renal disease. the italkid project is a prospective, population-based registry that was started in . prevalent and incident cases of chronic renal insufficiency (cri) in children and adolescents were identified throughout italy (total population base: . million children). the inclusion criteria were: i) creatinine clearance (ccr): < ml/min/ . m bsa; and ii) an age of < years at the time of registration. as to december st, a total of patients had been registered. the incidence of cri was estimated . cases per million and the (point) prevalence . per million of the age-related population (marp). the probability of kidney survival at years of age was significantly different depending on the ccr at study entry, being % in patients with mild renal insufficiency (ccr - ml/min), % in those with moderate renal insufficiency (ccr - ml/min) and % in those with severe renal insufficiency (ccr < ml/min). the patients with normal (< . ) and low ( . - . ) upr/ucr compared to those with mild (> . ), showed a significantly slower decline in ccr (deltaccr + . ± . and - . ± . vs - . ± . ml/min/yr) and a higher kidney survival ( . and . vs . %). the incidence of renal replacement therapy (rrt) was . /year/ patients and the casefatality rate on conservative treatment . %. patients showed a significantly different slope of ccr before pubertal growth spurt as compared to after: - . ± . ml/min/ . mq/yrs and - . ± . . a non-linear pattern of decline in the probability of kidney survival, with a steep decrease during pubertal and early post-pubertal age was observed: the overall probability of rrt at age was estimated . %, while . % of the patients will eventually required rrt before the nd decade of life was over. suggesting that pubertal development triggers the progression of cri in children. treatment with angiotensin converting enzyme inhibitors did not significantly modify the naturally progressive course of hypodysplastic nephropathy. ambulatory blood pressure monitoring (abpm) is a relatively new technique of blood pressure assessment in children and adolescents that offers several distinct advantages over traditional methods of blood pressure measurement, including the ability to detect white coat and masked hypertension, as well as the ability to assess nocturnal blood pressure. the role of abpm in the diagnostic evaluation of pediatric patients with elevated blood pressure is well-established, and recent surveys have demonstrated that it is used quite often by pediatric nephrologists and other practitioners during the initial evaluation of elevated blood pressure. it is less well-established, however, what role abpm might play in hypertensive children and adolescents once hypertension has been diagnosed and treatment initiated. studies in adults have demonstrated that abpm can assess whether patients on antihypertensive medications have achieved goal blood pressure, or whether their hypertension has progressed in severity. abpm can be used to follow nocturnal blood pressure in patients with chronic kidney disease (ckd) and diabetes, facilitating early identification of non-dipping, which is a known risk factor for progression of ckd or development of diabetic nephropathy, respectively. abpm can also be incorporated into clinical trials of antihypertensive medications to help assess their efficacy and safety. while additional data supporting these applications of abpm to pediatric hypertension clearly need to be generated from well-designed clinical trials, we propose that there is ample justification to utilize abpm just as frequently after the diagnosis of hypertension as before. childhood obesity is increasing globally in epidemic proportions and affects children in both industrialized and non-industrialized nations. in the last years the percentage of overweight or obese children has increased from % to almost %. if current trends continue, as many as % of children may be overweight or obese by the year . obesity predisposes to development of the metabolic syndrome, which is defined in children as the presence of three or more of the following features: abdominal adiposity (bmi > %ile), serum triglycerides > %ile, serum hdl cholesterol < % ile, fasting blood glucose > mg/dl, and/or hypertension (systolic or diastolic blood pressure > %ile adjusted for age, gender and height). the metabolic syndrome occurs in about % of children, but in - % of overweight children. the presence of the metabolic syndrome increases the risk for cardiovascular disease and chronic kidney disease almost ten-fold in adults. adipose tissue does not just store fat, but also has important endocrine and immune functions mediated through adipocytokines, including leptin, adiponectin, resistin, apelin and visfatin, and classical cytokines such as tnf-a and il- . increased leptin, decreased adiponectin and increased inflammatory cytokines, which occur in obesity, are known to induce vascular endothelial dysfunction and increase blood pressure. increase in adipose tissue also leads to infiltration by monocytes, macrophages and lymphocytes, which are stimulated to produce additional cytokines that may contribute to the systemic inflammation associated with obesity and vascular inflammation associated with hypertension. screening for hypertension and metabolic syndrome in obese children is critical to allow early identification of the metabolic syndrome and aggressive early intervention to reduce the risks for progression to cardiovascular disease and chronic kidney disease in later life. therapeutic strategies must include lifestyle changes of weight loss, healthier diet and regular physical exercise as well as treatment of hypertension, hyperlipidemia or hyperglycemia. blood pressure (bp) regulation is affected by numerous physiologic, biochemical, genetic and environmental factors. it has been suggested that exogenous conditions affecting intra-uterine growth and development may pre-program individuals for hypertension, metabolic abnormalities and cardiovascular morbidity in later life. animal data and human autopsy findings support a link between intrauterine growth, nephron endowment and postnatal hypertension. conceptually, it appears increasingly unclear whether the association of birth weight and bp in later life is mediated by intrauterine growth retardation as suggested by various animal models, whether prematurity per se affects bp programming independent of the fetus, nutritional status, or whether postnatal circumstances statistically linked to low birth weight affect this relationship. we have designed a study to evaluate the relationship between gestational age, birth weight and bp abnormalities by applying abpm in a group of children born preterm with and without intrauterine growth retardation and a local control group of children born at term with appropriate weight. this study represents the first systematic assessment of -hour cardiovascular regulation in children and adolescents born preterm. our findings indicate that a fraction of these preterm born subjects has a selective nocturnal increase in systolic bp, resulting in an elevated prevalence of non-dipping. our analysis suggests that intrauterine growth retardation, rather than prematurity per se, is the major effector of the early cardiovascular abnormalities observed in preterm children. moreover, we have found that nocturnal systolic bp was closely linked to heart rate, pointing to a possible role of sympathetic hyperactivation. while little data is available regarding a link between low birth weight and/or prematurity and sympathoadrenal function in adult humans, a role of the sympathetic nervous system in the programming of adult hypertension has been consistently demonstrated in various animal models of fetal growth retardation. in conclusion, we detected subtle abnormalities of circadian bp regulation in those preterm born children who suffered from intrauterine growth retardation and this may reflect sympathetic hyperactivation. the intrinsic tendency of kidney disorders with reduced nephron mass to progress and the quest for renoprotective strategies are an ongoing focus of renal research. in adults, hypertension is not only a marker but also a major driving force of renal failure progression. renin-angiotensin system blockers (ace inhibitors and at receptor blockers) are preferred antihypertensive drugs in ckd due to their specific renoprotective effects beyond blood pressure (bp) control, mediated by their antiproteinuric, antiinflammatory and antifibrotic properties. it is less clear whether bp reduction to low-normal values has an additional salutory effect on gfr preservation. children suffer from a markedly different spectrum of renal diseases than adults, with a preponderance of hypo/dysplastic kidney malformations. hypertension and proteinuria are common but usually moderate. to elucidate the renoprotective efficacy of ace inhibition and strict bp control in children, the escape trial was launched by a consortium of european pediatric nephrologists. a total of children and adolescents with stage ii-iv ckd received a fixed dose of ramipril and were randomized to intensified (< th percentile) or conventional bp control ( th- th pct). h-bp, proteinuria and gfr were monitored over a -year period. h mean arterial pressure (map) was reduced by ramipril from to mm hg (i. e. from . to sds) on average. subsequently, mean map was lowered further to mm hg at months in the intensified arm, and maintained around mm hg ( . sds) in the conventional control arm (p< . ). on average . antihypertensive drugs were added to ramipril in the intensified and . in the conventional treatment arm (p= . ). treatment tolerability was excellent in both arms, with less than % dropouts due to side effects. in summary, ramipril was effective and well tolerated in children with ckd. it is possible and safe to target low-normal bp in children. final results regarding renal survival will be available in summer and presented at the ipna meeting. nephronophthisis and joubert syndrome: converging on convergent extension? nephronophthisis (nphp), an autosomal recessive cystic kidney disease, leads to terminal kidney failure in adolescence. nphp may be associated with retinitis pigmentosa (rp) in senior-loken syndrome (slsn) or with cerebellar vermis aplasia in joubert syndrome (jbts). we have identified by positional cloning genes as mutated in nphp. the gene product of nphp , nephrocystin- , acts in focal adhesion signaling. by positional cloning we detected mutations in the nphp /inversin gene as causing infantile nphp (type ) with association of situs inversus or rp. we demonstrated expression of nphp , in primary cilia of renal epithelial cells, supporting a new unifying theory for the pathogenesis of cystic kidney diseases (watnick et al. nature genet : , ) , stating that the products of all genes mutated in cystic kidney disease in humans, mice, or zebrafish are expressed in primary cilia, basal bodies, or centrosomes of renal epithelial cells (hildebrandt et al. nature rev genet : , ) . identification of nphp mutations in nphp type also revealed the cause of the renal cystic disease mouse model "pcy", for which treatment has been demonstrated. positional cloning of nphp led to the demonstration that its gene product, nephrocystin- , is conserved in c. elegans and expressed together with nephrocystin- in ciliated head and tail neurons of the nematode. the role of primary cilia function for retinal-renal syndromes was confirmed by identification of the novel nphp gene. recently, several signaling pathways have been implicated in the downstream signaling pathways that connect ciliary/basal body function to the renal cystic phenotype. these include the wnt signaling/planar cell polarity pathways, and the hedgehog signaling pathway. we implicated the planar cell polarity signaling pathway in nphp by positional cloning of mutations in the gene nphp /cep as causing joubert syndrome. abrogation of nphp function in zebrafish caused planar cell polarity (convergent extension) defects and recapitulated the human phenotype of joubert syndrome. further gene identification in nphp will result in the definition of functional networks of primary cilia, centrosomes, and planar cell polarity as they pertain to the pathogenic mechanisms of nphpassociated syndromes and other cystic kidney diseases. hnf b is a transcription factor that is expressed in bile ducts, intestine, pancreas and renal epithelia. germ-line inactivation of the mouse hnf β/tcf gene is embryonic lethal (e . ) due to defective differentiation of the extra-embryonic visceral endoderm. hnf β is later expressed in endoderm derivatives and in the mesonephros. to understand the function of hnf b at later stages of development and during organogenesis, we applied a conditional inactivation based on a (cre-loxp) strategy. with the use of a cre recombinase that is expressed in renal collecting ducts and henle loops (ksp-cre) we found that hnf b inactivation leads to polycystic kidney disease (pkd). this is reminiscent of the renal phenotype of patients carrying heterozygous mutations in tcf /hnf β. these patients suffer from maturity onset diabetes of the young type (mody ) and at the same time from renal cysts (renal cysts and diabetes or rcad). this cystic phenotype is linked to the defective expression of pkhd and pkd , two genes mutated in pkd patients. the cellular and molecular mechanisms underlying pkd are still poorly understood. it was recently speculated that planar-cell-polarity signalling (wnt) could be at the basis of cyst formation. maturation of nephrons during development is accompanied by a considerable lengthening of tubules. this process involves an intense proliferative phase without any increase in tubule diameter. interestingly, we discovered that the progeny of consecutive cell divisions are adjacent one another and oriented in parallel to the axis of tubules. this suggested that upon lengthening, cells divide according the tubule axis. in addition, d image reconstructions revealed that oriented cell division is due to the alignment of the mitotic spindle with the axis of the tubule. we hypothesized that oriented cell division could play an essential role in preventing tubular dilation during the massive proliferative phase that accompanies tubular elongation. indeed, our results indicated that both in ksp-cre-kidney-specific-hnf β-deficient pups and in the pck rats, lacking the expression of pkhd , the mitotic alignments were highly distorted. our results indicate that hnf β plays a crucial role in activating the expression of genes involved in the control of tubular size maintenance during tubular elongation. emerging evidence suggests that the intravenous injection of bone marrow-derived cells improves renal function after acute tubular injury. examination of human transplant biopsies of female kidneys that had been transplanted into male recipients have shown the presence of tubular cells that co-express the y chromosome and epithelial markers. however, controversy exists as to whether the protective effect is due to engraftment of the cells in the injured tubule or an endocrine/paracrine effect of the injected cells. our studies demonstrate that intravenous infusion of whole bone marrow from male mice into female recipients results in the appearance of significant numbers of y chromosome + cells in the kidney interstitium, and rare y chromosome + cells in the tubules. the majority of the interstitial cells express leukocyte markers such as cd . in addition, we have found that i. v. or i. p. injection of bone marrow stromal cells (msc, adherent non-hematopoietic marrow cells) into mice reduced the severity of cisplatin-or ischemia-induced aki. examination of these kidneys demonstrates that mscs enhance tubular cell proliferation and decrease tubular apoptosis after injury. examination of multiple tissue sections at or days after injury failed to reveal any examples of y chromosome cells within the tubules, and only rare examples of y chromosome cells within the renal interstitium. furthermore, exposure to conditioned medium from cultured mscs (msc-cm) significantly diminished cisplatin-induced death of cultured proximal tubule cells in vitro, while i. p. administration of msc-cm in the mouse markedly diminished the rise in bun associated with cisplatin injection. thus our data suggests that hematopoietic cells and their derivatives from adult bone marrow enter the kidney in response to injury where they are primarily localized to the interstitial space as inflammatory cells. in rare instances, these cells may differentiate into, or fuse with, tubular epithelial cells. in contrast, bone marrow mscs fail to enter the kidney in significant numbers, but can protect the endogenous tubular cells from toxic injury by secreting a factor or factors that limit apoptosis and enhance proliferation. renal hypodysplasia (rhd) is characterized by a reduced nephron number, small kidney size and disorganized renal tissue. a hereditary basis has been established for a subset of affected patients, suggesting a major role of developmental genes involved in early kidney organogenesis. gene mutations with dominant inheritance causing rhd, urinary tract anomalies and defined extrarenal symptoms have been identified in tcf (renal cysts and diabetes syndrome (rcad)), pax (renal-coloboma syndrome (rcs)), eya and six (branchio-oto-renal syndrome (bor)) for the most frequent of these syndromes. a recent study on a cohort of patients with rhd and consecutive renal insufficiency demonstrated that % of them had mutations in one gene encoding for a transcription factor. the majority of mutations were identified in tcf (hnf β) (especially in the subset with kidney cysts) and pax . this study demonstrates that subtle extrarenal symptoms in syndromal rhd easily can be missed. genetic testing in children with rhd should be preceded by a thorough clinical evaluation for extrarenal symptoms, including eye, ear, and metabolic anomalies. the presence of these anomalies increases the likelihood of detecting a specific genetic abnormality. in addition, mutations in genes that are usually associated with syndromes can occur in patients with isolated rhd. the ret receptor, its ligand gdnf and the co-receptor gfra play a pivotal role during early nephrogenesis and enteric nervous development. in humans, activating ret mutations cause multiple endocrine neoplasia, whereas inactivating mutations lead to hirschsprung disease. while ret deficiency also causes renal hypodysplasia (rhd) in the mouse model, genetic abnormalities in ret have not been characterized in human isolated renal malformations to date. the ret mutations, y f and s l, reportedly predisposing to medullary thyroid carcinoma (mtc) were found in one and six patients respectively in the same rhd cohort. none of the patients or their carrier relatives had clinical evidence of mtc at the time of the study. our findings suggest that ret mutations predispose to both mtc and rhd, with a low penetrance for either disorder. interestingly, a gdnf mutation was found in addition to a ret mutation and to an eya mutation in a patient with the branchio-oto-renal syndrome suggesting an oligogenic inheritance. mutations in clcn , the gene encoding the chloride/proton exchanger clc- , underlie most forms of dent's disease, an x-linked nephrolithiasis syndrome that is always associated with low molecular weight proteinuria. clc- belongs to the clc gene family of chloride channels and transporters and, in addition to other sites, is expressed in apical endosomes of the proximal tubule. in these vesicles, it co-localizes with the proton pump and with endocytosed proteins. previously thought to be a clchannel, it is now known to mediate electrogenic cl -/h + -exchange. this notion remains compatible with a role in supporting the acidification of endosomes by providing an electrical shunt for the h + -atpase. to clarify the pathogenesis of dent's disease, we created a knock-out mouse model. it displayed low molecular weight proteinuria due to a largely reduced endocytosis by proximal tubular cells (fluid-phase and receptor-mediated). the acidification of renal cortical endosomes was reduced in the ko. the failure of the pt to endocytose pth led to an increased luminal, but not systemic concentration of this hormone. this, in turn, resulted in hyperphosphaturia due to a retrieval of the phosphate transporter napi- a from the pt plasma membrane. nephrolithiasis can be explained by altered renal handling of pth and vitamind, all of which are secondary to the impaired endocytosis. there is an increased prevalence of nephrolithiasis in individuals with obesity, type ii diabetes, and the metabolic syndrome. in particular, uric acid constitutes a much higher percentage of stones in these patients compared to the general stone-forming population. we strived to examine the pathophysiologic connection between the metabolic syndrome and uric acid stones. in the vast majority of cases, the principal abnormality in uric acid stones is not hyperuricosuria but an excessively low urinary ph. uric acid nephrolithiasis is in fact a disease of 'urinary acidification' although there is no systemic metabolic acidosis in the classical sense because acid-base balance is achieved and no excessive acid is accumulated. however, the excretion of protons using low pk closed buffers rather than the high pk open buffer ammonia dictates a low urinary ph. since protonated uric acid has a sparingly low solubility compared to ionized urate, low urine ph promotes uric acid precipitation. thus uric acid nephrolithiasis is an innocent bystander of low urinary ph. the link between the metabolic syndrome and urinary ph as a continuous variable is explored by epidemiologic, human metabolic, and laboratory studies. in population-based studies in stoneformers, low urinary ph is associated with higher body weight. urinary ph is also lower with increasing number of features of the metabolic syndrome (waist circumference, high triglycerides, low high density lipoproteins, hypetension, hyperglycemia) and within each of the features, the severity of each parameter is inversely proportional to urinary ph. in metabolic studies in humans, low urinary ph is associated with low peripheral insulin sensitivity. when studied as in-patients on identical metabolic diets, patients with type ii diabetes and uric acid stone-formers have high net acid generation than normal volunteers. this alone lowers urinary ph although the reason for the elevated acid load is not clear at present. in addition to high acid generation, uric acid stone formers tend to use buffers other than ammonia to buffer protons in the urinary resulting in unduly acidic urine ph. when challenged with an acute acid load, the ammonium excretion response is markedly blunted in uric acid stone-formers. a similar urinary abnormally of acidic urine ph and underutilization of ammonia is seen in the zucker diabetic fatty (zdf) rat compared to their lean counterpart. these animals have peripheral insulin resistance, elevated serum free fatty acid and have significant steatosis in their kidneys. one abnormality in the kidney is reduced expression and activity of the na + /h + exchanger nhe which is the major transporter that excretes ammonium into the urine and its activity is stimulated by insulin. causality is supported by the fact that treatment of the animals with a thiazolidinedione partially reversed the fat infiltration, urinary acidification abnormality and reduced expressed of nhe . the direct effect of fat on the renal proximal tubule was tested in cultured cells. provision of fatty acids beyond the oxidation capacity of the tubule leads to dose-dependent impairment of nhe , generalized dysfunction and eventually cell death. a sub-cytotoxic dose of free fatty acid did not affect baseline nhe activity and expression but reduced the ability of insulin to activate nhe . in summary, the metabolic syndrome is associated with increase acid generation that is independent of diet. this increased acid load is effectively excreted by the kidney. failure to maximally utilize the ammonium buffer system results in lower urinary ph and titration of urate to its insoluble form as uric acid and results in uric acid nephrolithiasis. part of the pathogenic mechanism maybe lipotoxicity from fat infiltration of organs. uric acid nephrolithiasis is an "innocent bystander" which is a sentinel of a more generalized alteration in acid generation and excretion. genetic hypercalciuria recurrent kidney stone production is one of the most common diseases of the bipedal human condition, occurring in up to % of the population in western societies. unlike four-footed animals who likely perish in the wild from a selection disadvantage from a painful calculus, human beings continue to function, and have the ability to express the biologic defects repetitively that result in a stone. idiopathic hypercalciuria, where a specific gene defect has not yet been established, is a shrinking subpopulation of recurrent calcium stone formers, as specific mutations and functional polymorphisms of genes intimately or distantly related to calcium homeostasis arise from the sequencing of the human genome applied to clinical stone disease. other postulated mechanisms can be sought for in this manner as well, and may await larger population-based studies. the familial nature of nephrolithiasis is clear and robust for most calcium-based stone formers, and may have a gender-specificity for that inheritance. the role of environment in its expression remains controversial. the systemic nature of genetic hypercalciuria may be seen through its associated effects on skeletal health and biology. between - % of children with genetic hypercalciuria have abnormally low bone density measured by dual-energy absorptiometry that cannot be explained by correction for height or body mass. further, normalization of urinary calcium excretion with a variety of therapies is associated with improvements in bone density values over time. a proposal for re-classifying hypercalciuria pathogenetically will be presented, and linked to observational data across the world for successful therapeutic approaches. a call for a stone registry and more careful determination of etiology will be sought through the ipna congress. the systems that regulate blood pressure are plastic during development and can be permanently reset. experiments in animals show that it is surprisingly easy to produce lifelong changes in blood pressure by minor manipulations of the mother's diet before and during pregnancy. this phenomenon has been referred to as "programming". epidemiological and animal studies show that programmed effects operate within the normal range of growth and development, and influence the risk of hypertension, coronary heart disease and stroke in later life. a clinical study of people aged years from the helsinki birth cohort showed that two different paths of growth preceded the development of hypertension. people already diagnosed as having hypertension had small body size a birth and low weight gain from birth to two years but grew rapidly after two. at age eleven years their body size was around the average. as adults they tended to be obese and insulin resistant. a second group of people had not been diagnosed but their blood pressures were classified as hypertensive under current definitions. they were short at birth, had low weight gain from birth to two years and remained small after two. at age eleven years they were short and thin. as adults they tended to be overweight and have atherogenic lipid profiles. the first path of growth is similar to that which leads to coronary heart disease in this cohort. the second path is that which leads to stroke. this paper will present data on the maternal and placental influences through which these paths originate. nephron number is a key feature of the conceptual paradigm positing that cardiovascular and metabolic diseases that arise during childhood and adulthood have their origin in events that occur during fetal life. in mammals, nephrons are derived from a subset of cells resident within the metanephric blastema. blastemal cells participate in reciprocal inductive tissue interactions with the ureteric bud. these interactions induce the ureteric bud to grow and branch. in turn, ureteric bud branches induce discrete populations of the metanephric blastema to undergo successive transitions resulting in the formation of mature nephrons. a distinct population of metanephric blastema cells in the stroma modulates branching morphogenesis and nephrogenesis. identification of genes that control both branching morphogenesis and nephrogenesis is providing insight into the molecular pathways that could be targeted by environmental, nutritional and hormonal factors that control fetal programming. this lecture will highlight the morphologic and cellular events critical to renal branching morphogenesis and nephrogenesis, and the gene networks that regulate or counter-regulate these events. these gene networks will then be considered in the light of non-genetic factors that modulate their activities. it is now accepted that early life environment can modulate adult phenotype, including the blood pressure. the likely primary mechanism is epigenetic modulation of gene expression during a sensitive period of fetal maturation, but the pathogenesis of the later development of hypertension is unclear. participation by extrarenal factors such as central regulation and peripheral vascular function has been evoked; however, a strong body of experimental evidence suggests that the "setpoint" for renal regulation of na balance and extracellular volume is altered. because both humans and many experimental models with prenatally programmed hypertension appear to have a decrease in the total number of nephrons, impaired filtration of na has been hypothesized to be an important pathogenetic factor. more recent evidence has suggested that postnatal inflammation and accumulation of reactive oxygen species in the renal interstitium may contribute to the genesis of hypertension by upregulating distal nephron na transport. furthermore, the role of renal vascular function remains to be determined. the different mechanisms are not mutually exclusive; it is conceivable that both a prenatal "priming" and a postnatal "second hit" are required for hypertension to become manifest. j. ingelfinger epidemiological studies published in the late s by barker and his group -and since replicated in many populations -provide evidence of an inverse relationship between birthweight and risk of cardiovascular disease, hypertension, and renal dysfunction in adult life. both clinical studies and animal models have been used to investigate mechanisms underlying these observations [as cited in recent reviews. the concept that changes in the intrauterine milieu affect the growing fetus resulting in alterations in physiology and general health in later life has been termed perinatal programming or developmental origins of health and disease [dohad] . yet, despite a large and burgeoning literature about this phenomenon and its relationship to cardiovascular and renal disease, involved mechanisms remain elusive. maternal malnutrition or exposure to various medications or substances leads to an adverse in utero environment that may impair nephrogenesis, evident in experimental animal studies as well as in clinical reports in humans. nephron deficit at birth persists throughout life, creating "low glomerular endowment, " an important risk factor for hypertension and esrd in adulthood. for a number of years it has been hypothesized that nephron number may strongly influence blood pressure as well as susceptibility to renal disease in later life. recently clinicopathologic observations suggest that a relationship more directly. renal morphogenesis involves complex events in which many genes interact in the formation of the final kidney. when the normal pattern of nephrogenesis is interrupted, renal abnormalities may ensue. during renal development, two major events -ureteric bud (ub) branching and mesenchymal-to-epithelial transformation -greatly impact the outcome of renal morphogenesis. renal malformation accounts for approximately percent of childhood renal failure and represents the end result of failure of fundamental embryonic processes in ub and metanephric mesenchyme (mm) lineages. this presentation will review the data concerning renal responses to perinatal challenges as these occur and later evolve during childhood. we will consider the implications and the data available concerning screening, follow-up and management of at-risk persons. generation of oxidized lipoproteins in obstructive nephropathy -atherogenic or fibrogenic? children's hospital and regional medical center, division of pediatric nephrology, seattle, united states chronic kidney disease, regardless of etiology, is characterized by a relentless progression of fibrosis that gradually destroys the normal renal architecture, particularly in the tubulointerstitium. obstructive uropathy accounts for approximately percent of pediatric patients with chronic kidney disease (ckd) and end-stage renal disease (esrd). after post-natal relief of obstruction, the optimal treatment of children with obstructive uropathies remains unknown and for many the progression of ckd to esrd is inevitable. therapeutic options are limited by an incomplete understanding of fibrogenic pathways in the kidney. the major renal fibrotic pathways identified thus far can be broadly classified into those involved in transforming growth factor beta (tgf-b) activation, macrophage-mediated inflammation, angiogenesis, and extracellular matrix production/degradation. it is becoming increasing clear that key molecules have multiple roles in several of these pathways triggering fibroinflammatory events targeting specific cell types. oxidative stress represents an intersection of many of these fibroinflammatory pathways leading to cellular activation and tissue injury. oxidized lipoproteins accumulate in the circulation and renal interstitium in both experimental models and patients with ckd and esrd. many parallels have been drawn between atherogenesis and the pathogenetic mechanisms of progressive kidney destruction by fibrosis. although ckd is clearly associated with an increased cardiovascular risk, it is not clear whether oxidized lipoproteins amplify fibrogenic pathways in the kidney. research in our laboratory suggests that hypercholesterolemia increases injury severity in obstructed kidneys. scavenger receptors mediate the cellular effects of oxidized lipoproteins during atherosclerosis and activate both inflammatory and oxidative pathways. dietary and antioxidant therapies have clear benefits in animal models but limited efficacy in patients. our studies suggest that blocking key scavenger receptors leads to a significant attenuation of both oxidative and pro-inflammatory pathways during chronic injury by obstruction in hypercholesterolemic mice. interventions targeting scavenger receptor signaling may represent an alternative strategy to attenuate both the progression of ckd and cardiovascular disease. the resolution of injury and promotion of renal repair comprises a delicate balance between cell death and destruction of tissue architecture in relation to cell differentiation, maturation and extracellular matrix (ecm) remodeling. although many studies have focused on the cellular and molecular events leading to the development of renal fibrosis, less is understood about the process of renal repair and regeneration. this is despite the fact that the kidney has a significant capacity for regeneration and cellular replacement following acute damage. the present study describes the structural, functional, and expression profile analysis of endogenous renal repair and the regenerative potential of the kidney following reversal of ureteral obstruction (r-uuo) in the mouse. days after unilateral ureteral obstruction there is renal tubular cell loss, activation of an inflammatory cascade leading to widespread cortical interstitial fibrosis and the loss of normal medullary architecture. following to weeks after r-uuo there was marked tubular repair and regeneration of medullary components, ecm remodeling and decreased inflammatory cell infiltration. the structural repair observed at weeks post-release of ureteral obstruction was associated with a - % recovery of the glomerular filtration rate (gfr). expression profile analysis was performed to visualize patterns of gene expression that were differentially expressed in the repaired and remodeling areas following r-uuo. we are also interested in the regulation of cellular recovery and the processes involved in epithelial cell re-differentiation in regenerating tubules following injury. tubular epithelial cell cilia may play potential roles in directing the orientation of cell division and epithelial differentiation during the endogenous remodeling process. our results suggest that renal cilium lengthening may be an important factor in the response to injury and subsequent recovery of renal function. these studies propose that a lengthening of renal epithelial cilia increases their sensitivity to flow and reduces damaging epithelial dedifferentiation in the injured renal tubules. a better understanding of the key events involved in endogenous renal repair and remodeling may open the way to new interventions based on their manipulations aimed at acceleration of renal regeneration and prevention of scarring. soren nielsen has kindly agreed to present this topic, however was not able to submit an abstract. the final regulation of urinary k excretion in the fully differentiated kidney is accomplished in the distal nephron, including the cortical collecting duct (ccd), where cell k passively diffuses into the urine through apical k selective channels. the prevalence of the sk/romk channel and its high p o at the resting membrane potential has led to the belief that this channel mediates baseline k secretion. less easily detected is the bk channel which is characterized by a low p o at the physiologic resting membrane potential and [ca + ] i . bk channels are activated by membrane depolarization, elevation of [ca + ] i , and/or membrane stretch, and can be selectively blocked by iberiotoxin (ibx). we have reported that flow-stimulated net k secretion (jk) in the adult rabbit ccd is (i) blocked by ibx and (ii) associated with increases in net na absorption (jna) and [ca + ] i , leading us to conclude that bk channels mediate this process. recent studies have examined the acute and chronic regulation of bk channel-mediated flow-stimulated jk. we reported that flowstimulated jk requires an increase in [ca + ] i due to luminal ca + entry and er ca + release, microtubule integrity, and exocytic insertion of preformed channels into the apical membrane. channel expression is regulated long term during postnatal development and by dietary k intake. specifically, an increase in tubular fluid flow rate fails to elicit an increase in jk in the rabbit ccd until the th wk of postnatal life, coincident with appearance of immunodetectable bk channels, whereas flow-induced increases in jna and [ca + ] i in -wk-old ccds are "mature". a role for the bk channel in renal k adaptation has been suggested by the observation that dietary k loading leads to an increase in abundance of bk message in microdissected ccds with redistribution of immunodetectable channel proteins from an intracellular pool to the apical membrane. additionally, ccds isolated from k loaded animals demonstrate enhanced flow-stimulated jk compared to tubules from control fed animals. in sum, emerging evidence suggests that the bk channel plays a prominent role in distal k secretion in response to increases in urinary flow rate and dietary k intake. the late developmental appearance of this channel is compatible with the need of the growing animal to retain k early in postnatal life. recent advances in molecular genetics of hereditary hypomagnesemia substantiated the role of a variety of genes in human magnesium transport. this knowledge on underlying genetic defects helps to distinguish different clinical subtypes and gives insight into molecular components involved in magnesium transport. during the last four decades, numerous reports concerning inherited magnesium losing disorders have been published and their distinctive phenotypic features have been discussed. phenotypic characterization of affected individuals and experimental studies of appropriate animal models have contributed to a growing knowledge of renal magnesium transport mechanisms. the identification of the affected nephron segments, the different modes of inheritance and the observation of additional characteristic symptoms promoted a classification into different subtypes of inherited magnesium losing disorders. in general, primary magnesium wasting disorders are relatively rare. the prevalence of the more frequent entities, for example gitelman syndrome, has been estimated to be approximately : . . for most of the other disease entities, relatively few cases have been reported in the literature. depending on the genotype, the clinical course is sometimes mild or even asymtomatic. therefore, the disease prevalence might be underestimated for some of these syndromes. magnesium transport has been intensively studied in humans and various animal models leading to accepted concepts underlying the pathophysiology of the different forms of hypomagnesemia. however, the electrophysiological characterization of magnesium pathways has been complicated by unintentional simultaneous measurement of other cations so that the molecular correlates mediating mammalian magnesium transport components remained undefined. a different approach to study components of magnesium transport arises from genetic analysis of families affected with magnesium wasting diseases. linkage studies enabled the localization of several genes involved in hereditary hypomagnesemia and in the last decade, a number of genes have been identified by positional cloning. these genes have provided first insight into mammalian magnesium transport molecules. distal renal tubular acidosis may be inherited as an autosomal dominant or recessive trait. mutations in three genes -slc a , atp v b and atp v a -are associated with the various forms of disease, and give rise to a wide spectrum of clinical severity. in general, dominant mutations do not affect ion transport function per se and do not affect hearing, whereas recessive disease is characterized by loss of function and deafness. some unusual functional consequences of mutations in ae and a proteins are mistargeting and loss of protein-protein interaction respectively, and these will be discussed. the heart in pediatric nephrotic syndrome y. frishberg shaare zedek medical center, pediatric nephrology, jerusalem, israel in recent years, the molecular bases of several conditions which lead to steroid-resistant nephrotic syndrome (srns) have been identified. the common denominator shared by these clinical entities is that they all result from structural defects in the glomerular barrier, thus explaining their unresponsiveness to immunosuppressants. for instance, the congenital ns of the finnish type is caused by mutations in the nphs gene encoding nephrin. a recessive form of srns was found to result from mutations in nphs encoding podocin which is specifically expressed in podocytes. we have previously shown that a founder mutation in nphs (r x) is the prevalent cause of hereditary srns ( % of tested are homozygotes) among arab children in israel. interestingly, we noted that a number of patients who are homozygous for the r x mutation in podocin have a co-existing cardiac disorder. only a few case reports described an association between srns and cardiac defects. we questioned whether the glomerular-barrier disorders, which have been considered to be kidney-specific, have implications on other organ-systems. thus, we systematically reviewed the cardiac status of these srns patients at the time of diagnosis while they had normal blood pressure and preserved renal function ( ). cardiac anomalies were detected in % of children, the most common of which were cardiac hypertrophy and pulmonary stenosis. analyzing two control groups enabled us to conclude that cardiac disorders in homozygotes for mutations in nphs cannot be attributed to an association by chance or to a state of persistent ns. because human podocin mrna is expressed in fetal heart, we hypothesize that it may have a role in normal cardiac development and this will be an issue of further investigation. this is the first study showing a role for podocin in extra-renal tissues and therefore recommends early cardiac evaluation for timely medical management. cvd is the world-wide biggest obstacle to long-term survival of children and adolescents with ckd. mortality from cvd is excessively high on dialysis and continues to be a threat after renal transplantation. early diagnosis of the individual risk for cvd would enable preventive measures on an individual basis. however, prospective studies with hard end points -cardiac events -are difficult if not impossible to conduct in children and adolescents. on the other hand, the known high morbidity and mortality in elderly dialysis patients may largely result from pre-existing comorbidity (advanced atherosclerosis has been demonstrated in this age group at initiation of dialysis). for this reason, investigations in patients with childhood onset ckd may provide a diagnostic window to study the pathogenesis of cardiac and vascular changes in subjects without comorbidities. several studies using non-invasive measurements of surrogate markers for cvd have demonstrated a pattern of early systemic cvd, including changes in intima-media thickness (imt) of conduit arteries (aorta, a. carotis) and muscular arteries (a. femoralis), altered function of peripheral resistance arteries (venous occlusion plethysmography) and abnormalities in the heart (echocardiography). patients show a significant decrease in post-ischemic vascular reactivity with evidence of vascular stiffness and frequently have extraosseous calcifications often involving coronary arteries and heart valves. importantly, these studies have found little evidence for correlations with classical risk factors (except hypertension), but with abnormalities of calcium and phosphorus metabolism and their therapy, including the intake of active vitamin d preparations and calcium-containing phosphate binders. thus, patients with childhood-onset ckd are at high risk to develop systemic cardiovascular changes, which may represent a new disease originating from the survival of ckd, a previously deadly disease, and interventions for the prevention of renal osteodystrophy. this therapeutic challenge needs to be addressed with high priority to enable long-term survival of children with ckd. while their mere existence is still questioned by some investigators, lipid rafts have recently gained a large amount of attention because of their apparent involvement in various cellular processes, including signaling, membrane trafficking, polarization, and endo-as well as exocytosis of proteins as well as pathogens. membrane rafts have been defined as small ( - nm) heterogeneous, highly dynamic, sterol-and sphingolipid-enriched domains that compartmentalize cellular processes and that can sometimes be stabilized into larger platforms by protein-protein or proteinlipid interactions. rafts are of special interest for pediatric nephrologists for two reasons: . they play a critical role in immune cell activation, especially in the formation of the immunological synapse (is), and thus in many important disease processes affecting our patients, including -but not limited to -transplant rejection. beyond their participation in is formation, rafts also facilitate signaling through other immune cell receptors, such as the interleukin- receptors, where they may ascertain cytokine selectivity and specificity. . equally important, rafts serve as essential site for proper interactions between nephrin and podocin, thus establishing the integrity of the glomerular filter. general aspects of raft biology as well as their role in immune cell signaling will be reviewed in more depth in this presentation. raft involvement in glomerular filter formation and especially genetic aspects relevant to disturbances of this involvement and of the associated integrity of the filter, as seen in hereditary nephrotic syndromes, are discussed in subsequent presentations in this symposium. reports of familial forms of fsgs date back to , with the observation of an autosomal recessive disease primarily within the finnish population. it is characterized by massive proteinuria in utero, with up to to grams of protein loss per day. nphs encodes a gene product termed nephrin that localizes to lipid rafts within the slit diaphragm of the podocyte. steroid-resistant nephrotic syndrome (srns) is an autosomal recessive nephrotic syndrome and manifests between months and years of age, rapid progression to esrd, and with few cases of recurrence after renal transplantation. the gene product is podocin (nphs ), located on q - . podocin most likely functions in the structural organization of the slit diaphragm and regulation of its filtration function. it has been shown to interact in vivo with both nephrin and cd -associated protein (cd ap), a cytoplasmic binding partner of nephrin. mutations in the alpha-actinin gene (actn ), localized to chromosome q have been associated with autosomal dominant fsgs, characterized by adult onset disease of variable severity and rate of progression to esrd. fractions of the mutant protein have been shown to form large aggregates within podocytes ultimately compromising the function of the normal actin cytoskeleton, both through its abnormal function and toxic accumulation. recently, a disease-causing mutation for hereditary fsgs has been localized to chromosome q - , and identified as the transient receptor potential cation channel, subfamily c, member (trpc ). the missense mutation causes a highly conserved proline in the first ankyrin repeat of trpc to become a glutamine at position (p q). the trpc p q mutation causes increased and prolonged calcium transients in transfected cells. the mutant channel also significantly enhances cation signals triggered by at receptor activation. biotinylation and immunostaining studies reveal that the mutation also appears to cause mislocalization of the ion channel to the cell surface. whereas previously reported mutations such as nphs , nphs and actn have emphasized the importance of cytoskeletal and structural proteins in glomerular diseases, trpc related fsgs suggests an additional mechanism for renal disease pathogenesis. knowledge of trpc mediated calcium entry into cells may offer unique insights into therapeutic options for glomerular diseases. t. huber university hospital, department of nephrology, freiburg, germany the sense of touch relies on the ability of specialized sensory cells to convert mechanical stimulation into ionic currents. mechanoreceptor cells respond to external force by opening ion channels. recent findings highlight now a potential role for the mechanosensitive ion channel trpc at the glomerular filtration barrier. trpc localizes to the slit diaphragm and mutations of trpc cause familial glomerular disease. mutations of the phb-domain protein podocin are the most common cause of hereditary nephrotic syndrome and we demonstrate that podocin and mec- , the closest homologue of podocin in caenorhabditis elegans, bind cholesterol to regulate the activity of associated ion channel complexes: deg/enac channels for mec- and trpc channels for podocin. both the mec- -dependent activation of mechanosensation in c. elegans and the podocin-mediated activation of trpc channels requires cholesterol. our data suggest that the recruitment of cholesterol by podocin and mec- to ion channels plays an important role in regulating their activity. these findings promote the concept that podocin, similar to the function of mec- , may be part of a mechanosensitive protein complex at the slit diaphragm of podocytes. isidro salusky has kindly agreed to present this topic, however was not able to submit an abstract is there a role for bisphosphonates in pediatric bone disease? f. santos hospital universitario central de asturias, universidad de oviedo, pediatria, oviedo, spain bisphosphonates are being increasingly and successfully utilized to prevent bone fractures and treat bone pain in children with severe osteoporosis from different origins. a largest experience has been accumulated with the administration of cycles of intravenous pamidronate in children with osteogenesis imperfecta. in addition, to the bone resorption inhibition mediated by their effects on osteoclasts, bisphosphonates given in large doses inhibit normal and ectopic mineralization. thus, bisphosphonates have also been used in children with hypercalcemia and in the treatment of calcinosis and heterotopic ossification, bisphosphonates have been administered to renal transplanted adults to prevent or treat bone loss induced by chronic administration of glucocorticoids and might also be useful in the management of urolithiasis in selected hypercalciuric patients. the potential clinical utilization of bisphosphonates in the prevention and treatment of vascular calcification in patients with chronic renal failure is now being explored, although no data on children in this clinical setting are available. a number of questions as to the precise clinical indications to start bisphosphonates' administration, the type of bisphosphonate to be used, the duration of the treatment, the best way to monitor its effectiveness and the risk of longterm toxic effects remain to be answered. water is the solvent in which all metabolic reactions occur. body water moves between compartments with diverse compositions that are separated by semi-permeable lipid membranes. water exchanges also occur between maternal and fetal blood separated by several layers of tissue, the so-called placental membranes. the fetus appears to be dependent on placental flow and perfusion pressure for the bulk of his water requirements, and the prostanoids play a significant role in the control of ureteroplacental and umbilicoplacental blood flows. osmotic and hydrostatic forces control placental water flux. the amniotic fluid (af) appears early during gestation and its volume increases rapidly. the net af volume turnover approximates % per day. major sources of af production are represented by fetal lungs secretions, and by fetal urine. the af is initially isotonic, and becomes hypotonic when significant amounts of dilute urine are produced by the fetus. disposal of water is effected by fetal swallowing of af and by the intramembranous (im) pathway, that is the route of absorption between the fetal circulation and the amniotic cavity. this route appears to play an important role in the overall regulation of af volume and composition. the fact that water crosses the im pathway in excess of solutes suggests a role for aquaporin water channels in allowing this transport. circumstantial evidence indicates that the im water flow is regulated by aquaporin . homeostatic changes in placental permeability could thus be up or down-regulated by the number of aquaporin water channels in the membrane. systemic lupus (sle) is a multigenic and multifactorial disease, characterized by b lymphocytes polyclonal activation with decreased tolerance, autoantibodies production and immune complexes formation. dna was initially thought to be the mayor auto-antigen, however, it is not immunogen and injection of dna-anti dna does not induce lupus nephritis. the complex of dna and histones (nulceosome) is provided with a positive electrical charge which favours the binding to heparansulphates in the gbm. in sle high levels of nucleosomes are present in circulation due to accelerated lymphocytes apoptosis or defective removal of apoptotic cells. lupus nephritis (ln) is consequent to deposition of immune complexes, activation of lymphomononuclear cells and reactivity of renal cells. the who classification of lupus nephritis has been recently reviewed by the isn/rps. the new classification takes into account a distinction between forms without endocapillary hypercellularity (mesangial or subepithelial deposits) and others with endocapillary hypercellularity (involving less or more than % with segmental or global distribution). prognosis and treatment of ln need a flexible therapy, tailored on histological picture and clinical data. steroids must be given at high doses for induction therapy but have drawbacks of heavy morbidity and mortality. the addition of immunosuppressive drugs improves the therapeutic index. the nih protocol used cyclophosphamide (cyc) pulses in severe ln (monthly pulse for months followed by quarterly pulses for year). more recent studies, comparing low with high doses cyc pulses, failed to prove a significantly different effect. for maintenance therapy of ln, mycofenolate mofetil may be a good alternative to cya or aza. rituximab, a chymeric monoclonal antibody anti cd , which selectively and profoundly depletes b lymphocytes, has provided very interesting results in sle with poor response to classical therapy or in relapse. the possibility of rotating agents with different side effects may allow to lower the doses of steroids, to reduce drug-specific morbidity, and to improve the compliance of patients. efforts should be done to minimize steroids and cyc which are very effective but are the main responsible of invalidating and even lifethreatening complications. for half a century now, physicians have tried to classify vasculitic syndromes. classification of vasculitides is required to put in perspective the pathogenesis and therapeutic advances and to provide a uniform language, given the variation in the epidemiology of these diseases. the "american college of rheumatology" criteria have been used for classification and the chapel hill consensus criteria for definition purposes in children as well however they are based totally on adult criteria. taking into account the differences in children and the new developments in medicine a group of pediatricians have aimed to revise the classification of vasculitic syndromes encountered in children. the consensus group consisted of a multinational panel of experts who were pediatricians, pediatric rheumatologists and pediatric nephrologists. the delphi and nominal group techniques were used. this project has provided classification criteria for henoch-schönlein purpura, childhood polyarteritis nodosa, wegener granulomatosis and takayasu arteritis. this was an important task since appropriate classification criteria for vasculitis in children has been missing for far too long. we hope that the international and multispecialist composition of the expert group involved will facilitate the applicability of this classification for most vasculitic diseases in children seen around the world and will meet the needs of pediatricians. these criteria are now to be validated using a large registry for childhood vasculitides. anti-neutrophil cytoplasm antibodies (anca) are well established as a diagnostic marker for small vessel vasculitis, including wegener's granulomatosis and microscopic polyangiitis. there is increasing evidence that anca are directly involved in the pathogenesis of vascular inflammation in these disorders. in clinical studies, there is a clear relationship between levels of anca and the activity and extent of disease, and anca positivity confers an increased risk of relapse. rising titres of anca predict relapse, and two studies have shown that pre-emptive treatment of those with rising titres can prevent relapse. of great interest is the recent report of a newborn child who developed glomerulonephritis and lung haemorrhage after transplacental transfer of anca. in vitro experiments have shown that anca can activate cytokine primed neutrophils to release oxygen radicals, enzymes and inflammatory cytokines. this is achieved through both direct f(ab) binding and fc receptor engagement. in co-culture, anca can induce neutrophil mediated killing of endothelial cells. in flow chamber studies, anca can induce neutrophil adhesion and transmigration across endothelial cell monolayers. more recently, anca have been shown to be pathogenic in experimental models of disease. high titre anti-mpo antibodies induced by immunisation of mpo deficient mice can transfer glomerulonephritis and vasculitis to naive recipients. immunisation of rats with mpo induces anti-mpo autoantibodies which lead to crescentic glomerulonephritis. intravital microscopy in this model confirms that anca can induce leukocyte transmigration and microvascular haemorrhage in vivo. however, many questions remain unanswered. some patients may have high levels of anca without disease activity, and others may have typical disease without detectable anca. it seems likely that t cells may be involved, not only in providing help for anca synthesis, but also in mediating tissue damage. it is also possible that an additional inflammatory stimulus, for example an infection is required, to enhance the inflammatory effects of anca. greater understanding of the role of anca in vascular inflammation will hopefully lead to safer and more effective approaches to treatment. hacettepe university, faculty of medicine, department of pediatric nephrology, ankara, turkey the therapy of vasculitic syndromes poses a problem for the caring pediatrician. the treatment of anca associated vasculitides will be presented to cover microscopic polyangiitis, wegener granulomatosis and churg strauss syndrome. treatment of all anca-associated diseases are similar. steroids and cyclophosphamide are the mainstay of induction treatment. in severe patients with kidney involvement steroids can be given in the form of intravenous methylprednisolone for - days ( - mg/kg/d, max. gr), followed by daily oral corticosteroids ( . mg/kg/d, max. mg/d). cyclophosphamide may be given at mg/kg/d p. o. or monthly iv pulses . gr/sqm for at least months. for maintenance treatment there are again many different regimens for oral corticosteroids. along with corticosteroids for maintenance regimen there are a number of protocols suggesting the continuation of cyclophosphamide. the cycazarem study has shown that the replacement of cyclophosphamide with azathioprine at months was also as effective for disease control. methotrexate has also been shown to be an alternative for maintenance treatment. treatment of the childhood polyarteritis nodosa (pan) with systemic disease is similar to that of anca-related vasculitides. there are a number of non-anca associated vasculitides in childhood. the most frequent in childhood are henoch-schönlein purpura (hsp), kawasaki disease (kd) and takayasu arteritis (ta). the treatment of hsp is usually symptomatic. however, for severe kidney involvement with extracapillary proliferation and rapidly progressive disease severe immunosuppressive treatment is indicated. triple treatment with steroids, cyclophoshamide and dipyridamole have been given in various series. for kd intravenous immunoglobulin at a dose of g/kg still remains the first choice of treatment along with salicylates. for ta therapy depends on the extent of vessel invovlement: severe disease necessitates steroids and cyclophosphamide whereas for less intensive vessel involvement methotrexate and steroids may suffice. treatment period depends on the actiivty of the disease. lb. zimmerhackl haemolytic uraemic syndrome (hus) is the most common cause of acute renal failure in children. the syndrome is defined by the triad of microangiopathic haemolytic anaemia, thrombocytopenia and acute renal failure (creatinine over the th percentile). world wide hus is increasing. in a german/austrian multicenter study we follow children with hus occurring in the years to . year follow-up data are now available www. hus-online. at. from this study the following results are obvious. hus affects predominantly children of kindergarten age. the median age at onset is , years. the majority of hus is of infectious origin. shigatoxin (stx) producing escherichia coli (stec, ehec) are present in over % of patients. the predominant shigatoxin type is type ii. hus is classified into two clinical subgroups. "typical" hus usually occurs after a prodrome of diarrhoea (d+hus), and "atypical" hus (ahus), which is not associated with diarrhoea (d-hus). the majority of d+hus worldwide is caused by ehec type o : h , which is transmitted to humans via different routes. however non-o groups are emerging and are predominant in europe. transmission of disease in elder patients is predominantly through food poisoning and direct contact to farm animals. in infants and small children direct transmission from human to human seems to be more likely. currently there are no specific therapies preventing the disease course. anti-shigatoxin antibodies are being tested by several companies. if this may prevent hus is open to study. otherwise the therapy at present is symptomatic. parenteral volume expansion before hus in patients with positive stx or ehec stool culture may counteract the effect of thrombotic process before development of hus and attenuate renal injury. use of antibiotics, antimotility agents, narcotics and non-steroidal anti-inflammatory drugs should be avoided during the acute phase in particular during the prodromal phase. from our own study the prevention is best done by preventing primary ehec infection. however, patients with severe course and long term sequelae should be screened for genetic abnormalities in the complement system. if auto antibodies against complement proteins or the vwf play an relevant role is under discussion. patients under one year of age at onset have a significant worse outcome and should be kept under surveillance. patients below month of age are very likely to have an inborn error of complement or vwf and should be tested specifically. the european registry on hus and related disorders may help to determine these abnormalities: www. haemolytic-uraemic-syndrome. org. in order to improve long term outcome of these patients, increased awareness and an european (international?) task force is mandatory. in adults with chronic kidney disease, protein-energy malnutrition and inflammation are risk factors for death and accelerated cardiovascular disease. the "malnutrition-inflammation-cachexia syndrome" (mics); anorexia, increased basal metabolic rate, and loss of lean body mass is associated with low serum albumin, decreased protein intake, elevated c-reactive protein, and low serum cholesterol levels in adults. in children, mics manifests as growth retardation. clinical research focusing on the evolution of mics in pediatric ckd to understand its causes and consequences and how nutritional interventions alter its course may be the key to improving survival in ckd. baseline cross sectional data from the ongoing chronic kidney disease in children study, of children (n= ) aged - yrs (mean= . yrs) with estimated gfr ± ml/min/ . m (mean iohexol gfr ml/min/ . m ) shows substantial growth retardation in ckd with median height percentile= . greater height deficits are seen at lower gfr's. symptoms of decreased appetite and nausea are reported by % and % of those with gfr < respectively. mean ldl cholesterol is lowest in those with gfr < ( vs mg/dl in gfr ± ml/min/ . m group). serum albumin declines as serum creatinine increases (r=- . ). unlike previous reports in adult ckd, increases in crp were not associated with lower gfr at baseline. further exploration of the mics in pediatric ckd will be presented. the causes of growth failure in pediatric patients with chronic kidney disease (ckd) are multifactorial. it is an open question as to which factors play a key role in diminishing physical growth. it is also unclear which mechanisms may become pace makers for the therapeutic improvement of growth. furthermore, growth failure in children with ckd affects total body height, body proportions and composition as well as organ development. growth failure may also lead to disproportion which can only be identified by detailed anthropometric measurements. we were able to demonstrate that ckd patients have a specific age-dependent pattern of growth and distinct changes in segmental growth (trunk, arm and leg length) from birth to adolescence. leg growth in relation to other parameters of linear growth showed the most dynamic growth changes and emerged as the best indicator of growth in children with ckd. trunk growth had little synchronicity with leg growth. furthermore, we found that anthropometric measurements can be used as a diagnostic tool in distinguishing different sub-groups of ckd patients, for instance, children with syndromic ckd. in the heterogeneous group of patients with focal and segmental glomerulosclerosis, patients with schimke's disease were found to have a dramatically decreased sitting height/leg length ratio. as the disturbance in growth of ckd patients is a marker of the severity of the disease and of the quality of renal care, the annual analysis of growth failure from early childhood to adolescence should be used as a landmark information of the quality of medical care and as a helpful tool in differential diagnosis and of specific courses of ckd in sub-groups of patients. for example, patients with congenital or acquired renal diseases, dialyzed or transplanted patients and in gender differences. in addition, anthropometric measurements are able to identify specific growth patterns in children with ckd, which should be considered in the assessment of treatment efficacy such as in rhgh therapy. b. tönshoff, l. weber, b. höcker university children's hospital, st department of pediatrics, heidelberg, germany it is currently under debate whether steroid avoidance or late steroid withdrawal provides the best overall risk-to-benefit ratio in pediatric renal transplantation. late steroid withdrawal has the advantage over steroid avoidance that immunological high-risk patients and those with unstable graft function can easily be identified beforehand and be excluded from steroid-free immunosuppression. in order to further validate this approach, we performed a prospective randomized open-label multicenter trial in low-risk pediatric renal transplant recipients ( f, m; mean age . yrs; range, . to . ) on csa (target trough level - ng/ml), mmf ( mg/m per day) and methylprednisolone ( ) ( ) mg/m per day), who were randomly assigned > year posttransplant to continue steroids or to withdraw over a period of months. an interim analysis was performed at a mean observation period of mo after study entry; patients had been followed for at least mo. there were drop-outs ( reversible acute rejection episode, switch to sirolimus and to tacrolimus). transplant function as assessed by calculated ccr remained stable in both groups, no graft was lost. prepubertal children off steroids gained relative height from baseline - . ± . sds to - . ± . sds after yrs, while patients on steroids lost relative height (- . ± . sds at baseline, - . ± . sds after yrs); a comparable pattern was observed in pubertal patients. the standardized body mass in patients off steroids declined from . ± . sds at baseline to . ± . after yrs (p< . ), while it tended to increase in patients on steroids (baseline, . ± . sds; after yrs, . ± . ). the rate of adverse events, mainly infections, was comparable in both groups. patients off steroids required less frequently antihypertensive medication ( %) than patients on steroids ( %). a significant reduction of serum cholesterol (by %) and triglycerides (by %) in response to steroid withdrawal was observed. conclusions: this interim analysis indicates that late steroid withdrawal in selected pediatric renal transplant recipients on csa and mmf is safe, allows catch-up growth and ameliorates cardiovascular risk factors. at the ipna meeting, full month outcome data of all patients will be available. u. frei, j. noeldeke renal transplantation faces two major challenges: the organ shortage resulting in extended waiting times and an aging population resulting in increased death with a functioning graft. the eurotransplant senior program (esp) allocates kidneys within a narrow geographic area from donors aged > years to recipients > years regardless of hla. this analysis investigates the impact of the esp on waiting time, graft and patient survival. the esp group (n= , old to old) was compared to two groups allocated via the eurotransplant kidney allocation system (etkas) with either similar donor age [old to any (o/a), donor age > , n= ] or recipient age [any to old, (a/o), recipient age - , n= ]. all patients were transplanted between and . since initiation of the esp ( ), availability of elderly donors doubled and waiting time for esp patients decreased. local allocation led to shorter cold ischemia time ( . vs. > . hours, p< . ) and less delayed graft function (dgf, esp . % vs o/a . %, p= . ) but - % higher acute rejection rates. importantly, graft and patient survival were not negatively affected by the esp allocation scheme. the esp age matching of elderly donors and recipients is an effective allocation system for organs from elderly donors. the effect of age matching on the duration of the waiting time a. rahmel, m. slot, j. smits eurotransplant international, leiden, the netherlands in eurotransplant the proportion of children, i. e. patients aged under the age of at time of registration, with end-stage renal disease (esrd) on the renal waiting list amounts to only . %. despite this small proportion the eurotransplant kidney allocation system (etkas) specially addresses pediatric transplant candidates. in order to increase their chances of receiving a transplant in time children are assigned via etkas extra points for hla matching and receive an age bonus. in order to evaluate this allocation policy, the chances for receiving a kidney for patients in different age groups were evaluated. for the cohort of patients registered in the year , a year followup was obtained. for patients aged under at time of registration [n= ] % and % received a kidney from a post-mortem donor, within year and years after listing. for children aged to [n= ] these rates were at and years after listing % and %, and for children between age and [n= ] % and % respectively. adult patients were less likely to receive an organ: % and % of patients aged between and were transplanted within and years after listing. senior esrd patients can benefit from the eurotransplant senior program (esp), their chances for a transplant were % and % within and years, respectively. the life span of a renal allograft is limited in time. in the eurotransplant experience % of the post-mortem kidneys used for transplantation in children failed within years, compared to % for the living donor renal transplants (rtx). donor age is an important factor associated with long term renal allograft function. age matching between donor and recipient is hampered by the low number of pediatric donors. in the period - , heart beating kidney donors aged under were reported and used for rtx, donors were between and years of age, and donors were between and years old. in the same period adult donors were reported and used for transplantation. in the period - , % of the pediatric donor kidneys ultimately served a pediatric recipient. to improve the allocation of pediatric donors to pediatric recipients, et is in the process of implementing a rule giving pediatric recipients priority in case of pediatric donors. gender and sex hormones are playing a central role in the incidence and progression of different renal diseases. vascular tone, endothelial function and immune response are influenced by gender. in renal transplantation ischemic injury is always present. females are more resistant to postischemic renal failure than males. following ischemia/reperfusion injury renal vascular resistance decreases, allowing fast restitution of blood flow and oxygen supply in females. additionally, stabilization and preservation of tubular function following ischemia is achieved by the protection of na+/k+ atp-ase and heat shock protein activity contributing to the observed gender differences. posttransplant immune reactions also differ between genders. female gender predisposes to more severe acute rejection following kidney transplantation, partly due to differences in the effectivity of immunosuppressants used. ineffective immunosuppression in females, as well as different cytotoxicity profile of the drugs is contributing to more prone immune reactions shortly after transplantation resulting in more severe acute rejection. in contrast, similar to the slower deterioration of other renal diseases, progression of chronic graft failure is less pronounced in females in experimental and clinical settings. estradiol decreases profibrotic processes, preserves endothelial function and modifies influx of immune cells into the graft. the fine balance between alloantigen dependent immune reactions and alloantigen independent factors and its impact on longterm graft function is modified by gender. new evidences supporting the significance of sexual dimorphism following kidney transplantation may present the base of gender modified therapeutic approaches in the future. iga nephropathy: aetiology, incidence, and geographic distribution iga nephropathy (igan) is characterized by mesangial deposits of iga, proliferation of mesangial cells and expansion of matrix. the accumulation of iga and complement fractions within glomeruli was initially ascribed to deposition of iga immune complexes (igaic) due to mucosal immune response with predominant iga synthesis. this hypothesis has offered an explanation of the relationship between infections of the upper airways and gross hematuria. high levels of igaic have been detected in - % of patients, mostly of polymeric iga , and polymeric iga are detectable in renal deposits. this observation is consistent with hypothesis of either bone marrow or mucosal origin. however, no specific viral or alimentary antigens have been found in mesangial deposits, and the qualitative properties of polymeric iga have rather become of interest, particularly the glycosylation pattern of iga . human iga is o-glycosylated with carbohydrate chains of n-acetyl galactosamine (galnac) and galactose (gal) which may be covered with sialic acid (neu ac). patients with igan exhibit circulating iga with reduced gal and/or neu ac and increased exposure of n-galnac. such aberrantly glycosylated iga can circulate in monomeric form or participate in the formation of autoaggregates/true immune complexes. it likely escapes clearance by hepatic receptors and has a preferential renal deposition by virtue of enhanced reactivity with the mesangial matrix components. the role of a triggering event has not ruled out. in recent reports, antigens of bacterial origin and the secretory tract component have been found in renal deposits, making scientists reconsidering again the role of bacterial infections. tonsils recurrent infections may provide a suitable aetiology for igan, and the effect of tonsillectomy on the long term outcome of igan is under evaluation. the prevalence of igan varies in different areas, due to ethnic and environmental factors, being particularly frequent in mediterranean europe, northern europe, asia and australia. it is still debated whether differencies in frequency, clinical features and disease progression among patients with igan from different countries are actually due to uneven distribution of this diseases or these discrepancies are due to the different criteria for performing renal biopsy. definition. igan is characterized by the presence of dominant (or codominant) mesangial deposits of iga on immunofluorescence microscopy, frequently with c and sometimes with igg or igm. classification. the glomeruli display a broad spectrum of histologic changes, related in part to the differences in the indication for the biopsy of the referring nephrologist. a number of classification systems have been used to describe the histologic manifestations of igan. two will be referred to here: the system of m. haas (ajkd : - , ): ) minimal histologic lesion -the glomeruli exhibit no more than a minimal increase in mesangial cellularity, without segmental sclerosis or crescents. ) fsgs-like -the glomeruli display focal segmental sclerosis in a pattern resembling primary focal segmental glomerulosclerosis, with at most a minimal increase in mesangial cellularity and no crescents. ) focal proliferative glomerulonephritis (gn) - % or fewer of the glomeruli are hypercellular. the increase in cellularity may be limited to mesangial areas, or there may be obstruction of glomerular capillaries by proliferated endocapillary cells. crescents may be present. ) diffuse proliferative gn -more than % of glomeruli are hypercellular. the hypercellularity may be segmental or global, and crescents may be present. ) advanced chronic gn - % or more of the glomeruli are globally sclerotic, and/or there is % or more tubular atrophy or loss in the cortex. the system of s. emancipator (heptinstall's pathology of the kidney, lippincott-raven, philadelphia, , pp - ) : a -normal/minimal glomerular lesions b -focal mesangial proliferation c -diffuse mesangial proliferation d -focal segmental endocapillary proliferation superimposed on mesangial proliferation d -focal segmental endocapillary proliferation alone e -diffuse endocapillary proliferation f -diffuse extracapillary proliferation (crescents in > %), with or without endocapillary proliferation g -glomerulosclerosis (> % of the glomeruli are sclerotic) h -unclassifiable or combined lesions diffuse proliferative gn (c) and focal proliferative gn (d ) are the major patterns of expression of glomerular injury. indicators of a poor outcome. these include a high proportion of glomeruli with crescents, numerous sclerotic glomeruli, interstitial fibrosis and tubular atrophy, extension of the iga deposits into the peripheral glomerular capillary walls, and hyaline arteriolosclerosis. differential diagnosis. mesangial iga deposits are present in henoch-schönlein nephropathy, and may be present in lupus nephritis, chronic liver disease, coeliac sprue, certain dermatologic diseases, and some rheumatologic diseases. iga nephropathy [igan] is defined by the presence of mesangial iga, but otherwise the histopathological and clinical features are very variable. we do not yet know sufficient about pathogenic mechanisms to understand whether igan is a single disease. although traditionally called an 'immune complex' disease there is no direct evidence that mesangial iga deposition in igan occurs through classical antigen-antibody interactions. mesangial cells do carry receptors for iga, which may play a key role in iga deposition and subsequent injury, but these are not yet fully characterised. mesangial iga in igan is polymeric iga . there is no evidence of mucosal immune system overactivity, indeed there seems to be underproduction and abnormal t cell control of mucosal iga production, along with overproduction by the marrow of iga iga has a hinge region peptide structure which is a site for o-glycosylation. in igan circulating and mesangial iga both have abnormal o-glycosylation at the hinge region. the same defect is seen in henoch-schönlein purpura only when there is renal involvement. the glycosylation defect is not due to abnormal peptide structure of the hinge; the possibility that there is reduced activity of the key enzyme b , galactosyltransferase in b cells or plasma cells has not yet been confirmed. alternatively the glycosylation changes may reflect a shift in the production of mucosal type of iga to the marrow. while iga deposition is caused by disease mechanisms specific to igan, subsequent inflammatory and fibrotic events are probably driven by mechanisms common to other chronic glomerular disease. in some patients iga deposition is not followed by inflammation, in others inflammation resolves without fibrosis. cytokine and growth factor production by mesangial cells is a sufficient explanation for glomerular inflammation and fibrosis. however little is yet understood of any genetic or environmental influences which protect some patients from progressive renal injury. our recent controlled trials by the japanese pediatric iga nephropathy treatment study group demonstrated that treatment of children with severe iga nephropathy with prednisolone, azathioprine, heparin/warfarin, and dipyridamole for years early in the course of the diseaseprevents immunological renal injury and progression of the disease. the majority of patients with iga nephropathy in our series are diagnosed early in the course of the disease, and the asymptomatic period before the discovery of urinary abnormalities is short. early diagnosis and early treatment is very important in iga nephropathy. . combined therapy for severe childhood iga nephropathy (j am soc nephrol : [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) . seventy-eight children with newly diagnosed iga nephropathy showing diffuse mesangial proliferation were randomly assigned to receive either the combined therapy of prednisolone, azathioprine, heparin-warfarin, and dipyridamole for two years (group ) or the combination of heparin-warfarin and dipyridamole for two years (group ). urinary protein excretion was significantly reduced in group patients, but remained unchanged in group patients. the percentage of glomeruli showing sclerosis was unchanged in group patients, but significantly increased in group patients. . steroid treatment for severe childhood iga nephropathy (clin j am soc nephrol, : - , ) . in this study we have compared the effects of prednisolone, azathioprine, warfarin, and dipyridamole (combination) with those of prednisolone alone in children with newly diagnosed iga nephropathy showing diffuse mesangial proliferation. patients were randomly assigned to receive either the combination or prednisolone alone for two years. the primary endpoint was the disappearance of proteinuria, defined as urinary protein excretion < . g/m /day. thirty-nine of the patients receiving the combination and of the receiving prednisolone completed the trial. thirty-six of the patients ( . %) receiving the combination and of the ( . %) receiving prednisolone reached the primary endpoint by the two-year follow-up point (p= . log-rank). the percentage of sclerosed glomeruli was unchanged in the patients receiving the combination, but increased in the prednisolone group (p= . ). the frequency of side-effects was similar in the two groups. long-term administration of recombinant human erythropoietin (epo) has become the most common way of treating anemia in chronic renal disease. standard amounts per unit body weight have been recommended for the initial dose. however, several authors have noted that the dose per unit body weight needed for a given response is higher in younger children than in older children or adolescents and that it is increasing with decreasing body weight. furthermore, for a given absolute dose of epo the outcome was investigated in adult hemodialysis patients, but no dependence was found in patients weighing - kg. a similar model to the hemoglobin-time data of children aged - years treated with epo for renal anemia did not find an impact of body weight on response when it was modelled in terms of absolute dose. in a similar analysis to the hemoglobin-time data children and adolescents aged - years were analyzed, in order to more definitively answer the question if, for given absolute doses the hematopoetic response to epo in children depends on body weight. neither the dose response parameter e max and ed showed dependence on body weight. the median hemoglobin response to a standard dose was similar to that reported for adults. it can be concluded that younger and smaller children need relatively more epo than older children. doses for children should be specified as absolute amounts rather than amounts per unit body weight. references: scigalla p. effect of recombinant human erythropoietin treatment on renal anemia and body growth of children with end-stage renal disease. in: baldamus ca, scigalla p, wieczorek l, et al, editors erythropoetic agents are the mainstay of treatment for renal anemia. although there are several different marketed forms of erythropoetin, they are not substantially different in their ability to stimulate erythropoesis. however, darbepoetin, which differs in one amino acid, and has additional glycosylation sites, has a longer half-life and therefore a presumed longer duration of action. this provides a theoretical advantage, suggesting that less frequent injections will be required. clinical experience and studies have confirmed that both erythropoetin (epo) and darbepoetin (dar) are effective to maintain hb values within the recommended range. also, though there is some experience with epo injected every couple of weeks, the overall evidence suggests that dar has a longer duration of action, and injections are required less frequently. for many children, particularly the pre-dialysis population, anemia is successfully controlled with dar injected every - weeks. however, this apparent advantage of dar is somewhat reduced because of the increased pain reported with dar injections compared to epo. both epo and dar have been used successfully in children of all ages. with epo, the doses required to maintain hb values appear to be increased in infants compared to older children; this may not be the case with dar, but there is much less experience with use of dar in infants. also, the administration of dar in infants is hindered by the need to inject portion of a unidose pre-filled syringe, which may introduce inaccuracies in dosing, is wasteful, and is not user-friendly. the side effect profile for each product is similar, and specifically each has been associated with development of hypertension, which is most likely with higher hb values. pure red cell aplasia has also been reported with each product. thrombocytosis has been reported with dar use. overall, there is little to recommend one product over the other. the need for less frequent injections may favor dar for use in most children beyond infancy, whereas it is easier to administer epo accurately in infants. how much iron is needed and how much is toxic? iron deficiency is the primary reason for ineffective erythropoiesis in patients with chronic kidney disease (ckd) who receive an erythropoiesis stimulating agent (esa). reasons for iron deficiency include inadequate dietary intake, blood loss from the gastrointestinal tract, frequent blood tests, loss of blood in the extracorporeal circuit of hemodialysis (hd), as well as the hepcidin related impairment of the intestinal absorption of iron and its release from the reticuloendothelial system. supplementation of iron can be by either the oral or intravenous (iv) routes, although the national kidney foundation-kidney disease outcomes quality initiative (k/doqi) strongly recommends the preferential use of iv iron in children and adult patients receiving hd. the k/doqi recommended target iron indices for all children on dialysis are a serum ferritin > ng/ml and a transferrin saturation (tsat) > %. while the serum ferritin should not regularly be > ng/ml, some such patients will achieve a higher hemoglobin value following an iv course of iron therapy. of the iv iron agents, the non-dextran products appear to be safest, and pediatric dosing recommendations exist for ferric gluconate and are currently being studied for iron sucrose. differences do exist for the clinical (e. g. proteinuria) and subclinical (e. g. oxidative injury) toxicities associated with the currently available iv iron products and should be taken into consideration when prescribed. until recently the major physiological function of erythropoietin (epo) was thought to be the induction of erythropoiesis. however, a growing body of evidence indicates that epo has tissueprotective properties and prevents ischemia induced tissue damage in several organs including the kidney. a main target of epo´s action is the endothelium, and one of the pivotal intracellular pathways mediating the beneficial effects of epo is the activation of akt, i. e. serine/threonine protein kinase b. as a result, akt phosphorylates the proapoptotic factor bad, which in turn causes inhibition of programmed cell death (apoptosis). moreover, experimental studies revelead that epo is a potent regulator of endotheial progenitor cell (epc) proliferation and differentiation. collectively, these data support the hypothesis that epo is a key molecule in the process of endothelial (vascular) repair and neoangiogenesis. treatment with rhuepo or analogues could therefore open new therapeutic strategies in regenerative cardiovascular medicine. introduction: africa as a continent is besieged by many health challenges including malaria, hiv (upwards of % of paediatric admissions), tuberculosis and malnutrition with an infant mortality rate (imr) ranging from (southern africa) to (mozambique). good health facilities are on the whole not available except in the extreme north and south of the continent with doctors/ population in south africa but in kenya only and even lower in other parts of africa. renal disease: renal disease in adults is an unknown quantity with no information being available regarding children's renal disease, where many babies do not even have access to antenatal ultrasounds. situation in south africa: in reality, there are only centres (cape town and johannesburg/ pretoria) doing paediatric dialysis and transplantation in significant numbers with small numbers interspersed in the rest of the country. this raises numerous issues: -accessibility for children to renal care -retaining minimum standards of care for children -both dialysis and transplantation -combined with adult units -central government funding in form of tertiary services grant for paediatric renal care -children not first priority on any transplant program in terms of organ allocation -private facilities vs state facilities -ethical decisions dialysis facilities: peritoneal dialysis (pd) first line therapy for acute renal failure, as can be performed in any setting with minimal equipment and expertise. in the setting at rxh, we have a greater than % survival in infants and children dialysed using pd even in a sophisticated intensive care setting. haemodialysis and chronic dialysis may not be easily available in most settings and realistically need transfer to one of the major centres. transplantation: again limited to only few centres, with at least % living related donations from family members. initial good year ( %) and year ( %) graft survival but results then deteriorating as patients enter their adolescent years often with little support and transfer to adult units in their early teens. controversial issues here include access to one kidney transplant only, no chronic dialysis if not suitable for transplant and transplantation in hiv positive recipients. conclusions: adequate resource allocation is required for paediatric renal care especially where resources are limited. immunosuppression remains the cornerstone of successful transplantation. in developing countries transplantation is mostly from living donors and transplant is thus a once in a lifetime chance. in this backdrop immunosuppression is a challenge as several issues have to be overcome. namely, non-availability of newer drugs, high costs and paucity of drug monitoring facilities. in most countries immunosuppression is based on a triple drug regimen of cyclosporin (cya), prednisolone (pred) and azathioprine (aza). in the last few years mmf and tacrolimus (tac) has been initiated in a few centres. several tailoring strategies have been employed taking into consideration costs, drug availability, tissue typing facilities and drug monitoring. firstly in hla identical transplants which constitute - % of the total, cya based regimen are used. marked reduction to - mg/kg at months and complete withdrawal at one year in rejection free transplants is safe with continuing of aza and pred. secondly several centres selectively use tac and mmf in cases with early rejection or transplants with > mismatches. it is possible to switch to cya or aza after months on individual basis. thirdly induction protocol with atg for days in transplants with > mismatches and in retransplants is cost effective. cost considerations have increased the use of generic calcinurin inhibitors with market share of - % in different countries. co administration of p competitors has reduced doses of cya by - % with considerable cost reductions. siut has been running a living related transplant program for more than years with dialysis and follow-up of recipients and donors. keeping in mind economic constraints a model of government public partnership was developed which provides all facilities including drugs free of cost. we adopted a number of tailoring strategies e. g. strict monitoring, tailoring by hla match and donor age and use of biological agents in risk groups. in first years we used parent drugs, however increasing costs necessitated use of generics after establishing bioequivalence in controlled trials. graft survival rates were maintained at % and % at and years. in conclusion, immunosuppression in developing countries require besides newer drugs, monitoring facilities, affordable costs and regular follow-up as transplantation for majority is once in a lifetime chance and failure equates with death. occurrence of infections following kidney transplantation is a major reason for hospitalization, and an important cause for renal dysfunction & mortality in developing countries. more than % renal transplant recipients get serious infections, with a - % risk of mortality. infections in the first month after transplantation are similar to those in surgical patients; opportunistic pathogens and cmv predominate between - months; and tuberculosis (tb) after months. the risk of tb in patients on maintenance dialysis & following transplantation is between - %. the onset of tb is usually within months of transplantation. clinical syndromes include pleuropulmonary tb, followed by disseminated tb, pyrexia of unknown origin and lymph node disease. demonstration of m. tuberculosis, on microscopy or culture might not be possible. nonrifampicin based treatment regimens (inh, pyrazinamide, ethambutol, fluoroquinolone for months, followed by hef for months) are used. inh prophylaxis ( - months) is advised in patients with tuberculin positivity or contact with active tuberculosis. cmv disease results in considerable morbidity & mortality; its timing is influenced by donor/recipient serological combination, state prior to transplantation, use of antilymphocyte induction therapy or preventive strategies. cmv disease is characterized by a non-specific febrile illness; features of enterocolitis, pneumonia, hepatitis, myocarditis, esophagitis, chorioretinitis & bone marrow involvement are variable; disseminated disease is rare. cmv disease exacerbates the net immunosuppression, increasing the risk for opportunistic infections. patients with cmv disease are also at risk for acute rejection and chronic allograft injury, atherosclerosis & vascular injury. diagnosis of cmv disease is based on a combination of viral serology, shell vial cultures, pp antigen assay and pcr. the cost of prophylaxis and treatment is a major limitation to the use of ganciclovir or valganciclovir. other infections in transplant recipients include malaria, p. carinii and fungi (cryptococcosis, candidiasis, mucormycosis, aspergillosis). infections are an important cause of morbidity & mortality in renal transplant recipients. their management continues to be challenging due to difficulties in diagnosis, unsatisfactory follow-up and cost of medications. ethical issues of renal replacement therapies n. orta, p. zibaoui, e. lara university of carabobo/insalud, pediatric nephrology, valencia, venezuela important ethical issues in pediatric nephrology (pn): genetic and molecular techniques, prenatal therapies for urinary anomalies, treatment of children with chronic renal disease (esrd). ecosonography can detect nephrourological anomalies and studies of amniotic fluid give information on chromosome alterations and renal function. particular situations, can lead to dilemmas related to pregnancy interruption and neonatal dialysis and transplantation (dt) possibilities. renal insufficiency (ri) presents at any age, and peritoneal, hemodialysis or hemofiltration could be applied. patients without structural abnormalities, ri secondary to toxics or isquemic nephropathies have better prognosis. these procedures are complicated and costly and increases, and may have secondary effects with ethical implications. treatment by dialysis developed in the 's and inclusion of children was not considered. this has changed with advances in dt. since 's dt programs were setup for children, but received criticisms and considered unethical, but were continued because of familiar and humanitarian demands and today it is clear that children benefit with that. scientific societies recommend: . children who receive dialysis must meet the following criteria: -diagnosis of esrd, legal authorization, possibility of transplantation, acceptable quality of life; may not be rejected for economic, social or psychological reasons, nor gender, age, race or mental conditions. biopsies are the current 'gold standard' for monitoring transplant patients, but it has been shown that even mild rejection episodes, based on pathology grading, can have poor outcomes and even biopsies with normal early pathology can progress rapidly with chronic allograft injury. there is considerable inter-observer variability of biopsy pathology readings that adds an additional confounder to this method of analysis. identification of non-invasive biomarkers in blood or other fluids would allow for the possible elimination of frequent biopsies. hence, the identification of diagnostic and predictive non-invasive genomic markers will be a worthy tool to aid in the clinical monitoring of transplant patients. the use of dna microarrays as a hypothesis generation tool for determining gene expression differences across thousands of genes in a data set is increasing. recently, the use of microarrays has been applied to the transplant field and holds great promise for unraveling the mechanisms at play in various transplant processes and for identifying new tissue specific and non-invasive biomarkers predictive of clinical outcomes. as microarrays produce large amounts of data, bioinformatics tools are being developed to determine gene expression patterns. gene clustering and class prediction tools aid in the discovery of molecular signatures in different disease processes while literature mining, gene family analysis and pathway analysis help in understanding the biological relevance of these signatures. initial studies in acute rejection and graft dysfunction have produced possible markers for risk stratification of the rejection event and have suggested underlying mechanisms at play, that may now allow us to test novel drugs for treating specific acute rejection episodes. the most exciting application of microarrays lies in our ability to predict clinical outcomes by non-invasive serial monitoring, eliminate the requirement of transplant biopsies and individualize patient management by accurately predicting the patient's sensitivity to immunosuppression-sufficient to suppress the allo-response, yet insufficient to abrogate the innate response. responsible array data handling and accessible reporting will open new doors for transplant researchers through increased use of computers and collaborations towards these kinds of novel insights and treatment options for transplant patients in the future. this talk focuses on dna microarrays, their application to transplantation, and discusses some of their limitations and recent applications, as well as some key research studies where dna microarrays are applied to understanding the molecular differences in acute transplant rejection that segregate and likely control the differences in rejection treatment responsiveness as well as decline in graft function, as well as gaining insights into the different biological processes that govern these differences. the molecular pathogenesis of vur is not well understood. uroplakins (ups) are expressed in the urothelium and are developmentally regulated by rab b and tbx genes. up ii and iiia-null mice exhibit a primary ( o ) vur phenotype. using microarrays and rt-pcr, we analyzed gene expression in surgically-discarded ureteric tissue from children undergoing reimplantation for o reflux, compared with adult living-related transplant donors as normal controls, as well as children with o reflux (megaureter, duplicated ureters, and posterior urethral valves) as age-matched disease controls. we also studied urine protein profiles using -dimensional electrophoresis ( d-page) followed by time-of-flight mass spectroscopy (q-tof-ms). rt-pcr showed partial expression of ureteric upia, upib, upii and upiiia genes in patients with o reflux. protein screening using western immunobloting confirmed that some uroplakins were undetectable. real-time rt-pcr revealed that ureteric up ia, up ib, upii, and up iiia gene expression decreased significantly, whereas upiiib gene expression increased at least -fold compared to controls. compared with patients with o vur, the decrease of upiiia expression in those with o reflux was highly statistically significant (p< . ). the expression of rab b and tbx genes also decreased significantly in patients with o and o reflux as well. total urinary protein concentration increased by -fold in the o vur patients without detectable renal scarring on dmsa scans; and increased further in patients with renal scarring, -fold for o vur and -fold for o vur patients. proteomic analyses of proteinuria revealed an overall increase of protein with mw> . kda in the pi range . to . in patients. q-tof ms identified one predominant urinary protein of ~ kda as sera-transferrin, which was confirmed by elisa quantitation. we hypothesize that the abnormal developmental expression pattern of the up, rab b and tbx genes in vur patients results in abnormal urothelial functions, which lead to leakage and/or secretion of proteins into the urine, and that this occurs in the absence of scarring from urinary infections. further identification of these protein biomarkers may lead to non-invasive diagnostic tests for vur. biomarker discovery in acute kidney injury p. devarajan cincinnati children's hospital medical center, department of pediatric nephrology and hypertension, cincinnati, united states acute kidney injury (aki), previously referred to as acute renal failure (arf), represents a common and persistent problem in clinical medicine. despite significant improvements in therapeutics, the mortality and morbidity associated with aki remain high. a major reason for this is the lack of early markers for aki, akin to troponins in acute myocardial disease, and hence an unacceptable delay in initiating therapy. fortunately, the application of innovative technologies such as functional genomics and proteomics to human and animal models of aki has recently uncovered several novel genes and gene products that are emerging as biomarkers. the most promising of these are chronicled in this symposium. these include a plasma panel (ngal and cystatin c) and a urine panel (ngal, . since they represent sequentially expressed biomarkers, it is likely that the aki panels will be useful for timing the initial insult and assessing the duration of aki. based on the differential expression of the biomarkers, it is also likely that the aki panels will distinguish between the various types and etiologies of aki. however, they have hitherto been tested only in small studies and in a limited number of clinical situations. it will be important in future studies to validate the sensitivity and specificity of these biomarker panels in clinical samples from large cohorts and from multiple clinical situations. such studies will be markedly facilitated by the availability of commercial tools for the reliable and reproducible measurement of biomarkers across different laboratories. a. watson children and young people's kidney unit, notthingham university hospitals, nottingham, united kingdom the achievement of adequate chronic peritoneal dialysis in children requires close attention to clinical, dietetic and psychosocial aspects of care. successful dialysis is dependent upon excellent peritoneal access and swan neck coil catheters with downward facing exit sites are increasingly favoured with many placed laparoscopically. automated peritoneal dialysis is employed in most developed countries but adolescents may be given the choice of capd which may be the only modality available in developing countries. training and support by committed nursing staff are of paramount importance as is regular review by a paediatric renal dietitian. growth parameters should be regularly monitored and supplemental enteral feeding introduced early. many infants are nasogastrically fed, but the preferred route for supplemental enteral feeding is via a gastrostomy which can be placed at the same time as the pd catheter. dialysis fill volumes should be assessed in terms of body surface area and intra-abdominal pressure measurements. there can be discrepancies between urea and creatinine clearances and adequate dialysis includes combining clinical parameters with regular growth measurements as well as biochemical data including phosphate, calcium and parathyroid levels. peritoneal function tests are useful in monitoring progress but the greatest challenges are in sustaining long-term dialysis, particularly in infants where transplantation is likely to be delayed. support for the families with a respite care 'package' may delay or prevent burnout and possibly reduce peritonitis rates. conventonal pd solutions are acidic, contain unphysiological concentrations of lactate and glucose and highly toxic glucose degradation products (gdp), which are substrates for advanced glycation end product (age) formation. repeated administration induces epithelial to mesenchymal cell transition, loss of the mesothel cell layer, progressive submesothelial fibrosis and angiogenesis, ultimately leading to ultrafiltration failure. meanwhile pd solutions with an improved toxicity profile are available. multi chamber pd solutions separate glucose from the buffer at a very low ph, which largely prevents gdp formation. after mixture ph is close to normal. they are equally effective with regard to solute-and water transport, reduce inflow pain and systemic age load. dialysate effluent markers indicate increased mesothelial cell mass, reduced peritoneal inflammation and reduced angiogenesis. animal studies demonstrate preservation of pd membrane morphology and function, respective human biopsy data however are pending. a european paediatric multi centre trial accomplished recently elucidates the impact of the lactate and bicarbonate buffer. a randomized cross over trial in adult patients points to an improved preservation of residual renal function; a korean registry suggests improved technique and patient survival. icodextrin solutions reduce glucose and gdp exposure, improve extracellular fluid status, left ventricular mass and stabilize membrane function in anuric adult capd patients and should be beneficial in children, too. amino acid based solutions achieve similar clearance and ultrafiltration rates, reduce glucose and gdp load and allow for a phosphate free amino acid supply. the nutritional benefit however is questionable. other, thus far experimental strategies include addition of locally active compounds to pd fluids such as gdp scavengers, inhibitors of age formation and antifibrotic agents. surface active phospholipids may increase peritoneal contact area and ultrafiltration. gene therapy appears highly promising but is still far from being clinically applied. in summary, there is substantial evidence for increased biocompatibility of the recently introduced multi chamber and icodextrin based pd solutions. they should improved long term morbidity and mortality of pd patients; this however still needs to be proven. the impact of the ippr on the treatment of peritonitis b. a. warady children's mercy hospital and clinics, pediatrics nephrology, kansas city, united states the international pediatric peritonitis registry (ippr) is an initiative that was established to evaluate the safety and efficacy of largely opinion based peritonitis treatment guidelines in which empiric antibiotic therapy ( st generation cephalosporin and ceftazidime or a glycopeptide and ceftazidime) was stratified by disease severity. forty-seven centers from countries contributed data on children and peritonitis episodes treated in accordance with the guidelines. culturenegative peritonitis accounted for % of all episodes, with a marked regional variability in the incidence of this disorder, as well as in the peritonitis causative organisms. overall, % of cases achieved full functional recovery, a portion following relapsing peritonitis ( %). in-vitro evaluation revealed only % sensitivity of gram-positive organisms to a st generation cephalosporin (eastern europe > north america) and % sensitivity of gram-negative organisms to ceftazidime. in contrast, % of gram-positive organisms and % of gram-negative organisms were sensitive to the combination of either a st generation cephalosporin or an aminoglycoside. whereas the risk of empiric treatment failure was associated with the presence of a gram-negative infection (p= . ), neither the risk factors assumed by the guidelines nor the choice of empiric therapy were predictive of the final functional outcome of the peritonitis episodes. the data collected by the ippr will serve as an important source of evidence to be incorporated into revised pediatric peritonitis treatment guidelines. ch. aufricht medical university, pediatrics, vienna, austria peritoneal dialysis (pd) is a safe, cost effective and widely used form of renal replacement therapy in patients with end stage renal failure. however, up to a third of patients on pd will suffer from technical failure during their course. identification of the patients at highest risk would be of high clinical relevance. cytotoxicity of pd fluids due to low ph, hyperosmolarity, and/or high concentrations of lactate, glucose and its degradation products causes mesothelial cell injury that ranges from minor cellular dysfunction to overt (apo)necrosis. the same physicochemical properties of pdf that cause such cellular injury also induce pathways leading to repair and recovery. this so-called cellular stress response results in a switch of the cellular machinery from routine procedures towards reaction against stressors. the complex machinery of the cellular stress responses not only counteract direct toxic injury caused by pdf but also attenuate inflammation or other potentially deleterious cellular processes. infectious, uremic and toxic injuries might converge in cellular inflammation. whereas inflammatory processes triggered by infection protect the peritoneal cavity against invading microorganism, chronic sterile smoldering 'cytotoxic' inflammation may result in aberrant healing processes and peritoneal fibrosis. recently, polymorphisms of many proteins involved in relevant cellular responses have been described and related to altered resistance and/or susceptibility to pathogenetic processes with potential influence in pd. in this review, we will focus on key effectors of stress responses, of cellular inflammation and of fibrogenesis such as heat shock proteins (hsp), cytokines (il- ), chemokines (il- ) toll-like receptors (tlr) and growth factors. given the recently shown role of these 'players' for the interplay between mesothelial injury, inflammation and cytoprotection, these polymorphisms will likely be relevant for mesothelial cell damage during pd. taken together, the ability to understand -and ultimately modify -the risk profile of a given patient will be essential for tailoring individual pd therapies. the pathologic diagnosis of chronic allograft nephropathy (can) was introduced in by the banff classification system for renal allograft injury. it originally included at least four entities that it was acknowledged could not always be distinguished by biopsy: ) chronic rejection; ) chronic calcineurin inhibitor (cni) toxicity; ) hypertensive vascular disease; ) chronic infection and/or reflux (solez, ki : ) . over the ensuing decade, the definition of can has expanded and fluctuated such that some pathologists have come to use the term to mean a specific pathologic entity comprising "…progressive graft dysfunction accompanied by chronic interstitial fibrosis, tubular atrophy, vascular occlusive changes and glomerulosclerosis. " (nankivell, nejm : , while others have suggested can should be used to describe all causes of renal allograft dysfunction involving fibrosis. the resulting confusion over terminology has in some ways hindered the growing awareness of the multiple discrete, diagnosable and often treatable diseases capable of causing chronic graft injury. these diseases include: ) chronic (primarily antibody-mediated) rejection; ) de novo and recurrent glomerular disease; ) calcineurin inhibitor toxicity; ) interstitial fibrosis and tubular atrophy without evidence of any specific etiology. to this list should be added other recognizable causes of late graft dysfunction such as polyoma virus infection and hypertension. in the new banff classification can will no longer be a diagnostic category (colvin, world transplant congress, ) . instead, the term sclerosis will be used to describe: "interstitial fibrosis/tubular atrophy, not otherwise specified, " or "if/ta nos. " the increasing use of protocol biopsies in clinically stable patients has dramatically increased awareness of the ongoing pathological changes almost every renal allograft appears to be undergoing almost from the first moments of engraftment. techniques are now available in most centers to reliably recognize the presence of chronic antibody-mediated rejection. these include: ) typical morphological findings: lamination of glomerular basement membranes, arterial intimal fibrosis, interstitial fibrosis/tubular atrophy; ) c d staining in peritubular capillaries or glomeruli; ) the presence of circulating donorspecific antibodies (takemoto ajt : . treatment of late, chronic antibody-mediated rejection is in its infancy and may include use of anti-b cell antibody (rituximab), ivig, and/or plasmapheresis. calcineurin inhibitor toxicity can be more reliably identified by focusing on blood vessels in the allograft, primarily the location of hyaline deposits in the arterioles. nodular, peripheral hyalinosis is found almost exclusively in cni toxicity, whereas sub-endothelial and transmural hyaline deposits are non-specific and can be seen in hypertension, aging and diabetic nephropathy. there is increasing concern that recent gains in short-term renal allograft survival and reductions in acute rejection rates have not resulted in improved long-term graft survival. while this is likely due to multiple factors, including infections and malignancies associated with over immunosuppression, unrecognized (sub-clinical) acute cellular rejection (moreso ajt : ), and noncompliance in some patients, much evidence points to the primary role of cni toxicity in many if not the majority of chronically failing allografts maintained on cni's. experience with conversion from cni to sirolimus in adult patients has been reviewed in a recent editorial (betard nephrol dial transplant : editorial comments) . in studies involving nearly patients, between % and % of patients with late allograft dysfunction failed to respond favorably to cni withdrawal and replacement with sirolimus. acute rejection episodes were rare, occurring in only six patients. common adverse effects included dyslipidemia, anemia and proteinuria. in one study, of patients developed proteinuria after conversion, in the nephrotic range. pediatric experience with cni withdrawal has been limited (kerecuk, pediatr nephrol : falger, pediatr transplant : , hocker, pediatr transplant . our recent experience at stanford with cni withdrawal in patients was not favorable, with % of patients experiencing an associated acute rejection episode (weintraub, wtc ) . prior history of acute rejection significantly increased the relative risk of acute rejection after cni withdrawal (rr= . ), and proteinuria was common. patients with advanced chronic graft dysfunction were at increased risk for graft loss. in summary, the use of the term can to describe all causes of chronically failing renal allografts is to be discouraged in favor of a search for specific etiologies whenever possible. antibody-mediated rejection and cni toxicity are major causes of late allograft dysfunction. protocol biopsies are helpful in identifying patients with treatable causes of late allograft dysfunction. cni withdrawal/avoidance may be successful, but optimum patient selection criteria and withdrawal/replacement strategies have not been determined. pediatric experience to date with cni withdrawal has been limited, but it appears that late withdrawal after cni injury and graft dysfunction have become well established may be associated with inferior outcomes. prospective trials in pediatric patients are needed to address these issues. which immunosuppression in pediatric transplantation? p. hoyer university children's hospital, essen, germany recent results in pediatric renal transplantation have reached one year graft survival rates better than %. current immunosuppressive drugs should be classified according to their interference with the immunesynapsis as signal , signal and signal blocking agents. the variety of immunosuppressive drugs does allow more treatment combinations than the potential number of large scale studies in children. the definition of current unmet needs should guide employment of drugs. calcineurin inhibitors (cni) are still the basis of immunosuppression. individual risk profile leads to preferences for cyclosporine or tacrolimus. while in adults cni reduction seems to be the major goal, the search for steroid sparing or avoidance protocols has attracted major interest in pediatric transplantation. growth and body configuration as well as cardiovascular risk factors should be in the focus of research. antibody induction protocols, mainly with il- receptor antibodies, are increasingly popular, but efficacy is less clear than concluded from adult studies and might depend on initial combination therapy. mmf (cellcept®) or mpa (myfortic®) are effective drugs with cni sparing potential. early adequate dosing seems to be of greater importance than the choice of the cni, but the price to pay may be an increase in infectious complications. mtor inhibitors are promising in avoiding nephrotoxic side-effects; specific side effects on male gonadal function and possible interference with growth should be considered before any recommendation can be given. fty would have been of especial interest for children because of maintaining viral infectious response, but phase- studies are on withhold. the vision of tolerance has stimulated research on regulatory t-cells; i. e. cd cd +t-reg cells and the mastergene foxp . the impact of lymphocyte depletion induction protocols with campath on operational tolerance needs further studies. newer drugs in development are isa , a cyclosporine analog without nephrotoxicity; a modified release form of tacrolimus which might improve compliance; the phosphokinase inhibitor aeb with the potential to avoid cnis; the jak inhibitor cyp , which might interfere with signal (il and il -receptor); and lea y (belatacept) with blocks costimulatory signals. according to the new european drug legislation some of these drugs will be subject for mandatory testing in pediatric patients to get marketing authorisation. the future might be a more tailored immunosuppression according to the induvidual needs of the patient. immunosuppression minimization strategies, under the umbrella of a newer generation of more powerful induction and maintenance immunosuppressants, are being increasingly applied to pediatric organ transplantation, with the greatest emphasis on minimization of steroids and calcineurin inhibitor agents. safe elimination of these steroids carry unprecedented advantages for reducing patient morbidity and chronic graft injury, but may also result in unanticipated changes in immunological homeostasis and drug pharmacokinetics, heralding closer surveillance for posttransplant infections and alterations in drug bioavailability and dosing, as well as break-through immunologic responses. in single center studies, pediatric renal transplantation appears safe without steroids. daclizumab first dose doubling and extended use for months replaces steroids effectively without evidence of over-immunosuppression, and may be the pivotal causative for the reduced acute rejection seen in the face of steroid avoidance. this pilot protocol has been tested in a prospective, multicenter randomized us and canadian study. b. maecker, c. klein department of pediatric hematology/oncology, hannover medical school, hannover, germany posttransplant lymphoproliferative disorders are severe complications of immunosuppressive therapy after solid organ transplantation causing significant morbidity and mortality. to define prognostic factors, we have analyzed pediatric solid organ graft recipients (kidney, liver, heart/lung) that were reported to the german ped-ptld registry. ptld was diagnosed at a median time of months post organ transplantation with sigifcantly shorter lagtime in liver versus heart or renal graft recipients. the five-year overall and event-free survival was % and %, respectively. stage iv disease with bone marrow and/or cns involvement was independently associated with poor survival. no differences in outcome were observed between early and late onset ptld, monomorphic or polymorphic ptld, and ebv-positive or ebv-negative ptld, respectively. patients with burkitt-like ptld and c-myc translocations had very short survival. these factors should be important to consider for future prospective interdisciplinary trials that are urgently needed to define rational treatment strategies. cystinosis is an autosomal recessive lysosomal storage disorder affecting children and adults all over the world. in cystinosis cystine is trapped in the lysosomal compartment due to a defect in its egress transport protein cystinosin encoded by the gene ctns. by mechanisms still not fully understood this leads to tubular and glomerular kidney and other organ failures (e. g., thyroid, muscles) if left untreated. kidney involvement is prominent from shortly after birth on as renal tubular fanconi syndrome with the clinical consequences of failure to thrive and rickets. cystinosis is the single most common cause of renal fanconi syndrome in childhood. therefore, any recognition of renal glucosuria, generalized aminoaciduria, phosphaturia, small molecular weight proteinuria, polyuria, and metabolic acidosis (due to renal bicarbonate loss) should lead to prompt consideration of cystinosis as possible cause. this can be done utilizing biochemical analytical methods measuring the cystine content of polymorphonuclear leucocytes. corneal cystine crystals, seen in slit lamp examination, are pathognomic as well, but may not be visible before months of age. left undiagnosed and untreated, patients will develop in addition to the existing tubular insufficiencies pronounced glomerular kidney failure often already present at diagnosis and inevitably leading to end stage renal failure typically at the end of the first decade of life. kidney failure in cystinosis presents differently from other forms of glomerular kidney failure because of the overlap of tubular and glomerular insufficiencies. kidney transplantation will be curative with respect to kidney function. specific treatment with cysteamine to lower the intralysosomal cystine content apparently is as important as before transplantation to prevent or attenuate other organ failures and therefore has to be continued after kidney transplantation. cysteamine treatment has been introduced in the s and has been approved in the s. early diagnosis and diligent treatment is able to prevent or ameliorate major organ complications. unfortunately, until now no newborn screening exists due to the biochemistry and cell biology involved. the high prevalence of a european founder mutation, i. e., a kb deletion in the ctns gene, makes molecular based methods not feasible. lowe syndrome and dent's disease: two ends of a spectrum d. böckenhauer great ormond street hospital for children nhs trust, nephrology, london, united kingdom lowe syndrome and dent's disease are x-linked disorders; the former is a systemic disorder characterized by cataracts, mental retardation and proximal tubulopathy whilst the latter was originally described as an isolated kidney disorder with tubular proteinuria, hypercalciuria/ nephrocalcinosis and progressive renal impairment. mutations in ocrl underlie lowe syndrome, whereas the majority of cases with dent's disease are caused by mutations in clcn . recently, mutations in ocrl have been identified in a subgroup of patients with dent's disease (also called dent- ). it is unclear, why some patients with ocrl mutations get dent's disease, while others develop lowe syndrome. however, careful clinical observation has revealed that dent- patients have evidence of systemic involvement. moreover, the degree of severity of symptoms in lowe syndrome is highly variable. thus, mutations in ocrl can cause a spectrum of symptoms, from tubular proteinuria and hypercalciuria to the full manifestations of lowe syndrome. here, we will review the clinical phenotype of the disorders, what is known about their pathophysiology and discuss genotype/phenotype correlation. fabry disease, the second most prevalent lysosomal storage disorder after gaucher disease, is an xlinked inborn error of the glycosphingolipid metabolic pathway and affects approximately : , live births. mutations in the gene encoding alpha-galactosidase a, lysosomal hydrolase, lead to systemic glycosphingolipid deposition, resulting in profound dysfunction of neurological, renal, cardiac, and cerebrovascular systems. the initial phase begins in childhood or adolescence and is characterized by neuropathic pain, angiokeratomas, and ocular deposits. the later phase is distinguished by progressive cardiac, cerebral, and renal involvement, leading to multi-organ dysfunction and death. few patients have historically survived past their mid s. although renal involvement usually becomes prominent in adulthood, adolescents may develop proteinuria and decreased glomerular filtration rate. timely diagnosis is critical, given that the enzyme replacement therapy likely delays progression of the serious complications of fabry disease and may have potentially preventive benefits. specifically, there is growing evidence that initiation of enzyme therapy slows progression of chronic kidney disease (ckd); it remains unknown whether enzyme therapy in the currently employed doses can prevent ckd. pediatricians have a particularly important role in making the diagnosis, since they are likely to be the first providers to encounter fabry patients and thus initiate therapy before irreversible tissue injury develops. nephrologists should consider the diagnosis of fabry disease when a patients present with ckd with nephrotic or subnephrotic proteinuria, often with skin lesions (but these may be limited in distribution), episodic extremity pain, and/or psychiatric problems. further research is required to determine the efficacy of enzyme replacement therapy to prevent organ damage in children, to identify optimal therapeutic doses and schedules, and to define efficacy of additional treatments for fabry kidney disease, include angiotensin converting enzyme inhibitors and angiotensin receptor blockers. w. van't hoff great ormond street hospital for children nhs trust, pediatric nephrology, london, united kingdom children with a complete deficiency of methylmalonyl coa mutase develop both renal tubular and glomerular dysfunction. the renal tubular dysfunction is characterised by renal tubular acidosis, defective urinary concentration and hyporeninaemic hypoaldosteronism. a chronic interstitial nephritis also develops leading to long-term glomerular renal damage. chronic kidney disaes is not evident on routine testing as muscle mass is reduced and protein intake is markedly restricted. formal measurement of gfr using chromium edta showed that of such mma patients have a gfr < mls/min/ . m ), and by years, of patients had a gfr < . most mma patients with ckd do not have excess proteinuria nor hypertension. although vit b responsive mma patients in general have a more favourable outcome, late onset renal complications have been seen. in addition to ckd, mma patients can develop cardiomyopathy, pancreatitis, gut dysmotility and chronic or acute encephalopathy. management is based on a protein-restricted, high calorie diet, allopurinol to control hyperuricaemia, supplements of carnitine and metronidazole therapy to reduce production of propionate. haemodialysis has successfully cleared plasma mma and improved the metabolic and nutritional status. liver transplantation has been performed in a number of younger children, as enzyme replacement therapy, but is associated with a significant morbidity and mortality (including late neurological deaths). renal transplantation has been reported in a small number of older patients but it is not yet clear how good the graft outcome will be. combined liver-kidney transplantation has been undertaken again in small numbers, with a high morbidity and significant mortality although there are a very few remarkable survivors. so far, there are only centre specific experiences and unfortunately reviewing the literature will not give a full picture of long-term outcome and complications, due to the bias of the reported results towards favourable outcomes. there is a clear need to share data on the management of these rare patients in order to better understand the best approach. estimations of the extent of hiv disease in sub-saharan africa are that million people are currently infected of which the total number of children is . million. worldwide it is thought that . million children are infected so it can be seen that the majority reside in africa. in south africa, we have a minimum of hiv infected children aged less than yrs of age with only on highly active anti-retroviral therapy (haart) at present. currently - % of all paediatric admissions to hospital may be hiv related. hiv associated renal disease, is not yet well documented among children -especially from africa -but now with the growing availability of haart, this information has become more important for appropriate management. hiv renal disease presents in many forms, including including hiv-assoc nephropathy (hivan) and hiv immune complex kidney disease (hivick) amongst others. questions have now been raised as to whether a screening program should be introduced as haart, despite side effects and drug interactions, has revolutionised management if hiv infection detected early enough. transplantation which was thought previously to be an absolute contraindication and potential waste of valuable resource is now possible, provided there is maintenance of haart, hiv viral load is undetectable for > mths and cd > cells/mul. there remains concern about feasibility in children with increased rejection, reduction of calcineurin inhibitors and infections such as recurrence of hepatitis c post-transplant. despite these concerns, studies in adherent adults have clearly shown that adult patients with hiv infection do better following transplantation than on dialysis. of concern, are some studies, showing that certain black patients may have a genetic predisposition to hiv infection. overall, transplantation can be successful in these patients provided the hiv disease is under control. however, hiv disease -including renal disease -remains a major problem in sub-saharan africa due to limited resources and lack of availability of drugs, where other health priorities may prevail. background. previous studies suggest that hiv- induces dysfunction and/or injury of endothelial cells, leading to the systemic release of fibroblast growth factor - (fgf- ). to date, the role that circulating fgf- may play in the pathogenesis of childhood hivan is not clearly understood. objective. here we sought to determine the potential role of circulating fgf- in the pathogenesis of hivan using wild type (wt) and hiv-tg mice. methods and results. to determine whether circulating fgf- induced ultrastructural changes in renal glomerular endothelial cells and podocytes, we injected human recombinant fgf- daily for days into fvbn wt and hiv-tg mice (n= in each group). by electron microscopy we found that fgf- induced endothelial swelling and mild fusion of the foot processes in wt mice. these lesions were more severe in hiv-tg mice, which showed enlargement of podocytes, protein reabsorption droplets, significant fusion of the foot processes, and collapsing glomerulopathy. subsequently, to confirm these findings in a different experimental model system, we used recombinant adenovirus carrying a secreted form of human fgf- (ad-fgf- ). four to five weeks old hiv-tg mice without evidence of abnormal protenuria (urine protein/creatinine ratio (up/uc) < ), and their wild type littermates were injected with x plaque forming units (pfu) per mouse of ad-fgf- or control ad-lacz vectors through the retro-orbital (r. o.) venous plexus (n= per group). all mice were followed for three weeks. all hiv-tg mice injected with rad-fgf- developed heavy proteinuria (up/uc > ). in addition, % showed elevated bun levels (> mg/dl) and renal histological lesions typical of hivan. in contrast, wt mice, developed transient and moderate proteinuria (up/uc < ), without renal failure or permanent renal damage. the number of animals with proteinuria in hiv-tg mice injected with ad-lacz group was consistent with the natural history of the renal disease progression. control wt mice injected with ad-fgf- developed mild proteinuria ( %) that returned to normal values - days after the injection. fgf- induced microcystic tubular dilatation and recruitment of mononuclear cells both in wt type and hiv-tg mice, although the changes were more significant in the later group. conclusion. taken together, these results suggest that the accumulation of fgf- in the circulation of hiv-tg mice induces glomerular endothelial and podocyte injury leading to the development of heavy proteinuria, renal failure, and the typical renal histological features of hivan. we conclude that the elevated levels of fgf- in the circulation of hiv-infected children may be a significant risk factor for the development and/or progression of hivan. human immunodeficiency virus associated nephropathy (hivan) is the third leading cause of kidney failure in young african american adults in the united states. the prevalence and natural history of the disease in children is not well documented. we have examined our experience in children, aged months to years (mean age . ± . years) with predominantly perinataly acquired hiv- infection from their mothers. since , of these children have been evaluated routinely for evidence of renal disease with quantitative assessment of proteinuria by random urine protein to creatinine ratios (upr/cr). renal functional studies included serum creatinine with estimation of glomerular filtration rate (egfr), urinalyses, renal scintigraphy, ultrasound and renal biopsy when possible. the patients were divided according to their level of proteinuria. those with nephrotic range proteinuria (upr/cr> . ) were designated as hiv-ns (n= ; %). those with persistent intermediate range proteinuria (upr/cr: . < . ) were designated as hiv-pp (n= ; %). those with no proteinuria (upr/cr< . ) were designated as having no nephropathy (hiv-non; n= ; %). the great majority of patients were treated with highly active antiretroviral therapy (haart), although those with hiv-ns had less time on treatment when their proteinuria was discovered. moreover, the virulence of the hiv infection as measured by viral load (vl) was significantly greater in those patients with proteinuria. also, viral load correlated positively with degree of proteinuria (r= . ; p< . ). mortality as shown by kaplan-meier survival curves was significantly greater in the hiv-ns group as compared to the pp and non groups. renal failure occurred only in the group with nephrotic range proteinuria. during the past years we have dialyzed children with hiv infection in our end stage renal disease (esrd) program for a total of patient dialysis months. since , all patients are managed on hemodialysis due to the high occurrence of fungal peritonitis in our initial experience. survival has improved remarkably during the past years with a median survival of months (range to months). the next stage is to begin renal transplantation in those patients with adequate control of the hiv infection. aim: to determine the spectrum of severe renal disease in our hiv infected children; excluding severe sepsis and septic shock syndromes. indications for their referral, renal biopsy and histology relating to outcome. methods: retrospective analysis of all children referred to the paediatric renal service from the general wards and hiv clinic from january to december . analysis includes age of presentation, sex, nutritional status, symptoms, renal function, histology, associated diseases including infections and follow-up. results: total of children with a mean age of . ± . years with a male: female ratio of : . . there was an overlap of symptoms but the commonest presenting symptom was haematuria in %, severe urinary tract infection and pyelonephritis in %, anasarca with or without any nephrosis in %, acute renal failure in %, chronic renal failure in %, severe electrolyte disturbances in %. renal biopsy was performed in ( . %) children. histogically % had immune complex disease (icd) of which . % had lymphoid interstitial pneumonitis (lip). . % had fsgs of which one had lip but also had icd, . % had severe interstitial nephritis, associated infectious changes in . % and atn in . %. one patient each had minimal change, mpgn, abdominal kaposi sarcoma and kidney/bladder stones. . % had or were treated for pulmonary tuberculosis. mean follow-up was ± . months. death occurred in . % ( ). all patients with fsgs with some renal dysfunction and severe sepsis demised. conclusion: despite the high burden of hiv disease, severe renal complications have a low prevalence. good correlation of icd and lip ( . %) but prognosis is good. pulmonary tuberculosis and infection is the main complications resulting in high mortality in nephrotic syndrome with fsgs. hiv associated nephropathy (hivan) is one of the most common causes of renal failure in hiv seropositive african americans. in the usa, hivan has become the third leading cause of end stage renal disease (esrd) in african americans over the age of . while the introduction of haart has decreased both the mortality and infectious complications of hiv infection, the incidence of hivan has reached a plateau and has not decreased. with reduced mortality, the prevalence of seropositive patients in the esrd program continues to increase dramatically. the histopathological findings of hivan include focal segmental glomerulosclerosis of the collapsing variant combined with microcystic tubule dilatation. the most common other diagnosis is mesangioproliferative glomerulonephritis associated with hepatitis c infection, a common comorbid condition. typical features of hivan include renal enlargement and echogenicity by ultrasound analysis. microscopic findings include coexistent microcystic tubule dilatation and glomerular involvement. usually there is mild to moderate tubulointerstitial inflammation, interstitial edema, and fibrosis as well. glomerulosclerosis is usually focal and segmental with collapse of the glomerular tuft and hypertrophy of visceral epithelial cells. hivan is caused by renal epithelial infection by hiv- in a susceptible host. clearly there are genetic factors, based on the racial predilection of this disease. patients with hivan are . times more likely to have a relative with renal failure. in susceptible individuals, hiv infection induces renal epithelial proliferation and apoptosis. the kidney represents a tissue-specific compartment in which hiv- can replicate in a previously unrecognized reservoir. while hivan is not currently considered to be an aids-defining condition, patients with hivan should be treated with haart. in some instances, haart has completely reversed the disease process, although it does not rid the kidney of virus. thus, in patients with hivan, the kidney is a true reservoir for replication competent hiv. whether this occurs in other forms of renal disease associated with hiv infection or in patients without renal disease remains to be determined. prenatal administration of dexamethasone causes hypertension in rats when they are studied as adults. renal sympathetic nerves directly innervate renal tubules and blood vessels and plays a role in the regulation of glomerular filtration rate and renal sodium excretion. we examined if renal nerves play an a role in mediating the hypertension in prenatal programming. pregnant sprague-dawley rats were injected daily with intraperitoneal dexamethasone between th and th day of gestation. renal norepinephrine concentration was measured at weeks of age. renal denervation was preformed at age weeks of age in control and prenatal dexamethasone treated rats and blood pressure was measured at age of weeks. renal norepinephrine concentration was ± ng/gr in controls and ± ng/gr in the group that received prenatal dexamethasone (p< . ). systolic blood pressure at weeks of age was ± mmhg in sham operated controls, ± mmhg denervated controls (p=ns). blood pressure was elevated to ± mmhg in dexamethasone treated sham operated group (p< . ), but was normal at ± mmhg in the dexamethasone treated denervation group. in conclusion, prenatal dexamthasone results in elevated renal norepinephrine levels. bilateral renal denervation normalized the systolic blood pressure in rats that received prenatal dexamethasone. these data are consistent with the renal nerve playing an important role in mediating the hypertension in prenatal programming by dexamethasone. objective: evaluation of clinical outcomes in surgically treated children with renovascular hypertension (rvh). methods: rvh patients treated surgically at a single centre between and were retrospectively reviewed: % were male, . - . (median . ) years of age, with systolic blood pressure (sbp) mmhg ( - mmhg). results: bilateral renal artery stenosis was present in %, midaortic syndrome(mas) in %, intrarenal disease in % and coexisting cerebral disease in % of patients. surgical procedures (n= ) included: a) nephrectomy (n= ), b) autologous surgery for both aortic reconstruction (n= ) and renal revascularisation (n= ) (renalartery reimplantation (n= ), renal bypass (n= ) and autotransplantation (n= )) and c) synthetic graft interposition for renal revascularisation (n= ), aortic reconstruction (n= ) or both (n= ). the majority ( %) of patients who received synthetic grafts had vascular anatomy too complex for autologous surgery. technical failure leading to secondary nephrectomy occurred in patients. postoperative complications were haemorrhage (n= ), septicaemia (n= ), and chylous ascites (n= ). there were no operative deaths. patients from the uk were followed up for . ( . - ) years. sbp post-surgery improved ( mmhg, range - mmhg, p< . ). outcomes were normal sbp without treatment ( %), improved ( %) or unchanged sbp ( %). reduction of sbp led to loss of contralateral kidney in patient. children required re-interventions ( angioplasties and surgical procedures) for progressive disease (n= ), narrowing of the synthetic graft (n= ) and re-stenosis of the autologous bypass (n= ). conclusion: rvh is a progressive disease of extensive nature. surgery benefited % of children when performed in conjunction with conservative therapy and, if indicated, interventional radiology. h. wong unlike adults with predominant primary hypertension (htn), the majority of children diagnosed with htn traditionally suffered from secondary forms of htn. however, substantial changes have occurred to the demographics of pediatric population over the past years. in addition, our definition, awareness and understanding of children with hypertension has also changed. we therefore retrospectively reviewed the current causes of htn in children followed in a single tertiary care pediatric nephrology referral center between january and december . patients who were either diagnosed with or treated for htn at the time of their last visit where included. gender, height, weight, age at the time of diagnosis, causer of htn and casual blood pressure were recorded. out of patients, ( . %) were diagnosed with htn. the majority were males (n= , %). median was years ( month- years) age at time of diagnosis and . years ( . months- years) at time of the last follow-up. secondary htn was the most common cause of pediatric htn (n= , %) followed by primary (n= , %) and then white coat (n= , %). renal htn was the most common cause of secondary htn ( / , %). for patients referred initially for assessment of htn (n= ), primary (n= , %) and secondary (n= , %) were the two most common diagnosis followed by normotension (n= , %) and white coat htn (n= , . %). twenty two ( . %) patients were diagnosed before the age of year. out of renal transplant patients, had htn ( %). renal htn remains the most common cause of pediatric htn overall and continues to represent a large portion of children referred for htn. all children suspected of having htn should continue to have thorough investigations of renal disease to identify the underlying cause. m. sinha , c. booth , j. simpson , n. dalton , s. qureshi , c. reid , s. rigden evelina childrens hospital, guys and st. thomas's nhs foundation trust, department of pediatric nephrology, london, united kingdom evelina childrens hospital, guys and st. thomas's nhs foundation trust, department of pediatrics cardiology, london, united kingdom king's college london, department of medicine, london, united kingdom background: hypertension (ht) is a frequent complication in paediatric tx patients. the evolution of end organ damage and its relationship to ht in these patients is not well described. aim: to study the predictive value of an abnormal -hour abp profile for end organ damage. methods: patients underwent simultaneous casual blood pressure (cbp), abpm, echocardiogram (lvh if lvmi > g/m . ) and ecg assessment, with measurement of several biochemical cardiovascular risk markers. cbp data for -months prior to study date was analysed as time averaged z-score. results: we present initial results of a -year prospective study. patients ( male) aged . y± . (mean±sd) and . y± . since tx were studied. on the day of study all patients had normal cbp. % had lvh of whom % had abnormalities on abpm. overall, % patients had both abnormal abpm and lvh. % had other findings: % abnormal abpm but no lvh; % normal abpm but no lvh; % normal abpm and lvh. data were analysed for differences between groups of patients, with and without lvh. bp alone was significantly associated with increased lvmi. time averaged cbp was normal in all patients although differed significantly between the groups: systolic bp z-score [mean (ci)] . ( . , - . ) with lvh; -. (- . , - . ) without lvh. there were significant differences by abpm criteria relating to several components of the abpm profile including mean arterial pressure, systolic and diastolic bp load. no difference was found between the groups for hb, ca*po product, ipth and cgfr. conclusions: we have found the majority of our renal transplant patients have normal cbp but have abnormal abpm in association with lvh. this suggests better control of hypertension should be achieved in patients who have abnormal abp profiles and lvh. a new group of patients with normal abpm but lvh has also been identified. background: obesity is an independent risk factor for renal failure. therefore, we compared the body composition of pediatric nephrology patients with the general child population over two decades. methods: , patients with a mean age of . ± . years were studied. in , patients ( . %), sufficient data were available to analyze body composition. body composition was measured as body mass index (bmi) z-score because of the age dependency, calculated on the basis of data from the national (usa) center for health statistics ( ) . results: enuresis ( . %), hematuria ( . %), recurrent urinary tract infections ( . %) and proteinuria ( . %) were the most common diagnoses. the bmi z-score of the pediatric nephrology patients increased significantly from . ± . in - to . ± . in - and . ± . in - . while the rate of this increase was not statistically different from that seen in the normal population, they consistently demonstrated a significantly higher bmi z-score (average + . ) over time. nephrotic edema, non-nephrotic proteinuria and hypertension were not confounding factors. conclusions: patients seen in our pediatric nephrology service over two decades had a higher bmi than the average child population. this implies that these patients are at even greater risk for development of chronic kidney disease later in life. we recommend therapeutic intervention to address this potentially modifiable risk factor. objective: b cell dysregulation is believed to be involved in the development of childhood-onset systemic lupus erythematosus (sle). there is limited evidence regarding efficacy and safety of interventions targeting b cell in children. in our study we evaluated efficacy and safety of b lymphocyte depletion therapy. methods: data of children ( % male) with sle aged . years ( . - . ) treated with rituximab in a single centre were retrospectively reviewed. biochemical parameters were evaluated before and after treatment, and the normalisation of the parameters was assessed as a primary outcome. results: prior to rituximab therapy all patients received extensive immunosuppressive agents. indications for rituximab therapy were chronic (n= ) or acute illness, in either relapsing sle (n= ) or first presentation (n= ). rituximab mg/m was intravenously administered twice within a -week period in combination with cyclophosphamide. patients were followed up for . years ( . - . ) . no serious side effects were seen, except for viral infections such as herpes zoster (n= ). all patients with high creatinine (n= ; ± mmol/l) prior to rituximab showed a decline within months (mo), achieving a stable level by mo ( ± mmol/l, p< . ). all patients with hypoalbuminaemia (n= ; . ± . g/l) improved ( mo: . ± . g/l, p< . ). low c level ( . ± . g/l) as seen in patients prior to treatment resulted in an increase up to mo ( . ± . g/l, p< . ). a decline of previously high anti-dsdna (n= ; ± iu/ml) was observed in all patients ( mo: ± iu/ml, p< . ). conclusion: rituximab is safe and effective when used in combination with standard immunosuppressive agents. further prospective studies are essential to evaluate the longterm safety of the drug. outcome of severe henoch-schönlein purpura nephritis treated with longterm immunosuppression m. shenoy, m. bradbury, l. lewis, n. webb royal manchester children's hospital, department of nephrology, manchester, united kingdom aims: to look at the long-term outcome of all children with severe henoch-schönlein purpura nephritis (hsn) treated with long term immunosuppression in a single centre over a ten year period. patients and methods: retrospective review of the records of children ( male) with iskdc grade b, , and hsn managed at our institution from / / to / / results: the mean age at presentation was . years (range . - . years). the median estimated glomerular filtration rate (egfr) at presentation was ml/min/ . m (iqr . - . ) and urine protein: creatinine ratio (up: uc) was mg/mmol (iqr - ). the indication for biopsy was nephrotic syndrome in , nephrotic range proteinuria in , sub-nephrotic range proteinuria in , acute nephritis in and nephritic-nephrotic syndrome in . a total of patients were treated with weaning dose of steroids, of whom were also commenced on long-term azathioprine (mean duration . months). of these children received an - week course of oral cyclophosphamide ( - mg/kg/day) prior to azathioprine therapy ( - mg/kg/day). outcome: after a mean follow-up period of years, ( %) have made a complete recovery, ( . %) have persistent proteinuria but normal egfr, ( . %) have persistent proteinuria and are on anti-hypertensive therapy with normal egfr and ( . %) have progressed to esrd. older age at presentation was the only independent risk factor for poor outcome ( . years vs. . years, p= . ). conclusions: despite treatment with cyclophosphamide, long-term steroids and azathioprine, a majority of children with hsn grade - b on initial biopsy have persistent renal abnormalities on long term follow-up. only older age at presentation was associated with poor outcome. background: resent advances in podocyte biology indicated that the main cause of the heavy proteinuria in nephrotic syndrome (ns) is a dysfunction of slit diaphragm. on the other hand, the classical charge selective barrier is not likely to have a place in slit diaphragm. therefore we reevaluated the charge selective barrier function in ns and chronic glomerulonephritis using recently established charge selectivity index (csi; takahashi et al, pediatr res : , ) in comparison with dent disease. patients and methods: csi is a clearance ratio of igg (stokes einstein radius - , pi . - . ) and iga (stokes einstein radius , pi . - . ) . the assay of serum and urinary igg and iga was performed using laser nepherometry and enzyme immuno-assay. in order to evaluate the csi of normal glomerular filtrate, we measured the csi of dent disease. the urine of dent disease is considered to be a concentrate of filtered protein from normal glomerulus, without having a process of tubular protein reabsorption. thirty eight patients with podocyte diseases (focal and segmental glomerulosclerosis , finnish type congenital nephrotic syndrome , steroid sensitive nephrotic syndrome ), patients with chronic glomerulonephritis (iga nephritis , henoch-schönlein purpura nephritis , mesangiocapillary glomerulonephritis , alport syndrome ) and patients with dent disease, were analyzed. results and conclusion: csi (mean±sd) of podocyte disesses, chronic glomerulonephritis and dent disease was . ± . , , ± . and . ± . respectively. the results apparently indicated that the charge selective barrier of gcw is working strongly in normal glomerulus, less strongly in podocyte diseases and not working in chronic glomerulonephritis. objectives: nphs mutations have been reported in familial and sporadic srns. we investigated the prevalence of nphs mutations among south-east asian chinese and their association with clinical outcomes. methods: genomic dna from patients with primary sporadic srns (mean age at onset . ± . years, range . - . years) and cord blood controls were screened on all exons and exonintron boundaries using direct sequencing. results: a missense heterozygous c>t mutation in exon was identified in only one patient. polymorphisms t>c and a>g in exon were detected in both groups. in the patient group, the genotypic frequency of tt, tc, cc at position was . , . and . , and aa, ag and gg at position was . , . and respectively, consistent with hardy-weinberg expectations. there was no significant difference in allele frequencies between patients and controls. using binary logistic regression analysis, individual polymorphisms did not appear as informative predictors of poor clinical outcome, defined as persistent proteinuria or renal failure (p> . ). on analyzing composite genotypes, carriers of at least a copy of the c allele were significantly associated with poor outcome (p= . , or= . , % ci: . - ), while heterozygotes for a>g were associated with good outcome (p= . , or= . , % ci: . ± . ), suggesting possible interactions between the polymorphic sites. further analysis showed that the genotypic combination of tc/cc with aa was more likely to have a poor clinical outcome. no significant linkage disequilibrium was detected between the two polymorphisms. conclusion: the concomitant occurrence of at least a copy of the c allele and the aa genotype may be associated with poor clinical prognosis in srns but larger studies are needed to confirm these findings. renal hypodysplasia (rhd) is characterized by a reduced kidney size and/or maldevelopment of the renal tissue following disturbed organogenesis. numerous deletion mouse models of developmental genes have been established presenting with anomalies of the kidneys resembling rhd, among these the knock-out of bmp and six . here, we report on the first human mutations in bmp and six identified in children with rhd, among these three different mutations in bmp in five unrelated patients (ser cys, thr ser, asn lys) and three different mutations in six also in five unrelated individuals (leu phe, pro leu, asp asn). overexpression assays in zebrafish demonstrated that ventralization and dorsalization caused by bmp and six overexpression, respectively, could be diminished after overexpression of mutant constructs expressing the human mutations identified. morpholino knock-down of zebrafish bmp and six . reveals specific roles of these genes for pronephric development, affecting the expression of wilms tumor- (wt ) and glomerular development. rna analysis of cos and hek transfected with different bmp constructs showed a lower level of mrna abundance in bmp mutants, indicating a possible negative feedback of the mutants on their own mrna expression and/or stability. nonreducing western analysis revealed that s c-bmp forms alternative protein complexes as compared to wildtype-bmp , due to the formation of extra disulfide bonds. these studies implicate six and bmp as important players in the development of the renal system, and suggest that defects in these proteins could affect kidney development at multiple stages leading to the congenital defects observed in rhd patients. apoptosis is important in normal renal development in which regulation of cell numbers is critical. studies have shown that apoptosis occurs in non-cystic tubules in pre-uremic pkd kidneys, thus providing the mechanism whereby expansion of cysts is accompanied by loss of normal nephrons. to date, it is unclear which initiating factors (intrinsic, through mitochondrial damage or extrinsic, through ligand activation of death receptors) are responsible for apoptosis in pkd and whether they are the same in ad-and arpkd. aim: to elucidate the sequence of activation of intracellular apoptotic pathway(s) in both ad-and arpkd. methods: proteins were extracted from tissues of human ad-and arpkd kidneys and normal adult (nhk) and fetal kidneys (hfk). quantitative western immunoblot analysis was carried out for markers of intrinsic and extrinsic apoptosis. immunohistochemical staining for these markers was performed on tissue sections of the same kidneys. results: markers of extrinsic apoptotic pathways, caspases and , were significantly increased in ar-and in adpkd tissue by comparison to nhk and hfk tissues. these increases were seen in early stages of adpkd and were more pronounced later in the disease. for the intrinsic pathway, caspase and bid were increased in hfk tissue, but unchanged in ad-and arpkd tissue compared to nhk tissue. staining for caspase was found in hfk, but was absent in all other kidney tissues. staining for caspase was seen in early adpkd and endstage (es) adpkd as well as in es arpkd. caspase was identified as the main executing caspase of fetal development and adpkd, but wasn't seen in arpkd, where caspase predominated. conclusion: induction of extrinsic pathways of apoptosis predominates in pkd and occurs early in the disease process in adpkd, but only later in arpkd. intrinsic apoptosis predominates during development. intrauterine growth restriction (iugr) is a risk factor for an aggravated course of renal diseases in later life. the influence of postnatal factors, eg. accelerated catch-up growth, is not well understood. we therefore analysed the influence of postnatal nutrition after iugr on the developement of later renal inflammation and fibrosis in the rat. iugr was induced by low protein diet ( % vs. %) in pregnant wistar dams. litter size was reduced to or male animals in iugr (lp , lp ) and control animals (np , lp ), respectively. animals were sacrificed on day . mean arterial blood pressure was similar in all four groups. lp -( . ± . ml/h/ g) and np animals ( . ± . ml/h/ g) showed reduction of endogen creatinine clearance by % (vs. np and lp ) (p< . ). renal mrna expression of il ( , x), tgfβ ( , x) , endothelin ( , x) und osteopontin ( , x) was significantly higher in lp than in np . lp showed the highest glomerulosclerosis-score (( . ± . ) (vs. np ( . ± . ), lp ( . ± . ) and, np ( . ± . )) (p< . ). as marker of extra cellular matrix expansion glomerular collagen-iv deposition was significantly higher in lp ( . ± . %) (vs. np ( . ± . %), lp ( . ± . %) and np ( . ± . %)) (p< . ). postnatal nutrition modifies the consequences of iugr in the kidney. increased postnatal nutrition of the individual animal is associated with aggravated renal inflammation and fibrosis after iugr. unilateral renal agenesis (ura): how intensively do we need to investigate and follow-up? s. rhodes, a. watson nottingham university hospitals, children and young people's kidney unit, nottingham, united kingdom a single kidney is one of the commonest urinary tract abnormalities in the general population. concerns remain about long-term outcomes with a reduced nephron mass and hence intensity of investigations and duration of follow-up. we identified cases with ura (ectopic and pelvic kidneys excluded) from our nephrourology database between and . ( %) occurred in males and ( %) had left ura. ( %) were detected antenatally with / ( %) recognised in the last years. median age of detection for postnatal ura was mths (range . - mths) with uti ( %) as the main indication for ultrasound scan (uss). % patients were classified as simple ura with no associated abnormality and % as complex with problems such as vesicoureteric reflux (vur)( %), hydronephrosis or scarring. all cases reviewed had uss which showed compensatory hypertrophy in / ( %). / ( %) had dmsa scan and / ( %) micturating cystogram. of those antenatally detected single kidneys with normal initial uss none had vur, scarring, hypertension or proteinuria. these patients were discharged from follow-up at the median age of mths (range - mths). all complex cases have continued under follow-up. conclusions: our data suggest that the incidence of antenatally detected ura may be increasing. investigations need to be individualised depending upon the initial uss. the value of routine dmsa and mcug in simple cases is questioned. most of these patients can be discharged after adequate documentation of compensatory hypertrophy of the normal kidney, absence of proteinuria, normal blood pressure and renal function. autosomal dominant pdk (adpkd) in childhood j. crocker, p. wornell, p. acott iwk health centre/dalhousie univeristy, division of nephrology, halifax, canada autosomal dominant polycystic kidney disease (adpkd) is the most common genetic kidney disease with in adults progressing to end-stage renal disease (esrd). a program for intervention in childhood at presentation with adpkd was developed and instituted in . our long-term objective is to modify clinical parameters that may contribute to risk of development of esrd in adulthood. seventy children with adpkd (average age . yr) were followed, of which ( %) had nephromegaly +/-cysts on antenatal ultrasound. modifiable risk factors were common including hypertension ( %), hyperlipidemia ( %), and proteinuria ( %). ace inhibitors were first line therapy for proteinuria and/or hypertension. ace inhibitors may modify cyst progression so they have been made available to non-hypertensive children as well. most patients with hyperlipidemia responded to dietary intervention with one patient developing gallstones. in the past years we have focused on renal calculi, as this is a known risk for a subgroup of adults with poor prognosis. we noted patients ( %) have glycinuria, which is a precursor to oxaluria. four patients have passed calculi with two of these being diagnosed by genetic linkage analysis for adpkd without radiographic cysts present. cerebral vascular studies of patients with severe headaches revealed two with vascular structural anomalies. all adolescent females received counseling regarding appropriate contraception and their pregnancy risks of hepatic cyst progression. an early intervention program targeting modifiable risk factors of adpkd patients during childhood and adolescence may modify adult renal failure risk in this population. background: techniques of chronic infant dialysis have evolved during the past decades but morbidity and mortality are not well described. methods: a retrospective review was performed on infants - months of age with end stage renal disease (esrd) treated with maintenance dialysis during the past years. the experience was divided into era ( era ( - (n= ) and era ( era ( - . dialysis modality, morbidity, and long term survival were assessed and compared between the eras. results: all patients were begun on peritoneal dialysis (pd). there were males and females. age at initiation of dialysis was , months. the predominant diagnoses were dysplasia/obstructive uropathy (n= ), autosomal recessive polycystic kidney disease (arpkd) (n= ), congenital nephrotic syndrome (cns) (n= ), other (n= ). overall survival is % ( / ) with current age of survivors ranging from months to years. mortality between era = % and era = % was not significantly different. fifteen ( %) survived to receive a kidney transplant. overall median survival is . years (era = . years; era = . years; p= . ). conclusions: although long term survival is possible in infants with esrd, mortality and morbidity remain high. improved technologies for automated pd should address the needs of the infant < kilograms. joubert syndrome and related disorders (jsrd) are a group of autosomal recessive conditions characterized by a complex neuroradiological malformation resembling a molar tooth on imaging. clinically, jsrd are characterized by overlapping phenotypes presenting neurological signs and variable involvement of other organs such as kidneys (mainly nephronophthisis -nph), retina and liver. seventy-nine italian jsrd patients from unrelated families were recruited in pediatric nephrology and neurology centers. medical records and brain mri were reviewed. patients without chronic renal failure (crf) underwent measurement of their glomerular and tubular function, a ddavp urine concentration test and a renal ultrasound. retinal examination was performed in most patients. seven patients younger then years had normal renal function but were not fully tested. of the remaining cases, had no evidence of renal disease, had developed crf mostly in their second decade of life, and were younger then years of age and had urinary concentration defects, of whom also had hyperechogenic kidneys by renal ultrasound. when comparing this latter group with age-matched jsrd patients, no other tubular function abnormality was detected. in multiplex pedigrees, no discrepancies in renal involvement between affected family members was observed. retinal involvement was significantly associated with renal disease. conclusions. evidence of interstitial renal disease was observed in one third of italian patients with jsrd. renal involvement should always be suspected in these patients, particularly if they have evidence of retinal dysplasia or other family members with symptoms related to nph. these patients should be assessed with a urine concentration test. we examined the course of children with primary obstructive megaureters (pom) treated in our hospital from - . pom occurred more often in boys ( %, p< . ) and on the left side ( %, p< . ). pom ( %) were only treated conservatively. four underwent immediate surgery following the first mag renography. one of these was nephrectomized after unsuccessful urinary diversion and persistent renal hypertension. of the kidneys primarily managed conservatively, needed a ureterocystoneostomy later on due to increasing obstruction. surgical correction of pom required a mean of days of hospitalization (incl. temporary urinary diversion, removal of catheters and treatment of complications). one child required surgical revision of early post-operative ureteric stenosis. urinary tract infections (uti) were a common complication (n= , mean . per patient). as utis occurred mainly in infants, hospital admission was commonly required ( %). only children never acquired a uti ( %). eight patients had a poor outcome as defined by partial kidney function < % on the affected side (n= ), atrophy on final ultrasound (n= ) or nephrectomy (n= ). the most potent predictor of reduced unilateral kidney function was a small kidney present from birth. secondary kidney growth failure occurred only in one case. the initial degree of obstruction on renography, but not the degree of hydronephrosis or size of megaureter predicted outcome. also, prenatal diagnosis of pom, surgical treatment and the occurrence of utis showed no association with outcome. in summary, the long-term prognosis of pom appears favorable. adverse outcomes were more closely related to congenital kidney size deficit than to the degree of obstruction. surgical interventions and the high uti incidence led to significant hospitalization times. r. bhimma, m. adhikari, k. asharam university of kwazulu-natal, maternal and child health, durban, south africa background: steroid resistant (sr) forms of ns have a poorer outcome in blacks compared to other racial groups. methods: children with srns - years old were analysed retrospectively for the period - . treatment schedules included oral cyclophosphamide with prednisone only (n= ); prednisone on alternate days with methylprednisolone and oral cyclophosphamide (n= ); oral prednisone on alternate days, doses of intravenous methylprednisolone on alternate days and monthly doses of intravenous cyclophosphamide (n= ) or cyclosporine adjusted to a trough level of - mg/ml (n= ). we compared the clinical, biochemical characteristics and outcome of these children using different forms of therapies. results: ( . %) underwent renal biopsy. ( . %) were indian and ( . %) were black. ( . %) had minimal change ns, ( . %) had focal segmental glomerulosclerosis (fsgs), ( . %) a proliferative form of ns, and ( . %) had other forms of ns. / ( . %) indian children biopsied were in complete remission and / ( . %) with mcd who were treated with oral cyclophosphamide and prednisone only achieved complete remission. / ( %) indian children not biopsied who received only oral prednisone and cyclophosphamide achieved complete remission. / ( . %) black children who were biopsied achieved complete remission. none of the eight black children who were not biopsied given only oral cyclophosphamide and prednisone achieved complete remission. conclusion: since % of indian children with srns responded to a trial of oral cyclophosphamide and prednisone but none of the black children did, we propose the use of oral cyclophosphamide therapy in non black children before embarking on renal biopsy. mj. kemper, c. moeller, n. rink, m. van husen, de. müller-wiefel university of hamburg, pediatric nephrology, hamburg, germany introduction: ssns is often complicated by a refractory clinical course with frequent relapses and steroid dependency despite aggressive alternative immunosuppressive regimens. since recent immunological findings suggest an alteration of not only t-but also b-cell immunity in ssns (kemper (kemper , we hypothesized that that immunological targeting of b-cells with antibodies directed against cd (rituximab) is able to maintain remission (rm) in treatment refractory patients with ssns methods: a total of six patients with complicated courses of ssns had severe steroid-dependency and toxicity. all patients had previously been treated with cyclophosphamide, two patients relapsed on maintenance therapy with cyclosporine, one relapsed on additional levamisole and one on mmf. treatment was initiated at a median age of (range - . ) years and rtx was given at steroid induced rm at a dose of x mg/m bsa within weeks. results: a complete b-cell depletion was induced for at least months in all patients. rm could be maintained in all patients and steroid treatment could be discontinued after a median of . months (range - . ) . also csa could be discontinued in the two patients on maintenance treatment. at current follow-up of . months (range - . ) the two patients after csa discontinuation relapsed after . and . months, respectively, but responded after steroid induced rm-to a second course of rtx. all other patients remained in remission off treatment so far. no significant clinical side effects were noted. conclusion: in summary and conclusion, rtx seems to be a therapeutic option in complicated ssns. long-term follow-up and future prospective studies are necessary to further define the role of rtx in the treatment of refractory steroid sensitive nephrotic syndrome. efficient control of secondary hyperparathyroidism can be achieved by calcimimetics. they increase calcium sensing receptor (car) sensitivity to extracellular calcium. in r- -treated uremic rats, proteinuria has been significantly reduced by calcimimetics. thus, we examined the potential direct effect of r- on podocytes. the car was expressed in cultured immortalized podocytes (quantative rtpcr, western blot) and in podocytes obtained from healthy and subtotally nephrectomized rats (immunohistochemistry). glomerular car abundance was increased by uremia and r- . the car colocalized with the plasma membrane and intracellular filaments in cultured podocytes, but not with the caveolin -and -rich membrane fractions. we then studied the effect of r- on the mitogen-activated protein kinase (mapk) family. jnk was not activated. p showed a biphasic response pattern, whereas erk / (and further downstream, p ribosomal s kinase) showed dose-( - nmol/l) and time-dependent phosphorylation, resulting in the activation of the transcription factor camp response element binding protein (creb). creb phosphorylation induced bcl-xl expression and bad phosphorylation, both of which have prosurvival activity. specificity was confirmed by addition of mek / inhibitor u , which completely blocked r- -induced creb phosphorylation. facs analysis revealed a significant, % decrease in puromycin-induced apoptosis in podocytes treated with r- for , and hrs. in conclusion, calcimimetics induced prosurvival gene expression in podocytes via mapk, protecting them from apoptosis. calcimimetics may have a direct renoprotective action beyond control of hyperparathyroidism in chronic kidney disease patients. we report our experience with plasma therapy in a family of three sisters from whom two are homozygous twins (patients b and c), presenting a missense mutation of the exon of the human complement factor h gene (hf- ). the factor h concentration has always remained normal and no systemic complement activation has ever been detected. in a ten years period, the followings have been observed: / no use of plasma exchange lead to immediate esrf of native kidneys (patient a); ) conventional plasma therapy ( sessions at presentation followed by repeated ml/kg plasma infusions when relapse of hemolysis and thrombopenia) could not impede esrf (patient b); ) the use of intensive pe at presentation (daily pe ( ml/kg ffp until plasma creatinine normalization followed by one pe/ w indefinitely) lead to a normal gfr years after presentation despite relapses (patient c); / no prophylactic pe for tx lead to immediate hus relapse and transplant loss (patient ); ) prophylactic pe allowed a successful tx in patient b (pl. creat mcmol/l after years); ) early and intensive pe allowed complete normalization of several hus relapses after tx (patient b). conclusions: in fh mutation-related atypical hus, ) intensive and indefinitely prolonged pe can allow a normal function of native kidney at long term; ) prophylactic pe allows successful kidney tx; ) early and intensive pe allow reversion of hus relapse after tx. the success of plasma therapy is bound to the followings: a/ the use of pe and not plasma infusion. b/ the prolongation of daily pe after normalization of hemolysis parameters, and further prophylactic pe. c/ the use of pe prophylaxis from before tx. d/ a minimum pes frequency of one/week in case of prophylactic treatment for tx. e/ immediate intensification of pe frequency in case of relapse. objectives of study: heparan sulfates (hss) are highly polyanionic sugar chains in the glomerular basement membrane (gbm) and have been reported to play an important role in the chargeselective permeability of the kidney. alterations in hs expression have been reported in a number of renal pathologies. in this study, we evaluated if degradation of hs in the gbm resulted in proteinuria in rats, using a controlled in vivo approach. methods: heparinase iii and neuraminidase were injected i. v. in -month old wistar rats at t= hr and t= hr, and kidneys were removed at t= hr. urine samples were taken at various time points. cryosections were stained for hs using specific antibodies, and for hs stubs (generated by heparinase). in addition, hs was evaluated at the electron microscopical level. neuraminic acid expression was analysed by peanut agglutinin lectin. the hs content in urinary samples was evaluated by agarose gel electrophoresis. urinary neuraminic acid was studied by an enzymatic colorimetric assay. presence of urinary albumin (proteinuria) was investigated by sds-page and by a competition elisa. results: injection with heparinase iii resulted in an almost complete absence of glomerular hs staining. cupromeronic blue staining was also greatly reduced in the gbm, further indicating that hs was largely degraded. staining for the hs proteoglycan core protein agrin was unaltered. in the urine a strong increase in hs was found, already at the first point in time of urine collection ( hr after the first injection). however, no urinary albumin or other proteins could be detected at any point in time analysed. injection of rats with neuraminidase resulted in a major increase of albumin in the urine. conclusion: in conclusion, removal of hs from the gbm does not result in acute albuminuria, whereas removal of neuraminic acids does. introduction and methods: children undergoing deceased ( ) or living ( ) donor kidney transplantation were randomized to receive tacrolimus, azathioprine, steroids and two doses of basiliximab (tas+b) or tacrolimus, azathioprine and steroids(tas). previously reported six month follow-up biopsy-proven acute rejection rates were . % (tas+b) and . % (tas). patient survival was % and graft survival % in both arms (am j transplant ; : - ) . in this investigator-driven follow-up study individual outcome data were submitted annually to the coordinating centre. results: two year follow-up data were obtained for ( . %) of the who completed the six month study. there was one death in the tas group occurring at month . there were graft losses in the tas+b arm and in the tas arm. all graft losses in the tas+b arm occurred within the first months. kaplan-meier estimates of year graft survival were . % for tas+b and . % for tas (p= . breslow generalised wilcoxon test). episodes of biopsy proven acute rejection occurred in in tas+b and in tas, kaplan-meier estimates of freedom from rejection being . % and . % respectively (p= . ). renal function did not differ significantly between the two arms; the median (iqr) plasma creatinine levels were ( - ) in tas+b and ( - ) in tas (p= . ). similarly there was no evidence of a difference in either systolic or diastolic blood pressure between the two arms. there was one case of b cell ptld in the tas+b arm at months in addition to two cases in the tas arm previously reported in the month study. conclusions: the addition of basiliximab to a regimen of tacrolimus, azathioprine and steroids does not appear to result in an improvement in either acute rejection rate or graft survival at two year follow-up. further data collection is ongoing. chronic renal dysfunction is a major complication after heart transplantation (htx). the pathophysiology is not yet fully understood but is thought to be in part due to calcineurin inhibitor (cni) toxicity, and reducing cni exposure has become one of the main strategies aimed at ameliorating renal outcome in htx recipients. we previously reported a significant improvement of renal function in htx children with biopsy-proven cni nephrotoxicity and chronic renal failure, year after the reduction of cni dosage with a concomitant replacement of azathioprine by mycophenolate mofetil. we ought to determine whether this improvement was persistent after years of follow-up, despite the histological lesions of chronic cni nephrotoxicity. gfr evaluated by annual inulin clearance had improved from a mean of . ± . ml/min/ . m (range - ) at time of the switch to . ± . ml/min/ . m (range - ) (p= . ) one year after ( % improvement), and remained stable at . ± . ml/min/ . m (range - ) (p= . ) years after the switch. maximal urinary osmolality followed the same increase profile from ± mosm/kg before the switch to ± at one year and ± after years (p= . ). meanwhile, the occurrence of serious adverse events such as infectious episodes, acute rejection and chronic allograft dysfunction as assessed by clinical examination, echocardiography and endomyocardial biopsies were not different from a control group of patients whose treatment was unchanged. no malignancy was observed in either group. in conclusion, reduction of cni dosage and replacement of azathioprine by mycophenolate mofetil lead to a safe and long-lasting improvement of renal function in children with heart transplants and cni-induced nephropathy. previous studies have demonstrated reduced bone mineral density (bmd) in some patients with idiopathic hypercalciuria (ih). reduced bmd during childhood may impact adult peak bone mass. bisphosphonates employed in adults with ih and reduced bmd resulted in conflicting outcomes. we evaluated the effects of oral bisphosphonate, alendronate (ale), in patients with persistent ih and reduced bmd. patients presented at ages , , yr, with hematuria/dysuria, had recurrent urolithiasis, and all had ih (uca > mg/kg/ hr). despite maximal traditional rx with low na/high k diet, thiazides, k-citrate, ih persisted ( . - mg/kg/ hr). at ages , and . yr, dxa showed reduced bmd, and ale , and mg/once weekly was given for , and months, respectively. after months of ale, uca decreased significantly compared to baseline (mean±sd, . ± . vs. . ± . mg/kg/ hr, p< . ). compared to baseline, bmd z scores year after starting ale improved at the spine (- . ± . vs. - . ± . , p< . ) and hip (- . ± . vs. - . ± . ) . the decline in uca during ale rx correlated with the increased bmd z scores in the spine (r=- . , p= . ) and hip (r=- . , p< . ). height z scores, serum creatinine, ca, p, electrolytes and pth remained normal throughout the rx period and no further hematuria or new stones occured. in summary, ale normalized uca previously resistant to traditional rx, eliminated urinary symptoms and improved reduced bmd in children with ih. the use of a single oral weekly dose appears adequate and safe. larger prospective studies are needed to confirm these preliminary results. in addition to its classical role in the regulation of calcium (ca) and phosphate (po ) homeostasis, vitamin d has important immunomodulatory and anti-inflammatory effects, that in turn can influence atherosclerotic vascular disease. we studied the impact of vitamin d levels and inflammation on vascular structure and function in children on dialysis. children (age . ± . yrs) on dialysis (mean duration . ± . yrs) were studied. all children received α-hydroxyvitamin d (alfacalcidol) . cumulative data on ca, po and pth, doses of po binders and alfacalcidol were recorded. , -dihydroxyvitamin d (vit d) and high-sensitivity crp (hs-crp) levels were measured by i radioimmunoassay and elisa respectively. all children had carotid intima-media thickness (cimt), pulse-wave velocity and cardiac ct for coronary calcification. ( %) children had vit d deficiency (levels< pmol/l), ( %) hadnormal levels ( ± pmol/l) and ( %) had high levels (> pmol/l). vit d positively correlated with serum ca, caxpo and alkaline phosphatase. both cimt and calcification showed a bimodal distributionpatients with vit d levels < or > pmol/l were significantly more likely to have calcification or raised imt than those with vit d levels in the normal range. hs-crp levels independently predicted cardiac calcification (p= . ) but not cimt. there was a strong inverse correlation between vit d levels and hs-crp (p< . , r=- . ). patients with vitamin d levels< pmol/l and hs-crp levels> mg/l had -fold greater calcification scores than subjects below these cutoffs. in conclusion, vit d deficiency is common despite treatment in children on dialysis. vit d may be an important mediator of vascular damage both through its hypercalcaemic and anti-inflammatory actions. severe growth failure remains one of the challenging problems in the care of children suffering from chronic renal failure (crf). although, rhgh has been proven to increase final adult height in prepubertal crf patients only limited data on its efficacy in the pubertal age-range are available. in addition, the impact of the underlying renal disease and the mode of renal replacement therapy on final height in these patients remain unclear. we report on final height data of ( female) severely growth-retarded crf patients (standardized height <- sds; database: kigs medical outcomes, pfizer). mean age at start of rhgh therapy was . ± . years, standardized height was - . ± . sds and duration rhgh therapy was . ± . years (range . to . years). at baseline % of the patients were on conservative treatment, % were on dialysis and % had a functioning renal allograft. in the whole study population mean standardized height was increased in the first treatment year and at attainment of final adult height by + . sds and + . sds, respectively (each p< . vs. baseline). prepubertal children aged less than years at start of rhgh therapy showed the best growth response (+ . sds). in pubertal patients mean increase in standardized height was + . sds, whereas growth response in patients with delayed onset of puberty (>+ sd) was significantly lower (+ . sds; p= . vs. other groups). the duration of rhgh therapy was positively associated with cumulative height gain. growth response was significantly lower in patients on long-term dialysis and in patients with nephropathic cystinosis. conclusion: rhgh therapy in severely growth retarded prepubertal and pubertal crf patients results in an increased final adult height. growth response is diminished in crf patients with markedly delayed onset of puberty. tightly regulated rankl/opg system is essential for normal bone remodelling. however, the exact roles of those osteogenic markers in uremic bone disease have yet to be defined. we therefore assessed the potential relationship of the rankl/opg system in bone biopsy proven secondary hyperparathyroidism (hpt) in dialyzed children. methods: patients aged ± years were on ccpd for ± months. s-ca, p, alk p'tase, pth, opg and rankl levels were measured. bone biopsies were obtained after double tetracycline labeling and none of the patients were treated with vitamin d for four weeks prior to biopsy. results: s-ca levels were . ± . mg/dl, p: . ± . mg/dl, alk p-tase: ± u/l, pth: ± pg/ml. bone biopsy findings revealed high turnover bone disease in patients, patients had normal bone formation rate (bfr). mean opg and rankl levels were . ± . and . ± . pmol/l, respectively (reference control=opg: . ; rankl: . ). opg correlated with bfr (r= . , p< . ) and adjusted apposition rate (r= . , p< . ), while inversely correlated with osteoid maturation time (omt) (r=- . , p< . ) and mineralization lag time (r=- . , p< . ). rankl/opg ratio was negatively correlated with mineral apposition rate (r=- . , p< . ) and positively with omt (r= . , p< . ). pth was correlated with bfr (r= . , p< . ) and resorption area (r= , , p< . ), but not with any mineralization markers. there were no correlations between pth and opg or rankl. conclusion: opg, in contrast to rankl, exerts a dual effect on the skeleton by promoting mineralization and increasing bfr. these osteogenic markers might be of benefit in characterizing the turnover, mineralization and volume of the skeletal lesions of secondary hpt as recently recommended by kdigo. "sevcan bakkaloglu was supported by tÜbitak (scientific and technological research council of turkey). this study was supported by usphs grants dk- , dk- and mo -rr . " pth values are widely used to guide therapy for renal osteodystrophy in patients treated with maintenance dialysis yet target values are based on cross-sectional studies and discrepancies between bone formation rates (bfr) and pth have been described during intermittent calcitriol rx. thus, we evaluated the relationship between serum biochemical parameters and bone turnover during treatment with intermittent vitamin d sterols. patients aged ± yrs with biochemical and bone biopsy (bbx) proven nd hpt received months of vitamin d ( , d or d ) given in twice weekly oral dosing and phosphate binders. dose of vitamin d was titrated upwards monthly to maintain st pth-ima(nichols r ) levels between - pg/ml. bbx was then repeated. s-ca, p, alk p-tase and pth by st and nd pth-imas were obtained monthly throughout therapy. baseline values were: p: . ± . mg/dl, ca: . ± . mg/dl, alk p-tase: ± iu/l, st pth-ima ± pg/ml, nd pth-ima: ± pg/ml. final values were: p: . ± . mg/dl, ca: . ± . mg/dl, alk p-tase: ± iu/l, st pth-ima: ± pg/ml, and nd pth-ima: ± . bone formation rate (bfr/bs) decreased from ± to ± um /mm /d (nl: - . ); % achieved normal bone turnover. nd pth-ima values were - % lower than st pth-ima levels; there was no difference in predictive capability of the two assays. patients achieving normal bfr/bs had st pth-ima values of ± pg/ml. the sensitivity, specificity and ppv of a st pth-ima range of - pg/ml for normal bfr/bs were % ( % ci: - %), % ( - %), and % ( - %) respectively. during therapy with intermittent vitamin d sterols, maintaining pth levels higher than currently recommended results in normal bfr/bs and prevents adynamic bone. maternal diabetes will induce abroad array of congenital malformation. consistently with these hypotheses, we observed the defects of renal development of diabetic pregnancy from late phase of embryogenesis to postnatal period in animal model (c bl/ j mice). histological analysis of phenotypes revealed decreased glomerular numbers, glomerular hypertrophy and hypercellularity, as well as renal tubular detachment in sequential late phase of kidney development in the offspring of diabetic female mice. tunel assay showed signficinatly increased cell apoptosis in fetal kidneys of hyperglycemic group. rt-pcr and fish study of kidneys of fetal and newborn mice revealed that gdnf and early growth response alpha (egr-α) are two of crucial genes inhibited in hyperglycemic ambience. in human, we presumed that children of gestational hyperglycemic mothers have the same defects of renal development as our animal model similarly, thus we measured and compared echogram of kidney/liver echoenic ratio in children born to gestational hyperglycemic mothers and health children. interestingly, our human ultrasonic study indicated that after age of months, the diabetic children had increased echogenic ratio of kidney/liver than the healthy age matched children (p< . ). we also found that . % of diabetic children had nonobstructive hydronephrosis. this simple sonographic procedure may provide a permissive was for clinicians to obtain the basis of long-lasting follow-up of these high-risk children as early as possible. keywords: diabetic embryopathy, renal development, glial cell line-derived neurotrophic factor, early growth response alpha, renal sonogram. genetic inactivation of spry in mice results in increased number of ub branches and expanded gdnf, c-ret and wnt- expression domains (basson et al., dev. cell, ) , indicating that spry is a negative regulator of the gdnf-ret-wnt pathway. ang ii induced ub branching morphogenesis, partly via stimulation of egfr tyrosine kinase activity (yosypiv et al. jasn, ) . we tested the hypothesis that ang ii stimulates the gdnf-ret pathway via repression of spry . cd mice metanephroi were dissected on embryonic (e) day e . , grown on filters in the presence or absence of ang ii ( - m, n= /group) for hours and subjected to whole-mount ish with digoexigenin-labelled spry , c-ret, wnt- and gdnf crna probes. spry mrna was expressed in ub branches and in condensing mesenchyme. c-ret and wnt- were expressed in ub tips, and gdnf-in the metanephron mesenchyme. ang ii downregulated spry expression in the ub. in contrast, c-ret and wnt- were induced by ang ii in the ub tip cells. gdnf expression in the mesenchyme was also upregulated by ang ii. in addition, ang ii stimulated ub tip cell proliferation, as determined by in vivo brdu in corporation ( . ± . vs. . ± . ; p< . ) compared to control. these findings suggest a model in which ang ii-mediated inhibition of spry gene expression releases. ret tyrosine kinase activity leading to upregulation of c-ret and its downstream target gene, wnt- . enhanced wnt- expression, in turn, induces gdnf in the adjacent mesenchyme. this causes focal bursts of ub tip cell proliferation and branching. these results support the hypothesis that abnormal collecting system development in angiotensinogen, renin, ace or at -deficient mice is at least partly due to aberrant regulation of the ub branching morphogenesis program. objectives of study: nephrogenesis requires a fine balance of many factors that can be disturbed by intrauterine growth restriction (iugr), leading to a low nephron endowment. our previous studies have shown that offspring born to mothers supplied low protein diets during pregnancy have fewer glomeruli than normal at birth in sd rats. the aim of this study was to identify the possible pathogenesis of abnormal nephrogenesis and decreased glomerular number in iugr by comparative proteomic approach. methods: iugr was induced in sd rats by isocaloric protein restriction in pregnant dams. kidney proteins were obtained from neonatal normal rats (control group) and iugr rats (iugr group) respectively. a series methods including -de, silver staining, mass spectrometry and database searching were used. the -de test was repeated three times in each group. results: after silver staining, the -de image analysis detected average ± spots in iugr group and ± spots in control group. the average matched rate was % and % respectively. the differential proteomic expression analysis found eleven protein spots were expressed only in iugr group and one in control group. seven protein spots were up-regulated more than folds and two down-regulated more than folds in iugr group compared with those in control group. these protein spots were preliminarily identified, which were structural constituents of cytoskeleton including vimentin, cytokeratin , perlecan and b-actin, transcriptional factors including splicing factor, rho gdp dissociation inhibitor alpha and cell division proteinkinase , enzymes including retinal dehydrogenase , transketolase and so on. conclusions: data from this study may provide, at least partly, valuable experimental evidence of proteins involved in the pathogenesis of abnormal nephrogenesis and decreased glomerular number in iugr. the aim of the study is to describe the natural history of tcf /hepatocyte nuclear factor- beta linked disease in children. prenatal and postnatal renal evolution and extrarenal manifestations of patients were reported. thirty one had prenatal diagnosis of developmental nephropathy: bilateral foetal hyperechogenic kidneys or a hyperechogenic kidney with a controlateral multicystic dysplastic kidney. % had cysts. the mean prenatal renal length was normal ( , sd) . intrauterine growth was normal with median birth weight of . kg (range . - . ) and % were small for gestational age. after a mean follow-up of months, the renal growth was impaired with a mean renal size of - . sd. patients with a solitary functioning kidney showed no compensatory hypertrophy. thirty one patients developed bilateral nephropathy and isolated unilateral multicystic kidney. twenty eight patients had cysts, mainly cortical bilateral microcysts. the mean gfr was . ± . ml/min/sc. sixteen patients had stage chronic kidney disease (ckd), four were classified as stage , eleven as stage or ckd and two were diagnosed with end stage renal failure. annual decline of the glomerular filtration rate was . ml/min. extrarenal manifestations included patients with diabetes, one with exocrine pancreatic insufficiency, one with pancreatic hypoplasia without clinical symptoms and with cholestasis. we found a complete heterozygous deletion of the tcf gene in patients and nine different point mutations. three patients had the g c mutation, with unilateral mcdk and with bilateral severe hypoplasia leading to early renal dysfunction. tcf gene anomalies are associated with low renal function decline but in some patients end stage renal failure appeared early in life. long term follow-up is needed to determine the incidence of extrarenal symptoms, particularly diabetes. objectives: although it has been observed more than one hundred years ago that the urinary tract is very resistant to infection, its antimicrobial mechanisms have not yet been systematically characterized. we sought to elucidate the expression and relevance of the antimicrobial peptide cathelicidin in this area. methods: in order to investigate the expression of cathelicidin in health, urine samples from healthy children, pieces of healthy renal tissue, and cell cultures were analyzed. to evaluate the expression of cathelicidin during infection, urine samples from children with urinary tract infection, a mouse model of ascendant pyelonephritis and cell culture experiments were employed. the relevance of cathelicidin production was tested by bacterial challenge of cathelicidin-deficient and neutropenic mice. in addition, we studied the in vitro effects of cathelicidin on the growth and multicellular behavior of bacteria as well as we tested sensitivity of clinical e. coli strains to the peptide. results: cathelicidin is expressed by epithelial cells of healthy urinary tract and excreted into urine in low concentrations. during urinary tract infection, the secretion of cathelicidin by epithelial cells significantly increases within minutes. invading neutrophils are the source of the second wave of cathelicidin. epithelial cathelicidin protects the urinary tract against bacterial infection while neutrophil-derived cathelicidin influences the severity of infection. cathelicidin displays multiple effects on bacteria. low concentrations of cathelicidin inhibit multicellular behavior, e. g. biofilm formation of e. coli, and high peptide concentrations kill bacteria. bacteria resistant to cathelicidin have an increased ability to invade the urinary tract. conclusion: the antimicrobial peptide cathelicidin is a key factor of the mucosal immunity of the urinary tract. the predictive value of procalcitonine (pct) plasma level for renal scarring after an acute pyelonephritis (apn) is still debated. during apn, the bacterial lipopolysaccharide of the membranes induce the release of tnf, il and il . these cytokines lead to inflammation syndrome and fibrosis sequellae resulting from cell apoptosis induced by nitric oxide (no) release that is catalysed by no-synthase. the aim of this work was to clarify the physiological role of pct in renal parenchyma apoptosis and fibrosis caused by apn. we conducted a prospective study in children with a first apn episode (fever> . c°, crp> mg/l, monomicrobial urine positive culture> . fcu/ml). we excluded patients with any concomitant infection, renal dysplasia or obstructive uropathy or grade - vur children were enrolled (age . m, median m). on admission, pct, crp and phospholipase a (pla ) were quantified in serum. scintigraphy with m tc-dmsa was performed on day and months later in case of initial abnormalities. fisher's test was performed and statistical significance was defined as p< . . results: on day , ( %) presented renal parenchyma alterations, at m underwent control scan and ( %) had renal scars. pla and pct levels were correlated with early dmsa lesion but not with renal scars at m. paradoxically, initial pct level was significantly lower in the presence of renal scars ( . vs . ng/ml, p< . ). significant pct increase was observed in favourable progress (recovery . vs aggravation . ng/ml, p< . ) and no difference between recovery and improvement evolution. these results suggest the protective effect of pct against apoptosis resulting from down-regulation of nitric oxide release; so high pct values could be interpreted with caution in apn. acute pyelonephritis (apn) may lead to renal scarring with later risk of hypertension and renal insufficiency. the aims of this study were to analyse prospectively renal scars progression with time and their impact on renal growth. methods: patients (pts), aged from to years who presented scars on dmsa at months after apn were included. in these children a second dmsa was done after years. evolution of scars was analyzed following pre-established criteria independently by observers. scar progression was classified as follows: =no change, =partial improvement, =total resolution. in addition a renal ultrasound was repeated to assess kidney growth using z-score. results: renal units ( pts: f, m) were studied. the incidence of vesicoureteral reflux (vur) was . % ( / ). per renal units, vur were observed in / ( %); ( % vur grade (g) i, ii and % g iii, iv). there were scars observed month after apn which evolution over years was as follow: = % ( / ), = % ( / ) and = % ( / ). incidence of vur was higher in children presenting scars; / ( %) against / ( %) in those with or scars. to identify factors interfering with renal growth, we analyzed potential confounding variables using robust linear regression. z-score was worsened with increased number of scars observed at month after apn p< . ) and improved with disappearance of vur ( . ci . - . ; p< . ). conclusion: between month and three years after apn, % of scars improved. in our population, the number of scars secondary to pna was the most important factor affecting renal growth. the second prognosis criterion was the correction of vur. prevention of pna and rapid treatment to avoid kidney scars seems to be the essential aim to preserve optimal kidney growth. v. smolkin , , r. halevy , , w. sakran , , y. kennes , a. koren , ha'emek medical center, pediatric b, afula, israel ha'emek medical center, pediatric nephrology unit, afula, israel ha'emek medical center, bacteriology and microbiology laboratory, afula, israel the ruth and baruch rappaport school of medicine, haifa, israel febrile urinary tract infection (uti) is a relatively common infection disease in childhood. children consider at risk for uti commonly receive prophylactic antibiotics to prevent recurrence of this urinary tract disease because of the risk of kidney scarring, which may lead to complications such as hypertension or end-stage renal disease. compliance with antibiotic prophylaxis after uti was assessed in children, using a parent questionnaire and a urine test for antibacterial substances. thirty six children ( st group) received prophylactic treatment during the period of months (range - months) and the other patients ( nd group) received antibiotic prophylaxis for a longer duration ( months, range - months). in the first group of patients, ( %) of parents reported giving the antibiotics every day in comparison with ( %) in the nd group. twenty nine ( %) of urine tests were positive for antibacterial substances in the st group but only ( %) in the second group. in the st group of patients the difference in recurrent infection between regular takers and non-takers was statistically highly significant. no significant difference was found in recurrent uti rate in takers and non-takers in the nd group. failure to understand the reason for prophylaxis and forgetfulness was found to be a main reason for non-compliance. imaging studies evaluating the kidneys and urinary tract are performed routinely after a febrile uti. evidence of their value in changing management or affecting long term outcome is limited. as part of a multicentre, rct (iris ) evaluating different antibiotic regimes in the treatment of first febrile urinary tract infections, we undertook as a secondary objective, an evaluation of the diagnostic protocol. the imaging modalities (ultrasound, dmsa scintigraphy within days and voiding cystogram within - months) were assessed for their ability to predict long term parenchymal damage. children of years of age or less at the time of investigation and who had normal renal function and antenatal ultrasound, were considered suitable for analysis of the diagnostic course. us was performed in children with ( %) normal, minor changes were noted in the remainder, apart from case requiring a change in management in the form of a pyeloplasty for pelvi-ureteric obstruction. the cystourethrogram was performed in of the children with ( %) demonstrating vur. the cystogram was a poor predictor of long term damage, being positive for reflux in only of the children who subsequently developed scarring. an acute dmsa scan performed in all children, exhibited findings consistent with acute pyelonephritis in ( %). a repeat dmsa scan at months in those with evidence of acute pyelonephritis demonstrated a scarring rate of %. the data did not demonstrate the clinical efficacy of routinely performing scintigraphy in the acute phase or a cystourethrogram. our recommendations for a reasonable diagnostic work up in small children with their first episode of uti are ) performance of a scintigram months following the acute infective episode, and ) close surveillance to identify eventual recidivists. introduction: focal segmental glomerulosclerosis (fsgs) has a high recurrence rate after renal transplantation (rtx). recurrence can lead to tx loss. disease recurrence (dr) seems to be influenced by genetic background. methods: patients with childhood onset of biopsy proven fsgs who were transplanted were evaluated. genetic investigations of the nphs gene were done in patients ( . %). results: mean age at diagnosis was . years. first renal transplantation was performed at age of . years. patients received a living related (lrd), a deceased donor (dd) graft. patients data under investigation. p ( . %) recurred after a mean time of , years, p with lrd ( . %) , p with a dd ( . %). patients ( . %) lost their graft after , years, patients due to recurrence. a second rtx was performed in patients, with dd, with lrd, patients data under investigation, with % dr. a third transplantation was performed in patients and a fourth in one patient. screening for nphs mutations revealed patients with mutation in the nphs gene, homozygot, heterozygot. all patients with a homozygote nphs mutation did not recur and only the one patient with a heterozygous mutation ( / ) recurred compared to / without a mutation (p< . ). conclusion: living related transplantation was advantageous to decreased donor transplantation. patients with nphs mutations had a lower risk of recurrence after transplantation compared to patients without mutations. patients with fsgs should be screened for nphs mutations. objective: prospective ebv surveillance post tansplantation reduces incidence of acute rejection and risks of post transplant lymphoproliferative disorders (ptld). methods: prospective screening of ebv by polymerase chain reaction (pcr) and serology in all patients transplanted between - . results: patients transplanted between may and september . were cadaveric and live-related transplants. recepient ebv serology status was known but not on donors. basiliximab was used for induction and maintenance comprised of tacrolimus/azathioprine (aza) until and mycophenolate (mmf)/tacrolimus from . all received corticosteroids. had mmf/tacrolimus, aza/tacrolimus. ebv screened within first week post transplant, weekly for a month, monthly for months. when ebv pcr lv > . , mmf/aza was withdrawn, tacrolimus levels kept between - ng/ml. pcr/ serology is checked weekly for months, monthly for , until lv falls < . and vca igg becomes positive. the mmf/aza is reintroduced. patients with ebv pcr lv < . are kept on full immunosuppression while viral load and vca igg monitored. ebv viraemia detected following prospective screening. was re-activation. were symptomatic. onset varied to . months post transplant (mean . months). were on mmf/tacrolimus received aza/tacrolimus. had pcr lv> . consequently maintained on tacrolimus an alternate day steroids for period of time. cmv patient and donor status was known and antiviral prophylaxis given to nonimmune. the use of antivirals made no impact on viral load. conclusion: no patient experienced acute rejection or ptld despite modification of therapy with our prospective screening programme. antivirals have no role in protecting or reducing viral load in already infected patients. graft attrition rate is highest in the first three months after renal transplantation. we analysed data in a recent cohort from all dutch centres for pediatric renal transplantation to determine incidence and causes of such early graft failure. methods: data from all pediatric renal transplants performed between - - and - - were analysed retrospectively. a common immunosuppressive protocol was used in all centres. thrombosis prophylaxis was given according to centre policy. early failure was determined as graft failure within months after transplantation. prevalence of possible risk factors of graft failure identified by literature search were extracted from patient charts. data were analysed with univariate and multivariate logistic regression. results: the cohort consisted of transplants. age of the recipients was - yrs (mean . ). there were early graft failures ( . %). major causes of graft failure were thrombosis ( . %) and are( . %). univariate analysis identified an association of early failure with complications during surgery (or . , p= . ), cold ischemia time (or . , p= . ), side of graft donation (or . , p= . ) and diuresis in the first hour after transplantation (or . , p= . ). multivariate regression analysis showed that complications during surgery were associated with the risk of early failure (or . , p= . ), as were side of graft donation (or . , p= . ) and diuresis in the first hour after transplantation (or . , p= . ) . only the occurrence of complications during surgery was significantly associated with early graft failure due to thrombosis (or . , p= . ). conclusion: thrombosis is the major cause of early graft failure after renal transplantation in dutch children, especially after surgical complications. prospective studies are needed to determine whether early failure can be decreased by more rigorous prophylaxis. background: interleukin (il)- is a major contributor to inflammation and cell death during ischemia-reperfusion (ir) injury and its deleterious effects are mediated mainly by nuclear factor-κb (nf-κb) activation. receptor binding and signalling of il- can be blocked by the il- receptor antagonist (il- ra). the aim of our study was to characterize the effects of il- ra administration on inflammation, apoptosis and infiltration in renal ir injury. methods: renal ischemia was induced in lewis rats (n= /group) by clamping of the left renal artery for min followed by reperfusion of h or five days respectively, when kidney were removed for histological and molecular analysis. results: treatment with il- ra ameliorated ischemic renal tissue injury and inflammatory infiltration. futhermore, the number of apoptotic tubular cells was lower in il- ra treated animals h after ischemia, which was paralleled by a bax/bcl- mrna ratio towards anti-apoptotic effect. il- ra reduced the expression of monocyte chemoattractant protein- (mcp- ) mrna h and days and that of intracellular adhesion molecule- (icam- ) expression h after reperfusion in the kidney. conclusions: our results indicate that il- ra treatment ameliorates renal ir injury and this protective effect might be mediated by reduced induction of nf-κb mediated mcp- , icam- and the decreased ratio between bax and bcl- mrna expression. k. satomura, y. santo osaka medical center for maternal and child health, pediatric nephrology and metabolism, izumi, japan many studies have reported that angiotensin-converting enzyme inhibitor (acei) and angiotensin receptor blocker (arb) show renoprotective effects in adult patients with acquired renal diseases. however, these effects have not been studied in children with renal hypoplasia or dysplasia (rhd). in this study, we explored the renoprotective effects of these drugs in children with rhd. patients and methods: participants of the study were patients with rhd aged less than years. a follow-up for more than one year was conducted in our outpatient clinic. the patients had chronic renal failure, and had not received acei or arb in the past. the change of glomerular filtration rate (gfr) per year, urinary protein/creatinine (up/cr) ratio, serum potassium levels, and blood pressure before the treatment with trandolapril or candesartan were compared with those of one year after the treatment. the estimated gfr was calculated by the schwartz formula. wilcoxon rank sum test was applied to evaluate the statistical significance. results: eleven patients were eligible for this study. the mean age of the patients was . ± . years and the estimated gfr was . ± . ml/min/ . m when trandolapril or candesartan was administered. the change in the estimated gfr for a year significantly improved after the treatment with trandolapril or candesartan compared with the pre-treatment period (- . ± . vs. . ± . ml/min/ . m /year, p= . ). the up/cr ratio significantly decreased at one year after the treatment compared with that before the treatment ( . ± . vs. . ± . , p= . ). the blood pressure and serum potassium level showed no significant changes. conclusion: these data suggest that treatment with acel or arb has beneficial effects on the renal function in children with mild to moderate renal failure due to rhd. objective of the study: postischaemic arf is influenced by sex hormones. dehydroepiandrosterone (dhea) pretreatment diminishes postischemic injury. previously we demonstrated that after renal ischaemia-reperfusion (i-r) injury the expression and activity of na, k-atpase (nka) is impaired in male rats. here we tested the impact of dhea on postischaemic survival, renal damage, mrna and protein expression of nka. methods: left renal pedicles of dhea ( . mg/kg/day) and propylene glycol, as vehicle (pg) treated male rats (g dhea and g pg , respectively) were clamped for min followed by (t ) and (t ) hours of reperfusion. survival rate, histological damage, serum creatinine (cn) and urea nitrogen (bun) were investigated. the mrna expression and protein level of nka α and β subunit were also determined. sham operated animals served as control. results: dhea treatment was associated with better postischemic survival (p< . g dhea vs. g pg ). postischaemic cn and bun were higher and renal histology showed more rapid progression vs. controls, however there was no difference between g dhea and g pg groups. mrna expression of nka α subunit was higher in g dhea vs. g pg at every time points, however it was decreased in i-r groups vs. controls (p< . ). similar changes were observed in nka α protein level (p< . , g dhea vs. g pg in controls, t , t ). mrna and protein expression of α subunit were different only at t (p< . , g dhea vs. g pg ). conclusions: our study indicates that nka is more protected from the detrimental effects of i-r injury in dhea treated animals, which might be a contributing factor of improved postischaemic renal function and could help to preserve cell and organ homeostasis even in male animals. the work was supported by otka f -t , bolyai and semmelweis grants. objective of study: recently bnp has been identified as a useful cardiac marker for risk stratification in adults. whether bnp has a similar diagnostic potential in pediatric population with ckd has to be established. the aim of the study was to assess the value of bnp to predict the cardiac dysfunction in children with ckd. methods: to test this suggestion, the relationship between plasma concentrations of bnp, echocardiographic parameters and cardiovascular risk factors (lipid profile, hypertension, secondary hyperparathyreoidism) has been evaluated. a cohort group consisted of children and young adults ( pts mean age x= . ± . years; controls mean age x= . ± . years). out of studied pts children were with ckd stage and k/doqi ( pts ckd stage ; dialyzed pts) and transplanted subjects with stable graft function (gfr= . ± . ml/s/ . m ). results: no association was found between bnp and gfr and/or s-creat (p= . ; p= . ; p= . ). the highest bnp plasma levels have been found in dialyzed children ( . pg/ml; resp. . pg/ml in tx; resp. , pg/ml in ckd stage group) as compared to controls ( , pg/ml p< , ). bnp was independently related to left ventricular mass (r= . ; p< . ) as well as to ejection fraction (r=- . ; p< . ) and preload (r= . ; p< . ). significant correlation between bnp and hypertension (r= . ; p< . ) has been observed. more over, bnp correlated with ipth (r= . ; p< , ) and diastolic dysfunction (r= . ; p< , ). plasma bnp concentrations did not significantly differ before/after dialysis procedure (p= . ). conclusions: bnp is a sensitive marker for cardiac dysfunction in ckd children. however, prospective studies in larger group of pts are needed to confirm our preliminary data. we have reviewed the data of patients with nephropathic cystinosis (nc) followed in our department since . overall, patients have died during the follow-up period. the mean follow-up was , ± , yrs (range , ) . / patients have initiated dialysis and / received a cadaveric renal transplant. univariate analysis showed that the time to reach a serum creatinine value of mg/dl was significantly associated with the patient's age at the last follow-up (o. r. , /yr; p< . ), the age at the beginning of cysteamine (mea) treatment (o. r. , /yr; p= . ), the dose of mea (o. r. , /g, p= . ) and the use of ace-inhibitors (o. r. , ; p= . ). by multivariate analysis, only the period of treatment (or , , p= . ) and therapy with ace-inhibitors (or , , p= . ) were significantly associated with better outcome. similar results were obtained when assessing the time to dialysis. there was a significant correlation between the dose of mea with intra-leucocytic cystine levels (ilc). by univariate analysis, the dose of mea expressed in mg/m correlated more with the outcome then the dose expressed in mg/kg. statural growth was significantly associated by multiple correlation analysis only with growth hormone (gh) treatment (p< . ). altogether, these results indicate that the renal prognosis of nc has been improving over the past two decades. this improvement may not be solely attributable to the introduction of mea for the treatment of nc. our data suggest that the overall management of these patients has improved, including more efficient symptomatic treatment of the fanconi syndrome and the use of medications such as ace inhibitors and gh. background: the chronic kidney disease in children (ckid) cohort study, targeted to enroll children aged - yrs with chronic kidney disease (ckd) by estimated gfr (egfr schwartz) of - ml/min/ . m aims to assess risk factors for kidney disease progression in children. objective: to describe the characteristics of the ckid cohort at study entry. design/methods: at the ckid baseline visit, gfr is measured by plasma disappearance of iohexol. children undergo physical exam, standardized bp measurements, blood and urine testing and parent and child interview. results: as of / / , children had completed the baseline visit, median age . yrs, % caucasian, % african american, % male and % hispanic ethnicity. median age-adjusted height and weight percentiles were % and %, respectively. underlying cause of ckd was urologic, cystic or hereditary in %, % had acquired glomerular disease. median egfr at study entry was . ml/min/ . m , % higher than the median iohexol-based gfr . ml/min/ . m . % of participants reported a history of hypertension, % anemia, % seizures, and % depression. symptoms of headache, nausea, loss of appetite and weakness steadily increased in prevalence with lower gfr. assessment of family history in parents and grandparents revealed: high blood pressure %, high cholesterol %, kidney disease %, dialysis %, and kidney transplant %. conclusions: children with stage iii ckd have significant height deficits, hypertension, anemia, and seizure disorders. cross-sectionally, increasing non-specific symptoms are associated with lower gfr. collection of plasma, serum and genetic material will facilitate understanding of novel risk factors and biologic mechanisms underlying kidney disease progression and associated morbidities. aim: increased glomerular filtration rate (gfr) has been implicated in the development of diabetic nephropathy. large normal interindividual variations of gfr hamper the diagnosis of renal hemodynamic alterations. we examined renal functional reserve (rfr) in children with insulindependent diabetes mellitus (iddm) to assess if hyperfiltration occurs. methods: the renal hemodynamic response following dopamine infusion was examined in iddm children ( . ± . y) with a mean duration of diabetes of . years and compared to controls. results: mean baseline gfr in diabetic children did not differ from control population ( . ± . vs. . ± ml/min/ . m ), whereas renal plasma flow was significantly lower ( . ± . vs. . ± ml/min/ . m , p< . ) and filtration fraction was increased ( ± vs. ± %, p< . ), compared to controls. the mean rfr was lower (p< . ) than in control subjects (- , ± vs. ± ml/min/ . m ). conclusion: the observation that rfr is reduced or absent suggests that all children are in a state of glomerular hyperfiltration with increased intraglomerular pressure regardless of the baseline normal values of gfr. while measurements of rfr may be helpful in diagnosing the presence of hemodynamic changes, the relevance to development of diabetic nephropathy remains unknown. only - % develops diabetic nephropathy, suggesting that glomerular hyperfiltration is only a concomitant risk factor. lp diet induces ischemic renal injury involving epithelial cells from osom. here, we tested whether hsp would stabilize renal na+k+atpase attachment to the cytoeskeleton during recovery from lp. after weaning, rats (n= ), were fed for days with a lp diet ( %), then were recovered by means of a normal protein diet ( %rp) each group had an age-matched control group ( %, np). tissues from cortex and osom were homogeneized in buffer plus . % triton x- . protein levels were measured by western blot. in vitro coincubation of solublen on cytoeskeletal and insoluble cytoskeletal-associated fractions in the presence or absence of anti-hsp antibody was performed. interaction between proteins was determined by coimmunoprecipitation. increased na+k+atpase dissociation was shown in soluble fraction from osom as a result of lp diet vs. np ( . ± . vs. ± . , p< . ). meanwhile, decreased hsp levels in the same fraction was shown (lp: . ± . vs. np . ± . , p< . ). translocation of hsp to the cytoeskeletal injured fraction associated with stabilization of na+k+atpase was shown in osom from lp, after in vitro coincubation of the cytoskeletal fraction of lp and non cytoskeletal fraction of rp. these effects were abolished by the addition of anti-hsp antibody. coimmunoprecipitation showed that the amount of hsp coprecipitating with na+k+atpase increased in lp osom, in rp results were similar to control. in cortex, absence of significant differences was shown in the na+k+atpase and hsp expression at in vivo and in vitro experiments among groups. in lp and rp cortex tissues, interaction of both proteins was similar to control. our results allow us to suggest that hsp has a critical protective role in the integrity of the cytoskeletal anchorage of na+k+atpase during recovery from ischemic lp injury in osom. tubular reabsorption of mg + occurs predominantly by paracellular flux in the thick ascending limb of the loop of henle. it is mediated by the, tight junction, mg + channel protein, paracellin- , which is encoded by the gene pcln- . cyclosporin a (csa), a widely used immunomodulatory drug, decreases tubular mg + reabsorption leading to urinary mg + wasting and hypomagnesemia. the exact molecular mechanisms of this modulation are unknown. in this study we examined the effect of csa on the paracellin- gene in renal cell lines and mouse kidney. the effect of csa on the pcln- gene promoter was examined. a plasmid, containing the human pcln- (hpcln- ) promoter ( . kb) upstream to a luciferase reporter gene, was transfected into opossum kidney (ok) and human embryonic kidney (hek ) cells prior to exposure to micrograms/ml csa for hours. mice received csa ( mg/kg/day) for up to days. at h intervals blood/urine mg + and ca + levels were determined and kidneys harvested for paracellin- mrna quantitation (real-timepcr) as well as protein quantification (western blot) and visualization (immunofluorescence). csa decreased hpcln- promoter activity by %- % in transfected ok and hek cells, compared to control cells. csa-treated animals displayed hypomagnesemia with increasing urine mg + and ca + levels paralleled by a - % decrease in pcln- mrna after and days of csa exposure. a similar effect on paracellin- protein expression inthe renal tubule was evident in response to csa treatment. csa may influence paracellin- -mediated mg + transport at the transcriptional level. involvement of the calcineurin-dependent tonebp pathway or the calcineurin-independent map kinase pathway in this response is subject to future research. this effect of csa on the paracellin- gene may play a role in the renal magnesium wasting and hypomagnesemia induced by csa. it is well established that proteinuria induces tubular injury, which is closely associated with progressive decline of renal function. megalin has an important physiological role in the reabsorption of a variety of low molecular weight proteins along the proximal tubule. in this study, we examined whether megalin mediates tubular injury secondary to glomerular diseases. we utilized megalin knockout (ko) mice, in which % of proximal tubular cells have mosaic nullmutation in the megalin gene. to induce glomerular injury, these were mated with a transgenic line, nep , in which selective podocyte injury can be induced by injection of immunotoxin, lmb . megalin ko/nep mice were injected with lmb ( . ng/g bw) and analyzed weeks later. they showed moderate proteinuria (upro/cr= , vs . before lmb ) and mild tubular injury, which were comparable to those observed in nep mice with intact megalin gene injected with the same dose of lmb . in the latter, megalin was still detectable in injured tubules. within each megalin ko/nep mouse, we compared megalin-intact (+) vs deficient (-) proximal tubular cells by immunostaining. the majority of megalin+ cells showed enhanced staining for albumin. in contrast, most megalin-cells were not stained for albumin. aquaporin- , which is highly expressed in normal proximal tubules, was diminished in . % of megalin+ cells, whereas it was diminished in only . % of megalin-cells. some proximal tubular cells expressed mcp- . in that, % of mcp- expressing cells were megalin+. the results suggested that megalin plays an important role in the reabsorption of massively filtered proteins in glomerular diseases, thereby contributing to proximal tubular cell injury. objectives of study: the hallmark of nephropathic cystinosis is lysosomal cystine accumulation, primarily leading to fanconi syndrome. although all tissues haveelevated cystine levels, it is not known why the kidney is first affected. it is postulated that decreased atp production in cystinosis results in defective proximal tubular reabsorption, a process driven by na, k-atpase. to study this hypothesis, we have monitored atp levels and viability in conditionally immortalized proximal tubular cells (ptc) of cystinosis and healthy controls. methods: urinary sediment of cystinotic patients and healthy controls was suspended ins supplemented culture medium. primary cultures were transfected with sv ts a t antigen allowing proliferation at °c and maturation at °c. to confirm the proximal origin of the cells ) expression of aquaporin- (aqp ) and dipeptidyl-peptidase iv (dpp-iv) was demonstrated using immunoblot technique and ) morphology was determined using em. ptc were matured at °c for - days, followed by cystine measurement using hplc and atp determination using luciferase assay. results are expressed as nmol/mg protein. results: colonies of cystinotic and control cell lines (n= ) with cobblestone morphology developed after weeks and expressed aqp and dpp-iv, confirming their proximal origin. in cystinotic ptc, cystine levels increased from . at °c to . after days at °c compared to . in controls. intracellular atp decreased in cystinotic ptc during days from . to . , while atp levels in controls remained stable (range . - . ). atp levels inversely correlated with cystine accumulation in cystinotic ptc (r=- . , p= . ). conclusion: decreased atp levels in conditionally immortalized ptc during days maturation suggest that alterations in atp levels are involved in tubular dysfunction in cystinotic patients. aquaporin ( aqps have been identified to date. aqp conveys % of the peritoneal water transport in pd. cell migration and angiogenesis are altered in aqp ko mice; erythrocyte pco depends on aqp . human peritoneal mesothelial cells (hpmc) from non-uremic patients and a human mesothelial cell line (met- a) were incubated with conventional (c-pdf), icodextrin (ico), bicarbonate (b-pdf) and lactate based double chamber pd solution (l-pdf). mrna was measured by real time rtpcr, and protein by western blot and immunocytochemistry. hpmc and met- a express aqp , , and . incubation of met- a and hpmc with c-pdf, ico and l-pdf did not change aqp and expression compared to medium. in contrast, incubation with b-pdf increased aqp and mrna and protein in both hpmc ( h aqp mrna: ± , aqp : ± %) and met- a (aqp : ± , aqp : ± %). the effect on aqp was in part explained by differences in ph, the effect on aqp was largely independent of ph. addition of mmol/l of bicarbonate to l-pdf increased aqp and mrna (l-pdf+bic: aqp : ± , aqp : ± %). aqp expression was suppressed by all three pd fluids (b-pdf: ± . , l-pdf: ± . , c-pdf %: ± %), aqp was up regulated by b-pdf ( ± %). b-pdf improved hpmc migration. we for the first time demonstrate the expression of four different aqps in peritoneal mesothelial cells. they are markedly regulated by pd-solutions. the upregulation of aqp , , and by bicarbonate based pdf may have important implications on long term peritoneal membrane function, wound healing and neoangiogenesis. the regulation of cx cl (fractalkine) by thromboxane a in inflammation there is marked leukocyte infiltration into the damaged tissue. chemokines recruit and direct leukocytes to the injured site. the chemokine cx cl is up-regulated in renal inflammation such as glomerulonephritis and allograft rejection. thromboxane a (txa ), a potent vasoconstrictor in the kidney, is also pro-fibrotic. txa is up-regulated early in inflammation and its effects are mediated by binding to the tp receptor. the aim of this study was to examine the effect of txa on cx cl expression. we previously showed that cx cl recycles between the cell surface and an internal compartment. cell surface cx cl is cleaved by the enzyme, tace, to yield the soluble species of the chemokine. we generated human ecv- cells stably expressing cx cl and treated cells with a tp agonist. levels of cx cl were quantitated by western blotting. cx cl decreased by - min after tp stimulation, but recovered by h. using flow cytometry, we found that cell surface levels of cx cl decreased by min, but began to recover before levels of total cx cl were replenished. to verify if early recovery of cx cl was due to redistribution from the internal to the plasma membrane compartment, we used fluorescence recovery after photobleaching (frap). after min tp stimulation decreased endocytosis of cx cl was seen. we postulated that loss of cell surface cx cl is due to cleavage by tace. accordingly, a tace inhibitor prevented early loss of cx cl after tp stimulation. in summary, txa induces rapid proteolytic shedding of cell surface cx cl by tace, but later increases expression of cx cl at the cell surface by inhibiting internalization of the chemokine. this could release the soluble chemotactic protein from the cell adhesive transmembrane protein, promoting leukocyte recruitment initially, whilst promoting leukocyte adhesion later in the time course. the response to steroid therapy is used to characterize idiopathic nephritic syndrome (ins) as steroid sensitive (ssns) or steroid resistant (srns). ssns pathogenesis has been associated with activation of t-cells and srns has been associated with activation of tgfb and progression to chronic kidney disease. our objective was to determine differences in the urinary excretion of inflammatory cytokines; opn, icam and tgfb , between ssns (n= ), srns (n= ), and controls (ctr, n= ) in an attempt to identify specific biomarkers of steroid sensitivity or lack thereof. for this purpose, we used a protein array high-throughput technique and confirmed the findings by elisa. in addition, we performed immunohistochemistry (ihc) for the above cytokines on renal biopsy samples. mean age, gender, race, body mass index, and estimated glomerular filtration rate were not statistically different among three groups. there were no statistically significant differences between ssns and srns in regard to the presence of hypertension, ace treatment, and renal histology (p= . , . , and . , respectively) . urinary excretion of icam , opn, and tgfb were statistically significantly higher in ins subjects vs. ctr. urinary icam and opn were higher in ssns than in srns (p= . and p= . , respectively). however, the urinary excretion for tgfb was similar in ssns and srns. the ihc failed to reveal differences in renal tissue expression of the studied cytokines. there was no correlation between urine and kidney tissue expression. in summary, our preliminary data suggest that urinary opn and icam may serve as biomarkers of ssns. this assumption needs to be tested prospectively. methods: this is an interim report of this single center study on proteinuria in hiv positive children. there are children aged - yrs. registered in our hiv clinic. all children attending the outpatient clinic or seen on admission are studied. questionnaires included bio and clinical data. blood pressure was measured in all children. a clean catch or bag urine is obtained from all and urine biochemistry done on an aliquot. patients found to have proteinuria + or above are referred to the nephrology unit. their urine is quantitated (timed urine collection), renal function, renal ultrasound and cd count estimated. anf, le cells, fbc including platelet count and genotype will be assayed. a renal biopsy will be performed for nephrotic range proteinuria. result: eighty children positive for hiv have been studied. there were males and females giving a ratio of . : . their mean and median ages were . yrs and . years respectively. all had normal blood pressures, renal ultrasound, and renal function. fifteen of the children ( . %) had - mg/dl proteinuria; ( . %) haematuria. their mean cd + cell count was . /mm , range - . there was no significant difference between low cd + count and the presence of proteinuria (p> . ). seventy seven of the patients had vertical transmission of hiv; two acquired the infection from blood transfusion; one from scarification marks. conclusion: there is a high prevalence of proteinuria among children with hiv infection in our region. hiv positive children should be screened and intervention instituted to avert or delay the onset of chronic renal failure. carotid intima media thickness (cimt) and brachial artery flow mediated dilatation (fmd) are novel indices of subclinical atherosclerosis. we studied these indices in children with nephrotic syndrome (ns) using high resolution ultrasonography (hrus). children with ns ( ssns; srns) of - months duration and normal sibling controls underwent cimt and fmd determination using a . mhz us probe. routine biochemistry, lipid profile and hscrp were carried out to look into associations with cimt and fmd. statistical analysis was carried out using epiinfo . . cases and controls were similar in age, sex, growth and egfr. mean maximum cimt (+- % ci) (in mm) was higher in the ns group ( . +- . ; range . - . ) vis-a-vis controls ( . +- . ; range: . - . ) (p< . ). srns and ssns cases were similar ( . +- . vs . +- . mm, p= . ). nephrotic children showed significantly lower fmd ( . +- . % vs . +- . %, p= . ). cimt and fmd varied with frequency of relapses in last months ( . + . mm, . +- . % (no relapses); . +- . mm, . +- . % (> relapses). children with ns had mean hscrp of . +- . mg/l. on univariate analysis, cimt correlated with disease profile at onset (r= . , p< . ), fmd (r=- . , p= . ), male sex (r= . , p= . ), bmi (r= . , p= . ), cyclosporine exposure (r= . , p< . ), total cholesterol (tc) (r= . , p< . ), ldl (r= . , p< . ), vldl (r= . , p< . ), triglycerides (r= . , p< . ), atherogenic index (ai) (r= . , p< . ) and creatinine (r= . , p= . ). fmd correlated with systolic blood pressure, age, bmi, weight, total cholesterol, vldl and triglycerides (p< . ). to conclude, hrus can detect early atherosclerosis using fmd and cimt as the indices in children with nephrotic syndrome with disease duration of years and more. a ten-year old girl, who presented with biopsy proven acute severe changes of type membranoproliferative nephritis (mpgn ) appears to have shown complete resolution of her disorder after nine months mycophenolate moffetil (mmf) (cellcept -roche) added to relatively rapidly reducing steroids. she presented aged nine years with incidental finding of significant proteinuria and upper tract haematuria when presenting with abdominal pain. blood pressure, chemical renal function and haematology were normal. c and total haemolytic complement were at the lower limit of normal. renal biopsy showed light microscopy (lm) changes of markedly enlarged glomeruli with significantly increased mesangial cellularity and matrix, together with 'double contours' of basement membrane. inmmunofluorescence (if) was strongly positive for igg and c . electron microscopy (em) showed mesangial cell interposition into the basement membranes. she was treated with iv pulse methylprednisolone, followed by high dose oral prednisolone (pnl). after one month, mmf mg bd was added as pnl was tailed to alternate day therapy. pnl was reduced more quickly than usual due to difficulty with side effects and excellent clinical response. within three months of mmf, proteinuria and haematuria had disappeared. blood pressure and renal function have remained normal throughout treatment. after nine months, while on . mg/kg alternate day pnl and mg bd mmf, repeat biopsy showed normal sized glomeruli on lm with no significant changes, no positive staining on if and normal em without mesangial interposition. this case suggests that mmf may be a key drug in management of mpgn . g. stringini, e. malagnino, f. emma bambino gesu children's hospital and research institute, department of nephrology and urology, rome, italy serum creatinine values may vary considerably between normal subjects. these variations are in part secondary to differences in muscle mass, body composition and creatinine tubular secretion. in addition, low nephron number, which is influenced by genetic and intrauterine factors, is associated with increased incidence of arterial hypertension, late-onset proteinuria and chronic renal failure. despite compensatory glomerular hypertrophy, autopsy data indicates that kidneys with fewer glomeruli tend to be significantly smaller. on these bases, we have hypothesized that a significant part of the variance of normal serum creatinine levels is related directly to individual differences in renal size. to test this hypothesis, we have reviewed the data of renal ultrasound examinations performed at our institution between and . patients were selected if they had conditions that should not influence renal size (low tract uti, enuresis, bladder instability, idiopathic hypercalciuria), if they had normal gfr and an ambulatory blood pressure measurement. analyses were performed after expressing renal length, serum creatinine levels and blood pressure values as standard deviation scores (sds) corrected for gender, age, height and weight, by multiple nonlinear regression analysis. a significant negative correlation was found between serum creatinine levels and renal length (p< . ). when renal length measurements were grouped in quartiles, serum creatinine sds was on average . sds higher in the st quartile (small kidneys), in comparison with the th quartile (large kidneys). no correlation was found between kidney length and single measurements of ambulatory blood pressure. these data indicate that renal size is accountable for a significant part of the variance in serum creatinine levels that is observed in the normal pediatric population. henoch-schönlein purpura (hsp) is the commonest small vessel vasculitis of childhood. henoch-schönlein purpura nephritis (hspn) is the major determinant of long term prognosis in hsp. the objective of this randomised controlled trial was to determine the effect of early prednisolone treatment on the development and progression of nephropathy in children with hsp. methods: children under years of age, with a diagnosis of hsp, presenting to secondary care centres in england and wales were randomly assigned to receive either placebo or prednisolone ( mg/kg/day (max mg) for days, followed by mg/kg/day for days (max mg)). patients, parents, paediatricians and investigators were 'blinded' to assignment of treatment or placebo. the primary outcome measure was the determination of the presence or absence of proteinuria, defined as urine protein: creatinine ratio (up: uc) > mg/mmol, months after initial presentation in treated and untreated patients. results: children with hsp were randomised. patients were assigned to receive prednisolone (group a) and patients were assigned to receive placebo (group b). patients in group a and patients in group b did not complete the study. there was no difference in the incidence of proteinuria at months, in patients receiving prednisolone ( / ) compared with those receiving placebo ( / ) or= . , % ci . - . , p= . . conclusions: this is largest prospective randomised placebo-controlled trial of the role steroids in hsp in the literature to date. this study provides compelling evidence of absence of a beneficial effect of early treatment with prednisolone in the development of nephropathy months after disease onset in children with hsp. while quality of life (qol) is generally assumed to be poor on dialysis and to improve markedly after kidney transplantation, systematic assessments of qol in children have not been performed to date. to date, we have examined general and health-related qol in children and adolescents with esrd aged - years treated by hemodialysis (hd; n= ), peritoneal dialysis (pd, n= ) or renal transplantation (tx, n= ), using a well-established instrument (kindl) comprising an ageadapted set of questionnaires (kindl). the obtained measures of overall and item-specific qol were transformed to standard deviation scores (sds). general qol was close to normal and did not differ significantly between hd (- . ± . sds), pd (- . ± . ) and tx (- . ± . ). psychological well-being was better in children on pd ( . ± . ) than after tx (- . ± . , p= . ) and on hd (- . ± . , p= . ). physical wellbeing did not differ between treatment groups (hd: - . ± . , pd: . ± . , tx: (- . ± . ). qol related to family life tended to be compromised in dialyzed (- . ± . ) vs. tx children (- . ± . , p= . ) . social interaction with friends was considered moderately impaired by all patient groups (hd: - . ± . , pd: - . ± . , tx - . ± . ). self-esteem was close to normal in all groups (hd: - . ± . , pd: - . ± . , tx . ±. ). in summary, our preliminary results suggest that subjective qol is remarkably good in children with esrd, with surprisingly small differences between treatment modalities. tx appears to be perceived beneficial with respect to the integrity of family life but provides poorer psychological qol than pd, possibly due to the constant concern with graft loss. background: gfr is determined in the ckid cohort study by plasma disappearance of iohexol (igfr). updated serum creatinine (scr)-based formulas (sgfr=k ht/scr) are needed for bedside clinical use. objective: derive formulas based on enzymatic scr to estimate gfr in the ckid study in children aged - yrs with sgfr of - ml/min/ . m . methods: from children, height (ht, meters), igfr, and scr & bun (mg/dl) by bayer advia were obtained. gfr was estimated from regression models: a(ht/scr) b ( /bun) c where a is gfr if ht=scr and bun= ; b and c are exponents. results: % (n= ) were male; median age= , scr= . , bun= and igfr= . formulas ranged from an updated schwartz formula (a= . , b= , c= ; r = . ), to sex-specific (a= . , b= . , c= in girls, and a= . , b= . , c= in boys), which yielded r = . , to the most complex (a= . , b= . , c= . in girls, and a= . , b= . , c= . in boys), which yielded r = . , higher (p< . ) than the r of the updated schwartz formula. by random selection of of subjects in independent trials, we assessed the predictive ability of each formula on the other observations. sex-specific formulas produced unbiased results and increasing precision with increasing complexity. the updated schwartz underestimated igfr in boys by % (p< . ) and overestimated igfr in girls by % (p< . ). conclusions: scr, ht, sex, and bun together provided unbiased estimates of igfr and explained % of its variability in children with igfr of to ml/min/ . m . extrapolation to ht/scr of (normal body habitus and kidney function) and bun of yielded predictions of ml/min/ . m for gfr in girls and boys. including cystatin c and broadening the gfr range to include normal levels are data being collected by ckid to extend the formulas and provide wider clinical utility. f. hussain, m. mallik, a. watson nottingham university hospitals, children and young people's kidney unit, nottingham, united kingdom considerable variation exists between units in terms of techniques used for renal biopsy. the bapn agreed an audit using published standards and a questionnaire was sent to all uk paediatric nephrology centres. agreed to a prospective audit between / / and / / . the survey revealed information leaflets are sent pre-biopsy in ( %) centres with only one using play preparation. ( %) routinely perform biopsies as daycase procedures (dc); ( %) use general anaesthetic (ga). realtime ultrasound is the favoured method in ( %) of centres. biopsies are performed by nephrologists only in ( %), nephrologists with radiologists in ( %) and radiology alone in ( %). of biopsies ( native), ( %) were performed as a dc with ( %) being done under ga. the mean age of patients was yrs (range . ± . yrs). the standard for the number of passes of native kidneys (< in %) was achieved in . % with no significant difference between grade of operator or nephrology/radiology speciality. standard number of passes in transplanted kidneys (< in %) was achieved in . %. adequate tissue was obtained for diagnosis in . % (standard > %). the significant complication rate (macroscopic haematuria and/or delay indischarge) was higher than the set standard of < % at . %. there was no significant difference in complication rates whether the biopsy was performed as a dc or inpatient procedure (p= . ) or whether ga or sedation was used (p= . ). conclusions: the survey highlights significant variation in practice with limited use of preparation materials and dc. the results may enable individual units to reflect upon their techniques and complication rates and has stimulated constructive debate about indications and training issues. objective: to characterize bp in children enrolled in the ckid study, an observational cohort study of children - y old with schwartz estimated gfr of - ml/min/ . m . design/methods: bp's were obtained using an aneroid sphygmomanometer. gfr was measured by iohexol disappearance. bp was classified according to the th report on bp in children. hypertension (htn) was defined as bp- th percentile (uncontrolled), or as self-reported htn plus current treatment with antihtn meds. pre-htn was defined as bp th- th percentiles. results: children (mean age ± y; % male) were studied. mean gfr was ± ml/min/ . m and mean ckd duration was ± y. for sbp, / ( . %) subjects had htn of these, subjects ( %) had uncontrolled htn. additional subjects ( %) had pre-htn. of subjects with systolic htn, only % had measured sbp< th percentile, and among the subjects with measured sbp> th percentile, only ( %) were taking antihtn meds. for dbp, / subjects ( . %) had htn of these, subjects ( %) had uncontrolled htn. subjects ( %) had pre-htn. of subjects with diastolic htn, just % had measured dbp < th percentile, and among the subjects with measured dbp> th percentile, only ( %) were taking antihtn meds. among children with gfr< ml/min/ . m , the prevalence of systolic or diastolic htn appeared to increase with decreasing gfr. conclusions: a significant proportion of children enrolled in the ckid study suffer from elevated bp. nearly % of children with ckd had measured bp> th percentile, and more than % of these children were not receiving antihypertensives, indicating that htn in pediatric ckd is frequently under-or even untreated. long-term follow-up of the ckid cohort should reveal the effect of elevated bp on ckd progression. background: we recently demonstrated elevated excretion of the putative urinary biomarkers tgf-β and et in a large cohort of children with ckd. tgf-β excretion was highest in kidney disorders associated with marked tubulointerstitial fibrosis, such as obstructive uropathy, nephronophthisis and pkd. aim: to investigate the course and predictive value of urinary tgf-β and et excretion in children with ckd undergoing ace inhibition (acei). methods: to date, patients have been followed for years and patients for years in a prospective, interventional trial investigating the nephroprotective efficacy of acei w/out intensified blood pressure control. results: average bp was reduced to the mid normal range. proteinuria initially decreased by %, but gradually reincreased to baseline levels within years. urinary tgf-β excretion, which was initially elevated -fold above healthy controls, continuously decreased during treatment from . ± . ng/g creatinine to . ± . , . ± . , and . ± . after , , and years, respectively (p< . ). in contrast, et excretion increased by % within the first years of follow-up. neither baseline nor the change in tgf-β and et excretion during treatment predicted the short-or long-term antihypertensive, antiproteinuric response to acei or ckd progression rate. conclusions: the marked reduction of urinary tgf-β excretion probably reflects the antifibrotic effect of acei but, at least over yrs of observation, does not predict the early and late course of proteinuria and ckd progression. hence, urinary tgf-β appears to be a biomarker of tubulointerstitial disease activity rather than of global disease progression. the surprising increase of et excretion may reflect the induction of compensatory hemodynamic mechanisms during acei. cardiovascular complications are the most important cause of death in pediatric patients with endstage renal disease. therefore early diagnosis and treatment are very important. brain natriuretic peptide (bnp) is released in response to volume overload or conditions that cause ventricular stretch. the aim of the study was to investigate whether bnp can be used for early diagnosis of cardiac complications in pediatric patients with esrd. twenty-four patients on peritoneal dialysis (mean age . ± . years), patients on hemodialysis (mean age . ± . years) and sex and age matched healthy children (mean age . ± . years) were included the study. plasma bnp levels were significantly higher in the patient group than those in the control group ( . ± . vs . ± . pg/ml, respectively, p< . ), but there was no significant difference between hemodialysis and peritoneal dialysis patients. in patients with hypertension, bnp levels, left ventricular systolic and diastolic diameters were significantly higher than those in the patients without hypertension. in patients with higher crp levels, bnp levels were significantly higher than those in the patients with low crp levels. bnp levels had a positive correlation with left ventricular mass index (r= . , p= . ) and a negative correlation with ejection fraction (r=- . , p< . ) and shortening fraction (r=- . , p< . ) significantly. there was no significant relation between bnp levels and anemia, dialysis duration, and dialysis modality. in conclusion, high plasma bnp level is significantly correlated with dilated left ventricle and it may be useful as a biochemical marker for identification of pediatric dialysis patients with cardiac dysfunction. we observed a high prevalence of left ventricular hypertrophy (lvh) and impaired lv contractility in children with stage ii-iii chronic kidney disease (ckd) (jasn , jasn . in a prospective, open-label assessment in children receiving ace inhibition (ramipril mg/m /d) with or without additional antihypertensive medication, we evaluated by echocardiography lv mass (lvm), geometry and myocardial mechanics at baseline and after (n= ) or mos (n= ) of treatment. lvh was defined by lvm index> g/m and concentric geometry by relative wall thickness> . ( th normal percentile). lv systolic function was assessed at the midwall level by circumferential shortening (ms). normalized h mean arterial blood pressure (bp) was reduced from . ± . at baseline to . ± . and - . ± . sds after and mos respectively. lvmi was reduced significantly after (from . ± . to . ± . g/m . , p< . ) and mos (from . ± . to . ± . , p< . ). of those patients presenting with lvh at baseline, lvm regressed to the normal range in / ( %) after mos and in / ( %) after mos. the prevalence of concentric lv geometry remained unchanged (baseline: %, mos: %, mos: %). age and afterload-corrected myocardial function increased from ± % to ± % at mos (p< . ). the changes in lvm and myocardial performance were independent of the randomized bp target and gfr. change in lvm was correlated with change in hemoglobin level (r= . , p< . ) and change in myocardial function with change in bp level (r= . , p< . ). in conclusion, fixed-dose ace inhibition and tight bp control induce regression of established lvh in the majority of children with stage ii-iii ckd. this is associated with a normalization of myocardial contractility. objectives of the study: periods with insufficient erythropoietic activity may occur during the erythropoietin (epo) treatment in chronic haemodialysis (hd). we determined the effects of a short-term suspension of epo therapy on various oxidative stress parameters during a -week follow-up in hd patients. methods: the antecedent epoetin beta (eb) treatment was suspended for days. after that, patients received eb two times a week and patients received darbepoetin alfa (da) once weekly. concentrations of whole blood oxidized and reduced glutathione (gssg, gsh) and various haematological parameters were determined weekly. erythrocyte malondialdehyde (e-mda) and the activities of erythrocyte superoxide dismutase, catalase and glutathione peroxidase were determined at weeks , and . results: the ratio gssg/gsh was increased in both groups after continuation of the suspended epo therapy (p< . and p< . week vs. the baseline in the da and eb group, respectively) and also at week (p< . and p< . vs. the baseline in the da and eb patients, respectively). the activities of the antioxidant enzymes were increased at week in both groups (p< . vs. the baseline for da and p< . vs. the baseline for eb), and returned to their week levels by week . the e-mda level decreased in both groups (p< . week vs. the baseline for da and p< . weeks and vs. the baseline for eb). conclusions: a short-term suspension of epo therapy caused characteristic time-dependent changes in the oxidative stress. the ratio gssg/gsh increased at weeks and . activities of the antioxidant enzymes were elevated at week , resulting in an improvement in lipid peroxidation. these results might have implications in certain conditions with transient alterations in the erythropoietic activity in hd patients. rrf has been associated with better nutritional status both in adults and children on peritoneal dialysis and in adults on chronic hd. there are no data on the influence of rrf on nutrition in children on chronic hd. three-days dietary reports and simultaneous urea kinetic monitoring of children, adolescents and young adults on chronic hd (age: . - . years) were retrospectively analyzed. protein catabolic rate, an index of nutrition adequacy, was normalized by body weight (npcr). in patients with rrf, total kt/v (kt/vtot) was calculated summing hd kt/v(kt/vhd) and rrf (evaluated by residual urea clearance ku-). in all patients, npcr and dietary protein intake (ndpi) were significantly correlated (p< . ). kt/vtot was correlated with npcr(p< . ) while correlation between kt/vhd and npcr was not significant (p: . ). in patients with rrf, ku resulted significantly associated with npcr (p< . ) while kt/vhd was not (p: . ). npcr was significantly higher in patients with rrf ( . ± . vs . ± . g/kg/day; p< . ). patients on recombinant growth hormone (rhgh) treatment showed npcr higher than those without rhgh ( . ± . vs . ± . g/kg/day; p< . ). however, in a multiple regression model including age, the use of rhgh, rrf, kt/vtot and kt/vhd, npcr resulted significantly associated only with rrf (b: . ; p< . ). inconclusion: in children, adolescents and young adults on chronic hd treatment, rrf is associated with better nutrition. rrf positively affects nutrition independently from hd efficiency and rhgh effects. possible hypothesis are a more selective (although decreased) depuration and the positive influence of water excretion maintenance on food intake. more efforts have to be made in order to maintain rrf in children on chronic hd. during the past three years, six women have undergone chronic haemodialysis during pregnancy at the pediatric renal unit of the adelaide women's and children's hospital. five have delivered normal infants at between and weeks gestation; one is presently at weeks gestation, with an apparently normal fetus. four were already receiving chronic haemodialysis at the time of conception; the others began dialysis at weeks gestation. the protocol includes six days per week dialysis for at least two hours per treatment. a number of practical and emotional issues have arisen, with major potential psychosocial hazards, including: unplanned pregnancy due to ignorance of fertility; precipitation onto the dialysis program; acceptance of increased dialysis time; concerns regarding effects of drugs and dialysis/kidney failure on the fetus; the likelihood of prematurity; the perceived difficulties of motherhood while on a chronic dialysis program; loss of income, social networks and independence. the program has been successful due to the cooperative approach from the multidisciplinary team consisting of nephrologists, obstetricians, obstetric physicians dialysis nurses, midwives, dieticians, physiotherapists, psychiatrists and social workers. the social worker has provided counselling and coordinated transport and assistance with housework, childminding and other day to day tasks. although the program has had overall success, there have been a number of pitfalls worth discussing, including those arising from the complex interactions between the members of the various disciplines, and those involved in maintaining the balance of clinical and psychosocial needs of the women. (median . ) , weight from . to . kgbw (median ). the vascular access was a central catheter (kt) in children, an arteriovenous fistula (avf) in , avf and kt alternatively in patients. duration of hd ranged from to m (median . ). dual lumen tunnelled cuffed kt were inserted in children through the internal jugular vein [ijv]), surgically in , percutaneously in . all kt have had an immediate good function. nine kt were exchanged over a guide wire for dysfunction. kt infections with positive blood culture were successfully treated in cases. duration of kt ranged from to m (median ). at the end of the follow-up, kt were still in function, removed for a mature avf, after renal transplantation (rt), for improved gfr and failed. patency of the venous network after withdrawal of kt was assessed in children (doppler , mri ) and showed normal patency in , ijv thrombosis in , brachiocephalic thrombosis in and stenosis in . thirty avf were created in children, distal in ( %). immediate patency was obtained in all cases except . the median blood flow ranged from to ml/min/m (median ). following the primary surgery, repeated surgical procedures included a superficialization of the vein in , refection for stenosis or thrombosis in , reduction of overflow in , nd avf creation in and ligation after rt in . percutaneous transluminal angioplasty was performed in children. duration of patency ranged from to m (median . ). in conclusion, hd is feasible in small children. nevertheless, kt are associated with risk of venous occlusion and obtention of a reliable avf frequently need several interventions, altogether leading to a limitation of hd indications in young children. - , ( %) were < years of age. the underlying disorders were congenital nephropathies in % (malformations %, hereditary %) and acquired diseases in %. living related donation (ld) was performed in % and preemptive tx in %. immunosuppressive (is) protocol varied considerably between the countries and over time. -year graft survival (gs) was % in ld and % in grafts from deceased donors (dd). gs improved significantly for dd grafts with time. the number of acute rejections (ar) during the first year posttx was significantly lower in ld recipients, in tac-treated children and during the second half of the study period. this improvement over time was also seen in separate analysis of cya-treated children. the proportion of rejection-free patients increased in all countries. median height sds at tx was - . (- . to + . )(boys - . , girls - . ). height sds increased to - . at years posttx. conclusions: gs results were excellent and the frequency of ar low, especially in children with ld grafts and tac treatment. interesting differences between the countries concerning donor source, preemptive tx, is and use of protocol biopsies were found. n. marcun varda, a. gregoric maribor teaching hospital, department of pediatrics, maribor, slovenia objectives: essential hypertension (eh), identifiable in children, is associated with cardiovascular (cv) diseases in adulthood. the aim of our study was to evaluate the presence of some traditional and non-traditional cv risk factors in our children and young adults with eh in the search for additional cv risk. the prevalence of metabolic syndrome (ms) was also investigated. methods: a total of children and young adults, diagnosed with eh, were included in our study. they were compared with a control group of healthy children, matched for sex and age, with regards to specific aspects in the history, body mass index (bmi), waist: hip ratio, full blood count, crp, serum cholesterol, hdl cholesterol, ldl cholesterol, triglycerides, uric acid, glucose, insulin, fibrinogen, homocysteine, apolipoprotein a , apolipoprotein b and lipoprotein (a). in addition, the prevalence of ms was calculated. ms was defined as having three or more ms components according to the national cholesterol education program's adult treatment panel iii criteria, tailored for children. results: the differences in values of bmi, crp, platelets, triglycerides, uric acid, apolipoprotein a , apolipoprotein b and homocysteine between the hypertensive patients and the controls were statistically significant. in all hypertensives positive family history of hypertension in the first or second generation was revealed. overweight (bmi > th percentile for age and sex) was identified in %, obesity (bmi > th percentile) in %, abnormal glucose homeostasis in %, high serum triglycerides in % and low hdl in % of the hypertensives. ms was present in % of these children and in % of our controls. conclusion: we demonstrated that children and young adults with eh differ from the population of healthy children in some specific cv risk factors, and are therefore at an increased cv risk. background: rtd is a rare autosomal recessive disease of differentiation of fetal kidneys with poorly developed proximal tubules. fetal and neonatal findings include oligohydramnios, preterm birth and neonatal death due to pulmonary hypoplasia, anuria and hypotension. mutations in genes in the renin-angiotensin system (ras), encoding for angiotensinogen, renin, angiotensin converting enzyme and angiotensin ii receptor type , have been revealed. we report the first rtd patients surviving the neonatal period and still being alive. both patients had affected siblings demised in utero or neonatally. case : oligohydramnios, birth at weeks, grams. neonatal course: pulmonary hypoplasia, pneumothorax, hypotension and anuria with ventilation ( weeks) and dialysis ( days) . current findings at years: creatinine umol/l, normal blood pressure. genetic and functional analysis: homozygous mutation of angiotensinogen gene ( g-a); very low angiotensinogen concentration ( . ng/ml; normal - ), absent plasma renin activity (normal . - . ng/ml/h) despite very high active renin ( pg/ml; normal - ). case : oligohydramnios, birth at weeks, grams. neonatal course: mild respiratory distress, hypotension and anuria with oxygen ( day) and dialysis ( months) . current findings at years: renal transplantation at age years, good graft function. genetic and functional (as neonate) analysis: homozygous mutation of renin gene ( g-a); very low active renin (< . pg/ml; normal - ). conclusions: rtd is caused by inactivating mutations in genes encoding the ras resulting in chronic low perfusion pressure of the fetal kidney. genetic and functional analysis of ras contributes to diagnosis of rtd. this observation extends the rtd phenotype from a uniformly fatal to a more favourable disease. objectives of study: to evaluate the relationship between serum uric acid (ua), new onset essential hypertension (eh) and endothelial dysfunction (ed) in the youth. methods: subjects with abpm proved new onset eh (aged , ± , years, bmi , ± , kg/m ), overweight/obese normotensive youth (oo) matched for age and bmi, and age matched healthy normotensive controls (nt) with normal weight were enrolled. ua, total cholesterol, hdl, ldl, triglycerides and creatinine were analyzed in blood, glomerular filtration rate (gfr) was calculated according to schwartz formula and endothelial function was assessed using flow-mediated dilation (fmd, %). results: new onset eh was associated with overweight/obesity in % of subjects. serum ua levels were significantly higher in eh than oo ( ± vs. ± umol/l, respectively, p< , ), in eh than nt ( ± vs. ± umol/l, respectively, p< , ), and in oo than nt ( ± vs. ± umol/l, respectively, p< , ). total cholesterol, hdl, ldl and triglycerides were significantly higher in eh and oo compared with nt (p< , ). no significant differences were found in lipidograms between eh and oo. serum creatinine and gfr did not differ significantly between the groups. fmd was significantly lower in eh comparing with oo and nt ( , ± , vs. , ± , vs. , ± , %, respectively, p< , ) and in oo comparing with nt ( , ± , vs. , ± , %, respectively, p< , ). conclusions: new onset eh in the youth is associated with overweight/obesity, higher serum ua and ed. ua may play a causal role in the pathogenesis of eh and commonly with eh and proatherogenic serum profile contributes to ed in overweight/obese hypertensive youth. objective of study: fibromuscular dysplasia (fmd) is a systemic arteriopathy of the small and medium sized vessels. it is the first cause of renal arterial stenosis (ras) in childhood. the aim of this study was to describe the natural history of fmd in children. we analysed all the data of children with fmd. results: mean age at diagnosis was years months old. hbp was discovered fortuitously in cases, after symptoms of malignant hypertension in . in all cases bp values corresponded to severe hypertension (mean bp of / mmhg). extra renal localizations were found in half of the patient, and the most frequent pathological arteries were the superior mesenteric and the carotida. the mean number of arterial stenosis at diagnosis was per patient. seven patients had a primary fmd with familial history for patient. in the others fmd were associated with polymalformatif syndromes: reported by grange ( ), moya-moya disease ( ), neurofibromatosis type i ( ). after a median follow-up time of months the number and severity of stenosis increase at arteries per patient. these lession, although to a lesser extend, were already observed as soon as months of follow-up. percutaneous transluminal renal artery angioplasty were proposed in cases when the bp was uncontrolled indeed a multi antihypertensive therapy with severe renal stenosis (> %) or when renal growth was impaired. prognosis is severe with cardiologic complications ( / ) and death. conclusions: intimal form of fmd accounts for the majority of multivisceral fmd. at diagnosis several hypertension is almost present. vascular ultrasonography imaging techniques is usefull in follow-up. a conservative treatment has to be privilegied. this disease is evolutive with increase of pathological arteries number, aggravation of stenosis degree and sometimes renal function impairment. objective: the effect of over weight on blood pressure elevation (bp) is more frequently present in childhood. several studies have demonstrated the efficacy of angiotensin-converting enzyme inhibitors (acei) therapy in obese hypertensive adults, but data on children are very limited. methods: obese (bmi: z score > . sd) primary hypertensive (systolic ordiastolic blood pressure > th) children (aged - years) were enrolled to this single centre prospective study. patients received ramipril ( . - . mg/bwkg/day) once daily. office and ambulatory bloodpressure measurements and serum biochemical analysis were performed at start and after and months of treatment. patients ( , %) hadimpaired glucose tolerance (igt) on oral glucose tolerance test (ogtt). results: ( , %) patients completed the six months ramipril therapy. reduction in -hour mean arterial pressure (map) was , mmhg (- , sd) after month and , mmhg (- , sd) months treatment respectively. bp was reduced with equal efficacy during day-and night time. / ( , %) patients were lost during the follow-up. ( , %) patients with high uric acid levels also were treated with allopurinol. eleven patients ( %) received second antihypertensive medication because of the blood pressure remained uncontrolled. ( pts metoprolol, pts amlodipine) ( , %) patients suffered recurrent cough, but otherside effect has not observed. the serum glucose and insulin levels havenot changed significantly during the follow-up. conclusion: oncea day given ramipril significantly decreases the blood pressure inobese hypertensive children. it is effective, tolerable and safe bloodpressure lowering monotherapy in childhood. further studies and longer follow-up are necessary to prove its long term beneficial effect in the childhood metabolic syndrome combined with hypertension. hw. zhang, j. ding, f. wang, yf. wang peking university first hospital, department of pediatric nephrology, beijing, people's republic of china objectives of study: females with x-linked alport syndrome (xlas) have variable phenotypes, from microscopic hematuria to chronic renal failure, which can not be clarified solely by mutation features of col a gene. x-inactivation has been suspected to be one of the responsible reasonsfor this phenomenon, but no definite correlation has been demonstratedso far. in order to confirm whether the phenotypes of xlas femalescorrelate with x-inactivation, we analyzed the xinactivation patternsin peripheral blood cells in xlas females and in skin fibroblasts in xlas females. methods: the x-inactivation analysis was performed using hpaiipredigestion of dna followed by polymerase chain reaction (pcr) of thehighly polymorphic cag repeat of the androgen receptor (ar) gene. results: results showed that the average x-inactivation levels of the mutant allele decreased while the degree of proteinuria increased, there was anegative correlation between the degree of proteinuria and thex-inactivation ratios of the mutant allele in blood cells (r=- . , p= . ). however, there was no correlation between the degree of proteinuria and the x-inactivation ratios of the mutant allele in skin fibroblasts (r=- . , p= . ). though of patients ( . %) had the similar x-inactivation ratios in both blood cells and skin fibroblasts, there was also no correlation between the x-inactivation ratios of the mutant allele in skin fibroblasts and that in peripheral blood cells (r= . , p= . ). conclusion: we concluded that the x-inactivation ratios in blood cells correlated with the degree of proteinuria, which might explain partially the diverse phenotypes in female xlas patients. more studies, including post-transcription regulation, environmental factors, and so on, are still needed. objective: to report frasier syndrome (fs) with wt mutation and abnormal expression of podocyte molecules which is the first case in mainland china. methods: peripheral blood cells were analyzed for chromosome karyotype and wt gene mutation. the ratio of +kts/-kts isoforms was quantified with genescan and genescan software. expressions of podocyte molecules were detected by immunohistochemical staining. result: the patient presented with steroid-resistant fsgs and male pseudohermaphroditism. the wt ivs + g>a mutation was found in one allele in the proband, but not in her parents. the ratio of +kts/-kts was . in the proband, and was . and . in her mother and father, respectively. podocyte molecules expression altered in normal-and abnormal-appearing glomeruli. wt expression showed diffuse nuclear staining with less obvious speckles compared with that in controls. wt (antibody against c-terminal) displayed strong, normal, faint and negative stained podocyte nuclei within the same glomerulus. the staining intensity of wt (antibody against the n-terminal) was very faint. conclusion: taking clinical data, pathology, karyotype analysis and genetic testing together, we diagnosed the first case of fs in mainland china, which prompts there might be more cases underdiagnosed. wt displayed diffuse nuclear staining with less visible speckles compared to controls, supporting the view of the differential nuclear localization of kts isoforms. our study further confirmed that wt mutation resulted in abnormal expression of podocyte molecules in glomeruli of fs, though we did not know whether this phenomenon directly or indirectly resulted from loss of wt regulation. dent disease is an x-linked disorder characterized by low-molecular-weight proteinuria, hypercalciuria, nephrocalcinosis, calcium nephrolithiasis and the development of renal insufficiency after the middle age. so far, two genes responsible for the development of dent disease have been identified, i. e., clcn and ocrl . ocrl was originally identified as a causative gene for lowe syndrome. in japan, igarashi et al. described for the first time that idiopathic tubular proteinuria in japan is identical to dent disease by mutational analyses. most of japanese patients with dent disease are identified by annual urinary screening as chanced proteinuria and several clinical phenotypes, such as incidence of nephrocalcinosis and long term outcome of renal function remains to be elucidated. furthermore, identification of ocrl as a second causative gene for dent disease has made the understanding of dent disease more complex. here we report patients with dent disease phenotype with the results of genetic analyses and clinical features. out of patients in different families, mutations ( %) in clcn were identified. in the patients with no clcn mutations, genetic analysis in ocrl is ongoing, and at the moment different mutations in ocrl ((i stop, r c, r w and r h) were identified. the remaining patients are now beeing investigated. among the patients in whom clcn mutations were detected, hypercalciuria are not always present. in several elderly patients, mild renal function impairment is present. there are similar clinical phenotypes between patients with clcn or ocrl mutations, but serum levels of ldh and ck are likely to be higher in those with ocrl mutations. in summary, we will present genotype and phenotype heterogeneity in japanese dent disease, and will discuss the clinical spectrum of dent disease. a. gulati , s. sethi , j. lunardi , m. kabra , n. gupta , p. hari , a. bagga all india institute of medical sciences, st department of pediatrics, new delhi, india hôpital de la tronche, genetics, grenoble cedex. france, france objectives: to study the clinical features and genetic basis of patients with lowe syndrome and identify female carriers. methods. case records of patients with lowe syndrome presenting to this hospital, between - yr old, were reviewed. the clinical features were recorded and glomerular and tubular functions assessed. a detailed genetic analysis was performed on dna extracted from peripheral blood of patients and their mothers, which involved sequencing of all exons of the ocrl gene. results: all patients showed failure to thrive, bilateral congenital cataracts, refractory rickets, delayed motor and language milestones and proximal renal tubular acidosis with fanconi syndrome. the mean schwartz gfr was ml/min/ . sq. m. genetic analysis showed distinct mutations of ocrl gene in all patients studied. we report new mutations having identified the variants c. a>g and c. g>t in exon , the variant c. _ ins t in exon and c. - a>g in intron in independent patients. we also found previously described mutations involving the region c. _ del tg and c. c>t in exon . four of mothers were heterozygous carriers. all genotypically proven carriers showed characteristic lenticular opacities. conclusion: the identification of mutations in the ocrl gene provides confirmation of the diagnosis of lowe syndrome. the new mutations described in north indian children expand the range of mutations that give rise to this condition. these observations have important implications for molecular diagnosis and genetic counseling in families with lowe syndrome. juvenile nephronophthisis (nph), an autosomal recessive nephropathy, is the most common genetic cause of chronic renal failure in childhood. in - % of known cases, nph is associated with joubert syndrome (js), a neurological disorder described in patients with cerebellar ataxia, mental retardation, hypotonia and respiratory dysregulation. mutations in three genes, ahi , nphp and nphp have been identified in patients with nph and js. as nphp mutations usually cause isolated nephronophthisis, the factors which predispose to the development of neurological symptoms in some patients are poorly understood. to determine such genetic factors and to assess the mutation rate of ahi , nphp and nphp in nph and js, a cohort of families with nph and at least one js-related neurological symptom was screened for mutations in these genes. thirteen ( %) and ( %) unrelated patients were homozygous or compound heterozygous for nphp and nphp mutations, respectively. in patients ( %) without nphp , nphp or ahi mutations, mutations in a novel gene (nphp /cors ) encoding a ciliary protein have been identified. interestingly, of the patients with nphp mutations carried either a heterozygous truncating mutation in nphp ( patient), a heterozygous missense mutation in ahi ( ) or the ahi variant r w ( ) . the variant r w affects an amino acid conserved in vertebrates and predicted to be 'possibly damaging' by polyphen software. in conclusion, nphp , nphp or nphp mutations can be found in % of patients with nph and js in our cohort. our finding that half of all patients with nphp mutations carry a mutation or a damaging variant in nphp or in ahi strongly supports the notion that epistatic effects provided by these genes contribute to the appearance of neurological symptoms in patients with nphp mutations. molecular cytogenetic techniques such as array-based cgh have been instrumental in the identification of microimbalances associated with syndromic phenotypes. we investigated patients with unclear syndromic nephropathies (e. g. urinary tract malformations, focal segmental glomerulosclerosis, and persistent hematuria/proteinuria) and additional clinical features, such as mental retardation, heart defects or growth abnormalities. array-cgh analysis was performed with a whole-genome array with large insert clones providing an average resolution of < . mb. results: in one -year old female patient presenting with microhematuria, proteinuria, mental retardation including severe speech impairment, senso-neuronal hearing loss, and recalcitrant focal epilepsy, we detected a microdeletion in chromosomal bands xq . -q . this deletion was verified by fish, found to be uniallelic, . - . mb in size, and not to be inherited from the mother. electron microscopy of kidney biopsy showed splitting of the lamina densa and a thin basal membrane, which is diagnostic for alport syndrome. high-resolution cranial magnetic resonance imaging including white fibre tracking revealed a severe neuronal migration disorder with subcortical band heterotopia (double cortex syndrome), i. e. a second band of cortical neurons within the white matter below the true cortex. conclusions: in patients with unclear syndromic nephropathies, we identified a female with a contiguous gene syndrome at xq . -q . the microdeletion includes the x-linked alport syndrome gene col a and the lisx gene associated with subcortical heterotopia, mental retardation and epilepsy. thus, the phenotype observed in our female patient combines features of the amme-complex (alport syndrome, mental retardation, midface hypoplasia, elliptocytosis) with x-linked lissencephaly. ( f, m; . ± . yrs, hemoglobin . ± . gr/dl, ferritin ± mg/dl) were enrolled. lipid profile, acute phase proteins (apps) were measured. renal tubular functions, plasma vegf level, urinary nag/cre ratio were determined. abpm and imt measurements were performed. the results were compared with healthy controls. results: mean -hour, day and night systolic-blood pressure (sbp), diastolic-bp (dbp) and mean arterial pressure values were comparable to that of control group. dipping in dbp was less in tm ( . % vs . %; p< . ). the ratio of patients with less than % dipping in sbp (non-dippers) was higher in tm ( . % vs . %, p< . ). mean plasma vegf level was . ± . pg/ml [ . - . ] in tm, was within normal range (< pg/ml) in controls. apps were normal. imt of common carotid artery (cca) was . ± . mm in tm group and . ± . mm in controls, (p< . ); imt of internal carotid artery (ica) was . ± . mm in tm group and . ± . mm in controls (p< . ). positive correlations were found between vegf and microalbuminuria, b -microglobulin and homosistein; between nag/cre and microalbuminuria; between cca-imt and age, and a negative correlation between cca-imt and ferritin. conclusions: renal tubular damage, abnormalities in abpm, increase in vegf and increase in cca-imt and ica-imt occur when the patients are asymptomatic and routine laboratory test are normal. optimal hemoglobin levels and deferoxamine therapy do not prevent the development of renal and vascular damage. l. sylvestre , e. santos , p. granzotto , e. siqueira , l. moreira , l. rispoli , n. mendes , r. meneses hospital pequeno principe, pediatric nephrology, curitiba, brazil centro universitario positivo unicenp, curitiba, brazil introduction: hypertension is frequently underdiagnosed in children. early diagnosis and a planned follow-up is helpful in detecting and preventing the harmful long-term consequences of hypertension. therefore, we created a specific outpatient clinic to have a better follow-up of these patients. material and methods: we reviewed the files of patients from the outpatient clinic of hypertension, from the dept. of pediatric nephrology in hospital pequeno principe, curitiba, brazil, followed for more than months, from march to december . we analyzed demographic and anthropometric data, diagnosis, staging of hypertension, presence of target-organ damage and treatment. results: patients were eligible, boys, mean age at the first visit . years old, mean follow-up of months. mean bmi= . ( % overweight and obese). secondary hypertension was present in % of the cases, predominantly due to parenchymal renal disease; essential hypertension associated to overweight and obesity in patients ( %) and there was no established diagnosis yet in other patients. fifty-five patiens performed at least one abpm of hours, showed hypertension. twelve from patients showed left ventricular hypertrophy and from patients had abnormalities of the retinal vasculature associated to hypertension. the most frequent drugs used to treat hypertension were ace inhibitors ( ) and calcium channel blockers ( ). conclusion: our data are in accordance that secondary hypertension is frequent in children, mostly associated to renal disease. furthermore, we could detect a large number of obese hypertensive children and adolescents. target-organ abnormalities are not as frequent as in adults but need to be monitored. intrauterine growth retardation (iugr) is characterized by low nephron number with or without reduced kidney size. leptin, an important hormone in the regulation of body fat massand weight, is decreased in fetuses with iugr. in the present study, weexamined the effects of leptin in a metanephric mesenchymal cell line ms . ms is generated from the metanephroi of embryonic day . homozygous mouse transgenic for h- kb-tsa. incubation of ms withleptin , , , or ng/ml for h did not affect either [ h]-thymidine incorporation or cell number. on the other hand, [ h]-leucine incorporation was significantly increased by leptin in a dose dependent manner ( ± %, ± %, ± %, and ± % of control by , , , and ng/ml, respectively). protein/dna was also increased . -fold by leptin ng/ml. leptin ng/ml activated both erk and p . the levels of phosphorylated-erk (p-erk) and phosphorylated-p (p-p ) , as assessed by western blot analysis, started to increase at min, peaked at min ( . -and . -fold increase respectively) remaining elevated at , , and h, and began to decrease at h returning to the baseline level at h. the levels of p-erk and p-p at min were increased by leptin in a dose dependent manner ( . -, . -, . -, and . -fold increase by , , , and ng/ml respectively). the levels of total erk and p remained unchanged. increase in [ h]-leucine incorporation stimulated by leptin ng/ml was completely inhibited by coincubation with a mek inhibitor pd μm or a p inhibitor sb μm. these results demonstrate that leptin induces hypertrophy of metanephric mesenchymal cells via erk and p . the hypertrophic effect of leptin may play a role in normal renal development and may explain reduced kidney size in a hypoleptinemic state, iugr. objectives of study: to investigate the mechanism of nephron deficit in rat model of intrauterine growth retardation (iugr). methods: a rat model of iugr was built by maternal low-protein ( %) dietthroughout pregnancy. newborn male pups were chose as our studyobjects. the proliferation and apoptosis in kidney was showed by ki- detection and tunel method. expression of wt , bcl- , bax, and p mrnas in renal tissue were examined by real-time pcr, and expression of wt and bcl- gene products in renal tissue were examined by immunohistochemistry and western blot. the final number of glomeruli was determined at weeks of age when nephrogenesis has finished. results: at weeks postnatally, iugr offspring had fewer glomeruli per kidney than those in controls (p< . ). in iugr newborns, tunel positive cells were more numerous in the nephrogenic zone. renalwt and bcl- mrna levels were significantly reduced in newborn iugrpups, and the bcl- mrna/bax mrna ratio was also decreased, but therewas no change in the expression of p mrna. in iugr newborns, the wt and bcl- protein expressions were significantly decreased, and the irimmunostaining were also suppressed in the nephrogenic zone. conclusions: these results suggest that reduction of nephron number in iugr rat may be associated with enhanced apoptosis in kidneydevelopment. decreased wt and bcl- expressions and reduction of the bcl- /bax ratio may contribute to the molecular mechanisms behind these findings. objective of the study: the aim of this study was to identify risk factors for urinarytract infection (uti) during follow-up of children with isolatedantenatal hydronephrosis. methods: between and , patients were diagnosed with isolated fetal renal pelvicdilatation (rpd) and were prospectively followed. after initialclinical and imaging evaluation, us scans, clinical examination, andlaboratory reviews were scheduled at -month intervals. the event ofinterest was time until occurrence of first episode of uti. cox's regression model was applied to identify variables that wereindependently associated with the uti. results: a total of patients were included in the analysis ( boys and girls) themedian fetal rpd was mm (iq range, . ± ) and patients ( . %) presented bilateral rpd. seventyeight ( %) infants presented urinarytract anomaly. the most frequent detected uropathy was upjo ( ), followed by primary vur ( ), and megaureter ( ). median follow-up timewas months (iq range, - months). during follow-up, uti occurred in ( %) of the children. the incidencerate of uti was episodes per person-month. the incidence rate of uti has decreased from . episodes per person-month in the first year of life to . in the second year, and to . after the third year. by survival analysis, the risk of uti for the whole series was estimated in . % at months, % at months, and % at months of age. after adjustment, two variables were independent predictors of uti during follow-up: female gender (rr= . , % ci, . - . , p= . ) and presence of uropathy (rr= . , % ci, . - . , p= . ). conclusion: according to findings, in a cohort of antenatal hydronephrosis, girls with vur or urinary tract obstructionhad a higher risk of uti during follow-up. objective of the study: to identify predictive factors of resolution of fetal renalpelvic dilatation (rpd) in a cohort of medically managed children. methods: between and , patients were diagnosed with isolated rpd and were prospectively followed. of infants, ( %) were clinically managed. after initial clinical and imaging evaluation, us scans, clinical examination, and laboratory reviews were scheduled at -month intervals. the event of interest was rpd resolution, regardedas renal pelvis < mm on two consecutive renal sonograms. cox's regression model was applied to identify variables that were independently associated with the event. results: a total of patients were included in the analysis and uropathy was diagnosed in ( %) infants. median follow-up time was months (interquartile range, to months). during follow-up, ( %) patients presented rpd resolution. by survival analysis, the estimate of rpd resolution for the whole series was % at months, % at months, and % at months of age. the median time for rpd resolution was estimated at months ( % ci, - ). in the survival analysis, three variables were found to be significantly associated with resolution of rpd during follow-up: mild fetal rpd, grades - (sfu grading system), and presence of uropathy. after adjustment, only absence of uropathy remained as an independent predictor of rpd resolution (rr= . , % ci, . - . , p< . ). conclusion: according to these findings, it was estimated that rpd resolution occurs in about half of the patients without uropathy at years of age. objective: to study clinical and pathological characteristics of antineutrophil cytoplasmic autoantibody (anca)-positive glomerulonephritis(gn). methods: clinical data of thirteen patients during years, with anca-positive gn were analyzed. results: of patients with anca-positive gn with an average age of . ± . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) years, patients were female and were male. the average course was . ± . months. cases onset between december and february. there was , , cases whose chief complaint on admission was anaemia, swollen and hematuria respectively. the main clinical symptoms were: anaemia ( %), hematuria/proteinuria ( %), renal functional lesion ( %), edema ( . %), oliguresis ( . %), hypertension ( . %), arthralgia ( . %), rash ( . %), abdominal pain ( . %), fever ( . %). laboratory tests: bun, scr and esr were high while hemoglobin was low in all patients. mpo-anca was positive in cases c was normal in cases and low in cases. pathology features: all glomeruli are affected and show different degree of segment and glomus sclerosis. there was different degree of capsula glomeruli thickening. glomerulus capillary loop was necrotic, nuclear leukocytes and cell debris could be seen. inflammatory cell interstitial infiltration with lymphocyte and plasmocyte. endotheliocyte of small vessels of interstitial was swelling and vessel wall was edema, necrosis and glassy degeneration. immunofluorescence showed no or small immune complex deposition and showed pauci-immune gn. conclusion: onset of patients with anca-positive gn was hiding and there were nonspecific clinicalsymptoms in the early stage that reduced late diagnoses until esrd. female patients was predominant. renal pathology showed segment necrotic nephritis interstitial inflammation and polyangitis. the disease had unfavourable prognosis. background: renal function maturation isn't achieved at birth. vlbw infants exposed to intensive care have an increased risk of developing renal function impairment. moreover, we showed that ibu was associated with a significant impairment in renal function at one week of life in vlbw infants. objective: to evaluate renal function development in infants treated with ibu for pda closure as compared to infants not exposed to ibu, during the first month of life. methods: multicentric prospective cohort study of to weeks gestation (ga) infants exposed or not exposed to ibu within the first days of life. infants presenting with renal impairment at birth, urinary tract malformation, or contraindication to ibu were excluded. infants exposed to ibu were paired to controls according to ga, centre and crib score. creatinine clearance (ml/min/ . m ) was measured for glomerular filtration rate evaluation. fractional excretion of sodium (fena%), micro-albuminuria (mg/l) and alpha -microglobinuria/creatininuria ( /ucr: mg/mmol) were also measured once a week up to month of life results: infants were studied, half exposed to ibu. birth weight was ± g (mean±sd), and ga ± wks. results are presented in the table: *p= . ;**= . ;***< . . j. rouillard lafond, mp. morin, c. girardin centre hospitalier universitaire de sherbrooke, département de pédiatrie, sherbrooke, canada objectives of study: many studies have focused on the negative effects of low birth weight, especially caused by intra-uterine growth restriction, on adult renal function. however, few have addressed the impact of extreme prematurity (< weeks) on renal function of these children during their later childhood and adolescence. the aim of the present study is to estimate the renal outcome of this population, by determining blood pressure, glomerular filtration rate, fractional excretion of sodium and microalbuminuria in children ( girls and boys) aged to years old (mean age ) born between - weeks of gestation (mean: weeks). methods: during one encounter, height, weight and blood pressure were measured for each subject. blood tests were conducted to quantify creatinine, electrolytes and cystatin c. microalbumine, creatinine and electrolytes were dosed in one micturition. pertinent risk factors of renal damage in their perinatal history were noted. results: renal insufficiency, defined by a clearance of less than ml/min/ , m , was present in subjects ( %) when estimated by schwartz formula ( , - , ml/min/ , m ) and in ( %) when estimated by cystatin c ( , ml/min/ , m ). furthermore, ( %) children presented an elevated fractional excretion of sodium ( , - , %) . finally, children ( %) presented microalbuminuria, with albumin/creatinine ratio greater than , mg/mol ( , - , mg/mol) . those children presented more episodes of hypotension during neonatal period (p= , ) and have a tendency to have had neonatal asphyxia more than the others (p= , ). conclusions: these results suggest that children born extremely preterm may present renal insufficiency and sign of tubulopathy as early as adolescence, with microalbuminuria possibly announcing upcoming glomerulopathy. organogenesis isregulated by epithelial-mesenchymal interactions that take place in theembryonic kidney between the metanephric mesenchyme (mm) and theepithelium of the ureteric bud (ub). the mm expresses signals thatregulate ureteric branching while the ub signaling leads to inductionof nephrogenesis. as a response to the ub signals the mm cellscondense, aggregate, epithelialize and undergo simple morphogenesis togenerate segmented nephrons during kidney organogenesis in connectionto ureteric bud branching. we reported earlier that mutagenesis of fgf function from the whole embryonic mesoderm leads to kidney failure. activation of wnt- gene expression encoding another essential signal for nephrogenesis also depends on fgf function (perantoni et al., ) . given the important role of fgf in kidney development we targeted fgf roles in urogenital system (ugs) development with an ugs specific cre line pax cre. pax credeletion was expected to recombine the floxed genome in the nephronprecursors, ureteric bud and the wolffian duct derivatives. in crossesbetween fgf c/c and fgf n/+ ; pax cre mouse lines fgf gene was deleted successfully. as a result the whole ugswas affected. the kidney was severely reduced in size. newborn nullmice were born alive but died within hours likely due to kidneyfailure. in the deficient kidney the organization of theproximal-intermediate segments of the developing nephron was disturbed. marker analysis with in situ hybridization was consistentwith serious defects in nephrogenesis. we conclude that fgf functionis involved in the control of wolffian duct development andsegmentation of the assembling nephron. the zellwegerspectrum disorders (zsds) are characterized by a generalized loss of peroxisomal functions caused by deficient peroxisomal assembly. clinical presentation and survival are heterogeneous. although most peroxisomal enzymes are unstable in the cytosol of peroxisomedeficient cells of zsd patients, a few enzymes remain stable among which alanine: glyoxylate aminotransferase (agt). its deficiency causes primary hyperoxaluria type (ph , mim ), aninborn error of glyoxylate metabolism characterized by hyperoxaluria, nephrocalcinosis, and renal insufficiency. despite the normal level of agtactivity in zsd patients, hyperoxaluria has been reported in several zsdpatients. we aimed to determine the prevalence of hyperoxaluria in zsds and tofind clinically relevant clues that correlate with the urinary oxalate load. methods: we reviewed medical charts of dutch zsd patients with prolonged survival (>one year). results: urinary oxalate excretion was assessed in and glycolate in patients. hyperoxaluriawas present in ( %), and hyperglycolic aciduria in ( %). renal involvement with urolithiasis and nephrocalcinosis was present in five of whichone developed end-stage renal disease. the presence of hyperoxaluria, potentially leading to severe renal involvement, was statistically significant correlated with the severity of neurological dysfunction. discussion: zsd patients should be screened by urinalysis for hyperoxaluria and renal ultrasound for nephrocalcinosis in order to take timely measures to preventrenal insufficiency. menkes disease is a very rare x-linked recessivedisorder of copper metabolism. the frequency is : . live births. mutations in the atp a gene are described, which encodes for aintracellular copper-binding membrane protein. pathogenetically a defect in copper absorption is responsible for inadequate synthesis of copper requiringenzymes and causes multisystemic manifestations. the clinical picture ischaracterized by early neurodegenerative symptoms like muscular hypotony andcerebral seizures. the patients also present with the so called kinky hair, hyperelastic skin, and anomalies of the kidneys and the urinary tract. wereport on a patient of non consanguineous parents of german origin. theprenatal ultrasound did not show any malformations. birth at weeks ofgestation. postnatally a softening of the cranial bones and a vesicoureteralreflux iv° with dilatation of the renal pelvis combined with a subpelvicureteral stenosis had been observed, which were operated at the nd month of life. at the age of months the patient presented with seizuresand abnormal hair structure. within the diagnostic course menkes diseasehas been suspected and the nonsense mutation parg x has been identified inthe atp a gene. the mother is not a conductor, a mutation in thegermline cannot be excluded. conclusion: the combination of urinary tract malformations and neurodegenerative symptoms should let you think of the very rare menkes disease. introduction: primary hyperoxaluria type (ph ) is an inborn error of glyoxylate metabolism due to the deficient activity of the hepatic peroxisomal enzyme agt (alanine: glyoxylate aminotransferase). it leads to excessive endogenous oxalate production. patients develop urolithiasis and renal insufficiency. the contribution of specific precursors in the pathway leading to endogenous oxalate synthesis is not known. this is warranted to design appropriate treatments. we aimed to test the contribution of different precursors to oxalate synthesis. methods: wild type mouse hepatocytes were incubated with different potential precursors of glyoxylate, either in the presence or absence of alanine. in the absence of alanine flux through agt is deficient thereby mimicking agt deficiency. similar experiments were also performed in hepatocytes from agtdeficient mice. results: oxalate production was found to be highest with glyoxylate as substrate in the absence of alanine, whereas oxalate production was lower with glycolate, hydroxypyruvate, glycine, fructose, and ethylene glycol. the results obtained in wild-type hepatocytes incubated in the absence of alanine were comparable to those obtained in hepatocytes from agt-deficient mice. upon addition of alanine to wild-type mouse hepatocytes, however, resulted in % lower rates of oxalate production, in contrast to hepatocytes from agt deficient mice. discussion: hepatocytes derived from agt deficient mice represent a good model to study the contribution of different precursors to oxalate production in ph . s. grisaru , c. geary-joo , f. snider , j. cross university of calgary, department of pediatrics, calgary, canada university of calgary, department of biochemistry and molecular biology, calgary, canada gcm (glial cell missing), is a transcription factor necessary for the formation of placental syncytiotrophoblast in mice. gcm mutant mice die before nephrogenesis at embryonic day (e) . during early murine development gcm expression is limited to the placenta. however, immediately after birth, gcm is increasingly expressed in the kidney in proximal tubular cells in the outer medulla. we recently reported successful rescue the gcm null phenotype using a tetraploid aggregation approach (jasn vol. , ) . since our previous report, further analysis of the aggregation products confirmed only homozygous mutants ( males and a female) obtained from six hundred and twenty five transferred aggregate embryos resulting in live pups. abnormal cortico-medullary patterning was demonstrated by histology analysis of adult gcm null mice kidneys. this abnormality was further defined by immunohystochemical detection of known nephron segment-specific markers (aquaporin- , aquaporin- and tamm-horsfall protein) in gcm null kidney sections. to define the expression of gcm in human kidneys, commercially available anti-human gcm polyclonal antibodies were used to detect gcm protein in tissue sections of newborn kidneys obtained from autopsies. gcm was detected by immunohystochemistry in the renal cortex in tubular structures with cells having a brush border suggestive of proximal tubules. gcm signal was not detected in the renal medulla. conclusion: in humans, gcm is expressed in renal proximal tubules at birth whereas in adult mice its mutation is associated with abnormal renal cortico-medullary ultrastructure. this effect may represent a primary role for gcm in late renal development and patterning, or structural changes occurring postnatally secondary to alterations of tubular physiology caused by gcm inactivation. objectives: lupus nephritis (ln) in singapore children treated with cyclophosphamide and/or azathioprine has a poor prognosis with a reported -year renal survival of %. this study examined the long-term outcome of children with lupus nephritis using a new protocol comprising pulse intravenous methylprednisolone, mmf ± cyclosporine. method: twenty-one children with ln (age range at start of treatment . - . years) who were treated between the years to were included in this retrospective study. mmf dose was mg/m /day. mean duration of follow-up was . ± . (range . - . ) years. treatment outcome was defined by systemic lupus erythematosus disease activity index (sledai), renal function, proteinuria and serologic markers. effect of steroids on growth was assessed by height standard deviation score (htsds). statistical analysis was performed using wilcoxon signed rank test. results: at presentation, % had nephritic-nephrotic syndrome, % had nephrotic syndrome, while % had renal failure requiring dialysis. renal biopsy classification (who) was ii in %, iii in %, iv in %, and v in %. comparing pre-mmf treatment and current follow-up parameters respectively, sledai ( . ± . objectives of study: to understand the effects of response gene to complement (rgc- ) in tgf-β induced epithelial-mesenchymal transition (emt) on human renal proximal tubular epithelial cells (hptecs). methods: constructed rgc- expression plasmids and rgc- sirna hairpin plasmids, transient transfected them into hptecs in vitro, and then treated hptecs with tgf-β ( ng/ml) or vehicle alone for indicated time ( , min, h, h, h) . rt-pcr and western blot were used to determine the expression of a-sma, ecm (col-i, fn ). the mrna expressions of e-cadherin and sm a were detected by rt-pcr. results: ( ) the promoting effects of rgc- on emt. instead of stimulation with tgf-β , the hptecs, those overexpressed rgc- gene, de novo obtain the ability to produce markers of myofibroblast phenotype (a-sma, col-i and fn) and sm a gene, as well as lost the capability of expressing e-cadherin gene. ( ) the eliminating effects of rgc- sirna on emt that induced by tgf-β . after stimulation of tgf-β for hours, the expression of a-sma, col-i, and fn as well as sm a gene in hptecs, those rgc- genes were interfered with rgc- sirna, were significantly decreased than that in controls. conclusions: rgc- was an important regulator for tgf-β and its downstream signalling smad proteins on emt. background: low birth weight is associated with a low nephron endowment. this may predispose to hyperfiltration and cascading proteinuria particularly if obesity develops. our report relates to an emerging population of children with proteinuric kidney disease in our multiethnic community. methods: forty-two obese children (mean age ± years) with proteinuric kidney disease (kd) were studied. twenty-four were of normal birth weight (nbw> grams) and were of low birth weight (lbw< grams). there was a female ( / = %) and an ethnic predominance ( african, hispanic). degree of proteinuria was determined by the random urine protein (pr) and albumin (alb) to creatinine (cr) ratios (upr/cr and ualb/cr). renal function (egfr) was estimated from the schwartz formula. body mass index was used as a measure of obesity (> % centile). insulin resistance was measured by the homeostatic model assessment (homa). kidney tissue was obtained in of the patients for pathology and histomorphometry. results: average bmi was ± % tile. fasting insulin and homa scores were not significantly different in the obese nbw versus obese lbw children. renal biopsy specimens revealed focal glomerulosclerosis (fsgs) in the majority of patients ( / = %). progression to end stage kidney disease was significantly greater in lbw compared to nbw children with a median renal survival of years, p< . . glomerulomegaly as measured by glomerular diameter was similar in obese patients and significantly greater than non-obese controls with fsgs. conclusions: obesity appears to be a confounding factor in the development of glomerulosclerosis and progression of kidney disease in children. low birth weight and concomitant low nephron endowment may contribute to disease progression, especially in those of african and hispanic descent. objective: to determine long term outcome and prognostic factors of iga nephropathy in a large single center cohort of pediatric patients. patients and methods: we have reviewed the medical charts of patients with biopsy proven igan that have been followed at our institution from to , with a minimal follow-up of years. follow-up data, including proteinuria > mg/ h or the need for ace-is therapy, chronic renal failure (crf) and hypertension were analysed after years and years of follow-up. data from patients with follow-up longer than years were also available (mean follow-up . years, range - years). % of patients received therapy (cyclophosphamide in patients and/or steroid±ace-is in the remaining). clinical features at the onset, histology class (lee and haas) and treatment during the first years were analysed by multivariate analysis against the above mentioned dependet variables. results: the average follow-up was . years (range - years). presentation symptoms included macroscopic hematuria in % of patients. at the end of follow-up, renal function was normal in % patients, patients have reached end-stage renal disease and had chronic renal failure. proteinuria or the need for aceis at years was significantly associated with the age of onset (or: . [ . - . ] ) and proteinuria at the onset (or: . [ . - . ] ). crf was significantly associated with familial igan (or> ). hypertension at onset was significantly associated with persistent hypertension during follow-up (or: . [ . - ] . conclusion: taken together, these data indicate that the overall prognosis of igan is good during childhood and that the worst prognostic factor for development of crf is familial igan. overall, histological classification had a poor correlation with the outcome of the disease. this study was designed to compare three urinary protein expert systems for profiling proteinuria (pu) in children with kidney diseases. freshly voided urine was collected from children with glomerular diseases, children with tubular diseases and healthy children aged - years. out of children with renal disease had a glomerular filtration rate (gfr) < ml/min/ . m . the urinary protein expert systems were . albumin/total protein ratio (apr), . alpha- microglobulin/alpha- -microglobulin + albumin algorithm (aaa), and . the complex upes algorhithm (using serum creatinine, urinary total protein, alpha- -microglobulin, albumin, igg, alpha- -macroglobulin and dipsticks). apr correctly identified glomerular pu in of ( %) children with glomerular diseases, tubular pu in of ( %) children with tubular diseases and normal pu in of ( %) healthy children. aaa correctly identified glomerular pu in all ( %) children, tubular pu in of ( %) children, and all healthy children were characterized as having no pathological pu. upes differentiated the type of pu in children with glomerular diseases into glomerular ( / patients) and mixed glomerulo-tubular ( / patients). tubular pu in children with partial or complete renal fanconi syndrome was identified in / patients and described as mixed glomerulo-tubular pu in / patients. mixed glomerulo-tubular pu was only found in children with ckd stages - of glomerular and tubular diseases. in conclusion, urinary protein expert systems may be used to distinguish between glomerular and tubular pu. the aaa algorithm had the highest reliability when compared with the two other expert systems and the accuracy was not negatively influenced by a decrease of gfr. however, upes provided additional information on mixed glomerulo-tubular pu in patients with a low gfr. background: the three lmw proteins cystatin c (cys), β -microglobulin (β -m) and β-trace protein (β-tp) are useful markers of gfr. cys is particularly well suited for the detection of incipient renal failure. however, corticosteroid medication has been shown to stimulate cys production. aim of the study: analysis of the effect of corticosteroid therapy on the correlation between gfr and the three lmw markers. patients: patients ( f, m; median age . years, range . to . ) with malignant (n= ) or nephrological (n= ) diseases underwent a single-shot inulin clearance. the respective lmw proteins were measured by particle-enhanced immuno-nephelometry. children received corticosteroids (prednisone or dexamethasone) in a mean dosage of mg/m /d of prednisone equivalent (pred/bsa). multiple linear regression analysis was performed between the lmw markers as dependent and both gfr and steroid-dose as independent variables. results: mean gfr was . ± ml/min/ . m , mean cys . ± . mg/l, β -m . ± . mg/l and β-tp . ± . mg/l. cys was highly correlated with the reciprocal of gfr (p< . ) but not with corticosteroid-dose (p= . ), whereas both β -m and β-tp were highly correlated (p< . ) with both the reciprocal of gfr and the reciprocal of pred/bsa. discussion: using gold-standard gfr measurements, we cannot confirm earlier reports indicating an increase in serum cys during corticosteroid medication. by contrast, steroids significantly lowered both β -m and β-tp serum concentrations. we conclude that at least in patients with mild renal insufficiency cys -unlike β -m and β-tp -appropriately reflects gfr also during steroid therapy. this further supports the concept of cys being a superior marker of incipient renal failure. objective: to repeatedly follow kidney function since onset of type diabetes and evaluate whether gfr can predict development of micro-or macroalbuminuria or end stage renal disease. design: observational cohort study. methods: since , all diabetic patients undergo renal function tests every nd to rd year from onset. children, boys, have done clearance studies. healthy children and young adults, - years of age, served as controls. gfr was evaluated by clearance of inulin during water diuresis and continuous infusion. results: gfr during the first years after onset of diabetes was significantly higher than that of controls (mean - vs. ml/min/ . m ). at onset, and years after, boys had significantly higher gfr than girls (mean , , vs. , , ml/min per . m ) but after years no differences were found between sexes. the occurrence of microalbuminuria, albuminuria during the first - years was analysed and mean of gfr of , and years, and years, , and years and all those gfrs separately were compared between patients still normoalbuminuric, microalbuminuric and macroalbuminuric after and years resp. no significant differences were found between the groups. moreover the change in gfr from to , to and to and to years were also compared between the groups and no significant differences were found. young adults reached end stage renal disease (esrd) after - (median ) years and comparing their gfrs during the first - years with those still normoalbuminuric after years, no significant difference was found. conclusions: hyperfiltration is found in children with type diabetes during the first - years from onset and hyperfiltration was equally seen during the first - years in those children who in the future developed normo-, micro-, albuminuria and/or esrd. background: hiv associated nephropathy (hivan) remains an important entity despite the use of highly active anti-retroviral therapy (haart). our objectives were to determine the prevalence and severity of renal manifestations in a cohort of hiv infected children during the haart era. methods: a retrospective analysis was conducted on children infected with hiv. renal assessments included quantitation of proteinuria, radiologic abnormalities, and renal function. persistent proteinuria (pp) was defined by urine protein to creatinine ratio (upr/cr) > . detected on at least two measurements month apart. renal sonography and mag renal scintigraphy were categorized according to the presence of bilateral increased echogenicity and/or nephromegaly, and cortical retention and/or diffuse parenchymal disease, respectively. hivan was considered in those children that had pp associated with any radiological abnormalities. results: of the children, . % were perinatally infected. eighty-five ( . %) had pp. of these, had pp alone, while ( . %) developed hivan. the mean age of onset of hivan was . ± . years. overall mortality at the time of analysis was . % and it was highest in those with hivan. viral load (vl) > , copies was significantly associated with hivan. creatinine clearance was significantly decreased in patients with hivan. conclusions: the prevalence of pp in our population of perinatally infected children remains high ( . %), with at least half of them showing evidence of hivan. persistently high vl (> , copies) was associated with the presence of hivan. a spectrum of renal related disorders is a frequent occurrence in hiv infected children and should be sought with periodic urinalysis, quantitation of proteinuria and renal function, and imaging and/or histopathological studies. mmf has shown to be effective in adult ln, whereas only anectodical data are reported in childhood. we evaluated mmf in children with ln, f/ m, mean age: . ± . yrs, proteinuria > g/day, decreased c and increased anti-dsdna serum levels, normal renal function. renal biopsies, before mmf, showed the following classes (weening) : iv in cases, iii in , ii in , vi in . before mmf: patients have received i. v. cyp; more received aza and csa but were in flare-up of disease; the remaining were newly diagnosed patients. each patient received three i. v. metilprednisolone pulses and thereafter mmf (plus oral prednisone(p): mg/kg/day) was administered (mean dose: ± . mg/kg/day; through level: . ± . μg/ml). outcome was monitored by sledai score, renal function, proteinuria. in children p was tapered and, after . ± . month mean time, stopped; children were receiving p ( . mg/kg/day). the mean followup is ± months. sustained clinical remission was observed: proteinuria was absent in all, in patients an increase of serum c and c and a decrease of anti-dsdna levels was seen. significant steroid sparing effect was obtained: hypercorticysm dramatically improved. of the patients achieved years of mmf treatment and in them, at this time, a serial second renal biopsy was performed: histopathological activity indices reduced ( . ± . vs. . ± . , p< . ), whereas chronicity indices did not change ( . ± . vs. . ± . ). no haematological and/or gastrointestinal side effects were observed. our pilot study suggests that mmf represents a good alternative to traditional therapy in the treatment of sle in children, and in controlling disease activity and as steroid sparing agent without significant side effects over the entire period of therapy. mmf has shown to be effective, during treatment, in mantaining remission of childhood sd and csad ns, but few data are available on the mmf long term effectiveness after drug stopping. we report the results of two years mmf treatment in children with sd and csad ns. the characteristics of sd and csad groups were, respectively: patients, boys, mean age . yrs vs. pts, boys, mean age: . yrs (p< . ); first episode ns mean age: . yrs vs. . yrs; ns mean duration: . yrs vs. . yrs (p< . ); mean steroid therapy duration: . yrs vs. mean csa therapy duration: . yrs; histologic features: fsgs , mc vs. fsgs , mc . in both groups mmf was started after remission was achieved with prednisone administered at the last relapse. mmf treatment: lenght: months; mean dose: . ± , mg/kg/day; plasma through level: . ± . mcg/ml; non responder: patient presenting a ns relapse during mmf. in sd group ( %) and in csad ( %) subjects were responders. in patients of sd group and patients of csad group p could be withdrawn over a mean period of . months, so that ns remission was sustained just by mmf; remaining patients were receiving p at a mean dose of . mg/kg/a. d. two years mmf treatment was accomplished in / ( %) patients. at . ± months mean followup since mmf withdrawal, ( %) patients ( of sd and of csad group) relapsed after . months ( . - . ) mean time no haematological or gastrointestinal side effects were observed. our results demonstrate that two years mmf treatment in sd and csad ns children is effective not only in maintaining remission during therapy, but also in achieving persistent remission after withdrawal of drug in a significant rate (> %) of patients; the side effects and the rate of mmf dependence are negligible with respect to those of steroids and csa. information on long-term renal function following treatment for wilms tumor (wt) are relatively scanty. previous studies reported a worrying late development of microalbuminuria (uma), hypertension (hpt) and even reduction in glomerular filtration rate (gfr). the aim of the present study was to evaluate the long-term renal outcome in a cohort of patients who underwent uninephrectomy for wt. glomerular function (as creatinine clearance by cockroft-gault formula) was calculated and uma (as uma/ucr ratio) as well as urinary b microglobulin excretion were detected. -hours ambulatory blood pressure monitoring was also recorded. fifteen patients ( f) with a median age at wt diagnosis of . yrs (range . - . ) were studied. the median follow-up was . yrs ( . ± . ). eight patients had been classified as wt stage and as wt stage ii. all patients had been treated with unilateral total nephrectomy and chemotherapy. two of the children had also been addressed to radiotherapy. the primary disease did not recur in any of the patients. the median age at time of investigation was , yrs (range: , - , ). none of them had a gfr below normal limit (mean gfr was . ± . ml/min/ . m ). urinary b microglobulin excretion was normal (mean ub /ucr: . ± . ) in all of the patients. the mean uma/ucr ratio, was . ± , with only patient exhibiting higher then normal values (uma/ucr ratio: , ). the hr blood pressure was normal in all patients with a mean systolic and diastolic blood pressure sds of - . ± . and - . ± . , respectively. we conclude that as far as renal function, unilateral total nephrectomy combined with chemotherapy for low-stages wt can be look at as a safe treatment although it might be wise to monitor renal function at -year interval. classicaly, patients are divided into monosymptmatic enuresis (mne) and non-monosymptomatic enuresis, however, there is upcoming evidence that this subtyping might be artificial. the aim was to register the characteristics of nocturnal diuresis-rate and bladder volume in both subtypes. methods: retrospective analysis of consecutive patient-files, age - , primary consulting for enuresis in a tertiary center. registration of incontinentia diurna (id) and maximal functional bladder volume (vmax), hours urine-collections in day and nighttime-collections with uosmol and diuresis-volume (dv) and-rate. patients are divided into a mne and nmne-group. results: ) vmax is significantly lower than bladder volume for age, ) nocturnal polyuria is only present in / patients, ) nocturnal diuresis is >vmax, ) there is a significant linear correlation between nd and the nocturnal/daytime-diuresis-ratio, indicating fluid intake dependency. ) there is a negative correlation between nd and urinary osmolality. ) but the positive correlation between total nocturnal osmotic excretion and nd is much stronger. this unexpected observation cannot be explained by the classical primary vasopressin-theory. conclusion: our data show (almost) no statistical difference between the mne and nme-groups, suggesting a continuum instead of separate identities. both groups have a significant low vmax and nocturnal polyuria. the observation of the extremely strong correlation of nocturnal polyuria with the high osmotic excretion and high h urine-production suggests that nocturnal diuresis-rate is highly fluid-and nutrition-dependent, and therefore more attention should be given to this part of the urotherapy. a. deguchtenaere, a. raes, j. dehoorne, r. mauel, e. vanlaecke, p. hoebeke, j. vande walle there is increasing evidence that a subgroup of patients with nocturnal polyuria may have an abnormal circadian rhythm of tubular sodium which may result in vasopressin resistance. the pathogenesis of this phenomenon remains to be elucidated. however if the increased sodiumexcretion overnight results in the ddavp-resistance, decrease of the sodium-excretion-overnight may respond in subsequent ddavp response. aim of the study: retrospective study on the circadian rhytm of diuresis-rate and osmotic excretion in basal condition and subsequent during introduction of ddavp, diet and furosemide. results + discussion: ) baseline-values show significant lower uosmol and higher diuresis-rate overnight compared to controls. striking is the > % part of electrolytes to explain the high osmotic excretion. ) introduction of ddavp results in a normalization of nocturnal uosmol, but despite a significant decrease of uosmol overnight, nocturnal polyuria persists. ) protein-and sodium-restriction results only in slight differences, but of course we do not have data on the compliance. ) furosemide in the morning results in a significant increase of daytime diuresis, osmotic and sodium-excretion, but as compensation decreased nighttime diuresis, osmotic and sodiumexcretion. ) in / cases the antidiuretic effect results in an anti-enuretic effect. conclusion: this pilot study clearly demonstrates that introduction of early morning furosemide results in significantly lower nocturnal diuresis. because the urinary osmolality remains high, this correlates with decreased nocturnal osmotic excretion associated with increased osmotic excretion (sodium) during daytime. background: the elasticity of the vessel walls decreases with age, this process is dramatically speeded up by uremia. as an early indicator of arteriosclerosis pulse wave velocity (pwv) increases along with arterial stiffness. aim: to establish normal values for pwv in healthy children; to compare it with children on dialysis. patients, methods: pwv was measured with a pulsepen device in healthy children and young adults (age range - years) as well as in uremic children ( , ± years) (crf) treated by hemodialysis (n= ) or peritoneal dialysis (n= ). two control groups of - childrens were formed using the database of healthy children: one matched for age (a-c) and one adjusted for height and weight (h/w-c). blood pressure, heart rate, serum calcium (ca), phosphate (p) , and parathyroid hormone levels were also determined. results: a significant linear correlation was found between pwv and age (r= , ), height (r= , ), weight (r= , ), (p< , ), systolic blood pressure (r= , ) and heart rate (r=- , ) (p< , ). crf patients were smaller by , cm than a-c (p< , ), and younger than h/w-c by , years (p< , ). pwv in crf ( , ± , m/s) did not differ significantly from a-c ( , ± , ), however it was elevated in comparison to h/w-c ( , ± , p< , ). serum p, caxp and pth was increased in crf (p< , ) conclusion pwv is higher in children with crf as a sign of increased arterial stiffness. controls matched for height and weight should be used in states of severe growth retardation. a number of established risk factors potentially responsible for arterial dysfunction are present in crf. ngal has been identified as an early marker of acute renal failure (arf). sepsis in very low birth weight (vlbw) infants is associated with arf more often than recognized. the aim of this study is to determine whether ngal represents a marker of renal impairment in vlbw infants affected by sepsis. samples of urine of vlbw infants were prospectively collected for weekly measurement of ngal. after evaluation of the clinical course, groups were identified: group sepsis includes infants affected with septic events associated with some degree of renal impairment and group normal includes uncomplicated vlbw infants. a mouse model of sepsis was created in neonatal mice by intra-peritoneal introduction of salmonella lipopolysaccharide. kidneys were harvested hours after the challenge, and ngal mrna was quantified by real time pcr. ngal values of the normal group did not differ with gestational age or post-natal age of the neonates. the upper bound of the th percentile confidence interval was ng/ml. the median value of ngal in the sepsis group at days before the septic event was ng/ml and during sepsis was ng/ml: these values were not significantly different, but both were significantly higher (p< . ) than the median of the normal group ( ng/ml). once sepsis had been treated, the median value of urinary ngal was similar to normal ( ng/ml p= . ). changes in urine ngal concentration paralleled changes in serum creatinine. sepsis induced animal models showed a dramatic increase of ngal mrna in kidney tubules that paralleled acute renal failure. these neonatal animal and human data suggest that ngal may be an early marker of renal impairment in septic vlbw babies. further investigation is necessary to more exactly define the temporal relationship between the onset of sepsis/arf and rise in urine ngal concentration. we report cases of acute renal failure (arf) associated with orellanus syndrome, a cortinarius mushroom poisoning. grand-father, mother, father and son presented with arf week after gastrointestinal symptoms and weeks after repetitive ingestion of wild mushrooms. critically arf was observed for the year-old boy: anuria, severe metabolic disorders (hyponatremia mmol/l, hyperkaliemia mmol/l, serum creatinine mmol/l, blood urea mmol/l). renal biopsy was performed for the grand-father, father and son (day , and respectively after presentation) and showed similar lesions: severe tubulointerstitial nephritis (tin) with tubular necrosis and interstitial fibrosis. renal replacement therapy was necessary for the father and the son. the mother recovered completely in two weeks without dialysis while renal function improved slowly for the two men. the boy is still hemodialyzed months later. his main problem is uncontrolled hypertension. the diagnosis was confirmed weeks later since fungal spores of cortinarius orellanoides were observed in the contaminated meal by light microscopy. the severity of the disease seems to be related to the toxin quantity: the kg boy ate mushrooms as much as his father and grand-father, the mother ate much less. cortinarius spp poisoning is an exceptional paediatric cause of arf. gastrointestinal disorders are the main symptoms of the initial phase of the poisoning appearing days after the mushrooms ingestion. the renal phase is delayed (median . days) characterized by arf secondary to tin. the toxin effects are dose-related, explaining the severity of the boy's symptoms. the prognosis is severe with % of end stage renal failure. currently no treatment is available. although rare, mushroom poisoning should be considered in the differential diagnoses of arf with tin. l. mendels, ah. bouts, j-c. davin, j. groothoff emma children's hospital/academic medical center, pediatric nephrology, amsterdam, the netherlands background: inchronic dialysis, tertiary hyperparathyroidism (th) is clinically revealed by persistent combined high parathyroid hormone (pth), normalor high total serum calcium (tca) and normal phosphate levels. sincethe introduction of bicarbonate containing dialysate in peritoneal dialysis (pd), we have observed combined high tca and pth level sunusually early after onset of dialysis therapy. in most of the secases, ionized calcium (ica) levels were low. we aimed to investigate the extent of this discrepancy and its association with the mode of therapy. methods: serum ica, tca, pth, bicarbonate and capillary ph were assessed over years in pediatric pd, hemodialysis (hd) and in transplanted (tx) patients. associations between tca, pth and ica were analyzed. results: comparedto tx patients, we found in pd and hd patients a lower mean ica/tcaratio (both p< . ), an increased mean tca-ica (p< . and p < . , respectively), and a higher number of combined normal/increased tca and decreased ica and increased pth values ( . % and . %, respectively for pd and hd, vs. % for tx). alow ica/tca was associated with a high capillary ph (r=- . ; p< . ), a high venous bicarbonate (r=- . , p= . ) and a lowage (r= . , p= . ). conclusions: ica levels are warranted for monitoring calcium phosphate homeostasis in dialysis patients, especially in young pd patients. the use of only tca levels might lead to an inadequate treatment with vitamin d, and henceinduce the development of autonomous hyperparathyroidism in these patients. preterminal renal failure (prf)and end-stage renal disease in children and adolescents are associatedwith an increased risk of atherosclerosis and cardiovascular disease. oxidative stress is one of the pathogenetic factors that could possiblybe influenced by therapeutic interventions. we investigated biomarkers of oxidative stress in children (median age . years) with prf (median gfr ml/min/ . m , range - ) andin children (median age . years) under peritoneal dialysis (pd)and healthy age-matched controls (c). plasma samples wereinvestigated for malondialdehyd (hplc) and carbonyl groups in proteins(elisa) as biomarkers for oxidative stress as well as the plasmaantioxidative substances vitamin c (photometric), vitamin e (hplc), ubichinols (hplc), sulfhydryl groups in proteins(photometric), erythrocyte resistance to radicals and the total radicaltrapping antioxidant capacity (trap). in both patient groups prf and pdwe found a depletion of sulfydryl groups and ubichinol- and a reducedresistance of erythrocytes to radicals. malondialydehyd (p< . ) andcarbonyl groups (p< . ) were elevated in the pd group compared tocontrols. conclusion: from these studies we concludethat in children under peritoneal dialysis biomarkers of oxidativestress are elevated. moreover antioxidative defenses in preterminalrenal failure as well as under peritoneal dialysis are impaired. significant acute renal failure due to non-steroidal anti-inflammatory drugs: inpatient setting in united states non-steroidal anti-inflammatory drugs (nsaid) are freely available over-the counter. many children routinely use them without medical supervision. fourteen inpatients mean age of . ± . years ( males, females), were referred to nephrology for acute renal failure. based on history, biochemistry, imaging and urinalysis the diagnosis of acute renal failure due to nsaid was made. all patients admitted to taking ibuprofen and six also consumed naproxen. the exact doses of either could not be scientifically determined as none were prescribed by a physician. none of the patients had underlying renal diseases at the time of admission. nine patients had proteinuria and had hematuria (including one with gross hematuria). one patient had nephrotic syndrome but resolved spontaneously without steroids and has remained in remission for years. two patients required dialysis. only one of the dialyzed patient required steroid therapy for recovery of renal function. all data are expressed as mean±sd. the mean duration of hospitalization was ± . days. the mean serum creatinine at the peak of renal failure was . ± . mg/dl (range . - . ). all patients recovered renal function with normalization of serum creatinine to . ± . mg/dl (range . - , p< . ). however, the duration from onset to normalization of serum creatinine was ± days; indicating many patients had abnormal renal function for aprolonged period. in conclusion, nsaids pose significant risk of renal failure forsignificant duration and as an entity may be under recognized. objectives: treatment with growth hormone (gh) improves growth retardation of chronic renal failure. cdna microarrays were used to investigate gh-induced modifications in gene expression in the growth plate of uremic young rats, the organ where longitudinal growth takes place. methods: rna was extracted from the tibial growth plate from two groups (n= ) of young rats: uremic (nx) and uremic treated with . mg/kg/day of intraperitoneal gh for one week (nxgh). after reverse transcription, agilent technology was used to analyze differential gene expression by microarrays containing , rat probes (four hibridizations were performed). most expressed genes were detected using linear models and bayesian methods. to confirm gene expression changes shown by the chips, some genes known to play a physiological role in growth plate metabolism were analyzed by real-time quantitative polimerase chain reaction (qpcr). the ribosomal protein l (rpl ) expression did not show changes in the array and was used as the housekeeping gene. results. gh modified the expression of genes, being upregulated and down-regulated. the assay was validated by the qpcr results, which confirmed the sense of expression modification found in the arrays for insulin like growth factor i (down), insulin like growth factor ii (up), collagen alpha (down) and proteoglican type (up) . conclusions: this study shows for the first time the profile of growth plate gene expression modifications caused by gh treatment in experimental uremia. the further analysis of selected individual genes, whose expression is differentially modified by gh will contribute to explain the mechanism of the stimulating effect of gh on growth in chronic renal failure. objectives of study: children with chronic renal failure have an increased risk of cardiovascular disease. this is associated with endothelial dysfunction, a key pathophysiological factor in atherosclerotic disease. circulating endothelial progenitor cells (epcs) have the potential to repair endothelial damage and promote angiogenesis. in adults, the number of epc in peripheral blood correlates with endothelial function and reduced epc levels are associated with a higher incidence of cardiovascular events. we aimed to investigate if children on long-term hemodialysis (hd) therapy have reduced epc levels. methods: we quantified circulating epc in pediatric hd patients before a midweek hd session and healthy age-matched controls. epc are a subfraction of the haematopoeietic stem cells (hsc) expressing both hsc-marker cd and the vegf-receptor- kdr. using flow cytometry, epcs were identified as cd +kdr+ cells and quantified relative to the number of granulocytes in the sample. results: the number of epcs in the peripheral blood was significantly reduced in hd patients ( . ± . vs . ± . / granulocytes, % reduction; p= . ). the total number of circulating hsc also tended to be lower in hd patients ( . ± . vs . ± . / granulocytes, % reduction; p= . ). conclusion: the number of circulating epcs is significantly reduced in children on long term hd. reduced epc levels may contribute to endothelial dysfunction and accelerated atherosclerosis in children on long term hd. future studies are needed to identify the cause of this deficiency and to evaluate if increasing epc levels provides therapeutic benefit. objectives: darbepoetin alfa (aranesp ® ) is a novel erythropoiesis stimulating protein that has been shown in adult trials to have safety and tolerability equivalent to recombinant human erythropoietin. however, to date there is only limited published data on the use of aranesp inpaediatric patients. the objective of this study was to determine the safety and efficacy of darbepoetin in children with chronic and endstage kidney disease. methods: from to , children with either chronic or end stage kidney disease were enrolled in a prospective observational study. the initialdose of darbepoetin was . mcg/kg weekly (either iv or sc) and subsequent dose was titrated to achieve haemoglobin (hb) between and g/dl. results: data analysis to date includes patients ( male : female) whose agesranged from month to years (mean years). hb improved significantly with darbepoetin treatment from mean g/dl (range - ) at start of treatment to g/dl (range - , p< . ) at completion. the mean starting dose was . mcg/kg/week (range . - . ) which was not significantly different to the dose atthe end of the study ( . mc/kg/week, range . - . ). however, there was a significant change in the frequency of administration, with % commencing on weekly treatment, but only % still on weekly treatment at the end of the study (p< . ). the most common treatment interval in stable patients was fortnightly ( %) but a significant number tolerated even longer intervals ( % dosed every weeks or longer). injection pain was common, but there were no other significant adverse events. conclusions: darbepoetin alfa is a safe and effective therapy for anaemia associated with kidney disease. the majority of children will maintain satisfactory haemoglobin at a dosing interval of every weeks orgreater. high prevalence ( %) of left ventricular hypertrophy (lvh) and impaired systolic myocardial function in children with mild-to-moderate chronic renal failure (crf) were observed in previous studies (jasn , jasn ). in adult patients with uncomplicated arterial hypertension, lv mass (lvm) exceeding compensatory value for body size and cardiac workload (inappropriate or ilvm) is associated with poor prognosis, independently of lvh. we tested in crf children if increased lvm compensates or exceeds the expected values for individual cardiac load and if ilvm is associated with impaired cardiac function. complete anthropometrics, biochemical profile and doppler echocardiograms were obtained in children (age . ± . yrs; gfr . ± . ml/min/ . m ). ilvm was defined above % of the value predicted for individual body size, gender, and stroke work and lvh was defined as lvm/m . > g/m . . patients showed ilvm. children with ilvm had higher mean age and lower heart rate as compared to patients with appropriate lvm (both p< . ), without differences in blood pressure, bmi and gfr. after controlling for differences in age, gender distribution and presence of lvh, patients with ilvm showed similar cardiac geometry and diastolic function parameters compared to children with compensatory lvm (p=ns). in contrast, presence of ilvm was associated with lower lv ejection fraction ( . ± . % vs . ± . %) and lower midwall fractional shortening ( . ± . % vs . ± . %)compared to children with compensatory lvm (both p< . ), indicating impaired lv chamber performance and reduced systolic myocardial function. in conclusion, in . % of children with mild-to-moderate crf, lvm is inappropriately increased for individual cardiac workload and body size. presence of ilvm is associated with reduced systolic function, independently of age, gender and presence of lvh. pediatric nephrology centers were enrolled. age groups of the patients were as follows: . % newborn, . % - months, . % months - years, . % - years. underlying diseases were prematurity ( . %), malignancy ( . ), congenital heart diseases (chd, . ), urologic disorders ( . %). low fluid intake was noticed in % of cases. . % of cases developed arf after they have been hospitalized. time to diagnose arf was longer in the surgery department ( . ± . days) compared to pediatrics ( . ± . days), p< . . thirty-nine percent of patients were on mechanical ventilation (mv) before the diagnosis of arf, an additional . % needed mvl after the diagnosis of arf. arf was prerenal, intrinsic and obstructive in %, % and % respectively. hemodialysis and peritoneal dialysis was performed in . % and . % of cases. mortality was . %; and it was secondary to non-arf related causes in . % of cases; presence of mv, intrinsic arf, prematurity, chd, malignancy and being in intensive care unit were poor prognostic factors. conclusion: our nationwide data suggest that nephrologist, intensivist and pediatrician should focus on risk groups to prevent and to diagnose arf earlier. appropriate fluid intake and earlier consultation to a nephrologist are simple but may be effective measures to prevent arf.. hemolytic uremic syndrome is characterized by the triad of hemolytic anemia, acute renal failure, and thrombocytopenia. recent studies have shown that shiga-toxins (st) may stimulate apoptotic cell death in renal tubular cells, but the underlying molecular mechanisms remain to be elucidated. in the present study, confluent llc-pk cells were exposed to st and cell death was studied with morphological and biological assay. in llc-pk cells st was found to induce apoptotic cell death in a dose-and time-dependent manner. the expression of calpain and bax were significantly up regulated by st, while the expression of bcl- was down regulated. cell death was completely inhibited by a specific calpain inhibitor, but not by a broad caspase inhibitor, zvad-fmk, implicating a caspase-independent pathway via calpain. moreover, we found that serum factors could trigger a survival signal against st-induced cell death through pi k/akt pathway. in conclusion, activation of calpain mediates st-induced renal proximal tubular cell death, and the expression of bcl- and bax were oppositely altered. stimulation of pi k/akt signalling protects cells against death. verocytotoxin (vt)-producing e. coli (vtec) infection represents the main cause of hemolytic uremic syndrome (hus) in children. a nationwide surveillance system of hus was introduced in italy in may to follow the trend of vtec infections. for each patient, epidemiological and clinical information was collected by a standardized questionnaire. laboratory diagnosis of vtec infection was based on the detection of vtec and free vt in stools and of antibodies to the lipopolysaccharide (lps) of serogroups, o , o , o , o , and o in the sera. the immuno-detection of vt on circulating neutrophils was also performed on some patients. as of december , cases have been notified, accounting for a mean annual incidence of . x , in the - age group with a significant difference among the regions (from . to . ); median age of patients: months, % males. most cases ( %) occured in summer from june to september. seventy-nine per cent of the cases had prodromal symptoms such as bloody diarrhea ( %) and non-bloody diarrhea ( %). five patients ( . %) died from the disease. stools and/or sera were collected from cases. evidence of vtec infection was observed in cases ( %). the vtec serogroups most commonly detected were o ( % of the vtec-positive patients), followed by o , o , o and o . the number of cases associated with non-o infections increased over time: from the o -associated cases are the most frequent. during the surveillance-period epidemic clusters have been registered: -lombardia, -veneto, and campania. the role of vesico-ureteral reflux (vur) as a predisposition for acquired renal scarring with urinary tract infections (uti) has been questioned in recent years. few studies have investigated baseline factors associated with chronic nephropathy in severe reflux. we aimed to evaluate dmsa scans in children having any degree of primary vur associated with uti in order to identify variables that are predictors of the presence and/or development of renal scar. data of patients with proven uti who have primary vur were evaluated retrospectively. patients and renal units were classified as scar (+) and scar (-) by dmsa results. the following parameters were assessed with respect to their relation to presence of renal scarring: sex, age at diagnosis, grade (g) of reflux, number of subsequent utis (on new renal scars). there were patients (m/f: / , median age months) and refluxing units. variables increasing the likelihood of scar detection were: male gender ( / vs. / , p= . ; or . ), > months of age (for girls only; / vs. / , p= . ; or . ), g iv-v reflux (or . vs. g i-iii reflux and . vs. no reflux). all boys having g iv-v reflux and girls over months of age having g iv-v reflux had very high rate of scarring compared to the rest ( / vs. / , p= . , or . and / vs. / , p= . , or . , respectively). however, variables increasing the likelihood of new/progressive scar development were only the presence of previous scar (or . ) and uti number > (or . ). neither uti number nor new/progressive scar development was affected by vur grade. in conclusion, the most predictive variables for the presence of renal scarring among children presenting with a uti were male gender, age (being > months; only for females) and grades iv-v reflux, while new/progressive scar development was associated with presence of previous scar and uti number. d. hothi , e. harvey , c. goia , d. geary hospital for sick children, department of pediatric nephrology, toronto, canada hospital for sick children, educational, toronto, canada introduction: adequate ultrafiltration (uf) is necessary for good health in dialysis dependent patients. however uf can be hindered by development of intradialytic symptoms and hypotension. objectives: to determine whether sodium ramping, uf profiles and mannitol could improve uf without increasing intradialytic morbidity in children. method: a standardized hd practice was instituted in our unit. we prospectively analysed dialysis treatments from chronic patients with routine scheduled hd, hrs x - /wk. results: uf volumes between . to . % of the dry weight were achieved. mannitol reduced the risk of developing intradialytic symptoms by % (p< . ) without altering the risk of hypotension, with a mean uf volume of . % of the dry weight. a linear sodium ramp ( - mmol/l) increased the odds of intradialytic symptoms (p= . ) and hypotension (p< . ), with no difference in the mean uf volume. all uf profiles increased the risk of intradialytic symptoms but the effect was not statistically significant except with profile (stepwise reduction of uf during procedure). achievement of dry weight was least likely with uf profile (p< . ); there was no statistical difference in the mean uf volume between them all. conclusion: uf volumes higher than the traditional recommendations of % of the dry weight can be achieved in children. the use of mannitol increased the uf volumes and reduced symptoms without increased hypotensive episodes. objective: innate immunity and urinary tract response play a central role int he development of urinary tract infection (uti), in which heat shock protein (hsp) and toll-like receptor have a key position. patients and methods: hspa b a( )g and tlr a( )g genotypes were determined using allele-specific polymerase chain reaction in patients treated with recurrent urinary infection. allelic prevalence was related to reference values of healthy controls. clinical data were also reviewed and statistically evaluated. results: hspa b ( )gg genotype and hspa b ( )g allele occurred more frequently in uti patients versus controls (p= . ) and both were associated with a higher risk of renal scarring (p= . and . , respectively). tlr ( )ag genotype and tlr ( ) g allele had also higher prevalence among uti patients than controls (p= . and . , respectively). the combination of carrying ag genotype at both sites meant the greatest risk for uti (p= . ). conclusion: our data indicate an association between the carrier status of hspa b ( )g and tlr ( ) one of the major goal of hemodialysis adequacy is to achieve the fixed endsession body weight, so called dry weight, in order to limit overhydration and thereby cardiovascular risks. the prescribedultrafiltration, can induce hypotensive episodes and thereby limit thedry weight achievement. on line equipments offer the assessment of theblood volume (bv) and its relative variation. the bv is derived fromdirect measurement of the hematocrite. weroutinely use such an equipment (fresenius a c) over all thesessions since february , conducting to a clinical experience of bvm curves. these registered curves could be related to thehemodialysis prescription parameters (uf, nad, td, kt/v) to the dryweight, the blood pressure and to the clinical dialytic symptoms. thisexperience conducts us to define the normal bv curve over a sessionand its variations. starting dialysis induces an acute initial ( to min) decrease of bv, to %, mostly asymptomatic: extra corporeal circuit filling; this initialdecrease is a sign of normality. there after the normal bv curve should be flat; uf rate/amount being compensated by the plasma refilling rate: iso osmotic dialysis, no symptoms, no cramps, no hypotension, no vomiting. incase of no bv decrease over the dialysis session, the patient isoverloaded: reduce his dry weight. in case of a decrease of the bvhigher than %, there is a hypotensive risk: uf rate/amount, dryweight, sodium dialysate, sodium temperature and kt/v urea (cellular water shift) should be individually adapted conducting to arefilling curve. the effectiveness on the bv of these individual changein dialysis prescription can be directly, on line attested by the bvmcurve: plasma refilling capacity test. the bv changes reactivity is rapid, to min. renalscarring following acute pyelonephritis (apn) in children is a frequentcomplication which may impair renal growth. its pathophysiology includes host response, bacterial virulence, associated malformationand/or renal dysplasia. we prospectively studied virulence factors of e. coli isolates from children with a first episode of apn (fever > . c°, crp > mg/l, monomicrobial e. coli positive culture > * cfu/ml). we excluded patients with anyconcomitant infection, renal dysplasia or obstructive uropathy (us examination, renal length < sd) or grade - vur. renal scarring was evaluated by dmsa scan performed to months after apn. patients were included in a multicentre prospective randomized study comparing short vs long i. v. treatment with ceftriaxone as a first line antibiotic treatment [in press]; out of them fulfilled criteria for virulencestudy. six virulence genes were investigated by multiplex pcr (pap, sfa, afa adhesine genes; cnf , hly toxin genes, aeraerobactin gene) and the k capsular antigen was researched by latextest. we identified distinctive virulence profiles; % of e. coli strains had one or more virulence factors; % expressed the aer genewith at least one adhesin or one cytotoxic factor. renal scars occurredin % of cases and low grade ( - - ) vur was detected in %. statistical analysis did not show any correlation between the presenceof scars and e. coli virulence pattern. in addition, scarring was not correlated with the antibiotoc regimen but was correlated with grade vur (p . ). most e. colistrains associated with apn in children show several virulence factors, mainly adhesins and cytotoxins, but their profile was not correlated with renal scarring. background: acute lobar nephronia (aln), a severe renal parenchymal inflammatory disease, ranging between acute pyelonephritis (apn) and frank abscess formation, has been diagnosed with increasing frequency due to the advancement of non-invasive diagnostic modalities and the development of systematic diagnostic schemes. e. coli is the most common bacterialpathogen isolated from the urine samples of aln patients and the associated percentage is significantly higher than those among the patients with first time urinary tract infections. this prospective study was conducted to elucidate and differentiate the bacterialvirulence factors associated with aln and apn in pediatric patients. methods: patients included in the present study were those suspected of anupper uti and underwent a systematic scheme of ultrasonographic, ct and tc m-dmsa evaluation for the differential diagnosis of aln andapn. exclusion criteria were any evidence of underlying diseases orurinary anatomical anomalies except vur. the e. coli isolates from the urine samples of patients were screened with pcr analysis for various urovirulence genes. pulsed-field gelelectrophoresis was used to analyze the genetic association of theisolates. results: a total of patients were enroled. forty-six patients were diagnosed as aln, while the other cases were apn. diverse genotypes were found among the e. coli isolates in either group. among the pathogenetic determinants examined, multivariate logistic regress analysis indicating that a papg ii allele was the only significant urovirulence factor associated with aln (p< . ; odds ratio, . ). conclusions: while no specific genetic lineage was identified among the e. coli isolates studied, a papgii gene was found strongly associated with the cause of aln among pediatric patients without underlying disease other than vur. -< yr during - were sent to leading paediatric nephrologists of asian countries/regions. those having national renal registry were to use the registry data. results: data from countries/regions were returned (incl. national registries), namely china, hong kong sar, india, indonesia, japan, malaysia, pakistan, philippines, singapore, south korea & thailand. a total of esrd patients were reported: on peritoneal dialysis (pd), on haemodialysis (hd), & transplant (tx) of %, % & % respectively. chronic pd: capd and automated pd (apd) were the main modes of pd at ratio of . to . only countries had apd morethan capd. peritonitis rate ranged from episode in to patient-months, and seemed less common in those having more apd. chronic hd: hd comprised of % chronic dialysis, mostly adolescents. a-v fistula wasused in %, and permanent catheter % for vascular access. background: current data suggest the role of chronic inflammation and lipid disorders in atherogenesis. the aim of the study was to evaluate established and new markers of atherosclerosis in apd and hd pediatric patients and to assess whether the method of dialysis has an impact on those factors. methods: soluble(s) e-selectin, il- and il- concentrations were evaluated by elisa in sera of apd patients on, hd patients and controls. hscrp levels were assessed by nephelometry. the lipid profile (total cholesterol (chol), hdl-chol, ldl-chol, triglycerides (tgl)) was also estimated. results: se-selectin concentrations in dialyzed patients were higher than in controls (apd p< . ; hd p< . ) and in apd were increased vs. hd (p< . ). there were no differences in median values of il- , il- and hscrp between examined groups. chol levels were increased only in apd vs. controls (p< . ). hdl-chol concentrations were decreased in all dialyzed patients when compared to controls (apd p< . ; hd p< . ), without difference between apd and hd. ldl-chol in apd and hd were higher than in controls (apd p< . ; hd p< . ), but failed to differentiate between two dialysis modalities. tgl levels behaved in the same way. conclusions: the elevated se-selectin concentrations in all patients show the role of endothelium in atherogenesis in ckd children. thus, the se-selectin augmentation may serve as an early marker of endothelial activation, appearing prior to inflammation (unchanged hscrp, il- ). increased seselectin and cholesterol levels in apd patients prove that children on peritoneal dialysis are more prone to atherosclerosis than those on hemodialysis. background: end-stage renal disease (esrd) is associated with an increased risk of cardiovascular morbidity and mortality. according to recent data, arterial stiffness measured by aortic pulse wave velocity (pwv) and augmentation index (aix) is a strong independent predictor of cardiovascular mortality in adult esrd patients. few studies have been reported regarding arterial stiffness in the paediatric renal population. methods: aortic pwv and aix (difference between the first and the second systolic peaks on the aortic pressure waveform divided by the pulse pressure) were determined in haemodialysis children ( boys; age ± years) by applanation tonometry using a sphygmocor device. seven of the hd patients ( boys; age ± . years) received a renal transplant (tx) and were restudied ( ± months post tx). the immunosuppressive regimen included basiliximab induction, cyclosporine, mycophenolate mofetil, and steroids. results: in the hd population, aortic pwv ( . ± . m/s) was correlated with age (p= . ), weight (p= . ), height (p= . ) and systolic blood pressure (p= . ). in the transplanted cohort aix decreased in six children out of seven after transplantation ( . ± . % on hd versus - . ± . % after tx). no significant change was observed for aortic pwv ( . ± . m/s on hd versus . ± . m/s after tx). objective: to study the pathogenic role of host and escherichia coli virulence factors in the development of e. coli febrile urinary tract infection (uti) in children with acute cystitis (ac), acute pyelonephritis (apn) and renal scar. materials and methods: isolates recovered from children consecutively admitted to the hospital with e. coli febrile uti that diagnosed as ac (n= ) or apn (n= ) were retrospectively enrolled into this study. virulence genes of e. coli, that included papg genes (classes i-iii), aer, cnf , fimh, hlya, afa, sfa/foc, iha, usp, irone and ompt, were detected by polymerase chain reaction analysis. results: young age (=< months), male sex were more frequently associated host factors for patients with apn, but old age (> months) and female sex were more frequently associated with renal scar formation. after multilogistic regression analysis, with regard to e. coli virulence factors, the papg class ii gene might play a more important role in the development of e. coli apn. however, iha was significantly higher in young children with acute pyelonephritis. afterwards, age, gender, duration of fever before admission, and crp level were considered as potential confounders for the further multivariate analyses, specifically estimating the relative risks of e. coli genotypes to the incidence of acute pyelonephritis and renal scar by age group and the existence of vesicoureteral reflux. odds ratios with % confidence intervals for each variable were utilized to estimate the relative risk of acute pyelonephritis and renal scar. in addition, there were no differences between young children and old children, if we excluded the factor of vesicoureteral reflux (vur). conclusion: both host and e. coli virulence factors contribute to the development of febrile uti, apn and renal scar. since / we have started an acute peritoneal dialysis (duration - days) in infants (age days to months) with the use of the baxter acute set for children under constant warming of the complete dialysate inflow tract to °c (barkey system). as dialysate solutions we chose a glucose/bicarbonate/lactate solution (physioneal ) in all patients and in patients a mixture of this solution with a . % amino acid solution (nutrineal) in a : ratio. the body weight before the renal insufficiency was . to . kg. in patients the renal failure followed cardiothoracic surgery. the handling of the system was easy. because of obstruction by omentum and fibinous layers, respectively, the dialysis catheter had to be cleared surgically in patients. body temperature could be kept constant and in the normal range, even with low body weight and intensive dialysis (as measured by dialysate volume per kg body weight and day). in the infants dialyzed with the glucose/amino acid-mixture a decreased loss of albumin through the dialysate (as measured by the necessary intravenous albumin substitution), a better glucose homeostasis (less episodes of hyperglycemia and less need for insulin infusions) as well as a better acid-base control (less episodes of metabolic alkalosis) could be found. the detected tendency to a better homeostasis (concerning body temperature, serum albumin, blood glucose and acid-base) with this dialysis system and the used dialysate solutions could help to increase the survival chances of infants with renal failure. this will be evaluated prospectively. objectives: varicella-zoster-virus (vzv) infection can cause significant morbidity and mortality in the immunocompromised patient. since there is no clear correlation between antibody titers and protection monitoring after vzv vaccination is unclear. patients and methods: serum samples of nineteen pediatric transplant recipients were investigated for vzv igg antibody titers and avidity (elisa test). a relative avidity index (rai) < % showed evidence for low-avidity antibodies, an rai > % high-avidity antibodies, borderline avidity inbetween. the control group consisted of healthy children. had suffered from varicella infection after wild-virus contact, had undergone varicella vaccination. as there was no difference between diseased and vaccinated controls both subsets were treated as one group. results: median vzv igg antibody titers were u/ml (range - ) for transplanted children and u/ml (range - ) for control subjects (n. s.). median rai was % for transplant patients and % for controls (p= , ). there was no correlation between rai and antibody titers in either group. rai increased significantly with time after vaccination or infection in both groups. despite protective antibody titers after vaccination and an rai of % one transplant recipient showed a moderate vzv infection that required antiviral treatment. postinfectious course showed an increase of rai up to nearly %. conclusion: vzv igg antibody avidity might be a pathbreaking parameter regarding decision making for a second vaccination before transplantation or preemptive treatment in a transplanted patient in case of exposure. in japan, almost half of children with esrd received renal transplantation and more than % of those were living kidney transplants from their parents. burden of esrd during childhood frequently causes psychosocial problems in their families, including parental relationship problems. we investigated how parental divorce or death affected the choice of renal transplantation in children. patients and methods: in children younger than years old who started renal replacement therapy in our hospital, percentages of the children losing a parent or parents by divorce or death were investigated. we compared renal transplantation rates and percentages of fathers as kidney donors between those living with both parents and those without. results: in observation periods ( . ± . years), ( %) received renal transplants from living and deceased donors. nineteen children ( %) lost a parent or parents by divorce (n= ) or death (n= ). in all divorced families, mothers got parental authority. ten parents divorced during ckd period, after start of dialysis, and after transplant. of children living with both parents, ( %) transplanted with kidneys from fathers, mothers, and deceased donors. of children whose parents divorced, ( %) transplanted from fathers ( just before and after their divorce), mothers and other family members. however, in children at least one parent died, only ( %) transplanted from a deceased donor. conclusion: a high parental divorce rate from ckd period was observed in children with esrd, suggesting burden of the disease on their families. renal transplantation was preferred even in divorced families and divorced fathers still were willing to donate kidneys to their children. objective of study: to determine the importance of gastrointestinal evaluation in pre-transplantation phase in pediatrics with end stage renal disease (esrd). methods: twenty four children with esrd ( female, male) mean age . (± . ) years on maintenance hemodialysis were included in this study. upper gastrointestinal endoscopies were performed and four gastric antral and duodenal biopsy specimens were obtained for urease test and histological study for all patients. serum gastrin levels were measured in all patients, too. a control group was chosen to compare the rate of h. pylori infection using student's t. test. results: gastrointestinal symptoms were present in ( %) of patients. seventeen ( %) patients had abnormal upper gastrointestinal endoscopic findings. h. pylori was detected in % of patients and % in control group (p< . ). in symptomatic patients % had abnormal endoscopic findings and % had positive urease test for h. pylori infection. while, in asymptomatic cases these rates were % and %, respectively. seventy one percent of patients with gastrointestinal lesions and % of patients with normal endoscopic examination were infected. high serum gastrin levels in infected and non-infected patients were detected in % and . %, respectively (p< . ). conclusion: we demonstrated a significant number of patients with peptic ulcer diseases and h. pylori infection and secondary hypergastrinemia. this study showed that, clinical symptoms are not a reliable predictor of gastrointestinal problems. our results emphasize the importance of periodic, and also pre-transplant gastrointestinal evaluation in these patients to find out their problem and manage appropriately. key words: renal failure, hemodialysis, peptic ulcer disease, helicobacter pylori, hypergastrinemia. background: preservation of a stable allograft function in children following renal transplantation (rtx) depends on various factors including genetic variability. the gene of the angiotensin i converting enzyme (ace) has been shown to influence allograft function. we therefore analysed various polymorphisms of the renin-angiotensin system in children following rtx and kidney donors and associated genotypes with loss of renal function. patients and methods: children and adolescents ( male, female, mean age at transplantation . ± . years) with stable renal function and observation period exceeding months were included. mean follow-up time was . years ( . to years). dna was extracted from all recipients and donors and genotyped using rflp. the following polymorphisms were studied: renin g/a; ace i/d; angiotensinogen (agt) met/thr and angiotensin ii receptor type- (at r) a/c. the slope of glomerular filtration rate (gfr) was determined by linear regression analysis and correlated with the genotype. results: allelic frequencies were not different from healthy controls. genotypes of renin, agt and at r showed no significant association with the slope of gfr but patients homozygous for the ace-d-allele had a significantly steeper decline of gfr when compared to homozygous carriers of the ace-i-allele (slope dd: - . ± . vs. ii: - . ± . ; p= . ). the dd-genotype was also present in out of donors and in four cases a dd-recipient received a kidney from a dd-donor. those four patients showed a more pronounced decline of gfr (- . ± . ; p= . ). in addition, dd-recipients had a significantly increased systolic and diastolic blood pressure before rtx. conclusions: the dd-genotype is associated with a faster, non-immunological loss of graft function which has to be evaluated in prospective studies. year large single-center review b. warshaw, l. hymes, l. greenbaum, s. amaral from - , children received renal transplants at emory university/children's healthcare of atlanta of whom ( %) had nephroticsyndrome (ns) as their primary diagnosis ( fsgs, minimal change). all children received calcineurin-based immunosuppression. thirteen children ( %) developed recurrent ns within the first week post-transplant and received plasmapheresis (pp) - times weekly. nine ( %) had complete resolution of proteinuria. two who responded to pp suffered graft loss fromlate recurrences of ns at years. ns did not resolve with pp in children who suffered either delayed function ( ) or early cessationof function ( ); each of the latter lost their grafts within the first months. patients did not have recurrences of ns. comparison of these groups showed significantly increased riskfor recurrence with younger patient age (p< . ), interval < years from onset of ns to esrd (p< . ), and living donor source ( / = % ld vs / = % dd; p< . ). no differences were seenfor hla match, donor age, gender, or african american race. actuarial graft survival for children with recurrence was % at year and % at years vs. % & % for patients without recurrence. conclusions: ns recurred in % of children with ns as their primary cause of esrd. risk factors for recurrence included younger age, interval < years from onset of ns to esrd, and living donors. most recurrences responded to pp ( %); failure to respond was associated with delayed or early cessation ofrenal function & early graft loss. the incidence of recurrence was strikingly high ( %) among living donor recipients, suggesting a need to explore prophylactic strategies such as preemptive pp in this group. methods: a single-centre retrospective case-controlled study including children < yr (g ) and matched kidney tx recipients older than yr ofage (g ). patients were matched for donor type and tx period. kaplan-meier method was used for patient and graft survival. results: tx were performed using deceased donors in both groups. median recipient age, weight and height at tx in g were . [ . - . ] yr, . [ . - . ] kg and . [ . - . ] cm, respectively, while median age in g was . [ . - . ] yr. hypoplasia-dysplasia wasmore frequent in g ( vs %). median hla-dr mismatch, time ondialysis and number of blood transfusion before tx were not different. in g , kidneys were placed intraperitoneally and most of vascular anastomoses were done on distal aorta ( %) and inferior vena cava ( %). median follow-up was . [ . - . ] yr and . [ . - . ] yr ing and g , respectively. patient survival was % at yr and % at yr in g ; patients died in g ( ptld, recurrence of primary disease), none in g . fiveyear graft survival was % in g and % in g . acuterejection episodes occurred in % in g and in % in g (p . ). chronic rejection led to late graft losses in g ( . to . yrafter tx) vs in g . renal function did not differ between the groups during the first yr post tx. the average height gain was better in g at yr post tx (+ . sds vs. - . ). primary disease recurrence was observed in cases ( in g ) causing graft lossin cases. two arterial thromboses were observed in g causing earlygraft-loss. conclusion: the outcome after cadaveric kidney transplantation is as good in children under yr of age at transplantation as in older recipients in our experience. c. garcia, v. bittencourt, d. malheiros, a. tumelero, j. antonello, a. oliveira, v. garcia cancer is an increasingly recognized problem associated with immunosuppression. recent reports, however, suggest that sirolimus (srl) has anti-cancer properties that could address this problem. aim: to report a retrospective analysis of preliminary results of patients who received srl because of post-transplant de novo malignancies in a consecutive cohort of pediatric kidney recipients. patient and methods: we retrospectively evaluated the efficacy and safety of srl in pediatric renal transplantation recipients, who were ± years when converted to srl. the post-transplant de novo malignancies were: gall bladder and hepatic leiomyoma (n= ), wilms tumor in the native kidney (n= ), ptld (n= ) and hpv-associated neoplasia. the immunossupressive regimen at the malignancy diagnosis was tacrolimus/cyclosporin, mmf/azathioprin and prednisone. all were converted to double immunossupression with sirolimus at a standard dose of mg/day (tl - ng/ml) and prednisone. patients with ptld were also treated with rituximab, and the patients with wilms tumor received chemotherapy. mean follow-up after srl conversion is ± months. results: all patients were maintained with srl and pred without rejection, with good renal function and no cancer recurrence (follow-up to months). the patients with wilms tumor are still on chemotherapy. follow-up control after srl conversion in the patients: conclusion: although the intraperitoneal group had characteristics associated with increased surgical risk (they tended to be younger and smaller, with a higher incidence of aortic anastomoses and a higher incidence of multiple vessels), surgical complications were significantly lower than expected in the extraperitoneal group % v. %. objective of study: proteinuria is a frequent complication in adult patients after renal transplantation (r-tx) and is associated with poor graft survival. in children, there are no studies focusing primarily on proteinuria after r-tx. the aim of this study was to investigate the prevalence of proteinuria in children after r-tx and to evaluate changes of proteinuria during a -yr study on intensified antihypertensive therapy. methods: protein excretion was measured in -hr urine and proteinuria defined as > mg/m /day. proteinuria was investigated at baseline, and years after intensifying of the antihypertensive therapy in children with uncontrolled hypertension at baseline (i. e. additional antihypertensive drugs given to children with blood pressure > . pc). children ( . ± . yrs) out of from our center fulfilled inclusion criterias (> months after r-tx, no acute rejection (ar) in the last months, no recurrent fsgs). results: the prevalence of proteinuria was % at baseline, % after year (ns) and it decreased to % after years (p< . ). the mean protein excretion was ± mg/m /day at baseline, ± after year (ns) and it decreased to ± after years (p< . ). mean number of antihypertensive drugs increased from . ± . drugs/patient to . ± . after years (p< . ). mean nighttime bp decreased significantly after years. the number of patients on ace-inhibitors increased from % at baseline to % after years (p< . ). conclusions: this is the first study on proteinuria in children after r-tx. it showed that proteinuria is a frequent finding in transplanted children and that intensified long-term antihypertensive treatment using ace-inhibitors can decrease not only bp but also proteinuria in these patients. allograftrejection involves t cell activation and proliferation and multipleinflammatory components. monocyte chemotactic peptide- (mcp- ) is achemoattractant and activating factor for monocytes. interleukin- (il- ) may contribute to monocyte recruitment, results intubulointerstitial damage. cytotoxic lymphocytes induce target cell death by ligation of the fas-fasligand. allelic polymorphisms in recipient genes coding for them reported to beassociated with variations of outcome in renal transplantation. the aim was to investigate impact of mcp- - a/g and il - g/c, fas- a/g polymorphisms on acute allograft rejection (ar). there were males and females, ± . years meanly; of the graftscame from living-related donors, were from cadavers. the controlgroup consisted of unrelated, healthy individuals with similar ageand sex. ar group was composed by patients experienced at least one ar episode within the first months of transplantation. the non ar group was comprised by kidney transplant patients without ar. there was no significant difference between renal transplant patients and healthy controls in genotype distribution of allelic frequencies of il- , fas and mcp- polymorphisms. while il- and fas gene polymorphisms had no effect on the incidence of ar episodes, there was significant association with mcp- . the distribution of the genotypes for mcp- - a/g in ar group were aa/ag/gg , %, , %, , % respectively. the distribution of the genotypes for mcp- - a/g was aa/ag/gg %, %, % in nonar group respectively. the carriage of g allele at - position of mcp- gene has a significant association with ar (or: , , %, ci: , - , ). the il- and fas gene polymorphisms had no effect on the incidence of ar. mcp- - g allele carriage increases the ar risk in turkish renal transplant patients. the high recurrence rate of focal segmental glomerulosclerosis (fsgs) in transplanted kidney recipients suggests the hypothesis that such patients have a circulating factor that changes glomerular capillary permeability. serum from patients with fsgs increases glomerular permeability to albumin, and this permeability factor was partially identified as a protein. the removal of this protein by plasmapheresis (pp) decreases proteinuria. object: the aim of this paper is to provide data about the therapeutic effect of pp in fsgs children with recurrence in the transplanted kidney. methods and results: twenty eight pediatric kidney transplant recipients had fsgs as cause of renal failure from to in our center, confirmed by biopsy pre-transplant. seventeen of these ( . %) had a recurrence (proteinuria > g/m per day associated with hypoalbuminemia). the mean age was ± . years, , % were caucasians and , % were performed with living donor. since , patients who presented fsgs recurrence were treated with cycles of pp ( cycles/weekly), initiated immediately post-recurrence (n= ). immunosuppression comprised of cyclosporin in high doses (c levels of - ng/ml) or tacrolimus (tl= mg/dl), mycophenolate sodium or mofetil (until azathioprine was used) and prednisone. among patients who received pp (n= ), ( . %) achieved a complete remission. there were no cases of remission among those six patients who were not treated with pp. those who achieved remission after pp had no recurrence. the patients treated with pp had infectious complications: one patient had cytomegalovirus disease and two patients had varicella. conclusion: pp appears to be effective in treating recurrent fsgs following kidney transplantation. it should be started as soon as possible. because the calcineurin inhibitors (cni) cyclosporin a (csa) and tacrolimus (tac) are drugs with a narrow therapeutic index, individualization of cni dosage by therapeutic drug monitoring is indisputable. however, the optimal strategy for monitoring cni therapy is currently under debate. dosing of cnis according to the molecular effect of the drug on its target cells could optimize immunosuppressive therapy with cnis. for this purpose, we developed a reliable, precise, and robust whole blood assay based on the measurement of the expression of three nfat-regulated genes (il- , ifng and gm-csf) in pma/ionomycin-stimulated lymphocytes before and . (tac, c . ) or hrs (csa, c ) after oral drug intake. the inhibition of genes in this assay is independent from other commonly used immunosuppressive drugs and reflects calcineurin inhibition expressed as residual nfat activity. in a pilot study, patients (mean age yrs, mean time period posttransplant mo.) were analyzed. in csa-treated patients (n= ), a mean c concentration of ng/ml (range, - ng/ml) corresponded to a mean residual nfat-activity of % (range, - %) ; the correlation between individual residual nfat-activity and c was moderate (r= , , p< . ). at a csa-c of ng/ml, the residual nfat-activity varied between % and %. in tactreated patients (n= ), a mean c . concentration of ng/ml (range, - ng/ml) corresponded to a mean residual nfat-activity of % (range, - %); the correlation between individual residual nfat-activity and c . was also only moderate (r= , , p< . ). conclusion: these data indicate that there is a considerable inter-patient variability of residual nfat-activity at a given maximal cni blood concentration. ongoing studies are validating this assay regarding clinical outcome criteria of immunosuppression such as acute rejection and infections. hus due to antibodies against factor h (husafhab) is a very rare disease for which a limited experience in its management is available. we present a case of husafhab who was transplanted but lost her graft after only mos. in aug a -mos old child was admitted for a d-hus which did not go into remission and required chronic peritoneal dialysis. no fh and mcp gene mutation were detected nor adamst- activity was decreased. afhab were not searched at that time. in apr. the child underwent cadaver renal transplant (rtx). the immunosuppressive regimen was basiliximab-prednisone-cyclosporine-mycophenolate mofetil. fifteen days after rtx, following surgery for urinoma, the child exhibited an hus relapse with thrombocytopenia, haemolytic anemia and increased serum creatinine (scr). high afhab were detected ( au/ml). four plasma exchanges (pe) were performed over wks with a drop of afhab to control level ( au/ml) and a remission of hus. until the end of aug, afhab remained low (< au/ml) and the child was well (scr range: . - . mg/dl). in early aug, the patient was shifted to tacrolimus for severe hypertrichosis with a fluctuation of its plasma level (lower recorded value: . ng/ml) signs of acute rejection developed and metilprednisolone (mtp) pulses brought scr to baseline level. in oct. , following an urti, the child presented with severe proteinuria (upr/ucr: , ) without other clear signs of hus recurrence. since afhab were increased ( au/ml), pe was restarted but an acute hemorrhagic complication (hemotorax) occurred and pe had to be interrupted. septicemia followed and the child became anuric. the renal biopsy performed days later showed signs of glomerular and vascular thrombotic microangiopathy. renal function did not recover despite mtp pulses and pe. in nov the child was back to pd and in dec the graft was removed. background & aims: recently, the role of nitric oxide (no) in the pathogenesis of idiopathic nephrotic syndrome (ins) has been intensively investigated. however, its rapid turnover has made us impossible to investigate the quantity and the source. as we have developed a novel method for quantitative analysis for no by a new fluorescent indicator, , -diaminofluorescein (daf- ), its amount produced by both t and b lymphocytes in ins was studied. methods: five children with steroid-sensitive ins (mean age: . y) were included in this study, together with children with other renal diseases (mean age: . y) such as chronic glumerulonephritis and alport syndrome with significant amount of proteinuria, and healthy adults (mean age: . y) for the control. no production from cd + cell and cd + cell was investigated by a flow cytometry using daf- . results were expressed as mean fluorescence intensity and were compared among the groups. results: the amount of no produced by cd + cell and cd + cell in children with ins was significantly greater than those in children with other renal diseases and healthy adults (cd + cell: . ± . [mean±sd], . ± . , and . ± . , respectively; cd + cell: . ± . , . ± . , and . ± . , respectively, p< . ). additionally, both cd + cell and cd + cell during nephrotic relapse produced more no than in nephrotic remission (p< . ). discussion: patients with relapsing ins showed increased production of no by both t and b lymphocyte. these findings indicate that no plays some role in the pathogenesis of ins and suggest that an abnormal immune system may exist not only in t but also in b lymphocytes. a. bagga, a. sinha, s. menon, p. hari aim: the treatment of patients with srns is challenging. based on suggestions that b-lymphocytes are crucial in the pathogenesis of nephrotic syndrome, we examined the efficacy of rituximab (rtx) in patients with srns refractory to standard therapies. methods: six patients ( with initial, late resistance), - yr old, were included; biopsy showed minimal change & focal segmental glomerulosclerosis in each. all had previously received iv high-dose steroids, alkylating agents & calcineurin inhibitors (cni) for - yr with periods of partial (pr; urine - +) or complete remission (cr; urine trace/negative). all now had srns refractory to -months treatment with cni. rtx ( mg/sq. m) was infused iv every week for weeks. therapy with cni and/or alternate-day prednisolone, & cotrimoxazole prophylaxis was continued. patients were monitored for proteinuria and renal functions. results: at a median interval of wk following the last rtx dose, cr was seen in & pr in patients. remission was sustained in patients, despite tapering doses of steroids & cni. one case had relapse of nephrotic syndrome -months later, which responded to steroid treatment. at median follow-up of wk, cr, pr and recurrence of nephrotic proteinuria ( - +) were seen in , and patients respectively. mean urine albumin-to-creatinine ratio was . at baseline and . at followup; respective blood levels of albumin were . and . g/dl & cholesterol and mg/dl (all p< . , anova); difference in leukocyte counts and levels of igg were not significant and none had serious infections. conclusions: this is the first report on the efficiacy of rtx in sustaining remission in patients with srns. therapy with this agent appears promising for difficult srns, with a better risk/benefit profile than other medications. quantitative or functional deficiency of factor h results in uncontrolled complement activation and is an important cause of familial hemolytic uremic syndrome (ahus). factor h-related proteins (fhr) constitute a protein family which share structural and most likely functional similarities to factor h. we here describe complete deficiency of fhr- /- as novel cause of ahus. factor h and fhr- /- were quantified by elisa and were further analyzed by western blot using specific antibodies. complement activation was determined by measuring c and c . serial hgb (g/dl), platelet, creatinine (mg/dl), and ldh (u/l) were measured. a year old girl presented with a day history of lethargy, pallor, vomiting and hypertension. hgb was g/dl, platelets x /l and creatinine was . mg/dl. initial therapy consisted of packed red cell and platelet transfusion, followed by steroid therapy. representation occurred weeks later with hypertension, edema, persistent anemia thrombocytopenia and renal dysfunction (creatinine . mg/dl). renal biopsy demonstrated features of chronic thrombotic microangiopathy. low c levels indicated activation of the complement system. while western blot analysis showed normal factor h level, fhr- /- was absent. by repetitive plasma infusion and plasmapheresis, the cycle of hemolysis and thrombocytopenia could be disrupted. chronic periodical plasma infusion q days resulted in regression of renal impairment to a degree (current baseline creatinine . mg/dl). in conclusion, fhr- /- are thought to have co-factor activity and play a role in complement activation in ahus. deficiency of fhr- /- may lead to a subclinical form of ahus such that patients may initially present with features of chronic renal failure. however, factor replacement therapy may lead to regression of renal impairment. s. choudhry objectives of the study: the aim of the study is to investigate the long term prognosis ofsevere childhood iga nephropathy after years combined therapy. patients: we examined patients who had entered thejapanese pediatric iga nephropathy treatment study group between and , had been treated with years combined therapy (combinationof prednisolone, azathioprine, dipyridamole and heparin/warfarin) andhad been followed for more than years after the therapy. significantproteinuria is defined as more than . g/m /day. results: mean age at onset was . years ( - years), proteinuria at diagnosis was . ± . g/m /day, proteinuria after the combined therapy was . ± . g/m /day and mean follow-up period after the combined therapy was . years ( . - . years). proteinuria improved in all patients during thecombined therapy (p< . ). the final prognoses were as follows: patients ( %) showed no proteinuria, ( %) showed proteinuria withnormal renal function and ( %) proteinuria with decreased renalfunction. we compared the clinical and pathological parameters betweenpatients with proteinuria (n= ) and those without proteinuria (n= ) at the last observation. period between disease onset and start of treatment, glomeruli showing crescents before the combined therapy (%) and glomeruli showing pathological changes after the combined therapy (%) were the significant risk factors for the proteinuria at the last observation. logistic multivariable analysis revealed that glomeruli showing pathological changes after the combined therapy (%) was theonly independent risk factor for the proteinuria at the last observation. conclusions: pathological activity of nephritis at the end of the combined therapy might correlate well with the final proteinuria and the long term prognosis. s. arun, a. bagga, s. bhatnagar, p. hari, s. menon, s. saini aim: relapses in ssns of ten follow minor infections and are associated with perturbed t-cell function. based on data that zn supplements modulate t-cell function and reduce risk of infections, we examined its efficacy in reducing relapses in patients with ssns. methods: in this double blind rct, consecutive patients with ssns - yr old, stratified into frequent (fr= ) and infrequent (ifr= ) relapsers, were randomized to -months therapy with zn ( mg daily) or placebo. patients with fr also received long-term, alternate day prednisone. relapse and infection rates were monitored monthly. blood levels of zn, sil r, il and interferon (ifn) were measured at baseline, relapse andend of study. results: patientsin the zn (n= ) and placebo (n= ) groups had similar baseline clinical & laboratory features. the former showed % lower frequency of relapses (difference in means - . ; % ci - . , . ) with trend towards reduction from -months onward. a higher proportion ( . %) of patients in the zn group had sustained remission compared toplacebo ( . %). reduction in relapse rates was higher in fr receiving zn vs. placebo (- . ; ci - . , . ); respective sustained remission was seen in % and % patients (relative risk . ; ci . , . ; p . ). no differences were found in infection rates, and levels of zn, sil r & il ; levels of ifn were higher in those receiving zn compared to placebo (p= . ). conclusions: zn supplementation for -yr was effective in maintaining remission and reducing relapse rates. the effect was mediated not by reducing infections but perhaps through effect on th cytokines. while zn therapy appears promising, these results need confirmation in patients with frequent relapses and perhaps at a higher dose. background: n-glycosylation process in the endoplasmic reticulum (er) is tightly regulated and orchestrated by many factors such as chaperones and energy systems. we showed that adequate nglycosylation is crucial for nephrin to assemble to the plasma membrane (jasn, ) . additionally we recently demonstrated that the er stress evoked by glucose starvation induces hypoglycosylated nephrin retained in the er, which is rescued by dexamethasone (dex) (ki, ) and immunosuppresant: mizoribine (mzr) (submitting). in the present study, we tested whether other er stress inducer, hypoxia, could also interfere the alteration of nephrin n-glycosylation system and whether dex and immunosuppressants rescue its defective process. methods: nephrin-expressing cell line was cultured either in % o or % o for hours in the presence or absence of dex, mzr and cyclosporin a (csa), followed by western blot analysis with nephrin, cytochrome c. intracellular atp concentrations were measured by the highperformance liquid chromatography. protein expression of cyclophilin d (cyp-d), a component of mitochondrial permeability transition pore (mptp), was tested in the samples from human glomeruli and cultured podocyte. results: hypoxia induced hypoglycosylated nephrin. csa, but not dex and mzr, inhibited the formation of this hypoglycosylated nephrin and rescued mature form. csa inhibited the increase of cytochrome c in the cytoplasm caused by hypoxia. in addition, csa partially rescued the decrease of intracellular atp. cyp-d was distinctly observed in human glomeruli and located in podocytes. conclusion: csa inhibit the formation of hypoxia-induced hypoglycosylated nephrin through protecting the mptp opening via selectively binding to cyp-d in the mitochondria, resulting in a recovery of atp. csa may exert direct action on the alteration of nephrin biogenesis induced by the er stress. background and objectives: in two previous randomized controlled trials (rcts) we showed that treatment of severe childhood iga nephropathy (iga-n) with diffuse mesangial proliferation using prednisolone, azathioprine, heparin-warfarin, and dipyridamole reduced immunologic renal injury and prevented any increase of sclerosed glomeruli. in one of the two rcts we also showed that treatment with prednisolone alone did not prevent a further increase of sclerosed glomeruli. accordingly, the immunosuppressant is considered to play an important role in the combination therapy. often however, we were unable to complete the azathioprine regimen due to its severe side effects. therefore we considered that a different, but effective immunosuppressant would be worth trying. mizoribine, like azathioprine, is an antimetabolite that exerts its immunosuppressant effect by inhibiting lymphocyte proliferation. design, setting, participants, and measurements: in this pilot study, we administered mizoribine instead of azathioprine as part of the combination therapy for treatment of children with severe iga-n and evaluated the efficacy and safety of the regimen. results: eighteen patients reached the primary endpoint (urinary protein/creatinine ratio < . ) during the two-year treatment period. the cumulative disappearance rate of proteinuria determined by the kaplan-meier method was . %. mean urinary protein excretion was reduced from . g/m /day to . g/m /day (p< . ). after treatment, the mean percentage of glomeruli showing sclerosis was unchanged in comparison with that before treatment. no patients required a change of treatment due to side effects. the efficacy and safety of the mizoribine combination seems to be acceptable for treatment of children with severe iga-n. objectives of study: alport syndrome is a hereditary renal disease which is normally diagnosed by either histopathological studies or a genetical analysis. we attempted to diagnose alport syndrome by means of immunofluorescence staining of cultured cells with collagen type alpha chains obtained from voided human urine specimens. methods: the cells were cultured from the voided human urine of patient with x-linked alport syndrome, patient with sporadic alport syndrome, and patient with autosomal-dominant alport syndrome. for comparison purposes, controls cells were cultured from the voided human urine of patient with iga nephropathy, patient with fsgs, and patient with purpura nephritis. the cultured cells were stained by immunofluorescence techniques with collagen type alpha , , , , and chains. results: in the cultured cells of the controls staining for collagen type alpha and chains were observed both in the extracellular matrix and in the cytoplasm while for the staining of collagen type alpha , , and chains were observed in the cytoplasm. in cultured cells of xlinked and sporadic alport syndrome staining of collagen type alpha chain was lost or attenuated. in the cultured cells of autosomal-dominant alport syndrome the staining patterns of collagen type alpha , , and chains were observed. the staining patterns of the collagen type alpha chain in cultured cells of alport syndrome correlated with that observed in renal biopsies obtained from alport syndrome patients as reported previously. hence, the staining of cultured cells with the collagen type alpha chain obtained from voided human urine may therefore be a potentially useful means of diagnosing alport syndrome in a non-invasive manner. the aim of our study: was to examine zeta chain expression in cd +, cd + t cells and nk cells from ins children in active phase of the disease and in remission and to assess the effect of h and h anti-cd + ril- stimulation on zeta chain expression. we enrolled ins children in relapse before initiating the therapy, ins children in complete remission of proteinuria on prednisone for - weeks ( mg/kgbw/d) and age-matched controls. zeta expression was determined by flow cytometry as mean fluorescence intensity (mfi). results: cd +cells: mfi in relapse was higher than in remission and in controls. anti-cd + ril- stimulation had no impact on zeta expression in acute phase and in cotrols, but increased mfi values after h in pts with remission. cd +cells: zeta expression stayed unchanged irrespective of the examined group or antibody stimulation. nk cells: there were no differences between mfi values before stimulation and in relapse after stimulation. in remission and in controls antibody stimulation decreased zeta expression. in controls, mfi values for nk cells were higher than those for cd + and cd + populations, but this preponderance disappeared after h stimulation. in remission, that nk cell predominance vanished after h stimulation. in relapse, mfi values in all cells were comparable and stimulation had no impact on lymphocyte proportions. urinary protein, creatinine, and scd were measured. scd was measured using a elisa kit. scd was expressed as ng/g of urine creatinine. data were analyzed using anova and spearman rank correlation (src) tests. ) scd urinary concentrations in patients with mlns in relapse were higher than patients in remission, healthy controls and other patients with proteinuria (anova p . ) but similar to those seen in sle. ) in patients with mlns relapse, scd concentration did not correlate with urine protein/creatinine ratio (src, r: . , p: . ) ) in patients with mlns, serial urine scd concentrations were measured over a period a time. scd was increased at the time of relapse and decreased toward normal range weeks before patients went into remission. conclusion: urinary scd is elevated in mlns patients in relapse. this increased urinary concentration is not due to the proteinuria, since scd was not elevated in other patients with glomerulopathies and proteinuria. upregulation of podocyte scd during relapse may play a role in the pathogenesis of proteinuria in mlns. aim: patients with mpgn type ii/dense deposit disease (ddd) and atypical haemolytic uremic syndrome (ahus) secondary to defective complement control are found to have a high prevalence of y h polymorphism of factor h gene (cfh), which is linked to age-related macular degeneration (amd). however, no studies have looked into an ocular phenotype of children with complement based renal diseases, yet. methods: in two pediatric nephrology centres all patients with mpgn ii/ddd and ahus were identified and screened prospectively for the presence of y h polymorphism and drusen maculopathy. all patients have been on immunomodulatory therapy at the time of screening. results: four children were identified (male:female= : ) with mpgn ii/ddd and ahus. there were two children in either group. the median (range) age at examination was . years ( . to . years). of the four patients, all were found to have the y h polymorphism. none of the patients had evidence of drusen at the time of examination. two patients with mpgn ii/ddd and one patient with ahus had additional factor h mutations, which were thought to be responsible for the renal disease. conclusion: in our study of children with mpgn ii/ddd and ahus we found a % prevalence of the y h polymorphism of factor h gene, which puts these patients at higher risk for drusen maculopathy. therefore, all children with either mpgn ii/ddd or ahus should be screened for y h polymorphism; and if found positive have regular follow-up ophthalmologic examination. in the future, should y h be proven to be of functional significance with respect to complement control, there would be a role for plasma infusion or replacement of purified factor h for the treatment of both the renal and the ocular phenotype. we previously demonstrated that angiotensin-( - ) is an endogenous ligand for the g-protein coupled receptor mas. the aim of this study was to evaluate the role of angiotensin-( - ) mas receptor in kidney structure and function by using transgenic mice with genetic deletion of the receptor mas. mas -/-(knockout) mice were compared to mas +/+ (wild type) mice regarding renal function parameters and kidney histology. the animals were housed in metabolic cages to obtain -hour urine samples for measuring urinary volume, osmolality and microalbuminuria. at the end of the experiment, mas -/-and mas +/+ mice were sacrificed by decapitation to harvest the kidneys for histological analysis and immunofluorescence of collagen types iii and iv. the quantification of collagen expression was determined by confocal microscopy (zeiss lsm ). urinary volume was significantly reduced in mas -/-mice as compared to mas +/+ animals ( . ± . vs. . ± . ml/ hs in mas +/+ mice, p< . ). this change was associated with an increase in urinary osmolality ( ± vs. ± mosm/kg in mas +/+ mice, p< . ) and albumin excretion ( . ± . vs. . ± . mg/ hs in mas +/+ mice, p< . ). the histological analysis showed a significant reduction in the glomerular diameter in mas -/-mice as compared to mas +/+ animals ( . ± . vs. . ± . μm in mas +/+ mice, p< . ), where as any significant change was observed in tubular diameter. the immunofluorescence of mas -/-kidneys revealed a marked increase of the expression of collagen types iii and iv in periglomerular region as well as in external and internal medulla. collagen iv was also augmented in mesangial area of mas -/-mice. these results suggest that the receptor mas is critical for the regulation of renal structure and function. a circadian rhythm in calciuria is evident with a peak after : h, a lower excretion overnight and a nadir in the early morning. during the peak period both ca/creat ratio (figure) and calcium output frequently surpass the reference values of . mg/mg and mg/kg/day respectively. conclusion: a significant circadian variation in calciuria is evident in normal school age children, with peaks surpassing commonly used reference values for hypercalciuria. this peak excretion is independent from urine output, glomerular filtration and intake. the average h excretion of mg/kg is rarely surpassed despite this peaks. the management of children with secondary hyperparathyroidism is complicated and should start early in the course of renal insufficiency. in spite of an optimal management hyperparathyroidism is sometimes uncontrolled and calcimimetics like cinacalcet hydrochloride which directly stimulates calcium sensing receptors and potently suppress pth secretion are an alternative to parathyroidectomy. they are very promising agents, but paediatric experience is lacking. a years old girl with a bardet biedl syndrome without medical care came last year with end stage renal failure. thanks to daily hemodialysis, serum phosphate level was kept within normal limits and phospho-calcic product remains below . as recommended. in spite of this treatment, serum pth level increased to ng/l. this toxic hyperparathyroidism with optimal monitoring of serum calcium, phosphate, vitamin d levels led us to start calcimimetics. a , mg/kg cinacalcet dose was administrated and induced a decline of pth level to ng/l one month later. a years old boy with recessive polycystosis and chronic renal failure was treated with calciumbased phosphate binders and sevelamer hydrochloride but with a poor compliance and a free diet which led him to hyperparathyroidism (pth to ng/l). in addition, a parathyroid gland hyperplasia with two adenoma was individualized. start of calcimimetics treatment (less than mg/kg) led to a rapid decline in pth level from ng/l to ng/l. the two adenoma decreased in size. in case of hyperparathyroidism, with close monitoring of serum calcium, phosphate, alkaline phosphatase and vitamin d levels, calcimimetics are an excellent alternative to surgery, with safe use and low dose in these cases. preliminary favourable experience has been reported in children but paediatric experience is lacking. side effects result from chronic administration of steroids. the aims of this study are to analyze graft function and metabolic effects of low dose and withdrawal of steroid therapy. this is a single center pilot, one arm and prospective study. methylprednisone (mp) was decreased to . ± . mg/kg/day (low dose) after months. we studied changes in graft function, height velocity, lipid profile, body composition and bone mass after year of low dose mp and after a nd year following mp withdrawal. patients received daclizumab induction; tacrolimus and mycophenolate mofetil. the inclusion criteria was st living related graft and pra < %; patients were enrolled and total follow-up was . years. age at transplantation was . - years, females, prepubertal, postpubertal patients. patients and graft survival were %, acute rejection (ar) occurred after months of mp withdrawal in / ( %) prepubertal patients (banff , b). in prepubertal patients, at the moment of steroid withdrawal and year later creatinine clearance was . ± . and . ± . ml/min/ . m , p< . ; height velocity . ± . and . ± . cm/year, p: ns, with a height increment of . ± . sds, p< . during the last year of follow-up. graft function did not change in postpubertal patients. in all patients at the moment of steroid withdrawal and year later lipid profile was normal; fat body mass . ± . and . ± . kg, p: ns; lean body mass . ± . and . ± . kg, p< . ; total skeleton bmd - . ± . and - . ± . sds, p: ns and lumbar spine bmd - . ± . and - . ± . sds, p< . . this study demonstrates that low dose and steroid withdrawal allow catch up growth, normal lipid profile with no fat accumulation. steroid withdrawal prevents bone loss with increment of lean body mass, but with a concerning rate of ar and graft function deterioration in prepubertal patients. children with x-linked hypophosphatemic rickets (xlh) usually present with progressive disproportionate stunting. we therefore conducted a year randomized controlled trial on theeffect of rhgh therapy on body anthropometry ( parameter) in prepubertal children with xlh (each patients in rhghandcontrol-group). age at baseline was . ± . yrs (mean±sd), height was - . ± . sd, calcitriol dosage was ng/kg x day, and phosphate dosagewas mg/kg x day (each p> . rhgh-vs. control-group). results: within the whole study population longitudinal bodydimensions were more affected than transversal body dimensions aswell as circumferences (extremities/trunk). leg length (- . ± . sd; p< . ) was the most impaired longitudinal parameterexplaining % of the overall variability of total body height, whereassitting height (- . ± . sd) was the best preserved longitudinalparameter. longitudinal body dimensions were significantly increased after months rhgh-treatment (height + . ± . sd; sitting height + . ± . sd, leg length + . ± . sd; arm length + . ± . sd; each p< . ). in contrast, progressive stunting was noted in control patients (height - . ± . sd; sitting height - . ± . sd; leg length - . ± . sd; arm length - . ± . sd; each p< . vs. rhgh-group). rhgh treated patients showed a significant increase in all transversal body dimensions (each p< . ), as well as a decrease in skin folds (range - . up-to - . sd; each p< . ). one year rhgh treatment in severely growth retardedprepubertal children with xlh leads to improvement of longitudinal bodydimensions, harmonization of body (i. e. transversal body dimensions & body proportions), and decrease of body fat. thalassemia is an hemolytic anemia characterized by decreased production of β globin. the chronic hemolysis requires frequent bloodtransfusions that caused hemosiderosis, including iron deposition in the kidney. removal of excess iron via iron chelators, the most commonof which is desferal produce iron excretion in urine and stool. few studies have been published, the studied patients, mostly adults, exhibited proteinuria, aminoaciduria, low urine osmolarity and excess secretion of the proximal tubular function markers, n-acetyl-d-glucoseaminidase (nag) and β microglobulin. the iron accumulation may causes lipid oxidative peroxidation and this oxidative process cause's tissue damage. in this study we examined thalassemia major patients treated with desferal. the degree of hemosiderosis was determined by measuring serumiron and ferritin. children without iron metabolism disorders orrenal disease serve as controls. the renal and tubular function was analyzed. no differences in creatinine clearance, blood hco , na and k fe, tmp/gfr was found. serum uric acid was equal in the two groups but itsurine excretion was significantly higher in the thalassemic group probably due to persistent hemolysis. the nag level and its ratio to creatinine were significantly higher compared to the control group. the results of our work showed that most of the thalassemic patients have sub clinical disturbances in tubular function and high nag in theurine. these results raise the question of treating thalassemic patients with oral chelators which removes iron from cells preventing the oxidative process; moreover, and add antioxidants which may prevent the deposition of iron in tissues. in light of these findings, it would be advisable to routinely check glomerular and tubular function as part ofthe follow-up in these patients. objectives of study and methods: little information is available on the long-term follow-up in patients with biallelic mutations in the two genes slc a and kcnj , encoding the bumetamidesensitive na-k- cl cotransporter and the in wardly rectifying renal potassium channel, respectively. we evaluated the long-term follow-up (> years) in patients with these two forms of bartter syndrome. the slc a and kcnj genes were screened by dhplc and sequencing techniques. results: the long-term follow-up period was to years, median , after diagnosis, in patients with mutations in slc a ( homozygotes, compound heterozygotes) and patients with mutations in kcnj ( homozygotes, compound heterozygotes) genes. medical treatment with indo methacin at last follow-up control including supplementation with potassium in patients and medical treatment with indomethacin in patients (meandose . mg/kg/day). in two patients (one with slc a and another one with kcnj mutations) growth hormone (gh) deficiency was detected with specific tests. both patients were treated with recombinant human gh. at the end of follow-up, body height was < ° percentile for agein of the patients, of whom with gh deficiency and body weightwas < ° percentile for age in patients (none of them with gh decifiency conclusions: these data demonstrate that some patients with biallelic mutations inthe slc a and kcnj genes tend to present slight impaired glomerular kidney function after a median follow-up of years and that growth retardation and gh deficiency are often present in these patients. the cytosolic c-terminus of nhe does not mediate its apical localization or baseline activity -implications for blood pressure and ph homeostasis the epithelial sodium proton exchanger, nhe , is expressed in the apical membrane and subapical endosomes of the proximal tubule. apical localization is fundamental to proximal tubular na+, water and hco -absorption, a process necessary for the maintenance of plasma ph and blood pressure. moreover the redistribution of nhe between these compartments alters its activity. for example, acute hypertension leads to an increased endomembrane accumulation of nhe and pressure natriuresis. nhe is composed of a n-terminus with transmembrane helices and a cytosolic c-terminus. the former is necessary for sodium-proton exchange while the latter regulates activity. the goal of our studies was to evaluate the contribution of the cytosolic c-terminus to apical localization and therefore to nhe function. to this end we generated a series of nhe constructs with sequential deletions in the cytosolic c-terminus. all constructs contained an extracellular epitope tag to facilitate the delineation between cell surface and endomembrane nhe . stable renal epithelial cell lines were generated expressing each construct. surprisingly, even when the entire c-terminus was deleted nhe was still detectable at the apical membrane. we proceeded to evaluate the activity of the truncated exchangers and found they retained activity. finally, we assayed the attachment of nhe to the actin cytoskeleton (a process thought to be mediated by the c-terminus), by measuring their solubility in the weak detergent triton x- and by measuring their mobility in the plane of the plasma membrane. both assays confirmed that exchangers lacking the c-terminus retained their association with the plasma membrane. in conclusion, the cytosolic c-terminus of nhe is not necessary for apical localization nor baseline nhe activity. further studies will be needed to confirm its role in specific regulatory processes. background: ibu is used as a safer alternative to indomethacine for pda treatment. however, safety/efficacy balance has not been extensively studied. animal and a few clinical studies suggested that ibu might also have significant side effects. objective: to evaluate renal function at one week of life in infants treated with ibu as compared to infants not exposed to ibu, within the first days of life. methods: multicentric prospective cohort study of to weeks gestation (ga) infants exposed or not exposed to ibu. infants presenting with renal impairment at birth, urinary tract malformation, or contraindication to ibu treatment were excluded. infants exposed to ibu were paired to controls according to ga, centre and crib score. creatinine clearance (ml/min/ . m ) was measured for glomerular function evaluation; fractional excretion of sodium (fena) and microglobinuria/creatininuria ( /ucr) for tubular function evaluation. results: infants were studied: exposed to ibu for pda closure with . % efficiency and controls. birth weight was ± g (mean+sd), and ga . ± . wks. glomerular filtration rate (gfr) significantly decreased on day in ibu exposed infants. noteworthy, diuresis remained in the normal range, but was significantly lower after ibu treatment (given on day ) as compared to controls. antiresorptives, particularly bisphosphonates (bp), offer a promising treatment inpediatric bone disease. bp have been successfully used to treat childrenwith osteogenesis imperfecta (oi), secondary osteoporosis, fibrousdysplasia, hypercalcemia. concerns exist regarding bone mineralizationand bone growth and transient adverse reactions. according to available literature, bp were successfully used in ~ children, intravenous pamidronate (pm) being the most frequently used one (> children, mostly with oi), followed by alendronate (al) (~ patients with oi, secondary osteoporosis, hypercalcemia), risedronate, etidronate, zoledronate, clodronate, olpadronate. oi treatment with bp resulted in an increase in bmd, improved growth, relief from pain, mobility improvement, improved quality of life and a drop in fracture rate there are sparse data comparing oral and i. v. bp. oral and i. v. bp seem to have a similar effect in children with oi. daily al therapy seems to be safe and effective in children with oi, and daily or weekly administration of al led to increase in bmd in patients with secondary osteoporosis. there is scarcity of randomized, double blind, placebo-controlled or active comparator trials with bp in children. currently, double-blind, placebo-controlled study with risedronate andactive comparator trial with intravenous zoledronate in children with oi are planned. bp therapy should be used in context of a well-runclinical program with specialist knowledge in the management of pediatric metabolic bone disorders. other emerging antiresorptive agents include denosumab, glucacon-likepeptide- and calcitonin tablets. these drugs are tested in phase iii trials in adults. their applicability to children is likely to be discussed in the coming years. the current kdigo recommendations on classification or renal osteodystrophy recommend assessment of three areas of bone histology: turnover, mineralization, and volume. while lesions of bone turnover are prevalent in children treated with dialysis, little is know about the prevalence of mineralization defects and their response to therapy with vitamin d sterols and phosphate binders. we evaluated the skeletal mineralization (osteoid thickness (o. th.) and osteoid maturation time (omt)) in patients ages ± years treated with maintenance dialysis who were not receiving vitamin d sterol therapy. serum biochemical markers were: ca: . ± . mg/dl, p: . ± . mg/dl, pth: ± pg/ml, alk p'tase: ± iu/dl. % of patients with high turnover bone disease ( % ci: - %) and % ( - %) of patients with normal or adynamic bone had abnormal skeletal mineralization as reflected by both a prolonged omt and widened o. th. subsequently, a subset of patients underwent treatment with calcitriol and calcium carbonate. while serum pth levels decreased by % (p< . ) and bone formation rate decreased by % (p< . ) with therapy, there was no change in o. th or omt from baseline. indeed, % ( - %) of patients had abnormal mineralization after therapy. we conclude that mineralization defects are prevalent in children treated with dialysis and are not affected by current therapeutic options. further studies are needed to determine the pathophysiology and optimal treatment of these defects. introduction: clara cell secretory protein (cc ) is a protein synthesized primarily by non-ciliated bronchiolar epithelial cells, the clara cells. like other low-molecular size proteins, plasma cc is rapidly eliminated by glomerular filtration and reabsorbed by proximal tubular cells. this protein has been rarely studied in the paediatric age. the sensitivity of cc in urine was compared to that of b -microglobulin (b m) and n-acetyl-b-d-glucosaminidase (nag conclusions: cc is a good marker of the proximal tubular function. cc is related better with the urinary b m elimination, since both are low-molecular size proteins that are reabsorbed by the proximal tubule. sd. kim, bs. cho kyunghee university hospital, pediatrics, seoul, south korea background: many studies have demonstrated that arb prevents renal progression in patients with glomerular nephritis or diabetic nephropathy by inhibition of hmc proliferation and reduce of extracellular matrix expansion and glomerulosclerotic changes. however, the molecular effects of arb in cultured hmc have not been completely defined. we investigated differential gene expression by arb treatment on cultured hmc according to time sequence using cdna chip (affymetrix). methods: mc was grown in dmem with % fbs and then arb was treated on cultured mc. rnas of hmc at different time points ( , , and h after arb treatment and no treatment) were compared using affymetrix cdna chip. to validate the patterns of gene expression analyzed by the microarrays, some genes were selected and semi-quantitative rt-pcr was performed. results: among genes, humoral immune response, cytokine activity, il- receptor binding, chemotaxis, cell cycle arrest, and morphogenesis associated genes were down-regulated for , , and h after arb treatment. they also showed different clustering according to their changing patterns. conclusion: the present study demonstrates profile of gene expression as time goes by after arb treatment on proliferation of human mc. gene expression by arb treatment on cultured hmc showed sequential changes. our results showed that chemotaxis and immune response associated genes were suppressed by arb treatment on hmc. further evaluation of individual genes will be conducted to elucidate molecular mechanism. podocin is the major component of the slit diaphragm, the site responsible for size and charge selectivity of filtration. mutations in the nphs gene, which encodes podocin can lead to steroidresistant nephrotic syndrome (srns). in this work we studied whether genetic changes of podocin might predispose to the development of sporadic non-familial srns in childhood. we screened for podocin mutations children ( m/ f; mean age . ± . years) with sporadic srns and healthy controls. renal biopsy in srns patients revealed mesangial proliferative glomerulonephritis (n= ), focal segmental glomerulosclerosis (fsgs; n= ), membranoproliferative glomerulonephritis (n= ) and membranous nephropathy (n= ). the mean age of onset of srns was . ± . years. all exons of podocin gene of patients with srns and controls were amplified and direct dna sequencing was performed. there is one novel nonsense heterozygous mutation of c. g>t p. glu>stop was identified in the st exon of nphs gene in srns child with fsgs who has renal transplantation at the age of years without recurrence of fsgs in her graft. we found one kind of single nucleotide polymorphism c. + a>g in the th exon of nphs gene in % ( / ) srns patients ( with fsgs; with membranoproliferative glomerulonephritis) and % ( / ) children in controls. allele frequency of this polymorphism of the nphs gene in srns patients and controls was not different significantly. our results indicate that mutation-detected rate in the nphs gene in russian children with sporadic srns was %. the low mutation-detected rate and identified polymorphism c. + a>g in nphs gene unlikely predispose to the development of sporadic srns in russian children. further determining the slit diaphragm genetic profile of children with sporadic srns is warranted in order to improve disease classification and tailoring of treatment. for diagnose of essential hypertension is necessary except all causes of secondary hypertension (sh). case: family history of -year-old female patient was unremarkable for hypertension, incl. renal diseases. during last months she had often headaches with intermittent vertigo. she was not anywhere examined. at admission on intensive care unit patient had headache, her pulse rate was /min, respiratory rate /min, bp (right arm) was / mmhg and the lower extremity bp / mmhg. other physical examination was normal, incl neurological exam. fundoscopy of the eyes did not show any evidence of hypertensive retinopathy. cardiac ultrasound showed mild left ventricular hypertrophy. abnormal laboratory parameters (without medication) were: hypokalemia ( . mmol/l), metabolic alkalosis (ph . , hco . mmol/l), low urinary output of sodium ( mmol) and chloride (< mmol), high urinary output of potassium ( mmol). renal function tests were normal and no abnormalities were detected by renal ultrasonography, incl. doppler exam of renal blood flow. by large hormonal analyse were detected high plasma renin activity (pra; . ng/ml/hod; n.r. . - . ) and very mild increased serum aldosterone (ald; . nmol/l; n.r. - . ). during the ct renal angiography was found solid mass in the upper part of the left kidney. a partial left nephrectomy was performed and histological exam revealed juxtaglomerular cell tumor (so-called reninoma, re). after the resection we stopped subsequently patients antihypertensive therapy. in a -month follow-up our girl was normotens. re is a very rare cause of sh. re typically present during adolescence or young adulthood. this cause of severe sh should be considered along renal artery stenosis in adolescents presenting with secondary hyperaldosteronism or in causes with renin-secreting tumor of non-renal origin. we report our preliminary molecular findings in twelve turkish cystinosis patients. the patients were to years; male/female ratio was : . all presented initially with severe failure to thrive, polyuria and polydipsia. cystinosis was diagnosed at age month to years. six of the patients reached end stage renal failure at ages ranging from . to years necessitating renal replacement therapy; are currently on hemodialysis, one is on capd, and two were transplanted. while three of remaining have renal fanconi syndrome with proteinuria, had kidney failure in varying degrees. molecular analyses involve an initial multiplex pcr, checking for the presence or absence of kb founder deletion, and subsequent sequencing of the coding exons of ctns. interestingly, none of the nephropathic cystinosis patients carried the kb deletion. instead, one patient had a new homozygous kb deletion of exons to of ctns. one patient was homozygous for a known bp deletion in exon , i.e., c. del gact. two patients were homozygous for new missense mutations in exons and , i.e., c. g>a (r g) and c. a>g (y c), respectively. the most common mutation in our turkish patients was a new exonic splice site mutation in exon , i.e., c. g>a (e e). of alleles studied, carried this mutation, which is expected to disrupt proper splicing. two patients were compound heterozygous for one of the above-mentioned mutations and a known missense mutation in exon , i.e., c. g>a (g r). in two patients, we could not find any disease-causing mutation; in two patients, we could find only one disease-causing mutation. in summary, cystinosis patients of turkish ancestry show ctns mutations different from those of western european patients. these findings will be of relevance for molecular-based screening and diagnostic methods for cystinosis. introduction: the association of hypertension with bell's palsy in adults has been reported from - %, but there is few data in children. the presence of bell's palsy in children requires a complete evaluation for hypertension, solid tumors, leukemia, neurofibroma, and trauma. hypertensive children usually present with clinical manifestations of underlying disease, but with substantial elevation, symptoms of hypertension develop. although headache, dizziness, blurred vision and seizure are common neurologic symptoms of hypertension, but facial paralysis is not a wellrecognized presenting feature of hypertension in children. case report: this paper describes two severely hypertensive children who referred to children's hospital of tabriz with periferal hemifacial nerve paresis and initial diagnosis of bell's palsy. case : a years old girl who admitted with blood pressure of / mmhg on admission. renal ultrasound study revealed left small size kidney and renal scintigraphy followed by angiography confirmed renovascular hypertension. case : a years old boy with blood pressure of / mmhg on admission. sonography of kidneys was normal except for a small size ( mm) stone in left kidney. renal scintigraphy and angiography were normal. all other evaluations for etiology of hypertension including cardiac and endocrine investigations were negative. treatment of hypertension with antihypertensive drugs resulted in complete recovery of facial paresis in both cases within - months. conclusion: unilateral peripheral facial nerve paresis is a rare presentation of hypertension in children. unawareness of this presentation may result in delay in diagnosis of hypertension which may increase further with steroid therapy for bell's palsy. to uncover the frequency and the spectrum of nphs mutations in egyptian children with non familial steroid-resistant nephrotic syndrome (srns), patients were screened by pcr-singlestrand confirmation polymorphism analysis of nphs gene followed by direct sequencing. nphs mutations were evident in patients ( . %) who were bearing five novel mutations including two frame shift mutations ( - insg and - insg), two missense mutations ( a>c and t>a) and a silent mutation ( a>t). there were no phenotypic or histological characteristics of patients bearing nphs mutations, apart from the earlier onset of the disease, compared to those who were not bearing mutations. in conclusion, nphs mutations are prevalent in egyptian children with non-familial srns and this may in part explain the less favorable prognosis reported in these patients. , which is an inherited systemic disease of connective tissue primarily affecting the skin, retina, and cardiovascular system, also leads to rvh. these symptoms of pxe are usually apparent in adulthood and rarely observed in children. here, we describe a very rare pediatric case of rvh caused by pxe. case report: a -year-old boy was noticed to have severe hypertension ( / mmhg) when he was admitted to our hospital for an operation for exotropia. he had no previous or family history of pxe or hypertension. laboratory examination showed that plasma renin ( . pg/ml) and aldosterone ( . ng/dl) concentrations were markedly elevated. his systolic and diastolic blood pressure (bp) decreased . % and . % from baseline after administration of captopril, respectively. a computerized tomographic scan of his abdomen showed multiple calcified vessels in kidneys and spleen. yellowish papules on the bilateral axillary regions and inguinal area were detected. characteristic histological changes of pxe such as elastic fiber mineralization and calcification were noticed in the biopsy of affected skin lesions. conclusion: pxe is characterized clinically by high heterogeneity in the age of onset and extent and severity of organ system involvement. although its symptoms usually appear in the second or third decade of life, gastrointestinal bleeding and acute myocardial infarction have been reported in childhood. we should also consider pxe as one of the causes of rvh in children, because its prognosis depends largely on the extent of extracutaneous organ involvement. the clcnkb gene is rarely reported as having a large deletion mutation, but all cases reported previously were large homozygous deletions and a large heterozygous deletion is impossible to detect by direct sequencing. patients and methods: this report concerns a genetic analysis of japanese patients with type iii bs. to identify the mutations in the clcnkb gene, we used polymerase chain reaction (pcr) and direct sequencing to investigate all exons and exon-intron boundaries in the patients and their family members. to detect large heterozygous deletion mutations of the clcnkb gene, we conducted semi-quantitative pcr amplification using capillary electrophoresis. results: four mutations were identified, comprising novel bp deletion mutation (c. _ delct), an entire heterozygous deletion and a heterozygous deletion mutation of exon and of the clcnkb gene. the nonsense mutation w x in the clcnkb gene was detected in all patients ( of them were homozygous and were heterozygous) and this finding indicates that this nonsense mutation is likely to constitute a founder effect in japan. two patients had large heterozygous deletion of the clcnkb gene, which was proved by semi-quantitative pcr amplification. conclusions: capillary electrophoresis is a new method and extremely useful for detecting large heterozygous deletions, and should be employed to examine type iii bs cases in whom only a heterozygous mutation has been detected by direct sequencing. obesity defined as body mass index (bmi) above th percentile for age and gender is regarded as a risk factor for cardiovascular (cv) target organ damage (tod) in children and adults with ph. however, when using percentile-based definition of obesity one may miss children at risk of cv complications. the aim of the study was to compare sensitivity of traditional definition of obesity (bmi> th pc) and bmi thresholds (tbmi) for cv complications described by katzmarzyk et al. ( ) majority of children with idiopathic nephrotic syndrome (frequent relapsers, steroid dependent and steroid resistant) require adjunctive therapy. the response to cyclophosphamide (cp) in these children is variable and difficult to predict. there may be an effect of polymorphic expression of gst on the remission with cp. in this study, we have tried to evaluate the correlation of gst polymorphism and response to cp therapy in these children we studied gst polymorphism in consecutive children ( males, females) with steroid sensitive (n= ) and steroid resistant (n= ) nephrotic syndrome, receiving cp therapy. we evaluated the inter-relationships between gstm , gstt , and gstp genotypes and correlated it with the response to cp therapy in these children. the mean age of onset was . ± . years. out of children, % children responded to cyclophosphamide therapy. the null genotype of gstm and gstt was observed in . % and . % respectively while val genotype of gstp was seen in % children. there was no significant correlation among the various individual genotypic combinations. however, a trend was seen towards remission in children with a combination of gstp polymorphism with gstt null genotype (p= . ) or combination of gstp polymorphism with gstm wild type genotype (p= . ) another important finding in our study was that there was a significantly higher frequency of val allele of gstp in responders to cyclophosphamide as compared to nonresponders (p= . ). the results indicate that the presence of the val allele correlates with the response to cyclophosphamide in these children. gst gene polymorphism may be a significant therapeutic tool in the management of children with idiopathic nephrotic syndrome receiving therapy. objectives of study: primary vesicoureteral reflux (vur) is a common pediatric disease that may lead to reflux nephropathy and end-stage renal disease. the renin-angiotensin system (ras) was proposed to be associated with primary vur. the objective of this study was to investigate whether the gene polymorphisms of the ras are involved in primary vur and correlation with the severity of vur in taiwanese children. methods: we studied the angiotensin ii type receptor (at r) c a gene polymorphism for association with susceptibility to primary vur and disease severity in vur children and healthy controls. fifty four of the vur patients had low-grade vur (grade i-iii) and had high-grade vur (grade iv and v). to analyze the polymorphisms in the c a of at r gene, the snp genotyping assay were performed. the genotypic frequency and allele frequency for four ras genes were analyzed to detect the correlation between the patients with mild, severe vur, and healthy control. results: we found that the c a of at r gene was associated with the development and severity of vur. significantly higher c and lower a allele frequencies were presented in vur patients (c allele . and a allele . ) compared with controls (c allele . and a allele . , p< . ). the similar results were observed in both mild (c allele . and a allele . ) and severe (c allele . and a allele . ) vur compared with controls (p< . ). the cc genotype was higher in vur patients compared with controls (p< . ). conclusions: at r c a gene polymorphism was associated with the development and the severity of vur in taiwanese children. it raises the possibility to utilize the genotype of at r as a risk factor to evaluate the development and severity of primary vur. results: stone analysis led to diagnosis of cystinuria in patients ( % of all), but only were children ( . % of the paediatric stone patients). age at diagnosis in three patients was - years and in four - years. time from first manifestation (pain x, gross haematuria x, urinary retention x, uti x) until diagnosis was - years in seven, - in three and even and years in two. renal function was impaired in patient (ckd stage ii). the urinary cystine test was positive in all patients with cystine stones examined, but was negative in family members thus excluding cystinuria in them. family history of urinary stones was positive in two; the brother of one had died of renal failure due to bilateral urolithiasis. conclusions: delays in diagnosis of cystinuria in armenia are unacceptable. production of tablets containing nickel/dithionite which is non-toxic in contrast to brand test (cyanide/nitroprusside) is planned and could allow screening of all patients with stones of unknown origin. background: classically, childhood hypertension has always been recognized as secondary and frequently demanded an exhaustive etiological investigation. however, in the last two decades, many studies have been shown that pediatric patients also present primary hypertension and, sometimes, the adult disease probably begins during childhood. the aim of this study was to analyze a cohort of patients followed-up at a single tertiary unit (belo horizonte, brazil). methods: in this retrospective cohort study, the records of diagnosed with arterial and followed at our unit between and were analized. a data base was used for statistical analysis. results: of patients, . % were male and . % female. the distribution of patients according to the age at diagnosis was: - . years, ( . %), yr- . yr, ( . %), yr- . yr, ( %), and yr, ( . %). the causes for hypertension were: renal diseases in ( %), primary hypertension in ( %), renovascular disease in ( %) and ohers in patients ( %). the comparison between primary hypertensive subjects and patients with renal diseases showed that, although blood pressure was similar at admission, a better control was achieved in the first group (p< . ). the frequency of overweight and/or obesity was higher in primary than in secondary hypertension ( nephrnophthisis (nphp) is a very rare cause of crf in korea. identification of five genes mutated in nphp subtypes - has linked the pathogenesis of nphp. ten percent of affected individuals have retinitis pigmentosa, constituting the senior-löken syndrome. we experienced juvenile-onset crf with leber's amaurosis in two sibilings. case : a -year-old boy presented with pale appearance. he had severe renal impairment and visual disturbance, but no symptom of polyuria and polydipsia. his past annual school screening urinalysis was normal. his growth and development were normal except opthalmological findings and pallor. case : his -years-old sister also had a visual disturbance and was found to have crf. there was no specific problem during perinatal period. opthalmologic findings were similar to her brother's. nphp and on chromosome q was analyzed by direct sequencing. sequencing of mitochondrial dna-mbol digestion for mutation was analyzed by pcr-sequencing and rflp. electroretinogram revealed a decreased in amplitude of a and b waves. on the kidney biopsy, some of glomeruli were globally sclerotic. remaining showed no cellular proliferation or capillary wall thickening. interstitium was diffusely fibrotic and in which were scattered lymphocytes. most tubules were preserved well but a few dilated tubules were intermingled. no positive reaction for immunoglobulines or complements in if. by em, tubular membranes showed thickening, splitting and disintegration. nphp and genes were not identified. there was no transition mutation at mitochondrial dna nt. , , , . late-onset senior-löken syndrome were diagnosed in these cases even though there were no polyuria and polydipsia of initial symptoms of nphp and nphp and were not identified. we need to identify other known or novel mutation genes. nail-patella syndrome (nps) is an autosomal dominant disease characterized by classic tetrad of dysplastic nails, absent or hypoplastic patellae, elbow dysplasia, and iliac horns. some patients manifest nephropathy and adult-onset glaucoma. nps is associated with mutations in the lmxib gene. there is marked inter-and intrafamilial variability in the phenotypes. in this study, phenotype-genotype correlation was analyzed in unrelated korean children with nps. the probands were boys and girls. they manifested dysplastic nails ( / , %), absent or hypoplastic patellae ( / , %), elbow dysplasia ( / , %), iliac horns ( / , %) and nephropathy ( / , %) . four missense mutations/ in the lim-b domain (h q and l p) and in the homeodomain (r q and a p)/and frame-shifting deletion (c, dela) were identified in the lmxib gene.r q and a p are known to be common mutations, and r q was detected in patients in this study. autosomal dominant inheritance was identified in patients by phenotype and genotype analysis of the family members and in patients by phenotype analysis only. remaining patient had de novo r q mutation. one patient and her mother with r q mutation developed nephrotic syndrome, which progressed to end-stage renal disease (esrd). another patient with h q mutation had asymptomatic proteinuria with microscopic hematuria, and her father had esrd. galucoma was not detected in any patients or family members affected. there were inter-and intrafamilial variability of the phenotypes, but no genotype-phenotype correlation was identified. this is the first study to characterize mutations in the lmx b gene in korean patients with nps. r q is a common mutation in korean, also. the mechanism underlying the phenotypic variations and predisposing factors to the development nephropathy remain unknown. the pathological mechanism which would be responsible for higher production of digitalis similar compounds in essential arterial hypertension (ah), would be a genetically defect kidney, which causes difficulty in na + excretion. higher intake of salts can be an etiological factor inessential ah only patients with inherited abnormalities of thetransport mechanisms in the cell membrane.the objective of the studywas to establish the incidence and type of ah and frequency of genetic factor in the investigated population of school children (age - years). in children with essential and borderline ah we evaluated the activity of erythrocyte membrane na+, k+-atpase in the presence ofvarying atp concentrations. atp, adp and amp levels and lipid peroxides (as tbars) in the erythrocytes and tbars in plasma were measured. our data have shown that the prevalence of ah is lowest in - years oldchildren, while it is the highest in - years oldchildren. essential ah was established in ( . %) and borderline in ( . %) children. genetic factor were found in . % of children with essential ah and in . % of children with borderline ah. but, statistical analyses of the first and second degree relatives of children with essential and borderline ah suggested normal prevalence of hypertension. atp, adp and amp levels, as well as, lipid peroxides were not significantly altered compared to healthy children. kinetic profileof erythrocyte plasma membrane na+, k+-atpase activity revealed the presence of noncompetitive (allosteric) inhibition of enzyme activityin the children with essential and borderline ah. the differences in the kinetic properties of na+, k+-atpase between two investigated groups of children suggested that this dynamic model could be used as potential biological marker for early diagnosis and differentiation of these two type of ah. majority of these patients were obese and with increasing body weight nighttime hypertension became prominent in these patients. objectives: it has been shown that weight gain is directly related to increase inblood pressure. the objective of this study was to analyze the frequency of overweight/obesity in children/adolescents with primary hypertension (ph) and the relationship between the overweight/obesityand the stage of hypertension (h). methods: we analyzed the data of patients aged - . years (m ; f ) diagnosed with primary hypertension. overweight/obesity was defined asperc. of bmi - / c. the stage of hypertension was determined according to the th report on the diagnosis, evaluation,and treatment of high blood pressure in children and adolescents of the nhlbi working group. results: out of pts, prehypertension was found in pts ( . %), stage i h in ( . %) and stage ii h in pts ( . %). stage ii h was more frequentin boys ( % vs. % in girls). combined systolic/diastolic h was found most frequently, in pts ( . %), isolated elevation in systolic blood pressure (bp) was found in pts ( . %), while only pts ( . %) had isolated elevation in diastolic bp. sixty-one pts ( . %) were found overweight/obese; of which ( . %) above c bmi. theobese children were predominantly found to have stage ii h: . % ofthe obese children. none of the obese children had prehypertension. contrary to the general perception, boys were found more frequently overweight/obese ( . % boys vs. . % girls). conclusion: our data shows that stage ii ph is not rare also in theteen-age group. frequently it is accompanied with overweight/obesity, especially in boys. we can conclude that the roots of ph in the adultage are already set from the childhood. our efforts should focus onearly diagnosis of ph and include prevention of obesity as the possible contributing factor for the development of ph. objectives of study: alport syndrome (as) is a progressive renal disease characterized by hematuria, progressive renal failure, high-tone sensorineural hearingloss and ocular lesions. xlinked dominant alport syndrome (xlas) isthe major inheritance form, accounting for almost % of the cases, caused by mutations in col a genes. there are no good cures available for as at present, but there are some patients who requestfor prenatal diagnosis and genetic counciling. this study performed thefirst prenatal diagnosis in chinese as family. methods: the entire coding sequence of col a mrna of peripheral blood lymphocytes was amplified using nest pcr to screen mutations in a chinesexlas family. mutation analysis of the fetus was performed on both cdna-based level and dna-based level of amniocytes. fetus sex was determined by pcr amplification of sry as well as karyotypes analysis. maternal cells contamination was excluded by linkage analysis. results: mutation screen showed that there was a g to a substitution at position in exon of col a gene (c.g a), it was subsequently confirmed at genomic dna level by pcr amplification of exon of col a gene. the mutation was identified in the index case, family members aswell as the pregnant lady. the prenatal diagnosis showed that fetus didnot carry the same mutation as the mother detected by both cdna-basedand dna-based mutation analysis. pcr amplification product of sryas well as karyotypes analysis revealed a male fetus. linkage analysis of the three x chromosome markers showed that there was no contamination of maternal cells in amniocytes. conclusion: after mutation identification of col a gene in a large chinese as family, a successfully prenatal diagnosis was performed in one of the female members in this family based on both cdna as well as genomic dna level of amniocytes. objectives of study: alport syndrome (as) is a clinical and genetic heterogenousdisease. autosomal recessive as (aras) is caused by mutations in col a and col a genes, accounting for % of the cases. thin glomerular basement membrane nephropathy (tbmn), is also caused by mutations in col a and col a genes, inherited as an autosomal dominant trait. differentiation between early stages of aras and tbmn may be difficult in clinic, itdepends on gene mutation analysis of col a or col a . methods: the whole entire coding regions of col a and col a mrna of peripheral blood lymphocytes were analyzed using reverse transcription polymerase chain reaction (rt-pcr) and direct sequencing to screen mutations in three chinese aras families, the corresponding exon with flanking intronic sequence was further amplified to confirm the abnormality. results: both the entire coding regions of col a and col a mrna were successfully amplified and completely sequenced by seven overlapping pcr products, respectively. results showed that there were variations of col a and variations of col a , respectively. among the variations of col a ,three were snp reported previously, four were new snp, one nonsense mutation, one small insertions and one splicing mutation, the latter three were the pathogenic mutations for the three families, respectively. all the four variations of col a were snp reported previously. we concluded that rt-pcr and direct sequencing using peripheral blood lymphocytes rna is a practical, sensitive and feasible approach for analysis col a and col a gene variants in autosomal recessive alport syndrome patients, which offers a useful, inexpensive and timesaving approach for systematic gene analysis in patients with aras. objectives of study: gitelman syndrome (gs) is an autosomal recessive tubular disorder characterized by metabolic alkalosis, hypokalemia, hypomagnesemia and hypocalciuria. the majority of gs patients carry inactivating mutations of the slc a gene encoding the sodiumchloride cotransporter located in the distal convoluted tubule. this study aimed to detect mutations in a chinese family with gs. methods: two brothers presenting muscle weakness, hypokalemic metabolic alkalosis, hypomagnesemia and hypocalciuria were clinically diagnosed as gitelman syndrome. the two brothers, as well as their healthy brother and parents, were detected for mutations in slc a gene by direct pcr for each exon and then sequencing on genomic dna extracted from peripheral blood cells. results: the two patients were found to have the same compound heterozygous mutations (c. c>t and ivs - t>c) in the slc a gene. the two mutations were also detected in paternal and maternal genomic dna, respectively. the unaffected brother had one mutation (c. c>t) only. conclusion: a novel compound heterozygous mutation on the slc a gene was revealed in a chinese family with gs. the objective: to determine the clinical value of ambulatory blood pressure monitoring (abpm) in pediatric kidney disease. methods: patients with common kidney diseases aged from - yrs were enrolled. -hour abp were performed by welch allyn abpm . the number of cases whose ccr> mmol/l/ . m , ccr - mmol/l/ . m , ccr - mmol/l/ . m , ccr - mmol/l/ . m and ccr< mmol/l/ . m is , , , and , respectively. seven patients only took fosinoprilto control blood pressure did abpm again more than one weeks after therapy. healthy children performed in german in was used asthe normal data. casual bp was measured by sphygmomanometer. children took echocardiography to calculate left ventricular mass index (lvmi). results: the incidence of nocturnal hypertension was significantly higher than that of diurnal hypertension (p< . ).theincidence of non-dipper in children with kidney disease was . %. nocturnal dipping rate in the patients was significantly lower than that in the healthy children (p< . ). the incidence of masked hypertension and white coat hypertension inchildren with kidney disease were . % and . % respectively. nocturnal systolic and diastolic dipping rate of the children with lupus nephritis and acute glomerulonephritis were lower than those of the children with henoch-schönlein purpura nephritis (p< . ). lvmi hadpositive correlation with -hour diastolic blood pressure load (r= . , p= . ), but it had no correlation with casual bp. after taking fosipril, -h, diurnal and nocturnal average abp decreased significantly (p< . ). nocturnal dipping rate increased, but did not reach statistical difference (p> . ). conclusions: abpm was an effective tool for diagnosis and management of hypertension in childhood with kidney disease. identification of novel mutations in the col a gene of japanese patients with x-linked alport syndrome background: alport syndrome consists of nephritis, often progressing to renalfailure, and sensorineural hearing loss. x-linked phenotype (omim# ) is the result of mutation in the gene for the alpha- chain of collagen iv (col a ). objectives of study: to find mutations causing x-linked alport syndrome in japanese patients. patients and methods: diagnosis criteria of alport syndrome were proteinuria, familial history of renal failure andchanges of gbm in electron microscopy. to identify the mutations in the col a gene. results: for the time being we finished genetic analysis of patients with suspected x-linked alport syndrome, males and females. we identified mutations in of patients; of them were novel mutations. they comprise: nonsense mutations, missense mutations and mutations of splicing acceptor site resulting in exon skipping or truncation, and establishing of premature stop codon. in previous reports of x-linked alport syndrome, mutation detection rate was around %. the present study provides a detection rate of . %, although our number of examined cases is limited. conclusions: direct sequencing of rt-pcr and pcr products is efficient method of finding mutations in col a gene. we found mutations in high percentage of investigated patients. objectives of study: to make a genetic diagnosis of juvenile nephronophthisis for a chinese boy. methods: analyze the presentation, family history, laboratory investigations, and histological features of a patient suspected of juvenile nephronophthisis, make a clinical diagnosis. to confirm the diagnosis on genetic level by pcr amplification of satellite markers located within the known homologous deletion of nphp ,including del- , del- , del- , del- -( ) , del- and markers outside the deletions (ranbp / and d s )as control. results: the boy was nine years old, he was admitted becauseof renal failure for months. this case manifested by school age, negligible onset, anemia, polyuria, renal failure at years old,without hypertension and abnormal urine analysis. his sister presented with anemia at year old, and died of uremia at years old.laboratory investigations showed no proteinuria and hematuria. thekidney size is normal, and the cortical medullary boundary is obscure.the histological features consist of the disintegration of tubularbasement membrane, the atrophy and dilation of renal tubules, theinterstitial cell infiltration and fibrosis. he was suspected asjuvenile nephronophthisis. by pcr amplification, we found the missingof the satellite markers of del- , del- , del- -( ) and del- , which indicate that there is the common large homologous deletion ( kb) in the child's nphp . conclusions: nephronophthisis is the major hereditary cause ofchronic renal failure. the boy was suspected of nephronophthisis because of chronic renal failure, family history, normal kidney sizeand hitological features. according to the age of renal failure, he was suspected as juvenile nephronophthisis. the diagnosis was confirmed by gene analysis. it is the first juvenile nephronophthisis case for chinese confirmed by gene analysis. cutaneous small-vessel vasculitis is a rare condition in children and is commonly associated with a wide spectrum of systemic inflammatory conditions, malignancies, infections or drug hypersensitivities. enalapril is anangiotensin-converting enzyme inhibitor, commonly used for the treatment of hypertension. cutaneous vasculitis due to enalapril has very rarely been reported and only with adults. we report a case of an -yea-old boy presented with a pruritic eruptionover his lower legs that started hours after he had initiated treatment with enalapril at a dose of . mg/kg/daily. he had a history of hypertension due to a shrieked right kidney since infancy and he wason treatment with nifedipine and propranolol for the last three years. this medication was discontinued because it was ineffective, the day before initiation of enalapril. clinical examination revealed palpable purpuric lesions involving lower legs and ankles. he was otherwise well. a skin biopsy of the lesions showed leucocytoclastic vasculitis of small vessels. abnormal investigations were elevated c-reactive protein, esr and leucocytosis. further laboratory tests including creatinine, liver function tests, urineanalysis, antinuclear antibody, cryoglobulins, viral serology, complement levels, were normal or negative. enalapril was discontinued and he was started oral prednizolone and ceterizine over the next ten days. the skin eruption regressed rapidly. cutaneous vasculitis induced by enalapril is a rare adverse effect and it is essential a prompt recognition and withdraw of the suspicious drug. objectives of study: barttin, the gene product of the bsnd gene involved in bartter's syndrome with sensorineural deafness, is an essential b-subunit for clc-ka and clc-kb chloride channels, and it is expressed in the kidney as well as in the inner ear. one patient affected by deafness and renal bartter phenotype without bsnd mutations has been previously reported with simultaneous mutations in both clcnkb (responsible for classic bartter syndrome) and clcnka genes. we report here on a new case of a -months-old boy presenting such a disease. a severe polyhydramnios was detected during the pregnancy. he presented also polyuria, growth retardation, nephrocalcinosis and sensorineural deafness. laboratory studies revealed metabolic alkalosis (plasma hco , mmol/l), hypokalemia ( , mmol/l), hypercalcuria (cau/cru , mg/mg) and elevated plasma renin ( pg/ml). the aim of the study was to identify the cause of the severe renal salt wasting and sensorineural deafness in this patient. methods: dna sequencing analysis was performed on the bsnd, clcnkb, and clcnka genes. results: no mutation was detected in the bsnd gene. we identified a reciprocal partial homozygous deletion of exons - for the clcnkb gene and theloss of exons - for the clcnka gene. conclusions: the disruption of both clc-ka and clc-kb chloride channels leads to a syndrome clinically not distinguishable from bsnd, characterized by severe salt wasting and deafness. this digenic disorder is due to simultaneous mutations on the two genes clcnka and clcnkb respectively. the tight topology of the highly homologous clcnka genemight predispose to an unequal crossing over leading to partial orcomplete deletions of the clcnkb gene. we hypothesize that thischimaeric resulting gene interferes with the correct function of both the channels clc-ka and clc-kb, and leads to a bsnd-like phenotype. familiary hypomagnesemia with hypercalciuria and nephrocalcinosis (fhhnc) is a nautosomal recessive tubular disorder that is frequently associated with progressive renal failure. mutations in cldn which encodes the renal tight junction protein paracellin- were identified as the underlying genetic defect. in this work we present a gipsy family with fhhnc in which the mother and daughter both showed homozygous mutations in the cldn gene. a three-year-old girl was investigated after acute pyelonephritis and was found to have medullary nephrocalcinosis, hypomagnesemia ( , mmol/l), hypercalciuria ( , mg/kg/d), hypermagnesuria (femg %) and incomplete distal renal tubular acidosis. her renal function was normal. her mother demonstrated also bilateral medullary nephrocalcinosis, hypomagnesemia ( . mmol/l) with high femg ( %), moderate renal failure (creatinine umol/l) and high ipth levels ( pg/ml). as a child she had afebrile seizures, but serum mg levelwas not measured. index patient's uncle had history of recurrent passage of calculi in childhood, bilateral medullary nephrocalcinosis, normocalcemic hypercalciuria but his serum mg was not determined. he developed obstructive uropathy due to impaction of the calculus in urethra and eventually progressed to terminal uremia and later was transplanted. mutational analysis confirmed that the index case, motherand uncle were homozygous for the common mutation in the cldn gene (leu phe), while the father was heterozygous. we present a new family from macedonia with fhhnc with unusual presentation over two generation. mutational analysis confirmed also the diagnosis of fhhnc in the uncle although as a child he was considered to have idiopathic hypercalciuria. thus, serum mg should be routinely checked in children with nephrolithiasis/nephrocalcinosis. m. pan ' czyk-tomaszewska, j. s ' ladowska, j. so l /tyski, m. roszkowska-blaim arterial hypertension is one of the complications of reflux nephropathy. the aim of the study was to assess the risk factors of arterial hypertension in children with primary vesicoureteric reflux (vur). we studied children aged from to years mean ± . , with unilateral and with bilateral vur. in all children ambulatory blood pressure monitoring (abpm) and m tc dmsa renal scanning (dmsa) were performed and z score body mass index (z-score bmi) were calculated. the following criteria were examined as predictive risk factors: age, gender, age at diagnosis andat resolution of vur, period between diagnosis and resolution of vur,grade of vur, type of vur (unilateral or bilateral), treatment modality (medical, surgical), z-score bmi, grade of dmsa and birth weight. results: i grade of dmsa scan was diagnosed in children, iigrade in , iii grade in and iv in patients. hypertension (hp) was diagnosed in children ( %). the mean value of z-score bmi in children with hypertension was significantly higher in comparison withchildren with normal blood pressure ( . ± . and . ± . ). the multivariate discriminate analysis showed that zscore bmi and grades of dmsa scars were significant risk factors for developing arterial hypertension in children with vur. both parameters had the same influence on development of hypertension (standardized coefficient of discriminate analysis , and , respectively). conclusion: the development of hypertension in children with vur is associated with higher bmi and higher grades of renal scars in dmsa scan. grange syndrome comprises arterial stenoses with hypertension, brachy syndactyly, bone fragility, learning disability, and cardiac defects and it has been reported in the members of two families up to now. we report here a -year-old boy with hypertension, multiple arterial stenoses, microcephaly and brachysyndactyly. severe hypertension ( / mmhg) was detected on his routine control for acute rheumatic carditis and he was hospitalised for investigation. he had no complaints. his parents were first degree relatives. his physical examination revealed microcephaly, bilateral brachysyndactyly between the forth and the fifth fingers of hands and the second and the third fingers of feet. complete blood count, electrolytes, renal, thyroid, and hepatic functions and acute phase reactants were all in normal limits. echocardiography showed aortic and mitral insufficiency and left ventricular hypertrophy. renal and cerebral magnetic resonance angiographies demonstrated stenoses at bilateral renal, internal carotid, superior cerebral and posterior cerebellar arteries. association of hypertension with microcephaly and finger abnormalities and multiple arterial stenosis suggested grange syndrome. chromosomal analysis showed xy karyotype. hypertension persisted despite triple antihypertensive agents and percutaneous renal angioplasty was performed leading to a reduction of antihypertensive medication. with this case report we wanted to remind the recognition of this extremely rare syndrome in a hypertensive child with multiple morphological abnormalities and percutaneous angioplasty as a treatment modality in cases with persistent severe hypertension. hypertension is usually indicative of an underlying disease process in children. the combination of severe hypertension with hyponatremia is called hyponatremic hypertensive syndrome (hhs). in this report we present a case of hhs. the boy was referred to our hospital at the age of years old with generalized tonic clonic convulsion. his past history was insignificant and positive findins of the patients were as follows: hypertension ( / mm/hg), agressive behaviors after convulsive period, metabolic alkalozis (blood gases, ph: , , hco : , , pco : , ), hypocloremia ( meq/l), hypokalemia ( meq/l), hyponatremia ( meq/l), low urine density, polyuria and high serum aldosterone levels ( pg/ml, range: - ). the serum renin, cortisol, tyroid and antidiuretic hormones were within normal range. abdominal color doppler ultrasound were revealed double renal arteries in both kindneys. cranial and abdominal tomography examinations and cebrospinal-fluid examination were normal. the diagnosis of hhs was suggested based on these clinical and laboratory findins and therapy of nifedipine was started. the arterial pressure improved with this therapy. in hss due to renal ischemia, activation of renin angiotensin system which induce pressure natriuresis and thus, thence hyponatremia. we think that presence of renal arterial anomaly might be a cause of an ischemic condition and activation of renin-angiotensin-aldosterone system in our patient. also, activation of aldosterone could enhance with hyponatremia and it could be suppressed of renin secretion in our patient. [hadtstein et al. hypertension ] . the aim of this study was to analyze whether children with renal scars have altered rhythms of mean arterial pressure (map) and heart rate (hr). study design: ambulatory -hour blood pressure profiles of untreated patients with renal scars associated with recurrent urinary tract infections and vur were investigated and compared to healthy controls. results: pre-pubertal, but not pubertal patients with renal scars displayed a number of significant differences to controls. before puberty, the mesors of map and hr were significantly elevated, and the peak-trough difference of the h curve was blunted by . mm hg for map and . bpm for hr. the amplitudes of h and h map rhythms were blunted by . and . mmhg, and those of h and h hr rhythms by . and . bpm (all p< . ). pubertal patients did not display any abnormalities of bp or hr rhythms. we did not find any correlations of the degree of renal scarring, bmi or gfr with the abnormalities in cardiovascular rhythms. conclusion: in summary, pre-pubertal children with renal scarring due to vur show blunted circadian and ultradian rhythms of bp and hr. this phenomenon may reflect subtle alterations of autonomous nervous signaling in children with damaged kidneys; it remains to be addressed whether such abnormalities constitute an independent cardiovascular risk factor. mutations in the eya gene are associated with bor/bo syndrome and rarely with an isolated renal phenotype. we present a family from macedonia displaying a novel eya gene mutation. a six-year-old female was found to have bilateral grade iii vesicoureteral reflux (vur) after an episode of acute pyelonephritis. mutational analysis detected a novel eya gene mutation [an inframe bp deletion (c. _ delttg), resulting in l del of eya a]. she had no clinical stigmata for bor/bo syndrome. the paternal grandmother died due to end stage renal failure. all first grade relatives underwent detailed physical and ophtalmological examination, audiometry, ultrasound screening of the urinary tract and mutational analysis of the eya gene. the father and older sister were mutation carriers and both had normal ultrasound findings. the physical examination did not reveal abnormalities suggestive for bor/bo syndrome, except the sister had esotropia/ hypermetropia and horizontal nystagmus. the male sibling was found to have mild hydronephrosis on the left side. he was not a mutation carrier and cystographic study was not performed at that time. on repeat ultrasound examination he demonstrated dilatation of the right prevesical ureter. the cystography revealed presence of right sided vur grade iii. in conclusion: we present two siblings with vur; although eya gene mutation was found in one of them, it can not be incriminated for the renal phenotype in this family, as co-segregation of the mutation with the vur does not occur in all affected members of the family. decision to perform cystographic study should be still based on clinical grounds. associations asymmetric dimethylarginine (adma) is a novel predictor of cardiovascular (cv) outcomes in adults. aim: to evaluate adma in children with hypertension. subjects: children ( girls/ boys; median age: yrs) with primary (n= ) and secondary (n= ) hypertension. methods: adma levels were analyzed by elisa method. in study subjects antropometrical data, ambulatory blood pressure monitoring (abpm), left ventricular mass index (lvmi), carotid artery intimamedia thickness (cimt), -hour urinary albumin excretion (uae) and serum biochemical markers (lipids, uric acid) were also evaluated. results: adma concentration was positively correlated to serum uric acid (r= . , p< . ) and uae (r= . , p< . ). when analyzed in boys separately, more apparent correlation was found for uae (r= . ) and a tendency for adma to be associated with lvmi r= . , p= . ). interestingly, when analysis restricted to older children (above the median age), adma correlated to lvmi more significantly (r= . , p< . ). no relation was found of adma to cimt, lipids, and abpm parameters. moreover, patients with left ventricular hypertrophy ( %) and microalbuminuria ( %) had a tendency for higher adma values compared to those without these abnormalities ( . ± . vs . ± . μmol/l, p= . and . ± . vs . ± . μmol/l, p= . , respectively). when data analyzed on the basis of adma values, patients in the top quartile showed the worst profile. when compared to the lowest quartile, they had higher lvmi (p< . ), higher uae (p< . ; inter-quartile comparison p= . ), and higher uric acid concentration (p= . ). conclusions: the associations of adma with known factors of cv damage found in this study provide evidence that adma is closely linked to the early cv dysfunction in hypertensive children. nephrogenic diabetes insipidus (ndi) is a disease characterized by unresponsiveness of distal tubule and collecting duct to vasopressin. although ndi usually presents with polydipsia and polyuria, most infants do not have any of these symptoms and presentation is with features of dehydration like fever, constipation, vomiting, failure to thrive and developmental delay. so, the diagnosis is usually delayed until hypernatremia is noted. almost all infants go through a period of hypogammaglobulinemia at approximately the th- th months of age. at this time, the serum ig g level reaches its lowest point, and many normal infants begin to experience recurrent respiratory tract infections. the clinical findings of ndi and transient hypogammaglobulinemi of infancy (thi) may be seen at the same period. here, we report a five-month old boy with ndi. on his history, he was admitted because of recurrent fever attacks and was diagnosed as thi when he was three-months-old. on his follow-up, hypernatremic dehydration was detected and he was diagnosed as ndi. at the time of diagnosis, he had intracranial calcification secondary to delayed diagnosis of ndi. in infants with ndi, recurrent fever attacks due to dehydration may occur and incorrectly lead to think as an infectious disease. we think that this report can be an important warning for clinicians. we analyzed nphs , nphs and neph gene in japanese cns patients independent of the patients in previous report (k.i. ) from different japanese group which suggested that the mutation of nphs was not a major cause of cns in japanese patients. we extracted genomic dna from leukocytes and analyzed all exons and exon-intron boundaries for nphs , nphs and neph using polymerase chain reaction and direct sequencing after informed consent had been obtained. the study was approved by the ethics committees of okayama university medical school. results: we found compound heterozygous mutations of nphs in patients and homozygous mutations in patients. one of these homozygous mutations was already reported in paper from europe and was not found in more than healthy japanese. another one cause defection of trafficking to the membrane as we reported before (k.i. (k.i. , ajkd . the other patients have only heterozygous mutation in nphs that healthy parent also has. we could find any mutations in neither nphs nor neph in the patients with heterozygous mutation. one of these patients has mild form of cns. another one has neither expression of nephrin nor podocin protein on kidney tissue by immunohistochemistry. interestingly, patients out of have the same mutation in nphs as nt (delc). parents who have this mutation heterozygously were from neighboring prefectures. all mutations including this mutation but one have never been reported out of japan which was isolated from continent. all amino acids substituted by missense mutations which seem to be causative were preserved among mouse, rat and human. conclusions: our studies clearly demonstrated that nphs is a major cause of cns even in japanese patients. moreover, nt (delc) is a common mutation in japanese cns patients like fin major or minor. long-term survival of childhoodonset ckd is mainly limited by the manifestation of cardiovasculardisease (cvd). the development of early stages of cvd can be assessedby non invasive methods, e.g. flow mediated vasodilation (fmd) ofperipherial arteries and measurement of intima media thickness (imt) of the common carotid artery. wetherefore performed fmd and imt investigations in children and adolescents (mean age . ± . years) suffering from ckd (mean gfr ± ml/min/ . m ) on conservative treatment (n= ), dialysis treatment ( hd, pd) and after renal transplantation (n= ), and in sex-and age-matched healthy controls. ckdpatients showed significantly decreased fmd ( . ± . % vs . ± . %, p< . ), where as imt did not significantly differ between patients and controls ( . ± . mm vs . ± . mm, p= . ). within the ckd group the presence of arterial hypertension tended to be associated with increased imt ( . ± . vs . ± . mm, p= . ). in contrast, duration of ckd, mode of renal replacement therapy and degreeof renal dysfunction was not significantly associated with fmd and imt findings. conclusion: children and adolescents suffering from ckd show decreased arterial elasticity irrespective of the mode of renal replacement therapy, the rebycontributing to increased long-term cardiovascular morbidity and mortality. the genetic researches have shown the connection between the essential hypertension and angiotensinogen gene. the researches of preeclampsia also showed the connection with angiotensinogen gene. according to established connection of angiotensinogen gene with essential hypertension and also preeclampsia the aim of our research was to determine by the help of m t, g- a anda- c polymorphisms of angiotensinogen gene whether there is a genetic disposition for essential hypertension in those children whose mothers had preeclampsia. at the same time we wanted to establish whether the polymorphisms of angiotensinogen gene can be connected with preeclampsia in women in our population. two groups of children were studied: children of mothers who had preeclampsia and children of mothers without hypertensive disease in the pregnancy. we also studied two groups of mothers: mothers who had preeclampsia and mothers without hypertensive disease in the pregnancy. m t, g- a and a- c polymorphisms of angiotensinogen gene were performed using the pcr method. in investigating the differences between the two groups of children no statistically significant differences were found in m t,g- a and a- c polymorphisms of angiotensinogen gene. in investigating the differences between two groups of mothers no statistically significant differences were found in genotype distribution. the results of our study failed to confirm that with help of m t, g- aand a- c polymorphisms of angiotensinogen gene we might establish genetic disposition for essential hypertension in those children whose mothers had preeclampsia. we did not confirm the association between m t, g- a and a- c polymorphism of angiotensinogen gene and preeclampsia either. ( ) previously treated also with cyclosporine. before start of fosinopril treatment all had proteinuria . - . g/ h and gfr > ml/ . m /min. all active steroid and immunosuppressive treatment were discontinued. eleven children also were treated with calcium channel blockers to control hypertension. after twelve months of fosinopril ( . - . mg/kg) treatment a dna analysis for ace-gene polymorphism was performed. three patients carried ii, -id and -dd gene polymorphism of ace gene. no significant differencein proteinuria at start of fosinopril treatment between all polymorphism types was observed. all patients with ii polymorphism had a good antiproteinuric effect of fosinopril with more than -fold decrease in proteinuria in comparison with just , fold decrease in id polymorphism and no response in dd. renal function remained stable in all children except of with id and with dd gene polymorphism who demonstrated decrease in gfr. we suggest that ii polymorphism of ace gene may be associated with better antiproteinuric effect of acei while dd predicts poor response. wider study is required to confirm genetic predisposition for ace blockade efficacy in proteinuric diseases. introduction: dent disease is x-linked recessive proximal tubulopathy, due to mutations in the clcn gene. it is characterized by low molecular weight proteinuria, hypercalciuria, nephrocalcinosis and progresive renal failure. aim: case report of patient with short stature and proximal tubulopathy where dent disease is determined by gene analysis. method: seven-year-old boy is refered after endocrinological exemination where abdominal ultrasound showed nephrocalcinosis. there are anamnestic data neither of oedema, macrohaematuria, nor poliuria or hypertension. there are also no data of chronic renal failure in the family. we describe detailed diagnostic procedures performed in the boy and his family. results: we determined: proteinuria ( , g/day), elevated urinary excretion of beta- microglobuline, microscopic hemathuria, hypercalciuria ( - mg/kg/day), nephrocalcinosis, decreased tubular reabsorption phosphate ( - %). values of grow hormone, parathormone on thyroid hormone are normal. except hypercalciuria, which is registered in patient's mother, all other analysis performedin family members are betwen referent values. diagnosis is finalized by mutation analysis, which has showed s l substitution on cncl . mutation carrier is mother with normal fenotype. conclusion: dent disease is rare x-linked nephrocalcinosis. definitive diagnosis ofthis proximal tubulopathy which leads to progressive renal demage, is not possible without evidence of gene mutation in renal chlor channel. introduction: the segmental renal infarction is a rare disease, allthough it is more frequent in children than in adults and can be clinically veryrelevant. objective: we describe the clinical course of two children with idiopaticsegmental renal infarction who suffered severe arterial hypertension. cases description: the typical clinical picture of this disease, as seen in our twopatients, is characterized by metabolic alkalosis, hyponatremia, hypokaliemia, hyper-reninemia, hyperaldosteronism and renal salt lossfrom the contralateral enlarged kidney. hypertension was diagnosedduring the study of haematuria in the first case and due to ahypertensive emergency in the second case. the ethiology was found tobe renovascular in both patients, involving the occlusion of small renal arteries causing segmental renal infarction. our first patient was treated with partial nephrectomy, and the second patient wastreated with antihypertensive medication given the impossibility ofremoving the renal infarcted area. conclusions: in the clinical picture, the sodium depletion with increased urinary volume of the contralateral healthy kidney can be explained by the goldblatt model. the gold standard test for the diagnosis is theselective renal arteriography, which is the most sensible and specifictest for diagnosing renovascular hypertension secondary to a segmental renal infarction because it helps identifiing the segmentary artery ofthe infarcted area, this being the source of increased focal renin production. the definitive treatment is the surgical segmentectomy. if segmentectomy is not feasible because of the localization of the infracted area as inour second patient, a medical treatment is needed. conclusion: although an inverse association between birth weight/blood pressure has been suggested in several large studies, interpretation is still controversial. in our study, we have found only a weak inverse correlation between birth weight and pad (abpm): no statistical significance has been found among other variables, although graphs show a trend of low birth weight children towards hypertension. probably a long term follow-up is necessary. he took longer to have improvement, but his calcemia, phosphatemia and alkalinephosphatase are normal. the coding region of the vdr was amplified by pcr and directly sequenced. results: three mutations (two novels) were identified. two patients had anovel mutation in exon , changing the amino acid glutamine to glutamicacid at position (q e). one patient had a novel mutation in exon changing glycine to valine at position (g v). those mutations are in the ligand binding domain and belong to the patients with better control of the disease. one had mutation in exon , in the dna binding domain, changing arginine to a stop codon at position (r x) and it was from the patient with worse response to the treatment. conclusions: two novel mutations are presented in the vitamin d receptor and it could be possible to do a correlation between the clinical evolution and the localization of the mutations. we aimed to evalute the effects of intrauterine growth retardation (iugr) on blood pressure (bp) in small for gestational age (sga) children. sga children ( f, m) aged . ± . y ( preterm and term) and ( f, m) agematched control with appropriate for ga (aga) were included in the study. -hr ambulatory blood pressure monitoring (abpm)was performed using an oscillometric device (mobilograph). th centile limit was set according to published data sets, nocturnal threshold was % less than awake limits. bp was classified as normal if the mean sbp is < th percentile and sbp load is > %. nocturnal bp dip for sbp and dbp were evaluated. in sga and in aga case, office sbp were above th%, all dbp values were normal in both groups. according to the mean of abpm records, systolic, diastolic ht were determined in sga group, and systolic, no diastolic ht were in aga group. there were sga and aga children whose sbp load over %, and only of them remarked as hypertensive according to mean sbp values. children considered as hypertensive had significantly higher sbp loads than those that were not hypertensive( % vs %, p< . ). abpm records were not different between preterm and term sgas. sga group had lower nocturnal bpdip for sbp and dbp in comparison to aga group( . % vs . % for sbp, . %vs . %for dbp, p: . ). although it was not statistically significant, the frequency of non-dipper children was higher in sga group ( . %) than those in aga group ( . %). except the lower nocturnal bp dip and higher sbp loads in sga group which may be a marker for further hypertension, no clear association between being sga and hypertension could be found in our study population. pres is a rare clinico-radiological entity associated with acute hypertension, renal insufficiency and immunosuppressive therapy. it is typically reversible but cases with irreversibility had rarely been reported. we report contrasting cases of pres associated with renal disease, one with full recovery and the other subsequently had epilepsy. first patient had steroid sensitive nephrotic syndrome with acute hypertension, fluid overload and acute renal failure while the second patient had severe flare of lupus nephritis with malignant hypertension, renal failure and thrombotic thrombocytopenia. both had acute onset of drowsiness, blindness and seizures and mri findings of subcortical oedema in the parietal-occipital-temporal regions. while the second patient had full recovery, the first patient developed temporal epilepsy and repeat mri showed mesial temporal sclerosis. pres is attributed to capillary leak from functional cerebral vascular changes of hypertension, rather than infarction. prolonged vascular disruption may lead to ischemia resulting in neurological sequelae and chronic epilepsy. using mri, pres can be readily diagnosed and normalisation of blood pressure is imperative in patients at high risk of pres. efforts have been done to describe the significance of various genetic polymorphisms (snps) in acute renal failure (arf). available reports do not investigate the predictive value of snps in disease forecasting, because so many interacting factors influence arf that classical statistical methods become unstable. high-dimensional nonparametric methods such as random forest technique overcome this problem and help to identify each clinical and genetic factor that possibly contributes to disease. we tested the classification value of basic clinical data available at birth and snps in arf of preterm infants. we determined the relative importance score (ri) of each parameter in classification. low birth weight and gestational age had the highest ri; just few snps had medium ri, while the majority of snps had small ri. then we created variable-patterns and searched for pattern with the highest accuracy of classification. for each complication, the accuracy was . solely basic clinical data were considered. if snps were incorporated, the accuracy of classification for arf was not improved. in contrast with previous observations these findings suggest that the snps do not provide additional information about arf-risk of the general preterm population. conclusions: srbd in children with elevated blood pressure is higher than that of the general pediatric population. the prevalence appears highest in patients with pre-hypertension and may be higher in patients with essential and secondary hypertension than in patients with white-coat hypertension. the renal phenotype in lowe syndrome is similar to dent's disease a -month-old girl presented with heart failure due to severe hypertension ( / ). doppler ultrasonography (us) revealed a right renal artery stenosis. biological findings showed normal serum creatinine (scr) ( mmol/l), hyponatremia ( mmol/l) and hypokalemia ( mmol/l). aldosterone plasma level was increased as were epinephrine ( pg/ml n< ) and norepinephrine ( pg/ml n< ) plasma levels measured times. renal arteriography confirmed the presence of a nearly obstructive right renal artery stenosis with a normal left kidney. pta failed to improve signifcantly the renal artery flow. in the following hours after pta, her scr level increased, up to mmol/l. doppler us showed an unchanged right kidney but hypoperfused area in the left kidney confirmed by the tc -dmsa scan. both aspects were strongly in favor of focal ischemic events. secondarly, her renal function improved but hypertension remained difficult to control autotransplantation of the right kidney was then done, but unfortunately, thrombosis of the right renal artery occured in the following hours. six months later, her plasma creatinine level is of mmol/l. her cardiac function is normal but she has to remain on antihypertensive drugs. what exactly happened during arteriography in her left kidney, in order to provoke such ischemic injury, knowing that the left renal artery was not catheterized during arteriography and pta? one hypothesis is that arterial vasospasms occured, explained by a high vasospastic predisposition due to enhaced cathecolamines secretion. such increased has already been drescribed in patients with renal artery stenosis. this case raised the question of preparing patients in this condition with efficient antispasm therapy agents before radiological vascular investigations are done. rtd is a cause of oligohydramnios leading to potter's sequence and neonatal anuria. it is characterized by absent or hypoplasic proximal tubules. these lesions can be secondary to non genetic conditions involving renal hypoperfusion. genetic forms of rtd have autosomal recessive transmission. mutations of genes encoding for the renin-angiotensin system have been reported. evolution is most often severe with in utero or neonatal death. case report: this boy was born at weeks of gestation with oligohydramnios, arthrogryposis, large fontanels with poor calvarian ossification. he was referred to intensive care unit for respiratory distress, low blood pressure (bp) unresponsive to vasopressors and anuria (plasma creatinine μmol/l at day ). renal ultrasound (us) showed enlarged kidneys with bilateral cortical hyperechogenicity. weaning from ventilation and vasoactive drugs was possible at day . glomerular filtration recovered (plasma creatinine μmol/l at day ). at age , the child is well with normal growth and a mild chronic renal insufficiency (creatinine clearance ml/min/ , m ). bp is in the low normal ranges with plasma renin x over the upper range of normal values and normal plasma aldosterone. on renal us, kidney volume normalized with persistent cortical hyperechogenicity. genetic study revealed compound heterozygous mutation in the gene encoding angiotensin converting enzyme. one is a nonsense mutation (r p), the other is a truncating mutation (k fsx ). it is possible that the first mutation is less deleterious than the other and this could partly explain the unusually favourable evolution of this rtd. in conclusion, this is a rare report of a child with autosomal recessive rtd surviving after neonatal period. further functional studies are needed to explain this unusual phenotype. data on hbp in children are very limited, and it is unclear how much it is specific in pediatric patients. the objective of our study was to determine the reproducibility of hbp in children and adolescents. automatic omron -cp devices, which have been validated for use in children and adolescents, were provided to all families. hypertensive children measured blood pressure (bp) every minutes, three times consecutively in the morning or early afternoon, and three times in the evening during days. the reproducibility of hbp was quantified using repeated measures analysis of variance test and the sd of differences between average hbp values of consecutive days. confidence interval (ci) was calculated. we studied patients ( girls, boys); mean age was , year, range - years. there were measurements of systolic blood pressure (sbp) and diastolic blood pressure (dbp). in the morning or early afternoon the mean sbp and dbp were , mmhg (sd , ) ( % ci , - , mmhg) and , mmhg (sd , ) ( % ci , - , mmhg), respectively. in the evening the mean sbp and dbp was , mmhg (sd , ) ( % ci , - , mmhg) and , mmhg (sd , ) ( % ci , - , mmhg). the mean average difference between the daily measurements of sbp and dbp were analyzed with each period and were not statistically significant (p> . ). on the basis of these results, we conclude that self-monitoring of blood pressure at home in children has good reproducibility and is not influenced by white coat effect. case report: a -year-old caucasian girl presented with history of severe polyuria and polydipsia of few months duration. past history was significant for head injury and possible seizure activity at age yr. there was no history of headaches, vomiting, or visual problems. family history negative for di. physical examination was essentially normal. basal plasma and urine osmolality, and plasma vasopressin were and mosm/kg, and < . pg/ml, respectively. at the conclusion of water deprivation test these readings were and mosm/kg, and . pg/ml, respectively. however, urine osmolality increased to mosm/kg after desmopressin injection, confirming the diagnosis of cdi. mri scan revealed absence of the bright spot on t weighted images. genetic analysis detected avp gene mutation a t, where the normal alanine at amino acid position is changed to threonine. elevated levels of plasma vasopressin after water deprivation were misleading and intriguing. we believe that elevated plasma vasopressin, although immunoreactive was devoid of biological activity. conclusion: molecular genetic evaluation should be performed in all children with cdi without an identifiable cause, even in the absence of a positive family history of cdi. mutations of the nphs gene encoding podocin lead to autosomal recessive corticoresistant nephrotic syndrome, focal and segmental glomerulosclerosis (fsgs), and early end-stage renal disease (esrd). in mice, podocin inactivation by homologous recombination results in diffuse mesangial and glomerular sclerosis, esrd and death within the first weeks of life. this early demise precludes extensive study and elucidation of the molecular pathways engaged by podocin in the mature kidney. we have, therefore, generated a novel mouse model in which a tamoxifeninducible creer-loxp system allows for conditional inactivation in a temporal fashion in podocytes. following tamoxifen administration in nphs flox/-, cre+ mice, cre expression was noted in % of glomeruli and in - % of podocytes. two weeks after cre induction, podocin expression is decreased in podocytes correlating with the appearance of selective albuminuria at - days. this progresses to massive, nonselective proteinuria by weeks, along with high blood pressure and impaired renal function. optical microscopy of kidneys showed no lesion at week and fsgs progressively developed by weeks along with tubular lesions. however electron microscopy revealed a partial foot process effacement at week with no significant albuminuria that extends by weeks along with abnormalities of the basement membrane and development of albuminuria. no mesangial or vascular lesion has been noted, differentiating it from our previous podocin null model in which renal development may be affected by podocin loss or nephrotic syndrome. this model will allow a better understanding of the mechanisms underlying the development of nephrotic syndrome and the role of podocin in the mature kidney, and will be crucial to test new therapeutic approaches. glomerulonephritis is a group of diseases with complex etiology, pathogenesis, morphological features and clinical course. the renin-angiotensin and coagulation systems genes are important group of candidate genes involved in pathogenesis of chronic renal diseases. the purpose of our study was to analyze the association of genetic polymorphisms of these genes with glomerular kidney diseases. the study population consisted of patients with immunological glomerular kidney diseases and patients with renal failure with glomerulonephritis as primary disease. the control group consisted of healthy subjects. by means of the polymerase chain reaction (pcr) the following polymorphisms were evaluated: insertion/deletion (i/d) polymorphism in intron of the angiotensin-converting enzyme gene (ace), g/ g polymorphism of the plasminogen activator inhibitor- (pai- ). no significant association was found between the ace and pai- allele and genotype frequencies and the disease. more progressing of glomerulonephritis current was marked at patients with simultaneous has dd genotype of ace gene and g/ g gene pai- (c = , ; p= , ). our results suggest that ace i/d and pai- g/ g polymorphism is an important modifying gene in the progression of glomerulonephritis. captopril objectives: secondary causes of hypertension such as renovascular hypertension are more abundant in children unlike adult population. the objective of this retrospective study is to assess the use of captopril renography (cr), which provides a non-invasive approach in the differential diagnosis of hypertension. patients and methods: clinical, radiological and scintigraphic data of a total of patients were analyzed. there were girls and boys (mean age: ± years). none of the patients had parenchymal renal disease or reduced renal function. all patients were orally hydrated before scintigraphic study. cr was performed hour after orally captopril administration and iv furosemide injection was done simultaneously with - mci tc m-mag . when post-captopril study was normal, baseline scintigraphy was not performed. computed tomography angiography (cta) was performed in and gadolinium-enhanced magnetic resonance angiography (mra) was performed in children in addition to routine renal doppler ultrasonography (dus). results: nineteen out of patients had other comorbid diseases as follows: obesity n= , previosly-diagnosed fibomuscular dysplasia n= , n= neurofibromatosis, n= demyelinating diseases, n= bartter and n= turner syndrome. cr was normal in patients. in children abnormal cr findings in correlation with radiological methods were reported. correlation with radiological methods could not be done due to suboptimal technique in patients, of whom dus in obese children could not be interpreted. in the other patient, although cr was abnormal, radiological methods could not confirm scintigraphy. conclusions: captopril renography is a useful and simple-to-perform imaging modality in children suspected of having renovascular hypertension. takayasu's arteritis (ta) is a chronic, inflammatory, large-vessel vasculitis affecting the aorta and its main branches, which causes stenosis, occlusion, rarely aneurysm and distal ischemia. the disease is most common in young women, it is rare in inviduals before the age of years. clinical presentation may be heterogeneous. in this report, we present a pediatric patient with ta who had hypertension as the sole manifestation of multipl critical arterial involvement but no other symptoms. a -year-old boy was admitted with hypertension. the acute-phase reactants were moderately elevated with an erythrocyte sedimentation rate mm/h, and a c-reactive protein value of mg/l. serologic tests including ana, anti-ds dna, c and panca, complement c , and c were negative and other laboratory data were normal. mr angiography showed multiple severe stenosis or occlusions of the thoracic and abdominal aorta together with bilateral renal arteries, and saccular aneurysm in the abdominal aorta. immunosuppressive treatment including pulse steroid and methotrexate was prescribed. the patient underwent angioplasty of bilateral renal arteries and suprarenal aorta, and a stent was placed in the right renal artery. ta should be kept in mind in the differential diagnosis of hypertension in children, even if they do not have other associated symptoms of the disease. human urotensin ii is the most potent vasoconstrictor which circulates in the plasma of healthy individuals. it was suggested that it has an endocrine role in sodium handling and even in metabolic syndrome. the aim of this study was to investigate the role of u-ii in obese adolescents with hypertension. fourteen obese adolescents with essential hypertension (group ) were compared with thirteen age-and sex-matched obese adolescents with white-coat hypertension (group ). they underwent twenty-four hour abpm and echocardiographic investigation, complete physical examination, including adiposity indexes. plasma and urinary levels of u-ii were measured by ria. obese adolescents in group have significantly higher blood pressure measurements than those in group confirmed by abpm. there was no significant difference in left ventricular mass index between two groups. no significant difference was found in plasma u-ii concentrations (pg/ml) between group and group ( . ± . and . ± . , respectively), whereas mean urinary u-ii level (pg/mg urinary creatinine) was significantly higher in group than that of group ( . ± . , . ± . , respectively). considering the renal synthesis and vasoactive role of u-ii, these results suggest that u-ii may have a role in adolescents with white-coat hypertension. distal renal tubular acidosis (drta) and deafness is a rare autosomal recessive disease characterized by severe metabolic acidosis in childhood and inappropriately high urinary ph along with sensorineural hearing loss. the disease is caused by defects in the atp v b gene. the aim of the present study was to determine the molecular basis for drta with deafness in eight patients from four families (a-d) in israel. molecular testing was done by sequencing the coding exons of the atp v b gene in one affected child from each family. a population screen was performed for mutations found in family a. the results yielded a different mutation in the atp v b gene, as follows: families a and d: missense mutation, c>g (p r), in addition to a single nucleotide polymorphism ( t>c) in the first codon; family b: insertion mutation, - insc (i fs); family c: a novel nonsense mutation, c>t (r x). in conclusion, the phenotype of drta and deafness concurs with mutations in the atp v b gene. in the present study, four families of different origins with the same phenotype had three different genotypes, indicating that there is no single common mutation in israel. these findings have implications for genetic counseling during pregnancy and testing of families. the fact that all the patients that were examined have harbor mutations in the atp v b gene, pointed for the specific clinical phenotype. making correct and early clinical diagnosis is a fundamental step in finding the molecular basis of this rare disorder. delta f is the most common cystic fibrosis (cf) mutation worldwide. the prevalence is approximately % in caucasian and - % in asian while f l is demonstrated in only . %. homogenous delta f mutation is recognized as the most common genotype however there are small numbers of cf patients having delta f /f l. in the present study we report a year-old thai boy, originated from north india, presented with recurrent episodes of febrile illness, hyponatremia, hypokalemia and metabolic alkalosis since months of age. he was transferred to our hospital for further investigation. blood chemistry revealed serum electrolytes: sodium , potassium . , chloride . , bicarbonate . meq/l, and urine electrolytes: sodium< , potassium . , chloride< meq/l. after intravenous fluid administration, hyponatremia and metabolic alkalosis improved. dna sequencing analysis of his blood demonstrates compound heterogenous mutation for delta f and f l in cftr gene. t to g transversion at nucleotide and g to a transversion at nucleotide are found without altering amino acid encoding gene. in conclusion, we report a rare case of cf with delta f /f l genotype presented with recurrent hyponatremia and metabolic alkalosis. awareness of electrolyte abnormalities during febrile illness, proper genetic counseling and long-term follow-up are necessary in this patient. objectives of study: about % of families with congenital nephrogenic diabetes insipidus (ndi) have mutations in the aquaporin gene (aqp ), which codes for the vasopressin-sensitive water channel. only seven aqp mutations are known to cause a dominant form of the disease. in this study we performed genetic and clinical studies in a generation family with autosomal dominant inheritance of a partial di phenotype. methods and results: the proband (man, yrs old) was initially diagnosed with partial central diabetes insipidus due to antidiuretic effect of ddavp. his daughter ( . yrs old) also showed polyuria and polydipsia which was responsive to high doses of intranasal ddavp. the pedigree was consistent with an autosomal dominant inheritance pattern. sequence analysis of the entire coding region of the avp gene and aqp gene was performed in the proband and his affected daughter and in unaffected family members. the avp gene was normal in all subjects. in the two affected patients but not in the healthy subjects we identified a novel missense mutation in one allele of exon of the aqp gene (c. c>t) which predicts a substitution in the c-terminal part of the aqp protein (p.r w). conclusion: partial ndi can be caused by heterozygosity for a p.r w substitution of the aqp water channel. the substitution is likely to significantly alter the c-terminal tail of aquaporin which is important for proper trafficking to the apical plasma membrane. the preservation of some residual antidiuretic function indicates that some aqp tetramers are processed correctly. the study further illustrates the importance of molecular diagnostic tools in establishing a correct differential diagnosis in familial cases of di. a background and aim: dent's disease is a renal tubulopathy characterized by low-molecular-weight proteinuria, hypercalciuria, nephrocalcinosis and nephrolithiasis. mutations in the clcn gene encoding the chloride/proton exchange transporter clc- cause this disease. we have described an alu insertion in clcn that leads to exon skipping in the patient's mrna. in this study, we investigated the consequence of this mutation on the function of two putative exonic splicing enhancers (eses) in exon and the role of alu '-end sequences on splicing inhibition. methods: minigenes were constructed by inserting exon and exon -alu with their intronic flanking sequences into the exon trap vector. artificial mutations were introduced by site-directed mutagenesis. plasmids were transfected into cos cells by electroporation. pre-mrna splicing analysis was performed by rt-pcr. the ese finder web resource was used to predict the mutagenesis effects on the eses. results: alteration of one of the putative eses, the predicted binding site for srp , induced exon skipping. restoration of this site within the alu sequence promoted the incorporation of exon -alu in the mrna. however, restoration of both eses leaving the alu sequence intact resulted in exon skipping. furthermore, substitution of the eses for the first seven nucleotides of the alu element, and insertion of this sequence next to the eses increased exon skipping. deletion or modification of the alu '-end enhanced exon inclusion in the mrna. in the patient carrying the clcn alu insertion, dent's diseases is caused by disruption of an ese and by inclusion of splicing inhibitory sequences leading to exon skipping. this work was supported by grant pi from fondo de investigación sanitaria. factor h-associated hemolytic uremic syndrome (fhd-hus) is a rare disease with incomplete penetrance. it is not clear why and how carriers of the same mutation will eventually develop or not develop the disease and this uncertainty is sometimes responsible for anxiety in the carriers badly affecting their quality of life (particularly of parents with children carrying the mutation). in the attempt of estimating disease risk in subjects with factor h gene mutation, the families of fhd-hus patients (all of which had a documented mutation on the scr ) currently being treated at our center, were screened to identify the carriers after having been informed on the purpose of the analysis. twenty-eight subjects (age range - yrs), out of analyzed, revealed heterozygous mutations in the carboxy-terminal region of fh gene ( %). among subjects carrying the mutation, ( %) had exhibited the disease at a mean age of years (range . - ), of which ( %) before age , whereas the remaining subjects (mean age of yr -range - ) were healthy at time of the study. the figure shows the probability of carriers to be hus-free by age (no event occurred after age yrs). in the meantime that predisposing factor are identified, the presented survival curve (fig. ) can be an useful tool to estimate the residual risk of hus in individual carriers according to their specific age. cerebello-oculo-renal syndrome (cors) (also called joubert syndrome (js) type b) and meckel (mks) syndrome belong to the cilliopathy group of developmental autosomal recessive disorders associated with primary cilium dysfunction. nephronophthisis (nphp), the most frequent genetic cause of renal failure in children and young adults, is associated with retinal degeneration and cerebellar vermis aplasia in cors. mks is characterizd by renal cystic dysplasia, central nervous system malformations and hepatic developmental defects. these syndromes are genetically heterogenous: mutations in ahi and nphp can cause cors and mutations in mks can lead to mks, while mutations in mks and nphp are found in both syndromes. using snp mapping, we identified missense and truncating mutations in a novel genee, nphp , in both cors and mks. interestingly, all sequence changes were either nonsense or frameshift mutations in fetuses with mks whereas patients with cors had either only one or no truncating mutation. we then show that inactivation of nphp mouse orthologue recapitulates the cerebral and renal defects of cors/mks. we further demonstrate that nphp protein co-localizes at the basal body/centrosomes with nephrocystin- and nephrocystin- , the protein products of both nphp and nphp , known disease genes for nphp. in addition, missense mutations of nphp protein found in cors patients diminishes its interaction with nephrocystin- . taken together. our findings demonstrate that mutations of this novel ciliary gene can cause the multiorgan syndromes of either cors or mks, which therefore represent a continuum of the same underlying disorder. severe antenatal bartter's syndrome ga + , bw: g). both had classical signs of antenatal bs including very poor thrive, polyuria ( - ml/kg b.w./h) and responded to indomethacin treatment. direct sequencing was performed on pcr-amplified genomic dna. the entire coding region of both genes was analyzed. the kcnj gene was normal but both children were homozygous for a single base substitution ( t>a) in exon of the slc a gene predicting a premature stop codon (y x). the parents of both children and two siblings were heterozygous for the same mutation. by restriction enzyme analysis, the t>a substitution was absent among chromosomes from healthy subjects. conclusion: two children with severe antenatal bs were identified and the clinical phenotype was characterized. we identified in both children a novel mutation causing a premature stop codon of the bumetanide-sensitive-sodium-potassium-chloride co-transporter (nkcc ). despite large potassium supplements and indomethacin treatment, both children show persistent polyuria, vomiting, and insufficient thrive. background: mutations of nphs encoding the transmembrane slit diaphragm protein nephrin cause congenital nephrotic syndrome of the finnish type, characterized by massive proteinuria and the development of nephrotic syndrome before months of age. about different nphs mutations have been described. a large number of these are missense mutations resulting in single amino acid replacement mostly located in the extracellular domain. some nphs mutations have been associated with mild phenotypes responding to angiotensin-converting enzyme and prostaglandin synthesis inhibition. patient history: we report on a son of consanguineous turkish parents with a novel nphs alteration and steroid-resistant congenital nephrotic syndrome. after normal pregnancy and delivery at weeks of gestational age the boy presented with edema and proteinuria at the age of months. he responded to angiotensin converting enzyme inhibitor treatment reducing his proteinuria from a maximum of g/g creatinine to g/g creatinine and allowing him to develop normally until the age of months when cardiovascular insufficiency in the course of a hyperpyretic infection led to hypoxic encephalopathy. genetic testing revealed a homozygous in-frame -bp insertion in exon of nphs . both parents were found to be heterozygous. no mutations were found in nphs or in exons and of wt . the alteration results in an insertion of a glycine in an extracellular immunoglobulin domain of nephrin. the pathogenicity of this alteration is unclear. nephrin may be misfolded and mislocalized as in some missense mutations of the extracellular domain. alternatively the alteration might lead to an altered extracellular homo-and heterodimerization of nephrin. functional studies are currently underway to determine the effect of this novel alteration in nphs . objectives of study: interleukin receptor antagonist (il- ra) gene polymorphism has been found to affect disease susceptibility and activity in several inflammatory diseases. we investigated the association between il ra gene polymorphism and childhood nephrotic syndrome (ns) in a turkish population. methods: we analyzed the genetic polymorphism of il- ra gene in patients with childhood ns and healthy controls by using pcr. five alleles of the il- ra gene were identified and designated as il- ra* , il- ra* , il- ra* , il- ra* , and il- ra* , according to the variable number of tandem repeats in intron . results: in the ns group, the allele frequencies of il- ra* , il- ra* , il- ra* , il- ra* , and il- ra* were . , . , . , . , and . % compared with %, %, %, %, and % in the controls. a high allele frequency of il- ra* (x = . , p= . ) and a lower allele frequency of il- ra* (x = . , p= . ) were found in childhood ns. the other polymorphisms were not significantly different from normal controls. conclusions: a high allele frequency of the il- ra* allele may affect the disease susceptibility in childhood ns. objectives of study: congenital anomalies of the urinary tract (caut) are common in humans, and the incidence is increasing with recent advances in prenatal ultrasonographic examinations. interstitial fibrosis, which correlates with infiltration of inflammatory cells is common finding in the kidney with long-term ureteral obstruction. up-regulation of monocyte chemoattractant protein- (mcp- ), may be a common regulatory pathway involved in the progressive renal damage with any etiologies leading to interstitial fibrosis. mcp- gene polymorphism - a/g had been suggested to influence circulating mcp- levels and gene expression thus, might be one of the genetic markers for progression of renal damage. our aim was to investigate the frequency of mcp- genotypes and allele - g in patients with caut. objectives of study: congenital urological anomalies are well recognized as causing renal dysfunction. on the other hand, patients without congenital anomalies but with urinary bladder dysfunction (bd) could also develop renal parenchymal damage. it has been reported that angiotensin converting enzyme (ace) i/d polymorphism was a risk factor for renal parenchymal damage in certain renal diseases including vesicoureteral reflux. the aim was to determine i/d polymorphism as a potential risk factor for renal parenchymal damage in patients with congenital obstructive uropathy and to compare them to patients born with normal anatomy and innervation of bladder, sphincter and pelvic floor but which could develop upper urinary tract abnormalities. objectives od study: to determine the frequency of pyelocaliceal dilation (pcd) in asymptomatic infants and its connection with presence of other urinary tract anomalies (uta) and urinary tract infection (uti). methods: ultrasonographic screening (us) of urinary tract (ut) was performed on unselected population of healthy infants ranging between days and months of age ( boys and girls). kidneys were divided into two groups according to grade of pcd. group i consisted of kidneys with pcd, whose anterio-posterior diameter was - mm, while patients from the group ii had a-p diameter wider than mm.patients were followed up (ranging - months) by serial ultrasound examinations and with other methods for presence of uti and uta if necessary. results: in examined population , % had uta, and , % had uti. pcd was found in infants ( , %). in the group i, consisted of infants ( males and females) pcd increased during the time in , % infants, remained unchanged in , %, decreased in , %, and disappeared in , % patients. uta was found in ( , %) infants, and uti in ( , %) infants. in the group ii, consisted of male infants, pcd has not changed in ( , %) infants, decreased in ( , %), while dilation disappeared in ( , %) patients. uta was found in ( , %), and uti in ( , %) infants. conclusions: us of ut is useful and valuable method for detecting pcd. our results indicate that mild pcd in infants increases the risk for uta approximately times and uti times, while severe pcd raises the risk for uta approximately times, and uti times. early diagnosis and early treatment of uta and alertness for possible uti should be the final goal of the kidney damage prevention. therefore we recommend that us of ut should be done in all children in the first months of life. in order to determine factors involved in kidney development, the spatial and temporal expression pattern of intermediate filaments (cytokeratins, vimentin) , epithelial growth factor (egf) and transforming growth factor alpha (tgf-α), was investigated in developing kidneys (mesonephros and metanephros) of - week human embryos. immunohistochemistry for detecting specific antibodies was used on paraffin sections. in the - week human mesonephros, vimentin was moderately expressed in all mesonephric structures, while cytokeratins were seen only in the mesonephric nephrons. moderate to strong expression to egf and tgf-α detected in all mesonephric structures, decreased with advancing development. in the - -week metanephros, vimentin was mildly expressed in all metanephric structures. later on, its expression increased in collectin system and interstitium. in the th developmental week, first to appear were cytokeratins and in the ureteric bud and ampullae, while from the th week onward, both cytokeratins showed increasing expression in the collecting system and nehrons. at early stages, egf and tgfá showed moderate to strong reactivity in the collecting system, the metanephric mesenchyme and cups. from the th week onward, expression of both factors decreased in differentiating nephrons. expression of all investigated developmental factors was in line with subsequent mesonephric degeneration. expression pattern of intermediate filaments in the metanephros might be associated with mesenchimal to epithelial transformation of developing nephrons. some mutations of cytokeratins are lethal, while others might lead to some multifactorial disorders. egf and tgf-α expression patterns of the metanephros indicate their role in induction, proliferation and growth of metanephric structures. their disturbed expression might cause reduction in kidney growth. we have demonstrated that renin-angiotensin system (ras) and mitogen-activated protein kinase (mapk) family constribute to the renal development. growing evidences indicate that aldosterone, a final element or ras, is an independent and powerful mediator of various renal disease. purpose of this study was to evaluate the role of endogenous aldosterone in renal development including cell proliferation and apoptosis, and the expression of mapk family. newborn rat pups were treated with spironolactone ( mg/kg/d) in olive oil or vehicle for d. to identify cellular changes, kidneys were examined for proliferating cell nuclear antigen (pcna) by immunohistochemical (ihc) stain, and apoptotic cells by tunel stain. immunoblot, ihc stain and rt-pcr for mapks, phospho-mapks, and p gene were performed. spironolactone treatment resulted in decreased body weight, decreased pcna-positive proliferating cells and increased tunel-positive apoptotic cells, especially renal cortical epithelial cells (p< . ). in the spironolactone-treated group, c-jun n terminal kinase (jnk)- and phospho-jnk- protein expressions were significantly increased, whereas extracellular signal -regulated kinase (erk)- and p protein expressions were sigificantly decreased compared with the control group (p< . ) in immunoblot and ihc stain. expressions of erk- , phospho-erk- and , and p sere not changed by spironolactone treatment. in rt-pcr, erk- and p mrna expressions were significantly increased in the spironolactone-treated group (p< . ). we conclude that aldosterone inhibition in the developing rat kidney decreases cellular proliferation and increases apoptosis, and modulates the expressions of jnk- , erk- and p . mapk family expression may be implicated to differentially participate in aldosterone-related intracellular signaling pathways in the developing kidney. objectives: early detection of anomalies of the kidney and urinary tract (ut) helps to prevent complications but is hampered in moldova by diagnostic and logistic problems. to assess the extent of late diagnosis we studied the clinical data of all children referred to us for suspected ut infection (uti) in / and found to have renal or ut anomalies. methods: children ( males; age months- years) found to have anomalies of the kidney and ut and treated conservatively were studied (newborns and infants < months were seen elsewhere). work-up included ultrasonography in all, voiding cysto-urethrography (vcug) in %, urography in % and scintigraphy in % of patients. results: reasons for referral were febrile uti ( %); abdominal pain ( %), diarrhea and vomiting ( %), enuresis ( %) and dysuria ( %). uti was confirmed by urine culture in two thirds of cases. age at diagnosis of renal or ut anomaly was < year in %, - years in %, - years in %, - years in % and > years in %. renal hypo/dysplasia was found in , solitary kidney in and a horseshoe kidney in children. anomalies of the ut included hydronephrosis due to ureteral obstruction ( up and uv-obstruction), vesico-ureteral reflux ( ), duplex systems ( ) and bladder anomalies or mild infravesical obstruction ( ). serum creatinine was in the normal range in all children. urolithiasis was found in patients. conclusions: anomalies of the kidney and ut were diagnosed in nearly half beyond the age of years, thus with considerably delay. based on the results of this study a new strategy of renal ultrasound screening in newborns including prenatal diagnosis and of closer co-operation with referring physicians has been implemented. objective of the study: the purpose of this study was to report the outcome of infants with antenatal hydronephrosis. methods: between may and june , all patients diagnosed with isolated fetal renal pelvic dilatation (rpd) were prospectively followed at asingle tertiary renal unit. inclusion criteria were presence of rpd equal to or greater than mm on prenatal ultrasound after weeks gestation, at least six-months of follow-up, and at least two postnatalus scans. the events of interest were presence of uropathy, rpd resolution, urinary tract infection (uti), and hypertension. rpd was classified as mild ( - . mm), moderate ( - . mm) and severe (> mm objective of the study: the aim of this study was to compare the accuracy of ultrasound renal parameters to discriminate between significant uropathy and idiopathic renal pelvis dilatation. methods: neonates who were found to have isolated fetal renal pelvis dilatation (rpd) underwent systematic investigation and were prospectively followed. a us scan was performed after the first week of life and all infants underwent vcug. neonates with rpd larger than mm were examined by renal scintigraphy. receiver-operating characteristic (roc) plots were constructed to determine the accuracy of three indexes: fetal rpd, postnatal rpd, and sfu grading system. results: a total of infants were included in the analysis. ninety-five fetuses ( %) presented bilateral renal pelvis dilatation. seventy-nine infants ( %) presented urinary tract anomaly, corresponding to renal units. the most frequent detected uropathy was ureteropelvic junction obstruction ( ), followed by primary vesicoureteral reflux ( ), and megaureter ( ) conclusions: our data support the view that fetal and postnatal us renal parameters are useful markers to identify infants with clinically significant uropathies. there was no significant difference in performance among the indexes. objective of the study: the aim of this study was to evaluate the diagnostic accuracy of ultrasound (us) renal parameters to identify vur in infants withisolated antenatal hydronephrosis. methods: neonates who were found to have isolated fetal renalpelvis dilatation (rpd) underwent systematic investigation and wereprospectively followed. a us scan was performed after the first week of life and all infants underwent vcug. neonates with rpd larger than mm were examined by renal scintigraphy. receiver-operating characteristic (roc) plots were constructed to determine the accuracy of three indexes: fetal rpd, postnatal rpd, and sfu grading system. results: a total of infants were included in the analysis. seventeen infants ( . %) presented vur, corresponding to renal units. to discriminate between renal units with and without vur areaunder the curve (auc) was estimated by the roc curve, which was . ( % ci= . - . ), . ( % ci, . - . ), and . ( % ci, . - . ) for fetal rpd, postnatal rpd, and sfu grading system, respectively. there was no statistically significant difference between the indexes. the optimal threshold for fetal rpd was mm with a sensitivity of % ( % ci, - ) and specificity of % ( % ci, - ), for postnatal rpd the respective figures were: % ( % ci, - ) and % ( % ci, - ) for the cut-off of . mm. conclusions: our data shown that the magnitude of rpd is a poor predictor of presence of primary vur. there was no significant difference in performance among the indexes. objetive: we investigated the prevalence of renal calcification in children with autosomal ressecive polycystic kidney disease (arpkd) and studied the metabolic changes thats could cause this complication. methods: patients with arpkd. girls/ boys; range age m to y. criteria inclusion presence typical imaging findings: enlarged kidney and diffusely increased renal echogenicity and poorly defined renal margins on sonography; suggestive imaging features with positive results renal or liver biopsy, results patients, girls and boys, range of age - y, had ct scan renal clacification bilaterally. without renal clacifications < year. children renal calcifications, sistemic hypertension, portal hypertension and gastrointestinal bleeding and one renal colic. renal insufficiency patients, it was mild in (gfr > ml/min/ , mt ), moderate in (gfr - ), and severe in one (gfr< ). all with renal insufficiency had distal tubular acidosis. hypocitraturia urine patients. urinary calcium, uric acid, oxalates, and cystines normal in all. tuberoussclerosis (tsc) -an autosomal dominant inherited genetic disorder -is characterized by development of hamartomatous growths in many organs.two causative genes, tsc (chromosomal locus q ) and tsc (chromosomal locus p . ) have been identified. tsc gene is adjacent to pkd , the major gene for autosomal dominant polycystic kidney disease (adpkd) on chromosom p and contiguous germline deletion of both genes results in severe polycystic kidney disease phenotype at birth. at months of age bilateral abdominal masses were occasionally palpatedin a previously healthy girl. ultrasonography demonstrated enlarged (approximately cm) kidneys with multiple large cysts resembling those seen in adpkd. renal function and blood pressure was normal. suspicion of tuberous sclerosis was raised due to numerous hypopigmented cutaneous macules on the trunk and extremities. echocardiography demonstrated rhabdomyomas in the left ventricle with no hemodynamic significance. an isolated juxtapapillary astrocytoma was found in the left eye. her psychomotor development was normal with no history of seizures. cerebral magnetic resonance imaging revealed multiple subependymal nodules with noobstruction of the cerebral fluid pathways. by multiplex ligation-dependent probe amplification (mlpa) a large dna deletion was identified spanning from tsc exon to pkd exon permitting the diagnosis of tsc -pkd contiguous gene syndrome. cardiac rhabdomyoma and cutaneous manifestations were found in her father as well but no renal changes. at years of age the girl is doing fine with ace blockers against hypertension. renal function is still normal. the size of the cardiac rhabdomyomas is diminishing while the cerebral and ocular hamartomasare unchanged. this additional report focuses tsc in an infant presenting with polycystic kidneys and cutaneous lesions. improvements in ultrasound technology and the appropriate timing of antenatal ultrasound has led to refined prenatal diagnosis and enhanced accuracy of diagnosis of fetal renal anomalies and makes it possible to treat obstructive and/or refluxing uropathies before the onset of clinical symptoms.a retrospective review of patients; girls ( , %) and boys ( , %) admitted to our clinic between january -december with antenatal urinary anomalies were investigated to determine the urinary tract anomalies, and the follow-up results are presented. routine prophylaxis was started at admision and the imaging studies were performed. the mean gestational age at detection was , ± , weeks. the mean age of admittance was , ± , days and the average follow-up period was , ± , months. antenatal ultrasonoghrapy examination showed anomalies in / renal units. of these antenatally observed renal units, had postnatal urinary tract anomalies. of these postnatally observed renal units, urinary tract anomalies were detected (multiple urinary tract anomalies in patients) ( table ) . fifty-two ( , %) children had surgical interventions such as; ureteroneocystostomy, pyeloplasty, nephroureterectomy, puv resection. eighty-one ( %) of our patients had urinary tract infection during follow-up and renal scar was detected in ( %) patients. acute renal failure developed in patients and chronic renal failure developed in patients and three patients died. we conclude that all infants with fetal urinary abnormalities should be evaluated, so that we can recognize and treat congenital anomalies that may affect renal function or cause urinay tract infection, renal scarring. the majority of patients with fetal urinary anomalies can be managed safely with close conservative follow-up. fetal urinary tract obstruction at days gestation (e ) produces small kidneys with cysts, whereas obstruction at days (e ) generates large kidneys with cysts. in the present study, we investigated the mechanism for the generation of small kidneys by urinary tract obstruction at an earlier gestational age, e . fetal lambs underwent urethral and urachal ligation at e (n= ) or e (n= ). fetal lambs were delivered by c-section , , days after obstruction, or at term ( days gestation). unoperated kidneys of e , e , e , and at term served as controls. the percentage cystic area of kidneys obstructed at e and e was not different days after obstruction ( ± % vs ± %). after days, however the percentage of cystic area became larger in kidneys obstructed at e ( ± % vs ± %), and was significantly larger days after obstruction ( ± % vs ± %). proliferating cells, detected by pcna staining, were found in cysts and tubules of obstructed kidneys increasing toward term, and were more abundant in kidneys obstructed at e . on the other hand, pcna-positive cells in the nephrogenic zone were reduced in obstructed kidneys. the decrease was more prominent in kidneys obstructed at e . apoptotic cells, identified by tunel staining, were detected in the inner medulla of obstructed kidneys equally in kidneys obstructed at e and e during the fetal stage. at term, tunel-positive cells were rarely present in normal kidneys or kidneys obstructed at e , but were found abundantly in the interstitium and occasionally in cysts and tubules of kidneys obstructed at e . in conclusion, urinary tract obstruction at an earlier gestational age produces small kidneys by inhibition of mesenchymal cell proliferation, which may be due to compression by cysts. a. results: detrusor hyperreactivity, most commonly in i and iv or v grade was found in . % of vur children. the maximum detrusor pressure was above cm h . detrusor-external dyssymetry was found in % of children, most frequently in grade i and iv or v grades, and detrusor-internal dyssymetry was recognized in . % of children with vur, most frequently in grade i and iv or v. in . % of children with i-iii grade of vur cystometric capacity was reduced but child with v grade had increased capacity of the urinary bladder. glomerular filtration according to schwartz equation was normal and independent of vur grade. decrease in osmolality below mosm/kg h in nocturnal urine was only detected in the group of children with iv and v grade of vur,. there was no correlation between detrusor tension and osmolality of urine and glomerular filtration rate. conclusions: ). dysfunction of the lower urinary tract, with detrusor hyperactivity was detected, as the most frequent dysfunction in % of children below year old with i-v degree of vur, ). the maximun detrusor pressure in the voiding phase was highest in grade i and iv iv-v reflux children. hypomelanosis of ito was first described as a disorder characterized by unusual unilateral or bilateral macular hypopigmented whorls, streaks and patches. subsequently, neurologic, skeletal and ocular involvement were described. kidney involvement has only been exceptionally reported. herein, we describe a case of a male infant with hypomelanosis of ito and renal involvement. the patient was born at weeks of gestation by cesarian delivery. the ultrasound scan at weeks of gestation revealed bilateral enlargement of kidneys, decreased corticomedullary differentiation and cysts located in the cortical and subcapsular regions. these findings were confirmed at two months of life by ct scan. skin examination showed hypopigmented linear and round diffuse lesions located on the right leg and arms. the ophthalmological examination showed anterior capsular and posterior subcapsular cataract of the left eye. as previously reported in other cases of hypomelanosis of ito, the patient presented a transient leucocytosis (max . /mm ) during the first months of life.the renal biopsy showed a classic picture of glomerulocystic kidney disease, whereas the skin biopsy confirmed the clinical diagnosis of hypomelanosis of ito.three other cases of kidney disease in hypomelanosis of ito have been reported. of these, one case presented abnormalities of the glomerular basement membrane, and one case presented with polycistic kidney disease. the third case had renal cystic dysplasia with a histological picture containing glomerular cysts. alltogether these reports suggest that genes involved in hypomelanosis of ito are important for normal renal development and may be implicated in cystogenesis, when mutated. here we report on a male newborn (birth weight g, length cm) who presented with progressive edemas, oliguria and failure to thrive during the first week of live. on clinical examination he showed bilateral microcoria and decreased muscle tone. laboratory work-up revealed large proteinuria ( g/g creatinine), hypoalbuminemia ( g/l) and renal failure ( objectives. to investigate the incidence, nature, and management of associated genitourinary malformations in children with multicystic dysplastic kidney (mcdk). methods. in this retrospective study, we analyzed the medical records and imaging studies of children with mcdk. in children ( %) anomalies of the urinary tract were suspected prenatally in ultrasound studies. in the remaining children the diagnosis of mcdk was made postnatally. results. the male/female sex ratio was : . the left side was involved in ( %) children. voiding cystourethrography was done in ( %) children, the isotopic m tc-dmsa scan of the kidney in ( %). urogential anomalies were present in ( %) children. among them, contralateral urologic anomalies were found in patients (vesicoureteral reflux in and hydronephrosis in ), and ipsilateral in (vesicoureteral reflux in , ureterocele in , and hydroureter in ). genital abnormalities such as uterine didelphys and hydrocele were found in children. fourteen ( %) patients underwent follow-up examinations with ultrasonography (mean follow-up . years, range months to years). compensatory hypertrophy of the contalateral kidney was found in most children and decreased size of ipsilateral dysplastic kidney was found in out of children with follow-up. no cases of hypertension or tumor developed during the follow-up. conclusion. ultrasound can be used safely to diagnose unilateral mcdks and associated genitourinary malformation. although the risk of hypertension and development of malignancy is low, follow-up evaluation of contralateral renal function and genitalia will be needed. in cases of hydronephrosis and/or urinary tract infection, voiding cystourethrography is necessary and possibility of association with genital anomalies should be considered until the puberty. a. background: ectopic ureter is a rare anomaly. its incidence is at least four times higher in females and also more than % of the ectopic ureters drain duplicated systems in females. the most common presenting symptoms of an ectopic ureter are urinary tract infection and incontinence. diagnosis is often delayed and may remain undiagnosed until adulthood. case report: a -month-old girl was admitted to our hospital with the complaints of fever and discomfort. her mother recognized intermittent dribbling of urine while changing her napkin. physical examination revealed fever ( . °c), diaper dermatitis and intermittent dribbling of urine. urinalysis revealed leukocytouria, acute phase reactants were elevated (crp: . , esr: ) and renal function tests were normal. the patient was hospitalized with the diagnosis of acute pyelonephritis. tc m dimercaptosuccinic acid (tc-dmsa) scan revealed an increase in the size of the right kidney and decreased uptake in the upper half of the same kidney. ultrasound was performed with the suspicion of an ectopic ureter and it showed right duplicated kidney with marked dilatation of the upper collecting system. the ureter was also dilated in its whole length and ended ectopically distal to the bladder. contrast-enhanced magnetic resonance urography (mru) demonstrated right obstructed duplicated system with vaginal ectopic insertion of upper pole ureter. discussion: this case was presented to underscore the role of careful physical examination in the diagnosis of this rare anomaly that is by paying attention to the complaints of the family. ultrasound is the initial, important diagnostic modality in these patients especially if done by experienced radiologists. the diagnosis can be confirmed with mru by depicting the exact insertion of the ectopic ureter. objectives of study: to evaluate the occurrence and severity of vesicoureteral reflux (vur) in young infants with a history of mild prenatal hydronephrosis. the usefulness of voiding urosonography (vus) in the diagnosis of vur was also evaluated. methods: forty seven infants ( males, females) with a history of mild prenatal hydronephrosis, diagnosed between st to th week of gestation, were enrolled in the study. postnatal ultrasound was performed within the first month of life. voiding cystourethrography (vcug) and at the same time, contrast-enhanced harmonic vus was performed at the age of . - . months. results: the prenatal ultrasound revealed an anterior-posterior pelvic diameter of - mm in fetuses and - mm in . postanatal ultrasound showed an anterior-posterior pelvic diameter of - mm in infants and - mm in . vur was found in of ( . %) infants (grade i: , ii: , iii: ). the vur was detected by both vcug and vus in of children, only by vcug in and only by vus in of infants. the vur that was missed by vcug was more severe (grade ii and iii), compared with this one missed by vus (grade i). conclusions: even though prenatal hydronephrosis was associated with a quite important occurrence of vur, this was of mild or moderate severity. comparison between the two imaging modalities showed that the vur missed by vus were with no clinical significance (grade i), whereas the vur missed by vcug were more severe. although further study is needed, vus could be an alternative method, mainly in girls, in whom the imaging of the urethra is not necessary, thus avoiding the radiation exposure. early treatment with indomethacin in a neonate with a bartter syndromea case report neonatal bs is a rare genetic disorder characterized by sodium, potassium and chloride urinary wasting, hypokalemic metabolic alkalosis with hyperreninemia and hyperaldosteronism in the absence of hypertension and high level of urinary prostaglandins. indomethacin therapy is controversial because of toxicity for gut and kidney. a premature boy of unrelated couple was born by cesarean section at weeks because of early rupture of membranes and fetal distress. birth weight was g, length cm and apgar score / / . pregnancy was complicated by severe polyhydramnios. baby was mechanically ventilated for first hours and treated with antibiotics because of suspected sepsis. marked polyuria and dehydration were present from st week. metabolic parameters revealed hypokalemia, hyponatremia and hypochloremic metabolic alkalosis. serum creatinine was slightly elevated and gfr in normal ranges. blood pressure was normal with raised plasma renin activity and aldosterone level. sodium excretion via urine and level of renal and systemic prostaglandins were increased. nephrocalcinosis was detected on us from week. additonally to electrolyte supplementation indomethacin was started on the th day at a dose of mg/kg/day. in first months child experienced septic episodes, candida pyelonephritis and was operated because of bowel obstruction. dna analysis of affected child found new mutations in romk gene: p l and q x in herited from parents who carried one mutation each. at months height and weight are at and head circumference at percentile with slightly retarded psychomotoric development. he continues on . mg/kg/day indomethacin therapy. blood electrolyte profile is normal without supplements. us shows no progression of nephrocalcinosis. early treatment with indomethacin may prevent life-threatening complications and reduce the development of nephrocalcinosis. nimuselide, a cox inhibitor is widely used in india for relief of pain and fever. we describe cases of fetal renal abuse leading to neonatal renal failure due to maternal ingestion of nimuselide in the third trimester of pregnancy. results: all patients were diagnosed as having renal failure in the first few days of life.there were boys and one girl.. all the mothers had normal pregnancies except for oligohydramnios that was detected during the last months of pregnancy in all cases. children presented with anuria from birth. the remaining two had non-oliguric renal failure with metabolic acidosis as the presenting feature in one and poor feeding and lethargy in the other. usg revealed normal sized kidneys. one patient also showed increased echogenicity. out of the anuric children underwent peritoneal dialysis for a period varying from to weeks without recovery of renal failure. the remaining were managed conservatively. two of these patients are now in chronic renal failure at ages and years. only one patient recovered completely after days of anuria. all the mothers had taken nimuselide in the last trimester for periods varying from few days to several weeks for relief of pain or fever. some of them had taken multiple courses of short duration. the mother of the child who recovered completely had taken nimuselide in the last days before delivery. renal biopsy done in one baby revealed renal tubular dysgenesis. conclusion: nimuselide intake in the last trimester of pregnancy can be associated with oligohydramnios and neonatal renal failure that can be irreversible. renal tubular dysgenesis may be the underlying pathology. objectives of study: pkd is the most common inherited renal disease. aim of ours study was to analyse clinical and laboratory features of the different types pkd. patients and methods: we described the clinical presentation of children with pkd ( boys, girls) diagnosed in pediatric nethrology department between and . the patient's age range was from months till years. we retrospectively studied the family histories, clinical and biochemical data (physical examination, level of arterial blood pressure, blood and urine creatinine levels, serum levels of urea, glomerular filtration rate), ultrasonography, scintigraphy. results: the analysis of the family histories revealed adpkd in patients ( boys, girls), arpkd in ( boys, girls) and nondifferential pkd in ( boys, girls) children. pkd diagnosed by antenatal ultrasound in cases ( adpkd, arpkd). the mean follow-up adpkd were , year (range - years), arpkd - , year (range - , years). conclusion. patients with arpkd demonstrated the early beginning of an arterial hypertension and progressing chronic renal failure. one girl with neonatal form of arpkd died. chronic renal failure developed in ( , %) cases of pkd. objectives: this prospective study was to answer the question on the need of long-term follow-up and correlation of renal functions with the age at surgery and grade of o.u. prior to surgery in patients after surgery of obstructive uropathy (o.u.). methods: selected biochemical markers of glomerular and tubular functions and ultrasonographic findings in patients ( boys) who underwent surgery due to uni-or bilateral o.u. of grade iii. and iv. (age at surgery < months) in - were examined at mean age of . ± . years. the results were compared to healthy controls and/or to reference values according to age. consequently, patients were devided into groups according to the age at surgery ( - months, - months, - months) and grade of o.u. prior to surgery. results: serum concentration of cystatin c (s-cysc) was significantly higher in patients when compared to control group (p< . ). while s-creatinine was within reference interval in all patients, s-cysc was increased in . % when compared to reference interval. decreased tubular resorption and concentration ability was found in % and % patients, respectively. non-specific aminoaciduria was detected in . % patients. on ultrasound, . % kidneys after surgery had residual dilatation of renal pelvis. the differences in renal functions in patients according to their age at first surgery were not significant except for u-nag activity with significant negative linear trend with higher age at surgery. the grade of o.u. prior to surgery did not have significant influence on renal functions. conclusions: mild tubular dysfunction and slightly reduced gfr in the part of patients make longterm nephrologic follow-up reasonable. our results support the trend of postponing early postnatal surgical intervention in patients with positive ultrasound screening of o.u. and normocreatininemia. objectives of study: to evaluate, during almost five years of follow-up, the changes among preoperative and postoperative renal function in infants ( m/ f) with prenatal severe hydronephrosis (hn) and upj obstruction. methods: upj obstruction was diagnosed by a mag renal scan, performed at - weeks of age to establish baseline differential renal function; surgery was made if there was evidence of obstruction injury, and/or progression of hn and/or symptoms. the group was re-imaged months after surgery, after months, year and then annually. results: initial differential renal function was moderate in . % of males and in % of females and good in . % and in % respectively. also, % of kidneys required surgery because of declining function, with mean differential renal function in the affected kidney of % that improved to % already at months after pyeloplasty. there was no significant functional improvement, in the kidneys that underwent correction because of increased hn or symptoms and final renal function was > %. after pyeloplasty t was > min. in % and - min. in % of cases (p< . ) there was no statistically significant correlation between initial grade of hn and initial renal function. surgical treatment was performed between - months of age and there was no significant difference in postoperative results, ascribed to patient age at surgery. ma values, greater than controls at diagnosis, reduced at months after surgery in all, but % of children. during the follow-up, the mean ccr and bp values were in normal range for age in all children. conclusions: our findings showed improvement also in kidney with preoperative uptake less of %. this may be to explain in according to an inverse correlation between degree of renal dysplasia and gestational age. objective of study: is to determine the postnatal course and follow-up of children with fetal hydronephrosis. methods: in years period ( ) ( ) ( ) ( ) ( ) ( ) ( ) we followed infants with antenataly detected hydronephrosis. all infants were submitted to ultrasonographic examination of kidneys and bladder. if indicated, the isotope renography, micturating cysto-urethrography, i.v.urography and mr were performed. results: the diagnosis of hydronephrosis was established during - th weeks of gestation by obstetritian. first postnalat ultrasound investigation was performed during neonatal period in most children ( %). in ( , %) infants we diagnosed idiopathic hydronephrosis, in ( , %) vesicouretheral reflux (vur) grade ii-iv, in ( , %) hypofunction of one kidney, in ( , %) ureteropelvic junction obstruction (upjo), in ( , %) ren duplex and ureterocele, in ( , %) ampular pelvis and in ( , %) afunction of one kidney. after - months we found normal ultrasound in ( , %) children. the ultasound results were stable in ( , %) children and in ( , %) there was progression of hydronephrosis. four ( , %) infants underwent immediate surgery. conclusions: in a group of infants with antenataly detected hydronephrosis the diagnosis was confirmed postnataly in % infants. more than % of infants required long term follow-up. in , % the immediate surgey was required. this data support the need for antenatal detection of hydronephrosis. in the same period we followed up infants with urologic abnormalities which were not detected antenataly.the fetal ultrasound is reliable screening method in detection of urologic abnormalities. the considerable number of anomalies which were not detected antenataly are the result of insuffitient use of fetal ultrasound investigation. hemolytic uremic syndrome (hus) is defined by acute renal failure, microangiopathic hemolytic anemia, and thrombopenia. perinatal asphyxia (pa) may cause renal failure after birth and is often associated to disseminated intravascular coagulopathy (dic) with platelet consumption. however, no biological investigation permits to distinguish clearly neonatal hus from dic. we report three neonates with renal failure due to different degrees of pa. they presented biological features compatible with hus such as fragmentocytes ( %), thrombopenia (< , /mm ), anemia (< g/dl). serum creatinine on day was , , mmol/l respectively, requiring peritoneal dialysis in one patient. haptoglobin was undetectable for all three patients. factor h and i were in the lower normal range; components of the complement system (c , c ) and adamt activity were decreased. two patients received daily fresh frozen plasma infusions over the first weeks. renal function improved in two patients until day ; one patient has chronic renal failure. all other parameters suggestive for hus were normal on day , , and respectively. no severe neurological consequences were noted for either of them. pa may be responsible for multiorgan damage via ischemic lesions. ischemia may result in endothelial cell injury, the crucial event for the development of thrombotic microangiopathy. we hypothesize that endothelial cell damage concomitant with pa may lead to a vicious circle resulting in consumption of platelets and plasma factors involved in hemostasis and/or fibrinolysis. early use of fresh frozen plasma may correct these alterations. renal biopsies might have been useful but are technically difficult in newborns. in conclusion, pa and neonatal hus are difficult to distinguish and endothelial cell damage may be a common pathyphysiological aspect and might requirespecific treatments. a. medynska, m. nalesniak, k. kilis-pstrusinska, d. zwoliñska congenital posterior urethral valves (puv) are the most common cause of lower urinary tract obstruction in male neonates. we aimed to review our experience with puv children ( boys) in respect to retrospective analysis of the clinical course of disease. we analyzed: ultrasound during pregnancy, age of disease onset, clinical symptoms at admittance to hospital, outcome. average lenght of follow-up was , years, varying between month and years.obstruction of urinary tract was suspected by prenatal ultrasound in patients. the initial presenting symptoms were as follows: urinary tract infection boys, failure to thrive patients, increased abdominal circumference - , abdominal pain , enuresis - , acute renal failure , and chronic renal failure children. in association with puv renal dysplasia/hypoplasia in patients, undescended testis , bladder trabeculation were found. the diagnosis of puv was confirmed by voiding cystourethrograms and/or cystoscopy. primary vesicouretral reflux was documented in pts. hydronephrosis and/or megaureter were observed the most often in boys. the diagnosis of puv was established in pts at the age of less month, in pts between - months, and in between - years. surgery was performed in pts in neonates period including primary valve surgical ablation and/or cutaneostomy vesicostomy. chronic renal failure was diagnosed in boys in first year of live. of them progressed to end-stage renal disease. globally during the follow-up pts developed end-stage renal disease. pts have done a graft. only boys survive without progression to chronic renal failure. the presentation of puv is variable and currently antenatal detection is the most common mode. outcome boys with puv is poor. patients need nephrologic assesment from birth. background: furosemide is among the most frequently used drugs in the neonatal unit but few studies analyze the beneficial effect and complications in this patient group. objectives of the study: to analyze the therapeutic clinical effect and to document side effects of furosemide therapy in extremely preterm infants born < weeks gestational age (ga). methods: twelve infants born < weeks ga were prospectively included during the fall . the following parameters were documented prior, during and after furosemide administration: clinical status, serum/urine electrolytes, creatinine, albumin, blood gases and furosemide exposure. ultrasound of the kidneys and a wrist radiograph were performed at - weeks to rule out osteopenia/rickets and nephrocalcinosis respectively. no statistical analysis were done due to the small study size. results: general oedema, respiratory rate, apneic spells and oxygen supplementation decreased. arterial/venous pco decreased and partial oxygen saturation increased indicating improved lung function. hco increased and ph decreased. urinary excretion of sodium, potassium, chloride and calcium increased while phosphate excretion decreased. serum sodium and chloride decreased and potassium increased initially. six infants had electrolyte disturbances and metabolic alkalosis. one infant died during the study period. in the remaining infants, of had worsening of their patent ductus arteriosis, had osteopenia or rickets and had nephrocalcinosis. the total side effect score was increased in the infants with the highest furosemide exposure. conclusions: this small study suggests that furosemide is beneficial in extremely preterm infants born < weeks ga and that the associated side effects correlate to the total drug exposure. we recommend caution for long term administration of furosemide. conclusion: although children in our study suffered significant neonatal hie resulting in arf, glomerular and tubular function recovered sufficiently to cope with increasing body mass and metabolic needs. unlike reported studies, we did not find any significant evidence of cri in the survivors of neonatal hie and arf. one with marginal microalbuminuria will need further observation. c was born after a monozygotic monoamniotic twin pregnancy (gestational age= weeks). she presented with twin-twin transfusion syndrome with hypotrophy (birth weight= g, other twin= g), severe hypovolemia, anemia and acute renal failure. she required a blood transfusion, mechanical ventilation ( days), and peritoneal dialysis ( days). she recovered without bronchodysplasia but with chronic renal failure (creatininemia at months= μmol/l). the following months were uneventful but, as usual in tts, she exhibited growth retardation and slight mental delay compared to her twin. she reached terminal renal failure at years of age and was successfully kidney transplanted. after age of years, she presented with increasingly frequent and severe pulmonary infections predominantly in lower lobes of both lungs. after extensive explorations, the diagnosis of bilateral bronchiectasis was made. the search for classical aetiologies of such pathology was negative. the symmetric aspect and the absence of other etiologies lead to the consideration of bronchiectasis as a congenital pathology. numerous publications demonstrate the role of the renin-angiotensin system (ras) in renal and cerebral damages in tts. authors demonstrate the role or ras in development of vasculature in fetus but also of cartilage and muscle in different organs including lung. associations between tts and lung pathologies need to be further investigated. urofacial ( the urofacial (ochoa) syndrome (ufs) is a rare disease that occurs in both sexes and is more frequent when the parents are closely related. it has both urinary and facial abnormalities. ufs is a rare autosomal recessive disorder and a potential gene has been mapped to chromosome q -q . they present a bladder voiding dysfunction due to impaired neural communication between the bladder and the spinal cord, resulting in incomplete emptying of the bladder. this usually results in enuresis, urinary tract infection, hydronephrosis and in some severely affected patients, end-stage renal disease developed. the facial abnormality is a characteristic expression that, when these patients smile, their facial musculature inverts and they appear as if they are crying. we report a year-old girl who has inverted facial appearance, voiding dysfunction and vezicoureteral reflux. she had constipation and did the intermittan uretral cathaterization for five years. after a detailed evaluation, she was diagnosed as ochoa syndrome due to inverted facial expression. we report this case, because early diagnosis of ufs is very important for early assessment and management of urinary problems to prevent development of chronic renal failure. we think that only a smile can give a strong high light for this unusual 'inverted' facial expression and patients can be screened earlier for severe voiding dysfunction. tar syndrome is a congenital malformation syndrome characterized by bilateral absence of the radii and a thrombocytopenia. the known urinary anomalies with tar are duplex ureter, dilatation of renal pelvis, horseshoe kidney, and functional problems like vesicouretheral reflux and pyelonephritis. case: nine years old patient with tar syndrome was admitted with a complaint of bright red urine repeated three times. the microscopic hematuria without dysmorphism of erythrocytes accompanied with no proteinuria were determined in repeated urine sample microscopy. iga, ana, anti dna serology were negative. urine culture was clean. stone formation ( x mm) in the upper pole of the right kidney was established by the abdominal ultrasonography. postoperative chemical analysis of the stone, revealed that it was consisted of oxalate monohydrate and dihydrate. but the patient discontinued his follow-ups afterwards for a year. in this period, he had macroscopic hematuria attack once. when he applied for the second time, he reported macroscopic hematuria. cystoscopy was done for etiology. many tortuous and engorged vessels were seen by this evaluation in the bladder mucosa ( figure ). there was no active bleeding point. result: in this report, kidney stone and telangiectasia found co-incidentally in the bladder of a patient with tar syndrome during the examination of hematuria are discussed as there is no case report demonstrating nephrolithiasis and telangiectasia in tar patients in the literature. figure : many tortuous and engorged vessels in the cystoscopy. antenatal hydronephrosis (anh) is one of the common fetal abnormalities detected on ultrasound (us). the long-term renal prognosis for infants with mild to moderate postnatal hydronephrosis (hn) is unclear and controversial. a systematic review of the published literature was performed to determine an evidence based approach in infants with antenatally diagnosed hn and to identify those at risk of significant post natal nephro-uropathy (pnu). key questions were identified. does anh predict renal tract pathology in neonates? what is the value of prophylactic antibiotics in infants with anh? can postnatal us diagnose significant pnu? when is the optimal time to screen infants postnatally? which imaging modalities are necessary to diagnose the cause of the hn? how many neonates with anh would need to be investigated to prevent one case of esrf/crf? a search strategy was formulated. out of titles only seven studies met the validity criteria for inclusion. the results indicate that antenatal us is a valid screening test for pnu (sensitivity %, specificity %), but is not a predictor of pnu. the detection rate of hn by us is the same whether it is done early or late in neonates. two normal ultrasounds over a minimum of one month are required to screen for pnu. infants with a renal ap diameter over mm are at risk of a significant pnu and should be investigated further. us is not a substitute for cystourethrogram or dynamic isotope studies to determine the cause of hn. none of the studies addressed the role of prophylactic antibiotics. there was insufficient data to calculate the total number of cases that would need to be investigated to prevent one unfavourable outcome (esrf/crf). high quality population based cohort studies with long term follow-up into adulthood are required to determine the optimum postnatal management of mild to moderate hn in infants with anh. jeune asphyxiating thoracic dysplasia: a case report jeune asphyxiating thoracic dysplasia (jatd) is one of the congenital hepatorenal fibrocystic syndromes. it is characterized by renal, hepatic, pancreatic abnormalities with associated skeletal abnormalities including a long and narrow thorax, metaphyseal irregularities, and shortness of the ribs and long bones. this report describes a pediatric patient with jatd developed end-stage renal failure. a -year-old boy was admitted with complaint of vomiting and pallor. he had dysmorphic appearance including trigonocephaly, short stature, long thorax and short limbs and fingers, polydactyly and fascial dysmorphism. laboratory findings revealed severe anemia (hb . g/dl), high bun and creatinine levels ( mg/dl and . mg/dl respectively) and normal liver tests. abdominal usg showed a severe intrahepatic biliary tract dilatation and intraparenchymal cysts in liver, pancreas and kidneys. mr pancreatocholangiography was consistent with caroli's disease. jatd should be considered when caroli's disease exists with skeletal abnormalities. follow-up antenatal hydronephrosis: one centre experience the most common renal abnormality detected antenatally is hydronephrosis ( % to % of all pregnancies). in this paper, we report follow-up our patients with antenatal hydronephrosis (ah) between and . diagnosis of hydronephrosis was made > mm of antero-posterior diameter (ap) of the renal pelvis. ah was detected in patients on antenatal ultrasound examination. of the patients with ah, ( . %) were found to have hydronephrosis postnatally and ( . %) postnatal scans were normal. in of these patients ( . %) had bilateral and ( . %) of these patients had unilateral hydronephrosis. in these patients with ah, uretero-pelvic junction obstruction (upj) ( . %), reflux ( . %), uretero-vesical junction obstruction ( . %), posterior urethral valves ( . %) and mega-ureter ( . %) were identified. in follow-up period, ( . %) patients with reflux, ( . ) patients with upj were treated with surgery (p< . ). in conclusion, upj was most important cause of ah and most of them were treated with surgery. hyponatremia and renal tubular acidosis in severe vesicoureteral refluxa case report sahlgrenska academy, department of pediatric, gothenburg, sweden case report: st child to healthy parents without heredity for kidney or metabolic disease. antenatal bilateral hydronephrosis. postnatal examination showed bilateral vur grade v, normal urethra. antibiotic prophylaxis was started, no urinary tract infection (uti) occurred. normal s-creat and s-na + at weeks of age. the electrolytes remained normal during the next months. normal growth. the boy was thirsty with high urine volumes. at month of age feeding problems began with retarded weight gain. no vomiting or diarrhoea. at admission to the hospital the child was dehydrated, s-na + mmol/l, s-cl - mmol/l, s-ph . , bicarbonate mmol/l, s-creat μmol/l. crp mg/l, urine culture negative. u-na + mmol/l, u-ph . , u-osmolality mosm/kg. the anion gap was normal and there was no lactacidosis. the s-aldosterone was elevated , nmol/l, s-cortisone normal. treatment included intravenous rehydration, na + supplement and oral bicarbonate. blood chemistry normalised and the child's general condition improved rapidly. conclusions. children with severe reflux are at high risk for uti but may also develop impaired tubular function with diabetes insipidus, renal tubular acidosis and hyponatremia. the mechanisms include down-regulation of vasopressin receptors and impaired distal tubular function. close clinical monitoring of these children with regular blood chemistry and weight controls is important. purpose: we aim to prospectively study the natural history of minimal to severe grades of antenatal hydronephrosis (anhn) in our local chinese population and correlate the renal pelvic diameter (rpd) with the outcome. patients and methods: cases of anhn were prospectively followed up along a predefined protocol using us, mag and mcu in all. obstruction (pujo or vujo) was defined as a need for surgery based on symptoms and deteriorating function, not on mag drainage time. results: neonates were followed up for minimum of years. eighty percent had normal or minimal hn on postnatal scans (rpd - mm), . % had mild ( - mm) or moderate ( - ) hn and . % severe hn (> mm). seventy-eight percent infants had benign course; . % had partial obstruction which improved; . % had vesicoureteric reflux (vur) one of which required surgery. another . % required surgery for obstruction. the roc curve for obstruction requiring surgery showed optimal cut-off point of . mm (sensitivity %, specificity . %). prolonged diuretic t / was not predictive of surgery. severity of hn did not correlate with presence or grade of vur. fifteen patients developed uti despite antibiotic prophylaxis and had focal scars, all occurred in association with high grade vur or obstruction. the prognosis of infants with minimal or mild anhn is good. however rpd is poorly correlated with vur. the chances of obstructive lesions requiring surgery are high when the rpd is above mm. in those with high grade reflux or obstruction, urinary tract infection may lead to renal scars. objectives of study: cystinosis is a rare disease presented initially with renal fanconi syndrome, and renal glomerular failure develops later in childhood. without cysteamine treatment, patients affected with cystinosis uniformly died during childhood in the absence of renal replacement therapy (rrt). cysteamine is not available here and in some other areas of the world. the aim of this paper is to describe a beneficial effect of acacia gum in a patient with cystinosis and chronic renal failure. method: years old girl with cystinosis presented with symptomatic uremia as she didn't receive cysteamine. serum creatinine . mg/dl, blood urea mg/dl. the girl was hospitalized and vomiting controlled with intravenous fluid and pyridoxine. chronic dialysis was not available for her and the parents refused treatment with intermittent acute peritoneal dialysis. the girl was treated with a new therapeutic regimen (therapy ; ( ): ) combining the traditional conservative management of crf (dietary and pharmacologic) with addition of acacia gum (ag) g/day as an urea lowering agent aiming at improving her condition without dialysis. results: treatment was associated with amelioration of the uremic symptoms and improved general well being. after weeks of treatment, serum creatinine . mg/dl, blood urea mg/dl. during months of follow-up she continued in experiencing improved well being and urea levels was kept below mg/dl without dialysis. conclusion: it was possible to improve the health of patient with cystinosis despite the nonavailability of cysteamine and the appropriate rrt. objectives of study: the pattern of renal tubular disorder (rtds) has been infrequently reported in the literature, and the pattern of rtds in iraqi and arab children is not known. methods: from june to august , it was possible to evaluate children with suspected rtd to determine the type of their tubular defect. there was evidence of rtd in only patients; males ( %) and females ( %). their ages at referral ranged between months and years (mean . years). in patients with oculo-cerebro-renal syndrome, there was no evidence of rtd and one patient had hyperoxaluria which not a rtd. results: seven types of rtds were identified. the three most common disorders were: idiopathic hypercalciuria ( %), cystinosis ( %) and renal tubular acidosis rta ( %). four of the patients with rta have proximal rta, and four have distal rta. four of the patients with hypercalciuria have also significant hyperoxaluria > mg/kg/day. conclusion: the pattern of rtds in iraqi children differs from the previous studies: in germany the three most frequent disorders were cystinosis, xlhr, and idiopathic hypercalciuria. objectives of study: few literatures reported the incidence of ocular abnormalities in chronic renal failure (crf). the aim of this paper is to determine the incidence of ocular abnormalities in childhood crf. methods: from january to december , patients with crf (at the university hospital in al kadhimiyia) were examined to determine the presence of ocular abnormalitites. fifty patients were males ( . %) and ( %) were female. their age at referral ranged from months to years (mean year). they were followed for a period ranged from days to f years. results: corneal cystine crystals were the most common ocular abnormalities associated with childhood crf observed in patients with nephropathic cystinosis ( . %). congenital cataract & glaucoma were observed in patients ( . %) with oculo-cerebro-renal syndrome (ocrs). congenital cataract & chorioretinal hypoplasia were present in patient with ocrs. hypertensive retinopathy occurred in patients. acquired cataracts occurred in one patient with hinman syndrome in association with hypocalcaemia and non-compliance with calcium and onealphacalciferol supplementation. retinitis pigmentosa in one patient with laurence moon biedl syndrome. bilateral optic atrophy in one patient with familial nephropathy associated with club feet. proptosis in one patient with membranoproliferative glomerulonephritis. conclusion: ocular abnormalities are relatively common in childhood crf occurring in approximately %. objective: hypocalcaemia has been reported as a complication of phototherapy especially in neonates. we studied the relation between serum calcium level and urine calcium to creatinine ratio in neonates under phototherapy. method: icteric newborns ( males and females) treated by phototherapy entered into study by non accidental sampling. the consent was taken from parents on admission. all were breastfed healthy newborns. weight was checked and serum samples for calcium and bilirubin and urine aliquots for calcium, creatinine and osmoloality were sent on arrival (group i), after hour of starting (group ii) and hour after discontinuing phototherapy (group iii). hypercalciuria was defined by uca/ucr > . , hypocalcemia was defined by serum calcium < mg/dl in the term and < mg/dl in the premature. chi , anova, wilcoxon rank test and spearman were used to compare frequency, means, median and correlation. p< . was considered significant. two groups were designed, pateints whose therapy were finished at least months (group ) and those either on therapy or less than months passed from the last protocol of cytostat (group ). demographic data, cumulative dosages of anticancer drugs, history of other nephrotoxic agents, nephrectomy, radiotherapy and acute renal failure were recorded. we used ctc ( ) to evaluate renal function. chi and mann whitney u test and biniary logistic regression were used to compare percentage, scoring and correlation respectively. p value less than . was considered significant. result: out of patients were in group and ones were in group . the mean of age was . years (± . sd). the median (range) of therapy and termination was months ( - months) and month ( - month) in group and month ( - ) and months ( - months) in group respectively. the percentage of reversible renal failure, proteinuria, abnormal serum calcium and magnesium, metabolic acidosis and urinary concentration defect was higher in group . (table ) these differences were statistically significant (p< . ). we found no correlation between ctc score and dosage of drugs, age, sex, history of radiotherapy or nephrotoxic agents (p> . ). conclusion: mild to moderate tubular dysfunction has been observed in survivors of leukemia. routine follow-up of renal functions is recommended. v. tramma, k. giourtzis, v. fotoulaki, k. nousia-arvanitaki aristotle university, th pediatric clinic, thessaloniki, greece although cftr is expressed in the kidney, patients with cystic fibrosis (cf) have not been reported to have major renal abnormalities with the exception of urolithiasis. the aim of this study was to determine renal function and the potential risk factors for renal stone formation in cf patients older than years of age. the findings of metabolic evaluation of cf patients having confirmed urolithiasis (mean age: , ± , ) were compared with those of cf patients without urolithiasis (mean age: , ± , ) and those of healthy volunteers (mean age: , ± , ). evaluation included plasma sodium (na), potassium (k), chloride, bun, creatinine, uric acid, calcium (ca), phosphorus (p), magnesium (mg) and parathormone (pth). twenty-four hour urine collection for creatinine, uric acid oxalates, ca, mg, k + , na + and microalbuminuria was also performed. glomerular filtration rate (gfr) was calculated and fresh urine samples were examined for the presence of crystals, erythrocytes, glycosuria and microorganisms. patients with cf and urolithiasis showed significantly increased values of bun (p: . ), pth (p: . ) and gfr (p: . ), very low urine mg levels (p: . ) and microalbuminuria (p: . ) as compared to cf patients without urolithiasis. there was no correlation of urolithiasis with hypercalciuria and hyperoxaluria. furthermore, all cf patients showed significantly increased pth levels (p: . ), very low urine mg levels (p: . ) and microalbuminuria (p: . ) as compared to healthy volunteers. conclusions: renal dysfunction was demonstrated in older cf patients, probably, secondary to the primary defect of renal chloride channels. extracellular volume regulators, such as hormones, may also be implied. urolithiasis may be the result of renal dysfunction. conclusions: the morbidity of hsp had obviously increased in recent years. the familial cases, the initial symptoms of no palpable purpura at onset and the cerebral, pulmonary, cardiac and pancreatic involvement should be paid attention. objectives of study: systemic lupus erythematosus (sle) is an autoimmune disease affecting multiple organs and tissues including central nerve system, cardiovascular system and kidney. although etiologic mechanisms of sle are incompletely known, overproduction of immunoglobulin g autoantibody may contribute to onset of this disease. while still incompletely understood, the etiology of systematic sle is considered to involve both genetic and environmental factors. we encountered two boys with severe sle from unrelated families and analyzed polymorphisms of the gene that encodes cytotoxic t-lymphocyte associated (ctla)- , a protein important in t-cell activation and immune tolerance. abnormal function of the gene may participate in causation of autoimmune disease including sle, resulting in production of immunoglobulin against various self-antigens. case report: in family , a boy showed serious cardiovascular complications associated with heart failure while his mother also had clinically active sle including nephritis. a boy in family developed severe renal complications and peripheral vasculitis accompanied by disseminated petechiae in the lower extremities; his paternal grandfather had died from fibrinous pneumonia caused by sle. results: analysis of the ctla- gene indicated that the boy in family and his mother possess a gg genotype in ctla- exon at + together with a -bp fragment length of the ' untranslated region (utr) in exon . the boy in family also showed gg at + . no association with disease activity was found for polymorphism of the promoter region in exon at - in either family. conclusions: disorders of the ctla- gene, especially a gg genotype in exon at + and/or bp fragment length of the 'utr in exon , may be involved in early development of sle in japanese children such as the boys described here. this disorder is transmitted mainly as x-linked trait, and is caused by mutations in the col a gene encoding α chain of type iv collagen. in some families, x-linked as is associated with diffuse leiomyomatosis. we present clinical, pathologic and molecular-genetic findings in japanese family with this inheritance mode of as in association with leiomyomatosis. case report and results: as was diagnosed in a one-year-old boy with recurrent aspiration pneumonia caused by esophageal stenosis from leiomyomatosis. he had macroscopic hematuria and bilateral cataracts. diagnosis was confirmed by electron microscopy coupled with type iv collagen chain subtype staining in a renal biopsy specimen. thickening and irregular contours of the glomerular basement membrane (gbm) and splitting of the lamina densa were evident by electron microscopy. immunofluorescent staining for type iv collagen chains failed to show staining for α (iv), α (iv), or α (iv) in the gbm, associated with lack of α (iv) and α (iv) staining in the bm of bowman's capsule. his mother, who exhibited esophageal leiomyomatosis and is heterozygous for as, showed a discontinuous staining pattern for α (iv) along the epidermal bm. genetic analysis in the boy revealed the deletion of the first two exon of col a together with deletion of the ' end of col a . conclusion: identification of an as patient during infancy is extremely rare. clinical manifestations, including macrohematuria, cataracts and leiomyomatosis caused by the large deletion involved col a to col a , led to early presentation with as. functional voiding disorders of the bladder occur in the absence of any anatomic/neurological abnormality and present with wetting. invasive urodynamic studies are discomforting, not easily available in emerging countries and costly. this study aims to validate non-invasive urodynamics. children below years, with possible voiding disorders evaluated prospectively. non-invasive evaluation included history, examination, frequency volume charting, ultrasonography, urinalysis and renal functions. micturating cystourethrogram was carried out for children with urinary tract infection. all children underwent invasive urodynamic studies (uds) and the significance of association of the parameters of non-invasive assessment with invasive urodynamics was determined. the chi square test was used for statistical analysis using the epi software. children underwent invasive uds. the commonest abnormality was detrusor instability (di) in ( . %). dysynergic voiding (dv) noted in ( . %), lazy bladder in and an occult neurogenic bladder in . the study was normal in . repressing the disease progression may be . mg/kg/day or more background: henoch-schoenlein purpura is classified into the small vessel vasculitis. there may be no reliable indicator of the disease activity. steroid treatment ( mg/kg/day of prednisolone) has been thought of as a means with which alleviate abdominal pain. however, this dose seemed to be not effective to intervene the disease progression to nephritis. objectives: forty-three japanese children with henoch-schoenlein purpura were enrolled in this study. fibrinogen degradation product e-fraction (fdp-e) value was measured once or twice a week in the patients. coagulation factor xiii was simultaneously measured in of the patients in the early phase of illness. with an aim to alleviate abdominal pain, . - . mg/kg/day of prednisolone had been administered to of the patients. results: at presentation, only of the patients had low factor xiii activity. on the contrary, of them had elevated serum fdp-e value. longitudinal fdp-e measurement revealed that patients whose fdp-e value normalized within the second weeks of illness had minimal risk of nephritis. in this group, of had microhematuria. in the other patients group with prolonged (after fourteen days of illness) elevation of fdp-e values, of had nephritis. furthermore, of had proteinuria after three months of illness. these patients who had received prednisolone therapy with less than . mg/kg/day in the early phase of illness. the other patients with . mg/kg/day or more prednisolone therapy had no nephritis. summary: the disease activity of hsp and hspn might reflect the duration of elevated serum fdp-e. more than . mg/kg/day of prednisolone may repress the disease progression to nephrits. background: all major organs are involved more or less in thalassemia and most of them have been studied thoroughly in previous literature. renal system involvement has not been scrupulously scrutinized yet. method: in a randomized prospective study, renal findings of children and young adults, aged - years, with thalassemia major (group ) were compared to other cases of thalassemia intermedia (group ). blood urea nitrogen, serum creatinine, uric acid, calcium, phosphate, urinalysis, and sonographic findings were evaluated. results: mean age was ± . years in group and ± . in group . mean serum ferritin level was ± ng/ml in group vs. ± . ng/ml in thalassemia intermedia group (p< . ). % of subjects of group had received or was on hydroxyurea at the time of evaluation. serum uric acid was significantly higher in patients with thalassemia intermedia ( conclusion: significant renal involvement is not a frequent complication in children and young adults suffering from thalassemia. hyperuricemia and microscopic hematuria is more common in thalassemia intermedia than thalassemia major. case: a -year-old female patient was born at term (weight g, lenght cm) and for aspiration of amniotic fluid required resuscitation and mechanical ventilation for days. perinatal hypoxia was a cause of her acute renal failure but dialysis was not needed. patient's follow-up during next yrs showed mild form of chronic renal failure (crf) without hypertension: serum creatinine (scr; range during follow-up [rdf] - μmol/l), glomerular filtration rate (gfr; rdf - . ml/min/ , m ) and p (rdf - mg/ h). at the age yrs we performed renal biopsy (rb) because girl's p and scr increased ( mg/ h, μmol/l, respectively) and gfr decreased ( ml/min/ . m ). rb showed c q-nephropathy (c qn) with focal glomerular sclerosis and hyalinosis. c qn is a rare disease and as a first diagnostic step is differentiation against lupus nephritis. progression of c qn to crf is infrequent. probably two renal diseases were a cause of crf in our patient -hypoxic renal damage during neonatal period and c qn. objective: renal dysfunction has been reported in survivors of neoplastic disease. early diagnosis of renal damage may decrease the morbidity in those with partial or complete remission. we studied the frequency of nephrotoxicity in pediatric patients whose therapy were completed. method: pediatric cancer patients ( f, m) who were at least one year off therapy, enrolled in a prospective cross sectional study from to in oncology department of ali asgar children hospital. demographic data, cumulative dosages of anticancer drugs, history of other nephrotoxic agents, nephrectomy, radiotherapy were recorded. fasting blood and urine samples were collected to calculate fractional excretion of mg, ca, p, upr/ucr, clcr, urine osmolality and blood gas analysis. result: the mean of age was . years. out of patients had lymphoproliferative malignancies (group ) and had solid tumors (group ). the mean of therapy was . month. treatment was discontinued for . month in average. the median of blood ca, p, mg, bicarbonate,and cr were . mg/dl, . mg/dl, . mg/dl, . meq/l and . mg/dl, respectively. the median of fractional excretion of ca was . % this rate was . % for p excretion and . % for mg excretion. clcr was . ml/min/m in median. the medians of urine osmolality was mosmol/kg/h o. the median of urine protein to urine creatinine ratio was . mg/mg. these values were not different between two groups (p> . ) but urine concentration was defective in solid tumors group (p= . ). mild to moderate nephrotoxicity was seen in . % of cases. using binary logistic regression we found no correlated factor (p> . ). conclusion: mild to moderate tubular dysfunction has been observed in survivors of chemotherapy. routine follow-up of renal functions are recommended. the study is to discuss the treatment of hemolytic uremic syndrome (hus) after acute stage. methods: there were children who lived through acute stage of hus then continued treating. besides angiotensin converting enzyme inhibitors (acei) and early restriction of protein intake, the study was to use therapeutic schedule according to clinical classification, response to prednisone and pathological manifestation, which referred to clinical classification diagnosis and treatment of child with glomerulus disease (the program) established by nephrology group in pediatric branch of chinese medical association (cma). results: after months to years follow-up mild type children maintained the normal blood pressure and renal function and urine examination, except for recurrence. in gravis type children maintained the normal blood pressure and renal function and urine examination, another children who manifested as durative abnormality of urine examination developed into end stage renal failure (esrd) and died in the th, th and th month at last. another gravis type children untreated after stage of hus died in the th day to th day of the course. conclusion: it could improve the prognosis of children after acute stage of hus evidently to use therapeutic schedule according to clinical classification, pathological manifestation. objective: to find the prevalence of hematuria in patients with thalassemia major. methods: of total patients with thalassemia major under regular blood transfusion, cases were randomly selected. history was reviewed and physical examination was done. urinalysis was performed in all the patients. in those with hematuria ( or more rbc/hpf) or suspicious to hematuria ( - rbc/hpf) second urinalysis was done at the next transfusion time. more investigations were done in those with persistent hematuria. results: the patients had age range of months to years and male to female ratio was . . hematuria was detected in ( %) and suspicious in patients ( . %). sixty four percent of the patients with hematuria were female and it was persistent in urinalysis in % of cases. in % of the patients with hematuria, blood transfusion was started before the end of first year. in those with hematuria or suspicious to hematuria, % had sterile pyuria and % had proteinuria (these figures were . % and . % respectively, in those without hematuria). hypertension was not detected, but patients had secondary diabetes mellitus. conclusion: hematuria is not uncommon in patients with thalassemia major and is more prevalent in girls and in those with early transfusion. background: it has been widely recognized that cyclosporine a (cya) is a useful immunosuppressive drug in renal transplantation. although it has been also accepted that cya is an effective drug for pediatric nephrotic syndrome in the past two decades, the effective serum concentrations are not revealed. the functional roles of cya has been reported that cya inhibits the production of interleukin (il- ) in vivo and in vitro. aim: in this study, we investigated the correlation of serum concentrations of cya levels with il- levels in pediatric nephrotic syndrome cases. methods: seven children ( boys and girl, mean age . ± . years) with minimal change nephritic syndrome were enrolled in this investigation. cya (mean dose, . ± . mg/kg/day) was administrated in two divided doses before meal with or without administration of predonisolone. blood samples were collected just before, , , and hours after administration of cya. the serum concentrations of cya and il- were measured immediately. results: the peak blood concentrations of serum cya were observed at hour after administration. the concentrations of serum il- levels reduced at hour after administration of cya, and kept the same levels during hours afterwards. the serum concentrations of cya which inhibited more than % of the serum concentrations of il- required ng hr/ml. conclusions: we confirmed that cya inhibited the production of il- in children with nephrotic syndrome. these findings suggest that the necessary serum concentrations of cya to maintain the sufficient suppressive rate were more than ng hr/ml in pediatric nephrotic syndrome. this study aimed to evaluate the circulating angiotensins in female adolescents with type diabetes (dm ) and to compare with the results obtained in healthy age-matched adolescents to disclose possible changes in plasma peptide concentrations that could be related to microalbuminuria and metabolic control. patients were divided as female adolescents with dm (n= ) and adolescent age-matched controls (n= ). diabetic patients were evaluated at our endocrinology center and healthy adolescents were selected from our primary care unit. plasma levels of angiotensin (ang) i, ang ii and ang-( - ) were determined by radioimmunoassay. glycohemoglobin and microalbuminuria were also measured. results were expressed as medians or means and standard deviation. kruskal wallis was used for median comparisons and t-test for means. the level of significance was p< . . adolescent dm patients exhibited high levels of glycohemoglobin ( . ± . %). microalbuminuria was detected in ( %) patients with a disease duration of . ± . years. angiotensin concentrations were significantly increased in dm patients (p< . compared to controls) and ang-( - ) levels were -fold higher than control values. on the other hand, the levels of ang-( - ) in microalbuminuric patients were significantly lower than in non-microalbuminuric diabetic adolescents (p< . ). the comparisons between ratios of ang-( - )/ang i and of ang ii/ang i suggested a predominance of ang ii formation rather than ang-( - ) in microalbuminuric diabetics when compared to normoalbuminuric patients. our results showed an overall increase of angiotensins in a young female diabetic population, and further suggested a pathophysiological role for angiotensin-( - ) in dm . the pediatric nephrologist is often faced with the difficulty of determining adequate iron supplementation in children with chronic kidney disease (ckd). soluble transferrin receptor (stfr) and the stfr to log(ferritin) ratio (stfr-f index) have been proposed as markers of iron deficiency (id) independent of inflammation; however, their relationship with c-reactive protein (crp) and their age dependency have not been established. we therefore embarked on a prospective study of healthy children undergoing minor surgery to determine reference ranges for stfr (dade behring n-latex stfr analyser, dade behring bn prospec) and stfr-f index. we studied the relationship between crp and ferritin, transferrin, stfr and stfr-f index. we also compared the relationship between mean corpuscular volume (mcv) and ferritin, stfr and stfr-f index in children. results: for ages . . , . ) with mcv, which we used as a marker of id in the absence of a non-invasive gold-standard; however, only stfr-f index, but not ferritin, transferrin and stfr, was independent of crp. this study shows that ferritin, transferrin, and stfr, but not stfr-index, are dependent on acute phase reactions. it is therefore hypothesized that stfr-f index provides a more useful marker for monitoring the iron status in ckd patients. conclusions: low osmolality is a crucial factor to facilitate water absorption at least in the rat small intestine, while the absorption of sodium may be influenced by the concentration of sodium and glucose. (definition iccs). standard treatment consisted of general advice on voiding and drinking habits, alarm treatment and occasionally vasopressin. constipation was diagnosed on clinical considerations (history, stool charts, physical examination, occasionally x-ray). all patients received general instructions according to bowel habits. laxatives were prescribed when the patient was diagnosed as constipated. treatment goal was daily bowel movements. treatment results were evaluated months and years after discharge. results: patients were included. mean follow-up was . yrs. overall success rate (full response) was . % ( months) and . % ( years). laxative use: . % (n= ) of the patients received laxatives, % (n= ) did not. in patient information was lost. there was no significant difference in success rate between the laxative group compared with the non-laxative group (p= . , chi-square). treatment modality: . % (n= ) received general advice only without laxatives, all but one had a full response. . % (n= ) were treated with advice and alarm, ( . %) of them received laxatives. response to alarm treatment was . %. no significant difference in success rate between the laxative and non-laxative group (p= . , chi-square). patient was dry after vasopressin and laxatives. conclusion: the majority of patients with mse can achieve nocturnal continence without laxatives. constipation treatment with laxatives may be supportive, but is not essential in the treatment of mse. aim: hypocalcemic tetany is a known complication of plasmapheresis. we studied the changes in ionised and total calcium, and magnesium concentrations during plasmapheresis, with and without supplementing the replacement fluid with calcium and magnesium. methods: plasmapheresis was carried out by using . % human albumin solution (has) with or without supplements for the first % of the exchange, and fresh frozen plasma (ffp) for the last %. we measured ionised and total calcium and total magnesium at the beginning and end of the has, and after minutes of ffp infusion. results: we undertook pairs of plasmapheresis runs with and without supplements in children who had a variety of renal conditions. during the exchange with unsupplemented has, the total calcium fell from . to . mmol/l (ci . - . , p< . ), the ionised calcium fell from . have raised significant problems in minor surgeries. but the developmental mechanism of ponv is not clear until now. previously, we have experienced a case with ihn and ponv who showed extremely high plasma antidiuretic hormone (adh) level at the onset of ihn and that elevated adh level induced by minor surgery was supposed a trigger of ihn and ponv. in this study we investigated various values including plasma adh in cases taking kidney biopsy in order to clarify the mechanism of ihn and ponv. methods: fifteen patients taking percutaneous kidney biopsy were study subjects (mean age . years). plasma adh, serum electrolytes and osmolality were measured before and - hours after kidney biopsy. urine samples were collected to measure electrolytes and osmolality. results: high plasma adh level ( . ± . pg/ml) was observed in out of subjects ( %). serum sodium level dropped significantly in these cases. six of cases showed ponv, we divided all cases into groups: ponv group and non-ponv group. the result was that plasma adh level was significantly high in ponv group. conclusion: our study make it clear that elevated plasma adh level is frequently seen in children taking kidney biopsy and suggest that hydration with hypotonic saline solution after surgery is inappropriate because of the risk of developing ihn. it also become clear that high plasma adh level might lead to ponv as the same mechanism seen in motion sickness. it is suggested that adh secretion by stress after minor surgery is associated with not only ihn but also the onset mechanism of ponv. polyarteritis nodosa (pan) occurs more commonly in patients with familial mediterranean fever (fmf) and visceral hematomas are seen in almost half of the patients. we report here a year-old girl with pan and fmf presented with multiple visceral hematomas. the patient was on colchicine therapy for four years because of fmf but uncompliant to therapy. she addmitted with the complaints of fever, malaise, abdominal pain and artralgia lasting for two months. she was pale and extremely cachectic with atrophic muscles of extremities. she had fever, hypertension, hepatosplenomegaly and arthritis. she had anemia with normal renal and hepatic function tests, albumin levels, and electrolytes. multiple hypoechogenic mass lesions were detected on liver and bilateral kidneys on ultrasonography and computerised tomography and diagnosed to be hematomas by laparascopic examination. urinalysis, hematological tests for bleeding and blood marrow examinations were normal. bacterial cultures and serological tests did not reveal any infectious agent. serum complement levels were normal with negative antinuclear antibody, anti-dna, p and c antineutrophil cytoplasmic antibodies. renal angiography showed multiple aneurysms in bilateral renal arteries leading to the diagnosis of pan. she was successfully treated with intravenous pulse methylprednisolone followed by oral perdnisolone and oral cyclophosphamide together with colchicine and antihypertensive agents. she has been followed up for four years without any complaints and normal laboratory and radiological findings except multiple scar formations on kidneys on dmsa-renal scanning. results: the stone-free rate was % after one eswl session. the above rate increased to % and % after the second and the third session respectively. regarding surgical treatment with pcnl, the overall stone-free rate was %. in children initially treated with pcnl, an eswl session was performed later successfully, for residual calculi. open surgical removal was required in children with structural anomalies. the patients with staghorn calculi underwent nephrolithotomy combined with eswl in cases of residual fragments. patients underwent ureterscopic procedures to address ureteral stones and complete fragment removal was obtained. no major sideeffect were observed, during the above procedures. conclusions: it seems that the advances in instrument technology provide a variety of safe and effective methods in the management of paediatric urolithiasis. the incidence of open surgery has thus fallen. minimally invasive methods must form the first choice of treatment, while open surgery should be undertaken mainly in cases of coexisting congenital abnormalities. in all children the following parameters were estimated: a) timetable of ne, b) feeling/volume chart (frequency and biggest quantity of urination=functional capacity of bladder), c) ultrasound of urinary tract (size of kidneys, bladder capacity, bladder wall thickness, postvoiding residual urine) and d) urodynamic parameters (uroflowmetry and water cytometry). the ud bladder parameters were then correlated with the us and voiding diary findings. results: all children had sufficient data registered to allow reliable analysis. ud studies showed that children with mild pne had normal urodynamics findings, us parameters and voiding diary findings as well. ud studies reveal a relatively high incidence of instability in children with moderate and mainly in those with serious ne. conclusions: in children with pne, urodynamics did not have a significant additional value compared to baseline diagnostics and it should be avoided. on the contrary, findings from urodynamic studies in children with serious ne show that it has a useful role in this type of enuresis evaluation and management. objectives of study: hyperlipidemia, especially when started during early childhood will increase the risk of atherosclerosis. it is also a major risk factor for allograft nephropathy and post-transplant hyperlipidemia, so its diagnosis and treatment is highly suggested. in this study we have evaluated the effect of hemodialysis on the lipid profile of children with end stage renal disease (esrd). methods: twenty-two children with esrd who were on maintenance hemodialysis in shiraz pediatric hemodialysis unit were studied. they were asked not to take greater than % of their total daily calories as fat at least month before sampling. after a -hour overnight fasting and before starting dialysis, blood samples were taken for lipid profiles. for each patient with total cholesterol, tg or ldl-c levels more than th percentile for age and gender or hdl-c level less than mg/dl, was defined as dyslipidemia. results: nineteen out of children ( . %) had abnormal lipid profiles. atherogenic factor of tg/hdl-c ratio more than as a major risk factor for cardiovascular disease was in %. conclusion: dyslipidemia is common in hemodialysed children. so, hemodialysis set-up change and antilipimic medication, and replacement of l-carnitinine is recommended for correction of dyslipidemia in this group of patients. objectives of study: bipolar renal length measurement is an integral part of the assessment of urinary tract in childhood, and is routinely performed on ultrasonography and renal scintigraphy investigation. correlation between kidney size measurement on ultrasonography and dimercaptosuccinic acid (dmsa) scintigraphy is not well recognized. the purpose of this study was to comparison renal size measured by dmsa scintigraphy and ultrasonography to find if there is acceptable agreement between renal lengths by these two methods. methods: as cross sectional retrospective study, patients enrol in this study and their dmsa scan results and kidney ultrasonography reports compared. the agreement between renal size measured by two methods for left and right kidneys were evaluated separately using bland-altman plot. pearson's correlation coefficient was used to examine their correlation. statistical significance was calculated by paired-student t-test. the same tests were used to for kidneys with normal dmsa scans. results: correlation coefficient showed close correlation between kidney length measured by ultrasound and dmsa scan, but there were significant differences between two methods (paired t-test, p< . ). comparison between renal size measured by ultrasonography and dmsa scan using the methods of bland & altman plot in all patients and the group with normal kidneys showed a systematic bias of about + . mm for left and + . mm for right kidneys. conclusion: despite of close correlation between dmsa scan and ultrasonography for kidney length measurement; kidney size is overestimated by about percent in dmsa scan study and this matter must be considered in practice. medical treatment of cystinuria is often considered disappointing. patients undergo frequent surgery which is often followed by early relapse. the aim of our study was to prospectively evaluate, in a paediatric population, the efficacy of a conservative medical approach for long-term treatment of cystinuria, to prevent the formation of new renal stones and reduce the number and dimension of pre-existing stones. twenty-one stone former cystinuric patients were treated with a combined approach which included cystine-binding drugs. free and bound urine cystine levels were routinely measured every four months. drug dosage was adjusted in order to maintain a steady free urine cystine level below mmol/mmol creatinine (a three fold increase of normal level). in the patients who completed the study, renal stone episodes were reduced from . to . episodes/year, and in several patients the number and dimension of pre-existing renal stones were reduced. during the entire follow-up, percutaneous lithotripsy to remove an obstructive stone was required in only one subject. no relapse was observed months after treatment. the dosage required to achieve target levels was very closely correlated to patient body weight: older children required a lower dose to achieve target levels. in conclusion: medical management of cystinuria is feasible. the treatment must be personalised, at least in pediatric age. the amount of required drug is strictly depending from body size. it is mandatory to obtain a low free urine cystine level before any invasive procedure to reduce the risk of early relapse. objective: to study the pathophysiology of nutcracker syndrome (ns) and to assess the role of the upright position imaging and superior mesenteric artery (sma) angle measurement in the diagnosis. methods: doppler us findings in children with ns and in healthy control subjects were compared. the mesenteric angle, peak velocity (pv) and anteroposterior (ap) diameter of the left renal vein (lrv) at the hilar and aortomesenteric portions were measured in both the supine and upright positions. the means ±sd of the sma angle, ap diameter and pv ratio between the two portions were calculated and cut-off levels for the diagnosis of ns were established. results: the diameter and pv ratios were significantly different between the patient and control groups both in the supine and upright positions (p< . ). differences (d) between the supine and upright positions were also significant for the diameter of the lrv at the aortomesenteric portion, diameter ratio and sma angle in both groups. upright position imaging revealed comparatively narrower sma angles and more pronounced entrapment findings in patients with ns. the sma angle measurement had a sensitivity of . % and a specificity of . % in the supine position and . % and . % in the upright position when the cut-off values were set to less than ° and °, respectively. the upright position has significant effects on the lrv hemodynamics and angle of sma both in patients and healthy subjects. sma angle measurement may be a useful adjunct parameter in the diagnosis of ns. ). in addition, a statistically higher rate of pathological abnormalities on renal biopsy was noted in the group with microscopic hematuria combined with proteinuria and also in cases with more severe hematuria. conclusions: school urinary mass screening has greatly contributed to diagnosing chronic renal diseases. continuous medical observation is required when abnormal urinalysis is observed, and a more aggressive medical approach such as renal biopsy should also be performed if necessary. this study compared the outcome of children with proliferative ln (who class iii/iv) using a new protocol comprising pulse intravenous methylprednisolone, mmf +/-cyclosporine, with standard prednisolone and cyclophosphamide/azathioprine. method: twenty-three children with proliferative ln (age range at diagnosis . - . years) who were followed up for . - . (range . - . ) years, were included in this retrospective study. group i (n= ) received prednisolone with cyclophosphamide and/or azathioprine. group ii (n= ) received the combined mmf protocol with mmf dose of mg/m /day. poor outcome was defined as death or chronic renal failure. survival analysis was performed using the log-rank test. effect of treatment on growth at last follow-up was assessed using height standard deviation score (htsds). differences between the groups were analyzed using the mann-whitney and fisher's exact test. results: at last follow-up, significantly more group i compared to group ii patients had higher serological activity as defined by low serum complement c ( % vs % respectively, p= . ). in addition, -year actuarial survival was higher in group ii ( %) compared to group i ( %). all the group ii patients achieved complete remission of proteinuria compared to group i ( . ± . vs . ± . g/d/ . m respectively, p= . ). group ii patients also had lower htsds on long-term follow-up compared to group i (- . ± . vs - . ± . respectively, p= . ). conclusion: combination immunosuppressive protocol involving mmf +/-cyclosporine resulted in better renal outcome in children with proliferative ln without compromising on growth. this regimen allowed steroid tapering to alternate day dosing without increasing lupus activity. background: a full dose of corticosteroid is required to induce complete remission (cr) in steroidsensitive nephrotic syndrome (ssns), unless it is possible to taper and discontinue along with the course after cr. however, the mechanism of this change in steroid sensitivity remains unknown. p-glycoprotein (pgp) has a function to eliminate given corticosteroids from cytoplasm, which results in inducing corticosteroid resistance. therefore, we analyzed a drug delivery perspective using the real-time polymerase chain reaction (pcr) of multiple drug-resistant gene (mdr ; encoding pgp) messenger rna (mrna) expression. patients and methods: fourteen patients with steroid-sensitive nephrotic syndrome (ssns; male/ female: / , age: - years old; mean . ) were enrolled in this study. mdr mrna gene expression of peripheral blood nucleated cells (pbnc), before and after cr (a total of nineteen sets of blood samples), were quantified using real-time pcr and then carried for analysis. results: the mdr mrna levels before cr were variable in each patient. however, there was an apparent decrease in the mdr gene expression of pbnc after cr (p< . ). the results suggest that pgp may play a role in the ability to taper corticosteroids after cr in ssns. : week prednisone mg/m /day + weeks mg/m every other day). all other patients (b) received daily prednisone . - mg/kg/day for weeks and - % of initial dose for week, followed by alternate day steroids ( week) with tapering by . mg every - weeks down to . - mg. "frequent relapses" (less than months after discontinuation of initial steroid therapy or of first relapse therapy) were treated with chlorambucil . - . mg/kg/day for weeks and half of this dose for - months. results: seven patients (with long treatment) were lost to follow-up and were studied. six of ( %) of a had a relapse . ± . months after the end of initial therapy; became infrequent and frequent relapsers. of ( %) of b relapsed . ± . months after the end of initial therapy; became infrequent and frequent relapsers. frequent relapsers ( % in a and % in b) were treated with chlorambucil and all but one achieved long remission (> year). conclusions: first relapse occurred later after onset of ssns in patients with long ( weeks) as compared to short ( weeks) initial steroid therapy but the time interval between the end of initial therapy and the first relapse and the proportion of relapsers were similar. longer initial therapy may result in a lower number of frequent relapsers. nearly all patients had long remissions periods that were, however, achieved at the expense of early administration of chlorambucil. conclusions: the medium age of pts with metabolic stones was found to be higher than the medium age of pts with infectious stones. the familial occurrence of kidney stones was found to be important %. the ultrasonographic examination is the most important one. the stones composed by calcium oxalate and calcium phosphate were found to have the highest percentage. metabolic abnormalities were found in % of patients and hypercalciuria was the most common disorder. hypocitraturia is considered to be a risk factor the calcium stones. in an attempt to explore the new treatment for the childhood-onset intractable steroid-dependent nephrotic syndrome (sdns), we have recently performed the treatment with high-dose mizoribine (mzr), the inhibitor of inosine monophosphate dehydrogenase, and suplatast tosilate dimethylsulfonium std), a selective th cytokine inhibitor, which were both made in japan. mzr has been commonly used for the treatment of frequently relapsing sdns in japan at a dose of - mg/kg/day (maximally mg/day) divided into two doses (kidney int : , ). we used high-dose mzr (mean: . mg/kg/day) once before morning meal for adolescent patients with frequently relapsing sdns who had been treated with long-term cyclosporine (csa) resulted in moderate to severe csa nephropathy. with this treatment for years, seven out of patients weaned off csa and experienced less relapses without apparent adverse effects by high-dose mzr. std is a both il- and il- inhibitor and commonly used for childhood asthma. we used std at a dose which is for the treatment of asthma for children with sdns (mean . years) without previous csa treatment. after one year follow-up with std treatment, the relapse rate of nephrosis was decreased from . ± . to . ± . per year (p= . by wilcoxon signed-ranks test), where as the dosage of orally given predonisolone was also decreased from . ± . to . ± . mg/kg/day (p= . by wilcoxon signed-ranks test). objectives of study: to evaluate the efficacy and safety of long-term cya treatment for pediatric sle patients. pediatric sle patients in their teens suffer from many relapses and severe side effects caused by steroid and cyclophosphamide. there have hardly been any reports on the long-term cya treatment in children. methods: we retrospectively compiled cases of childhood-onset sle female patients (mean: . years) admitted to our department from to . the initial treatment was methylprednisolone pulse therapy followed by prednisolone (psl). at the onset, patients had class lupus nephritis and showed class . after several relapses, cya was added and used for to months. the dose of cya ranged from . to . mg/kg/day, and the target trough level from to ng/ml. results: under this low-dose cya treatment, patients had no relapse while had a relapse after months. in all patients, psl was reduced to alternate day treatment (mean: . mg/ days), and patients under years gained the target height. of all patients, developed hypertrichosis, gingival hyperplasia, transient elevation of s-cr with acute gastro-enteritis. although case had elevated s-cr after months of cya treatment, it returned to normal level within months after the cessation of cya. five patients had second biopsy after years, and showed mild tubulointerstitial (t-i) changes. two had third biopsy after years and both showed mild t-i changes only. the presence of t-i changes had no relation to s-cr, u-beta mg and u-nag. conclusion: low-dose cya treatment might be an effective and safe second line treatment for sle patients with many relapses in teens. it is also important to perform renal biopsy periodically to detect cya-induced renal damage which hardly shows any abnormalities in blood or urinary tests. hypersensitivity to inulin is rare; two cases of food allergy and some cases of allergy after inulin infusion have been reported. an -year-old boy suffering from severe iga nephropathy (igan) is reported with both anaphylactic reaction and concomitant relapse of his nephropathy due to inulin infusion, used for measuring gfr years after first symptoms. pruritus, sibilants and cough were observed during a first renal function test. prick and intradermal tests were negative for inulin. the patient presented with pallor and asthenia during a second inulin infusion performed under dexchlorpheniramin, leading to immediate infusion stop. he was read mitted because of fatigue and nausea; acute renal failure was diagnosed days after inulin infusion. a drug-induced acute interstitial nephritis was first suspected. however, due to the presence of macroscopic hematuria and proteinuria, a renal biopsy was performed and showed acute proliferative relapse of igan. few data are available about inulin-induced hypersensitivity. chandra described anaphylaxis and cardiorespiratory arrest immediately after administration of sinistrin. a retrospective study of all recorded cases of hypersensitivity associated with renal function tests was performed by our pharmacovigilance unit. , tests using inulin clearance were realized both in adults and children; patients experienced side effects which were divided into groups: respiratory symptoms, rash and general signs. most side effects were minor and no life threatening complication occurred. the underlying mechanism of inulin hypersensitivity is not well known. although % of patients with inulin-associated hypersensitivity underwent a first renal function test, we can speculate that presensitization with food inulin may occur, sometimes leading to severe problems such as in our patient with iga-mediated immunological dysregulation. . we have previously demonstrated a composite heterozygous nphs mutation of both v x and r h in a chinese patient with srns. however, it is not clear the molecular mechanisms of mutant podocinlead to proteinuria. some evidences proved the possible interaction between podocin and trpc . this study explored the effects of mutant podocin on the free cytosolic ca + and apoptosis of podocyte in order to clarify the possible causative mechanism of mutant podocin. methods: . the pdsred n -wild/mutant podocin was constructed by using site-directed mutagenesis. . mouse podocyte clone was cultured and transfected with pdsred n -wild/mutant podocin. . free cytosolic ca + was measured using the fluorescent indicator, fluo -am. results: the low level of free cytosolic ca + was detected in normal podocyte and the transfected podocytes with r h mutant podocin. the v x mutant podocin increased the free cytosolic ca +more evidently than the over-express podocin in transfected podocytes. podocyte apoptosis were not detected in the blank-vector (just pcdna . ) transfected podocytes and normal podocyte. the v x and r h mutant podocin increased the podocyte apoptosis more evidently than the over-express podocin in transfected podocytes. conclusions: the v x mutant podocin might induce podocyte apoptosis via the increment of free cytosolic ca +. however, whether the increment of free cytosolic ca + is induced by trpc and the involved signal pathway should be further investigated. y. xing, q. fan, j. ding objectives of study: podocytes slit diaphragm (sd) associated molecules (nephrin, podocin and cd ap) play a critical role on maintaining the integrity of glomerular filter. vegf is produced by podocyte, and acts on endothelium and podocyte itself. but, it is not clear whether there are some relationships between vegf and sd associated molecules. our study detected the expression of sd associated molecules and vegf in adriamycin (adr) nephrotic rats. methods: the adr rat was established by adr injection. distributions of sd molecules and vegf were detected by immunochemistry. the mrna and protein of sd molecules and vegf was examined by real-time pcr and western, respectively. nephrin phosphorylation were detected by immunoprecipitation. results: distribution of nephrin, podocin and cd ap changed evidently, and the staining intensity of vegf decreased evidently. nephrin mrna increased at day , and returned to the normal at day and ; podocin and cd ap mrna constantly increased from day until day . the protein of nephrin increased at day until day ; podocin was dramatically upregulated at day , and thereafter recovered again, but was downregulated at day ; cd ap prominently increased at day and day . tyrosine phosphorylation of nephrin was decreased evidently at day , and vegf mrna did not show significantly changes at any time points observed. however, vegf protein reduced significantly from the th day, and also reduced evidently at days and days . conclusion: the abnormality of nephrin, podocin and cd ap may be one of the mechanisms that lead to proteinuria in adr-induced nephrotic rats. the occurrence of proteinuria in adr rats may be also associated with the reduced vegf protein, which may be related with the reduction of nephrin phosphorylation. these results suggested there may be some relationship between vegf and sd molecules. the objectives of study: mutations in genes encoding structural proteins of slit diaphragm can lead to nephritic syndrome. just recently, another gene trpc mutation was identified in autosomal dominant fsgs. trpc encodes ion channel protein trpc , whose expression has not been clarified completely in kidney. this study aims to explore the expression and distribution of trpc in normal human, mouse and rat renal tissue and the mouse podocyte clone (mpc ). methods: distributions of trpc in normal human, mouse and rat renal tissue and cultured podocyte was observed with immunochemistry staining. the mrna expression of trpc , , , , and was detected by using rt-pcr. the protein expression of trpc in human, mouse and rat renal cortex and differentiated mpc was detected with western. results: trpc showed weak staining in glomeruli and strong in renal tubules and vessels in human kidney, however, strong in glomeruli and was mainly distributed along the capillary loops and mesangium in mouse and rat kidney. the staining of trpc was observed in differentiated mpc , which is distributed evenly on the cell membrane. the specific pcr band of trpc , , , , and was detected in mouse kidney and differentiated mpc . the sequence of the amplified pcr products is same as that published in genebank. the specific kda protein band of trpc was detected in normal human, mouse renal cortex and differentiated mpc . conclusion: the expression of trpc was verified in normal human, mouse and rat kidneys and in differentiated mpc . these results will benefit for further screening the possible mutation of trpc in acquired nephrotic syndrome, and investigating the relationship between trpc and the proteinuria-related podocyte molecules. methods: twenty children with kd ( boys and girls, aged from to months) were enrolled in our study. kidney sizes (including kidney length and kidney volume) were measured during acute stage in these patients. twenty age-and sex-matched healthy children and febrile children served as healthy controls and fever controls. left kidney length and age were used for correlation analysis and analysis of covariance. results: kidney lengths in patients with kd were significantly larger than those of healthy children (p< . ). the mean sd score of kidney length was . ± . for these patients (p< . , vs - . ± . in normal control). kidney volume analysis yields the similar result ( . ± . cm vs . ± . cm , p= . ). there was no kidney enlargement in the fever controls. up to % of the children with kd have absolute nephromegaly (>mean+ sd). this incidence is as frequent as that of lymphadenopathy and extremities change, the diagnostic criteria of kd. conclusion: these results confirm the presence of large kidneys in the children with kd and also provide another useful indicator for kd diagnosis if the diagnostic criteria is not yet well established. during renal inflammation macrophages infiltrate the renal parenchyma, and their number correlates with the intensity of inflammation. macrophage migration inhibitory factor (mif) was described originally to be a product of t-cells and macrophages. mif plays an important role in renal tissue injury. to our knowledge, the studies that assessed the role of macrophages in acute renal infection were few and the role of mif was not evaluated. the aim of this study was to assess mif in uti and compare the urinary excretion of mif in pyelonephritis, cyctitis and also control group to find a non-invasive and sensitive method to differentiate them. in this prospective case-control study pediatric patients with uti ( patients with acute pyelonephritis, patients with acute cystitis) and healthy children were recruited. urine mif concentration was quantitated by elisa and corrected for urine creatinine. the mean ratios of urine mif/cr were calculated as . (sem= . ) pg/μmol creatinine in acute pyelonephritis, . (sem= . ) in acute cystitis and . (sem= . ) in healthy individuals. urine mif/cr ratio was significantly higher in pyelonephritis than the ones in acute cystitis (p= . ) and control (p= . ). roc analysis was demonstrated that urine mif/cr ratio could considered potentially useful index to detect acute pyelonephritis [p= . , area under curve (auc)= . ]. the optimal cut-point of . pg/μmol creatinine for urine mif/cr ratio could potentially separates acute pyelonephritis patients from healthy individuals (sensitivity and specificity of % and . %, respectively). the underlying histopathological characteristics in biopsied renal diseases are of great importance in determining the long-term prognosis and provides useful information in clinical practice. ethnicity seems to play a critical role in the epidemiology of biopsied renal diseases the aim of this study is to provide data of clinical manifestations of biopsy-proven native renal diseases in iranian children. in this retrospective study, iranian children who were diagnosed as renal disease between and january , were evaluated. diffuse and focal mesangial proliferative glomerulonephritis was present in . % of all biopsies performed. mpgn, fsgs and mcd were observed in . %, . % and . % the most common clinical syndrome at any age is nephrotic syndrome ( . %), followed by nephritic syndrome ( . %), nephrotic-nephritic syndrome ( . %), recurrent macroscopic hematuria ( . %), asymptomatic urine abnormalities (aua) ( . %) and azotemia was seen in . % of patients. mesangial proliferatiove gn ( / = . %), poststreptococal gn ( / = . %) are the most frequent pathologies with acute nephritic syndrome presentation. the most frequent causes of aua were mesangial proliferative gn and hsp. thrombotic microangiopathy (hus) was the most prevalent cause of arf. inthis study, chronic tubulo interstitial nephritis ( . %) and alport ( . %) were the most common causes of crf presentation in our patients. in conclusion, mpgn remains the most common histopathological subtype in children with renal biopsied disease. the incidence of fsgs continues to be high in iranian children. the aim of this study is to assess postnatal kidney volume development and to compare the intrauterine and extrauterine kidney growth curves in premature infants. one hundred neonates were enrolled in this study. all infants had their kidney volumes measured by renal ultrasound examination. group ga consisted of neonates whom were evaluated within hours after birth, and their gestational ages were used in the analysis. group ca included premature infants born before weeks of gestation and was evaluated - days after birth, and their conceptional ages were used in the analysis. left kidney volume, body weight, body height and age were used in the correlation analysis. kidney volumes in group ca infants were significantly larger before weeks of age, but smaller after weeks of age than those of group ga infants (p= . ). there was a significantly better growth in body weight (p= . ) and body height (p< . ) in group ga infants. however, a larger kidney volume was noted in group ca infants with the same body weight (p< . ). conclusion: chart of postnatal growth of normal kidney volume before weeks of conceptional age in premature infants is presented. our data suggests that intrauterine growth may have a regulatory influence on kidney growth, and the reduced kidney volume in the premature infants may start from the early extrauterine period. objectives of study: to illuminate the role of prohibitin (phb), a tumor suppressor which inhibit cell proliferation by repressing e f-mediated transcription, in tubulointerstitial fibrosis (tif). methods: renal biopsy specimens were obtained from children with primary glomerulonephritis. phb and α-sma proteins expression were detected by immunohistochemistry. subcellular location of phb in nrk- f was detected by confocal microscope. changes of phb protein and mrna expression in cells upon tgf-β stimulation were detected. after transfected with phb plasmid, cell cycle and α-sma protein and mrna expression in cells treated with or without tgf-β were detected. results: phb protein was found at normal renal tissues, with a positive distribution in interstitial cells and tubular epithelial cells. phb was down-regulated in tissues with tif and negatively correlated with tif degrees (p< . ). phb is majority located at cytoplasm as well as at nucleus in nrk- f. phb protein and mrna expression in cells were decreased when treated with tgf-β , and the effects were both time-dependent and dose-dependent. extraneous phb inhibited cells proliferation induced by tgf-β , and phb over-expressing cells failed to enter the cell cycle compared with non-transfected cells (p< . ). α-sma was not expressed in control cells while de novo expression of α-sma in cells upon tgf-β stimulation was increased. overexpression of phb did not affect basic α-sma expression but dramatically repressed tgf-β -initiated α-sma expression (p< . ). conclusions: extraneous phb suppresses renal interstitial fibroblasts proliferation and cell phenotypic change induced by tgf-β , which indicates phb as a potential target to halt tif progression. results: the prevalence of urine abnormalities of first screening was over . %, and that of the second screening was about . %. the prevalence was different with various methods. the specificity of method b was higher than method a. testing two urine samples for each child had higher specificity. the direct cost of method a and b was - . and - . rmb, respectively. for screening twice, the corresponding cost was no more than - . and - . rmb, respectively. using method a to screen twice for each child was convenient and economical, which also reduced the false positive rate effectively. the prevalence of urine abnormalities of junior highschool children was significantly higher than that of elementary school-children in xh and the peak point was seen at the point of years old. however, there was no significant difference between children in ja and yp. more than months of follow-up diagnosed cases of iga nephropathy. conclusions: urine abnormalities of school-children could be detected through urine screening at school. for shanghai, method a with screening twice was convenient, economical, and could reduce the false positive rate effectively. objectives: angiopoietin-like protein (angptl ) is involved in lipid metabolism and angiogenesis. the present study was to examine angptl expression in human kidneys with proteiuria, in adramycin rats (adr), and in puromycin induced podocyte damage. methods: immunohistochemistry was performed on kidney biopsies from children with mcd, mn, fsgs, tbmn. in adr, angptl expression was determined by quantitative real-time rt-pcr in glomeruli and tubuli dissected from frozen section of kidneys with laser microdissection system. in mpc , a conditionally immortalized mouse podocyte cell line in vitro, angptl , perlecan and agrin were detected through real-time pcr with the induction of puromycin. detachment assay was performed in podocytes tranfected by angptl -pcdna . . results: in human kidneys, co-labeling showed angptl expressed in the cytosol of wt positive cells. quantitative computerized analysis showed that angptl in glomeruli in mcd and mn were significantly higher than that of tbmn, fsgs respectively (p< . ). in adr, angptl in glomeruli increased significantly at st or th day (p< . ) after adriamycin injection compared with control. and the expression of angptl in glomeruli was correlated with h urinary protein (r= . , p< . ). in mpc both protein and mrna expression of angptl on podocytes were up-regulated with the induction of puromycin. in podocytes transfected by angptl -pcdna . the expression of perlecan or agrin increased significantly compared with control (p< . ). the attachment ratio was shown . %± . % hs after puromycin treatment on podocytes transfected by angptl compared with . %± . % on normal podocytes, and . %± . % on untransfected podocytes. conclusions: angptl is predominantly expressed in podocytes which could be involved in podocyte damage and the development of proteiuria. ( ), iv ( ) and iii ( ), respectively. only one patient had microhematuria. we found that of them had a very low c serum levels. clq and c deposits were all strong positive in renal tissues. our findings suggest that biopsy should be strongly considered in this patient population. the significant renal involvement (class iii, iv, or v ln) could be found in sle patients with very lower proteinuria with or without hematuria. patients in bfb group received computer-assisted biofeedback program while those in ddavp group took minin. both therapies were carried out for month and then months follow-up was taken. parameters of follow-up included enuresis diary-urine flow rate and aqp in urine. results: pne patients were recruited ( boys, and girls), whose mean age was ( . ± . ) years. at the end of treatment and three months later, total effective rates in bfb group were significantly higher than those in ddavp group. uroflowmetry findings showed that in bfb group maximum flow rate, voided volume and ratio of coordinative detrusor-sphincter contraction increased after treatment. ratio of normal flow curve increased at second follow-up (p< . ). in ddavp group voided volume and voiding time decreased after treatment. ratio of normal flow curve and coordinative detrusor-sphincter contraction had no change after treatment. two bands of aqp ( and ) were detected in the morning urine. density of patients bands was significantly lower than that of the controls. density of bands in ddavp group after treatment were significantly higher than that before, but there was no difference between datas before and after treatment in bfb group. conclusions: bfb and ddavp are both effective therapies for pne in children. bfb is helpful in correcting voiding dysfunction and ddavp can increase aqp protein in the urine. with higher effective rate within four month, bfb is strongly recommended. objective: to describe the clinical course of non-parasitic chyluria in a thai pediatric case. this is the first report in children. results: the -year-old boy presented milky urine lasting for one year. urine tests showed heavy proteinuria (protein to creatinine ratio . mg/mg), lipiduria (triglyceride mg/dl). the proof of a pronounced hypertriglyceriduria led to the diagnosis of chyluria. his renal function was normal. numerous red cells and lymphocytes were observed in the urine, and postprandial cystoscopy revealed milky cloudy urine emanating from right ureteral orifices. retrograde pyelography demonstrated pyelolymphatic backflow. serum immunoglobulin g for wuchereria bancrofti and circulating filarial antigen in the peripheral blood were negative. chest x-ray, abdomen computed tomography and intravenous urography did not demonstrate abnormal mass or malformation. proteinuria and lipiduria ceased before sixth week of a medium-chain triglyceride-rich diet. there was no recurrent chyluria after weeks of mct-rich diet were completed. conclusion: in non-parasitic chyluria with unknown etiology, the low-fat diet with mct supplementation alone is effective. the prognosis is excellent. there was a significant improvement of waz comparing data at admission and at the end of follow-up (p< . ). there was also a significant improvement of whz comparing data at admission and at the end of follow-up (p= . ). only ( . %) patients presented with a whz less than - . at the end of the follow-up. conclusion: children with primary vur presented an improvement in somatic growth with medical management. objective: the aim of this study is to investigate the clinical practical value of using doppler ultrasound to detect renal blood flow in renal parenchymatous diseases of children. methods: the renal arteries, segmental arteries and interlobar arteries were detected by doppler ultrasound. the parameters were peak systolic velocity (vmax), minimum velocity in diastole period (vmin), vmax/vmin (s/d), resistive index (ri) and pulsatility index (pi). there were cases of healthy children, cases of acute poststreptococcal glomerulonephrits, cases of primary nephrotic syndrome and cases of chronic renal failure. results: the doppler renal blood flow in normal school children was high velocity and low resistant type. typical cases of acute nephritis with edema and oliguria appeared low velocity and high resistant type, ri, pi and s/d of all renal arteries were significantly increased, vmin are significantly decreased (p< . ). after to weeks all parameters returned to normal. during edema period and convalescence, the renal blood flow of primary nephrotic syndrome is low resistant type, ri, pi and s/d of segmental arteries and interlobararteries were significantly decreased (p< . ). the feature of low circulating blood capacity was not alleviated even though edema was vanished and urine output was increased. the doppler in chronic renal failure was high resistant and low velocity type. ri, pi and s/d were all significantly increased, vmin were significantly decreased (p< . ). when ri was great than . , the extent of damage in kidney function was serious and the prognosis was bad. conclusion: renal blood flow provided a new non-invasive method for clinic diagnosis and evaluation of the prognosis in children renal parenchymatous diseases. we concluded that the dms is an important cause of congenital nephrotic syndrome. the outcome of our patients was poor and most of our patients died before years old. objectives: the antiphospholipid syndrome is defined by the association of arterial/venous thromboses or obstetrical fetal loss with the presence of antiphospholipid antibody. this syndrome may be primary or secondary, particularly in association with systemic lupus erythematous. this study is to examine the frequency of anticardiolipin antibodies and the association between anticardiolipin antibodies with some symptoms in children with lupus nephritis. methodology: twenty-five children with lupus nephritis from / to / in department of nephrology, children's hospital o were included in the study. we find the relationship between anticardiolipin antibodies with hematologic and renal involvement. results: anticardiolipin antibodies was positive in patients ( %), for anticardiolipin igm antibody ( %), for anticardiolipin igg antibody ( %). there was a positive correlation between the presence of anticardiolipin antibodies and thrombocytopenia. in patients with positive anticardiolipin antibodies, patients had mta on renal biopsy. conclusion: anticardiolipin antibodies are associated with thrombocytopenia and mta. aim: the methodologies for quantitating urinary calcium excretion have not been standardized. the aim of this study was to compare urinary calcium/osmolality (uca/osm) ratio with calcium/creatinine (uca/cr) ratio and to assess the correlation of both ratios with daily urinary calcium excretion for the diagnosis of hypercalciuria in children. patients and methods: children aged - years (mean . ± . years) were included in the study. they were randomly selected from previous study's larger patient population. non-fasting, second morning urine samples were collected from all children. children were divided into two main groups: ) children with uca/cr < . (mg/mg) and ) children with uca/cr < . . -hour urine samples were collected from the second group, who were further divided into two subgroups: a) children with daily calcium excretion < mg/kg/day and b) hypercalciuric children (daily calcium excretion > mg/kg/day). results: mean uca/osm ratio was significantly lower in the first ( ) group than the second ( ) group ( . ± . vs . ± . mg/l/mosm/kg, p< . ); but there was no difference between a and b subgroups. the correlations of both uca/osm and uca/cr ratios with -hour calcium excretion were poor (r= . for both). conclusion: uca/osm ratio correlated with spot uca/cr ratio. but its superiority on uca/cr ratio in the diagnosis of hypercalciuria could not be shown. interestingly, values of -hour calcium excretion as a definite diagnosis test of hypercalciuria; did not correlate mathematically with those ratios of hypercalciuric or non-hypercalciuric children. using uca/osm ratio as a screening test would not separate hypercalciuric children. background: microalbuminuria is a biomarker of renal damage. the presence of microalbuminuria in patients with a solitary kidney has been described, but the pathophysiology leading to its occurrence is poorly understood. it is postulated that microalbuminuria is the early result of hyperfiltration. methods: we concomitantly measured inulin clearance, filtration fraction (ff) and microalbuminuria in children with a single kidney. correlation between the occurrence of microalbuminuria and a high filtration fraction was done. microalbuminuria was defined as an albumin/creatinine ratio (acr) > g/mol for boys and girls. normal filtration fraction was defined as < %, and normal inulin clearance as > ml/min x . m . during the same study, we also measured microalbuminuria in children with severe grade iii to v vesico-ureteral reflux (vur). results: children with a single kidney were evaluated. patients ( %) had a normal ff, and only one ( %) in that group had an abnormal acr. patients ( %) had elevated ff, and ( %) had an abnormal acr. the presence of an abnormal acr was highly correlated with an abnormal ff (p= . ). the mean gfr between the groups with normal or abnormal microalbuminuria did not differ significantly ( ± ml/min x . m vs. ± ml/min x . m , respectively). there was no significant association between microalbuminuria and a high ff in patients with severe reflux (p= . ). discussion: we found the presence of microalbuminuria to be significantly associated with an elevated ff in children with a single kidney. this finding goes in line with the pathophysiology of a reduced nephron mass, leading to hyperfiltration, and ultimately to glomerular sclerosis. the benefit of renin-angiotensin-aldosterone blockade in these patients remains to be proven. chyluria is the excretion of chyle from the urinary tract and indicates the presence of an abnormal communication between intestinal lymphatics and the urinary tract. it can be of parasitic or nonparasitic etiology. southern brazil is not an endemic region for filariasis. aim: report a case of a -yrs caucasian adolescent girl referred to our out-patient clinic. history: yrs before, she started to pass milky urine with white clots. no edema. normal blood pressure. she was investigated in another hospital and underwent a renal biopsy, that was normal. a diagnosis of nephrotic syndrome was made. she was treated initially with steroids and after changed to cyclosporin, lisinopril and simvastatin. conclusion: chyluria, although a rare conditione specially in children and adolescent in nonendemic areas, should beconsidered in the differential diagnosis of nephrotic syndrome. macroscopic examination of the urine, that is milky and cloudy, is simple and very helpful. also, triglycerides are found only in the urine of patients with chyluria. these simple tests will avoid unnecessary treatment, which is not without side effects. low-density lipoprotein apheresis (ldl-a) has been tried in the treatment of patients with steroidimmunosupression resistant nephrotic syndrome (ns) due to focal segmental glomerulosclerosis (fsgs). we would like to report a child case study of fsgs with ns and renal insufficiency due to mitochondrial abnormality treated by ldl-a and to clarify the therapeutic effects of this treatment. a -year-old boy was referred to our hospital with complaints of heavy proteinuria and edema. a routine examination revealed proteinuria of . g/day, serum albumin (alb) of . g/dl and creatinine clearance (ccr) of . ml/min. renal biopsy specimen showed fsgs and perceptive deaf nass was recognized, necessitating a hearing aid. the a g point mutation in mitochondrial gene was detected by using genomic dna isolated from peripheral blood leukocytes and by the molecular analysis using an allele-specific polymerase chain reaction (pcr). oral prednisone ( mg/kg/day for eight weeks), intravenous methyl-prednisone pulse therapy ( . g/day,three times a week on the consecutive days for three weeks) and oral cyclophosphamide ( mg/day for eight weeks) were not effective to reduce proteinuria. a protocol of ldl-a was designed for treatment twice-a-week for four weeks and then once-a-week for six weeks. following treatment by ldl-a, serum total cholesterol and ldl were markedly changed form to mg/dl and from to mg/dl, respectively. a small but significant increase in alb from . to . g/dl and a remarkable decrease in proteinuria from . to . g/day were also successfully obtained. conversely, no marked changes in ccr were detected. the results of the present study indicate that a rapid decrease in proteinuria and an excellent increase in alb by ldl-a provide a possible therapy for drug-resistant ns due to fsgs with mitochondrial abnormality. glomerular filtration rate (gfr) can be estimated in children by various formulas based on body height and serum creatinine (s cr ) measurements such as the schwartz formula (egfr sch =kxbh/s cr ). we evaluate the performance of egfr sch in estimating gfr in a pediatric cohort when compared to i-iothalamate clearance (igfr), used as the reference standard for measuring gfr. between and , we obtained igfr and egfr sch on subjects. for subjects who had more than one igfr, the first measurement was used for analysis. mean age was ± (range - , % age= ), % male. mean s cr was . mg/dl (median . ), mean igfr ± ml/min/ . m and mean egfr sch ± ml/min/ . m . figure shows a scatter plot of the data with a line representing perfect agreement. figure shows a residual plot comparing the difference between estimated and measured gfr to egfr sch . pearson r correlation between the two variables was . (ln scale). accuracy of egfr sch within % and % was % and %, respectively. the median difference between igfr and egfr sch was . ml/min/ . m (median % difference %). for igfr > , - , - and < ml/min/ . m , egfr sch overestimated gfr by %, %, % and %, respectively. however, the median difference between igfr and egfr sch for the same groups was , , and ml/min/ . m , respectively. in conclusion, agreement between egfr sch and igfr is poor. egfr sch overestimates igfr at all levels of gfr, but bias of egfr sch vs. igfr increases progressively with higher gfr levels. in clinical instances when an accurate estimation of gfr is critical for patient management, the use of egfr sch should be reconsidered. until a more applicable estimation equation is developed, isotope measurement of gfr remains the ideal method to determine gfr in this population. background: immunosuppressive therapies other than corticosteroids, potentially associated with serious adverse effects, are urgently required for children with frequently relapsing nephrotic syndrome (frns). this study evaluated the efficacy and safety of long-term treatment with a moderate dose of cyclosporine (cya) in children with frns. methods: in this prospective, open-label multicenter trial, patients, from to years old, were randomly divided into two groups. for the first months, both groups received cya (sandimmune) in a dose that maintained the whole-blood trough level between to ng/ml. during the next months, the dose of cya was adjusted to maintain a trough level between and ng/ml in group a, while group b received a fixed dose of . mg/kg per day of cya. the primary end point was the rate of sustained remission. results: at months, the rate of sustained remission was % in group a (n= patients), as compared with only % in group b (n= ) (p= . ). the hazard ratio for relapse was . ( % ci, . to . ) in group a as compared with group b (hazard ratio= . ). at months, the rate of progression (to frns)-free survival was % in group a and % in group b (p= . ). mild arteriolar hyalinosis of the kidney was found in ( . %) of patients in group a and ( . %) of in group b; no patient had striped interstitial fibrosis or tubular atrophy. conclusion: cya given for years in a dose producing a trough level between and ng/ml for the first months, followed by a trough level between and ng/ml for the next months is an effective and relatively safe treatment for children with frns. with this regimen, about % of patients are expected to remain relapse-free during years of treatment, without the most critical adverse effect of cya, i.e., interstitial changes of the kidney. renal stone disease has been regarded as an uncommon problem in children especially in the first year of life. we evaluated clinical findings and metabolic examination of children with urinary tract stone presenting in the first year of life. there were boys ( %) and girls ( %), the mean age of admittance was , ± , months. the average follow-up period was , ± , months. urolithiasis was diagnosed during evaluation for uti and incidentally. positive family history for urolithiasis was reported in ( , %) patients. in / ( , %) patients urinary metabolic examination was not normal (table ). in of patients ( %), stones were located in kidneys which was bilateral in ( %) patients and one patient had passing stone which had never seen in ultrasonographic examination. stones were examined in subgroups. in ( %) patients stones were measured mm or smaller (group ), in patients ( %) they were between - , mm (group ) and in only patient the stone (cystin) was larger than mm (group ). stones measuring mm and larger were found highly associated (in of children, %) with abnormal ultrasonographic findings mainly hydronephrosis. in group , stones disappeared spontaneously in / ( %) patients. urinary tract infections (uti) were present in ( %) patients. one fourth of cases had associated genitourinary tract abnormalities mainly vesicoureteral reflux in ( %) patients. we conclude that the presenting symptoms of urolithiasis in the first year of life show a wide spectrum so that high index of suspicion is important for early detection. stones measuring mm and smaller may have great chance to disappear. we also emphasize the importance of screening for uti in patients with urolithiasis under year of age. background: long term complications of glycogen storage diseases (gsds) include delayed puberty, hepatic adenoma and renal disease. in the present study we aimed to detect renal involvement in children with glycogen storage disease and to determine the most accurate laboratory test to be the gold standard for early detection of this renal dysfunction. methods: twenty-seven children known to have gsd were included in this study. fifteen healthy age-and sex-matched children were also included as controls. routine urine analysis, urinary β microglobulin and microalbumin were done for all patients and controls. renal function tests, serum electrolytes, alkaline phosphatase, urinary calcium, blood and urine ph, urinary and plasma aminogram, in addition to calculation of glomerular filtration rate (gfr), bone x-ray to detect rachitic manifestations and abdominal ultrasound to measure renal size were done for all patients. results: twenty-one patients had one or more renal abnormality. the most common was increased urinary β microglobulin ( / ) followed by abnormal gfr whether low or high ( / ) and microalbuminuria ( / ). sonographically there was nephrocalcinosis in one case and renal stone in another one. the auroc curve for β microglobulin was . , (p= . ) and . for urinary microalbumin/creatinine ratio (p= . ). the best cutoff level to predict renal abnormality for urinary β microglobulin was . mg/l with % sensitivity and % specificity and the best cutoff value for urinary microalbumin/creatinine ratio was . with % sensitivity and % specificity. in conclusion: renal abnormalities are common in patients with gsd. urinary β microglobulin can be considered the gold standard for early detection of renal dysfunction in these patients. the aim of this study was to investigate the role of neutrophil activation, protein oxidation and ceruloplasmin in the pathogenesis of hsp, which has been not investigated previously. serum activities of myeloperoxidase (mpo) and arylesterase (aryl) and levels of free thiol, ceruloplasmin (clp) and total oxidant status (tos) were measured in children with hsp ( boys, girls; mean age . ± . years) at the onset of the disease and during remission in comparison with matched healthy subjects. patients at active stage had significantly higher mpo activity ( ± vs. ± u/l, p< . ), higher clp ( ± vs. ± mg/dl, p< . ) and tos values ( . ± . vs. . ± . μmol h o /l, p< . ) than controls. patients had significantly lower aryl activity ( ± vs. ± u/l, p< . ) and lower free thiol levels ( ± vs. ± μmol/l, p< . ) than controls. there were patients with gis involvement, with joint and with renal involvement. no significant differences were found in the oxidant stress markers between patients with or without organ involvement (p> . ). significantly positive correlations were found between tos and mpo (r= . , p= . ), and tos and clp (r= . , p= . ) at the disease onset; while a negative correlation was found between mpo and thiol (r=- . , p= . ) during remission. in conclusion, protein oxidation and neutrophil activation may play important roles in the pathogenesis of hsp. gastrointestinal system, joint and/or renal involvements were not together with different magnitude of oxidant stress. further studies are required to identify oxidizing substances and to develop therapeutic strategies to reduce oxidant stress in hsp. , ) . if the first remission occurred after days, the median time to relapse after discontinuation of steroid therapy was significantly lower than in children with shorter remission time ( . vs . months; p< , ). in conclusion children who fail to achieve a prompt remission after a first episode of ns are more likely to have frns or sdns. these retrospective data provide the rationale for individualizing the initial steroid treatment of mcns according to the time to obtain a remission. a prospective study is needed to validate this approach. the aim of this study was to determine the influence of osmolality of the first morning urine (ofmu) to efficacy of the desmopressin therapy in enuretic (pne) children and to compare the values of ofmu in enuretic and non-enuretic children. methods: we investigated ofmu in group of children with pne and in group of control non-enuretic children. pne group was divided into subgroup i (ofmu < mosm/kg h o) and subgroup ii (ofmu > mosm/kg h o). additionally, we measured ofmu months after the initiation of desmopressin therapy and recorded the number of wet nights. regarding the number of wet nights we divided pne group to subgroups: subgroup a (< wet nights/month), subgroup b ( - wet nights/month), and subgroup c (> wet nights/month). results: the statistically significant difference between control group and pne group regarding ofmu was not found (p= . ). all children from subgroup i had < wet nights/month during desmopressin therapy. children from subgroup ii had < wet nights/month, and had > wet nights/month during desmopressin therapy. the difference between those two groups was statistically significant (x = . , p= . ). in children from subgroup a the difference between ofmu-s during and before treatment was mosm/kg h o, in children from subgroup b it was mosm/kg h o and in children from subgroup c it was , mosm/kg h o. there was the statistically significant difference among those subgroups. conclusion: children with pne had usually similar ofmu like non-enuretic children. low ofmu is a good prognostic factor for desmopressin therapy of pne, especially in patients whose ofmu is < mosm/kg h o. children with bigger difference of ofmu before and during therapy had better response to desmopressin therapy. we can conclude that ofmu can help in choosing the appropriate therapy for pne in children. yh. ng , kl. chan kk women's and children's hospital, pediatric nephrology, singapore, singapore singapore general hospital, neonatology, singapore, singapore aim: to evaluate the clinical course and outcome of primary vesicoureteric reflux (vur) in patients with antenatal hydronephrosis in a neonatal unit. method: a prospective observational study of neonates with antenatal hydronephrosis born between january and december in the neonatal unit of singapore general hospital. neonates with significant hydronephrosis postnatally underwent micturating cystourethrography (mcu). records were reviewed with regards to the clinical course and outcome of primary vur. results: of neonates with antenatal hydronephrosis, ( %) had significant hydronephrosis postnatally and underwent mcu. . % ( / ) were diagnosed with primary vur at median age of weeks. there were more male (n= ) than female infants with primary vur. ( %) infants had bilateral vur. % (n= ) of the renal refluxing units (rru) had low grade vur and % had high grade vur with the majority ( %) being grade iii vur. repeat mcu for rru at years showed that % (n= ) had spontaneous resolution of vur, % had improved vur grade and % had similar vur grades as before. infants develop vur in the contralateral kidney which was previously normal. infants ( rru) underwent dmsa with renal scarring noted in infants. all infants were noted to have renal scarring without a history of urinary tract infection (uti). interestingly, male siblings were found to have grade iii vur with renal scarring with subsequent spontaneous resolution. none of the study subjects underwent surgery. median age of follow-up was . years (range . - . years). conclusion: unlike neonates with vur detected after uti, infants with primary vur were predominantly male, had higher grade of vur with spontaneous resolution in the majority. early diagnosis of primary vur may provide the opportunity for reduced incidence of reflux nephropathy. t. neveus , g. läckgren , j. wahlberg , n. wahlin uppsala university children's hospital, uppsala, sweden uppsala university hospital, department of transplantation surgery, uppsala, sweden objectives and methods: loin pain hematuria syndrome is a rare entity consisting of recurrent macroscopic hematuria with debilitating loin pain. it has only been described in adults, etiology is unclear and treatment is controversial but the therapy with best recorded success is to remove the kidney and reposition it in the pelvis. our objective was to show that the condition exists in childhood as well. results: aj, a previously healthy -year-old girl, was admitted because of recurring cystitis-like symptoms with microscopic hematuria but without bacteriuria. ultrasound and urography were normal. the episodes continued during the following years with increasing hematuria, now macroscopic, and increasing loin pain that was somewhat exercise-dependent. a renal ct scan was normal, as was cystoscopy, urography and ultrasound, but during cystoureteroscopy dilated vessels were noted in the mucosa of the right renal pelvis. antegrade pyelography, high resolution renal ct angiography, invasive renal angiography, mag renogram were all normal, gfr . nephrological evaluation, including kidney biopsy and coagulation tests were also normal and during cystoscopy blood could be seen emerging from the right ureteral orifice. by this time the patient was years old and was dependent on opioids in order to be able to go to school. after long discussions with the nephrologist, urologists, pain specialist and transplantation surgeon, the family opted for autotransplantation as a last resort. this was performed january and the girl became almost momentarily pain-free. nowadays she does not need any analgesics, but after prolonged exercise (like several days of horseback riding) she may experience slight pain in the left loin and/or hematuria. conclusions: idiopathic loin pain hematuria syndrome exists in childhood and may possibly be treated with renal autotransplantation. j. van der deure, a. ockhuijsen, m. sondaar deventer ziekenhuis, st department of pediatrics, deventer, the netherlands objective: enuresis is a common pediatric problem. psychosocial factors (psf) influence the results of enuresis treatment in children. aim: to determine the short and long term effects of psf on enuresis treatment in a general pediatric population. methods: we reviewed the data of our enuresis patients treated from - . relevant contributing psf were categorized. initial follow-up was at months after training. a written questionnaire was sent years after training. treatment success was defined as > % improvement in dry nights. results: pts were included. in pts ( . %) contributing psf were recognised. categorized problems: family related n= ( %), behavioural problems n= ( %), motivation/support n= ( . %), learning disabilities n= ( . %). overall success rate was . % at months and . % at yrs (overall resp quest . %, psf . %, psf %, > psf %). success rate in the psf group was . % ( psf . %, > psf . %) at months and . % ( psf %, > psf %) at yrs. statistics: success rate in the group with psf is significantly lower as compared to no psf at months (p< . (chi-square), or . , % ci . - . ) and at yrs (p= . (chi-square), or . , % ci . - . ) success rate at months is significantly lower in pts with > psf, compared with psf. (p= . (chi square), or . , % ci . - . ) . no significance could be demonstrated at yrs (p= . , chi-square) but this may be due to the variety in response rates. t. papalia, r. greco, r. bonofiglio hospital annunziata, nephrology, cosenza, italy actually a new litholitic therapy includes the phytotherapy agents as phyllantus niruri (pn), a plant used for years in brazil to treat urinary stones. in this work we estimate the effect of pn intake (uristone gr/die) in children ( m/ f, ± years old) with urolithiasis. the pn has been administered for short term (from to months) in children wih caox urinary stones and for months in with struvite stones. besides all children treated with dietary intervention: high fluid intake, sodium restriction, normal calcium intake and a diet low in animal protein. urinary and plasma analysis, body weight, map, ph, creatinine clearance, urinary excretion of mg and citrate were determined at baseline, month and at the end of the study. the patients were studied by renal ultrasonography at baseline, , , months. nobody of them had been undergone extracorporal shock wave lithotripsy. there were no differences in the mean values of urinary and plasma parameters before and after pn intake, except for a significant reduction in the mean urinary calcium in hypercalciuric pts ( ± , vs , ± mg/kg/die). in this follow-up n° patients showed a faster stone clearance after a regular intake of pn and the others showed a smaller stone diameter. previous reports showed pn has a potent inhibitory effect on caox crystal adhesion and/or endocytosis by renal tubular cells and inhibitory effect on crystal growth, which might be related to the higher incorporation of gags into the calculi. our results suggest pn appears to represent a nontoxic and a low cost alternative for the prevention and treatment of stone disease, especially in the children. further studies are necessary to validate these preliminary findings. d. weitzel, c. schäfer, k. hohenfellner, u. pfeffer, m. neukirch german clinic for diagnostic, pediatrics, wiesbaden, germany objective: does sonographic quantification of the renal parenchyma allow estimation of isotopic renal function? method: sonographic kidney images of patients (age to months; mean ) were measured retrospectively. in all images of both kidneys taken from dorsal the volume on the base of length, width and depth was calculated. the parenchymal area (pa) in the longitudinal and cross section was calculated by planimetry. the distribution of renal function via mag was compared with sonographic values as volume and pa of each kidney in relation to whole kidney volume and pa respectively. patients with reduced global kidney function and time space of more than months between isotopic study and sonography were excluded. results: interrater variability regarding planimetry of pa in longitudinal section (from dorsal taken images) was as good as measurement of kidney length (correlation coefficient (k)= , - , and , - , respectively). all sonographic parameters correlated significantly with the isotopic parameters of renal function. the latter correlated best with the pa in longitudinal section (from dorsal taken images) k , . the combination with planimetry in cross section did not improve correlation (k , ). difference of the proportional pa of the left kidneys (in correlation to whole kidney pa) in comparison to isotopic proportional renal function lead to mean difference of - , % with a standard deviation , %. if only kidneys with split function of - % the mean difference of proportional pa was - , % and the standard deviation , %. conclusion: the distribution of total pa of both kidneys correlates significantly with the distribution of renal function (left and right) in isotopic studies. if sonographic planimetry might change the indication for isotopic studies in respect of renal function needs to be proofed in prospective studies. background: childhood incontinence is a common important urologic problem. especially daytime incontinence is often neglected by the parents until it turns out to be a significant clinical problem. the aim of this study was to evaluate the clinical characteristics of the patients with incontinence that were followed in our nephrology clinic. study design: patients were followed between the dates of . . - . . and they were admitted solely due to incontinence or with concomitant urinary tract infections were enrolled. results: the study comprised patients ( m, f; mean age . ± . years). fourty-two patients had only nocturnal enuresis (ne) ( primary, secondary). twelve patients had daytime incontinence (di) ( primary, secondary) and had both ne and di ( primary, secondary and both primary ne and secondary di). all, except two (neurogenic bladder), had functional incontinence. twelve patients had additional fecal incontinence and had constipation. sixty-two percent of the patients had one or recurrent urinary tract infections (uti) in their past history, % had accompanying vesicoureteral reflux and % had urinary stones. ultrasound revealed unilateral or bilateral dilatation in % and other anomalies in % of the patients. nineteen patients had abnormal dimercaptosuccinic acid scintigraphy findings. timed voiding schedule and double voiding were recommended to all patients with daytime incontinence, % of the patients received anticholinergic treatment and % received antimicrobial prophylaxis. discussion: overall, approximately / of our patients had associated uti and / had abnormal dmsa findings. therefore every patient with uti should be questioned about urinary incontinence and be treated carefully if present. the aim of the study was to determine early parameters of ultrasound and dmsa scanning diagnostics of reflux nephropathy (rn) in children. we examined children with rn and vesicoureteric reflux (vur). all children were comparable on gender and age. all patients underwent color doppler ultrasound (cdus), x-ray and dmsa scan. they were divided into two groups: ) children with unilateral rn a according to classification of smellie j. et all, (n= ) ; ) children with vur without renal damage (n= ). we established that data of cdus (diastolic velocities (vd) , ± , mm/sec, systolic velocities (vs) , ± , mm/sec, resistive indices (ri) , ± , , pulsatility indices (pi) , ± , ), dmsa scanning (time of the maximal accumulation , ± , sec, maximal activity , ± , sob/sec, mean velocities of accumulation , ± , mm/sec, the contribution to the common accumulation , ± , %) are characteristic for patients with rn a. data of cdus (vd , ± , mm/sec, vs , ± , mm/sec, ri , ± , , pi , ± , ), dmsa scanning (time of the maximal accumulation , ± , sec, maximal activity , ± , sob/sec, mean velocities of accumulation , ± , mm/sec, the contribution to the common accumulation , ± , %) are characteristic for patients with vur without renal scars. the ranges of cdus and dmsa scanning were significantly different between children from comparing groups (p< , ). our result suggest that data of cdus (vd, vs, ri, pi), dmsa scanning (time of the maximal accumulation, maximal activity, mean velocities of accumulation, the contribution to the common accumulation) can be used to early diagnostics of scarring in children with vur. the purpose of this study was to determine normal reference values for urinary uric acid/creatinine ratios in healthy turkish children. in this study, random urine specimens from children ( boys, girls) aged month to years were analyzed for uric acid and creatinine, and urinary uric acid/creatinine ratios were determined from each sample. uric acid/creatinine ratios were the highest in children aged - months and showed a significant decrease with age (p< . ). uric acid/creatinine ratios were not significantly different between the sexes except - years. girls between - years had higher urinary uric acid/creatinine ratios when compared with boys (p< . ). there was no correlation between urinary uric acid/creatinine ratios and protein intake. our results show that urinary uric acid/creatinine ratio changes with age. when assessing the urinary uric acid/creatinine ratio, a child's age should be considered. we provided normal reference values of urinary uric acid/creatinine ratio for using in our region. the aim of the study was to investigate microbiological marker of activity of uti. e. coli and s. aureus p were isolated from urine of children with uti. the children were divided into groups: . with pyelonephritis in the acute period (n= ); . with pyelonephritis in the period of remission (n= ); . with cystitis in the acute period (n= ); . with cystitis in the period of remission (n= ) healthy children consists the group of control. definition of bactericidal activity of urine (bau) was carried out by our original method. the essence of the method consisted in measuring of the optical density (od) of the bacteria after their contact with urine (experience) and isotonic solution of nacl (control) after minutes of endurance in meat peptone mediums with c during - hours. bau was calculated under the formula: bau (%)=(odc-ode)/odc* %, (odc -control group, ode -experience group). we established that the level of bau did not correlate with urine ph (r= , ), osmolality (r= , ), lysozymuria (r= , ), lysinuria (r=- , ). we established that the low level of bau was marked in children of control group ( - %). the patients in active period of uti had high level of bau (> %). the parameters of bau didn't depend from the level of uti (pyelonephritis or cystitis). the level of bau reduced in the period of remission of uti. we established that the level of bau correlated with bacteriuria (r= , ), leucocyturia (r= , ). the level of bau didn't depend from the degree of urine dissemination (r=- , ). so, the level of bau is correlated with laboratory parameters of uti and can be used as new additional microbiological marker of diagnostics of activity of uti. the evolution of the alport syndrome in brazilian children vesicoureteric reflux (vur) is common in children with urinary tract infections (uti). if vur coexisting with uti there is a high risk of progression to end-stage renal disease (esrd). the correct diagnosis is important. we observed children ( girls and boys) aged mo to yrs at the time they have been diagnosed as having vur. the follow-up period was mo up to yrs after the diagnosis. all children with vur grade have been operated. after antireflux operation incidence of uti dramatically decreased even this cannot prevent progressive kidney damage in some patients. children with less severe vur have been put on prophylaxis. controlled mcu was performed usually after year later. if vur disappeared medication have been stopped. vur grade - had a tendency of resolution under conservative treatment in . % of the patients. in children associated urinary tract malformations were found: duplicated system, dysplastic kidney, kidney agenesia, dystopic kidney, urethral stenosis and bladder outlet obstruction. in patients nonfunctioning kidney have been found. dysfunctional voiding was common finding. blood pressure and physical development have been controlled. kidney size, function and scar formation have been followed by dmsa scan. we observed kidney growth at mos intervals. during the follow-up period infants have had reversible renal insufficiency. one patient with bilateral vur grade went into renal failure at the age of yrs. conclusions: vur is still one of the most common leading causes to esrd in childhood. even the existing controversy concerning treatment modalities it is obvious that low grade vur does not need operative treatment. it is indicated in high grade vur to prevent repeated and severe uti but it cannot preserve progression of the disease because of high incidence of coexisting kidney dysplasia. results: from forty children with nephrolitiasis, ( %) were boys and ( %) were girls. the mean age was . ± . months. the youngest age was months old. the most common clinical presentation was abdominal discomfort ( %), followed by uti ( %), microscopic hematuria ( . %), macroscopic hematuria ( %), spontaneous urinary calculi ( %), flank pain ( %). nine of children were presenting with chronic renal failure (crf). statistical analysis showed that age had correlation with the present of crf in children with nephrolitiasis (p= . ). the clinical presentations of nephrolitiasis were varied. abdominal discomfort and uti were the major signs and symptoms. there was correlation that age may influence the present of crf in children with nephrolitiasis. objective: renal involvement is one of the most frequent and serious manifestations of sle. we analyzed the treatment and renal outcome of patients with lupus nephritis. methods: seventy-seven identified patients were retrospectively analyzed from jan. to dec. . the outcome was divided as complete remission ( -hour proteinuria < . g, plasma creatinine level normal and sledai < ), partial remission (abnormal renal damage index improved > %, -hour proteinuria > . g, sledai < ) and no response, respectively. results: fifty-four patients were biopsy proven ln ( %). fifty-seven patients followed up more than month. all the eleven patients with class i or ii achieved remission, using prednisolone together with either hcq, or tripterygium or mmf or cyclophophamide (ctx). in forty-three patients with class iii or iv or v, they were given prednisolone together with mmf or ctx. we found that remission was in cases, part remission cases and no response in cases. associations between methylenetetrahydrafolate reductase (mthfr) c t polymorphisms and several vascular diseases have been reported. this is a clinical study designed to investigate the possible effects of (mthfr) c t polymorphisms on the developement of henoch-schönlein purpura (hsp), renal involvement, and clinical course. fourty-one patients with hsp ( m/ f) mean age ( , ± , years) were included in the study. eighteen of the patients had renal involvement. the control group consisted of healthy children. blood samples were obtained for mthfr c t transition, homocysteine, folic acid and vitamine b in the patients and controls. the genotype frequencies (cc/ct/tt) of mthfr in the hsp group were , / , / , and , / , / , in the control group, respectively (ns). the genotype frequencies (cc/ct/tt) were , / , / , in the patients without renal involvement and , / , / , in those with renal involvement, respectively (ns). homocysteine levels were , ± , in the hsp patients and , ± , μmol/l in controls (ns). vitamine b levels were , ± , pg/ml in the hsp patients and , ± , pg/ml in the control group (ns). folic acid levels were , ± , in the hsp and , ± , ng/ml in the control group (p< , ). no significant relationship was present with the mthfr genotype and plasma homocysteine, folic acid and vitamine b levels. no association with mthfr gene polymorphism and homocysteine plasma levels could be detected in patients with hsp and hsp nephritis. although mthfr gene polymorphisms have been found to be associated with several vascular diseases, the results of this study indicate that other mechanisms should be operative in the developement of hsp and hsp nephritis. we report the symptoms, signs and laboratory values at onset and during month-follow-up of hsp in a prospective study of children ( girls, boys) with mean age of . years ( . - . y). the first sign of hsp was purpura in ( %), oedema or other joint symptoms in ( %), abdominal pain in ( %) and melena in ( %) patients. petechiae appeared on the average days after the first symptoms ( - d) if purpura was not the first sign (n= ). % of the cases were diagnosed between september and march. the mean delay from the first symptoms to the diagnosis was days ( - d our results based on an unselected and prospective patient material demonstrate that renal symptoms in hsp children develop early, are common and should be followed up at least months. the kidney is a metabolically active organ, so any alteration in kidney function might affect nutrient utilization. objective: analyze the nitrogen balance (nb) as a marker for adequate food consumption in children with chronic renal insufficiency (cri). material and methods: patients ( boys, girls) diagnosed and managed in the nephrology and nutrition departments. they were placed in two groups depending on age: group a: patients aged ± . years, follow-up ± . years, glomerular filtration rate (gfr) estimated by cr-edta: ± ml/min/ . m ; group b: patients aged . ± years, follow-up . ± . years, gfr estimated by cr-edta: ± ml/min/ . m results: group a had a worse weight and height evolution: weight: - . ± . sd in group a vs . ± sd in group b; height - . ± . sd vs - . ± . sd (respectively). group a showed a significant increase in tnf blood levels (p< . ) that was inversely related with weight and height. bn was significantly greater in group a ( . ± . gr/day) than in group b (- . ± gr/day) (p< . ) and this was related with higher calorie (p< . ) and protein (p< . ) intakes. there was no difference in alimentary nutritional breakdown. nb improved significantly over the follow-up (p< . ). there was no relation between nb and gfr. there was a significant increase in triglyceride levels and significantly lower blood urea levels in group a (p< . ). we conclude that nitrogen balance depends on protein and calorie consumption and is independent of the severity of renal affectation. we present a case of a months old boy, who was delivered to our intensive care unit because of high fever, acute renal failure and dilatation of the urinary tract. his hemoculture and urinary culture were positive for e. coli and a severe urosepsis was diagnosed. his urethral catheterization was unsuccessful, so a suprapubic puncture was performed to relieve the urinary system and provide sufficient urinary flow. after the urinary sepsis was cured with adequate board spectrum antibiotics, a voiding cystourethrography (vcug) was performed to reveal the suspected anatomical abnormality, vesicoureteral reflux (vur) respectively. meanwhile a continuously growing nodular tumor of the penis was observed. the vcug showed the signs of urethral stenosis, but posterior urethral valve and vur was excluded. the doppler ultrasound found a solid vascularised tumor, x . cm in its diameter. during the surgical operation the tumor couldn't been totally removed, as it was infiltrating the surrounding tissues and the urethra. the histopathological examination of the biopsy specimen confirmed a juvenile xanthogranuloma (jxg). this is an uncommon, benign, non-langerhans cell histiocytosis, primarily seen in infancy as a solitary cutaneous lesion, predominantly in males. systemic form of the disease is rarely seen. usually it resolves spontaneously without any further treatment, but the differentiation from a malignant neoplasm is essential. according to the authors' search, this is the nd reported case in the literature and the first pediatric report of the jxg of the penis. urine examination using x-ray diffractometry background and goal: x-ray powder diffraction analysis is widely used in chemistry and pharmacology and for other industrial purposes. in medical science it is used for analyzing kidney stones and investigating retained crystals in tissue sections. in the department of mineralogy and petrology we investigated urine samples, at first diagnostically to detect urinary amino acids, glucose and compounds and, secondly, to detect calcium oxalate hydrate, which can be employed for early detection of renal tubular injury when no significant differences in renal function values exist. materials and methods: after sedimentation and dehydration, authors investigated more than urine samples of children using x-ray diffractometry. results: of them were glucosuric due to diabetes mellitus; in these cases glucose could be detected in each of their urine samples. in cases different amino acids due to aminoacidopathy were detected. the urine samples of children -kidney stone problems in history -were examined, in one case struvit, in the other cases ca oxalate crystals were identified. also, samples of children were examined, hours after at least hours long anesthesia, ca oxalate hydrate appeared in their urine referring to renal tubular injury due to inhalational anesthetic agents. in cases urine samples of children treated in the intensive care unit were analyzed, in % ca oxalate crystals could be detected. in cases healthy children's urine were investigated, as control ones. conclusion: x-ray diffractometry, as a highly sensitive method can be used efficiently in clinical measurements. further investigations are needed in order to determine its place in clinical trials. authors emphasize the importance of collaboration of different sciences, as well. drug intake in the background of sudden death? microalbuminuria was significantly more in patients more than years of age as compared to younger patients on bivariate analysis (p= . ). on logistic regression analysis, though microalbuminuria was more in patients more than years of age, it was not statistically significant. the association between microalbuminuria and urinary specific gravity levels of < . was statistically significant (p= . ), similar results were seen on logistic regression analysis. there was no correlation between microalbuminuria and hospitalizations, crises, previous blood transfusions, hemoglobin electrophoresis and serum creatinine levels. conclusion: identification of risk factors for microalbuminuria may allow earlier intervention to prevent renal complications in patients with ssd. in developing countries at primary health care level urinary specific gravity should be done routinely in patients with ssd to identify cases at risk of microalbuminuria. m. bak, e. serdaroglu, y. bicilioglu aim: the aim of the present randomized-controlled study was to compare desmopressin (dp), alarm and combined treatments in nocturnal enuresis. the study included children ( boys and girls) with nocturnal enuresis. the mean age was . ± . years (ranged - years) and the mean wet-nights was . ± . day per month before treatment. the patients were followed for one month before treatment and randomized to dp ( patients), alarm ( patients) and combined ( patients) treatment groups. the dp group was received μg orally one-hour before sleep and alarm group was used wet-stop bedwetting alarm device after education of parents. the patients were followed months in treatment period and months after discontinuation of treatments. results: wet-nights per months was significantly reduced between before treatment and last month of treatment in dp ( . ± . to . ± . , p< . ), alarm ( . ± . to . ± . , p< . ) and combined treatment ( . ± . to . ± . , p< . ) groups. treatment success (> % decreasing in wet-nights) and complete response ( % dry) rates was %, %, % and %, %, % in dp, alarm and combined treatment groups respectively. the more rapidly decreasing in wetnights was observed between dp used and only alarm treatment group but this effect disappeared after months. relapse rates was %, % and % in dp, alarm and combined treatment groups respectively between successfully treated patients (p= . ). conclusion: alarm treatment is the best intervention with low relapse rates and no potential adverse effect in nocturnal enuresis. dp group has higher relpse rate but adding to dp may achieve more rapid decreasing in wet nights especially in patients and parents expecting rapid result. aim: it is often difficult to collect urine from infants. use of specifically designed urine collection pads gives reliable results for routine biochemistry tests in adult urine. their use for routine and metabolic tests in paediatric urine has not been investigated. the aim of this study was to evaluate whether the pads give reliable results for routine and metabolic biochemistry tests in paediatric urine. methods: urine collected by bag or clean-catch from infants < y without metabolic disorders was divided into two aliquots, one of which was added to a collection pad, incubated for min at °c, then recovered by aspiration. routine and metabolic analyses were performed on pad/non-pad aliquots. additionally, selected metabolic analyses were performed on pad/non-pad urine from patients with diagnosed inborn errors and urine spiked to simulate metabolic disorders. for quantitative analyses, pad/non-pad results were compared using bland-altman bias plots, passing and bablok regression and paired t-tests. results: routine tests (urea, electrolytes, creatinine, osmolality, calcium: creatinine, phosphate: creatinine, magnesium: creatinine, urate: creatinine, n= ) showed close concordance with no clinically significant pad/non-pad differences. in infants without metabolic disorders, aminoacids (n= ), organic acids (n= ) and mucopolysaccharides (n= ); and in patients with metabolic disorders -phenylketonuria (n= ), mucopolysaccharidoses ii (n= ) and iii (n= ), inborn errors of organic acid metabolism (n= ) and cystinuria (n= ), all showed excellent pad/non-pad concordance. sugar chromatography in urine spiked with glucose/galactose/fructose showed identical staining intensity in pad/non-pad samples. conclusion: urine collection pads give reliable results for a wide range of routine and metabolic tests in paediatric urine. a post-translational modification of arginine residues in proteins and subsequent proteolysis result in release of symmetric dimethylarginine (sdma). sdma is considered an end product of metabolism, excreted primarily by the kidney. several previous studies have reported a significant relationship between glomerular filtration rate (gfr) and plasma sdma. to determine the potential value of sdma in the assessment of gfr in children we have measured sdma in samples taken during routine measurement of glomerular filtration rate (gfr) using plasma clearance of inutest. patients ( male) requiring routine gfr measurement were studied. median (range) age . y ( . - . ) , height (ht) cm ( - ), and surface area . m ( . - . ). gfr was measured using the plasma clearance of inutest, and plasma sdma and creatinine (pcr) by liquid chromatography stable isotope dilution electrospray mass spectrometry-mass spectrometry method. estimated gfr (egfr) was calculated from the formula x ht (cm)/pcr (μmol/l). median gfr was ml/min/ . m ( - ), plasma sdma . μmol/l ( . - . ), pcr . μmol/l ( . - ), and egfr ml/min/ . m ( - ). as expected both plasma sdma and pcr increased with a decline in gfr. compared to gfr the correlation with /sdma, r= . (p< . ) was better than for /creatinine, r= . and similar to that for egfr, r= . . comparing sdma with inutest gfr for detection of gfr < ml/min/ . m the area under the roc curve was . (p< . ). the equivalent areas for pcr and egfr were . and . , respectively. in conclusion plasma sdma is an endogenous marker of gfr in children and is superior to pcr because it appears to be independent of body size. since the calculation of egfr requires accurate measurement of height, plasma sdma may provide a practical alternative for assessment of gfr in children. thrombotic microangiopathy (tma) consists of thrombocytopenia, microangiopathic hemolysis, and thrombi in the microvasculature of vital organs. broad categories of causes of tma include infectious (verotoxin-induced hus), hematologic (ttp), complement based (atypical hus), immune-mediated (sle, anti-phospholipid antibody syndrome), and drug-induced (cyclosporine). thorough investigation is required to detremine the underlying etiology in order to provide specific therapy and information about prognosis. a year girl presented with short stature and was found to have hypertension, proteinuria, renal failure (creatinine umol/l), and anemia (hgb g/l). platelets were normal. she also had spondylometaphyseal dysplasia, scoliosis, lymphopenia, mild pulmonary hypertension and aortic stenosis. on pulmonary function testing, her dlco was decreased. chest ct demonstrated small micronodules. a ventilation-perfusion scan was normal. renal biopsy showed features of tma. she was treated with dialysis and underwent renal transplantation one year later. there has been no disease recurrence months post-transplant. genetic and immunologic workups were negative, including anti-cardiolipin antibodies. a thrombophilia workup was negative apart from a heterozygous mutation in mthfr. c levels were mildly reduced. anti-neutrophil antibodies were negative. complement system studies, including factor h, and smarcal analysis for schimke immuno-osseous dysplasia are underway. although the descriptive diagnosis of tma can be applied here, the underlying pathophysiologic diagnosis has still to be defined. it is of particular importance that further efforts be made to identify the etiology given the potential risk of disease recurrence in the renal graft. background: long term outcome of renal functions after liver transplantation (lt) in wd is not studied yet. aim: the aim of this study was to determine the long term outcome of renal functions in children receiving lt for wd. patients and methods: renal functions were examined in (f/m: / ) liver transplanted patients for wd before and long after lt and compared with renal functions of patients (f/m: / ) with lt for a hepatic disease other than wd. the mean age of subjects was . ± . years in the patients group and . ± . years in the controls. the mean duration of follow-up was at least years. glomerular and tubular functions were assessed using the conventional equations for measured creatinine clearance (gfr), tubular phosphate reabsorption (tpr), daily protein and calcium excretion in both groups. results: mean gfr before lt was . ± ml/min/ . m in the study group and . ± . ml/min/ . m in the controls (p= . ). the mean tpr before lt was found to be . %± . % in the study group and %± . % in the controls (p= . ). daily protein excretion rate before lt was found to be high in both groups, as well as urinary calcium excretion. an increase in gfr was observed in the study group after lt (p> . ), while it was slightly decreased in the controls (p> . ). tpr increased significantly in the study group after lt ( . %± . %) (p= . ) and although it was found to be significantly lower in the study group than the controls before lt, in the long term follow-up the difference between the groups was disappeared (p= . ). conclusion: tubular dysfunction is frequent in patients with wd. liver transplantation for hepatic failure secondary to wd is a lifesaving procedure. it corrects the underlying hepatic defect as well as renal defects and leads to long-term survival. rather conflicting results are available regarding the neurocognitive development of children with ckd, due to small sample sizes, cross-sectional study designs, differing methodological approaches and historical trends in patient selection for renal replacement therapy. we prospectively examined in a standardized, multi-center effort children with ckd aged . - years. children were treated either conservatively (n= , gfr < ml/min/ . m ) or by dialysis (hd: n= , pd: n= ). a sub-sample of children underwent repeated testing after - months. bayley and snijders-oomen developmental tests were performed and the measured values normalized to standard deviation scores (sds). general cognitive development averaged at - . (± . ) sds. % of the patients scored <- . sds, i.e. below the th percentile of the normal population. no significant differences were observed between pre-dialysis (- . + . ) and dialyzed patients (- . + . ). impaired neurocognitive function was marked in infants (- . + . sds), whereas school children showed a distribution similar to healthy children ( . + . sds, p< . ). the global neurocognitive sds remained unchanged in the longitudinal sample (t =- . ± . ; t =- . ± . ). in summary, our preliminary results demonstrate a high prevalence of neurocognitive impairment in infants with ckd. we assume that this finding reflects the improved survival of children with complex disorders affecting not only the kidney but also brain development. the poor performance of this age group highlights the importance of close neurocognitive follow-up and early developmental interventions. objectives of study: to make a diagnosis of a girl with kidney subcapsular hydrops, abnormal urinanalysis and hypertension. methods: physical examination and laboratory investigations were analyzed. results: a years old girl was admitted because of kidney subcapsular hydrops, proteinuria without edema, and hypertension ( / mmhg) for days. no trauma or familial hypertension history were provided. no hydrops was found before the age of year. urinary rbcs were - /hp and protein was mg/kg/ hr. the serum albumin was normal. ultrasound examination revealed normal sized kidneys, increased echogenicity in both kidneys, and subcapsular hydrops on the upper pole of the right kidney connected with an old renal fissure. ucg and fundus examinations were normal. gfr of the right kidney was slightly decreased as compared to the left ( ml/min vs. ml/min, by dtpa scan). by puncture of hydrops, yellow clear fluid was drained, the analysis showed similar composition to that of original urine, so subcapsular urinoma was diagnosed. urine collection from two kidneys separately was performed by cystoscopy; nonselective proteinuria of + was found in urine from the right and + from the left kidney. analysis revealed urea . mmol/l, potassium . mmol/l, creatinine . mmol/l in the right kidney urine compared to urea . mmol/l, potassium . mmol/l, and creatinine . mmol/l in the left, which suggested that the right kidney function was compromised. according to proteinuria from both kidneys with microscopic hematuria, without edema and hypoalbuminemia, glomerulonephritis was diagnosed. the girl was diagnosed with glomerulonephritis and subcapsular urinoma. it was a rare case because of their co-incidence. reasons for the hypertension, if caused by the glomerulonephritis or the pressure by subcapsular urinoma, as well as reasons for subcapsular urinoma need to be clarified during the follow-up. the aim of this study was to detect factors that could interfere with the results of des treatment. methods: fifty-six patients . to . years old with des without improvement by previous therapies were randomly distributed into two voiding training programs: group (g ): patients submitted to kegel exercises training sessions for three months; group (g ): patients submitted to biofeedback sessions over a two month period. both groups adhered to a voiding and drinking schedule, received adequate toilet posture instructions and were reinforced through the maintenance of voiding diaries. clinical evaluation was carried out before each programs initiation and , , and months after end of the program. all patients were submitted to renal and dynamic ultrasound before and months after each program's conclusion. the following variables were analyzed: gender, age at diagnosis, treatment group type, vesico-ureteric reflux, constipation, urinary tract infection, asymptomatic bacteriuria, bladder wall thickening and post void residual (pvr) urine. the logistic regression model was applied to identify independent variables associated with response to treatment. results: urinary continence was improved after completion of either training program. success in diurnal urinary incontinence varied from . to % in g and from . to . % in g . success in nocturnal urinary incontinence varied from . to . % in g and from . to . % in g . in multivariate analysis three variables remained independently associated with bad response to treatment: constipation with soiling, bladder wall thickening and pvr urine (p< . ). conclusion: studies using multivariate regression analysis to identify predictors of response to behavioral therapy are important for the development of selection criteria for prescribing these therapies to children. we report the case of a four-year-old child born to consanguineous parents, who presented first at two months of age with respiratory failure. during the admission he developed panyctopenia, hypertension and nephrotic range proteinuria. the metabolic workup revealed methylmalonic academia and aciduria along with homosystinuria; highly suggestive of cobalamin deficiency. the renal biopsy showed chronic thrombotic microangiopathy (tma). the muscle biopsy showed the presence of nemaline rods on electron microscopy. cobalamin c deficiency was confirmed by genetic analysis as the patient was homozygous for the mutation c / . at the age of one, he was noted to be visually inattentive and developmentally delayed. on ophthalmology examination there was evidence of bilateral maculopathy and dysfunction of rods and cons on electroretinogram. he subsequently went on to develop bilateral bovine maculopathy. since his initial presentation he has been maintained on hydroxycobalamin, betaine and folate; with no further relapse of proteinuria or panyctopenia. however, despite adequate doses of hydroxycobalamin, the maculopathy progressed. to our knowledge, this is the first report of a child with both tma and bovine maculopathy. the aim of the study was to assess the rate of vesicoureteral reflux (vur) in patients with lower urinary tract dysfunction (lutd) of nonneurogenic origin. dysfunctional voiding may result in lower urinary tract symptoms in children and is commonly associated with urinary tract infections and vur. we investigated patients with voiding dysfunction during last three years: boys and girls, a mean age of . years, with a mean follow-up of months, all with normal renal function. mean pre and post treatment symptom scores were . and . respectively. vur was detected in % of the children with unstable bladders and . % of the children with stable bladders as detected by video urodynamic investigation, % of the children with urinary tract infection (uti) on admission, and % of the children with no history of uti on admission. the co-existence of vur in our group with voiding dysfunction was . % ( patients). all patients with vur had low grade reflux (grades i-iii) and of them bilateral, the remaining unilateral. renal us was performed in patients and revealed hydronephrosis in patients, while the remainder showed no abnormalities. vur was found to be present in % of the children with abnormal us findings, while only % of the children with normal us findings were affected. furthermore, the patients that had spontaneous resolution of reflux showed a markedly greater improvement in symptom scores. a significant portion of patients with lutd ( . %) have low grade vur. in detection of vur in patients with lutd, hydronephrosis is a good indicator of the presence of reflux, while utis and urodynamic findings were not found to be significant indicators. the overall spontaneous resolution rates of vur in patients with lutd and stable bladder following treatment was found to be . % and . %, respectively. - g) were grouped: group (n: ) was the sham group. group , and (n: for each) received mg/kg twice daily ptx intraperitoneally (i.p.), mg/kg/day gen i.p. and both ptx and gen at the same dosages for consecutive days, respectively. the rats were weighed at the beginning and than weekly during the study. after the last dose -hour urines were collected. then, rats were sacrificed and blood samples were obtained from the abdominal aorta. bun, serum creatinine (scr), creatinine clearance (ccr), renal superoxide dysmutase (sod), catalase (cat) and thiobarbituric acid reactive substances (tbars) levels were determined. all the parameters were compared between the groups. results: body weights were not different between the groups either at the beginning or during the study. bun levels were significantly higher in group than the other groups (p< . ). scr and ccr levels were similar between the groups and , but the levels were higher than those of groups and (p< . ). sod and tbars levels were similar between all groups. the levels of tubular cell apoptosis and caspase- expression were significantly higher in group than the other groups (p< . ). conclusion: we may conclude that ptx administration significantly reduced the apoptosis in gentoxicity, but we could not demonstrate any evidence of ptx-related reduced oxidative stress. the lack of evidence for the widespread use of antimuscarinics and holding exercises in mne prompted us to design a randomized controlled trial comparing interventions in four groups of children with mne: placebo (a) or oxybutynin chloride (b) in combination with a daily regimen of standardized fluid intake and holding exercises or as monotherapy (c) and (d). a fifth group, to be treated with alarm only, was planned as control. randomization was stratified for participating hospital, sex, age, tanner stage, family history of mne, previous treatment, and bladder capacity class, being the largest from either the maximum voided volume (mvv) from a h frequency volume chart or the volume after baseline holding exercises (hev). after weeks intervention with holding exercise (a and b) , hev had increased, both with oxybutynin ( ± (sd) ml to ± (sd) ml, p< . ) and placebo ( ± (sd) ml to ± (sd) ml, p< . ). without holding exercises, only oxybutynin (d) increased hev ( ± (sd) ml to ± (sd) ml (p< . ). mvv increased also in groups a and b (holding exercises), not c and d. cure rate (less than wet night in the last for weeks) was low: a / , b / , c / and d / . control group with alarm had / cure. cure was not related to hev, mvv or delta hev and mvv. this questions the relevance of increasing bladder capacity in mne. background: sickle cell disease (scd) is an inherited disorder of beta-globulin synthesis of haemoglobin, resulting in a tendency for haemoglobin polymerisation and consequent vasoocclusion, tissue hypoxia, and ensuing organ damage. the kidney is a particularly sensitive to hypoxia and renal failure is a major cause of morbidity and mortality in scd. children with scd commonly hyperfiltrate, the glomerular filtration rate (gfr) then typically falls back towards normal in adulthood. routine estimation of gfr in children is primarily derived from the height and plasma creatinine (pcr) measurements using k a constant dependent on the creatinine analytical method. this formula has reduced accuracy in children with a gfr > ml/min/ . m . it has never been validated in hyperfiltration or children with scd. recently, new gfr markers have been proposed including symmetrical dimethylarginine (sdma) that may be independent of body size. in this pilot study we tested the hypothesis that estimated gfr and/or sdma allow a reliable estimation of gfr in scd. methods: hbss patients, age range - yrs (mean age yrs) attending the evelina children's hospital were studied. the patients were on regular blood transfusions for stroke management and undertook a formal gfr measurement using plasma clearance of inutest. the plasma samples were also used for the measurement of pcr and sdma by stable isotope dilution mass spectrometry. egfr was calculated using k= . results: inutest gfr ranged from - ml/min/ . m . there was significant inverse correlation between sdma and inutest gfr (p< . )). there was no significant correlation between either pcr or egfr and inutest gfr. conclusions: this early data suggests that sdma might prove valuable in monitoring gfr in children with scd. introduction: the aim of this study was to identify the risk factors for renal scarring in children with lower urinary tract dysfunction (lutd) by using data available at the time of patient admission to the interdisciplinary management program of lutd at hospital das clínicas. material and methods: medical records of patients were assessed retrospectively concerning gender, presence of vesicoureteric reflux (vur), bladder capacity, detrusor overactivity, residual urine, urinary tract infection (uti), asymptomatic bacteriuria, constipation, detrusor-sphincteruncodination (dsu), high detrusor pressure at maximal cystometric capacity, low compliance, thickness and trabeculation of the bladder wall. renal scarring was diagnosed by dmsa scan. statistical analysis was performed by univariate and multivariate analysis. a p value < . , % confidence interval was considered significant. results: renal scarring was detected in patients ( %). abnormal bladder capacity, detrusor overactivity, residual urine, asymptomatic bacteriuria, constipation, dsu, high detrusor pressure and low compliance were not associated with renal sccaring. vur, uti, decreased bladder capacity, urinary residue, trabeculated and thick bladder wall were associated with scarring at univariate analysis. multivariate analysis showed vur (p< . ) and female gender (p= . ) as independent risk factors for renal scarring. thickness of the bladder wall was a marginal risk factor (p= . ). conclusion: urodynamic parameters didn´t predict renal damage in this study. uti was not a risk factor for renal scarring; however, it was associated with vur (p= . ). although vur was the main risk factor in our analysis, renal scarring was probably due to multifatorial causes as vur was associated with itu. results: comparison of test a and b demonstrates that a mild fluid load h before the administration of ddavp nasal spray ( puffs) results in major significant differences. ). maximal concentrating capacity (cc) is reached later than h after administration (p< . ). in / % cc at sleeping time is < % of max, thereby resulting in a persistent np in the first hour of the night. ) uosmol is significantly ( %) lower in the overnight collection (u ), correlating with a higher diuresis-rate ( %) ). the duration of the ddavp effect is shorter leading to an increase in diuresis-rate and to a decrease in the u osmolality in / children in the urine-collection between - h in the morning. this proves that in up to % of the patients the ddavp-effect does not cover the full night. conclusion: test b demonstrate sthat fluid intake prior to the ddavp-administration influences significantly the antidiuretic effect of ddavp (onset, maximum and duration). this might explain the partial response, suggestive for insufficient pd (and pk) effect of the spray. test a proves that fluid restriction h before ddavp administration, significantly reduces the nocturnal diuresisvolume. m. schmidts, c. schnakenburg, k. häffner, c. jacobi, k. schwab, m. pohl university hospital, center for pediatrics and adolescent medicine, freiburg, germany background: enteropathic hemolytic uremic syndrome (d+hus) is responsible for % of all hus cases. in addition to the nephrological and neurological complications, pancreatic damage resulting in diabetes mellitus is also possible and appears to be associated with more severe cases and elevated mortality. case report: a -year-old girl suffering from d+hus with severe colitis, acute renal failure, dyskinesia, dysarthria and agitation provoked by shiga-like toxin positive ehec infection in july, . the severe affection was characterized by partial thalamic infarction, prolonged leukocytosis (max. g/l) and the necessity of weeks of dialysis. days after the disease onset, hyperglycemia (max. mg/dl glucose) was noted. c-peptide was found to be low indicating reduced insulin secretion. months after hus the patient continues to be insulin dependent. clinically apparent exocrine pancreatic insufficiency has resolved spontaneously. gfr had recovered to ml/h/ , m , but then kidney function deteriorated and dialysis had to be resumed after months. kidney histology at this time showed severe nephron loss compatible with chronic changes after hus and ruled out other unrelated kidney disease. conclusion: in addition to the kidney damage, chronic pancreatic damage can occur in hus. therefore blood glucose levels should be monitored in all hus patients. it is tempting to speculate that patients after childhood hus might be at risk for diabetes mellitus later in life. objective: childhood nephrotic syndrome (ns) is characterised by a relapsing course resulting in significant corticosteroid burden or prescription of cytotoxic immunosupressive therapy. this randomised controlled study was carried out over years at a single centre in sri lanka to compare the efficacy and safety in children with steroid dependant ns treated with intravenous cyclophosphamide or intravenous vincristine therapy. methods: thirty-nine sequential children with steroid dependant ns with evidence of steroid toxicity were randomly allocated to receive either intravenous cyclophosphamide ( mg/m monthly for months) or vincristine ( . mg/m weekly doses followed by doses monthly). both groups received an identical tapering regimen of oral prednisolone for months. all children were reviewed on monthly basis for one year focusing on recurrence of proteinuria and side effects of therapy. finding of +++ proteinuria for consecutive days was diagnostic of relapse. results: there were ( m: f) children in the cyclophosphamide group (mean age . years) and ( m: f) in the vincristine group (mean age . years). during one year of follow-up / ( %) in the cyclophosphamide group suffered a relapse while / ( %) suffered a relapse in the vincristine group. p= . (comparison of proportions using standard error. ci . to . ). no serious adverse effects were encountered in either group. conclusion: in steroid dependant ns, intravenous cyclophosphamide therapy is superior to intravenous vincristine therapy in maintaining sustained remission. we present the clinical and biochemical features of a patient with antenatal bartter syndrome who was found to have a novel romk mutation. the patient presented antenatally with severe polyhydramnios. polyuria, hyponatraemia and hyperkalaemia were evident soon after birth. she had marked hypercalciuria and developed medullary nephrocalcinosis in early infancy. failure to thrive was evident from months. hypokalaemia was a late feature, developing gradually from months. serum chloride levels were consistently - mmol/l whilst urinary chloride levels were consistently < mmol/l, only reaching higher levels after treatment was commenced. alkalosis was not present and the patient did demonstrate some response to furosemide implying some functional capability of na-k- cl. renin and aldosterone levels were persistently elevated. treatment with indomethacin, nacl and kcl produced a good clinical response. mutational analysis revealed compound heterozygous mutations in kcnj , the gene encoding romk. both mutations, m t and l r are in the terminus of the protein thought to have a role in channel gating. similarities and differences from the classically described presenting features of antenatal bartter syndrome highlight the clinical heterogeneity in this condition. this relates to the different identified kcnj mutations which are likely to affect romk function in different ways. the m t mutation has been described, but past electrophysiological studies in sf cells transfected with the m t mutant have not identified any differences in k + conductivity from wild type romk. given that the mutation appears to be clinically relevant in this case, further functional studies are indicated. l r is to our knowledge a novel mutation. expression of these mutations in oocytes is now planned to enable evaluation their effects on channel function and regulation. a -year-old boy was admitted because of nephrotic syndrome. renal biopsy, performed after weeks of prednisone ( mg/m od) + methylprednisolone pulses ( mg/kg each), showed focal segmental glomerulosclerosis. prednisone was tapered (to mg/m od) and enalapril was introduced, without any significant improvement. two weeks later, the patient had transient hypoperfusive acute renal failure which required acei discontinuation. due to the persistence of proteinuria, cyclosporine was started ( mg/kg/day). proteinuria gradually decreased and ceased within the subsequent two weeks. in the meantime the boy had started to complain of low-grade fever without other symptoms and with normal physical examination. laboratory tests only showed leucocytosis (wbc x /ml) and increased c-reactive protein ( mg/l). a chest x-ray revealed an upper mediastinal enlargement and a total body ct scan confirmed the presence of several enlarged mediastinal lymph nodes, whose biopsy led to the diagnosis of hodgkin disease (hd) nodular sclerosis subtype, cd +; stage was iia. cyclosporine and the residual steroid treatment were discontinued and the patient was given six cycles of abvd (doxorubicin, bleomycin, vinblastine, dacarbazine), followed by radiation therapy. presently, months after stopping chemotherapy, both hd and nephrotic syndrome are still in remission. once again, this case points out both that fsg can be secondary to a lymphoproliferative disease and that chemotherapy for hd might have been effective to keep fsgs in long-lasting remission. several treatment methods including increased fluid intake and dietary modification, medical therapies such as potassium citrate and use of extracorporeal shockwave lithotripsy (eswl) and finally surgery methods are used for treatment of urolithiasis. the aim of this study was to evaluate the etiological and clinical characteristics and level of response to medical therapy with polycitra in children with urolithiasis. one hundred thirty-four patients had urolithiasis of which cases followed thetreatment instructions and fulfilled the inclusion criteria for this study. struvite stone were excluded from the study. all other patients who had an initial ultrasonography showing stone inurinary tract were treated with polycitra-k (potassium citrate grams, citric acid . grams in liter of distilled water) irrespective of the cause of the stone. at the end, complete resolution or passage or a decrease in the size of stone in later sonography was defined as response to treatment. hypercalciuria and hyperuricosuria were found to be etiological factor in % and % of patients respectively. the stone analysis was found that % of them were ca-oxalate. stone disease was more common between the age of - years. the most common complaint was hematuria ( %). eswl was performed in % of patients who did not respond to polycitra and had surgically active stones. calcium-oxalate stones were the most frequent stone which responded to polycitra. the response rate in girls and boys was equal and in different age groups the response rate was almost equal. methods: mmcs were expanded in culture and immunocytochemistry was used to characterize the cells. after gentamicin-induced atn, fluorescently-labeled cells were transplanted and traced in kidney tissues by fluorescence microscopy. kidney pathology was studied by hematoxylin-eosin staining, apoptosis was examined by the tunel assay, and ki- and bcl- expression were examined by immunohistochemistry and reverse transcription-polymerase chain reaction, respectively. results: ( ) mmcs (rimm- cells) were successfully expanded in culture. the phenotype of the cultured cells were vimentin-positive and kreatin-negative by immunocytochemistry. ( ) in the mmcs-treated group: the mortality rate decreased; renal function clearly improved; damage to the cell-treated kidneys was reduced and histopathologic lesion scores were lower; proliferation of renal tubular epithelial cells was improved; the apoptosis of renal tubular epithelial cells was reeuced; and the expression of bc - mrna and protein was upregulated. the subcapsular transplantation of mmcs could ameliorate renal function and repair kidney injury. atn is the most common reason for arf, and there is still an absence of effective therapies. this study was done to observe the effect of mobilizing bone marrow cells with stem cell stimulating factor (scf) and gm-csf on recovery from gentamicin-induced acute tubular necrosis (atn) in rats. atn was included in male sprague-dawley rats with five daily high dose intraperitoneal injections of gentamicin. subcutaneous injections of scf and gm-csf were administered simultaneously and these cytokines was observed at day , , , , and . leukocyte numbers, percent venous blood cd + cells, mortality rate, and concentration of the urine proteins, urine nag, bun, scr, and ccr, histopathogic lesion scores were determined. twelve hours after bone marrow ablation (bma) by lethal x-ray radiation, gentamicin-induced spf atn rats were given five daily injections of scf and gm-csf. bun, scr, and histopathogic lesion scores were evaluated at day , and . the effects and mechanism of scf and gm-csf on atn was observed. the number of leukocytes and the cd + cell percentage increased significantly in atn rats between and days after scf and gm-csf injection. in addition, mortality rates dropped, the peak value of renal function increased, renal function were rapid ameliorated and histopathologic lesions were reduced. there was no significant effect on atn rats after bma. this study demonstrates that scf and gm-csf effectively mobilized bone marrow stem cells in atn rats. rapidly improving renal function and decreasing mortality rate. these results suggest that bone marrow stem cell mobilization may be an effective therapy for atn. key words: acute tubular necrosis, bone marrow stem cells, stem cell factor, granulocytemacrophage colony stimulating factor, irradiation. objective of the study: the response to recombinant human erythropoietin (rhuepo), unit/kg twice weekly was studied prospectively in children and adolescents with end stage renal failure who were either transfusion dependent or had hematocrits (hct) < %. methods: rhuepo was given to haemodialysis (hd) patients and patients on conservative treatment, with mean age ( . ± . ) years, males and females with mean hct ( . ± . ). blood pressure, haematocrit, iron-indices, serum potassium, calcium, phosphorus, alkaline phosphatase, urea nitrogen and intact parathyroid hormone (ipth) were monitored serially. results: serum aluminum was measured randomly in patients, results were normal ranging from - ug/l. when serum ferritin was < ng/ml during therapy, they received iron supplementation. according to the response, patients were divided into groups, the non-responders group with hct< , mean age ( . ± . ) years, males and females with mean ipth ( . ± . pg/ml) and group of responders with hct > with mean age ( . ± . years), males and females with mean ipth ( increase of fatty acids such as nonesterified fatty acid (nefa) and triglyceride (tg) with oxidative stress and production of cytokine/chemokine occured during cisplatin (cp) toxicity. statin ( hydroxy- -mthylglutaryl coenzyme a reductase inhibitors) have been postulated to have pleiotrophic effects. we examined whether statin, pravastatin, would ameliorate renal damage induced by cp. male wistar rats (weight - g) fed standard chow were divided into groups: control-rats received tap water alone for days; cp treatment-rats that received cp ( mg/kg, i.v.) on the th day of the study; cp+pravastatin treatment-rats that received pravastatin ( mg/kg/day) in their drinking water for days and cp injection as indicated in the preceeding group. blood and urine samples were collected and the kidney were removed days after cp treatment. urinary excretions of protein and -hydroxy-deoxyguanosine ( -ohdg), serum levels of creatinine and fatty acids were measured. histology was evaluated by light microscopy with immunohistochemistry for pentosidine, n-carboxymethyllysine (cml), and heme oxygenase (ho)- . expression of ho- mrna in the kidney was also measured. pravastatin decreased urinary excretions of protein and -ohdg and ameliorated renal function diminishing areas of tubular damage and positive staining of pentosidine and cml compared with those of cp treatment alone. however, positive staining area and mrna expression of ho- were not significantly changed by pravastatin treatment. although pravastatin did not influence serum levels of total and low-density lipoprotein cholesterol, serum tg level decreased and was equivalent to that of control group. these findings suggest that pravastatin treatment partially protects against cp-induced nephrotoxicity in rats, through its antioxidant as well as lipid-lowering effect. n. bresolin, v. fernandes, f. carvalho, j. goes, l. araujo, m. simon, g. gamborgi, m. zanin hospital infantil joana de gusmo, nephrology pediatric department, florianópolis, brazil objectives: the objective is a report case of acute renal failure (arf) in a child contact with lonomia obliqua caterpillar in southern brazil. the accidents with lonomia oblique has increased in south of brazil in recent years. this increase can be related with reduction of caterpillar natural predators and deflorestation. the venom of lonomia caterpillar provokes hemorrhagic syndrome resembling disseminated intravascular coagulation (dic) and hemolytic anemia. arf could be an important complication of hemoglobinuria that has been recently described in adults. methods: a case report. results: the present is a first case described of arf in a child after contact with lonomia obliqua caterpillar. conclusions: the arf can occur in any age, however, the contributing factor to the development of arf remains obscure. there are mechanisms pointed out: fibrin deposition in glomerular microcirculation, ischemia in hemorrhagc shock with hypotension and venom direct action. the present article related a case of lonomia obliqua accident in a child who revealed coagulation disorder, hemolytic anemia, arf and always, she was hemodynamic stable. the treatment included antilonom serum, urine alkalinization, hyperhydration and peritoneal dialysis for four days. she was treated and followed per year when she recovered her normal renal function. introduction: secondary hyperparathyroidism develops in chronic kidney disease as a consequence of impaired phosphate, calcium and vitamin d homeostasis. the treatment includes phosphate binders and vitamin d analogues, but sometimes ineffective. we report two cases of refractory secondary hyperparathyroidism treated successfully with cinacalcet. case : a -month-old boy with end stage renal disease (esrd) due to posterior urethral valve started on peritoneal dialysis at months of age. he developed secondary hyperparathyroidism with serum parathyroid hormone (pth) level reaching pg/ml. serum calcium had been in the range of . to . mg/dl and serum phosphorus in the range of . to . mg/dl. despite treatment with phosphate binders and vitamin d analogues, pth levels kept increasing to pg/ml. x-ray showed the cupping and fraying of the distal ends of radius and ulna. we started cinacalcet mg daily and increased the dosage up to mg daily. eight months later, pth level decreased to pg/ml and bone changes resolved. case : a -year-old boy with esrd due to primary hyperoxaluria started on peritoneal dialysis at years of age. he developed secondary hyperparathyroidism with serum pth level of pg/ml. serum calcium had been in the range of . to . mg/dl and serum phosphorus in the range of . to . mg/dl. despite treatment with phosphate binders and vitamin d analogues, pth level kept increasing to pg/ml. x-ray showed the distal radius and ulnar fracture of left arm and right femur fracture. we started cinacalcet mg daily. five months later, pth levels decreased to pg/ml. conclusion: cinacalcet is effective in the secondary hyperparathyroidism resistant to phosphate binders and vitamin d analogues in children with chronic renal failure. rota virus (r) is a common pathogen as the cause of gastroenteritis in childhood. we experienced some cases with r infection who had the renal failure induced by uroammoniac calculi as well as dehydration. we examined the clinical feature and laboratory findings of the cases with viral acute gastroenteritis in r and non-rota virus (nr) groups for - . with rapid diagnosis test, we checked the patients that needed the hospitarization medical treatment from newborn to five-years old. in the cases of r group and cases of nr group, we campared the clinical findings, blood chemistry test and urinalysis of r groups in acute and convalescent a tage with those of nr group. r group had significantly (p< . ) lower in ph (vein blood gas test) and higher in blood uric acid (bua) compared with those of nr group. these findings suggest that the elevation of bua and acidosis in r group may induce the formation of renal calculus resulting in postrenal failure. our patient is white male y/o. at year of age, he was dx. with acute lymphocytic leukemia and was induced to remission on pog ; he presented tumor lysis syndrome during induction, acute renal failure with no recovery in renal function and rrt was started (ccpd) and continue on the same therapy. during the last years, he presented chronic pancreatitis, ards, sepsis. he had episodes of major vessel thrombosis probably due to central lines (several femoral lines and vascath placed in his thorax) and l-asparaginase. our patient did receive years of chemotherapy and radiation; and he is on complete remission. on / , , for pre-kidney transplant evaluation, a mri test was requested using gadolinium ml/kg for evaluating his vascular system (abdomen and pelvis) with inconclusive results. another mri test was requested months later using gadolinium . ml/kg. weeks later, his mother noticed brawny hyperpigmented, shiny, tightly bound-down, indurate plaques of his bilateral lower extremities, (more significantly on his lateral and posterior calves, and in his anterior and lateral thighs) a punch skin biopsy showed increasing number of fibroblastic cells and widened space between septa in the deep reticularis dermis compatible with nfd. nfd is a fibrosing disorder identified among patients with renal disease with cutaneous finding of skin thickening in extremities and trunk, very similar to those of systemic sclerosis. etiology, pathogenesis and clinical course remain unknown. the majority of cases have been reported in dialysis or kt patients and gadolinium has been identified as a trigger of nfd. in our case, there appears to be a link between the use of gadolinium and the developed of nfd. background: chronic renal failure (crf) is an independent cardiovascular risk factor. changes in calcium-phosphate homeostasis not only affect the quality of bones but also constitute the biochemical base for vascular calcification. aim: to find a method better describing factors of calcification using routine laboratory examinations and computed evaluation of complex equilibria. methods, patients: data of crf and of transplanted (tx) children were compared to a healthy control group of . tx children's parameters were taken before and and month following transplantation. three different strategies were used to analyse factors of calcification: ca x p product, ca-p activity value and the concentration of cahpo . the ca x p product and the ca-p activity value were not informative, because they didn't represent the direction of change in the complex chemical equilibrium. the cahpo concentration was increased in the crf and the tx group (before transplantation) ( . ± . mmol/l) compared to the healthy control group ( . ± . mmol/l) (p< . ). after and months to transplantation the cahpo concentration was in the normal range in the tx group. a negative correlation was found between the concentration of ica + (ionic calcium) and pth (parathyroid hormone) in the dialysed children (r= . ), but not in the transplanted group (r= . ). conclusion: according our findings the force driving calcification is better represented by the concentration of cahpo , the base compound of all primary calcification, than by measuring ca and p separately. follow-up study is needed to establish the predictive value of determination of cahpo . this study was supported by grants otka-t and ett / , the national office for research and technology (nkth) and szentágothai j. knowledge centre. introduction: acute renal failure is a rare complication of nephrotic syndrome and its cause is still unknown. several investigators reported that the most important factor for renal failure was acute tubular necrosis (atn); however, some cases did not have laboratory findings of tubular dysfunction paradoxically. patients and methods: we reviewed cases of nephrotic syndrome with acute renal failure (nsarf) since at metropolitan kiyose children's hospital. seven of cases had calcium deposition in the distal tubules predominantly. we analyzed the clinicopathological findings in these cases. results: the pathological diagnoses of these cases were as follows: minor glomerular abnormalities, mesangial proliferative glomerulonephritis (without iga deposition), and focal segmental glomerulosclerosis. interstitial nephritis was not documented in any case. the common characteristics of these cases were calcium deposits in the distal tubules. some cases had focal simplification of tubular epithelium. all cases were an initial episode of nephrotic syndrome, and cases were steroid resistant. almost all cases had hypertension. in addition, the range of urinary β microglobulin and fena were to and . to . %, respectively. discussion: in these cases, there was enhanced na reabsorption and urinary β microglobulin was only mildly elevated at the time of renal failure. these findings were not consistent with atn. additionally, pathological finding of severe tubular damages was not found on biopsy. contrarily, tubular obstructions due to ca depositions were consistent with these clinicopathological findings. conclusion: our findings suggest that tubular obstruction due to calcium deposition plays an important role in the etiology of nsarf except for atn. background: natriuretic factor was found in urine of chronic uremia for more than years. n-terminal pro-b-type natriuretic peptide (prontbnp) is postulated to be the natriuretic factor owing to its elevation in chronic kidney disease (ckd). however, salt wasting and non-saltwasting chronic kidney disease haven't been partitioned as different entities before. this study is designed to clarify whether prontbnp is different in salt wasting and non-salt wasting ckd and if it is the main causative factor of natriuresis. methods: patients with salt wasting ckd, which are mainly composed of congenital renal structure abnormalities, and patients with non-salt wasting ckd, which are mainly composed of glomerulonephritis, were collected. all of them are non-dialysis-dependent and without heart failure. serum prontbnp in these two groups and normal controls were sampled. fractional excretion of sodium (fena) and estimated clearance of creatinine (ccr) were also checked. results: prontbnp was elevated in salt wasting group compared to normal controls (p= . ). moreover, prontbnp was even significantly higher in non-salt wasting group than in salt wasting one (p< . ). in salt wasting ckd, prontbnp and fena were correlated (r= . , p= . ), but the same result was not observed in non-salt wasting group. prontbnp was significantly correlated to ccr and age using multiple regression analysis (p< . ). conclusion: prontbnp elevation was different between salt wasting and non-salt wasting ckd. volume expansion explained the difference and prontbnp elevation in salt wasting ckd resulted from other mechanisms. since salt wasting ckd, in which the influence of volume expansion was eliminated, had a good correlation between prontbnp and fena, prontbnp may be one of the major contributing natriuretic factor in chronic uremia. background: cidofovir is a new antiviral drug that has a broad spectrum of activity against a number of dna viruses. several observations reported its efficacy as topical treatment of resistant warts. we herein report a systemic complication of acute renal failure associated with such topical therapy. casereport: girl aged , received a renal transplant in and for end-stage renal failure secondary to haemolytic uremic syndrome. her initial immunosuppressive regimen consisted of prednisone, tacrolimusand mycophenolate. five years post transplant she developed chronic allograft nephropathy with mild renal impairment. as a consequence of long standing immunosuppression she also developed invalidating, widespread periungueal warts. a well conducted, aggressive, conventional management of her warts including reduction of immunosuppression failed to improve the symptoms. she subsequently received an intralesional injection of a mg/ml cidofovir solution. forty eight hours after the treatment she developed local swelling, inflammation and pain along with acute alteration of renal function. although cidofovir seric dosages performed on day , , and postinjection were negative we attributed this acute renal failure to a potential nephrotoxic side effect of cidofovir. renal biopsy showed no evidence of rejection but mild alterations of the tubes compatible with tubulo-interstitial nephritis. spontaneous recovery of renal function occurred within months. conclusion: we describe an acute renal failure as a consequence of topical cidofovir treatment of warts in the context of renal transplant with mild preexisting renal failure. topical administration of cidofovir needs as carefull use and monitoring as its parenteral administration, especially in patients with altered renal function. the hemolytic uremic syndrome (hus) is a disease characterized by microangiopathic hemolytic anemia and variable organ impairment with a predominat feature of renal failure in children. the aim of this study was to investigate the presence of plasma lipid peroxidation products in the acute phase of hus. we have analyzed the levels of lipid peroxidation, determined fluorometrically as thiobarbituric acid-reactive substances (tbars), in the plasma of patients (aged - months with a median of ) diagnosed with the shiga toxin-associated form of the disease. in all cases, tbars determinations were performed at hospital admission, during treatment and upon discharge. tbars values averaged . ± . and . ± . mm sem at admission and discharge respectively (reference value < . mm). of the patients examined, presented conserved diuresis during the course of the syndrome, while the other were anuric and required dialysis. maximum tbars values resulted significantly higher (p< . by anova followed by newman-keuls test) in the dialysis-requiring patients as compared to those that had conserved diuresis ( . ± . vs . ± . mm respectively) we also investigated a possible correlation between tbars and plasma creatinine, urea, lactate dehidrogenase (ldh) and platelet count. positive and highly significant correlations (r= . and . , p< . ) were observed when tbars values were plotted as a function of plasma creatinine and urea values respectively. no significant correlations were detected for tbars and plasma ldh values or platelet count. thus, patients affected by shiga toxin-associated hus exhibit increased levels of oxidative stress. also, there is a positive correlation between the magnitude of oxidative stress and the severity of renal failure. c. soares, j. diniz, e. lima, g. oliveira, c. camargos, b. sousa, e. oliveira objective of the study: the purpose of this retrospective cohort study was to report the clinical course of children and adolescents with chronic kidney disease (ckd) enrolled in a pre-dialysis program. methods: the records of patients with ckd admitted to an interdisciplinary pre-dialysis program from to were retrospectively analyzed. the program consisted of conservative management of children and adolescents with ckd and was conducted by an interdisciplinary team including pediatric nephrologists, pediatricians, nurses, psychologists, nutritionists, and social workers. the patients were admitted with a glomerular filtration rate (gfr) equal to or below % of the value expected for their age according to normal reference data. demographic, clinical and laboratory data at entry and at the end of the follow-up were analyzed. renal survival analysis was performed using the kaplan-meier method. results: the median age at admission was . years (interquartile range: . - . yr). the most frequent primary renal disease was congenital urological anomaly in patients ( %), following by glomerular diseases in ( %), cystic diseases in ( %), and others in children ( %). at admission, patients ( %) had ckd stage , ( %) had ckd stage , and ( %) presented ckd stage . median follow-up time was . years (iq range, . - . ). at the end of the follow-up, children presented ckd stage or ( %), patients were in stage ( . %), in stage ( %), and children were in stage ( %). it was estimated by survival analysis that the probability of ckd stage was % at years, % at years, and %at years after admission to the pre-dialysis program. conclusion: the long-term overall renal survival is relatively poor in a cohort of children and adolescents with ckd. objective: characterize the association between proteinuria and gfr in a cross-sectional study of children with mild to moderate chronic kidney disease (ckd). methods: first morning urine protein to creatinine ratios (up/c) and gfr (measured by iohexol blood-disappearance) for children enrolled in the ckid cohort study were examined using loglinear regression of proteinuria and gfr, adjusted for age, sex, body surface area (bsa), and ckd cause. conclusions: in children with mild to moderate ckd, there was a log-linear relation between proteinuria and gfr. the prospective cohort design of ckid will assess the risk of gfr decline associated with level of proteinuria in children with glomerular vs non-gn causes of ckd. objective: to study the clinical characteristics of chronic renal failure (crf) in children. the clinical data of children with crf in the last fifteen years were retrospectively analyzed. results: the first main causes of crf in children were still glomerular disease, and congenital deformities of urinary system and hereditary renal disorders were the second main causes. the initial age of children with crf which were caused by congenital deformities of urinary system and hereditary renal disorders were relatively younger than children with crf which were caused by glomerular disease. the symptoms of some crf in children were not typical. conclusions: glomerular disease were still the first main causes of crf in children. urine screening test, early renal function examination and kidney b-mode ultrasonic were attribute to early diagnosis and proper management of crf in children. the aim of the study was the evaluation of influence of clinical and biochemical parameters upon degree of impairment of cardiac function in dialysed children. methodology: chronically dialysed ( hd, pd) children participated in the study ( m, f), aged - , yrs (x= , ± . yrs). echocardiography examinations were carried out with a hp device. diastolic and systolic left ventricular (lv) dimension, ejection fraction (ef) and lv mass index (lvmi) were evaluated. mean values of estimated parameters in months preceeding echo were calculated. results: on the basis of echo examinations groups were singled out: a (n= ) of normal heart function, b (n= ) of impaired systolic and diastolic heart function and c (n= ) of normal systolic and impaired diastolic heart function. no differences between groups according age, bmi, dialysis and renal insufficiency duration were found. in group of children with severe cardiac lesion (b group) a higher lv mass (a vs b vs c: , vs , vs , g/m) and statistically significant lower ejection fraction ( , vs. , vs. , %) were ascertained. these children were anuric ( vs. vs. ml/d), their systolic ( , vs. , vs. , ) and diastolic ( , vs. , vs. , ) blood pressure were significantly higher, so was the number or hipotensive medications ( , vs. , vs. , ) . bioimpedance analysis showed overhydration in group b (tbw% vs vs . ; ecw/icw . vs . vs . ). conclusions: the vast majority of chronically dialysed children demonstrate an impairment of cardiac function mainly of diastolic parameters. anemia, malnutrition, hypervolemia, anuria and hypertension stand for a significant risk factors of cardiac impairment in dialysed children. we report here the clinical findings and prognosis of patients ( girls, boys) with infantile oxalosis diagnosed between june and december in order to remind this rare autosomal recessive metabolic disorder as the potential cause of acute renal failure in infancy. the mean age of the patients was . months (range: . - months). all patients had the complaint of vomiting since birth, had irritability, and had convulsions. seven of them had parental consanguinity ( %) and family histories revealed urolithiasis in four patients and infantile deaths in one. two patients were cousins without any other family history. all patients presented with anemia (hemoglobin: . - . g/dl), renal failure (creatinine levels: . - . mg/dl) and metabolic acidosis. abdominal x-rays showed bilateral nephrocalcinosis, renal ultrasonographies revealed normal sized kidneys with diffuse and intensive hyperechogenity and loss of corticomedullary differentiation in all patients. crystal deposition was demonstrated in fundoscopic examination of patients, bone marrow aspiration of patients, and renal tissues of patients that underwent renal biopsy. besides supportive therapy, peritoneal dialysis was performed on patients, but only one patient accepted to continue the therapy. four patients died within few months and were lost to follow-up, probably died. two patients have been followed up for months one on continuous ambulatory peritoneal dialysis. in conclusion, this rare disease with fatal outcome should be remembered and investigated in infants with renal failure and bilateral nephrocalcinosis since early combined renal and liver transplantation may be life saving if it can be performed. acute renal failure following halothane anesthesia in young child? case report we present here the case of renal failure and hepatocellular lysis that developed h after the exposure of halothane anesthesia during eye examination. previously a healthy months old boy had a cardiac arrest, during the above mentioned diagnostic procedure, therefore cpr was applied which all happened in another hospital. after a few hours he was transferred to icu at our hospital, consciousness, hemodinamic stabile. in the following hours he developed acute non-oliguric renal failure (maximal level of urea mmol/l, creatinine mmol/l), as well as hepatocellular lysis (alt u/l, ast u/l). plasmaferesis and continuous venovenous hemodiafiltration were immediately applied followed by conservative measures. the level of serum transaminase returned to the normal values within a week and the level of creatinine and urea within two weeks. fully recovered boy was released home. toxic effects of halothane anesthesia in children are reported in only few cases in the literature. objective of study: many cases of chronic aristolochic acid nephropathy (caan) in adults had been reported, but it had rarely been described in children. we reported children with caan to investigate its clinical and pathological characteristics. methods: three cases were studied retrospectively and relevant literatures were reviewed. results: three children received traditional chinese herb medicine containing aristolochic acid to months for different basal diseases including chronic aggressive hepatitis b, secondary hydrocephalus and purpura nephritis and suffered from caan from mouths to years after they began receiving the chinese medication. the main manifestations were renal failure of various degree accompanied with proximal and distal tubular dysfunctions. two of them began with anemia and suffered from serious renal failure. the onset of another case was glucosuria with renal function impaired mildly, and she presented secondary fanconi's syndrome simultaneously. their pathological characteristics were diffuse paucicellular interstitial fibrosis and marked tubular atrophy with mild glomerular impairment. after withdrawal of the chinese herb medicine, renal failure in two patients attenuated progressively. the clinical features of caan in children are progressive renal failure and renal tubular disfunction. its pathological characteristics are diffuse paucicellular interstitial fibrosis and marked tubular atrophy. therefore, we emphasize the recognition of the nephrotoxicity of traditional chinese herb medicine and prevent caan from happening in children. objective of study: recombinant human erythropoietin (rhuepo) treatment may cause pure red cell aplasia (prca), but it had been rarely described in children. in order to acquaint ourselves with this disease, we reported a boy with chronic renal failure developed prca following rhuepo treatment. methods: one case was studied retrospectively and relevant literature was reviewed. results: a -year-old boy suffered from chronic renal failure combining with renal anemia and received rhuepo treatment. two weeks later, his hemoglobin (hb) increased from to g/l, and maintained to g/l for weeks. subsequently his hb declined suddenly at a rate of g/l/day, despite rhuepo increased in dose. his reticulocyte count reduced to . /l without other cytopenias in peripheral blood. a series of laboratory examinations were performed, including bone marrow cell smear and culture to confirm his prca. because various of other factors such as parvovirus etc. induced prca was excluded, we considered the boy's prca was due to rhuepo treatment, although we didn't detect anti-epo antibodies for lacking of the reagent. the boy received erythrocyte suspension transfusion to correct his anemia and was waiting for renal transplant in the following period. conclusions: during the treatment of rhuepo, sudden and rapid reducing of hb might be a hint of rhuepo induced prca. the diagnosis should be based on the clinical presentation, the absence of red cell precursors in bone marrow and the detection of anti-epo antibodies. renal transplant and immunosuppressive therapy might be effective. m. zaniew, b. mroziñski, a. warzywoda, e. stefaniak, a. siwiñska, j. zachwieja among ambulatory blood pressure monitoring (abpm) parameters, pulse pressure (pp) provide an information on cardiovascular (cv) status. recently, a novel parameter i.e. ambulatory arterial stiffness index (aasi) has been proposed. aim: to investigate pp and aasi in relation to left ventricular (lv) geometry and carotid intima-media thickness (cimt) in children with chronic renal failure (crf). subjects: children ( f/ m; median age: yrs) with crf treated conservatively (n= ) and with dialysis (hd; n= /pd; n= ). methods: we studied demographic data, echocardiography data [left ventricular mass (lvm), left ventricular mass index (lvmi), interventricular septum (ivs), left ventricular posterior wall (lvpw), left ventricular end diastolic diameter (lvedd), relative wall thickness (rwt)], cimt and abpm. from abpm, we calculated pp [difference between systolic blood pressure (sbp) and diastolic blood pressure (dbp)] and plotted dbp against sbp (regression slope). aasi was defined as minus this regression slope. results: a positive correlation was found between aasi and pp (r= . , p< . ). aasi was correlated to lvedd (r= . , p< . ) and rwt (r=- . , p< . ). pp was related to: weight (r= . , p< . ), body surface area (r= . , p< . ), body mass index (r= . , p< . ), and lvm (r= . , p< . ), lvmi (r= . , p< . ), lvpw (r= . , p< . ), lvedd (r= . , p< . ), rwt (r=- . , p< . ). neither aasi nor pp was associated to cimt. children with lv hypertrophy had higher pp than without this alteration (p< . ). when data analyzed across quartiles of pp, children in the upper quartile showed higher lvm (inter-group comparisons p< . ), lvmi (p< . ), lvpw (p< . ) and lvedd (p< . ). conclusions: pp is a stronger predictor than aasi of lv geometry in children with crf.. acute renal failure in newborn period may be caused by prenatal, natal and postnatal factors. among them, obstructive lesions of the genital tract (e.g. imperforate hymen and vaginal atresia) are very rare. children with hydrometrocolpos due to distal vaginal atresia may present with severe obstructive uropathy and its consequences. hydrometrocolpos is the result of vaginal obstruction and can become an emergency in newborn period. acute renal failure associated with distal vaginal atresia appears to be rare, with only one report in the paediatric literature. here we report a -dayold infant with a hydrometrocolpos causing life-threatening renal failure. percutaneous drainage did result in dramatically improved clinical and laboratory findings of the patient. objectives of study: sympathetic overactivity is currently considered as an important mechanism of both development and progression of chronic renal failure. however, this statement was mostly based on the researches in which the participants were adult patients with terminal renal failure. little information is available on autonomic changes in pediatric patients with mild renal insufficiency. our aim was to determine whether there is sympathetic activation in children with chronic pyelonephritis in a stage of mild renal insufficiency. methods: patients met the inclusive criteria were selected and assigned into two groups according to the creatinine clearance. group i had patients with creatinine clearance between and ml/min/ . m while group ii have patients with normal creatinine clearance. baseline of age (from - years old), gender and diagnosis between the groups are comparable. time domain analysis of heart rate variability in short-term recordings of minutes was performed in both groups. as well vain questionnaire for assessment of autonomic state was performed in all participants with their parents help. results: the outcomes of heart rate variability analysis showed sympathetic overactivity of . % patients in group i vs . % in group ii, and the difference is statistically significant (t= . , p< . ). significant difference was also found in results of vain questionnaire: . % of patients in group i were estimated as "sympathetic", while only . % in group ii (t= . , p< . ). conclusions: based on the consistent findings of the two methods used in this study, we conclude that sympathetic overactivity may be found in children with even mild renal insufficiency, and it should be considered as an early event in the development of pediatric renal failure. the aim of this study was to describe the prevalence of myocardiopathy in pediatric patients with different stages of ckd (stages to ).methodology: inclusion criteria -gfr < ml/ . m , ckd treatment > months, age < years old. echocardiograms were performed using standard techniques. left ventricular mass (lvm) was measured by two-dimensional directed m-mode echocardiography according to the american society of echocardiography criteria. lvm index was assessed and when > g/m . it was considered severe hypertrophy. the relative wall thickness (rwt) was measured to assess the lv geometric pattern. age, high blood pressure (hbp), anemia, time and type of treatment were compared to the echocardiographic findings. results: we evaluated patients, mean age years old, % on pre-dialysis, % on hemodialysis (hd) and % on peritoneal dialysis (pd). patients on hd were evaluated in the interdyalitic period. twenty-seven patients ( %) had myocardiopathy, clvh in ( %), elvh in ( . %) and cr in ( %). severe hypertrophy ocurred in pacients ( . %). there was no significant difference in relation to age and high blood pressure. patients with clvh were on hd for longer time and had a lower hematocrite when compared to the patients without clvh ( ± vs ± months; p< . ) and ( ± vs ± ; p< . ) respectively. there was a significant correlation between hematocrite and left ventricular mass (r = . ). conclusion: we observed a high prevalence of myocardiopathy in this study population. the risk factors associated to clvh were anemia and time on hd. larger and prospective studies are needed to analyze the impact of myocardiopathy in the cardiovascular mortality in children as well as the results of interventions applied to correct these risk factors. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . urological problems such as vesicoureteral reflux ( , %), obstructive uropathy ( , %) and neurogenic bladder ( , %) were the leading underlying conditions causing cri with a total of , %. while majority of the patients were having gfr levels less than ( , %) or between to ml/min/ , m ( , %), gfr level was between - in only . %of the patients. patients with pth levels between - and more than pg/ml comprised the majority ( , and % respectively). the gfr levels correlated positively with hemoglobin/hematocrit and calcium levels and negatively with phosphorus and pth levels (p< . ). renal replacement therapies were initiated in , % of the patients. the most striking result of this study is the predominance of vur or related urological problems that are relatively preventable as the underlying causes of cri in children. early diagnosis and appropriate medical or surgical management of these conditions should be emphasized together with achieving broader coverage of the pediatric cri population in terms of supportive treatment. twin-twin transfusion syndrome (ttts) complicates up to % of monochorionic twin pregnancies. shunting of blood between twins through common placental blood vessels can cause growth restriction, oligohydramnios and anaemia in the donor twin. renal impairment in the donor twin has been reported as a transient phenomenon with full recovery. we describe a case series of three children with chronic renal failure due to ttts. all cases were monochorionic diamniotic twins. in cases and , growth discrepancy was noted on prenatal scanning. in the case anomaly scans were normal. gestation at birth ranged between and weeks. in all cases there was a significant birth weight discrepancy between twins. post-natal ultrasound appearances were variable: case had normal scans within the first month but echogenic kidneys at months; case had initial increased echogenicity but features consistent with cortical necrosis at weeks; case had small kidneys with no cortico-medullary differentiation. all children became dialysis dependent within the first year of life. age of commencement ranged from days to months. case was successfully transplanted at years. case had an unsuccessful transplant at years and remains on dialysis at years. case remains on dialysis at years. cases and are now at mainstream school with only mild learning difficulties; case has some gross motor delay but other wise normal development. with advances in neonatal intensive care and improved survival of low birth weight babies, this presentation may become increasingly common. even severe renal involvement can occur in the absence of other significant hypoperfusion injury. the management of survivors of ttts with established renal failure may present unique challenges and opportunities. introduction: endothelial heparan sulfate proteoglycans (hspg) play an important role in various biological processes in the renal glomeruli. it is involved in the inflammatory process by acting as a ligand for l-selectin. furthermore, leukocytes are able to interact with chemokines bound to hspg (examples are il- , rantes and mcp- ). this will lead to activation of the integrins on leukocytes and result in more stable leukocyte-endothelial wall adhesion. in this work, we have studied the effect of a subtoxic dose of shiga-like toxin (stx) and on the hspg and the possible implications on the pathogenesis of the hemolytic uremic syndrome (hus). methods: to study this effect, primary human umbilical venous endothelial cells (huvec) and primary human glomerular microvascular endothelial cells (gmvec) were incubated for hours with a subtoxic dose of stx or . then, cells were treated with the enzyme heparinase (which cleaves off hspg). non-treated cells were used as controls. after treatment with the enzyme, the endothelial cells were exposed to flowing human leukocytes in a parallel plate flow chamber. the amount of adherent leukocytes was calculated. -: not treated with heparinase , +: treated with heparinase conclusion: stx and cause an upregulation of the amount of adhering leukocytes on both endothelial cell types. treatment of the endothelial cells with heparinase decreases markedly this upregulation. the effect can not be detected without stx-incubation. this can be explained by a possible upregulation of hspg on endothelial cells by stx, resulting in a higher level of bound chemokines or an increased binding of released chemokines to hspg. this will lead to an increased adhesion of leukocytes and will induce a more severe inflammatory process in the renal endothelium. this effect will contribute to the devastating pathogenesis of the hus. c. soares, j. diniz, e. lima, g. oliveira, c. camargos, b. sousa, m. almeida, e. oliveira objective of thestudy: the purpose of this study was to identify clinical, nutritional and laboratory factors associated with the rate of progression of chronic kidney disease (ckd) among the children and adolescents admitted to a pre-dialysis interdisciplinary program. methods: one hundred eight children and adolescents aged months to years with ckd in conservative management were prospectively followed up from to . renal survival was analyzed by the kaplan-meier method and cox's regression model. a multivariate model was developed from the admission until occurrence of ckd stage (glomerular filtration rate < ml/min). the following data were obtained at admission: gender, race, age at admission, weight z score, renal primary disease, blood pressure, and laboratory data (serum creatinine, serum urea, glomerular filtration rate, hr urinary protein excretion, hematuria). results: median follow-up time was . years (iq range, . - . ) and patients ( %) progressed to ckd stage . in the univariate analysis the following variables were significantly associated with the event: non-white race (p= . ), age > years (p= . ), ckd stage at baseline (p= . ), renal primary disease (p< . ), severe proteinuria (p< . ). after adjustment, variables remained as independent predictors of ckd stage : severe proteinuria (rr= . , % ci= . ± . ), glomerular disease as renal primary disease (rr= . , % ci= . ± . ), and ckd stage at baseline (rr= . , % ci, . ± . ). conclusion: the combination of three factors -severe proteinuria, glomerular disease, and ckd stage at admission -was an independent indicator of adverse outcome in children and adolescents in a pre-dialysis interdisciplinary program. background: allogenic hematopoetic stem cell transplantation (allo-hsct) has gained world wide acceptance as a treatment for various diseases. renal dysfunction is one of the major complications that influences transplant related mortality (trm) rates following hsct. in this prospective study, we aimed to investigate the effect of allo-hsct on renal function in children. methods: renal ultrasonography, dmsa scintigraphy, analysis of renal and tubular function tests were performed before, shortly and -year after hsct. acute renal toxicity (art) was classified according to bearman criteria. grade =increase in creatinine up to twice the baseline; grade =increase in creatinine above twice baseline; grade =increase in creatinine above twice baseline and need for dialysis. chronic renal insufficiency (cri) was defined as gfr< ml/min/ . m and failure (crf) as need for dialysis. results: between april and june , children (median age: . years) underwent allo-hsct because of hematologic disorders (malignancy, ; hemoglobinopathy, ; aplastic anemia, ). all patients except one received nontbi conditioning regimen. six patients ( . %) were died because of trm but none of these patients had primary art. during the first days, patients ( . %) had grade art (csa nephrotoxicity in , vod in patients). grade art was defined in patients ( . %) (vod in , sepsis in , csa nephrotoxicity in patient). eleven patients had structural renal abnormalities before hsct, of them persisted and new patients had pathologic results one year after hsct. in long term period, ( . %) of evaluable children had cri and no patient had crf requiring dialysis. conclusion: renal dysfunction was found to be a frequent complication after allo-hsct in children. therefore, renal functions should be followed carefully in these patients. . years and at the end of follow-up, and compared between the three groups. there were no significant differences between groups in so far as gender, underlying disease, age at diagnosis, proteinuria, hypertension, hyperparathyroidism, use of ace inhibitors or renal size. erithropoietin use was significantly higher (p< . ) in group . gfr improved in all three groups during their first two years of life. the cut-off point on the roc curve indicating worse gfr long term evolution was ml/min/ . m at two years of life (sensitivity %, specificity %). g. zilleruelo, am. onder, j. chandar, o. nwobi, c. abitbol background: catheter-related bacteremia (crb) is a common complication of tunneled-cuffed hemodialysis catheters. our objective was to investigate the effectiveness of tissue-plasminogen activator-tobramycin locks (tpa-abl) in preventing crb in pediatric patients. methods: a retrospective analysis of pediatric hemodialysis patients was performed. patients with > crb/ catheter days (cd) were designated as high risk. those with < crb/ cd were of average risk. three eras of consecutive months were studied. in era , high risk patients were detected. during era , the high-risk group was placed on times weekly prophylactic tpa-abl. in era the high-risk group was given once weekly tpa-abl. results: there was a significant decrease in the rate of crb with prophylactic tpa-abl which was more pronounced when given three times/week. conclusions: the use of prophylactic tpa-abl times weekly significantly reduces the rate of crb in patients at high risk. prophylaxis once weekly may be less effective than thrice a week. l. was born after a normal pregnancy without a special personal or familial history, was seen at the age of years, after a days long ordinary oro-pharyngeal viral infection treated by symptomatic treatments. he presented with inflammation of the left cheek with slight fever ( °) and a sole purpuric lesion of the left leg ( cm) and some petechiae on the thorax. blood count showed haemolytic anemia (haemoglobin= g/dl, schizocyte= %, increased ldh), white cells ( % neutrophils) and platelets. no germs were found in hemoculture, lumbar punction, stools or urines cultures. creatininemia was μmol/l. in the following hours, despite immediate antibiotics administration and without any shock sign, several purpuric extensive necrotic lesions appeared, renal insufficiency increased (creatininemia= μmol/l), platelets count decreased to and markers of diffuse intravascular coagulation dramatically increased. in the following days, proteinuria, macroscopic hematuria and hypertension appeared. after days on anticoagulation therapy, renal function remained stable while anemia, thrombopenia and coagulation disorders persisted. coagulation factor tests demonstrated a heterozygote deficiency of factor v leiden (also found in the father) and an acquired protein s deficiency secondary to streptococcal infection. after protein s infusion and plasma exchanges, his state improved and necrotic lesions ceased. this initial hematologic and renal presentation could have suggest a hus but the large purpuric lesions remain unusual in such pathology. a in children on chronic peritoneal dialysis malnutrition is being diagnosed with an objective combined nutritional score (abn score) based on anthropometry and bioimpedance analysis indices (nephrol dial transpl ; : - ) . aim of this study was to investigate the prevalence of malnutrition and the main factors associated with it in children with ckd - . we planned a cross-sectional study of children with ckd - , mean age . ± . years, who underwent controls in our institution between september and december , . the data of abn score, age, primary renal disease, standard blood and urinary tests, and estimated gfr (schwartz formula) were collected.the prevalence of malnutrition (abn score < . ) in the whole population was %. the abn score was positively correlated with age, height sds, serum hemoglobin, total protein and albumin (p value from < . to < . ), while a negative correlation was found with serum phosphate and proteinuria (p< . ). patients with steroid-resistant nephrotic syndrome had lower abn score values than those with other primary renal diseases ( . ± . vs . ± . ; p< . ). the percentage of children with malnutrition in the different stages of ckd increased in parallel with the decrease of gfr, from % in the ckd group to . % in the ckd group. in conclusion, the prevalence of malnutrition in children with ckd - is not negligible. low hemoglobin, total protein and albumin levels and high serum phosphate and urinary protein excretion, particularly in small children with growth impairment, strongly suggest the need for an in depth nutritional assessment, in order to diagnose malnutrition and treat it accordingly. e.c. developed atypical hus at months of age. a heterozygous factor h gene mutation was found. despite plasma-exchange treatment numerous relapses led the child to ckd stage : creatinine clearance (ccr) . ml/min/ . sqm according to schwartz formula. at yrs we started a programme of fresh frozen plasma (ffp) infusions, - ml/kg bw. the child was poliuric and hypertensive, notwithstanding the treatment with ramipril, amlodipine, clonidine and furosemide. in the first months he received ffp every days. mean ccr during this period was . ± . ml/min/ . sqm. haptoglobin (hap) was still < mg/dl in / tests ( . %), ldh was increased ( . ± . u/l), hemoglobin and platelet count were always in the normal range. the treatment schedule was then changed to ffp every days for the next months. during this period, ccr was significantly higher ( . ± . ; p< . ) and ldh significantly lower than in the first months ( . ± . ; p< . ); haptoglobin was always > mg/dl. no differences between the two periods were found for hemoglobin, platelet count, proteinuria, microalbuminuria and blood pressure values. both in the first and the second period, ccr was negatively correlated with ldh (r . , p< . ) and with the bioimpedance analysis (bia) measure of resistance, which is an index of body hydration. in conclusion: . the only signs of disease activity in atypical hus can be minor abnormalities in laboratory tests, such as increased ldh and decreased haptoglobin levels; . ffp infusions are useful in maintaining hus remission and preserving kidney function, provided that the treatment schedule is optimized; . bia is useful in monitoring hydration status of children with ckd, especially those with poliuria and under ace-inhibitors, as it allows for the correct interpretation of serum cr values. analgesic-antipyretic agents are commonly used medications worldwide for the treatment of pain and fever in children. acute renal failure is commonly seen in adults after treatment with analgesicantipyretic agents. this complication has rarely been reported in children. two patients, ages and years were admitted with a diagnosis of acute, non-oliguric renal failure. one had symptoms of upper respiratory tract infection, and the other had been suffering from vomiting and abdominal pain. appropriate evaluations including detailed history especially the history of drug ingestion, physical examination, and measurement of serum creatinine concentrations were performed in the emergency department. both patient had ingested analgesic-antipyretic agents (mefenamic acid, and paracetamol) before the onset of acute renal failure. none of the patients had previous history of renal disease or concomitant treatment with other drugs. none had oliguria or anuria, dehydration, abnormal serum electrolyte concentrations, or evidence of glomerulonephritis. microscopic hematuria and leukocyturia were found in one patient. serum creatinine was . and . mg/dl at presentation. both of them recovered completely within a week. we emphasize that clinicians must be aware of renal toxicity of analgesic-antipyretic drugs with low doses. with the increasing use of over-the-counter analgesic-antipyretic agents, this association may become more prevalent. cardiovascular disease is a main cause of morbidity and mortallty in patients with chronic kidney disease (ckd). the pathophysiology of cardiovascular disease (cvd) in ckd remains uncertain but nowadays sympathetic hyperactivity is recognized as an important mechanism involved. this observational and transversal study of patients from five to years old, submitted to dialysis or at least four months after kidney transplantation (ktx), without signs of transplantations rejections, with definite ckd and creatinine clearance of ml/min or less. the subject (median age= years; . % female) were classified accordingly with treatment modality: conservative (n= ), peritoneal dialysis (capd) (n= ), hemodyalisis (n= ) and renal transplantation (n= ) submitted to l-metaiodobenzilguanidine ( l-mibg) planar and tomography scintigraphy and heart rate variability (hrv). comparisons among groups were made using anova and the association between variables was assessed using spearman's correlation coefficients and bonferroni correction was used during multiple comparisons testes. a p value < . was considered significant. hemodialysis patients presented increased cardiac washout (p= . ), heterogeneous pattern of l-mibg distribution (p= . ) and lower values of low frequency component of hrv (p= . ). capd subjects had reduced lung washout (p= . ). the cardiac washout had positive correlation with pth and negatives correlation with creatinine clearance. there was a significant negatives association between the rr interval in low frequency (lf) and cardiac washout. the uremic cardiac disautonomia might be characterized by decreased low frequency component of hrv and increased l-mibg washout and heterogeneous distribution pattern by left ventricular walls; these abnormalities subsided after ktx. d+hus is the main cause of acute renal failure in children. extrarenal manifestations are associated in more than % of the cases. hus causes toxin mediated endothelial cell damage, resulting in thrombotic microangiopathy and intraluminal thrombosis of small vessels, with subsequent tissue ischemia and necrosis of involved organs. a -year-old boy has been admitted for d+hus associated with escherichia coli o diarrhea. he presented with renal failure and hypertension requiring hemodialysis for days, hemolytic anemia ( g/dl, schizocytes %) requiring blood transfusions, severe thrombopenia ( g/l) and hyperleucocytosis ( /mm ). severe hemorragic colitis with duodenitis required prolonged parenteral nutrition. at days after onset, the child presented with confusion, slurred speech followed by loss of consciousness associated with major hyperglycemia ( mmol/l) and elevated corrected natremia ( mmol/l) without ketosis requiring transfer in intensive care unit (icu). continuous hemofiltration associated with insulin therapy ( . ui/kg) was then established with slow decrease of natremia and serum glucose within hours. neurologic condition rapidly improved. serum amylase and lipase were normal. insulinemia at the same time as the highest hyperglycemia was low ( , ui/ml), and search for human insulin, islet cell and glutamic acid decarboxylase antibodies were negative. insulin therapy could be discontinued within days. at the last follow-up, months later, neurologic examination, serum glucose and glomerular filtration rate were normal. in conclusion: / hyperglycemic hyperosmolar coma is a severe complication yet never reported in d+hus; / continuous hemofiltration with constant monitoring of biologic parameters could avoid permanent lesions due to rapid correction of this major metabolic unbalance. chronic renal failure (crf) can interfere with the regulation and time dependent secretion of multiple hormones. adrenocortical function in children with crf is examined in a few studies with a limited number of patients, and the results are controversial. in this study our aim is to evaluate adrenocortical function in basal and stimulated conditions, and to determine the relationship with the glomerular filtration rate (gfr), etiology and duration of crf in a larger group of patients. sixty-one patients with crf ( f, m; mean age . ± . years) were studied. the patients were grouped according to etiology [structural abnormalities (n: ), glomerulonephritis (n: ), others (n: )], duration of crf [ - (n: ) , - (n: ) and > months ( )] and gfr [ - (n: ), - (n: ), < ml/min/ . m (n: )]. cortisol levels were measured at : a.m. (basal cortisol) and : p.m. low dose acth test ( . micg/m synacthen iv) was performed. delta cortisol was calculated as peak cortisol minus basal cortisol during the acth test. diurnal rhythm is accepted to be preserved if : a.m. cortisol/ : p.m. cortisol is greater than two. basal cortisol levels and peak cortisol response to low dose acth is similar in all groups. median levels of delta cortisol found to be higher in the gfr< ml/min/ . m group; p= . . diurnal rhythm seems to be more preserved in the gfr - ml/min/ . m group (% ) compared to gfr< group (% ); p= . . no correlation was found between the basal, peak and delta cortisol, gfr and duration of crf. our preliminary results have shown that there is no difference in the basal and peak cortisol levels between all groups. this is the first study in children showing that adrenocortical function is preserved in groups with gfr levels between - ml/min/ . m . objective: this study was we evaluated bk virus and jc virus in urinary after renal transplantation. methods: because these polyoma viruses are excreted in urine, these patients ( females and males, . ± . years old) was analyzed by polymerase chain reaction. all patients were living donor renal transplantation from a parent. results: two patients have detected bk virus in urine. as the type of immunosuppressive treatment, one had tacrolimus and mycophenolate mofetil, and one more had methylprednisolone and tacrolimus. seventeen percent of the patients had quantifiable bk virus-dna in urine. thirty-three percent of the patients had quantifiable jc virus-dna in urine. there was non significant relationship between these polyoma viruses in urine and the type of immunosuppressive treatment. no patients developed interstitial nephritis during the study. conclusions: the activation of bk virus and jc virus does not seem to be related to the type of immunosuppressive treatment. the pathogenetic role of polyoma virus infection in renal transplantation recipients further researches are needed. background: urinary tract infection (uti) due to neurogenic bladder, secondary to large spina bifida as myelomeningocele, is well known, but the association of small occult spina bifida (sbo), having normal physical examination, with that of infection has not been reported. we studied the frequency of spina bifida occulta in children with urinary tract infection. method: the kub of voiding cystouretrography in patients ( f, m) with average of age year (± . sd), who referred to radiology department of ali asgar children hospital for uti, were observed for sbo. all patients had normal physical examination. chi were used to find the frequency of the level of sbo and the differences respectively. p< . was considered significant. result: out of patients had sbo. the order of frequency of the level of sbo was s ( %), l ( , %), s s ( , %), l s ( , %), and l s s ( %). patients had vesicoureteral reflux (bilateral in cases, at left and at right side). the severity of vur was % grade (g) ii, , % g iii, . % g iv, and . % g i. spina bifida occulta was detected in out of patients with vur. this difference was not statistically significant (p= . ): conclusion: the high frequency of lumbosacral sbo in the patients with urinary complaint may imply some lower urinary tract dysfunction in these patients although we need a control study in normal children. we evaluated interleukin- and interleukin- levels in the urine of children with renal scarring, with vesicoureteral reflux ( / , group a ) and without vesicoureteral reflux ( / , group a ) and in the urine of healthy children (group b). none of the children had urinary tract infection for the last ten months. interleukin- and interleukin- were determined using a commercially available human enzyme-linked immunosorbent assay kit. results: urinary interleukin- levels were below the lower detection limit in all samples. interleukin- levels were detectable in all urine samples of children with renal scarring and below the detection limits in the urine samples of healthy children. there were no statistically significant differences between urinary interleukin- levels in children with and without vesicoureteral reflux. there is a relationship between the grade of renal scars, the time past from their development and the urinary levels of il- . the introduction of mycophenolate mophetil (mmf) was an important advance in immunosuppressive therapy but its use is associated with gastrointestinal intolerability (gi) requiring dose reductions or drug interruptions. enteric coated mycophenolate sodium (ec-msp) was designed to improve mycophenolic acid (mpa)-related gi by delaying the release of mpa until reaching the small intestine. at present, its immunosuppressive activity in pediatric renal transplant with gi has not been clarified. we studied trough levels of active metabolite mpa (c ), changes in kidney function, mixed lymphocyte culture, cytotoxic antibodies as well as cytotoxic response before and after months of the conversion from mmf to ec-mps in renal transplant recipients with gi. in the immunosuppressive protocol used: mmf, tacrolimus and corticosteroid, mmf ± mg/m /day was replaced by ec-mpa ± mg/m /day. after months of treatment with ec-mpa, the incidence of gi decrease to . %. the levels of mpa were about % higher on ec-mps ( . ± . ug/ml) compared to mmf administration ( . ± . ug/ml). serum creatinine, creatinine clearance and urinary protein excretion did not change ( . ± . to . ± . mg/dl, . ± . to . ± . ml/min/ . m and . ± . to . ± . gr/ hr, respectively). also, during ec-mpa, proliferative response and cytotoxic antibodies showed no significant change. the release of il- was striking augmented with mmf or ec-mps therapy, but interferon-γ and tnf were low under both treatments. our data indicate that conversion from mmf to ec-mps leads to an improvement in gi without altering key elements of immunosuppression. however, the monitoring of mpa before and after conversion should be appropriated to the optimization of therapy efficacy. re. munarriz, ju. arakaki, ce. munarriz pediatric clinic, pediatric nephrology, buenos aires, peru objective: to describe the results of a program of chronic ambulatory peritoneal dialysis (capd) in children in peru by means of conventional indicators. methods: children ( , % male) were included in a longitudinal descriptive study. the average age was , ± , years (rank of , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . % were from lima (the capital city) and % came from other cities of the country. primary glomerulonephritis ( , %) was the main cause of the renal insufficiency. we evaluated the program from to . results: the average weekly kt/v was , ± , . the average dose of erythropoietin (epo) was ui/kg/week. % of the patients had average annual albumin of more than , gr./dl. the average annual protein catabolism index (icp) was , ± , gr/kg/d. the weight/age, height/age, weight/height z scores at the beginning and at the end were . / . , - . / . , - . / , - . / . , . / . - . / . , respectively. the average hematocrit was . ± . %. the rate of peritonitis adjusted for the period was , episodes/patients-year ( episode every months) and the mortality for the same period were %. conclusions: the indicators evaluated in our patients are according to the results of the international literature. is repeated urine culture essential after antibiotic therapy in uti in thai children? background: in , the american academy of pediatrics recommended for uti treatment, that urine culture be repeated only in children < years with fever > hours, since the chance of a positive urine culture in other children is very low. objective: to evaluate the cost-effectiveness of repeated urine culture after antibiotic therapy in childhood uti. patients and methods: a retrospective review of the records of children diagnosed with uti in songklanagarind hospital from jan -dec , . results: there were patients total, of which were excluded due to no repeated urine culture. patients with uti episodes were analyzed ( boys and girls). ( . %), ( . %) and ( . %) patients aged < , - and > years respectively. ( . %) had a repeated urine culture with significant growth. multivariate analysis showed that age < year, etiologic agents psuedomonas aeroginosa or enterococci spp., fever > hours and kub anomalies were the most significant risk factors for positive repeated culture, while vur and recurrent uti episodes were not significant risk factors. if we consider that a child who has at least one of the above risk factors should have a repeat urine culture, then cases ( . %) will require repeating urine culture and x . =$us . will be saved and ( . %) positive repeated urine culture will be missed. conclusion: our study in a group of thai children indicates that repeated urine culture after antibiotic therapy is still recommended. our aim was to find out if there are any signs of renal scarring and reduced renal function without recurrent uti in patients with obstructive pyelonephritis. there were investigated children ( - y) with - years passed after diagnosis of obstructive pyelonephritis. these patients were investigated during years long period without uti. all the children had a treatment with nitrofurantoin during season viral infections. we investigated excretion with urine of the collagen product (hydroxyproline) and activity of lisosomal enzymes (b n-acetilglutamase, elastase, pseudocholiesterase). as a control group, healthy children of the same age were investigated. our result demonstrates the decrease of the level in urine of collagen product and lisosomal enzymes and normalization of tubular and glomerular functions during years remission of pyelonephritis. prevention of recurrent uti and maintenance of the remission of pyelonephritis leads to the decrease of sclerosing processes on kidney. regular dialysis induces insecurity and special psychological problems associated with staff-, machine-and artificial material-dependence. the more severe the child's physical problems are the more probable is developing of emotional disorders, a sense of loneliness and an exaggerated dependence on the parents and staff. a psychological and social study of children on regular dialysis was performed. there were girls and boys, aged - (mean: ) ys. two children ( %) are exclusively treated with haemodialysis, ( %) are on peritoneal dialysis and in ( %) both methods interchanged. somatic concomitant disorders are present in ( %) of children. among psychological disorders, an inclination to unsociability, autoaggression or aggression towards the immediate environment has developed in children ( %), ( %) do not like talking about disease while ( %) are communicative and sociable. psychosocial characteristics showed: emotional difficulties (anxiety, mild depression) in %, feeling of being physically different from peers (short stature, less physical ability) in %, lowered self-esteem and social isolation as a result of school absenteeism in %. overprotection of parents was presented in %. different psychological changes were present in some children. of the children are of school age: ( %) attend special schools and the remaining follow regular education programs. with the help from their teachers, children on dialysis can master regular school programs, in spite of the time spent on dialysis. a good and continuing co-operation of dialysis staff and sick children and their parents as well as a more intensive co-operation with psychologists and teachers are necessary to reduce psychological disorders and promote a better adaptation to the life of their healthy coevals. we report a -year-old girl with syndrome frasier who developed b cell lymphoma within nine month after live related kidney transplantation. in induction therapy we applied atg up to days, mycophenolate mofetil and cyclosporine. routine abdominal ultrasound revealed multifocal hypoechogenic changes in liver and spleen. computed tomography showed diffuse focuses of changed liver tissue in length up to . cm, precontrast density of - hu and postcontrast of - hu. in spleen there were three similar changes (up to . cm). after surgical biopsy of liver, patohistological examination confirmed diffuse large cell b lymphoma (cd positive, moderate risk). pcr ebv was positive. we immediately started with ganciclovir intra venously and decreased cyclosporin and mmf (within two weeks) up to completely exclusion from therapy. in the same time we increased prednisolon on mg daily. after weeks from beginning ganciclovir she treated with rituximab, one dose of mg every week (five weeks). repeated abdominal ultrasound and two controls computed tomography showed markedly regression of tumorous lesions. after . months of last rituximab doses scan showed normal spleen and liver findings. all lesions were resolved. in two occasions she developed severe leucopenia without any infection complication. she still has got moderate lymphopenia due to continual ganciclovir therapy. during this period ( months) of illness course she treated with ganciclovir intravenously due to repeated ebv reactivation (positive pcr). despite enormous reduction in immunosupressive therapy renal function remain stabile without episodes of acute rejection. - . years) . the most of them, % ( patients) received graft from live related donor. % of patients had preoperative dialysis and % were preemptive. the mean waiting period for transplantation was months (range to months). congenital anomalies of kidney and urinary tract were the most common underlying diseases ( patients), then nephrotyc syndrome ( patients), hereditary nephritis ( patients), polycystic kidney disease ( patients) and others. daclizumab was the most commonly used as immunosuppressive induction agent and the maintenance immunosuppressive therapy consisted of azathioprine or mycophenolate mofetil (mmf), cyclosporine or tacrolimus and prednisone. two patients had immediate postoperative surgical complication and graft loss due to thrombosis of a. renalis and donor tubular necrosis respectively. three patients had delayed graft function; two of them underwent cadaveric transplantation. one patient had recurrence of primary kidney disease only few days after transplantation and graft loss after one year. other patient lost the graft after years due to noncompliance and chronic cellular rejection. after one year of follow-up graft survival rate is % and patient survival rate %. at the end of follow-up (mean range . months), patients had normal, patients slightly decreased renal graft function. catch-up growth was seen during the first year after transplantation from mean height sds of - . to . . the mean goal of our further intention is improvement of cadaver renal transplantation. j. lee, y. shim, s. lee objectives; although the variable risk factors of urinary tract infection (uti) in children such as virulence factors of the pathogenic bacteria and vesicoureteral reflux are already well known, the role of normal flora clononizing the intestinal tract and genitourinary tract is not fully understood. the change in colony forming units (cfu) of lactobacillus in chidren with uti is primarily investigated to explore the role of lactobacillus, one of the human normal flora, in development of uti. methods; lactobacillus was cultured from stool, urine, and periurethral or vaginal discharge of febrile infants with uti. those with confirmed uti by the suprapubic urine culture were classified to uti group (n=- ), and those with negative urine culture and confirmed viral illness were classified to control group (n= ). lactobacillus was anaerobically cultured in dico rogosa sl agar (becton, dickinson and company, usa) for hours at °c. results: the cfu of lactobacillus in stool was correlated with those in periurethra, vagina and urine (p< . ). the cfu of lactobacillus in stool was significantly lower in uti group than in control group ( , ± , vs , , ± , , , p< . ) . the cfu of lactobacillus in periurethra or vagina was significantly lower in uti group than in control group ( , ± , vs , ± , , p< . ). the cfu of lactobacillus in urine was significantly lower in uti group than in control group ( ± vs , ± , , p< . ). the cfu was distributed mostly at low level in uti group, which was significantly different from that in control group (p< . ) conclusions; the cfu of lactobacillus in stool, periurethra, vagina and urine is low in infants with uti. it is suggested that lactobacillus has a role in the development of uti. pediatric small bowel transplantations are associated with pronounced electrolyte inbalances in the posttransplant period. we investigated the sources of possible electrolyte losses. our hypothesis was that electrolyte inbalances after intestinal transplantation might be augmented by fk (tacrolimus) mediated renal toxicity rather than short bowel syndrome alone. we retrospectively reviewed eleven living-related small bowel transplantations between october and december . the data collected included frequent serum and urine electrolyte profiles, renal function parameters, enterostoma electrolytes, and fk levels in the postoperative period up until either discharge or graft loss. we analyzed pearson's correlations between fk levels, serum electrolytes, renal function parameters, and also fractional excretions (fe). in order to investigate possible delayed nephrotoxic effects of fk , we correlated all values of the same day as well as with fk levels of , , and hours earlier. furthermore, we analyzed our data stratified by fk dosing ranges. our results show decreased gfr and prominent increase of renal sodium, phosphorus, and magnesium losses along with rising fk levels, suggesting this pathway as a major contributor to their imbalances. furthermore, fk levels were associated with serum calcium and phosphorus decline, though urinary calcium excretion was not significantly changed. signs of renal toxicity are apparent within the first hours of fk challenge. our data suggest that fk mediated nephrotoxiticy is a significant contributor to electrolyte imbalances observed after small bowel transplantation. objectives of study: urinary tract infections (uti) are common in children and c-reactive protein (crp) in serum is often used to evaluate the severity of the renal inflammation. recently it was demonstrated that crp can be produced locally in the kidney. we therefore measured the crp concentration in both serum (s-crp) and urine (u-crp) from children with uti to evaluate the extent of local production and the usefulness of measuring u-crp for diagnosis of inflammatory kidney disease. methods: children ( boys) with uti were studied (median age . years, range days- years). children had fever . °c or more. the uti was caused by e.coli in patients. all children were examined within a few days of diagnosis by dmsa scan for evaluation of renal function. as controls were used children with respiratory infection (pneumonia in most) and elevated s-crp in whom uti was ruled out by negative urine culture. u-crp was measured in a commercial hscrp elisa. normal value was < mg/l results: in the uti patients, the median s-crp was mg/l (range - ) and u-crp mg/l (range - ). there was a significant correlation between the s-crp and u-crp concentrations (< . ). dmsa scans were abnormal in ( %) uti patients. the proportion of abnormal scans increased significantly with the crp concentration in both serum (< . ) and urine (< . ). all control patients had increased s-crp concentrations (median mg/l, range - ) but the median u-crp was . mg/l (range - ). the u-crp in the patients with uti was significantly higher than in the controls with other infections (< . ). conclusions: our data strengthens the concept that crp can be produced locally in the kidney during uti. the usefulness of measuring u-crp to evaluate inflammatory kidney disease needs to be tested further. s. paunova, a. kucherenko, i. smirnov, g. serova, i. donin, l. revenkova, n. goltsova in order to reveal the role of cytokines in renal tissue damage in infants with urinary tract infection (uti) patients aged from to months were examined. in all of them inflammatory markers (esr, crp, leukocyte count), urine concentration of tumor necrosis factor-α (utnf-α) and transforming growth factor-β (utgf-β) standardized to urinary creatinine concentrations were evaluated. two groups of patients were determined: ) with uti and normal urodynamics (n= ), ) with uti and urodynamic disorders (vur, hydronephrosis) (n= ). healthy infants were used as controls. as a result, all the patients demonstrated significantly elevated utnf-α, utgf-β creatinine ratio in comparison with controls (p< , ) with no difference between groups. but children with normal urodynamics (from the st group) presented with severe uti ( st -a) showed urine tnf-α tgf-β creatinine ratio in , times higher than other patients of st gr and close to nd gr. data ( st gr.-utnf-α/ucr= , ± , , utgf-β/ucr= , ± , , st gr.-utnf-α/ucr= , ± , , utgf-β/ucr= , ± , ; nd gr -utnf-α/ucr= , ± , , utgf-β/ucr= , ± , , p , - < , ) . to conclude, tnf-α and tgf-β are responsive for renal tissue impairement in infants with uti. elevated tnf-α tgf-β creatinine ratio in a part of infants with normal urodynamics suggests that renal damage begins early in infection mostly due to inflammation. one may suspect a predisposition of that subgroup of patients to fibrogenic process and subsequent scar formation. prompt diagnosis and localization of pyelonephritis are of great importance in treatment and prognosis of the patients. the urinary excretion of enzymes, in particular n-acetyl-beta-dglucosaminidase (nag), is considered a relatively simple and non-invasive method in the detection of renal tubular function under various conditions such as pyelonephritis. this study was performed to determine the diagnostic value of urinary nag in acute pyelonephritis and to compare it with other indices traditionally used for this purpose in children. this is a quasi experimental study conducted from april to may on children with pyelonephritis. diagnosis of pyelonephritis has been based on standard criteria. seventy-two patients between month and years were recruited. fresh random urine samples were obtained on the admission time and at th hour of treatment and were tested for nag and creatinine. there was a significant difference in pre and post-treatment urinary nag/creat ratio (p< . ) and the sensitivity and specificity of urinary nag in diagnosis of pyelonephritis were % and % respectively. there was a significant correlation between urinary nag level and kidney ultrasonography results. patients whose ultrasonography showed hydronephrosis, had the highest level of urinary nag and patients who showed urinary stone in their ultrasonography had the lowest level of urinary nag. in addition, there was a reverse correlation between urine culture results and urinary nag level; patients who had negative urine culture had higher level of urinary nag in comparison with patients with positive urine culture. we conclude that urinary nag is elevated in children with pyelonephritis especially in the presence of urinary tract abnormality and the absence of renal stone. type- hyperoxaluria (ph- ) is an autosomal recessive disorder caused by the impaired activity of the hepatic peroxisomal alanine-glyoxilate aminotransferase. the disease leads to end stage renal disease (esrd) and combined liver-kidney transplantation (clkt) is required. we report cases diagnosed with ph- who received clkt. case- : she had attacks of dark urine without any pain and renal stones were determined on sonography when she was . years old. she was diagnosed with ph- and received peritoneal dialysis (pd) at the end of the first year and cadaveric clkt was performed when she was yearsold. at the age of , she had chronic allograft nephropathy and began to have hemodialysis (hd). recently, . year after hd, cadaveric renal transplantation (tx) was performed. she is well after the second tx. case- : he was admitted with polyuria, polydypsia, stomachache and renal stones were determined on sonographic examination. he had esrd and pd was started when he was years old. at the age of , cklt was performed from his mother. his liver and renal functional tests are well months after cklt. case- : he was evaluated because of having an older brother diagnosed with ph- when he was . years old. he had no complain, but sonography showed multiple calculi. within years he experienced flank ache, hematuria attacks and anuric phases due to obstruction and esrd appeared and he received hd and clkt was performed from his full-match sister at the age of . . he is doing well years after tx. here, we present the favourable clinical outcomes of our patients with cklt to indicate the validity of this treatment of choice in ph- . tenascin (tn) is a glycoprotein component of extracellular matrix (ecm) which is not present in the normal kidney tissue. tissue plasminogen activator inhibitor- (pai- ) regulates fibrinolysis and the plasmin mediated matrix metalloproteinase activation and it is also not expressed in the normal kidney. recent studies focus on the pathogenesis of advanced renal diseases. in this study we evaluated tn and pai- staining in the renal tissues of pyelonephritic rats using immunohistochemistry (ihc) as to understand if these markers may be served as histological parameters of pyelonephritis like fibrosis, tubularatrophy or vascular changes. seven rats were injected . ml solution containing e. coli atcc cfu/ml into left renal medullae. seven rats were designed as sham group and were given . % nacl. rats were sacrificed days after injections. renal tissues were studied histopathologically by hematoxylin and eosinand scored for the parameters of pyelonephritis. tn and pai- expressions were studied semiquantatively by ihc by tenascin novocastra (ncc-tenas-c) and pai- (h- ) santa cruz biotechnology. both tn and pai- expressions increased in the pyelonephritic groups. we observed acorrelation between tenascin and fibrosis, vascular changes and tubular atrophy and pai- expression showed a correlation with only fibrosis. we conclude that increase in renal tn and pai- expression shown in experimental pyelonephritis are the responsible factors for the fibrotic changes of persistent renal damage. introduction: urinary beta microglobulin (β mg) urinary excretion is a good index of proximal tubular cell dysfunction. objective: to determine β mg excretion significance in determining the outcome in respect to scar and renal insufficiency. patients and methods: urinary β mg and creatinine (cr) was measured in urine samples of whom proceed to do dmsa renal scan at the time of admission and months later to detect scar. β mg was measured using radioimmunoassay method using β mg -test kit (radim company). twenty children had various grades of renal scars. results were compared with ratios of children with low uptake and normal scanning and normal children. student t test, anova, and unpaired t-test was used for analysis and differences considered significant if p< . . results: the mean urinary β mg/cr was significantly higher in the scarring group ( . ± . ) than in the normal group ( . ± . ) and in low uptake group ( . ± . ) (p< . ). patients with grade iii had higher values ( . ± . ) than grades i ( . ± . ) and ii ( . ± . ) (p< . ). patients without renal scar had β mg/cr ratio below . microgram/mg. the mean β mg/cr was higher in patients with vur grades and ( . ± . ) than patients with vur grades to ( . ± . ) (p= . ). maximum β mg/cr was detected in patients with grade vur ( . ) and the minimum was zero in non-refluxing patients and normal children. two patients with high grade vur and the highest levels of β mg/cr ratio ( . and ) progressed to renal failure in years time, the first patient was treated by hemodialysis and the second underwent renal transplantation. conclusion: measurement of urinary β mg is useful in the early detection of tubular damage in patients with renal scars. introduction: chronic allograft nephropathy refer to the progressive decline of renal function seen in some renal transplant recipients in association with alloantigen-dependent and alloantigenindependen factors. hyperlipidemia is a risk factor for chronic allograft nephropathy in adult pts, where no data exist in pediatric transplant population. methods: in this cross sectional study, patients ( can/ non-can) that aged - yr and - mo (mean: mo) after transplantation, were evaluated for lipid profile and renal function tests. results: hyperlipidemia has high prevalence in our patients both pre and posttransplantation and hypercholesterolemia and increased ldl had significant correlation with chronic allograft nephropathy (p= . ) and p= . respectively. conclusion: in pediatric patient as in adults hyperlipidemia and particularly hypercholesterolemia has significant correlation with chronic allograft nephropathy and as adults may need specific therapy. results: pre-transplantation renal replacement therapy time ranged from to months. eleven children underwent pre-emptiverenal transplantation. / transplants were from living related donors. donor age ranged from days to years. grafts were from donors < year of age and of these grafts were transplanted en-block. hla mismatches ranged from to antigens. primary disease was: focal segmental glomerulosclerosis in , rapidly progressive glomeluronephritis in , reflux nephropathy in , nephronophthisis in , iga nephropathy in , congenital nephrotic syndrome in , dysplasia-hypoplasia in , idiopathic membranous glomerulonephritis in , henoch-schönlein purpura in , hemolytic-uremic syndrome in , nephroblastoma in , polycystic kidney disease in and of unknown origin in children. patient survival at five years was %. allograft survival with living related transplants at one, two and five years was %, % and % respectively and with cadaveric transplants at the same periods was %, % and % respectively (p< . ). regarding en-block grafts, they functioned immediately and satisfactory and presented excellent graft function years later. most kidneys were lost due to acute or chronic rejection (n= ). other causes were renal artery thrombosis (n= ), infections (n= ), withdrawal of immunosupressive regime (n= ). conclusions: results of this single center series of pediatric renal transplants are encouraging from the standpoint of patient and allograft survival. conclusion: in infants with hn, the incidence of uti was higher especially in those with ou, hn of higher sfu grade or hun. the antibiotic prophylaxis may be recommended during year after birth in infant with hn because the incidence of uti was high in these period. results: the underlying diseases were: sepsis with mods ( . %), septic shock ( . %), severe intoxication ( . %), trauma with sirs ( . %), drowning ( . %), abdominal compartment syndrom ( . %) and inborn metabolic disorders ( . %). children ( %) had acute renal failure, ( %) patients met non-renal crrt criteria. cvvh was performed in ( %) children, cvvhdf in ( %) children. crrt duration was to hours (median . hours). dynamics of blood urea, creatinine, c-reactive proteine (crp) and white blood cells (wbc) were evaluated. significant decline (p< . ) of creatinine along the treatment with cvvh as well as during cvvhdf was observed. blood urea levels showed significant decrease only in children treated with cvvhdf (p< . ). significant decrease of wbc and crp was observed only using cvvh. children from the study group survived (overall mortality . %). in non-survivors was time from crrt initiation to its termination compared to time interval from crrt initiation to the death of children with - organs failure significant (p< . ) where as in non-survivors with - failured organs it was not. conclusion: cvvh is efficient at removing urea and creatinine as well as inflammatory mediators (crp, wbc). cvvhdf is more potent to blood urea elimination. authors suggest preferring cvvh to cvvhdf in critically ill children to affect basic inflammatory parameters. to analyse hd and pd prescription (pr) adopted in chronic dialysis children, were viewed data of pd regimens in patients ( . - years) and hd regimes in patients (age . - years) treated in pediatric centres in . pd patients were on automated pd: -nightly intermittent pd (nipd; pr): . ± . ( - ) hrs; . ± . ( - ) cycles/night; dwell volume (dv) ± ( - ) ml/m bsa; -tidal pd ( pr): . ± . ( - ) hrs; . ± . ( - ) cycles/night; dv ± ( - ) ml/m ; tidal volume . ± . ( - )%; -continuous cycling pd (ccpd; pr): . ± . ( - ) hrs; . ± . ( - ) cycles/night; dv ± ( - ) ml/m ; daytime dv ± ( - )% of night dv. in % of pr dialysis fluid (df) glucose concentration was > . %, and in % buffer was bicarbonate. df of daytime dwell was . % glucose ( pr) or icodextrin ( pr). patients with residual diuresis were . % of those on nipd, % on tidal pd, and . % on ccpd. hd was performed as bicarbonate hd ( %), hemodial filtration ( %) and acetate-free biofiltration( %). patients received sessions/week in % of cases, /week in %, and /week in % of cases; oxalosis patients were on daily hd. session duration was hrs in pr, hrs in , and . hrs in . dialyser membrane was: polysulfone ( %); hemophane ( %); polyamide s ( %); cellulose acetate ( %); polyacrylonitrile ( %); cellulosediacetate ( %); cellulose triacetate ( %); polymethylmetacrylate ( %); polyether/carbonate ( %). ratio between dialyser surface area and patient bsa was . ± . ( . - . ) and was - . in %, . - in %, > . in %, and < . in % of cases. isoniazid (inh) is widely used in most prophylactic and therapeutic anti-tuberculosis regimens because of its effectiveness and low cost. acute intoxication by isoniazid is known to cause symptoms of seizures, metabolic acidosis, coma, and even death. we present a case of acute isoniazid poisoning in a seven years old patient who ingested tablets ( mg) of isoniazid. she was admitted unconscious, with ventilatory insufficiency and convulsions. renal and liver function tests were in normal ranges. she was intubated and mechanically ventilated. despite parenteral midazolamand pyridoxine (vitamine b ) treatments convulsions went on. then hemodialysis was performed and after hemodialysis convulsions and ventilatory insufficiency were disappeared and the patient was conscious and she was extubated. hemodialysis may be an effective treatment alternative for the patients who doesn't respond pyridoxine treatment. the aim of this study is to analyse children under two years of age, with their first febrile urinary tract infection (uti), identifying bacteriological etiology, antimicrobial resistance, urologicalabnormalities and renal damage. this is a prospective study including children ( % girls) with their first febrile uti. mean age was months ( - ), ( %) patients were younger than months ( % of them were boys). urine was obtained by suprapubic aspiration ( . %) or transurethral catheterization ( . %). % had positive nitrite on urinalysis and . % had leukocyturia. they were submitted to ultrasonography (usg), dmsa scan (within months) and voiding cystourethrography (vcug). the most frequent microorganism found in urine culture was escherichia coli, ( . %). in this study high bacterial resistance to antimicrobials was observed in relation to the following antibiotics: ampicillin ( . %), first generation cephalosporyn ( . %), sulfamethoxazole/ trimethopin ( . %). resistance to second generation cephalosporyn, aminoglycoside, nitrofurantoin and nalidixic acid was lower than . %. renal ultrasound was abnormal in . % of the infants. vesico-ureteral reflux (vur) was observed in . %, although only . % had vur grade iii or more. the dmsa scan showed that ( %) patients had renal parenchymal damage. fourteen of these ( . %) had normal esr. there were ( . %) reinfections within a months period, even under prophylactic treatment, and the presence of vur grade iii or more was the only one with a significant relationship. conclusion: there were high levels of bacterial resistance to frequent used antimicrobials. this finding points toward a need for reviewing criteria of choosing initial blind therapy. investigation with dmsa scan is important in the detection of renal parenchymal scars, irrespective of the reflux grade. purpose: urinary tract infection (uti) has a risk of renal damage and is associated with vur. vur is investigated only by vcu. however, vcu is an invasive, painful study and many patients hesitate to be taken the study. we studied the correlation of vur in vcu and defect of dmsa scan and investigated the possibility of substitution of vcu by dmsa scan. material and methods: from to , the medical records were searched for children admitted to cheongju st.mary's hospital with the first uti who had been evaluated with both dmsa scan and vcu within months of the infection. the value of several clinical signs, laboratory findings, the resultsof dmsa scan and vcu were investigated. bacteriuria was defined as , or greater colony-forming units in urine from a bag, midstream or catheter sample. results: there were patients underwent both studied at the first uti. mean age of the patients was months old. the male patients were ( %). the vur was found in of the patients ( %), grade i-ii in and grade iii-v in patients. there was no significant correlation with the presence of vur in sex, fever duration, blood white cell count and the level of serum creactive protein (crp). but the patients with vur grade iii-v were significantly older than the patients with grade i-ii reflux or without vur. there were abnormal dmsa scan findings in of ( %). of these patients, were without vur, with vur grade i-ii and with vur grade iii-v. the abnormal dmsa scan was correlated with the presence and severity of vur. but vur was found in % of patients with normal dmsa scan. conclusions: abnormal dmsa scan is correlated with the presence of vur, so the patients with abnormal dmsa scan require vcu. in order to prevent missing a quarter of patients with vur shown normal dmsa, vcu should be recommended in all children with first febrile uti. cuba is the largest of the carribean islands with its , millions inhabitants. cuba is considered as a developing country and is classified in the group of: "lower middle income countries and territories". despite low financial resources, cuba has succeeded to develop an efficacious health care system with comparable results to those of west europe and usa (who data) ccl: ) hd is the most prominent form of pediatric dialysis (automated night pd is in progress); ) the no of transplantations is relatively low because of no participation to an international transplantation network; ) high no of pediatric nephrologists; ) high quality of patients care. background: inborn errors of metabolism in neonates are often characterised by hyperammonaemic coma within the first days of life and require prompt diagnosis and specific treatment such as toxin removal and nutritional support. cvvhd seems to be the optimal modality for extracorporal ammonium detoxification, however, little experience with small numbers of children has been accumulated. patients and methods: from to , patients with hyperammonaemia ( male, female) were admitted for dialysis treatment: neonates (mean age . ± . days, range - days) with a mean birth weight of ± g and infants (mean age . ± . years, range to years). in neonates and infants we inserted venous double lumen shaldon catheters (predominately femoral or jugular vein) for cvvhd treatment while neonates and infant underwent capd treatment. results: plasma ammonia levels (range - μg/dl before dialysis and - μg/dl after dialysis) were reduced by % within . ± . h by cvvhd and within . ± . h by capd (p< . ). total dialysis time was . ± . h for cvvhd patients. no major mechanical complications were observed with cvvhd and stable blood flows ( - ml/min) and dialysate flows ( - ml/m /h) were achieved. due to severity of underlying disease, out of neonates ( %) undergoing cvvhd died on day - while out of neonatal capd patients ( %) died on day and one infant patient died after days of capd treatment. twelve out of neonates ( %) survived with no or moderate mental retardation. conclusions: cvvhd is an effective modality to eliminate plasma ammonia within few hours. however, vascular access and blood flows are critical restrictions. mental retardation has to be evaluated in larger scale studies. r. vilalta, e. lara, a. madrid, s. chocron, j. nieto hospital materno-infantil vall de hebron, nefrologia pediatrica, barcelona, spain background: transplant nephropathy is the main cause of renal failure in kidney transplanted children. until this situation is proved by biopsy, sometimes the progressive raise of creatinine leads to raise the anticalcineurinic (cni) drugs with added nephrotoxicity. sirolimus (sir) plus an anticalcineurinicin less dose and mycophenolate (mmf) could offer in kidney-transplanted children an immunosuppressive regime with less toxicity and even an improvement of renal function. methods and patients: paediatric kidney-transplanted patients developed biopsy-proved chronic allograft nephropathy (age - y, mean ) a follow-up post-transplant of y and exhibit also tubular involvement and acute cni toxicity. sir was added in all patients as a rescue therapy at . mg/kg/d. results: after a follow-up period of months, creatinine level diminished (p< . ) in patients ( in group tac, in group cya, with no significant differences). creatinine level did not show a significant change in the other patients ( group tac, group cya, basal creatinine . mg/dl. serum cholesterol changed from ± mg/ ml to ± (ns) and serum tryglicerides from ± mg/ ml to ± (ns). proteinuria also did not show changes ( ± to ± mg/m /h (ns). conclusions: a poly-drug approach with less dose of anticalcineurinic added to the antiproliferative effect of sirolimus and the inhibition of purine synthesis based on mycophenolate mofetil could suppose an improvement of the renal function in children graft nephropathy an even in the graft survival. steroids have been a cornerstone in renal transplant immunosuppression. several strategies have been used to minimize their side effects. new immunosuppressive drugs have allowed steroid withdrawal or total avoidance. aim: to evaluate a new protocol with steroid-free maintenance immunosuppression in pediatric renal transplant. patients and methods: a prospective, non-randomized study in consecutive first renal allograft recipients, followed-up to months. patients received prednisone the first days, two-dose basiliximab induction and maintenance therapy with tacrolimus (tac) and mycophenolate mofetil (mmf). no steroids were given after d posttransplant. controls were historical-matched steroid-based children receiving basiliximab, tac and mmf. all patients gave informed consent. anthropometric, biochemical variables, acute rejection and cmv infection were compared using student-t test and regression analysis. results: a better growth pattern was seen in steroid-free maintenance group reaching a normal growth at months. gfr and serum glucose were similar in both groups. total cholesterol levels were significantly lower in the study group. the incidence of acute rejection was . % in steroidfree maintenance vs . % in steroid-based group, no differences in cmv infection and blood pressure were observed. hematocrit levels were lower during the first months after transplant in the steroid-free group, increased after months post-transplant. patient and graft survival was % at two-yr post transplant in the two groups. conclusions: this steroid-free maintenance immunosuppressive protocol was efficacious, safe, with a lower incidence of acute rejection, not increased risk of infection, preserving optimal growth, renal function and reducing cardiovascular risk factors. objectives of study: to evaluate the lipid profile and its possible implications in children with end stage renal disease (esrd) or renal transplantation. methods: children ( boys, girls) aged from . to years, on peritoneal dialysis (group i) and with renal transplantation (group ii) were studied. in all children were examined: serum creatinine, total cholesterol, triglycerides, high density lipoproteins (hdl) and low density lipoproteins (ldl). a cardiac and liver ultrasonography were also performed. the body mass index (bmi) and blood pressure were evaluated in all children. / children received also a triplex carotid study. the median values of blood creatinine, cholesterol, triglycerides, hdl, ldl as well as the number of children with bmi over th percentile in both groups were shown in table i . all children had normal findings in triplex carotid study. cardiac ultrasonography was abnormal in child of group i and in children of group ii. only child presented lipoid invasion in liver ultrasound. / children of group i and / children of group ii presented hypertension, well controlled, with antihypertensive therapy. conclusions: frequent evaluation of lipid profile is recommended in all children with esrd or renal transplantation independently their bmi. in our study, children with renal transplantation presented better lipid profile compared with children on peritoneal dialysis. group i with < months (n= ; , ± , months) and group ii > months (n= ; , ± , months). results: serum albumin, serum lipids values and the distribution of the categories of the peritoneal membrane did not present significant differences between the groups. hypertension, renal residual function (p= , ), the renal urea kt/v (p= , ) and the weekly renal ccr (p= , ) were significantly higher in group i, while the weekly peritoneal ccr (p= , ) and the total weekly ccr (p= , ) were significantly higher in group ii. catch-up was not observed in any group. control of the cholesterolemia, trigliceridemia and albuminemia were maintained with the dialysis time in both groups. the goals of adequacy of the doqi for kt/v and ccr were gotten respectively in , % and , % of the group i and in , % and , % of the group ii. the longer time in dialysis was associated with the lowest values of renal residual function, renal kt/v and renal ccr. the capacity of transport of the membrane was similar in both groups. objectives of study: to explore the characterize of peritoneal transport in chinese children with chronic peritoneal dialysis. methords: pet was carried out times for six children (mean ages . ± . , aged from to years) who were maintained by capd, and the infusion volume of dialysate was ± ml ( ml/m ). the peritoneal solution transport rate was evaluated by the standards of twardowski's and ppdsc's criteria. results: in our study, the initial pet was performed at . ± . days following initiation of pd, the -hours of peritoneal creatinine clearance ( h-d/p) and glucose absorption ( h-d/d ) was . ± . and . ± . , respectively. according to the standards of twardowski's and ppdsc 's criteria, the peritoneal transport categories were divided into high transport (h) ( / ), high average transport (ha) ( / ), low average (la) ( / ) for peritoneal solution transport, and h ( / ), ha ( / ), la ( / ), low transport ( / ) for glucose absorption. no low transport type of solution was uesd in our patients. the coincidence rate of peritoneal creatinine and glucose transport types were % and % between the twardowski's and ppdsc's criteria, respectively. the different changes of peritoneal transport type were found in two patients with continuous pet. the value of h-d/p increased after peritonitis episodes. our results showed that the pet in % of capd children fall into high and high average transport categories elevated by ppdsc's and adult standards. the peritoneal solute clearance was adequacy in the children, but net water ultrafiltration was lower. standard pediatric pet and its criterie are consistent with the adult criteria. the capability of peritoneal solute transport increased after peritonitis episodes. verapamil (vp) is known to alter cyclosporine (csa) bioavailability. the impact on immunoregulators (il- , tgf-β , and tgf-β ) in allograft recipients remains unresolved. a prospective open study to examine the impact of vp on peripheral blood cell mrna encoding il- , tgf-β , and tgf-β and serum il- , tgf-β , tgf-β protein levels was performed. parental written informed consent was obtained in all cases. children with stable renal allograft function (< months), and receiving immunosuppression (csa, pdn, either with aza or mmf) were included. in the first visit, a clinical examination, two-point ( and h) csa pharmacokinetic profile, serum creatinine, serum for il- , tgf-β , and tgf-β protein levels (by elisa) were obtained; peripheral mononuclear cells were collected for measurement of transcripts for s rrna (house keeping gene) and mrna for il- , tgf-β , and tgf-β (by real time quantitative pcr assay). after the visit one, patients were either withdrawn of vp (if the subject was already receiving vp) or started on vp mg/kg/day (if the subject was not receiving vp). two weeks after, a repeat clinical evaluation and blood collection, as in the first visit, were performed. pediatric recipients of renal allografts were included ( were from ld, mean post-transplant time . years, mean csa dose . mg/kg/day). the c h and calculated auc - h were significantly higher in those receiving vp, but there was no difference in csa trough levels. protein and mrna levels of il- tgf-β , and tgf-β were not different. were previously seen by a nephrologist. logistic regression was performed on anemia (hgb< . g/dl) and showed relative risk in blacks was . vs. whites. relative risk in those who did not receive epo was . vs. those who did. of black patients, were anemic and previously seen by a nephrologist. of white patients, were anemic and previously seen by a nephrologist. in summary, blacks and patients not receiving epo at the time of dialysis initation were more likely to be anemic. despite being seen previously by a nephrologist, nearly % of patients were anemic when starting dialysis. further analysis is needed to determine causality to improve anemia control in incident dialysis patients. of the avf were in whites with in a black patient. the avg was in a black patient, with a cvc distribution of whites and blacks. patients with cvc had been previously followed by a nephrologist and of these had been followed for > months. in summary, incident pediatric hemodialysis patients are primarily having cvc as initial access type. with . % having been previously seen by a nephrologist and % of these for greater than months, the reasons behind not having an avf or avg as primary access need to be explored and improved upon. this high incident cvc use is consistent with data reported in the united states, but not with other european and asian countries. an effort to have a permanent avf or avg in incident pediatric hemodialysis patients needs to be made by the patient's nephrologist. to find the preventive measures for recurrent uti in infants with first febrile uti and normal urinary tract (ut), the incidence of recurrent uti and its risk factors were investigated. method: from june, to june, under months of age (- mon: , - mon: ), who were diagnosed as the first febrile uti and proved to have normal ut, were enrolled to the retrospective study. for all infants with nonretractile prepuce, topical application of hydrocortisone for - weeks and physiotherapy was recommended. during the following year, the incidence of recurrent uti and the well-known risk factors such as female, young age, phimosis, vaginal reflux, and initial mtc-dmsa(+) pyelonephritis were evaluated. result: the incidence of recurrent uti in infants with normal ut was . % and recurrent uti episode was . /patient-year. the recurrent incidence in male infants was . %, which was not significantly different from . % in female infants (p= . ). the recurrent incidence in younger infants was significantly higher than in older infants [- mon: . %, - mon: . %, p= . ]. this age-related difference was significant in male infants [- mon: . %, - mon: . %, p= . ], but not in female infants (p= . ). in infants with persistent nonretractile prepuces, recurrent uti developed in . %, which was higher than . % in infants with retractile prepuces (p= . ). the presence of the vaginal reflux (p= . ) or initial mtc-dmsa(+) pyelonephritis (p= . ) showed no significant difference in the incidence of recurrent uti. conclusion: in uti infants with normal ut, younger infants under months of age and nonretractile prepuces of male infants were the risk factors for recurrent uti. objective: vascular endothelial growth factor (vegf) appears to play a central role in the process leading to peritoneal angionesis and increased level of vegf may conrtibute to high peritoneal small-solute transport rate (ptsr) in continuous ambulatory peritoneal dialysis (capd) patients in adult. vegf-c is related to lymphogenesis, but its role in peritoneal solute transport rate is not known. in this study, we evaluated possible relationship between dialysate vegf and vegf-c levels and pstr in children. method: twelve children with no apparent inflammation process or disease, who had been on capd, were enrolled. standard peritoneal equilibration test (pet) was done to evaluate pstr. d/pcreat and d/d gluc were calcualted at hr of pet. overnight dialysate levels of vegf and vegf-c were measured using commercial elisa kit. correlation between dialysatevegf (or vefg-c) and d/pcreat (d/d glu) was analyzed. results: mean peritoneal dialysis duration was . ± . months. mean overnight dialysate vegf and vegf-c level were . ± . pg/ml and . ± . pg/ml, respectively. a significant correlation was noted between the dialysate vegf-c and vegf level (r= . , p= . ). dialysate vegf level had negative correlation with d/d glu of hr pet (r=- . , p= . ). vegf-c had no correlation with d/d glu or d/p creat. conclusion: there was significant relationship between dialysate vegf and vegf-c levels in children and significant correlation was also noted between dialysate vegf and ptsr. it seems that vegf contribute to high ptsr also in children on capd. m. feldkötter, l. stapenhorst, b. beck, u. bangen, b. hoppe we currently use sirolimus as a second line medication in transplanted patients with a distinct nephrotoxicity of calcineurin-inhibitors. as our short term experiences were not as positive as expected, we performed a short term meta-analysis in our renal transplant recipients under sirolimus treatment: we give an account of seven kidney transplant patients who were either directly started or were switched to a medication with sirolimus during september to february . the reasons for this action taken were calcineurin-inhibitor side effects like severe arteriolopathy with lossof gfr, atypical haemolytic-uraemic-syndrome, seizures after the first dosages of cya and a tacrolimus induced exanthema. in four of seven patients switched to sirolimus we observed severe side effects, exaggerating those of the calcineurin-inhibitor and hence, in three patients the latter treatment was installed again. findings were distinct proteinuria in two patients, hyperlipidemia in three patients, wound healing disorders and, most strikingly, treatment resistant severe pancytopenia in one patient and severe interstitial pulmonary fibrosis in another patient, both with amelioration after termination of the medication, but still the need of oxygen therapy in the latter patient. in addition we noticed a slightly faster reduction of the gfr calculated with the schwartz formula in five patients compared to the previous immunosuppressive regimen. based on these findings we strongly feel that a more critical discussion of each case is necessary before changing the immunosuppressive medication. also, the question arises on whether sirolimus can really be valued as an equivalent alternative to a calcineurin-inhibitor based immunosuppressive regimen in pediatric kidney transplantation. y. kovalski, r. cleper, i. krause, m. davidovits schneider children's medical center of israel, nephrology and dialysis unit, petah tiqwa, israel background: despite significant technical improvements, haemodialysis in infants with end-stage renal disease (esrd) is still associated with significant morbidity and mortality. methods: the files of patients weighing less than kg with esrd who were treated with haemodialysis at our institute between and were reviewed for background and treatment characteristics, morbidity and outcome. results: the study group included patients aged - months (mean . months) weighing . - . kg (mean . kg). mean duration of dialysis was . months. vascular access posed the major problem. ten patients were dialysed through a central venous cuffed catheter and one through an arteriovenous fistula. an average of three different vascular accesses was required per patient (range - ). mechanical difficulties were the most common cause of central line removal ( . %), followed by infections ( . %). major complications causing significant morbidity were intradialytic haemodynamic instability, hyperkalemia, coagulation within the dialysis set, anaemia, hypertension, inadequate fluid removal and recurrent hospitalisations. analysis of outcome revealed that patients underwent successful transplantation, one returned for haemodialysis after . years due to graft failure, and died. conclusion: haemodialysis is a suitable option for low-weight paediatric patients with esrd awaiting transplantation, when performed in highly qualified centers. the importance of antibiotic prophylaxis in management of vur vesicoureteral reflux (vur) cause urinary tract infection (uti) and renal scarring is a common condition in children. the detection and treatment of vur before renal scarring is vital. recently, optimal management of low grade vur is controversial. the aim was to explore the kidney outcome in a cohort of patients with vur. the patients were divided into five subgroups according to vur grades. all of them were treated with low dose prophylactic antibiotics until the age of years. urine culture was repeated monthly. background: anemia is a common complication in patients on hemodialysis. treatment of anemia with recombinant human erythropoietin (rhuepo) may lead to iron deficiency. intravenous sodium ferric gluconate complex (sfgc) therapy improves iron stores. objectives of study: aim of our study was to assess effects of maintenance sodium ferric gluconate therapy in pediatric patients on hemodialysis on mean hemoglobin (hb), hematocrit (hct), transferrin saturation (tsat), serum ferritin and rhuepo dose, as well as safety of therapy with sfgc. methods: intravenous sfgc therapy was administered for months in mean dose of . mg/kg/week to eight pediatric patients on hemodialysis. patients were from to years old ( males and females, aged . ± years). all patients were prescribed rhuepo before start of study. results: sfgc therapy was successful in maintenance of mean hb (increased from . to . g/dl), mean hct (improved from % to %), mean tsat (from to %) and mean ferritin level (from to ng/ml). high ferritin levels in two patients were due to inflammatory disease rather than the sign of iron overload. the mean weekly rhuepo dose decreased from to iu. no significant adverse event due to intravenous sfgc therapy occurred. conclusions: intravenous maintenance sfgc use in pediatric patients on hemodialysis was safe and successful in maintenance of iron indices, thus allowing reduced use of rhuepo. the the viral hepatitis b still remains a serious problem, especially actual in patients with end-stage renal disease (esrd) on renal replacement therapy (rrt). the high frequency of hbv infection transmission in hemodialysis units and immunodeficiency modify hepatitis clinical course and outcomes and worsening vaccination results and renal graft survival. we have analyzed the results and influence on transmission of hb -infection of hepatitis b vaccination in children aged from to years with esrd on chronic hemodialysis. majority of children were boys ( . %) older than years ( . %). an assessment of hbs-ag has been conducted prior and during the vaccination (engerixb) by scheme - - months. after first vaccination hbv infection was detected there after in . % of children, after second vaccination in . %. in all patients ( ) which have received three tours of vaccination, an active immune response was developed. thus, vaccination against viral hepatitis b is effective and prevents hbv infection in children with end stage renal disease on chronic hemodialysis. renal transplantation (tx) represents the best treatment for the patient with crf. scientific advance has been able to optimize the immunosuppressive treatment however the adherence to treatment has been not maintained. aims: to identify the factors that influence in non-adherent behavior with the purpose of designing effective educational strategies. methods: the qualitative focus was carried out through patients and tutors interviews. the quantitative aspect applies for epidemic variables, time post-tx, percentages and frequency of the sentences coming from the analysis of the interviews. nurse, psychologist and a social worker were incorporated with the purpose of elaborating an instrument based on seven questions related to the transplantation, risk and/or loss of the graft; besides the events happened as consequence of this, allowing that interviewed manifested with freedom their opinions. the interview was recorded in a microcassette and later transcribed. analysis was determined by categories containing the answers of each question granting the agreement sentences according to the frequency which was repeated in each interview. informed consent was obtained. results: tx ( - ; non-adherent, % of them were interviewed. mean age: . ys. loss the graft: %, time post-tx: . months, dd: % ld: %. the lack of supervision in the taking of medications, numbers/schedules medications, family conflicts and the poor communication with the parents/medical team seem to be the main factors for non-adherence. conclusion: it is necessary to modify the pattern of the patient's attention transplanted under the pattern of chronic suffering that allows the sick person's and their family active incorporation to the process in an integral way to the multidisciplinary group. infantile results: patients ( females, males) < kg, / -< kg at pd start were treated. they consisted % of our center's pd patients ( pts). age at pd start: . ± months (median ), / pts < mo. pd therapy duration: - mo (median ), pts > mo. esrf cause: congenital nephrotic syndrome pts, dysplastic kidneys , cortical necrosis . pts were fed by gastrostomy, pts received gh (growth hormone). / pts had hypertension (ht) treated with > drugs and - cv events. pd type: / cycler-assisted, / capd (continuous ambulatory pd), / both. pd adequacy targets (kt/v> . ) were reached in / . peritonitis: . episodes/patient-month, pts had > episodes. / pts had > pd catheters and / > pd-related surgery. outcome: / -kidney transplantation, / switched to hd for infections or uncontrolled ht. height ±sds median , weight ±sds median + . . conclusions: small infants with esrf can be successfully treated by pd despite high rate of infectious, cv and surgical complications. pd therapy main target is optimal growth towards kidney transplantation. hyperlipidemia is a well recognised complication of renal transplantation. it is a fairly common problem in the paediatric renal transplant population. its prevalence ranges from % to % though the mechanism is not clear. steroids, calcineurin inhibitors and rapamycin are the main culprits in inducing hyperlipidemia, which is a potential risk factor for cardiovascular heart disease and graft dysfunction. long term effects of these immunosuppressive drugs in children have not been adequately studied. of the calcineurin inhibitors cyclosporine (csa) was found to induce hyperlipidemia compared to tacrolimus (tac). post-ransplant hyperlipidemia is well described in adults; the same cannot be said in children. in adults, post-transplant hyperlipidemia increases risk of cardiovascular disease to fold. screening and management of hyperlipidemia has therefore become an important part of current long term management of transplant patients. there is a limited data on prevalence of hyperlipidemia in renal transplant in children and even more so locally here in south africa. most of the known studies have been conducted in the first world, there was therefore need to determine prevalence locally. this information would ultimately assist in the overall management of our renal transplant recipients. majority of the patients had normal lipid profile. % of the patients had high cholesterol levels, while % of the patients had high tg levels. / ( %) of the patients on csa had hypercholesterolemia compared to only / ( %) on tac (p= . ). / ( %) of the patients on csa had high tg compared to / ( %) on tac (p= . ). the study concluded that the prevalence of hypercholesterolemia and hypertriglyceridemia in renal transplant pts is high, comparable to other studies and that there is a tendency towards having more lipid abnormalities in transplant pts on csa. grade vur in ( %) and . the incidence of abnormal findings was significantly higher in children with uti and vur than in those with uti without vur ( . % vs %; p< . ). in children with no vur, grades - vur, grade vur and grades - vur, renal scarring rates were %, %, % and %, respectively. the patients with higher grades vur tended to have more than scars on their dmsa scans (p< . ). our findings suggest that renal scarring resulting from uti is mostly related to vur, but sometimes is caused by the infection itself. we can conclude that vcu is essential for diagnosis of vur, but mtc-dmsa scan shouldn't be avoid in the management of children with uti. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] years. seventythree ( . %) of them were on triple immunosuppressive therapy, one on double therapy, and one didn't use any medication. overall, subjects ( %) had at least one episode of uti. twenty-four episodes of urinary tract infection occurred in children: episodes in two girls with neurogenic bladder (ngb), episodes in two boys with posterior urethral valve (puv), four episodes in an obese girl with laurence-moon-biedl syndrome, episode of uti in girl with unknown primary renal disease and episodes in girl, one with polycystic kidney disease and one nephronophthisis. conclusion: uti following kidney transplantation was more common in children with known lower urinary tract abnormalities. key words: urinary tract infection, kidney transplantation. background: in japan, the severe shortage of cadaveric kidneys led clinicians to attempt performing abo-incompatible living kidney transplantation (tx). some reports demonstrate successful results of the combination of plasmapheresis (pp), strict immunosuppression and splenectomy. however, we should concern about a great risk of surgical invasion and postoperative serious infection in younger patients who underwent splenectomy. recently, a few reports suggested anti-cd monoclonal antibody (rituximab) can be an alternative to splenectomy. patient and method: a years old boy with bilateral hypoplastic kidneys had been treated with peritoneal dialysis for years. since his blood type o was incompatible with paternal blood type a, we arranged to perform tx using pp and rituximab without splenectomy. a single pp was performed on days - , - , and - to reduce anti-a antibody (ab) titer. rituximab was administered in a single dose of mg/m on day - . basiliximab, tacrolimus, mycophenolate mofetil and methylprednisolone were used for immunosuppression. results: before tx, the anti-a ab titer was reduced from : to : , and cd level was suppressed from % to %. tx was performed without splenectomy and he had excellent initial graft function. we observed anti-a ab titer rose up to : on day + , but it decreased spontaneously to : . there were no side effects and severe infections during the perioperative period, but the neutropenia treated by gcsf appeared months after rituximab administration. the protocol biopsies were performed in month and months, which revealed no signs of rejection. conclusions: abo incompatible tx using pp and rituximab without splenectomy can be a therapeutic option in children to avoid a invasive surgery and infectious risks. further establishment of optimal protocol for children are necessary to obtain excellent outcomes safely. . . , . . , and . . , . . , in hivan, and od, p= . , p= . , respectively. serum p levels were . . , . . , and cap were . . , and . . , in hivan and od, p= . , p= . the aim of this study is to identify the outcome of the physically or socially handicapped children with end stage renal disease (esrd) receiving chronic peritoneal dialysis (cpd). among patients commenced on cpd, handicapped children with esrd receiving cpd were identified in our unit during the period between november and february . age at cpd initiation ranged from . to . years (median age: ; girls, boys). underlying diseases were neuropathic bladder and vesicoureteral reflux (in patients), chronic pyelonephritis (in patients), vesicoureteral reflux (in patients), amyloidosis (in patients), and alport syndrome (in patient). causes of handicapped status against cpd were inadequacies of indoor resources (in patients), cerebral palsy (in patients), down syndrome (in patient), inadequate psychosocial status (in patient), surgically corrected rectovesicale fistula and ectopic anus (in patient), blindness (in patient), ventriculoperitoneal shunt and paraplegia (in patient), colostomy (in patient). all catheters were implanted percutaneously by the same pediatric nephrologist. median duration of dialysis was (range - ) months. during a total of dialysis months, episodes of peritonitis ( episode/ . patient-month), episode of exit-site infection, and episode of tunnel infection occurred in of children. except for an inguinal hernia in patient, we did not observe any mechanical complication related to catheter. cpd was terminated in children (death in , renal transplantation in , switch to hemodialysis in ). before initiation of renal replacement therapy, some negative baseline factors may not be really contraindications for cpd. the socioeconomic and geographic factors greatly influence the prevalence and outcome of renal disease in children. the subspecialty of pediatric nephrology in sudan was established few years ago and the facilities for the management of renal problems are limited. the aim of this study is to review the demographic profile, complications and outcome of capd after nineteen months of treatment. all children who underwent capd from june to january were studied. there were children ( males), the mean age was years (range from months to years). the majority of children has undetermined cause of esrd ( children). the most common complication was peritonitis (peritonitis rate was / . patient/months. patients had refractory peritonitis that necessitate catheter removal, exit-site infection was documented in children and catheter block in children. there were drop out of the program were due to deaths, changed modality and one family withdraw treatment. in conclusion this analysis has stimulated improvement in nurses training and supervision as well as attempts to improve catheter survival and microbiology monitoring. the - ) , looking for symptoms of hypovolemia (cramps, abdominal pain or headache) during or at the end of hd treatment. bioimpedance measurements were performed at the end of each session according to the khz tetrapolar technique; resistance and reactance values were plotted on the age and gender specific th , th and th percentiles of the vector distribution in the healthy population (reference tolerance ellipses) as a resistance-reactance graph. hypovolemia (hv) was indicated by a vector shifted to the upper pole, out of the % tolerance ellipse; normovolemia (nv) by a vector inside the ° ellipse. patients complained of one or more of the above-mentioned symptoms in % of hd sessions, while biva suggested hv in . % of the sessions. symptoms were significantly more common (p< . ) in sessions with hv ( / cases; positive predictive value . %) than in those with nv ( / cases; negative predictive value . %). biva suggested hv in / sessions with symptoms (sensitivity . %) and nv in / sessions without symptoms (specificity %). no significant differences in the accuracy of biva were found between patients either younger vs older than years, or with height sds <- vs >- , or taking vs not taking antihypertensive drugs. in conclusion, biva can be useful in assessing dry weight in children and young adults on hd: since patients with a vector shifted to the upper pole, out of the reference % tolerance ellipse, are at high risk of hypovolemia during the next hd treatment, the increase of the dry weight is then indicated chronic antibody-mediated rejection can occur as a de novo complication in renal allograft recipients and is associated with c d deposition in peritubular capillaries in the renal graft and positive circulating anti-hla antibodies, although the sensitivity and specificity of positive c d staining for chronic humoral rejection requires further study. renal outcome appears to be worse in c d positive patients. current treatment strategies to manage c d-positive chronic humoral rejection are poorly defined. various protocols with enlarged doses of tacrolimus, mycophenolate mofetil, plasmapheresis, ivig and rituximab have been reported in adult patients. we investigated four pediatric patients (mean age . yrs; range to yrs) after renal transplantation that developed c d positive chronic rejection. in of patients, maintenance immunosuppression with calcineurin inhibitors had previously been minimized because of severe toxicity. in of patients, an elevated anti hla class ii antibody titre could be detected; donorspecific antibodies were positive in patients. all patients experienced a progressive deterioration of graft function. treatment with repeated intravenous immunoglobulin (ivig) ( g/kg body weight per week over four consecutive weeks) followed by a single dose of rituximab ( mg/m ) was therefore initiated. three of four patients showed an improvement of graft function with a mean increase of gfr by %. one patient with advanced chronic transplant nephropathy lost his graft after months. this pilot study demonstrates that the combination of high-dose ivig and rituximab can stabilize or improve transplant function in chronic antibody-mediated rejection without major side effects. the use of ivig and rituximab appears to reduce the active immunologic process, but larger trials are needed to support these observations. cardiovascular diseases are some of the most important causes of morbidity and mortality in children with end stage renal disease (esrd). chronic inflammation has been suggested to be a risk factor for cardiovascular diseases. the aim of this study was to investigate the relation between crp and cardiac changes in children on hemodialysis. this study was conducted on patients ( patients were hypertensive & were normotensive), males ( %) and females ( %) on regular hemodialysis due to esrd. their ages ranged from to years (mean . ± . ). sixty age-and sex-matched controls were also included. significantly higher velocity of circumferential fibre shortening (vcfs), tei index, interventricular septum thickness in diastole (ivsd), left ventricular mass index (lvmi) and isovolumetric relaxation time (ivrt) and significantly lower e/a ratio were found in all patients as well as in hypertensive & in normotensive groups as compared to the controls. significantly higher ivsd and lvmi were found in hypertensive patients than normotensive patients. significantly higher high sensitivity crp (hs-crp) & crp latex were found in all patients as well as in hypertensive & in normotensive groups when compared to the controls. crp was significantly higher in both study groups with cns symptoms and cardiac symptoms in comparison to those without. it was also significantly higher in patients with increased lvmi & than in those with abnormal e/a ratio. hdlc showed a significantly direct negative effect on crp. s. ca + , se. p and ca x p had a significantly direct positive effect on it. we can conclude that the cardiac affection in children with esrd appears in the form of lv hypertrophy with early diastolic affection. crp could be correlated to these changes and to cns symptoms and cardiac symptoms in these patients. is. lim, hs. lee, dw. kim, wh. choi chung-ang university, pediatrics, seoul, south korea purpose: urinary tract infections are common clinical problems occurring in infants and pediatric patient groups, most frequently caused by uropathogenic e. coli. urinary pathogens almost always infect the host through ascension from the rectum, vagina to the urethra and bladder. recurrent urinary tract infection is a disorder involving repeated or prolonged bacterial infection of the bladder or lower urinary tract. in this study, we examined the substitusion effect of probiotics in the high risk group of recurrent urinary tract infection. objectives & methods: patients diagnosed as recurrent urinary tract infection were administered probiotics for six months, and urine cultures were checked during the period. probiotics in this study were selected among the products commercially saled in korea, namely lactobacillus acidophillus, bacillus subtilis, and bifidobacterium infantis. single blind study was done for selection of probiotics for patients. result: the separated bacteria from the urinary tracts of the patients were the same as administered probiotics in some patients. conclusion: in recurrent urinary tract infection, there seemed to be a substitution effect of probiotics for uropathogenic bacteria, and it is reasonable to administer probiotics for long period in the high risk group of recurrent urinary tract infection. renal insufficiency therapy in children: quality assessment and improvement: the rich q study objectives: outcome studies in children on chronic renal replacement therapy (crrt) have revealed a -time increased mortality and % co-morbidity in adult survivors. information on the quality of care of treatment centers and on the impact of advised quality indicators on outcomes in children are lacking. no data exist on the impact on these outcomes of the different treatment modalities, peritoneal dialysis, hemodialysis & transplantation either. until now, no structural corporation and consensus on general guidelines with respect to crrt exist between the dutch (nl) and belgium (b) centers for pediatric crrt. aim of the study: . assessment of the current quality of treatment crrt in children (qt) in nl & b and of the effect of recurrent peer review of the achieved outcomes on the qt. . the assessment of the effect of different treatment modalities on outcomes. . the creation of a format for multicenter trials. methods: all prevalent patients on chronic dialysis aged < years at onset of the study & all incident patients during the study period with onset of crrt< years of age, from b & nl will be included. treatment characteristics and quality indicators of crrt with respect to physical and psychosocial outcomes will be collected of all patients. operational data collection and management will be performed by members of the dutch institute for quality care in dialysis patients (hans mak institute). each months, all data will be revealed and actively discussed by representatives of all centers (peer review). the effect of registration and peer review on the qt will be analyzed after & years. comparison will be made between the effects of cumulative periods of different rrt models on outcomes. the study will be performed between august & . on estimation, patients will be analyzed. renal renal transplantation in patients with lower urinary tract dysfunction (lutd) of different origin is a challenging issue in field of pediatric transplantation. we report our single centre experience to evaluate the patient and graft survival as well as risks of the surgery and immunosupressive therapy. among pediatric transplant patients patients had severe lower urinary tract dysfunction. videourodynamic test was performed in all patients preoperatively and postoperatively. the cause of urological disorders was secondary to neurogenic bladder (n: ) and valve bladder (n: ). clean intermittent cathatetization (cic) was needed in patients to empty the bladder. pretransplant augmentation ileocystoplasty was created in four patients and gastrocystoplasty in one patient to achieve low-pressure reservoir with adequate capacity. three of the patients received kidneys from cadaveric and of them from living donors. the mean age at transplantation was ± . years. the median duration of transplantation was months (range - months). at their last visit median creatinin levels were . mg/dl ( . - . ) . three patients had recurrent symptomatic urinary tract infections who had augmented bladder and on cic. one of them had creatinine levels of . mg/dl. one patient with ileocystoplasty who developed urinary leak and ureteral stricture in early postoperative period was treated by antegrade j stent. severe lutd reserves high risks for graft kidney. however our data suggests that renal transplantation is safe and effective treatment modality if the underlying urologic disease properly managed during the whole course of transplantation period. since surgery and follow-up of these patients is more complicated, patient compliance and experience of transplantation team will have significant impact on the outcome. r. meneses, l. sylvestre, j. sousa, d. ribeiro hospital pequeno principe, pediatric nephrology, curitiba, brazil introduction: in july , we started a systematic evaluation program of each patient on chronic pd. the aim of this study was to analyze the long-term outcome of children on pd program. material and methods: we evaluated all the patients on pd between july and may , who performed complete protocols, with a minimal interval of months between them, consisting of: anthropometric measurements, blood pressure and cardiological status, standardized laboratorial evaluations, pet test, clearance and kt/v, measurement of the intra-peritoneal pressure (ipp), occurrence of infections, hernias or constipation and need to change the catheter. we then compared all the evaluations using the graphpad prism software, a p value < . was considered significant. results: out of patients were eligible, mean age ± years old at the first evaluation, % boys, primary renal disease: % uropathies, % glomerulopathies, % tubulopathies and % other causes. there was an improvement on bmi and weight/height z-scores and worsening of height/age z-score, but none was significant. there was also no significant decrease in residual renal function (p= . ), adequacy parameters remained stable: clearance (p= . ) and kt/v (p= . ). most patients were converted from capd to ccpd and nipd, and some had to increase daytime dwells (p= . ).constipation and the number of infections improved but not significantly. laboratorial evaluations, peritoneal membrane characteristics, ipp, need to change the catheter and occurrence of hernias did not change over the time. conclusion: a long-term maintenance of children in peritoneal dialysis program is possible, but reaching a satisfactory clinical condition is a great challenge. several points need to be checked for planning a better adequacy and survival of dialysis technique in children waiting for a graft. a rigorous follow-up protocol seems helpful in precocity of prescription strategy modifications. we observed a stable long-term outcome observing these adequacy tools. outcome the recurrence of primary disease in transplants is a well-known problem. we report our single centre experience to assess the frequency of the recurrence of primary glomerulonephritis in children after renal transplantation. medical reports after of children with primary glomerular disease were evaluated. the grafts were nine from living related and four from cadaveric donors. eight of them were diagnosed as fsgs, of them mpgn and of them pan. the mean age was . ± . years. however the median transplantation duration was months, one of the fsgs patient had hyperacute rejection. five years later she had second graft with the serum creatinine . mg/dl at th year of second transplantation. and all recipients were immunosuppressed with either cyclosporin a or tacrolimus, azothioprine or mmf and steroid based regimens. mutational analysis was available in two patients, they had homozygous podocin mutations. post transplant recurrence of fsgs was confirmed in one patient. glomerular tip lesion was the only histologic abnormality on graft biopsy. he has treated with plasmapheresis with no improvement of proteinuria. two of the fsgs patients had thromboses after transplantation. one of them had cardiac thrombosis with heterozygote mthfr mutation and one of them had renal artery thrombosis and loss of graft with prothrombin a mutation. both of them have had additional risk factors for thrombosis. they have all functioning grafts except one. we have not observed any recurrence in patients with pan and mpgn. although the number of our patients quite small, renal and patient survival seems to be more favourable in our experience but we strongly recommend the evaluation of all risk factors of thrombosis and give appropriate anticoagulation. skin involvement in factor h deficiency (fhd) associated to hemolytic uremic syndrome (hus) has never been reported. we describe the case of a young adult on regular hemodialysis (hd) for fhd-hus who developed microangiopatic skin lesions and was successfully treated with plasma exchange (pe). the patient developed end stage renal disease secondary to fhd-hus (scr ) in , when she was . after one year of hd she complained of severe night pain in the perimalleolar areas, followed by skin lesions which evolved into superficial ulcers (fig ). in august , due to the worsening of the skin lesions, the patient started hd and pe ( litres of fresh frozen plasma per session twice a wk) based on the hypothesis that skin lesions were expression of thrombotic microangiopathy. after wks of pe there was a skin improvement (fig. ) and a pain relief. pe was discontinued. wks later she started to complain of the usual pain in the right foot. pe program combined to hd was restarted and the symptoms ceased again. pe was gradually discontinued and she was addressed to regular plasma infusion of . litre per wk. so far, after months the pain and the skin lesions did not show up again. m. belingheri, s. cristino, p. basile, v. bianchi, a. leoni, s. testa, l. ghio, a. edefonti, g. ardissino ospedale maggiore policlinico irccs, mangiagalli e regina elena, pediatric nephrology, milan, italy background: in rapidly growing children on hemodialysis (hd), the determination of dry weight still remains troublesome. bioimpedance analysis (bia) is potentially helpful in quantifying the fluid to be removed but its specific role, in routine clinical practice, is not yet clearly set. the aim of the present study was to test the feasibility of prescribing ultrafiltration (uf) exclusively based on bia parameters. methods: differences in body weight, resitance (rx) and reactance (x-c) between pre-and post-hd were calculated in order to derive the equivalence between uf and bia parameters in a years old girl over a period of months. for consecutive hd sessions, uf was prescribed exclusively based on the derived uf-bia equivalence. this period was compared with hd sessions where uf was prescribed by the conventional approach. results. xc correlated with ultrafiltration better (r: . ) than rx (r: . ). bia-based compared with weight-based uf prescription showed a significantly lower number of hd sessions complicated by hypotension ( % vs. %), need of fluid reinfusion ( % vs. %) and a better quality of the hd sessions ( % vs. %). conclusion. prescription of uf solely based on xc is feasible and provides a better outcome compared to the conventional modality of uf prescription. we believe that this approach could be useful for any patients with low tolerance to uf or with problems in setting the correct dry weight. aim: the aim of the present prospective study was to determine the incidence of urinary tract infection (uti) and related abnormalities in children ages between - years. material and methods: all children between - years old whose admitting to first step health offices (routine controls and immunization) was screened for uti with urine dipstick test after education of minimum two persons from first step health offices according to protocol with two tertiary child care center and health directorate of izmir province in turkey between july and july . all patients with urine dipstick test abnormalities were referred to tertiary child care centers for evaluation. urine microscopic evaluation and urine cultures and other further investigations were performed in tertiary care centers after obtaining urine with urinary catheterization. results: . children ( % boys) were screened with urine dipstick test. the children's mean age was . ± . mo (median mo). screening test was found normal in . ( %) children. of ( %) of referred child were admitted to tertiary care centers and evaluated for uti. uti was demonstrated in children ( . % of screened and % of evaluated children's). uti incidence was found . % in girls and . % in boys. urinary tract abnormalities were found in children ( . % of screened and . % of evaluated children's). the most common urinary abnormality was vesicoureteral reflux ( patients). conclusion: the uti incidence was . % in children ages between - years, uti more common in girls than boys in this age group and only small group of children has urinary tract abnormality which is determined with routine urine screening. knowledgement: thank you for this opportunity to health directorate of izmir province. we describe ds post-peldrt in children with no known neurologic problems and discuss potential predisposing factors. a . kg girl with renal dysplasia was started on a calcineurin inhibitor (cni) one week pre-t and when her blood urea nitrogen (bun) was mg/dl. on admission for t, the bun had increased to , and her serum sodium (na) was mmol/l. post-t, she remained intubated and paralyzed to permit generous volume supplementation, including : replacement of her vigorous urine output (uop), initially with . % nacl in water. five hours post-t, her bun was and her na . after modification of uop replacement, her na normalized. on the morning of post-t day , paralysis was discontinued, but she did not awaken and had sluggish pupillary reactions. computed tomography of the head (cth) revealed diffuse cerebral edema, and brain death occurred. a kg adoloescent with polycystic kidneys was started on a cni days before peldrt. his bun and na then were and , respectively, and had not changed on the day of t. post-t, the patient was immediately extubated. with uop replacements as described above, his bun and na decreased from to and to , respectively, over hours despite adjustments in the na content of his intravenous fluids based on urine na levels. the patient then had a -second tonic-clonic seizure, followed by a -hour post-ictal state. cth was negative, and the patient recovered completely. we conclude that ds, caused by a rapid decrease in serum bun and thus osmolality, may complicate peldrt in settings even with older pediatric recipients or without excessive elevation of pre-t bun. other factors contributing to this ds may include relatively mild hyponatremia and cni effects on both pre-t uremia and seizure threshold. results: patients, predominantly males, ages between months and years old. the mean incidence of peritonitis was . episodes/patient months. fifty-seven patients ( %) had at least one episode of peritonitis.there were peritonitis, % percent from all episodes began at home, % caused by gram negatives, % by gram positives, % by fungus, % had a negative culture and in less than % it was not performed. the mean treatment time was days, % had a good response to initial empiric antibiotics (cefazoline and amicacine). the interval between the beginning of dialysis and the first peritonitis episode varied from to days, occurring in the first months in % of the patients. successful treatment occurred in % of the cases, % were transfered to hemodialysis, % had a consecutive peritonitis episode, and patient died due to mesenteric artery trombosis. conclusion: peritonitis occurred early in our patients. even though most of them have a good initial response, there is still a great amount that have complications leading to technique failure. continuous education for the patients and health team, aiming early diagnosis and treatment, are useful to preserve the technique and decrease morbidity and mortality associated to peritonitis. d. davis, j. emancipator, x. zhu, c. rosen objective: to assess for sd in p chronic kidney disease (ckd) patients before and after rtx. methods: we assessed symptom (sx) domains of sleep disorders: ) sleep-disordered breathing (sdb); ) insufficient sleep (is) (shortened sleep time or nap); ) excessive daytime sleepiness (eds); and ) restless leg syndrome (rls) using a set of standardized questionnaires in patients with ckd (age - yrs) including non-d non-tx (ndntx) (n= ), d (n= ), rtx (at least months post-tx) (n= ), and age-matched sibling controls (c) without known ckd. the presence of an overall sd was defined by positive responses in any of the sx domains. results: mean age (se) ranged from . ( . ) to . ( . ) in the pt groups (p> . ) without significant differences in gender, race, or congenital ckd. estimated mean gfr (ml/min/ . m ) (se) was significantly higher in the rtx group [ . ( . ) methods: in a prospective design, renal transplanted children, who had renal transplantation at least months before, at namazee hospital, were enrolled in our study. immunosuppressive regimen consisted of cyclosporine and prednisolone plus mycofenolat mofetil or azathropin. data regarding gfr, serum creatinine, electrolytes, lipids and c and c levels was collected at beginning, in one-month, and five-month intervals. cyclosporine was adjusted to - ng/ml based on c level. patients were divided into two c (< and > ng/ml) and two c (< and > ng/ml) subgroups. discussion: similar creatinine levels, drug dosage, and complications of c and c subgroups may be due to dependence of renal function to several factors other than cyclosporine dosage. regarding coefficient of variation, c was more accurate and reliable than c level. as there was no significant difference in mean c and c levels, and renal function at beginning and the end of the study, there seems to be no need to check c levels after renal transplantation. purpose: preparation is necessary in order to effectively meet the critical needs of the post-operative pediatric kidney transplant patient upon their arrival to the icu following transplantation. the increasing number of children requiring liver transplantation services has made it evident that it is important to have guidelines in place for their initial and often specialized post-operative care. methods: the main goal is to provide the child with appropriate post-operative care and to recognize and quickly address complications. therefore the icu nurse will: · monitor the patient continually and conduct full assessments a minimum of time/hour (airway, breathing, ventilation, perfusion, neurological status, etc) . · observe the incision for signs of bleeding, evisceration, and dehiscence. · treat post-operative pain. · update family with findings, etc. · see that appropriate post-operative studies (ultrasound, laboratory studies, etc) are completed. outcomes: nurses in the icu monitor the pediatric post-operative kidney transplant patients very closely as outlined. this allows for quick recognition of problems and immediate intervention. it is the practice of these nurses to be fully aware of the patient's status as well as any changes that might be problematic. conclusions: nurses are prepared to care for pediatric kidney transplant patients and very carefully follow established guidelines for assessment. following guidelines for assessing and caring for pediatric kidney transplant patients upon admission to the icu has proven to be affective in allowing nurses to quickly recognize complications and notify the appropriate clinician. background: uremia is an independent cardiovascular risk factor. transplantation increases life expectations of patients with crf, however there is still an increased risk of accelerated arteriosclerosis. the pulse wave velocity (pwv) is a non-invasive marker of arterial distensibility, it increases along with arterial stiffness, as an early indicator of arteriosclerosis. aim: to evaluate pwv values of transplanted (tx) children. patients, methods: pwv was measured with a pulsepen in tx (age , ± , years). two control groups were formed using a database of healthy children ( - years): one matched for age (a) and one adjusted for height and weight (h/w). blood pressure, heart rate, serum calcium (ca), phosphate (p) , and pth were also determined before transplantation and at the time of the pwv measurement. results: tx patients were smaller by , cm (p< , ) than a and younger by , years than h/w (p< , ). pwv in tx ( , ± , m/s) did not differ significantly from a ( , ± , ) , however it was elevated in comparison to h/w ( , ± , p< , ). serum p, caxp and pth was increased before transplantation, all the values returned into the normal range except for creatinine ( ± micromol/l) at the time of the study. there was no correlation between pwv and the actual values of ca, p and pth. conclusion: pwv is higher in transplanted children as a sign of increased arterial stiffness. controls matched for height and weight should be used in states of severe growth failure. although a number of established risk factors potentially responsible for arterial dysfunction were present before transplantation, they were normal at the time of the study. the long lasting effect of uremia before transplantation could be in part responsible for the increased pwv in children after transplantation. supported otka-t -fo -f and ett / . d. derakhshan , h. jalaeian , a. derakhshan department of pediatric nephrology, shiraz, iran shiraz organ transplantation center, nemazee hospital, shiraz, iran backgrounds: bartter syndrome is an inherited recessive autosomal tubulopathy characterized by hypochloremia, hypokalemia, metabolic alkalosis associated with potassium renal leakage, and normal blood pressure despite increased plasma renin activity. patients with this syndrome may have proteinuria or hematuria, but most of them have normal gfrs. here we report on a child with bartter syndrome who developed esrd (end stage renal disease) and underwent successful cadaveric kidney transplantation. case presentation: a -year-old girl presented to the pediatrics nephrologist with failure to thrive, severe hypokalemia, hypochloremia, metablolic alkalosis, and normal blood pressure and the diagnosis of bartter syndrome was considered for her. however, due to poor compliance, she did not receive any medications, did not give consent for kidney biopsy and did not attend her opd follow-up visits for about years, when she developed esrd and went on chronic hemodialysis ( /weeks) . her little sibling also was diagnosed to be suffering from bartter syndrome at this time. after months, she received a cadaveric renal allograft. afterwards, her kidney function, serum electrolytes, and growth have improved dramatically. discussion: in this case, we postulate that long-term hypokalemia due to bartter syndrome led to chronic interstitial nephritis and renal dysfunction. successful renal transplantation, even after the onset of esrd, for severe clinically bartter syndrome results in correction of metabolic abnormalities and excellent graft function. we propose that bartter syndrome should be considered as a possible cause of esrd and an indication for early renal transplantation, a procedure that results in a cure for the underlying disease and significant improvements in patient's quality of life. h. jalaeian , a. derakhshan , d. derakhshan , m. fallahzadeh , z. bazargani , m. basiratnia shiraz organ transplantation center, nemazee hospital, shiraz, nemazee hospital, shiraz, iran fasa university of medicine, pediatrics, fasa, iran shiraz university of medical sciences, pediatric nephrology, shiraz, iran background: obesity is a major issue in the end stage renal disease population. while studies evaluating the effect of obesity on transplant outcomes in adults have yielded varying results, this issue is even still more controversial in children. methods: in a cross-sectional design, pediatric recipients, aged - at transplantation and with normal graft function for at least months after transplantation, were evaluated. we grouped the data with regard to the body mass index (bmi) percentiles as group i (bmi > th), group ii (bmi < th), group iii (bmi > th), group iv (bmi < th). we compared the clinical and laboratory findings between groups i and ii and between groups iii and iv. obesity was defined as bmi > th and being overweight was defined as bmi > th. results: there were children ( males, females) with mean age at time of transplantation of . ± . years (range, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , and mean follow-up of . ± . years. . % of children were overweight and . % were obese. no difference was found regarding age, height, duration of pretransplantation dialysis, or age at transplantation between groups i and ii and between groups iii and iv. (p> . ). further more, no difference was found in regard to serum creatinine, bun, glomerular filtration rate, and -year graft survival rates among obese and/or overweight and other children. no correlation was found between bmi and gfr (p> . ). conclusion: obese and overweight recipients can have excellent graft function and survival rates that are comparable to their non-obese counterparts. denying patients access to renal transplantation on the basis of obesity per se does not appear to be justified. d. derakhshan , h. jalaeian , a. derakhshan , b. sabet , m. fallahzadeh nemazee hospital, shiraz, iran shiraz organ transplantation center, nemazee hospital, shiraz, iran introduction: tb is an important cause of morbidity and mortality in renal transplant recipients, especially in developing countries. this study was done to identify the incidence of tuberculin test positivity before transplantation as well as the influence on outcome of graft function and patient survival in children who receive renal allografts. methods: all children with esrd who received a renal allograft between and were evaluated. as a routine pre-operative measure, a tb test was administered, using ppd. the ppdpositive recipients were compared with ppd-negative subjects, regarding age, gender, graft function, graft outcomes and patient survival rates. patients were divided into < mm versus > mm induration. results: the mean age of recipients was . ± . years (range, - ) with a male/female ratio of . : . the majority of children were on chronic dialysis with mean duration on dialysis of . ± . months. the tuberculin test was positive in . % of children; all of them received isoniazide prophylaxis on diagnosis of latent tuberculosis. overall, the -year, -year, and -year survival rates were . ± . %, . ± . %, and . ± . %. three year survival rate was not different among ppd positive or ppd negative individuals. ( . ± . vs. ± . %; p> . ) in addition, no difference was found for -year or -year graft survival rates (p> . ). also serial serum creatinine levels at -month, -month, -year, -year, and - year interval after transplantation was not statistically different (p> . ). conclusions: detection of latent tuberculosis infection is an important step in the control of tuberculosis among asymptomatic pediatric kidney transplant. with proper management, latent tb does not affect transplantation outcome among children. h. xu, q. shen, ss. ruan, yl. bi, yq. lu, x. wang children's hospital of fudan university, department of nephrology, shanghai, people's republic of china objectives of study: we have started the first pediatric renal transplantation project in children hospital in china from . survival of patients and grafts for the patients are %. the clinical features were analysed and specific problems related to drugs and infections were reviewed. methods: children ( ~ years old) underwent rtx. the duration of follow-up was months to months (average of . months). results: all the patients were on automated peritoneal dialysis prior to rtx. the transplanted kidneys came from cadaveric donors (one were a -year-old brain-dead boy). patients received il- receptor antibodies as induction therapy and the other one with alg due to high level of population reactive antibody. after the rtx, all the patients were on triple immunosuppressive treatment (prednisolone, mmf, fk or csa) . no patient developed postoperative complication and delayed graft function occured. during the follow-up, case suffered from calcineurin inhibitor renal toxicity and changed to rapamycin treatment, from acute respiratory distress syndrome due to infection and from elevated liver enzymes owing to drugs. one had acute rejection at months after the operation. a severe anemia appeared on him after the rejection recovered. the cause of the anemia was found by the positive of serum anti-parvovirus b igm and completely recovered from the ivig treatment. at latest follow-up, the mean serum creatinine level of the patients was . ± . umol/l and egfr was . ± . ml/min/ . m . some patients received a support from "shanghai child renal failure trust fund". conclusions: the improvement of surgical technique, adequate dialysis prior to rtx, rational use of medicine, financial support and regular follow-up are all important for improving the outcome. h. bunker-wiersma , , j-c. davin the area under the curve (auc) of cyclosporine is strongly related to the efficacy and toxicity of the drug and its variability is mainly determined by the absorption phase. close therapeutic drug monitoring (tdm) is warranted to optimise therapy, using more appropriate methods to estimate the auc, than trough concentration measurement. from july we started auc guided monitoring of cyclosporine therapy based on two concentration measurements, c and c . the results of this method are reported. methods: all paediatric renal transplant recipients treated with cyclosporine were included in the analysis. bayesian, model based estimation of auc values was performed at each out-patient visit or during hospital admission. calculated pharmacokinetic parameters, treatment efficacy data and side effects were collected over the month period after introduction. target auc values were derived from previous studies in adult patients: ng/h/ml in the first three months after transplantation and ng/h/ml after three months. results: early or stable post renal transplant patients were evaluated, divided in two groups (group i: < months after transplantation; group ii: > months after transplantation). in patients with trough concentrations below the therapeutic range, more than % auc's were in the therapeutic range in both groups. conclusion: auc guided monitoring of cyclosporine after kidney transplantation in children using c and c is practically feasible and presents the major advantage that c has not to be determined precisely hours after csa administration. it is more closely related to the total drug exposure as compared with trough concentration monitoring and isolated c . this method may facilitate the use of lower doses of cyclosporine and by this way limitside-effects. objectives: there is no satisfying data about reproductive functions after kidney transplantation in adolescence who have end stage renal disease (esrd) during childhood. we analysed the reproductive functions of kidney transplanted male adolescences. patients and methods: nine patients who followed between - were enrolled in the study. except one preemptively transplanted patient, all were on hemodialysis/peritoneal dialysis before transplantation. mean dialysis duration was ( - ) months. their ages ranged between - years (mean . ) at transplantation. at the urologic examination, their mean age was years. all patients had normal renal functions. results: all patients had normal testicular volume, libido and erectil functions. except one all patients had normal serum levels of lh, fsh, total and free testosterone. seven of the patients semens were available for analysis. / patients had normal sperm parameters. transplantation had been performed before adolescence period in these patients. one of these patients had been treated with intensive cyclophosphamide before. oligospermia was detected in , defective morphology in , low sperm motility in / patients. conclusion: although adult transplanted patients mostly have normal semen profiles; male children with end stage renal failure would not have normal spermatogenesis at the adolescence period; even after successful renal transplantation. in our study only patients had normal semen profile, even hormon levels were normal. renal transplantation age seemed to be more crucial than the duration of esrd, of primary diagnosis or previous cyclophosphamide usage. r. vilalta, j. nieto, e. lara, a. madrid, s. chocron hospital materno-infantil vall de hebron, department of pediatric nephrology, barcelona, spain background: inhibition of il- receptors by basiliximab is irreversible and extended in time (mean days). basiliximab (anti cd receptor) is used usually in the induction regime in our first cadaveric-donor kidney transplants. its re-use when chronic allograft nephropathy (can) develops could be useful. however some concern could exist related to possible adverse reactions (anaphylactic shock) linked to re-exposure to this drug because is an heterologous protein. less adverse reactions as lymphokine release syndrome has been described with the use of other monoclonal antibodies as the anti-cd receptor rituximab. objective: to describe our experience in the treatment with basiliximab of seven children with banf ii can. patients: seven children ( - years old (means . y.), boys, girls) showed biopsy-proved banf ii can. its period post-transplant ranged from to years (mean . y.) and their creatininine level from to mg/ ml (mean . ). all of them had been received at the transplant time basiliximab, tacrolimus or cyclosporine, mycophenolate and tapered steroids to reach . mg/kg/day in the third month post-transplant. when can developed, sirolimus was used in two patients, but was withdrawn due to increase of proteinuria. results: one dose of basiliximab ( mg/ . m ) was administered after steriod pulses ( mg/kg/day) in all patients. their basal immunosuppression was not changed. plasma creatinine diminished by % in four patients in the second week post-treatment and this improvement was sustained in two patients after one year follow-up. proteinuria did not change in any patient. in the course of this treatment no adverse reactions were observed. conclusion: ) use of basiliximab in can is safe and possibly useful. ) exposure to different monoclonal antibodies in paediatric kidney transplantation could be usual in the future; in the induction time, in the treatment of humoral rejection if exists (rituximab) and in the treatment of can. ) it is necessary to establish that exposure and re-exposure to different antibodies is safe and without major adverse effects as our limited experience supports. r. vilalta, e. lara, a. madrid, s. chocron, j. nieto hospital materno-infantil vall de hebron, department of pediatric nephrology, barcelona, spain background: there are limited knowledge of kinetics and pharmacodynamic effect of sirolimus in paediatric renal transplantatation. provided that sirolimus is effective and safe in combination with tacrolimus and mycophenolate (mmf), the initial dose needed, the evolution of blood levels and the steady state should be studied in order to optimise its clinical use. objective: to establish a possible correlation between dose/level ratio of rapamune and other parameters as age, gender or puberal state. patients and methods: between and , paediatric patients ( girls, boys) received a cadaveric kidney transplant. age ranged from to years (mean y.), and all of them received mmf and steroids. sirolimus were used from . to . mg/kg/day, to obtain levels between to ng/ml. results: dose/level ratio obtained allowed us to describe three types of patients: an infant-type i dose-level patient (age - y), a prepuberal type ii (age - y) and an adult-type iii dose-level patient (age - y). type i needed sirolimus between . and . mg/kg/day (sd± . ), type ii between . and . mg/kg/day (sd± . ) and type iii between . and . mg/kg/day (sd± . ) to obtain all of them a constant blood levels between and ng/ml. the same positive correlation was obtained regarding the puberal status. no correlation were observed regarding the gender. introduction: developing of diabetes mellitus after renal transplantation is one of the determining factor in the survival of the patient and the graft. in present study we assessed the carbohydrate metabolism status of ntx. methods: we analyzed patients' data about recently developed carbohydrate metabolism failure after ntx. children underwent ntx between - were investigated. thirty-nine children ( girls/ boys) underwent ogtt, who had no ptdm. we analyzed the incidence of ptdm/igt, the combination of immunsuppressive therapy, the number of transplants, the proportion of cadaver/living donor, hcv, blood pressure, lipid metabolism, bmi, graft function parameters and the time since ntx. results: ptdm developed in children ( %). four of patients required insulin therapy. we diagnosed igt in of with ogtt investigated patients ( %). all ptdm/igt patient got tacrolimus and continous steroid therapy. the dose of steroid was . mg/day in the ptdm/igt group vs. . mg/day no ptdm/igt (p< . ). during ogtt the trough level of tacrolimus was higher in the ptdm/igt group . ng/ml vs. . ng/ml (p< . ). in the other parameters we did not find any significant differences between ptd/igt and no ptdm/igt patients. discussion: the most important reasons in the development of ptdm and igt after transplant are steroid therapy and higher tacrolimus trough level. in transplant children we recommend the regular fasting glucose and ogtt examimation, the reduction of steroid and tacrolimus in case of stable graft function. otka f- , otka-t , ett / , ett / the introduction: measurement of plasma bnp is a novel noninvasive approach in the assessment of cardiovascular status. in our study we investigated the role of bnp in the monitoring of cardiovascular status of children with crf or renal transplant (ntx). methods: we examined children with crf (n= , boys/ girls, age: , year ( , - )) or ntx (n= , boys/ girls, age: , ) ). patients underwent echocardiographic investigations (ivs, lvedd, lvesd, pw and fs) and their bnp levels were measured (age matched normal values were used). other cardiovascular risk factors, such as hgb, htk, ca, p, creatinine and blood pressure were also evaluated. a correlation between bnp and echocardiographic results was calculated. results: the values of lvesd, fs and bnp levels of renal transplant patients were significantly better than those of crf patients (p< , ). the other parameters did not show significant differences. bnp levels were significantly higher in all age groups of crf patients as compared to the normal levels. in younger ntx patients this value was within normal limits. in older ntx patients, and in those that had their transplants a long time ago we measured higher bnp levels, which correlated significantly with graft function as well (p< , ). bnp showed a significant positive correlation with lvesd and a significant negative correlation with fs only in crf patients. the elevated bnp levels showed the worsening of cardiac function even when the echocardiographic parameters were still normal. the hgb, htk, ca, p and creatinine values were significantly better in ntx patients and showed no correlation with bnp. summary: bnp is an early, easily usable marker in diagnosing and following decreased cardiac function of both crf patients and after ntx. otka f- , otka-t , ett / , ett / c. garcia , v. bittencourt , s. vitola , e. didone , e. guerra , f. pires , a. tumelero , d. malheiros , v. garcia department of pediatric nephrology, porto alegre, brazil complexo hospitalar santa casa, department of nephrology and kidney transplantation, porto alegre, brazil complexo hospitalar santa casa, department of surgery, porto alegre, brazil the objective is relate the results of consecutive kidney transplants carried out in children in a single center. patients and methods: analysis of kidney transplants performed in patients less than years old, carried out from may to december . results: kidney transplants were performed. % of the patients were female, % were caucasian and % were african-brazilian. the mean age at the transplant was . ± . years. the most frequent etiology of renal failure was vesico-ureteral reflux/obstructive uropathy ( %), followed by glomerulopathy ( %). the donor was deceased in % and living related in % (parents %). the initial immunosuppression was cya+aza+pred in . %, cya+mmf+pred in , %, tac+aza+pred in . %, tac+mf+pred in . %, tac + mf without pred in . %. sirolimus was employed initially in cases. induction with okt /atg occurred in patients and received anti-il receptor antibody. the graft losses during years of follow-up were secondary to chronic allograft nephropathy in ( %), vascular thrombosis in ( . %), acute rejection in ( . %), recurrence of original disease in ( . %). there were transplants in patients with focal segmental glomerulosclerosis, ( . ) had a recurrence after transplant. eight were treated with plasmapheresis and % obtained a total remission. the survival of graft in the first, fifth and tenth year was: %, % and % respectively. the graft survival in the th year according the immunosuppression was % using azathioprin and prednisone, % with cya/aza or mmf and % with tac/aza or mmf. the patient survival in the first, fifth and tenth year was: %, % and % respectively, infection was the main cause of death. j. feber , p. geier , b. chaudry , h. wong , g. filler children's hospital of eastern ontario, division of pediatric nephrology, ottawa, canada london health science center, departments of pediatrics, london, ontario, canada successful pediatric renal transplantation (tx) should fully correct the metabolic abnormalities of end-stage renal failure. however, ckd may persist because of only half of the normal nephron endowment and other factors (ischemia, nephrotoxocity etc). height, bmi and blood pressure (bp) z-scores, cystatin c-gfr, hemoglobin (hb), serum pth, hco , cholesterol, mycophenolic acid (mpa) and sirolimus (sir) levels were analyzed retrospectively in tx recipients ( males, age . ± . years) at months post tx (t ) and at . ± . years (median . ) post tx (t ). data are expressed as mean±sd. height z-scores remained significantly lower than controls (t : - . ± . ; t : - . ± . , ns), growth failure occurred in % of pts at t and % of pts at t . bp z-score did not change from t to t , but hypertension was diagnosed in % pts at t and % pts at t . gfr (ml/min/ . m ) was . ± . at t and . ± . at t (ns), mean decline of gfr was . ± . %/year. hb z-score remained below normal at - . ± . at t and - . ± . at t (ns) and anemia was diagnosed in % and % of pts at t and t respectively, despite trough levels of both mpa ( . ± . mg/ml, pts) and sir ( . ± . mg/ml, pts) that would be considered adequate. hypercholesterolemia was detected in . % pts at t and % pts at t , whereas only . % of pts at t and . % of pts at t were labeled as obese. bone disease was diagnosed in . % pts at t and . % pts at t . we observed suboptimal growth, hypertension, hypercholesterolemia, bone disease and persistent anemia in a significant proportion of tx children despite iron supplementation, adequate mpa and sir levels and good kidney function. these ckd complications require careful monitoring and intervention. a. al midani , g. koffman , j. john , s. stephen , s. suzanne , r. lord royal free hospital, transplantation, london, united kingdom great ormond street hospital for children nhs trust, transplantation, london, united kingdom objectives: to document factors predisposing towards surgical complications over years in a single pediatric renal transplant centre. methods: we retrospectively analysed consecutive renal transplants between jan and dec . patients were divided into group , without complications, and group , with complications. we compared variables previously identified as risks for surgical complications between the two groups: live/deceased donor, donor and recipient age, gender and weight, side of organ donation, cold ischaemia time, single/multiple vessels, intraperitoneal/extraperitoneal approach, anastomosis to aorta/iliac vessels, thrombosis prophylaxis (changed from heparin to aspirin in oct ). results: / ( %) were complication free; % patients developed one or more surgical complication: wound infection / ( . %), wound dehiscence ( . %), prolonged ileus ( . %), lymphocoele ( . %). patients were re-explored: ( . %) for bleeding, ( . %) for graft repositioning. we observed ( . %) cases of renal artery stenosis. overall, ( . %) graft loss occurred secondary to thrombosis, % ( / ) prior to changing our prophylaxis from heparin to aspirin ( . % on aspirin). urological complications occurred in ( . %): ureteric leaks and ureteric stenoses. the variables between group and group were as follows: under kg: % v %, less than yrs old: % v %, intraperitoneal approach: % v %, anastomosis onto the aorta: % v %, no aspirin prophylaxis: % v %, other variables were the same in both groups. conclusions: % of patients developed surgical complications. a higher rate of surgical complications was seen in recipients under , using the intraperitoneal approach onto the aorta. the introduction of aspirin prophylaxis reduced graft loss due to thrombosis from % to . %. other variables did not affect the complication rate. m. medeiros , v. sharma , r. ding , s. valverde , am. hernández , p. garcía , y. fuentes , m. suthanthiran hospital infantil de mexico federico gomez, departamento de nefrologia, mexico, mexico weill cornell medical college, immunogenetics and transplantation center, new york, ny, united states the forkhead transcription factor foxp is highly expressed in cd +cd + regulatory cells (tregs). the foxp +cd +cd + cells play a central role in immune tolerance and tgf-β is reported to induce foxp expression in vitro. whether there is an in-vivo association between foxp and tgf-β is not known. we investigated the hypothesis that there is a positive association between foxp and tgf-β in children with stable renal graft function. parental written informed consent was obtained before enrollment in all cases. children with stable renal allograft function for a minimum of months were studied. a complete clinical examination was performed; peripheral mononuclear cells were collected for measurement of transcripts for foxp , tgf-β , tgf-β , and s rrna (house keeping gene) using by real time quantitative pcr assay. correlation between transcript levels was performed using pearson r. results: pediatric recipients of renal allografts were studied. tgf-β and foxp were highly expressed in peripheral blood mononuclear cells, and there was a highly significant and positive correlation between levels of mrna for foxp and tgf-β (r= . , p< . )), whereas no significant correlation was found between tgf-β vs. tgf-β (and tgf-β vs. foxp ). conclusion: foxp expression in vivo is strongly correlated with tgf-β expression in peripheral mononuclear cells of stable renal transplant recipients. introduction: studies suggest that pre-emptive lamivudine therapy improves survival in hbv renal transplants. however, long-term outcome is not well established. method: four chinese adolescents with chronic hbv infection were transplanted. they were put on cyclosporin a, mycophenolate mofetil and prednisolone. prophylactic lamivudine was given just before transplantation and was continued afterwards. hbv status and liver enzymes were monitored serially. results: four patients were transplanted at the age of . ± . ( . - . ) yrs old. they were followed up for . ± ( - ) months and no mortality was reported. alanine transaminase (alt) was only transiently elevated in the first months post-transplant in all cases and became normal afterwards. there was no hepatitis flare and liver function was normal at the last follow-up. hbeag and hbv dna were positive in patient before transplantation and remained positive at the latest follow-up. mutation in the ymdd motif of the hbv genome was detected in the same patient and undeterminable in the other three due to low virus load. this patient remained clinically stable with normal liver function except there was a rise of viral load from baseline. all grafts were functioning and there was one late acute cellular rejection which responded to treatment and there was no hepatitis flare. latest mean serum creatinine was ± ( - ) umol/l. conclusion: ymdd mutation and resistance to lamivudine treatment may happen but appear to have little clinical significance. our long-term results showed that renal transplant seems feasible and safe in this population up to yrs follow-up. there are no studies in mexican children (mx) . the aim of the study was to determine tacrolimus pharmacokinetics (pk) in mexican renal transplant children and compare it wih reported pk in aa and ca. methods: a seven point pharmacokinetic profile ( , . , , , , and h) was performed in ten children receiving tacrolimus as part of the immunosuppressive therapy, mean age was . ± . years, mean post transplant time . ± months. c and cmax were obtained directly from experimental points, the auc and t / was obtained with a non-compartmental model using winnonlin version . . results: in cyclosporine (csa) is widely used for immunsuppression in transplant recipients and for treatment of srns. however, patients can develop csa associated cutaneous side effects, e. g. hypertrichosis, skin cancer, and viral warts due to human papillomavirus infection. here we report on a -yearold boy suffering from a microdeletion syndrome ( q-) and srns (histology: minimal change nephropathy) starting at the age of years. since the initial combination therapy with corticosteroids and cyclophosphamide was associated with severe side effects (sepsis, leukopenia) and did not lead to sustained remission csa therapy was initiated. csa-treatment resulted in rapid clinical remission. however, after months the patient developed viral warts (hands, trunk and head), although csa trough levels were kept below μg/l. therefore, immunosuppression was switched to mmf ( x mg/day) resulting in sustained remission of srns and rapid disappearance of viral warts within months. conclusion: conversion to mmf may be a usefull treatment strategy in srns showing csa associated side effects like viral warts. - . were live related (lrd) and the remaining cadaveric (cad). were pre-emptive(pet). all received basiliximab induction hrs prior to surgery. in addition, induction immunosuppression consisted of tacrolimus and methylprednisolone. in all but patients, basiliximab was re-administered at day . patients, aged and yrs (one cad and other lrd respectively) developed acute noncardiogenic pulmonary oedema - hrs after transplantation. both children had renal dysplasia as primary cause of renal failure. both required delayed ventilation and were ventilated for to days respectively. there was a rapid rise in c reactive protein in both patients. both grafts had primary function, but the cad transplant subsequently developed acute tubular necrosis, and was eventually lost within weeks due to thrombotic micro angiopathy and severe acute antibody mediated rejection despite immunosuppression with sirolimus, mycophenylate, steroids and plasma exchange therapy. conclusion: we report a rare but serious side effect of basiliximab. to our knowledge, this is the first report of basiliximab induced non-cardiogenic oedema so early post transplantation and in such young children. early recognition and aggressive appropriate supportive therapy is vital for patient and where possible, graft survival. ( ); cmv seroconversion ( ); seizures ( ); hypertension ( ), uti ( ), adverse reaction to basiliximab ( ), delayed graft function ( ), acute rejections ( ), chronic allograft nephropathy ( ). patients had well matched kidneys ( or less mismatches), were poorly matched. grafts were lost from latter group, both were cad, had acute tubulointerstitial nephritis and tacrolimus toxicity and the other thrombotic microangiopathy and eventually acute antibody mediated rejection. chronic allograft nephropathy (can) is a complex phenomenon caused by underlying kidney disease and superimposed by environmental and genetic factors. we investigated the association of polymorphism in the genee nos with the can. nitricoxide is synthesized from l-arginine in vascular endothelial cells by nitric oxide synthase. endothelial nitric oxide plays an important role in endothelial dysfunction and involved in the inflammation. the gene encoding enos maps to chromosome q q . . a missense variant of the enos gene in exon shows a transversion of g to t at nucleotide position (g t) that results in a replacement of glu by asp at amino acid residue (glu asp). the aim was to investigate the association between can and g t polymorphism of the endothelial nitric oxide synthase gene. the g t mutation at exon of the endothelial nitric oxide synthase gene, enos gene polymorphism, was analyzed in turkish children with renal transplantation. the g t polymorphism of the endothelial nitric oxide synthase gene was determined by polymerase chain reaction and restriction fragment length polymorphism. were grouped according to stages of chronic kidney disease (ckd) as estimated by the calculated glomerular filtration rate (gfr, schwartz formula). measurements of structural and functional surrogates for cardiovascular disease (cvd) included intima-media thickness (imt) of the common carotid artery (cca), pulse wave velocity (pwv) and augmentation index (aix). aix and pwv reflect the degree of arterial stiffness and were calculated from pulse wave recordings at the arteria carotis and arteria femoralis (sphygmocor device). results: patients and healthy control subjects had a mean age of years. imt was not significantly different in patients and controls. significant differences were found in the aix, which was increased by %: the mean aix was in healthy subjects was - , % and in transplanted subjects - , %. pwv was increased by % ( , m/s vs. , m/s). both aix and pwv increased in parallel with the degree of renal impairment (stages of ckd). table . discussion: weight gain post transplant is multifactorial, like cultural, psychological and associated to steroids. weight gain was observed in general, patients with overweight or in risk of overweight didn't loose weight postransplant even they were aware of the consequences. introduction: tacrolimus is metabolized by cytochrome p a and has a narrow therapeutic range. we report a kinetic interaction between tacrolimus and amlodipine, a potent cytochrome p inhibitor, resulting in anuric acute renal failure. case report: a -year-old male renal transplant recipient received amlodipine, a calcium channel blocker as antihypertensive treatment while he was on tacrolimus ( . mg/kg per day). he presented first with diarrhea and developed subsequently, dizziness and fatigue, related to acute anuric renal failure, requiring hemodialysis for days. tacrolimus trough levels were in the desired therapeutic range ( - ng/ml) until recently. three days after introduction of amlodipine, tacrolimus trough levels increased to a toxic level of . ng/ml. after discontinuation of amlodipine, tacrolimus levels returned to the normal range in seven days and renal function recovered progressively. no polymorphisms in the expression of cyp a and p-glycoprotein were detected. discussion: tacrolimus is known to be a substrate of p-glycoprotein, responsible for drug secretion into the intestinal lumen and metabolized by enterocytic cyp a. amlodipine is a competitive inhibitor of cyp a. as no abnormalities of cyp a and p-glycoprotein were found, we suspect that drug interaction due to competitive inhibition of tacrolimus metabolism by amlodipine was responsible for these toxic effects. concomitant diarrhea might have played an additional role for increased tacrolimus serum levels, presumably in relation to diarrhea associated dysfunction of enterocytic cyp a and p-glycoprotein. conclusions: amlodipine and diarrhea increase tacrolimus blood concentration by inhibiting its metabolism. amlodipine should not be used in patients on tacrolimus. careful monitoring of tacrolimus blood levels is recommended in case of concomitant diarrhea. urinary tract infection (uti) remains a significant cause of infectious complications in renal transplant recipients. the aim of the study was to determine the frequency of uti following renal transplantation in our center. the records of patients (f/m: / ) who underwent renal transplantation were evaluated retrospectively. among them patients (f/m: / ) were found to have at least one episode of uti during follow-up. the records were examined for the age, sex, primary disease, and duration of chronic renal failure, donors, posttransplant follow-up and recurrence of uti. biochemical analysis of blood for renal functions, complete blood count, creactive protein and sonographic examination of patients were also recorded and results were compared with renal transplanted patient who did not develop any episode of uti (group ). the mean age of the group was . ± . years, while it was . ± years in the group . mean duration of post-transplant follow-up was . ± . years for group and . ± . for group . four patients ( . %) in group and patients ( . %) in group had vesicoureteral reflux (p> . ). five patients had single uti while patients had more than one uti. though we did not find any difference between girls and boys in terms of presence of vesicoureteral reflux, frequency of uti in girls was found to be significantly higher than in boys (p= . ). ultrasonographic examination of patients during uti in group revealed pyelonephritis in and hydronephrosis in patients. the most frequent microorganism causing uti was e. coli. age, donor source and etiology of chronic renal failure did not influence the incidence of urinary tract infection. our data suggests that urinary tract infection remains a frequent but mostly benign complication in the pediatric transplant population, especially in female gender. the growing population of transplanted patients requires the consideration of the potential side effects of the different treatment regimens. experience of the last decade with calcineurin and nucleoside reverse transcriptase inhibitors revealed important renal side effects. we describe a years old girl who was known to have liver failure related to wilson's disease (wd). she had orthotopic liver transplantation from her mother years ago and treatment with tacrolimus and mmf was initiated. although she was known to have proximal renal tubular acidosis secondary to wd, renal tubular functions were found to be normal within the three months of transplantation. two years after the transplantation lamivudine was initiated because of de novo hepatitis b infection in transplanted liver. a couple of months later she developed renal fanconi syndrome with metabolic acidosis, hypophosphatemia, glycosuria and aminoaciduria. she needed high doses of sodium bicarbonate and phosphate supplementation. tacrolimus was suspected to be the cause of late post transplant renal acidosis and was replaced by sirolimus. however, months later, at the th month of lamivudine treatment, she was hospitalized because of metabolic acidosis, mild hyperglycemia and inability to walk. electromyographic examination revealed myopathic changes while liver biopsy was normal with a normal tissue copper level. renal biopsy showed findings of karyomegalic nephropathy which could be the result of the action of antimitotic agents. we suspect that our patient's tubular dysfunction, myopathy and hyperglycemia may have resulted from mitochondrial dysfunction which is triggered by tacrolimus and augmented by lamivudine. however, randomized and prospective studies with large groups of patients are needed for definite results about mithocondrial side effects of these drugs. recombinant factor viia (rfviia, novoseven) is a new hemostatic agent that was initially indicated in hemophiliac patients. recently it has been used successfully for the treatment of bleeding in patients with thrombocytopenia, and acquired and congenital platelet dysfunction. epstein syndrome, also known as alport-like syndrome, is a rare autosomal dominant disease characterized by proteinuria, chronic renal failure, hearing loss, and thrombocytopenia with giant platelets. our group previously reported functional alterations of giant platelets of boy with epstein syndrome, who rapidly progressed to end stage renal disease during adolescence. the first nonheartbeating kidney transplantation at age was failed because of the severe postoperativebleeding irresponsible for traditional therapy (packed red cells, platelets, and fresh frozen plasma), result in immediate graft failure and the need for transplant nephrectomy. the second kidney transplantation was years later, after a single intravenous bolus injection μg/kg body weight rfviia, which was repeated one and hours after the surgery. rfviia successfully controlled the bleeding in the peri-and postoperative phase and no side effect and thrombotic complication occurred and his graft function is still stable after years. recombinant factor viia may have a potential role in the treatment of phenotypic bleeding associated with chronic kidney disease. cyclosporin a (csa) and mycophenolic acid (mpa) have a wide interindividual variability in their pharmacokinetics (pk). among others, intestinal p-glycoprotein (p-gp) expression and cyp a activity have been held to be responsible for that variability. in adult kidney transplant (rtx) patients, an influence of these gene polymorphisms has not been shown; however, there are no data in pediatric patients. we reasoned that such an influence might be masked in adults by confounding environmental factors accumulating over the decades of life. we therefore investigated a possible influence of gene polymorphisms of p-gp and cyp a on defined dose-adjusted pk-parameters in children with rtx (age . ; range, . - . yrs). pk parameters (auc, c ) were assessed , , , and weeks after rtx. real-time, rapid-cycle pcr methods were used for genotyping. the allele frequencies for the mdr c t allele (expression and in vivo activity of p-gp) of % and for the cyp a -v allele of % were comparable to those reported for caucasian populations. dose-adjusted pk parameters of csa and mpa were not significantly different in patients with and without the cyp a -v allele or patients with different mdr c t genotypes. along with that finding, neither of the polymorphisms investigated into was associated with renal function or the incidence of acute rejection episodes. we studied how the il- r β-chain becomes enriched in lipid rafts of activated human t cells, isolated by ficoll gradient and sheep red cell rosetting, and how its tyrosine phosphorylation, which requires its heterodimerization with the common cytokine r β-chain (βc), occurs there. imunoblots (ibs) of sucrose gradient fractions of cell lysates obtained during a -hour activation with phytohemeagglutinine (pha) showed the gradual, largely selective, translocation of the β-chain into rafts. as dimerization or lipid modification can be mechanisms underlying raft enrichment, we assessed lysates of pha-activated cells in ibs under non-reducing versus reducing and crosslinking conditions but did not see evidence of β-chain dimerization. however, exposure to cycloheximide to interfere with post-translational acylation, or to the palmitic acid analogue -bromohexadecanoic acid substantially diminished raft enrichment of the il- r β-chain. we next performed ibs of il- r β-chainand βc-immunoprecipitates from raft and non-raft fractions of activated t cells before and after il- treatment. we found that il- exposure triggers the translocation of small amounts of βc, accompanied by il- r β-chains, into rafts, resulting in its heterodimerization with the il- r β-chain and their tyrosine phosphorylation. all of these processes were attenuated in the presence of the il- r β-chain-blocking antibody daclizumab. we conclude that the raft enrichment of the il- r β-chain requires palmitoylation and provides the focal point for the formation of the highaffinity il- r via il- r β-chain-mediated "chaperoning" of few βcs into these domains, establishing novel raft-dependent mechanisms underlying cytokine r specificity and selectivity in human t cells. iga nephropathy (igan) is an immunecomplex disease resulting from a defect in mucosal iga response. food antigens have been implicated in the pathogenesis. gut permeability to antigenic substances is immature at birth and its maturation is delayed by early administration of antigenic foods while breast feeding accelerates this process. we aimed to evaluate if exposure to antigenic foods in early life is associated with a predisposition for igan in childhood. three groups including children with igan (group , n= ), primary non-iga glomerulopathies (group . n= ) and healthy controls (group , n= ) were formed. their parents filled a questionnaire regarding the age at diagnosis, gestation time, birth weight, feeding by breast milk, formula, cow's milk and complementary foods. all groups were similar for age, sex, gestation period, birth weight and the rate and duration of breast feeding. in addition, the rate of formula feeding was also similar in all groups. however, cow's milk consumption rate was higher in group and than in group . introduction of formula was earlier in groups and than in group . in addition, the children in group were younger than the other groups at the onset of feeding by cow's milk and weaning. roc curves predicted . , . and . months as the best cut-off age values for formula feeding, cow's milk feeding and weaning for predicting the presence of igan, respectively. ors for igan with respect to these cutoff levels were ( % ci: - ), . ( % ci: . - . ) and . ( % ci: . - . ), respectively. the results of this preliminary study indicate that early introduction of antigenic foods might increase the risk of future primary igan. results: they were males and females, with a male: female ratio of : . their ages ranged from months to years (mean . years), with a peak age of - years. the common presenting complaints were generalised oedema ( %); oliguria ( %) and hypertension ( % we report nine patients (three males) with mesangiocapillary glomerulonephritis (mcgn) from a single paediatric nephrology centre. the average age at presentation was . years (range . to . ). all had nephrotic syndrome. seven had mcgn type and two had mcgn type ii. six of seven tested had positive c nephritic factor. three patients responded well to steroids and ace inhibitors and received no further therapy. five had a good response initially but relapsed when steroids were tapered and one patient had a poor response to steroids. these six patients received calcineurin inhibitor (ci) therapy. four responded well with resolution of proteinuria. one patient relapsed when tacrolimus was withdrawn after months of therapy but proteinuria resolved after re-introduction of therapy. two patients had a poor response to ci therapy. one remains stable but with heavy proteinuria. the second patient (with mcgn type ii) initially had a complete remission of proteinuria on steroids but relapsed months after presentation while on prednisolone mg on alternate days. repeat biopsy showed % crescents. treatment with pulsed intravenous steroids, cyclosporin and mycophenolate mofetil was ineffective and she progressed rapidly to end stage renal failure. we conclude that ci treatment might be useful in mesangiocapillary glomerulonephritis. prospective, randomised controled trials are required to determine their place in the management of this disease. iga nephropathy (igan) is caused by a primary defect in mucosal iga response leading to increased antigenic stimuli reaching to bone marrow. enteric flora is important for mucosal and systemic immunity, and probiotics regulate specific and innate immunity by maintaining microbial balance in the gut. saccharomyces boulardii (s.boulardii), a probiotic, increases intestinal siga production, protects enteric infections and also prevents atopic and immunoinflammatory diseases. we aimed to evaluate the effect of s.boulardii on experimental igan, induced by oral polio virus vaccine (opv) administration to the mice. four groups of male balb/c mice (n= for each) were formed. groups i and ii were immunized enterally by opv at the onset, nd and th weeks. group ii was also given s.boulardii in drinking water throughout the study. group iii was given only s.boulardii, while group iv received no treatment. two weeks after the last opv dose, all the animals were sacrificed to obtain their kidneys for histopathological evaluation and all four groups were compared with respect to the severity of histopathological changes. while there was mild to moderate mesengial proliferation and widening, tubular atrophy, interstitial inflammation and fibrosis in group i, no remarkable histological changes in the other groups were noted. immunofluorescence microscopy revealed universal deposition of iga and some c in group i, while there was no iga or c deposition in the other groups. electronmicroscopy revealed mesengial proliferation along with matrix expansion, focal basement membrane thickening and electron-dense deposits in the mesengial area in only opv group and the other groups were normal. in conclusion, enteral s.boulardii administration prevented experimental igan development in mice. the aim was to assess the correlation of renal histopathological findings with clinical diagnosis in order to recognize the pattern of kidney diseases in our pediatric population. methods: a total of renal biopsies performed on children who presented to the surgical kidney hospital in damascus during a period of years were retrospectively reviewed. results: nephrotic syndrome alone accounted for % of all cases, followed by hematuria in %, mild to moderate renal impairment including allograft dysfunction in %, nephritic syndrome in %, and hsp in %. the most common histologic lesion was mcd in ( %). fsgs was the second most common lesion ( %) followed by mesangial gn ( %), mpgn ( %), post-infectious gn ( %), iga nephropathy ( %), membranous gn ( %), cns of finnish type ( %), alport syndrome ( %), interstitial nephritis ( %), nephronophthisis ( %), hsp ( %), acute rejection ( %), chronic rejection ( %), nephrocalcinosis ( %), crescentic gn of undetermined origin ( %), and lastly, % were completely within normal limits. familial and inherited diseases were encountered in %. histopathologic diagnosis was mostly useful in nephrotic cases. while in hematuria cases, the usefulness of the histologic findings in terms of therapeutic and/or prognostic point of view was definitely less. one of the reason for that in our series is perhaps because we still do not have facilities to perform electron microscopic evaluation of the renal tissue. however, controversy about the usefulness of renal biopsy in such cases is still there. conclusion: this study provides an important data on the pattern of pediatric renal diseases in our center and highlights the usefulness histologic findings in guiding the therapeutic plan especially for nephrotic children. aim: the aim of this study was to determine the efficacy of tacrolimus in the management of sr fsgs in children. study design: this was a prospective study of children with sr fsgs treated with tacrolimus ( . - . mg/kg per day in divided doses over hours adjusted to a trough level between - ng/ml) for months in combination with low dose steroids. other therapies included angiotensin converting enzyme inhibitors, folic acid, multivitamins and lipid lowering agents. results: the mean age at study entry was . years (range . - . ). the mean duration of nephrotic syndrome before initiation of tacrolimus therapy was . years (range . - . ). at the end of the treatment period ( %) children were in complete remission, ( %) children were in partial remission and ( %) failed to respond. the average period of follow-up following cessation of tacrolimus treatment was . months (range . - . ). at last hospital follow-up ( %) of children were in complete remission, ( %) in partial remission and ( %) in relapse. children demised from dialysis related complications following cessation of tacrolimus treatment. adverse events included sepsis ( ), nausea ( ) diarrhea ( ), anaemia ( ) and worsening of hypertension ( ) . conclusion: tacrolimus is a safe and effective treatment for sr fsgs. however, like cyclosporine some children tend to relapse following cessation of treatment. it has been rarely reported in association with graves-disease. now we present a previously healthy -year-old japanese girl who had proteinuria due to stage i mn and graves disease. patient: she was found to have + proteinuria and a goiter at her school medical examination simultaneously. serum free thyroxine was . ng/dl (normal range . ~ . ), thyroid-stimulating hormone (tsh) less than . microu/ml ( . ~ . ), anti-microsomal antibody t (~ ), anti-thyroglobulin antibody t (~ ), and tsh-receptor antibody % (~ ) consistent with graves' disease. the electron microscopy finding of her renal biopsy specimen showed the presence of electoron-dense deposits located in the subepitherial and intramembranous spaces. with immunofluorescence microscopy, the bright granular staining of igg along the gromerular capillary wall was found. these findings were characteristic of mn. objectives of study: to investigate whether graves disease caused mn in this patient. methods: we examined the presence of thyroid microsome and thyrogrobulin in glomeruli by immunofluorescence study using anti-thyroid microsomal antibody and anti-thyrogrobulin antibody. result: glomerular granular staining of thyroid microsomal antigens was demonstrated corresponding to igg granular deposits, but that of thyrogulobulin was absent. conclusion: mn in this patient is presumed to be caused by immunecomplexes mediated by thyroid microsomal antigens. objective: to explore the role of oxidative stress reaction on the injury of glomerular podocyte slit diaphragm molecular barrier. methods: thirty-two male spraque-dawley (sd) rats were randomly divided into control, low dose ( . mg/kg), nephrotic ( . mg/kg), overdose ( . mg/kg) groups by the dosage of adriamycin (adr) injection.the levels of malondialdehyde (mda) glutathione peroxidase (gsh-px), hydroxy radical ( . oh) and superoxide dismutase (sod) in renal cortex were measured; the expression of podocin was measured with immunohistochemistry. results: ( ) compared with control group, the levels of mda in renal cortex and -hour urinary protein were increased, the levels of sod in renal cortex was decreased in adr-treated groups, especially in nephrotic group (p< . ). ( ) in control group, podocin staining was a sable linearlike pattern along the capillary loops of glomerulus; in nephrotic group, podocin staining was a light tan discontinuous punctiform or short linear-like pattern along the capillary loops of glomerulus. compared with control group, the score of podocin immunohistochemical staining was decreased in adr groups, especially in nephrotic group (p< . ). ( ) there were some significant negative correlations between the score of podocin immunohistochemical staining and the levels of mda in renal cortex. there were some significant positive correlations between the score of podocin immunohistochemical staining and the levels of sod in renal cortex. conclusion: ( ) there was close relationship between podocin and the development of proteinuria. ( ) there were significant correlations between the reduction of podocin in glomerular podocyte slit diaphragm and oxidative stress reaction, especially lipid peroxidation. lupus nephritis (ln) remains an important problem in patients with sle. to evaluate the clinical course, histopathology and the efficacy and safety of high-dose pulse cyclophosphamide (ctx) in children with ln. retrospectively, children with ln were studied; all patients underwent renal biopsy and were followed up for at least years. the clinical and serologic data at the time of renal biopsy were recorded. five of them were excluded because of short period of follow-up or defective laboratory data. based on renal biopsy (who classification for ln), patients were treated with the following regimens: one patient (class i) with low-dose prednisolone (pred), (class ii, iii) with high-dose of pred, (class iv) with high-dose pred and received intermittent intravenous (iv) ctx pulses (monthly for months, then every months) followed by mycophenolate mofetil (mmf) as maintenance therapy. there were girls and boys. the mean age at the time of diagnosis of sle was . years. eighteen patients were more than years old. sixty percent of the patients were presented as nephritic-nephrotic syndrome. there was with class i, with class ii, with class iii, with class iv and none with class v based on biopsy. eighty-five percent of cases went in remission, one was hemodialytic and died due to renal failure and cns involvement. among cases with class iv, responded to pred and iv ctx pulses. there was no evidence of side effects. it seems that iv pulse ctx does induce remission of clinical and renal disease in the majority of early diagnosed children with severe ln. furthermore, it appears that mmf is an appropriate drug for maintenance therapy. however, this study was based on a small number of subjects. further studies to confirm the long-term efficacy and safety of ctx pulse therapy on larger numbers of patients are needed. forming group i were compared with children on short course steroid therapy (iskdc regime) (group ii). children were examined for steroid side-effects and underwent blood tests, ophthalmologic evaluation and radiological examination. results: though remission was achieved in < weeks by % in group ii against % in group i, the total dose received ( - mg/kg) was lower in group i ( % vs %). forty-six % had - relapses, % had - relapses and % had - relapses. the proportion of children having > relapses was much higher in group ii ( % versus %). mean relapse/patient/ year was . (sd . ) in group i against . (sd . ) in group ii. delayed bone age ( %), radiological evidence of osteoporosis ( %). cushingoid facies ( %), posterior subcapsular cataract ( %), decreased growth velocity ( %) and hypertension ( %) were the side effects and were almost equally distributed in the two groups. more patients from group ii received a higher cumulative dose/ kg/year of > mg ( %versus % in group i) and these had higher risk for hypertension, delayed bone age and osteoporosis. conclusion: alternate day, prolonged therapy (soyka regime) compared to short course, daily therapy (iskdc) resulted in lower cumulative dose to the patient. acute side effects and severity of infections were less. mean relapse/patient/year were lower. group ii patients receiving higher cumulative dose had osteoporosis and delayed bone age. objetive: to assess urinary protein excretion decrease in patients with primary srns treated with ec-mps methods: cohort of patients, mean age: years with primary srns. inclusion criteria: primary sncr with of focal segmental glomerulosclerosis (fsgs). exclusion criteria: glomerular filtration rate (gfr) % than baseline level, leukopenia, absence of decrease of proteinuria excretion by month of treatment with ec-mps. mean time after the initial diagnosis of ns until the introduction of ec-mps was calculated in patients who decreased urinary protein excretion below nephrotic range and in non-responsive patients and the glomerular damage, interstitial fibrosis and tubular atrophy were classified as: absent, mild, moderate, severe ( to , risk grade> ). ec-mps dosing: - mg/m /day. complete response was considered a reduction in the urinary protein excretion lower than or equal to mg/m /hour; partial response: urinary protein excretion ranging from to mg/m /hour and absence of response: urinary protein excretion in the nephrotic range. laboratory monthly assessments: serum creatinine, urea, hemoglobin and blood cell counts, lipids, serum proteins, amilase, hours urinary protein excretion. . no significant differences in the frequency of both alleles were observed among patients with different grades of hypertension or proteinuria. in conclusion, drb * , and possibly alleles confer susceptibility to psagn. however the severity of the disease is not determined by these two alleles. methods: fifty children who diagnosed as biopsy-proven fsgs were studied retrospectively by medical records. response to treatment and pathologic slides, we compared normal renal function group (n= ) and decreased renal function group (n= ), assessed the factors affecting renal survival and progression to renal failure. results: the mean age at onset was / years, gender ratio m: f was . : and the mean duration of follow-up was / years. the overall renal survival rate was % at years, % at years. five-year survival rate was % in normal renal function group, but % in decreased renal functin group. between the two groups, there were no significant differences in age at onset, gender ratio, amount of proteinuria, incidence of hematuria, hypertension and mesangial hypercellularity. decreased renal function group showed higher serum creatinine level, poor response to treatment, higher percent of glomeruli with sclerosis, moderate to severe tubulointerstitial change and vascular change (p< . ). the prognostic factors of renal survival rate were same as above (p< . ). there were no significant factor has shown relations with the progression rate to renal failure. conclusion: we reviewed the factors affecting long-term outcome of fsgs. serum creatinine level, steroid responsiveness and the degree of glomerulosclerosis were significant prognostic factors. but, age at onset, gender, amount of proteinuria, incidence of hematuria and hypertension were not considered as a prognostic factor. a background: several studies have suggested that cyclosporine (csa) and methylprednisolone pulse therapy (mpt) may be effective for idiopathic steroid-resistant nephrotic syndrome (isrns) in children; however, the optimal regimen has yet to be established. the present study evaluated the efficacy and safety of years' treatment with csa (neoral) combined with mpt and prednisolone (psl) in such patients. methods: in this prospective study, children with biopsy-proved isrns were enrolled. all patients received csa and psl ( mg/kg every other day). patients who had focal segmental glomerular sclerosis (fsgs) additionally received mpt (methylprednisolone at a dose of mg/kg per day for consecutive days at weeks , , , , and ) . the dose of csa was adjusted to maintain a trough level from to ng/ml for the initial months, followed by to ng/ml for months to , and to ng/ml for months to . results: twenty-six patients were enrolled. their mean age was . ± . years. two-year follow-up was completed in patients. histological examination at study entry revealed minimal changes in patients, diffuse mesangial proliferation in , and fsgs in . at the end of the therapy, patients had complete remission, including who had occasional relapses of steroid-sensitive nephrotic syndrome, and had partial remission; the remission rate was . %. nephrosis persisted in patient. disease progressed to end stage renal failure in patient. serial renal biopsy at the end of the study showed mild signs of csa-related renal toxicity, including tubulointerstitial fibrosis in ( . %) of patients. conclusion: combination therapy with csa, mpt, and psl for years was clearly effective and produced a high remission rate without serious csa-related renal toxicity in children with isrns, in contrast to previous reports. objectives: patients with hemolytic uremic syndrome who do not require dialysis in acute stage usually have a good prognosis. however the spectrum of renal compromise is wide. we believed non-anuric patients with higher creatinine values in acute stage could have different evolution when compared to patients with lower values. aims: ) to analyze the outcome after a year and ) to determine if peak serum creatinine values in acute stage would be a prognostic marker. methods: patients, aged . months at hemolytic uremic syndrome, were analyzed. they were classified into groups: group i, complete recovery; group ii had subgroups: iia, microalbuminuria, and iib, proteinuria and/or high blood pressure, both with normal renal function; group iii, chronic renal failure; and group iv, end stage renal disease. peak creatinine value was definided as the highest value of at least determinations in acute stage. these data were available in patients and they were divided in those with creatinine equal to or higher than , mg/dl ( patients) and those with lower values ( patients). the relationship between creatinine and final outcome was analyzed. we applied fisher's test. results: after a mean follow-up of years, patients were in group i, in group iia, in group iib ( with hypertension, with proteinuria and with both) and in group iii. eight out of patients ( %) with creatinine equal to or higher than . mg/dl in acute stage and out of ( . %) with lower values were in groups iib and iii in the last visit (p= . ). conclusions: ) after years, % developed proteinuria, high blood pressure or chronic renal failure and % microalbuminuria. ) peak creatinine values in acute stage were a prognostic indicator. objective of study: the aim of this study was to assess the serum concentration of hs-crp in children with nephrotic syndrome (ns) treated with prednisone and cyclosporine a (cya). methods: patients were divided into groups: i - ns children ( - years) in relapse, examined twice: a -before treatment and b -after proteinuria regression (a - week course of prednisone therapy), ii - children with steroid-dependent or steroid-resistant ns, treated with cya, also examined twice: d -before treatment with cya, e - months after therapy. control group (c) consisted of healthy children. serum hs-crp level was determined using a nephelometric method with behring nephelometer analyzer, dade behring. results: it was shown that median hs-crp concentration was the highest in children with relapsing steroid-sensitive ns before treatment (ia). after proteinuria regression (ib), the hs-crp level decreased and did not differ from healthy controls (c) (p> . ). in group ii, before cya administration (iid) the level of hs-crp was normal, but increased after months of treatment (iie) up to a level six times higher that of the control group (p< , ). conclusions: in children with steroid-sensitive nephrotic syndrome in relapse, the serum hs-crp level is increased but returns to normal values after a - week glucocorticoid treatment course. in children chronically treated with cya due to ns, serum hs-crp level increases significantly during the therapy. slit diaphragm connecting adjacent foot processes of podocyte is the final barrier of glomerular capillary wall to prevent proteinuria. both podocytes and neuronal cells are terminally differential cells and they share many common features. nurexin is a presynaptic adhesion molecule that plays a role in synaptic differentiation, and they have been understood to be specifically expressed in neuronal tissue. we found that neurexins are expressed not only in neuronal cells but also in several organs including kidney. our immunofluorescence study shows that neurexins are restrictedly expressed in glomeruli in kidney. dual-labeling immunofluorescence studies show that neurexins are localized close to a cd ap. we also detected some portions of neurexin staining are coincident with that of rab a, a synaptic vesicle associated molecule. we found that a single splice variant of neurexin- is expressed in glomeruli. the staining intensity of neurexin in the glomeruli clearly reduced and their staining pattern shift to more discontinuous patchy pattern in puromycin aminonucleoside nephropathy and anti-nephrin antibody induced nephropathy. the alteration of neurexin in these models was detected more clearly and rapidly than nephrin. we confirmed that neurexin is expressed in podocyte also in human kidney section. these observations suggest that neurexin is involved in the development of proteinuria and that neurexin could be an early diagnostic marker of podocyte injury. to further elucidate the clinical relevance of t-cell abnormality in minimal change nephrotic syndrome (mcns), and to predict the consequences of mcns, we studied t-cell receptor (tcr) diversity by analizing cdr size distribution and the frequency of v repertoire usage. thirty-six pediatric patients with mcns were enrolled. eighteen were frequent relapsers and/or steroiddependent (fr/sd) and were non-frequent relapsers (nfr). the study was performed to analyze serial changes of tcr v repertoires in the two groups of patients. frequencies of v repertoire usage were determined by flowcytometry, and tcr cdr length distribution was analyzed by genescan. in nfr patients, abnormalities in the distribution of v repertoires were few in both cd + and cd + t cells. in fr/sd patients the patterns were normal in cd + t cells, while selected v repertoires were significantly increased in cd + t cells in some patients. furthermore, tcr diversity was significantly reduced in both cd + and cd + t cells in fr/sd patients as shown by marked skewing of cdr size distributions. it is noteworthy that in some fr/sd patients the initially abnormal tcr diversity improved as the clinical symptoms improved such that they became nfr over the years. analysis of tcr diversity may delineate the subgroup of patients with fr/sd and provide a rationale for early intervention with immunosuppressive therapy for these patients. background: transforming growth factor-β is known to play a role in the interaction between metabolic and homodynamic factors in mediating accumulation of extracellular matrix in the diabetic nephropathy. tgf-β gene polymorphism was associated with circulating tgf-β levels and influenced the pathogenesis of fibrotic diseases including diabetic nephropathy. in this study, we examined the relationship between tgf-β gene codon polymorphism and type diabetic nephropathy with more than -year history of disease. methods: we conducted a case-control study, which enrolled type diabetes. a total of patients with diabetic nephropathy were compared with patients without diabetic nephropathy. tgf-β codon genotyping was determined using polymerase chain reaction with sequence specific primers method. results: distribution of tgf-β codon genotype in the patients either with nephropathy or without nephropathy is confined to hardy-weinberg equilibrium. methods: nzb/w f female mice were distributed into three experimental groups (n= per group) according to age: , . and months. at specific time-point for each group, -hour urine and blood samples were collected to determine proteinuria, osmolality and creatinine levels. after sacrifice, kidneys were removed to measure chemokines and cytokines levels by elisa (pg/ mg of tissue). results: urinary flux was significantly lower at . than at and months. a significant reduction in creatinine clearance and an increase in proteinuria were detected at . and months when compared to months. no significantly changes were observed in serum and urinary osmolality. regarding inflammation, mcp- significantly increased at . ( . ± . ) and remained elevated at months ( . ± . ) when compared to months values ( . ± . ). kc was also higher at than at months ( background: nephrotic syndrome (ns) is related to immunological factors and renal inflammatory mechanisms. many studies showed that inflammatory mediators, especially interleukin- (il- ) and monocyte chemoattractant protein- (mcp- ), have a role in kidney injury. changes in their urine concentration were found in lupus nephritis and iga nephropathy. thus, the aims of this study were to evaluate il- and mcp- in serum and urine samples of pediatric patients with primary ns and to verify the relation between these measurements and protein excretion. methods: patients were divided according to current -hour proteinuria into two groups: lower than mg/ hours (group , n= ) and higher than mg/ hours (group , n= ). blood and -hour urine samples were collected and stored at - °c. il- and mcp- were measured by elisa standard methods. results: blood il- and mcp- did not differ between the groups. urinary il- levels (pg/mg of creatinine) were significantly elevated in patients of group when compared to group ( . ± . vs. . ± . , p< . ). although group also exhibited higher values of urinary mcp- ( . ± . pg/mg creatinine) than group ( . ± . pg/mg creatinine), they did reach statistical difference. conclusion: the inflammatory process in ns seems to be a local phenomenon, since blood levels of these chemokines were similar in all groups. moreover, our findings showed a relation between il- and the presence of proteinuria and suggested a role for this local inflammatory mediator in disease activity. the characteristics of iga nephropathy detected in school urinary screening iga nephropathy (igan) is one of common types of glomerulonephritis in children. however, progression to esrd in patients with igan is not as rare as originally thought. in korea, school urinary screening (sus) program, an useful tool to find out abnormal urinary findings, initiated in . igan was the most common histopathological change in children with isolated hematuria and/or proteinuira in sus. we studied to clarify the clinical and pathologic characteristics of iga nephropathy detected by sus in korea. we investigated patients (symptomatic group= vs sus group= ) had been diagnosed with igan following renal biopsy at the yeungnam univ. hospital between may and may . these patients were analyzed clinical nature, laboratory data and histopathologic findings (haas classification in lm) and progress, retrospectively. their mean age were . ± . and . ± . , respectively, at the time of kidney biopsy. gross hematuria and edema apt to be common in symptomatic group. there were no significant difference in serum iga level, estimated ccr, -hours protein amount, light microscopic class and electron microscopic findings between two groups. mesangial iga deposition was significantly more intense in symptomatic group with gross hematuria. in addition to iga deposition in capillary and immune dense deposition in intramembrane is significantly common in symptomatic group with nephrotic range proteinuria. however, progression to chronic renal failure was not noted in both groups during . ± . and . ± . months respectively. also there were no difference in outcome according to treatment modalities. a longer follow-up period is needed to obtain more information on progression of igan with nephritic range proteinuria by disclosing iga deposition in capillary and immunedense deposition in intramembrane. outcome of srns is uncertain and especially patients unresponsive to treatment have a high risk to develop esrd. prognosis has improved with the introduction of csa, however but long-term follow-up data are scarce and response to csa in patients with genetic forms of srns is uncertain. we report on patients with srns, that was diagnosed at a median age of . (range . - . ) years. treatment with csa was initiated on concomitant prednisone therapy, however steroids were discontinued after due course in all patients. median follow-up is . ( . - . ) years. patients had fsgs on renal histology and patients had mcns. complete remission (cr) was defined as reduction of proteinuria < mg/m /d. partial remission (pr) was defined as reduction of proteinuria of at least % and cessation of edema with serum albumine levels > g/l. results: patients ( fsgs, mcns) reached cr with csa treatment. in of these ( fsgs, mcns) csa could be tapered and discontinued successfully after a median time of ( . - . ) years. eight patients showed ( fsgs) a pr while patients ( fsgs) showed no repsonse (nr). of patients going into esrd had podocin mutations (pm). only one patient with pm showed partial remission on csa. our data indicate a positive effect of csa treatment in srns, especially in sporadic cases. in patients with cr tapering and even discontinuation of csa is possible. prognosis of srns has improved with csa treatment. objective: we planned to investigate the effects of rsv on the proteinuria and glomerular structure of rats and to explore the role of rsv in the pathogenesis of minimal change nephrotic syndrome. methods: sd rats were inoculated with , , and pfu rsv respectively, and sacrificed on days , , , and postinoculation (rsv , rsv , rsv , rsv , rsv ). renal histology was observed by light microscopy and electron microscopy. meanwhile, the proteinuria and serum parameters were measured. the rsv rna and rsv titer were determined by in situ hybridization and plaque assay respectively. immune complex deposits were detected by immunofluorescence microscopy. results: after inoculation, the urinary protein excretion was increased, especially in pfu rsv , , (p< . ). the serum albumin of pfu rsv , , and different-titer rsv decreased, but no significant differences in cholesterol, urea nitrogen and creatinine were found among all. slight hypercellularity in minority glomeruli and swelling of partial tubular epithelial cells were observed in rsv , of different-titer, whereas a relief of the above changes and no abnormalities were detected in rsv and rsv respectively under a light microscopy. extensive foot process effacement was observed in pfu rsv , , under an electron microscope. rsv rna signal and rsv titer of renal and pulmonary tissues, depending on the dose of inoculum, reached their climax on day postinoculation, especially in pfu rsv . no immune complex deposits were detected in the renal tissues. conclusion: our study reports for the first time that rsv can lead to nephropathy in rats on day - postinoculation, especially in pfu rsv-inoculated rats, which may be a new exploration of the pathogenesis of mcns. objectives of study: podocytes play an important role in maintaining the glomerular filtration barrier structure and functions, which associates with several podocyte-specific proteins. our previous study indicated the antiproteinuric effects of dexamethasone were achieved by changes the expression of certain podocyte molecules in vivo. the extracellular signal-regulated kinases regulates a wide range of cellular processes. the aim of the present study is to analyze the potential effects of dexamethasone on podocytes in vitro and to investigate its associated signal transduction pathway. methods: immortalized mouse podocyte clone was divided into three groups: the dexamethasonetreated group (dex-group), the dexamethasone with puromycin aminonucleoside-treated group (dex-pangroup), and control. in dex-group, cultured podocytes were treated with dexamethasone, while in dex-pan group, cells were treated with dexamethasone for min first, then added puromycin for different time periods. changes of the protein expression of podocyte-specific proteins and phosphorylation of erk were analyzed by western blotting analysis. result: compared with the control group, in dex-group, the expression of nephrin, podocin, cd ap, α-actinin proteins and vegf protein started to elevate at hr, while neph showed no obviously change. erk signaling pathways was activated. increased phosphorylation of erk was marked but transient, which increased from min to min, then decreased. at min the level of phosphorylation of erk returned to the baseline. the phosphorylation of erk level was significant raised in dex-pan group, and lasted to min. conclusion: dexamethasone alters the expression of certain podocyte-specific proteins not only in vivo but also in vitro, and in part, through the activation of the erk signal pathway. kh. kim minimal lesion in the renal biopsy of idiopathic nephrotic syndrome (ns) patients (pts) generally predicts a benign course. fsgs lesions in nspts, on the other hand, are associated with increased risk of steroid resistance and progression to renal failure. fsgs may be observed in follow-up biopsies despite being initially undetectable. whether this represents sampling error or the true natural history of this condition, earlier markers of steroid resistance and poorer prognosis could prove helpful. renal morphometric analyses was performed in ns pts, ages to years, initially diagnosed with minimal lesion, with (n= ) or without(n= ) subsequent progression to fsgs or end stage renal disease (esrd), along with controls ages to years. the age of patients in progressive and non-progressive group and controls were similar. gbm width in patients with minimal lesion ( ± nm) who subsequently progressed, was significantly greater than that in non-progressive group ( ± nm, p< . ). gbm width in both groups was not significantly different compared with the controls ( ± nm). average foot process width was increased in patients both with progression and non-progression as compared with controls, but there was no significant difference between progressive and nonprogressive group. the length density of podocyte detachment per gbm surface was not significantly different between progressive, non-progressive groups and control groups. there were no significant differences in the mean glomerular volume and cortical interstitial volume fraction between progressive and non progressive group. in conclusion, gbm width may help to differentiate between progressive and non-progressive groups in minimal lesion nephropathy. this may be a pathogenetic clue and needs further study. objective: our study is to investigate the correlation between clinical features and pathological characteristics on henoch-schönlein purpura nephritis (hspn) and the therapeutic methods. methods: fifteen boys and five girls aged - years (median . years) with hspn were analyzed retrospectively. the clinical characteristics, laboratory data, pathological findings and therapeutic methods were investigated. results: the patients with isolated hematuria and isolated proteinuria, the pathologic patterns were lighter then gradeii b ; eight patients with hematuria and proteinuria and seven patients with nephrotic syndrome, the pathologic patterns of injury is more severe then gradeii b , whose pathologic patterns injury exceeded gradeii b is . %. twelve patients with nephritic-range proteinuria (> mg/kg.d) and nephrotic syndrome received corticosteroids, cyclophosphamide, heparin and dipyridamole treatment. nine of twelve patients received intravenous pulse methylprednisolone (mp) and pulse cyclophosphamide (ctx). fourteen of twenty patients obtained stable remission after months to years, and five of twenty patients have asymptomatic microscopic hematuria, another one only has minimal proteinuria. conclusions: if the clinical features showed nephritic-range proteinuria or nephrotic syndrome, the renal pathologic changed markedly as well. for patients whose pathologic exceeded grade iii b or have renal tubule and interstitial damage, our study suggests that mp pulse therapy have satisfied curative effect. materials and methods: in experiment , higa mice, c bl/ mice and balb/c mice were inoculated intravenously with live cb and inactivated cb once a month from to mo of age. in experiment , higa mice, c bl/ mice and balb/c mice were inoculated intravenously with live cb and inactivated cb once at wk of age. mice in the control group were inoculated with vehicle. the kidneys were extirpated from mice of each group killed with time after inoculation for histological evaluation. experiment : we examined prostaglandin (pg) synthetic activity of cultured human mesangial cells. results: the scores for mesangial iga deposition, pcna-positive and matrix scores at weeks were higher in higa mice with live cb than in higa mice with inactivated cb or without cb . on em examination, swelling and detachment of endothelial cells from hours after inoculation and increase of serum ifn-gamma concentration were found in mice with live cb . the scores for mesangial iga and igg depositions, pcna-positive and matrix scores at weeks were more frequently found in balb/c mice with live cb . production of pge and txb significantly increased in cultured human mesangial cells damaged by live cb . conclusion: these results suggest that cb provokes exacerbation of renal pathological findings in higa mice via endothelial injury and ifn-gamma production, and may play important roles in igalike glomerulonephritis pathogenesis. rapidly progressive glomerulonephritis (rpgn) is a rare occurrence in alport syndrome (as). this report describes the case of a -year-old malewith as who developed rpgn and considers the cause of rpgn in this patient. he had a history of persistent hematuria and proteinuria since birth. at the age of years, he was diagnosed with as based on a renal biopsy. he developed nephrotic syndrome at the age of years. before administration of cyclosporine (cya), repeated renal biopsy was performed at the age of years. the biopsy specimen showed pathologic lesions characteristic of as without crescents. using immunofluorescence (if) staining, the expression of alfa- chains of collagen iv was found to be absent in the glomeruli. therefore, cya was administered for eight months. although he recovered from nephrotic syndrome, the effect of cya was limited. after the cessation of cya, his renal function slowly exacerbated. at the age of years, the administration of angiotensin receptor blocker was started. no subsequent anti-proteinuric effect was noted and his renal function improved to cr . mg/dl. however, by the age of years, he showed macrohematuria and acute deterioration in renal function to cr . mg/dl. subsequently, he underwent a third renal biopsy. on light microscopy, the biopsyspecimen showed diffuse cellular crescentic glomerulonephritis. if findings indicated pauci-immune type and electron micrography showed a few subepithelial deposits. a serological study revealed negative results for mpo-anca, pr -anca, and anti-glomerular basement membrane antibody. despite immediate treatment with pulses of methylprednisolone, cyclophosphamide, and plasma exchange, he progressed to end stage kidney disease. the patient reported here presents either a super imposition of rpgn upon a preexisting case of as or a new morphologic and clinical presentation for as. the wt gene encodes a zinc finger transcription factor involved in kidney and gonadal development. mutations of the wt gene have been shown to cause denys-drash syndrome (dds) and frasier syndrome (fs). the association of early onset nephrotic syndrome progressing to renal insufficiency, xy pseudohermaphrodism and wilms' tumor characterizes dds. renal biopsy shows diffuse mesangial sclerosis (dms). fs is also characterized by xy pseudohermaphrodism and nephropathy, but patients have delayed kidney failure characterized histologically by fsgs. this report examines three girls with nephrotic syndrome related to mutations in the wt gene, but with normal female karyotype and development. two girls with early-onset steroid-resistant nephrotic syndrome presented classical wt mutations coding for an amino acid change (d n) and (r w) at exon that is typical of dds. both children were phenotypically and genotypically females. they developed end stage renal failure within years. one girl had a wilms' tumor on the right kidney. the third child was identified with heavy proteinuria at years of age. laboratory investigations revealed a protein level of . g/dl ( - g/dl), albumin . g/dl ( . - . g/dl). proteinuria worsened to g/ h and she failed to respond to prednisone. renal biopsy demonstrated fsgs in % of glomeruli. the splice site mutation ivs + g >a, known to be associated with fs, was found in this patient. karyotype was , xx and she had normal uterus and adnexae on ultrasound. angiotensin-converting enzyme inhibitors were prescribed but she still has heavy proteinuria without renal failure. the classical clinical presentation of dds and fs is out dated. pediatric nephrologists need to consider the possibility of these genetic syndromes in evaluation of females with steroid-resistant nephrotic syndrome. we aimed to compare the effects of cyclosporine (csa) or mmf with or without combination of vitamin a,d,e or n-acetyl-l-cysteine (nac). the study included rats in eight groups: control, nephrotic syndrome without treatment, treatment with csa, mmf, vitamin a,d,e, combination of csa and vit ade, combination of mmf and vit ade and combination of nac and vit ade. all rats except the control group were given adriamycin. blood samples were drawn and -h urine were collected on day and at weeks and . at the th week, -h urinary protein excretions in the treatment groups were higher and serum albumin levels were lower than that of th week and control groups (p> . ). at the th week, urinary protein excretions in group csa&ade was lower than of the groups of csa, mmf, mmf&ade, ade and nac&ade with non-significance (p= . , p= . , p= . , p= . , p= . ) . serum albumin in group mmf&ade and group ade were significantly higher than of control group (p= . , p= . ). serum albumin in group ade was significantly higher than that of groups of csa and csa&ade (p= . , p= . ). serum triglyceride in group mmf&ade was significantly lower than that of groups csa and csa&ade. serum creatinine in group mmf&ade was lower than that of the groups of csa, csa&ade, mmf, ade and nac&ade and was significantly lower than that of control group (p= . ). serum creatinine in group csa was significantly higher than of groups of csa&ade, mmf, mmf&ade (p= . , p= . , p= . , respectively). in group nas+ade, total oxidant was significantly higher and total anti-oxidant was significantly lower than other treatment groups (p< . ). we showed that the better effect on proteinuria, serum triglyceride and albumin and lower serum creatinine by adding vitamin a, d, e in the treatment of experimental nephrotic syndrome with csa or mmf. conclusion: ht is associated with known risk factor of progression of biopsy-proven gn such as s-cr or proteinuria. the crb is an important tool for studies focusing on the epidemiology of gn in the czech republic and serves as a basis for cooperation in this field. ( ), lupus-nephritis ( ), iga-nephropathy ( ), minimal change disease and membranous nephropathy (by ) were observed. the distinction of morphological variants of the fsgs was started recently (last months). among the patients with fsgs, which were biopsied during this short period ( ), all have had a tip-lesion. these patients were started cyclosporine a mg/m /day with complete ( ) and partial ( ) remission achievement after - months. thus, the focal and segmental glomerulosclerosis is the most frequent cause of the nephrotic syndrome in children. the focal and segmental glomerulosclerosis with tip-lesion is characterized by favourable course and good response to therapy with cyclosporine a during the short-time period. objectives of study: molecules of monocyte chemoattractant protein- (mcp- ), β-catenin and cytokeratin (ck ) express increased in cellular crescent, which is a severe pathological change in renal diseases. however, it is unknown whether these molecules in urine correlate to the number or extent of cellular crescents. methods: urinary molecules mentioned above were detected in healthy subjects and patients with renal diseases by elisa. the expressions of these molecules and macrophage (cd positive) in biopsy specimens were also investigated. results: significant higher levels of these molecules in urine were demonstrated in all patients with renal diseases compared with healthy subjects (p< . ), but the highest level in patients of the cellular crescent group. the significant correlations were revealed between these molecules in urine and the index of cellular crescents (r= . , r= . , r= . , p< . ), between these molecules in glomeruli and the index of cellular crescents (r= . , r= . , r= . , p< . ), and between these molecules in glomeruli and in urine (r= . , r= . , r= . , p< . ). conclusions: this study suggested that the detection of urinary mcp- , β-catenin and ck might become potential biomarkers for clinical diagnosing cellular crescent lesions and assessing cellular crescent extent in renal diseases. this study aims to evaluate the benefits and harms of levamisole in steroid dependent (sd) and frequent-relapsing (fr) nephrotic children. material and methods: a total of steroid-sensitive nephrotic children were recruited prospectively from january to december . females and males, ( %) fr, ( %) sd. mean age at the beginning of levamisole was , years. twelve didn't receive any alternative drug before, received cyclophosphamide. renal biopsy was perfomed in patients, had minimal change disease (mc), one patient had mc at the first biopsy and fsgs in the second. the patients were divided in two groups according to their steroid response: sd and fr. levamisole was started at a dose of , mg/kg/ h as a second line drug in order to try to prolong periods of remission. clinical and laboratorial controls were performed monthly. patients were evaluated as: total responders: when steroid withdrawal was possible, partial responders: when steroid reduction was possible, non-responders: no steroid modification in months. the responders used levamisole for one year. results: the response of frequent-relapsing patients was: % of total response, % of partial response and % of non-responders. steroid-dependent patients had % of total response, % partial and % non-responsers. only one patient developed leukopenia. now % ( ) are out of levamisole and in remission, % ( ) are still using levamisole(alone or low-dose of prednisone), % ( ) are using cyclosporin, one used cyclophosphamide and one is using low-dose prednisone. conclusion: levamisole is a promising alternative drug for nephrotic syndrome. the major advantage of levamisole is its steroid-sparing effect with minimal toxicity. conclusions: hypertension and renal insufficiency were less frequently seen in chinese children with fsgs, isolated hematuria as unique clinic presentation was common in fsgs. all pathological variants had tubular-interstitial lesions, but vascular lesions were rarely seen. most fsgs children with nephrotic syndrome were sensitive to steroid at initial stage, and easy to develop frequent relapse gradually, immunosuppressive agent may be helpful to elevate remission rate. the aim of the study was to assess whether the serum index iga/c can be a usefull marker of activity igan and hsn in children. twenty children with igan (mean age . ± . years) and children with hsn (mean age . ± . years) were retrospectively analysed. in all children urine analysis, gfr were checked and the levels of serum iga and c were measured before therapy, serum iga/c was than calculated. at the onset of illness, igan and hsn was diagnosed based on the renal biopsy in mean time . ± . years. changes in light microscopy were graded i-v according to the classification of who (cwho). all biopsies were scored for activity and chronicity index (ai max score , ci max score ) (pediatr.nephrol. , , heparan sulfate proteoglycans are present both as structural components of the gbm and as modifiers of growth factor signaling on the cell surface. in mcns the presence of certain hs epitopes inthe gbm is decreased. hsulf and hsulf are recently identified endosulfatases, that can remodel the sulfation pattern of hs and thereby control the availability and presentation of factors such as fgf and hgf to their high affinity receptors. sulfatase activity requires posttranslational modification by formylglycine-generating enzyme or sulfatase modifying factor (fge/sumf ) that is counteracted by its paralogue pfge/sumf . we demonstrated that podocyte, endothelial and tubular epithelial cell lines express mrna for sulf , sulf , sumf and sumf . we investigated the in vivo distribution patterns of these enzymes in human kidney specimens by in situ hybridization. in histologically normal kidneys (n= ) expression of hsulf mrna was largely restricted to peritubular and glomerular endothelial cells, where as hsulf mrna was weakly expressed in all glomerular resident cell types. expression of sumf and sumf mrna was present in a minority of mesangial cells and podocytes, as well as in avariable number of glomerular and peritubular endothelial cells and invascular smooth muscle cells. in mcns (n= ), the glomerular expression patterns of hsulf , sumf and sumf mrna did not differ significantly from that in controls. in contrast, hsulf mrna expression was increased in podocytes. increased hsulf expression by podocytes is a novel factor to be considered in the pathogenesis of mcns. the onset and duration of ins, histopathological changes in renal biopsy, results of corticosteroid therapy and proteinuria selectivity reflecting the alteration of glomerular capillary wall were analysed. materials and methods: children with ins aged - , followed up to month, and healthy children were studied. in all patients stage of ckd were diagnosed. ins children were divided in two groups regarding to serum cystatin c levels as a marker of gfr: group i (n= )children with unchanging gfr, ii (n= ) -patients with impairment renal function over the study period. serum total protein, albumin, cholesterol, cystatin c, creatinine and immunoglobulin igg, and urinary protein, albumin, igg and creatinine were measured. results: serum cystatin c levels were higher in both groups of ins patients compared to healthy children (gr. i: . ± . , gr. ii: . ± . vs . ± . mg/l; p< . ). in group ii amount of -hour proteinuria was significantly higher than in group i ( . ± . vs . ± . g/l; p<. ), however other biochemical parameters (including igg excretion, albuminuria, selectivity index) were not different. in group ii higher age of onset was found. in this group mesangial proliferation and focal segmental glomerulosclerosis more often were observed. conclusions: the age of onset, histopathological diagnosis and proteinuria can be considered as important markers of ckd progression in children with ins. probably, longer follow-up of children with ins is necessary to find other prognostic factors. k. kilis-pstrusinska, k. fornalczyk, d. zwoliñska cyclosporine a (csa) has been used as a therapeutic option for steroid-dependent and steroidresistant nephrotic syndrome (ns). the aim of the study was to assess the effects of long term csa treatment in children with ns. methods: we performed retrospective study to evaluate safety and efficacy of csa therapy in children with ns ( girls and boys), aged - years. results: before introducing csa, in patients steroid-dependent ns and in -steroid-resistant ns were observed. children presented symptoms of steroid toxicity. pre-treatment renal biopsy was performed in patients ( children without biopsy because of renal agenesia). minimal change disease was diagnosed in ( %) children, focal segmental glomerulosclerosis (fsgs) in ( %), mesangial glomerulonephritis (gn) in ( %) and membranoproliferative gn in ( %) cases. all children were taking csa (target blood trough levels - ng/ml) more than months, mean months (range - ). complete remission was achieved in ( %) children, partial in ( %). in ( %) patients csa treatment was continued with mild dose of steroids. patients ( %) did not respond to the therapy and one of them end stage renal failure developed. following side effects have been observed: hyperuricuria ( % of patients), hyperuricaemia ( %), hypomagnesaemia ( %), hypertension ( %), hypertrichosis ( %), gingival hyperplasia ( %), hepatotoxicity ( %), gastritis and ileitis symptoms ( %). in patients control renal biopsy was performed after - months of csa therapy. in patients progression to fsgs was seen. only in one case histological findings of csa nephrotoxicity occurred. conclusion: long-term csa treatment in children with steroid-dependent and steroid-resistant nephrotic syndrome can be consider as an effective and safe therapy. introduction: membranous nephritis represents a rare disease in childhood with an incidence of . to % in renal biopsy specimens among various types of glomerulonephritis. although in many cases the disease is considered as idiopathic the association of membranous nephritis and infectious agents it is also well known. aim: we report a case of a months old baby girl of asian origin, presented with macroscopic haematuria of glomerular origin, proteinuria, - gr/ hours, hyaline and granular casts, maculopapular rash on the legs and microcephaly. methods: renal function tests in terms of plasma urea and creatinine were normal. the renal biopsy showed membranous nephritis. tests for infectious diseases (torch screen) showed a primary cmv infection. this diagnosis was based on the presence of high level cmv specific igm antibodies, increased igg antibodies and low avidity of cmv specific igg antibodies. a real-time-pcr of the renal biopsy specimen was positive for cmv as well, confirming this virus as the causative agent of membranous nephritis in the presented case. treatment with gancyclovire per os was introduced and it was most impressive since proteinuria disappeared in the following two to three weeks. two years after the diagnosis the child remains well and asymptomatic. in summary: to our knowledge, among various infectious agents, there is no case of congenital or secondary nephropathy described so far due to cmv infection in children. objective of study: pulse methylprednisolone therapy (pmt) has been shown effective in proteinuric renal diseases. but its exact effect in children with steroid-sensitive relapsing nephrotic syndrome still has no definite conclusion. to evaluate the effect and adverse effects of pmt, we performed a retrospective study. methods: there were cases of steroid-sensitive relapsing nephritic syndrome received pmt. they all had been treated with oral prednisone in similar condition previously. a self control design was used to compare the effect of pmt and oral prednisone. results: the average age was . ± . years. ten cases attained complete remission after the first course of pmt, and the average duration of pmt until remission was . ± . days. one case attained complete remission after the second course of pmt. compared with the effect of oral prednisone previously, seven cases attained complete remission more rapidly. paired-samples t-test was performed to compare the effects of pmt and oral prednisone in six cases with very similar state, however, the difference between them was not significant (p= . ). during the treatment of pmt, adverse effects were found in cases. conclusion: compared with oral prednisone, the superiority of pmt had not been definitely confirmed, and adverse effects might appear during the treatment. therefore we should be very strict with administering pmt in children with steroid-sensitive nephrotic syndrome. the study we performed was retrospective, so it was necessary to design a prospective clinical randomized controlled trial to further evaluate its effect. objective of study: pulse methylprednisolone therapy (pmt) has been shown effective in proteinuric renal diseases. but the exact effect of pmt in children with steroid sensitive nephrotic syndrome (ssrn) still has no definite conclusion. to evaluate the effect and adverse effects of pmt, we performed a prospective study. methods: a prospective clinical randomized controlled trial was conducted to compare the effect and adverse effects of pmt with oral prednisone (op) in children with ssrn. thirty-one children were enrolled with only suitable for evaluation including patients in the pmt group and in op group. results: there was no significant difference between both groups in complete remission rate. the average durations of therapy until remission were . ± . days in pmt group and . ± . days in op group, respectively. complete remission was more rapidly attained in pmt group (p= . ; < . ). during the treatment and the following months, no significant difference of adverse effects was found between both groups. there was no significant difference between both groups in relapse rate during months follow-up. conclusion: compared with oral prednisone, pmt could induce complete remission more rapidly and did not company with more adverse effects in children with ssrn. pmt had no effect on the reduction of relapse rate in the following months after administration. outcome of childhood henoch-schönlein purpura nephritis with nephroticrange proteinuria in a single center objective: the majority of children with henoch-schönlein purpura nephritis (hsn) only with hematuria and/or mild proteinuria have good chances for recovery. however, it is still unclear how we should treat hsn with persistent massive proteinuria. the aim of this study is to evaluate the outcome of childhood hsn with nephrotic-range proteinuria treated with angiotensin converting enzyme inhibitor (acei) and corticosteroids. methods: patients with henoch-schönlein purpura ( boys, girls) ranging from . to . ( . ± . ) years old at onset visited our hospital between april and december . thirty seven ( . %) developed hsn. mean age of ( boys, girls) hsn patients with nephroticrange proteinuria (> mg/h/m ) at the time of diagnosis was . ± . years old. two developed nephrotic syndrome, but none had renal insufficiency at onset. one patient suffered moderate proteinuria and renal dysfunction years after the onset. renal biopsies were done in cases and showed for grade i, for grade ii and for grade iii respectively (classification by international study of kidney diseases in children). results: eleven of the patients received acei and no patients were treated with immunosuppressive agents except for corticosteroids and methylprednisolone pulses. after a mean follow-up of . years, patients showed complete remission, had mild proteinuria or microscopic hematuria, only one postpartum patient presented with nephrotic-range proteinuria, and none developed renal insufficiency. conclusions: our results suggested that the short-term outcome of childhood hsn with nephroticrange proteinuria but not renal insufficiency was relatively favorable. thus, the degree of proteinuria is not a sole prognostic factor for childhood hsn. therefore, the indication for corticosteroid therapy should be clarified. recent observations determined a r x specific exon mutation in the gene encoding nephrin (nphs ) which evidenced an unexpectedly mild finnish-type congenital nephrotic syndrome (cns) phenotype. the long-term follow-up of patients with this mutation is actually known only in a few patients. we reported the long term follow-up of a girl originary of sicily (italy) presenting such a mutation. the first years of her life were previously reported (s.guez et al pediatr nephrol ). in brief the child was pre-term born from related parents and she presented proteinuria ( - g/day) from birth. renal biopsy was consistent with the diagnosis of cns and molecular evaluation demonstrated a homozygous exon r x nonsense mutation in the nphs gene. in the first years she was treated by human albumin without a regression of proteinuria that decreased up to . - . g/day with enalapril treatment ( . mg/kg/day); clearance of creatinine at years of age ranged between and ml/min/ . mq. during the following years (at the last control the girl was year old) she had continued enalapril treatment ( . mg/kg/day). creatinine clearance was ml/min/ . mq/day, serum total protein g/l; serum albumin g/l and proteinuria ranged between . - . g/day. both height and weight were at th for age and pubertal stage was normal; blood pressure was / mmhg. in conclusion, this is the first reported long-term follow-up in an italian patient affected by finnishtype cns with the specific r x nonsense mutation in the nphs gene: even if proteinuria persisted there was no worsening in gfr. serum total protein, albumin and growth were normal confirming the milder phenotype in comparison with the typical finnish forms. long-term enalapril treatment may also have contributed to the prognosis in this specific form of congenital nephrosis. atypical hemolytic uremic syndrome (ahus) frequently results in end-stage renal failure and can be lethal in many cases. recently, it has been recognized that many cases of ahus are associated with a defective control of the complement activation cascade. more than sixty different mutations in complement factor h gene (cfh) have been reported so far. guidelines for treatment modalities are yet to be established although plasma infusions and exchanges are often advocated. we describe a patient who presented at months of age with ahus (anemia, thrombopenia, acute renal failure requiring hemodialysis) associated with heterozygous combined de novo complement factor h mutations (s l and v a) on the same allele. laboratory investigations showed normal levels of complement c , c and factor h. during the first episode, daily plasma exchanges (pe) using cryosupernatant (cr) as replacement fluid resulted in a resolution of hemolysis and complete normalization of renal function. two ahus recurrences were successfully treated with daily pe and subsequently pe were weaned to twice weekly. one year after the first episode, pe were stopped and pi regimen ( ml/kg twice weekly and weekly thereafter) was started. at the present time, the patient has been receiving weekly pi ( ml/kg) for one year. transitory falls in haptoglobin levels or platelet counts are observed periodically and successfully treated by intensification of pi ( ml/kg) twice weekly for one or two weeks. renal function remains normal.although our observation demonstrates the effectiveness and good tolerance of large volumes of pi ( ml/kg), long-term efficacy of such a therapy remains to be evaluated. because of the possibility of secondary failure of plasma therapy, it is important to investigate alternative approaches such as combined liver-kidney transplantation. common variable immunodeficiency (cvid) is characterized by reduced serum immunoglobulin levels and recurrent bacterial infections. there have been only previous case reports of renal granulomas in cvid and only one of them was associated with immune complex glomerulonephritis. we present a case of renal granuloma and glomerulopathy in a patient with cvid. a -year-old girl, with a past history of uveitis, presented with cardiac tamponnade and bilateral pleural effusions. investigations revealed nephrotic syndrome (serum albumin of (normal - ) g/l and proteinuria > g/l), microscopic hematuria and reduced serum igg levels ( . g/l, normal . - . g/l). lupus nephritis and serositis were first suspected and corticosteroids were initiated. no serum anti-nuclear or anti-dna antibodies, nor complement activation were detected. a renal biopsy was performed and showed global glomerular endocapillary proliferation. intratubular calcium deposits were present. in the interstitium, a noncaseating epithelioid granuloma was found. immunofluorescence studies showed significant mesangio-parietal igm deposits with few c and c q. as igm-immune complex glomerulonephritis has been reported in sarcoidosis, this diagnosis was highly suspected. further investigation revealed normal lung parenchyma and mediastinum, normal serum angiotensinconverting enzyme, . oh d , calcemia and calciuria. the nephrotic syndrome gradually improved, but serum igg levels remained persistently low ( . g/l). the diagnosis of cvid was confirmed and iv immunoglobulins were initiated. this is the first report of concomitant renal granuloma and igm-immune complex (without igg) glomerulonephritis in a cvid patient. in summary, cvid must be included in the differential diagnosis of renal granuloma and should be differentiated from sarcoidosis to ensure appropriate therapy. o. nwobi, c. abitbol, j. chandar, w. seeherunvong, g. zilleruelo background: rituximab, an anti-cd antibody, has been proposed as therapy for refractory systemic lupus erythematosus (sle), although its use in children remains anecdotal. we present our initial longterm experience on the safety and efficacy of rituximab for treatment of sle in children. methods: pediatric patients with sle refractory to standard treatment protocols were treated with rituximab for - doses ( mg/m ). all had proliferative nephritis and systemic manifestations of vasculitis. clinical disease activity was scored using the sle-disease activity index (sledai). proteinuria is reported as the urine protein to creatinine ratio (upr/cr). patients have been followed an average of . ±i. years. results: b cell depletion occurred within month and remained suppressed for up to months. clinical course, renal function and proteinuria improved in the majority of patients as summarized below: objective: to assess efficiency and safety of treating crns patients with srl. subjects: patients, mean age . years old ( yrs- yrs) ( females) affected by crns. inclusion criteria: histological diagnosis of focal and segmental glomerulosclerosis, glomerular filtration rate (gfr) above ml/min/ . m , negative plasma pregnancy test, signed child and parents informed consent. exclusion criteria: secondary nephrotic syndrome, white blood cells (wbc) count below /mm , chronic hepatopathy, coagulopathy, tumoral or infection processes. discontinuation criteria: sustained decrease in gfr by more than % of the initial rate, decrease of the wbc count to less than /mm , occurrence of lymphoprolipherative and tumoral processes, severe infection, alterations in coagulation parameters, positive pregnancy test or inflammatory process or lack of changes in proteinuria or its increase after four-month treatment. methods: srl dose and dosage: dose of to mg/m /day (up to mg/day) administered once a day. expected dosage range: to ng/ml (hplc-uv method). treatment duration: months. results: patients showed nephrotic syndrome remission; average srl dose: mg/m /day; average srl dosage: . ng/ml (range . - . ). average proteinuria prior to treatment: mg/m /hour (range - ); average proteinuria after treatment: mg/m /hour (range . - ); average time of remission: months and days, none of patients showed adverse events that would have lead to the treatment discontinuation. if these data are representative of the universe of patients we are dealing with, the confidence interval (p= . ) of the percentage of patients with not proteinuria after treatment is going to be between % and % if patients are assessed. conclusions: srl caused crns remission in patients who were refractory to traditional immunosuppressive treatments. background: retinoic acid-inducible gene-i (rig-i) may play an important role on inflammatory and immune processes by regulating the expression of various genes, and has been reported to be expressed in various inflammatory diseases. we studied the expression of rig-i in human lupus nephritis and evaluated the correlation between its expression and the histological activity of the renal disease in these cases. methods: expression of rig-i in the glomeruli was assessed by indirect immunofluorescence method; frozen sections of ten kidney tissue specimens obtained from eight patients with lupus nephritis were stained with a monoclonal antibody for rig-i. kidney tissue specimens from eight patients with minimal-change (mc) disease were used as controls. results: expression of rig-i was detectable as granular immunofluorescence in a mesangial and capillary distribution in all the patients with lupus nephritis, but was absent or only trace-like in the patients with mc disease. the glomerular immunoreactivity for rig-i was correlated with the histological activity and severity of the renal disease in the patients with lupus nephritis. conclusions: rig-i expression occurs at levels detectable by indirect immunofluorescence and may be potentially useful as a parameter reflecting the renal histological activity in cases of lupus nephritis. cyclophosphamide pulse therapy for crescentic, proliferative iga nephropathy in children iga nephropathy is one of the most common glomerular kidney diseases in europe, up to % of affected adults need dialysis after years. therapy of crescentic, proliferative iga nephropathy in children is not well examined. between / and / seventeen children (main age years ( - ), male/female= / ) with biopsy-proven mesangioproliferative glomerulonephritis as manifestation of iga nephropathy were enrolled. nine patients (male/female= / ) had severe clinical manifestations (renal failure, nephrotic proteinuria or cerebral vasculitis) with extracapillary glomerular proliferations (crescents). this children were treated by intravenous methylprednisolone pulses ( / / / mg/m body surface area over days) followed by monthly intravenous cyclophosphamide (cph) pulses ( x mg/m body surface area) with gradually tapered oral prednisolon ( - mg/m body surface area/ h over months) and aceinhibitor (enalapril . - . mg/kg/d). after months of treatment a significant reduction of proteinuria ( . ± . to . ± . g/m /d; p< . ) and improvement of kidney function (gfr ± . vs. ± ml/min/ . m , p< . ) was observed. no notable adverse events were recorded. six patients had a second renal biopsy after completing cph-therapy; only crescent was found in examined glomeruli (initial findings: crescents in glomeruli). after follow-up of ( - ) months all children have unaltered renal function, further episodes of macrohematuria or gross proteinuria did not occur. intravenous cph pulse therapy seems to be an effective therapeutic option in paediatric patients suffering from crescentic iga nephropathy. eye involvement in children with primary fsgs distinct eye abnormalities have been described in children with nephrotic syndrome, particularly in diffuse mesangial sclerosis (pierson syndrome). the aim of the study is to investigate whether there are any associated ocular anomalies in childhood primary focal segmental glomerulosclerosis (fsgs). demographic characteristics, age at onset, drug therapy and duration of the disease were defined in patients ( girls, boys, mean age . ± . years) with biopsy proven fsgs. standard steroid therapy was prescribed to the patients. a detailed ophtalmological examination was performed in all patients. the median age at diagnosis was years ( - years). mean followup time was months ( - months). eleven patients ( . %) reached to chronic renal failure during follow-up period. overall, patients ( %) showed various eye abnormalities. nuclear opacity was found inone child and posterior subcapsular opacities probably due to corticosteroid therapy were present in two cases. two patients had myopic astigmatism and two had exotrophia. importantly, patients had anisometropic ambliyopia, had mittendorf spots and had pigmentary changes in macula, which had never been described in the literature. mutational analysis for nephrin, podosin, wt and lamb genes are still going on. we don't know whether particular mutations are related to particular eye findings like pierson syndrome, yet. however our findings emphasize that ophtalmological evaluation should be performed in all patients with primary fsgs at the time of diagnosis. regardless of the underlying disease, the proteinuric condition demonstrates ultrastructural changes in podocytes with retraction and effacement of the highly specialized interdigitating foot processes. to investigate whether high glucose and advanced glycosylation endproduct (age) induce podocyte phenotypical changes, including quantitative and distributional changes of zo- protein, we cultured rat glomerular epithelial cells (gepc) under ) normal glucose ( mm,=control) or ) high glucose ( mm) or ) age-added or ) high glucose plus age-added conditions. high glucose plus age-added condition could increase the permeability of monolayered gepcs and induce ultrastructural separation between confluent gepcs. zo- moved from peripheral cytoplasm to inner actin filaments complexes by both age-added and/or high glucose condition in cutured gepc by confocal imaging. high glucose plus age-added condition also decreased zo- protein amount and its mrna expression to statistically significant level compared to normal glucose or osmotic control conditions. we could also confirm the activation of pkb/akt signaling pathway in gepc by age, high glucose and insulin in pi k-dependent manner. in addition, an inhibition of pi kinase by ly was able to prevent quantitative and distributional changes of zo- protein induced by high glucose and age. these findings suggest that both high glucose-and age-added condition induce the cytoplasmic translocation and suppresses the production of zo- at transcriptional level and these changes may be mediated by pi k/akt signaling. this pathway could explain the role of zo- in the phenotypic changes of podocytes in diabetic conditions. henoch-schönlein purpura (hsp) is common in the pediatric population, while wegener's granulomatosis (wg) is rare. although both diseases are classified into the vasculitis syndrome, their clinical symptoms, the treatment and the prognosis are considerably different. the classic clinical triad of wg consists of upper and lower airway disease, renal involvement and small vessel vasculitis. we present a rare childhood case in whom hsp-like symptoms were developed prior to wg symptoms. a -year-old girl developed ankle joint pain and swelling and purpura on bilateral legs and hands in the absence of abdominal pain. she was diagnosed as hsp and treated with oral prednisolone (psl) therapy. although high dose psl temporarily rescued these symptoms, purpura and joint swelling and pain reappeared in parallel with a reduction of psl dose. at this moment, because microscopic hematuria, mild proteinuria and hoarseness were also noticed for the first time, serum proteinase- antineutrophil cytoplasmic antibody (pr- anca) was evaluated and detected to be high. moreover renal pathology showed necrotizing pauci-immune glomerulonephritis, leading to the final diagnosis as wg. after methylprednisolone pulse therapy followed by oral psl combined with cyclophosphamide, her clinical symptoms with wg were resolved together with the reduction of serum pr- anca titer. taken together we emphasize that pr- anca should be evaluated even in the patients who only develop hsp symptoms. background: short-term efficacy of steroid therapy for pediatric patients with iga nephropathy (igan) has been reported. however, there are a number of cases in whom their igan recurs after stopping the steroid therapy. recent japanese study indicated that tonsillectomy had a significant impact on renal outcome. also, another japanese study showed mizoribine was effective for igan in children. in this study, we examined the effects of a treatment regimen consisting of tonsillectomy and steroid pulse therapy followed by mizoribine (tx) for chronic relapsing igan in children. method: ten cases who showed chronic relapsing igan were included as the subjects (mean age at onset: . yrs, mean age at initiation of tx: . yrs). they were divided into two group, a normal renal function group (group a, n= ) and an impaired renal function group (group b, n= ). the changes in hematuria, proteinuria, renal function, and adverse events were prospectively examined for more than months. result: a negative of hematuria was observed in % of group a and % of group b. a negative of proteinuria was seen in % of group a. in addition, in group b, deterioration of renal function was not observed during the observation periods. there were no serious adverse events associated with this treatment regimen. conclusion: a treatment regimen consisting of tonsillectomy and steroid pulse therapy followed by mizoribine treatment seems to be effective to control of acute inflammation coexisting with chronic glomerular lesions, and can be a valuable addition to therapeutic options for treating patients with chronic relapsing igan in children. objective of study: to present a case of silent stenosing ureteritis in a boy with henoch-schönlein purpura (hsp). case report: a -year-old boy was admitted with a typical hsp. urine findings were normal on admission. a gastrointestinal bleeding on the th day of illness suggested corticosteroid treatment. the ultrasound on the th and th day revealed a normal urinary tract. on the th day he developed non-painful macroscopic haematuria, followed by microscopic haematuria and proteinuria, which reached the nephrotic range on the th day. thus, the boy was treated with methylprednisolone pulses and cyclophosphamide for weeks. renal biopsy was not performed because of his parent's refusal. microscopic haematuria and proteinuria gradually subsided, with complete disappearance at the th month. during this time he was asymptomatic, with no episodes of macroscopic haematuria or colicky flank pain. at the th month of illness a new ultrasound revealed a major left hydronephrosis. computer tomographic urography showed a complete ureteropelvic junction obstruction. the mtc-dmsa scan revealed a % relative function ipsilaterally. a left pyelostomy was performed. during the next four months after draining, the urine volume of the affected kidney was . - . ml/kgr/hour, the creatinine clearance - ml/min/ . m and the mtc-dmsa scan showed a % relative function. based on the above findings a nephrectomy was decided. conclusions: although rare, stenosing ureteritis should be considered in hsp. the typical clinical presentation with haematuria in association with colicky flank pain may not always occur, as in the present case, or may be confused with the symptoms of hsp itself. thus, the repetition of an ultrasound during the process of the disease may be necessary, in order for this complication to be diagnosed and treated early, preventing serious renal outcome. mitochondrial diseases are either due to sporadic or inherited mutations mainly in mitochondrial dna located genes. with regard to renal manifestations, tubular dysfunctions are common; however, the existence of solitary glomerulopathy has recently become apparent. in such case, the pathomechansim of the glomerular proteinuria is still obscure. wepresent a year-old girl who was found to have asymptomatic proteinuria (up/cr . ) in the absence of hematuria, azotemia, tubular dysfunctions, lacking any neurological manifestations. her family history showed maternal inheritance with mild proteinuria of grandmother and renal insufficiency of young uncle. light microscopy revealed glomeruli of normal appearance and of global sclerosis. electron microscopy showed swollen mitochondria in podocyte of normal appearance glomerulus. pointmutation rate of mitochondrial dna, a g, was detected as less than % in grandmother, % in mother and % in the patient examined byperipheral blood cells. the proteinuria completely disappeared months after treatment with combined therapy of arb and acei. to determine the responsible molecule for the pathomechanism of proteinria, immunostaining followed by conforcal microscopy with slit diaphragm associated molecules (sdm) (nephrin, podocin), gbm associated molecules (type iv collagen alpha chains, laminin isoforms, perlecan) and podocalyxin was studied and compared to the controls. interestingly distinct decrease of expression with sdm was observed even in normal appearance glomerulus of the patient. taken together, a g mutation itself may lead to depletion of atp and/or increase of free radicals in podocyte, which predominantly affect the biogenesis of sdm, result in pathological glomerular proteinuria. the mechanism of antiproteinuric effect of arb/acei therapy should be evaluated by serial biopsy specimen. objectives: to report the effectiveness of pulse cyclophosphamide induction therapy in children with diffuse proliferative lupus nephritis. to identify predictors for unresponsiveness to the treatment. methods: thai children under years of age with biopsy-proven diffuse proliferative lupus nephritis who were admitted to chiang mai universityhospital between and were retrospectively studied. responsiveness to treatment, defined as urinary protein to creatinine ratio of less than . , was assessed at the end of induction period. the clinical characteristics and laboratory data including gender, age at diagnosis of sle, duration of disease before treatment, hypertension, clinical nephrotic syndrome, amount of proteinuria, serum creatinine, creatinine clearance, serum c level and presence of crescentic formation in renal biopsy were compared between the two groups who responded and did not respond to the treatment. results: a total of patients ( % female) with the mean age at diagnosis of sle of . ± . year were studied. nineteen patients ( %) achieved remission at the end of induction therapy. there were no significant differences in all parameters studied between responsive and nonresponsive groups. despite the indifference in the amount of proteinuria, the proportion of patients with nephrotic-range proteinuria was higher in unresponsive group. conclusions: pulsecyclophosphamide is an effective regimen for induction therapy in children with diffuse proliferative glomerulonephritis. although no definite predictor was detected in this study, higher proportion of patients with nephrotic-range proteinuria in the unresponsive group wasnoted. born small for gestational age, but not early postnatal weight gain aggravates the course of idiopathic nephrotic syndrome in children clinical and animal studies have shown a higher risk of an aggravated course of renal disease in childhood after birth small for gestational age (sga). fast catch-up growth after sga seems to support the development of later disease. in a retrospective analysis of cases with idiopathic nephrotic syndrome treated between and in a university centrefor paediatric nephrology we identified children as sga and asappropriate for gestational age (aga). we related the course of disease to birth weight and catch-up growth. median age of manifestation in sga was . ( . - . ) years vs. . ( . - . ) years in aga children. in all sga children renal biopsy was performed, while only % of the aga children underwent renal biopsy showing nodifference in renal histology. in the sga group, % patients developed steroid resistance (vs. % aga, p< . ). the number of relapses was not different. % sga children needed antihypertensive treatment inthe course of the disease compared to % of aga children. catch-up weight gain between birth and months of age did not influence the course of disease. in conclusion we could find evidence for an aggravated course of idiopathic nephrotic syndrome in former sga children, but weight gainduring the first two years of life did not influence the course of disease. the mechanisms of perinatal programming in later renal disease need further investigation. wilson's disease(wd) is a disorder of copper metabolism that affects numerous organsystems including kidneys. besides renal tubular dysfunction as a result of excessive storage of copper, renal manifestations due to therapeutic complications can also develope specially with d-penicillamin. in this study we investigated the frequency and spectrum of renal manifestations during d-penicillamin therapy in wd. of patients receiving d-penicillamin for wd, patients( . %) ( boys, girl) developed findings of glomerulopathy within month to year after initiation of therapy and all were histologically diagnosed to have membranoproliferative glomerulonephritis (mpgn). the patients were between - years old, and they had normal urinalysis and renal function tests in their first presentations. two siblings developed hematuria and proteinuria below nephrotic range while the other two developed nephrotic syndrome. one of these latter patientsalso had acute renal failure needing temporary peritoneal dialysis. three patients had low complement (c) levels, had antinuclearantibody (ana) positivity, two had c-antineutrophil cytoplasmic antibody (anca) and one p-anca positivity. d-penicillamin therapy replaced by zinc sulphate in all patients. all renal findings improvedin patients within - months with normal renal functions and complement levels, and negative ana, p and c-anca tests. after years all were clinically in remission of mpgn confirming the role of d-penicillamin in development of renal disease. objectives of the study: the use of tacrolimus in steroid-resistant (sr) focal segmental glomerulosclerosis (fsgs) has been reported in single and small series. the aim of this report is to exhibit experienceon the management of children with sr fsgs in whom tacrolimus had been started on due to the therapy resistance. methods: fk combined low-dose oral steroid was started on three male patients ( , , -yearold) with sr fsgs who had been following for three years. all of them had failed various cyclosporin a, cyclophosphamide and steroid regimens prior to treatment with fk . the application was . mg/kg/day in two divided doses over h adjusted to a trough blood level between and ng/ml for months. other therapies included angiotensin-converting enzyme inhibitors, vitamin d and calcium analogues, and lipid-lowering agents. results: a reduction in proteinuria to normal levels was noted between - weeks following the initiation. the remission was achieved overall during the treatment. the relapse was recorded following cessation of tacrolimus in - weeks. the drug was generally well tolerated with no sideeffects and adverse reactions. the ratio of infectious events did not differ from the former regimens. conclusion: tacrolimus may be effective in controlling the proteinuria of patients with srfsgs during the therapy. there is a trend of relapse following cessation of treatment. the duration for drug uptake is a topic of debate. further study in larger population is warranted. introduction: histological features of focal segmental glomerulosclerosis are found in % of pediatric patients with steroid resistant nephrotic syndrome. upto % (between - %) children with fsgs progress to esrd. objective: to study the clinical course of childhood fsgs and determine the possible predictive factors of chronic kidney disease. method: case records of children who had biopsy proven fsgs and had presented to the sindh institute of urology and transplantation between - , were retrieved. clinical and laboratory parameters at baseline, response to steroids and cyclosporine, development of crf (as defined by a gfr of < ml/min/ . m ), and histopathological details were analysed. result: a cohort of children with a mean age of . ± . years and a m: f ratio of : was identified. after a mean follow-up time of years, / ( . %) developed crf. on univariate analysis, male sex ( % vs %, p- . ), > years age at onset ( % vs. %, p- . ), hypertension ( % vs. %, p- . ) and microhematuria at presentation ( % vs. %, p- . ) were significantly associated with risk of developing crf. steroid resistant course ( % vs. %, p= . ) was more prevalent in those who developed crf. the crf group was also more likely to have an elevated creatinine at baseline ( . % vs. %, p< . ). moderate tubular atrophy and a high percentage of segmentally and globally sclerosed glomeruli were found in those who developed crf. patients progressing to crf were more likely to have a partial response to cyclosporine ( % vs. %, p= . ) conclusion: factors such as age, microhematuria, hypertension, elevated baseline creatinine, steroid resistance, tubular atrophy, percent global sclerosis and partial response to cyclosporine are likely predictive of progression to chronic kidney disease in children with fsgs presenting to our center. chronic glomerular nephropathies in children are marked by an often unfavourable evolution, so that the establishing of a prognosis at the time of the diagnosis is both a professional and a moral duty for the pediatric nephrologists. purpose: the estimation of the current practice renal survival prognosis in children with chronic glomerular nephropathies, by using clinical and laboratory elements in different histological forms of primitive chronic glomerulonephritis (cgn), with a minimum period of observation of one year. we analyzed parameters that may intervene in the duration of renal survival: type of cgn, age at the debut of the illness, histological scores of activity and chronicity, the presence of tubular atrophylesions and that of interstitial fibrosis, renal failure (rf) installment time, in cases with normal renal function at the beginning, the time until the initiation of dialysis in cases with esrf, respectively. the statistic analysis of data has been carried outwith epi soft (fishcer test). the results have been as follows: unfavourable evolution has been taken into consideration in the cases which have presented fixed nitric retention or which required the initiation of dialysis. the initiation of dialysis was necessary in cases ( %), out of which ( %) having associated between and of the considered risk factors. if the histological type (sfgs, dgs, mpgn) is added to the obtained score, the accuracy of the estimation increases to %. in conclusion: the usage of prognosis scores composed of current elements of diagnosis that have proven to have statistical significance, as far as the renal survival prognosis is concerned, may allow the invoking of a medium-term prognosis in the evolution of children with cgn. introduction: the srns can lead to a progressive deterioration of the renal function and therefore needs an aggressive therapy. one of the alternatives of treatment is the association described by mendoza et al which consists of prolonged use of methylprednisolone with cyclophosphamide (cp), which has a remission rate of %. the objective of this study is to evaluate retrospectively the clinical evolution of children with srns treated with mendoza's protocol. method: between and , children, male and female, with srns were subjected to a renal biopsy and later treated with mendoza's protocol. cp was used in children that had not responded to pulses of methylprednisolone and presented a relapse. all of the patients received supplemental calcium. the clinical evaluation included stature, weight, ophthalmic fundus examination, proteinuria in urine recollection of hours and/or protein to creatinine ratio and blood chemistry. results: eleven patients ( %) had fsgs. nine ( %) presented complete remission, two ( %) had partial remission, four ( %) did not respond to treatment, of which evolved to terminal kidney disease. nine patients received cp. of the complications secondary to treatment with steroids, % had a linear growth suppression and an increase in their bmi and patient presented cataracts with visual impairment. conclusion: the prolonged treatment with boluses of methylprednisolone and cyclophosphamide is a good alternative in patients with srns. the prolonged use of high doses of steroids can cause linear growth suppression and other adverse reactions, so it is advisable torealize a genetic study in all of the patients with srns to be able to exclude the patients that have a genetic mutation and so avoid unnecessary treatment. objectives: to study the clinicopathological profile and outcome of lupus nephritis (ln) in indian children. methods: clinical and histopathological features and outcome of children with ln was retrospectively reviewed. patients were included if they fulfilled the acr criteria for the diagnosis of sle and had either of persistent proteinuria, active urinary sediments or renal dysfunction. outcome was analyzed at years and at last follow-up. results: ofthe children studied, were boys. the mean age (sd) at diagnosis was . ± . (median . , range - . ) yr; children were youngerthan years of age. the mean age at presentation and renal biopsy was . ± . (median . , range . - ) years. the mean duration of follow-up was . ± . (median . , range . - . years) years. . % patients were followed for more than years. commonest clinical manifestations were fever ( %), hypertension ( %) and malar rash ( %). and % of patients presented with nephrotic and nephritic syndrome respectively before the diagnosis of sle. the commonest pathology was class iv nephritis ( %) followed by class ii ( %). hypertension, hematuria, nephrotic syndrome and decreased egfr were significantly associated with class iv ln. at last follow-up . , . and % patients were in ckd stage ii, iii, and iv respectively. the patient survival rate at year and at last follow-up was and % respectively, while no patient developed esrd at years. infections were seen in % cases that resulted indeath in patients; died of hepatic encephalopathy. conclusion: sle nephritis has a varied presentation and high morbidity. a significant proportion of patients developed infections during the course of disease. clinical, pathological features and outcome in our study do not differ markedly from those in most pediatric series. background: atypical hus has a frequently relapsing course and a poor renal prognosis. low c plasma concentration suggests alternate complement pathway regulatory abnormalities: factor h (fh), factor i (fi) and membrane cofactor protein (mcp). case report: we report an year old girl with atypical hus due to acquired fh deficiency caused by anti-fh antibodies (abs). hus was diagnosed on the basis of acute renal failure, microangiopathic hemolyticanemia and thrombocytopenia. past history: recurrent fever with culturenegative pharyngitis (suspected pfapa syndrome). decreased c ( mg%, normal> ) with normal c . adamts activity was depressed, no cleaving protease abs. hemodialys (hd) and plasma exchange (pex) were started days later. severe urticaria and angoiedema during pex was treated with methylprednisolone and chlorpheniramine. hematological and renal improvement were observed after the rd pex session. relapses occurred in months: -controlled by pex; -(with suspected pfapa) with single dose corticosteroids, -with prednisone therapy, terminated with single dose ivig mg/kg. elevated anti fh ab titer- au with decreased fh functional activity were found in pre-pex plasma. fh, fi, factor b and c antigenic levelsnormal. hematological remission and renal function improvement without hus relapse ensued while tapering corticosteroids. two years after presentation, onprednisone mg/day anti fh titer dropped significantly with restoration of functional fh activity, gfr ~ ml/min/ . m . conclusions: in cases of atypical hus, active search for anti fh ab iscrucial for implementing specific and effective therapy: plasma exchange, iv ig and steroids for improving course and longterm prognosis. research centre for child health rams, department of pediatric nephrology, moscow, russian federation children aged , - years with idiopathic biopsy-proven steroid-resistant focal and segmentary glomerulosclerosis (fsgs) were treated with cyclosporine a (csa) , - , mg/kg as initial dosage, oral prednisolone , mg/kg every other day tapered to the -th month and methylprednisolone pulses (mp) - mg/kg every other day for the first - weeks in of patients. serum creatinine level was controlled once a month. after months of csa treatment complete or partial remission of proteinuria was in ( %) of children, no effect in ( %). serum creatinine level increased in % on an average in the group remission of proteinuria. in the group of non responded patients the creatinine elevation was significant same - %. after year of csa treatment complete or partial remission observed in ( %), no effect in ( %). elevation of serum creatinine level in children with remission was , % (without significant difference compared to month's csatreatment). increasing of the creatinine level more than % in two patients leaded to double tapering csa dose resulted in normalization of serum creatinine level. in the group of csa non responders the significant increasing of serum creatinine level ( %) was revealed (compared to month's csa treatment). in cases the elevation ofcreatinine level was more than % and these patients turned into esrd eventually. in all of non-responders csa was discontinued. we concluded that serum creatinine level in csa respondrers was stable without significant elevation during the year of treatment. csa therapy for year without any effect influenced on renal function decreasing. clinical objective: to describe the clinical course and outcome of pediatric patients with cgd treated with iv mpt ( mg/kg x doses monthly for months, then dose monthly for the next months) methods: patients' medical records were reviewed. pre, post-treatment and follow-up hr urineprotein, creatinine and gfr were compared using paired t-test; and proteinuria, hematuria and blood pressure using mcnemar's chi square. outcome measures were analyzed usingmean ± sd and frequency distribution. results: patients were included, male, female. mean age at disease onset is . ± . years. mean duration of follow-up is . ± . months. % achieved complete remission after a mean of . cycles, % partialremission after a mean of . cycles and % were treatment failures. mean relapse rate is . ± . on treatment and . ± . at follow-up. renal survival rate is %. hour urine protein and the proportion of patients with proteinuria, hematuria and hypertension significantly decreasedafter treatment and remained stable at follow-up. serum cr/gfr were also stable pre, posttreatment and at follow-up. no serious side effects were noted. conclusion: this protocol induced a high and early remission rate ( % after . cycles)among the patients. majority demonstrated stable renal function and blood pressure over time. relapse rates were low and treatment is generally safe. recommendation: the protocol can be offered to oral-steroid or alkylating agent-resistant patients with satisfactory remission rates. objectives of study: nestin, an intermediate filament protein which has a role in regulating cellular cytoskeletal structure, is restrictedly expressed in the podocytes of human kidneys. in the present study nestin expression was investigated in biopsy specimens of children with focal segmental glomerulosclerosis (fsgs). methods: kidney biopsy specimens taken from children with diagnosis fsgs were investigated. diagnosis was performed on light microscopy, immunofluorescence microscopy, taking into account clinical data. for immunomorphology monoclonal anti-nestin antibody from mouse (sc- , clone c . a , santa cruz biotechnology) diluted : , was applied on cryostat or paraffin sections using labeled streptavidinebiotin (lsab+ dako) method. visualization was performed by dako aec substrate. kidney biopsies of patients without nephrotic syndrome, mainly with mesangioproliferative gn were used for control staining. results: the mean age at the time of biopsy was . ± . years, and all patients had nephrotic syndrome. half of them revealed some focal tubulointerstitial changes: tubular atrophy, slight interstitial fibrosis and lympho-monocytic infiltration. in two cases mutation of wt gene and in one case mutation of nphs gene was detected. four cases had familial character of fsgs. nestin expression was variably present in different cases of fsgs. decreased expression was detected in glomeruli with segmental mesangial sclerosis and capsular adhesions. conclusion: fsgs revealed heterogenity concerning nestin expression. nestin expression was diminished in affected glomeruli. background: renal effects of altered ob/ob-r pathway may contribute to obesity, and diabetesassociated proteinuria. in the kidney ob/ob-r stimulates collagen type i and iv synthesis and upregulates tgfβ and tgfβ receptors. objective: to determine ob/ob-r and its downstream (jak/stat/socs) pathway expression in nephrotic syndrome (ns) and fsgs. design/methods: microarray analysis of kidneys of -week ( w) and -month ( m) old transgenic mice (tg) and controls (ctr) was performed, and confirmed by quantitative pcr. kidney sections were analyzed by immunohistochemistry (ihc) and western blot analysis (wb). urinary ob/ob-r of children with ns classified as steroid sensitive (ssns) or steroid resistant (srns), were measured by elisa. results: ob, ob-r, and jak , , mrna expressions were not statistically different at w and m between ctr and tg. stat and socs mrna were increased . -fold (sem ± . ), and . fold (sem± . ) at m in tg, p= . and p= . respectively. ihc and wb (p= . ) of kidney sections showed no significant difference between the groups. we examined ctr, ssns, and srns patients with comparable bmi, age, race and gender. urinary protein to creatinine ratio in ssns and srns was . (sem± . ) and . (sem± . ) respectively, p= . . urinary ob (p= . ), ob-r (p= . ), and tgfβ (p= . ) were not statistically significantly different between the groups. conclusions: ob/ob-r was not upregulated in tg at the onset of proteinuria and fsgs. however, advanced fsgs ( m tg) showed significant activation of socs , an ob/ob-r negative regulatory pathway. pediatric patients with early srns had no significant increase in urine ob/ob-r. this data suggests the role for ob/ob-r regulatory pathways in the development of advanced fsgs. primary fsgs presents clinically with steroid-resistant (srns) or steroid-dependent (sdns) nephrotic syndrome or proteinuria. the data shows, that % patients with fsgs progress to esrd in years follow-up. objectives: the aim of the study was to analyze the long-term outcome of patients with primary fsgs diagnosed in kidney biopsy. material: the study group consisted of children ( males, females) followed from . all patients were treated with immunosupression and renoprotection. the clinical data were analyzed after follow-up lasting for mean ± , years ( , - years) . children presented with nephrotic syndrome ( srns and sdns) and with proteinuria. the age ranged from , - years mean , ± , at the time of diagnosis. more then kidney biopsy was performed in children -in progression from mcd (n= ) and mes (n= ) to fsgs were observed. results: the clinical remission was observed in / patients ( %) and was not correlated with initial proteinuria (mean , ± ). in / patients crf was observed, of them progressed to esrd ( were successfully transplanted). among patients, who had fsgs as their initial glomerular lesion (n= ), the percentage of glomerular sclerosis was significantly higher in a group in which remission was not obtained after long-term follow-up ( , vs. %, p< , ). in out of patients with follow-up over years progression to esrd was observed ( , %), / were transmitted to adult centers with persistent proteinuria. conclusions: immunosuppression and renoprotection in patients with fsgs can prevent the progression of crf. extensive glomerular sclerosis is a predictor of unfavourable outcome. further clinical and genetical studies are needed to establish the effective therapy modalities. mycophenolate and who had previously undergone a renal biopsy, recieved mg twice daily (maximum gram twice daily) during six months. prednisone was concurrently prescribed at at dosage of mg/kg/every other day, during weeeks and . mg/kg/every other day during the subsequent weeeks. results are expressed as mean±sd. results: seven chidren, boys and two girls were enrolled. oncet of their ns was at age . ± , yr (range - yr) and mmf was initiated at . ± . yr ( . - . yr) . six were sr and one sd. two patients had previously recieved cyclosporine, two patients cyclophosphamide and one chlorambucil. renal histology displayed: focal segmental glomerulosclerosis (n= ), minimal change (n= ), mesangial proliferation (n= ) and membranous glomerulonephritis (n= ). at the end of the follow-up: three patients were in partial remission, two were in complete remission and two had no response to mmf. initial and final serum creatinine concentration . ± . vs . ± . mg/dl), estimated gfr ( . vs. ± ml/min/ . m ) and serum albumin ( idiopathic nephrotic syndrome is the most frequent glomerular disease in childhood. most patients are steroid responsive but half of them relapse and often become steroid-dependent. they are exposed to long term steroid complications on the one hand and relapses due to insufficient disease control on the other hand. our aim is to determine predictive risk factors for high degree steroid dependence. in france, steroid-resistance is defined as persistent proteinuria after one month of daily oral prednisone ( mg/m ) and pulses of methylprednisolone (mpn) ( g/ . m ). we included steroid responsive children with disease onset between and . the mean age at diagnosis was . years (range . - ). all patients initially received prednisone mg/m per day. the following parameters were analysed: age at onset, gender, days to remission with initial steroid therapy, mpn pulses, numbers of relapses, steroid dependency, immunosuppressive drugs. twenty of the patients were steroid-dependent; among the steroid dependent patients, received mpn pulses. % of those patients ( / ) were treated by cyclosporine during follow-up. on the other hand, only % ( / ) of the patients who did not receive mpn required cyclosporinebased therapy during follow-up (chi-square test, p= . ). interestingly, there was no correlation between treatment days until remission during the initial prednisone course and the risk for later steroid dependence. conclusion: the need for mpn pulses, but not the time interval until remission helps to predict steroid dependence. patients, necessitating mpn pulses to obtain remission are at risk to require cyclosporine for disease control. by identifying these children, we could eventually / avoid multiple relapses by earlier use of adequate immunosuppression and / avoid side effects related to long term high dose steroid therapy. membranous nephropathy (mn) with antitubular basement membrane antibodies is a rare condition. relapse of tubular dysfunction in renal transplant recipients has been published in one case, but relapse of mn in the renal graft has not yet been reported. a -year old boy presented first with steroid resistant nephrotic syndrome associated to tubular dysfunction. renal biopsy revealed mn associated to interstitial fibrosis and granular deposits of iga, igg, and c along the tubular basement membrane. indirect immunofluorescence (if) revealed circulating anti-tubular basement membrane antibodies. he received a renal allograft at the age of years. an acute rejection episode on day required three steroid pulses and okt- . renal biopsy revealed the presence of interstitial and vascular rejection (banff iii) and relapse of tubular basement membrane deposits. renal function normalized within days and remained stable (gfr estimated by schwarz formula= ml/min per . ). proteinuria remained negative and urinalysis normal over years under the immunosuppressive regimen including fk, azt, and prednisone. at the age of years, proteinuria increased progressively over weeks reaching . g/day, whereas serum creatinine remained stable. renal biopsy revealed the presence of granular deposits along the glomerular basement membrane suggesting a late relapse of mn in the transplant. rituximab therapy (day , , , and ) followed by switch from azathioprine (aza) to mmf resulted in a complete biological remission with negative proteinuria. indirect if revealed progressive decrease of antitubular basement ab level during rituximab treatment and a negative signal was obtained months after the switch from aza to mmf. this is the first report of glomerular relapse of mn with anti tubular basement antibodies in a renal transplant recipient. nephrotic children are at risk for severe pneumococcal infections. the best moment for antipneumococcal vaccination is controversially discussed. we investigated the serologic response after pneumo vaccination in children ( girls) with nephrotic proteinuria and hypoalbuminemia, immediately after initialisation of prednisone therapy at mg/m (group ) and in children after tapering down of prednisone to < . mg/kg eod (group ). there was no difference in both groups concerning antibody (ab) response, relapse frequency, or number of steroid dependent forms. in group , pneumo ab levels at presentation (m ) were . ± . (mean±se) . at m antibody levels increased -fold to . ± . (p< . ). serum levels at m were . ± . . one year after vaccination ab levels ( . ± . ) decreased compared to m (p< . ), but remained increased compared to m (p< . ). there was no increased delay until remission in both groups compared to a retrospective control group. severe hypoalbuminemia (< g/l) at the time of vaccination was not related to a lower serological response on m . during relapses, antibody levels decreased significantly compared to levels before relapse (p< . ), but increased again once remission was obtained. even during relapses, ab levels remained higher (> -fold) than pre-vaccination levels. conclusion: nephrotic children on high dose glucocorticoid therapy respond to anti-pneumococcal vaccination and their ab levels remain elevated during relapses. vaccination at disease onset may be beneficial as those patients with relapses during the tapering down of steroids already have increased anti pneumo ab at the time of relapse. crescentic glomerulonephritis with isolated c deposits associated to complement abnormalities: a new entity? introduction: several progressive renal diseases present proteinuria, as a result of glomerular and tubulointerstitial injuries. thus, some studies prove that proteinuria is an important predict factor for progression of renal failure. angiotensin converting enzyme inhibitors (acei) are efficient in reducing proteinuria and preserve renal function in patients with diabetic or non-diabetic nephropathy. the purpose of this study was to evaluate the efficacy and security of acei in children. material and methods: the acei (enalapril) was used in normotensive and hypertensive patients with chronic renal disease, with microalbuminuria/proteinuria. results: we studied patients ( girls), for at least months, mean age was . ± . years ( month to years). / patients had glomerulopathy, / chronic pyelonephritis, / systemic disease, / renal hypoplasia/ dysplasia, / cystic renal disease and / arterial hypertension. the mean dose of enalapril was , mg/kg/d ( , to , ) and it was used during , months (mean). we observed a normalization of proteinuria/microalbuminuria in , % of cases. in seven patients, the drug was discontinued due to: / irregular use, / vertigo, / hypercalemia and acute renal failure recovered after withdrawn the drug. during the use of enalapril we did not observe significant difference in potassium or creatinine serum levels, as well as blood pressure measurements. conclusions: the use of enalapril in pediatric patients with renal disease and proteinuria/ microalbuminuria showed security and efficient. therefore, we suggest it as a antiproteinuric and renoprotective agent in children. a. filleron, al. adra-delenne, l. ichay, f. dalla-vale, h. valette, d. morin chu montpellier, pediatric nephrology, montpellier, france in order to evaluate the long-term efficacy of oral cyclophosphamide (cp) in children with sdns, the outcome of patients ( girls) treated in our unit for steroid sensitive ns were studied retrospectively. median age at diagnosis was . years (range . to ). initially, they received oral prednisone (p) : mg/m /d for weeks and p dosage was then tapered for the next weeks (totale dose p: mg/kg). relapses of proteinuria were treated with p ( mg/m /day) and, in case of steroid dependency (sd), p was maintained on an alternate day regimen. one single child had no relapse, while had a relapse rate of less than /year. the remaining frequently relapsed and received oral cp - mg/kg/day for weeks, totale dose mg/kgbecause of their high relapse rate with steroid toxicity. median duration of p treatment was . years (range . to ) before cp was given. in one case cp had to be stopped because of hemorragic cystitis. follow-up after cp treatment was, at least, years. p was stopped in the following months after cp in / children, but has to be continued in the remaining because of early relapse of proteinuria. among those children, only one had no more relapse years after cp. in children, relapse of proteinuria occured . ± months after cp. in those patients, / had to receive another steroid sparing drug such as cyclosporine or mycophenolate mofetil (mmf) because of recurrence of sd. in our experience, cp treatment in ns with steroid toxicity is associated with a significant change in the relapse rate in only / children and in the remaining , improvement was transient. our results suggest that alternative treatment, such as mmf, has to be evaluated as first-line steroidsparing agent in those patients with sdns and steroid toxicity. interleukin - the aim of our investigation is to compare the concentration of total ige, specific ige, interleukin- (il- ) and gamma-interferon (gamma-ifn) in serum of children with initial and relapsed steroid-sensitive mcns and of children with atopic dermatitis at the age from to years. the concentration of total ige was measured by immunoenzymatic method and il- , gamma-ifn by immunoassay technique using monoclonal antibodies. the result showed that % of children with atopic dermatitis had the increased concentration of total ige; specific ige was increased to alimentary allergens- , %, household- , %, inhaled- , %. the concentracion of il- was , ± , pg/ml, of gamma-ifn was ± , pg/ml. the result showed that % of children with mcns had increased concentration of total ige; specific ige was increased to alimentary allergens- , %, household- , %, inhaled- , %. the concentration of il- was , ± , pg/ml, of gamma-ifn was , ± , pg/ml. according to our investigation, the concentration of il- and gamma-ifn in children with mcns were not significantly different then in children with atopic dermatitis. conclusion: the fact that there were not significant differences in serum total ige and specific ige, il- and gamma-ifn in children with mcns and atopic dermatitis gives us a reason to suppose that these diseases have identic mechanisms of pathogenesis with ige reaction i-type with activation of t-limfocyte. to clarify the pathogenesis of mcns, comprehensive studies for these cells would be worthwhile. there are several lines of evidence that the slit diaphragm (sd) not only serves as a structural framework for filtration barrier but also has an essential role as a signaling platform. nephrin is tyrosine phosphrylated by src-family tyrosine kinase, fyn. phosphorylated nephrin recruits nck to sd, and regulates assembly of actin filament. the crucial roles of tyrosine phosphorylation in podocyte is also indicated by renal malfunction observed in fyn knockout mice. neph has a longer cytoplasmic domain and a larger number of tyrosine residues in its cytoplasmic region than nephrin. but knowledge about tyrosine phosphorylation of neph is limited. here we characterize neph as a substrate of fyn. fyn interacted with and phosphorylated cytoplasmic domain of neph in vitro and in cultured cells. peptide mass fingerprinting of neph cytoplasmic domain phosphorylated by fyn in vitro identified at least five tyrosine phosphorylation sites. site-directed mutagenesis confirmed that these tyrosine residues were indeed phosphorylated in cultured cells. in pull-down analysis with neph from rat glomerular lysate, neph specifically bound to an adaptor protein grb and a tyrosine kinase csk in a phosphorylation-dependent manner. coimmunoprecipitation experiments revealed phosphorylation of y and y were crucial in neph -grb binding. furthermore, tyrosine phosphorylated neph suppressed erk activation elicited by fyn, and also inhibited fyn-induced ap- transcriptional activation. these inhibitory effects required the intact binding motif of the grb sh domain, and both y f and y f mutants failed to inhibit erk activation. these results indicate that fyn orchestrates a wide spectrum of protein-protein interactions at sd by phosphorylating neph as well as nephrin, and neph modulates downstream signaling by phosphorylation-dependent association with adapter proteins. celiac disease (cd) is a common disorder in southern europe and has a protean clinical presentation. hla class ii aplotypes dq and/or dq are present in % of cd patients and in % of the normal population. the observation of three patients with both cd and nephritic syndrome (ns) prompted us to study hla class ii aplotypes in our patients with ns. in all children with ns admitted to our unit we determined the presence of dq /dr , dq /dr , dq /dr e dq /dr aplotypes and anti-transglutamidase antibodies (ab-httg). hla typing was done by dna extraction and pcr amplification and electrophoresis in agarose; ab-httg determination was made by elisa. as control groups we examined children with cd and first degree relatives (of theirs). in so far we have studied children with ns ( males, females, age ranged - years); are steroid sensitive (ssns), steroid resistant (srns). a renal biopsy was done in and showed minimal lesions in , focal and segmental sclerosis in , membranoproliferative gn in , membranous gn in and iga deposition in . corticosteroids or other immunosuppressant were administered in when blood was drown. dq and/or dq aplotypes were present in out of patients ( . %), in out of ssns ( . %), in out of cd relatives ( %) and in all cd patients. dq /dr combination was present in a smaller percentage of ns compared to control groups. ab-httg were detected in one patient out of ( . %). purpose: to investigate activity of antithrombin and a protein c at children with mcns: at active period (proteinuria more g/m /d; hypoalbuminemia < g/l), at in incomplete remission (the third day of absence of proteinuria, hypoalbuminemia < g/l), at in proof remission. methods: activity of natural anticoagulants in blood was defined by a clotting method with use of reactants "roche" and "behring". results: activity of antithrombin in blood in the active period of disease sharply decreased ( , ± , %, p< , ), and already in the period of incomplete remission came back to norm ( , ± , %), characteristic for the period of full remission ( , ± , %). activity of a protein c in blood in the active period of mcns was high ( , ± , %, p< , ), during incomplete remission decreased ( , ± , %, p< , ), in the period of proof remission was in norm ( , ± , %, p< , ). at children with mcns dependence of decrease in activity antithrombin from weight hypoalbuminemia (r= , , p< , ), hyperfibrinogenemia (r=- , , p< , ), hypercholesterolemia (r=- , , p< , ) and hyper-lipoproteinemia (r=- , , p< , ) is established. authentic distinctions of factor of the attitude of activity of protein c/ activity of antithrombin depending on the period (the active period - , , incomplete remission - , , proof remission - , ) are received. conclusion: at children with mcns changes in system of natural anticoagulants: decrease in activity antithrombin below % and increase of factor of a parity of anticoagulants (more than , ) testify to hypercoagulation and risk of thrombosis. varicella objectives: the pattern of steroid responsiveness of nephrotic syndrome may change during the course of the disease in children with steroid sensitive nephrotic syndrome (ssns) and/or in different populations. patients and results: a prospective cohort study was conducted in centers. patients who were initially diagnosed as ssns in and followed for five years were included. standard questionary forms from children( boys) with a mean age of . years ( months- years) at presentation were submitted for entry to data coordinating center. / patients who showed initial steroid sensitivity with a follow-up period of at least one year ( - years) were included in the study. seventy three ( . %) children remained in sustained remission at year; nine patients showed steroid resistance. / patients were followed for years, whose clinical course were sustained remission in ( %) and steroid resistance in ( %). steroid response rate from to years remained stable ( - %). eight children out of totally patients who were steroid sensitive initially, became steroid resistant in the first year. the remainder showed steroid resistance at the nd year ( ), at th year ( ) or at th year ( ) . renal biopsy was performed in children who developed steroid dependency or steroid resistance. nine patients revealed fsgs, minimal change disease, mesangioproliferative gn, membranoproliferative gn, one igm nephropathy. only two patients who had minimal change nephropathy in initial biopsy progressed to fsgs after and years. conclusion: steroid response rate was between - % and steroid resistance was - % in years follow-up. secondary steroid resistance within the first year of presentation seemed to be predictive for their subsequent courses. the need of biopsy was not high. ssns seemed still as a relatively benign condition in our population. the aim of this study was to asses the changes in coagulation/fibrinolysis system in chronic renal disease (crd) by measuring plasma levels of von willebrand factor (vwf) and plasminogen activator inhibitor - (pai- ). we studied children ( - years old) with nephrotic syndrome (ns): minimal change disease (n= ), focal segmental glomerulosclerosis (n= ), mesangioproliferative glomerulonephritis (n= ), membranoproliferative glomerulonephritis (n= ). relapse of the disease was observed in patients. healthy age matched children served as controls. serum levels of pai- : ag and vwf were measured by elisa. results. pai- and vwf levels were elevated in all morphological forms of ns in relapse and remission compared with controls (p< , ) except the mcd remission in which they were the same as controls (p> , ). the highest levels of pai- and vwf were discovered in relapse of proliferative forms (mespgn, ± ng/ml and , ± , me/ml, respectively; mpgn, , ± , ng/ml and , ± , me/ml, respectively) compared with nonproliferative (mcd , ± , ng/ml and , ± , me/ml, respectively; fsgs , ± , ng/ml and , ± , me/ml, respectively, p< , ). conclusion. these data suggest activation of coagulation/fibrinolysis system in relapse of ns and the absence of normalization in the remission phase. our results confirmed that more severe fibrin formation via activation of intraglomerular coagulation and fibrin accumulation is characteristic for mpgn, likely by deficiency of the fibrinolysis system. introduction. several recent case reports suggest that rituximab (rtx) could be an effective treatment for idiopathic nephrotic syndrome. in a retrospective study, data were collected from patients (mean age: . years) treated with rtx for steroid dependent nephrotic syndrome (mean duration of the disease: months). four of were treated during a remission period. eight of were treated in association with one or several other immunosuppressive (is) treatments (prednisone, anticalcineurin, mycophenolate mofetil). rtx efficacy was admitted when the previous is treatment was withdrawn or significantly tapered-off, or when the proteinuria disappeared with no other change than rtx treatment. a complete b-cell depletion was confirmed in all patients when assessed ( / ) even when rtx was infused during a period with nephrotic proteinuria. rtx was considered to be effective in cases especially when given in association with other immunosuppressive treatment during a period with remission of proteinuria ( / success, follow-up to months). conversely rtx failed to induce remission among patients who were treated during a proteinuric period with no other immunosuppressive drug ( / failures). finally rtx was considered to be effective among of patients treated in association with other is drugs during a proteinuric period (follow-up and months). there was no significant side effect during rtx infusion. delayed side effects were observed for patients: case of neutropenia and pneumocystis pneumonia and case of hypogammaglobulinemia. conclusion. rtx is an effective treatment in a subset of patients with severe steroid dependent nephrotic syndrome. further prospective data are necessary to determine if rtx could become an alternative to other immunosuppressive drugs in patients with toxic side effects. infections are leading causes of death in lupus patients. disseminated histoplasmosis has been commonly documented in immunocompromised patients including lupus patients. we report a case of lethal cerebral histoplasmosis in a child originating from french guyana. lupus disease was revealed by typical malar rash. she developed a class ii lupus nephritis treated with prednisone and azathioprine. then she developed restrictive lung disease, recurrent arthritis and pericarditis. later on, nephrotic syndrome revealed a class iii lupus nephritis treated with methylprednisolone pulses and mycophenolate mofetil. four years following the onset of the disease, she was admitted because of febrile seizures and five months later for a febrile coma. repeated lumbar punctures displayed hypercellularity with depressed levels of glucose and elevated protein concentrations but sterile cultures. according to the presence of high titers of lupic specific antibodies and cerebral mri suggesting vasculitis, neurological flare of lupus was considered and immunosuppressive treatment was increased (methylprednisolone and cyclophosphamide pulses, plasma exchanges). a repeated lumbar puncture evidenced presence of histoplasma capsulatum. despite antifungic treatment the child died. our report emphazises the difficulty to discriminate opportunistic infections from the wide spectrum of lupus clinical features. symptoms of infection may mimic those of lupus, or conversely, may be masked by immunosuppressive drugs. infection screening should take in account clinical feature as well as endemic context. our report is the first case of isolated cerebral histoplasmosis in a child with systemic lupus. renal manifestations of mitochondrial cytopathies have been described, but nephrotic syndrome with respiratory chain disorders (rc) was described extremely rarely in infancy. we report a months-old boy with a mitochondrial cytopathy preceded by months history of steroid-resistant nephrotic syndrome. on admission his clinical condition was deteriorating rapidly with gross oedema, ascites, hypertension and oliguria. fundoscopic examination revealed salt-pepper sign which was thought to be consistent with intrauterine infection (iui) at that time. however, serologic and microbiologic investigation of iui was inconclusive. a sensorineural hearing loss was found to associate his findings. podocin mutation was negative. a percutaneous renal biopsy was undertaken and revealed diffuse mesengial sclerosis. a significant decrease in mitochondria was observed on electron microscopic examination. the child progressed to end stage renal failure and was successfully managed by peritoneal dialysis. during his follow-up a fine tremor was observed in his hands and cranial mri revealed demyelinisation in left thalamus and occipital lobe. steroid resistant nephritic syndrome, sensorineural hearing loss, ocular and neurologic findings has led us to be suspicious about mitochondrial cytopathy and muscle biopsy was done. though muscle biopsy was normal, the results of biochemical analysis showed a deficiency of the respiratory chain complex iv (cytochrome c oxidase) (rc iv). the clinical phenotype and the deficiency of respiratory complex iv thought to be compatible with deficiency of the cytochrome c oxidase deficiency protein cox . nephrotic syndrome with rc disorder were described extremely rarely in infancy. based on these observations, we suggest that rc disorders should be considered in patients with early onset nephritic syndrome. human parvovirus b (hpvb ) was identified as the cause of a self-limited childhood febrile illness with rash, namely erythema infectiosum. most of hpv-b infections are usually mild or asymptomatic, but in some cases infection is associated with serious systemic complications. renal involvement in patients with hpvb infection was discussed in recent, mostly anecdotal, case reports. the majority of these reports were described in adults, whereas only a few cases of childhood were defined whom presented with mesangiocapillary proliferative glomerulonephritis, fsgs or tubulointerstitial nephritis. a literature search revealed no cases of acute endocapillary proliferative glomerulonephritis in childhood. a -year-old girl was admitted with fever, cough, maculopapuler rash, hemoptysis, dark-colored urine, multiple lymphadenopathies, hepatosplenomegaly. she developed acute nephritic syndrome during the course of this complex clinical features. laboratory data showed proteinuria, hematuria, hypocomplementemia, the presence of igm and igg antibodies to hpvb and positive reaction of serum hpvb dna using a polymerase chain reaction. renal biopsy showed acute endocapillary proliferative glomerulonephritis with coarse granular c depositions in a "starry sky pattern" which is more peculiar to poststreptococcal glomerulonephritis. electron microscopy revealed subendothelial and hump-shaped subepithelial dens deposits. there was no evidence of either a mycobacterial or a streptococcal infection and the diagnosis of goodpasture syndrome and connective tissue disorders were excluded by clinical and laboratory investigations. based on the literature review, this case represents, to our knowledge, the first time that a direct relationship between parvovirus infection and acute endocapillary proliferative glomerulonephritis has been demostrated in a child. objective: the purpose of this retrospective cohort study was to report the clinical course of children and adolescents with focal segmental glomerulosclerosis (fsgs) according to steroid response. methods: the records of patients with biopsy-proven fsgs admitted between and were retrospectively reviewed. demographic, clinical and laboratory data at entry and at the end of the follow-up were analyzed. the patients were classified according to the initial prednisone response into two groups: group (g ): response (complete or partial remission) (n= ) and group (g ): non-response (prednisoneresistant) (n= ). renal survival analysis was performed using the kaplan-meier method. results: the median age at admission was . years (iq range: . ± . yr) in g and . years (iq range: . ± . yr) in g . seventeen patients ( %) of g , and patients ( %) of g presented with hematuria at admission, and ( %) children of g and ( %) of g presented blood pressure levels above the th percentile. g presented a higher h proteinuria ( . mg/ h) at admission when compared to g ( . mg/ h, p= . ). median follow-up time was . years in g and . years in g . the renal survival rate was % at years and % at years in g , % at years and % at years in g . conclusion: progressive renal insufficiency was more frequent in patients with fsgs who have initial resistance to prednisone therapy. objectives of the study: adults with chronic kidney disease (ckd) show impaired immune status. in this study, the profile of mononuclear cell subsets was related to the age and actual gfr in children and compared to healthy controls. methods: the expression of lymphocyte surface antigens was evaluated on peripheral blood (pb) mononuclear cells using three-color flow cytometry in children with ckd (stage - ) on conservative treatment. we analyzed absolute and relative numbers of total leukocytes, total lymphocytes and subsets: cd +, cd +, cd +cd +, cd +cd +, cd -cd / +, cd +hla-dr+, cd +cd +, cd +, cd +αβ+, cd +γδ+, cd ra+, cd ra+cd +, cd ra+cd +, cd ro+, cd ro+cd +, cd ro+cd +, cd +cd +. results: in younger ckd children (below years) absolute numbers of cd +, cd +cd +, cd +cd +, αβ+t, γδ+t cells and cd /cd ratio was higher, the percentage of cd +cd +, cd ra+cd +, cd ro+cd +, cd ro+cd +, αβ+t cells and the absolute number of cd ro+cd + cells was lower than in the oldest group. in children with the lowest gfr (below ml/min) the percentage of cd +, cd + was lower, the absolute number of cd +cd +, cd +, and the percentage of nk-cells, cd +cd +, cd +, cd ro+cd + cells was elevated as compared to ckd stage group. the absolute number of cd +, cd +cd +, cd ra+cd +, αβ+t, γδ+t cells and percentage of total lymphocytes, cd +, cd +cd +, cd + was lower in ckd children than in controls. conclusion: impaired immune status is observed already in early stages of ckd. progressive disturbances in pb lymphocytes percentage mostly in the naive and memory t cells and the shift in the cd /cd balance were found in pre-dialysis children with ckd. with progressive loss of renal function, we observed an increased expression of activation markers on t cells such as cd or cd . introduction: relapse of steroid resistant nephrotic syndrome (srns) after renal graft occurs iñ % of the pediatric patients. medical management is based on increased immunosuppression with the use of iv cya and plasma exchanges (pe). however, this strategy fails in ~ % of the treated patients. new immunosuppressive agents may improve the outcome of relapsing srns post transplant. case report: a -year-old boy with srns reached esrd and received a cadaveric kidney transplant after two years on hemodialysis. the immunosuppressive regime was cya, mmf and steroids. seven days post transplant gross proteinuria ( g/day) reoccurred. iv cya was administered over two months (blood level: ~ ng/ml) associated to pefloxacine and pe (n= ), and followed by oral cyclophosphamide (cyp), resulting in partial disease control. cyp was discontinued due to haematological toxicity after one month. proteinuria increased again from to g/day within months, despite high dose oral cya ( mg/kg/day) and mmf. etanercept (a tnf blocking agent) was introduced at a dose of mg twice weekly (combined with three steroid pulses) and maintained over two months: proteinuria decreased to . g/day over days. etanercept was discontinued followed by a relapse of the ns and re-introduced eight months later, with, again a significant decrease of proteinuria to a baseline level of . g/day. conclusion: treatment with anti-tnf agents in nephrotic children has been reported once in a boy with high degree steroid dependent ns; a spontaneous decrease of disease activity over time cannot be excluded in this patient and might jeopardize data interpretation. our case is the first report of successful antiftreatment despite a constantly high activity of the nephrotic syndrome, demonstrated by relapse after discontinuation of etanercept while the patient was on post transplant immunosuppression. fournier´s gangrene (fg) is defined as a specific, quick and progressive form of synergic necrotizing fasciitis of multi-bacterial origin that affects perineum muscular fascia, genital region and surrounding areas with skin gangrene due to thrombosis of subcutaneous blood vessels. it describes the clinical case in a male preschooler of four years of age with idiopathic nephrotic syndrome (ns) that subsequent presented fg of the scrotum. broad-spectrum antibiotics, intravenous albumin and surgical cleaning of the scrotal necrotic tissues were indicated. pseudomona aeruginosa was isolated from necrotic tissue cultures. the later evolution was satisfactory with healing of the affected area and remission of the ns subsequent to the steroidal treatment. fg is an uncommon in children, rapidly progressive infection of the genital, perineal and perianal regions. it is characterized by a synergistic necrotizing fasciitis leading to thrombotic occlusion of small subcutaneous vessels and development of gangrene. until now few cases have been report fg in children, and still less associate to the kidney diseases. et all ( ) described a -year-old boy presenting with steroid resistant ns developed fg of the scrotum so that to our knowledge, this patient seems be the second case reported in medical literature with both pathologies. high index of suspicion, prompt diagnosis, broad spectrum antibiotics followed by wide debridement is the key to successful treatment. objectives of study: to evaluate a long term experience on iga nephropathy (igan) presenting in childhood and investigate clinical and histological factors that may act as early markers of renal disease progression. methods: retrospective review of data from children and adolescents with biopsy proven igan in the last years. demographic and clinical data at presentation and severity of renal histological involvement were recorded and related to renal dysfunction markers identified at the last review. results: twenty-five patients were studied ( m/ f) with median age at onset of ( - ) and follow-up of ( - ) years. on presentation recurrent macroscopic hematuria was present in patients, microscopic hematuria (mh) in , proteinuria in ( nephrotic), hypertension in and transient acute renal failure in . renal histology findings were focal mesangioproliferative in , focal proliferative in , diffuse proliferative in and focal sclerosing glomerulonephritis in . six patients showed tubulointersticial and extraglomerular vascular lesions (tevl) with glomerular crescents in . on follow-up, patients remitted ( spontaneously, with ace inhibitors). of the remaining, were kept on ace inhibitors due to proteinuria ( ), hypertension ( ) or both ( ). one patient (with focal glomerulosclerosis and tevl) developed esrd within a year after diagnosis, despite treatment. at last review, patients presented progressive renal disease with a mean decrease of ml/min/ , m in gfr per year. these ( m/ f) showed mainly mh and proteinuria at onset and tevl. conclusions: early renal function impairment in childhood igan can occur and may be associated with mh and proteinuria at presentation and with focal glomerulosclerosis and tevl on renal histology. proteinuria persistence in a number of patients emphasizes the need for long term followup into adulthood. adhesion molecules, il- +p and cd +cd + and cd +cd + lymphocyte subsets in childhood nephrotic syndrome background: parathyroid hormone (pth) can modulate t cell activation and proliferation through as yet incompletely identified mechanisms. since the pth receptor (pthr) is a g protein-coupled receptor and thus a candidate for association with lipid rafts, and since pth has been shown to alter membrane phospholipid metabolism, we explored the relationship of the pthr with lipid rafts in human t cells. methods and results: we found by flow cytometry that neither physiologic nor pathologically elevated concentrations of pth affect the up-regulation of the raft marker gm- or of the partially raft-associated activation marker cd in purified t cells stimulated with phytohemagglutinin (pha). moreover, we detected the pthr exclusively in non-raft fractions of these cells after sucrose gradient separation. conclusions: these data indicate that in human t cells, the pthr does not associate with lipid rafts and that pth does not modulate these domains. accordingly, other mechanisms underlying the actions of pth on human t cells need to be sought. the direction and magnitude of potassium transport in nephron segments depend on the sitespecific distribution of transporters in tubule cell membranes. potassium depletion has been demonstrated to be associated with altered sodium reabsorption in renal tubule segments. we examined whe her potassium transporters protein expression is associated with altered abundance of major renal na + transporters, that may contribute to the development of hypokalemia in lp. after weaning rats (n= ) were fed days with lp diet ( %), then they were recovered with a normal protein diet ( %, rp), each group had a control group ( %, np). we examined the changes in the abundance of the na + /h + exchanger (nhe ), na + k + atpase, na + k + clcotransporter (bsc- ), na + clcotransporter (tsc), epithelial sodium channel (enac) subunits and romk in kidneys of lp, np, rp rats. controls were normalized to . results reduced clcreat (ml/min) in lp vsnp ( . ± . vs . ± . ), hypokalemia ( . ± . vs . ± . meq/l) and increased fe k+ ( . ± . vs . ± . %) were demonstrated. immunoblotting revealed that the abundance of nhe in cortex was severely decreased. the amount of bsc- ( . ± . , p< . ) and tsc ( . ± . , p< . ) protein levels were enhanced in the inner stripe (isom) and outer stripe of the outer medulla (osom), respectively. romk protein levels were increased in lp ( . ± . , p< . ), the protein abundance of the enac subunits α, β and γ was increased near . fold each in response to lp. na + k + atpase protein levels showed no differences in cortex and osom. after rp, na + transporters expression returned to control values. conclusion: increased expression of bsc- , tsc, enac subunits and romk, contributing to distal potassium secretion was shown in hypokalemia from lp. a role of aldosterone may be suggested. v. belostotsky , mz. mughal , j. berry , n. webb royal manchester children's hospital, pediatric nephrology, manchester, united kingdom st. mary's hospital, pediatrics, manchester, united kingdom manchester royal infirmary, vitamin d laboratory, manchester, united kingdom aims: to describe the prevalence of vitamin d deficiency in south asian and white uk children with renal disease. to establish how decreased levels of vitamin d affect pth in patients with a normal gfr. methods: children aged - years were enrolled in the study: were of white uk, of s asian and of other ethnic origin. were on dialysis, had chronic renal failure, had various renal disorders with normal gfr (> ml/min/ . m ), had a transplant ( with anormal gfr). blood samples were collected to establish the levels of -vitamin d ( -ohd); pth; creatinine. -ohd concentration < ng/ml was defined as vitamin d deficiency; levels between - ng/ml as vitamin d insufficiency. serum pth of . - . pmol/l was defined as normal. results: the prevalence of vitamin d deficiency/insufficiency was higher in s asian ( %) than white ( %) children (p< . ). ofthe ( s asian, white and other) children with normal gfr / s asian and / white children had pth concentrations > . pmol/l. of these / s asian, / white children had low levels of -ohd (p= . ). of transplant patients with reduced gfr, of with a high pth had low -ohd levels, compared with of with a normal pth (p= . ). conclusions: many s asian children attending our renal clinic are vitamin d deficient/insufficient and the prevalence of this problem is significantly higher than that in the white population. high pth values in the setting of a normal gfr can often be explained by vitamin d deficiency and should result in serum -ohd levels being measured. nephronophthisisis a rare recessive autosomal disease which may be either limited to progressive chronic tubulointerstitial nephritis or associated with extrarenal involvement (eye, liver, central nervous system, etc.); mutations/deletions have been found in at least nphp genes. fibrous dysplasia is a benign skeletal lesion due to an activating mutation inthe gene that encodes the α subunit of stimulatory g protein and occurs after fertilization in somatic cells; it involves one or several bones and may be part of mccune albright syndrome. we report on a boy with fibrous dysplasia of bone diagnosed at yrs of age, who underwent protocol renal function tests at yrs of age in the follow-up of pamidronate treatment. inulin clearance was ml/min/ . m and potassium reabsorption rate was . % where as there was neither urinary phosphate wasting nor hypercalciuria. serum magnesium was decreased ( . mmol/l) without reabsorption abnormality and serumuric acid progressively increased with age. in addition, due to increasing microalbuminuria, a treatment with acei was started at yrs of age. renal ultrasonography at yrs of age showed hyperechoic reduced-sized kidneys with few microcysts. a renal biopsy (light and electron microscopy) was performed at yrs of age, which showed nephronophthisis-like lesions, i.e., diffuse interstitial fibrosis and focal thickening of tubular membrane basement. dna analysis revealed no nphp gene deletion but is still under investigation.nephronophthisis has been reported in association with skeletal involvement (coneshapedepiphyses) and fibrous dysplasia with hypophosphatemic rickets or fanconi syndrome. however no association between fibrous dysplasia of bone and nephronophthisis-like lesions has been described and may be a new picture of the nephronophtisis/medullary cystic kidney disease complex. m. bald, m. holder, h. leichter olgahospital, pediatric nephrology, stuttgart, germany puumalaviruses belong to the group of hanta viruses and are transmitted by inhalation of aerosolized particles of the red bank vole (cletriomonysglareolus) which is endemic in the alb-danube region of southern germany. infections with puumala virus were first described as "nephropathia epidemica" in scandinavia with the clinical symptoms of fever, thrombocytopenia and acute renal failure. over the last seven years three boys with acute renal failure were admitted to our hospital after vacationing in the region endemic for puumalavirus. all three presented with high fever, influenza like symptoms aswell as pronounced abdominal or flank pain. they showed a decreased gfr ( , and ml/min/ . m , respectively) with hematuria and proteinuria. cbc revealed no leucocytosis or anemia, but thrombocytopenia in of the patients. they had no oliguria, but patients had marked polyuria in the recovery phase of renal function. arenal biopsy in the boy with the most severe presentation showed diffuse tubular damage. puumala virus infections were confirmed in all patients by serological tests, and renal function normalized within - weeks. nephropathia epidemica due to puumala virus infections have to be included in the differential diagnosis of acute renal failure in patients from endemic regions. severe abdominal or flank pain are common symtoms in these patients; renal failure is transient and the general prognosis is good. aims: the objective of this study is to determine the relationship of urinary calcium excretion (uca) with sodium and protein intake in a pediatric population of families with low income. methods: children, f and m, ages to years from families with income <$ /month were studied. protein intake was estimated with a -day dietary record. a nonfasting urine sample was collected for dipstick, calcium, creatinine, sodium, potassium, urea and uric acid. urinarycalcium/creatinine (ca/cr), sodium/potassium (na/k), uricacid/creatinine (au/cr) and urea/creatinine (u/cr) ratios were calculated. children with a urinary ca/cr > . mg/mg, were submitted to a day period of high sodium foods restriction after which a second urine sample was collected. results: mean (x) and standard deviation (sd) for ca/cr, na/k, au/cr and u/cr ratios were: . ± . mg/mg, . ± . meq/meq, . ± . mg/mg and . ± . mg/mg respectively. the th percentiles for ca/cr, na/k, au/cr and u/cr were . , . , . and . respectively. x±ds for protein intake was . ± . g/kg/day. the incidence of hypercalciuria was . % in the initial urine sample and . % in the second. correlation was significant between ca/cr ratio and na/k ratio (r: . , p< . ), acu/cr ratio (r: . , p< . ) and u/cr (r: . , p< . ), not significant between ca/cr ratio and protein intake. conclusions: the incidence of hypercalciuria in this serie is lower than previously reported values in venezuela for the general pediatric population and decreases further when sodium intake is controlled. although no correlation was found between uca and protein intake, we could speculate that protein intake near to the daily recommended requirements of g/kg/day, could be a possible reason for the lower incidence of hypercalciuria in this population. -year old girl presented with rapid onset of muscular weakness and a short history of severe dysphagia, dysphonia nad significant wasting. on examination, she was dystrophic (bmi , ) and had signs of myopathy. laboratory findings confirmed myopathy (cpk , ukat/l, ast , ukat/l, myoglobin ug/l). there was striking hypokalemia (s-k , mmol/l) suggesting hypokalemic paralysis. diagnosis of distal renal tubularacidosis (drta) was based on confirmation of hyperchloremicmetabolic acidosis, severe hypokalemia, high urinary ph and positive value of urinary anion gap (s-cl mmol/l, ph , , be , urinary ph , ). there was evidence of other signs of renal tubular impairment (urinary beta- -microglobulin mg/l, glomerulo-tubular proteinuria , g/ h). autoimmune tests (high positive rheumatoid factor, anf, ena ss-a/ro, ss-b/la, high circulating immunocomplexes) and low values of sialometric measurements ( , ml/ x minutes) revealed primary sjogren´s syndrome as the underlying cause of drta. the renal biopsy confirmed chronic tubulo-interstitial nephritis compatible with this diagnosis. full recovery of muscle weakness and laboratory findings of hypokalemia and acidois followed potassium and alkali replacement. corticosteroids were administered with subsequent addition of cyclosporine a because of disease activity. conclusion: primary sjogren´s syndrome is a rare diagnosis in childhood and adolescence and should be considered in patients presenting with hypokalemic paralysis due to drta. m. caletti, h. lejarraga, s. caíno, a. jiménez introduction: ndi is a chronic, genetic disease caused by an inability to effectively conserve urinary water, due to a lack of response of distal renaltubule to antidiuretic hormone. the main symptom is polyuria, polydipsia and growth impairment. objective: to evaluate long term growth in height and weight of children with ndi. patients and methods: sixteen patients with ndi attending hospital for a median period of . years (range . / . yrs) were studied. treatment consisted of indometacine, hydroclorotiazide and amiloride (iha). height and weight was measured with standardized anthropometric techniques. z scores(sds) for all measurements were calculated according to national standards. results: all children responded favourably to treatment. mean birth weight sds was not different from zero; mean height and weight at diagnosis was ± . and ± . sds respectively, and at the end of follow-up was ± . and ± . respectively. the majority of patients´s growth curves evolved below the th centile. ten out of children experienced some catch up in height (mean height gain: . sds (r: - . / . )). mean weight gain during follow-up was . sds (r: . / . ) . mean gain in body mass index was . sds (range . / . ). in the two patients who attained adult height, adolescent growth spurt was normal, and final height was within normal limits for standards and for parental height. correlation coefficient between gain in height andage at diagnosis was ± . . conclusion: although mean height at follow-up was below the expected normal value, combined therapy with iha is compatible with some catch up growth in height and weight. the lower the initial height, the greater the height gain. adherence to treatment is essential for normal growth in children with ndi. body growth of children with steroid-responsive idiopathic nephrotic syndrome m. noer, i. irwanto, n. sumiarso, m. chalim soetomo hospital, school of medicine airlangga university, department of child health, surabaya, indonesia objectives of study: the present study was designed to evaluate the statural growth of children with steroid-responsive idiopathic nephrotic syndrome, attending the pediatric nephrology unit department of child health, school of medicine airlangga university, soetomo hospital, surabaya, indonesia, with a minimum follow-up of years. methods: anthropometrice valuation included weight, height, and growth velocity expressed as mean and standard deviation scores (sds), relative to the normal population (nchs/cdc ). these indices were analyzed at admission and then every months of follow-up. all patients were treated with prednisone, according to indonesian consensus of management of idiopathic nephrotic syndrome in children. results: of children ( boys and girls), patients ( boys) aged / years to years (mean . years) were analyzed. initial mean height and z score (height for age) were . ± . cm and - . ± . , respectively. mean height and z score (height for age) of the last follow-up were . ± . cm and - . ± . , respectively. mean growth velocity were . ± . cm/year where boys ( . %) had growth velocity less than cm/year. total cumulative dose of steroid during years of follow-up were . ± . mg or . ± . mg/kgbw. conclusions: the cumulative dose of steroid up to . mg/kg body weight in children with nephrotic syndrome during years of treatment did not influence their growth velocity. background: recently it has been reported in adult patients (pts) that deterioration of renal function was associated with the lost of nocturnal blood pressure (bp) dip and enhanced urinary sodium (una) and protein (uprt) excretion during night. objectives of study: to investigate the circadian rhythms of bp, una and uprt in children with chronic kidney disease stage i (ckd i). methods: in pts ( boys) aged . ± . years with ckd i (chronic glomerulopathy confirmed by renal biopsy in % pts), hour bp was monitored during daytime (d) and nighttime (n) and urinary samples for uprt, urinary creatinine (ucr), and una, were collected for both periods. results: serum creatinine-based gfr was ± ml/min/ . m , uprt ranged from to (median ) mg/ h, and una from to (median ) mmol/ h. in general we found a highly significant nocturnal decrease in systolic bp (from to mmhg), diastolic bp ( to mmhg), mean arterial pressure ( to mmhg), heart rate ( to /min) urinary output (uo), una and uprt. the regression equations were as follows: uod (ml/m /h)= + . xuon (ml/m /h); unad (mmol/l)= . + . xunan (mmol/l); uprtd (mg/m /h)= . + . xuprtn (mg/m /h) and urinary osmolality (us) d= + . xusn. nocturnal decrease of uo correlated with nocturnal decrease of ucr and uprt, and nocturnal decrease of uprt correlated with nocturnal decrease of uo. more than half of the patients were classified as non dipper. they differ significantly from dipper only in night/day changes of us. conclusion: night/day changes of uo, una and uprt in pts with ckd i may be calculated from the given regression equations. these changes are not correlated with nocturnal bp decrease. non dippers have greater nocturnal change of us compared to dippers. follow-up of these parameters will clarify their importance in progression of ckd. autosomal autosomal dominant proximal renal tubular acidosis (prta) it is described l. g. brenes ( ) at seven members of one family. we diagnosed seven members of the afghani family with prta: mothers and children ( girls, boy from , till years) with hyperchloremic metabolic acidosis. pedigree analysis suggested an autosomal dominant inheritance pattern. observable patients did not have ricket and nephrocalcinosis. deafness and ocular abnormalis are absent. the plasma hco concentration is decrease in the range of , to , mm/l, minimal urine ph is < , . parameters of blood creatinin and glomerular filtration rate were normal. urine calcium excretion was normal. therapy strategy of prta at observable patients provides high dozes of citrates/bicarbonates - mmol/kg per h. all india institute of medical sciences, division of nephrology, department of pediatrics methods: retrospective case-search. data of previously reported prospective trial (n= ) was also included. results: all except patients had previously been treated with both levamisole and cyclophosphamide. forty-two cases qualified for the study and were administered mmf for a mean duration of . months ( % ci, . , . /patient in the first months of treatment and . episodes (n= ) in next six months of mmf treatment (p< . ), an average reduction of % ( % ci, . , . ) from the pre-mmf phase. nine ( . %) patients had no relapses while on mmf therapy we present sibling cases of as with heavy proteinuria at early childhood. a boy ( year-old) and a girl ( yearold) were diagnosed as x-linked as. since a boy developed persistent heavy proteinuria (up/cr . ) with macrohematuria andresistant to arb/acei therapy, we treated him with cyclosporina (csa) that could lead to complete remission. to investigate pathomechanism of proteinuria, we tested immunostaining for slit diaphragm associated molecules (nephrin, podocin), gbmassociated molecules (laminin, perlecan, agrin) and podocalyxin using frozen sections from his firstand second biopsy and girl's one (up/cr . ). in the specimens from boy's first biopsy and girl's one, light microscopy revealed mild mesangial proliferation and no differences ofthe expression with perlecan, agrin and podocalyxin compared with controls. however, when determined laminin isoforms, fetal type laminin (alpha beta gamma ) wasdistinctly observed in the gbm, whereas that was localized only inmesangium with controls. interestingly when compared mature laminin isoform (alpha beta gamma ), beta chain was specifically less expressed in the gbm. however there were no differences of expression of these molecules in the specimens between pre-and post-treatmentwith csa. in boy's second biopsy, % glomeruli were detected to becollapsed. together with the recent report showing that laminin beta mutation causes congenital nephrotic syndrome factor v leiden mutation and steroid resistant membranous glomerulonephritis: a case report m. buyukcelik , m. karakok turkey renal compications of d-penicillamin therapy in wilson's disease sami ulus children's hospital, department of pediatric nephrology sami ulus children's hospital, department of pediatrics sami ulus children's hospital hass classification), treatment and outcome. thirty-nine patients; boys ( . %) and girls ( . %) time of the last examination (median months, min< year) after the admission as a long term follow-up. clinically, group i; while microscopic hematuria was detected in patients, patients had repeated attacks of hematuria, had isolated mild proteinuria/hematuria, group ii; patients had nephritic, had nephrotic syndrome and had both. biopsy grades in the patients: %, % had grade i, . %, % had grade ii, %, % had grade iii, %, % had grade iv in group i and ii, respectively. group i and ii patients recovered completely (no hematuria and proteinuria) . %, . % as well as %, %, short-term, longterm, respectively. while recovery rates in fish-oil and/or ace-inh treatment group was . % and . %, in corticosteroids group, it was %, % short-term, long-term,respectively. no patients who received immunosuppressive treatment had improved. however, ( . %) patients would suffer from esrd. initial presentation, severity of renal involvement and type of the treatment were not found to have a prognostic value (p> . ). in children, igan is characterized by extreme pathogenetic, clinical and histological polymorphisms radojevic university of belgrade, faculty of medicine, institute of pathology, belgrade, serbia institute of mother and child health of serbia, belgrade, serbia university children's hospital, department of nephrology, belgrade, serbia celiac disease hla aplotype in children with nephrotic syndrome s i (if) or mcp or with anti-cfh autoantibodies. varicella hasn't been described as a triggering event of ahus. we report two cases of ahus associated with complement dysfunction revealed after varicella infection. case . a five year-old boy presented with non post-diarrheal hus, days after varicella. serum creatinine was μmol/l, hemoglobin . g/dl, schizocytes %, platelets g/l. glomerular filtration rate normalized within days. search for shiga toxin-producing e coli in the stools and serum anti-lipopolysaccharides antibodies were negative. plasma c , cfh and if levels were normal. no mutations of cfh and if were found. mcp cell-surface expression was decreased and a c f mutation in mcp exon was demonstrated. case . a four year-old girl had ahus days after varicella at that time, complement system study showed normal c level ( mg/l, normal to mg/l), normal cfh level ( %, normal - %), but the presence of anti-cfh autoantibodies. no mutations of cfh, if or mcp were found. in conclusion, these cases outline that varicella can be the triggering event of ahus associated with complement dysregulation about ( . %) children had relapses after initial remission. various infections were responsible for relapsed with in / ( . %) who had relapses. about children ( . %) relapsed with out cause where as poor compliance was observed in ( . %). overall infection and relapse rate was . and . /pt/yr respectively. among children with infections, most common types of infections were acute respiratory infections (ari), diarrhea and uti seen in ( . %), ( . %) and ( . %) of cases respectively. other types of infections like malaria, peritonitis, skin infection and pulmonary tuberculosis were seen serum pai- and tgf-beta levels in profliferative forms of glomerulonephritis in children russian federation research centre for child health rams, department of pathology, moscow, russian federation we aimed to investigate serum levels of plasminogen activator inhibitor - (pai- ) and transforming growth factor-beta (tgf-beta ) in children with proliferative forms of glomerulonephritis (gn). children were examined ( - years old) with gn (steroidresistent ns, n= ; steroidsensitive ns, n= , isolated haematuria, n= ) and healthy age matched controls. mesangioproliferative gn (mespgn) was detected in patients, membranoproliferative gn (mpgn) in cases. serum levels of pai- : ag and tgf-beta were measured by elisa. results. the highest levels of pai- : ag and tgf-beta were observed in relapse of mpgn: , ± , ng/ml and these results confirm prosclerotic effects of pai- and tgf-beta via increased fibrin deposits and extracellular matrix accumulation in the renal tissue and promotion of disease progression rituximab treatment for idiopathic nephrotic syndrome: a retrospective study of cases v. guigonis , a. dallocchio , m. dehennault urinary and serum annexin v levels in children with steroid sensitive and steroid-resistant nephrotic syndrome hôpital robert debré-aphp, pediatric intensive care unit indonesia this study was aimed to evaluate the efficacy of pulse dose of cyclophosphamide in children with srns admitted in child health department faculty of medicine university of indonesia/cipto mangunkusumo hospital jakarta between - . -month period, one child died, and the rest ( children) did not complete the regimen. five out of children who finished the treatment had remission, while others were still experiencing heavy proteinuria. remission was achieved in various time, children were in remission after the first dose, in children it was achieved at the third and sixth dose. in further follow-up time; one child remained in remission, one child had relapse when still receiving cpa, children got relapse one month after stopping cpa, and one child had relapse after months ceasing cpa. nausea and vomiting were found in children indonesia this study is to evaluate the anthropometric measurements of children with nephrotic syndrome methods: a descriptive retrospective study at child health department, cipto mangunkusumo hospital, jakarta. data were collected from medical records of nephrotic syndrome %) irns; body height and body weight of <p was found in none of frns/sdns, / ( , %) srns, and / ( , %) irns; bmi >p was found in / ( , %) frns/sdns, / ( , %) srns, / ( , %) irns. conclusion: the percentage of children with frns/dsns and srns with body height <p il- ) during active stage (as: urinary protein > mg/m per hour, serum albumin < . g/dl) and remission stage (rs) in ss-mcns. a total of patients with ss-mcns ( of patients with as and of patients with rs) and healthy children were recruited for studies. the mean±sd of serum il- , se-selectin and sicam, levels were significantly higher in patients with as than in patients with rs ( ± . / . ± pg/ml; . ± . / . ± . ng/ml and . ± . / . ± . ng/ml respectively, p< . ). in spite of, higher levels of il- , se-selectin and sicam in patients with as than controls, difference was not statistically important. the percentage of cd +cd + lymphocyte subsets were statistically grater in patients with as severe proximal renal tubular acidosis in pearson syndrome birth weight was g. pallor was initially noted during the neonatal period and referred to our hospital with anorexia, vomiting, diarrhea, weakness, and increased pallor at wk of age. on the physical examination she was pale and the other systems were unremarkable. investigation showed hypoplastic anemia, and bone marrow examination showed cytoplasmic vacuolization of both myeloid and erythroid precursors, and maturation arrest of granulopoesis. family history was negative for hematological disease. the diagnosis ps was considered on the basis of early severe refractory anemia associated with vacuolization of bone marrow precursor cells and ring sideroblasts. treatment was started consisting of vitamine b and folic acid. she was followed with growth retardation, moderate anemia and leucopenia up to age . . at that age, the girl was readmitted with severe vomiting and dehydration. on admission, she had moderate metabolic acidosis, hypokalemia, high plasma lactate, and hypophosphatemia. further investigations showed tubuler proteinuria, glucosuria, aminoaciduria, and defective bicarbonate reabsorbtion in the proximal tubule. she developed refractory metabolic acidosis resulting in a cardiac and respiratory failure and death. to confirm the diagnosis of ps, molecular studies were performed bp common deletion was found medial calcification in intact human arteries from children with chronic kidney disease is associated with apoptosis and osteogenic differentiation -clinical and laboratory correlations r using intact human vessels we studied the phenotypic changes in medium sized arteries ex vivo and in vitro after exposure to ca and po . arteries were retrieved during insertion of pd catheters or at transplantation from children: dialysis (n= ), ckd stage iv (n= ) and compared with mesenteric vessels from controls. vessel rings were incubated with graded concentrations of ca and po upto days. calcium and alkaline phosphate (alk) were measured by cresolphtalein complexone and colorimetry. immunohistochemistry for bone marker proteins, inhibitors of calcification and apoptosis were performed. laboratory findings were related to patient's clinical and biochemical parameters, carotid intimamedia thickness (cimt) and coronary calcification. vessels from ckd or dialysis patients had increased baseline vessel wall ca compared with controls (p= . ). when exposed in vitro to ca and/or po , dialysis vessels showed greater calcification than those from controls or ckd patients (p< . ). in the presence of elevated po even a small increase in ca increased calcification (p< . ). calcification was associated with apoptosis (tunel +) and could be inhibited using apoptosis inhibitor zvad. alk in ckd and dialysis vessels and along with upregulation of bone-markers suggests an osteogenic conversion of vsmcs using our unique in-vitro model, we have shown for the first time that vascular damage induced by elevated ca-po as well as factors specific to dialysis primes vessels for rapid progression of medial calcification altered expression of major renal na + and k + transporters c. ruete , p. vallés , university of cuyo, department of pathology turkey the effect of corticosteroid therapy on bone metabolism in nephrotic syndrome was examined. sixty-nine patients with idiopathic nephrotic syndrome (age: . ± , years) and healthy controls (age: . ± , years) were divided into groups: group : patients who were on remission but still receiving steroid therapy, group : patients who were on remission and free of steroids within the last year and group : patients with active nephrotic syndrome and receiving steroid therapy. serum total calcium, ionized calcium, phosphorus, alkaline phosphatase, magnesium, parathyroid hormone, (oh)d, serum cystatin c, urine protein, urine creatinine and urine cystatin c levels measured in all patients including the control group. in addition, lumbar spine bone mineral density z scores were measured in the patient group objectives of study: we evaluated the clinical, laboratory and urinary tract echosonographic findings in patients with ah and rh. methods: there was prospective clinical study, included patients (mean age . ± . ) with ih (normocalcemic, normophosphatemic, with hours urinary calcium excretion greater than mg/kg/day) all analyzed parameters (dysuria, positive family history of urolithiasis, microscopic hematuria, urinary tract microlithiasis) showed low sensitivity and specificity, and none of the parameters could be considered reliable in differentiating ah versus rh. average value of una/cr was greater in patients with rh conclusion: none of the analyzed clinical parameters, laboratory and echosonographic parameters except values of urinary excretion after calcium deprivated diet could be considered reliable in differentiating ah versus rh. patients with rh have higher level of hours urinary calcium excretion than patients with ah. patients with rh have significantly greater excretion of urinary sodium compared with patients with ah idiopathic hypercalciuria (ih) is defined as hypercalciuria with no detectable cause. low bmd with increased fracture rate and tendency to short stature has been reported in ih patients. we aimed to perform calcaneus qus in children with ih and relate to u-ca, body height and number of prevalent fractures (fx). children ( girls, boys; patient. body height was recorded and qus was measured on both heels with cuba clinical. the -h u-caexcretion (u-ca/ h) was assessed and calculated in mmol/kg/ h. results were expressed as z-scores ±sd. czech anthropometric parameters from a survey and previously obtained qus values of the healthy czech pediatric population served as reference data. qus results were also calculated as height adjusted values with the use of heightmatched standards. u-ca/ h was matched to healthy european paediatric population values we found no correlations between fx and bua (either age-related orheight-adjusted) or fx and vos (age-related or height-adjusted). neither were there any correlations between u-ca and fx, or u-ca/ hand bua or vos, respectively. in conclusion, children with ih had normal height, normal values of bua and low vos (fc) (p) (p) (mr) (fc) (fc) (op) (p) alpay h. (p) (p) amann k. (fc), (p), (p) amanullah f. (p) (op) amaro a. (op) (op) amore a. (sy) (p) anarat a. (fc) (mr) (p) (op) (fc) (op) (p) (p) bael a. (op) (p), (p), (p) (fc) (fc) (p) balat a. (p) (p) (fc) bayazit ak. (p) (p) (p), (p), (p) (p) (p) (p) (p) bensman a. (op) (sa), (p) (p) (fc) bereczki cs. (op) (fc) (op), (fc) (op) (sy) bi yl. (p) (fc) (p) (op) (p) biyikli n. (p) (p) (fc) bocanegra v. (fc) (fc) (p) boh m. (fc) bökenkamp a. (op) (fc) (fc) (op) (op) (op) bourrier t. (p) bouts ah. (op), (fc) (op) (p) bubic-filipi lj (p) (op), (fc) (op) (p) (p) caropreso m. (op) (fc), (p) (fc) (p), (p) chartapisak w. (p) (p) (p) chaves a. (op) (p) chemodanova m. (p) (p) chen j. (op) (p) (p) (p) (p) (op) (p) (p), (p), (p) clermont mj (p) (fc), (p) (sy) codoceo a. (p) coelho g. (op) (sy), (fc) (sy) (p) (fc) (fc) (p) (fc) (p) coutinho s. (p) coviello d. (p) (fc) craig j. (op), (p) cransberg k. (fc) (p) (p) cristino s. (p) (fc) (p) cross j. (op) cruz mr (fc) (p) (fc), (p), (p) (sy) deanfield j. (fc) (p) decena-galvez a. (p) (fc) (p) (p) deguchtenaere a. (op) (p) (p) (sa), (p) (p) delucchi a. (p) (p) (p) (p) (p) (p) (fc), (p) (fc) dinda a. (p) (p) (p) (p) dittrich k. (fc) (fc) (p), (p) dötsch j. (fc), (p), (p) dragon-durey ma (p) (fc) (p) (fc) (p) (p) (p) (p) dursun i. (p) (p) (p) edefonti a. (p) (p) eke f. (fc), (p) (p) (fc), (fc), (p), (p) (fc) (p) (p) (p) evim m. (p) f faerch m. (p) fallahzadeh mh. (p) (p) (sy) feig d. (p) (p) (p) fella a. (op) feneberg r. (op) (op) (p) filler g. (fc) (p) (op) fischbach m. (op) sy) fitoz s. (p) (fc) (p) (p) fujita h. (op) (p) fujita t. (p) (p) fukuhara d. (p) (op) (p) (p) (op) (op) garnier a. (p) (p) (op) (sy) geary-joo c (fc) (fc) (op) (sy) (fc) (p) gross ml. (fc) (p) (p) (fc) (fc) (p) (p) guo w. (op) (p) (op) (p) haberal m. (p) (fc) (op), (fc) (fc), (p) (fc) (fc), (p) (fc) (p) (mr) (p) (p) (op) (op) hernández am. (p) (op) (op) (fc) (op), (fc) (p) hou jr. (p) (p) (op) (p) (fc) (fc) (p), (p) iharada a (op) (op) (p) (fc), (fc) (p) (p) (sy) (p) kathiravelu a. (fc) (op) (op) (op), (fc) (p) (p) (p) (p) (p) (p) (mr) (p) (op) (p) kondo y. (fc) (p), (p) kosuljandic-vukic d. (p) (fc) kovalski y. (p) (op) (p) (p) (p) kru èic d. (p) krylova-olefirenko a. (p) (p) (p) (p) (sy) (fc) (p) (p) kurayama r. (op) (p) (fc) lalatta f. (op) (p) (sy), (p) (op) (p) lau yw (op) (op) (p) llanas b. (op), (fc), (p) llewellyn-edwards a. (fc) (fc) (p) (fc) luis-yanes m (p) (p) (sy) maeda a. (p) maekawa k. (p) (p) (p) (p) (p) (p) (p) mak r. (sy) (op) (op) (p) (fc), (fc) (fc) (p) (sy) (fc) (p) (p) (p) medynska a. (p) (p) mehls o. (fc) (p) (fc), (p) (op) (op) (op) (fc), (p) (p) (fc) (p) molnár-varga m. (p) (fc) (fc) (p) montini g. (fc) (p) (p) (op) (p) (p) morimoto t. (op) (p) (op) (p) morita t. (p) (p) mortazavi f. (p) (fc) moscaritolo e. (p) (p) mosig d. (p) (op) (fc) (p) moxey-mims m. (fc) (op) (p) mudun a. (p) (fc) mughal mz. (p) (p) müller t. (op) müller v. (fc), (sy) müller-esterl w. (p) müller-wiefel de. (fc) (sy), (fc) (op) fc) (op) (fc) (p) nghia h. (p) niaudet p. (mr) (p) (p) nuzzi f. (op), (op), (p) nwobi o. (p) (op) (op) (p) (op) (p) (sy) (p) ostalska-nowicka d. (p) (p) otukesh h. (p) (p) (p) (p) ozen a. (p) (sy), (p) (p) (p) paik kh. (p) (p) pan'czyk-tomaszewska m. (p) (p) (fc) paripovic d. (p), (p), (p) (fc) pasqualini t. (op) fc) pastori a. (p) pászka d. (op) (op) (p) pereira a. (op) (fc) (fc), (p) (p) fc) (op), (p) raes a. (op), (op), (fc) (fc) (p) rigden s. (fc) (fc) ring e. (p) rink n. (op) (op) ristoska-bojkovska n (fc), (p) roszkowska-blaim m. (p) (p) (p) ruffo gb. (p) ruhlmann a. (op) ruiter j. (op) rumeau r. (fc) rusai k. (fc) rusnak f. (p) rüther u. (p) rutjes n. (p) rybarova s. (p) rychlik i. (p) ryckewaert-dhalluin a (p) sabasiñska a. (p) (p) sabolic-avramovska v. (p) (p) (op) safouh h. (p) saha a. (p) sahin h. (p) (op) saint-cyr c. (p) saito a. (p) (fc) sakalli h. (p), (p), (p) sakalli ercoban h. (p) (sy) (p) salusky i. (fc) (op) (p), (p) sarkissian a. (p) (p) (fc) (p) (fc) (op) sayili a. (p) schäfer b. (p) (fc), (fc), (fc), (sy), (fc), (fc), (fc), (fc) (fc) schmidt-gayk h. (mr) schmidts m. (p) schmitt cp. (fc) (op) (p) (fc) schneider-maunoury s. (p) (p) (sy), (fc) (fc) (op) (p) seeherunvong w. (fc) (p) (op) (p) semama d (op) (p) (p) (p), (p) shin yh (p) (p) (fc) (p) (p), (p), (p) siwiñska a. (p) (fc) (op) (p) spasojevic b. (p), (p), (p) spasojevic-dimitrijeva b stanic m. (p), (p), (p) stankovic a. (p) (p) (mr) (fc) (op) (mr) (p) (p) (p) (p) (p) (p) szteblich a. (op) t (fc) (p) taha g. (p) (p) taheri derakhsh n. (p) (p) (p) (fc), (p), (p) tan ph (p) (p) (fc) (p) (op) (p) (p) (p) tizard e. (fc) (p) toenshoff b. (fc) (p) tönshoff b. (fc) (p) (op) (fc) (fc) (op) (op) (p) (op) (fc) urdaneta-carruyo e. (p), (p) urdaneta-contreras a (fc) (p) (p) valverde s. (p) (p) van den heuvel l. (fc) (p), (p) van't hoff w. (sy), (p) (p) (fc), (p) (sy) (sy) (fc), (fc) (p), (p), (p) waters a. (op) (fc), (fc), (fc) (mr) (op) (fc) (fc) (op) (fc), (p) (fc) wingen a. (op) (sy) (fc) (sy), (fc) (fc), (p) (fc) (sy) (p) (fc) (p) (p) (p) (op), (p) (fc) (p) yap hk. (fc) (p) yata n. (p) (op) (p) (p) yilmaz a. (p) (op) (op) (p) (p) (p) zhou jh (fc) (op), (fc), (sy) zingg-schenk a (p) (fc) zurowska a. (fc) (op) the il (- g/c) polymorphism is associated with initial peritoneal transport status in children commencing chronic pd acknowledge: this study was from iran university of medical science. atypical hemolytic uremic syndrome: an unsolved case of complement dysregulation (p) aim: we have shown that rats overexpressing il- gene developed a mcn with proteinuria, hypoalbuminemia and hypercholesterolemia. this study aimed to determine the role of il- on hypercholesterolemia in this model. methods: recombinant rat il- gene in a mammalian expression vector was transfected into quadriceps of wistar rats by in-vivo electroporation. serum il- , albumin, cholesterol, creatinine and urine albumin were measured serially. after sacrifice on day , hepatic gene expression of hmg-coa reductase (hmg-coar), acat , cholesterol- a-hydroxylase (ch ah), ldl-receptor (ldlr) and il- receptor subunits were determined by rt-pcr. results: compared to control rats (n= ), il- -transfected rats (n= ) showed significant albuminuria ( . ± . vs . ± . mg/day, p< . ), hypoalbuminemia and hypercholesterolemia ( . ± . vs . ± . mmol/l, p< . ) at day . serially, this rise in serum cholesterol preceded the increase in proteinuria and fall in serum albumin. serum cholesterol correlated significantly with il- levels (r= . , p< . ). in of the il- -transfected rats with serum cholesterol> . mmol/l, hepatic gene expression (mean±sem) was significantly upregulated compared to controls for hmg-coar ( . ± . vs . ± . , p= . ), acat ( . ± . vs . ± . , p= . ), ch ah ( . ± . vs . ± . , p= . ) ldlr ( . ± . vs . ± . , p= . ) and il- ra ( . ± . vs . ± . , p< . ). conclusion: the increased cholesterol synthesis in il- -induced mcn was associated with increased hepatic gene expression of hmg-coar and acat , which are important enzymes for cholesterol synthesis. associated increased hepatic gene expression of ch ah and ldlr involved in cholesterol metabolism could be a negative feedback response. e. bordador, f. anacleto philippine general hospital, pediatric nephrology, manila, philippines general objective: to formulate a clinical scoring system that will predict the presence of glomerular crescents in patients with severe nephritis. specific objectives: ( ) to describe the profile of children with acute nephrotic-nephritic syndrome ( ) to correlate clinical parameters with renal histopathology. methods: this is a retrospective study. twenty six charts from the philippine general hospital, admitted between january -march were retrieved. included in the study were children with acute nephritic -nephritic syndrome who underwent kidney biopsy. excluded were patients with small/contracted kidneys on renal ultrasound. statistical tool used were univariate analysis, pearson's product moment method and chi -square test. results: profile variables of the subjects were analyzed. afterwhich, each clinical parameter was tested using univariate analysis, if significantly correlated with the renal biopsy result using pearson's product moment method at critical value= . at p< . . out of parameters, only parameters were noted to be significant, these were serum creatinine, blood urea nitrogen and glomerular filtration rate. further analysis was made by separately treating male from female population using a chi-square test with critical value x ( ,. ) = . . the test identified another three clinical features among female which were significantly associated with renal biopsy results, these were blood pressure, anemia and hematuria. from these significant parameters associated with renal biopsy results, a clinical scoring system was then conceptualized in order to identify patients with high probability of crescents on renal biopsy. conclusion: cresent maybe use as an accurate screening tool to predict presence of glomerular crescent in patients with severe nephritis. heterogeneous effect of acei therapy in children with proteinuric nephropathies b. kranz, s. diepenbruck, u. vester, r. buescher, a. wingen, p. hoyer university of duisburg-essen, pediatric nephrology, essen, germany background: chronic proteinuric nephropathies are at high risk of developing progressive renal insufficiency. the renin-angiotensin-aldosteron-system blockade is a well documented strategy to reduce proteinuria in adult patients. the efficacy and risks of renal-protective therapy with angiotensin-converting-enzymeinhibitors (acei) in children with proteinuric kidney diseases is of concern. method: in this retrospective study the efficacy of acei as antiproteinuric therapy in children with chronic proteinuric nephropathies is evaluated. patients: sixty-three children (mean age . ± . years) have been treated with acei for a mean of . ± . years (range . ± . years) because of proteinuria (hus n= , alport syndrome n= , psh n= , others n= ). results: proteinuria in all patients declined from a median of . g/d to . g/d after years (p= . ). there was a drop out of patients because of end stage renal failure during the followup. one-third of patients showed a continuous reduction in proteinuria from . g/d to . g/d (median) within years while a second third had a transientimprovement followed by a reincreasing proteinuria later. patientswith hus showed a good response (decrease of proteinuria from . g/d to . g/d) in contrast to patients with alport syndrome who developed increased proteinuria ( . g/d to . g/d) despite of acei and patients with psh who had no change in proteinuria.interpretation: it has to be discussed whether biological compensation mechanisms may bypass the ace inhibition in single patients and whether the underlying illness may predict the efficacy of acei.aims: to determine the clinicolaboratory renal manifestations; glomerular, extra-glomerular histopathologic lesions; renal tubular dysfunction (rtd) frequency, and outcome of a short-term renal follow-up in nigerian children with systemic lupus erythematosus (sle). methods: a non-randomized prospective study of consecutive cases of childhood-onset sle with nephropathy. baseline/follow-up clinicolaboratory data were collected. each patient was followedup for months. results: seven of children studied were girls (f:m, . ). median age at diagnosis was . years. median diagnosis time interval ( . years) and median time of renal disease onset ( . year) were similar. hypertension, nephrotic syndrome, and acute renal failure occurred in . %, . % and . % of the patients, respectively. the glomerular lesions were non-proliferative lupus nephritis (ln) in . % (class ii ln); focal (class iii ln) and diffuse (class iv ln) proliferative ln (pln) in . % and . %, respectively. tubulointerstitial nephritis (tin, . %), and rtd ( . %) were common. arf (p= . ) and rtd (p= . ) were significantly associated with severe tin. complete renal remission rate at end-point was . %. relapse and renal survival rates were . % and . %, respectively. rtd was persistent in . %. conclusion: renal function disorders, diffuse pln, and extra-glomerular lesions were frequent. significant association of arf and rtd with severe tin in this series suggests the need for early renal tubular function (rtf) assessment in our sle patients. deranged rtf may be marker of severe tin in sle warranting early confirmatory renal biopsy and aggressive interventional treatment.we report two cases of children with crescentic glomerulonephritis (gn) associated to isolated c deposits. patient . a year old girl was admitted for macroscopic hematuria, nephrotic range proteinuria (proteinuria/creatininuria= mg/mmol) and renal failure (serum creatinine μmol/l). anca and other antibodies were negative. c , c and ch activity were normal but c nef was detected. the patient was treated by prednisolone and cyclophosphamide pulses followed by oral corticotherapy. renal function normalized, but proteinuria persisted (proteinuria/creatininuria= mg/mmol). a relapse occurred ten months later. corticotherapy and cyclophosphamide pulses were reinitiated and were successful, followed by mmf maintenance therapy. patient . a year old girl was admitted after viral infection for macroscopic hematuria and fever. proteinuria was of nephrotic range (proteinuria/creatininuria= mg/l). the search for autoimmunity was negative. c nef was detected but c , c and ch activity were normal. serum creatinine increased to μmol/l. after three pulses of prednisolone followed by oral prednisone, renal function normalized. histological examination of the two renal biopsies revealed endo-and extracapillary gn with numerous granulocytes in the capillary lumen. cellular crescents involved % of the glomeruli. immunofluorescence demonstrated isolated c deposits in the mesangium and along the glomerular basement membrane (humps). c q, igg, iga and igm staining were negative. background: the risk of end stage renal disease (esrd) is low in unilateral wilms tumor, although patients with wagr or associated genitourinary anomalies are at higher risk. esrd is attributed mostly to hyperfiltration in the remnant kidney. immune complex glomerulonephritis (icg) has not been previously reported in wilms tumor patients. objectives: to report cases of icg in unilateral wilms tumor. methods: retrospective chart review. patient # a boy with cryptorchidism, diagnosed with unilateral wilms tumor at y of age. patient # a girl with wagr and unilateral wilms tumor diagnosed at y of age. both had chemotherapy after tumor resection. results: patient # : within mo of tumor resection, a proteinuria of . g/ hrs and rising creatinine were noted. renal biopsy was consistent with icg. within mo of surgery the patient developed esrd requiring chronic hemodialysis. patient # : within y of tumor resection, the patient developed progressive, asymptomatic proteinuria up to g/ hrs. the renal biopsy revealed changes typical for icg. the patient was treated initially with enalapril and prednisone. due to no response, mycophenolate mofetil (mmf) was added and prednisone was weaned. after mo of therapy, her proteinuria improved to . g/ hrs. her serum creatinine continued to be normal at . mg/dl, with calculated gfr of ml/min/ . m . conclusions: this is the first report of icg in patients with unilateral wilms tumor with rapid progression to esrd in the first patient, but successful response to mmf in the second patient. despite low risk for progressive proteinuria in wilms tumor patients, it is prudent to monitor these patients for proteinuria and perform a renal biopsy if proteinuria is progressive. mmf therapy may be attempted to decrease proteinuria and to delay the onset of esrd.aim of the study: to present our first results of rhgh treatment mainly in children on hemodialysis. patients and methods: sixteen children, aged . - . years (mean age . ± . ) with height below - . standard deviation score (sds) for age or height velocity below - . sds for age, were selected to receive rhgh therapy at our nephrology and hemodialysis department. most of them were on hemodialysis ( children) with mean spent time . ± . years ( - years) before an initiation of rhgh therapy. one half of patients were prepubertal ( children) and second half were in early puberty (testicular volume between and ml for boys and breast development b or b in girls). all received - iu/ml per week by daily subcutaneous injection for months to years. the year before rhgh therapy served as a control period. results: during the first year of treatment, mean height velocity in hemodialysis patients increased from . cm/year to . cm/year (p< . ) and in the second year was . cm/year (p= . ). the mean height sds in hemodialysis children did not improved significantly during the first year of rhgh treatment (from - . sds to - . sds, p= . ). neither weight, nor the body mass index varied compared with the pretreatment period. no change was observed in glucose, total proteins, albumins, cholesterol and triglycerides levels. the mean increment in bone age was . years. pubertal status had no influence on response to rhgh. conclusions: therapy with rhgh improved height velocity in children with esrd. no significant side effects were observed in children during the . treatment years. two patients developed secondary hyperparathyroidism but the relationship with rhgh remains uncertain. in our treatment group rhgh therapy was safe. a. waters , a. trautmann , p. zipfel , e. harvey , ch. licht hospital for sick children, department of pediatric nephrology, toronto, canada university children's hospital, department of pediatric nephrology, heidelberg, germany atypical hemolytic uremic syndrome (ahus) is characterized by the absence of a diarrheal prodrome, the tendency to relapse and a poor outcome. functional and quantitative deficiency of complement regulatory proteins or inhibiting autoantibodies result in uncontrolled complement activation, which eventually causes ahus. -we report a case of ahus with complement dysregulation associated with a progressive refractory response to plasma infusions. factor h and factor h-related proteins (fhr) were quantified by elisa and were further analyzed by western blot. complement activation was determined by measuring c . serial hgb (g/dl), platelet, creatinine (mg/dl), ldh (u/l) were measured. initial presentation was at months of age with thrombocytopenia, hemolytic anemia and increased creatinine. ahus was suspected as e coli infection was ruled out. disease remission followed several plasma exchanges. monthly plasma infusion maintained remission. therapy intervals exceeding month promoted relapses. nine years later, the relapse interval decreased and over the subsequent years, thrombocytopenia persisted as plasma infusion requirements increased. a concomitant decline in renal function (creatinine . mg/dl) occurred with the development of persistent proteinuria and hypertension. at years of age, she deteriorated acutely with hypocomplementemia and thrombopenia. quantitative factor h was normal. autoantibodies to platelets and factor h were negative. intravenous immunoglobulin combined with oral steroids resulted in normalization of platelet count. complement dysregulation is associated with ahus. hereditary defects can be treated with factor replacement therapy. refractory responses may subsequently arise due to the development of autoantibodies against complement regulatory proteins. complement dysregulation requires further analysis in our patient. objectives: angiopoietin-like protein (angptl ) is involved in lipid metabolism and angiogenesis. the present study was to examine angptl expression in human kidneys with proteiuria, in adramycin rats (adr), and in puromycin induced podocyte damage. methods: immunohistochemistry was performed on kidney biopsies from children with mcd, mn, fsgs, tbmn. in adr, angptl expression was determined by quantitative real-time pcr in glomeruli and tubuli dissected from frozen section of kidneys with laser microdissection system. in mpc , a conditionally immortalized mouse podocyte cell line in vitro, angptl , perlecan and agrin werer detected through real-time pcr with the induction of puromycin. detachment assay was performed in podocytes tranfected by angptl -pcdna . . results: in human kidneys, co-labeling showed angptl expressed in the cytosol of wt positive cells. quantitative computerized analysis showed that angptl in glomeruli in mcd and mn were significantly higher than that of tbmn, fsgs respectively (p< . ). in adr, angptl in glomeruli increased significantly at st or th day (p< . ) after adriamycin injection compared with control. and the expression of angptl in glomeruli was correlated with h urinary protein (r= . , p< . ). in mpc both protein and mrna expression of angptl on podocytes were up-regulated with the induction of puromycin. in podocytes transfected by angptl -pcdna . the expression of perlecan or agrin increased significantly compared with control (p< . ). the attachment ratio was shown . %± . % hs after puromycin treatment on podocytes transfected by angptl compared with . %± . % on normal podocytes, and . %± . % on untransfected podocytes. conclusions: angptl is predominantly expressed in podocytes which could be involved in podocyte damage and the development of proteiuria. purpose: we present cases of a previously undescribed pattern of membranoproliferative glomerulonephritis, in children with neuroblastoma on chemotherapy. the pattern of injury shows unusual focal capillary loop proteinaceous deposits possibly related to toxic chemotherapeutic drugs. the resultant hypertension and renal impairment made bone marrow transplant a challenging prospect. method: case series results: case : this boy with stage neuroblastoma, developed severe renal impairment and hypertension during treatment. thus there were difficulties in administration of chemotherapy and he required early surgery. at tumor resection a nephrectomy was necessary. he received an autologous stem cell transplant. he became unwell at transplant and required haemofiltration. he made a good renal recovery and did not relapse. case : he was diagnosed at months with stage s neuroblastoma. he completed treatment but later relapsed. during treatment his gfr reduced and he developed severe hypertension. this lead to restrictions in chemotherapy. renal biopsy was carried out at tumor resection. at bone marrow transplant he was very unwell and required haemofiltration. he has chronic hypertension and low gfr. light microscopy findings in both -global diffuse membranoproliferative pattern of injury -large numbers of proteinaceous resorption droplets -features of a protein deposition disease electron microscopy findings common to both -large number of differently sized protein droplets in the endothelial cells -no obvious immunecomplexes/deposits -protein deposition disease with a membranoproiferative pattern of injury conclusion: both cases showed deposits in the kidneys which may be tumor protein in origin and the resultant glomerulonephritis, hypertension and renal impairment lead to challenges in transplant. the long term consequences are yet to be revealed. methods: establish the cultured glomerular mesangial cells of rat in vitro, ~ generations of cells were used in the experiment after identification. the experiment included five groups: ctrl, lps, high, middle and low dose fos groups. gmc proliferation were detected by mtt. the changes of ln, fn and col protein secretion were detected by the elisa. the changes of lnbeta mrna expression were detected by semi-quantitative real-time pcr. results: ( ) fos can inhibit the effect of proliferation induced by lps. ( ) mesangial cells can secrete some ecm protein in normal culturing medium, ecm protein secreted by mesangial cells was significantly higher in lps group than that in ctrl group (p< . ), while ecm protein was significantly lower in all fos groups than that in lps group (p< . ). ( ) lnbeta mrna expression was significantly higher in lps group than that in ctrl group, while that in fos group was significantly lower than in lps group. conclusions: lps can induce the increase of secretion of the ecm, including ln, fn, col fos can inhibit the secrection of ecm in gmc as dose-dependent manner at the mrna and protein levels. the conclusion supplies the theoretical evidence for the renal protection of fos. h. hong, w. na, y. li, w. qiang guangzhou first municipal people's hospital, department of pediatrics, guangzhou, people's republic of china objective: to observe the effects of fosinopril (fos), the new generation angiotensin-converting enzyme inhibitor (acei), on protein and mrna expression of tgf-β of rat glomerular mesangial cell (gmc) induced by lps; to demonstrate the preventive mechanism against glomerular sclerosis by applying fos. methods: culture rat gmc in classic way. the cultured cell were divided into groups, namely ( ) control group, ( ) lps group, ( ) lps+fos group. detect tgf-β concentration in gmc supernatant fluid by elisa; estimate tgf-β mrna expression by semiquantitative real-time rt pcr. results: lps group is obviously higher than control groups in tgf-β secretion and mrna expression, while lps+fos group drops distinctively in tgf-β secretion and mrna expression compared with lps group. conclusions: fos has obvious inhibited on tgf-β expression of rat gmc both at protein level and mrna level, which reveals that it might be an important mechanism by fos on restraining the development of glomerulosclerosis. r. kahn , n. akbari , j. wieslander , w. müller-esterl , a. christensson , k. westman , t. hellmark , d. karpman lund university, pediatrics, lund, sweden wieslab ab, lund, sweden institute of biochemistry ii, frankfurt, germany lund university, nephrology, lund, sweden vasculitis is an inflammation with neutrophil influx in and around blood vessels. patients may have elevated plasma levels of neutrophil-derived proteinase and anti-neutrophil cytoplasmic antibodies (anca) directed to proteinase , suggested to be involved in the pathogenesis of disease. we have previously shown that the kallikrein-kinin system (kks) is activated in vasculitis. in vivo the kks is activated on endothelial cells and neutrophils when high-molecular-weight kininogen (hk) is cleaved by kallikrein thus liberating bradykinin. bradykinin is a potent mediator of inflammation. in the present study we investigated if neutrophil-derived proteases, and proteinase in particular, could induce activation of the kks and bradykinin release. purified neutrophils from ten vasculitis patients ( adults, children) and thirteen controls were treated with triton-x to induce lysis. proteinase was immunoadsorbed from the neutrophil extracts. bradykinin and proteinase levels were measured by elisa. hk proteolysis was detected by immunoblotting. proteinase incubated with purified hk induced physiological breakdown of hk and bradykinin release. this was inhibited by preincubation of proteinase with anti-proteinase . triton-x treated neutrophil extracts from both patients and controls induced hk proteolysis and bradykinin release whereas the neutrophil extracts from which proteinase had been immunoadsorbed did not. levels of proteinase in the neutrophil extracts from patients and controls did not differ. these findings suggest that neutrophil derived proteinase can proteolyse hk in a physiological manner thus liberating bradykinin, thereby initiating kallikrein-independent activation of the kks. introduction: this is a prospective study to evaluate the safety and efficacy of tacrolimus in consecutive children with steroid-resistant nephrotic syndrome (srns). methods: all of them were subjected to kidney biopsy. tacrolimus was given in dose of . - . mg/kg/day in two divided doses to attain trought levels of . - . ng/l. these patients were followed-up every weekly initially for the first month, followed by monthly visits. urine spot protein creatinine estimation was done at each visit. besides blood glucose, serum creatinine, urea, electrolytes, albumin, and complete blood count were done once a month. results: the mean age of onset was . ± . yrs. of the children, had mcd, had fsgs and another had dmh on histopathology. tacolimus had to be withdrawn in children: of the rest children who received adequate therapy, complete remission was seen in ( %) children, ( %) attained partial remission and was non responsive. the mean time to achieve remission was . + . days and the mean dose of tac was . + . mg/kg. the mean urine spot protein/creatinine ratios were significantly lower ( . ± . vs . ± , p= . ) and mean serum albumin significantly greater ( . ± . vs . ± . , p= . ) as compared to those prior to tac. of the children who attained complete remission, patients are off steroids and tac and in sustained remission, while the rest are still on tac therapy. conclusions: this is the largest study so far on the safety and efficacy of tacrolimus therapy in children with srns. we conclude that tacrolimus is a useful therapeutic alternative in children with srns who are unresponsive to cyclophosphamide and cyclosporine. objectives: to describe hiv infected paediatric patients from our centre with pathology proven renal disease. methods: retrospective review of biopsy data base and case notes of patients with hiv referred with renal problems. results: patients were identified who had biopsy confirmed renal disease. the mean age of the patients was , yrs (range: months to years). twelve of the patients were african and two were of mixed race. renal pathology was divided into three groups: ) hiv associated nephropathy (hivan): five patients. ) mesangioproliferative nephropathy: patients ) other: acute pyelonephritis in , mesangial proliferation plus interstitial nephritis in , renal tuberculosis in , hiv immune complex disease (hivick) in one. conclusion: there is a high degree of variability of renal pathology in children with hiv and renal disease which upholds the need accurate diagnosis when confronted with these patients. background: acute poststreptococcal glomerulonephritis (apsgn) is the most common glomerular disease of children in our country. it has not been studied well in this region yet. here, we report our experience with psgn in a tertiary referral center during a five-year period. method: hospital records of all children who had been admitted from mar. to mar. to nemazee hospital with diagnosis of acute glomerulonephritis (agn) were reviewed. all demographic, clinical, paraclinical data and consumed medications were obtained. results: among children diagnosed as agn, ( %) had apsgn. other ( %) children had mpgn (n= ), mespgn (n= ), iga nephropathy (n= ), lupus nephritis (n= ), rpgn (n= ), and fsgs (n= ). mean age in children with apsgn was ± . (range, years. children ( %) developed apsgn following a sore throat or upper respiratory infection while ( %) cases developed after impetigo. ninety-five ( %) patients developed apsgn during the cold seasons of the year. periorbital edema was found in children ( . %), hypertension in ( %), gross hematuria in ( %), oliguria in ( %), generalized edema in ( %), azotemia (bun> ) in ( %), and nephrotic range proteinuria in ( . %). aso titer was high in ( %). low c was detected in ( %) and low c in ( %). dilutional anemia in ( . %), hyponatremia in ( %), and hyperkalemia in ( %) children among whom, required hemodialysis. regarding medications, patients had received only furosemide, cases took furosemide and nifidipine and for patients furosemide+nifidipine+another antihypertensive medication was prescribed. conclusion: acute psgn is the most common type of glomerulonephritis in this region. it follows sore throat in the majority of cases. it usually has an uneventful course. y. guo, zh. wang, x. liu west china second university hospital, sichuan university, department of pediatrics, chengdu, people's republic of china objective: we planned to explore the mechanism of glomerular basement membrane (gbm) damaged by rsv, through investigating the effects of lmwh on proteinuria and glomerular structure of rsv nephropathy. methods: sd rats were inoculated with pfu rsv and lmwh iu/kg. group a: rsv was given in the first days, and lmwh was given for the following days; group b: the mixture of rsv and lmwh was given in the first days, then lmwh was given for other days; group c: lmwh was continuously given throughout days and on the th - th day rsv was also given; group rsv and the control were respectively inoculated by rsv and dmem for days. renal histology, urinary protein excretion and serum parameters were observed. rsv rna in renal and pulmonary tissue was determined by in situ hybridization. results: there was no significant increase in urinary protein excretion of the lmwh-treated groups (a . ± . , b . ± . , c . ± . , mg/ h) compared with the control, but that of group rsv ( . ± . mg/ h) gradually increased after rsv inoculation. there was just a decrease in albumin ( . ± . g/l) and an increase in urea nitrogen ( . ± . μmol/l) of group rsv only. no change of the glomeruli detected in all lmwh-treated groups, while congestion and swelling in glomeruli of group rsv were observed significantly. glomerular microstructures of the lmwh-treated groups were almost normal, while extensive foot process effacement was observed in group rsv. rsv rna signal expressed weaker in the lmwh-treated groups than in group rsv. conclusion: rsv damages hs on gbm by electrostatic interaction. lmwh, as the analog of hs, charged with anion, competes with hs to combine with rsv to keep gbm from being destroyed, and then reduce the proteinuria. s. zhai, zh. wang west china second university hospital, sichuan university, department of pediatrics, chengdu, people's republic of china objective: the study is to explore the relevance among gags, hpa and ela in the steroid responsive nephrotic syndrome (srns). methods: ( ) children with srns were selected, including the active (n= ), the convalescent (n= ), the remissive (n= ). purpuric nephritis and healthy children were served as the control.( ) using the improved whiteman process detected the urinary gags. ela activities in plasma were determined by the amount of -nitroaniline released per unit time. immunocytochemistry and image analysis method were used to detect the expression of hpa of peripheral blood leukocyte. results: . gags of the active were the highest ( . ± . ) of all (p< . ). in contrast with the healthy, the active and the convalescent ( . ± . , p< . ) were significant difference, but the remissive no difference ( . ± . , p> . ). . all of ns showed higher level of hpa than the healthy (p< . ). comparing with the healthy, hpa was significant difference both in the active (iod . ± . , p< . ) and in the convalescent (iod . ± . , p< . ),but no difference in the remissive (iod . ± . , p> . ). by contrasting the active and the purpuric, their difference of hpa was no statistic significance (p> . ). . all of ns showed higher levers of ela than the healthy (p< . ). the healthy was strikingly different, contrasting with the active ( . ± . ) and the convalescent ( . ± . , p< . ), but no difference with the remissive ( . ± . , p> . ). .there was a significant correlation among the urinary protein, urinary gags, hpa and ela with simple linear regression analysis. conclusion: in the srns, proteinuria may be resulted by the spallation of hpa and ela for gags on gbm. ( ), combination withhaematuria, hypertension and/or renal insufficiency ( ), extrarenalsymptoms ( ), and familial mediterranean fever (fmf, ) . of the non-nephrotic patients, had extrarenal symptoms, were nephritic, had rapidly progressive glomerulonephritis (gn), renal failure and isolated urinary abnormalities. biopsy samples were evaluated by light microscopy in yerevan and zurich and by electron microscopy (except for amyloidosis) and immunohistochemistry (last ) in zurich. results: the most common histological lesion was renal amyloidosis ( %), followed by focal segmental glomerulosclerosis (fsgs, %), lupus nephritis ( %),systemic vasculitis/hus and minimal change disease (mc, . % each),mesangioproliferative gn/iga-nephropathy and membranous nephropathy(mn, % each), hereditary nephritis and membrano-proliferative gn typei ( % each), acute postinfectious gn (apgn, %), and dense deposit disease (ddd, %). the miscellaneous group includes,apart from interstitial nephritis ( %), unclassified or inadequate biopsies and specimens with mostly sclerosed glomeruli( %). the majority of patients with amyloidosis of fmf, fsgs/mc andmn were nephrotic, but % of patients with amyloidosis had non-nephrotic proteinuria. conclusions: several glomerular lesions were considerably more frequent than in other studies, particularly amyloidosis of fmf, mn and lupus nephritis, and to lesser extent membranoproliferative gn type and ddd. apgn is underrepresented because less than % of all patients (> ) had a biopsy. this study would not have been possible without international collaboration. henoch-schönlein purpura in children: an epidemiological study amongst dutch pediatricians on incidence and diagnostic criteria j. aalberse , , k. dolman , g. ramnath , r. rodrigues pereira , j-c. davin the aim of the present study on the incidence of henoch-schönlein purpura (hsp) in dutch children is not only to give some insight in the epidemiology of hsp in the netherlands but also to record the diagnostic criteria used by dutch pediatricians and to evaluate the accuracy of the latter using the presence of iga in the skin when biopsies are available. methods: in , all dutch pediatricians received monthly a card asking to mention new diagnosed hsp. pediatricians reporting one or more new patients with hsp were sent a list of questions concerning symptoms, blood and urine parameters, skin biopsy, diagnostic criteria and follow-up duration needed. results: two hundred and thirty-two patients from - of age ( . / ) were reported as having started hsp in . twenty nine % presented with renal symptoms. in accordance with the classification criteria of the american collegeof rheumatology (acr), eighty percent of pediatricians consider that isolated purpura (without hematological abnormalities) is sufficient to allow the diagnosis of hsp in children. from the skin biopsies performed, only ( %) presented with iga deposits. the follow-up duration considered as necessary was longer in case of renal symptoms at presentation. however, % of patients without renal symptoms would be followed for more than one year. conclusion: considering the recent ( ) eular/pres endorsed consensus criteria for the classification of childhood vasculitides, hsp should have been diagnosed in only of the patients of our study. the use of isolated non-thrombocytopenic purpura as only criterian to diagnose hsp in children might therefore lead to over diagnosis and unnecessary follow-up. noteworthy, the eular/pres criteria remain to be validated by a prospective study. the clinical presentation and response to therapy of childhood pan in johannesburg, south africa. method: retrospective record review of twelve children with a clinical diagnosis of pan treated between and . results: there was unequal number of males and females; average age at presentation was . ± . - . years, all were black children. eight children had more than acr criteria and sufficient clinical criteria (eular/pres consensus criteria). musculoskeletal and cardiac diseases were the commonest finding at presentation ( %), cutaneous, hypertension ( %), renal and gastrointestinal disease ( %), central nervous system disease ( %) and constitutional features ( %). two children had bone involvementwith periosteal reactions on plain x-ray. angiographic abnormalities were found in ( %), and ( %) had positive histology (skin/renal biopsies). tuberculosis was diagnosed in ( %), and had positive streptococcal titers. all patients were ana and hepatitis b negative, but there were five patients anca positive ( =p-anca, =c-anca, =both) ( %). the crp was elevated in / ( %), esr also in / , while % had both elevated. all patients received oral glucocorticoids, methylprednisolone ( - pulses- mg/m ), ivi cyclophosphamide ( - pulses, mg/m ), oral azathioprine, and required i. conclusions: children with pan in johannesburg present at a younger age with multi-organ disease. they require aggressive therapy with both glucocorticoids and cytotoxic therapy to ensure good outcomes. objective of the study: in order to evaluate the predictive factors of chronic kidney disease (ckd), the records of children with biopsy-proven mesangioproliferative nephrotic syndrome (mpns) admitted between and were retrospectively reviewed. methods: renal survival was analyzed by the kaplan-meier method and cox's regression model. two multivariate models were developed: ( ) from the onset of symptoms to the occurrence of ckd and ( ) from the time of renal biopsy to ckd. the following data were obtained at admission an dat the time of renal biopsy: gender, race, age at the onset ofnephrotic syndrome symptoms, age at admission, blood pressure, laboratory data (serum creatinine, serum urea, glomerular filtration rate, -hr urinary protein excretion, hematuria). patients were classified according to the response to the initial course of prednisone: ( ) a complete response was defined as a proteinuria < . g/day; ( ) a partial response was defined as urinary protein excretion of < g/day and > . g/day, and ( ) no response was defined as urinary protein excretion of > g/day. results: median follow-up time was years (iq range, . ± . ) and patients ( %) progressed to ckd. at baseline, after adjustment variables remained as independent predictors of ckd: creatinine > . mg/dl (rr= . , ci %= . ± . ) and non-response to steroids (rr= . , ci %= . ± . ). at the time of renal biopsy, after adjustment variables remained as independent predictors of ckd: age> . yr (rr= . , ci %= . ± . ) and creatinine > . mg/dl (rr= . , ci %= . ± . ). conclusion: serum renal function at baseline and initial response to prednisone were strong predictors of progression to ckd in our cohort of children with mesangioproliferative nephrotic syndrome. methods: an illustrative case history of a boy with sle and vhd in the absence of antiphospholipid antibodies was described. results: a -year-old boy with a history of sle for about five years was admitted to our hospital due to intermitted arthralgia, facial erythema, increased serum creatinine and oliguresis in october . he had been treated irregularly with prednisone and immunosuppressants. however,the disease was not always controlled well. during thishospitalization, the problems of hypertension, renal failure and anemia had been resolved and maintained, but the problem of intolerance to increased circulation volume was obvious, and three times echocardiography (ecc) showed moderate to severe mitral valve insufficiency. reviewed his history, suspected mitral leaflets vegetations was revealed by ecc four months after onset, he complained of chest pain, chest distress and breathholding several times without causes since eighteen months after onset and manifested with heart failure once, and ecc showed moderate to severe mitral valve regurgitation four months ago and twenty days ago respectively. ruling out the possibility of infective endocarditis, rheumatic heart disease and congenital heart diseases, vhd were considered secondary to sle. since the vhd becomes hemodynamically significant, valve surgery is needed. conclusions: vhd is generally asymptomatic and omitted easily, so routine cardiac evaluation of children with sle using electrocardiography, echocardiography and chest x-ray is recommended to early detect and treat cardiac abnormalities, which may lead to better survival. objective: we have previously reported that deleted in esophageal cancer (dec ), a potent tumour suppressor gene, was specifically upregulated in cd + cells of patients with relapse of mcns, using differential display rt-pcr. this study aimed to further characterize the potential function of dec in mcns. methods: semi-quantitative rt-pcr was used to verify the dec gene expression in children with relapse and remission of mcns. jurkat cells were transfected with plasmid containing dec gene or vector alone. gene expression was regulated by tet-on/off system. the effect of dec on jurkat cell proliferation was assessed by h-thymidine incorporation. cell cycle analysis was performed following propidium iodide staining. protein localization was determined by immunofluorescent staining with anti-dec antibody. results: we confirmed that dec gene expression was significantly increased in children with mcns in relapse ( . ± . ), as compared to remission ( . ± . , p< . ), normal controls ( . ± . , p< . ), patient controls with viral infections ( . ± . , p< . ) and nephrotic patients with other forms of glomerulonephritis ( . ± . , p< . ). in dec -transfected jurkat cells, cell proliferation was inhibited by . %, compared with vector control. cell cycle analysis indicated that dec arrested jurkat cell cycle progression by blocking its entry into the g /m phase. immunofluorescent staining with anti-dec antibody suggested that dec was a cytoplasmic protein, which was in agreement with psort. conclusion: dec gene expression was significantly upregulated in children with relapse of mcns. our results showed that dec acts as a t-cell proliferation suppressor and arrests cell cycle progression, and thus may be important in mediating the number or function of cd + cells during relapse of mcns. objective of study: the aim of the study was to assess plasma and urine concentrations of vascular endothelial growth factor (vegf) in nephrotic syndrome children (ns) depending on the total dose of glucocorticoids (gc) and the percentage of lymphocytes with glucocorticoid receptor expression (cd /gcr). methods: we examined children ( - years) , allocated to three groups: group i: children with the first ns onset, group ii: children with ns relapse, group c: healthy children. the ns patients were examined: a: before treatment and b: - weeks after prednisone administration at a dose of mg/m / h. plasma and urinary vegf levels were determined using the immunoenzymatic elisa method. flow cytometry was applied to assess cd /gcr expression. results: higher plasma and urinary vegf concentrations were noted in ns children before treatment (a), as compared to control subjects (c). following prednisone therapy (b), vegf level was reduced but it was still higher than in the control group. positive correlation was observed between vegf and protein in the urine (group i r= . , p< . , group ii r= . , p< . ) and a weak positive correlation between vegf in plasma and urine (group i r= . , p< . , group ii r= . , p< . ). cd /gcr expression was lower in group ii. in both groups, the correlation between plasma vegf and cd /gcr was positive (p< . ). conclusions: . plasma and urinary vegf levels increase during nephrotic syndrome onset. . glucocorticoid treatment reduces plasma and urinary vegf levels in ns children. objective of study: the aim of the work was to determine the expression of p-glycoprotein (p-gp) on peripherial lymphocytes (cd ) in children with steroid-dependent nephrotic syndrome (sdns) during cyclosporine a (cya) and ace-inhibitor (ace-i) treatment. methods: the study group (i) consisted of children with sdns aged - years, with a subsequent proteinuria relapse at the time of prednisone dose reduction. all ns children were examined three times: a: at proteinuria relapse, before cya treatment, b: after months, c: after months of cya administration. control group (ii) consisted of healthy children. cd /p-gp was measured using a flow cytometry assay. serum cya level was assessed by means of the immunofluorescence method. results: the expression of cd /p-gp in ns relapse, prior to cya+ace-i administration was much higher (median . %, range . - . %) when compared to healthy controls ( . % range . - . %). the absolute number of cd /p-gp in this examination was almost times higher when compare to healthy controls (p< . ). after months of cya+ace-i therapy the expression of cd /p-gp decreased dramatically and was similar to the controls. similar results were obtained after -months of treatment. when analysing the correlation between cd /p-gp and serum cya concentration a strong negative correlation was found in both examinations. the correlation was stronger in group ib (during the treatment with higher cya doses): (r=- . , p< . ) than in ic (after reduction the cya dose: (r=- . , p< . ) conclusions: the results of our studies indicate that cya in sdns inhibits the expression of p-gp. cya is an alternative therapy that may lead to optimization of glucocorticoid doses, thus reducing the risk that goes along with treatment. backround: hemolytic uremic syndrome is considered as the main cause of acute renal failure in childhood. it is characterized by microangiopathic hemolytic anemia, thrombocytopenia and acute renal failure. the epidemiology of the disease varies between counties. aim of the study: to describe demographic and epidemiologic aspects of hus, presented in a years period at the biggest children's hospital in the country. material-methods: patients aged days - years, mean age . years, ( boys, girls) were diagnosed with the syndrome. of them , . %, presented as d+ cases, with preceeded respiratory system symptoms and with no preceeded symptoms. treatment consisted of fresh frozen plasma (ffp) and whole blood transfusions in all cases. peritoneal dialysis was necessary in cases, haemodialysis in , while plasmapheresis was performed in cases. three children, all boys, suffered from recurrent type of syndrome. a girl required treatment with peritoneal dialysis for months followed by recovery of renal function. one-five years follow-up: one baby months old died, children received renal transplantation, in renal function remained mildly reduced (gfr - ml/min/ . m ) and suffered of hypertension. the rest recovered fully. summary: hus represents a rather minor public health problem with low mortality rate in greece. methods: three children with pauci-immune ln were retrospectively reviewed. results: the reported cases fulfilled the american rheumatism association criteria for sle. at admission, all had a -month history of glomerulopathy without intensive therapy. case presented with nephrotic proteinuria, macroscopic hematuria and progressively deterioration of renal function. laboratory data included a positive antineutrophil cytoplasmic antibodies (anca) on myeloperoxidase immunoassay. she was positive for lupus anticoagulant (la) but negative for anti-cardiolipin (acl) and anti-beta- glycoprotein i (β gpi) antibody. renal biopsy showed pauciimmune necrotizing and crescentic ln. case manifested with proteinuria, microhematuria and hypertension. anca was negative. case had nephrotic proteinuria, microhematuria and hypertension. the case had positive la, acl and anti-β gpi antibody. anca was negative. the biopsy findings of both case and case indicated pauci-immune mesangial proliferative ln. electronic microscopy revealed segmental and diffuse foot process effacement respectively. all three ln remitted following the treatment of steroid and immunosuppressive agents. conclusions: these atypical ln were considered to be associated with the distinct pathogenesis, rather than immune complex-mediated glomerular injuries. we supposed the possibility of ancaassociated necrotizing and crescentic glomerulonephritis for the first case. for the others, primary or secondary podocytes lesions might alter the glomerular permeability. the nephrotic syndrome is a clinical picture that characterized by proteinuria, hypoproteinemia, oedema and hyperlipidemia. although the primer nephrotic syndrome is the most common type of nephrosis in children, it may also develop during the course of infections including hepatitis b and c virus infections, whereas hepatitis a virus infection related nephrotic sendrome is very rare in children. in this paper, we present a case of who had suspected diagnosis hepatitis a virus infection related nephrotic syndrome. the boy at the age of years was referred to our hospital due to vomiting, abdominal distension and oliguria. physical examinations were revealed palpebral and tibial oedema, hepatomegaly, decreased breath sounds and mat percussion on right hemithorax. icter were not detected. laboratory examination were showed proteinuria, hyperlipidemia, hypoalbuminemia, high alt and ast levels with normal levels of bilirubin, alkaline phosphatase, complement c /c , urea and creatinine. in viral serologic examinations, hepatitis b and c related antibody were found negative, but anti-hav igm was found positive. chest radiography and ultrasonography examination were revealed right pleural effusion and abdominal ultrasonography examination was revealed ascites. based on these findings, we thought that the nephrotic syndrome could be developed due to anicteric hepatitis a virus infection in our patient. low dose steroid treatment was started (prednisolon mg/kg/day, month). edema was improved, negative urine protein was seen, and liver functions were not deteriorated during this therapy in our patient. hepatitis a virus may be cause of nephrotic syndrome by forming of immune-complexes. in conclusion, although hepatitis a virus infection is rare cause of nephrotic syndrome in children, it should be investigated as a seconder casuse. membranoproliferative glomerulonephritis (mpgn) is a rare, chronic glomerulonephritis, and its prognostic factors and outcome are not known very well in childhood. in this retrospective study, we reviewed the clinical, laboratory and histopathological features of children with primary mpgn. thirty-three children ( boys, girls) presented at a mean age of . years (range - years). they were followed for a median of months (range - months). the clinical presentation in children was nephritic-nephrotic syndrome in children ( . %), nephritic syndrome in ( . %) and nephrotic syndrome in ( . %). nine patients had renal failure at presentation. at the end of study, patients ( . %) had complete remission and patients had abnormal findings ( proteinuria, microscopic hematuria, hypertension, esrd). all of patients were treated with steroid. eight patients were given another immunosuppressant drug (cyclophosphamide , azathioprine ) in addition to steroid therapy. the interval between appearance of symptoms and admission, durations of microscopic hematuria and proteinuria, and systolic blood pressure at presentation were higher in children with abnormal findings when compared with children with complete remission. there were no significant differences in clinical presentation type or histopathological features between children with abnormal findings and children with complete remission. our results showed that delayed detection and treatment, uncontrolled hypertension and unresponsiveness to steroid in early period were poor prognosis predictors. we did not determine any correlation between histopathological findings and outcome. we need further investigations including larger patient population. partial lipodystrophy (pl) is a rare condition of unknown etiology, with childhood onset. it is characterized by progressive loss of subcutaneous fat of face, neck, trunk and upper extremities together with c hypocomplementemia. usually, patients do not have clinically evident renal disease or abnormalities until they have had the disease for or more years. but, the case we reported here, firstly presented with membranoproliferative glomerulonephritis (mpgn), and during follow-up pl was observed. a six years old girl was presented with sore throat, vomiting and loss of appetite for the last fifteen days. her development was normal and the child was asymptomatic till years of age. the parents were relatives of the third degree. there was no history of similar cases in the family. the physical examination of the patient was normal. urinalysis revealed hematuria and pyuria. proteinuria was not present. renal function tests were normal. laboratory examination revealed low serum complement c but normal serum c . the lipid profile was also normal. patient was followed with the diagnosis of poststreptococcic glomerulonephritis. because of persistent low complement c and nephrotic range proteinuria renal biopsy was performed at the rd month of follow-up. renal histology revealed mpgn consistent with type . c nephritic factor was negative. at the same time it was observed that the face took on a cadaverous look with prominent malar bones, chin and zygoma because of the loss of buccal fat. according to these findings, partial form of lipodistrophy, which is frequently associated with mpgn, was considered in the patient. during two years of follow-up she had two recurrences of nephrotic range proteinuria and she is now in remission with prednisolone therapy. as far as we know this is the first example of pl which is developed during follow-up of mpgn. central nervous system abnormalities in children with acute post-streptococcal glomerulonephritis (apsgn) are rare and are considered to be secondary to acute severe hypertension, electrolyte imbalances and uraemia. cerebral vasculitis associated with acute post-streptococcal glomerulonephritis has been rarely reported in pediatric literature. a -year-old girl with a severe headache, vomiting, edema and macroscopic heamaturia is presented. she had history of upper respiratory infection before two weeks. so, the patient was diagnosed as apsgn. on admission, she was normotensive and biocemically well balanced. two hour later, she experienced a grand mal seizure. mri examination of brain showed not only multiple areas of increased density in white and gray matter, and cerebellum but also subarachnoid bleeding, consistent with vasculitis. during follow-up, abducens nerve palsy was detected. histopathological features on renal biopsy specimen, an elevated antistreptolysin level and fallen c complement level were compatible with apsgn. all clinical and laboratory abnormalities improved with steroid therapy (pulse and oral methylprednisolon). in conclusion, children with apsgn may present central nervous system abnormalities without hypertension, uraemia and electrolyte disturbances. results: hsp was diagnosed in patients, median age years old. all had the skin manifestations, . % abdominal pain and % arthritis. patients developed hsp nephritis ( . %), mean presentation time was . months after phs diagnosis. renal biopsy was performed in patients, and the most common histopathological finding was hsp nephritis grade iii a. age of onset older than years was statistically significant for nephritis development (chi square < . ). chronic renal insufficiency incidence was . %. conclusions: the main complication of hsp is nephritis. follow-up should include evaluation by a pediatric nephrologist. age of onset older than years is an important risk factor for hsp nephritis. objectives of study: acquired abnormalities of coagulation and fibrinolysis in nephrotic syndrome have been implicated in the pathogenesis of deep vein and arterial thrombosis. resistance to activated protein c due to amutation in the gene for factor v, the commonest inherited risk factor for venous thrombosis, could contribute to risk of both arterial and deep vein in patients with nephrotic syndrome. we report an arterial thrombosis in a young girl with idiopathic membranousglomerulonephritis (mgn) and factor v leiden mutation. case report: a year-old girl was admitted to our hospital with swelling of both legs and cyanosis of her toes. her mother had history of abortion in the second trimester of gestation, and parents were second-degree relatives. physical examination showed peripheral edema in both extremities and peripheral cyanosis in toes. laboratory study showed the nephrotic range proteinuria. serum albumin was . g/dl, and cholesterol was mg/dl. creatinine, electrolytes, prothrombin/partial-thromboplastin times, c , c , fibrinogen, protein s, c, antithrombin iii and homosistein levels were within normal limits. ana, anti-dsdna, p-anca, and c-anca, antiphospholipid igg/igm, anticardiolipin igg/igm were all negative. genetic study showed the heterozygote mutation of factor v leiden (fv/g a). in arteriography, there was complete occlusion on the posterior tibiaartery of left leg, occlusion of mid portion of right femoral artery and the posterior tibia artery of right leg. renal biopsy findings werefelt to be compatible with mgn. conclusions: we postulate that patients with concurrent nephrotic syndrome and factor v leiden mutation may have an increased risk of thrombosis. screening for factor v leiden mutation may be indicated in patients with idiopathic nephrotic syndrome. introduction: hus (d+) is the nd cause of chronic renal failure (crf) in children in argentina. proteinuria is the main predictor of progression to crf. patients with renal failure, when treated with restricted proteinin take show slower progression to end-stage of rcf. proteinuria appeared in patients with hus sequelae subject to an overload of protein intake. objective: to evaluate the effect of a controlled protein intake on proteinuria in patients with renal disease due to hus and normal renal function (> ml/min/ . m ). patients and methods: within a multicenter, randomized, double blind, controlled trial, carried out inorder to study the effect of iace on the development of renal disease*, proteinuria before and after a controlled diet was measured in patients with proteinuria due to hus and normal renal function. protein intake was indicated according to rda for age. protein intake was estimated with a questionnaire on former hours, and with hrs urea excretion. proteinuria was measured in hours urine collection at the beginning of the study and at , and days after onset of the study. results: median age at onset was . months (r: . - . ); mean of length of follow-up after hus onset was . months (r: . - ). in sixty five ( , %) patients, proteinuria reduced to normal values; in the remaining ( , %) there was no change. median of initial and final proteinuria in the children whose proteinuria became normalised, was . mg/k/day (ds . ) and . (ds . ) respectively < . . conclusion: controlled protein diet (rda) normalizes proteinuria in patients with significant proteinuria secondary to hus and normal renalfunction. * a trial financed by roemmers laboratory, argentina. differential diagnosis of hematuria is the significant task of any nephrologist while most common reasons for hematuria demand histopathological diagnosis. iga-nephropathy is the progressive glomerular disease which is known to be a common reason for hematuria. the diagnosis ofiganephropathy is often missed because of variability of clinical presentations, long-term asymptomatic course and therefore waiting tactics in prescribing renal biopsy. the aim of the study was to evaluate the incidence of iga-nephropathy and to define its characteristic clinical and morphological features in children in belarus. we present results of immunohistochemical staining for iga mesangial deposition of kidney biopsy preparations. the mean age of the patients enrolled in the study was , ± , years. at the moment of biopsy patients clinically presented isolated hematuria ( %), hematuria with proteinuria ( %), nephrotic syndrom ( %), nephrotic syndrom with hematuria and hypertension ( %), isolated proteinuria ( %) and others in less than % each. iga mesangial deposition was detected using immuno histochemical staining with polyclonal rabbit anti-human iga. we found diffuse mesangial deposition of iga in patients ( % of all). two of them had nonnephrotic isolated proteinuria, one nephrotic syndrom. vast majority of patients were hematuric (either isolated or combined with proteinuria). iga nephropathy incidence among hematuric patients was %. in histopathological examination we found mild segmental mesangial hypercellularity in patients, mild to moderate global and segmental mesangial proliferation in (in two of this patients we also found cellular and fibrous crescents in less than % glomeruli). one patient had focal-segmental glomerulosclerosis secondary to diffuse mesangial proliferative glomerulonephritis and clinically presented heavy proteinuria. we analyzed nphs mutations in chilean pediatric patients with srns due to fsgs, diffuse mesangial sclerosis (dms) and minimal change disease (mcd). nphs mutation analysis was performed in patients (sporadic cases n= , familial cases n= ). nphs exons and were amplified by pcr and subjected to automatic sequencing or enzyme restriction analysis using clai (c. g>a) and hin i (c. c>t) respectively. patients median age at disease onset was months (range , % of which were male. histological diagnosis were fsgs (n= ), dms (n= ) and mcd (n= ). ten of patients ( . %) had mutations in nphs ( / fsgs, / dms, / mcd). eight of patients bearing mutations were sporadic cases. seven patients were compound heterozygous for r q and a v. patients with mutations were significantly older than those without mutations (median age versus months, p< . ). resistance to cyclosporin was observed in of cases with mutations and of cases without mutations (ns). we studied the frequency of r q and a v in healthy volunteers with similar ethnic background. only one control individual was heterozygous for r q. no a v mutation was detected. our study demonstrated that nphs mutations are a major cause of srns in chilean pediatric patients. since most of the srns patients bearing nphs mutations were cyclosporin resistant, it is advisable to perform nphs mutation screening before starting immunosuppressives. in this study we aimed to investigate the long-term prognosis of henoch-schönlein nephritis (hsn) in childhood. between and , patients with hsn were investigated retrospectively. there were males and females with a mean age of . years. they were graded according to the degree of renal involvement. grade : isolated microscopic hematuria (n: ); grade : hematuria and mild proteinuria (n: ); grade : acute nephritic syndrome (n: ); grade : nephrotic syndrome/hematuria (n: ); grade : acute nephritic and nephrotic syndrome (n: ). renal biopsy was performed on patients in grade and . twenty patients had extensive crescent formation (> %) on renal biopsy, and were given triple therapy [iv pulse methylprednisolone (mpz) mg/kg/d for days, followed by oral prednisolone (op), oral cyclophosphamide- mg/kg/day for - months and dipyridamole]. the other patients with < % crescent formation were given mpz followed by op and dipyridamole. the patients in grade and were given op and dipyridamole. grade and were not given any immunosupressive agent. during the follow-up period (mean ± . ; range - months), patients in grade , patients in grade , patients in grade , patients in grade and patients in grade showed complete remission ( %). of the patients with extensive fibrosis on renal biopsy, had persistent nephropathy ( %) and developed endstage renal failure ( %). the remaining patients showed near-complete recovery with minimal urinary abnormalities ( %). in conclusion, although initial presentation of renal involvement determines the prognosis in hsn, intensive treatment with triple therapy appears to be effective in severe renal disease especially if started before the development of fibrotic changes in crescents and tubulointerstitial tissue. aim: the bacterial infection in nephrotic syndrome (ns) is still the big problem and is one of the leading death causes in ho chi minh city, vietnam. we did this study with aims to overview this complication in children with ns. methods: our study population consisted of children with nephrotic syndrome during one-year prospective cohort. twenty seven out of patients who developed severe bacterial infection including pneumonia, peritonitis, urinary tract infection, bacteremia or cellulitis were recorded. results: from june to june , there were children with nephrotic syndrome recruited to the study. the severe bacterial infection stood at . % (n= ). in these children, children were first ns, children were relapsing ns. the percentages of pneumonia, urinary tract infection, cellular infection and peritonitis were . % (n= ), . % (n= ), % (n= ) and . % (n= ), respectively. no patients with bacteremia were recorded. in patients with uti, e.coli wasin patients, proteus in and enterococus in . ns children with uti were asymptomatic. ns children with peritonitis had typically clinical manifestations of fever, abdominal pain, tenderness. one out of four patients with peritonitis cultured streptococcus pneumoniae inperitoneal fluid. some factors associated with severe bacterial infection were increase in weight ( . vs . %, p= . ), very low serum albumin ( . vs g/l; p= . ), rise in serum a globulin level ( . % vs . %; p= . ) and hyperfibrinogenemia ( . vs . g/l; p= . ). conclusions: bacterial infection has still been a common problem in children with nsin ho chi minh vietnam. it is important to investigate and manage this complication early to reduce mortality rate. primary nephrotic syndrome (ns) is the most common glomerular disease in children which mainly responds to corticosteroids. however, > % of children experience a relapse with recurrent episodes. the aim was investigation of outcome in ns patients, retrospectively. clinical, histological data and treatment responses of children presenting with ns from to were reviewed. all patients were treated with steroid treatment firstly and classified as steroid sensitive ns (ssns) and steroid resistant ns (srns) according to clinical or laboratory responses. there were patients, male and female, had followed-up for . ± . months. age at onset ranged from - (median ) months. seven patients were admitted with hematuria and ns ( mpgn, mgn) that excluded from this study. patients were treated by only classical steroid treatment. thus, ( . %) patients were ssns and classical steroid therapy was successful in this group. of all ssns patients were evaluated with biopsy ( fsgs, dmp) because of frequently recurrent ns. in srns group ( patients) with one cytotoxic agent, complete and stable remission was induced in patients ( in fsgs, in mlh, in dmp) while patients ( in fsgs) who responded to more than one cytotoxic agents had partial remission with symptomatic relief. five children ( in fsgs) were refractory to all cytotoxic therapies. cyclophosphamide (cp) was used as the first cytotoxic agent in patients and induced complete remission in ( . %). the patients who relapsed following cp and patients who failed to respond were treated with further cytotoxic therapies such as cyclosporine a (cs) or mmf. in patients, cs was used as the first cytotoxic agent and induced remission in patients ( . %). steroid must be the initial drug in childhood ns. cp could be used successfully as an immunosuppressive agent in srns patients. aim: annexin v has a molecular weight of - kda and has been reported to possess anticoagulant activity, inhibition of phospholipase a , regulation of membrane transport, proliferation and signal transduction. it is reported that urinary annexin v concentration may be an indicator of apoptosis and acute renal injury related to the urinary protein level. the aim of this study is to define the role of urinary annexin v, serum annexin v concentrations as new prognostic tools and follow criteria in children with steroid sensitive and resistant ns. methods: annexin v concentrations were measured in serum and hour urine samples in steroid sensitive nephrotic syndrome (ns) patients in both relaps and remission periods (group and respectively) and in steroid-resistant ns (group ) and sex and age matched healthy controls (group ). total protein, albumin, cholesterol concentrations and hour urinary excretion of protein and creatinine were measured in all groups. results: in steroid resistant ns group (group ), median of urinary annexin v/creatinine ratio was significantly higher than all the other groups ( . ng/g creatinine (min-max: . - . ) vs . ng/g creatinine (min-max: . - . ) in group (p: . ); . ng/g creatinine (min-max: . - . ) in group (p: . ), and . ng/g creatinine (min-max: . - . ) in group (p: . )). serum annexin v concentration was significantly higher in group (median . ng/ml) than in group (median . ). no significant correlation was found between urinary protein excretion and urinary annexin v/creatinine ratio. conclusion: remarkably increased urinary annexin v/creatinine ratio could be used as a determinant factor in children with steroid resistant ns, and it may be a prognostic factor in these children. v. baudouin , f. bernaudin , a. garnier , t. kwon , m. peuchmaur , g. deschenes , c. loirat hôpital robert debré-aphp, service de néphrologie pédiatrique, paris, france chic, service de pédiatrie, créteil, france cgvhd is the most common late complication of hsct. clinical manifestations mimic lupus disease but renal involvement is unusual. a year-old boy underwent hsct from an hla-identical sibling donor for sickle cell disease. he received myeloablative therapy (cyclophosphamide, busulfan, antithymocyte globulin). prophylaxis of acute gvh consisted in prednisone and mmf until month . moderate skin and mucosa cgvh appeared at month so that prednisone and mmf were restarted. at month prednisone was stopped and mmf decreased to half dose. at year, while clinical features of cgvh intensified, fortuitous diagnosis of ns was done. glomerular filtration rate and blood pressure were normal. biopsy showed membranous glomerulonephritis and mesangial hypercellularity. immunofluorescence confirmed granular immune deposits of igg and c treatment consisted in prednisone ( . mg/kg/d for month, progressively tapered to . mg/kg/e.o.d at month ) and cyclosporine ( mg/kg/d, trough levels - ng/ml). proteinuria decreased to < . g/l in months. cyclosporine was progressively stopped between month and without relapse of proteinuria. ns associated with cgvhd had been reported in about patients ( patients < yr-old). retrospective studies estimate occurrence around % of patients with cgvhd. it was secondary to membranous glomerulonephritis in % of cases, minimal changes disease in %. strengthening of immunosuppression led to complete remission in % of patients with minimal changes disease and % of those with membranous glomerulonephritis ( % partial remission). usual treatment consisted in prednisone ( %) and cyclosporine ( %). this manifestation of cgvhd is probably underestimated and can occur at the same time or later than other clinical features. early detection of proteinuria in patients with cgvhd is recommended to adapt immunosuppressive treatment. objectives: to see if cyclosporine a (csa) is safe and effective in reducing proteinuria in children with the iga nephropathy (igan) or the henoch-schoenlein purpura nephritis (hspn). methods: the biopsy proven patients ( with igan, with hspn) who showed increased proteinuria (> +) for longer than months were included. the blood level of csa, serum chemistries, urine analysis and complete blood cell counts were carried out every other month along with the physical exams. results: csa was given at an amount of . . mg/kg/day for . . months in average. complete remission of proteinuria in ( . %) and partial remission in ( . %) were achieved by csa treatment. five ( . %) non-responders were discontinued for csa treatment in the middle of the trial. the ration of urine protein to creatinine was initially . . and reduced gradually with time to . . , . . , . . at , , months after csa treatment, respectively. twenty eight patients showed hypertrichosis, three experienced transient elevation of serum creatinine, and two complained difficulties in taking the medication due to severe nausea. for . months after completion of the csa treatment, patients redeveloped proteinuria and had to receive the nd csa trial. no clear difference was observed in the pharmacokinetic profiles of csa attributable to the non-response or recurrence. follow-up renal biopsies were carried out in patients after completion of the csa therapy and no csa toxicity was found. there was no alteration of linear growth pattern. conclusions: this study has a limitation of lacking the control group but the csa treatment is assumed to be very effective and a safe method to attain the remission of proteinuria in pediatric patients with the igan or hspn. j. madrigal , e. fernandez , p. noguera , p. carranza the aim of this retrospective study was : ) to correlate the histopathological diagnosis with steroid response,persistent hematuria, hypertension and or abnormal renal function tests (gfr) ) to evaluate the response of the patients with srns and sdns to the oral cytotoxic drugs , in a period of consecutive years. ) to correlate the response of this group of patients to the oral cytotoxic drugs with their histopathological diagnosis ) to observe the incidence of fsgs in costarrican children during a period of years. ) based on these observations, reevaluate the indications of the kidney biopsy in our patients . we reviewed all the clinical records of patients with the diagnosis of ns and in whom a kidney biopsy have been done. patients with incomplete data were excluded. two consecutive reviews were made: the first included all patients diagnosed between january and december (group a) and the second, between january and december (group b). a total of medical records were analyzed; patients were excluded, and the remaining were studied. results: all patients had been referred for edema or new onset nephrotic syndrome before treatment had been initiated. in our patients the steroid response was also the most important factor to predict the histological diagnosis and the response to the treatment with cytotoxics. the presence of hematuria and abnormal serum creatinine at the time of diagnosis were a predictive factor for the steroid response but not for the histological diagnosis. arterial hypertension achieved statistical significance only between mcns and fsgs but it was useful as a predictive factor for the hystological. in our group of patients with srns treated with cytotoxics, . % with mcns responded, versus . % of the patients with dmgn p< , . a. guersoni, v. mello, v. benini, s. laranjo children with srns are exposed to prolonged and high doses of steroid therapy and other immunosupressants that can lead to a variety of serious side effects. these include statural growth impairment, obesity, osteoporosis, cataract, hypertricosis and psychological disturbances.we carried out a prospective single-center study to evaluate the efficacy of mycophenolate in children with steroid-resistant disease, female and male, aged . ± . years. histological findings were: minimal change disease (mcd) in children, focal segmental glomerulosclerosis (fsgs) in and membranous nephropathy in one. all patients had been treated with at least one course of cyclophosphamide, metil-prednisolone in , while had also been treated with cyclosporine before mmf. the initial dose of mmf was mg/m per day, together with a minimal reduction dose of corticosteroids associated with angiotensin ii receptor blockers (arbs) and sinvastatin.three patients went into complete remission, into partial remission and showed no remission. partial remission was described as loss of edema and improvement in symptoms, despite persistence of significant but improved proteinuria, that was classified either as moderate or low proteinuria according to the level. side effects were: diarrhea (n= ), neutropenia (n= ), infectious disease (n= ). mmf is an important new therapeutic option when associated with angiotensin ii receptor blockers (arbs) and sinvastatin for srns with mcd or fsgs, providing improvement in edema and symptoms despite persistence of proteinuria, with no compromise of physical appearance or risk of nephrotoxicity. background: primary focal segmental glomerulosclerosis (fsgs) that is resistant to steroids and other immunosuppressive agents has a guarded long-term prognosis. patients who fail to respond to current treatment may benefit from therapies that inhibit renal fibrosis and retard progressive loss of kidney function. objective: the font study (novel therapies in resistant fsgs) is a phase i clinical trial designed to test the safety, tolerability, and pharmacokinetics (pk) of novel agents that reduce renal fibrosis in patients with resistant fsgs. methods: patients, age - yr and egfr > ml/min/ . m , with resistant fsgs who fail treatment in the nih supported trial evaluating cyclosporine vs. dexamethasone plus mycophenolate mofetil or who are screen failures due to prior exposure to these drugs are eligible. patients are assigned to receive rosiglitazone mg/m per day po or adalimumab mg/m every other wk sc. the treatment phase is wk and patients undergo an initial (wk ) and steady state (wk ) pk assessment. results: patients have been screened and have been randomized to each test therapy. patients have completed rosiglitazone therapy and have completed adalimumab. four serious adverse events have occurred in patients receiving rosiglitazone, none related to the study drug. fatigue ( %), gastrointestinal complaints ( %), and headache ( %) were the most common adverse events in patients given rosiglitazone. the outcomes in the adalimumab group have not been analyzed. conclusion: these preliminary results indicate the feasibility of performing phase i assessments of novel agents that can target renal fibrosis in patients with resistant fsgs. the findings will be used to design phase ii randomized clinical trials in this cohort of patients at high risk of progression to end stage renal disease. supported by grant niddk r . object: to study the effect of fty on glomerulosclerosis and expression of cell cycle regulatory proteins in subtotal nephrectomized rats. methods: rat were divided into sham-operation group, glomerulosclerosis model group and fty treated glomerulosclerosis group, rats in each groups. the rats in later two groups were subjected to / nephrectomy. after operation, the treat group was fed with fty for weeks. the expression of collagen, fibronectin, and cycline, p , p were determined by immunohistochemistry methods. results: after treatment with fty , up began to decrease from w after operation, significantly lower than in model group (p< . ). the model group showed higher level of scr from w, which was much higher than in control group (p< . ). in fty treated group, scr level were much lower than in model group. fty could obviously inhibit the expressionof col-and fn in glomeruli and attenuate the extent of glomerulosclerosis. moreover, fty could upregulate glomerular expression of p and downregulate glomerular expression of p and cycline. the expression levels of p and cycline were significantly lower in treatment group than in model group (p< . ), but still higher than in control group (p< . ). p expression in glomeruli was stronger in treatment group than in model group (p< . ), and lower than in normal group but without significant statistic difference. conclusion: fty can diminish urine protein excretion and prevent glomerulosclerosis in subtotal nephrectomized rats. this protective effect is presumed to be associated with its role in downregulation of cycline expression and upregulation of p expression in glomerular cells, and inhibition of extracellular matrix accumulation in glomeruli. the authors illustrate severe side effect of steroid therapy ulcerative gastroduodenitis-and rare complication (multiple cerebral thrombo-embolism) in the case of a year old girl with steroid resistent nephrosis. in childhood occurence of thrombosis in steroid sensitive nephrosis syndrome is . %, while it comes up to . % in steroid resistant cases. on admittance she presented the classic symptoms of nephrotic syndrome. one month after the initiation of steroid therapy haematemesis, melaena occurred, and after appropriate therapy was cured. due to the progression of the nephrotic syndrome, steroid shot and later immunesuppressive therapy was started. eight weeks after onset she became unconscious for a shortwhile and had a transient episode of right hemiparesis. at the same time ct and mri disclosed bilateral parieto occipital ischemic territorial vascluar lesions, with relative sparing of the cortical ribbbon. following icu observation her state rapidly improved and after a two week period she became free of symptoms. renal biopsy disclosed the pattern of minimal change nephrosis with diffuse mesangial hypercellularity and a slight amount of igm positivity. immunological evaluation-with the capacitiy to reveal systemic immunological diseases remained negative. having been put on an evidence based protocol the patient's present nephrological state was unremarkable, with proteinuria less then g/day. in the present work the authors discuss the factors predisposing to thrombo-embolism with special emphasis on the possible preventive measures and therapy. igg autoantibodies to c q (antic q) have been reported to play a pathogenic role in immunecomplex mediated diseases (sle, apsgn, membranoproliferative gn, etc). the occurrence of antic q in adult patients with sle has been shown to correlate with disease activity and some immunological parameters (hypocomplementemia, anti-dsdna) and may be useful in the early diagnosis of lupus nephritis (ln) or even as a predictor of renal flares. the presence of antic q in children with apsgn was associated with more severe disease manifestations and a lack of spontaneous recovery. associations between antic q, c and c complement levels and disease manifestations in children with gn were investigated and compared with healthy controls. antic q were measured by elisa and c and c by immunoturbidimetry, respectively. of patients with gn were positive for antic q compared to / healthy controls. antic q were associated with active ln and hypocomplementemia: / patients with sle were found to be antic q-positive. nine of these had active renal disease at the time of blood sampling compared to / being antic q-negative. / antic q-positive patients had low c level and / had low c level. in children with apsgn, / were positive for antic q. antic q positive patients had significantly higher proteinuria, more often hypertension and c -hypocomplementemia. all patients in which apsgn did not resolve spontaneously were antic q-positive. antic q were associated with active nephritis and hypocomplementemia in patients with sle. in children with apsgn antic q-positive patients have more severe disease and stronger c -hypocomplementemia then those being antic q-negative. m. zahrane , l. fawaz , l. nesseim cairo university hospital, pediatric nephrology, cairo, egypt cairo university hospital, pediatrics, cairo, egypt cairo university hospital, cell pathology, cairo, egypt objective of the study: growth hormone (gh) and insulin-like growth factors are essential for normal growth and development. chronic renal failure (crf) results in major changes in the circulating growth hormone/insulin-like growth factor (igf) system. our aim is to study clinical and laboratory parameters of growth and osteodystrophy including igf and igfbp as part of the somatotropic hormone axis in egyptian children suffering from crf on conservative therapy. methods: egyptian children ( boys and girls) with a mean age of . y ( . to . y) suffering from crf on conservative therapy and controls were included in the study. ht, wt and tsf were measured and followed up for a period of months. at the end of the follow-up period serum for igf and igfbp , renal function, electrolytes, ca, p and alkaline phosphatase and acid base balance were measured and an x-ray of the left hand and wrist was done to determine their bone age by tanner and whitehouse. results: our study shows that children suffering from crf in egypt on conservative therapy have growth retardation with a mean ht of . sds, a mean wt of - . sds. tsf mean was - . sds. on the average the patients had a delay of . y (± . ) in their bone age. their height was retarded more than their bone age with a height age/bone age of . (± . ). alkaline phosphatase as a markers of renal osteodystrophy is significantly correlated to the height, height age, bone age and to the ph. the mean igf sds (- . ± . ) did not differ from that of controls while the mean igfbp sds ( . ± . ) was significantly higher in patients with crf than in controls. height and weight were significantly correlated to igf but not igfbp . there is a significant correlation between igfbp level and the glomerular filtration rate. conclusions: the imbalance between normal insulin-like growth factor-i (igf-i) and markedly increased igfbp plasma levels plays a pathogenic role for growth retardation in children with chronic renal failure. the lower the gfr the higher the igfbp level. the latters inhibitory action may provide hope for improving growth in cases of crf by reducing the level of igfbp or displacing igf from it. s. sultana , h. rahman , m. hossain bangladesh medical college, pediatric department, dhaka, uttara, bangladesh bangabandu sheikh mujib medical university, pediatric nephrology, dhaka, bangladesh objective: to find out the impact of different etiology of chronic renal failure on growth in children. methods: this prospective study was carried out in the department of pediatrics, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh, from october to october . fifty children of both sexes under years of age with clinical and biochemical evidence of chronic renal failure (crf) with creatinine clearance (ccr) of < ml/min/ . m were included in the study. on the basis of underlying causes of crf, the children were divided into congenital (n= ) and acquired (n= ) groups. all patient's height and weight were measured. radiographs of hands, digits, ankle and knee joints, lumbar spine & skull were obtained to evaluate the presence of renal osteodystophy (rod) and for assessment of bone age. serum intact parathormone (ipth) level was also assayed in all patients. growth parameters and presence of radiographic and biochemical features were evaluated in two groups. results: crf children due to congenital anomalies had stunting and wasting in ( . %) and ( . %) cases respectively and the difference between two groups of crf patients was highly significant (p< . ). alkaline phosphatase ( . ± . u/l) and ipth ( . ± . pg/ml) were also significantly higher than acquired group (p< . and p< . respectively). radiographic features of rod were present in ( %) cases in congenital group in comparison to ( %) in acquired group and the growth zone lesion was the commonest type of rod in congenital group ( . %). conclusion: all efforts should be made to diagnose the presence of crf as early as possible, especially in infants and in children with early onset crf who seem to lose growth potential. introduction: in patients with thalassemia major the most important cause of morbidity and mortality is organ failure due to iron deposits, desferioxamine toxicity and anemia. this study was designed to define renal abnormalities associated with thalassemia and to find early marker (markers) of renal dysfunction. patients & method: thlassemic children ( female and male) with mean age of . ± . yr. were studied. all of them were received desforioxamine. age and sex matched healthy children were involved in the study. blood and timed urine sample were obtained for hematologic and biochemical tests. the results were compared between case and control group. results: mean value of bun, serum creatinine, creatinine clearance, serum electrolytes, urine osmolality, fractional excretion of sodium and potassium were not statistically different between two groups. level of urinary nag (n-acetyle-beta-d-glycosaminidase) was significantly higher in patients than in controls (p: . ). there was a positive relation between urinary nag and duration of disease (p: . ). the was no statistically significant relation between urinary nag and serum ferritin. tubular function was not altered by hypertransfusion. conclusion: proximal tubular dysfunction is found in thalassemic patients. measuring urinary nag can guide the physician to find the early tubular abnormality in patients without frank renal dysfunction. severity of the abnormalities is correlated with the duration of disease. the present study aimed to investigate the effects of isolated ma and ma associated with mild renal function impairment on fracture healing in rats. ma was induced by chronic ingestion of % ammonium chloride solution as the unique source of liquid and renal dysfunction was produced by unilateral nephrectomy. thirty male holtzman rats ( - g) were divided into six groups: control group (c,n= ) non-operated rats receiving tap water, acidotic group (ac,n= ) non-operated rats ingesting % ammonium chloride; sham water (s,n= ) sham-operated animals receiving tap water; sham acidotic (sac,n= ) sham-operated rats ingesting % ammonium chloride; nephrectomy water (n,n= ) nephrectomized rats ingesting tap water; and nephrectomy acidotic (nac,n= ) nephrectomized rats ingesting % ammonium chloride. after one week, blood samples were obtained to measure ph and gases, and a fracture of the right tibia was manually produced. four weeks later, fracture healing was evaluated by radiological and histological parameters. blood ph and gases, serum electrolytes and creatinine were also determined. data were compared by anova followed by newman keuls or fisher's exact test. fracture healing in nac, ac, sac animals was significantly altered as compared to c group. there was an additive effect of metabolic acidosis and unilateral nephrectomy in fracture healing process as shown by the comparison of sac and ac rats using radiological and histomorphometrical parameters. there was no difference between electrolytes and creatinine levels in all groups at the end of the experiment. this study showed a higher frequency of delayed fracture healing and nonunion in the presence of ma, which is worsened by unilateral nephrectomy. our data indicated an important interaction between bone and kidney in acid base homeostasis. introduction: dent disease, an x-linked recessive tubulopathy, is historically characterized by lowmolecular weight proteinuria, hypercalciuria, nephrocalcinosis/lithiasis and slowly progressive renal failure. most cases are caused by mutations in the clcn gene (dent disease , omim # ), some patients with dent like phenotype have defects in the lowe syndrome gene ocrl (dent disease , omim # ). patients: male patients from families with urinary findings resembling dent disease are reported. in patients, mutations in the clcn gene were found, in patients ocrl mutations. all children have increased values of urinary alpha- -microglobuline, but also unselective glomerular proteinuria. / have mild hypercalciuria, / demonstrate mild renal insufficiency. amost all patients have increased echogenicity of renal parenchyma, but mild medullary hyperechogenicity is found only in of patients. metabolic acidosis or renal phosphate wasting is not found. interestingly, of children have increased values of creatinine kinase of unknown origin, clinically asymptomatic and independant of clcn or ocrl mutations. conclusion: the phenotype and genotype of dent disease is very heterogeneous. diagnostic criteria of dent disease and of lowe syndrome should be discussed. e. sahpazova, d. kuzmanovska, l. spirevska, n. ristoska bojkovska pediatric clinic, nephrology, skopje, macedoniathe nutritional condition of children ( males and females) mean age . ± . (range - years) with moderate renal failure have been followed for three year. glomerular filtration rate (gfr) was measured by creatinine clearance calculated with schwartz formula and was ranged from . to ml/min per . m . the nutritional condition was determined by anthropometrics and nutritional measurements. the patients were divided in four groups depending of their protein intake, primary disease, ages and glomerular filtration rate. all patients were following an -ad libidum -diet. nutritional intake was determined by minimum of two -day prospective dietary diaries. % of children received significantly lower protein intake. the mean protein intake (% of who recommendation) determined by dietaries of patients with -sub-optimal intake -was . % vs. . % in patients with -adequate protein intake -(p< . ). all patients have a calorie intake of at least % of the who recommendations. the relative distribution of calories was . % from proteins, . % from carbohydrates and . % from lipids. nitrogen balance in patients was positive and correlated most significantly with increasing energy intake (r= . ). average values for height, weight, triceps skin fold, mid-arm muscle circumference, and body mass index were within sd of the mean of the normal population. the protein intake, primary disease and age of the children did not have any effect on growth and development. only patients with more advanced renal disease showed small score for height and growth velocity. key words: chronic renal failure; uremic children; nutritional status; nutritional intake; u. aslanova , t. morimoto , e. farajov , n. kumagai , n. sugawara , a. ohsaga , y. maruyama , s. tsuchiya , s. takahashi , y. kondo tohoku university, pediatrics, sendai, japan tohoku university, medical informatics, sendai, japan tohoku university, physiology, sendai, japan nihon university school of medicine, pediatrics, tokyo, japan the extracellular calcium-sensing receptor (casr) located in either luminal or basolateral cell membranes of various types of renal tubules including proximal tubules, henle's loop and collecting ducts has been thought to play a fundamental role in electrolyte metabolism. to further identify the physiological roles of the casr, we examined the effects of ca + and calcimimetics neomycin (neo), gentamicin and gadolinium chloride gd + on the intracellular ph (phi) of in vitro microperfused mouse medullary thick ascending limb (mtal) cells of henle's loop, by loading the cells with fluorescent ph indicator ', '-bis-( -carboxyethyl)- -(and- )-carboxyfluorescein and measuring the ratio of fluorescence emission at nm after exciting the dye at and nm. in a steady-state condition in hepes-buffered solution, the phi in the mtals was . ± . (n= ). a concentration of micromol/l neo in the basolateral side decreased the phi after min by - . ± . (n= , p< . ). the other calcimimetics showed similar effects on phi, whereas none of these calcimimetics in the lumen affected phi. na + removal or the inhibition of na + and proton transport with amiloride, bumetanide, or bafilomycin did not eliminate the effect of neo on phi. on the other hand, clremoval clearly eliminated the neo-induced phi decrease (- . ± . vs - . ± . in clremoval, n= , p< . ). thus, we have demonstrated for the first time that the casr is involved in the regulation of the phi in the mtal and requires clto exert its effect. background: paediatric nephrologists are often consulted for atypical rickets of renal or non-renal origin. the comeback of vitamin d deficient (classical) rickets in armenia and elsewhere is not only a public health problem but also a new diagnostic challenge for nephrologists. the aim is to analyse all paediatric patients seen in with bone deformities and suspected rickets at the arabkir hospital in yerevan. patients and methods: patients with bone deformities came spontaneously or were referred by one of us (gk). routine serum chemistry was done in yerevan. further investigations, if needed, and urine chemistry were performed in zurich. patients with rickets due to renal insufficiency were excluded. results: in we have seen patients ( males) with rachitic bone deformities aged - months (mean ± . ) at diagnosis. of these, patients had florid vitamin d deficient rickets and had sequelae of rickets but were radiologically and biochemically cured. these children with classical rickets had to be distinguished from patients with other forms of rickets: x-linked hypophosphataemia (xlh; ), vitamin d dependant rickets type ( ), and renal fanconi syndrome ( ) due to fanconi-bickel syndrome and idiopathic. conclusions: (i) the rising number of vitamin d deficient rickets is of concern and due to neglected prophylaxis, (ii) children with classical rickets came late and were in the same age range as patients with atypical rickets, (iii) hence, and because of the larger number of rachitic children, an increased awareness of nephrologists -including a full diagnostic work-up -is needed in order not to overlook rare forms of rickets, (iv) polar vitamin d metabolites should not be used before the precise type of rickets is known. b. spasojevic-dimitrijeva, m. kostic, a. peco-antic, d. kruscic, d. paripovic, m. stanic university children's hospital, nephrology department, belgrade, serbia t. porowski , w. zoch-zwierz , j. konstantynowicz , k. taranta-janusz medical university of bialystok, st department of pediatrics, bialystok, poland medical university of bialystok, department of pediatrics and auxology, bialystok, poland there are no published data on calcium oxalate (caox) crystallization and therewith associated kidney stone disease in children. the aim of this study was to determine bonn risk index (bri) in children with urolithiasis in relation to healthy age-and sex-matched controls and to assess possible associations between bri values and the size of renal stones. methods. in this cross-sectional study, we compared bri in caucasian children and adolescents ( girls, boys) aged - years (median: . ) in whom kidney stones were newly diagnosed and healthy age-and sex-matched controls ( girls, boys) without urolithiasis. urinary ionized calcium [ca + ] was measured using a selective electrode, while the onset of the spontaneous crystallization was determined using a photometer and titrating with mmol/l ammonium oxalate (ox ). the calculation of bri value was based on [ca + ] to (ox ) ratio. high resolution renal ultrasonography was done to estimate the size of renal stones. results. our results showed that bri values in children with renal stones were greater compared with healthy children without stones. bri was -fold greater, bri/kg body weight - -fold greater, bri/per . m b. s. - -fold, whereas bri/bmi was even -fold greater in cases with stones than in controls. no significant association was observed between bri and the size of stones. interpretation. children with kidney stones demonstrate increased bone risk index compared with healthy subjects without urolithiasis. an increased bri during growth, although unrelated to renal stone size reflects the risk for crystallization of calcium oxalate and may suggest early metabolic disorders leading to urolithiasis. this simple method appears to be accurate and cost-effective, thus bri may be widely used for discrimination between stone-formers and healthy children. m. dixit, n. dixit florida children's hospital, florida children's kidney center, orlando, united states acute tubulo-interstitial nephritis (atin) is an important cause of acute renal failure resulting from a variety of insults including rare immune complex-mediated tubulo-interstitial injury. drugs including non-steroidal anti-inflammatory drugs (nsaids) are far most frequent cause of atin, but overall as an entity it remains under-diagnosed as symptoms resolve spontaneously if the medication is stopped. we present a -year-old male who developed acute renal failure weeks after aortic valve surgery. he was put on aspirin following surgery and took ibuprofen for fever for nearly a week prior to presentation. he then presented to the emergency department feeling quite ill and was found to have bun of mg/dl, creatinine of . mg/dl and serum potassium of . meq/l. dialysis therapy was immediately initiated. a kidney biopsy showed inflammatory infiltrate consistent with atin. however, very intense tubular basement membrane (tbm) granular deposits of polyclonal igg and c were noted. he needed dialysis for nearly two weeks and was treated successfully with steroids. his renal recovery and disappearance proteinuria took almost a year. in conclusion, we present an unusual case of tbm immune complex-mediated atin due to nsaids with severe but reversible renal failure. the effect of corticosteroid therapy on bone metabolism in nephrotic syndrome background: nephropathic cystinosis is characterised by lysosomal cystine accumulation leading to generalized fanconi syndrome. defective tubular reabsorption of proteins, mainly by the multi ligand receptors megalin and cubilin, is considered to be the cause of proteinuria in cystinosis. whether increased glomerular permeability contributes to proteinuria in cystinosis is investigated in this study by evaluating ) urinary protein pattern in cystinotic patients and healthy controls ) expression of megalin, cubilin and their ligands transferrin, albumin, a -microglobulin (a m) and b -microglobulin (b m) in renal tissue. methods: urine of cystinotic patients and controls (n= ), aged - , were immunoblotted using antibodies against megalin, cubilin, transferrin, albumin, a m and b m. additionally, urinary levels of igg, albumin, a m and creatinine were measured. results are expressed as mg/mmol creatinine (median, range). presence of proteins in semithin paraffin sections from cystinotic and control kidneys was evaluated using antibodies mentioned before. results: cystinotic patients had increased urinary excretion of , p < ) and all tested ligands of megalin and cubilin. immuno histochemistry showed comparable expression of megalin, cubilin and their ligands in convoluted proximal tubules (pt), while the ligands in straight pt were only present in cystinotic patients. conclusion: a selective proteinuria with high molecular weight protein excretion such as igg indicates increased permeability of glomerular filtration barrier in cystinosis already at an early age. the presence of the megalin and cubilin ligands in endocytic vesicles suggests functional endocytosis. however, the enhanced staining of the ligands in cystinotic straight pt may be a result of incomplete reabsorption in convoluted pt. background: dent's disease and lowe syndrome are the most frequent x-linked tubulopathies. dent's is characterized by lmw proteinuria, hypercalciuria and nephrocalcinosis. in ca. %, this phenotype results from mutations in the clcn -gene. lowe syndrome (congenital cataract, mental retardation and generalized fanconi syndrome) is due to mutations in the ocrl gene. stunted growth is another typical finding in lowe patients. recently, in a subgroup of dent patients ocrl gene mutations have been demonstrated (dent- disease). aim of the study: comparison of the growth pattern of patients with clcn and ocrl mutations. patients: boys with proven mutations in clcn (n= , mean age . ± yrs) were compared with those with dent- disease (n= , ± yrs) and those with ocrl mutations and a lowe phenotype (n= , . ± . yrs). comparison of z-scores for height, weightand bmi. results: clcn positive boys had a significantly higher height-sds (- . ± . ) than ocrl positives (dent- : - . ± . /lowe: - . ± . ). there were no significant differences in bmi-sds and weight-sds. the difference between weight and height sds as a parameter for obesity in these small-statured children was higher in lowe than in classical dent patients, with intermediate values being found in dent- . discussion: although the renal phenotype of dent- patients is identical with classical dent, the former are more stunted. therefore, the abnormal growth pattern in dent- patients cannot be ascribed to renal dysfunction. taken together with other findings (elevated ck and ldh, mild mental retardation) our findings illustrate that dent- is indeed a mild variant of classical lowe syndrome. quantitative ultrasonometry of the calcaneus in children with idiopathic hypercalciuria lesch-nyhan syndrome is a very rare x-linked recessive disorder characterized by mental retardation, spasticity resembling cerebral palsy, choreoathetosis, self-mutilation and hyperuricemia. self-mutilation behavior is a hallmark of the disease. hyperuricemia leads to hyperuricuria and uric acid nephrolithiasis. we report on a -year-old boy with lesch-nyhan syndrome with no self-mutilation behavior who was erroneously diagnosed as having athetotic cerebral palsy. besides, he had no renal stones, the only renal abnormality detected were hyperechoic renal medullary pyramids, sonographicaly indistinguishable from medullary nephrocalcinosis. bone disease is frequently observed in children with homozygous beta-thalassemia (thal). we have observed an increased prevalence of renal stones in these patients. in order to understand the cause of this predisposition to renal stone formation we investigated markers of bone metabolism in our thal children. we studied thal children (age range - years; females and males) with no eviodence of renal stones. thal was diagnosed with haemoglobin hplc study and genetic typing. all received blood transfusion and iron chelants on a regular schedule. serum levels of pth, osteocalcin, telopeptide c-terminale (cross-laps) were determined with eclia technique; serum vitamin d ( ohd ) with elisa technique. serum calcium, phosphate, uric acid, bicarbonate, creatinine, alkalin phosphatase and sodium, calcium, oxalate, citrate and creatinine in hours and fasting urine were determined with common methods. as controls we studied children with comparable age. serum pth and vitamin d were increased in % of our patients, serum osteocalcin in % and telopeptide c-terminale (cross-laps) in %. hypercalciuria was observed in %, hyperoxaluria in % hypocitraturia in %. significant correlation were found between pth and osteocalcin (p< . ) cau/cru (p< . ); osteocalcin and cross-laps (p< . ) and vit d and cau/cru (p< . ). bone disruption due to bone marrow expansion may produce an increase in vit d and pth production with hypercalciuria producing renal stones. losartan is an angiotensin ii subtype (at ) receptor antagonist used for controlling blood pressure and urinary protein excretion in patients with hypertension and chronic renal disease. there are a few reports about the clinical implications of at- receptor antagonism that may interfere with the kidney's defense against an acid load and may thereby exacerbate metabolic acidosis in the literature. the suggested mechanism is that at- blockade by losartan exacerbates acidosis by inducing a distal-tubular acidification defect.we observed metabolic acidosis and hyperkalemia in five patients ( females/ males, age ranged - years) whom were given losartan. during the second week of the therapy all patients revealed a metabolic acidosis with (ph; ranged , to , and hco ; ranged , to mmol/l) hiperkalemia (ranged , to , mg/dl). the etiologies of chronic renal disease in the patients were focal segmental glomerulosclerosis (fsgs) in one, lupus nephritis in one and three had undergone renal transplantation according to different etiologies. glomerular filtration rate was higher than ml/sec/ , m in all patients. immune suppressive regimen of renal transplanted patients was based on tacrolimus in two patients and on cyclosporine a in one. both renal transplanted patients and other two patients with fsgs and lupus nephritis were all receiving steroid, enalapril and mycophenolate mophetil at the same time during the losartan therapy. metabolic acidosis and hyperkalemia were recovered within a week following the exclution of the losartan. in conclusion, we think detailed and controlled studies are necessary to determine the pathogenesis of the metabolic acidosis due to losartan and patients must be followed up very closely for the adverse effects of metabolic acidosis and hyperkalemia during the treatment. objectives of study: bartter's syndrome is a rare renal tubular disorder characterized by hypokalemia and metabolic alkalosis. it is also known to be effectively treated with potassium supplement, potassium sparing diuretics and indometacin. we experienced two sibling cases whose problems were incompletely solved with above mentioned conventional treatment, but rather completely with adjunctive therapy of regular hemodialysis with dialysate of low bicarbonate concentration. case : this male patient was diagnosed of bartter's syndrome when he was months old. he was treated with potassium supplement, aldactone and indometacin with marked improvement. but he still had some problems of retarded growth, severe headache and episodes of marked hypokalemia which needed repetitive admission. when he was years old, we put him weekly hemodialysis with dialysate of low bicarbonate concentration ( meq/l). with hemodialysis, he has been in good condition for years with stable blood ph and serum potassium levels. case : this female patient, the elder sister of case , was diagnosed of bartter's syndrome at one year of age. with those therapy on conventional medications, she seemed to grow out of failure to thrive, but needed repeated admissions due to episodes of dehydration and hypokalemia. after start of weekly hemodialysis with low bicarbonate dialysate, for one year she has been on good control of blood ph and serum potasium level, and was never admitted with those episodes. conclusion: regular hemodiaysis with dialysate of low bicarbonate concentration can be considered as effective adjunctive therapy in intractable bartter's syndrome. a. deguchtenaere, a. raes, j. dehoorne, c. vande walle, r. mauel, j. vande walle university hospital gent, pediatric uro-nephrologic center, gent, belgiummonosymptomatic enuresis nocturna (mne) may be associated with nocturnal polyuria (np) and low urinary osmolality during the night. besides vasopressin, recent studies have stressed the possible role of renal sodium-handling, hypercalciuria, prostaglandins and/or osmotic excretion.the aim: was to study circadian rhythm of gfr and diuresis in a highly selected group of children with persistant np. methods: population existed of children with mne and np, age - y, males. controls n= children, - y with mne, but no np. (=b). renal function during h concentration-prophyle, with timed urine samples, and measurement of p and u for na, k, osmol, creatinin. calculation of gfr by creatinine, uosmol, feosmol, diuresis vol (ml/min), fena, fecl, fek, u k /u k +u na %. statistics: paired t-test p< . between d and n, unpaired t-test, between the groups. conclusion: children with nocturnal polyuria have not only lost their circadian rhythm of diuresis and sodium-excretion but also of gfr. another observation for a reanl involvement in mne. sarcoidosis is a systemic disorder of unknown etiology, rare in children, characterized by the presence of noncaseating granuloma in affected organs. we report a -year-old boy of french african origin who presented with left hearing loss followed by bilateral deafness within months. a history of bilateral uveitis was secondarily unveiled. mild renal insufficiency (creatinine level μmol/l ; clearance: mmol/min) was diagnosed prior to cochlear implant surgery. a percutaneous renal biopsy evidenced a granulomatous interstitial nephritis with widespread interstitial fibrosis. complementary explorations showed elevated lysozyme activity at μg/l (normal < ) with elevated cd /cd ratio in bronchoalveolar lavage specimen. pulmonary function test was notable for mild diffusion impairment. cerebral mri demonstrated abnormal enhancement involving the periventricular white matter and the intracanalicular portions of both viii cranial nerves. cerebrospinal fluid showed abnormal hyperlymphocytosis ( lymphocytes per mm ) while protein was normal. three weeks after admission, bilateral uveitis recurred and was cured by local steroid therapy. despite intensive treatment with intravenous prednisone g/ , m /j per day, successive days per month associated with oral prednisone during months, glomerular filtration rate did not improve. in conclusion, sarcoidosis may apparently be revealed by acute bilateral deafness, and prompt diagnosis is needed to avoid permanent lesions. gfr cystcin= . cystc - . , formgfr= *height (cm)/s-creat (mmol/l). d difference between c inulin and tested method. conclusion: none of the tested methods seems to reveal hyperfiltration in type diabetes patients as clearance of inulin. the best correlation was found to clearance of iohexol and second best gfr estimated by /cystatin c. creatinine clearance overestimates and formula clearance underestimates gfr in diabetic patients without nephropathy. objective: to study the effects and mechanism of fty on the renal interstitial fibrosis in unilateral ureteral obstructic rats. methods: fouty-five males sd rats were randomly divided into sham-operated (sham), unilateral ureteral obstruction (uuo) and uuo treated with fty (uuo+fty ) group. . mg.kg - .d - of fty or vehicle was administrated through daily gavage and begun from two days before the operation till being sacrificed. -hour urine protein, blood urea nitrogen and plasma creatinine were determined. the renal tubular interstitial fibrosis lesion and the expression of α-sma,col-i, cd , ed were scored semi-quantitively. results: the amount of hours urine protein was much lower than that in uuo group, (p< . ). serum creatinine in fty treated group were significantly lower than those in uuo group (p< . ). the scores of renal interstitial fibrosis were lower in fty group than that in uuo group. α-sma expression was limited to vessels in sham group, but extended to renal tubule and interstitium in uuo and fty treated group, while relatively weaker expression was observed in fty group than in uuo group. some collagen expression was found in sham group, which was much enhanced in uuo group and mainly distributed in renal interstitium, the expression in fty group was also increased compared to sham group, but much lower than that in uuo group. obvious lymphocyte and macrophage infiltration were found in tubular interstitial area in uuo group but significantly less in fty treated group (p< . ).conclusion: novel immunomodulator fty can obviously inhibit renal interstitial lymphocyte and macrophage infiltration, renal tubule cell transdifferentiation, and interstitial fibrosis, thus prevent renal disease progression. background: the mesangial cell, especially as a fundationtal component in normal mature glomeruli, is essential to keep glomerular capillary lumen open and to maintain efficient ultrafiltration. loss of mesangial cells due to pathologic conditions such as glomerulonephritis leads to impaired renal function. the exact developmental origin of mesangial cells is unknown. it has been established that mesenchymal stem cells, which are derived from bone marrow, have a potential to differentiate into different lineages in response to different environments. the purpose of the study is to examined the effect of platelet-derived growth factor (pdgf) in the differentiation of bone marrow-derived cells into mesangail cells. method: isolated bone marrow cells were cultured in the medium containing collagen type i within hours, and then transferred to collagen type i.-coated dishes. the cells attached to collagen type i. in the following days were maintained in the differentiation medium containing % horse serum, μmol/l, and μmol/l of pdgf and all-trans retinoic acid. results: after cultivation under the above condition, approximately % of cells expressed β actin and desmin, which highly resembled cultured mesangial cells in rat. the induced cultured cells changed into a wide range of shapes from spindle to stellate. the results indicate that bone marrow-derived stem cells could differentiate into mesangial-like cells in vitro. key: cord- -uj fe y authors: nan title: scientific abstracts date: - - journal: reprod sci doi: . / sha: doc_id: cord_uid: uj fe y nan by reduced placental oxygenation, hypoxia-induced oxidative stress is a predominant mechanism. we investigated the effect of hypoxic pregnancy, with and without antioxidant treatment, on placental and maternal circulatory indices of oxidative stress in rats. methods: on pregnancy day , wistar rats were randomised into: normoxia ( % o litters), hypoxia ( % o litters) and hypoxia + vit c ( % o + mg. ml - vit c in water, litters). on day , dams were anaesthetised, maternal blood taken, pups measured and weighed, placentae weighed and frozen. only placentae from two male pups from any one litter were investigated. blood was processed for ascorbate, urate, l-cysteine and glutathione (gsh) measurement. placental protein was analysed for heat shock protein (hsp ; western). results: hypoxia + vit c did not affect maternal food or water intake. vit c elevated maternal ascorbate by % of baseline; a similar increment to human trials (poston et al. ) . hypoxia elevated placental hsp and maternal plasma urate and l-cysteine, but decreased gsh. vit c in hypoxic pregnancies prevented all stimulated effects, but the reduction in gsh persisted. hypoxic pups had a reduced ponderal index and elevated head diameter: body weight ratio; effects also prevented by vit c. fetal oxygen uptake in normal and gdm pregnancies. emanuela taricco, tatjana radaelli, veronica cozzi, gabriele rossi, danila puglia, giorgio pardi, irene cetin. department of obstetrics gynecology "l. mangiagalli", irccs policlinico, mangiagalli e regina elena, milan, italy. background. diabetes in pregnancy has been associated with alterations of fetal growth probably due to increased nutrient availability and placental transport. fetal hypoxia and acidemia have been reported in pregestational diabetic pregnancies with poor glicemic control but this is still uncertain in well controlled patients. the role of placental function and the relationship between maternal and fetal circulation is crucial for efficient exchanges of oxygen and nutrients. since umbilical blood flow can be obtained by us in utero, we studied normal and gdm pregnancies in order to evaluate fetal oxygen uptake. methods. normal (n) and gdm pregnancies were studied at term, at the time of elective caesarean section. umbilical vein volume flow (qumb) was measured by us before caesarean section and blood samples from umbilical vein (uv) and artery (ua) were obtained. blood gases and acid-base balance were evaluated. results. average fetal weights were similar in both groups (n= ± ; gdm= ± g) while placental weights were significantly different (n= ± ; gdm= ± g). n and gdm pregnancies showed similar values of qumb and qumb/kg of fetal weight. (qumb: . ± . in n and . ± . ml/min in gdm; qumb/kg: . ± . in n and . ± . ml/min/kg in gdm). in fetuses from gdm pregnancies a significant reduction in o sat, o cont and po and a significant increased lactate conc was found in both uv and ua compared to n (table ) . o umb uptake (n= . ± . ; gdm= . ± . mmo/l/min) and o umb uptake/kg (n= . ± . ; gdm= . ± . mmo/l/ min/kg) were significantly lower in gdm compared to n fetuses. conclusions. our data indicate that fetuses from gdm pregnancies show a significant reduction in oxygen supply despite a normal blood flow/kg of fetal weight. these data may suggest that a good maternal metabolic control is not sufficient to ensure normal placental oxygen supply and/or utilization by the gdm fetus. background: synthetic glucocorticoids (sgc) are given to mothers at risk of preterm delivery to promote fetal lung maturation. evidence is emerging indicating long-term effects of such treatment on endocrine function and behavior in offspring. however, virtually nothing is known concerning potential transgenerational influences on growth, endocrine function and behaviour. we hypothesize that repeated treatment of grandmothers (f ) with sgc will alter hypothalamic-pituitary-adrenal (hpa) function in f offspring with no manipulation of the f pregnancy. methods: pregnant guinea pigs (f ) were subcutaneously injected with betamethasone (beta; mg/kg) or vehicle (veh) on gestational days / , / / . adult f female offspring from each group were mated with control males. hpa function was assessed in adult f offspring by non-invasive measurement of salivary cortisol concentrations: ) under basal conditions, ) during and following exposure to psychological stress (high frequency strobe light) or psychological/physical stress (forced swim) and, ) following dexamethasone suppression. results: there was no effect of beta (f ) on bodyweight from birth to adulthood in f offspring. basal salivary cortisol in the betaf females was lower than in the vehf group in the morning but not the afternoon; there were no differences in male f offspring. in contrast, both male and female betaf failed to mount adrenocortical responses to psychological stress compared to vehf offspring that mounted robust responses (p< . ). swim stress induced robust adrenocortical responses in all groups (p< . ), however, the response was consistently lower in betaf offspring. beta exposure also led to a significant difference (p< . ) in the cortisol response to dexamethasone suppression in female (f ) offspring, with a similar trend in males. conclusion: prenatal exposure to sgc (f ) causes transgenerational programming of adrenocortical function in adult f offspring. grand maternal exposure to beta results reduced basal adrenocortical activity in betaf female offspring, and caused stress hypo-responsiveness in both males and females. dexamethasone suppression tests indicate altered central glucocorticoid feedback. these findings have important ramifications for the management of human preterm labor. support: canadian institutes of health research. in the uterine and umbilical vasculatures, we hypothesized that their remodeling would also be blunted in pregnant enos -/-mice, leading to an elevated vascular resistance and decreased blood flow to the placenta contributing to fetal growth restriction. methods: utero-and umbilical-placental blood velocity waveforms and umbilical arterial diameters were measured using mhz ultrasound biomicroscopy in control (c bl/ j) and enos -/-mice at . days of pregnancy (n= mothers). spiral artery and fetal capillary morphologies, and uterine arterial diameters were evaluated from vascular corrosion casts. tissues were collected for hydroxyprobe- and actin immunohistochemistry to identify hypoxic and smooth muscle regions. we calculated resistance index ((s-d)/s) from systolic (s) and diastolic (d) velocities, and blood flow from mean velocity and vessel area. results: calculated uterine blood flow normalized to the weight of the uterus and its contents was % lower (p< . ) in pregnant enos -/-mothers due to large reductions in uterine artery diameter (- %, p< . ) and mean velocity (- %, p< . ). uterine arterial resistance index was % higher (p< . ), and the spiral arteries were less coiled and contained more smooth muscle actin in enos -/-mice than controls. more intense hypoxic immunoreactivity was detected in the spongiotrophoblast and trophoblast giant cell layers of the junctional zone of enos -/-placentas, whereas fainter staining was only detected in the spongiotrophoblast cell layer in controls. in the umbilical circulation, flow normalized to fetal weight was not significantly changed although the resistance index was slightly elevated ( %, p< . ) and capillary lobule length was reduced by (- %, p< . ). fetal organs showed increased hypoxic immunoreactivity suggesting reduced organ oxygen delivery in enos -/-fetuses. conclusions: results suggest that enos plays an important role in uterine and spiral artery remodeling and in augmenting utero-placental blood flow during pregnancy. it also appears to enhance oxygen delivery to the placenta and fetus. enos may contribute to normal fetal growth by these mechanisms. integrin methods: hpmcs isolated from term placentas were assessed for their phenotype markers, mutilineage capacity, and the expression of integrin molecules. the hpmcs were induced to endothelial cell differentiation in the presence of endothelial cell growth medium with % of fcs and ng/ml vegf for to days. the angiogenesis ability of these cells was demonstrated by using an in vitro angiogenesis kit and in vivo chick chorioallantoic membrane assay from ten-day-old embryos. blocking antibodies specific to integrin , associated with gdm. this study was adequately powered to detect association in the caucasian and asian group. the absence of association suggests that gdm and t dm may have more divergent molecular pathophysiology than previously suspected. background: uterine endometrium has a unique cycle of physiological angiogenesis. in mice, endothelial progenitor cells (epc) contribute to endometrial angiogenesis being incorporated after oestradiol administration. objective: to determine whether circulating © epc number and function vary through the menstrual cycle in response to changes in circulating sex steroid concentrations. methods: ten healthy, nulliparous, pre-menopausal, non-smoking women (mean age years) with regular menses ( - days) were studied. venous blood was collected during menstrual, follicular, periovulatory and luteal phases of a single cycle (days - , - , - , - ) . cepcs, serum oestradiol (e) and progesterone (p) were measured at each phase. cepcs were quantified by phenotype using flow cytometry (leukocytes co-expressing cd , kdr and cd ) and function by the epc-colony forming unit (cfu) assay. epc-cfus were stained for endothelial markers including uptake of acetylated low-density lipoprotein, binding of lectin (ulex europaeus) and endoglin. results: luteal p was > nmol/l in all women. cepc numbers increased in the menstrual and follicular phases being -fold higher in the follicular compared to periovulatory phase (p< . ). there was no significant variation in cepc function over the menstrual cycle. there was no correlation between serum e or p levels and cepc number or function. conclusion: cepcs number but not function (epc-cfu assay) vary during the menstrual cycle with numbers increasing during the menstrual and follicular phase and falling in the periovulatory and luteal phase of the menstrual cycle. this may represent mobilisation of cepcs from the bone marrow and subsequent incorporation into the endometrium. neither function nor cepc number correlate with serum p or e. our previous studies demonstrated that tissue factor (tf), which binds factor vii to act as a potent pro-coagulant and angiogenic factor, is over-expressed in endometriotic lesions. thus, we determined whether tf could serve as a target for the elimination of pre-established ectopic human endometrial growth in a mouse model. icon is composed of a mutated factor vii (fvii) domain targeting tf and an igg fc (fvii/igg fc) effector domain that activates antibody-dependent immune responses against tf bearing endothelial cells. methods: athymic, ovariectomized and estrogen-treated mice received intraperitoneal (i.p.) injections of . mg of proliferative phase human endometrial tissue derived from normal (disease-free) women. twelve days after inoculation to establish lesions, icon protein ( ug) was delivered i.p. once a week for weeks. after sacrifice, animals were subject to gross inspection. residual endometriotic tissue was formalin fixed, paraffin embedded and immunostained for von willebrand's factor (vwf) and tf. results: compared to control mice, treatment with ug of icon abolished all lesions in of mice and reduced both size ( . to . mm) and number of lesions ( . to per diseased mouse) in the remaining mice. moreover, residual lesions from icon treated mice were atrophic and displayed significant reductions in vessel areas of % +/- % (p= . , mean +/-sem, n= ) as determined by vwf immunostaining. no hemorrhagic or thrombotic sequelae were observed in icon treated mice. conclusions: unlike other treatments that target developing angiogenesis, icon can target both developing and established human endometriotic lesions in athymic mice. the gross and microscopic vessel analysis suggests that icon directly or indirectly destroys endometriotic vessels. thus, icon presents a novel, non-toxic therapy for endometriosis. compared to the miscarriage and top groups. ihc for crisp demonstrated increased secretion of crisp in the glandular epithelium and expression in the leucocytes of the tubal uterine decidua. conclusions: there are differences in decidual gene expression in tubal compared to iu pregnancies. we believe that potential biomarkers of tubal pregnancy can be discovered by focusing on secreted proteins associated with uterine decidualization. one of these proteins, crisp , is significantly increased in decidua of tubal ectopic pregnancies and we are currently investigating its expression pattern in sera from women with tubal compared to iu pregnancies. progesterone and hoxa regulate gaba-a pi receptor expression, membrane translocation and activation. homayoun sadeghi, hugh s taylor. obstetrics, gynecology and reproductive sciences, yale school of medicine, new haven, ct, usa. objective the expression of the gaba-a pi receptor has been previously described in the human endometrium in both luminal epithelium and stroma. it is upregulated during stromal decidualization in the rat and in the implantation window of human endometrium. the gaba receptor is modulated by progesterone metabolites, with the resultant opening of the receptor ion channels which allow the water flux necessary for trophoblast attachment. here we identified regulators of pi subunit receptor gene expression and activity. the well-differentiated human endometrial adenocarcinoma cell line (ishikawa) and human endometrial stromal cells (hesc) were transfected with hoxa , treated with progesterone, or treated with vehicle or empty plasmid controls. gaba-a pi receptor mrna upregulation was evaluated by real time rt-pcr. protein expression was evaluated using immunohistochemistry. results gaba-a pi receptor mrna expression was increased with either progesterone treatment ( %, p= . ) or hoxa transfection ( %, p= . ). coadministration of progesterone along with increased hoxa transfection had no additive effect on the expression of gaba-a pi receptor mrna (p= . ). gaba-a pi receptor protein expression was similarly increased by each treatment. either hoxa or progesterone independently caused translocation of the gaba receptor from the cytoplasm to the cell membrane in ishikawa cells. conclusion gaba-a pi receptor expression is increased in the human luminal epithelium and stroma in the window of implantation. activation of the pi subunit leads to opening of ion channels, likely allowing flux of water into the epithelial cells and out of the uterine lumen. progesterone and hoxa each increase both pi subunit receptor expression and membrane translocation. the lack of additive effect suggests progesterone induced pi subunit receptor expression is likely mediated indirectly through progesterone's regulation of hoxa expression. finally, after receptor expression and translocation, progesterone mediated gaba receptor ion channel activation mediates water resorption necessary for implantation. cancer. suzy davies, donghai dai, kimberly k leslie. obstetrics and gynecology, university of new mexico, albuquerque, nm, usa. objectives: endometrial cancer is the most frequent gynecologic cancer in women. it affects an estimated , women in the us every year, and long term outcomes for patients with advanced stage or recurrent disease are poor. targeted molecular therapy against the vascular endothelial growth factor (vegf) and its receptors constitute a new therapeutic option for patients that is now under study by the gynecologic oncology group in a phase trial, gog e (now in second stage accrual). the goal of our work was to assess the potential effectiveness of vegf/vegfr blockade in preclinical endometrial cancer models. methods: these studies employed two agents, bevacizumab (avastin, a vegfa blocking antibody) and vandetanib (zactima, a tyrosine kinase inhibitor of egfr and vegfr ). ic experiments were performed on endometrial cancer cells in culture using four established cell line models. xenografted athymic mice were also employed to test the ability of compounds to inhibit tumor growth in vivo. tumors were isolated from controls and treated animals, mrna was extracted, and affymetrix gene expression arrays were performed to determine the genes consistently modulated by treatment. results: compared to vandetanib with an ic of . m, bevacizumab showed little activity on cell proliferation in vitro, and cell numbers were not reduced by % using concentrations up to . m. however, bevacizumab demonstrated robust activity in the athymic mouse model, resulting in a significant decrease in tumor formation and growth compared to vehicle treated animals when dosed bi-weekly in a concentration of . mg/mouse ip. tumors from this model demonstrated that eighteen genes were consistently up or down regulated in the presence of bevacizumab. among the regulated transcripts was microrna , which was significantly down-regulated. microrna is an anti-apoptotic factor, and its inhibition by bevacizumab predicts for increased expression of the tumor suppressor pten, decreased cell proliferation, and a reduced capacity for metastasis. conclusions: these studies confirm that the vegf pathway is a good target for new therapies against endometrial cancer. blocking this pathway not only inhibits angiogenesis, but also results in changes in gene expression that enhance apoptosis and reduce cellular proliferation and tumor invasion. we collected fibroid and adjacent normal tissues following hysterectomy with patient consent and institutional irbs. to date, data points for each gene from arrays have been collected from patients. the fluorescence readings were log-transformed and normalized with the robust quartile normalization method. quality control of the normalized data was performed to remove arrays that deviated from twice the inter-quartile range calculated from the array signals. results: the custom microarray profiling identified genes that were differentially expressed between normal and fibroid tissues (p < . ; fdr< . ). among them, genes encode receptor tks, genes encode tk ligands, and genes encode cell cycle and apoptosis proteins. clustering analysis of the mean log ratios of these genes has led to the division of the patients into two major groups. thirty four ( %) belong to a group characterized by the significant downregulation of the cyr (ccn ) gene in fibroid tissues. the cyr -down group can be further divided into two sub-groups based on the expression of another tk ligand, efn a. other receptor differentially expressed tk did not segregate with the three defined sub-groups. finally, there was no sub-group segregation based on age of the patient, menstrual phase, or weight of the fibroid. conclusion: our results have demonstrated that tyrosine kinases and their ligands are uniquely differentially expressed between normal and fibroid tissues. unique tyrosine kinase ligands in our population were cyr and efn a, and these markers created three molecular classification groups based on their differential expression. these results support the hypothesis that tyrosine kinase ligands are involved in fibroid growth, and may offer targets for a strategy to avoid hysterectomy. microvascular perfusion sonographic imaging to detect early stage ovarian cancer. joanie mayer hope, arthur c fleischer, brian day, stephanie v blank, bhavana pothuri, robert wallach, john p curtin, david a fishman. gynecologic oncology, new york university school of medicine, new york, ny, usa; radiology, vanderbilt university medical center, nashville, tn, usa. objective: epithelial ovarian cancer (eoc) is the th leading cause of death in us women due to the inability to detect early stage disease. recent sonographic developments involving harmonics, pulse inversion, and the use of contrast agents justify the hope that depiction of aberrant tumor microvascularity associated with early disease can occur. this study utilizes these new techniques to assess the unique microvascularity associated with early stage eoc. methods: we used pulse inversion harmonic microvascular imaging (mvi) technology to depict differences between benign and malignant ovarian lesions. contrast enhanced harmonic transvaginal (tv) sonography was performed using the philips iu scanner after intravenous injection of g of definity (bristol-myer-squibb). split screen real-time images were acquired displaying conventional sonographic views adjacent to harmonic, low mechanical index images. morphologic features (thickened wall, papillary excrescence, calcifications) and aberrant vascularity were noted. q-lab quantification of wash-in, peak enhancement, and wash-out times as well as area-under-thecurve (corresponding to microvessel perfusion) were compared using student's t-tests. results: to date, contrast enhancement patterns of ovaries have been analyzed, benign and malignant. of the malignancies ( fallopian tube, ovarian: stage i, stage iii), / women were correctly identified using conventional tv imaging and others were identified using mvi / . all benign lesions were correctly identified by mvi / while tv detected normals ( false negatives). the lesions detected as malignant by mvi were -stage i fallopian tube and -stage i eoc. contrast enhancement kinetics of malignant lesions demonstrated similar wash-in ( . ± . vs . ± . , p = . ), greater peak enhancement ( . ± . vs . ± . , p < . ), longer wash-out ( . ± . vs . ± . (p < . ), and greater perfusion ( . ± . vs . ± , p < . ) when compared to benign lesions. conclusion: contrast enhancement patterns are significantly different in benign vs. malignant ovarian masses. this technique has clear potential in differentiating benign from malignant lesions and for detecting occult stage i disease. identification and characterization of mir- a as regulator of ikk expression and its function in ovarian cancer cells. rui chen, ayesha b alvero, thomas rutherford, gil mor. department of obstetrics and gynecology, yale university school of medicine, new haven, ct, usa. introduction: the proinflammatory environment associated with tumor growth and chemoresistance is produced by both immune cells and cancer cells. the nf-b pathway plays a critical role mediating the capacity of cancer cells to produce pro-inflammatory cytokines. recently, we described a group of epithelial ovarian cancer (eoc) cells characterized by ikk expression as the main factor promoting nf-b activation and cytokine production. in this study we evaluated the regulation of ikk in eoc cells. we describe the identification and characterization of mir- a as a regulator of ikk expression, thus indirectly of nf-b activity and function. materials and methods: human eoc cell lines were established from malignant ovarian cancer ascites. protein expression were determined by western blotting. ikk mrna was measured by rt-pcr. cytokines were profiled by the luminex system. ikk transfection was done with roche fugene transfection reagent. mirna microarray was done with invitrogen ncode multi-species mirna microarray kit. mir- a qrt-pcr was performed with invitrogen ncode sybr greener mirna qrt-pcr analysis kit. mirna transfection was done with ambion siport neofx agent. the ikk '-utr luciferase reporter plasmid was established based on ambion pmir-report mirna expression reporter vector. results: ikk expression was associated with nf-b cyclic activity and the ability of type i eoc cells (but not type ii) to produce inflammatory cytokines. transfection of ikk into type ii eoc cells reversed their phenotype. mirna microarray identified mirnas differentially expressed in type i versus type ii cells, one of which, mir- a, had putative binding sites in the '-utr of ikk mrna. mir- a introduction into type i cells inhibited ikk expression, and direct inhibition through ikk 's '-utr was confirmed by luciferase assay. conclusion: we describe for the first time the identification of ikk as a potential key switch between chemo-resistant and chemo-sensitive phenotypes, by regulating nf-b activity in eoc cells. furthermore, we identified mir- a as a direct regulator of ikk expression. ikk expression may represent an adaptational stage in tumor progression allowing cancer cells to create their own inflammatory environment. these findings may provide novel molecular targets and potential markers for individual therapy selection. regulation of cd in the rat uterus by nitric oxide and the involvement of p kinase pathway. uma yallampalli, rebakah elkins, pawel goluszko, chandra yallampalli. obstetrics gynecology, university of texas medical branch, galveston, tx, usa. objective. cd is expressed in many cell types including uterine cells and has been shown to play an important role in protecting against compliment attack. we have previously shown in endometrial cell lines that cd levels were down regulated by nitric oxide (no) . in this study we extend our previous observations to determine if no down regulates cd in rat uterine tissues and assess its mechanisms of action. methods. non pregnant rats ( g; b wt) were bilaterally ovariectomized under ketamine anesthesia. groups of ovariectomized rats were implanted with alzet mini pumps to deliver nitro-l-arginine melthylester (l-name) at or /mg/rat/day in saline or saline alone. uteri were obtained from these rats at or hours after infusion. in another set of experiments uteri were obtained from ovariectomized rats and cut in to small pieces and incubated in vitro with either l-name ( mm), diethylenetriamine-no mm) or worthmanin ( . m) in mem without phenol red for hours. uterine tissues were homogenized in trizol and mrna levels for cd were measured using rt-pcr and expressed as a ratio to s. results. results show that in vivo treatment with l-name to ovariectomized rats caused elevations in uterine cd mrna levels in a time and dose dependent manner with maximal responses seen with mg l-name and at hours. in vitro studies show that deta-no suppressed cd mrna levels in the rat uterus. both l-name and pi kinase inhibitor, worthmanin caused increases in cd levels in these tissues and the effects of worthmanin are reversed by deta-no. these results suggest that cd levels in the rat uterus are down regulated by no and are upregulated when no synthesis is inhibited by l-name. further, pi kinase appears to be involved in cd regulation in the rat uterus and no donor appears to modulate this response. lung. lakeitha r foster, daniel b hardy, carole r mendelson. dept of pediatrics; depts of biochemistry and ob/gyn, ut southwestern medical center, dallas, tx, usa. during % of human pregnancy, the maternal uterus is maintained in a state of almost complete quiescence by elevated circulating levels of progesterone (p ). we previously observed that p acting through the progesterone receptor (pr) serves an anti-inflammatory role and inhibits uterine contractility by antagonizing nuclear factor b activation and cyclooxygenase- (cox- ) expression (hardy et al., ) . our previous findings also suggest that the fetus provides an important signal for the initiation of labor near term through augmented secretion of the major lung surfactant protein, sp-a, into amniotic fluid (condon et al., ) . secreted sp-a, in turn, activates fetal macrophages which migrate to the maternal uterus where they release cytokines and promote an inflammatory response, leading to labor. in the present study, we tested the hypothesis that maternal p also maintains uterine quiescence by inhibiting sp-a production by the fetal lung. age matched icr mice were injected s.c. once daily either with sesame oil (control) or p ( mg/ml) from to days post-coitum (dpc). as expected, treatment with p delayed parturition by - h. this also was associated with a decrease in uterine cox- mrna expression, as compared to the vehicle-injected controls. interestingly, maternal p treatment caused a marked decrease in the levels of immunoreactive sp-a protein secreted by the fetal lungs into in amniotic fluid at dpc. furthermore, sp-a protein and mrna levels were reduced in the fetal lungs of p -injected mothers, as compared to controls. this was associated with an inhibitory effect of p treatment on cox- protein and mrna levels in the fetal lungs. these findings were of interest, since cox- expression is markedly upregulated during differentiation of human fetal lung (hfl) explants in culture (hardy et al., ) and endogenous and exogenous prostaglandins increase sp-a expression in hfl (acarregui et al., ) . collectively, these findings suggest that maternal p treatment prevents increased uterine contractility, in part, by inhibiting inflammatory response pathways within the fetal lung. this, in turn, blocks the developmental induction of sp-a expression and its secretion into amniotic fluid. in this manner, maternal p inhibits an important fetal signal leading to labor. supported by nih p hd ; nih r hl . recent evidence suggests that leukocytes infiltrate uterine tissues at the time of parturition implicating inflammation as a key mechanism of human labor. ccl- is a pro-inflammatory cytokine that may contribute to the development of inflammatory reaction in the myometrium. previously we showed upregulation of rat ccl- gene expression in myometrium during term and ru -induced preterm labor. also ccl- was elevated specifically in the gravid horn of unilaterally pregnant rats suggesting that mechanical strain imposed by the growing fetus controls its expression in the myometrium. the objective of this study was to investigate the role of mechanical stretch as a possible regulator of myometrial leukocyte infiltration and ccl- as a mediator of this stretch response. we also studied the effect of progesterone (p ) on the myometrial secretion of ccl- . methods. we used primary culture of rat myometrium smooth muscle cells (smcs) to study in vitro ccl- gene and protein induction by static mechanical stretch. ccl- gene expression analysis was performed by real-time rt-pcr and immunoreactive (ir) protein content was measured by elisa assay. we used primary rat monocytes to access whether stretch-induced ccl- production by myometrial smcs resulted in enhanced monocyte chemotactic activity. results. myometrial cells were stretched for - hours and the supernatants collected. analysis of media conditioned by primary myometrial smcs revealed that static mechanical stretch ( % elongation for hours) caused a significant accumulation in ir ccl- which was repressed by pretreatment with p ( um). the rise in ccl- protein levels was preceded by a transient increase on ccl- mrna. the migration of primary rat monocytes in response to conditioned medium from stretched myometrial smcs was much greater than that of conditioned medium from control non-stretched cells. co-incubation with a neutralizing antibody to ccl- significantly reduced the chemotaxis of monocytes in response to the stretch-conditioned medium. conclusion: uterine smcs play an active role in uterine inflammation by producing chemokines and promoting the chemotaxis of immune cells into the myometrium. the blockade of this effect by p offers a potential explanation for the therapeutic actions of this hormone in the prevention of preterm birth. membranes during human labor. nardhy gomez-lopez, , guadalupe estrada-gutierrez, lourdes vadillo-perez, felipe vadillo-ortega. direction of research, instituto nacional de perinatologia, mexico city, df, mexico; escuela nacional de ciencias biologicas, ipn, mexico city, df, mexico. introduction. leukocytes arriving to the choriodecidua (chd) during labor are capable to secrete cytokines and matrix metalloproteinases that may play a role in the fetal membranes (fm) extracellular matrix degradation. objective. the aim of this work was to identify changes in the leukocyte subpopulations in the chd and fm during human labor. methods: fm were obtained from two groups of women: ) term without labor (n= ) and ) term with spontaneous labor (n= ). chd cells were isolated and analyzed by flow cytometry. explants of fm were embedded in paraffin and analyzed by confocal microscopy. in both techniques, cd , cd , cd , cd and cd subpopulations of leukocytes were identified. intracellular mmp- was also identified in these cells. results: major changes in leukocytes subpopulations during labor involved a higher amount of cd +, cd+ and cd + cells, both in the chd and inside the fm. mmp- was associated to cd + cells. cd + exhibited a more widespread localization in the fm and cd + cells were localized in the contact with the trophoblast layer during labor. conclusions: leukocyte populations changes both in the chd and fm during labor and are characterized by arrival and infiltration of specific subpopulation of lymphocytes and monocytes. nk cells are enriched in mmp- , which may be related to a role in extracellular matrix degradation leading to the rupture of fetal membranes. women with a history of a pregnancy complicated by preeclampsia or intrauterine growth restriction (iugr) have an increased risk of future cardiovascular disease. excessive weight, particularly abdominal fat mass, is associated with cardiovascular morbidity and mortality. objectives: the aim of this study was to investigate differences in body composition and fat distribution between women with a history of preeclampsia or iugr and uncomplicated pregnancies. methods: from a genetically isolated population in the southwest of the netherlands, non-pregnant women with a history of preeclampsia (n= ), iugr (n= ) and uncomplicated pregnancies (n= ) were recruited at a mean follow up time of . years after pregnancy. body composition and fat distribution were assessed by dual energy-x-ray absorptiometry (dxa) and anthropometric measurements. results: women with a history of preeclampsia compared to controls had higher mean total-, fat-and lean mass (p < . ) as well as higher mean indices of body mass, fat mass and lean mass (p< . ). no significant differences were found for these variables between women with a history of iugr and controls. women with a history of preeclampsia had higher waist circumferences and waistto-hip ratios (p< . ) as well as excess of android fat mass and increased android-to-fat ratios (p< . ). women after pregnancies complicated by iugr had higher waist-to-hip ratios (p < . ). after controlling for body mass index, both women with a history of preeclampsia or iugr had higher waist circumferences (p < . ) and waist-to-hip ratios (p < . ) as well as smaller hip circumferences (p < . ). conclusion: despite differences in body mass index, both women with a history of preeclampsia and women after pregnancies complicated by iugr have a metabolically adverse fat distribution, marked by an excess of fat deposition in the abdominal region relatively to the hip region. these findings may explain, at least partly, their increased cardiovascular risk. women with a history of preeclampsia. marc ea spaanderman, timo h ekhart, robert aardenburg, louis lh peeters. obstetrics and gynecology, radboud university medical center, nijmegen, netherlands; obstetrics and gynecology, university medical center maastricht, maastricht, netherlands. background: a history of preeclampsia is associated with persistent short-term alterations in circulatory function and remote cardiovascular disease. in this study we tested the hypothesis at least years after preeclamptic pregnancy renal and central hemodynamic function is impaired as compared to women with uncomplicated pregnancy. methods: in formerly preeclamptic women (pe) and healthy parous controls (control) who were normotensive at weeks post-partum follow up, we assessed at least years after delivery blood pressure (mmhg), cardiac output (co, doppler ultrasonography, l/min) and effective renal plasma flow (erpf, pah clearance, ml/min/ . m ) after which we calculated total peripheral vascular resistance (. dyne.s/cm ) and renal vascular resistance (. dyne.s/cm ). data were analyzed parametrically (p< . ). results: age and bmi were comparable between groups. blood pressure was higher in formerly pe. moreover, % of formerly pe women and % of control were hypertensive (p< . ). although cardiac out was comparable between groups, total peripheral and renal vascular resistance were about % higher and erpf % lower in formerly pe women as compared to control. conclusion: at least years after gestational hypertensive disease, women who were normotensive at direct follow up have impaired renal and central hemodynamic function and developed more often chronic hypertension. long-term follow up may also be warranted in apparently healthy formerly pe women who are normotensive at post-partum follow up. circulatory function in formerly preeclamptic women and healthy parous controls co erpf tpvr rvr formerly pe . ± . ± * ± * ± * control . ± . ± ± ± * = p< . pregnancy increases blood-brain barrier permeability coefficient (l p ) to lucifer yellow: role of estrogen. marchien j wiegman, , marilyn j cipolla. neurology, ob/gyn and pharmacology, university of vermont, burlington, vt, usa; ob/gyn, university medical center groningen, groningen, netherlands. background: eclampsia is similar to posterior reversible encephalopathy syndrome in which an acute rise in blood pressure causes breakthrough of autoregulation, blood-brain barrier (bbb) disruption, and cerebral edema formation. we previously showed that late-pregnant (lp) animals developed cerebral edema during breakthrough, a response that was absent in nonpregnant (np) animals. in the current study we hypothesized that pregnancy predisposes the brain to edema during acute hypertension by enhanced bbb permeability. we further hypothesized that the underlying effect of pregnancy on the bbb permeability is due to elevated estrogen levels. methods: permeability coefficients (l p ) to lucifer yellow (ly), a polar compound that does not pass through tight junctions, were compared in posterior cerebral arteries (pca) from groups of sprague dawley rats: np (n= ), lp (d ; n= ), ovariectomized and implanted with -estradiol ( . mg, -day release) and estriol ( . mg, -day release) pellets for days (ovx+e; n= ), and ovariectomized and implanted with placebo pellets for days (ovx; n= ). pcas were isolated, pressurized in an arteriograph, and perfused with . mg/ml ly in saline. concentration changes of ly outside the vessel wall were determined at pressures from - mmhg. the slope of the pressure vs. permeability curve is the rate of flux, or l p for ly. results: l p for ly was significantly increased in pcas from lp and ovx animals vs. np (p< . ; figure ). estrogen was protective of the bbb only in ovariectomized animals, decreasing l p % in ovx+e vs. ovx. however, pregnancy did not afford protection and had a l p that was % greater than np. conclusions: pregnancy significantly increases bbb permeability to ly, an effect that may predispose the brain to edema formation during acute hypertension. these data also show that estrogen modulates l p in ovariectomized animals differentially than pregnancy, suggesting that the increased bbb permeability in pregnancy is caused by a mechanism other than elevated estrogen levels. in both pre-and early pregnancy, the sympathoinhibitory response to volume expansion is blunted in formerly preeclamptic women with low plasma volume. ineke krabbendam, marc ea spaanderman, dorette a courtar, robert aardenburg, ben j janssen, fred k lotgering, louis lh peeters. obstetrics and gynecology, radboud university nijmegen medical centre, nijmegen, netherlands; obstetrics and gynecology, university hospital maastricht, maastricht, netherlands; pharmacology and toxicology, university of maastricht, maastricht, netherlands. background: the circulation of formerly preeclamptic women with a low plasma volume (lpv) is characterized by sympathetic dominance. these women respond to a new pregnancy with an aberrant rise in atrial natriuretic peptide (anp) and a times higher chance to develop recurrent gestational hypertensive disease compared to their counterparts with normal plasma volume (npv). anp has sympathicomimetic capacity. we postulate that the sympathetic overdrive in lpv-women is associated with a reduced venous capacitance. to this end, we compared the response to volume expansion (ve) in women with lpv and npv, both before and in pregnancy. method: in non-pregnant normotensive formerly preeclamptic women, we measured pv (hsa i indicator dilution method) at least months post partum. we intravenously infused ml of iso-oncotic fluid over minutes. during the infusion, we recorded changes in heart rate (hr, bpm), blood pressure (bp, mmhg), cardiac output (co, l/min), sympathetic activity (lfsys, mmhg , low frequency component of spontaneous fluctuations in systolic bp, portapress) and anp (nmol/l). eight women became pregnant within year and were evaluated at weeks gestation. changes in circulatory and autonomic function between and within groups were analyzed non-parametrically (p< . ). results: before pregnancy, ve leads to comparable changes in hr, bp and co in women with lpv ( / ) and npv ( / ). in npv, lfsys decreased %, but only % in lpv (p< . ). anp remained unaltered in npv, but increased in lpv. in the pregnant group, women had lpv and had npv. in both groups, pregnancy did not alter the response to ve. conclusion: irrespective of pregnancy, the sympathoinhibitory response to ve is diminished in lpv. these data suggest that in these women ve leads to venous overfill, giving rise to anp-release and consequently sympathetic activation, flattening the normal baroreceptor-mediated sympathoinhibitory response. we speculate that this mechanism contribute to circulatory maladaptation to pregnancy, sympathetic dominance and subsequent gestational hypertensive disease. in both pe and ht, serum sflt- was increased, and plgf reduced at all gestations (p< . ). seng levels were also increased in pe. after weeks (but not before) antihypertensive treatment was associated with a significant fall in serum sflt- and seng, in pe only. the concentrations of both sflt- and seng were significantly higher in the placentas of women with pe, but not ht, compared with controls (p= . ). only sflt- was significantly reduced in the placenta in women who received antihypertensive therapy. conclusion in pe, antihypertensive therapy after weeks' gestation is associated with a significant fall in serum sflt- and seng, and in placental sflt- . these findings raise the possibility that these drugs may have an effect on the pathophysiology of pe other than their known antihypertensive action. the synergistic effect of soluble vegf receptor pre-treatment and small doses of tnf-on endothelial cells. tereza cindrova-davies, debbie a sanders, olivera spasic-boskovic, graham j burton, d stephen charnock-jones. dept of pdn, university of cambridge, united kingdom; dept of obstetrics and gynaecology, university of cambridge, united kingdom. introduction: preeclampsia is marked by an enhanced endothelial inflammatory response manifested by maternal endothelial activation. soluble fms-like tyrosine kinase- (sflt- , svegf-r ), a naturally occurring circulating antagonist of vegf-a and plgf, is one of the secreted factors implicated in the pathogenesis of preeclampsia. in women who develop preeclampsia, sflt rises sharply, preceding the onset of the clinical disease. the aim of this study was to examine the effect of a combined treatment with recombinant sflt- and tnf-on the activation of human umbilical cord endothelial cells (huvec) by examining leukocyte adhesion, and the expression of icam, vcam, endothelin and vwf. methods: huvec were seeded, grown overnight and pre-treated with recombinant sflt ( - ng/ml) in a basic % fbs-dmem medium for hr. on day , low doses of tnf-( . ng/ml) were applied to pre-treated cells for hr. antagonism of the vegf-a action was mimicked at the protein level by pre-incubating huvec with anti-flt antibody ( - g/ml), anti-kdr antibody ( g/ml), anti-vegf antibody ( g/ml), or vegf receptor inhibitor su ( m). at the rna level, the effect of sflt was mimicked by sirna transfection of huvec with siflt or sikdr. at the end of each experiment cells were either harvested for western blotting, fixed in % pfa for immunofluorescence or incubated with labelled hl leukocyte cells, followed by fluorescent detection of adhesion. results: pre-incubation of huvec with sflt and subsequent treatment with low doses of tnf-increased the adhesion of hl leukocytes and increased icam- , vcam- , endothelin and vwf, compared to tnf-treatment alone. similar results were obtained when cells were pre-treated with su , anti-flt, anti-kdr or anti-vegf. transfection knock-down of flt or kdr gene also significantly increased leukocyte adhesion when small doses of tnfwere added. conclusions: pre-incubation with recombinant sflt, anti-flt, anti-kdr, anti-vegf, su or knocking-down flt or kdr transcripts all antagonised the autocrine actions of vegf and/or plgf. this predisposes huvecs to be more sensitive to the effect of tnf-. our study shows that sflt and tnfcombine to induce an enhanced synergistic effect, activating endothelial cells. maternal obesity is associated with increased production of inflammatory cytokines and risk of poor perinatal outcome. inflammatory cytokines can stimulate production of reactive oxygen (ros) and nitrogen (rns) species, which can covalently modify protein function. placental oxidative and nitrative stress are increased in pathological pregnancies and associated with altered placental function. objectives: determine the effect of increasing body mass index (bmi) on placental nitrative stress, measured by the expression and localization of nitrated (nitrotyrosine) and oxidized proteins. methods: placental tissue was collected at term ( - wks) from lean kg/m ), overweight ( - . kg/m ) and obese ( - kg/m ) patients (n= or /group). tissue was sectioned for immunostaining with nitrotyrosine antibody. protein samples were either dot blotted onto nitrocellulose membrane, probed with nitrotyrosine ab, and nitrated proteins detected using ecl, or derivatized using , -dinitrophenylhydrazine (dnph) (oxyblot® kit), separated on sds-page, probed with anti-dnph ab ( : ) and oxidized proteins detected using ecl. protein band intensity was measured by densitometry. oxidized proteins were selected for maldi mass spectrometry analysis. results: nitrotyrosine residues were immunolocalized primarily in the fetal capillary endothelial cells and the villous stroma, but were almost absent in the syncytiotrophoblast. by dot blot, nitrotyrosine expression differed across the three groups (p< . , anova) with expression in tissue from obese women being significantly increased compared to lean (p< . ) and overweight (p< . , tukey test). several oxidized proteins were detected with significantly greater expression seen in the lean versus overweight groups (p< . , mann-whitney u). one oxidized protein was identified by maldi-ms with four peptide matches and . % coverage as -beta hydroxysteroid dehydrogenase ( bhsd). discussion: with increasing bmi, an increase in nitrative stress appears to occur in parallel with a decrease in oxidative stress. oxidative stress is apparently reduced as ros are consumed by the interaction with rns to give nitrative stress. bhsd is involved in the biosynthesis of steroid hormones and glucocorticoids. its activity and hence steroid metabolism in the placenta may be regulated by oxidation with implications for fetal development. background teenagers are susceptible to delivering small-for-gestationalage (sga) infants. previous studies implicate continued maternal growth as a causal factor . growing adolescent sheep have reduced fetal birthweight due to impaired placental development and nutrient transfer . we hypothesized that placental function is impaired in human teenage pregnancy if there is maternal growth. methods placentas were collected from teenagers ( - years) and adults. activity of the amino acid transporter, system a, was quantified by the sodium-dependent uptake of c-methylaminoisobutyric acid into placental fragments. teenagers were defined as growing (> mm increase in kneeheight per days) or non-growing. system a activity was analysed in relation to individualised birthweight centile and maternal growth. results placental system a activity was significantly lower in teenage compared to adult pregnancies (p< . ). this was unrelated to birthweight; teenagers who delivered infants appropriate-for-gestational age (aga) had significantly lower placental system a activity compared to aga infants delivered to adults (p< . ). growing teenagers did not deliver lower birthweight infants than non-growing teenagers (median birthweight g and g respectively). furthermore, system a activity in placentas from growing teenagers was significantly elevated compared to that in non-growing teenagers (p< . ), and was similar to placental activity in adults. conclusions system a activity was reduced in placentas from teenagers compared to adults. this suggests that inherently lower placental function predisposes teenagers to sga, but that other factors (e.g. adequate nutrition) can compensate in those teenagers delivering aga infants. in contrast to our hypothesis, placental system a was elevated in growing teenagers and mimicked that of adults. this may be related to a hormonal-milieu in growing teenagers that is conducive to fetal growth, in part through stimulating placental transport. homocysteine inhibition of system a amino acid transport activity in human placenta. eleni tsitsiou, susan l greenwood, colin p sibley, stephen w d'souza, jocelyn d glazier. maternal and fetal health research group, st. mary's hospital, university of manchester, manchester, united kingdom. background: elevated plasma levels of the amino acid homocysteine (hcy) during pregnancy are associated with vascular-related complications and adverse neonatal outcomes including a reduced birthweight. fetal and maternal plasma hcy concentrations are positively correlated suggesting placental transport of hcy may be an important determinant of fetal plasma hcy. the mechanisms involved in placental hcy transport are uncharacterised. evidence that the system a amino acid transporter, which transports neutral amino acids in a na + -dependent manner, is important in promoting fetal growth and that a reduced system a activity is associated with intrauterine growth restriction (iugr), led to our hypothesis that system a provides one mechanism for placental hcy transport. this hypothesis was tested by measuring the ability of hcy to inhibit system a activity in isolated microvillous plasma membrane (mvm) vesicles and placental fragments. materials and methods: mvm vesicles and placental fragments were isolated from placentas of normal pregnancies at term. system a activity was measured at initial rate ( s and min respectively) as na + -dependent cmethylaminoisobutyric acid (meaib) uptake into mvm vesicles ( . mm) or fragments ( . mm) in the absence (control) or presence of l-hcy and dl-hcy or model substrates. results: mm l-hcy (custom-synthesised) and dl-hcy (commercial source) significantly (p< . ) inhibited na + -dependent c-meaib uptake into mvm vesicles compared to control; comparable in magnitude to other model substrates (meaib, l-ala, l-ser, l-met; n= , kruskal-wallis with dunn's multiple comparison test). l-hcy, l-met and meaib ( . - mm) caused a dose-dependent inhibition of na + -dependent c-meaib uptake into mvm with ec values (in mm; mean ± se) of . ± . , . ± . , and . ± . respectively, n= ). na + -dependent c-meaib uptake into fragments was reduced substantially in the presence of mm l-hcy or dl-hcy causing a ± and ± % reduction (mean ± sd, n= - ) of control respectively. conclusion: these observations suggest that hcy is a relatively high affinity substrate for system a in the human placenta. we speculate that inhibition of placental amino acid uptake by hcy could impact on fetal growth and development. supported by the mrc and action research endowment fund. glucose regulates placental mtor activity and glucose deprivation down-regulates placental system l activity in an mtor-dependent manner. sara roos, theresa l powell, thomas jansson. department of physiology, institute of neuroscience and physiology, gothenburg, sweden; department of obstetrics and gynecology, university of cincinnati, cincinnati, oh, usa. placental amino acid transporters are down-regulated in intrauterine growth restriction (iugr). we have previously shown that mammalian target of rapamycin (mtor) regulates placental system l transporter activity and that placental mtor activity is decreased in iugr. however, the upstream regulators of placental mtor are unknown. in iugr, fetal hypoglycemia and reduced maternal glucose levels are common and the placenta may therefore be exposed to low glucose levels. hypothesis: we hypothesized that glucose availability regulates placental amino acid transporter activity mediated by changes in mtor signaling. methods: cytotrophoblast cells were isolated and cultured until syncytialization at hours. cells were cultured for an additional hours in culture media containing . mm, . mm, or mm glucose (control), which corresponds to standard culture media. at hrs, the activity of the mtor signaling pathway was assessed by measuring the protein expression of s k phosphorylated at thr- , the primary site of mtor phosphorylation. in another set of cells, system l activity was assessed by measuring the bchinhibitable uptake of h-leucine. results: as compared to control, phospho-thr- -s k expression was reduced by % in cells incubated in . mm results: fgr pregnancies were delivered earlier ( ± . v ± . w; p< . ), weighed less ( . ± . v . ± . kg; p< . ) and had higher s/d ratios ( . ± . v . ± . ; p< . ). eaa concentrations were similar between groups, but there were differences (non-parametric testing; p< . ) in transport rates between groups with his crossing considerably faster and ile crossing slower in fgr . the table shows fetal vein/maternal (fv/m) ratios standardized to the leu fv/m ratio for all eaa for both groups. amino acids fell into groups for fgr pregnancies: ) his (ratio . ), ) leu, phe, met (ratios ), and ) val, thr, ile, trp, lys with intermediate ratios ( . ns conclusion: this is the st study to compare the relative rates of in vivo placental transport for all eaa between normal and fgr human pregnancies showing striking differences in the transport rates of two eaa. in the absence of eaa concentration differences between groups, the higher his transport rate in fgr suggests higher utilization by the placenta. vasculature of women who received exogenous estrogen compared to those who received placebo. the purpose of this investigation was to identify the gene expression in response to the estrogen, equilin, as the major component of conjugated equine estrogen and genistein, a phytoestrogen in human coronary artery endothelial cells. human coronary artery endothelial cells from a -year old female were used. cells were treated with estradiol [e ], equilin [eq] ( . nm) or genistein [gen] ( micromolar) for hours. focused oligomicroarrays for cardiovascular disease and endothelial cell function were used to study gene expression. rt-pcr was used to confirm the transcription of genes analyzed in oligoarrays. vascular adhesion molecules and genes involved in the inflammatory response were most affected with the three estrogen sources. significant reduction of integrin alphae was seen with all three . , . and . for e , eq and gen respectively. similarly nfkb was also reduced . , . and . fold compared to controls. significant reduction of ccl was demonstrated with eq ( . fold) and gen ( . fold). tnfreceptor a and b were only significantly decreased by gen. vcam- which is regulated by proatherogenic factors and upregulated mainly at atherosclerosis -prone sites, was significantly reduced ( . -fold) with genistein, and a slight reduction was seen with e and no change was observed with eq. our data support the clinical findings that estrogen has favorable effects on the genes involved in atherosclerotic disease. while e has been shown to be slightly more effective than equilin in the modulation of gene expression, genistein was significantly more effective in the favorable expression of genes involved in particularly the inflammatory response. olga n lekontseva, sandra t davidge. physiology and obstetrics/gynecology, university of alberta, edmonton, ab, canada. introduction: the prevalence of cardiovascular disease in women dramatically rises in the postmenopausal period. although deficiency of estrogen has been implicated in the pathophysiology of systemic vascular dysfunction, the effects of estrogen on vasculature are complex and not completely understood. we have previously shown that estrogen exerts a beneficial effect on the aging vascular system by reducing circulating levels of the inflammatory cytokine tnf . tnf is a known regulator of matrix metalloproteinases (mmps), proteolytic enzymes that may modulate vascular tone through cleavage of vasoactive peptides such as big endothelin- (et- ). the role of estrogen in this pathway is unknown. we tested the hypothesis that in aging/estrogen deficiency, tnf -induced mmp activity mediates greater vasoconstriction, in part, through the et- pathway. we further hypothesized that estrogen replacement reduces vascular sensitivity to the constriction by preventing mmp activation. methods: aged ( month old) female sprague dawley rats were ovariectomized and treated with either placebo [ovx] , -estradiol [ovx+e ], or the tnf inhibitor etanercept [ovx+etan] . after four weeks, resistance mesenteric arteries were isolated and studied on the pressure arteriograph. concentrationresponse to exogenous big in the absence or presence of mmp inhibitor (gm , μm) was assessed in the vessels. results: treatment of "menopausal" [ovx] rats with either estrogen or the tnf inhibitor reduced sensitivity of arteries to big et- (ec = . ± . μm in ovx versus . ± . μm in ovx+e or . ± . μm in ovx+etan groups; p< . ). although mmp inhibition attenuated maximal constriction in all of the arteries, there was a significantly greater (p< . ) role of mmps in big et- -induced vasoconstriction in the ovx+e group (reduction in max constriction= . ± . %) compared to ovx ( . ± . %) and ovx+etan groups ( . ± . %). conclusions: both estrogen and tnf inhibition reduced big et- vasoconstriction. however, contrary to our hypothesis, tnf is not contributing to mmp modulation of et- vasoconstriction. interestingly, our study demonstrates a novel role for estrogen to increase mmp contribution to big et- vasoactivity with the net effect being less vasoconstrictive. understanding this unique pathway of regulation by estrogen in the aged vasculature will allow for development of new therapeutic options for women. mo, usa. introduction: the etiology of pelvic organ prolapse is multifactorial, with both inherited and acquired components. the molecular mechanisms of prolapse have not been established yet. we have previously shown that lysyl oxidase (lox) expression is suppressed in uterosacral ligaments of women with pelvic organ prolapse. it has also been shown that lox is a tumor suppressor gene inactivated by methylation in human gastric cancers. hypothesis: the aim of this study was to analyze the dna sequence of the promoter region of the lysyl oxidase gene in tissues from women with pelvic organ prolapse and identify whether methylation is present. our hypothesis is that the promoters of the lox gene in women with pelvic organ prolapse have significantly more methylation sites than women without prolapse. materials and methods: genomic dna was isolated from the uterosacral ligaments of eight women with pelvic organ prolapse and women without prolapse (controls). genomic dna samples were treated with ez dna methylation kit (zemo research, orange, ca). the lox gene promoter region of - to + was amplified by pcr and then cloned into pcr . -topo (invitrogen, carlsbad, ca) and transformed into an e. coli dh a strain. amplified plasmid dna samples containing the lox gene promoter region from each woman were sequenced and methylated cpg islands were identified by sequence comparison. results: a total of methylated cpg sites were found in the patient group with pelvic organ prolapse while only methylated cpg site was found in the non-prolapse control group. conclusion: these findings suggest that methylation in the promoter region suppresses lox gene expression in women with pelvic organ prolapse. background: reports from case-control and cohort studies have suggested an inverse association between lactation and breast cancer risk, but findings have been inconsistent. methods: we conducted a prospective observational cohort study of , parous women participating in the nurses' health study ii from to . our primary outcome was incident premenopausal breast cancer. results: during the study period, cases of premenopausal breast cancer were diagnosed during , person-years of follow-up. women who had ever breastfed had a % lower incidence of premenopausal breast cancer ( % confidence interval [ci] - %) compared with women who never breastfed, adjusting for parity, age at first birth, year of first birth, height, body mass index (bmi), bmi at age , family history, personal history of benign breast disease, participant birth weight, preterm birth, age at menarche, oral contraceptive use, physical activity, and alcohol consumption. no trend was observed with duration of lactation (p= . ). the association between ever-breastfeeding and premenopausal breast cancer was modified by use of medication to suppress lactation (p= . ); in analyses restricted to women who had never used suppressive medication, ever-breastfeeding was associated with a % ( %ci - %) reduction in incident disease. the association between lactation and premenopausal breast cancer was further modified by family history of breast cancer (p= . ). among women who had never used suppressive medication and reported a family history, those who had breastfed had a % lower covariate-adjusted risk of premenopausal breast cancer ( % ci - %) than women who had never breastfed. among women without a family history, ever-breastfeeding was not associated with breast cancer incidence (hazard ratio . , % ci . - . ). among women who had ever breastfed, we observed no association between breast cancer risk and duration of lactation amenorrhea or exclusive breastfeeding. conclusion: in a large, prospective cohort study, ever-breastfeeding was inversely associated with risk for premenopausal breast cancer. at the durations observed in our cohort, we observed no trend with duration of breastfeeding or lactation amenorrhea. the inverse association with ever-breastfeeding was stronger among women with a family history of breast cancer. regulatory and nkt cells at the maternal-fetal interface. thomas f mcelrath, rachael a clark. brigham women's hospital, boston, ma, usa; harvard skin disease research center, brigham women's hospital, boston, ma, usa. introduction: pregnancy represents an immunologically challenging event requiring maternal tolerance of the fetal semi-allograft. an increase in decidual cd + cd + t cells has been documented but it is unclear if these represent foxp + t cells (tregs) . the possibility also exists that other cd + lineages with potential regulatory function exist within the decidua parientalis. we examined if cd + cd + cells are true foxp + tregs and evaluated the frequency of other t cell subsets with possible regulatory potential. methods: we extracted t cells from term deciduas of planned cesarean deliveries. cells were stained with directly conjugated monoclonal antibodies and were analyzed on a six color flow cytometer. results: we found that only a subset (median %) of cd + t cells were true foxp + regulatory t cells. from donors, foxp + tregs accounted for a median of . % of all cd + cells. these cells were memory cd ro + t cells lacking ccr , and l-selectin but expressing cd , ctla- , gitr, and hla-dr. additionally we found that a median % of cd + t cells expressed the nkt marker cd . these cells were a mixture of cd and cd -cd -t cells, with variable numbers of cd t cells, suggesting they do not represent merely recently activated t cells. there was enrichment for t cells with nkt markers after culture on hela cells expressing cd d, suggesting that these cell represent true nkt cells. nkt cells were of the non-classical type, with a diverse t cell repertoire ( . % iv jq) and also expressed cd , hla class ii, cd ro but were ccr and l-selectin low. comments: we find that only a minority of cd -expressing t cell in the decidua are true foxp + tregs. because much of the work on treg in pregnancy has used cd as a treg marker, this suggests additional studies are needed to confirm the role of these cells in pregnancy. we find that a novel population of non-classical nkt cells exists in the human decidua. nkt cells can either promote or antagonize tolerance, depending on the immunologic context. the large number of these cells in the decidua suggests they may play a role equal or exceeding that of regulatory t cells. prolapse. marsha k guess, kathleen a connell, richard bercik, lloyd g cantley. obstetrics, gynecology reproductive sciences, yale university school of medicine, new haven, ct, usa; internal medicine/neprhology, yale university school of medicine, new haven, ct, usa. objectives: thy- is a cell surface glycoprotien expressed in human fibroblasts, neurons, hematopoetic stems cells and endothelial cells. thy- expression affects fibroblast proliferation and migration, cell-cell, as well as, cell-matrix interactions. moreover, thy- expression has been shown to play a critical role in fibroblast dedifferentiation into myofibroblasts, as well as in extracellular matrix (ecm) production and fibrosis. women with pelvic organ prolapse (pop) have alterations in vaginal ecm protein expression and metabolism, as well as decreases in smooth muscle fractional content. in the current study, we evaluated thy- as well as the smooth muscle markers alpha-smooth muscle actin (asma) and desmin expression in women with pelvic organ prolapse compared to women with normal pelvic support (controls). methods: anterior apical vaginal wall specimens from women with pop and controls were collected at the time of hysterectomy. messenger rna and protein expression of thy- , asma and desmin were evaluated using semiquantitative rt-pcr, real-time pcr and western blot analysis. gapdh and beta actin were used as internal controls. results: rt-pcr demonstrated the presence of thy- , asma and desmin in vaginal tissue from women with pop and controls. further, thy- mrna expression was downregulated % in women with pop compared to controls (p = . ). a parallel decrease in thy- protein was seen in women with pop compared to controls (p= . ). although a % and a % decease were seen in asma and desmin mrna, these differences were not statistically significant. similarly, no differences were seen in asma and desmin protein expression. conclusion: we demonstrate that there is significantly less thy- expression in vaginal tissue from women with pop compared to controls. differential expression of thy- in prolapsed vaginal tissues suggests that thy- may have a functional role in mediating ecm metabolism in the female genitourinary tract. hur expression is altered in ectopic endometrium. s karipcin, t altun, ua kayisli, e seli. ob gyn, yale u., new haven, ct, usa. introduction: cytokines and growth factors contribute to cyclic turnover of the normal endomterium and to the pathogenesis of endometriosis. cytokine and growth factor messenger rnas (mrnas) undergo rapid turnover that is primarily mediated by au-rich elements (are) that consist of multiple stretches of adenylate and uridylate residues located in the ' untranslated region ( '-utr) of their mrnas. hur is a ubiquitously expressed rna-binding protein that stabilizes are containing mrnas and prolongs their expression. we hypothesized that hur may play a role in the regulation of cytokine expression during normal menstrual cycle and in endometriosis. methods: tissue sections obtained from normal (n= ) and ectopic (n= ) endometrium were immunostained for hur. staining intensity was evaluated by hscore and grouped according to menstrual cycle phase. statistical analysis was done with one-way anova. cultured stromal cells isolated from normal endometrium were treated with vehicle, estradiol (e ; - m), or progesterone (p, - m) for and h, and hur expression was determined using western analysis and normalized to ß-actin. results: hur immunostaining was nuclear in endometrial cells. hur immunoreactivity was significantly lower in the early proliferative and late secretory phases ( . ± . and . ± . , respectively), compared to the mid-late proliferative ( . ± . ) and early-mid secretory phases ( . ± . )(p< . ). moreover, hur expression was significantly lower in ectopic endometrial cells when compared to normal endometrium in midlate proliferative and early and mid-secretory phases (p< . ). progesterone suppressed hur levels significantly in cultured endometrial stromal cells at both and h compared to control (p< . ) while estrogen did not cause a significant change. discussion: decreased hur levels in the late secretory and early proliferative phases are likely to contribute to degradation of cytokines and result in lower cytokine levels observed mid-cycle. late secretory decrease in hur levels may be mediated by progesterone as suggested by in vitro findings. in ectopic endometrium, persistent low expression of hur compared to normal endometrium most probably results from elevated cytokine levels associated with endometriosis. the effect of lower hur expression in ectopic endometrium on other are-containing transcripts, and on the pathogenesis of endometriosis remains to be elucidated. tissue. hong zhao, joy innes, scott reierstad, mehmet bertan yilmaz, serdar e bulun. department of obstetrics and gynecology, northwestern university, chicago, il, usa. background: aromatase is the key enzyme for estrogen biosythesis, and is encoded by the cyp a gene. thus far, only three unique untranslated first exons associated with distinct promoters in the mouse cyp a gene were described (brain-, ovary and testis-specific exon i). however, it remains unknown whether aromatase is expressed in other mouse tissues via previously unknown tissue-specific promoters activating new exon is. methods: real-time pcr was used to examine the aromatase expression levels in various c bl mouse tissues. '-rapid amplification of cdna ends ( '-race) was used to determine the transcriptional start sites of cyp a transcripts. promoter activity was measured using serial deletion mutants of dna fused to the luciferase reporter gene. results: real-time pcr results showed that aromatase was expressed in male gonadal fat and the expression level is lower than that in testis. the adipose tissue-specific untranslated exon i of cyp a transcript was isolated using '-race and this novel gonadal fat-specific exon i of cyp a mrna did not show sequence similarities to previously reported ones. this new adiposespecific exon i was mapped to kb upstream of the translation start site in the coding exon ii. the genomic region upstream of the adipose-specific exon i was cloned into luciferase plasmids. transfection of murine t -l cells with these plasmids showed that promoter activity was conferred by the sequence located at - to - bp upstream of the transcriptional start site. dexamethasone significantly induced activity of the adipose-specific promoter region. conclusion: taken together, our results suggest that a novel cyp a transcript is regulated by a tissue-specific promoter in male murine gonadal fat. these sacrificed; reproductive and selected other organs were removed, weighed and evaluated histologically by an observer blinded to treatment. results: the table below shows that tcc augmented effects of tp on weights of accessory sex organs. histological assessment revealed that tcc induced greater glandular distention with more secretions compared to the effects of tp alone; furthermore, mitotic figures were seen only in prostates from rats exposed to tp+tcc. conclusions: tcc is a newly identified endocrine disruptor with unique and novel actions resulting in potentiation of androgen effects on sex organs. these observations underscore possible environmental risks related to exposure to tcc. background: blastocyst implantation is dependent on the differentiation of human endometrial stromal cells (hesc) into decidual cells. transforming growth factor family members have well defined roles in cell differentiation and proliferation. activin a, a tgf superfamily member, enhances hesc decidualization and localizes to decidualized cells in human endometrium. other tgf superfamily members, including bmp , bmp , bmp , gdf , gdf (myostatin), gdf and nodal, may also be present in decidual cells and therefore may also play a role during this important process. this study aimed to determine whether activin is the major family member driving decidualization or whether other family members contribute to the process. methods: broad ranging activin inhibitors (activin-m a and sb ) that effect receptor-ligand interactions of other tgf superfamily members were used in hesc decidualization. protein localization was examined in secretory phase endometrium and first trimester decidua by immunohistochemistry and mrna expression was examined in an ex vivo model. the secretion of candidate proteins was measured during hesc decidualization and certain recombinant proteins added during decidualization to examine their effect. results: m a ( nm) and sb ( m) significantly reduced decidualization ( % and % respectively) demonstrating that activin and possibly other tgf family members are involved in decidualization in vitro. bmp , gdf and tgf protein were detected in decidual cells of mid-late secretory endometrium and first trimester decidua whilst all ligands except nodal, were expressed by hesc. both bmp and tgf secretion increased during hesc decidualization and administration of both these proteins significantly enhanced decidualization in vitro. conclusions: these data support a role for activin a, bmp and tgf in hesc decidualization. this is important as the elucidation of factors involved during decidualization will aid in better understanding implantation and fertility. abnormal chromatin remodeling in diabetic murine oocytes. laura lawrence, ann ratchford, cybill esguerra, qiang wang, kelle moley. ob/ gyn, washington university, st. louis, mo, usa. background: diabetic women experience increased miscarriages and adverse pregnancy outcomes. previous studies suggest adverse diabetic outcomes may occur earlier than the preimplantation period, particularly during oogenesis. we hypothesize that diabetes affects chromatin remodeling and chromosomal condensation in murine oocytes. methods: mii oocytes from diabetic and control mice were fixed with % pfa, permeabilized with . % triton x- for min, and immunostained against a-tubulin and the nucleus for hr at rt. images were obtained with laser confocal scanning microscope. protein expression levels of chromatin with dimethyl h k modifications were measured in nondiabetic and diabetic denuded murine oocytes at hours post pmsg ( hour) and at six hours post hcg ( hour) via western immunoblots. mature nondiabetic denuded oocytes were fixed in %pfa and permeabilized with . % triton x- . they were stained via immunohistochemistry against histone protein h at lysine (h k me ) and heterochromatin. results: immunohistochemistry reveals that diabetic mii oocytes have aberrant spindle formations and metaphase chromosome alignment. approximately / ( %) diabetic oocytes examined had abnormal spindles and metaphase alignments compared with only about / normal oocytes ( . %). western blot demonstrated times higher expression of dimethylated chromatin in diabetic oocytes at time compared with nondiabetic oocytes. at time hours, diabetic oocytes had significantly fewer h k modifications than the controls. when staining mature murine nondiabetic oocytes for dimethylation of h k me by immunohistochemistry, we demonstrated h k me expression in a condensed heterochromatin ring surrounding the nucleolus, consistent with transcriptional silencing. conclusions: diabetic mii oocytes have a significant increase in abnormal spindle formation and metaphase chromosome alignment. they also have increased dimethylation compared with normal oocytes at a time point when they should be transcriptionally active, storing maternal mrna in preparation for the silencing period. in addition, after hcg injection to trigger maturation and gene silencing, the diabetic oocytes had decreased dimethylated chromatin changes. our findings suggest that diabetic oocytes may be exiting the transcriptionally active period prematurely and may ultimately experience decreased, partial, and incomplete gene silencing. and xenopus epab genes and proteins were performed. expression of human epab and pabpc mrna was tested in ten different somatic tissues, testes, and ovaries by rt-pcr. amplification with actin primers provided a positive control and allowed semi-quantitative analysis. epab and pabpc expression in human prophase i (pi) and metaphase ii (mii) oocytes, -cell embryos and blastocysts was evaluated using quantitative real time pcr. results: human epab is a aa protein with % identity and % similarity to mouse epab and contains rna recognition motifs and a pabp domain. human epab mrna is detected in ovaries and to a lesser extent in testes and several somatic tissues including kidney, liver, and muscle. similar to its mouse orthologue, human epab mrna is expressed in pi and mii oocytes, but not in -cell embryos or blastocysts. pabpc mrna is ubiquitously present in all tissues as well as -cell, and blastocyst stage embryos. however, its levels are significantly lower than that of epab in oocytes. conclusions: in this study we report the identification of human epab. similar to that observed in xenopus and mouse, human epab is the predominant poly(a) binding protein in oocytes and it is replaced by pabpc following zga, which occurs at -to -cell stage in human. our findings suggest that the unique translational regulatory pathways that control gene expression during oogenesis and early embryo development may be common between model organisms and humans. objective: c-jun nh -terminal kinase (jnk), a member of mitogen-activated protein (map) kinase family, is involved in cell proliferation, differentiation, and survival. fsh is required for granulosa cell proliferation and antral follicle growth but its mechanism of action in preantral stages is not well defined. we previously showed that pharmacological inhibition of jnk pathway halts invitro growth of murine preantral follicles in serum free media supplemented with fsh ( miu/ml). sigcs (spontaneously immortalized rat granulosa cell line) have characteristics similar to preantral granulosa cells and hence they were used in this study to determine whether the jnk pathway plays a key role in preantral granulosa cell proliferation. our specific aims were to determine whether: a) fsh activates jnk pathway in granulosa cells; b) the inhibition of jnk pathway blocks cell cycle progression. material and methods: sigcs were treated with miu/ml recombinant fsh in serum free media two days after serum starvation. activation of jnk pathway was analyzed with if and wb using phospho-jnk and phospho-cjun expression, respectively. fsh receptor expression (fshr) was analyzed with if. the inhibition of jnk pathway on cell cycle progression was analyzed by facs using a jnk inhibitor sp . results: fshr protein was expressed in sigc indicating that they can respond to fsh (fig a) . likewise by if, phospho-jnk expression was significantly increased in sigc hour post fsh exposure (fig- a) . similarly on wb, phospho-cjun expression increased as early as min after fsh exposure and peaked at hrs. cjun phosphorylation was abolished hr after treatment with sp ( mm) (fig b) . facs analysis showed that the inhibition of jnk by sp resulted in cell cycle arrest at g /m transition in a dose dependent fashion (fig c) . conclusion: these results strongly suggest that the proliferative effect of fsh on immature granulosa cells is mediated through the activation of jnk pathway. this is the first experimental observation implicating jnk signaling in granulosa cell cycle control. (nichd - ). the induction of {alpha}-hydroxylase (cyp ) expression in granulosa cells. satin s patel, victor e beshay, william e rainey, bruce r carr. reproductive endocrinology and infertility, university of texas at southwestern medical center at dallas, dallas, tx, usa; physiology, medical college of georgia, augusta, ga, usa. according to the traditional two-cell two-gonadotropin hypothesis of the ovary, androgen production arises exclusively from theca cells. the granulosa cells, in turn, utilize androstenedione, which is aromatized eventually to estradiol. studies involving immunohistochemical analysis of normal ovaries have shown that granulosa cells express significantly higher levels of the activator protein- (ap- ) transcription factor, cfos compared to theca cells, where cfos expression is virtually absent. we hypothesize that cfos functions to inhibit the expression of cyp in granulosa cells, thereby suppressing androgen production. hence, the inhibition of cfos activity might result in cyp expression in the granulosa cell. our objective was to define the role of cfos, in the regulation of cyp expression in granulosa cells. transformed human luteinized granulosa (hgl ) cells were utilized for all experiments. hgl cells were cultured in monolayer for h. cells were treated for h with and without pd (pd), a mapkk inhibitor, which also blocks cfos expression. rna was isolated and real time rt-pcr was performed for cyp . cfos rna interference experiments were carried out using rnaifect, cfos smartpool sirna and scrambled sirna for h. rna was isolated and rt-pcr was also performed for cyp . immunochistochemical studies were performed on normal ovaries, staining for cfos and cyp . treatment of hgl cells with the mapkk inhibitor pd for h, resulted in a -fold increase in cyp mrna expression compared to basal conditions. in cfos gene silenced cells, cyp mrna expression also increased by -fold compared to control sirna conditions. immunohistochemical staining for cfos and cyp showed significant staining of cfos in the granulosa cell layer, but absent staining for cyp . conversely, the theca cell layer did not stain for cfos, but staining was evident for cyp . these results suggest that the ap- transcription factor, cfos, may play a role in the inhibition of cyp expression in granulosa cells. this may provide an explanation for the lack of cyp expression in granulosa cells. the g /m stages of the granulosa cell cycle. as clip- has been identified as an mtor substrate, we hypothesized that its function at the mitotic spindle would be positively regulated by mtor during the late g and m phases of the cell cycle in granulosa cells. during periods of stress (e.g., mtor inhibition), mtor would fail to phosphorylate clip- , leading to spindle checkpoint failure and follicle undergrowth. objectives: the expression of clip- and mtor were evaluated. computational analysis of potential clip- phosphorylation sites and comparison with residues on known mtor targets were performed. clip- threonine and serine were chosen and evaluated as bona fide mtor phosphorylation sites. a preliminary assessment of the effects of mtor inhibition upon clip- function was performed. methods: for protein expression analyses, western blots, immunostaining of tissues and primary granulosa cells in culture were performed. computational analysis of potential clip- phosphorylation sites was followed by in vitro assessment of mtor kinase activity upon clip- and a peptide substrate. results: clip- was expressed in the ovarian stroma, blood vessels (including the endothelial cells of both arteries and veins), granulosa cells, and in the oocytes of primordial and growing follicles. overlapping expression was found between clip- , mtor, and the mtor cofactors raptor and rictor in granulosa cells. this expression was conserved between the mouse and the human. evaluation of clip- phosphorylation supported thr as a bona fide mtor target. conclusions: clip- was supported as an mtor substrate protein during granulosa cell mitosis. the mechanism of mtor action during granulosa cell growth and survival is likely to include the phosphorylation of clip- and subsequent positive regulation of mitotic spindle function. the effect of a selective oxytocin antagonist (barusiban) in threatened preterm labour: a randomised, double-blind, placebo-controlled trial. steven thornton, thomas m goodwin, gorm greisen, morten hedegaard, joan-carles arce. warwick medical school, university of warwick, coventry, united kingdom; maternal-fetal medicine, university of southern california, los angeles, usa; dept of neonatology, rigshospitalet, copenhagen, denmark; dept of obstetrics, rigshospitalet, copenhagen, denmark; clinical research development, ferring pharmaceuticals, copenhagen, denmark. objective: a mixed oxytocin/vasopressin v a antagonist, atosiban, has been shown to reduce uterine contractions in placebo-controlled clinical trials and is useful in the management of preterm labour. the objective of this study was to determine the effect of a selective oxytocin antagonist, barusiban, in delaying delivery and reducing uterine contractions in women with threatened preterm labour at a late gestational age and relatively high risk of delivery. methods: this was a randomised, double-blind, placebo-controlled multicentre study in countries. a total of women between + and + weeks gestation, and with uterine contractions of sec duration during min, cervical length mm, and cervical dilatation > and < cm were randomised to receive a single intravenous bolus dose of either barusiban . mg, mg, mg, mg or placebo. rescue tocolytics were prohibited. the primary end-point was percentage of women who did not deliver within h. uterine contractions were monitored by cardiotocography. obstetrical and neonatal outcomes were determined. results: there were no significant differences between the placebo and any barusiban group in percentage of women who did not deliver within h ( % in the placebo group and % to % in the barusiban groups). there was no dose-effect relationship nor an effect at or h. none of the barusiban groups were associated with a significant reduction in number of uterine contractions compared to placebo at any time point up to h post-dosing. postpartum blood loss and time to established lactation were not significantly increased with barusiban. barusiban was well tolerated and was not associated with safety concerns for the women, fetus or neonates. conclusion: a single intravenous bolus of a selective oxytocin antagonist, barusiban (dose range . - mg), did not delay delivery or reduce uterine contractions compared to placebo in women with preterm labour at late gestational age and with short cervical length. the results contrast those of the mixed oxytocin/vasopressin v a antagonist, atosiban. prolonged delivery intervals in triplet gestations. tracy a manuck, heather l mertz, leah passmore, david c merrill. obstetrics and gynecology, wake forest university health sciences, winston-salem, nc, usa. objective: delayed interval delivery is one management strategy for previable preterm labor affecting multiple gestations. prior reports of asynchronous deliveries have examined twins and higher-order multiples as a group. this study was conducted to analyze the unique situation of asynchronous triplet deliveries. study design: cases of asynchronous triplet deliveries resulting in an ongoing twin gestation were ascertained through medline. data were abstracted and combined with two similar previously unpublished cases. patients were grouped by management with and without rescue cerclage. variables compared included use of tocolytics, antibiotic administration, gestational age at delivery of each fetus, interdelivery interval, delivery mode, birthweights, and short and long term outcomes. chi-square or t-test analyses were used where appropriate. results: fifty-one cases of asynchronous triplet deliveries met inclusion criteria and were analyzed. twenty-three patients ( . %) underwent placement of a rescue cerclage following delivery of the first infant. these patients delivered the first fetus at a significantly earlier gestational age as compared to those patients without a cerclage ( . +/- . weeks vs. . +/- . weeks, p= . ). patients with a rescue cerclage had a significantly longer prolongation of the remaining twin gestation ( . +/- . days vs. . +/- . days, p= . ). no significant differences in use of tocolytics or antibiotics, gestational age at delivery of triplets "b" and "c," mode of delivery, short term outcome (alive at hours), or long term outcome (alive at discharge) were noted, despite delivery of triplet "a" at a significantly younger gestational age. conclusion: rescue cerclage, particularly when placed following previable delivery of a first triplet, may significantly prolong the delivery interval for the remaining twin gestation. mean pregnancy prolongation (days). objective the aim of our study was to evaluate the role of amnioinfusion in pregnancies complicated by pprom. we studied singleton pregnancies with pprom at < weeks gestation. all patients were managed conservatively with bed-rest, prophilactic antibiotics, tocolytics and steroids. only patients without vaginal bleeding and/or contractions were included: patients showed an amniotic fluid pocket (afp) persistently cm and did not undergo amnioinfusion (group b) whereas had a maximum afp < cm and were offered amnioinfusion to restore an adequate amount of amniotic fluid (group a). in patients of group a amnioinfusion was successful (afp cm for hours following the procedure: group a ) whilst in it was unsuccessful (afp< for hours: group a ) and repeated. results were analized with the student t test for unpaired samples and with the when appropriate. p values < . were considered significant. results the group where amnioinfusion was not successful (group a ) showed the worst outcome (see table) . there were intrauterine deaths, all in this group. pulmonary hypoplasia was present in / ( . %) newborns (both survived and deceased) newborns, / in group a . no maternal complications were recorded. conclusions our data confirm that a conservative-active management with amnioinfusion can be considered a reasonable option in women with pprom. in our series it was effective in preventing both neonatal death and pulmonary hypoplasia. group a (infusion successful) background. synthetic progestogens are effective in reducing the risk of spontaneous preterm birth in high risk singleton, but not multiple, pregnancy. we hypothesized that myometrial stretch may inhibit the response of human myometrium to progestogens. methods. myometrial strips obtained with written consent at the time of term planned cesarean section were studied using a modification of the method of young and zhang (jsgi ; : - ) . strips were maintained in individual tubes in tissue culture media in an incubator for a period of three days. the effect of prolonged stretch was assessed by comparing strips connected to a . g weight with those connected to a . g weight. the effect of prolonged exposure to progestogen was studied by adding medroxyprogesterone acetate (mpa, nm or nm). following the day incubation, myometrial strips were transferred to an organ bath containing kreb's solution. all were placed under g tension and responses obtained to mm potassium then oxytocin. contractility was expressed as the ratio of the maximum response to potassium or oxytocin to the wet weight of the tissue (units = g.tension per gram), summarized as the mean (sem) and compared using student's paired t test. prolonged stretch increased the maximum response to both potassium ( . g weight = . [ . ]; . g weight = . [ . ], n= , p= . ) and oxytocin ( . g weight = . [ . ]; . g weight = . [ . ], n= , p= . ). in strips with a . g weight, incubation in mpa for three days reduced the maximum response to potassium (vehicle = . [ . ]; mpa = . [ . ], n= , p= . ) and there was a trend towards a reduced maximum response to oxytocin (vehicle = . [ . ]; mpa = . [ . ], n= , p= . ). in strips with a . g weight, incubation in mpa for three days had no effect on either the maximum response to potassium . prolonged stretch increases human myometrial contractility in vitro. . prolonged exposure to a progestogen inhibits the contractility of human myometrium but this effect is blocked by prolonged stretch. these properties of human myometrium may explain the failure of oh progesterone caproate to reduce the incidence of spontaneous preterm birth in multiple gestations. sangeeta jain, william l maner, janet l brandon, gary dv hankins, robert e garfield. obstetrics and gynecology, the university of texas medical branch, galveston, tx, usa. objective: to determine if transabdominal uterine electromyography (emg) correlates with parturition factors such as measurement-to-delivery time (mtdt), cervical dilation (cd), cervical effacement (ce), and station (s) for preterm labor patients with and without tocolysis. materials and methods: pregnant preterm labor women were included. uterine electromyography (emg) was measured for minutes. cd, ce, and s were assessed at or near the time of uterine emg measurement. the power density spectrum peak frequency (pdspf) was calculated on emg. patients were grouped (g : tocolysis, n= ; g : no tocolysis, n= ). pearson-product-moment test was used for correlation. significant differences were sought between groups using student-t test. p< . significant. results: there was a significantly higher uterine emg activity (pdspf: . ± . vs. . ± . ), but no difference in cd ( . ± . vs. . ± . ), for patients delivering within days of emg recording compared to those who delivered later, regardless of tocolysis. there was no apparent difference in uterine emg in tocolytic vs. non-tocolytic patients, regardless of mtdt (table ) . conclusions: uterine emg activity is significantly greater in patients in preterm labor who delivered within days of measurement, making it a viable alternative diagnostic parameter for assessing the state of parturition. tocolytics may not affect uterine emg, but this should be further verified with larger studies. supported by grant nih r -hd . objective: calcium sensitizers are a novel class of drugs with unique molecular and phsiological actions. levosimendan, the best characterized of these compounds and is used in the treatment of acute and chronic heart failure. levosimendan can exert an inotropic effect via sensitization of myofilaments to calcium. it also exerts a relaxant effect on vascular smooth muscle through the opening of atp-dependent potassium channels and has been shown to be a potent inhibitor of human uterine contractions in vitro. for these reasons we investigated the effects of levosimendan on uterine contractions, both spontaneous and agonist induced, in the presence of glibenclamide, a k-atp channel blocker. method: biopsies of human myometrium were obtained at elective caesarean section (n= ). dissected myometrial strips suspended under isometric conditions, undergoing spontaneous and oxytocin-induced contractions, were exposed to glibenclmide ( mmol) followed by cumulative additions of levosimendan in the concentration range of nmol/l to mmol/l. control experiments were performed simultaneously. results: levosimendan exerted an inhibitory effect on spontaneous and oxytocin induced contractions in human m yometrium in vitro, in comparison to control experiments. the effect of levosimendan was significantly antagonized by glibenclamide with the mean maximal inhibition seen due to levosimendan greatly reduced (n= , p< . ). conclusion: the calcium sensitizer levosimendan exerted a potent relaxant effect on human uterine contractility in vitro. this action was antagonized by glibanclamide and this study demonstrates that the effect of levosimendan on uterine smooth muscle is mediated at least in part through the k-atp channel. introduction: the determination of the beginning and ending points for "bursts" of electrical activity occurring during uterine contractions is sometimes difficult. if bursts cannot be discerned, the preferred burst-by-burst analysis cannot be performed. one solution to is to analyze any given electrical recording in its entirety. but this approach has often lead to meaningless results when traditional analytic methods are applied. chaos analysis, using lyapunov exponents, may provide an answer. materials and methods: term patients were included in the analysis: were in labor (group ), while were non-labor (group ). minute recordings were analyzed using "lyapunov exponent." for each pair of subsequent trajectories in phase space, only the most positive lyapunov exponent was calculated. the mean largest exponent was found by averaging over all of the trajectories in the recording. the lyapunov exponent is given in units of bits per data sample. thus a value of + means that the separation of nearby orbits doubles on the average in the time interval between data samples. the mean largest exponent was found for each patient recording. these values were compared using t-test (p < . considered significant). results: the mean and sd of the lyapunov exponent for all the patients was . ± . . moreover, the lyapunov exponent calculated for each patient was positive. comparing lyapunov exponents of the two groups showed a statistically low value (low chaos) for the laboring group, compared to the non-laboring group (figure) . conclusions: there is a chaotic component associated with uterine emg traces, since small but non-negative lyapunov exponents were found in all the traces observed. the lyapunov exponent indicated significantly lower chaotic behavior in the whole emg traces of patients who were in labor than found in those who were not in labor, implying that this measure could be a good diagnostic parameter for labor, possibly eliminating the need for tedious burst-by-burst analysis. supported by grant nih r -hd . comparing uterine emg to tocodynamometer for monitoring contractions. robert e garfield, lynette b mackay, sangeeta jain, william l maner. obstetrics and gynecology, the university of texas medical branch, galveston, tx, usa. objective: to determine whether uterine electromyography (emg) plots contractions similarly to tocodynamometer (toco). study design: pregnant term labor patients were recorded using both uterine emg and toco simultaneously. uterine emg signals were sampled at hz and band-pass filtered in the . to . hz range. root-mean-square (rms) function was calculated from the uterine emg signals in order to produce a "toco-like" trace from the original emg trace. emg-generated rms contraction plots were then compared to toco contraction plots using the following criteria: contractions were assigned a marker value of " ." in-between contraction periods were assigned a " ." from these marker values, contraction rates were established. correlation was found between the contraction rates of rms and toco. temporal overlap of contractions plotted by the two methods was used to find overall percent agreement (opa), positive percent agreement (ppa), and negative percent agreement (npa). these parameters were corrected for within-patient variation using a bootstrap method. results: uterine rms contraction plots were seen to correspond with toco contraction plots (fig. ) . corrected opa, ppa, and npa were high at . %, . %, and . %, respectively. there was a large, statistically significant correlation between uterine emg and toco contraction frequency (fig. ) . conclusions: the similarity between toco and uterine emg contraction plots (specifically, using rms to convert) will allow emg to be used interchangeably with toco in the clinic. supported by grant nih r -hd . introduction -this is a secondary analysis of women participating in a center randomized placebo controlled trial (rct) evaluating the impact of -ohpc in preterm birth (ptb) prevention among women with twins. objective -to evaluate the relationship between plasma -ohpc concentrations and gestational age (ga) at delivery in women with twins receiving weekly injections of -ohpc. methods -women with twins were randomized between - weeks to receive weekly im injections of either -ohpc ( mg) or placebo until weeks. after a minimum of five consecutive injections had been administered to assure steady state concentrations a plasma sample was collected between - weeks. the sample drawn just prior to the next scheduled injection was analyzed for -ohpc by hplc-ms in a blinded manner. the lower limit of quantification of -ohpc was ng/ml. we conducted univariate analyses to assess the association of -ohpc concentration and ga at delivery. we also conducted a proportional hazards model to evaluate the time from sample draw to spontaneous delivery (censoring indicated preterm deliveries), and a logistic regression to evaluate ptb< weeks; in both analyses we adjusted for bmi, race and ga at sample draw. results - women assigned to -ohpc were included; all received all of their scheduled injections. the concentration of -ohpc was significantly higher in women delivering < weeks compared with those women delivering > weeks (p= . , table) . concentration of -ohpc was significantly correlated with ga at delivery (r = - . , p= . ). each unit increase of -ohpc was associated with a % increased odds of delivering < weeks (odds ratio . , % ci, . - . , p= . ) and a % increase in hazard of spontaneous delivery (hazard ratio . , % ci, . - . , p= . ) after adjusting for confounders. gestational age at delivery mean (sd) -ng/ml < weeks (n= ) . ( . ) > weeks (n= ) . ( . ) conclusion plasma -ohpc concentrations after weekly injections were inversely related to ga at delivery in women with twins. since -ohpc induces its own metabolism it is possible that higher concentrations during initial treatment are associated with lower plasma concentrations and reduced efficacy in later pregnancy . clearly more studies are needed. objective: in many non-human species, maternal circulating progesterone levels fall prior to delivery, leading to the theory that in humans progesterone withdrawal occurs on a local and/or functional level. our objective was to characterize maternal and fetal progesterone in human preterm and term labor. methods: women between . and . weeks' gestation (cases) or term controls ( - weeks) with either labor with intact membranes or premature rupture of the membranes prior to labor (prom) were enrolled in a prospective case-control study. progesterone was measured by immulite assay in maternal serum collected upon enrollment and again within minutes after delivery and in umbilical cord serum obtained at delivery. maternal progesterone treatment was not used in any subjects. results: cases and controls were studied (see table for comparisons). controls p value ga at enrollment, weeks . ± . . ± . < . interval to delivery, days (median, range) ( - ) ( - . ) < . maternal progesterone at enrollment, ng/ml ± ± < . maternal progesterone after delivery, ng/ml ± ± . cord progesterone, ng/ml ± ± . among cases, fetal but not maternal progesterone was significantly lower in preterm labor with intact membranes ( ± ng/ml, n = ), as compared to prom ( ± , n = ), p< . . this difference increased further when cases of clinical chorioamnionitis were excluded. conclusions: serum progesterone in laboring patients prior to delivery is higher at term than in the preterm period, which may be attributable to increased placental mass in late pregnancy. this disparity disappears shortly after delivery of the fetus and placenta. fetal progesterone levels are several-fold higher than peripartum maternal levels. preterm labor with intact membranes is associated with diminished fetal progesterone, a phenomenon unrelated to clinical infection. these findings suggest the possibility of fetally regulated progesterone withdrawal as a mechanism underlying preterm labor with intact membranes. [snps] and ptb. however, many of these studies are inconclusive and non reproducible. the challenge of identifying robust associations between genetic variation and either susceptibility or protection from ptb is enormous. a systematic review of literature followed by metaanalysis was performed to understand true associations between snps and ptb. methods: for systematic review, articles were chosen based on medline and embase searches ( ( -april and relevant articles were chosen based on stringent inclusion criteria. primarily, studies reporting genetic associations between snps in maternal dna in singleton pregnancies and spontaneous ptb were included. other criteria included, but not limited to, provided genetic data in a complete enough format so that it could be evaluated in meta-analysis and defined the clinical outcome clearly. meta-analysis was performed wherever > replication data sets were available results: a total of abstracts were reviewed and were selected for full text review. data were extracted from articles. over associations were reported between snps on various candidate genes and ptb; however only had replication dataset. meta-analysis documented significant association between pon a g (odds ratio [or]= . ( %ci . - . ), pon (rs# )(or= . ; ci- . - . ), tnfrsf - a/g (fas) (or= . ; ci- . - . ) and ptb. two snps pon s c (or= . ; ci- . - . ) and ifn gamma (rs ; or- . ; ci- . - . ) documented protective effect. conclusions: systematic review concludes significant heterogeneities leading to lack of reproducible data in genetic association studies of ptb. heterogeneities are contributed predominantly by lack of adequate power, poor phenotype selection, and population admixture. the functional relevance of the risk and protective alleles needs to be verified. jignesh parvadia, mounira habli, jeff livingstone, william polzin, foong lim, timothy crombleholme. pediatric and thoracic surgery, cincinnati children's hospital medical center, cincinnati, oh, usa; obstetric and gynecology, university of cincinnati, cincinnati, oh, usa; obstetric and gynecology, good samaritan hospital, cincinnati, oh, usa. objective little is known about the response of ttts to treatment either by amnioreduction or selective fetospopic laser in triplet pregnancy, particularly the survival of the bystander fetuses. in order to define the response of triplet pregnancies to treatment for ttts we reviewed our experience with higher order multifetal gestations complicated by ttts. study design retrospective chart review of patients diagnosed with in high order gestation from - was performed. results among cases of ttts / ( . %) patients with high order gestations were identified (n= ) with a mean ga at diagnosis of . ± . weeks. pregnancies ( . %) were dichorionic triamniotic and ( . %) were monochorionic triamniotic. cincinnati modification of quinterro staging was utilized to characterize recipient cardiomyopathy as mild (stage iiia, n= ), moderate (stage iiib, n= ) and severe (stage iiic or iv, n= ) categories. / ( . %) were treated with amnioreduction alone (ar), / ( . %) with selective fetoscopic laser photocoagulation (sflp) alone, / ( . %) with ar followed by sflp and / ( . %) with ar followed by intrafetal radio frequency ablation (rfa). / ( . %) patient had a cervical cerclage. / ( . %) patients were treated but remain undelivered. mean ga at delivery was . ± . weeks. overall survival was / ( . %) with bystander survival was / ( %), donor survival / ( . %), recipient survival was / ( . %). conclusion triplet pregnancies treated for ttts have % survival rate for bystander fetuses and have . % survival rates for donor and recipients comparable to twins treated for ttts. ga at diagnosis . ± . weeks cincinnati modification of quinterro (i), (ii), (iii), (iiia), (iiib), (iv) ga at delivery . ± . weeks live birth -donor / ( . %)* # -recipient / ( . %)*# -bystander / ( %) # birth weight -donor to assess the effect of breast feeding (bf) on perinatal outcome in relation to maternal antenatal methadone dose. study design a retrospective chart review study of methadone dependent mother and infant pairs. patients were categorized into groups based on maternal dose at time of delivery: group : dose mg, group : dose - mg, group : dose > mg. the finnegan's scoring system was used to monitor neonatal abstinence syndrome(nas). treatment for nas was initiated if there were scores of . neonatal outcome data included:% nicu admission, % of babies discharged(d/c) at time of maternal d/c, % nas, % treated for nas and total hospital stay. data were analyzed by t-test and fisher's exact test. maternal characteristics between the groups were similar. regardless of maternal methadone dose, bf infants have shorter hospital stays and higher rates of d/c at time of maternal d/c, lower incidence of nas and fewer nicu admission (table) . in all three groups, breast feeding did not impact the severity of nas as reflected in finnegan's score(fs). (table) conclusion regardless of maternal methadone dose, breast feeding improves perinatal objective: to evaluate the effects of preventive collagen plugging of the fetoscopic access port at the time of balloon removal on pregnancy outcome in fetoscopic endoluminal tracheal occlusion pregnancies. study design: fifty-one pregnancies involving fetuses with severe congenital diaphragmatic hernia (cdh) were studied. all patients underwent feto between - weeks gestational age (ga) and fetoscopic balloon removal around weeks ga. at the time of balloon removal, a purified dried collagen plug was inserted through the fetoscopic access port in consecutive pregnancies but not in the first pregnancies considered as controls. all patients underwent post-plugging ultrasound and magnetic resonance imaging studies to evaluate for membrane dehiscence, amniotic fluid volume and fetal well being. ga at delivery, incidence of premature rupture of the membranes (pprom), bleeding at port retrieval and adverse fetal effects were compared in both groups. results: mean (sd) ga at feto [ . ( . ) vs. . ( . ) weeks; p= ns] and balloon removal [ . ( . ) vs. . ( . ) weeks; p= ns] was similar in the treatment and in the control group. incidence of pprom following the second fetoscopy was / in the study group compared to / in the control group (p< . ). mean (sd) ga at delivery was . ( . ) weeks in the study group, compared to . ( . ) in the control group (p= . ). bleeding from the trocar insertion site occurred in cases in both groups, but clinically significant bleeding occurred only in one of the controls. membrane dehiscence was noted in patient in the treatment group compared to in the control group (p=ns). conclusion: preventive collagen plugging of the fetal membrane defect created by the fetoscopic access resulted in a significant reduction in pprom rates and a trend towards increased ga at birth without adverse fetal effects in feto pregnancies. wider application of this technique should be considered, but needs evaluation in larger, randomized trials. hydrops fetalis is an uncommon fetal condition characterised by the abnormal accumulation of fluid in two or more body cavities, traditionally associated with a poor prognosis. the relative rarity of this presentation has meant that published case series have consisted of small numbers. a retrospective review of case notes of all cases managed at kemh between and was performed. in western australia, kemh is the only tertiary maternity hospital incorporating a maternal-fetal medicine unit. cases were obtained from the mfm database. in the period to there was a total of pregnancies affected by hydrops (incidence . per births). the average maternal age was years. in cases a fetal abnormality had occurred in a previous pregnancy. the median gestational age at diagnosis was weeks (range - weeks). in just over half ( %) of cases, the diagnosis was confirmed prior to delivery. a post-mortem was performed on all but of the babies not born alive. edema was present in at least cavities in over half of cases (n= ). chromosomal anomalies included trisomy , trisomy and turners syndrome. in all cases of infection, parvovirus b was implicated. cardiac arrythmias included svt and atrial flutter. cases classified as other included alpha thalassemia and syndromic disorders. in cases an interruption of pregnancy was performed at a mean gestational age of weeks. of those who did not elect to terminate the pregnancy, there were fetal deaths in utero, live borns with neonatal death. for the live borns, the median gestational at delivery was . weeks (range to . weeks). the causes of hydrops in live birth cases included cardiac arrythmia (n= ), infection (n= ), chromosomal abnormality (n= ), unknown (n= ) and other (n= (dmv) have been noted to play a role in the development of hemorrhagic and periventricular leukomalacic lesions in premature babies. since deep vein drainage system is relatively more prominent in the developmental brain than adult brain, we investigated if dmv anomalies could be associated with clastic lesions in-utero. methods two senior neuroradiologists reviewed fetal brain exam performed between and , seeking for unequivocal anomalies in dmv, such as periventricular venular engorgement. all mr scanning is performed at . tesla, using surface abdominal coils and single-shot fast spin-echo t -weighted - mm thick sections, with . - . mm in planar spatial resolution. we found cases with dmv anomalies (tab. ). most of the dmv engorgement is located at frontal lobes level. from this limited preliminary series it appears that dmv involvement plays a role in the development of periventricular leukomalacia and periventricular hemorrhagic necrosis. the observation that these lesions are mostly located at frontal level may suggest that some of the term neonates carrying sequelae of atypically located leukomalacia (i.e. deep frontal lobe) might have developed these lesions in-utero. it is of interest to notice that most of our cases were related to heart failure. therefore, central venous hypertension affecting immature deep cerebral venous system has to be taken into account. in our center, patients with an estimated risk for chromosomal abnormalities at term greater that in after st trimester combined screening test (ft) are offered non-directive genetic counseling. the aim of this study was to evaluate the responses of women younger than attending this genetic counseling session. material and methods: data from patients referred for a positive ft from september , to july , was retrieved from our database. information concerning women younger than years of age at the estimated date of delivery was extracted and tabulated. results: during the study period women had genetic counseling for positive ft. thirteen patients were excluded from further analysis ( had incomplete clinical documentation and had spontaneous miscarriages prior to weeks gestation). four hundred and twenty-five patients were older than and were younger than at the estimated date of delivery. table depicts summary statistics for studied variables in this younger group of women. conclusions: overall this data suggests that approximately % of this younger group of women opted for chorionic villous sampling (cvs), % for amniocentesis and more than % declined prenatal genetic testing. moreover, this data also suggests that: ) these women opted for cvs when the ft risk (mean = in ) almost doubled the cvs procedure related risk quoted at % and, ) when the ft risk is between in and in almost half ( out of ) declined not only the st trimester cvs but also the nd trimester amniocentesis. we believe that understanding our patient population is important to optimize both the efficiency and efficacy of the alternative prenatal screening programs. acceptance for prenatal genetic testing after a positive first trimester combined screening test in women of less than to determine the optimal diagnostic test using prenatal ultrasonography and mri for predicting pulmonary hypoplasia in fetuses with congenital diaphragmatic hernia. methods: relevant papers were identified by searching medline ( medline ( - , embase ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and the cochrane library ( issue ). in addition, the specialist literature on the topic and reference lists were hand searched for relevant articles. studies were selected if they examined diagnostic tests for the prenatal prediction of pulmonary hypoplasia in fetuses with congenital diaphragmatic hernia. the primary outcome measure was perinatal survival. study selection, quality assessment and data abstraction were performed independently and in duplicate by separate observers. results: of a total number of articles (published studies), there were eighteen studies that fulfilled the entry criteria. six examined entirely unique heterogeneous parameters. of the remainder, all examined the ultrasound measurement of lung to head ratios (lhr) at a 'cut-off of greater than or less than the thresholds of . , . , . , . . in addition, the presence of liver in the fetal thorax was included (if present) as a co-variable (liver "up"). a lhr > . compared to < . provided the strongest association with perinatal survival (peto or . , % ci . - . ). the finding of "liver up"in the fetal thorax had a negative association with survival (peto or . , % ci . - . ). only three studies provided data for lhr in conjunction with the presence of liver in the fetal thorax (peto or survival for lhr > . compared to < . was or . , % ci . - . ). data was also available for liver up and lhr > . which had a peto or of . ( % ci . - . ). discussion: the data supports the view that lhr may be a useful prognostic indicator of perinatal survival in fetuses with congenital diaphragmatic hernia. however, heterogeneity still exists regarding the timing of ultrasound measurement and the use of mri. the majority of studies have small sample sizes. objective: to estimate, in fetal anaemia, the diagnostic value of fetal ultrasonography and doppler blood flow in the evaluation of fetal anaemia methods: literature from to was identified using medline and embase, the cochrane library and relevant specialist register of the cochrane collaboration, and by checking reference lists of known primary studies and review articles. studies were selected if the accuracy of the fetal ultrasound parameters or doppler studies of blood flow in the fetal vessels was estimated compared with a reference standard. diagnostic tests evaluated were ultrasound measurement of the fetal spleen and liver length and doppler studies from the umbilical vein and middle cerebral artery. data from the selected studies were abstracted as x tables comparing the diagnostic test result with the reference standard. results were pooled where appropriate. diagnostic accuracy was expressed as sensitivity and specificity. twenty-nine primary studies were identified containing suitable data. twentyone of these gave data on middle cerebral artery doppler peak systolic velocity (mca-psv) and could be pooled in the meta-analysis giving a sensitivity of . ( . - . ) and a specificity of . ( . - . ) for cases in detecting severe anaemia. four studies gave data on spleen perimeter and it was possible to pool three of these giving a sensitivity of . ( . - . ) and a specificity of . ( . - . ) for cases. three studies had data for liver length measurements and two were pooled. the sensitivity was . ( . - . ) and the specificity was . ( . - . ) but only cases were used in the analysis. there were three studies on umbilical vein maximum velocity doppler studies and all were suitable for meta-analysis giving a sensitivity of . ( . - . ) and a specificity of . ( . - . ) with cases analysed. two studies gave data on middle cerebral artery time-averaged mean velocity score giving cases. the sensitivity was . ( . - . ) and specificity was . ( . - . ). discussion: middle cerebral artery peak systolic velocity dopplers remain the gold standard for non-invasive screening of fetal anaemia. middle cerebral artery time-averaged mean velocity scores require further investigation. other tests perform poorly when diagnostic accuracy is assessed. cochrane review of treatment in twin to twin transfusion syndrome. twin-twin transfusion syndrome is a condition affecting monochorionic twin pregnancies associated with a high risk of perinatal mortality and morbidity. the objective of this review was to evaluate the impact (maternal,fetal and pediatric)of treatment modalities in twin-twin transfusion syndrome. register and cochrane controlled trials register. we also searched conference proceedings and made personal contact with experts active in the area of the review. randomised and quasi-randomised studies of amnioreduction versus laser coagulation, septostomy versus laser coagulation or septostomy versus amnioreduction. eligibility was assessed by one reviewer. study authors were contacted for additional information. two studies were included. this review shows that laser coagulation of anastomotic vessels results in less fetal (rr . ; % ci . , . ) and neonatal deaths (rr . ; % ci . , . ) than amnioreduction ( figure ). there is no difference in perinatal outcome between amnioreduction and septostomy. more babies in the laser arm are alive without neurological abnormality at six months of age (developmental delay at < years rr . , % ci . , . )( figure ). conclusions: endoscopic laser coagulation of anastomotic vessels should be considered in the treatment of all stages of twin twin transfusion syndrome to improve perinatal outcome. further research on the effect of treatment on milder forms of twin twin transfusion syndrome (quintero stage and ) are required. (produced in collaration with the cochrane collaboration, uk). (cvs) concluded that although the risks of pregnancy loss are relatively low, lack of adequate controls tends to underestimate the true added risk of prenatal invasive procedures (obstet gynecol. ; ( ): - ). the west midlands is a large region within the uk containing approximately % of the total uk population. the congenital anomaly register for this region is able to monitor pregnancy outcomes with accurate deminator data. results: there were first trimester cvs performed, by ten operators, in the west midlands (uk) in . this equates to . procedures per births. significantly higher rates were noted in areas of high socioeconomic status. the median number of procedures performed per operator was (range - ). all operators were performing other invasive tests such as amniocentesis or cordocentesis,etc. the most common indication for cvs was: i) fetal anomaly on dating scan ( . %) ii) abnormal (> in ) risk on combined first trimester screening ( . %) iii) molecular genetic diagnosis ( . %) and iv) maternal request ( . %). using a combination of first trimester scanning and cvs, % had abnormal karyotype/structural anomaly.the corrected loss rate (background and procedure-related) following cvs in normally formed, singleton pregnancies was . % ( thci . - . %) up to days postnatal (perinatal loss) and . % ( thci . - . %) with days of procedure. the proportion of cvs in which an adequate sample was not obtained was . % ( th ci . - . %). conclusions: this epidemiological study using accurate demoninator data provide interesting statistics relating to the uptake and prenatal risks of first trimester cvs. with the increasing prevalence of obesity in the last two decades, we have seen a tremendous increase in bariatric procedures in reproductive aged women. malnourishment and vitamin deficiency are common complications after gastric bypass which may impact on fetal development. we present the case of a yo who underwent a duodenal switch procedure in . she was discovered to be pregnant during evaluation for persistent malnutrition in . multiple prenatal ultrasounds were performed; the first at weeks gestation was unremarkable. the week sono revealed a male fetus with shortened femurs and humeri bilaterally, nasal bridge hypoplasia, macroglossia, poorly defined hands, and possible clubbed feet. amniocentesis revealed a normal karyotype. d ultrasound redemonstrated the abnormal facial findings. a fetal echocardiogram was normal. the lagging long bone measurements continued to worsen, ultimately with femurs weeks behind. the fetal thoracic circumference was two standard deviations below the mean, giving rise to concern for pulmonary sequelae. growth restriction was noted at the wk sonogram. delivery by cesarean section was at / weeks secondary to nonreasuring fetal status. the birthweight was gm; apgars were , , and . postnatal radiographs confirmed antenatal ultrasonographic findings and demonstrated evidence of epiphyseal stippling. the infant remained intubated until weeks of life, after which it died secondary to respiratory complications associated with pulmonary hypoplasia. gene mapping studies have not found any point mutations on the recessive gene as an etiology of this disorder. rhizomelic chondrodysplasia punctata refers to a heterogeneous group of bone dysplasias with a familiar radiographic phenotype involving punctate calcifications and epiphyseal stippling. the etiology of this may be secondary to chromosomal abnormalities, mendelian gene disorders, or teratogens, notably warfarin. this case may be explained by vitamin k deficiency of the embryo due to maternal malabsorption after bariatric surgery. the maternal vit k level was <. ng/dl at time of delivery(normal > . ). the teratogenic effects of vitamin k deficiency in this instance highlight the need for strict counseling and screening for vitamin deficiency in those women undergoing bariatric surgery since previous obesity-related anovulation is reversed as patients lose weight, resulting in unexpected pregnancies and potentially preventable fetal abnormalities. term preeclampsia: any risk for the neonate? sindhu k srinivas, jamie bastek, christina m andrela, emmanuelle pare, michal a elovitz. obstetrics and gynecology; crrwh, university of pennsylvania, philadelphia, pa, usa. introduction: preeclampsia continues to be a major contributor to maternal morbidity and mortality worldwide. preeclampsia at term is not associated with the same risk of neonatal morbidty and mortality as preterm preeclampsia . however, neonatal outcomes in term women with preeclampsia have not been adequately studied. we sought to compare short term neonatal outcomes in term infants born to women with and without preeclampsia. methods: this study was part of a large case control study. women with preeclampsia (n= ) and term controls (n= ) were prospectively identified. infants with congenital anomalies were excluded. hospital length of stay (los), admission or transfer to the nicu, and use of mechanical ventilation or cpap within first week of life were assessed. associations between neonatal outcomes and preeclampsia were evaluated using chi-square analysis and wilcoxon rank sum test. significant confounders were controlled for using multivariable logistic regression. results: discharge day of life was significantly different between neonates born to women with preeclampsia (median = ; mean = . ) versus those born to women with uncomplicated term deliveries (median = ; mean = . , p< . ). this difference persisted even when neonates with iugr and those born to diabetic mothers were excluded (p< . ). term infants born to women with preeclampsia have a higher odds of being admitted or transferred to the nicu (aor= . [ . - . ], p= . ) after controlling for iugr, delivery mode, race, and gestational age at delivery. these infants also have a higher odds of mechanical ventilation (aor= [ . - . ], p= . ) and cpap use (aor= . [ . - . ], p= . ) after controlling for the same confounders. there was no difference in ivh or nec between the two groups. conclusion: neonates born to women with preeclampsia have differences in short-term morbidity when compared to neonates born to women without preeclampsia, despite being born at term. whether this increase in neonatal morbidity is attributable to medications used in preeclampsia, such as magnesium sulfate, is unclear. these findings may have implications for patient counseling as well as hospital resource allocation. further investigation correlating these findings with long-term morbidity is warranted. could confined placental mosaicism account for adverse perinatal outcomes in ivf pregnancies? benoit c jacod, gh schuring-blom, kd lichtenbelt, jse laven, d van opstal, mjc eijkemans, nick s macklon. reproductive medicine gynaecology, university medical centre, utrecht, netherlands; clinical genetics, university medical centre, utrecht, netherlands; obstetrics gynaecology, erasmus medical centre, rotterdam, netherlands; clinical genetics, erasmus medical centre, rotterdam, netherlands. background: ivf singletons have poorer perinatal outcomes than singletons from spontaneous conceptions. this may be due to the influence of ovarian stimulation on the chromosomal constitution of the embryos which could be translated into localized chromosomal anomalies in the placenta. aim: to compare the incidence of confined placental mosaicism (cpm) in ivf/icsi pregnancies and spontaneous conceptions. methods: multicentre retrospective analysis of karyotype results obtained by chorionic villus sampling (cvs) performed because of advanced maternal age ( years at weeks of gestation) in the netherlands between and . results: from a total of pregnancies, cvs results were analysed: in the ivf/icsi group and in the control group. the mean age of women in both groups was . years (mean difference - . , % ci - . - . ). foetal karyotype was missing in cases of possible cpm, all in the control group. when taking into account missing data, the incidence of cpm was lower in the ivf-icsi group than in the control group, . % vs. . % (odds ratio . , % ci . - . ) whereas the incidence of foetal chromosomal anomalies was increased . % vs. . % (odds ratio . , % ci . - . ) although both differences are not significant. conclusions: the incidence of confined placental mosaicism is not increased in ivf/icsi pregnancies compared to spontaneous conceptions. cpm probably does not account for the adverse perinatal outcomes following ivf/icsi. fetal rh d, cc and ee genotyping using fetal dna from maternal blood is not impaired by the presence of maternal alloimmunization. chad a grotegut, stacey l jeronis, john p gaughan, enrique hernandez, ossie geifman-holtzman. obstetrics and gynecology, duke university, durham, nc, usa; obstetrics, gynecology and reproductive sciences, temple university, philadelphia, pa, usa; biostatistics, temple university, philadelphia, pa, usa. this study was conducted to assess the impact of maternal alloimmunization on the accuracy of fetal rh d, cc and ee genotyping from maternal blood. we performed a literature search of english-written articles describing fetal rh d, cc and ee determination from maternal blood (am j obstet gynecol ; : - ) . using this database, we determined the accuracy of rh d, cc and ee genotyping in the presence of maternal alloimmunization. for each subgroup, % confidence intervals for a proportion were calculated and compared between groups. we found english-written publications reporting non-invasive rhd genotyping and reporting non-invasive rh ce genotyping from maternal blood. fourteen ( . %) of the rh d articles and three ( %) of the rh ce articles provided accuracy results in the setting of alloimmunization. the accuracy results are reported as follows: . % of the samples were determined correctly in the presence of alloimmunization.* this accuracy was significantly lower than the accuracy reported for all rh cc samples. when only studies utilizing free fetal dna for rh cc genotyping were used (vs fetal cells), fetal cc genotype was determined correctly in / ( %, % ci . , ), which was similar to the overall success rate for rh cc determination. overall, there were no differences in the success of rh d, cc or ee determination in the setting of alloimmunization compared to the overall accuracy seen when free fetal dna was used. the presence of maternal alloimmunization does not reduce the accuracy of fetal rh d, cc or ee non-invasive genotyping from maternal blood utilizing free fetal dna. further research into structure and rearrangements of the rh d, cc and ee genes may further improve diagnostic accuracy of free fetal dna from maternal blood. fetal dna, most likely of trophoblast origin, is present in both the plasma of pregnant women and provides a potential basis for non-invasive fetal diagnostic tests. however, fetal dna in maternal plasma is highly contaminated with maternal dna, and this contamination is the main technical challenge in trying to accomplish non-invasive detection of fetal chromosome abnormalities. existing methods for the selective amplification of fetal dna have generally relied on specific sequence differences between the mother and fetus. as an alternative, we have developed a method for selective amplification of fetal dna that makes use of observation that trophoblast dna is globally hypomethylated in comparison with dna from other sources. in this method, a dna mixture is first digested with a methylation sensitive restriction enzyme and then amplified by linker-mediated pcr. after an initial amplification, a second isothermal rolling-circle amplification is performed. this procedure results in the differential amplification of short, relatively hypomethylated fragments. after amplification, the resulting "representations" are comparatively hybridized to a microarray consisting of oligonucleotides that correspond to restriction fragments generated by the initial digest. copy number differences are then detected through statistical analysis of array addresses that show significant amplification. to test the feasibility of this method for detecting aneuploidy, we have prepared mixtures of peripheral blood dna and first trimester trophoblast dna from either normal or from samples with trisomy and trisomy . we present data showing that aneuploidy can be detected even when % of the starting dna sample was derived from a euploid source and only % was from an aneuploid trophoblast sample. two different approaches to data analysis are presented. one relies on prior analyses of trophoblast methylation and the second is independent of any prior knowledge or analysis. both methods provide similar ability to detect aneuploidy. future work will focus on testing whether this approach can be used for non-invasive prenatal diagnosis. chromatin immunoprecipitation and emsa analysis of nf-b and c/ ebp synergism on the otr promoter. shirin khanjani, yun s lee, vasso terzidou, mark r johnson, phillip r bennett. institute of reproductive developmental biology, imperial college, london, united kingdom. we have shown, the transient transfections of the transcription factors nf-bp and c/ebp leads to a synergistic increase in otr promoter activity in human myocytes. this effect is mediated through a bp region of the promoter between - to - from tss. we now report that this sequence binds both nf-bp and c/ebp in vitro and chip studies show binding of both transcription factors to be increased by il- in vivo. materials and methods: emsa studies were performed using a bp oligonocleotide sequence (- to - ) , containing the bp region responsible for the synergistic activation of the otr promoter and nuclear extracts from primary human myocytes treated with il- ng/ml for hours. for chip analysis, dna protein complexes were crosslinked and antibodies recognizing p , c/ebp and h (positive control) and igg (negative control) were used for immunoprecipitation. primers were designed to amplify the region - to - , which includes the bp response sequence. to further confirm the interaction between nf-bp with c/ebp a xnf-b consensus/luc reporter construct was cotransfected with an expression vector for either nf-bp or c/ebp . results: specific nf-bp and c/ebp binding was seen in the emsa study. preincubation with antibodies to nf-bp and c/ebp led, not to supershift, but to elimination of dna binding for both nf-kb p and c/ebp . chip analysis confirmed increased in vivo binding of nf-b p and c/ebp to this region of the otr promoter following stimulation with il- . transfection of the nf-b/luc reporter construct with an expression vector for c/ebp caused a significant reduction in the basal promoter activity suggesting that c/ebp is binding to nf-kb. this interaction was further confirmed using a tf-tf interaction array. conclusion: these data support the role of nf-b and c/ebp in regulation of otr. the bp region contains a c/ebp but not a nf-b dna binding site suggesting that c/ebp primarily binds to this part of the otr promoter but also interacts with nf-b. the emsa data shows that the bp region binds both nf-b and c/ebp . the loss of the supershift observed in previous emsa studies suggests that the antibodies inhibit the interaction between c/ebp and nf-b, therefore inhibiting dna binding. chip analysis supports the concept that il- leads to binding of nf-b and c/ebp to the bp region. regulation of pro-labour genes by c/ebp, nf-b and ap- in human uterine myocytes. suren r sooranna, shirin khanjani, yun s lee, phillip r bennett, mark r johnson. imperial college parturition research group, imperial college, london, united kingdom; irdb, imperial college, london. introduction: the transcription factors c/ebp (lap), nf-b (p ) and ap- (c-fos and c-jun) are implicated in inflammatory processes such as parturition. the promoter regions of the pro-labour genes il- , pghs- and otr contain putative transcription factor-binding sites for these transcription factors. our aim was to determine the effect of transfecting these transcription factors either alone or in combination into uterine myocytes and to determine their effects on the expression of pro-labour genes including il- , pghs- , otr, connexin- and fp. methods: primary cultures of human uterine myocytes (n= ) were grown from myometrial samples obtained at the time of elective lscs. cells were cultured in well plates to % confluence at which point expression constructs for c/ ebp (lap), nf-b(p ), ap- (c-fos and c-jun) were transfected either alone or in different combinations. the empty expression vector psg was used as a filler construct. cells were cultured for and h after which culture medium was collected for elisa and cells frozen at - °c prior to rna extraction. copy numbers of il- , pghs- , otr, fp, connexin- and gapdh were measured by qpcr using a rotor-genetm (corbett research). results: h post transfection with c/ebp (lap), nf-b (p ), c-fos and c-jun alone or in combination showed no significant changes in pghs - , otr and connexin- expression. over expression of p alone or together with either c-fos or c-jun increased fp expression by , and % respectively (p= . ). nf-bp consistently increased il- expression either alone (by %; p= . ) or in combination with lap, c-fos or c-jun (by , and % respectively; n= ; p= , ). rel a, lap, c-fos and c-jun together also increased il- expression (by %; p= . ) and a small but significant increase was seen with a combination c-fos and c-jun (by %; p= . ). the changes observed in il- expression were reflected in the medium il- concentration at h post transfection. in the presence of rela and c-fos il- increased from . ± . to . ± . pg/ml of culture medium (mean ± sem; n= ). conclusions: nf-b (p ) consistently increased fp and il- expression in human myometrium. the data suggest that pghs- activation has greater dependence upon other transcription factor(s) in addition to p . true identity of myometrial pr-c: fact or fiction? yun s lee, suren r soorana, mark r johnson, jan brosens, phillip r bennett. imperial college parturition research group, hammersmith campus, london, united kingdom. progesterone is thought to be central to maintenance of pregnancy. multiple progesterone receptor (pr) isoforms underlie complex and diverse biological action of progestins. previously two human pr isoforms have been identified: pr-b and pr-a. pr-a is n-terminally truncated form of pr-b (initiation site methionine ). in some cells pr-a inhibits pr-b. it has been proposed that increased expression of pr-a in myometrium underlies a 'functional progesterone withdrawal'. the breast cancer cell t d contains a kda progestin-specific binding protein that is not found in pr negative cells. it was proposed that there is a downstream methionine (met ) which serves as a translation initiation site for the generation of a pr isoform of kda. based on such findings condon et al (mol endo ) have focused on the possible role of kda pr-c in human parturition. they found that expression of "pr-c" using pr antibody (sc- santa cruz, sc) is increased in upper segment myometrium with labour and that overexpression of this protein inhibits pr-b function. we cloned the same human pr cdna into psg expression vector. in vivo translation produced a protein of only kda. furthermore overexpression of pr-c did not significantly decrease pr-b activity in human myocytes. we examined other downstream initiation sites, which may produce a kda protein. we constructed potential pr isoforms in psg vector with initiation sites at met and . in vivo translation produced proteins of approximately and kda respectively. to determine the effect of pr isoforms on pr-b function, myocytes were co-transfected with pr-a, pr-c , pr-c and pr-c with constant amounts of pr-b. the progesterone dependent pre/luc was used as reporter. unlike pr-c both pr-c and pr-c significantly inhibited ligand dependent pr-b mediated transcriptional activity. we found in western analysis that the antibodies pgr- (nc) and the sc- (sc) detected both endogenous and overexpressed pr-a and pr-b but none of the pr-c isoforms. the sc- antibody detected only pr-a and pr-b very poorly. our data suggests that the sc- antibody would not detect any pr-c protein and that none of the commercially available antibodies in the uk do so. great care needs to be taken when over-expressing pr isoforms to ensure that proteins are of the expected size. if pr-c does exist in vivo then the kda but not the kda isoform might inhibit pr-b function. tnf receptor antibody (tnf ri ab), nf-b inhibitor (nf-b activation inhibitor) and erk inhibitor (u ) (p< . ), but not by tnf receptor antibody (tnf rii ab), p mapk inhibitor (sb ) and jnk inhibitor (sp ). by western blot analysis, we found that the protein level of tnf receptor associate factor (traf ) was higher than that of tnf receptor associate factor (traf ) (traf >traf ) in untreated ct cells. however, after tnf treatment for h to h, traf protein level was increased, but traf protein level was reduced (traf >traf ). the increase of traf and decrease of traf were blocked by tnf ri ab, but not by tnf rii ab. we also found that tnf rapidly (within - min) and significantly increased phosphorylation of ikk , erk / and jnk / / and the phosphorylation of these protein kinases by tnf was reduced significantly by tnf ri ab, but not by tnf rii ab. moreover, we found that the changes of increased traf and decreased traf in ct cells (traf >traf ) resulted in a dramatic deficiency in phosphorylation of the above protein kinases induced by tnf compared with the normal ct cells (traf >traf ). nuclear localization of nf-b p in tnf treated cells was increased compared to untreated controls. conclusion: we have demonstrated for the first time that tnf stimulates mmp- production in ct cells through tnf ri-trafs-ikk /erk-nf-b signaling pathways, but not through the jnk/p -ap- pathway. these studies reveal steps within this pathway as possible therapeutic targets to inhibit mmp- expression potentially attenuating tnf -induced degradation of extracellular matrix and pre-term rupture of the fetal membranes. objective: women with preterm birth are at elevated risk of cardiovascular disease, but mechanisms that might relate these conditions are not understood. we hypothesized that women with spontaneous preterm vs. term births may have early gestation evidence of activation of the fibrinolytic cascade, as measured by the thrombin-antithrombin iii (tat) complex. we also tested if this relation may be associated with inflammation. methods: tat was measured in plasma collected < weeks gestation (mean . weeks, sd . ) among women without chronic medical conditions, preeclampsia or growth restriction who delivered singleton liveborn infants. inflammation was assessed by c-reactive protein (crp) measured in serum from the same samples. women with spontaneous preterm birth (sptb) < weeks (n= ) and -< weeks (n= ) were compared to women with term births >= weeks (n= ). high tat was defined as > . ng/ml (highest quartile among women with term births) and high crp was defined as >= ug/ml. multinomial logistic regression was utilized to relate elevated tat and inflammation to risk of sptb subtypes. results: women with sptb were more likely to have tat concentrations in the highest quartile compared to women with term births (< weeks, . %; -< weeks, . %; >= weeks . %, p< . ). women with high tat concentrations had a . -fold ( % ci: . - . ) increased risk for sptb < weeks, after adjustment for body mass index, race, age and gestational age at sampling. there was no relation between high tat and sptb -< weeks (or . , % ci . - . ). additional adjustment for elevated crp (>= ug/ ml) did not effect the estimates associated with tat, and elevated crp was independently related to risk for both sptb subtypes (< weeks, or . [ . - . ]; -< weeks, or . [ . - . ]). thus, women with high tat and elevated crp appeared to be at particularly elevated risk of sptb < weeks (or . , % ci . - . ). conclusions: the thrombin-antithrombin iii complex was elevated early in gestation among women with sptb < weeks, perhaps secondary to microvascular injury. this effect was independent of inflammation, suggesting that the elevated fibrinolytic cascade may function independently from inflammation among women with sptb. plasma cortico-releasing hormone and cortisol concentrations and psychological stress among pregnant women. katherine p himes, hyagriv n simhan. obstetrics and gynecology, university of pittsburgh medical center, magee womens hospital, pittsburgh, pa, usa. objective: many studies have found an association between psychological stress and preterm birth. we sought to determine if women with greater psychological stress during pregnancy had higher concentrations of plasma cortico-releasing hormone (crh) or cortisol. study design: this is a secondary analysis of a multicenter case-control study, nested within an observational cohort. of , participants, plasma crh and cortisol concentrations at and weeks gestation were available in controls who delivered after weeks and cases who delivered before weeks. the abbreviated scale for the assessment of psychosocial status in pregnancy (asaps) was available for all women. concentrations of crh and cortisol were compared between women above and below the lowest quartile score on the asaps among cases and controls. the same analysis was done for the portion of the scale related to psychological stress. concentrations of crh and cortisol and psychological stress were also compared between black and non-black cases and controls. univariate analysis was performed with kruskal wallis or chi-square. results: there was no difference in crh or cortisol concentrations at or weeks among women above or below the lowest quartile on the asaps (controls:p= . - . cases:p= . - . ). greater psychological stress was not associated with higher concentrations of crh or cortisol at or weeks(controls:p= . - . cases:p= . - . ). crh concentrations were not different between blacks and non-blacks. among both cases and controls, cortisol concentrations at and weeks were lower in black women than non-black women (controls:p< . cases:p< . ). the median cortisol concentration among control black women was . g/ml at weeks compared to . g/ml among non-black women and . g/ml compared to . g/ml at weeks. black women reported less psychological stress than non-black women (p= . ) conclusion: we found no relationship between psychological stress and plasma crh or cortisol. furthermore, while stress is hypothesized to play a role in the racial disparity of preterm birth, black women reported less psychological stress and had lower cortisol concentrations than non-black women. improved assessments of psychological stress and additional biomarkers involved in the stress response may broaden our understanding of how stress contributes to preterm birth. expression, tissular traffic and activation of mmp- in human fetal membranes during labor. rodrigo vega-sanchez, arturo flores, marisol castillo, nardhy gomez, felipe vadillo-ortega. direction of research, instituto nacional de perinatologia, mexico city, df, mexico. introduction. rupture of the fetal membranes (fm) during human labor occurs as a consequence of extracellular matrix degradation. this process is controlled by increased secretion and activity of matrix metalloproteinases, particularly mmp- .several evidences suggest that mmp- is mainly produced by infiltrating choriodecidual leukocytes that could arrive from placental circulation. characterization of the synthesis, transport and activation of mmp- within the fm is critical to understand the process of membrane rupture during human labor. objectives. expression and secretion of mmp- in placental leukocytes, trafficking of the enzyme through the fm and one possible mechanism for its activation were analyzed. methods. leukocytes were isolated from placental blood of women after active labor. maternal leukocytes were used as controls. cells were cultured for h. relative expression of mmp- by rt-pcr and enzyme secretion by elisa and zymography were followed at different times. to analyze the traffic of mmp- through the fm, fluorescein-conjugated prommp- was added to the choriodecidual side of the fm in an in vitro system that allows the separation of amnion and chorion. labeled mmp- was localized at distinct times by confocal microscopy. the protease responsible for the activation of mmp- was identified using neutralizing antibodies and specific inhibitors. results. no difference in the relative expression of mmp- in leukocytes throughout the culture was found. however, secretion of the enzyme significantly increased since h (p< . ). experiments using labeled mmp- , repeatedly showed that after h in culture, the enzyme was mainly localized within the amniotic epithelium. specific inhibition of mmp- significantly decreased the activation of pro-mmp- . conclusions. our results demonstrate that the increased secretion of mmp- by placental leukocytes is not associated to increased gene expression, suggesting that homing of a specific leukocyte subpopulation to the choriodecidua is occurring during labor. mmp- can be trafficked from the choriodecidua to the amnion, suggesting a transmembranal pathway that may regulate the tissular localization of the enzyme to the area of the fm with high content of connective tissue. once secreted by the placental leukocytes, activation of mmp- depends mainly on mmp- , which seems to be derived from the same leukocytes. objective: preterm labour is a major problem in terms of perinatal morbidity and mortality. the histone-deacetylase inhibitor (hdaci), trichostatin a (tsa) has been shown to have an inhibitory effect on myometrial contractility. the aim of this study was to evaluate the effect of the hdaci's suberic bishydroxymate (sbha) and valproic acid (vpa) on human uterine contractions and hence their potential role as tocolytic agents. methods: biopsies of human myometrium were obtained at elective caesarean section (n= ). dissected myometrial strips suspended under isometric conditions, undergoing spontaneous and oxytocin-induced contractions, were exposed to cumulative additions of sbha in the concentration range of nmol/l to mmol/l and vpa ( nmol/l- mmol/l). control experiments were run simultaneously. results: sbha and vpa exerted a potent and cumulative inhibitory effect on spontaneous and oxytocin-induced contractions, compared to control strips. the mean maximal inhibition (mmi) values for sbha were . % for spontaneous contractions (n= ; p< . ), and . % for oxytocin-induced contractions (n= ; p< . ). the mmi values for vpa were . % for spontaneous contractions (n= ; p< . ), and . % for oxytocin-induced contractions (n= ; p< . ). conclusion: these results raise the possibility that hdaci's may have tocolytic potential, in addition to their current clinical indications. the inhibitory effect observed may be linked to the ability of hdac inhibitors to induce the expression of genes involved in the maintenance of myometrial quiescence via epigenetic mechanisms but may potentially also involve non-epigenetic pathways. progestin suppresses thrombin-enhanced interleukin- expression in term decidual cells: implications for abruption-induced preterm delivery. edward kuczynski, lynn f buchwalder, frederick schatz, charles j lockwood. obstetrics/gynecology reprod. sciences, yale university school of medicine, new haven, ct, usa. background and objective: decidual hemorrhage (abruption) promotes binding of factor vii to decidual cell (dc)-expressed tissue factor to generate thrombin. thrombin in turn induces several biological effects leading to preterm delivery via activation of cell surface protease-activated receptors (pars). interleukin- (il- ) is a pleiotropic proinflammatory cytokine induced by pars. this study assessed the separate and interactive effects of thrombin and medroxyprogesterone acetate (mpa) on il- expression in term dcs. methods: term decidua from stripped fetal membranes were isolated and the dcs were purified on a percoll gradient, grown to confluence and passaged until leukocyte-free. confluent dcs were primed in - m estradiol (e ) of e + - m mpa for days, then incubated in a defined medium (dm) with corresponding steroids ± thrombin. after hours, il- levels in conditioned dm were measured by elisa and western blotting. in parallel -hour incubations, il- mrna levels were assessed by quantitative rt-pcr and normalized to -actin mrna. results: secreted il- levels were similar in cultures maintained in e alone ( . ± . ) and e + mpa ( . ± . pg/ml/ug protein; mean ± sem; n = ). the addition of thrombin ( . u/ml) enhanced secreted il- levels by . ± . fold (p< . ) in incubations with e and by . ± . -fold (p< . ) in incubations with e + mpa. the inhibitory effect of mpa was statistically significant (p< . ). in confluent dcs incubated with e + mpa, exogenous thrombin ( . - . u/ml) elicited a concentration-dependent increase in secreted il- levels. hirudin acted as a pure thrombin antagonist, exerting no agonist effects alone, but counteracting thrombin-enhanced il- secretion. western blotting confirmed the elisa results. quantitative rt-pcr confirmed that il- m-rna levels corresponded to protein changes. conclusion: thrombin enhances il- mrna and protein expression in term dcs and progestin blunts these effects. since thrombin-generating abruption is closely associated with preterm delivery, anti-inflammatory effects induced by progestin inhibition of dc-derived il- may contribute to the protection against ptd, and may explain the reported protective effects of administration of -oh-progesterone in recent clinical trials. introduction: catechol-o-methyltransferase (comt) catalyzes the methylation of the phenolic hydroxyl groups in a variety of catechols. during estrogen metabolism, this enzyme converts the catechol estrogen, -hydroxyestrogen ( ohe ), to -ethoxyestrogen ( meohe ). the comt substrate, -ohe , can exhibit an anti-estrogenic effect in multiple biologic assays while the methoxyestrogen ( -meoe ) can exhibit an estrogenic effect. the biologic activities of these estrogen metabolites ( ohe meoe) depend upon their concentrations and tissue type. since comt activity ultimately controls levels of these metabolites, it appears to be a key factor in regulating the cellular estrogenic milieu. we have recently reported that amnion layers of human fetal membranes from laboring women exhibited folds higher comt mrna expression when compared to non-laboring women (wentz et. al. sgi ) . objective: to investigate the impact of comt inhibition on prostaglandin e (pge ) production by human amniotic membrane explants. study design: explants consisting of -cm circular sections of the amnion layer (obtained from term pregnant women who underwent elective repeat cesarean section) were prepared and placed in tissue culture explants media at ºc. after a -hour incubation, explants were treated with the selective comt inhibitor ro - , at and m concentrations. the incubation media was harvested after and -hour intervals. the levels of prostaglandin e (pge ) in the media were measured by sensitive elisa and were normalized against total protein concentration. results: ro - comt inhibitor induced major reductions in pge production in media collected from amnion explants of human fetal membranes. in the group treated with m of ro - for hours there was %± % reduction of pge after hours compared to untreated control (p< . ). in the amnion explants treated with m of ro - , there was %± % after hours and %± % after hours of treatment compared to untreated control (p< . ). conclusions: this finding indicates that comt activity in the amnion layer of human fetal membranes affects pge production. by facilitating a pro-estrogenic milieu in human fetal membranes in late gestation, increased comt activity may indirectly increases production of factors associated with labor such as pge . hypothesis: an extensive remodeling of the human cervical connective tissue takes place throughout pregnancy with a decrease in the total concentration of collagen and proteoglycans due to an altered higher metabolic turnover. we hypothesize that the profound changes in proteoglycan production in the human pregnant cervix can be seen in corresponding cervical fibroblasts as well. we also hypothesize that proteoglycan production in cervical fibroblasts from preterm partal women are simmilar to the production in fibroblasts from partal women. method: cervical biopsies were obtained from non-pregnant women, women during elective cesarean section, woman after spontaneous parturition and after a preterm vaginal delivery. by explant technique fibroblasts were cultured from the biopsies. produced proteoglycans were metabolically labeled with s during hours and then purified by ion-exchange chromatography and separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. results: the total proteoglycan production decreases with approximately % in partal and preterm partal cell cultures. the reduction of proteoglycans in preterm partal and partal cell cultures is significant compared to non pregnant fibroblast cultures. the distribution of biglycan and perlecan are similar in partal and preterm partal cells. biglycan are significantly reduced by around % and perlecan are significantly increased by around % compared to non pregnant cultures. preterm partal cervical fibroblasts secreates significantly more heparan sulfate proteoglycans compared to non pregnant cultures. the changes in total proteoglycan production in the human pregnant cervix can be seen in corresponding cervical fibroblasts as well. both partal and preterm partal cell cultures differ in their proteoglycan production compared to their non pregnant counterpart, suggesting a role for proteoglycans in cervical ripening. the role of the oxytocin/oxytocin receptor system is not well defined in human amnion. previous studies in rabbit amnion have demonstrated an up-regulation of oxytocin receptors in the end of pregnancy and have shown that there is a large increase in the ability of ot to stimulate pge production. we and others have previously shown a role for nf-b in otr regulation. in whole genome array analysis of human amnion we found that otr was the gene with the second highest increase associated with activation of nf-b (the highest being cox- ). the present work was directed towards further understanding of otr expression and function in human amnion at term. we have shown that pge release by pre-labour primary human amnion cells is significantly increased after oxytocin treatment for hrs (ot: - m; n= ; triplicate samples; fold increase p< . ). the expression of otr in labour (+) and labour (-) primary amnion cells was measured with real time rt-pcr. we found a significantly higher level of expression in the labour (+) cells (n= ; duplicate samples; p< . ). western blot analysis confirmed the upregulation of otr in labouring amnion. treatment with il- b resulted in a significant upregulation of otr which peaked with a fold induction after hours (p< . ). il- caused a fold increase in otr mrna levels in labour (-) cells, bringing the expression level up to that found in labour (+) cells. our findings provide further evidence for a role of otr in human amnion. expression of otr in human amnion is significantly increased after the onset of labour. term non laboured amnion can be stimulated with il- to increase otr expression to levels of laboured amnion. one of the functions of otr in amnion cells is stimulation of prostaglandin synthesis. expression of antioxidant defence proteins in human myometrium before and after the onset of labour. vasso terzidou, mandeep s kandola, shirin khanjani, jan j brosens, phillip r bennett. parturition reserach group, irdb, imperial college, london, united kingdom. background oxidative stress is a result of an imbalance between the production of reactive oxygen species (ros) and the antioxidant defence mechanisms present in biological systems. parturition and infection-induced preterm labour resemble inflammatory processes that are linked to the production of ros including super-oxide (o -), hydrogen peroxide (h o ) and peroxynitrite. low concentrations of ros can act as second messengers in the regulation of several cellular functions. in an attempt to maintain redox homeostasis cells are equipped with machineries to both produce and scavenge ros. enzymatic scavengers include superoxide dismutase (sod), glutathione peroxidise and catalase. sod is the first enzymatic step in the defence system against oxidative stress. nuclear factor-kappa b (nf-b), a transcription factor family classically associated with inflammation, is activated in response to infection and proinflammatory cytokines, such as those prevalent during labour. labour is associated with an increase in nf-b activity in human myometrium and in fetal membranes. nf-b is known to regulate a range of genes associated with the onset of labour. in a study using affymetrix whole genome arrays analysis nf-b overexpression was associated with increased expression of sod- ( . fold). to determine changes in ros scavenging potential upon onset of labour, lower segment myometrial biopsies were taken at term before and after the onset of labour (n= ; each group). cdna was extracted from the tissues and real time rt-pcr was performed for sod- , serum/glucocorticoidinduced protein kinase- (sgk- ) and the dna repair enzyme gadd a. we found that labour onset is associated with a two fold increase in the levels of expression of each. oxidative damage at the fetomaternal interphase has been extensively studied in the placenta as part of investigations for first trimester pregnancy losses, iugr and pre-eclampsia. the role of ros is less well defined in human decidua and the underlying myometrium. our results suggest a role for oxidative stress and redox homeostasis in the maintenance of myometrial quiescene during pregnancy and onset of labour. plasma anandamide levels increase during labour induction and appear to delay labour progression. vijianitha nallendran, anthony h taylor, patricia mw lam, stephen c bell, david j taylor, justin c konje. cancer studies and molecular medicine, university of leicester, leicester, united kingdom. background: the evidence for a role of the endocannabinoid, anandamide (aea) in labour is conflicting. we previously showed elevated aea plasma levels in labouring women whilst another group showed that activation of functional receptors for anandamide actually inhibited uterotonin-induced contractions through an adenylate cyclase pathway . the aim of this study was to explore further the relationship between labour and plasma aea levels. methods: plasma aea levels in women undergoing induction of labour for various indications at term, were measured by a sensitive isotope dilution method using hplc-ms/ms. each volunteer had an assessment of her cervix prior to the start of the induction when the first sample for aea was collected. once active labour was established (cervix cm dilated; contractions every - minutes), a second sample was collected. results: seventeen ( %) of the subjects were multigravida. the inductions were for postdates(n= ); decreased fetal movements(n= ), fetal growth restriction(n= ), symphysis pubis dysfunction(n= ), diabetes mellitus(n= ), pre-eclampsia(n= ), fetal cardiac complication(n= ), spontaneous rupture of newborn offspring with persistent pulmonary hypertension, despite enhanced fetal membranes(n= ). plasma aea levels increased significantly once labour was established (figure) and demonstrated in ( %) of the cases. the median (interquartile range) plasma aea level increased from . nm ( . - . ) at induction to . nm ( . - . ); *p= . ; mann-whitney u-test) at active labour. there was a positive correlation between plasma anandamide levels taken before induction and the time taken for the women to enter into active labour (r = . , p= . pearson correlation). plasma aea levels were higher in labouring women compared to non-labouring women after the induction of labour confirming our previous observations and suggesting a direct role for this endocannabinoid in labour. further studies are required to elucidate this role. nuclear factor-kappa b (nf-b) is a transcription factor family classically associated with inflammation, activated in response to infection and proinflammatory cytokines, such as those prevalent during labour. as a cytokineinducible transcription factor it plays a key role in the expression of a variety of genes involved in inflammatory responses and cell survival. nf-b dna binding and transcriptional activity plays an important role in labour associated gene expression in myometrium. in this study we examined the range of genes regulated by nf-b in myometrium using transient transfections and wholegenome array analysis. myometrial cells were extracted from myometrial biopsies taken at the time of elective caesarean sections at term. transient transfections of primary myocytes were performed using expression vectors for nf-b p .the amount of dna was constant and psg was used as a control construct. cdna was made from myocytes transfected with either nf-b or psg . affymetrix genechip u microarray was performed (n= , each group). we found that genes were significantly differentially expressed between control and overexpressed nf-b samples. twenty eight of these genes were upregulated with nf-b and were down regulated. several chemokines and cytokines were identified in the upregulated group. interleukin demonstrated the highest, fold, induction in the upregulated group, followed by tumor necrosis factor, a-induced protein (tnfaip ), chemokine ligand (ccl ), chemokine ligand (ccl ), pentaxin related gene (ptx ), interleukin (il ) and superoxide dismutase (sod- ). nine genes were present in the nf-b group that were absent in the control group. these included chemokine ligand (ccl ), chemokine ligand (ccl ), chemokine ligand (cxcl ) and il . ingenuity pathway analysis demonstrated that immune response, inflammatory, cell growth and proliferation and cell death were the main pathways involved. standardisation experiments have been performed, and the microarray results were confirmed with real time rt-pcr in several candidate genes. our results provide further support in the role of nf-b in human labour and suggest its direct link in upregulation of inflammatory genes, cytokines and chemokines, consistent with the imflammatory nature of the biochemistry of labour. inflammation is widely accepted to be a key feature of human labor. secretory leukocyte protease inhibitor (slpi), an innate immune molecule, has been shown to be an antimicrobial and anti-inflammatory protein. the aims of this study were to verify its expression and localization in human myometrium methods: specimens were obtained at time of cesarean delivery with or without labor. expression and localization of slpi was detected using immunohistochemistry. slpi expression pattern relative to nf-b p subunit was compared between not in labor and in labor subjects, between different tissue sections as well as in in vitro model systems including myometrial explants, uterine smooth muscle cells (usmc) and ishikawa endometrial adenocarcinoma cells. slpi was predominantly localized to the nuclei of myocytes. the observed nuclear immunoreactivity of myocytes was increased during the labor relative to not in labor, paralleled with p nuclear translocation. the nuclear pattern of slpi is specific to myometrium since slpi immunostaining was present exclusively in the cytoplasm of all other tissues examined, including amnion, chorion, decidua and endometrium. slpi staining was also positive in macrophages, indicated by co-localization of slpi with cd positive cells. treatment with il- or tnf-induced nuclear translocation of p in myometrium explants and usmc, but not in ishikawa cells. in human myometrium, slpi is predominantly localized in the nuclei of myocytes and in macrophages. the nuclear expression pattern of slpi is myometrium-specific and increased following the onset of labor and correlated with nf-b activation. further understanding of its physiological significance may suggest new strategies aimed at preventing preterm birth. application of a new proteomic technology on amniotic fluid in prom. sara consonni, niccolo bosso, marianna andreani, agnese pizzardi, fulvio magni, anna locatelli. obstetrics and gynaecology, university of milano-bicocca, monza, italy; experimental medicine, university of milano-bicocca, monza, italy. objective: mass spectrometry (ms) is the obligatory tool for proteomics studies. biological samples must be purified before ms analysis due to the matrix complexity. a recent approach combines active surface prepurification with maldi-tof (matrix assisted laser desorption) analysis. clinprot technology provides the prepurification of the sample through the use of magnetic beads (mb) with activated surface. this technique can be carried out by robot in an automated way on a large number of samples. a unique example of the use of mb before maldi-tof analysis to determine proteomic profiles of amniotic fluid (af) is reported for rapid detection of fetal aneuploidies (wang ) . the objective of our study was to verify the applicability of clinprot prepurification before maldi-tof analysis on amniotic fluid collected noninvasively in premature rupture of membranes (prom). methods: we sampled af from vaginal posterior fornix of women with preterm prom (group , n= ) and term prom (group , n= ). samples were prepared with mb and analyzed with ms maldi-tof in order to generate proteomic profiles. results: it was possible to generate average proteomic profiles in the two study groups and the observed profiles were different. samples of af non invasively collected in prom can be analyzed by ms maldi-tof after preparation with mb. this technique allows to retain part of the eluted sample for characterization of protein peaks of interest. due to the less laborious characteristics of this method in comparison with techniques based on bidimensional electrophoresis its application can be useful in clinical proteomics. progestins accentuate the maternal but not fetal inflammatory response of women with intra-amniotic inflammation. sonya abdel-razeq, irina a buhimschi, michael cackovic, guoyang luo, antonette dulay, victor rosenberg, mert bahtiyar, errol norwitz, edmund funai, catalin buhimschi. ob./gyn. reprod.sci., yale university, new haven, ct, usa. introduction: data from animal research suggests that progestins have a marked pro-inflammatory capacity. recent studies support the administration of -hydroxyprogesterone caproate in women at risk for preterm birth. we sought to determine the impact of progestins during gestation on the extent of maternal and fetal inflammatory responses in pregnant women with intraamniotic inflammation. methods: amniotic fluid, placenta and cord blood were obtained from women who delivered preterm (median[range], ga: [ - ] wks). an amniocentesis was done to rule out infection. women exposed to progestins (n= ) within one week prior to amniocentesis were matched to controls (crl) by age, parity, history of preterm birth ga, membrane status and interval to delivery. proteomic profiling of amniotic fluid [mass restricted (mr) score] identified the presence or absence of intra-amniotic inflammation. an mr score of or confirmed intra-amniotic inflammation. amniotic fluid and umbilical cord interleukin- (il- ) levels were measured by elisa. histological chorioamnionitis was graded based on recognized criteria. results: overall, women and their fetuses exposed to progestin did not exhibit an increased inflammatory response (table) . however, sub-analysis restricted to women with mr or (n= ) showed that in the context of intraamniotic inflammation, progestins were associated with significantly elevated amniotic fluid il- levels compared to unexposed women (progestins (n= ): vs. crl (n= ): [ . - ] ng/ml, p= . ). these relationships were maintained after correction for steroid and antibiotic exposure. such significance was not found for amniotic fluid glucose, ldh, wbc count or cord blood il- . conclusion: our results suggest that progestins may amplify the maternal, but not the fetal inflammatory response of women with intraamniotic inflammation. objective: recently progestins have been shown to reduce the incidence of recurrent preterm labor in women. progestins have long been known to inhibit preterm labor in some species including rats and are also known to delay term labor. nitric oxide (no) donors, including ng, inhibit uterine contractility and have been used as tocolytics. the aim of this study was to examine the inhibitory effects of r on preterm labor in rats induced with a progesterone antagonist (onapristone, zk) with and without ng. materials and methods: charles river s-d timed pregnant rats (n= /group) were treated with zk ( mg/rat, s.c.) alone or vehicle (controls) on day of gestation. other groups of rats were treated with zk in combination with various doses of r ( . , or mg/rat s.c) with and without ng ( mg s.c. pellet) from days to of gestation. all rats were sacrificed on day of gestation and the number of fetuses and implantation sites were counted to determine the preterm delivery rate. one way anova was used for statistical analysis. p< . was considered significantly different. results: rats treated with zk alone delivered all their fetuses prematurely compared with controls (p< . ) treated with vehicle only (ca. % fetuses delivered). ng treatment alone did not affect the delivery rate (p> . ) compared to controls. similarly zk + ng did not reduce the preterm delivery rate compared to zk alone (p> . ). however r dose dependently reduced (p< . at all doses) the number of fetuses delivered prematurely in response to zk and the premature delivery rate was further reduced when treatment included the combination of r plus ng (p< . ). conclusions: zk effectively induces premature delivery. premature delivery produced by zk can be effectively reduced with a r , a progestin known to bind with high affinity to nuclear progesterone receptors. ng by itself, at the dosage used, does not reduce the prematurity rate caused by zk. however, r and ng act synergistically to reduce the preterm delivery rate. this study indicates that combinations of a progestin with an no donor may be an effective treatment for preterm labor and delivery. monkeys. pl grigsby, jp rasanen, , dw sadowsky, m bertolino, m carbonatto, e gillio tos, s canali, j lacy, a chollet, mj novy. reprod sci, oregon primate res ctr, beaverton, or; ob/gyn, oregon health sci univ, or, usa; rbm, merck serono, italy; merck serono, switzerland. objective: to investigate the pharmacokinetics (pk) and pharmacodynamics (pd) of as , a novel orally active non-peptide oxytocin (ot) antagonist in rhesus monkeys. study design: dose finding and pk/pd studies were done in chronically instrumented non-pregnant (n= ) and pregnant ( - dga, term d; n= ) monkeys. maternal and amniotic fluid compartments were serially sampled during dosing and washout. treatment phases included: ot infusion control, ot infusion + as , and ot rescue therapy. ot infusions ( - mu/kg/hr, iv) were given to determine the lowest dose required to produce stable, sub-maximal uterine contractions in each animal. as was administered p.o. at , , mg/kg and the effects on inhibition of uterine activity (hca, mmhg.sec/hr) were compared. to verify antagonist reversibility, objectives: infection such as chorioamnionitis is thought to be the cause of premature rupture of the membrane and induce uterine contractions leading to preterm delivery. however, the mechanism for enhancement of uterine contractility is not well understood. we have reported that non-selective cation channels (nsccs) regulate pacemaker potentials to generate rhythmical contractions and should be targets of magnesium ions used for tocolysis. the purpose of this study is to investigate the changes of the expression of nsccs during normal pregnancy and the effect of inflammation in preterm. methods; atp receptors (p x) and transient receptor potential canonical (trpc) channels were examined as uterine nsccs. the mrna was extracted from the rat myometrium of non-pregnant and pregnant rats at days , , and . the expression of each subtype of p x and trpc channels was measured by real time rt-pcr (abi ) with taqman probes (abi). as an inflammatory model lipopolysaccharide (lps; . mg/kg) was injected into intraperitoneal cavity at day and the tissue was sampled after six hours. results; p x and p x were determined to be dominant subtypes of p x channel. the expression of p x was increased by % at day , compared with day and that of p x was enhanced by %. on the other hands, trpc and trpc were detected dominantly. the expression of trpc was increased three times in the late stages of gestation. however, trpc was suppressed by %. in the lps treated rat myometrium cox- mrna expression was measured to be fold higher than that of the control rat, showing inflammatory effects in the myometrium. in this model the expressions of p x , p x and trpc were enhanced by . , . and . times, but trpc was not changed. the mrna expression of p x , p x and trpc channels in rat myometrium was increased in the late stages of pregnancy. these channels are suggested to be concerned with onset of labor. in the inflammatory model the expression of these channels was accelerated dramatically and these values were much higher than those in normal pregnancy. this finding supposed inflammation may enhance some types of nsccs to accelerate uterine contractility and induce preterm delivery. anandamide ( to determine the mechanism of rho protein activation during oxytocin and carbachol induced contraction, freshly prepared myometrial strips in krebs henseleit buffer were treated with oxytocin ( nm) and carbachol ( μm) under isometric and tension free conditions. control strips were exposed to buffer only. treated myometrial strips were solubilised and separated into membrane and cytosolic extracts and equal aliquots were immunoblotted with rhoa and rhob antibodies. rhoa translocated to the membrane after oxytocin and carbachol stimulation under both isometric and tension free conditions (p< . ). there were no significant changes in rhob membrane to cytosol ratios relative to control. agonist induced contraction in human myometrium is associated with rhoa but not rhob membrane translocation. during pregnancy components of the intracellular camp signalling pathway show increased gene expression resulting in the maintenance of myometrial quiescence until term where a substantial decrease in expression of these genes is observed. protein kinase a regulatory subunit riia (rii ) is upregulated at both the mrna and protein levels in the human myometrium during pregnancy. this particular subunit is membrane-bound and by directing phosphorylation to myometrial cytoskeletal proteins may affect contractile machinery thus playing a role in maintaining uterine relaxation. acetylation of histones promotes a favourable chromatin environment for transcriptional activity of many genes. this process is largely inhibited by histone deacetylases (hdacs), whereby its activity leads to transcriptional repression. hdacs can be recruited to the promoter region of a gene by other transcription factors such as sp proteins. since the rii promoter contains three sp - consensus binding sequences in its proximal part, we investigated whether this gene is a target for transcriptional regulation by hdacs. using dna precipitation assays we found that sp , and as well as hdac and form complexes with biotin-labelled fragments relating to sp - elements in the promoter region of rii . additionally, treatment of myometrial primary cell cultures with hdac inhibitor trichostatin a (tsa), or with the methyltransferase inhibitor -azac resulted in increased mrna and proteins levels. further studies with full and truncated luciferase constructs of the promoter region of the rii gene in transiently transfected myometrial cells confirmed that all three sp - elements are involved in the transcriptional regulation of the gene. this process involves hdacs, as h treatment with tsa significantly increased the luciferase signal. changes in the binding of sp proteins and hdacs to the promoter after tsa and azac treatment were investigated employing chromatin immunoprecipitation assays. alterations in the methylation status of the promoter after treatment were examined by bisulfite modification and dna sequencing. together, this study highlights the importance of chromatin modifications in the maintenance of uterine quiescence during pregnancy as well as identifying a potential mechanistic target for drugs that may reduce the incidence of preterm labour. objective: progesterone maintains pregnancy by promoting myometrial quiescence. typically progesterone effects are thought to be mediated through the classic genomic pathway. there is evidence, however, that progesterone also acts via a non-genomic pathway by interacting with specific membrane progesterone receptors (mprs) and in particular progesterone receptor membrane component - (pgrmc- ). the role of non-genomic progesterone actions in human pregnancy and parturition is not clearly understood. the goal of this study was to measure the extent of mpr expression in biopsy specimens of human myometrium obtained at cesarean delivery, and to determine whether expression changes with advancing gestation or the onset of labor. study design: lower uterine segment myometrial biopsies were obtained at the time of delivery from consenting women who were at term and not in labor (n= ), preterm and not in labor (n= ) and term and in labor (n= ). protein extracts were prepared and subjected to polyacrylamide gel electrophoresis and immunoblot analyses for pgrmc- and gapdh. abundance of pgrmc- protein relative to gapdh was determined by digital densitometry. we also performed immunohistochemistry (ihc) to determine the cellular localization of pgrmc- in the human pregnancy myometrium. results: pgrmc- protein was identified in each biopsy specimen. there was a -fold increase in pgrmc- protein in term compared with preterm biopsies (relative to gapdh p< . ). the relative level of pgrmc- protein was not different between biopsy specimens from laboring and non-laboring women at term (compared to gapdh, p= . ). pgrmc- immunoreactivity was localized to granular cytoplasmic staining. conclusion: this is the first description of the presence of pgrmc- protein in the human myometrium during pregnancy. its presence suggests that progesterone may influence contractility non-genomically via these receptors. the functional significance of the gestational age associated two fold increase in pgrmc- is unclear. changes in expression of this receptor during pregnancy may be important for the hormonal control of parturition and can be the focus of future studies. (ruddock et. al., abstract smfm, ) . the aim was to examine the mechanism of p inhibition. methods: uterine tissues from women (n= ) at term with cesarean section, were suspended in organ chambers and exposed to various agents or solvents. contractility was registered, stored, analyzed and compared before and after addition of agents or kcl. tissues were treated with p alone ( - to - m) or p bound to bovine serum albumin (bsa/p , - to - m p ), a progestin with low affinity to mpr (r , - - - m), or a non-sex steroid (cholesterol, - to - m). other tissues were pretreated with selective inhibitors of adenylate cyclase (sq , - m), guanylate cylase (odq, - m), phosphodiesterase (rolipram, - m), nitric oxide (no) synthases (l-name, - m) or a nuclear p receptor antagonist (mifepristone, mif, - m), followed by p . data were analyzed by anova for statistical differences (p< . ). results: p rapidly (< hour), effectively ( %) and dose-dependently inhibits spontaneous and kclinduced contractility (ed of < - m incubation of strips with zd- , at concentrations up to m for one hour prior to the experiment, led to no significant reduction in the total work done. however, incubation of strips with l- with a concentration of nm for one hour prior to the experiment, led to a statistically significant reduction in the total work done after one and a half hours. furthermore, when increasing concentrations of pge ( - to - ) were added to l- ( nm) pre-treated strips, total work done per contraction was comparable to that of non-treated controls. similar effects were not observed in zd- ( nm) pre-treated strips. since the reduction in contractility caused by l- was greater than that caused by zd- , it is likely that the stimulating effect of pge acts predominantly via ep receptors. taken together with our previous data showing an increase in ep at labour, this data shows that targetting an ep receptor may be a useful strategy in managaing pre-term labour. recently a truncated kda isoform of the er-has been described in human endothelial and testicular cells. we describe the presence of this kda erisoform in pregnant and immortalized non-pregnant human myometrial cells. methods: myometrial tissue obtained from non-laboring pregnant women undergoing cesarean section at term (n= ) was dissected prior to being finely minced. a portion of the tissue was placed in pbs and sonicated, while the remainder of the tissue was dissociated with collagenase prior to filtration and placement on culture plates. cells were then cultured in mem w/ % fetal bovine serum (fbs) until confluence. cultured cells were then dissociated with . % typsin/edta, subsequently re-plated and grown to confluence. immunohistochemistry directed toward smooth muscle protein was used to verify myometrial phenotype.) protein was extracted and quantified. western blot was performed with mouse monoclonal anti-er-receptor antibody (santa cruz biotechnology) to the f- domain of the human er-receptor. an immortalized non-pregnant human myometrial cell line provided by ann word, htert, was cultured and isolated as described above. results: htert cells expressed both the truncated ( kda) and the full length ( kda) er-isoforms. fresh and cultured myometrial cells from non-labored term pregnant patients also expressed both isoforms of er-. subsequent subcultures of myometrial tissue continued to express the kda erisoform, yet the expression of the kda isoform was lost. a representative blot is below. conclusions: we demonstrate, for the first time, the presence of a kda erisoform in cultured and non-cultured pregnant and cultured nonpregnant human myometrial tissue. discovery of this isoform of er-in myometrial tissue could provide insight into the molecular mechanisms involved in parturition. the action of prostaglandin f (pgf ), a potent uterotonic stimulant that is associated with labour at term and preterm, is mediated by its receptor, ptgfr. myometrial ptgfr mrna levels fall during pregnancy and this likely plays a role in uterine quiescence. however, the mechanisms by which this occurs are poorly understood. we previously reported that pgf downregulates fp mrna expression in cultured human myometrial ultr cells in a protein kinase c (pkc) dependent manner. in addition to the downregulation of mrna levels, receptor desensitization may also represent another mechanism of decreasing ptgfr activity because ligand binding to g protein coupled receptors often results in receptor internalization. we therefore hypothesized that pgf treatment of ultr cells also results in pkc dependent ptgfr internalization. methods: near confluent cultured human myometrial ultr cells were treated +/- - m or - m pgf for , , or hr. cells were fixed with formaldehyde and visualized for localization of ptgfr by immunofluorescence. to examine the potential involvement of pkc in the process, ultr cells were treated +/- - m pgf and +/- m myristoylated pkc inhibitor ( - ) and examined for ptgfr cellular localization as described above. results: pgf treatment resulted in a dose dependent decrease in ptgfr membrane signal at , , and h. this decrease was dependent on pkc as cotreatment with the myristoylated pkc inhibitor ( - ) prevented the pgf induced decrease in membrane ptgfr at h treatment. there was no visible effect of the pkc inhibitor on ptgfr membrane signal on its own. conclusion: we conclude that pgf decreases membrane levels of ptgfr protein in human myometrial ultr cells in a pkc dependent manner. these results suggest that pkc may be required for both the pgf induced internalization and desensitization of ptgfr protein and downregulation of ptgfr mrna in human myometrial ultr cells. therefore pkc may play a crucial role in downregulating ptgfr expression and activity and maintaining uterine quiescence during pregnancy. rhoa is a small gtpase that acts as a molecular switch to control a variety of signalling pathways in smooth muscle, including contractility. it is thought that increases in rhoa-gtp levels facilitates phosphorylation of target proteins such as cpi- , promoting contractility at pre-term and term labour in humans. however, in situations of acute or chronic hypoxia in the uterus, it is important that myometrial contractility and subsequent labour is not facilitated prematurely. given the importance of rhoa to a cell's response to hypoxia in other cell types, it was hypothesised that rhoa plays a central role in the mechanism controlling smooth muscle contraction in the uterus too. following acute hypoxia ( . % o ) for one to six hours, rhoa mrna, total protein and activation (rhoa-gtp) levels were analysed, using semi-quantitative pcrs and western blot, and compared to normoxic non-pregnant human uterine smooth muscle control cells. next, we investigated whether reduced oxygen conditions affected oxytocin induced activation of rhoa, following a two hour treatment of nm oxytocin. firstly, our results demonstrate that the rhoa itself is significantly activated under low oxygen conditions, resulting in phosphorylation of myosin phosphatase, myosin light chain and cofilin, three proteins known to be central in contraction and actin filament organisation. secondly, hypoxia significantly reduced the coupling of oxytocin to rhoa activation under the conditions examined. we observed a significantly reduced level of rhoa expression and activation which correlated with an increase in the level of another rhogtpase protein, rhoe. we propose that rhoa inactivation occurs through a rhoe-mediated mechanism, suggesting a balance in the activity of these two antagonistic rhogtpases in oxytocin-induced hypoxic human uterine smooth muscle cells. these results provide a possible explanation for the reduced coupling of oxytocin as a stimulant of myometrial contractions during slowly progressing labours. oxytocin-induced release of calcium ions (ca + ) from sarcoplasmic reticulum (sr) and sensitisation of contractile proteins to ca + have been suggested to mediate the oxytocin-induced potentiation of myometrial contractions. objective: we investigated the effects of oxytocin in the presence of nifedipine, a known inhibitor of the l-type calcium channel (ltcc). method: samples of myometrium were obtained from women undergoing term caesarean section with the approval of the local ethics committee. a standard organ bath system (ad instruments, uk) was employed to analyse contractile activity. stable spontaneous contractions were recorded for - minutes before addition of nifedipine. results: in agreement with our previous findings, application of oxytocin to spontaneously active strips produced a two-component effect: a transient tetanus-like contraction, followed by prolonged augmentation of phasic contractions. nifedipine ( um) rapidly abolishes spontaneous contractions, subsequent addition of nm oxytocin produced an initial, transient rise in force, approxiamately % compared to oxytocin alone, followed by high frequency oscillations in > % of strips. calcium-free solutions were used to confirm that oscillations were due to ca + entry. disabling the sr store using thapsigargin ( um) had no effect on oscillations, confirming the sr not to be involved. the t-type calcium channel blocker, mibefradil ( um ) showed no inhibition of oscillations. an ip receptor and store-operated calcium channel inhibitor, -aminoethyldiphenylborate ( -apb) um also had no effect on oxytocin-induced oscillations. the store-operated calcium channel inhibitor skf- ( um) showed partial inhibition of oscillations. conclusions: based on these results, we propose that the most likely mechanism of ca + entry producing oxytocin-induced oscillations in the presence of nifedipine is the transient receptor channel-c (trpc) channel, known to be present in the human myometrium. further work needs to be completed to clarify this further. identification of stim and orai in human myometrium. a new paradigm in store-operated calcium signaling. evonne c chin-smith, mark r johnson, rachel m tribe. division of reproduction and endocrinology, king's college london, london, united kingdom; department of maternal fetal medicine, imperial college school of medicine, chelsea and wesminster hospital, london, united kingdom. background: recent reports have suggested that two novel proteins, stim and orai, are involved in the regulation of store-operated calcium entry. we have previously reported that members of the trpc family, putative basal and store operated calcium entry channels, are present in human myometrium and regulated by labour associated stimuli il- beta and mechanical stretch. although stim and orai isoforms have been reported in other smooth muscle cell types, there are no published reports of stim and orai expression in human myometrium. the aim of this study was to identify mrna expression of stim , stim , orai and orai in human myometrium. methods: human myometrial biopsies were obtained from women undergoing elective caesarean section at term (prior to labour) with informed written consent and institutional ethics committee approval. whole myometrial tissue was either snap frozen and stored at - o c or used for cell culture. rna was extracted from whole tissue (n= ), primary cultured myometrial cells (n= ) and passaged (p ) myometrial cells (n= ) and stim , stim , orai and orai mrna expression was assesed by quantitative real-time pcr. results: all four genes were expressed in whole myometrial tissue and cells. stim and stim mrna expression in cultured myometrial smooth muscle cells (primary and passaged) was significantly reduced compared to myometrial tissue expression (p< . ). however, there was no significant difference in either orai or orai expression in whole tissue versus cultured myometrial smooth muscle cells. conclusion: to our knowledge this is the first report of stim / and orai / mrna expression in human myometrium. these genes may contribute to the regulation of calcium signalling in human myometrium, but the functional significance of their expression remains to be determined. funded by the bbsrc. obstetrics and gynecology, national university of ireland, galway, galway, ireland. objective: the ability of uterine smooth muscle cells to stimulate collagen contraction has been well established as an in vitro model of myometrial contractility. devost and zingg ( ) reported that the contractility of human myometrial cell lines layered onto collagen matrices was increased by oxytocin while another group described the stimulation of human uterine smooth muscle cell contractility, cultured within collagen lattices, with endothelin- (dallot et al., ) . our study investigated the response of human primary uterine smooth muscle cells cultured within collagen lattices, to various compounds, including the non-specific depolarizing agent potassium chloride (kcl), the inflammatory cytokine tnf , the rock- inhibitor y- , oxytocin, and oxytocin plus its clinically used antagonist, atosiban. methods: human primary uterine smooth muscle cells (utsmc) (lonza) were maintained in dmem high glucose media. cells ( , per well) passage - , were embedded in . mg/ml collagen, in . ml aliquots, in dmem-f media on well plates (invitrogen) (dallot et al., ) . effects on contraction were studied by monitoring changes in gel area (alpha innotech imager, image j software (nih)). statistical significance was determined by the student t test. results: the utsmcs displayed basal contraction of the collagen gels while the non-contractile cell line hek cells, did not. kcl ( nm) stimulated an % increase in contractility (n= , p= . ) while nm tnf resulted in an . % increase (n= , p= . ), in comparison to unstimulated cells embedded in gel. the rock inhibitor y- ( m) inhibited contractility, with a . % decrease in collagen gel contractility (n= , p= . ). a % increase (n= , p= . ) in utsmc embedded collagen contractility was observed with nm oxytocin, which was antagonized by atosiban ( m) (n= ). conclusion: this study highlights the importance of the development and optimisation of a reproducible human in vitro myometrial contractility model, to evaluate the effect of various known labor-associated, and also unknown compounds. this should aid in our understanding of the many complex biochemical pathways involved in myometrial contractility at labor, and ultimately contribute to the prevention of preterm labor. changes in intra-mural myometrial blood flow during spontaneous labour using d power doppler angiography (pda). nw jones, , nj raine-fenning, h mousa, mj taggart, k jayaprakasan, gj bugg. nottingham university hospitals nhs trust, united kingdom; nottingham university, united kingdom; university of newcastle upon tyne, united kingdom. methods d pda was used to measure the percentage (%) change in the vascularization index (vi), the flow index (fi) and the vascularization flow index (vfi) in a volume of myometrium at the uterine fundus of nulliparous women at term, in the first stage of uncomplicated spontaneous labour. d data sets were obtained during a single cycle of uterine relaxation (r ), contraction and subsequent relaxation (r ). measurements were made independantly by two authors (nwj and gjb) using vocal® (ge kretz) and the mean value was used for analysis. the results from each woman are presented as a % change of r . data is presented as medians [interquartile range (iqr)] and analysed using non-parametric tests. the median volume (cm ) of interest for r was . cm ( . - . cm ), for the contraction was . (fig. ) . the % change for all three indices between r and r was not significantly different. however, there was a significant difference between the contraction and r (p< . ). the mean intra-class correlation coefficient and % confidence interval (ci) of vi, fi and vfi for the authors (nwj and gjb) were . ( . - . ), . ( . - . ) and . ( . - . ), indicative of good inter-observer reliability. conclusion d pda is a useful and reliable tool in the assessment of changes in intramural myometrial blood flow, which was found to reduce significantly during a contraction but increase again during the following uterine relaxation. . raine-fenning nj, et al. the inter-observer reliability of d pda acquisition within the female pelvis. ultrasound obstet gynecol. ; : - . the role of pgf on myometrial contractility; studied with a selective fp antagonist. shankari arulkumaran, andre chollet, phillip r bennet. imperial college parturition research group, institute of reproductive and developmental biology, hammersmith hospital campus, london, united kingdom; merck serono, geneva, switzerland. objectives: human myometrial strips established in culture will usually begin contracting after one hour. we have previously shown that stretch upregulates prostaglandin synthesis and have therefore hypothesized that spontaneous contractions occur because of stretch-related prostaglandin synthesis. methods: experiments were performed using x mm human pre-labour, lower uterine segment myometrial strips in a dmt myograph ms in oxygenated kreb's solution, with adi powerlab software. spontaneous contractions required stretch force and initial experiments determined that the maximum number of strips attaining spontaneous contractions was greatest at a force of - g. a novel antagonist to pgf (fpa) was studied in this model. the fpa has a ki of nm for fp and is - fold selective for fp compared with other prostanoid receptors. results: addition of pge and pgf after the commencement of spontaneous contractions caused a statistically significant increase in the total work done by the strips. the effect of pge was being greater than that of pgf . pre-incubation of the baths with a novel and selective fp antagonist (fpa) with concentrations up to m ( - ) did not affect the total work done by spontaneous contractions compared to non-treated controls. however, increasing concentrations of the fpa ( - to - ) decreased the total work done by -fold on strips treated with pgf beforehand in comparison the pgf -treated strips alone. conclusion: these data suggest that stretch and synthesis of prostaglandins is essential for spontaneous contractility in human myometrial strips. since fpa is able to block pgf induced but not spontaneous contractions, it is likely that pgf does not play a role in spontaneous myometrial contractility in vitro, although it may do so in vivo. because other factors may combine to increase contractility, the combination of an fp antagonist with other inhibitors may therefore, be a more effective strategy in reducing pre-term deliveries. objectives: brain natriuretic peptide (bnp) is synthesized in fetal membranes and inhibits oxytocin-induced contraction of preterm human myometrium. we hypothesized that bnp may be a paracrine mediator of human myometrial quiescence. we showed bnp content is higher in membranes from preterm pregnancies absent labor and significantly decreased with idiopathic preterm labor. while bnp activates natriuretic peptides receptors a (npr-a), b (npr-b), and its clearance receptor (npr-c), we have shown bnp does not inhibit myometrial contraction via npr-a or npr-b. herein, we test in part the hypothesis that bnp inhibits myometrial contractions by activating npr-c by quantitating npr-c in human myometrium at different gestations and labor status. methods: myometrial samples were obtained at the time of cesarean section after informed consent from groups of patients: preterm not in labor (pt-nl), preterm in labor (pt-l), term not in labor (t-nl) and term in labor (t-l). myometrial samples were obtained from women - weeks' gestation, and term between and weeks. mrna for npr-a, b and c were semiquantitated by realtime pcr (normalized by s mrna), and npr-c protein by western blot. results: natriuretic peptide receptors a, b and c mrnas were identified in all groups. while there were no differences in mrna levels among groups, npr-c protein was increased in samples from term laboring women. conclusion: since bnp inhibits the contraction of human preterm but not term myometrium independent of npr-a and npr-b, we have previously speculated that bnp activates another "unknown" receptor. herein we find that myometrial npr-c protein but not mrna increases during human labor at term. the increase in npr-c at term could compete with the unknown quiescent receptor to functionally reduce the availability of bnp and thus permit or promote myometrial activation/contraction. (supported by a grant from chilean government fondecyt ). objective: bnp is synthesized within human chorion and amnion and inhibits oxytocin-induced contraction of human myometrium. bnp activates guanylate cyclase (gc) natriuretic peptides receptors a (npr-a) and b (npr-b). bnp also stimulates the clearance receptor (npr-c) whose action is not mediated by gc. the intracellular pathway of bnp/npr-c inhibition is not known. we determined that bnp does not inhibit myometrial contraction via npr-a or -b. we hypothesized that bnp inhibits myometrium by npr-c activation. we test aspects of our hypothesis by determining whether bnp/npr-c pathway inhibits myometrial contractions via myometrial nos pathway. methods: bnp and canp (specific npr-c agonist) were added to primary human myometrial cell cultures and enos/inos activity/expression determined. cell cultures (n= ) were prepared from myometrial samples of nonlaboring, term pregnant women. after confluence ( d), the cells were incubated ( h) with nm bnp and/or canp. nos activity was measured ( l-citruline assay) and transcription/translation semi quantitated (realtime pcr and western blotting). results: bnp had no effect on either nos expression or activity. canp significantly reduced inos but not enos mrna level. canp did not alter the protein level of nos but significantly reduced nos activity. co-incubation with bnp and canp reduced both mrna levels (p< . ) and significantly decreased enos, but not inos, protein without change in overall nos activity. within the female pelvis. ultrasound obstet gynecol. ; : - . conclusion: the activation of npr-c by canp reduces nos activity and expression. the same effect was not observed by bnp. the difference may be explained because bnp (but not canp) activates all natriuretic peptide receptors, and they may have opposite actions on nos pathway. we conclude unlikely bnp inhibits human myometrial contraction by npr-c activation via the nos pathway. ( introduction: ultr is a retroviral immortalized human uterine smooth muscle cell line which we use as a model for uterine hypertrophy studies. however, this cell line has limited usage due to a reduced rate of cell division and eventually replicative senescence in culture. one of the mechanisms of human somatic cellular senescence is un-compensated shortening of telomeres, the specialized dna structures located at the ends of eukaryotic chromosomes. introduction of human telomere reverse transcriptase (htert) has been shown to induce telomerase activity and telomere elongation, and extend life-span of normal human cells. objective: to recover ultr cell division without altering the phenotypic characteristics of smooth muscle cells by introducing htert, therefore improving ultr cell line. methods: ultr cells were transfected with a modified htert expression vector at a relatively early stage (passage ) in the presence of selective antibiotic. ultr cell growth rate, with (ultr-ht) or without transfection, was determined by plating cells in multiple plates at a fixed density and counting cell numbers after days. single cell clones of stably transfected cells were further isolated by plating in well plates. expression of htert, smooth muscle specific genes (smc-sgs), and target genes was identified by rt-pcr of total rna extracted from ultr and ultr-ht cells. results: rt-pcr demonstrated successful introduction of htert into ultr cells. the growth rate of ultr-ht cells was increased and cell morphology was improved (free of the typical aneupoid appearance). at passage , ultr-ht cells grew . fold (p< . ) and . fold (p< . ) faster than ultr cells at passages and , respectively. currently single cell clones have been selected. ultr-ht cells express a set of smc-sgs, including -actin, caldesmon, calponin, myosin heavy chain, sm , and smoothelin, confirming that the smooth muscle phenotype is preserved. a panel of genes involved in angiotensin ii signalling, including angiotensin ii receptors (at / ), nox family (nox , , and duox ), nox-associated genes (p phox, p phox, p phox, and rac / ), was also preserved. conclusion: this is the first report of rescuing uterine smooth muscle cell replicative senescence via activation of telomerase. we have established a human uterine smooth muscle cell line which will provide an improved in vitro model for studying human myometrium. at term, myometrium is characterized by spontaneous contractions which vary in the amplitude, frequency and duration depending on specie and hormonal status. repetitive depolarization of plasma membrane followed by transient elevation in [ca + ] i is thought to underlie the contractions. however, the detailed pathways which regulate the spontaneous contractility remain unclear. objective: this study was designed to elucidate the effect of protein kinase c (pkc) on the spontaneous contractions and [ca + ] i transients in the myometria from term pregnant mice and women. methods: the human samples were obtained from women undergoing cesarean section with the approval from the institutional review board committee while mice myometria were dissected from the days pregnant mice sacrificed according to the animal study protocol. the isometric force and [ca + ] i were measured simultaneously in fura- loaded myometrial strips using spectrofluorometer equipped with force transducer. results: the pkc activator phorbol , -dibutyrate (pdbu) applied at - m first stimulated the amplitude of spontaneous contractions in mice and human myometria followed by their inhibition. under the pdbu treatment the frequency of the contractions was first increased and then decreased in both species. at the same time, pdbu didn't initially increase the amplitude of [ca + ] i transients but attenuated it over time. however, the frequency of the transients was first increased and later decreased upon the pdbu exposure. in addition, pkc activation with pdbu resulted in the elevation of the uterine basal tone without corresponding changes in the basal level of [ca + ] i in human myometrium. in mice myometrium, on the contrary, pkc activation didn't result in an increase of the muscle tone and the basal level of [ca + ] i . conclusions: we propose that pkc causes bi-phasic effect on uterine spontaneous contraction in mice and human first to potentiate the amplitudes and the frequencies and later decreases them. the amplitude of [ca + ] i was not initially potentiated by pdbu suggestive of the dissociation of the contractile and [ca + ] i response. the stimulatory effect of pdbu on the basal muscle tone in human myometrium and the absence of the effect in mouse suggest different mode of pkc action on uterine contraction in human and mice. introduction: mechanical stretch of uterine myocytes is detected through integrins on the cell surface which form part of the focal adhesion complex, this signals through mapk, ultimately leading to the up-regulation of various pro-labour genes including pghs- and il- . on integrin activation fak is recruited to the focal adhesion complex and activated by autophosphorylation at tyr- , creating a src binding site. this promotes further fak phosphorylation at tyr- , and , enhancing fak catalytic activity. however fak can also act as a scaffold protein and its exact role in the expression of pro-labour genes is uncertain. in this study we used inhibitors for the kinase activity of fak and mek / in order to test the affect of fak kinase activity on expression on pghs- mrna. methods: primary human myometrial cell cultures were grown from myometrial biopsies taken from women undergoing elective caesarean section. cells were plated onto -well flexible bottom plates coated in type i collagen. cells were subjected to % static stretch for up to minutes. cells were also incubated with either the rho kinase inhibitor y or the mek / inhibitor u prior to being stretched. western blots were performed using antibodies to fak phospho- , fak phospho- and erk / phospho- / , -actin was used as a loading control. rna was also extracted and levels of pghs- measured using q-pcr. results: stretch increased levels of phosphorylation at both tyr- and tyr- with the greatest increases occurring at and minutes. however the increase at tyr- appeared to be greater than at tyr- . incubation with the rho kinase inhibitor reduced phosphorylation of fak- , however this did not affect phosphorylation of erk / or stretch induced up regulation of pghs- mrna. in contrast incubation with the mek / inhibitor reduced erk / phosphorylation and expression of pghs- mrna, whilst also reducing fak phosphorylation (n= ; p= . ). conclusions: fak has previously been shown to be important in activation of the stretch induced mapk cascade and pghs- expression. however these data suggest that while stretch causes fak phosphorylation fak kinase activity is not essential to pghs- expression. this suggests fak may be acting as a protein scaffold. . our aim was to examine the effects of both natural progesterone and hp on spontaneous myometrial contractions. myometrial biopsies were taken with informed consent and ethics approval from non-labouring women at elective caesarean section weeks gestation. strips of myometrium mm long , mm wide were cut and suspended under a resting tension of mn in organ baths of krebs gassed with % o / % co within hours of collection. progesterone or hp were added in a cumulative manner at -minute intervals. changes in amplitude were recorded. results were compared using anova. following equilibration for hours, myometrial strips contracted in a rhythmic manner (amplitude . ± . mn, n= pairs). progesterone ( nm- m) produced a concentration dependent inhibitory effect on myometrial contractions (fig ), which was greater than that of vehicle (p< . ). maximum inhibition measured . ± . % and . ± . % for progesterone and vehicle, respectively. hp exerted an inhibitory effect, this was not significantly different from the vehicle (p> . ). progesterone exerts an inhibitory effect on myometrial contractility in vitro. this is apparent within minutes suggesting a nongenomic action. our data are in agreement with some reports in the literature but conflict with others[ ]. this acute inhibition of myometrial contractility may contribute to the mechanism by which progesterone prevents preterm birth. in contrast, we were unable to demonstrate an inhibitory effect of hp on contractility despite its demonstrated ability to reduce the incidence of preterm delivery [ ] . our data suggest that natural progesterone may be a more effective tocolytic agent in the acute setting than hp. obstetrics and gynecology, ramathibodi hospital, mahidol university, bangkok, thailand; pathology, ramathibodi hospital, mahidol university, bangkok, thailand; obstetrics and gynecology, samuel lunenfeld research institute, toronto, canada. objective: chemokines has been shown to play an important role in regulating uterine function. recent evidence demonstrates that monocyte chemotactic protein (mcp) level in amniotic fluid increases during spontaneous labor. the aim of this study was to examine the expression of mcp in human myometrium. methods: myometrial biopsies were taken from nonpregnant women undergoing hysterectomy and term pregnant women undergoing cesarean section followed written consent and local ethics committee approval. elective cesarean section was performed before the onset of labor while emegency section was done after the onset of labor. immunolocalization (n = each) was performed on paraffin sections by avidin biotin complex (abc) technique using monoclonal antibody specific to human mcp . reverse transcriptionpolymerase chain reaction (n = each) using gene specific primer against mcp and mcp receptor was performed to identify mcp messenger(m) rna in human myometrium . results: immunohistochemical findings demonstrated mcp in human myometrial cells from nonpregnant, term pregnant women before and after the onset of labor. mcp was labelled on plasma membrane and cytoplasm of myocytes from these three groups of women. similarly, mcp and mcp receptor mrna were found in nonpregnant and term pregnant women before and after the onset of labor. in this prospective study a group of fetuses was consecutively enrolled. one ultrasound examination was performed to each patient within days from delivery. we considered fetal macrosomia a birthweight g and big babies a birthweight g. cut-off points for identifying the best value of fetal abdominal circumference for fetal macrosomia prediction were chosen by receiving operator characteristics' curve (roc) analysis. using the best cut-off indicated by roc analysis, specificity and sensitivity were calculated. mean gestational age at delivery was + weeks ( + sd). neonates weighted less than g, had a weight range between and g and weighted more than g. the fetal ac measurement was the selected criterium to evaluate the risk of fetal macrosomia. to identify macrosomic fetuses the roc curve analysis identified a cut off of ac > mm which allowed to select fetuses. analysing this population we found true negative cases, false negatives, false positives and true positives, with a sensitivity of . % and a specificity of %. to detect big babies the roc curve analysis identified a cut off of ac > mm (n. fetuses), reaching a sensitivity of % and a specificity of %, without false negative cases and with false positives ( true positives, true negatives). the cases that weighted between and g, were included in the cases considered false positives by this cut-off. conclusions. these results clearly indicated that ultrasounds alone can not be used to manage a pregnancy suspected for fetal macrosomia or big babies. in fact, to avoid shoulder dystocia and all other complications strictly related to macrosomic fetuses, clinicians should perform a large number of useless elective cesarean sections. . pathway analysis of differentially expressed genes (pa; z-score . ) showed up-regulation of axon guidance, folate biosynthesis, nitrogen metabolism and down-regulation of steroid biosynthesis, insulin signaling, oxidative phosphorylation, tgf-beta signaling, and ubiquinone biosynthesis pathways in cm vs cf. comparison of mnr vs c in f showed genes up-and down-regulated (n= , ; p< . ). pa showed up-regulation steroid biosynthesis, fatty acid metabolism, glycolysis/gluconeogenesis, phosphatidylinositol signaling, ketone body metabolism, and ubiquinone biosynthesis pathways and down-regulation of bile acid biosynthesis, cell adhesion molecules, dna polymerase, notch signaling and ti diabetes mellitus pathways in mnr vs c. comparison of mnr vs c in m showed genes up-and down-regulated (n= , ; p< . ). pa showed up-regulation of jak-stat signaling, autophagy, renin-angiotensin system (ras), and ubiquinone biosynthesis pathways and down-regulation of apoptosis, basal transcription, folate biosynthesis, nitrogen metabolism, protein export, and snare interaction pathways in mnr vs c. only the ubiquinone biosynthesis pathway up-regulation of mnr vs. c was common to both m and f. conclusions: ta and pa demonstrate sex-specific transcriptome expression in fetal kidneys at . g. in addition, these results show sexspecificity in response to mnr. we have seen similar effects of mnr on gene expression for autophagy, apoptosis, ras, ubiquinone and cell adhesion pathways at . g, suggesting these pathways may contribute to persistent affects of mnr. finally, we postulate that stress in utero may contribute to sex differences in risk of hypertension in adult life. leptin and neuropeptied y protein expression paradoxally increased in gestationall food restricted dams. louiza belkacemi, chun-hung chen, andrea jelks, michael g ross, mina desai. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: placental insufficiency is associated with marked increase in placental leptin production. this results in a rise in maternal leptin levels that serves as an early index of placental dysfunction. further increased placental leptin and suppressed neuropeptide y (npy) are associated with preeclampsia. leptin, an anorexigenic hormone and npy, an orexigenic peptide regulate food intake. importantly, leptin also serves as a placental and fetal growth factor. we have shown that maternal food restriction (mfr) results in intrauterine growth ... sf ()to:!)) df(,..)l) ...._ bf(jtolo) ... -m bf(,..lj) =- ( . ) <(u.)) ( . ) )( . )"" ' ~. ) !( . )' d.'cbom< ( ) f( ))""" s( l) background teenagers are more likely to deliver small-for-gestational age (sga) infants than adults, even after adjustment for socioeconomic factors , . previous studies of mostly black and hispanic subjects in the usa have suggested that maternal growth may contribute to reduced infant birthweight, due to preferential nutrient partitioning to the mother . the impact of maternal growth on birthweight and nutrient partitioning in pregnant teenagers in the uk has not been examined. methods skeletal growth (change in knee-height from st to rd trimester), weight gain and skinfold thicknesses were measured in pregnant teenagers (n= , % non-white) in london and manchester. key mediators of nutrient partitioning and metabolism: insulin-like growth factor(igf)- , igf binding protein(bp)- and leptin, were measured in maternal plasma ( weeks gestation). results maternal growth (defined as increase in knee-height > mm/ days) was detected in % of pregnant teenagers. this growth was not associated with sga birth; in fact these mothers were more likely to deliver large-forgestational age (lga) infants (p< . ). maternal weight gain and fat accrual at peripheral and central sites were greater in growers (p< . ). these parameters correlated positively with maternal igf- and leptin but negatively with the igf inhibitor, igfbp- (p< . for all). subjects delivering sga infants gained significantly less weight (p< . ) and had lower igf- levels (p< . ) than those delivering non-sga infants. conclusion maternal growth in teenage pregnancy was not associated with reduced birthweight. indeed the increased weight gain and fat accrual observed in growing teenagers may protect against sga birth and promote fetal growth. igf- and leptin promote fetal growth, primarily through effects on maternal metabolism and nutrient partitioning to the fetoplacental unit. these data suggest that higher maternal igf- and leptin in growing teenagers may provide an anabolic drive for both maternal and fetal growth. background. umbilical oxygen uptake (o umb uptake) has been estimated in human pregnancies only in acute experiments at the time of caesarean section. the recently developed possibility to measure umbilical blood flow by ultrasound in utero, prompted us to study normal and iugr pregnancies in order to evaluate fetal oxygen uptake utilizing the fick principle, i.e. uptake equals umbilical blood flow times (a-v) differences. methods. thirty-six iugr pregnancies were studied at the time of elective caesarean section and compared to twenty-one controls (c) (gestational age: c= . ± . and iugr= . ± . wks). an ultrasound examination was performed within hours from the caesarean section in all the recruited patients. umbilical vein absolute volume flow (qumb) was measured as the result between umbilical vein area and the time-averaged peak velocity * . . blood samples from umbilical vein (uv) and artery (ua) were obtained after the delivery and blood gases and acid-base balance were evaluated. umbilical oxygen uptake was calculated as o umb uptake = qumb*(uv-ua) o content. results. as expected, average fetal and placental weights were significantly different in the studied groups ( ± and ± g in iugr vs ± and ± g in n) . iugr pregnancies showed a significant reduction in qumb ( . ± . vs . ± . ml/min; p< . ) but no differences in the qumb/kg of fetal weight. iugr fetuses showed a significant reduction in o sat, o cont and po in both uv and ua compared to n. (uv-ua)o content ( . ± . vs . ± . mmol/l; p< . ) and o umb uptake/kg ( . ± . vs . ± . mmol/min/kg; p< . ) were significantly reduced in iugr. conclusions. we here report an evaluation of fetal oxygen uptake that proved surprisingly similar to the values reported in chronically catheterized animals. however, iugr fetuses showed a significant reduction in both blood and oxygen supply: this latter was reduced more that % on a per kg basis. iugr fetuses therefore utilize less oxygen than normally grown fetuses. circulating levels of vitamin d and il- in pregnancies with iugr. calvin j hobel, chander p arora, adegoke adeniji, priya arora, susan e jackman, olga miadel, baldjyan lilit. ob-gyn, cedars-sinai medical center, burns ans allen research institute, los angeles, ca, usa; university of california los angeles, los angeles, ca, usa. background: any condition resulting in under exposure to sunlight, including the use of sun block or poor nutrition may result in insufficiency ( . - nmol/l) or even deficiency of vitamin d (< . nmol/l).vitamin d regulates placental development and function. vitamin d deficiency has been linked to increased risk of serious chronic and inflammatory diseases. objective: to determine if the circulating levels of vitamin d and interleukin - (il- ) in maternal plasma correlates to pregnancies resulting in fetus with intrauterine growth restriction (iugr). hypothesis: the metabolism of vitamin d initiates the biochemical cascade of events leading to the expression of il- and the inflammatory response in iugr births. study design: in a behavior in pregnancy study, plasma samples at all three time points were analyzed in a cohort of women for (oh)d using elisa. the samples were also analyzed for il- at three stages of pregnancy: t ( - weeks), t ( - weeks) and t ( - weeks). iugr was defined as birth weight below the tenth percentile for gestational age. none of the iugr cases had spontaneous preterm birth. results: iugr was diagnosed in of women with available samples from a behavior in pregnancy study (bips) . out of these subjects, were selected as matched case controls. circulating levels of vitamin d ( (oh)d) were significantly lower in iugr cases at each visit (p<. ). the levels indicated deficient ( . ± . nmol/l) vitamin d in iugr group at t but sufficient vitamin d levels ( . ± . nmol/l) in controls. subsequent visits also showed lower levels in the iugr cases compared to the control group (t : ± . nmol/l vs ± . nmol /l; t : ± . nmol/l vs ± . nmol /l). at all three time intervals, significantly (p<. ) higher levels of il- were associated with the iugr cases ( pg/ml, pg/ml and pg/ml respectively) as compared to the controls ( pg/ml, pg/ml and pg/ml respectively). conclusions: vitamin d deficiency or even insufficiency may be an unrecognized cause of iugr. it is possible that a primary non-infectious inflammatory process is activated by vitamin d deficiency. combined assessment of vitamin d deficiency and il- expression during different stages of pregnancy may facilitate the resognition of the risk of developing iugr. response to global % maternal nutrient restriction (mnr). nathan drever, thomas j mcdonald, peter w nathanielsz, cun li. obstetrics and gynecology, university of texas health science center at san antonio, san antonio, tx, usa. background: igf-ii is a major growth factor in the developing pancreas and studies in the human fetus demonstrate that the peptide localizes to b cells of the islets (j endocrinology : ). rodent studies show decreased fetal pancreatic growth and igf-ii and ins abundance and increased apoptosis with mnr (j endocrinology : ). we previously demonstrated a fall in most components of the placental and fetal baboon liver igf systems with mnr. here we have evaluated fetal pancreatic igf-ii and ins changes in response to mnr. methods: pregnant baboons were fed ad lib (ctr, n= ) or % of wt adjusted ctr diet (mnr, n= ) from . gestation (g) and fetuses were recovered at c-section under general anesthesia at . (n= ; ctr and mnr) and . g (n= ; ctr and mnr). igf-ii and ins expression were determined by immunohistochemistry (ihc) and quantified by image analysis for fraction (area immunostained/area of the field x %) and density. data are expressed as mean + sem; ctr data are expressed] first; comparison made with two tailed t-test. results: at . g there was no difference in igf-ii or insulin fraction or density between groups. at . g, igf-ii fraction ( . ± . vs . ± . ,p< . ) and density ( . x ± . x vs . x ± . x , p< . ) and insulin fraction ( . ± . vs . ± . , p= . ) were reduced. conclusion: moderate mnr decreases abundance of fetal pancreatic igf-ii and ins at . g. in the fetal baboon and supports the extant evidence for impaired pancreatic development with mnr seen in rodents. maintenance of liver growth in the hypoxic growth restricted fetal sheep: a role for intrahepatic glut ? sheridan gentili, janna l morrison, i caroline mcmillen. sansom institute, unisa, adelaide, south australia, australia. objective: we have previously demonstrated that there is a differential tissue response to chronic placental and fetal growth restriction. growth of fetal tissues such as the brain and the adrenal are consistently spared in the face of chronic substrate restriction, whilst we have demonstrated that the growth of the fetal liver may be either maintained or reduced. it is unclear whether the growth response of the fetal liver to hypoxia and hypoglycemia are determined by intrahepatic metabolic adaptations. hypothesis: we hypothesize that there will be a differential profile of hepatic expression of glut , hsd , the gluconeogenic and glycolytic enzymes pepck and g pdh and the transcription factors pgc and ppar in animals in which liver growth is maintained or reduced. methods: carunclectomy was performed in non-pregnant ewes to induce placental restriction (pr). vascular catheters were inserted in pr and control (c) fetuses at - d and arterial blood samples were collected for blood gas analysis. mean gestation po < mmhg was defined as hypoxic (h; normoxia, n). post mortem was performed at - d. hepatic mrna expression of glut , hsd , pepck, g pdh, pgc and ppar was determined using qrt-pcr. results: four experimental groups were defined by fetal po and liver growth (c-n, pr-n, pr-h and pr-h-reduced liver growth). fetal weight correlated with mean gestational po (r = . , y= . x+ . , p< . ). liver weight was significantly lower in a cohort of pr-h fetuses (c, . ± . ; pr-n . ± . ; pr-h . ± . ; pr-h-rlg . ± . g:kg; p< . ). glut expression was highest in those pr-h fetuses in which liver growth was maintained, whilst the expression of hsd , pgc , ppar and pepck was highest in the pr-h fetuses in which liver growth was reduced (p< . ). conclusions: in the pr-h fetuses in which liver growth was reduced, the increase in hsd expression may be associated with an increase in hepatic exposure to cortisol and an associated increase in pepck, pgc and ppar . interestingly the compensatory increase in hepatic glut expression did not occur in fetuses in which liver growth was reduced. predicting the trajectory of fetal growth. racine n edwards-silva, jeffrey gornbein, calvin j hobel. obstetrics gynecology, los angeles, ca, usa; biomathematics, david geffen school of medicine at university of california, los angeles, ca, usa; obstetrics gynecology, david geffen school of medicine at university of california, los angeles, ca, usa. objective: to evaluate twelve potential predictors of fetal growth trajectory defined as the rate of fetal weight change over time. study design: a longitudinal prospective study of singleton fetal growth trajectory. the twelve potential predictors considered were: fetal gender, gestational age, parity, race, bmi, age, weight at st clinical exam, cumulative weight gain at each exam, smoking, and alcohol use. estimated fetal weight was computed using the hadlock formula and sonographic fetal biometric parameters at - weeks, - weeks, and - weeks. the rate of change in fetal weight was defined as x (fetal wt at exam j -fetal wt at exam i )(j > i)/ (gestational age at exam j -gestational age at exam i ). bivariate statistical analysis included the non-parametric spearman rank correlation and wilcoxon rank sum test. all factors were assessed multivariately using multiple linear regression. results: there were multi-ethnic women included in the study, after were excluded. they underwent a total of , exams. fetal gender (p= . ), maternal weight at st exam (p= . ), and cumulative maternal weight gain at exam (p < . ) were significant predictors of fetal growth trajectory. in this model, male fetuses had an average rate of fetal weight change of . grams per days higher than females. the rate of fetal weight change increased by an average of . grams per days for each lb increase in maternal weight at the st exam. the fetal growth rate increased . grams per days for each lb of cumulative weight gain at the rd exam. conclusions: in this study, maternal weight at the st exam and cumulative maternal weight gain were the significant determinants of fetal growth trajectory. adequate initial maternal weight and cumulative gestational weight gains probably ensure sufficient nourishment for normal placental growth, uteroplacental blood flow, and fetal nutrient uptake. this supports the emphasis on periconceptual nutritional counseling for all pregnant women. the implication of this study is that similar to fetal programming of adult diseases, there is nutritional programming of fetal growth trajectory. high risk patients. other predictors include the known risk factors of age < and > , single, tobacco/alcohol use, and african american race. interestingly, hispanic and native american patients have a lower lbw rate compared to other groups. introduction: catecholamines released by the sympathetic nervous system and adrenal medulla act via b-ars to regulate glucose and insulin function in liver, pancreas, adipose and muscle tissue. b-ar knock out mice show increased fat mass and glucose intolerance (asenslo et al.,diabetes, ) . mnr animal models have increased sympathetic activity. we, therefore, evaluated effects of mnr on baboon fetal liver b -ar. methods: baboons were fed as ad lib controls (ctr) or % of wt adjusted ctr diet (mnr) from . gestation(g) with fetuses retrieved at c-section under general anesthesia at . or . g. protein expression determined by immunohistochemistry for b -ar in the central liver lobule was quantified by image anaysis and expressed as fraction = area immuno-stained/area of the field x %. all data are expressed as mean + sem with ctr data presented first. liver glycogen expression was determined by the periodic accid schiiff (pas) method. comparisions were made with student's t-test with alpha level set at . . results: fetal body and liver wts were not changed by mnr at either age. pas stained liver glycogen at . g = . ± . vs. . ± . %, p< . . b -ar fraction was lower following mnr at . g and at . g (p< . ; fig ) conclusions: mnr decreased b -ar over % at . g and % at . g. decreased fetal liver b -ar in mnr alters glucose metabolisam and may result in reduced lipolysis predisposing to fatty liver. infection with noncytopathic bovine viral diarrhea virus (ncpbvdv) during early bovine pregnancy (< d gestation) results in fetal immunotolerance, persistent infection (pi) and intrauterine growth restriction (iugr). in contrast, infection after the development of adaptive immune competence (> d gestation or postnatal) results in a transient infection (ti). we have previously reported an iugr in pi fetuses presenting as decreased body weight and ponderal index. a growth defect can be the result of many factors, including placental insufficiency and nutrient restriction, however it was hypothesized that the iugr seen in bvdv pi fetuses may be an immunopathological effect caused by the persisting virus. our two part experimental design examined the relationship between bvdv and its pi host. in experiment (exp) , blood cell mrna was collected from pi steers (n= ; confirmed by virus isolation), or uninfected control steers (n= ) and used to identify differentially expressed genes using microarray (affymetrix) and qtrt-pcr approaches. in exp , bvdv naïve pregnant heifers (n= per group) were not infected (control) or infected with ncpbvdv on d. or d. of pregnancy creating pi and ti fetuses, respectively. fetuses were collected by c-section on d. ; infection was confirmed by elisa and qtrt-pcr. histology of placental tissue revealed no placentitis or pathology, and glucose and lactate levels in fetal serum were normal. microarray analysis revealed genes that were differentially regulated in pi vs. controls (p< . , > . fold). qtrt-pcr of steer and fetal blood revealed a significant upregulation of activators and products of the antiviral type-i interferon (ifn-i) pathway. as ifn-i can act as a growthsuppressive cytokine, a long-term upregulation may contribute to the iugr seen in persistent bvdv infection and in other viral infections observed during pregnancy. nricg - from the csrees. patients with a short cervix are at an increased risk for spontaneous preterm delivery. therefore, it is possible that women with a short cervix during pregnancy are also at risk to deliver an sga neonate. this study was conducted to address this question. study design: patients > weeks of gestation were prospectively enrolled into an observational study ( / to / ). transvaginal sonographic examinations were performed every weeks until delivery. the shortest cervical length between - weeks was used for analysis. sga was defined as less than the tenth percentile of birth weight. results: asymptomatic patients were studied. . % of patients delivered an sga neonate ( / ). the median cervical length was mm ( to mm); patients had a cervical length < mm. of these, % ( / ) delivered an sga neonate. similarly, % ( / ) patients with a cervical length < mm had an sga neonate. no relationship was found between a short cervix and sga (short cervix was defined as either < mm and < mm). the frequency of sga was not significantly different between women with a short cervix and those with a long cervix [ % ( / ) vs. % ( / ); p= . ]. newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced background folate is an essential micronutrient for cellular growth. recommendations on periconceptional folic acid use are mainly focussed on prevention of neural tube defects, despite growing evidence that folic acid use may have positive effects on birth weight. objective to examine associations between folic acid use, intrauterine fetal growth and birth weight. design the study was embedded in the generation r study in rotterdam, the netherlands, a population-based prospective cohort study from early pregnancy onwards. methods information on folic acid use was obtained by questionnaires and categorized into three groups: ) preconception start of folic acid use; ) start of folic acid use in first ten weeks of gestation; ) no folic acid use at all. fetal growth measurements included head circumference, abdominal circumference and femur length measured in mid-and late pregnancy, i.e., gestational age - and > weeks, respectively, and birth weight. fetal weight in mid-and late pregnancy was estimated using the haddock method. results data from , pregnant women were available. overall, folic acid use was positively associated with fetal growth. preconceptional folic acid use resulted in an increased growth of grams ( %ci . - . , p< . ) per week from late pregnancy to birth, compared to no folic acid use. similarly, start of folic acid use in the first ten weeks of gestation resulted in an increased growth of grams ( %ci . - . , p= . ) per week from late pregnancy to birth. both preconceptional folic acid use and folic acid use started in the first ten weeks of gestation resulted in higher birth weights of grams ( %ci - ) and grams ( %ci - ), respectively, compared to no folic acid use. a tendency was found for an increased risk of birth weight less than grams when folic acid was not started preconceptionally (or . , %ci . - . ). conclusion periconceptional folic acid use is significantly associated with increased fetal growth resulting in a higher birth weight. ductus venosus isovolumetric relaxation in severely premature growth-restricted fetuses. jason l picconi, katherine drennan, farhan hanif, michael kruger, giancarlo mari. obstetrics and gynecology, wayne state university/dmc, detroit, mi, usa. objective: ductus venosus (dv) doppler waveforms are characterized by two periods in which blood velocity decreases. the first represents the isovolumetric relaxation (ir) at the end of ventricular systole and the second represents atrial contraction at the end of ventricular diastole (a). ductus venosus reversed flow (dvrf) occurring at the time of the a-wave is considered a risk factor for intrauterine fetal demise (iufd). we have previously reported that absent or reversed a-wave flow can be present for weeks before iufd occurs or delivery is performed for non-reassuring fetal testing. the guiding hypothesis for this study is that decreased flow at the time of ir in combination with absent or reversed a-wave flow allows a more accurate prediction of fetal outcome than a-wave absent or reversed flow alone. material and methods: ductus venosus doppler was serially studied in severely premature iugr fetuses (estimated fetal weight < th percentile and umbilical artery pulsatility index > th percentile) from diagnosis until demise or delivery. ductus venosus waveforms were assessed quantitatively for peak systolic velocity (psv), isovolumetric relaxation velocity (irv), and end diastolic velocity (edv). the psv/irv + edv were compared to fetal and neonatal outcome. a kruskal-wallis one way anova, mann whitney u post-hoc test, and a roc, were used for statistical analysis. a p < . was considered statistically significant. results: all fetuses were delivered at < weeks. six cases resulted in iufd, five cases resulted in neonatal demise (nd), and six cases resulted in neonatal survival (ns) at the time of discharge from the hospital. the psv/irv+edv correlated better than a-wave reversal of flow with perinatal outcome. a psv/irv+edv score less than - . resulted in iufd, whereas a score greater than - . resulted in live birth. live births segregated based on estimated gestational age, where those fetuses at less than weeks resulted in nd and those fetuses at or greater than weeks resulted in ns. all results were statistically significant. conclusions: the isovolumetric relaxation velocity is a novel doppler parameter in the assessment of severely premature iugr fetuses. these data indicate that assessment of irv should be considered part of the evaluation of severely iugr fetuses. background: fetal growth restriction has been linked to an increased incidence of chronic hypertension, which may be the result of extracellular matrix changes (ecm) within the vascular tree. in previous studies, ecm changes were observed in the umbilical arteries of preterm growth restricted infants. objective: to determine if there are alterations in collagen subtypes within the umbilical cords from growth restricted fetal rat pups after a period of maternal nutrient restriction. methods: timed pregnant sprague-dawley rats were fed either a % food restricted diet (mfr; n= ) or were fed ad libidum (control; n= ) from d until d of gestation. litter size, fetal weights and placental weights were then noted and umbilical cords from randomly selected pups in each litter were snap frozen. gene expression for collagens i, iii, xiv and decorin was evaluated by real-time rt-pcr with normalization to the gadph housekeeping gene. data were analyzed from fitting general linear regression models with estimation based on the quasi-likelihood estimation (generalized estimating equations) to account for clustering of responses within litters. data are shown as cycles to amplification (ct), which is inversely proportional to mrna levels. results: no difference in median litter size was detected. however, fetal and placental weights in the mfr group were significantly less than those from control dams. no significant differences in umbilical cord gene expression for collagens i, iii, xiv or decorin were detected between mfr and control pups. conclusions: maternal food restriction does not result in any detectable alterations in collagen or decorin expression within the intact umbilical cord, despite causing significant reductions in fetal growth. control (n= ) p-value litter size (median, range) ( , ) ( , ) . fetal weight (mean ± sd) g . ± . . ± . < . placental weight (mean ± sd) g . ± . . ± . . collagen i (mean ± sem) ct . ± . . we have previously demonstrated that the restriction of placental and fetal growth results in fetal hypoxia and fetal brain sparing suggesting a redistribution of cardiac output. furthermore, placentally restricted (pr) hypoxic fetuses are more dependent on their sympathetic nervous system for the maintenance of blood pressure during late gestation. nerve growth factor (ngf) plays a significant role in sympathetic innervation. hypothesis: we hypothesize that the expression of ngf will be higher in the aorta and femoral artery of the pr hypoxic compared to the control fetus. method: carunclectomy was performed in non-pregnant ewes to induce pr. vascular catheters were inserted in pr and control (c) fetuses at - d and arterial blood samples were collected for blood gas analysis. all pr fetuses introduction elevated sflt- levels have been shown to be a feature of pre-eclampsia and is considered to play a significant role in the pathogenesis of the condition. the role of angiogenic factors in fetal growth restriction has not been as well established. this study evaluated the levels of circulating vascular endothelial growth factor (vegf) and its soluble receptor sflt- , in normal pregnancies and isolated placental vascular disease without evidence of pre-eclampsia. method maternal peripheral venous samples were collected antenatally from two groups of pregnant women between - weeks of gestation. group a: uncomplicated normal pregnancies (n = ) and group b: pregnancies complicated by isolated placental vascular disease( n = ) as defined by birth weight less than th centile for gestation and umbilical artery doppler s:d ratio above the th centile for gestation, with no evidence of maternal preeclampsia or pre-existing hypertension. plasma vegf and sflt- levels were measured using standard eliza techniques. comparison between groups were performed by using one way analysis of variance. the maternal plasma sflt- levels (figure ) in group a: normal pregnancies increased with gestation (p < . ). the sflt- levels in group b: isolated placental vascular disease were significantly higher throughout all gestations (p = . ) and did not show a significant variation with gestation ( p = . ). the plasma vegf levels were below the detectable levels of the assay in all samples except normal pregnancies. the significantly increased maternal plasma sflt- levels in established isolated placental vascular disease without evidence of pre-eclampsia suggest a disease of placental origin. the dysregulation of angiogenic factors may be part of a repair and regeneration process in the placenta. objectives: production of -reduced neurosteroids is critical for reducing fetal vulnerability to stressors in pregnancy and inhibition of -reductases ( r) increase acute hypoxia-induced apoptosis in the fetal brain (yawno et al neurosci : . we have developed a model of placental insufficiency that results in fetal growth restriction (gr) in the guinea pig (palliser et al repro sci # ). the aim of the present study was to determine the effects of suppression of -reduced steroid synthesis on apoptosis in vulnerable regions of the fetal brain and on neurosteroid synthetic enzymes in pregnancies compromised by chronic placental insufficiency. methods: placental insufficiency was induced in guinea pig dams by surgical ablation of uterine artery branches at mid gestation (term d). sham operated or gr dams received finasteride (a r inhibitor; mg/kg/day) during late gestation ( d until term). activated caspase- , a marker of apoptotic cell death, was measured by immunohistochemistry and steroidogenic enzymes, r and cytochrome p side chain cleavage (p scc) were measured by real time pcr and western blotting in fetuses ( d) and neonates h after birth. results: placental insufficiency significantly reduced fetal body and organ weight by % whilst sparing brain weight. the number of activated caspase- positive cells was significantly increased in the fetal hippocampus of gr fetuses and further increased in the cortex of gr fetuses receiving finasteride. the neonatal brain also exhibited changes in caspase- activation following gr and finasteride treatment. the fetal adrenal and the placenta responded to the compromise with increased expression of p scc mrna and r protein, respectively. conclusion: the combination of placental insufficiency and suppressed neurosteroid system leads to markedly increased apoptotic cell death in the fetal brain which continues to affect the neonatal brain. the fetus responds to these conditions by increasing steroid synthetic enzyme expression in the placenta and adrenal glands suggestive of a possible neuroprotective feedback process. to study the effect of smoking by mothers on the fetal and neonatal brain using non-invasive magnetoencephalography technique (meg). materials and methods: using fetal magnetoencephalography, cortical auditory evoked responses (aer) were measured from fetuses ranging from to weeks gestational age for a total of recordings. measurements were taken from mothers with a history of smoking (sm) and from mothers with no smoking history (ns). after delivery, five sm and five ns newborns had meg aer measurements twice for a total of recordings. aer was quantified by cross-correlation analysis and its significance was assessed by boot-strap technique. results: aers were detectable in out of fetal recordings in the ns group and of in the sm group. the neonatal response rate was % for each group. the latencies were divided into three components: c ( - ms), c ( - ms) and c ( - ms). in both fetuses and neonates as well, there was a statistically significant difference (p< . ) between the two groups in the c -component and the sm group showed faster aer compared to the lr group. conclusion: meg technique provides a non-invasive approach to study the effects of smoking on developing fetal and neonatal brain. the observed decrease in the latency of fetuses and neonates of the smoking mothers could indicate a hypersensitive cortical response to auditory tone. adenosine (ado) modulates metabolism in adult mammals through multiple mechanisms that involve ado a and a a receptors. objective: this study was designed to test the hypothesis that ado a and a a receptors participate in fetal metabolic homeostasis. methods: experiments were performed in chronically catheterized fetal sheep (> . term). intravascular infusion for h of dpcpx (a receptor antagonist) or zm (zm, a a receptor antagonist) was performed alone or in concert with ado administration. the highly selective ado receptor antagonists were also infused in fetuses in which hypoxia was induced for h by having the ewe breathe a hypoxic gas mixture (fio = . ). data were analyzed by two-way repeated measures of anova. results: blockade of ado a receptors (n= ) increased significantly (p < . ) fetal concentrations of glucose [control (c): . ± . (se)]; experiment (e): . ± . mg/dl] and lactate (c: . ± . ; e: . ± mg/dl) without significantly altering insulin levels and arterial blood gases or ph. antagonism of ado a a receptors (n= ) did not affect plasma levels of glucose, lactate, or insulin. intravenous infusion of ado (n= ), which did not alter pao or paco , increased concentrations of glucose (c: . ± . ; e: . ± . mg/dl) and lactate (c: . ± . ; e: . ± . ). zm (n= ), but not dpcpx (n= ), abolished ado-induced rise in glucose and lactate concentrations. isocapnic hypoxia (pao torr), which increases ( - fold) fetal plasma ado levels to those similar to ado infusion, decreased arterial ph (c: . ± . ; e: . ± . ), and increased fetal levels of glucose (c: . ± . ; e: . ± . mg/dl) and lactate (c: . ± . ; e: . ± . mg/dl) without altering changing insulin concentrations. these effects of hypoxia were not altered by dpcpx or zm. conclusions: ) a receptors modulate plasma levels of glucose and lactate in normoxic fetuses; ) a a receptors mediate the adoinduced rise in plasma glucose and lactate; and ) a and a a receptors are not significant modulators of hypoxia-induced changes in plasma levels of glucose and lactate. supported by usphs hd- . objective: to investigate the dynamic changes of the relationship between leptin, adiponectin and resistin in maternal and fetal circulation during pregnancy and in the early post-natal period. materials and methods: thirty pregnant women with uncomplicated singleton pregnancy delivered at term. maternal and fetal/neonatal venous blood samples were obtained at delivery and at hours from birth. leptin, adiponectin and resistin were measured by specific elisa assays. neonatal anthropometric measurements, glucose metabolism and lipid profile, blood pressure information were obtained. statistical analysis was performed by anova followed by student t test or duncan's test whenever appropriate. correlations were calculated by using the pearson coefficient. results: adipokines concentration at birth and at h from birth was showed in table. multivariate regression analysis showed that fetal leptin levels were positively associated with female gender and adiponectin levels, but not with anthropometric characteristics. fetal leptin and adiponectin levels were not correlated with maternal concentration, whereas fetal and maternal resistin levels were. fetal and maternal resistin concentration was positively associated with gestational age and birth weight and fetal resistin levels correlated negatively with lipid profile. after birth leptin concentration in maternal and neonatal circulation decreased dramatically and the correlation between leptin and adiponectin levels was lost. a positive correlation between resistin and leptin concentration in neonatal circulation was found at h from birth. conclusions: in contrast to adult life a positive correlation between leptin and adiponectin is present in fetal life. placental secretion of leptin, but not of adiponectin and resistin, contributes significantly to maternal and fetal circulating levels. significant changes in the relationship among adipokines occurred immediately after birth and may affect growth and development in early post-natal period. adipokines concentration in maternal and fetal circulation ) antagonism has been shown to normalize placental perfusion and fetal growth in several rat models of fetal growth restriction. however, direct administration of et a antagonists to newborn rats within hours of delivery has been consistently associated with neonatal demise due to failure of the ductus arteriosus to close, raising concerns about the safety of their use late in pregnancy. perinatal exposure to et a antagonists (maternal administration in late gestation) and its impact on rat pup survival and oxygen saturation has not been investigated. objective: to determine the impact of a maternally administered et a antagonist on oxygen saturation in newborn and -day-old rat pups. methods: timed pregnant sprague-dawley rats were treated with fr ( mg/kg/day; et a antagonist) or . % nahco vehicle, by subcutaneous osmotic pump connected to an intravenous catheter, from gestational day (term= days) through parturition. all five pregnant rats in each group delivered spontaneously and nursed their pups through postpartum day . oxygen saturation of each rat pup was measured by pulse oximeter on postpartum days and . results are presented as means ± se. newborn -day neonate vehicle . ± . . ± . eta antagonist . ± . . ± . there were no statistically significant differences between the treatment groups. maternal administration of an et a antagonist from gestational day through parturition, at a dose sufficient to ameliorate fetal growth restriction, has no adverse impact on oxygen saturation in neonatal rat pups. helen l torrance, jan b derks, martijn a oudijk, avnesh s thakor, tereza cindrova-davies, frank van bel, gerard ha visser, graham j burton, dino a giussani. perinatal center, university medical center utrecht, netherlands; department of physiology, development neuroscience, university of cambridge, united kingdom. introduction: the management of perinatal asphyxia remains a major concerns in obstetrics. umbilical cord compressions (ucc) induce fetal asphyxia and ischaemia-reperfusion (i/r). i/r increases reactive oxygen species, for instance via activation of the xanthine oxidase (xo) pathway, which may promote oxidative stress in the fetal circulation. while treatment with allopurinol of asphyxic human neonates reduced free radicals and improved cardiovascular status, treatment started postnatally was deemed too late to prevent oxidative damage (benders et al. arch dis child : , ) . consequently, in complicated pregnancy, recommendations to treat the fetus via the mother, rather than the neonate, with allopurinol are being entertained today. we investigated the effects of maternal allopurinol treatment on indices of oxidative stress in the fetal heart following repeated ucc in sheep. methods: at . of gestation, surgically instrumented sheep fetuses were submitted to i/r ( x min repeated ucc) under maternal allopurinol (n= ) or saline vehicle (n= ) infusion. fetal hearts were collected h after i/r and snap frozen for measurement of (anti)oxidant proteins by western blot. hearts from uninstrumented fetal sheep at . gestation served as controls. statistical comparisons were made using one-way anova. results: i/r episodes led to increased expression of cox- , enos, hsp and decreased expression of sod and gluthatione peroxidase (gpx) in the fetal heart, findings consistent with cardiac oxidative stress. maternal treatment with allopurinol ameliorated these effects (fig. objectives: hypoxic-ischemic fetal brain injury (hie) is a major cause of neonatal death and morbidity. evidence suggests that the brain cell injury associated with chronic hpx (in contrast to an acute ischemic reperfusion injury) is a complex process reflecting a series of adaptive intracellular events that are duration and gestational age dependent. we applied advanced proteomic tools as a next step toward ascertaining a more complete understanding of the impact of hpx on the fetal brain proteome. methods: time-mated guinea pigs were housed in a chamber beginning on day for d, breathing either room air (nmx), or . % or % o ( % o hpx or . % o hpx). on day (term), the fetal brains were removed and preserved for study. total protein was extracted, and the proteome first characterized by d gel electrophoresis. the density of the resulting protein spots were acquired and analyzed using the gs densitometer and pdquest software. identified spots of interest were trypsin digested and subject to maldi mass spectrometry using the proteomics analyzer mass spectrometer for peptide mapping or sequencing. the hpx-induced protein spots were identified based on a minimum of a x change from nmx. results: hpx had a clear effect on the fetal brain proteome. superoxide dismutase (sod), heat shock protein (hsp ), actin (actg ), interleukin- (il- ), and glutamine synthetase (gs) were each up regulated, while cofilin- , brain-type creatine kinase (bb-ck), and - gtp binding protein were each down regulated. all protein changes were proportional to the hpx ( % o hpx vs nmx, % o hpx vs . % o hpx, p< . ). conclusions: this initial application of proteomic techniques confirms that fetal brain damage secondary to chronic hpx (in contrast to acute hpx) is a complex processes characterized by fetal adaptations mediated by multiple protein activations and inactivations. while sod, il- , and gs have each been previously investigated, the potential roles of actg , bb-ck, beta- gtp binding protein, and cofilin- in the fetal response to hpx and the associated brain damage are unclear and represent strong candidates for future investigation. acknowlegement: this study was supported by grants from the phs (r hl - , cpw) and cdc grant (u dp - , cpw). intermittent umbilical cord occlusion occurs in % of human pregnancies.given that elastogenesis within the vascular wall is in part mediated by hemodynamic conditions during development, the blood pressure response to acute hypoxic insults such as cord occlusion may alter arterial composition. elastin content of a central and peripheral artery and blood pressure responses in fetal sheep exposed to varying degrees of cord occlusion were determined. methods: over a day period, near term fetal sheep received total umbilical cord occlusion (uco) lasting min/ hour (mild group; n= ), min/hour (moderate group; n= ), min/hour (severe group; n = ) or no occlusion (control group; n= ). fetal arterial blood samples were drawn min prior to and at the end of cord occlusions. mean arterial pressure (map) was monitored continuously. the carotid and superior mesenteric arteries were excised and a colorimetric assay (biocolor) performed for determination of elastin content. results are presented as mean ± sem. results:umbilical cord occlusions produced decreases in fetal arterial oxygen pressure and oxygen saturation that were progressively more pronounced across mild, moderate and severe uco groups (p < . ). lactate concentration rose during occlusions in the moderate and severe groups, but not the mild group (p < . ).elastin content of the superior mesenteric artery did not differ between the experimental groups and the control group. elastin content of the carotid artery and map response elastin content (μg/mg tissue) max ∆ in map duration of rise in map (min) control . ± . . ± . -mild . ± . . ± . ** . ± . moderate . ± . . ± . ** † . ± . † severe . ± . * . ± . ** † † . ± . † † * p < . ; ** p < . : experimental groups compared to control † p < . ; † † p < . : compared to mild group the max in map was positively correlated with elastin content (r = . , p < . ). conclusions:the transient rise in blood pressure and preferential blood flow to the brain that occur in response to acute hypoxemia during severe intermittent umbilical cord occlusion induce an increase in elastin synthesis in the carotid artery.this may give rise to adaptive programming of postnatal central arterial compliance. electrocortical activity during repetitive umbilical cord occlusions (uco) with worsening acidemia in the ovine fetus near term. martin g frasch, roy mansano, michael g ross, robert gagnon, bryan s richardson. obgyn, chri, univ of western ontario, london, canada; obgyn, harbor-ucla med ctr, torrance, ca. objective: uterine contractions during labour can restrict umbilical blood flow compromising fetal oxygenation and leading to adverse neonatal outcome including newborn encephalopathy/subsequent cerebral palsy. while electronic fetal heart rate (fhr) monitoring is widely used for assessment during labour, abnormal fhr patterns as used clinically have a poor positive predictive value for concerning/significant acidosis at birth. there is limited study of fetal electrocortical activity (ecog) in animal models with induced hypoxia/ acidemia as might be seen during labour. thus, we aimed to induce repetitive ucos in fetal sheep leading to worsening acidemia to determine the predictive value of ecog activity for fetal compromise. methods: near-term fetal sheep (n= ) underwent chronic preparation with artery catheters, ecg/ecog electrodes and placement of an inflatable umbilical cord occluder. following a baseline recording period, fetuses underwent a series of mild ( min every min), moderate ( min every min) and severe ( min every min) ucos with each series lasting h or until fetal arterial ph decreased to < . . fetal arterial blood samples for blood gases and ph were taken at selected time points during the baseline, ucos, and recovery periods. arterial blood pressure (abp) and fhr were continuously monitored and spectral edge frequency (sef) was calculated from ecog. correlation of sef with fhr change was calculated for time intervals using sef maxima and fhr minima during uco series. data are presented as means±sem. results: repetitive ucos led to development of a marked acidosis (ph . ± . to . ± . , p< . ). ± min prior to fetal ph drop < . , the sef of ecog began to increase abruptly during each fhr deceleration from ± hz up to ± hz (p< . ) and was correlated to both fhr change and a decrease in fetal abp during each fhr deceleration at this time (p< . ). conclusion: our findings suggest that in the animal model studied ( ) fetal ecog activity is impaired with progressive acidemia accompanied by fhr decelerations and pathological abp decreases; ( ) there is a consistent temporal relationship between the occurrence of ecog alterations and the subsequent critical drop of ph < . . these findings could contribute to improvement in the clinical ability to predict fetal compromise during labour using ecog/fhr monitoring. background: the ductus arteriosus (da) plays a pivotal role in fetal development and circulation. during gestation, patency of the fetal da is maintained by nitric oxide (no) and prostaglandins (pg). no and pgs are downstream effectors of estrogen (e ) and progesterone (p ). however, the roles of e and p in da regulation have not been studied. objective: we hypothesized that: e and p have opposite effects in the da; that rising e and falling p levels help trigger da closure via specific hormone receptors; and that no and/or pgs mediate da responses to e and p . methods: expression of er , er , pra, prb, and the putative membrane receptors mpr-, -, -, pgrmc- , - , and serbp- was examined by rt-pcr and qpcr on days , , (term), and p . the effects of e and p ( - - - m) on the d fetal da were examined in a cannulated microvessel myography system. e and p effects were also studied in the presence of receptor antagonists (ici , ru ) and no and pg inhibitors (l-name, indomethacin). results: er and pr receptors were expressed at low levels; pgrmc- expression was stronger than other membrane prs, and increased with advancing gestation. under fetal o conditions, e induced rapid, concentrationdependent dilation at - - - m (n= ); p induced progressive vasodilation at all doses (n= ). e and p -induced dilation occurred within - seconds of exposure. while e -dilated das did not respond to ici, ici-pretreated das failed to dilate to the same dose of e (n= ) suggesting antagonism of e effects. the vasodilatory effects of e were partially inhibited by pretreatment with l-name. p -dilated das did not respond to ru , whereas ru pretreated das showed a small, significant response to p (n= ), suggesting partial antagonism or signaling via alternative, ru -independent pathways. pre-treatment with indocin did not block the vasodilatory effects of p . conclusions: contrary to our expectation, both e and p have dilating effects on the fetal da, via no, pgs and non-no, non-pg pathways. expression studies and the rapid response of ex vivo das are consistent with non-genomic actions via membrane receptors. hormone shifts in parturition may have longterm effects on da preparation for postnatal closure, but strategies to maintain fetal da patency or treat newborns with pda will require better understanding of this process. background. for the fetus, arterial blood gases are critical in the regulation of cerebral blood flow (cbf) and cerebral oxygenation. however, the relation of cbf, cortical tissue po (tpo ), and electrocorticographic (ecog) activity to arterial o tension (pao ) are not well defined. in an effort to elucidate these interrelations, we tested the null hypothesis that in the near-term fetus, acute hypoxic-associated cerebral oxygenation and related variables are not closely associated with ecog state. methods. by use of a laser doppler flowmeter with a fluorescent tissue o probe, and with fluorescent-labeled microspheres, and with ecog electrodes, in near-term fetal sheep (n = ) we measured laser doppler cbf (ld-cbf), tpo , ecog (root mean square (rms) voltage with high voltage low frequency, hvlf versus low voltage high frequency, lvhf) and spectral edge frequency- % (sef ) in response to min moderate isocapnic hypoxia. results. ld-cbf, cerebral o delivery, tpo , and several other variables correlated highly with ecog state. in the normoxic control fetus, in association with a shift from hvlf to lvhf ecog activity, tpo decreased briefly to ± from a control value of ± torr; however, as ld-cbf increased ± %, and sef increased to ± from ± %, tpo returned to near normal value. with acute hypoxia (pao = ± torr) when in the lvhf state ld-cbf increased only ± %, as opposed to a ± % increase when in hvlf ecog state. with this degree of hypoxia, tpo decreased to ± torr, sef remained at ± %, and cerebral metabolic rate for o (cmro ) decreased ± % (p< . ). conclusions. for the near-term fetus, normoxia with changes in ecog state was associated with brief periods of decrease in tpo , which were restored quickly by increased ld-cbf. in contrast, acute hypoxia was associated with a significant depression of cortical tpo , cmro , and ecog state, with increased ld-cbf failing to restore cortical tpo . thus, we reject the null hypothesis that in such fetuses, hypoxia demonstrates no compromise in cerebral oxygenation. (supported by usphs hd- ). releasing hormone and arginine vasopressin in the ovine fetus. charles a ducsay, kanchan m kaushal, malgorzata mlynarczyk, kimberly hyatt, dean a myers. ctr. for perinatal biol., loma linda univ., loma linda, ca; ob/gyn, univ. oklahoma hlth. sci. ctr., oklahoma city, ok. background: long term hypoxia (lth) profoundly affects the hypothalamicpituitary-adrenal axis of the fetal sheep. we previously showed that lth causes augmented corticotrope function. the present study was designed to test the hypothesis that lth enhances sensitivity to the acth secretagogues; cortiocotrophic releasing hormone (crh) and arginine vasopressin (avp) resulting in increased anterior pituitary corticotrope secretion of acth. methods: pregnant ewes were maintained at high altitude ( , m) from day to - of gestation (dg), when they were returned to the lab and a maternal tracheal catheter was implanted. maternal po was maintained at a level comparable to that observed at altitude ( mmhg) by nitrogen infusion. on dg, lth (n = ) and age-matched, normoxic control (n = ) fetuses were implantated with vascular catheters. each fetus received a min infusion of either saline vehicle, ng/kg of ovine crh or ng/kg of avp (estimated body weight/min) in a randomized order over consecutive days ( - dg). blood samples were collected at min (baseline prior to infusion), , , and min following the start of the infusion and analyzed for acth, as well as the acth precursors pro-opiomelanocortin and the major processing intermediate kda proacth. results: vehicle had no effect on any of the measured parameters. with crh infusion, acth (pg/ml) increased in both groups over the course of the study. however, peak concentrations (at min) were significantly higher in the lth group compared to control ( ± vs. ± , respectively; p< . ). acth precursor secretion (pm) was greater in lth fetuses compared to controls during the experiment (p< . ). in response to avp, peak acth concentrations were also higher in the lth fetuses compared to control ( ± vs. ± respectively; p< . ), however peak levels were reached at between and min after start of infusion with levels in both groups returning to pre-infusion values. a similar pattern was observed with precursor levels ( . ± . vs. . ± . , p< . , lth vs. control). conclusions: lth significantly increases pituitary sensitivity to both crh and avp. this enhanced sensitivity may be mechanism of our previously observed enhanced corticotrope function. (supported my nih grants hd and hd ). martin g frasch, roy mansano, michael g ross, robert gagnon, bryan s richardson. ob/gyn, chri, university of western ontario, london, canada; ob/gyn, harbor-ucla med. ctr., torrance, ca. objective: repetitive uco leading to worsening fetal acidosis with fetal heart rate (fhr) decelerations (fhr dec ) are accompanied by pathological decreases of fetal arterial blood pressure (bp). we hypothesized this bp change may be caused by the bjr, a vagally mediated reflex with bradycardia and hypotension to reduce cardiac workload, via stimulation of cardiac chemoreceptors during systemic acidemia. methods: ten near-term fetal sheep ( ± dga) underwent chronic preparation with brachial artery catheters and placement of an inflatable umbilical cord occluder. after a control period, fetuses underwent a series of mild ( min every min), moderate ( min every min) and severe ( min every min) uco each lasting h or until ph decreased to < . . fetal arterial blood samples were taken at selected time points during the control and uco periods. bp and fhr were continuously monitored. individual fhr nadir during each fhr dec and accompanying bp change ( bp = [bp at the time of a fhr nadir] -[bp at baseline preceding a uco series]) were determined during all uco. data are presented as means±sem. results: control period ph ( . ± . ), fhr ( ± bpm) and bp ( ± mmhg) were within the physiological range. average depth of fhr dec for all uco was ± bpm and increased with higher lactate concentrations (r = . , p < . ) and lower ph (r = . , p = . ). bp during all uco demonstrated an initial hypertensive response to fhr dec , which decreased with lower ph (r = . , p < . ). bp increased ± mmhg (p < . ) during mild uco (ph to . ± . ), ± mmhg during moderate uco (ph to . ± . , p < . ) and ± mmhg during severe uco (ph to . ± . , p < . ). conclusion: these results suggest that bjr, a short-acting, ph dependent depressor reflex, blunts the physiologic hypertensive response to cord occlusion insults leading to worsening acidemia as might be seen in the human fetus during labour with repetitive variable fhr dec . the failure to increase bp may prevent optimal blood flow distribution responses necessary for preservation of vital organs. role of nos and pde in placental dysfunction following fetal bypass. mitali basu, r scott baker, christopher t lam, kenneth e clark, pirooz eghtesady. cardiothoracic surgery, cincinnati children's hospital, cincinnati, oh, usa; ob/gyn, university of cincinnati, cincinnati, oh, usa. introduction rising placental vascular resistance following fetal cardiopulmonary bypass (bypass) remains the achilles' heel of fetal cardiac surgery. we have previously shown in real-time that nitric oxide (no) production rises during bypass and falls post-bypass, while cgmp levels rise throughout. using immunohistochemical and western analysis of placenta, we examined the involvement no pathway components in this placental vascular pathophysiology. ovine fetuses at - days gestation were placed on bypass for minutes and followed post-bypass for hours. placental samples were collected immediately prior to bypass and at and min post-bypass (n= ) and compared to a group of similarly instrumented controls, (n= ). placental enos, inos and pde protein expression was measured using standard methods and relative expression normalized to beta-actin. statistical analysis utilized students t-test, and anova for trend and group-wise analysis, (significance at p= . ). pre-bypass protein expression did not differ between groups. pde protein levels and phosphorylated pde- expression were both elevated min post bypass, and reduced min post bypass compared to sham, (p= . ). enos levels in the bypass group increased linearly from pre-bypass to min postbypass (p< . ), and were also elevated compared with shams (p< . ), while shams had declined significantly by min post bypass, (p< . ). similarly, phosphorylated enos expression in the bypass group increased linearly from pre-bypass to min post-bypass, (p= . ), while shams trended towards decline by min post-bypass. simultaneously, placental inos expression remained stable within groups, but was lower in the bypass group at and min post-bypass, (p< . ). the preceding data correlated with observed immunohistological changes in the same placental cotyledons. fetal bypass leads to significant increases in placental protein levels of pde , phosphorylated pde- , enos and ostensibly phosphorylated enos. increased pde expression may be a response to increased no and the generated cgmp. this data suggests a compensatory upregulation of pde and enos that eventually fails, leading to increasing placental vascular resistance and subsequent lethal placental dysfunction. angiotensin receptors (rat-ii) in neuronal nuclei of the brainstem have been implicated in integration of baroreceptor responses. in near term fetal sheep, we have previously shown that days of mild chronic hypoxemia increases heart rate (hr) and blood pressure (bp). the aim of the present study was to investigate the effects of chronic mild hypoxemia on the expression of rat-ii in the medulla oblongata and on baroreflex control of the circulation. methods: at days of gestational age, pregnant sheep were submitted to days of hypoxemia ( % of fetal arterial po ; at day fetus ± vs ± . ; mother ± vs ± mmhg). hr and arterial bp were continuously recorded from mother and fetus in control (n= ) and hypoxemic (n= ) animals. baroreflex sensitivity (brs) as well as hr and diastolic bp variability were analyzed (nevrokard software). brainstem was collected and rat-ii expression in the nucleus tractus solitarius (nts) and dorsal motor nucleus of the vagus (dmnx) was measured by autoradiography using i-sarthran labeling. data are shown as mean±sem and were analyzed by t-test. results: hypoxemia induced a greater total binding of i-sarthran in nts and dmnx resulting from an increased expression of at receptors. in the time-domain analysis of brs hypoxemia induces lower baroreflex sensitivity in the fetus (brs in ms/mmhg; . ± . vs. . ± . , p< . ). in the frequency domain, hypoxemia changes the relative power of low frequencies (lf: . - . hz) and high frequencies (hf: . - . hz) of rri and dbp with an increased value of the lf/hf ratio (rri lf/hf . ± . vs ± . , p< . ; dbp lf/hf . ± . vs . ± . , p< . ). also the alpha index for baroreflex sensitivity is decreased in hypoxemic animals (alpha lf . ± vs . ± . , p< . ; alpha hf . ± . vs . ± . , p< . ). no differences were observed in maternal variables. conclusions: our results suggest a link between a prenatal insult, alterations in cns receptors and functional alterations of baroreflex responses. a higher sympathetic outflow, suggested by a greater lf/hf ratio, and impaired reflex gain, both possibly mediated by increases in nts rat , may have potential long-term consequences for the development of hypertension. hd ;hd ;hl . objective : we evaluated velocity profiles, relative wall distension rate (rwdr), and wall shear rate (wsr) of fetal descending aorta (fda) in uncomplicated singleton gestations. study design: ninety seven uncomplicated singleton fetuses were studied throughout gestation using multigate spectral doppler analysis (msda) working with gasp software. this consists of a personal computer (pc) add-on board including a single high-speed digital signal processor. the analysis of echo-signals backscattered from range cells located along the axis of the interrogating ultrasound (us) beam. post-processing was accomplished using gasp software. statistical analysis consisted of spearman correlation and chi-square test. results: velocity profiles, wall distension, wall shear rate were obtained from fetal descending aorta throughout gestation establishing gestational age specific norms. wdr[%] is highly correlated with gestational age in appropriate growth fetuses ( . ± . , rs= . p< . ) with linear regression with standardized coefficient of . (p< . ). in contrast, wsr ( ± ) is unchanged during the first , second and third trimesters (p= . ).conclusion: we speculate that the relative wdr changes observed during gestation, in normally grown fetuses, may be secondary to adaptive vascular and autonomic responses and the evolving composition of the vessel wall, particularly with respect to elastin. conversely, the mean wsr for the study group was independent and constant throughout the gestation. these findings suggest that there is an increase in the diameter of the fetal aorta, which provides adaptation to the progressive flow demands, while preserving other key hemodynamic parameters. in this study, we have established normative values of rwdr and wsr, which are new rheological parameters that may be useful in distinguishing normal and pathologic hemodynamic states. objective: placental dysfunction is a key barrier to successful fetal cardiopulmonary bypass (cpb) for repair of congenital heart defects in utero. endothelial cells regulate vascular tone during fetal cpb through interactions of vasodilation by nitric oxide (no) and endothelin- (et- )-mediated vasoconstriction. the objective was to determine the time during fetal cpb when endothelial cell-mediated changes occur. methods: human umbilical vein endothelial cells (huvec) were cultured in media containing % serum collected from ovine fetuses (n= ) that underwent min of cpb, then were maintained for min. serum was collected before cpb, from pump prime before initiation of cpb, min on cpb, or and min after fetal cpb. control cells were cultured in normal fetal serum. cells were harvested and hr after addition of fetal serum. no production was measured in real time with an electrochemical detection system (inno-t, harvard apparatus). et- was measured in the culture media by elisa. results: no production by huvec after and hr was stimulated above control levels by fetal serum collected during and up to min after fetal cpb (p< . ). serum collected from fetuses that were surgically instrumented, but not yet subjected to cpb, decreased no levels below controls (p<. ). stimulation of et- after and hr of huvec culture peaked with serum collected at min after fetal cpb (p<. compared with control), but was elevated above control levels at each collection time point (p<. , table ). conclusions: fetal cpb releases serum proteins that elevate endothelial cell no and et- production during and for at least min after cpb. although the specific regulatory proteins remain to be identified, the no and et- pathways share circulating mediators and participate in a feedback loop to modulate vascular tone. to test the hypothesis that hypoxia-induced upregulation of no is linked to cardiac inos expression, a selective inos inhibitor, l-nil (l-n -( -iminoethyl)-lysine), was administered in vivo to fetal guinea pigs and no levels measured in fetal hearts. methods: pregnant guinea pigs were exposed to either normal room air (normoxia; %o ) or . %o (hypoxia) in a hypoxic chamber for days prior to term (term= d). l-nil was administered to pregnant normoxic and hypoxic guinea pigs via their drinking water at a dose of - mg/kg/d for days. at d gestation, pregnant sows were anesthetized and near-term fetuses removed via hysterotomy. the fetal hearts were excised, weighed, and normalized to their respective fetal body weights. left cardiac ventricles were obtained and frozen in liquid n and stored at - o c until ready for analysis. the effect of total no product (no and no -, nox) of left ventricles of fetuses exposed to normoxia (n= ), hypoxia (n= ) and hypoxia plus l-nil (n= ) was quantified by a commercial fluorometric no assay kit. results: intrauterine hypoxia significantly reduced fetal body weight by % and increased placenta/fetal body wt by % as expected for hypoxic stress. hypoxia induced a slight increase in heart/fetal body wt by %. fetal cardiac nox levels (pmoles/mg) were increased by hypoxia ( . + . ) by . fold compared to normoxic controls ( . + . ). l-nil significantly decreased (p< . ) nox levels in hypoxic hearts by % ( . + . vs . + . ; hypoxic vs hypoxic+l-nil, respectively). conclusion: l-nil inhibits inos-derived no generation in the hypoxic fetal guinea pig heart. since previous study in our lab showed a significant increase in inos expression but a decrease in enos and no change in nnos expression, we hypothesize that hypoxia upregulates cardiac no generation via the inos pathway. further study is needed to identify the important role of cardiac inos in the adaptive response of fetal hearts to chronic intrauterine hypoxia. objective: fetal asphyxia-mediated metabolic acidosis results in a ph decrease and an increase of lactate and base deficit in blood (bd blood ) and extracellular fluid (bd ecf ). it is not clear whether bd blood and bd ecf are similarly altered with worsening fetal acidosis. in the present study we sought to study the dynamic relations of bd blood and bd ecf to lactate in the ovine fetus subjected to repetitive uco with worsening acidemia. methods: ten near-term fetal sheep ( ± dga) underwent chronic preparation with brachial artery catheters and placement of an inflatable umbilical cord occluder. following a baseline recording period, fetuses underwent a series of mild ( min every min), moderate ( min every min) and severe ( min every min) uco with each series lasting h or until fetal arterial ph decreased to < . . fetal arterial blood was sampled at baseline, immediately before and during the first mild, moderate and severe uco and at min intervals during the moderate and severe uco. bd gap (bd blood -bd ecf ) was studied in relation to lactate. presented as means±sem. results: lactate correlated to bd blood (r= . , p< . ). bd ecf correlated strongly with bd blood (r= , p< . ). bd ecf increased by . ± . mmol/l more than bd blood from baseline to ph nadir, with bd gap therefore decreasing with increasing lactic acidemia ( fig. ) . lactate, bd blood , bd ecf and bd gap correlated to ph (r= . , r= . , r= . and r= , respectively, all p< . ) and ph could therefore be predicted with any of the four acid-base parameters. conclusion: the increases of bd blood and bd ecf and the decrease of bd gap with increasing lactic acidemia suggest a relatively more rapid accumulation of [h+] in ecf during uco of increasing severity. this may be because the metabolic build-up of acidosis occurs primarily in the tissues and the endothelial permeability for [h+] is impeded during increasing acidosis with atp depletion thus decreasing [h+] movement from ecf to plasma. previous studies have shown that intraperitoneal transplantation of human umbilical cord blood (hucb)-derived mononuclear cells led to the specific 'homing' of these cells to a hypoxic-ischemic brain lesion in perinatal rats. motor deficits resulting from the lesion were alleviated upon transplantation. thus, the presence of hucb cells at the lesion site seems to be a major prerequisite for their potential beneficial effect. however, the mechanisms of cell 'homing' are still unclear. in this study, we focused on elucidating mechanisms underlying the specific migration of hucb-derived mononuclear cells to the brain lesion. one possibility to induce cell 'homing' are chemotactic signals present at the lesion site. the cxc chemokine stromal derived factor- (sdf- ), which was previously shown to be a potent chemoattractant for directed migration of other stem and progenitor cells, is a putative candidate in our lesion paradigm. therefore we investigated the spatial and temporal expression of sdf- in brain hemispheres with or without hypoxic-ischemic lesion. sdf- expression was substantially increased at the lesion site during the investigated period of fourteen days after the insult. furthermore, hla-positive hucb cells were mainly detected in sdf- expressing brain regions and we were able to show that these cells express the sdf- receptor cxcr on their surface. the functional implication of sdf- in directing hucb cell migration was determined by application of neutralizing sdf- antibodies in vivo, resulting in a reduced number of hucb-derived mononuclear cells at the lesion site. with these functional effects, together with the observed timing and location of its expression, the involvement of the chemokine sdf- in hucb cell 'homing' seems conceivable. novel pathways in inflammation-induced fetal brain injury. michal a elovitz, jinghua chai. obstetrics and gynecology; crrwh, university of pennsylvania, philadelphia, pa, usa. intro: while survival of extremely preterm infants continues to improve, the number of children with cognitive impairment and/or cerebral palsy is increasing. if preterm birth (ptb) cannot be prevented, then strategies to identify and treat fetal brain injury in the setting of a ptb must be investigated. these studies were performed to explore novel pathways involved in fetal brain injury in the setting of inflammation-induced ptb. methods: cd- mice on e receive intrauterine injection of lipopolysaccharide (lps) or saline. hours after injection, fetal brains from the left upper horn were harvested. fetal brains were removed from each dam with dams per treatment group. separate rna samples were prepared and used for microarray (ma) analysis. all protocols were conducted as described in the affymetrix genechip expression analysis technical manual in the ma core facility using the moe av chip. data analysis was performed using significance analysis for microarray (sam). the brain samples from the same dam were considered as dependent samples. pathway analysis and functional annotation clustering tools were used with david. validations studies using qpcr with fetal brain samples (n= - per group) were performed. results: while there was significant differences in gene expression between lps and saline exposed fetal brains, variability existed even between pups from the same dam. genes were significantly differentially expressed between lps and saline brains (p< . ). with a p value of < . , genes were differentially expressed. pathway analysis revealed significant involvement of ) the cadeherin, cadherin-like, cell fraction and calcium binding (enrichment score . ) and ) ribosomal processing, rna metabolism, pyrimidine metabolism (enrichment score . ). specifically, genes involved in neurogenesis, synaptic function, and neuronal and glial metabolism were most differentially regulated. qpcr confirmed observed fold changes in / genes analyzed. inflammatory pathways were not differentially regulated. conclusions: current theories regarding fetal brain injury in ptb focus on activation of inflammatory processes as essential events. this data suggests that long-term neurological injury in a ptb may be secondary to altered neuronal function, metabolism and/or communication. disruptions in these pathways should be explored as key mechanisms to adverse neurological outcomes in preterm neonates and should be targets for future investigations. regulation of microglial activation in the developing murine brain. mariya hristova, virginia zbarsky, daniel cuthill, adam wallace, donald peebles, gennadij raivich. institute for women's health, university college london, london, united kingdom. introduction: the aim of this study was to assess the process of microglial differentiation in developing white matter, an area of the brain that is particularly vulnerable to damage pre-myelination (approx weeks gestation). microglia form a distinctive non-neuronal component. although related to peripheral macrophages they undergo highly specific processes of regional maturation and differentiation inside the brain with a slimming of the cell body, development of very elaborate crenulated arborised branches and downregulation of most macrophage activation markers. this process is relatively rapid in most grey matter brain regions, but is retarded in and around the subcortical white matter (swm) giving rise to the phagocytic fountains of microglia (fom). methods:we examined the process of deactivation and morphological differentiation in the cortex and swm of mice - days after birth (p -p ) using confocal microscopy for monoclonal antibodies against alpha and beta integrin subunits and the costimulatory factor b . , colocalised with standard microglial marker iba . results: strikingly, only the fom macrophages, but not cortical microglia, strongly expressed typical activation markers alpha- , alpha- , alpha-m, alpha-x, beta- and b . . the data for alpha-x are shown as an example in the figure; cortical microglia are shown in the grey bars and swm in black. fom activation was maximal at p , decreased linearly over p and p and disappeared at p . this process followed the presence of ingested phagocytic material but correlated only moderately with ramification, demonstrated by non-ramified but inactive p cortical microglia and formation of stubby processes in p fom. conclusion: these data describe strong and selective biochemical activation of fom phagocytes in p -p swm, roughly equivalent to early rd trimester human foetal development. this presence of highly active phagocytes in the neighbourhood of vulnerable wm could play an important role in the genesis of axonal damage in the foetus and premature neonate. , pp. - ) . mbp is expressed in mature oligodendrocytes (jakovcevski and zecevic, glia ) . although myelination in the fetal sheep brain, a model extensively used to evaluate fetal development, has been described using conventional staining techniques (barlow, j comp neurol ) the use of specific mbp staining allows a more precise determination of the onset of myelination (antonow-schlorke et al., reprod sci . , , a) . aim: to use mbp expression to determine the trajectory of development of different white matter tracts of fetal sheep brain. methods: the ontogenetic profile of mbp expression was estimated in healthy fetuses at . (n= ), . (n= ), . (n= ), . (n= ), . (n= ), . (n= ) and . (n= ) of gestation (term days). after brain fixation and embedding in wax, sections at the level of the optic chiasm were stained with a monoclonal anti-mbp antibody using the abc-technique. immunohistochemical distribution of mbp was morphometrically assessed in the dorsal internal capsule and cortical white matter tracts, i.e. the lateral centrum semiovale, superficial white matter and median corpus callosum using an image analysis system (scion image . , nih, usa). results: mbp expression of various fetal white matter structures started at different time points; initially in the internal capsule at . of gestation followed by the cortical white matter structures at . of gestation. cortical myelination advanced from the cortical deep white matter via superficial white matter to the corpus callosum reflecting different rates of progression. conclusions: the onset of mbp expression estimated here explicitly antedates previous observations in sheep (barlow, ) the way the embryonic heart functions before cardiac morphogenesis is completed is still subject of many studies. to gain more insight into the early cardiac structure-function relationship, doppler blood flow velocity waveforms at four different locations in the embryonic chicken heart during cardiovascular development were assessed. we collected waveforms using high frequency ultrasound biomicroscopy with a -mhz transducer at hh stages , and which are comparable to humans at to weeks of gestation. waveforms were obtained at the inflow tract, the primitive left ventricle, the primitive right ventricle, and at the outflow tract in ten different embryos per stage. by exploring the time relation between the waveforms, cardiac cycle events were outlined. our results demonstrate that stage and location dependent, intracardiac blood flow velocity waveforms can be obtained in the chicken embryo which reflect stage dependent pumping mechanisms. the blood flow profiles assessed at the four locations in the embryonic heart demonstrated a developmental related increase in velocity. in the primitive ventricle the passive filling wave decreased, whereas the active filling wave increased resulting in a decreased p to a ratio in the course of time. high frequency derived cardiac blood flow velocity characteristics support previous findings that the embryonic heart functions like a suction pump at early development and transforms towards another pumping mechanism at later developmental stages. these findings are of importance for the interpretation of human first trimester cardiac velocimetry studies. figure a . changes in the perimeter of the thymus with gestational age by fetal gender are depicted in figure b . background. for the fetus, the roles of arterial blood gases are recognized to be critical in the regulation of cerebral blood flow (cbf) and cerebral metabolic rate for oxygen (cmro ), cortical tissue po (tpo ), and electrocorticographic (ecog) activity. in addition, metabolites such as adenosine (ado) are important in this regard. nonetheless, the relation of adenosine and its metabolites to these indices of cerebral oxygenation are not well defined. in an effort to elucidate these interrelations, we tested the null hypothesis that acute hypoxic-associated cerebral oxygenation and related variables are not closely associated with adenosine. the most common cause of perinatal brain injury is chronic hypoxia/ischemia. the mechanisms are complex and poorly understood. applying proteomics tools, we identified a set of hypoxia-related proteins in the fetal guinea pig (gp) brain (companion abstract). one protein, cofilin- , which regulates the rapid cycling of actin assembly and disassembly, was dramatically altered by chronic brain hpx. herein, we test the hypothesis that confilin- modifications during hpx contributes to brain damage via apoptosis and is an example of an adaptive response that becomes maladaptive. methods: time-mated gps were housed in a chamber from d to d (term) with either room air (nmx) or . % or % o . fetal brains were removed and sections prepared for double staining specific to bax and dephosporylated cofilin- . total protein was isolated and equal amounts loaded on a sds gel, separated by electrophoresis, and transfered to pvdf membranes probed with primary antibodies to dephosphorylated and phosphorylated cofilin- , bax and bcl-xl, and incubated with second antibody. protein signals were detected, quantified by densitometry, and normalized to -actin. total rna was isolated, reverse-transcribed, and quantified by real-time pcr using sybr green i labeling. expression was calculated by the ct method using s for control. melt analysis was performed to confirm specificity of the amplification, and efficiency determined by the slope of the standard curve. the mitogen activated protein kinase (mapk) signalling pathway is upregulated in perinatal hypoxic-ischaemic brain. the role of the extracellular signal-regulated kinase (erk) cascade, a pivotal component of mapk signalling, remains unclear with reported actions ranging from mitogenic and trophic effects to a neuronal death-promoting role. the aim of this study was to assess the role of neuronal erk activity using selective neuronal inhibition in a perinatal model of hypoxic-ischemic brain injury. methods: we explored the effects of selective neuronal inhibition of erk activation using transgenic mice expressing dominant-negative (dn) mek , the upstream activator of erk / , which was under the control of the pan-neuronal talpha alpha-tubulin promoter. p-erk immunoreactivity was quantified following a hypoxic inschemic (hi) insult in p c bl/ mice, caused by unilateral occlusion of the carotid artery, followed by hypoxia with % oxygen for mins at °c. the volume of surviving brain on the affected hemisphere was expressed as a % relative to the control side. results: expression of the mek dn was associated with a reduction in erk / activation following hypoxia ischaemia, as assessed by p-erk immunoreativity. compared with the wild type, littermate controls, mek dn animals exhibited significantly decreased volume of forebrain damage brain following unilateral, min hi insult (*p< . , **p< . , anova). similar protective effects of mek dn were observed in cerebral cortex, hippocampus, thalamus and striatum when compared to wild type littermate controls and correlated with a significant reduction in microglial activation in all brain areas. conclusion: overall, these results suggest that neuronal mek and its downstream signals have an important death-inducing role in this model of perinatal brain injury and could serve as potential targets for therapeutic intervention. oup, ) . however, whether melatonin protects placento-fetal development during hypoxic or undernourished pregnancy is unknown. we investigated in rats the effects on placental and fetal growth of maternal treatment with melatonin in hypoxic and undernourished pregnancy. methods: on pregnancy day , wistar rats were divided: control ( % o ) + melatonin ( g.ml - drinking water), hypoxia ( % o ) + melatonin, and undernutrition ( % reduction in food intake) + melatonin (n= per group). on day , dams were anaesthetised, the pups, placentae and fetal brain were weighed. results: relative to controls (fetal weight: . ± . g; brain/body weight ratio: . ± . mg/g; n= ), both hypoxic ( . ± . g; . ± . mg/g, n= ) and undernourished pregnancy ( . ± . g; . ± . mg/g, n= ) promoted asymmetric iugr (p< . ), without affecting placental weight. melatonin treatment had no effect on iugr, but it decreased placental weight in normoxic ( . + . , n= ), hypoxic ( . ± . , n= ) and undernourished ( . ± . , n= ) pregnancies relative to untreated controls ( . ± . , n= ; p< . ). when fetal body weight was expressed relative to placental weight, a measure of placental efficiency, melatonin prevented the fall in the ratio in undernourished, but not hypoxic pregnancies (fig. objective: midkine (mk) is a -kda heparin-binding growth factor with various functions including cell proliferation, migration, differentiation and angiogenesis. mk expression is strictly regulated in temporal sequence; it is highly expressed during midgestation. we recently studied mk expression in the midgestation human fetus, and showed that the highest mk expression were observed in the adrenal gland, brain, lung and kidney. in the present study, we investigated the profile of mk in human amniotic fluid (af) and amnion (am). methods: amniotic fluid and amniotic membranes were collected at diagnostic amniocentesis, preterm no labor, and term no labor. mk protein levels were analysed by western blot. expression of transcripts encoding mk and putative mk receptors were examined by rt-pcr and real-time quantitative rt-pcr (qpcr). results: ) western blot analysis demonstrated abundant mk protein in the human am; mk levels were higher at midgestation than at term ( -fold: wks vs. wks). ) tissue transglutaminase known to polymerize mk was abundant in af. ) qpcr revealed that mk mrna was not expressed in am whereas it was highly expressed in the fetal adrenal, kidney and lung (positive controls). ) among the receptors implicated in mk signaling, lowdensity lipoprotein receptor-related protein and syndecan- were expressed in am while protein-tyrosine phosphatase, anaplastic lymphoma kinase, and syndecan- were not. conclusions: abundant mk protein in the midgestation af is likely to be derived from the fetus. mk in af may play a role in feto-amniotic communications and/or development of fetal organs exposed to af. short term hfix expression. we hypothesized that long term hfix expression could be achieved in fetal sheep using an aav vector, without stimulating an immune response to the transgenic hfix protein. we injected aav hfix vector ( - x p/kg) into the peritoneal cavity of fetal sheep under ultrasound guidance in early (n = ) or late (n = ) gestation. fetal blood was retrieved by ultrasound guided sampling from the intra-hepatic umbilical vein. fetal and lamb blood was tested for hfix expression using elisa, antibody responses using functional assays, and for liver damage up to a year after birth. vector spread was detected in maternal and fetal tissues by quantitative pcr analysis. results: the highest level hfix was detected days after late ip injection ( % and % normal human levels). early gestation ip injection gave . % and . % at and days after injection. hfix levels dropped rapidly correlating with the increase in size of the fetal liver and lamb. however, hfix was detectable at a low levels ( . %) year after birth in early and months after birth in late gestation injected lambs. up to year after birth, liver function tests and bile acid levels were normal, showing no evidence of liver pathology. no functional antibodies to the hfix protein or aav vector were detectable. high vector levels were detected in the fetal liver, and other peritoneal organs; no vector was present in fetal gonadal tissue. conclusion: hfix expression is detectable up to year after delivery of aav vector to the fetal sheep using a clinically applicable method. this is the first study to show long term hfix expression after fetal gene therapy in a large animal. further work will include testing for immune tolerance to exogenous hfix protein in these animals. objective: placental estrogens play a pivotal role in the endocrine control of pregnancy and may be involved in the key changes occuring during parturition. it has been established that crh interacting with crh receptor has a positive effect on estrogen production throughout pregnancy. urocortin (ucn ), a novel peptide of the crh family binding exclusively crh receptor , is expressed by human placenta and the aim of the present study was to evaluate the influence of ucn on estrogen biosynthesis in cultured trophoblast cells. methods: cultured term placental cells were treated with various concentrations of ucn in the presence of the estrogens precursors dehydroepiandrosterone sulphate (dhea-s), androstenedione or testosterone. estradiol secretion was measured in the culture medium using a specific elisa, p arom mrna and protein expression were evaluated by real time pcr and western blot analysis respectively. results: the addition of ucn , in presence of dheas significantly increased e levels at , and hours treatment, while in presence of androstenedione and testosterone an increase in e secretion was detected only at , and hours (at different ucn doses). both p arom mrna and protein were up-regulated in presence of each estrogen precursor and the addition of ucn caused a synergistic increase. anti-sauvagine (a crh type receptor antagonist) resulted in a significantly attenuated ucn effects on e secretion and on p arom mrna and protein expression. conclusions: the present study supports a possible role of ucn on placental e biosynthesis: e secretion and p arom transcript and protein expression were significantly increased after ucn treatment. in conclusion, the crf family may play a major role on placental steroidogenesis, stimulating dheas secretion in fetal adrenals by crh and controlling placental estrogen biosynthesis through ucn . a possible influence on the mechanisms of parturition may be hypothesized. increased expression of kiss- gene in preterm placenta. letizia galleri, michela torricelli, chiara voltolini, fernando m reis, felice petraglia. department of pediatrics, obstetrics and reproductive medicine, university of siena, siena, italy. introduction placenta expresses a large number of peptides involved in delivery. neuropeptides, cytokines, are expressed and secreted by human placenta at the time of preterm delivery. human placenta is a major source of kiss- , a -amino-acid peptide encoded by a putative metastasis suppressor gene. kiss- acts on its placental g protein-coupled receptors (kiss- r); this peptide stimulates release of oxytocin in rats, the most potent known uterine stimulant, suggesting a possible role of kiss- in the mechanisms of labor. aim of study the aim of this study was to evaluate placental expression of kiss- at preterm labor. material and methods placental tissue and plasma samples (both maternal and fetal) were collected at term in the absence of labor (tnl), at term spontaneous vaginal delivery (tl), and at preterm labor (ptl). changes in placental mrna expression were determined by real-time quantitative rt-pcr analysis. kiss- protein levels were measured by specific immunoenzymatic assay (elisa). results placental kiss- mrna expression was significantly higher (p< . ) in ptl than in tnl and in tl. however, maternal and fetal plasma kiss- levels did not differ among tnl, tl, and ptl samples. conclusion the present study showed that placental kiss- mrna expression is increased in preterm delivery. further studies are needed to better understand the role of kiss- on cascade leading term and preterm labor. placental angiogenesis is essential for placental development, which occurs under a hypoxic environment ( - % o ) during normal pregnancy. it has been reported that in transformed human dermal microvascular endothelial cells, hypoxia activates erk / , which stabilizes hypoxia-inducible transcription factor- (hif- ). however, signaling mechanisms governing placental angiogenesis under hypoxia is largely unknown. herein, we tested whether hypoxia affected fgf -and vegf-stimulated cell proliferation partly via activating erk / and stabilizing hif- protein levels in human placental artery endothelial (hpae) and transformed human placental microvascular endothelial (hpme) cells. methods: cells cultured under normoxia ( % o ) or hypoxia ( % o ) for days were treated with fgf and vegf. after days, the number of cells was determined. activation of erk / and levels of hif- protein were determined by western analysis. results: under normoxia, fgf and vegf stimulated (p < . ) cell proliferation and induced ( min, p < . ) erk / phosphorylation in hpae and hpme cells. hypoxia promoted (p < . ) fgf -and vegf-stimulated cell proliferation in hpae cells, whereas hypoxia blocked (p < . ) such actions in hpme cells. hypoxia enhanced fgf -, but not vegf-induced erk / phosphorylation in hpae cells. in contrast, hypoxia promoted (p < . ) vegf-, but not fgf -induced erk / phosphorylation in hpme cells. hypoxia increased (p < . ) hif- levels in the hpae cells: first detected at . hr and maintained up to hr. hpme cells had high basal levels of hif- ( folds; p < . ) compared with hpae cells. hypoxia did not alter hif- levels up to hr and decreased (p < . ) hif- levels at hr in hpme cells, conclusions: in hpae cells, hypoxia enhances fgf -and vegf-stimulated cell proliferation possibly partially via promoting activation of different protein kinases. this stimulatory effect is associated with increased hif- protein levels. however, inhibition by hypoxia on fgf -and vegf-stimulated hpme cell proliferation is associated with relatively high hif- levels in the first hr and decreased hif- levels at hr. thus, these data suggest that different signaling mechanisms are involved in hypoxia-modulated growth factor-induced placental angiogenesis in which an increase in hif- levels plays a critical role. objective: corticotrophin releasing factor (crf) is a well established neurohormone involved in the initiation of the stress response. we recently documented that rat placenta is analogous to human placenta in the expression of crf-mrna and protein, and that placental crf release may contribute to in utero meconium passage. time-of-day variation in crf expression is a highly recognized phenomenon at the brain cellular sites of crf synthesis. we sought to determine whether crf expression in rat placenta is subject to time-of-day variation. method: time-dated pregnant rats were obtained on day of gestation (term= days), housed in under h- h light-dark conditions (lights on ). lab chow and water were continuously available. on day , pregnant rats were quickly anesthetized by exposure to isoflurane, abdomen opened and fetuses and placenta exteriorized either at - hr (zeitgeiber time, zt ) or - hr (zt ). individual placentas were processed either for rna extraction or immunohistochemical investigation. the levels of crf-mrna were assessed by pcr using rat specific pcr primers. pcr bands were subsequently cloned and sequenced. bouin's solution fixed paraffin sections of placenta were subjected to crf immunohistochemistry with antibodies specific to rat species and intensity of immunostaining was analyzed using image pro-plus software and expressed in arbitrary units (au). results: one specific pcr band of bp size was consistently identifiable in placenta harvested at zt but not at zt . nucleotide sequence of the pcr band confirmed its identity as crf-mrna. intensity of crf-immunostaining was significantly greater at zt in giant trophoblast (gt) cells (gt-crf: zt = . ± . au, zt = . ± . au, p= . ) but not in spongiotrophoblast cells (stc) (stc-crf: zt = . ± . au, zt = . ± . au, p=ns) or labyrinth cells (lbc) (lbc-crf: zt = . ± . , zt = . ± . au, p=ns) . conclusion: similar to adult brain, rat placenta expresses crf mrna and protein. time-of-day variation of crf expression originally seen in central nervous system neurons is also identifiable in giant trophoblasts cells at zt . these findings suggest that stress-mediated placental crf release, and potentially fetal meconium passage, may be dependent upon time-of-day. objectve: transplacental water flow is essential for the provision and maintenance of fetal body water and amniotic fluid. water flow across membranes is regulated by aquaporin (aqp) water channels in many tissues. thus aqp , expressed in the placenta, is a candidate to regulate maternal to fetal fluid exchange. maternal beta-mimetics have been hypothesized to augment fetal growth by increasing the availability of nutrients and perhaps water. as camp acts as a second messenger to increase expression of selected aqps in other tissues, we sought to determine if betamimetics acting through camp could modulate placental aqp , and potentially influence placental water transfer. methods: trophoblastic cell cultures were established in first trimester-derived extravillous htr- /svneo cells and term placenta-like trophoblast carcinoma cell line jeg- . cultures were treated with sp-camp, a membrane-permeable and phosphodiesterase resistant camp, and forskolin, an adenylate cyclase stimulator, in doses of . , and m for hrs (aqp mrna expression) and hrs (aqp protein expression). for time course experiments, cells were incubated with μm of either sp-camp or forskolin for , and hrs at °c, % co . after cell harvest, mrna and protein expression were assayed using real time pcr and western blotting. results: sp-camp and forskolin increased aqp mrna expression in both cell lines after hrs (p< . ) in a dose-dependent manner. protein expression paralleled the increase seen in the mrna. m of sp-camp and forskolin stimulated aqp mrna expression after hrs in htr- /svneo cells and after hrs in jeg- cells (p< . ). m of either sp-camp or forskolin stimulated aqp protein expression in both cell lines after hrs (p< . ) and the expression remained high at hrs. conclusion: aqp gene expression in trophoblast cells is up-regulated by camp agonists. these results suggest that maternal beta-adrenergic agonists or antagonists may modulate maternal-fetal water flux via modulation of aqp water channels. rat placenta expresses corticotrophin releasing factor-binding protein and mrna. jayaraman lakshmanan, thomas r magee, bindu cherian, sharon k sugano, hanalise huff, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: corticotrophin releasing factor-binding protein (crf-bp), a kda secreted glycoprotein, was originally isolated from human plasma. it binds crf and urocortin i with an equal or greater affinity than does the crf receptor. crf-bp expression has been reported in target tissues such as brain and placenta. based on its ability to inhibit crf actions in vitro, it is speculated to function as a "gate keeper" for crf-initiated stress responses. we recently documented expression of crf and urocortin- in rat placenta. in the present study we sought to establish the expression of crf-bp in rat placenta by immunohistochemical and pcr-analyses. methods: placental tissues (n= ) collected from sprague-dawley pregnant rats on day of gestation (term= ) were either fixed in % paraformaldehyde solution (ph . ) and paraffin embedded or processed for total rna extraction. paraffin sections of five micron thickness were subjected to immunohistochemical analysis with goat polyclonal antibodies to human crf-bp precursor (sc- santa cruz biotechnology, ca) by avidinbiotin-peroxidase complex technique. the structure of cloned human crf-bp precursor exhibit significant amino acid sequence homology among all species studied. immunoreactivities on the sections were quantified using image pro . software and staining intensity (od/area) expressed as arbitrary units (au). all values are expressed as mean±sem. for pcr, cdna was synthesized and pcr amplified with a one step rt-pcr kit. fragments were gel purified, clone into plasmid vector and dna sequenced. results: the crf-bp antibody elicited strong positive staining in decidua, giant trophoblasts, spongiotrophoblasts and labyrinth cells. the results of image analyses revealed (au): decidua: . ± . , giant trophoblast cells: . ± . , spongiotrophoblasts: . ± . , fetal membranes: . ± . . pcr analyses identified a single bp band, consistent with crf-bp. conclusion: our study establishes for the first time that rat placenta is analogous to humans in that both express crf-bp mrna and protein. immunohistochemical findings reveal that crf-bp protein expression occurs at multiple sites within the placenta. expression of per clock protein in rat placenta: an internal timer for placental functions. jayaraman lakshmanan, reuben lakshmanan, sharon k sugano, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: corticotrophin releasing factor (crf) expression time-of-day variation occurs in giant trophoblast cells on the maternal side of the rat placenta. this temporal change in crf expression pattern is very similar to that of central nervous system neurons, suggesting that placental cells may use a similar mechanism to read time of the day. the self-sustaining rhythm generating capacity of the suprachiasmatic nuclei is believed to be derived from cell-autonomous, transcriptional feed-back loops dependent on a number of canonical clock genes. in the present study we sought to determine whether rat placenta expresses period gene (per ), one of the clock/cycle related genes. methods: time-dated pregnant sprague-dawley rats were received on day of gestation and housed in a controlled environment ( - h lights on) with free assess to food and water. placentas collected on days and of gestation (term= days) between and . am were fixed in % paraformaldehyde and paraffin embedded. for each gestational ages a total of placentas from different pregnant rats were used. paraffin sections ( sections per placenta) were subjected to immunohistochemical analysis with antibody to per ( : , santa cruz biotechnology, ca) by abc technique and , 'diaminobenzidine as a chromagen. sections were examined under microscope, imunostaining quantified by image pro . software and expressed in arbitrary units (au). data are presented as mean ± sem. statistical significance was analyzed by anova with a p value < . as significant. conclusion: the present results indicate that rat placental cells, devoid of any neural innervations, express per clock protein, similar to central nervous system neurons. based on the differences in the relative intensities between trophoblasts and labyrinth cells on day of gestation, we conclude that fetalmaternal interactions in per regulation disappear at term (or at the time of birth.). our findings imply that per may function as internal physiological modulator in placenta. to determine the mechanism(s) underlying placental time-of-day crf variation, we examined the effect of maternal administration of betamethasone (a synthetic glucocorticoid) on nuclear gc receptor expression in placental cells. method: time-dated pregnant rats (n= ) on day of gestation were given a single subcutaneous injection (at : am) of betamethasone ( μg/kg body weight) while control pregnant rats (n= ) received saline. dams were exposed to isoflurane anesthesia at : am, and placentas harvested, fixed in bouin's solution and paraffin embedded. sections were subjected to immunohistochemical analysis with gc-receptor antibody (sc- , santa cruz biotechnology), with immunoreactive material identified by abc technique using , ' diaminobenzidine as a chromagen. percentages of gc-nuclear receptor (gc-nr) positive cells and their intensities (od/area) were quantified using image pro . plus software. all values are expressed as mean ± sem. statistical analysis was by anova with p< . considered significant. results: in placentas of saline exposed pregnant rats, isolated labyrinth (lb) cells (< %) were positive to gc-nr. no positive staining for gc-nrs was seen either in giant trophoblasts (gt) or in spongiotrophoblasts (st). betamethasone administration was associated with a significant and marked increase in gc-nr staining in all three placental cell types (p< . ). among the cells, gt ( ± %) demonstrated a greater percentage of cells expressing gc-nr than did st ( ± %) or (lb= ± %) (p< . ), though there was similar immunoreactive intensities (gt: . ± . , st: . ± . , lb: ± . au; p=ns) conclusion: our findings indicate that all placental cells respond to gc with upregulation of gc-nr with an enhanced response among gt cells. these results suggest that endogenous or exogenous maternal stress-induced gc exposure may influence signaling responses within both maternal and fetal placental compartments. ovine placenta at very-preterm gestation expresses corticotrophin releasing factor (crf), crf-binding protein (crf-bp) and glucocorticoid receptors (gr). jayaraman lakshmanan, john d richard, guo l liu, sharon k sugano, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: in humans, the placenta is the major source of maternal and fetal plasma crf. based on its critical functions, crf is considered as a "placental clock" of parturition. we recently reported that ovine fetal as well as maternal plasma contain measurable amounts of crf at near-term but not at very preterm gestation. we interpret the absence of crf in plasma at very preterm gestation is either due to lack of placental crf expression and/or placental crf release. here, we examined the expression status of crf, crf-bp (a known specific binding protein for crf and a known regulator of crf functions in human placenta) and gr (a known positive regulator of crf expression in human placenta) in ovine placenta collected at very-preterm gestation. method: placenta harvested from time-dated pregnant ewes on ± days gestation were fixed in bouins's solution and processed for paraffin embedding. paraffin sections were subjected to immunohistochemical analysis with polyclonal antibodies specific to ovine crf( : - : , phoenix pharmaceuticals, ca,) crf binding protein ( : - : , sc ) and gr ( : - : , sc: , santacruz biotechnology, ca). immunoreactive material on the sections were identified as brown staining by abc technique using diaminobenzidine as chormagen. immunoreactive material was quantified by image analysis using image pro . plus software and the immuoreactive intensity (od/area) expressed as arbitrary units (au). results: strong positive staining for crf ( . ± . au), crf-bp ( . ± . au) and nuclear-gr ( . ± . au) were noticed in syncytiotrophoblast cells in all placental sections obtained from pregnant ewes at days gestation. control sections exhibited no positive staining. conclusion: our findings indicated that ovine placenta at very-preterm gestation expresses crf, crf-bp and gr. these results suggest that absence of measurable crf in maternal and fetal plasma at very-preterm gestation is not due to lack of placental crf expression but rather due to the absence of regulated crf secretory mechanisms. rat placenta expresses urocortin i protein and mrna. thomas r magee, michael g ross, john d richard, sharon k sugano, jayaraman lakshmanan. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: urocortin i (ucn- ), a amino acid neuropeptide belongs to corticotrophin releasing factor (crf) stress hormone family. in humans, the placenta and several gestational tissues have been reported to express ucn- protein and ucn- mrna. a number of published studies indicate that ucn- is similar to crf in expression pattern and biological functions. we recently reported that rat placenta is a site of crf protein and crf mrna expression. in the present study we sought to determine whether rat placenta expresses ucn- protein and ucn- mrna. methods: placenta (n= ) collected from pregnant rats at day gestation were either fixed in bouin's solution and processed for paraffin embedding or placed in rna later preservative and frozen for rna extraction. for immunohistochemical localization, five micron thickness paraffin sections were cut and immunostained with rabbit polyclonal antibodies to ucn- ( : to : , sigma) by standard abc technique. control sections were incubated with omission of ucn- antibody. immunoreactive materials on the sections were identified using , ' daminobenzidine as chromagen. immunostaining intensity (od/area) was quantified by image-pro plus software and expressed in arbitrary units (au). for pcr, cdna was synthesized and pcr amplified with a one step rt-pcr kit. fragments were gel purified, cloned into a plasmid vector and dna sequenced. all values are given as mean ± sem. results: ucn- polyclonal antibody elicited strong immunostaining in placental trophoblast cells with variable intensity. the pattern of immunostaining is as follows: giant trophoblast cells: . ± . au, spongiotrophoblast cells: . ± . au and labyrinth cells: . ± . au. the relative intensity in labyrinth cells was significantly lower than the other two cell types (p< . ). pcr analyses revealed the presence of a single band of bp, consistent with ucn- mrna. conclusion: similar to human placenta, rat placenta expresses ucn- protein and ucn- mrna, with most expression localized to the maternal side trophoblast cells. these results support our hypothesis that rat placenta can be used as a model to understand the role of this peptide in feto-maternal stress. the role of the nuclear hormone receptors fxr, pxr and car in placental bile acid homeostasis in normal and pathological pregnancy. victoria geenes, peter dixon, selina raguz, jenny chambers, kishore bhakoo, catherine williamson. imperial college, london, united kingdom. background: obstetric cholestasis (oc) is a pregnancy specific liver disorder characterised by raised maternal serum bile acid levels and associated with adverse fetal outcome. the aetiology of oc is complex and not fully understood, but the fetal complications are likely to result from an accumulation of bile acids in the fetal circulation. bile acids are the toxic end products of hepatic cholesterol metabolism and are synthesised from weeks gestation. in common with other waste products, accumulation in the fetal compartment is prevented by excretion across the placenta into the maternal compartment. however, studies of maternal and cord serum from normal and oc pregnancies have suggested that bidirectional transfer of bile acids is possible. hepatic bile acid transport and metabolism is regulated by members of the nuclear hormone receptor family, namely fxr, pxr and car, but the mechanisms for regulating placental transfer are unknown. objectives: this study used placenta from normal and cholestatic pregnancies to investigate the expression of genes involved in hepatic bile acid homeostasis. methods: villous trophoblast samples from oc and normal pregnancies (np), and human livers were collected and preserved in rnalater. explant cultures were prepared from a further np placentas and cultured for days at % oxygen. on day they were treated with chenodeoxycholic acid, lithocholic acid or vehicle for hours prior to fixing in rnalater. total rna was extracted using trizol, and reverse transcribed to cdna. quantitative real-time pcr was performed using sybr green. target gene mrna abundance was calculated from a standard curve and normalised to l . results: the expression of fxr, pxr and car, the nuclear hormone receptors responsible for hepatic bile acid homeostasis and several fxr target genes (shp, mdr and bsep) was found to be very low in np, and unaffected by the presence of maternal cholestasis. furthermore, the expression of these genes could not be induced by bile acid treatment in an in vitro model. here we have shown that the nuclear hormone receptors (fxr, pxr and car) involved in hepatic bile acid homeostasis are expressed at very low levels in normal and pathological pregnancy and are thus likely to be of limited importance in placental bile acid transfer. a placental phenotype for obstetric cholestasis. victoria geenes, jenny chambers, jo wyatt-ashmead, kishore bhakoo, catherine williamson. imperial college, london, united kingdom; hammersmith hospital, london, united kingdom. background: obstetric cholestasis (oc) is a pregnancy specific liver disorder that affects . % of pregnant women in the uk. biochemically, oc is characterised by liver dysfunction with elevated maternal serum bile acids (sba), and clinically by an increased risk of fetal complications including fetal distress, meconium staining of the amniotic fluid, preterm labour and sudden intrauterine death. the aetiology of oc is complex and not fully understood, but the fetal complications are likely to result from the toxic effects of bile acids, which can cause vasoconstriction in the placenta and fetal cardiac dysrrhythmias. furthermore, in a rodent model of oc, bile acids cause oxidative stress in the placenta and a reduction in litter size. these changes are absent in animals treated with ursodeoxycholic acid (udca), a drug used to treat oc. however human data are lacking. objectives: this study used whole placenta and explant cultures to investigate the effects of bile acids on human placental architecture and to establish whether udca protects the placenta against bile acid induced damage. methods: villous trophoblast samples were collected from oc and normal pregnancies (np) and fixed in formalin. explant cultures were prepared from a further np placentas, and cultured for days at % oxygen. on day a subset were treated with udca overnight, and on day the explants were treated with taurocholic acid, taurochenodeoxycholic acid or vehicle for hours prior to fixing. m sections were stained with haematoxyllin and eosin. slides were reviewed by a perinatal pathologist and syncytial knots (sk) counted. results: oc tissues showed marked alterations in morphology, including congestion of the terminal villi, and loosening of the stroma and fibrotic change of the membranes of the stem villi. there were significantly more sk the oc samples (mann-whitney u test p= . ). furthermore, sk were increased in explants treated with bile acids, but not those treated with udca prior to the addition of bile acids. conclusions: here we describe several morphological abnormalities of the placenta associated with maternal cholestasis. these changes were confirmed using a placental explant model, which also showed that udca protects the placenta against bile acid induced damage. in summary, this study indicates that udca is likely to protect the fetus in oc. the placenta has complex metabolic and endocrine activities and is essential for the growth and survival of the fetus in utero. ultrasound is the most sensitive and less invasive method to evaluate placental size, morphology and function. the three-dimensional approach allows to calculate placental volume in the i and ii trimester of pregnancy. pregnancies from assisted reproduction technologies (art) show an increased rate of pathologies potentially related to placental insufficiency such as intrauterine growth restriction and preterm delivery. aim. to determine placental volume in art pregnancies in a cross sectional study in the first trimester of gestation. design. using three-dimensional ultrasound machine (ge ) placental volume measurement from art pregnancies (n= ; - wks) were compared with data from normal controls (n= ) matched for gestational age. data were analysed with software stata . results. mean placental volume was . ml (sd± . ) in art pregnancies and . ml (sd± . ) in normal controls. mean difference resulted in . ml (- - . ) and was statistically different (p= . ). multiple linear regression analysis showed a statistically significant interaction (p= . ) between gestational age and case status, i.e. differences in placental volume increase significantly with advancing gestational age between cases and normal controls. mean gestational age at birth was not essentially different between the two subsets ( . weeks ± . ) however a statistically significantly lower mean fetal birthweight was found in art pregnancies: g (sd± ) vs .(sd± . ) (p= . ). conclusions. placental volume is slightly decreased in art pregnancies. measurements of placenta volume by d ultrasound may play a role in identifying the degree of placental growth early in gestation in a risk population. in vitro effects of adenovirus-mediated gene transfer of insulin like growth factor- (ad-igf- ) in trophoblast cells. mounira habli, datis alae, foong yen lim, jignesh parvadia, timothy crombleholme. obstetrics and gynecology; pediatric surgery, university of cincinnati/children's hospital, usa. objective:recently, ad-igf- corrected both fetal and placental weights in rat model of fetal growth restriction (fgr) . to elucidate the mechanism of action of ad-igf- ;we examined the effect of ad-igf- on trophoblast proliferation, differentiation and invasion. methods: rcho- trophoblast cell line derived from rat choricarcinoma was used. ad-igf- and galactosidase transgene (ad-lacz) were given at moi of : and : in all the experiments.transduction efficiency was assessed hr after infection with ad-lacz by galactosidase enzyme activity. the invasiveness of rcho- was measured by using bdmatrigel invasion chamber kit. rcho- proliferation cell density was assessed by crystal violet assay. morphologic analysis of rcho- differentiation in response to treatment (differentiated cells are multinucleated giant cells) was assessed byimunocytochemistry staining using placental lactogen- antibodies(specific hormone produced by giant cells). results: % efficiency of gene transfer of ad-lacz to rcho- cells was observed at both moi's.there was no significant difference in proliferation between treated control group regardless of the dose at and hrs. ad-igf- induced morphologic differentiation of trophoblast cells compared to control (fig ) at hrs.ad-igf- induced higher rate invasion in a dose dependent fashion as compared to control(ad-lacz) group( % at moi vs . % in control p< . )(fig ). conclusion: ad-igf- gene transfer induces differentiation and invasiveness of trophoblast cells. these may be the mechansim of correction of fgr in rat model of placental insufficiency. placental gene transfer may be an effective treatment strategy for placental insufficiency. types of human placenta. martina dieber-rotheneder, ursula hiden, gernot desoye, mila cervar-zivkovic. department of obstetrics and gynaecology, medical university graz, graz, austria. background and hypothesis: endothelin- is a polypeptide with a wide range of functions. in the placenta it acts as a potent regulator of vasotonus on endothelial and smooth muscle cells, whereas on the trophoblast it regulates cell proliferation, invasion and apoptosis. endothelin- action is differently signaled through two endothelin receptor (etr) subtypes, etr-a and etr-b. several alternative splice variants of etr were identified. here we hypothesize that the etr-a splicing varies with gestational age and is different in trophoblast vs endothelial cells of the human term placenta. methods: mrna of placental tissue from first trimester (pregnancy terminations, missed abortions) and term of gestation, first trimester and term trophoblasts, arterial and venous placental endothelial cells as well as cell lines representing first trimester trophoblast (ach p) and term placental endothelial cells (hpec) were analyzed for full length etr-a and known as well as unknown splice variants by sqrt-pcr using primers spanning the exons - . the predominant dna bands in agarose gel were excised and sequenced. results: all tissues and cells expressed full length etr-a. in all tissues an additional -deletion variant was identified which was not found in the isolated cells. trophoblasts expressed another yet unidentified splice variant. the endothelial cells expressed a -deletion variant and a novel splice variant, which was identified as partial -partial deletion. this novel splice variant was found regardless of the arterial or venous origin of the cells as well as in the cell line (sv -transformed). in tissues und trophoblast no difference in splicing was found between first trimester and term. conclusion: gestational age does not alter splicing of endothelin receptor-a. splicing is different between trophoblasts and endothelial cells. the endothelial cells contain a novel splice variant. the differential splicing may allow maternal and fetal endothelin- to induce different effects on the two major cell types of the placenta. (supported by grant , jubilee fund, austrian national bank, vienna). adrenomedullin production and secretion by human trophoblast cells are regulated by glucocorticoids and hypoxia. francesca ciardo, katia pacioni, emanuela marinoni, giovanna corona, massimo moscarini, alfredo patella, romolo di iorio. department of gynecology, perinatology and child health, university "la sapienza", rome, italy; department of obstetetrics and gynecology, university of ferrara, ferrara, italy. objectives: adrenomedullin (am) is produced by intrauterine tissues and is involved in the regulation of implantation, placental hemodynamics and endocrine function. circulating am is increased in pregnancy complications such as preeclampsia and intrauterine growth retardation. we investigated whether am output by human trophoblast cells is regulated by hypoxia and/or glucocorticoids. study design: trophoblast cells obtained by human placentas at term (n= ) were cultured in presence or absence of hypoxia ( % o ) and treated with or without betamethasone at the dose of - , - , - m. media and cells were collected at h and at , and h from syncytiotrophoblast cultures. am was measured in cultured media by specific ria kit. protein expression in trophoblast cells was evaluated with immunohistochemistry and western blot. results: hypoxia stimulated am output and protein expression by cytotrophoblast and syncytiotrophoblast cells. betamethasone induced an increase in am production and secretion in a time-and dose-dependent manner (figure). effects of hypoxia were partially reversed by betamethasone in a dose and time-dependent fashion. conclusions: am production in trophoblast cells is up-regulated by hypoxia and glucocorticoids, independently. increased am levels in pregnancy complications characterized by placental insufficiency might derived by an increase in am placental secretion stimulated directly by hypoxia or indirectly by an increase in fetal cortisol levels. preeclampsia complicates - % of pregnancies, and while associated with significant maternal and fetal morbidity and mortality, the mechanisms responsible for preeclampsia are not completely understood. recent advances suggest there are imbalances of pro-and antiangiogenic factors, present from the time of implantation affecting vascular responsiveness of the fetal placental unit and maternal vasculature. in this study, we investigate vasomotor responsiveness of placental arteries from normal and preeclamptic (pet) pregnancies using an in vitro muscle bath contractility assay. transverse rings of placental arteries were cut and equilibrated in the muscle bath containing a bicarbonate buffer aerated with % o / % co at °c. viability was demonstrated by contraction to mm kcl prior to all experiments. cumulative logarithmic dose dependent responses to four different contractile agents: pgf , serotonin, carbochol, and norepinephrine were compared. placental arteries precontracted with pgf at half maximal concentration were relaxed with three vasorelaxants: sodium nitroprusside (snp), forskolin (fsk) and lactate (lct). agonist studies revealed contraction to both pgf and serotonin but not to carbochol or norepinephrine. there were no statistically significant differences between the responses of normal and pet arteries. both normal and pet arteries demonstrated heightened responsiveness to sodium nitroprusside compared with forskolin and lactate. this study reveals that the placental vessels are more sensitive to sodium nitroprusside, that mediates relaxation through nitric oxide -cyclic gmp signal transduction pathway, than forskolin that induces relaxation through the cyclic amp pathway. cancer complicates approximately one in , pregnancies. depending on the type of cancer and trimester, patients can terminate the pregnancy or choose treatment such as chemotherapy. since there is limited knowledge on the safety of chemotherapy on fetal tissues in utero, clinicians cannot efficiently analyze the risks of particular anticancer agents when deciding on a course of therapy. since carboplatin is among the most common anticancer agents used for treatment of cancer during pregnancy the primary objective of this study was to evaluate if carboplatin will readily cross to placental barrier and determine total potential platinum fetal exposure. this project utilizes an ex vivo placenta perfusion model to determine the concentration of carboplatin that crosses the human placental barrier. placentas are obtained within minutes of spontaneous delivery and re-perfused. two carboplatin concentrations were selected of ng/ml and ng/ml to represent clinically relevant maternal plasma concentrations. antipyrine was used as the internal control. serial samples were collected every minutes for total minutes in open-open model then experiment repeated with closed circuit model. antipyrine concentrations were determined by hplc methods. platinum concentrations in media samples were determined with a validated atomic absorption assay. a cell culture-based approach will be used to determine whether cell cycle or apoptotic proteins are altered (p , bax, bcl- , aif, and pro-caspase- ) using western blotting as a detection method. a total of two placentas have been completed at the low carboplatin concentration and one at the high concentration. the mean carboplatin clearance was . +/- . ml/min and . +/- . ml/min at the low and high carboplatin concentrations, respectively. an estimated % increase in the transport fraction was observed in the high concentration experiments compared to the low concentrations model. fetal carboplatin exposure ranged from to ng/ml. the placental perfusion experiments conducted at carboplatin and ng/ml indicate that carboplatin crosses the placenta through simple diffusion. the toxicology assays are ongoing to determine potential effect on fetal tissues. preterm delivery represents one of the predominant causes of perinatal mortality and morbidity, and is one of the most unpredictable gestational disturbances. urocortin is a peptide expressed by trophoblast and gestational tissues (amnion and chorion), whose maternal levels correlate with gestational length, since they are increased at preterm delivery and decreased in post-term pregnancy, when compared to term pregnancy. the addiction of urocortin enhances contractility of human myometrial strips, suggesting a possible role on uterine contractility. high maternal urocortin levels in threatened preterm delivery correlates with the timing of delivery, suggesting a possible role in the predictivity pf preterm delivery. in the present study urocortin concentrations in amniotic fluid collected at mid gestation for amniocentesis were correlated with gestational age at delivery. a case-control study with amniotic fluid obtained from healthy women undergoing amniocentesis for genetic indications was performed; urocortin concentrations were measured by a specific elisa. amniotic fluid urocortin concentrations resulted significantly lower (p= . ) in women delivering preterm (n= ; ucn= . ± . pg/ml) (m ± se) than in those delivering at term (n= ; ucn= . ± . pg/ml). in conclusion, the present preliminary data showed that amniotic fluid urocortin concentrations at mid gestation may represent predictive marker of preterm delivery. human placentas throughout pregnancy. annunziata mastrogiacomo, elisabetta federico, francesca caprio, maria teresa schettino, gabriele coppola, antonio de luca, luigi cobellis. department of obstetrics and gynecology, second university of naples, naples, italy; department of medicine and public health, section of anatomy, second university of naples, nales, italy. hypothesis apoptosis is intimately involved in placental homeostasis, growth and remodeling and the apoptotic rates increase progressively during normal pregnancy as part of normal placental development. moreover, apoptosis increases in pregnancies complicated by some pathologies such as preeclampsia, fetal growth restriction, diabetes. in the present study, we describe differences in the expression of pro-apoptotic protein bax, in first trimester voluntary termination of pregnancy, first trimester abortion (reserved abortion), caesarean birth, spontaneous birth, preeclampsia and diabetes. material and methods human placental samples were obtained with informed consent from patients undergoing surgery such as first trimester voluntary termination of pregnancy (n= ), first trimester abortion (miscarriage) (n= ), delivery section (n= ), spontaneous birth (n= ), preeclampsia (n= ) and diabetes (n= ). the gestation period ranged from to weeks. the specimens were immediately fixed in formalin for immunohistochemistry. we first observed a strong increase of bax expression in the cytotrophoblast, stroma, endothelial cells and decidua of placentas of the first trimester abortion compared to the low/moderate bax immunopositivity in all the placental compartments during the first trimester voluntary termination of pregnancy. secondly, we showed a more intense immunopositivity for bax in the third trimester spontaneous birth respect to the third trimester caesarean birth. thirdly, we observed an increase of bax expression in preeclamptic placentas compared to the normal full-term placentas. on the contrary, we observed a moderate bax expression in diabetic placentas only slightly decreased compared to the normal full-term placentas. our results seem to suggest that deregulation of apoptotic turnover may lead to placental dysfunction and pathologies. objectives: maternal endothelial activation in preeclampsia (pe) is attributed to the release of unknown factors from a hypoperfused placenta. the application of proteomic technologies such as mass spectrometry promises the reward of identifying and characterising these factors. using a placental explantconditioned culture media model system we have developed a proteomics workflow to obtain relative quantification of proteins released into placental explant culture media. methods: term villous explants were cultured in serum-free conditions and exposed to differing oxygen concentrations ( % %) to mimic physiological and non-physiological intervillous o tensions. the d media was concentrated, immunodepleted to remove fibrinogen (using beckman igy- columns) and proteins labelled using an itraq (applied biosystems) kit following the manufacturer's protocol. labelled peptides were fractionated by strong cation exchange and then analysed using lc-maldi on a maldi-tof/tof (applied biosystems) mass spectrometer. data was analysed using protein pilot . (applied biosystems). results: when matched pooled (n= ) media samples were subjected to our proteomics workflow over proteins were identified with a calculated false positive identification rate of < %. of these proteins a total of display a statistically significant difference in protein levels between the % % o samples (p=< . ). from a list of proteins of interest we selected proteins for validation using elisa/western blotting to measure their relative abundance in both pooled and individual explant media samples. interleukin is an example of a low-abundance differentially expressed protein identified in our proteomic workflow and subsequently validated by elisa; il- (pg/ml) in % o : . , range . to . ; % o : . , range . to . ; values are median with interquartile range. *** p< . , mann-whitney test (n= ) conclusions: we demonstrate a successful reduction to practice of a relative quantitative proteomics strategy applied to placental explant-conditioned culture media. having optimised and validated this proteomic workflow we will apply the same methods to compare proteins released by normal and preeclamptic placentas. a proteomics screen of human placental microvillous syncytiotrophoblast (stb) revealed the expression of dysferlin (dysf), a membrane repair protein associated with certain muscular dystrophies (vandré et al., ) . a second ferlin protein, myoferlin (myof), was also discovered which has not yet been characterized in the placenta. in human c c myoblasts, dysf and myof are reciprocally expressed as a function of differentiation into multinucleate syncytial myotubes, with dysf predominating in differentiated cells. we hypothesized that dysf and myof would show a similar reciprocal expression pattern in human trophoblasts as a function of syncytialization. methods term placentas from uncomplicated pregnancies were obtained with informed consent (n= ) and either fixed for immunofluorescence (if) labeling or flash frozen for subsequent immunoblotting (ib). human trophoblastic (bewo, jar, and jeg- ) and other cell lines (mrc- , hl- , huvec) were cultured in the absence or presence of μm forskolin or solvent control for - days. dysf and myof expression was examined by rt-pcr, ib, and if. results ib validated proteomics data showing myof expression in term placenta. by if, myof labeling was predominant in apical and basal stb plasma membranes. myof was expressed in trophoblastic cell lines (bewo, jar, and jeg- ), cultured endothelium (huvec), and a fibroblast cell line (mrc- ), but was not detected in a leukemic cell line (hl- ). dysf was constitutively expressed in jar, but minimally expressed in unstimulated bewo. following forskolin-induced syncytialization, we observed a time-dependent increase in dysf expression in bewo concomitant with increasing syncytin- levels. by if, dysf expression was restricted to bewo cells in syncytial structures. in contrast, myof expression was robust in mononuclear bewo cells and not down-regulated over the course of days of differentiation. conclusions two ferlin-family genes are expressed in trophoblasts. fusion-competent bewo cells behave similarly to cultured myoblasts and ctbs with regard to dysf expression, which is restricted to syncytializing cells. myof, in contrast, is expressed constitutively in bewo and other models. while both proteins are likely to function in stb plasma membrane repair (e.g., following syncytial sprouting), the relative contributions of each to this process awaits clarification. features of chronic placental insufficiency are significantly more common in small for gestational age placentas from infants with intrauterine growth retardation. emily king, violetta kolesnikova, carri tillotson, jean-marie guise, terry morgan. pathology; center for biostatistics; obstetrics and gynecology, ohsu, portland, or, usa. background: there is a strong association between intrauterine growth restriction (iugr) and small for gestational age (sga) placentas (heinonen et al. placenta ( ), : - ) . the cause is likely multifactorial, but we hypothesize that chronic uteroplacental insufficiency may play a role. our objective was to test whether sga placentas from human neonates with iugr show significantly more pathologic features of placental insufficiency compared to controls. design: we performed a retrospective review of consecutive singleton placentas submitted to ohsu pathology ( - ), excluding elective terminations and spontaneous abortions before weeks gestation. clinical records were reviewed and pregnancy outcomes recorded, including: ) neonatal sex; ) weight (iugr calculated by routine methods), ) trimmed weight of the placenta (sga calculated by routine methods), ) gross placental infarctions, ) gestational age at delivery, and ) maternal features (e.g. race, gravida). controls were defined as cases within the series without sga or iugr (e.g. submitted for meconium, infection, etc). histologic sections were scored by two pathologists while blinded to clinical diagnoses as positive or negative for features of placental insufficiency, including accelerated villous maturation (avm), chorangiosis, and microscopic infarctions. significant associations were tested by analysis and logistic regression for multiple variables. results: similar to prior reports, we observed a strong association between iugr and sga placentas ( . ; p < . ). this relationship was independent of maternal race, fetal sex, and parity, although it was more common in primigravidas. avm and placental infarctions were significantly more frequent in sga placentas with superimposed iugr. controls ( introduction: messenger rna expression peripheral blood cells (pbc) has been recently used as biomarkers of environmental exposures (ionizing radiation or tobacco), physiological conditions (stress) and diseases (hypertension, neurological disorders). pbc evaluation is a useful diagnostic tool in an era of individualized medicine. since there is an urgent need for non-invasive methods for determination of fetal (f) and placental (p) function, this study was designed to evaluate the genes differently and commonly expressed in p tissue and leukocytes in maternal (m) and f circulation.material and methods. p (n= ), f (n= ) and m blood (n= ) were obtained during cesarean section in pregnant baboons at term. total rna from a buffy coat pellet was isolated using a modified procedure of the qiagen rneasy mini kit (qiagen). anti-sense rna (arna) was synthesized and purified using the illumina rna amplification kit (ambion, usa). hybridization of arna to illumina sentrix human whole genome (wg- )beadchips and subsequent washing, blocking and detection was performed using illumina's beadchip ´ protocol. samples were scanned on the illumina beadarrayer gx reader using illumina beadscan image data acquisition software (ver. . . . ). differential gene expression data analysis was performed using illumina beadstudio software (ver. . . . ). results. the detection level of gene transcripts using illumina methodology with control human rna was - at p< . . gene transcripts were detected in f blood and in maternal blood. transcripts were uniquely expressed in fetal blood. transcripts were found in m, but not in f leukocytes. the number of gene transcripts expressed in p tissue was and of these genes were not expressed in m leukocytes. conclusion. despite white blood cells trafficking through the p barrier there is a set of unique genes expressed only in p or in the m or f circulation. the application of these genes as the biomarkers of p barrier function still need to be evaluated. objective: to evaluate if a relationship exists between duration of placental exposure to meconium in vivo and histologic evidence of severity and extent of meconium uptake by macrophages. study design: from a cohort of / ( %) consecutive singleton liveborn infants delivered at term with thick meconium-stained fluid, ( %) had placental histologic examination performed, and in / the timing of meconium appearance after membrane rupture was documented. placental histologic examination quantitatively evaluated the intensity of meconium uptake by resident macrophages based on the number of macrophages/field, and the extent of uptake based on histologic location, graded in a score to . results: mean interval between meconium appearance and delivery was . ± . min (range - ). after exclusion of cases in which severe placental inflammation interfered with analysis, meconium uptake by macrophages was documented in / cases at the level of amniochorionic membranes, in / cases at the placenta, and in / cases at the umbilical cord. there was no correlation between the interval meconium appearance-to-delivery in relation to presence of meconium in the membranes (p= . ), in the placenta (p= . ), in the cord (p= . ), or score of severity of meconium uptake (p= . ). the results did not change after correcting for gestational age, oligohydramnios, presence of placental acute inflammatory or vascular lesions. conclusion: there is no relationship between duration of placental exposure to meconium and the extent and intensity of its uptake by macrophages in cases with exposure up to . hours. transfer of bisphenol a across the human placenta. biju balakrishnan, , kimiora henare, , eric thorstensen, , murray d mitchell. , the liggins institute, university of auckland; national research centre for growth and development, auckland, new zealand. introduction: there are growing concerns over the effects of developmental exposure to the xenoestrogen bisphenol a (bpa). animal studies have shown that bpa is transferred through the placenta and can cause deleterious effects to the fetus. the presence of bpa in feto-placental tissues in humans has also been reported. however, a detailed study of the time-course of bpa transfer across the human placenta has not been performed. the aim of this research was to study the transfer of bpa in ex-vivo perfused human placental tissues. methods: a dual recirculating single cotyledon perfusion was used to monitor the placental transfer of bpa. bpa ( ng/ml), antipyrine (ap) ( μg/ml), and fitc dextran (fitc-dx) ( . μg/ml) were added to the maternal perfusate, and perfusion was continued for hours. perfusate samples were collected from both reservoirs at timed intervals and analysed. bpa, ap, and fitc-dx were determined by hplc with fluorescent detection, hplc with uv detection, and spectrofluorometry respectively. the viability and metabolic activity of the placentae were assessed by measuring -hcg (elisa), glucose utilization, and lactate production (autoanalyzer). fetal pressure, ph, flow rates and fluid shifts were monitored continuously. results: the biochemical validation parameters (glucose consumption, lactate production and -hcg secretion) indicated that the placental tissue was metabolically active and viable throughout the -hour perfusion period. the physical parameters observed (fetal pressure < mmhg, ph range . - . ) were in concordance with other published works for placental perfusion. membrane integrity was confirmed by fluid shifts from either circuit of < ml/hr, and by < % materno-fetal transfer of fitc-dx. an observed ap transfer of - % further validated our model. bpa first appeared in the fetal compartment within minutes of perfusion and reached a peak of about - % of maternal concentration within hours of perfusion. this figure is likely to be an underestimate since it does not include conjugated bpas. conclusion: this first study of bpa transfer in ex-vivo perfused human placental tissue shows that our model can serve as a useful tool to study the transfer kinetics and metabolism of bpa in human term placentae. we found that bpa rapidly crosses the human placenta at environmentally-relevant doses, with potentially harmful effects on the human fetus. angiogenic growth factor secretion by uterine natural killer cells in co-culture with extravillous trophoblast. gendie e lash, katsu naruse, , barbara a innes, stephen c robson, judith n bulmer. institue of cellular medicine, newcastle university, newcastle upon tyne, tyne and wear, united kingdom; obstetrics and gynaecology, nara medical university, nara, japan. objectives. uterine natural killer (unk) and extravillous trophoblast (evt) cells have been proposed to play roles in remodeling of uterine spiral arteries through secretion of various angiogenic growth factors. we have previously demonstrated that unk cells are a significant source of angiogenic growth factors within the decidua, many of which alter with gestational age. however whether the secretion of these proteins is altered by interactions of unk cells with evt is unclear. hypothesis. unk cell angiogenic growth factor secretion is regulated by evt in early pregnant decidua. methods. placental and decidual samples were collected from women undergoing termination of pregnancy with written informed consent ( - and - weeks gestation, n= each group). . × cd + unk cells were positively selected from decidua and co-cultured with evt ( . × ) or cytotrophoblast (ctb; . × ) purified from the same placenta for h in direct or indirect contact (n= each group). angiogenin, ang , pdgf-bb, fgf-basic, timp , icam and vegf-a were measured by fast quant ® angiogenesis multiplex assay system, and vegf-c, ang and plgf by elisa. results of unk co-culture with evt or ctb (negative control) at each gestational age were analyzed with wilcoxon rank test. in addition, the effect of direct and indirect co-culture of unk cells with evt at each gestational age was compared with mann whitney u test. results. at - weeks gestation unk secretion of ang (p= . ), icam (p= . ) and plgf (p= . ) was increased in the presence of evt compared with ctb. no differences were observed at - weeks gestation. in addition, at - weeks gestation unk secretion of ang (p= . ), vegf-c (p= . ) and ang (p= . ) was increased in direct co-culture with evt compared with indirect co-culture. at - weeks gestation unk secretion of timp- (p= . ) was reduced in direct co-culture with evt compared with indirect co-culture. conclusions. unk cell secretion of several key angiogenic growth factors was altered by direct culture with evt. these data suggest that a membrane bound molecule (such as hla-g) mediates this modulation of unk cell activity. abnormalities in placentation and impaired placental circulation can lead to fetal growth restriction. -d ultrasound can be used to evaluate this through the quantification of the power doppler signal that may be expressed as a percentage of colour voxels within a user-defined volume (vi: vascularisation index). we aimed to test the hypothesis that increased fetoplacental blood flow correlates with an increased vi, using the in vitro dual perfusion model of the human placental lobule. three term lobules were dually perfused through both circulations with earles bicarbonate buffer (ebb), and supplemented on the fetal-side only with adult erythrocytes, prepared to a % haematocrit. following initial equilibration perfusion at normal flow values, fetal-side flow was varied between and ml/min, whilst maternal-side flow was held at ml/min. images were obtained with a 'voluson i' ultrasound machine and a neonatal transducer (pulse repetition frequency = . hz, wall motion filter = low , and gain = . ). three -d datasets were acquired at each flow rate from each placental lobule and these were measured in triplicate using vocal. a sphere was centred on a visibly perfused cotyledon along the chorionic-decidual axis, with a diameter corresponding to placental thickness. linear regression analysis was used to assess the relationship between the total fetal-side flow and mean vi. the mean vi showed a high degree of correlation with total fetal-side flow for each lobule ( figure ) suggesting increased vascular perfusion and the inclusion of perfused vessels that cross the detection threshold with increased flow. this data provides qualifying information for translation to a clinical application, where early gestational fetoplacental blood flow will be assessed to predict the onset of fetal growth restriction. anthony n imudia, brian a kilburn, anelia petkova, samuel s edwin, roberto romero, d randall armant. objective survival of first trimester cytotrophoblast cells depends on their upregulation of heparin-binding egf-like growth factor (hbegf), which is downregulated in placental tissues diagnosed with preeclampsia. we have examined the expression and cytoprotective activity of hbegf in term villous explants subjected to hypoxic stress in vitro. non-pathological placentas were collected by cesarean section at term (n= ). chorionic villous explants were prepared and cultured at either % or % o and treated with the hbegf antagonist crm or recombinant hbegf. paraffin sections were assayed for trophoblast cell death by the tunel assay, proliferation by immunohistochemical labeling of nuclear ki and hbegf expression by semi-quantitative immunohistochemistry. data were compared using anova and the student-newman-keuls posthoc test. results crm ( mg/ml) increased trophoblast cell death after culturing villous explants h at % o (p< . ), but only slightly affected proliferative capacity. culture at % o increased trophoblast cell death % above explants incubated at % o (p< . ). trophoblast cell proliferation decreased after h in explants cultured at either % or % o (p< . ). exogenous hbegf ( nm) prevented the elevation of cell death during hypoxia (p< . ) and maintained nuclear ki expression at %, but not %, o . contrary to first trimester trophoblast, hbegf was not upregulated by hypoxia in term trophoblast. the failure of term trophoblast to elevate hbegf expression in response to hypoxia could contribute to their decreased survival at low o compared to early gestation. endogenous hbegf signaling appears to facilitate survival of term trophoblast during villous explants culture. exogenous hbegf supplementation prevented cell death due to hypoxia and maintained trophoblast proliferation rates under in vitro conditions. therefore, hbegf, which is downregulated in preeclampsia, could have significant impact on trophoblast survival during late gestation. supported by the intramural research program of nichd. conspicuous meconium-laden macrophages in the chorionic plate are an independent predictor of clinically significant fetal distress. violetta kolesnikova, emily king, carrie tillotson, jean-marie guise, terry morgan. pathology; center for biostatistics; obstetrics and gynecology, ohsu, portland, or, usa. background: meconium is a common indication for placental examination, present in approximately % of placentas routinely submitted to pathologists (beebe et al. obstet gynecol ; : - ) . prolonged meconium exposure leads to accumulation of meconium-laden macrophages in the chorionic plate (estimated to require at least hours). our objective was to test whether prolonged meconium exposure is associated with clinically significant fetal distress. design: retrospective review of consecutive singleton placentas submitted to ohsu pathology ( - ) was performed, excluding abortions before weeks gestation, and placentas without representative sections of the chorionic plate. clinical records were reviewed and pregnancy outcomes recorded, including: ) evidence of fetal distress prompting c-section (non-reassuring fetal heart rate), ) gestational age, ) maternal diagnosis, ) apgar scores, and ) neonatal length of hospital stay. routine histologic sections were independently scored by two pathologists while blinded to clinical diagnoses and outcomes. cases were scored as positive or negative for: ) diffusely conspicuous meconium-laden macrophages in the chorionic plate (at least / hpf), ) chorioamnionitis, and ) features of placental insufficiency. significant associations were tested by the mann-whitney u test for paired comparisons, x analysis, and logistic regression for multiple variables. results: conspicuous meconium staining of the chorionic plate was common ( / , %) and was significantly more frequent in c-sections performed for fetal distress ( / cases, %) (x . ; p-value < . ). logistic regression modeling showed that this association was independent of chorioamnionitis and features of placental insufficiency. there was no association between meconium and neonatal outcome, including no difference in apgar scores or length of hospital stay. conclusions: our data support the hypothesis that meconium-laden macrophages in the chorionic plate are associated with fetal distress prompting c-section. whether meconium is the cause or consequence of this distress is uncertain. however, given the acute time frame between clinical diagnosis and c-section, we suspect prolonged meconium exposure may be a significant cause of non-reassuring fetal heart rate changes. apoptotic index in normal and intrauterine growth-restricted rat placentas. elissa scotland, tri nguyen, s chiang, radmila runic. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: intra-uterine stress caused by maternal food-restriction may have adverse fetal and placental effects. we sought to assess the effect of maternal food restriction during pregnancy on placental apoptosis. methods: rat placentas were analyzed from control dams fed ad libitum and dams % food-restricted from day of gestation. placentas were harvested at embryonic days and (n= ). placentas were fixed in % pfa and two methods of analysis were utilized to determine the proportion of apoptotic to non-apoptotic cells within maternal food restricted and control rat placentas: immunohistochemistry (ih) using fas-ligand and in situ tunel (terminal deoxynucleotidyl transferase biotin-dutp nick end labeling). tunel: after rehydration, slides were subjected to tdt enzyme. dab was used to visualize brown apoptotic nuclei. dna-se treated slide was used as a positive control. ih: primary rabbit polyclonal fas-ligand antibody was used at : dilution, after which secondary antibody linked to peroxidase and dab staining was performed. results: food-restricted placentas demonstrated . % relative apoptotic index when compared to . % in the control group. the iugr iod (integrated optical density) per unit area in the placental membrane was higher than in the control group. fasl demonstrates an iod of . + . in food restricted placentas as compared to . + . per μm surface area in controls. apoptosis was seen in the amnion as well as trophoblast (syncytialtrophoblasts and some cytotrophoblasts). conclusion: the increased apoptotic index in maternal food restricted placentas suggests that the accompanying iugr may be a result of both maternal/fetal nutrient restriction and increased fetal stress. this study found that maternal food restriction during pregnancy affects placental apoptosis. there is more apoptosis in the iugr placental bed at e than at e , with the reverse being true for the placental membrane. more research is required to statistically validate the data. the suggested next step is to evaluate fas and fas-l and to address possible mechanisms of placental apoptosis. cord. jayaraman lakshmanan, avish arora, lilit baldjyan, sharon k sugano, olga miadel, adegoke adeniji, michael g ross, calvin j hobel. ob-gyn, harbor-ucla medical center, torrance, ca, usa; ob-gyn, cedars-sinai medical center, los angeles, ca, usa. background: crf-bp is a kda protein, that specifically binds corticotrophin releasing factor (crf). the structure of cloned crf cdnas in all species examined predicts that the precursor is larger than the kda in size and contains one n-glycosylation site. marked reductions in plasma crf-bp levels seen in pregnant women prior to both preterm and term delivery led to the notion that crf-bp is a "gatekeeper" of crf responses. recently we identified crf-bp expression in term human umbilical cord (uc) by immunohistochemical analyses. objective: to characterized the expression of crf-bp by immunohistochemical and biochemical analyses in human uc. methods: freshly obtained human preterm ( to < weeks, n= ) umbilical cord ( pieces of mm thickness taken at - cm intervals close to placenta) were fixed in bouin's solution and paraffin embedded. also, pieces of ucs were dissected, arteries and vein separated, weighed and frozen at - c. for immunohistochemical localization, uc sections were subjected to immunostaining with polyclonal antibodies to human crf-bp precursors. for western blot analyses, whole uc as well as isolated arteries and vein were homogenized in a buffer containing detergents and protease inhibitors. the homogenate supernatant proteins were subjected to western analyses by standard protocol. immunoreactive protein bands were identified by chemiluminescent reagent. results: both goat and rabbit crf-bp polyclonal antibodies elicited weak to moderate positive staining in uc epithelial layers, vascular musculature and barely endothelial cells. they identified a strong kda band in whole uc as well as in isolated artery and venous preparations. in addition minor immunoreactive protein bands of , , kda in size were noticed in all three preparations. conclusion: we conclude that preterm uc expresses crf-bp. we postulate that the kda major band is either glycosylated crf-bp precursor or glycosylated kda mature protein. the low molecular weight immunoreactive proteins likely represent proteolytically processed, glycosylated crf-bp precursor or a proetolytically processed mature da crf-bp. uc obtained at delivery could be useful as a tool to understand the critical functions of crf-bp in feto-placental unit. objective: adenosine, known to be released from inflammatory sites and tisse ischemia, has many important biologic roles. four specific adenosine receptors have been cloned to date, termed a , a a, a b, and a . recently our study has shown that increased a receptor in the trophoblast of preeclamptic pregnancy was noted and non-vascular and trophoblast-mediated a receptor may play an important role in the pathogenesis of preeclampsia. there are evidences of impaired trophoblast invasion related to matrix metalloproteinase (mmp) in preeclampsia and the relationship between adenosine receptor and mmp in other fields. the objective of this study is to evaluate the effect of mmp expression by adenosine a receptor in preeclamptic villous explants at different oxygen conditions. methods: placental villous explants from normal (n= ) and preeclamptic (n= ) pregnancies were cultured at high ( %) and low ( %) oxygen levels for days. explants were analyzed for mmp- /- and timp- /- by rt-pcr and western blot. preeclamptic villous explants in hypoxic culture condition were treated with a receptor agonist, cl-ib-meca and a receptor antagonist, mre. mmp- / - expression was determined in a time-and dose-dependent manner by rt-pcr, western blot. also mmp- /- activity was evaluated by zymogram assay. results: there were significantly increased a receptor intensity and reduced mmp- /- and timp- /- expression at low oxygen level in normal and preeclamptic villous explants. interestingly, in preeclamptic villous explants, after high oxygen culture mmp- /- and timp- /- expression were recovered to almost same level compared to those in normal villous explants. treatment of preeclamptic villous explants with cl-ib-meca in low oxygen level resulted in a time-and dose-dependent enhanced expression of mmp- /- . this cl-ib-meca-induced expression of mmp- /- was inhibited by pretreatment with mre. conclusion: to our knowledge, this study is the first to evaluate modulation of mmp secretion by adenosine a receptor in preeclamptic villous explant. our results provide evidence for the existence of functional adenosine a receptors in the trophoblast and suggest that adenosine a receptor will be investigated as a therapeutic target in preeclampsia. murray d mitchell, timothy a sato, anderson wang, jeffrey a keelan, anna p ponnampalam, michelle glass. liggins institute; department of pharmacology and clinical pharmacology, university of auckland, auckland, new zealand. introduction: it is well established that prostaglandins play critical roles in multiple aspects of pregnancy and that the fetal membranes are an important site of intrauterine prostaglandin production. endocannabinoids have been implicated in the maintenance of pregnancy and parturition in women and are a source of arachidonic acid which is a substrate for the production of prostaglandins. the aim of the present study was to determine the effects of endocannabinoids on the production of prostaglandins in extraplacental membranes -amnion, chorion and decidua. methods: explants of term amnion and choriodecidua were established and treated with endogenous endocannabinoids -arachidonoyl glycerol ( ag) and anandamide (aea) and with the synthetic cannabinoid cp , , to determine the ability of these substances to modulate prostaglandin e (pge ) production. pge was measured by radioimmunoassay. the explants were also treated with cp , in the presence of either sr a (a selective antagonist of the cannabinoid receptor cb ) or ns (a cox- inhibitor), to determine whether any observed stimulation of pge production was mediated through cox- activity and/or the cb receptor. cox- , cox- , cpla and pgdh protein levels were measured by western blotting. results: all three cannabinoids caused a significant increase in pge production in amnion but not in choriodecidua. however, separated fetal (chorion) explants responded to cannabinoid treatment in a similar manner to amnion, whereas maternal (decidual) explants did not. the enhanced pge production caused by cp , was abrogated by co-treatment with either sr a or ns , illustrating that the cannabinoid action on prostaglandin production in fetal membranes is mediated by cb agonism and cox- . preliminary data from western blotting show that cannabinoid treatment results in the up-regulation of cox- expression. however, there was no change in cox- expression and no evidence either for up-regulation of cpla or for down-regulation of pgdh expression. conclusion: this study demonstrates a potential role for endocannabinoids in the modulation of prostaglandin production in late human pregnancy, with potentially important implications for the timing and progression of term and preterm labour and membrane rupture. inactivation of vegf receptor- , but not vegfr- or vegfr- , during the peri-implantation period prevents normal pregnancy development in the rodent through disruption of uterine angiogenesis. nataki c douglas, hongyan tang, raul gomez, bronislaw pytowski, daniel j hicklin, jan kitajewski, mark v sauer, ralf c zimmermann. division of reproductive endocrinology and infertility, columbia university, new york, ny, usa; imclone systems, inc., new york. objective: vegf is involved in the regulation of uterine angiogenesis and implantation in both rodents and non-human primates. vegfr- , r- , and r- are expressed in the uterine decidua and are involved in the regulation of vessel formation in many systems. to determine if these receptors have a functional role in the regulation of post-implantation angiogenesis and pregnancy development, we examined the effects of blocking vegfr- , r- , and r- function. design: prospective animal laboratory material and methods: to avoid effects of vegf receptor neutralization on ovarian function, we utilized a progesterone replaced, ovariectomized mouse model. vegf receptor blocking antibodies were administered on ed . , prior to embryonic expression of these receptors. embryonic development was evaluated on ed . , blood vessel density and apoptosis on ed . , and cellular proliferation on ed . (n= per time point in each group). anova with bonferroni correction was used to compare sample means. results: see tables. conclusions: neutralization of vegfr- and vegfr- , but not vegfr- resulted in a significant reduction in cellular proliferation and decidual angiogenesis. vegfr- mediates decidual angiogenesis, but is not required for normal pregnancy development. in contrast, an intact vegf/vegfr- pathway is required for the decidual angiogenesis that mediates early pregnancy development. effect of vegfr neutralization on ed . control anti r- anti r- anti r- no. of implantation sites . +/- . +/- . . +/- . . +/- . hoxa encodes a transcription factor required for endometrial receptivity and embryo implantation. our objective was to identify and to characterize those molecular markers regulated by hoxa in multiple cellular model-systems. using microarray technologies, we identified putative hoxa target genes involved in early implantation. liposome-mediated transfection delivering either empty vector or the same plasmid constitutively expressing hoxa was introduced into newly impregnated mice during laparotomy or layered onto cultured human endometrial stromal-cells (hescs). rna products from these in vivo and in vitro transfections were used to identify targets and to validate the microarray screen employing semi-quantitative real-time pcr (qrt-pcr). we identified statistically-significant genes regulated by hoxa overexpression of which genes were down-regulated greater than -fold when compared to controls. cellular ontogenies of differentially-expressed genes include: cell adhesion molecules, signal transduction factors as well as metabolic regulators. furthermore, we identified the -phosphoglycerate dehydrogenase gene, (pgdh) whose products are regulated by hoxa during implantation in both murine model systems in and cell culture. this genes codes for an enzyme critical to de novo l-serine biosynthesis via a phosphorylation-dependent pathway. microarray analysis demonstrated a fold expression decrease when hoxa is overexpressed. this diminution in pgdh expression was noted in the validation experiments using qrt-pcr and corroborated in hesc cells where the mrna levels decreased to % when compared to controls. the repression of pgdh during the implantation window may represent a conservation of activity as secretory-phase protein synthesis may be suppressed in order to promote cellular differentiation and resultant implantation. these regulatory relationships identified in mouse implantation likely function to enhance uterine receptivity and may have a role in human implantation. objective: hoxa is expressed in endometrium, where it is regulated by sex steroids and is necessary for endometrial receptivity and implantation. hoxa is also expressed in leukocytes. here we hypothesized that hoxa would be regulated by sex steroids in both cell types. we further hypothesized a correlation between expression of hoxa in peripheral blood cell (pbcs) and endometrium in both mice and in humans. methods: real-time pcr was used to determine differential expression of hoxa mrna in u cells, a monomyelocytic cell line, in response to increasing concentrations of estradiol. to determine if hoxa is expressed in leukocytes in vivo, peripheral leukocyte hoxa mrna expression was measured over sequential estrus cycles in mature cd nulliparous mice and correlated to vaginal smear-cytology. additionally, peripheral leukocytes were isolated either from pregnant or normally-cycling women to assess hoxa mrna expression. results: there was a direct, dose-responsive correlation between exposure to increasing estradiol and hoxa mrna expression levels in u cells. in a murine model, we demonstrated that hoxa mrna expression-levels varies throughout the estrus cycle with a marked increase in expression following vaginal plug detection. the nadir of hoxa expression is prior to proestrus and increased up to -fold during the receptive phase. this increased expression continues throughout gestation. the heightened expression in murine leukocytederived hoxa mrna also is demonstrated across species. our preliminary data suggests that the greatest fold-increase of expression occurs during the window of implantation of the secretory phase in normal, cycling women. this level was sustained in pregnancy. there appears to be a trend with the highest levels of expression associated with viable gestations. women with attenuated expression profiles had non-viable gestations. conclusions: hoxa expression is regulated by sex steroids in both leukocytes and endometrium. the temporal pattern of peripheral hoxa transcript expression demonstrated in mice and humans mimics the differential rna expression documented within the uterus. leukocyte hoxa expression during the reproductive cycle in mice and humans is a marker of endometrial receptivity. peripheral leukocyte expression of hoxa mrna may correlate with implantation success. carolien m boomsma, annemieke kavelaars, marinus jc eijkemans, gijs teklenburg, bart cjm fauser, cobi heijnen, nick s macklon. reproductive medicine and gynaecology and laboratory of psychoneuroimmunology, university medical center, utrecht, netherlands. the purpose of this study is to assess the association between the intra-uterine cytokine expression profile at the time of embryo transfer and successful embryo implantation following ivf/ icsi treatment. materials and methods women undergoing ivf/ icsi underwent endometrial secretion aspiration prior to embryo transfer. known soluble mediators of implantation were measured using a multiplex immunoassay, namely il ß, il , il , il , il , il , il , il , tnf , vegf, ifn , eotaxin, mcp- , ip- , dkk- and hbegf. mif was determined using an elisa. the total protein concentration was measured for normalization purposes. data were log transformed to obtain normal distribution. multivariable logistic regression analysis with a backward elimination procedure (p< . ) was used, potential confounders (age, blood contamination, embryo quality) were included in a forward stepwise model. ten mediators of the analysed were detectable in - % of the samples. il was detectable in % of samples, dkk- %, il- %, il- %, il- % and hbegf was detectable in % of samples. ifn-was not detectable in any of the samples. multivariable logistic regression showed only logmif concentrations to have a significant correlation with achieving clinical pregnancy (p = . ). higher mif concentrations were correlated with a higher chance of conceiving. endometrial secretion analysis represents a novel means of assessing the intra-uterine milieu encountered by the embryo and offers new perspectives in the study of endometrial receptivity. in this large prospective study assessing an array of cytokines, mif was found to be significantly correlated with pregnancy. mif, macrophage migration inhibitory factor, is a cytokine with numerous proinflammatory, immunomodulatory, angiogenic and tissue remodelling properties. mif induces the synthesis and secretion of matrix metalloproteinases by endometrial cells, which may contribute to embryo invasion. its expression is particularly increased during the secretory phase, suggesting a role in reproductive processes. analysis of aspirated endometrial secretions offers a direct clinical test of endometrial receptivity which can be applied during treatment cycles without disrupting implantation. endometrial receptivity and secretory differentiation require progesterone (p). it has been hypothesized that low p levels result in delayed endometrial differentiation and infertility due to reduced receptivity. objective: test the effects of low luteal p on histologic and molecular markers of differentiation and function. methods: normal cycling women (n= ) were treated with daily leuprolide ( . mg/d) beginning in the midluteal phase and continuing through the protocol. after menses, subjects received transdermal estradiol (e, . mg/d) for days. after day of e, subjects also received daily i.m. injections of p, randomized to mg/d (sub-physiological) or mg/d (physiological). endometrial biopsy was performed after days of combined e and p treatment. additional untreated women had biopsies performed days after spontaneous lh surge. endometrial histologic dating was performed by two individuals according to the criteria of noyes et al. mrna levels were assessed using real-time rt-pcr. results: mean(s.d.) of peak and trough p serum concentrations in the mg/d p group were . ( . ) and . ( . ) ng/dl, respectively, while those in the mg/d group were . ( . ) and . ( . ) ng/dl. there were no differences between treatment groups for histologic dating; the mean(s.d.) histologic date was . ( . ), . ( . ), and . ( . ) for the mg, mg, and spontaneous cycle groups, respectively. there also were no differences among the three groups in mrna levels of ten functional markers (er , pr, integrin subunit, osteopontin, cyr , egr- , fkb , c-fos, and cd ), although variability of gene expression was greater in those who received mg/d p than in those who received mg/d p. there was also no correlation between serum progesterone level and gene expression or histologic date. conclusions: sub-physiological levels of progesterone, in the range seen in ovulatory women, do not induce detectable changes in expression of marker genes or histological dating, although low p levels were associated with greater variability of gene expression. these data suggest that abnormalities in endometrial histologic development and function likely result from intrinsic abnormalities rather than from low levels of p secretion. (supported by unc nova carta fund and nih u hd- ). endometrial ip attracts trophectoderm through cxcr interaction. simcha yagel, caryn greenfield, hen sela, jacob hanna, irit manaster, orna singer, ronit haimov-kochman, shira natanson-yaron, diana prus, benjamin reubinoff, debra s goldman-wohl, ofer mandelboim. obstetrics and gynecology, hadassah-hebrew university medical centers, jerusalem, israel; lautenberg center for immunology, jerusalem, israel; human embryonic stem cell research center, jerusalem, israel. introduction: implantation is initiated in part by attraction of the blastocyst to the endometrium lining the uterus. we hypothesized that this process is partly accomplished by chemokines expressed by the endometrium interacting with chemokine receptors on the blastocyst, suggesting that they play an important role in implantation. materials and methods: chemokine receptors were characterized in jeg cells, placental villi, primary trophoblast cell culture, trophectoderm cells derived from human es cells, blastocyst trophectoderm, and st trimester placental tissue sections. expression of chemokines was tested in decidua, endometrium, and ishikawa and hec- cell lines. immunohistochemistry, intracellular staining, elisa, facs analysis, and rt-pcr were employed to characterize chemokine receptor and ligand expression. functional testing was performed using transwell migration assays and in a nude mouse model using a matrigel gel plug cell attraction assay followed by facs analysis. results: trophoblasts demonstrated expression of various chemokine receptors, most prominently cxcr and cxcr . immunohistochemistry of trophoblast from placental villi plated on matrigel expressed cxcr and cxcr as well as hla-g. noteworthy is that trophectoderm cells derived from hes cells treated with bmp- and jeg cells, and blastocyst trophectoderm expressed principally cxcr . elisa and immunohistochemistry showed that decidua and endometrium expressed chemokines ip and il . migration assays demonstrated that ip significantly attracted various trophoblast and trophectoderm cells in vitro, and in the mouse model in vivo. taken together these results demonstrate the interaction between trophoblasts and endometrial cells is mediated by cxcr and cxcr , and il and ip . these interactions are important in the attraction of trophoblasts at the feto-maternal interface. however, ip -cxcr is the most relevant to early implantation as only cxcr is expressed consistently by trophectoderm. the endometrial proteome: changes from proliferative to secretory phase. lois a salamonsen, jenny i-c chen, xian mak, peter j stanton, david m robertson, andrew n stephens. prince henry's institute of medical research, melbourne, vic, australia. global gene analyses have demonstrated major changes across the menstrual cycle, but which of these are reflected in the proteome is not known. this study aimed to globally assess proteins differentially expressed in the endometrium between the proliferative and. secretory phases. d page analysis with dige minimal dye labelling was conducted across the pi range - on endometrial tissue from either the mid-proliferative or midsecretory phases (n= /group). profiles were assessed using samespots software. differentially expressed proteins were identified using maldi-tof ms and the interrelationship of proteins examined using ingenuity software. a total of spots were detected: were differentially expressed (p < . ) with spots having an overall false discovery rate < % (q < . ). hierarchical clustering analysis revealed that these proteins lay within three main branches in the protein dendrogram. one cluster had proteins upregulated in the proliferative phase and two contained proteins up-regulated in the secretory phase. the unique protein profiles were also revealed using principle component analysis (pca): proteins clustered into two main groups, according to cycle phase. pca thus indicated similar unique protein signatures as suggested by hierarchical clustering. thirty one of the differentially expressed proteins were identified using maldi-tof ms. these proteins could be grouped into seven categories, which included structural ( ), transport ( ), regulatory ( ), membrane ( ), enzyme ( ), motor ( ) and others ( ). proteins involved in matrix assembly and those needed for subsequent establishment of secretory endometrium were up-regulated in proliferative endometrium. proteins important for cellular organisation and communication as well as products responding to environmental stress and the immune system were highly up-regulated during the secretory phase. biological pathways were constructed based on the proteins identified. the top network for secretory endometrium clustered around tgf-b. others related to inhibition of cell death / cell viability and leukocyte extravasation. these studies provide a global approach to the cyclic changes of the endometrium and highlight the complex dynamics of protein expression in human endometrium. hormonal regulation of prokineticins in the human fallopian tube: potential regulators of embryo transport. aw horne, hn jabbour, p lourenco, s wright, s battersby, arw williams, hod critchley. reproductive and developmental sciences, university of edinburgh, edinburgh, united kingdom; mrc human reproductive sciences unit, queen's medical research institute, edinburgh, united kingdom. background: understanding the factors regulating embryo transport in the fallopian tube (ft) has important clinical implications. embryo retention in the tube due to ft dysfunction is thought to lead to tubal pregnancy, a considerable cause of morbidity and occasional mortality. transport of the embryo through the ft is, for the greater part, accomplished by smooth muscle contraction. a group of multi-functional proteins and their receptors, called prokineticins, have been shown to affect smooth muscle function in other tissues, such as the intestine. the expression pattern of prokineticins, and their receptors, was examined in normal human ft obtained throughout the menstrual cycle, and the effect of the sex steroids on prokineticin expression was examined in an in-vitro model of the ft. methods: ft biopsies (n= ) and sera (for measurement of oestradiol and progesterone for endocrine staging) were collected from women undergoing gynaecological procedures for benign conditions. using a combination of quantitative taqman rt-pcr and immunohistochemistry, the mrna and protein expression pattern of prokineticins, and their receptors, were examined in the ft throughout the menstrual cycle. tubal explant culture was established using surgical tissue from the biopsies and exposed to varying concentrations, and time courses, of oestrogen and progesterone. results: prokineticin (pk ) and prokineticin receptor (pkr ) mrna are up-regulated in the progesterone-dominant mid-secretory phase. pk and pkr protein are expressed in the epithelium, smooth muscle and around the blood vessels of the ft. stimulation of tubal explant cultures with a physiological concentration of progesterone showed an up-regulation of pk and pkr . conclusions: prokineticins show temporal variation in expression in human ft and appear to be regulated by progesterone. their role in embryo transport needs to be investigated to further understanding of pregnancy complications, such as tubal pregnancy. translating mouse to human: a dynamic model of xenografted human endometrium. alex j polotsky, liyin zhu, nanette santoro, jeffrey w pollard. albert einstein college of medicine, bronx, ny, usa. in the mouse endometrium, the hormonal environment controls cellular proliferation and cell cycle activity. estradiol (e ) inhibits glycogen synthase kinase beta (gsk- ), resulting in nuclear accumulation of cyclin d and progression of the cell cycle, as well as dna replication licensing. in utero administration of the gsk- inhibitor, licl, results in epithelial cell proliferation in the absence of e (zhu, pollard. pnas. ; : ) . in this study, we derived a functional model of xenografted human endometrium to perform mechanistic studies of human endometrial proliferation. methods: human endometrial samples were obtained from volunteers aged - . immuno-compromised mice were transplanted with disaggregated/ recombined human epithelial glands and stroma under the kidney capsule. after weeks of out-growth, mice were ovariectomized, and replaced with e or licl. xenografts were harvested and processed for immunohistochemistry (ihc) and glandular labeling index (li). t test was used to compare group means. results: - % of engraftments were successful, resulting in a vascularized endometrium with characteristic architecture (a, b). hoechst staining confirmed that xenografts were made up of human cells ©. e (e) induced significantly greater proliferation compared to control (d) as assessed by ihc for ki , with li of . ± . and . ± . , respectively, p = . ). minichromosome maintenance- , a protein involved in dna replication licensing, was more sensitive for e -treated cells synthesizing dna than was ki staining (i). estrogen (g) and progesterone receptors (h) were expressed in xenotransplant tissue, the latter being up-regulated by e . licl (f) induced proliferation similar to e and greater than control (li = . ± . , p= . for e vs. licl). conclusion: xenografted human endometrium provides a dynamic model of endometrial proliferation that is well suited for translational studies. administration of licl in the absence of e induced glandular proliferation, supporting the notion that similar mechanisms are operative in human proliferation as in the mouse. gnrh analogs have been extensively used in assisted reproduction. although the main effects of gnrh analogs are via gnrh receptors on the pituitary gonadotrope, gnrh and gnrh receptors have been identified in many reproductive tissues including human endometrium, suggesting their potential action at endometrial level. in the present study, we examined the potential regulatory action of gnrha, la on sex steroid mediated gene expression in human endometrium. human endometrial surface epithelial (hes) cells and isolated endometrial stromal (esc) cells were used as in vitro models. all experiments lasted for h. the cells were treated with estradiol (e , nm, h), progesterone (p , nm, h), gnrha (la μm, h), e ( h) followed by p (last h) and gnrha plus e plus p where, gnrha added either first, second or last in order at h intervals. total rna was extracted, reversed-transcribed and subjected to real-time pcr simultaneously, measuring the expressions of il- , il- , il- , il- , il- , il- , il- , il- p , il- p , il- , ifn-and tnf . both hes and esc expressed majority of these cytokines with the exception of low to undetectable levels of il- , il- , il- and ifn-. treatment with e and p , either alone, or in combination significantly upregulated the expression of many of these cytokines at varying extend as compared to controls. however, gnrha either alone or in combination with e and p significantly diminished e , p or e plus p induced mrna expression of cytokines. the suppressive effects of gnrha on some of the cytokines varied significantly by the order which gnrha was introduced into the culture medium. we conclude that gnrha by acting directly on the endometrial cells effectively suppresses the mrna expression of several key proinflammatory cytokines upregulated by ovarian steroids. our results imply that gnrha therapy during assisted reproduction may modify endometrial receptivity via downregulation of proinflammatory cytokines induced by estradiol and progesterone. supported by nih grant hd . introduction: endometrial angiogenesis is characterized by a rapid increase during the early proliferative phase that peaks midcycle, followed by a gradual decrease in the secretory phase, while menses involves generalized endometrial inflammation, necrosis, and vascular thrombosis. vascular endothelial growth factor (vegf), whose expression is regulated by sex steroids, is a mediator of endometrial angiogenesis. recently, myoferlin, a kd transmembrane protein, was identified in endothelial cells where it mediates vegf-dependent endothelial cell proliferation, migration, and nitric oxide synthesis by affecting vegf receptor- function and stability. myoferlin also appears to play a role in vesicle trafficking and membrane repair. objective: to characterize myoferlin protein expression in endometrium. methods: western analysis of cultured human endometrial stromal cells (hesc) and human endometrial endothelial cells (heec) treated with physiologic concentrations of estradiol and progesterone was performed using a polyclonal rabbit antibody against myoferlin. subsequently, immunohistochemistry (ihc) was performed on human endometrium samples obtained from various stages of the menstrual cycle. results: myoferlin protein was expressed in hescs and heecs, but expression was not affected by sex steroids. ihc staining for myoferlin was specific, intense, and localized to the apical membrane of glandular epithelial cells and endothelial cells, with less intense staining in the stroma. h-score quantification showed that in endometrial endothelial cells, myoferlin protein expression was highest during the early proliferative and early secretory phases, while glandular and stromal myoferlin expression peaked during the late proliferative/early secretory phase. conclusion: myoferlin expression in human endometrium correlates with periods of greatest endometrial angiogenesis, and expression is not limited to endothelial cells, but also includes glandular and stromal cells. given the involvement of myoferlin in vegf signaling as well as membrane repair, understanding its role in human endometrium may further elucidate an understanding of endometrial development both under physiologic and pathologic conditions. the human embryo is the primary regulator of embryo-endometrial molecular cross talk during early implantation. gijs teklenburg, , cobi heijnen, esther baart, karima amarouchi, carolien boomsma, janet carver, helen mardon, annemieke kavelaars, nick macklon. reproductive medicine and gynaecology, and laboratory of psychoneuroimmunology, university medical center, utrecht, netherlands; nuffield department of obstetrics and gynaecology, university of oxford, women's centre, john radcliffe hospital, oxford, united kingdom. introduction: uterine receptivity and implantation are controlled by locally acting trophic factors and cytokines. in humans, the regulation of the embryo-endometrial dialogue beyond the early blastocyst stage is poorly understood. we hypothesized that the interaction between a healthy conceptus and the receptive endometrium is associated with a distinct local regulation of cytokine production favouring implantation. methods: human embryos, cryopreserved at day after fertilization and donated for research, were thawed and cultured under standard conditions until day five. forty-two embryos from donors developed to the blastocyst stage. following removal of the zona pellucida, they were placed in individual coculture on a confluent monolayer of endometrial stromal cells. on day , the developmental potential of each embryo was assessed as early arrested, late arrested or developing. culture supernatants were analysed for concentrations of il- , il- , il- , il- , il- , il- , il- , il- , tnf-, mcp- , ip- , eotaxin and hb-egf using a multiplex immunoassay. day supernatants from culture systems in which no embryo had been placed were also analysed as controls. results: out of ( %) embryos continued to develop and were able to attach and invade into the stromal cell compartment of the co-culture environment. twelve late arrested embryos showed signs of degradation on day and the totally disintegrated embryos were assigned to the early arrested group. supernatants from both early and late arrested embryo cultures contained significantly lower levels of a number of cytokines and growth factors in comparison to developing embryo cultures. moreover, the levels of these mediators in co-cultures were significantly lower than those in non-embryo control stromal cell culture supernatants. conclusion: these data suggest a pivotal role of the embryo in embryoendometrial cross talk. whether reduced mediator expression in co-cultures reflects a selective down regulation of stromal cell cytokine and growth factor production is now being investigated. epithelial cell dynamics during human implantation. hiroshi uchida, tetsuo maruyama, toru arase, masanori ono, takashi kajitani, maki kagami, hideyuku oda, sayaka nishikawa, yasunori yoshimura. department of obstetrics and gynecology, keio university school of medicine, shinjuku, tokyo, japan. epithelio-mesenchymal transition (emt) is thought to play a role in functional differentiation of endometrial epithelial cells during human implantation. molecular mechanism of epithelial sheet remodeling caused by embryo invasion remains elusive. to address this, we investigated cellular dynamics of n-cadherin and vimentin, the two representative major markers of emt, during implantation. in in vitro implantation assay using a human endometrial epithelial cell line, ishikawa, and a human choriocarcinoma cell line, jar (uchida et al., hum reprod ), we pre-treated human ishikawa cells with or without ovarian steroid hormones ( -estradiol + progesterone; ep), fa- (n-cadherin blocking ab), or suberoylanilide hydroxamic acid (saha), one of histone deacetylase inhibitors, which has a potential to improve in vitro implantation (ibid). implantation or treatment with or without ep or saha enhanced the expression of n-cadherin and vimentin but down-regulated ecadherin. furthermore, treatment with ep or saha accelerated ishikawa cell motility and increased the number and spreading area of jar spheroids. in vitro implantation assay, the most prominent staining intensity of n-cadherin was observed just around the adhered spheroid from which its intensity decreased away. functional blockade of n-cadherin by fa- resulted in the complete suppression of ishikawa cell motility, the unique distribution of n-cadherin around jar spheroids, and the spreading area of jar spheroids, while it did not affect the number of the adhered spheroids. human implantation consists of the multiple steps, including apposition, adhesion and penetration. thus, these results collectively indicate that emt may take place after the apposition and that n-cadherin may be required for the remodeling and emt of the epithelial sheet during embryo invasion. n-cadherin may enhance the recruitment of spheroid-neighboring cells, suggesting its role in the covering-up of the invading embryo through acceleration of epithelial cell motility. endocannabinoid regulation in human endometrium. jessica g scotchie, marc a fritz, steven l young. obstetrics and gynecology, university of north carolina, chapel hill, nc, usa. background: research in mouse models demonstrates two cyclically regulated endocannabinoids produced in murine endometrium, anandamide and -arachidonoyl glycerol ( -ag); both play critical roles in murine embryonic implantation. no studies of endocannabinoids in human endometrium have been performed. objectives: determine menstrual cycle expression and localization of synthetic and degradative enzymes for anandamide and ag in human endometrium. methods: human endometrium was collected from volunteers across the menstrual cycle (n= ). quantitative rt-pcr was performed analyzing the expression of: n-acylphosphatidylethanolamine (nape) and fatty acid amide hydrolase (faah), the synthetic and degradative enzymes for anandamide, respectively; sn- -diacylglycerol lipase-a (dagla), and b (daglb), the synthesis enzymes for ag; and monoacylglycerol lipase (magl) and cyclooxygenase- (cox ), the degradative enzymes for ag. the constitutive gene ppia was used for comparison. immunohistochemical localization of nape protein was performed using nape-pld polyclonal antibody (cayman chemical, # ). anova and student's t-test analysis performed on samples grouped by proliferative (pro), early, mid-, and late secretory (es, ms, ls) phases. results: mrna expression of all enzymes responsible for synthesis and degradation of anandamide and ag was detected throughout the cycle. no significant cyclic change in nape, faah, or daglb gene expression was seen. a decrease in dagla gene expression in the ms and ls phases compared to the pro and es phases (p= . ) was seen. magl gene expression was higher in the secretory phase than the pro phase (p= . ). cox gene expression was detected at low levels in the pro, es and ms phases, with marked increase in the ls phase (p< . for all comparisons). protein localization of nape showed a cytoplasmic epithelial location, with increased staining on pro and es samples compared to ms and ls samples. immunolocalization of remaining proteins is ongoing. conclusion: this is the first report documenting the presence of endocannabinoid synthetic and degradative enzymes in human endometrium. genes controlling anandamide expression do not fluctuate significantly across the cycle. however, ag's degradative enzymes increase in the secretory phase, suggesting that lower ag levels may be advantageous for embryo implantation. our findings suggest that human endometrial endocannabinoid regulation differs from murine regulation. interleukin- beta (il- ) regulates il- signaling in decidua-implication in the pathophysiology of preeclampsia (pe). sj huang, cf yen, cp chen, f schatz, cj lockwood. obstetrics, gynecology and reproductive sciences, yale university, new haven, ct, usa; ob/gyn, chang gung memorial hospital, tao-yuan, taiwan; ob/gyn, mackay memorial hospital, taipei, taiwan. objective: previously, we found much higher cytoplasmic immunoreactive il- levels in the preeclamptic decidual cells than in adjacent interstitial trophoblasts. such decidual cell-derived il- contributes to the systemic endothelial cell dysfunction that elicits the proteinuria and hypertension of the maternal syndrome. il- promotes the transition from innate to adaptive immunity. moreover, by skewing monocyte differentiation from a dendritic to a macrophage phenotype, decidual il- may promote the macrophage excess observed in the preeclamptic decidua. macrophages impair trophoblast decidual invasion to foster incomplete spiral artery remodeling that elicits placental ischemia and hypoxia. the current study: ) localized il- mrna levels in preeclamptic versus normal decidual sections; ) evaluated mechanisms regulating il- synthesis by targeting intracellular signaling pathways with specific inhibitors; ) identified potential il- targets by immunolocalizing the il- receptor (il- r) to specific cell types in placental bed biopsies. methods: in situ hybridization localized il- mrna in normal versus preeclamptic decidua. il- r was immunolocalized in placental bed biopsies. leukocyte-free first trimester decidual cells were incubated with e and mpa ± il- ( ng/ml) ± an inhibitor of p mapk (sb ) or protein kinase c (calphostin c) or nf b (activation inhibitor iii) for hrs. an elisa measured secreted il- levels. results: il- mrna was present primarily in decidual cells with increased il- mrna levels observed in pe. preferential expression of the il- r was observed on decidual cells in placental bed biopsies. compared with basal il- levels ( . ± . pg/ml/ g cell protein) by decidual cells, il- enhanced il- output by decidual cells ( . ± . pg/ml/ g cell protein). only the p mapk inhibitor significantly reduced this output to . ± . pg/ml/ g cell protein (n= , p< . ). our results indicate that inflammatory cytokine enhances il- synthesis in decidual cells of the preeclamptic decidua by a mechanism involving p mapk. such il- is likely to act as an autocrine/paracrine effector via decidual cell-expressed il- r to contribute to the macrophage excess observed in the preeclamptic decidua. heparanase is up-regulated by estrogen and during the secretory phase of the human endometrium. ronit haimov-kochman, shira natanson-yaron, caryn greenfield, achinoam lev-sagie, lichtenstein michal, haya lorberboum-galsky, israel vlodavsky, simcha yagel, arye hurwitz. ob/ gyn, jerusalem, israel; cellular biochemistry human genetics, hadassah hebrew university medical centers, jerusalem, israel; cancer and vascular biology research center, technion school of medicine, haifa, israel. introduction: heparanase is an endoglycosidase that cleaves heparan sulfate (hs) proteoglycan of the extracellular matrix. the full-length proheparanase is activated by cleavage into an active isoenzyme, resulting in the release of hsbound cell-differentiation factors, such as hb-egf. the cycling endometrium involves remarkable steroid hormone-induced tissue remodeling. in vivo, increasing exposure to unopposed estrogen may lead to endometrial malignant transformation. aim: to investigate heparanase expression and regulation in the cycling endometrium. materials and methods: heparanase mrna levels were measured by quatitative rt-pcr in naturally menstruating women and in hec a, estrogen receptor (er)-negative and ishikawa, er-positive endometrial carcinoma cell lines exposed to increasing doses of estradiol. heparanase isoenzymes were localized by immunohistochemistry using specific anitbodies in murine endometrium and human normal, hyperplastic and malignant endometrium. results: heparanase mrna level increased fold in secretory phase (d ) compared to proliferative phase (d ) endometrium. heparanase transcript levels increased fold during hr culture in er positive adenocarcinoma cell line exposed to increasing doses of estradiol, but not in hec a, er negative cell line. both heparanase isoforms were localized to murine glandular endometrium. human glandular endometrium at both proliferative and secretory phases was immunoreactive with the active isoform of heparanase. proheparanase was detected in basal membrane of endometrial glands and endometrial stroma during secretory phase. along with malignant transformation of the endometrium the presence of proheparanase increased dramatically from none in stroma of normal and hyperplastic endometrium to abundance in malignant tumors. conclusions: heparanase gene expression is higher during the window of implantation and up-regulated with estrogen in endometrial cells via er in vitro and vivo. heparanase is differentially localized in the secretory phase of the endometrium compared to the proliferative phase, suggesting a role for this molecule during the window of implantation in man. interleukin- (il- ) system mrna and protein expression in the human fallopian tube with ectopic implantation. hong-yuan huang, , tien-hung huang, chin-jung li, chyi-long lee, , hsin-shih wang, , yung-kuei soong. , obstetrics and gynecology, chang gung memorial hospital, kwei-shan, tao-yuan, taiwan; obstetrics and gynecology, chang gung university and school of medicine, kwei-shan, tao-yuan, taiwan. objective: ectopic pregnancy, an abnormal implantation of a fertilized ovum outside the uterine cavity, has been increasing in number at a staggering pace of all pregnancies. il- system is one of the major cytokines involved in human endometrium during embryo implantation and might perform a defensive role against maternal immune response. very little information is available regarding the expression and synthesis of cytokines in the pathogenesis of fallopian tube with ectopic gestation. the purpose of this study is to investigate il- system expression in human fallopian tubes with ectopic pregnancy. methods: paired segments of human fallopian tubes with ectopic implantation site and side portion close to ectopic gestation (n= ) were collected from women undergoing laparoscopic salpingectomy after informed consent and irb approval. segments of fallopian tubes from women undergoing tubal ligation (n= ) were used as control groups. total extracted rna was reverse transcribed and amplified by pcr using specific primers for gapdh ( bp), il- ( bp), il- bp ( bp) and il- r ( bp). quantitative il- and il- bp mrna expression in human fallopian tube was determined by real-time pcr. to determine the presence of il- system proteins, tissues were fixed and processed for immunohistochemical study. data analysis was done with anova and pearson's correlation. results: il- and il- bp as well as il- r mrna were all expressed in tubal ectopic implantation and normal tubes. according to real-time pcr with c t value quantification and -ct method, a significantly higher il- expression in tubal ectopic implantation and lower ratio of il- antagonist to agonist in portion close to ectopic implantation is demonstrated in comparison to normal tubes (p< . ). immunoreactive il- system at the protein levels was also present in human fallopian tubes with ectopic implantation and normal tubes. conclusions: these results suggest that fallopian tube il- system expression may play a crucial role during the process of early embryonic implantation. the expression and ratio of antagonist to agonist in fallopian tubes may indicate an earlier "dialogue " in human fallopian tubal gestation prior to uterine implantation. replacement. marcia c ferreira, ines kd cavallo, fernando m reis. gynecology, ufmg, belo horizonte, mg, brazil. activin a is a growth factor expressed in the endometrium, where it modulates tissue remodelling and enhances decidualization. the effects of activin a are counteracted by two binding proteins, namely follistatin and follistatin-like (fstl ). while the endometrial expression of activin a increases during the secretory phase of menstrual cycle, the effects of ovarian steroids on these proteins and their mrnas has not been assessed yet in postmenopausal women or in ovariectomized animals. we have evaluated the effects of estrogen alone or estrogen plus progestin on the endometrial expression of activin beta-a subunit, follistatin and fstl in ovariectomized rats. adult female wistar rats (n= ) were ovariectomized and received one week later a single dose of estradiol benzoate ( . mg/kg body weight, i.m. injection), either alone (n= ) or associated with depot medroxyprogesterone acetate ( . mg/kg body weight, i.m. injection, n= ), or oil vehicle (control group, n= ). one week after the hormone or placebo treatment, the animals were sacrificed and their uteri were removed and processed by immunohistochemistry and real-time pcr. data were normalized to the expression of ribosomal phosphoprotein p (rpp ) and analyzed with the delta-delta ct method, anova and newman-keuls test. activin beta-a subunit mrna levels increased significantly in the uteri of rats treated with estradiol alone ( . fold increase over controls, p< . ) and to the same extent in rats receiving estradiol plus medroxyprogesterone ( . fold increase over controls, p< . ). this was accompanied by increase of beta-a subunit immunostaining in estradiol and estroprogestin-treated rats, which was noted only in the surface endometrial epithelium. follistatin mrna expression, conversely, showed a significant decrease in the groups treated with estrogen alone ( . fold compared to controls, p< . ) and estrogen plus progestin ( . fold compared to controls, p< . ), while follistatin immunostaining in the glandular epithelium was weaker in estradiol and estroprotestin-treated rats compared to controls. fstl expression was similar in the groups. in conclusion, the expression of activin beta-a subunit increases and that of follistatin decreases following estrogen replacement in the endometrium of ovariectomized rats, and these effects are not further altered by the addition of progestin. endometrial nk cells are a unique inert nk subset until pregnancy. simcha yagel, irit manaster, jacob hanna, ronit haimov-kochman, miri godin, yuval bdolach, caryn greenfield, shira natanson-yaron, arye hurwitz, debra s goldman-wohl, ofer mandelboim. obstetrics and gynecology, hadassah-hebrew university medical center, jerusalem, israel; lautenberg center for tumor immunology, hadassah-hebrew university medical center, jerusalem, israel. introduction: we recently demonstrated that nk (natural killer) cells play a critical role in trophoblast migration and angiogenesis at the fetal maternal interface. nk cells populate the endometrium at the secretory phase of the menstrual cycle, the time of anticipated blastocyst implantation. peripheral blood (pb) nk cells and decidual nk (dnk) cells express a variety of activating receptors, including nkp , nkp and nkp , collectively known as natural cytotoxicity receptors (ncrs), and nkg d which regulate nk cell killing and growth factor production. to compare endometrial nk cell (enk) activating receptor expression and function to pbnk and dnk cells and endometrial ligand expression, with a focus on their roles in blastocyst implantation. patients and methods: subjects were ivf patients undergoing natural menstrual cycles. endometrium samples were collected on treatment days and . a lymphocyte profile of the endometrial cells and pb was performed. facs analysis was performed on isolated endometrial nk cells, pbnk cells and dnk cells for cd , cd , nkp , nkp , nkp and nkg d. ncr ligand expression was characterized on adherent endometrial cells using ncr-ig fusion proteins and nkgd -ig and nkg d specific ligands as well as control ccmi-ig. redirected killing assays and cytokine secretion assays of ifn , vegf, plgf, and il- with and without il- were performed. results: endometrial lymphocytes of day and in these women are mostly cd bright cd -nk cells, with a significant amount of t cells, similar to pbnk cells and in marked contrast to dnk cells. unlike pbnk and dnk cells, enk receptors do not express nkp , nkp . nkp and nkg d are the only activating enk receptor expressed. like decidual cells, adherent stromal endometrial cells expressed the ligands for nkp , nkp and nkg d, suggesting that these nk cells have potential for activation. finally enk cells could not kill or secrete cytokines. conclusions: these findings of a unique activating receptor profile on endometrial nk cells, unlike that of dnk and pbnk, suggest that enk cells are a special local population of nk cells that change dramatically and are activated at the onset of pregnancy. variation in platelet activation throughout the menstrual cycle. fiona c denison, amy o robb, imogen b smith, nicholas l mills, hilary od critchley, david e newby. centre for reproductive biology; centre for cardiovascular sciences, the university of edinburgh, united kingdom. background: platelet-monocyte aggregation (pma) is a sensitive and novel measure of platelet activation with important proinflammatory consequences including release of cytokines and chemokines. previous studies using less sensitive techniques suggest that platelet activation alters during the menstrual cycle in response to circulating concentrations of sex steroids. the effect of sex steroids on circulating (c) pmas during a single menstrual cycle is not known. objective: to determine whether cpmas, platelet surface (ps) p-selectin and plasma (p) p-selectin vary through the menstrual cycle in response to changes in circulating sex steroid concentrations. methods: healthy, nulliparous, pre-menopausal, non-smoking women (mean age years), with regular menses ( - days) were studied. subjects gave written informed consent and the study had ethical approval. serial venous blood samples were taken at menstrual, follicular, periovulatory and luteal phases of a single cycle (days - , - , - and - ). cpmas (monocytes positive for the platelet marker cd a) were measured by flow-cytometry. psp-selectin expression was calculated on cd a positive cells. isotype-matched controls were used. serum oestradiol (e) and progesterone (p), plasma and pp-selectin were measured by elisas. data were analysed by one-way anova with repeated measures and bonferroni's post-tests for multiple comparisons. results: luteal phase p was > nmol/l in all women. numbers of cpmas and expression of psp-selectin were both significantly higher during menstrual compared with periovulatory phase of the menstrual cycle ( . ± . vs. . ± . %, p= . and . ± . vs . ± . %, p< . , respectively). there was no significant difference in pp-selectin concentration during the menstrual cycle (p= . ). there was no correlation between levels of serum e or p and numbers of cpmas, expression of psp-selectin or pp-selectin concentration. conclusions: numbers of cpmas and expression of pspselectin are maximal at menstruation with neither numbers of cpmas nor expression of psp-selectin correlating with serum e or p levels. this study suggests that activated platelets may potentially contribute to the inflammatory response at menstruation by releasing inflammatory mediators. by angiogenic factors and peri-cellular proteases in decidual secretory endometrium (dse), decidua parietalis (dp), and basalis (db) of miscarriage patients and matched controls. comparison of these parameters between the two groups enabled hypothesizing about their correlation with the occurrence of miscarriages. methods: decidua was obtained during st trimester termination of pregnancy (control group) and vacuum aspiration of missed abortions (case group). vascularization was studied by cd -immunohistochemistry. the expression of vascular endothelial growth factor-a, placental growth factor, flt- , kdr, angiopoietin- , angiopoietin- , tie- and the membrane-type matrix metalloproteinases mt -, mt -, mt -and mt -mmp were determined at mrna and antigen level and cd -positive unk cells, cd -positive macrophages, proliferation (ki ) and apoptosis (activated caspase- ) were evaluated by immunohistochemistry in consecutive serial sections. results: the decidual vascularization pattern showed differences between cases and controls: i.e. fewer vessels with larger circumference in cases, and this correlated with the differential expression of various angiogenic factors and proteases at mrna and antigen level. moreover, the endothelial protein expression of flt , kdr, mt -and mt -mmp was increased at the implantation site of cases. ki and active caspase- showed similar levels in the two groups and also the immune cells, both unk cells and macrophages, showed no differences at the implantation site between both groups. conclusion: differences between cases and controls appeared not to be based on altered proliferation, apoptosis, and/or inflammation. the differences in vascularization pattern and in the expression of angiogenic factors and proteases between both study groups suggest a correlation between decidual vascularization and the occurrence of miscarriages. respond to adrenomedullin. yaun-lin dong, hong y wen, janice endsley, alison hogg, hui-qun wang, manubai nagamani, chandra yallampalli. background: natural killer (nk) cells are the predominant lymphocytes present in human implantation site. decidual nk cells express perforin, an essential molecule required for lysis. formation of the placenta involves cooperation between maternal nk cells and fetal trophoblast cells that remodels the blood supply; however, the interaction between trophoblasts and decidual nk cells is largely unknown. adrenomedullin (adm) has been implicated in regulating early placental function and fetal growth. objective: to determine the role of multifunctional peptide adm in the decidual nk cells and fetal trophoblast cells interactions. methods: decidual and placental tissues were obtained from normal firsttrimester pregnancies terminated for social reasons. ethical approval to use these tissues was obtained from the irb of university of texas medical branch. cell preparations containing all decidual mononuclear cells were isolated by collagenase enzymatic disaggregation. cd decidual nk cells were purified by magnetic bead isolation. results: ) immunohistochemical analysis showed that adm is expressed primarily in decidual cells and trophoblast cells at the human implantation site; ) confocal imaging analysis demonstrated that decidual nk cells, which were identified by anti-cd staining, express adm receptor components crlr/ramp /ramp and their mrna expressions were futher confirmed by rt-pcr; ) k target cell killing assay indicates that adm inhibits cytokine il- /il- -induced decidual nk cell cytotoxicity; and ) immunofluorescent labeling and flow cytometric analysis revealed that adm suppresses perforin expression by decidual nk cells. conclusion: trophoblast-derived adm inhibits decidual nk cell cytotoxicity via suppressing perforin expression, thus, our results provide evidence for a new paradigm of embryonic-maternal communication involving a adm mediated interaction between decidual nk cells and fetal trophoblasts. leandro g oliveira, gendie e lash, judith n bulmer, barbara a innes, roger f searle, stephen c robson. institute of cellular medicine, newcastle university, newcastle upon tyne, tyne and wear, united kingdom. background: we have previously demonstrated that co-culture with extravillous trophoblast cells (evt) (expressing hla-g) alters cytokine secretion by uterine natural killer (unk) cells, particularly at - weeks gestation. we have also reported that unk cells can stimulate evt invasion, but only at - weeks gestation (not at - weeks gestation). in addition, unk cell cytokine profiles alter with increasing gestational age. other reports have suggested that evt or hla-g expressing cells may alter the expression of cytokines and angiogenic growth factors by unk cells. hypothesis: hla-g expressing cells alters unk secretion of cytokines. methods: cd + unk cells were isolated from early pregnancy decidua ( - and - weeks gestation, n= each group) using enzyme digestion and positive immunomagnetic bead separation. the human b lymphoblastoid . transfected with either hla-g ( g) or a mock cdna ( cdna) were obtained as a kind gift from mr r apps (university of cambridge, uk). isolated unk cells were cultured in the presence or absence of the two cell lines in either direct or indirect contact (n= each group and each gestational age) for hours. cell supernatants were analysed for cytokines using a fastquant® th /th multiplex protein assay (il- , il- , il- , il- , il- , tnf-, il- , il- , ifn-) or by standard elisa (tgf- ). the effect of direct co-culture of unk cells with g compared with co-culture with cdna at each gestational age was tested using mann whitney u test. the effect of co-culture of unk cells with g in both direct and indirect contact was also tested using mann whitney u test. results: there was no difference in the level of cytokines secreted by the g or cdna cells. cytokine secretion by unk cells was not altered after direct co-culture with either g or cdna cells at either gestational age. in addition, direct or indirect co-culture of g or cdna with unk did not alter cytokine secretion at either gestional age. conclusions: hla-g does not alter the secretion of cytokines by unk cells from either - or - weeks gestation. other evt or decidua derived factors (including hla-e) may be responsible for the alteration in secretion of cytokines by unks with increasing gestational age. introduction: natural killer (nk) lymphocytes are central to innate immunity and contribute to tissue homeostasis by eliminating altered cells. their nkg d receptor pathway plays a fundamental role in target elimination through binding nkg d ligands on the cell surface. reduction in the nkg d ligand, ulbp , expression is associated with immune resistance in neoplastic processes. we have previously shown that fibroblasts from adhesion tissue (at) are characterized by increased extracellular matrix molecules and inflammatory cytokines compared with normal peritoneal (np) fibroblasts. objective: to determine if there is a difference in nk lymphocyte-mediated elimination between np and at fibroblasts and to investigate potential role of nkg d pathway in this process. material and methods: expression of nkg d ligands; ulbp , ulbp , mica, and micb was evaluated by flow cytometry and western blot in primary cell cultures of fibroblasts from np and at, established from two patients. peripheral blood nk lymphocytes (cd +cd -) from three healthy volunteers were isolated using macs system with purity greater than % and kept in interleukin overnight. fibroblast elimination with and without ulbp blocking was investigated following -hour co-incubation with allogeneic nk lymphocytes using our established flow cytometric cell mediated cytotoxicity assay. paired t test was used in statistical analysis. results: the flow cytometry studies showed that nkg d ligands (ulbp , ulbp , mica and micb) were lower in at compared to np fibroblasts, reaching a statistical significance in ulbp expression (p = . ). western blot analysis also revealed a lower ulbp protein level in at than np fibroblasts. furthermore, nk lymphocyte-mediated elimination was % lower in at in comparison with np fibroblasts. blocking ulbp expression resulted in decreased nk lymphocyte-mediated np fibroblast elimination by %, supporting the role of nkg d receptor pathway in the process. conclusions: our results demonstrate that nkg d pathway is operational in at fibroblast resistance to immune elimination, and extends our prior observations of the potential role of immunological mechanisms in the pathogenesis of adhesion development. objective: galectin- is an anti-inflammatory lectin that has pleiotropic regulatory functions at the crossroad of innate and adaptive immunity. human galectin- is expressed in the placenta and immune privileged sites and it has been implicated in establishing immune tolerance. the aim of this study was to examine the evolution and placental expression of the lgals gene in primates. methods: seven primate nucleotide sequences were generated, aligned to vertebrate orthologs from all classes and subjected to phylogenetic analysis. deduced amino acid sequences were analyzed for functionally important substitutions. placental galectin- expression was studied by immunohistochemistry and western blot. results: ) the lgals gene had high sequence identity among all investigated species. ) phylogenetic analysis revealed that intense purifying selection had been acting on the lgals gene in placental mammals (dn/ds= . ); ) residues responsible for sugar binding or molecule stabilizing were highly conserved in primates. ) immunostaining showed a uniformly abundant and ubiquitous galectin- expression pattern in human, old and new world monkey and prosimian placentas, regardless the type of placentation. the lgals gene has conserved sequence and placental expression pattern in primates that may suggest its important function in maternal-fetal immune interactions. these results support the view that immune interactions at the maternal-fetal interface evolved in concert with invasive placentation and that these interactions have been maintained regardless of the degree of placental invasion in primates and other mammals. expression of interleukin- in human endometrium throughout the menstrual cycle and early pregnancy. yesim h uz, , william murk, umit a kayisli, aydin arici. department of obstetrics, gynecology and reproductive sciences, yale university school of medicine, new haven, ct, usa; department of histology and embryology, trakya university school of medicine, edirne, turkey. background: interleukin- (il- ) is a recently discovered heterodimeric cytokine, comprised by a novel p subunit and a p subunit shared by il- . it has biological activities that are similar to but distinct from il- , and is known to be involved in th /th cell class switching and the regulation of cytokines such as ifn-gamma, il- , tnf-alpha, and il- . early pregnancy is associated with alterations in the maternal immune response, such as changes in cytokine expression, and leukocyte recruitment and subtype switching. we hypothesized that expression of il- in the human endometrium is menstrual cycle-and pregnancy-dependent. materials and methods: endometrial samples from women (n= ) undergoing surgery for benign gynecologic conditions, and decidual tissues from women (n= ) with clinically normal pregnancies terminated voluntarily in the first trimester, were obtained after receiving informed consent. endometrial samples were grouped according to menstrual phase. paraffin sections were stained with il- p antibodies and evaluated semi-quantitatively with hscore. statistical analysis of the data was done using anova, with p< . considered significant. results: il- immunoreactivity was predominantly located in the cytoplasm of both endometrial stromal (esc) and glandular (egc) cells. escs showed mild il- immunoreactivity without significant changes in intensity throughout the menstrual cycle. on the other hand, first trimester decidual cells showed significantly stronger il- staining compared to escs from non-pregnant endometrium (p< . ). il- immunoreactivity in egcs was high in the late proliferative phase, as compared to other cycle phases and first trimester tissues (p< . ). moreover, egcs from the early secretory phase (p< . ) and first trimester tissues (p< . ) showed higher il- immunoreactivity compared to the early proliferative and late secretory phases. conclusions: this is the first study describing il- expression in the human endometrium and decidua. these results suggest that il- has a cycledependent expression in endometrial cells and may be involved in regulating cytokine expression and immune cell modulation during the menstrual cycle and early pregnancy. gercel-taylor, douglas d taylor. obstetrics, gynecology, and women's health, university of louisville, louisville, ky, usa. objective: estrogen appears appear to be a critical regulator of the immune system. since hypoestrogenism is present in the postmenopausal woman, our objective was to determine whether t cell activation and function, defined as il- production and signaling molecule expressions at the transcriptional and translational levels, were affected by a low estrogen environment. design: prospective study in a university research laboratory. materials and methods: jurkat . t cells, initially grown in estrogen free media, were incubated in pm (representing postmenopausal levels) or pm (premenopausal levels) of estradiol (e ) for hours. cells were either resting or activated with a phorbol ester, -phorbol -myristate -acetate (pma), and ionomycin. enzyme-linked immunosorbent spot assay (elispot) was performed to analyze production of il- . expression of signaling protein components, cd and jak, were determined by western immunoblotting. real time-polymerase chain reaction was performed to quantify cd , jak , and jak gene expression. a p value of < . was considered significant. results: jurkat cells exposed to pm e and activated exhibited significantly diminished numbers of il- producing colonies compared to t cells exposed to pm ( . ± . vs. . ± . colonies, p< . ). analysis of cellular cd and jak protein demonstrated that jurkat cells incubated in pm e expressed a . -fold decrease in cd and . -fold decrease in jak compared with cells incubated in pm e (p< . ). these diminished protein levels appeared to be the consequence of suppressed transcription, as the mrna levels of cd , jak and jak were significantly decreased in jurkat cells incubated in low levels of estrogen ( . , . , and . fold, respectively, compared to pm). conclusions: jurkat cells exposed to low postmenopausal estrogen levels produce significantly less il- following activation, which was associated with a significant decrease in signaling proteins. the diminished levels of signaling proteins appear to result from decreased cd , jak and jak gene expression in the presence of low estrogen. these findings support the observation of decreased cellular immune response in postmenopausal women and may provide a basis for the increased risk of infections and cancer proliferation associated with aging. support: dept. of ob/gyn research seed fund. the expression pattern of novel cytokines (il- and ) in human fetal membranes. judith eckardt, , stephen j fortunato, holger maul, ramkumar menon. the perinatal research center, nashville, tn, usa; womens' hospital, university of heidelberg, heidelberg, baden-wuerttemberg, germany. objective: interleukin (il) and are novel cytokines produced by various immunological cells in response to microbial antigens. the functions of these cytokines in reproductive system is unknown. this study examines the expression pattern of il- and il- in human fetal membranes from preterm and term births and in in vitro in normal term membranes in response to bacterial endotoxin (lipopolysaccharide-lps). methods: fetal membranes collected (n= ) from cesareans at term (normal, not in labor) were placed in an organ explant system for hours and were stimulated with lps for an additional hrs. fetal membranes were also collected (n= ) either at preterm or term after vaginal deliveries. in a case -control study (preterm birth vs. normal term deliveries) amniotic fluids (af) (n= ) were collected to document the role of il- and il- in ptb. tissue expressions of il- and il- were studied by rt-pcr using specific primers. elisa documented culture media and af cytokine concentrations. statistical analysis was performed using non-parametric mann-whitney u test. results: both il- and il - expressions were seen in fetal membranes in culture (in vitro) regardless of stimulation. in vivo in membranes from preterm and term deliveries and membranes at term not in labor also documented the expression of these cytokines. culture media analysis documented higher concentration of il- after lps stimulation (lps- . vs. . pg/ml; p= . ) whereas no difference was noticed in il- concentration (lps- . control- . pg/ml; p= . ) between the two groups. af analysis, regardless of the status, did not document detectable concentrations of either of the cytokines (lower limit . pg/ml for both). conclusion: this is the first study to document the expression of two novel cytokines in laboring and non laboring human fetal membranes and also in membranes from preterm deliveries. il- production was stimulated by lps whereas il- was not affected. these cytokines are not physiological components of af and their role in fetal membranes is unclear. higher il- concentration in response to lps but lack of its presence in term or preterm af is suggestive of an autocrine immune response during pregnancy in response to a microbial antigen. evidence for a selective migration of fetus specific cd + cd bright regulatory t cells from the peripheral blood to the decidua in human pregnancy. tamara tilburg, , dave l roelen, barbara j van der mast, godelieve m de groot, carin kleijburg, sicco a scherjon, frans hj claas. department of obstetrics, leiden university medical centre, leiden, netherlands; department of immunohematologie and bloodbank, leiden university medical centre, leiden, netherlands. during pregnancy the maternal immune system has to tolerate the persistence of fetal alloantigens. many mechanisms contribute to the prevention of a destructive immune response mediated by maternal alloreactive lymphocytes directed against the allogeneic fetus. murine studies suggest that cd + cd + t cells provide mechanisms of specific immune tolerance to fetal alloantigens during pregnancy. previous studies by our group demonstrate that a significantly higher percentage of activated t cells and cd + cd bright t cells are present in decidual tissue in comparison with maternal peripheral blood in human pregnancy ( ) . in this study we examined the phenotypic and functional properties of cd + cd bright t cells derived from maternal peripheral blood and decidual tissue. depletion of cd + cd bright t cells from maternal peripheral blood demonstrates regulation to a rd party umbilical cord blood cells comparable to non-pregnant controls, whereas the suppression capacity to umbilical cord blood cells of her own child is absent. furthermore, maternal peripheral blood shows a reduced percentage of cd + cd bright foxp + and cd + cd bright hla-dr + cells compared to peripheral blood of non-pregnant controls. in contrast, decidual lymphocyte isolates contain high percentages of cd + cd bright t cells with a regulatory phenotype that are able to down regulate fetus-specific and non-specific immune responses. these data suggest a preferential recruitment of fetus-specific regulatory t cells from maternal peripheral blood to the fetal-maternal interface where they may contribute to the local regulation of fetus specific responses. ( ) tilburgs t, roelen dl, van der mast bj, van schip jj, kleijburg c, de groot-swings gm, kanhai hh, claas fh, scherjon sa. differential distribution of cd (+) cd (bright) and cd (+) cd (-) t-cells in decidua and maternal blood during human pregnancy. placenta. apr; suppl a:s - . alicia del toro-arreola, lourdes nunez-atahualpa, juan velazquez-rodriguez, laura gonzalez-lopez, jorge i gamez-nava, adrian daneri-navarro. there is evidence that the maternal immune system is influence by changes in the hormonal levels during the menstrual cycle (mc). so far, the information related to the levels of t, treg, nk cells and receptors of activation and inhibitors is scarce. aim: to analyze the populations of t, treg, nk cells and their receptors of peripheral blood of healthy women and their correlation with hormones during mc. material and methods: we studied to women not using hormonal contraceptives in the day th of the follicular phase and st of the luteal phase of the mc. pbmc subsets and their receptors were determined by flow cytometry and hormone levels by chemiluminescence method. we found that the progesterone and prolactin were positive correlated (rho= . , p< . and rho= . , p< . , respectively) with cd /nkg in t cells and negative correlated (rho= - . , p< . and rho= - . , p< . , respectively) with nk cells. meanwhile cortisol was positive correlated (rho= . , p< . ) with the receptor nkg d expressed in nk cells. the results observed in this study in the luteal phase of mc on the expression of cd /nkg inhibitor receptor and nkg d activator receptor were related to a particular hormone (progesterone, prolactin and cortisol) might contribute to understanding the physiological role of the neuroendocrine axis on the expression of some receptors of the immune system in order to keep the homeostasis milieu of the mc. objective: sp-d, a key component of the innate immune system, is detected in amniotic fluid (af) and believed to originate in the fetal lung. however, sp-d is produced by other cells and therefore extra-pulmonary sources must be considered. the objective of this study was to determine the maternal and fetal plasma and af concentrations of sp-d to gain insight into the behavior of this natural antimicrobial peptide in pregnancy. moreover, we studied sp-d expression in maternal and fetal peripheral leukocytes. methods: maternal and fetal plasma and af samples were obtained from patients in the following groups: ) term not in labor (tnl; n= ); ) term in labor (til; n= ); ) preterm labor without histologic chorioamnionitis (ptl; n= ) and ) preterm labor with histologic chorioamnionitis (ptl-hc; n= ). sp-d concentration was measured by elisa. sp-d mrna expression in maternal and fetal leukocytes was evaluated by real-time qrt-pcr. flow cytometry and confocal microscopy were used to study the localization of sp-d in leukocytes. results: ) the af sp-d concentration increased as a function of gestational age (mean, til: , . ng/ml vs. ptl: , . ng/ml; p< . ); ) in contrast, the maternal and fetal plasma sp-d concentrations decreased with advancing gestational age (mean, til: . ng/ml vs. ptl: . ng/ml; p< . , and til: . ng/ml vs. ptl: . ng/ml; p< . , respectively); ) the maternal plasma sp-d concentration was lower than that of fetal plasma (mean: . ng/ml vs. . ng/ml; p< . ); ) however, sp-d mrna expression in maternal leukocytes was . fold higher than that of fetal leukocytes (p< . ); ) neutrophils (both maternal and fetal) expressed sp-d as demonstrated by flow cytometry and confocal microscopy. conclusion: ) the concentrations of sp-d in the maternal and fetal circulation decreased with gestational age while the af concentration increased; ) the expression of sp-d mrna is higher in maternal leukocytes than in fetal leukocytes; ) we report for the first time that maternal and fetal neutrophils are a source of sp-d and propose that this molecule plays a role in host defense against infection and in the modulation of the maternal and fetal immune response. introduction intrauterine insemination (iui) is a fertility technique that allows for couples to have intercourse after the procedure is performed. it has been postulated that intercourse after iui may increase the pregnancy rate by either endometrial stimulation or because it may represent a second spermatic flow in the periovulatory period. in the present study we evaluate the effect of intercourse on the pregnancy rate of patients undergoing iui. material and methods: from to patients were enrolled in the study. every couple undergoing iui was instructed at the moment of insemination to decide whether to have or not intercourse on the same day of the procedure. all couples were abstinent three to seven days before iui. the information regarding intercourse was recorded the day after treatment. ovulatory, insulin resistant, cervical, male, tubal and endometrial factors as well as parity and time of infertility were compared between the two groups. all these factors were analyzed based on number of follicles that ovulated in each group. our principal outcome was to determine the pregnancy rate. intercourse was practiced by . % of the couples. the global pregnancy rate was . %. the pregnancy rate for the couples who had intercourse was . % and . % for those who did not have intercourse (p< . ). even though age, parity, time of infertility and stimulation protocols were similarly distributed in both groups, the proportion of tubal and endometrial factors were higher among those who had intercourse (p< . ). when subjects with tubal and endometrial factors were excluded, the pregnancy rate between both groups (n= ) was similar ( . % vs . % for positive and negative intercourse, respectively). the average number of ovulatory follicles was . + . for the group that had intercourse and . + . for those who did not. according to our results, intercourse after iui does not improve pregnancy rate after this procedure is performed. furthermore our study indicates that iui does not interfere with sexual intimacy since almost % of the couples decided to have intercourse on the same day of the procedure. . we sought to investigate the effects of gravidity on mmc and fmc in healthy, parous women. methods: mc was assayed in dna extracted from peripheral blood mononuclear cells (pbmc). hla-genotyping was first conducted and mc quantified employing a q-pcr assay targeting a non-shared maternal-or fetalspecific hla polymorphism. gravidity was dichotomized as a history of one pregnancy compared with two or more, and the prevalence of mc was analyzed using logistic regression. possible confounders were included as appropriate, including subject age and time since last pregnancy. adjustment for possible correlation between values was also made when there were repeated measures for the same subject. results: for the mmc analysis, there were subjects with observations. for the fmc analysis, there were subjects with observations. table provides a summary of mmc and fmc by gravidity. mmc was significantly decreased with higher gravidity. fmc was not affected by gravidity. gravida gravida or more adjusted* or ( %ci) mmc / ( %) / ( %) . ( . - . ) fmc / ( %) / ( %) . ( . - . ) *adjusted for possible correlation between values within a subject, subject age, and time from last pregnancy, as appropriate. increasing gravidity is significantly associated with a decreased prevalence of mmc. despite additional sources of fmc, there does not appear to be an increase in fmc prevalence with increasing gravidity. the biology of mc is incompletely understood, and the nature of mmc and fmc are likely to be different given that acquisition of the former, but not the latter, occurs within a nascent immune system. these data raise interesting questions when considered as interactions of acquired grafts within a host, including whether emergence and persistence of one dominant source of mc may be most advantageous for an individual. anti-igd antibody treatment as a novel immunosuppressive agent for autoimmune diseases and its effects on th /th gene expression. tommie g nguyen, eileen d gallery, , jonathan m morris. elevated t-helper cell type- (th ) and type- (th ) cytokine expression have a role in autoimmune diseases, allograft rejection and pregnancy-related complications. thus, molecules that can shift the immunity away from th /th responses toward a th response represent a novel therapeutic treatment for these conditions. we have previously demonstrated that pregnancy is associated with a suppression of t-bet in peripheral t cells. in this study, we examined a novel effect of anti-igd antibody on t-bet expression, th /th gene expression in human peripheral blood mononuclear cells (pbmc) and its therapeutic effects in an animal model of collagen-induced arthritis. methods: human pbmc were isolated and then cultured in the presence of anti-igd antibody at various time points followed by stimulation with pma/ionomycin (p/i) for hrs. gene expression was examined by rt-pcr, western blotting and elisa. for in vivo study, arthritis-prone dba/j mice were induced to undergo joint inflammation by intradermal injections with bovine type-ii collagen. these mice were then given daily doses of mg/kg of intravenous injection with anti-igd antibodies as preventive or therapeutic treatments (n = per group). results: treatment with anti-igd antibodies significantly suppressed p/iinduced expression of t-bet (a master regulator of th immunity), tnf-(a classical pro-inflammatory th cytokine), and il- (a critical proinflammatory th cytokine) in human pbmc. this suppression is highly specific to these genes because anti-igd antibodies have no effects on the expression of ifn-g and il- (two classical th cytokines). in vivo experiment showed that anti-igd antibody treatment markedly reduced clinical severity of joint inflammation when comparing the clinical score of control mice group ( . ± . , mean ± s.e.m), preventive group ( . ± . ) and therapeutic group ( . ± . ) . conclusions: our study has demonstrated that suppression of t-bet by anti-igd antibodies, similar to the changes seen in human pregnancy is a novel in vivo anti-inflammatory effect. given the essential role of t-bet, tnf-and il- in the pathogenesis of human autoimmune diseases, anti-igd antibodies may represent a novel immunosuppressive treatment that needs further studies and evaluation. objective: women with circulating anti-phospholipid antibodies (apl) are at risk for recurrent miscarriage, preeclampsia and preterm labor. apl antibodies directly target the placenta by binding to phospholipids or phospholipid-binding proteins expressed on the surface of viable trophoblasts. the objective of this study was to determine the effects of apl antibodies on first trimester trophoblast cells. methods: two mouse igg anti-human beta -glycoprotein i monoclonal antibodies (mabs), designated id and iic , were used in these studies. the first trimester trophoblast cell line, htr , was incubated with either medium, a mouse igg control, id or iic ( - g/ml), in the presence or absence of unfractionated heparin ( ng/ml). trophoblast cell death and apoptosis was determined using a viability assay, hoechst staining and a caspase activity assay. cytokine production was evaluated by multiplex analysis. results: following a hour incubation, significant trophoblast cell death was induced by iic ( . ± . %) and id ( . ± . %) at the high dose of g/ml, when compared to the medium and mouse igg controls (p< . ). hoechst staining showed that id -and iic -induced trophoblast cell death was a result of apoptosis. moreover, id and iic induced a significant increase in caspase- , - and - activity (p< . ). treatment of trophoblasts with heparin significantly inhibited the effects of iic and id on cell death by . ± . % and . ± . % %, respectively (p< . ). following a hour incubation at lower concentrations ( g/ml), treatment of trophoblast cells with id or iic resulted in a significant upregulation of il- , mcp- , gro production (p< . ), and a significant reduction in il- secretion (p< . ). conclusion: this study demonstrates that at low levels apl antibodies can modulate trophoblast cytokine production, while at higher levels, the same antibodies induce trophoblast apoptosis in a caspase-dependent manner. these findings shed new light on the mechanisms by which apl antibodies may impact placental survival and function. antigenic targets for the diagnosis of premature ovarian failure. hc bohler, c gercel-taylor, lt ku, st nakajima, dd taylor. obstetrics, gynecology, women's health, university of louisville, louisville, ky, usa. objective: premature ovarian failure (pof) is a premature depletion of ovarian follicles before the age of , affecting approximately % of women < years. the involvement of autoimmune mechanisms in pof has been suggested and similar mechanisms have been postulated for other ovarian pathologies, including idiopathic infertility, polycystic ovary syndrome (pcos), or endometriosis. while the association of autoantibodies has been demonstrated for these ovarian pathologies, variation in specificity and frequency of false positivity have limited the diagnostic use of autoantibodies. the objective of this study was to develop an antigen array to differentiate antibody recognition patterns of pof from other infertility pathologies. design: prospective study in a university research laboratory. materials and methods: patients diagnosed with infertility were included in this pilot study: endometriosis (n= ), pcos (n= ) and pof (n= ). autoantibodies were assayed by dot immunoblotting using an antigen array derived from endometrial and ovarian cells. for the cellular antigen preparations, solubilized total proteins were separated by reverse phase-hplcquid chromatography and the individual proteins were blotted onto nitrocellulose membranes and reactivity visualized by peroxidase-labeled antihuman igg. results: patients with pof, endometriosis, and pcos all exhibited autoantibodies reactive with these cellular proteins. while some antigenic reactivities were shared by all infertility patients, the pattern of antigen recognition was distinct for patients with pof. patients with pof all recognized a common antigenic proteins (row , antigens a,b,d-g). conclusions: alterations in autoreactivity are observed in patients with the diagnosis of infertility; however, distinct patterns of autoantibody recognition can be demonstrated for patients with different pathologies. while this study needs to be expanded to reliably establish the specificity, sensitivity and positive and negative predictive values, patients with pof clearly exhibit a shared recognition pattern that may be useful a diagnostic marker. cicek gercel-taylor. ob/gyn, university of louisville, louisville, ky, usa. objective: americans' consumption of nutraceuticals is one of the most rapidly expanding health markets, growing at a rate of % annually. multiple nutraceuticals containing phytoestrogens have been marketed as "immune boosters" despite suboptimal evidence-based medicine to support such statements. as immunomodulatory therapies should affect downstream cytokine expression, the relative effects of estradiol and genistein in regulating expression of cd -and jak were tested. these markers were chosen since they are central to t cell signaling. cd -is a critical transducer of tcr activation and regulates t cell proliferation and cytokine production. jak upregulation is a specific marker for hematopoietic cell stimulation. methods: to test the immunomodulatory effects of phytoestrogens and estrogen, jurkat . (t cell leukemia) cells were grown in estrogen-free, phenol red-free media for hours. these cells were then exposed for hours to pm, pm (postmenopausal), or pm (premenopausual) of estradiol in the presence of increasing concentrations of genistein ( , . , . , . , , and m). cells were then solubilized and cellular protein quantitated. protein concentrations were standardized and western blots for each set of culturing conditions were run in triplicate. cd -and jak expression were quantitated following visualization with chemiluminescence by digital pixel quantification. results: our findings show that in the absence of estradiol and at postmenopausal levels of estradiol, genistein induced a dose dependent increase in cd -reaching a maximum of fold. although cultivation of t cells in pm of estradiol significantly increased the levels of cd -and jak relative to hypoestrogenic conditions, the genistein mediated dose response was not observed. conclusions: these in vitro results indicate that genistein can at least partially reverse suppression of signaling molecules observed in postmenopausal estrogen environments. clinically, this suggests that phytoestrogens may have greater immunomodulatory properties for postmenopausal females than those that are premenopausal. maternal serum il- as a biomarker of acute immunologic rejection of pregnancy. joaquin santolaya-forgas, juan deleon-luis, isabel galan. obstetrics and gynecology, brigham and women's hospital, boston, ma, usa; amarillo women's health research institute, texas tech university health science center, amarillo, tx, usa. objective: markers of acute rejection of pregnancy are very scarce. in this study we aimed at determining if rapid changes in maternal serum concetration of a variety of biomarkers could be used for this purpose. we used an established baboon model for in utero stem cell therapy to introduce at - days from conception and via ultrasound-guided celocentesis, human hematopoietic stem cells with different proportions of natural killer t-cells (nk). maternal blood was collected before and hours after celocentesis for quantification of hormones and il- using solid phase, enzyme labeled, chemiluminescent sequential immunometric assays. pearson correlation analysis was used for determination of significant changes from baseline (p< . ). results: all animals survived their pregnancies. seven animals receiving < % concentration of nk delivered at term ( days gestation) while animal receiving more than % concentration of nk had dead fetuses on ultrasound evaluation hours after celocentesis. table depicts mean maternal serum concentration of the biomarkers investigated (all n.s.). figure shows mean il- changes from baseline in continuing (n.s.) and rejected pregnancies (p< . ). conclusions: we have described a model in which in utero graft vs host disease can be studied. these preliminary results suggest that of all the biomarkers investigated, il- might be the most sensitive for detection of an acute rejection of pregnancy. biomarkers of acute immunologic rejection of pregnancy biomarker unit pre-celocentesis ( ) the activity of cytotoxic cd + t cells during pregnancy protects the mother and fetus from infection. however, pregnancy's effect on the proliferation and apoptosis of cd + t cells has not been clearly defined. objective: to determine if normal pregnancy changes the number of proliferating or apoptotic splenic cd +t cells. methods: female c bl/ mice were used unmated (um) or underwent timed mating. one day prior to harvest, mice were i.p. injected with bromodeoxyuridine (brdu), which is incorporated into replicating dna. harvested spleens were homogenized, enumerated, and stained for cell surface expression of cd and t cell receptor beta chain (tcr ). apoptotic cells were detected by treatment with terminal transferase and fitc-dutp (tunel). the numbers of cd +tcr + cells that were brdu+ or tunel+ were calculated from the percentage of positive cells obtained by flow cytometry and the absolute number of cells counted. for each experiment, the ratio of the number of positive cells in pregnant to um mice was compared by anova with dunnett's post-test. results: at day of pregnancy (n= ), the number of brdu positive cd + t cells was two fold higher than that found in um (n= , p< . ). the number of proliferating cd + t cells continued to be non-significantly elevated at day ( . x, n= ), day ( . x, n= ), and day of pregnancy ( . x, n= ) compared to um. by day of pregnancy (n= ) the number of proliferating cd + t cells returned to the um level, however by this time the total number of splenic cd + t cells was . fold higher than um (n= p< . ). on gestational day , the number of proliferating cd + t cells declined further ( . x, n= ), and the number of splenic cd +t cells returned to the um level (n= , p> . ). compared to um mice, there was no significant difference in the number of cd + t cells undergoing apoptosis at any gestational day examined ( . - . x, p> . ). in normal murine pregnancy, the number of cd + t cells is increased in late gestation, and then returns to baseline at the end of pregnancy. this is due to an early increase then gradual decline in cd + t cell proliferation, accompanied by a steady rate of apoptosis. this argues that the maternal immune system undergoes dynamic homeostatic changes, and is not globally suppressed. supported by nihro hd - niht ai . arturo cerbulo-vazquez, cun li, , gene hubbard, natalia e schlabritz-loutsevitch, , peter w nathanielsz. objectives: early thymocyte (t) maturation occurs in the cortex while later stages occur in the medulla. thymic epithelial cells (tec) synthesize gc and t express gr. tec may influence t cell maturation by regulating apoptosisinduced gc-gr interactions. igf- (also synthesized by tec) may support thymocyte prolifetarion. human fetuses of mothers in premature labor are exposed to gc. gc administered to pregnant baboons at . , . , and . gestation (g) alters fetal lymphocyte populations at . (g) (j repro immunol, , : ) . we determined if fetal gc exposure alters thymic ) structure; ) gr and igf-i protein. methods: pregnant baboons received saline (control ctr; n= ) or betamethasone i.m. ( μg/kg daily for two days at . , . and . g; gc group; n= ), c-sectioned at at . g under general anesthesia and thymic gr and igf-i evaluated by immunohistochemistry. results: gr localized to medulla and a few cortical cells. igf-i localized to cortex with little medullary expression. medullary necrosis was greater in ctr than gc fetuses. t gr was located in cytoplasm. no gross differences were observed between ctr or gc fetuses for either igf-i or gr. conclusions: a) early thymocyte maturation may be supported by igf- , b) later differentiation involves gr, and c) after exposure to gc doses equivalent to human therapy, no gross effects were detected on gr or igf, but d) natural thymic necrosis was inhibited. lindsay s christensen, peyman bizargity, elizabeth a bonney. ob/gyn, university of vermont, burlington, vt, usa. background: the exact mechanism by which bacterial products trigger preterm delivery and the immune cellular circuits involved remain unclear. our recent data in normal c bl/ (b ) or recombinase deficient c bl/ mice (rag-ko) indicates that t and b cells are not critical for lps-induced preterm delivery and stresses the importance of related innate mechanisms. rag-ko mice are more susceptible to lps, suggesting that t or b cells may control the innate response. macrophages are vital to innate immunity and produce proinflammatory cytokines that can activate prostaglandin synthesis and myometrial contraction. we questioned whether differences in susceptibility between the strains are due to differences in the uterine macrophage response to lps and thus examined macrophages at the maternal-fetal interface early after injection. objective: to compare uterine macrophages levels at and hours after lps injection in pregnant b and rag-ko mice. methods: b and rag-ko mice were mated and on gestation day , females were injected intraperitoneally with μg lps in l saline (pbs) or l pbs alone. euthanasia and uterine harvest occurred or hours after injection. frozen uterine sections were stained with the macrophage marker f / or an isotype-matched control followed by an alexafluor -conjugated secondary and a nuclear stain (dapi). sections were visualized by fluorescence microscopy. for each mouse, f / + dapi+ and total dapi + cells were counted in areas of representative section and the percentage of f / + dapi+ cells was calculated. the mean percentage for at least representative areas per experimental group was analyzed by anova. results: two hours post-injection, macrophages levels were similar in b and rag-ko mice injected with pbs (b , n= , . ± . ; rag-ko, n= , . ± . % + per area). lps injection increased macrophages (p< . ) in both strains (b , n= , . ± . ; rag-ko, n= , . ± . ,); no difference was evident between strains. the percentage of f / + cells was similar hours post-injection (b , n= , . ± . v. rag-ko, n= , . ± . ), and not elevated relative to the hour time point. objective. decay-accelerating factor (cd ), is expressed in the plasma membranes and protects mammalian cells against the lytic action of serum complement. phosphoinositide -kinases (pi ks) are involved in the regulation of cell functions by synthesizing a second messenger molecule ptdins ( , , ) p . akt, a serine-threonine kinase acts downstream of pi k and regulates cell survival, growth and proliferation. the pi k-akt activity is controlled by tumor suppressor gene pten. in this study we assessed whether the pi k-akt activity affects the expression of cd in human endometrial and cervical cells. methods. endometrial and cervical cell lines which differ in the constitutive pi k activity were used in this study. ishikawa and rl - endometrial cell lines harbor pten mutation and have high levels of phosphorylated akt (p-akt). hec- -a and kle endometrial cell lines and hela cells express wild-type pten and have minimal or no demonstrable levels of p-akt. the expression of cd was evaluated by rt-pcr, immunoblotting and flow cytometry. the pi k activity was assessed by immunoblotting with anti-p-akt antibodies. the effect of inhibition of pi k-akt pathway on cd expression was evaluated in cells treated with wortmannin ( nm), ly ( mm), or with akt inhibitor sh ( mm). results. immunoblotting densitometry and measurements of mean fluorescence intensities showed that the level of cd expression correlates with the status of pi k-akt pathway. the cd expression was lowest in hec- -a, ishikawa and rl - cells which constitutively express p-akt. higher cd expression was found in hela cells and kle cells which express wild-type pten product and has no detectable phospho-akt. mean fluorescence intensities were . -fold higher for kle cells and -fold higher for hela cells compared to hec- -a cells. treatment of cells with akt inhibitor led to . - . -fold increase in cd expression. the . - . -fold increase following treatment with pi k inhibitor wortmannin was found in ishikawa cells, rl - and kle cells. conclusions. human endometrial cell lines with elevated pi k-akt activity express lower level of cd compared to cell lines with intact pten gene function. these findings may indicate that structural alteration at the dna level and resultant overexpression of pi k-akt pathway are involved in the downregulation of cd . endometrial and cervical cells. pawel goluszko, chandra yallampalli. obstetrics gynecology, university of texas medical branch, galveston, tx, usa. objective. cell shape is determined by the cytoskeleton, which provides the mechanical support and is involved in cellular signaling. apoptotic cells undergo major morphological changes such as rounding and contraction, a process regulated by caspases, the cysteine proteases responsible for events controlling the cell disassembly. the motifs in certain cytokeratins make them substrates for caspase degradation. anti-apoptotic serine/threonine kinase akt provides a survival signal by phosphorylating downstream effector molecules including caspase- . while studying the akt distribution in human endometrial cell line we found that akt shows filamentous pattern of staining resembling cytoskeleton organization. in this study we evaluated whether akt staining correlates with the microfilaments (mf), microtubules (mt) or intermediate filaments. endometrial ishikawa, rl - , hec- -a, kle and cervical hela cell lines were used in the study. incubation with cytochalasin d, ( ug/ml) or nocodazole ( mg/ml) and labeling with bodipy fl phallacidin, anti -tubulin or anti-akt antibody were used to assess whether cytoskeleton disruptors affect akt distribution and mf and mt organization. for colocalization, cells were stained with anti-cytokeratin mouse antibody followed by anti-mouse alexa conjugate, and then stained with anti-akt rabbit antibody and anti-rabbit alexa conjugate. the scans collected with laser scanning confocal microscope from channels filtered for alexa and alexa were combined digitally and evaluated with imaris colocalization analysis software. filamentous pattern of akt staining was most pronounced in ishikawa and less obvious in hec- -a cells. treatment with cytochalasin d or nocodazole resulted in disruption of mf and mt but had no effect on cytokeratin organization and akt distribution. double staining with anti-cytokeratin- and anti-akt antibody showed overlapping staining for cytokeratin and akt. analysis of digitally acquired images showed highest correlation for colocalized channels in rl - cells ( . ) followed by ishikawa ( . ) and hela cells ( . ). lowest correlation was found for kle ( . ) and hec- -a cells ( . ) conclusions. this study indicates a strong colocalization pattern of serine/ threonine kinase akt with cytokeratins, and suggests a mechanism by which cytokeratins might be protected against cleavage by caspase- and caspase- in the early apoptotic stages. background: cd + cd + t regulatory cells (t-reg), express foxp ,suppress antigen-specific immune responses and are important for allograft tolerance. during pregnancy the mother tolerates an allograft expressing paternal antigens (the fetus), requiring substantial changes in immune regulation over a programmed period of time. the presence of t-reg cells (cd + cd highfoxp +) was assessed in the peripheral venous blood of non-pregnant, pregnant and seven postnatal healthy women by flow cytometry. human decidua was obtained by surgical termination of pregnancy in the first (n= ), second (n= ) and third (n= ) trimester of human pregnancy. paraffin sections were immunostained for foxp and cd . foxp +cells were quantified in x fields and results compared between first, second and third trimester samples and according to the presence of extravillous trophoblast. results: fluorometric studies of blood samples indicate an increase % of circulating cd + cd highfoxp t-cells in pregnant ( . % [range . - . %]) vs. non-pregnant controls ( . % [range . - . %]; p< . ). a progression from st, nd and rd trimesters indicated the % of cd + cd highfoxp t-cells was . %, . % and . %, respectively. low numbers of foxp + cells were detected in all decidua samples and their distribution mirrored that of cd + cells. in st trimester samples, foxp + cells were often detected in lymphoid aggregates adjacent to endometrial glands. increased numbers of foxp + cells were detected in st ( . ± . ) compared with nd trimester decidua ( . ± . ; p< . ) but there was no difference between st and rd trimester ( . ± . ), nor between nd and rd trimester decidua. in st trimester decidua, numbers of foxp + cells were increased in areas without extravillous trophoblast. conclusion: normal human pregnancy is associated with an increase in the number of circulating cd + cd highfoxp t-cells. the presence of foxp + cells in early gestation human decidua may be important in the initiation of materno-fetal tolerance at an autocrine level. (supported by mrc). aims: -defensins are small cationic peptides with antibiotic and antimicotic activity. hyaluronan and its degradation products have been described as endogenous ligands for tlr and tlr , whose involvement in -defensin expression has been reported in different epithelial tissues and cell lines. we aim to investigate weather low molecular weight hyaluronic acid induces -defensin release by keratinocytes, via tlr and tlr . methods: the induction of -defensin production following in vitro treatment of human keratinocytes with a low molecular weight hyaluronic acid solution was evaluated by pcr-analysis and elisa techniques. studies on the involvement of tlr and tlr in -defensin production have been performed using specific blocking antibodies. results: pcr and elisa revealed an intense -defensin production following hyaluronic acid treatment in human keratinocytes. the -defensin production induced by hyaluronan was abolished following block of tlr and tlr by specific antibodies, demonstrating the involvement of these receptors. the same hyaluronic acid treatment did not induce activation of inflammatory genes, such as il- , tnf-, il- and il- . conclusion: our data show that hyaluronic acid is an efficient inducer ofdefensin production in keratinocytes, via tlr and tlr . this observation might be important to open new perspectives in the development of possible topical products containing hyaluronic acid, to improve the release ofdefensins by keratinocytes, ameliorating the self-defence of the skin in case of skin infections. therefore, one of the possible applications for this kind of topical products might be the treatment of infective vulvitis, one of the most distressing gynaecological diseases for adult women. pregnancy outcome? kiera von besser, serena wu, mary d stephenson. , obstetrics and gynecology, university of chicago, chicago, il, usa; obstetrics and gynaecology, university of british columbia, vancouver, bc, canada. objective: to investigate whether gender of an ongoing pregnancy impacts the probability of a successful outcome, and, to ascertain whether the gender of prior live birth(s) impacts subsequent pregnancy outcome, among women with rm/aps. materials and method: cohort-control study. rm subjects were evaluated by mds between - (stephenson, . couples who met aps criteria (wilson et al, ) , restricted to rm only, were followed prospectively. cohort data was compared to live birth data from the vital statistics agency of british columbia from - . secondary sex ratios (ssrs) among successful pregnancy outcomes were calculated by dividing the number of male live births by female. sex ratios were calculated for all pregnancies weeks, regardless if they ended in success or demise. pearsons test with yates continuity correction was applied. results: subjects were identified. subjects had prior live births of known gender ( male/ female), giving a ssr of . . there were also prior fetal demises wks of known gender ( / ) giving a sex ratio for all prior pregnancies at wks of . . subjects delivered subsequent live births of known gender ( / ), giving a ssr of . . there were also subsequent fetal demises ( / ) giving a sex ratio for all subsequent pregnancies of . . subjects delivered both prior and subsequent live births. the ssr was . ( / ) among their prior and . ( / ) among their subsequent live births. including fetal demises, subjects had ongoing prior and subsequent pregnancies. the sex ratio was . among their prior pregnancies and . among their subsequent. as the control, a ssr of . ( , / , ) was calculated from vital statistics data. when the prior and subsequent ssrs of the cohort were compared to each other, as well as to the control, there were no statistically significant differences. conclusions: our findings, from the largest study of its kind to date, suggest that, in patients with rm/aps, the gender of an ongoing pregnancy does not significantly affect the probability of a successful outcome, to any greater degree than it does in the general population. also, the gender of a prior ongoing pregnancy does not significantly impact the likelihood of developing rm/aps. oocyte maturation. jk friend, fb bezirci, e seli. ob gyn, yale u., new haven, ct, usa. introduction: oocyte maturation is associated with repression of transcription. during oocyte maturation, fertilization, and early embryo development until the onset of zygotic gene expression, proteins are synthesized from maternallyderived mrnas. the regulation of protein expression from these maternal mrnas is post-transcriptional, and occurs mainly via poly(a)-tail elongation. the embryonic poly(a)-binding protein (epab) is the predominant poly(a)binding protein before the activation of the zygotic genome, and plays a critical role in the activation of certain maternal mrnas, those bound by cpeb and probably pumilio. we are characterizing additional functions of epab during the process of oocyte maturation. methods and results: our model system is the xenopus laevis oocyte where oocyte maturation is induced by the addition of progesterone. our preliminary findings indicate that epab is phosphorylated, and that levels of phosphorylated epab increase upon progesterone-induced oocyte maturation. moreover, glycerol gradient centrifugation revealed that nonphosphorylated and phosphorylated epab are contained in distinct complexes that change mobility upon oocyte maturation. furthermore, oligo-dt selection for poly(a)-containing mrnas strongly suggests that these mrnas are bound exclusively by phosphorylated epab. using affinity purification, we have determined that nonphosphorylated epab exists primarily in a large protein complex prior to oocyte maturation that is later disassembled after the addition of progesterone. conclusions: based on these preliminary findings, we conclude that prior to oocyte maturation, the bulk of epab is nonphosphorylated and is found in a protein-rich complex separate from poly(a)-containing mrnas. upon oocyte maturation (when certain maternally-derived mrnas are activated for translation), the majority of epab becomes phosphorylated, and this phosphorylated form of epab is likely bound to translationally-active mrnas. we are currently investigating what kinase phosphorylates epab and whether this phosphorylation plays a role in translational up-regulation of epab-bound mrnas. introduction: reactive oxygen species (ros) play important roles in all aspects of cellular fate. nadph oxidase isoforms, a family of genetically preserved enzyme complexes, have been shown to be the main sources of ros in various cell types. however, the role of nadph oxidase isoforms in human myometrium proliferation and differentiation has not been defined. in the myometrium, different smooth muscle phenotypes maybe associated with specific physiologic functions. we have shown that angiotensin ii (angii) stimulates hypertrophy but not cell proliferation in ultr cells, an in vitro model of human myometrium. ultr cells at greater than passages display a replicative senescent phenotype. by introducing human telomerase reverse transcriptase (htert) gene, we have obtained a stable cell line (ultr-ht) which has a significantly increased division rate and distinct cellular morphology than the original ultr cells. objective: to determine the relationship of expression of nadph oxidase to ultr cellular fate. methods: early and late passages (p - ) of ultr and ultr-ht (p - ) cells were grown on either plastic or collagen iv (cn )-coated surfaces. ultr-ht cells were further stimulated with angii ( . um) for hrs. expression of nadph oxidase core (nox - and duox / ) and associated subunits (p phox, p phox, noxo , p phox, noxa , p phox, and rac / ), and angii receptors at / was identified by rt-pcr from cellular total rna. fluorescent immunohistochemistry (ihc) was employed to determine protein expression and localization. results: the mrna level of house keeping gene -actin was unchanged by any cellular manipulation. the senescent phenotype of ultr cells was accompanied by an apparent down-regulation of nox , p phox, and noxa genes, and an up-regulation of at / . overexpression of htert did not reverse nox , p phox and noxa expression while cell division rate was increased. however, there was a down-regulation of nox , at / and rac . plating ultr-ht cells on cn induced nox / down-regulation and up-regulation of duox / , with no apparent change of at / . however, exposure to cn re-directed cellular response to angii such that only nox was induced by angii stimulation. conclusion: expression of nadph oxidase isoforms nox , , , and duox / are correlated with ultr cell differentiation and cell fate control. data also suggests that ang ii-induced myometrial hypertrophy involves nox mediated ros generation. fluids from reproductive women -the influence of aging. eriko y fujii, masahiro nakayama. women's health, national center for child health and development, tokyo, japan; aska reproductive clinic, nara, japan. [introduction] receptor for advanced glycation end products (rage) is a multiligand type glycoprotein, and is characterized based on its ability to bind ages, adducts formed by non-enzymatic glycation and oxidation of protein and lipids. this process occurs during normal course of aging. ages/rage interaction regulates various physiological function, such as inflammation, angiogenesis through vegf inducement. a soluble form of rage (srage) works as a decoy in the body and inhibits intracellular signaling. [objectives] the balance of these factors may contribute to reproductive dysfunction by aging. we aimed to measure the ages, srage and vegf concentrations in plasma and follicular fluids from reproductive women, and examined the differences of those factors between young group and old group. [material and methods] patients' plasma and follicular fluid were collected with consent based on regulations of the ethical committee, and we measured ages (pentosidine, cml), srage and vegf in duplicate using commercially available elisa kits (fushimi co, r d and cyelex). concentrations were calculated from each standard curve, and compared between the young group under years old, and the old group over y.o. data were evaluated for the difference in two groups by student's t test , and the significance was determined by p< . . [results] ) srage in plasma, ± pg/ml (mean±sd), n= in the young group was significantly higher than ± pg/ml, n= in the old group. there was no significant difference in plasma vegf. ) vegf in follicular fluid was ± pg /mg protein, n= in the young, and ± pg /mg protein, n= in the old was increased significantly. ) we could not see statistical difference of pentosidine nor cml concentrations between two groups in plasma and follicular fluid samples. [conclusions] it has been reported that higher concentration of vegf in follicular fluid may relate to worse pregnancy rate in art. there was a significant decrease of plasma srage in older group in our result, and because of this decrease of 'decoy', focal ages-rage-vegf signaling might be activated in older women. our results showed the possibility that ages/rage and vegf regulation may contribute to the reproductive dysfunction by aging. and leiomyosarcoma cells. qun pan, xiaoping luo, nasser chegini. ob/ gyn, university of florida, gainesville, fl, usa. as a part of a novel endogenous rna silencing machinery, a noncoding short rna strand referred to as "microrna" (mirna) has been identified to regulate the stability of the target gene expression through mrna degradation and repression. we have identified the expression of many of these mirnas in leiomyoma, myometrium, their isolated smooth muscle cells (lsmc and msmc), transformed lsmc (t-lsmc) and sklm (leiomyosarcoma cell line), including mir- which is predicted to target the expression of many genes, including tgf-b and tgf-b type ii receptor (tgf-brii). however, the biological significance of these mirnas in various cellular processes remains to be established. as such in the present study we examined the expression, regulation and function of mir- in lsmc, msmc, t-lsmc and sklm. we found that mir- is expressed and regulated by b-estridiol and medroxyprogesterone acetate ( - m) in these cells (p< . ). we further assessed the regulatory function of gain of and loss of function of mir- on the expression of tgf-brii. transfection of lsmc, msmc, t-lsmc and sklm with pre-mir-and anti-mir- oligonueclotides resulted in a significant increase and/or inhibition of mir- expression in these cells, respectively as determined by realtime pcr (p< . ). over-expression of mir- resulted in a significant reduction, while transfection with antimir- increased the expression of tgfbrii mrna and protein in these cells as compared to controls (p< . ). we concluded that mir- is expressed in leiomyoma and myometrial cells, its expression is regulated by the ovarian steroids and it functions by targeting the expression of tgfbrii and possibly other genes with key regulatory action on cell growth, angiogenesis, transcription regulation, ecm turnover and apoptosis that results in leiomyomas growth and regression. (supported by nih grant hd ). objective: placenta and a number of gestational tissues are well recognized to express corticotrophin releasing factor (crf), urocortin (ucn ), ucn , ucn and crf -r and crf-r receptor subtypes together with crfbinding proteins locally. ucn and ucn are implicated in the reversal of stress responses initiated by crf. in the present investigation, we evaluated functions of crf and ucns by quantifying their contents in venous smooth muscle layers using image pro . in human umbilical cords collected at preterm and term gestation methods: umbilical cord specimens ( - mm thickness, pieces per umbilical cord) collected at preterm and term (n= each) at delivery were fixed in bouin's solution and paraffin embedded. sections were subjected to immunohistochemical analyses with polyclonal antibodies to crf ( : ), ucn ( : ), ucn ( : ) and ucn ( : ) (peninsula laboratory, pa and sigma aldridge, ms) by standard abc technique. immunoreactive materials on the sections were identified using , '-diaminobenzidine as a chromagen. immunostaining intensities (od/area) on uc-sections were quantified by image pro . software and expressed as arbitrary units (au). all values were expressed as mean ± sem. differences between groups were evaluated by anova, followed by the post-hoc tukey test for multiple comparison. results: antibodies to crf and ucns elicited positive immunostaining of variable intensity in venous smooth muscle layers in uc-sections of preterm and term gestations. immunostaining intensity (au) of venous smooth muscle layers at preterm (pt) and term (t) are as follows: crf-pt= . ± . vs crf-t= . ± . (p< . ); ucn -pt= . ± . vs ucn -t= . ± . (p< . ); ucn -pt= . ± . vs ucn -t= . ± . (p=ns); ucn -pt= . ± . vs . ± . (p< . ). conclusion: crf content in venous smooth muscle layer markedly increased at term, while ucn and ucn contents significantly decreased and no significant change occurred in ucn content. based on the opposing changes in crf vs ucn and ucn immunostaining, we speculate that crf, but not ucn or ucn , is the major key player of vasodilation and function locally at the level of venous smooth muscle cells at term. ucn and ucn may perform cytoprotective functions at preterm. physiol. ; : - , am j physiol. ; : - ) . these studies showed that when ad libitum (al) feeding was resumed in cr females, fertility was sustained well beyond the age at which al-fed females became infertile. however, much of what is known on the effects of cr on fertility derives from models in which cr was initiated at weaning. further, there is large variation in how the experiments were conducted. objective: herein we tested if adult-onset cr could delay age-related infertility in females. methods: cr ( %, nia protocol as described in j geront. a:b -b ) was initiated in c bl/ female mice at months and continued until . months of age, at which time al feeding was resumed. matings were initiated at months of age. for mating during cr, a male mouse was housed overnight in a cage with a female and removed the next morning, so that the female mice could be fed their dietary food ration. al-fed and cr females followed the same mating regimen. the number of offspring born and that survived to weaning (day ) were recorded. results: fertility was lost in of al-fed females by months of age and continued to decline through . months of age. age-matched females maintained on cr during the same period exhibited poor fertility, with a total of pregnancies achieved out of females. although cr females showed poor fertility while on cr, their fertility improved dramatically after the reinitiation of al feeding at . months of age. while only out of , al-fed females achieved a pregnancy between . - . months of age, out of age-matched cr-then-al-fed females achieved a total of pregnancies in this -month time. notably, % of the pups born to cr-then-al-fed females between . - . months of age survived and developed to weaning without complications. conclusions: adult-onset cr allows maintenance of female fertility into advanced maternal age after the reinitiation of al feeding. how long fertility can be maintained and the minimum time needed for the beneficial effects of cr to be realized remain to be investigated. nonetheless, these observations suggest that there may be ways to safely extend fertility in females at ages when reproductive function is suboptimal (nih r -ag ). bile acids in human ovarian follicular fluid. laura p smith, , kaila deiorio-haggar, jason reindollar, alan s penzias, , anny usheva-simidjiyska. ob/gyn reproductive endocrinology infertility, bidmc, boston, ma, usa; boston ivf, boston, ma, usa; endocrinology, bidmc, boston, ma, usa. introduction: bile acids are known to serve important functions in the hepatobiliary and gastrointestinal systems. the presence of bile acids in the human ovary and relation with fertility potential have never been previously evaluated. methods: human follicular fluid (ff) from large follicles and small follicles was obtained at vaginal oocyte retrieval. human serum was obtained before and hours after human chorionic gonadotropin (h-cg). follicular fluid and serum samples were analyzed for total bile acids by spectrophotometry. bile acid concentrations were correlated with age, number of retrieved and mature oocytes, number of fertilized oocytes, and pregnancy. results: bile acid concentrations were analyzed and compared to the normal human serum bile acid concentration which ranges from to micromoles/l. bile acids are present in follicular fluid with a mean concentration of . micromoles/l in large follicles and . micromoles/l in small follicles (p= . ). pre and post h-cg serum bile acid concentrations differed significantly ( . micromoles/l vs. . micromoles/l, p= . ). there was a trend toward higher bile acid concentration in large follicles of young patients < years old compared to older patients years old ( . ± . vs. . ± . , p= . ). there was also a trend toward higher pre h-cg serum bile acid concentrations in older patients ( . ± . vs. . ± . , p= . ). there was no correlation between serum and follicular fluid bile acid concentrations and number of oocytes retrieved or number of mature oocytes, but there did appear to be a positive correlation between pre h-cg serum bile acid concentration and number of fertilized oocytes (spearman's correlation coefficient . , p= . ). conclusions: this is the first demonstration of the presence of bile acids within human ovarian follicular fluid. there may be a relationship between bile acid concentration and fertility potential. the precise function of bile acids in human ovarian follicular fluid is under investigation. objective to investigate the impact of ovarian hyperstimulation treatment on the biomarkers of the homocysteine pathway in blood and follicular fluid, and their association with the follicle diameter as a measure of follicular maturation. methods in women undergoing ivf/icsi treatment blood samples were collected on cycle day and the day of hcg administration. during oocyte retrieval in each woman the diameter of two follicles was measured and the corresponding follicular fluids were collected. in blood and follicular fluid total homocysteine (thcy), folate, cobalamin and pyridoxal' 'phosphate (plp) concentrations were determined. women with a serum folate . nmol/l were classified as folic acid supplemented. results ovarian hyperstimulation significantly decreased thcy and cobalamin blood levels (both p . ). the blood and follicular fluid concentrations of thcy, folate, cobalamin and plp were significantly correlated (all p . ). in the total group, a two-fold increase of thcy in follicular fluid resulted in a . mm decrease of the follicular diameter (p . ). in non-supplemented women this decrease was . mm (p . ). in supplemented women a twofold increase of follicular fluid folate resulted in a . mm decrease of the follicular diameter (p . ). conclusions ovarian hyperstimulation reduces thcy blood levels independent of folic acid supplementation. however, high follicular fluid thcy and folic acid supplementation may have detrimental effects on the maturation of the follicle. ), post-fixed for rain in % w/v osmium tetroxide in the same buffer, quickly dehydrated in a series of ethanol solutions, and embedded in epon. thin sections were stained with uranyl acetate followed by lead citrate and were observed at electron microscope. results: ten blastocysts from each group were collected and analyzed. compared to the in vivo embryos, blastocysts generated in vitro exhibited significant differences. the surface of their trophectoderm (te) layer had a reduced number of microvilli, the number of the apoptotic cells in the inner cell mass (icm) was higher and the presence of non functional mitochondria was elevated. in this study we have, for the first time, compared the ultrastructure of the in vivo and in vitro conceived blastocysts. taken together, these results suggest that both, the higher rate of apoptosis and the morphological alterations in the mitochondrial structure in ivf embryos, are associated with stress during in vitro embryo culture. therefore, these parameters can be used, in the future, as markers for the assessment of the embryo wellbeing in the ivf settings. deteriorating oocyte quality is a critical hurdle in the management of infertility, especially one associated with advancing age.here, we explore a newly discovered role of nitric oxide (no) in the sustenance of oocyte quality. methods: sibling oocytes from superovulated mice were subjected to intracytoplasmic sperm injection (icsi) with cauda-epididymal spermatozoa following exposure to either the no donor, s-nitroso n-acetyl penicillamine (snap, . m/min); a soluble guanylyl cyclase inhibitor, h-[ , , ] oxadiazolo [ , -a] quinoxalin- -one (odq, m) or an no synthase inhibitor, n w -nitro-l-arginine methyl ester (l-name, mm). their sibling oocytes were subjected to icsi either before (young) or after culture for the corresponding period (old). outcomes of fertilization, cleavage and development to the morula and blastocyst stages were compared. some embryos from each subgroup were also subjected to tunel assay for apoptosis. results: oocytes deteriorated in their ability to undergo normal fertilization and development to morulae/blastocysts after aging in culture, as compared to their sibling cohorts subjected to icsi immediately after ovulation (p< . ). this deterioration was prevented after oocyte exposure to snap. while, exposure to l-name or odq resulted in a significant compromise in fertilization and development to the morulae/blastocysts (p< . ) with detection of apoptosis, which was also noted in embryos derived from aged oocytes but not in those from young or snap exposed oocytes. conclusions: no is essential to sustain oocyte fertilizability and developmental ability, and to prevent blastomere apoptosis. objective to investigate the effects of the levels of the biomarkers of the homocysteine pathway on ivf outcome. methods from women undergoing an ivf or icsi procedures, two blood samples and two mono follicular fluid samples were collected for determination of folate, cobalamin, and total homocysteine (thcy). total protein was determined in follicular fluid to adjust the biomarker concentrations for follicular maturation. primary endpoint of the study was oocyte quality measured by fertilization and embryo quality (range - ; with being best quality). secondary endpoint was the occurrence of pregnancy. results % of the included women used a folic acid supplement (serum folate . nmol/l). in non-supplemented women higher cobalamin levels in follicular fluid correlated with a better embryo quality (estimate - . ; p . ) and higher thcy levels (median . mol/l, range . - . ) correlated with a worse embryo quality (estimate . ; p . ). in supplemented women higher follicular fluid thcy (median . mol/l, range . - . ) correlated with better embryo quality (estimate - . ; p . ). the follicular fluid folate level of oocytes that did not fertilize was . -fold higher than in the fluids of a fertilized oocyte ( % ci . - . ; p . ). a two-fold increase of follicular folate corresponded with a . higher chance to achieve pregnancy ( % ci . - . ). conclusions cobalamin levels in follicular fluid are correlated with embryo quality. folic acid supplementation modifies the thcy and folate levels in follicular fluid and thereby affects oocyte quality. the level of folate in follicular fluid is important in the fertilization process. we recently reported that increasing relative oocyte immaturity is associated with worsening outcome, and that cycles with many immature oocytes are more common in younger women. (moore et al, asrm annual meeting, ) to further investigate this trend, we conducted a case/control analysis of patients with repeated cycles of high-level oocyte immaturity (hloi). methods: oocyte maturity data was collected on all icsi cycles starting in . we defined a cycle with hloi as having > % immature oocytes (> sd's above the median). a case was defined as a patient with hloi on more than one cycle. control subjects were age-matched and defined as having </= % ( sd above median) immature oocytes on all cycles. results: from subjects, we identified cases of recurrent hloi (comprising icsi cycles) and control subjects. at baseline, cases had more oocytes retrieved per cycle than controls ( . vs. . , p<. ). all other baseline characteristics were similar. all case subjects were younger than . outcomes are shown in table . discussion: clinical pregnancy and live births were reduced in the case group, but more than expected based on % immaturity. during cycles, there were no live births among the case group. patients with recurrent hloi represent a previously undescribed group of young patients with a very poor prognosis during icsi treatment. this study may suggest that the problem underlying the immaturity may relate to overproduction of oocytes during stimulation, a factor which may be modifiable. however, the additional trend (though not significant) that even the mature oocytes from the case patients tend to have poor outcomes suggests the possibility of a maturation defect and warrants further consideration. data on response to gonadotropins, fert rates, and implantation rates will be presented. amongst those, were performed for an initial diagnosis of premature ovarian aging (poa), for the diagnosis of premature ovarian failure, and for repeated pregnancy loss. in women under age , b-fsh levels over miu/ml and up to < miu/ml denoted a diagnosis of poa, while levels of miu/ml were considered diagnostic for pof. all patients signed consent permitting review of medical records for clinical research purposes. results: day fsh levels ranged from . to . miu/ml (mean . ± . miu/ml). amh levels ranged from < . to . ng/ml (mean . ± . ) and allele repeats ranged from to , (mean for allele- , . ± . ; allele- , . ± . ). mixed model analysis of variance for all patients, adjusted for age, race, and allele- revealed a statistically significant correlation between b-fsh levels and number of repeats in allele- ( figure ; p < . ). we did not observe a significant linear relationship between serum amh levels and cgg repeat counts, however cgg repeat counts above were significantly associated with serum amh levels less than ng/ml (chi square = . ). conclusions: triple repeats above , a level currently considered well within normal, are associated with evidence of premature decline in ovarian function. the evaluation of triple repeats in frm gene offers a first objective assessment of ovarian function and should be predictive of autologous reproductive life span in most women. objective: the levels of mis in the serum and in the ovary have been demonstrated to decrease in response to increasing doses of cisplatin. we hypothesize that ovarian stimulation also will reveal dose related decreases in ovarian and serum mis levels after cisplatin exposure, further demonstrating the follicular damage from chemotherapy. methods: adult female sprague-dawley rats were treated with saline, . mg/kg cisplatin or . mg/kg cisplatin as two weekly injections. five days following the last cisplatin injection, the rats were injected with pregnant mare serum gonadotropin (pmsg) and euthanized hours following the pmsg injection. serum was collected and both ovaries were obtained for protein analysis. serum and ovarian levels of mis were determined using an elisa kit. western blot analysis, immunohistochemical analysis, and tunel analysis were also performed on the ovarian proteins. results: stimulated mis levels declined in a linear fashion in response to increasing cisplatin doses (p< . ). ovarian protein levels measured by elisa and western blot both indicated that stimulated ovarian mis levels also decrease in a linear fashion (p= . and p< . respectively.) immunohistochemical analysis revealed that while the total number of follicles remains the same, both the total number of mis positive follicles, and the percentage of mis positive follicles declines in a linear fashion (p= . for both). tunel analysis reveals that there is no change in the incidence of apoptosis in the stimulated ovaries from any treatment group. conclusions: the administration of pmsg after treatment with cisplatin causes a dose dependent decrease in the levels of mis in both the serum and in the ovary. serum mis levels following ovarian stimulation may be useful as a serum biomarker in this animal model to assess ovarian damage following the administration of cisplatin. correlations of micro-rnas a, b, - pp, and - p with inflammatory and steroidogenic factors in human granulosa/cumulus cells. tannaz toloubeydokhti, orhan bukulmez, kenneth c drury, r stan williams, nasser chegini. obstetrics and gynecology, university of florida college of medicine, gaineville, fl, usa. as part of the novel endogenous rna silencing machinery, noncoding short rna strands, referred to as micrornas (mirnas), have been identified to regulate the stability of the target gene expression through degradation and repression. the expression of many of these mirnas has been identified in human tissues however, their biological significance in various cellular processes remains to be elucidated. in this cross-sectional study of human granulosa cells, we aimed to study the potential correlations between five selected mirnas, mir- a, mir- b, mir- - p, mir- and mir- - p, and mrna expressions of some of their predicted target genes namely, cyclooxygenase (cox)- , il- , steroidogenic acute regulatory protein (star), aromatase and estrogen receptor (er) . granulosa/cumulus cells were obtained from women (age range - ; mean age . ± . ) undergoing oocyte retrieval for assisted reproduction. total rna was extracted from these cells and reversed-transcribed and real-time pcr was performed to measure steady-state levels of mirnas and mrna transcripts. we observed that the expression of mir- a, mir- - p, mir- and mir- - p displayed a significant and positive correlation with the expression of cox- . moreover, mir- b significantly correlated with star mrna expression, but not with other genes tested (p< . ). with advancing age, the expression of mir- - p and cox- was significantly decreased, with cox- expression displaying a positive correlation with aromatase, star and er mrna expressions (p< . ). none of the factors tested showed any significant correlations with peak estradiol levels and number of oocytes retrieved. receiver operating characteristic curve analysis revealed that female age cut-off value of . y best predicted whether mir- - p was below its mean arbitrary value. in conclusion, given the importance of mirnas' regulatory function in gene expression, our results suggest that mir- b may play an important role in gene expression related to granulosa cell luteinization, while variation in mir- - p expression with female age may suggest its potential role as a predictor of oocyte quality and granulosa cell function. given the importance of mirnas in gene regulation, the role of mirnas in ovarian physiology and aging requires further investigation. support: nih grant . introduction: a symbiotic relationship between ovarian granulosa cells (gc) and the enclosed developing oocyte is critical to reproductive efficiency. genetic modulations in gc's can lead to reproductive insufficiency, highlighting the critical role of gc's in reproductive competence. defects in the oocyte-gc repertoire in women with dor include lower e levels, luteal deficiency, poor fertilization rates, higher incidence of aneuploidy, lower pregnancy and higher miscarriage rates. utilizing global gene expression analyses in cumulus gc's, we attempt to enhance our understanding of biological mechanisms that may contribute to poor reproductive capacity in young women with dor. methods: infertile women (< years old) undergoing ivf were prospectively enrolled into two groups based on ovarian reserve (normal reserve, fsh< dor, fsh > miu/ml). at egg retrieval, cumulus gc's were isolated, rna extracted transcribed into cdna. microarray targets were generated cdna hybridized to affymetrix human genome u plus . genechips. microarray data were analyzed (array assist) and normalized (robust multichip analysis). a difference in gene expression of > fold was considered biologically relevant. results: of the , genes identified to be differentially expressed in young women with dor compared to normal reserve, genes demonstrated consistency of expression across five different normalization schema; were down regulated and up-regulated. expression of gremlin, a member of the dan family of genes known for its highly regulated expression pattern during folliculogenesis, was noted to be down-regulated -fold over two probe sets (- . ) in women with dor versus normal reserve; this down-regulation was confirmed by real-time pcr (- . ) . conclusions: this is the first demonstration linking differential expression of gremlin with etiology of infertility in women. gremlin is a downstream effector of oocyte-derived gdf- which facilitates cumulus cell expansion, a critical event in reproductive physiology. our finding of a significant downregulation of gremlin expression in cumulus gc's associated with dor may partly explain the physiology of poor reproductive performance. nih k cd . nih k rr . ferring pharmaceuticals. the objective of the present study was to investigate the effects of the gnrh antagonist ca on expression of mis and aromatase (cyp ) using luteinized human granulosa cells obtained during in-vitro fertilization cycles and an immortalized human granulosa cell line (hgl ). the granulosa cells were cultured +/-dibutyryl camp ( mm) and incubated +/-the gnrh antagonist, ca, for - h. rna was isolated, reversed-transcribed and real-time pcr was performed to measure mrna transcripts for ovary-specific cypiia and mis. we observed that camp markedly induced aromatase mrna in both the primary and immortalized human granulosa cells. interestingly, camp treatment of these cells also caused an upregulation of mis mrna. objectives: bisphenol a (bpa), a known endocrine disruptor, is a chemical used as a plasticizer in the manufacture of polycarbonate plastics and epoxy resins and is present in multitude products, including the interior coating of food cans, milk containers, and baby formula bottles. bpa can leach into foods during heat processing and is known to exert a variety of endocrine-like effects on different cell types acting as an estrogen because it contains two hydroxyl groups in its diphenyl structure. in this study we focused on the effects of bpa on aromatase expression and estradiol production in the human granulosa kgn cell line. we also evaluated its effects on several transcription factors crucial in cyp expression. materials and methods: kgn cells were cultured in f- dmem and were starved for h before experiments. subsequently they were treated for h with vehicle (control), fsh ( ng/ml), and/or bpa ( , , , , um) . messenger rna expression was quantified by real time pcr and estradiol secrection was measured in supernatants by elisa. results: fsh induced a -fold increase in aromatase expression. bpa induced a dose-dependent decrease in cyp production, with the greatest effect at um (p< . ), resulting in +/- % (mean+/-sem) inhibition, compared to aromatase expression induced by fsh alone. bpa also reduced levels of estradiol secretion in a dose-dependent manner, with the greatest inhibition at um (p< . ) resulting in +/- % decrease. we also evaluated expression of transcription factors known to be involved in regulating the activity of the ovary-specific aromatase proximal pii promoter. interestingly factors known for induction of aromatase such us steroidogenic factor- and gata- , mimic the pattern of cyp expression after bpa treatment, whereas, other receptors previously reported to act as aromatase inhibitor, such as ppar gamma were up-regulated by the addition of bpa. moreover, expression of creb remained virtually intact, suggesting that most likely mechanisms governing endocrine disruption by bpa are highly selective. conclusions: bpa inhibited fsh stimulated aromatase expression and downstream estradiol secretion. we propose that constant exposure to this chemical may result in endocrine disruption which may contribute to reduced fertility and early ovarian senescence. oocyte maturation occurs during folliculogenesis as a result of complex cell-tocell communications between the granulosa cells and the oocyte. maintaining the granulosa cells' spherical structure and network of gap junctions surrounding the oocyte is critical. this project tests the ability of a novel substrate-free threedimensional culture system to form viable granulosa cell spheroids. methods: after irb approval, freshly obtained follicular fluid from in vitro fertilization was obtained and granulosa cells were purified by percol gradient. nonadhesive agarose hydrogels, containing cylindrical round bottom recesses m in diameter, were cast from micro-molds designed using computer-assisted rapid prototyping. granulosa cells seeded at a density of , cells per gel were incubated for up to days. cellular viability was assessed with live:dead assay. results: after three days in culture, granulosa cells formed spheroids of densely packed cells that were difficult to disperse with multiple pipettings. the cells remained viable for at least days. conclusions: granulosa cells can be cultured in a novel substrate-free threedimensional culture system. the cells form tightly adherent spheroids that remain viable for extended culture. the cohesiveness of the cells suggests the formation of gap junctions. this is under investigation with immunohistochemistry and electron microscopy. these experiments suggest that a substrate-free threedimensional hydrogel culture system may be ideal to reassemble follicular structure important for future in vitro evidence testing and oocyte maturation. known to function as responders to pathogens, inflammation, and tissue injury. previous studies in our laboratory demonstrated that saa was produced in mouse granulosa and production was regulated by cytokines. ovulation has long been considered an inflammatory reaction and patients with chronic inflammatory conditions often experience infertility. the present study was undertaken to explore the role of saa in human ovarian function. methods: ovarian granulosa and luteal cells were obtained from surgically removed specimens and mural and cumulus granulosa-luteal cells were obtained from ivf aspirates. rna was extracted from fresh or cultured cells. some cells were treated in vitro with tnf or other cytokines for h. expression of saa was assessed by quantitative rt-pcr. in addition, serum levels of saa were determined using a commercial elisa in women undergoing ovulation induction (oi) and art. saa levels were measured at baseline, during oi, on the day of hcg administration and at the time of the pregnancy test. results: saa mrna was expressed in theca, granulosa, and granulosa-luteal cells. in granulosa-luteal cells both saa and saa mrnas were expressed at higher levels in cumulus compared to mural granulosa. expression of saa and saa in theca was increased following treatment with tnf in vitro. serum levels indicated that patients with ovulatory dysfunction had increased levels of saa at the time of hcg injection while patients without ovulatory dysfunction had lower saa levels as compared to the baseline level. in addition, patients undergoing oi who achieved pregnancy exhibited increased levels of saa at the time of the pregnancy test compared to baseline levels, whereas patients who did not become pregnant had lower post-cycle levels of saa. interestingly, saa levels did not change in art patients that became pregnant without undergoing oi (donor egg or frozen embryo transfer) conclusions: human ovarian cells express saa mrnas which can be altered in vitro. serum levels of saa may correlate with the responsiveness of the ovary to gonadotropins as evidenced by altered levels in women with ovulatory dysfunction, and by an increase in pregnant patients following ovarian stimulation. yeh, beom su kim, felicia hercules, jennifer peresie, armando arroyo. gynecology-obstetrics, university at buffalo, buffalo, ny, usa. objective: cisplatin is a common chemotherapeutic agent given to women for treatment for a wide variety of cancers. we hypothesize that one mechanism by which cisplatin may cause damage to ovarian structures is by decreasing the amount of anti-oxidant activity in the ovary. we examined super-oxide dismutase (sod ), a critical anti-oxidant enzyme that has been shown to be affected by cisplatin in other tissues, in the ovaries of cisplatin treated animals. methods: adult female sprague dawley rats were injected with saline, cisplatin . mg/kg or cisplatin . mg/kg as weekly doses. five days following the last injection, the rats were euthanized and both ovaries were excised. one ovary was processed for immunohistochemistry and the other was processed for protein analysis using western blot techniques for sod . the anti-sod antibody was purchased from santa cruz. the immunohistochemical sections were scored using a semiquantitative h scoring method. results: immunohistochemistry analysis of the expression pattern of sod following cisplatin administration revealed that there was a significant linear decrease in a dose response pattern in the expression of sod in antral follicles and in corpora lutea (p< . for both). no change was found in the h score of sod in other ovarian structures. western blot analysis of sod in the ovaries following increasing doses of cisplatin revealed no changes in the overall protein levels of sod in the ovary. conclusions: this is the first report that administration of cisplatin causes changes in the expression pattern of sod in antral follicles and in copora lutea. cisplatin decreases the amount of sod available in these structures, possibly leading to increased oxidative stress and free radical damage, thereby leading to ovarian damage found after cisplatin administration. is there evidence for aromatase activity in the stroma of postmenopausal ovaries? mf landay, rh fogle, rb allen, s patel, fz stanczyk, rj paulson. ob/gyn, usc, keck school of medicine, los angeles, ca, usa. background: following menopause, the ovaries continue to secrete androgens and estrogens. we have recently confirmed the production of androstenedione, testosterone and estradiol (e ) up to ten years after menopause by measuring gradients from ovarian venous effluent and peripheral blood. anti-müllerian hormone (amh) and inhibin b have been shown to be markers of follicular activity. peripheral levels of these hormones have previously been found to be undetectable in menopause, suggesting the absence of follicular activity in the postmenopausal ovary. objective: to investigate if the postmenopausal ovary continues to demonstrate evidence of follicular activity as the source of steroid production. design: observational study materials and methods: eight subjects aged ± . yr (range - ) were enrolled. postmenopausal status was confirmed by preoperative fsh levels of more than u/l and/or amenorrhea greater than months. serum was collected from the ovarian veins during total abdominal hysterectomy and bilateral oophorectomy. peripheral blood was also collected pre-operatively, intraoperatively and postoperatively. all samples were analyzed for amh and inhibin b using elisas with sensitivities of . ng/ml and pg/ml, respectively. androgen and estrogen levels in these samples have previously been reported, and documented a gradient between ovarian venous effluent and peripheral serum in all cases. results: ) six patients had no detectable follicular activity by amh and inhibin b levels. ) one patient demonstrated detectable inhibin b levels with an -fold gradient between ovarian venous effluent ( pg/ml) and peripheral blood ( pg/ml), however no amh was detected. ) in one patient, aged and months postmenopause, both amh and inhibin b were detected. peripheral inhibin b levels were high at pg/ml. amh was detectable at levels of . ng/ml. conclusions: ) in the majority of patients, continued e and androgen production in the ovary occurs in the absence of follicular activity as detected by amh and inhibin b production. ) some patients have evidence of follicular function up to ten years after menopause. ) since e is produced in post-menopausal ovaries in the absence of follicular activity, these data provide evidence for aromatase activity in the stroma of post-menopausal ovaries. to elucidate the process by which prostaglandin f (pgf ) mediates luteal regression, this study examined the role that the transcription factor yin yang (yy ) and histone deacetylase (hdac ) play in altering luteal cholesterol uptake by the scavenger receptor class b type i (sr-bi), intracellular cholesterol transport by steroidogenic acute regulatory protein (star), and cholesterol processing by p side chain cleavage enzyme (p scc) expression. rat luteal cells ( days post-ovulation) were treated with pgf ( hr) and trichostatin a (tsa; hr), a potent hdac inhibitor. protein expression was measured post-treatment by western blot and cholesterol was localized via filipin staining. star and sr-bi promoter activation was also assessed in hek t cells treated with yy , myy , a deletion mutant lacking an essential region required for transcriptional repression, and tsa. pgf caused a significant -fold decline in star (p< . ), and smaller declines in sr-bi and p scc which occurred concomitantly with an increase in yy ( -fold, p< . ) and intracellular lipid staining ( % increase). in contrast, nm tsa treatment caused a dose dependent increase in sr-bi, star, and p scc protein levels, . -fold (p< . ), . -fold (p< . ), . -fold (p< . ), respectively, and a . -fold decline (p< . ) in intracellular lipid levels. tsa prevented the pgf -induced decline in sr-bi, star, and p scc expression. promoter analysis demonstrated that wildtype yy , but not myy , repressed sr-bi and star activation while the addition of tsa overcame the repressive effects. this study shows the critical role that yy plays in pgf induced luteal regression by recruiting a histone deacetylase to block three essential processes in steroid production. in luteal cells yy -mediated global repressive action prevents cholesterol metabolism by inhibiting cholesterol uptake, intracellular transport, and processing thus leading to functional and structural luteal demise. supported by nih hd and nih hl . regulation of intermedin expression in cycling rat ovary. madhu chauhan, rebekah elkins, chandra yallampalli. obstetrics gynecology, university of texas medical branch, galveston, tx, usa. background: intermedin (imd) is a ct/cgrp family peptide involved in a variety of physiological functions, including vasodilatation and fetoplacental growth. this peptide is expressed in a variety of tissues such as stomach, placenta, uterus, pituitary and ovary suggesting its different functions including in reproduction. imd gene has an estrogen response element and we have shown that the plasma concentration of immuno-reactive imd is elevated in rats with pregnancy. however, expression of imd in the ovary and its regulation during estrous cycle is not known. we hypothesize that imd is expressed in the ovary and its expression is hormonally regulated throughout the estrous cycle in rat. objective: ) to assess expression of imd mrna and its receptors components calcitonin receptor like receptor (crlr), and receptor activity modifying proteins, ramp and ramp mrna in rat ovary; on diestrus, proestrus and estrus stages of rat estrus cycle and ; ) to demonstrate immunohistolocalization of imd, crlr, ramp , ramp and ramp in rat ovary. methods: groups of sprague-dawley non-pregnant and pregnant rats on day of gestation were used in this study. non-pregnant rats were sacrificed on diestrus, proestrus and estrus stage. ovaries were collected and total rna was extracted using trizol method. rna was treated with dnase before performing the reverse transcriptase polymerase chain reaction (rt-pcr). immunohistolocalization of imd, ramp , ramp and ramp proteins were assessed in tissue sections of ovaries from pregnant rats sacrificed on day . results: ) imd mrna is regulated in rat estrus cycle and its expression is significantly downregulated in estrus stage compared to the diestrus and proestrus; )expression of imd receptor crlr is highest in the diestrus stage, followed by a decline in proestrus which further declined during estrus; ) expression ramp mrna is higher in proestrus compared to diestrus and estrus (p< . ) but there is no significant change in the ramp expression during the estrus cycle and ; ) imd, ramp , ramp and ramp are immunolocalized in rat ovary in granulose cells of all follicles and granulosa cells of the corpus luteum. conclusion: imd mrna and protein are expressed in rat ovary suggesting a possible role for imd in ovarian function. defining and defying deterioration in oocyte quality with advancing chronological age: role of nitric oxide. pt goud, ap goud, mp diamond, b gonik, hm abu-soud. div reprod endocrinology, dept ob/gyn, wayne state university, detroit, mi, usa; div maternal and fetal medicine, sinai grace hospital, wayne state university, detroit, mi, usa. nitric oxide (no) is a ubiquitous free radical essential for oocyte maturation, function and sustenance of oocyte quality post-ovulation. the current study investigates the role of no insufficiency in the causation of oocyte quality deterioration with advancing chronological age. methods: in set , oocytes were retrieved from the following superovulated b d f mice: (a) young breeders (yb, n= ); (b) retired breeders (rb, n= ), and © old animals (oa, n= ), aged - , - , and - weeks respectively; and studied for zona pellucida dissolution time (zpdt), spindle ( -tubulin fluorescence immunocytochemistry, sigma) and chromosome morphology (dapi, vector), ooplasmic microtubule (mt) dynamics (omd) in response to taxol [ ], and cortical granule (cg) status (rhodamine conjugated lectin, vector). in set (n= ), oocytes from retired breeders were studied after exposure in vitro to an no-donor, s-nitroso acetyl penicillamine (snap in m- , . m no/min , n= , h, °c, % co ), while their sibling control oocytes were cultured for corresponding period under identical conditions without snap. [ ]. zpdt, spindle and chromosome morphology, omd and cg status were assessed with a confocal microscope and compared between the subgroups using anova, chi square and/or fisher's exacts test and appropriate post-hoc tests. results: in set , a significantly fewer oocytes were retrieved per animal (mean) in rb ( ) and oa ( ) compared to yb ( . , p< . ). advancing age was also associated with a significant increase in zpdt, omd and cg loss in rb compared to yb (p< . ). furthermore, significantly fewer oocytes from rb than yb had normal spindle and chromosome morphology (p< . ). oocytes from oa had significant spindle and chromosome disarray, a near total cg loss and significantly harder zp (p< . ). these oocytes also exhibited diminished omd in response to taxol although, metaphases were exquisitely sensitive to disruption with taxol. in set , exposure to snap in oocytes from rb resulted in a significantly lowerzpdt, omd and cg loss, and significantly higher incidence of normal spindles ( the gamma-aminobutyric acid (gaba), its biosnthetic enzyme gad and gaba-a receptors have been found in the oviduct and ovary. objective: this study examined the expression of gaba-a receptor subunit genes and gad and whether the gaba-a receptor could alter cytosolic ca + in gc. methods: for qrt-pcr, both human cumulus and mural gc were obtained at the time of oocyte retrieval for ivf and cultured separately. total rna was isolated separately from each gc type and from human brain ( positive control). the total rna from patients was pooled for each gc type and all rna was treated with dnase i. two-step qrt -pcr was performed using gene-specific lux™ primers for all gaba-a receptor subunits, gad and gad plus gapdh. single and specific qrt-pcr products were verified by melting curve analysis, gel electrophoresis, and dna sequencing. for ca + study, gc were cultured on coverslips. gc were loaded with fura- -am and changes in ca + concentration of gc were studied using a dynamic digital ca + imaging system. gaba-a agonist, muscimol, was used to study any dose-dependent effects on gc. gaba-a antagonist, m bicuculline, were perfused min. prior to and during application of muscimol. the responses were represented as changes in the / nm fluorescence ratio over time. m atp was used as positive control. results: the qrt-pcr results indicated that all gaba-a receptor subunits were expressed to various degrees in both types of gc, with the expressed highest in both cell types. gaba-a receptor subunits showing the next highest expression in both cell types were , and . gad isoenzyme was more abundantly expressed in cumulus and mural gc than gad . ca + imaging showed that muscimol, had the ability to increase ca ++ in gc, about % gc (n= ) cells responded to muscimol. muscimol increased intracellular ca + in a dose-dependent manner. the muscimol responsive cells was reduced by bicuculline, from % to % (n= , p< . ). conclusion: qrt-pcr indicates that gaba-a receptor subunit gene and gad expression occurs in both cumulus and mural gc. the ability of bicuculline to inhibit the ca + response to muscimol suggests the activation of gaba-a receptor. the current study confirms the presence of functional gaba-a in gc for the first time, and suggests that gaba may exert trophic effects in the ovary via gaba-a receptor. the present study test the hypothesis that administration of l-nitro-l-arginine methyl ester (l-name), a nos inhibitor, prior to hypoxia prevents the hypoxiainduced activation of p mapk, erk and jnk in the cerebral cortex of the guinea pig fetus during gestation. to test this hypothesis guinea pig fetuses at and days gestation were assigned to normoxic (nx, n= ), hypoxic (hx, n= ) and hypoxic pretreated with nos inhibitor (hx+l-name, mg/kg i.p., n= ) groups. hypoxia in the fetuses was induced by exposing the pregnant guinea pigs at both gestational ages to an fio of . for min. cerebral tissue hypoxia was documented biochemically by determining the tissue levels of atp and phosphocreatine (pcr). neuronal nuclei were isolated, purified and proteins separated by sds-page, and then probed with specific phosporylated erk, jnk and p antibodies. in the days gestation group: expression of p-p was . ± . (nx), . ± . (hx) . ± . (hx+l-name). p-erk expression was . ± . (nx), . ± . (hx), . ± . (hx+l-name). p-jnk expression was . ± . (nx), . ± . (hx), . ± . (hx+l-name). in the days gestation group: expression of p-p was . ± . (nx), . ± . (hx), . ± . (hx+l-name). p-erk expression was . ± . (nx), . ± . (hx), . ± . (hx+l-name). p-jnk expression was . ± . (nx), . ± . (hx) . ± . (hx+l-name). the data show that administration of l-name prior to hypoxia decreased the expression of phosporylated p , erk and jnk at both gestation ages however expression of phosporylation was higher at term as compared to preterm. since a nos inhibitor prevented the hypoxia-induced phosphorylation of p , erk and jnk in both gestational ages, we conclude that the hypoxia-induced activation of p , erk and jnk in the cerebral cortical nuclei of preterm and term guinea pig fetus is no-mediated. we speculate that no-mediated modification of cysteine residue leading to inhibition of map kinase phosphatases results in increased activation of p , erk and jnk in the guinea pig fetus. (nih-hd , nih-hd and st. christophers foundation for children). the the endocannabinoid, anandamide (aea), is involved in the hormone-cytokine network that regulates implantation and early pregnancy maintenance with levels at the endometrial level considered a major checkpoint . high levels ( nm) in culture are associated with embryo death while plasma levels (> nm) at weeks in women undergoing ivf-et are associated with failed pregnancy . what is uncertain is whether systemic aea levels after spontaneous conception in women presenting with threatened miscarriage are predictive of pregnancy outcome. our aim was therefore to measure plasma aea levels in women presenting with threatened miscarriage and to relate these to outcomes. methods: plasma aea levels were measured using a sensitive and previously validated hplc-ms method at - weeks gestation in women (nonsmokers, bmi < kg/m ) presenting with threatened miscarriage and in whom a viable pregnancy was confirmed by ultrasound scan. results: nine of the women subsequently had a miscarriage. the plasma aea levels in those women who had live births was . -fold lower than that in those who subsequently miscarried ( . ± . nm versus . ± . nm, mean ± sem; respectively; p< . unpaired student's t-test). the roc analysis revealed an area under the curve of . ± . with a sensitivity of % ( %ci of . % to . %) and a specificity of . % ( % ci of . % to . %). using an aea level of . nm as the optimal cut-off point, a single plasma aea measurement provided a sensitivity of % and a specificity of % with a negative predictive value of % and a positive predictive value of % for subsequent miscarriage. conclusion: these findings suggest a possible predictive role for plasma aea in women presenting with threatened miscarriage. the data also indicate that systemic aea levels may reflect local endometrial levels and therefore the local hormonal milieu in the early stages of normal pregnancies and in those complicated by threatened miscarriage. introduction: follicle stimulating hormone (fsh) mediates cyclic follicle growth and development and is widely used for controlled ovarian stimulation. the ovarian response of different women to fsh is variable, ranging from poor response to ovarian hyperstimulation and has been partly attributed to two common variants of the fsh receptor (fshr). we have previously identified four abnormal fshr splicing products ( exon deletions and intron insertion) in women with low and high response to fsh. two of the splice variants, deletion of exon and deletion of exon , showed a correlation with low and high response to fsh, respectively. in the current study, we evaluated the functional competence of the mutant fshrs in vitro. methods: we established stable hek cell lines expressing wild-type (wt) and splice-variant (del) fshr under the control of the inducible tet on/off system. the cells were transfected with a camp-responsive luciferase reporter plasmid and stimulated with fsh. results: the subcellular distribution of all splicing variants was the same as the controls and the protein localized mainly on the cell surface. all four splicing variants showed markedly decreased camp activation compared to controls when stimulated with fsh. however, all variants were able to form functional heterodimers with the wt receptor when co-expressed. interestingly, the heterodimer containing the form of fshr lacking exon , found in patients with decreased response to fsh, resulted in lower intracellular camp compared with the wild-type homodimer. conclusion: our findings suggest that fshr variants can contribute to abnormal response to stimulation in certain women undergoing ivf treatment. the variants require the presence of wild-type receptor in order to initiate signaling in response to fsh. further analysis of this signaling cascade in granulosa cells is underway to estimate the final production of estrogen from these heterodimeric receptors. objective: to compare the proteome of human endometrium in the prereceptive versus the receptive phases of the menstrual cycle. m m: endometrial biopsies were collected and days after urinary lh surge in the same menstrual cycle from three fertile women (n= ). proteins were extracted using sample grinding kit (ge healthcare) and interfering substances removed using -d clean-up kit (ge healthcare). labelling was performed with cydye dige fluors (ge healthcare) and proteins were separated using difference gel electrophoresis (dige). for the isoelectric focusing, cm ipg-strips in the nonlinear range of ph - were used. the second dimension was carried out using sds-page. differentially expressed proteins were detected by image analysis using decyder v . and the statistical module eda (ge healthcare). the spots of interest were subject to protein identification based on in-gel digestion, maldi-tof/tof mass spectrometry and database searching. western blot analysis were performed in the same biopsies in order to validate some candidate proteins. results: table displays the differentially protein abundance between days lh+ and lh+ (> -fold change). of these proteins, were increased at lh+ in comparison with lh+ , whereas only proteins were decreased. stathmin was found more than -fold decrease in lh+ compared to lh+ in the three patients studied in the validation studies performed by western blot. conclusions: this study shows that the human endometrium has a differential protein repertoire during the window of implantation compared to the prereceptive phase. the role of these proteins in the molecular events directed to embryo implantation is under research. differential protein abundance in human endometrium ( the extracellular signal-regulated kinases and (erk / ) are a mitogen-activated protein kinase (mapk) subfamily that act as key links in eukaryotic intracellular signaling transduction. activated by phosphorylation in response to specific stimuli, erk / is known to play a role in the regulation of cellular proliferation and survival. the human myometrium is a tissue known to undergo cycle-dependent proliferative and apoptotic changes in response to sex steroids. we hypothesized that erk / activity is involved in mediating menstrual cycle-dependent changes in the myometrium. materials and methods: immunostaining for phospho-erk and total-erk was performed on myometrial tissues obtained from normal women (n= ) at different phases of the menstrual cycle. staining intensities were evaluated by hscore. myometrial smooth muscle cells were isolated and cultured from normal women and treated with vehicle, estrogen ( - m), and progesterone ( - m) for and minutes, and then subjected to western blot analysis for p-and t-erk. statistical analysis was performed using one-way anova. results: tissue staining revealed that p-erk was mostly nuclear in all tissues, while t-erk was cytoplasmic and nuclear. p-erk staining was significantly stronger in the secretory phase and strongest at the early secretory phase, compared to other phases (p< . ). t-erk staining intensity was moderatehigh without variation across the menstrual cycle. in cultured myometrial cells, progesterone significantly increased p-erk levels within and minutes (p< . ) when compared to control. our results suggest that erk activity in the human myometrium is regulated in a menstrual cycle-dependent manner. the increased phosphorylation in the secretory phase suggests the involvement of progesterone in erk activation, as supported by our in vitro results. this increased erk activity may play a role in regulating myometrial proliferation. measures of insulin resistance (ir) including: fasting serum insulin, gir and homa. measures of plasma levels of endothelin- (et- ), soluble intercellular adhesion molecule- (sicam- ), soluble vascular cell adhesion molecule- (svcam- ) and high sensitivity c-reactive proteins (hscrp). results: women with pcos exhibited significantly higher levels of et- (p < . ), sicamp- (p < . ), svcam- (p < . ) and hscrp (p < . ) as compared with age-matched controls, respectively. positive correlations were evident between et- and fai (r = . ; p < . ) but et- negatively correlated with shbg (r = - . ; p < . ). svcam- positively correlated with total t (r = . ; . ), hscrp correlated with: bmi (r = . ; p < . ), and homa (r = - . ; p < . ), respectively. conclusions: women with pcos exhibited abnormal levels of endothelial and inflammatory markers, which appear to be inter-related to hyperandrogenaemia. ( ), and a higher expression of fatty acid amide hydrolase (faah) in peripheral lymphocytes post-ovulation ( ), suggest an involvement of the endocannabinoid system in menstrual cycle control. our aims were to investigate changes in plasma aea levels and in endometrial faah expression throughout the menstrual cycle. methods: plasma aea levels were measured using a hplc ms/ms method from women, median age yrs (range - ) and bmi kg/m (range - ), with regular menstrual cycles, with no medical problem and not on any medication for the preceding months. the menstrual cycle was divided to early follicular d - (n= ), late follicular d - (n= ), ovulatory d - (n= ), early luteal d - (n- ) and late luteal phases d - (n= ). uterine biopsies were taken from hysterectomy specimens taken for benign conditions and subjected to immunohistochemistry for faah with polyclonal antibodies. results: aea levels were significantly higher around ovulation in comparison to the pre-ovulatory or post-ovulatory phases as shown in the figure. faah expression in the endometrial stroma was unchanged throughout the follicular phase but increased during the mid to late luteal phase reaching a maximum in the late luteal phase. a high aea level in the early follicular phase and during ovulation suggests a role for aea in ovulation. the lower levels of aea in the luteal phase, essential for successful implantation, may be regulated by increased faah expression at the uterine level. the modulation of plasma aea levels during the menstrual cycle strongly suggests that it is regulated by gonadal steroid hormones. ( , , , , , , and , as well as at pregnancy. binding activities of igfbp and their protein levels (igfbp , , , , , ) were assessed by western ligand blot (wlb) and western blot (wb), respectively. the glyscosylation and phosphorylation status of igfbps were examined by deglycosylation treatment. our results showed that both glycosylated and unglycosylated igfbp elevate in fetal and newborn rat and graduately decline to a lower level at day and kept lower constant level since then. interestingly, biding activity of glycosylated igfbp was not detected by wlb assay. the igfbp- cleaved products were observed after rat day age day , which associated with a decrease in full length of igfbp- , suggesting endoproteolytic processing may involved in decreasing igfbp content. igfbp- , with heterogeneous glycosylation, were appeared after age day and disappeared during pregnancy, recurrence again postpartum. glycosylation of igfbp has no effect on its binding activity. unglycosylated and glycosylated igfbp were constant in life time. physiologically constant igfbp were detected by wb in protein, but not by wlb in binging activity. conclusion: highly elevated circulation igfbp suggest physiological role in new born and early postnatal development. its binding activity are well regulated by its posttranslation modification, such as glycosylation of igfbp in inactivating binding activity and possible involvement of active endoproteolytic processing in maintaining binding active igfbp- at low background: cigarette smoking affects hormone biosynthesis, storage, release, binding, transport and clearance, resulting in changes in circulating hormone levels. we used metabolomics to analyze the effects of cigarette smoking and second hand smoke (shs) on changes in hormone levels in women of childbearing age. methods: this is a three arm study; women aged - years who are active smokers, exposed to shs (passive smokers), or non-exposed were recruited from the washington d.c. area. all women completed a detailed staffadministered questionnaire probing their medical history, occupational, lifestyle factors and diet. blood and urine samples were collected at the follicular phase. hormone profiles were determined using metabolomics for serum thyroxine and triiodothyronine and steroid hormones, as well as for cotinine using isotopedilution tandem mass spectrometry (lc/ms/ms-api ). in addition, all samples were analyzed for serum lh, fsh, tsh and creatinine. results: the relationships of cigarette smoking, age, relative weight, and dietary intake to serum thyroxine, triiodothyronine, estradiol (e ), estrone (e ), progesterone (p), -hydroxyprogesterone ( ohp),dehydroepiandrosterone (dhea), dehydroepiandrosterone sulfate (dheas), androstenedione, cortisol, -deoxycortisol, corticosterone, testosterone, aldosterone and vitamin d were analyzed using lc/ms/ms. mean tsh in non-exposed, shs-exposed and smokers: . , . , and . miu/ml respectively. similarly, mean t . , . ( % increase) (p= . ), . μg/dl (- %) in active smokers; (active vs. exposed p= . ). shs increased dhea levels ( % higher, p = . ), dheas ( % higher, p = . ), cortisol ( % lower, p = . ), aldosterone ( % lower, p = . ) and androstenedione ( % higher, p = . ). these data suggest that active smoking and shs can have a profound effect on serum t , adrenal steroid and sex hormone concentrations in women of childbearing age. objective: to determine the prevalence and predictors of the metabolic syndrome (mbs) among in saudi women with polycystic ovary syndrome (pcos) in comparison to women without pcos and to assess the role of androgens and insulin resistance (ir) in mbs development. design: a prospective case control study. setting: tertiary referral university hospital. subjects: six hundreds saudi women living in the jeddah area were classified as follows: with pcos and age-matched women without pcos. interventions: blood samples were collected from all women with or without pcos between : - : , after an overnight fast. main outcome measures: measures of abdominal obesity, blood pressure and that of serum levels of lh, fsh, tsh, ft , -ohp, -a, dheas, total t, free t, shbg, insulin, hdl-c, triglycerides and plasma levels of glucose. measures ir including: fasting serum insulin, gir and homa. results: age-adjusted prevalence of mbs was higher in women with pcos ( . %, % ci: . - . %) as compared with women without pcos ( . %, % ci: . - . %) (p< . ). in the same age group, the risk of mbs in women with pcos was greater than that for women without pcos (p< . ). markers of ir were significantly abnormal in women with both pcos and mbs in comparison to those without mbs (p< . ). the most common abnormal components of mbs in women with both pcos and mbs (after adjustment for age) were: decreased hdl-c ( . ± . %); increased triglycerides ( . ± . %); and increased bmi ( . ± . %), respectively. the prevalence of mbs from lowest to highest tertile of free t level was . , . and . %, respectively; in women with both pcos and mbs. in women with pcos, % exhibited all components of mbs; . % had components, and . % had components. conclusions: women with pcos exhibited significantly higher prevalence of mbs ( . -fold) as compared with age-matched control without pcos. ir is a possible common pathogenetic factor for both mbs and the pcos. it is suggested that more intensive screening and/or therapy monitoring of mbs among women with pcos should be part of the therapeutic modalities of the condition. case of sisters with complete androgen insensitivity syndrome and discordant mullerian remnants. jennifer l nichols, jennifer j gell, eric j bieber. reproductive endocrinology and infertility, geisinger medical center, danville, pa, usa. complete androgen insensitivity is an x-linked recessive disorder resulting in the abnormal expression of the androgen receptor. affected individuals are most commonly phenotypically female but genotypically male. the prevalence of this disorder is in , live male births. we present a case of complete androgen insensitivity in members of the same family with differing residual mullerian tissue. sister a presented at age for evaluation of primary amenorrhea. a karyotype revealed ,xy. an mri of the pelvis showed a hypoplastic uterus but no ovaries. this patient underwent laparoscopic bilateral gonadectomy and hemihysterectomy. on examination under anesthesia, she was noted to have a normal vagina with no cervix noted. at laparoscopic evaluation, she was noted to have bilateral elongated gonads and what appeared to be a remnant of uterine tissue. pathology revealed portions of immature testicles and fragments of smooth muscle in what grossly appeared to be the uterine remnant. the patient's total testosterone following surgery was noted to be elevated at . ng/ml. other laboratory evaluation showed fsh . miu/ml, lh . miu/ml, free testosterone . pg/ml, and estradiol . pg/ml. approximately two years later sister b presented at age for evaluation of primary amenorrhea. no uterus or ovaries were visualized on pelvic ultrasound. again a karyotype revealed ,xy. laboratory evaluation demonstrated fsh . miu/ml, lh . miu/ml, estradiol . pg/ml, total testosterone . ng/ml, and free testosterone . pg/ml. she underwent a laparoscopic bilateral gonadectomy. no uterus, cervix or pelvic masses were identified on exam under anesthesia. at laparoscopy, both gonads were visualized and removed without difficulty but no uterus was visualized. pathology reported two testicular and epididymal-like structures. this case demonstrates the presentation and laparoscopic results of complete androgen insensitivity syndrome discovered in two siblings. although both girls are genotypically male, they differ in the presence of vestigial mullerian tissue. the case shows with complete androgen insensitivity, as an x-linked defect, one should consider apparent sisters of affected individuals, as well as offspring of unaffected individuals with a family member diagnosed. background: anandamide (n-arachidonoylethanolamine, aea) is an endocannabinoid that binds to and activates the cannabinoid receptors, cb and cb and may have important roles in the regulation of human reproduction. the traditional lipid extraction methods used for aea are cumbersome, slow and of low efficiency. the aim of this study was to determine whether the use of a solid phase (spe) method of aea extraction from human plasma would offer any advantages over the traditional liquid phase (lpe) method. methods: pooled human plasma was obtained from the local blood transfusion unit and aliquots stored at - °c prior to extraction. an internal standard of . pmol of deuterated aea (aea-d ) was added to each plasma sample and aea extracted from aliquots on each occasion over three days using the lpe and spe methods. spe was performed with waters oasis hlb cc/ mg cartridges on a waters vacuum manifold. cartridges were activated with methanol and water, the samples applied and washed with % methanol at ml/min. aea was eluted with ml acetonitrile and the eluents dried under a stream of nitrogen before reconstitution in ml acetonitrile. aea levels were measured using uplc-ms/ms against authentic standards. results: these are shown in the table. conclusion: the spe method was -fold more efficient at extracting aea compared to the traditional lpe method. the intra-day and inter-day assay variability were similar for both techniques, although the spe method was quicker, cheaper and required less plasma to generate data similar to that from the traditional lpe method, suggesting that the spe method may be more efficient than the lpe method, and thus making it more suitable for routine analysis of multiple plasma aea samples. background: the precise role of the endocannabinoid, anandamide (narachidonoylethanolamine, aea) in reproduction has been hampered by difficulties in its accurate measurement. aea levels have previously been measured by tlc, gc-ms and hplc-ms but these are laborious. our aim was to improve the analysis of aea using uplc and tandem ms/ms with a standard isotope-dilution method , . methods: authentic non-labelled and deuterium-labelled aea (aea-d ) diluted in acetonitrile were maintained at °c before analysis and separation by uplc on a c ( . x mm) column maintained at °c using a gradient of % a, . min: % a, . min: % a, . min: % a, . min: % a with a flow rate of . ml/min. the mobile phases were a ( mm ammonium acetate, . % formic acid) and b (acetonitrile, . % formic acid). the analytes were quantified using multiple-reaction monitoring in positive ion mode with a quattro premier mass spectrometer. entry, collision and exit energies were - , and - ev, respectively. calibration curves were performed in triplicate with . pmol aea-d as the internal standard. transitions employed were . > . and . > . for aea and aea-d , respectively. results: calibration curves ( . to fmol aea on column; n= ) were linear, producing a mean (±sd) gradient of y = . ± . x, crossing the y-axis very close to the origin ( . ± . units). variability was limited, with an r = . . measurements were precise, fmol aea produced a cv of only . %, and the retention time was consistent at . ± . min (n= ). the limit of quantification (signal/noise> ) was . fmol on column and the limit of detection (lod) was . fmol on column (signal/noise= ). accuracy for . fmol, . fmol and fmol aea was . ± . %, . ± . % and . ± . %, respectively. conclusions: the method described is an improvement over other lc-ms/ms methods , with a lower lod [ . fmol v. fmol or fmol ] and shorter run time [ min v. min or . min ]. thus, an improvement in terms of speed, increased sensitivity and better reproducibility will allow for a more accurate assessment of aea concentrations in a number of biological samples. objectives: the gata family of transcription factors consists of six zinc-finger proteins with a critical role in tissue-specific and developmentally-regulated gene expression. gata factors exert their effects alone and through interactions with cofactors, such as friend of gata (fog), as well as with nuclear hormone receptors, including steroidogenic factor- (sf- ), a well-described activator of gonadotropin gene expression. the objective of these studies was to define the role of gata family members in the gonadotrope. methods: ) total rna was extracted from the gonadotrope cell line, l t , and analyzed by standard rt-pcr analysis. ) the cv- fibroblast cell line was transiently transfected by the calcium phosphate precipitation method with a rat - /+ lh promoterreporter vector as well as cmv-driven expression vectors for gata- , gata- , dngata- , fog- and/or sf- . results: gonadotrope l t cells were found to express transcripts encoding gata- , gata- , and gata- as well as fog- and fog- . gata- and gata- stimulated lh gene promoter activity by approximately -fold (p< . ) and synergistically increased the sf- response ( -fold versus -fold for sf- alone; p< . ). the gata-mediated increase in lh gene expression was nearly eliminated with co-transfection of fog- . similarly, co-transfection with a gata- dominant negative construct blunted wild-type gata- effects in a dose-dependent fashion. conclusions: these data demonstrate expression of both gata and the functionally related fog proteins in a well-characterized gonadotrope cell line. furthermore, they demonstrate a functional role for these factors in regulation of gonadotrope function, specifically expression of the lh gene. low-dose dexamethasone (dex) therapy early in pregnancy is used in fetuses with suspected risk of congenital adrenal hyperplasia. several adverse neurological events in prenatally treated children have been reported and the fetal hypothalamic-pituitary-adrenal (hpa) axis may be involved. aim: to investigate the immediate and long-term effects of early maternal dex administration on fetal growth and pituitary-adrenal activity in sheep. method: pregnant ewes carrying singleton fetuses (total n= ) were randomized to control ( ml saline/ewe) or dex treatment ( . mg/kg ewe weight) consisting of four intramuscular injections at -hourly intervals over hours on - days of gestation (dg). at , , , and dg fetal weights were recorded. i -ria, qrt-pcr and in-situ hybridisation were used to measure fetal plasma cortisol and acth levels and to analyse adrenal and pituitary mrna expression. results: dex-exposed fetuses were lighter than control animals at dg*, but not at other times; in general fetal organ weights were similar between treatment groups. fetal plasma acth was unaffected by dex and did not differ between genders. similarly, pomc and pc- mrna in pars distalis were unaltered after dex. however, fetal plasma cortisol was reduced after dex in both male and females at dg*, was similar at and dg, then elevated at dg*. plasma cortisol in female fetuses in control and after dex was significantly higher than in males. the increases in cortisol after dex at dg* were associated with increased fetal adrenal expression of p c and bhsd mrna in females, reduced expression of mc r in males, but no difference in star mrna. conclusion: we conclude that in sheep, early dex programs the developmental trajectory of the fetal hpa with increased activation directly of the adrenal, but not pars distalis function. in females this effect may be attributed to increased fetal adrenal steroidogenic activity. the effect of dex in increasing cortisol in males, albeit at a significantly lower level than in females, appears to be independent of the enzymes that we have measured.*p< . . synaptophysin and gonadotropin-releasing hormone (gnrh) are colocalized in rat hypothalamus. armando arroyo, beom su kim, amanda biehl, blenna cl bett, , john yeh. gynecology-obstetrics, university of buffalo, buffalo, ny, usa; physiology and biophysics, university at buffalo, buffalo, ny, usa. the cellular and molecular mechanisms that control gonadotropin-releasing hormone (gnrh) release are not completely understood. gnrh is stored in synaptic vesicles and released by exocytosis at gnrh nerve terminals. there are currently nine families of synaptic vesicle proteins that are involved in neurotransmitter release by exocytosis. synaptophysin is one of the most common synaptic vesicle proteins present in synaptic vesicles in neurons. the hypothesis of this study is that synaptophysin is expressed in gnrh neurons. we obtained sections from the hypothalamus of female sprague dawley rats. double-label fluorescence immunohistochemistry was performed on free-floating sections. sections were incubated with a mixture of mouse monoclonal antibody against gnrh ( : -chemicon international) and with a rabbit polyclonal antibody against synaptophysin ( : -santa cruz biotechnology) for h. after incubation the sections were washed and incubated with a mixture of alexa conjugated goat antimouse and alexa conjugated goat antirabbit ( : ; molecular probes) for h. slices were visualized with confocal microscopy (zeiss lsm- ). fifteen out of a total of fifteen gnrh cell bodies in the medial preoptic area and most gnrh neuron terminals in the median eminence showed intense immunostaining for synaptophysin. this is the first study to demonstrate that synaptophysin is expressed in rat gnrh neuron terminals. this suggests that synaptophysin is present in gnrh neuron vesicles. thus, gnrh release by exocytosis may be mediated by synaptic vesicle proteins. objective: our aim was to identify the effects of early gestation gc exposure on fetal and postnatal hpa axis development and function in postnatal life. method: pregnant ewes carrying singleton fetuses were randomized to control ( ml saline/ewe) or dex groups ( . mg/kg), consisting of four at h intervals on days - of pregnancy. at months postnatal age, catheters were implanted; a bolus injection of crh ( . mg/body weight) and avp ( . mg/body weight) were administered and arterial blood samples were taken at - , - , , , , , , , and min. levels of hepatic cbg mrna were determined by qpcr, expressed relative to s rrna. plasma cortisol and cbg levels were measured by radioimmunoassay. results: both total and free cortisol levels in the dex females (n= ) were lower than in dex males (n= ) from to min (p . ) and lower than in control females (n= ) at minutes (p . ), also in the dex-m group were higher than in control males (n= ) at min (p . ). plasma cbg levels and cbg mrna expression were not altered by dexamethasone exposure or sex. conclusions: these findings suggest that prenatal glucocorticoid exposure alters the development of the hpa axis differentially according to the sex of the exposed fetus. to determine maternal injections of synthetic glucocorticoids in early gestation can alter expression of hippocampal corticosteroid receptors at months postnatal age. method: pregnant ewes carrying singleton fetuses were randomized to control ( ml saline/ewe) or dexamethasone treatment ( . mg/kg) consisting of four injections at h intervals on days - . hippocampal was collected from the offspring at months postnatal age. levels of mrna of gr and mr were determined using qpcr and levels relatived to s rrna. results: dexamethasone-treated male animals (n= ) had significantly higher levels of mr gene expression than both control males (n= ; p= . ) and females (n= ; p= . ). gr gene expression levels were higher in treated vs. control males (p= . ), but in females levels in treated and control animals were similar. total body, brain and hippocampus weights were similar. conclusions: maternal dexamethasone administration in early pregnancy resulted in gender-dependent changes in hippocampal gene expression when measured in the offspring seven months after birth. objective: diminished ovarian reserve (dor) affects many younger women. we analyzed superovulation with intrauterine insemination (so) cycles in vitro fertilization (ivf) cycles of women with dor to determine if women < with dor differ from their older counterparts. method: irb approved retrospective review of so ivf cycles from / - / with follicle stimulating hormone (fsh) levels based on age < or . results: so cycles were performed in women. no differences were noted in clinical pregnancy. women < were more likely to have inseminates with a lower mean tms/ins, median tms/ins was . among pregnancy cycles compared to for unsuccessful cycles. for ivf, mean total gonadotropin dosage was significantly lower in women < , mean number of follicles mm peak e were significantly higher in women < . so ivf measures are in tables , respectively. conclusions: similar clinical pregnancy outcomes were seen despite age. in ivf, women < required less gonadotropins and generated more follicles but with no significant difference in number of mature oocytes or clinical pregnancies. of note, pregnancy rates for so in women < with dor are substantially lower than expected in our clinical practice. as ivf yielded a substantially higher chance of pregnancy, consideration should be made to expedite progression to ivf. to assess the effects of intraovarian injection of ad-fshr on the reproductive system of fshr (-/-) mice. methods: about l containing x pfu of ad-hfshr were injected directly into each ovary of treated group and same amount of ad-lacz were injected into the ovaries of control animals. vaginal smears were collected and body weight was measured daily. four weeks after the injection animals were sacrificed and all organs were weighted and evaluated by h e. fsh, e and p measured before and after treatment. results: ad-hfshrtreated mice showed obvious estrogenic changes in vaginal smear while in control animals vaginal smear remained at diestrus stage. significant increase in total body weight and estrogen dependent organs weight (uterus, ovary, vagina) was observed in treated animals compare to control group (p< . ). no significant weight changes were observed in other organs. h e evaluation of the ovaries showed significant increases in both the total number of follicles and the collective diameter of the follicles in treated animals compare to controls. on average follicles/ovary were observed in ad-hfshr-treated group of which follicles were at the antral stage while only follicles observed in ad-lacz control group, with zero follicles at antral stage. a . to folds increase in e and about % decrease of fsh observed in treated animals compared to control mice. there was no significant change in serum progesterone level between treated and control groups. conclusion: intraovarian injection of an adenovirus expressing human fshr gene is able to restore folliculogenesis and resume estrogen hormone production in female forko mice. objective: the sentinel issue surrounding multiple gestations following ivf is the inability to precisely estimate the reproductive potential of individual embryos with the currently used embryo grading systems based on embryo cleavage rate and morphology. recently, metabolomic profiling of spent culture media using raman and near-infrared spectroscopy have been reported to predict reproductive potential of embryos. in this study we applied proton nuclear magnetic resonance (¹h nmr) spectroscopy to analyze metabolomic profile of embryo culture media and to identify components of the media that correlate with reproductive potential. methods: eighteen spent media samples from embryos that failed to implant, and samples from embryos that resulted in pregnancy and delivery were individually collected after embryo transfer on day , and evaluated using ¹h nmr. the spectra obtained were analyzed using a selective genetic algorithm (ga) to determine regions predictive of pregnancy outcome as determined by logistic regression. to avoid random correlations, a leave-one out crossvalidation was used. sensitivity and specificity of predicting pregnancy (described as implantation and delivery) were calculated. results: using the ga, two areas in the ¹h nmr spectral region were identified as most discriminatory between the two groups. viability indices calculated by ¹h nmr using these regions were significantly higher in culture media of embryos with proven reproductive potential ( . ± . ) compared to those that failed to implant ( . ± . ) (p< . ). compiled outcomes from the leave-one-out cross-validation of the logistic regression using the ¹h nmr measurements resulted in a sensitivity of % and a specificity of . %. quantification by integration showed significantly decreased glutamate levels (p= . ) and a trend toward an increase in pyruvate levels (p= . ) in culture media of embryos that did not cause pregnancy. conclusion: metabolomic profile of spent embryo culture media using ¹h nmr correlates with the reproductive potential of embryos. the lower glutamate levels detected in culture media of embryos that failed to implant could potentially be due to the toxicity associated with increased embryonic glutamate uptake. additional studies using complementary approaches are needed to further delineate molecular components associated with reproductive potential. objective: beta-carotene and other carotenoids are known antioxidants previously identified in human follicular fluid (ff). in addition to their inherent antioxidant properties, carotenoids have been identified as precursors of the antioxidant retinol in bovine ff. high retinol levels in bovine ff are associated with non-atretic follicles. this would suggest a possible role for retinol and its carotenoid precursors in follicular heath and the general oxidative state of the follicle. we sought to measure carotenoids and retinol in the ff of women undergoing ivf and correlate these levels with normal fertilization as a marker of follicular/oocyte health. design: prospective cohort study materials and methods: ff from a single - mm follicle was obtained from women (age - ) undergoing ivf and intracytoplasmic sperm injection (icsi). serum was also obtained at the time of oocyte retrieval. retinol, vitamin e ( , , and tocopherol) and carotenoids ( -carotene,cryptoxanthin, lycopene and lutein/zeaxanthin) were measured using hplc. we correlated ff carotenoid and retinol levels with oocyte fertilization status following icsi. results: as previously reported, retinol, vitamin e and carotenoids were all identified in the ff. each fat-soluble vitamin level was significantly lower in ff compared to serum (p< . for all analytes) and the levels were strongly correlated (r > . , p< . for all analytes). mean levels of ff -carotene were significantly higher in those follicles that resulted in a fertilized oocyte ( . +/- . g/ml vs. . +/- . g/ml, p= . ). other carotenoids, retinol, and vitamin e levels did not correlate with fertilization outcomes. conclusions: our finding of a strong association between ff -carotene concentration and subsequent normal fertilization of the oocytes suggests an important antioxidant role for -carotene in the health of the human ovarian follicle/oocyte. the lack of correlation with other carotenoids, retinol and vitamin e suggests that the antioxidant properties of -carotene act by preventing singlet oxygen and scavenging the peroxyl radical and may directly influence oocyte competence. mature oocytes obtained during egg retrieval have been shown to undergo spindle depolymerization as a result of cooling. for this reason, ivf programs strive to maintain constant temperature during follicle aspiration. we sought to elucidate if there was a difference in temperature of fluid aspirated into a hand held (hh) or heating block (hb) encased collection tube. the experiment was performed in an ambient temperature of °c. thermistors, pinhead sized sensors with an accuracy of %, were used to monitor temperature differences between control fluid (cf) (sterile water ºc) and aspirated fluid. data was recorded using an -channel data acquisition system from dataq instruments. one thermistor was placed into the cf, the other was placed into an empty collection tube set in the heating block or held in a gloved hand. a cm, gauge, single lumen needle connected to cm of tubing was used to aspirate into the empty collection tube. temperature was recorded x/second, each experiment was repeated times. baseline empty collection tube temperature was significantly cooler in the hh vs the hb group ( . ± . °c vs . ±. °c, p=. ). two seconds after aspiration, the lowest aspirate temperature was observed, (hh . ±. °c, hb . ±. °c, p>. ) no difference between groups. in both groups, temperature quickly increased as aspiration progressed (hh . ±. °c, hb . ±. °c, p>. ). the hb group took an average of . min to return to baseline ( °c), the hh group never returned to baseline. substantial cooling of aspirated fluid occurs during oocyte retrieval, with a mean temperature decrease of . ±. °c corresponding to . °c. considering this dramatic decrease, the difference between temperatures in the hh vs. the hb group is negligible. current aspiration systems poorly regulate temperature, thus the choice of aspirating into a test tube warmed by hand or by heating block is inconsequential. clinical management of twin gestations with recurrent preterm labor symptoms. lesley de la torre, luis roca, niki b istwan, debbie j rhea, gary j stanziano, victor hugo gonzalez-quintero. obstetrics and gynecology, university of miami medical center, miami, fl, usa; clinical research, matria healthcare, marietta, ga, usa. objective to examine pregnancy outcomes in women with twin pregnancies receiving nifedipine tocolysis (nt) who experienced recurrent preterm labor symptoms (rptlsx). study design twin pregnancies enrolled for outpatient preterm labor (ptl) surveillance services prescribed nt following an initial episode of ptl were identified from a database (n= ). eligible for inclusion were patients later hospitalized with acute rptlsx (n= ). included were those < weeks' gestational age (ga), with intact membranes, remaining undelivered for > hours after rptlsx . pregnancy outcomes of women resuming nt (rnt group, n= ) following hospitalization were compared to those having an alteration in treatment (alttx group, n= ) to continuous subcutaneous terbutaline. per normality assumptions, either independent student´s t or mann-whitney u test statistics were used for continuous variables; pearson´s chi-square for categoric. all p-values presented as two-sided, significant at < . . results overall, ( . %) of twin pregnancies prescribed nt experienced rptlsx; ( . %) were not eligible for continued tocolysis. pregnancy outcomes are presented in table. conclusion rptlsx are common. in twin pregnancies receiving nt, alteration of tocolytic treatment following rptlsx had a positive impact on pregnancy prolongation and neonatal outcomes. routine cervical dilatation during elective cesarean section -is it really necessary? arie koifman, avi harlev, eyal sheiner, fernanda press, arnon wiznitzer. obstetrics and gynecology, soroka university medical center, ben-gurion university of the negev, beer-sheva, israel. objective: the purpose of this study was to examine the necessity of routine cervical dilatation during elective cesarean section. material and methods a retrospective cohort study was performed, including all cases of elective cesarean sections performed at a tertiary medical center during . stratified analysis, using the mantel-haenszel technique, was done to control for confounders. results out of a total of elective cesarean deliveries (cd), underwent routine cervical dilatation. the overall rate of febrile morbidity was . %. no significant differences in postpartum febrile morbidity were noted between the groups ( . and . %; p= . ). in addition, hospitalization duration did not differ between the groups ( . ± . and . ± . days p= . ). about % of all elective operations were repeated cd. there was no difference in febrile morbidity between the groups even in that subgroup of the elective cd. likewise, there was no difference in anemia rate between the two groups (hemoglobin . ± . mg and . ± . mg p= . ). controlling for a previous vaginal delivery, using the mantel-haenszel technique, no significant association was noted between cervical dilatation and fever (weighted or= . ; % ci . - . ; p= . ). nevertheless, in a subgroup of patients following a previous vaginal delivery, cervical dilatation was significantly associated with post-operative fever (or= . the majority of women with an unfavorable cervix undergoing iol at term deliver vaginally, even with a prolonged first stage of labor. this is important information to discuss with women prior to iol when establishing labor expectations. providers should consider the ongoing success of labor induction when contemplating a diagnosis of "failed induction". objective: this study was performed to investigate and compare changes of the lipid peroxide levels and the protein carbonyls formation in the maternal venous plasma of preterm premature rupture of membrane (pprom) during antibiotics administration. materials and methods: thirty-six pregnant women with pprom between and weeks of gestation were chosen for this study. eighteen patients (group ) were treated with amoxicillin and erythromycin for day period while the other patients (group ) were treated with rd generation cephalosporin and erythromycin for the same period. samples of maternal blood were obtained from the two groups at before the antibiotics administration, day , and day after the antibiotics administration. lipid peroxide levels were measured by thiobarbituric acid reaction and protein carbonyl contents were determined by the , -dinitrophenylhydrazine method. results: . the lipid peroxide levels and protein carbonyls formation in the maternal venous plasma of pprom was significantly higher than that of normal pregnancy ( . ± . vs . ± . nmol/mg protein, p< . ), ( . ± . vs . ± . nmol/mg protein, p< . ). . there were no significant differences in the lipid peroxide levels and protein carbonyls formation of the maternal venous plasma with pprom mixed and incubated by amoxicillin, cefodizime, and erythromycin (in vitro). . there were no significant differences in the lipid peroxide levels and protein carbonyls formation of the venous plasma of group among before the antibiotics administration, day , and day after the antibiotics administration. . the protein carbonyls formation in the venous plasma of group was significantly decreased at day and day after the antibiotics administration than that of before the antibiotics administration ( . ± . , . ± . , . ± . nmol/mg protein, p< . ). conclusion: in the maternal venous plasma of pprom, the lipid peroxide levels and protein carbonyls formation were increased. the results suggest that reactive oxygen species formation by inflammatory reaction is suppressed by combined treatment of rd generation cephalosporin and erythromycin. objective: the aim of the present prospective cohort study was to evaluate the correlation between blood flow pulsatility index in fetal middle cerebral artery (mca) and the onset of spontaneous labor. study design: doppler evaluation of fetal mca were performed between and weeks gestation in consecutive pregnant women with a singleton pregnancy and known gestational age. the study population was divided according to the mca pi (< . or >/= . mom) and, using survival analysis and cox regression, the two subgroups obtained were compared. in these analyses, the event was delivery (following spontaneous labor) and the time variable was time elapsed since doppler exam. results: the median time elapsed between doppler evaluation and spontaneous labor was significantly shorter in the women with mca pi lower than . mom ( . days, interquartile range - ) in comparison with the women with mca pi higher or equal than . mom ( . days, interquartile - . days (p< . , mann-whitney test). after correction for birth weight and umbilical artery pi, survival analysis and cox regression confirmed that mca pi was independently associated with the number of days elapsed from doppler to spontaneous labor and delivery (p< . , exp(b) . , ci % . - . ). conclusions: the present data show that, at term of pregnancy, fetal cerebral resistance reduction anticipates the onset of spontaneous labor. novel calcium sensitizers and human uterine contractility. mark p hehir, audrey t moynihan, terry j smith, john j morrison. department of obstetrics and gynaecology, national university of ireland, galway, ireland. objective: the factors regulating contractility of uterine smooth muscle are central to the occurrence of preterm labour and delivery. calcium sensitizers are a novel class of drugs with unique molecular actions. levosimendan, the best characterized of these compounds, is used in the treatment of acute and chronic heart failure and is a compound which exerts a number of effects on smooth muscle. it can exert an inotropic effect via sensitization of myofilaments to calcium and also exerts a relaxant effect by opening atp-dependent potassium channels. for these reasons we hypothesized that levosimendan may have an effect on myometrial contractility and investigated its action on both spontaneous and agonist induced contractions. method: biopsies of human myometrium were obtained at elective caesarean section (n= ). dissected myometrial strips suspended under isometric conditions, undergoing spontaneous and oxytocin-induced contractions, were exposed to cumulative additions of levosimendan in the concentration range of nmol/l to mmol/l. two sets of control experiments were performed simultaneously as follows: . strips exposed to either physiological salt solution (pss) only, for spontaneous contractions, or . nmol/l oxytocin; . strips exposed to pss/oxytocin and vehicle for levosimendan. results: levosimendan exerted an inhibitory effect on spontaneous and agonist induced contractions, compared to control strips. the mean maximal inhibition values were as follows: . ± . % for spontaneous contractions (n= ; p< . ) and . ± . % for oxytocin-induced contractions (n= ; p< . ). no significant difference was found between control and control for both spontaneous and oxytocin induced contractions. conclusion: the calcium sensitizer levosimendan exerted a potent relaxant effect on uterine contractility in vitro. this action was seen in both spontaneous and agonist induced contractions. the results from this study raise the possibility of calcium sensitizers holding potential tocolytic properties in vivo and further studies are required to investigate the potential benefits of this novel class of drugs. to determine to what degree extensive patient movement affects uterine emg signals and toco signals. study design: pregnant term labor patients were recorded using both uterine emg and toco simultaneously. baseline recordings were obtained when patients were still, and these were used as control records. test recordings for both devices were obtained from all patients by asking the patients to perform movements. area under the rectified-voltage amplitude curve of the uterine emg signals and area under the curve for the toco signals were found. mean %-increase was calculated for the uterine emg and toco devices (each device %-increase values were averaged over all patients). mann-whitney rank-sum test was used to look for any statistical differences in %-increase in area for uterine emg vs. toco methods (p < . considered significant). results: there was a large increase in activity (artifact) on both devices' signals during patient movement (figure ) . both devices' traces eventually returned to baseline after the patient movement stopped. toco movement artifact was significantly higher than emg movement artifact ( table ) . conclusions: both uterine emg and toco signals experience artifact when patients move the uterine emg electrodes and toco pressure transducer, respectively. toco seems to be more adversely affected by such movements. uterine emg may be a preferred method for monitoring contractions of laboring patients in the clinic. supported by grant nih r -hd . results: % of obstetricians completed the questionnaire. none would counsel patients against labour unless there were contraindications. the majority would recommend labour for all indications for previous caesarean section investigated although in all instances, personal preferences were lower (p< . ); after a failed instrumental delivery, % obstetricians would recommend labour but only % would choose that option for themselves (p< . ). overall, female obstetricians would contemplate and recommend labour more readily than male obstetricians. labour augmentation and induction were recommended to patients more frequently ( % and % respectively) than chosen for personal care ( % and %). reluctance for labour augmentation and induction was greatest among younger consultants. conclusion: consultants have responded to consumerism and aim to meet the requests of their patients. they more readily recommend labour than they would choose for personal care, and a majority would recommend labour induction when necessary. informed patient choice is paramount rather than attaining a target figure for women attempting to labour, and the views of those requesting delivery by caesarean section should be respected. (table) . cd increased in nullipara singleton, cephalic, term pregnancy in spontaneous labor, mostly due to dystocia; nullipara singleton, cephalic term pregnancy with induced labor, mostly due to non-reassuring fetal status and dystocia; singleton, cephalic term pregnancy with previous cd, mostly due to elective cd; singleton cephalic preterm. no changes in neonatal outcome were observed. conclusion: clinical audit was useful to keep under control cd rate in our institution in comparison with italian reality, but it was not sufficient to maintain stable cd rate suggesting the need of other, multifaceted strategies. elective delivery at weeks' gestation is a common obstetric intervention. the purpose of this study is to estimate the maternal mortality rates (mmr) associated with this acog -approved intervention. there are no reliable us data describing mmr by mode of delivery. therefore, we base our estimates on british data indicating a procedure related mmr of . / , , . / , and . / , for vaginal, elective cesarean section (c/s) and emergency-unplanned c/s deliveries, respectively. a decision tree model was constructed assuming that all eligible patients (approx. , , /annually in the u.s.) would be delivered at weeks by either an elective c/s or an induction of labor. we further assumed that % of inductions would result in a vaginal delivery. our estimates show that the annual, delivery-related maternal mortality associated with an elective delivery of all patients at weeks would be and for elective c/s and induction of labor, respectively. because vaginal delivery results in the lowest mmr, we performed a oneway sensitivity analysis to identify the impact of changing the success rate of induction on the estimated mmr. the results indicate that once the success rate exceeds %, this intervention would be associated with a lower mmr as compared to elective c/s. our estimates indicate that although the overall mmr associated with elective delivery at weeks is relatively low (approximately . / , deliveries), it is certainly not negligible. in addition, the mmr is highly dependent on the likelihood of a successful vaginal delivery following induction of labor. when the success rate for induction of labor falls below %, an elective c/s appears to be the safer delivery method. background: the first obstetric visit is an opportunity to provide the pregnant patient information regarding substances that can cause potential harm to the pregnancy. little is known about how obstetric care providers handle these topics. objective: to examine patient-provider communication about substance use during the first prenatal visit. methods: we audiotaped first prenatal visits and qualitatively analyzed those tapes in which patients disclosed substance use. we invited patient participants to return for a semi structured interview during which they reviewed their audiotaped conversations and described their reactions to the providers' communication styles. results: providers ( residents, midwives, nurse practitioners) and patients participated. providers asked about smoking, alcohol and drug use in all ( %) visits. patients reported being smokers, reported alcohol use, and reported drug use. provider responses to smoking disclosures included brief discussions of smoking effects on pregnancy, encouragement to quit/cut down, and referral to smoking cessation programs. provider responses to alcohol or drug disclosures included only general statements regarding effects on pregnancy (e.g., "we find that this is bad for babies.") and referral to ultrasound/genetics for reassurance. few alcohol or drug discussions assessed whether the patient had intentions or concerns regarding continued use during the pregnancy. few discussions addressed strategies for behavioral change. none included assessment for motivations, readiness, or barriers to change. in follow up interviews, patient participants said they expected to be asked about substance use but advised providers to ask non-judgmentally. those who used alcohol/drugs wanted more information on potential effects of these substances on the pregnancy/fetus and appreciated the reassurance from referrals to ultrasound/genetics. discussion: counseling for risky behaviors in the first obstetric visits contained only limited discussion of the effects of the risky behaviors and primarily focused on referral-which may be a proxy for avoiding a difficult and time consuming conversations. background. there are conflicting results regarding the association of maternal psychiatric disorders or psychological distress due to stressful life events with pre-term birth and low birth weight. aims. to investigate the association between maternal psychiatric disorders and/or stressful life events and intrauterine growth abnormality, low birth weight or preterm birth. method. three mutually exclusive and homogeneous groups of pregnant women ( with actual psychiatric disorder, with stressful life events, and healthy comparisons) underwent serial fetal ultrasound examinations and uterine and umbilical artery doppler velocimetry at (+ ), (+ ) and (+ ) weeks of gestational age. subjects were recruited from all consecutive women attending two antenatal clinics. the presence of any maternal medical illness, drug treatments, fetal chromosomal and/or structural malformations, were exclusion criteria. all women recruited underwent a structured interview at - weeks for the psychiatric diagnosis (mini international neuropsychiatric interview -mini) (sheehan et al, ) ; moreover, the -item hamilton rating scale for depression and the hamilton rating scale for anxiety were included in the assessment. the person who obtained obstetrical clinical data was blind to the results of psychological evaluations. results. the three groups were comparable for: age, parity, socioeconomic status, smoking, alcohol consumption, body mass index. gestational age at birth was not different in the three groups. infants of women with psychiatric disorders had significantly lower birthweight ( + g) and higher percentage of birth weight below the th centile for gestational age ( %) than infants of healthy mothers ( + g and %, respectively). there was also a trend towards lower mean birth weight ( + g) and higher incidence of birth weight below the th centile ( %) in the stressful life event group. there was no significant difference among groups in the percentage of abnormal uterine or umbilical doppler results. conclusions. maternal psychiatric disorders are associated with a lower birth-weight, but the effect is unlikely to be due to abnormal utero-placental or feto-placental vascularisation. objective: the purpose of this study was to evaluate antenatal ultrasound as a tool for the detection of intrauterine growth restriction (iugr) and small for gestational age (sga) infants among subjects with elevated human chorionic gonadotropin (hcg) levels on second trimester serum screening. although iugr has been linked to elevated hcg levels, the optimal screening regimen for antenatal sonographic surveillance has not been previously established. methods: a retrospective cohort study was performed at saddleback memorial medical center where serial ultrasounds from weeks-delivery are generally recommended for patients with hcg levels > . mom. all pregnancies were dated by second trimester ultrasound ± last menstrual period. subjects with an hcg > . mom, who had at least one antenatal ultrasound evaluation for iugr, were identified from an electronic ultrasound database used for clinical report generation. ultrasound data were then linked to an obstetrical birth outcomes database for relevant demographic/delivery information using unique identifiers. iugr was defined as a sonographic estimated fetal weight (efw) < %ile for the estimated gestational age (ega). sga was defined as an actual birthweight < %ile for the ega at the time of delivery. results: from - , there were subjects with elevated hcg levels who underwent antenatal ultrasound surveillance for iugr and who had known delivery information. a total of ultrasound examinations were performed. the median number of examinations per subject was with a range from - examinations per subject. the incidence of iugr and of sga were . % (n= / ) and . % (n= / ), respectively. no fetus with iugr demonstrated absent or reverse end diastolic umbilical artery doppler flow. antenatal ultrasound examinations only identified . % (n= / ) of sga infants. however, the sensitivity for the detection of sga was % when an efw cut-off of % was used. conclusions: although the majority of sga infants did not demonstrate growth restriction on antenatal ultrasound, a sonographic efw > %ile appears to be a safe cut-off to rule out fetuses at risk for sga. neonatal dry lung syndrome after pprom: reason to change intrauterine referral practice in the netherlands? ellen s hoogakker, christiaan v hulzebos, gerda g zeeman. obstetrics and gynecology, university medical center groningen, groningen, netherlands; pediatrics, division of neonatology, university medical center groningen, groningen, netherlands. background: neonatal dry lung syndrome (dls) is a distinct clinical entity following pprom, mimicking pulmonary hypoplasia but with dramatic respiratory improvement during the first - h . its pathogenesis implies complete collapse of small airways to a degree that capillary forces impede distension by ordinary ventilatory pressures. in the netherlands, women with pprom remain admitted at a level iii nicu perinatal center until they reach wks. when they are referred back to their community hospital, unless they live in the neighborhood of the tertiary center. we question this referral pattern because we still see severe respiratory problems occur > wks. we sought to determine the prevalence of such morbidity, in particular dls, in women with pprom who deliver > wks. methods: retrospective descriptive study of neonatal outcome data of singleton pregnancies complicated by pprom between - wks, who deliver > wks (latency > h) , during the -yr period of - at a single academic center. data were extracted from medical records and electronic department databases. results: pprom pregnancies were identified. all but received at least full course of steroids. ( %) delivered > wks. newborns born at the community hospital needed emergency transportation to a level iii nicu for respiratory morbidity. neonatal outcome data (means ± sd) are listed in the table. there were no cases of late onset sepsis, nec or perinatal mortality. conclusions: respiratory morbidity still occurs after pprom with delivery > wks. further investigation of pregnancy-related characteristics, such as the presence of anhydramnios and the latency period, with regards to dls is needed. modification of current referral practice depends upon complete data derived from all dutch level iii perinatal care centers (n = ). tertiary care center (n = ) to determine if an association exists between macrosomia (birthweight > g) and perinatal outcomes in women with and without gestational diabetes mellitus (gdm). study design: this is a retrospective cohort study of , singleton pregnancies. the study cohort was stratified by the diagnosis of gdm, with the presence or absence of macrosomia as the dependent variable. perinatal outcomes examined included neonatal hyperbilirubinemia, hypoglycemia, respiratory distress syndrome (rds), shoulder dystocia and erb's palsy. chisquare tests were performed as well as multivariable analyses controlling for confounders, using p< . to indicate statistical significance. results: in women diagnosed with gdm, macrosomia is associated with a higher frequency of hypoglycemia, respiratory distress syndrome, shoulder dystocia and erb's palsy. though the prevalence of these outcomes is relatively decreased in patients without gdm, they are still more prevalent in macrosomic patients. macrosomia is associated with a higher prevalence of adverse perinatal outcomes in women with and without gdm. therefore, it is important to evaluate neonates with birthweights greater than grams for hypoglycemia and unrecognized erb's palsy. conclusion a significant proportion of our obstetrical patients are obese and many do not perceive themselves to be obese. while our finding of an inverse correlation between level of education and bmi may be confounded by socioeconomic status, our results suggest that in order to address the problems of obesity in our population an important first step will be improving the education of our reproductive age women regarding normal weight gain and nutrition in pregnancy. this may have a significant impact on improving pregnancy outcomes of today's obstetrical population. objective: the aim of the study was to evaluate the impact of a "flat" oral gct upon the outcome of pregnancy. the gct was considered flat when the difference between the basal value and the after load value was %. methods: we prospectively analyzed the outcomes of pregnancies who delivered at our department. inclusion criteria were singleton pregnancy; bmi < kg/m , absence of major risk factors for diabetes and of pregestational diabetes. g -hour oral gct was performed at - weeks of gestation. women were subdivided into groups according to the result of the gct: group = negative (load glucose > % and < mg/dl) women ( . %); group =flat (load glucose % than basal and < mg/dl) women ( . %); group =positive gct/negative ogtt, women ( . %). data are mean ± sd. differences were calculated with the student t test for unpaired samples and test. regression analysis were performed by the least squared method. p-values were considered significant at p< . . results: the characteristics and obstetric outcomes in the three groups are presented in the table . in all patients there was a significant linear relationship between the load and basal glucose values (load value= . + . basal value; r= . ; p< . ) and between birthweight and load values (birthweight= . + . load value; r= . ; p< . ). the relationships were significant also in group and separately but not in group . in this preliminary study we found no major outcome differences in women with flat gct compared to women with normal and gct positive/ ogtt negative results. it seems important, however, to futher investigate the meaning of a flat curve in a bigger population and/or by means of metabolic studies with the use of stable isotopes. results characteristic of the study population and obstetric outcomes are presented in table . the probability to be primiparous and to deliver babies < ° centile decreased significantly with bmi whereas the risk of cesarean section, of post partum hemorrhage at vaginal delivery and to deliver babies > ° centile increased significantly. also the risk to develop preeclampsia and gestational diabetes was increased, although not significantly, with bmi. compared to lean and normal, obese were more likely to be hypertensive and diabetic before pregnancy (p< . ) and to start pregnancy without any medical and obstetrical risk but obesity ( . % vs . and . %; p< . ). african women exhibited the highest bmi and the highest rate of obesity (table ). conclusions we confirm that obese women have an increased risk of prepregnancy and pregnancy complications: less than % have an uncomplicated pregnancy. at delivery there is an increased risk of cesarean section and post partum haemorrhage. objective: overweight and obese women often give birth to larger babies, which is associated with traumatic birth injuries and an increased risk to develop obesity, diabetes and hypertension in childhood and later in life. the mechanisms underlying fetal overgrowth in obese pregnant women are largely unknown. the aim of this study was to establish a mouse model of obesity/high fat diet in pregnancy. we hypothesized that a moderately high fat diet prior to and during pregnancy would result in increased maternal adiposity, fetal overgrowth and a metabolic profile similar to that of obese newborn offspring with persistent pulmonary hypertension, despite enhanced pregnant women. method: c bl/ j female mice were fed control (c, % of energy from fat) or isocaloric high fat (hf, % of energy from fat) diets ad libitum for weeks prior to mating and during gestation. at gestational day . maternal blood samples were obtained to measure adiponectin, leptin and cytokine levels and maternal fat pads were isolated and weighed. in a sub set of animals measurements of transplacental transport of neutral amino acids and glucose were performed in vivo under ketamine anesthesia using h-meaib, and c-glucose. results: no significant differences were observed in maternal pre-pregnancy bodyweight, total caloric intake, weight of the dam at e . or litter size between treatment groups. fetal weight was increased in the hf group by % (p< . ). maternal adiponectin levels were significantly (p< . , n= ) decreased (hf ± , c ± g/ml) and leptin levels increased by % in animals fed a high fat diet, but this difference did not reach statistical significance (n= ). adiposity (fat pad weight) was increased by % (p< . , n= in the dams fed high fat diet, however no difference was observed in maternal il- levels and neither group had measurable levels of tnf-. maternal red blood cell lipid profiles were altered in high fat animals with an increase in stearic and linoleic acids but decreased oleic acid levels. preliminary data showed that placental uptake and transfer to the fetus of glucose and meaib were increased by at least % in dams fed high fat diet. conclusion: this murine high fat diet model has several features consistent with human obesity in pregnancy and the maternal metabolic environment is similar to that seen in the human. the increase in placental uptake and transfer of nutrients constitute a key mechanism underlying fetal overgrowth in overweight/obesity in pregnancy. objective: epidemiological studies have demonstrated a positive relationship between maternal overnutrition and the development of the metabolic syndrome in the offspring. we previously reported that lambs of well fed ewes have increased plasma glucose levels in early life, this may be a consequence of altered hepatic glucose production. increased hsd expression is associated with an increase in intracellular cortisol, promotion of hepatic insulin resistance and a consequential increase in gluconeogenic activity. hypothesis: we hypothesised that maternal overnutrition in late gestation in the sheep results in increased hepatic expression of hsd in the lamb before and after birth. methods: ewes were provided with either % (control,c) or % (well fed, wf) of maintenance energy requirements from d gestation until delivery. post-mortem was performed on either ± d gestation (c= ,wf= ) or and postnatal day (c= ,wf= ). plasma glucose and leptin concentrations in the fetuses and lambs were determined. the relative hepatic mrna expression of hsd and reference gene rpp were determined by qrt-pcr. results: relative liver weight was significantly higher in lambs of wf ewes compared to c at d (p< . ). the expression of hsd mrna was significantly higher in the postnatal compared to the fetal lamb (p< . ) independent of maternal nutritional treatment. however, there was no effect of maternal overnutrition on the hepatic expression of hsd mrna before or after birth. there was no effect of prenatal nutrition on fetal or postnatal plasma cortisol concentrations. the expression of hsd in the liver of lambs of wf, but not c ewes, was inversely related to plasma glucose concentrations in the first hrs after birth (r =- . , p= . ). we have therefore demonstrated that exposure to prenatal overnutrition results in an inverse relationship between hsd mrna expression in the liver at d and plasma glucose concentrations on the first day of life. this suggests that exposure to high glucose levels before and immediately after birth results in a reduced expression of hepatic hsd . we would expect a reduction, rather than promotion of intra-hepatic cortisol production, and therefore it is unlikely to explain the hyperglycemia present in lambs of wf ewes in early life. ninety-seven ( %) of mothers were classified as obese (bmi> ) based on their first pregnancy weight. glycemic control at weeks was superior in the non-obese group (table ) . there were no differences in glycemic control during the last week of pregnancy. obesity was significantly associated with increased maternal weight gain during pregnancy. mean birth weights, ponderal indices and rates of macrosomia were significantly higher in infants born to obese women when compared to non-obese (table ) . primary cesarean deliveries rates were comparable. the rate of neonatal hypoglycemia, hyperbilirubinemia, phototherapy and neonatal icu admissions did not differ between obese and non-obese diabetic women (table ) . although not statistically significant, there was a trend towards an increased rate of birth injuries in the obese group. a similar comparison between obese and non-obese women treated with medication (glyburide or insulin) demonstrated a higher mean birth weight ( g+ vs. g+ , p=. ) and higher rate of macrosomia ( vs. %, p= . ). there were no differences in glycemic control, cesarean delivery rates and other neonatal outcomes between the obese and non-obese treated with medication. conclusion: obese women with type ii and gdm give birth to larger infants than their non-obese counterparts and have a higher incidence of fetal macrosomia. there was a trend towards increased rate of birth injuries in the obese group. despite these differences other maternal and neonatal outcomes were similar which may be a reflection of glycemic control. introduction: tlrs are key components of the innate immune system which recognize conserved sequences on the surface of pathogens and trigger effector cell functions. the placenta, and more specifically the trophoblast, may play an important role in the response to infection. previously, we described the expression of tlr- by human trophoblast and their ability to respond to polyinosinic-polycytidylic acid (polyi:c), a synthetic double strand rna which mimics viral rna. in the present study we evaluate the effect of polyi:c in mouse pregnancy and characterize the local and systemic response. material and methods: human first trimester trophoblast cell line, htr , was treated with polyi:c. c b/ wild type and tlr- knock out mice were injected intraperitoneally with polyi:c at . gestation day. cytokine and chemokine level were determined in supernatant and lysates using the bio-rad multiplex assay and analysis was done using the bio-plex is. results: polyi:c induced cytokine (il , il and il ) and chemokine (il , rantes, gro , mcp and mip ) secretion and production by human cultured trophoblast in a time ( - h) and a dose ( - g/ml) dependent manner. injection of polyi:c to c b/ wild type mice induced preterm delivery within h at a dose of mg/kg body weight. no effect was observed in tlr- knock out mice. a robust systemic (spleen and serum) and local (placenta and amniotic fluid) inflammatory response was observed and h following polyi:c treatment. trophoblast cell cultures from tlr- ko mice confirmed that the response to polyi:c is tlr- dependent. conclusion: we demonstrate that viral infection may trigger an immune response leading to preterm labor. furthermore we show that the trophoblast is able to recognize and respond to viruses through the expression of tlr- . our findings provide a novel mechanism of pathogenesis of preterm labor associated with tlr- mediated inflammatory response. introduction: adverse neurological outcome is a major cause of neonatal morbidity after a preterm birth (ptb). a growing body of evidence demonstrates the involvement of inflammatory pathways in ptb and implicates these pathways as a causative factor in fetal brain injury. however, activations of cytokine pathways in normal labor (whether iatrogenic preterm or at term) has been observed. what remains understudied is the effect of labor on the preterm fetal brain and whether an inflammatory stimulus is essential for fetal brain injury. methods: mouse models were utilized: ( ) a model of intrauterine inflammation (lps into uterine horn) (n= ); controls received intrauterine saline (n= ) and ( ) autism is a neurodevelopmental disorder with a strong genetic component and several known environmental risk factors, such as infection. in addition, its onset of etiology is likely to occur during prenatal development. we propose that subjecting fetal sheep via amniocentesis to the bacterial endotoxin lipopolysaccharide (lps) injected to the amniotic fluid at gestational day (gd) will result in morphological alterations in the offsprings' cerebellum resembling alterations found in the cerebellum of patients with autism. using high precision design-based stereology, we investigated mean total-and layer-specific volume and mean total granule and purkinje cell (pc) number in the cerebellum of lps infected animals and controls. the results of the present study showed preserved volumes of the total cerebellum as well as of the molecular layer, outer and inner granular cell layers and white matter. interestingly, compared to controls, the lps infected brains showed a statistically significant increase (+ . %) in the mean total number of granule cells, whereas the pcs did not show any difference between the groups. these seemingly paradoxical results might be explained by ( ) the so-called time of origin of these neurons, i.e. the pcs develop prenatally whereas the granule cells develop postnatally or ( ) the direct correlation between pcs and granule cell number in the cerebellum. these results might contribute, as an animal model, to our understanding of the biological basis for interindividual differences in morphological alterations found in the brains of patients with autism. the previous studies have shown that there is a higher incidence of spontaneous preterm birth and poorer neonatal outcome in pregnancies with a male fetus. in vitro studies also report a sex dependent pattern in different placental enzymatic systems. we have shown previously that lactobacillus rhamnosus gr- supernatant is able to antagonize the actions of lps on cytokines and ptgs in placental trophoblasts. we hypothesize that fetal sex will influence the production of cytokines and prostaglandin regulating enzymes in lps and lactobacilli treated placental trophoblast cells. methods: term placentae were collected from women undergoing elective caesarean section. placental trophoblasts were isolated using established primary culture protocols. cells were pretreated with lactobacilli supernatant and subsequently treated with lps. pgdh and ptgs expression levels were measured by western blot analysis and tnf-, and il- concentrations measured by elisa. results: lps stimulation caused a marked increase in production of tnf-( . pg/ml to . pg/ml, n= , p< . ), an effect that was greater in placentae of the male fetuses ( . pg/ml, n= ) compared to female fetuses ( . pg/ml, n= ). lactobacilli supernatant abolished this response in both sexes. lps-activated trophoblasts from placentae of the male fetuses showed an increase in il- production (n= , p< . ) and ptgs expression (n= , p< . ). however, there was no response to lps in placentae of the female fetuses. lactobacilli supernatant up-regulated pgdh (n= ) by %, and this effect was greater in placentae of the female fetuses (n= ). conclusion: we conclude that human placentae from pregnancies carrying male fetuses are more responsive to lps by producing more pro-and anti-inflammatory cytokines, as well as ptgs . conversely, placentae of the female fetuses upregulate pgdh with lactobacilli treatment. these findings may explain the underlying mechanism for the higher incidence of preterm birth and adverse pregnancy outcomes seen with male fetuses in the clinical setting. , ) . this study investigates whether iai is associated also with altered expression of neuropilin- . methods: (i) immunohistochemistry (ihc) was performed on tissue sections of term decidua with or without clinical / histologic evidence of iai (n= for each). neuropilin- expression was scored by an investigator blinded to the identity of the samples. (ii) cultured term dscs were retrieved from elective cesarean (n= ), purified, and depleted of leukocytes. after treatment with - m estradiol (e ), - m medroxyprogesterone acetate (mpa), both, or vehicle for days, dscs were stimulated with il- b ( - ng/ml), tnfa ( ng/ ml), or thrombin ( . iu/ml) for h. since no elisa exists for neuropilin- , protein expression was determined by immunocytochemistry (icc). (iii) total rna was extracted and the effect of il- b on neuropilin- mrna expression measured by real-time rt-qpcr and corrected for b-actin mrna. results: neuropilin- expression in term decidua was increased in tissues with iai vs controls (p< . ), and localized primarily to dscs. using icc, an increase in neuropilin- was noted after stimulation with il- b and tnfa, but not thrombin. il- b increased neuropilin- mrna expression in dscs by . ± . -fold (from . ± . to . ± . neuropilin- mrna/b-actin mrna; p= . ). conclusions: iai is associated with increased expression of the vegf receptor, neuropilin- , in term decidual tissues. il- b and tnfa (but not thrombin) stimulated neuropilin- expression in term dscs, and this effect appears to be mediated at the level of gene transcription. since aberrant vegf function alters vascular permeability, these data provide a mechanism by which iai can promote 'decidual activation' and preterm labor. inflammation, university of glasgow, glasgow, united kingdom. objective: asthma is associated with inappropriate activation of airway smooth muscle, chemokine expression and accumulation of mast cells which drive smooth muscle reactivity. labour is similarly associated with smooth muscle activation and expression of cxcr and cxcr ligands. the role of mast cells in human parturition is unknown; however, mast cell products can stimulate myometrial contractions and preterm labour in animal models. we have quantified mast cells in association with human labour and determined whether they express cxcr and cxcr . methods: lower segment myometrial and cervical biopsies were taken at term caesarean section from women not in labour (nil) (myometrium n= ; cervix n= ) and in labour (il) (myometrium n= ; cervix n= ). mast cells were localised in myometrial and cervical sections by icc with a primary antibody against c-kit. the number of cell transects in randomly selected high-powered fields ( x) was quantified blindly by two observers for each specimen, with median density and interquartile range (iqr) calculated. backto-back icc was performed to determine whether c-kit co-localised with the chemokine receptors cxcr and cxcr . results: mast cells were in close association with myometrial smooth muscle in non-labouring lower segment myometrium. labour was associated with a significant influx and increase in mast cells numbers (nil median . , iqr . - . ; il median . , iqr . - . , p= . ). in contrast no significant increase in mast cells was observed in cervical tissue in association with labour (nil median . , iqr . - . ; il median . iqr . - . , p= . ). analysis of chemokine receptor expression demonstrated co-localisation of cxcr to c-kit positive cells present within the myometrium. conclusions: human labour at term is associated with an increase in mast cells within the myometrium, with close approximation to smooth muscle bundles. these mast cells express the chemokine receptor cxcr , the ligands of which we have previously shown to be up-regulated in labouring myometrium. mast cells are not accumulated in cervix in association with labour suggesting a less critical role in cervical ripening. further analysis of the role of mast cells in modulating myometrial smooth muscle physiology is warranted. progestins and the glucocorticoid receptor in human myometrial and amnion-derived wish cells. alison j tyson-capper, stephen c robson. reproductive sciences, newcastle university, newcastle upon tyne, united kingdom. background and objectives: progesterone (p) can reduce the risk of preterm birth in some high risk women. in this context there is accumulating evidence that this, at least in part, may be due to anti-inflammatory and immunoregulatory properties of p. target tissue responsiveness to p is considered to be determined by the progesterone receptors (pr) and nuclear co-factors that directly interact with pr. pr and glucocorticoid receptors (gr) share several structural and functional characteristics, including similarities in dna sequence recognition by binding to the same hormone response elements. pr and gr interact with similar chaperones in the absence of ligand and with a similar group of co-activators in the presence of hormones; both can display comparable anti-inflammatory activities under specific physiological conditions. in this study we aimed to investigate whether the anti-inflammatory properties of progestins may be mediated by pr and gr signalling. methods: primary cultures of non-pregnant and term pregnant human myometrial (passage - ) and wish cells were serum starved for hrs and treated with -hydroxyprogesterone ( -hp), progesterone (p), dexamethasone (dex) and immunofluorescent staining and immunoblotting analyses performed. in some experiments cells were pre-treated with ru (a pr/gr antagonist) or org (a pure pr antagonist). results: in the absence of hormone gr appeared to be predominantly cytoplasmic, whereas, upon treatment with -hp and p ( and m) and dex ( nm) gr was abundant within the nuclei of myometrial cells. immunoblotting analyses demonstrated that levels of gr progressively increased within the nuclear fractions of both pregnant myometrial and wish cells in response to increasing concentrations of p ( nm to m), and decreased sequentially within cytoplasmic fractions. in the presence of org gr protein levels remained constant within the cytoplasm. there also appeared to be a slight increase in gr expression, though not statistically significant (p> . ) within both cells types in response to p. conclusion: in this study we show that gr is activated by -hp and p and translocates to the nuclei of human myometrial and amnion-derived cells. in addition, levels of gr increase in response to p. whether p and -hp act as agonists or antagonists for gr in the regulation of hormone response genes associated with the onset of term and preterm labour remains to be elucidated. objective: using a mouse model of inflammation-induced preterm birth (ptb), we have demonstrated dramatic cytokine elevations in the uterus and placenta with concomitant, though less dramatic, cytokine elevations in the fetal liver and brain, associated with neuronal injury. because precise mechanisms of fetal injury in ptb remain unclear, we sought to examine inflammatory cell trafficking, and target organ damage by histopathologic assessment of the placenta, fetus, and fetal brain. study design: hours after intrauterine infusion of saline or lps into the right lower uterine horn of cd- mice, the left upper horn, with the gestational sacs(gs) in situ, was removed en bloc(n= per group) each with - gs with fetuses/treatment group. specimens were fixed, bisected and processed for histology and ihc. inflammatory and hematopoietic cells were quantified using pas, gata- (erythroid precursors), cd , and bm (macrophage-mp) within the placenta, liver, extremity mesenchyme, brain and leptomeninges. the presence of hemorrhage, necrosis, and apoptosis (h ax stain) was assessed. erythopoietin (epo) levels were measured in brain and liver by elisa. results: more neutrophils were present in maternal decidual vessels in lps compared to saline (p= . ). in lps-exposed, fetal mp were increased in the placenta (p= . ), fetal extremity mesenchyme (p= . ), fetal liver (p= . ) and leptomeninges (p= . ) but not in the brain or spinal cord compared to saline. no necrosis, hemorrhage or increased apoptosis was noted in the fetal brains. % of lps-exposed fetuses and % of saline-exposed had liver hemorrhages (p< . ). increases in nucleated erythrocytes and erythroid precursors were found in fetal vasculature of the placenta in lps-exposed (p= . ). epo levels were not elevated in either group. conclusion: intrauterine lps infusion induces acute inflammation predominantly in the maternal circulation of the placenta. in the fetus, there is widespread mp activation, liver hemorrhage and increased erythroid precursors seen in the fetal circulation of the placenta. although histologic evidence of cns damage was not evident, the increased mps present in the leptomeninges may play an important role in inflammatory-mediated cns damage. non-toll-like innate immune proteins: do they change during pregnancy? juan m gonzalez, hua xu, ella ofori, michal a elovitz. obgyn; crrwh, university of pennsylvania, philadelphia, pa, usa. introduction: trem- (trigger receptors expressed on myeloid cells) is an important regulator of innate immunity. the natural ligand for trem has not been identified. activation of trem- in the presence of toll-like receptors results in substantial amplification of the host inflammatory response (klesney-tait et al nature immunology ). since inflammatory pathways are implicated in adverse pregnancy outcomes, this novel mediator of inflammation may play a critical role in preterm birth (ptb). therefore, we sought to determine trem- expression in the uterus, cervix, and placenta across gestation and to determine if trem- levels are altered by intrauterine inflammation. methods: in cd- mice, trem- was investigated in non-pregnant (np) and throughout gestation e , e (n= - per group). uterine, cervical, and placental tissues were harvested. using an established mouse model of inflammation-induced ptb, uterine tissue was collected hours after intrauterine infusion of saline (n= ) or lipopolysaccharide (lps) (n= ). for a non-pregnant model, using cd- mice, lps (n= ) or saline (n= ) was injected into the uterine horn following same procedures as with pregnant mice. uteri were harvested hrs later. quantikine ® mouse trem- immunoassay was utilized for these studies. statistical analysis was performed using oneway anova followed by pair-wise comparison if statistical significance was reached (p< . ) results: trem levels are significantly different between np and pregnant uterine tissues (p= . ). e and e trem expression is significantly increased . and . -fold compared to np (p= . and . respectively). trem- levels in the placenta and cervix were not significantly different between e and e . trem levels increased about -fold in the uterus after intrauterine infusion of saline or lps compared to e controls. in nonpregnant, trem levels were significantly different (p= . ) with a -fold increase in trem expression in uteri exposed to lps or saline compared to controls. conclusions: non-toll-like innate immune proteins are differentially regulated during pregnancy compared to the non-pregnant state. the role of trem- in inflammation-induced ptb requires further study. research is warranted to determine if uterine up-regulation of trem in gestation is associated with an increased likelihood of responding to pathogens or severe as a protective mechanism. reduced plasma levels of vitamin d in caucasian women at term are associated with increased rate of infection. chander p arora, adegoke adeniji, susan e jackman, babak forooghi, isaac mostadim, phillip yadegari, calvin j hobel. og-gyn, cedars-siani medical center, los angeles, ca, usa; university of california los angeles, los angeles, ca, usa. background: vitamin d plays an important role in human pregnancy by acting as a regulator of immunity at the fetal-maternal interface. inflammatory changes associated with pro-inflammatory cytokines were reduced by vitamin d while anti-inflammatory cytokines were increased in t lymphocytes. vitamin d status has been defined as deficiency (< . nmol/l), insufficiency ( . to nmol/l) and sufficiency (> nmol/l) . objective: to assess the involvement of vitamin d in the occurrence of maternal infection during pregnacy in women with term deliveries. hypothesis: vitamin d metabolism could affect the rate of infection during pregnancy. study design plasma levels of (oh)d were determined by elisa and the rate of infection was recorded in a behavior in pregnancy study. in this study, ethnically diverse women were evaluated at - weeks (t ), - weeks (t ) and - weeks (t ). maternal infections were documented at each stage as well as at baseline visit with history of infection in current pregnancy. of these subjects who delivered at term two groups ( with no infection during pregnancy, with infection or history of infection) were matched further for non-smoking status, non-diabetics, ethnicity and maternal age. plasma from these were assayed for (oh)d and analyzed for the rate of maternal infection using fisher´s exact test or chi-square test. results although the women delivered at term, the levels of (oh)d in caucasians were significantly lower in the subjects with infection than the ones without (p<. ). women with vitamin d insufficiecy in the first trimester were more likely to develop infection during pregnancy ( . nmol/l ± . at t , . nmol/l ± . at t and . nmol/l ± . at t ; all p<. ) but not subjects with sufficient vitamin d at t ( . nmol/l ± . at t , . nmol/l ± . at t and . nmol/l ± . at t ; all p<. ). conclusion the results reveal a positive association between (oh) d concentrations and greater risk of infection. vitamin d deficiency or even insufficiency may, therefore be involved in the pathogenesis of maternal infection during pregnancy. it is probable that vitamin d deficiency or even insufficiency could modulate the maternal susceptibility to infection during pregnancy by a proinflammatory mechanism. in vitro and in vivo observational data suggest that infection leads to caspase activation and apoptosis in the placenta and membranes, however currently there are no data on the role of apoptosis in the pathogenesis of infection associated preterm delivery. here we used group b streptococcus (gbs) as a model pathogen and examined the role of caspase dependent and independent apoptosis in preterm delivery. methods: we injected ( . x ) heat killed group b streptococcus organisms (hk-gbs) intraperitoneally (i.p.) in . day pregnant c b/l mice. the mice were euthanized at hr (n= ) and hr (n= ), the placentas and membranes were removed and assessed for apoptosis by tunel staining. caspase activation and expression were determined by immuno-histochemistry (ih) and western blotting. the effect of apoptosis on preterm delivery was assessed by i.p. treating the pregnant mice with pbs (n= ), dmso (n= ) or pancaspase inhibitor z-vad-fmk (n= ) prior to hk-gbs and observing the animal for delivery for hrs. results: there was a time dependent, gbs-induced increase in apoptosis by tunel assay and caspase activation in the placenta and membranes. in addition hk-gbs-induced the expression of caspase and caspase independent m-calpain in the placenta. z-vad-fmk ( mg/kg), at the maximum concentration that did not induce maternal illness, did not prevent hk-gbsinduced preterm delivery. conclusions: caspase dependent and independent mechanisms are activated in the placenta upon exposure to gbs. systemic adminstration of a pan-caspase inhibitor did not impact upon the occurance or timing of bacterially induced preterm delivery. further studies are needed to assess the role of apoptosis in the pathogenesis of infection associated preterm delivery. early and ( . %) had a late sptb. the mean + sd gestational age at blood draw was + weeks. the median level of bb was higher in women with early as compared with late sptb or term births (p= . for trend). women with bb in the top quartile were . times more likely to have an early sptb as compared with women who had lower levels of bb ( % ci . to , p = . ). there was no association between bb and late sptb (rr= . , % ci = . to ). the adjusted or of an elevated bb for early sptb was . ( % ci = . to , p= . ). when the analysis was restricted to the women with sptb the rr of an elevated bb for early sptb was . ( % ci . to . , p = . ). conclusions: a significant relationship was found between an elevated bb in early pregnancy and early sptb suggesting inflammatory events in early pregnancy, perhaps infection-related, are part of the pathogenic mechanisms. objective: genital tract infection and/or inflammation appears to contribute to the majority of ptds preceding weeks of gestation. ptd in humans has been associated with colonization and/or infection with a variety of different organisms including gram positive and negative bacteria, mycoplasma, ureaplasma, trichomonads, malaria parasites and viruses. the innate immune response to these pathogens is produced by a family of pattern-recognition cell membrane receptors known as the toll-like receptors (tlrs). these studies sought to characterize the tlr isoforms expressed in the preterm mouse uterus, and their modulation during lipopolysaccharide (lps)-induced ptd. methods: using sterile surgical technique, day- pregnant cd- mice underwent intrauterine injection of g lps. subsequently, the mice were euthanized at , , , , and hours after lps injection. uterine tissue was harvested and placed in rnalater; subsequently total rna was isolated using the trizol reagent and genomic dna was removed using turbo dnafree. cdna was made using iscript cdna synthesis kit. pcr primers were designed using published mouse tlr gene sequences. real-time quantitative rt-pcr was performed using the power sybr green master mix and an abi prism multicycler. to confirm tlr amplicon sizes, the rt-pcr products were visualized on a % agarose/tbe gel stained with gelred. results: these studies have confirmed mrna expression of all of the reported mouse tlr isoforms. these tlr amplicons range in size from to bp as expected; amplicon sequences are pending. quantitative rt-pcr studies performed using uterine tissues from five mice at each time point demonstrated that at hours after lps injection, tlr increased -fold and tlr increased -fold (both p< . ). in contrast, the expression of tlr (the ligand for lps) remained stable during the hours after lps; the expression of tlr , , , , , and also remained stable. tlr expression trended upward and tlr trended downward, although neither was statistically significant. conclusions: these studies have confirmed expression of all tlrs within the preterm pregnant mouse uterus, along with characterization of their modulation during lps-induced ptd. these observations are important because they contribute to our understanding of the immunologic signaling events leading to ptd. (funded by nih hd ). udp-glucose and its receptor p y as a new innate immune system in the female reproductive tract. toru arase, tetsuo maruyama, hiroshi uchida, takashi kajitani, masanori ono, maki kagami, hironori asada, yasunori yoshimura. obstetrics and gynecology, keio university, shinjukuku, tokyo, japan. objective: innate immune system involving toll-like receptors has recently emerged in the female reproductive tract (frt). we hypothesize that there may exist new other mucosal immunity in frt. recently, it has been reported that p y , a g protein-coupled p y receptor for udp-glucose (udp-g), is involved in the lung epithelial immune system. the aim of this study is to investigate whether udp-g and p y have a potential as the defense immune system in frt, in particular endometrium. materials and methods: we obtained human endometrial tissues from consenting reproductive-aged patients. the spatiotemporal expression of p y in human and mouse endometrial tissues was analyzed using rt-pcr and ihc. isolated human endometrial cells and a human endometrial epithelial cell line, ishikawa, were cultured, treated with udp-g, and subjected to rt-pcr analysis for il- mrna expression. we also measured the il- secretion using elisa. small interfering rna was used to knock down p y expression. the chemotactic activity of udp-g on neutrophils was tested using transwell assay with ishikawa cells. lastly, mouse uterine tissues were incubated with udp-g and subjected to rt-pcr analysis for mrna expressions of kc and mip- , the il- homologues in mice. results: p y was exclusively expressed in the glandular and luminal epithelium both in human and mouse uteri. treatment with udp-g induced the secretion of il- in ishikawa and human endometrial glandular cells, but not stromal cells, in a dose-and a time-dependent manner. p y knockdown abrogated udp-g-induced il- production. treatment with udp-g also significantly increased the chemotaxis of neutrophils, which was attenuated by co-addition of anti-human il- neutralizing antibody. in the mouse uterus stimulation of udp-g significantly up-regulated the expressions of kc and mip- mrna. conclusions: udp-g is an endogenous molecule and released into the extracellular environment in a lytic manner after cell damage. taken together, our results collectively substantiate a model in which udp-g released from endometrial cells damaged by infection stimulates il- production via p y in endometrial glandular epithelium, which, in turn, recruits neutrophils thereby preventing the progression of infection. thus, udp-g and its receptor p y may be involved in the trans-species mucosal immune system in frt. (jsgi ; , (suppl) , abst # ) but in utero effects on fetal lung remain to be established. we have examined the relationship between duration of iai and subsequent azi treatment on the severity of fetal lung histopathology. we hypothesized that early treatment would prevent the development of advanced lesions, while late treatment may reduce the severity of lung damage. study design. thirteen chronically instrumented rhesus monkeys received intraamniotic inoculation of u. parvum (serovar ; - x cfu) at ± . days gest. age (dga, mean ± sem, term= d). six of these animals received maternal i.v. azi ( . mg/kg q h or q h for d) either alone (n= ) or in combination (n= ) with dexamethasone (dex; mg/kg/d i.v. for d) and indomethacin (indo; mg/d p.o for d). tissues were obtained at cesarean section for histopathologic assessment. leukocytic infiltration of aveolar spaces and septal walls, type ii pneumocyte hyperplasia and peribronchiolar lymphocytic aggregates were scored as absent ( ), minimal ( ), moderate ( ) and severe ( ). results. inoculation-to-delivery interval was - d for combined treatment groups and was similar to long duration infection without treatment ( - d). treatment effects were tabulated as mean scores and compared as follows: control (n= ), score ; short duration infection ( - d; n= ), score ; long duration infection ( - d; n= ), score ; short duration infection + treatment (n= ), score ; long duration infection + treatment (n= ), score . conclusions. histopathologic findings of fetal pneumonia progressively worsen with duration of u. parvum iai. early maternal azi treatment prevents development of advanced lung lesions, while later treatment may reduce the severity of fetal lung damage. our results suggest that in utero treatment of iai may lower the risk of neonatal bronchopulmonary dysplasia. support: nih hd , rr . brain associated with adverse neurodevelopmental outcome. lps triggers proinflammatory responses through toll-like receptor- (tlr ). mitogen activated protein kinases including c-jun-n-terminal kinase (jnk) have been reported to be implicated in tlr signalling pathways and play important role in both onset of labor and brain injury. in the present study, we used a mouse model of intrauterine infection-associated preterm labor to determine whether the administration of specific inhibitor of jnk signaling, d-jnk inhibitory peptide (d-jnki) can (i) inhibit jnk activity in vivo, (ii) delay lps-induced preterm delivery, and (iii) improve neonatal outcome in the presence of intrauterine inflammation. intrauterine administration of tlr- specific lps to cd pregnant mice at day of pregnancy caused preterm delivery after to h with % pup mortality. in vitro kinase assay demonstrated the activation of jnk in response to lps in the maternal uterus and fetal brain. furthermore, the brain specific jnk was found to be the major jnk isoform activated by lps in the fetal brain. co-administration of d-jnki with lps to pregnant mice delayed significantly (p< . ) lps-induced preterm delivery and reduced pup mortality up to %. this was associated with inhibition of jnk activity in both maternal uterus and fetal brain. in addition, we have found that treatment with lps significantly up-regulated cox- , cxcl (il- equivalent) and ccl in myometrium and this is significantly suppressed after co-administration of d-jnki. we conclude that specific inhibition of jnk signaling may have a potential of controlling preterm labor and preventing fetal brain damage as a result of infection/inflammation. the prostaglandin -deoxy- , -prostaglandin j delays lps-induced preterm delivery and reduces mortality in the mouse. intrauterine infection is a common trigger for preterm birth, and is also a risk factor for the development of neurodevelopmental abnormalities in the neonate. bacterial lipopolysaccharide (lps) binds to toll-like receptor- (tlr ) to activate pro-inflammatory signaling pathways. the transcription factor nuclear factor kappa b (nf-kb) is a key player in the orchestration of the inflammatory response and has a central role in parturition. we have previously shown that exposure to the anti-inflammatory cyclopentenone prostaglandin -deoxy- , -prostaglandin j ( d-pgj ) inhibits il- b-induced nf-kb activity and cox- expression in human myometrial and amnion epithelial cells in vitro. in the present study, we used a mouse model of intrauterine infection-associated preterm labor to determine whether the administration of d-pgj can (i) inhibit nf-kb in vivo, (ii) delay lps-induced preterm delivery, and (iii) improve neonatal outcome in the presence of intrauterine inflammation. intrauterine administration of tlr specific lps to cd pregnant mice at day of pregnancy caused preterm delivery after to h with % pup mortality. co-administration of d-pgj with lps to pregnant mice delayed significantly (p< . ) lps-induced preterm delivery and conferred protection from lps-induced fetal mortality up to %. we have looked at the expression profile of several labor associated genes in myometrium hours after lps administration. (otr, connexin and , cox- , cox- , cxcl (il- equivalent) and ccl ). we have found that treatment with lps significantly up-regulated cox- , cxcl and ccl and this is significantly suppressed after with co-administration of d-pgj . western analysis for ser -phosphorylated p and ikkb in-vitro kinase assay has demonstrated that lps induced activation of nf-kb at both h and h. co-administration of d-pgj was associated with inhibition of nf-kb activation in both the maternal uterus and the fetal brain. conclusion d-pgj may have potential as a therapeutic agent in the management of preterm labor and, by targeting the player nf-kb, may have the added advantage of preventing detrimental effects to the fetus that may result from infection/inflammation. synergistic macrophage response to co-activation of tlr- and tlr- : mechanisms and implications for bacterial/viral co-infection. vladimir ilievski, emmet hirsch. , department of ob/gyn, evanston northwestern healthcare, evanston, il; department of ob/gyn, feinberg school of medicine, northwestern university, chicago, il. background: toll-like receptors (tlrs) recognize structural components of pathogens and initiate host defenses. tlr- responds to gram-positive organisms and peptidoglycan (pgn), a gram-positive cell wall constituent. tlr- is activated by viral infection in response to double-stranded rna. polyinosinic-cytidylic acid (poly(i:c)) is a tlr- ligand. we have shown that pgn and poly(i:c) have a synergistic effect on the expression of downstream genes for both tlr- and tlr- . here we identify mechanisms underlying this synergy. methods: mouse peritoneal macrophages or a mouse macrophage cell line (raw . ) were treated in tissue culture with either pgn ( g/ml), poly(i: c) ( g/ml) or both pgn and poly(i:c) either simultaneously or sequentially for - hours. total rna was extracted and duplex rt-pcr was performed for inducible nitric oxide synthase (inos), interleukin (il- ), tumor necrosis factor (tnf), the chemokine rantes and tlr- , normalized to the housekeeping gene gapdh. results: compared to stimulation with either pgn or poly(i:c) alone, costimulation of raw . cells with both pgn and poly(i:c) resulted in synergistic expression of inos, il- , tnf and rantes (p< . for all) at and hours . sequential stimulation with either pgn or poly(i:c) for h followed by incubation for an additional h with the alternate ligand also induced synergistic expression of the same rnas, albeit at lower levels than were elicited by simultaneous stimulation. in contrast, incubation with either pgn or poly(i:c) for h followed by medium for h induced minimal to no gene expression. both pgn and poly(i:c) induced tlr- mrna after h but not h. tlr- mrna was not detectable by rt-pcr. in primary peritoneal macrophages, similar synergy due to pgn and poly(i:c) was seen. conclusions: simultaneous or sequential exposure to pgn and poly(i:c) exerts a synergistic effect on the expression of inflammatory mediators in macrophages. interestingly, either one of these two tlr pathways can prime cells for activation of the other pathway. a possible mechanism for this effect may be induction of tlr- by either tlr- or tlr- activation. these observations have implications for bacterial/viral co-infection. this is a secondary analysis of a prospective cohort study. after irb approval, daily blood samples were obtained from pprom subjects and analyzed for il- by elisa. paired maternal serum il- levels from subjects were divided into groups: il- levels obtained - hours prior to completion of antibiotics and those obtained - hours after completion of antibiotics. the wilcoxon signed rank test was used to perform the data comparison on the analyze-it statistical software program. statistical significance was defined as p< . . of the pprom subjects, the maternal age was . yrs; gestational age at admission was . weeks; latency was . days; gestational age at delivery was weeks; and infant birth weight was grams. median maternal serum il- levels obtained off antibiotics were significantly higher when compared to those on antibiotics ( . vs. . pg/ml, p< . ). the results of this investigation suggest that maternal serum il- levels rise after discontinuation of antibiotics. the optimal duration of antibiotics administration in the setting of pprom is unknown. this data suggests a role for continuation of antibiotics in women with pprom in order to prolong the latency period and potentially decrease neonatal morbidity. to identify clinical and pathologic factors associated with fetal inflammatory responses in the placenta from term parturients. methods: retrospective cohort study of consecutive term parturients with submitted placentas in . placentas with histologic chorioamnionitis were divided into two cohorts: group -maternal inflammatory responses only, and group -maternal and fetal inflammatory responses. maternal and fetal inflammatory responses in the placenta were classified according to guidelines established by the amniotic fluid infection nosology committee of the perinatal section of the society of pediatric pathologists. selected demographic, intrapartum, newborn and placental characteristics were analyzed with t-tests and chi-square tests as appropriate. multiple logistic regression was used to identify independent predictors of fetal inflammatory responses in the placenta. results: of consecutively submitted placentas, had histologic chorioamnionitis: with maternal inflammatory responses only (group ) and with both maternal and fetal inflammatory responses (group ). fetal inflammatory responses observed in group were associated with higher stages of maternal inflammatory responses (p<. ). % of fetal inflammatory responses were stage i (acute chorionic vasculitis or phlebitis).group patients were more likely to have had amnioinfusion ( % v %, p=. ) and less likely induction of labor ( % v %, p=. ). group was more likely to have had intrapartum fever ( % v %, p=. ) and maternal tachycardia ( % v %, p=. ). newborns from group were more likely to have been observed for sepsis ( % v %, p <. ) and have an apgar score at minutes ( % v %, p=. ). a logistic regression model showed that stage ii or greater maternal inflammatory responses (or . ) and amnioinfusion (or . ) were independent predictors of fetal inflammatory responses. conclusion: higher stages of maternal inflammatory responses in the placenta and amnioinfusion were independent predictors of fetal inflammatory responses in term parturients with histologic chorioamnionitis. objective: previous studies have shown that sulfasalazaine (sasp) inhibits lipopolysaccharide (lps)-induced nf-b activation and decreases lpsstimulated interleukin- (il- ) production by cultured explants of placenta, amnion and choriodecidua with no effect on cell viability. bacteria-induced il- production in the cervix is a potential mechanism for premature cervical ripening that may lead to preterm birth. it is unclear, however, whether sasp can inhibit il- production by endocervical cells. therefore, we performed a series of in vitro studies to determine if sasp inhibits il- production by endocervical epithelial cells stimulated with bacterial pathogens associated with preterm birth. methods: human endocervical epithelial cells were incubated with - . mm sasp overnight and then stimulated with ccu/ml ureaplasma parvum, cfu/ml escherichia coli, or x cfu/ml gardnerella vaginalis for another overnight incubation in -well cultures. conditioned medium was then harvested and production of il- was quantified by elisa. viability of the cells was ascertained at the end of the experiment with the mtt-assay. each treatment was applied in quadruplicate wells and experiments were repeated times using different batches of cells for each pathogen. results were evaluated using the general linear models procedure of sas for a randomized block design. results: sasp had no detectible effect on il- production by endocervical cells not treated with bacteria. at the highest concentration tested ( . mm), sasp significantly inhibited il- production by cultures stimulated with e. coli (p< . ), u. parvum (p< . ), and g. vaginalis (p< . ). viability of the cells, however, was significantly reduced by sasp at . and . mm in the both the presence and absence of bacteria for all experiments. conclusion: although high concentrations of sasp inhibit il- production by cultures of endocervical cells stimulated with pathogens associated with preterm birth, this effect may be due to toxicity of the antibiotic on the cells. the effect of -hydroxyprogesterone caproate on lipopolysaccharide stimulated peripheral blood mononuclear cells from pregnant women. richard h lee, aimin li, frank z stanczyk, jinwen i lin, t murphy goodwin. obstetrics and gynecology, university of southern california, los angeles, ca, usa. introduction: -hydroxyprogesterone caproate ( -ohpc) reduces the rate of recurrent preterm birth in high-risk women. however, there are lines of evidence to suggest that -ohpc alters inflammatory response in the setting of gram-negative infection. in a mouse model, -ohpc decreased the rate of preterm birth but was associated with significantly increased maternal morbidity when mice were exposed to lipopolysaccharide (lps). in non-pregnant women, -ohpc pre-treatment of whole blood exposed to lps significantly increased the production of tnf-. objective: to determine if -ohpc has an effect on the production of proinflammatory cytokines from peripheral blood mononuclear cells (pbmc) in pregnant women. methods: pbmc were isolated from fresh whole blood samples of pregnant women between and weeks. pregnant women had no prior history of preterm birth. cells were treated with -ohpc ( m) and escherichia coli lipopolysaccharide (lps, g/ml) alone or in combination. after and hours of culture, supernatants were collected and tested for tnf-and il- levels by enzyme-linked immunosorbent assay (elisa). statistical analysis was performed using non-parametric tests. p < . was considered significant. results: pbmc exposed to lps significantly increased tnf-and il- secretion compared to untreated controls (p= . and p= . ). tnf-concentrations were not significantly different between lps and lps+ -ohpc treated cells at both and hours (p= . and p= . ). il- production was significantly increased after -hour treatment with lps+ -ohpc compared to lps alone ( , [ , - , ] background. recent clinical trials indicate that progestins reduce the incidence of preterm birth in some high risk pregnancies. it has been proposed that progesterone promotes uterine quiescence, in part, via its antiinflammatory properties with inhibition of pro-inflammatory gene expression. it is intriguing that progestins are clinically effective given the considerably increased background circulating levels of the hormone during pregnancy. we hypothesised that non-classical progesterone signalling pathways contribute towards mediation of the anti inflammatory effects of progestins. to the endotoxin lipopolysaccharide (lps) by activation of inflammatory pathways. myometrial cell cultures were treated with lps ( g/ml)+/progestin ( nm). two progestin compounds were investigated. natural progesterone (p) is known to have a strong affinity with progesterone receptor (pr) analogues in contrast to -hydroxyprogesterone ( -hp) which, in the absence of esterification with caproate or acetate, has been reported to have no progestogenic activity at pr. the effect of p and -hp on the activation of two inflammatory genes known to be associated with labour (cycloxygenase [cox- ], toll-like receptor [tlr- ]) was evaluated. cox- and tlr- were detected at the protein and mrna levels using sds-page and rt-pcr. results. lps-induced expression of cox- and tlr- proteins were significantly inhibited by both p (p< . and p< . , respectively) and -hp (p< . and p< . , respectively). furthermore, preliminary results indicate that co-incubation with the anti-progesterone mifepristone, fail to abrogate the anti inflammatory effect associated with progestin treatment. conclusion. non-classical progesterone signalling pathways have a role in mediating the anti-inflammatory properties of progestins. further elucidation of the molecular actions of progestins may allow novel approaches to ameliorate the inflammatory response associated with preterm labour. detection and transcriptional expression of tlr- , tlr- and tlr- at the maternal-fetal interface. jacqueline p tilak, karen zakharian, alexandra tungol, gabriel o schubiner, david m svinarich. patient care research, providence hospital, southfield, mi, usa. preterm labor and delivery remains a leading cause of neonatal morbidity and mortality and bacterial infection is considered to be the most common etiology. toll-like receptors (tlr's) and the associated components of the innate immune system may represent a first line of defense against these pathogens. tlr's belong to a family of pattern-recognition receptors that bind to highly conserved pathogen-associated molecular patterns (pamps) including lipopolysaccharide (lps), lipotechoic acid (lta) and cpg dna, and are a key component of the innate immune system. this study was undertaken to characterize the transcriptional expression and regulation of tlr- , tlr- and tlr- within gynecologic and gestational tissues. human first trimester trophoblasts, endometrial mesoderm, ectocervix, choriocarcinoma and neonatal epithelium, were cultured in media alone or in the presence of either lps ( mg/ml) or lta ( mg/ml) for , , , , and hours. total rna was isolated and semi-quantitative rt-pcr was performed using intron-spanning amplimers to tlr- , tlr- , tlr- and gapdh. following gel electrophoresis, the integrated optical densities were determined for the corresponding pcr products and normalized with respect to gapdh levels. inducible transcription of tlr- with lta was observed in choriocarcinoma cells ( -fold, h), and endometrial mesoderm cells ( -fold, h). tlr- induction with lps was observed in ectocervical cells ( -fold, h), choriocarcinoma cells ( -fold, h) and endometrial mesoderm cells ( -fold, h). tlr- induction with lps was observed in choriocarcinoma cells ( fold, h) and neonatal epithelial cells ( -fold, h). all cell lines showed at least constitutive levels of transcription for tlr- , tlr- and tlr- . these data demonstrate that tlr- , tlr- and tlr- are transcriptionally expressed either constitutively or inducibly in both gynecologic (endometrial mesoderm, ectocervix) and gestational (chorion, trophoblast), tissues. translation of these receptors suggests that the innate immune system may function at the maternal-fetal interface to help protect the fetus against infection and prevent or diminish the likelihood of prematurity. objective: further to our development of a sheep model of intrauterine ureaplasma spp infection, we aimed to examine the capability of ureaplasma colonization in the amniotic fluid to infect the fetus and alter lung and brain development. methods: at days of gestation (d, term= d) ewes bearing single fetuses were given a single ultrasound-guided intra-amniotic injection of (a) x colony forming units (cfu) of u parvum (serovar , n= ; serovar , n= ), (b) x cfu of u parvum (serovar , n= ; serovar , n= ) or (c) media control (n= ). at d, fetuses were delivered by cesarean section. amniotic fluid and umbilical arterial blood samples were collected. fetal body weight was recorded, fetal cerebrospinal fluid (csf) collected and a descending pressurevolume curve constructed after inflation of the lungs to cmh o. fetal membranes were immersion fixed and the fetal brain was perfusion fixed with % paraformaldehyde. the fetal brain and membranes were blocked, paraffin embedded, stained and viewed under the light microscope. results: chronic intra-amniotic colonisation with u parvum serovar or (ureaplasmas) did not result in fetal abortion or death. amniotic fluid ureaplasma titers at delivery were not dose-dependent. chronic ureaplasma exposure did not affect fetal body or brain weights, or result in a fetal systemic inflammatory response. umbilical arterial blood gases at delivery were similar between ureaplasma-and media-exposed fetuses. chronic intra-amniotic exposure to ureaplasmas resulted in higher inflammatory cell scores in the fetal membranes compared to media controls (p< . ). lung compliance was increased in ureaplasma-exposed fetuses compared to controls (p< . ). there were no gross anatomical changes observed in the white or grey matter in the cerebral hemispheres of fetuses that had been exposed to ureaplasmas; even in animals (n= ) that had csf ureaplasma colonisation. conclusion: chronic ureaplasma colonisation enhances fetal lung compliance without gross anatomical changes in the fetal brain. background: an important source of vitamin d is its synthesis by skin from uv solar radiations. the skin pigment melanin absorbs uv photons thus reducing the vitamin d synthesis by more than % making african americans at high risk for vitamin d deficiency. low maternal vitamin d status during pregnancy has been linked to molecular pathways for adverse outcomes. objective: the nf b transcription factor regulates genes involved in inflammation and immune processes, and is proposed to play a major role in the successful outcome of pregnancy and labor. prior immunohistochemical (ihc) and biochemical studies have been conflicting regarding nf b activation in human intrauterine tissues. the aim of this study was to quantify nuclear localization of p , the major tranactivating nf b subunit, in full-thickness fetal membranes (fm) and myometrium using ihc. methods: a retrospective analysis of paired fm, decidua, and myometrial samples was conducted using tissues collected from women in cohorts: preterm no labor (pnl, n= ), preterm labor (ptl, n= ), spontaneous term labor (stl, n= ), and term no labor (tnl, n= ). subjects were delivered between gestational ages - weeks (preterm) and - weeks (term) by cesarean. paraffin sections were stained with polyclonal (rabbit) anti-human p and microscopically examined. myometrial samples were categorized in a blinded fashion to groups of staining: no nuclear p (-), rare nuclear p (+), and > % nuclear p (++). a p nuclear labeling index (nli; % nuclear p /total cells) was calculated for each histological layer in full-thickness fm specimens using a blinded targeted randomization scheme consisting of non-overlapping low-magnification fields. results: nuclear p labeling was rare in amnion and inconsistently present in chorion. in decidua, p nuclear labeling was observed in all cases; however, decidual nli did not vary significantly across cohorts [pnl- % ( - %); ptl- % ( - %); tnl- % ( - %); stl- % ( - %); all values are median (iqr)]. in myometrium, ++ p nuclear labeling was significantly associated with labor, but present only in a portion of cases (ptl- %; stl- %). despite a trend, decidual nli was not significantly correlated with myometrial nuclear p labeling: myometrial specimens classified as -, +, and ++ corresponded with decidual nli of % ( - %) [median (iqr)], % ( - %), and % ( - %), respectively. conclusions: in a comprehensive ihc analysis, significant nuclear p immunolabeling was observed in myometrial cells following labor. nuclear p labeling in decidua was present in all cases, and did not vary significantly among the cohorts. the inflammatory cytokines interleukin- and tnf-increase g-csf expression in term decidual cells. objectives: chorioamnionitis (cam) elicits premature rupture of the membranes and pre-term delivery. previously, we found that the decidua from cam patients contains much higher neutrophil numbers than control decidua, but macrophage numbers are similar in both groups. granulocyte colony-stimulating factor (g-csf) enhances granulocyte colony formation chemoattraction and activation. the amniotic fluid during cam contains elevated tnf-and il- levels. to account for the marked influx of neutrophils infiltration in cam-complicated decidua, tnf-and il-effects were assessed on g-csf expression in term decidual cell (dc) monolayers. methods: confluent leukocyte-free term dcs from normal term deliveries were primed with - m estradiol (e ) + - m medroxyprogesterone acetate (mpa) for days, then switched to serum-free defined medium (dm) with steroids ± tnf-or il- . after h, aliquots of conditioned dm supernatants, cell lysates and extracted rna from h parallel incubations were frozen. secreted g-csf was measured by elisa in conditioned dm and normalized to cell protein and mrna was assessed by quantitative real time rt-pcr and normalized to -actin mrna. results: in cultured first trimester dcs, basal g-csf levels in conditioned dm were . ± . pg/ml/ug cell protein [mean ± sem, n= ] and did not differ from e +mpa basal levels. the addition of ng/ml of tnf-or il- significantly elevated g-csf output to . ± . and ± respectively (p< . ), representing more than a -fold and , -fold change; respectively. western blotting confirmed the elisa results. quantitative rt-pcr demonstrated corresponding changes in g-csf mrna levels as found for the elisa measurements. concentration-dependent effects for both tnfand il- from . to . ng/ml were observed. conclusions: when extrapolated to the placental milieu of cam, the marked increase in g-csf elicited in term dcs by tnf-and il- may provide a mechanism to account for the selective increase in decidual neutrophils versus macrophages. background. the immunological mechanisms of the female reproductive tract are unclear. toll-like receptors (tlrs), innate immune receptors that combat microbial infections and establish adaptive immunity, may play a role. infection in pregnancy has been associated with preterm birth and tlrs may modulate the host response to such infections. we hypothesised that the distribution of tlr and tlr in cervical epithelial cells may differ with pregnancy, and that oestrogen may contribute to the modulation of these receptors. aims and objectives. . to compare tlr and tlr protein expression, using immunocytochemistry, in the cervical epithelium of pre-menopausal non-pregnant women with pregnant women at term. methods. fresh non-pregnant (n= ) and pregnant (n= ) human cervical cells were obtained by smear and tlr and tlr expression investigated by immunocytochemistry. cervical epithelial cells from nonpregnant women obtained by smears were then coincubated with varying concentrations of estradiol, and tlr and tlr protein expression quantified by immunocytochemistry. results. using pixel-based image analysis software, we demonstrated a reduction in tlr expression in late pregnant compared with non-pregnant cervical epithelium (p= . ), whilst tlr did not appear to differ. there was an apparent up-regulation of tlr protein expression in response to beta-oestradiol (n= ) objective: to evaluate in vitro antimicrobial activity of cranberry-exposed urine against common urinary pathogens. subjects were pregnant women enrolled in a clinical trial evaluating the effect of daily cranberry juice cocktail or matching placebo on asymptomatic bacteriuria and other urinary tract infections. methods: -hour urine samples from pregnant women who were randomized to cranberry or placebo in three treatment arms: a. cranberry two times daily with meals (c, c; n= ), b: cranberry in the am, then placebo at dinner (c, p; n= ), c: placebo two times daily with meals (p, p; n= ). we identified non-pregnant, reproductive-aged controls, randomized them to the same treatment groups and collected -hour urine specimens from them. the ph of all urine specimens was adjusted to ph= and filtered. aliquots of each were independently inoculated with overnight culture of - cell/ml each of single strains of e. coli with fimbriae type i and type ii, k. pneumoniae, and c. albicans. after hours of incubation for e. coli and k. pneumoniae, and hours for c. albicans cfu/ml of each specimen were enumerated by subculture with quantitative plate counts in duplicate. results: there were no differences for any of the antimicrobial activities between pregnant and non-pregnant groups, or based on treatment allocation. we were able to perform antimicrobial assays on the urine of women exposed to cranberry juice or placebo, but unable to demonstrate differences based on treatment allocation or pregnancy. this may be due to beta-error. further studies are planned. supported by r dk - ; clinical trials registration nct . ...,.. e. coli . x .:!: . x . x .:!: . x group a (c, c) group b ( c, p) . x + . x . x + . x . . . group c (p, p) . x o"::!>s x o" . x ~ .ox: o• k. ~neumoniae group a ( c, c) . x + . x . x + . x . . . group b (c, p) . x + . x . x + . x group c (p, pl . x ~ . x . x ~ . x c. al bicans group a (c, c) . x '+ . x . x + . x group b (c, p) . x o•+ . x . x + . x . . . group c (p, p) . x ~ . x . x ~ . x • objective: to measure compliance, we sought to evaluate the use of a bioassay for cranberry in the urine of women enrolled in a clinical trial designed to determine the effect of daily dosing of cranberry juice cocktail or matching placebo on the incidence of asymptomatic bacteriuria (asb) and other urinary tract infections (uti) during pregnancy. methods: we collected -hour urine specimens from pregnant women who were randomized to ingest cranberry or placebo in three treatment arms: a: cranberry two times daily with meals (n= ), b: cranberry in the am, then placebo at dinner (n= ), c. placebo two times daily with meals (n= ). we identified non-pregnant, reproductive-aged controls, randomized them to the same treatment regimens (group a: n= , group b: n= , group c: n= ), and collected -hour urine specimens from them. bacterial anti-adhesion effects of the cranberry-exposed urine were evaluated utilizing a human red blood cell hemagglutination assay specific for uropathogenic p-fimbriated e. coli. activity was quantified as , , and %. results: when combining all subjects and dosing regimens, the sensitivity of the assay was %, range % in the pregnant group assigned single daily dose of cranberry to % in the non-pregnant group assigned to multiple daily doses. the specificity ranged from % to %. conclusions: these data indicate that the bioassay can be applied to the pregnant patient population, although the sensitivity of the assay is variable. higher daily dosing appears to confer greater sensitivity. further studies are needed to evaluate the utility of this bioassay for compliance. supported by r dk - . clinical trials registration nct . objective: increasing evidence suggests that inflammation plays a crucial role in initiation of labour both at term and preterm. we have previously shown upregulation of pro-inflammatory cytokines in myometrium, cervix and membranes at term labour. we have also shown that myometrium and cervix is invaded by leukocytes at the time of labour, and these leukocytes express pro-inflammatory cytokines. in this study, we aimed to test the hypothesis that pro-inflammatory cytokines and toll-like receptor and (tlr and ) mrna expression are up-regulated in circulating leukocytes during term and preterm labour. methods: peripheral blood samples were taken from pregnant women: - weeks gestation (w) preterm not in labour (ptnl) n= ; - w preterm in labour (ptl), n= ; - w term not in labour (tnl) n= ; and - w term in labour (tl) n= . leukocytes were isolated using dextran sedimentation. total rna was isolated and reverse transcribed using high capacity cdna archive kit, and mrna expression determined by real-time pcr (abi, taqman). student's t-test was used to compare outcomes between groups. results: messenger rna expression of il- , icam- , mcp- , tlr and tlr was significantly increased in tl compared to gestation matched tnl. the expression levels of il- b, il- and tlr- were significantly greater in ptl compared with gestation matched ptnl. (table i) . conclusions: we show up-regulation of pro-inflammatory cytokine production in circulating leukocytes in both term and preterm labour. thus, the pathophysiology of labour seems to involve the upregulation of proinflammatory cytokine production in peripheral blood leukocytes, followed by their invasion into the myometrium and cervix. this work further contributes to our understanding of the pathophysiology of parturition, and suggests that peripheral blood leukocytes may be potential targets for therapeutic agents aimed at modifying the time course of parturition. introduction. the mechanisms of innate immunity and tolerance in the female reproductive tract (frt) are ill-understood but involve the pattern recognition toll-like receptors (tlrs). we have previously demonstrated high expression levels of tlr gene and protein in fresh human cervical epithelium. aims. in order to gain insight into the immunological role of cervical epithelial cells (cecs), we sought to determine cec responses to the following tlr- agonists: macrophage-activating lipopeptide (malp- ), pam csk , and peptidoglycan. methods. cecs were isolated by smears and compared between pregnant ( rd trimester) and nonpregnant women. following cell preparation, flow cytometry was performed using a direct staining procedure with mouse anti-human tlr primary antibody and its igg , isotype control, to determine tlr- protein expression. a further nonpregnant smear samples were each prepared, and seeded at a concentration of , cervical epithelial cells/ml into -well cell plates. cells were incubated at °c in % co overnight with the tlr agonists malp- and pam csk (at concentrations of and ng/ml), peptidoglycan( ng/ml), il- ( ng/ml, positive control) and rpmi + -glutamine media only (vehicle). following centrifugation, all resulting supernatants were stored at - °c until the concentration of il- was determined by elisa and an array of cytokines by bead assays. results. both pregnant and nonpregnant cecs expressed tlr (specific mean fluorescence . vs . respectively) but did not differ (p = . ). unstimulated cells incubated with buffer alone demonstrated high il- levels ( pg/ml), which did not differ following stimulation with malp- ( pg/ml), pam csk ( pg/ml) or peptidoglycan ( pg/ml). results of an array of pro-and anti-inflammatory cytokines following incubation of cells stimulated with tlr agonists are pending. conclusion. high basal il- levels suggest constitutive expression by cecs but the physiological relevance of this intriguing observation is unclear. that cec stimulation with tlr- agonists did not lead to further release of il- may epitomise the resistance of these cells to antigenic challenge by the vaginal commensal flora. cecs may play a pivotal role in modulating the immunological tolerance necessary to minimise inappropriate inflammation in the cervix. there are several epidemiological and clinical studies that omega- fatty acids and related fish oils can decrease the premature labor and birth. however, the scientific mechanisms are not well elucidated. this study was carried out to investigate the effects of omega- fatty acids on producing pge and il- , in human umbilical vascular endothelial cell(huvec) media with artificial inflammation as an infection-induced premature labor tissue model. also, if there are some significant effects with omega- fatty acids, we want to investigate the possible mechanisms. materials and methods; human umbilical vascular vascular cell primary culture was done. in the adequate cell confluence in each cell dish, pretreatment with various concentrations of epa, dha and troglitazone (another ppar-ligand) and incubation were done for hours in °c, co incubator. after that, g/ml conc. of lipopolysaccharide(lps) was treated to the each cell dishes and incubated for hours. the cell media were collected, and pge and il- concentration were checked by elisa. the each cell lysates were collected and western blot anaysis for cyclooxygenase(cox)- were done. on the other hand, nuclear factor kappa b (nf b) luciferase vector was transfected and then did the same pretreatment with epa, dha and troglitazone and lps treatment to each cell dishes. after that, nf b luciferase activity was checked with luminometer. statistical analysis was done by student t-test. results: epa, dha and troglitazone decreased the pge (p< . ) and il- (p< . ) significantly in elisa. cox- expression revealed the significant reduction with pretreatment of epa, dha and troglitazone in higher concentration ( , m) in the western blotting (p< . ). nf b luciferase activity were also significantly decresed with pretreatment of epa, dha and troglitazone in higher concentration (p< . ). conclusion; this study offers some scientific mechanisms, by which omega- fatty acids (epa, dha) and troglitazone may be one kind of the preventive medicine for infection-induced preterm labor and delivery. also, these effects may come from the common mechanism of epa, dha and troglitazone, ppar-ligands. the next study would be how the cox- , nf b and pparare related. ( mg/ml). cytokine expression was measured in medium using the bio-plex suspension array system (bio-rad). mean expression was compared between the two groups using t test. results: -aminopurine significantly inhibited lps stimulated cytokine production by human myometrium. in contrast, there were no significant differences in expression after mpa treatment, although a trend towards inhibition of proinflammatory cytokine and an increase in il- production was noted. introduction: intrauterine infection is now recognised as a major antecedent of white matter injury (wmi) in the preterm infant brain, which can manifest later as cerebral palsy or as varying degrees of cognitive dysfunction. wmi in these infants is characterized by damage to immature oligodendrocytes, and has been linked both to microglial activation and to elevated levels of tnfa, il- b and il- . we have developed a fetal sheep model for diffuse and focal wmi, based on repeated administration of e. coli lipopolysaccharide (lps) as the stimulus for an inflammatory response. methods: surgery to implant fetal vascular catheters was performed on pregnant ewes carrying single fetuses at d - of gestation. fetuses received repeated iv injections of lps ( ng/kg estimated fetal weight/day) between d and d . plasma levels of pro-inflammatory cytokines were determined in fetal arterial blood samples taken between d and d . at d ewes and fetuses were euthanized and fetal brain tissue samples collected for histological analysis. results: five days after final administration of lps to fetuses we observed a pattern of wmi similar to that seen clinically, ranging from focal to diffuse injury within the periventricular region, impairment of white matter (cnpase; marker for immature/mature oligodendrocytes) tracts, and thinning of the corpus callosum, characterised by oligodendrocyte disruption and microglial proliferation in the surrounding and sub-cortical white matter. we also found a progressive rise in fetal plasma tnf levels between days and (day two of treatment to third day following final dose of lps). background: plasma fatty acid (fa) levels are associated with altered host inflammatory responses, blood pressure regulation, and insulin resistance, characteristic features of pregnancy-induced hypertension (pih). most studies compare the n- and n- polyunsaturated fatty acids (pufas). in addition, recent data demonstrate that saturated and trans-fas promote inflammation. based on the immunomodulatory activity of various fas, we explored their effects on placenta inflammatory responses ex vivo. methods: placenta cells were isolated from fresh human (anonymous), term placentas and treated with/without lipopolysaccharide (lps) with various fas, including saturated fas, trans-fas, and n- and n- pufas (at physiological concentrations). after an overnight treatment, tnf-alpha (tnf) production was determined. data were analyzed by analysis of variance (anova) followed by the dunnett's test. results: oleic acid ( : n- ), a cis-monosaturated fa common in the mediterranean diet, did not induce significant placenta tnf production (fig. a) . by contrast, elaidic acid ( : n- ), a trans-monosaturated fa, induced tnf production by -fold compared to vehicle (fig. a) . likewise, palmitic acid ( : ), a saturated fa, induced placenta tnf production by -fold (fig. a) . to mimic inflammation, placenta cells were treated with lps ex vivo in the presence/absence of fas. docosahexanoic acid ( : n- , dha) reduced placenta tnf production by up to % following stimulation (fig. b) . similarly, treatment of placenta cells with linoleic acid ( : n- , la) or arachidonic acid (n : n- , aa) suppressed tnf production by up to % and %, respectively (fig. b) . conclusions: both saturated fas and trans-fas, which positively correlate with hypertension, induce placental tnf production. the n- fa precursors to prostaglandins, aa and linoleic acid, reduce placental tnf production following stimulation. likewise, dha, a product of n- fa metabolism commonly consumed in fish oil and associated with improved blood pressure, suppresses tnf production by stimulated placenta cells. vegf and flk mediated glomerulogenesis in offspring exposed to maternal hypernatremia. roy z mansano, mina desai, ahmed abdel-hakeem, thomas r magee, tazmia q henry, cynthia nast, john s torday, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: growth restricted human and animal offspring, resulting from maternal nutrient restriction or uteroplacental insufficiency, consistently demonstrate reduced glomerular number and a predisposition to adult systemic hypertension and renal compromise. in contrast, maternal water restriction (wr) produces newborns with a unique programmed phenotype of increased glomerular number. glomerulogenesis is dependent, in part, on appropriately timed and quantified vascular development. as vegf and its receptor flk have crucial stimulatory effects on renal vasculogenesis, we hypothesized that maternal wr-induced morphologic renal changes are secondary to vegfmediated vasculogenic effects. methods: from day to term gestation, pregnant rats received either ad libitum food and water (control, n= ), or wr to produce an increment of meq/l in plasma sodium (n= ). following delivery, all dams received ad libitum food and water. at d after birth, offspring kidneys were extracted for mrna. vegf and its receptor, flk , mrna levels were determined using real-time rt-pcr (presented as fold difference normalized to s). at d after birth, offspring glomerular number were determined in formalin fixed m sections using histomorphometric analysis. values are means±se. results: wr offspring (day ) had higher glomerular number than control (wr ± , control ± per mm , p< . ). flk mrna expression was increased in wr offspring kidneys (wr . ± . , control . ± . , p< . ) as compared to controls. in contrast, vegf mrna expression in wr offspring kidney was comparable to control (wr . ± . , control . ± . , p= . ). conclusion:prenatally wr offspring demonstrate significantly increased glomerular number. as vegf recruits angioblasts to the developing glomerulus via its receptor flk , increased receptors (flk ) with the same level of the ligand (vegf) suggest that enhanced vasculogenesis may represent a putative mechanism for increased nephrogenesis in wr offspring. modulation of newborn vasculogenesis via vegf and flk expression may represent a therapeutic option for growth restricted offspring with decreased glomerular number. objective: maternal food restriction (mfr) during gestation (embryonic day to birth) reduces rat kidney glomerular number by % at weeks of age. undernutrition during human gestation leads to similar impaired nephrogenesis and increased hypertension in adults. renal development may be delineated into stages including ureteric bud branching, mesenchymal to epithelial transformation and glomerulogenesis. previously, we detected dysregulation of genes controlling nephrogenesis at gestational ages, e -e , suggesting that mfr has significant effects on ureteric bud branching. in the present study we evaluated the effect of this dysregulation on early nephron development in e fetal kidney explants from dams with mfr. methods: e fetal kidneys were collected from % mfr pregnant rats and ad libitum control rats (n= per group and time point), incubated in dmem/f k medium for , , , , and days, and fixed with % paraformaldehyde. kidneys were stained with fluorescein-labeled dolichos biflorus agglutinin (dba), images captured and terminal ureteric buds quantitated. all values are presented as mean ± sem. differences were considered significant at p< . . results: mfr ex-vivo kidneys at day demonstrated an initial moderate reduction in terminal branches versus control (c) samples (mfr: ± vs c: ± terminal branch ends per kidney). both mfr and control (c) kidneys demonstrated significant (p< . ) increases in branching in explant culture to maximum values at days (mfr: ± vs c: ± ). with increasing culture days, the percent reduction in mfr branching increased with terminal branch point decreases of % at day , % at day , % at day , % at day , and % at day (p< . , mfr vs c at day ). conclusion: kidney explant cultures from mfr treated fetuses display basal and culture-based decreased branching compared to controls. this decrease in terminal ureteric buds, in combination with our previous findings of dysregulation of branching-associated kidney transcription and growth factors, suggests mfr induces early (e ) dysregulation of branching as a major mechanism of the associated nephropenia. these results indicate that early programming events in kidney development induce nephropenia and renal disease in adults. intrauterine growth restriction (iugr) has important implications for the neonate not only at the time of birth, but also as an adult. in humans and animals with iugr, the elevated risk of developing hypertension is thought to involve an upregulation of the renin-angiotensin system (ras). however, the link between the intrauterine insult and enhanced ras is not known. a novel mechanism leading to hypertension has emerged recently involving two orphan g-protein coupled receptors (gcr and gcr ) and their endogenous ligands, succinate and -ketoglutarate. infusion of succinate into adult mice induces hypertension, an effect which was eliminated in gcr knockout mice or by pretreatment with ace inhibitors. interestingly, succinate levels have been shown to increase in the circulation under conditions of oxidative stress, one of the hypothesized mediators of developmental programming of hypertension. thus, we hypothesized that gcr and gcr are upregulated in a rat model of iugr and may contribute to in utero programming of hypertension. timedpregnant rats were fed either control (c, % casein) or low protein (lp, % casein) diet throughout gestation. kidneys were collected on embryonic day (e ), post-natal day (d ) or (d ), n . real-time pcr was used to compare gcr , gcr and renin expression. data were standardized to a housekeeping gene (s ) and are expressed as fold increase/ decrease compared to control. a student's t-test was used to determine significance between groups (p< . ). offspring from lp dams were significantly smaller at birth and did not display catch-up growth. in kidneys from lp fetuses, both gcr and gcr were significantly elevated compared with controls ( . fold and . fold respectively; p= . ), whereas renin was . fold lower. on post-natal d , there was a trend towards increased expression of both gcr ( . fold; p= . ) and renin ( . fold; p= . ) in offspring from lp dams. at d , there were no significant differences between groups. in conclusion, these preliminary data suggest that in iugr offspring from lp rats, the gcr / pathway may be enhanced, indicating a novel mechanism for the programming of hypertension. objective: in addition to excess adipose tissue, obesity is accompanied by increased fat storage in organs such as the liver. peroxisome proliferatoractivated receptors (ppars) are ligand-activated transcription factors involved in the regulation of lipid metabolism, and lipid-associated inflammatory response. obesity represents a state of chronic low-level inflammation, with ppar and ppar implicated in this process. we have previously shown that nutrient restriction in pregnancy results in intrauterine growth restricted (iugr) newborns which develop adult obesity with elevated c-reactive protein (crp) levels. as crp is derived from the liver, we hypothesized that iugr-induced obesity inhibition of hepatic ppar and ppar is associated with an increased inflammatory response. methods: control dams received ad libitum food, whereas study dams were % food-restricted from pregnancy day to to produce iugr newborns. all pups were nursed by control dams and weaned at weeks to ad libitum feed. at day and months of age, male offspring were analyzed for hepatic ppar , ppar and crp mrna (real time rt-pcr) and protein (western blot) expression. data was normalized to -actin and presented as fold change for protein levels. at months, hepatic triglyceride content was determined enzymatically. results: at d of age, iugr pups showed significant downregulation of ppar ( . -fold) and ppar ( . -fold) expression, though crp expression was significantly upregulated ( -fold). findings persisted at months of age, with continued downregulation of ppar and ppar ( . -fold) and upregulation of crp expression ( -fold). furthermore, iugr adults had significantly increased hepatic triglyceride content ( ± vs. ± mg/g liver, p< . ). conclusions: reduced expression of hepatic ppar and ppar in iugr offspring may contribute to elevated hepatic crp levels and triglyceride content. thus, developmental hepatic dysregulation leads to programmed obesity-induced inflammation in iugr offspring. offspring. mina desai, ederlen casillas, guang han, darran n tosh, , michael g ross. dept. of ob/gyn, labiomed at harbor-ucla med. ctr., torrance, ca, usa; dept. of physiology, univ. of adelaide, australia. objective: leptin and insulin mediate central anorexigenic signaling responses via different receptor molecules: leptin binds to the obrb receptor activating jak-stat and pi k pathways, whereas insulin activates pi k pathway by binding to its receptor (ir) and substrate (irs ). maternal food restriction in pregnancy results in iugr newborns that develop hyperphagia and adult obesity. the iugr newborns have significantly decreased plasma leptin levels with increased hypothalamic expression of basal obrb, stat and decreased expression of ir and irs , suggesting altered anorexigenic pathways. we studied the response of hypothalamic leptin/insulin signal molecules to peripheral leptin in iugr newborns. methods: control dams received ad libitum food, whereas study dams were % food-restricted from pregnancy day to . day old male offspring were given saline or leptin ( g/g, i.p). hypothalamus was dissected at , and minutes and protein expression of total stat , phosphorylated stat (p-stat ), inhibitor of leptin signal (socs ), ir, irs , total akt and phosphorylated akt was determined by western blot (normalized to -actin). data is compared between leptin and saline treatments in iugr and controls. results: in response to peripheral leptin, iugr newborns showed marked dysfunction in stimulated hypothalamic leptin and insulin signaling responses. ( ) jak-stat : leptin-treated controls show progressively increased pstat ( -fold) with initial suppression of socs ( . -fold) as compared to salinetreated controls. conversely in leptin-treated iugr, the pattern is reversed such that there is sustained decline in pstat expression ( . -fold) with failure to downregulate socs . ( ) pi k pathway: leptin-treated controls showed a significant reduction in irs ( . -fold) and pakt ( . -fold) as compared to saline-treated controls. however, leptin-treated iugr newborns exhibited a paradoxical increase expression of irs ( -fold) and pakt ( -fold). conclusion:the iugr offspring demonstrate persistent upregulation of leptin receptor, a reduced phosphorylated stat (p-stat ) response in conjunction with an enhanced socs- response. the persistent increase in insulin responses indicates a dysfunction in dynamic signaling, leading to altered anorexigenic response and development of programmed obesity. we have previously demonstrated that maternal food restriction (mfr) in rats induces a marked increase in the expression of vegf protein in the aorta and mesenteric arterioles, accompanied by an increase in tgf-and collagen in both vessel types in adult rat offspring (am j physiol, ) . the aim of this study was to determine if this in vivo finding could be reproduced in an in vitro preparation. methods: two types of preparations were used in this study. we isolated endothelial cells from week old male control rat aortas. these cells were used after the third passage. staining with von willerbrand factor demonstrated that these cells were pure endothelial cells. the second type of preparation was aortic explants from week old male control rats. endothelial cells and aortic explants were transfected with a vegf adenovirus ( - viral infective particles) or a -galactosidase-adenovirus as a control. after hours of culture protein was isolated from cells and explants for western blot analysis using rat specific antibodies. culture media was assayed for vegf by elisa. results: transfection of vegf adenovirus induced a dose-dependant increase in the expression of vegf protein in primary endothelial cells and aortic explants. the transfection of vegf into the endothelial cells showed a bell shaped curve, and was accompanied by an increase in media levels of vegf protein. maximal secretion of vegf was found with viral infective particles. vegf adenovirus transfection induced a dose-dependant increase in c-reactive protein (crp) (inflammatory marker), and tgf-protein in both aortic explants and primary endothelial cells. these results indicate that upregulation of vegf in blood vessels induces inflammation and tgf-expression which in turn can induce collagen synthesis. thus the increased collagen expression and reduced compliance previously reported by us in vessels of mfr offspring can be explained by the over-expression of vegf which we reported. therapeutic intervention aimed at prevention of the increase in vascular vegf expression in mfr offspring could potentially prevent programmed hypertension. maternal regulation of high fat nourishment during lactation period reduce a hypertension of male offspring. hidenori takahashi, toshiaki okawa, keiya fujimori, akira sato. obgyn, fukushima med.univ., fukushima, fukushima, japan. objective: exposure to undernutrition or high fat nourishment during fetal life has been proposed as an underlying cause of adult hypertension, but the effect of maternal feeding regulation during lactation period on blood pressure of offspring is unclear. our objective was to investigate the effects of either high-fat diet (hfd) during gestation to lactation period or restrictive fed a hfd during lactation period on blood pressure in male rat offspring. we use types pregnant wistar rats as fed with normal nutrition (group a), with a high fat diet (hfd) during gestation to lactation period (group b) and with hfd nutritionally restricted by feeding with % of the normal lactationmatched dietary intake from the day of delivery to the end of lactation period (group c). the male offspring was measured blood pressure at , and weeks by using indirect tail-cuff method. statically analysis was performed using oneway annova. results: body weight was significantly reduced in c offspring compared to a and b in male offspring at day after delivery (p< . ). at weeks old, the body weight of c offspring was no difference to catch up compared to a and b offspring. systolic and diastolic blood pressures were significantly elevated at all , and weeks in offspring of b > c >a. (p< . , vs. a) conclusions: under high-fat nutrition during gestation to lactation period induced hypertension in male rat offspring. maternal high fat environment make a hypertensive offspring, but regulation of fat feeding during lactation period may reduce adulthood hypertension. background: uterine artery (uta) doppler velocimetry has been validated in populations of heterogeneous parity in the second trimester for prediction of obstetric outcomes requiring preterm delivery to include: fetal growth restriction, fetal demise, hypertensive disorders of pregnancy, abruption, and indicated preterm delivery. understanding that parity may affect uta doppler indices in subsequent pregnancies, we sought to validate these predictive values in the first trimester in a homogeneous population of multiparous women. study design: multiparous women undergoing first trimester screening of singleton pregnancies were enrolled and followed prospectively until delivery (n= ). these women were divided into controls, ri < . (n= ) and cases, ri . (n= ), based on prior studies. demographic, clinical, and sonographic data (including uta indices and assessment of notching) were obtained. statistical analysis included student's t test and chi square. results: cases were not significantly different from controls in terms of maternal age, ethnicity, bmi, or medical history. uta doppler indices were significantly different between the two cohorts in terms of the presence of unilateral or bilateral notching ( % vs, % p< . and % vs. %, p< . , respectively). in contrast to that observed in patients of heterogenous parity previously, ri . was not associated with adverse pregnancy outcomes despite an average ri of . , significantly above this threshold. conclusions: in this multiparous cohort ri was not predictive of adverse obstetrical outcome, in contrast to that observed in cohorts including nulliparous patient. parity may affect uta vasculature and obscure the ability of doppler velocimetry to predict adverse obstetric outcome in multiparous women. presence of uta doppler notching in the first trimester remained a robust predictor of adverse obstetric outcomes in multiparous patients. objective: epidemiological studies have shown that offspring exposed to preeclampsia during fetal development are more susceptible to airway disease later in life. we have shown previously that gender, but not sflt- over-expression during pregnancy determines higher reactivity in the offspring airways at months of age. the objective of this study was to examine the effect of preeclampsia on the trachea from female and male offspring in our model of sflt- induced preeclampsia at year of age and compare responses between the two age groups. methods: cd- mice at day of gestation were injected via the tail vein with adenovirus carrying sflt (adsflt , pfu/ l) or mfc (admfc, pfu/ l). mice were allowed to deliver. tracheas were isolated from female and male offspring at months and year of age, and rings were mounted in organ chambers for isometric tension recording. responses to potassium chloride (kcl, mm), the mast cell degranulating agent compound / ( / , g/ml), and concentration-responses curve to acetylcholine ( - - - m) were obtained. results: there was no significant difference in responses to acetylcholine, kcl, or compound / between year old offspring born to the sflt and mfc groups. when comparing offspring within the same pregnancy exposure groups, responses to acetylcholine in adsflt -treated group were significantly higher in year old females than males. comparison between age groups by pregnancy exposure revealed that in the mfc group, year old male offspring had higher responses to compound / and acetylcholine than months old males. responses to kcl were significantly higher in months old males than year olds independent of maternal treatment during pregnancy. in females, the only difference between age groups was observed in the mfc group, where months old offspring demonstrated significantly higher responses to acetylcholine compared to year old offspring. conclusions: our findings did not show that airways of year old offspring born to mice with a preeclampsia-like syndrome induced by sflt- over-expression have airway hyperreactivity. however, sex and age differences in airway responses dependent on maternal exposure during pregnancy were observed, and needs to be explored further to elucidate underlying mechanisms. objective: maternal food restriction (fr) results in iugr newborns that when normally nursed exhibit rapid catch-up growth and adult obesity. continued fr during nursing delays catch-up growth and prevents adult obesity. igf- , which modulates growth and is secreted by the liver, may contribute to these morbidities. igf- is epigenetically regulated involving two promoters, alternative exon splicing and multiple transcription termination sites. we determined if hepatic igf- mrna levels correlate with obesity, and whether these changes are due to programmed epigenetic modification. methods: control pregnant rats received ad libitum food from gestation day to and lactation, whereas study dams were % fr. fr pups were nursed by either control (fr/adlib) or fr dams (fr/fr) and weaned to ad libitum feed. at day and months, male livers were analyzed for igf- mrna variant levels (real time rt-pcr). chromatin immunoprecipitation (chip) was performed using the antibody for h k trimethyl, and associated levels of each igf- species were measured by pcr. results: at months, obese fr/adlib males showed increased mrna levels of igf- a, igf- b, igf- exon , and igf- exon as compared to controls ( ± , ± , ± , and ± %). comparing fr/adlib month to newborn offspring, h /k was increased at igf -promoter , promoter , exon , utr# and utr# ( ± , ± , ± , ± , and ± %), though there was no differences between control month and newborns. in contrast, month fr/fr males had comparable mrna levels to the controls except for igf- b (% of control: ± ). further, fr/fr month h /k was only different from newborns at utr# (% of newborn: ± ). conclusion: iugr newborns with rapid catch-up growth and adult obesity have increased postnatal hepatic igf- mrna levels, likely a result of igf- histone and chromatin structure modifications to h k trimethylation. conversely, iugr with delayed catch-up growth and absence of adult obesity have levels similar to that of controls. thus, modulation of the rate of iugr newborn catch-up growth may protect against igf- epigenetic modifications. introduction: igf-ii is synthesized as a pro-hormone (proigf-ii; -amino acid peptide) which is then processed into its active forms: "big" igf-ii ( - ) and mature igf-ii ( - ). these active forms are essential for placental and fetal development and have also been shown to persist into postnatal life. since maternal smoking is known to adversely affect feto-placental growth and postnatal development, we postulated that these effects might be mediated through nicotine-induced alterations in igf-ii processing. methods: in the present study, nulliparous female wistar rats ( - g) were given nicotine ( mg/kg/day) or saline for days prior to mating, during pregnancy, and throughout lactation. at gestational day , and , dams were euthanized and we collected serum (fetal and maternal), amniotic fluid and recorded fetal body weight. a subset of dams were allowed to deliver at term. following parturition, serum samples from the offspring were collected at birth (pnd ) and weaning (pnd ). body weight was recorded weekly from birth to weaning. pro, "big" and mature igf-ii levels were determined by western blot analysis. results: maternal nicotine exposure during pregnancy resulted in a significant reduction in fetal body weight by gestational day . however, there was no effect of nicotine on fetal serum or amniotic fluid igf-ii levels at any gestational age examined. in maternal serum, mature igf-ii in control animals decreased with advancing gestational age such that igf-ii levels were lowest at gestational day . nicotine administration prevented this decline, which resulted in significantly higher mature igf-ii levels in nicotine-exposed mothers at gestational day . in postnatal life, nicotine exposed offspring had significantly lower levels of "big" igf-ii expression at weaning (pnd ). conclusions: these data demonstrate that nicotine can alter the amount of the active forms of igf-ii in the mother and the newborn. dysregulation of maternal igf-ii occurs concomitantly with suboptimal fetal growth. results from this study suggest a mechanism by which maternal smoking causes impaired fetal growth and adverse postnatal health outcomes. objective: maternal food restriction in pregnancy results in iugr newborns which develop adult metabolic syndrome. programming of both increased appetite-mediated hyperphagia and enhanced adipogenesis contribute to the development of obesity. transcription factors, peroxisome-proliferatoractivated-receptor (ppar ), ccaat/enhancer binding-protein (c/ebp ), and sterol regulatory element binding-protein (srebp c) regulate adipogenesis and lipogenesis. although iugr offspring exhibit acute upregulation of the adipogenesis signaling cascade prior to the development of obesity, we determined if this increased adipogenic potential was an intrinsic cellular response, and thus maintained in cell culture. we further examined the responses to adipocyte stimulators (ppar activator-ligand rosiglitazone) and inhibitors (ppar repressor-ligand badge). methods: control dams received ad libitum food, whereas study dams were % food-restricted from pregnancy day to term. adipocytes from day old iugr and controls were isolated and cell proliferation rate was determined (mtt). primary adipocyte cell cultures were established and following % confluence, iugr and control adipocytes were treated to two doses ( and m) of either rosiglitazone or badge for h. mrna and protein was extracted for expression of ppar , c/ebp , srebp c. data was normalized to -actin and compared to the respective untreated cells. results: iugr adipocytes had significantly increased protein expression of ppar ( . -fold) and c/ebp ( -fold) as compared to control adipocytes, though srebp c levels were unchanged. mrna levels showed similar changes in iugr newborns. importantly, iugr adipocytes exhibited increased cell proliferation ( % of control, p< . ) and showed greater response to rosiglitazone ( . -fold), though similar response to badge, as the control adipocytes conclusion: iugr primary adipocytes cell culture exhibit basal phenotypic characteristic of programmed upregulation of adipogenic transcription factors which promote adipose cell proliferation. the enhanced response to the adipogenic stimulant is further evidence of the predisposition to obesity. in contrast, the normal suppressive response to the inhibitor suggests that iugr adipocytes may respond to pharmacologic approaches to prevent obesity during this period. objective: maternal nutrient restriction results in intrauterine growth restricted (iugr) newborns which develop programmed obesity despite a normal post-weaning diet. the epidemic of obesity has been attributed in part to programmed "thrifty phenotype" and exposure to "western" diets. hepatic igf- is epigenetically regulated involving two promoters, alternative exon splicing, and multiple transcription termination sites. iugr offspring with normal post-weaning diet have increased postnatal hepatic igf- mrna levels, likely a result of igf- histone and chromatin structure modifications to h k trimethylation. we hypothesized that iugr newborns that develop programmed obesity would demonstrate discernable hepatic igf- changes which are distinct from diet-induced obesity. we determined igf- hepatic mrna levels and epigenetic characteristics in programmed (iugr) and dietinduced (dio) offspring. methods:: control pregnant rats received ad libitum food whereas study dams were % maternal food restricted from day to . all pups were nursed on ad libitum fed dams. controls were weaned to high-fat (fat, %) diet whereas iugr were weaned to normal ad libitum diet (fat, %) to produce diet-induced (dio) and programmed obese groups, respectively. at months, male hepatic igf- were analyzed for igf- mrna variant levels (real time rt-pcr). chromatin immunoprecipitation (chip) was performed using the antibody for h k dimethyl and h k trimethyl, and associated levels of each igf- species were measured by pcr. result: relative to dio control males, iugr had increased mrna of igf- a, exon and exon ( ± , ± , ± %). chip with h k dimethyl showed increased igf- exon ( ± %) and with h k trimethyl, increased igf- promoter and promoter ( ± , ± %) as compared to dio controls. conclusion: adult obese iugr males exposed to normal postweaning diet have increased hepatic igf- a mrna and h k dimethylation and trimethylation of igf- than dio controls. changes in igf- in adulthood from a prenatal insult thus suggest that igf- is programmed during the fetal period and may be associated with programmed adult obesity. rebekah elkins, pandu gangula, chandra yallampalli. obstetrics gynecology, university of texas medical branch, galveston, tx, usa; internal medicine, university of texas medical branch, galveston, tx, usa. objectives: we previously reported that the offspring of rats fed % protein during gestation develop hypertension at two to four months and that the hypertension is exacerbated in males. this study is to evaluate: ) changes in estrogen receptor (er) angiotensin ii subtype receptor (at -r) and endothelial nitric oxide synthase (enos) in the mesenteric artery and aorta of offspring and assess if these changes, if any, are gender specific. methods: pregnant sprague dawley rats were fed either % protein (ctrl) or % protein (lpd) from day of gestation. the offspring were evaluated for hypertension by means of systolic blood pressure measurements. at four months for the males and nine months for the females, mesenteric artery and aorta were collected in rnalater. expression of estrogen receptor a (er-a) and b (er-b), at -r, and enos were analyzed by western immunoblotting and rt-pcr and expressed relative to b-actin or s. results: mesenteric artery shows no differences between ctrl and lpd female offspring in at -r, enos, er-a or er-b. similarly mesenteric artery shows no diet exposure related changes in at -r, er-a or er-b in male offspring. however, enos expression was lower in mesenteric artery of lpd male offspring. on the other hand, in the aorta both er-a and er-b levels are lower in lpd female offspring while there were no changes in at -r or enos. no changes in at -r, er-a or er-b were observed in male offspring aorta of ctrl and lpd rats. conclusion: the in utero exposure to lpd results in adult hypertension in both male and female offspring. some mechanisms for hypertension include the decrease in er-a and er-b but not at -r or enos in females, and the decrease in enos but not at -r or er in males indicating gender related differences. offspring. hidenori takahashi, toshiaki okawa, keiya fujimori, akira sato. obgyn, fukushima med. univ., fukushima, fukushima, japan. our objective was to investigate the effects of either severe undernutrition during late gestation or lactation period on blood pressure and the development of vascular function in male rat offspring. we use normal pregnant wistar rats (group a), nutritionally restricted by feeding with % of the normal gestation-matched dietary intake from day of gestation to delivery (group b) and % restricted after delivery to the end of lactation period (group c). the offspring was measured blood pressure at and weeks by using indirect tail-cuff method. rings of thoracic aorta with intact endothelium from the male offspring of a and b at weeks, were equilibrated at g passive tension in organ chambers filled with krebs-henseleit solution continuously bubbled with %co in air ( °, ph . ) for isometric tension recording. concentration-response relationships to norepinephrine (ne) and angiotensinii(atii) were obtained in the absence or presence of n(omega)-nitro-l-arginine methyl ester (l-name) or a selective atii type- receptor blocker (valsartan). responses to cumulative concentrations of sodium nitroprusside (snp) and to - m oxyhemoglobin (hb, nitric oxide scavenger) were also determined. contractions were expressed as a percent of the reference contraction induced by potassium chloride ( mm). statically analysis was performed using one-way annova. results: body weight was significantly reduced in b offspring compared to a and c in male offspring at day (p< . ). at weeks the body weight of offspring of b was no difference to catch up compared to a and c offspring. systolic and diastolic blood pressures were significantly elevated at both and weeks in offspring of b > c >a. ne concentration-dependently stimulated tension of aortic rings from in a and b offspring, which was not significantly (n= ). maximal contractions to ne were significantly stimulated by l-name in a (p< . ), but not b offspring. valsartan significantly inhibited aortic contractions by ne in r (p< . ), but not a offspring. there was no significant difference on responses of aortic rings by atii, snp and hb in a and b offspring. conclusions: severe under nutrition during not only late gestation but also lactation period induced hypertension in male rat offspring in adulthood. fetal origin of adult hypertension might be vascular endothelial dysfunction. fujimori, akira sato. obgyn, fukushima med. univ., fukushima, fukushima, japan. objective: exposure to undernutrition during fetal life has been proposed as an underlying cause of adult hypertension, but the effect of either high fat nourishment or undernutrition during lactation period on blood pressure is unclear. our objective was to investigate the most effective maternal nourishment and feeding period for offspring induced adulthood hypertension in using high-fat diet (hfd). study design: we use types pregnant wistar rats as fed with normal nutrition (group a), nutritionally restricted by feeding with % of the normal gestation-matched dietary intake from day of gestation to delivery (group b), % restricted after delivery to the end of lactation period (group c), with a high fat diet (hfd) during gestation to lactation period (group d) and with hfd nutritionally % restricted from the day of delivery to the end of lactation period (group e). the offspring was measured body weight (bw) and measured blood pressure at , and weeks by using indirect tail-cuff method. statically analysis was performed using one-way annova. results: bw was significantly reduced in b offspring compared to another (a, c, d, e) male offspring at day (p< . ). at day after delivery, bw was significantly reduced in c, e offspring compared to a, d in male offspring (p< . ). at weeks old, bw of all type offspring was no difference. systolic and diastolic blood pressures were significantly elevated at weeks in offspring of d> b > e > c >a. (p< . , vs. a). at weeks, hypertensive offspring as b>d>e>c>a (p< . , vs. a). at weeks, d> e > b > c >a (p< . , vs. a). conclusions: maternal high fat environment make a hypertensive offspring, but regulation of fat feeding during lactation period may reduce adulthood hypertension. in case with normal food, restrictive feeding during late gestation is more effective than lactation period for inducing hypertensive male offspring. regulation of maternal feeding not only during late gestation but also lactation period may control adulthood hypertension. the strongest epigenetical factor of maternal nutrition is high fat feeding during pregnancy to lactation period for f blood pressure, respectively. or residence at high altitude, impacts fetal growth and development. in a preliminary study, we observed a significant decrease in birth weight, subsequent compensatory postnatal growth, and an increase in relative right ventricular (rv) weight at postnatal (pn) day in female offspring of rats exposed to hypoxia ( , ft; . % po ) from days thru of gestation (dga). thus, our objective was to further elucidate the impact of prenatal hypoxia on fetal growth and postnatal development. methods: pregnant dams (hx, n= ) were hypoxic from - dga with additional control dams either fed ad libitum (al, n= ), pair-fed with the hx dams throughout gestation (pg, n= ), or only pair-fed during the window of hypoxia (ph, n= ). female offspring from hx, pg, and ph dams were cross-fostered onto additional al dams (n= /litter) by h after birth. results: at birth, there was no difference in litter size; however, body weight (bw) of the hx, pg, and ph pups was lower (p< . ) than that of al pups, and hx pups were lighter (p< . ) than ph pups. weight of hx offspring remained lower (p< . ) than al pups until the termination of the study at pn , while the pg and ph pups reached weights comparable to the al offspring by pn . relative to bw, heart weight and left ventricular/septal (lvs) weight was not different among groups; however, right ventricular weight (rv/bw) was greater (p< . ) in the hx offspring at pn as was rv/lvs (p< . ). cardiac function was evaluated by echocardiography at pn . rv wall thickness was % greater (p< . ) in hx pups as compared to al pups, confirming the significantly higher relative rv weight observed at necropsy. pep, pep/at, and pep/et were %, %, and % higher respectively in the hx offspring relative to the al offspring. lv end diastolic and end systolic diameters were smaller (p< . ) in hx and ph offspring relative to the al group. myosin heavy chain (mhc) and mrna concentrations in the rv were evaluated by qrt-pcr, and the mhc / mrna ratio was greater (p< . ) in the hx pups. conclusion: prenatal hypoxia from - dga impacted both fetal and postnatal growth, altered postnatal heart development and function, with the primary impact being on the rv. supported by nih hd . reproductive sciences; pharmacology experimental therapeutics, university of maryland, baltimore, md, usa. background: exposure to nicotine (nic) is a significant risk to normal fetal development. fetal nic, which readily crosses the placenta, can be acquired from pregnant mothers by smoking or nicotine replacement therapy. the impact of nic on fetal organs may be mediated directly and/or via intrauterine hypoxia (hpx) via constriction of the uterine circulation. in adult hearts, both nic and hypoxia stimulate gene expression of matrix metalloproteinases (mmp), although the study of nic and hypoxia on gene expression in fetal organs remains incomplete. because mmps are involved in the regulation of extracellular matrix turnover and cardiac remodeling, we tested the hypothesis that prenatal nic and intrauterine hpx upregulate protein expression and activity of mmp in the fetal guinea pig heart. methods: pregnant guinea pigs were placed in either normoxia (nmx) or hpx ( . %o in chamber) for d prior to term ( d). in two separate groups, nic was also added to the drinking water ( mg/kg/d) for d at a dose that generates fetal nic levels ( ng/ml cotinine) equivalent to a moderate smoker. anesthetized near-term fetuses ( d) were excised and weighed. left ventricles of hearts were obtained and frozen at - c for storage. mmp protein levels and enzymatic activity were measured by western analysis and gel zymography, respectively. results: nic alone (nmx+nic) decreased (p< . ) fetal body wt by %, increased (p< . ) the relative fetal brain wt (brain wt/fetal body wt ratio) by . % and had no effect on relative placental or fetal heart wts. hpx alone decreased (p< . ) fetal body wt by . %, increased the relative fetal brain wt by % but, in contrast to nic alone, increased relative placental wt by . %. both mmp protein levels (mmp /a-actin density values) and activity (clear band density) were increased (p< . ) by nic alone (by . and . fold, respectively) and hpx alone (by . and . fold, respectively). in addition, both protein and activity levels of hpx hearts were further increased by nic (by . and . fold) compared to hpx alone. conclusion: prenatal nic upregulates mmp expression in nmx fetal hearts and is potentiated by hpx. this suggests that under conditions of intrauterine stress cardiac remodeling by mmp activation may be an important mechanism by which nic and hpx affect fetal heart function. objective: in addition to peripheral hypoglycemic effects, insulin induces central anorexigenic responses via stimulation of the phosphoinositide- kinase (pi k) pathway and cellular growth by mitogen activated protein kinase (mapk) pathway. the pi k signaling cascade is activated by insulin binding to its receptor (ir), recruiting ir substrate (irs- ), and phosphorylating pi k. activated pi k in turn causes phosphorylation of protein kinase b/akt which subsequently modulates hypothalamic anorexigenic responses. in contrast, the mapk (erk /erk ) signaling pathway likely involves irs- . further, insulin signaling is inhibited by the lipid phosphatase pten. we have previously shown that maternal food restriction (mfr) during pregnancy results in iugr newborns that develop hyperphagia, obesity and insulin resistance as adults. we sought to determine if altered hypothalamic basal insulin signaling expression of pi k and mapk pathways contribute to reduced satiety responses and thus enhanced growth in iugr newborns methods: pregnant control dams received ad libitum (n= ) food, whereas study dams were % mfr (n= ) from pregnancy day to to produce iugr newborns. at day , hypothalamic region was dissected and analyzed for mrna levels (real time rt-pcr) of insulin signaling components via pi k (ir, irs , pi k and akt) and mapk (irs , erk , erk ) pathways, and pten. data is presented as fold difference normalized to beta- -microglobulin. results: at d of age, iugr pups exhibited downregulation of the entire pi k pathway with significantly decreased (p< . ) mrna levels of ir ( . -fold), irs- ( . -fold), pi k ( . -fold) and akt ( . -fold). further, iugr pups showed similar decreased mrna expression of erk ( . -fold) and erk ( . -fold). however pten expression was similar to the controls. conclusion: reduced insulin-mediated pi k signaling likely contributes to the suppressed anorexigenic responses and development of obesity in iugr offspring. reduction of central mapk signaling suggests a potential maldevelopment of additional neuronal pathways in iugr offspring. objectives: in the rat, uteroplacental insufficiency restricts fetal growth and impairs mammary development further compromising postnatal growth. both male and female growth-restricted offspring have a reduced nephron endowment but only males develop hypertension with glomerular hypertrophy, which can be reversed by improving the lactational environment. this study used cross-fostering to assess the influence of the prenatal and postnatal environments on renal development and nephrogenesis. methods: bilateral uterine vessel ligation (restricted, r) or sham surgery (control, c) was performed on day of gestation in wky rats. control and restricted pups were cross-fostered onto c or r mothers on postnatal day (pn ). post mortem was carried out on pn (c and r) and pn (c-on-c, c-on-r, r-on-c, r-on-r). results: body and kidney weights were decreased in r and r-on-r pups on pn and pn (p< . ). there was some evidence of accelerated pup growth for r-on-c relative to r-on-r on pn . male, but not female, relative bmp mrna expression on pn was higher in r than c (p< . ) while gdnf, tgf and at receptor were not different. on pn , wnt (but not at r, vegf-a) mrna expression (males only) was relatively higher in r-on-r (p< . ) when compared to c-on-c (p< . ). this and the histological analyses suggests an up-regulation of nephrogenic activity with more immature nephrons (males and females) in r-on-r (p< . ) when compared to c-on-c, while r-on-c remained intermediate. intrauterine growth-restricted pups were born lighter and with smaller kidneys. this was partially rescued by improving lactational nutrition (r-on-c) at pn . higher bmp mrna expression indicates impaired branching morphogenesis in pn r male, but not female kidneys, suggesting the timing and/or molecular mechanisms underlying the nephron deficit may be sex specific. at pn there was evidence of extended and increased nephrogenic activity in r-on-r, however, this was unable to restore the later nephron deficit. improved lactation for r-on-c, which prevented the adult nephron deficit and hypertension, increased and extended nephrogenesis to a lesser degree than r-on-r suggesting that the restoration of nephron endowment was likely to have occurred prior to pn . amy m tetrault, sarah b lieber, marya shanabrough, tamas l horvath, hugh s taylor. obstetrics, gynecology and reproductive sciences, yale university school of medicine, new haven, ct, usa. objective: classically recognized for its role in energy balance, body weight and appetite, ghrelin has also been implicated in reproduction. ghrelin (-/-) mice are infertile while administration of ghrelin to wt mice results in decreased litter size and constrained embryonic growth. here we investigate the effect of maternal ghrelin deficiency on in utero developmental programming of the female reproductive tract. hox genes determine developmental identity of the paramesonephric duct. we determined that hoxa is regulated by ghrelin in vitro and that in utero ghrelin deficency alters f hoxa gene expression and reproductive success. methods: wild-type females mice parented by ghrelin +/-b d f (ghrellin deficient) mice were analyzed for litter size, oocyte, and corpus luteum number. rna was extracted from the uterus of mice exposed to ghrelin deficiency in utero. ishikawa cells were treated with ghrelin with/without receptor (ghsr) antagonist, or saline and rna extracted. in both hoxa expression was analysed by real time rt-pcr normalized to -actin and also determined by ihc. experiments were repeated in triplicate and mrna expression compared by student's t-test. results: wild-type female offspring of ghrelin deficient dams had smaller litter sizes than controls (n= , . ± . pups; n= , . ± . pups, respectively; p< . ). no differences were seen in oocyte or corpus luteum number suggesting a uterine defect. hoxa mrna and protein expression were decreased in the uterus of the f females. ghsr was expressed in uterine endometrium. treatment of ishikawa cells with nm to nm ghrelin resulted in a to % increase (p< . ) in hoxa expression. treatment with ghrelin and ghsr antagonist resulted in similar increases in hoxa expression indicating a non-receptor mediated mechanism. conclusion: ghrelin contributes to reproductive tract developmental programming; in utero ghrelin deficiency compromises reproduction in female offspring. the developmental effects of ghrelin were mediated by alteration in hox gene expression and not through the classic ghsr receptor. obesity and decreased ghrelin may lead to defects in developmental programming of the reproductive tract. these findings demonstrate the importance of nutrition, energy utilization and appropriate ghrelin levels on normal uterine development. we have previously studied the deleterious effects of lack of the endothelial nitric oxid synthase (nos ) in mouse dams and their offspring. our laboratory demonstrated that adaptive responses in subsequent pregnancies may offset the harmful effects of the genetic deficiency of nos . in this study we aimed to determine hepatic and renal histopathologic damage in nos deficient pregnant mice comparing animals carrying their first versus their second pregnancy. study design: gravid nos +/+wt and nos -/-ko mice during their first (p ) or second (p ) pregnancy were sacrificed at day of gestation. livers and kidneys were stained and analyzed for the presence and extent of histopathologic lesions. results: nos +/+wt dams displayed a low incidence of significant renal or hepatic lesions in either the first or the second pregnancy. in nos -/-ko mice the incidence of liver necrosis and inflammation during the first pregnancy was % and %, respectively. in nos -/-ko dams sacrificed during the second gestation the incidence rates for the same lesions were % and %, respectively (p< . ). this correlation persisted when we analyzed the relative severity of hepatic lesions between p and p animals. although a similar trend was observed, the difference between p and p animals with regards to kidney lesions did not reach the level of statistical significance in our study. conclusions: a second pregnancy in this animal model of hypertension was associated with a significantly improved hepatic histopathology compared with the first pregnancy. this observation is consistent with our previous studies showing a decrease in systemic vascular resistance in p versus p nos -/-ko mice. the beneficial effects of a prior pregnancy may partially underlie the phenomenon of a decreased risk of preeclampsia in multiparous versus nulliparous women. further studies are required to delineate the counterregulatory mechanisms leading to improved cardiovascular function in subsequent pregnancies in these genetically modified animals. maternal hypomethylation is associated with congenital heart defects in down syndrome. lmjw van driel, , r de jonge, wa helbing, bd van zelst, j lindemans, eap steegers, rpm steegers-theunissen. , , , obstetrics gynecology; pediatrics; clinical chemistry; epidemiolog y biostatistics; clinical genetics; erasmus university mc, rotterdam, netherlands. background: maternal age and hyperhomocysteinemia are risk factors for having a child with down syndrome (ds) and congenital heart defects (chds), respectively. evidence is rising that ageing is associated with a state of hypomethylation. objectives: to investigate whether the risk of a child with ds and chd is associated with maternal hypomethylation. methods: we conducted a case-control triad study at months after the index-pregnancy. case-children (n= ) were included if they had ds and chd. children (n= ) without a major congenital malformation served as controls. the concentrations of s-adenosyl methionine (sam), s-adenosyl homocysteine (sah), sam/sah ratio, and homocysteine in maternal blood were measured as biomarkers for methylation. the data were analyzed using the mann-whitney u test and a logistic regression model. results: maternal age was included in the model as potential confounder. the levels and the crude and adjusted or( %ci) of the biomarkers are shown in table . an increase of the sam/sah ratio with unit decreases the risk of a child with ds and chd with percent. moreover, every increase of mol/l of homocysteine . fold increases this risk. conclusions: maternal hypomethylation is significantly associated with an increased risk of having a child with ds and chd. since, the effects are confounded by maternal age, hypomethylation can be considered as feature of ageing. the developmental origins hypothesis postulates that during critical ontogenetic periods, transient environmental stimuli perturb developmental pathways and induce permanent changes in gene expression, metabolism, and chronic disease susceptibility. one likely mechanism is via early nutritional influences on epigenetic gene modification consisting of the presence of a methyl group on the carbon of a cytosine residue. this modification is responsible for an important form of gene regulation in eukaryotes. in the present study, we have tested the hypothesis that maternal low-protein diet altered epigenetic regulation of specific gene of the offspring. c bl/ female mice were mated and on the day the plug was detected, these females were then randomly allocated to be fed isocaloric diets consisting % protein or % protein. at delivery, offspring were killed and the livers were removed immediately, frozen in liquid nitrogen and stored at - c. genomic sequencing after bisulfite modification is used to study site-specific dna methylation. dna methylation status of oct- and sphk- gene upstream regions in the mouse liver was analyzed. hepatic oct- or sphk- promoter methylation was not significantly different between both groups. however, dna methylation pattern of the genomic dna is specific in low-protein diet group. aberrant oct- and sphk- gene expression may cause perturbations in cell differentiation. we suggest that the epigenetic mechanism consisting of dna methylation underlies the fetal programming theory. primary human cytomegalovirus (hcmv) infection during pregnancy can have devastating consequences for both the mother and fetus. hcmv infection has been implicated in the development of pre-eclampsia and intrauterine growth retardation (iugr), as well as congenital cmv syndrome in newborns exposed in utero. previously, we have shown that hcmv infection of placental cytotrophoblasts inhibits their normal invasion, proliferation, and migration. however, the mechanisms occurring during early establishment of placental infection are largely unknown. we assessed the impact of hcmv infection on cytotrophoblasts by performing immuno-based assays for various cytokines and cellular growth factors. we detected significant cytokine dysregulation at both and hours after in vitro hcmv infection of cytotrophoblast cells. soluble cytokines involved in recruitment of monocytes and macrophages (gro-a, mcp- ) were downregulated at both and hours after infection. sdf- , which is chemotactic for lymphocytes during early inflammation, was also decreased. these results suggest that recruitment of cells involved in the anti-viral immune response is being interrupted early in the course of infection by hcmv. additionally, a large decrease in the amount of soluble hgf was seen. hgf normally induces migration of cytotrophoblasts along the invasive pathway, and downregulation of this factor could severely affect these processes. finally, we saw increased amounts of soluble icam- , contrasted by decreased amounts of vcam- , indicating dysregulation of adhesion molecules that are necessary for successful placental invasion to occur. all together, these data indicate significant alterations in cytokine profiles as early as hours after hcmv infection, which could provide important clues to the pathogenesis of hcmv in placental invasion and inflammation. additional studies will further elucidate this dysregulation, and determine whether these effects are due to alterations in pre-existing cellular factors or if transcriptional alterations are involved. method: studies were performed in pregnant ewes (n= in each group) with twin fetuses at - days (very preterm) and - days (near-term). neither mother nor fetuses were instrumented prior to the time of blood collection. maternal blood was collected from the jugular vein before sedation. anesthesia was then induced with isofluorane, the abdomen was opened, fetuses exteriorized and blood collected from umbilical cords. blood samples were transferred to plastic tubes containing ethylene-diamino tetraacetic acid and reduced glutathione, plasma separated and stored at - c. commercial radioimmunoassay kits for ovine-crf (phoenix pharmaceuticals, b : . ± . pg/ml) and cortisol (diagnostic laboratory, b : . ± . ng/ml) were used according to the manufacturer's instructions. results: in very-preterm gestations, maternal and fetal plasma crf levels were undetectable. maternal, but not fetal, plasma cortisol levels were measurable ( ± ng/ml). in near-term gestations, both cortisol and crf were measurable in maternal (crf: ± pg/ml; cortisol: ± ng/m) and fetal plasma (crf: ± pg/ml; cortisol: ± ng/ml). plasma crf levels were higher in nearterm fetuses than in their maternal ewes (p < . ). conclusion: ovine plasma crf levels are measurable in maternal and fetal plasma in near-term but not very-preterm gestations. the absence of crf in preterm plasma, perhaps due to reduced placental expression and/or placental crf release, may contribute to the rarity of in utero meconium passage in preterm gestations. interleukin - objectives: interleukin- (il- ) is a pro-inflammatory cytokine produced in adipose cells. recent studies suggest il- may be a marker of maternal obesity and in utero fetal programming. our hypotheses were ) il- correlates with maternal obesity and ) il- mediates the effect of maternal obesity on infant birth weight. methods: the parity, inflammation, and diabetes (pid) study is a longitudinal study of adipokine levels in a diverse sample of pregnant women. we present a cross-sectional analysis of first trimester il- levels from non-diabetic women who underwent a live birth. the independent variable was il- (pg/ml), measured with monoclonal antibody elisa assays. the dependent variable was infant birth weight (gms). maternal bmi categories were: normal/underweight (< kg/m ); overweight ( - kg/m ); and obese (> kg/m ). data on demographic and clinical factors, nutrition and physical activity were collected at baseline. average il- levels were compared across bmi categories using anova. the association of il- levels with infant birth weight was estimated using multiple linear regression, adjusting for covariates. results: average il- levels were significantly higher in obese women ( . ± . ) compared to overweight ( . ± . ) and normal/underweight women ( . ± . ) [p< . ]. after adjustment, il- levels was positively correlated with pre-pregnancy bmi [regression coefficient (rc) . ; % ci: ( . , . )]. as shown in the table below, elevated levels of il- were statistically significantly associated with a . gm higher infant birth weight after full adjustment. each unit increase in pre-pregnancy bmi was associated with a gm higher infant birth weight. table . association of il- with infant birth weight characteristic regression coefficient % confidence interval interleukin- . . , . pre-pregnancy bmi . , gestational weight gain - - , bmi = body mass index; coefficients adjusted for demographics, clinical factors, pre-pregnancy bmi, gestational weight gain, non-fasting first trimester glucose levels, gestational age, nutritional intake and physical activity conclusion: il- and pre-pregnancy bmi were associated with infant birth weight after adjustment for covariates. our findings suggest that the effect of maternal obesity on infant birth weight may be mediated through il- or an alternative independent pathway. we have demonstrated that -tetrahydrocannabinol (thc), in physiologically relevant concentrations, inhibits the growth and tight transcriptional control of the bewo trophoblast cell line . the mechanism involved the decreased expression of the transcriptional regulator histone deacetylase (hdac ). in these experiments we sought to answer the question, 'does anandamide (aea) work in the same manner as thc?' methods: the first trimester human trophoblast cell, bewo were plated at or x cells /well to -well and -well plates for growth and rna experiments, respectively. after growing to - % confluence, cultures were treated with varying concentrations of aea up to a maximum of m for hr. cell numbers were determined using the xtt apoptosis/proliferation assay. total cellular rna was prepared and the relative levels of hdac and gapdh determined by end-point rt-pcr. aea exhibited an inhibitory effect on the bewo cell cultures, but only at concentrations in excess of m where confluency was significantly reduced from % at m to - % at m and m (*p< . ; one-way anova with tukey's hsd test; n= ). cultures treated with m and m aea did not exhibit increased cell death or failure to attach to the substratum, as evidenced by the lack of increase in the shedding of cells into the spent medium. bewo cells treated with aea showed a dose-dependent decrease in hdac mrna expression with a significant effect at . m (*p< . ; oneway anova with tukey's hsd test; n= ). at this dose, the effect of aea had reached an effective maximum decrease in hdac mrna levels ( %) because hdac mrna levels were not decreased further by either m aea ( %) or m aea ( %). the alteration of hdac gene expression by aea in bewo cells with its associated decrease in cell number suggest that the trophoblast cell may be an important target for circulating endocannabinoids during the st trimester of pregnancy. the data indicates that although exocannabinoids and endocannabinoids both inhibit bewo cell growth, they do so using different transcriptional mechanisms. further understanding of the mechanism(s) by which aea alters placental physiology may lead to new strategies for the prevention of pregnancy complications such as st trimester miscarriages. ( ) taylor background: anandamide (aea) exerts its effects by acting on two cannabinoid receptors, cb and cb with the main regulator for aea levels being the metabolising enzyme, fatty acid amide hydrolase (faah). aea, cb , cb and faah constitute the endocannabinoid system and previous studies have shown that faah and cb are expressed in term human placenta( ) suggesting that the endocannabinoid system might be present earlier in gestation. this study aimed to document changes in faah, cb and cb expression in the placenta during the first trimester of pregnancy. methods: first trimester samples ( to weeks gestation) were fixed in % neutral-buffered formalin for days before embedding into paraffin wax or frozen in liquid nitrogen for rna analysis. for immunohistochemistry, faah polyclonal antibodies were used at an optimal dilution of : in pbs, cb at : and cb at : . transcripts were measured using q-pcr with gene-specific primers. results: immunoreactive faah, cb and cb were detected in all samples. faah immunoreactivity in the syncytiotrophoblast increased between the th and th gestational week and by week faah was barely detectable within large parts of the placenta. simultaneously, faah immunoreactivity increased in the mesenchymal core of the developing villi. immunoreactive cb and cb localised to the syncytiotrophoblast, cytotrophoblast and mesenchymal core with cb immunoreactivity showing diminished intensity after week , although this did not reach significance at the transcript level. cb immunoreactivity was absent from fetal blood cells and infiltrating maternal plasma cells, whereas cb and cb immunoreactivity was detected in endothelial cells but not in the vascular smooth muscle cells of blood vessels. the intensity of cb immunoreactivity in the syncytiotrophoblast differed from that of cb and faah in that it remained constant throughout. conclusion: the data suggest that placental faah and cb levels do not alter significantly during the first trimester, but alter their cellular distribution from the syncytiotrophoblast to the mesenchymal core. the significant loss of cb expression from the syncytiotrophoblast after the th week of gestation, a point of critical alteration in the developing placenta, suggests that its retention may be detrimental to normal placental development. reference: park, b. et al., ( ) hankins, chandra yallampalli. obstetrics gynecology, university of texas medical branch, galveston, tx, usa. background: numerous angiogenic proteins synthesized in the placenta are thought to be involved in placental vascularization and development; however, the molecular mechanism modeling the angiogenic process in early pregnancy remains elusive. calatonin gene-related peptide (cgrp) is a multifunctional peptide expressed at the human implantation site; but its influence on in vitro angiogenesis by human micro vascular endothelial cells is not known. objective: the present study was designed to determine the influence of cgrp on angiogenesis by human dermal microvascular endothelial cell (hdmvec) in vitro. methods: hdmvecs (vec technologies) were cultured in mcdb- complete solution containing cgrp ( - m), cgrp plus its antagonist cgrp - ( - m), in well plates with x cells per well. the existence of cgrp receptor components calcitonin receptor-like receptor (crlr) and receptor activity modifying protein (ramp ) was determined using immunofluorescent staining. cell proliferation was examined using methylthiazoltetrazolium (mtt) assay. the pro-angiogenic bioactivity of cgrp was evaluated using cell migration and capillary like tube formation on the matrigel. results: ) immunofluorescent staining showed that cgrp receptor components crlr and ramp are abundantly expressed by hdmvecs. replacement of the primary antibodies with preimmune serum resulted in a negative staining; ) cgrp dose-dependently ( - to - m) stimulated hdmvec proliferation, and this effect was totally blocked by cgrp antagonist, cgrp - ; ) quantitative analysis for cell migration revealed that cgrp increases hdmvec migration in a dose and time-dependant manner; and ) cgrp promotes hdmvec capillary like tube formation, and the length of capillary tube induced by cgrp ( - m) was significantly increased over that of the untreated controls. this increase was observed at hours of treatment and further increase was noted at hours of culture. conclusion: cgrp induces in vitro angiogenesis by promoting microvascular endothelial cell proliferation, migration and capillary like tube formation. therefore, trophoblast derived cgrp at the implantation site may play a role in placental angiogenesis and fetal growth. over-expression of socs- gene promotes il- production by jeg- trophoblast cells. qin dong, , ruping fan, yang gu, david f lewis, yuping wang. biochemistry, harbin medical university, harbin, heilongjiang, china; obstetrics and gynecology, lsuhsc-shreveport, shreveport, la, usa. objective: suppressor of cytokine signaling- (socs- ) plays an important role in negative regulation of inflammatory response in biological cells. evidence has shown anti-inflammatory cytokine il- expression was significantly reduced in trophoblasts of preeclamptic (pe) placentas. we sought to determine if over-expression of socs- in placental trophoblasts could promote il- production. methods: full-length socs- open reading frame (socs- cdna) was generated by rt-pcr from total rna samples isolated from human leukocytes and cloned into a pzsgreen -n vector, which encodes a green fluorescent protein zsgreen . successful socs- cloning was confirmed by sequencing. for transfection, jeg- cells were placed into well/cluster plates at a concentration of . x /well. the tranfection was carried out with . g of socs- /zsgreen plasmid (psocs- /zsgreen ) for hours when cell reached - % confluence. siport lipid were used. jeg- cells transfected with zsgreen plasmid (pzsgreen ) only was used as control. after approximately hours of transfection, cells were treated with il- at and ng/ml. medium was then collected and measured for il- by elisa. il- production was calculated as the percentage of increase by psocs- /zsgreen transfected cells compared to the cells transfected with pzsgreen only. result: il- production was increased by psocs- /zsgreen transfected jeg- cells compared to the cells transfected with pzsgreen only when stimulated by il- , control: . % increase; ng/ml il- : . % increase and ng/ml il- : % increase, p< . , respectively. data are means from three independent experiments. conclusion: over-expression of socs- gene could promote il- production by placental trophoblast cells. reduced sil- r release and increased ratio of sgp /sil- r production by placental tissues from women with preeclampsia. shuang zhao, ruping fan, jingxia sun, yang gu, david f lewis, yuping wang. obstetrics and gynecology, lsuhsc-shreveport, shreveport, la, usa; obstetrics and gynecology, first hospital, harbin medical university, harbin, heilongjiang, china. objective: placental tissue/trophoblasts release more inflammatory cytokines (il- , il- and tnf ) in preeclampsia (pe) than in normal pregnancies. however, the reason for increased inflammatory cytokines released by pe placentas is not clear. soluble il- receptor (sil- r) and membrane receptor il- /gp complex play an important role in the negative regulation of cytokine signaling in suppressor of cytokine signaling (socs) pathway. in contrast, soluble gp (sgp ) is an antagonist for il- /il- r trans-signaling. this study was undertaken to determine sil- r and sgp production by villous tissues from normal and pe placentas. methods: placentas delivered by normal and pe pregnant women were used in this study. placental explants were incubated with dmem for h. the culture medium was collected. placental villous tissue productions of sil- r and sgp were measured by elisa. all samples were assayed in duplicate. data are expressed as mean ± se and analyzed by mann whitney test. a p level < . was considered statistically different. results: placental tissues from pe produced significantly less sil- r than tissues from normal pregnancies, . ± . vs. . ± . pg/mg of wet tissue, p< . . soluble gp production was relatively compatible between pe and normal placental tissues: . ± . vs. . ± . pg/mg of wet tissue. the ratio of sgp /sil- r release was significantly higher in pe than in normal placentas, . ± . vs. . ± . , p< . . conclusion: reduced sil- r production and/or increased ratio of sgp /sil- r production by pe placentas suggest less cytokine inhibitory activity in pe placentas, which may contribute to the increased toxic cytokine production in placentas from pe. using chemiluminescence immunoassays. peter s uzelac, jing dai, frank z stanczyk, daniel r mishell, jr. obstetrics and gynecology, university of louisville, louisville, ky, usa; obstetrics and gynecology, university of southern california, los angeles, ca, usa. objective: characterizing human chorionic gonadotropin (hcg) levels throughout normal pregnancy is critical to its use as a bio-marker for abnormal gestations. there is a paucity of data describing hcg trends during pregnancy and most of the relevant studies use older, less specific assays. our first objective was to characterize hcg levels throughout normal gestation using two different contemporary chemiluminescence immunoassays. our second objective was to compare hcg patterns in healthy gestations with pregnancies affected by diabetes, a common obstetrical complication. methods: a single blood sample was collected from healthy pregnant women and diabetic pregnancies. gestational age was confirmed by ultrasound. serum hcg levels were quantified by chemiluminescence immunoassays using the acs- and immulite systems. data was grouped in -week intervals until weeks of gestation and -week intervals thereafter, with to samples in each interval for healthy women and to samples in each interval for diabetic women. paired t-test and wilcoxon rank sum test were used for statistical analysis. results: using the acs- system, mean hcg levels (miu/ml) for healthy pregnant women were , at - weeks, , at - weeks, , at - weeks, , at - weeks, , at - weeks, and , at - weeks. mean hcg levels obtained from the immulite system were similar. for diabetic pregnancies, mean hcg levels (miu/ml) were , , , , , , , , , and , , respectively. between - weeks of gestation, the hcg levels were significantly lower in diabetic pregnancies (p= . ) compared to healthy controls. ) compared to healthy pregnancies, diabetic gestations have significantly lower peak hcg levels. the cause of this difference is an area deserving further investigation. background: mouse and human placentae share several cellular and molecular features, including a haemochorial interface, allowing the murine labyrinth to be compared with the human fetal placenta. there is an autonomous embryonic ras from at least the time of implantation. ace converts angiotensin i to the active angiotensin ii (angii). angii's actions as a pro-inflammatory agent, in promoting cell migration, angiogenesis and cellular growth and apoptosis, strongly suggest a rôle in placentation. hypothesis: there would be counterregulation of the placental ras if the effect of ace were removed. this study investigated for the first time whether the knockout of somatic ace affected the expression and localisation of various components of the ras in the placentae of wild-type (wt/wt), heterozygous (wt/ ) and ace knockout ( / ) mice. methods: immunohistochemistry (dako envision plus) was used to localise and semiquantify ang type receptor (at r), ang type receptor (at r), ace, and ace- in the three genotypes (n= /group). placental sections were blinded to genotype; a score range of - was used. the test was used (spss version . ) to analyse the difference in staining score by genotype. results: immunoreactivity of all antigens increased in the placental labyrinth of / mice compared to wt/wt and wt/ mice (at r p< . ; at r p<< . ; ace p<< . ; ace- p<< . ). at r and ace- displayed increased staining in the fetal vascular endothelium of / mice (at r p<< . ; ace- p= . ), and in the cells lining the maternal central artery (at r p<< . ; ace- p<< . ). ace- expression was very high in cytotrophoblast lining the maternal blood space in all genotypes. no gross structural differences were seen. comment: the antibody used did not differentiate between ace and the membrane-bound "testicular"-ace (tace). immunohistochemically-identified ace expression was upregulated in / placentae despite the loss of somatic ace, suggesting that t-ace can be expressed placentally. we believe this is the first demonstration of such expression. ace and t-ace are catalyticallysimilar in converting angi to angii. furthermore, angii acting via the at rs is vasodilatory and ace- catalyses production of the vasodilatory ang ( - ); placental blood flow was presumably well-maintained and pregnancy outcome is normal in / mice. it is generally accepted that prostaglandin production plays a crucial role in both term and preterm parturition, and recently the administration of alpha hydroxyprogesterone acetate has been shown useful in preventing preterm labor. what is not clear is the biochemical pathway of prostaglandin production during labor and what, if any, effect alpha hydroxyprogesterone acetate has on this pathway. in order to address this question, we used immunohistochemical staining techniques to evaluate the effect of treating human placental amnion and chorion decidua with alpha hydroxyprogesterone acetate. membranes from unlabored patients were obtained at cesarean section and immediately seperated into control and drug treated specimens. controls were from the same placenta and were subjected to all experimental procedures except for the addition of alpha hydroxyprogesterone acetate to the culture media. specimens were compared at zero, six, and twenty four hour intervals. at the appropriate time, each specimen was formalin fixed and then paraffin blocked. tissue sections were then mounted on slides which were immunohistochemically stained using appropriate primary and secondary antibodies and standard techniques. the slides were then analyzed via light microscopy for changes in staining of three enzymes involved in prostaglandin production--cyclooxygenase (cox- ), cyclooxygenase (cox- ), and -hydroxy prostaglandin dehydrogenase (pgdh). compared to control, the slides treated with alpha hydroxyprogesterone acetate had differing amounts of enzyme expression. cox- was relatively unchanged and pgdh was only slightly increased, but cox- was noticeably decreased in the treated slides. these results were time dependent. this data suggests that alpha hydroxyprogesterone acetate decreases prostaglandin production in fetal membranes primarily by downregulation of the cyclooxygenase enzyme. objectives: in the human placenta, proliferation, differentiation and fusion of cytotrophoblasts (ct) are essential events in the formation of the multinucleated syncytiotrophoblast, however the regulation of these processes is poorly understood. using an explant model of human first trimester placenta we have established that both igf-i and -ii enhance ct proliferation, differentiation and survival mediated via igf r signalling. we have also shown that non-specific inhibition of protein tyrosine phosphatases inhibits igf-mediated signalling in trophoblast; therefore, we have now used sirna-mediated knockdown to investigate the role of the tyrosine phosphatase shp- in this pathway. methods: amaxa nucleofector technology was used to deliver shp- or scrambled sirna ( nm) to bewo cells or first trimester villous tissue fragments. knockdown was confirmed by q-pcr and western blotting. transfected cells and tissue were maintained in culture for hours, then treated with igf-i or igf-ii ( nm) for a further hours before immunohistochemical (ihc) analysis for cell proliferation (ki , brdu) or apoptosis (m ). results: sirna-mediated knockdown of shp- in bewo cells ( % reduction on western blot) demonstrated that igf-induced proliferation was reduced from . ± . % to . ± . % (p< . , n= ). ihc analysis of tissue demonstrated that shp- is localised to ct. following knockdown ( % decrease by q-pcr), igf-i-and igf-ii-induced ct proliferation was decreased by . ± . % and . ± . % respectively (p< . , n= ). furthermore, the ability of igf-i-and igf-ii to prevent ct apoptosis (m staining) was reduced by . ± . % and . ± . % respectively (p< . , n= ) after shp- knockdown. conclusions: igf stimulation of cytotrophoblast proliferation is mediated by shp- . exogenous igf rescues cytotrophoblast from apoptosis, and this pathway is also shp- -dependent. villous endothelial cells. emily j su, zhi-hong lin, ping yin, scott reierstad, joy innes, serdar e bulun. obstetrics and gynecology, northwestern university feinberg school of medicine, chicago, il, usa. background: within the human vascular system, estrogens have been shown to enhance vasodilatation in both normal and abnormal endothelium. estrogenic function occurs by activation of one or both of two estrogen receptors, estrogen receptor-alpha (esr ) and estrogen receptor-beta (esr ). these estrogen receptors are expressed in a wide variety of tissues. within the vasculature, estrogen receptors regulate the expression of multiple vasodilator and vasoconstrictor proteins. specifically, esr has been shown to be critical in maintaining normal vascular physiology in a murine model, where esr knock-out mice demonstrate significant systolic and diastolic hypertension. we hypothesize that within placental endothelium, estrogen plays an important role in maintaining normal vascular function that is critical for normal fetal growth and development. methods: term placentas from uncomplicated pregnancies were obtained, and the decidua was removed. an iv cannula was inserted into the umbilical vein, which was perfused with a collagenase/dispase solution. the perfusate was collected and subjected to further purification. these cells were cultured in complete medium, and after the initial passage of these cells, purity was confirmed via immunofluorescence and flow cytometric studies. estrogen receptor expression was determined in these cells via western blotting. additionally, these endothelial cells underwent treatment with varying doses of estradiol ( - m to - m), and quantitative real-time pcr was performed thereafter for mrna levels of various genes important in prostanoid production. results: western blotting demonstrated that esr is the only estrogen receptor expressed within villous placental endothelial cells. estradiol induced cyclooxygenase- (cox- ) mrna levels -to -fold, as quantified by real-time pcr (p< . ). conversely, there was no effect of estradiol on cyclooxgenase- (cox- ). conclusion: these results suggest that estradiol and esr are important in mediating the balance of prostanoid production that is essential in maintaining placental vascular health. future studies will further delineate estrogenic effects on prostanoid production within placental endothelial cells in health and disease. supported by the smfm/aaogf scholarship award and the nih grant u -hd . previously we established that proteins secreted by the decidua promote the differentiation of extravillous trophoblasts (evt) from a proliferative phenotype (characterized by cx , her- and alpha integrin protein expression) to an invasive phenotype (characterized by her- and alpha protein expression). the ability of decidua-conditioned media (dcm) to induce trophoblast differentiation was inhibited in the presence of the her- receptor antagonist, ag . furthermore, dcm-induced jar cell migration was also attenuated in the presence of ag . thus, the purpose of this study is to define the role of her signaling in evt differentiation and invasion. methods: evt differentiation was assessed in placental villous explant outgrowths and jar cells using antibodies against markers of the proliferative and invasive phenotypes. trophoblast migration was assessed using jar cells in transwell migration assays. results: treatment of placental villous explants with egf, a her- ligand, resulted in the downregulation of her- and an upregulation of her- expression, as well as an induction of alpha integrin expression. pre-treatment of placental villous explants with ag blocked this effect. in the jar cell line, egf treatment mimicked the differentiation-promoting effects of dcm by downregulating her- and upregulating her- expression, effects that were both blocked when jar cells were pre-incubated with ag . in contrast to dcm however, egf stimulation did not induce jar migration. stimulation of jar cells with hb-egf, a her- /her- heterodimer ligand, induced jar migration in a dose-dependent manner. analysis of dcm using antibody arrays confirmed the presence of many members of the egf family including hb-egf. immunohistochemical assessments of placental villous explants verified the expression of her- in evt outgrowths and in jar cells; her- expression was not affected by stimulation with either egf or hb-egf. conclusions: her signaling is an important and necessary component of the invasive evt differentiation cascade. our data supports a role for her- signaling in the induction of the invasive evt phenotype. chandrasekhar thota, chandra yallampalli. obstetrics gynecology, university of texas medical branch, galveston, tx, usa. background: parathyroid hormone related peptide (pthrp) is expressed in trophoblast cells and may play a role in placental growth and function. studies conducted in pregnant rats using pthrp antagonist showed decreases in fetoplacental growth during mid gestation. objective: to assess the effects of pthrp silencing on the expression of growth factors in immortalized first trimester trophoblast cells (htr- /svneo cells). methods: htr- /svneo cells cultured at º c and %co in rpmi- medium supplemented with % fbs were transiently transfected with nm of three different sirna sequences of pthrp, si , auaccuaacucaggaaacuuu; s i , g a g c u g u g u c u g a a c a u c a u u ; a n d s i , caagauuuacggcgacgauuu. for control, a scrambled sirna sequence was used. at % confluency, cells from each well were split and transfected again in triplicates with respective sirna sequences. total rna was isolated using trizol reagent h after transfection, and protein was extracted using lysis buffer h after transfection. the isolated rna and protein were subjected to reverse transcription and polymerase chain reaction (rt-pcr) and western analysis, respectively, using primers and antibodies specific for pthrp, plgf, vegf and lif. the results are expressed relative to either s for changes in mrna expression or -actin for changes in protein expression. results: rt-pcr of total rna obtained from htr cells subjected to double transfection with sirnas for pthrp showed a significant decrease in pthrp expression. expression of growth factors plgf, vegf and lif showed decreases with all the three sirna sequences used compared to the scrambled sequence. western analysis of cell lysates obtained from htr cells subjected to transfection with sirnas for pthrp showed a significant decrease in protein expression of pthrp and vegf. however the protein expression for plgf, and lif decreased in cells transfected with only si sequence of pthrp. conclusions: our studies showed that transient transfection of htr cells with sirna for pthrp caused decreases in both mrna and protein expression of pthrp. our results further suggests that decrease in pthrp peptide in transfected cells resulted in a decrease in vegf, plgf and lif suggesting that pthrp may play role in regulating trophoblast cell functions. objective. maternal obesity poses an increased risk to the fetus during pregnancy, and has long term consequences for the progeny. we tested the hypothesis that maternal caloric excess effects growth-related gene expression changes in the murine placenta. methods. female c bl/ mice were fed a hypercaloric diet ( % fat, % sugar) or standard chow for six weeks prior to mating and throughout pregnancy. near-term (day gestation) the dams ( controls, overfed) were sacrificed. following placental rna extraction, we used the affymetrix mouse a_ . array to measure gene expression changes. we performed pathway analysis on regulated genes. results. maternal overfeeding was associated with a two-fold increase in body fat mass. probe sets, corresponding to genes showed differential expression (p < . ); twenty-seven of which were up-regulated, and ten down-regulated, as compared to the placenta of control fed dams. of note, several genes related to obesity, diabetes, dna methylation, and the tgf beta pathway were differentially expressed. conclusions. diet-induced obesity in mice was associated with altered placental gene expression, including genes involved in tgf beta signaling and dna methylation pathways. these findings may have important implications for placental growth and epigenetic regulation. (supported by usphs hd- , earnest eu framework , tommy's the baby charity, uk). objective. maternal dietary protein restriction has been shown to have deleterious effects on placental development, and has long-term consequences for the progeny. to comprehend more completely stress responses to maternal protein restriction, we measured gene expression changes in the mouse placenta. methods. pregnant fvb/nj mice were fed an isocaloric diet containing % less protein than normal chow ( % vs. % protein content) from embryonic day . (e . ) to e . . following placental rna extraction, we used the affymetrix mouse a_ . array to measure gene expression changes. we performed pathway analysis on the regulated genes, and used both qrt-pcr and immunohistochemistry to verify the results. results. the weights of the e . pups were decreased % (p< . ). probe sets, corresponding to genes, were regulated by protein restriction (p< . ); ninety-one being up-regulated and down-regulated. of particular note, several genes related to the p pathway were up-regulated. along with p itself, positive regulators of p (zmiz , jmy, hipk ) and genes activated by p (inpp d, cebpa) were induced. for selected genes we confirmed these results using qrt-pcr and immunohistochemistry. conclusions. by microarray analysis, we have described the genetic response to maternal protein deprivation in the mouse placenta. we observed that pups were growth restricted, and genes related to the p pathway were regulated. we propose a model through which intrauterine growth restriction is triggered, in part, by activation of the p pathway. (supported by usphs hd- and the sgi medical student grant to cpg). purpose: human placental villous tissue cultures have been underused in the study of placental drug disposition. thus we assessed the utility of this model by studying the effect of time in culture on the viability and integrity of the tissue and the, expression and function of proteins involved in the formation and efflux of -chloro- , -dinitrobenzene (cdnb) conjugate , -dinitrophenyl-s-glutathione (dnp-sg) as a model system for phase ii metabolism and cellular efflux. methods: placental tissue samples were obtained within minutes of cesarean deliveries following normal pregnancies in three patients. villous tissue was cultured in m medium to hr. at , , , , , and hr post culture, villous tissue was preincubated without or with atpase inhibitor sodium orthovanadate, exposed to μm cdnb, rinsed and incubated in buffer at °c to determine formation and efflux of dnp-sg, which was assayed by hplc. changes in expression of gstp - , abc transporter isoforms b , c and g (abcb , abcc , and abcg , resp.) were assessed by immunoblotting. lactate dehydrogenase (ldh) release, methyl tetrazolium thiazolyl blue (mtt) incorporation, and total tissue glutathione content were monitored up to hr. villous tissue morphology was assessed by immunohistochemistry. results: villous tissue structure and protein expression of glutathione-stransferase isoform p - (gstp - ) and abcg remained unchanged over hr in culture. expression of abcb and abcc , and total tissue glutathione decreased with culture time. ldh release was unchanged up to hr and increased at hr, while mtt incorporation remained constant to hr and decreased at and hr suggesting a decline in tissue integrity and viability at hr. however, dnp-sg formation, dnp-sg buffer/tissue ratio, and the extent of inhibition of dnp-sg efflux by sodium orthovanadate remained unchanged through hr. sodium orthovanadate decreased the dnp-sg buffer/tissue ratio by . ± . % (p< . ), consistent with inhibition of apical abc transporters. conclusions: these results support the use of this model to study the coordinated function of metabolizing enzyme gstp - and apical abc transporters in the formation and efflux of the model substrate dnp-sg. the model may be useful to study metabolism and transport of other compounds. syncytiotrophoblast. shauna f williams, ewa fik-rymarkiewicz, stacy zamudio, nicholas p illsley. obstetrics, gynecology and women's health, umd-new jersey medical school, newark, nj, usa. introduction: multiple inputs influence placental protein synthesis. nutritional, endocrine and metabolic factors have been implicated but its regulation has not been investigated. one of the factors shown to be associated with the inhibition of protein synthesis is hypoxia. the goal of this study was to determine the effects of hypoxia on a marker of placental protein synthesis. eukaryotic initiation factor (eif ) is a subunit of eif which is required for initiation of translation however when phosphorylated, eif is unable to participate in the assembly of the initiation complex. hypoxia has been shown previously to cause increased phosphorylation of eif . we hypothesized that hypoxia would increase the levels of phosphorylated eif in term syncytiotrophoblast, thus inhibiting protein synthesis. methods: primary syncytiotrophoblast cultured from term cytotrophoblast were incubated for hr in atmospheres of , , or % o or in the presence of the hypoxia-mimetic, dimethyloxalylglycine (dmog, . - . mm) in % o . cell extracts were analyzed by western blotting to determine the degree of eif phosphorylation. results: incubation in , , or % o did not increase eif phosphorylation relative to the % o control (n= , separate placental preparations). incubation in dmog concentrations up to . mm did not affect eif phosphorylation however incubation in . mm dmog increased eif phosphorylation by ± % (p < . , n= ). conclusions: contrary to our expectations, inhibition of protein synthesis via the eif regulatory pathway was not apparent except when induced by the highest concentration of dmog, consistent with severe hypoxia. thus while eif phosphorylation does occur, we did not observe changes at dissolved oxygen levels of %. these data suggest that a reduction in syncytial protein synthesis via the eif pathway takes place only under severe hypoxic stress. (supported by nih hd ). the increasing prevalence of overweight and obese women of childbearing age is a growing public health concern. the impact of maternal obesity on placental aa transport, which is essential for normal fetal development, remains poorly defined. there are three sub-types of the placental na-dependent system a transporter, snat , and which mediate neutral aa transport. snat is ubiquitously expressed in mammalian tissues and is likely responsible for the majority of placental system a activity. objective: to examine the impact of maternal obesity and over-nutrition on the fetal: maternal (f:m) aa ratio and placental protein abundance for snat . methods: nonpregnant ewes were randomly assigned to a control (c, % of nrc recommendations) or obesogenic (ob, % of nrc) diet from - to days of gestation (dg). under isofluorane anesthesia, maternal and fetal blood samples were collected for aa analysis by hplc from five twin bearing ewes in each dietary group. after euthanasia, placental cotyledonary (cot) tissue was separated from caruncular tissue, frozen in liquid nitrogen and stored at - c for western blot analysis. results: fetuses from ob ewes were % heavier (p< . ) than those from c ewes at dg ( ± vs. ± g). blood concentrations of asn, thr, cit, arg, tau, tyr, trp, val, phe, leu and orn were higher (p< . ), or tended to be higher (met and lys, p< . ) in ob than c ewes. in contrast, f:m ratios, for asn, ser, gln, his, gly, thr, cit, arg, b-ala, tau, ala, tyr, trp, met, val, phe, leu, orn and lys were reduced (p< . ) in ob compared to c ewes. snat content in cot tissue was reduced in ob when compared to c ewes ( . ± . vs. . ± . arbitrary units; p< . ). conclusions: maternal obesity in pregnancy reduced expression of placental snat protein and efficiency of placental aa transport in ewes, providing a mechanism whereby fetuses may mitigate excessive delivery of aa under conditions of maternal obesity and over-nutrition. decreased aa transport to the fetus may play a role in altered cellular structure and function. nih inbre p rr . early gestation utero-placental hemodynamics in an ovine model of fetal growth restriction. lucia dohnal, james s barry, henry l galan, randall b wilkening, russell v anthony. perinatal research center, university of colorado health sciences center, aurora, co. objective: fetal growth restricted (fgr) pregnancies, during late gestation, exhibit altered placental hemodynamics, and reduced capacity for o and nutrient transfer. it was our objective to examine utero-placental hemodynamics and o uptake during early gestation in an ovine model of fgr. methods: singleton-bearing ewes were instrumented with uterine artery flow probes, uterine venous and femoral artery catheters before being placed into a highambient temperature (fgr; n= ) or normothermic (con; n= ) environment at days of gestation (dga). maternal arterial and venous blood, uterine artery flow, heart rate, arterial pressure and respiration rate was collected until dga, at which time umbilical venous blood, fetal weight, placental weight and tissue were harvested. data reported here were analyzed by students t-test. results: maternal respiration rate ( . ± . vs . ± . breaths/min) and arterial po ( . ± . vs . ± . mmhg) were increased (p . ), whereas maternal heart rate ( . ± . vs . ± . beats/min), blood pressure ( . ± . vs . ± . mmhg) and arterial pco ( . ± . vs . ± . mmhg) were reduced (p . ) in fgr pregnancies. at dga, fetal weight was not different (p . ), but placental (total placentome) weight ( . ± . vs . ± . g) was reduced (p . ) in fgr pregnancies. while uterine artery (pregnant horn) flow ( . ± . vs . ± . ml/min) tended (p= . ) to be reduced in fgr pregnancies, relative uterine artery flow ( . ± . vs . ± . ml/min/g fetus; . ± . vs . ± . ml/min/ g placenta) was not different (p . ). uterine o uptake (mmol/min), relative uterine o uptake (ml/min/g fetus or ml/min/ g placenta) and uterine o extraction (%) were not different (p . ) between fgr and con pregnancies. at dga, umbilical vein po (mmhg), o content (mm) and o capacity (mm) were also not different between fgr and con pregnancies. conclusions: reduction in absolute uterine artery flow (ml/min) did not impact utero-placental o uptake or transfer to the umbilical vein, and may have resulted from reductions in maternal cardiac output. relative uterine artery flow was not reduced, suggesting that uterine blood flow and delivery of o to the conceptus does not mediate the ongoing placental growth restriction initiated during early gestation. supported by nih hd . barton c staat, anna maria marconi, cinzia paolini, alex cheung, henry l galan, frederick c battaglia. obstetrics gynecology and pediatrics, univ of colorado at denver health sciences center, aurora, co, usa; dept of obstetrics and gynecology, san paolo institute of biomedical sciences, university of milano, milano, italy. objective: to determine relative contributions of transplacental flux vs fetal production for myo-inositol and mannose in normal term pregnancies using stable isotopic methodolgy. background: myo-inositol and mannose are important in biologic functions. an external supply of mannose may be required for glycoprotein synthesis. low maternal myo-inositol is associated with spina bifida. mannose concentrations are known to be higher in the mother than the fetus. in contrast, myo-inositol concentrations are higher in the fetus than the mother. what remains unknown is whether fetal levels of these polyols are a result of direct maternal transport or from conversion of glucose. design: four term uncomplicated pregnancies undergoing an elective ceasaran section were infused with c labeled isotopes of glucose, myo-inositol and mannose over hours prior to delivery. maternal samples were obtained prior to infusate being administered, and at hour (h), . h and h. fetal concentrations were measured from umbilical artery and vein plasma. the concentrations of labeled and unlabeled glucose, mannose and myo-inositol were measured using high pressure anion exchange chromatogrpahy permitting detection of polyols and sugars at concentrations in the μm range. the feto-maternal molar percent enrichment (mpe) ratio was calculated for each glucose, mannose, and myo-inositol as the ratio between fetal plasma enrichment and the maternal plasma enrichment at steady state. steady state was calculated as the mean of the three maternal samples taken during infusion. results: the feto-maternal mpe ratios of mannose ( . ± . , p= . ) and glucose ( . ± . , p= . ) were not significantly different from . , consistent with transplacental supply. the feto-maternal ratio for myo-inositol ( . ± . , p= . ) indicates little transplacental flux ( % of fetal inositol derived from maternal plasma). conclusion: in normal term pregnancies, fetal mannose and glucose concentrations are dependent upon maternal transplacental supply. in contrast, fetal myo-inositol concentration is not dependent upon transplacental supply, but fetal demands are met by placental conversion, likely from glucose. christian wadsack, manuela augsten, christian guelly, ursula hiden, ingrid lang, manfred moertl, uwe lang, gernot desoye. clinic ob/gyn; center of med res; inst cell biol, histol embryol, med univ graz, austria. background placenta and fetus need lipids for growth and synthesis functions. part of the lipids is supplied from maternal sources by transplacental transfer. recently, we identified in human placenta the high density lipoprotein (hdl) receptor scavenger receptor class b type i (sr-bi). among other functions it mediates hdl-induced ser -phosphorylation of endothelial nitric oxide synthase (enos) resulting in enos activation. this mechanism allows hdl to contribute to regulation of vasotonus in arteries. we hypothesized that term placental endothelial cells (ec) express sr-bi at levels different between arteries and veins. methods sr-bi was localized by ihc and quantified by qrt-pcr in rna isolated from arterial and venous vessels. arterial (eca) and venous (ecv) placental ec were rigorously characterized. sr-bi levels were measured by qrt-pcr and immunoblotting. hdl binding and uptake was measured in eca and ecv with i-labelled hdl. hdl from human donors was used to stimulate ser enos phosphorylation. epigenetic regulation was studied by methylationspecific pcrs for cpg-rich promoter regions of sr-bi. pdzk a key adaptor for sr-bi mediated enos activation was measured by sqrt-pcr. in situ analyses (ihc, qrt-pcr) showed more sr-bi in arteries than in the vein. the differential expression persisted in vitro in isolated eca and ecv even after passages and culture under same conditions suggesting epigenetic mechanisms regulating sr-bi. however, no methylation was found in eca or ecv. sr-bi was functional since hdl cell association was -fold higher in eca than in ecv ( ± . vs ± . ng hdl/mg prot). hdl did not induce ser enos phosporylation in eca or ecv, which was stimulated by ionomycin about -fold in both cell types. pdzk was undetectable in eca and ecv, whereas it was expressed in placental tissue. conclusion more sr-bi is expressed in ec from arteries than from veins in situ and in vitro. this is not the result of different methylation of sr-bi promoter and, hence, unlikely an epigenetic phenomenon. mechanism of differential expression and its functional consequences for vasotonus regulation is yet unknown. the lack of pdzk may account for the failure of hdl to activate enos. (grants , , oenb). cells. juan a arroyo, brad ziebell, mi-hye park, henry l galan. obstetrics and gynecology, university of colorado andgealth sciences center, aurora, co, usa. introduction: mtor is a protein that regulates cell growth in response to nutrients and growth factors. downstream effectors of the mtor pathway include the p and the ebp proteins. activation by phosphorylation of these proteins increases protein synthesis. given that various signaling pathways are regulated by hypoxia in human trophoblast and that mtor is expressed in human trophoblast, our objective was to determine the effects of hypoxia in the activation of mtor, p and ebp in cultured human trophoblast. study designs: trophoblast cell were isolated from term uncomplicated placentas using a trypsin, dnase and disapase solution. cytokeratin immunocytochemistry confirmed trophoblast cells culture purity. trophoblast cells were treated with hypoxia ( % o ) or normoxia ( % o ) for and hours. western blot for p-mtor, mtor, p-p , p , p- ebp , and ebp were done for each time studied. results: trophoblast cells demonstrated: ) positive staining for cytokeratin, ) non significant differences for mtor at either ( . -fold; p= . ) or hours ( . -fold, p= . ), ) no differences in p protein at ( . fold; p= . ) or hours ( . -fold, p= . . ), ) no differences for ebp at either or hour. conclusion: we conclude that the mtor pathway is not regulated under hypoxic conditions in cultured trophoblast, which suggests that hypoxia does not affect protein synthesis in cultured human trophoblast. however, this may not reflect what happens in vivo in iugr. (supported by nih grant r hl - a ). increased expression of phospho-mtor, phospho-p , phospho-akt and phospho-erk in an ovine model of fetal growth restriction. juan a arroyo, brad ziebell, henry l galan. obstetrics and gynecology, university of colorado and health sciences center, aurora, co, usa. objective: both phosphorylated (p) mtor and p are known to be involved in protein synthesis and are regulated by physiological conditions such as fetal growth restriction (fgr). in a hyperthermic (ht) ovine model of fgr we hypothesize that mtor, p , ebp , erk and akt will be phosphorylated (activated) in the placentae of age (dga) animals. study design: ewes were exposed to ht conditions for days to induce iugr and were placed in ambient conditions. at necropsy ( dga), placentomes were separated into the maternal (caruncle) and fetal (cotyledon) components and frozen for western blot analysis with antibodies against (p) mtor, mtor, (p) p , p , (p) ebp , ebp , (p) erk, erk, (p)akt and akt. results: compared to control animals, fgr animals had smaller fetuses ( ± g v. ± g; p= . ) and smaller placentae ( ± g v. ± g; p= . ) at dga. fgr cotyledon showed an increase in p-mtor ( . -fold; p= . ), p-p ( . -fold; p< . ), p-erk ( . -fold; p< . ) and p-akt ( . -fold; p< . ). in contrast, caruncle (maternal) did not show any changes for the mtor pathway. conclusion: in fgr ovine pregnancies, the fetal placental tissues (cotyledons) showed upregulation of the mtor pathway for protein synthesis via phosphorylation of the p but not ebp while this was not seen in the maternal (caruncle) tissues. in addition neither the cotyledon or caruncle tissues at mid-gestation ( dga) showed changes in these endpoints, which is prior to the exponential fetal growth that starts at mid-gestation. (supported by nih grant r hl - a ). hyperuricemia has long been recognized as a common clinical finding in preeclamptic (pe) women. to date, elevated uric acid concentrations in these women have been considered a marker of disease severity. however preeclamptic pregnancies with hyperuricemia, are associated with an increased frequency of preterm birth and fetal growth restriction. over the past decade several pathogenic roles for uric acid have become evident, raising the possibility of a role(s) for uric acid in the altered vascular and placental functions associated with pe. objective: examine the effects of syncytial uric acid uptake on system a amino acid transport across the human placenta using a primary placental villous explant model. methods: placental villous explants from placentae of healthy, term pregnancies were incubated for hours with uric acid ( . mg/dl), corresponding to concentrations of uric acid observed in pe women. these experiments were conducted in the presence or absence of probenecid ( m), a uric acid cellular uptake inhibitor. system a amino acid transport was subsequently assayed using a radiochemical assay in which na+-dependant uptake of radio-labeled system a substrate, [ c] methyl-amino-isobutyric acid, was measured over minutes. data were analyzed using a paired student's t-test and presented as mean ± sem. results: uric acid attenuated system a amino acid placental transport by % (± . %, p< . ). this inhibitory effect of uric acid on system a activity was prevented by probenecid. conclusions: uric acid reduces placental amino acid transport at concentrations observed in pe women. this inhibitory effect of uric acid is dependant upon syncytial uptake of uric acid, being inhibited by the uric acid transporter inhibitor probenecid. these results may be relevant to the increased frequency of fetal growth restriction observed in hyperuricemic pe. additionally the results of this study, indicating a detrimental effect of hyperuricemia on placental function, also suggest a role for uric acid in the pathophysiology of pe. hyperuricemia, a well-documented clinical finding in preeclamptic women, is associated with pre-term birth and intrauterine growth restriction. uric acid is higher in women destined to develop preeclampsia as early as weeks of gestation at a time when cytotrophoblast are invading decidua and myometrium and remodeling uterine spiral arterioles. we propose that elevated concentrations of uric acid may have detrimental effects on placental development in part through inhibition of trophoblast invasion through the decidua. objective: examine the effects of increasing concentrations of uric acid on trophoblast invasion through a reconstituted extracellular matrix. methods: using the in-vitro matrigel invasion assay, the effects of increasing concentrations of dissolved uric acid ( . mg/dl, . mg/dl and . mg/dl) on the ability of immortalized first trimester extravillous trophoblast cells (htr -svneo) to invade through a reconstituted extracellular membrane were assessed. the concentrations of uric acid used were comparable to those measured in healthy pregnant women and preeclamptic women with an increase in uric acid of two or four standard deviations above normal. cells that successfully invaded through the matrigel membrane within hours were fixed with methanol, stained with hematoxylin and counted. data were analyzed using a one-way analysis of variance with fisher's post-hoc analysis. results: uric acid attenuated trophoblast invasion in a dose-dependent fashion (p< . ), with decreases of % (± . %), % (± . %) and % (± . %) respectively compared to untreated controls. conclusions: exogenous uric acid, at physiological and pathological concentrations, is capable of attenuating trophoblast invasion through a reconstituted extracellular membrane in a dose dependent fashion. these results suggest uric acid is a potential contributor to the pathophysiology of altered placental perfusion in preeclamptic pregnancies. previous studies have shown that transforming growth factor (tgf)-is a key inhibitory factors in the invasion of early trophoblast cells, suggesting therefore that overcoming tgf-beta signaling may be necessary for successful implantation. smad ubiquitin regulatory factor (smurf ), a hect type e ubiquitin ligase, is a key regulator of tgf-signaling pathway, targeting tgf-receptors and various smads for proteasome-mediated degradation. in this context, smurf has been shown to play important roles in embryonic development, cell senescence and tumor formation. as a key regulator of tgfbeta signaling, we wished to determine whether smurf has a physiological role during embryo implantation, especially in trophoblast invasion. we have examined the spatio-temporal expression of smurf in human placental villi during pregnancy. we have also investigated the possible function of smurf in trophoblast cell migration and invasion in a model system involving a human extravillous trophoblast cell line, htr /svneo. our results showed that expression of smurf in placental villi was the highest during the first trimester and the expression decreased in the nd trimester. expression of smurf was lowest in placental villi at parturition. overexpression of smurf in htr /svneo cells reduced tgf beta type i receptor levels and attenuated the inhibitory effect of tgf-on cell migration and invasion. conversely, rnai-mediated down-regulation of smurf resulted in significant increase of tgf-type i receptor protein levels. in contrast, the levels of smad , another potential target of smurf , was unchanged. in conclusion, the present study suggests that smurf participates in trophoblast cell migration and invasion by down-regulating the expression of tgf-type i receptor. our previous data demonstrated the extensive expression of mmp- in various kinds of trophoblast cells in human placenta at the early pregnancy. however, the modulation of the enzyme in trophoblasts is largely unclear. in the present study, the effects of the two types of gonadotropin releasing hormone (gnrh) on mmp- expression were examined in an immortalized human cytotrophoblast cell line, b tert- that has been established in this lab. real-time quantitative pcr and western blot analysis revealed that both types of gnrh (gnrh i and gnrh ii) could increase mmp- mrna and protein levels in b tert- cells in time-dependent manners. in particular, regulatory effect of gnrh i on mmp- expression was concentration-independent, whereas that of gnrh ii was dose-dependent. moreover, both gnrh i and gnrh ii could evidently activate jnk kinase, and sp , an inhibitor of a jnk kinase, reversed the up-regulation of mmp- induced by either gnrh i or gnrh ii. on the other hand, it is not likely that erk / pathway participates in the signaling of gnrh i or gnrh ii. collectively, our observations suggest that gnrh i and gnrh ii elicit their modulation effects in human trophoblastic cells through jnk pathway leading to up-regulation of mmp- . during the first trimester of pregnancy, the oxygen tension of the developing trophoblast cells is less than %. however, the majority of studies on primary trophoblast cell development have been performed at % oxygen. primary third-trimester trophoblast cells are believed to be nonproliferative syncytiotrophoblast cells. we have previously demonstrated that low oxygen tension dramatically affects the differentiation pathway of these cells. we now hypothesize that cell culture in low oxygen tension will improve cell growth and restore proliferation. methods: primary trophoblast cells were purified from third-trimester placenta by enzymatic dispersion and cd- negative selection and cultured at %, % or . % oxygen tension for up to days. the number of cells in culture was assessed by cell counting and by measuring genomic dna. live:dead and mtt assays were used to determine viability. proliferation was assayed with brdu and immunohistochemistry for proliferating cell nuclear antigen. to assess cellular activity, radioactivity of protein precipitated from cells cultured in the presence of tritiated leucine was measured. results: there were no obvious morphologic changes in the cells cultured in different oxygen tensions. the amount of cell loss was directly proportional to oxygen tension: at % oxygen % of the cells remain in culture; at . % oxygen tension % of the cells remained. the cells at . % oxygen tension were proliferating and had a five-fold increased metabolic activity. conclusions: it was previously believed that third-trimester trophoblast cells are non-proliferative. we have demonstrated that low oxygen tension increases the survival of primary third-trimester trophoblast cells. this may reflect the change in the differentiation pathway of these cells. however, the cells also begin to proliferate and increase their metabolic activity. trophoblast cells in vivo form a three dimensional structure which promotes critical complex cell-to-cell interactions that cannot be studied with traditional monolayer cell culture. we developed a substrate-free three-dimensional trophoblast culture system capable of studying cellular interactions without a confounding artificial matrix. methods: nonadhesive agarose hydrogels containing cylindrical recesses m in diameter were cast from molds designed using computer-assisted prototyping. tcl trophoblast cells were seeded into the gels ( , cells per) for up to days. viability and cellular stress were assessed and the threedimensional structures of the spheroids were analyzed. results: tcl trophoblast cells formed uniform spheroids within three days of seeding. the spheroids remained intact after being removed from the mold. when placed in traditional cell culture dishes the cells adhered to the plate within one hour and rapidly proliferated into a monolayer. repetitive reseeding allowed easy transition between monolayer and spheroid without affecting cellular morphology. serial sectioning on days , and revealed central vacuolization forming a trophoblast vesicle with an outer rim . m (+/- m) thick. this rim size remained constant for at least days. live:dead assay demonstrated that the outer cells remained viable and staining against proliferating cell nuclear antigen demonstrated that the cells were proliferating. the inner cells undergo apoptosis as demonstrated by caspase- staining. there is an abundance of vegf staining in the cells remaining in the on the inside of the sphere suggesting a gradient of nutrient or oxidative stress. the formation of a vesicle has been confirmed with confocal imaging. em imaging revealed the structure of the rim. conclusions: trophoblast cells cultured in a novel substrate-free three dimensional system form trophoblast vesicles within days of seeding. these vesicles remain viable after long-term culture and can be repeatedly reformed with repetitive seeding. this new cell culture technique allows us to better study placental cell-cell interactions with the potential of forming microtissues. the transcription factor glial cell missing- (gcm ) mediates cell cycle arrest and differentiation of human trophoblast progenitors into villous syncytiotrophoblast and invasive extravillous cytotrophoblast (evt). micro-array analysis of total rna extracted from cultured bewo cells, in which gcm mrna and protein were repressed using sirna, identified tissue inhibitor of metalloproteinase- (timp- ) in the highest ( -fold) upregulated group of genes. confirmatory rtpcr demonstrated a -fold mrna induction. in placental villi, gcm acts as a transcription factor promoting expression of the fusogenic protein syncytin that mediates syncytial fusion into the overlying syncytiotrophoblast. by contrast, syncytial fusion is uncommon in evt. rather these cells invade several millimeters into the distal myometrium where they transform spiral arterioles. to investigate the role of timp and gcm in the trophoblast we assessed its mrna by qrt-pcr and protein by western blot in cellular extracts from both bewo cells grown under standard cultivation conditions (synchronized by prior thymidine exposure) and floating cultured first trimester villous explants cultured in % oxygen with prior exposure to either gcm sirna or anti-sense oligo-nucleotides to gcm . gcm inhibition in the bewo system was associated with a - % increase in timp- protein expression and alteration of cell proliferation and differentiation in both models. we are presently utilizing the explant model of evt invasion (explant tips cultured on matrigel in % oxygen) to test the hypothesis that gcm mediates metallo-proteinase expression and evt invasion via timp- . presently we conclude that gcm -mediated evt differentiation involves more than an arrest of mitosis and may include promotion of invasion via repression of timp- . funding: cihr. scott h purcell, jeremy d cantlon, virginia d winn, russell v anthony. , colorado state university, fort collins, co; university of colorado health sciences center, aurora, co. background: periattachment factor (pf) is a nuclear protein first described in the bovine conceptus. our research in sheep has shown pf mrna concentration peaks when the conceptus is undergoing elongation and initial apposition to the endometrium, and that pf is a nuclear protein localized to the trophoblast. in silico analysis identified a human homolog, hprr . objective: the objective of this experiment was to determine if pf was expressed in the human placenta, and to develop short-hairpin (sh) rnas for hpf to begin investigating its function. materials and methods: immunohistochemistry was performed on paraffin embedded first and second trimester human placental samples. placental sections were immuno-stained using rabbit polyclonal antiovine pf or anti-human cytokeratin- . cytotrophoblasts from first trimester pregnancies (n= ) were subjected to an in vitro invasion assay and rna was harvested following , , and h. quantitative rt-pcr was performed on these samples with intron-spanning primers for hpf, and normalized on hs mrna concentrations. based on the human pf sequence, four putative shrna constructs were generated and cloned into a lentiviral expression vector. bewo human choriocarcinoma cells were treated with one of four shrna contructs or an empty vector for h and then rna was harvested from cells for analysis by quantitative rt-pcr. results: periattachment factor was present in the nuclei of both first and second trimester cytotrophoblasts. hpf mrna concentration increased as invasion occurred from , , to h in all samples; while hypoxia decreased expression at h of invasion compared to h under normoxic conditions. the four lentiviral vectors expressing shrna against hpf resulted in hpf mrna concentrations at , , and % of hpf mrna concentration with the control vector. conclusion: the presence of pf in the human placenta and the increase in pf mrna during cytotrophoblast invasion may indicate this gene plays a role during implantation. we have developed shrnas against pf that result in greater than % mrna knockdown and will be using these to begin to elucidate the function of pf in the human placenta, specifically during the invasion process. recently we demonstrated that infusion of imd antagonist (imd - ) in rat caused distorted labyrinth indicative of a deficient vasculature in placenta. we hypothesize that imd has a role in migration of first trimester trophoblast cell (htr- /svneo) via regulating human leukocyte antigen (hla-g) and stimulating mek / / erk / phosphorylation. objectives: ) to asses the effect of imd on migrating capacity of htr- sv/neo cells using scratch assay in presence or absence of mek and ras/raf inhibitor, u and manumycin a, respectively ; ) to assess the effect of imd peptide on phosphorylation of mek / and erk / in first trimester htr cells ) to analyze the effects of imd on the expression of human leukocyte antigen, hla-g, a critical factor involved in the invasion and vascular remodeling of spiral uterine arteries and subsequent pregnancy in human. methods: htr- sv/neo cells were used to assess the effect of imd ( - m) on the expression of hla-g mrna and phosphorylation of erk / and mek / protein by reverse transcriptase polymeration chain reaction (rt-pcr) and western blot analysis respectively. scratch wound assay was used to determine the migration capacity of htr cells. total rna was isolated from cells using trizol reagent and processed for rt-pcr and results are expressed relative to s mrna. trichloroacetic acid was used for the extraction of total protein for western blot analyses. results: our data demonstrates that, ) imd enhances the migrating capacity of htr cells (compared to the untreated cells) and these effects are inhibited by mek and ras/raf inhibitors, u and manumycin a, respectively; ) imd ( - m ) stimulates phosphorylation of erk / and mek / proteins in htr cells, ) imd increases the expression of hla-g mrna in htr cells. conclusion: imd promotes migration of first trimester htr cells through mek/ erk signaling pathway and modulates the expression of immunoregulatory molecule, hla-g in these cells. chymotrypsin-like protease promotes the placenta tissue release of sflt- . yang gu, shuang zhao, david f lewis, yuping wang. obstetrics and gynecology, lsuhsc-shreveport, shreveport, la, usa. objective: the placenta is a major source of soluble vegf receptor- (sflt- ) in the maternal circulation during pregnancy. increased placental release of sflt- is believed to play an important role in the pathophysiology and pathogenesis in pe. however, the mechanism of increased placental sflt- release in pe is unknown. we recently reported increased chymotrypsin-like protease (clp) activity and expression in placental trophoblasts from pe. in this study, we tested if proteolytic effects of chymotrypsin may play a role in promoting sflt- release by placental trophoblasts. methods: placentas delivered by normal pregnant women (n = ) were used. we tested if chymotrypsin could promote sflt- release by placental tissue, in which villous explants were cultured with dmem containing chymotrypsin at . , . , and . g/ml for hours. the culture medium was then collected for measuring sflt- . we then determined the specificity of chymotrypsin induced sflt- release. villous tissues were cultured with or without chymotrypsin inhibitor (ci) in culture and then the medium was collected and measured for sflt- . soluble flt- was measured by elisa. all samples were assayed in duplicate. data are presented as mean ± se and analyzed by anova. a p level < . is considered as statistically different. results: ) sflt- concentrations in the medium were increased when chymotrypsin was present in culture and the increased sflt- release induced by chymotrypsin was in a concentration-dependent manner: control: . ± . ; . g/ml: . ± . ; . g/ml: . ± . ; and . g/ml: . ± . (p< . ) pg/mg tissue/hour. ) ci could attenuate sflt- release. this inhibitory effect was also revealed in a concentration-dependent manner: control: . ± . ; ci . g/ml: . ± . ; and ci . g/ml: . ± . (p< . ) pg/mg tissue/hour. conclusions: increased placental sflt- release stimulated by chymotrypsin and decreased placental sflt- release inhibited by chymotrypsin inhibitor suggest that the proteolytic effect of clp may play a role in sflt- generation. therefore, increased clp activity in placental trophoblasts may contribute to the increased placental sflt- production in pe. (supported nih grants hl and hd ). the change of autophagy-related proteins, lc and beclin- , by tnfa stimulation in cultured primary trophoblasts. soo-young oh, kyung hee kim, suk-joo choi, jong-hwa kim, cheong-rae roh. department of obstetrics and gynecology, samsung medical center, sungkyunkwan university school of medicine, seoul, korea. objective: our previous work have demonstrated that the expression of lc , but not beclin- , was increased in placentas from pregnancies complicated by severe preeclampsia (sgi abstract # ) . to understand the regulatory mechanism of these autophagy-related proteins in trophoblast cells, we investigated the changes in these proteins in response to cytokine or hypoxic stimulation in cultured primary trophoblast. material and methods: primary human cytotrophoblasts obtained from normal term placenta were cultured with stimulation of tnf-a or cocl for a given time and the changes of beclin- and lc were assessed using immunoblot analysis. paired t test was used for statistic analysis. results: tnf-a stimulation induced a significant increase of the expression of lc -ii in cultured primary trophoblasts while decreasing the expression of beclin- (p< . for each). however, cocl stimulation did not induce a significant change of both lc -ii and beclin- . conclusions: our data suggests that tnf-a stimulation in cultured primary trophoblasts is associated with increased autophagic activity. background: thyroid hormones play vital roles in the development of the fetal brain. mutations in mct , recently recognised as a specific thyroid hormone transporter, define a novel syndrome of severe x-linked psychomotor retardation accompanied by elevated serum t . we previously reported that mct expression in n-tera- (nt ) cells (a human embryonal cell line with characteristics of cns precursors), as well as mct -null jeg- choriocarcinoma cells, resulted in markedly reduced cell proliferation. further, the s x mct mutation, as reported in males affected by severe psychomotor impairment, resulted in a similar repression of proliferation to wild type, whereas the l p mutant failed to influence cell turnover compared with control. methods: we now examine the effect of "knocking down" mct via sirna and evaluate the effects of cell proliferation (mtt and [ h]-thymidine assays) and tri-iodothyronine (t ) uptake. results: repression of endogenous mct expression in nt cells by % caused a significant increase in proliferation compared to matched-dose nonspecific sirna treatment, independent of t concentration ( . %, . % and . % induction at , and nm t , n= , p< . ). we also sought to examine the role of mct in t uptake. in jeg- cells, wild type mct induced a . -fold increase in the uptake of i-labelled t . by contrast, mutants s x and l p failed to significantly augment t uptake, though r h caused a mild but significant . fold induction in uptake, hence retaining approximately % of wt activity. in parallel experiments, co-transfection of mu-crystallin, a t binding protein, resulted in a similar increase in t uptake compared with control ( . -fold; n= ; p< . ), implying that mct plays only a minor role in thyroid hormone efflux in jeg- cells. mutants s x, l p and r h showed analogous responses to those in the absence of mu-crystallin. conclusion: these results further extend the evidence of a potential role for mct in the modulation of cell proliferation, independent of t transport. to determine predictors of failure for labor induction in women with preeclampsia. we conducted a retrospective cohort study to examine cesarean delivery rates in all the preeclamptic women at a single institution undergoing labor induction between - with a singleton pregnancy >= weeks gestational age (ga). bivariate analyses informed the creation of multivariable logistic models to predict the risk of cesarean delivery using multiple predictors (maternal age, race/ethnicity, unfavorable cervix, gestational diabetes, diabetes, and gestational age). analyses were stratified by parity. our study population included , preeclamptic women undergoing labor induction. in the bivariate analyses, the risk of cesarean delivery ranged from as low as . % (p= . ) among multiparous women - weeks ga to as high as . % (p< . ) among nulliparous women with diabetes. a total of , women had adequate data to be included in the multivariable analyses. odds ratios of the predictors are presented in the objective: preeclampsia and cardiovascular disease share many risk factors, and women with preeclampsia are at increased risk of cardiovascular mortality later in life. we investigated whether risk factors associated with cardiovascular disease and preeclampsia remain elevated months postpartum. methods: we measured plasma sflt , endoglin, plgf, cellular fibronectin (cfn), uric acid, homocysteine, and asymmetric dimethylarginine (adma) in women with uncomplicated normotensive pregnancies compared to women with preeclampsia in samples collected at pre-delivery and again several months postpartum (average . ± . months). data are mean±sd or median (interquartile range). statistical analysis was by wilcoxin rank-sum or students unpaired t-tests with statistical significance accepted at p< . . results: the mean concentration of sflt , endoglin, plgf, homocysteine, adma, cfn, and uric acid were all significantly different in samples collected pre-delivery in subjects with preeclampsia compared to controls (table). adma, cfn and uric acid remained significantly higher postpartum in subjects with previous preeclampsia compared to postpartum controls (table) . conclusions: biological markers associated with altered vascular function or cardiovascular risk are elevated in women with preeclampsia, and some remain significantly higher in postpartum preeclamptic women. these data suggest that vascular dysfunction persists in women with previous preeclampsia, and may contribute to the increased risk of future cardiovascular disease. funded in part by national institutes of health nih- mo -rr and nih- po -hd . (ajp, ) . as leptin is a known potent angiogenic factor we hypothesized that leptin deficiency and/or resistance to leptin-induced vegf expression might be a mechanism for reduced angiogenesis in mfr offspring. methods: pregnant sprague-dawley rats had % mfr from day of gestation until delivery. mfr and control offspring were sacrificed on day of life (p ). some tissues were used to determine the expression of leptin by western blot analysis. for culture experiments, thoracic aortas were dissected, cut into - mm explants and incubated with leptin ( - ng/ml) in dmem ( % fbs). after hours of culture, rna was extracted from the tissues and subjected to real time rt-pcr using specific rat primers for vegf, vegfr and r , and ob-ra, stat and socs ( s mrna as control). culture media was analyzed for vegf protein by elisa. results: expression of leptin mrna and protein in p mfr aortas was significantly reduced. in culture, leptin significantly increased expression of vegf, vegfr and vegfr mrna in explants of aortas obtained from the control but not mfr tissues. as expected, control but not mfr aortic explants secreted significantly more vegf in vitro. to determine the mechanism for resistance to leptin-induced vegf in mfr offspring, we assessed expression of leptin receptor (ob-ra) in explants treated with leptin. leptin was found to induce the expression of ob-ra in aortas from both dietary groups. this upregulation of leptin receptor was accompanied by significant upregulation of stat and socs mrna in the control tissues. in contrast, in mfr explants only the ng/ml concentration of leptin induced an increase in stat mrna, and the magnitude of socs mrna increase by both concentrations of leptin was significantly less in the mfr explants. conclusion: these results indicate that reduced angiogenesis in mfr vessels is in part due to reduced leptin expression and ability of leptin to stimulate vegf expression. although in vitro leptin induced the expression of its receptor in both groups, it was only in the mfr group in which leptin up-regulated vegf and its receptors. our results suggest that this defect in leptin receptor function in mfr vessels is due, in part, to defects in jak/stat signaling. objective: women with a history of early-onset preeclampsia are at increased risk of developing major cardiovascular disease (cvd) related events, that have a detrimental effect on their long-term health and life expectancy. in this follow-up study, we measured established risk factors predictive of first cvd events after early-onset preeclampsia. study design: over a -year interval, primiparous women with a history of early-onset preeclampsia (delivery < weeks gestation) were included and tested for major cardiovascular risk factors at least six months after delivery, in addition to a population-based control group of healthy non-pregnant women. women with chronic hypertension were excluded. results: mean age was . years for cases compared to . years for controls (p<. ). after adjustment for age, we observed significantly increased mean values for weight (p=. ), body-mass index (p<. ), systolic blood pressure (p<. ), diastolic blood pressure (p<. ), total cholesterol (p=. ), ldl cholesterol (p<. ), triglycerides (p=. ), fasting blood glucose (p<. ), and lower hdl cholesterol (p<. ) in women with previous early-onset preeclampsia. no difference was found for height, smoking, diabetes, and ethnicity. estimated -year risk of first cvd events by framingham risk scores remained < % for all women (low-risk). nonetheless, at mean (sd) . ( . ) years after early-onset preeclampsia, % of women met the criteria for metabolic syndrome, % of women exhibited >= , % of women >= and % of women >= major cvd risk factors. conclusion: the majority of women with a history of early-onset preeclampsia exhibit at least one modifiable risk factor for future cvd. although most of these women are classified as low-risk according to the current aha guidelines, this is mainly due to their young age masking other, mostly modifiable, major risk factors. our data thus support life-style intervention programs aimed at primary prevention of cvd in women with a history of early-onset preeclampsia. it has recently been shown that antihypertensive drugs can stimulate cytokine release in normal and hypertensive pregnancy. there is evidence that these cytokines alter the secretion of inhibin a. inhibin a and activin a levels are increased in pre-eclampsia (pe), but it is not known if antihypertensive therapy can affect their secretion. patients and methods we recruited women with hypertensive disorders in pregnancy ( pe and non-proteinuric hypertension [ht]) and matched normotensive controls. inhibin a and activin a levels, before and - hours after initiating antihypertensives, were measured in serum and urine, using an elisa. the same markers were measured using validated assays in placentas delivered at cesarean section at similar gestational age ( pe, ht and controls). analysis the three study groups were compared using anova multiple comparisons with bonferroni post hoc testing. the data were normally distributed after logarithmic transformation. marker levels before and after antihypertensive therapy were compared using paired t-test. we compared placental concentrations between the group which received antihypertensive therapy and the group which did not, using an independent t-test. data were analysed using spss®. in pe, both serum and urine levels of inibin a and activin a were increased at all gestations (p< . ). activin a (but not inhibin a) level was also increased at all gestations in ht (p< . ). after weeks' gestation (but not before), antihypertensive treatment was associated with a significant fall in both inhibin a and activin a serum levels, and urinary inhibin a, in both pe and ht. the placental concentration of inhibin a, but not activin a, was significantly higher in women with pe compared with controls (p< . ). there was no significant difference in either marker between controls and women with ht. the fall in serum levels of inhibin a and activin a following antihypertensive treatment after weeks' gestation may indicate that these drugs have an effect on the pathophysiology of pe other than their known antihypertensive action. pre-eclampsia (pe) is a placental disease of unknown etiology. anti-angiogenic factors, such as soluble fms-like tyrosine kinase (sflt- ) and soluble endoglin (seng), and pro-angiogenic factors, such as vascular endothelial growth factor (vegf) and placental growth factor (plgf), are believed to play an important role in its pathophysiology. maternal plasma concentrations of these markers are altered in pe, even weeks before the clinical manifestations. the aim of this study was to compare the concentration of these markers in placental extracts of normotensive pregnant women, and women with pe and non-proteinuric hypertension (ht). patients and methods placental samples were collected at cesarean section from women with pe (n = ), ht (n = ) and normotensive pregnancies of similar gestational age (n = ). these samples were stored at - ºc. the frozen tissue samples were homogenised and these four markers measured by specific, validated enzymelinked immunosorbent assays. analysis the three study groups were compared using anova multiple comparisons with bonferroni post hoc testing. the data were normally distributed after logarithmic transformation. data were analysed using spss®. the concentrations of both sflt- and seng were significantly higher in the placentas of women with pe, but not ht, compared with controls (p= . ). there was no significant difference in plgf concentration between controls and women with pe or ht. placental vegf concentrations in both pe and ht were higher than in controls (p< . ); there was no significant difference between the levels in pe and ht (p= . ). the fact that placental concentrations of sflt- and seng mirrored the known rise in serum levels in pe suggests that the placenta is the main source of these circulating factors. although sflt- was significantly raised in pe, plgf was not reduced. this suggests that the lower levels of free plgf found in the serum of women with pe are not the result of impaired placental production or secretion, but are due to increased binding by (the increased levels of) sflt- in the serum. objective. the purpose of this study was to evaluate whether systematic screening with uterine artery doppler (utad) and serum biochemical markers of oxidative stress, endothelial dysfunction and vasculogenesis performed during the first trimester predict efficiently pre-eclampsia (pet), specifically early-onset pet, in an unselected chilean population. methods. this nested case-control study involved asymptomatic pregnancies scanned at + - + week of gestation. the subjects for biochemical testing were women who were delivered due to pet (n= ) and normotensive controls (n= ) that were enrolled during the first trimester scan. mean pulsatility index (pi) of the utad was calculated. blood samples were obtained and stored at - o c until biochemical analysis of oxidative stress, endothelial dysfunction and vasculogenesis were performed. normally distributed data were analysed by the unpaired t test, and non-normally distributed data by the mann-whitney rank sum test. chi-square tests were used for the comparison of categorical variables. a probability level of p< . was considered significant. multiple logistic regressions were used to develop a combined predictive index. results. there was % and % significantly increased of the mean pi utad in women who later developed pet or early-onset pet compared to control pregnancies during the first trimester scan. although oxidative stress and endothelial dysfunction biochemical markers were not different between all pet pregnancies and control groups, plasma levels of sflt ( . ± . vs. . ± . pg/ml, p< . ) and placenta growth factor ( . ± . vs. . ± . pg/ml, p< . ) were significantly higher in women who subsequently developed early-onset pet compared to controls. multivariate logistic regression showed that a combination between abnormal utad and both biochemical markers of abnormal vasculogenesis were the best predictor test for early-onset pet, being its detection rate % with % false positive rate. conclusion. this study has shown early and selective changes in markers of impaired placentation and angiogenic state in women who later developed earlyonset pet, without alteration in oxidative stress and endothelial dysfunction. supported by fondecyt . currently it is unknown whether maternal inflammatory changes are specific to pregnancy or reflect an innate susceptibility to inflammation. c-reactive protein (crp) and interleukin- (il- ) are markers of the acute-phase inflammatory response and predictive of future cardiovascular events. we compared crp and il- levels after influenza vaccination, as an in vivo model for lowgrade inflammation, in non-pregnant women with a history of early-onset preeclampsia and controls with only uneventful pregnancies. methods: forty-four women with a history of early-onset preeclampsia (delivery < weeks' gestation) and twenty-nine controls with at least one uneventful pregnancy received an influenza vaccination. we then compared plasma levels of crp and il- at baseline, . days and . days after vaccination. results: median baseline crp and il- levels of women with a history of early-onset preeclampsia were comparable to controls ( . versus . mg/l; p= . and . versus . pg/l; p= . , respectively). however, high crp and il- responses to vaccination were more common in cases (ors for response > th, > th, > th, > th and > th percentile based on the distribution of control values of . , . , . , . and for crp [p for trend . ] and of . , . , . , . and . for il- [p for trend . ], respectively). the relationship between high il- responses and early-onset preeclampsia persisted after adjustment for body-mass index (p for trend . ). conclusion: women with a history of early-onset preeclampsia more frequently exhibit an innate pro-inflammatory phenotype not specific to pregnancy. background altered maternal inflammatory responses play a role in the development of preeclampsia and the hemolysis, elevated liver enzymes and low platelets (hellp) syndrome. we examined whether allelic variants of the innate immune receptors toll-like receptor (tlr ) and nucleotide-binding oligomerization domain (nod ), that impair the inflammatory response to endotoxin, are related to preeclampsia and hellp syndrome. we determined five common mutations in tlr (d g and t i) and nod (r w, g r and l fs) in primiparous women with a history of early-onset preeclampsia, of whom women developed hellp syndrome and in women with a history of only uneventful pregnancies as controls. in addition, we assessed plasma levels of pro-inflammatory biomarkers c-rp, il- , sicam- , fibrinogen and von willebrand factor in a subset of women included at least six months after delivery. after adjustment for maternal age and chronic hypertension, attenuating allelic variants of tlr were more common in women with a history of early-onset preeclampsia than in controls (or . [ % ci . - . ]). highest frequencies for tlr variants were observed in women who developed hellp syndrome (adjusted or . [ % ci . - . ]). in addition, high levels of il- and fibrinogen were associated with a history of early-onset preeclampsia. combined positivity for any of the tlr and nod allelic variants and high levels of il- was . -fold more common in women with a history of early-onset preeclampsia ( % ci . - . ) compared to controls. we observed an association of common tlr and nod gene variants, and pro-inflammatory phenotype with a history of early-onset preeclampsia and hellp syndrome, that suggests involvement of the maternal innate immune system in severe hypertensive disorders of pregnancy. thus, we sought changes in pbef in the serum of patients with mild and severe pe, compared with matched controls. immunodistribution of pbef in fetal membranes and placentas from similar patients was also studied. methods: serum samples ( ) were collected with clinical data including; gestational age, medications, ethnicity and recognized complications. patients in labor or infection were excluded. the standard bp and proteinuria criteria was utilized to classify cases for pe grouping; no pe (n= ), mild pe (n= bp; / - / , proteinuria; trace to + or - mg/ hr urine) and severe pe (n= bp; > / , proteinuria; > + or > g/ hr, or other associated symptoms). pbef concentration was determined by eia (phoenix pharmaceuticals) in accordance with the manufacturers instructions. fetal membranes and placentas of additional patients, no pe (n= ) and with pe (n= ) were fixed and embedded in paraffin. sections ( um) were immunostained with pbef antibody / (pheonix) and treated with abc reagent (vector labs) followed by dab ( . % mg/ml), washed, counterstained, mounted and viewed under brightfield microscopy. results: the concentrations of pbef in serum were between - ng/ml and were significantly higher in those patients with mild pe (p= . ) and further significantly elevated in those with severe pe (p= . ) compared with the matched controls. pbef was detected by immunocytochemistry in the placental syncytiotrophoblast and in the amnion and choriodecidua of the fetal membranes. conclusions: pbef was elevated in the serum of patients according to the degree of pe severity and may be derived from the placenta and/or fetal membranes. (supported by nih #u rr - to the pacific research center for early human development, university of hawaii). background: platelet-monocyte aggregation (pma) is a novel sensitive measure of platelet activation and indicates a proinflammatory state (cytokine release). less sensitive techniques demonstrate platelet activation during pregnancy and pre-eclampsia (pe) but platelet activation has not been assessed by pma.objective: longitudinal study of pma in normal pregnancy and pe. methods: healthy, non-smoking primigravida with an uncomplicated pregnancy and primigravida women with pe were studied. pe was defined by standard definitions. informed consent was obtained and the study had ethical approval. serial venous blood collected at , , , wks in controls, at time of diagnosis in pe cases and wks post-natal (pn) in all. pma, platelet surface p-selectin (psp-sel) and monocyte cd expression (mcd ) were analysed by flow-cytometry and plasma (p) p-sel by elisa. results: groups were matched for mean age and bmi. in controls, pmas, psp-sel and mcd expression and pp-sel increased with gestation and decreased post-natally (table ) . for pe analysis, data was divided into pre-term (sampled at mean wks), and term (mean wks). pp-sel was lower in pre-term pe than control (normal pregnancy wks; p= . ) there was no significant difference in other measures between pe and control ( objective: much effort has been put into the evaluation of novel markers to identify pregnant women at risk for the development of pre-eclampsia. soluble endoglin (seng) and soluble fms-like tyrosine kinase (sflt ), two antiangiogenic agents, appear to be involved in the pathogenesis of pre-eclampsia. despite several studies describing higher midtrimester serum concentrations of these markers in women with subsequent pre-eclampsia, information on first trimester serum levels is scarce. the aim of this study was to assess seng and sflt as first trimester serum markers for the prediction of pre-eclampsia. methods: sera were obtained between + and + weeks of gestation from women who later developed late-onset pre-eclampsia and from controls matched for gestational age, maternal age, maternal pre-pregnancy weight, and storage. using commercially available microplate enzyme immunoanalytical methods, seng and sflt were determined and the results analyzed using non-parametric statistical tests. results: the serum concentration of seng was found to be increased in women with subsequent pre-eclampsia when compared to controls (mean ± sd, . ± . ng/ml versus . ± . ng/ml, p = . , unpaired mann-whitney test). similarly, the serum levels of sflt were higher in women later developing late-onset pre-eclampsia ( ± ng/ml) when compared to controls ( ± ng/ml, p = . ). sensitivities and specificities for predicting pre-eclampsia were % and % for seng and % and % for sflt- , respectively. the combination of the two markers by multiplication yielded a sensitivity of % and a specificity of %. conclusion: seng and sflt , showing increased first trimester serum levels in women with subsequent pre-eclampsia, might both fulfill the characteristics of first trimester markers to predict pre-eclampsia. the combination of the two, however, did not improve the sensitivity nor the specificity compared to their individual determinations. moderate sensitivities and specifities, however, limit the clinical use of these molecules as single markers. pregnancy is associated with increased monocyte/platelet aggregate formation in whole blood. beth a bouchard, adrienne schonberg, gary j badger, ira m bernstein. biochemistry; obstetrics and gynecology; medical biostatistics, univ of vt, burlington, vt, usa. background preeclampsia is associated with increased rates of platelet clearance, changes in platelet function and platelet activation. the goal of the current study was to examine basal levels of platelet activation through pregnancy beginning prior to conception, and to examine the association of platelet activation with the development of hypertensive complications during pregnancy. methods two indices of platelet activation, platelet cd expression (%cd ) and monocyte/platelet aggregate (%mp) formation, were measured in whole blood by flow cytometry using specific, fluorescentlylabeled monoclonal antibodies in healthy, nonsmoking women during the follicular phase of their menstrual cycle (pp, cycle day . + . ). all women subsequently conceived singleton pregnancies and were re-examined in early (ep, - wks) and late pregnancy (lp, - wks). five of these women were diagnosed with hypertensive complications ( hypertension, preeclampsia) at term although hypertension was not observed at any study time point. data are expressed as mean±sem. p< . was accepted for significance. results subjects were . + . years old with a bmi of . + . kg/m at the time of prepregnancy studies. a significant increase in the %mp formed over time of pregnancy was observed (p= . ). there was little change in the %mp formed between pp and ep (pp, . ± . % and ep, . ± . %, p= . ). however, the %mp increased significantly in lp ( . ± . %) as compared to pp (p= . ) and ep (p= . ). this increase occurred independent of the development of hypertensive complications (p= . ) and independent of pp platelet activation status. although statistically significant increases in cd expression were not observed, the change in cd expression over pregnancy correlated with the change in %mp over pregnancy (r= . , p= . ) and cd expression correlated with %mp in lp (r= . , p= . ). conclusion these combined observations suggest that pregnancy is associated with increases in levels of unstimulated platelet activation and that these increases occur in the presence or absence of subsequent hypertensive complications. furthermore, we observed a correlation between the changes in two distinct platelet activation events, %mp and cd expression, during pregnancy. supported by nih hl . backgound sildenafil citrate (sc) has been proposed as a therapy to improve uterine perfusion in pregnancies complicated by iugr or preeclampsia. we sought to determine the effects of sc on uterine vascular resistance, uterine blood flow and cardiac output in young healthy nulliparous women. methods eleven young healthy nulligravid women were studied during the luteal phase (cycle day + ) of the menstrual cycle. women were randomized in a double-blind fashion to receive placebo (pl), or sc at a dose of or mg. uterine artery vascular resistance, uterine artery volumetric flow, brachial artery volumetric flow and cardiac output were measured at baseline and at and hours post dosing employing color doppler ultrasound. comparisons were made by anova between those randomized to pl (n= ) versus sc (n= ). p< . was accepted for significance. data are expressed as mean + s.e.m. results there were no significant differences in subject age, cycle day, body mass index, uterine blood flow, brachial blood flow or cardiac output at baseline comparing the two groups. there was a tendency towards increased uterine blood flow in subjects randomized to receive sc ( % increase) compared to pl (no change), changes in uterine blood flow, brachial blood flow and cardiac output are outlined in the objective reduced maternal plasma volume in the third trimester has been associated with both fetal growth restriction and preeclampisa. we sought to determine the degree to which third trimester plasma volume is dependent on plasma volume prior to pregnancy. methods sixteen young ( . + . years) healthy nulligravid women had their plasma volume measured during the follicular phase (cycle day . + . ) of the menstrual cycle and subsequently conceived. subjects were predominantly caucasian ( / ) with a mean prepregnancy bmi of . + . kg/m . plasma volume was re-estimated at - weeks gestation. all patients were placed on sodium and total calorie balanced diets for days prior to each plasma volume determination. plasma volume was determined employing evans blue dilution with multiple post injection sampling time points. data are expressed as mean + s.d. results baseline prepregnant plasma volume was , + ml or + ml/unit bmi. third trimester plasma volume was , + ml representing a % increase (p< . ). the range of plasma volume expansion was - % dependent upon prepregnant plasma volume. plasma volume in the third trimester of pregnancy was strongly correlated to prepregnant plasma volume r= . (p= . ). plasma volume expansion was consistent across the range of prepregnancy plasma volume. conclusions pre-pregnancy plasma volume contributes approximately % of the variance in third trimester plasma volume. the observed increase is plasma volume is independent of prepregnancy volume resulting in a greater percentage increase for those starting at the lower end of the plasma volume range. as third trimester plasma volume is strongly associated with pregnancy outcome the correlation of prepregnancy plasma volume to third trimester plasma volume suggests that prepregnancy status contributes to these adverse reproductive events.this work was supported by nih hl . background: hydatidiform mole is a rare disorder of pregnancy and may predispose the mother to severe morbidity. molar pregnancies are known to be associated with high risk for the development of early onset preeclampsia. in recent years, the expression of sflt- (soluble vegfr- ) was found to be increased in preeclampsia, and contributes to the pathogenesis of the maternal systemic disease. the objective of the present study was to examine the expression of sflt- in placentae from molar pregnancies. methods: placental samples from unique cases of twin pregnancies with complete molar pregnancy in one sac and developing fetus in the other sac were prospectively collected (n= ). the first set delivered at weeks due to excessive bleeding. the second set delivered at weeks due to severe iugr and elevated blood pressure. mrna level of sflt- was measured by quantitative real-time pcr using specific taqman primers and probe. protein expression of sflt- in placental tissue lysates were measured by western blot analysis using a polyclonal antibody against flt- . immunohistochemistry of paraffin embedded samples was performed using specific antibody for sftl- . results: mrna level of sflt- was increased by . fold in the molar placentae compared to matched controls. the placentae of the developing fetuses which were growth restricted exhibited . fold increase compared to controls. sflt- protein expression in the molar placentae was increased by . fold compared to controls, while the co-twin placentae exhibited a . fold increase compared to controls. immunohistochemistry revealed strong positive immunoreactivity for sflt- in the trophoblast layer of both molar pregnancies and iugr co-twin relative to controls. conclusion: our data suggest that sflt- expression is increased in placentae from molar pregnancies and thus may explain the increased risk for developing early onset preeclampsia. the expression of sflt- in the growth restricted twin placenta is also increased compared to controls and support our previous observation (supported by cihr and owh/igh). (n= ); ) neonates of patients with pe (n= ); and ) sga neonates (n= ). cord blood was collected immediately after delivery and pz plasma concentrations were measured by elisa. pz deficiency was defined as a cord plasma concentration < th percentile of the normal pregnancy group. non-parametric statistics were used for analysis. results: ) cord plasma pz concentration differed significantly among the study groups (kruskal wallis, p< . ); ) neonates of patients with pe and sga neonates had a significantly lower median cord plasma pz concentration than those delivered after normal pregnancy (pe: median . g/ml, range . - . , p< . ; sga: median . g/ml, range . - . , p= . ; normal pregnancy: median . g/ml, range . - . ); ) there were no differences in the rate of pz deficiency among the groups; and ) there was no relationship between placental histologic findings and median cord plasma pz concentrations between and among the sga and pe groups. conclusions: ) at the time of delivery, the median cord plasma pz concentration was lower in sga neonates and those born to women with pe than in neonates born to normal pregnancies; ) there was no difference in the rate of pz deficiency among the study groups, suggesting that the lower median pz cord blood concentrations in pe and sga groups may result from activation of the coagulation cascade rather than an inherited pz deficiency. objective: periconceptional multivitamin (mv) use may be related preeclampsia risk. we examined the relation between timing and frequency of periconceptional multivitamin use and the risk of preeclampsia. methods: women in the danish national birth cohort who delivered singleton liveborn infants (n= , ) reported upon enrollment at . weeks (sd . ) the number of weeks of regular multivitamin use during a week periconceptional period (lmp- to lmp+ ). preeclampsia cases were identified using icd- codes (n= , . %). logistic regression was used to estimate the effect of frequency (number of weeks of use) and timing of use to lmp+ ] and post-conception [lmp+ to lmp+ ]). results were stratified a priori by overweight status. results: overall, , women ( %) reported mv use in the periconceptional period. after adjustment for bmi, smoking, parity and chronic hypertension, infrequent mv use (< weeks of use) had no relation to risk (or . ; % ci . , . ) but regular use (>= weeks) was associated with modestly reduced risk ( . ( . , . ). similarly, when mv use was modeled as a continuous variable, each additional week of use was related to reduced risk for preeclampsia (or . , % ci . - . ). this potential dose effect of periconceptional mv use appeared to be limited to normal weight women (bmi < kg/m², or . ; % ci . - . ), with no apparent effect among overweight women (bmi kg/m², or . ; % ci . - . ). a total of , women reported regular mv use in both the preconception and post-conception periods, and , women reported regular use only in the post-conception period. among normal weight women, regular use in the preconception period had no effect on preeclampsia risk (or . , % ci . - . ). in contrast, use in the post conception period was associated with reduced risk for preeclampsia (or . , % ci . - . ). conclusions: regular periconceptional mv use was associated with a modestly reduced risk for preeclampsia among normal weight women. if causal, mv use immediately after conception appeared to be the critical exposure window. background: pre-eclampsia (pe), a disorder of pregnancy characterized by maternal inflammation, results in immune, cardiovascular and metabolic dysfunction. in non-pregnant persons, inflammatory disorders are treated with and prevented by pharmaceuticals and lifestyle methods such as physical activity (pa). while most pharmaceuticals are contraindicated for pregnant women, pa during pregnancy has been found safe, healthy and beneficial for both mother and baby. clinical evidence has found pa can beneficially affect pregnancy outcome, decrease excessive inflammation and decrease the risk of pe. epidemiological studies indicate that pa may be useful in preventing pe. unfortunately, previous studies have quantified pa based on recall of postpartum women and have not controlled for differences in women's interpretations of amount, type or intensity of pa. however, investigating pa utilizing a laboratory-based exercise intervention to control these variables inflicts difficulties translating the intervention into a community-based program that attracts and retains pregnant women in order to enhance public health. method: a retrospective study was performed to determine the rates of pe among the , women who gave birth at yale-new haven hospital (ynhh) during and , and a person subset of this group who performed prenatal pa in a community-based program that is evidence-based and standardized, thereby controlling for type and intensity of pa. additionally, the program is established in the community, has been offered to the public for years and is internationally known. results: during during - , the pe rate for the general population at ynhh was . %. for the pa group, the rate was . %. two women in the pa group were diagnosed with pe in the last month of pregnancy and delivered normal infants at term. no pe was observed in this group (pa group) during the second or early third trimesters nor was there any prematurity in this group. significance: these findings support the hypothesis that adequate physical activity provided in a standardized community-based group setting may provide a non-pharmacological approach for preventing pe. growth restriction. margreet plaisier, esther streefland, pieter koolwijk, frans m helmerhorst, jan jaap hm erwich. department of gynecology and reproductive medicine, leiden university medical center, leiden, netherlands; department of obstetrics and gynecology, university medical center groningen, groningen, netherlands; department of physiology, vu univerity medical center, amsterdam, netherlands. objective: disturbances in decidual and placental vascular development may play a role in the pathogenesis of pregnancy complications, like pre-eclampsia (pe) or fetal growth restriction (fgr). whether the regulation of decidual vascular adaptation to implantation is altered in these illnesses, is not elucidated yet. the present study focused on the role of first-trimester angiogenic factors in the pathogenesis of pe and or fgr. methods: first-trimester decidua samples were obtained during routine chorionic villous sampling. the expression of vascular endothelial growth factor (vegf-a), placental growth factor (plgf), flt- , kdr, angiopoietin- (ang- ), angiopoietin- (ang- ) and tie- mrna was determined by rt-pcr. the expression of the angiogenic factors was related to the pregnancy outcome, i.e. uncomplicated, pe or fgr. results: the first-trimester decidual tissues expressed all angiogenic factors. mrna levels of vegf-a, plgf, kdr, ang- , ang- and tie- appeared increased in fgr cases compared to matched controls. in addition, plgf, ang- and tie- mrna appeared increased in pe cases compared to matched controls. the differential expression of angiogenic factors was more pronounced in cases with fgr than pe. the large inter-individual variation disallowed a significant outcome. conclusions: various angiogenic factors showed differential mrna expression in st trimester decidua of patients developing pe or fgr in later pregnancy compared to their matched controls. the first-trimester decidual samples provided a unique opportunity to obtain information regarding the onset of pe and fgr. early st trimester changes in angiogenic factor expression may well occur as a compensatory mechanism. in turn, this may set the stage for increased non-branching angiogenesis and altered decidual and placental vascular adaptation, which may be part of the pathogenesis of pe and/or fgr. complications. beth a bouchard, adrienne schonberg, gary j badger, ira m bernstein. biochemistry; obstetrics and gynecology; medical biostatistics, univ of vt, burlington, vt, usa. background preeclampsia is characterized by endothelial dysfunction. the goal of the current study was to prospectively measure plasma levels of the soluble endothelial cell adhesion molecules, sicam- and svcam- , beginning prior to pregnancy and determine if subjects destined to develop hypertension complicating pregnancy had differences in the concentrations of these molecules. methods serum levels of sicam- and svcam- were measured in healthy, nonsmoking women (cycle day . + . , prepregnancy) by elisa. all women subsequently conceived singleton pregnancies and were re-examined in early (ep, - weeks) and late pregnancy (lp, - weeks). five of these women developed hypertensive complications ( gestational hypertension, pre-eclampsia) near term. all subjects were normotensive at all study time points. data are expressed as mean ± sem. p< . was accepted as significant. results subjects were . + . years old with a mean bmi of . + . kg/m at the time of prepregnancy studies. significant differences in sicam- levels as a function of pregnancy were observed (p= . ) and are outlined in table p= . differences were dependent upon the stage of pregnancy in those women who were not diagnosed with hypertensive complications with a decrease in sicam- levels in ep (p= . ) followed by an increase in sicam- levels in lp (p= . ). in women with hypertension in pregnancy, these differences in sicam- levels were not evident (p= . ). there were no differences in sicam- levels comparing women with or women without hypertensive complications prior to pregnancy (p= . ). in contrast to sicam- , we observed no significant differences in svcam- levels over pregnancy or between those with and without hypertension. conclusions these combined observations suggest that levels of the soluble adhesion molecule sicam- change significantly over time in normal pregnancies. subjects destined to develop hypertension did not demonstrate the early pregnancy reduction in sicam- . supported by nih hl . yuval bdolah, uriel elchalal, shira natanson-yaron, hadas caspi, tali bdolah-abram, angelika bord, caryn greenfield, debra goldman-wohl, ariel milwidsky, franklin h epstein, s ananth karumanchi, simcha yagel, drorith hochner-celnikier. ob/ gyn, jerusalem, israel; ob/gyn medicine, beth israel deaconess medical center, harvard medical school, boston, ma, usa. objectives: nulliparity is a risk factor for preeclampsia (pe) with a reported incidence of up to - times higher than multiparous pregnancies. soluble fms-like tyrosine kinase- (sflt ), a circulating anti-angiogenic molecule of placental origin plays a pivotal role in pe by antagonizing placental growth factor (plgf). increased sflt and sflt /plgf have been shown to antedate clinical signs in pe. we therefore hypothesized, that the higher risk of pe in nulliparous pregnancies is associated with high sflt (or sflt /plgf). methods: maternal serum samples from nulliparous (n= ) and multiparous (n= ) term singleton pregnancies without pe, at the time of admission to delivery room, were used. serum samples were analyzed for levels of sflt and plgf by elisa. statistical analysis was performed applying t-test and the kruskall-wallis test and using spss software. results: for nulliparous and multiparous pregnancies, the mean serum sflt levels were , ± and , ± , (p= . ), the mean serum plgf levels were ± and ± (p= . ), and the mean ratios of sflt- /plgf were ± and ± (p= . ), accordingly. in a subgroup of multigravidous nulliparous pregnancies, sflt levels were , ± . correcting for maternal age did not alter the results. moreover, results did not differ between multiparous pregnancies with a - years interpregnancy interval compared with a - years interval. conclusions: in nulliparous pregnancies, circulating sflt levels and sflt / plgf ratios are significantly higher than in multiparous pregnancies. these findings suggest that the increased risk of pe in nulliparous pregnancies may involve anti-angiogenic imbalance. nulliparity may be more substantial than primigravity, as a risk factor for pe, suggesting that first semester abortions in primigravidas may not protect from pe in a subsequent term pregnancy. nevertheless, even - years intervals from the previous gestation do not increase the risk for pe. different normograms of angiogenesis should be used, when assessing the risk for pe in multiparous versus nulliparous pregnancies. objective: we determined whether maternal serum levels of angiogenic proteins namely soluble fms like tyrosine kinase (sflt- ), soluble endoglin (seng), and placental growth factor (plgf) -measured during the first trimester are associated with the subsequent development of placental abruption. methods: we performed a prospective, nested case-control study of women enrolled in the massachusetts general hospital obstetric maternal study (moms). first trimester serum samples from placental abruption cases and normal pregnancies were measured for angiogenic factors. cases and controls were matched by body mass index and age. placenta abruption was diagnosed by standard clinical findings and pathological examination of the placenta. women with confirmed preeclampsia or chronic hypertension were excluded. results: compared to controls, cases had more pregnancies, delivered infants at an earlier gestational age and with lower birth weight. first trimester levels of seng were significantly increased in cases compared to controls: . ± . ng/ml vs. . ± . ng/ml, p < . . there were no significant difference in serum levels of plgf, . ± . ng/ml versus . ± . ng/ml, p=ns, although sflt levels were lower in cases: . ± . ng/ml vs. . ± . ng/ml, p=ns. in logistic regression analysis adjusted for age, race, smoking, number of pregnancies, gestational age at delivery, gestational age of blood sampling, and blood pressure at first prenatal, seng levels remained independently associated with subsequent risk (odds ratio . , % ci . - . ) of placental abruption. examining this relationship by tertiles of seng, in the unadjusted model, women in the second (or . , % ci . - . ) and third (or . , % ci . - . ) tertiles were at increased risk of developing placental abruption compared with women in the lowest tertile. after adjusting for known risk factors of placental abruption, women in the second (or . , % ci . - . ) and third (or . , % ci . . ) tertiles remained at increased risk for placental abruption. conclusion: increased first trimester maternal serum levels of seng are associated with increased risk of subsequent placental abruption. ob/gyn, univ of vermont. shear stress is the most potent physiologic stimulus for elevating endothelial no production for flow-mediated vasodilatation. we measured in vivo shear stress during the proliferative and secretory phases and at and weeks of gestation hypothesizing that uterine blood flow (ubf) elevations in turn increase shear stress in early and late gestation. methods: during proliferative, secretory phases, and at and - weeks of pregnancy ua blood velocity and internal radius were measured bilaterally using color doppler ultrasound. blood viscosity was measured at shear rates in excess of /sec. results: compared to the proliferative phase viscosity was decreased at weeks and more so at weeks gestation (p< . ). . ± . . ± . nsd . ± . *** . ± . *** ua velocity (cm/sec) . ± . . ± . *** . ± . *** . ± . *** ubf (ml/min) . ± . ± *** . ± . *** . ± . *** shear stress (dynes/cm ) . ± . . ± . *** . ± . *** . ± . *** internal ua radius was not altered by the menstrual cycle, and was greater at weeks (+ %) and weeks (+ %). compared to proliferative, secretory phase showed significant rises in unilateral ubf and velocity that rose progressively during gestation. in contrast, shear stress increased in secretory ( %) and did not rise further in early pregnancy but by weeks shear stresses was further elevated %. conclusions: equivalent rises in shear stress during the secretory phase and weeks gestation demonstrate increases in radius and profound remodeling of uas that reflect the physiologic process of "normalization of shear". by late gestation, continued but modest rises in radius illustrate that further increases in shear stress occur almost solely due to rises in ubf via falls in down stream impedance. continued rises in shear stress into late gestation provide progressive stimuli for no production by ua endothelium. nih hl , hd , hl background: hypertension during pregnancy is associated with altered uterine vascular reactivity and blood flow, although its effects on arterial myogenic behavior have not been explored. the purpose of this study was to evaluate the effects of hypertension and no inhibition on myogenic tone in pregnancy, as the ability of a vessel to constrict and dilate in response to pressure plays a key role in regulating blood flow to the uterus. methods: three groups of sprague dawley late pregnant (day ) rats were used: control (n= ), hypertensive ( . g/l l-name in the drinking water, n= ), and treated with l-name and hydralazine (also in the drinking water, . g/l, n= ) to prevent the blood pressure increase, yet maintain no inhibition. resistance-sized radial arteries (< m) were mounted in a pressure arteriograph and equilibrated at mmhg (in pss containing l-nna and indomethacin) to induce a myogenic response. vessels were then subjected to pressure steps from to mmhg. tone (%) was calculated by comparing the vessel diameter at each pressure with the passive diameter at the same pressure (determined by incubation with . mm papaverine and m diltiazem). results: myogenic tone developed in controls ( ± % maximal), and was maintained over a broad range of transmural pressures . arteries from the l-name group did not develop tone at any pressure. co-treatment with hydralazine reinstated tone ( ± % maximal) over the same range of pressures as in the control group. the reduction in average placental weights in the l-name group ( vs. mg, p< . ) was restored by hydralazine ( mg, p< . vs. l-name). average fetal weights were also reduced in the l-name group ( . vs. . g, p< . ), but only partially restored by hydralazine co-treatment ( . g, p< . vs. control and l-name groups). conclusions: surprisingly, radial uterine arteries from the l-name group did not develop tone over any range of pressures, despite the fact that matched arteries from late-pregnant controls developed significant myogenic tone. this abolishment of tone was reversed by hydralazine, which also had beneficial effects on fetal and placental growth. these results implicate hypertension rather than no inhibition as the key factor in the suppression of myogenicitiy and dysregulation of uterine blood flow. charles r rosenfeld, timothy roy. division of neonatal-perinatal medicine, ut southwestern medical center at dallas, dallas, tx, usa. background: upbf b rises -fold in ovine pregnancy; but the mechanisms responsible for the rise and maintenance are unclear. we (jsgi ) reported that uterine vascular smooth muscle bk ca k + channels contribute to uterine vasodilation and upbf b maintenance; but up-stream activators are unclear. uterine vascular prostacyclin synthesis increases in pregnancy, but cyclooxygenase inhibition does not alter upbf b (ajp ) . vascular nitric oxide synthase (nos) also increases; but acute inhibition with l-name decreases upbf b only % (jci ) . it is unclear if l-name doses were insufficient or if prolonged nos inhibition has a greater effect. objective: to determine if local nos inhibition with l-name dose-dependently decreases upbf b and if prolonged inhibition exerts a greater effect on upbf b . methods: pregnant ewes were studied at - d gestation age (ga). had doseresponse studies with uterine artery l-name infusions to achieve . - . mg/ml over min. had h arterial l-name infusions to achieve and maintain levels of . mg/ml at (n= ), (n= ) and d (n= ) ga, while measuring arterial pressure (map), heart rate (hr) and upbf b before, during ( , , , , , , and h) and after ( , h) infusions. uterine arterial and venous cgmp were measured. data were analyzed by anova. results: acute nos inhibition decreased upbf b - %, but was not doserelated. h arterial l-name infusions decreased upbf b by - h at each ga (p . , anova) and values returned to baseline by h postinfusion. sensitivity did not differ between ga (p= . , anova), upbf b falling - % at each ga. contralateral upbf b was unaffected at all ga. map rose and hr fell during infusions at and d ga, p . ; but were unaffected at d ga. venous-arterial cgmp concentration differences were seen at d and absent at h of l-name infusion, p= . . conclusions: uterine vascular nos increases in ovine pregnancy, but its inhibition decreases upbf b %, suggesting study doses were insufficient to fully inhibit vascular nos activity. alternatively, nos contributes to the maintenance of upbf b , but other mediators, not yet identified, are more important in activating bk ca and regulating upbf b . notably, l-name reached the systemic circulation, and although further diluted, map rose - %, suggesting the systemic vasculature may be more sensitive to nos inhibition than upbf b . charles r rosenfeld, xiao-tie liu. division of neonatal-perinatal medicine, university of texas southwestern medical school, dallas, tx, usa. background: uteroplacental blood flow (upbf) rises -fold in ovine pregnancy, reflecting increases during pre-implantation, placentation and finally, in the last third of gestation. we reported that bk ca density in uterine vascular smooth muscle (uvsm) increases in ovine pregnancy (sgi ) and inhibition with tetraethylammonium ( . mm) dose-dependently decreases basal upbf % in the last third of pregnancy (jsgi ) . it is unclear how bk ca subunit expression changes and activity is regulated in pregnancy; since uterine vascular nitric oxide is increased, signaling via cgmp-dependent protein kinase g (pkg) is one potential pathway. objective: to determine simultaneous changes in uvsm bk ca density and regulatory -subunit expression and the cgmp signaling pathway for activation in ovine pregnancy. methods: endothelium-denuded segments of nd generation uterine arteries obtained from nonpregnant (n= ), pregnant (n= , - d gestation; term d) and postpartum (n= , - d) sheep were used to measure expression of bk ca -and regulatory -subunits and signaling proteins in uvsm by immunoblot analysis and immunohistochemistry. results: uvsm bk ca density, reflected as a change in the kda -subunit, rose % with placentation (p< . ) and was unchanged thereafter. expression of the kda regulatory -subunit paralleled the rise in bk ca density during placentation, increasing % (p< . ), but increased another -fold and exponentially in the last third of pregnancy (p< . , r = . , n= ). changes in subunit immunostaining in uvsm paralleled increases in protein. although uvsm soluble guanylyl cyclase was unchanged in pregnancy (p= . , r= . , n= ), pkg expression rose -fold (p= . , r= . , n= ) and gradually returned to nonpregnant levels by d postpartum (p= . , r= . , n= ). uvsm cgmp is being measured. conclusions: these are the st data suggesting that increases in ovine upbf during placentation involve vascular growth and bk camediated vasodilation. the rise in upbf in the last third of pregnancy reflects bk ca -mediated vasodilation due to enhanced channel activation via increases in uvsm pkg, bk ca phosphorylation and changes in subunit stoichiometry due to an exponential rise in the regulatory -subunit. it is unclear what initiates and directs these changes in bk ca expression and sensitivity. relaxin (rlx) is a hormone traditionally associated with changes in the female reproductive tract during pregnacy. recent evidence suggests that rlx may play a pivotal role in regulating cardiovascular function during gestation. analogous to pregnancy, administration of recombinant human relaxin (rhrlx) to nonpregnant female rats reduces systemic vascular resistance, as well as increases global arterial compliance. additionally, we demonstrated that, concurrent with rlx´s influence on overall cardiovascular function, small renal arteries (sra) from rhrlx-treated mice and rats are characterized by reduced passive stiffness and increased arterial wall area whereas external iliac arteries (eia) are not. we hypothesized that rlx regulates arterial passive mechanical properties by altering the cellular and biochemical composition of the arterial wall. nonpregnant female mice were administered rhrlx for days after which sra and eia were isolated. we measured arterial collagen, elastin, and total protein using the sircol collagen assay, the fastin elastin assay, and the pierce bca protein assay, respectively. additionally, we quantified arterial smooth muscle cell (smc) density using immunofluorescent techniques. sra isolated from rhrlx-treated mice were characterized by a significant reduction in collagen to total protein ratio ( . ± . vs . ± . μg collagen/μg protein; mean±sem; p< . ) as well as a significant increase in smc density ( . ± . vs . ± . cells/ μm ; p< . ) compared to control mice with no significant change in elastin content ( ± vs ± μg elastin/mg dry weight). in contrast, there were no significant changes in collagen to total protein ratio ( . ± . vs . ± . μg collagen/μg protein), smc density ( . ± . vs . ± . cells/ μm ) or elastin content ( ± vs ± μg elastin/mg dry weight) in eia from the rhrlx-treated mice compared to control mice. of note, comparable results were observed for rlx knock-out (rlx -/-) and wild-type mice with rlx -/mice exhibiting increased arterial collagen and decreased smc density. we conclude that the rlx-induced decrease in passive stiffness of sra that we previously reported is, at least in part, due to rlx-induced alterations in arterial wall cellular and biochemical composition. further, our findings suggest that these vessel wall remodeling effects of rlx are artery-type specific. relaxin is a peptide hormone that emanates from the corpus luteum of the ovary and circulates during pregnancy. this hormone plays an important role in renal vasodilation and hyperfiltration, two fundamental maternal adaptations in pregnancy. chronic administration of recombinant human relaxin (rhrlx) to both virgin rats and mice inhibits myogenic reactivity and increases compliance of small renal arteries, thus further mimicking pregnancy. we hypothesize that these arterial responses to rhrlx are mediated by the lgr , and not the lgr receptor. both lgr and lgr receptor-deficient, and wild-type virgin mice were investigated. the mice were chronically infused with rhrlx or vehicle (veh) for days. small renal arteries were isolated and mounted in a pressure arteriograph and myogenic reactivity was assessed (% change in diameter over baseline in response to a mmhg step increase in intraluminal pressure). small renal arteries from rhrlx-infused lgr wild-type mice showed inhibited myogenic reactivity with a . ± . % increase in diameter whereas the arteries from rhrlx-infused lgr knock-out mice exhibited robust myogenic reactivity with only a . ± . % change in diameter (p= . ). in contrast, myogenic reactivity of small renal arteries was inhibited in both the rhrlx-infused lgr knock-out and wild-type mice. the veh-treated lgr and lgr mice, regardless of genotype, exhibited robust myogenic reactivity. arterial compliance was also assessed for each genotype/treatment group. rhrlx infusion increased arterial compliance of small renal arteries from lgr wild-type, but not from lgr knock-out mice (p= . ). in contrast, the arteries from rhrlx-infused lgr wild-type and knock-out mice showed increased compliance relative to veh-infused animals. conclusion: relaxin-induced inhibition of myogenic reacitivity and increase in compliance of small renal arteries is mediated by the lgr , and not the lgr receptor. smoking is associated with adverse pregnancy outcomes including fetal growth restriction. pathologic effects of smoking on maternal vasculature is a potential mechanism leading to fetal growth restriction. the objective of this study was to determine whether cigarette smoke exposure during pregnancy affects the functional properties of uterine and peripheral arteries using a gravid murine model. study design: pregnant and virgin c bl/cj mice were exposed to whole body side stream smoke using an inhalational chamber for hours/day. smoke exposure was increased from day of gestation until late pregnancy (day - ) with mean total suspended particle levels of mg/m , representative of moderate to heavy smoking in humans. control animals were exposed to ambient room air. late pregnant and virgin mice were sacrificed and uterine, mesenteric, and renal arteries were isolated and studied in a pressure arteriograph system (n= - in each group). plasma cotinine was measured by elisa. means were compared using t-test or analysis of variance. results: fetal weights were significantly reduced in mice exposed to smoke compared to control fetuses ( . ± . g vs . ± . g, p= . ), while litter sizes were not different. cotinine levels in smoking mice were significantly elevated compared to control mice ( . ± . vs . ± . ng/ml for virgin mice and . ± vs . ± . ng/ml for pregnant mice). there was no significant difference in phenylephrine responses between groups. endothelial mediated relaxation responses to methacholine were significantly impaired in both the uterine and mesenteric vasculature of pregnant mice exposed to cigarette smoke during gestation. no difference in endothelial-mediated relaxation was seen in isolated renal arteries in pregnant mice exposed to cigarette smoke, however relaxation was significantly reduced in renal arteries from smokeexposed virgin mice. conclusions: passive cigarette smoke exposure is associated with impaired vascular relaxation of uterine and mesenteric arteries in a gravid murine model. functional vascular perturbations during pregnancy, specifically reduced uterine blood flow and impaired peripheral vasodilation, may be a mechanism by which smoking results in fetal growth restriction. human chorionic gonadotropin (hcg) is essential during early human gestation for "rescue" of the corpus luteum. however, its potential contribution to the widespread maternal vasodilation of pregnancy that occurs at this stage of pregnancy remains uncertain. our objective was to use the renal circulation of conscious rats as an experimental model in which to test the vasodilatory potential of hcg. in addition, we investigated both myogenic reactivity and relaxation responses in small renal and mesenteric arteries isolated from rats, as well as in small human subcutaneous arteries using a pressure arteriograph. we chronically instrumented rats for measurement of renal function. five were ovariectomized, and sham-ovariectomized. after days of surgical recovery, baseline glomerular filtration (gfr) and effective renal plasma flow (erpf) were measured on two separate days and the values averaged. then, an osmotic minipump containing hcg ( iu/min) was implanted s.c. and renal function was again assessed and days thereafter. gfr and erpf significantly increased and calculated effective renal vascular resistance decreased from baseline in the intact (p< . vs. baseline), but not ovariectomized (p=ns) rats on both days and of hcg administration. in the intact, but not ovariectomized rats, plasma osmolality declined and progesterone increased (both p< . vs baseline). plasma hcg concentrations were , miu/ml and comparable in both groups of rats. incubation of small renal arteries from rats with recombinant human relaxin (rhrlx, - ng/ml), but not hcg ( , - , miu/ml) in vitro inhibited myogenic reactivity and relaxed phenylephrine (pe)-constricted arteries. in contrast, both rhrlx and hcg inhibited myogenic reactivity and relaxed pe-constricted small mesenteric arteries from rats and small human subcutaneously arteries. in conclusion, consistent with our earlier work showing a virtually exclusive role for relaxin in mediating the renal circulatory changes of pregnancy, hcg is likely to play little or no role. in contrast, hcg and relaxin are both likely to contribute to the vasodilation of other organ circulations during pregnancy. pierre-andre scott, , michele brochu, jean st-louis. , research centre, chu ste-justine, montréal, qc, canada; pharmacology, université de montréal, montréal, qc, canada. uterine vasculature undergoes major structural and functional changes during pregnancy. estrogens have been shown to induce increased uterine blood flow in this circulation. we have reported that estradiol ( -e ) induced direct vasorelaxant response on smooth muscle of the uterine arteries that, for it major part, is not mediated through tissue nitric oxide. to investigate the cellular effectors mediating this vasorelaxant effect of -e , we set-up uterine arteries of non-pregnant rats in wire myograph systems for microvessels. -e and -e were equipotent in relaxing phe ( μmol/l)-preconstricted uterine arteries, although the later produced significant smaller relaxations. genistein, a phytoestrogen presumed to inhibit phosphatases, also produced uterine artery relaxation with significant lower potency. to try interfere with the vasorelaxant effect of -e , tissues were preincubated with different substances. cycloheximide (protein biosysthesis inhibitor), ici , (estrogen receptor modulator), and kt (pka inhibitor) did not significantly influenced the response to -e . rp- -pcpt-cgmps (pkg inhibitor) slightly displaced the concentration-relaxation curve to -e to the right. inhibitors of potassium channels, penitrem a (bkca) and glybenclamide (katp), showed opposite effects for -e concentration-response curve; the former producing a right shift and the latter a small not significant left shift. these data indicated that the direct acute effect of -e in uterine artery is the result of complex interactions within smooth muscle cells, involving potassium channels, and protein kinases and phosphatases. the renin-angiotensin-aldosterone system is paradoxically activated during pregnancy, since blood pressure decreased. earlier data showed that the high levels of aldosterone present during pregnancy may be involved in cardiovascular adaptation to pregnancy. in order to delineate this effect of aldosterone on vascular tone, potassium canrenoate, an antagonist of mineralocorticoid receptors (mr), was administered ( mg/kg/day) to pregnant rats from the day to of gestation. rats were sacrificed at day , and of gestation together with untreated and day pregnant rats. the thoracic aorta was quickly removed and set up in tissue baths as ring ( - mm) preparation. as observed previously, canrenoate enhanced responsiveness to phe for all time of treatment tested, but only at day ( days treatment) for kcl responsiveness. aortic contractile responses to tea (tetraethylammonium) gradually decreased during pregnancy to almost disappear at the end of gestation. in the present results, canrenoate treatment made the response statistically different by day of pregnancy. finally, the activity of na/k-atpase was measured by the relaxant effect of kcl added to physiological solution without potassium. the activity of the pump was decreased when approaching parturition compare to day of pregnancy. canrenoate treatment abolished this effect. the present data show that vascular changes that occurred during pregnancy are markedly modified by treatment of rats with an antagonist of mineralocorticoid receptors, suggesting that aldosterone may be involved in vascular adaptation to pregnancy. background impaired endothelium-dependent vasodilatation has previously been demonstrated in small myometrial arteries from women with gestational diabetes. this impairment may play a role in mediating the complications observed in diabetic pregnancies. it is not known which mechanisms of endothelium-dependent vasodilatation are affected in myometrial arteries by gestational diabetes. aim to investigate mechanisms of endothelium-dependent vasodilatation in uterine arteries using a mouse model of pregnancy complicated by diabetes. methods diabetes was induced in female c bl /j mice (streptozotocin; mg/kg) prior to mating. mice were culled at day of pregnancy (term) and uterine arteries dissected, mounted on a wire myograph, normalised to mmhg and equilibrated ( °c; %co /air). arteries were constricted with phenylephrine ( m) and a concentration-response curve to the endotheliumdependent vasodilator acetylcholine (ach; . nm- m) constructed in the presence and absence of a nitric oxide synthase inhibitor (l-nna; m), a cyclooxygenase inhibitor (indomethacin; m) or a combination of the two to determine the contribution of nitric oxide (no), prostacyclin and endothelium derived hyperpolarising factor (edhf) to vasodilatation. results sensitivity to ach was comparable between diabetic and vehicle treated mice (ec . ± . nm vs . ± . nm). the contribution of individual endothelium-dependent vasodilators was significantly altered in arteries from diabetic mice. at m ach, edhf-mediated relaxation was significantly reduced (p= . , one-way anova) compared with controls ( . ± . vs . ± ). in comparison, no-mediated relaxation was significantly increased (p= . , one-way anova) compared with controls ( . ± . vs . ± . %). conclusions endothelium-dependent relaxation was not reduced in uterine arteries of diabetic mice compared with controls. however, there was a profound change in the contribution of endothelium-dependent vasodilators in arteries of diabetic mice. this may alter compensatory capacity as disease progresses. supported by mfn training grant (cihr). raf- serine/threonine protein kinase has been extensively studied as the upstream kinase linking ras activation to the mek/erk module. mek/erk has been shown to play a role in the modulation of vascular contraction. however, the role of raf kinase in vascular contraction and its possible involvement in alteration of maternal vascular function during pregnancy is not known. objectives: to determine ( ) if raf kinase contributes to phenylephrine (pe)induced contractile response, ( ) the role of raf kinase inhibitor (gw ) in regulating vascular tone during pregnancy, and ( ) mechanism by which gw produces vasodilatation in rat mesenteric arteries. methods and results: conscious non pregnant (np) and pregnant (p) sprague dawley rats received increasing doses of pe in the absence or presence of gw . pe induced a dose-dependent increase in map in both np and p rats but responses were substantially depressed in pregnancy. gw shifted the pe-induced dose response to the right in both np and p rats. gw itself did not affect basal blood pressure. isometric tension studies in mesenteric arteries showed that gw did not change the kcl-evoked contraction but significantly inhibited the contraction to pe in both np and p arteries. interestingly, at a given concentration, gw produced greater inhibition of pe-induced contractile response in p than in np arteries. also, in p arteries the inhibitory effects of gw were greater as the pregnancy progressed from day to day . raf kinase expression and activity was significantly decreased in arteries of p compared to np rats. in mesenteric vascular smooth muscle cells (vsmcs), pe stimulated activation of raf kinase as indicated by phosphorylation of its immediate target, mek / in a time-and dose-dependent manner. measurement of [ca + ] i with fura- showed that gw -mediated inhibition of pe-induced contraction was not associated with decrease in [ca + ] i . vsmcs treated with pe exhibited higher levels of the contractile proteins, p-mypt and p-mlc which was inhibited by gw . conclusion: to our knowledge, for the first time we show that raf kinase plays an important role in the regulation of vascular contractility. decreased expression and/or activity of raf kinase during pregnancy may explain in part, for decreased systemic vascular reactivity during late gestation. the mechanism(s) that contribute to reduced vascular sensitivity to phenyleperine (pe) during pregnancy is not well understood. pe, in addition to activating the classical contractile pathways, also stimulates growth factor pathways that results in activation of ras/mitogen-activated protein kinases. it is not clear whether these pathways play a role in the modulation of vascular contraction. hence, the present study was designed to determine ) if ras is involved in mediating the pressor response to pe in non pregnant (np) and pregnant (p) rats, ) if so, the mechanism by which ras protein contributes to pe-induced vascular contraction, and ) any differential expression and/or activity of ras during pregnancy that might contribute to altered vascular response. methods: ) mean arterial pressure (map) was measured in conscious np and p rats. ) isometric tension was measured in mesenteric arteries of np and p rats. ) expression of contractile proteins, p-mlc and p-mypt were studied in cultured vascular smooth muscle cells (vsmcs). ) expression and activity of ras in mesenteric arteries of np and p rats were measured by western blot analysis. results: ( ) intravenous administration of pe resulted in a dose-dependent increase in map but responses were substantially depressed in pregnancy. inhibiting ras activation with manumycin, decreased pe-induced increase in map in both np and p rats. manumycin by itself had no effects on basal map. ( ) isometric contraction studies in myograph with mesenteric arteries showed that manumycin shifted pe-induced dose response curve to the right with a decrease in e max in np and p rats. higher concentration of manumycin was required to inhibit pe-induced contraction in np ( μm) compared to p ( - μm) rats. ( ) pretreatment with manumycin inhibited pe-induced increase in the extent of phosphorylation of both mlc and mypt in mvsmcs. ( ) compared to p rats, mesenteric arteries of np rats revealed increased basal and pe-induced expression and activity of ras. reduced expression of this contractile ras pathway might contribute to decreased vascular reactivity during pregnancy. conclusion: ras protein plays a role in regulation of vascular contraction. the decreased amount and activity of vascular ras may be a novel mechanism that explains the reduced vascular resistance during pregnancy. overweight affects the relaxin-induced response of mesenteric arteries. joris van drongelen, arianne van koppen, marc ea spaanderman, paul abm smits, frederik k lotgering. obstetrics and gynecology, radboud university nijmegen medical centre, nijmegen, netherlands; pharmacology and toxicology, radboud university nijmegen medical centre, nijmegen, netherlands. objective: overweight affects pregnancy-induced vascular adaptation and predisposes to gestational hypertensive disease. relaxin plays a key role in normal gestational vascular adaptation by increasing endotheliumdependent vasodilation and compliance, and reducing myogenic reactivity. we hypothesized that overweight blunts the vascular response to relaxin. the vascular responses to flow and pressure of mesenteric arteries after pre-treatment to human recombinant relaxin (rlx) or placebo (plac) were examined in overweight (ow) and normal weight (nw) rats in a pressure-perfusion myograph. overweight was established by a high-fat diet. the endothelium-dependent vasodilatation was measured in response to flow: e (flow inducing % dilatation) and e max (maximal dilative effect). active contractile (myogenic reactivity) and passive dilative (compliance) vascular responses to pressure were determined. all vascular responses were calculated as the proportional change in diameter to % precontraction with u . results: in nw rats rlx decreased e and increased e max to flow and attenuated myogenic reactivity without affecting vascular compliance. in ow plac-treated rats, compared to nw rats, an upregulated vasodilative state was present (decreased e and increased e max , and lower myogenic reactivity). in ow rats rlx increased e to flow and unaffected e max . rlx increased myogenic reactivity mildly in absence of changes in vascular compliance. values are presented as mean±sem; * p< . between nw/ow, # p< . within nw/ow. whereas rlx stimulates endothelium-dependent vasodilation to flow and myogenic reactivity in nw rats, ow overturns the flow-induced response and decreases myogenic reactivity to a lesser extent than present in nw rats. we speculate that these overweight-induced adverse effects of rlx prelude to vascular maladaptation and gestational hypertensive disease. compared to the luteal (lut) phase, uterine blood flow is increased in vivo during the follicular (fol) phase and more so during pregnancy (preg). both of these are physiologic states of high estrogen and shear stress. endothelial cells express enos and produce greater amounts of nitric oxide (no) in response to elevations of shear stress. phosphorylation of enos is a signaling marker of activation. we have recently validated lut, fol and preg uaec culture models for evaluating enos phosphorylation responses to shear stress and vascular mediators. we hypothesized that uaecs derived from fol and preg sheep will show greater enos phosphorylation than lut phase uaecs, and with more robust responses in the presence of estrogen (e ). methods: uaecs were cultured until % confluence, and then subjected to (static control), or dynes/cm for hrs in the absence or presence of e ( nm). western analysis was used to compare optical densities of ser -penos (penos) normalized to total-enos (mean + sem). results: in lut uaec penos was equally increased two fold by and dynes/cm (from . + . to . + . and . + . , respectively). compared to lut uaecs, the static control fol uaecs appeared to have higher penos levels ( . + . ) and this was further increased . - . fold with dynes/cm ( . + . ) and dynes/cm ( . + . ). as seen with fol uaecs, preg uaec static penos ( . + . ) appeared higher than lut uaec, but unexpectedly, neither nor dynes/cm significantly raised these levels of penos ( . + . and . + . ). regardless of shear stress level, e replacement in the culture media only increased the penos levels in the nonpregnant, but not the pregnant derived uaecs. conclusions: increasing amounts of shear stress have a corresponding increase in the ratio of enos that is phosphorylated at serine in lut and fol uaecs. pregnant uaecs do not appear to increase the constitutive ratio of serine phosphorylation of enos at either or dynes/cm . in contrast to our hypothesis, chronic treatment with e for hrs did not augment the ratio of enos phosphorylation in pregnancy. nih hl , hd , hl . cells. honghai zhang, wu xiang liao, dong-bao chen. reproductive medicine, university of california san diego, la jolla, ca, usa. s-nitrosylation (sno) is a rapid, reversible, and nitric oxide (no) dependent post-translational protein modification critical for signal transduction. estrogen stimulates endothelial cell (ec) no production but yet to be determined is if this leads to increased formation of sno-proteins in ec. hypothesis: we hypothesize that estrogen stimulates the formation of sno via a receptor and endogenous no dependent pathway in huvec or ovine uterine artery ec. methods: cells on glass coverslips were treated with mm of no donor gsno or dea nonoate, estradiol- ( nm) in the presence of l-name ( mm) for min. the cells were fixed with methanol. in situ sno-proteins were detected by a rapid biotin derivatization method by blocking thiols by methylmethanethiosulfonate (mmts), followed by ascorbate reduction and labeling with texas red-labeled ethylmethanethiosulfonate (mtsea) and examined by fluorescence microscopy. cells ( x /group) were lysed in hen buffer, and then similarly prepared but labeled with biotin-mtsea. a portion of the samples were separated on sds-page and blotted with anti-biotin antibody for total sno-protein patterns. the biotin-labeled sno-proteins were captured by avidin, followed by immunoblotting with specific antibodies. results: basal sno-protein labeling was apparent in both ec types. exogenous no donated by gsno or dea nonoate significantly increased red fluorescence labeling of sno-proteins in the cytosol of both ec types. treatment with estradiol- also increased total sno-protein labeling in both ec types. pretreatment with l-name significantly reduced sno-protein labeling. sds-page and immunoblotting with anti-biotin antibody analyses identified multiple bands of sno-proteins. in avidin captured biotinylated samples, multiple proteins were indentified. conclusion: exogenous no donated by gsno or dea nonoate and endogenous no upon estrogen stimulation increased s-nitrosylated proteins in ec (supported by nih ro hl and ). background and objective: the renin-angiotensin system (ras) functions both systemically and locally as a primary regulator of blood pressure and fluid volume and is therefore involved in the etiopathogenesis of essential hypertension as well as preeclampsia, a pregnancy-induced hypertensive disorder in pregnant women. while much progress has been made in the development of strategies to block the systemic ras and thus treat essential hypertension, relatively less advance has been achieved in the development of effective local ras inhibitors to treat preeclampsia, primarily due to the fact the conventional systemic ras inhibitors generate potential teratogenic risks to pregnant women during critical stages of their pregnancies. ginger has been widely and effectively used in pregnant women to treat pregnancyinduced nausea and vomiting with minimal adverse effects. the present study was designed to investigate whether ginger could down-regulate renin secretion by human decidual cells (the major source of renin in the tissue-based uteroplacental ras), as an initial step toward a long-term goal to develop potential safe and effective ras inhibitors for use in obstetric patients. methods: full-term normal human placentas were obtained within one hour of vaginal deliveries or cesarean sections. decidual cells were isolated from the decidua parietalis. after an initial culture for days in a serum-containing medium, the decidual cells were treated with ginger juice at various doses in a serum-free medium for hours. the culture supernatants were then harvested and subject to western blot analyses of renin protein contents. the ginger juice used was freshly prepared from the ginger roots purchased from a local grocery store and different batches of juice preparations were standardized based on their optical density values at a wavelength of μm on a spectrophotometer. results: a dominant band of renin at approximately kd was detected in all samples. when compared with the control (i.e. %), ginger juice decreased the renin protein contents in the culture supernatants in a dose-dependent manner. no significant difference in the cell morphology was observed between the control and treatment groups. conclusion: ginger root juice down-regulates renin secretion in human decidua, showing a great potential of a novel ras inhibitor, particularly, in obstetric patients. noninvasive quantification of the autonomic nervous system throughout pregnancy. dietmar schlembach, karoline pickel, daniela ulrich, philipp klaritsch, isa alkan, uwe lang, manfred g moertl. obstetrics and gynecology, medical university of graz, graz, styria, austria; cnsystems medizintechnik ag, graz, styria, austria. introduction: the analysis of heart rate variability (hrv), blood pressure variability (bpv), and baroreflex sensitivity (brs) has become a powerful tool for the assessment of autonomic control. although hrv analysis was initially developed for risk stratification in cardiology, the field of clinical application has broadened in recent years. the aim of our study was to investigate the adaptation of autonomic control during pregnancy based on analysis of heart rate variability and baroreceptor sensitivity. methods: patients with uncomplicated pregnancy were measured with the taskforce® monitor i made by cnsystems. all measurements were performed in supine position under standardized resting conditions. autonomic parameters were recorded at rest and within the "deep breathing method" as a "cardiovascular challenge test". results: throughout pregnancy a shift to higher sympathetic activity respectively a lower parasympathetic activity was observed. , and . ± . [> wks]) (figure ). during the deep breathing maneuver we could show an increase of the sympathetic / parasympathetic ratio (figure ). the noninvasive determination of autonomic parameters throughout pregnancy is possible. these results can be used as basic parameters for classifying and assessing autonomic changes in pathological conditions in pregnancy such as hypertensive disorders. how far the characterization and challenge of these autonomic functions can be utilized for diagnosis and prediction of preeclampsia has to be shown in future studies. hemodynamic parameters measured noninvasively throughout pregnancy. daniela ulrich, manfred g moertl, karoline pickel, philipp klaritsch, isa alkan, uwe lang, dietmar schlembach. obstetrics and gynecology, medical university of graz, graz, styria, austria; cnsystems medizintechnik ag, graz, styria, austria. background: hemodynamic changes throughout pregnancy have been measured predominantly by invasive techniques. the discussion on the valence und the low acceptance of these invasive procedures by pregnant women demands a noninvasive method for evaluating and distinguishing cardiovascular adaptative mechanisms throughout normal and especially complicated pregnancy. method: healthy patients with uncomplicated pregnancy were measured with the taskforce® monitor i (cnsystems, austria) at different time points throughout pregnancy. cardiovascular parameters were recorded in supine and left lateral position under standardized conditions. results: throughout pregnancy an increase of global parameters such as heart rate (hr), blood pressure (bp), total peripheral resistance (tpr) and total peripheral resistance index (tpri) were observed. stroke volume (sv), stroke index (si), cardiac output (co), contractility index (ci), acceleration index (aci), and left ventricular ejection time (lvet) decreased throughout pregnancy (table). discussion: the noninvasive determination of cardiovascular parameters throughout pregnancy is possible and the results of this pilot study can serve as basic parameters for classifying and assessing cardiovascular changes in pathological conditions in pregnancy such as hypertensive disorders. assigning pregnant hypertensive women into hyper-and hypodynamic groups may aid in planning individual therapeutic strategies. objective: both gnrh i and gnrh ii are expressed in humans. gnrh i is produced by the hypothalamus under the regulation of gonadal steroids and stimulates pituitary gonadotropins. during pregnancy gnrh i is also produced by the placenta and affects hcg. gnrh ii, the ancient isoform, is produced by numerous human tissues including immune and reproductive tissues and circulates in blood in quantifiable levels. we have demonstrated that gnrh ii analogs directly affect fertilization and uterine function, and propose that it acts via immune regulation. during pregnancy it is known to regulate numerous hormone productions, yet the levels of gnrh ii has not been reported. in these studies we have determined the circulating levels of gnrh ii throughout pregnancy and in early pregnancy loss. study design: thirty-three women having normal pregnancies were followed prospectively. plasma samples were drawn at , , , , , , weeks gestation and during labor. plasma was also collected from patients have spontaneous abortions (n= ). circulating gnrh ii and crh and gnrh i were measured by specific radioimmunoassays. results: circulating gnrh ii increased from non-pregnant levels ( +/- pg/ ml, mean+/-sem) to +/- pg/ml by -week lmp. gnrh ii concentrations continued to increase through weeks gestation over the -week levels, although a significant increase was only attained by weeks. gnrh ii continued to increase in late term, attaining levels of +/- pg/ml which was significantly higher than that of early gestation. during labor and delivery gnrh ii in maternal plasma was further increased to +/- pg/ml, i.e., . times that of -week gestation ( +/- pg/ml). circulating gnrh ii did not parallel gnrh i in early pregnancy but did in late gestation. gnrh ii did correlate with crh in early pregnancy but not in late gestation. patients having spontaneous abortion had increased circulating gnrh ii at -weeks lmp ( +/- pg/ml) as compared to normal pregnancies ( +/- pg/ml). conclusion: gnrh ii increased throughout pregnancy attaining highest concentrations during labor and delivery. patient with early pregnancy loss had increased gnrh ii expression. the function of gnrh ii or factors affecting this increased gnrh ii in normal or abnormal human pregnancy should be investigated. introduction: plasma levels of the endocannabinoid, anandamide (aea) decrease during the luteal phase of the menstrual cycle and early pregnancy and increase during parturition. high plasma aea levels at weeks in women undergoing ivf-et was associated with a failure to achieve an ongoing pregnancy . what is uncertain is what happens to aea levels when the pregnancy has already failed. we aimed to quantify aea levels in women presenting in early pregnancy with a diagnosed non-viable pregnancy and to compare them to those of a viable pregnancy. methods: plasma aea was measured by a sensitive isotope dilution hplc-ms/ms method from women in early pregnancy ( - weeks) of whom had a viable pregnancy and had a non-viable pregnancy. serum hcg and progesterone were measured in blood samples by standard elisa methods. results: the ages and bmi of both groups were similar ( ± . versus ± . years; mean ± sd; p= . ; student's unpaired t-test and ± . versus ± . kg/m ; p= . ) respectively. plasma aea levels in women with non-viable pregnancies were significantly higher than those in women with viable pregnancies ( . ± . versus . ± . nm; p= . ). there was no correlation found between aea levels and hcg or progesterone levels p= . and r= . ; p= . , respectively) , despite progesterone being significantly lower in the non-viable group ( . ± . versus . ± . ng/ml; p= . ). conclusion: higher plasma aea levels were associated with early pregnancy failure, and this association appeared to be independent of serum hcg or progesterone concentrations. these data suggest that plasma aea levels are linked with pregnancy failure through a mechanism that does not involve hcg or progesterone production. the precise involvement of anandamide in early pregnancy needs to be investigated further. n- ) and arachidonic (aa, : n- ) acids, the major brain long-chain polyunsaturated fatty acids (lc-pufa) are generated by elongation-desaturation of dietary essential fatty acids (efa). the maternal liver is principally responsible for efa elongation-desaturation. objetive. we determined effects of protein restriction in pregnancy on expression of d, d and elongases and (elov and ) in the maternal liver rat. methods. pregnant rats were fed control ( % casein; c) or restricted ( % casein; r) isocaloric diets. at day gestation maternal blood and livers were collected. serum triglycerides, cholesterol and glucose were determinate with the synchron cx autoanalyser and leptin and insulin by ria. liver fat determination was performed by the soxhlet method. liver ara and dha were calculated by gas chromatography based upon retention times from methyl ester standards. liver d, d, elov and mrna were measured by rt-pcr and northern blot. data are m ± sem; analysis by t-test. results. liver weights did not differ in c and r. total liver fat ( ± vs ± mg) serum leptin ( ± . vs ± . ng/ml) and insulin ( . ± . vs . ± . ng/ml) differed in c and r respectively (p< . ). serum triglycerides, cholesterol, and glucose did not differ. desaturase and elongase mrna and % of maternal liver aa and dha were lower in r (fig ) . conclusion. low liver fat content and desaturase and elongase mrna in r indicate impaired lc-pufa synthesis which may adversely impact fetal development, especially the brain. objective: to test the hypothesis that obstetrical dic results from an excessive leak of fetal material into the maternal circulation. a secondary objective was to assess maternal morbidity. methods: all cesarean hysterectomy cases for hemorrhage at our hospital from to were included. intravascular presence of fetal material was determined by two pathologists, blinded to each other and any clinical information. the percentage of those with any fetal material in the maternal circulation was calculated for each diagnosis for hemorrhage. for a given diagnosis, the percentage of intravascular fetal material in those with the given diagnosis was compared to those without that diagnosis using fisher's exact test. most patients had multiple hemorrhage diagnoses. a two sample t-test was used to evaluate the difference in mean blood loss between those with and without intravascular fetal material. results: primary outcome* % of patients received blood products and % received clotting agents. the average blood loss was cc. there were no maternal deaths and injuries to adjacent organs, all to the bladder. conclusions: there was no association between the presence of intravascular fetal material and any specific hemorrhage diagnosis or amount of blood loss. although the power to detect a relationship was low, the excessive leakage of fetal material as a specific and exclusive mechanism of obstetrical dic, as postulated, seems unlikely. while % of the population was transfused, there were few intraoperative complications and no maternal deaths. hypertension, tel-aviv university, sheba medical center, ramat-gan, israel. objective: the joint national committee on high blood pressure (jnc ) determined blood pressure of - / - in adults to be prehypertension that requires health promoting life style modifications to prevent cardiovascular disease. similarly, we hypothesize that gestational prehypertension in pregnancy is associated with increased risk of pregnancy complications and its management would improve pregnancy outcome. methods: prospective and retrospective recruitment resulted in a study group consisting of patients who were diagnosed in the first and early second trimester (< weeks) with blood pressure of - / , and a control group consisting of patients with blood pressure < / at similar gestational age. comparisons between the two groups were accomplished for demographic characteristics and outcome measures using the chi-square test statistic and two-sample t-tests for categorical and continuous variables, respectively. results: all outcome measures analyzed resulted in poorer results being associated with the study group compared with control as follows: % versus % of the study and control group pregnancies, respectively, experienced preeclampsia (p= . ); and % versus % of the study and control group, respectively, were associated with gestational hypertension (p= . ). % of the control group deliveries were associated with admission to the nicu, compared to only % in the control group (p= . ); % versus % of the study and control group deliveries, respectively, were preterm (p= . ); twenty-nine percent of the study group were cesarean deliveries, compared to % in the control group (p= . ). on admission mean sbp and dbp was and mmhg, respectively, in the study group, compared to and mmhg in the control group (p= . for sbp and p= . for dbp). conclusions: "gestational pre-hypertension" may be a real pregnancy condition that when is recognized, physician attention, patient close monitoring during prenatal care and delivery and early intervention in patients at risk, may all promote improved pregnancy outcome. larger scale study is in progress to evaluate and confirm these findings in the larger pregnant population. are contractions at - weeks gestation less painful than those at full term? kristy a ruis, karin blakemore, abimbola aina-mumuney, valerie jones. gynecology and obstetrics, johns hopkins hospital, baltimore, md, usa. objective to determine if gestational age plays a role in severity of pain associated with uterine contractions. study design self-reported pain from women in labor, on a scale of - , is assessed and recorded in an obstetrical database by nurses at regular intervals at two hospitals within our medical system and was retrospectively reviewed from - . pain at various dilatations ( - cm) of women who were laboring and then delivered at - weeks' gestation was compared to women in labor at term. maternal demographics of age, race, education level, bmi, presence of support person, request for analgesia at any point in labor, and epidural placement were abstracted from maternal records. categorical data were analyzed using chi square or fisher exact test; continuous variables using student t-test. results laboring patients between - weeks gestation and at term were identified. term and preterm patients did not differ with respect to maternal demographics. pain reported by preterm patients was significantly less at - cm dilatation ( . vs. . ‚ p= . ) and significantly greater at - cm ( . vs. . ‚ p= . ). pain reported at - cm and - cm was not statistically different between the groups. of note, fewer of the preterm patients received an epidural despite the request for analgesia. conclusion preterm laboring patients between - weeks gestation may perceive less pain at - cm dilatation compared to term laboring patients; however, their pain perception at advanced dilatation was comparable to those at term despite the fact that they were less likely to have an epidural in place at the time of pain evaluation. in light of these findings, the widely accepted etiology of labor pain as the result of cervical dilatation may need to be re-examined. also, factoring in the patient's discomfort level into the evaluation for onset of early active labor may not be valid in the preterm patient. background and objective: asthma is a risk factor for adverse pregnancy outcome. this has been attributed to the effect of allergy in pregnancy. mast cell mediators can induce uterine contractility. the objective of the study was to test the hypothesis that pregnant women with asthma have different uterine electrical signals from those generated by normal pregnant women. materials and methods: uterine electromyography (emg) recordings from gestational age matched pregnant women at term were analyzed. the cases consisted of patients with asthma and the controls, those women without asthma. emg was recorded for approximately minutes from surface electrodes placed upon the maternal abdomen, with the electrical signals filtered in the uterine-specific range of . to . hz to remove noise components. the recordings were analyzed in their entirety first by power spectrum analysis and then by lyapunov analysis. the power-spectrum-largest-peak frequency and the largest lyapunov exponent were calculated for each patient, and then the mean and standard deviation of these parameters was compared using student's t-test. results: patients with asthma had significant lower power spectrum frequency and higher lyapunov exponent than women without asthma. see ) the power spectrum frequency and the lyapunov exponent used to analyze uterine emg signals were different in women with and without asthma; ) the results suggest that uterine electrical activity is altered in women affected by asthma; ) these findings may explain the observed increased frequency of preterm birth in women with asthma. further studies are required to dissect the mechanisms. fetal microchimeric cells trafficked into the maternal circulation persist in blood and tissues for years after pregnancy. increasing data suggest that microchimerism occurs after every pregnancy, but the biological role of fetal microchimerism or the cell types involved is unclear. while persistent fetal cells were initially implicated in autoimmune disease, animal studies suggest these fetal cells play a broader role in response to tissue injury. methods: appendix specimens were acquired from women undergoing appendicectomy during pregnancy. detailed reproductive histories were obtained. fluorescence in situ hybridisation (fish) with two different probes allowed investigation of the presence of male presumed-fetal cells and nested pcr amplification of sry gene confirmed male dna in the appendix. immunostaining was used to determine the fetal cell phenotype. results: male cells were identified in appendix tissues from women with known male pregnancies (n= ) and also from a woman with no sons and a previous miscarriage of undetermined gender (n= ). no male cells were observed in the control (n= ), a woman with daughters. male cells of presumed fetal origin were evenly distributed in the muscle, mucosa and submucosa layers of the appendix. morphology and co-localisation analysis suggested the identified male cells had differentiated primarily into muscle cells or lymphocytes. combined immunostaining and y-fish demonstrated male desmin+ muscle cells and cd + and cd + lymphocytes. finally, the presence of male dna in the appendix specimens was confirmed by nested pcr. male cells of presumed fetal origin were identified in the appendix of pregnant women. microchimerism frequency varied according to the reproductive history and the degree of inflammation. microchimerism rates were higher in the appendix from women with current male pregnancies than in those with previous male pregnancies and were higher in those with histological acute inflammation, when compared to milder cases. male microchimeric cells identified were of haematopoietic and mesenchymal origin. this study suggests that fetal cells are present in sites of tissue injury and may participate in tissue repair during pregnancy. collagen i and collagen-binding integrins mrna expression in rat cervix during gestation. huiling ji, tanya l dailey, vit long, edward ks chien. obstetrics and gynecology, maternal fetal medicine, women and infants' hospital of rhode island, providence, ri, usa. objective cervical remodeling is associated with cell proliferation and extracellular matrix (ecm) remodeling. integrins are a family of multifunctional cell adhesion receptors which mediate ecm-cell interactions including binding collagen. of the integrin (i) heterodimers, , , and are primary receptors for collagen. the predominant cervical collagen is collagen type . the purpose of this study is to investigate collagen and integrin expression in the pregnant rat cervix. the cervix was harvested from timed pregnant sprague-dawley rats. non pregnant (np)and timed pregnant day , , , , and animals were euthanized using a protocol approved by the iacuc. four animals were sacrificed on each day of gestation. quantitative rt-pcr was used to evaluate mrna expression and normalized to -actin. a standard curve was generated from a single sample. data was analyzed using anova and multiple comparisons testing. collagen i mrna expression increased through mid-gestation but decreased to np levels on day . a similar pattern was seen with the integrin beta subunit. the pattern of integrin alpha subunit expression was different for each subunit during pregnancy. the changes in collagen, integrin alpha , , and integrin beta were found to be statistically significant. (figure) . the pattern of collagen binding integrin alpha subunit expression during the rat gestation appears to vary independently of each other. the expression of the subunit paralleled col expression. collagen binding integrins may play independent roles in signaling and biomechanics during gestation. funding: women infants' hospital research fund; phs nih-ncrr p rr p rr . background. the effects of chemotherapy on human fetal development are poorly studied, mainly due to the lack of adequate animal models in which placentation and embryological development resembles humans and pharmacokinetic studies, prenatal sonography as well as histological studies can be performed. aim of the study. to test the baboon as model for studying pharmacokinetics and fetal effects of chemotherapy administered during pregnancy. methods. experiments were performed in pregnant baboons at a mean gestational age of (+/- ) days. detailed ultrasound examination (biometry, doppler, screening) was performed days before, at and day after the drug administration. the administration of different schemes of chemotherapy and the fetal samplings occurred under endotracheal anaesthesia. maternal blood samplings, as well as percutaneous ultrasound guided fetal blood ( ml) and amniotic fluid ( ml) samplings were performed at least once immediately after drug administration. in case of fetal demise, the fetus underwent detailed macro-and microscopic examination. in the other animals mother and fetus were euthanized h after the experiments, with collection of blood, amniotic fluid and tissues for further analysis. results. all mothers survived the experiments, one mother developed paralitic ileus. none of the fetuses died during the acute phase of the experiment but / ( %) fetuses died within h following the experiment. none of the animals showed significant clinical or histological signs of infection or anaemia. a total of ultrasound examinations were performed in fetuses, allowing the creation of sonographic growth charts in this model. at the time of drug administration the mean maternal weight was . kg (range . - . ) and the estimated fetal weight was gr (range - ). sixteen out of cordocenteses ( %) and all amniocenteses ( %) were successful in obtaining the required samples for analysis. conclusion. the pregnant baboon can be used as a model for studies on pharmacokinetics and fetal effects of chemotherapy administered during gestation. prenatal ultrasound is comparable to the human situation, and amniocentesis and cordocentesis can be performed with a high success rate and short term survival. therapy to prevent preterm birth is limited". moreover, -hydroxyprogesterone ( ohp) caproate is a category d drug according to the fda (evidence of fetal harm). p is produced in the adrenal glands, gonads and brain. after weeks gestation p is secreted from the placenta independently to the mother and the fetus. p is the precursor of aldosterone and after conversion to ohp, of cortisol and androstenedione. baboons have similar reproductive system and development to humans and are used to study mechanisms of labor and prevention of preterm labor. currently, there are no normative data on the concentration of p, ohp, cortisol ©, estradiol (e ) or inhibin (i) throughout their pregnancy. therefore, a doseresponse or the teratogenic effects of p or ohp caproate cannot be studied in a controlled manner in this animal model. the aim of this study was to generate reference values for these hormones during baboon gestation and early postpartum life. material and methods: hormonal quantitative measurements were performed (immulite analyzer) results: the mean concentrations of these hormones are depicted in figure (maternal serum, from conception to term days) and figure (newborn serum) conclusion: this study provides reference values for hormones quantified during the baboon gestation and early postpartum life. this may be useful for future research concerning the effects of p and ohp administration during pregnancy. ( )non-pregnant women eligible for ivf treatment and ( )pregnant women receiving prenatal care. the pre- / samples were drawn in the year prior to / / ; the post- / samples were drawn within months after. the pre- / and post- / normal pregnant samples were drawn at + weeks' gestation. the non-pregnant samples were from ivf candidates with serum e levels< newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced pg/ml and fsh serum levels< . miu/ml. the samples were assayed for acth and cortisol by a commercially available immulite™ system. hsp and hsp were measured by commercially available elisa. these results were compared in the patient populations before and after / . t-tests were used for analysis. statistical significance was set at p< . . results: in the pregnant subjects, there were no statistical differences in the mean levels of acth, cortisol, and hsp pre-and post- / (table ) . only serum hsp levels were significantly increased in the pregnant women post- / .* mean serum acth, cortisol, hsp , and hsp levels were all significantly different in non-pregnant subjects pre-and post- / . conclusions: except for hsp , serum markers for stress were unchanged in pregnant subjects after the stress of / / in comparison to non-pregnant women whose serum hsp , hsp , cortisol, and acth levels were significantly different. the lack of change in serum markers of stress in pregnant women suggests that the hormonal milieu of pregnancy may buffer against acute environmental stressors. objective: in human pregnancy, maternal body composition provides an indicator of maternal nutritional status and metabolic capacity. previously, we reported that ß hsd- activity was significantly reduced in term placentas from thin women and women with a smaller mid-upper arm circumference before conception. this suggests that these fetuses may have been exposed to inappropriate levels of maternal cortisol, which is a mediator of gestation length. in this study, we hypothesize that the duration of gestation will be shorter in women who tend to be thin and have a lower mid-upper arm circumference prior to conception. methods: within the longitudinal, population-based southampton women's survey (sws), analyses were performed on women whose estimated date of conception was set using an algorithm that combined menstrual and early ultrasound scan data and who had a spontaneous onset of labour and delivered after weeks of gestation. linear regression was used to examine the relationships between maternal body composition and the duration of gestation. results: within the women surveyed, lower maternal body mass index, mid-upper arm circumference and arm muscle area before conception were all associated with shorter duration of gestation at delivery (r= . , p= . ; r= . , p= . ; and r= . , p= . , respectively). a lower subscapular skinfold thickness, sum of skinfolds and height were also associated with shorter duration of gestation (r= . , p= . ; r= . , p= . and r= . , p= . , respectively). mother's age, own birthweight and ratio of subscapular/triceps skinfold thickness were not related to the duration of gestation. conclusions: in this study, we found that thinner women with a lower midupper arm circumference and arm muscle area tended to have a shorter duration of gestation. our findings of shorter gestation length in thinner women are in keeping with our previous observation of lower ß hsd- activity in term placentas from thinner women. we conclude that metabolic capacity prior to conception could influence duration of gestation through mechanisms that include alteration in placental metabolism and fetal cortisol exposure. fecal incontinence (fi) is a debilitating condition affecting - % of the us. our prior studies found that % of women report new onset fi after childbirth. the goal of our study was to examine the impact of fi on postpartum quality of life (qol). women reporting fi on a statewide survey who agreed to participate in a -year study of qol were included in the analysis. women were considered to have fi based upon the nih definition of fi. the quality of life survey was based upon the uebersax incontinence impact questionnaire and was administered every months for years. qol in women with fi was examined using chi square, and impact of severe fi (stool incontinence) was determined by multivariate logistic regression. results women with fi were surveyed and of those, ( %) returned at least survey during the study period, completed all survey questions, and were included in the final analysis. among women with fi, % felt frustrated due to fi, % reported fi impacted their emotional health, . % reported fi impacted child-caring abilities, and . % reported a negative impact on social activities. qol was similar across survey periods. one out of three women with fi reported severe symptoms (incontinence of stool). women with severe symptoms were - times more likely to report negative impacts on qol compared to milder (e.g. flatus) fi after adjusting for age, parity and urinary incontinence. . % felt their stool was stored elsewhere before bowel movements, . % reported using digital defecation and more than half ( %) reported symptoms of urinary leakage. despite the substantial impact on postpartum quality of life, few women sought medical help with only % of women at months, . % at year, and . % at years ever reporting their symptoms to a medical provider. postpartum women report that fecal incontinence has a substantial negative impact on their qol after delivery including their emotional health and ability to care for their newborn. despite this profound impact, few women will discuss fi with medical providers. these data suggests there may be a benefit for providers to inquire about fi at postpartum visits. objective: the objective of this study was to determine what characteristics contribute to racial/ethnic differences in breastfeeding rates. study design: a retrospective cohort study of all women who delivered a viable infant (n= , ) was conducted. the primary outcome was breastfeeding upon discharge of the hospital. we first examined the association between race/ ethnicity and breastfeeding. next, we conducted stratified analyses examining a variety of predictors of breastfeeding within the racial/ethnic groups including maternal demographics, obstetric interventions, and perinatal complications. results: we found that both asians (or . , % ci . - . ) and blacks ( . , % ci . - . ) had statistically significant lower rates of breastfeeding, while latinas (or . , % ci . - . ) showed a trend towards higher rates of breastfeeding. in latinas, we found that rd and th degree lacerations were significantly associated with lower rates of breastfeeding, but were not predictive of breastfeeding in the other racial/ethnic groups. epidural use was predictive of lower rates of breastfeeding in caucasians and blacks, but was not predictive in latinos and asians. some of the other predictors which differed between the racial/ethnic groups were obesity and induction of labor (table ) . conclusion: race/ethnicity is significantly associated with breastfeeding, with blacks and asians having the lowest rates of breastfeeding at discharge. a variety of other factors are associated with breastfeeding and interestingly, their effect appears to differ between the racial/ethnic groups. future studies might elucidate the sociocultural and biomedical reasons that explain the differences. these results help focus our efforts during the peripartum period to advocate for mothers who have factors that might impede breast feeding. epidemiology, erasmus medical centre, rotterdam, netherlands; pediatrics, erasmus medical centre, rotterdam, netherlands; public health, erasmus medical centre, rotterdam, netherlands; clinical genetics, erasmus medical centre, rotterdam, netherlands. background recommendations on folic acid use to prevent neural tube defects are launched in several countries. however, the adequate use of folic acid supplements during the periconception period seems to be low. objective to assess the prevalence of adequate folic acid use, defined as the preconception start of supplements, and to identify its determinants in a multi-ethnic population. design the study was embedded in the generation r study in rotterdam, the netherlands, a population-based prospective cohort study from early pregnancy onwards. methods from all women in the cohort who delivered between april and january information on folic acid use and potential determinants was obtained by questionnaires and physical examination. logistic regression models were used to identify determinants of periconception folic acid use. results. data from , pregnant women were available. of all women % adequately used folic acid supplements. the most important risk factors for inadequate use were unplanned pregnancy (or . , p< . ), nonwestern ethnicity (or . , ci . - . , p < . ) and a low educational level (or . , ci . - . , p< . ). other risk factors were single marital status, smoking, multiparity (all p< . ) and alcohol use (p< . ). prior spontaneous abortion was associated with increased adequate folic acid use (p< . ). conclusion adequate periconceptional folic acid use is low. improved preconception care and public health education programs are necessary to improve the uptake of folic acid. although methamphetamine (ma) use has been front and center of the united states drug control policy since , little attention has been given to ma use in pregnancy, despite the fact that pregnant admissions to drug treatment for ma have been rising sharply. to determine trends in the prevalence of ma treatment admissions during pregnancy, we undertook a secondary analysis of the treatment episode data set (teds), an administrative data set that captures at least % of all known treatment admissions in the us. in particular, we investigated risk factors for ma use and how these characteristics have changed over time. demographic, geographic and substance use data were collected for the , pregnant admissions captured between and . logistic regression models were constructed by year. confounding was assessed via backwards elimination with a change-in-estimate criteria of . considered substantial. trend results were reported as adjusted proportions and represented graphically. overall ma prevalence, reported as the primary drug of use upon admission, rose from . % in to . % in . although white women had times the odds of using ma in (adjusted or ( %ci) . [ . , . ]), this had dropped to . [ . , . ] by , mostly due to an increase in latina ma use in pregnancy. pregnant women admitted for ma had fewer prior treatment admissions, were more likely to be unemployed, and less likely to use alcohol or marijuana. we found great geographic variability in use. ma was more common in the pacific region and least common in new england. there was little change in regional variation over the study time period. less is known about the perinatal effects of ma compared with other substances, yet it is the primary drug of choice for pregnant women admitted into treatment. as pregnant women occupy a unique place in drug treatment, analysis of national trend data is essential to guide both policy and research. background: epidemiologists have grouped the multiple disorders that lead to extremely preterm delivery in a variety of ways. we sought to identify characteristics that would support the combining or dividing of the disorders that lead to preterm delivery. methods: we enrolled , women who delivered a live born singleton infant between and completed weeks gestation at tertiary centers in the united states. each delivery was classified according to the complication that prompted presentation: preterm labor, preterm premature rupture of newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced fetal membranes (pprom), preeclampsia, placental abruption, cervical incompetence, and fetal indication/intrauterine growth restriction (iugr). we compared these entities on the frequency of characteristics identified by standardized interview, chart review, histological examination of the placenta, and culture of placenta parenchyma. results: the percents of women who presented with each antenatal complication were: preterm labor ( ), pprom ( ), preeclampsia ( ), placental abruption ( ), cervical insufficiency ( ), and fetal indication/iugr ( ). after considering antecedents and correlates of the processes leading to preterm delivery, we observed two overarching epidemiologic patterns. the first pattern, characterized by recovery of organisms from the placenta and by histologic chorioamnionitis, tended to be associated with preterm labor, pprom, placental abruption, and cervical insufficiency. the second pattern, characterized by a paucity of organisms and inflammation and the presence of histologic features of dysfunctional placentation, tended to be associated with preeclampsia and fetal indications/iugr. conclusions: disorders leading to preterm delivery can be categorized broadly into two groups: those associated with intrauterine inflammation and those with aberrations of placentation. predictors of compliance with tuberculosis screening in pregnancy. nadav schwartz, sarah wagner, sean keeler, may tam, julian mierlak, , aaron caughey. obstetrics and gynecology, nyu school of medicine, new york, ny; obstetrics and gynecology, ucsf, san francisco, ca; obstetrics and gynecology, gouverneur health care services, new york, ny. objective: poor compliance with tuberculosis screening and treatment is a major obstacle to the containment of this disease. we sought to identify predictors of ppd and cxr compliance during pregnancy. methods: a retrospective cohort study at a single institution which serves a largely immigrant population in nyc, from november , through june , . data on maternal age, ethnicity, country of origin, level of education, ppd and cxr status were collected. results: of the , pregnancies, asian and hispanic race/ethnicities accounted for . % and . % of the population, respectively, with . % being us-born. the mean age was . years and the overall ppd+ rate was . %. there was % non-compliance with ppd testing, and % of ppd+ patients were non-compliant with their chest x-rays. asian women were more likely to be ppd-compliant than hispanic or caucasian women. ppd+ asian women were also more likely to be compliant with cxr. us-born women were significantly less likely to be compliant with their ppd or with their cxr. women > years old were less likely to be compliant with their cxr, while women with an elementary school education or less were more likely to be compliant. (see table for odds ratios and %ci) conclusions: age, education, immigrant status and other cultural and ethnic factors appear to play a role in compliance with tuberculosis screening. further elucidation of these effects may help clinicians target at-risk subpopulations and improve overall compliance, working towards better control of this disease. background: in the us, differential outcomes in cervical cancer among medically underserved women are linked to multiple barriers impacting loss to follow-up and failure or delay in diagnostic resolution. prior studies have found risk factors for acquisition of hpv and for inability to obtain a pap smear. no study has explored health literacy and physician communication as a key factor. methods: this research represents the formative phase of a randomized controlled trial of african american (aa) and hispanic women aimed to improve communication and abnormal pap smear follow-up in chicago. semi-structured interviews and focus groups were conducted face to face in spanish or english. each interview lasted minutes, and each focus group lasted - minutes. we recruited patients ( hispanic, aa) and providers from a purposive sample representative of two large clinics that serve low-income women. results: all interviews were transcribed by two investigators. each interview was coded by two investigators separately and then a third investigator reviewed the transcripts and coding to achieve triangulation. codes for these themes were developed and the responses were tabulated using the coding scheme. atlas ti was utilized to analyze all qualitative data. from these data, we uncovered provider-patient challenges in cancer communication including: the providers' trade off between medical accuracy and/or literacy when communicating with their patients. for the patients, the word cancer was important to hear since they wanted the truth and needed to hear this word in order to encourage them to respond more quickly. however, many providers believed that the word cancer was too "scary" and to "extreme" of a word that may communicate too much exaggerated information. both the hispanic and aa patients did not seem to differ in their responses. conclusion: results exemplify not only the importance of health literacy and patient provider communication, but demonstrate the wealth of information gained from qualitative research-a method of data collection seldom utilized in ob/gyn investigations. funding: women's reproductive health research award: hd - ; r ca (spring). population. kristine beckers, isabelle guelinckx, greet vansant, roland devlieger. obstetrics and gynaecology, university hospital gasthuisberg, leuven, belgium; clinical nutrition, katholic university leuven, leuven, belgium. objective: to generate reference charts for weight gain during pregnancy for the different bmi-categories (underweight, normal weight, overweight, obesity), based on recent data in a homogeneous caucasian population. methods: in a retrospective study at the department of obstetrics of the leuven university hospital (belgium), weight gain and pre-pregnancy bmi were determined in belgian pregnant women with accurately dateable, uncomplicated singleton pregnancies. centile curves for the different bmicategories were constructed using of the linear mixed model, one set of charts based on the absolute weight gain, another set based on the relative (expressed as percentage) weight gain. the effect of parity on weight gain was examined. results: overall mean weight gain was . ± . kg ( . ± . lbs). mean weight gain was . ± . kg ( . ± . lbs) in the underweight population, . ± . kg ( . ± . lbs) in the population with normal weight, . ± . kg ( . ± . lbs) in the overweight population and . ± . kg ( . ± . lbs) in the obese population. weight gain (pattern and amount) of the underweight and normal weight patients differed significantly of the overweight and obese patients. parity had a statistical, but no clinical significant influence on amount and evolution of weight gain. conclusion: by using strict inclusion criteria, bmi-category-specific reference charts were generated representing the optimal gestational weight gain, rather than the mean weight gain. this enables the weight charts to be used as a clinical tool during the counselling of pregnant women. further studies are required to assess the effectiveness of this clinical tool. female fshr(-/-) mice are sterile, because of a block in folliculogenesis at the primary follicle stage, show decrease in e and elevated fsh. this animal model is an appropriate model for studying hypergonadotropic ovarian dysgenesis and infertility, caused by c t mutation in fshr gene. objective: to investigate the effects of bmt on serum hormonal levels, follicular maturation and fertility of fshr(-/-) mice. methods: fshr (-/-) mice at - weeks of age were randomized into treated versus control groups.bm from syngenic female donor was injected into the tails of recipients. control group received vehicle alone. vaginal smears were collected, body weight was measured daily. sample animals were sacrificed at , , , , and weeks post bmt. all organs were weighted and examined by h e. fsh, e , and p were measured before and after treatment. for donor cell tracking, dna was extracted from various organs. specific primer sets were designed for normal and mutant hfshr gene. pcr amplification was done and pcr products were analyzed in % agarose gel. results: total body weight significantly increased in treated animals(p< . ). significant increase in both the total number of follicles, and the collective diameter of the follicles in treated animals observed(p< . and p< . ). six out of treated animals showed estrogenic changes in daily vaginal smear. e level increased . - . times and fsh level dropped to % in treated animals. normal (donor allele) fshr gene was amplifiable in out of recipient mice, and was detected only in the ovaries and uterus but not in any other tested organs.control group did not show any changes in vaginal smear, hormonal level, and normal fshr allele. conclusion: intravenously injected syngeneic bone marrow cells were able to home to the ovaries of female fshr (-/-) mice and restore folliculogenesis and resume steroid hormone production. potential mechanisms for these observations will be discussed. conclusion: neural stem cells (nscs) give rise to progenitors, which expand by rapid proliferation until cell cycle arrest followed by differentiation along one of cns cell lineages: neurons, astrocytes and oligodendrocytes. increased differentiation of neuronal cells with ins and even more with leptin suggests that iugr-associated reduction of these growth factors may contribute to impaired hypothalamic pathway development. objective: to develop a technology of modulating hucb in order to achieve neuronal cells for future potential replacement of damaged neuronal tissue. design: we developed a two-dimensional ( d) tissue culture technology for isolation and differentiation of collagen-adherent hucb neural progenitors (hucbnps). we further used the extracellular matrix protein collagen, organized in a three-dimensional ( d) gel, supplemented with neuronal conditioning medium and nerve growth factor (ngf), to facilitate ex-vivo long term neuronal differentiation of hucbnps. we developed a stable green fluorescence protein (gfp)-pc cell model, to be used as a positive control for monitoring neuronal outgrowth for proper evaluation of the hucbnps growth in the d scaffold, mimicking a neural tissue organization. results: our experimental data indicate that d collagen environment is neuronal biocompatible, supporting attachment, long-term survival, proliferation and differentiation of both hucbnps and gfp-pc cells. conclusions: improvement of the d technology with cultures of hucbnps that is in progress in our laboratory might be the first step in validating the concept for the feasibility of generating a neuronal d tissue construct for future potential treatment of neurodegenerative disorders. piane, justin tsai, gnanaratnam giritharan, emin maltepe, paolo rinaudo. reproductive sciences, university of california san francisco, san francisco, ca, usa. objective: ivf embryos are often used to generate stem cells. however, it is unknown if stem cell lines originated from in vitro generated embryos are different from stem cell originated from in vivo embryos. trophoblastic cells, due to their external position within the embryo, are most susceptible to environmental factors encountered in vitro. furthermore, our previous data showed that trophoblast transport functions may be impaired after culture in vitro and that the number of trophoblastic cells is reduced in the embryo after ivf. in this study, we assess the differentiation characteristics of ts cell lines obtained from in vivo and in vitro fertilized embryos. methods: oocytes were isolated from superovulated c bl/ j female mice and in vitro fertilized with sperm from male c bl/ j mice. the resulting late-cavitating blastocysts were harvested. in vivo controls were obtained by flushing the blastocysts from the uteri of superovulated pregnant mice days post hcg. ts cells from the two groups were allowed to develop and maintained in vitro in the presence of fgf and heparin, using a feeder layer of human placental fibroblasts. ts cells were then allowed to differentiate without fgf and heparin, fixed on day , stained with -tubulin and zo- antibodies and then observed under fluorescence microscopy. three ts cell lines per group were analyzed and their differentiative capacity was evaluated using morphological criteria. results: in vivo and ivf derived ts exhibit a similar differentiation pattern. in particular, the number and timing of trophoblast giant cells and spongiotrophoblasts derivation is similar in the two groups. there are no obvious abnormalities in the immunologic staining morphology of the different cell lines at different time points. conclusion: there are no apparent morphological alterations in ts cells lines derived from ivf embryos as compared to in vivo embryos. this finding in an animal model increases our confidence in the reliability of human stem cells derived from ivf. as a further investigation, markers of trophoblast giant cells, spongiotrophoblast, syncytiotrophoblast and chorionic trophoblast cells will be examined and compared in the two different groups by northern blot hybridization. genomewide high density snp-cgh reveals several new deletion copy number variants on the x chromosome in pof patients. erik ah knauff, cisca wijmenga, ruben van 't slot, lude franke, bart cjm fauser. reproduction gynecology, university medical centre, utrecht, netherlands; complex genetics group, university medical centre, utrecht, netherlands. introduction: around % of women have a post-menopausal hormonal profile before age , referred to as premature ovarian failure (pof). pof could act as a genetic model for accelerated follicle loss and may render useful information about the polygenetic background of major individual differences in menopausal age. macrodeletions on the x chromosome are associated with pof but karyotyping has a maximal resolution of mb. when using genotyping whole genome arrays it is now possible to detect submicroscopic deletions and duplications (copy number variants (cnv)) up to kb effective resolution. we have screened for microdeletions on the x chromosome in a well-phenotyped cohort of pof patients. methods: our study included caucasian, ,xx patients with spontaneous secondary amenorrhea before age , fsh > iu/l and absence of (low) x/ xx mosaicism and fmr premutations. dna analysis was performed using illumina k cnv arrays containing , probes. , probes were located on the x chromosome ( probe for every kb), of which , probes were specifically designed to detect known cnvs. ten samples with call rates < % were removed from the analysis and one sample gave inconsistent x probe intensities. we screened for deletions ( kb) using an algorithm detecting at least five consecutive probes with intensities (logr > - . ) below the mean probe intensity. we identified a total of x chromosomal microdeletions, divided in loci and varying between - kb in size. of the samples showed at least one deletion on the x chromosome. % of the identified deletions had already been recorded in the database of genomic variants. in the newly identified newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced loci, we found coding regions containing genes. eight of these are established or potential pof candidate genes, including five that are clustered on the terminal xq critical pof region. conclusions: we observed abundant variation in the cnv regions, a proof-of-principle for this specially designed cnv-chip. snp comparative genomic hybridization revealed possible new deletions specific to pof on the x chromosome. data on duplications, validation and whole genome cnv analysis, compared to a control cohort, will become available soon and will be presented at the sgi annual scientific meeting. unexplained intrauterine fetal death (iufd) is associated with long qt syndrome. irene cetin, patrizio antonazzo, sabrina cozzolino, stefania calabrese, lia crotti, francesca ferrari, roberto insolia, fabio facchinetti, peter j schwartz. dept. of obst/gynecol, univ. of milano, milano, italy; molec cardiol lab, policlinico san matteo, pavia, italy; mother-infant dept., univ. of modena/reggio emilia, modena, italy. introduction: in developed countries, nearly in every pregnancies ends in late fetal loss. many iufds can be attributed to maternal disorders, fetal pathology, placental pathology and fewer to complications of labor and delivery. however, - % of cases remain unexplained. we recently demonstrated that % of sudden infant death syndrome (sids) cases carry functionally relevant genetic variants in long qt syndrome (lqts) genes. aim of the study was to analyze whether lqts genes are associated with iufd. materials and methods: patients with iufd were enrolled in two years, as part of an italian multicentre study. iufd was defined as fetal death at weeks or more of gestation according to the definition of late fetal death of the who. out of cases were classified as "unexplained stillbirths" according to the wigglesworth and aberdeen classifications. at birth placental and/cord samples were collected and dna extracted. the main lqts genes kcnq , kcnh , scn a, kcne and kcne were screened through dhplc and sequence analysis. any amino-acid substitution identified in the samples was checked for in a control population of caucasian women with uneventful pregnancies. preliminary data on the first cases (gestational age of death: - weeks) are reported. results: a total of missense mutations were identified in of stillbirths ( %), two on scn a and one on kcnh . the two mutations on scn a (v l; p a) were observed in two iufd occurred at term; they had been previously associated to sids and shown to increase the late sodium current. the mutation on kcnh is a novel genetic variant absent in reference alleles, never described in any control populations; this mutations was present in a case of iufd diagnosed at weeks of gestation. we are currently performing the electrophysiological cellular studies to define its functional effect. conclusions: these preliminary data indicate that a potentially significant number of currently unexplained iufd might be caused by ion channel diseases such as lqts. the potential prevention of sids or iufd recurrence and the identification of other affected family members could have important implications for the affected families. alternative splicing of epab is regulated by exonic splicing enhancers. e seli, a yaba, o guzeloglu-kayisli, md lalioti. ob gyn, yale u., new haven, ct, usa. introduction: alternative splicing is an important mechanism by which the genome gives rise to the observed diversity of proteins. embryonic poly(a) binding protein (epab), expressed exclusively in oocytes and early embryos, mediates translation of maternal mrnas. we identified an alternatively spliced form of epab lacking exon (cex del), and investigated its regulation as a model for alternative splicing in early development. specifically, we evaluated: imprinting (expression from maternal or paternal allele only); rna editing (post-transcriptional single nucleotide substitution); and exonic splicing enhancers (eses, exonic sites that bind splicing proteins). methods: a single nucleotide polymorphism (snp) detected in exon (c a/g) served as a marker for the parental origin of the spliced form. snp genotyping was performed by pcr amplification of exon followed by restriction enzyme digestion. to evaluate imprinting, we characterized heterozygous mice (a/g) that inherited the snp from either the mother or the father. to test for rna-editing and exonic enhancer contribution we tested mice homozygous for the exon snp (a/a or g/g). efficiency of alternative splicing in different genetic backgrounds was tested using real-time pcr normalized to actin expression. results: in mice heterozygous (a/g) for the exon snp, cex del was only expressed from the (a) allele. however, this was independent of the parental origin of the allele, ruling out imprinting. in mice homozygous (g/g) for the exon snp, the cex del variant also contained (g). therefore, rna editing did not occur. further sequence analysis led to the identification of an additional snp in exon (c g/c) that co-segregated with the exon snp. presence of c g led to the formation of an ese that binds splicing regulatory protein srp , leading to efficient exclusion of exon . real time pcr revealed a five-fold increase in the expression of the cex del alternative splicing variant in animals carrying the enhancer (homozygous g/g) for the exon snp compared to those that did not (homozygous c/c) at the same locus (p < . ). conclusions: in this study, we found that eses mediate the alternative splicing of oocyte-specific transcripts. our findings suggest that single nucleotide polymorphisms may alter the ratio between alternative splicing variants of oocyte-specific proteins. the role that these subtle differences play in determining individual reproductive outcome remains to be identified. epigenetics and chromosomal abnormalities in human oocytes. ilse van den berg, , joop se laven, robert jan galjaard, j hikke van doorninck. , obstetrics gynaecology; clinical genetics, erasmus medical center, rotterdam, netherlands. humans have a low fertility rate compared to other mammalian species. moreover their fertility declines with increasing age. both phenomena are largely due to an increasing number of chromosomal abnormalities in human oocytes during life. identifying factors that cause aneuploidy in oocytes may offer possibilities to diminish these abnormalities in vitro or in vivo. chromosomal segregation errors can result from aberrant recombination but little is known about epigenetic factors that may cause aneuploidy. epigenetic modifications such as histone acetylation and subsequent de-acetylation in oocytes are necessary for a correct progress through meiosis. if disturbed it may lead to aberrant segregation of chromosomes or chromatids due to decreased kinetochore function and imperfect spindle figures resulting in aneuploidy. mice oocyte data have shown a correlation of abnormal histone de-acetylation and aneuploidy and a correlation between age, remaining histone acetylation and aneuploidy (akiyama et al., ) . our research focused on human oocytes and investigated whether a similar relationship between histone acetylation, age and aneuploidy is present. human oocytes were surplus from standard ivf/icsi treatments (ic+). human oocytes showed immunostaining for histone , lysine acetylation (h k ) at the germinal vesicle stage and complete deacetylation at the mii stage in % of the oocytes, while % keep high levels of h k acetylation. treatment of germinal vesicle oocytes with a histon deacetylase inhibitor (tsa) during in vitro maturation until mii stage resulted in high levels of acetylation. remaining acetylation in tsa treated oocytes was correlated significantly with abnormal spindle figures (tubulin staining), a hallmark of developing aneuploidy. similarly, % of oocytes with naturally remaining h k acetylation showed abnormal spindle figures. in contrast % of the normal de-acetylated oocytes showed normal spindles (p= . ). this suggests that defective de-acetylation of h k in human oocytes leads to abnormal spindle figures and subsequent aneuploidy. advanced maternal age is associated with a reduction in de-acetylation during in vitro maturation and an increase in spindle abnormalities. these results may stimulate the development of assays for histone modifications as biomarkers to follow oocyte quality in in vitro maturation studies or in optimizing general ivf treatments. objective: racial disparity in preterm birth (ptb) is unexplained and genetic risk factors are suspected as a major cause. this large scale candidate gene study examines differences association of single nucleotide polymorphisms [snps] in caucasians (c) and african americans (aa) to help elucidate racial disparity in preterm birth (ptb) methods: in this case (preterm birth < weeks) control study (term birth > weeks) maternal and fetal dna from ( cases and controls) c and ( ptb and term) aa were collected. a high-throughput candidate gene association study was performed examining snps in genes of selected from hypothesized ptb pathways. single locus association analyses were performed separately on maternal and fetal samples. results: snps in genes associated with ptb (p< . ) were common between races with both maternal and fetal dna analyses. however, snps in genes in c and in aa in both maternal and fetal dna differed in its association with ptb. in c maternal dna, the single strongest association between ptb and snp was in plasminogen activator tissue (plat) gene (c- t; rs ) at both allelic (p = . x - ) and genotypic (p= . x - ) level with an odds ratio (or) of . ]. the single strongest effect in c fetal dna was observed in a snp in the interleukin- receptor antagonist gene (a g; rs ) for both allele (p= . ) and genotype (p= . x - ), or . ). in aa, the strongest associations were in interluekin- (c t-rs , allele p= . x - , genotype p= . x - ) in maternal dna with an or= . [ci . - . ] and in fetal dna interleukin- receptor b (a g; rs , allele p= . x - , genotype p= . x - ) with an or . ]. conclusion: large scale high throughput analyses of snps in candidate genes of ptb pathway reveals significant differences between races at both maternal and fetal levels. we found that the strongest single locus associations differed in the two races in both maternal and fetal dna samples. these findings support the hypothesis that underlying genetic predispositions may differ between these populations, perhaps partly explaining racial disparity in preterm birth. candidate gene association study indicates differential etiologies in gdm and in t dm. johann urschitz, tarik sultan, kenneth ward. obgyn, jabsom, university of hawaii, honolulu, hi, usa. objective: recently several genome-wide association studies have associated multiple single nucleotide polymorphisms (snps) in multiple genes with increased risk of type diabetes. as risk factors are similar between t dm and gestational diabetes (gdm), we investigated a possible association of those snps with gdm. study design: blood was collected from caucasian ( cases, controls) women who met coustan-carpenter criteria for gdm and non diabetic controls. dna was extracted and a candidate gene association study was performed (taqman, abi). results: chi contingency tests were used to analyze genotype and allele frequencies in controls and gdm affected pregnancies (see table below). none of the snps showed a significant association after bonferroni correction. conclusion: several polymorphisms which displayed highly significant associations with type diabetes are not associated with gestational diabetes. these results suggest that gdm is not a simple unmasking of a t dm predisposition by the metabolic demands of pregnancy; rather it appears that different biological mechanisms are responsible for the respective diseases. introduction: histone acetylation/deacetylation plays an important role in the regulation of gene expression. histone deacetylase inhibitors (hdaci), in general, maintain gene expression, although in some cases they cause repression of specific genes. in this context we have previously shown that the hdaci tsa suppresses activation of the pro-contractile gene cox- in human myometrial and amnion-derived cells [reproductive sciences, vol , no (supplement, # )]. we have also shown that expression profiles for hdacs ( - , ) differ significantly within upper and lower regions of the myometrium during pregnancy and in labour. objectives: since changes in both acetylation and phosphoryation status can influence the activity of individual hdacs we aimed to define whether there are any changes in the levels of acetylation and phosphoryation of myometrial hdac , and during pregnancy and labour. methods: protein homogenates prepared from non-pregnant, term and labouring myometrium were treated +/-shrimp alkaline phosphatase and subjected to sds-page and western immunoblotting (wb) using antibodies to hdac , and . the acetylation status of the hdacs was assessed by a co-immunoprecipitation assay using anti-hdac and anti-acetylated lysine antibodies. results: distinct patterns of acetylation were observed for the individual hdacs; hdac and appeared to be more acetylated in non-pregnant and labouring lower tissues when compared to pregnant myometrium. in contrast, hdac appeared to be slightly more acetylated in lower uterine samples from pregnant and labouring myometrium. in experiments to evaluate changes in phosphorylation status we observed that ) myometrial hdac appeared to less phosphorylated in both upper and lower labouring samples when compared to non-pregnant and pregnant samples; ) hdac appeared to be more phosphorylated in labouring samples than non-pregnant and pregnant myometrium; ) no changes in phosphorylation levels were observed for hdac using this test system. conclusions: the difference in hdac acetylation and phosphorylation levels in the human myometrium may indicate differential regulation of the activity of the hdacs within the distinct myometrial regions, perhaps leading to the alteration of their epigenetic effect on genes related to myometrial quiescence and contraction and the subsequent onset of both term and preterm labour. objective: native hawaiians and pacific islanders experience a higher perinatal morbidity secondary to the increased incidence and earlier onset of heart failure. this increased incidence is likely multi-factorial and includes co-morbidities and genetic factors. mutations in the human adrenergic receptor gene may play a role in the determination of heart function. mutations in the b -adrenergic receptor (adrb ) located on chromosome have been identified as a cause progressive cardiomyocyte loss leading to a dilated cardiomyopathy. the minor allele frequencies for most of these polymorphisms have been determined for caucasian, japanese, african-american and chinese as part of the hapmap project. the frequencies have not been determined in the pacific islander groups. this study helped determine the hawaiian allele frequency and determine the allele frequency in the presence of cardiac or other vascular co-morbidities such as hypertension, preeclampsia, and gestational diabetes. study design: real time pcr technology (taqman genotyping assays, applied biosystems) was used to screen maternal dna (n= ) from the phenotyping sample core of the pacific center for early human development (prcehd) for the rs single nucleotide polymorphisms (snps). genotype frequencies were also determined in % complete ethnic controls as determined by a four grandparent descent. results: chi square was used to analyze allele and genotype frequencies differences between controls and affected pregnancies. the results are summarized in the following tables. conclusion: the rs snp was not significantly associated with hypertension, preeclampsia or gdm in our overall hawaiian population. the genotype frequency in the % pacific islander group was significantly different from the caucasians (p= . ) and asians (p= . ) in our overall hawaiian population. angiotensin-converting enzyme and -adducin polymorphisms in preeclamptic mothers and fetuses. c mando, p antonazzo, s tabano, f colleoni, a martinelli, s calabrese, c benedetto, l marozio, f facchinetti, m miozzo, i cetin. inst. obstetrics and gynecology, fondaz. irccs policlinico mangiagalli regina elena, univ. milan, milan, italy; dept. biology and genetics, univ. milan, italy; dept.obstetrics and gynecology, univ. torino, italy; univ. modena and reggio emilia, modena, italy. background the genes encoding angiotensin-converting enzyme (ace) and -adducin (add ) share the potential of influencing blood pressure. previous studies demonstrated in humans the association of hypertension with the combined effect of both ace insertion/deletion (i/d) polymorphism, which leads to a different activity of the enzyme, and add g w non-sense single nucleotide polymorphism (snp). ace i-i genotype has been associated with low serum ace activity. controversial studies concerning the association of ace polymorphism with preeclampsia (pe) were reported and the possible combined effect of both ace i/d and add g w polymorphisms yet remains to be investigated. population association study we genotyped polymorphisms (ace i/d and add g w) in women: with pe ( / with severe pe) and controls. moreover, we investigated a subset of their fetuses: from severe pe, from mild pe and controls, in order to identify specific maternal and/or fetal genotypes conferring a higher risk to develop pe. we both evaluated the single and the combined effects of ace and add genotypes on mother-fetus couples and singularly on mothers and fetuses. ace i/d genotype was analyzed using a pcr method; an allelic discrimination approach was performed to detect the add snp. in mother-fetus genotype couples, neither ace nor add polymorphisms are associated with pe, nor are the combination of their genotypes separately in mothers and in fetuses. nevertheless in mothers with mild pe ace i-i genotype is significantly less frequent ( % vs %; p< . ) and ace i-d is significantly more frequent ( % vs %; p< . ) compared to controls. ace i allele frequency is not significantly different in mild pe compared to controls ( % vs %). in women with mild pe the i allele seems to move from i-i to i-d genotype. it leads to the increase in mild pe women of those genotypes with a higher ace activity conferring a higher susceptibility to develop pe. this association with mild pe and not with severe pe could be due to the contribution in the latter of many other genetic and environmental factors. introduction: maternal mrnas stored in the oocyte are critical for early development as transcription ceases upon oocyte maturation, and gene expression until zygotic genome activation (zga) is mediated by translation of maternal transcripts. cytoplasmic polyadenylation element binding protein (cpeb) plays a central role in this process by stabilizing maternal mrnas and regulating their timely activation. this function has been well characterized in xenpous, and a similar role in mammals is suspected as the cpeb knockout mouse displays infertility as a result of arrested oogenesis. in order to investigate if translational regulation of maternal transcripts by cpeb is maintained in mammals, we characterized the spatial and temporal expression of cpeb- in the mouse and human. methods: ten different somatic tissues, testes, and ovaries were tested by rt-pcr for the expression of cpeb mrna in mouse and human. cpeb mrna expression in mouse was also tested in prophase i (pi) and metaphase ii (mii) oocytes, -cell, -cell, -cell, -cell embryos and blastocysts. in human, pi and mii oocytes, -cell embryos and blastocysts were evaluated. sequencing of the pcr products was performed to confirm specific amplification of cpeb. amplification with actin primers provided a positive control and allowed semi-quantitative analysis. results and discussion: highest level of cpeb mrna expression was detected in ovaries and testis of both mouse and human. in addition, differential expression of cpeb in somatic tissues was also observed. among these, prominent expression was present in brain, where a role for cpeb in facilitating gene expression through cytoplasmic polyadenylation has been proposed. these data would suggest that translational control of mrna by cpeb may be a mechanism utilized by multiple somatic tissues to regulate gene expression. in the mouse, cpeb was expressed in pi and mii oocytes and -cell and -cell embryos, and became undetectable in -cell or more advanced embryos. human cpeb was expressed in pi and mii oocytes, but not in -cell embryos or blastocysts. zga occurs at late -cell stage and -to- -cell stage, in mouse and human, respectively. the tightly controlled temporal expression of cpeb prior to zga in both mouse and human is consistent with a conserved role for cpeb in the regulation of maternal mrna expression during early development in mammals. background embryonic stem cells (esc) express specific transcription factors that are indicative of their ability to maintain pluripotency. these factors are activated during preimplantation embryo development. the interplay between the transcription factors pou f (oct / ) and caudal-homeobox domain (cdx ) is thought to regulate inner cell mass (icm) and trophectoderm (te) differentiation; however, the mechanism of cell fate determination in mammalian embryos is poorly understood. genetic ablation of oct / in mice prevents icm development, while cdx knockout embryos fail to implant. esc deficient in nanog, a second key regulator of pluripotency, fail to maintain pluripotency and undergo differentiation. expression of nanog in primate embryos has not been investigated, therefore the localization of oct / , nanog and cdx was determined in rhesus macaque blastocysts. methods oocytes were collected from rhesus macaque females, fertilized and cultured in vitro to the blastocyst stage. embryos were collected hours post insemination, then fixed prior to incubation with primary antibodies directed against oct / , nanog and cdx . following incubation with cy conjugated secondary antibodies, nuclei were counterstained with dapi and embryos visualized using an olympus bx fluorescence microscope. results nanog protein was restricted to the icm of monkey blastocysts. unlike the mouse embryo, oct / protein was detected in both the icm and te, based on two different antibodies. the expression of cdx was localized specifically to the te. conclusions the ubiquitous pattern of oct / expression is consistent with observations in human, cow and pig embryos. significantly, lack of restricted oct / protein, and icm localization of nanog in primate blastocysts, suggests that nanog more specifically determines cell fate in primate embryos. these results contrast markedly with current mechanistic hypotheses, although other factors may lie upstream of nanog. importantly, this difference may underlie observations that regulatory mechanisms in esc differ between mice and primates. further investigations will focus on determining the onset of marker expression, and the upstream regulators of nanog activation. supported by nih grants r hd r rr , and the intramural research program of nichd. in vitro-conceived mice tend to be smaller at birth and throughout their life. luisa delle piane, annemarie donjacour, francesca di sebastiano, gnanaratnam giritharan, paolo rinaudo. obstetrics, gynecology and reproductive sciences, university of california san francisco, san francisco, ca, usa. objective: epidemiological evidence indicates that ivf is associated with an increased incidence of low birth weight. this phenomenon has not been studied in a mouse model; in addition, it is unknown if the resulting offspring show different growth pattern later in life. we therefore created an ivf mouse model to follow growth patterns till adulthood. methods: we generated experimental groups of b mice: one cohort of in vivo generated mice (in vivo group), one cohort of in vitro generated animals (ivf group) transferred to cd foster mothers and one cohort of animals fertilized in vivo and transferred to cd foster mothers (flushed blastocysts group, fb). the fb group was generated because our preliminary results showed that embryo transfer to b foster mothers was not successful. all pups were delivered at term, measured and weighed at birth and then weekly up to weeks. parametric tests (anova with bonferroni correction) were used as appropriate. a mixed model was used to compare growth curves. results: average litter size was . (in vivo), . (fb) and . (ivf). birth weight of male mice both ivf ( . mg) and fb ( . mg) was larger than male in vivo mice ( . mg) (p< . ). ivf mice tended to be smaller than fb mice in both sexes (p= . ). the bmi (body mass index) was not different among all the groups. male fb growth curves were different from in vivo mice (p< . ) and more importantly from ivf growth curves (p= . ) (fig. ) . conclusion: the method of conception and the maternal environment play a significant role in determining birth weight in this mouse model, emphasizing that the fb group is the best control for the effects of ivf in this model. these preliminary results confirmed for the first time an ivf effect on growth and interestingly the ivf males did not show a catch-up growth. the finding of smaller ivf mice when compared to fb is both noteworthy, because it confirms human data, and worrisome, because lower birth weight is associated with long term sequelae according to the barker hypothesis. the effect of betamethasone exposure in mid-gestation on renal sodium excretion in male sheep. lijun tang, luke carrey, nancy valego, philip deibel, james perrott, jorge figueroa, mark chappell, james c rose. obestetrics and gynecology, wake forest university, medical school, nc, usa; hypertension center, wake forest university, medical school, nc, usa. objective: whereas prenatal exposure of ovine fetuses to clinically relevant doses of glucocorticoids during the time of peak nephrogenesis results in a reduction in nephron number in adulthood, there is little information about its effect on sodium excretion. in the present study, we evaluated the effect of exposure to betamethasone on renal sodium excretion in adult male sheep. methods: we studied nineteen conscious adult rams at . years of age which were exposed to either vehicle or betamethasone at - days gestation. we implanted vascular and bladder catheters and then allowed the animals a - days recovery period prior to study. inulin and para-aminohippuric acid (pah) clearances were performed for estimating glomerular filtration rate (gfr) and renal plasma flow (rpf) respectively. following determination under basal conditions, an acute hypertonic sodium load was administrated intravenously by a continuous infusion of nacl ( . meq/kg/min at . ml/min) for minutes. urine was continuously collected for determination of na + excretion. results: basal gfr was decreased in steroid exposed adults ( . ± . ml/min/kg) compared with the vehicle animals ( . ± . ml/min/kg) (p= . ). rpf was similar in the vehicle and steroid exposed group ( . ± . ml/min/kg vs . ± . ml/min/kg). at basal conditions, na + excretion (u na v) was similar in vehicle and steroid exposed group ( . ± . μmol/h vs . ± . μmol/h). this similarity was also present after normalization by body weight ( . ± . μmol/h/kg vs . ± . μmol/h/kg). the vehicle group excreted . ± . % of the dose of na during the experiment while the betamethasone exposed group excreted only . ± . % (p< . ). gfr and prpf did not change during the experiments. these results suggest that prenatal exposure to glucocorticoids affects renal function in adult male sheep which results in a decreased basal gfr and an attenuated ability to excrete on acute sodium load. the elevated blood pressure previously observed associated with this prenatal steroid treatment may be related to the alteration in renal function. the study is supported by nih grants hd , hl and hd . characterisation of human fetal cardiac stem cells. marah alfakir, nicholas dawe, annette meeson, stephen c robson. school of surgical reproductive sciences, newcastle university, newcastle upon tyne, united kingdom. objectives: for many patients with severe cardiac disease treatment is limited to surgical intervention and/or heart transplantation. the heart has a limited regenerative capacity but it is insufficient to repair extensive damage. cellular therapies might provide an alternative treatment. we have identified stem cells (sp cells) in the adult mouse and human heart and have shown that the mouse cardiac sp cells can differentiate along a cardiac lineage. sp cells can be identified using facs combined with hoechst dye efflux. this ability to efflux hoechst dye is due to expression of abcg (an abc transporter). we have hypothesized that the fetal heart would contain more cardiac stem cells, relative to the adult, and the aim of this project was to determine the spatial and temporal expression of known stem cells markers in the embryonic/fetal heart. methods: human fetal hearts were collected aged between - wk. we used rt-pcr, using primers for several stem cell (abcg , cd , cd ) and cardiac specific (mlc- v, mhc) markers, and ihc on frozen and paraffin sections, using a panel of antibodies (abcg , cd , cd , islet ). cdna was generated from the following regions of the heart at different developmental stages: right and left atrium, right and left ventricle, and outflow tract. results: abcg mrna was highly expressed in all regions of the fetal heart between - wk. expression was down regulated at - wk especially in the la and lv. a similar pattern of expression was observed for cd . cd showed low/moderate expression in all heart regions examined; however, this expression was absent in the lv at - wk. mrna and protein analysis showed similar results. whilst protein expression of abcg was robust at wk (approximately - %), it declined with increasing gestational age. cd was also strongly expressed at weeks of age. there was no co-localisation between abcg and islet . conclusion: abcg and cd are both expressed between - wk of age. based on this analysis, further studies are underway to isolate and characterise both the abcg and cd expressing fetal cardiac cells which might be a potential source of cardiac stem/progenitor cells. xanthine oxidase plays a significant role in the fetal cardiovascular defence to hypoxia. ja hansell, a kane, e herrera, da giussani. physiology, cambridge university, united kingdom. prenatal hypoxia remains a major concern in obstetrics. the fetal defence to hypoxia includes redistribution of the cardiac output, away from peripheral and towards essential ciculations, such as those perfusing the brain (cohn et al . ajog : , ) . the physiology underlying this response is well characterised and involves chemoreflex and endocrine responses (giussani et al. fet mat med rev : , ) . more recently, local factors such as nitric oxide (no) and reactive oxygen species (ros), and the interaction between them, have been shown to play a role. antioxidants, such as vitamin c, scavenge hypoxia-induced ros, maintain no high and thereby depress peripheral constriction (thakor et al., sgi ) . in this study, we address the source of hypoxia-induced ros production and investigated the effects on the in vivo fetal femoral constrictor response to hypoxia of maternal treatment with the xanthine oxidase inhibitor allopurinol in sheep. methods: under anaesthesia, sheep at . gestation, were instrumented with maternal and fetal catheters and a fetal femoral transonic probe. five days later, all animals were subjected to h normoxia, . h hypoxia (mat fio to reduce fetal pao to ca. mmhg) and h recovery, either following maternal i.v. treatment with vehicle or allopurinol in low ( mg.kg - over min) or high ( mg.kg - over min ) doses. treatments finished min prior to hypoxia. the low allopurinol dose was adopted from human studies (benders et al. arch dis child : , ) . the timing of the hypoxic challenge coincided with peak concentrations in fetal sheep plasma of oxypurinol (active metabolite). we evaluated the effect of bpa exposure on uterine gene expression in a nonhuman primate model. method: a total of nine vervet monkeys (cercopithecus aethiops sabaeus) were ovariectomized. three monkeys were treated with bpa via alzet pumps ( microgram/kg/day), two with estradiol benzoate and three received combined treatment with bpa and estradiol. the remaining monkey was untreated and served as a control. following days of treatment the monkeys were hysterectomized and immunohistochemistry performed to examine endometrial gene expression. we evaluated hoxa , proliferating cell nuclear antigen (pcna), and caspase iii gene expression as markers of differentiation, proliferation, and apoptosis respectively. differential expression was evaluated by h-score. results: exposure to a combination of estradiol and bpa resulted in increased expression of hoxa and pcna compared to control (p< . ). lower, but increased, levels of hoxa and pcna gene expression were seen in the specimens exposed solely to estradiol (p< . ). those specimens exposed to bpa alone demonstrated a small induction in hoxa expression (p< . ) with no change in caspase iii or pcna expression when compared to the control. conclusion: bpa induced the expression of hoxa in the uteri of a non-human primate. exposure in the presence of endogenous estrogen further augmented estrogenic stimulation confirming that bpa is a xenoestrogen. bpa's effect of developmental gene expression may alter uterine differentiation. bpa acts as an endocrine disruptor by altering estrogen regulation on a gene required for fertility. contractility and meconium passage. jayaraman lakshmanan, john d richard, guo l liu, sharon k sugano, ahmet karadag, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa; dept. of pediatrics, harbor-ucla med. ctr., torrance, ca, usa. objective: endogenous glucocorticoids (gcs) increase with advancing fetal age suggesting that gcs function as a hormonal modulator of organ maturation. although fetal colonic motility and meconium passage primarily occur near term, the role of gc in colonic maturation is poorly understood. we sought to examine gc-nuclear receptor (gc-nr) expression in ovine fetal distal colon smooth muscle from very-preterm to term gestation to define the cascade of gc initiated biochemical changes as a prerequisite for maturation-associated meconium passage. methods: ovine fetal distal colonic segments removed at very-preterm (vpt: - d gestation), preterm (pt: - d), near term (nt: - d) and term (t: - d) (n= fetuses in each group) were fixed in bouin's solution and paraffin embedded. sections were subjected to immunohistochmical analysis with gc-receptor antibody ( : , sc- , santacruz biotechnology, ca) using standard abc regimen. immunoreactive material identified by , 'diaminobenzidine as chromogen. the percentage of gc-nr staining in smooth muscle-enteric unit was analyzed by counting dark brown immunostained nuclei at different fields at x magnification. all values are expressed as mean ± sem. results: the gc-receptor antibody immunostained nuclei both in smooth muscle and enteric units and the observed pattern (expressed as percentage of total nuclei) are as follows: nuclear gc expression varies with gestational age with maximal expression occurring near-term in smooth muscle and enteric neurons, in a synchronized manner. a near total disappearance of gc-nr expression occurs at term. these results suggest that peak gastrointestinal gc-nr mediated effects may occur prior to term with secondary signaling effects resulting in distal colonic motility maturation and meconium passage. the rna-binding protein hud co-localizes with choline acetyl mechanisms of in utero meconium passage. jayaraman lakshmanan, john d richard, guo l liu, sharon k sugano, octavio balbuena, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: we have previously speculated that crf, acting through its receptor crf-r , increases gastrointestinal (gi) motility and potentiates in utero meconium passage. patients with paraneoplastic syndrome with auto-antibodies to hud, a neuronal rna binding protein, develop severe gi dysmotility, indicating a role for hud in gi motility. hud binds mrna for actylcholinesterase implying a role in the cholinergic neurotransmitter system. based on these known functions, we hypothesized that hud may regulate post-transcriptional activity in fetal colonic cholinergic neurons expressing crf-r . method: bouin's solution-fixed paraffin-embedded sections of distal colonic segments were prepared from very preterm (vpt: - days), preterm (pt: - days), near term (nt: - days) and term ( - days) ovine fetuses (n= at each age). sections were immunostained with anti-human neuronal protein huc/hud antibodies ( : to : ) with abc reagents and examined at x. neurons positive for hud staining were quantified. double immunofluorescence and laser confocal analyses evaluated co-expression of hud in neurons expressing peripheral choline acetyl transferase (pchat) (a marker for peripheral cholinergic neurons) and crf-r receptor. results: hud immunostaining was seen in either entire cytoplasm (c) or cytoplasm and nuclear regions (c+n) in both submucosal and myenteric neurons. a greater percentage of submucosal (vpt: ± , pt: ± , nt: ± , and t: ± %) than myenteric neurons (vpt: ± , pt: ± , nt: ± , t: ± %) exhibited positive staining at all ages. the percentages of neurons with c+n staining in submucosal neurons were significantly lower at very-preterm gestation. confocal studies co-localized the hud staining with pchat and crf-r receptor immunoreactivity both in submucosal and myenteric neurons. conclusion: in the fetal enteric nervous system hud may function both as a rna-binding protein and as a nuclear cytoplasmic shuttling protein. colocalizaion studies suggest that both pchat-mrna and crf-r mrna species are target transcripts for hud in myenteric neurons. we speculate upregulation of hud contributes to in utero meconium passage. meconium passage during mild stressors. jayaraman lakshmanan, guo l liu, john d richard, sharon k sugano, raina khan, octavio balbuena, kimberly chap, virender rehan, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa; dept. of pediatrics, harbor-ucla med. ctr., torrance, ca, usa. objective: mr exhibit a greater affinity to glucocorticoids (gc) than do glucocorticoid receptors (gr). thus low circulating gc levels may preferentially bind mr during mild-stress periods, while the high gc levels may bind gc-receptors. mr antagonism increases gc-mediated responses, suggesting that mrs have a regulatory impact on gc-mediated stress responses. we recently documented that fetal in utero meconium passage is a neurovisceral stress response. to test our hypothesis that mrs play a primary role in mediating suppressive gc effects, we examined the expression patterns of mr in ovine fetal distal colon. methods: bouin's solution fixed paraffin sections of distal colonic segments collected from ovine fetuses (n= for each gestational ages) at very preterm (vpt: - days gestation), preterm (pt: - days), near term (nt: - days) and term (t: - days) were subjected to immunohistochemistry with polyclonal antibodies to mr. digital photos ( field per colonic ring, rings each gestational age) taken at x were used to count the number of intensely stained neurons, referred to as "mr-capped neurons". differences over time were determined with anova. results: mr antibody elicited a punctate staining pattern in all layers of ovine fetal distal colon. significant immunoreactive intensity was observed in submucosal and myenteric ganglia at all ages: submucosal ganglia: vpt= . ± . , pt= . ± . , nt= . ± . , t= . ± . ; a subpopulation of enteric neurons exhibited dense staining ("mr-capped"). advancing gestation was associated with a significant decreased in the percentage of mrcapped myenteric (vpt = ± , pt = ± , nt = ± , t = ± %; p< . ), though not submucosal ganglia neurons. results indicate a significant decrease in the percentage of mr capped myentric neurons with advancing gestation. in view of the potential inhibitory effect of mr on gc-mediated stress responses, these results suggest that the decrease in mr expression may contribute to near term and term in utero meconium passage. the ambiguity of myometrial progesterone receptor expression in pregnancy and labour. alison j tyson-capper, elizabeth a shiells, stephen c robson. surgical reproductive sciences, institute of cellular medicine, newcastle university, newcastle upon tyne, united kingdom. background and aims: in contrast to many other species, human parturition is not due to a reduction in circulating levels of progesterone (p) but appears to be related to changes in expression, ratios or signalling events of p receptors (pr-a and pr-b). the literature on pr expression in human myometrium in pregnancy and labour remains conflicting. we hypothesise this is due, at least in part, to differing specificities of the various pr antibodies employed. we carried out a comprehensive analysis of pr expression using ten 'pr-specific' antibodies that recognise different amino acid epitopes within the pr proteins. two phosphorylation-specific antibodies for pr were also included to define whether phosphorylation status of myometrial pr changes in pregnancy and in labour. methods: western immunoblotting and semi quantitative rt-pcr were undertaken using protein lysates and rna prepared from myometrial tissue from: -first (n= ) and second (n= ) trimesters, paired upper and lower segment myometrium from preterm ( - wks, n = ), term not in labour (n = ), term spontaneous labour (n = ) and non pregnant (n = ). results: using the same set of myometrial lysates for each antibody, we found that the specificity of individual pr antibodies, in particular those raised against internal and c-terminal epitopes of the pr proteins, varied considerably resulting in different patterns of expression. there also appeared to be temporal and spatial differences in levels of myometrial pr proteins ( - kda/ - kda) in pregnancy and in labour with use of the phosphorylation-specific pr antibodies, however, it remains to be resolved which pr isoforms these may be. in contrast, data using four antibodies all of which react with the amino terminal domain of pr consistently indicated that expression of pr, in particular pr-b, decreased significantly at term (p < . ) and in labour (p < . ) when compared to non-pregnant levels. a decrease in levels of pr-b protein was also observed when comparing preterm levels to non-pregnant levels. rt-pcr using primers specific to pr-b consistently indicated that levels of pr-b mrna decreased at term and in labour. conclusion: interpretation of gestation-related changes in myometrial pr expression and phosphorylation status must take into account the pr antibodies used. further studies are now underway to validate the specificity of the pr antibodies. objective to test the hypothesis that expression of fshr in mural gl cells from ivf follicles varies with the infertility diagnosis and correlates with the outcome of ovulation induction (oi). materials and methods women undergoing ivf were classified as: . "no ovarian factor", (tubal or male factor and egg donors, nof;n= ); . endometriosis (endo; n= ); . poor responders (pr; n= ); . polycystic ovary syndrome (pcos; n= ). ovulation induction was carried out using a long or microflare or antagonist protocol based on clinical parameters and gonadotrophin doses were selected based on ovarian reserve (day fsh and e and basal antral follicle count) and adjusted to the individual response. after ultrasound guided egg retrieval, mural gl cells were isolated from pooled follicular fluids from each patient using a percoll gradient and anti-cd immunobeads to eliminate wbcs, viability was assessed by trypan blue. fshr was measured by rt-pcr as relative expression compared to beta actin. statistical analysis was performed with the spss using pearson´s correlation, one way anova and student´s t-test. results fshr expression in nof ( ± . ) was statistically significantly higher than in pr ( ± . ) and lower than in pcos ( ± . ). both endo ( ± . ) and pr levels of fshr were statistically significantly lower than in pcos. analysis of all cycles showed that fshr expression correlates positively with the number of total (r= , ; p< , ) and mii (r= , ; p< , ) oocytes and negatively with the units of fsh (r=- , ; p< , ) and lh (r=- , ; p< , ) administered for oi. separate analysis of nof showed a positive correlation with the number of total and mii oocytes retrieved and with estradiol levels on day of hcg but not with the total dose of gonadotropins received during oi. fshr expression correlates negatively with day fsh levels in all patients except in pcos (r=- , ; p< , ). conclusions these results suggest that expression of fshr in the hyperstimulated ovarian follicle is "average" in normoresponders, high in high responders (pcos) and low in poor responders (pr and endo). knowledge of the level of expression of fshr might be useful to individualize gonadotrophin doses and oi protocols thus improving pregnancy rates. comparison of intracellular atp levels between non-vitrified and surviving post-vitrification/thawed human oocytes. somjate manipalviratn, zhi-bin tong, eric widra, , alan h decherney. reproductive biology and medicine branch, nichd/nih, bethesda, md, usa; department of obstetrics and gynecology, georgetown university hospital, washington, dc, usa; shady grove reproductive science center, washington, dc, usa. objective: to compare intracellular atp level in non-vitrified and surviving post-vitrification/thawed human oocytes using an atp bioanalysis assay. design: prospective match-controlled laboratory study material and methods: all oocytes were obtained from women undergoing controlled ovarian stimulation for ivf/icsi. oocytes were discarded due to nuclear immaturity at the time of planned icsi. all immature oocytes (gv and mi) were incubated overnight. oocytes from patients with or more discarded eggs which matured to mii stage were used in this study. oocytes from each women were randomly divided into groups. in group , the oocytes were placed in l of ultrapure water and kept at - o c for further atp analysis. in group , the oocytes were vitrified using % ethylene glycol, % dimethyl sulphoxide and . m sucrose as cryoprotectant. these oocytes were kept in liquid nitrogen for - days before thawing with a rapid thawing method. oocyte survival was determined by morphological assessment after minutes of incubation then oocytes were placed in l of ultrapure water and kept at - o c for further atp analysis. intracellular atp level was determined using luciferin-luciferase bioluminescent assay. result: ninety-one discarded human oocytes were obtained from women. oocytes were vitrified/thawed before measuring for atp content. the other oocytes were measured for their atp content without undergoing vitrification/thawing process. oocyte survival rate after vitrification/thawing is . % ( / ). mean oocyte atp levels in non-vitrified oocytes is significantly higher than surviving post-vitrification/thawed oocytes (table ). coefficient of variation of luciferin-luciferase bioluminescent assay is less than %. conclusion: oocyte atp level in surviving post-vitrification/thawed human oocytes is significantly lower than non-vitrified oocytes. objective to study the expression of genes involved in cell proliferation and steroidogenesis in the human follicle (kl , kl , fshr, papp, p ) and its relationship with ivf outcome. materials and methods patients with different infertility diagnosis underwent ovulation induction with either a long or microflare or antagonist protocol based on clinical parameters; the dose of gonadotrophin used for ovulation induction was selected based on the ovarian reserve (day fsh and e and basal antral follicle count) and adjusted to the individual patient response. ultrasound guided egg retrieval was performed hours after administration of . iu of hcg. mural granulosa-lutein cells (gl cells) were isolated from pooled follicular fluids (ff) from each patient using a percoll gradient and anti-cd immunbeads to eliminate wbcs, viability was assessed by trypan blue. the genes under study were measured by rt-pcr as relative expression compared to actin. statistical analysis was performed with the spss statistical software using pearson´s correlation and mann-whitney u. results kl expression correlates positively with kl levels (r= , ; p< , ) and with genes implicated in granulosa cell function such as fshr (r= , ; p< , ), papp (r= , ; p< , ) and p (r= , ; p< , ). the number of mii oocytes obtained is positively correlated with both fshr (r= , ; p< , ) and papp (r= , ; p< , ) expression, but not with the other genes. kl expression in women who became pregnant during the ivf cycle studied was higher ( , ± ) than in non pregnant women ( , ± , ).(n= , mann-whitney u p< , ). conclusions patients who become pregnant have increased expression of kl , which is associated with optimal granulosa cell proliferation and maturation. this is in accordance with the presence of lower apoptosis in granulosa cells in the same patients. syndrome during assisted reproduction treatment. k jayaprakasan, r jayaprakasan, h al-hasie, js clewes, bk campbell, ir johnson, nj raine-fenning. school of human development, university of nottingham, nottingham, united kingdom. objective: to test the hypothesis that an increased pre-treatment ovarian blood flow is associated with the development of ovarian hyperstimulation syndrome (ohss) and to evaluate ovarian vascularity as a predictor of ohss during invitro fertilization (ivf). methods: subjects undergoing first cycle of ivf had d transvaginal ultrasound in the early follicular phase of the menstrual cycle preceding ivf. of them developed ovarian hyper-response, defined as retrieval of oocytes and ohss. subjects had normal ovarian response with retrieval of to oocytes in the absence of ohss. antral follicle count (afc), ovarian volume (ov), and ovarian vascularity (vascularisation index, vi; flow index, fi and vascularisation flow index, vfi) were measured and an unpaired t-test was used to compare these parameters between the ohss and the control groups. multiple logistic regression analysis was used to assess the predictive value of these variables against age, bmi and basal fsh for the development of ohss. results: the ovarian vi ( . ± . vs. . ± . ), fi ( . ± . vs. . ± . ) and vfi ( . ± . vs. . ± . ) were similar in both the groups. afc and ov were significantly higher (p< . ) in the ohss group ( . ± . and . ± . cm respectively) than in the control group ( . ± . and . ± . cm respectively). afc was the only significant (p= . ) predictor of ohss on multiple regression analysis (table ) . conclusion: women developing ohss during ivf do not demonstrate an increased pre-treatment ovarian blood flow as measured by d ultrasound but do have a significantly higher afc, which is the only significant predictor of ohss. compared to other species, little is known about the steroid biosynthetic capacity and gene expression profiles of human cumulus cells. objective: to examine the ability of human cumulus cells in primary and long-term culture to synthesize steroids and respond to gonadotropin or camp-dependent stimulation. methods: human cumulus cells were isolated from cumulusoocyte complexes during assisted reproductive technology (art) and placed in primary culture or propagated to third passage. at subconfluence, cells were transferred into serum-free conditions in the presence of vehicle, forskolin, fsh, or hcg. at h, media was collected and progesterone (p ) and estradiol (e ) levels were determined by eia. aromatase activity was measured by the tritiated water assay. aromatase (cyp ) and cholesterol side-chain cleavage (cyp a ) mrna abundance was determined by quantitative real-time pcr (qrt-pcr). transcriptional regulation of the cyp and cyp a promoters was investigated by transient transfection of cumulus cells with promoter luciferase constructs. results: substantial amounts of p and e were synthesized by cumulus cells in culture, which were further elevated by forskolin, hcg, or fsh treatment. the presence of cyp and cyp a mrna in cumulus cells was confirmed by qrt-pcr, and the relative mrna abundance of both transcripts was induced by forskolin, hcg, or fsh treatment. changes in cyp and cyp a gene expression in response to camp and gonadotropin stimulation were associated with increased transcriptional regulation of both the cyp and cyp a gene promoters. our studies demonstrate that human cumulus cells are sites of significant p and e biosynthesis and respond to camp-and gonadotropin-stimulation in vitro. the ability to examine human cumulus cells in primary and long-term culture provides a unique model system to investigate cumulus cell function, and the paracrine role of cumulus cells in oocyte development, maturation, and subsequent fertilization. background: there is increasing evidence suggesting that events occurring during fetal development may result in increased predisposition to adult conditions, such as diabetes. in vitro fertilization (ivf) is a new environmental stressor and the long-term effects of these manipulations are currently unknown. there is some evidence that lower number of insulin-secreting cells at birth signals predisposition to diabetes later in life. in this study, we compare areas of pancreatic insulin-secreting cells in newborn mice conceived in vivo versus in vitro. methods: oocytes were collected from super ovulated cf- mice and fertilized in vitro with cauda epididymal sperm from b d f /j mice. fertilized eggs were cultured in whitten medium under % co in humidified air at °c for h. blastocysts were transferred to the uteri of pseudo-pregnant recipients. control mice were allowed to conceive in vivo. the newborn animals were sacrificed within hours of birth. pancreases were sectioned, immunostained with anti-insulin, and total areas and stained areas were compared using t-test with two-tailed distribution. p value of < . was considered significant. results: there were total of newborn animals: females ( ivf, controls) and males ( ivf, controls). percentage of total pancreatic area occupied by insulin-secreting cells was lower in female ivf ( . mm , . %) animals compared to female controls ( . mm , . %) and higher in male ivf ( . mm , . %) animals compared to controls ( . mm , . %). the average of males and females was slightly lower for ivf ( . mm , . %) than controls ( . mm , . %). none of these differences were statistically significant. there was a trend in newborn female mice towards lower amount of insulin-secreting cells in the ivf offspring, suggesting possible predisposition to diabetes later in life. this effect was not observed in newborn males. while our study failed to demonstrate consistent and significant differences in the areas of insulin-secreting cells between newborn mice conceived in vitro and in vivo, the number of animals in the study may have been too small to show significant results. larger studies are needed to further investigate this question. peter s uzelac, phyllis risch, kassi shelton, steven t nakajima. obstetrics and gynecology, university of louisville, louisville, ky, usa. objective: several fertility preservation methods currently available may not be viable options to certain patients due to their high cost and limited number of centers offering these services. for women undergoing bilateral oophorectomy, in vitro maturation (ivm) of oocytes retrieved from unstimulated whole ovary specimens may represent a more practical solution. here we describe out initial experience in offering ivm as a fertility-preserving measure to two patients undergoing total abdominal hysterectomy and bilateral salpingo-oophoectomy (tah-bso). case one was a year old nulligravid with chronic pelvic inflammatory disease unresponsive to medical management. case two was a year old nulligravid with stage ia endometrial carcinoma. surgery was planned for the mid-follicular phase in order to collect prophase i oocytes before the onset of late-follicular phase atresia. upon surgical removal, suction aspiration of all identifiable follicles was performed. ovaries were then serially sectioned and all tissue was examined for the presence of prophase i oocytes. results: total number of prophase i oocytes retrieved was and , maturation rate after hours was % ( / ) and % ( / ), fertilization rate after hours was % ( / ) and % ( / ), maturation rate after hours was % ( / ) and % ( / ) and fertilization rates after hours % ( / ) and % ( / ), for case and case respectively. ivm of oocytes retrieved from unstimulated whole ovary specimens may be a simple and inexpensive approach to fertility preservation in women undergoing bilateral oophorectomy. by requiring minimal adjustments to in vitro fertilization protocols, this treatment could easily be implemented in centers which currently have no fertility preservation program. patient age at time of retrieval may be predictive of developmental potential. continued patient enrollment and follow-up studies on the developmental potential of embryos derived from this technique are necessary to fully evaluate its potential for a role in fertility preservation. the routine use of progesterone as luteal phase support in women with a diagnosis of polycystic ovary syndrome (pcos) undergoing ovulation induction cycles with oral agents has not been fully elucidated. we hypothesize that women with pcos utilizing either clomiphene citrate or letrozole, an aromatase inhibitor, should administer intravaginal progesterone in the luteal phase to increase pregnancy rates. design: retrospective chart review. materials and methods: cycle data from women with pcos undergoing ovulation induction with clomiphene citrate or letrozole at the university of cincinnati medical center from to were evaluated. diagnosis of pcos was based on rotterdam criteria and all other infertility diagnoses were excluded. clinical pregnancy rates (presence of fetal cardiac activity on ultrasound at - weeks gestation) in women who received intravaginal micronized progesterone ( mg bid) following ovulation induction (with and without intrauterine insemination) were compared to those who did not receive progesterone. results: no significant differences were noted in demographic parameters, including patient age or bmi. a total of cycles were evaluated in women treated with clomiphene citrate. clinical pregnancies were documented in . % ( / ) of cycles in the progesterone group compared to . % ( / ) of the non-progesterone group (p < . ). forty-three cycles were evaluated in patients treated with letrozole. clinical pregnancies were documented in . % ( / ) of cycles in the progesterone group compared to none ( / ) in the non-progesterone group (p < . ). conclusions: patients with pcos who used letrozole for ovulation induction had superior clinical pregnancy rates when using intravaginal micronized progesterone compared to women who did not receive luteal phase support. there was a trend toward increased clinical pregnancy rates in pcos patients utilizing luteal support following clomiphene citrate for ovulation induction. therefore, in women with pcos undergoing ovulation induction with oral agents, luteal supplementation with progesterone should be strongly considered, especially in those using letrozole. were measured and an unpaired t-test was used to compare these parameters between poor and normal responders. multiple logistic regression analysis was used to assess the predictive value of these variables against age and basal fsh for poor ovarian response. results: the ovarian vi ( . ± . vs. . ± . ), fi ( . ± . vs. . ± . ) and vfi ( . ± . vs. . ± . ) were similar in both poor and normal responders. afc and ov were significantly lower (p< . ) in poor responders ( ± . and . ± . cm respectively) than in normal responders ( . ± . and . ± . cm respectively). afc was the best (p< . ) predictor of poor ovarian response on multiple regression analysis ( objective: gay male couples increasingly seek parenthood through in vitro fertilization using an oocyte donor and a gestational carrier, but no studies describe this unique experience. the purpose of this study was to determine medical and psychosocial issues unique to gay men using art. design: qualitative analysis of semi-structured interviews with gay male couples seeking parenthood through art. materials and methods: sixteen gay males (eight couples) entering an art program were assessed through the use of a semi-structured interview. characteristics evaluated included age, relationship status, duration of their relationship, psychological health and stability, how the decision was made concerning who would donate the sperm, the decision to use an anonymous or known oocyte donor, and whether their gestational carrier was someone previously known to them or not. results: the average age of the men in this study was years. all eight couples were in a committed relationship and had been together for an average of . years. five of the couples ( %) had been joined in a civil union which is legal in the state of connecticut. all subjects were psychologically stable and in good health. six couples ( %) were very clear about which partner would inseminate the oocytes. of those couples, two felt that the older partner should donate; two felt that the partner who cared more about a genetic connection to the child should donate; and two felt that the partner with "better genes" should donate. the remaining two couples chose to inseminate equal numbers of oocytes in order to transfer an embryo from each partner. all couples chose an anonymous oocyte donor, two couples chose relatives as their gestational carriers, while the others chose carriers recruited through an agency. conclusions: participants in this study were determined to become parents through assisted reproduction. they had given thoughtful consideration to the medical and psychosocial issues unique to this process including which partner would be the genetic parent, and why. clomiphene superovulation. rb allen, az steiner, rh fogle, mj kalan, rj paulson. ob/gyn, usc keck school of medicine, la, ca, usa; ob/gyn, unc, chapel hill, nc, usa. intro: micro-dose hcg has been demonstrated to increase ovulation and pregnancy rates following clomiphene administration in women resistant to clomiphene. since micro-dose hcg stimulates growth in follicles expressing the lh receptor, we hypothesized that its use following clomiphene in women with unexplained infertility would increase the number of follicles that ovulate and subsequently, pregnancy rates. m m: irb approval was obtained for this prospective pilot study of women with unexplained infertility. on day # a baseline ultrasound was performed and serum fsh and e levels were measured. subjects were given mg of clomiphene daily from days - and then returned for serial ultrasounds on day # . when at least follicles mm were present, iu of hcg im daily was initiated. cycles were monitored by ultrasound every days until a +lh surge occurred. all subjects had previously undergone a cycle using clomiphene alone for superovulation followed by iui and these cycles were used for comparison. results: subjects, aged . ± . yrs (mean±sem) and bmi . ± . kg/m with . ± . yrs of infertility were enrolled. the mean fsh and e levels were . ± . miu/ml and . ± . pg/ml, respectively. there was an average of . ± . days from starting clomiphene to the attainment of follicles mm. out of the subjects had follicles mm by day # . a mean of . ± . days of treatment were required until ovulation occurred. there were twice as many follicles in the micro-dose hcg cycles, although due to the small sample size this did not reach statistical significance ( . ± . follicles, measuring . ± . mm in the micro-dose hcg cycles, compared to . ± . (p= . ), measuring . ± . mm (p= . ) in the control cycles). there was no difference in the endometrial thickness at the time of ovulation between the micro-dose hcg cycles and the control cycles: . ± . mm vs. . ± . mm (p= . ), respectively. all subjects had at least ovulatory sized follicles in the study cycles. % of subjects had an iui performed, however there were no pregnancies resulting from this study. conclusions: ) the addition of micro-dose hcg to clomiphene may allow more follicles to reach an ovulatory size, which should theoretically increase pregnancy rates ) this pilot study demonstrates that adding micro-dose hcg may increase the effectiveness of clomiphene when given in a superovulatory protocol. jessica salas, donald maier, john nulsen, claudio benadiva, lawrence engmann. obstetrics gynecology, university of connecticut, farmington, ct, usa. objective: to evaluate the antepartum, intrapartum, and neonatal complications in patients undergoing ivf using a gnrh-antagonist protocol where a gnrhagonist was used to induce final oocyte maturation. materials and methods: a retrospective review of data from high responders undergoing their st or nd ivf cycle using a gnrh-antagonist protocol who were triggered with leuprolide acetate (study group) or hcg (control) and achieved at least a singleton pregnancy reaching the third trimester. patients younger than years old were included. both groups received luteal phase support with intramuscular progesterone. the study group received estrogen patch supplementation. outcomes measured were antenatal and intrapartum complications, order of gestation, gestational age at delivery, birth weight, neonatal adverse outcomes, and congenital anomalies. pearson chi square, fisher's exact test, or independent t-test were used as appropriate. results: the baseline characteristics were different (table ) . maternal antenatal and intrapartum complications were similar in both groups ( . % vs . %, p= . ). there were more singletons in the study group ( . % vs . %, p< . ). a subgroup analysis of gestational age at delivery, birth weight, neonatal complications and congenital anomalies in singletons showed no difference (table ) . conclusions: this is the first study reporting the maternal and perinatal outcomes after gnrh-agonist trigger. differences in response to ovarian stimulation may dictate use of gnrh-agonist triggering for prevention of ohss, which may explain the differences in baseline characteristics. maternal and neonatal complications remain unaffected. table lupron (n= ) objective: moderate to severe ovarian hyperstimulation syndrome (ohss) occurs in - % of assisted technology cycles and carries the potential for severe complications. traditional management consists of hospitalization with intravenous fluids (ivf), bedrest, and close monitoring. early and aggressive paracentesis is an alternative method of treatment for ohss in an outpatient setting, but the economic consequences of the two treatment regimens have not been compared. design: cost-effectiveness analysis materials and methods: two scenarios, outpatient management with transvaginal paracentesis and conservative therapy with hospitalization, were compared. potential initial outcomes were analyzed for the conservative group to include hospitalization either in a ward hospital bed or the intensive care unit (icu) for an average of seven days. costs included ivf administration, ultrasound, and daily bloodwork. initial outcomes for the outpatient management group included no further therapy beyond the initial transvaginal paracentesis, bloodwork, ivfs, and ultrasound versus admission for an average of three days to a ward bed with similar management. the probability of the negative outcome for the conservative group was set at % (icu admission) and % for the outpatient group (regular hospitalization). results: the cost of conservative therapy including first tier complications ranged from a low of $ , to a high of $ , . the cost of outpatient management with aggressive paracentesis and its first tier complications ranged from a low of $ to a high of $ , . this resulted in an estimated cost burden of $ , to $ , for conservative management with hospitalization. the main improvement factor was that patients in the outpatient management group had a much lower likelihood for prolonged hospitalization than the conservatively managed group. conclusions: aggressive outpatient treatment of moderate to severe ohss with early paracentesis appears to be a cost-effective strategy. induction. zeynep alpay, michael p diamond, michael l kruger, elizabeth e puscheck. obstetrics and gynecology, division of reproductive endocrinology and infertility, hutzel hospital, wayne state university, detroit, mi, usa. introduction: aromatase inhibitors (ai) are a new method of ovulation induction and is proposed to replace clomiphene citrate (cc) due to their reported advantages. their superior effect is thought to be due to up-regulation of the estrogen receptors and increase in the sensitivity of the endometrium, resulting in better proliferation despite low estrogen levels in the circulation. objective: to compare the effect of different ovulation induction methods, including ai, cc and gonadotropins (gt) on the endometrium in infertility patients. methods: we reviewed ovulation induction cycles performed in our institution in the last one-year period retrospectively. there were gt, cc and ai cycles. age, gravida, day (d et) and midcycle (mcet) endometrial thickness, endometrial pattern (ep) on day of hcg injection, endometrial growth during the induction cycle (d-et), which was calculated by the difference between mcet and d et, and the pregnancy rates (pr) were compared. the ep was categorized as type a (homogenous and hyperechogenic), type b (intermediate isoechogenic pattern and a poorly defined central echogenic line), and type c (multilayered triple-line). chi-square, anova, t test and pearson correlation were used for statistical analysis. results: in all cycles, ep was closely related to the d-et (p < . ). this correlation appeared to be more pronounced when observed ep was compared with d-et (r = . ; p < . ) rather than with mcet (r = . ; p = . ). there was a reverse relationship between the age of the patients and ep (r = - . ; p < . ). a negative correlation was also found between the gravida and ep (r = - . ; p < . ). pregnancy rate was significantly correlated with ep (r = . ; p < . ). pregnancy rate was % in type a ep, . % in b, % in c when all cycles were analyzed. aromatase inhibitors and gt treatments each resulted in % type c pattern in contrast to % with cc (p = . for ai vs. cc; p = . for gt vs. cc). the d-et was greater in gt cycles compared with ai or cc (p < . ). conclusion: these results show that ep has a strong correlation with pr in ovulation induction cycles. additionally, ai and gt treatments have similar effects on ep. both ep and the growth of the endometrium during the induction (d-et) are good prognostic variables for the successful pregnancy initiation. ovarian response in patients undergoing ovarian stimulation after myomectomy. hyacinth browne, , desiree mccarthy-keith, , barbara stegmann, , alicia armstrong. , reproductive biology and medicine branch, nichd, nih, bethesda, md, usa; reproductive endocrinology and infertility, walter reed army medical center, washington, dc, usa. objective: the impact of myomectomy on ovarian function has not been wellstudied. other surgical treatments of fibroids, such as hysterectomy and uterine artery embolization, have shown an increase of fsh into the peri-menopausal range. the objective of this study is to examine ovarian response in infertile women undergoing ovarian stimulation after abdominal myomectomy. design: retrospective analysis. materials and methods: a retrospective analysis of all infertile women with known fibroids who had a failed art cycle, from january to , followed by an abdominal myomectomy and a subsequent art cycle was performed. women served as their own controls. ovarian function pre and post-myomectomy was assessed by age, day and fsh levels, days of stimulation, total gonadotropins used, peak estradiol level, number of oocytes retrieved, embryos obtained, and high-grade embryos, and pregnancy outcome. quantitative results are presented as mean + sd. results: four women had a failed art cycle and underwent an abdominal myomectomy prior to a subsequent art cycle. the mean age was and pre-and post-myomectomy, respectively. all subjects had uterine factor infertility. two of these women also had tubal factor infertility, and one had endometriosis and male factor infertility. we found no difference in ovarian response pre and post-myomectomy. pre-myomectomy post-myomectomy age (years) + . + . day fsh (u/l) . + . . + . day fsh (u/l) . + . . + . objective: anti-mullerian hormone ( amh) is produced by developing primordial follicles. amh levels are stable through the menstrual cycle and therefore can be drawn randomly. the objective of this study was to assess the association of anti-mullerian hormone ( amh) and oocytes obtained at ivf retrieval. design: cross-sectional cohort study. materials and methods: the study cohort is comprised of thirty women in cycles of in vitro fertiization (ivf). serum levels antimullerian hormone (amh) were drawn before starting an ovulation induction cycle for ivf. standard ovulation induction was performed with leuprolide flare and miu/ml per day of follicle stimulating hormone. we performed linear regression of log convert d oocyte number against the log converted amh level. serum amh was measured using an enzymatically amplified two-site immunoassay dsl- - active mis/amh elisa. statistical analysis was performed using spss version . . continuous values are presented as mean std error. results: the log number of oocytes retrieved was directly related to the log value of amh (p = . ). conclusions: our data demonstrate an association between serum amh and oocytes produced in response to ovulation induction. using amh levels in addition to fsh levels in evaluating for ovarian reserve and pregnancy outcome may help improve predictions of reproductive performance. support: foundation for reproductive medicine. context: prediction of outcome after in vitro fertilization (ivf) can be difficult due multiple factors. human chorionic gonadotropin (hcg) levels correlate with pregnancy outcome, but data that can be used to easily counsel patients on their possible outcome is lacking. objective: to investigate the use of hcg levels along with other significant factors to predict the likelihood of an ivf pregnancy progressing to the point of detection of cardiac activity by ultrasound design: retrospective data analysis of ivf cycles performed from january to july resulting in pregnancies. multiple logistic regression analysis modeling was performed to determine the factors most predictive of an ongoing early pregnancy and to assess possible confounding variables. setting: an academic fertility center. patients: patients undergoing in vitro fertilization using autologous fresh embryos. intervention: none main outcome measure: pregnancy continuation to the documentation of cardiac activity by ultrasound. results: maternal age, day (post-oocyte aspiration) hcg level, and day hcg levels were significant in predicting pregnancy outcome. day and day hcg levels were highly correlated and can be considered proxies for each other. the most accurate predictive model used only a single day hcg level and maternal age. the type of fertilization method used, the cycle number for that patient, and the number of embryos transferred were not found to be significantly different. ongoing pregnancy rates were directly proportional to day hcg level, and inversely proportional to maternal age. the incidence of multiple pregnancies also increased proportionally to the initial hcg level. % of ongoing pregnancies had hcg level > miu/ml. conclusions: a single day post-oocyte aspiration hcg level and maternal age are the most predictive of an ongoing ivf pregnancy. there was no difference in outcome between fertilization methods or number of embryos transferred. there is no benefit to obtaining serial hcg levels after the initial one. erk activation with u ( m)) reduced fsh stimulated cyclin d mrna expression by %. fsh has also been shown to stimulate mtor, a regulator of growth and proliferation of many cell types. inhibiting mtor activation with nm rapamycin for min significantly reduced fsh-mediated cyclin d mrna expression. dht exposure for hours also inhibited fsh stimulated mtor signaling, as shown by a % reduction in the phosphorylation of its down stream target p s kinase. furthermore, pretreatment with dht resulted in significantly reduced fsh-mediated tsc- phosphorylation, which is an upstream regulator of mtor pathway. further studies revealed that fsh mediated tsc- phosphorylation and mtor signaling is regulated by erk, but independent of akt. based on these results we conclude that elevated reduced metabolites of androgens inhibit fsh-stimulated pka-erk pathway resulting in the inhibition of multiple mitogenic signaling pathways leading to defective follicle maturation culminating in anovulation. thus, rescuing the erk activation might serve as a potential therapeutic target to restore normal granulosa cell proliferation in hyperandrogenic states. (supported by nih grant hd- ). searching pcos-genes: results of a genome screen for pcos in a dutch founder population. olivier valkenburg, annemarie g mulders, aida bertoli-avella, ben a oostra, joop se laven. department of gynecology and obstetrics, erasmusmc, rotterdam, netherlands; department of internal medicine, erasmusmc, rotterdam, netherlands. context: although the etiology of pcos is not yet fully understood, evidence has accumulated for a complex genetic background i.e. a combination of multiple genetic and environmental factors. to reduce genetic heterogeneity, this study was conducted in a genetically isolated population in the netherlands . objective: in order to identify genomic loci that are associated with pcos, a whole genome screen using highly polymorphic microsatellite markers was performed in a founder population. subjects and methods: pcos patients ( rotterdam criteria) were identified in the founder population (rucphen, the netherlands) of ± . inhabitants. patients underwent a standardized screening procedure that included clinical, ultrasound and endocrine evaluation. all patients plus unaffected first-degree family members were genotyped using polymorphic markers on (microsatellites) from the abi prism ® linkage mapping set md- (average spacing cm). association-analysis was performed with the transmission disequilibrium test (tdt, genehunter software). linkage analysis was performed in clusters of or more closely related patients (simwalk ). results: there was an average number of . alleles per polymorphic marker. the tdt identified two non-adjacent markers on chrome (d s and d s ) that showed significant association with pcos (p , ). other markers that showed significant association were positioned on chromosomes (d s ), (d s ), (d s ) , (d s ), (d s ) and seventeen (d s ) (all p values . ). linkage analysis in sub-pedigrees revealed no significant linkage for these, or other, loci with pcos. moreover the results of a prior report of linkage of a marker on chromosome (d s ) could not be confirmed. conclusions: the lack of consistent results suggests the absence of a consistent genetic background in this select group of pcos patients. this supports the hypothesis of a complex genetic background for pcos that allows relatively small contributions of multiple risk-genes to be involved in the pathogenesis of this syndrome. in this founder-population the genetic heterogeneity was not sufficiently reduced to find risk-loci in a genome wide screen using highly polymorphic markers with an average spacing of cm. objectives: to objectively quantify uterine and endometrial blood flow in women with polycystic ovarian syndrome (pcos) and to examine if this was different in women with different phenotypic expressions of the disease. methods: transvaginal d and d ultrasound was performed in women with pcos, as defined by the rotterdam criteria, and sub-group analysis conducted based on the subjects' body mass index (bmi), ovulation status, and hirsutism score. anova was used to compare the mean values between the groups. results: pcos women with clinical hyperandrogenaemia had significantly lower endometrial and subendometrial blood flow than their anovulatory normoandrogenic counterparts (table ). there were no differences between lean and obese women or between anovulatory and ovulatory women with pcos. the pulsed wave doppler parameters were similar in all three phenotypic groups. conclusions: hirsute women with pcos have impaired endometrial perfusion compared to their normoandrogenic counterparts which is only evident with d ultrasound and not conventional pulsed wave doppler. nusayba a bagegni, jill blaine, anuja dokras. obstetrics gynecology, university of iowa hospitals clinics, iowa city, ia, usa; obstetrics gynecology, university of pennsylvania, philadelphia, pa, usa. background: there is conflicting evidence on the association between pcos and early and late obstetric complications. it is unclear if the reported risks are independent of bmi, preexisting hypertension and diabetes. we examined the risk of early and late obstetrical complications in a large group of women with pcos compared to controls. methods: we reviewed pregnancy records of women with pcos (rotterdam criteria, n= ) and controls (tubal infertility, n= ) after in vitro fertilization at university of iowa from - . the wilcoxon rank sum test and fisher's exact test were used to evaluate differences between variables and logistic regression analysis was used to determine the independent risk of pcos. results: subject demographics and medical history are shown in table. the first trimester miscarriage rate was % in women with pcos and % in controls. after logistic regression analysis pcos was not associated with miscarriage (p= . ). the prevalence of gestational dm (gdm) was similar in both groups % pcos vs % controls. pcos was not associated with gdm after adjusting for age and bmi (p= . ). however, bmi was significantly associated with gdm after adjusting for age and pcos (p= . ). risk of both pre-eclampsia and pih was % in pcos and % in controls, but not statistically significant after adjusting for age, bmi and twin gestation. preexisting htn showed a significant association with preeclampsia (p< . ). there was no significant difference in preterm delivery, cesarean section, twin gestation, intrauterine fetal death and intrauterine growth restriction in the groups. conclusion: despite adequate power, our study did not detect an increased risk of miscarriage in women with pcos. obesity was a significant contributor to late obstetric complications, namely gdm. these findings may warrant aggressive counseling of women with pcos on the potential benefits of weight loss prior to pregnancy. objective: to assess the prevalence of polycystic appearing ovaries (pcao) as defined by the rotterdam criteria; and to determine whether metabolic parameters differ between regularly cycling women with pcao and those with normal ovaries. studies have demonstrated a population frequency of pcao of - %, with - % among women with regular cycles. most were performed in a young reproductive age population; none examined the impact of age. all were performed prior to adoption of the rotterdam criteria. recent studies have shown an increased prevalence of metabolic syndrome among women diagnosed with polycystic ovarian syndrome (pcos). however studies focused on women in their s found no increase in bmi or fasting insulin with pcao but regular menses. participants: women aged - with regular cycles (every - days) enrolled in the ova study, a population-based study of ovarian aging. each subject underwent a transvaginal ultrasound for assessment of ovarian volume and antral follicle count (afc). outcomes collected included waist measurements and hdl, ldl, total cholesterol, triglycerides, fasting glucose and insulin. pcao were determined by the rotterdam criteria (afc of on one ovary or ovarian volume > cc). student's t-test and chi-square tests were used to assess differences between those with and without pcao for continuous and categorical variables, respectively. the prevalence of pcao decreased with increasing age (table ) . of the women with pcao, % met the afc criterion only, while % met the volume criterion only, and % met both. women with and without pcao did not differ in waist measurements, or in fasting lipids, insulin, or glucose. the rotterdam criteria, while less subjective than those described by adams in , have led to an increased prevalence of pcao among women with regular menses, over / of women in their s. women with pcao do not differ from those with normal ovaries in metabolic parameters associated with pcos. consideration should be given to adopting an age-adjusted criterion for afc, or a combination of afc and ovarian volume, for diagnosing pcos. background: pcos, especially accompanied by obesity, has been reported to be associated with a characteristic dyslipidemia comprising elevated triglycerides (tgs) and depressed hdl, especially the hdl- fraction. this is an atherogenic profile; in fact, studies suggest low hdl- may correlate most strongly with cardiovascular disease risk. weight loss is a mainstay of treatment and improves all manifestations of the disease, but the optimal diet to recommend remains undetermined. preliminary studies show a high protein diet may improve total hdl levels and insulin responses. however, the effect of weight loss and dietary composition on hdl- levels in pcos has not been investigated. objective: to evaluate the fasting lipid profile in newly diagnosed obese pcos patients and to determine the effects of a high-protein diet with or without metformin on weight loss, hdl- and other lipoproteins, and menstrual cyclicity. methods: in this pilot retrospective observational study, the fasting lipid profile of obese women newly diagnosed with pcos was determined. they were then placed on a high protein ( - g/day), low carbohydrate ( - g/day) diet with or without metformin ( and %, respectively) and followed monthly for an average of months (range - ). results: at diagnosis, % had low hdl and % had low hdl- ; only % had elevated tgs. on the diet, the patients demonstrated an average weight loss of . lbs ( . to . , p< . ) and decreased bmi of . kg/m ( . to . , p< . ). hdl levels increased significantly ( % increase from . to . , p< . ), especially the hdl- fraction ( % increase from . to . , p< . ). triglycerides decreased as well ( . to . , p< . ). ldl decreased but did not reach statistical significance. resumed menstrual cycles, were started on oral contraceptives, and had a hysterectomy. pregnancies occurred. no difference was seen with metformin use. conclusion: a majority demonstrated decreased hdl and hdl- at diagnosis. the high protein diet resulted in significant weight loss and improvement in hdl- levels, as well as improvements in total hdl, tgs and menstrual cyclicity. metformin produced no added benefit. prospective trials based on these data will help determine the optimal diet to reduce the significant short-and long-term morbidity in the large population of women with pcos. resistin is an adipokine that has been associated with obesity and insulin resistance in animal models. studies on the role of resistin on insulin resistance in humans have been controversial. recently resistin has been shown to exert atherosclerotic effects and elevated resistin levels have been observed in women with coronary heart disease (chd). women with polycystic ovary syndrome (pcos) are at high risk for chd. our present study investigates potential association of resistin and markers of inflammation, c-reactive protein (crp) and insulin resistance in women with pcos. methods: thirty two women with pcos participated in the study. all were hirsute and had irregular cycles. nineteen women with normal ovulatory cycles who matched the pcos patients in bmi served as controls. fasting glucose, insulin, resistin and crp levels were measured in all women. after a high carbohydrate diet for days, a standard oral glucose tolerance test (ogtt) was performed. blood samples were collected for glucose and insulin before and , and hrs after g oral glucose. the area under the curve (auc) for insulin and glucose was calculated. women with overt diabetes were excluded from the study. results: fasting insulin levels ( . + . μu [±se] /ml) and insulin response to oral glucose (auc) ( . + . μu/ml) were higher (p < . ) in women with pcos compared to controls. all were insulin resistant with homa-ir value > . mol x μu / l . resistin levels in women with pcos ( . ± . ng/ml) was significantly (p < . ) higher compared to control women ( . ± . ng/ml). crp levels in women with pcos ( . ± ng/ml) was also significantly (p < . ) higher than the controls ( . ± ng/ml). there was a significant positive correlation between resistin and crp levels (r = . , p < . ). there was no correlation between resistin levels and fasting insulin levels or insulin auc. there was also no correlation between resistin levels and fasting glucose or glucose auc. conclusions: our results indicate that ( )women with pcos and insulin resistance have increased resistin levels, ( ) there is a strong association between resistin and crp ( ) elevated resistin and crp levels may predict women who are at increased risk for chd ( ) ) it is unlikely that resistin plays a major role on insulin resistance in women with pcos. vuk p jovanovic, enrico carmina, prati vardhana, michel ferin, rogerio a lobo. department of obstetrics and gynecology, columbia university, new york, ny, usa; department of internal medicine, university of palermo, palermo, italy. current diagnostic criteria for pcos includes both ovulatory (ov) and anovulatory or "classic" (c) phenotypes. in an effort to further characterize differences and /or similarities between these phenotypes, we studied hyperandrogenic women with pcos (age . ± . , bmi . ± . ) and age matched controls (age . ± . , bmi . ± . ). women with pcos were divided into weight matched (ov) n= and (c) n= groups. fat and weight distribution were assessed by dexa (total fat, r fat, trunk fat) as well as fasting levels of lh, e , mis/amh, kisspeptin and testosterone, the adipocytokines (leptin, adiponectin, visfatin and retinol-binding-protein- rbp ) and serum glucose, insulin and crp. the hyperandrogenic pcos groups had characteristically altered hormone profiles compared to matched controls. although total fat mass was comparable, women with c-pcos had a significantly larger waist circumference ( . . vs. cm, p< . ) trunk fat, r fat and %trunk and %r fat compared to ov-pcos (p< . ). leptin, rbp and visfatin did not significantly differ among the pcos subgroups although adiponectin was lower in the c-pcos group (p< . ). quicki was significantly lower in c-pcos ( . ± . vs. . ± . , p< . ) and insulin was higher ( . ± . vs. . ± . , p< . ). serum lh was also higher ( . ± . vs. . ± . , p< . ) but kisspeptin, testosterone and estradiol were similar. mis/amh ( . ± . vs. . ± . ng/ml, not significant) and crp ( . ± . vs. . ± . , p< . ) were higher in c-pcos. significant correlations (p< . ) were noted among kisspeptin/rbp (r . ), mis/testosterone (r . ), insulin/ %trunk fat (r . , p< , ), total fat/leptin (r . , p< . ), %trunk fat/adiponectin (r - . ). in conclusion, women with c-pcos when compared to similarly hyperandrogenic women with ov-pcos with similar bmi, have increased abdominal fat, and appear to have differences in serum lh, crp and increased insulin resistance. the latter, as well as subtle differences in the adipocytokines may explain these differences in anthropometric findings. problems of normal oogenesis and folliculogenesis but also disturbed oogenesis and folliculogenesis in polycystic ovaries are not fully understood. oocyte specific genes play an essential role in oogenesis and folliculogenesis. there are suggestions about possible role of some oocyte specific genes in etiopathophysiology of pcos. zona pellucida gene (zp ) is recently identified gene, which belongs to zona pellucida genes such as zp , zp and zp . the role of zp , contrary to above-mentioned other zp genes is not well described. the aim of this study was to analyze zp coding sequence and expression in patients with polycystic ovary syndrome. material included blood received from patients (mean age , +/- , years; mean bmi , +/- , kg/m ) with polycystic ovary syndrome. all patients with pcos were diagnosed with the use of eshre/asrm criteria from . dna was isolated from blood cells( after separation of blood cells from serum) using a dna isolation kit (qiagen ). genomic dna was used for in vitro amplification by pcr with a specific set of primers complementary to the coding sequence of the zp gene. products from each pcr reaction were examined by sscp method. samples with changes detected by sscp in comparison to control probes were cloned into plasmid vector and then automatically sequenced from a total of patient samples with pcos, we identified nucleotide changes in the zp coding seguence : silent nucleotide changes in exons , , , , and nucleotide change in the exon ( position , t>g). the mutation in exon ( t>g ) results in substitution of cystein for glycin of amino acid in position of zp protein. in summary, our data demonstrate that zp nucleotide changes account for % of patients with pcos. relationship between serum mullerian inhibiting substance levels and insulin in women with polycystic ovary syndrome. rebecca a chilvers, shilla chakrabarthy, summer james, xin ma, manubai nagamani. ob/gyn, university of texas medical branch, galveston, tx, usa. müllerian-inhibiting substance (mis) is a member of the transforming growth factor-superfamily of growth factors. it is expressed exclusively in granulosa cells and is believed to play a role in the regulation of follicle selection and maturation. women with pcos have anovulation and most of them have hyperinsulinemia. the purpose of our study is to investigate possible association between insulin and mis in the dysregulation of folliculogenesis in pcos. methods: twenty one women with pcos who had anovulatory cycles and hyperandrogenism were recruited for the study. sixteen women with ovulatory cycles and matched the pcos patients in age and bmi served as controls. an oral glucose tolerance test (ogtt) was performed in all women. blood samples were obtained at fasting and , and hours after glucose ingestion for measurement of glucose and insulin. to investigate the effect of hyperinsulinemia on mis secretion, mis levels were measured in ten patients during the ogtt. fasting mis, testosterone, dheas, fsh, and lh levels were measured in all patients. results: fasting insulin levels ( . + . μu/ml) vs . + μ u/ml [+ se]) (p < . ) and area under the curve (auc) of insulin ( . + . vs . + . μu/ml) (p < . ) were significantly increased in women with pcos compared to control women, while the glucose levels were normal indicating insulin resistance. mis levels were significantly (p < . ) increased in women with pcos ( . + . ng/ml) compared to controls ( . + . ng/ml). there was no correlation between age and mis levels in pcos patients while there was a highly significant negative correlation between the age and mis levels in the control women ( r = - . , p< . ). there was significant negative correlation between mis and fasting insulin levels (r = - . , p < . ) and insulin auc during the ogtt (r = - . , p < . ). there were no changes in mis levels during ogtt. conclusions: results of our study indicate that in women with pcos, ( ) there is an increase in secretion of mis, ( ) higher insulin levels are associated with lower mis levels, ( ) acute increase in insulin levels has no effect on mis levels, ( ) lower mis levels in women with severe hyperinsulinemia could be due to associated increased follicular atresia and a decrease in the ovarian reserve. further studies are needed to investigate the role of insulin on mis secretion. hiroyuki asakura, noriko tanaka, kyoko nishio. ohgimachi ladies' clinic, osaka, japan. objective: elevation of serum anti-müllerian hormone (amh) levels among polycystic ovary syndrome (pcos) patients has been reported. however, the regulatory factors of amh in pcos remain unknown. we examined correlations between amh values and various indices of insulin resistance in pcos women. methods: infertile women compatible with rotterdam criteria for pcos were recruited under informed consent. the subjects underwent g oral glucose tolerance test ( ggtt, sampling at , , minutes), and -step elisa for amh (sensitivity . pmol/l, inter intra-assay c.v. : . %, . %, respectively). p< . was considered as statistical significance. results: average amh level of the subjects (age: . + . years, bmi: . + . kg/m , mean+s.d.) was . + . pmol/l, which was higher than normo-ovulatory women ( . + . pmol/l, n= ). amh levels had significant positive correlation with total ovarian volume by ultrasound ( . + . cc), but not with bmi, waist-hip ratio ( . + . ), and levels of serum lh ( . + . iu/l), total testosterone ( . + . ng/dl). although fasting glucose levels ( . + . mg/dl) were positively correlated with total ovarian volume (r= . ), amh levels had no significant correlation with fasting insulin ( . + . iu/l), fasting glucose/insulin ration ( . + . ), homa-ir ( . + . ), and the sum of insulin levels ( . + . iu/l)during ggtt. conclusions: increased serum amh level of pcos and its positive correlation with total ovarian volume implies that determination of serum amh level would aid in confirming diagnosis of the ovulatory disorder. absence of relationship between amh and various clinical indices of insulin resistance suggests alternative regulatory factors of amh gene expression in the follicular compartment. reproductive tissues. amisra a nikrodhanond, keeley l mui, helen h kim. ob/gyn, university of chicago, chicago, il, usa. background: although primarily a neuroendocrine hormone, gonadotropinreleasing hormone (gnrh) is also produced in reproductive tissues, where it acts locally. the study of gnrh regulation in these tissues is limited by low levels of expression. objective: to elucidate mechanisms that regulate gnrh expression in male tissues, our objective was to identify regions of the gnrh gene that target expression in vivo. methods: transgenic mice were generated with different fragments of the mouse gnrh gene promoter (- /+ and - /+ bps), fused to the luciferase reporter gene. in these mice, luciferase activity (detected as light) reflects gnrh promoter activity. using bioluminescent imaging, gnrh promoter activity was assayed in live gnrh-luc mice and in their reproductive tissues ex vivo. to confirm imaging results, luciferase activity was also measured as relative light units (rlu) in tissue homogenates. for each dna construct, male mice were examined. with whole-body imaging, bioluminescence was detected in the genital region of the gnrh-luc transgenic mice (fig.a) . in mice that incorporated the - luc transgene, examination of reproductive tissues ex vivo revealed bioluminescence in the prostate and penis, but not in the seminal vesicles, epididymis, or testes (fig.b) . in contrast, in the - luc mice, bioluminescence was detected in the testes, but not in other tissues (fig.c) . examination of luciferase activity in tissue homogenates from - luc mice confirmed gnrh promoter activity in the prostate ( ± rlu) and penis ( ± rlu) and absence in the testes ( ± rlu). in the - luc mice, however, luciferase activity was detected only in the testes ( ± rlu) and not in the prostate ( ± rlu) or penis ( ± rlu). conclusions: our studies demonstrate that gnrh is present in male reproductive tissues, but may be differentially regulated in the testes vs. prostate/penis. promoter elements, contained within the proximal - bp of the mouse gnrh gene, are sufficient to mediate testicular gnrh expression while - bp of the gene promoter are necessary to direct expression to the prostate and penis. characterization of mouse ringo/speedy homologues. z walton, s uckac, o guzeloglu-kayisli, md lalioti, d sakkas, e seli. ob gyn, yale u., new haven, ct, usa. introduction: ringo/speedy (ringo/spy) is a recently discovered cyclindependent kinase (cdk) activator that functions similar to cyclins in controlling the cell cycle. ringo/spy plays a crucial role during meiotic maturation in xenopus by inducing meiotic g /m progression and germinal vesicle breakdown (gvbd). more recently, padmanabhan and richter demonstrated that ringo/spy mrna is repressed in the xenopus oocyte cytoplasm by pumilio . upon meiotic reactivation, pumilio loses its interactions with ringo/spy permitting its translation. ringo/spy is then expressed, leading to activation of cpeb by phosphorylation, which in turn elicits polyadenylation and translation activation of the mrna for a critical oocyte maturation factor, the mos kinase. in this study, we investigated the expression of ringo/spy in mouse. methods: ten different somatic tissues, testes, and ovaries were tested by reverse transcription-polymerase chain reaction (rt-pcr) for the expression of ringo/spy homologues and their alternative splicing variants. ringo/spy mrna expression was also tested in prophase i (pi) and metaphase ii (mii) oocytes, -cell, -cell, -cell, -cell embryos and blastocysts. amplification with actin primers provided a positive control and allowed semi-quantitative analysis. results: we analyzed the two previously identified homologues of ringo/spy (a and b). the two alternative splicing variants of ringo/spy a (a and a ) were separately studied for their expression profile. we also identified an additional alternative splicing variant of ringo/spy b and evaluated similarly. ringo/spy a ( and ) were expressed in testes, ovaries, and certain somatic tissues including brain, and spleen. ringo/spy b (both variants) were only expressed in testis. ringo/spy a or b were not present in mouse oocytes or early embryos. conclusions: our findings indicate that the previopusly described ringo/spy homologues a and b are not expressed in mouse oocytes or early embryos suggesting that either an alternative cdk-activator or a yet to be identified homologue of ringo/spy may be mediating meiotic g /m progression in mouse. testis specific expression of ringo/spy b, and previously described role of ringo/spy in meiosis suggests a role for this protein in male gametogenesis in mouse. treated with glyburide. jennifer aguayo, gladys a ramos, alethea hanley, carri r warshak, thomas r moore. reproductive medicine, university of california, san diego, san diego, ca, usa. objective: to determine the risk factors that may predict inadequate response to first-line glyburide monotherapy in pregnant women with type diabetes mellitus (dm) or gdm and to assess if non-responders are at increased risk of adverse pregnancy and neonatal outcomes. study design: this was a retrospective cohort of women diagnosed with type ii or gdm initially treated with glyburide at a single institution from - . maternal characteristics, adequate glycemic control defined as more than % of fasting glucose < mg/dl and one-hour post-prandials < mg/dl, and neonatal outcomes were assessed. non-responders were defined as failure to achieve adequate glycemic control on maximum daily doses of glyburide or intolerance due to side effects, necessitating switch to insulin therapy. statistical methods included bivariate analyses. results: of the women initially treated with glyburide, ( %) failed to achieve adequate glycemic control or did not tolerate glyburide. reasons for glyburide non-response were maximum dose ( mg/d) reached ( %), maternal hypoglycemia ( %) and other side effects ( %). there were no statistically significant differences between non-responders and responders with respect to family history of diabetes ( % vs. %, p= . ), prior history of gdm ( % vs. %, p= . ) and macrosomia (> g) ( % vs. %, p= . ) or hour glucose challenge test ( + vs. + mg/dl, p= . ). non-responders had a higher rate of obesity (bmi> ) ( % vs. %, p= . ) and earlier gestational age at initiation of therapy ( + . vs. + . wks, p= . ). there were no differences between the groups in the mean -week fasting ( + vs. + mg/dl, p= . ) and post-prandial glucose values ( + vs. + mg/dl, p= . ). no significant differences were observed in incidence of pre-eclampsia, primary cesarean delivery or birth weight. neonatal outcomes including ponderal index, neonatal hypoglycemia, nicu admission, and birth injuries also did not differ between the groups. conclusion: women who are obese and who require earlier initiation of glyburide therapy are at increased risk of non-response to glyburide monotherapy. however, despite non-response, these women can be managed with subsequent insulin therapy to achieve similar glycemic control and pregnancy and neonatal outcomes. a different diagnostic strategy using the gram, -hour glucose tolerance test for the diagnosis of gestational diabetes mellitus. yvonne w cheng, ingrid block-kurbisch, jennifer lydell, aaron b caughey. obstetrics, gynecology and reproductive sciences, university of california, san francisco, san francisco, ca, usa. objective: to examine whether a simplified strategy using the gm, -hour glucose tolerance test (gtt) may be useful for the diagnosis of gestational diabetes mellitus (gdm). methods: this is a retrospective cohort study of women with singleton pregnancy who received the -gm, -hour glucose challenging test (gct) for initial screening and the gm, -hour gtt as confirmatory tests for the diagnosis of gdm between and . various combinations of the gm, -hour gtt results were examined and compared to the diagnostic criteria for gdm established by the carpenter and coustan criteria using the receiver-operator characteristic (roc) curves. perinatal outcomes of women who would have had a false-positive or false-negative test results were compared to those who did not have gdm using the carpenter and coustan criteria. potential confounding factors were controlled for using multivariable regression models. results: , women had gm, -hour gtt results available for analysis during the study period. using gdm diagnosed by the carpenter and coustan criteria as reference, various diagnostic strategies was compared using roc curves (figure ) . summation of the -hour and -hour gtt results with a diagnostic threshold of mg/dl yielded the most optimal balance between sensitivity ( . %) and specificity ( . %). when compared to women without gdm, women who were diagnosed with gdm by c c criteria but not by summation of -hour and -hour gtts had higher odds of operative vaginal delivery (aor= . , % confidence interval [ci] . - . ) and neonatal birthweight > gm (aor= . , % ci . - . ). conclusion: using only the summation of only the -hour and -hour gtt results of the gm -hour gtt offers an alternative test strategy which may be more convenient and less costly for the diagnosis of gdm. however, women who would have gdm by the carpenter and coustan criteria but not by the summation method have higher odds of having an operative vaginal delivery and neonatal birthweight > gm. outcome of induction of labor indicated for term prom among women with or without a uterine scar. yifat ochshorn, avital skornick rapaport, adi reches, joseph b lessing, ariel many. obstetrics gynecology, lis maternity hospital, tel aviv sourasky medical center, tel aviv, israel. objective: we aimed at comparing the outcome of induced term deliveries presenting with prom with or without a previous uterine scar. methods: the computerized files of women delivered following induction of labor due to term prom, were reviewed. perinatal outcome parameters such as the mode of delivery, indication for cesarean section, rate of low ' apgar scores and nicu admissions were compared between women with and without a previous cesarean. results: during the study period women delivered in our institution following prom and induction of labor , of them had a previous uterine scar. parturients of both groups (with and without a scar) were similar with regard to age, gestational age at delivery and parity. cesarean section rate was higher for the previous scar group ( % vs %, p< . ). the most common indication for cesarean was arrest of dilatation and/or descent among women with previous scar accounting for % and % (p< . ) for women with and with no uterine scar, respectively. no differences were noted in neonatal outcome parameters such as rate of low ' apgar scores and nicu admission rate between the two groups. conclusion: induction of labor due to prom culminates in higher cesarean rate in women with one previous scar compared with parturients with no scar. perinatal outcome is similar between the two groups. acid base balance and immediate perinatal outcome of vertex compared with breech presentation in elective cesarean section. avital skornick rapaport, yifat ochshorn, joseph b lessing, yuval yaron, michael kupferminc, ariel many. obstetrics gynecology, lis maternity hospital, tel aviv sourasky medical center, tel aviv, israel. backround: apgar scores, umbilical blood ph and bicarbonate are generally lower and pco levels are higher in vaginally delivered breech neonates compared to cephalic deliveries. although cesarean delivery improved apgar scores there is a debate wether it improved the acid base status. this retroprospective study compared umbilical cord blood acid-base values and perinatal outcome of elective cesarean breech-delivery with those of elective cephalic cesarean delivery and to determine whether a different metabolic status and perinatal outcome should be expected in neonates in breech presentation. study design: the study group included singleton pregnancies delivered by elective cesarean section at term between january and march . computerized files of singleton breech presentation elective cesarean sections were compared to those of singleton vertex neonates delivered by elective cesarean section. demographic data included: maternal age, pregnancy week at delivery and parity. perinatal outcome measures checked were: birth weight, apgar scores at 'and ', umbilical cord venous and arterial ph and base excess. results: during the period between january and march there were singleton elective cesarean sections, of them were breech and vertex. the mean age, gravida and parity were significantly different between groups ( . vs. . , . vs. . . and . vs. . respectively, p< . ). the birth weight was significantly different - . gram for the vertex and . gram in the breech deliveries (p< . ) there were no differences in either apgar scores or umbilical ph between the breech and vertex neonates delivered by cesarean section at term ( - + w). venous and arterial po and pco levels were significantly different, though the differences were very small and we doubt if these differences have any clinical importance. conclusion: although vaginal breech deliveries are associated with increased risk of asphyxia during delivery, elective cesarean breech deliveries are not at increased risk for lower ph levels or apgar scores. the clinical significance of bleeding during the second trimester of pregnancy. arie koifman, amalia levi, yaron zaulan, avi harlev, eyal sheiner. obstetrics gynecology, soroka university medical center, ben gurion university of the negev, beer-sheva, israel; epidemiology and health services evaluation, faculty of health sciences, ben gurion university of the negev, beer-sheva, israel. objective: this study aimed at investigating clinical importance and pregnancy outcome in women suffering from bleeding during the second half of their pregnancies. methods: a population based study including all deliveries which took place in the soroka university medical center between the years - were examined. comparison was performed between patients with and without second trimester bleeding pregnancies terminated before weeks, multiple gestations and women lacking prenatal care were excluded . stratified analysis, using the mantel-haenszel technique, and a multiple logistic regression model were performed . results: during the study period, , singleton deliveries occurred in our institute. of these, ( . %) were complicated with bleeding upon admission during the second half of pregnancy. the cases were attributed to placental abruption ( . %; n= ) and placenta previa ( . %; n= ). independent risk factors associated with bleeding, were oligohydramnios, polyhydramnions, (odds ratio [or]= . ; % confidence interval [ci] . - . ; p= and . ; . - . ;p< . respectively ), suspected intra uterine growth restriction (iugr, . ; . - . ; p<. ), gestational age, previos abortions and maternal age. these patients subsequently were more likely to deliver by cesarean section (cs, . % vs. . %, or= . ; %ci . - . ; p< . ). perinatal mortality among patients admitted due to second half bleeding was significantly higher as compared to patients without bleeding (p<. ). conclusion: bleeding upon admission during the second half of pregnancy is an independent risk factor for perinatal mortality. careful surveillance, including fetal monitoring, is suggested in these cases in order to reduce the adverse perinatal outcome. crude and adjusted odds ratios for perinatal mortality among patients with vaginal bleeding. characteristics or % ci p crude or for perinatal mortality . . - . < . or adjusted for: < . iugr . . - . < . oligohydramnios . . - . < . premature rupture of membranes . . - . < . the predictors included neonatal pi, bmi, or birthweight while the outcomes included hypoglycemia, shoulder dystocia, acidemia and hyperbilirubenemia. roc curve analyses were utilized to evaluate the relationship between sensitivity and specificity for each of the predictors and outcomes, with an area under the curve (auc) significantly greater than . indicating a screening test that is better than chance. results: neonatal pi, bmi and birthweight are poor predictors of nicu admission, acidemia and hypoglycemia with all auc values not statistically significantly different than chance alone. they are a reasonable predictor of shoulder dystocia, with birthweight functioning the best (p< . ). in general, neonatal anthropometric measurements do not appear to be good predictors of short term neonatal outcomes. although they are a reasonable predictor of shoulder dystocia, they are not useful clinically for this outcome since they cannot be calculated until after birth. in future studies, new models of neonatal anthropometrics should be created to better predict adverse neonatal outcomes. neonatal anthropometric measurements and their relationship to perinatal outcomes expressed as auc and % confidence intervals history of at least one spontaneous preterm delivery were offered protocolbased prenatal care including first-or second trimester bacterial vaginosis screening, repeated ultrasound cervical length assessment, and supportive care by specialized nurses. women with a positive test for bacterial vaginosis were treated with oral metronidazol therapy, and women with a cervical length below . cm (before weeks of gestation) underwent a vaginal cerclage. progesterone administration was not provided. data on obstetrical and medical history, pregnancy, delivery and neonatal outcome were prospectively collected and evaluated. results: in total, pregnant women were prospectively followedup. eighty-seven women had experienced a preterm delivery in their last pregnancy, of whom had delivered before weeks. three women were diagnosed previously with a bicornual or septal uterus. twelve women received metronidazol therapy and women underwent a vaginal cerclage. eighty-four women ( . %) delivered at weeks or beyond. one-hundred and three women ( . %) delivered no earlier than weeks, and only one woman delivered at weeks. two women gave birth to a twin (at and weeks, respectively). two neonatal deaths due to pulmonary hypoplasia were recorded. conclusion: women at high risk of preterm delivery who were offered protocol-based prenatal care not including progesterone therapy had a better pregnancy outcome than would be expected from previous studies. our findings may question the reported beneficial effects of prenatal progesterone administration. premature rupture of membranes. tracy a manuck, alexandra g eller, m sean esplin, robert m silver. obstetrics gynecology, university of utah health sciences, salt lake city, ut, usa. objective: historically, outcomes following expectant management of midtrimester preterm premature rupture of membranes (pprom) have been uniformly poor. thus, many patients elected pregnancy termination. however, outcomes may be improved with recent advances in neonatal medicine. our purpose was to assess outcomes in expectantly managed early pprom in an era of improved maternal and neonatal care. study design: this is a retrospective cohort of patients from tertiary healthcare systems from - experiencing pprom . weeks gestation. patients electing immediate termination of pregnancy, carrying fetus(es) with lethal anomalies, or delivering within hours of pprom were excluded. survival without major morbidity was the primary outcome. data were analyzed using student t-test and chi-square as appropriate. results: a total of women carrying fetuses ( singleton, twin, triplet, quadruplet) met inclusion criteria. only the fetus in the "ruptured sac" was studied. pprom occurred at a mean of . (+/- . , range . - ) weeks. the average latency period was . (+/- . , range . - ) days, with a mean delivery gestational age of . (+/- . , range . - ) weeks. this communication provides the first report of fundal uterine necrosis following placement of multiple uterine compression sutures. only two previous published cases report occurrence of uterine necrosis following application of a uterine compression suture --both identified as the b-lynch technique --and neither of these cases report necrosis confined to the fundus. in our case, uterine atony was refractory to pharmacologic therapy and manual compression of the uterus appeared to decrease the amount of blood loss. therefore, we applied a traditional b-lynch which effectively contracted the majority of the uterus, while the fundus remained atonic. a second horizontal, square suture was then placed between the cornua and carried over the fundus (see figure one: red reflects b-lynch suture; blue represents second fundal, square stitch). the patient subsequently experienced significant, persistent fevers despite antibiotic therapy. a repeat laparotomy was performed, at which time we found uterine necrosis confined to the uterine fundus (see figure : photograph taken at the time of hysterectomy). the placenta showed no histologic evidence of chorioamniotis --hence, the patient's main risk factor for fundal necrosis was the compression sutures. physicians should be aware of the risk of uterine necrosis, especially after placement of multiple compression sutures and, more specifically, after placement of a compression suture confined to the uterine fundus. background: migraines are far more common in women than in men. the incidence of migraines increases in girls after puberty, reaching an incidence of % in women who experience migraine at least once a year around middle age. migraine has been postulated as one of the major risk factors for stroke during pregnancy and the puerperium.triptans are a class of serotonin receptor agonists used in the treatment of migraine headaches. triptans administered in combination with other drugs have been known to precipitate serotonin syndrome, a rare but potentially life-threatening condition clinically manifested by a triad consisting of mental-status changes, autonomic hyperactivity, and neuromuscular abnormalities. objective: to determine whether triptan monotherapy is associated with serotonin syndrome methods: using data mining techniques we analyzed the entire food and drug administration's (fda) adverse event reporting system (aers) database. results: after excluding reports of concomitant serotonergic medication or other potentially confounding medication, eleven reports remained of serotonin syndrome associated with triptan use without concomitant serotonergic medication. the mean age for these eleven cases was . years; nine cases occurred in females and two occurred in males. there were no apparent instances of overdose among these eleven cases. conclusions: serotonin syndrome is a rare but serious occurrence with the use of triptan monotherapy. such cases were seen with eletriptan, rizatriptan, sumatriptan, and zolmitriptan. because of the spontaneous nature of voluntary reporting to aers, the actual number of occurrences of serotonin syndrome in patients using triptans is probably higher and cannot be assessed from aers data. users of triptan in combination with an ssri or snri should be warned of this rare but serious adverse effect. during periods of drug initiation, dose escalation, or the addition of another serotonergic agent, patients should be particularly vigilant for symptoms of concern and seek urgent medical attention if any occur. the offending agents should be withdrawn and the patients closely monitored and treated with supportive measures as required. rising maternal mortality in the midst of modern technology. oormila p kovilam, jane khoury, padmini c sekar, ralph c buncher. obstetrics gynecology, university of cincinnati, cincinnati, oh, usa; center for epidemiology and biostatistics, cincinnati children's hospital medical center, cincinnati, oh, usa; environmental health, university of cincinnatic, cincinnati, oh, usa. introduction: maternal mortality rate (mmr) is an index of overall wellbeing of the community and safe motherhood should be given utmost priority in obstetric care. as per , who estimates % of maternal mortality occurs in developed countries . this rate has established without much decline in recent years. the mmr for ohio for to was reported by cdc to be . per , live births with % confidence interval . to . . objective: our objective was to audit the trend in maternal mortality in the state of ohio for the last years. methods: information from the death certificates completed by attending physicians, medical examiners, coroners, funeral directors filed with ohio state registration offices were analyzed. we only used women who were residents of the state of ohio at the time of death, and cause of death was coded as a "complication of pregnancy, childbirth and the puerperium", icd codes to and icd codes o to o . five year maternal mortality pattern and long term trend was assessed. results: the number of maternal deaths recorded as due to pregnancy complications varied over the years from a high of in to a low of in and . in general the five-year mortality rate was decreasing over time until the last four years to , when we may be seeing an upward trend compared to to (p= . ). the rates and associated % confidence intervals (ci) are shown in the table below. years mmr % ci ci - ci . . - . ci - . . - . - . . - . - . . - . - . . - . the rate of maternal mortality is on the rise after a period of downward trend. we should develop a multidisciplinary approach to analyze and target the root causes of maternal death. introduction. women with thrombophilia are at higher risk of vte during pregnancy due to the acquired hypercoagulable state. it is likely that not only maternal veins but also placental vessels are more prone to the development of thrombosis. our objective was to compare maternal and fetal placental circulation disorders in women with intra-uterine fetal death (iufd) and thrombophilia and women without thrombophilia. methods. in a dutch multi-centre study on iufd, during the period - we studied singleton deaths > weeks of gestation for which the diagnosis of iufd was determined before labour. factor v leiden and prothrombin g a were tested at induction of labour. panel classification of cause according to the tulip classification was performed by assessors after individual investigation of structured patient information. we studied the cause of death group "maternal and fetal placental circulation disorders": placenta bed pathology with abruption or infarction as origin of mechanism and placental parenchyma pathology with fetal thrombotic vasculopathy and massive perivillous fibrin deposition as origin of mechanism. results. of the women tested for factor v leiden, ( . %) were carriers. of the deaths caused by "maternal and fetal placental circulation disorders" ( . %) mothers were carriers of factor v leiden. of the deaths with another cause of death ( . %) mothers were carriers of factor v leiden (p= . ). of the women tested for prothrombin g a, ( . %) were carriers. of the deaths caused by "maternal and fetal placental circulation disorders" ( . %) mothers were carriers of prothrombin g a mutation. of the deaths with another cause of death ( . %) mothers were carrier of prothrombin g a mutation (p= . ). in women with iufd and factor v leiden or prothrombin g a mutation "maternal and fetal placental circulation disorders" did not seem to cause iufd more often than in non-carriers. , university medical center groningen, groningen, netherlands; pathology, university medical center groningen, groningen, netherlands; trial coordinating center, dept of epidemiology, university medical center groningen, groningen, netherlands; hematology, university medical center groningen, groningen, netherlands. introduction. growing evidence suggests that women with thrombophilic defects may be at higher risk of fetal loss. although some paternal components to the predisposition of preeclampsia have been demonstrated it is not known whether paternal components contribute to intra-uterine fetal death (iufd). our objective was to investigate the relation between paternal thrombophilic defects and iufd. methods. in a dutch multi-centre study on iufd, from - we studied singleton deaths > weeks of gestation for which the diagnosis of iufd was determined before labour. we tested male partners of women with iufd for antithrombin (at), protein c, protein s type i and iii, factor v leiden, prothrombin g a (factor ii) and factor viii: ag. standard tests were performed in one laboratory. normal ranges were determined in healthy male blood donors. we compared prevalence of thrombophilic defects to reference values from the literature. . of the men tested for factor v leiden, ( . %) were carrier versus ( . %) non-carriers. prevalence of factor v leiden in the normal population is % (p= . ). men were tested for prothrombin g a, ( . %) were carriers and ( . %) non-carriers. all were heterozygous. prevalence of prothrombin g a mutation in the normal population is % (p= . ). decreased levels of antithrombin, protein c, protein s type i and iii and increased levels of factor viii: ag were observed significantly more often in male partners of women with iufd compared to the normal population. conclusion. in our iufd group the prevalence of male factor v leiden carriers was comparable to the normal population, prevalence of prothrombin g a mutation was lower. the difference in other factors imply an as yet unexplained association of male thrombophilia with fetal death in their partner. objective fetal macrosomia, the most important complication of gdm, increases the risk of shoulder dystocia, erb's palsy and intrauterine hypoxia. we compared frequencies of fetal macrosomia and erb's palsy in two gdm cohorts with different severity of glycemic disturbance and in healthy controls. methods we studied consecutive gdm women with singleton childbirth and or abnormal values in -h ogtt with g of glucose. abnormal plasma glucose values of the ogtt were: fasting . , -h . and -h . mmol/l. insulin treatment was started when values were . preprandially or . mmol/l postprandially in the -h glucose profile done within days of diagnosis. if the same woman had more than childbirth during the study period, only the last pregnancy was included. the control group consisted of women from a nearby town with singleton childbirth in the same hospital. women with diabetes were excluded from controls. macrosomia was defined as birth weight (bw) > . sd above the mean of a standard population. erb's palsy was diagnosed by pediatric surgeons. results gdm women were older, more obese, had more childbirths and more often a previous child with bw > g than controls. insulin was started in gdm women ( . %). c/s rate was . % in controls, . % in diettreated and . % in insulin-treated gdm women. macrosomia rate was . % in controls, . % in diet-treated and . % in insulin-treated gdm women (p< . compared with controls or diet-treated gdm women). the frequency of macrosomia did not differ between the diet-treated gdm and control women. erb's palsy occurred in . % of controls, in . % of diet-treated and in . % of insulin-treated gdm women. the frequency of erb's palsy was significantly higher in both gdm groups than in controls (p= . ). by regression analysis, previous child with bw > g (p< . ), previous c/s (p= . ), mother's age (p= . ), bmi (p= . ), insulin treatment (p= . ) and fasting plasma glucose of the -h profile (p= . ) were significant independent predictors of fetal macrosomia. conclusions the -h glucose profile done shortly after the diagnosis of gdm clearly distinguishes between low-risk (diet-treated) and high-risk (insulintreated) gdm pregnancies for fetal macrosomia. unfavourable fetal body composition of diet-treated gdm women is the likely explanation for the high rate of erb's palsy in this group. . '-:·:tpartq,-, '-:·:tpartq,-, '-:·:tpartq,-, % p= . ). first trimester uta doppler indices were similar in the two cohorts in terms of the resistance and pulsatility indices (ri . vs. . , p= . ; pi . vs. . , p= . ) . however, bilateral notching was much more common in the cohort of prior adverse outcomes ( % vs. % p= . ) as well as in patients destined to have a subsequent poor outcome (p= . ). conclusions: not surprisingly, prior poor obstetric outcome was strongly associated with recurrent adverse obstetric outcome. uta notching was robustly associated with prior poor obstetric history as well as a recurrent poor outcome. this clinical history had no discernable influence on ri or pi. reassurance may not be offered based on first trimester uta ri and pi. anti-retroviral therapy is associated with increased blood loss and uterine atony for patients undergoing primary cesarean section. carey eppes, alice cootauco, melissa russo, jessica bienstock. gynecology and obstetrics, johns hopkins university school of medicine, baltimore, md, usa. objective: anti-retroviral therapy has been associated with gastrointestinal smooth muscle dysfunction. it has also been hypothesized that myopathies can occur secondary to anti-retroviral therapy due to mitchondrial alterations. in our experience, we have noticed an increased incidence of uterine atony in our hiv patients on anti-retroviral therapy. we sought to examine the incidence of postpartum hemorrhage and uterine atony in patients currently on anti-retroviral therapy. study design: a retrospective case-controlled study was conducted on all hiv positive pregnant women on anti-retroviral therapy undergoing a primary low segment transverse cesarean section from through . these patients were obtained from an irb approved database containing hiv positive patients within our institution. patients' medical records were abstracted for demographic data, use of uterotonics, preoperative and postoperative hematocrits, and incidence of blood transfusions. controls were matched for age, parity, gestational age and surgical indication. data was analyzed using the t-test, fischer's exact test and chi square. results: there were no differences in demographics, incidence of chorioamnionitis or magnesium sulfate use between groups. patients on anti-retroviral therapy had a statistically greater decrease in hematocrit and estimated blood loss compared to controls. they also had an increased need for uterotonics and blood transfusions. conclusion: anti-retroviral therapy may impact uterine smooth muscle contractility in pregnancy, as evident by the increased incidence of uterine atony and change in hematocrit. additional research is needed to elucidate the mechanism. clinicians should be aware of the potential for uterine atony and excessive blood loss in patients on anti-retroviral therapy. background: adolescent pregnancy is frequently associated with adverse outcomes, especially small-for-gestational age (sga) deliveries. some studies have implicated maternal nutritional status in these poor outcomes. methods: in a prospective longitudinal study, ethnically-diverse, pregnant adolescents were studied from booking to parturition, with collection of anthropometric and nutritional variables. blood samples ( - weeks' gestation; n= subjects) were assayed for a spectrum of nutritional biomarkers. logistic regression was used to determine significant associations between studied variables and pregnancy outcomes. results: median age at recruitment was . years (iqr: . - . ). outcome data was available for subjects. ( . %) had uncomplicated pregnancies. median birthweight was , g (iqr: , - , g) and median birthweight centile was . % (iqr: . - . %). ( . %) infants were born sga and ( . %) were preterm. spontaneous vaginal deliveries occurred in . % of cases. there were ( . %) cases of pre-eclampsia and ( . %) admissions to neonatal care. . % of subjects reported smoking at booking. iron deficiency anaemia was prevalent in . % of subjects by - weeks and was strongly associated with higher infant birthweight centile (p< . ). . % had serum -hydroxy vitamin d concentrations < ng/ml, although this was not associated with any outcomes. low folate status, as indicated by low red cell folate (p= . ), low serum folate (p= . ) and high serum homocysteine (p= . ) concentrations, was associated with higher rates of sga birth. conclusion: adolescent pregnancy in inner-city populations is associated with a high risk of sga and preterm birth, increasing the likelihood of health problems in later life and perpetuating social disparities in health. the association between anaemia and higher birthweight is unexplained. impaired maternal folate status may contribute to impaired fetal growth. we suggest that sga birth in this population could be reduced by the use of antenatal supplements or the mandatory fortification of flour with folic acid. amount of cigarette use pre-pregnancy and during pregnancy were self-reported and subgrouped into nonsmokers, quitting during pregnancy, and continued smoking throughout pregnancy. categorical outcomes were compared using chi-square test. multivariable logistic regression analyses were used to control for potential confounders (continued smoking compared to quitting during pregnancy). results: women who quit smoking during pregnancy had higher rates of pregnancy-associated hypertension and cesarean delivery but lower rates of preterm delivery and neonatal birthweight < gm compared to non-smokers. compared to women who quit smoking during pregnancy, those who continue to smoke have lower odds of pregnancy-associated hypertension and cesarean delivery, but higher odds of preterm delivery, neonatal birthweight < gm, and apgar score < at minutes (see table) conclusion: quitting cigarette smoking during pregnancy appears to reduce undesirable neonatal outcomes, though an increase in pregnancy associated hypertension. these findings should be emphasized to women who are smoking during pregnancy. to achieve effective tamponade the balloon was inflated initially up to - ml with incremental increases of volume by ml until bleeding stops. to measure intrauterine balloon pressures we used a standard pressure transducer (edwards lifesciences) connected to the balloon port and to a pressure monitor (ge dash ). the pressure transducer was mounted on the bedrail at uterine level, primed with sterile saline and then connected to the balloon port of the catheter. the system was zeroed to atmospheric pressure, the stopcock of the intrauterine balloon port was opened and the pressure was recorded (p : the total pressure on the fluid). to verify the accuracy of measurements we used another balloon catheter (reference), inflated with the same amount of saline, connected to the pressure transducer and zeroed to atmospheric pressure. the reference balloon measured p (the intrinsic balloon pressure caused by distension at that volume). the system was then zeroed to the reference balloon. the pressure transducer was then reconnected with the intrauterine balloon and the actual intrauterine pressure was recorded (p ). we calculated the correlation coefficient between p and systolic, diastolic and mean blood pressure using a linear regression (statsdirect statistical software there is a growing body of evidence to suggest that peripartum assessment of fetal or neonatal lactate levels are as good as or better than standard blood gas analysis in the prediction of neonatal outcome. in this study we have evaluated the ability of umbilical cord blood gases and lactate levels in the prediction of neonatal hypoxic-ischaemic encephalopathy (hie). department of neonatal paediatrics, king edward memorial hospital, perth, western australia, australia; women and infants research foundation, king edward memorial hospital, perth, western australia, australia. objective: current evidence suggests that umbilical cord ph at delivery provides the most sensitive reflection of birth asphyxia. paired umbilical artery/vein blood gases have been routinely collected at king edward memorial hospital over the last years. the objective of this study was to determine: local reference ranges; accuracy of sampling; and the rates of metabolic acidosis. of the , births ( ) ( ) ( ) ( ) , accurate paired results were available on % of births. over the study period there was a progressive improvements in accuracy rates of paired sampling (p< . ). the median ( . th , . th centile) values for cord arterial blood gases were: ph . ( . , . ); po . mmhg ( . , . ); pco . mmhg ( . , . ); base excess - . (- . , . ); and lactate . mmol/l ( . , . ). there was a progressive improvement in all blood gas measures over the years of this study (all p< . ). moreover, there were significant reductions in all measures of metabolic acidosis (see table) . the progressive improvement in the measures of metabolic acidosis remained significant after multivariate analysis including obstetric, fetal, and demographic factors associated with metabolic acidosis. the introduction of universal umbilical cord blood gas analysis to all births is associated with significant improvements in all markers of metabolic acidosis. together with other compelling evidence in the literature, these data support the routine use of cord arterial and venous gases at all births; however, improved accuracy rates on paired sampling requires an ongoing education program umbilical artery indicators of acidosis, percentage of total ph < . ph < th centile* objective: intrapartum pcn prophylaxis aims to prevent early-onset gbs sepsis by interrupting vertical transmission from colonized mothers to their newborns. however, despite its wide clinical use, systematic pharmacokinetic evidence in support of the current pcn dosage regimen is lacking. current cdc guidelines recommend intensified surveillance and testing of infants exposed to < h of prophylaxis. our goal was to examine the relationship between maternal time of exposure to pcn and fetal serum pcn levels among maternal-fetal dyads exposed to short durations of pcn prophylaxis (< h) compared to those exposed to longer durations. study design: ninety-eight laboring gbs positive women were administered million units (mu) of intravenous pcn to be followed by . mu every hours until delivery (cdc ) . subjects with renal disease, multiple gestation, and preterm delivery (< wks) were excluded. umbilical cord blood samples were collected at delivery and pcn levels measured by high-performance liquid chromatography. intra and inter-assay coefficients of variation were < %. results: the pcn concentrations (mean±sd) by duration of prophylaxis were: < h, . ± . g/ml (n= ); - h, . ± . g/ml (n= ); - h, . ± . g/ ml (n= ); - h, . ± . g/ml (n= ); - h, . ± . g/ml (n= );> h . ± . g/ml (n= ); and for those without a second dose after h, . ± . g/ml (n= ). fetuses exposed to short duration (< h) had higher levels of pcn than those exposed to > h (p= . ). in multivariable linear regression analysis, fetal pcn levels were determined by total duration of exposure, time since last dose, dosage, and number of doses, but not maternal bmi. pcn levels in cord serum increased linearly until hour; thereafter, they decreased rapidly, but all groups were significantly above the minimum inhibitory concentration (mic) for gbs ( . g/ml)(p< . ). furthermore, every sample individually remained - fold above the mic. conclusion: in this study, even short durations of prophylaxis achieved levels above the mic, suggesting a benefit to prophylaxis even in precipitous labors. the data also suggests that the current cdc designation of infants exposed to < h of pcn prophylaxis as particularly at risk for gbs sepsis may be inaccurate from a pharmacokinetic standpoint. objective: -oh aa is a metabolite of tryptophan with pro-oxidant and proapoptotic properties and has been shown to increase in umbilical cord blood in pregnancies with intra-uterine infection. since labour-related events may also activate inflammatory pathways, we sought to determine the placental release of -oh aa into the umbilical circulation in labouring vs non-labouring patients at term. methods: twenty-six patients were studied (term labour n= , and term elective cesarean section n= ) with blood sampling from a clamped segment of umbilical cord after delivery of the fetus and from the cord at its insertion into the placenta after delivery of the placenta, with subsequent measurement of blood gases/ph and -oh aa (isocratic hplc using fluorometric detection with assay sensitivity at pmol). results: -oh aa measurements from respective umbilical and placental cord vessels were all variably higher in the labouring group vs the elective cesarean group patients (table ) . for labouring group patients, the -oh aa levels from the umbilical vein were significantly higher than those from the umbilical artery, indicating net release from the placenta into the fetal circulation. placental vein levels were also significantly higher than those from the umbilical vein, indicating continued placental release of -oh aa into the cord blood after delivery of the fetus. conclusion: labour at term is associated with changes in the placental metabolism of tryptophan resulting in the increased release of -oh aa into the fetal circulation with the potential for pro-oxidative and apoptotic effects in many tissues, including the brain. obstetrics, gynecology, and reproductive sciences, new brunswick, nj, usa; department of obstetrics and gynecology, mineola, ny, usa. objective: ischemic placental disease (preeclampsia, small for gestational age, sga and placental abruption) is a major contributor to pregnancy-related morbidity. although the placenta is considered a fetal organ, it is accepted that ischemic placental disease (ipd) can present clinically with either fetal or maternal manifestations. we hypothesized that the pattern of diagnosis (maternal versus fetal) varies by gestational age and would provide insights in to origins of indicated and spontaneous preterm birth. methods: this was a retrospective cohort study utilizing the maternallylinked reproductive history data for missouri residents , restricted to singleton live births. women who experienced spontaneous onset of labor and subsequently delivered preterm were classified as spontaneous preterm birth. medically indicated preterm birth included women who delivered preterm through a labor induction or (prelabor) cesarean delivery. ipd was classified as maternal (preeclampsia only), fetal (sga only) or both (preeclampsia with sga or abruption, and all conditions). results: among term births with ipd, . % presented as maternal disease only, . % as fetal disease, and the remainder ( . %) as both. among spontaneous preterm births with ipd, a greater proportion were of fetal presentation ( bethesda, md, usa; dept ob/gyn, wayne state univ, detroit, mi, usa; dept pathology, wayne state univ, detroit, mi, usa; dept ob/gyn, soroka univ medical center, israel. objective: hemoglobin (hg) and its catabolic products have been observed in cases of amniotic fluid (af) discoloration, which is a risk factor for intraamniotic infection/inflammation (iai). the study aimed to determine the association between af fetal hg concentration and gestational age, term and preterm labor and iai. study design: this cross-sectional study included: ) mid-trimester (n= ); ) term not in labor (tnl) (n= ); ) term in labor (tin) (n= ); ) preterm labor (ptl) who delivered at term (n= ); ) ptl without iai (n= ); ) ptl with iai (n= ); ) preterm prelabor rupture of membranes (pprom) with (n= ) and without iai (n= ). af fetal hg concentrations were determined by elisa. results: ) fetal hg was detected in . % of all af and . % of mid-trimester samples; ) women at tnl had a higher median af fetal hg concentration than patients at mid-trimester ( . ng/ml, iqr - vs . ng/ml, iqr . - . , p= . ); ) no differences were found in median af fetal hg concentration among patients with and without labor at term (til: . ng/ml, iqr - . ; p= . ); ) median af fetal hg concentration was not significantly different among the ptl subgroups [ptl with iai: . ng/ml, ptl who delivered preterm: . ng/ml, ptl without iai who delivered at term: . ng/ml, p= . (kruskal wallis) ]; ) in pprom, there were no differences among patients with and without iai ( . ng/ml, respectively; p= . ) ; ) median af fetal hg concentrations were significantly higher in ptl or pprom, with or without iai than in pregnant women at term, with and without labor (p< . for all comparisons). conclusions: ) immunoreactive af fetal hg increases with gestational age; ) among women with ptl or pprom, the median af fetal hg concentration is not associated with iai; ) the median af fetal hg concentration is higher in pregnancies complicated with ptl or pprom than in term pregnancies. the impact of latency time to delivery after preterm premature rupture of membranes (pprom) on neonatal outcome. dan nayot, deborah penava, barbra de vrijer, orlando da silva, bryan s richardson. obstetrics and gynaecology; pediatrics, university of western ontario, london, on, canada. objective: there continues to be controversy as to the management of pprom with conservative management to advance gestational age (ga) versus aggressive management with early induction to avoid chorioamnionitis. we have therefore used the perinatal and neonatal databases of a large regional patient population to determine the association of pregnancy variables with latency time to delivery after pprom and the impact of latency duration on adverse neonatal outcomes. methods: the perinatal/neonatal database of st. joseph's health care, london, ontario was used to obtain demographic and neonatal outcome information for all patients with pprom > and < weeks gestation, singleton and no major anomalies, delivering between january , and december , . patients were grouped according to ga at pprom stratified for latency time < hrs vs > hrs with incidences for those pregnancy related variables and neonatal outcomes available from the database then compared with the use of logistic regression analysis. results: there were patients who met the inclusion criteria of whom %, %, and % had pprom at - wks , at - wks, or at - wks, respectively, and with these pprom groupings showing a stepwise decrease in the percentage of patients with latency to delivery > hrs, at %, %, and %, respectively. pregnancy related variables and neonatal outcomes for these patient groupings are as shown in table . conclusion: despite a to fold increase in the incidence of chorioamnionitis with latency to delivery > hrs, a policy of conservative management to advance ga after pprom will result in decreased severe infant morbidity until weeks, and moderate infant morbidity until weeks. hospital. outcomes studied were prolongation of latency period with intact membranes and prom using magnesium sulfate (mgso ), nifedipine, terbutaline and tocolytic agents. secondary outcomes examined were maternal complications. statistical analysis performed were t-test and . comparisons were expressed as odds ratios ( % ci). results: in a -year period, twin gestations were admitted in ptl and administered tocolytic agent(s) with mean gestational age of . weeks. when tocolytic agents were used, maternal complications were: ( . %) with intact membranes and ( . %) with prom had pulmonary edema (or= . , ci . - . ); ( . %) with intact membranes and ( . %) with prom had chorioamnionitis (or= . , ci . - . ); ( . %) with intact membranes and ( . %) with prom had postpartum hemorrhage (or= . , ci . - . ). conclusion: there is no difference in prolongation of latency period achieved in twin gestations in ptl with intact membranes or prom using tocolytic agents. similarly, there is no difference between the groups with latency period hrs. there is an increased likelihood of pulmonary edema and chorioamnionitis with use of tocolytic agents. however, results are not significant due to type ii error. mean latency period and latency ≥ hrs using single or multiple tocolytic agent ( introduction: high sensitivity crp (hscrp) is a serum marker of inflammation and has proven clinical utlility in predicting cardiovascular disease (cvd). considering the hypothesized association between preeclampsia (pre) and inflammation and cvd, it is plausible that hscrp may have utility in predicting pre. prior to widespread utilization of this marker, the affect of labor on levels of crp needs to be clarified. we assessed the association between labor and hscrp levels in term deliveries and between elevated hscrp and adverse perinatal outcomes. a secondary analysis comparing hscrp in women with preeclampsia (pre) to those without was performed. methods: women presenting for term delivery or pre were prospectively identified as part of a case-control study. clinical data and serum were collected for all subjects. a standard immunoturbidimetric assay was used to measure hscrp levels. women presenting for induction of labor or planned cesarean delivery (non-labor) were compared to women presenting in labor. a secondary analysis comparing non labor women with and without pre was performed. serum was collected prior to labor induction in the non-labor group. nonparametric comparisons were made using wilcoxon rank sum tests. mvlr was used to evaluate dichotomous outcomes and control for confounders. results: women were included (non-labor group (n= ), labor group (n= ), non-labor pre (n= )). the median and mean hscrp levels were and and and in the non-labor and labor groups respectively (p= . ). elevated levels of hscrp in these term deliveries were not associated with chorioamnionitis (p= . ), maternal postpartum complications (endometritis, hemorrhage, transfusion) (p= . ), mode of delivery (p= . ), or admission to the nicu ( . ). levels of hscrp were significantly greater in the non-labor pre group compared to non labor without pre (mean . vs. . , median vs. , p< . ). conclusion: use of hscrp as a biomarker may improve clinical prediction of obstetrical complications such as pre. levels of hscrp are affected by labor and this should be taken into account when studying the utility of this biomarker. further, crp levels are elevated in women with pre even after excluding patients in labor. further investigations to determine if crp elevation in term labor is associated with adverse outcomes may be warranted. the role of hscrp as a valid and discriminating biomarker in pre should be assessed. review of the electronic labor record facilitated collection of maternal demographic, intrapartum, and newborn data. data analyzed with t-tests, chi-square tests, and calculated odds ratios with % cis as appropriate. a forward stepwise logistic regression analysis was used to identify predictors of histologic chorioamnionitis. results: of submitted placentas, had histologic chorioamnionitis (cases) and did not (controls). the groups were similar with respect to age, race, gbs status, and mode of delivery. gestational age, birthweight, duration of labor and ruptured membranes, and number of vaginal exams were greater in the cases (p . ). the cases were more likely to have had epidural anesthesia (or . ), internal monitoring (or . ), fever (or . ), maternal tachycardia (or . ) and fetal tachycardia (or . ) and less likely to have had induction of labor (or . ). newborns in the histologic chorioamnionitis group were more likely to have been observed for sepsis (or . severe sepsis defined as sepsis associated with acute respiratory distress syndrome (ards) or cardiovascular dysfunction(cvd) or with or more other organ dysfunction.all patients were resuscitated with fluids and treated with broad spectrum antibiotics and supportive care as needed. outcome data were: etiology, management, maternal complications, duration of icu stay and perinatal survival. results patients were young (mean age= . ± . years) with a mean gestational age at delivery . ± . weeks. etiologies were pyelonephritis(n= ), septic abortion(n= ), endomyometritis (n= ), chorioamnionitis (n= ), ruptured appendix(n= ), pneumonia( n= ) and one unknown. eighteen ( %) were diagnosed during antepartum and ( %) postpartum period.there were ( %) maternal deaths and high rate of major morbidities (table) . among the antepartum patients,there were, abortions, iufd, neonatal death for a perinatal survival rate of only %. conclusion pregnancies complicated with severe sepsis/septic shock are associated with substantial maternal and perinatal morbidities. the low maternal mortality rate in our study as compared to previous reports is attributed to early diagnosis and aggressive management of maternal complications. fetal loss rate, however continues to be high when septic shock develops antepartum. and tnfa levels are elevated. we developed a dynamic computer (in silico) model of pregnancy (uterine myometrial environment -infection/inflammation and endocrine crosstalk). mathematical differential equations were used to describe the interactions between molecules. infection was represented as increased levels of activated, nuclear transcription factor nf-kb. in the model ru inhibited both the glucocorticoid receptor and progesterone receptors. simulations were run adding different concentrations of ru ( . um= dose used in patients, . um, . um) at different time points during infection (before, at the time of or after nf-kb activation). ru degradation kinetics was also included. the effect of ru on nf-kb induced il- and tnfa levels was assessed. results: infection induced nf-kb activation led to increased il- and tnfa levels. there was a subsequent increase in cortisol that led to dampening of nf-kb activation, il- and tnfa levels. in the presence of ru , il- and tnfa levels continued to rise. the effect of ru on nf-kb induced il- and tnfa was dose dependent and was more prominent in slow metabolizers who had ru in the system for a longer time. addition of ru after the onset of nf-kb activation led to increased il- and tnfa levels above those observed without ru . the addition of misoprostol (prostaglandin e analogue), at the concentrations used together with ru for medical abortion, did not add to the effect of ru on nf-kb induced il- or tnf. conclusions: ru has dose dependent effects on infection induced immune activation and may contribute to the pathogenesis of c sordelii induced sepsis syndrome. the increased susceptibility of neonates to infection remains a major clinical problem. we previously found that after intraperitoneal (ip) listeria monocytogenes infection, neonatal mice have an ld that is orders of magnitude lower than adults. we also found that the inflammatory response of neonatal mouse macrophages, but not neutrophils, in the peritoneal fluid was deficient, and that this correlated with low levels of macrophage chemokines mcp- and rantes. given that the liver and spleen are important organs in listeria infection, we sought to characterize the innate immune response in these organs. a sublethal dose of listeria was injected intraperitoneally into balb/c - week old adult mice and - day old neonatal mice. liver and spleen was collected at , , and hours, sectioned serially for staining with hematoxylin-eosin and primary antibodies (rabbit anti-listeria monocytogenes igg; mhc class ii rat anti-mouse igg, a marker for activated macrophages; f / rat antimouse igg, a marker for macrophages) and secondary antibodies (cy- goat anti-rabbit igg; af goat anti-rat igg) were applied. negative controls used only secondary antibody. real time pcr was used to compare the levels of the chemokines mcp- and rantes in adult and neonatal liver. after ip infection, both adults and neonates showed similar influx of neutrophils to the sites of infection within the liver and spleen. at hours post-infection with listeria, adult liver and spleen showed increased staining for f / and class ii, which increased further and became confluent surrounding microabscesses at and hours. in contrast, the listeria infected neonatal mouse showed some increase in f / around microabscesses but no apparent increase in staining for mhc class ii. the neonates showed greater staining for listeria at each time point. mcp- and rantes levels were higher in infected neonatal liver compared to adults. in the neonatal mouse, the innate immune response in the liver and spleen was characterized by a deficiency of activated macrophages. this deficiency was not correlated with hepatic expression of macrophage chemokines. is there a seasonal pattern in the incidence of post-cesarean endometritis? tamula m patterson, alan tn tita, william w andrews. obstetrics and gynecology, the university of alabama at birmingham, birmingham, al, usa. objective: several theories, including one suggesting a peak in july coincident with resident turnover, postulate seasonality in post-cesarean infections. we assessed whether there is seasonal variation in endometritis. a retrospective cohort study of post-cesarean endometritis at our university-based institution using our obstetric computerized database to compare annual variation in monthly incidence patterns from to . prior to establishing an average aggregate seasonal pattern for all years, years were assessed separately for a recurrent pattern of peaks and nadirs in incidence. peak incidence (or nadir) was defined as any monthly incidence that differed from the mean incidence for the year by over %. results: a total of . % ( , ) of , deliveries from to were by cesarean. annual cesarean rates increased by an absolute rate of over %; while, post-cesarean endometritis rates decreased from % to %. monthly incidence of post-cesarean endometritis did not reveal a consistent recurrent pattern of peaks (figure ) or nadirs. the month of july accounted for only out of a total of peaks for all years. the adjacent months of june and august accounted for only each. the month with the highest number of peaks was april with only . these findings contraindicated the establishment of an average aggregate monthly pattern for all years. the incidence of post-cesarean endometritis did not follow a seasonal pattern. chi-square analyses were used to compare associations between race (black (bl) vs non-black (nbl)) and dichotomous characteristics. student´s t-test was used to compare continuous variables. results , patients were evaluated ( cases and controls). % and % of cases and % and % of the controls were bl and nbl respectively. the baseline prevalence of chtn in bl and nbl controls was . % and . % (p= . ). when comparing bl and nbl cases, bl women had a higher mean systolic blood pressure and screening bmi. bl women also had a trend toward being discharged on post partum blood pressure medicine when compared to nbl women. there was no difference in chtn, diabetes, severity of disease, iugr, or delivery < wks between the two groups (table) . to determine the leading causes of death in a case series of stillborn infants examined in a large hospital autopsy service, and to describe the most common post-mortem observations. study design: one hundred and sixty one stillborn infants were examined. gross pathology observations were recorded at autopsy and during the placental exam, and tissue sections were collected and examined microscopically. immediate and underlying cause of death (cod) were recorded, along with contributory cod, concomitant/significant cod, and incidental findings. statistical analysis was conducted using the software spss v. . . results: the immediate anatomic cod could be determined in . % of all infants examined. in over % of these cases, cod was attributable to placental or umbilical cord findings affecting the maternal-fetal blood supply. the most prevalent among these findings were placental lesions (maternal floor infarction, placental abruption, fetal thrombotic vasculopathy), umbilical cord lesions (entanglement, true knot, compression, excessive length/twisting), and infectious/inflammatory processes (chorioamnionitis, chronic villitis objective: advanced maternal age (ama) is associated with increased risk of intrauterine fetal demise (iufd). antenatal testing (at) is widely used in clinical practice to prevent iufd due to uteroplacental insufficiency and has been suggested to reduce the risk of iufd in ama women. we sought to assess the impact of at on obstetrical interventions and compliance with new practice recommendations. methods: retrospective cohort of ama women ( and older at their due date) who delivered at or after weeks. non-exposed women delivered from july to december (when at for ama was not routinely recommended); exposed women delivered from july to december (after at for ama was introduced at our institution). subjects were identified through the perinatal database; records were abstracted for demographics, medical history, and labor/delivery variables. outcomes included rates of at and induction of labor (iol) and mode of delivery. associations between at for ama and outcomes were tested using t test and chi square. assuming a baseline rate of iol of %, we had % power to detect an increase to % after the introduction of at. results: women met the inclusion criteria: delivered before the introduction of at (non-exposed=before at) and delivered after the introduction of at (exposed=after at). baseline clinical characteristics were similar in both groups. as anticipated, at was more common in the after at group than in the before at group ( % vs %; p< . ). women were not eligible for or declined trial of labor, thus not "at risk" for iol and not included in all analyses. ob intervention rates were increased after at compared to before at (table ) . the corrected iufd rates were similar in both groups ( / vs / ). conclusion: at an academic center, compliance with new practice recommendations was excellent. introducing at testing for a new indication seemed to increase iol and cs rates. these findings should be considered when assessing the risks:benefits ratio of antenatal testing. . we stratified indications for cesarean into the following: failed induction (cervix < cm dilated), arrest of dilation, arrest of descent, failed operative delivery, fetal intolerance of labor (fil), and "other" reasons (e.g., pre-eclampsia, abruption, chorioamnionitis, malpresentation). both fil and "other" reasons were more likely to occur among the medically indicated group (rr . , . physicians in solo practice had higher rates of elective inductions (p< . ), but there was no association between cesarean and practice type. conclusions: inductions accounted for . % of cesareans. these results suggest an increased risk for cs for patients undergoing medically indicated inductions at our institution. there was no association between cesarean and type of practice, whether solo or group, suggesting institutional clinical policies may be more important than practice type in determining delivery outcome after induction. further research is needed to understand how age, race/ethnicity, or other unmeasured patient factors may impact these findings. given rising rates of both cesarean delivery and inductions, this information may be pertinent to women considering elective induction prior to weeks. objective: fetal demise can lead to a consumptive coagulophathy ("fetal death syndrome") traditionally attributed to the release of "tissue thromboplastin", now known as "tissue factor" (tf). tf is the most potent activator of coagulation. despite the appeal and acceptance of this proposed pathophysiology, there is no evidence supporting this view. this study was undertaken to determine if fetal death prior to development of fetal death syndrome is associated with changes in maternal plasma concentration of cd l (a marker of platelet activation), tf and its soluble inhibitor (tfpi). methods: a cross-sectional study included the following groups: ) women with normal pregnancy (n= ) and ) patients with fetal demise without disseminated intravascular coagulation (n= ). plasma concentrations of scd l, tf and tfpi were measured by elisa. standard coagulation tests were performed. non-parametric statistics were used for analysis. results: ) patients with fetal demise had a higher median maternal plasma scd l concentration than women with normal pregnancy (median . pg/ml, range - vs. median . pg/ml, range . - . , p< . ); ) there was no significant difference between the groups in the median maternal plasma tf concentration and ) in contrast, the median maternal plasma tfpi concentration was significantly lower in patients with fetal demise than in women with normal pregnancy (median . ng/ml, range . - . vs. median . ng/ml, range . - . , p< . ). conclusions: ) a change in the plasma concentration of tf was not demonstrated; ) a change in the ratio of tf/tf inhibitor pathway may predispose to thrombin generation and activation of the coagulation cascade; ) however, maternal platelet activation is present in patients with a fetal demise without fetal death syndrome and ) the role of tf in fetal death syndrome remains to be proven. lipoic acid inhibits matrix metalloproteinase production, activity and prostaglandin e secretion by cultured amnion epithelial and mesenchymal cells. r moore, j novak, d kumar, j moore. case western reserve university, cleveland, oh, usa. introduction: cytokines, free radicals, matrix metalloproteinases (mmp) and prostaglandins (pg) have been implicated in processes of fetal membrane rupture and labor. dietary anti-oxidant supplementation has been suggested as a possible therapy for high risk patients, however, clincal evidence supporting the efficacy of agents such as vitamin c or n-acetylcysteine remains controversial. in fact, we have previously shown that vitamin c increases matrix metalloproteinase (mmp) activity in isolated fetal membrane fragments and fails to inhibit tumor necrosis factor (tnf) induced fetal membrane weakening in vitro. in this study, we examine the effect of the naturally occurring anti-oxidant, -lipoic acid, on tnf induced mmp activity/protein and pge secretion in isolated amnion epithelial and mesenchymal cells. methods: amnion epithelial and mesenchymal cells were pre-treated with increasing doses of -lipoic acid ( - mm/ h), then with increasing doses of tnf ( - ng/ml/ h). medium and cells were analyzed by gelatin zymography/western blotting for mmp /mmp activities/protein. pge output was determined by immunoassay. results: tnf induced a dose dependent increase in mmp production, secretion and activity in amnion epithelial cells. tnf ( ng/ml) induced an fold increase in cellular active mmp production and fold increase in secreted mmp enzyme activity by amnion epithelial cells. these increases were reduced - % following h pre-treatment with . - . mm -lipoic acid. mmp protein/activity and pge secretion by amnion epithelial cells were barely detectable and unaffected by tnf and/or -lipoic acid treatment. in striking contrast, mesenchymal cells exhibited little basal or tnf induced mmp protein/activity. mmp protein/activity in mesenchymal cells were unaffected by either tnf and/or -lipoic acid. however, tnf treated mesemchymal cells exhibited a dose dependent increase in pge production ( fold increase/ ng/ml tnf/ h) that was inhibited by %- % following . objective: nearly fifty years after the discovery of microphthalmia-associated transcription factor (mitf), its gene was identified as a specialized transcription factor that dictates cell-specific differentiation. unique mitf isoforms are generated from alternative promoter usage. an isoform of mitf (mitf-cx) is down-regulated in cervical stromal cells of the ripened cervix. further, mitf-cx inhibits il- gene expression and thereby suppresses signaling of the final pathway in cervical ripening. since mitf binds to canonical eboxes (canntg) in promoter regions of target genes, we sought to determine if mitf regulated its own promoter through ebox motifs. methods: the kb genomic dna sequence upstream of the mitf-cx transcription start site was cloned into pgl luciferase reporter vectors which were co-transfected with wild type or mutmitf-cx (impaired dna binding) into cervical stromal cells or hek cells. at h, promoter activity was determined and normalized for transfection efficiency. results: gel-shift assays conducted with oligonucleotides corresponding to eboxes in the mitf-cx promoter revealed two strong binding sites (eboxes - to - and - to - ). specific binding was established using oligonucleotides with or without mutated ebox, antibody supershift experiments, competition with cold probe, and absence of binding to mutmitf-cx. binding specificities were confirmed in nuclear extracts from cells that overexpressed mitf-cx, but not control or mutmitf-cx. reporter gene studies indicated that mitf-cx, but not mitf-m, increased mitf-cx promoter activity -to -fold. whereas mutations in ebox or resulted in significant decreases in mitf-stimulated promoter activity, mitfinduced increases in promoter activity were abolished by mutations in both eboxes. conclusions: collectively these experiments indicate that mitf-cx is a vital regulator of its own promoter activity and acts in a positive feedforward loop through two specific binding sites in its promoter. moreover, isoform-specific amino acids are important to mediate mitf-induced mitf-cx promoter activity. decreasing mitf protein or mutating its promoter would interrupt this loop resulting in rapid reduction of mitf synthesis. since mitf-cx suppresses il- gene expression in cervical stromal cells, we suggest that preservation of mitf-cx-induced mitf gene expression is an important mechanism to maintain the "brake" on cervical ripening and ensure cervical competency during pregnancy. the role of cd in cervical remodeling. denisse sanchez, brenda timmons, mala mahendroo. obstetrics and gynecology, ut southwestern medical center, dallas, tx, usa. objective: prior to the onset of parturition, the uterine cervix undergoes a remodeling process from a closed, rigid structure, to one that is soft and dilatable. many changes occur, including increases in hyaluronan (ha), a glycosaminoglycan that facilitates loosening of the collagen matrix. in the postpartum period, the concentration of ha is reduced to that of the nonpregnant state. cd , a transmembrane glycoprotein expressed in hematopoietic and epithelial cells, is a receptor for ha. cd expression by immune cells is important in extravasation of leukocytes into tissue. cd may also be required for ha catabolism through the action of hyaluronidases and . in the cervix, cd is expressed in the endo-cervical epithelia as well as in immune cells localized in the stromal matrix. to study the importance of cd in cervical remodeling, mice with a null mutation for cd (cd -/-) were evaluated during pregnancy, parturition and postpartum. methods: changes in ha amount and size distribution were assessed using ha molecular weight gels and fluorophore assisted carbohydrate electrophoresis. to identify defects in cervical remodeling in the cd -/mice, differences in expression for genes regulated in the cervix were studied by quantitative real time pcr . to determine whether cd plays a role in the recruitment of immune cells during cervical ripening and postpartum repair, immunohistochemistry with antibodies against leukocytes was done. in the postpartum period, there is a higher ratio of high molecular weight ha relative to low molecular weight ha in the cd -/mice. this suggests that postpartum breakdown of ha in cd -/cervices is delayed. as compared to wt cervix, there was a significant increase in hyaluronidase (hyal- ) mrna in the postpartum period. the distribution and relative numbers of immune cells in the cd -/cervix was similar to wt. conclusion: these studies provide evidence that cd may play a role in remodeling of the postpartum cervix back to the nonpregnant state. our current data suggests that the catabolism of ha after birth is delayed in the mutant mice and upregulation of hyal may compensate to allow ha removal. furthermore, the activity of hyal- may be dependent on cd . little difference in the recruitment of immune cells between cd and wt animals suggest that cd expression is not required for this process. these experiments provide a greater understanding for the role of cd and ha in cervical remodeling. in background: during in vitro experiments we have shown that separation of amnion from choriodecidua occurs as an integral part of the process of fetal membrane (fm) rupture. although spontaneous amnion and choriodecidual separation is seen in fm after both svd and elective c/s deliveries, its etiology is uncertain. biochemical degradation at the amnion-choriodecidua interface may be a key contributing factor. our previous biomechanical studies have demonstrated that separated fm require less physical work to rupture than intact membranes. the purpose of this study was to determine whether fm separation was associated with clinical differences in the birth process. hypothesis: during term, normal labor, spontaneous separation of fm is associated with differences in the clinical parameters of labor and delivery. study design: fm from consecutive term deliveries were cut off the placental disk. separated areas of fm were cut from the intact areas. both were weighed and their weight ratios determined. maternal medical, pregnancy, and delivery data were collected and analyzed. results: term fm had the following characteristics: maternal age ± . yr, gravida . ± . , gestation ± . wks, elec. cs . %, duration of rom ± min, duration of contractions ± min, african american %. % of the fm had < % separation; % had more than % separation. srom fm with > % separation (vs. < %) had significantly shorter duration of rom (p= . ) and admission to birth (p= . ) times. srom fm with > % separation (vs. < %) had even shorter rom (p= . ), duration of contractions (p= . ) and admission to birth (p= . ). the > % group (vs. < %) was further along, gestationally (p= . ). srom fm (vs. arom) had shorter admission to birth (p= . ), but longer rom to birth (p< . ) times. absence of epidural (p= . ), srom mode of rupture (p= . ), svd (vs. elec. c/s) (p= . ), and the presence of meconium (p= . ), were all associated with increased fm separation. conclusion: spontaneous separation of fetal membranes is nearly universal and is associated with increased gestation, spontaneous rupture of membranes, shorter duration of contractions, and svd. speculation: we speculate that programmed biochemical changes initiate fm separation which then facilitates rom and childbirth. whole genome array and si-rna investigation of the function of nfkb in human amnion epithelial cells. sheri e lim, shirin khanjani, yun s lee, tg teoh, , philip r bennett. institute of reproductive and developmental biology, imperial college, london, united kingdom; maternal fetal medicine, st. mary's hospital, london, united kingdom. introduction: labour is associated with activation of nfkappab in the amnion. nfkappab increases prostaglandin synthesis through the upregulation of cyclooxygenase- (cox- ), which is essential to the labour process. cox- mrna expression increases with gestation in the amnion. primary amnion epithelial cells cultivated from tissue collected prior to the onset of labour display a spectrum of nfkappab activation, similar to the spectrum of cox- expression presumably relating to the nearness of labour. our aim was to investigate the full range of genes under nfkappab control in amnion epithelial cells by using whole genome arrays. methods: amnion from women undergoing elective caesarean section was collected and primary cell cultures established. total rna and protein were extracted from each culture. nuclear localization of nfkappab is required for its activation. western analysis of nuclear p was therefore performed to identify the samples displaying the lowest and highest nfkappab activity. the corresponding rna samples displaying the three lowest and three highest nuclear p protein concentrations were used for whole genome analysis using affymetrix u arrays. results and conclusions: we identified significantly regulated genes. the gene with the highest fold change was cox- (x . ) followed by oxytocin receptor (x . ), ch orf (x . ), integrina (x . ), and connective tissue growth factor (x . ). other significant genes included interleukin- (il- ) (x . ). pathway analysis revealed the majority of other nfkappab associated genes were involved in cell signaling, turnover and proliferation. we used real-time pcr (rtq-pcr) to validate cox- and il- expression. to prove that cox- is directly regulated by nfkappab, primary amnion epithelial cells were then transiently transfected with nfkappab p sigenome smart pool and sicontrol non-targeting sirna pool. western blot analysis confirmed knockdown of nfkappab p associated with inhibition of cox- demonstrating that nfkappab is essential for cox- expression. objective: premature birth is a major public problem accounting for over , deaths and , surviving infants with life-long morbidity yearly. in order to develop a rational basis for treatment and prevention of premature fetal membrane (fm) failure, we first need to understand the sub-failure fm structural and mechanical behavior at near full term. methods: we utilized planar biaxial mechanical testing, which approximates the physiologic loading state, for mechanical evaluation of the fm, and a structural constitutive model approach was used to offer insight into the structure-strength of the fm by integrating information on tissue composition and structure. small angle light scattering (sals) was used to nondestructively quantify the collagen fiber architecture of both intact and separated fm layers. results: in the stress free state, the gross collagen fiber architecture of the fm and separated layers were not homogenously align but exhibited small regions of fiber alignment. the amnion layer displayed the greatest alignment. the model fit the equi-biaxial strain data well (r = . ) and indicated that fm collagen fibers were rapidly recruited and straightened well below failure stress levels. collagen fibers were gradually recruited followed by a drastic increase in fiber recruitment. conclusion: this study provided the first data on the effective collagen fiber stiffness in the intact fm under physiologic biaxial loading, which was related to quantitative collagen fiber architectural measures. modeling results indicated that the collagen fibers became fully loaded and straighten well below physiological loading levels. failure did not occur during physiological loading, indicating that fibers do not begin to fail until all collagen fibers are fully straightened and bearing load. this result suggested modest structural reserve in the fm collagen architecture, and may be an important aspect of its failure properties. previously, we demonstrated that a physically "weak zone" exists overlying the cervix in the fm, evident of collagen remodeling and cellular apoptosis. we are currently extending the present study to include the "weak zone" tissues, allowing us to elucidate the micro-mechanical mechanisms that facilitate failure in this newly identified fm zone. supported by nih . the extracellular matrix of the cervix undergoes extensive remodeling during parturition. hyaluronan (ha) is a major constituent of the extracellular matrix of the term pregnant cervix. the onset of labor is preceded by an increase in ha and after delivery, the concentration of cervical ha gradually decreases to that of the non-pregnant state. these dramatic changes suggest that ha plays an important role during parturition. hyaluronan synthase (has ) is one of three known ha synthases and the most abundant isoform in the pregnant cervix. transcripts for has are regulated by two alternative promoters, one upstream of the first coding exon (proximal promoter) and another upstream on an untranslated exon (distal promoter). the focus of the current study is to further our understanding of the transcriptional regulation of has during cervical ripening. methods: rna blotting was carried out using transcript specific probes corresponding to the distal and proximal promoter of the mouse has gene. the regulation of has was evaluated in a cervical epithelial cancer cell line (caski cells) which we have previously shown to express endogenous has . regulation of has expression by epidermal growth factor was assessed in the caski cells by western blotting and quantitative real time pcr assessment of transcripts. results: has mrnas in the nonpregnant (np) and pregnant cervix are transcribed from the distal promoter upstream of exon . two transcripts of approximately . kb and . kb were detected that arise from use of polyadenylation sequences. as compared to np, the expression of has is increased , , and fold on gestation days , and shortly postpartum respectively. has mrna expression is increased upon treatment of caski cells with epidermal growth factor ( ng/ml) and is suppressed in cells treated with ag ( m), an inhibitor of egf receptor phosphorylation. maximal stimulation was observed at and hours of treatment. conclusion: has is the major ha synthase expressed during cervical ripening and the majority of transcripts are driven by the distal promoter in the has gene. in vitro studies using caski cells suggest has is regulated in part by the egf signaling pathway resulting in a several fold increase in has expression. these results provide an understanding of has gene regulation at the time of cervical ripening which will ultimately enhance our understanding of the molecular mechanisms important to cervical ripening. chorion and decidua cells. chad a grotegut, bernard j canzoneri, liping feng, phil heine, amy p murtha. obstetrics and gynecology, duke university, durham, nc, usa. objective: preterm premature rupture of the fetal membranes accounts for approximately % of all preterm deliveries. cigarette smoking independently carries a fourfold increase risk for pprom. our laboratory has previously demonstrated that the chorion layer undergoes apoptosis in women with pprom. this study was conducted to determine if extract of cigarette smoke causes cell death in specific cells of the fetal membrane. fetal membranes were collected at the time of elective cesarean section from women without labor and at term. the chorion and decidua layers were separated and purified on a gradient spin column and then plated near confluence. cigarette smoke extract (cse) was collected in cell media and used to treat chorion and decidua cells in culture at concentrations ranging from % to % in -well plates. cell viability was determined at , and hours following treatment with a non-radioactive cell viability assay. data were analyzed using paired t test (analyse-it, leeds, uk). chorion and decidua cells underwent cell death when exposed to cse in a dose dependent fashion. increasing concentrations of cse resulted in increased cell death at hours in both cell types (figure ). at hours, chorion exhibited greater percent cell death compared to decidua at concentrations of , and % cse (p= . , . , and . , respectively). for any given concentration of cse, the degree of cell death increased with increasing length of exposure ( , and hours) for each cell type. chorion cells routinely exhibited greater percentage of cell death following treatment with cse at concentrations ranging from - % compared to decidua cells. human chorion and decidua cells in primary cell culture exhibit a dose-response and time dependent cell death in the presence of cse. human chorion cells show greater sensitivity to cell death when compared to decidua cells. further studies are needed to determine the mechanisms through which these cell types undergo cell death and the implications for the differential sensitivity to cigarette smoke. yoon ha kim, tae-bok song, cheol hong kim, jong woon kim, moon kyoung cho, sung yeul yang, bong whan ahn. obstetrics gynecology, chonnam national university medical school, gwangju, korea; biochemistry, chonnam national university medical school, gwangju, korea. objective: to investigate the lipid peroxide levels and protein carbonyls levels in the amniotic fluid of pregnant women with preterm premature rupture of membranes (pprom). the lipid peroxide levels in the amniotic fluid of normal pregnancy (n= ) and pregnant women with pprom (n= ) were newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced measured by thiobarbituric acid reaction. the protein carbonyl contents in the amniotic fluid of normal pregnancy (n= ) and pregnant women with pprom (n= ) were determined by the , -dinitrophenylhydrazine method. after amniotic fluid of them were mixed and incubated up to hours with . ml of mm moxalactam, cefodizime, amoxacillin, erythromycin, the lipid peroxide levels and protein carbonyl contents in them were measured. results: . the lipid peroxide levels in the amniotic fluid of pregnant women with pprom was significantly higher than that of normal pregnancy ( . ± . vs. . ± . nmol/mg protein, p< . ). . the protein carbonyl levels in the amniotic fluid of pregnant women with pprom was significantly higher than that of normal pregnancy ( . ± . vs. . ± . nmol/mg protein p< . ). . the lipid peroxide levels and protein carbonyls formation by moxalactam in the amniotic fluid of pregnant women with pprom was significantly higher than basal level ( . ± . vs. . ± . nmol/mg protein, . ± . vs. . ± . nmol/mg protein, p< . ). . the lipid peroxide levels and protein carbonyls formation by cefodizime in the amniotic fluid of pregnant women with pprom was significantly lower than basal level ( . ± . vs. . ± . nmol/mg protein, . ± . vs. . ± . nmol/mg protein, p< . ). . there were no significant differences in the levels of lipid peroxide and protein carbonyls by amoxacillin and erythromycin in the amniotic fluid of pregnant women with pprom between antibiotics-induced and basal levels. background: chorioamnionitis (cam) is a major antecedent of preterm delivery (ptd) associated with elevated amniotic fluid tnf and il . we hypothesized that these cytokines enhance the term decidual cell (dc) expression of the matrix metalloproteinases (mmp) and , which can then promote ptd by degrading the extracellular matrix of the decidua, fetal membranes, and cervix. methods: immunostaining for mmp- , mmp- , and vimentin (a dc marker) was performed on cam-complicated (n= ) and gestational age-matched control decidua (n= ), and staining intensities were evaluated by hscore. confluent, leukocyte-free term dcs were primed with - m estradiol (e ) or e + - m medroxyprogesterone acetate (mpa), and then switched to a defined medium with e +/-mpa with or without ng/ml of il or tnf . secreted mmp- and mmp- levels were measured by elisa (n= ), and quantitative rt-pcr assessed mmp- and mmp- mrna levels (n= ). results: tissue staining revealed that mmp- and mmp- levels in cam-complicated decidua (hscore mean±sem: ± and ± , respectively) were significantly higher than in control decidua ( ± , and ± respectively; p< . ). in cultured term dcs incubated with e , tnf and il significantly increased secreted levels of mmp- compared to e alone (pg/ml/ g protein: . ± . and . ± . , respectively, vs. . ± . ; p< . ). in parallel incubations with e +mpa, basal mmp- output was lowered by %, and tnf -and il -elicited mmp levels were blunted by % and %, respectively. rt-pcr confirmed that tnf and il increased mmp mrna levels (p< . ), although mrna levels in e +mpa incubations were not different from those of e alone. mmp levels in all treatments were similar. conclusions: mmp- and mmp- are elevated in cam decidua compared to controls. our in vitro results suggest that mmp- expression is enhanced by the high levels of il and tnf associated with cam, and that mpa may be able to blunt this effect. we have previously found a similar regulatory mechanism of mmp- and mmp- and their over-expression in cam-complicated tissues. synergy among these mmps may represent a potent pathogenic mechanism of cam that can be targeted through the therapeutic use of progestins in preventing cam-induced ptd. domerudee preechapornprasert, patama promsonthi, wasun chantratita, mana rochanawutanon, patcharee karnsombut, chutatip srichunrusami, stephen j lye, boonsri chanrachakul. obstetrics and gynecology, ramathibodi hospital, mahidol university, bangkok, thailand; pathology, ramathibodi hospital, mahidol university, bangkok, thailand; obstetrics and gynecology, samuel lunenfeld research institute, toronto, canada. objective: cervical ripening is an inflammatory process involving chemokines, cytokines and various mediators. recent study has shown that the level of monocyte chemotactic protein (mcp) , a chemokine, increases in amniotic fluid during spontaneous labor. the aim of this study was to examine the localization and expression of mcp in human cervix before pregnancy, during pregnancy and after the onset of labor. methods: this study was approved by the local ethics committee and written informed consent was obtained from each participant. cervical biopsies were taken from groups of women; nonpregnant women, first trimester pregnant women, term pregnant women with and without labor. tissue samples were fixed in % formal saline for paraffin section. immunohistochemistry (n = each) was performed by avidin biotin complex (abc) technique using monoclonal antibody specific to human mcp . the mcp messenger(m) rna was identified by reverse transcription-polymerase chain reaction using gene specific primer against mcp and mcp receptor (n = each). results: immunohistochemistry demonstrated mcp in cervical tissues from all four groups of women. mcp was localized on plasma membrane and cytoplasm of both squamous epithelial and columnar cell lining of endocervical gland. mcp and mcp receptor mrna were identified in nonpregnant, first trimester and term with and without labor human cervix. conclusion: mcp and mcp receptor were located in cervical tissues of nonpregnant and pregnant women at different gestation both before and after the onset of labor.ongoing studies are investigating the role of this chemokine during pregnancy and labor. whether preterm cervical ripening is just an aberrant regulation in timing or whether divergent mechanisms and pathways are involved in preterm versus term cervical ripening remains to be elucidated. methods: cervical tissue was collected from groups of cd- mice. group : mouse model of ptb that utilizes intrauterine infusion of lipopolysaccharide (lps). group : e dams representing preterm controls. group : e . - dams selected from a timed pregnant batch where half of the dams had delivered representing term cervical ripening. n= dams/treatment group. separate rna samples were used for microarray analysis (ma). significance analysis for ma and partek software was used for biostatistical analysis. pathway analysis was performed using david. quantitative pcr was performed to confirm the most differentially regulated genes. results: using a cut-off of -fold change with p value of < . , genes in the cervix were differently regulated between the groups. principal component analysis revealed three distinct groups (see graph). functional annotation clustering demonstrated the following pathways: ) in preterm cervical ripening (e lps vs e ): immune and inflammation response, defense response ) in term cervical ripening compared to preterm controls: negative regulation of cellular process and biological process, ecm, cell-cell communication. qprc confirmed the highly significant differences found in ma (see table) . conclusions: the molecular mechanisms and pathways governing preterm and term cervical ripening are distinctly different. elucidating these unique pathways can lead to improved therapeutics for prevention of ptb as well as for postdate pregnancies. cervical ripening at term involves activation of apoptotic enzymes. maria kb sennstrom, valentina ciani, gunvor e ekman. obstetrics and gynecology, women and child health, karolinska institute, stockholm, sweden; obstetric and gynecology, university of siena, siena, italy. aim: to investigate if the human cervical ripening at term involves programmed cell death. during the final cervical ripening the extracellular matrix dominated cervix undergoes an extensive remodelling of the tissue. inflammatory mediators such as the cytokines increase in ripening cervical tissue at term. programmed cell death, apoptosis, has been suggested as important in this process. apoptosis can be induced by inflammatory mediators such as cytokines. we also looked upon the distribution of inflammatory cells in cervical tissue. materials and methods: cervical biopsies from pregnant women at term and post partum women with fully ripened cervix were studied. biopsies from non-pregnant women served as controls. immunohistochemical analysis of the apoptotic enzyme caspase- and the inflammatory cell marker cd was performed on paraffin embedded sections of cervical tissue. double staining was performed. mann-whitney u-test was used for statistical analysis. results: there was a significantly higher frequency of caspase- staining in the post partal sections from ripened cervical tissue compared to tissue from term pregnant (p= . ) with unripe cervix and from non-pregnant patients (p= . ). the inflammatory cells staining for cd increased in post partal and term pregnant sections compared to non-pregnant (p= . ). there was a higher frequency of caspase- positive cells in the post partal tissue than of cd positive cells (p= . ). the localization of cd- positive staining was highest in the epithelia and basal lamina while caspase- staining was most pronounced in stromal tissue and around vessels. conclusion: our data show apoptotic activity in stromal tissue in fully ripened human cervix at term of pregnancy, suggesting that apoptotic mechanisms are involved in the extracellular matrix remodelling at term. the apoptotic activity is not co-localized with inflammatory cells suggesting non-infectous inflammation with apoptosis as important for cervical ripening at term. objective: cervical biomechanical responses are important for accommodating the increased stress induced by an enlarging uterus. a mechanical testing system was modified to evaluate the stress relaxation response in the pregnant cervix. methods: tissue harvested from the non pregnant and timed pregnant (days , , , , and ) sprague-dawley rats underwent tensile testing using an instron material testing system. the testing regimen consisted of tissue extension to near maximal strain over seconds followed by a period of constant strain for minutes, then return to rest over seconds. this cycle was repeated additional times with a minute rest period between cycles. strain and force measurements were recorded at second intervals. - animals were used for each time point. in addition, stress and strain at the yield point was also determined for each gestational time point. results: the pregnant and non pregnant samples exhibit marked differences in response in both stress and strain. the timed pregnant tissue demonstrated progressively increased compliance and lower nominal stress compared to non pregnant tissue. peak nominal stress declined with each successive cycle. this was demonstrated in the peak nominal stress and strain values at the yield point. conclusion: the cervix becomes more distensible (compliant) but less resistant to force with increasing gestational age. ...,.. e. coli . x .:!: . x . x .:!: . x group a (c, c) group b ( c, p) . x + . x . x + . x . . . group c (p, p) . x o"::!>s x o" . x ~ .ox: o• k. ~neumoniae group a ( c, c) . x + . x . x + . x . . . group b (c, p) . x + . x . x + . x group c (p, pl . x ~ . x . x ~ . x c. al bicans group a (c, c) . x '+ . x . x + . x group b (c, p) . x o•+ . x . x + . x . . . group c (p, p) . x ~ . x . x ~ . x • introduction: a growing body of evidence supports that inflammatory processes are implicated in spontaneous preterm birth (ptb). using an inflammatory and non-inflammatory mouse model of ptb, we sought to determine if activation of these inflammatory pathways are essential for ptb and/or cervical ripening to occur. methods: timed pregnant cd- mice were used in these two models of ptb: ) a model of intrauterine inflammation where lipopolysaccharide (lps) is injected into the uterine horn (n= ); controls for this model received intrauterine saline (n= ) and ) a non-infectious model of ptb using ru sq ( ugrams/dam) (n= ); controls for this model received no intervention (n= ) were used for these studies. for both models, hours later uterine and cervical tissues were harvested. the tissues were processed for protein and rna studies. elisas were performed to assess il- and tnf-alpha in the uterine tissue. mrna expression of ifn , il- , il- , il- , tnf-alpha were assessed in cervical tissue from both models by quantitative pcr. results: in uterine tissues, both il- and tnf were significantly elevated in the lps-induced ptb when compared to control, saline, and non-infectiousinduced preterm birth (p< . ) (figure ). in cervical tissue, an increase in il- , il- beta and tnf mrnawas observed in both models, while ifn-gamma and il- were only increased in the lps model. (figure ). conclusions: up-regulation of pro-inflammatory cytokines in the uterus do not appear to be essential for ptb. cytokine expression in the cervix is greater in an inflammatory model of ptb but is also present in a non-infectious model. these studies suggest that targeting a cytokine response in the cervix may hold the most promise in prevention of ptb. the initiation of labor at term and preterm is associated with an inflammatory response, with increased interleukins in amniotic fluid (af) and infiltration of the myometrium by neutrophils and macrophages (m ). whereas, in preterm labor, intra-amniotic infection may provide the stimulus for increased af interleukins and inflammatory cell migration, the stimulus for these events at term has remained uncertain. in studies using pregnant mice, we observed that the m that invade the maternal uterus near term arise from the fetus. furthermore, we obtained compelling evidence that surfactant protein-a (sp-a), a developmentally regulated c-type lectin secreted by the fetal lung into af near term, activates af m , which migrate to the uterus where they promote an inflammatory response culminating in labor. we propose that interactions of m surface receptors with sp-a, at term, or bacterial lipopolysaccharide at preterm, initiate changes in m phenotypic properties, resulting in the enhanced expression of genes that promote their migration to the uterus. the objectives of the present study were to analyze the numbers and phenotypic properties of mouse af m during late gestation and to identify their putative tissue source(s) of origin. to assess changes in the number of m in af during late gestation, af cells were isolated and stained for the m marker f / . the density of adherent f / + cells greatly increased in equivalent volumes of af between . and . days postcoitum (dpc) ( . dpc = term). interestingly, the f / + cells at . dpc were highly similar in morphology to those present in . dpc fetal lung, but distinctly different from those in fetal liver, suggesting their pulmonary origin. the af m were foam cell-like, suggesting the presence of lipid inclusions, a property shared by adult alveolar m . to further analyze gestational changes in the m population(s) in mouse af, we used flow cytometric analysis. in our initial studies, cells isolated from af were stained for f / and for cd , a pan-leukocyte marker. we observed that af from . and . dpc mice contained two sub-populations of cd + f / + cells. studies are in progress to analyze these af m populations for expression of cell surface antigens indicative of their maturity, activation state and chemotactic properties in association with the developmental induction of sp-a synthesis and secretion by the fetal lung. april bleich, patrick keller, r ann word. ob-gyn, ut southwestern, dallas, tx, usa. the role of prs, proinflammatory cytokines, cell adhesion molecules, cox- , and toll-like receptors in mediating cervical ripening prior to labor is not clear. the objective of this study was to quantify pr isoforms and determine the relative expression of certain inflammation-related genes in cervical stroma from nonpregnant and pregnant women in early gestation (eg), term before and after cervical ripening, and during labor. methods: standard curves of pr-b, -a, pra+b and qpcr were used to quantify total and pr-b in cervical stroma from nonpregnant (proliferative, n = ; progestin treatment, n = ) and pregnant women undergoing hysterectomy (eg, n = ; term before ripening, n = ; after ripening, n = ; in labor, n = ). cervical status was determined by modified bishop scoring. results: total pr expression was maximal in nonpregnant women in the proliferative phase ( . ± . pg/ug cdna) and decreased % by progestins ( . ± . pg/ug cdna). this level was maintained in stroma from pregnant women before labor ( . ± . , eg.; . ± . before ripening; . ± . after ripening pg/ug cdna). in contrast, total pr was decreased significantly in the dilated cervix ( . ± . pg/ug, p < . ). interestingly, whereas pr-b was ± % that of total pr in the nonpregnant cervix, pr-b mrna levels were ± % to ± % in cervical tissues from all pregnant women and did not vary with labor status. using immunoblot analysis and pr-specific antibodies (pgr ), pr-b immunoreactivity was % that of total pr in all samples from pregnant women, and both pr-a and -b were downregulated significantly in the dilated cervix (from ± to ± units/atub). decreased expression of pr in the dilated cervix was accompanied by significant increases in il- , mcp- , tlr- , cd l, cox- , and s a mrna (all p < . , anova) but not cd b or tlr- . pgdh mrna was decreased significantly in the dilated cervix. with the exception of cox- , expression of these genes was similar before labor regardless of cervical ripening. conclusions: both pr and pr-b are decreased proportionately in the dilated cervix, but not during cervical ripening. further, a number of inflammatory gene products are increased dramatically in the cervix during labor, but not before. taken together, the results suggest that cervical ripening is distinct from cervical dilation and involves upregulation of cox- but not il- , mcp- , or toll-like receptors. ifn-y il- il- , il- tnf- "p value < . lps/saline ru /controls . "" . " . " . * " " . * . . " association between interleukin- (il- ) and il- to examine association of amniotic fluid interleukin (il- ) concentration with il- and its receptor il -r haplotypes in term and preterm caucasians (c) and african americans (aa) samples. methods: in this study case (preterm birth -ptb [< weeks]) and control (term [> weeks]) amniotic fluid (af) il- concentrations were analyzed for association with haplotypes of the il- and il r genes in aa and c separately. in il- , eight, and in il- r, single nucleotide polymorphisms (snps) were examined. aa and c maternal and fetal genotypes were assessed (aa: maternal:cases- controls- fetal: cases- fetal controls-; c: maternal cases- , controls- , fetal:cases- ; controls= ). haplotype associations were performed by using a sliding window with outcome il- concentration. analyses were performed separately on maternal and fetal dna. results: the strongest haplotype associations were observed in il- r rather than in il- . in c fetal dna il- r haplotypes defined by markers - bp from the transcription start site associated most strongly with af il- concentrations (global p= . x - ) and in aa maternal il- r haplotype markers at - - - (global p= . x - associated with il- concentrations. in the c fetal cases the - haplotype with the highest concentration was a-g (log(cytokine) = . pg/ml). in aa maternal samples the highest concentration was observed for haplotype t-t-g-c at - - - .this was seen in both cases and controls at (case log (cytokine) = . ; control log(cytokine) = . pg/ml). significant associations from haplotype analyses converged on three regions of the il- r in both races. no strong differences were observed between the haplotypes of cases with and without microbial invasion of the amniotic cavity (miac), with the exception of aa fetal samples that showed two overlapping haplotypes in il- that associated in cases with miac but not in cases without miac (- and - ; - and - )(both with p < x - ) conclusion: differences in the af il- concentration in ptb do not result from single snp effect on il- but are a result of complex relationships between il- and il- r haplotypes. these associations exhibit racial disparity. the role of tnf-in parturition. helen alexander, amanda tattersall, mark tattersall, suren sooranna, peta grigsby, leslie myatt, mark johnson. obstetrics gynaecology, imperial college, london, united kingdom; obstetrics gynaecology, university of cincinnati college of medcine, cincinnati, oh, usa. introduction: tumour necrosis factor-alpha (tnf-) is thought to play a role in inflammation-induced preterm labour since the decidua produces tnfin response to bacterial products and amniotic fluid tnf-concentrations are increased in the presence of intra-amniotic infection. the aims of this study were to (i) investigate the expression of myometrial tnf-and its receptors in relation to the onset of preterm and term labour; (ii) to identify which intracellular pathways are activated by tnf-; and to investigate the effect of tnf-alone and in combination with il- or il- on gene expression in uterine myocytes. methods: biopsies of human myometrium were taken at caesarean section from women before and after the onset of preterm and term labour and analysed for tnf-and its receptor mrna expression. a further samples were obtained before the onset of labour (n= ) from which myocytes were isolated and cultured in -well plates. when cells were - % confluent either tnf-at a concentration of ng/ml was added to the cells for , , , and min and the cells analysed by western blotting or tnf-at concentrations of , . and ng/ml was added either alone or in combination with similar concentrations of il- or il- to cells for hours and mrna was extracted and converted to cdna to determine il- and gapdh gene expression by qpcr. results: there was no change in tnf-mrna expression in relation to the onset of labour, but the expression of tnfr and tnfr mrna levels were significantly increased with gestation and further increased with the onset of labour. incubation of uterine myocytes with tnf-( ng/ml) activated all three mapk substypes: erk, jnk, and p , activation peaked between - minutes. preliminary data suggest that tnf-induces il- mrna expression but exposure to il- or il- itself did not enhance this response. conclusions: although there is no significant increase in tnf-concentration from baseline during labour we have shown tnf receptor mrna levels do increase with labour at term. exposure of isolated uterine myocytes to tnfcauses activation of all mapk subtypes and an increase in il- mrna expression. this enhanced mapk-dependent il- expression at term may be mediated via increased myometrial sensitivity to tnf-through increased tnf receptor expression. remodeling. brenda c timmons, anna-marie fairhurst, mala s mahendroo. obstetrics and gynecology, ut southwestern medical center, dallas, tx, usa; immunology, ut southwestern medical center, dallas, tx, usa. objective: the molecular mechanisms involved in cervical ripening are not well understood. immunohistochemical studies from our lab report a recruitment of inflammatory cells to the cervical stroma one day before birth in the mouse using a neutrophil/monocyte marker (neutrophil / ). in this study, we sought to identify and quantitate inflammatory cells migrating into the mouse cervix and to determine if this recruitment was affected by changes in progesterone levels. peripheral blood was also evaluated to see if changes in the cervix was paralleled in blood. methods: flow cytometric analysis was performed using cervical cells and peripheral blood obtained before and during cervical ripening along with - h postpartum. dispersion of cervical cells was optimized. these cells were stained with a panel of fluorescent conjugated antibodies directed against leukocyte antigens and analyzed on an lsrii flow cytometer. cells were also sorted and stained to visualize cell morphologies. to determine the effect of progesterone on the migration of leukocytes, gestation d mice were treated for h with a progesterone receptor (pr) antagonist prior to tissue collection. results: neutrophils do not appear to increase in the cervix until after birth. monocyte (mo) numbers do increase during cervical ripening (late day , d . ) and remain high through postpartum (pp). macrophages (mØ) are present prior to cervical ripening and steady state levels are maintained during labor and pp. pr antagonist treatment on d resulted in a premature increase in mo but not neutrophils or mØ. in contrast to the cervix, mo and neutrophil numbers do not significantly increase in the peripheral blood until pp. results from lymphocyte studies suggest a low level of b and t cells in the cervix. in the peripheral blood, b cells remain consistent through parturition and the t cells decrease by d . and continue to decrease pp. conclusion: tissue mo are increased in the cervix during ripening. this recruitment is dependant on loss of pr function. in contrast, neutrophils are increased in the pp cervix while mØ numbers appear constant. timing of changes in mo and neutrophil numbers in the peripheral blood differed from that observed in the cervix suggesting quantitation of these cell types in blood is not reflective of what is occurring in the cervix during ripening, dilation and pp repair. novel interactions between nf-b and other labour-associated transcription factors identified by a tf-tf array. shirin khanjani, yun s lee, suren r sooranna, mark r johnson, phillip r bennett. irdb, imperial college, london, united kingdom. introduction: external stimuli lead to changes in cellular gene expression through activation of inducible transcription factors. nf-b is a ubiquitous transcription factor classically associated with inflammation, which is activated in response to infection and proinflammatory cytokines such as those prevalent during the labour. the tf-tf interaction array uses a novel technology for detecting interactions between transcription factors based on binding of tfs to their own consensus dna binding sequence. materials and methods: primary myometrial cells were grown until - % confluent and stimulated with ng/ml il- prior to nuclear protein extraction. the nuclear extracts were incubated with the provided set of biotin-labeled, double-stranded oligonucleotide probes, which represent a known library of cis-elements. during the incubation step, these tf probes bind to their specific tfs in the nuclear extract. next, immunoprecipitation was performed using an antibody against nf-bp , which pulled out nf-bp and any tfs bound to it, bound to corresponding cis-elements. normal igg was used in a parallel experiment to represent a negative control. free cis-elements and nonspecific binding proteins were washed away and the cis-elements were finally eluted and hybridized to the array membrane, which is spotted with different tf consensus sequences. results: table shows the different tfs interacting with nf-bp based on the degree of binding stimulated by il- compared to no-il- control. conclusion: these data show that il- stimulation causes nf-b to bind to a wide variety of other treansciption factors. of particular interest in the area of parturition is binding to the other pro-inlammatory tfs such as c/ebp and ap- , which are known to regulate labour-associated genes in synergy with nf-b. the lack of association between nf-b and pr without il- stimulation supports the concept that with the onset of labour inflammation leads to functional progesterone withdrawal, rather than pr acting to inhibit inflammation. table high ap- , c/ebp, cbf, creb , c-myb, e f- , ets, ets- /pea ,fast- , gas/isre, hse, mef- , mef- , myc-max, nf- , nfatc, nf-e , nf-e , pax- , objective: pre-partum cervical ripening involves remodeling of collagen structure and inflammatory immune cell activity (jsgi : , ; reprod biol endo : , ) . although parturition is associated with systemic or local progesterone withdrawal (ajog : , ) , effects of a decline in progesterone on cervical ripening is not known. the present study tested the hypothesis that progesterone withdrawal promotes collagen degradation, innervation, and immune cell trafficking in the cervix of nonpregnant mice. methods: adult virgin female c bl mice received capsules (sc) with oil vehicle (v) or estradiol (e) and progesterone (p) to simulate concentrations in pregnancy (hum reprod : , ) . after days, mice in the v and e+p groups were euthanized. the p capsule was removed from some mice on day (e-p) and groups killed on days and . cervix sections were stained for collagen, nerve fibers, macrophages, or neutrophils (n= /group/day; sections/ cervix; biol reprod : , ; jsgi : , ) . stained macrophages and neutrophils were counted (image pro-plus , media cybernetics). results: e+p treatment for days promoted hypertrophy of the cervix compared to v controls, i.e., collagen content and structure diminished, cell nuclei density declined, and nerve fibers increased. removal of p did not affect these endpoints. for immune cells, e+p for , , or days decreased immune cell numbers. by contrast, p removal increased macrophages and neutrophils in the cervix on days and (p< . , e-p vs e+p groups, respectively). the census of resident immune cells in e-p groups at and h after p removal equaled that in the v group. conclusions: mimicking gonadal steroid concentrations in circulation during pregnancy promotes hypertrophy and suppresses immigration of immune cells in the cervix. in this non-pregnant murine model for parturition, progesterone withdrawal recruits immune cells, but fails to promote further remodeling or hyperplasia of nerve fibers in the cervix. the findings raise the possibility that ripening of the cervix requires not only recruitment, but also activation of immune cells. whether proinflammatory activities by specific immune cells affect nerve fiber hypertrophy or neural activity, as part of the mechanism for ripening of the cervix, remains to be determined. we have previously identified and characterized a truncated pr (pr-m), that localizes to the mitochondrion by multiple experimental techniques, including confocal imaging of a recombinant gfp fusion protein, western blot analysis after cellular fractionation of nuclear pr negative t d-y breast cancer cells and western blot analysis of purified human heart mitochondrial proteins. initial studies with nuclear pr negative mcf- a breast epithelial cells shown to express pr-m demonstrated an increase in mitochondrial membrane potential (mmp) with progesterone/progestin treatment. these studies led to the hypothesis that progesterone modulates cellular respiration via the mitochondrial receptor, pr-m. objectives: the present studies sought to further localize pr-m to the outer, inner or matrix portion of the mitochondrion and to correlate the increase in mmp with total cellular atp production. additionally, the potency of progesterone and synthetic progestins on the change in mmp was evaluated. methods: the location of pr-m was determined by western blot analysis after fractionation of human heart mitochondria with digitonin treatment and differential centrifugation. mmp was determined in mcf- a breast epithelial cells and a rhabdomyosarcoma cells by the change in fluorescent emission of jc- . total atp was determined by a bioluminescent assay. results: western blot analysis after mitochondrial fractionation showed pr-m localization exclusively in the outer membrane. a dose-dependent increase in mmp was seen in cell lines with - min treatment with progesterone and r which were inhibited by a specific pr antagonist, rti- - b, and not affected by the translational inhibitor, cycloheximide. similar changes in mmp were seen with the same concentration of progesterone, mpa and r . progesterone/progestin treatment for min led to an increase in total cellular atp without a change in cell number. conclusions: progesterone/progestin treatment results in an increase in cellular respiration in cells expressing an outer mitochondrial membrane pr and known to lack nuclear pr expression. this may represent a mechanism whereby progesterone enhances cellular energy production to meet the demands of pregnancy. introduction pge is a major product of the fetal membranes, decidua and myometrium and plays an important role in cervical ripening and myometrial contractions. there are four pge receptors, ep- and ep- mediate contractions whilst ep- and ep- mediate quiescence. ep- contains multiple consensus sequences for transcription factors known to be of importance in labour, in particular nfkappab. we therefore performed experiments to determine the effect of activation and inhibition of nfkappab upon ep- expression. myocytes plated in well plates were treated with il- ( ng/ml), to activate nfkappab. myometrial cells were also transiently transfected with nfkappab p sigenome smart pool and sicontrol non-targeting sirna to knock down nfkappab p . rna was extracted for amplifying ep- using quantitative rt-pcr with amplification of l as a control to normalise data. il- caused an increase in expression of ep- . knock down of nfkappab using si-rna resulted in a further increase in ep- . this data suggests that although il- stimulates expression of ep- it does so through an nfkappab independent mechanism. the upregulation of ep- with sirna knock down of p suggests that activation of nfkappab would inhibit ep- expression consistent with the concept that activation of nfkappab at term causes the myometrium to adopt a more contractile phenotype. introduction: a role for the pro-inflammatory cytokine il- is suggested in preterm and term birth, independent of the presence of infection. we previously showed that mice with a null mutation in the il- gene (ko) delivered one day later than wild type (wt) mice due at least in part to altered timing of uterine expression of prostaglandin (pg) f receptor, ptgfr, mrna. we also observed differences in mrna expression of other uterine activation proteins (uaps), pg h synthase (pghs)- , oxytocin receptor (otr) and connexin- (cx- ), suggesting multiple physiological effects for il- in term delivery. objective: to examine the effect of il- deficiency on the peri-partal uterine mrna expression of the pge receptors (ep) , and ; the post-partum changes of all uaps; and the relationship of these to serum progesterone (p ) concentrations. methods: gestational length was observed in pregnant c bl/ wt (n= ) and ko (n= ) mice. uap mrna levels were measured by real time rt-pcr in wt and ko dams sacrificed from d through delivery and up to h postdelivery. serum p was determined by ria. data were analyzed by one-way and two-way anova using the holm-sidak test to differentiate treatment effects at p< . . results: birth was delayed in the il- ko mice ( . ± . d vs. . ± . d), and this affected the timing of peri-partal changes for all uaps similarly. both ep and ep (relaxatory receptors) were elevated at d in ko dams, but returned to low levels before delivery and were elevated at delivery (ep ) or afterwards (ep ). ep levels did not change. otr increased several hours before delivery in all dams. cx- increased at delivery, then fell, while pghs- increased at delivery and remained elevated afterwards. ptgfr mrna increased - -fold at delivery and a further - -fold after delivery, suggesting loss of pgf permitted enhanced ptgfr expression. p serum concentrations fell pre-partum in both groups. conclusions: il- ko alters the expression pattern of several pregnancy and parturition-related genes and may delay the pre-partum p fall, suggesting a potential ovarian effect. a uterine role for il- in regulating the timing of normal term parturition cannot be ruled out. objective: recent studies have highlighted the prevalence of vitamin d deficiency in pregnant women, particularly in those from ethnic groups with darker skin who require higher levels of uv light to make parental vitamin d. as the active form of vitamin d, , -dihydroxyvitamin d ( , (oh) d ) is a potent immunomodulator, we postulated that vitamin d deficiency may lead to dysregulated placental immunity. both trophoblast and decidua express the enzyme -hydroxylase (cyp b ) which catalyzes synthesis of , (oh) d from the inactive pro-hormone -hydroxyvitamin d ( ohd ). in view of the role of trophoblast as a barrier site protecting the fetus against infection, we investigated the impact of cyp b , ohd and , (oh) d on innate immune responses in trophoblastic cells. methods: a trophoblast cell line was used to assess the effect of vitamin d on innate immune responses. the cells were treated for hrs with various concentrations of , (oh) d ( - nm) and antimicrobial cathelicidin expression was assessed by real time pcr. to assess whether expression of cyp b was affected by pathogenic stimuli, a cells were treated with ligands for toll-like receptor (tlr) - , cyp b expression (real time pcr) and ohd utilization were assessed. results: a trophoblast cell line; which shows temperature-sensitive differentiation, revealed expression of cyp b with higher levels of enzyme activity under conditions of syncytiotrophoblast development. cells treated for hrs with , (oh) d showed dose-dependent induction of the antimicrobial defensin cathelicidin expression ( . - fold induction), whilst cells treated pro-hormone ohd ( nm) showed . -fold induction of cathelicidin expression. activation of tlr (poly i:c) and tlr (lipopolysaccharide) enhanced the expression of cyp b ( -and . -fold) and increased the sensitivity to ohd as a consequence. conclusion: these data show that autocrine synthesis of , (oh) d from ohd can stimulate trophoblast immune responses in a similar fashion to macrophages. as ohd is the major circulating form of vitamin d, we hypothesize that trophoblast innate immunity may be significantly compromised under conditions of vitamin d deficiency. introduction: secretory leukocyte protease inhibitor (slpi) is a potent -kda protein inhibitor of neutrophil elastase and it is a mediator of mucosal immunity and an inhibitor of nfkb regulated inflammatory responses. however, its source, function and regulation within the uterus during pregnancy and at parturition are not well defined. it has previously been shown to be present in fetal membranes and cervical mucus and in amniotic fluid, where its levels is increased from second trimester to term and with a further increase at parturition. slpi has also been shown to be responsive to progesterone in human epithelial cells. our aim was to determine the effects of il- on slpi gene expression in human myometrium. methods: primary human uterine myocytes were isolated from non labouring myometrium and cultured in well plates and when cells were - % confluent they were serum starved overnight and incubated with m methyl- -hydroxy-progesterone acetate for h and with or without ng/ml il- for a further hours. at the end of incubations rna was extracted and converted to cdna. paired upper and lower segment myometrial tissue was collected at caesarean section either before or after the onset of term or pre-term labour and frozen for extraction of rna (n= for ptnl, ptl, tnl and l). copy numbers of slpi, gapdh and beta-actin were measured by qpcr. results: h incubation of uterine myocytes with ng/ml il- caused a marked increase in slpi by % (n= ; p< . ). incubation of uterine myocytes with m progesterone for h also increased slpi by % (n= ; p< . ). incubation with il- for h in the presence of h with progesterone increased slpi: gapdh mrna ratio from . ± . to . ± . (mean ± sem; p< . ). slpi expression was similar in the upper and lower segment myometrium in preterm patients. in term myometrium the slpi: beta-actin mrna ratio was increased by -and -fold in term labour versus term non labour samples in the lower and upper segment respectively (mean ± sem; p< . ). these data show slpi is present in human myometrium and that it is increased by il- . progesterone also increases its expression. its expression is increased in term labour where its anti-bacterial, anti-fungal and anti-viral properties could allow it to act as an endogenous block to infections. objective: pre-b cell colony-enhancing factor (pbef) downstream mapk signaling and transcription factor activation. introduction: pbef is expressed in all layers of the human fetal membranes and the myometrium and is upregulated by labor, infection, nf-kb, ap- and stretching. pbef has the ability to protect a variety of cells from apoptosis, however it also appears to act as an insulin mimetic via the insulin receptor (fukuhara et al. science : ; - ) . its levels are elevated in obese patients, those with type diabetes and in gestational diabetes. because pbef has poorly understood biological activities an investigation of mapk signaling and transcription factor activation induced by pbef has been undertaken in order to gain insights into its mechanisms of action. methods: primary aec were isolated from fetal membranes and treated with rhpbef ( ng/ml) for h, lysed and the resultant proteins labeled with cy or cy (amersham). there were used on a protein microarray containing constituents of the mapk signaling pathways (sigma). isolated aec were transfected with luciferase constructs for nf-kb, ap- , cre, hse and gre response elements using the exgen reagent. the cells were treated with rhpbef ( . , . , , ng/ml) hrs, lysed and ul of sample was analyzed for luciferase activity with dual-luciferase reporter assay system (promega). co-transfection with gfp and sv luciferase constructs to control for transfection efficiency and cell number (respectively) was also performed for each experiment. results: pbef significantly upregulated mapk signaling components including functioning as part of the erk pathways and belonging to p signaling. it also activated nf-kb and camp response elements. however, it significantly down regulated signaling molecules belonging to the jnk pathway that resulted in decreased c-jun phosphorylation. conclusions: pbef signaling in aec is consistent with its anti-apoptotic ability and its upregulation of the pro-inflammatory cytokines. although some mapk components responsive to pbef could be associated with insulin receptor signaling, some may not. therefore, it appears likely that pbef interacts with another potentially unique, but currently unidentified receptor. was the first effector to be characterised, but camp is now known to have other effectors, including camp receptor protein, cyclic nucleotide-gated channels and camp-guanine nucleotide exchange factor/exchange protein directly activated by camp (camp-gef/epac). two epac's have been identified and they consist of functional domains: camp-binding domains, a dep domain, a ras exchange motif and a gef domain. our aim was to determine the presence of epac's in human myometrium and to study the effect of camp responses on prolabour genes such as il- , pghs- , otr and fp. methods: primary human uterine myocytes were isolated from non labouring myometrium and cultured in well plates until - % confluent. cells were serum starved overnight and incubated with μm methyl progesterone, . mm sodium -bromo-camp, . mm forskolin, μm kt , ng/ml brefeldin a and . mm -pmeopt- 'o-me-camp either alone or in combination for h. rna was extracted and converted to cdna. paired upper and lower segment myometrial tissue was collected at caesarean section either before or after the onset of term or pre-term labour and frozen for extraction of rna (n= for ptnl, ptl, tnl and l). copy numbers of epac , epac , il- , pghs- , otr, fp, gapdh and -actin were measured by qpcr. results: epac and epac were present in the upper and lower segment of myometrium with epac levels being some -fold higher than those of epac . there was no change with the onset of labour at or before term. treatment with il- for h significantly increased epac (n= ; p< . ) but had no effect on epac . when conditions mimicked pregnancy, (the presence of forskolin and progesterone), brefeldin a, an epac antagonist, increased basal pghs- and fp mrna expression (n= ; p< . ), but had no effect on il- and tended to reduce otr. the il- -induced increase in pghs- and il- , but not fp, was greater with the epac antagonist. conclusions: these data show epac's are present in human myometrium and that camp acts via epacs to reduce pghs- and fp expression during pregnancy. background: inflammatory events have been implicated in the process of labour. glucocorticoids mediate strong anti-inflammatory effects through binding to the glucocorticoid receptor (gr), which on activation translocates to the nucleus and either increases or decreases the expression of responsive genes thereby suppressing inflammation. objective: to characterise the expression profile for gr protein and mrna in human myometrium during fetal maturation and parturition. methods: western immunoblotting (wb) was employed to characterise gr protein expression in first (n= ) and second trimester myometrium (n= ), and in paired upper and lower segment pregnant (non-labouring, p, n= ) and labouring (l, n= ) myometrium; as compared to non-pregnant (np, n= ) control samples. immunofluorescence staining with confocal microscopy and rt-pcr were also undertaken. results: detection of gr protein by wb revealed two bands at - kda, representing the alternatively spliced isoforms, gr-and gr-. densitometric analysis showed that gr levels decreased significantly during pregnancy and remained at very low levels at term and in labour when compared with np samples (p< . ); this decrease was seen for gr-and gr-. no significant temporal variations were observed in gr protein levels at term or during labour. gr protein was localised by immunofluorescence staining to the nuclei and cytoplasm of cells. less intense staining was apparent in p compared to np tissues; consistent with wb data. rt-pcr showed a consistent predominance of gr-to gr-mrna in all the tissues used. the observed decrease in protein expression was also mirrored at the mrna level: gr-mrna levels appeared to gradually decrease throughout gestation (p< . ). differences between the upper and lower myometrial regions were only observed in the labouring samples, where gr-mrna levels were significantly decreased in the lower segment (p< . ). nested pcr was additionally used to amplify gr-, but no consistent pattern of mrna expression was obtained. conclusions: these data are the first to characterise gr expression in human myometrium. spatial and temporal variations have been found with expression evolving through the three trimesters of pregnancy and in labour. further studies are now underway to evaluate whether gr contributes to the sequence of inflammatory events implicated in triggering term and preterm labour. these studies sought to determine the mechanism by which pas modulate the immune response. methods: ) an in vitro co-culture model mixed with human cervical epithelial hela cells and pma-induced human macrophage u cells at epithelial/macrophage cell ratio of : was employed. ) the co-culture was pre-treated with medroxyprogesterone acetate (mpa), progesterone (prog) and dexamethasone (dex) at concentrations of , , and nm for hrs followed by day stimulation of g/ml lipopolysaccharide (lps). these experiments were repeated using hela cells transfected with sirna for glucocorticoid receptor (gr). the production of cytokines il- , il- and il- , il- and tnf were determined using elisas. ) the co-culture was pre-treated with nm of each pas for hours prior to lps stimulation at g/ml for . , . , , , and hours. the phosphorylation of p mapk and gr and the expression of mapk phosphatase (mkp ) were determined by western-blotting. results: il- , il- and il- , il- and tnf were elevated by . fold, . fold, fold, . fold and . fold in the co-culture model in response to lps(p< . for all). pretreatment of mpa and dex, but not prog, inhibited the lps-induced cytokine production. the anti-inflammatory effect of mpa occurs in a dose-dependent manner. in the absence of gr, the inhibitory effect of mpa and dex on il- , but not on il- , was lost. mpa and dex, but not prog, induced the phosphorylation of gr and expression of mkp . p mapk was activated by lps for up to hrs and pretreatment of mpa and dex attenuated this response. the ability of mpa and dex to suppress the inflammatory response in cervical tissues appears to be mediated through a gr-dependent pathway, specifically though p mapk. our studies suggest that prog is not a significant immunomodulator in these tissues. background: progesterone (p ) has been shown to play a critical role in maintaining pregnancy and preventing preterm birth. these effects are likely related to its immunomodulatory properties. we investigated whether camp plays a role in the immunosuppressive action of progesterone on fetal mononuclear cells. methods: umbilical cord blood mononuclear cells were isolated using density gradient centrifugation. to establish a p effect and optimize concentrations, cells were pretreated with p ( - m- - m), dexamethasone ( um) or vehicle for hour prior to overnight lps ( ng/ml) stimulation. supernatants were assayed for tnf-using elisa. ldh assays confirmed the absence of a cytotoxic effect. next, cells were pre-incubated with forskolin (adenylate cyclase activator) or db-camp (camp agonist) prior to lps to determine the effects of camp on tnf production. finally, cells were pretreated with rp-camp (camp antagonist) prior to p incubation and lps stimulation to determine whether the p effect was reversed by a camp antagonist. results: p significantly inhibited lps-induced tnf production in a dose dependent manner, with maximum suppression observed at - m. both forskolin and db-camp suppressed lps-induced tnf production in a doserelated manner (fig ) . finally, a dose-dependent partial reversal of tnf production was observed when cells were pretreated with rp-camp. (fig ) conclusions: progesterone suppresses the inflammatory response in fetal mononuclear cells as measured by tnf expression. this effect is mimicked by adenylate cyclase activators and camp agonists and partially reversed by camp antagonists. this implicates the camp pathway in mediating the immunomodulatory actions of p . objectives estrogen improves endothelial function after vascular injury via largely unknown mechanisms. endothelial progenitor cells (epcs) are known to be implicated in various vascular events requiring endothelialization. we hypothesized that estrogen and progesterone could influence the function and the change of epcs in menstrual cycle. material and methods peripheral blood mononuclear cells (pbmcs) were isolated from peripheral blood of healthy young women in each menstrual period by density gradient centrifugation with ficoll separating solution. pbmcs were seeded in endothelial basal medium with or without estrogen or progesterone. on the th day in culture, nonadherent cells were removed. on the th day in culture, adherent cells were incubated with di-ldl, fixed with paraformaldehyde, and stained with fluorescein isothiocyanate-labeled lectin. the number of ldl-and lectin-positive cells was measured as epcs using flowcytometry. the expression of estrogen and progesterone receptor mrna in epcs were measured by real time pcr in menstrual and luteal period. the number of epcs was significantly increased in the menstrual and luteal period compared with the follicular phase. estrogen and progesterone significantly increased the number of adherent epcs dose dependently in menstrual period, but not in luteal period. the expression of estrogen-alpha receptor in menstrual period was higher than luteal period. also, estrogen-beta receptor in luteal period was strongly expressed compared with menstrual period. these results suggest the expression of estrogen receptor and progesterone receptor play important roles to regulate epcs' proliferation during menstrual cycle. objective: elevated levels of fetal plasma avp are associated with the development of oligohydramnios, in part a result of avp-mediated reduction in fetal urine production. as avp urinary concentration effects are mediated via upregulation of renal tubular aqp water channels, we propose that avp modulates placental aqp channels, influencing bidirectional maternal-fetal water flow. we sought to study the effect of avp on trophoblast aqp gene expression using the first trimester-derived extravillous htr- /svneo cells and the term placenta-like trophoblast carcinoma cells jeg- . methods: cultures of both cell lines were treated with a physiological concentration of avp ( . nm) to determine aqp mrna and protein expression. negative controls consisted of cells incubated in medium supplemented with % fbs without avp. to determine whether avp regulation of aqp occurs by a camp signaling pathway, jeg- cells were preincubated with μm -(tetrahydro- '-furyl) adenine (sq ), a cell-permeable camp inhibitor, before being treated with avp ( . nm). cells were incubated for hrs for aqp mrna expression and for hrs for protein extraction at °c. after harvest, real time pcr and western blotting analysis were used to detect the aqp mrna and protein expression levels, respectively. results: avp increased aqp mrna expression in both cell lines by . and . fold after hrs. aqp protein expression paralleled the increase seen in the mrna (p< . ). pretreatment of jeg- cells with sq inhibitor completely blocked the stimulatory effect of avp. conclusion: aqp gene expression is up-regulated by avp in first trimester and term trophoblast cells, with a higher induction in the later. avp activation of aqp gene expression occurs via a camp mediated pathway, as the adenyl cyclase inhibitor blocked avp effects on aqp gene expression. these results suggest that increased fetal plasma avp may contribute to oligohydramnios by an increase in aqp-mediated fetal to maternal water flow. objective: changes in expression, ratio and activity of progesterone receptors within human myometrium have been proposed as potential contributory mechanisms for the functional progesterone withdrawal effect which precedes labour. progesterone receptor c (pr-c) is an n terminally truncated isoform of the full length progesterone receptor; pr-c has been shown to be abundant in fetal membranes, placenta and upper segment of laboring myometrium ( , ). the function and regulation of pr-c is at present unclear. in this study we aimed to investigate the regulation of pr-c in cultured human myometrial and amnion-derived wish cells. methods: myometrial primary cell cultures were prepared from non pregnant and term pregnant uteri. both myometrial and wish cell cultures were treated with natural progesterone ( , nm, mm, mm, mm) for , and hrs. western immunoblotting was employed using nuclear and cytoplasmic extracts prepared from treated cells to observe the effect of progesterone on a) expression and b) subcellular localisation of pr-c within both cell types. immunofluorescent staining and confocal microscopy were also employed. experiments were also undertaken whereby nuclear and cytoplasmic extracts were subjected to shrimp alkaline phosphatase treatment to evaluate the phosphorylation status of pr-c in response to hormone. results: data indicates that a kda cytoplasmic protein, representing pr-c is abundant in myometrial and amnion cell cultures. we show that expression of pr-c increases in both cytoplasmic and nuclear fractions within both cell types in response to progesterone. evidence also suggests that pr-c is phosphorylated in a progesterone-independent manner. concurrent treatment with progesterone and the pr-antagonists ru and organon in amnion-derived cells still led to an increased abundance of pr-c but seemed to alter the phosphorylation status of pr-c. conclusion: pr-c expression and subcellular localisation within myometrial and wish cells alters in response to progesterone. speculation is generated about potential role of pr-c in reproductive tissues and its contribution to functional progesterone withdrawal. . taylor smooth muscle responses have been studied, data on regional blood flow (bf)distribution are scarce. we have studied the effect of a single dex course on relative bf distribution within the brain, skeletal muscle, heart, omental fat, placenta and adrenal in fetal sheep at . g, the equivalent of weeks. methods: fetal sheep received amniotic, jugular, carotid and femoral artery and vein catheters at days g (dg). experiments started at dg in dex ( mg) and saline treated controls (ctr), each receiving injections h apart. fetal blood pressure was recorded continuously (windaq pro+). microspheres ( . x total; sterispheres, biopal) were injected at : am into fetal jugular and femoral veins before maternal i.m. injection (t ) and h after the rd injection (t ) in both groups. tissues were collected hours after the th injection for assessment of bf (biopal). results: fetal bp increased above baseline after dex ( . + . mmhg; p= . ) with no change in ctr (- . + . mmhg). regional bf distribution is presented as a percent of the total counts per g tissue (table ) and after normalization within each animal to placentomal flow, shown previously to be unchanged by dex, in table . no significant differences in flow were found. discussion: although dex altered bp, regional distribution of bf among key organs was unaffected. whether gc does not affect regional bf, or the rise in bp is the result of a non-specific, system-wide vasoconstriction, or the impact of gc on bf is similar in all organs, will be subject of further investigation that will include determination of regional vascular resistance and absolute flow. stimulator while crf-r is an inhibitor of gi motility at times of stress. we recently hypothesized that stress-induced in utero meconium passage in fetuses is analogous to stress-induced defecation in adult rats and likely mediated by crf pathway. in support, we demonstrated hypoxia-induced meconium passage in conjunction with marked increases in fetal plasma crf levels. as the mouse is a common experimental model, with known genome, we sought to determine the presence of crf-r and crf-r receptors in mouse fetuses. methods: time-dated cd- pregnant mouse were anaesthetized and fetuses (n= ) were collected at e (term = e ). whole gi tracts were dissected, fixed in bouin's solution, paraffin embedded and sectioned at five micron thickness. sections were immunostained with rabbit polyclonal antibodies to crf-r and crf-r by abc technique with vector abc reagents. immunoreactivity was identified as brown staining using ', diaminobenzamidine as chromagen. slides were counter stained with mayer's hematoxylin and examined under the microscope. immunoreactive signals in the smooth muscle layers of gi tracts were quantified by image analysis using image pro . plus software. results: immunostaining for both crf-r and crf-r was seen in the smooth muscle layers of all lumens examined ( lumens per section). the immunostaining intensity expressed as intensity over density (iod) in arbitrary units for crf-r (maximal iod: . ± . au and minimal iod: . ± . au) and for crf-r (maximal iod: . ± . au and minimal iod: . ± . au) greatly varied between lumens. the mouse fetal gi tract expressed both crf-r and crf-r receptors, suggesting that the mouse is an appropriate model for fetal-stress induced neurovisceral motor responses. the non-uniform distribution of crf receptors in the fetal gi tract suggests the existence of regional differences in the expression patterns of crf-receptors of both types. we speculate that mouse devoid of crf and crf-r or r receptors will be useful to confirm the participation of crf pathway in stress-induced in utero meconium passage. antenatal exposure to glucocorticoids (gc) is associated with a reduction in nephron number and hypertension in adult life. one of the mechanisms for the development of hypertension is thought to be the long term effect of single nephron hyperfiltration. however, in most studies there is only a - % reduction in nephron number with no change in gfr. thus, although a reduction in nephron number may be a contributing factor it is unlikely the only variable. the aim of the present study was to evaluate nephron mass, renal function and blood pressure in a cohort of adult sheep exposed antenatally to betamethasone. methods: pregnant sheep were treated with two im doses of betamethasone (bm, . mg/kg) or vehicle (ctr) -hs apart at days gestational age and allowed to deliver at term. at . yr of age in female (f) and male (m) offspring, glomerular filtration rate (gfr) was measured as inulin clearance and effective renal plasma flow (erpf) as pah clearance. blood pressure was measured though an indwelling catheter in the femoral artery over a -hour period. nephron number was measured by the acid maceration technique. data mean±sem were analyzed by anova and/or two sample t test. results: antenatal bm was associated with an elevation in arterial blood pressure and a reduction in nephron number in both f and m offspring. in contrast, a reduction in gfr and erpf was present only in males. plasma and urinary electrolytes as well as urinary protein excretion were not different from ctr. conclusion: our data show that prenatal exposure to a single course of gc at . gestation has long-term effects on blood pressure regulation. interestingly, while the decrease in nephron number was of similar magnitude in m and f, evidence of alterations in renal function was present only in males. these suggest that the decrease in renal function observed in males is not solely a consequence of the decrease in nephron number. furthermore, it is possible that different mechanisms are responsible for the elevation in arterial blood pressure observed in m and f. hl ; hd p hd . clr l>t-x to evaluate the effects on blood pressure, urine output, sodium excretion and gfr of the intrarenal infusion of angiotensin - in the male sheep with or without prenatal exposure to b. we studied male sheep which had received either b (n= ) or vehicle (n= ) at - days gestation and were born at term. catheters were placed in the femoral artery, femoral vein, left renal artery and the bladder. the right kidney was removed. after days recovery the sheep received an infusion of ang - ( ng/kg/min) with or without its antagonist, [d-ala ]-ang-( - )(d-ala, ng/kg/min), into the renal artery for hours. blood pressure, gfr, urine output and sodium excretion were measured before and after the infusion. two-way analysis of variance (anova) was used to test mean values between the groups. with or without d-ala, map and urine output didn't change significantly during ang - infusion. however, the infusion of ang - resulted in a decrease (change from baseline) (p= . ) in na + excretion of . ± . meq/kg/ h in the vehicle animals and . ± . meq/kg/ h in the b animals. there was no significant change in gfr during ang - infusion. gfr was lower in the b group during the combined ang - and d-ala infusion ( . ± . ml/min vs . ± in vehicle group, p= . ). intrarenal infusion of ang - at ng/kg/min is followed by a significant decrease in sodium excretion but no significant change in urine output and gfr. the decrease tended to be greater in the vehicle animals and was not markedly attenuated by the antagonist d-ala. this suggests the effect of ang - may be mediated by a receptor other than the mas receptor for ang - and may be of lesser magnitude in animals exposed to b before birth. and norepinephrine ( . - . g/kg/min) and to an l-name ( mg/kg) bolus were studied. vascular reactivity was analyzed by curve fitting of either the blood pressure or hr responses to obtain the maximal response. data are expressed as mean±sem of change from baseline. statistical significance was established using t test. results: bm-exposed animals displayed a higher blood pressure response to at-ii (atii max ± vs ± % of baseline, p< . , figure left panel). no differences in blood pressure or heart rate responses to norepinephrine infusion were detected in bm when compared to control animals (figure right panel) . maximal response to l-name was also elevated in bm-exposed animals but did not reach statistical significance with the current sample size. conclusion: we have shown that antenatal gc treatment significantly increases blood pressure in sheep. here we show an enhanced in vivo response to at-ii. this response may contribute to the increased blood pressure observed. the greater response to l-name most likely represent an increased no production as a compensatory mechanism to the higher blood pressure observed. hl . women at risk of delivering preterm are frequently treated with glucocorticoids to facilitate fetal lung maturation. animal studies have revealed that prenatal exposure to glucocorticoids may alter aspects of hypothalamic-pituitary adrenal functioning in later life. in this study we examined the effects of clinically relevant prenatal betamethasone treatment on the responsiveness of pituitary cells (in terms of adrenocorticotropin, acth, secretion) isolated from adult sheep. time-dated pregnant sheep were injected with betamethasone ( . mg/kg) or vehicle on days and of gestation. thereafter pregnancy was allowed to continue unimpeded and offspring were born. pituitaries were isolated from adult sheep aged between and months and cells were dispersed and plated at a density × cells per well in well plates. after h, cells were stimulated with normal medium, nm arginine vasopressin (avp), nm avp, nm corticotropin releasing factor (crf) or nm crf for h. medium was collected and analyzed for acth using a commercially available kit. acth secretion (given as % increase from untreated cells) was similar between the control and betamethasone groups following nm avp ( . ± . vs. . ± . ) and nm crf ( . ± . vs. . ± . ). at higher stimulatory concentrations of both avp and crf, acth secretion remained similar in control cells ( . ± . and . ± . respectively), but was significantly decreased in betamethasone cells ( . ± . and . ± . respectively). these findings suggest that prenatal exposure to clinically relevant doses of betamethasone can alter pituitary responsiveness to both avp and crf in adulthood. this research was supported by nih grants hd and hd . lcc is supported by an rjr-leon golberg fellowship in pharmacology and toxicology. objective: newborn meconium (mec) passage normally occurs within the first - h after birth. in contrast, more than half a million infants born annually in the us pass mec in utero. neither the physiological mechanism(s) nor causes for in utero mec passage are well understood, though both fetal maturation and stress are associated. we recently reported in utero mec passage and marked increases in plasma crf levels in term fetal rats exposed to maternal hypoxic stress. we hypothesize that stress-induced in utero mec passage is mediated by the crf pathway in a manner analogous to stress-induced defecation in adult rats. in the present investigation we examined placental crf content prior to and following maternal hypoxia, to determine the source of increased plasma crf. methods: time-dated pregnant rats (n= ) were exposed to a paradigm of graded, stepwise hypoxia on day (term= ) (pediatr. res. : - , ) . control pregnant rats were exposed to % oxygen for a similar duration as experimental animals. at the end of the study, placentas were harvested, fixed in % paraformaldehyde and paraffin embedded. sections (n= per placenta) were subjected to immunohistochemical analyses with rat/human crf antibody (peninsula laboratory) by abc technique. immunoreactivities on placental sections were quantified using the image pro . software and intensity expressed as arbitrary unit (au). all values are mean± sem. results: in control maternal rats exposed to normoxia, positive staining for crf was seen in decidua ( . ± . au) and in all three major placental cells types (giant trophoblast cells: . ± . au, spongiotrophoblast cells: . ± . au and labyrinth cells: . ± . au.) in contrast, in animals exposed to hypoxia, there was a total absence of crf staining in the placental cells, with only positive crf staining seen only in the decidua ( . ± . au). conclusion: the total absence of crf staining in both the basal and labyrinth zones in placentas of pregnant rats subjected to hypoxic stress suggests that placental cells rapidly release crf into the maternal and fetal circulation in response to hypoxic-stress. our findings support our hypothesis that the peripheral crf pathway mediates in utero mec passage. offspring. angela g massmann, jie zhang, jorge p figueroa. department of obstetrics and gynecology, wake forest university school of medicine, winston-salem, nc, usa. objective: in rats and sheep, exposure to glucocorticoids (gc) in the perinatal period induces hypertension in adult life. recent evidence suggests that endothelin b (etb) receptor plays an important role in the regulation of sodium balance and blood pressure. renal medulla is an important site of expression and action of etb receptor. furthermore, in kidney it is the medulla (km) where the highest concentrations of immunoreactive et- and etb receptor are found. the aim of this study was to measure eta and etb expression in adult sheep kidney exposed antenatally to gc. methods: pregnant sheep were treated with two im doses of betamethasone (bm, . mg/kg) or vehicle (v) hours apart at days of gestational age and allowed to deliver at term. at . yr of age, male and female offspring exposed to either vehicle or bm were euthanized and the kidneys harvested. kidney medulla (km) was obtained by sharp dissection. eta and etb protein and mrna expression were evaluated by western blot and rnaase protection assay. data are expressed as mean±sem and were analyzed by two way anova. results: a significant decrease in etb (f= . , p= . ) but not eta protein was observed in km of bm exposed male and female adult sheep. at the mrna level, bm exposure also affected etb, but not, eta expression. however, bm treated animals had higher mrna levels than control sheep (f= . ; p= . ). conclusion: our data show that prenatal exposure to a single course of gc at . gestation has long-term effects. the activation of etb receptor by et- inhibits sodium transport function in the collecting duct and the selective gene deletion of the etb in medulla results in hypertension.therefore, our finding of a significant reduction in etb protein suggests that there may be an impairment in the kidney's ability to regulate sodium reabsorption. the functional relevance of the alterations in etb protein expression as well as the discrepancies in mrna regulation need to be established. hl ; hd p hd . in the placenta, -hydroxysteroid dehydrogenase type ( hsd ) regulates the transfer of cortisol. maternal glucocorticoid (gc) administration has been shown to affect the ovine fetal growth trajectory and regulate hsd expression in mid and late gestation. however, little is know about the effects of gc administration in early gestation. we hypothesized that maternally administered low-dose dexamethasone (dex) in early gestation would affect hsd expression, which will subsequently alter fetal birth weight. pregnant ewes were randomized and received intramuscular injections consisting of either saline ( ml saline/ewe) or dex ( . mg/kg) given hours apart starting on days of gestation (dg). the animals were sacrificed at , , , and dg and fetal weights were recorded and placental tissue was collected. qrt-pcr was used to measure hsd placental mrna expression. statistical analysis was done by anova with student's t-test posthoc. overall, there was no significant effect of dex treatment on placental hsd mrna expression across gestation. however at dg, there was a significant increase in hsd expression after dex (p= . ). there was an increase in placental hsd mrna progressively from dg (mean = . ) to dg (mean = . ), independent of treatment. overall, a positive correlation between hsd and fetal weight (r = . ) was apparent at dg and at dg (p= . ) in both control (p= . ) and dex (p= . ). significant positive correlations between placental hsd and fetal weight (r = . ) were found in females (p= . ) and a similar trend was found in male fetuses (p= . ). we conclude that in the sheep placenta, hsd expression increases throughout gestation and may respond, at least transiently in early gestation, to elevations in maternal gc. the positive correlation between hsd and fetal weight is consistent with the thesis that the fetal growth trajectory may be influenced by maternal cortisol levels and that placental hsd is an important mediator of these effects. antenatal gc exposure induces hypertension in the young adult rat (neuroendocrinol; ; : ) and increases femoral vascular resistance in the lamb (jphysiol; ; : ) . unpublished own examinations in preparation of this study have shown age dependency of the vascular reactivity. vascular contractility of the middle cerebral artery (mca) decreased in response to k + and noradrenaline (na) between mo and , y of age (p< . ). vascular relaxation to acetylcholine (ach) but not to pge decreased during the same time (p< . ). vascular contractility of the renal artery (ra) increased in response to k + (p< . ). aims: to examine if antenatal gc alter vascular reactivity in the aged individual when cardiovascular diseases are predominant. we studied the ra because its vascular tone is involved in modulation of arterial pressure control (amjphysiol; ; :r ) and the mca because depressive disorders that are associated with dysregulation of the hpa axis (jcem; ; : ) increase stroke mortality for unknown reasons (amjpsychiatry; ; : ) . to be clinically relevant, we administered dexamethasone at the dose used to enhance lung maturation in babies threaten premature labor. methods: pregnant dams received saline (n= ) or μg/kg dexamethasone (n= ) i.p. at day e / equivalent to x mg dexamethasone administered to a kg pregnant woman. at . years of age, vascular response of the ra and mca to endothelium-dependent and independent mediators was measured using wire myography. vessels were inspected histologically for intact endothelium. results: basal vasoconstrictory and dilatory responses to all mediators were less pronounced in the mca than in the ra probably reflecting autoregulatory properties of cerebral vessels (p< . ). after prenatal dexamethasone exposure, contractility but not sensitivity to k + and na was enhanced in the mca and even more pronounced in the ra (p< . ). relaxation to ach and pge was similarly diminished in both vessels after precontraction with na (p< . ). conclusions: prenatal dexamethasone exposure at the dose used clinically increases renal and cerebral vascular tone in the aged rat by endotheliumdependent and independent mechanisms. this effect may be a potential mechanism of fetal programming of cardiovascular diseases in later life. betamethasone (bmz) therapy during pregnancy to improve fetal lung maturity may result in long term side effects, including hypertension, during adulthood. the kidney is an important organ which regulates systemic blood pressure via the local renin angiotensin system (ras). the major enzymes of the intrarenal ras include angiotensin converting enzyme (ace), angiotensin converting enzyme (ace ), and neprilysin. the hypothesis of this study is that prenatal bmz exposure will result in alterations of the enzymes regulating the intrarenal ras. specifically, sheep that are treated with bmz in utero will have higher amounts of ace activity in kidney cortex compared to control animals. pregnant sheep of known mating date were either treated with vehicle (n= ) or with two doses of bmz (n= ), . mg/kg, hours apart at days of gestation. renal cortex from the male offspring was harvested at - months of age. cortical membranes were then solubilized and incubated at °c with either i-ang i or i-ang ii in the presence or absence of lisinopril to inhibit ace activity, mln to inhibit ace activity, or sch to inhibit neprilysin activity. the metabolic products were separated by reversephase high performance liquid chromatography (rp-hplc). the rate of enzyme activity was quantified by calculating the area under the curve for each product and converted to fmol of product per mg protein per minute of incubation. statistical analysis was performed using student's t-test. p< . was considered significant. results: bmz treatment resulted in a significant increase in ace activity compared to control animals (p= . ). ace and neprilysin levels were not significantly different between treatment groups. when expressed as a ratio of ace/ace activity, bmz treated animals exhibited a . fold greater proportion of ace activity versus control animals (p= . ). this study demonstrates that bmz exposure during fetal life results in a significant increase in renal ace activity during adult life. this increase in enzyme activity would be expected to be associated with increased levels of ang ii in the kidney and na + retention, possibly underlying the development of hypertension. hd , hd . we recently hypothesized that stress-induced in utero meconium passage in term fetuses utilizes peripheral and/or central crf pathways in a manner analogous to stress-induced defecation in adult rats. as participation of central crf pathway requires the crf circuitry system in brain-gut axis, we exploited immunohistochemical techniques to address whether term fetal colon is wired by crf-nerve fibers. methods: fetal distal colon segments (n= ) were dissected from term ovine fetuses ( - d gestation). in addition, lumbosacral spinal cord with spinal roots and dorsal root ganglia (drg) (n= ) were dissected from ovine fetuses, and vagal nerve trunk with nodose ganglia (n= ) were dissected from mouse fetuses. paraffin sections fixed either in bouin's solution or zamboni's were subjected to immunohistochemistry with rabbit polyclonal antibodies specific to ovine-crf (ocrf). immunoreactivity on the sections was identified by standard abc technique, immunostaining quantified by image-pro plus software and expressed (intensity over area) as arbitrary units (au). results: ocrf antibody elicited strong positive staining on the serosal surface (port of entry for extrinsic nerve fibers) in distal colonic segments objective: we hypothesize that stress-induced in utero meconium passage is mediated by the crf pathway. ucn-i, similar to crf, is a potent contractility inhibitor of preterm ovine fetal distal colon, which has abundant crf-r receptors. both ucn- and crf thus may inhibit colonic motility and prevent preterm in utero meconium passage via crf-r receptors. however, ucn-i is reported to stimulate contractility of adult rat colonic smooth muscle strips more strongly than crf. we sought to study the pattern of ucn-i innervation in distal colon of ovine fetuses to delineate whether ucn- functions as a facilitator or inhibitor of colonic propulsive motility. methods: bouin's solution fixed, paraffin sections of very preterm (vpt: - days gestation), preterm (pt: - days), near term (nt: - ) and term (t: - days) ovine fetal distal colon rings were subjected to immunohistochemistry with polyclonal antibodies to human ucn- ( : sigma) by abc system. intensity of ucn- immunostaining in smooth muscle layers and myenteric neurons were quantified by image-pro plus software and expressed (intensity/area) in arbitrary units (au). differences over time were assessed with anova. in all groups very preterm was significantly greater than term (p< . ). conclusion: ucn- immunoreactivity in all three muscle layers, as well as myenteric and submucosal neurons, is highest at very preterm as compared to more mature gestations. these results suggest that the reduction of ucn- inhibitory function may facilitate stress-induced meconium passage at term. to evaluate the effect on blood pressure (bp), urinary output (uop), sodium excretion (nae) and gfr of the intrarenal infusion of ang ii in the male sheep after prenatal exposure to b. methods: we studied male sheep which had received either b (n= ) or vehicle (n= ) at - days gestation. catheters were placed in the femoral artery and vein, left renal artery and in the bladder. a right side nephrectomy was performed. after days of recovery, the sheep were infused with ang ii ( ng/kg/min) with or without candesartan ( ng/kg/day) or pd (pd g loading dose and ng/kg/min infusion) into the renal artery over hours. bp, gfr, uop and nae were measured before and after the infusion. two-way analysis of variance was used to test mean values between the groups. results: bp and uop did not change with ang ii infusion with or without candesartan. the infusion of pd did not affect uop but did increase bp in the b sheep (p= . ). ang ii decreased the nae in both groups(p= . ). candesartan increased nae among controls(controls . and b . meq/kg/h, p= . ). pd infusion decreased nae among controls but this was not significant. baseline gfr was higher among vehicle compared to b animals (p= . ). during ang ii infusion there was a decrease in gfr among control compared to b sheep (- . vs. - . ml/min, p= . ). this difference was not seen during candesartan or pd infusion. conclusion: ang ii infusion led to a decrease in nae in both groups and gfr among controls but not b animals. infusion of ang ii with candesartan increased nae while pd decreased nae among controls but not b animals. this suggests that prenatal steroid exposure can alter at receptor mediated response in renal function by decreasing the effect of ang ii on renal sodium excretion. the differences in gfr suggest that this may be due to an effect on tubular sodium reabsorption rather than glomerular perfusion. antalarmin antagonism of acth-induced cortisol secretion by ovine adrenal cells probably not at acth receptor. nancy k valego, james c rose. center of research for ob/gyn, wake forest u. school of medicine, winston-salem, nc, usa. in addition to regulating the hpa axis, crh and its type receptor (crhr- ) occur peripherally and in the female reproductive system. late in human pregnancy, a surge in placental crh probably stimulates adrenal secretion of cortisol and dheas requisite to parturition. we previously reported that, in dispersed fetal or adult ovine adrenal cortical cells, hour incubation with the specific crh-r antagonist, antalarmin (ant), significantly reduced both cyclicamp and cortisol responses to acth, suggesting an interaction with acth-r (like crh-r , a g-protein-coupled membrane receptor). however, forskolin (fsk; direct stimulant of adenylyl cyclase)-stimulated cortisol secretion was also attenuated by hour co-incubation with ant. our objective was to clarify the effect of ant on binding of acth to its receptor after a short ( . hours) treatment. method: acth binding: the adrenals from adult sheep were obtained at necropsy and the cortex cells dispersed and plated @ cells/well. after hours in culture, wells were rinsed x and refilled with serum-free dmem/ f containing vehicle (dmso) with or without ant. after . hours, wells were washed very gently and the binding assay (adapted from rainey et al; j biol chem, : , ) completed. triplicate vehicle or ant wells were treated with i -tyrosine human acth ( - ) with or without - m acth (for non-specific binding). after hour, wells were chilled, washed, and the cells lysed and counted on a gamma counter. fsk treatment: cells were treated as above except that fsk ( - m) was added to the wells. after . hours, medium was removed and stored @ - ºc for camp eia and cortisol ria. results (mean±se) of . hour incubation on acth binding and fskinduced secretion. vehicle antalarmin acth binding (net cpm) n= ± ± cortisol (ng/ml/ . hr) n= ± ± * (p=. ) camp (pmol/ml/ . hr) n= . ± . . ± . * (p=. ) * indicates significant difference from vehicle alone. conclusion: the crh-r antagonist, antalarmin, attenuates acthstimulated cortisol secretion but not by preventing acth receptor binding. however, its effect is early in the secretory process and is associated with a reduced camp response. objective glucocorticoids are often administered to pregnant women to prevent neonatal respiratory distress syndrome. prenatal steroid treatment increases blood pressure in adult sheep. exposure to excess corticosteroids before birth is hypothesized to be a key mechanism underlying the fetal origins of adult disease hypothesis and effects on the renin-angiotension system (ras) may modulate the steroid-induced increases in blood pressure. we therefore sought to determine if renin processing and secretion were altered in adult female sheep exposed antenatally to betamethasone ( ) and to compare them with data from males studied previously. methods pregnant sheep were randomized to receive doses of . mg/kg of or vehicle, at and days of gestation; the offspring were studied at and months of age. in female offspring, active renin concentration (arc) and total renin concentration in plasma were measured by ria of angiotensin i generated by incubation with excess substrate. prorenin concentration (prc) is the difference between total and active renin. nine or control exposed female animals born at term ( - days of gestation) were brought from the farm at - months of age, and had vascular and bladder catheters placed. five days after surgery, a sodium load of hypertonic nacl ( . meq/kg/min at . ml/min) was given for min. blood samples were obtained. data are expressed as mean sem and were analyzed by t test. the prc was significantly higher in the females than in the males ( . ± . vs . ± . p< . ) but there was no effect of prenatal steroid treatment. arc was similar in both genders. however, arc was a significantly greater percent of the total plasma renin concentration in the males ( . ± . vs . ± . p< . ) during the na infusion experiment, the exposed females had lower arc than did the control females ( . ± . vs . ± . p< . ). conclusion the data suggest that prenatal exposure to didn't alter the processing and secretion of renin in adult female sheep. prenatal steroid treatment does not appear to alter the effect of gender on plasma renin levels in adult sheep.it seems unlikely that the elevated blood pressure seen in adult ewes after prenatal exposure is the result of increased secretion or processing of renin. supported by hd and hd . background: mrap is a recently discovered protein with alpha and beta isoforms, a common amino terminal region and divergent c-terminal sequences generated by alternative splicing. in human and mouse mrap plays an essential role in the generation of a functional, g-protein coupled acth receptor (melanocortin- receptor; mc r) but has not been described for ruminants. we previously reported that lth fetal sheep exhibited elevated basal acth - yet decreased expression of key steroidogenic enzymes and the mc r in the adrenal cortex while basal cortisol levels were not different from control. we hypothesized that mrap could play a key role in mediating the effect of lth as well as developmental regulation of fetal adrenal cortisol synthesis in fetal sheep. the goals of the present study were to determine the ontogenic pattern of mrap expression in the sheep fetus and to determine if lth alters mrap expression. methods: we searched the bovine genomic sequence database (www.ncbi.nlm. nih.gov/genome/guide/cow/) and found a sequence with > % homology to the human mrap n-terminal residues, with partial homology to the beta isoform in the carboxyl region ( %). using primers based on the bovine sequence, we confirmed the presence of mrap in the ovine fetal adrenal cortex. adrenal cortical tissue was collected from sheep fetuses from - (n= ) and near term ( - ; n= ) days of gestation (dg) as well as from lth (n= ) fetuses (exposed to high altitude hypoxia from to - dg) and age-matched normoxic controls (n= ). cyclophilin was used as a housekeeping mrna. data are expressed in fg mrna/ ng total rna. results: the expression of mrap, based on quantitative rt-pcr, was low between - dg ( . ± . ) and increased (p< . ) approx. -fold near term ( - dg; . ± . ). levels of mrna for mrap were highly correlated to cyp mrna in individual samples. mrap expression in control ( . ± . ) and lth ( . ± . ) did not differ between groups. gender differences in hypertension are well described and there is growing evidence that the regulation of the renin angiotensin system (ras) is influenced by sex hormones. the major enzymes of the ras include angiotensin converting enzyme (ace), angiotensin converting enzyme (ace ), and neprilysin. the peptide products of these enzymes have opposing actions. angiotensin ii (ang ii), the product of ace, is a potent vasoconstrictor. on the other hand, the peptide products of ace and neprilysin, ang ( - ) and ang ( - ), exhibit vasodilatory properties. thus, modifications in the relative proportions of these enzymes and their peptide products can result in alterations of systemic blood pressure. the purpose of this study was to describe the gender differences in angiotensin converting enzyme (ace), angiotensin converting enzyme (ace ), and neprilysin (nep) enzyme activities in adult sheep kidney cortex. renal cortex from male (n= ) and female (n= ) sheep were harvested at - months of age. the tissue membranes were solubilized and incubated at °c with either i-ang i or i-ang ii in the presence or absence of lisinopril to inhibit ace activity, mln to inhibit ace activity, or sch to inhibit neprilysin activity. the metabolic products were then separated by reverse-phase high performance liquid chromatography (rp-hplc). the rate of enzyme activity was then quantified by calculating the area under the curve for each product and converted to fmol of product per mg protein per minute of incubation. statistical analysis was performed using student's t-test. p< . was considered significant. results ace activity was over times greater ( ± . vs. . ± . fmol/mg/min, p< . ), ace activity was . times greater ( ± . vs. . ± . fmol/mg/min, p= . ) and nep activity was nearly times greater ( . ± . vs. . ± . fmol/mg/min, p= . ) in female kidney cortex. in adult sheep, key enzymes of the intrarenal ras have signficantly greater activity in female kidney cortex. these findings suggest that there are fundamental, gender specific, differences in the regulation of the enzymes of the intrarenal ras. the physiologic significance of these findings remain to be elucidated. hd , hd . in rats and sheep exposure to glucocorticoids (gc) in the perinatal period is associated with a reduction in nephron number and hypertension in adult life. furthermore, antenatal exposure to gc alters glucose tolerance in animals and in people. the aim of the present study was to determine ) if insulin resistance is a contributing factor for the development of hypertension in adult sheep exposed antenatally to gc and ) if diet-induced obesity has a more pronounced effect in sheep exposed antenatally to gc. methods: pregnant sheep were treated with two im doses of betamethasone (bm, . mg/kg) or vehicle (ctr) -hours apart at days gestational age and allowed to deliver at term. at mo of age, female sheep were randomly allocated to be fed at either % of recommended nutritional allowance or ad libitum for three months. sheep were chronically instrumented under general anesthesia to place intravascular catheters. insulin sensitivity was evaluated both by iv glucose tolerance test (ivgtt) and euglycemic clamp (hec)techniques. for the ivgtt a . g/kg glucose bolus was used and for the hec mu/kg human insulin was used. data mean±sem were analyzed by anova and/or two sample t test. results: ad lib fed sheep gain > % of the original weight. antenatal bm was associated with an elevation in basal and ivgtt plasma insulin values. as shown on the figure, diet-induced obesity significantly increased insulin plasma levels during ivgtt in bm-exposed adult female sheep (f= . ;p< . ). insulin sensitivity derived from hec was significantly decreased by obesity in bm-exposed adult female sheep. conclusion: our data show that prenatal exposure to a single course of gc at . gestation has long-term effects on glucose metabolism regulation. bm-exposed sheep exhibit alterations in glucose tolerance, hyperinsulinemia and insulin resistance. these abnormalities are exagertated by diet-induced obesity. hl . syngergistic induction of -hydroxysteroid deyhdrogenase type expression by cortisol and interleukin- in human fetal lung fibroblasts. z yang, p zhu, cm guo, l myatt, k sun. school of life sciences, fudan university, shanghai, china; obstetrics and gynecology, university of cincinnati, cincinnati, oh, usa. objectives: glucocorticoids acting via glucocorticoid receptor (gr), serve as crucial hormones in fetal lung maturation. glucocorticoids and proinflammatory cytokines to induce b-hydroxysteroid dehydrogenase type ( b-hsd ) which converts inactive cortisone to active cortisol, but their effect on b-hsd expression has not been addressed in human fetal lung. we examined the interactions and mechanism of cortisol and interleukin- b (il- b) effect on b-hsd in human fetal lung fibroblasts (hfl- cells). methods: the expression of b-hsd in hfl- was examined with immunocytochemistry and pcr. b-hsd , prostaglandin h synthase- (pghs- ) and cytosolic phospholipase a a (cpla ) mrna levels in cultured human fetal lung fibroblasts treated with cortisol and il- b were measured with real time pcr. the roles of gr and c/ebps in the effect of cortisol and il- b were studied using a gr antagonist (ru ) and transfection of plasmid carrying c/ebp-specific dominant-negative gene (cmv -a/cebp). results: hfl- cells expressed a high level of b-hsd . both cortisol ( - - - m) and il- b ( . - ng/ml) induced b-hsd mrna expression in a concentration-dependent manner, an effect blocked by the mrna transcription inhibitor , -dichlorobenzimidazole riboside ( μm). ru ( - m) blocked the induction of b-hsd by cortisol. induction of b-hsd mrna expression by cortisol ( - m) was synergistically increased by co-treatment with il- b ( . - ng/ml) in a concentration-dependent manner. in contrast, the induction of cpla and pghs- expression by il- b was inhibited by cortisol, suggesting a different mechanism of interaction. transfection of the cells with c/ebp-specific dominant-negative plasmid attenuated induction of b-hsd mrna expression by either cortisol or il- b. these data suggest induction of b-hsd expression by cortisol is a gr dependent process involving c/ebps, which also mediate induction of b-hsd expression by il- b. conclusions: cortisol and il- b synergistically induce b-hsd expression in human fetal lung fibroblasts. this would lead to greater local cortisol production, perhaps providing either a self-attenuating mechanism for control of inflammation or a mechanism for enhancing fetal lung maturation when the fetus is exposed to cytokines e.g. with infection-induced preterm labor. do alterations in placental -hydroxysteroid dehydrogenase ( hsd) activities explain differences in fetal hypothalamic pituitary adrenal function following periconceptional undernutrition or twinning in sheep? kl connor, pl van zijl, cw rumball, , al jaquiery, , je harding, , mh oliver, , fh bloomfield, , jrg challis. medicine, university of toronto. periconceptional undernutrition (pcun) leads to activation of fetal hypothalamic pituitary adrenal (hpa) function, whereas twinning results in delayed fetal hpa activation. we hypothesized that these differences in fetal hpa activity were the result of altered patterns of expression of placental of hsd isozymes and hence of the maternal glucocorticoid (gc) effect on the fetus. we developed a mass spectrometric assay for the measurement of hsd- and - activities and validated this method against a widely used thin layer chromatography method. sheep were randomly assigned to ad libitum (n control) concentrates throughout gestation or were undernourished (un) from days before until days after mating to reduce maternal body weight by %, with ad libitum feeding thereafter. placentomes were collected on days , , , and of gestation (term, d) and hsd- and - activities were determined by measuring the rate of interconversion between cortisone to cortisol. with un, there was a trend towards lower hsd- activity at d (p= . ), a significant reduction at d (p< . ), but no difference at d or d . hsd- activity was not different between n and un animals at any time. there was no effect of twinning on hsd- or - at d . however, with twins both hsd- (p= . ) and - (p< . ) activities increased at d . hsd- activity was reduced in twins (p= . ) at d but was higher than any singleton pregnancies at d (p= . ). hsd- was not different between singletons and twins at either d or d . overall, hsd- was lower in placentae of male compared to female fetuses in late gestation; hsd- was higher in male than female fetuses. there was no interaction with un in either sex. we conclude that pcun and twinning result in alterations of placental hsd activities in sheep. modifications in these enzymes during critical periods of fetal development may affect transplacental transfer or placental generation of gcs reaching the fetus potentially influencing the timing of activation of the fetal hpa axis, fetal maturation and later life development. methods: pregnant sprague-dawley rats had % mfr from day of gestation until delivery. control animals had ad libitum food. offspring were sacrificed on day of life (p ) and at months (n= - per group). adrenals were dissected and snap frozen in liquid nitrogen for later extraction of rna. real time rt-pcr using specific rat primers was used to quantify mrna levels ( s as control). we evaluated the expression of -beta hydroxylase (cyp b ), aldosterone synthase (cyp b ), acth receptor (mcr ), p side chain cleavage enzyme (cyp a ), star protein, -hydroxysteroid dehydrogenase type (hsd ) and type (hsd ), glucocorticoid receptor (gr), and mineralocorticoid receptor (nr c ). fold changes in mrna expression in controls and mfr offspring was compared by student's t-test. results: there was a marked downregulation in expression of cyp b (p=. ), cyp b (p=. ), hsd (p=. ), p (p=. ), acth receptor (p=. ), star (p=. ) and nr c (p=. ) mrna in p mfr offspring, with no changes in hsd and gr. gender specific differences were found in the adult mfr offspring. in the male mfr offspring the expression of hsd and gr were significantly upregulated with a trend towards an increase in acth receptor (p=. ) whereas in the female mfr the expression of acth receptor (p=. ) was increased and nr c (p=. ) and cyp b were decreased (p=. ). in combined data for adult male and female offspring the expression of acth receptor was significantly (p=. ) increased. conclusion: these results indicate that mfr has a suppressive effect on steroidogenic enzymes of the newborn offspring regardless of gender. this may be an adaptive mechanism in the fetus/newborn to offset the high circulating maternal glucocorticoids in response to undernutrition. in adult male mfr offspring, increased hsd indicates an increase in gc synthesis whereas in the females there were no changes in gc synthesizing enzymes with a suppression of mc synthesizing pathway. the common finding of an increased acth receptor expression in both genders would suggest an increased sensitivity of adult mfr offspring adrenals to the effects of stress. objective: during gestation the fetal adrenal undergoes phases of active growth ( - d), quiescence ( - d) followed by reactivation (> d) before birth. insulin like growth factors play an important role in stimulating adrenal growth throughout late gestation. interestingly the prepartum activation of the adrenal is delayed in the female compared with the male fetus, but the mechanisms underlying this delay are unknown. hypothesis: we hypothesize that there are gender specific differences in the gestational profile of adrenal igf mrna expression between male and female fetuses. methods: a total of twin fetuses were used in this study. post mortem was performed at either - d, - d or - d gestation. adrenal mrna expression of igf , igf , igf r, igf r and cyp was determined by qrt-pcr. results: fetal weight was not different between males and females, and increased (p< . ) with increasing gestational age. the relative adrenal weight was lower however after d when compared to the earlier gestation age group (p< . ). adrenal igf mrna expression was lower (p< . ) at - d when compared to the earlier gestation age groups. interestingly, igf r expression was highest at - d (p< . ). there was an interaction between the effects of age and gender on adrenal igf and igf r mrna expression such that the expression was higher in males compared to females at - d (p< . ), but was not different to either the earlier or later gestational ages. there was no effect of either gender or gestational age on adrenal cyp mrna expression. conclusions: it has been speculated that a delay in prepartum activation of the adrenal in female fetuses may be due to gender specific differences in the intra-adrenal bioavailability of igf . in this study we have demonstrated there is an increase in both igf and igf r mrna expression in males compared to female fetuses. this may be evidence that adrenal igf expression plays a role in the earlier activation of the adrenal gland in male fetuses. we have previously shown that in response to a secondary stressor, in vivo cortisol secretion is elevated in long term hypoxic (lth) ovine fetus despite lower acth receptor mrna expression, and no differences in plasma adrenocorticotropic hormone (acth) levels when compared to normoxic controls. the present study was designed to determine the potential mechanism(s) of this enhanced cortisol secretion. specifically we tested the hypothesis that post receptor signaling events including camp production and expression of steroidogenic acute regulatory protein (star) are enhanced following lth. methods: for the lth group, pregnant sheep were maintained at high altitude ( , m) from day to near term. on days - (term = days), fetal adrenal glands were collected from lth (n= ) and age-matched, normoxic signal transduction pathways that control embryogenesis, cell differentiation, cell proliferation and cell death. the roles of extracellular signal-regulated kinase / (erk / ) and p map kinase in the differentiation and invasion of human trophoblasts have been studied. however, the in vivo expression and activation of erk / and p at the placental bed has not been elucidated. the study group consisted of placental bed biopsy tissues obtained from the pregnancies without preeclampsia (n= ) and with preeclampsia (n= ) between and weeks of gestation. we evaluated the expressions and phosphorylations of erk / and p map kinase in the invasive trophoblasts in the placental bed tissues using immunohistochemistry. results: p and phospho-p map kinase were not detected in invasive trophoblasts in cases or controls. erk / and phospho-erk / were positive in invasive trophoblasts albeit with variable staining. phosphorylation of erk / was significantly less frequent in invasive trophoblasts in placental bed biopsies from women with preeclampsia compared with normotensive controls. conclusion: these findings suggest that preeclampsia is associated with decreased activation of erk / in invasive trophoblasts in vivo. objective: placentae from preeclamptic pregnancies are characterized by an excess of immature hyperproliferative trophoblast cells, however the molecular mechanisms regulating cell cycle progression in this pathology are unclear. our aim was to examine the expression of g phase cell cycle regulators in normal and preeclamptic placentae and to establish whether the hyperproliferative state of trophoblast cells in preeclampsia may result from a developmental delay. methods: human placental samples were collected from normal pregnancies throughout gestation (n= ) and from severe early onset preeclamptic (n= ), and age-matched control placentae (n= ). protein expression of cyclin e , cyclin d , cyclin d and cell cycle inhibitors, p , p , p , and p was assessed by western blot analysis. spatial and temporal localization of cyclins e , d , d , p and p was determined by fluorescence immunohistochemistry. expression of cyclin e and cyclin d mrna was evaluated by qpcr analysis. results: immunohistochemical analysis showed cyclin e and cyclin d to be localized to cytotrophoblast (ct) cells of the chorionic villi; additionally cyclin e was also expressed in the extravillous trophoblast cells of the anchoring columns. in contrast, cyclin d expression was predominantly restricted to the villous stroma. cell cycle inhibitor p was expressed in both ct and syncytiotrophoblast (st) cells whereas p was restricted to the st. during normal placentation, levels of both cyclin e and cyclin d were high in the first trimester and decreased with advancing gestation. the expression of cyclin d , p and p showed an inverse correlation to cyclins e and d whereby their expression increased towards term. levels of p and p remained constant throughout pregnancy. preeclamptic placentae showed a significant increase in both cyclin e and p and a decrease cyclin d and p expression, as compared to age-matched control tissues. interestingly, preeclampsia was associated with an increased number of cyclin e positive progenitor ct cells in the floating villi and an increased expression of p in the endothelial cells lining the villous vessels. conclusion: preeclampsia displays an altered expression of g phase cell cycle regulatory molecules portraying an expression profile that closely resembles that of first trimester placentae. (supported by cihr, owh/igh). we have also demonstrated elevated, hif- -mediated placental and circulating sflt- at high altitude. we sought to correlate circulating levels of plgf, free vegf and sflt- with maternal and fetal oxygen tensions. we hypothesized that circulating sflt- and free vegf would be increased at m, and that plgf, known to be up-regulated by higher oxygen tension, would be decreased. methods: we collected both serum and plasma samples, the latter treated with inhibitors of platelet activation. maternal and umbilical samples were obtained from and healthy mother-infant pairs living at m and m respectively. plgf, free vegf and sflt- were measured in both serum and plasma using commercially available elisa kits (r d). data were log-transformed and analyzed by unpaired student's t test or anova as appropriate. results: plgf did not differ between altitudes. free vegf ( ± pg/ml vs. ± pg/ml, p<. ) and sflt- ( . ± . vs. . ± . ng/ml) were increased at m. however concentrations of all the angiogenic growth factors were reduced when platelet activation was prevented (- ± % plgf; - ± % free vegf; - ± % sflt- , p<. ). cord blood free vegf was -fold greater than in the mothers, but inhibition of peripheral cell activation abolished detectable levels in % of the babies. similar results were obtained for sflt- . thus, while free and total maternal circulating vegf and sflt- are elevated at high altitude, these increases are due to activation of peripheral blood cells. moreover, free vegf does not exist in detectable amounts in human pregnancy. there was no relationship between variation in the angiogenic growth factors and maternal or fetal oxygen tensions. the objective of this study is to identify candidate genes responsible for the variance between severe preeclampsia (spe) and hellp syndrome (hs). placental biopsies from spe (n= ) and hs (n= ) were collected. diagnosis of spe was confirmed by blood pressure and protein criteria. hs was diagnosed in preeclamptic patients who developed characteristic laboratory abnormalities. placental tissues were embedded in oct for sectioning, h e staining and rna isolation (invitrogen, carlsbad). gene expression data was obtained by hybridizing fluorescently labeled reverse transcription products to spotted cdna microarrays. the microarrays were produced by the laboratory of microarray technology at the van andel institute (grand rapids, mi) using a custom microarrayer. microarrays were scanned using an agilent g b scanner. images were analyzed using genepix . (axon). limmagui was used to generate lists of discriminating genes for these data, while david provided functional annotations. there were differentially expressed genes between spe and hs (p<. ). among these candidate genes, were up-regulated and were downregulated. the most up-regulated genes are ( )-deoxyribonucleotidase (dnt- ), superoxide dismutase , hydroxy-delta- -steroid dehydrogenase, caspase , and general transcription factor iih. further analysis of functional groups revealed the most enriched gene categories are related to cellular energy (mitochondria), cell cycle regulation, and protein metabolism. the underlying role of the placenta in the development of hs is currently unknown. this study shows that there is a relatively mdest number of genes that are differentially expressed between hs versus spe placentals. thes data provide the molecular context for placental changes seen in this variant of preeclampsia and provides an opportunity to study the role of the effected genes in disease variance. ( ), severe preeclampsia ( ), hellp syndrome ( ) and eclampsia ( ) and control group ( patients) uncomplicated pregnancies. total rna was isolated and reversely transcribed to c-dna. the mrna level of tert was detected with a probe-specific real-time quantitative pcr assay using ß-actin as the reference gene. crossing point (cp) values were obtained during the pcr amplification and the relative expression level of htert equals to (cp htert -cp ß-actin) . statistical analysis was performed using the student's t test. immunohistochemistry (ihc) staining was employed to localize htert protein on placenta tissue sections using abc method, incubation with rabbit anti-htert antibody followed by application of a goat anti-rabbit antibody with results evaluation using microscope. objective tgf s are involved in the regulation of trophoblast differentiation and invasion, and we have previously reported that tgf- is over expressed in pre-eclamptic placentae. tgf s signal via a receptor complex composed of type ii (t r-ii) and type i (t r-i) receptor. to date, seven type i receptors, designated as activin receptor-like kinase (alk - ) have been identified. our aim was to investigate the expression pattern of alk and alk receptors, known to exert tgf signaling, in preeclamptic and iugr placentae. methods human placental tissue throughout gestation was used in order to determine the development profile of the receptors. in addition, placental tissue from preeclamptic and iugr pregnancies and from age matched controls was collected. all iugr pregnancies were characterized by absence of end diastolic velocity in the umbilical artery and had no evidence of preeclampsia. expression of alk and alk mrna was measured by real-time pcr analysis, and protein by western blot analysis using alk and alk antibodies. immunoblot analysis demonstrated a unique developmental profile whereby alk expression increased with advancing gestation. in preeclamptic placentae alk expression was significantly increased compared to preterm and term controls, whereas alk expression was significantly decreased. preeclamptic placentae also exhibited decreased phosphorylation of smad , a tgf signaling molecule, which is activated by alk and increased phosphorylation of smad , which is triggered by alk . the expression of alk and alk in iugr placentae differed from that of preeclampsia as both alk and alk mrna levels were significantly increased in iugr compared to preterm and term controls. however, only alk expression was significantly increased in iugr placentae at the protein level, while no differences in alk protein levels were noted between iugr and controls. conclusions imbalance between alk and alk signaling pathways might play a role in the pathogenesis of preeclampsia and iugr. as tgf signaling via either alk or alk has been found to differentially regulate vasculogenesis, changes in these signaling pathways may contribute to the altered vasculogenesis found in these pregnancy-related disorders. (supported by cihr and owh/igh). ( ), severe preeclampsia ( ), hellp syndrome ( ) and eclampsia ( ) and patients, the control group who had uncomplicated pregnancies. total protein was isolated from placental tissue. gadd a and its downstream signal proteins--phospo-p , phospho-mkk /mkk were assessed by western blot. immunohistochemistry (ihc) staining was employed to localize the expression of gadd a and sflt- proteins in placenta tissue sections using abc method. huvec cells were cultured to - % confluence and were divided into groups: control, stress induction (sorbitol, . m, h), p inhibition (sb- , ug/ml, ug/ml and ug/ml, hour) + sorbitol ( . m, h). total protein was isolated from cells and the supernatant of huvec was collected. western blot was processed to detect the induction of gadd a and phospho-p . supernatant sflt- was measured with an eia kit and the results were read at nm wavelength. results: gadd a protein was elevated in the preeclamptic placentas with its downstream proteins (mkk and p ) activation compared with control. overexpression of gadd a and sflt- in preeclamptic placentas was observed with ihc staining. in huvec cells, gadd a was induced by sorbitol, triggering the activation of the downstream p- pathway and the accumulation of sflt- in the supernatant. the up-regulation of sflt- secretion by inducing gadd a was depleted when treated with p- inhibitor. conclusions: our study reveals that gadd a and its down stream p- pathway were activated in preeclamptic placentas and this stress inducible signal pathway regulates the secretion of sflt- , which is a key player in preeclampsia. it provides novel evidence that links placental stress to sflt- secretion via the gadd . trophoblast adipose triglyceride lipase (atgl) expression is upregulated in preeclampsia. beth a plunkett, jennifer a doll, emily j su, serdar e bulun, mona cornwell, susan e crawford. obstetrics and gynecology, northwestern university, chicago, il, usa; pathology, northwestern university, chicago, il, usa. objective: preeclampsia is characterized by placental endothelial cell dysfunction and elevated maternal triglyceridemia (tg). tg traverse the placenta in a process of uptake followed by lipolysis with subsequent release of fatty acids to the fetus. although three placental lipases (hormone sensitive lipase, endothelial lipase and lipoprotein lipase) have been identified, they do not account for all lipolytic activity. here, we introduce a new lipase, adipose triglyceride lipase (atgl), which is responsible for the hydrolysis of triglycerides to diglycerides in adipocytes and was recently identified as a receptor for endothelial cell modulator pigment epithelium-derived factor. the purpose of this study is to determine if expression of atgl, a potential modulator of both lipid metabolism and vasculature, is upregulated in preeclampsia. methods: immunohistochemical studies were performed on placental tissues from normal pregnancies (n= ) and those complicated by severe preeclampsia (n= ) with anti-atgl antibodies. the degree of positivity in the trophoblasts and endothelial cell was scored ( =none, =spotty, light, =consistent, dark). to determine if atgl is a product of placental endothelial cells (plec), microvascular cells were isolated from normal placental tissue. purity of the sample was confirmed using flowcytometry (> / positivity for factor antigen). atgl was detected immunohistochemically and via western blot using anti-atgl antibodies. results: mean atgl expression in preeclamptic trophoblast was significantly higher than normal placentas ( . + standard deviation versus . + . , p = . ). endothelial expression was not significantly different in preeclamptic ( . + . ) versus normal placentas ( . + . , p> . ). atgl stained intensely and demonstrated a beaded pattern in the endothelial cells, suggestive of a lipid droplet pattern. immunohistochemistry of plec and western blot analysis of cell lysates revealed strong immunopositivity for atgl, although at a smaller size than anticipated. conclusion: these findings demonstrate that a novel lipase, atgl, is produced by trophoblasts and is upregulated in severe preeclampsia. plec express high levels of atgl, suggesting that atgl could prove to be important in the vascular dysfunction and lipid abnormalities characteristic of preeclampsia. increased endothelial chymotrypsin-like protease (chymase) expression is responsible for endothelial activation in preeclampsia. yuping wang, yang gu, yanping zhang, david f lewis. obstetrics and gynecology, lsuhsc-shreveport, shreveport, la, usa. objective: endothelial (ec) activation is an important component of inflammatory phenotypic changes in preeclampsia (pe). our previous study showed enhanced chymotrypsin-like protease (clp)/chymase expression in the maternal vessel endothelium in women with pe. in this study, specific effect of placental-derived clp on ec activation was examined. methods: human uterine microvascular endothelial cells (utmvecs) were used. placental conditioned medium (cm) was prepared by culturing villous explants from normal and pe placentas. confluent utmvecs were treated with placental cm with or without depletion of chymotrypsin. ec adhesion molecule expressions for icam, vcam, p-selectin and e-selectin were determined by a colorimetric assay at od nm. depletion of chymotrypsin from cm was performed by immunoprecipitation. to further determine if activation of endogenous clp/chymase in ecs is responsible for up-regulation of p-selectin and e-selectin expression, chymase sirna was applied to ec culture before the cells were treated with normal or pe cm and then ec adhesion molecule expressions were examined. data was expressed as mean ± se and analyzed by anova. a p level < . was set for statistically different. results: ) expressions of vcam, p-selectin and e-selectin, but not icam, were significantly increased in pe-cm treated utmvecs compared to those of normal-cm treated cells and untreated controls, p< . ; ) there was no difference for adhesion molecule expression in utmvecs between normal-cm treated with untreated controls; ) utmvecs transfected with chymase sirna significantly reduced p-selectin and e-selectin expressions when exposed to pe-cm, p< . . conclusion: placental-derived clp/chymase is responsible for activating ecs and inducing ec adhesion molecule expression. activation of ec chymase may be directly related to the inflammatory phenotypic changes that occur in ecs in pe. (supported nih grants hd and hl ). corin is a transmembrane serine protease that is important in processing natriuretic peptides (nps) and maintaining normal blood pressure. genetically modified mice without corin function develop a syndrome during pregnancy similar to preeclampsia. corin is present in the pregnant uterus and a deficiency in the enzyme may lead to hypertension and preeclampsia. we tested the hypothesis that corin expression was increased in human myometrium from women with preeclampsia. methods: myometrium was obtained from groups of women at the time of primary cesarean section: (i) preterm no labor with preeclampsia (n= , ptspe, . weeks); (ii) preterm labor (n= , ptl, . weeks); (iv) term no labor (n= , tnl, . weeks); (v) term labor (n= , tl, . weeks). microarray gene profiling was performed using affymetrix human genome u plus . arrays. women who were not in active labor at the time of delivery (tnl) served as the control group. conventional and real time pcr was performed to verify corin expression in the arrays was directionally accurate. corin protein expression was examined by western blot. results: compared to tnl control, corin levels decreased nearly -fold in myometrium from women in term labor (tl). there was a small increase in corin gene expression of preeclamptic women (ptspe) and little-to-no change in myometrium from women in preterm labor (ptl). these results were confirmed by pcr analysis. conclusion: blood volume surges during pregnancy, increasing the potential for hypertension and preeclampsia in the mother. the corin-np control system could contribute to this condition. however, there are no reports on corin message or protein levels in women with preeclampsia. our preliminary results suggest that preeclampsia is not a consequence of a corin deficiency (decreased corin preeclampsia). acknowlegement: supported by grants from the phs (r hl - , cpw) and cdc grant (u dp - , cpw). the expression of gp at implantation site: implication for the pathogenesis of preeclampsia. objective: gp is a common shard signal transducing subunit of the il- cytokine family which is critical for implantation, and viewed as marker of endometrial blastocyst receptivity. preeclampsia (pe) is highly related to the restricted trophoblast invasion, which leads to impaired spiral artery remodeling. our hypothesis was that the poor placentation of pe is associated with the altered expression of gp at the implantation site. methods: human decidua from patients with pe and uncomplicated term deliveries (n = , respectively) were immunostained for gp . the intensity and distribution of immunostaining on decidual cells and extravillous traphoblasts were evaluated with hscore. statistical analysis of the data was performed using student's t-test and kruskal-wallis one way anova on ranks followed by post hoc test. results: immunostaining of gp was significantly higher in decidual cells of patients with pe compared with normal specimens, with hscore (median, [interquartile range]) value [ . - . ] and , respectively (p< . ). in pe specimen, the hscore of decidual cells was also significantly higher than that of trophoblast ( [ - ]; p< . ). there were no difference in the comparison of hscore of trophoblasts between the pe and normal specimens, and in normal specimens between decidal cells and trophoblasts. conclusions: the increase of gp expression in the decidual cells of preeclamptic placenta may be implied to the pathogenesis of poor placentation in preeclampsia. we have previously demonstrated that decidual cells are the major source of renin at the human uteroplacental interface, but little is known regarding the human decidual renin expression in hypoxic conditions. therefore, the present study was undertaken to determine the effect of hypoxia on renin secretion by human decidual cells in vitro. methods: full-term normal human placentas were obtained within one hour of vaginal deliveries or cesarean sections. decidual cells were isolated from the decidua parietalis. after an initial culture for days in a serum-containing medium, the decidual cells were exposed to normoxia or hypoxia ( % or % oxygen) in a serum-free medium for hours. the culture supernatants were then harvested and subject to western blot analyses of renin protein contents. a dominant band of renin at approximately kd was detected in all samples. when compared with the cells cultured in the normoxic condition, the cells cultured in both hypoxic conditions (i.e. % and % oxygen) had significantly lower renin protein contents in their culture supernatants. conclusion: our data for the first time show that hypoxia down-regulates renin secretion in human decidua, suggesting a link between the uteroplacental ras and oxygen tension during human gestation. the effect of nucleated fetal red blood cells derived from preeclamptic patients on endothelial progenitor cell proliferation. keiichi matsubara, emiko abe, yuko matsubara, shinji hyodo, masaharu ito. obstetrics and gynecology, ehime university school of medicine, toon, ehime, japan. objectives inadequate uteroplacental circulation results in placental ischemia and the development of preeclampsia (pe). endothelial progenitor cells (epcs) are thought to be a key player in the fetal angiogenesis. vascular endothelial growth factor (vegf), which is up regulated in pe, is involved in epcs proliferation. recently, it was reported that fetal nucleated red blood cells (nrbcs) have the capability to generate vegf. we hypothesized that nrbcs could influence epcs proliferation in the placenta and may be involved in the pathogenesis of pe. material and methods mononuclear cells (mncs) were isolated from the umbilical venous blood of normal pregnant women and preeclamptic patients by density gradient centrifugation. mncs were incubated with anti-cd antibody conjugated with microbeads. nrbcs were collected using a mini macs separator. nrbcs were incubated for hours with or without angiotensin ii (ang ii) and erythropoietin (epo). vegf and placental growth factor (plgf) concentrations in the supernatant were measured using elisa. also, pbmcs without nrbcs were seeded in endothelial basal medium with or without nrbcs using a boyden chamber. these samples were incubated for days with or without ang ii and epo. the adherent cells were incubated with di-ldl, fixed with paraformaldehyde, and stained with fluorescein isothiocyanate-labeled lectin. di-ldl and lectin positive cells was considered to represent epcs and the number was measured using flowcytometry. the number of nrbcs derived from umbilical venous blood was significantly increased in pe. both ang ii and epo significantly increased vegf concentration in the supernatant of nrbcs derived from normal pregnant women. however, ang ii and epo did not influence the nrbcs' vegf production in pe patients. plgf was not detectable in the supernatant. the number of epcs in the umbilical venous blood was significantly decreased in pe and the number was not changed by nrbcs. on the other hand, the number of epcs was significantly decreased in the culture with nrbcs. epo significantly increased the number of epcs in pe at the lower concentration of epo compared with normal pregnant women. conclusions it appears that fetal nrbcs may inhibit fetal epcs proliferation in pe. since epo reduced the inhibitory reaction of nrbcs without vegf production epo may affect epcs proliferation independently of nrbcs. relationship between the hypoxia-inducible factor- (hif- ) and the receptor svegf-r /sflt- : implication for phatophysiology of preeclampsia. julio e valdivia-silva, , juan c gonzalez-altamirano, keisy lopez- the trophoblast invasion is critical for the establishment of the uteroplacental circulation. at early phases of this process local oxygen pressure in the placenta is lower, that pathologically in preeclampsia remain constant. because of this, is important to understand the response of placental cells against these stimuli. in the present work, we use primary cultures of trophoblast cells, fibroblasts of the villous, and human umbilical endothelial cells, isolated of preterm and term placentas (with and without preeclampsia), to explore the effect of the oxygen pressure in the expression and synthesis of vegf, svegfr- /sflt- , hif- and- . our results show that the low pressure of oxygen resulted in a significant increase of the mrna and the protein of the receptor svegf-r selectively in the cts. the vegf's expression and synthesis was raised in three cellular types, but the free protein (not bounded to svegf-r ) of the cts was diminished. on the other hand, the expression of the arnm of hif- or - in cells was comparable in all the types of placentas, nevertheless, the protein hif- was more increased in the cts of preeclamptic placentas. to evaluate the relation of hif- and the increase of the receptor svegfr- , we used sirna-hif . in response to the inhibition, the expression of the receptor svegf-r diminished dramatically. the blockade of hif- did not alter vegf's expression. our data are the first that propose that the protein of the factor of transcription hif- is one of the molecules involved in the selective expression of the receptor svegf-r in trophoblast cells during hypoxia. figure: reduction of the expression to soluble receptor flt- /svegfr- after transfection with sirna-hif in trophoblast cells. sirna= interference rna, lu=luciferase. luc-sirna was used as control. effects of estradiol on synthesis, secretion, and activation of von willebrand factor in endometrial endothelial cell. shumei zhao, chainarong choksuchat, michael s scholfield, todd d deutch, thomas d kimble, david f archer. obstetrics and gynecology, eastern virginia medical school, norfolk, va, usa. objectives: heavy menstrual bleeding (hmb) is a serious clinical condition affecting % of women. due to inefficient and ineffective medical interventions, women with hmb often elect endometrial ablation or hysterectomy to eliminate hmb symptoms. morbidity and loss of fertility linked to these surgical treatments support the search for more effective medical remedies. von willebrand factor (vwf), a principle initiator of blood clotting produced by endothelial cells. women with von willebrand disease (vwd), have a high incidence of hmb indicating poor clotting. these findings suggest vwf heavily impacts the amount of blood loss during menstruation. estrogen stops/reduces hmb and has been used to treat hmb in women with vwd, although the mechanism(s) is unknown. this proposal addresses the hypothesis that estradiol (e ) increases the synthesis and activation of vwf, promoting clotting. materials and methods: immortalized human endometrial endothelia cells (heecs) were used for the studies. to determine if e increases synthesis of vwf, we treated heecs with e at . μm, . μm and . μm for hours. vwf protein and mrna levels were determined by western blotting and real time pcr, respectively. to establish if e can convert vwf from an inactive to an active conformation, the release of activated vwf by cells into culture medium will be assessed by elisa. decreased adamts (a disintegrin and metalloproteinase with thrombospondin type motif) activity results in increased amounts of active vwf. rrelease of activated adamts will be determined by fret. to ascertain if e regulated vwf secretion is by genomic pathway, heecs will be exposed to the estrogen receptor antagonist ici , . elisa and fret will assess the release of active vwf and adamts , respectively. results: western blotting demonstrated e increases vwf mrna and protein levels in a dose-dependent manner in heecs.conclusion: the project will determine if e acts at the heecs to increase synthesis, secretion and activation of vwf. preliminary results show e increases intracellular vwf protein and mrna levels in heecs, supporting our hypothesis that e increases synthesis of vwf in heecs in vitro. if e increases activated vwf, it could reduce/stop hmb by increasing activated vwf, providing justification for a clinical trial of e to treat hmb. over-expression of vegf-d does not induce lymphangiogenesis in the mouse endometrium. peter a rogers, jacqui f donoghue, marc g achen, steven a stacker, jane e girling. obstetrics gynaecology, monash university, melbourne, victoria, australia; ludwig institute for cancer research, melbourne, victoria, australia. background: the human endometrial functionalis has reduced lymphatics compared to the basalis and myometrium . this study examines the distribution of lymphatics in mouse uterus and investigates if over-expression of the lymphangiogenic growth factor vascular endothelial growth factor-d (vegf-d) stimulates growth of new endometrial lymphatic vessels. methods: the distribution of uterine lymphatics was examined in c bl/ jxcba mice collected during the oestrus cycle, early pregnancy and following oestrogen and progesterone treatment. human ebna cells with/without stable transfection of vegf-d were injected into the uterine horn of nod/scid mice. uteri were collected after weeks. serial sections were immunostained with lyve- and/or vegfr (lymphatic endothelial cell markers), cd (blood endothelial cell marker), mab (human vegf-d), mab (human mitochondria) and pcna (proliferative cell nuclear antigen). results: lymphatic vessel profiles were mostly found in the connective tissue between the longitudinal and circular muscle layers of the myometrium. they were rare in the endometrium and only observed in % of the sections. when present in endometrium, lymphatic vessel profiles were usually situated adjacent to the endometrial/myometrial border. ebna tumours formed inside and outside the uterine horn of both the control (n= of ) and vegf-d group (n= of ). localization of ebna cells within the mouse uterus was confirmed by anti-human mitochondrial expression. vegf-d immunostaining confirmed that transfected ebna cells expressed vegf-d in vivo. over-expression of vegf-d did not stimulate endometrial lymphangiogenesis, although there was an increase in vessel diameter of lymphatics in the myometrium adjacent to tumours. initial analysis shows no significant effect of vegf-d ebna cells on endometrial blood vascular density or endothelial cell proliferation. conclusions: minimal lymphatics are present in the mouse endometrium, as is the case for lymphatic vessels in the human endometrial functionalis. the lack of endometrial lymphangiogenesis in response to vegf-d suggests the presence of an inhibitory factor limiting lymphatic growth in this tissue. in early pregnancy, decidual-derived vegf mediates angiogenesis and is required for implantation and placentation. the role of decidual vegf in later pregnancy is poorly understood. decidual hemorrhage (placental abruption) generates excess thrombin and is a major risk factor for pprom and preterm birth. this study compares immunohistochemical (ihc) localization of vegf in decidual tissue sections from term pregnancies complicated by abruption and gestational age-matched controls, and investigates the effect of thrombin on vegf expression by cultured human term decidual stromal cells (dscs). study design: ihc was performed on serial sections of term placental tissues (no labor) with (n= ) and without (n= ) abruption. purified term dscs were passaged until > % free of cd + cells by facs. confluent dscs were primed with - m estradiol (e ), - m medroxyprogesterone acetate (mpa), both, or vehicle for days. after h incubation in defined medium with corresponding steroids ± thrombin ( . - . iu/ml), conditioned supernatants were analyzed for vegf by elisa. extracted total rna was used to assess vegf mrna levels by quantitative rt-pcr using established primers. results: vegf expression was localized by ihc primarily to dscs in placental tissue sections, and was increased in tissues from placental abruption vs controls. in term dscs, thrombin increased vegf secretion in a dosedependent fashion irrespective of the hormonal milieu (eg, . -fold stimulation by . iu/ml thrombin from . ± . to . ± . pg/ml per mcg protein for e +mpa; p= . ). this effect was abrogated by the thrombin inactivator, hirudin. vegf mrna were similarly increased by thrombin with or without steroid hormones (eg, . -fold for e +mpa; p< . ). conclusions: placental abruption is associated with increased vegf expression in term decidual tissues in vivo with thrombin enhancing vegf mrna and protein expression in term dscs in vitro. excess thrombinmediated vegf expression in term decidua aberrantly increases endothelial cell permeability to further generate thrombin by continuous exposure of tissue factor-expressing decidual cells to circulating factor vii. thrombin-enhanced matrix metalloproteinase expression in term dscs would degrade decidual and fetal membrane extracellular matrix to induce pprom and preterm birth. basal directional release of angiotensin ii by endothelial cells stimulated by chymotrypsin-like protease (clp)/chymase. yuping wang, david f lewis, yang gu. obstetrics and gynecology, lsuhsc-shreveport, shreveport, la, usa. objective: chymotrypsin-like protease (clp)/chymase is a serine protease which plays a major role in angiotensin ii (ang ii) generation in the human heart. our previous study showed a higher clp activity in the maternal plasma in women with pe than in normal pregnancies. we also found enhanced chymase expression in the maternal vessel endothelium in women with pe. in this study, we determined if clp could promote endothelial cell (ec) generation of ang ii. methods: we specifically examined basal directional release of ang ii by cultured ecs. ecs were grown on cell culture insert ( well/plate, micron pore size). when ecs reached confluence, chymotrypsin (chy) at concentrations of . , . , . , . , and . g/ml were added to the upper chamber of the cell insert. after hours of culture, medium in the lower chamber was collected. medium concentrations of ang ii were measured by enzymelinked immunoassay (eia). all samples were measured in duplicate. data are expressed as mean ± se and analyzed by anova. a p level < . was considered statistically different. results: chymotrypsin produced a concentration-dependent increase in basal directional release of ang ii by cultured ecs, control: . ± . g/ml; chy . : . ± . g/ml; chy . : . ± . g/ml; chy . : . ± . g/ml; chy . : . ± . g/ml (p< . ); chy . : . ± . g/ml (p< . ), respectively. data are means from independent experiments. conclusion: apical exposure of ecs with chymotrypsin-like protease could promote basal directional release of ang ii. our result implicates that in pe, elevated clp levels in the maternal circulation are very likely to affect ec generation of ang ii. basal directional released ang ii may bind to its receptor on underlying vascular smooth muscle cells and contribute to the increased vasoconstriction in pe. (supported nih grants hd and hl ). vegf stimulates angiogenesis and vasodilation critical for dramatic rises in materno-feto interface blood flows directly linked to fetal growth/survival. extracellular signal-regulated kinase (erk / ) pathway mediates partially vegf-induced angiogenic and vasodilatory responses in placental endothelial cells (ec). it is, however, unknown how this vegf-induced signaling is organized in placental ec. objectives: ovine fetoplacental artery ec (ofpaec) and its transformed counterpart, sv -of to test whether: ) vegf-activated erk / signaling is compartmentalized in the caveolae and disruption of caveolae interferes vegf-induced erk / activation and; ) caveolin- , the structure protein of caveolae, regulates vegf-stimulated erk / phosphorylation. methods: ofpaec or sv -of cells were cultured in mcdb- / % fbs/antibiotics. serum-starved subconfluent ( %) cells were treated with rhvegf ( to ng/ml) for various times. caveolae were disrupted by -cyclodextrin ( -cd, mm, min) or caveolin- scaffolding domain (cav-sd, m, hr). sv -of cells were used for fractionation of caveolae membranes by discontinuous sucrose gradient ( %/ %/ %) ultracentrifugation. activation of erk / signaling pathway were analyzed by western-blotting with specific antibodies. results: in total cell extracts, vegf stimulates erk / phosphorylation in a time-and dose-dependent manner. erk / phosphorylation maximized by vegf ( ng/ml) at - min, which was abrogated by -cd or cav-sd. all the molecules for compromising the erk / signaling module, plc , pkc , src, ras, raf- , mek / and erk / , were detectable in purified caveolae membranes positive for various markers including caveolin- , enos, flotillin- , and -adaptin. in caveolae, vegf dramatically increased phosphorylated erk / without altering total erk / in a time-dependent manner similar to that in total cell extracts, which also maximized at - min. pretreatment with -cd or cav-sd blocked vegf stimulation of erk / phosphorylation in caveolae. conclusion: vegf activates the erk / signaling pathway in caveolae and caveolae integrity is essential for vegf-activated erk / signaling pathway. we conclude that caveolae/caveolin- serves as a platform for compartmentalizing the vegf-induced erk / signaling pathway in placental ec (hl and hl ). hypoxia upregulates gcm in human placenta. david mccaig, fiona lyall. institute of medical genetics, university of glasgow, glasgow, united kingdom. introduction: studies in transgenic mice have shown that a variety of genes regulate the differentiation of trophoblast cells. these genes include gcm . gcm is also expressed in the human placenta. placental gcm- protein has been reported to be reduced in pre-eclampsia, in view of the close link between hypoxia, hypoxia-reoxygneation, pre-eclampsia, placental development and the reported reduction in gcm we hypothesised that gcm expression would be affected by hypoxia. aim: the aim of this study was to determine the effects of hypoxia on gcm expression in the human placenta. two model systems were used; ( ) free floating villous explants and ( ) cultured primary cytotrophoblast and syncytiotrophoblast cells as described previously*. methods: explants or cell cultures were exposed to either hypoxia or hypoxia followed by re-oxygenation. western blot analysis was used to assess gcm protein levels. bands on the gels were quantified using scanning densitometry. statistical differences (n= experiments for both models used) were calulated by anova and turkey's post-hoc test. results: gcm protein was detectable at a low level in villous explants maintained for h in % o . a striking increase in gcm protein was observed when villous explants were incubated for h in % o (p< . ). incubation of villous explants for h in % o followed by re-oxygenation for h in % o resulted in a marked decline in gcm protein (p< . ). expression of gcm was also analysed in primary cytotrophoblast and syncytiotrophoblast cultured in % o or reduced oxygen ( % o ) conditions. gcm protein was not detected in any of the experimental conditions used. discussion: the present study has shown that acute hypoxia increases gcm- protein in villous explants. the experiments with purified trophoblast do not support a role for hypoxia increasing gcm- in these cells under the experimental conditions used. the present findings are in keeping with the complex effects of oxygen depending on the conditions used. the observed hypoxic effects on gcm warrant further investigation. the effect of acute alcohol exposure on histone -lys modification in the mid-gestation embryonic lung. xiangyuan wang, debra wolgemuth, , , laxmi baxi. ob/gyn; genetics development; human nutrition, columbia university medical center, new york, ny, usa. objective maternal alcohol abuse during pregnancy produces an array of birth defects comprising fetal alcohol syndrome. lung development depends on a balance between cell proliferation and apoptosis. we have previously shown that the acute alcohol exposure in the mid-gestation embryo can delay lung development and induce apoptosis. acute exposure to ethanol of selected tissues in mouse embryos has been reported by others to initiate apoptosis within hours after exposure and result in histone modifications. specifically, histone acetylation and deacetylation are involved in transcriptional activation and repression, respectively, but can also involve apoptosis. in the present study, we have investigated the effect of alcohol on acetylation of histone at lysine (ach lys ) in the mid-gestation embryonic lung. pregnant c bl/ j mice at day . of gestation (e . ) were injected intraperitoneally with doses of % ethanol ( . g/kg ), hr apart (alcoholexposed: ae) or with ringers solution (controls: c). ae and five c fetuses were retrieved and hr later and the lungs were fixed and processed for morphological evaluation and staining with rabbit polyclonal anti-ach ly antibody. the entire lung tissue field was evaluated for the levels of ach lys staining and scored as (-) to (++++). three areas were selected randomly from each sample and the total number of cells and staining positive cells were counted in the bronchial epithelium and in the mesenchyme. twelve hr after alcohol exposure at e . , the morphology of ae embryonic lungs was normal. however, high levels of ach lys were detected in % of the bronchial epithelial cells and % of the mesenchymal cells. the expression level in both lineages decreased hr after alcohol exposure. in the controls, the expression of ach lys was virtually undetectable in both the bronchial epithelium and the mesenchymal cells. our previous study showed that ae e . lungs significantly increased apoptotic cell in both bronchial epithelium and mesenchyme hours after alcohol treatment. we now observe that elevated expression of ach lys in the embryonic lung preceded the observation of apoptosis, suggesting that alteration in the acetylation of h could be one of the molecular mechanisms involved in the induction of apoptosis following acute alcohol exposure. objective: our purpose was to evaluate the effect of vitamin c and e supplementation on lipid peroxide levels, total antioxidant ability, and antioxidant levels in the umbilical venous plasma. materials and methods: women at risk for preeclampsia (nullipara, previous preeclampsia, chronic hypertension) were recruited at to weeksgestation and randomly assigned to receive either mg of vitamin c and iu of vitamin e (study group, n= ) or placebo (control group, n= ) daily until delivery. umbilical venous blood were collected after full term delivery. lipid peroxide levels, oxygen-radical absorbance capacity (orac) values, antioxidant levels were measured by each method (thiobarbituric acid reaction, cao's method, and high performance liquid chromatography). results: . the lipid peroxide levels in the umbilical venous plasma of study group were significantly lower than that of control group ( . ± . vs. . ± . nmol/mg protein, p< . ). . the orac values in the umbilical venous plasma of study group were significantly higher than that of control group ( . ± . vs. . ± . u/ml, p< . ). . the -tocopherol levels in the umbilical venous plasma of study group were significantly higher than that of control group ( . ± . vs. . ± . nmol/ml, p< . ). . there were no significant differences in the ascorbic acid, uric acid, -carotene, retinol, and -tocopherol levels in the umbilical venous plasma between control and study group. conclusion: this suggested that maternal vitamin c and e supplementation may affect the oxidant-antioxidants balance of the utero-placenta unit and fetus. placental tnf-related apoptosis-inducing ligand (trail) in normal pregnancy and pre-eclampsia. xilian bai, jenny e myers, philip n baker, john d aplin, ian p crocker. maternal and fetal health research group, the university of manchester. introduction: enhanced placental trophoblast apoptosis is well known to occur in pre-eclampsia. however, the potential role of membrane associated or soluble trail, an apoptosis-inducing ligand, and its death receptor, dr , is not known. we tested the hypotheses that the trail/trail-receptor system is compromised in pre-eclampsia and that soluble trail is a circulating factor which triggers the vascular complications of pre-eclampsia. method: this study was conducted on placental samples and plasma (edta) from women with uncomplicated pregnancies (n= ) and with pre-eclampsia (n= ) at - weeks gestation. protein expression levels and tissue localisation of trail and dr were defined in villous tissue by western blotting and immunohistochemistry. soluble trail (strail) was measured in maternal plasma from both groups using a commercial elisa (diaclone). results: placental villous trail and dr protein was unaltered in preeclampsia compared to normal pregnancy. whilst there was differential distribution of trail and dr within the component cells, this also was unaffected in pre-eclampsia. within the villi, trail was mainly confined to the cytoplasm and perinuclear regions of cytotrophoblast, syncytiotrophoblast, stromal cells and the fetal capillary endothelium. conversely, dr was restricted to trophoblast only, distributed evenly between cytoplasm, plasma membranes and nucleus. strail was present in plasma from non-pregnant women of childbearing age [ . ( . - . ) , median (interquartile range), pg/ml, n= ]. however, there was no significant increase either in pregnancy [ . ( . - . ) pg/ml, n= ] or pre-eclampsia [ . ( . - . ) pg/ ml, n= ] (kruskal-wallis test, p> . ). conclusions: these results suggest that placental villous trail is not adversely regulated in pre-eclampsia. the absence of dr in stromal and endothelial cells may increase resistance to apoptotic stimuli in cells of the villous core. the co-localisation of trail and dr in trophoblast suggests a role in autocrine regulation of cell turnover in this cell type. introduction: preeclampsia is associated with apoptosis of the syncytial layer of placenta and the release of particulate and soluble factors which are deleterious to maternal endothelial function. the goal of the current study was to determine whether laser capture microdissection (lcmd) and western blotting could be used to assess levels of syncytial fas ligand (fasl), a key protein in the apoptotic cascade. methods: frozen sections of term placenta delivered from uncomplicated pregnancies at term were used for study (n= ). following staining with mayer's hematoxylin (n= ), lcmd (leica instruments) of an intact terminal villus was carried out using a focused laser pulse directed to the area of interest using a microscope. in the first round of microdissection the placental villus core consisting of fibroblast, macrophages, fetal vessels, and connective tissue, were removed. in the second round of lcmd, the syncytial layer of that same villus was removed and collected in lysis buffer containing detergent and protease inhibitors, and the number of nuclei per sample was recorded. this procedure was repeated until syncytial tissue from - villi were collected. electrophoretic separation of lysate proteins was then carried out, and western blotting and immunodetection using an anti-fasl antibody was performed. results: we observed that fasl was detected in microdissected syncytial specimens at a molecular weight of approximately kda ( figure) , consistent with our previous reports. it is of note, that western blotting of samples containing approximately (lane ), (lane ), (lane ), and (lane ) nuclei revealed that fasl could be reliably detected in specimens containing as few as nuclei. conclusions: since fasl is a cytokine of low to moderate abundance in placenta, this suggests that lcmd coupled with western blotting will be a valuable methodology to elucidate pathways of syncytial apoptosis and pathophysiology in pregnancies complicated by preeclampsia. supported in part by nih grant hd . the placenta of preeclamptic pregnancies shows oxidative and nitrative stress. we have shown low protein abundance but paradoxically high activity of inducible nitric oxide synthase (inos) in the placenta with severe preeclampsia compared with normal pregnancies. protein nitration and phosphorylation are post-translational modifications possibly involved in nos activity. objectives: examine inos localization and tyrosine phosphorylation in the preeclamptic placenta and the effect of a peroxynitrite generator (sin- ) on inos expression in primary human placental microvascular endothelial cell (hpmec) cultures. methods: placental lysates from normal (n= ), mild (n= ) and severe (n= ) preeclamptic pregnancies were western blotted for inos and what are the roles played by peroxynitrite in preeclamptic women? yoshikatsu suzuki, tamao yamamoto, yoshimasa watanabe, takeo itoh, hidetaka izumi. obstetrics and gynecology, nagoya city university, nagoya, japan; pharmacology, nagoya city university, nagoya, japan; obstetrics and gynecology, izumi women's hospital, fukuoka, japan. aim preeclampsia is characterized by hypertension plus proteinuria. it is hypothesized that the endothelial cell function might be activated by placental faculty in early pregnancy and the activation might cause the vascular disease in preeclampsia. peroxynitrite, which is produced by combination with superoxide (o -) and nitric oxide (no), is strong oxidant as well as o -.we investigated whether or not the localization of peroxynitrite in both placenta and resistance artery might play important roles of developing preeclampsia. omental arteries or placentas were obtained from severe preeclamptic and term-normotensive pregnant women at cesarean section. they were stained by ant-nitrotyrosine (nt, a marker of peroxynitrite) antibody. furthermore, the concentration of nt was measured in omental arteries. in formed consent was obtained from all patients in written. preeclampsia was diagnosed according to the criteria of japan society of obstetrics and gynecology. the localization of nt was seen in placentas obtained from sever preeclamptic women ( / ), although it was not seen from normotensive pregnant women ( / ). the localization was also seen in placentas from of severe preeclamptic women with intrauterine fetal restriction. in omental arteries from both groups, the localization of nt was seen to same degree, and the concentration of nt was similar ( . ± . for sever preeclampsia and . ± . for normotensive pregnant women). from these results, it was suggested that an increase in o production, a decrease in no as well as peroxynitrite production in the placentas might cause the vascular dysfunction and subsequently damage uteroplacental blood circulation in preeclampsia. however, the role played by peroxynitrite in resistance artery might be different and more complicated. background: preeclampsia (pe) is associated with shallow cytotrophoblast (ct) invasion of the decidua, leading to impaired vascular transformation and poor uteroplacental perfusion. ct invasion requires the selective proteolysis of the peri-decidual cell (dc) extracellular matrix. we hypothesized that il and tnf , cytokines that have been linked to pe, may induce aberrant expression of the matrix metalloproteinases (mmp) and in dcs, thereby preferentially degrading the decidual ecm and interfering with sequential ct invasion. methods: immunostaining for mmp- , mmp- , and vimentin (a dc marker) was performed on decidua from normal (n= ) and preeclamptic (n= ) women, and staining intensities were evaluated by hscore. confluent, leukocyte-free first trimester dcs were primed with - m estradiol (e ) or e + - m medroxyprogesterone acetate (mpa), and then switched to a defined medium with e +/-mpa with or without ng/ml of il or tnf . secreted mmp- and mmp- levels were measured by elisa (n= ) and confirmed by western blotting. quantitative rt-pcr assessed mmp- and mmp- mrna levels (n= ). results: tissue staining revealed that mmp- and mmp- levels in preeclamptic decidua (hscore mean±sem: ± and ± , respectively) were significantly higher than in normal decidua ( ± and ± , respectively; p< . ). in cultured first trimester dcs incubated with e , tnf increased secreted mmp- and mmp- levels by ± and ± -fold, respectively, while il increased them by ± and ± fold, respectively (p< . ). in parallel incubations with e +mpa, basal mmp- and mmp- output were lowered by approximately % and %, respectively, while tnf -and il elicited mmp- and mmp- levels were blunted by - %. western blotting confirmed the elisa results, and mrna levels corresponded to changes in mmp- and mmp- secreted protein levels. conclusions: over-expression of mmp- and mmp- in decidual cells may promote pe by disrupting decidual ecm and impairing normal ct invasion. the high levels of il and tnf associated with pe may be contributing to this over-expression. our in vitro observations that mpa blunts tnf -and il -elicited mmp expression suggests that exogenous progestin may offer a novel therapeutic approach in preventing pe. to produce -methoxyestradiol ( -me), a compound with diverse biological activities including inhibition of hif- , a transcription factor that mediates cellular response to hypoxia. circulating levels of -me and placental comt activity are significantly reduced in preeclampsia, raising the possibility that reduced production of -me contributes to the pathophysiology of preeclampsia by altering placental response to hypoxia. genetic variation in the comt gene is linked to comt activity and has been associated with intrauterine fetal growth restriction. we determined if a snp in exon of the comt gene (rs ), which does not change amino acid sequence ( leu ), but reduces comt mrna translation, was associated with preeclampsia. we analyzed comt genotypes in paired dna samples extracted from maternal and cord blood from normal pregnancies and pregnancies complicated by preeclampsia by allele discrimination. the study population was predominantly (> %) african-american. the frequency of the minor rs "g" allele, which is associated with low comt activity, was similar in maternal cases and controls (cases: %; controls: %, p= . ), but was significantly greater in fetal dna from pregnancies complicated by preeclampsia compared to control pregnancies (g allele frequency cases: %; control: %; p< . ). likewise, fetal carriage of the rs "g" allele conferred a significantly greater risk of preeclampsia (odds ratio: . ; % c.i.: . , . , p< . ). there was also a significant discordance between paired maternal and fetal rs genotypes with significantly greater discordance for the "g" allele in fetuses hosted in preeclamptic pregnancies (odds ratio: . ; % c.i.: . , . ). we conclude that genetic variation in the comt gene is associated with risk of preeclampsia, possibly through a mechanism involving reduced production of -me. supported by nih p md . smoking is associated with elevated adma in preeclampsia. michael p frank, robert w powers. , magee-womens research institute, pittsburgh, pa, usa; obstetrics gynecology, university of pittsburgh, pittsburgh, pa, usa. objective: cigarette smoke exposure paradoxically reduces the risk of preeclampsia. asymmetric dimethylarginine (adma) is an endogenous competitive inhibitor of nitric oxide synthase (nos), an independent risk factor for cardiovascular mortality, adma is elevated in women who develop preeclampsia, and adma has been reported to be both higher and lower in smokers. the objective of this study was to investigate the concentration of adma in pregnant smokers and nonsmokers with and without preeclampsia. study design: case-control study of women with uncomplicated pregnancy (controls), and women with preeclampsia matched for gestational age at sample collection. adma was measured by hplc. cigarette smoke exposure was determined by questionnaire and confirmed by plasma cotinine. data are mean±sd. analysis was by two factor anova with fishers post-hoc testing, significance accepted at p< . results: as previously reported, maternal plasma adma concentrations were higher in women with preeclampsia compared to controls (p< . ). in addition, the concentration of adma was significantly higher in preeclampsia smokers compared to controls and preeclampsia nonsmokers (p< . ). in contrast, there was no difference in adma concentration between control smokers and nonsmokers. conclusion: these data may suggest a differential effect of cigarette smoke exposure on circulating adma concentrations between women who do and do not develop preeclampsia. previous data has suggested that cigarette smoking is associated with lower adma in low risk elderly patients, and higher adma in high-risk subjects with diabetes. therefore, the data in preeclamptic and non-preeclamptic subjects may be consistent with these studies, however, the underlying biological explanation for this differential effect has yet to be determined. objective: eclampsia is similar to hypertensive encephalopathy in which an acute elevation in blood pressure causes autoregulatory breakthrough, hyperperfusion and edema formation. we previously reported that the pressure of breakthrough was similar between nonpregnant (np) and late-pregnant (lp) rats, but only lp animals developed edema. this study tested the hypothesis that lp animals have decreased in cerebrovascular resistance (cvr) and hyperperfusion in response to breakthrough vs. np. we further hypothesized that acute hypertension would cause greater blood-brain barrier (bbb) permeability in lp rats due to elevated hydrostatic pressure. methods: in vivo models of bbb permeability and cerebral blood flow (cbf) were used in np (n= ) and lp (d - ; n= ) rats that were either normotensive or hypertensive (np-htn, lp-htn) by infusion of phenylephrine to raise mean arterial pressure. permeability was determined in anterior and posterior brain regions by calculating the flux of kd dextran into the brain tissue, measured by a fluorescent spectrophotometer after flushing the vasculature with saline. cbf and cvr were measured by infusion of m fluorescent microspheres and determined based on the flow rate and fluorescence intensity of a reference sample for each animal. animals were ventilated to maintain blood gases within normal ranges (po > mmhg, pco = - mmhg). results: although the pressure change was similar between np and lp ( and mm hg), lp animals responded to acute hypertension with hyperperfusion. cbf increased from ± to ± ml/ g/min in np ( %) and ± to ± ml/ g/min in lp ( %; p< . vs. np). hyperperfusion in lp animals was associate with decreased cvr vs. np ( . ± . vs. . ± . mm hg/(ml/ g/min); p< . ). bbb permeability was significantly increased in lp animals at breakthrough vs. np in both anterior and posterior brain regions. the flux of dextran in anterior and posterior brain regions for np vs. lp animals was: ± vs. ± for anterior (p< . ) and ± vs. ± for posterior (p< . ). conclusions: these data demonstrate that pregnancy decreases cvr and causes hyperperfusion of the brain during acute hypertension. because increases in cvr is a protective function in the brain, impairment of these mechanisms during pregnancy may predispose the brain to edema when blood pressure is elevated, as in eclampsia. introduction: this study used the in vitro dually perfused human placental lobule to test the hypothesese that placental release of vegf and the fetoplacental vasodilatory response to exogenous vegf- are altered by tissue oxygenations that mimic healthy and preeclamptic pregancies. methods: lobules were dually perfused for six hours under one of two oxygenation conditions, representing 'normoxia' and 'hypoxia' (n = each): delivering maternal side inflow perfusate at oxygen concentrations of . % and %, respectively, distributed via cannulae; and fetal side inflow perfusate oxygen concentration of - % in both systems. venous perfusates were sampled and assayed, appropriate to side of release, for erythropoietin (epo), macrophage inflammatory protein- alpha (mip- alpha) (reference oxygen sensitive hormones), free vegf, svegfr- and plgf. in separate perfusions, fetoplacental vasodilation in response to pm vegf was investigated, following preconstriction of the fetoplacental vasculature to steady state fetal-side inflow hydrostatic pressure (fihp) with the thromboxane mimetic, u , (n = each). results: maternal-side mip- alpha release was higher in the 'hypoxic' than the 'normoxic' system ( ± and ± pg/ml, respectively, at hours, mean ± se; -way anova: p< . ). maternal-side epo and fetal-side soluble free vegf and svegfr- release were not different between groups. fetal-side release of plgf was higher in the 'hypoxic' group than the 'normoxic' group ( . ± . and . ± . pm, respectively, at hours, mean ± se; -way anova: p < . ). there was no difference in the vasodilatory response to vegf- in the fetoplacental vasculature between the groups ( . ± . and . ± . % change in fihp, mean ± se). discussion: differences in mip- alpha and plgf release provide evidence for metabolic separation of the adapted systems, caused by a changed oxygen environment. our failure to observe differences in epo, vegf and svegfr- release may be explained by longer lag-times for up regulation of their gene expression. vegf associated endothelial signalling appears to be unaffected by 'hypoxia' in the placenta over the time course studied here. background: there is a placental renin-angiotensin system (ras) from very early pregnancy. ang iv mediates various effects by binding to its specific receptor, the at r, the active site of which is an insulin-regulated aminopeptidase (irap). there is at r expression in both endothelial and smooth muscle cells. ang iv at low concentrations is vasodilatory, increasing blood flow via the at rs; it also stimulates nf-kappa beta and modulates glut- . to date at r expression has not been investigated in the placenta. we propose that at r plays a part in the placental vascular development necessary for successful pregnancy, and that reduced at r expression may be associated with inadequate vascular adaptation contributing to pre-eclampsia (pe). aim: to identify and locate at r expression in both np and pe placentae. methods: the study had hospital ethical approval; written informed consent was obtained from all women. placental samples were obtained from np and pe at delivery (gestational ages: and weeks respectively). samples were taken from areas, near cord, middle and outer edge of the placenta. paraffin embedded sections were immunostained for irap reactivity using a rabbit polyclonal antibody (gift from professor david james, garvan institute, australia). immunoreactivity of trophoblast and uterine cell populations was assessed using a semi-quantitative grading system. grade = no positive labelling, = - %, = - %, = - % and = - % of cells positively labelled. median (max, min) are shown. results: ) at r immunostaining was prominent in the syncytiotrophoblast and hofbauer cells of all placental villi examined, with no differences in expression between sampling sites. ) at r positivity was reduced in near cord pe samples ( . ( . , . )) compared to np ( . ( . , . ) p= . ). conclusion: we have shown for the first time, dense at rs in syncytiotrophoblast and hofbauer cells in np placentae, and their down-regulation in pe. reduced ang iv/at r binding may contribute to increased placental vasoconstriction resulting in increased ischemia/reperfusion. this in turn may stimulate xanthine oxidase, which is itself stimulated by angii, leading to increased superoxide production. further work is needed to clearly define the role of this newly identified component of the renin-angiotensin system in normal pregnancy and pe. pre-eclampsia is associated with lower percentages of regulatory t cells in maternal blood. jr prins, hm boelens, jj hm erwich, j heimweg, s van der heide, ajm van oosterhout, aej dubois, jg aarnoudse. obstetrics, university medical center groningen, groningen, netherlands; laboratory of allergology and pulmonary disease, university medical center groningen; pediatric allergology, beatrix children's clinic, university medical center groningen. pre-eclampsia is a serious disease of human pregnancy and immunological mechanisms play a role in its pathophysiology. normal pregnancy is associated with an increase in regulatory t (treg) cells and with a predominant th immune profile. treg cells are a subpopulation of cd + lymphocytes and are specifically characterized by the lineage specific transcription factor foxp . treg cells seem to induce immunological changes that have a protective role in maintaining normal pregnancy. we hypothesised that percentages of treg cells are decreased in pregnancies complicated by pre-eclampsia. methods in total, women with pregnancies complicated by pre-eclampsia and healthy pregnant controls were enrolled. to obtain control umbilical cord blood as well, control group i consisted of eighteen healthy pregnant women at term. in addition, since women with pre-eclampsia delivered preterm, control group ii (peripheral blood only) consisted of women during normal pregnancy with a gestational age matched for the preterm pre-eclamptic group. treg cells were measured from whole blood using four-color flow-cytometry. women with a pregnancy complicated by pre-eclampsia had a significantly lower percentage of cd + foxp + treg cells ( . vs . %; p< . ). in the pre-term group the pregnancies complicated by pre-eclampsia showed a significantly lower percentage of cd + foxp + cells in the peripheral blood as compared to the healthy pregnant controls. at term this percentage was also lower but not significantly so. between pre-term and term pregnancies both complicated by pre-eclampsia no significant difference was found in the percentage of cd + foxp + treg cells. no difference was found in umbilical cord blood ( . vs . %). conclusions our data suggest that pre-eclampsia is associated with a diminished percentage of treg cells in peripheral blood. we conclude that a deficiency of regulatory t cells may play a role in the pathophysiology of pre-eclampsia. background: preeclampsia and eclampsia are significant causes of maternal and fetal death. however, the pathophysiology of these conditions is unclear. we and others have reported that inhibition of endogenous nitric oxide (no) synthesis produces symptoms similar to preeclampsia in pregnant rats. several studies demonstrate that fetoplacental weights are altered in pregnancies of spontaneous hypertensive (shr) rats. in addition, impaired synthesis of tetrahydrobiopterin (bh ), a major co-factor for endothelial nitric oxide synthase (enos) activity and enhanced expression of enos has been observed in the pathogenesis of hypertension. in the current study, we examined whether supplementation of bh and sepiapterin (sep, a precursor for bh biosynthesis in the salvage pathway) reduces increased blood pressure and improves fetoplacental weights in shr pregnant rats. methods: groups ( - ) of shr pregnant rats were either treated with bh , sep ( mg/k.g body weight/day/rat, oral tablets) or vehicle (normal diet) beginning from day of pregnancy until day of gestation. animals were sacrificed on day of gestation and fetoplacental weights were recorded immediately. western blot analysis was performed to determine vascular enos expression (enos/gapdh). results: significant (p< . ) elevations in blood pressure (bp, mmhg) were observed in shr (shr, ± . vs. wky, ± . mmhg) compared to wistar-kyoto (wky) group. supplementation of either bh or sep ( ± . ), significantly (p< . ) reduced elevated bp beginning from day of pregnancy. fetal but not placental weights were significantly (p< . ) reduced in shr ( . ± . grams) compared to wky ( . ± . ) rats. bh ( . ± . ) treatment partially (p< . ) increased fetal weights compared to the shr group. vascular enos expression is significantly (p< . ) elevated in shr ( . ± . ) compared to wky rats ( . ± . ). further, treatment with bh ( . ± . ) but not sep ( . ± . ) significantly (p< . ) reduced elevated enos protein expression in shr rats. conclusions: bh may be beneficial treatment of preeclampsia to reduce blood pressure and improve fetal perfusion to increase fetal weights. genetic risk factor for severe preeclampsia: significance of endothelial nitric oxide synthase gene t- ->c and missense glu asp variants. toshihiro yoshimura, michihiro yoshimura, masafumi nakayama. obstetrics and gynecology, kumamoto university school of medicine, kumamoto, japan; cardiovascular medicine, jikei university school of medicine, tokyo, japan; cardiovascular medicine, kumamoto university school of medicine, kumamoto, japan. introduction: we recently identified two endothelial nitric oxide synthase (enos) gene polymorphisms, a glu asp missense variant in exon and a t- -->c variant in the '-franking region, which are associated with coronary spasm and myocardial infarction in japanese population. and we also identified a missense glu asp variant is associated with severe preeclampsia and placental abruption. our objective was to analyze the association between the t- -->c and severe preeclampsia. materials and methods: the study participants included patients with histories of severe preeclampsia. this is a preliminary study, therefore, the comparisons were made with the general normal population. results: the analyses revealed that the frequency of the missense glu asp variant (n= / , %) was significantly higher than the general population (n= / , %), as we previously published. however, the frequency of the t- -->c variant (n= / , %) was not different from the general population (n= / , %). interestingly, only one patient had both t- -->c and missense glu asp variants, and she developed placental abruption. conclusion: although our sample size is small, it is very unlikely that the t- -->c variant is associated with severe preeclampsia. the t- -->c variant may not be a genetic susceptibility factor to severe preeclampsia. the t- -->c may have some reproductive significance in combination with missense glu asp variant, however huge number of patients would be needed to analyze such rare ( . %) combination of the variance. the association between the development of preeclampsia and methylenetetrahydrofolate reductase, angiotensinogen, vascular endothelial growth factor single nucleotide polymorphism genotype combinations. hyun soo park, jong kwan jun, chan-wook park, joong shin park, bo hyun yoon, hee chul syn. obstetrics and gynecology, dongguk university international hospital, goyang-si, gyeonggi-do, republic of korea; obstetrics and gynecology, seoul national university college of medicine, seoul, republic of korea. objective this study was conducted to investigate if there exists any genotype combination of multiple single nucleotide polymorphism (snp)s which is frequently found in preeclampsia patients. study design one hundred sixty two preeclampsia patients and normotensive pregnant women were included in this study between jan and jul . diagnosis of preeclampsia and assignment of severity were made according to the criteria by national high blood pressure education working group and american college of obstetricians and gynecologists. the patients were reclassified as early ( weeks or before) and late-onset ( weeks or beyond) disease. genotypes were measured with pcr-rflp for methylenetetrahydrofolate reductase (mthfr) c t, angiotensinogen (agt) m t, vascular endothelial growth factor (vegf) c t with the dna extracted from maternal blood. case-control study for each snp was done and the frequencies of genotype combination were compared. anova, t-test, chi-square test, fisher's exact test and logistic regression analysis were used for statistical analysis. a p value of < . was considered statistically significant. results genotypes of mthfr polymorphism showed significant difference between late onset preeclampsia and control (cc+ct/tt, or: . , p< . ) but agt and vegf polymorphism did not show statistical difference between any case-control combination. only out of possible genotype combinations were found and there was no statistical difference in the frequencies of genotype combination between case and control group. conclusion mthfr polymorphism might be associated with the development of preeclampsia, but there was no combination of mthfr, agt and vegf polymorphisms which is associated with the development of preeclampsia. diffuse staining and vascular smooth muscle (vsm) staining. resistance-sized vessels ( - μm) were evaluated. results: for mpo, the intensity of staining (fig) and the % vessels with neutrophil, diffuse and vsm staining was significantly greater for obese than for overweight or normal weight patients: % diffuse staining ( . ± . vs. . ± . vs. . ± . , p< . ); % vsm staining ( . ± . vs. . ± . vs. . ± . , p< . ). for mmp , obese and overweight patients had a greater (p< . ) % vessels with neutrophil, diffuse and vsm staining than normal weight patients: % diffuse staining ( . ± . vs. . ± . vs. . ± . ); % vsm staining ( . ± . vs. . ± . vs. . ± . ). conclusions: neutrophils infiltrate the systemic vasculature of obese women and release mpo and mmp . speculation: obesity may put women at risk for pe because their vasculature may already be dysfunctional due to neutrophil infiltration and release of mpo and mmp . hl . collagen is an important protein that maintains the structural integrity of tissues. disruption of vascular smooth muscle collagen could result in vascular dysfunction in women with preeclampsia. recently, neutrophil infiltration of the systemic vasculature was demonstrated in preeclamptic women. neutrophils produce inflammatory mediators, such as reactive oxygen species (ros) and tnf-. we hypothesized that neutrophils, ros and tnf-would alter expression of collagen regulating genes. methods: primary cultures of human vascular smooth muscle cells (vsmc) were seeded into t- flasks ( , cells/flask) and grown for days to % confluence. the cells were treated for hours with medium control, ros (hx, . mm + xo . u/ml), tnf-( ng/ml); and neutrophils ( , ) activated with arachidonic acid, μm, ( : ratio of neutrophils to vsmc). rna was extracted from cell homogenates and analyzed for gene expression with an rt profiler pcr array system for human extracellular matrix genes (superarray). to determine the fold-change of gene expression, the results were first normalized to a housekeeping gene and then ct was calculated across two rt-pcr arrays where group was the control and group was the experimental treatment. results: table . conclusions: neutrophils, ros and tnf increased mmp expression. interestingly, genes involved in collagen synthesis (col a ) or inhibition of mmp- activity (timp ) were either not affected or down-regulated. these data suggest that neutrophil infiltration in preeclamptic women could cause vascular dysfunction by creating an imbalance between collagen synthesis and collagen breakdown favoring breakdown. hl , fogarty d tw , p md . objective: hypoxia increases membrane attack complex (mac) binding to cultured human trophoblasts, and mac enhances apoptosis in trophoblasts exposed to low compared to normal fio . trophoblast microparticles and cellular fragments released into the maternal circulation in vivo may contribute to the systemic pathophysiology of preeclampsia. we tested the hypothesis that hypoxia induced mac deposition on cultured human trophoblasts yields microparticles and fragments coated with mac. study design: primary cytotrophoblasts from term human placentas (n= ) were cultured h in % and % oxygen in dmem with % human serum with active mac or heat inactivated serum (control). media were centrifuged to obtain pellets of microparticles and cell debris which were immunostained for mac or exposed - h to confluent, phorbol myristate acetate differentiated u macrophages. the percentage of macrophages that ingested trophoblast debris was quantified by counting the number of macrophages with immunofluorescence for trophoblast cytokeratin filament staining, as assessed by confocal microscopy. results: cultures exposed to normal human serum, but not heat inactivated control serum, showed mac immunofluorescence on microparticles and fragments in medium, with the highest level of mac in cultures exposed to extreme hypoxia. the maximal percentage of macrophages that ingested the trophoblast debris coated with mac from cultures with % oxygen was . %, not different from the . % from cultures exposed a % fio and control serum. conclusion: trophoblasts exposed to hypoxia and active complement release microparticles and cellular fragments coated with mac into the extracellular environment. mac coating does not influence phagocytic removal of the debris by macrophages suggesting that placental derived, membrane bound mac could circulate to yield systemic affects on maternal endothelium. supported by nih hd and hd . is there a role for fatty acids in the pathogenesis of pre-eclampsia? nicola j robinson, laura j minchell, jenny e myers, philip n baker, carl a hubel, ian p crocker. maternal and fetal health research group, the university of manchester; obstetrics, gynecology and reproductive sciences, university of pittsburgh. objectives: women with pre-eclampsia (pe) display altered lipid metabolism as characterized by elevated circulating triglycerides and non-esterified fatty acids (nefa) and these changes are evident before the disease is clinically apparent. we have tested the hypothesis that the increased circulating levels of nefa contribute to endothelial dysfunction in pe. methods: human umbilical vein endothelial cells were incubated for h with pooled plasma ( %) from normal or pe pregnancies, or with palmitic, oleic and linoleic acid in culture media at the concentrations and molar ratios to albumin identified in normal ( , , m, ratio . ) and pe pregnancies ( , , m, ratio . ) , . lipid droplet accumulation was determined using an oil red o absorbance assay. endothelial metabolism was measured using the mtt test and mitochondrial membrane potential determined by jc- assay as a marker of early apoptosis. results: plasma from pe pregnancies increased endothelial cell lipid droplet accumulation compared to normal plasma (p< . , wilcoxon signed ranks, n= ). this change was replicated following exposure to nefa at the combined concentrations found in pe compared to normal pregnant controls (p< . , n= ). plasma from women with pe caused a significant decrease in mitochondrial dehydrogenase activity (mtt test; p< . , n= ) and a reduction in jc- fluorescence (p< . , n= ), compared to normal plasma, suggestive of mitochondrial membrane depolarization and increased cellular apoptosis. again these effects were replicated using nefa in culture medium at the levels found in pe compared to normal pregnancies (mtt test: p< . , n= ; jc- assay: p< . , n= ). conclusions: in endothelial cell cultures, plasma from women with pe caused increased lipid droplet accumulation, decreased cellular metabolism and increased apoptosis. these changes to cellular function were mirrored using nefa in culture medium at the concentrations and molar ratios to albumin previously reported in pe. these findings provide evidence that the changes in endothelial cell function induced by plasma from women with pe may be due to the increased nefa circulating levels and that increased palmitic, oleic and linoleic acid, in combination, could play a role in pathogenesis of pe. lorentzen ( ) bjog; endresen ( ) ajog. background: skewing of the maternal endothelial phenotype in pre-eclampsia (pe) is attributed to the release of unknown factors from a hypoperfused placenta. we hypothesise that factors secreted from pe placental tissue will impair endothelial cell function. we have tested the effect of soluble factors by menopausal status, there was a significant increase in bmi in pre-but not in postmenopausal women. in postmenopausal women there was insufficient power to note a statistically significant change in bmi. results are summarized with the follow-up for each group represented by "n" in the graph below. premenopausal patients were divided into hysterectomy with oophorectomy (pbso) versus hysterectomy alone (ph). the ph group showed an increase in bmi that plateaus at time . in the pbso group the bmi continued to increase over time. subgroup analysis comparing ph to pbso demonstrates initial weight loss in pbso but a significant increase in bmi from baseline at time compared to ph. conclusions: hysterectomy appears to be associated with an increase in bmi over time. subgroup analysis suggests that, in premenopausal women, oophorectomy is more strongly associated with continuing weight gain than hysterectomy alone. purpose: obesity is implicated as a key risk factor in chronic disease, but no studies have associated central obesity to the presence of chronic abdominal and/or pelvic pain. we set out to identify the prevalence of chronic abdominal/ pelvic pain in an underserved, primarily latina population by a cross-sectional study in the olive view-ucla outpatient gynecology clinic. we sought to identify an association between the presence and severity of abdominal/pelvic pain and central obesity. methods: nonpregnant women presenting to the gynecology clinic were prospectively evaluated and grouped according to the presence of abdominal/ pelvic pain ('none-mild' or 'moderate-severe' pain). body mass index (bmi) and abdominal circumference (ac) were measured. patients with 'moderate-severe' pain completed standardized questionnaires for pelvic pain and global health scores. results: / ( %) of patients has 'none-mild' pain, and ( %) had 'moderate-severe' pain. pain prevalence was not significantly associated with bmi (mean: 'none-mild' . + . kg/m ; 'moderate-severe' . + . kg/m , p= . ), nor was pain severity (p= . ). pain prevalence was significantly associated with ac (mean: 'none-mild' . + . inches; 'moderate-severe' . + . , p= . ). a borderline positive association exists between ac and pain severity (p= . ). conclusions: we demonstrate an association between both the presence and severity of chronic abdominal/pelvic pain and central obesity, independent of bmi. ac appears to be a more relevant factor than other traditional measures of habitus in patients with this chronic malady. to improve preventative care in women's health management, further evaluation of the role of central obesity in the pathogenesis of chronic pain is necessary. aims: vulvitis is one of the most frequently diagnosed gynaecological infections. we aim to assess the efficacy against infective vulvitis of a new topical medical device containing low molecular weight hyaluronic acid (lmw-ha). the ability of this molecule to stimulate -defensin release in keratinocytes has been recently shown. methods: we report preliminary data regarding women suffering from infective vulvitis, as assessed by a gyneacologist: patients were randomly selected to receive sphg ( patients), a cream containing low-molecular weigh hyaluronic acid, or vehicle ( patients). patients were asked to apply the cream to the vulva twice-daily for days. at the end of treatment, evaluation of efficacy, tolerability and acceptability of the cream was assessed by a specific questionnaire. results: preliminary results show that patients receiving sphg report a significative improvement of vulvitis symptoms, in terms of itch, redness of the skin and burning, in comparison to vehicle. sphg also showed a good tolerability, cosmetic acceptability and symptomatic relief perceived by patients. conclusion: sphg seems to be efficacious in ameliorating the symptoms of infective vulvitis. this activity may be probably related to the lmw-ha presents in this formulation: in fact, low molecular weight hyaluronic acid has been recently shown to induce -defensin production by human keratinocytes. since this peptide exerts antimicrobial and antimicotic activity, the improvement of symptoms assessed in patients receiving sphg might be linked to a reduced infective charge, attributable to the activity of -defensin . background: allogeneic hematopoietic stem cell transplant (hsct) is a treatment used for many malignant and nonmalignant diseases of the bone marrow and immune system. hsct may be complicated by chronic graft-versus-hostdisease (cgvhd) in to % from matched unrelated donors. genital cgvhd complicates about % of hsct and may uncommonly result in labial fusion. case: year old woman with a history of ewing's sarcoma and acute myelogenous leukemia, had received chemotherapy and total body irradiation (tbi) followed by a matched unrelated donor hsct. menarche occurred at years of age after normal pubertal development. she menstruated regularly until cancer diagnosis. premature ovarian failure resulted after chemotherapy and tbi and oral contraceptive pills were used for hormone replacement. after transplant, she developed chronic gvhd involving the skin, eyes, mouth and joints, and concomitantly complained of vulvar pruritus. she was presumed to have a yeast infection which was treated with fluconazole without a pelvic exam. she was evaluated by a gynecologist when she was unable to insert a tampon. pelvic exam revealed dense labia minora adhesions from the clitoris to urethral meatus and posteriorly leaving a cm opening at the urethra. pelvic mri revealed a normal uterus and ovaries. after weeks of topical estrogen cream, the adhesions remained dense and were lysed under general anesthesia. vaginal examination revealed pale, minimally rugated, normal mucosa. cervical cytology was normal. post-operatively she used daily topical estrogen and hydrocortisone creams. at months after surgery, her urinary stream was stronger. on pelvic exam, the labial opening was cm, but a small posterior forchette adhesion elicited severe pain. after using dilators coated with topical steroids and estrogen, she was able to insert a tampon. conclusion: genital gvhd should be considered in women with genital tract complaints after hsct. labial fusion secondary to chronic gvhd may be treated successfully with surgery and medical therapy. support: rbmb/nichd/nih. dana r ambler, mazen e abdallah, rahi victory, michael p diamond, elizabeth e puscheck, jay m berman. obstetrics and gynecology, wayne state university/detroit medical center, detroit, mi, usa. objective: to determine which factors are predictive of a ruptured ectopic pregnancy, and whether endometrial stripe thickness can be used as an alternative to such criteria in the diagnosis of an ectopic pregnancy. design: retrospectively collected ectopic pregnancy database. setting: detroit medical center, detroit, michigan. patients or participants: women with a diagnosis of an ectopic pregnancy were studied, with surgically confirmed tubal rupture cases. interventions: abstracted data included hcg(iu), gestational age (days), presenting symptoms of pain and/or bleeding, hemoglobin (hgb), hematocrit (hct), historical risk factors, ultrasound-determined ectopic size, endometrial stripe thickness (mm), amount of cul de sac fluid (cds), tubal rupture at time of surgery, and estimated blood loss (ebl)(ml). covariates included demographics. results were significant when p< . . results: chi square analysis revealed that there is a relationship between endometrial stripe thickness and hcg levels. logistic regression models demonstrated that endometrial stripe thickness was not predictive of ectopic rupture, (or . , p= . ) . however, logistic regression, both forced and forward stepwise analysis, demonstrated that hcg (or= . , p< . ), a large volume of cul-de-sac fluid (or= . , p< . ), and increasing pain (or= . , p= . ) were associated with increased risks of rupture. gestational age, and ectopic related risk factors were also not predictive of rupture. conclusions: endometrial stripe thickness is not a useful predictor for the diagnosis of a ruptured ectopic pregnancy. serum hcg measurement, cds fluid volume and the presence of pain are much stronger diagnostic indicators of ectopic pregnancies. clinical profile of migraineurs in a university hospital gynecology department in japan. [objectives] the changes in hormonal milieu associated with menarche, pregnancy, menopause, and post-menopause are frequently accompanied by changes in the patterns and frequency of migraine. little is known on the relationship of women's issues of migraine though the balance between estrogen and progesterone is critical in the elimination of migraine. our aim was to investigate the relations among the prevalence of migraine, the reproductive stage, and gynecologic diseases. [materials and methods] female patients (average age: . years old) who consulted a physician and agreed to answer about the questionnaires during september, -june, . migraineurs were diagnosed with the migraine screener by the japanese headache medical treatment promotion committee in . and the patients answered questionnaires that screened about menopausal disorder and abnormal menstruation at once. they were conducted a survey in the form of a questionnaire and sometimes were taken blood samples. [results] in patients had migraine ( . % average age: . years old). prevalence were . % in one's twenties, higher than another ages. most patients with migraine was complicated by menstruation disorders (premenstrual syndrome %, dysmenorrhea . %), sterility ( . %), and severe menopausal disorder ( %). when trh and the lh-rh test were examined for the sterility patient, migraineurs had higher prolactin basal level and lh level after lord but lower fsh level before and after lord than nonmigraineurs. on the other hand, the prevalence of migraine for postmenopausal women and women who had gynecology cancer treatment was low, and there was no relation between migraine and pregnancy history. [conclusions] this study provides migraine headache is influenced by reproductive stage and that women with migraine are frequently complicated by menstruation disorder. it is thought that migraine account for abnormality of hormone milieu including abnormality of the hypothalamus-pituitary system. objective: this study evaluated the efficacy of doses of estradiol (e ) gel . % (divigel ® ), a novel formulation of e consisting of mg e per g transdermal gel, to reduce frequency and severity of vasomotor symptoms and signs of vulvar and vaginal atrophy (vva) associated with menopause. design: postmenopausal women were evaluated in a -week study comparing placebo to e gel . % at doses of . g/day, . g/day, and . g/day with estimated nominal daily deliveries of . mg, . mg, and . mg of e respectively. endpoints included mean change from baseline in daily frequency and severity of moderate to severe hot flashes (msvs). vaginal ph and % superficial cells were collected at baseline and end of study. results: e gel . % showed statistically significant improvements from placebo gel as early as week (table) that were maintained throughout treatment. signs of vva (vaginal ph and % of superficial cells) showed statistically significant improvements from baseline with all doses of e gel . % compared to placebo. conclusion: e gel . % significantly decreased the frequency and severity of msvs at all doses evaluated in this trial. e gel . % offers multiple dosing options to individualize patient therapy, including the lowest effective dose that was studied ( . mg e , delivering . mg e /day), to treat vasomotor symptoms associated with menopause. estradiol (e ) gel . % (divigel ® ) is a novel formulation of e consisting of mg e per g transdermal gel for the treatment of vasomotor symptoms associated with menopause. safety and tolerability of e gel . % were evaluated in a large placebo-controlled trial. design: postmenopausal women participated in a -week study comparing placebo to . g/day, . g/day, and . g/day of e gel . %. circulating e and estrone (e ) concentrations were measured. safety analyses included the incidence of adverse events (aes) and clinical laboratory evaluations, including plasma levels of sex hormone binding globulin (shbg). application site tolerability was assessed using the draize scale. results: all doses of e gel . % produced physiologic e :e ratios similar to those seen in premenopausal women. e :e increased from a baseline mean of . to . , . , and . with, respectively, the . , . , and . g/day doses of e gel . %. the most frequently reported aes were breast tenderness and postmenopausal bleeding that appeared to be dose-related and would be expected with increased circulating estrogen concentrations. there were no remarkable changes in hematology, blood chemistry, urinalysis, lipid, coagulation, and carbohydrate values following treatment with e gel . %. shbg levels remained unchanged after weeks of treatment at all doses. the vast majority of patients had no evidence of skin irritation throughout the treatment period. mean draise scale scores after , , and weeks of treatment were . for all treatment groups except for a mean value of . ± . for the . g dose group after weeks of treatment. conclusion: e gel . % is a safe and well-tolerated therapy for the treatment of menopausal symptoms. design: pharmacokinetic parameters, dosing, efficacy, and safety information for divigel ® , elestrin ™ , evamist ™ , estrogel ® , and estrasorb ® were obtained from current prescribing information (obtained from manufacturer websites) and the data were compared. results: together, these new transdermal therapies offer multiple dosing/ delivery options and contain a wide range of e ( . mg to . mg), with the lowest systemic daily delivery of e attained by the divigel ® . g dose. following weeks of treatment, across the dosing options, each treatment significantly reduced both the frequency and severity of moderate to severe vasomotor symptoms (msvms) compared to placebo. change in frequency of msvms ranged from - . (divigel ® . g) to - . (estrasorb ® ); change in severity scores for msvms ranged from - . (divigel ® . g) to - . (divigel ® . g). all treatments are safe and well tolerated. breast tenderness was the only adverse event reported in % of subjects, occurring with all therapies. conclusions: current treatment guidelines recommend using the lowest effective dose of estrogen for the treatment of menopausal symptoms. this side-by-side comparison of the recently available e non-patch transdermal options to the standard transdermal therapies is meant to assist physicians in individualizing treatment for their patients. introduction: cdb- (cdb) is a relatively new progesterone receptor modulator being clinically evaluated for contraception and treatment of fibromas. its use in an intrauterine device/system (ius) has not been reported. in this study we prepared cdb-filled intrauterine devices (cdb-ius) and evaluated their effects on endometrial growth and bleeding patterns in rhesus macaques. methods: short ( . - . cm) lengths of silastic tubing (od . mm), either empty (n= ),or filled with silicone rubber matrix containing % of micronized cdb (n= ), were inserted into the uterine lumens of ovariectomized rhesus macaques. animals were induced to cycle by sequential treatment with systemic estradiol and progesterone (p) as reported (brenner et al, ann ny acad, ) . after . cycles, at the end of the follicular phase, the uterus was removed and processed. results: when systemic p treatment was withdrawn at the end of each cycle, animals with empty ius menstruated normally, while animals with cdb-ius bled little or not at all. over the whole . cycles, animals bearing a blank ius bled for an average of . ± . days while cdb treated animals bled for an average of only ± . days. at the end of treatment, animals exposed to blank ius had mean endometrial wet weights of ± mg while the cdb-treated endometria weighed only ± mg. the proliferation markers ki- and phospho-h were substantially lower in the cdb-ius treated than in the blank treated animals. histologically, the cdb exposed endometria were atrophied with evidence of glandular degeneration while the blank controls were proliferative and normal. summary: in cycling rhesus macaques, a cdb-ius prevented progestational development, blocked menstruation after p withdrawal, and suppressed endometrial proliferation. if these effects are confirmed in women, the cdb-ius could provide estrogen-free and bleed-free contraception, and could help control heavy menstrual bleeding. supported by rr , hd and the population council. introduction: irregular uterine bleeding is a major side effect and cause for discontinuation of ltpoc use. while endometria of ltpoc-exposed women display abnormally enlarged, fragile blood vessels (bv), decreased blood flow and evidence of oxidative stress, the mechanisms by which structural and vasomotor endometrial dysfunction occurs remains unknown, in part by the difficulty of manipulating hormone levels in women. the aims of this study were ) to validate the guinea pig (gp) as a model to study uterine effects of ltpoc and ) to investigate ltpoc-effects on endometrial histology and oxidative stress markers. methods: oophorectomized gps were implanted s.c. with time release pellets containing either placebo (crl,n= ); estradiol (e ,n= ); medroxyprogesterone acetate (mpa,n= ) or e +mpa (n= ). after days, uterine horns were weighed and frozen or paraffin embedded. angiogenesis was assessed by quantitative image analysis of vonwillebrand factor staining and included bv density and size. oxidative stress was detected by isoprostane and -oh-deoxyguanosine ( oxog). apoptosis was investigated by the tunel method. statistical analysis was by -way and -way anova. results: gp uteri were enlarged by both e (p< . ) and mpa (p= . ). effects of mpa on uterine weight differed significantly depending on e levels (p< . ), where mpa opposed the e effect in combined treatments. angiogenesis parameters were similarly impacted upon. thus, mpa alone increased bv density (p= . ) and bv average area (p= . ). the presence of e significantly decreased these parameters (bv density mean± sem: crl: . ± . %, e : . ± . %, mpa: . ± . %, e +mpa: . ± . %, p= . ). these changes were associated with highly elevated -isoprostane content in e +mpa-treated uteri compared to all other groups (p< . ). abnormalities in the e +mpa group were consistent with chromatin redistribution, nuclear pyknosis, karyolysis and increased nuclear oxog staining and a marked increase in tunel labeling. conclusions: ltpoc exposure alters endometrial vascular and tissue morphology consistent with oxidative stress and apoptosis in a complex interplay with endogenous estrogens. the gp is an excellent model for the study of ltpoc effects on the uterus. physiologic and psychological symptoms associated with injectable and oral contraceptive use. abbey b berenson, susan odom, carmen r breitkopf, mahbubur rahman. ob/gyn, utmb, galveston, tx, usa. objective: to compare physiologic and psychological symptoms over mo among users of depomedroxyprogesterone acetate (dmpa), an oral contraceptive with micrograms ethinyl estradiol (oc), and non-hormonal (nh) contraception. methods: a total of women reported the presence of symptoms prior to initiating contraception ( dmpa, oc, nh) and every mo thereafter for mo. longitudinal relationships between symptoms and contraceptives (reference: nh), as well as race/ethnicity (non-hispanic black, non-hispanic white, and hispanic) were assessed by gee-analysis after adjusting for age, visits and baseline status of symptoms. persistence, resolution, and new development of symptoms were noted by method in mo increments for mo and compared with that of nh controls. the gee analyses showed that oc was protective against mastalgia (or= . ), cramping (or= . ), hair loss (or= . ), acne (or= . ), nervousness (or= . ) and mood swings (or= . ). when race was considered, oc was protective for all women against acne, for whites against mastalgia and cramping, and for non-whites against nervousness. for whites, it was a risk factor for bleeding between menses. oc use resulted in resolution of acne within mo in nearly % of those with it at baseline, but no significant resolution after mo. also mastalgia ( % at baseline) was less likely to persist at and mo. bleeding between menses was reported for the first time at mo by % of oc users. dmpa users of all races had an increased risk of missed periods (or= . ), bleeding between menses (or= . ), bleeding > d (or= . ) and loss of libido (or= . ) relative to nh users. it reduced cramping (after mo) and bloating (all mo). racial differences were observed with dmpa protective against mastalgia and mood swings in whites, cramping in whites and hispanics, and bloating in non-whites. it was a risk factor for loss of energy in whites only. neither method affected depressive symptoms. conclusion: side effects of these two methods are mostly related to abnormal bleeding. very low dose pills can be protective against symptoms (mastalgia, cramping, hair loss, acne, nervousness and mood swings) commonly associated with pills while dmpa protects against cramping and bloating. knowledge about racial differences will allow physicians to individualize therapy. counseling should include that some symptoms can develop after mo while resolution often occurs within mo. methods: twenty-four women were enrolled in irb approved prospective, randomized, cross-over trial comparing months of oc (ortho cyclen) vs. tc ortho evra). the daily oc administers micrograms of ee; the weekly tc contains . milligrams of ee. each treatment was followed by months of washout and months of the alternative contraceptive. blood was drawn at baseline and final week of treatment for each arm of the study. ee was quantified by ria, with preceding organic solvent extraction and celite column partition chromatography. data were analyzed by t test with boferroni's correction, p < . . results: after two months of treatment the mean (+/-sem) ee levels for tc = . pg/ml (+/- . ) and oc = . pg/ml (+/- . ). the ee level is not significant different for the two medication (p = . ). conclusions: there is no difference in ee levels with the use of these oral and transdermal contraceptives. this suggests the transdermal contraceptive, despite the lack of the hepatic first pass effect, has similar levels of ethinyl estradiol compared to oc. the continuous elevation in ee seen with the tc route of administration, versus the episodic increases seen with the oc route, raises concerns of constant exposure to ee. this may explain the increased risk of estrogen-induced thrombotic events with this tc route of administration. impact of paracervical block, in combination with general anesthesia, on post-abortion pain. gweneth b lazenby, tod aeby. obstetrics and gynecology, university of hawaii, honolulu, hi, usa. objective to evaluate the impact of paracervical block with a long-acting local anesthetic, in conjunction with general anesthesia, on post-operative pain. methods a power analysis determined patients per arm were needed to demonstrate a significant difference of in mean pain scores. seventy-two patients were allocated to one of two arms using urn randomization. all patients received standardized anesthesia; intravenous sedation for gestational age under weeks and general anesthesia for over weeks. thirty-nine patients were randomized to receive a paracervical block with . % bupivacaine and thirtythree were randomized to no local anesthesia prior to surgical abortion. patients completed visual analog scales for pain and anxiety prior to the procedure, upon awaking, and minutes post-operatively, and prior to discharge. data were analyzed using an anova and students t-test the experimental and control groups were equivelent in age, ethnicity, gravidity, parity, prior abortions, prior vaginal deliveries, prior c-sections, gestational age, number of laminaria, pre-operative and intra-operative dilation, operative time, estimated blood loss, and reported complications. pain and anxiety were not significantly affected by placement of a paracervical block. these data do not support the hypothesized benefit of local anesthesia, prior to surgical abortion under general anesthesia, to reduce post-operative pain. we do not recommend the routine use of a paracervical block to decrease post-operative pain. age, parity, history of abortion and contraceptive choices affect the risk of repeated abortion. oskari heikinheimo, mika gissler, satu suhonen. ob gyn, university of helsinki, helsinki, finland; national research and development centre for welfare and health, helsinki, finland. objective the rate of repeat abortion varies from to % in northern europe. however, risk factors for repeat abortion are poorly understood. we characterized risk factors (demographic, as well as those related to abortion and postabortal contraception) of repeat abortion. design a prospective cohort study of women undergoing medical abortion between august and december . the subjects were followed by means of finnish registry on induced abortions until december ; the follow-up time (mean ± sd) was . ± . months. results altogether ( . %) of the subjects requested repeat abortion within the follow-up time. in univariate analysis previous abortion, parity, young age, smoking and failure to attend the follow-up visit were associated with increased risk of repeat abortion. immediate -in contrast to postponed -initiation of any contraceptive method was linked to lower risk of repeat abortion. in comparison to combined oral contraceptives, use of intrauterine contraception was most efficacious in reducing the risk of another pregnancy termination. in multivariate analysis the effects of young age, parity, previous abortion and type of contraception on the risk of another abortion persisted. conclusions increased focus on young, parous and those with the history of an abortion may be efficacious in decreasing repeat abortion. contraceptive choices made at the time of abortion have an important effect on the rate of reabortion. postabortal use of intrauterine contraception, specifically that of lng-ius, might decrease the rate repeat abortion. objective. to determine the rate of failure and to analyze factors associated with failure for the essure permanent birth control device at the detroit medical center (dmc). methods. a chart review was conducted on patients who underwent essure placement at the dmc from january through june . patient demographics, past medical and surgical history, anesthesia type, procedure time, intraoperative complications, and procedure failures were noted. data were analyzed for statistical significance using spss. results. there were essure procedures attempted at the dmc from january through june . of the attempted procedures, there were failures ( . %). of the failures were attributed to difficulty visualizing the ostia ( %). other causes of failure included expulsion of the device ( ), tubal spasm ( ), uterine perforation ( ), and tubal ostia too large for the device ( ). there were cases of failed placement for undocumented reasons, one case requiring a laparoscopic tubal ligation secondary to postprocedure tubal patency, and post-procedure pregnancies. age, race, body mass index, gavidity, parity, history of sexually transmitted infections, medical history, history of cesarean section, tobacco or illicit drug use, anesthesia type, and physician experience with the procedure were not significantly associated with placement failure or difficulty visualizing the ostia. a longer procedure time was significantly associated with failure ( . vs . min, p = . ), and history of ectopic pregnancy was significantly associated with difficulty visualizing the ostia ( . % vs . %, p = . ). conclusion. the failure rate for placement of the essure permanent birth control device at the dmc is . % with a pregnancy rate of . %. the majority of failures may be attributed to difficulty visualizing the ostia. a history of ectopic gestation was significantly associated with difficulty visualizing the ostia; thus, it may be reasonable to advise these women that success in essure placement may be reduced. introduction. the essure permanent birth control device is a relatively new form of minimally invasive sterilization for women. under hysteroscopic guidance, a dynamically expanding micro-insert is introduced into the proximal portion of the fallopian tube. the micro-insert induces local fibrosis and ultimately occlusion of the tubal lumen. a hysterosalpingogram (hsg) is performed three months after the procedure to confirm bilateral tubal occlusion. objective. to determine the follow-up rate for the post-essure hsg for a clinic population. methods. a retrospective chart review was conducted on university health center (uhc) patients who underwent placement of the essure permanent birth control device at the detroit medical center from january through june . follow-up for the post-essure hsg as well as the result of the hsg were noted for each patient. results. placement of the essure permanent birth control device was attempted in uhc patients of which were successfully completed. of the patients, ten underwent a post-essure hsg ( . %). the hsg was performed three to six months after placement of the essure permanent birth control device. bilateral tubal occlusion was documented in all ten patients. conclusion. despite counseling patients prior to their procedure that a hsg is needed and providing an information sheet, the follow-up rate for the post-essure hsg for this clinic population is only . %. for those in whom a hsg was performed three to six months after essure placement, bilateral tubal occlusion was confirmed in all. steps and or approaches to improve compliance with post-procedure confirmation of tubal occlusion should be employed to increase follow-up in the future. towards fibroids gene therapy: adenovirus mediated delivery of herpes simplex virus thymidine kinase gene/ganciclovir shrinks uterine leiomyoma in the eker rat model. memy hassan, dong zhang, salama salama, cheryl walker, hala el-mazar, ayman al-hendy. ob/gyn, utmb; md anderson; ob/gyn, meharry medical college, nashville, usa. aim: assessment of the efficacy of gene therapy of uterine leiomyoma in the immune-competent eker rat model using adenovirus mediated delivery of herpes simplex- -thymidine kinase gene followed by ganciclivir treatment (ad-tk/gcv). method: female eker rats with mri-confirmed uterine fibroid lesions were randomized to a single treatment with direct intratumor injection of ad-tk/gcv, ad-lacz/gcv, or medium.the tumor volume was evaluated by serial mri scanning and confirmed with caliper measurement at time of euthanasia. sample rats were selected randomly and killed at the following time points; , and days post treatment. samples were collected from tumors, other body organs and blood to assess the safety and efficacy of the treatment. results: ad-tk/gcv treatment produced dramatic shrinkage of the total uterine fibroid volume by % ± , % ± and %± of pretreatment volume at days , and respectively. the tumor size in negative control animals receiving ad-lacz/gcv continued to grow by + %± , + %± , + % ± while receiving media continue to grow by + % ± , + % ± and + % ± at same time points. ad-tk/gcv induced significant increase in caspase activity, bax expression, decrease in bcl and parp proteins expression and increased tunnel apoptosis index. additionally ad-tk/gcv treatment decreased cyclin d and pcna expressions. ad-tk/gcv did not produce any significant change in liver function tests or relative uterine horns weight to total body weight. the adenovirus transfection did not disseminated significantly to other distal organs except to liver and myometrium in limited number of animals. h e staining of non targeted organs did not revealed any sign of tissue damage. ad-transfection increased local cd and cd expressions as well as serum anti-ad antibodies. conclusion: ad-mediated delivery of hsv tk gene by direct intra-tumor inoculation followed by sc treatment of gcv for ten days effectively shrinks uterine leiomyoma lesions in eker rats. this effect is mediated via induction of apoptosis and decreasing the proliferation. the treatment regimen is well tolerated. these studies provide essential preclinical data for the development of gene therapy as an alternative non-surgical treatment option for women with symptomatic uterine fibroids. inhibitors of catechol o-methyl transferase shrinks uterine fibroids in the eker rat model. memy hassan, dong zhang, hala el-mazar, cheryl walker, ayman al-hendy. ob/gyn, utmb; md anderson; ob/gyn, meharry medical college, nashville, usa. background :the sex hormone dependent pattern of uterine leiomyomas and their high content of catechole -o-methy transferase (comt) raise the possibility for the development of novel treatment option using comt inhibitors.aim : to assess the potential therapeutic utility of a synthetic comt inhibitor (ro - ) in the eker rat model of uterine leiomyoma. methods female eker rat were evaluated by mri to confirm the prescence uterine fibroid lesion, then randomized for sc treatment with ro - mg /kg ,twice/ day for days versus vehicle injection.fibroid tumor burden was evaluated by serial mri measurement and confirmed by direct caliper measurement at time of euthanasia. sample animals were euthanized at and weeks. at that time tumor tissue, blood and most of animal organs including long bones were collected and subjected for further evaluations. hours urine samples were collected for evaluation of estrogen (e ) metabolites and bone resorption marker. results:animals treated with ro - exhibited significantly lower uterine fibroid tumor burden ( % and %) of pretreatment volume at and weeks post treatment respectively. conversely, the tumor size in control animals continued to grow and reached %, and % of pretreatment size at the same time points. ro - treatment resulted in an increase in urinary / hydroxy e metabolite ratio. in addition ro - increased bax expression and decreased parp , pcna and cyclind experssions . all ro - treated animals tolerated the treatment protocol with no signs of toxicity. h e staining of different body organs did not reveal any signs of tissue damage. furthermore, there was no significant change in both liver function tests (alt, ast, billirubin) and bone resorption marker , deoxypyridinoline croslinks, between treated and control rats. conclusion ro - , a synthetic selective comt inhibitor, caused immediate arrest of the growth of eker rat uterine leiomyoma. this effect might be in part due to modulation of various estrogen dependent genes regulating leiomyoma apoptosis (parp, bax) and proliferation (pcna, cyclin d ). this anti-estrogenic effect is due to the accumulation of the the antiestrogenic metabolite hydroxy estrogen secondary to comt inhibition.comt inhibitors might present an alternative non-surgical option for the treatment of women with symptomatic uterine fibroids. background development of uterine leiomyomas (fibroids) is the most common pathological feature in the female reproductive tract. they negatively impact patients of virtually every gynecologist. despite such morbidity, leiomyoma development is poorly understood. we have recently demonstrated that leiomyomas have a genomic expression pattern that limits retinoic acid (ra) exposure. our group and others have demonstrated that tgf-beta regulation is altered as well. these two pathways likely play central roles in leiomyoma development. the central feature of uterine leiomyomas, the extracellular matrix (ecm), is regulated by both all-trans retinoic acid and tgf- , focusing on versican as a critical ecm component. human uterine leiomyoma and patient-matched myometrium were obtained from surgical specimens under an irb-approved protocol. these tissues were immortalized and treated with either all-trans retinoic acid, tgf- , or anti-tgf- antibody. rna was isolated for qrt-pcr. human immortalized leiomyoma cells demonstrated the same increased template expression of tgf- ( . ± . fold), retinoic acid metabolizing protein (cyp a ; . ± . ), and versican variant v ( . ± . fold) as was found in the progenitor tissue. when treated with all-trans ra, expression of versican variant v decreased to levels found in myometrial cells ( . ± . fold). conversely, when treated with tgf- , expression of versican variant v increased . ± . fold. to confirm that tgf- was central to the overexpression of v , we treated leiomyoma cells with anti-tgf- antibody, and found that baseline over-expression of v template was decreased to expression levels similar to untreated myometrial cells. finally, we elucidated a link between the ra and tgf-pathways by assessing the impact of ra treatment of tgf- expression, demonstrating that tgf- template decreased to levels comparable to myometrial cell expression ( . ± . fold). the disrupted leiomyoma ecm, of which versican is a central component, defines the leiomyoma phenotype. in this study, the leiomyoma fibrotic phenotype regressed when treated with ra and increased when treated with tgf- , providing the basis for novel therapeutic interventions directed at cell differentiation and ecm formation. objectives: uterine fibroids are the leading cause for hysterectomies in the us. the lack of an appropriate in vitro cell model for the initiation of fibroid growth has hindered advancement in understanding the cellular and molecular basis for the development and progression of uterine fibroids. fibrosis is the underlying mechanism of uterine fibroid formation and myofibroblasts cells are the principal fibrogenic cell type in the uterus. we sought to develop a myofibroblast in vitro cell model for analyzing the initiating molecular events of uterine fibrosis. methods: smooth muscle cells (smcs) were enzymatically isolated from the myometrium of non-pregnant women and cultured in the presence of % serum until % confluent. for the next h cells were cultured in serum-free media followed by replacement with serum containing media. cells were fixed at , , , , m later. cell fine structure and cytoskeletal organization were evaluated by transmission electron microscopy. smooth muscle specific alpha-actin ( -sma) and progesterone receptors (pr) were detected by western blot. results: we observed smc differentiation into myofibroblasts, marked by the presence of notched nuclei ( figure) and the increased expression of -sma m after serum replacement. pr-a and pr-b were detectable at , and m. conclusions: the development of myofibroblasts is important in wound healing and fibrosis. we show for the first time that uterine myofibroblasts can be derived in culture from myometrial smcs. thus, these cells will be utilized as a model for developing "in vitro fibroids". this model will enable the study of myofibroblast activation, cytokine signaling, intracellular regulation of uterine fibrogenesis, production of extracellular matrix proteins and development of antifibrotic drugs. the presence of prs in our model enables us to evaluate pr mediated events in fibroid pathogenesis and treatment. this model will be more useful in determining the molecular biology of fibroid initiation than cell models derived from established fibroids that are already well past their initial stages of development. novel approach to genome-wide expression profiling analysis. liping feng, morgan walls, insuk sohn, millie behera, sin-ho jung, phyllis leppert. obgyn; biostatistics and bioinformatics, duke university medical center, durham, nc, usa. background: microarray studies have examined the differential gene expression between uterine fibroid and normal myometrium. all previous studies considered the fibroid as a whole and analyzed only fold changes. we have developed a novel statistical approach to genome-wide expression analysis comparing two fibroid tissue sites to myometrium. methods: using affymetrix tm u a genechip, we have compared the gene expression between c and e and matched adjacent m. data has been analyzed by considering the specimens per subject and subjects as individuals. we used a block one-way anova method to test if each gene was differentially expressed among the three sites. the p-value is calculated using a permutation method accounting for possible dependency among three lesions. the multiple testing issue was addressed by controlling the false discovery rate. expression values were calculated using the robust multichip average (rma) method. rma estimates are based upon a robust average of background corrected perfect/mismatch (pm) intensities. normalization was done using quantile normalization. expression values were then transformed by taking logarithm base . confirmatory rt-pcr was performed. results: we applied a hierarchical clustering analysis to all raw data sets and then displayed a dendrogram, where the height of each branch point indicates the similarity level at each generated cluster. identical gene expression among sites clusters together. due to a strong site effect, m tissues clustered separately from e and c combined. genes were differentially expressed when we used a . q-value cut off. expression data revealed concordant changes in genes regulating cholesterol biosynthesis, gene transcription, estrogen and extracellular matrix formation when both e and c were examined. cyp was detected and we report for the first time that scc- (a cell cycle-regulated molecule) folliculin and l-selectin are differentially expressed suggesting that they may be involved in the regulation of cell growth and proliferation of uterine fibroids. conclusions: our novel robust analysis of gene expression provides new clues to the relevant pathways of fibroid development. this new statistical approach that can be used in clinical and/or translational studies to identify differentially expressed genes comparing treatment regimens, cells or tissues. objectives: thrombospondin- (tsp- ) is a large matricellular glycoprotein secreted by many cell types. matricellular proteins modulate interactions between cells and their environment, regulate cell adhesion and are expressed during tissue formative processes. they are especially important in fibrosis. tsp- plays an important role in angiogenesis and is an activator of tgf - . in a previous study, we found that differential expression of tsp- in uterine fibroids may contribute to an altered healing process leading to fibrosis. this alteration in tissue response to injury initiates the development of abundant, nonaligned collagen fibrils and changes in other components of the ecm. methods: we measureed the pattern of mrna and protein expression of tsp- by rt-pcr and western blot in an in vitro serum-deprived differentiated myometrial cell (myofibroblast) model. specifically, smooth muscle cells (smcs) were enzymatically isolated from the myometrium of non-pregnant women and grown in primary culture to % confluence. then smc were serum deprived for h and treated back with % serum for , , , and m. cells were collected for rna and protein, and tsp- expression was evaluated. in addition, cells were stained using the combination of anti-cd and anti-smooth muscle -actin or combination of anti-cd d and anti-smooth muscle -actin as well as the appropriate single and double negative controls. stained sections were analyzed using zeiss axio imager widefield fluorescence confocal microscopy. results: tsp- mrna and protein was present in cells in this serumstarvation model after the addition of serum and the expression level remained elevated for m following the addition of serum. fluorescence staining analysis indicated that these cells were positive for human smooth muscle -actin, but negative for leukocyte antigen cd and platelet marker cd d suggesting that the myofibroblasts cells themselves were the source of the tsp- . conclusions: unlike skin wounds, where tsp- is derived from the blood macrophages, monocytes and platelets, differentiated myometrial cells appear to produce tsp- . elucidating the roles of tsp- in myometrium physiology and pathobiology will increase our understanding of the etiology of uterine fibroids and may lead to improved therapies. further studies utilizing this cell model to determine the role of tsp- in the activation of tgf - are indicated. phospholipid s p via gi, rac and rho pathways. yoel smicun, armando wu pimentel, jennifer gilman, david a fishman. obstetrics gynecology, new york university school of medicine, new york, ny, usa. objectives: sphingosine- -phosphate (s p) levels are elevated in serum and ascites of ovarian cancer patients. we have demonstrated that low concentration s p enhances while high dose s p inhibits invasion of epithelial ovarian carcinoma (eoc) cells in a dose and attachment mode dependent manner. we sought to further dissect the pathways by which s p affects invasion, using specific inhibitors. methods: dov eoc cells were pretreated for -hrs with vehicle, . m or m s p and with inhibitors for gi, p -mapk, rac and rock, thereafter cells were detached and tested for invasion towards m lpa chemoattractant in matrigel-coated chambers. conditioned media from pretreated cells and invading cells were quantified for upa activity using colorimetric assays. the significance of results was calculated by student's t-test. results: inhibition of gi mildly increased invasion of both control ( p= . ) and m s p treated cells ( p= . ). inhibition of both p -mapk and rac did not affect m s p treated cells, in contrast invasion of control cells was mildly increased (p= . , . ). inhibition of rock, a protein effector downstream of rho, highly elevated invasion of both control and m s p treated cells ( fold, p= . , fold, p= . ). both upa and gelatinase activities were higher in conditioned media of invading cells than of attached cells. gelatinase activity was enhanced by both concentrations of s p (p= . , . ). ptx fully inhibited gelatinase activity of control and . m s p treated cells, and partially of the m s p treated cells (p< . ). . m s p significantly increased upa activity of attached (p= . ) but not of invading cells. this increase was sensitive to ptx and rac inhibitor. m s p inhibited upa in both attached and invading cells (p= . ), this inhibition was rock dependent. conclusions: these findings suggest a strong inhibition of invasion and upa by the rho pathway, of both control and m s p treated cells. this inhibition is induced partially by upstream gi protein. increased invasion by . m s p is associated with elevation of gelatinase activity through gi, rac and rock pathways. this suggests that attached cells and invading cells affect upa activity through different pathways. objectives: sphingosine- -phosphate (s p) levels are elevated in serum and ascites of epithelial ovarian cancer (eoc) patients. we have demonstrated that invasion of attached eoc cells differentially react to s p as compared to invading cells. we examined the impact of the inhibitors for gi and rac on attached and invading eoc. methods: dov eoc cells were pretreated for -hrs with vehicle, . m or m s p and with inhibitors for gi (pertussis toxin (ptx)), and rac (nsc , (rac-i)), and cells were detached and assayed for invasion towards m lpa in matrigel-coated chambers. to distinguish the response of attached from invading cells, inhibition of cells pretreated with inhibitors was either continued or not in the invasion chambers. conditioned media (cm) of invading cells were quantified for upa and gelatinase activity by fluorometric and colorimetric assays. significance of results was calculated by student's t-test. results: the significant (p= . ) increase of invasion by . m s p was inhibited by both ptx and rac-i, either by pretreatment alone or by continuous treatment (p= . - . ). however, the invasion was higher in cells inhibited continuously than cells inhibited only in dishes. both inhibitors did not affect cells treated with m s p. control cells invasion was increased ( . fold, p= . ) by continuous rac-i treatment. . m s p increased gelatinolysis in cm of invading cells. this and control cells activity was inhibited by ptx pretreatment. continuous treatment with ptx or rac-i elevated and fold gelatinase activity of control and m s p treated cells. in contrast upa activity was inhibited by both . m and m s p. activity of control cells was inhibited by both pretreatment and continuous treatment with both ptx and raci. upa activity of cells treated with . m s p was increased only by pretreatment with ptx and raci. in contrast, in cells treated with m s p upa was inhibited only by continuous inhibition with ptx and raci. conclusions: invasion of s p induced eoc cells correlated with the gelatinase and upa activities in their microenvironment. ptx and rac-i affect attached and invading cells in different manner, inhibition of invasion and gelatinolysis of attached and increased invasion of invading cells. this suggests a dual effect of the gi-rac pathway, inhibiting attached and stimulating invasion via gelatinolysis of invading cells. lysophosphatidic acid (lpa) levels are elevated in the ascites and plasma of early-and late-stage ovarian cancer patients, underscoring the unique role this bioactive lipid plays in the pathobiology of epithelial ovarian cancer (eoc). lpa binding to its cognate g-protein-coupled receptor can transactivate the receptor tyrosine kinase, egfr, which is often overexpressed in ovarian tumors. in the current study, we investigated the role that lpa activation of egfr plays in the processing of the metalloproteinase, mmp- , and eoc dissemination. lpa stimulates tyrosine phosphorylation of egfr in ovarian cancer cells, and egfr kinase activity is required for optimal lpa induction of pro-mmp- activation. lpa-dependent pro-mmp- activation does not require the egfr ligands, amphiregulin, b-cellulin, egf, hb-egf, and tgf-a. we previously reported that when cells are cultured at high density, lpa represses rhoa activity to induce loss of stress fibers, and these changes in actin microfilament organization contribute to pro-mmp- activation. in the current study, inhibition of rho-kinase/rock with y- reversed the repression of lpa-stimulated pro-mmp- processing observed with treatment of the egfr kinase inhibitor, ag . correspondingly, lpa induced the loss of stress fibers, while inhibition of egfr kinase restored stress fiber formation in lpa-treated cells. this suggests that lpa acts through egfr to modulate microfilament organization and pro-mmp- processing. finally, lpa-induced cellular haptotactic migration and invasion are abrogated when egfr kinase activity is blocked. taken together, these results suggest that egfr signaling plays a critical role in lpa regulation of metastatic pathways by mediating changes in the cytoskeleton which impact protease activity. objectives: membrane-derived vesicles are active modulators of tumor dissemination; they promote and contribute to extracellular matrix degradation and tumor cell invasion. we have isolated vesicles from ascites of ovarian cancer patients and from ovarian cancer cells in vitro. here we analyzed the functional consequences of exposure of cancer cells to vesicles derived from a different type of malignancy in order to evaluate their proinvasive properties. methods: ovarian cancer (dov ), breast cancer (mda mb ) and mesothelioma (hp- ) cells were grown in media supplemented with % fbs. after serum deprivation, % vesicle-free fbs was added for hr to induce vesicle release. vesicles were isolated from media by differential centrifugation and quantified with a bradford assay. fusion to cells was followed by fluorescence of the lipophilic tracer dii. each cell line was stimulated with and g/ml of each type of vesicles and tested in a matrigel invasion assay. changes in proliferation were evaluated in an mts assay. gelatin zymography was used to assess matrix metalloproteinase activity of vesicles. results: zymographic analysis showed that vesicles contained mmp- and . fusion experiments showed that all vesicles fused to all cell types. all vesicles induced the invasion of their respective cell types in a dose-dependent manner. when vesicles were used at g/ml they induced significantly high levels of invasion in all cell types tested. at g/ml they significantly inhibited invasion in different cell types. both concentrations of vesicles stimulated cell proliferation in all cell types tested. conclusions: membrane derived vesicles are potent mediators of invasion for mesothelioma, breast and ovarian cancer cells in vitro. this effect occurs in a dose-dependent manner when vesicles induce invasion of the same cell type from which they were isolated. when vesicles are used to induce a different cell type, low concentrations induce invasion while high concentrations inhibit invasion, this effect was independent of cellular proliferation. these results suggest that a novel mechanism may be at play where activation of recognition of self and non-self specific pathways may determine the invasive potential of the tumor cell upon fusion to microvesicles. the identification of signaling pathways responsible for this heterotypic signaling is a current effort. vegfr- as a potential target to inhibit lpa-induced epithelial ovarian cancer (eoc) invasion. sonia dutta, fengqiang wang, elaine barfield, david a fishman. obstetrics and gynecology, new york university school of medicine, new york, ny, usa. objective: vegf and vegf receptors (vegfrs) play important roles in ovarian cancer metastasis. in this study, we examined the expression profiles of vegf and vegfrs (vegfr , vegfr , co-receptor nrp and nrp ) in established eoc cells lines (dov , r , ovca , skov ) and an immortalized normal ovarian epithelium (iose- ). the effect of lysophosphatidic acid (lpa) on vegf and vegfrs expression and the effect of vegfr- silencing by rnai on lpa-induced invasion were also evaluated. methods: vegf and vegfrs expression in ovarian cancer cell lines and normal ovarian epithelium was quantified by real time pcr. cell invasion differentiate into either a pro-tumor or anti-tumor phenotype depending on the specific tumor microenvironment. previously, we described a subgroup of epithelial ovarian cancer (eoc) cells with a functional tlr- -myd -nf-b pathway (type i eoc cells). these cells have constitutive nf-b activity and constitutively secrete il- , il- , mcp- , and gro . we hypothesize that type i eoc cells, but not type ii, can promote macrophage differentiation into a tumor-supporting immune cell. methods: eoc cell conditioned media (cm) was prepared by incubating eoc cells in log-phase growth in optimem for h. migration assay was done using an in vitro cell culture insert with m-size pore and pkh red fluorescentlabeled thp- . cytokine profile of thp- cells co-cultured with eoc cell cm was determined using xmap technology. modulation of response to apoptotic bodies was determined by "pre-educating" thp- cells with eoc cell cm for h prior to exposure to apoptotic bodies ( : ratio with thp- cells). results: monocytes migrate toward eoc cells. however, migration is significantly higher towards type i eoc cells. type i, but not type ii, eoc cells alter monocytes' cytokine profile by inducing the secretion of high levels of progrowth and angiogenic cytokines il- , il- , mcp- , and gro . furthermore, type i eoc cells modify monocytes response to apoptotic bodies by inducing a significant increase in the secretion of il- , il- , mip- , mip- , and gro ( -fold, . -fold, -fold, -fold, and -fold respectively). conclusion: we demonstrate for the first time a differential interaction between two subtypes of eoc cells and monocytes. we showed that the microenvironment created by type i eoc cells is able to modify the function and differentiation of immune cells towards a tumor supporting phenotype. understanding the molecular mechanisms mediating this tumor-immune interaction will help to design appropriate immune therapies that will take into consideration the tumor microenvironment. objectives: the standard of treatment for patients with ovarian cancer (oc) is intravenous combination chemotherapy (ct) after primary cytoreductive surgery. although initial response is above %, most of these patients experience recurrence. the only approach for these patients is salvage ct which may prolong their lives for months. early detection of patients who are not responding to current therapy or are at risk of experiencing an early relapse of disease might improve response rates and survival if alternative therapy is possible. no single predictive marker has yet been proven sufficiently sensitive or specific to find a place in the daily clinic. in the present study we use a newly described biomarker test for the detection of oc (visintin et al clinical cancer research) and evaluated the ability of the test to monitor ct response methods: patients with oc, figo stage i-iv, were included in this study. all patients recieved postsurgery first line combination ct (paclitaxel/carboplatin). samples were evaluated at ) baseline (mean days after surgery), prior to the first cycle of ct, and ) after cycles of ct. μl serum samples were analyzed by multiplex assay (beadlyte® cancer biomarker panel kit) for six markers. changes during ct and differences in markers between patients with short time to progression (ttp) and patients with long ttp were determined. results: positive test for oc was observed in % of the patients evaluated at baseline. all patients had residual disease after surgery. from patients with long ttp, / patients (specificity %) had a negative test after cycles. from the patients with short ttp, / had a positive test (sensitivity %) p= . ( ²). the risk of experiencing a ttp shorter than months when having a positive test after cycles of ct was %. conclusion: we describe for the first time the use of a panel of biomarkers for oc that might have an application for monitoring ct response and risk of relapse. the test detects the presence of residual disease following debulking surgery, and differentiates between long term and short term progression. a longitudinal study is performed to determine how early during ct the test can identify responder versus non responder. ksp inhibitor (arry- ) as an alternative for paclitaxel in myd -positive epithelial ovarian cancer cells. ki h kim, ayesha b alvero, yanhua xie, david trollinger, gil mor. obstetrics, gynecology, and reproductive sciences, yale university school of medicine, new haven, ct, usa; array biopharma inc., boulder, co, usa. background: we previously described that epithelial ovarian cancer (eoc) cells ubiquitously express tlr- , but not the adaptor protein myd . when treated with paclitaxel, a known tlr- ligand, myd -positive eoc cells exhibited nf-b activation, increased secretion of il- , il- , mcp- , and gro , and increased p-erk levels . since majority of eoc patients are given paclitaxel in combination with a platinum drug, it is not only important to distinguish those patients that should not be given paclitaxel; it is also important to identify alternative chemotherapy agents that would benefit this sub-group of patients. the objective of this study is to determine if the ksp inhibitor, arry- , can be an alternative for paclitaxel in myd -positive ovarian cancer patients. methods: myd -positive and myd -negative eoc cell lines isolated from either ascites or tumor tissue were treated with increasing concentrations of arry- ( to nm) or paclitaxel ( . to m) for , , and hours and cell viability was determined using the celltiter aqueous one solution cell proliferation assay. cytokine profiling was performed from supernatants using xmap technology. nf-b activity was determined using a luciferase reporter system. p-erk levels were measured by western blot analysis. results: arry- and paclitaxel exhibited the same cytotoxic effect on myd -negative and positive eoc cells. the ic at h for myd -negative eoc cells was . m and . um for arry- and paclitaxel, respectively. for myd -positive eoc cells, the ic at h was m and m for arry- and paclitaxel, respectively. however, unlike paclitaxel, arry- did not induce nf-b activation or enhance the secretion of il- , il- , mcp- , and gro , and did not induce erk phosphorylation on myd positive cells. conclusions: administration of paclitaxel to patients with a myd -positive tumor could have detrimental effects due to the paclitaxel-induced enhancement of cytokine production which promotes chemoresistance and tumor growth. arry- has similar anti-tumor activity in eoc cells as that of paclitaxel. however, unlike paclitaxel, it does not induce cytokine production in myd positive eoc cells, and therefore, the ksp inhibitor arry- may represent an alternative to paclitaxel in this subgroup of eoc patients. introduction: nf-b activation has been associated with cell proliferation, angiogenesis, metastasis and suppression of apoptosis in ovarian cancer. in addition, nf-b activity induces the production of pro-inflammatory cytokines which may contribute to chemoresistance. inhibition of nf-b may represent a new approach to prevent tumor growth and reverse chemoresistance. in the present study we described the characterization of a novel nf-b inhibitor, eriocalyxin b (erib) that is able to re-establish the apoptotic cascade in chemoresistant ovarian cancer cells by suppressing pro-inflammatory cytokines and antiapoptotic proteins. materials and methods: eoc cell lines were isolated from malignant ovarian cancer ascites. caspase activity was determined by caspase-glotm assay. cytokine production and secretion were determined using multiplex assay. erib effect on cancer cells was evaluated in a time and dose dependent manner using celltiter cell proliferation assay. protein expression was determined by western blot analysis. combination studies were done with paclitaxel and carboplatin in addition to erib treatment. nf-b activity was determined by monitoring the expression of a nf-b luciferase reporter. results: erib decreased cell viability of ovarian cancer cells with an ic of . - μm in hours and was associated to increasing levels of caspases , and activity. intracellular changes induced by erib included: ) inhibition of nf-b activity; ) decrease in cytokine production; ) down regulation of anti-apoptotic proteins xiap and flip, and reversal of resistance to tnf-and fasl-mediated cell death; and ) chemosensitization to carboplatin and paclitaxel. at present, evidence is accumulating regarding the existence of unique populations of specialized tumor-initiating, stem-like cells within various tumor types of distinct origins. these cancer stem cells (csc), with characteristics reminiscent of normal stem cells, are thought to be responsible for driving tumor growth. we propose that ovarian cancers arise from csc, and are using microarray-based technology to identify specific genes/cell surface markers associated with ovarian csc that will permit distinction of these rare cells from the remaining tumor bulk. to identify unique gene signatures associated with an ovarian tumor-initiating cell population, we have utilized an in vivo serial transplantation model. this model selects for primary human ovarian tumor cells with increased tumorigenic capacity, given that time to tumor formation decreases with successive serial transplant despite fewer cells injected. our initial studies used cells derived from a human ovarian clear cell carcinoma, serially transplanted for three passages in nod/scid mice. rna derived from these transplanted tumors was analyzed on human genome microarrays. from these analyses, several differentially expressed genes were identified. the differential expression noted for potential genes of interest is currently being validated by rt-pcr. of particular interest, expression of the transmembrane glycoprotein muc was found to increase both at the rna and protein level with successive transplant of this clear cell carcinoma. further studies are ongoing to determine the functional significance of muc and other identified differentially expressed genes in ovarian clear cell cancer. in addition, we are carrying out parallel microarray analyses in other ovarian tumor subtypes. background recent observations suggest a decreased incidence of neoplastic lesions in hiv infected individuals treated with highly active anti-retroviral therapy comprised of protease inhibitors, such as ritonavir. the polycomb group protein ezh is associated with aggressive human malignancies via transcriptional suppression of dna repair proteins. objective objective of the present study was to assess the antineoplastic impact of ritonavir on epithelial ovarian cancer (eoc) cell lines. methods eoc cell lines (mdah and skov- ) were treated with serial dilutions of ritonavir ( - mm) dissolved in dmso. normal diploid human fibroblasts served as controls. growth curves, apoptosis and cell cycle analysis were performed with cell counting kit- , annexin v and flow cytometry. signal transduction was studied with western blotting. dna double strand breaks (dsb) were induced with . mm etoposide treatment for hours. homologous recombination (hr) repair of dna damage was measured by assessment of rad foci formation in the nucleus of the cells as visualized by fluorescence microscopy according to previously published criteria. untreated eoc cells expressed higher levels of ezh and lower levels of rad and xrcc as compared to controls and in turn, had lower prevalence of rad repair foci formation in response to dsb. serial treatments of eoc cells with ritonavir resulted in a decrease in expression of ezh and an increase in expression of rad and xrcc when compared to untreated eoc cells. after induction of dsb, the rad repair foci formation was significantly more prevalent in eoc cells treated with ritonavir as compared to untreated eoc cells. in addition, ritonavir induced apoptosis in ovarian cancer cell lines by down-regulation of akt pathway and caused g cell cycle arrest mediated by down modulating levels of prb phosphorylation and depleting the cyclindependent kinase and . ritonavir effectively induces apoptosis, cell cycle arrest and improves repair of dna damage by hr in ovarian cancer cell lines. as impaired hr is a key event in causation and progression of neoplastic lesions, ritonavir may have a role in chemoprophylaxis and treatment of human malignancies. a rare case of ovarian cystic lymphangioma. tomer singer, tamer seckin, noa feldman, susan jormark, michael divon. department of obstetrics and gynecology, lenox hill hospital, n.y., ny, usa; department of pathology, lenox hill hospital, n.y., ny, usa. cystic lymphangioma (cl) is a rare, benign malformation of the lymphatic system whose exact etiology remains uncertain. cl may arise in different sites: the spleen, the mediastinum, the axillary region, the retroperitoneum, and the mesentery. retroperitoneal cl is extremely rare and its true incidence is unknown. the majority of cases are symptomatic during childhood. clinical presentation of adult cl is variable and may be misleading. typically, this is a slow-growing tumor and it remains asymptomatic for a long period of time. it is most often found incidentally during abdominal or pelvic imaging studies, surgeries or autopsies. total surgical removal of the lesions with microscopically clear margins is the best approach when it is possible. we report, for the first time, a case of cystic lymphangioma arising from the ovary in a post-menopausal woman and present the feasibility and the advantages of laparoscopic surgery, allowing accurate diagnosis, optimal treatment and minimal risk for the patient. lgsc) is a chemoresistant ovarian neoplasm that has been molecularly linked to low malignant potential tumor (lmp), which often behaves in a non-invasive fashion. micropapillary features within lmp (lmp-mp) are associated with increased invasive behavior. the aim of this study was to determine the differential gene expression of lmp, lmp-mp, and lgsc to identify genes involved in malignant transformation and carcinogenesis. methods: laser capture microdissection was used to isolate epithelial cells from snap-frozen lmp (n= ), lmp-mp (n= ) and lgsc (n= ). rna was extracted, amplified, reverse transcribed to cdna and hybridized to affymetrix u plus arrays. data was analyzed by significance analysis methods: medical records were reviewed for patients who underwent hysterectomy for all indications at wsu hospitals from / / - / / . pathology reports were reviewed to identify the incidence of adenomyosis. data obtained from medial records included: age, race, insurance, bmi, social history, medical history, and presenting symptoms. the correlation between adenomyosis and all the above factors was tested using the appropriate statistical methods. results: patients were included. adenomyosis was confirmed by pathology in patients, an incidence of . %. incidence was not significantly different among races after controlling for parity. . % in african americans, . % in caucasians, and . % in others. incidence was not statistically different between uninsured( . %), privately insured ( . %), and medicaid ( . %) patients. p=. . incidence of adenomyosis was not different between smokers ( . %) and nonsmokers ( . %). p= . . table i shows the correlation between adenomyosis and different risk factors. conclusion: adenomyosis was diagnosed in . % of hysterectomy specimens. race, socioeconomic status or social habits didn't affect its incidence. diabetes and endometrial cancer were negative risk factors for adenomyosis, whereas htn, hypothyroid, breast cancer, fibroids, polyps and endometriosis didn't affect its incidence. menorrhagia, dysmenorrhea, dyspareunia, and chronic pelvic pain but not metrorrhagia had a positive correlation with adenomyosis. there is a protective adipocytokine profile. we hypothesize that this finding may precede some ill-defined threshold of fat mass and/or insulin resistance after which adiponectin decreases. the objective: to correlate reproductive hormone production with menstrual bleeding patterns among women in the menopause transition. methods: a sub-cohort of the swan study consisting of women age - was studied. each woman collected daily first void urine samples for one complete menstrual cycle or days (whichever came first) once a year for years. urine was assayed for excreted levels of fsh, lh, estrogen metabolites and progesterone metabolites which were normalized for creatinine concentration. ovulation was detected by a validated algorithm. menstrual bleeding parameters were derived from daily calendars. correlations between bleeding characteristics, hormone concentrations, and other potential clinical predictors were analyzed using multivariate logistic regression models. results: the cohort was ethnically diverse with a median age of and with % in the early perimenopause at the start of the study. % of all cycles were anovulatory. short cycle intervals (< days) were associated with the early perimenopause (or . , ci . , . ) and with anovulation (or . , ci . , . ). long cycle intervals ( + days) were associated with late perimenopause (or . , ci . , . )and with anovulatory cycles (or . , ci . , . ). both short ( - days) and long ( + days) duration of menstrual bleeding were significantly associated with anovulation (or . and . , respectively). women with anovulatory cycles were less likely to report heavy menstrual bleeding than women with ovulatory cycles. menorrhagia was not associated with steroid hormone concentrations but was associated with obesity (or . , ci . , . ) and with the self-reported presence of fibroids (or . , ci . , . ). conclusions: among women in the menopause transition, abnormalities in timing of menstrual bleeding (cycle intervals or bleeding duration) have a hormonal basis and are frequently associated with anovulation. in contrast, abnormally heavy periods do not have a hormonal basis and are less likely following anovulatory cycles. heavy periods are associated with obesity and fibroids. to undetectable levels. the use is vaginal e is contraindicated, although these women have even higher rates of av. topical testosterone (tt) has successfully treated vulvar atrophy; testosterone receptors are also present in the vaginal epithelium. objective: assess the effect of tt on vaginal maturation index (mi) and relief of av symptoms. methods: postmenopausal women on aromatase inhibitor with symptomatic atrophic vaginitis were enrolled in prospective, irb approved study. estradiol (e) and testosterone (t) levels, av questionnaires (score - ; none to most severe symptoms of dryness, irritation, and dyspareunia), gynecologic exam, and vaginal smears (for ph and vaginal maturation index, mi, by meisels criteria) were performed at baseline and after month of daily treatment with mcg of tt. data was assessed by t test and fischer's exact test; significant p < . . results: e levels were undetectable at baseline and following treatment. t levels increased (mean +/-sem) from baseline ( +/- . ) to treatment ( +/- . ); the difference was not significant; p = . , although one patient had an appreciable rise in serum t level. two av symptoms improved significantly with tt use; comparing baseline to treatment scores: vaginal dryness ( . vs. . ; p = . ) and dyspareunia ( . vs. ; p = . saliva analysis is a convenient, non-invasive and rapid method for assessing estradiol (e ) levels. however, particularly in postmenopausal women, the low salivary e levels are often near or below the sensitivity of available assays, compromising both accuracy and precision. we present results using an extraction step prior to e assay, which concentrates the sample to increase sensitivity and removes potentially interfering substances. morning saliva samples were obtained from premenopausal (mid-luteal phase, n= , ) and postmenopausal women (n= , ) not taking hormones, and from postmenopausal women receiving oral conjugated equine estrogens (cenestin, n= ; premarin, n= ), oral micronized e (estrace, n= ; compounded e , n= ), transdermal e patches (climara, n= ; vivelle, n= ); or topical e cream (compounded e , n= ). e levels were determined by an automated enzyme immunoassay (eia) after solid phase extraction. the functional sensitivity of the assay was determined to be . pg/ml, compared with > pg/ml without extraction. . . . . . oral conjugated equine estrogens; oral e ; e patch; topical cream salivary e levels corresponded with the hormone dosage, suggesting a reliable assessment of unbound e levels with each formulation, dosage and type of estrogen therapy. extraction prior to eia in an automated assay dramatically increased precision and accuracy at low concentrations. omitting the extraction step may have contributed to poor serum versus saliva correlations in other studies. this method may therefore allow reliable monitoring of estrogen therapy without the need for expensive and inconvenient blood tests. the role of fibulin- in pelvic organ prolapse. david d rahn, jesus f acevedo, patrick w keller, lihua marmorstein, r ann word. ob-gyn, ut southwestern, dallas, tx, usa; visual sciences, univ arizona, tuscon, az, usa. objectives: fibulin- (fib- ) is crucial for normal elastic fibers in the protein showed a statistically significant reduction in its expression (p= . ). lox, loxl , and proteins were detected by immunohistochemistry in all three layers of vaginal skin biopsies: ( ) stratified squamous epithelium; ( ) the lamina propria and ( ) the muscularis layer from both patients with pop and controls. significantly, in both groups we detected a numerous macrophages scattered throughout the vaginal thickness which displayed a very strong immunostaining to loxl . patients with severe pop showed reduced expression of proteins regulating collagen and elastin biogenesis. our finding raises the possibility that failure of ecm homeostasis could underlie the etiology of pop in women. fibroblast proliferation is regulated by hoxa : molecular implications for pelvic organ prolapse. kathleen a connell, marsha k guess, richard bercik, hugh s taylor. obstetrics, gynecology reproductive sciences, yale university school of medicine, new haven, ct, usa. objectives: the integrity of the extracellular matrix (ecm) is maintained by a delicate balance between collagen synthesis and degradation. previously, we have demonstrated that hoxa is essential for the development of the uterosacral ligament in mice and regulates the expression of collagen type iii and mmp . we have also shown that hoxa is deficient in the uterosacral ligament of women with pelvic organ prolapse (pop) compared to women with normal support. the exact mechanisms by which hoxa regulates pelvic organ integrity and repair remains to be elucidated. the aim of this study was to determine the effect of hoxa expression on fibroblast proliferation, and its potential role in pop. methods: nih t cells, a murine fibroblast cell line, were seeded onto a six well plate ( x cells/well) and transfected with either a vector carrying a hoxa cdna or empty vector alone as a control. immunohistochemistry using bromodeoxyuridine (brdu) was performed to evaluate cell proliferation. cell division in the uterosacral ligament (usl) was also compared in women with and without pop. usl specimens were obtained at the time of hysterectomy for benign disease. immunohistochemistry was performed on paraffin embedded sections of the usl to evaluate expression of two mitotic markers, cyclin b and phospho-histone . results: constitutive expression of hoxa in murine fibroblasts resulted in significantly higher proliferation. cells transfected with hoxa had a mean brdu incorporation of . + . cells/ cells compared with . + . cells/ cells in controls (p= . ). in the usl obtained from women with and without pop, cell proliferation as determined by cyclin b and phospho-histone expression was not significantly different. cyclin b and phosphor-histone were expressed in comparable numbers of cells in both groups. conclusion: hoxa is necessary for usl development and promotes proliferation of adult fibroblasts. hoxa may have a similar function in vivo in usl, and may regulate fibroblast proliferation during growth and the acute phase response following trauma when fibroblasts are activated to proliferate and remodel the ecm. it is likely that hoxa mediated proliferation of usl fibroblasts contributes to the tensile strength and resilience of these structures and thereby prevents pop. supported by nichd wrhr: k hd - . connective tissue composition, in term of collagen i, iii and proteoglycans content, in support and nonsupport structures of women with uterine prolapse. elisabetta trabucco, gennaro acone, sara d'avino, marco torella, gennaro trezza, annamaria marenna, nicola colacurci, luigi cobellis. department of obstetrics and gynecology, second university of naples, naples, italy; loreto mare hospital, naples, italy. objective. connective tissue consists mainly of collagen and elastic fibers, glycoproteins and proteoglycans (pgs) and is considered an important factor of the support and nonsupport structures of the genitourinary region. it has been already demonstrated altered morphologic features in the pelvic support connective tissue in women with genital prolapse. however, analysis of nonsupport tissue may provide a more accurate reflection of body collagen. the objective of our study was compare the expression of collagen i, iii and four pgs (decorin, fibromodulin, lumican, biglycan), essential for synthesis and regular assembly and diameter of the collagen fibrils, in uterosacral ligaments and in a nonsupport tissue, the uterine cervix, between premenopausal women with uterine prolapse respect to age matched controls. we characterized uterosacral ligaments and uterine cervix of premenopausal women with uterine prolapse and controls. this immunohistochemical study was performed on paraffin-embedded sections. results. uterosacral ligaments of the prolapsed uteri are characterized by a higher expression of collagen iii, decorin, fibromodulin and byglican and a lower quantity of collagen i. no differences in the immunoreactivity of lumican between the two patients groups. the abnormalities of support connective tissue composition are not observed in the uterine cervix of patients with prolapse. conclusions. our results suggest an altered remodeling of connective tissue in the ligaments of premenopausal patients with prolapse, with a significant decrease in collagen i content and an increase in collagen iii and pgs expression . in the prolapse patients this abnormal collagen metabolism and organization, mainly related to the observed change in pgs expression, might affect significantly the tensile strength of the connective tissue and consequently the support that is provided by the suspensory apparatus to the uterus. the alterd remodeling of support tissues, not detectable in nonsupport tissues, may suggest a predominant role of local biomechanical stresses (childbirth, chronic straining) in the pathogenesis of prolapse respect to systemic connective tissue deficiency. objective: to achieve vaginal delivery with minimal maternal injury, vaginal smooth muscle (sm) contractility likely decreases. the objective of this study was to characterize changes in rat vaginal sm contractility in pregnancy that affords circumferential vaginal distension. methods: a tubular segment of the vagina of virgin, late pregnant , immediate and late post vaginal delivery rats were mounted in an organ bath between a force transducer and an adjustable support block. dose response curves to norepinephrine (ne) and potassium (k+) were used to assess contractility. relaxation capacity was determined in ne preconstricted vagina, using cumulative doses of sodium nitroprusside (snp). differences in active vs. passive length-tension curves were used to measure sm contractility relative to the vaginal wall forces. sm -actin levels were measured using quantitative confocal immunofluorescence. results: cumulative doses of ne induced a maximum constriction force of . ± mn/g in virgin vagina while no measurable force was generated in response to ne in late pregnant or postpartum vaginas. virgin vagina relaxed with cumulative doses of snp; no measurable relaxation response was observed from pregnant or postpartum animals. in the presence of the high dose k+ ( mm), virgin vagina generated the greatest contractile force ( . ± mn/g) vs. late pregnant vagina ( . ± . mn/g, p< . ) or immediate post partum vagina ( . ± mn/g, p= . ). four week postpartum k+ induced forces were similar to virgin levels ( . ± mn/g). sm force generation (difference in active vs. passive length tension curves at mm of displacement) was decreased in late pregnancy ( . ± mn/g) compared with virgin ( ± mn/g, p < . ) and week postpartum vagina ( ± mn/g, p < . ). the expression of sm -actin was lowest in late pregnancy ( ± . , p < . ) and immediate postpartum vagina ( ± . , p < . ) relative to virgin ( ± ) with a return to virgin levels week postpartum ( ± ). conclusions: vaginal sm contractility diminishes in pregnancy. the altered contractility is mirrored by a decrease in sm -actin protein expression. near complete recovery to pre-pregnancy levels occurs by weeks post partum. these functional and biochemical changes likely represent maternal adaptations designed to minimize trauma during passage of the fetus(es). background: diagnosis or exclusion of endometriosis usually requires laparoscopy and peritoneal biopsy. we have described a novel and consistent observation of small nerve fibers in the functional layer of eutopic endometrium in women with endometriosis (tokushige et al, ) . these nerve fibers are not present in women without endometriosis. this finding allows the possibility endometriosis in the nude-mouse and inhibited mmp- expression in human endometrial stroma. the present findings may lead to the development of novel treatments of endometriosis involving statins. supported by nih u hd . k-ras actived immunocompetent retrograde menstruation model of endometriosis. ching-wen cheng, , di licence, , cristin g print, , d stephen charnock-jones. , pathology, university of cambridge, cambridge, united kingdom; obstetric gynaecology, university of cambridge, cambridge; department of molecular medicine pathology, university of auckland, auckland, new zealand. objective: to establish a new murine model of endometriosis that mimics the retrograde menstruation theory using immuno-competent mice. method: ovariectomised donor female k-ras v +/-/cre +/+ /rosa r-lacz +/+ transgenic mice were treated sequentially with steroid hormones. to induce decidualization and activation and k-ras transgene, mg/kg b-nf dissolved in maize oil was injected into the uterine lumen. tissue degeneration mimicking menstruation was induced by hormone withdrawal. menstruating endometrial tissue was collected from donor mice hours after last hormone treatment, re-suspended in matrigel, and implanted subcutaneously in female c bl/ recipients. immunohistochemical and morphometric methods were used to characterize the endometriosis-like lesions. microarray analysis (illumina, n= in each group), was used to study the molecular changes in "menstruating" uteri following k-ras activation. result: simple transplantation of decidualised endometrial tissue into immunocompetent animals does not lead to endometriotic lesion development but using tissue with the genetic modification described here overcomes this. viable endometriosis-like lesions are visible days after implantation. these lesions are histologically similar to those seen in man with intact glands, functional blood vessels, leukocyte infiltration and collagen deposition. statistical analysis revealed that transcripts were differentially regulated in the ras activated and control tissue. gene ontology (go) analysis indicated that transcripts associated with epithelial cell function and differentiation were over represented within this gene set (chloride transport and epidermis development) as were those associated with the acute inflammatory response and neutrophil chemotaxis. we developed a new model of endometriosis using immunocompetent mice to mimic retrograde menstruation induced endometriosis. this permits for the first time, the ready use of transgenic and knock-out tools to investigate the cellular and molecular mechanisms underlying endometriosis. since the animals have an intact immune system it also allows the testing of therapeutic agents that modify the inflammatory response. stra is expressed and induced by progesterone in the endometrium and is absent in endometriosis. mary ellen pavone, serdar e bulun, scott s reierstad, joy innes, magdy p milad, you-hong cheng. obstetrics and gynecology, northwestern univeristy, chicago, il, usa. objective: retinoic acid (ra) plays important roles in development, growth and differentiation by regulating the expression of target genes. in the mouse endometrium, ra deficiency leads to hyperkeratinization, while high concentrations of retinoids promote secretory characteristics. this leads many to believe that ra mediates important actions of progesterone in the endometrium and may account for progesterone resistance in endometriosis. the mechanism for regulation of ra production by progesterone is unknown. moreover, the conversion from retinol to retinoic acid is not different between normal endometrium and endometriotic tissue. we hypothesize that retinol intake into cells rather than conversion of retinol to ra is the critical step that determines ra activity in the endometrium and endometriosis. stra , a widely expressed multitransmembrane domain protein and member of a group of "stimulated by retinoic acid" genes, has been identified as the retinol binding protein receptor. it is strongly expressed in adult mice in several tissues including the female genital tract. we hypothesize that ra activity in the endometrium may be regulated by stra . here we investigate the differential expression of stra in the endometrium and endometriosis. design: we studied primary stromal cells isolated from the eutopic endometrium of disease free women and walls of ovarian endometriomas from women with endometriosis with respect to stra expression and regulation by progesterone. materials and methods primary culture of eutopic endometrial and endometriotic stromal cells were treated with - m estradiol (e ), - m r , a progesterone agonist, or vehicle for hours. real-time pcr was employed to quantify stra mrna levels. we treated cells for hours and quantified protein levels by immunoblotting. results basal mrna of stra levels in endometrial cells (n= ), were > , fold higher than those in vehicle-treated endometriotic cells (n= , p<. ). in endometrial stromal cells (n= ), r stimulated stra mrna levels by . - fold. r induced stra protein levels in endometrial stromal cells (n= ). conclusions stra is highly expressed and regulated by progesterone in endometrial stromal cells, whereas it is practically undetectable in endometriotic cells. stra may mediate important actions of progesterone in endometrium. upregulation of aromatase expression in endometrial cells disseminated into the peritoneal cavity (pc) may influence their survival and persistence via local estrogen synthesis. the inducing factors for the upregulation of aromatase in endometriosis are not well defined, but increased expression of sf- has been suggested to play an important role. given that the aromatase substrate androstenedione (a ) is the predominant steroid in peritoneal fluid, we aimed to determine whether a has a role in the regulation of aromatase expression in human endometrium. we found that culture of primary endometrial stromal cells and explants with a ( - nm) for h significantly upregulated expression of aromatase mrna transcripts containing exon iia at their '-ends. moreover, in human endometrial surface epithelial cells (hes), dose-response studies with a ( - nm) revealed that nm a maximally upregulated expression of both aromatase and sf- . when tissue samples were evaluated from women with endometriosis and control endometrium, expression of aromatase mrna mirrored sf- . treatment of hes cells ( h) with tritiated a demonstrated its metabolism to estradiol (e ), testosterone (t), dihydrotestosterone (dht) and androstanediol (a-diol). although equimolar concentrations of a , t and e upregulated aromatase and sf- mrna expression in hes cells, the nonaromatizable androgens, dht and a-diol, had no effect. a positive feedback role of estrogen in aromatase upregulation was suggested by the finding that the estrogen receptor antagonist, ici , , markedly diminished aromatase and sf- mrna expression induced by a . finally, chromatin immunoprecipitation revealed that a significantly enhanced recruitment of sf- to its response element (- bp) upstream of cyp exon iia. collectively, our findings strongly suggest that exposure of endometrial cells within the pc to c -steroids may cause an acute upregulation of cyp gene expression through their aromatization to estrogens. thus, estrogen may play a critical positive feedback role in the pathogenesis of endometriosis. supported by nih r -dk . the hpa axis and depression/anxiety scores in chronic pelvic pain patients. b stegmann, b frank, j gemmill, g chrousos, m ballweg, p stratton. rbmb, nichd/nih, bethesda, md; som, wake forest university, winston-salem, nc; endometriosis association, milwaukee, wi. stress, pain, anxiety and depression adversely affect the hypothalamic-pituitaryadrenal (hpa) axis. we examined the influence of depression and anxiety on the hpa axis response to corticotropin-releasing hormone (crh) testing in women with and without chronic pelvic pain (cpp). methods: healthy women, aged - , with without cpp, with regular menses and off hormonal contraception were studied. none had pelvic infections, untreated depression, manic depression, fibromyalgia, or chronic fatigue syndrome. after ovine crh injection ( mcg/kg), serial blood samples (- , , + , + , + minutes) were obtained for acth and cortisol measurements. depression and anxiety were scored using the duke quality of life questionnaire. hpa response was abnormal if peak acth levels were > pg/ml without a rise in cortisol levels. subject groups were: no pain and normal acth response (npnr), pain and normal acth response (pnr), no pain with an abnormal acth response (npar) and pain with an abnormal acth response (par). student t-test was used for comparisons. results: women ( cpp, controls) had a mean age of . ± . years (range: - ). women responded normally ( pnr, npnr) and women responded abnormally ( par, npar). peak and absolute rise in acth were significantly higher in abnormal (a) vs normal (n) responders; (peak: . a vs . pg/ml n, p< . ; absolute: . a vs . pg/ml n, p= . ). there was a significant difference within groups: peak acth: . par vs . pg/ml pnr, p= . ; . npar vs . pg/ml npnr, p< . ; absolute acth: . par vs . pg/ml pnr, p= . , . npar vs . pg/ml npnr, p< . ). however, total cortisol level was not different between or within the groups ( . a vs . mcg/dl n, p= . ). mean depression score did not differ among cpp patients ( . par vs . pnr, p= . ), but differed among controls ( npar vs . npnr, p= . ). anxiety scores did not differ between or within groups ( . npar vs . npnr p = . ; par vs . pnr, p= . ). conclusions: chronic pelvic pain is associated with an abnormal hpa response, regardless of anxiety or depression symptoms. abnormal hpa responses in control women, however, appear to be influenced by depression. the mechanism and clinical significance of these findings should be explored. support: rbmb/nichd/nih and endometriosis association. objective: the eutopic endometrium in women with endometriosis demonstrates altered endometrial receptivity and altered gene expression. it is unknow if the endometrium is defective giving rise to a predisposition toward endometriosis or alternativly if the endometriosis causes the altered endometrial receptivity. here we created experimental endometriosis in a mouse model through allotransplantation of the uterus to the peritoneal cavity in immunocompetent mice and examined the expression of several markers of endometrial receptivity in the eutopic endometrium. materials and methods: the uterus of -week-old cd female mice was transected at cervicovaginal junction and each horn divided and transplantated into the abdomidnal cavity of eight cd mice. seven controls received sham surgery only. after weeks the uterus was removed, snap-frozen in trizol. total rna was extracted and cdna generated. quantitative real time rt-pcr using sybrgreen was performed and normalized to -actin. fold changes in normalized hoxa , hoxa , bteb , emx , igfbp , integrin - , total progesterone receptor (pr-ab) and progesterone receptor-b (pr-b) were assessed. all experiments were conducted in duplicate, repeated at least three times and compared using mann-whitney rank sum test. results: hoxa , hoxa , bteb , emx , and igfbp mrna expression showed . -fold (p= . ), . -fold (p< . ), . -fold (p= . ), . fold (p= . ), and . -fold (p< . ) decrease in the uterus of mice with experimental endometriosis compared with controls. pr-ab and pr-b mrna showed . -fold (p= . ) and . -fold (p= . ) increase in endometriosis group compared to controls, respectively, however the ratio of pr-b to pr-ab (b/ab) showed no significant change in both groups ( . vs. . , endometriosis vs. control, p> . ). there was no significant change in integrin - mrna expression ( . -fold, p> . ). conclusion: we demonstrate significant changes in multiple markers of endometrial receptivity in eutopic endometrium after induction of endometriosis. these findings suggest that origionally normal endometrium can develop defects with the creation of endometriosis; an abnormal endometrium is not a prerequisite for the development of endometriosis or associated abnormalities. this data also suggest the existance of a signal conduction pathway from endometriosis that alteres endometrial gene expression. endometrial expression patterns of relaxin and relaxin receptor mrna suggest involvement of relaxin in endometriosis. sara s morelli, felice petraglia, gerson weiss, stefano luisi, pasquale florio, jeff gardner, andrea wojtczuk, laura t goldsmith. obstetrics, gynecology and women's health, new jersey medical school, newark, nj, usa; pediatrics, obstetrics and reproductive medicine, university of siena, siena, italy. objective: in normal endometrium, relaxin is a potent inhibitor of matrix metalloproteinases, which have been implicated in the invasive process of endometriosis. we tested the hypothesis that relaxin plays a role in endometriosis by comparing expression of relaxin and its lgr receptor in normal human endometrium to levels in samples from patients with endometriosis. materials and methods: total rnas, extracted from ectopic (n= ) and eutopic (n= ) endometrium of patients with endometriosis and from endometrium of normal controls (n= ), were reverse transcribed into cdnas. real-time pcr was performed using primers previously shown to identify human lgr relaxin receptor mrna, h relaxin mrna, and beta-actin mrna, with sybr-green detection of double stranded dna products. the comparative c t method ( -ct ) determined relative lgr and relaxin mrna expression (normalized to beta-actin mrna expression). relaxin mrna was detectable in normal endometrium from of ( %) control patients. in contrast, relaxin mrna was detectable in a lower proportion of samples [ of ( . %)] from patients with endometriosis, among whom relaxin mrna was detectable in a lower proportion of ectopic samples [ of ( %)] than in eutopic samples [ of ( . %)]. lgr relaxin receptor mrna was detectable in all samples, with lower expression in endometriosis samples than in endometrium from normal controls. relaxin receptor lgr mrna levels vary with cycle phase, with greater expression in the secretory phase (sp) than in proliferative phase (pp): in normal controls . -fold higher levels in the sp than pp; and in endometriosis patients . -fold higher levels in the sp than pp. in both phases, lgr mrna levels were lower in ectopic samples than in either eutopic samples ( . -fold lower in pp and . -fold lower in sp) or endometrium from normal controls ( . -fold lower in pp and . -fold lower in sp). eutopic endometrium had similar lgr mrna expression to controls throughout the cycle. decreased local expression of relaxin and relaxin receptor mrna in ectopic endometrium from patients with endometriosis throughout the menstrual cycle suggests that relaxin may be protective against endometriosis. ovarian reserve after laparoscopic cystectomy of endometriotic ovarian cysts. shinichi hayasaka, takashi murakami. obsterics and gynecology, tohoku university, sendai, japan. objective laparoscopic ovarian cystectomy is generally recommended for endometriotic ovarian cysts because it has been associated with a higher pregnancy rate and a lower recurrent rate. however, residual ovarian function after laparoscopic cystectomy of endometriotic ovarian cysts has been questioned. in this study, we retrospectively evaluated ovarian response to hyperstimulation in women selected for ivf and icsi cycles who previously underwent laparoscopic cystectomy of a monolateral endometriotic ovarian cyst. methods a retrospective review of the patients between january and september was performed. the operated ovary and contralateral intact ovary were compared in terms of number of oocytes retrieved, number of follicles with a mean diameter > mm at the time of hcg administration. the patients who had recurrent endometriotic ovarian cysts were excluded. in total, ten patients were identified. the mean(±sd)number of oocytes retrieved was . ± . in the control ovary and . ± . in the previously operated ovary(p= . ). the mean(±sd)number of follicles with a mean diameter > mm was . ± . in the control ovary and . ± . in the previously operated ovary(p= . ). the age of patients and diameter of the operated ovary had little influence on the difference between the response of the control ovary and one of the previously operated ovary. laparoscopic cystectomy of endometriotic ovarian cysts is associated with a significant reduction in ovarian reserve. background pre-eclampsia (pe) is associated with systemic maternal endothelial dysfunction, which is thought to result from the presence of circulating factors released following placental damage. it is hypothesised that this occurs as a result of reduced oxygen (o ) delivery. some features of placental pathology seen in pe, such as increased apoptosis, can be reproduced by culture of placental explants in % o . metabolomics operates to study 'all' metabolites within a biological system. this strategy has previously identified differences in maternal plasma between normal pregnancies and those complicated by pe. in these experiments we used metabolomics to investigate differences in the metabolic profile of explants cultured in different o tensions. hypothesis the metabolic profile of placental villous explants is altered by culture in different o tensions. methods placental villous explants were cultured with either % serum (n= ) or in serum-free conditions (n= ) for h in %, % and % o . after h, conditioned culture medium and tissue were collected and snap frozen. tissue was homogenised in % ice cold methanol prior to analysis. samples were analysed using gas chromatography-mass spectroscopy (gc-ms). samples cultured at %, % and % o were compared to identify concentration differences in metabolites in conditioned cultured medium and tissue lysate. kruskal-wallis test was used for statistical analysis. due to the large number of metabolites identified, a p value of . was considered significant. results the mean intra-assay variability was . %. there were no differences in the metabolic profile of conditioned culture medium from % and % o . several metabolites differed in culture medium from % compared to % and % o including: deoxyribose, glycerol and threionic acid. these changes were present in both serum and serum-free conditions. using these metabolites alone, culture in % o could be completely discriminated from % and % o . deoxyribose was also elevated in tissue lysate from % o compared to % o . conclusion this metabolomic strategy can identify differences in metabolic profile in placental tissue cultured in % o . these novel compounds may provide further insight into pathophysiology of pe. objective a strategy of metabolic footprinting (the study of extracellular metabolites, which are related to intracellular metabolism) was used to detect a wide array of low molecular weight metabolites. metabolic profiles were employed to differentiate between placental explants cultured at different oxygen tensions. two separate studies were combined to validate initial observations. methods metabolic footprints of placental villous explants, obtained from uncomplicated pregnancies, (n= ) were cultured for h in %, % and % oxygen. conditioned culture medium was then collected and frozen, prior to analysis by uplc/ltq-orbitrap mass spectrometry in both negative and positive ion mode. samples cultured at %, % and % were compared to identify differences in the metabolic profiles. this procedure was repeated for different explants and the results compared across the studies in order to validate initial findings. approximately unique peaks were detected in both sample sets in negative ion mode and peaks in positive ion mode. a number of metabolites were identified as being significantly different using kruskal-wallis (pval< . ) under different oxygen tensions. some differences were seen between the results obtained from both runs due to separate batch preparation of the medium but good reproducibility was obtained for many metabolites between batches. metabolites of biological interest included amongst others -deoxyribose, valine, tyrosine and aspartic acid. the largest differences were those seen between o % and o %. comprehensive metabolic profiles were detected and employed to identify differences in the metabolic footprints of explants cultured under differing oxygen conditions. a number of biologically interesting metabolites were characterized. objective: brain weight and dna content were reduced in leptin deficient (lep ob /lep ob ) mice postnatally. leptin is detected in the sera and its receptors are expressed in the brain of the mouse fetus. we examined the role of leptin in the proliferation and differentiation of neural lineage cells in the mouse fetus. methods: the number of total cells in the cerebral cortex was compared between (lep ob /lep ob ) and wild type fetuses from embryonic day (e) to . the number of brdu positive cells was also compared on e and e . brdu uptake, the ratio of viable colony number to plated cell number, the proportion of multipotent, neuronal or glial progenitor colonies, and the expression levels of hes mrna were compared between leptin-and non-treated neurosphere cells. moreover, we examined stat phosphorylation by leptin stimulation with elisa to investigate whether or not jak/stat pathway transduces the leptin signal in the prenatal period as in the adult. results: lep ob /lep ob fetuses had reduced total cell numbers in the ventricular zone (vz) on e and e , and in the cortical plate on e . the number of brdu-positive cells was reduced in vz of e and e lep ob /lep ob fetuses. brdu uptake and the number of viable colonies were increased by days-leptin treatment in the neurosphere culture. the proportions of glial-restricted and multipotent precursor colonies were increased by leptin, whereas that of oligodendrocyte precursor colonies were decreased. hes mrna expression was enhanced in neurosphere cells by leptin. neither the amount of phosphorylated stat nor that of stat was increased in neurosphere cells by leptin stimulation. conclusion: our study suggests that leptin maintains the neural stem and glial-restricted precursor cells through upregulation of hes expression and increases the number of cerebrocortical cells in the mouse fetus, however, jak/stat pathway does not mediate the leptin signal in undifferentiated neural lineage cells. a vaginal wall, and > % of fib- knockout (ko) mice develop pelvic organ prolapse by weeks of age. in contrast, fib- and - deficiencies do not result in prolapse, and fib- kos die shortly after birth. herein, we evaluated the role of fib- in pelvic organ support. methods: two observers serially measured the degree of vaginal, perineal, and anal prolapse in fib- ko (fib -/-) and in fib -/-mice severity of prolapse was significantly related to age, but not parity, and the average age at diagnosis was wks. fib -/-animals with advanced prolapse had attenuated uterosacral ligaments and descent of the bladder and uterus caudal to the symphysis. pro-mmp ( -fold, p= . ), active mmp ( -fold, p= . ), and prommp ( -fold, p= . ) were increased in vaginal tissues from mice with gross prolapse compared with age-, strain-, and cycle-matched controls. this increase in protease activity, however, was also accompanied by increased expression of fib- and tropoelastin ( . -fold, p< . ). regardless of prolapse maternal morbidtties tf ards-n(%) ( ) acute ren~m f lure-n (%) ( ) car~tovascular ~ysfunrtion-n ("/o) ( ) hepatc fa..lure-n (%) dt sst'dlm atl:d inlfavascul..-coagul tipalhy-n(%) ( ) durallon of !cu suy (days. mean+sd) :t . hospital my (days.. me +sd) . condon, j. c., hardy, d. b., kovaric, k., and mendelson, c. r. ( ) mol endocrinol ( ), - . objective: innervation of the uterine cervix is important for the process of parturition (physiol beh : , ; j histochem cytochem : , jsgi : , ) . the hypogastric nerve is a major pathway that innervates the uterine cervix, yet its contribution to processes associated with cervical ripening and parturition is not known. the objective of this study was to determine the effect of hypogastric nerve transection on processes associated with cervical remodeling and parturition. methods: time-dated pregnant rats were sham-operated or the hypogastric nerve bilaterally transected just anterior to the inferior mesenteric ganglion on day post-breeding. live pups were born spontaneously by all rats at term on days - post-breeding. on the day of birth, the cervix was excised, postfixed overnight, sectioned, and processed to evaluate collagen content and structure (nih image j). sections were also processed by immunohistochemistry to assess cell nuclei density, the census of resident macrophages, and area of tissue that contained nerve fibers. results: hypogastric neurectomy did not affect cell nuclei density, the number of macrophages, or density of nerve fibers in the cervix. the failure of hypogastric nerve transection to affect indices of cervical remodeling is consistent with the finding that duration of pregnancy and timing of birth were not different in sham-operated and hypogastrectomized rats. conclusions: nerve fibers in the hypogastric nerve that innervate the lower uterus and cervix, including sympathetic and neuropeptidergic projections, are thus not essential for birth. these novel findings provide support for the contention that innervation of the uterine cervix other than through the hypogastric nerve contributes to processes associated with cervical ripening and parturition. receptor system in prostaglandin synthesis in pregnancy. eugenie r lumbers, , della m yates, carolyn m mitchell, jonathan j hirst, , tamas zakar. , school of health sciences, university of newcastle, newcastle, nsw, australia; mothers and babies research centre, hunter medical research institute, newcastle, nsw, australia; obstetrics and gynaecology, john hunter hospital, school of medical practice and public health, university of newcastle, newcastle, nsw, australia. the fetal membranes and decidua contain prorenin, which requires proteolytic activation. ngyuen (j clin invest. : ) described a renin/prorenin receptor that conformationally activates prorenin, so that it can form ang i from aogen. in addition, receptor-bound prorenin can stimulate intracellular pathways directly. prostaglandins (pgs) participate in the control of term and preterm labour, and renin can stimulate pg production by amnion and decidua when angiotensin's action is blocked mitchell placenta : ) . the prorenin receptor may mediate these effects. our aim was to find out if the prorenin receptor gene is expressed and colocalised with prorenin and prostaglandin h synthase- (pghs- ) in human placenta, amnion, chorion and decidua. we have also determined if there is any change in the expression of the prorenin and prorenin receptor genes with labor. placentae with attached membranes were collected after term birth either by elective caesarian section or by spontaneous labor, and prorenin, prorenin receptor and pghs- mrna levels were quantitated relative to beta-actin mrna by real-time rt-pcr in amnion, chorion, decidua and placenta. before labor, mean prorenin mrna levels were . times higher in decidua and . times higher in chorion and placenta than in amnion (p< . ). there were no significant changes with labor. proenin receptor mrna was expressed in all tissues. proenin receptor mrna levels in prelabor amnion, chorion and placenta were similar, while levels in decidua were % of those in amnion (p= . ). this low level of prorenin receptor mrna in decidua persisted after labor (p< . ). pghs- mrna expression was highest in amnion; in decidua and placenta it was only and % of amnion. similar differences were present after labor. we conclude that the decidua is the principal source of prorenin within the pregnant uterus, and all gestational tissues are targets for prorenin. decidual prorenin may affect pghs- expression in amnion through the prorenin receptor forming a maternal-fetal paracrine system that stimulates pg production at labor. the immuno-suppressive effects of progesterone on umbilical cord blood mononuclear cells and the effect of culture media estradiol content. nadav schwartz, xiangying xue, christine n metz. obstetrics and gynecology, nyu school of medicine, new york, ny, usa; feinstein institute for medical research, manhasset, ny, usa. objective: progesterone (p ) is known to supress the maternal immune response and similar effects have been seen with fetal cells. we sought to ascertain whether p action was modulated by the phenol red and/or estrogen content of the culture media. methods: umbilical cord blood mononuclear cells were isolated using a density gradient centrifugation. the cells were incubated with p ( - m) hour prior to overnight stimulation with lps. supernatants were assayed for tnf-using elisa. the following culture media were used: a)'red' media: rpmi+ % fbs, b)'yellow' media: phenol red-free rpmi+ % fbs, and c)'clear' media: phenol-free rpmi+ % dextran/charcoal treated fbs. finally, the 'clear' media experiments were repeated with estradiol add-back. results: p suppressed tnf production in all medias. tnf levels were suppressed to . % (p< . ) of controls using 'red' media and to . % (p< . ) in 'yellow' media. the degree of suppression was not as substantial using 'clear' media where tnf levels were . % (p< . ) of control. (fig ) adding estradiol to the 'clear' media had little or no effect on the degree of tnf suppression. (fig ) conclusions: progesterone exerts an immuno-suppressive effect on lpsstimulated fetal mononuclear cells which is more pronounced when using media containing untreated fetal bovine serum. the phenol-red/estradiol content of the culture media did not modulated the p effect. dextran/charcoal treatment of fbs appears to deplete the media of factors other than estradiol that are necessary for p to exert its full effects. culture conditions should be optimized when studying progesterone's effects on immune response. ovine fetal regional blood flow following prenatal dexamethasone (dex) at . gestation (g). antonine d van heesewijk, jan g nijhuis, susan l jenkins, peter w nathanielsz, mark j nijland. ob/gyn, academisch ziekenhuis maastricht, maastricht, netherlands; ob/gyn, cpnr, uthscsa, san antonio, tx, usa. background: pregnant women at risk for premature labor receive antenatal glucocorticoids (gc) to reduce neonatal morbidity and mortality. while fetal blood pressure (bp), heart rate and vascular endothelial and control fetuses (n= ). dispersed adrenal cortical cells ( . x cells/tube; in duplicate) were challenged with - m acth. samples were collected at time (baseline), , , , and min after acth treatment, and tissue and media samples were frozen for determination of cortisol, camp, and star. results: cortisol output (ng/ . x cells) was higher in the lth group compared to the control, (p< . ) at min ( . ± . vs. . ± . ), min ( . ± . vs. . ± . ), and min ( . ± . vs. . ± . ). peak camp levels (fmol/ . x cells) were observed at min but did not differ between control ( . ± . ) and lth ( . ± . ) adrenal cells. western analysis demonstrated that star protein expression was higher in the lth adrenal cortex compared to control (p< . ) at min ( . ± . vs. . ± . ), and at min ( . ± . vs. . ± . ), relative optical density units. conclusions: results from the present study taken together with those of previous in vivo studies suggest that the enhanced cortisol output in lth fetuses is the result of increased adrenal acth sensitivity. this enhanced sensitivity is not due to differences in camp generation. star, which is a key element involved in cholesterol transfer at the level of the mitochondrial membrane appears to play a key role in the enhanced cortisol response to acth in the lth group. (nih grants hd , hd and llu-nih imsd r gm - ). expression. hiroaki itoh, makoto kawamura, shigeo yura, haruta mogami, tsuyoshhi fujii, norimasa sagawa. obstetrics and gynecology, national hospital organization osaka national hospital, osaka, japan; gynecology and obstetrics, kyoto university graduate school of medicine, kyoto, japan; obstetrics and gynecology, mie university school of medicine, tsu, japan. objective: epidemiological evidences suggested that undernutrition in utero develops risk factors for adult cardiovascular disorders, such as blood pressure increase. the present study was designed to prove the hypothesis that maternal iso-caloric high protein diet alleviates blood pressure increase in the adult offspring by affecting placental beta-hydroxysteroid dehydrogenase type ( beta-hsd ) expression. methods: the % calorie restriction was applied to pregnant mice by using either standard protein diet (spd; % casein protein; spd-un) or high protein diet (hpd; % casein protein; spd-un). in some groups, these pregnant mice were sacrificed at . d.p.c.; then maternal and fetal plasma as well as placental tissues were corrected. while in other groups, systolic blood pressure was measured in the offspring at wks. fetal and maternal corticosterone levels were measured by elisa. the placental beta-hsd gene expression was measured by quantitative taqman pcr. results: systolic blood pressure in the spd-un offspring at weeks ( mmhg) was higher than that in spd-nn offspring ( . mmhg). by contrast, systolic blood pressure in the hpd-un offspring ( . mmhg) was similar to that in spd-nn offspring. maternal calorie restriction with spd and hpd caused similar elevation of maternal plasma corticosterone concentrations. by contrast, fetal plasma corticosterone levels in hpd-un offspring ( ng/ml) was lower than those in spd-un offspring ( ng/ml), indicating the amelioration of fetal exposure to high corticosterone by maternal hpd. the placental beta-hsd gene expression in the hpd-un was % higher than that in spd-un, suggesting that maternal hpd augmented placental beta-hsd gene expression in the placenta and probably facilitated the inactivation of maternal cortocsterone in the process of placental transfer to fetal circulation. conclusion: the preset study suggests that maternal high protein ingestion may elevate placental beta-hsd gene expression and ameliorate blood pressure increase in the adult offspring via modification of fetal exposure to maternal corticosterone. elevated cortisol levels at birth exert critical maturational effects through action at glucocorticoid receptors, gr. in contrast, the low cortisol concentrations in the preterm fetus, before the time of increased fetal cortisol secretion, are near to the kd for cortisol at the higher affinity mineralocorticoid receptor, mr. we hypothesized that endogenous cortisol in the fetus exerts physiologic actions at mr in tissues without appreciable cortisol-inactivating enzyme, hsd , including the fetal lung and brain. we therefore tested the effect of infusion of a mr-antagonist, ru (mra, . mg/h over h) into - day fetal sheep. we tested for effects on lung liquid production rate, lung liquid and plasma electrolytes, plasma acth and cortisol, and hematocrit at - h after start of the infusion. although there was no significant difference in the liquid production rate in fetuses infused with ru , the ratio of na + to k + in lung liquid was significantly greater in mra-treated fetuses than in the control fetuses ( . ± . vs . ± . ). plasma acth was significantly greater in the mra-treated fetuses than in control fetuses at h ( ± vs ± pg/ml); in the mra-treated fetuses, acth concentrations at h were greater than in the same fetuses at h ( ± pg/ml), wheras there was no increase in plasma acth in the control fetuses ( h: ± pg/ml). similarly, plasma cortisol concentrations at and h were greater in the mra infused fetuses than in control fetuses ( h: . ± . vs . ± . ng/ml), and cortisol increased significantly over time in the fetuses infused with mra, but not in control fetuses ( h, mra: . ± . , control: . ± . ng/ml). infusion of mra did not alter fetal plasma electrolyte, fetal blood pressure or fetal heart rate. however, fetal packed cell volume was significantly increased at - h of infusion of mra ( h: ± vs ± %) and fetal pco was significantly greater at h of infusion of mra as compared to control fetuses ( . ± . vs . ± . ). these results suggest that endogenous cortisol concentrations in the preterm fetus exert negative feedback control of acth via action at mr in the fetal brain, and play a role in regulation of fetal lung liquid composition and in fetal fluid balance. preparturient increases in fetal acth secretion are cyclooxygenase- (cox- ) dependent. charles e wood. dept. physiology and functional genomics, university of florida college of medicine, gainesville, fl, usa. maturation of the fetal hypothalamus-pituitary-adrenal axis is critical for the timely somatic development of the fetus and readiness for birth. in sheep, increased preparturient activity of the fetal hpa axis appears to be responsible for triggering parturition itself. this study was designed to test the hypothesis that prostaglandin generation, mediated by cox- in the fetal brain, is critically important for stimulation of the preparturient increase in fetal acth secretion. singleton fetal sheep were chronically catheterized with vascular, amniotic, and lateral cerebral ventricular catheters. nimesulide, a selective cox- inhibitor, was infused ( mg/day, n= ), and vehicle ( % dimethylsulfoxide, n= ) was infused. arterial blood samples were drawn from fetuses at hour intervals for measurement of plasma hormone concentrations and arterial blood gases. in the vehicle-treated fetuses, fetal plasma acth, pomc, and cortisol concentrations increased exponentially (p< . by anova) before spontaneous parturition at ± . days. in the nimesulide-treated fetuses, fetal plasma acth and pomc were constant and did not increase prior to parturition (p=ns by anova). in contrast, fetal plasma cortisol increased independent of acth (p< . by anova) and the fetuses were born spontaneously on ± . days gestation. the slight delay in spontaneous parturition in the nimesulide-treated fetuses was statistically significant (p< . by mantel-cox test). intracerebroventricular nimesulide infusion did not decrease fetal plasma concentrations of prostaglandin e , demonstrating that the action of the nimesulide was restricted to the fetal brain. fetal blood gases were normal in all of the fetuses, and there were no differences in blood gases between groups. we conclude that the spontaneous increase in fetal acth and pomc prior to parturition is cox- dependent. however, we also conclude that the increase in fetal plasma cortisol concentration can occur independent of increases in fetal acth, suggesting that the increase in cortisol can result from increases in adrenal sensitivity to acth. the results of this study demonstrate that the timing of parturition in the sheep is not dependent upon increased acth secretion, and the results suggest that parturition is regulated primarily by changes in adrenal sensitivity. expression of extracellular signal-regulated kinase / and p mitogen-antiphosphotyrosine. immunolocalization of inos was performed in the same tissues. hpmec were used to determine effect of sin- ( mm) on inos protein expression ( min, and h). results: inos protein was detected in microvascular endothelium, smooth muscle and syncytiotrophoblast of the placenta. inducible nos levels in placentas from severe preeclampsia were significantly decreased compared to normal (p< . ) but were not different from mild preeclampsia. aligning western blots of anti-phosphotyrosine and inos revealed a phosphorylated band corresponding to the molecular weight of inos. the proportion of tyrosine phosphorylated inos was reduced by % in severe preeclampsia compared with normotensive. preliminary data with ip for phosphotyrosine and crossblotting with inos confirmed this finding. sin- treatment decreased inos protein abundance at and h in hpmec. conclusions: our results demonstrate decreased tyrosine phosphorylation of inos in preeclamptic placenta. phosphorylation of tyrosine in inos has been reported to negatively regulate its activity. we therefore postulate that decreased phosphorylation of inos may be responsible for the increased catalytic activity of the enzyme that we have previously observed. the decreased levels of inos observed on sin- treatment may be due to nitration, an effect analogous to preeclampsia, where the presence of peroxynitrite has been well established. it remains to be seen if protein nitration has an effect on enzyme stability. objective: -isoprostane ( -iso), a prostaglandin-like compound formed in vivo, is a reliable measure of oxidative stress which occurs in response to many different stimuli, including infection. periodontal disease is a chronic oral infection associated with fetal growth restriction and preeclampsia. our objective was to determine if maternal periodontal disease is associated with oxidative stress as measured by -iso. methods: a secondary analysis was conducted using prospective data from the oral conditions and pregnancy study. a cohort of healthy women enrolled < weeks underwent oral health examination and serum sampling. maternal periodontal disease was categorized as healthy, mild, or moderate-severe by clinical criteria. maternal serum was analyzed for -iso by ultra-sensitive elisa. elevated -iso was defined by a value th %tile. maternal factors associated with elevated -iso were determined using chi-square or t-tests as appropriate. a logistic regression model was created to determine adjusted odds ratios ( th %ci) for elevated -iso. results: women had complete data for analysis. the median -iso level (iqr) was , ( - , pg/dl). using bivariate analysis, moderate-severe periodontal disease, non-white race, use of wic/food stamps, unmarried status, obesity, and lack of insurance were associated with elevated -iso. the logistic regression model for elevated -iso is shown below. adjusted or ( th ci)* mild periodontal disease . maternal periodontal disease and utilization of public assistance are associated with oxidative stress in pregnancy. the relationship between periodontal disease, social hardship, oxidative stress, and adverse pregnancy outcome remains to be determined. antioxidant therapy could represent novel therapy for the prevention of adverse pregnancy outcome. severe transient immunological thrombocytopenia in a preeclampsia patient whose bone marrow production of platelets had been restricted. toshihiro yoshimura. obstetrics and gynecology, ntt-west kyushu general hospital, kumamoto-city, kumamoto, japan. introduction: idiopathic myelofibrosis is a chronic myeloproliferative disorder in which clonal haemopoetic stem cell proliferation is accompanied by reactive fibrosis. case report: a -year-old primiparous woman was referred to our hospital for prenatal care after weeks of gestation. her medical history was significant for idiopathic myelofibrosis, and congenital agenesis of the spleen. the laboratory workup showed the patient's white blood cell count to be , / l; hemoglobin, . gm/dl; and platelet count, , / l. her bleeding time was normal ( min). until the th week, the patient's pregnancy was uneventful. during the th week, however, the patient's platelet count declined to , / l, when proteinuria became evident. her bleeding time was prolonged to min. the coagulation system was normal. by the th week, the patient's blood pressure was elevated to / mmhg, and her urinary protein excretion exceeded g/day. our initial diagnosis was thrombocytopenia due to bone marrow suppression. the patient had no history of platelet transfusion, but we expected it would increase the platelet count, particularly since in the absence of destruction by the spleen, the lifespan of the platelets would be prolonged. this was not the case, however. elective induction of labor was carried out after weeks. at the same time, the patient was transfused with units of platelets, but her platelet count remained unchanged ( , / l). it was then that we realized that immunological thrombocytopenia may be involved, and massive doses ( mg/kg) of gamma globulin were given intravenously for one day. thereafter, platelets ( units) were again transfused, this time raising the platelet count to , / l. cesarean section was promptly carried out under general anesthesia. we later found that the patient's serum platelet associated immunoglobulin (paigg) level was positive, though antiplatelet and antinuclear antibodies were negative. the postoperative course was uneventful. the maternal platelet count declined to the pretransfusion level within days after delivery, but gradually increased to the prepregnancy level by weeks. comment: this idiopathic myelofibrosis patient in whom bone marrow production of platelets had been severely restricted demonstrates that immunological destruction may play a major role in the development of thrombocytopenia in preeclampsia. early l-arginine therapy improves notably the fetal growth in preeclamptic women. a randomized controlled trial. keisy lopez-molina, juan c gonzalez-altamirano, julio e valdivia-silva. , oncoinmunología y biología vascular, facultad de medicina, universidad nacional san agustín, arequipa, peru; cardiología y cirugía de tórax, hospital nacional case essalud, arequipa, peru; inmunología, instituto de investigaciones biomédicas, méxico, distrito federal, mexico. objective: to assess the benefit of early administration to l-arginine, the precursor to nitric oxide, on fetal growth. methods: one hundred women with preeclampsia were randomized to receive either l-arginine or placebo until day postpartum. live singleton infants were born after preeclamptic pregnancies and compared those with other control infants. birth size was expressed as the ratio between observed and expected birth weights, and infants smaller than two standard deviations from expected birth weights were classified as small for gestational age (sga). all the women had neither previous precedents of the preeclampsia nor other factors that they cause sga. results: no significant differences existed between the groups with preeclampsia before randomization. preeclampsia was associated with a % ( % confidence interval [ci] %, %) reduction in birth weight. women with hellp syndrome had to leave the study. the risk of sga was three times higher (relative risk [rr] = . ; % ci . , . ) in infants born after preeclampsia without l-arginine therapy than in control pregnancies, and two times higher (relative risk [rr] = . ; % ci . , . ). in infants born after preeclampsia with l-arginine therapy. conclusion: fetal growth improve markedly with l-arginine therapy in women with preeclampsia. introduction: although the pathogenesis of severe preeclampsia (pe) and intrauterine growth restriction (iugr) is poorly defined, inadequate remodeling of uterine spiral arties may promote reperfusion injury leading to focal infarction and reduced nutrient flow between mother and fetus. our goal was to determine whether an intravillous inflammatory cytokine cascade was associated with pe and iugr. methods: immunohistochemistry (ihc) examined il- and il- expression in preterm placentas with severe pe+iugr, and idiopathic preterm controls (ptc) with no evidence of clinical or histological chorioamnionitis. cultures of fibroblasts (fibs) and syncytiotrophoblasts (scts) from term placentas (n= ) were treated with il- and cytokine levels in conditioned media were determined using elisa or multiplex array. results were analyzed by student's t test or anova. results: the gestational age at delivery was not significantly different in pe+iugr and ptc groups ( . ± . vs . ± . wks). ihc of pe+iugr samples revealed intense villus core staining of il- adjacent to infarcts. villi distal to infarcts stained with a lower intensity. in contrast, staining was virtually undetectable in ptc. the pattern of il- staining was nearly identical in pe+iugr and ptc groups, was localized to the syncytium, and did not differ with respect to distance from infarct. to identify cellular targets of il- action, primary cultures of fibs and scts were incubated for h in serum-free medium ± ng/ml il- . by elisa we observed that il- treatment of fibs increased il- levels from ± to ± pg/ g protein (p< . ). similarly, multiplex array revealed that levels of il- , il- , and il- were induced -, -, and -fold, respectively in fibs. the presence of ng/ml il- receptor antagonist reduced the il- -mediated increase in il- levels ± % (p< . ), indicating that this response was mediated through il- receptor. in marked contrast, il- treatment did not significantly affect levels of il- , il- , il- or il- in scts, indicating that this response was cell type-specific. conclusions: these results indicate that increased expression of il- in the placental villus core in pe and iugr may promote an inflammatory cascade in fibs at this site leading to focal infarction and reduced flow of nutrients to the fetus. introduction: in human pregnancy, decreased responsiveness to angiotensin ii (angii) starts in week , promoting an expanded vascular bed. at the same time levels of the vasodilatory hemopexin increases . during pre-eclampsia the vascular bed is contracted and the responsiveness upon angii persists. this may be due to the increased levels of extra cellular atp, a natural inhibitor of hemopexin . in the present study we tested whether extra cellular atp is toxic in the pregnant condition. methods: pregnant rats were infused with either atp ( g/kg bw; n= ) or saline (n= ) on day of pregnancy (permanent jugular vein cannula/ hr infusion). non-pregnant rats (n= ) were infused with atp identically. one day before and , , days after infusion, hr urine and blood samples (wbc count and hemopexin activity) were collected. seven days after the infusion, rats were sacrificed and kidney tissue processed for immunohistology. results: urinary albumin excretion was increased in pregnant atp infused rats only (fig ) . wbc were also increased only in pregnant rats infused with atp (days and vs pre-infusion value). in pregnant atp infused rats intraglomerular influx of monocytes was increased, which correlated with urinary albumin excretion on the same day (r = . ). staining of glomeruli for the angii receptor (at- r) showed decreased at- r expression in control pregnant rats as compared to non-pregnant rats, while at- r expression in atp infused pregnant rats was increased as compared to control pregnant rats. hemopexin activity was increased on days and in control pregnant rats as compared to all other groups. discussion: these data support the notion that atp is toxic exclusively in the pregnant condition. it may be suggested that atp induced an inflammatory response, although the exact mechanism by which atp induced its effects needs further investigation. background: hepatocyte growth factor (hgf) is a multifunctional cytokine that is known to promote division, motility, invasion and morphogenesis of a wide range of cell types and to inhibit apoptosis. the effects of hgf are mediated through its interaction with the tyrosine kinase receptor c-met. in pregnancy hgf/met system is involved in the physiologic growth and development of the feto-placental unit. hgf/met effects are counteracted by transforming growth factor- (tgf- ), that is known to promote progressive fibrosis in human tissues. moreover tgf- plays a major role in trophoblast growth and differentiation. tgf- inhibits hgf expression as well as hgf inhibits tgf- expression. an understanding of the mechanisms regulating placental balance of these growth factors may provide insights into the processes that occur in complications of pregnancy, such as preeclampsia (pe) and fetal growth restriction (fgr). objective: to verify the hypothesis that hgf, c-met and tgf- are differently expressed in tissues of normal and pe placentas. methods: we studied placentas from pregnancies complicated by pe ( with normal fetal growth and with fgr) and placentas from normal pregnancies. from each placenta random samples were excised and rna was extracted; quantitative real-time rt-pcr analysis was used to investigate mrna expression of hgf, c-met and tgf- in pe (with or without fgr) and in normal placentas. results: gestational age, neonatal weight and placental weight were, as expected, lower in pe groups. the mrna expressions of the three molecules are higher in pe than in normal placentas, but the difference is statistically significant only for c-met. the higher values are mainly due to the increase in the pe group without fgr for c-met and tgf- and the increase in the pe-fgr group for hgf. conclusion: increased levels of expression of hgf/met system in pathological placentas could be explained as an attempt to repair placental damages; nevertheless placental regeneration could be inhibited by the increase of tgf- , that promote fibrosis. placental expression of hgf, c-met and tgf- is increased in all pe placentas, but particularly in placentas of pe with normal fetal growth, where placental tissue is probably less compromised. obesity is a risk factor for preeclampsia (pe), but the reason for this risk is unknown. previously, we found that neutrophils infiltrated into the vasculature of pe women released myeloperoxidase (mpo) and matrix metalloproteinase (mmp ), products that can cause oxidative stress and vascular dysfunction. if neutrophils infiltrate the vasculature of obese women and release mpo and/or mmp , this may help explain why they are at risk of developing pe. hypothesis: systemic vascular tissue of obese women will have a significant presence of mpo and mmp as a result of neutrophil infiltration. methods: subcutaneous fat, which is highly vascularized, was obtained at abdominal surgery from normal weight, overweight and obese women. formalin fixed, paraffin embedded μm sections of fat biopsies were stained using immunohistochemistry with specific antibodies for mpo and mmp . data were evaluated for intensity of vessel staining by visual score ( - ), density of staining using image analysis software, and % vessels with neutrophil staining, liberated from serum-free placental villous explant cultures from normal and pe pregnancies on human endothelial cells, and identified candidate mediators of their differential effects on metabolism and behaviour. methods: term placental villous tissue from normal (n= ) or pe (n= ) pregnancies were explanted for days at % oxygen. conditioned h medium (day - ) was applied to human umbilical vein endothelial cells (huvecs). an angiogenesis assay was conducted in which tubule length and number were measured by morphometric imaging following seeding on % matrigel. the effect of explant conditioned medium on endothelial cell metabolism was determined by mtt and bioluminescent atp assay. the release of vasoactive metabolites (nitrite, endothelin- , prostacyclin) from huvecs exposed to this medium was also measured. finally, a luminex bead array was used to screen the explant media for a panel of chemokines/cytokines. results: in the angiogenesis assay, tubule length (p< . , mann-whitney u test) and number (p< . ) were significantly decreased in pe compared to normal pregnancy medium. there was no change in mtt reduction, but endothelial cellular atp levels were also significantly reduced following exposure to pe explant medium (p< . ). both normal and pe-derived medium stimulated huvecs to produce vasoactive metabolites. the following cytokines were detectable in the explant media: interleukin (il)- , il- , gro-, monocyte chemotactic protein- and macrophage inflammatory protein- (mip- ). higher levels of both il- and gro-were present in the normal medium compared to pe (both p< . ). mip- was present in pe conditioned media but undetectable in media generated from normal placental explants. conclusions: these results suggest that pre-eclampsia stimulates the release of soluble factors from the placenta which have adverse effects on endothelial cell angiogenic potential and metabolism. altered levels of several cytokines were detected in the explant medium, and the effects of these on endothelial cell function are currently being addressed. yang gu, davis f lewis, yuping wang. obstetrics and gynecology, lsuhsc-shreveport, shreveport, la, usa. objective: placentas from women with preeclampsia (pe) release more chymotrypsin-like protease (clp). the purpose of this study was to determine if placenta-derived clp was responsible for altering endothelial (ec) barrier function in pe. approaches: endothelial junctional protein complex ( -catenin/ve-cadherin/ p ) expression and junctional protein ve-cadherin distribution were examined in ecs treated with pe placental conditioned medium. methods: ) confluent ecs were treated with pe placental conditioned medium (cm). the association of ec junctional protein complex ve-cadherin/catenin/p was examined by a combined immuno-precipitation (ip) and immuno-blotting (ib) assay, in which total cellular protein was immunoprecipitated with monoclonal antibody against -catenin and then immunoblotted with antibodies against ve-cadherin or p- . ) confluent ecs grown on cover slips were exposed to pe placental cm with or without depletion of chymotrypsin. ec junction protein ve-cadherin distribution was examined by fluorescent microscopy. results: ) ve-cadherin and p are expressed in control ecs but not in ecs exposed to pe cm, which indicate that the junctional protein complex vecadherin/ -catenin/ p is lost in ecs exposed to pe cm. ) ecs exposed to pe placental cm showed a discontinuous distribution and reduced expression for ve-cadherin at cell contact areas. the zipper like structure was lost and cleft was formed at cell-cell contacts. these observations indicate that the homotypic cell-cell adhesion and junction protein intracellular partner complex are disrupted. these disruptive phenomena in cells treated with pe conditioned medium were not present in control cells and in cells treated with cm after depletion of chymotrypsin. conclusion: clp released by the placenta could be a candidate agent that is responsible for disrupting ec integrity and inducing endothelial permeability in pe. (supported by nih grants hl and hd ). introduction: chronic pelvic pain (cpp) syndromes such as endometriosis, irritable bowel syndrome, and interstitial cystitis are associated with visceral hyperalgesia, and often coexist in the same patient. one possible explanation for this phenomenon is viscero-visceral cross-sensitization in which increased nociceptive input from an inflamed pelvic organ sensitizes neurons that receive convergent input from an unaffected organ to the same dorsal root ganglion (drg). nociception induces upregulation of perk and substance p. the purpose of this study was to determine, in a rodent model, whether uterine inflammation increased the number of perk-and sp-positive neurons in sensory ganglia innervating both uterus and colon. methods: colonic and uterine drgs were retrogradely labeled with fluorescent tracer dyes micro-injected into the colon and uterus. ganglia were harvested, cryoprotected and cut for fluorescent microscopy. results:approximately % neurons were colon-specific and % were uterus-specific. among these uterus-or colon-specific neurons, up to % of labeled drg neurons in the l -s levels innervated both visceral organs. uterine inflammation increased the number of perk and sp-immunoreactive neurons in drg neurons innervating colon, uterus, and those innervating both organs. furthermore, this effect was specific as non-retrograde labeled drg neurons did not manifest a significant increase in perk or sp immunoreactive cells. conclusions: localized uterine inflammation leads to increased expression of sp and perk in uterine afferents as well as dichotomizing afferents innervating both uterus and colon, suggesting that viscero-visceral convergence is present at the level of drg primary afferent cell bodies. this visceral sensory integration may underlie the co-morbidity of female pelvic pain disorders and may provide basic information regarding the etiology of cpp syndromes. purpose: success rates of medical and surgical modalities for the treatment of severe fecal incontinence due to obstetric trauma are modest. we tested whether the intrasphincteric injection of autologous myoblasts is clinically safe and feasible for postobstetric fecal incontinence. methods: using ultrasound guidance a suspension of autologous myoblasts was injected in the anal sphincter muscle complex in three women with severe postobstetric fecal incontinence. main outcome measures were safety, feasibility and the wexner grading score. secondary outcome measures were incontinence episodes, rockwood fecal incontinenece quality of life scale, external anal sphincter morphology and anal pressure values. results: all procurement procedures and injections were performed without complications; there were no clinically or laboratory signs of infection or inflammation. three months post myoblast injection, wexner continence grading scores and rockwood incontinence scales were markedly improved and incontinence episodes reduced in all three patients. no change could be observed in sonographic anal sphincter morphology. mean anal squeeze pressure improved. conclusion: autologous myoblast injection for fecal incontinence is clinically feasible and safe; further studies will evaluate the efficacy of this approach. objective: to evaluate whether hysterectomy is associated with a change in postoperative bmi. methods: a retrospective cohort study was conducted of hysterectomies performed for benign indications from june to june . institutional review board approval was obtained. the data were collected by a medical student blinded to the hypothesis. basic demographic data were recorded. body mass index (bmi) was determined at time points: time (immediately postoperatively), time ( weeks to months postoperatively), time ( months to year postoperatively) and time ( to . years postoperatively). one-way anova was performed using ncss statistical software. a bonferroni multiple comparison test (p< . ) was used to compare median changes in bmi from baseline. the starting bmi served as the control group. results: there was a statistically significant increase in bmi at time compared to baseline in all women ( . to . ). when sorted was measured by matrigel invasion assay. small interference rna targeting vegfr- were predesigned by ambion inc. and cells were transfected using ambion siport neofx according to the optimized protocol. results: of the four receptors (vegfr- , vegfr- , nrp- and nrp- ), vegfr- was the predominant receptor that expressed in the more invasive cell lines (dov , skov and r ). lpa, at - m, significantly induced vegfr- expression in dov and skov cells (p< . ), without significantly affecting vegfr- expression. lpa ( - m) also significantly induced the expression of vegf and vegf (p< . ) in dov and skov cells. by small interference rna (sirna) transfection, we demonstrated that inhibition of vegfr- expression could significantly decrease dov cells' invasiveness (p< . ) and moderately decrease skov cells' invasiveness. moreover, silencing of vegfr- by sirna significantly suppressed lpa-induced dov and skov invasion. conclusion: these results suggest that knocking down vegfr- expression by rnai may be an effective strategy to inhibit lpa-induced ovarian cancer metastasis. cancer. fengqiang wang, david fishman. obstetrics and gynecology, new york university school of medicine, new york, ny, usa. objectives: expression of matrix metalloproteinases, such as mmp- and mmp- , has implicated in epithelial ovarian cancer (eoc) invasion and metastasis. osteopontin (opn) was also expressed in various human cancers and associated with tumor progression, invasion and metastasis. in the present study, we examined the correlation of mmp- , mmp- and osteopontin expression with tumor stage in ovarian tumor tissues and normal ovaries using a commercial tissue scan array. methods: complimentary dna (cdna) from normal ovaries (n = ) and ovarian tumors (n = ) of different stages (stage i, n = ; stage ii, n = ; stage iii, n = ; stage iv, n = ) was amplified by real time pcr using gene specific primer pairs for mmp- , mmp- , and osteopontin. gapdh was also amplified as a reference control. the expression level of mmp- , mmp- and osteopontin was calculated as relative expression normalized to that of gapdh in each tissue sample, and the expression in sample that has the lowest target gene expression was arbitrarily set as . the average expression of mmp- in ovarian tumor tissues ( ± ) is fold of that in normal ovaries ( ± , p = . ). using an arbitrarily set standard, of normal ovaries ( . %) has elevated mmp- expression; in ovarian tumor tissues, the percentage is . % ( of ), significantly higher than in normal tissues (p = . ). in early stage tumors (stage i/ii, n = ), of them have elevated mmp- expression ( . %, p = . vs. normal ovaries), whereh the average expression of mmp- is fold of that in normal ovaries (p = . ) and . fold of that in late stage tumors (stage iii/iv, n = ). the mmp- expression in ovarian tumors (n = , ± ) is fold of that in normal ovaries (n = ), however, the difference is not significant (p > . ) due to the extremely high expression of mmp- in two tumor tissues. osteopontin expression in ovarian tumor tissues is . fold of that in normal ovarian tissues ( ± . , n= vs. . ± . , n = , p< . ). in early stage (i/ii) ovarian tumors, osteopontin expression is . fold of that in normal ovaries, while in late stage (iii/iv) ovarian tumors, its expression is . fold of that in normal ovaries (p< . ), suggesting an increase trend associated with disease stages. conclusions: our results suggest that mmp- , mmp- and osteopontin alone or combined may have clinical value for ovarian cancer detection. objectives: -tubulin acetylation has been proposed to control the dynamic nature of microtubule stability. acetylated -tubulin plays a role in regulating microtubule functions in mitosis and cell migration. here, we sought to identify the relationship between post-translational -tubulin acetylation and the expression of epithelial cell adhesion molecules (ep-cam) after exposure to microtubule interacting agents in ovarian cancer cells. methods: epithelial ovarian cancer cell line, hey was treated with microtubule stabilizing agents (taxol, epothilone b and discodermolide), microtubule-destabilizing agent (vinblastine), hdac inhibitor trichostatin a (tsa), anti-metabolite fluorouracil ( fu), or alkalyting agents (cisplatin and carboplatin). cells were separately treated with either ic or -fold ic of each agent, and incubated at °c for h, h and h. acetylation oftubulin and pan--tubulin were evaluated by western blot analysis followed by protein quantification. cell surface ep-cam expression was examined by flow cytometry. results: increased acetylation of -tubulin was seen with taxol, epothilone b, discodermolide, vinblastine and tsa. -tubulin acetylation was time and dose dependent. the highest level of -tubulin acetylation ( . -fold) was observed with vinblastine at -fold ic after h. exposure to microtubule interacting agents and tsa resulted in increased cell surface expression of ep-cam in a time and dose dependent manner. the highest level of cell surface ep-cam expression ( . fold) was observed with -fold ic of vinblastine at h. the increase in acetylated -tubulin and ep-cam expression was clearly detectable after h treatment. this data reveals a similar dose and time dependent increases between the acetylation of -tubulin and the increase of ep-cam expression. conclusions: these data demonstrate the promotion of -tubulin acetylation and cell surface ep-cam expression by a microtubule destabilizing agent and by microtubule stabilizing agents. interestingly, vinblastine induces the highest -tubulin acetylation and ep-cam expression. acetylation of alpha-tubulin may be associated with redistribution of cell surface antigens in ovarian cancer cells. objective: epothilone b (epob) is similar to taxol in its ability to enhance tubulin polymerization and to stabilize microtubules. epob is currently being evaluated as an antitumor agent and is in phase iii clinical trials. the tumor suppressor gene, p plays an important role in the induction of apoptosis by a variety of anticancer drugs. p mitogen-activated protein kinase is activated by a wide array of stress stimuli including chemotherapeutic agents and promotes apoptosis. since both p and p activation induces apoptosis, we hoped to evaluate the relationship between p , p-p and parp cleavage, an early indicator of apoptosis, in ovarian cancer cells after treatment with epob. methods: hey cells were treated with epob ( to nm) for h. parp cleavage product p as well as p-p , p , phospho-p (ser- ), p and survivin were determined by western blot analysis. a wild type ovarian cancer cell line hey, was treated with or without m sb , a specific inhibitor of p-p , followed by treatment with epob ( or nm) for h. lysates were prepared and western blot analysis was performed with polyclonal phospho-p and anti-phospho-p antibodies. results: epob induces p activation and apoptosis demonstrated by increased parp cleavage product. time course studies indicated that phosphorylation of p precedes phosphorylation of p in hey cells. the expression of p targeted gene, p (survivin) were differentially expressed depending on the dose of epob and the duration of drug exposure. pretreatment with specific inhibitor of p markedly inhibited the p phosphorylation at serine . conclusions: nm epob (a concentration that triggered mitotic arrest) causes a decrease in p expression and an increase in survivin expression. epob induces parp cleavage. p inhibitor sb inhibits epo-b -induced p phosphorylation. these results suggest that phosphorylation of p may lead to p activation and these signaling events may be related to epo-b induced cell death in ovarian cells. conclusions: nf-b has been shown to control the expression and function of anti-apoptotic proteins and pro-inflammatory cytokines. in the present study we demonstrated that specific inhibition of nf-b by erib reversed the anti-apoptotic state of chemoresistant ovarian cancer cells, therefore may provide a new potential venue for the treatment of ovarian cancer patients. expression in cervical cancer. madhu chauhan, chandra yallampalli. gynecology, university of texas medical branch, galveston, tx, usa. background: intermedin (imd)/adrenomedullin is a ct/cgrp family peptide. imd is expressed in a variety of tissues such as pituitary, stomach, placenta, uterus, and ovary .we have shown that imd plays a role in a variety of physiological functions, including vasodilatation and fetoplacental growth regulation. further we have data indicating an angiogenic activity of imd in first trimester trophoblast cells. we hypothesize that imd is expressed in cervix and may have a role in the pathology of cervical cancer objective: ) to analyze expression of imd mrna in human cervix, rat cervix from non-pregnant and pregnant rats; ) to assess the differences in the expression of imd in normal human cervix and cervical carcinoma tissues and ) to analyze the effect of imd on the expression of tnf-alpha and il- beta in human epithelial cervical carcinoma cells (hela). methods: groups of sprague-dawley, non-pregnant and pregnant rats on day of gestation were used in this study. cervical tissues were collected from the non-pregnant and pregnant rats, women undergoing hysterectomy and from women diagnosed with cervical carcinoma. total rna was extracted using trizol method. hela cells were grown to % confluency in rpmi medium supplemented with % fbs. the cells were starved in %fbs for hrs followed by treatment with imd ( - m) in presence or absence of imd antagonist, imda ( - m). cells were further incubated for hrs and total rna was extracted using trizol reagent. rna was treated with dnase before performing the reverse transcriptase polymerase chain reaction (rt-pcr). the rt-pcr data was normalized to that of s. results: ) imd mrna is expressed in rat and human cervix and in hela cells. ) expression of imd is elevated in pregnant rat cervix as compared to the non-pregnant. ) imd has no effect on tnf-alpha expression in hela cells treated with imd but caused a decline in the expression of il- beta mrna and, ) expression of imd mrna is significantly elevated (p< . ) in cervical carcinoma as compared to the normal cervix. conclusion: imd is expressed in both rat and human cervix and is elevated in pregnant rat suggesting that it may have a role in cervical function during pregnancy in rat. in addition we demonstrate that imd is involved in the pathology of cervical carcinoma and thus may have a clinical significance in the pathology of cervical cancer. objective: there is minimal information about the impact of treatment delays or dose reductions on chemotherapeutic treatment responses and overall outcomes in ovarian cancer patients. the primary objective of this study was to quantify the impact of treatment delays and dose reductions in an in vivo xenograft ovarian cancer model and to evaluate if the growth factors could improve overall survival. methods: heya- and skov -ip xenograft mouse models to determine the effect of treatment delays or dose reductions on tumor response. results: the results indicated that full dose of paclitaxel ( mg/kg) and carboplatin ( mg/kg) delivered on timeevery daysachieved better tumor response in both aggressive (heya- ) and metastatic (skov -ip ) human ovarian tumors compared to the non-treatment and vehicle groups. in heya- mice, paclitaxel/carboplatin alone and paclitaxel/carboplatin followed by growth factor support agents including pegfilgrastim ( μg/kg) and darbepoetin ( μg/kg) improved overall survival rate. growth factors also improved the tolerability in heya- model. for skov -ip mice, the treatment delays resulted in a significant reduce in overall survival time compared to full dose, on time treatment (p< . ). for the dose reduction group, there was a significant different survival comparing to full dose, on time treatment (p< . ). conclusion: treatment delays had a negative impact on tumor response and overall survival compare with treatment controls. in addition, use of growth factor agents also improved treatment response and tolerability of chemotherapy and ultimately overall survival. - ) . median age at recurrence was ( - ), and median interval to recurrence . months ( - ). ( %) patients died of recurrent disease and ( %) of other causes. site of recurrence and was local in , groin in and distant in . of the local recurrences were managed with wide local excision (wle) radical surgery ( radical excisions with skin flaps, posterior exenterations, anterior exenteration, total exenteration), wle and radiotherapy (rt)/chemort, chemo/chemort/rt, and palliation. groin recurrences were managed surgically ( adjuvant rt), rt alone, chemotherapy alone, and palliation. patients with distant metastases were managed surgically, with rt/chemo/chemort, and palliation. overall median survival after recurrence was months. median survival (months) by site of recurrence was: local , groin , distant , groin or distant . there was a significant difference in survival in local vs groin node recurrence (p< . ), local vs groin and distant (p< . ), and groin node vs distant (p . ). and years after recurrence survival rates were: local % and %, groin % and % distant , . conclusion patients with vscc remain at risk of recurrent disease therefore long term follow up these patients is essential. patients with local recurrence often have a good prognosis. outcomes for groin and distant recurrences are poor, but a proportion of those with groin recurrences can be salvaged. therefore early identification of local and groin recurrences is essential for improving outcomes in recurrent vscc particularly in cases with more conservative management of primary disease. introduction: endocrine disrupting chemicals (edcs) are environmental agents possessing hormone-like activity. exposure to edcs during differentiation can interfere with hormonal signaling, resulting in predisposition to some cancers. it has been suggested that some of these effects may be epigenetic, mediated by changes in dna and histone methylation. we hypothesized that edcs, diethylstilbestrol (des), and bisphenol-a (bpa), may act by altering the expression of dna and histone methyltransferases (dnmts and hmts). methods: ishikawa (endometrial) and mcf (breast) cells were cultured in steroid-free, phenol-free media with bpa ( m), des ( x - m) or vehicle for hours. pregnant cd- mice were treated with intraperitoneal injections of des ( mg/kg) or vehicle on days - of gestation. weeks after birth, offspring were sacrificed and tissue obtained. mrna was extracted, cdna was generated and quantitative real time rt-pcr was performed and normalized to -actin. all experiments were conducted in triplicate, repeated three times and compared using anova. results: dnmts (dnmt , a, and b) and hmts (mll and ezh ) were screened after in vitro exposure to edcs (table ) . ezh mrna expression was significantly increased in ishikawa cells after treatment with des or bpa. a similar response in ezh expression was seen in mcf cells treated with des or bpa. due to the consistent induction of ezh in all cells with either treatment, we examined the effect of des exposure on ezh expression in vivo. in adult mice exposed to des in utero, ezh expression was persistently increased ( . ± . fold, p< . ). conclusions: breast and uterine cell lines show increased expression of ezh in response to bpa or des exposure. this differential expression persists in the adult offspring of mice exposed to des in utero. ezh has been identified as a risk for neoplastic progression in the breast and for increased proliferation in uterine cancers. des induced ezh expression may be a mechanism for the increased incidence of breast and reproductive tract cancers seen in des exposed women. defects in cellular programs that control apoptosis lead to an imbalance of cell proliferation and cell death in ovarian cancer. recent evidence suggests that the use of some anti-inflammatory drugs decreases risk of ovarian cancer. natural curcumin-based anti-inflammatory therapies were shown to be beneficial in preclinical models of ovarian cancer (lin et al., ) . in this study, we examined the effects of plant derived curcumin on cell proliferation, apoptosis, and vegf expression in cultivated ovarian cancer cells. ovarian cancer igrov cells were cultured under standard conditions to study the effects of curcumin on cell kinetics and on vegf expression. cell proliferation was measured by srb and mtt assays. apoptosis was determined by measuring cytoplasmic histone-associated-dna-fragments (cell death detection elisa, roche, germany). vegf gene promoter-reporter activation and real-time quantitative reverse transcription polymerase chain reaction were used. conditioned media concentrations of vegf were measured with a commercially available enzyme-linked immunosorbent assay (quantikine, r d systems, minneapolis, mn). we observed that curcumin dose-dependently suppressed cell growth in igrov cancer cells (ic = um). treated cells showed a - fold increase in dna fragmentation compared to controls. curcumin also resulted in a significant decrease of vegfmrna expression and vegf protein secretion into the conditioned media in a dose-dependent manner. in this study, we have demonstrated that curcumin induces apoptosis, suppresses growth, and inhibits vegf gene and protein expression in an ovarian cancer cell line. experiments are underway to identify specific mechanism of curcumin action. curcumin may act as a chemosensitizing drug by potentiating the antitumor effects of standard treatments including taxols and platins in ovarian cancer. supported by the caldwell family foundation and the vesa w. and william j. hardman, jr. charitable foundation inc. daniel r christie, faheem m shaikh, john a lucas iii, susan l bellis. obsterics and gynecology, university of alabama at birmingham, birmingham, al, usa; physiology and biophysics, university of alabama at birmingham, birmingham, al, usa. introduction: previous work has shown that an upregulation of the enzyme st gal i, which is responsible for the , sialylation of integrins, confers a more tumorigenic/metastatic phenotype to colon carcinoma cell lines. it is not known, however, if this is unique to colon cancer, or if it is more broadly applicable to other forms of cancers. quantitatively increased expression of st gal i has been reported in ovarian cancers versus controls, but no biochemical or functional assays have been described to date. objective: because integrins are involved in cell adhesion and migration, and because metastasis of epithelial ovarian cancers is largely an intraperitoneal dissemination, we hypothesized that upregulation in the expression of st gal i in an ovarian cancer cell line would enhance binding with the extracellular matrix, increase invasiveness, and alter migration. methods: in the present study we forced a stable transduction of st gal i into the ov ovarian tumor cell line, which we found to be lacking the st gal i enzyme, establishing a parental (par), an empty lentiviral vector (ev), and an st gal i expressing (st ) cell line. a collagen i cell adhesion assay was performed and quantified by staining adherent cells and measuring absorbance. a haptotactic collagen i cell migration assay was performed by seeding cells in boyden chambers lined with collagen i concentration gradient, and quantified with cell staining and absorbance measurement. cell invasion through a reconstituted basement membrane (matrigel) was quantified as previously described for the cell migration assay. results: we were able to demonstrate successful creation of the ov -st gal i cell line by western blot analysis. functional assays demonstrated increased adhesion to collagen i (p < . ), increased haptotactic collagen i cell migration (p < . ), and increased invasiveness (p < . ) in the st cell line as compared to par and ev when analyzed by one-way anova. conclusion: this initial study into st gal i in ovarian cancer may have future therapeutic implications, and, in addition, lend greater insight into the intraperitoneal dissemination of disease.of microarrays (sam), arrayassist and binary tree structured vector quantization. differentially expressed genes were integrated with a database of known predicted protein-protein interactions (ophid) and key genes are being validated with real-time pcr and immunohistochemistry. results: unsupervised hierarchical clustering revealed collective clustering of all tumors, irrespective of their pathological classification. sam analysis has highlighted probe sets as differentially expressed between lmp and lmp-mp, probes between lmp and lgsc, and probes between lmp and lmp-mp+lgsc. no differential gene expression was detected between lmp-mp and lgsc. ophid analysis demonstrated gene members of the egfr and mapk / pathways to be differentially regulated between the non-invasive and the invasive tumors. to date, we have successfully validated members of the mapk / pathway-poly adp ribose polymerase (ppol) and traf family associated nf kappa b activator (tank)-using real-time pcr. conclusion: our data demonstrate that although the tumors have related genetic profiles, lmp-mp and lgsc are similar to each other and different from lmp, in keeping with their clinical behavior. members of the mapk / and egfr pathways appear to play a key role in low grade serous cancer. identification of novel genes associated with malignant transformation, may lead to development of more effective targeted therapy for lgsc. background: approximately % of pap smears with the ambiguous diagnosis of atypical squamous cells, cannot exclude high grade (asc-h), are negative for dysplasia in follow up colposcopic examination and biopsy. although hpv testing provides excellent negative predictive value (npv) ( %), the prevalence of high risk hpv infection is high in young women and the positive predictive value (ppv) in asc-h pap smears is no better than cytologic diagnosis alone ( %). recent studies have shown that immunostaining for p ink a , or proex tm c, supports a diagnosis of dysplasia in surgical biopsies. our objective was to determine whether staining for p or proexc provides sufficient predictive value to reliably distinguish high grade dysplasia in asc-h pap smears. design: we retrospectively collected samples from liquid based pap smears diagnosed as asc-h at either ohsu or portland oregon kaiser permanente ( - ). known hsil and negative pap cases were included as immunostaining controls. asc-h cases with followup cervical biopsies (n= ) were included for subsequent immunostaining according to manufacture's instructions. samples were also sequestered for hpv testing (pending). immunostained slides were scored as positive or negative by two independent cytopathologists (as and tm) while blinded to pap diagnoses and surgical biopsy outcomes. results: we observed excellent agreement between pathologists' scores (pairwise kappa statistic . ). the correlation between p and proexc scores was moderate (kappa . ). chi-square analysis comparing staining to biopsy outcome revealed a significant association between proex c positivity and cervical dysplasia (*** p< . jing lin, zhenmin lei, ch v rao. ob/gyn women health, university of louisville health sciences center, louisville, ky, usa. introduction: matrix metalloproteinases (mmps) are a family of highly homologous zinc-dependent endopeptidases, which degrade all kinds of extracellular matrix proteins. the degradation process is required for tissue growth and remodelling. these enzymes are probably involved in uterine growth and devolopment and its differentiated functions. ovarian steroid hormones, estradiol (e ) and progesterone (p ), are known to regulate some of the uterine mmps. since it is now known that lh/hcg can directly regulate uterine growth and devolopment and its functions, we questioned whether these gonadotropins could also regulate mmps in the uterus. methods: sixty day old wild type (wt) and lh receptor knockout (lhrko) mice and -day e and p treated -day old animals were used. in addition, primary cultures of uterine epithelial cells from wt animals were treated for hrs either with no hormone or with a single or a combination of pg/ml of e or p , ng/ml of hcg. then mmp- , - and - mrna levels were quantified by the semiquantitative rt-pcr. results: while the uterine mmp- mrna levels were unaffected, mmp- mrna levels significantly decreased and mmp- mrna levels significantly increased in lhrko animals as compared with wt siblings. e and p treatment reversed mmp- and mmp- changes in lhrko animals. treatment of wt type primary endometrial epithelial cell cultures with hcg had no effect on mmp- mrna levels, but it did increase mmp- mrna levels. this increase was synergistic with both e or p . conclusion: while lh/hcg do not regulate uterine mmp- and mmp- , they seem to co-regulate mmp- with ovarian steroid hormones. cancer. radhika gogoi, christine ardalan, dorota popiolek, leslie gold, john curtin, stephanie v blank, bhavana pothuri. new york university, new york, ny, usa. objective: megesterol, a synthetic progestin with strong androgenic properties, is used in the medical management of patients (pts) with atypical endometrial hyperplasia (aeh) or endometrial carcinoma (emca). our hypothesis was that androgen receptor (ar) expression in the endometrium of aeh and emca pts would correlate with degree of response to treatment. methods: pre-and post-treatment endometrial biopsy specimens were obtained from pts treated with megesterol for aeh or emca. ar expression was investigated by immunohistochemical (ihc) analysis with appropriate positive and negative controls. ihc staining was scored for intensity ( - ) and percentage of positive cells ( - ) in the glandular and stromal compartments by a pathologist, blinded to clinical response data. a composite score utilizing both intensity and percentage of positive cells was calculated. we evaluated pre-and post-treatment ar expression in responders and nonresponders as well as ar expression in emca, aeh and normal endometrium. the mann whitney u and the wilxocon signed rank tests were utilized for statistical analysis. results: eight pts' pre-and post-treatment samples were obtained; with emca and with aeh. three pts had no response, , a partial response and , complete responses. ar expression in emca samples when compared to the normal endometrium was significantly lower in both the glands (mean . vs. ; p< . ) and the stroma (mean . vs. ; p< . ). although there was no statistically significant difference in glandular ar expression in the pretreatment biopsies of responders compared to nonresponders (mean . vs. . ; p= . ), there was a significantly higher level of glandular ar expression in the post treatment biopsies of responders compared to non-responders (mean . vs. ; p< . ). furthermore, we noted a trend towards higher levels of glandular ar expression in the post-treatment versus the pre-treatment biopsies in the responders (mean . vs. . ; p= . ). we noted a significant decrease in ar expression in emca compared to the normal endometrium. increased ar expression after treatment in responders suggests an important role of the ar in pts treated conservatively with progestational therapy, and needs further prospective validation as a means to predict treatment response in these pts. objectives: study the correlation between adenomyosis and some potential non-surgical risk factors. objective: o -methylguanine-dna methyltransferase (mgmt) acts to repair dna damaged by alkylation of guanine residues. mgmt promoter methylation and gene silencing is seen in a variety of cancers and pre-cancerous changes. the loss of mgmt activity is associated with increased sensitivity to alkylating agents and is a favorable prognostic indicator in gliomas. we sought to determine if mgmt promoter methylation plays a role in endometrial cancer. methods: one hundred and twenty primary endometrial cancers were analyzed for mgmt promoter methylation by combined bisulfite restriction analysis (cobra). the cohort included endometrioid endometrial cancers, endometrial tumors of adverse histologic type, and endometrial cancer cell lines. twenty one endometrioid and mixed endometrioid ovarian cancers were also analyzed. a subset of the primary tumors was analyzed for mgmt expression by immunohistochemistry. results: no mgmt promoter methylation was seen in the endometrial cancers evaluated or the endometrial cancer cell lines. one of the ovarian cancers showed methylation. immunohistochemistry for mgmt expression is ongoing. conclusion: mgmt promoter methylation is an infrequent event in endometrial cancer. mgmt expression in tumor cells and repair of alkylguanine residues could explain in part the limited response of endometrial tumors to alkylating chemotherapy. objective: uterine sarcomas ( % of gynecological malignancies) originate from uterine mesenchyma. patients with high-risk disease (i.e. high grade) or at advanced stages have poor -years overall survival (< - %). pelvic radiation and/or chemotherapy have not demonstrated to improve survival. identification of new therapies for this malignancy is a major goal. few in vitro models have been established to test therapeutic agents for uterine sarcoma. here we sought to establish a new human uterine sarcoma cell line and to test the effects of chemotherapeutic drugs: tnf-related apoptosis inducing ligand (trail) used alone or in combination. methods: tissue sample was obtained from a woman with uterine sarcoma undergoing hysterectomy. sarcoma cell lines were established using a published protocol for endometrial cancer. phenotypic characterization was made through the different passages ( to ) by western blot. levels of estrogen (er), progesterone (pr) and trail receptors were also studied (rt-pcr, w-b). cells were incubated with chemotherapy agents (cisplatin, paclitaxel and doxorubicin and trail) and cytotoxicity (mts assays) and apoptosis (flow cytometry, parp cleavage by w-b, and dna laddering) measured. results: human uterine sarcoma cell line was established from a highgrade uterine sarcoma. through the different passages the cell line remains expressing cytokeratin, vimentin, tissue factor, caveolin- and -actin. this cell line expresses low er and pr levels. trail receptors (r and r ) were also detectable (rt-pcr, w-b). cisplatin, paclitaxel and doxorubicin ( um for h) produced low cell cytotoxicity (< %). trail ( ng/ml for h) induced about % cell cytotoxicity. apoptosis was confirmed by parp cleavage. doxorubicin significantly enhances trail mediated cytotoxicity (up to %), this was demonstrated by a significant increase in the sub g /g region in the dna histogram. conclusions: we establish a human uterine sarcoma cell lines using protocols for endometrial cancer. more importantly, we demonstrated that doxorubicin enhances trail effect on this uterine sarcomas cell line. thus, this combination might be considered as a treatment for high-risk uterine sarcomas. (financial support fondecyt ). defining the tumor initiating capacity of cd + human endometrial cancer cells. anne m friel, petra a sergent, christine l cummings, rosemary foster, current data suggest rare subpopulations of cells with tumor initiating capabilities are a common feature of solid tumors. several investigators have recently identified cd , a cell surface marker expressed on primitive cells of neural, hematopoietic, endothelial and epithelial lineages, as a potential tumor initiating cell (tic) marker in solid tumors of the brain, colon and pancreas. in our efforts to investigate such a population in human endometrial cancers (enca), we developed an in vivo model that is based on serial transplants of tics from endometrial tumor explants. serial transplant experiments were initiated in nod/scid mice that were injected with primary human enca cells. a subset of cells derived from the generated tumor was subsequently transplanted into new recipients. tumors formed following serial transplantation retained the original histological phenotype of the primary enca, and the number of cells required to initiate tumor formation was reduced at each successive transplant stage suggesting an increase in the ratio of tics to non-tics. we exploited this model in our initial efforts to investigate the tumor initiating potential of cd -expressing enca cells. to evaluate the tumorigenic potential of cd + cells, the tumor initiation capacity of xenograft derived cd + and cd cells were compared following subcutaneous injection of each population into nod/scid mice. only the cd + fraction was tumorigenic consistent with the hypothesis that tumors are generated and maintained by a subpopulation of cells with phenotypically distinct profiles. we are further investigating the functional significance and characteristics of this fraction in vitro and in vivo. objectives. central issues in tumor biology are the understanding of factors that control tumor cell proliferation and the identification of extracellular matrix cues controlling the signaling transducing repertoire that make cancer cells proliferate and invade the host tissues. among these factors, small leucine-rich proteoglycans (srlps):decorin, fibromodulin, lumican, biglycan, are emerging as powerful modulators of angiogenesis and cell growth, by affecting several key elements including matrix assembly, growth factor binding, and receptor tyrosine kinase activity. recently has been demonstrated that srlps can act as a pan-erbb ligand and, in doing so, down-regulate the activity of one of the most potent oncogenic proteins, erbb , whose overexpression is linked to poor prognosis and increased cancer mortality in breast, ovary, and prostate. since srlps have not been previously investigated in the endometrial cancer biology, we investigated their role in the benign and malignant endometrial neoplasia. method. the sampling has been obtained in women (n= ; mean age ± . ) with endometrial hyperplasia (n= ), polyps(n= ), and cancer(n= ), during therapeutic and diagnostic procedures (hysterectomy, colpohysterectomy, hysteroscopy). physiological endometrial samples (n= ) were obtained from menopausal women (n= ; mean age ± . ), during procedures for others gynaecologic indications. immunohistochemestry was the biology technique used for the detection of srlps.results. in the physiological endometrial samples immunoreactivity for decorin, fibromodulin and biglycan was intense (+++), while it was weak in polyps and hyperplasia (+) and absent (-) in cancer. no significant difference in the staining of lumican between the physiological and pathological samples. conclusions. these results could provide a mechanism by which naturally occurring proteins normally synthesized by fibroblasts and smooth muscle cells, the two key components of the tumor stroma, may play a protective role in the genesis and progression of endometrial neoplasia counteracting the growth of neoplastic cells and suppressing tumor cell-mediated angiogenesis. although further studies are necessary to understand mechanisms whereby srlps might influence endometrial cell growth and survival, these molecules may represent potential target for pharmacological cancer therapy. myostatin is a member of the tgf-beta superfamily of protein and a wellknown inhibitor of skeletal muscle proliferation. the muscular component of the uterus is the myometrium, a tissue that regulates its mass in response to different physiologic conditions under the influence of steroids. we determined the expression of myostatin mrna in immortalized pregnant human myometrial (phm ) cells and we verified its biological activity. functional assays showed myostatin induced phosphorylation of smad- and reduction of proliferation of phm cells in a time and dose-dependent manner. to investigate the physiological relevance of our in vitro findings, the expression of myostatin in rat uterus was examined at various phases of the estrous cycle. for the first time we report that myostatin is expressed in rat uterus and that levels of myostatin mrna change during distinct phases of the estrus cycle. uterine levels of myostatin peaked during late estrous and were the lowest at pro-estrous. to further examine the role of steroids in myostatin regulation, we examined the effects of gonadal steroid administration in ovariectomized (ovx) rats. ovaryectomy increased myostatin expression compared to normal cycling controls. estrogen treatment strong decreased myostatin levels while progesterone produced less robust effects on myostatin expression. these findings taken together suggest an important role for myostatin in the regulation of myometrial functionality. her neu over-expression and pi kinase/akt pathway activation in paget's disease of the vulva. amy stenson, bita behjatnia, jaime shamonki, jianyu rao, amer karam, jonathan berek, oliver dorigo. ob/gyn and pathology, ucla, los angeles, ca, usa; ob/gyn, stanford university, palo alto, ca, usa. background: paget's disease of the vulva is rare with high recurrence rates. treatment of recurrent disease is challenging due to its extent and location. non-surgical approaches have limited clinical efficacy, obviating the need for novel therapies. in contrast to paget's of the breast with well-described overexpression of her neu, molecular features of vulvar paget's are poorly characterized. our objective was to study therapeutic targets in vulvar paget's, including the her neu protein and the phosphorylated oncoprotein akt (pakt). in addition, detailed clinical characteristics were correlated with molecular expression. methods: specimens with vulvar paget's disease were retrieved from ucla's department of pathology. protein expression was evaluated by immunohistochemistry on slides from paraffin embedded tissue using the hercep test (dako) for her neu expression and a standard protocol to assess expression of activated pakt. slides were scored by two independent pathologists based on a nominal scale of (negative) to (strongly positive). clinical data was retrieved via chart review. results: between and , patients with vulvar paget's were identified. median age was yrs ( - yrs). a family history of cancer was found in / ( %), / ( %) were smokers and / ( %) had a history of hormone use. intraepithelial lesions accounted for the majority ( / , %), while / ( %) demonstrated invasion and / ( %) were associated with underlying gi malignancy. / ( %) had at least one recurrence, with median time to recurrence months. so far, specimens were stained for her neu and pakt. overexpression of her neu was found in / ( %.) positive staining for pakt was evident in / ( %.) statistical analysis suggested a correlation between her neu and pakt expression. conclusions: our study demonstrates that overexpression of her neu and activation of the pi kinase/pakt pathway are important features of vulvar paget's disease. to the best of our knowledge, this is the largest series evaluating these molecular pathways in vulvar paget's. our data suggest that her neu and pakt may be important molecular targets for novel therapies using for example the monoclonal antibody trastuzumab directed against her neu, or a pi kinase pathway inhibitor like rapamycin. introduction: uterine leiomyomas are the most frequent tumor of the female reproductive tract and are the primary indication for hysterectomy in women worldwide. these tumors occur in up to % of adult women, and their prevalence is especially high in africa-american women. currently there is no effective and safe medical treatment for uterine fibroids and surgery is the main stay. epigallocatechin gallate (egcg) constitutes the main solid extract of green tea and is believed to contributes most of the antioxidant and antiinflammation capacity of green tea. egcg has been shown to have beneficial effects on prostate cancer and breast cancer by inducing apoptosis and inhibiting proliferation of cancer cells. in this study, we investigated the ability of egcg to inhibit proliferation of human leiomyoma cells (hlm) in vitro. methods: human immortalized leiomyoma cells were cultured at ºc in a humidified atmosphere of % co - % air in smbm medium supplied with %fbs, . % insulin, . % hfgf-b, . % ga- and . % hegf(lonza). the cells were plated at density of × cells/well in -well plates and grown under the same conditions above. the monolayer cultures at approximately % confluence were treated with various concentrations ( , . , . , , , and μm) of egcg (sigma) for days. a fluorometric assay using hoechst dye (sigma) for dna quantitation was conducted at the following designed time points, day , , , and post egcg treatment. the cells were lysed and dna content was determined using hoechst dye solution ( μg/ml). fluorescence was measured after excitation at nm and emission at nm. results: egcg exhibited marked anti-proliferation effect on the growth of hlm cells. compared with untreated control, the inhibitory effect of egcg on hlm cells was observed at μm and peaked at μm concentration. the difference was statistically significant (p = . ). evaluation of the mechanism of action of egcg is cuurently under investigation in the lab.conclusion: egcg significantly inhibited the proliferation of human leiomyoma cells in a dose-depended pattern. egcg may present a potential effective and safe medicinal treatment for uterine fibroids. objective: choriocarcinoma is an aggressive form of germ cell tumor that exhibits rapid growth with early metastases. choriocarcinomas autonomously secrete hcg which acts as an autocrine/paracrine growth factor in these cancers. we hypothesize that a novel hcg antagonist (hcg-ant) can limit tumor expansion by blocking hcg-induced expression of pro-invasive genes. we investigated if hcg-ant could alter rna expression of matrix metalloproteinases (mmp- and mmp- ), which facilitate basement membrane degradation and hence invasion, and metastin (kisspeptin), a strong suppressant of metastasis, in the choriocarcinoma cell line jeg- . design: in vitro experiments using the jeg- cell line. materials and methods: after plating jeg- cells in a well tray overnight in rpmi media containing % fbs, cells were washed twice with pbs and then cultured in ul of serum-free rpmi media containing one of four treatments: ) saline; ) hcg ( iu); ) hcg ( iu) plus hcg-ant ( iu); or ) hcg-ant ( iu). rna was extracted from each well using trizol and reverse transcribed using sensiscript (qiagen). the relative expression of mmp- , mmp- , and metastin mrna was quantified using sybr-green based real time pcr. the expression of the housekeeping gene hprt was used to normalize expression data. results: treatment of jeg- cells with hcg-ant vs. hcg alone reduced expression of mmp- ( . ± . vs. . ± . ) and . hcg-ant reduced mmp- and mmp- expression by % and %, respectively (p< . ). treatment with hcg-ant vs. hcg increased metastin expression ( . ± . vs. . ± . ). metastin expression was increased by % following hcg-ant treatment. conclusion: treatment of the jeg- choriocarcinoma cell line with hcg-ant reversed the increased expression of mmp- and mmp- following treatment with hcg. metastin expression was increased by hcg-ant. this data suggests that hcg antagonism is capable of altering gene expression thereby inhibiting invasion in a choriocarcinoma cell line. the role of hcg-ant as an adjuvant therapy in hcg sensitive tumors offers promise. retinoids, but not progesterone, directly induce differentiation and apoptosis of endometrial cancer cells. you-hong cheng, serdar e bulun. ob/gyn, northwestern university feinberg school of medicine, chicago, il, usa. objectives: the opposing actions of estrogen and progesterone during the menstrual cycle regulate endometrial proliferation, differentiation and secretion. the unopposed action of estrogen contributes to the development of type i endometrial cancer. however, the mechanisms for progesterone protection of estrogen-induced carcinogenesis in endometrium remain unclear. methods and results: in the current study, we demonstrated that retinoids ( -cis retinoic acid (ra) or all-trans ra (atra)) significantly inhibited basal and hormone-stimulated ishikawa cell proliferation by over % using mtt assay. the same experiment indicated that estrogen had no significant effect, whereas progesterone slightly induced, on cell proliferation. cell cycle analysis indicated that atra significantly increased the g /g cell population by % and decreased s phase cells by %, suggesting that ra induces cell cycle arrest at the s phase. knock-down of rar alone or both rar and rxr significantly increased proliferating cell nuclear antigen (pcna) levels in epithelial ishikawa cells, suggesting that ra signaling via rar/rxr activation is critical for normal endometrial growth and differentiation. to determine whether retinoids are naturally secreted by the endometrial stromal cells, we cultured primary stromal cells and analyzed the culture media using hplc. we found that retinol is the predominant retinoid form secreted by stromal cells. the average concentration of retinol in the cultured media of eutopic endometrial stromal cells was approximately to ng/ml/ cells (n= ). although there was less than . ng/ml/ cells of all-trans retinal or atra in the cultured media, we did find a small peak for all-trans retinal and atra in the media using hplc analysis. furthermore, progesterone significantly increased secreted retinol levels from eutopic endometrial stromal cells, but decreased retinol levels secreted from endometriotic stromal cells. retinol is a precursor for ra that is converted to retinal and then to ra. conclusions: we demonstrated that progesterone signaling via pr induces endometrial stromal cells to secrete paracrine retionids that in turn control the phenotype of adjacent epithelial cells. conversely, this interaction is disrupted in diseased endometrial tissues, such as endometrial cancer and endometriosis. the effects of hormonal contraceptives on antimullerian hormone by obesity status. anne z steiner, frank z stanczyk, stan patel, alison edelman. ob/gyn, university of north carolina, chapel hill, nc, usa; ob/gyn, usc keck school of medicine, los angeles, ca, usa; ob/gyn, oregon health and sciences university, portland, or, usa. background: antimullerian hormone (amh) is emerging as a predictor of reproductive potential. serum levels of fsh, a commonly used measure of ovarian reserve, are suppressed with the use of oral contraceptives (ocs) thereby limiting its use. the impact of ocs and on serum amh levels in normal and obese women is unknown. objective: to examine the impact of ocs on serum amh levels by obesity status in reproductive-age women. materials and methods: ovulatory women, ages - years, of normal (< kg/m ; n = ) and obese (> kg/m ; n = ) body mass index (bmi) received a low dose oc ( mcg ethinyl estradiol/ mcg levonorgestrel) for two cycles. serum was obtained at three time points: after days of active pills (cycle , day ), at the end of the -day hormone-free interval (cycle , day ), and during the first week of active pills in cycle (cycle , day , , or ). amh levels were quantified by elisa; fsh and lh levels were determined by chemiluminescent immunoassay. amh at the three time points was compared using repeated measures anova. models were used to assess the relationship between amh and cycle day by obesity status. amh and gonadotropin levels were compared using spearman's correlation. results: amh levels did not differ by oc cycle day (p anova = . ) or by active versus placebo pill use ( . ng/ml ± . vs. . ng/ml ± . , p= . ) among normal bmi women. among obese women, amh levels differed by oc cycle day (p anova = . ), but not by use of active or placebo pill ( . ng/ml ± . vs. . ng/ml ± . , p = . ). across the cycle, cv(standard deviation/mean) averaged . %± . in the obese and . %± . in the normal bmi women ( p= . ). modeling to determine differences in amh throughout the cycles based on obesity status showed a significant interaction (p = . ) and lower amh levels in the obese group (p< . ). among both bmi groups, serum amh and fsh levels did not correlate during active pills or after days of placebo pills. conclusions: in young, normal bmi women serum amh levels do not appear to fluctuate during oc use. among obese women, amh levels are lower and fluctuate significantly. these fluctuations do not appear to mirror changes in gonadotropins and may complicate clinical interpretation of amh. background: menopausal hormone therapy (ht) is a confusing topic for many clinicians and patients. objective: to assess comprehension of basic clinical trial features among prospective participants for the keeps trial, designed to study the effects of ht initiated within years of menopause on chd markers. methods: screening materials were provided giving an overview of study purpose, duration, medications, likelihood of receiving drug vs. placebo, ht related risks and side effects. at a subsequent interview, a -item questionnaire assessed the participant's level of comprehension. a score of % was adequate to complete the informed consent process. those scoring < % were re-counseled and retested. demographic variables determining the likelihood of an initial score > % were evaluated by univariate and multivariable analyses. results: % ( / ) scored > % on initial testing. all women scored > % after re-counseling and retesting. likelihood of an initial response > % correct was unrelated to age or time since menopause. ability to correctly respond was influenced by highest educational level attained. none of women whose furthest educational level was high school scored > % on initial testing, significantly less than those with a college education (p= . ). a higher proportion of college graduates ( / ) scored > % compared to those attaining further education ( / ) (p= . ). comprehension was greatest for study purpose and duration ( / and / correct responses respectively) and least for questions related to results of the whi hormone trial breast cancer and chd. that e alone was not associated with an increased risk of chd ( %) or breast cancer ( %) was poorly understood. conclusion: comprehension of the risks and benefits of ht by potential research subjects is low despite provision of reading materials prior to the informed consent process. (supported by the montefiore medical center/albert einstein college of medicine site for the kronos longevity research institute and k -hd to ns). variation in menopausal symptoms within a sample of hispanic women: swan, the study of women's health across the nation. robin r green, alex j polotsky, aileen p mcginn, carol a derby, rachel p wildman, lhasa ray, kavitha t ram, gerson weiss, nanette f santoro. albert einstein coll of med, bronx, ny; univ of med and dent of new jersey, newark, nj. background: menopausal symptoms are experienced by over % of women. purpose: to describe symptom frequency in a sample of midlife hispanic women from different countries of origin. methods: the study of women's health across the nation (swan) recruited women at baseline who self-identified as hispanic. their baseline responses to validated questionnaires regarding common menopausal symptomatology were examined. symptoms were reported over the previous two weeks and scored on a frequency scale ranging from (not at all) to (every day). for all analyses, symptoms were dichotomized into "absent" vs. "present" variables. responses were correlated with acculturation ( -item scale: marin, hisp j behav sci : , ) and analyzed by sub-ethnicities: central/south american (c/s am), puerto rican (pr), dominican (dr), and cuban (cu). associations between symptoms and sub-ethnicity were tested by chi-square. logistic regression was used to test for associations with acculturation and being us-born. there was significant variation in several menopausal symptoms. while puerto-rican women had the highest likelihood of reporting trouble sleeping (or= . , %ci: . - . ) and headaches (or= . , %ci: . - . ), dominican women were most likely to report vaginal dryness (or= . , %ci: . - . ) acculturation and being us-born did not explain the variation between subethnicities in any of the models tested conclusion: there appear to be significant differences among hispanic women with respect to menopausal symptomatology. these differences were not readily explained by measures of acculturation. (supported by the study of women's health across the nation (swan) has grant support national institutes of health, dhhs, through the national institute on aging, from the national institute of nursing research and the nih office of research on women's health (grants nr ; ag , ag , ag , ag , ag , ag , ag , ag and cd ). purpose: to compare the relative effects of conjugated equine estrogen, raloxifene, and tamoxifen therapies on cognition among women aged years or older. participants and methods: annual modified mini mental state ( ms) examinations were used to assess global cognitive function among the , women enrolled in the two randomized placebo-controlled clinical trials of the women s health initiative memory study (whims) and women enrolled in co-star, the cognitive substudy of the nsabp's study of tamoxifen and raloxifen (star) trial who had baseline ms testing. associations between baseline cognitive risk factors common to both trials and baseline ms scores were assessed and interactions used to examine whether risk factor relationships differed between cohorts. factors for which relationships were similar were used as covariates in analyses comparing ontrial ms scores. factors for which relationships did not appear to be similar were used to stratify analyses. results: compared to placebo, each of the active therapies was associated with a small mean relative deficit in ms scores of . units or less, which was fairly consistent between women with and without prior hysterectomy. overall, relative deficits appeared to be most marked for tamoxifen (unadjusted p= . ) but were also evident for raloxifene (p= . ) and cee (p= . ). conclusions: while unmeasured differences between trials may have confounded our analysis, these findings suggest that both tamoxifen and raloxifene may adversely affect cognitive function in older women. weight gain and increased abdominal fat have been found in women after menopause and is associated with higher levels of leptin, and decreased levels of the cardioprotective adipocytokine adiponectin. at the same time, bmd characteristically decreases. in an effort to determine the evolution and correlates of these changes, we studied postmenopausal women (pm) within years of menopause (age . ± yrs) of normal weight (bmi . ± ) and compared them to weight matched (bmi . ± ) premenopausal (pre) controls (age . ± yrs.) all subjects had bmd and body composition studies by dexa and measurements of leptin, adiponectin, visfatin and retinol-binding protein (rbp .) while total fat was similar in the groups, pm had more trunk and abdominal fat ( ± ; ± g) compared to pre ( ± g p< . ; ± g p< . ) pm also had greater %trunk fat and %central abdominal fat compared to pre, p< . .serum leptin ( . ± . vs ± pg/ml) and visfatin ( . ± vs. . ± . ng/ml) were similar but adiponectin ( ± vs. . ± g/ml) and rbp ( . ± vs. . ± ng/ml) were higher, p< . in pm. while in pre, abdominal fat correlated negatively with adiponectin (p< . ) in pm only leptin correlated with various parameters of fat mass, p< . , and adiponectin did not correlate but correlated positively with age (r . , p< . .) as expected, pm had reduced bmd at the lumbar spine and hip ( . ± . vs. . ± . g/cm ; . ± . vs. . ± . g/cm , p< . ) but there was a correlation between total and trunk fat in pm and lumbar bmd (r . , . , p< . ) but not with hip bmd; or any correlations in pre. there was a correlation between leptin and lumbar bmd in pm (r . , p< . ) but not in pre. in summary, in normal weight early pm, abdominal fat is increased, but only adiponectin and rbp are altered with an increase in the former correlating with age. lumbar bmd correlated with fat mass in pm and is partially explained by increases in leptin. it is suggested that in spite of increasing abdominal fat in normal weight early pm, (which correlates with a higher lumbar bmd) david d rahn, jesus f acevedo, r ann word. ob-gyn, ut southwestern, dallas, tx, usa. objectives: matrix metalloprotease (mmp) activity is increased in the postpartum vagina of wild type (wt) animals, and this activity is accompanied by a burst in elastic fiber synthesis. the mechanisms that precipitate these changes are unclear. the goals of this study were to determine how vaginal distention (such as in parturition) affects elastic fiber homeostasis in the vaginal wall and the potential significance of these changes in the pathogenesis of pelvic organ prolapse. methods: nonpregnant ( ) and pregnant (d ) wt mice underwent either vaginal distention with a μl balloon x min (to simulate parturition) or sham procedure. tissues were obtained at and h for immunoblot analysis, zymography, and histology. distention was also performed in young fbln -/-, fbln +/-, and wts, and prolapse was quantified for weeks. results: distention resulted in marked increases in mmp activity in nonpregnant animals (prommp , . -fold; active mmp , . -fold; prommp , . -fold; active mmp , . -fold; all p < . compared with sham) which was accompanied by fragmented and disrupted elastic fibers in the vaginal wall. abundant amounts of tropoelastin and fibulin- in the nonpregnant vagina were not increased further by distention. in pregnant animals (which normally have suppressed vaginal wall fibulin- and tropoelastin), however, distention resulted in -fold upregulation of both proteins (p< . ). distention also induced increased mmps in pregnant animals (mmp- , . -fold; prommp- , . -fold; active mmp- , . -fold; all p < . ). thirteen young fbln -/-( - wks prior to age of prolapse development), het siblings, and age-matched wts underwent serial exams after ballooning. distention induced rapid increases in perineal bulge and vaginal diameter (within d) in fbln -/mice which never recovered. conclusions: in pregnant mice, vaginal distention results in increased protease activity in the vaginal wall but also increased synthesis of proteins important for elastic fiber assembly. distention may thereby contribute to the burst of elastic fiber synthesis in the postpartum vagina. the finding that distention results in accelerated pelvic organ prolapse in fbln -/animals, but not wt, indicates that distention results in loss of pelvic organ support if elastic fiber synthesis is compromised. further, the data suggest that elastic fiber synthesis is crucial for recovery of the vaginal wall from parturition/distention-induced increases in vaginal protease activity. the molecular etiology of pelvic organ prolapse (pop) is complex and not yet well understood. defects in the connective tissue, such as a decrease in extracellular matrix (ecm) protein content may predispose women to pop. our objective was to study the expression and the enzymatic activity of matrix metalloproteinases (mmps) and their tissue inhibitor (timps) in vaginal tissue of patients with advanced pop and controls. after informed consent, pre-menopausal caucasian patients affected by pop ( grade by pop-q), and control patients (no pop) matched for age and bmi, undergoing vaginal and abdominal hysterectomy respectively were recruited. full thickness anterior vaginal epithelial tissue was obtained from the surgical cuff of patients and controls in the proliferative phase of the menstrual cycle. total protein was extracted using ripa lyses buffer. western immunoblot analysis was performed (patients: n= , controls: n= ) to study the protein expression of mmp- , - , timp- , - , - . gelatin zymography was used to quantify the activity of mmp- and - . immunohistochemical analysis for timp- and - was performed on pfa-fixed vaginal biopsy tissue (n= ) in each group. both patient and control vaginal biopsy samples expressed latent and active forms of mmp- , and mmp- . the protein expression of the kda active form of mmp- was significantly increased in patients with pop compared to controls (p= . ). zymography detected the enzymatic activity of the proform and active form of both mmp- and mmp- . we found a significant increase in gelatinolytic activity of both kda pro-form and kda active forms of mmp- (p= . and p< . respectively) as well as kda active form of mmp- (p< . ) in patients with pop compared to controls. timp- protein expression in vaginal tissue showed a significant reduction in pop patients compared to controls (p= . ). timp- and - immunostaining were mainly localized in the smooth muscle cells at the muscularis layer of the vaginal biopsies. in vaginal tissue of patients with pop, we have shown a decrease in timp protein expression paralleled by an increase in mmp protein expression and activity. these findings reflect an active ecm remodelling that may compromise the structural integrity of the pelvic floor leading to pop. aberrant elastin and collagen synthesis may play a role in the pathogenesis of pelvic organ prolapse (pop). the lysyl oxidase (lox) family of enzymes direct cross linking of collagen and elastin polymers, however to-date no information is available on the expression and localization of these proteins in human vaginal tissue. our objectives were to study the expression and in situ localization of lox, loxl , loxl and loxl proteins in the vaginal tissue of patients with advanced pop and asymptomatic controls. pre-menopausal caucasian patients affected by pop ( grade by pop-q) and control patients (no pop) matched for age and bmi, undergoing vaginal and abdominal hysterectomy respectively were recruited. full thickness anterior vaginal epithelial tissue was obtained from the surgical cuff of patients and controls in the proliferative phase of the menstrual cycle. total protein was extracted using ripa lyses buffer and western immunoblot analysis was performed (patients: n= , controls: n= ). pfa-fixed vaginal biopsy tissues (n= for each group) were used for immunohistochemical study. vaginal biopsy samples from both patient and control groups expressed all four members of lox family proteins: lox ( kda pro-form and kda active form), loxl ( kda pro-form and kda active form), loxl ( kda) and loxl ( kda). the expression of all lox family proteins was reduced in patients with pop compared to controls; however only the pro-form of lox of making the diagnosis of endometriosis from an endometrial biopsy. objective: to evaluate the diagnostic value of examining endometrial biopsy specimens for small nerve fibers in women with pelvic pain or infertility in a double-blinded prospective comparison with laparoscopy. methodology: we undertook to compare the detection of endometrial nerve fibers with laparoscopy and peritoneal biopsy for the diagnosis of endometriosis in women (aged . years; range - years) who presented with chronic pelvic pain or infertility. small nerve fibers were detected in the functional layer of endometrium using immuno-histochemical staining with the highly specific pan-neuronal marker pgp . , using a carefully validated technique and blinded assessment of nerve fiber density. laparoscopic assessment of the presence of endometriosis and peritoneal biopsies was undertaken by three experienced gynecologic endoscopic surgeons. data from these assessments were recorded independently of endometrial findings and maintained under blinded coding until the codes were broken. results: small nerve fibers were detected in all of the women in whom endometriosis was surgically diagnosed and in none of the women in whom endometriosis was excluded at laparoscopy, giving the specificity and sensitivity of %. the density of nerve fibers in the endometriosis cases was . per mm²± . (mean ± sd). conclusions: endometrial biopsy provided a reliability of detection or exclusion of endometriosis which was equal to that of diagnostic laparoscopy carried out by experienced gynecologic laparoscopists. background: erk / are mapk intracellular signaling proteins involved in cell survival and differentiation. endometriosis requires angiogenesis for ectopic implant growth. we hypothesized that the endometriotic peritoneal environment, known to be high in estrogen (e ), vegf, and cytokines such as il- and mcp- , stimulates angiogenesis in human endometrial endothelial cells (heec) through erk signaling. methods: serial sections from normal (n= ) and ectopic (n= ) endometrium were immunostained for total-(t-) and phospho-(p-) erk / and cd (an endothelial progenitor cell marker); results were quantified by computer densitometry and grouped by menstrual phase. cultured normal heec were treated with control, e ( - m), il- , mcp- , and vegf (all ng/ml) for min, and western blotted for p-/t-erk (n= ). heec were treated with peritoneal fluid (pf; diluted : in basal media) from normal (n= ) and endometriotic (n= ) women, with or without pd erk / inhibitor ( m) for h, and cell viability was analyzed by mtt assay. statistical analysis was done with one-way anova. results: tissue staining revealed that ectopic cd + endothelial progenitor cells undergoing angiogenesis (vessel sprouting and/or angiogenic cell cord formation) exhibited the strongest levels of p-erk. heec of ectopic foci showed moderate-high p-erk staining, while surrounding mesothelial capillaries were weak for p-erk. in normal endometrium, p-erk was cycledependent, with low levels in the late secretory phase vs. other phases (p< . ). p-erk of ectopic heec showed no cycle dependence, with moderate-high levels in all phases. t-erk in all tissues was high and invariable. in cultured heec, treatment with pf from endometriotic women significantly increased heec viability after h compared to normal pf (p< . ). this effect was abrogated by erk / inhibitor. among factors known to be high in endometriotic pf, vegf increased p-erk in cultured heec in and min (p< . ), while e , il- , and mcp- had no effect. conclusions: high p-erk found specifically in sprouting endothelial progenitor cells and focal ectopic capillaries suggests that erk / is involved in endometriotic angiogenesis. the peritoneal microenvironment of endometriosis may be persistently stimulating erk-mediated endometrial angiogenesis through vegf. further investigation into erk / inhibitors may offer a novel treatment of endometriosis. the events leading to the development of post operative adhesions are unknown, though recent observations emphasize the crucial role played by the superoxide ion generated by hypoxia. exposure of normal peritoneal fibroblasts to hypoxia caused the development of the adhesion phenotype, which is characterized by increased extracellular matrix molecules and inflammatory cytokines as well as high protein nitration and low nitric oxide. superoxide dismutases (sod) are a family of metalloenzymes that eliminates superoxide by converting it to hydrogen peroxide, protecting mammalian organisms against superoxide. objective: to determine whether sod is differentially expressed between normal peritoneal and adhesion fibroblasts and whether its expression is modulated by hypoxia. methods: fibroblasts from normal peritoneal and adhesion tissues were cultured under normal ( % o ) and hypoxia ( % o ) conditions for and hours. real time rt/pcr was utilized to measure the absolute mrna levels for sod in both cell lines before and after hypoxia exposure. results: normal peritoneal fibroblasts exhibited significantly higher basal mrna levels for sod ( . pg/ grna, p< . ) as compared to adhesion fibroblasts ( . pg/ grna, p< . ). short exposure to hypoxia resulted in a significant increase in sod mrna levels to . and pg/ grna in normal and adhesion fibroblasts respectively, p< . . in contrast, long exposure to hypoxia resulted in a significant decrease in sod mrna levels to . and . pg/ grna in normal peritoneal and adhesion fibroblasts respectively, p< . . conclusion: sod mrna levels are lower in adhesion as compared to normal fibroblasts, both basally and following short and longer exposure to hypoxia. reduced sod expression creates an milieu with greater free radical levels, which leads to the development of the adhesion phenotype. enhancement of sod levels and/or function are likely to be of benefit for reduction of postoperative adhesion development. objectives: development of endometriosis requires ectopic attachment and proliferation of endometrial tissue. the invasive process required to establish endometriosis may involve matrix metalloproteinases (mmps), including mmp- . recently, we have demonstrated that statins inhibit proliferation of endometrial stroma. this study evaluated the effects of simvastatin on a nude mouse model of endometriosis and on modulation of mmp- . methods: proliferative phase human endometrial biopsies were established as organ cultures or utilized for stromal cell isolation. to establish endometriosis in the nude mouse, endometrial tissues were maintained in nm estradiol (e) for hrs and subsequently injected intraperitoneally into ovariectomized nude mice. mice were treated with e ( μg, silastic capsule implants) and simvastatin ( - mg/kg/day) by gavage for days beginning day after tissue injection. control mice received e+vehicle. subsequently, animals were sacrificed and endometrial implants were evaluated. studies of endometrial stroma involved plating the cells in the presence of e ( nm) or e+medroxyprogesterone acetate (mpa; pm) with and without simvastatin ( - μm). some cultures additionally received interleukin- (il- , ng/ml). conditioned media was subjected to western analysis for expression of mmp- . results: in vivo studies demonstrated a dose-dependent inhibitory effect of simvastatin on number and volume of endometrial implants in mice. at the highest dose of simvastatin ( mg/kg/day), the number of endometrial implants was decreased by % and the volume by % in comparison to the control group. isolated stromal cells expressed abundant levels of mmp- following treatment with e, but minimal levels in cultures additionally receiving mpa or simvastatin. although il- induced a dramatic increase in mmp- secretion from cells pretreated with e alone, treatment with either mpa or simvastatin prevented this induction. cultures receiving e+mpa+simvastatin were the most resistant to mmp- induction by il- . objective: to increase awareness of potential presentations of adenomyosis and the differential of a uterine mass. material and method: in a tertiary medical center, a patient was being evaluated for a uterine cystic mass and cyclic dysmenorrhea. the patient is a year old nulliparous woman who has been complaining of cyclic dysmenorrhea for several years. the pain starts with the onset of menses and lasts around weeks. the patient did not improve on contraceptives. the patient had prior laparoscopy and imaging studies which misdiagnosed the mass as either a leiomyoma or an adnexal hemorrhagic cyst. the patient underwent exploratory laparotomy and resection of the mass. results: on ultrasound, the mass appeared as an echodense cyst within the uterus. intraoperatively, a cm thick-walled well circumscribed uterine chocolate cyst was identified. the resection of the cyst was performed in similarly to an ovarian cystectomy. tissue examination confirmed the diagnosis of cystic adenomyosis. following surgical intervention, the patient reported significant improvement of symptoms. conclusion: this case highlights an unusual presentation and treatment of adenomyosis and cyclic dysmenorrhea. cystic adenomyosis should be on the differential of uterine cystic mass, particularly in young women with cyclic dysmenorrhea and menorrhagia. the earlier misdiagnosis probably resulted from the unfamiliarity of physicians with this condition. similar clinical presentations may occur with congenital uterine anomalies (with an obstructed uterine segment) and cystic degeneration of a leiomyoma. the incidence and pathogenesis of cystic adenomyosis are unknown. oral contraceptives may be helpful as a first line therapy. however, resection of the adenomyotic cyst appears to be more effective, particularly in women seeking fertility. objective: it is hypothesized that abnormalities within the eutopic endometrium of females with endometriosis can cause the ectopic growth of the endometrial tissue at extrauterine sites. previous studies have shown that gene expression in eutopic endometrium of women with endometriosis is markedly different from disease-free females. inflammatory cytokines and receptor-dependent kinase pathways are widely recognized as therapeutic targets for immune disorders, which is believed to be the underlying pathogenesis of endometriosis. in this study we asked whether responses of primary eutopic endometrial cell cultures are dysregulated between females with or without endometriosis. methods: a total of biopsies of endometriotic eutopic endometrium (eee) and disease-free endometrium (dfe) were obtained from proliferative phase females. the primary cell cultures established from these biopsies were treated with tnfa to induce expression of inflammatory mediators. parallel cultures were also treated with kinase inhibitors of p , mek, pi k and ikk. after a period of or hours, concentrations of il- , mcp- , and gm-csf in cell culture supernatants were analyzed by elisa. results: in eee, basal concentrations of mcp- and gm-csf were - times higher, while il- was times higher compared to dfe. as expected, tnfa treatment stimulated higher levels of cytokine secretion in dfe mimicking disease state, however, the same treatment had almost no effect on eee. kinase inhibitors were very effective in lowering the cytokine levels of dfe, however, their effect on eee were less dramatic. conclusion: eee expresses higher levels of inflammatory cytokines under basal conditions, which is in concert with the current literature. our results validate that high il- levels in endometrium are diagnostic for females with disease. the increase of gm-csf, il- and mcp- following tnfa treatment was expected in dfe however; tnfa's effect was blunted in eee, which implies that eee are already highly activated. the effect of kinase inhibitors on cytokine production from eee was unaltered relative to dfe, which implies that tnfa stimulated kinase pathways are modified even in eee. endometrial cancer is the fourth leading cause of cancer in women, and hyperplasia and adenocarcinoma are more commonly seen in women with polycystic ovary syndrome (pcos). mig- , a negative inhibitor of egf signaling, is expressed in normal secretory phase endometrium and associated with hyperplasia in mig- knockout mice. objective: we examined and compared endometrium from normal and pcos women for mig- expression and characterized its regulation using in vivo and in vitro models. methods: immunohistochemistry (ihc) and real-time pcr were performed in endometrium from normal (n= ) women and pcos (n= ) women. regulation of mig- was studied in ishikawa and ecc- endometrial cell lines, treated with sex steroids or egf. endometrial xenografts from normal and pcos women were implanted in ovxd rag -(c) immunocompromised mice, treated with e or e + p pellets to mimic a natural cycle. results: mig- protein expression was low in the functionalis of the proliferative phase and high in the secretory phase; this pattern was reversed in the basalis layer. pcos secretory phase endometrium had significantly less mig- protein and mrna than normal endometrium (p < . ). xenografts using pcos samples had paradoxically elevated expression of mig- compared to normal, and appeared unresponsive to steroid treatments. mig- expression in endometrial cell lines was regulated by egf but not by ovarian steroids, e or e + p. conclusions: mig- expression is low in proliferating endometrium and regulated by egf. risk of hyperplasia or cancer in pcos women can be explained by altered expression of mig- . reduced expression mig- provides insight into endometrial function and may lead to better treatment options for disorders of endometrial proliferation including endometriosis, adenomyosis, endometrial hyperplasia and cancer. supported in part by nih-u -hd (sly), u hd (lcg) and u hd (fjd). could androgens influence human luteal cells function? anna tropea, mariateresa orlando, maria francesca gangale, federica romani, isamaria loiudice, federica tiberi, stefania catino, antonio lanzone, rosanna apa. cattedrà di fisiopatologia della riproduzione, università cattolica del s. cuore (ucsc), roma, italy; istituto scientifico internazionale (isi) "paolo vi", ucsc, roma, italy; istituto di ricerca "associazione oasi maria ss onlus", troina (en), italy. in pcos patients reproductive dysfunctions are frequently observed even if ovulation occurs. an impaired luteal function could partially explain this subfertility, since luteal steroidogenesis deficiency and premature luteal degeneration have been described in pcos patients. based on the frequent observation of high plasmatic levels of androgens in pcos, we investigated whether hyperandrogenism could negatively affect luteal function.to this aim, we tested the in vitro effects of androgens on progesterone (p) and on vascular endothelial growth factor (vegf) production by human luteal cells. indeed, vegf is essential for normal luteal development and function being an important regulator of angiogenesis and vascular permeability. since prostaglandins (pgs) play a central role in modulating luteal function, the influence of androgens on pge and pgf a secretion was also investigated. in order to investigate whether testosterone and androstenedione act directly or after local aromatisation, we tested the in vitro effects of estriol, estrone and --estradiol on p, vegf, pge and pgf secretion by human luteal cells. moreover, we tested the effects of testosterone and androstenedione in presence of exemestane -an aromatase inactivator. highly purified human luteal cells were cultured for h with medium alone (control) or in presence of increasing concentrations of testosterone or dihydrotestosterone or androstenedione (from - to - m) or in presence of increasing concentrations of estriol, estrone and --estradiol (from . to ng/ml). moreover, testosterone and androstenedione - m were tested in presence of exemestane (from to nm). in the culture medium vegf, p, pge and pgf secretion was assayed by commercially available elisa kits. in order to evaluate the influence of androgens and estrogens on vegf mrna expression on luteal cells real-time rt-pcr has been performed. our results demonstrated that testosterone, androstenedione and dihydrotestosterone were all able to significantly reduce vegf secretion in human luteal cells, while no effect was seen on vegf mrna expression. androgens were also able to significantly decrease p and pgf secretion, while an increase was observed on pge production. moreover our preliminary results demonstrated that in human isolated luteal cells estriol, estrone and -estradiol at all tested doses are able to mimic androgens effects on p and pge production. on the contrary estrogens were able to increased vegf release. estrogens seemed to have no effect on pgf  released. data regarding exemestane inhibition of testosterone and androstenedione are still in progress. increased levels of androgens were able to decrease luteal vegf, p and pgf release and might be involved in pcos-luteal phase defect. nevertheless, the observed effects could probably be attributed -at least in part -to estrogens locally produced via the aromatase enzyme, rather than be directly mediated by testosterone and androstenedione. the in vitro effect of proghrelin-derived peptides on purified human luteal cells. anna tropea, mariateresa orlando, maria francesca gangale, federica romani, isamaria loiudice, federica tiberi, stefania catino, antonio lanzone, rosanna apa. cattedrà di fisiopatologia della riproduzione, università cattolica del s. cuore (ucsc), roma, italy; istituto scientifico internazionale (isi) "paolo vi", ucsc, roma, italy; istituto di ricerca "associazione oasi maria ss onlus", troina (en), italy. ghrelin, well known mediator of neuroendocrine effects, has been demonstrated to have a role as signal for energy insufficiency. several evidences suggested that ghrelin might also operate as regulator of reproductive function. indeed, we recently demonstrated that both p and vegf released were significantly decreased by ghrelin in isolated human luteal cells. moreover ghrelin was also able to reduce prostaglandin (pg) e and increase pgf luteal cells release. in the present work we investigated whether two ghrelin-related peptides derived by the same ghrelin precursor (unacylated ghrelin and obestatin) might affect human isolated luteal cells function. conventionally regarded as an inert form of ghrelin, unacylated ghrelin has been recently proven as biologically active in specific cellular contexts. obestatin has been suggested to directly control porcine ovarian cell functions. in these assumptions, we investigated whether unacylated ghrelin and obestatin could directly affect luteal progesterone (p) release. moreover, since vascular endothelial growth factor (vegf) is known to play a critical role in luteal development and function, the influence of unacylated ghrelin and obestatin on luteal vegf, pgf and pge production was also analysed. highly purified human luteal cells were incubated for h with medium alone (control) or with hcg ( ng/ml) or with cocl ( μm) or in presence of increasing concentrations of unacylated ghrelin ( - nm) and obestatin ( - nm). in the culture medium vegf, pgf , pge and p secretion was assayed by commercially available elisa kits. moreover real-time rt-pcr has been performed in order to evaluate whether unacylated ghrelin and obestatin could affect vegf mrna in human luteal cells. our preliminary results demonstrated that either unacylated ghrelin or obestatin are able to negatively affect luteal steroidogenesis. moreover, both peptides seemed to increase the release of two luteotropic factors -vegf and pge and to reduce pgf release -a luteolytic prostanoid -from isolated human luteal cells. finally data regarding the expression of vegf mrna are still in progress. our results suggest that unacylated ghrelin and obestatin -two ghrelin-related peptides -could play a role in regulating luteal function affecting both luteal steroidogenesis and luteotropic/luteolytic imbalance. the mechanisms responsible for labor progression have yet to be fully elucidated. in a previous study, over-expression of small conductance calcium-activated k + channel isoform (sk ) in transgenic mice compromised parturition, suggesting a role for sk channels in this process. based on these findings, we hypothesized that sk channel expression is reduced late in pregnancy to enable the uterus to produce the forceful contractions required for parturition. we investigated the effects of sk channel expression on gestation and parturition by comparing transgenic mice over-expressing mice sk (sk t/t ) mice to wild-type (wt). in wt mice, sk transcript and protein are significantly reduced during pregnancy. the force produced by uterine strips from sk t/t mice on the day of delivery was significantly less than wt or sk knockout control (sk dox ), and the contractile force reached wt levels by application of the sk channel inhibitor, apamin. moreover, lipopolysaccharide and ru , which induce pre-term labor in wt mice, failed to result in completion of delivery in sk t/t mice. thus, stimuli that initiate parturition under normal circumstances are insufficient to coordinate the uterine contractions needed for the completion of delivery when sk channel activity is in excess. the mechanism(s) down-regulating this channel in the uterus during pregnancy is unknown. the sk gene promoter region contains two specificity protein (sp) binding sites; ) sp , is a transcription factor known to enhance the transcription of genes in response to estrogen, and ) sp , which competes for the same binding motif as sp , reduces gene expression. sp protein expression in mice uteri dramatically decreases in late pregnancy, while sp protein level remains consistent. our data indicate that sk channels must be downregulated for the gravid uterus to generate labor contractions sufficient for delivery in both term and preterm mice. the changes in sk channel expression may be transcriptionally regulated by sp and sp . key: cord- -uftc inx authors: nan title: abstract of th regional congress of the isbt date: - - journal: vox sang doi: . /vox. sha: doc_id: cord_uid: uftc inx nan in the fin de siecle was heavily concentrated in vienna. freud, boltzmann, schr€ odinger and mach might be the first names to find, whenever one cites austrian scientists. but more related to transfusion are the noble prize winners max perutz and karl landsteiner. landsteiner s fate illustrates the brain drain beginning in the early s escalating in with the "anschluss", which lead to the forced emigration of many scientists. a loss which was not regenerated in the post war years and was further aggravated by dubious and often undisclosed relations and scandals in the nazi-era. all together this leads to a severe loss of credibility and productivity of universities across decades. opening university access in the early s and intensive historical work-up of scandals transformed the austrian universities to open and effective scientific institutions driving innovation in the country. austria has achieved a great economic deal in recent decades, which was accelerated by the eu membership in . as a result of strong long-term economic performance, the country's gross domestic product (gdp) per capita is the eighth highest among oecd countries and fourth in the eu . levels of poverty and income inequality are both below the oecd average. investment in research and development (r&d) increased since the eu accession, when austria's r&d intensity (aggregate r&d expenditure as a percentage of gdp) was well below the oecd average and significantly far lower than switzerland -a country to which austria prefers comparison. the eu target of % r&d intensity was first met in and is the sixth highest among oecd countries and the second highest in the eu . austria showed the second highest increase in r&d intensity of all oecd countries, exceeded only by korea. the rapid expansion was matched by a similar increase in human resources and scientific output of universities. austrian science in quantum mechanics, quantum communication and information is world renown. vienna is a major biotech hub, as is linz in mathematics and mechatronics and graz in automotive and production technologies. austria has been a net resource recipient in the horizon and the preceding th framework programme. small and mediumsized enterprises show a high propensity to co-operate with universities and other research organisations and more and more included in scientific grant schemes. vienna is the largest student city in the german-speaking world and consistently ranks among the top cities in the world on quality-of-life indices. as austria possesses globally recognised cultural attractions ranging from famed salzburg festival to the vienna new year concert its inhabitants are not aware of the progress made in r&d and how thriving innovation is going on in their country. they still love to show their cultural heritage and events and impress the world with some kind of eternal sound of music. patients with refractory b-cell malignancies as non-hodgkin lymphomas (nhl) resistant to standard therapies have a dismal prognosis. the outcome is even poorer in patients relapsing after autologous stem cell transplantation. most of these patients do not qualify for an allogeneic hematopoietic cell transplantation (hct) due to refractory disease, lack of a suitable allogeneic donor, higher age or cumulative toxicity of previous chemotherapy. despite patients undergoing allogeneic hct normally profit from a graft-versus -lymphoma effect, overall survival in patients with nhl after hct remains short. a similar situation can be observed for patients with acute lymphoblastic leukemia (all). therefore novel treatment modalities are urgently needed. chimeric antigen receptor (car)-t cells, a new class of cellular immunotherapy involving ex vivo genetic modification of t cells to incorporate an engineered car have been used in clinical trials. in the majority of studies b-cell malignancies treated with cd targeting car-t cells have been analyzed. austria had the advantage to participate in two international trials in the past and is currently involved in further car-t studies. recently, results from cd directed car-t cell trials with an increased follow-up of patients led to fda (food and drug administration) and ema (european medicines agency) approval of tisagenlecleucel and axicabtagene ciloleucel. common adverse events (aes) include cytokine release syndrome and neurological toxicity, which may require admission to an intensive care unit, b cell aplasia and hemophagocytic lymphohistiocytosis. these aes are manageable when treated by an appropriately trained team following established algorithm. in this presentation, results of four large phase ii cd car-t cell trials for patients with nhl and all and focus on aes is summarized. preoperative anemia is a known risk factor for increased perioperative morbidity and mortality in patients undergoing major surgery. previous studies have not only shown higher in-hospital mortality, but also an increased hospital length of stay, greater postoperative admission rates to intensive care and prolonged use of mechanical ventilation and intensive care resources in patients with anemia compared to those with normal preoperative hemoglobin concentrations. about % of patients scheduled for major surgery suffer from preoperative anemia. this figure is even higher in patients requiring orthotopic liver transplantation, where up to % of all patients are diagnosed with anemia prior to surgery. transfusion of packed red blood cells (prbcs) is commonly used to correct anemic hemoglobin values. however, transfusion of prbcs has been associated with increased morbidity and mortality in patients undergoing cardiac, orthopedic, and abdominal surgery. additionally, transfusion of prbcs is associated with a greater incidence of postoperative acute kidney injury in patients undergoing orthotopic liver transplantation. as preoperative anemia might increase the perioperative use of prbcs, negative effects observed after prbc transfusions might even be augmented. data on the influence of preoperative anemia on morbidity and mortality after orthotopic liver transplantation are limited. thus, we retrospectively analyzed the association of preoperative anemia and mortality in adult patients undergoing orthotopic liver transplantation at our institution. in addition, we examined the influence of anemia on perioperative parameters such as transfusion requirements, surgical complications, early allograft dysfunction, acute kidney injury, and the need for renal replacement therapy. based on the results obtained in the retrospective analysis, an ongoing prospective randomized clinical trial was initiated. the two suspensive treatments in sickle cell disease (scd) are hydroxycarbamide, inducing the production of the functional hbf, normally repressed at birth, and red blood cell (rbc) transfusion, a critical component of scd management. however, rbc transfusion is not without risk. repeat exposure to allogeneic rbcs can result in the development of rbc alloantibodies which can make it difficult to find compatible rbcs for future transfusions. however, the main concern of alloimmunization is the development of hemolytic transfusion reaction, with in the most severe cases, hyperhemolysis, leading to multi organ failure and death in % of the cases. the prevention of this life threatening condition must be based on risk factors. however, although some risk factors, such as alloimmunization, have been identified, much of the mechanism underlying dhtr remains a mystery, particularly in severe cases presenting hyperhemolysis. here we will describe the current and future development to prevent and treat this severe syndrome in order to decrease exposure to transfusion in scd but also improve red blood cell quality, some new products are developed. oxidative damage is one of the parameter that could be diminished. some work is also ongoing to prevent filter blockage during leucodepletion of precious rbcs units from afro-caribbean donors carrying the sickle cell trait. finally, in countries with higher risks of transmission of infectious disease, treatment of red blood cell units against infectious agents can be discussed. the only current curative treatment of scd is hematopoietic stem cell transplantation (hcs). however, the occurrence, frequency, and effects of immune hematologic complications in hcs remain and will be discussed. finally, gene therapy is a real hope as a definitive curative treatment. clinical trials are ongoing in france and will be discussed as well as the remaining place of transfusion in this therapeutic. in the context of the chronic myeloid leukemia (cml), we have hypothesized that quiescent leukemic hematopoietic stem cells (hsc) compartment, escaping to the current tyrosine kinase inhibitors (tkis) treatment, in part associated in the molecular relapse, may be targeted by cart-cells immunotherapy. gene expression profiling studies have established that a cell surface biomarker il- rap is expressed by the leukemic but not by the normal cd + /cd -hsc. this talk will focus of the whole process of development of a cart-cells starting from recombinant il- rap protein mice immunization to produce a specific monoclonal antibody (mab), to the proof of concept demonstration, before moving into the clinic. we produced and selected a specific anti-il- rap mab (#a c clone, diaclone sa, besanc ßon, france). after molecular characterization of antigen-binding domain, nucleotide sequences were fused with rd generation t cell activation coding sequences and cloned as a single chain into a lentiviral backbone comprising a safety switch suicide gene icasp (inducible caspase ) and a monitoring/selection cell surface marker Δcd . we demonstrated in-vitro and in an in-vivo xenograft murine model that il- rap car t cells can be activated in the presence of il- rap+ cell lines or primary cml cells, secrete pro-inflammatory cytokines, degranulate and specifically killing them. we also demonstrated that multi-tkis treatment over a -year period does not affect transduction efficiency of cml patient t-cells by il- rap car vector and that autologous cart-cells are able to target il- rap+ leukemic primary hsc. "off-tumor-on target" toxicity prediction, by studying il- rap expression on a tissue macroarray comprising normal human tissues ( donors) , with #a c , detected various il- rap intensity staining in only few tissues. regarding the healthy hematopoietic system, #a c flow cytometry staining did not detect hematopoietic cells, except monocytes that express poorly il- rap. as expected, monocyte subpopulation is targeted by autologous il- rap cart cells (ratio e: t = : ), but at a lower level that il- rap cml cell line. in-vivo investigation of specific toxicities of autologous il- rap cart-cells against hsc and/or immune cells on a human-cd + cord blood cell engrafted/nog murine model, but also by an in-vitro cd + colony forming unit assay didn't reveal any significant toxicities in immunocompetent cell subpopulations, suggesting that healthy cd + hsc are not affected. finally, to overcome potential toxicity, functionality of the icasp / rimiducid â safety switch was demonstrated in-vitro but also in-vivo in a nsg tumor xenograft model, showing that, when activate, the system is able to eliminate more than % of cart-cells, after exposure to ap . in conclusion, based on cml model, we demonstrated that il- rap is an interesting target for cart-cell immunotherapy, with a limited "on target, off tumor" predictable toxicity. next step will be the up-scaling of the process in order to match with the use in human regarding also the regulatory requirements. this strategy may be applied, in the future, in other hematological malignancies. mortality ranges from to % for trauma victims with severe bleeding and is largely dependent on the transfusion therapy from which they can benefit. the nature of this therapy has an impact on prognosis with a halving of mortality when the plasma/prbc ratio is greater than ½ and a decrease of about % when the proportion of platelets transfused is close to that of whole blood. the speed with which such therapy is actually administered has a major impact as well with an increase in mortality of % for each minute of delay in making the entire therapy available. this can be explained mainly by the fact that the probability of death of these patients is greater within minutes of their admission to hospital with a median time to death of h after admission. to allow plasma, platelets and prbc to be made available in a timely manner, north american trauma centers have mandated that trauma centers have massive transfusion packs at the patient's bedside within min. to further simplify and speed up logistics from distribution to transfusion, several trauma centers now use whole blood stored at °c. this return of an "old" product is largely inspired by military experience where whole blood is mainly used "warm" immediately after collection with compelling evidence of its effectiveness. its return to civilian practice requires the ability to deleukocyte it while preserving platelets and to store it while maintaining their hemostatic functions. good quality data shows this is achievable and several clinical studies are planned to begin in the coming months. in france, the french blood establishment and the french army are cooperating to initiate the prospective randomized non-inferiority storhm trial (sang total pour la r eanimation des h emorragies massives) which will be comparing whole blood to separate blood components in an / / ratio in severely bleeding trauma patients. the primary endpoint will be a thromboelastographic parameter (maximum amplitude) assessed at the th hour after admission. secondary endpoints will include early and overall mortality, lactate clearance (reflection of the effectiveness of resuscitation) and h organ failure. this trial will be recruiting patients in french trauma centers and is planned to be initiated second half of . local/neighbours day: innovation in germany c- - mesenchymal stromal cells for regenerative therapy bm-msc / asc obtained from these protocols have been characterized in detail in preclinical evaluations. manufacturing licenses for msc and asc and a platelet-derived growth factor concentrate have been obtained and they have been explored in several clinical trials for treatment of bone defects (ortho-ct : eudract number: - - ; ortho-ct : eudract number: - - ; maxillo : eudract number: - - ) . we will summarize results of completed clinical trials which confirmed feasibility and safety of autologous msc /asc treatment and provided evidence for efficacy (gjerde et al, stem cell res. introduction: in vitro produced megakaryocytes (mks) may serve as source to produce platelets (plts) ex vivo or in vivo. we have established a strategy to differentiate mks from induced pluripotent stem cells (ipscs) in bioreactors. this study aimed at the large-scale production of mks using microcarriers to increase the mk yield and to characterize their phenotype and functionality after irradiation as a method to decrease possible safety concerns associated to the ipsc origin. methods: ipscs were cultured in an aggregate form in presence or absence of microcarriers using ml stirred flasks. cells were differentiated into mks using tpo, scf and il- in apel medium for a period of days. non-irradiated or irradiated ipsc-derived mks were analysed for polyploidy, phenotype and proplt production using flow cytometry and fluorescence microscopy. also, plt-production was investigated in vivo. non-irradiated or irradiated mks were transfused to nod/ scid/il- rcc-/-mice and blood was analyzed for human plts. results: differentiation of mks in presence of microcarriers resulted in an -fold increase of mks per ipsc in comparison to only aggregates. this resulted in mean of total mk harvest of . ae . in microcarrier-assisted bioreactors in comparison to . ae . mks collected from bioreactors containing only aggregates. interestingly, mks produced in microcarrier-assisted bioreactors showed higher proplt formation capacity than mks derived from only aggregates bioreactors. mk phenotype and dna content was comparable between mks derived from both types of bioreactors. irradiation of mks did not affect their phenotype and capability to form proplts or plts after transfusion into nod/scid/il- rcc -/mice. conclusion: microcarriers showed to significantly increase the yield of ipsc-derived mks in stirred bioreactors to clinically relevant numbers. this may facilitate the use of ipsc-derived mk for ex vivo production of plts, direct transfusion or for innovative mk-based regenerative therapies. although the rosetta stone, found by the troops of napoleon in egypt near the city of rosetta (rashid) contains only a small amount of text in three languages it was key in deciphering hieroglyphs. the rosetta mission tried to achieve something similar: by looking at a tiny body its goal was to decipher the origin of the solar system, planets including earth and life. after more than years the rosetta spacecraft softly crashlanded on comet churyumov-gerasimenko on september , . it has travelled billions of kilometers, just to study a small ( km diameter), black boulder named p/ churyumov-gerasimenko. the results of this mission now seem to fully justify the time and money spent in the last decades on this endeavor. where are we from? where are we going? are we alone in the universe? these are some of the big questions. in this talk i will show which answers we got from rosetta and comet chury. we follow the pathway of the material which makes up our solar system from a dark cloud to the solar nebula and finally to planets and life. i will show that indeed we are the result of stardust and that what happened here may happen elsewhere in the universe. cells, tissues and entire organs can collectively be seen as "living drugs". genetically unaltered cells are routinely used in clinical practice to treat diseases as diverse as anemia, bleeding disorders, leukemia and organ failure. ground-breaking advances in genetic and genome engineering technologies are propelling cell therapies to the frontline of medical research and practice. the hematopoietic system is particularly amenable to genetic engineering because specific cell types can be purified based on the expression of specific surface proteins and the ability to culture and expand cells ex vivo. the recent unprecedented clinical success of killer t cells reprogrammed by chimeric antigen receptors (cars) to attack cd expressing tumor cells demonstrates the power of immunotherapy with genetically engineered immune cells. however, given the rapid development of novel genome engineering and synthetic biology tools we are likely only at the beginning of a new era of engineered cellular therapies. i will present recent progress in immune cell reprogramming, gene correction, safety aspects and remaining challenges such as manufacturing. d- - cell free nucleic acids (cfna) circulate in the plasma of all individuals and are thought to be released by host and foreign cells into the circulation. after fractionation by centrifugation, cfnas can be extracted from the supernatant of whole blood samples or manufactured blood products. these dna or rna sequences can be of human, bacterial, viral or fungal origin. most of them are human double stranded dnas. research on cfnas is increasing, thanks to technological advancements in molecular biology. some of their results are already implemented in clinical practice in the areas of prenatal diagnosis, oncology and infectious diseases. the latter investigation focuses on the exploration of non-human cfnas, the field of metagenomics. high throughput sequencing associated with bioinformatics, the so-called new generation sequencing (ngs), has sped up the investigations of non-human cfnas. this tool provides the opportunity to classify cfnas into a human or non-human category, and then to identify them. it is thus possible to explore simultaneously the whole landscape of bacterial, viral and fungal populations. presently, ngs of human blood has already proven its feasibility and its value in identifying emerging viruses or investigating clinical cases of fever of unknown etiology. ngs of cfnas is also particularly effective in analyzing the different genotypes of a virus in case of a co-infection (e.g. hepatitis c virus). studying cfnas with the new molecular technologies is therefore of great importance in transfusion medicine, especially regarding security and clinical transfusion reactions. first, transfusion transmitted infections are the most feared adverse complications. second, febrile non-hemolytic transfusion reactions are also the most frequently reported adverse events in hemovigilance systems and their physiological mechanism -if only one-remains not clearly elucidated. investigating cfnas could thus improve our understanding and strategy aiming at reducing those two clinical adverse events. surveying comprehensively the composition of circulating infectious agents in a blood product by ngs technology could be very interesting for investigating a severe febrile transfusion reaction. moreover, when the costs of analysis will be reduced, it might be possible to screen prospectively and regularly the whole metagenomics of asymptomatic blood donors, in addition to the classical epidemiological surveillance. for instance, in a study testing a ngs method on manufactured fresh frozen plasmas, an astrovirus (mlb ) has been identified. finally, it is the responsibility of transfusion physicians implicated in the manufacturing of blood products to ensure that cfnas within a blood product do not have a clinical impact on the innate immunity of the recipients. according to recent research in vitro, cfnas purified from blood products can induce the transcription of inflammatory cytokines by mononuclear cells. as nonhuman cfna have an effect on toll-like receptors (tlr-linked inflammatory pathways), it would be also relevant to insure that donor's cfnas have no significant effect on the immune system of the recipient. in conclusion, cfnas are very diverse molecules contaminating blood products. technological progress makes now their investigation more available. besides being useful markers of infection in asymptomatic donors, their impact on the recipients' immunity should be further investigated. an active life and regular training is part of a healthy life style and for many this includes participation in endurance exercise competition at different levels. thus, it is highly relevant to know how a blood donation affects exercise performance and how close this can done to an endurance competition. endurance exercise performance is determined by many factors, but three of the primary are maximal oxygen uptake, the relative load that an individual can sustain over time and finally the efficiency of movement in the given discipline. over the years, a number of studies have sampled blood volumes ranging from - ml and applied different methodological approaches to measure maximal oxygen uptake over a recovery period ranging between - days. overall, the general finding is a reduction in blood haemoglobin and an attenuated maximal oxygen uptake as well endurance performance after blood donation. in normal to well-trained men maximal oxygen uptake and performance was normalized after two weeks in one study after a normal blood donation ( / ml), but remained attenuated after four weeks in another study, despite the change in blood haemoglobin concentration was similar and the design and methodology also similar in the two studies. in addition to maximal oxygen uptake the relative load that can be tolerated during exercise is probably also attenuated, through a decreased arterio-venous oxygen extraction, but the available data is very limited. the first part of this talk will highlight the major findings and discuss some of the methodological issues that complicate interpretation and conclusions. there are sex differences in circulating blood volume, haemoglobin concentration, haematocrit and hormone levels and thus it is entirely possible that there is a sex difference in the effect of blood donation on physical performance and the recovery after blood donation. in addition to the basic physiological sex differences, there is also a higher prevalence of iron deficiency in premenopausal women, physically active women and women donating blood. therefore, we studied the influence of a standard ml blood donation on maximal oxygen uptake and endurance performance and the subsequent recovery in physically active women. we observed that in iron sufficient women blood haemoglobin concentration and maximal oxygen uptake were back to baseline days after blood donation, but endurance performance was normalized already after days. the second part of this talk will discuss the sex differences in the effect of blood donation on maximal oxygen uptake and endurance performance. overall, the available data suggest that, with a careful conservative approach, - weeks are needed after a normal blood donation to be fully recovered to participate in endurance exercise competitions. more than one in ten attempts to donate blood result in a temporary deferral, due to concerns about the impact of the donation on the donor or recipient. there is well established evidence that temporary deferrals impact negatively on donors, with a large proportion of those deferred failing to return at the end of the deferral period. this presentation provides an overview of deferrals from the donor perspective, describing the likelihood of receiving a deferral for different donor subgroups. the impact of temporary deferrals on the future donation of donors, considering both short-term and longer-term donation patterns, will also be reviewed, outlining which donors are at highest risk of non-return following a deferral, and what is known about the accumulative impact of multiple deferrals on donors. several hypotheses have been proposed to account for the strong negative impact of deferrals on donor behaviour, and there is preliminary evidence of psychological factors, such as emotional reactions, predicting intention to return. research is also beginning to emerge on the effectiveness of tailored interventions to mitigate the impact of deferrals on donor behaviour. the evidence for these preventative interventions, and for strategies to reactive donors once they have lapsed post-deferral, will be reviewed. recommendations for blood centres will be made, as well as suggestions for future research to address continuing gaps in knowledge. in his influential study "the gift relationship" ( ) , richard titmuss coined the idea of voluntary, non-paid, blood donation being the gift of life for a fellow citizen. this metaphor has been powerful in mobilizing donors (busby ) . it conveys a direct relationship between blood donation and patients' vitality, as well as a difference between gains and costs. as the gift of life, blood donation is seen to symbolize pure altruism and promoting solidarity between strangers. but can we apply the metaphor as successfully into donating blood for research? we asked a group of finnish blood donors what they would think if the frc blood service invited them to give a blood sample and personal information for research. the blood donors were usually willing to contribute to research for the public benefit, because they saw great potential in science to create solutions to help patients in the future. however, based on our interview data and previous research, we suggest that the analogy between gift of life and donation for research did not work all the way. the metaphor fails to address donors' questions on new types of relationships, interests and risks related to the use of personal data for research. left unanswered these could discourage donating for research. hence, we argue that the gift of life metaphor is not applicable to donor recruitment at the research context. in this presentation we wish to look for a better metaphor for donation for research that blood services collecting research data could apply. academy day: transfusion challenges in patients with sickle cell disease a- - immunohaematological features of patients with sickle cell disease (lfa) should be considered as polymorphic antigens in the african population and these lfa are not present in most commercial panels. the situation is even more complicated when recipients lack high-frequency antigens, the most common ones being hr-, hr b -, sec-, u neg , u+ var , js(b-), (hy-), and jo(a-). finally, there is a high rh diversity among people of african descent. because they harbor variant alleles and/or partial rh antigens, they are at risk of developing alloantibodies. in this setting, screening for partial rh antigens makes sense. the figures illustrating this diversity vary with the approach used. one of them is to take into consideration rhd or rhce*ce variant alleles. in several american studies, their prevalence was estimated to be - % and - %, respectively. other teams take into consideration d, c and e partial antigens. their prevalence was estimated to be . - %, . - . %, . - . %, respectively, and the alloimmunization rates were . %, . - %, . %, respectively. as a result of these phenotype discrepancies, scd patients are more likely to be alloimmunized. an overall immunization rate of - % is commonly admitted in the general population. depending on the unit selection policy and/or the study design, the immunization rate in scd patients varies from % to %, the highest figures being established when an abo/rh -only matching policy is implemented. in a meta-analysis of publications, the overall alloimmunization rates were around %. alloimmunization is thought to be enhanced by an inflammatory state, which is often present in scd patients. they are more prone to develop a new alloantibody. using a stochastic modeling of alloimmunization, they have a % increased risk of producing additional antibodies versus % in the general population. autoantibodies have been identified as a risk factor of alloimmunization. as a result, scd patients often have complex mixtures of allo and autoantibodies. rh antibodies and those considered as irregular natural antibodies are present in a significant proportion. another characteristic of the antibodies in scd patients is their evanescence; up to % of alloantibodies become undetectable within a few years of their initial development. relatedly, about a third of dhtrs are reported to happen in patients with no previous history of immunization. in addition, a third of patients will not develop an antibody after a dhtr. identifying patients at risk of developing a dhtr is key to managing them properly. alloimmunization is a serious risk of red blood cell transfusion in patients with sickle cell disease (scd) and can result in severe (delayed) haemolytic transfusion reactions, exacerbation of clinical symptoms and life-threatening hyperhaemolysis. once alloimmunized, the presence of alloantibodies in the patients' blood further complicates pretransfusion testing and hampers the selection of compatible blood products. numerous studies have shown that scd patients have a relatively high risk of alloimmunization as compared to the 'general' population. this is not only explained by the large number of transfusions given but also by the increased exposure to foreign antigens as a result of differences in the antigen make-up of the scd recipients and the blood donor population. other factors involved in the immune response such as age at first transfusion, inflammatory state, hla typing are under investigation and are starting to unravel. because blood transfusion is still one of the main treatment modalities for scd and some patients have a life-long transfusion dependency it is important to minimize the alloimmunization rate. theoretically, complete matching for all relevant blood group antigens would prevent alloimmunization. this however, is only possible when all donors are comprehensively. matching strategies should be developed to minimize alloimmunization while balancing patients' need and donor availability and is cost effective. to develop a (preventive) matching strategy some factors need to be established; ) which antibody specificities are clinically relevant ) which antigens are most immunogenic ) what is the availability of specific antigen typings in the donor population ) how should recipients (and donors) be typed, phenotypically and/or genotypically and to what extent. the latter is especially important in scd patients since they are of african descent and the prevalence of genetic variations in this population is relatively high. rhd and rhce variants are common and can remain undetected when serological typing is used but can be discovered with high resolution molecular typing. patients with partial rh phenotypes are at risk for alloimmunization. apart from special rh phenotypes in individuals from african descent, the fy(a-b-) phenotype related to the gata-box mutation in the fyb allele and the u-or u var phenotype resulting from genetic variations in the mns alleles are also common. several studies have shown that in scd patients antibodies directed against rhd, rhe, rhc and k are most frequently found when unmatched transfusions are given. preventive matching for these antigens has proven successful in reducing alloimmunisation. extended matching for all rh antigens fy(a), jk(a) and jk(b) can further decrease the alloimmunisation rate. currently, different countries have preventive matching strategies in place for this vulnerable patient group. as genotyping is more and more available and within reach, optimal antigen typing approaches for patients and donors, combining serology and genetics are being developed. in this lecture several aspects of antigen typing approaches and preventive matching strategies that will most benefit scd patients of will be discussed. artificial intelligence has become a buzzword that will appear about anywhere in the media. we can forget that ai, or the subfield in this computer science field machine learning, has been around for over years. improvements in computing power, abundance of data, progress in computer science, and the arrival of affordable cloud solutions have now brought it to our daily lives. also in health care news about ai has become omnipresent. and some landmark papers have come out on algorithms outperforming (teams of) physicians in the diagnosis of all kinds of skin disease, eye disease from retina scans, and detect cancer in ct scans. however, little of these solutions have actually shown up in our clinical practice yet. in anaesthesia, we worked with the first algorithm to come to anaesthesia practice; hypotension during surgery is associated strongly with poor outcome like myocardial ischemia, surgical complications, renal failure and even mortality. we worked on a machine-learning trained algorithm that predicts hypotensive events using the arterial blood pressure curve up to - min before the actual event. to get fda and ce approval, however, mere mathematic validation is required. this can be achieved on retrospective datasets. in reality, we need more before we can use these algorithms to support our decision-making; after internal (retrospective) and external (prospective but passive use) validation steps, clinical (i.e. rct validation is needed. moreover, we will need to assess the economic impact too. ultimately this tool has now reached clinical practice and is starting to help us go from reactive to more proactive hemodynamic management. like this, we have started to work on machine-learning tools to predict the incidence of specific types of patients coming into a&e and predicting infections after surgery. we will discuss our approach, essentials to start with machine learning, practical learnings. we will also discuss a first project design to use machine learning in managing bleeding patients to get the best therapy advice for blood product use like plasma, fibrinogen et cetera. how can we start using this tool in unison with our existing tools to improve science and clinical practice in our respective (bio)medical fields? thrombocytopenia is a very common hematological abnormality found in newborns, especially in preterm neonates. two subgroups can be distinguished: early thrombocytopenia, occurring within the first h of life, and late thrombocytopenia, occurring after the first h of life. early thrombocytopenia is associated with intrauterine growth restriction, whereas late thrombocytopenia is caused mainly by sepsis and necrotizing enterocolitis. platelet transfusions are the hallmark of the treatment of neonatal thrombocytopenia. most of these transfusions are prophylactic, which means they are given in the absence of bleeding. however, the efficacy of these transfusions in preventing bleeding has never been proven. in addition, risks of platelet transfusion seem to be more pronounced in preterm neonates. because of lack of data, platelet transfusion guidelines differ widely between countries. in a recent randomized controlled trial (planet- /matisse study) among preterm infants with severe thrombocytopenia, we found that those randomly assigned to receive platelet transfusions at a platelet-count threshold of /l had a significantly higher rate of death or major bleeding within days after randomization than those who received platelet transfusions at a platelet-count threshold of /l. this presentation summarizes the current understanding of etiology and management of neonatal thrombocytopenia. transfusion-associated circulatory overload (taco) is a severe transfusion adverse reaction that is associated with increased mortality and morbidity. the incidence of taco in adults varies from % to %, but is probably underdiagnosed and underreported. the incidence in the pediatric population is undetermined. taco usually occurs in patients who receive a large volume of blood product over a short period of time. it is more common in patients with known risk factors such as cardiovascular disease, renal failure, and older or younger age (> years or < years). hospitalised patients and intensive care patients are also more at risk. the typical presentation of taco is respiratory distress (dyspnea, tachypnea) occurring within h of a blood transfusion. associated signs and symptoms are hypoxia, hypertension, tachycardia, positive fluid balance, high central venous pressure, and acute or worsening pulmonary edema on chest x-ray. echocardiography and measurement of brain natriuretic peptide (bnp) or its n-terminal prohormone (nt-probnp) is helpful for diagnosis. several definition criteria have been proposed for taco, but none are adapted for children, particularly critically-ill children who are more at risk. this is probably the main reason why taco is even more underdiagnosed and underreported in the pediatric population. in a recent study, we compared the incidence of taco in a pediatric intensive care unit using the international society of blood transfusion (isbt) criteria, with two different ways of defining abnormal values: ) using normal pediatric values published in the nelson textbook of pediatrics; and ) using patients as their own controls and comparing pre-and post-transfusion values with either a % or % difference threshold. we monitored for taco up to h post-transfusion. a total of patients were included. taco incidence varied from . % to %, depending on the definition used. with such wide variability, we conclude that a more operational definition of taco is needed in pediatrics, particularly for critically-ill children. differential diagnosis from other dyspnea-associated transfusion adverse reactions (e.g. transfusion-associated lung injury, anaphylaxis) is important because treatment differs, as do guidelines to the blood bank. treatment for taco is similar to that of any other cardiogenic pulmonary edema: oxygen, diuresis, ventilatory support. prevention is possible by avoiding unnecessary transfusions, transfusing only the necessary amount of blood product, avoiding rapid transfusions, and using diuretics. background: the risk and importance of transfusion-transmitted hepatitis e virus (tt-hev) infections by contaminated blood is currently a controversial discussed topic in transfusion medicine. in particular, the infectious dose is a not finally determined quantity. the different countries have chosen different approaches to deal with this pathogen. one central question is the need of individual nat screening (id) versus minipool nat screening (mp) approaches to identify all relevant viremias in blood donors. aims: comparison and evaluation of the available screening strategies in relation to the infectious dose to minimize the risk of tt-hev infections. methods: we systematically reviewed the presently known cases of tt-hev infections and available routine nat-screening assays. furthermore, blood donation screening strategies for hev ehev in effect in the european union were compared. we also describe our own experiences of hev screening utilising an id-nat-based donor screening algorithm compared to mp-nat in pools of samples. from november to january , a total of , blood donations were screened for the presence of hev rna using a mp-nat (in house, realstar hev rt-pcr kit) and an id-nat (cobas platform). results: the review of the literature revealed a significant variation regarding the infectious dose causing hepatitis e. in the systematic case review, all components with a viral load (vl) greater than . e+ iu caused infection (definitive infectious dose (difd) . the lowest infectious dose resulting in tt-hev infection observed in general was . e+ iu (minimal infectious dose (mifd). the infectious dose of the different blood products is mainly influenced by the remaining plasma content. our data comparing the two different hev screening algorithms revealed eight hev rna positive donations using a mp-nat (incidence : , ) , whereas hev rna positive donations were identified by id-nat (incidence : ); all id-nat only positive donations had vl < iu/ml. summary/conclusions: taken into account the current knowledge on the required mifd, the difd, and the analytical sensitivities of the screening methods, we extrapolated the detection probability of hev-rna positive blood donors using different test strategies (nat assay, id vs. minipool with different pool sizes). we also considered the amount of plasma in the different blood products and calculated the infectious doses needed to be detected. only id testing would be sufficient to detect the minimum vl in the donor to avoid tt-hev infections based on the currently known mifd, but a highly sensitive mp-nat should be adequate as a routine screening assay to identify high viremic donors and avoid tt-hev infections based on the difd. we have also determined that the incidence of hev infection was approximately % higher if id-nat was used. however, vl were below iu/ml and will most likely not result in tt-hev infection taken into account the currently known mifd or difd. the clinical relevance of and need of identification of these low level hev positive donors still require further investigation. in the last years several pathogen inactivation (pi) technologies have been developed to be applied to blood components. technologies for inactivating pathogens in plasma and platelets are available in the european union, and some others are currently under development. the first pi technology introduced in the market was for plasma, and was based on the addition of methylene blue and the illumination with light (theraflex mb-plasma, macopharma and gr ıfols). for platelets and plasma two technologies are licensed, one is based on the addition of amotosalen and the illumination with ultraviolet light (uv) (intercept â , cerus) and the other one combines the addition of riboflavin (vitamin b ) and the illumination with uv light (mirasol â , terumo bct). currently another technology for platelet inactivation, based on the illumination with uvc light and strong agitation is under development (theraflex, macopharma). for red blood cells one technology based on the addition of one molecule (amustaline, cerus) is being developed. the mechanism of action, and the spectrum and level of inactivation of pathogens varies among the different technologies. in addition, the number of studies with clinically relevant endpoints and the number of patients included in the studies is not homogeneous. there is published evidence for most of them that show that the treated blood components are safe and efficacious for the patients although, for treated platelet concentrates some decrease in the posttransfusion recovery and survival of the transfused platelets occur, with differences between the different technologies. however, cumulative experience on the use in routine, for some of the technologies for almost years, support the concept of the safety and efficacy of the blood components treated with pathogen inactivation technologies without a significant increase in utilization. the use of pathogen inactivation for blood components is not widespread. differences in epidemiology between countries, infectious risk perception, concerns about potential adverse effects associated with its use and economical considerations might explain the differences observed in its implementation. the history of the p and p k antigens is complicated and sometimes confusing because of several changes to the nomenclature. the association between the antigens and their genetic home has raised many questions as well as the longstanding enigma regarding the molecular mechanism underlying the common p and p phenotypes. the system (isbt no. ) currently includes three different antigens, p , p k and nor. the p antigen was discovered already in by landsteiner and levine while p k and nor were described in and , respectively. as for the abo system, naturally-occurring antibodies of igm and/or igg classes can be formed against the missing p /p k carbohydrate structures. anti-p is usually a weak and cold-reactive antibody very rarely implicated in hemolytic transfusion reaction (htr) or hemolytic disease of the fetus and newborn (hdfn). however, some antibodies against p have been reported to react at °c, bind complement and cause both immediate and delayed htrs. the p k antibodies can cause htr and anti-nor is regarded as a polyagglutinin with unknown clinical significance. a higher frequency of miscarriage is seen in women with the rare phenotypes p and p k /p k . the rbc of the fetus as well as of the newborn express low amounts of p , p and p k antigens but the placenta shows high expression and is consequently a possible target of the antibodies and the cause of the miscarriages. the p k and p antigens have wide tissue distributions and can act as host receptors for various pathogens and toxins. furthermore, altered expression of p k antigen has been described in several cancer forms. a longstanding question has been why individuals with p phenotype not only lack p k and p expression but also p . recently it was clarified that the same a galtencoded galactosyltransferase synthesizes both the p , p k and nor antigens and in addition the p and p phenotypes was confirmed to be caused by transcriptional regulation. transcription factors bind selectively to the p allele in the '-regulatory region of a galt, which enhance transcription of the gene. it has been debated whether the p k and p antigens exist on glycoproteins in the human rbc membrane or if glycolipids are the only membrane components carrying these epitopes. a recent publication shows that the p antigen can be detected on human rbc glycoproteins and thus glycosphingolipids can no longer be considered as the sole carriers of the antigens. the blood group system which started out with one antigen, p , has now gained two more members namely p k and nor. step by step the biochemical and genetic basis underlying the antigens expressed in this system has been revealed but still many questions remain to be solved. neither gata nor klf represent a blood group system but mutations in the genes encoding these transcription factors (tfs) have been shown to result in simultaneous altered expression of blood group antigens in certain rare blood group phenotypes. in particular, mutations in the klf gene are responsible for the dominantly inherited in(lu) phenotype, commonly referred to as lu(a-b-) because of the gross reduction in lutheran antigens expression. red cells from in(lu) individuals, though, have also weakened expression of other blood group antigens, like the high-incidence antigen anwj, the antigens of the indian blood group system (cd ) and p , among others. since the first description of klf variants associated with the in(lu) phenotype, many other variants of this gene have been reported with an impact on blood group antigen expression and they are listed on the klf table of blood group alleles. other than klf , a mutated gata gene has also been found associated with the x-linked form of the lutheran-mod phenotype and has likewise been registered in the gata allele table. besides the effect of tf variants on blood group antigen expression, there are transcription factor-binding site polymorphisms in regulatory regions of blood group genes, which also have an impact on the expression of the encoded antigens in red cells. the first example of such type of polymorphisms was described in , when the disruption of a gata motif in the ackr gene promoter was found to abolish erythroid gene expression in fy(a-b-) individuals of african descent. the impact of mutations affecting gata binding sites has also been described in some abo subgroups, like the am and bm phenotypes. a regulatory element with gata binding sites in the first intron of the abo gene has been found to be altered in individuals with these phenotypes, either by deletion or by a point mutation disrupting the gata motif. recent findings have also revealed that xga expression on red cells is dependent on gata binding to a control element located . kb upstream of the xg gene. a single nucleotide polymorphism (snp) within this region was shown to correlate very well with the expected distribution of the xga negative phenotype in different populations. further work has demonstrated that this g>c snp disrupts a gata binding site and consequently abolishes erythrocyte xg expression. overall, these investigations have allowed to elucidate the underlying genetic basis for xga expression and have made xga genotyping possible. similar to xga, the p antigen has been known for a long time to be determined by the a galt gene but the molecular basis underlying the common p /p phenotypes has remained elusive till recently. several cis-regulatory snps had been identified in non-coding sequences around exon a, which showed a very good correlation with p antigen expression. interestingly, potential binding sites for several hematopoietic tfs were identified in the same region. finally, recent investigations have demonstrated the role of the runx tf in the expression of p antigen, by selective binding to a regulatory site present in p but not in p alleles. to summarize, variation in blood group antigen expression may result from mutations or polymorphisms in the regulatory region of blood group genes. recent reports have unravelled the molecular mechanisms underlying the expression of p and xga blood group antigens, which involves tf binding to allele-specific regulatory elements. similar mechanisms may also regulate antigen expression in other blood group systems. c- - clinical immunology, copenhagen university hospital, copenhagen, denmark since the discovery of cell-free fetal dna (cffdna) in pregnant women's blood, the development of noninvasive prenatal testing (nipt) has provided new diagnostic applications in prenatal care. in transfusion medicine and clinical immunology, cffdna is extracted from maternal plasma to predict fetal blood groups with the purpose of ) guiding targeted rh prophylaxis in non-immunized rhd negative women and ) assessing the risk of hemolytic disease of the fetus and newborn (hdfn) in immunized women. i will give an overview of noninvasive prenatal testing of fetal blood groups. based on the literature, i will summarize the current experience with noninvasive prenatal testing of fetal rhd and other blood groups. for rhd negative pregnant women, routine clinical testing is available in several countries world-wide to assess the risk of hdfn in d immunized women, and routine testing to guide rh prophylaxis is now implemented as nationwide service in - european countries. noninvasive prenatal testing for fetal rhd is highly accurate with sensitivities of . %, as reported from clinical programs. in general, the sensitivity is challenged be low quantities of cffdna, especially in early pregnancy. the specificity is challenged by the polymorphic rh blood group system, where careful attention is needed to navigate among the many rhd variants. rhd variants may complicate cffdna analysis and interpretation of results, especially in populations with mixed ethnicities. despite these challenges, fetal rhd testing is very feasible when implemented with careful attention to these issues. for blood groups that are determined by snps, such as kel or rhc, the main challenge has been interference from the maternal dna when analyzing the fetal dna which has resulted in low accuracy and lower sensitivity, when using qpcr. with the application of more novel techniques such as next generation sequencing and droplet digital pcr, accurate noninvasive prediction of these fetal blood groups has been demonstrated. the success of predicting fetal rhd and its successful clinical implementation into national programs should encourage wide-spread use of cell-free dna based analysis. future work on noninvasive prenatal testing of fetal blood groups determined by snps may consolidate the application for cell-free dna testing for such targets, including human platelet antigens. at isbt, the newly formed cfdna subgroup of the red cell immunogenetics and blood group terminology working party will work to facilitate clinical applications, implementation and evaluation of cell-free dna testing. blood banks in most of the nordic countries all share a vein-to-vein approach which in short means that the collection of blood, the preparation of blood components, testing/release and storing is served by a single actor. on top of that recipient and donor blood grouping, crossmatching, delivery, registration of transfusion and of any complications is usually handled in a single blood banking information system (bbis). this means that blood banks in the nordics are traditionally operated by a single vendor. the needs for process control in a single vendor bbis, the present solutions, unsolved challenges and untapped possibilities of streamlining processes have been scrutinized with the intention to describe separate processes and to acquire best of breed or best of suite it-systems. the aim for integrations, rather than building an integrated it-system, to support the need for a vein-to-vein process is a precondition in the nordic countries. with multiple it-systems supporting isolated processes, we intend to facilitate development in these and furthermore increase the flexibility in the whole process. we set out to reveal any existing knowledge in the literature on it vendor strategies for blood banks, but we didn't succeed in identifying any relevant literature. however, a systematic literature study on vendor strategies when choosing health it was based on the prisma method, and identified studies, but only was eligible for full text review and met the inclusion criteria. even this broader literature study reveals very little evidence. two studies find single vendor strategies poor and conclude "best of suite" solutions to be optimal. one study was not able to correlate vendor strategies to the investigated productivity, but concludes that best of suite and best of breed strategies requires larger organizational changes than a single vendor strategy. in summary, the existing research is contradictory. this paper adds basic knowledge for breaking down the process control of blood banking in smaller processes. this adds the possibility for identifying best of breed or best of suite vendors, instead of relying on single vendor it solutions. furthermore it is a call for more research in the field of vendor selection strategies which this study didn't succeed in identifying. d- - applying drones to supply blood to remote areas: rwanda's experience biomedical services, rwanda-ministry of health-national blood services, kigali, rwanda background: in rwanda, blood transfusion services started in . during the genocide against the tutsis almost all the socioeconomic fabric of rwanda was destroyed as well as its health infrastructure. the healthcare system was suffering in its aftermath, and there were health inequalities between urban and rural areas, including access to blood for transfusion. from , the government started to rebuild all courses of life including the health system and the blood service in particular. the national center for blood transfusion (ncbt) was then mandated to provide safe, effective and adequate blood and blood components to all patients in need. this was pivotal in achieving health related mdgs , and . today, rwanda has an ambitious vision to put all million citizens within minutes of any essential medical product. while every second matters in emergency management, the use of drones was the perfect solution to many of the last mile challenges that have been traditionally difficult to overcome. it is impossible to forecast accurately down to the need of a single patient. the government has provided an easy solution by centralizing supply and providing on-demand, emergency medical deliveries by drone. doctors are now empowered to provide the quality care with all the supplies on hand, patients can now be treated close to home, and we eliminate waste from potential overstocking when health workers know that they have a quick and reliable source of supply. description: in , the government of rwanda started to operate the world's first national drone delivery program for blood and other lifesaving medical products. these drones can carry two to six units of blood at a time and deliver in - minutes depending on a hospital's location. the average duration was between - hours round trip with the vehicle system, before the use of drones. drones currently deliver blood to health facilities throughout the country and are set to reach % of transfusing health facilities outside kigali by the end of the year. within the first year, healthcare workers saved an average of . hours per delivery and a total of , hours of lost time on road pick up they could instead dedicate to patient care. by march , over , deliveries have been made, with % of those being emergency deliveries. a total of more than , blood units have been delivered. in february , zipline obtained the highest rating from the health facilities being served in a performance evaluation conducted by the national center for blood transfusion. when a doctor or medical staffer needs blood, they place an order through the hemovigilance order portal. they are then sent a confirmation message saying a drone is on its way. the drone flies to the health facility at up to km/h. when it is within five minutes of the destination, the medical staffer receives a notification. the drone then drops the package, attached to a parachute, into a special drop zone. conclusion: supply is not a developing country problem, it is a global issue. rwanda was just the first one to recognize the potential of this technology and decided to do something about it first and fast, to ensure access to universal access to all blood products. d- - scottish national blood transfusion service, edinburgh, united kingdom supporting the provision of viable transfusion services in remote/rural areas is more than just a geographical challenge. limited qualified blood bank resource; small throughput volumes; increased regulation are only three of the additional factors combining to threaten safe and sustainable transfusion service delivery. inventory management and out of hours service provision were identified as essential areas where it was thought that technology, in the form of a remotely controlled blood fridge, could provide a key element of the overall solution. a radio frequency identification (rfid) fridge racking system was installed in a standard blood bank fridge and connected to the laboratory information management system (lims) common to both the remote and central blood bank. the central blood bank was enabled to test patient samples from the remote laboratory, identify components located in the remote fridge suitable for the patient and allow correct component issue, even when qualified staff were unavailable in the remote laboratory. testing has concluded that installation of remote fridge management can play a major role in helping to maintain a remote inventory permitting patient compatible components to be issued. by sustaining transfusion services in remote communities we can avoid transportation of patients who require transfusion support to locations miles from home. antibodies to hna- b, fcgriiib and hna- have been reported, too. neonatal alloimmune neutropenia results from maternal antibodies transferred transplacentally to the fetus and is caused by all known hna-antibody specificities, i.e. hna- a, - b, - c, - d, hna- , hna- a, - b, hna- a, - b and hna- a specificity. hna and hla antibodies can induce mild febrile transfusion reactions and trali. since the introduction of the male only plasma strategy, in many countries the trali incidence decreased but it is still one of the most common causes of severe transfusion reactions. especially hna- a antibody containing plasma from female donors is responsible for severe or even fatal reactions. but also hna- a, - b, hna- and hla class i and class ii antibodies were reported. the latter activate monocytes to secrete soluble factors that act on the primed neutrophils in the narrow lung capillaries. laboratory testing: laboratory work-up requires the knowledge of the patient's clinical condition and the methods that are appropriate to detect the relevant antibodies. the classical granulocyte agglutination test (gat) in combination with the granulocyte indirect immunofluorescence test (gift) can detect nearly all relevant antibodies. hna- , - , - , - and hla class i antibodies are clearly detectable in the gift while hna- antibodies strongly agglutinate neutrophils in the gat. the monoclonal antibody-specific immobilization of granulocyte antigens (maiga) test detects all hnaantibodies except for hna- with high glycoprotein specificity and sensitivity but is time consuming and requires highly skilled personnel. for trali diagnostics laboratory testing is completed by methods like the indirect lymphocyte immunofluorescence test (lift) or elisa for hla class i antibodies and hla class ii specific elisas. since several years fluorescent bead based assays (luminex) enable faster and more automated hna antibody detection but to date not all specificities, especially hna- , can be reliably detected so that still the classical gift and gat have to complete the methodological spectrum. serological typing today is mostly reduced to the determination of hna- in the gift because the molecular reason for the hna- -null phenotype is not completely understood. establishing only one pcr-asp reaction for the main cd * a>t polymorphism would comprise the risk to miss other molecular causes. however, for all other hna allelotyping by pcr methods is the first choice. summary/conclusions: granulocyte serology still today is widely based on a variety of manual methods and will be reserved to specialized laboratories as it requires experienced laboratory staff and profound knowledge of granulocyte immunobiology. d- - norwegian national unit of platelet immunology, laboratory medicine, university hospital of north norway, tromso, norway maternal alloantibodies against antigens on human platelets can cause severe thrombocytopenia and bleeding in fetus or newborn, identified as fetal/neonatal alloimmune thrombocytopenia (fnait) . although most cases the thrombocytopenia is selfresolving within the two first weeks of life, some infants present bleeding symptoms and thus require platelet transfusion. a set of laboratory analyses are required to confirm the fnait diagnosis. in addition to guiding compatible platelets to the affected newborn, the correct diagnosis will be valuable to assess the risk of fnait in subsequent pregnancies. in addition, platelet alloantibodies may also complicate platelet transfusions by immune-mediated platelet refractoriness, and require proper identification of the patient's antibody specificities prior to selection of donor platelets. the algorithm for laboratory investigations include both serological and molecular assays, and depend on the objective and timing: whether there is an urgent need for platelet transfusion, follow-up of a pregnancy with known risk, or to do full-scale laboratory testing to confirm diagnosis. molecular genotyping should include all hpa systems relevant for the local population (in caucasians hpa- , - , - , - and - ), preferably with optional extended panels for systems for low frequency populations due to immigration/mobility and for less frequently seen alloantibodies (hpa- , - to - are most commonly included). serological testing of antibody binding to platelets is often initially tested by flow cytometry analysis (direct test and/or cross-match). however, the detection of platelet-specific antibodies is often complicated by the presence of anti-hla class i antibodies and thus require sensitive platelet glycoprotein-specific assays. serological testing for platelet-specific antibodies includes as a minimum panels of antigens on gpiib/iiia, gpib/ix, gpia/iia and cd and preferably additional targets for populations with asian/african origin. several methods are available; i.e. bead-based assays and elisa based methods. however, most reference laboratories perform variants of the monoclonal antibody immobilization of platelet antigens assay (maipa), as reported by the th international platelet immunology workshop of isbt ( ) . the investigations also include measurement of the anti-hpa- a by quantitative maipa if present, as this is reported to potentially predict the severity of fnait. for pregnancies with known risk of fnait, there are methods available to perform non-invasive prenatal typing from maternal plasma. the most feasible and so far appropriate for routine testing is fetal hpa- typing with quantitative pcr or by melting curve analysis. other sophisticated, yet resource-demanding techniques have also recently been reported -importantly also for typing of other hpa-systems. d- - molecular basis of hna- expression justus liebig university, institute for clinical immunology and transfusion medicine, giessen, germany human neutrophil antigen (hna- ) is a neutrophil-specific antigen located on gpi-anchored glycoprotein cd (also known as nb ). hna- is absent on the neutrophil surface of - % of the healthy individuals that divided the population to hna- positive and hna- null individuals. exposure of hna- null individuals to hna- positive neutrophils during pregnancy, after transfusion or transplantation, induces immunization against hna- and consequently the production of iso-antibodies. the hna- iso-antibodies are involved in the mechanism of neonatal alloimmune neutropenia (nain), transfusion-related acute lung injury (trali) and graft failure following bone marrow transplantation. presence of cd on a neutrophil surface of hna- positive individuals follows a bimodal expression that categorizes the circulating neutrophils to hna- positive and negative subsets. the cd gene contains exons encoding a protein of amino acids. the lack of hna- (in hna- null individuals) is associated with the presence of a missense mutation, cd *c. a>t in exon of cd gene inducing a premature stop codon in codon . this mutation alone or in combination with cd *c. delg has been introduced as the main reason for the absence of cd in hna- null individuals. a pseudogene (cd p ) highly homologous to exons - of cd gene is located downstream of the cd gene. conversion of exon of cd p into cd gene is responsible for the generation of cd *c. a>t missense mutation. in addition, the heterozygosity or homozygosity of cd *c. a>t is accounted for regulation of hna- negative and positive neutrophils subpopulations. genotyping has revealed the hna- null individuals, heterozygous for cd *c. a>t mutation without cd *c. delg, indicating the presence of a complementary mechanism regulating cd expression. newly in hna- null individuals and individuals with atypical cd expression a cd * g>a polymorphism in combination with cd * a>t is described. altogether these data indicate a complex compound mechanism(s) for regulation of cd expression on the neutrophil surface. this presentation will summarize recent findings on cd expression and highlights the potential genotyping methods for genetic assessment cd expression of donors and patients. blood products ordered, transfusion start and end times, whether patients experienced a reaction to the transfusion as well as vitals measurements taken before and during the transfusion, including temperature, oxygen level, blood pressure and heart rate. for the validation process, transfusion nursing notes were sampled and reviewers assessed the accuracy of the information regarding ) blood product ordered, ) whether the patient experienced a reaction, and ) the start and end times of the transfusion. for each of these fields across all sampled notes, the claritynlp tool reproduced these data points with percent accuracy. in addition, the tool supplied transfusion end times for numerous structured records that were missing this key data point. summary/conclusions: claritynlp can very efficiently digest a large number of transfusion nursing notes simultaneously and also does an excellent job of extracting the main characteristics of a transfusion, which can be used in partnership with structured data to produce a more accurate and more complete picture of patient transfusions. immunohematology and genomics, new york blood center, new york, united states antibody-based typing, with a positive result reflected in agglutination of the red cells (rbcs), has served the profession for nearly a century enabling safe and effective transfusion therapy. the power of rbc typing by serologic methods lies in the availability of standardized antibody reagents which target many of the specificities of significance for transfusion, and the ability to directly detect antigen expression on the rbcs. hemagglutination has historically been relatively inexpensive, particularly for abo and rhd as the most important blood groups in most populations. serologic rbc typing is reliable, requires no sophisticated equipment, is generally straightforward to perform, and is fast requiring less than h to results. hence, antibody-based testing has been considered the "gold standard" for blood group typing. with the age of genomics, dna-based genotyping is increasingly being used as an alternative to antibody-based methods. most antigens are associated with single nucleotide changes (snps) in the respective genes. genotyping has been validated by comparison with antibody-based typing and has been shown to be highly correlated. the power of genotyping of rbcs lies in the ability to test for antigens for which there are no serologic reagents, and to type numerous antigens in a single assay using automated dna-arrays. this increases accuracy and weak antigen expression can be revealed. fresh rbc samples are not required for dna extraction, and there is no interference from transfused rbcs or igg bound to the patient's rbcs. dnabased typing is economical in that it provides much more information, but testing requires special equipment, training, and -h turn around. what then is the best approach to use? will serologic typing be replaced by dnabased typing? indeed, genotyping will increasingly be used in the practice of transfusion medicine, especially with the growth of whole genome sequencing (wgs). however, because serologic typing for abo and rhd is fast and accurate and often relied on for sample identification, genotyping will not be the sole means for routine typing. genomic sequencing approaches will certainly reveal unrecognized changes and genetic variability in rbc membrane proteins, but not all variation will be immunogenic. a genetic polymorphism must be associated with antibody production to be considered a blood group antigen. the importance of an antibody, and antibody reactivity, then will continue to be the central defining principal in transfusion. as two sides of a coin, both are key to safe and effective transfusion therapy. since the mid- s, research in the molecular basis of structural and functional aspects of proteins carrying and producing the antigens has led to an upgraded and modern understanding of blood group variation. most commonly, single nucleotide polymorphism (snp) based basic molecular typing techniques were utilized to test new findings on a smaller subset of samples, and resulted in concordant sero-and genotyping results in general. however, quite commonly a small number of all samples delivered discrepant results, triggering consecutive rounds of analysis and resolution, finally resulting in a better knowledge with respect to the underlying blood group variation. such rounds of repetitions represented the synergistic incremental process of learning, learning for serologists and molecular biologists. inheritance of public, presence of high frequency, or low frequency, or partial antigens and notice of weakly expressed, or almost undetectable antigens marked the path of incremental learning and may best be exemplified by discoveries within the blood group systems abo, rhd and kell. naming for pheno-and genotypes coevolved alongside the permanent discovery of new antigens. at present, antigens and their antithetic counterparts (if tested and if existent), are more commonly reported independently, as exemplarily shown for the following kell phenotype consisting of three antithetic antigen-couples: kk, kp (a+b+), js(a+b+). alternatively, the same phenotype could be stated as: kel:- , , , , ( ), , . genotypes, on the other hand, rather mirror the actual biological background, e.g. display the two parental alleles (or "haplotypes") present in an individuals' sample. genotype of the above mentioned example would read: kel* . / . (italicized). in an idealized diagnostic environment and for most blood group systems encoded by proteins, every single blood group allele would be defined by its full genomic sequence, derived from one parental chromosome (including "some" 'and '-untranslated regions). thereby, every such "ideal allele" would fully declare presence or absence of all its public, low-and high-frequency antigens and possess its "ideal name". by trend, biallelic snps and their immediate relation to antithetic antigen couples might have distracted from the originally intended meaning of "blood group alleles", more recently. finally, genotypes only dependent on (ideal) allele names, and considering mendelian inheritance patterns (dominant, recessive), would allow for fully comprehensive phenotype predictions. more recently, blood group serology, e.g. the "second side of the coin", seems to gain momentum. since the advent of whole genome sequencing and access to many more than human genomes, it seems that dozens of new blood group alleles are discovered, almost on a daily basis. beside the challenge of naming this multitude of alleles, respective discoveries are frequently made in samples lacking any phenotypic blood group pre-values. clear procedures will be needed to address naming and analyzing the phenotypes resulting from previously unknown alleles. as a consequence, questions asked years ago have changed: today, molecular biologists looking at hundreds of newly discovered blood group alleles find themselves not being asked by serologists any more: "can you confirm my serology?", but instead, pose their question to the experts for the blood group phenotype: "can you confirm my genotype?" a-s - background: the screening of blood donors and returning travelers from active transmission areas have highlighted the importance of diagnosis of acute arboviral infections. in the context of co-infections and similar clinical signs in endemic zones, the differential diagnosis of arboviruses is essential to discriminate the causative agent. the detection of viral nucleic acids in serum or plasma provides a definitive diagnosis, however, in most instances, viremia is transient within less than two weeks after the onset of clinical illness. in addition, the cross reactivity due to the high degree of structural and sequence homology between zikv and other flaviviruses is a significant concern. the combination of molecular (identification of viral genomes) and immunological assays (detection of the immune response) is a key challenge to follow the natural history of these infections and to improve the patient management and the epidemiological surveillance. aims: in this context, we have developed an innovative platform based on agglutination of superparamagnetic nanoparticles (npmag) covalently grafted either with nucleic or proteic probes to face the continuing emergence of arboviruses. methods: dengue (denv) and zika (zikv) viruses are selected as models in this study. a pan-flavivirus rt-pcr is used for the molecular assay to amplify the viral genomes. then, biotinylated viral amplicons are captured specifically on complementary original polythiolated probes coated on npmag. for the immunological assay, npmag are grafted with viral ns proteins to capture anti-denv or anti-zikv antibodies potentially present in the plasma samples. both tests are performed in disposable cuvettes in a homogeneous format. a magnetic field generated by an electromagnet is applied to the reaction medium to align the npmag into chains to enhance the capture of the targets between two npmag. aggregates formed are detected when the field is turned off. the optical density is measured in real-time at nm during several cycles of magnetization / relaxation. results: in this study, molecular analytical performances were evaluated on human samples from blood donors with no history of infections as negative controls, on viral standards and on clinical samples. using viral references standards, we have observed sensitivities of - tcid /ml for zikv and denv (serotypes / / / ) after a detection phase of around min. the first results obtained on zikv (+) clinical samples previously tested by commercial real-time pcr (ct < , altona) showed an % correlation between the two detection methods. no false positive results or cross reactions were observed. concerning immunological assays, commercial human plasma from donors tested positive for denv or zikv antibodies were detected positive with our innovative approach in less than min (sampling + detection) instead of h with classical elisas. further assays on clinical samples are planned to confirm these preliminary results. summary/conclusions: this innovative strategy combining molecular and immunoassays on the same analytical platform offers new opportunities for rapid blood testing to improve the surveillance and the prevention of arboviral infections. background: zika virus (zikv) caused a dramatic epidemic in puerto rico (pr) during , with up to~ % of blood donors reactive for zikv rna in id-nat testing at the peak in june . aims: perform a serosurvey for anti-zikv igg using six panels of donor specimens each collected in march , at the beginning, peak and end of the epidemic, and from march and april . methods: we employed a commercially available zikv igg elisa antibody (ab) assay based on the zikv ns antigen from bio-techne to characterize zikv seroprevalence in the cross-sectional sample sets (anonymized with selected demographic information). results: pr donor samples collected in april were initially evaluated using the manufacturer supplied cut-off to confirm that the zikv ab results were largely negative ( positive, equivocal) despite the high dengue virus seroprevalence (> %) in pr that could potentially lead to false positive zikv ab results. we then used this dataset, together with known positives collected - months postdetection from zikv nat yield donors, to set a population-specific cut-off based on receiver operating characteristic (roc) curve analysis. this cut-off yielded sensitivity and specificity values of > %, and an area under the curve (auc) of . , demonstrating a highly accurate assay. we used this new cut-off to calculate final rates of seroreactivity in the additional sample sets ( samples) and estimate seasonal incidence. rates of reactivity, together with mean net od for only the reactives (shown in parentheses), were calculated for each sample set: background: sex hormone intake in blood donors occurs in three demographic groups: premenopausal women who take contraceptive drugs (progestins with or without estrogens), postmenopausal women who receive estrogen replacement therapies that may be combined with progestins, and testosterone therapies in men. we hypothesized that sex hormone therapies may modulate the quality of red blood cell (rbc) products via alterations of rbc function and predisposition to hemolysis during cold storage. aims: the objectives of this study were to evaluate the association between sex hormone intake and rbc measurements of hemolysis, and to examine possible mechanisms by which sex hormones interact with rbcs. methods: self-reported sex hormone intake and menstrual status were evaluated in , female blood donors from the national heart, lung and blood institute's rbc-omics study. the associations between hormone intake and donor scores of spontaneous storage, osmotic, or oxidative hemolysis were determined in all women and by menstrual state. the interactions between sex hormones and rbcs were determined by sex hormone (progesterone, b-estradiol, or testosterone) potency to inhibit calcium influx or hemolysis during incubations or cold storage. the calcium fluorophore, fluo- am, was used to define rbc calcium influx in response to treatments with sex hormones or drugs that modulate transient receptor potential cation (trpc) channel activity including hyp (a selective trpc activator). results: sex hormone intake by menstrual status was higher in premenopausal women ( . %) than in postmenopausal women ( . %). female hormone intake was significantly (all p < . ) associated with reduced storage hemolysis in all females ( . ae . % versus . ae . % in controls), enhanced susceptibility to oxidative hemolysis ( . ae . % versus . ae . % in controls), and reduced osmotic hemolysis in postmenopausal women ( . ae . % versus . ae . % in controls). in vitro, supraphysiological levels of progesterone ( or lmol/l), but not b-estradiol or testosterone, inhibited spontaneous or hyp -induced calcium influx into rbcs, and were associated with lower spontaneous hemolysis after day cold storage ( . ae . % versus . ae . %, progesterone lmol/l versus solvent control (dimethyl sulfoxide, . %), p < . ). co-incubations ( . h, °c) of rbcs in the presence of progesterone and a trpc activator (hyp , lmol/l) suggested that progesterone protected against hyp -induced hemolysis ( . ae . % and . ae . % versus . ae . %; hyp + progesterone at or lmol/l versus hyp alone, p < . by one-way anova). summary/conclusions: this study revealed that sex hormone intake in blood donors is capable of modulating rbc predisposition to hemolysis and led us to propose new mechanistic pathways by which progesterone regulates calcium influx and hemolysis in human rbcs. pre-and postmenopausal women respond differently to hormone intake and its effects on rbc responses to osmotic or oxidative stress. progesterone modulates calcium influx into rbcs via a mechanism that may involve interactions with membrane trpc channels, activation of which is associated with pre-hemolytic events such as senescence and eryptosis. a-s - international cooperation, swiss red cross, wabern, switzerland background: red cross and red crescent societies were playing an important role in setting up blood transfusion establishments in many low resource countries. by the mid- s, the red cross was active in the national blood programs in approximately % of countriesmostly in blood donor recruitment and education. today, major organizational developments in blood transfusion services were made in high income settings, where nearly % of all worldwide donations take place (home to only % of the population). who data shows that the median annual blood donation rate in high-income countries is . % of the population compared to . % in low-income countries. the factors for this low turnout are multilayered, but it is well-known that most resource poor settings suffer from a low rate of regular donors and challenges to set-up and financially sustain a national blood donor program. the red cross and red crescent (rc) societies assume a key role by reaching and retaining donors from the communities and contribute significantly to better safety and availability of blood. partnerships and international collaboration, such as the swiss red cross (src) program, are aiming to strengthen national structures to improve blood safety and to face today's epidemiological, demographical, and technological challenges. aims: the present work aims to review the role, the mandate and the impact of rc societies in improving blood safety through systematic "voluntary non-remunerated regular blood donor" (vnrbd) programming and international partnerships. methods: data and evidence is drawn from the src international cooperation projects over the last years, more specifically partnering with three rc societies, and the data from the global advisory panel (gap) of the ifrc including their global mapping. results: the promotion of vnrbd has been a specific objective in all src supported programs. through the engagement of the rc society, the training of volunteers and partnering with the health authorities, the projects significantly increased the blood donor rate by recruiting and retaining donors from the communities. for example, the rc societies increased total donations by % in lebanon; vnrbds by % annually in kirgizstan, and from practically zero to ' in south sudan. the importance of rc societies was also underlined in the published global mapping of gap, which showed that ( %) of them provide level a (full blood service), ( %) are level b (systematic blood donor recruitment) and ( %) are level c (vnrbd blood promotion) blood services. gap has also commenced a new three year vnrbd support program aimed at establishing tools and materials for national societies. summary/conclusions: the red cross / red crescent movement has a unique mandate and position in improving global blood safety at all levels; with its huge network of volunteers, even blood donors in remote communities can be reached and retained. rc societies in low resource settings with a level b or level c role should further capitalize on partnerships with local and international actors to leverage technical assistance and funding for their activities. background: it is essential to motivate and encourage the public to donate blood and be eager to help saving lives, in order to maintain safe and adequate national blood supply. aims: "technical assistance for recruitment of future blood donors (europeaid/ /d/ser/tr)" project aimed to avoid problems in supplying the safest blood to contribute to the improvement of public health by (i) increasing the knowledge of primary and secondary school students regarding blood donation, (ii) creating sensitivity in school principals and teachers regarding voluntary non-remunerated blood donation (vnrd), (iii) motivating family members of the students for blood donation and (iv) creating public awareness through media. methods: an effective coordination is established between ministry of health (moh), ministry of national education (mone) and turkish red crescent (trc). the existing curricula and textbooks of primary and secondary schools were reviewed and revised, and corresponding materials on the importance of blood donation were created. the human resources capacity of moh, mone and trc to support raising awareness on blood donation were developed. to raise public awareness on blood donation nationwide, education and recruitment campaigns on were organized in pilot schools. additionally, media and public relation campaigns on blood donation were organized throughout the country. results: ( ) existing curricula and textbooks relevant to promoting blood donation were reviewed, revised and reported to the board of education of mone. ( ) corresponding educational materials for students and teachers were developed and distributed. ( ) blood donation clubs were established in pilot schools. ( ) trainings were conducted for personnel of moh and trc on blood donation regarding their responsibilities. ( ) cascade trainings were conducted for personnel of transfusion centers and school principals in provinces. ( ) information seminars were delivered to . students and . teachers and family members of students during school campaigns. ( ) four animation films on blood donation were produced and broadcasted on the national tv channel (trt). ( ) three different computer games targeting different age groups were developed and uploaded to the web portal of the project and distributed to the pilot schools. ( ) media spots were produced and broadcasted . times in different tv and radio channels. ( ) billboard posters and brochures were prepared and distributed to provinces for raising public awareness. ( ) advertisements about the project and the importance of vnrd were displayed times on national and local newspapers, . times on online news, and broadcasted on national tv channels. ( ) during the campaigns, . units of whole blood were collected in pilot schools. ( ) visibility kits to recruit future blood donors are prepared and distributed throughout the project activities. ( ) awareness and knowledge level of students and their teachers/parents on the importance of blood donation are increased to . % and . % respectively, assessed through pretest and posttest. voluntary non-remunerated donation rate of national demand increased from . % to . in two years. summary/conclusions: training and campaign programmes successfully increased the knowledge on blood donation. to achieve national self-sufficient safe blood supply, efforts for recruitment should be continued. background: despite % of pakistan's population being under years, only % of blood supplies come from voluntary donors while remaining blood is collected from 'family replacement donors'. in pakistan the system has outsourced the mobilization of blood donors to the patient families. as a result many people reach out to their networks including on facebook to locate blood donors. there are thousands of posts each month in pakistan seeking blood donors on facebook. to facilitate needy families, the global social media giant facebook launched a special blood donation feature for pakistan in collaboration with sbtp, pakistan. the feature makes it easier for people to sign up to become blood donors and helps connect these voluntary donors with people and organizations in need of blood. similar features have been launched by facebook in india, bangladesh and brazil to address the problem of blood shortages in those countries. however, among these four countries pakistan has unique position because of the existence of a national counterpart, sbtp which can facilitate facebook in promoting its feature and provide the feedback on the impact of this innovative effort for continuous improvement of the feature. aims: to promote voluntary blood donations and blood safety in pakistan through facebook. methods: the facebook and sbtp teams launched a pilot to study the impact and effectiveness of the facebook blood donation feature as a tool of community engagement. a six months plan has been chalked out to measure the impact of this tool in five selected blood centres. a checklist called "p checklist" was shared with these blood centres to fulfill some basic requirements for an official blood bank page including a display picture, cover photo, contact information, directions, etc. regular skype meetings are held between the teams of sbtp, facebook (san francisco and singapore) and the blood centres to monitor the progress of the pilot and generate feedback. results: the facebook blood donation feature has recorded remarkable success with over one million signups within few months in pakistan. the blood centres participating in the pakistan study have experienced enhancement in the voluntary blood donations trend with - walk-in donors and an average of more than telephonic queries regarding voluntary blood donation per month in each center. the trend is gradually surging as the feature is being refined on the basis of feedback received. the pilot will end in june . the statistics generated since january are very encouraging and underscore the importance of social media in reaching out to the untapped potential blood donors. the study will be used to plan an effective nationwide strategy to increase donor mobilization, recruitment and retention. background: in our region, an increasing number of patients of african or asian origin with sickle cell disease (scd) or transfusion dependent thalassemia (tdt) require red blood cell (rbc) transfusions, and many have rbc alloantibodies. selecting optimally matched rbc units for these patients is essential for preventing not only acute hemolysis but also further alloimmunisation. beside antigen-matching for abo, rh d, c, c, e, e and k, patients with scd and tdt should ideally receive rbc units matched also for m, s, s, fya, fyb, jka and jkb (extended phenotype). this is the policy at our center, which currently provides rbc products to patients with hemoglobinopathies. because the vast majority of our blood donors are caucasians, the selection of matched rbc units for patients of different ethnic origin can be difficult. therefore, expanding the number of available african and asian blood donors is becoming increasingly necessary. aims: hereby the recruitment strategy of non-caucasian blood donors introduced at our center is described and the results obtained during six years are reported. methods: since . . , whenever a first-time blood donor of non-caucasian origin is registered, an alert is entered in the donor file to trigger the determination of the extended rbc phenotype along with routine testing. rbc antigen determination is performed in our laboratory with serologic methods. in selected cases (i.e. suspected rhd or rhce variant), samples are sent for molecular analysis (ssp pcr). rare rbc phenotypes relative to ethnicity are, among others, fy(a-b-), s-s-, lu(b-) and those with uncommon rh phenotypes. if a rare rbc phenotype is detected, a coded comment is entered in the donor data and the donor is listed in the national rare donor file. results: from . . until . . , an extended determination of rbc antigens was performed in subjects presenting for blood donation. twenty-nine rare donors ( %) were identified and included in the rare donor file: fy(a-b-), lu (a-b-), lu(b-), fy(a-b-) and s-, ccddee (r'r'). overall, these donors provided rbc units (range . to date, all donors are still active and are reserved for dedicated donations. the internal price of rbc antigen testing per donor is approximately . -chf, resulting in a total financial effort of around , .-chf in the time since the project was started. summary/conclusions: in our experience, a "passive" recruitment of non-caucasian blood donors based on ethnicity has an overall low efficiency from a logistic and financial point of view. moreover, african and asian blood donors may require investigations for hemoglobin variants and serology for malaria in addition to routine testing. nevertheless, a targeted determination of extended rbc antigen phenotype does allow the identification of persons with rare phenotypes. currently, measures for the active recruitment of potentially rare blood donors are being implemented at our center. after a pilot phase, a project for a nationwide recruitment strategy will be elaborated. a further goal is to build a national registry of patients with hemoglobinopathies requiring transfusions. blood transfusion is an essential treatment. transfusion safety consists of several components. although all are important, ion richer countries the order of priority is typically: .) avoidance of transfusion transmittable infections; .) quality of the blood product with a strong focus on component therapy; .) prevention of severe transfusion reactions; .) avoidance of clerical errors; .) sufficient availability of blood. the keynote of this lecture will be that the order of priorities on transfusion safety should probably be different in resource limited environments. .) sufficient availability of blood and proper utilisation; .) avoidance of transfusion transmittable infections; .) avoidance of clerical errors; .) prevention of severe transfusion reactions; .) quality of the blood product. most important, in regions with limited resources patients suffer from under-transfusion because not enough blood is available. all efforts should be made to reduce wastage of the available blood either by inappropriate storage, handling, or nonindicated transfusions. in addition, prevalence and number of pathogens transmittable by transfusion is much higher than in the richer parts of the world. this is aggravated by the fact that rejection of blood donors based on their history is problematic when the blood bank is empty. the aim to develop centralized national blood services with few sites manufacturing cost effective (low personnel costs) high-quality blood products, which are distributed to regional hospitals is not matching the reality of infrastructure, governmental support, and functionality. in healthcare systems with limited resources usually available personnel (hands) is not a problem, while reagents, equipment and even electricity are precious resources. the lecture will propose to focus on staff training and education, establishing local hospital-based transfusion services, which provide the blood products for the region, based on donor recruitment campaigns adjusted to the available technology, local culture, including replacement donor programs, with retention of safe donors as highest priority. fractionation of blood into components had been standard in transfusion medicine, but recently whole blood has experienced revival for patients with acute blood loss. given main transfusion indications such as postpartum hemorrhage, or severe trauma, in regions with limited infrastructure, whole blood might be the more appropriate product. most patients requiring transfusion in these regions are younger and volume overload by whole blood is not a major issue. in addition, frequent electricity failures do not allow prolonged storage of plasma at - °c (this is therefore mostly wasted), although this issue can be overcome by solar powered freezers. ideally whole blood should be pathogen inactivated for which two methods are currently available. to reduce frequencies of acute hemolytic transfusion reactions again education and training to minimize clerical errors in the transfusion process are most important. extended testing for other rhesus antigens and k beside abo and rh-d in transfusion dependent hemoglobinopathy patients may help to reduce delayed hemolytic transfusion reactions. currently a leukodepleted pathogen-inactivated whole blood product might mostly serve the needs for blood transfusion in regions with limited infrastructure . the developed world should invest research efforts to develop such a product available at affordable costs. background: in modern transfusion medicine, serological investigations for blood cell antigens are complemented by genotyping arrays and pcr assays. whilst these platforms are informative in the majority of reference investigations, they are limited in their ability to define nucleotide variants associated with rare antigens and unable to detect novel variants potentially affecting antigenicity. next-generation sequencing is increasingly being employed in reference settings, providing information that cannot be obtained through these methods. whole genome and whole exome sequencing have been successfully employed in many investigations of novel and rare antigens, however concerns remain regarding the collection of genomic data unrelated to reference investigations, and reporting clinically significant incidental findings. these concerns can be addressed through the use of targeted sequencing panels. we report on the design, testing and efficacy of a panel providing a comprehensive genotyping profile for red cell, platelet and neutrophil antigens in a single test. aims: design a customised targeted exome sequencing panel for red cell, platelet and neutrophil antigen genes, and benchmark the efficacy against a commercial medical sequencing panel (illumina trusight one -tso). -test the panel and in-house genotype prediction script on sequence outputs from samples with known red cell, platelet and neutrophil genotypes and phenotypes and determine whether predictions are concordant. methods: the panel was designed with probes covering exons of genes associated with red cell, platelet and neutrophil antigens. using illumina nextera rapid capture technology, samples were tested over five sequencing runs, on standard and micro chemistries, to determine optimal sample plexity per standard run, and the efficacy of smaller flow cells for lower throughput applications. an in-house python script was used to predict star-allele genotypes based on variants listed in isbt and embl databases. these predictions were compared to results from serology, snp array and previous tso data. results: coverage consistently averaged > , with % of target at a quality of q . optimal sample plexity for a standard run was determined to be samples, allowing for sufficient coverage of all clinically significant variants. for red cell samples with previous typing data (excluding rh structural variants), the script correctly predicted . % of snp based red cell genotypes. script predictions were % concordant for platelet genotypes, and four of five neutrophil antigen genotypes. hna genotypes defined by cd could not be reliably determined. the increased target coverage of the panel allowed for detection of a clinically significant heterozygous variant in scianna system, previously undetected by the tso panel due to extremely low coverage. additionally, a variant defining a potentially novel null allele was detected in the p pk system. summary/conclusions: the panel demonstrates considerably higher coverage, quality and throughput compared to the tso and allows for detection of variants previously overlooked due to low sequencing coverage. up to samples can be reliably sequenced in a single run. our script correctly predicts over % of snp based alleles; however, rh structural variants require further manual analysis. background: to ensure the safety of a transfusion it is critical to identify the blood type of both donor and recipient. serological methods for typing abo, rh and kel use monoclonal antibodies, however, typing reagents for rare blood groups are expensive, unavailable or unreliable. dna-based identification of human blood groups has been used to overcome these limitations and its application has reduced rates of alloimmunisation in chronically transfused patients. however, to date, the cost per sample has prevented the universal application of dna-based donor typing aims: to achieve universal adoption of dna based donor typing, the blood transfusion genomics consortium (bgc) set out to develop an affordable dna based platform, capable of typing all red cell antigens, hla class i and ii and human platelet antigens. methods: the uk biobank axiom array, previously used to type , uk citizens, was redesigned for donor typing using three approaches: i) mining transfusion medicine knowledge, e.g. isbt allele tables; ii) inclusion of loci associated with donor health; iii) extraction of all coding variants in relevant genes with a frequency > : , identified in large-scale sequencing data. samples from nhsbt and sanquin blood donors (n = , ) were used for performance assessment. red cell and platelet antigens for each donor were inferred from genotypes using the bloodtyper algorithm and concordance with clinical serological typing results assessed. results: concordance between genotypic and serological typing results was . % for , comparisons; of the discrepancies were serologically negative and genotypically positive for a given antigen (k/k, fy[a/b], lu[a/b]). in all cases dna variants known to modify or weaken antigen expression were detected, displaying the power of genotyping to detect variant 'weak-antigen' expression. across antigens for which serology was available, genotyping provided a . -fold increase in the number of typing results available per donor ( . vs . ). furthermore, genotyping provided data on an additional clinically relevant antigens, allowing identification of antigen-negative donors and blood group identification for which antibodies are not commercially available. the power of a genotyped panel of donors to support patient management was demonstrated by a retrospective analysis of clinical cases referred to nhsbt. from , patient referrals with > alloantibodies between and , unique alloantibody profiles were identified. we found that there was a . -fold greater likelihood of finding o negative compatible donors for these patients when using genotyping data from the , nhsbt donors. importantly, the number of alloantibody combinations for which no compatible antigen-negative donor could be identified fell from to , representing an additional patients that could be provided with directly compatible blood using the same donors. summary/conclusions: through the bgc efforts an affordable fully automated genotyping platform, including the processes for quality assurance and data analysis, has been developed. furthermore, we have demonstrated the real-world benefits more extensive donor characterisation can provide when selecting blood for patients with multiple antibodies. the results of this international collaboration provide opportunities to introduce fully-automated genotype-based donor typing in a safe and cost-efficient manner in blood supply organisations. c-s - biobank performs whole-genome sequencing (wgs) from individuals nation-wide. these data are suitable for allele frequency analysis to demonstrate gene expression and genetic profile in our population, also to estimate the significance of each antigen in transfusion practice. aims: we aim to provide and verify population-based blood group antigen profile using wgs and dna samples from taiwan biobank. methods: a near wgs and demographic data were analyzed. annotations of blood group antigen were performed according to variants from isbt allele tables, including transcription factors; variants for the lewis system were obtained from previous studies. annotations of blood group variants were verified by dna samples with targeted sequencing on illumina miseq, and specific variants were verified by dna samples with the commercial genotyping kit or sanger sequencing. allele frequencies from wgs analysis were compared with population serology data using two-proportion z test. results: population-wide blood group antigens were analyzed, revealed in-depth antigen expression profiles in all systems (except ch/rg). the antigen frequencies from wgs were similar compared with published serology data, except for the antigens and possible explanations listed as follow, ) m, n: insufficient sequencing reads, ) c, c: identical rhce exon with rhd exon for c allele, ) mur: insufficient read length/depth for gypa/gypb hybridization calling and individuals from high prevalence of mur antigen in aboriginal tribes were not enrolled. blood group antigen predictions and variants from wgs were accord to dna verification. furthermore, systems shown no genetic variations, predicting uniform antigen expression in our population, and we can manage transfusion with minimum concerns for antigen mismatch in these systems. moreover, we found weak and null alleles in our population for blood group systems that we had previously no knowledge of, such as lan, jr, and vel. these variants were helped to identify a patient with anti-jr a carrying homozygous jr a null alleles. summary/conclusions: taiwan biobank wgs is suitable for full blood group antigen profile determination with few adjustments required for specific antigens. the population antigen allele frequency provides valuable insight to antigen significance in transfusion practice, matching strategy for our patients, and estimation of the likelihood to obtain for specific antigen negative blood from mass population. also, the genetic variants revealed in this study can help us to locate rare donors, and to integrate variations into routine donor blood group screening to provide suitable blood at a low cost efficiently. background: providing adequate amounts of safe, appropriately matched blood to meet the demands of an expanding and aging patient population presents a challenging global problem. for these reasons, sustainable in vitro sources of red cells may offer a desirable alternative to reliance on donor blood. the first stable immortalized early adult erythroblast cell line, bel-a , has been shown to differentiate efficiently into mature, functional reticulocytes (trakarnsanga et al., nat commun. : , ) and consequently could provide a readily available tool for diagnostic use and proof of principle for future therapeutic use. aims: at ibgrl, next generation whole exome sequencing (wes) has been used previously to accurately predict blood group phenotype in a number of blood group systems, including abo, rh and mns (tilley & thornton, transfusion medicine (suppl. ) : , ). here we have used it to analyse and document bel-a blood group-related genotypes and predict blood group phenotypes. additional genes involved in cell-growth and enucleation were also analysed in order to further elucidate the characteristics of the bel-a cell-line. methods: bel-a cells (day ) were cultured in expansion medium and genomic dna (gdna) was isolated from cells on day . for wes, gdna libraries were prepared using nextera â rapid capture exome enrichment and sequenced on illumina â miseq. sequence alignments for genes encoding all known blood group systems and further genes encoding transcription factors and cell enucleation-associated proteins were visualised using integrative genomics viewer, whilst illumina â variant studio was used to identify observed mutations. mutations in coding regions were used to determine bel-a genotype and predicted phenotype. results: good coverage of most of the selected genes was achieved. alignment of homologous blood group genes including rhd/rhce, gypa/gypb and c a/c b was problematic and additional analysis of coverage of these genes was required for accurate interpretation. despite a number of polymorphisms observed across the tested genes, bel-a did not express any novel or rare blood group antigens. genotyping results predicted a common antigenic profile, in agreement with previous serological and genotyping results where available. although a number of missense single nucleotide variations were detected in analysed genes, including cr , cdan and tmx , these were common polymorphic variants and unlikely to be of any functional significance. summary/conclusions: wes was used to determine bel-a genotype in relation to blood group genes and selected genes encoding transcription factors and proteins associated with cell enucleation. wes allowed accurate prediction of blood group phenotypes, showing full concordance with available serological data (trakarnsanga et al, ) . a small number of mutations were identified which are of unknown significance and require further work to determine any potential phenotypic effects. this complete record of the bel-a blood group-related exome will enable reliable gene editing strategies for future diagnostic and therapeutic purposes. additionally, knowledge of the full cell line exome will allow analysis of any emerging genes of interest and provide better insight into the mechanisms of erythroid differentiation and enucleation. background: emerging evidence, especially in neonates, has shown potential harm associated with liberal platelet transfusion strategies. very little evidence exists regarding optimal platelet transfusion thresholds in critically ill children. randomized controlled trials may be difficult due to lack of equipoise from providers. if regional variation in practice exists, comparative effectiveness studies may be an alternative approach. aims: to describe regional variation in platelet transfusion practices in critically ill children. methods: secondary analysis of a prospective, observational study. subjects were grouped according to region (north america, europe, middle east, asia and oceania) and nation. transfusions were analyzed as prophylactic (given to prevent bleeding) or therapeutic (given to treat bleeding). the primary outcome was the total platelet count (tpc) prior to transfusion. sub-groups analyses were performed in children with an underlying oncologic diagnosis and those supported by extracorporeal life support (ecls). the dosing and processing of the platelet transfusions were analyzed as secondary outcomes. results: five hundred and forty-nine children from countries were enrolled ( % in north america, % in europe, % in oceania, % in asia, and % in the middle east). overall, the median (iqr) tpc prior to prophylactic transfusions (n = ) differed significantly on a regional basis (p = . ) and ranged from ( - ) x cells/l in the middle east to ( - ) x cells/l in asia. the median tpc prior to prophylactic transfusions did not significantly differ between countries (p = . ), nor did the tpc prior to therapeutic transfusions (n = ) differ on either a regional (p = . ) or national (p = . ) basis. for children supported by ecls (n = ), there were no regional (p = . ) or national (p = . ) differences for prophylactic transfusions. however, significant differences in the tpc prior to therapeutic transfusions were observed on both a regional (p = . ) and national ( . ) basis with the middle east, in particular israel, transfusing at the lowest median (iqr) tpc [ ( - ) x cells/l]. for children with an underlying oncologic diagnosis (n = ), no differences were seen in the tpc for prophylactic transfusions (n = ) on a regional (p = . ) or national (p = . ) basis. nor were differences seen in the tpc prior to therapeutic transfusions on a regional ( . ) or national (p = . ) basis. there was significant variability in the dosing of platelet transfusions on both a regional (p < . ) and national basis (p < . ). the median (iqr) dose based on volume ranged from . ( . - . ) ml/kg in north america to . ( . - . ) ml/kg in europe. the vast majority of transfusions were leukoreduced and irradiated but significant variation exists in storage duration on both a regional (p < . ) and national (p < . ) basis. summary/conclusions: regional and national variation exists in platelet transfusion practices among critically ill children, especially in those given therapeutic transfusions while supported by ecls. considering this variation, comparative effectiveness studies may be an appropriate approach to gain evidence to optimize platelet transfusion thresholds. background: the optimal threshold for prophylactic platelet (plts) transfusion in pediatric patients with cancer is still controversial and current clinical practice comes from studies on adults and on inpatient setting. the international guidelines (icmtg, ) recommend, for all age patients, a prophylactic platelet transfusion when plts count is ≤ /l and a platelet dose of . per square meter (sm) of body-surface area (bsa) in inpatient and . /sm in outpatient setting. aims: in january we started in our children's hospital a prospective protocol in order to evaluate the impact on bleeding risk of current clinical practice of prophylactic platelet transfusion in inpatients and outpatients onco-haematological patients. methods: bsa was calculated from age-standardized weight. inpatients received a dose per transfusion of . /sm and outpatients a dose per transfusion of . /sm. platelets were transfused when the count was ≤ /l or in presence of bleeding signs; pediatric aliquots were obtained from buffy coat derived pooled platelet concentrates or apheresis platelet concentrates, according disponibility. results: from january to december a total of platelet pediatric aliquots were transfused: ( . %) were obtained from apheresis platelet concentrates and ( . %) from buffy-coat-derived pooled platelet concentrates. the majority of platelets pediatric aliquots ( - . %) were transfused to onco-hematological patients undergoing hematopoietic stem cells transplant (hsct) or conventional chemotherapy. among them, aliquots were transfused in inpatient setting: ( %) in the hematology unit, ( . %) in the oncology unit and ( . %) in hsct unit. a total of ( . %) aliquots were transfused in outpatient setting: ( . %) to patients affected by hematological malignancies and ( %) to patients with solid tumors. five major bleeding events (who grade ≥ ) were observed during the study period and all of them occurred in hospitalized patients. two patients with solid neoplasm developed a who grade bleeding event. two patients with hematologic malignancies and a patient with neuroblastoma (n = , . %) developed intracranial bleeding (who grade ). the platelet count at the time of the event was /l, /l and /l, respectively. summary/conclusions: our results showed the efficacy, in onco-hematological pediatric patients, of a prophylactic platelet transfusion protocol based on international guidelines: a very low incidence of who grade bleeding has been observed in inpatients setting only ( . % vs % of plado trial, sj slichter, nejm, ) , while in outpatients setting the double platelet dose prevents the major bleeding event (who grade ≥ ) occurrence. background: the problem of blood-borne infections remains relevant in transfusion medicine. pathogen reduction technologies (prt) provide a preventive approach to a wide range of transfusion-transmitted infectious diseases. to date, prt widely used for platelet concentrates and blood plasma, however, the use of these technologies for the treatment of red blood cell-containing blood products undergo research. aims: the aim of our study was to evaluate the safety and efficacy of transfusions of pathogen-reduced (test group) red blood cell suspensions (rbcs) and compare these data with gamma-irradiated rbcs (control group). methods: the technology based on the combined action of riboflavin and ultraviolet (mirasol prt, terumo bct, belgium) was used to reduce pathogens in whole blood. subsequently, the rbcs of the test group were derived from pathogenreduced whole blood. the control rbcs were irradiated at the gammacell elite (best theratronics, canada) at a dose of gray. all rbcs were used for transfusion for days from the harvest day. pediatric patients with various oncological and hematological diseases were randomized to groups of members in each group. the test group of patients received transfusions of a pathogen-reduced rbcs; the control group received transfusions of a gamma-irradiated rbcs. the next day after transfusion were assessed hemoglobin and hematocrit increment, the level of potassium and haptoglobin in the patients' serum, the frequency and severity of transfusion reactions. - days after the transfusion, the direct antiglobulin test (dat) was performed and after - days the indirect antiglobulin test (iat) was performed. the interval to the next need for transfusion was also evaluated. results: the increase in hemoglobin and hematocrit (p = . ), as well as the concentration of potassium (p = . ) and haptoglobin (p = . ) in the patients' serum after the transfusion did not differ between groups. none of the patients in both groups had hyperkalemia after transfusion. in each group, two patients had febrile non-hemolytic transfusion reactions of comparable severity (p = ). all dat and iat tests were negative in both groups. the interval between transfusions were not significantly different between groups (p = . ). only in the test group was found the correlation between the increase in the hemoglobin and hematocrit values with the volume of transfusion, with the dose and the adjusted dose of hemoglobin obtained for the transfusion on body weight. and in this group was found inverse correlation between the hemoglobin and hematocrit increment with the level of hemolysis in the rbcs. summary/conclusions: we found that the clinical efficacy and safety of rbcs of the compared groups did not differ. there was no evidence of immune elimination and allo-sensitization caused by pathogen-reduced rbcs. according to our data, the spectrum of efficiency and safety indicators of pathogen-reduced rbcs is no worse than that of gamma-irradiated rbcs, provided that rbcs is used for days of storage. the founded correlation suggests that the efficiency of pathogen-reduced rbcs transfusions is more dependent on the characteristics of the rbcs. background: patient blood management (pbm) programs are expanding at an international level. a recent nationally representative study from united states observed pediatric age group as the only age group showing lack of objective evidence of pbm initiatives (goel et al, jama ) . aims: this study aims to identify trends in peri-operative blood utilization in children undergoing elective and non-elective surgeries over years duration from to . methods: using years data ( ) ( ) ( ) ( ) ( ) perioperative transfusions decreased steadily per year from . % in to . % ( % cumulative decline) in for children of all ages (or . ; % ci . - . ; p trend < . ). the cumulative change in elective procedures was . % versus . % decrease in urgent/emergent procedures (p trend < . ). summary/conclusions: in this large prospective registry study of > , children undergoing elective/non-elective surgeries, a statistically significant decrease in utilization of peri-operative rbc transfusions was seen across years from through with more significant decrease in urgent/emergent procedures than elective procedures while these findings need evaluation for non-surgical indications of transfusion, these results may provide first evidence of peri-operative pediatric patient blood management strategies being implemented to optimize transfusions in pediatric population. adverse events -tti, immune interactions and risk c-s - transfusion-transmitted infections (tti) are a long-standing and well recognized concern in medicine, which is tackled on the highest level to guarantee the safety of the transfusion procedure for all stake holders. these include the recipient patients, the donating volunteers, the health care workers involved, and their respective contact persons. accordingly, current national and international guidelines including expert societies and the who provide medical, technical, and legal frameworks, which are the basis for the standard operating procedures. nevertheless, there are important challenges, which render tti a "moving target", and reflect the dynamics in three main areas. first, a change in the type and number of recipient patients with past or ongoing immunomodulatory / immunodeficiency component (examples being hiv/aids, sot, allogenic hct, monoclonal antibody therapies, small molecule inhibitors). second, changing exposure to known agents in donors due to global travel, migration and displacement, as well as environmental/climate change. third, discovery and diagnostics of old and new agents with their known or presumed impact as tti. these aspects will require careful review of data and studies, and judicious discussion of the potential action such as selection versus close monitoring to keep tti rates as low as possible, to deliver maximal safety of patients and stakeholders. background: the implementation of nucleic acid testing (nat) and the development of sensitive and specific serologic assays to detect hbsag and anti-hbc antibodies significantly reduced the risk of hbv transfusion-transmission. the apparent redundant testing for two direct viral markers prompted debates on maintaining hbsag screening, particularly in low endemic countries where blood donations are screened for anti-hbc. however, frequencies of - % of hbsag-confirmed positive/nat negative donations have been reported depending on the sensitivity limit of the molecular assays used. the nature of this discrepancy between hbsag and dna remains largely unknown and it is essential to evaluate any potential negative impact on blood safety before considering removing hbsag testing. aims: the prevalence in blood donors and the molecular mechanisms responsible for a persistent undetectable or barely detectable level of viral replication in the presence of a sustained hbsag production were investigated in a collaborative study including five laboratories/blood centers in europe and south africa. discrepancy between viral dna and hbsag levels suggested the presence of mutations that may negatively affect hbv replication and/or infectious viral particle production. methods: donor samples from france, south africa, poland, and croatia were selected for having hbsag levels ≥ iu/ml and being id-nat (procleix-ultrio plus tm [ % lod: iu/ml]) non-reactive/non-repeatable reactive (nr/nrr) with undetectable viral load (vl) or < iu/ml (n = ) or nat repeat reactive (rr) with vl < iu/ml (n = ). french samples initially tested nat nr/nrr with procleix-ultrio (lod %: iu/ml) were retested with ultrio plus prior inclusion in the study. hbv dna load was quantified (cobas taqman hbv [loq: iu/ml]). hbv dna was purified from to ml of plasma after ultracentrifugation. the whole hbv genome, pre-s/s, precore/core and bcp regions were amplified and sequenced. results: following viral concentration, hbv dna presence was confirmed in % of all samples with undetectable or vl < iu/ml. hbv genotypes were a ( . %), a ( . %), a ( . %), b ( . %), c ( . %), d ( %), and e ( %). all samples were anti-hbc positive and % of ultrio-negative samples tested positive with ultrio plus. unusual - nt insertions/deletions identified in bcp regulatory elements (tata boxes, pginr, epsilon domain) suggest altered viral replication. amino acid substitutions (n = ) or deletions (n = ) at positions reported involved in nucleocapsid formation, particle envelopment and virion formation were observed in the core protein of samples. the replicative properties of the bcp and core variants are currently evaluated in vitro as a surrogate model for direct infectivity testing. preliminary results indicate that the variants tested so far have replicative capabilities similar to those of control viruses. analysis of pol, s, and hbx proteins is ongoing. summary/conclusions: these data confirmed the presence of extremely low level of circulating dna-containing viral particles in id-nat non-reactive or nonrepeated reactive blood donations with concomitant high hbsag levels and anti-hbc reactivity. despite the presence of mutations in the viral genomes potentially affecting virion production, preliminary data indicate that some of the viruses in plasma retain the ability to replicate in vitro and to constitute a potential infectious risk. c-s - background: in switzerland highly sensitive nucleic acid screening in an individual donation format for hepatitis b virus (hbv id-nat) and hepatitis b surface antigen (hbsag) detection is mandatorily performed (guidelines of swiss transfusion src, switzerland). since , hbv (hb) vaccination is recommended in switzerland for children and adolescents until the age of and for adults belonging to known risk groups. aims: to highlight that low anti-hbs titers several years following hbv vaccination still confer protection and enable the host immune system to clear hbv dna without development of serologic markers of disease. methods: a retrospective donor interview was conducted to complete information not covered by the questions included in the standard donor questionnaire. routine hbv serological donor screening was performed on a quadriga system (diasorin, former siemens) with the enzygnost hbsag assay (diasorin, former siemens). further hbv tests were performed on the abbott architect i analyser (hbsag neutralisation, hbeag, anti-hbc igg/igm, anti-hbc igm, anti-hbe and anti-hbs). routine id-nat screening for hiv/hcv/hbv was performed with the roche cobas mpx test on a roche cobas platform. hbv id-nat positive samples were confirmed with a quantitative hbv nat assay (abbott). background: hepatitis b core-related antigen (hbcrag) is a structural antigen of hbv, consisting in hbcag, hbeag and the p cr precore protein. quantitative hbcrag measurement is a sensitive marker of viral replication reflecting the cccdna content and persistence of disease. hbcrag positivity was found to be a significant risk factor of hbv reactivation in hbsag-, anti-hbc+, hbv dna-patients (occult hbv infection, obi) undergoing immunosuppressive therapy. aims: no data about hbcrag status in apparently healthy subject with obi are available. the aim of this study was to analyse this marker in our cohort of obi blood donors. methods: hbcrag was measured in blood donors confirmed to be carriers of obi (hbsag-, hbv dna+). of them, / ( . %) donors were anti-hbc positive, and ( . %) negative. donors had both anti-hbc and anti-hbe reactivities. a group of young blood donors vaccinated for hbv infection (hbsag-, hbv dna-, anti-hbc-), and patients with chronic hbv infection (hbsag+, hbv dna+) were used as negative and positive controls group, respectively. serum hbcrag was measured using a chemiluminescent enzyme immunoassay on the lumipulse g automated analyzer (fujirebio, tokyo, japan). the lower limit of detection (lod) of the quantitative assay is logu/ml and the lower limit of quantification (loq) is > logu/ml, due to nonlinearity results between and logu/ml. levels of hbcrag were tested in the three groups and analysed in comparison to the presence of anti-hbc and anti-hbe. statistical analysis was performed by the ibm statistics spss . . . results: all donors in the negative control group had undetectable hbcrag levels, whereas all patients in the positive control group have detectable hbcrag (mean value: . logu/ml, range . - . ), confirming that individuals without prior exposure to hbv would not have detectable hbcrag. hbcrag was detectable in / obi donors ( . %), with a mean value of . logu/ml (range . - . ). hbcrag could be measured only in obi donors ( . and . logu/ml), being below the loq of the test in the majority of obi ( / ). considering the presence of anti-hbc, hbcrag was detected in / ( . %) anti-hbc+ and in / ( %) anti-hbc-obi, with no significant difference in their mean levels ( . ae . vs . ae . ; p = . ). interestingly, the presence of anti-hbe ( / ) was independently associated with higher hbcrag levels ( . ae . vs . ae . ; p = . ). summary/conclusions: identification of donors with obi is critical to prevent the risk of hbv transfusion-transmission. being hbcrag associated with the cccdna content and replication, our results suggest that the presence of hbcrag, even if not quantifiable, could be useful marker to confirm the occult infection status, even in anti-hbc negative donors. the association between hbcrag, anti-hbc and anti-hbe could also be a useful marker to identify obi donors with a higher risk of hbv reactivation. c-s - hc group. human peripheral blood mononuclear cells (pbmcs) from blood donors were stimulated with hbv polypeptides pool in vitro. t cell proliferation assays (cfse) was used to detecting t cell proliferation, enzyme-linked immunospot assay (elispot) was used to detecting the frequency of hbv-specific ifn-c secreted t cells. spss . statistical analysis software was used for statistical analysis. the measurement data of normal distribution were tested by two independent samples t test; and the comparison between multiple groups was analyzed by one-way anova. mann-whitney u test was used for comparison between non-normal data sets. p < . was considered statistically significant. results: . proliferation characteristics of t cells. the proliferation of cd + t lymphocytes was mainly stimulated by specific hbv polypeptide pool, and the proliferation rates of obi group and chb group were significantly higher than those of hc group ( . %, . % vs. . %), with significant difference ( . % vs. . %, p = . , . % vs . %, p < . ). . the frequency of specific ifn-c secreted t cells. the response intensity of the obi group ( sfc/ pbmcs) and chb group ( sfc/ pbmcs) was higher than that of the hc group ( sfc/ pbmcs) under the stimulation of hbv polypeptide pool, and the positive rate of t cell response to the stimulation of hbv polypeptide pool was the highest in the obi group ( . %). summary/conclusions: both obi and chb had higher rates of hbv-specific t effector cell proliferation and ifn-c secretion than the healthy control group. compared with the chb group, obi group had a higher positive rate of t cell response, which may be one of the causes of host immunity resulting in obi. further studies on other immune factors are required. background: western blood transfusion practices are currently changing due to various drivers such as blood management policies, ongoing technological developments, and new therapeutic options. in the netherlands, as in many high-income countries, these have resulted in a diminishing trend of red blood cells. therefore, it is important for blood bank management to anticipate the future demand of blood products for the sake of medium and long term decision making. to support this decision making, we have employed scenario development, which is used in many other sectors (such as finance and transportation) and can also be applied to blood transfusion. building upon a prior literature review and semi-structured interviews of international experts, we gathered experts together for scenario sessions to assess the opportunities and threats for sanquin's medium-term ( - years) strategy using an online platform and face-to-face discussions. aims: to assess for opportunities, threats, and the organizational implications thereof for the medium-term future of sanquin, the dutch national blood bank. methods: twenty-one multidisciplinary experts in blood transfusion agreed to participate and were separated into two groups for half-day interactive sessions. using an iterative process through an online platform, experts brainstormed opportunities and threats for sanquin, which were categorized into themes. these themes were ranked according to importance and certainty, and through consensus, experts chose two themes with high impact and high uncertainty. for these chosen themes, specific actions for the blood bank were listed to mitigate and/or enhance the threat or opportunity. discussions were ample throughout. results: with regards to opportunities and threats for sanquin's medium term strategy, experts brainstormed many ideas and categorized them under themes: political context/ changing legislation, novel products and alternative applications, donors, international markets, commercialization, digitalization, change in perceptions, research, demand, and organizational structure. after ranking for importance and certainty, six themes were chosen: change in perceptions, international markets, political context (opportunities), demand (opportunities), research (vulnerabilities), and donor (vulnerabilities). for each of these themes experts provided specific actions for the organizations to mitigate threats or stimulate opportunities accordingly. these actions included increased transparency and improved communication with the (donor) public, lobbying in political spheres, increased activities in educational institutes and large funding organizations, and creating and collaborating on novel blood products on an international level, to name a few. summary/conclusions: these results show that mapping and assessing a blood bank's future using a multi-disciplinary group of experts is conducive as an effective means of collection a diverse range of opportunities and threats. this provides an opportunity for blood bank management to become proactive towards these potential opportunities and threats and possibly evolve future strategies for the organization. showed that iron-deficient female blood donors were more likely to have depressive symptoms than non-iron deficient female blood donors. among participants with depressive symptoms, females with low plasma ferritin levels had significantly increased odds for reporting a "feeling of lacking energy and strength" (or = . ; % ci: . - . ). as it is known that blood donors are at an increased risk of iron deficiency, it is important to determine whether those genetically predisposed to lower plasma ferritin levels have a higher risk of experiencing the tiredness/lack of energy symptom. aims: to investigate whether there is an association between polygenic risk scores (prss) based on plasma ferritin levels and the tiredness/lack of energy symptom in blood donors. methods: the dbds is an ongoing nationwide blood donor cohort, of which genome-wide genotype data are available for , participants. genotyping was performed using the infinium global screening array (illumina â ) and imputation was achieved based on a scandinavian reference genome. ferritin prss, based on an icelandic ferritin gwas (n = , ), were calculated for all dbds participants. , female donors were available for the analysis. data on depressive symptoms were obtained using the validated major depression inventory scale (mdi), a selfreport mood questionnaire, which assesses the presence of depressive symptoms. a donor was classified as "tired" if they responded "all the time" or "most of the time" to the question "how often do you feel that you lacked energy and strength?". logistic regression analysis was performed, adjusting for age. for generating the quantile plots, the participants were distributed evenly into six quantiles based on their prs, whereby quantile contained the donors with the lowest prss (genetically predisposed to lower ferritin levels) and was set as the reference quantile with or = from the age-adjusted regression analysis (tiredness~quantile). results: prss in females ranged between - . and . (mean . ). a total of , female donors were classified as "not tired" and ( . %) were classified as "tired". no significant difference in ferritin prs was found between "tired" and "not tired" female donors (tired mean prs: . ; not tired mean prs: . ). an age-adjusted logistic regression model found this to be insignificant (or: . , % ci: . - . ), p = . ). to visualise the lack of association, a quantile plot was created, separating the female donors into six equal quantiles based on their prs. no clear trend was observed; donors with the highest prss (in quantile ) had or = . (p = . ) of being tired when compared to those in quantile (or set as ). summary/conclusions: no significant association was found between the ferritin prss of female blood donors and the tiredness/lack of energy symptom. further studies are needed to understand the effect of blood donation versus genetic constitution on tiredness among female iron-deficient blood donors. background: antiretroviral therapy (art) is critical for the control of clinical progression of human immunodeficiency virus (hiv) infections. however, the outcome of art could be limited by drug resistance-associated mutations (drms), even lead to the transmission of drug-resistant hiv to treatment na€ ıve patients such as blood donors, which is a huge concern to art. drms surveillance in hiv infected groups is strongly recommended by world health organization. characteristics of genetic diversity and drms of hiv among blood donors may provide comprehensive data to monitor viral evolution and optimize art, play important roles in blood safety. aims: limited data concerning the epidemic of hiv- subtypes and drms of blood donors is available in china. this study is to investigate genetic characteristics and drms of hiv- infected blood donors. methods: from - , blood donations collected from blood centers, covering almost the whole of china, were confirmed as hiv- positive by national centers for clinical laboratories using abbott realtime hiv- assay or cobas taq-man hiv- test, version . . then hiv- gag ( bp, hxb : - ), pol genes ( bp, hxb : - ) (encoding the whole protease (pr) and a part of reverse transcriptase (rt)) was sequenced after viral rna extraction and amplification. hiv- subtype based on gag and pr-rt regions was determined by comprehensive analyses of los alamos hiv blast tool, rega hiv- subtyping tool, phylogenetic trees and online jphmm program. drms analysis was performed in the stanford hiv drug resistance database. results: among donations, gag and pr-rt regions of samples were sequenced successfully. the distribution of hiv- genotype was as follows: crf_ bc = ( . %), crf_ ae = ( . %), b = ( . %), crf_ bc = ( . %), crf _ b = ( . %), crf _ b = ( . %), crf _cpx = ( . %), crf _ b = ( . %), crf _ = ( . %), crf _bc = ( . %), urf_ = ( . %) and urf = ( . %). of hiv- isolates were identified to have drms. there were ( . %, / ) protease inhibitors (pi) accessory drms, pi major drms and ( . %, / ) non-nucleoside reverse transcriptase inhibitors (nnrti) drms. most of blood donors with drms were crf _ae and crf _bc ( . %, / ). of pi accessory drms were q e. the pi major drms included m l, m i and n s. n s could result in hlr to atazanavir (atv) and nfv, llr to indinavir (idv) and saquinavir (sqv). v d/e is main nnrti drm ( . %, / ). a combination of v d and k r among two samples acted synergistically to reduce efavirenz (efv) and nevirapine (nvp) susceptibility. furthermore, two blood donors with k n mutation in reverse transcriptase gene had high level-resistance to efv and nvp. summary/conclusions: overall, the most prevalent subtypes among blood donors in the study were crf _bc ( . %), crf _ae ( . %). besides, other rare crfs and several urf_ and urfs were also found in these hiv- isolates, which suggested the epidemic of hiv has been shifted from high risk populations into general populations, including blood donors in china. drms were observed in . % donors in the study, which may result in resistance to pis and nnrtis, especially the hiv- variants with n s mutation in pr gene and k n mutation in rt gene. in summary, our findings indicate that increasing diversity of hiv- in blood donors and remind us the necessity of timely genotypic drug resistance monitoring and molecular epidemiology surveillance of hiv- among blood donors. background: labeling of platelets is required to measure the recovery and survival of transfused platelets in vivo. currently a radioactive method is used to label platelets. however, its' application is limited, due to safety issues and the inability to isolate transfused platelets out of the circulation. biotin-labeling of platelets is an attractive non-radioactive option, however, no validated protocol to biotinylate platelets is currently available for clinical purposes. aims: the aim of this study is to develop a simple, standardized, reproducible method to label platelets with biotin as a non-radioactive alternative to trace transfused platelets in vivo. methods: six pooled buffy coats derived platelet concentrates (pcs) stored in % plasma were biotinylated at day and day of storage. to distinguish the effect of the processing steps from the effects of biotin incubation, 'sham' samples were processed. for the biotinylation procedure, ml of pcs was washed twice and incubated with mg/l biotin, dissolved in phosphate buffered saline-pas-e ( : ), for min. stability of the biotin labeled platelets after irradiation was tested. annexin v and cd p expression were assessed as measures of platelet activation. applicability of this method to other platelet products was assessed in three pooled pcs stored in % pas-e and three single donor apheresis pcs. results: the method was reproducible performed in a closed system. after biotinylation, . % ae . % of platelets were labeled. platelet counts, ph and 'swirling' were within the range accepted by the dutch blood bank for standard platelet products. the number of annexin v positive cells was not significantly altered by the biotinylation procedure in both fresh and stored platelets. in contrast, cd p expression was increased in biotinylated platelets . % iqr( . - . %) compared to the control samples . % iqr( . - . %) on day of storage. however, biotinylated platelets were not more activated compared to sham samples % iqr( . - . %). thus only the procedural steps led to increased cd p expression and not the biotin label itself. all samples showed maximal response to thrombin receptor-activating peptide. for platelets labeled at day , a similar pattern was observed. irradiation of biotin labeled platelets did not alter the stability of the biotin label nor cell quality. furthermore this method is also applicable to pooled pcs stored in pas-e and apheresis pcs, with similar patterns in annexin v and cd p expression. summary/conclusions: we developed a standardized and reproducible protocol according to good practice guidelines (gpg) standards, for biotin-labeling of platelets for clinical purposes. the procedural steps, which are similar to the steps used for production of hyperconcentrated platelet products, led to an increased cd p expression, but did not alter the annexin v expression. this method can be applied as non-radioactive alternative to trace and recover transfused platelets in vivo. blocking activity over the prototypic chs insulator in cell lines and substantially reducing genotoxicity in a c-retroviral vector-mediated carcinogenesis mouse model. in contrast to chs , these insulators are small-sized ( - bp vs . kb) and can be easily accommodated in gt vectors without detrimentally affecting vector titers. aims: we aimed to test whether a , one of the newly discovered cis, could reduce vector-mediated genotoxicity in the challenging context of sin-lvs, by insulating a therapeutic globin-vector. methods: we tested the genotoxicity effect in the il- -dependent d cells, which upon transduction with oncogenic vectors become il- -independent, leading to transformation. d cells were transduced with sin-lvs: the b-globin-ΤΝs . . -, the insulated b-globin-a -tns . . and the oncogenic sffv-gfp-vector. transduced cells were expanded in % il- and transduction efficiency was determined by vector copy number (vcn). transduced d cells were seeded in methylcellulose with % or - % il- to detect the il- -independent and potentially transformed clones. the il- -independent clones were further expanded in % il- and infused in partially myeloablated and il- -treated c h/hej mice. wbc analysis, blood smears and bone marrow(bm) cytospins were performed. results: the a insulator did not negatively affect vector titers (ΤΝs . . , a -tns . . , sffv-gfp: . , . , . x ^ iu/ml, respectively). d cells were successfully transduced with all vectors (%vcn positive colonies: - %) and expanded up to -fold. the a -insulator decreased the number of il- -independent colonies by - % over the uninsulated vectors. the uninsulated vector-transduced, il- -independent colonies, were greatly expanded in culture with % il- over the a -transduced colonies (sffv, ΤΝs . . , a -tns . . : , , fold change, respectively). il- independence as a transformation event was confirmed in vivo by the development of overt leukemia (hyperleukocytosis, splenomegaly, bm-and extramedullary site-infiltration) in mice transplanted with the il- -independent and expanded colonies. summary/conclusions: under forced oncogenic conditions, the a insulator effectively protected a therapeutic vector from vector-mediated genotoxicity. a may serve as a safety feature in the construction of globin-sin-lvs. background: novel rare nucleotide substitutions are frequently identified in rhd, the gene encoding the immunogenic d antigen of the clinically-relevant rh blood group system, resulting in d variant phenotype. so far, it has been commonly accepted that substitutions of amino acids located either in a transmembrane or intracellular domain of the rhd protein induce weak d phenotype, i.e. reduced d antigen density at the surface of red blood cells. recently we showed by functional analysis using a "minigene splicing assay" (msa) that a decrease in d antigen expression may be due also to alteration of cellular splicing. aims: here we pay attention to the general disruption of this mechanism and the related phenotypic consequences in novel and previously reported single-nucleotide variations in rhd. we then sought to characterize functionally by msa novel candidate splicing variants in rhd. then we extended the project by studying prospectively all single-nucleotide variations reported in rhd exons, in order to assess globally the correlation between in silico prediction and functional analysis and to gain insights into the reliability of bioinformatics tools in line with the available phenotypic and/or clinical data. methods: seventeen novel or uncharacterized rhd variations, including missense, synonymous and intronic substitutions, were selected for functional analysis by msa in human cell models. a second set, including missense variants reported in rhd exons and , was further analyzed. functional data were compared with an algorithm derived from the quepasa method and tools available in the alamut suite. a published d protein model was used to visualize the location of missense amino acid substitutions and to assess potentially their respective phenotypic consequence. results: a novel "universal" minigene was validated and used successfully to characterize eleven novel splicing variants. those variants include six intronic and four missense substitutions close to the consensus dinucleotide splice sites, as well as the c. c>t synonymous variation associated with a weak d phenotype, which creates a de novo splice site. very interestingly, c. g>t (gly val; d-negative) disrupts totally normal splicing, while c. g>c (gly ala; weak d) and c. g>a (gly asp; d-negative) only partially alter the mechanism. further visualization of amino acid changes in a d model suggests that gly asp, but not gly ala, dramatically impair rhd protein structure/folding. subsequently the global analysis of mutations in rhd exons and by msa showed that inclusion of whole exon sequence in the mature transcript is significantly reduced in / ( . %) variants, which correlates well with the quepasa-like prediction (sensibility = . , specificity = . ). additionally, while normal exon inclusion is affected by c. c>g (weak d type ), the associated leu val substitution does not seem to be deleterious to the protein. summary/conclusions: on the basis of our functional data, this work shows that splicing disruption in the presence of rhd variants is a common and general mechanism that may act independently or synergistically with alteration of protein structure through amino acid substitutions, resulting in a weak d phenotype. it also illustrates the potency of combining functional tests and in silico tools towards the phenotypic/clinical interpretation of rare variants. background/aims: monetary and non-monetary incentives may support blood services in recruiting blood donors but have also been criticized for violating ethical principles and threatening blood safety by attracting donors with a high risk for infectious diseases. although incentives for blood donors have been discussed extensively over the past decades, empirical research on this topic remains limited. the aim of this study was to describe attitudes towards incentives for blood donors in europe and show donor return rates of compensated and non-compensated blood donors in south-west germany. methods: first, we present results of a secondary analysis of the eurobarometer, a nationally representative survey in all member states of the european union. in , participants were asked to evaluate eight potential incentives for blood donations as acceptable or unacceptable. these incentives were refreshments (e.g. coffee), physical check-ups (e.g. blood pressure), free (testing) laboratory parameters, free medical treatment, complimentary items (e.g. first aid kits), monetary travel reimbursements, additional cash reimbursements, and release from work. second, we conducted a retrospective analysis of donor return patterns of . compensated and . non-compensated donors who started donating blood at mobile and fixed donation sites. compensated donors received either eur as a regular reimbursement for their expenses (at a fixed donation site), in accordance with the german transfusion law, or a singular free entrance for an amusement park (at a mobile donation site). these compensated donors were compared with noncompensated donors who started either at a fixed or mobile donation site. chisquare statistics were used to test for differences in regular donor status after , , and months between compensated and non-compensated first-time donors. results: among german participants of the eurobarometer, physical check-ups ( . %), refreshments ( . %) and free (testing) laboratory parameters ( . %) showed the highest acceptance as an incentive for blood donors. travel reimbursements and free medical treatment were rated as acceptable by . % and . %, respectively. the lowest acceptance was for release from work ( . %), complementary items ( . %) and additional cash reimbursement ( . %). interestingly, the acceptance of potential incentives varies considerably across europe. in south-west germany, donor return of first-time donors differed significantly by type of compensation. among compensated first-time donors, who received eur as a monetary reimbursement, the proportion of regular donors after months ( . %) was significantly higher than among comparable non-compensated donors ( . %). however, a non-monetary compensation (free entrance) did not increase donor return rates. conclusion: the eurobarometer survey indicates that in most european countries monetary incentives are only accepted by a small minority. refreshments, checkups, free (testing) laboratory parameters and free medical treatment were most popular as incentives for blood donors. however, results of our four non-randomized donor samples from south-west germany suggest that monetary compensation may increase the likelihood of donors returning to fixed donation sites. regular monetary reward may therefore help to recruit regular donors especially in urban settings. incidentally, non-monetary compensation by a free entrance, however, may not affect donor return. background: previous research showed that whole blood (wb) donors that are temporarily deferred on-site are at higher risk of lapsing, yet very little studies have focused on differentiating the effects that different deferral reasons (e.g., travel, hemoglobin [hb]) may have on donor lapse. in addition, donor experience (i.e., firsttime or repeat donor) has also previously been found to affect donor lapse, yet novice ( - prior donations) and reactivated donors (returning after years of not donating) may respond differently. finally, it is currently unclear how and why different deferral reasons and donor experience interact in influencing donor lapse. aims: our aims were to understand ) how deferral reasons and donor experience jointly affect donor lapse, and ) why donors may lapse after temporary deferral. methods: a mixed methods approach was used. first, we used sanquin's donor database for a quantitative analysis of return behavior of all dutch wb donors between and (n = , ). the first wb donation for each donor was identified as the target donation. lapse was defined as non-return within a followup period of two years after the target donation. target donations included % new donors, % novice donors, % experienced donors, and % reactivated donors. deferral reasons included travel, hb, medical short-term (< days duration), medical long-term (> days duration), and miscellaneous. next, we interviewed temporarily deferred donors to understand the deferral process from their perspective. semi-structured interviews were used to understand how these donors cognitively and emotionally experienced on-site temporary deferral. we analyzed the interviews (using the framework approach, cf. hillgrove et al., bmc public health, ) to identify key topics and underlying themes. results: of target donations, % were deferred, mostly for travel ( %), medical short-term ( %), and hb ( %). survival and time-to-events methods showed that the different deferral reasons and donor experience levels differentially impacted donor return or lapse. importantly, experience and deferral interacted in influencing return (rate). for instance, deferred new donors were more likely to lapse than eligible or experienced donors (ors < . , p's< . ). even though deferral also affected return of experienced donors, this effect was smaller or even non-existent for certain deferral reasons (e.g., travel-and hb-related deferrals). qualitative results showed that almost all donors experienced temporary deferral as disappointing, particularly when it was unexpected (e.g., first-time deferral). not all donors (fully) understood the aims of deferral or how to prevent on-site deferral. donor beliefs about why deferral would lead to lapse were related to recurring deferrals, (mistakenly) interpreting deferral as permanent, or feeling all the effort did not pay off. summary/conclusions: reasons for temporary deferral differently impact risks of donor lapse at different levels of donor experience. for new donors all reasons for deferral are related to higher risks of lapse, whereas some reasons for deferral seem not to affect lapse among more experienced donors. unexpected or recurring deferrals may explain why donors lapse after temporary deferral. blood banks may tackle disappointment after deferral by explicitly showing that the donor is still valued, for instance by using personalized communication or offering an alternative good deed. background: blood donors experience a temporary reduction in their hemoglobin (hb) value after whole blood donation. in the netherlands, the hb value is measured before each donation, and a too low hb value (cut-off values: . mmol/l ( g/l) for men and . mmol/l ( g/l) for women) leads to a deferral for donation, in order to prevent iron deficiency and anaemia. the minimum interval between two donations is internationally set at weeks, but over time donors exhibit iron deficiency so that blood donors are temporarily deferred from donation each year. in the us % - % of deferrals are due to low hb, especially in women (editorial, transfusion, ) . due to the recovery process after each donation and the unobserved heterogeneity of donors, advanced statistical methods are needed to model the longitudinal data of hb values of blood donors. aims: to estimate the shape and duration of the recovery process of hb until the hb value has returned to its pre-donation level, to assess whether one can distinguish between donors with fast and/or slow recovery of their hb level and to predict future hb values. methods: the study is based on data of the donor insight study, which was a prospective cohort study performed by sanquin in the netherlands from to . we employed three statistical models for the hb value: (i) a mixed-effects models, (ii) a latent-class mixed effects model, and (iii) a latent-class mixed-effects transition model. in each model, a flexible function was used to model the recovery process after donation. the latent classes identify groups of donors with fast or slow recovery times, and donors whose recovery time increases with the number of donations. the transition effect accounts for possible state dependence in the observed data. all models were estimated in a bayesian way, using data of a sample of new entrant donors ( males and females). prior information from the clinical literature (boulton, vox sanguinis ) about the recovery process three days after blood donation was incorporated into the analysis since these values were not identified in the observed data. results: the results show that the latent-class mixed-effects transition model fits the data best. we also found that the recovery process shows a concave process (initially fast followed by slower recovery). the estimated recovery time is much longer than the current minimum interval of days between donations. namely, depending on the subgroup that the donor belonged to, males showed a recovery time of to days, while the estimated recovery time for females varies between to days. these results suggest that an increase of this interval may be warranted. summary/conclusions: the analysis shows the usefulness of the sophisticated statistical models that make use of historical information to model complex processes in time, in this case the hb trajectory over time across repeated donations. in addition, our results suggest a (much) longer time lag between subsequent donations to avoid anemia. background: complications of blood donation are known to reduce donors' return for future donation. the episode study (experience success in donation) showed that water drinking shortly before donation had an effect of % reduction of selfreported vasovagal reactions (vvr) in younger novice whole blood donors (wiersum-osselton, transfusion, ) . aims: in this study we analysed the return for a subsequent donation of the donors participating in the episode study. this was a predefined secondary outcome of the episode study. methods: the episode study was conducted in young (< years) whole blood donors making their first, second, third or fourth donation in geographically selected collection centres. the study interventions were: ml water drink, ml water drink or squeezing a ball (placebo intervention) during the wait after the screening interview and before phlebotomy, and a control group without intervention. participating donors were sent an online questionnaire about their experience within a week following their donation attempt. in the netherlands donors are usually invited for blood donation in accordance with hospitals' needs; the aim is to invite eligible donors at least once a year. donors were included in the return analysis if they had received at least one invitation within days after the index donation and we analysed their return for a donation attempt within days. associations with the interventions and donors' donation status, gender and reported symptoms at their index donation were analysed by calculating return percentage of eligible donors and by binomial logistic regression. results: out of the episode participants who had received an invitation, ( . %) returned within the study period. there was no difference in donor return between the two water groups. the likelihood of return was significantly increased in both water and placebo intervention donors compared to the questionnaire group (or . , % ci . - . and . , . - . respectively). return was slightly lower in women (or . , ) and lower in first-time donors (or . , . - . ) than after a nd - th donation. a staff-recorded or self-reported vvr at the index donation reduced donor return (or . , % ci . - . and or . , . - . respectively). other symptoms following donation were also associated with a lower return percentage. summary/conclusions: in this cohort of younger new and novice blood donors, . % returned for a subsequent donation. a vvr (either staff-recorded or selfreported) reduced donor return. donors who received a study intervention, either water or placebo, were more likely to return, whether or not they had suffered a vvr. it is conceivable that the mere fact of study participation could also have increased donor return, even in de questionnaire group; this will be examined in the total population of target group donors. background: the contribution of older blood donors to the blood supply is substantial. in australia, donors aged > years contributed % of all donations made in . however, with ageing, the general health status of older donors changes relatively faster, thus progressively affecting their ability to donate. an indepth understanding of the relationship between older donors' health status, future donation patterns, and risk of iron-deficiency could be of a great value to inform the blood service to predict the number of future donations, and manage the risk of iron-deficiency. aims: to understand the relationship between self-reported health, blood donation patterns, and the management of identified iron-deficiency in older blood donors. methods: we linked the sax institute's and up study baseline data collected between and to the blood service donation records, inpatient records, and medicare records*. the data-linkage was conducted by centre for health record linkage. using these linked data, we examined the relationship between health, donation patterns, and iron-deficiency and its management. results: we followed up , active whole blood donors for , eligible person-years (average age at recruitment . years, . % female, average follow up . years per-person). after adjusting for the effect of age, sex, body-mass index, education, non-english language spoken at home, country of birth, smoking, physical activity, regular use of multivitamins, alcohol consumption at enrolment, and total number of whole blood donations in the years prior to enrolment, participants with better self-reported health at recruitment showed significantly higher rates of donation. excellent, very good, good, and fair/poor health status donors made ( % ci - ), ( - ), ( - ), and ( - ) donations per person-years, respectively. iron-deficiency was identified in . % of donors in the study (n = , % ci . - . ) . sixty percent of those with iron deficiency (n = , , % ci . - . ) visited their general practitioner (gp) within days of the identification of irondeficiency, and . % ( % ci . - . ) of those visiting gp underwent further iron status examination and monitoring. after adjusting for several potential confounders including the total number of donations made during the follow-up period, excellent self-reported health status was independently associated with lower risk of iron-deficiency (p for trend = . ). summary/conclusions: information on self-reported health status can be an effective indicator to estimate the future donation yield of an older blood donor panel, and risk of developing iron-deficiency. donors with better self-reported health had a higher number of future whole blood donations and a lower risk of iron-deficiency. donors referred to gps for management of their iron status utilised the health services as expected, however there is an opportunity to improve their contact with their gps. * medicare records was provided by australian government department of human services. anaemia is a major public health issue, affecting % of the population worldwide according to the world health organization. iron deficiency is responsible for approximately half of all cases globally, with other causes including anaemia of chronic disease, other nutritional deficiencies, haemoglobinopathies, renal impairment, malignancy and bone marrow disease. in the elderly, where anaemia is even more common, the cause is frequently multifactorial. anaemia is associated with increased mortality, decreased cognitive and physical function, depressive symptoms and fatigue, particularly in older adults. poor outcomes have also been reported in anaemic patients with underlying comorbidities such as cardiac and renal disease, and cancer. within a hospital setting, anaemia is highly prevalent. preoperative anaemia, affecting up to % of patients, is associated with poor clinical outcomes including higher in-hospital mortality, longer length of stay and higher icu admission rates. anaemia management requires a proactive and multi-faceted approach, typically involving a multi-disciplinary team in which the transfusion practitioner plays a vital role. this includes screening of high-risk patients and pre-admission clinics to identify and manage patients at high risk of peri-operative anaemia. implementation of patient blood management (pbm) guideline recommendations has been shown to be effective to prevent and optimally manage anaemia within the community and hospital settings. the transfusion practitioner has key roles in the coordination, monitoring and auditing of pbm programs. active patient involvement and engagement of all members of the multidisciplinary team, including primary care clinicians, are also key to enhance the success of such programs. tp - the role of the transfusion practitioner in anaemia assessment and management: processes, tips and resources for creating background: patient blood management (pbm) is an evidenced based integrated multi-disciplinary approach aimed to improve clinical outcomes by effectively managing and conserving the patient's own blood, thus reducing unnecessary exposure to transfusion. pbm has the patient as the central focus with the aim being to improve their outcomes and include them in the process. pbm includes three pillars: ) optimising the patient's own blood, ) minimising blood loss and ) optimising a patient's physiological tolerance of anaemia. delayed assessment/management of anaemia contributes to increased health costs and unnecessary blood transfusions, and transfusion has been recognised to be associated with increase morbidity and mortality. the term transfusion practitioner (tp) includes those known as transfusion nurses, transfusion safety officers, haemovigilance officers, or patient blood management (pbm) coordinators. a key aspect of the role is driving and influencing clinical blood management activities to help align practice to internationally recognised guidelines and standards, including pbm. aim: to demonstrate the tp role in anaemia assessment & management and discuss strategies, processes, tips and resources for creating organisational and cultural change to implement pbm. context: literature outlines the importance of a multidisciplinary team to implement pbm related changes, and tps play a fundamental role within these teams to support 'buy in'. tps are seen as enablers, pulling resources together, engaging with those involved, providing education and facilitating change. they are often the ones to conduct audits, collating data and evaluating outcomes. approaches to implement pbm should be tailored to suit individual organisations. the authors will outline different approaches, highlighting where the tp can support or lead activities. one approach to anaemia assessment is to undertake an audit, examples of available tools will be shown. with this data, the tp along with the pbm team can explore options for corrective action. these could include interventions such as developing a pathway where all or a specific group of patients are assessed and or treated either at a preoperative clinic, or with their local general practitioner; through to more complicated strategies such as establishing anaemia clinics. the skills of the tp are a valuable asset to analyse clinical specialties/patient mix who should be targeted to achieve best outcomes, they know the organisation and as such are well placed to help develop a process/concept that will suit, and they can provide education and support to promote and embed these practices. conclusion: appropriate assessment and management of anaemia requires a multidisciplinary approach. the tp plays an active and crucial role in this team. examples of processes, tips and resources to support change and embed a pbm culture across the clinical spectrum will be shared. d-s - department of hematology and central hematology laboratory, inselspital bern, bern, switzerland immune haemolytic anaemia (iha) is characterized by an increased breakdown of red blood cells (rbcs) due to allo-and/or autoantibodies directed to rbc antigens with or without complement activation. clinical and laboratory signs of haemolysis in concert with the presence of a positive direct antiglobulin test characterize iha. alloantibodies formed during pregnancy and/or after prior transfusions may cause acute or delayed haemolytic transfusion reaction after transfusion of a rbc product incompatible with the specificity of the alloantibody. autoantibodies to rbcs reduce the survival of endogenous and hamper the recovery of donor rbcs after transfusion. lymphoproliferative disease, autoimmune disease, infection or drugs often cause autoantibodies to rbc, but frequently no obvious cause can be identified. besides the antigen specificity, the isotype critically determines the biological activity of rbc antibodies in vivo. the isotype defines the affinity to fc-gamma receptors on cells of the reticuloendothelial system as well as the capacity to activate the classical pathway of complement, igm being the most effective. antibody-mediated complement activation results in the opsonisation of rbc with c bc/c d with subsequent complement receptor-mediated removal by phagocytes (extravascular haemolysis). occasionally, complement activation proceeds via the activation of c to the formation and insertion of the membrane attack complex resulting in intravascular haemolysis. there is growing evidence that the innate immune system plays an important role in the pathogenesis of iha. the process of complement-mediated haemolysis results in systemic inflammation, which contributes to morbidity and mortality of patients suffering from iha. complement activation results in the release of anaphylatoxins, which are strongly vasoactive and mediate chemotaxis, inflammation and formation of radical oxygen species. release of cell-free haemoglobin and cell-free haeme upon haemolysis induces endothelial cell activation, no-depletion, cytotoxicity, ros formation and neutrophil activation. natural plasma scavengers, such as haptoglobin and hemopexin complex with their target molecules, cell-free haemoglobin and haeme, with subsequent removal of the complexes via cd and cd -mediated phagocytosis. although being positive acute phase proteins due to consumption the plasma scavengers become exhausted during chronic haemolysis thereby failing to prevent the adverse biological effects of cell-free haemoglobin and haeme in the circulation. inducible haeme oxygenase- (ho- ) is an efficient cellular scavenger by breaking down haeme into biliverdin with subsequent formation of bilirubin, co and ferrous iron with subsequent oxidation to ferric iron and storage by the ferritin h chain. ho- has an established role in the systemic protection from systemic inflammation induced by haemolytic and non-haemolytic diseases. the lecture will emphasise the role of innate immunity with a special focus on different plasma-and cellular systems involved in the pathogenesis of systemic inflammation in patients suffering from iha. d-s - understanding erythrocyte clearance c roussel, p amireault, p ndour and p buffet research and teaching, institut national de la transfusion sanguine, paris, france the clearance of erythrocytes is essential in physiology, disease and transfusion. elimination of erythrocytes altered because of senescence or pathological processes is expected to protect the microcirculation from obstruction by adhesive or rigid erythrocytes. it also contributes to the harmful consequences of anemia and hemolysis in hereditary and acquired red blood cells diseases as well as in conditions associated with auto-or allo-immunization. immunobiology has explored in great details antibody-mediated clearance of erythrocytes but conventional approaches may not be fully operational to explain delayed hemolytic transfusion reactions. some important clearance processes are independent from the recognition of molecules or antigens on the erythrocyte surface. increased erythrocyte stiffness triggers their clearance in hereditary spherocytosis, malaria and possibly also in the context of autoimmune anemia. knowns and unknowns on the mechanisms and sites of erythrocyte clearance will be presented based on a critical review of old and recent contributions. d-s - cardiovascular and endocrine-metabolic diseases and aging, istituto superiore di sanit a, rome, italy existing literature indicates that red blood cells (rbcs), beyond gas transport, exert a complex role in human physiology, being involved in many functions essential to maintain ion, metabolic and immunological homeostasis. rbcs display an immunomodulatory activity on adaptive immune cells by promoting t cell growth and survival and inhibiting activation-induced cell death. the balance between cell death and survival controls t cell homeostasis and anomalies in this balance account for diseases linked to excessive or faulty t cell growth. rbcs are able to modulate innate immunity by binding endogenous molecules such as chemokines and mitochondria-derived dna, as well as external agents such as pathogens. rbcs can also directly modulate innate immune cell activation or tolerance by controlling the maturation of the circulating pro-inflammatory subset of dendritic cells (dcs). these cells are potent inducers of primary antigen-specific t cell responses, produce tnf-a when stimulated by lps and are the principal il- p -producing cells among leukocytes. the pro-inflammatory capacity of circulating dcs is controlled by rbcs that are able to inhibit their maturation and il- production. in diseases characterized by local th inflammatory response such as psoriasis vulgaris and rheumatoid arthritis, pro-inflammatory dcs play a role in the induction and perpetuation of inflammation. collectively, literature data indicate that rbcs exert important modulatory functions that may result in immune activation or quiescence, depending on the environmental conditions. when rbcs encounter a microenvironment characterized by an intense production of ros, the rbc defenses get overwhelmed or are unable to counteract the new pro-oxidant status and become themselves a source of ros, which cause the generation of senescent signals on rbcs. the major feature of oxidized rbcs is the clustering and/or the breakdown of band . other features are the complexation of hb with spectrin, the loss of glycophorin a, the externalization of phosphatidylserine and the reduction of the "marker of self" integrin-associated protein cd . a similar senescence phenotype has been documented in rbcs during the storage period. oxidized, senescent or stored rbcs, due to surface antigen modification and to the release of pro-inflammatory molecules, fail to control immune cell homeostasis thus contributing to the perpetuation of inflammation and to the pathogenesis of immune-mediated diseases associated to oxidative stress, such as autoimmune diseases and atherosclerosis. our research group demonstrated that rbcs from patients with carotid atherosclerosis presented a senescent phenotype similar to that acquired by rbcs from healthy subjects following to in vitro oxidation. oxidized erythrocytes fail to control t lymphocytes apoptosis and lipopolysaccharide-induced monocyte-derived dc maturation, thus representing dangerous signals for adaptive and innate immunity and contributing to the pathogenesis of atherosclerosis. in conclusion, the crosstalk between rbcs and the immune system represents a mechanism to maintain immunological homeostasis. however, in high oxidative stress conditions, that can take place during a prolonged storage period or in particular diseases, rbcs can acquire a pro-oxidant behaviour and lose their functional and homeostatic features. by interfering in immune system homeostasis, rbcs become a potential tool that can be manipulated to improve or reverse pathological situations characterized by anomalies in the control of adaptive and innate immunity. transfusion therapy remains an important treatment modality for patients with sickle cell disease (scd). transfusions are given to lower the percentage of circulating sickle rbcs, and to decrease blood viscosity and have been shown in clinical trials to reduce the risk of stroke by %. however, many indications for transfusion in scd remain controversial partly due to insufficient randomized clinical trials data and in part because of our limited understanding of the complex pathologic networks leading to diverse disease complications in scd despite the common single mutation. similarly, we have incomplete mechanistic understanding of why chronic transfusion protocols must be continued for those indications supported by clinical data. the beneficial effects of transfusion therapy in scd need to also be weighed against potential transfusion risks including alloimmunization associated with lifethreatening delayed transfusion reactions, increased iron stores associated with increased oxidative stress and exposure to infectious agents. we believe that a deeper understanding of the benefits as well as harmful effects of transfusions is crucial to optimize our current transfusion therapy protocols in scd. this knowledge may provide highly needed guidance, which is currently lacking, for expansion or limiting existing indications for chronic transfusions in scd. d-s - treatment of thalassaemia department of pediatric hematology, ege university, faculty of medicine, bornova/ izmir, turkey thalassaemia is a devastating blood disease with a significant worldwide burden. annually, , children are born with a major thalassemia. life-time rbcc transfusions and iron chelation remain standard of care treatment in thalassaemia. transfusion therapy still account for significant iron overload related morbidity and mortality despite chelation therapy which is associated with poor adherence, safety concerns and varied efficacy. higher risk for transfusion transmitted infections (ttis) exists for thalassemia patients whose transfusion exposure sustains lifelong. although, the risk of transmission for traditional viruses is exceedingly rare in the modern era, emerging infectious diseases continue to be recognized as potential threats to transfusion safety. the inadequacy of blood safety points to the necessity for an additional layer of security for the blood supply in the developing world. pathogen reduction technologies for rbcc may imply a proactive, more generalized approach against new and re-emerging pathogens in the developed world and may be an ultimate safeguard for transfusion safety in the developing countries. rbc alloimmunization may become a major challenge in thalassaemia management. prevention is the key reducing the burden of alloimmunization. while the recommendation is to transfuse thalassaemic patients with c/c,e/e,kell compatible blood, it is not universally practiced. extended molecular rbc typing may be an appropriate adjunctive test in addition to serological typing before embarking on transfusion therapy. if a complete rbc antigen profile has not yet been performed in an alloimmunized patient, genotyping is the only option for accurate detection of rbc antigens that may guide the antibody identification. allogeneic stem cell transplantation (a-sct) is the only available curative therapy in children with hla matched sibling which is available to approximately % patients. in the absence of msd, mud transplant with high compatibility criteria has still limited experience. mismatch related, cord blood and haploidentical donor scts are considered experimental. a-sct carries a substantial risk of saes and mortality, both increasing with recipient age and disease severity. dfs is % in paediatric and % in adults. gene therapy for correction of the a-globin chain imbalance overcomes the problems of donor availability and immunologic complications associated with a-sct. multicenter clinical studies on gene addition therapy by using self-inactivating lentiviral vector are currently underway. recently, gene editing by either gene disruption or gene correction emerged as a potential alternative to gene addition therapy in beta-thalassaemia. a new era of novel therapeutics is unfolding in thalassemia management. several targets have been identified that can improve alpha/beta chains imbalance, ineffective erythropoiesis, or iron dysregulation and a number of those now have agents in preclinical and clinical development. hydroxyurea may improve globin chain imbalance and be beneficial for reducing or omitting transfusion requirement in selected group of patients. ruxolitinib has shown the limited effect on pretransfusion haemoglobin and reduction in transfusion needs, but allowed steady decrease in spleen volume that may serve for avoiding splenectomy in beta thalassaemia. luspatercept may restore normal erythroid differentiation and improves anaemia and hepcidin mimetics or tmprss inhibitors may modulates ineffective erythropoiesis by iron restriction and improves anaemia and organ iron loading. background: thalassaemia major (particularly b-type) and sickle cell disease (scd) are the commonest clinically important haemoglobinopathies, representing major sources of morbidity. recommended therapy is regular transfusion of safe, good quality blood, and monitoring of related complications. thalassaemia international federation (tif) guidelines, in place since , include strategies for precautionary measures and use of scientific progress in detection, inactivation and elimination of transfusion transmissible pathogens. antigen-matching strategies to avoid alloimmunization against rbc antigens and other measures including haemovigilance are key components for safe blood, alongside voluntary, non-remunerated blood donation and laboratory quality assurance programmes. aims: we present the contribution of tif and the greek experience in ensuring safety and availability of blood for thalassaemia patients applying internationally accepted standards and recommendations. methods: tif -a non-profit, patient-driven organization with national thalassemia associations in countries -promotes national control programmes for prevention and management contributing to the achievement of final cure. the main working methods are provision of education, expert support, networking, communications and projects to support improvements in the quality of health, social and other care. in greece, technical standards for blood donor selection and testing are applied in compliance with directive / /ec as well as haemovigilance programmes and traceability procedures for recording adverse reactions and events associated with the transfusion of rbcs (directive / /ec). pre-transfusion and transfusion measures recommended by the council of europe are applied. in particular, measures for transfusion of "the right blood at the right time for the right patient", leucodepletion, rbc washing and accurate cross-matching and antigen and antibody screening for an extended matching policy are practised. fresh (up to days old) rbcs are used. molecular testing for abo and rh d is performed in cases with blood group discrepancies. haemovigilance in greece covers % of total blood supply. data on ttis in , patients with thalassaemia and scd-thalassaemia in - are analysed. results: tti prevalence in thalassaemia syndromes was: hbv . % (occult type . %), hcv %, hiv . %, htlv . %, wnv . % and hev %. most frequent adverse reactions in - were allergic (incidence : ), non-haemolytic febrile reactions : , , "other" : , , alloimmunisation : , , taco : , , tad : , , tt-hev : , . hyperhaemolysis was diagnosed in two scd patients, delayed haemolytic transfusion reaction in one thalassaemia intermedia patient. trends in - show reduced incidence of alloimmunisation against rbcs. rates of allergic and pyrexial ars remained stable. no major abo incompatibility case was reported and no fatal transfusion reaction of transfusion has been recorded. summary/conclusions: blood safety in transfusion has significantly improved in high and upper-middle income but unfortunately not in lower and low income countries. blood shortages and lack of stringent protective measures for thalassaemia patients is the reality for many developing countries. tif focuses particular attention on the provision of support and the promotion of initiatives promoting the safety and adequacy of blooda key component of the lifelong management of patients with transfusion-dependent thalassaemia. background: b thalassemia is the most common group of hereditary hemoglobinopathy diseases. affected people with major thalassemia are dependent on regular blood transfusion which leads to iron overload. hepcidin is a peptide and an important regulator of iron homeostasis. expression of this hormone is influenced by polymorphisms within the hepcidin gene, hamp. aims: this study aimed to analyze the association of three polymorphisms in promoter of hamp, rs , rs , and rs with iron overload in major b thalassemia patients who do not respond to iron chelating therapy. materials and methods: a total of samples from major b thalassemia patients were collected. genomic dna was extracted and sequenced for snps rs , rs , and rs . statistical analysis was performed on ibm*spss* statistic using independent t test and fisher test. results: our analysis revealed statistically significantly difference between the level of cardiac iron concentration and c.- a>g variant (p = . ). for rs statistical analysis was on the edge of significant relationship between minor allele and serum ferritin (p = . ). all samples were homozygous for allele t of rs . summary/conclusions: different factors affect iron overload in thalassemia. our findings and others emphasize the role of hepcidin polymorphism as a key component in iron homeostasis. ten to twenty years ago, countries in south eastern africa faced the peak of the devasting hiv/aids epidemic leading to an up to years drop in general life expectancy. with the burden of hiv/aids falling mainly on the economically active population of young and medium-aged adults, the epidemic endangered social and economic stability in nations most heavily affected. today, despite aids still being a major cause of death in south eastern africa, the epidemic has become an example of public health gains that can be achieved through programmatic, evidencebased approaches that are endorsed by globally aligned policy and funding strategies. based on his work from lesotho, where one out of four among adults is infected by hiv, niklaus labhardt will take the auditors through the history of hiv programs in south eastern africa and show how innovative, pragmatic and evidence based implementation brought the region to a stage where the goal to end the aids epidemic by might be in reach. background: in france, the deferral for men who have sex with men (msm) was reduced from permanent to months in july . since this change has not impacted the residual risk (rr) of undetected hiv among blood donations, the ministry of health is considering a greater access of blood donation to msm. two scenarios have been studied: s . deferral of msm during the months preceding the donation; s . deferral of msm who have had more than one sexual partner in the months preceding the donation, similarly to all other blood donors in france. aims: to assess the impact of these two scenarios on the hiv rr estimated over the period july -december which is the baseline rr with the current month deferral for msm. methods: baseline hiv rr was calculated with the classical incidence-window-period method, where hiv incidence was derived from a detuned assay (eia-ri) detecting recent infections (≤ days) since all hiv- antibodies positive blood donations are tested with this test. the assessment of the impact of both scenarios on the baseline hiv rr was based on (i) data obtained from surveys among msm in the general population and in blood donors (compliance survey), to estimate the number of additional msm who would give blood in each scenario, and on (ii) hiv incidence estimate among these additional donors. this incidence was estimated: for s , from msm blood donors with the current deferral policy ( months) and for s , from monogamous msm of the general population. results: from july to december , / ( %) hiv- positive blood donors tested with the eia-ri were identified as recently infected, allowing to estimate the baseline hiv rr at . in million donations [ % ci: . - . ], or in , , donations. for s , the number of additional msm donors was estimated at and the number of additional hiv positive donations at . , resulting in an hiv rr of . in million donations [ % ci: . - . ] or in , , donations. for s , the number of additional msm donors was estimated at , and the number of additional hiv positive donations at . , resulting in an hiv rr of . in million donations [ % ci: . - . ] or in , , donations. sensitivity analysis shows that if both the number of msm and the hiv incidence were multiplied by . , the risk would be in , , donations for s , and in , , for s . summary/conclusions: for both scenarios, the hiv rr remains very low. for s ( -month deferral), the risk is identical to the baseline rr and is very robust to variations in the model parameters. for s (no more than one sexual partner, months), the risk is . higher than the point estimate of the baseline rr and sensitivity analysis shows that this estimate is less robust than for s , since the risk could be times higher than the baseline rr. for both scenarios, there was a modest increase in eligible msm donating. d-s - background: recruiting safe blood donors amongst the largest hiv-positive population in the world is a major challenge for south african blood transfusion services. south african donor deferral criteria and deferral periods for perceived high risk activities have evolved over time, but current risk factors for infection have not been formally assessed. in addition, most studies have reported risk factors for prevalent hiv infection whereas risk behaviours for incident infection are more informative as donations with these infections could occur during the window periods of available screening assays. aims: to identify the demographic and behavioural risk factors associated with incident hiv infection among blood donors in south africa. methods: we conducted a case-control study with incident hiv-infected blood donors compared to infectious marker negative controls. incident hiv cases and controls seronegative for hiv, hepatitis b and c viruses and syphilis were accrued from a donor pool covering of provinces in south africa. controls were frequency matched at a : ratio to cases on race, age and geography. incident hivinfections were hiv rna positive by individual donation nucleic acid amplification testing (id-nat; procleix, grifols) but antibody (ab) negative (prism, abbott) as well as those rna+/ab+ donors with recently-acquired hiv based on limiting antigen avidity (lag) assay results with normalized optical density values of < . . eligible cases and controls completed a confidential audio computer assisted structured interview (acasi) on motivations for blood donation and behavioural factors, including behaviours in the months before donation. frequencies and measures of statistical association for risk behaviours comparing cases and controls are reported after adjusting for multiple comparisons. results: from november to january , we enrolled incident hiv cases and controls; ( . %) cases and ( %) controls were ≤ years old. there were significantly more female cases ( . %) than female controls ( . %) (p < . ). significant hiv risk factors (all p < . ) reported within the -months before donation included: having a primary sex partner who is male; reporting increasing numbers of male sexual partners for both females and males; frequency of vaginal sex; frequency of vaginal sex without condoms; use of methods to clean, dry, or tighten one's anus before sex; and having visited a traditional healer for medical care. lack of medical aid (private health insurance) and reports of injury or accident with blood loss were also associated with an incident hiv infection. summary/conclusions: our study has identified a set of novel, putative risk factors for incident hiv infection among south african blood donors while confirming a number of previously known sexual risk behaviours. not having private health insurance and being injured may be markers of socio-economic context that place individuals at higher risk rather than behaviours that directly increase hiv transmission risk. the detection of risk behaviours by acasi in donors who passed predonation questionnaires and interviews suggests that acasi has the potential to improve risk behaviour identification. background: in france from to , among male blood donors (mbds) found hiv- positive at blood donation screening, % did not disclose any risk factor for hiv infection during post-donation interviews, while % reported having sex with men (msm), and % and % reported heterosexual sex (hts) and other risk factors, respectively. aims: in order to gain new insights into the risk factors for hiv- infection in mbds, we performed an hiv- genetic network analysis, including hiv- positive mbds and patients included in the french primary hiv infection anrs co primo cohort (pc). methods: mbds, who donated blood between and , and pcs, included between and , were studied. epidemiological data were collected by the french blood service (efs) upon blood donation or post-donation interviews for mbds, and upon inclusion for cps. viral strains were sequenced and genotyped in pol gene, and a recent infection assay was performed to date infection in mbds (recent: < months). a partial transmission network was computed based on tamura-nei nucleotidic distance (threshold for hiv- s/t b = . %; for non-b s/ t = . %) and assortative mixing was evaluated for mbds epidemiological data, including risk factors for hiv infection (msm, hts, others and unknown). selfreported data were then compared to assortativity-enhanced data. results: hiv- strains from mbds and pcs were linked into clusters including at least one mbd. primo-only clusters were excluded from the analysis. compared to mbds who did not cluster, those found linked to the network were younger ( vs. year-old; p < . ) and were more likely to have a recent infection ( % vs. %; p = . ). assortative mixing indexes showed that paired individuals were more likely to live in the same area (p < . ) and to have the same risk factor for hiv infection (p < . ) compared to a random distribution. imputing msm risk factor to non-msm individuals paired with msm changed the distribution of risk factors as follows: msm: % vs. %, hts: % vs. %, other: % vs. % and unknown: vs. %. summary/conclusions: after validating the assortativity of risk factors between paired individuals, and imputing msm risk factor to individuals self-reported as non-msm (including those with no identified risk factor), up to % ( / ) of mbds could be reclassified as msm. this is a worst-case scenario, as the network analysis does not exclude the possibility of one or several persons between two paired individuals (missing link). altogether, these results could help reevaluate the hiv residual risk linked to msm mbds, especially in the frame of the evolution of blood donor deferral criteria. background: although most individuals remain asymptomatic, htlv infection can lead to adult t-cell leukaemia/lymphoma (atll) and htlv- associated myelopathy (ham). the serious nature of these diseases, evidence of transmission via non-leucodepleted blood, and concern about a high prevalence among donors originating from endemic areas led to the uk blood services introducing universal blood donation screening in . monitoring through routine surveillance commenced and htlvinfected donors were invited to participate in the htlv national register cohort study to assess disease progression. these data together with evidence from lookback to previously untested donations and cost-effectiveness analysis were reviewed by an expert working group in and . aims: to describe the epidemiology of htlv among uk blood donors and evidence of disease progression from long term follow up of asymptomatic donors. methods: uk blood donations screened, and infected donors identified are reported to a national surveillance scheme. these donors are contacted, their results explained and information about clinical history and possible sources of infection are collected. where appropriate, htlv-infected donors are consented to the register, with participants completing a baseline questionnaire about their health, flagged in registries for cancer or death, and followed up about every - years. results: in the uk - , htlv-infected donors were identified. prevalence among new donors was steady around / donations. prevalence among repeat donors peaked in ( . / donations), with most in previously untested. from to , prevalence of . per , donations (average of one positive/year) was recorded. in , prevalence among new donors increased to . / , donations ( positives), with increased numbers associated with asian ethnicity and coinciding with an increase in collections from bame groups. overall, most were women ( / , %), uk-born ( / ; %) and htlv- infections ( / ; %). mean age was years. almost all positive donations were from previously untested donors ( / ), with seroconversion within a year of previous donation confirmed for only of the previously tested donors. typically, infections were associated with endemic countries (including caribbean region, west africa, iran, india and japan), acquired through breast feeding or from their heterosexual partner originating from these countries. interestingly, three were thought to have been infected through self-flagellation. a total of htlv-positive asymptomatic blood donors have already been recruited to the htlv national register, and during over -person years follow-up, none had developed atll or ham. summary/conclusions: over years of testing, few seroconverters were identified, suggesting very little ongoing transmission among uk blood donors. the lack of disease among the cohort study was also reassuring, although it is likely too early to detect associated symptoms of a slow progressing disease. recruitment to this unique dataset continues, also outside of the blood donation setting. as a result of these surveillance data, evidence from lookback, and cost-effective analysis, in nhsbt ceased to test donations from previously tested donors unless the donation was being used to manufacture a non-leucodepleted component. finland lies in northern europe between the °and °n latitude. the length of the country is km and width km. by surface area it is the fifth largest country in eu. the population of the country is . million resulting in the lowest population density in eu ( . inhabitants/km ). the whole country is inhabited, although most of the population is packed in the south. the climate of finland is influenced mainly by its latitude, but the warm waters of the gulf stream and the north atlantic drift current also play a role. due to finland's northern location, winter is the longest season. the southern portions of the country are snow-covered about three or four months of the year, and the northern regions for about seven months. long distances, low population density and the extreme climate give logistical challenges. it is estimated that these logistical costs can be as much as - % of gdp in finland. the finnish red cross blood service (frc bs) has been the nationwide blood service provider in finland since . frc bs collects annually about whole blood units of which % are collected in fixed sites and % in mobile sessions around the country. central activities (donor recruitment, medical support, production, testing, supply chain management, digital services and administration) are located in helsinki. management of transfusion is highly dependent on the logistical arrangements from blood donation sites to the central facilities and from the central inventory to the hospitals. the logistics is outsourced to three major partners all of whom have their roots in nationwide public transportation and logistics services. posti ltd is a state owned company having its roots in the national postal and telecom office. today it is the leading postal and logistics service company having the widest network coverage in finland. blood units collected at different fixed sites and mobile sessions are transported overnight by posti ltd to the frc bs central facilities by am on the day following the blood donation. posti ltd is also used for the regular deliveries of blood products to the hospitals. the other important partner is matkahuolto ltd, which was founded in the s to maintain bus stations and to serve as a common marketing company for the bus and coach services in finland. it maintains a nation-wide package delivery system based on the scheduled bus route network. matkahuolto ltd is used to transport donor testing samples from the donation sites to the central laboratory. by this arrangement it is possible to obtain most of the donor samples to the laboratory around midnight, which significantly speeds up the completion of laboratory results. the third logistics partner is jetpak finland ltd, which operates the air freight for the national flight company finnair. blood transfusion services can be managed centrally in a large sparsely populated country in a manner that is of high quality, safe and cost effective. however, the supply chain has to be planned carefully. background: elearning is a divisive topic. it is often criticised as an inferior form of education while simultaneously being promoted as a means to provide education to large numbers of people in a consistent, cost-effective manner. bloodsafe elearning australia (bea) is a government-funded blood transfusion education program that commenced in and provides courses in clinical transfusion practice and patient blood management (pbm) including: -clinical transfusion practice ( courses) -pbm: general ( courses) -pbm: medical ( courses) -pbm: acute care and surgical ( courses) -pbm: obstetrics and maternity ( courses) -pbm: neonates and paediatrics ( courses) aims: to determine the engagement, outcomes and impact of learning of bloodsafe elearning australia courses. methods: a retrospective analysis of user registrations, course completion records, course evaluation data and red cell usage in australia to determine learner demographics, and the impact on acquisition of knowledge and application to clinical practice. results: in the period from july to january : - , people registered as learners - , , courses were completed -these learners came from countries, with , ( . %) of them from outside of australia. analysis by profession shows that: - . % are nurses and/or midwives - . % are medical - . % are laboratory, anaesthetic technicians or other. analysis of user evaluation data (n = , ) from april to january shows that these courses have a positive impact, with . % of respondents stating they gained additional knowledge, . % able to make changes to clinical practice, and . % reporting that these changes will improve patient safety and outcomes. analysis of international participants shows greater benefits with . % gaining knowledge, . % able to change their clinical practice and . % believing this will improve patient outcomes. analysis of red cell usage in australia shows that since there has been a . % reduction in red cells issued. this has been achieved through a number of pbm activities including development of guidelines, research and audits, education, waste reduction strategies, and promotional campaigns. bloodsafe elearning australia courses on pbm were released in and are one part of this pbm activity, and it is notable that these courses have the widest reach as they are undertaken by a large proportion of doctors, nurses and midwives in australia who are not directly involved with the blood sector. stakeholder feedback shows that the program provides credible, consistent education that is cost-effective, reduces duplication, is 'best-practice' elearning, is readily accessible, and allows institutions to focus on the development of practical transfusion skills. summary/conclusions: this analysis shows that elearning is a well-accepted, wellutilised form of education for healthcare workers to learn about clinical transfusion practice and patient blood management, and learners gain knowledge that can change their clinical practice and improve patient outcomes. it is also likely that these courses have contributed to better utilisation of a scarce, freely-donated resource. this approach has global reach and availability, and is a cost-effective model for improving transfusion practice in the developing world by providing education for millions of healthcare workers. d-s - prospective platelet auditing: analysis of trainee compliance with guidelines pathology, columbia university, new york, united states background: apheresis platelets are a component product with high cost and limited supply. furthermore, there is a potential for severe transfusion reactions associated with this product such as transfusion related lung injury (trali), and sepsis due to bacterial contamination. therefore, transfusion guideline compliance is closely monitored by many centers. this quality assurance analysis describes our experience with prospective platelet auditing performed by physicians in pathology residency training. aims: this study aims to evaluate the ability of physicians in training to perform prospective auditing and compare policy compliance for different levels of experience. methods: this is a quality assurance analysis of a prospective platelet audit program for a -month period (january -december ). the blood bank paged the on call physician any time an order was placed for a patient with a platelet count of > , /ll, ≥ doses of platelets with no interim repeat count, or an unknown platelet count. audit records created by physician trainees in their first post graduate year (pgy ) were compared to subsequent years (pgy > ). information collected included the total number of doses requiring approval, number of products approved, training year for the approving physician, and transfusion indication. cost analyses assumed $ for a dose of platelets. descriptive statistics and comparative analysis using a pearson's chi-square were used with a difference of p < . considered statistically significant. results: there were platelet doses requiring approval with ( %) routed to the pgy group and ( %) to the pgy > group. there were ( %) ordered doses that were in compliance with hospital transfusion policy and ( %) that were not in compliance with hospital policy. of the appropriately ordered doses, the pgy group declined release of necessitating the clinical team to insist upon release without approval, and there were zero such instances in the pgy > group. when paged by the blood bank, pgy physicians approved product release not in compliance with policy for / ( %) doses while pgy > physicians approved not indicated products for / ( %) of doses (p < . ). products not indicated by hospital policy were held from release by pgy physicians for / ( %) doses and / ( %) doses by pgy > physicians (p < . ). the ordered doses not in compliance with hospital policy had an estimated cost of $ , . of this cost, there was a calculated $ , savings of products not released due to prospective auditing. there was an additional potential savings of $ , for products not indicated but released ($ , from the pgy and $ , from the pgy > group). summary/conclusions: despite a higher number of requests being routed to the more senior pgy > group, there were a disproportionately higher number of out of compliance platelet orders being released by the pgy group in addition to withholding needed products on several occasions. potential mitigation strategies for this could include a closer level of oversight for pgy physicians, and the potential monetary savings could justify a hiring a dedicated patient blood management team or quality assurance manager to monitor compliance and provide feedback to clinicians. d-s - what can we learn from how adverse events are detected? norwegian directorate of health, oslo, norway background: the primary aim of reporting systems, such as haemovigilance systems, should be learning and improvement and to identify risk areas, not simply counting errors. to understand and learn from adverse events the description of how, where and why they occur, and how they are detected, is important. to support our understanding, we use a predetermined classification that is required for reporting to eu, supplemented by classification suggested by ihn, who and ourselves. in we started asking the blood establishments what steps they would take to prevent recurrence of the event, and we added a simple classification to tell how the adverse event had been detected. aims: this study aims to analyze how different types of adverse events reported to the haemovigilance system were detected, whether the current quality management systems used in norwegian blood establishments had effective barriers and whether new barriers should be considered. methods: adverse events reported to the norwegian haemovigilance system in and were analyzed with focus on how the adverse event had been detected. in all cases classification had been performed by the reporter of adverse events and were confirmed, or reclassified if necessary, by the haemovigilance team before analysis. for analysis based on classification we used powerbi (microsoft). results: a total of adverse events were reported from norwegian blood establishments. all had been classified according to how the adverse event had been detected. twenty ( . %) adverse events were detected because of alarms or warnings from it-systems or equipment. routine checks by blood establishment staff detected ( . %) events and formal internal or external reviews detected one event. seven ( . %) events were detected because the donor became ill shortly after donation, but the illness was not caused by the donation. sixty-four percent of events were detected in a way that did not fit our present classification and hence were classified as "other". twelve out of wrong blood in tube were detected by an alarm from the it-system or routine check, as were six of events related to blood ordering, two of seven errors in testing, six of events where incorrect blood had been transfused, and eight of events related to donor selection. in reports human error was listed as the cause of the event and of these were detected by alarms or routine checks. summary/conclusions: detection of adverse events by alarms or routine checks are highly efficient when the blood establishment has historic data to check against, as exemplified with wrong blood in tube or a patient require irradiated blood components. when no historical data exists or when the quality management systems do not require routine checks, events are usually detected by chance. further analysis is needed to see if and where the quality management systems should be improved. the wide variety of adverse events can make it difficult to select which area to prioritize in the improvement work. results: the hb measurements from the finger prick were on average . g/l ( . %) higher than from the venous blood samples. the range of the difference was - -+ g/l. these results were used in order to add novel information to determine the measuring uncertainty of hb measurement in frcbs. in . % ( / ) of the donors in this study the venous hemoglobin measurements were below the cut-off point of donor eligibility. in those measurements the difference of the finger prick and venous hemoglobin measurement was at most + g/l. % of the hemoglobin results from the finger prick were in the range ae g/l compared to the venous hemoglobin results. % of the results from the finger prick were between ae g/l (the precision of the device) compared to venous hemoglobin results. in cases the difference between finger prick and venous measurements was outside standard deviations from the mean i.e. . % from the bottom (n = ) or top (n = ) of distribution. systematic errors were seen in some nurse's results both towards too low or too high hb result in the finger prick measurement and some nurses had random errors in both directions. the batch of cuvettes, donors' age, gender or the time of sampling were not detected to have an impact on the difference between finger prick and venous hb measurements in this study. summary/conclusions: the results of the poc measurements compared to the cell counter were in agreement with published data and with manufacturers' information on the device. the practical skill test is a workable way to develop competence and operations to measure the hemoglobin from the finger prick. it offers an opportunity to give personal feedback to nurses concerning their personal performance in the use of the current hb measurement technic. it also provided data on the accuracy of the poc method in the everyday donor selection process. background: whole blood donation has frequently been related to iron deficiency. a blood donor loses per donation about % (men) to % (menstruating women) of iron stores. to replenish the iron lost by blood donation in a donation interval of days, a donor needs to absorb . mg iron per day. this amount exceeds the reported maximal amount of absorbed iron of - mg/day, eventually leading to iron deficiency, with consequences such as donor deferral and possibly iron deficiency-related symptoms (decreased physical endurance, fatigue, pica, restless legs syndrome, and cognitive functions). since hb levels do not reflect donors' true iron status, measuring ferritin is a better way to detect low iron stores in whole blood donors. studies from usa and denmark showed that on the introduction of ferritin measurement with either extension of donation intervals or iron supplementation in case of low iron stores, deferral percentages for low hb declined in both male and female donors. aims: to gain more insight in iron status of whole blood donors during their donor career, how this affects donor health and which measures may prevent low iron stores in donors. methods: in the netherlands, sanquin blood bank is currently implementing a policy with ferritin-guided donation intervals. in brief, ferritin levels are measured in all new donors and in repeat donors every th donation or in case of an hb below the deferral threshold. donation intervals are extended if ferritin levels are < lg/ l, or ≥ and ≤ lg/l (for and months respectively). we anticipate that routine ferritin measurement will ultimately result in a lower prevalence of iron deficiency, less hb deferrals and improved donor retention. this will be further evaluated in a stepped wedge cluster-randomized trial 'find'em', which may also identify subgroups of donors prone to develop (symptoms of) iron deficiency. in addition, implementing ferritin screening may lead to a decreased donor availability. for this purpose, we modeled the impact of the implementation of our ferritin deferral policy on donor availability over time, which provides insight for both the expected size of the impact of the ferritin deferral policy and the time and rate at which this impact is expected to occur. this allows the blood bank to timely plan actions to counterbalance possible donor shortage and ensure an adequate blood supply. lastly, iron supplementation can be an alternative measure instead of donation deferral. as the used and recommended dosage of iron supplementation varies widely across blood services, sanquin is planning to start a new study in whole blood donors to gain evidence on the dosage and frequency of iron supplementation and its effect on ferritin and hemoglobin levels and donor health. results: the before-mentioned studies are ongoing and results will be expected from onwards. summary/conclusions: iron deficiency is a frequent side effect of whole blood donation. to prevent iron deficiency and its consequences, like donation deferral and health issues, more evidence-based insight in iron management of whole blood donors is being generated. d-s - superdonors -genetic risk profile and risk of low hemoglobin deferral background: no reliable method exists for stratifying new blood donors into those who can maintain sufficient hemoglobin (hb) levels and those who will be deferred because of a low hb (< . mmol/l [< . g/dl] for women and < . mmol/l [< . g/dl] for men). polygenic risk scores (prss) have shown great promise in predicting complex disease risk. prss could also prove useful for identification of donors genetically predisposed to low hb levels, and, thus, to an increased risk of deferral. aims: the objective of the study was to evaluate the association between prs (modelled to predict hb level as a quantitative trait) and risk of deferral as a binary outcome. methods: the danish blood donor study (dbds) is an ongoing nationwide blood donor cohort since with more than , participants. extensive genotyping has been performed on approximately , dbds participants using the infinium global screening array (illumina â ) and extended by use of imputing based on the pan-scandinavian reference genome. based on hb and genetic data on more than , icelandic individuals (an independent discovery cohort), we constructed different weighted prss for individuals from dbds. information on the donors' whole blood donations following inclusion into dbds unto end of was obtained from a nationwide donation database, scandat. the best predictor of hb among the nine prss was chosen and used in all subsequent analyses. we performed multilevel mixed-effects linear regression analysis with hb as outcome, and prs as factorized explanatory variable with cutoffs at , , , , , , , and th percentiles, respectively. moreover, the models had a two-level clustering on donor id and donation site and an id-specific random intercept; and further adjusted for: sex(binary), age(continuous), year of donation(factorized), and time since last donation (continuous). lastly, risk of deferral was evaluated in random effects logit models with similar covariables and clustering structure. results: mean number of donations per donor after dbds inclusion was . donations. generally, we observed a statistically significant positive association between prs(hb) and current hb levels. compared with donors in the - prs percentile group, donors below the th percentile had lower (- . hb mmol/l ( % ci: - . ; - . )) and donors above the th percentile higher (+ . hb mmol/l ( % ci: . ; . ) hb levels. in the random effects logit models we observed a marked increase in deferral risk with decreasing prs percentile strata. with the - prs percentile stratum as reference, donors below the th percentile and donors above the th percentile had odds ratios of deferral of or = . ( % ci: . ; . ) and or = . ( % ci: . ; . ), respectively. summary/conclusions: we found a statistically significant positive association between prs(hb) and hb levels and a markedly increased risk of deferral with decreasing prs(hb). from a scientific point of view, it is unsurprising that a genetic score for hb from an independent cohort is associated with hb in another cohort. however, from a practical perspective, prss may be the first step in a personalized donation approach to donors and their risk of deferral. background: individually calibrated inter-donation intervals for repeat blood donors have the potential to minimize the risk of iron related adverse outcomes (e.g., hemoglobin deferral or collecting a donation from a donor with low or absent iron stores) without unduly impacting the donated blood supply. machine learning has shown promise for personalized clinical risk assessment. aims: our aim is to use machine learning to develop donor-specific, personalized inter-donation intervals that minimize the risk of adverse outcomes while maintaining or improving the adequacy of the donated blood supply. methods: using a public use dataset from the reds-ii donor iron status evaluation (rise) study (cable, transfusion, ) we defined donor profiles with physiological measures including hemoglobin, ferritin and soluble transferrin receptor along with questionnaire responses regarding diet, reproductive health indicators, and demographics. we used these profiles ( features, , donations from , repeat donors) and the time until the next donation attempt to predict iron-related outcomes of the next donation attempt. possible outcomes were no adverse outcome, hemoglobin deferral, low-iron donation (ferritin < ng/ml for women and < ng/ml for men), or absent-iron donation (ferritin < ng/ml for men and women). we trained multiple machine learning models on , of the donations and selected the model with the best performance (lowest cross-entropy loss in cross validation). we assessed the best model's performance on a hold-out test set of donations, which were not used to train or select the model. we then used our model to generate risk estimates for these test donors as a function of days since their last donation, which varied from days to days. to show individual variation, we generated graphical representations of individual donors' risk over time. results: ferritin, log ferritin, body iron, and time since last donation were most useful for predicting iron-related adverse outcomes at the next donation attempt. the estimated risk of adverse outcomes at the next donation attempt varied considerably across donors. as expected, the risk of adverse outcomes days after the last donation was lower than the risk days after the last donation for most donors (risk of hemoglobin deferral decreased for % of donors; risk for low-iron donation decreased for %; and risk for absent-iron donation decreased for %). summary/conclusions: the risk of iron-related adverse outcomes as a function of time since last donation varies considerably between donors. machine learning models trained on relevant donor profiles can effectively estimate how an individual's risk will change over time. individual risk estimates could allow blood centers to protect highrisk repeat donors while continuing to allow more frequent collections from low-risk donors. further study is needed to ensure this approach works well for donor classes that are not well-represented by the rise dataset, to assess risk prediction outside of the physiological measures collected in the rise study, and to determine the viability of assigning an optimal inter-donation interval to a first-time donor using this approach. background: iron depletion is common among repeat blood donors, who contribute a large proportion of the blood supply in many countries. exogenous iron from multivitamins with iron or iron-only supplements helps prevent donation-induced iron depletion, but whether dietary iron protects against iron depletion in repeat donors has not been rigorously evaluated. available data from the reds-ii rise study in the us (cable, transfusion, ) and from the danish blood donor study (rigas, transfusion, ) suggest minor impact of dietary iron consumption on blood donor iron status in multivariable regression models. both studies, however, analyzed food items singly, such as beef or fish, rather than in aggregate, so precision was limited. aims: to evaluate whether a composite measure of dietary heme iron consumption, weighted for frequency and iron content, was associated with incident iron depletion among repeat blood donors. methods: a re-analysis of the rise cohort was undertaken to test the hypothesis that reported levels of animal protein consumption was associated with lower risk for incident iron depletion among repeat blood donors. the six blood centers participating in rise enrolled first-time and frequent donors for - month follow-up of donation frequency and iron status. a brief checklist of food categories was administered at baseline to assess frequency of consumption of several categories of animal protein that are rich in heme iron, the biochemical form of iron most readily absorbed. an iron composite score (ics) weighted for frequency and heme iron content was derived and subjects were grouped into tertiles (thirds) of ics. iron status was assayed at enrollment and study completion and at roughly one-third of donation visits in between. modified poisson regression with generalized estimating equations was used to generate risk ratios controlling for donation frequency and other covariates. results: of enrolled donors, were iron replete at baseline and completed the food checklist. the median value of the ics for each tertile (lowest to highest) was . , . , and . mg of heme iron weekly. these values are equivalent to approximately , , and servings of beef per week, or alternately twice as many servings of chicken or pork. across follow-up visits with iron outcomes assayed, almost % of donor visits were associated with intermediate iron depletion (serum ferritin < ng/ml) and . % with complete depletion of iron stores, representing serum ferritin < ng/ml. after controlling for demographic factors and donation frequency, the lowest tertile of ics was associated with a greater than fold higher risk for complete iron depletion during all follow-up visits (rr . , % ci . , . , compared to the highest tertile). summary/conclusions: in this longitudinal evaluation of dietary iron and iron status, blood donors with low intake of heme iron had an elevated risk for developing advanced iron depletion. these results suggest that blood centers should continue to recommend iron-rich diets to repeat blood donors. background: blood donors lose approximately mg of iron with every blood donation. as a result, frequent blood donors are at risk of iron deficiency and low hemoglobin (hb) levels, which may affect their health and eligibility to donate. lifestyle behaviors such as dietary iron intake and physical activity, may influence iron stores and thereby hb levels. gaining insight into associations between lifestyle behaviors and hb levels is valuable for blood supply organizations, as lifestyle behaviors can potentially be considered to prevent hb deferrals. examining the mediating role of ferritin, a measure reflecting iron stores, in these associations will help to gain insight into whether iron stores could be the limiting or enabling factor that links lifestyle behaviors to hb recovery after donation. aims: to investigate associations between lifestyle behaviors (dietary heme and non-heme iron intake and physical activity) and hb levels, and whether ferritin mediates these associations. methods: donor insight-iii (dis-iii) is a dutch cohort study of blood and plasma donors and included , donors. participants who were pregnant, had hemochromatosis, used iron supplements/medication, got a hysterectomy or bilateral oophorectomy were excluded (n = ). hb levels were measured in edta whole blood samples using a hematology analyzer (xt- , sysmex, japan) and ferritin was measured in plasma from lithium heparin tubes (architect ci , abbott laboratories, u.s.a.). dietary heme and non-heme iron intake (grams/day) were assessed using a food frequency questionnaire adapted to measure iron intake. moderate-tovigorous physical activity (mvpa, minutes/day) was assessed using the international physical activity questionnaire (ipaq)-short form. results: in total, , ( , female) participants were included. donors with higher intakes of heme iron had significantly higher hb levels (regression coefficient (b) ( % confidence interval ( % ci)) in men and women respectively: . ( . to . ) and . ( . to . ) mmol/l), independent of age, smoking, menstruation, number of donations in previous two years, donation interval, sedentary behavior, the other lifestyle variable (i.e. (non-)heme iron intake or mvpa), and initial hb level. non-heme iron intake was negatively associated with hb levels (- . (- . to - . ) and - . (- . to - . ) mmol/l for men and women respectively). ferritin mediated associations between dietary iron intake and hb levels (indirect effect in men and women respectively: . ( . to . ) and . ( . to . ) lg/l for heme and - . (- . to . ) and - . (- . to - . ) for non-heme). more mvpa was negatively associated with hb levels in men only (- . (- . to - . )), which was not mediated by ferritin. summary/conclusions: in conclusion, higher heme and lower non-heme iron consumption are associated with higher hb levels in donors via higher ferritin levels, indicating that donors with high heme iron consumption may be more capable of maintaining iron stores to recover hb levels after blood donation. more mvpa was associated with lower hb levels, although effect sizes were small, independent of ferritin. taking a donor's lifestyle behaviors into account may be useful in preventing low hb levels in blood donors. immune thrombocytopenia (itp) is still diagnosed by exclusion of other causes for thrombocytopenia. sensitive and specific detection of platelet autoantibodies may support the clinical diagnosis and prevent misdiagnosis of itp. for example, the direct monoclonal antibody immobilization of platelet antigens (maipa) assay, performed with in vivo sensitized patient platelets, offers platelet glycoprotein specific autoantibody detection with high accuracy. a drawback is that low platelet counts demand a large blood sample to have sufficient patient platelets available for analysis. circulating platelet autoantibodies are more difficult to detect by maipa; and may demand more sensitive detection platforms, such as those using surface plasmon resonance. in general, the presence of anti-gpiib/iiia, anti-gpib/ix and anti-gpv platelet autoantibodies is investigated. all these antibody specificities have been found in patients with itp. in itp, platelet autoantibody-mediated destruction via the spleen has been proposed; but also other mechanisms leading to low platelet counts in itp may play a role. inhibition of megakaryocytopoiesis by autoantibodies or by t cells has been suggested. in mice, gpib-directed antibodies induce loss of platelet-sugar epitopes, inducing hepatocyte-medicated platelet destruction. platelet autoantibodies can cause complement activation, which may contribute to platelet autoantibodymediated destruction. interestingly, we recently found that lack of detectable platelet autoantibodies is correlated with non-responsiveness to rituximab (cd moab) treatment in itp patients. in children with newly diagnosed and often transient itp, platelet autoantibodies of igg class or not often found, but of igm class are present for short duration. in conclusion, testing for platelet autoantibody characteristics and their pathologic effect may be helpful in establishing the diagnosis of itp and in choosing the best individualized therapy for itp patients. a-s - thrombopoietin receptor agonist (tpo-ra) treatment raises platelet counts and induces immunomodulation in immune thrombocytopenia (itp) jw semple , r aslam , e speck , j rebetz and r kapur lund university, lund, sweden st. michael's hospital, toronto, canada background: itp is an autoimmune bleeding disorder in which autoantibodies and/ or autoreactive t cells target the destruction of platelets and megakaryocytes in the spleen and bone marrow. several therapeutic options e.g. corticosteroids, intravenous immunoglobulins (ivig), rituximab and splenectomy are available for patients but inadequate efficacy, side effects and/or expense can make them undesirable. for the last years, tpo-ra e.g. romiplostim and eltrombopag have made a substantial contribution to the treatment of itp patient's refractory to first-line treatments. of interest, approximately % of patients that are tapered from tpo-ra therapy show a sustained response (e.g. a stable higher platelet count than before treatment). the mechanism of how tpo-ra induce these sustained responses is unknown. aims: to analyze the efficacy and immunomodulatory properties of a murine tpo-ra (amp , amgen) in a well-established murine model of itp that demonstrates both antibody-and t cell-mediated thrombocytopenia (chow l et al., blood ) . methods: platelet glycoprotein (gp) iiia (cd ) knockout (ko) mice were immunized with cd + platelets and itp was initiated by the transfer of their splenocytes into mice with severe combined immunodeficiency (scid). the scid mice were treated with either placebo or tpo-ra weekly and platelet counts and serum anti-platelet antibodies were measured weekly. results: in an initial pilot dose escalation study, control na€ ıve scid mice treated with a single subcutaneous bolus of different concentrations of murine tpo-ra ( , and ug/kg) had significantly higher platelet counts by h post infusion. in addition, compared with untreated mice, bone marrow histology revealed significantly increased numbers of megakaryocytes. maximal platelet count increases were observed with the highest tpo-ra dose and this dose was chosen to treat scid mice suffering from itp. when scid mice were treated with weekly injections of tpo-ra, platelet counts began to increase after weeks and were fully rescued to control levels after weeks post splenocyte transfer. of interest, compared with non-treated itp mice, serum igg anti-platelet antibody production in the tpo-treated mice was significantly reduced starting from two weeks post splenocyte infusion. summary/conclusions: these results suggest that murine tpo-ra is not only an efficacious therapy for murine itp but also induces immunomodulation indicative of immunosuppression. thus, this model may be able to elucidate the mechanism of how tpo-ra's induced immunosuppression in patients with itp. background: desialylation, the loss of sialic acid content on platelets (plts) glycoproteins (gps) was recently identified to contribute in immune thrombocytopenia (itp). however, the potential impact of autoantibodies (aabs) on megakaryocyte sialylation remains unclear. aims: to investigate the effect of itp aabs on plts and megakaryocytes (mks) sialylation and the subsequent impact on plt survival. methods: aabs from well-characterised itp patients induced gp-modifications were tested using a lectin binding assay. after incubation of mks or plts with itp or control sera, glycan changes were analysed by flow cytometry (fc). to investigate the impact of desialylation on plts life-span, the nod/scid mouse model was used. results: itp sera were investigated in this study. ( %) sera induced a significant increase in rca signal on plt surface compared to control sera from healthy donors (rca-mean fold increase (rca-fi): . , range: . - . , p = . ). in addition, ( %) sera caused higher ecl binding to test plts (ecl-fi: . , range: . - . , p = . ). injection of desialylating aabs resulted in accelerated clearance of human plts from the circulation of the nod/scid mice which was significantly reduced by a specific neuraminidase inhibitor that prevents background: autoimmune hemolytic anemia (aiha) is a rare autoimmune disease characterised by hemolysis associated with the presence of immunoglobulins (igg, igm, or iga) and/or components of complement system on red blood cells (rbcs), which is usually demonstrated by a positive direct antiglobulin test (dat). depending on the presence of an underlying disorder, aiha can be subdivided into primary and secondary and, by the temperature at which autoantibodies bind optimally to rbcs, into warm antibody aiha (waiha), mixed aiha (including both warm igg and cold igm antibodies), cold agglutinin disease (cad), paroxysmal cold hemoglobinuria (pch) and dat negative aiha. a frequent finding in immunohematology is the presence autoantibodies on rbcs without clinical symptoms of hemolysis that may later develop. aims: the aim of this study was to analyse serologic findings and transfusion support in patients with aiha and also to analyse dat positive patients without clinical symptoms. methods: we included data for all adult patients with aiha and dat positive patients without clinical symptoms diagnosed and/or treated at the university hospital centre (uhc) zagreb, croatia in the period between and . the diagnosis of aiha was defined by anemia with features of hemolysis (elevated bilirubin and/ or elevated lactate dehydrogenase and/or low haptoglobin level) and a positive dat. results: the data from patients ( % women) meeting the inclusion criteria was analysed. the mean age at the time of aiha was years (range - years). the mean hg level at diagnosis was . g/l. dat results were positive mostly with igg+c d ( %) or igg ( %). most patients had warm aiha ( %). other types of aiha diagnosed were mixed aiha ( %), cad ( %), pch ( . %) and dat negative aiha ( . %). in cases alloantibodies were detected with autoantibodies in the patient's plasma. patients were treated with corticosteroids as st line therapy and some with intravenous immunoglobulins (ivig). in severe or refractory patients rituximab and/or splenectomy was applied. a total of % of patients were transfused at a mean hemoglobin level of . g/l. during this period we detected dat positive patients without clinical symptoms. summary/conclusions: most patients from our study were diagnosed with warm type of aiha, followed by mixed type aiha and cad. on the other hand, pch and dat negative aiha were very rare, which is in concordance with relevant literature. most patients were transfused despite therapy used, which is not desirable in patients with aiha and should be better controlled, especially in moderate cases of anemias, where this is rarely necessary. a significant number of patients that were dat positive without clinical symptoms may later develop aiha and should be closely monitored. background: autoimmune haemolytic anaemia (aiha) is a decompensated acquired haemolysis caused by the host's immune system acting against its own red cell antigens. aiha is a rare disorder and although british society of haematology (bsh) guidelines for diagnosis and treatment were published in february , there is little evidence for clinical practice in the united kingdom. aims: to investigate the approach to diagnosis, investigation and management of patients with aiha in english nhs trusts. methods: a survey of diagnostic and management practice was designed, piloted and disseminated to clinical transfusion leads in all english acute nhs trusts from november to march . completion was by a consultant haematologist treating patients with aiha but a response that represented a departmental consensus was encouraged. results: responses represented % ( / ) of english acute trusts. median number of adults with aiha diagnosed annually was - . in the preceding years, % ( / ) recalled at least one patient who had died due to aiha. although % ( / ) undertook a bone marrow biopsy in all patients, % required additional features, mainly: neoplasia, age over or being treatment-refractory. for patients with suspected drug-induced immune haemolysis, % ( / ) would not organise confirmatory tests, either because it was considered unnecessary ( / ), or because clinicians were unsure how to access tests ( / ). when determining aiha subtype, % ( / ) indicated there were no circumstances in which they would undertake cold antibody testing (antibody titre and/or thermal amplitude), with considering this unnecessary and unsure how to access tests. in clinical scenarios of patients with aiha and dat positive to c d ae igg ae cold associated symptoms, up to % ( / ) of respondents would not test for cold antibodies. for first line treatment of primary warm aiha, mean duration of prednisolone mg/kg given before judging the patient refractory and reducing the dose was . weeks (sd . , range - weeks). second line treatment of choice was rituximab for % ( / ) of respondents and splenectomy for %. intravenous immunoglobulin and splenectomy were the most cited rescue therapies. for primary cold haemagglutinin disease (chad), first line treatment was rituximab-based for % ( / ) but single agent steroid for %. we also explored the potential for future audit and research. % ( / ) of respondents were able to identify patients with aiha who previously required transfusion. % ( / ) of respondents would consider supporting a registry of patients with aiha requiring transfusion. the key questions that respondents thought a registry should address were: morbidity and mortality, treatment response, and differences in the diagnosis and treatment of aiha subtypes. there was uncertainty over access to cold and drug-induced antibody tests and clinicians do not always conduct bshrecommended cold antibody tests for aiha with c d positive dat. initial treatment of primary warm aiha and chad broadly matched bsh guidelines although % ( / ) would continue prednisolone at mg/kg beyond the recommended days before starting a taper, with greater toxicity risk. summary/conclusions: the findings support the need for a range of research initiatives, including creation of an aiha registry. preoperative anemia is common and is associated with adverse outcomes in the peri-operative period. preoperative anemia also increases the risk of allogeneic blood transfusions, which may lead to increased perioperative mortality, increased hospital length of stay and infections. diagnosis and treatment of anemia is one of the tenets of patient blood management (pbm), along with reduction in unnecessary transfusions and diagnostic phlebotomy, as well as use of hemostatic agents to reduce bleeding among many others. effective pbm is multi-disciplinary, multi-modal, timely, individualized and patient-centered. early referral to pbm and multi-modal pbm interventions are associated with greater improvement in pre-operative hemoglobin. pbm has been shown to reduce transfusions and cost, while system-wide, multi-modal programs may also be associated with improvement in mortality. using examples from our local research and practice, i will discuss three aspects of pbm. iron and erythropoiesis stimulating agents (esa) are effective, safe and used extensively in management of pre-operative anemia. previous studies have questioned whether esa leads to increased risk of thrombosis, however, recent systematic reviews do not support these concerns. another pbm approach is to reduce bleeding during surgery by using hemostatic agents such as tranexamic acid (txa). txa reduces transfusion requirements in knee and hip arthroplasty, and is safe, widely available and relatively cheap. txa is effective in both anemic and non-anemic patients, making it an attractive universal pbm strategy. finally, recommendations and evidence-based guidelines on pbm exist, including the most recent international guidelines developed by the pbm international consensus conference. however, knowledge translation in pbm has been a problem and a number of barriers to its implementation have been identified. these include perceived or actual lack of expertise, time, and resources, as well as lack of physician and patient engagement. one way to address patient engagement is education through character driven animation and we are currently trying this approach. a-s - low vs . high hemoglobin trigger for transfusion in vascular surgery (tv): a randomized clinical feasibility trial (the tv trial) background: current guidelines advocate to limit red-cell transfusion during surgery, but the feasibility and safety of such strategy remains unclear as the majority of evidence is based on postoperative stable patients. aims: we assessed the effects of a protocol aiming to restrict red-cell transfusion during elective vascular surgery. methods: fifty-eight patients scheduled for lower limb-bypass or open surgery of abdominal aortic aneurysm were randomized to a low-trigger (hemoglobin < . g/ dl, mmol/l) vs. high-trigger (hemoglobin < . g/dl, mmol/l) for red-cell transfusion throughout hospitalization. intraoperative change in cerebral-and muscle tissue oxygenation was assessed by near-infrared spectroscopy. we used a nationwide registry to collect data on death and major cardiovascular events, which encompassed ( ) severe adverse transfusion reaction, ( ) acute myocardial infarction, ( ) stroke, ( ) new-onset renal replacement therapy, ( ) vascular reoperation, and ( ) amputation of the lower limb. results: the primary outcome, mean hemoglobin within days of surgery, was significantly lower in the low-trigger group: . g/dl vs. . g/dl in the hightrigger group (mean difference . g/dl; p = . , longitudinal analysis) as were units of red-cells transfused ( background: controlled non-hemato-oncological studies have consistently demonstrated a single-unit red blood cell (rbc) transfusion policy as well as a stringent hemoglobin (hb) rbc transfusion threshold to be safe and reduce blood product utilization. yet, it is unclear whether these conclusions also apply to the hemato-oncological patient population. aims: to quantify reduction of rbc blood product utilization by the introduction of a restrictive single-unit hb-triggered rbc transfusion policy among the inpatient hemato-oncological population. methods: under the liberal transfusion protocol, applied up till november , , standard double-unit rbc transfusion was indicated with a hb threshold ≤ . g/dl and/or anemia-related symptoms. following this date, the restrictive transfusion protocol was introduced involving a lowering of threshold to . g/dl and single-unit transfusion. for patients with an asa-score of ii-iii and iv, a hb threshold of respectively ≤ . g/dl and ≤ . g/dl applied. we evaluated rbc blood product utilization over a month period starting december , (liberal protocol) and december , (restrictive protocol) in all hemato-oncological patients admitted for chemotherapeutic treatment including hematopoietic stem cell transplantation (hsct) with an expected duration of neutropenia of ≥ days. analysis of categorical and continuous data was performed using the chi-square and mann-whitney test, respectively. results: during both observational periods, patients were admitted who in total received therapy cycles, including acute myeloid leukemia (aml) induction cycles and autologous hscts. distribution of indications of admittance, median age, duration of hospitalization and duration of neutropenia did not differ between both periods. during the restrictive period, in / ( . %) of transfusions the assigned hb trigger was adhered to. the percentage of single-unit transfusion episodes increased from / ( . %) to / ( . %) with the introduction of the restrictive protocol. overall, rbc blood product utilization per admittance did not reduce under the restrictive protocol (cumulative number of transfused rbc units . (interquartile range (iqr) . - . ) during the liberal versus . (iqr . - . ) during the restrictive period (p = . )). however, rbc blood product utilization per neutropenic day demonstrated a trend towards reduction: . (iqr . - . ) versus . (iqr . - . ) units per day during the liberal versus restrictive period, respectively (p = . ). this reduction was mainly attributed to autologous hscts during which rbc blood product utilization decreased from . (iqr . - . ) to . (iqr . - . ) units (p = . ), corresponding to a reduction from . (iqr . - . ) to . (iqr . - . ) (p = . ) units per neutropenic day. moreover, / ( . %) patients during the liberal versus / ( . %) during the restrictive period did not require rbc transfusion during admittance. consequently, stringent hb thresholds as compared to single-unit transfusions seem to more strongly impact rbc blood product utilization. summary/conclusions: a hb-triggered single-unit transfusion policy results in a strong reduction of rbc blood product utilization in the setting of autologous hsct. no utilization reduction was observed among other hemato-oncological inpatient populations receiving intensive chemotherapy. further improvement of protocol adherence rates could potentially increase the benefit of this blood saving strategy. a-s - assessment of hb content of packed red cells (prbc): is it time to label each unit with hb content? r jain , n marwaha and s sachdev transfusion medicine, aiims, new delhi transfusion medicine, pgimer, chandigarh, india background: in the current era of evidence based medicine and individualized care of patients, rbc transfusion continues to be administered on the basis of conventional wisdom and the notion of an average benefit per unit. the existing blood transfusion practice based on the "number of units transfused" ignores the fact that the total hb varies markedly among the individual rbc units. aims: the present study was aimed at estimating the hb content in packed red cell unit prepared by three different protocols from ml and ml whole blood collection in three types of blood donors: replacement blood donor (rd), first time voluntary donor (ftvd) and regular voluntary blood donor (rtvd). methods: a total of prospective blood donors were included in this study. three hundred whole blood collections were performed in each of the three groups of donors (rd, ftvd, and rtvd). within each group collections were done in double ml, triple ml and quadruple ml blood bags respectively. a pre-donation venous sample was drawn from sample collection pouch for analysis in hematology analyzer as reference method for hb concentration of donor. the hb content of packed red cell units were estimated after collection of representative sample from the blood unit. volume of prbc unit was estimated by the formula of weight of blood in prbc divided by specific gravity. the hb content in unit was estimated by the formula: hb content in unit = hb value of the prbc unit (g/dl) volume of prbc unit (dl). results: in this study the hb concentration (g/dl) was comparable among three types of blood donors except that rtvd had lower hb values when compared to rd (p = . ). hemoglobin concentration of prbc ranged from . - . g/dl; mean hb was . ae . g/dl. net hb content of prbc bag was lower in prbc prepared from rd as compared to ftvd (p = . ) and rtvd (p = . ). the hb content of prbc units prepared from ml collection ranged from . - . g and from ml collection ranged from . - . g. we observed a wide range of net hb content in the prbc units and the correlation coefficient showed the strongest association of net hb content of the prbc unit with the overall volume of prbc (r = . , p = . ).higher volume prbcs have more hb content. volume of prbc bags in the study ranged from ml to ml (including both and ml collections). summary/conclusions: the present study shows that labelling hb content of the prbc unit help in better inventory management for patients. the hb content may help in decision making for release of units for paediatric/low weight versus adults/ higher weight patients. adopting a policy of optimizing dosage of rbc transfusion could have the potential to significantly improve rbc utilization and decrease patient exposure to allogenic blood. this would help further in the clinical transfusion practices based on evidence. a-s - nv more, p desai, s rajadhyaksha, a navkudkar and n deshpande transfusion medicine, tata memorial centre, homi bhabha national institute, mumbai, india background: red blood cell (rbc) transfusion is an important medical therapy benefiting the patient in a wide spectrum of clinical setting. critically ill intensive care unit patients in particular, as well as medical and hemato-oncology patients, are among the largest group of the user of rbc. periodic review of blood components usage is essential to assess the blood utilization pattern in any hospital or health care set up. our institute is a bedded tertiary care oncology centre with approximately , to , rbc transfusions annually. these transfusions are required in various stages of patient treatment like chemotherapy, radiotherapy, surgical and palliative care and there are established guidelines by the institute to be followed by clinicians. aims: to study clinical practices of rbc transfusions based on indications and to evaluate appropriateness of rbc utilization practices at the institute. methods: this was a prospective observational study, started after approval from institutional ethics committee. total of rbc transfusion events in adult patients over a period of four months were included and analyzed as per institutional guidelines for their appropriateness. details of transfusion events in form of pre transfusion hemoglobin, indication of transfusion, type of request, number of unit requested and issued, time of issue, site of transfusion and adverse reactions, etc were obtained from department of transfusion medicine records. overall statistical analysis was descriptive using spss software. chi-square test in cross tables was applied to see the relationship between different variables and considered significant if p-value was < . . results: total rbc transfusion events for patients were analyzed. there were ( %) events in patients of medical oncology and ( %) in patients of surgical oncology. maximum transfusions were received by patients in age group of to years ( %). total % of transfusion events were appropriate as per institutional guidelines. all transfusions administered in operation theatre were found to be appropriate with p value < . . inappropriateness was more %( / ) and significant in daycare setup (p < . ). anemia was the most common indication of rbc transfusion observed in % of events ( / ). total % rbc transfusions were given as planned and % as urgent transfusions. most common adverse transfusion event observed was allergic reaction in . % of total transfusion reactions. summary/conclusions: clinical practice of rbc transfusions in our hospital was largely found to be appropriate and rational with adherence to institutional guidelines. blood utilization audits should be conducted regularly by transfusion services and results should be discussed with clinician for ensuring judicious use of the scarce resource. the concept of transfusion safety officer (tso) can be introduced for better coordination between clinicians and blood transfusion services to improve practices. a-s - paul-ehrlich-institut, langen, germany on a global scale, blood services are quite diverse in regard to aspects like organisational structure, regulatory background, donor populations, donation rates or pathogen epidemiology. the world health organization (who) recognizes blood and blood products as essential medicines and provides guidance to member states for various aspects like blood regulation, best practices in blood collection and transfusion, or screening parameters. more recently a who guideline on residual risk of transfusion associated infections has been established which may facilitate decision-making for the most appropriate screening algorithms. it emphasizes the need for regional evaluation of screening assays and regulatory control of blood-associated ivds. background: babesia, a protozoan parasite that infects red blood cells, is a leading infectious cause of mortality in u.s. transfusion recipients. babesia is usually transmitted through the bite of an infected tick but may be transfusion transmitted (tt) or transmitted from mother to child during pregnancy. babesiosis is a world-wide disease; the ticks that carry babesia have a global distribution. babesiosis has been reported throughout europe and in canada, korea, india, and japan. prospective testing of blood donations in endemic areas of the u.s. revealed . % of donors were positive for babesia dna or antibodies (moritz, nejm, ) aims: -to report results of ongoing babesia clinical trial -to explain significance of babesia as a tt infection methods: in cobas â babesia for use on the cobas â / systems, is a qualitative polymerase chain reaction nucleic acid amplification test, developed to detect in whole blood (wb) donor samples the babesia species that cause human disease: b. microti, b. duncani, b. divergens, and b. venatorum. testing began in october under a u.s. fda-approved investigational new drug application. wb was collected into a proprietary medium that lysed red blood cells and stabilized babesia rna and dna. donations were collected in states with high, low, and no babesia endemicity and screened as individual blood donor (idt) samples. reactive index donations were retested in simulated minipools of (mp ), plus idt replicates with cobas â babesia. reactive index donations were also tested with validated alternate babesia nat and for b. microti igm and igg antibodies. donors with reactive results were invited to enroll in a follow-up study to test for additional evidence of infection. results: to date, , valid donations have been screened with cobas â babesia, and ( . %) were reactive. of ( %) initially-reactive donations were confirmed to be positive for babesia with a positive alternate nat or serology result. of ( %) confirmed-positive donations was collected in a state with low babesia endemicity (pennsylvania), and ( %) was collected in a state where babesia is not considered endemic (iowa). of ( %) confirmed positive donations were collected in states with high endemicity. of ( %) confirmed babesia-positive donations were detected in late fall or winter. all ( %) confirmed babesia-positive donations were reactive in mp . serology results are available for of confirmed-positive donations: at index, of confirmed babesia-positive donations were only igg-positive, while none were only igm-positive; were positive for both igg and igm. of the confirmed-babesia positive donations were negative for both igg and igm antibodies. cobas â babesia showed an overall specificity of . % ( , / , ; % exact ci: . %> %). summary/conclusions: the cobas â babesia test successfully identified babesiapositive donations, including confirmed-positive donations with no igm or igg reactivity. donations were collected in states considered low-or non-endemic for babesia. confirmed-positive donations were collected outside of the summer babesia season, when most clinical cases occur. screening with cobas â babesia continues in several laboratories. cobas â babesia is not fda licensed or available commercially. background: babesiosis in humans is caused by the erythrocytic protozoan parasite, babesia microti which is transmitted by tick bites, but is also transfusion transmitted. although frequently asymptomatic or presenting with flu-like symptoms in a normal host, if immunocompromised infection can lead to severe complications and death. b. microti is endemic in the north eastern/upper midwest united states where partial testing of donations has been implemented. in canada, a study of~ , donors did not identify any b. microti antibody-positive samples, suggesting low risk at that time, but risk should be monitored. aims: to evaluate the prevalence of b. microti-positive donations in potentially atrisk areas in canada. methods: between july and november , , blood donor samples were selected from sites near the us border. minipools were tested for b. microti nucleic acid by transcription mediated amplification (tma) using the procleix â babesia assay on the panther â system with individual testing on reactive pools. reactive donations were also tested by b. microti-specific: american red cross (arc) igg immunofluorescence assay [ifa] and imugen ifa/pcr. a subset of , tma-negative samples, primarily from the province of manitoba and eastwards to nova scotia, were tested for b. microti antibody using the arc ifa and if positive, the imugen ifa/pcr. donor age, sex, donation status, residential location and collection site location were recorded. donors who tested reactive/positive were informed, deferred and asked about risk factors (possible tick exposure and travel within canada, the usa and elsewhere, history of symptoms) and a follow-up sample was requested for supplemental testing (tma, arc ifa). reactive donations were removed from inventory. results: the , donor samples were proportional to collections in target geographic regions. age group, sex and donation status were also similar to the donor base in the collection areas. one sample from winnipeg, manitoba was tma reactive and antibody positive on supplementary testing. the donor did not remember symptoms or spending time in wooded areas. he visited the city of fargo, north dakota, usa. the subset of , samples tested for antibody were also proportional to collections in the targeted areas. four antibody-positive samples were identified from mid-september to october , all in south western ontario near lake erie. none were tma reactive. three were interviewed and none remembered any symptoms, any likely tick exposure, or relevant travel within canada or the usa. summary/conclusions: this is the largest b. microti prevalence study in canada. the results indicate very low prevalence with only tma-confirmed-positive donation of , tested. the donor was from the only region in canada where one autochthonous human case has been reported and active tick surveillance identified b. microti positive tick populations. seropositive donations in south western ontario may suggest low prevalence in that region, but interpretation is less certain due to lack of corroborating supplementary results or case history. given the close proximity to the us border, forgotten us travel should not be ruled out. a-s - background: the protozoan parasite toxoplasma gondii is prevalent in animals and humans worldwide. wild and domestic felids are the definitive hosts, and homoeothermic animals serve as the intermediate ones. after primary infection, the parasite persists lifelong within latent tissue cysts. transmission is by ingestion of undercooked or raw meat infected with cysts, by ingestion of food or water contaminated with oocysts, or transplacentally. however, it can also be acquired by blood transfusion and organ transplantation. toxoplasmosis can be a severe disease in immunosuppressed people and neonates whose mothers have acquired primary infection during pregnancy. aims: there is no information about the specific epidemiology of t. gondii infection in blood donors in portugal. therefore, we sought to determine the seroprevalence of t. gondii and associated risk factors in the population of blood donors in portugal. methods: between september and july , blood donors who attended the portuguese blood and transplantation institute blood banks located in oporto, coimbra and lisbon, and also at regional blood collection meetings, were invited to participate in the study. a written informed consent was obtained and a questionnaire about socio-demographic and behavioural variables was answered. sera were assessed for igg antibodies to t. gondii by a modified agglutination test (mat) commercial kit (toxo-screen da â biom erieux, lyon, france). results: of the blood donors (mean age . ae . ; range - years old), . % were positive for antibodies to t. gondii. when questioned about toxoplasmosis, almost half the blood donors did not have any knowledge about the disease. the centre of portugal had the highest seroprevalence ( . %) followed by the north ( . %) and the south ( . %). blood donors living in rural areas had a significantly higher seroprevalence (p = . ) than those living in urban areas. seroprevalence increased with age, with the highest seroprevalence ( . %) found in the age group of - years old (multiple logistic regression [mlr]: or = . ; ci: . - . ; p < . ), and decreased with educational level (p < . ). engaging in soil-related activities (gardening or agriculture) was significantly related to t. gondii seropositivity (p = . ). regarding water consumption, untreated sources (even though including mineral and tap water) was confirmed as a risk factor (mlr: or = . ; ci: . - . ; p = . ). other behavioural and eating characteristics, including cats in the household, eating raw or undercooked meat, processed pork products, or not washing raw fruit and vegetables before eating, were not associated with t. gondii infection. summary/conclusions: the risk of t. gondii transmission through blood transfusion is low, and serologic testing of antibodies, with exclusion of blood donors, appears not to be feasible. immunosuppressed individuals, organ transplant patients and pregnant women, should receive t. gondii antibody-negative blood components for transfusion. this study explored the epidemiology of t. gondii in portugal thus providing useful information on the seroprevalence and potential risk factors for t. gondii transmission. information regarding toxoplasmosis and its prevention could be promoted by medical and public health authorities among blood donors, and also the general population, when addressing policies, and designing screening programs, for monitoring and controlling infection and disease in portugal. a-s - who is syphilis testing excluding? c reynolds , c pearson , k davison and s brailsford nhsbt/phe epidemiology unit, nhs blood and transplant nhsbt/phe epidemiology unit, public health england, london, united kingdom background: screening for treponemal antibodies to detect syphilis in blood donors has been in place in england since the s. there have been no reported syphilis transfusion transmissions in england since records began in part due to sensitivity of the organism to cold storage. since we have specific tests in place for other sexually transmitted infections such as hiv and hepatitis b virus (hbv), the utility of syphilis screening is often questioned. however, it may be a useful proxy for higher risk behaviours particularly following shortening of deferrals for higher risk sexual behaviours from to months in november and against a background of increasing infectious syphilis in the general population. aims: here we describe the epidemiology of recently-acquired syphilis in blood donors in england compared with hiv and acute hbv infection between and . methods: monthly donation testing results are collected from the nhs blood and transplant (nhsbt) screening centres and reference laboratory. the demographics, possible sources of infection, and compliance to donor selection in confirmed positive donors are collected by proforma at post-test discussion with the nhsbt clinical team. recent syphilis is classified as igm positive and/or recent history including a negative donation within months for regular donors. results: between and there were recent syphilis cases, hiv and acute hbv infections identified by donation screening. recent syphilis rates per , donations increased from . to . whereas hiv decreased from . to . with less than positive donations in . acute hbv rates rose slightly from . to . in . males outweighed females accounting for . %, . % and . % of cases of recent syphilis, hiv and acute hbv respectively. nearly a quarter of cases of recent syphilis and hiv were seen in donors below years old. of the male donors with recent syphilis, . % reported sex between men and women (sbmw), . % sex between men (sbm) and . % did not report a risk. this contrasted with hiv where . % of male donors reported sbm, just . % not reporting a risk. overall , and males with recent syphilis, hiv or acute hbv respectively were non-compliant to the sbm deferral in place at the time of donation. in , donors with recent syphilis aged - years (median years) were excluded from the donor pool, including non-compliant to the sbm deferral. there were fewer than hiv cases identified in , all over years old, all compliant, reporting sbmw. of the hbv acute cases in , were male, all but one in the and over age-group. summary/conclusions: over the year period demographics of recent syphilis cases appeared similar to hiv with highest rates in young males, albeit lower proportions reporting sbm. following the switch to a month deferral, hiv case detection continued at low level, while syphilis screening continued to exclude higher numbers spanning all age-groups, potentially at risk of other sexually transmitted infections, including non-compliant donors. background: globally, an estimated million blood donations are given annually. in the blood service we are obliged to monitor donor health and ensure that blood donation is safe. in recent years, large-scale blood donor cohort studies in several countries have increased our knowledge on health effects of blood donation. health concerns relate both to immediate side effects like fainting and to possible long-term health issues related to repeated blood or plasma donation. the studies have provided us with data that can now help us introduce an evidence-based individualised donor care -a parallel to personalised medicine. individualised donor care in the management of iron depletion: studies have shown that a large percentage of our frequent whole blood donors, especially young women, are iron depleted. iron depletion is a strong predictor of deferral for low haemoglobin but has also been associated with e.g. restless legs syndrome and lower birth weight in children of frequent donors. the risk of iron deficiency can be mitigated by ferritin-guided prolongation of interdonation intervals or by iron supplementation. prolongation of interdonation intervals can challenge our inventories. iron supplementation, on the other hand, may give gastrointestinal side effects and other effects have been proposed as well, e.g. the masking of malignant disease and increased iron availability with subsequent risk of infection. in a large study we found that iron supplementation is not associated with increased risk of infection. what is the optimal balance between iron supplementation and prolongation of interdonation intervals? a growing number of blood services have implemented various flavours of iron management regimens generating more results. moreover, genetic studies in e.g. the uk, us, holland, and denmark can help us to find donors at high risk of iron depletion or low haemoglobin. we can use all these data in a big data approach in the pursuit of an individualised risk assessment model. other risks for blood donors: the presentation will also cover other risks associated with donation. new studies identify predictors of fainting after blood donation and also new interventions to prevent fainting. the global demand for plasma derived medicinal products has increased severalfold the last years. plasma donors are bled up to times per year in the us. very little is known about the health effects of frequent plasma donation. we know that immunoglobulin levels decrease with frequent donation but how does this affect health? summary/conclusions: the precautionary principle mitigates risk through early intervention prior to evidence. we tolerate next to no risk of transfusion-transmitted infectious diseases. the health of the blood donors, however, has not been protected similarly. we owe to our whole blood and plasma donors to investigate health effects of blood donation and ensure their safety. while the first attempts may not be perfect, we now have the tools to construct models for individualised donor care. background: in , the isbt, aabb, ihn and eba jointly issued the standard for surveillance of complications related to blood donation which categorized donor adverse events (dae) into categories ( subcategories) defined by specific criteria. severity and imputability were briefly described but were optional. subsequent validation of these categories demonstrated consistency in categorizing reactions, but wide variation in assignment of severity. in , with international input, the aabb donor biovigilance committee developed a severity grading tool (sgt) using a recognized medical adverse event grading system in which neutral grades replace subjective terms (mild, moderate, severe). aims: a large us blood collection establishment (bce) applied the draft sgt to assess its use in real cases of dae. methods: we performed retrospective analysis of all allogeneic and apheresis needle-in donations between / / to / / . severity grading was assigned based on criteria defined by the sgt. database review of dae was performed, and each event was assigned a grade based on the type of outside medical care (omc), and on specific key search terms. search terms for omc included emergency room, emergency medical response, urgent care, healthcare professional, and hospital admission. additional specific key search terms included fracture, concussion, laceration, dental injury, surgery, and hospitalization. since duration and activities of daily living (adl) limitations were not captured in our dae database, cases in our dae claims' database were reviewed. case files of events classified as grade or higher were individually evaluated by a physician for grading accuracy. results: in , , needle-in collections, , dae were graded for severity. the majority ( , , . %) were vasovagal reactions (vvr), followed by , apheresis-related ( . %), , needle-related ( . %) and allergic ( . %) events. the majority of dae were grade accounting for . % of all dae, followed by grade ( . %), and grade ( . %). there were grade and no grade dae. among the vvr, . %, . %, . % and . % were grade , , , and respectively. grade vvrs included concussions, fractures, dental injury, and pre-faint and fainting events requiring hospitalization for work-up. two grade vvrs involved falls resulting in intracranial hemorrhage requiring immediate medical intervention. for allergic and apheresis dae, there were only and grade reactions respectively, and no grade or events. needle-related dae included . % grade , . % grade , . % grade , and no grade events. of the six grade needle-related dae, were nerve irritations lasting > months, and were dvts requiring hospitalization. summary/conclusions: the sgt provided consistent assignment of severity for the majority of dae, based on outside medical care and specific key search terms. assignment of severity based on impact on activities of daily living or on duration of injury/condition requires tracking over time making such assignments more difficult; modification of our dae tracking database and claims database to capture adl and duration should improve severity assignment for such cases. background: the international haemovigilance network (ihn) has collected aggregate data on complications of whole blood and apheresis donations from member national haemovigilance systems (hvs) since . aims: we analysed the data collected in - in order to learn from the data and consider future improvement of data collection. methods: national hvs entered annual data on donor complications in the passwordprotected "istare" (international surveillance of transfusion adverse reactions and events) online database. from the donor complication spreadsheet allowed entry of separate data for whole blood donation (wbd) and apheresis, but also provided an option for entering data for all donation types. annual numbers of whole blood and apheresis donations were also collected. the harmonised international standard definitions were implemented in . reactions were captured according to severity level (mild, moderate, severe) but without distinction between donor sex or first time vs repeat donation. extracted data were used to calculate national and aggregate donor complication rates (generally per donations). results: twenty-four hvs provided figures for donations and donor complications for one or more years (median years per country was , iqr - ). the total number of country years (cy) was , covering million donations. the overall complication rate was . / donations and the median country rate was . complications/ donations (iqr . - . ). rates were generally consistent within a hvs from year to year but showed considerable variation between hvs; this was also the case for reactions classed as severe. not all countries differentiated between mild and moderate reactions and some reported all reactions under a single severity level. vasovagal reactions were the most commonly reported complication: overall . / donations, median country rate . / donations (iqr . - . ). rare and apheresis-related types of complications such as generalized allergic reaction ( . per , , cy), and major blood vessel injury (category available since ; overall . per , , cy) were only reported occasionally. eighteen of the hvs provided separate data for complications of whole blood and apheresis donations in one or more years (total cy, . million wbd and . million aphereses, total million donations). for these hvs the median rate of vasovagal reactions was . / wbd (iqr . - . ) and . / apheresis procedures ( . - . ) . reported haematoma rates were higher for apheresis than for wbd: the median per hvs was . / wbd (iqr . - . ) vs . / aphereses ( . - . ); rates of arm pain and/or nerve injury (not separated in - ) also tended to be higher: median . / with wbd, iqr . - . , vs . / with apheresis, . - . . summary/conclusions: international reporting allows hvs to study rates of blood donation complications, to distinguish between wbd and apheresis complication rates and capture information about very rare events. variability of reporting and of severity assessment between countries impairs the feasibility of comparisons between hvs. work is needed to improve harmonisation of classification of donation complications and severity assessment for data comparison and research. background: to prevent iron related hb loss, screening with ferritin testing was implemented in stockholm county (approx. registered blood donors) during a two-year roll-out. iron supplementation is offered to blood donors but has not prevented hb deferrals resulting in control visits per year. ferritin testing is hypothesized to increase iron compliance. aims: implementation of ferritin testing for surveillance of iron levels for the entire blood donor population with specific attention to new donors, women returning after pregnancy, donors with low hb and at return visit after low hb. yearly testing of plasma and platelet donors. methods: ferritin testing, following a staff education program, was implemented for applicant donors, donors with low hb, women after pregnancy, apheresis donors, followed by screening of registered blood donors per donation site. after initial screening, donors will be tested at each th (women) or th (men) donation, and with yearly testing of young adult blood donors below years. six nurses were educated to process ferritin and blood count results. donors with aberrant ferritin were contacted by letter. results: establishment of cut-off levels and algorithms for ferritin testing and iron treatment was evidence based but met practical limitations such as number of analyses and results that could be processed per week, limitations in liss set-up, blood demand contra preferred cut-offs, iron supplementation compliance. for applicant donors, hb testing show that % of female and % of male applicants cannot be registered because of low hb ( and mg/l respectively). adding ferritin testing, a preferred cut-off level of lg/ml (male reference level), would result in additionally % female and . % male applicant donor loss. as this would threat the blood demand, cut-off was set to lg/ml for women, above the female reference lg/ml, with an acceptable % loss of female applicant donors. for registered blood donors, mg of extra iron tablets were offered at low ferritin ( - lg/ml). this was sometimes combined with prolonged intervals and often repeated before ferritin was restored above lg/ml. donors with ferritin below lg/ml (in . % applicant donors, . % registered donors) or above lg/ml ( . % applicant donors, . % registered donors) were deferred and recommended to see their physician. for hb deferral, the interval was prolonged from to months, irrespective of ferritin levels. this, together with iron supplementation, resulted in an increase from % to % approved hb at return. the team of nurses processing ferritin and blood count results ( ½ nurse fulltime weekdays) reacted to approximately donor results daily, representing % of test results. summary/conclusions: many female donor applicants have suboptimal ferritin levels although they meet required hb for donation. iron treatment was added to retain donors with low ferritin as only prolonged intervals may danger the blood supply. for implementation of ferritin testing, it is necessary to have a well-functioning and agile organization to create and apply algorithms for testing, extension of intervals and iron treatment. background: since november a new donor screening regime is introduced in the netherlands where serum ferritin levels in whole blood donors are measured periodically to further control potential iron deficiency in donors. donor deferral thresholds are set at and ng/ml, and donors are deferred for six and twelve months respectively if ferritin levels are below these values. as limited information is available on ferritin recovery in whole-blood donors, the policy is introduced in parts such that adaptations to the implementation may be considered based on intermediate results and the impact of the measure on donor well-being can be evaluated. aims: to assess the effect of donor deferral on donor ferritin levels. methods: ferritin levels are measured in new donors and at every fifth donation in repeat donors. donors with ferritin levels below the indicated thresholds are deferred and ferritin is re-evaluated at their return for donation after six or twelve months. the policy allows estimating long term trends in ferritin levels post donation in repeat donors. as ferritin levels are measured in all new donors a reference distribution of ferritin levels in healthy individuals is obtained as well. results: among repeat donors % ( % of , male donors, and % of , female donors) have ferritin levels below ng/ml and are deferred for their next donation. furthermore, the distributions of ferritin levels in repeat male and female donors are similar and each has an average ferritin level of ng/ml. in contrast, we found that only % of new female donors (n = , ) and . % of new male donors (n = , ) have a ferritin levels below ng/ml. the average ferritin level in new donors was ng/ml for males and ng/ml for females. comparing the ferritin levels in new and repeat donors, a reduction in average ferritin levels between . and . was observed in female donors and between . and . in male donors. both ratios increased with donor age. at the end of december donors with low ferritin levels returned for donation after six or twelve months deferral. repeat ferritin measurements show that on average the ferritin levels in female donors increased by ng/ml per year whereas average ferritin levels in male donors increased by ng/ml per year. summary/conclusions: in line with earlier findings in literature our results show that repeat donations substantially reduce ferritin levels in repeat donors. these range from . to . in female and from . to . in male donors, who generally have higher ferritin levels. deferral of donors with low ferritin levels seems to be effective in increasing ferritin levels in donors, however, further monitoring of follow-up in repeat donors is warranted to see whether the proposed scheme allows for sufficient donor recovery over time. there are~ different rare diseases and the genes for half have been identified. approximately . million uk citizens experience premature ill-health because of a rare disease. a conclusive diagnosis is generally not reached and on average the diagnostic odyssey lasts . years. the main aims of the , genomes project are to reduce the diagnostic delay by embedding whole genome sequencing (wgs) to accredited standards in the care path of patients with undiagnosed rare diseases. the project started in and dna samples from , nhs patients and their close relatives have been analysed by wgs. here we review the results from the nihr bioresource pilot study for the , genomes project comprising phenotype and genotype data from , individuals recruited at hospitals using approved eligibility criteria for rare disease domains. we determined the population structure including ethnicity and relatedness estimation, high level phenotypes collected using human phenotype ontology (hpo) terms and quality control and summary metrics for samples and variants. the sequence resource contains over million unique variants in the , genetically independent samples, with % of variants previously unobserved in other large scale publicly available genome datasets. we summarise the curation of gene lists and pertinent findings in , unique diagnostic-grade genes for the domains. over , reports assigning pathogenic or likely pathogenic causal variants have been issued with diagnostic yields varying between domains from . % to %, while the proportion of novel causal variants ranged between % and %. we show the power of the bayesian association test, bevimed, to recapitulate decades of clinical genetics discoveries and by identifying > novel genes and novel diseasecausing variants in the non-coding space of the genome. we show how typing data for all red cell, hpa and hla class antigens can be extracted from wgs data. we mined the data from the , genomes project and similar sequence resources to re-version the probe content of the uk biobank axiom array. we genotyped donors from england and the netherlands with this new array and observed a . % concordance when comparing , blood centredetermined antigen typing results with genotype-determined ones. for the red cell and hpa antigens that were available for , donors, the array typing provided a . -fold increase in typing results per donor ( . vs . ) and rare donors were identified. using the genotyping data we identified . times more compatible units among this cohort of donors when blood demand was modelled using referral data from , english patients with more than three red cell alloantibodies. in conclusion the , genomes project has shown the feasibility of using wgs across a universal healthcare system to deliver a diagnosis for patients with rare diseases. based on these results the nhs has commissioned the analysis of another , dna samples from patients with cancer and rare disease. with analysis of dna by wgs and arrays becoming part of routine clinical care, blood services must develop competencies to extract transfusion and transplant relevant information from clinical-grade genotyping data. next-generation sequencing (ngs) enables the sequencing of thousands of genes, the exomes, and even entire genomes by single experiments at a reasonable price. there have also been advances in cytometry: use of antibodies with different fluorescence tags enables simultaneous monitoring of the expression of dozens of antigens. however, immunological methods cannot detect every variant discovered by ngs. genome sequencing reveals not only the exome but also the regulatory elements of transcription/translation, such as promoters and enhancers. rna sequencing determines which genes and spliced transcripts are expressed. it is amazing to realize how much this novel technology has been contributing to the better understanding of various biological phenomena. since the initial cloning of the human blood group a transferase cdnas in the early s, we have been studying the abo genes, a and b glycosyltransferases, and a and b oligosaccharide antigens. various scientific disciplines including genetics, immunohematology, biochemistry, enzymology, and glycobiology have been applied to their study. we have made several important scientific contributions. we demonstrated the central dogma of abo: the a and b alleles at the abo genetic locus encode a and b transferases, which synthesize a and b antigens, respectively. we elucidated the allelic basis of the abo system. we found amino acid substitutions between a and b transferases and inactivating mutations in o alleles. we became the first who succeeded in the abo genotyping, discriminating the aa and ao genotypes, as well as the bb and bo, which was impossible by the immunological approach. we have taken a simple experimental strategy: preparation of eukaryotic expression constructs of a/b transferases and their derivatives, dna transfection to human hela cells or their sublines, and immunological detection of the a/b antigen and/or biochemical examination of the enzymatic activity. we used this to show that the codons and are crucial in determining the sugar specificities of galnac/galactose of a/b transferases. we also identified mutations in several subgroup alleles causing restricted substrate use and diminished transferase activity. we also showed that cis-ab and b(a) alleles specifying the expression of both a and b antigens by single alleles encode a-b transferase chimeras. since then, other scientists have characterized more than abo alleles. recent human genome sequencings have identified many more single nucleotide polymorphism variations. the genome sequences of many species are also available. taking advantage of those sequences and associated information, we have expanded our research to include evolutionarily related a , -gal(nac) transferases and their genes and scaled it up from the genetic to genomic level. in this talk, i would like to present the followings. : our elucidation of the molecular genetic basis of the abo blood group system (as requested by the organizer); : identification of novel abo alleles by others; : more snp data from genome sequences and potential problems for abo genotyping; : findings obtained from analysis of abo genes from other species; bacteria, vertebrates, to primates; : a , -gal(nac) transferases and their genes and the crosstalk between a transferase and forssman glycolipid synthase (fs); and : the potential causes of generation of abo polymorphism and of species variations of the gbgt gene specifying the fors polymorphism. in recent years, there has been a concerted effort to improve our understanding of the quality and effectiveness of transfused blood components. the expanding use of large datasets built from electronic health records allows the investigation of potential benefits or adverse outcomes associated with transfusion therapy. together with data collected on blood donors and components, these datasets permit an evaluation of the effect of donor and blood component factors on transfusion recipient outcomes. large linked donor-component recipient datasets provide the power to study exposures relevant to transfusion efficacy and safety, many of which may not otherwise be amenable to study for practicality or sample size reasons. analysis of these large blood banking-transfusion medicine datasets allow for characterization of the populations under study and provide an evidence base for future clinical studies. knowledge generated from linked analyses has the potential to change the way donors are selected and how components are processed, stored and allocated. however, unrecognized confounding and biased statistical methods continue to be limitations in the study of transfusion exposures and patient outcomes. results of observational studies of blood donor demographics, storage age, and transfusion practice have been conflicting. this review will summarize statistical and methodological challenges in the analysis of linked blood donor, component, and transfusion recipient outcomes. c-s - a large deletion spanning xg xg and gyg gyg constitutes a genetic basis of the xg null phenotype, underlying anti-xg a production background: the xg blood group system comprises the homologous antigens xg a and cd . the cd gene resides within pseudoautosomal region on the short arms of the sex chromosomes and thus mimics autosomal inheritance. xg, on the other hand, is x-linked and straddles the pseudoautosomal boundary; a truncated pseudogene composed of only the first exons remains on the y chromosome and therefore males carry a sole full-length copy of xg. this phenomenon manifests as asymmetric frequencies of the xg(a+) phenotype between the sexes: roughly % of women and % of men are xg(aÀ). also, whilst xg a immunization is rare, the vast majority of all anti-xg a makers reported are men. recently, we reported that the rs c variant disrupts a gata motif between xg and cd . this abolishes erythroid xg a expression and causes the common xg(a-) red cell phenotype. however, rare individuals who produce anti-xg a cannot be accounted for by this finding. we hypothesized that a structural defect in the xg coding region causes the true xg null phenotype underlying anti-xg a production. aims: we undertook to determine a genetic explanation for anti-xg a production. methods: genomic dna (gdna) was extracted from two whole blood samples and cell-free dna (cfdna) from archived plasma samples from donors producing anti-xg a ; one cfdna sample was from a female donor and the rest from males. polymerase chain reaction (pcr) experiments, sanger sequencing, and database searches were performed to identify and confirm the deletion. aliquots of gdna from four males reported to carry a similar deletion in the genomes project were also tested. results: in one gdna sample, exon-specific pcr identified a deletion involving part of xg and the downstream gene gyg . database searches indicated that the most likely deletion was the infrequent genomic structural variant esv reported in the genomes project. further analyses with a short ( bp) and a long ( bp) pcr amplicon across the suspected breakpoint determined that this deletion was approximately kb and corresponded well with esv . this finding was confirmed in the second gdna sample. given the rarity of anti-xg a producers, we decided to test for the same deletion in cfdna extracted from old archived plasma samples. of the cfdna samples, poor quality in four samples prevented amplification even from control reactions and one was contaminated with bacterial dna. in the remaining nine samples, eight could be amplified for the deletion-specific -bp short amplicon while one was negative for the deletion. sanger sequencing of the amplicons revealed a heterogeneous repetitive dna element, ltr b, hinting at a previously-reported recombination event. this deletion was not detected in the samples from the genomes project which reiterates the previously identified deficiency in data interpretation and reporting for deletions. summary/conclusions: a large deletion disrupting the xg and gyg genes accounts for the xg null phenotype underlying the majority ( of ) of anti-xg a makers. one sample remained unexplained, indicating further heterogeneity to be explored. our data help to explain why anti-xg a production is rare and has primarily been reported in men. background: s and s antigens encoded by gypb differ by one nucleotide (nt), c. c>t, p.thr met. two different genetic backgrounds are associated with silencing of s antigen and a u+ w phenotype. these include the nt change c. c>t (p.thr met) causing partial exon skipping and designated gybp* n. (gypb*ny) and c. + g>t, an intron change causing complete skipping of exon , designated gypb* n. (gypb*p ). aims: samples from three individuals, a previously transfused african american sickle cell patient (p ), a blood donor of unknown ethnicity (p ), and an african american patient (p ) (lapadat r. aabb abstract) were investigated for discrepant serologic and molecular results when determining s and s phenotype. methods: standard methods were used for rbc typing with licensed s and s reagents and rbcs from donor p were also tested with monoclonal and polyclonal anti-s and anti-s. dna was isolated from wbcs and hea precisetype performed on p and p . p was also tested by gypb*s/s as-pcr, exon pcr-rflp for c. + g>t and as-pcr for c. c>t. p was tested for gypb*s/s and c. c>t and c. + g>t changes by a real-time pcr-fluorogenic ' nuclease taqman chemistry. for all, gypb exons - were amplified and sanger sequenced and aligned to consensus using clustal x. results: rbcs of all three probands typed s-and strongly s+ while dna testing indicated c. t/c (gypb*s/s). assay for the two common gypb*s silenced alleles, c. c>t and c. + g>t, indicated all three samples had both silencing mutations previously reported to be independently associated with a sÀu+ w phenotype. hea precisetype could not interpret this novel allele combination and indicated gypb*s as pv (possible variant). samples were confirmed to be heterozygous for c. c/t, c. c/t and c. + g/t by exon specific sequencing and as-pcr, pcr-rflp and real-time pcr. by long range sequencing of gypb, all three were heterozygous c. t/g and c. a/g (p. leu/trp), c. a/t (p. thr/ser), c. a/g and c. g/t (p. glu/gly), c. c/t (s/s), c. g/t (p. val/leu), c. c/t (p. thr/met), and c. + g/t. all samples were also c. g/g (p. ser) and heterozygous for several previously recognized silent changes in exon , c. t/c, c. t/c and c. a/g. summary/conclusions: we report a novel silenced gypb*s allele that can confound gypb genotyping interpretation. the allele was found in three probands associated with a sÀs+ phenotype. in these samples, two changes previously reported to be inherited independently and both associated with silencing of s antigen are carried on the same allele. dna-based testing could not rule out that c. t or c. + t are separate and that gypb*s was also silenced. robust s+ rbc typing indicates both changes are on gypb*s. gene sequencing confirms the c. + t change is on a gypb* n. [gyp*he(ny)] background. c. c>t (rs ) and c. + g>t (rs ) have a frequency of . respectively . in the african population (exac). although we identified samples, the frequency of this novel allele is unknown. background: the lutheran blood group system currently consists of antigens. these antigens are of low immunogenicity and may cause mild-to-moderate transfusion reactions and hemolytic disease of the fetus and newborn. the activation of lu-glycoprotein/bcam on red blood cells (rbcs) and its interaction with laminin- a is thought to play a role in vaso-occlusion in sickle cell disease and other hematological disorders. the two glycoprotein isoforms lu-glycoprotein and bcam are encoded by the bcam gene which consists of exons located on chromosome q . . a number of rare lutheran phenotypes have been previously recorded in israel, including lu:- , observed among iranian jews, lu:- in one thalassemia patient and one case of lu:- . in this report, a previously transfused pregnant arab patient with b-thalassemia intermedia was investigated because she presented with an antibody to an unknown high frequency antigen (hfa), potentially related to the lutheran system. aims: to characterize a novel lutheran antigen through serological and molecular investigation of a patient with a lutheran related antibody. methods: initially, the red cell phenotype and the presence of a lutheran related antibody in the serum of the patient were detected by standard serological techniques, utilizing enzyme treated and chemically modified cells and rare cells and sera from the nbgrl collection. further serological investigations were carried out using standard iat (liss tube and bio-rad gel) technique. plasma inhibition studies were performed using soluble recombinant lu protein (srlu). eluates were prepared using acid elution method (gamma elu-kit ii). genomic dna was isolated from whole blood and all exons of the bcam gene were amplified by pcr and directly sequenced by sanger sequencing. the impact of the identified mutation on lutheran glycoprotein structure was studied by molecular dynamics calculations. results: the patient's plasma reacted with all cells tested, except for three examples of in(lu) cells and cells treated with -aminoethylisothiouronium bromide, trypsin and a-chymotrypsin. inhibition studies with srlu protein showed complete inhibition of the antibody, thereby confirming the antibody to be directed toward an epitope on the lu-glycoprotein. in addition, testing of inhibited plasma revealed the presence of underlying anti-e and anti-fy a . an eluate was prepared to isolate the patient's lu-related antibody and this eluate was found to be incompatible with examples of lu:- , lu:- , lu:- , lu:- , lu:- , lu:- , and lu:- cells, whereas in(lu) were compatible. results of serological typing of the patient's cells, for lu system hfas, could not be conclusively determined due to the patient having been recently transfused. however, results suggested (through absence of mixed field reactivity) the patient's cells to be lu: - , , , , ,- , . bcam sequence analysis confirmed the patient to be lu* , lu* and revealed a novel homozygous mutation c. a>c in exon , encoding p.lys gln in the lutheran glycoprotein. summary/conclusions: a novel homozygous mutation c. a>c (p.lys gln) in exon of bcam was identified in a patient with an antibody to a lutheran hfa. serological and genetic evidence presented here indicates discovery of a novel antigen of the lutheran blood group system, which we propose to name lura. background: lutheran glycoprotein and basal cell adhesion molecule antigen b-cam are two isoforms of a type i membrane glycoprotein residing on red cell surfaces. both isoforms are adhesion molecules with the main function of laminin binding, and both carry antigens of the lutheran blood group system (lu). the system currently comprises antigens, all encoded by mutations in the alternatively spliced single gene bcam located on chromosome . currently, isbt lists high incidence antigens in the system. aims: we report a case study of an individual with an unidentified alloantibody to high incidence antigen present in her plasma. samples from the patient and her family were investigated. we provide here serological and molecular evidence for a novel high incidence antigen of the lutheran blood group system. methods: serological investigations were performed by standard iat (liss tube and bio-rad gel) technique. plasma inhibition studies were completed with soluble recombinant lu (srlu) protein. genomic dna was isolated from whole blood of the patient and her family members; all the exons of the bcam gene were amplified by pcr and analysed by direct sanger sequencing. the impact of the identified mutation on lutheran glycoprotein structure was studied by molecular dynamics calculations. results: presence of a lu-related antibody in the patient's plasma was confirmed, reacting moderate strength by liss iat with untreated and papain treated cells. cells from the patient's mother, father and two siblings were all incompatible with her plasma, though weaker than panel cells, reflecting dosage. only in(lu) cells were compatible with patient's plasma. the antibody was successfully inhibited with srlu protein, thereby confirming the epitope recognised by the antibody resides on the lutheran glycoprotein. the patient's cells were found to be lu: - , , , , , , , , . bcam sequencing revealed a novel homozygous mutation c. g>a in exon , encoding p.val met in the lu glycoprotein. the c. g>a change appears to be an extremely rare mutation, listed in gnomad database with a frequency of . - and with no known homozygous examples. homology model of the novel lutheran glycoprotein was subjected to all-atom molecular dynamics calculations to analyse potential conformational changes. summary/conclusions: we report serological and genetic evidence for a novel antigen of the lutheran system, which we propose to name lunu. the evidence will be submitted to the isbt red cell immunogenetics and blood group terminology working party for consideration for allocation of antigen status. the absence of this high incidence antigen arises from a rare single amino acid change p.val met in the lutheran glycoprotein and the presence of anti-lunu in the patients' plasma was presumed to have been made in response to previous pregnancy. on native, papain-treated (diagast) and trypsin-treated (sigma) rbcs. genomic dna was extracted from peripheral blood cells by an automated method, amplified by sema a exon-specific primers and sequenced. results: the proband was a -year-old female patient of moroccan origin, group a, d+c+e-c+e+, k-, without transfusion history. she was hospitalized at weeks gestation for a blighted ovum requiring a manual vacuum aspiration, with a significant hemorrhage risk. a rbc antibody screening was performed by a first laboratory. the antibody reacted + by iat on all native reagent rbcs, with negative autocontrols, but was nonreactive on papain-and trypsin-treated cells. an anti-ge was initially suspected, due to the pattern of reactivity and ethnic background. new blood samples were referred to our national immunohematology reference laboratory. the antibody showed the same profile. anti-ge and anti-ch could be ruled out. the serum was nonreactive with two jmh:- and positive with two jmh:- samples. the patient was found to be jmh positive. in addition, a soluble recombinant jmh protein (jmh imusyn/inno-train) fully abolished the reactivity of the panagglutinating antibody. the antibody was an igg . overall, these results were consistent with a probable jmh variant and prompted us to perform sema a sequencing. three nucleotide changes were found, in homozygous state: a rare nonsynonymous change in exon , c. g>a (p.asp asn, rs , maf < . , sift score = ); a common synonymous change in exon , c. a>g (p.gln gln, rs , maf = . ); a rare non-synonymous change in exon , c. g>a (p.arg his, rs , maf < . , sift score = . ). the analysis of surface accessibility of asp and arg using the d structure of sema a (rcsb pdb- nvq https://www.rcsb.org/structure/ nvq) showed that only arg was predicted to be an exposed-epitope. interestingly, all other reported jmh variant phenotypes correspond to an arginine substitution. of note, we retrospectively found another individual of algerian ancestry (pregnant woman) with a pan-agglutinating igg antibody showing a similar pattern of reactivity, and with the same three changes in sema a. we unfortunately could not perform a cross-compatibility testing with the proband (no material left and unsuccessful contact). summary/conclusions: serological and molecular studies allowed us to provide evidence for a novel high-prevalence antigen in the jmh blood group system, very likely encoded by the p.arg his substitution in sema a. we propose to provisionally assign the name jmh for this antigen. interestingly, our two unrelated jmh:- individuals were from north african ancestry. background: the abo system was discovered almost years ago and the underlying structures later elucidated as carbohydrates carried by glycoproteins and glycolipids. the terminal trisaccharides galnaca (fuca )gal and gala (fuca )gal constitute the clinically important a and b epitopes, respectively. clausen et al. (pnas, ) showed that the a antigen could be extended to a repetitive glycolipid a epitope, galnaca (fuca )galb galnaca (fuca )galb glcnac-r. however, extended forms of b antigen have not been described. we encountered two related situations with unexplained serological reactivity. firstly, enzyme-conversion to group o treatment of group b (b-eco) red blood cells (rbcs) with a -specific gh family exogalactosidase (bzyme) abolishes b antigens as detected by hemagglutination and flow cytometry with all monoclonal anti-b tested. despite this, % of group o plasmas have been reported to give positive crossmatch results with b-eco rbcs. secondly, plasmas from ab and b individuals of the globoside-deficient p k phenotype contain anti-p and anti-px but react stronger with bpp-rbc than with app/opp-rbc. based on these findings, we hypothesized the presence of a bzyme-resistant, b-related glycolipid. aims: to identify the molecular basis of the enigmatic serological observations outlined above. methods: plasma and eluates from an a b individual with the p k phenotype were investigated by hemagglutination and flow cytometry, as were eluates from b p k and o plasma. rbc membrane glycolipids were extracted from two batches of pooled, expired group b-rbc units (frozen -litre reference preparation and confirmatory preparation from freshly collected units). native or enzyme-treated glycolipid fractions were analysed by liquid chromatography electrospray ionizationmass spectrometry (lc-esi/ms) and immunostaining of thin layer chromatography (tlc) plates. antigen expression in the h+bÀ human erythroleukemia (hel) cell line was analysed by flow cytometry following overexpression of selected glycosyltransferases. results: anti-p-depleted eluates made from a b p k plasma contained anti-px and antibodies of unknown specificity that reacted stronger with native or papaintreated bpp-rbcs compared to app/opp-rbcs. anti-px was removed by adsorption onto opp-rbcs but reactivity (here designated anti-extb) remained against b/bpp/b-eco rbcs. lc-esi/ms of glycolipid fractions from group b units revealed an unknown hexnac-hex-(fuc-)hex- hexnac-hex- hex heptasaccharide. upon b-nacetylhexosaminidase treatment of this candidate structure, a group b type hexasaccharide was produced, demonstrating that the terminal hexnac of the hexnac-gala (fuca )galb glcnacb galb glc heptasaccharide was b-linked. since the discovery of the anti-platelet effects of aspirin platelets have been a major therapeutic target for pharmaceutical companies and also a very profitable target. however, the effectiveness of aspirin has also been a challenge as it is an inexpensive drug and any new agent needs to show clear benefit over aspirin. furthermore the risk of bleeding from anti-platelet agents, especially cerebral bleeds, has also presented challenges. in the 's orally active gpiib/iiia antagonists were considered to be the 'super aspirin' but clinical trials showed increased mortality and ultimately this class of drugs was relegated to iv use only in high-risk patients. gpib/ix/v antagonists were also a promising drug target but no agent made it to market. the real breakthrough was the discovery of the p y antagonist clopidogrel which, in conjunction with aspirin, proved to be very effective at preventing thrombotic events and as a result it became the biggest selling drug in the world at the time. with clopidogrel now offpatent the combination of aspirin and clopidogrel is a formidable challenge to any new agent both in efficacy terms and pharmacoeonomic terms. so is there a future for new anti-platelet agents? with the growing awareness of the role of platelets in inflammation and an understanding of how the immune activation of platelets differs from the classical haemostatic activation of platelets it is now possible to develop novel anti-platelet agents that target inflammation without compromising haemostasis. it is here that we should look for the next generation of anti-platelet agent. c-s - university hospitals of geneva, geneva, switzerland platelet function defects, either congenital or acquired, are associated with increased bleeding risk, particularly in a perioperative setting. the use of platelet function assays is therefore tempting in order to tailor transfusion and limit platelet transfusion to those bleeding patients with impaired platelet function, as assessed by those assays. however, the current guidelines provide only weak recommendations supporting the routine use of these assays. indeed, there are numerous platelet function assays on the market that differ in their method of evaluation of platelet function and agreement between their results is at best moderate. the threshold values beyond which procedure-associated bleeding risk becomes worrisome is not standardized. moreover, observational studies addressing the predictive value of platelet function testing in perioperative or spontaneous bleeding are not consistent. finally, management trials with randomized patients assessing the benefit of platelet function testing are scarce. more recent data identified selected situations where platelet function testing may be useful though. i will review the different platelet function assays as well as selected clinical studies addressing the impact of platelet function testing to improve bleeding and transfusion-related outcomes. the latest recommendation will be addressed too. background: platelet refractoriness complicates the provision of platelet transfusions in management of thrombocytopenia in oncology patients. platelet refractoriness poses challenge due to alloimmunization to hla and human platelet antigens and is associated with adverse clinical outcomes. aims: a prospective study was undertaken to analyse result of platelet compatibility with post-transfusion platelet count increment and to ascertain presence of platelet antibodies as causative factor in platelet refractory oncology patients. pulmonary complication after blood transfusion is the leading cause of transfusionrelated morbidity and mortality, with an incidence reported between . - % of all transfused patients. the most important transfusion related pulmonary complications are transfusion associated circulatory overload (taco), transfusion related acute lung injury (trali) and transfusion associated dyspnea (tad). in this presentation the recent changes in the international definitions will be presented and discussed. furthermore, insights in the different underlying pathophysiologic mechanisms will be highlighted. in the past decades only for trali prevention strategies have successfully been designed and implemented. currently no evidencebased treatment strategy is available for any of these life-threatening syndromes. insight in the pathogenesis of pulmonary complications after transfusion should pave the way for future prevention and treatment studies. the issue of the impact of iron overload / toxicity on the hematopoietic stem transplantation (hct) outcome has been firstly addressed in the field of transfusion dependent thalassemia. today the concept has been extended to other diseases characterized by periods of variable duration of transfusion dependence such as myelodysplastic syndrome (mds) and myeloproliferative diseases. patients requiring regular blood transfusions certainly develop iron overload leading to tissues and organ damage. iron burden before transplant significantly impacts outcome and long-life posttransplant. it is well known that iron overload is deleterious for organs such as liver, heart and endocrine glands and it has been postulated could also increases the risk of infections and severe graft versus host disease early after hct. recent preclinical data has shown how increased production of reactive oxygen species (ros) resulting under iron overload condition, could impair the stem cells clonality capacity, proliferation and maturation. also, microenvironment cells could be affected through this mechanism. for this reason, iron overload is becoming an important issue also in the engraftment period early post-transplant. high baseline ferritin levels before hct have been shown to negatively influence clinical outcome, but nowadays, ferritin is considered a steady and not biologically active form of iron, while free iron forms as non -transferrin bound iron (ntbi) and labile plasma iron (lpi) are considered the main trigger of cell damage more representative of the dynamic tissue damage. the scientific community is moving the iron disease from a "bulky" disease, such as classically in thalassemia (based on quantitative iron parameters as ferritin, red blood cell transfusion number, mri) to a "toxic" disease (based on active and dynamic biological markers as ntbi/lpi). at this time in all the studies published on hct setting, only the correlation between direct or indirect estimates of iron overload (mainly serum ferritin) and outcome parameters has been explored, while the duration of exposure to toxic iron species has not been taken into account. the first study that explored the lpi role in relationship with outcome was published by wermke and colleagues in malignancies. they investigated the predictive value of both stored (mri-derived liver iron content) and non-transferrin-bound-iron, defined as enhanced labile plasma iron (elpi) on post-transplantation outcomes in patients with acute myeloid leukemia or mds. their prospective, observational all-ive study showed that patients who had raised elpi concentration at baseline, also had significantly increased incidence of non-relapse mortality at day ( %) compared with those who had normal elpi at baseline ( %) (p = . ). reinterpreting transplant predictive factors in the light of the current advances in understanding iron homeostasis further supports the concept that the key to successful transplantation is regular and life-long chelation therapy to consistently suppress tissue reactive iron species and prevent tissue damage in the years before hct. in transfusion medicine, the role of donor sex was long considered to be limited to the increased risk of trali observed after transfusions from female donors. this risk has been shown to be limited to female donors with a history of pregnancy and to plasma rich products (i.e. excluding red blood cell products, typically containing < ml plasma). until, in , we found that sex-mismatched red blood cell transfusions were associated with increased recipient mortality. since then, several other studies have confirmed these findings, but some studies also did not find an association. all of these studies relied on the analyses of routinely collected health care data, which was not primarily intended to be used for research. as a result, analyses are complex and often difficult to properly appraise based on published descriptions. therefore, the discussion about possible reasons for these discordant findings has largely focused on the methodological approaches of the different studies. other potential explanations include differences in donor or patient populations, production methods, or storage time of blood products. the different potential explanations are expected to be associated with different underlying biological mechanisms. therefore, further delineating which donor, patient, and product characteristics modify the observed association could provide more insight into the underlying mechanism. in , we observed that only transfusions from female donors with previous pregnancies were associated with increased mortality and only in male recipients under years. this leads us to postulate that pregnancy induced long term changes in the female immune system are transferred during red cell transfusion, with negative consequences for young male recipients. the low amount of plasma present in red cell products further lead us to assume a cellular component, like passenger leukocytes, to be involved. it has been shown that micro-chimerism of passenger leukocytes can persist for decades after transfusion, even of leuko-reduced blood products, suggesting long term immune-modulation could play a role. we hypothesized that passenger leukocytes would die during storage of blood products and the negative effect of ever-pregnant female donors, on the survival of young male red cell recipients, would therefore be attenuated by increased storage time. however, our data seem to indicate the opposite. the risk of death was increased over three-fold for young male recipients of old (> days storage) red cells from ever-pregnant donors, compared to for young male recipients of fresh (< days storage) red cells from ever-pregnant donors ( -year cumulative incidence of death . % versus . %). the negative control group (i.e. young male recipients of red cells from male donors) showed a much weaker association of mortality with storage time (i.e. . % versus . %). these findings seem to falsify our hypothesis that mortality could be caused by passenger leukocytes, establishing long term immune-modulatory effects. another potential mechanism that has been suggested could be the presence of cellfree dna in transfused blood products. this cell-free dna increases during storage. however, more research is needed both to establish if cell-free dna can also be linked to previously pregnant blood donors and by which mechanism it could negatively affect young male transfusion recipients. clinical trials (cts), the gems in clinical research for generating robust evidence in medicine and public health, are costly and complicated undertakings. in resource limited setting like sub-saharan africa (ssa) where the health systems are sub-optimal and where capacity for research is limited, the conducting of cts can be a daunting challenge. the challenges of undertaking cts in rls may be categorized based on the occurrence of the bottleneck(s) in relation to the ethics and regulatory approval process: pre-approval: protocol development: in order to develop a context-specific protocol which is subsequently subjected to an ethics and regulatory approval process, investigators need to review and ensure that the protocol is pragmatic and feasible with respect to implementation. this results into a time-consuming reiterative process of reality-checking the protocol. site selection: in light of the limited research infrastructure, investigators in rls and their developed world partners spend considerable time reviewing and selecting suitable sites for participation in the anticipated protocol for the cts. suitable sites are usually very few and with competing on-going studies. approval: institutional review board (irb) approval: the irb approval process can be quite lengthy ( - months) with considerable unpredictability in the periods between the initial and subsequent irb reviews. national regulatory approval: the requirements by national regulators are unusually innumerable with limited flexibility to accommodate specific cts. post-approval: the key post-approval challenges for cts implementation in rls are attaining appropriate participant enrolment and maintaining high retention rates. specifically, for participant enrollment, the challenge may be unforeseen competing cts targeting the same participant pool or community perspectives that may discourage participants from getting screened for the cts. retention may also be a challenge particularly where participants view enrollment as a chance to access healthcare services may therefore not have any incentive to keep in a study after the initial study visits. in conclusion, cts are complex undertakings wherever they are conducted but are doubly challenging in rls like sub-saharan africa. the bottlenecks at the preapproval, approval and post-approval stages are considerable. nevertheless, it is rewarding to perform ctus in rls given that the data generated therein is highly valued by national regulators and may hasten the registration process for medical products. background: interest in an appropriate and effective whole blood (wb) pathogen reduction technology (prt) is growing, especially in sub-saharan africa where the residual risk of transfusion-transmitted infections (ttis) remains unacceptably high and wb is still frequently used. cerus corporation, manufacturer of the intercept tm blood system, and swiss transfusion src are collaborating on a clinical development program to adapt intercept prt using amustaline (s- ) and glutathione (gsh) for red blood cells (rbcs) into an appropriate prt for wb in resource-limited settings in africa. treatment with amustaline/gsh has been shown to inactivate a broad spectrum of transfusion-transmissible pathogens in rbcs. studies with amustaline/gsh in wb have shown effectiveness against a duck hepatitis b virus (> . log reduction) and plasmodium falciparum (> . log reduction), with future studies planned. a wb prt system with amustaline/gsh also has the potential benefit of minimal electricity requirements. aims: to describe the safety and clinical objectives for a phase clinical trial using the amustaline/gsh prt system for wb in africa, and describe research and development efforts to adapt the intercept prt system for rbcs into a robust and appropriate wb system for settings with high burdens of tti and limited resources. methods: the protocol for a phase clinical trial using pathogen-reduced wb treated with amustaline/gsh in an african country is presented, as are current research and development activities related to the development of a prt system for wb. results: in the planned phase clinical trial in africa, clinically stable patients with anemia who require wb transfusion will be randomized into two study arms at a large medical center in a sub-saharan african country. enrolled patients will receive one unit of non-leucocyte-reduced wb treated with amustaline/gsh, or a unit of untreated control wb or rbcs. the primary safety endpoint will be the incidence of high-imputability transfusion reactions (swissmedic ≥grade ) within the first hours of transfusion. data will also be collected on all adverse events and transfusion reactions (all grades) and the development of treatment-emergent antibodies to pathogen-reduced wb or auto-antibodies within (ae ) days of the study transfusion. clinical efficacy will be characterized by hemoglobin increment hours after transfusion adjusted to hemoglobin dose and body weight. summary/conclusions: a prt system for wb is being developed based on the intercept prt for rbcs that is in advanced development in europe and the united states. intercept-treated rbcs have met efficacy and safety endpoints in phase clinical trials. the amustaline/gsh prt system used to treat intercept rbcs has demonstrated effective inactivation against a broad spectrum of agents that may result in ttis. a phase clinical trial using an adapted prt system for wb in africa is the first step in a clinical development program that includes additional pathogen inactivation efficacy studies and improvements to the wb prt implementation process. together, these developments and evaluations represent progress toward a realistic and appropriate prt for wb in africa and other resource-limited settings. background: in australia, demand for plasma-derived products has increased dramatically, and there is a need to increase plasma collections. first-time donor retention, including the rate at which first-time donors return, is a pressing issue. a quick return is optimal as this increases the overall plasma yield and is associated with long-term retention. however, we lack evidence of effective interventions to encourage first-time donors, particularly those donating plasma, to return and to establish a higher frequency donation routine. working from schultz's ( ) framework, this intervention study was based upon insights from interviews with first-time plasmapheresis donors. participants identified barriers such as time and lack of knowledge about plasmapheresis. facilitators included being able to help more people and to donate more frequently than allowed with whole blood. participants generally favoured donating at a frequency of every weeks. aims: the aim of this study was to test the effectiveness of three intervention conditions compared with the business-as-usual (bau) procedure on the proportion of donors returning to donate plasma and the number of plasma donations. we report on the data from months post-donation. methods: donors were randomly assigned to one of four study conditions. in conditions and , donors received an email one day after their initial donation. in the first condition, donors received the bau 'thankyou' email. donors in the second condition received an alternative email with content derived from the interview study. donors in the remaining conditions received either the bau email (condition ) or the revised email (condition ) coupled with a telephone call. the phone call was scripted to provide additional information about plasma, including how often plasma can be donated, a suggestion to donate every weeks, and a prompt to forward-book appointments. results: the final sample (n = ) comprised women ( %) and men ( %) aged - (mean = ). after two months . % of donors returned to donate plasma at least once. after controlling for gender, age, and blood group, donors in each of the intervention conditions were more likely to return to donate plasma than were donors in the bau condition. the greatest effect was found between donors randomized to condition (revised email + phone call), or = . , ci = . - . , and bau. donors assigned to the two telephone conditions (condition and ) donated plasma at a higher frequency than bau. summary/conclusions: this study tested the effectiveness of interventions designed to encourage first-time plasma donors to return to donate plasma and to establish a routine of donation. early indicators suggest that the evidence-based email and phone call elements are more effective than bau in bringing donors back to donate plasma, and the revised email combined with a phone call had the greatest positive effect on short-term plasma yield. background: healthy individuals with hereditary hemochromatosis (hh defined as hyperferritinemia and homozygous p.c y mutation), but also carriers of other hfe mutations (p.c y/p.h d or homozygous h d) with elevated serum ferritin (sf) are accepted as blood donors, if allowed by local regulations and if eligibility is fulfilled. generally, blood components are released for transfusion at normal sf levels (< ng/ml in females, < ng/ml in males). aims: prospective, two-center, randomized study comparing the efficacy and tolerability of double-erythrocyte apheresis ( rbcaph) and whole blood phlebotomy (wbph) for iron depletion in asymptomatic subjects with hh or hyperferritinemia and other hfe mutations in the setting of routine blood donation. methods: eligibility criteria included age ≥ - years, total blood volume ≥ l, bmi < kg/m , hb ≥ g/l, elevated sf levels and no end organ damage due to iron overload. rbcaph ( ml rbc) were scheduled every days and wbph ( ml) every days until sf was < ng/ml. a complete blood count and sf were measured at baseline, at every visit and at follow up weeks after completion of the study. adverse events were systematically recorded. the treatment effect was tested by poisson regression, with gender, hfe mutation, bmi and baseline sf as covariates. results: subjects ( females; mean age years) were randomized to wbph (n = ; female) or rbcaph (n = ; females). hfe mutations were p.c / p.c y in subjects, p.c y/p.h d in , and p.h d/p.h d in . at baseline, mean hb was g/l (sd . ) and median sf was ng/ml (iqr - ng/ml). procedures (wbph n = , rbcaph n = ) were completed; were interrupted (local hematoma, insufficient flow); ( wbph, rbcaph) were postponed because of low hb and for non medical reasons. there were drop-outs in the wbph arm due to depression and poor compliance, respectively. anemia (hb < g/l in males, < g/l in females) occurred after visits in wbph subjects and after visits in rbcaph subjects. fatigue was reported after phlebotomies and aphereses. only participants ( %) completed the study per protocol. blood components ( rbc concentrates and plasma units) for transfusion were obtained. overall, a median of . wbph (iqr . - . ) was needed to reach sf < ng/ml, corresponding to . times of rbcaph (median . , iqr . - . ) (p = . ). analyzing separately p.c /p.c y and p.c y/p.h d carriers, the relation wbph to rbcaph was . and . , respectively. treatment arm and hfe mutation were the covariates with significant effect on the primary endpoint (p = . and . , respectively). summary/conclusions: rbcaph is more efficient than wbph for iron depletion in healthy subjects with hh or other hfe mutations and moderate hyperferritinemia. intensive treatment schedules, generally recommended for hh, are difficult to keep because of hb drop and compliance. less intensive treatment in asymptomatic individuals with hh and their inclusion in blood donation would avoid negative effects on quality of life and benefit blood collection centers in the long term. background: serum ferritin (sf) measurements in whole blood (wb) donors demonstrated that female sex and intensity of donation are major risk factors for iron deficiency. approximately ml red blood cells (rbc) and - mg iron are lost with wb donation. double unit rbc ( rbc) collections of ml (ca. ml less than the rbc amount of two wb donations) lead to a loss of about mg iron. in switzerland, the maximal allowed donation frequency for male donors is once every months for rbc and once every months for wb donation. aims: to describe and compare the course of hemoglobin (hb) and sf in male subjects donating wb and rbc at our institution. methods: we included wb and rbc donors (n = ) who donated with the maximal allowed donation frequency over months between and , yielding , wb and , rbc donations. we excluded subjects with hyperferritinemia and known hfe mutations. hb limits were g/l for wb and g/l for rbc donation. with rbc apheresis ml rbc were collected. sf was measured on a predonation serum sample; hb was determined from finger prick samples. the donors received no iron substitution. we used generalized estimating equation models for hb and sf trajectories. results: mean age at the first blood donation was (wb) and years ( rbc), respectively. at the first donation, mean hb was g/l (sd ) in wb and g/l (sd ) in rbc donors; mean sf was (sd ) and lg/l (sd ), respectively. on average, hb and sf were higher in rbc donors ( . g/l and lg/l, respectively; p < . ). there were subjects with sf < lg/l in wb and in rbc group, and with sf < lg/l (but > lg/l) and , respectively. in rbc donors, between the first and the last donation, mean hb declined from g/l to g/l (p < . ) and mean sf from lg/l to lg/l (ns). in wb donors, mean hb dropped from g/l to g/l (p < . ) and sf from lg/l to lg/l (p < . ). similar results were found when adjusting for age and season. hb values dropped from baseline until the th donation for wb donors and until the th donation for rbc donors with an upward trend thereafter. in both groups, no hb value below the limits of blood donation and no anemia were observed. sf reached a nadir at the th donation in both wb and rbc donors ( lg/l and lg/l) and increased thereafter in rbc donors. in wb donors, sf followed a parabolic trend that peaked at the th donation, and then declined until the last donation. summary/conclusions: the maximal allowed blood donation frequency for wb and rbc male donors in switzerland is not only protective for the development of anemia, but also for deferral of blood donors because of low hb. this was observed even in subjects with low sf at baseline. background: granulocyte concentrate transfusion is a potentially lifesaving option for patients without functional neutrophils. however, recent studies have failed to demonstrate the anticipated clinical effectiveness of this procedure. granulocyte concentrates are manufactured using sedimentation agents to separate granulocytes from red blood cells and enhance granulocyte collection efficiency. high-molecularweight hydroxyethyl starch (hes) is most commonly used for this. however, authorities recently restricted the use of hes due to its unfavorable risk-benefit-profile. modified fluid gelatin (mfg) is an already used alternative sedimentation agent. as the granulocyte product contains these substances, any impact of the sedimentation agent on granulocyte function may affect the clinical effectiveness of granulocyte transfusion. aims: we tested the hypothesis that mfg is not inferior to hes in terms of the functionality and viability of granulocytes. methods: granulocytes from ten healthy donors were isolated, aliquoted and incubated in parallel for hours with either % (control), . %, % or % mfg (gelafundin %, b. braun melsungen ag) or hes (hespan %/ / . , b. braun medical inc.), respectively, and granulocyte migration, chemotaxis, reactive oxygen species (ros) production, neutrophil extracellular trap formation (netosis), antigen expression of cd b, cd l and cd b, and viability were subsequently investigated in vitro. testing was performed using live cell imaging of the cells embedded into a collagen i matrix for parallel testing of migration, ros production and netosis. in addition, flow cytometric (facs) analysis was utilized for surface marker expression, viability and respiratory burst measurement. results: granulocyte migration decreased in a dose-dependent manner in response to hes and mfg. relative to the controls, all three concentrations of hes lowered migration distances (p < . respectively), whereas only the higher concentrations ( % and %) of mfg showed lower relative migration distances (p < . respectively). track straightness was reduced with both sedimentation agents at % and % to the same extent (p < . respectively). hes resulted in lower cd b expression (p = . ) and higher cd l expression (p = . ) compared to the controls, whereas the differences for cd b did not reach statistical significance. mfg did not affect the expression of any investigated surface antigen mediating endothelial adhesion and transmigration in comparison to the controls. no significant differences in the timing of ros production or netosis, or in neutrophil viability or respiratory burst were observed. summary/conclusions: these results indicate that mfg is not inferior to hes in terms of granulocyte phenotype and function in vitro when used at equal concentrations, and that potential impairment of granulocyte function can occur with hes. background: plateletpheresis donation leads to a well-known transient decrease of donor's platelets. the question of long-term effects raised with the development of regular donations by some donors in order to satisfy a growing demand. a seminal work (lazarus, transfusion, ) stated that there is a sustained thrombopenia in frequent plateletpheresis donors, correlated with the total number of donations. aims: french regulation authorizes up to plateletpheresis donations per year, with a minimum weeks interval between them. we tried to evaluate the risk of sustained thrombopenia under these conditions. methods: we retrieved all plateletpheresis donations occurring between / / and / / from the french civilian blood donors' base and then selected a cohort of donors with at least donations during that period. in order to minimize measurement errors, platelet counts analysed were means of three consecutive donations, i.e. measures for each donor. results: the cohort includes , donors ( women and , men). mean platelet counts fluctuate between . and . platelets/ml. analysis of variance does not show any statistically significant difference (f = . ), even taking donor's sex or age in consideration. there is no difference if we consider the total duration of the donations, either. donors with the lowest first counts show a significant rise in subsequent measures and donors with the highest counts show a decrease trend, exhibiting a classical regression toward the mean. summary/conclusions: plateletpheresis french regulation does not seem to be at risk of sustained donor thrombopenia. this conclusion is in agreement with recent literature data. the primary biological role of the human leukocyte antigen (hla) system is the regulation of the immune response to foreign antigens. because of this role, hla genes and molecules have an important role in transplantation, etiology of many autoimmune, non-autoimmune and infection diseases, but also in transfusion medicine. an increasing probability of an hla non-compatible blood products, tissues or organs exists due to the extremely high polymorphism of hla genes, with more than , described alleles to date, and their different frequency distribution in various worldwide populations. the hla system, originally discovered as a result of a transfusion reaction in the s, can cause detrimental immune reactions in transfusion therapy. hla antibodies present in the patient are responsible for some of these reactions, while in other cases hla antibodies or hla reactive cells present in the transfused product are accountable for the immunoreactivity. hla antibodies form as a result of exposure to foreign hla antigens during pregnancy, transplantations and blood transfusions and can cause platelet immune refractoriness, febrile transfusion reaction, transfusion-related acute lung injury, and transfusion associated graft versus host disease. in order to avoid or reduce the development of these transfusion-related events, hla antibody negative or compatible products should be used. almost all existing methods presently used for molecular typing of hla polymorphisms are based on polymerase chain reaction, but with different resolution levels (low resolution -two digits or high resolution -four digits). in addition to providing a more precise detection of polymorphisms at hla classical loci (e.g. hla-a, -b, -c, -drb , -dqb ), molecular methods can also determine polymorphisms at hla loci which previously could not be typed by serology (e.g. hla-drb , -drb , -drb , -dqa , -dpa ). the most commonly used method for the detection of hla antibodies was until recently complement-dependent cytotoxicity (cdc) technique, but it is increasingly being replaced by a more sensitive, solid phase based method (luminex technology). in conclusion, an accurate and precise determination of both hla gene polymorphism and hla antibodies presence is essential for the safe and efficient administration of transfusion products. background: in only a minority of pregnancies complicated with anti-hpa a antibodies serious fetal/neonatal disease develops. the difficulty in predicting which mothers should be treated with ivig hampers implementation of fnait screening. we found that fc-core fucosylation and galactosylation are highly variable in anti-hpa a igg, and that these glycan features strongly affect binding to fccriiia receptor. the level of fc-core fucosylation of anti-hpa a alloantibodies was found to correlate with platelet count and outcome of the newborn, suggesting that antibodyspecific fucosylation might serve as a biomarker in fnait screening. however, at present the fc-glycosylation pattern can only be determined by complicated methods involving purification of the antigen-specific igg, and analyzing trypticly released -igg-derived-glycopeptides by tandem liquid chromatography-mass-spectrometry (ms) techniques. these methods, although powerful, are not yet suited for high throughput clinical screening. aims: our aim was to provide a simplified method to quantify the biological activity of anti-hpa- a antibodies, and possibly other alloantibodies against blood cells. methods: here we explored if cellular surface plasmon resonance (spr) imaging can replace ms, resulting in less complicated handling of patient sera and donorantigen-bearing cells. the strength of the binding of platelets to fccr on spr sensor was monitored under flow. the spr sensor was equipped with both wt fccriiia (sensitive to fc-glycosylation status) and mutant fccriiia-n a (insensitive to fcglycosylation status). in addition, the biosensor was prepared with anti-platelet cd (c ) and anti-igg to calibrate the number of injected platelet as well as to quantify igg-opsonization. the quality of the anti-hpa a glycosylation was monitored as the ratio of the binding of opsonized platelets to the wt and the mutant n a-fccriiia. platelets opsonized with recombinant glycoengineered anti-platelet antibodies with different levels of fc-fucosylation were used as standards. for validation, plasma samples with anti-hpa a antibodies, already analyzed by mass spectrometry and with known clinical outcome were tested (sonneveld, bjh, ) . results: we found that the ratio between the binding to the wt fccriiia and to the mutant n a-fccriiia correlated with the level of fucosylation of the hpa a antibodies, as measured by mass-spectrometry (r = À . ; p < . ). overall, a similar predictive value for disease severity was obtained as we previously reported for this retrospective cohort. in addition, quantitative information on antibody concentration can also be extracted using the fccriiia-n a receptor as sensor on the chip, while anti-igg gave aspecific signals, presumably because it recognized cytophilic platelet-fccriia-bound antibodies as well. summary/conclusions: in conclusion, the combined use of wt and mutant fccriiia in a label free spr assay provides both quantitative and qualitative information of platelet bound anti-hpa a antibodies, which circumvents the need for purification of specific antibodies and laborious mass spectrometric analysis. this approach might be generally applicable to determine the biological activity of cell bound antibodies not only for anti-hpa a in fnait, but also for anti-rhd alloantibodies in hdfn or anti-platelet antibodies in itp. background: immunization against the human platelet hpa- a alloantigen is the most common cause of severe fetal and neonatal alloimmune thrombocytopenia (fnait) in otherwise healthy term newborns. the screening for hpa- a antigen in pregnant women is an important tool for identification of pregnant women at risk of having a fetus/neonate with fnait. any targeted intervention depends on efficient screening methods as well as sensitive and specific methods for detection of anti-hpa- a. within the framework of the polish-norwegian project (prevfnait) we have performed hpa- a screening program in poland. aims: our aim was to assess the frequency anti-hpa- a antibody detection and the clinical outcome of newborns identified through the study. women who joined the program due to the fnait in the previous child or in the current newborn are not analyzed in this study. methods: hpa- a screening of pregnant women in - gestational weeks was performed by facs phenotyping or rq-pcr genotyping at ihtm in warsaw. hpa- a negative/hpa- b/ b women were tested for hla drb * : and for anti-hpa- a antibodies by maipa (followed up at week - , , , - and weeks after delivery). if anti-hpa- a were detected, quantitative maipa was performed. all hpa- a negative women were contacted for information concerning the newborn. if the baby had thrombocytopenia and anti-hpa- a were not detected by maipa, the look back samples were tested retrospectively by paklx test (immucor). results: hpa- a negative women were identified ( . %). anti-hpa- a was antibodies were detected by maipa in women (two delivered tweens). in addition, anti-hpa- a antibodies were later detected by paklx in further women who delivered baby with severe thrombocytopenia and/or ich. total number of immunized mothers was ( . %). they delivered babies; were boys. three women were treated by ivig: two by and injections since th and th gw respectively. the anti-hpa- a concentration in the st one was . ; . ; . iu/ml in , , gw respectively and in the nd < . iu/ml in all examined samples. the decision on treatment was based on the low plt count~ g/l in the fetus in cordocentesis. their newborns (one delivered tweens) were healthy. the rd treated woman entered the program in gw (anti-hpa- a concentration was high . iu/ml). she obtained one injection of ivig. her baby was born with mild thrombocytopenia with no ich. severe fnait occurred in / newborns: in with anti-hpa- a detected in paklx only and in with antibody concentration in maipa - st : . / . / . at / / th gw respectively; nd : . / . at / th gw respectively. ich was observed in all of them; plt count was < x in four, / in one. summary/conclusions: / the severe thrombocytopenia due to anti-hpa- a alloimmunisation in our prospective study occurred in / pregnancies / the paklx could improve anti-hpa detection in the screening program and should be considered as an additional diagnostic test, if maipa result is negative / the hpa- a alloimmunisation frequency is higher in pregnancies with male than female fetus. background: foeto-maternal platelet alloimmunization (fmpai) is mainly characterized by foetal and / or neonatal thrombocytopenia (fnait), sometimes revealed by intracranial hemorrhage (ich) or even by foetal death in utero (fdiu). the experience of the pnil milwaukee (usa) reported in that the diagnosis of alloimmunization was carried in only % of neonatal thrombocytopenia cases with a clinical symptomatology highly suggestive of an alloimmune etiology. aims: the aim of this two-year study was i) to determine the frequency of platelet incompatibilities in fnait, ich and fdiu and ii) to evaluate the frequency of detectable platelet alloantibodies (alloab) and their specificity in cases of incompatibility. methods: platelet genotyping was performed by hpa beadchip genotyping kit (bioarray solutions, immucor, warren, nj). serology investigation was carried out by different methods: complete maipa kit (apdia bvba, turnhout, belgium), pack lxtm assay (immucor gti diagnostics, waukesha, wi) and « in house » maipa. all and data were collected using the laboratory information management system. results: patient files were analyzed. no incompatibility is demonstrated in hpa- to - , - and - systems in . % (n = ). hpa- and / or and / or incompatibilities were found in cases ( . %), hpa- and / or in cases ( %). platelet alloimmunization was globally confirmed in only . % of the cases. platelet alloabs were identified regardless of clinical manifestations: anti-hpa- a ( . %), anti-hpa- b ( . %), anti-cd ( . %), anti-hpa- a and anti-hpa- b ( . % respectively) and anti-hpa- b and anti-cd ( . % respectively). alloabs were found in the context of neonatal thrombocytopenia, in ich and in fdiu, and in a follow-up of pregnancy. even if no anti-hpa- alloab could be identified, the incompatibility in this system was highly associated with fnait, ich and fdiu (n = , n = and n = on cases). summary/conclusions: this study strongly confirmed the known immunogenicity of some hpa systems and highlighted overall the severity of hpa- and hpa- incompatibilities. the definite diagnosis of fmpai is difficult to make due to the present technical difficulties in the detection of antibodies against the hpa- and hpa- systems. however, our results suggest that special attention should be paid to the management of pregnancies with these incompatibilities due to the frequency of severe foetal/neonatal adverse events. background: fetal and neonatal alloimmune thrombocytopenia (fnait) is a potentially life threatening disease caused by maternal alloantibody formation against fetal human platelet antigens (hpas), of which anti-hpa- a is accountable for the fast majority of the cases. population-based screening for fnait has been topic of debate for over decades. logistically as well as financially, the major challenge of such a screening is the typing of pregnant women to recognize the % hpa- a negative women. at present, hpa- a typing is mostly done by genotyping. for costeffective implementation of anti-hpa- a screening there is need for a high-throughput, quick and low-cost phenotyping assay. aims: the aim was to develop a high-throughput, quick and low-cost phenotyping assay in order to identify hpa- a negative pregnant women. methods: an automated sandwich elisa was developed to perform hpa- a phenotyping using a murine monoclonal anti-gpiiia as coating antibody and horseradishperoxidase-conjugated recombinant igg anti-hpa- a as detecting antibody. to ensure the applicability for high-throughput testing in a potential screening setting, ll of the uppermost plasma of - days-old stored edta anticoagulated blood tubes was used, without first swirling or spinning them. in two phases, samples of pregnant women were tested and compared to an allelic discrimination polymerase chain reaction assay as golden standard. in the first phase, samples from unselected consecutive pregnant women were tested. the second phase was part of a prospective screening study in pregnancy and confirmatory genotyping was restricted to samples with an arbitrary set od < . in the hpa- a elisa. the developed elisa was optimized to require no additional handling (swirling or spinning) of stored tubes. during phase i, consecutive samples were tested. in phase ii, the hpa- a elisa was performed in another , consecutive samples, with confirmatory q-pcr in , . the two phases combined, samples from in total , hpa- a negative and hpa- a positive pregnant women were genotyped. the assay reached a % sensitivity with a cut-off od between . and . , leading to a specificity of . %. summary/conclusions: a quick, low-cost and reliable assay for hpa- a phenotyping was developed that can be used in a population-based screening setting to select samples that has to be tested for the presence of anti-hpa a antibodies. because plasma from non-mixed or spinned tubes of three to six day-old samples can be used, this assay is applicable to settings with suboptimal conditions. background: cytomegalovirus (cmv) sero-prevalence in ireland is lower than that which is reported in many other european countries. a study of pregnant women in found that . % of irish women were cmv seropositive in comparison to % from western europe and % eastern europe and % from africa. an internal study carried out by the irish blood transfusion service (ibts) in indicated the rate of cmv seropositivity in irish blood donors was . %. therefore a significant proportion of the irish donor and recipient population are susceptible to primary cmv. this is of particular concern for patients for certain at-risk groups such as very-low birthweight cmv seronegative neonates, cmv seronegative patients undergoing transplantation and other cmv seronegative immunocompromised patients. this results in a demand for the provision of cmv sero-negative blood components. in the ibts evaluated the abbott alinity s cmv igg assay as a replacement for the cmv mastazyme eia (total ab eia). aims: to assess the performance of the abbott alinity s cmv igg screening assay in comparison to the cmv mastazyme eia (total ab eia). methods: diagnostic sensitivity was determined by testing confirmed cmv igg positive donors from an external laboratory. sensitivity was assessed using three seroconversion panels (n = ). analytical sensitivity was calculated using linear regression analysis of the who first international standard for anti-cmv igg. diagnostic specificity was determined by testing donors. further evaluation of discordant results was carried out using the architect anti-cmv igg and igm assays and vidas anti-cmv igg and igm assays. results: the diagnostic sensitivity of the alinity s anti-cmv igg assay was determined to be %. the seroconversion sensitivity reported out of samples reactive. the analytical sensitivity of the alinity s cmv igg assay was determined to be . iu/ml. the validation reported discordant results from donor samples tested with both the alinity s cmv igg assay and the current mastazyme total assay. discordant results were observed (alinity s anti-cmv igg positive/mastazyme total negative). further testing of these samples classified discordant results as positive, as negative and as indeterminate. discordant results were observed (alinity s anti-cmv igg negative/mastazyme total positive). further testing classified these samples as negative. overall the diagnostic specificity was determined to be . %. summary/conclusions: both the seroconversion and analytical sensitivities are comparable between the alinity s cmv igg assay, the cmv mastazyme total ab assay, the architect cmv igg assay and the vidas igg assay. the slight variations can be attributed to the individual assay cut-off definitions, which can vary greatly between cmv assays. it must be noted that the determination of the diagnostic specificity ( . %) does not include indeterminate discordant results. further testing will be carried out to try to characterize all discordant samples in collaboration with abbott. this evaluation did not identify any donors with isolated confirmed cmv igm antibodies in a pool of donors. based on this evaluation the abbott alinity s cmv igg assay is a suitable replacement to the mastazyme total ab assay for blood donor screening. background: africa has a unique set of challenges regarding safe blood transfusion. two of the largest contributing factors are: ) the most common disease states in sub-saharan africa (ssa) require large amounts of blood as lifesaving interventions e.g. malaria, ) the highest burden of infectious diseases transmissible through transfusion (tapko, toure, & sambo, ) is found in ssa. this has often led to the binary donor base that exists in ssa, consisting of voluntary non-remunerated blood donors (vnbd) and family or replacement donors (frd) as transfusion centres are unable to supply the demand when relying only on vnbd. voluntary non-remunerated donors are the safest blood donors as they have no incentive (other than altruistic motives) and are not under social pressure to donate, both factors that may induce individuals knowing or suspecting themselves to be infected with a blood-borne agent to donate blood. nucleic acid testing (nat) in conjunction with serological testing is the gold standard for testing, however, the vast distances and high temperatures of africa makes transport of traditional plasma samples a logistical challenge. many publications evaluating the stability, suitability, and ease of use of dried blood spots (dbs) for nat have been published. generally, results have been shown to be comparable to traditional plasma samples. dbs is being used successfully in the early infant diagnosis (eid) programs for hiv by means of pcr testing, especially in africa. aims: . to demonstrate that dbs and/or dried plasma spot (dps) testing is suitable for blood donor screening and can make nat testing more widely available in africa . to determine the diagnostic sensitivity and specificity of testing dps and dbs samples, in comparison to testing of plasma samples. methods: negative new donor samples and confirmed positive donor samples, as defined by routine blood safety screening done at western cape blood service, were screened using a dried blood spot kit. after routine testing was completed, one dbs sample and one dps sample for each blood donor were prepared and analysed with the ultrio elite assay on the panther analyser. summary/conclusions: dbs/dps can be used as a sample for screening blood donors as the invalid rate was . %, and only found on dbs samples. logistically dbs/dps is well suited for the resource-poor countries as samples are: -easy to obtain (fingerpick samples could be used.) -transport is simplified as samples will not leak or haemolyse due to high temperatures. -samples can be stored at room temperature dbs/dps demonstrated acceptable specificity. the ultrio elite performed well with regards to hiv and hcv sensitivity. sensitivity with regard to hbv was not as high but this could be due to very low and erratic viral loads. background: sanquin blood supply is responsible for the blood transfusion services in the netherlands. at the national screening laboratory sanquin (nss) annually more than . blood and plasma donations are tested, on average . samples per day. for more than years, infection serology testing was performed using the prism (abbott diagnostics), but since mid of july , serological testing for the hbsag, hiv ag/ab, anti-hcv and anti-hbc is done with abbott's alinity s system. aims: to compare the numbers of initially and repeatedly reactive results of whole blood and plasma donation samples and the rate of non-specific results leading to deferral of donations and donors for prism and alinity s assays using data from months before and months after implementation of the alinity s systems at nss. methods: initial and repeat reactive rate of the assays run by either prism (hbsag, hiv o plus, hcv) or alinity s (hbsag, hiv ag/ab combo, anti-hcv,) were calculated for january to june (prism) and august to december (alinity s). due to the lack of a true confirmatory method for anti-hbc, we only compared the rate of repeatedly reactive results for prism hbc and alinity s anti-hbc. results: the rate of repeat reactive results for prism (p) and alinity s (a) assays were as follows: ) hbsag p . % ( / . ) versus a . % ( / . ); ) hiv p . % ( / . ) versus a . % ( / . ); ) anti-hcv p . % ( / . ) versus a . % ( / . ). the rate of anti-hbc reactive samples was not significantly different between prism ( . %) and alinity s ( . %). over the study period, the rate of initially reactive samples for the three main screening assays (hbsag, hiv, hcv) was also comparable between alinity s ( . %) and prism assays ( . %), mainly attributable to a rather high number of initially reactive alinity s hiv ag/ab results. this was due to initial issues with blood collection tubes that were resolved. as a result in december, the rate of initially reactive samples decreased to . %, which was significantly lower than for the three prism assays ( . %). summary/conclusions: the introduction of the alinity s assays lead to a decrease of the average repeat reactive test results (hbsag, hiv, hcv) by . % as compared to the prism, mainly due to a lower false reactive rate of the alinity s anti-hcv assay. this will be further investigated for first time and multiple time donors. with the implementation of the alinity s at sanquin we aimed to improve not only the operational efficiency but also to further minimize unjustified disapproval of donors. these first data show that the low initial and repeat reactive rates of the alinity s assays indeed have a positive impact on unnecessary deferrals of donations and donors. background: in blood banks, testing all blood donations for markers of infectious diseases plays an important role in maintaining the safety of blood transfusions. mandatory serological testing in switzerland is performed for anti-hcv, hiv ag/ab, hbsag and syphilis. highly specific and sensitive tests with corresponding automation are essential for this purpose. aims: a comparative study was carried out to evaluate the usability of the newly launched alinity s system (abbott) and the specificity of the infectious disease parameters hbsag, anti-hcv, hiv combo and syphilis (abbott) with the currently used elisa methods on the quadriga befree system (all diasorin, formerly siemens healthcare diagnostics). methods: the study took place at the interregional blood transfusion service in berne, switzerland. the specificity of the parameters was studied on , blood donor sera from both first time and repeat donors. the samples were tested first on the quadriga be free system with enzygnost hbsag . , enzygnost anti-hcv . , and enzygnost hiv integral assays and on the pk with the newbio-pk tpha assay (newmarket biomedical). all samples were retested on the same day with hbsag, anti-hcv, hiv combo and syphilis on the alinity s. initial reactive samples were repeated in duplicate. discriminatory tests were carried out for repeatedly reactive samples using alternative screening tests and neutralisation (for hbsag) on an abbott architect i system and immunoblots (hiv-, hcv-, syphilis-inno-lia, fujirebio). for all samples, results from our routine individual donation nucleic acid testing (hcv, hiv, hbv, roche cobas system) were available. results: based on the results from testing , blood donations, the observed specificities of alinity s assays (a) and enzygnost assays ( summary/conclusions: the alinity s system was easy to use by the operators after a very short introductory training and provides good operational efficiency such as high throughput even when selective testing for samples is needed. the observed specificity of abbott alinity s versus siemens enzygnost assays is comparable in a blood donor screening setting. unfortunately, we were not able to analyse statistically the specificity data due to the insufficient number of donor samples tested in parallel. it is worth mentioning that around % of the samples included in the study derived from repeat donors who had been previously tested with the enzygnost assays but were "first time donors" for the alinity s assays. all four assays from both systems exhibit a very good specificity and are highly suitable and practicable for routine blood donor screening. background: effective screening for transfusion-transmissible infections is essential to ensure safe blood transfusions. the world health organization recommends mandatory serological testing of blood donations for human immunodeficiency virus (hiv), hepatitis b (hbv)/c (hcv), and syphilis. due to increasing demands on clinical laboratories, there is a need for reliable and accurate automated blood screening tests. the fully automated cobas e analyser can be used with elecsys â infectious disease parameters to screen donor blood samples. aims: to compare the performance of elecsys â infectious disease parameters on the cobas e analyser (roche diagnostics) with other commercially available assays for routine first-time blood donor screening. methods: we provide results from etablissement franc ßais du sang (montpellier), a blood bank which participated in a large, multicentre study of the cobas e analyser. the following infectious disease marker assays were compared: hiv, elecsys â hiv duo versus prism hiv o plus; hcv, elecsys â anti-hcv ii versus prism hcv; hbv surface antigen (hbsag), elecsys â hbsag ii versus prism hbsag; hbv core antigen antibodies (anti-hbc), elecsys â anti-hbc ii versus prism hbcore; syphilis, elecsys â syphilis versus newbio pk tpha assay. specificity was tested using residual fresh serum samples from unselected first-time blood donors, and calculated according to assay package inserts and site-specific cutoffs. samples were tested using comparator assays, then retested the same day using elecsys â assays. initially reactive samples were repeated in duplicate; confirmatory tests were conducted on repeatedly reactive samples. confirmatory tests: hiv, nucleic acid testing (nat), architect hiv ag/ab and inno-lia â hiv i/ii score assays; hcv, nat, archi-tect hcv and inno-lia â hcv score assays; hbsag, nat, architect hbsag and elecsys â /prism hbsag confirmatory assays; anti-hbc, nat, hbsag, anti-hbs, and architect anti-hbc assays; syphilis, architect syphilis tp and inno-lia â syphilis score assays. sensitivity was tested using preselected, anonymised, positive, citrate-phosphate-dextrose-plasma samples (plasmatec laboratory products) and compared with archived data for comparator assays. sensitivity was calculated according to the final nat result. results: across all infectious disease markers, specificity to detect repeatedly reactive samples using elecsys â versus comparator assays was similar ( . - . % versus . - . %; n ≥ ). in specificity analyses, there were discrepant results for hiv testing, for hcv, two for hbsag, eight for anti-hbc, and five for syphilis. sensitivity of the elecsys â hiv duo assay ( . %; % ci . - . ) was higher than the prism hiv o plus assay ( . %; % ci . - . ), but the difference was not statistically significant. sensitivities of elecsys â and comparator assays were the same for hcv ( . %; % ci . - . ), hbsag ( . %; % ci . - . ), anti-hbc ( . %; % ci . - . ), and syphilis ( . %; % ci . - . ); three hcv and six anti-hbc samples were classified negative/ indeterminate and excluded from the analyses. in sensitivity analyses, there were two discrepant results for hiv testing, three for hcv, and five for anti-hbc. summary/conclusions: elecsys â infectious disease parameters on the cobas e analyser demonstrate high specificity/sensitivity for screening first-time blood donor samples, with similar clinical performance to other commercially available assays. background: individual plasma and serum specimens from whole blood or plasmapheresis donors are tested for absence of infectious agents by serological assays prior to use for transfusion or production of blood derived therapeutics. the department of plasma analytics (pa), takeda (austria), and haema ag, grifols (germany), both labs with high throughput and a high level of automation, were seeking for alternatives to replace their current serological test systems (abbott prism next). aims: to allow a direct comparison of the two final candidate analyzers alinity s (abbott) and cobas e (roche diagnostics gmbh), a side by side evaluation was carried out by the pa and haema with support from abbott and roche (provision of instruments and reagents). the aim was to compare assay specificities as well as handling and performance of the instruments. the outcome should be used to better understand potential specificity differences and practical handling aspects (throughput, etc.) of a next generation serological analyzer. methods: the two candidate instruments were installed in the pa. from march to june , close to , aliquots from routine preselected repeat donors, provided by haema, were run on both study instruments in parallel. plasma samples were tested for hbs antigen (ag), hcv antibody (ab), hiv ag/ab, and partially for syphilis ab. serum samples were additionally tested on hbc ab. samples with repeat reactive results ("rr", two reactive results out of three tests) not confirmed by confirmatory tests were counted as false reactive. the necessary sample size was calculated based on a one-sided comparison of proportions with the aim to detect potential specificity differences (a = %) in the size of those specified by the manufacturers' instructions. two different lots were tested for the three main assays. results: out of , plasma and , serum samples, test results representing individual donations were found rr on one or both instruments. two samples were confirmed positive ( hbsag, hcv), two others were indeterminate. the sample containing low level antibodies against hcv was pcr negative and only detected by the roche system. the percentage of false reactive results for the five assays on the two systems were (alinity s/e ): hbs ag: . / . % in a total of / samples tested; hcv ab: . / . % in / , p < %; hiv ag/ab: . / . % in / , p < %; syphilis ab: . / . % in / ; hbc: / % in / . no significant difference was found between the calculated specificities in our study and the manufacturers' data. a potential influence of sample matrix and kit lots was assessed. a trend towards more false reactive results in serum vs plasma was found for nearly all assays. no clear-cut statistical difference was seen between lots. summary/conclusions: the study results are in line with the manufacturers' specificity data, showing that the alinity s hcv ab and hiv ag/ab assay show a slightly higher specificity in a population of plasma and serum samples from repeat donors prescreened by prism. a possible influence on the test specificity by the sample matrix was detected but needs further investigation. the possibility to edit complex genomes in a targeted fashion has not only revolutionized basic research but biotechnological and therapeutic applications as well. with the rapid development of genome editing tools, in particular zinc-finger nucleases (zfns), transcription activator-like effector nucleases (talens), and the crispr-cas system, a wide range of therapeutic options have beenand will bedeveloped at an unprecedented speed. therapeutic genome editing in hematopoietic cells enable new interventions in the blood and immune system, including novel approaches to treat immunological disorders, infectious diseases, and cancer. we have developed gmp-compliant protocols to manufacture gene edited cd + hematopoietic stem and precursor cells (hspcs) as well as chimeric antigen receptor (car) t cells, with the final goal to provide novel cell therapies for patients suffering from primary immunodeficiencies, chronic infection with human immunodeficiency virus type (hiv- ), and some tumor entities. despite great success in improving their specificity, engineered designer nucleases can induce genotoxic side effects by introducing mutations or chromosomal aberrations. we have established novel genome-wide assays that enable us to detect chromosomal aberrations induced not only by off-target activity but also by on-target activity, such as micro-aberrations and translocations, with unparalleled sensitivity. in toto, our developed protocols allow us to achieve genome editing in hematopoietic cells with high efficiency and to assess the genotoxic risk associated with the expression of crispr-cas nucleases and talens in clinically relevant human cells, so forming the basis for planned phase i/ii clinical studies. adoptive t cell therapy (act) has proven a potent means to treat blood-borne tumors and solid tumors. adoptive cell therapies include t cells that are genetically engineered with tumor specific t cell receptors (tcrs), or with chimeric antigen receptors (cars). in addition, tumor infiltrating cells (tils) can be isolated from tumor lesions, which are then expanded and reprogrammed in vitro prior to transfusion into the patient. the anti-tumoral efficacy of act products depends on several parameters, including the capacity of cd + t cells to produce cytokines, chemokines and granzymes, a feature that is critical for effective anti-tumoral responses. here i will discuss our efforts to develop and improve act products for future clinical use. i will present pre-clinical work on developing til therapy for non-small cell lung cancers. in addition, i will show that human cd + t cells can be divided into different subsets, and that only one of those subsets is highly cytotoxic. this finding may help improve the quality of genetically engineered t cell products, like tcr and car t cell products. background: the baltic states -estonia, latvia and lithuania have a lot in common. we are located side by side, share the baltic sea as a gate to the west, and more importantly, a common history. we were members of the ussr and suffered years of soviet occupation. we held hands in a km long human . . .chain" across the three states to express our mutual support, and later on, even joined the european union on the very same day -june st , . the three differ a bit in size, population and more in the languages spoken in each one, but that does not explain why the path towards voluntary unpaid donation varies as it does. aim: the aim is to describe the journey towards voluntary non-remunerated blood donation in the baltic states after regaining independence from the soviet union. methods: the information was collected from published and unpublished memories, annual reports and written interviews with latvian and lithuanian colleagues. results: in soviet times, all orders came from moscow and quality control was conducted from the capital city of latvia, riga. donors were mostly paid and given an extra vacation day. big factories were the best places to collect blood and people were queuing to donate. in , the soviet union fell apart and the baltic states suddenly got the freedom and responsibility to decide. in estonia the first edition of "guidelines for the preparation, use and quality assurance of blood components" was taken as guidance in . a lot of advice came from finnish colleagues. in , it was decided to move towards non-paid voluntary donations. the process took years. the first couple of years were economically difficult for the reborn state, as money had less value than food. instead of cash, donors were given rapeseed oil, sugar and pasta, for example. as the situation improved, food items were replaced by small symbolic gifts that carry sentimental value. it has been this way for more than years by now. in lithuania, the process started later, the first program for developing a framework for voluntary non-remunerated donations being carried out in - . it resulted in % of the donations being unpaid. the second program initiated in is still ongoing, aiming towards % non-remunerated donations by . by the end of , they had reached . %. in the beginning, the main obstacle was a private blood center creating unfair market conditions. in latvia, monetary compensation for blood donations still exists, but the younger generation has been encouraged to donate blood for free and some results can already be seen. summary/conclusions: a common starting point does not guarantee the same results, at least not at the exact same time. examining the circumstances leading to the different outcomes could benefit countries yet to start moving towards non-remunerated donations as well as those considering the opposite. haemoglobin (hb) was as expected significantly different between women and men (meanaesem: . ae . vs . ae . g/dl; p < . ). percentage of females with low hb < . g/dl were . %, . %, . %, . % and . %, percentage of males with hb < . g/dl were . %, . %, . %, . % and . % for the age groups - respectively. ferritin values were higher in males compared to females (median; th - th %>tile: ; - vs ; - lg/l; p < . ) and in older age groups compared to younger age groups (median; range in age groups - in females: ; - , ; - , ; - , ; - , ; - and in males: ; - , ; - , ; - , ; - , ; - respectively) . percentage of females with ferritin ≤ lg/l were . %, . %, . %, . % and . %, while percentage of males with ferritin ≤ lg/l were . %, . %, . %, . % and . % for the age groups - respectively. white blood cell counts (wbc) were slightly higher in females compared to males (meanaesem: . ae . vs . ae . ; p < . ). percentage of females with wbc > x /l were . %, . %, . %, . % and . %, while percentage of males with wbc > x /l were . %, . %, . %, . % and . % for the age groups - respectively. none had wbc < x /l. platelet counts (plt) were higher in females compared to males (meanaesem: ae . vs ae . ; p < . ).percentage of females with plt < x /l were . %, . %, . %, . % and . %, while percentage of males with plt < x /l were . %, . %, . %, . % and . % for the age groups - respectively. among the low plt counts most were caused by edta-dependent pseudothrombocytopenia. extreme deviations from normality were seldom and referred to gps for further investigations. summary/conclusions: first time donors are young with % younger than years of age and the female/male ratio was / . of the first time donors with data on ferritin available, % had low ferritin (≤ lg/l). the typical male first time donors neither had low hb nor low ferritin, even with a significantly lower ferritin in younger donors. in female first time donors the prevalence of low hb ( %< . g/dl) and low iron stores ( %≤ lg/l) is high. in all, while all first time donors are highly appreciated, campaigns could target the male population to even out the gender imbalance. blood centers must be aware of the higher prevalence of low iron stores in the youngest donors. background: the aim of assessing suitability of prospective blood donors is protection of their health and the safety of transfused patients. selection process is not always effective in obtaining all relevant information from blood donors in a timely manner. for several reasons, some risks remain undetected or they are disclosed at a future donation(s). therefore, recording and management of post-donation information (pdi) are of great importance for improvement of transfusion safety, donor counselling and education as well as overall improvement of the selection process. aims: the aim of the study was to present results of pdi management at croatian institute of transfusion medicine (citm) and the effect of education activities on their trends. methods: we have analyzed reports on pdi recorded in two-year period ( - ), according to the types of information obtained, age and sex of blood donors, total number of their donations preceding pdi, and the time of receiving the information. the effect of an information leaflet on pdi launched in november was assessed by comparing results in two study years. results: a total of pdi were recorded: in ( / donations) and in ( / donations) with the following distribution: nonsexual risk as tattoo and piercing ( . %), surgical procedures ( . %), travel history ( . %), infections/ contact ( . %), other medical reasons ( . %), endoscopy/invasive diagnostic procedures ( . %), malignancy ( . %), autoimmune diseases ( . %) and sexual risks ( . %). majority ( . %) were late pdi, revealed on the future donation(s): . % on the first next donation, . % on the second and . % after more than subsequent donations. the mean age of blood donors associated with pdi was ae years (median years), while the mean age of all donors in / was years (median years). of all pdi, . % were related to male donors ( % in total pool of citm donors). using chi-square test there were no significant difference between female and male donors in total pdi frequency and in their distribution to early and late pdi (p > . ). the median number of all donations preceding pdi was for female donors and for male donors. implementation of education leaflet for blood donors resulted in . % reduction of pdi in compared with (p > . ). the effect is more pronounced (p < . ) when comparing second and first half of (- . %). reduction is observed in all types of pdi with the exception of infections/contact (because they are mostly early pdi) and malignant diseases. the share of early pdi increased from . % in to . % in , which may suggest better awareness of blood donors on the importance to inform blood bank on changes in their health status. summary/conclusions: our study points to the importance of systematic recording and management of pdi, including education of blood donors about the need of providing all relevant facts related to their health and the safety of donated blood in a timely manner. we are planning further improvements by providing information on this topic on posters and screens on donation sites. background: currently, the transfer of data between organizations and/or computer systems is very limited, and where present is typically proprietary. in the absence of a standardized reference format individual organizations and vendors attempting to integrate disparate databases must develop unique solutions. aggregation of information from multiple sources is complex and costly, constituting a significant barrier to effective analysis of data to improve practice and inform policy. aims: to standardize the definitions and facilitate integration of key data items used in blood donation and transfusion. we report here on an initial effort to map internationally harmonized critical steps in the blood collection/donation process in order to test the approach. methods: through a collaborative process of serial conference calls and correspondence, an informal multi-national consortium of experts across the transfusion industry are attempting to create a vocabulary with sufficiently precise definitions to be usable by automated systems and that can be the foundation of a blood collection/transfusion medicine common data model (cdm), using the following steps: -define the scope of activity to be addressed and segment into key processes. -identify the set of data elements in each segment that are common to all systems. -review and consider existing standards and definitions for each data element. -develop draft definitions for each data element. -release draft to public domain for critical review and refinement with long-term goal of gaining widespread endorsement. results: a standardized approach to blood donation was mapped through identification of common pathways and core mappable data elements. denominator data associated with donor characteristics and blood collection was selected as the first segment to address. a dictionary (or vocabulary) of common terms has been created and will be presented for international comment. summary/conclusions: developing an international consensus on the core elements and their definitions across the transfusion chain is critical for data integration and automation efforts. the expected benefits of this endeavor include that it allows the establishment of algorithms to automate reporting and thus reduce hands-on staff time; reduces time and resources needed to integrate new databases; allows systems to continue to use existing concepts and definitions internally while also providing data output in a standardized format; supports the ability to consistently analyse, interpret and present information regardless of the data source; establishes data definitions against which new systems can be developed; helps to improve comparability of results by providing a common data model for researchers and policy makers; improves confidence in data integrity and reliability of the derived information as a © the authors vox sanguinis © international society of blood transfusion vox sanguinis ( ) (suppl. ), - basis for rational decision making; and reduces data gathering effort and cost thus improving opportunities for more efficient/complex data analysis. standardizing the transfusion medicine dataset is the first step in achieving the automation of data transfer and analysis needed globally to drive patient safety, research innovation, and best business practices. further steps must address the precise methods of data exchange, identification of responsible entities for maintenance and further development, and engagement of computer system developers. red blood cell (rbc) alloantibodies develop in a subset of individuals following exposure to non-self rbcs through transfusion, pregnancy, or other activities; these antibodies can lead to difficulty locating compatible rbcs, acute or delayed hemolytic transfusion reactions, or hemolytic disease of the newborn. alloimmunization is underestimated due in part to antibody evanescence, the random nature of posttransfusion antibody screens, fragmented medical care, and the lack of widespread antibody registries. factors that influence who will develop detectable alloantibodies are not well understood. transfusion burden is one risk factor for alloimmunization, though many highly transfused individuals never form alloantibodies despite exposure to many rbc units (and many non-self abo blood group antigens). individuals with sickle cell disease (scd) and myelodysplastic syndrome (mds) are more likely to form rbc alloantibodies than most other patient populations. individuals with rheumatologic and other forms of autoimmunity, though not chronically transfused, are also at higher than average risk of forming rbc alloantibodies. inflammation, in a broad sense, is one common thread among these diagnoses associated with high prevalence rates of rbc alloimmunization. reductionist murine models support some types of inflammation (including viral-like stimuli) around the time of rbc exposure as being associated with an increased likelihood of alloantibody formation. strategies other than transfusion avoidance or extended antigen matching beyond abo/ rh would be beneficial to prevent new rbc alloantibody formation, especially in patients at highest risk. background: the unique genetic makeup of the omani population makes them rich in the genetic blood disorder. % of omani populations are Àa/Àa gene carriers, % Àa/aa, and % of the population are aa/aa. around % of omani nationals carry the gene for hbs, and - % carry the gene for b-thalassaemia. recent statistics show that there are around patients with thalassaemia major and with scd in oman. the other rbc abnormality that is common in oman is g pd deficiency which is found in % of males and % of females. omanis are known to have the highest frequency of a thalassaemia and g pd reported so far in any race. although blood transfusion is one of the supporting treatments of scd, it can cause some serious complications for the patients. alloimmunization of red blood cells is one of the consequences of blood transfusion. alloimmunisation of the rbcs can cause haemolytic transfusion reactions and may trigger hyperhaemolysis, in which transfused and patient's own rbcs are destroyed. alloantibodies can cause delay in the process of transfusion, it can be costly and time consuming. high number of patients developing alloantibodies may indicate a major difference in the patient and donor population. it may also indicate lack of a controlled, generalised sickle patients management policy. in oman the decision of transfusing scd patient is left to physicians attending the patient. aims: this study is aimed to highlight the increasing number of alloimmunised sickle cell patients. in the royal hospital we get new cases of sickle patient with alloantibodies each year. the acknowledgement of these cases may help in is assessing the current practice of transfusing scd patients, or will help to define the donor and patient population difference. methods: patients were recruited in the royal hospital for this study. edta blood samples were taken for antibody screening test and in the positive cases antibody was identified, all tests done by capture technique using immucor neo machine. results: of the scd patients, % of the patients were male and % female, mean age was years, in the range of - years. % of the scd cases were positive for the alloantibodies, % were female and % were male, the age range was from - years. % of the positive were scd, % s trait and % were s/ bthal. most of the patients developed one antibody, however cases of multiples antibodies were also detected. % of the patients were with single alloantibody, % of them with two antibodies, % with three antibodies, % with four antibodies and % with five antibodies. the majority of the cases were igg against rh antigens anti-e is being the majority %, followed by anti-d %, anti-k %, anti-c %, anti-c %, anti-jk a %, anti-jk b %, anti-fy a %, anti-e %, anti-s %, antis %, anti-kp a . %, anti-fy b . % and igm being %. summary/conclusions: rbc alloimmunisation rate is high in oman majority of the patient affected are female. interestingly sickle trait patients were also transfused and % of them developed alloantibodies. the practice of transfusing rh and kell matching blood unit is implemented four years ago and still high alloimmunization percentage is achieved. background: in ghana, routine pre-transfusion investigations for patients with sickle cell disease (scd) involve only abo-d typing and immediate spin crossmatch, without screening for irregular rbc antibodies aims: determine the prevalence and specificities of and risk factors for rbc alloantibodies in multi-transfused patients with scd methods: in , a cross-sectional study in multi-transfused patients with scd, from two tertiary hospitals in ghana was performed. participants' data on demography, transfusion and medical history were recorded. antibody screening and identification tests were done at sanquin, the netherlands, with standard serology using liss as enhancer and with papain treated rbc panel cells ('enzyme only'). characterization of rhd genes was done by multiplex ligase amplification assay. logistic regression was used to determine the association of patient characteristics, i.e. sex, age at enrollment (continuous), age at first transfusion (categorized as ≤ , - , - and ≥ ), previous pregnancy, number of transfused units ( , - and - and > ), and years after last transfusion (< , - , - , > y) with presence of alloantibodies results: patients ( males and females, median age years, range . - ) were included. the median number of transfusions was (range - ). the median years after last transfusion was (range weeks- . years). in patients, anti-rbc antibodies were detected. in of them the antibodies were weakly reactive with enzyme treated cells only or pan-reactive, possibly some of them representing autoantibodies or antibodies against high frequency antigens. in seven patients enzyme-only anti-le a was demonstrated, likely naturally occurring antibodies. thus, in at least patients ( . %) alloimmunization was demonstrated or suspected; in patients the alloantibodies were 'enzyme only'. besides, the alloantibodies of known specificity ( anti-d, anti-d+c, anti-e, anti-c, anti-e, anti-k, anti-s, anti-le a , anti-go a ), three antibodies reactive only with fy(a-b-) cells and two antibodies of yet unidentified specificity were detected. in six d-patients ( had been pregnant) anti-d (together with anti-c in two patients) was found. in three out of four d+ patients with anti-d, an rhd variant gene was demonstrated ( dau-alleles and diii type or diva- ). logistic regression revealed that none of the risk factors analysed was associated with the presence of antibodies in the patients. immunobiology -red cell alloimmunity fifty-eight patients, had experienced an adverse reaction during or shortly after transfusion ( patients had dark urine). adverse reactions were associated with the number of units received (or . ( % ci, . - . ; p = . ), but not with the presence of antibodies (p > . ) summary/conclusions: in at least % of multi-transfused patients with scd alloimmunization could be demonstrated, mainly ( %) directed against rh antigens. the enzyme only reactivity, coupled with absence of antibodies in seven of patients with probable haemolytic reaction and known evanescence of especially non rh antibodies suggest possible low titre and disappearance of some clinically relevant antibodies. given the high immunization rate together with the high frequency of adverse transfusion reactions, pre-transfusion screening for rbc antibodies should be considered for patients with scd. background: rh blood group system and mainly antigen d is one of the most immunogenic, diverse and clinically important protein-based blood group. antibody anti-d may induce hemolytic transfusion reactions and hemolytic disease of the fetus and newborn. anti-d prophylaxes become ineffective if an anti-d immunization has occurred. approximately % of the d+ population carries rhd alleles associated with reduced d antigen expression. qualitative variants, in which some epitopes are lacking and can produce anti-d antibody, are usually termed partial d. by contrast, d weak is commonly defined as a quantitative variant that have all d epitopes and should not make anti-d. del is a very weak form of d antigen and cannot be detected by routine serological tests. because some of del individuals have already developed an anti-d antibody whereas others did not this group contains both qualitative and quantitative changes. aims: investigation was prompted by finding discrepant results in typing of d antigen in a pregnant woman / rd pregnancy, st delivery, abortions in st trimester/. routine serological techniques detected d negativity and the presence of antibody allo-anti-d in clinically significant titre. the non-invasive testing of d status of the foetus from maternal peripheral blood was indicated, but this was not applicable due to presence of the rhd gene in the woman's dna sample isolated from buccal swab. our aim was to investigate the discrepancy and determine the underlying rhd genotype. methods: blood samples, dna from peripheral blood and buccal swab of the pregnant woman were investigated. routine blood grouping and antibody testing were performed by column agglutination. two anti-d sera (id-diaclon anti-d igg (cell line esd ) by biorad and anti-d duo igm+igg, clone: th + ms by immucor) were used for adsorption/elution test for identification of del phenotype. initial rhd genotyping was performed by rt-pcr (exons , , ) with the dna from buccal swab; further resolution was performed using pcr-ssp (fluogene; inno-train diagnostik gmbh); sequencing was performed by sanger analysis (inno-train diagnostik gmbh). results: genotype was identified as rhd positive by ce-certified pcr-ssp kits (fluogene). sanger sequencing of rhd from exon to revealed presence of a nucleotide deletion in position c. dela, which is specific for allele rhd* el. . this nucleotide change results in the amino acid change p.val leufs* causing the del phenotype. presence of antigen d was proved by adsorption/elution technique. titre of the anti-d was rising during the pregnancy to the level two weeks before the delivery. the newborn was delivered by s.c. without a sign of hemolytic disease. blood grouping of the newborn revealed blood group a, d negative, dat negative, testing for del was not performed. summary/conclusions: the case reported here shows that females with rhd* el. allele are able develop strong anti-d immunization, so this type of del phenotype belongs to the "partial del subgroup". presence of variant rhd gene in mother disabling antenatal fetal genotyping from maternal blood by current methods requires a more attentive approach to care for such pregnancies. supported by mh cz-dro uhkt and rvo-vfn . a-s - ea scharberg , s rothenberger , a st€ urtzel , n gillhuber , s seyboth , e richter , g rink and p bugert institute for transfusion medicine and immunohematology, drk-bsd ba-w€ u-he, baden-baden institute for transfusion medicine and immunology, heidelberg university, medical faculty mannheim, mannheim, germany background: rb a (di ) is a low prevalence antigen of the diego blood group system. it has been found in few families only. the clinical significance of anti-rb a is unknown so far. the slc a *c. c>t (p.pro leu; isbt allele name: di* . ) allele is the molecular basis of the rb a antigen. in the gnomad database this gene variant was found in only one of , sequenced genomes (allele frequency: . ). aims: to prove the frequency of the allele in our population and gain an rb a positive donor we performed a molecular screening for di in , blood donors. after our antibody screening test accidentally contained an rb a positive test cell we found out that anti-rb a is a very common antibody specificity. the frequency of the antibody in patients and blood donors was proved. methods: for the molecular screening of the blood donors we developed a pcr-ssp method. the antibody screening test in , patients and in blood donors was performed in the gel technique (biorad ahg id-cards) using a cell screening panel (drk-bsd src) including an rb a positive test cell. positive reactions with the rb a positive cell were confirmed by an additional rb a positive test cell of different source. additional antibodies were excluded or identified in the same method using an antibody identification panel (drk-bsd irc). results: the molecular screening for the di* . allele in , blood donors revealed no single positive individual. within the first weeks of usage of our antibody screening test which accidentally contained the rb a positive test cell patients with anti-rb a were found. it was . % of , patients tested in laboratories in different parts of germany. some laboratories stopped using the rb a positive lot to avoid expensive and time consuming identification and conformation tests. in of randomly tested blood donors ( . %) anti-anti-rb a was also present. summary/conclusions: despite the very low frequency of the di* . allele, anti-rb a is a very frequent unexpected antibody in patients and blood donors in germany. it is obviously naturally occurring and is even more frequent than anti-wr a and anti-vw we found in previous studies in around % of patients and donors. a-s - national blood center, ministry of health and sports, yangon, myanmar hemovigilance which detects every event not only for patient' reactions and donor's complications but also incidents and near misses definitely improve quality of blood transfusion services especially for those situations where implementation of all the standards in one time is not possible. healthcare system in myanmar is still in the stage of requiring priority for clinical professions and has limited resources for supportive roles. supportive services including transfusion service are still not a center of interest from prioritization of health care system. blood transfusion service has been practiced in myanmar since . real essence of transfusion service is hidden behind laboratory practice and transfusion is regarded as part of laboratory investigation. hospital laboratories take care of testing of blood donated by replacement donors. this kind of transfusion services under laboratory umbrella is still being practiced in myanmar except national blood center (nbc) which was established in in accordance with blood and blood product law. this law was formulated cohesively with who strategies of blood safety. in , who global data-based study sent questionnaires for assessment of safety status of transfusion service. nbc noticed that there was no data which can support corrective actions for safety. from that time onward, active retrospective review of existing data and introduction of records, prospective finding of process errors and any events from hospital blood banks were recorded and taking into actions at local level. cost of every unit of blood is supported by government. in , national blood and blood product committee was established. the steering committee is working hard to get cooperation from every service by aiming to prevent those undesirable events before establishment of national level policy, standards and guidelines for sustainable service quality. in conclusion, by using essence of hemovigilance as a tool, quality of transfusion service can be improved step by step to fulfil the gap in spite of limited resources. the system started in local, extends to regional level by getting agreement of importance from hemovigilance results and is finally approaching to national level endorsement. background: erroneous transfusion of abo-incompatible(aboi) blood almost always reflects a preventable breakdown in transfusion protocols and standard operating procedures and can have disastrous consequences, with significant morbidity and mortality. these incidents need to be investigated in a systematic manner to identify system vulnerabilities to mitigate risks and improve patient safety. since , reporters to shot have been asked to score( - ) the extent to which the cause of incidents can be attributed to key factors: staff, environmental, organisational and government/regulatory which helps recognise the key factors identified whilst investigating these incidents. aims: to understand why unintentional transfusion of aboi blood components continue to happen despite standard procedures and national guidance available. methods: retrospective analysis of unintentional transfusion of aboi blood components reported to shot between - (inclusive) was done to identify common themes and recognise areas of improvement. information provided using the shot human factors investigation tool (hfit) between - was reviewed to understand more about why the errors occurred. results: sixty-seven unintentional aboi transfusions were reported between - ; majority ( / , . %) were red cell transfusions but aboi plasma ( / ) and platelet transfusions ( / ) were also seen. most errors occurred in the clinical area ( / , %), and could have been detected at point of administration. in ( %) cases, the error could not have be detected at the point of administration with a primary laboratory error in / ( %) incidents. reviewing data from hfit for cases in - ( aboi cases), the total score for staff culpability was , compared to a total score of for all the other three organisational and system factors. this disparity is most obvious for the aboi red cell cases, all of which scored the maximum for staff culpability, i.e. / compared to / as the combined total score given to the other factors. in the preceding years ( to ), there were no hf scores available; however, the emphasis on staff-related culpability is demonstrated by cases that included an outcome of the local case review and ( . %) mentioned staff-related retraining or disciplinary procedures. the risk of haemolysis and serious harm is more likely with aboi red cells than with other components with / ( %) that resulted in death, / ( %) major morbidity and / ( %) no or minor adverse reaction. of these cases, one resulted in conviction for manslaughter and at least two staff dismissals. summary/conclusions: transfusion never events continue to occur, and it is evident that investigations into such incidents focus mainly on staff failings and do not consistently identify system wide changes that need to be incorporated to address prevalent issues. national recommendations and a safety alert to 'use a bedside checklist' immediately prior to administration were issued between - to support prevention of such errors but never events continue to persist. current approach is ineffective because it often leads to apportioning blame, rather than understanding the often-complicated and multidimensional factors contributing to the error. this must be replaced by a holistic approach which addresses local work pressures and embraces advances in automated technology like electronic prescribing and barcode scanning. of the confirmed trars, n = were possibly related to treatment, n = trars were probable, and n = were definitely related to treatment; n = trars were grade , n = were grade , and none were grade . in recipients of conventional wb, there were n = ( . %) ars, n = ( . %) fnhtrs, n = ( . %) taco, n = trali, and n = ( . %) unclassified transfusion reactions. of the confirmed trars, n = were possibly related to treatment, n = trar was probable, and n = were definitely related to treatment; n = trars were grade , n = was grade and n = was grade . there were mirasoltreated wb transfusions in pregnant women and trars ( . %), both grade and probably related. there were transfusions of mirasol-treated wb and transfusions of conventional wb in patients < years old resulting in n = ( . %) trars in recipients of mirasol-treated wb and n = ( . %) in recipients of conventional wb. summary/conclusions: timely data reporting of trars and expanding the hv infrastructure has helped to improve the hv system in ghana. of wb transfusions in routine use in ghana, there were . % trars in recipients of mirasol-treated wb and . % in recipients of conventional wb. additionally, mirasol-treated wb was safely transfused in pregnant women and pediatric patients. haematology, monash health, melbourne, australia background: transfusion-associated graft-versus-host disease (ta-gvhd) is rare and usually fatal. it can be prevented by provision of irradiated blood products to at-risk individuals, such as those receiving nucleoside analogues, alemtuzumab, bendamustine or with hodgkin lymphoma (hl). duration of risk is uncertain, so ensuring these individuals correctly receive lifelong irradiated blood components, as currently recommended by anzsbt and bsh guidelines, is challenging. in australia, platelets are routinely irradiated, but red blood cells (rbc) are not. aims: to determine whether patients receiving fludarabine, cladribine, bendamustine, alemtuzumab, or dacarbazine (for hl), appropriately received irradiated rbcs. secondary outcomes included rates of ta-gvhd after unintended exposure to non-irradiated components, factors influencing correct issue of irradiated rbcs such as transfusion management plans, and provision of adequate clinical information on blood requests. methods: we performed a retrospective audit to identify patients receiving therapies indicating risk for ta-gvhd using pharmacy dispensing records from january to october at monash health, a multi-campus university hospital in melbourne, australia. diagnosis, treatment dates, group and hold (g&h) requests, rbc transfusions, and follow-up information were sourced from laboratory and medical records. results: we identified patients who received fludarabine (n = , %), bendamustine (n = , %), cladribine (n = , %), dacarbazine for hl (n = , %) and alemtuzumab (n = , %). the median age of patients was years (range - ) and ( %) were male. median follow-up was months (range - ). post-exposure, patients ( %) received transfusions with % correctly receiving irradiated rbcs. the remaining , all from haematology/oncology, received a total of unirradiated rbcs. in patients, this was rectified on subsequent transfusions. there were no cases of ta-gvhd at median follow-up of . months (range - ) from first rbc transfusion. after medication administration, patients had g&h requests after a median of months (range - ). only % of requests had sufficient clinical information to prompt irradiation, such as hl or medication details, and only % asked for irradiated components. preventive strategies have now been employed. transfusion management plans for haematology patients were implemented in march . for audited patients, these were written from days prior to days after medication exposure. two were written following inadvertent unirradiated rbc transfusion. patients identified in this audit will have a laboratory flag generated and prospectively, pharmacy dispensing records will be sent to blood bank to identify at-risk patients. our hospital is transitioning to electronic medical records (emr). an alert will be generated in emr when ordering transfusions if there has been exposure to these medications. however, clinical awareness and documentation remain vital. additional measures include patient education, alert cards, and ongoing collaboration with medical staff to encourage transfusion planning. summary/conclusions: recognition of patients at risk for ta-gvhd remains low, even among haematology units. we are making progress on ensuring provision of lifelong irradiated blood components in patients exposed to nucleoside analogues or alemtuzumab, as well as hl patients. implementation of an emr and additional strategies in this domain is important to prevent ta-gvhd. background: blood transfusion is considered an essential element in the management of patients globally. it might be risky and transfusion related adverse reactions may occur with the less adherence of transfusion policies. standard guidelines regarding the screening of blood for infectious disease, genuine need of transfusion and abo compatibility are followed and monitored drastically. however, patient assessment during transfusion especially at patient bedside and post transfusion is also equally important. aims: we are a newly established hospital and are working towards the best possible management of patients. in this regard to minimize the transfusion errors and to highlight if any lacking being practiced during transfusion, we conducted this study to observe the compliance rate of documentation of transfusion form by the healthcare staff and also to observe the compliance of line of action taken in case of occurrence of transfusion reactions. methods: this was a observational study conducted at nibd and bmt, pechs campus from february to february . ethical approval was obtained prior to the study. transfusion form for each transfusion was filled. the form provided information on documentation of blood product receiver name, employee identity number, date and time of receiving blood product, patient name, medical record number on units, on patient's wrist band and on transfusion form. abo compatibility on the unit and on form, medical record number from wrist band, name and employee identity number of two healthcare staff started transfusion, transfusion start and completion time. time, temperature, blood pressure, pulse and initials of staff at the time of order, onset, after minutes and at the completion of transfusion were also included. transfusion reaction form was also filled by the healthcare staff. data was analyzed by using spss version . . results: a total of transfusions forms were analyzed. over all compliance rate was %. out of , ( %) forms were available in source notes and of , ( %) were partially and completely filled. higher compliance was seen in the initial months of hospital establishment than later months (p-value = . ). highest non compliance was seen in documentation of initials of duty doctors on transfusion form at the completion of transfusion( %) and highest compliance was seen in documentation of name by healthcare nursing staff at the start of transfusion( %). a total of ( . %) adverse events were reported from red blood cells and platelets. mean time of start of symptoms was hours and minutes for red blood cells and for platelets it was hour and minutes. transfusion was instantly stopped as the symptoms appeared with no delay of time and actions were taken to resolve the reactions. time of appearance of symptoms and time of start of medication were documented and error free. all blood bags were returned to the blood bank and discarded after hours as per the policy of hospital. summary/conclusions: the study was conducted to highlight the scarce practices that are being implemented by healthcare staff in context of documentation and reporting of transfusion reactions at our hospital. stringent actions should be taken for the adherence of compliance by healthcare staff to avoid morbidities and mortalities. we believe that it will also be helpful to provide baseline information in the process of preparation of a national guidelines and protocol on blood transfusion procedures. a-s - as buser, a holbro and l infanti regional blood transfusion service, swiss red cross, basel, basel, switzerland to make blood supply safer, pathogen inactivation (pi) technologies have been developed. they are based on photochemical (amotosalen/uva or riboflavin/ uv) or uv-c light treatment to reduce potential pathogens in blood components. this gain of safety might however be offset by "off target" effects of these technologies. in virtually all clinical platelet transfusion trials, it has been demonstrated that post transfusion increments with pi platelet (plt) components are lower as compared to conventional components, indicating different biological behaviour such as survival/ clearance of nontreated and treated plt. published studies have also suggested shorter survival of platelets in vivo in animal studies. additionally, data of the rates of alloimmunization and refractoriness after transfusion of pi platelets are show discrepant results. animal studies suggest a reduction of the rates of alloimmunization when transfusing (leukoreduced) pi plt as compare to conventional plt. in the clinical setting, published data, including very recent reports, showed different rates of hla class i and ii alloimmunization with the two currently available photochemical based pi technologies. while pi of plt components surely benefit patients regarding pathogen safety, the impact of potential off target effects possibly impairing efficacy of pi plt transfusions need more investigation. background: brucellosis is an endemic disease and still a major health problem in saudi arabia. ministry of health in saudi arabia listed brucellosis as a notifiable disease due to its endemicity. in the last ten years, the incidence has decreased significantly to approximately cases per , but is still higher than that in developed countries. human-to human transmission is extremely rare including breast feeding, transplacental, sexually and blood transfusion. five cases of brucellosis through blood transfusion have been reported in the literature. brucella transmission through blood transfusion is likely underreporting due to the long incubation time of - weeks (range, days to months),vagueness of clinical presentation and lack of hemovigilance systems in endemic areas. (allohsct) and ( . %) autologous (autohsct) hsct patients, with mean corrected count increments (cci) of . , . and . , respectively. mean cci decreased in a linear fashion between day ≤ and day pcs ( . , . and . at ≤ days; . , . and . at days, respectively), although the number of pc transfused on day to autohsct patients was small (n = ). background: nipah virus (niv) is a paramyxovirus (genus henipavirus) that emerged in the late s in malaysia and has since been identified as the cause of sporadic outbreaks of severe febrile disease in bangladesh and india. niv infection is frequently associated with severe respiratory or neurological disease in infected humans with transmission to humans through inhalation, contact or consumption of niv contaminated foods. nipah virus (niv) belongs to the list of pathogens identified by the who to have the potential for a global pandemic. aims: this study aimed to investigate the efficacy of the theraflex uv-platelets system to inactivate niv in platelet concentrates (pcs). the theraflex uv-platelets system (macopharma) uses uvc light without the need of any additional photoactive compound. methods: plasma reduced pcs from bcs ( % plasma in additive solution ssp+) were spiked with virus suspension ( % v/v). pcs (n = , ml) were then uvcirradiated on the macotronic uv machine (macopharma) and samples were taken after spiking (load and hold sample) and after illumination with different light doses ( . , . , . and . (standard) j/cm )). the titre of the niv (malaysia) was determined as tissue culture infective dose (tcid ) by endpoint titration in microtitre plate assays on vero cells (atcc â crl- tm ). the results of the infectivity assay demonstrated that uvc irradiation dosedependently inactivated niv. after spiking a niv titer of . (bag no. ) and . (bag no. ) log tcid /ml was received in the pcs. at a uvc dose of . j/cm and higher niv was inactivated down to the detection limit of the system ( . log tcid / ml), resulting in log reduction factors of ≥ . (bag no. ) and ≥ . (bag no. ). summary/conclusions: our results demonstrate that the theraflex uv-platelets procedure is an effective technology to inactivate niv in contaminated pcs. vs. ae . e platelets/unit, p < . ), whereas the platelet content of apheresis pc did not change ( ae . vs. , ae . , p = . ). summary/conclusions: pathogen reduction resulted in the transfusion of older pc on average, but without altering the number of pc ordered or the use of pc per patient. pathogen reduction has improved pc stock management without an increase in platelet demand, despite lower platelet content of buffy coat pc after pr implementation. donors and donation -donor adherence -are we doing the right thing? the transfusion procedure is the last step in a multi-process supply chain. the task of matching supply with demand requires donor managers to consider average consumption rates on a weekly or monthly basis, but to also have insight into variability in order distribution and possible attribute (blood groups) requirements. since hospitals and blood banks are usually not deeply interwoven and often only ex-post data is available, forecasting methods should be implemented. a thorough analysis of order pattern to set weekly target inventories and safety levels is required to close the information gap. a collection plan needs to identify possible bottlenecks which can be prevented through the planning of inter-shipping, changes in message urgency and building of reserve donor pools. constant analysis of collection and mobilization kpis allows donor managers to implement the rolling-wave planning approach and continually adapt to changing requirements, unexpected events and overall systematic variability. the variability happens on the demand side, as order quantities and their attributes, such as blood group distribution, are subject to change. however, also the supply is subject to significant variation, as donor response rates, attrition, deferrals and overall availability of donors are not constant. the data was collected with the face-to-face interview method right after the donation. first-time donors has attended to the study in regional blood centres in cities in turkey. the survey included items in accordance with the standard tpb predictors of attitude, self-efficacy, and intention. self-identity, anticipated regret, donation anxiety, paraphernalia anxiety, personal moral norm, descriptive norm, satisfaction, motivation also assessed for the first-time donors. the relation between the predictors and intention confirmed with correlation analyses. the predictors' distribution analysed by multiple linear regression. a number of goodness-of-fit indices were calculated and examined for each tested models (ibm, amos spss). the results of goodnessof-fit tests for proposed model provided a better fit to the data than these models (cmin/df = ). moreover, this result indicated that the fit between the proposed model and the data could be improved with further modifications with the inclusion of paths between motivation and attitude, self-identity and intention. moreover, inclusion the paths between donation anxiety and intention and between self-efficacy and attitude, on contrary to recent analyses suggesting opposite paths. evaluation of goodness-of-fit tests showed good result for revised model with a value of cmin/df = . , close to perfect fit. the revised model revealed that attitude was the strongest positive direct predictor of intention followed by personal moral norm, self-identity, motivation and anticipated regret (path coefficients: . , . . . , . , and . , respectively). donation anxiety was the negative direct predictor of intention (- . ). satisfaction was the strongest positive indirect predictor of intention via attitude and followed by self-efficacy ( . and . ). paraphernalia anxiety was the negative indirect predictor of intention (- . ). descriptive norm did not show any significance. our model accounted for . % of the variance in intention. summary/conclusions: these findings suggest several potential avenues for enhancing donor retention. the results obtained with this study provide important data from the standpoint of donor retention, which should be, implemented in the future strategies of turkish red crescent. background: transpose-transfusion and transplantation: protection and selection of donors, is a european consortium project, including partners from countries, reviewing donor selection and protection policies for substances of human origin (soho).one of the main issues in the current donor selection system, which transpose aims to tackle, is that for many, if not most criteria, is not evidence based. the transpose consortium therefore tries to re-assess selection criteria, revised them where needed and provide recommendations as evidence-based as possible. transpose additionally adds to the current european directorate for the quality of medicines & healthcare (edqm) guidelines by emphasizing donor safety. aims: the aim is to compare existing donor eligibility criteria throughout europe, and to compile a list of risks to consider, with evidence-or consensus-based deferral criteria to provide more uniform donor screening criteria. methods: there are three horizontal work-packages (wps); wp coordination, wp dissemination, and wp evaluation of the project, and four technical ones with specific deliverables and milestones to be regularly produced: -wp inventory of donor selection & protection practices; -wp development of risk-based guidelines for donor selection and protection; -wp development of a standard donor health questionnaire (dhq); -wp training course/workshop on the use of the guiding principles, guidelines and the dhq. the transpose project launched in september and will complete in spring . wp has completed its work in october, wp will complete its work in june , and wp and wp have recently commenced. results: with the use of the deliverables created by wp , we have created an indepth inventory of current practices in donor selection and protection, including overview of similarities and differences across european countries and across soho types. there is an agreement amongst experts that existing guidelines are often based on the precautionary principle rather than on risk assessment. consequently, in the development of wp 's guidelines for donor selection and protection, we now make an effort to also emphasize donor safety, in a more evidence-based way via the use of risk-based assessments. this will result in a standardized dhq with a common trunk and more in -depth questions per soho. summary/conclusions: the impact of the outcomes of transpose will be threefold. first, outcomes are expected to be of help in revising donor selection and protection related eu directives. second, the set of guiding principles and donor selection & protection guidelines will facilitate eu member states to take a next step in implementing donor selection and protection policies in a consistent and clear-cut way to the benefit of both donors and recipients of soho. third, a standard donor health questionnaire with carefully guided local/regional/national adjustments will become available per soho which can be used widely and will consequently enable comparisons of the prevalence of certain risks and risky behaviours throughout europe. background: transpose-transfusion and transplantation protection and selection of donors is a european consortium project, including partners from countries, that reviews donor selection and protection policies for blood, plasma, tissues, assisted reproductive technology (art) and stem cells (together soho). donor selection criteria (dsc) in europe are based on eu-directives, guidelines and countries' own additional criteria. literature shows that particular criteria are outdated or not risk-based, often leading to unnecessary donor deferral or an underestimation of risks for donors. aims: to ) provide a comprehensive inventory of current systems for selection and protection of donors and donations, ) critically review them and ) recommend an over-arching donor health questionnaire (dhq) including all necessary criteria currently used by different eu-member states (eu-ms). methods: in-depth semi-structured interviews with key stakeholders in blood collection were conducted to identify main topics for improvement in the current dsc. these formed the basis for a survey sent to professionals from collection institutions of all soho to get feedback on current systems from as many eu-ms organisations as possible. questionnaires were sent to a total of experts ( blood; plasma; tissues; stem cells; art) and ( %) completed questionnaires were received. where information was lacking, additional experts were asked to recommend upon dsc. results: for blood and plasma donation four main areas of concern in dsc were identified: risk-based selection, adaptability, flexibility and consistency. the stakeholders agreed that dsc are often outdated and lack evidence, hence leading to unnecessary deferral of donors and underestimated risks for donors. they suggested to base dsc on group risk-assessment (risk-based selection) and on conducting more research to achieve standardized risk perceptions and evidence-based deferrals, either for safety of recipient or donors. criteria could be made more detailed to fit specific groups to defer less donors (adaptability). furthermore, implementing criteria was considered easy, but abolish criteria when not regarded as a risk anymore seems almost impossible (flexibility). additionally, deferral periods are perceived too long, seen as both negative, i.e. jeopardizing donor return intention and positive, i.e. no risk for safety (consistency). changing legislation into guidance was an often-mentioned suggestion to improve dsc. specific feedback on plasma donations revealed that many whole blood topics are not applicable to plasma-only donors, e.g. parasite infections such as malaria (no deferral needed); travel history (no deferral needed), and recent bacterial and viral infections (deferral periods currently too long). a clear need for more research on plasma collection-related issues was identified. summary/conclusions: dsc are perceived redundant on a substantial number of aspects by most stakeholders. besides achieving the goal of save and sufficient soho for patients, many regulations could be improved to diminish deferrals and decrease donor risks. transpose will add to reviewing, improving and harmonising these regulations and criteria. furthermore, transpose will provide suggestions to improve directives and guidelines and a dhq, focusing on both donor health protection and safety of donations, but also removing deferral criteria that are not relevant (anymore), and offer a future research agenda to make dsc more evidence-based. background: transpose -transfusion and transplantation: protection and selection of donors, is a european commission co-funded project with participation of stakeholders from both not-for-profit and private blood collecting organizations as well as researchers and officials. the project aims to create new evidencebased donor selection criteria as well as guiding principles for risk assessment of threats to the safety of all substances of human origin (soho) except solid organs. as part of this, an inventory of current donation-related risks was performed, including an investigation of both type and number of adverse events reported. aims: we here aim to present an overview of reported adverse events in plasma and whole blood donation in europe and to compare this to the anticipated risks rated by transpose stakeholders. methods: national or local data on adverse reactions from the years - , both serious and mild, in whole blood and plasma donors was collected from the relevant stakeholders (eighteen and nineteen respectively). stakeholders were also asked to grade the most important anticipated donor risks according to severity, level of evidence and prevalence. we then compared the relevant risk categories as evaluated by the stakeholders with the categories of the provided data, as well as the heterogeneity of category numbers. results: thirteen stakeholders provided data on adverse events during whole blood donation in a given year, including in total thirty-three different categories of adverse events, ranging from only one unspecified reaction to seventeen different categories, with an average of nine categories per stakeholder. the most frequently used categories were hematoma (included by %), arterial puncture ( %) and nerve damage ( %). vasovagal reactions were also frequently included ( %); however, this was being done variably as vasovagal reactions unspecified, and acute and/or delayed vasovagal reactions. only one stakeholder reported iron deficiency. for plasma donation, seven stakeholders provided data on adverse events. a total of twenty-seven different categories were reported, ranging from one to seventeen per stakeholder, with an average of nine. the most frequently reported adverse events were hematoma ( %), citrate reactions ( %) and arm pains and nerve damage (both %, respectively). anticipated risks in blood donation were rated by nine stakeholders rating iron deficiency, vasovagal reactions and hematomas the greatest risks to donors. for plasmapheresis, six stakeholders rated vasovagal reactions, hematomas and citrate reactions as highest risk. summary/conclusions: as shown, categories used to describe adverse events in blood donation vary tremendously across europe, with some countries only being able to provide total numbers of adverse events without further specification. furthermore, there is a gap between perceived high donor risks and reported adverse reaction categories in donor vigilance for whole blood, as reports on iron deficiency are virtually absent despite being considered the most significant risk. our findings show the need for international collaboration on creating an international standardized donor vigilance system, to gather more insight into donor risks to protect the health of donors. plenary session -a glimpse of the future pl- - modern transplantation medicine has made significant progress within the last decades due to a better immunological understanding of rejection and advances in immunosuppression. however, the severe side effects of long-term, typically lifelong, immunosuppression and the shortage of donor organs remain the major restrictions in transplantation. the idea behind all research to improve transplant outcome has always been the modification of the recipient's immune system to ideally induce a specific tolerance towards the donor's graft. in fact, the immunological blindness of the recipient towards the donor's graft is achieved by a general reduction of the immune system's competence and represents a major burden for transplant patients. the idea of invisible organs is an entirely different approach to solve the problem: instead of inducing an immunological blindness of the recipient's immune system an immunological invisibility of the donor's organ is created. this is achieved by genetically engineering the transplant to eliminate the organ's immunogenicity defined by the gene products of the major histocompatibility complex (mhc) and minor histocompatibility antigens. in addition to manipulating the expression of mhc genes required for immune recognition, immune cloaking strategies are used to evade immune rejection. these approaches take advantage of creating an immunosuppressive environment and expressing immune suppressive molecules by immunomodulatory transgenes. mhc engineering and immune cloaking in an entire organ is achieved during ex vivo perfusion by lentiviral transduction of gene expression modifiers and transgenes to induce a permanent immunological invisibility of the organ. importantly, mhc engineering also prevents the presentation of minor histocompatibility antigens, which usually are not possible to match between donor and recipient, but which trigger potent immune responses and graft rejection. eliminating the targets of cellular and humoral rejection as well as creating an allograft-specific immune environment through immune cloaking camouflages the organ and equips it with a powerful set of defense weaponry. immune-engineering of transplants achieved during the inevitable ex vivo period of the allograft after explantation without the need to accept off-target effects allows keeping the recipient's immune system fully functional and capable to combat infections and cancer. in pre-clinical in vivo studies from rodents to minipigs a clear survival advantage of ex vivo engineered transplants could be demonstrated. this approach has the potential of eliminating the burden of organ rejection and immunosuppression, thereby sustainably increasing transplant survival, organ availability and quality of life. gene editing for sickle cell disease: re-expression of the fetal c-globin genes (hbg / ) could be a universal strategy to ameliorate the severe b-globin disorders sickle cell disease (scd) and b-thalassemia by induction of fetal hemoglobin (hbf, a c ). we have previously identified bcl a erythroid enhancer sequences, marked by hbf-associated common genetic variants, that are required for repression of hbf in adult-stage erythroid cells but dispensable in non-erythroid cells. recently we have optimized conditions for selection-free on-target crispr-cas editing in human hscs as a nearly complete reaction without detectable genotoxicity or deleterious impact on stem cell function. we demonstrate that cas :sgrna ribonucleoprotein (rnp) mediated cleavage at core sequences of the + bcl a erythroid enhancer results in highly penetrant disruption of gata binding motif, reduction of bcl a expression, and induction of fetal c-globin. erythroid progeny of edited engrafting scd hscs express therapeutic levels of hbf and resist sickling, while those from b-thalassemia patients show restored globin chain balance. moreover we find that hscs preferentially undergo nonhomologous as compared to microhomology mediated end-joining repair. nhej-based bcl a enhancer editing approaching complete allelic disruption in hscs appears to be a feasible therapeutic strategy to produce durable hbf induction. in this presentation, i will compare and contrast bcl a enhancer editing to other autologous curative gene therapy and gene editing approaches at various stages of clinical and pre-clinical evaluation. oxygen is vital for life. without oxygen death is assured for aerobic organisms. although everybody knows this fact a lot of medical acts forget to take care of it, leading to a lot of potential troubles. indeed, during cell respiration the glucose oxidation by oxygen gives carbon dioxide, water and energy. this energy also called atp is necessary for cellular metabolism and consequently for life. we have identified an extracellular hemoglobin coming from a marine worm, called arenicola marina, which is able to deliver oxygen to this animal living in the intertidal areas on the atlantic coast in france between the north sea and biarritz. this molecule called m was developed in the medical device named hemo life â . we have showed that this product was very efficient to protect organs before transplantation. a multi centers clinical trial performed under the supervision of pr. le meur from the chu of brest, on patients waiting kidney grafts showed a delay graft function reduced roughly by three between the two kidneys harvested on the same donor with and without hemo life â and grafted on recipients. in , a world first was realized in france by the pr. lantieri to georges pompidou hospital in paris, france. indeed, it was the first time that a patient received a second graft face. this surgery was realized with hemo life â and showed a very nice result according the pr lantieri, the anastomosis were very easy and no edema was observed. furthermore, we have developed dressing incorporating m making a product called hemhealing â . preclinical data on diabetic mice showed an increase of healing process. hemoxycarrier â , a therapeutical oxygen carrier, is also in progress of development in order to address ischemic diseases such as the sickle cells disease, myocardiac infraction and stroke. this universal oxygen carrier without blood typing, which is the ancestor of our red blood cell containing hemoglobin showed that it is able to deliver oxygen at different biological levels, cellular, tissues and organs and could address a multitude of medical applications. background: main goal of transfusion is saving life and/or improve the health status of human by "safe blood" which needs regular, voluntary, unpaid blood donors. donor recruitment is being more sensitive and challenging part of the blood supply system in actual global socio-economic conditions. achievement to enough voluntary non-remunerated blood donation (vnrbd) can be established by an efficient donor recruitment. efficiency of the donor recruitment has still close relation with blood donor recruiter although there are so many new tools. occupational specifications, rights and responsibilities of blood donor recruiter have wide range differences between countries which cannot be explained completely by the specific conditions of each country. also, a concrete document which has an international consensus was not existing on this subject. turkish blood foundation (tbf) has been organizing an international workshop since ; anatolian blood days (abd). "who is a blood donor recruiter?" was the topic of abd-vii at - march . aims: main aim of the workshop was to check and evaluate the existing systems of the participant countries. than create a model for clearly defining occupational specifications, responsibilities and rights of blood donor recruiter. methods: experts from countries participated in the workshop. those countries are albania, algeria, bosnia-herzegovina, estonia, france, germany, hungary, india, kazakhstan, lithuania, macedonia, montenegro, oman, portugal, qatar, romania, russia, saudi arabia, serbia, slovenia, sri lanka, tajikistan, turkey, uganda, uzbekistan. these countries reflect almost all religious, ethnical, social, cultural and economic situations of the world. a questionnaire which was analyzing existing systems at participant countries sent before the workshop. after country presentations different discussion groups were organized. below listed topics were announced at final declaration. results: donor recruiter: . should have university degree preferably in marketing and business administration field. . should have a certificate and/or professional experience in public relation . should have efficient skill in conversation, sociability, independence, self-confidence, reliability, resilience and conscientiousness as well as to work in a team . should get a special training which includes not only social topics such as public relation, marketing, etc. and medical topics related bb&tm before practicing alone as a donor recruiter . should be a permanent staff . should have basic salary and performance bonus might be given . is eligible to monitor and modify mobile team working period at blood drive . should participate the mobile blood drive which he/she has organized . should participate the group who will create promotional materials for national blood service . number at each blood establishment should be defined based on annual blood collection such as staffs for , whole blood collection annually in germany. summary/conclusions: in conclusion; both donor recruitment and retention are not easy tasks to undergo while public are aging, and birth rates are decreasing all around the world. dedicated blood donor recruiter whose occupational specifications, rights and responsibilities are clearly defined will be the corner stone of the success for providing enough safe blood for transfusion. ct smit sibinga and j emmanuel background: africa is a large continent with independent states and a total population of , , , (february ) . healthcare policies and strategies are developed through who's advocacy, guidance, and support from hq in geneva and the who regional offices; eastern mediterranean regional office (emro) supporting arabic speaking countries and the african regional office (afro) responsible for sub-saharan countries. population distribution is approximately . % urban. there are a large number of different local dialects and languages spoken. the main languages spoken are english, french, portuguese, spanish and arabic. countries are mainly classified by undp as being of low and medium human development index the africa society for blood transfusion (afsbt) has members in most countries, advocates for the development of sustainable and effective blood services, and has developed a stepwise level accreditation program. in emro held a consensus meeting developing a "strategic framework for blood safety and availability for - " with a set of priority interventions focusing on leadership and governance, cooperation and collaboration, provision of safe blood and blood products, appropriate clinical use of blood, and quality system management. in all member states of the african union (au) countries, in abuja, nigeria, pledged that national budget for health should be at least % of the national fiscal budget. in ministers of health of who member states endorsed that blood and blood products be included in the essential medicines list; these endorsements and who's universal health coverage (uhc), have yet to be fully implemented. aims: to analyze (gap-analysis) to what extend countries in africa implement the world health assembly resolution wha . on availability, safety and quality of blood products, which urges governments to ensure safe, accessible, affordable and available supplies of blood and components from voluntary non-remunerated blood donors, which meet clinical transfusion requirements and achieve national self-sufficiency, following who guidelines and recommendations. methods: to provide an overview of the current status of the blood supply in africa strengths and weaknesses, data from who's global status report on blood safety and availability were analyzed and used. the study has been descriptive and explorative. results: the report identified a number of areas requiring attention; principle amongst these were -inadequate funding; -lack of governance and leadership; -ineffective public education on blood donation; -absence of capacity building for clinicians on rational use of blood; -lack of haemovigilance and implementation of quality management systems; -the need for regulatory or oversight mechanisms. summary/conclusions: national authorities should address areas requiring attention if progress towards ensuring a sustainable safe and sufficient supply of blood products is to be achieved. key is the commitment and support of national governments, which should implement resolutions and recommendations agreed by ministers of health at wha and african union. background: the core function of the blood donation testing (bdt) laboratory is to screen every unit of blood collected from a donor for blood group type and infectious disease markers to ensure safety of the national blood supply prior to transfusion. the lab operates daily on two work shifts, comprising of staff on the morning (am) shift (from : to : ) and staff on the afternoon (pm) shift (from : to : ) on weekdays and staff on the am shift and staff on the pm shift on weekends. bdt lab has a staff strength of to be rostered for the work shifts. each staff is on a five-day work week and has to work pm shift and am shift per month on average. the higher number of pm shift leads to staff feedback that they do not get sufficient time in the evenings for family and social or leisure activities. a lean six sigma project was initiated to review the work rostering to improve the work-life balance of the staff. aims: the project aims to reduce the number of staff working on the pm shift without affecting the downstream processes and continues to meet the timely release of blood supply to the hospitals. methods: lean six sigma tools were used to study the bdt lab workflow process and to identify factors that contributes to the higher number of pm shifts that the staff has to take on. data on the turn-around time and the man-effort required for each screening tests performed was analyzed. a survey was also conducted to understand the preference of the staff on the acceptable number of pm shifts per month. results: the main contributing factor for more staff required to perform the pm shift is due to majority of the daily donation samples being received only in the evening. as this factor is beyond the control of the bdt lab, redeploying work from the pm shift to the am shift was eventually selected as the solution to reduce the number of staff needed for the pm shift. the screening test that was shifted was determined based on the test system that has the shortest turn-around-time and is able to allow continuous release of results. at the same time, most of the staff must be trained for that test system. a trial on the new roster involving staff on am shift and staff on pm shift was conducted. the total number of pm shift per month was reduced from to using the re-defined process. the % reduction translates to fewer number of pm shifts that the staff has to undertake and was able to meet the staff's expectation. summary/conclusions: with the adoption of the new process workflow, bdt lab was able to reduce the number of pm shifts that the staff needs to be rostered using evidence based process improvement method. most importantly, the lab has a satisfied team of staff with better work-life balance. background: preparedness of blood transfusion services for emergencies and crisis situations is an important issue concerned with patient and transfusion safety. aims: having an experience of delay in blood component supply in an emergency situation due to partial interruption of hospital information system (his), it is aimed to create a crisis kit and constitute an alternative work flow for emergency in crisis situations. methods: it is stipulated that the failure of his which is normally conducts all process for transfusion would be disabled in a disaster or crisis situation. a brain storm was made on possible challenges associated with disability of his during transfusion emergencies. according to the scenarios a kit was developed for the process management of transfusion emergencies. results: a flow chart was designed in proper with transfusion emergency definitions of who and instructions were written to explain the flow chart. all forms categorized with different colour codes are designed to fill with handwriting. the kit consists of flow chart and instructions, analysis request forms (blue coloured), blood component request forms (pink coloured), proceeding forms (green coloured), pens and blood sample tubes with edta were put into a plastic folder labelled as transfusion emergency disaster & crisis (tedc) kit. additionally, the kit is placed in a sealed clear plastic bag and delivered to all inpatient and intensive care units of pediatrics and pediatric surgery. a training programme concerned with transfusion emergency situations and usage of the tedc kit was developed for health care workers involved in blood transfusion process. pre and post-assessment tests were developed for the evaluation of effectiveness of the training programme. summary/conclusions: it's challenging to improve the response capacity of blood transfusion services during emergencies and crisis situations. abstract withdrawn. background: india is a developing country having licensed blood banks majority have manual documentation which causes inaccuracies and errors in blood bank activities. monitoring is a herculean task. computerisation is the need of the hour but this goal involves many hurdles and challenges aims: the aim of this study is to discuss the challenges faced during computerisation of blood bank activities and the remedial solutions for it methods: department of transfusion medicine, king george medical university, lucknow is one of the biggest blood bank of the country with annual collection of , blood units. two years ago, the blood bank worked on totally manual system. computerisation involved challenges associated with hardware and software installation and personnel training. hardware was installed in two phases. initially hp system but later shifted to apple imac due to frequent breakdowns. with hp server. software installation (easy software) involved erratic internet connectivity hence changed to lan. customisation involved radical changes according to our needs. at times we had to change our way of working to suit the software. biometrics linking, medical registration, cash id generation, donation, serological crossmatch, automated blood grouping, labelling, chemiluminescence & nat testing, blood component preparation and camps were all included with challenges at every level. remedial actions were taken from small to big. training of the staff was the most essential part of the implementation of computerisation who initially showed considerable resistance and at time faking ignorance due to apprehension that their mistakes will be highlighted and they will be penalised for it. it was a herculean task in creating their password protected identity and enforcing them to use it. gradually the staff realised that computerisation made their task easier as it cut down on paper work and repetition and also prevented serious mistakes from happening. hard copies at certain essential areas were still maintained to continue work in the event of major breakdown of computer results: computerisation aided us in regulating the movement of the donor which at times was repetitive due to manual entry. transfer of data ensured a safe supply and the mistakes could be retraced very easily. implementation which included installation, training and enforcement took a period of months. after overcoming all the challenges we minimised hard copies to registers and started taking printouts of the other necessary details. the turnover time for the employees due to computerisation decreased by %. waiting time for attendant decreased by %. traceability of all the units became %.supervision of the activities being carried out was % accurate. identification of the donors was easy due to biometrics which included thumb impression and iris scanning. the decision making time for donors decreased by % thus making the system more efficient. summary/conclusions: manual to computerisation involves involvement from source to supply and it is essential to anticipate the challenges and be prepared for solutions in order to make its implementation successful p- ct smit sibinga , y abdella and f konings iqm consulting, zuidhorn, netherlands who eastern mediterranean office, cairo, egypt background: who defined essential medicines (ems) as medicinal products that satisfy health-care needs of the majority of a population. they should be available at all times, in adequate amounts, in appropriate dosage forms, with assured quality and affordability. in blood and blood products (whole blood, red cells, platelets, plasma, and plasma-derived products) were added to the who model list of ems. appropriate and effective regulatory framework (legislations, regulations, etc.) and a functioning regulatory authority (ra) is crucial for management of blood products as ems. however, particularly in the less developed world, these prerequisites have barely been implemented. aims: to analyze and advise on existing legislation and regulations. existing legislative instruments of the member states of who eastern mediterranean region (emr) were collected and analysed for relevance and appropriateness for preparation and use of blood and blood products as well as use of associated substances and relevant medical devices. a literature search was done on matching combinations of regulatory system, regulatory framework, legislation, regulation, with production and use of blood and blood products, which resulted in almost exclusively references with respect to national and international legislation. benchmark: who recommendations (aide m emoires) and eu directives. methods: existing legislative instruments of the member states of who eastern mediterranean region (emr) were collected and analysed for relevance and appropriateness for preparation and use of blood and blood products as well as use of associated substances and relevant medical devices. a literature search was done on matching combinations of regulatory system, regulatory framework, legislation, regulation, with production and use of blood and blood products, which resulted in almost exclusively references with respect to national and international legislation. benchmark: who recommendations (aide m emoires) and eu directives. results: various formal legislative documents of only / countries are put in force by governments [ (egypt) till (pakistan -sindh)]. most are detailed descriptions of ra, operational establishments, and specific requirements. however, none of these legislations complies with who and eu recommended formats and contents, and will not support effective regulatory oversight to promote and enhance quality, safety and availability of these ems. summary/conclusions: government should provide effective leadership and governance in developing a national blood system (nbs, fully integrated into the national health-care system. essential functions of a nbs include an appropriate regulatory framework with legislations, regulations and other non-legislative instruments administered by a ra. these documents should spell out principles and cadres, standard setting, and organization of the blood system to ensure an adequate supply of blood and blood products and safe clinical transfusion for which a model was designed. the structure of nbs will depend on organization and level of development of the health-care system. however, all critical activities within nbs should be coordinated nationally to promote uniform standards, economies-of-scale, consistency in staff competency, quality and safety of these ems, and best transfusion practices. key is formulation of an appropriate regulatory framework administered by a ra responsible for regulating the vein-to-vein chain in the preparation and use of these ems. background: the capacity of blood transfusion service to provide adequate supplies of blood components is the issue of concern for health providers worldwide; longer term observations of trends in this respect are therefore of crucial value. aims: the study aim was analysis of some basic activities of the polish blood transfusion service in - including organizational changes, numbers of donors, donations and blood components as well as activities directed at increasing their safety. methods: retrospective analysis of data supplied by the regional blood transfusion centers (btcs). results: in the discussed period, blood and blood components were collected in regional btcs and local collection sites as well as during mobile collections. although the number of local collection sites decreased from in to in in favor of mobile collections, which increased from , to , , the former is still the number one location for donating blood. on average . % of all donations were performed in local collection sites. the total number of blood donors both at the beginning and the end of the discussed period was similar ( , in and , in ); over % of all donors were non-remunerated. however, the number of first-time donors dropped significantly (from , in to , in ). the total number of donations increased from , , in to , , in ; most frequent were whole blood collections (from , , in to , , in ) . some blood components (mostly plasma and platelet concentrates) were also collected by apheresis. most frequently prepared blood components were red blood cell concentrates -rbcs ( , - , , units per year), fresh frozen plasma -ffp ( , , - , , units) and platelet concentrates -pcs ( , - , units, with significant increasing tendency). additional processing methods such as leukocyte depletion and irradiation were more frequently applied to pcs ( - . % in respective years irradiated, . - . % leukocyte-depleted), than to rbcs ( . - . % irradiated, . - . % leukocyte-depleted). in , the pathogen reduction technologies in plasma and the pcs were implemented. up to date however the use of these technologies is limited in most btcs. in approximately . % of pcs and % ffp units issued for transfusion were subjected to pathogen reduction technologies. summary/conclusions: our study data may contribute to the assessment of some long-term tendencies observed in polish blood transfusion service and may serve practical-benchmarking. this in turn may prove beneficial to the transfusion community as a whole. background: in poland % of hospitals depend on blood for the treatment of patients; over . mln units of blood components are annually transfused. it is therefore purposeful to expand the knowledge on factors impacting on blood transfusion service (bts). the institute of hematology and transfusion medicine (ihtm) as competent authority is responsible for collection of data related to the activity of all polish blood transfusion centers (bcts). this data is exploited to a much lesser degree than the recently available statistical methods and data processing tools would allow. moreover, survey of research in the field of public health indicates a negligible share of issues related to bts. it seemed therefore necessary to "fill in the gap" with true assessment of performance of the polish bcts for improvement of bts activity. st stage of our investigation refers to collection, merging of data from different sources, their unification and preparation (big data) for further analysis to be performed using multidimensional statistical analysis and data mining methods. aims: assessment of the activity of the polish btcs over the year-period in two stages. goals at st stage: . data digitalization; scanning of paper documents. . development of a uniform template for collecting digital data from various sources. . standardization, unification and quality improvement of available data: filling in missing data, elimination of errors, duplicate records etc, that may distort the outcome of analyzes. . selection of data for analysis. methods: digitalization and big data methods for processing various types of data: a) stored in paper form ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , b) digital stored in two file types (.doc and .xls, for the years - and - , respectively). for each data-type, a separate excel file model was created. the models were then merged into one analytical table with data processing methods. results: . pages of paper documents were scanned. . models developed for data from different sources: a. paper-data were rewritten and ascribed to its model; outcome - tables, columns, , rows. b. .doc and .xls. filesdata were ascribed to other models; outcome - tables, columns, rows. . the models were merged into analytical table to create a mb database (comparable to approx. min of music). . the data was subjected to standardization, unification and quality improvement: filling in missing data, elimination of errors and duplicate records that may distort the results of analyzes. . selection of data for analysis at nd stage. summary/conclusions: the st stage provided a set of selected data for analysis in the nd stage which will rely on multidimensional statistical analysis and data mining methods. the outcome of such analysis will contribute to optimal realization of objectives: a) gaining in-depth knowledge about the fundamental phenomena that shape polish bts, b) identification of potential changes bcts, c) development of overall guidelines for change management. aimed to touch untouched or less touched topics of bb&tm. so far workshops were organized and each year around countries were participated from almost all religious, ethnical, social, cultural and economic situations of the world. . supported realization of major changes in bb&tm in turkey; a convincing medical individuals and agencies mainly moh to give the deserved consideration to bb&tm b encouraging the recognition and establishment of national blood program c issuing a new blood act and numerous necessary bylaws, etc. d creating an appropriate standard donor questionnaire form e changing blood transfusion practice from % whole blood (at ) to %. f changing donated blood screening criteria; while anti-hcv screening became obligatory malaria, screening cancelled g preparing national guidelines h promoting haemovigilance nurse post i promoting patient blood management . around , blood bankers attended national courses, , attended national congresses, , attended nationwide symposiums. summary/conclusions: bbtst can be accepted as a sample how a scientific nongovernmental organization may give a very positive impact on developing and progressing bb&tm activities with close collaboration moh and other related organizations abstract withdrawn. background: globally there is growing investment in information technology (it) in business. this similar trend has been observed in blood establishment computerized systems (becs). the it investment can be high hence it decisions need to be properly informed. the africa society for blood transfusion (afsbt) encourages the use of its in african blood services as this optimize quality blood services, thereby improving patient's outcomes. afsbt established in an it working group (afsbt itwg) with the support of the swiss red cross (src) to spearhead the it standards among member blood services. a number of priority it thematic areas were identified. these includes it governance which focuses on creation (strategic alignment) and preservation (risk management) of business value. there is absence of published literature on how a structured it governance framework can be implemented in a resource constrained setting. a review of the national blood service zimbabwe (nbsz) it governance was done based on published it governance framework. aims: to explore how a structured it governance can be developed, implemented and monitored in a resource constrained setting. methods: a published mit-cisr framework which has six components was used to assess the strength, gaps and opportunities of the it governance. results: nbsz has been implementing an evolving structured it governance system. in terms of service strategy and organization there is a well-established it function which is reflected in the nbsz strategic plans. this ensures it annual budgetary support, which averages . % of the total budget. the it governance arrangements are such that decision rights are assigned to different it staff (executives, it specialist, and users). a range of it solutions have been embedded within the nbsz operations such as becs, financial, donor mobile application, social media, temperature monitoring, and human resources. the business performance goals are defined and are congruent across the various business units. it organization and desirable behaviors are documented in the ict policies and procedures and were needed remedial actions are available through the code of conduct. the it metrics are included within the nbsz monitoring and evaluation system which use a four colored traffic lighting reporting system. it was noted that the it accountabilities are undesirably tilted to the it specialist only hence some ict projects tend to have delayed deliverables. the it governance mechanisms are supported with tools such as service level agreements and established communication approaches. simple excel based solutions are used to track critical performance metrics such as on the interactive blood supply management status, which averages . % ( ) based on a -day projected stocking and supply levels. nbsz need to properly document the return on investments on all these ict initiatives, which is estimated ( / ) to be at . % of annual savings. summary/conclusions: blood services in resource constrained settings can implement a properly structured it governance and this will ensure maximum return on it investments. the nbsz approach will be shared and further developed in the afsbt itwg to support other blood services in improving their it governance. haematology/blood transfusion, alfred health, melbourne, australia background: in october , an integrated electronic medical record (emr) was implemented at an australian metropolitan multi-campus heath service using cerner millennium tm , aiming to achieve himss (healthcare information and management systems society) level . prior to implementation, large numbers of blood specimens were collected from patients unnecessarily and sent to pathology without a test request attached (no blood test requested -ntr). these specimens required additional processing in the laboratory. electronic specimen collection using cerner specimen collect tm allowed streamlining of specimen processing by eliminating paper requests. as part of the new workflow, individual specimen labels are printed with the specified blood test and correct tube type. this helps prevent the practice of collecting additional specimens due to uncertainty of the collection requirements. aims: • to quantify the expected reduction in ntr specimens following introduction of electronic specimen collection, and outline the benefits • to determine the impact on collection errors and wrong blood in tube (wbit) events methods: data was obtained directly from cerner millennium tm using a ccl (cerner command language) query which is run monthly by pathology it staff. this data includes all specimens registered for the month with indication of rejected specimens, wbit & ntr samples. 'rejected specimens' includes incomplete specimen and/or request certification, unlabelled specimens/requests and mismatched specimens. further information about wbit events was collated from riskman reports and staff interviews. results: data from the months prior to emr implementation was compared with months post. ntr numbers reduced from /month to /month ( % reduction), freeing up more storage space in fridges. rejected specimens due to inadequate patient request labelling reduced from a mean of /mth to /mth. wbit numbers have increased slightly: before having median (range - ), after with median (range - ). although it was hoped that wbit incidence may reduce with the new emr, of the post implementation wbits involved electronic specimen collection. departure from planned protocols involving a lack of working printers, causing staff to print patient labels away from the patient's bedside, as well as multiple patient labels printing on individual printers appear to be a main cause of the emr wbits. summary/conclusions: emr implementation has led to a reduction in ntr, and rejected specimens due to inadequate request labelling, as well as increased storage space in laboratory refrigerators. associated benefits include: • decreased financial costs of the wasted equipment • decreased staff time collecting and processing unusable specimens • decreased environmental impact of manufacture and disposal of unused specimens • decreased potential of iatrogenic anaemia work in preventing the occurrence of further wbits is ongoing, by ensuring that label printers are in working order, are in plentiful supply and easily accessible to staff; and also ensuring positive patient identification and blood collection by the patient's bedside remains a priority. jm mustaffa , k teo , s tsai , p heng , r sagun and m wong laboratory medicine khoo teck puat hospital, singapore, singapore background: khoo teck puat hospital (ktph) is a -bed general and acute care hospital, opened in , serving more than , people living in the northern sector of singapore. the blood bank of ktph department of laboratory medicine provides specimen testing and blood transfusion services for ktph as well as the neighbouring yishun community hospital (ych), one of the largest community hospitals in singapore providing intermediate care for recuperating patients including rehabilitative services. the process of ordering transfusion-related test requests in both hospitals is through printed forms. aims: in line with the hospital directive to move towards electronic patient management, the ktph blood bank intended to implement an electronic type and screen (e-t&s) system. the goal of the project is to ensure zero patient identification errors and maintain full traceability and accountability for the blood collection process in all transfusion-related testing. another aim of the system is to reduce repeated venepunctures when specimens are rejected due to missing essential patient information on the printed forms by implementing mandatory fields in the e-t&s form. methods: the e-t&s was implemented in phases. phase : an online version of the printed form was signed electronically by the ordering doctor and a witness within the electronic medical record system, sunrise clinical manager (scm) system with the doctor counter-checking by signing on the specimen label to ensure correct patient identification. phase : the ordering doctor is not required to sign on the specimen label since fingerprint biometrics are required for the electronic signin. phase : elimination of the witness step for blood collection. specimen collection and rejection data from to was analysed. specimen rejection rate was presented as percentage of rejected specimens (mislabelled, unlabelled and clerical errors) over total specimen count for each month. results: between january and march , before the implementation of the e-t&s phase , the average rejection rate for blood bank specimens was . % and . % for identification and clerical errors respectively. during phases and of implementation, rejection rate increased due to unfamiliarity to the new work processes. by february , with the implementation of the final phase of the e-t&s system the specimen rejection rate was . % and . % for identification and clerical errors respectively. rejected specimens were mostly from the few locations that had to use paper requisition due to workflow or infrastructure limitations. summary/conclusions: the e-t&s system was implemented successfully in ktph. full traceability and accountability of the blood collection process was maintained with the fully electronic system. the adoption of electronic documentation has also reduced the number of preventable repeated venepunctures that were due to incomplete order information on the printed forms. future developments in technology and full implementation of e-t&s system in all hospital locations may make zero patient identification error achievable and ensure transfusion safety in all patients in the near future. background: blood component administration represents a critical phase due to the possible occurrence of errors during the different steps from the identification of the patient to the infusion of the product. error occurrence can be reduced by the implementation of validated information systems. we tested the scweb â system at the bedside in a transfusion outpatient clinic. aims: the aim of the study is to validate a system designed to assist and to control blood administration step by step using electronic devices to ensure traceability and documentation of the process methods: the scweb â system is based on it monitored checklists which guide the personnel to follow the procedure, according to best practices; the system must initially be activated by the operator which is recognized by an auto-signing system based on bluetooth low energy which avoids the operator having to identify himself/herself beforehand. appropriate privacy protection is provided. thereafter the system takes up the task to give instructions and to verify the adherence, by asking an active confirmation of the proper fulfillment of the activities; a continuous registration and documentation is made by the system. standards and specifications for each step of the procedure have been configured on scweb â system to track in detail operator and patient identification, presence of informed consent to transfusion, blood pressure, pulse and temperature recording, vein access, verification of the blood unit. an alarm has been set after min, to ensure the control of patient's conditions. for each step, an active confirmation of the action is required and nurse and doctor direct involvement must be actively confirmed on the device by both operators. the system has been tested at the bedside on patients admitted to the outpatient clinic for red cell concentrate transfusion; compliance of the personnel and organizational impact has been recorded. results: the system required a very short training: ease of scweb â system allows its implementation without negative impact on organization of transfusion outpatient clinic and without difficulties by operators (nurses and doctors), who appreciated the help given by the it check system. the registration of the electronic check list offered a reliable tool for the traceability of the transfusion procedure, also granting a paperless and timely available documentation of the entire process through a registration in electronic format of all the operator's action in every single phase of the transfusion process. when prescribed, confirmation of the checklist was only possible in the presence and with the active confirmation of two operators (doctor and nurse). summary/conclusions: the scweb â system is useful as a barrier against the mismatch of transfusion (preventive measure), as a traceability and documentation measure and as a tool for training of personnel in blood transfusion administration; it avoids paper registration during the transfusion process, due to the timely registration of the activities performed by operators recognized by the system thanks to the bluetooth low energy auto-signing device. the scweb â system will be connected to the transfusion data management system, to monitor all the process from the arrival of the unit from the blood bank. background: he blood banks aims at reducing cost and increasing customer satisfaction by providing quality in service. the quality in service can be attained by streamlining the processes and restructuring the supply chain of the organization by implementing it tools. aims: aim is to understand the complex flow of information and processes within the supply chain of the blood bank. the requirement of such a study is a part of the integrated erp modeling for the integrated functioning of a blood bank. methods: he approach used to understand and map the sequence of processes, and the work responsibilities of each process and the operational decisions involved at each step is process mapping and data flow diagrams for front end system modeling and analysis. the processes are mapped and represented in a schematic diagram. dfd (data flow diagram) are constructed for representing the system. a context diagram is also constructed for understanding the entities interacting with the system. the emr systems aim at replacing (or supporting) the paper based medical records. the whole model of the system is divided into two parts-front end and back end. the front end design and analysis is done using epc (event-driven process chains), resource views, data flow diagram for data view. reporting was on donor selection, finance and collection of blood bag, blood collection process, component preparation, blood testing and blood distribution results: process mapping using event driven process chain generated a whole view of the processes involved. the resource view gave an organizational structure and the personnel involved. the data view using context diagram and data flow diagram gives a flow of data and amount of data involved. this framework can be used for business process reengineering for the blood banks by conducting a time study and removing non value added activities. data view helps analyze redundant data in each process. it also helps in staff training and orientation within the department. summary/conclusions: a systematic overview presented in this paper facilitates in removal of non value added processes, duplication of data, bottlenecks, reduction of cycle time and thereby improving service quality in blood banks. background: the transfusion of blood components, one of the most prevalent interventions in clinical practice is a major expenditure item in healthcare services which tend to increase in recent years. aims: it is intended to investigate the impact of transfusion associated costs to hospital costs in pediatric intensive care unit (picu) patients. methods: during a year period (january -december ) patients, females and males receiving transfusion with blood components along the stay in picu were included in the study. transfusion associated costs and total costs for healthcare services for children treated in picu was collected by using hospital information system (his). statistical analysis of data was performed by spss software (version . , spss inc., chicago, il, usa). mann-whitney u test and kruskal-wallis test was performed for comparison of independent categoric variables and numeric data; chi-square analysis was performed for comparison of two numeric variables and spearman correlation analysis was performed for associations. results: the median age of patients was . months (interquantile range-iqr ). the median length of stay was days (iqr ). in total blood components were transfused in which of red blood cell concentrates, apheresis platelet concentrates, granulocyte concentrates, fresh frozen plasmas, and cryoprecipitate and whole blood. the ratios of transfusion associated expenditures to hospital costs were categorized in intervals of percentages as < %, - %, - % and > %. most of the patients ( . %) were ranked in the lowest interval. the medians for hospital cost and transfusion associated cost were . euros (iqr = . ) and . euros (iqr = . ), respectively. a significant strong positive correlation between numbers of transfusions and hospitalization cost of picu was detected (r: . , p < . ). while it was found a significant weak positive correlation between transfusion associated cost and hospital cost (r: . , p = . ) there was also a significant weak positive correlation between the age and transfusion associated cost (p = . , r: . ). a significant difference was found between the patients with and without hematological malignancies (p < . ) for transfusion associated cost. the reason why pediatric dosages are mostly prefer is that the hospital provides healthcare for only children and splitting of the blood components was common in the hospital. but unexpectedly a significant increase on the transfusion associated costs which is related to split blood components was detected (p < . ). summary/conclusions: studies on the economics of blood transfusion have been conducted mostly in patients who require chronic or multiple transfusions. picus, specialized facilities that provide care for patients with severe life-threatening diseases are major departments often necessitate multiple transfusions. there are many variables to evaluate the impact of transfusion associated cost to hospital cost in picu patients, but the major factors are underlying conditions, admitting diagnoses and transfusion strategies. although there are unexpected data in our study demonstrated the increasing impact on transfusion associated cost originated from blood components split for pediatric usage no significant relationship was determined to explain this situation. further studies on the economics of blood transfusions have to be carried out to clarify the variables of transfusion associated costs. background: approximately . % of the transfused blood component is packed red cell (prc). over ordering of prc unit is a common practice and excessive pretransfusion testing was being wasteful of resources and have adverse consequences on cost. high crossmatch to transfusion (c/t) ratio as quality indicator of blood bank implies that crossmatches were performed unnecessarily. aims: the aims of this study were to evaluate the cost effectiveness of strategies for limiting the number of pretransfusion testing of ordering prc. methods: all prc units who ordered from dr. hasan sadikin hospital from january to december were collected in this retrospective study. number of ordering prc unit, completed pretransfusion testing of ordering prc units, and prc units that were transfused were recorded. restrictive pretransfusion testing strategies were done based on the hemoglobin level and diagnosis as transfusion indication criteria. cost effectiveness was measured by multiplying the unit cost of pretransfusion testing and number of prc unit. results: out of total , ordered prc unit, , ( . %) were subjected to pretransfusion testing and . % ( , ) of ordering prc unit which are pretransfusion testing were transfused. this means that . % ( , ) of ordering prc unit were not subjected to pretransfusion test. this showed savings of , , , rupiah. c/t ratio was . which demonstrate a good ordering pattern. however, . % ( , ) of completed pretransfusion testing of ordering prc unit were not transfused, leading to blood bank loss of , , , rupiah. summary/conclusions: strategies for limiting the number of pretransfusion testing on the good c/t ratio was still associated with saving cost effective background: blood is a precious resource for saving patient lives. the purpose of blood and blood component therapy is to provide suitable and safe blood products to achieve best clinical outcomes. nurses have an important role in ensuring safe blood transfusion. it is crucial for nurses to have sufficient knowledge about blood donation and collection, storage, component preparation, possible adverse effects of blood transfusion and necessary management and care. aims: the aim of this study was to assess the impact of an educational intervention on knowledge and awareness of nurses regarding blood transfusion services and practices. methods: the baseline study to assess the knowledge and awareness regarding blood transfusion services and practices of the nurses posted at various areas of the hospital including wards, operation theatres and critical care areas was carried out at our institute hospital which is a tertiary care teaching centre. the nurses were then sensitized and educated regarding blood transfusion services and practices during their day to day activities by referring them to the blood transfusion guidelines of the institute. subsequently, a self-developed questionnaire which was used for the baseline assessment of knowledge and awareness of the nurses was again used to reassess them. a total of questions were included in the questionnaire pertaining to: general awareness (two questions), blood donation (two questions), testing and blood component preparation related (two questions), storage of blood/blood components (two questions) and pre-transfusion checks and bed side transfusion practices (eleven questions). fifty nurses each were included for both the baseline as well as post-sensitization assessment. for different category of questions, the correct response rates were compared with those obtained in the baseline study using mann-whitney test. the entire study duration was spread over a period of three months (december, to february, . results: the overall mean percentage of 'correct' responses for questions in the baseline study was . %, whereas post sensitization it was . %. the mean percentage increase in general awareness related questions was . %, . % for storage of blood/blood components related questions, . % for pre-transfusion checks and bedside transfusion practices related questions, . % for testing and blood component preparation related questions and . % for blood donation related questions. the percentage increase in correct response was found to be statically significant for each of the five categories of questions. the overall mean percentage increase in correct response rate was also statistically significant (p < . ). summary/conclusions: this study revealed that after sensitization and educational intervention there was a significant improvement in the knowledge and awareness of nurses regarding the blood transfusion services and practices. abstract withdrawn. background: tact, introduced in the uk in to support managers, provides resource-saving, continual, 'real-time' monitoring of knowledge-based competency of staff in transfusion laboratories. tact is available online / , complementing existing practical competency schemes and external quality assessment. multiple variations on a standard pre-transfusion testing scenario are generated using constrained randomisation; logic rules for automatic assessment of sample acceptance, abo/d, antibody screen and identification (as/id), and component issue are based on bsh guidance. during , tact was offered internationally to transfusion laboratory managers to trial, and saw uptake in five countries. the core tact programme, based upon uk guidelines, is under review for programming conversion, to be customisable for the international community. aims: to assess the feasibility of tact programming conversion to meet the requirements of country-specific pre-transfusion testing guidelines, and to direct future programming in line with feedback from international users. methods: guidelines from / international users were obtained and translated where necessary. these were compared against the core assessment elements of current tact programming. international users were approached for their feedback on the current version of tact, as it compared to their local policies and practices. results: the following criteria were cross-referenced: specification of transfusion request forms, sample label acceptance criteria, reagents used for abo/d and as/id, resolution of grouping anomalies, alloantibody confirmation/exclusion, and selection criteria of blood components for transfusion-dependent patients and women of child-bearing potential. apparent differences included:-australia:--selection of red cells for patients with immune anti-d. greece:--inclusion of the name of the patient's father on the transfusion request. italy:--testing of all new patients with an anti-a,b reagent and two different monoclonal anti-d reagents. international users in the same three countries supplied feedback. this included suggestions for:-greater complexity of cases presented, provision of patient history, inclusion of follow-on tests e.g. phenotyping and cells for antibody confirmation/exclusion, broader range of reaction strength grading, and official professional cpd credits. the following differences were noted:-nomenclature used, the format and content of the request form, use of english abbreviations of patient clinical details, and the availability, provision and specification of blood components. summary/conclusions: this analysis has shown very few instances where the current tact iteration differs from the guidelines reviewed, and that it is feasible to expand the use of tact on a more international basis. the current iteration of tact has been developed to represent an abbreviated scope of pre-transfusion testing practices, which can be applied to laboratory practice outside of the uk without difficulty. further work is required to enable international users to configure tact such that the system represents all laboratory practice on an international basis. aims: these courses provide education to clinicians on patient blood management and safe transfusion in neonatal and paediatric settings in order to improve patient outcomes and increase awareness of the national patient blood management guidelines. this analysis aimed to investigate the uptake, practical use, and perceived value of the courses by learners. methods: a retrospective analysis of course completion statistics and course evaluation data. results: there have been , paediatric and neonatal courses completed from march to february with . % of learners being nurses and/or midwives. analysis of course evaluation data (n = ) showed that these courses: -provide knowledge ( . %) -improve patient safety and outcomes ( . %) -result in change to clinical practice ( . %) -are relevant to clinical practice ( . %) -are easy to use ( . %) -are readily accessible ( . %). examples that learners provided of how they can apply this learning to their clinical practice include: -"[i am now] more aware of special requirements for neonatal blood transfusion" -"[i] feel more confident especially when talking with parents" -"[i will now be] checking the patient's blood results and will speak up for unnecessary blood sampling" -"[it's good that] when there is ambiguity in clinical practice [this is] very well shown by explanation from experts in the field" -"we don't do a lot of transfusions [and this is] a reminder that transfusions are not always the first answer to the baby's clinical picture". summary/conclusions: analysis of course and user evaluation data demonstrates that these courses are being used by nurses and doctors working in the neonatal and paediatric settings and that they provide knowledge of pbm that can be applied to clinical practice, thereby contributing to improved patient care. background: blood transfusion is a high-risk clinical activity that must be mastered both theoretically and practically in order to guarantee the required result without any incident or complications. the mastery of transfusion knowledge among nurses represents a very important link in the transfusion chain. the objective of this work is to compare the theoretical and practical knowledge of transfusion among two groups of nurses divided according to their seniority. aims: this is a cross-sectional descriptive study conducted over a period of month [ st april- th april] . we selected two groups of care staff: the st group consists of students at the end of their training at the higher institute of nursing sciences. the nd is made up of nurses working in university hospitals of tunis, currently practicing blood transfusion. the evaluation's tool used was a questionnaire of simple or multiple choice questions, were related to theoretical knowledge of labile blood products and to transfusion practice. ten questions were considered "life-threatening" if their answers were false. a comparative study was made between the two groups. methods: this is a cross-sectional descriptive study conducted over a period of month [ st april- th april] . we selected two groups of care staff: the st group consists of students at the end of their training at the higher institute of nursing sciences. the nd is made up of nurses working in university hospitals of tunis, currently practicing blood transfusion. the evaluation's tool used was a questionnaire of simple or multiple choice questions, were related to theoretical knowledge of labile blood products and to transfusion practice. ten questions were considered "life-threatening" if their answers were false. a comparative study was made between the two groups. results: the participation rate in the survey was %. the nd group participants had an average seniority of years . more than half of them ( %) had seniority of less than years. only % had more than years of experience. the rate of correct answers for all items combined was . % for students versus . % for practicing nurses. the theoretical knowledge part was more mastered in the st group than that of practicing nurses ( . % vs . % of correct answers). on the other hand, the control of the transfusion act was better in nd group ( % vs . %). the overall "dangerous" response rate was % for students and . % for practicing nurses. false practical knowledge was more common in group ( . % vs. . %). summary/conclusions: the theoretical as well as the practical knowledge remains not well mastered by the care staff. our study highlighted the best theoretical mastery for young students and practical for practicing nurses. this could be explained by the freshness of knowledge in the first group and the daily practice in the second group. background: the european commission (ec) directive / /ec on blood donor selection criteria is years old. in the meantime, knowledge on risks related to blood donor selection has progressed and challenged several obligatory rules. transpose -transfusion and transplantation: protection and selection of donors, is a european commission co-funded project with participation of more than stakeholders from both not-for-profit and private organizations providing substances of human origin (soho). the project aims to provide evidence-based donor selection criteria and guiding principles for risk assessment of threats to the safety of soho. as part of this work, an inventory of current blood donor selection criteria in europe and an evaluation of the evidence behind current practice was performed by experts working on this project. aims: to identify the gap between the ec directive / /ec on whole blood donor selection criteria and a current evaluation of the clinical relevance of the criteria based on scientific literature by a panel of european experts within the transpose project. methods: in , we performed an inventory of blood donor and transfusion recipient risks in participating european countries. project members were asked to provide the existing donor selection criteria related to these risks and to carry out a risk-based evaluation for each of them. the evaluation was based on the available scientific literature and on a risk assessment template based on the abo risk-based decision-making framework, developed by transpose. all risks with divergent assessments within the panel were resolved through discussion; in all cases an expert consensus was established. subsequently we compared the results with the content of the ec directive / /ec for every risk, thereby identifying discrepancies and missing items in the directive. results: the panel identified risks considered to be significant, distributed between donors and recipients. for / ( %) of them the expert evaluation deviated from the content of the ec directive, or the ec directive provided no information about the decision making. in particular, a discrepancy was observed for / criteria concerning general health and medication, / for transfusion transmissible infections, / for high-risk behaviour and travel, and / for other diseases. summary/conclusions: our results highlight a significant gap between the whole blood donor selection criteria stated in the ec directive / /ec and the scientific evaluation performed by a panel of transpose participating experts. this gap includes both new risks not addressed in the ec directive and addressed risks that are however evaluated differently. this involves both blood donor and transfusion recipient safety, and various medical and epidemiological topics covering several aspects of the blood donation criteria. we strongly recommend a change in the european legislation, allowing a procedure to guarantee that blood donor selection criteria are updated regularly within the framework of the european institutions, to keep aligned with scientific progress, epidemiology and changes in medical practice, in order to enable an updated risk-and evidence-based framework for donor selection criteria. the risk-assessment method elaborated in the transpose project is a valuable instrument for this purpose. background: the brazilian health regulatory agency -anvisa has developed the method for assessment of potential risk in hemotherapy services (marpsh) which is based on the data collected during the inspections of blood services carried out by regulatory authorities. using marpsh any blood service can be classified in one of possible potential risk categories: high, medium-high, medium, medium-low and low risk. each category represents a different potential risk level, according to the proportion of compliance with the established regulatory requirements. marpsh has been used since , showing a trend of risk reduction on blood services evaluated all over the country. aims: this work aims to describe the utilization of marpsh as a tool for an integrated risk management model. also, it shows the main results obtained after years of data monitoring and coordination of regulatory actions and policies by anvisa, targeting quality and safety of blood products. methods: the utilization of marpsh follows a network risk management model since the inspections are carried out by decentralized organs in all states and some municipalities. the inspectors fulfill a standardized inspection guide containing the regulatory requirements, where each item is associated with a level of risk, varying from i to iii as the risk increases. at the end of the inspection, after a statistical calculation, the service is categorized. this classification gives an estimate of its quality profile, guiding the adoption of suitable measures for risk management by local authorities and services. these data are send to the states (if realized by municipalities) and to anvisa that perform consolidation in a national level. either states or anvisa use data to coordinate risk management measures in a broader spectrum. data are continuously monitored by anvisa as part of its strategical panel of indicators. anvisa follows up specially blood services in high and medium-high risk with the aim of helping or complementing local authorities' actions. additionally, anvisa periodically sends this information to the brazilian ministry of health and local governmental organs from brazilian national blood system that also support actions to improve quality in their blood services networks. results: since , when the assessment covered blood services, marpsh reached blood services in ( % of the blood services registered) what corresponded to almost % of the inspection cover in this year. over this period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) it is possible to notice a dramatic decreasing in trend for proportion of blood services classified as high and medium-high risk, varying from % to %. summary/conclusions: marpsh generates data necessary to the categorization of blood services into five levels of potential risk. as a result, the regulatory actions are applied by local organs with the purpose of reducing or eliminating risks involved in the production and use of blood components. data have shown a significant risk reduction over years of marpsh's utilization. additionally, monitoring of this data at a national level has been permitting appropriate planning and prioritization of integrated strategies directed to risk management and strengthening of blood services in brazil. background: sub-saharan africa has the highest need of blood transfusion in the world, mainly for childbearing women and children suffering from malaria. meeting basic quality and operational requirements to provide patients with safe blood remains a challenge in these settings. aims: the aim was to identify and prioritize potential hazards for patients in blood bank practices in the democratic republic of the congo (drc). we focused on two subsets: (i) sensibilisation and selection of donors, and (ii) qualification and production of blood products, using failure mode effect analysis (fmea). methods: two risk analysis workshops were organized at the national blood transfusion centre in kinshasa, the democratic republic of the congo. in both workshops, a multidisciplinary team was invited to represent different hospitals and profiles in transfusion management in drc: quality coordinators (n = ), training coordinator (n = ), medical doctor for donor selection (n = ), hemovigilance officer (n = ), laboratory technicians performing donor sampling, blood qualification and production (n = ), biomedical scientists (n = ), microbiologist (n = ), clinical biologist (n = ), nurse (n = ). the principle of fmea was applied, which implies identification of possible hazards (failures) in a process flow, followed by scoring each hazard according to their impact, probability, detection and feasibility. in the both workshops, participants were guided by an external facilitator who guaranteed common understanding of the methodology. main focus of the risk analysis was potential harm to the transfused patient in the process of (i) sensibilisation and selection of donors, and (ii) qualification and production of blood products. all ideas were written on coloured cards and mapped on a chart according to their impact, probability, detection and feasibility score. hazards were ranked according to their final risk score by multiplying these four scores. results: in the process of sensibilisation and selection of donors, the three hazards with the highest final score for impact, probability, detection and feasibility were: (i) a paid donor is recruited after sensibilisation by family members of the patient, (ii) donor selection staff approves a non-eligible donor for blood donation because of personal/financial motivation, (iii) blood donors are not correctly informed about blood donation during sensibilisation by family members of patients. in the flow of qualification of blood products, highest scores were made for: (i) no double check for validation and sorting of qualified blood products, (ii) stock-out of reagents, (iii) no check for match between registered test result and tested blood tube. regarding production of blood products, the top three consisted of: (i) transport time between blood collection and processing is > h, (ii) storage of qualified and quarantined blood products in the same fridge (some sites only), (iii) power cuts. summary/conclusions: the risk analysis resulted in three prioritized hazards in the process of donor selection/sensibilisation and blood product qualification/production. some are very specific to the sub-saharan african setting and have been described before (power cut, family and paid donors, stock rupture,. . .). an action plan needs to be put in place to reduce their final risk score. the risk analysis needs to be continued for the remaining blood transfusion flows. background: . million of germany's population, so just under a quarter of residents, have a migration background. the majority of these has roots in regions where the population has a distribution pattern of blood group and hla-antigens that differs considerably from the predominant one in the german population. sufficient supply of these individuals with red blood cell (rbc) and platelet concentrates (tc) will continue to be a major challenge in the future, as blood donors with compatible blood group antigens are dramatically underrepresented in the local donor pools. many migrants suffer from severe hematological disorders such as b-thalassemia or sickle cell disease and will not only need compatible blood transfusions, but an allogeneic stem cell transplantation in the foreseeable future. as healthy family donors often are not available, at present suitable stem cell donors with a similar genetic background can only be found in international donor registries. aims: this project was initiated to recruit new donors with a migration background for blood donation and to increase the number of blood stem cell donors among this group. methods: serological extended blood group phenotyping was performed by automated gel card technique (fa. grifols, erytra) and included ab , rh (ccdee), kk, fy (ab), jk(ab), lu(ab), m, n, s, s. hla typing for hla-a, -b, -c, -dr, -dq, and -dp was performed by next generation sequencing. allele frequencies were analysed using genepop version . ; the rare and very rare alleles were defined according to the allele frequency database (www.allelefrequencies.net) rbc genotyping using next generation sequencing is currently being established and will include additional antigens with the most frequent distribution pattern differences between migrant and resident populations according to literature. results: so far, more than blood donors with a migration background have been recruited for a blood donation in this project. amongst this group, over blood donors from more than non-european countries enrolled as potential stem cell donors. an initial evaluation of the data revealed a very similar distribution of blood groups compared to the current blood donor population in north rhine-westphalia. of migrant donors, ten fy(a-b-) donors were identified, which corresponds to a percentage of . %. amongst hla-typed potential stem cell donors, we found ( . %) with rare and very rare alleles. summary/conclusions: blood donors with rare blood group and hla phenotypes (e.g. null types such as fy(a-b-)), are in demand for adequate medical care of people with a migration background. the technological development of blood group determination by next generation sequencing will significantly improve the supply for all blood transfusion recipients in germany. this project is funded by the european development fund - (erdf) and the european union. background: mortality due to uncontrolled haemorrhage following trauma is the most important cause of potentially preventable deaths. trauma care systems in low and middle income countries like india, are still in developing phase. also, the role of blood component therapy in improving patient outcomes has been mostly derived from combat settings. application of these protocols in an urban setup has not been well established and marked variation in practice exists. hence this study aims to identify the key components of transfusion practices to optimize the transfusion protocol in trauma settings. aims: to study the current transfusion practices in severely injured trauma patients, admitted to the red area/resuscitation bay after initial triage in ed methods: this prospective observational study was conducted over a period of year starting from june to may at the department of transfusion medicine in collaboration with emergency department at jpnatc, aiims, new delhi. the study included severely injured patients (iss ≥ ) that were admitted within h to the red area/resuscitation bay after triage. data collected included the demographics, injury, laboratory and transfusion details for these patients results: during the study period patients ( . % males) were enrolled. mean iss scores was . . mean time to hospital admission after injury was : (iqr . - : ) hours. mean time to first rbc transfusion following admission was : (iqr : - : ) hours. approximately . % ( ) patients were in shock (sbp < mm hg &/or pulse rate > /min). whereas, ( . %) patients were coagulopathic (pt ≥ . times of normal). during initial h of admission, these patients were transfused with ( . %) rbc, ( . %) ffp, ( . %) rdp and ( . %) cryoprecipitate of total blood components utilized for these patients. massive transfusion (defined as transfusion of ≥ units/ h) was given to ( . %) patients. summary/conclusions: significant quantity of blood components were required during initial resuscitation in severely injured patients. pre-hospital transfusion can significantly reduce the time to transfusion. further studies are needed to assess utility of pre hospital transfusion in severely injured patients. background: allogenic stem cell transplantation recipients are known to be the main consumers of platelet concentrates (pc). the geneva university hospital is one of the three allogeneic hematopoietic stem cell transplantation (hsct) centers in switzerland. since the blood center is also part of the hospital, data of pc consumption are easily available. as needs rose steadily since several years, with an average increase of % per year, pc supply is a serious concern for our center. aims: in this study we tried to evaluate if any pre-transplant indicator could help to forecast the number of pc needed after an allogeneic hematopoietic stem cell transplantation. methods: this observational retrospective study was conducted in geneva hospital on patients suffering from various inherited or acquired disorders of the hematopoietic system who were treated by hsct in . pc consumption was examined from january to december . the five indicators were: gender, stem cell source (bone marrow (bm) vs peripheral blood stem cell (pbsc)), donor type (hla matched ( - / ) vs haploidentical), conditioning regimen (standard vs reduced intensity), and cmv serology of the recipient. results: data for a total of patients aged from to years were analyzed; ( %) were male and ( %) female; ( %) were cmv-negative and ( %) were cmv-positive. out of a total of transplants, ( . %) were haploidentical and ( . %) hla-matched. according to the stem cell source, bm was transplanted in cases ( . %), and pbsc in cases ( . %). two patients also received a cd + stem cell boost. our analysis showed that, with a mean follow-up of days, the number of pc transfused to our patients treated by hsct ranged from to units, with an average of and a median of , illustrating a high variability. the results indicated that gender, stem cell source (bm vs pbsc), conditioning regimen (standard vs reduced intensity), and cmv serology of the recipient do not have any statistical impact on platelet consumption. however, we observed a tendency of an increased need for platelet transfusion when patients were cmv positive. our results also showed a statistically significant (p = . ) higher number of pc transfused for patients treated with a haploidentical ( ) versus hla-matched ( ) transplant. summary/conclusions: this study points out the high variability of platelet consumption after hsct, which limits the forecast of platelet production needed to support allogeneic hsct recipients. a larger cohort would be required to confirm a potentially higher platelet consumption in cmv positive patients, and to consolidate our results showing a higher pc consumption for patients treated with haploidentical transplant. abstract withdrawn. background: historically at our institution, a minimum of four red blood cell (rbc) units were crossmatched for all cardiac surgery cases regardless of surgical case-type or patient characteristics. two rbc units were packed in validated blood product coolers and brought to the operating room (or); the balance of crossmatched units remained in the blood bank. a retrospective review revealed that very few rbcs were transfused ( : % ( / ), : % ( / )). moreover, approximately products were wasted each month as a direct result of this practice. thus, we recognized an opportunity to improve inventory management in terms of personnel activities and blood component utilization. aims: the goal of this study was to reduce advance preparation of coolers in cardiac surgery cases without compromising patient care and safety. we limited our intervention to those patients who were eligible for electronic crossmatch. we maintained the aforementioned historical practice for those patients with history of and/ or those who currently demonstrated clinically significant red blood cell alloantibodies. methods: a multidisciplinary group consisting of representatives from the blood bank, cardiac surgery, cardiac nursing, cardiac anesthesia and surgery quality department was assembled in october to determine whether a modification of practice was reasonable and safe. group members evaluated site specific society of thoracic surgery (sts) cardiac surgical data between july and december to establish intraoperative red cell transfusion rates classified by type and urgency of surgery. the group's main goal was to discontinue preparation of default coolers for patients eligible for electronic crossmatch who were scheduled for all types of non-emergency cardiac surgery cases in which ≤ % of historical cases required at least one red cell transfusion. additionally, team members simulated the multiple protocols by which red blood cells could be prepared and delivered to the or and estimated the time for each scenario. results: review of sts data showed that the following cases met the criteria of ≤ %: elective primary coronary artery bypass graft (cabg), urgent primary cabg, elective mitral valve repairs, and elective aortic valve replacements. simulation showed that, in patients eligible for electronic crossmatch, preparation from receipt of order to completion of unit packing for delivery took . min using the pneumatic tube system (maximum of units per tube) and . min using delivery of a cooler using a human courier. summary/conclusions: based on the simulation results, and with consensus agreement from the multidisciplinary group, default cooler preparation for elective primary cabg, urgent primary cabg, elective mvr, and elective avr was discontinued in december . one year following implementation of the change in policy rbc units were issued to the or (a % reduction); % ( ) were transfused, compared to % in . wastage rates decreased from products a month to per month on average. summary/conclusions: the most obvious drawback of pabd is the higher cost in running the program in comparison with collection of allogeneic blood in the areas of additional patient attention and clerical input in labeling, separate storage and so on. in this audit, % of the autologous blood components were not transfused into the intended recipients and wasted; in this context, the pabd program could not be considered as a cost-effective approach in protecting blood safety. background: the national blood service zimbabwe (nbsz)'s blood supply management status (bsms) is an integral process of ensuring the availability of a safe and sufficient blood supply provision. nbsz introduced a new daily blood bank statement with improved metrics from may . the new analytics approach focuses on three interactive components of the blood bank statement; the available stock, quarantine stock (as per the desired -days stocks level), and the demand versus supply. it is imperative to have a closely monitored blood supply chain because blood has limited shelf life with uncertainties in both supply and demand. the 'blood-for-free' proclamation by the government of zimbabwe in july set more pressure on the blood demand. these metric-based analytics seek to assess if the nbsz's improved blood bank statement is a realistic model for the bsms. aims: to assess the use of the interactive metrics in monitoring the blood supply management status. methods: a prospective cross-sectional study was conducted. a total of daily blood bank statements which were submitted between may and december from each of the five branches were analyzed. the bsms which is calculated as the average of the three interactive measures of quarantine stock, available stock and demand versus supply was determined. sub-analysis of branches was done to determine individual branch performance. analysis by month was done to assess seasonal variations. findings and recommendations were shared among key stakeholders to validate the bsms methodology. results: overall the quarantine stock average was . % (sd +/- . ), the available stock was . %: (sd +/- . ) and the demand versus supply was at . % (sd +/- . ).the overall bsms was . %; (sd +/- . ) for the study period. gweru and masvingo nearly supplied all the demanded blood with . %, overall bsms of . % and . %, overall bsms of . % respectively. bulawayo supplied . % of the blood demanded with an overall bsms of . %. mutare supplied . % with a bsms of . % and harare . % and a bsms of . %. there were monthly variations but the service could supply above % of the blood demand. in the month of may the service met . % of the demand and a bsms of . %. in november and december it supplied . %, bsms of . % and . %, bsms . % respectively. august also had a below average supply of %, bsms - . %. june, october and september recorded above the average values; . %, bsms of . % and . %, with a bsms of . % respectively. summary/conclusions: the overall bsms performance was satisfactory and it was noted that branches capacitated according to demand. the new interactive analytics approach is appropriate for showing the blood bank status and assessing the performance of the branches. this new approach has optimized the decision-making process in blood supply management. the metrics are tracked using excel based model hence this approach is suitable for resource constrained settings with limited ict infrastructure . st vincent's hospital melbourne (svhm), a tertiary hospital supporting medicine, surgery and non-major trauma emergency and itu services implemented a mtp in . subsequent mtp reassessment has led to implementation of regular multi-disciplinary review of all mts to identify areas for improvement in transfusion and other aspects of support for critically bleeding patients. aims: to implement a systematic service-wide stakeholder review of mt events at svhm aiming to identify deficiencies and implement improvements in mt management. methods: a multi-disciplinary mt review team was established as a subcommittee of the hospital transfusion committee (tc) to update the organisational mtp in and subsequently continued to meet quarterly as the mt review subcommittee (mtrs) of the tc, systematically reviewing all aspects of mts at svhm. instances where or more red cell units are transfused in < h are identified from the laboratory information system and reviewed by the mtrs which includes representatives from accident and emergency, intensive care, operating suite (os) and transfusion laboratory staff; the head of the patient's treating unit is also invited to contribute. reviews include: demographics, clinical details, comorbidities, time from patient arrival to pre-transfusion specimen collection/receipt, time from blood request to release/transfusion, regularity of full blood examination (fbe)/coagulation (coag) testing, timing of blood component transfusion, total component provision/ratios, component waste, patient outcome, and communication between various clinical areas and also the laboratory. a discussion summary with actions/ recommendations is provided to the tc and some cases referred to the hospital mortality/clinical review committee. results: cases reviewed: from treating units including cardiothoracic surgery ( ) hepatobiliary/gastrointestinal/colorectal surgery ( ), vascular surgery ( ), neurosurgery ( ), orthopaedic surgery ( ), endocrine ( ) and "other" (encompassing general surgery, urology, general medicine and oncology - ). areas for monitoring/improvement identified: transfusion documentation, regularity of fbe/coag specimen submission, reducing time between patient arrival and specimen collection, reducing specimen transport time, interfacing point of care bloodgas analysers to the central pathology result management system as well as component management/waste reduction and the introduction of viscoelastometry assessment in the os. of reviewed cases involved the transfusion of emergency uncrossmatched o rhd negative red cell units. the appropriateness of the use of this precious resource is also reviewed by the mtrs. summary/conclusions: the svhm mtrs meets regularly to review mt events and formalise multidisciplinary collaboration in identifying possible improvements to support these often critically ill patients. matters highlighted include communication issues, delays in specimen delivery and blood component waste minimisation. areas for further work include minimising delay between mt events and review, and formalisation of key performance indicators for mts. background: the use of radio frequency identification (rfid) technology to manage the blood supply chain is recognized as a major enhancement to the operations of blood banks and hospital transfusion services. to facilitate optimal blood supply management, it is crucial to guarantee the integrity of rfid tags throughout the transfusion chain. since rfid tags can be affixed to blood products very early in the process, these tags undergo the same process-steps as the blood products themselves (e.g. centrifugation, label printing, shock-freezing and irradiation). aims: the goal of this study was to validate the mechanical and functional resistance of biolog-id rfid tags through different blood related processes: centrifugation, label printing, shock-freezing, intensive reading at À °c, and irradiation. biolog-id tags are passive hf ( . mhz) tags. they are compliant with is , iso - and follow the guidelines for the use of rfid technology in transfusion medicine (vox sanguinis, ). methods: biolog-id tags were evaluated using a series of rfid encoding and reading tests. before each of the processing steps, each tag was encoded with donation number, site id, product code, blood group and expiry date. the data was encoded using the isbt format. the different processing steps and conditions tested were: -centrifugation: quintuple whole blood bags, filled with ml water. centrifugation at , rpm for min. tags processed, tags per kit affixed at different positions. -shock-freezing at À °c: shock-freezer (angelantoni, sf ), units processed, reading immediately after removal from shock freezer. water, tags irradiated at gy and tags at gy results: all biolog-id tags were encoded and read with a % success rate in all series of tests. summary/conclusions: biolog-id rfid tags can be encoded and read through common processes used throughout the blood transfusion chain. their mechanical and functional integrity is not affected by centrifugation, shock-freezing, intensive reading at À °c, printing, eto sterilization and irradiation. background: the provisioning of compatible red blood cells by international cooperation is presented. the units were meant for an -year old female, with homozygous sickle cell disease (scd) and multiple complications. patients' blood group was a positive with anti-c, -e, -wr a and an antibody to a high prevalence antigen in the rh system, anti-hr b possibly combined with anti-hr b (rh ). the antibody was not reactive with rh null , -d-or hr b negative cells. the donor center put out an international request for group a or o, rh null or -d-units lacking wr a and possibly k, fy a , jk a , wr a , do a and s (the latter antigens for prophylactic matching). the patient sample had been genotyped for rhd and rhce using mlpa and sanger sequencing and the patient was found to carry rhd* /rhd* n. and rhce*cevs. / rhce*cevs. . aims: the request was sent to the american rare donor program (ardp). the ardp working with the american red cross national molecular laboratory, used the rh genotype information to identify donors carrying the same or similar rh variant alleles using the rh allele matching approach described previously (keller et al. transfusion ( s): a). methods: a recent blood sample was used to confirm anti-hr b ; no anti-hr b was detected. the patient rhd and rhce alleles were used to build punnett squares for both genes with donors carrying the same and similar alleles that would be predicted to be compatible. tier donors are those predicted to carry the same combination of rhd and rhce alleles as the patient. tier donors are those predicted to be homozygous for one of the allele combinations carried by the patient. tier donors are those predicted to carry alleles similar (but not identical) to those carried by the patient, with similar predicted phenotype. the database of donors in the ardp carrying rh variant alleles was queried against the alleles in the patient-specific punnett square. results: donors of group a or o and matched for rh alleles were identified as follows: tier , tier and tier donors. after the clinical team agreed to drop one or more of the prophylactic antigen matches, one tier unit lacking s and jk a was identified at the american red cross. while the request was being processed, the patient experienced a sickle cell crisis, red cell aplasia and recurrent aiha and her hemoglobin level dropped from to . g/dl. at that time, she was transfused the only compatible units available - of the rare -dphenotype and her hb increased to . g/dl and eventually to g/dl. the tier rh allele matched unit was shipped to amsterdam where it was frozen, and reserved for the transfusion care of this patient. summary/conclusions: this case illustrates how rh allele matched blood can be found for a highly rh alloimmunized patient, and can avoid use of the exquisitely rare -d-or rh null blood. background: blood transfusion has been a complicated and high-risky clinical procedure. any error could cause serious injuries to patients. to better assure the procedure safety. aims: we enhanced and built a blood transfusion database platform and develop inventory management strategies to better guarantee the patient transfusion safety. methods: we designed six new features of the platform ( ) assuring the patient identification with barcode techniques; ( ) designing a structured order entry; ( ) proactively reminding the physicians with patient's previous blood transfusion reaction with related precautions including the use of leukoreduction filter; ( ) automatically reminding physicians the happening of reaction and suggesting relevant test; ( ) building a complete traceability log system; and ( ) supporting data analysis. the blood transfusion safety team includes medical technologists, nurses, physicians, system analysts, and blood transporter and the whole process is electronic management. the new blood transfusion platform integrated the workflow, reduced the incidence of abnormal blood samples collected ( % after implementation, p < . ), reduced the time of call for medical technologists with blood component preparation and improved the achievement rate of emergency -min blood crossmatch ( . % after implementation, p < . ). the barcode correctly identified patients and monitored the entire transfusion process to reduce the error rate of blood component supply ( % after implementation, p < . ). summary/conclusions: after the transdisciplinary team approach with e-monitoring and a better design of clinical decision support module with barcode technology, blood transfusion database platform improve the blood supply efficiency and assure blood transfusion safety. background: in the modern world, terrorist acts are characterized by a multiplicity of combined injuries to a large number of victims. qualified medical care is urgently required for a large number of patients in one locality at the same time. it leads to increase in emergency demand for blood components, mostly red blood cells. the desire to donate blood to the victims is a natural manifestation of society's solidarity in response to tragic events. however, donor activity and patient needs do not always correlate. aims: to analyze the donor activity during the terrorist attacks. methods: a retrospective analysis of donation activity in periods of terrorist attacks in moscow ( moscow ( - . the average daily blood donations' number (dbdn) before ta compared with the number of donations in day after ta and with the dbdn during days after ta. also the number of delivered rbc units (d-rbcu) daily before ta and daily in days after were compared. results: in - , terrible ta occurred in moscow: people died and more than were injured. with the explosion in subway in / people died, were injured. the number of d-rbcus increased by % on ta-day, and by % during next days. dbdn in the st day after ta increased , times, and in the next days - , times. second explosion in subway in / resulted in died, injured. the number of d-rbcus increased by % on ta-day, and by % during days. dbdn in the st day after ta increased , times, and in the next days - , times. in (explosion on market) resulted in died, injured. d-rbcus delivery increased by % on ta-day, and by % during days. dbdn in the st day increased , times, but decreased to , times during the next week. with subway explosion in people died, were injured. the number of d-rbcus increased by % on ta-day, and by % during days. dbdn in the st day after ta increased , times, and in the next days - , times. with the explosion in airport in people died, were injured. rbcus delivery increased by % on ta-day, and by % during next days. dbdn in the st day after ta increased , times, and in the next days - , times. summary/conclusions: an increase in donor activity is observed already the next day after ta and usually lasts for days, but does not correlate with the number of victims. the rbcs' delivery from blood bank increases in all cases on the day of the ta. therefore, the guarantee for patients is the maintenance of rbcs' stock, including cryopreserved ones. it is also necessary to promptly send excess of red blood cells harvested at the peak of activity to the cryobank. background: rh system is the major blood group system besides abo system. even after proper blood grouping and cross matching there is a possibility of alloimmunisation in recipients against the rh or minor blood group antigens like kell, mnss, duffy etc. in medical colleges which cannot bear the financial burden of complete phenotyping of patient and donor, implementation of rh & kell phenotypes match blood transfusion can play a major role in preventing alloimmunisation and adverse events in multitransfusion patients aims: to evaluate the efficacy of rh & kell phenotyping as a cost effective measure instead of extended phenotyping in multitransfused patients methods: study was carried out in the department of transfusion medicine, one of the biggest blood bank of the country with annual collection of , blood units. patients of thalassemia, aplastic anemia and leukemia were taken who required multiple transfusions. complete phenotyping was done initially of all the patients before transfusion. patients were taken as control and the other were taken as cases. blood units of healthy donors were chosen ( were males and were females). in all the donor units, identification of rh & kell phenotyping was done by the antigen antibody agglutination test by the erythrocyte magnetize technology on fully automated immunohaematology analyzer qwalys. these blood units were transfused to patients who had been selected as cases. in the control group, patients were transfused blood units which were not phenotyped for rh & kell but gel crossmatching was done. follow-up was done on these patients for transfusion reactions and at the end of six months they were evaluated for any alloimmunisation. results: at the end of months, no reactions were reported in cases receiving rh & kell phenotype blood and no alloimmunisation was seen on repeat phenotyping. the control group on the other hand reported reactions in cases ( . %) and phenotype at the end of three months showed alloimmunisation with 'e' antibody. the phenotypic frequencies of rh & kell blood groups in the population were comparable with other published studies. amongst the rh antigens (e) was the most common ( . %) followed by d ( . %), c ( . %), c ( . %) and e ( . %). thus 'e' was the most common and e was the least common of all the rh types. background: the prevalence of a particular blood group has an uneven distribution in different geographic areas and is largely determined by the national composition of the population. moscow is one of the largest city of europe with population of . million. the understanding of prevalence of red blood cells antigens (rbc-ag) among the population has great importance for blood banking planning. aims: to determine frequency and distribution patterns of transfusion-significant rbc-ag among donors in the moscow region. methods: the results of immunohematological studies on ab , rhesus and kell systems were analyzed retrospectively in blood donors for years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) in moscow. data collection and processing was carried out using the regional information system for transfusiology. rbc-ag detection (ab , rh, kell) systems was performed using microplate method (automatic immunohematological analyzer "galileo neo" (immucor, inc., usa)) and "ih- " (bio-rad laboratories, usa) with diagnostic cards. results: the most frequent blood group is a (ii) . %, (i) blood group . %, b (iii) . %, ab (iv) . % (n = ). rh(d+) was established as positive in the presence of antigen d and as rh(d-) negative in its absence. donors with weak variants of antigen d (du) were determined as rh (d+) positive. the ratio of rh (d+) and rh (d-) was . % and . %, respectively. donor's phenotype detection was routinely conducted from the year, therefore the number of donors was . the most common phenotype among donors ccdee ( . %), the second in frequency ccdee ( . %), the third in frequency rhesus negative phenotype ccddee ( . %) in the studied population. the ccdee and ccdee phenotypes were . % and . %, respectively. the most rare are ccdee ( . %), ccdee ( . %), ccddee ( . %). other options: ccddee, ccdee, ccdee, ccddee, ccddee, ccdee, ccddee were detected in single cases and amounted to a total of . % (n = ). cw antigen was tested in donors and was detected in . %. cw is most commonly found in donors with ccddee phenotypes ( . %), ccdee ( . %) and ccdee ( . %), with other variants of the data phenotype, the antigen was detected in . % of the examined (n = ). antigen k was detected in . % of donors, in . % of this antigen is absent (n = ). summary/conclusions: the study of transfusion-relevant antigens distribution in population is necessary for building of effective and flexible model for blood service managing. a differentiated approach in choosing a strategy to form a long-term bank for storing blood components, taking into account the frequency of various antigen variants, contributes to improving the quality, accessibility and safety of medical care. of dislocated division of our blood establishment in orthopaedic hospital valdoltra (obv) in the number of outdated units at the hospital side dropped considerably. results: since when the issued number of red blood cell units (rbc) was the amount of issued units rose to in and then dropped more or less steadily to in . in this period the hospitals' programmes rose for % in all areas. number of donated units declined from in to in . after reorganization in the number of outdated units fell from % of stocked units to . %. after setting a dislocated unit of ctdiz on obv location the number of discarded rbc fell from to in . for transfusion specialist who is constantly in contact with the clinician in the hospital the most important day routine is when the stock availability is displayed. it happens times a day; at a.m. when the previews' day collection is released and another three times a day when the updates occur. the central base is led in ljubljana (the capital) and all centres are able to control and order the stock for the blood banking. blood wastage remained low and the traceability of the blood usage in south-western region remains high ( %). though it is not supported by an informational system the traceability form the blood bank to the patient is done on paper. this issue demands a big effort by the staff in blood bank and in hospitals. summary/conclusions: reorganization enabled better stock utilization and traceability of issued units. sometimes it is impossible to predict the peak demand of rbc especially during the summer season when the population of the area doubles and car accidents as well. transfusion specialist's effort in assuring the optimal blood stock represents the crucial daily routine. blood bank, grande international hospital, kathmandu, nepal background: voluntary non-remunerated blood donor consists of % blood donor's population in nepal. therefore demographic about the distribution of blood donors according to the age group is important to achieve % voluntary nonremunerated blood donors in nepal. aims: to explore the demographic distribution of the blood donor in different age group in the kathmandu nepal. methods: this is retrospective study conducted at nepal red cross society central blood transfusion service. data from january to january were collected from donor management software. the data includes socio demographic data. data has been process with spss version - results: during years study period, total of , blood donation happened from both mobile blood collection and in-house blood collection. out of , collection, ( . %) are from - age group; ( . %) are from - age group ( . %) are from - age group; ( . %) are from group - age group; ( . %) are from age group - and ( . %) from age group above respectively. summary/conclusions: the distribution of abo blood group varies regionally and from one population to another. in kathmandu, nepal - years age group is the most common age group encountered donating blood. the data generated in the present study and several other studies of different geographical region of india will be useful to health planners and future health challenges in the region. background: the information system on hemovigilance sihevi-ins©, coordinated by the national health institute was available in to all blood banks in the country. this software allows to centralize and record the identification data of a donor, its infectious and immunohematological tests, as well as the fractionation and final destination of each blood component obtained from a donor. aims: to describe the abo and rhd typing discrepancies in blood donors found in the blood group variables registered by each blood bank to sihevi-ins©. methods: retrospective analysis of the information registered by of the blood banks authorized nationwide between january and december . results: sihevi-ins© received information of , accepted donors, % of them with more than one donation in the same blood bank in a period of months. a total of abo or rhd discrepancies were identified in people, who made donations in blood banks (estimated risk: one discrepancy per , accepted donors). five of the blood banks implicated in these discrepancies are hospital-based (annual average collection of , ae , units, representing . % of the national collect). the remaining blood banks are distributors (average collection: , ae , units per year, representing % of the national collect). % of blood group typing discrepancies (n = ) were related to the abo group. the most common discrepancy was between a typing group and ab typing group ( %) . in % of the cases, the same blood bank initially registered in the same donor, an o blood type donation and later an a blood type (n = ) or b type (n = ). rhd typing discrepancies account for % (n = ) of the total. additionally, in three donors, a simultaneous discrepancy between abo and rhd typing was detected in the same blood bank. the results could be due to: a) failure in the warning mechanism before the release of the blood component; b) errors in typing the information of the donor registered in the system or c) failures in the identification of the donors at the time of selection. the above shows risk in the process of control of blood components release, which can impact patient safety unless abo and rhd typing blood groups are systematically verified before transfusion. summary/conclusions: despite blood banks have a verification and validation process through software to release blood components, flaws were detected. although sihevi-ins© is not a software to validate the information before the release of blood components, it was through this program that abo and rhd typing discrepancies were identified in donors who attended the same blood bank multiple times. this finding implies increasing the controls that should be used in each blood bank, to avoid lose traceability of the processes and to put at risk the life of the recipients. blood donor testing department, blood transfusion institute of nis, nis, serbia background: the ability to automate blood grouping and antibody detection procedures is a requirement for blood donor testing laboratories. mistakes in the sample identification and testing procedures could be prevented by testing on automated immuno-hematology systems. irregular antibody screening and abo/rhd grouping of blood donors are tests performed routinely in blood transfusion institute of nis. neo iris (immucor, usa) is a fully automated instrument for the abo and rh d grouping using microplate hemagglutination technique and antibody screening and identification using solid phase red cell adherence (sprca). aims: evaluation of the automated neo iris system for abo and d grouping and irregular antibody screening of blood donors in blood transfusion institute of nis. methods: during the evaluation period a total of edta-anticoagulated samples for abo and d forward and reverse grouping using microplate anti-s, anti-s, anti-jka and anti-k. in one case ih- failed to identify anti-c antibody in very low titer in sample with anti c+d antibody presence. in two samples ( . %) false-positive result were observed both on ih- system and neo iris and in two cases ( . %)only on neo iris due to nonspecific reasons. summary/conclusions: abo/rhd grouping results obtained on neo iris system, using microplate method, have a good correlation with results on ih- system as our routine column agglutination method. for antibody screening and identification neo iris showed high sensitivity for detection of clinically significant antibodies which is important step for increasing blood transfusion safety. background: continuing improvement of laboratory quality to provide accuracy test results for precise diagnosis and treatment is the mission of advanced laboratory. immunogenetic testing for histocompatibility including human leukocyte antigen (hla) typing, hla antibody detection and cytotoxicity test is critical for diagnosis and evaluation of transplantation and prognosis monitoring. in order to improve the quality of experiment competency, an external quality assurance schemes with review and education per year program was established and performed during the period from to in taiwan. aims: the proficiency testing (pt) held semiannually from to were reviewed to investigate the outcome of competency improvement of laboratories participated in the program. methods: the test items in the exercises were classified into groups, hla genotyping (including pharmacogenetics hla typing), cytotoxicity test, hla and platelet antibody. the methods of hla genotyping include ssp (sequence specific primer), sso (sequence specific oligonucleotide), sbt (sequence based typing) and either ssp+sso or ssp+sbt were used, the methods of hla antibody including elisa, flow cytometry and luminex were used and the methods of platelet antibody including sprca and elisa were used. there are four shipments of exercise materials in two years and each shipment include two positive and one negative samples for antibody detection, two each of whole blood and serum for cytotoxicity of t and b cell and three whole blood for hla genotyping. aims: this study aims to survey transfusion related laboratory tests for the quality improvement of hospital's blood bank management. methods: we analyzed survey results of kinds of routine work categories of blood banks that were registered on korean association of external quality assessment service. blood bank worker voluntarily replied this electronic survey. the categories were as follows: . characteristics of institution . the equipment of blood bank . the kinds of tube in blood bank . the present kinds of blood bank tests . abo and rh type tests . the cross-match tests . the irregular antibody tests . hemovigilance system . other blood bank tests . massive transfusion protocol . quality control issues we analyzed and compared each category data according to considering characteristics of hospitals. results: there were consensus and some differences of current blood bank tests. we presents the result of a pilot survey. especially the cross-match tests were divided by saline phase method added with irregular antibody tests or completion of rd step anti-human globulin phase according to institutional environment. automated typing machines or automated irregular antibody test devices were more increased in large-scale hospitals than small-scale hospitals. different kinds of tubes were used such as edta tube for abo and rh typing, plain tube for cross-match test. the retention segments of rbc were reserved for minimum days. most blood bank were registered and regularly listed up transfusion events to korean hemovigilance system for safety transfusion. also, a lot of institution have none or underdeveloped massive transfusion protocol. more specific survey results will be analyzed in further poster presentation. summary/conclusions: this survey will show the current status of transfusion related blood bank test. this institutional blood bank comparison will be helpful to assess the currency of individual blood bank environments. abstract withdrawn. background: we know that quality management is a continuous process, involving implementation, maintenance and improvement. aims: our purpose is to show our experience in implementing the quality management system in the whole institution and our first steps in achieving the jacie accreditation in the stem cell collection facility in order to provide our patients and donors the best possible care. methods: the institute for transfusion medicine of the republic of macedonia (itm) is the main institution in charge of blood transfusion service (bts) in the whole country, which is the national unified system. the stem cell collection facility is a part of the itm. this facility is operational since year with collections of stem cells ( in patients and collections in sibling donors) till now. we are obtaining the implementation and maintenance of qms through the establishing of the iso standardization for the whole institution (itm), as well as of implementing jacie standards in the stem cell collection facility. the two of our colleagues became the jacie inspectors and the standard operating procedures (sops) were developed, followed by regular meetings, trainings and self-evaluation of the personnel. we asked for the orientation visit from the independent jacie inspector in order to come one step closer to the jacie accreditation and to improve our overall qms. results: the institute for transfusion medicine of rm was a part of the ipa project "strengthening the blood supply system". this project aimed to ultimately bring the blood transfusion service to european union standards allowing the exchange of blood components and all other types of collaboration with other european union countries in future. the project put the basis for unification of blood transfusion standards and operating procedures in the whole country as well as set up essential education of blood transfusion personnel. although a lot of strengths were found during the orientation visit from jacie inspector, there are still a lot of areas for improvement. our strengths are motivated team and supportive institutional leadership including macedonian ministry of health. areas for improvement are: labeling of cellular therapy products and lack of laboratory for quality control. there is a national regulatory framework in place and who and world bank initiatives in macedonia which support quality in health care and accreditation. summary/conclusions: our institution has in plan to implement isbt standards for labeling of cellular therapy products and to establish a laboratory for quality control of cellular therapy, as well as to meet all the requirements to become jacie accredited facility. working by standards, following the rules and regular self-evaluations will help us to maintain the strong quality management system. every institution will benefit from a quality management system that brings you into line with international standards. ensuring the quality of our services and products is essential to keep safe and strong blood transfusion service. background: implementation of robust quality assurance program is key to high performing blood establishments. quality control and quality assurance systems together constitute the key quality systems and are parts of quality management. effective and efficient quality control policies not only provide guidance that help to increase the reliability of results but also maintains the laboratory's consistence performance overtime. aims: therefore, we established a set of qc limit using historical data which can timely identify unexpected variation in the testing systems and trigger a review of test processes in blood screening laboratories as part of quality assurance system. methods: last two consecutive years (jan, to dec, ) qc data from archi-tect i sr (abbott laboratories, chicago) was extracted using abbottlink for philippines red cross tower national blood center total of data points ( data points in & data points in ) were obtained for different qc levels for four serological blood screening assays (hiv combo, hbsag, anti-hcv, syphilis). the data was sorted for each assay/lot and qc level combination by year. qc limits were calculated using simple mean, standard deviation (sd) and coefficient of variation (cv%) and were validated and compared with manufacturer's recommendation. results: all the six positive quality control levels cv% ( . - . ) were within manufacturer's precision recommendation (within lab precision hbsag ≤ %, anti-hcv ≤ %, syphilis ≤ %, hiv ≤ %) in . five out of six positive quality control levels cv% ( . - . ) showed within manufacturer's precision recommendation (within lab precision hbsag ≤ %, anti-hcv ≤ %, syphilis ≤ %, hiv ≤ %) in except syphilis tp positive control ( . %). all four negative quality control levels showed the sd values within . - . in and . - . in respectively. summary/conclusions: excellent qc performance was observed in philippines red cross tower national blood center blood screening laboratory based on historical data and evidence-based laboratory qc limit for blood screening assays were established using historical data which takes into account total variation expected in a test system and offers a more robust and meaningful mechanism for setting control limits, for the first time. background: quality indicators (qi) in transfusion medicine (tm) are 'critically important aspects of transfusion medicine practice that are measured and utilized to gain insight for continuous quality improvement, into the degree to which the tm is capable of providing quality tm care, products or services for the aspect of practice measured following comparison of the measurement against acceptable local or international reference thresholds, benchmarks, standards, or practice guidelines'. the critical control point (ccp) selected for this study is 'administration techniques and monitoring of key elements'. this has been selected since the clinical fraternity plays a larger role in ensuring quality services in administration of blood components. there was a need to follow up compliance to standard protocol for bedside transfusion practices hence was decided to study the same with four selected quality indicators and introduce corrective measures if necessary. aims: . to assess the existing transfusion practices in the institute with specific quality indicators . to introduce corrective reforms to improve the existing practice . to assess the transfusion practices after interventions using the same quality indicators methods: to assess the existing transfusion practices in our centre, transfusions were prospectively followed up with a structured checklist. the quality indicators used were (i) verification of blood components prior to transfusion (ii)initiation of transfusion within min of release from the blood bank (iii) close observation of transfusions for the first min (iv)completion of transfusion within the right time frame for each component. as a corrective measure, a transfusion monitoring format was designed which was distributed in every ward and the nursing officers were informed to monitor and document transfusions using that. in addition, the blood bank staff was made to call up the wards and ensure that the transfusions of every component had been initiated within min of issue. transfusion practices were once again monitored by following up transfusions using the same quality indicators. results: there was significant difference in all the four variables between the two phases. . % transfusions were verified in phase i while . % were verified in phase ii (p < . ). . % transfusions were started within half an hour of issue while in the second phase, it rose to . % (p < . ). . % transfusions were observed in the first min in phase i and . % were observed in the second phase (p < . ). in phase i, . % transfusions were completed within right time while the same in phase ii was . % (p < . ). summary/conclusions: we recommend the following as quality indicators for bedside transfusion practices: background: antibody titration consists in performing antibody detection with selected red cells of different sample dilutions. the titer is reported as the reciprocal of the highest dilution that induces macroscopic agglutination. the usual applications of titration are prenatal studies and complex antibodies identification. some publications have demonstrated that more variation in antibody titer and titration score are noted upon repeat testing of the same sample when testing was performed in tubes as compared to repeat testing in gel. aims: to evaluate the efficacy of automated antibody titration versus manual method by using gel microcolumn technology. methods: edta-anticoagulated whole blood donors' and plasma frozen samples containing a known irregular (rh, kidd, duffy, mns, etc.) and regular (a & b) antibodies were selected. the titers of samples were determined in parallel by using grifols analyzers (erytra and erytra eflexis) and compared versus grifols gel manual method by using grifols gel microcolumn technology and grifols red blood cell reagents. sixty of these also processed in parallel in erytra and erytra eflexis analyzers for comparison. for the precision study, of these samples were tested in the automated systems for times ( datapoints for each analyzer) on different testing days. the hands-on (manual intervention) average time required to complete a titration was measured ( expert technicians) in different sample workload ( and samples testing). these results were compared with the same number of independent titrations performed in grifols analyzers. for the walk-away time, different sample workload ( and samples testing) were assessed in manual method ( expert technicians) and compared to timings obtained when reproduced in grifols analyzers. results provided by analyzers were reviewed and compared to manual method. results: titer obtained by erytra or erytra eflexis was equivalent to the titer obtained manually (differences ≤ titer: % ≤ . titer). the results proved that both instruments were equivalent in performing titration (differences ≤ titer; % ≤ . titer). the precision results showed no difference between titers obtained through the % of the runs performed with the grifols analyzers (differences ≤ titer: % ≤ . titer). the manual hands-on in automated system was reduced in a % compared to manual method for sample. when the number of samples was increased ( samples), the difference in hands-on in was even more reduced ( %). in addition, the walk-away was % higher in automated system compared to manual method. furthermore, when the number of samples was increased ( samples), the walk-away difference was increased even more ( %). finally, automated system software demonstrated to increase the standardization of the test as all samples, results and reagents traceability were automatically managed. summary/conclusions: grifols gel system including erytra and erytra eflexis analyzers provided a scalable and efficient solution to perform standardized titrations in the immunohematology lab. the study proved that using grifols gel system, titrations can be run in an automated reliable way (less than one-fold differences versus manual gel), thus reducing at least % the hands-on, increasing at least % the walk-away, rising the standardization and automating all testing traceability. , and fourth case of use (results) scenarios, tasks were considered "very easy" by %> % of users and "easy" and by - % of users; %> % of the users considered "sufficient" the design to ease the interaction; and %> % of users never founding any situation of not knowing how to proceed. for the fifth case of use (user roles), % of users considered tasks "very easy" or "easy"; % of users considered "sufficient" the design to ease the interaction; and % of users never found any situation of not knowing how to proceed. for the sixth case of use (maintenance plan), % of users considered tasks considered "very easy" or "easy"; % of users never found any situation of not knowing how to proceed; and % of users considered the maintenance plan similar or better than other instruments. reliability analysis ( background: quality control procedures in blood group serology for reagents, techniques, personnel working and automated equipment are essential for the accuracy of the laboratory results. the observation of high number of uninterpreted results during blood donor grouping was a motive for investigation and possible targeting the problem. aims: to identify blood group interpretation problems by analyzing the testing results obtained with the commercial quality control samples routinely used during blood grouping. methods: a microplate (mp) system for performing abo and rhd, as well as rh phenotype and kell blood group determination with two automated analyzers techno ( and ) and correspondent two mp-readers lyra ( and ) using maestro software from diamed is currently in use for blood donor typing. three types of mp are being used such as: a, b, ab, dvi-, dvi+, ctl/a , b profile for first time donors, then a, b, d ctl for repeat donors and finally, the c, c, e, e, k, ctl profile. the accuracy and safety of the blood grouping results is ensured by using the diamed q.c. system which consists of + tubes of whole blood and tubes containing serum with known specific antibodies. we analyzed and compared the interpretation of the q.c. whole blood samples' results from both of the analyzers after a new optic camera was installed on the techno /lyra system. ward to ward. methods: a prospective observational pilot study was done for around prbc unit issues which were followed in real time for understanding the tat within blood bank & from ward to ward. as per the definitions, the areas where the times are documented perfectly are understood and considered for calculations. based on the conclusions of pilot study a monitoring form has been designed and utilised to monitor the tat within bb & wtw. the data is analysed monthly and an avg tat for bb & wtw is calculated. the common causes of delay in providing the blood components were analysed and strengthened to both reduce & control the tat. results: in pilot study, total wtw tat averaged to min, with highest time taken min, where there were additional processings like leukodepletion, irradiation, saline washing of red cells and holding the transfusion. lowest wtw tat was found to be min where there was a prior information for crossmatch. after the surveillance form has been started, the average time taken for wtw tat came down to min, maximum being min (jan ), the areas where delay happened were identified as internal courier delays, technician delays, billing & other logistics delay. the concerned staff are put on regular training to maintain the tat. summary/conclusions: although ethically all the staff work for providing better care for patients, there will be few areas that delay the life supporting blood transfusion. monitoring using tat surveillance forms help in avoiding the delays and hence provide better & timely transfusion support. blood donation -blood donor recruitment p- hematological and physiological characteristics of regular blood donors with beta-thalassemia traits background: according to recent evidence, the physiological variability observed in the hematological characteristics of regular blood donors (linked -in certain caseswith genetic factors or the donor's lifestyle) may affect red blood cell (rbc) storage lesion. beta-thalassemia heterozygous (b-thal-het) blood donors represent a group of particular interest because of a) the high frequency of thalassemia mutations in specific geographical areas b) the physiology of the b-thal-het rbcs, which predisposes towards more effective management of storage-associated stress. aims: the goal of the present study was the comparative examination of the hematological and rbc physiological features of regular blood donors with or without beta-thalassemia traits before blood processing for transfusion purposes. methods: healthy blood donors of greek origin ( - years old), who met the blood donation criteria were recruited in this study. plasma/serum (uric acid, electrolytes, extracellular hemoglobin, antioxidant capacity), cellular (rbc indices) and biological parameters (corpuscular fragility, proteasomal activity etc) were measured. the results were statistically analyzed and topologically represented in biological networks for both donor groups (+/-b-thal-het). significance was accepted at p < . . results: b-thal-het represented % of the donor cohort. no differences in lifestyle (smoking, alcohol consumption, physical exercise) were observed between the two groups. nevertheless, regardless of sex and sex-dependent parameters (e.g. hct, hb concentration), b-thal-het demonstrated: a) reduced hct, mcv and mch ( % p = . , % p = . and % p = . , respectively) and b) increased rbc count ( %, p = . ) compared to the average donors. moreover, mpv platelet index was found slightly elevated (p = . ) and serum total protein concentration slightly reduced (p = . ) in the same group. a trend for higher plasma antioxidant capacity (p = . ) was evident in the group of b-thal-het, in addition to statistically significant lower levels of osmotic fragility (by %, p = . ) and hemolysis (by %, p = . ) compared to controls. finally, analysis of the three proteasome-associated enzymatic activities (n = per group) in the rbc cytosol and the membrane, revealed similar levels in the two groups (p > . ). the b-thalhet and control biological networks showed insignificant variations in respect to the amount of connections and their hub profiles. however, differences were observed regarding the number or type of connections, or even their topology in the network, in the cluster of lipids (triglycerides, ldl etc), nitric oxide, clusterin, carbonylated plasma proteins and rbc osmotic fragility (correlated with the concentration of electrolytes selectively in b-thal-het donors) between the two groups. summary/conclusions: b-thal-het who meet the criteria for blood donation are a non-negligible sub-group of the total donor population in greece. they exhibit several similarities to the general cohort, but differ in fine characteristics of rbc physiology, including resistance to hemolysis and extracellular antioxidant capacity. the differential network profile of hematological and redox parameters may be important in respect to the subsequent blood processing and storage of b-thal-het erythrocytes for transfusion purposes. background: blood service in poland is based on voluntary and non-remunerated donations. regional blood donor centre in poznan as well as other regional centres (total of ) are the only entities authorized to collect, process, store and distribute blood and its components to hospitals in the region of their activity but they are also responsible to provide sufficient amounts of blood and its components. regional blood donor centre in poznan is one of the largest blood centers in poland with the total number of donations exceeding , per year. in the recent years we have observed a growing popularity of tattoos among various age groups as well as among people registering to donate blood (first time and repeat donors) hence, it is critical to introduce suitable measures to ensure the safety of blood and its components. aims: the aim was to analyse the correlation between the increasing number of donors deferred from donating blood due to having tattoos made and the number of recorded confirmed hcv infections and the effect it may have on the safety of blood and its components. methods: the analysis was made using the data for the years - obtained from the computer system 'blood bank' which is in operation in regional blood centre in poznan, poland. we have analysed the total number of deferrals of donors due to recently acquired tattoo and the total number of recorded confirmed hepatitis c infections. we must note that the category of temporary deferrals due to tattoos is a broad one: it includes so called regular 'artistic' tattoos, permanent make-up procedures as well as medical tattoos. results: we have recorded a significant increase in number of deferrals due to tattoos from in to in (+ %). in the group of male donors this trend remained rather stable with a slight decrease: from in to in (À . %). in the group of female donors the growth was more prominent: from in to in (+ %). in terms of the recorded confirmed hcv infections a downward trend can be observed: from in to in (À . %). in the group of male donors from in to in (À %), in the group of female donors from in to in (À %). summary/conclusions: as we can conclude from the analysis the applied policy of temporary deferrals of donors with recently acquired tattoos (in the last months) proves to be a reliable method of increasing the safety of blood and its components. nevertheless, the current conduct of the qualification of the donors which requires a month deferral following the new tattoo must be complemented by various and numerous educational activities regarding the means of hcv transmission (and other bloodborne viruses such as hbv, hiv) and ways of protection from possible infections. special emphasis must be put on the group of female donors as the growth of deferrals was more prominent among them. at the same time it is vital to ensure for constant availability for all donors of well designed, concise educational materials (hard copies on the premises, articles, infographics, downloadables etc. on the website). background: a temporary deferral has a negative impact on donor retention, with many donors failing to return at the end of their deferral period. anecdotal evidence collected by the australian red cross blood service suggested that many donors do not know when they are eligible to return to donate, suggesting that a reminder message may be effective at promoting donor return once the deferral has ended. aims: the aim of this study is to evaluate the effectiveness of a reminder message on the return rates of deferred donors at the end of their deferral period. this reminder message notified donors that their deferral period was ending and encouraged them to make an appointment to donate. this study also aimed to determine the most effective time to send the message, message content, and mode of communication (sms vs email) in optimising donor retention post deferral. methods: three separate randomised controlled trials were conducted to answer these questions. data on donors' attempted return behaviour and subsequent deferrals, appointments and donations made one month after the deferral end date were collected and analysed. results: overall, . % of donors who received a reminder message attempted to return compared to . % of donors in the control group (p < . ). looking at each time point, donors who received the message week before their deferral ended were % more likely to attempt to return compared to the control group (p < . ). the week prior reminder message was particularly effective with males, with . % attempting to return to donate, compared with . % of females (p < . ). there were no significant differences in the return rates of donors who received the recipient versus non-recipient focused message, or donors who received the message via email or sms. summary/conclusions: a reminder message sent to deferred donors at the end of their deferral period is a simple, cost-effective way to promote donor retention, providing clear information regarding the date on which the donors can return to donate as well as a prompt to make an appointment background: our challenge is to provide % voluntary donation for safe blood, thus taking into account the current history of family donation, promotion of blood donation, level of awareness and voluntary donations from various institutions, the opinion of interviewees will give us a clearer idea of what we want to achieve and what needs to be improved in the future. aims: . provide % voluntary donation for safe blood. . establishing a special department within the national blood transfusion center responsible for marketing and promotion of voluntary blood donation. methods: this study was conducted as a combination of qualitative and quantitative methods. the study was a combination and identification of existing data, direct interviews with persons of different age groups, preparation and dissemination of questionnaires and analytical processing of the collected information. the study questionnaire with questions in total was divided into sections out of which questions on blood practices were answered by all interviewees. people answered questions on the blood transfusion service. questions on blood knowledge were answered by people. questions on the knowledge of the blood transfusion were answered by people, questions on blood donation were answered by people and questions on the communication channels were answered by people. results: out of interviewees, % have never donated and did not intend to donate, due to the fact that most of them were afraid of needles and infections, while the smallest part didn't donate blood because it was not allowed by the religion, % did not donate, but expressed the readiness to donate in the future, % have donated voluntarily only once, % were family donors, % regular volunteer donors, and % have donated voluntarily several times and did not want to donate anymore. from those who have donated, % have donated for one of their relatives, % have donated for thalassemic children, % have donated to benefit free check-up and % have donated because it was valuable for their health. the question as to whether they would voluntarily donate again, % have answered yes, % no and % were still not sure. this means that donation of those who have donated once did not leave a positive impression, did not increase the desire to repeat the donation once again, rather it has restrained or made it unsafe for them to repeat donation. among the causes mentioned by the interviewees were bad conditions in the donation facilities, staff behavior, inadequate treatment, they did not feel good after donation and had hematoma at the venipuncture. summary/conclusions: based on the results obtained from the study, the national blood transfusion center needs the establishment of a genuine promotion department where there is a need for a transfusion doctor who should be an active part of it. the national blood transfusion center should build up and implement a rigorous retention policy for voluntary blood donors, as the study found out that around % of donors who have donated once would like to donate again. their attraction through a donor retention policy will surely lead to self-sufficiency with safe blood. the safe blood is a public good and for this reason it is the duty of all state instances, the media and non-governmental organizations to give their support in the promotion of voluntary blood donation. background: smoking, unhealthy diet, sedentary behavior and inability to maintain adequate exercise have significant consequences for several chronic disorders, including obesity. a balanced and equilibrate nutrition may prevent the negative consequences associated to the status of obesity. in italy, overweight and obesity is increasing with adults of overweight and of obese in with a higher frequency in the south. blood centers can play a public health role in obesity surveillance and interventions. aims: since the quality of life, self-reported by the patient, related to health and adequate quali-quantitative nutrition, are becoming necessary and relevant in the field of nutrition, we conducted a demographic study to evaluate the health status of the blood donors by monitoring the nutritional habits and lifestyle. methods: a descriptive cross-sectional face-to-face questionnaire was developed. it included a item dietary assessment, reporting semi-quantitative food frequency, dietary behavior and questions on self-rated health status. normal weight was established with bmi < kg/m , overweight with a bmi ≥ and < kg/m , and obesity with bmi ≥ kg/m . obesity prevalence was standardized by sex. donors were repeat blood donors, who had made at least donations in the last years, and were eligible to donate. results: of the blood donors enrolled between july and january , were regular repeat donors, did not wish or chose not to respond at survey for several reasons (i.e. lack of time or privacy) and accepted, of which were deferred from blood donation and were excluded from the analysis. among the included participants . % (n = ) were male, age ranged from - years with a mean age of . ae . sd and . % (n = ) were female age ranged from - years with a mean age of . ae . sd. data showed that donors followed mainly a mediterranean diet and had more awareness to lifestyle, women more than men, in comparison with general population. the prevalence of overweight was found . % in men and . % in women. our survey showed that . % of the participants evaluated their health as "good", without gender difference (men, . % vs women, . %). besides, . % reported their health as "very good". summary/conclusions: overweight and obesity are common among regular blood donors and it is more frequent in men than women. our preliminary data showed that women have a better knowledge of the nutritional properties of food and consequently adopt a more balanced and proper diet. furthermore, it is clear that they are aware about the relationship between lifestyle and health putting into practice their information. unfortunately, the survey structure, of observational nature, does not make it possible to establish whether women are more alert to health to participate more in donation programs or if, on the contrary, the status of regular donor could help the improvement of knowledge and healthy lifestyle. background: donor recruitment pose an ongoing challenge to blood banks worldwide. one approach to improve the effectiveness of donor recruitment is to target influencing factors. a yearly league is conducted at the sultan qaboos university (squ) to encourage university students and faculty to donate blood. during this, the colleges are evaluated based on different measures including the number of donors recruited from each college and the efforts made by the students in increasing the awareness of blood donation in the colleges and in the society via different means including the utilization of the social media. the whole competition is organized and ran by an independent group of students. aims: this study aims at studying the impact of the yearly squ college competition on the perception of blood donation among squ students. methods: a comprehensive anonymous voluntary survey was developed and used to assess perception of students aged - attending squ and other universities (non-squ) over a two years' period. analysis was performed using ibm spss statistics . . categorized variables were presented in numbers with percentages and associations between the groups were analyzed using chi-square test. a p-value of < . was considered statistically significant. results: a total of students were surveyed ( squ, non-squ). there was no statistical difference between squ and non-squ students with regard to past history of blood donation and the number of donations made. when comparing between both cohorts, % of the squ and % of non-squ students reported the university as the main source for information (p < . ), while % of squ and % of non-squ students reported that the social media was the main source respectively (p = . ). there was no statistical difference between male and female donors on their perception of level of self-knowledge on blood donation (p = . ). about % of the youth agreed that blood donation is one of the duties toward the community. squ students reported higher rates of respond to specific requests for blood donation ( . % vs . %, p < . ). squ students reported greater influence of peers ( % vs . %, p < . ), personal knowledge ( % vs . %, p = . ) and personal experience ( . % vs %, p = . ) when compared to non-squ students. they also reported more feeling of commitment to the society ( . % vs %, p < . ). squ students reported lower influence of parents ( % vs %, p = . ), lower rates of fear from needles ( % vs %, p < . ) and lower rates of fear from blood ( % vs %, p < . ). there was no difference between male and female genders in any of the discouraging factors. summary/conclusions: these results highlighted the positive impact and important rule of the youth in the promoting blood donations among themselves through this yearly college competition; in recruiting blood donors and in the dissemination of the knowledge of blood donation. distinct promotion strategies should be adopted to increased first time and repeated blood donation among the youth. we advocate for similar initiatives in encouraging blood donation and disseminate knowledge among individuals in the community. dubai blood donation center, dubai health authority, dubai, united arab emirates background: dubai is multicultural city in united arab emirates. only about % of the population consists of uae nationals with the rest comprising expatriates from various countries all over the world. approximately % of the expatriate population (and % of the emirate's total population) are asian, chiefly indian ( %) and pakistani ( %). dubai blood donation centre is the only centre providing blood donation services in dubai. arabic is the national and official language and english is used as a second language. in order to have good quality screening, it is important that blood donors understand the educational material and questionnaire properly. aims: dubai blood donation centre receives donors (nationals, residents and gcc card holders) from various countries. the aim of this study is to analyze the multinational profile of donors and to find out the need to add any third language to meet the customer needs and expectations. methods: a cross-sectional study of blood donors was conducted in dubai blood donation centre in . the donors were asked about their country of origin, languages which they can read & understand and about the preferred mode of communication. results: a total of donors were surveyed and asked about the languages which they can read and understand and responses were obtained. the most common languages which can be read and understood by blood donors in dbdc are english (n = ; %), arabic (n = ; . %), hindi (n = ; . %) and malayalam (n = ; . %). the donors come from different countries, most common ( . %) donors are indian and ( . %) are from uae. it was found that % donors can read and understand only one language. majority ( . %) donors can read and understand either of the official languages arabic or english. however, ( . %) donors can't read and understand these two official languages, the other common languages being hindi and malayalam. the donors were asked about the preferred mode of communication, responses were obtained. the most common mode of communication were sms and telephone ( % together). summary/conclusions: based on the above findings, it can be concluded that the blood donor profile in our centre is multinational which is a unique and almost similar to the population profile of dubai. as . % donors can't read and understand arabic and english, so it has been decided that the educational material and questionnaire need to be prepared in one more language. hindi has been decided as the third language in the centre and donor questionnaire and educational materials in hindi will also be made available to the donors. further,the donors will be communicated through sms for routine messaging and disease notification while telephonic calls will be done only when the blood is urgently required. background: metabolic disorders (metds), including hypertension, dyslipidemia, hyperglycemia, and central obesity, are tightly associated with cardiovascular diseases and type diabetes mellitus. due to the sedentary lifestyle and increased consumption of high-calorie diet in modern society, metds have become serious health problems worldwide. to have a better understanding and possible improvement on blood donors' health condition, we conducted a survey of the prevalence of metds among blood donors in a blood donation station located in the hsinchu science park in taiwan. participants with metds will be provided with health education materials about metabolic risk reduction, in order to prevent the development of future complications. aims: the aims of this study were to determine the prevalence of metabolic disorders among blood donors, and to calculate how much money would be paid to identify a case of hyperglycemia, hyperlipidemia, or undiagnosed diabetes. methods: this study was approved by the institutional review board of taiwan blood services foundation (tbsf). the body weight, body height, waist circumference (wc) and blood pressure (bp) of participants were measured. blood samples were obtained to determine the values of hemoglobin a c (hba c) background: the law on blood donation supports the development of the blood service and guarantees the protection of the donor's rights and the maintenance of health during blood donation in the russian federation. national criteria for donor selection for blood donation are used in the activities of blood service establishments and are aimed at ensuring the blood products safety. the study of the characteristics of blood donors allows to predict the development of blood service and to plan the volume of blood products for transfusion and plasma fractionation. aims: the aim of this work was to study the characteristics of whole blood and apheresis donors in the blood service in the russian federation. methods: indicators of activity in the blood service establishments in the russian federation in sectoral statistical observations over the period - and the calculation of indices characterizing the whole blood and apheresis donors were analyzed. data are presented according to the administrative division of russian federation into federal districts (fd). results: the proportion of whole blood donors was . %, plasmapheresis donors - . %, blood cell apheresis, including plateletapheresis, donors - . %. for the period - , the percentage of repeated and regular whole blood and apheresis donors increased from . % to . %. the percentage of first-time donors ranged from . % to . %. the largest proportion of plasmapheresis donors was observed in the volga fd ( . %). about . % of the total plasma was collected by apheresis from donors. the percentage of plateletapheresis donors increased from . % to . %. the largest percentage of plateletapheresis donors was observed in the central fd ( . %), where a significant part of medical centers of cardiac surgery, hematology and bone marrow transplantation are located. the proportion of platelet concentrate collected by apheresis increased to . % in . actions to recruit young donors for blood donation and its components were regularly carried out in all federal districts. summary/conclusions: in the russian federation, the structure of donation is characterized by an increase in the proportion of plateletapheresis donors, stabilization of the percentage of plasmapheresis donors and an increase in the proportion of repeated and regular whole blood and apheresis donors. there are significant regional variations of donor's characteristics in the federal districts. background: shortage of blood supply despite continuous blood donation campaigns especially during local festive seasons has been a major issue in our country. thus, our faculty initiated blood donation drives in collaboration with national blood centre in order meet the demand for the blood requirements. however, the pre-donation deferral rate was relatively high among our young blood donors leading to loss of valuable blood units. understanding the causes of donor deferral provides direction on strategies for young donor recruitment and retention of future blood donation. aims: the aim of this study is to evaluate the young donor deferral pattern and to identify factors which could help in minimizing the preventable deferrals. methods: this is a retrospective study of voluntary young blood donors age between to years old recruited during mobile blood donation in faculty of medicine, universiti teknologi mara, malaysia. the study was conducted between january to december . the data were retrieved from the official reports of each mobile blood donation. results: a total of young blood donors had attended mobile blood donation during the study period. the overall pre-donation deferral rate is . %. the main causes of deferral are low haemoglobin (hb) level ( . %) followed by low blood pressure ( . %), upper respiratory tract infection ( . %) and sleep less than h ( . %). summary/conclusions: low haemoglobin and low blood pressure are the two common reasons for blood donation deferral among our young blood donors. in our study a significant proportion of deferrals are due to sleep less than h whereby this could be prevented if the donors are aware of the donor selection criteria. strategies to mitigate preventable deferrals and improve blood donor retention particularly young blood donors as source of motivation for future blood donation are urged to avoid additional stress on the blood supply. background: in the modern world, donating blood has become a humane manner for saving of patients life. but there are barriers to blood donation which are designed to ensure both donor and blood recipients' safety. anemia is one of the most common health problems in the world. based on the who estimation, nearly a quarter of the world's population are suffering from anemia, its prevalence varies among the populations and age groups. the prevalence of anemia among men is . % and in non-pregnant women is . %. aims: the aim of this study was to determine the status of hemoglobin in volunteer blood donors referring to fars province blood transfusion service and to determine the demographic status of them during the last two years. our study included blood donors for all blood donors during the last two years. methods: the study is descriptive cross-sectional and our sampling was non-random and simple sampling method. all parameters related to the donors, including age, sex and type of donation were investigated and analyzed in spss software. results: the total number of referrals for blood donation was . repeated blood donors was . % of total population and had the highest number of referrals, followed by first and lapsed donors with . % and % respectively. in terms of gender distribution, . % were female and . % were male. the highest rate of hemoglobin level less than . g/dl was found in first-time donors with . % and the lowest prevalence was observed in lapsed donors, followed by repeated donors with . %. . % of the repeated blood donors have hemoglobin higher than . . there was a significant difference between blood donation type and hemoglobin level. summary/conclusions: according to our findings, low hemoglobin levels are more common among first-time and female donors, and this requires a special training among these groups. because the high share of first time donors in blood supply and the positive impact of female donors on the blood safety, corrective action for that groups is recommended. finnish blood donor biobank j partanen, t wahlfors, m arvas, j clancy, k l€ ahteenm€ aki, e palokangas and n nikiforow background: the increasing need for large, well-characterized cohorts of healthy individuals for modern biomedical research, such as genomics or phenomics studies typically including tens or even hundreds of thousands of subjects, has posed the possibility of using blood services as an option for collecting samples and related data. the possibility to re-contact blood donors for repeated sampling or asking for additional data has further increased interest in collecting large biobanks from blood donors. there is also a need to study more thoroughly the effects of blood donation on donor health. aims: the first-phase goal is to recruit , blood donors with broad biobank consent for the finngen (https://www.finngen.fi/) project, a large publicprivate effort aiming to collect genome and health-related registry data of % ( , ) of the finnish population. ( . %), dental examination ( . %) and medication history ( . %). permanent deferral namely, risk factor involving transfusion transmitted infections and chronic disease were ( . %) and ( . %) respectively. the prime cause of permanent deferral was risk factor involving transfusion transmitted infections while the temporary deferral was bed side hypertension. gender wise, the leading cause of donor deferral in male was bed side hypertension and anaemia was the major cause in female. summary/conclusions: the findings of the survey aid to evaluate the significant causes of blood donor deferral. this study suggests that the restrictive criteria can be used for blood donor selection. this will in turn increase the blood supply of tertiary care hospital. background: donor selection is the first step towards safe blood but retaining blood donors is also very important for the blood supply. donor questionnaire and the medical interview should provide optimal doctor deferral. aims: to evaluate deferral rate in blood donors in order to identify the main reasons and to target eventual corrective activities. methods: we analysed the data concerning blood donors who were registered in the period of three years ( - ). we used data from the information system e-delphyn. background: iron deficiency (id) in blood donors is an underestimated issue in many countries and may cause symptoms to blood donors even without anemia. id prevention is mainly based on the prevention of anemia in whole blood donors, which is done by deferring donors whose haemoglobin level is under defined threshold ( g/l in women, g/l in men in france). efs (french blood establishment) studies has observed that the rate of deferral for anemia is significantly higher in women than in men, either in french west indies ( . % versus . %) or in continental france ( . % and . %). assessing the prevalence of id is of great interest since strategies to counteract it must deal with donor health and self-supply. however, data on id are missing in france. aims: to estimate the prevalence of id in french whole blood donors and to identify risk factors associated with id. methods: this non-interventional, cross-sectional, multicenter study is performed in blood donors of efs and ctsa (blood center of the french military health service). all whole blood donors who met selection criteria are potentially included. donors coming for bloodletting and donors who refuse to participate to the study are excluded. no additional sample is taken for the study, ferritin is tested after blood qualification on surplus amount. samples are selected at random within all the geographical areas and all mobile blood drives and blood centers between march and march , . results: this study ferridon has been approved by ethical research committee. nine thousand ( ) whole blood donors will be included in efs centers in continental france. to have information on donors of afro-caribbean origin and comoros origin, donations should be included in the french west indies and in reunion island. additionally, whole blood donors will be included in ctsa centers. in this study, id is defined by ferritin lower than ng/ml and iron overload is defined by ferritin higher than ng/ml. all donors with iron deficiency or overload will received a letter advising to consult their general practitioner. weights will be calibrated on age, sex and geographical area so the sample will be representative of the french whole blood donors. estimation of id prevalence will take into account the weights and logistic regression model will be used to analyze risk factors associated with id. data will be analyzed during april and may to get result at the end of may. summary/conclusions: ferridon will be the first study on id in the french blood donors. considering the french health care system and diet, it will be interesting to compare those results to results from other countries. mostly this study will allow to consider various strategies dealing both with donor safety and self-supply. background: in portugal, with an aging population of around million people, only . % are blood donors. the country has a national center of blood supply and some central hospitals with a blood donation center. despite the growing practice of the excellent concepts of patient blood management, it is imperious to attract new donors. this need has been our inspiration to use new approaches towards people, in a constant work of promotion. aims: reach the majority of our local population using radio and telecommunication as well as social networks in an attempt to raise the number of new blood donors in a central hospital of the north of portugal. methods: active communication with the population of our reference area, via the social networks facebook tm and instagram tm , through educational digital posters and messenger service to answer any kind of questions. establish contact with radio and television stations as well as with the mayor of the city, journalists, schools, town hall deputies and celebrities, through email and telephone calls. design posters, flyers and public advertising to distribute in the city. results: through the social networks it has been possible to reach a population of dozens of thousands in our city, in a daily basis. the national and world donor days were celebrated with success, in our health facility, with city mayor and journalists, and also in three television stations with national broadcast, reaching millions of people. celebrities (sport, television, music, stand-up comedy, journalists and a magician) have accepted our challenge through videos or donating blood, appealing to blood donation and sponsoring our cause. these projects and continuous availability to innovate have given our hospital a self-sufficiency of % in , instead of % in , which implied receiving less blood unities from the national center of blood supply. our most recent project involves high schools, in an attempt to educate our next generation of donors, with meetings in the town hall with deputies and district school delegates. summary/conclusions: the aging population and the low percentage of blood donors are an important issue concerning public health. nevertheless, the good will and continuous advertising and educative work towards the population, appealing to the ethical and civil responsibility since young ages have shown to improve our capacity of response as a central hospital, increasing the auto-sufficiency of blood unities and the interest of younger donors. it is of the utmost importance to understand that this is a continuous and a hard work of the professional team of our hospital, involving countless calls, emails and hours to obtain some positive response, in an endless job. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the mean interval between donations is shorter for former regular donors ( . months, p < . ) whereas donors with an interval of to months are more likely to be regular (aor ; % ci . - ). summary/conclusions: at the provincial blood transfusion centre of bukavu, the percentage of regular donors is low and there is a substantial loss of former regular donors. some factors identified to be linked to fidelity are unique to our study: female gender and a longer interdonation interval. other factors that are similar to those found elsewhere have a particular significance in our donor population which consists mainly of young people and people without income. efforts must be undertaken to ensure a supply from voluntary donations; recruitment strategies and target groups must be refined. future qualitative studies are needed to explain the various associated factors and better understand the motivations of regular and non-regular donors to improve donor retention. results: in kazakhstan, the proportion of donors is higher, especially primary. the number of blood and especially plasma donations is higher, which can be explained by the presence of several albumin and immunoglobulin production sites. increased evidence of blood transfusion rules, the development of a patient's blood management in combination with an increase in the quality of blood components cause a reduction in clinical need for red blood cells and plasma for transfusion. at the same time, the need for platelets is growing. it is difficult to assess the correctness of comparing the amount of banked whole blood. it is equally difficult to compare the number of received and distributed donor red blood cells and plasma: in russia they are measured in liters, and in kazakhstan in doses. with a certain degree of conditionality platelet extraction can be compared. in russia, they are counted in equivalent doses isolated from a dose of whole blood (at least cells per dose), and in kazakhstanin therapeutic doses (at least cells per dose). in , the estimated consumption of platelets in kazakhstan exceeded the russian indicator by . %. % of platelets in kazakhstan and . % in russia are harvested by the apheresis method. inactivation of pathogens is performed in % of platelets in kazakhstan and in . % in russia. pathogen inactivation with amotosalen allows us to abandon the examination of donors for cytomegalovirus and irradiation of platelet concentrate. the main modern trend in the use of cryoprecipitate is using it as a source of fibrinogen, a blood coagulation factor that is first depleted in coagulopathy associated with injury and massive bleeding. its production is growing in both countries, endowment in kazakhstan in exceeded the russian indicator by . %. a significant plasma percentage in both countries does not pass quarantine due to repeated non-appearance of the donor and is subject to destruction. inactivation of pathogens is performed in % of plasma in kazakhstan and in . % in russia. despite the instruction and selection of donors, laboratory screening of infection markers remains effective: russia more often identifies hiv and viral hepatitis c from potential donors, and viral hepatitis b and syphilis are detected in kazakhstan. . % of donors in kazakhstan are exempted due to the results of multiplex screening of nucleic acids of three hemotransmissive viruses. summary/conclusions: the blood services of russia and kazakhstan perform tasks to provide medical organizations with effective blood components. in conditions of decreasing demand for red blood cells and plasma, it is advisable to focus on the efficiency of resource use and improving the quality of blood components produced. blood collection including apheresis p- finnish red cross blood service, helsinki, finland background: skin disinfectant must effectively reduce microbes from the arm of the donor. as a result of poor disinfecting microbes may be transferred from skin via venepuncture to the collected blood and contaminate the blood components. aims: to ensure the efficiency of the skin disinfectant used for donor arm disinfecting by validation. the validation has two criteria which the post-disinfection samples must achieve: . no bacteria growth near the puncture spot (result cfu) in ≥ % of the samples. . total amount of bacteria on average is at most cfu/ cm . at most % of samples are allowed to have - cfu/ cm . methods: microbiological samples were taken with contact plates from voluntary persons' elbow folds before and after skin disinfection. the disinfecting was performed according to normal procedure by five nurses altogether with ethanol based disinfectant used in blood donation. on the sample plates an x was marked and this was directed to the puncture spot pointed by nurse. post-disinfection sample was taken at the moment the skin would be punctured with needle. results: the amount of bacteria varied from to above cfu/ cm in the pre-disinfection samples. disinfection reduced bacteria very well; the critical puncture spot was totally clean ( cfu/ cm ) in . % of the samples and . % of the samples had or only cfu/ cm . the average number of bacteria after disinfection was , cfu/ cm and the maximum number was cfu/ cm . most of the remaining bacteria were single colonies at the edges of the plates. summary/conclusions: both main criteria are fulfilled. the sub criteria of the second main criteria is also full filled if the not so critical colonies at the edges of the plates are not taken into account. the skin disinfectant in question is shown to be effective and can still be used in blood donation paying attention to thorough procedure performance according to the instructions and sufficient drying time of the disinfectant. background: research questions involving blood donation and recipient data often require advanced statistical methodologies. while such methodologies may appear in other medical research areas, specific tailor-made statistical tools and approaches are required for the analysis of blood-related data. these toolkits, which often require collaboration, are not always readily available to blood services, especially so in resource-limited settings. an international network of statisticians, epidemiologists and clinical researchers has been established for this purpose, which started with an invited session at the meetings of the international biometric society. aims: to exchange ideas, experience and knowledge to further improve the quality of blood sector research. methods: currently our network covers four major blood services and members from five different countries. the network has monthly conference calls about past and current research topics. we wish to extend this network further, and establish a subcommittee on statistical and epidemiological methodology with regular face-toface meetings at an international organization such as isbt. results: the monthly meetings have already demonstrated that the members share common problems and interests. for example, we are discussing techniques to analyze data with repeated measurements, e.g. eligibility haemoglobin tests, ways to assess the healthy donor effect, e.g. determining appropriate controls groups, and predictive models of blood supply and demand, e.g. stochastic processes and queuing models. the network also aims to organize training sessions in methodology either on site and/or by developing web lectures. summary/conclusions: an international network on statistical methodology for the analysis of blood donation and recipient data will improve the quality of research in the field of transfusion medicine research. expanding the network to include countries and blood services in research limited settings needs to be actively pursued. background: blood donor hemoglobin concentration (hb) is commonly measured from a skin-prick sample at the donation site, and low hb is the most common reason for temporary donor deferral. while a proportion of the deferrals do reflect true low hb, the skin-prick sample is prone to preanalytical error and variation resulting in false deferrals. aims: we assessed the applicability of a venous blood sample for second-line hb screening in blood donors failing the initial skin-prick test. methods: initial hb was measured from a skin-prick sample with the hemocue hb + (hemocue ab) point-of-care (poc) device. donors with hb < g/l for females or < g/l for males or with a decrease > g/l from latest donation were included in the study. in the study group, a venous blood sample was collected for hb measurement with the poc device at the donation site. donation eligibility was based on this hb result. venous hb was also determined with a hematology analyzer (sysmex xn, sysmex co.). the blood service's current workflow served as the control group: two more skin-prick samples were collected and the donor's final hb and donation eligibility assessed with an algorithm based on all three skin-prick hb results. results: in the study (n = ) and control (n = ) groups, the proportion of male donors ( % and %) and the mean initial skin-prick hb ( g/l and g/l) were similar. significantly less donors were deferred from donation in the study group ( %) than in the control group ( %; chi-square test p = . ). the mean difference in venous hb with the poc device versus the hematology analyzer was À g/l (range À to + g/l). two donors were incorrectly accepted based on venous sample poc result; however, in both, hb measured with the hematology analyzer was only g/l below the limit of donation eligibility ( g/l for a female and g/l for a male). interestingly, a further donors ( % of all deferred in the study group) would have been eligible for donation based on the hematology analyzer result. summary/conclusions: utilizing a venous blood sample for second-line screening of donors failing the initial skin-prick hb test significantly decreased low hb deferrals without compromising donor health. blood donors' and blood service nurses' reactions to the new workflow have been favorable. we conclude that valuable donations can be recovered and donor satisfaction increased by implementing a second-line hb screening model utilizing venous sample analysis at the donation site. background: there is a paucity of literature on haemoglobin (hb) reference values for adults above years of age. this age group has been reported to use up to % the blood supply. some studies report a decline of mean hb with age, but others have found no change with age. conflicting findings of hb levels in the healthy elderly population may be associated with challenges in accessing data from healthy older adults, small sample sizes, selection bias and recent health population data. to donate blood, each individual is assessed as 'healthy' and must meet the minimum hb criteria. however, the hb criteria across countries vary and many blood collection services have an upper age limit for donors. as many populations around world are aging, restricting the upper age limit for blood donation may potentially affect the size of the donor pool and consequently the nation's blood supply. aims: to explore the hb levels of healthy older adults, through a multi-centre retrospective observational study of blood donors aged years or older. methods: over a one-year period, hb values were collected from blood donors aged ≥ years from blood centres of four countries. the estimated proportion of blood donors aged ≥ years old for each country was . % in south korea (sk); . % in hong kong (hk), < . % indonesia (indo) and % in japan (jap). the minimum hb criteria varied between each country and ranged from . - . g/dl for women and . - . g/dl for men. hb levels were determined using point of care testing (hemocue, compolab, hemcontrol) or the xe- d sysmex dependant on the country of origin. statistical analysis of the mean, standard deviation and cumulative distribution of hb were determined by gender and age. background: medication usage is assessed to determine donor eligibility from the perspective of both recipient and donor safety. different time frames since last taken apply to different medications. assessment of medication use varies by jurisdiction, but most european centres use multiple questions. these often include a general question about recent medication use whereas the usa does not. at canadian blood services there are medication questions on the donor history questionnaire (dhq), including any medication use in the last days, vaccination and specific medications over different time frames (high teratogenicity medications). the name of each medication taken and reason for use are documented by staff at each donation attempt. assessment of the frequency with which this process occurs is the first step in improving efficiency of this aspect of donor screening. aims: to determine the percentages donors answering yes to medication questions by demographic variables. methods: all whole blood donors who completed the dhq (full length or abbreviated) in were included in the analysis. donors' answers to each of the medication questions were extracted from the national epidemiology donor database, as well as sex and age. the number and percentage of donation attempts in which a donor answered yes to each medication question were calculated. donors who answered yes to any medication question were sorted by sex and by age group, the totals and percentages calculated. results: there were , donation attempts with a completed dhq. overall, % of donors answered yes to medications in the last days, % to vaccination, and less than . % to others ( % any). slightly more were female ( vs %) of those who answered yes to any medication question, as well as by individual question. the percentage of donors answering yes to any medication question increased progressively in each age group from % of - year olds to % aged + (p < . for trend). summary/conclusions: more than one third of all donation attempts answer yes to a medication question and require further questioning and documentation. this is more common in older donors and follows a similar trend to general population medication use. comparison of ways of assessing medication use in different countries may help identify effective but more efficient approaches. in addition, the contribution to donor and recipient safety of assessing all medications should be assessed. blood center experience with trima accel and tomes software j schreier , a davison , j gambarte , y l opez , c calonge and e herranz terumo bct, lakewood, united states centro de transfusi on de la comunidad de madrid, madrid, spain background: in the madrid community, more than apheresis platelet collections were completed in , of which almost were completed in the blood transfusion center and the remainder in several hospitals in the region. trima accel was implemented to meet the productivity needs of the blood transfusion center while improving the donation experience. tomes (terumo operational medical equipment software), which enables bidirectional communication with trima accel devices, was used to connect and centrally manage all trima accel devices with automated data capture and reporting. aims: the aim of this study was to evaluate operational improvements using trima accel with tomes compared to trima accel version . methods: this was a retrospective study analyzing apheresis procedures on trima accel version during the control period from january to september compared to apheresis procedures on trima accel during the test period from september to december . this was not a paired study. operator interventions, and completed procedure rate comparisons, were analyzed using a -proportions test, whereas donor demographic data were analyzed using a -sample t-test. results: trima accel was used to collect single and double platelet products stored in platelet additive solution. operators selected either a single (target platelet yield = . or . ) or double (target platelet yield = . ) platelet donation based on desired procedure time not the maximum number of products that could have been collected per donor. no statistically significant differences were observed for donors in the test arm compared to donors in the control arm for total blood volume (control = ml, test = ml, p = . ), hematocrit (control = . %, test = . %, p = . ), or platelet pre-count (control = / ll, test = /ll, p = . ). females represented % of donors in the control arm compared to % of donors in the test arm. platelet split rate (platelet products per procedure) increased from . with trima accel version to . with trima accel ; procedure time decreased from . min to . min for single collections and from . min to . min for double collections with trima accel (these differences were not statistically significant). the percentage of procedures that completed with no operator interventions due to access alerts increased from . % to . % (p < . ) and the rate of completed apheresis procedures increased from . % to . % (p = . ) with trima accel . manual transcription of data during the procedure was discontinued with the implementation of trima accel with tomes. tomes captured procedural data and operator steps with barcode scanning and tracking of configured events. this information was transferred to tomes post procedure and printed as a final report. summary/conclusions: trima accel significantly decreased operator interventions, and automated data capture with tomes eliminated manual transcription of data. both outcomes freed operators to complete other tasks and focus on donor well-being. background: the european committee (partial agreement) on blood transfusion (cd-p-ts) of the council of europe (coe) has appointed a working group (wg) to focus on issues with plasma supply management (psm). the task of the wg is, among others, to collect and analyze data in order to fill knowledge gaps concerning donor safety in plasmapheresis. in doing so, the working group will gather evidence base data to support the upcoming revision of the th edition of coe's "guide to the preparation, use and quality assurance of blood components", the blood guide. an international survey was conducted sept-dec , distributed to blood establishments (bes) by the cd-p-ts representatives to coe's member and observer states. the questionnaire included sections covering collection practices (volume and frequency), management of red cell loss, donor panel demographics and data on donor adverse events. aims: the aim of this study was to investigate whether collection practices following the recommendations published in the blood guide for maximal collection volumes and number of donations per year were indeed associated with higher levels of donor safety and improved donor base sustainability. methods: from the total of respondents, bes collected plasma for fractionation (pff) by apheresis and the study had a dataset covering , , plasma donations in the latest fiscal year (lfy). the parameter used as marker of donor safety was the rate of immediate vasovagal reactions with loss of consciousness (vvr with loc) per , plasma collections. the parameter used as marker of donor base sustainability was the retention rate of donors, ie % donors active in the previous year returning to make a donation in the lfy. results: in the blood guide, the collection volume per apheresis is limited to % of the estimated total blood volume but maximally ml, including anticoagulant. respondents had differing practices and scale of collection program be were aligned or lower, and be had higher collection volumes. altogether reported the immediate vvr with loc rate, which mainly was lower than / collections. there was a small trend towards reduced rate with larger collection volumes than allowed by the current blood guide. saline compensation during or after collection did not affect the rate of vvr with loc. no correlation was observed between the annual donor retention rate and the rate of vvr with loc or saline compensation practices, as reported by respondents. the retention rate banded in the range of %> % (mean = %, min = %, interquartile range = %, max = %). the association between maximum allowed yearly plasma collection ( l) appears to be reasonably constant and showed no clear association with the donor retention rate. summary/conclusions: restricting the maximum collection limit according to the current blood guide was not associated with either lower vvr with loc or with higher donor retention rate. this study supports reassessment of current blood guide s limits for collection volume of maximum of ml per donation and l per year per donor. methods: serum ferritin concentrations were established from sera stored at À °c from repetitive platelet donors between and , using architect â ferritin assay chemiluminescent microparticle immunoassay (cmia). the hematimetric parameters were evaluated in a total blood sample using the celldyn â . sixteen samples were obtained from women (age: . ae . years, range: - ) and samples from men (age: . ae . years, range - ), corresponding to . % and . % of the total female and male repetitive donors of platelets by apheresis using trima accel â terumo-bct and amicus tm fresenius-kabi. the difference in the concentration of serum ferritin between the last and first donation was established, as well as the change in the predonation platelet count between the last and first event. results: in the study population, . % of women and % of men performed repetitive donations of platelets by apheresis with an interval of less than three months. the change in ferritin concentration was evaluated according to the interval between donations. in women ferritin delta was À . ae . ng/ml when the donations had an interval less than three months, vs . ae . ng/ml when the time between donations was higher (p = . ). in men the change in the ferritin levels was À . ae . ng/ml with donation times less than three months vs © the authors vox sanguinis © international society of blood transfusion vox sanguinis ( ) (suppl. ), - À . ae . ng/ml with prolonged donation times (p = . ). in women, the change in platelet count was À ae . /ul, when the donations had an interval less than three months vs À ae . /ul when the time between donations was greater (p = . ). in men, the delta of the platelet count was À ae . /ul in donation times less than three months vs À ae . with higher donation times (p = . ). no correlation was found between the concentrations of serum ferritin and the platelet count (r = . , q = . for males, and r = . , q = . for females). summary/conclusions: the data obtained suggest that repetitive donation of platelets by apheresis with intervals between donations of less than three months, significantly reduce serum ferritin concentrations in women and men, although normal levels were maintained in both groups. there was no correlation with platelet count. therefore, it is proposed to develop prospective studies to establish the minimum time interval safety for platelet apheresis donor procedures. background: the demand for platelets concentrates is increasing continuously and becomes a challenge for the blood establishments. apheresis platelet collections may be a solution for this challenge. improving apheresis collection efficiency while maintaining blood donor safety is an important goal for the service du sang of the belgian red cross. aims: our establishment evaluated the improvements of the trima accel automated blood collection system version (ta ) by comparing its routine performance with that of the previous software version . (ta ). methods: prospective, multi-site, controlled, non-randomized trial. apheresis collections were performed in three sfs sites: liege, mons and namur using the two trima software versions ta and ta sequentially. data were collected from december to april on ta and from june to july on ta . simple and double doses of platelets (respectively . , . and . , . ) were collected in platelet additive solution (ssp+, macopharma) with concurrent plasma from the same cohort of donors in accordance to donor's eligibility and preferences. in order to maintain the same final platelets content in platelets concentrates, the trima accel's tool yield scaling factor (ysf) was subsequently adjusted from . (ta ) to (ta ). platelet yield, duration of procedure, number of alarms requiring operators' interventions were recorded and evaluated. donor's hypocalcemia was avoided by giving preventively oral or intravenous calcium which was documented by the operators. results: five hundred ninety ( ) collections with ta and with ta were recorded, with % and % complete procedures respectively. mean duration of procedures was min on ta against min on ta , p < . . the mean alerts number per procedure on ta was . against . on ta , p < . whereas the maximum alerts number per procedure was and respectively. on ta , % procedures did not require operator's intervention against % on ta ,. with ta the inlet flowrate was automatically adjusted in . % procedures. the inlet flowrate was increased in response to access pressure in . % of procedures, for % of the procedures the inlet flowrate was decreased and for . % of the procedures the inlet flowrate was increase and decreased on the same procedure by the ta autoflow system. summary/conclusions: ta with its autoflow function improves apheresis donors experience while decreasing operator' interventions through a significant reduction of access draw alerts. as expected from the trima accel platform, post-donation safety remains high. a weak increase in procedure duration was observed for the same platelet yield which may be resolved with further adjustments. background: trima accel system is an apheresis platform relying on continuous flow centrifugation to collect from a donor platelets, plasma or rbcs based on donor qualification. the latest software version -trima accel (ta ) introduced the autoflow feature which allows for automated flow rate adjustments. moreover, ta leverages the mobilization capacity of the spleen increasing potential platelet productivity while maintaining high post-donation safety standards characteristic of trima accel. aims: the objective of this evaluation was to assess the impact of ta software by retrospective comparison of procedure data and potential for increased productivity with those of trima accel version (ta ) in the same cohort of platelet donors. methods: eight hundred twenty one procedures, started on ta from th january to th october were compared to procedures, started on ta from th october to st december . procedural data from the trima devices were captured using the cadence system (terumo bct, lakewood co). parameters investigated were the number of machine access pressure alerts per procedure, the potential for higher platelet yield collections and the actual collected yields within the same cohort of platelet donors. results: both donor populations (ta vs. ta respectively) were comparable and were characterized by: tbv - vs. ml; platelet count pre-procedure - ³/ll vs. ³/ll; hematocrit pre-procedure - % vs. %. gender distribution was % female with ta vs. % with ta . venous access pressure alerts were significantly improved by ta with an average of . alerts per procedure as compared to . with ta , i.e. % decrease. this decrease went down to % if only male procedures were analyzed. the maximum number of pressure alerts went down by % from alerts in one particular run in the ta cohort to alerts in one ta procedure. procedure time for single platelet products was reduced from to min and for double platelet products from to min (ta and ta respectively). donor qualification possible was % of procedures yielding single products and % of procedures yielding double products with ta . the percentage of procedures qualifying for doubles increased to % with ta . in terms of split rates, i.e. how many platelet doses could be produced per apheresis collection, potential split rates increased from . to . from ta to ta , respectively. in fact, the observed split rate rose modestly from . to . , as shorter procedures were generally selected according to donors' preferences. summary/conclusions: in comparable donor populations, implementation of ta decreased the number of access pressure alerts significantly compared to previous trima versions. the average procedure duration was also found to be slightly reduced. implementation of ta has the potential to increase productivity significantly. the observed modest actual rise in split rate suggested that factors related to donor and inventory management will determine at which extent the potential of the new software will be used. donor compared experience on trima accel to trima accel version august to october or trima accel during the test period from november to january . this was not a paired study. donors completed the survey while recovering from the apheresis procedure in the cantina. results from the paper survey were transcribed into excel for analysis. results: donors completed the survey during the control period whereas donors completed the survey during the test period. the mean number of previous donations for the control period was . (min max ) and for the test period was . (min max ). there were no first time donors during the control period and first time donors during the test period. % of donors rated their overall donation experience as good on trima accel compared to % on trima accel version . zero ( ) donor rated their experience on either trima accel device as poor. % of donors who responded to the question said they would donate on trima accel again. summary/conclusions: no significant difference was observed in donor experience between trima accel version and trima accel as both versions receive high marks. background: the trend on growth of query for donor platelet concentrates is observed in russia for past few years. as reported by edqm in , a higher number of the platelets was consumed compare to by . %. patients' with hematological malignancies treatment requires platelet concentrates transfusions during chemotherapy, immunotherapy and hematopoietic stem cells transplantation. according to the data collected in national research center for hematology (nrch) in , ( . %) of the , patients, treated within facility, received platelet transfusions as transfusion therapy. the total number transfused units is , , which is higher (by . %) comparing to . platelet concentrates production can be performed either by apheresis process or by pooling individual units recovered from the whole blood. taking into account that the nrch produces blood units for its own needs, the pooling is not suitable method for production because its implementation doesn't cover require for platelets and overproduces rbcs. that is why platelet concentrates in nrch are obtained by apheresis only. in summary, the growth on requirement for platelet concentrates and their safeness explains the need for a comparative study for effectiveness of platelet production using various apheresis systems. aims: the aim of the study is to compare effectiveness of platelet concentrate production using mcs + (haemonetics), upp and trima accel (terumo bct) version . protocols. methods: the data for protocols of platelet donations performed in were analyzed: on trima accel and on msc + . all donors were voluntary and non-paid donors with previous experience of blood donations. the choice of the platelet collection device was random; analysis of the main characteristics of donors did not reveal any significant differences between the groups. the median age of the donor was years old, height - cm, weight - kg, platelet count before donation - /l, hematocrit - %. detailed data are presented in table . student's t-test for unrelated sets was used for statistical analysis of the data. a value p of less than . was considered as significant. results: the data obtained showed significant difference (p < . ) between average number of platelets collected on trima accel ( . ae . /l) and on mcs + ( . ae . /l). while cost of consumables are comparable, trima accel demonstrated . % higher efficiency. procedure duration also was comparable and averaged within min for both devices. detailed data are presented in table . it is crucial to mention that proportion of trima accel's donations was significantly increased in nrch during and reached , % in total ( - . %). a flexible usage of trima accel's consumables for different procedures (regular platelet collection and collection in pas) allowed to change the pas/regular platelets collection ratio from . % up to . %. summary/conclusions: obtained results proved the effectiveness of the trima accel's use for platelets concentrates production. it allowed to increase the average count of platelets obtained for one procedure by . % compared to mcs + while the cost of consumables and procedure duration are comparable. the donor's comfort during procedure did not affect either. in long terms increasing of number of platelets collected is reducing the cost of platelet concentrates production. abstract withdrawn. background: apheresis collected platelet concentrate is preferable in terms of reducing the risks of adverse reactions in platelet transfusion when compared to random donor platelet concentrates. aims: the aim of our study is to present our experience in collection donation of single donor platelets with apheresis. methods: this is a retrospective study performed in the institute for transfusion medicine from till . all donors were fully informed on the donation procedure and signed an informed consent for donation. the optimal platelet count that we want to achieve was ≥ . equal to random donor platelet doses. minimum preapheresis platelet count in donors requested to start the apheresis collection was . /ll. platelet collection was performed using flow cell separators haemonetics mcs+ and trima accel. acid citrate dextrose formula a was used for anticoagulation. median precollection platelet count of donors was . /ll, with range from . /ll to . /ll. male were % of the donors and females were %. the single procedure usually took - min. the median platelet count collected was . , range - . . the median processed blood volume was ml and median used acd-a was ml. mean total volume of collected product was ml. the adverse effects included vein perforation and the numbness of the extremities as reaction of acd-a (hypocalcemia), which occur rarely and was very mild. summary/conclusions: the collected platelet count was more than the wanted optimum platelet count. the number of apheresis donors is increasing and we are working on expanding our voluntary platelet donors registry and increasing the number of typed donors in the registry. background: to determine value of hemoglobin in blood donors, there are some tools or methods used, such as: cyanmethemoglobin method that can detect of hemoglobin quantitative and methods cupric sulfate solutions (cuso ) can detect of hemoglobin qualitative. according to who (world health organization) to determine the level of hemoglobin in blood donors enough used cuso solutions with specific weight (y) . can to detect value of hemoglobin above or same with . gr/dl. but, cuso solution specific weight . can not to detect and elimination value of hemoglobin above gr/dl or polycythemia sick. because it, central blood transfusion unit (utdp) as the central of blood service in indonesia to manufacture cupric sulfate solution (cuso ) with a specific weight (y) to detect value of hemoglobin below gr/ dl and determine value of hemoglobin above gr/dl. because it, do the testing the accuracy of the solution cupric sulfate in detecting and eliminating donor with value of hemoglobin above gr/dl with the test of samples. aims: to determine accuracy and effectiveness by blood donors unit in indonesia red cross to use cuso solution with specific weight . in to detect and elimination value of hemoglobin donors above gr/dl. methods: used the method cyanmethemoglobin and cuso (y) . determination value of hemoglobin donor. test results were analyzed with spss software version using nonparametric analysis wilcoxon test. results: this research testing the accuracy and effectiveness of using a cuso solution with specific weight (y): . in detecting and eliminating hemoglobin value donors above gr/dl. from data processing using spss with the wilcoxon test p value . . summary/conclusions: it was found that the cuso solution (y): can detect hemoglobins value above gr/dl and more effective in checking the hemoglobin in blood donors. it can be seen from the data processing with spss version with the wilcoxon test p value < . . it is important to monitor the precise course by which repeated blood donation affects hb and the probability of low hb deferral. zinc protoporphyrin (zpp) is a functional indicator of body iron levels and is hypothesized to predict hb levels among blood donors. advanced statistical methods are necessary to properly analyze the longitudinal associations between zpp and hb in data with repeated donations per donor. aims: to determine whether predictions of future hb levels using current hb levels can be improved by taking zpp levels into account, and to illustrate the use of statistical models for repeated measurements of blood donors. methods: we used data from the zpp and iron in the netherlands cohort (zinc) study. we identified previous zpp levels (log-transformed) as the main predictor and adjusted for previous hb level, age, day and time of donation, donation history, bmi, blood volume and blood pressure. we used linear mixed models, which take into account missing data in the outcome and associations between repeated measurements, to investigate the longitudinal association between previous zpp and current hb levels. the longitudinal analysis with linear mixed models was contrasted with a simpler analysis based on the area under the receiver-operating-characteristic (roc) curve for the probability of low hb deferral. results: in total, whole blood donors ( , whole-blood donations) were included in the zinc study, % being female donors. previous zpp showed a statistically significant association (p < . ) with hb levels in females, but the size of the association was quite small (regression coefficient, b = À . , % confidence interval À . to À . ). the same was true for males, but the size of the association was even smaller. blood volume and age for women were significant secondary predictor variables; blood volume, age and donation interval for men. by comparison, the roc analyses showed relatively larger, but less statistically significant predictive effects of zpp on hb. summary/conclusions: zpp is a statistically significant predictor of hb levels, but the size of the effect after adjustment for previous hb and other variables is small. the results cast doubt on whether zpp is an effective predictive marker for hb level and low hb deferral, and suggest that zpp should not be included in prediction models for hb levels. by properly adjusting for associations between repeated measurements and by using all available data, longitudinal models provide less biased and more precise estimates than simpler cross-sectional analyses. background: finnish red cross blood service (frcbs) is a national blood service and is responsible for all blood collection and component production in finland. the highest age for blood donors was years until the end of year and since beginning of donors between and years have been able to donate blood. blood donation after the age is possible if the donor has donated within the last months. the upper age limit was raised up based on adverse event data from frcbs donors up to years and on published data from other blood establishments. aims: the aim of this study is to find out if the new policy from with upper age limit of years is safe. therefore donor adverse event data was analyzed in order to evaluate if the blood donors older than years have more adverse events compared to other donors. the most common donor adverse event for donors over years, haematoma, was registered times ( . %). in the other age groups haematoma was registered times ( . %) and the difference between the oldest age group compared to all other donors was statistically not significant (chi , p = . ). vvrs with loc were registered times ( . %), vvrs without loc times ( . ), and the total number of all daes was ( . %) in the age group years or older. the respective numbers in the other age group were: , . %; , . %; ( . %). the number of vvrs with and without loc, and total number of all daes in the age group years and older was smaller than in the other groups and the difference between these groups was statistical significant (chi , p < . ). summary/conclusions: donors over the age of years have less donor adverse events than other age groups. decision to raise the age limit from to seems proven to be right as the older age group has even less donor adverse events than other donors. background: deep vein thrombosis (dvt) of the donor's phlebotomy arm is a rare, but serious complication of blood donation that needs to be recognised and managed appropriately in a timely manner. post donation dvt will be classed as a 'serious adverse events of donation' (saeds)these are events that either result in donor death, hospitalisation, intervention or significant symptoms persisting for more than one-year post donation. aims: to review cases of dvt post donation reported in uk in - years and identify any common themes for improving practice methods: all data relating to saeds from the four uk blood services reported to shot in the last years ( - inclusive) were reviewed to look for reports of dvt post donation results: a total of saeds were reported in uk from approximately . million donations (whole blood and apheresis) collected during this period. three cases of upper limb dvt were reported during this time accounting for % of the saeds reported and rate of dvt of in . million donations collected. -case : a regular male whole blood donor in his early s reported worsening arm pain days following blood donation, had a painful venepuncture and a small bruise at site of donation. he was diagnosed to have an upper limb dvt extending to the subclavian and brachiocephalic vein and started on oral anticoagulants. no other contributory factor was obvious -case : a female donor in her mid- s gave her sixth whole blood donation without event. days after donation, she developed worsening arm pain in the donation arm and was diagnosed with an upper limb dvt and commenced oral anticoagulation. there was no other identifiable risk factor for the thrombosis -case : a female donor in her s developed pain, swelling, redness and itchiness in her donation arm and chest wall two days after donation. she also described prominent veins on the affected side compared to her other arm. she contacted the transfusion service one week after donation; by this time she was also breathless on minimal exertion. she was admitted to hospital and commenced on anticoagulant therapy. a diagnosis of dvt and associated pulmonary embolus was confirmed. the donor's only risk factor for thrombosis was use of the oral contraceptive pill. summary/conclusions: rare complications of blood donation, like dvt, can occur. superficial venous thrombosis may occasionally progress into the deeper veins of the donor's arm but dvt can also occur without signs and symptoms of superficial thrombosis. none of our patients had any overt evidence of superficial thrombosis. one patient in our series reported using oral contraceptive pill. no other risk factors for thrombosis was forthcoming. transfusion services should encourage donors to make early contact with the blood service if they experience arm complications so that they can be investigated and managed in a timely manner. staff dealing with such donors must recognise the possibility of this rare complication, explore other additional contributory factors and initiate prompt and appropriate management. background: voluntary blood donation is widely considered to be safe with very minimum chance of adverse reaction, which may occur during or after the end of phlebotomy procedure. aims: to find the adverse blood donor reaction among voluntary blood donors in tertiary care hospital in kathmandu methods: this is a prospective study done among voluntary blood donors at grande international hospital, kathmandu, nepal from february to march . the outlines of reported and communicated adverse donor reaction were also collected after the blood donation from voluntary blood donors in different locations including outdoor and in-house blood donation drive results: in the present study , whole blood donors were included, during the period of years, ( . %) adverse donor reactions were reported. majority ( . %) of adverse donor reactions were mild in nature such as, sweating; ( . %), light headedness; ( . %), nausea and vomiting; ( . ), allergy and bruises; ( . %), sore arm; ( . %) and hematoma; ( . %) while ( . %) were severe adverse reactions similarly, anaphylaxis; ( . %), loss of consciousness; ( . %) and convulsive syncope; ( . %). markers of the adverse donor reaction were age, sex, pulse, weight, blood pressure and donation status. age and first time status were related with significantly higher risk of adverse reaction with - years old at higher risk compared to - years old. first time donors were at higher risk compared to repeated volunteer donors. summary/conclusions: the results of the study are helpful to identify and understand the complication of adverse donor reactions though the incidence of reactions in the blood donors is lower than in other studies. donor age and donation status were strong possibilities of complications. background: blood donors with pollen-induced allergy and asthma must often refrain from donation in pollen season despite medication, because of symptom severity or similarity to airways infection. extracts of the medicinal mushroom agaricus blazei murill (abm) given orally have been found to reduce ige anti-ovalbumin levels and ameliorate the skewed th /th cytokine balance in mice sensitized to ovalbumin (takimoto, immunopharm immunotox, ; ellertsen & hetland, clin mol allergy, ). aims: the objective was now to examine whether supplementation with the abmbased extract that we used in the mouse model for allergy, could alleviate allergy and asthma in blood donors by reducing specific ige levels and basophil sensitization. methods: sixty donors at oslo blood bank with self-reported birch pollen allergy and/or asthma were recruited and randomized in a double-blinded, placebo-controlled study with oral supplementation for weeks before the birch pollen season with the abm-based extract andosan tm (immunopharma, oslo, norway). this is a water extract of the bacidomycetes mushrooms abm ( %), hericeum erinaceus and grifola frondosa. the participants filled in questionnaires for allergic conjunctivitis & rhinitis, asthma and medication. serum ige (immunocap â , immunodiagnostics, sweden) and bet v -induced basophil activation in whole blood determined by cd expression in a flow cytometer (flow cast â , b€ uhlmann lab ag, switzerland), were analyzed before and after the pollen season. (trial record: nct , clinical.trials.gov). results: there was significant reduction in allover allergy-related ailments and types of allergy medication used in the abm extract compared with placebo group during the pollen season and no side effects. also, abm treated asthmatics had fewer symptoms and used less medication than controls. in the abm group, serum levels of specific ige anti-bet v and anti-t , were significantly reduced during the pollen season as compared with levels in the placebo group. whereas the maximal allergen concentrations needed for eliciting basophil activation before the season changed significantly to lower concentrations (i.e. enhanced sensitization) after the season in the placebo group, these concentrations remained similar in the group given the mushroom extract. summary/conclusions: oral pre-seasonal supplementation with an abm-based extract for months reduced general allergy ailments, asthma symptoms and medication in blood donors with birch pollen-induced allergy and asthma during the pollen season. this was due to reduced specific ige levels and basophils rendered less sensitive to allergen activation. the study suggests that supplementation with abm mushroom extract can have prophylactic effect on aeroallergen-induced allergy and asthma in blood donors. it may therefore reduce such ailments in affected blood donors and impact blood donations in the pollen season. results: dhv started in / / . the data presented in this abstract is till / / . data is collected from total of blood donors ( . % male donors and . % female donors). repeat donors accounted for . % against . % of first time donors. of the total number of donor adverse events recorded, . % ( ) reported for male donors and . % ( ) for female donors when the donor adverse events stratified age-wise, the highest incidence reported in age group - years (male . % and female %). among age group - years, (male . % and female . %), whereas in age group - years, (male . % and female . %) data analysis of total reported and registered donor adverse events, are categorized as hyperventilation ( ), sweating ( ), dizziness (pre-syncopal ), loss of consciousness ( ), vomiting ( ), convulsions ( ), hematomas with re-bleed ( ), nerve irritation ( ) and off-site reactions ( ). many donors showed multiple forms of reactions. summary/conclusions: evaluation of donor side effects helps to improve donation process and donor compliance. most frequently recorded reaction remains dizziness (pre-syncopal). our donor vigilance data show reactions occurred more frequently in younger age, female and first time donors. repeat donation and age are predictors for low rates of adverse events. participation in dhv implies an effort to improve donor care and safety infrastructure and a desire for national and international comparisons to determine best practices and also to look into effectiveness of risk reduction strategies and follow-up trends. pre-donation hydration was implemented as an interventional tool to test the effects of hydration on pre-syncopal reactions to blood donation, specifically targeting those at highest risk such as female, first-time, high school donors. the results are awaited. background: descriptions of deferral categories and a knowledge in the percentage of deferrals in each category are of value in formulating recruitment and retention strategies. this can also help in planning more efficient recruitment strategies and thereby assist in reducing the shortage in blood supply. aims: the aim of the study is to categorize all donors who were deferred during medical checkup and find out the donor deferral rate in dubai blood donation center from january st to december st and also to find out whether there is any yearly or seasonal trend in any of the categories of deferral criteria's which can aid in forecasting and managing donor pool. methods: a retrospective study of donors deferred during last three years from january st to december st was done in dubai blood donation centre. the donors deferred during pre-donation medical check-up were categorized into categories including low hemoglobin, high and low bp, intake of antibiotic, fever and flu, taking other medications, travel history etc. the deferrals were analyzed monthly and yearly and then were compiled to find any yearly trend or seasonal trend in the donor deferral rate in any of the categories. the data were analyzed using the spss software and a p value of < . was considered significant. the assessment of donor suitability is in accordance with aabb standards and is consistently applied in every blood donation setting on each occasion of donation to all blood donors. results: during this study, , donors were registered from january st to december st and , ( . %) donors were deferred. the common reasons of deferral were low hb, high bp, travel history, intake of antibiotics and cough/flu symptoms. there was a significant decrease in deferral rate from . % ( / ) in to . % ( / )in and further to . % ( / ) in (p < . ). the specific deferral rate due to low hb also significantly (p decreased during these three years ( / in , / in , / in ), though no change was seen in the deferral due to other reasons. the reduction in the rate of deferral due to low hemoglobin may-be linked to the change in the staff performing the hemoglobin testing in dbdc (nurses instead of phlebotomist were assigned to perform hb estimation of donors). there was a seasonal variation in the deferral rate in all the three years-lowest in june ( / ) and then increasing with a peak in october ( / ) and plateauing till january. this pattern of deferral corroborated with the rate of deferral due to flu/fever and cough and antibiotics with an average of / in june and increasing to / in october (p < . ). summary/conclusions: staff competency is pertinent in accurately deferring donors. there is also a significant seasonal pattern in flu/fever and intake of antibiotics deferral rate that is reflected in the total donor deferral pattern. seasonal variation of specific category of donor deferral should be taken into account for donor recruitment and retention efforts. background: west nile virus (wnv) is a mosquito transmissible flavivirus. it has been shown (vogels thesis) that the common mosquito in the netherlands can transmit wnv in laboratory circumstances but presently does not lead to effective transmission. however, the number of outbreaks of wnv is increasing and moving from the eastern and southern european borders towards the traditionally more colder western and northern parts of europe. in order to prevent wnv transmission to blood transfusion recipients, dutch donors that travelled to regions with wnv risk are deferred for a period of days for whole blood, platelet donations and quarantine plasma in order to exclude potentially infected asymptomatic donors. aims: to assess numbers of dutch donors who are deferred for travelling to wnv risk areas within europe, and the return after onsite and offsite deferrals of donors. methods: data from to on donation attempts and deferral were retrieved from eprogesa, the blood bank information system. onsite deferral is defined as a donation that was attempted in the deferral period or in the days prior to deferral, all other deferrals are considered as offsite. a generalized estimating equation model was used to assess the association between onsite versus offsite wnv risk deferrals in - and subsequent return rates within two years (after which a donor is inactive according to domaine). results: in - , , donation attempts led to onsite deferral for wnv risk; % at whole blood donation attempts, % at new donor examinations. in total , offsite deferrals could not be traced directly to a donation, but based on the next donation more than % were probably whole blood donors. the number of deferrals peaks each year during august, the major holiday period in the netherlands, and increased from in august to in august . this increase is probably caused by the expansion of wnv risk regions. the return rate of wnv deferred whole blood donors is slightly lower than for donors who are not deferred ( % versus %); for wnv deferred new donors the return rate is % (versus % for no deferral). thus wnv deferral resulted in approximately - extra lapsing donors during these years. however wnv deferred donors, that are older (odds ratio (or) . ; % confidence interval ( % ci) . - . ), of male sex (or . ; % ci . - . ) and whole blood donors as opposed to new donors (or . ; % ci . - . ) were more likely to return to donate. there was no difference in return rate by offsite and onsite deferral. summary/conclusions: travel-related wnv deferrals are increasing with expanding risk regions, especially in the holiday season where the availability of donors is already low. although the numbers of donors who are permanently lost after wnv deferral are limited, the increasing numbers of lost donations make it important to consider alternatives to donor deferral such as wnv nat testing. background: low haemoglobin due to iron deficiency is increasingly recognized as a serious problem in many blood centers. donor education, iron supplementation, ferritin monitoring, and lengthening of inter-donation interval are currently the main mitigation measures. however, a number of factors in particular donor knowledge could impact their success. locally, iron supplementation programme was implemented since with target group of donors who have given blood within the last six months. aims: here we look at an online donor survey to gain insight on their view of the programme and knowledge. methods: donors with successful blood donation in the past six months would be given days of one tablet of iron supplementation ( mg elemental iron) since . an electronic questionnaire was sent to blood donors in to assess their view on the programme and knowledge which focused on iron store and absorption, compliance and any side effects occurred. results: donors (male to female was : . ) replied to the questionnaire. of them, received iron supplementation (male to female was : . ). most of the respondents ( %) had one or more donations in the preceding months. of the donors received iron tablets, only ( %) took all; ( %) took more than % but not all; ( %) took some but less than % and ( %) did not take any. gastrointestinal upset was reported in ( %) donors and constipation seen in ( %) among those who took at least some of the iron supplementation. most respondents answered correctly to the questions on the knowledge on iron store and absorption. when comparing those with better compliance (took more than %) to those who did not (took less than %), significantly more donors in the former knew vitamin c could enhance iron absorption (p < . ). on the other hand, no difference was seen when they were asked if ) iron can only be absorbed from meat; ) tea and coffee consumed during meal can enhance iron absorption; ) everyone can take iron supplementation on their own; and ) iron store in male is always more than female. summary/conclusions: the results suggested that there is definitely more room to enhance the blood donors' knowledge on iron store and absorption in order to improve the effectiveness of iron supplementation programme. besides, the side effects reported by the donors could be an important limiting factor that better alternatives should be explored and considered. background: vasovagal reactions (vvr) are a well-established deterrent to donor return. however, the correspondence between vvr experience and donor lapse is not perfect. in australia, for example, vvrs only reduce two-year return rates by % for whole blood donors and % for plasma donors. the elements of a vvr and the donor's interpretation of this event that protect against or encourage lapse have not yet been identified. aims: in this study we explored the views of donors on donating following a vvr, with a particular interest in their emotional reaction to the vvr, their understanding of what caused the reaction, and their intentions to return. methods: semi-structured telephone interviews were conducted with whole blood and plasma donors who had a recent vvr experience. data were analysed using the framework approach. results: donors are generally motivated to give blood to help others and to positively impact on those in their communities. they anticipate feeling good after their donation but in contrast, for many, a vvr leaves them feeling anxious, embarrassed, and disappointed. for donors, the experience of a vvr negatively influences their perceived ability to donate successfully, and many fear it will happen again. however, this effect appears minimised among donors who at least partially attributed their reaction to their own behaviour, such as poor hydration. for donors already juggling multiple demands, a vvr may tip the balance with donating becoming too much of an effort and perceived risk. however, donors appeared more confident to return if they felt supported by staff or if they could donate with family or friends. summary/conclusions: this study provides valuable insight into the vvr experience, which will aid in the improvement of donor safety and retention. the findings highlight the need to improve communication at the time of and following a vvr, to educate donors on how to reduce their vvr risk, and to intervene to help donors maintain their perceived ability to give blood in order to maximise retention following a vvr. background: frequent blood donation depletes the iron stores of blood donors. iron depletion might have negative effects on the health of the general population, but its effect on the blood donor population is not well known. aims: to investigate the iron status of finnish blood donor population and how it relates to donor health, the finnish red cross blood service set up the findonor , study in . we investigated whether there were changes in donors' selfrated health and if these possible changes could be associated with differences in iron biomarkers (ferritin and soluble transferrin receptor -stfr) or hemoglobin levels during the first study visit. methods: participants were recruited in three donation sites in the capital region of finland between may and december . participants filled out an electronic questionnaire about their health and lifestyle at the donation site during their enrollment visit. participants were asked by letter to fill out the same questionnaire electronically during the summer . we included the participants ( men and premenopausal and postmenopausal women) who completed both health questionnaires. to evaluate self-rated health we used the well-validated single question: "how would you rate your health in general?". participants were able to evaluate their health status on a five-point scale: excellent, very good, good, moderate, and poor. iron biomarkers and venous hemoglobin were measured from blood samples collected at the first study visit. we first computed the odds-ratios of reporting poorer health depending on demographic group. we then compared iron biomarker and hemoglobin levels between donors who reported improved, similar or poorer health rating. results: donors who rated their health in the first questionnaire as moderate (n = ), good (n = ), very good (n = ) or excellent (n = ) health tended to report improved ( %), similar ( %), similar ( %) or poorer ( %) health ratings respectively in the second questionnaire. pre-menopausal women reported their health poorer in the second questionnaire compared to the first questionnaire more often than post-menopausal women (pre-menopausal %, post-menopausal women %), or = . % ci . - . ). there were no differences between other groups. there were no significant differences in iron biomarkers levels (ferritin and stfr) or hemoglobin levels between donors whose health ratings were improved, similar or poorer. summary/conclusions: in this cohort, pre-menopausal women rated their health poorer at the end than at the beginning of the study more often than post-menopausal women. no association was found between changes in self-rated health and iron levels (ferritin, stfr) or hemoglobin levels. further studies about the factors relating to blood donors' self-rated health need to be carried out. background: in recent years, the blood donation business has made great achievements, but it still cannot avoid the occurrence of adverse reactions to blood donation which not only brings certain obstacles to the blood donation work, but also affects the enthusiasm of blood donors. aims: to understood the causes and other relevant factors of adverse reaction among blood donors, the information of blood donors at dai autonomous prefecture of xishuangbanna were analyzed in . methods: the data of volunteers from january to december were analyzed. the causes of adverse reactions were classified, and the incidence of adverse reactions was compared in terms of gender, frequency, age and blood type of blood donors. results: there were blood donors in , ( . %) of whom had adverse reactions and causes were induced, among which mental stress was the most common factor that accounted for . % ( cases). there was no significant difference in the incidence of adverse reactions between men and female (p > . ). from the frequency of blood donation, the incidence in the first donor was significantly higher than that in the second donor (p < . ). when it comes to age, the incidence was different and the - age group was the highest ( . %). among different blood group donations, there was no significant difference (p > . ). summary/conclusions: adverse reactions of blood donation is closely related to the psychological state and age of the blood donors. the staff of the blood center should further optimize the service, strengthen the communication and publicize the knowledge of blood donation. the ultimate goal is to increase the blood donation rate on the basis of reducing adverse reactions. background: blood loss due to repeated blood donation can lead to iron deficiency or anemia, but currently there is no management plan for the prevention of iron deficiency in korean blood donors. female and male donors are required to wait at least weeks between blood donations in korea, which is the shortest period among all northeast asian countries. female and male donors are allowed to donate whole blood up to five times per year and platelets up to times per year (if spaced more than days apart for the latter) due to the chronic blood supply shortage. these facts induce concern about the impact of blood donations on the donors' iron status. aims: this study aimed to evaluate the effect of oral iron supplementation in repeat donors based solely on donation history. methods: the high-risk group included male donors with ≥ whole blood donations or plasmapheresis or plateletpheresis donations, and female donors with ≥ whole blood donations or component donations, both within the previous year. the control group consisted of first-time or reactivated (ft-ra) donors who had no history of blood donation in the past years. the hemoglobin (hb) level, ferritin level, total iron binding capacity (tibc), transferrin saturation, and soluble transferrin receptor (stfr) of repeat donors at high risk for iron deficiency were compared to those of ft-ra donors. iron deficient erythropoiesis (ide) is defined as present if the log of the ratio of soluble transferrin receptor to ferritin was ≥ . . the repeat donors took iron supplements for weeks and the same tests were repeated after and weeks to evaluate their effects and the side effect and compliance was assessed. results: a total of male and female repeat donors were recruited, and each male and female ft-ra donors were recruited to the control group. after week iron supplementation, among male donors, the prevalence of: low hb level (< . g/dl) decreased from . % to . %; low ferritin level (< . ng/ml) decreased from . % to . %; high tibc level (> lg/dl) decreased from . % to . %; low transferrin saturation (< . %) decreased from . % to . %; and ide (stfr/ferritin ≥ . ) decreased from . % to . %. among female donors, the percentage of: low hb level (< . g/dl) decreased from . % to . %; low ferritin level (< . ng/ml) decreased from . % to . %; high tibc level (> lg/dl) decreased from . % to . %; low transferrin saturation level (< . %) decreased from . % to . %; and ide (stfr/ferritin ≥ . ) decreased from . % to . %. in total, male ( . %) and female ( . %) blood donors reported undesirable side effects related to iron supplementation. a total of male ( . %) and female ( . %) blood donors were administered iron supplementations for days. participants ( . %) answered that they were willing to take a complimentary iron supplementation. summary/conclusions: ferritin level, considered a reliable indicator of iron status, increased and ide decreased significantly after iron supplementation in female donor group, but not in male donor group, compared to the ferritin levels and ide of control donors. iron supplementation in repeat donors at a high risk of iron deficiency was shown to reduce their risk of iron deficiency or anemia irrespective of gender; however, -week oral iron supplement was not enough to restore iron storage level in the male donor group. background: c-reactive protein (crp) is an acute-phase protein and a non-specific maker of inflammation and tissue damage produced by the liver. several prospective epidemiologic studies have demonstrated that high-sensitivity c-reactive protein (hs-crp) is a predictor of future coronary events among apparently healthy men and women, hs-crp level greater than mg/l has been independently associated with a % excess risk in incident of coronary heart disease (chd) as compared with levels less than mg/l. frequent blood donation has been associated with a lower incidence of coronary artery disease (cad); however, there is a dearth of information on serum levels of crp in the nigerian donor population. aims: to investigate whether regular blood donation is associated with lower serum hs-crp level in nigerian blood donors. methods: a descriptive cross-sectional study carried out to measure serum levels of high sensitive c-reactive protein (hs-crp) and ferritin among blood donors attending the donors' clinic in lagos university teaching hospital (luth). subjects who did not meet criteria for blood donation were excluded. additional data on sociodemographic characteristics was collected using interviewer-administered questionnaire. serum ferritin was analysed using chemiluminescent microparticle immunoassay performed on the abbott architect ci (abbott laboratories, abbott park, il, usa). serum concentration of hscrp was estimated by immunoturbidimetry method using analytical kits from erba diagnostics mannheim gmbh in semi-autoanalyzer (xl , erba mannheim). data was analysed using stata version (stata corp) statistical software. results: in total of blood donors, ( . %) were males and ( . %) were females, the mean age was . ae . years. two hundred and thirty four ( . %) were first time donors and ( . %) were regular donors, serum levels of hs-crp was slightly higher in regular donors compared to first time donors ( . ae . vs . ae . mg/l, p = . ) though the difference was not significant. serum levels of ferritin was significantly higher in first time donors compared to regular donors ( . ae . vs . ae . ng/ml, p = . ). interestingly, levels of serum hs-crp were significantly higher in male than female population ( . ae . vs . ae . mg/l, p < . ) and smokers than non-smokers ( . ae . mg/l vs . ae . mg/l, p = . ). correlation analysis showed no correlation between serum hscrp and serum ferritin levels in both categories of donors while there was a weak positive correlation between hs-crp levels and white blood cells among the first time donors. summary/conclusions: this present study did not reveal any decrease in baseline levels of serum hs-crp with regular blood donation; smoking status and gender were however associated with an increase in baseline hscrp. this finding suggests that hs-crp level might not be a useful marker of future coronary events in healthy blood donors in nigeria. background: because the blood donation removes mg of iron from the donor, iron deficiency, frequently occurs in regular blood donors leading at a long term to the anemia. aims: to determine the effect of blood donations on ferritin levels in regular blood donors. methods: all prospective donors have been submitted to a physical examination and a health history assessment intended to ensure that the prospective donor is in a good general health and eligible to donate blood. the acceptance criteria are: • hemoglobin > or = . g/dl for male and > or = . g/dl for female • inter donation interval = days • donations/year for male and /year for female all eligible donors and deferred donors for all reasons except for low hemoglobin who accepted to enroll in this study and signed a consent. in addition to the medical exam, two samples have been collected one for cbc and another for ferritin. donation history, sex, age and weight have been documented. results: first time and regular donors accepted to enroll in this study. only female donors ( . %) participated to this study. . % of the participants were first time donor. % of male and % of female frequent donors are iron deficient out of male blood donors were iron deficient ( %) with serum ferritin < ng/ml. . % were repeat donors. out of female donors were iron deficient ( . %) with serum ferritin < ng/ ml, all were repeat donors. . % of repeat donors were iron deficient / of the deplete donors were first time donors summary/conclusions: frequent blood donors have higher prevalence of iron deficiency than first time donors. female donors have a slightly higher prevalence of iron deficiency than male donors. prevalence of iron deficiency in abu dhabi donor population is lower than the published data. changes need to be done on: increase inter donation interval or restrict the total number of allowable donations in a -month period for whole blood and red cells modifying donor hemoglobin requirements testing for serum ferritin iron supplementation donor education abstract withdrawn. background: haemovigilance procedures aim to guarantee not only the safety of the recipients of blood and its components but the safety of the donors as well. every adverse reaction that occurs during the donation of blood or its components can potentially be a threat to the health of the donor which can subsequently lead to the decision of the donor to resign from donating blood. aims: the aim is to analyse the type and the frequency of occurrence of adverse reactions among the donors donating blood or its components independently of the method of the donation. methods: we have analysed the number of collected donations and the number of adverse reactions in the years - in the group donors of aged - . we have specified following adverse reactions: vasovagal response without fainting, vasovagal response with fainting, vascular reactions (bruises) and other (e.g. allergic reaction to the anticoagulant, loss of blood pressure due to hypovolemia). the analysis was made using data obtained from computer system blood bank which is in operation in blood center in pozna n, poland. results: in years - the total number of adverse reactions among the donors was recorded which is . % of the total number of collected donations. % of the adverse reactions occurred in the group of donors aged - . vasovagal response without fainting was the most common adverse reaction in the total number of reactions and totalled . % of all adverse reactions. in the group of donors ages - it totalled % of all adverse reactions. the second most common type of adverse reactions was vasovagal syncope that totalled . %, in the analysed group of donors . %. vascular reactions (bruises) totalled . % of all adverse reaction, in the analysed group . %. the remaining adverse reactions totalled . %. summary/conclusions: . vasovagal reactions (with and without fainting) were proved to be most common adverse reactions in the group of donors aged - i.e. in the groups of donors just starting to donate blood. it seems reasonable to continue with further research into the reasons for the occurrence of this psychosomatic reactions. . it seems beneficial to provide constant educational activities of young donors regarding the preparation for the process of donation of blood and its components (proper nourishment, hydration as well as planning the time for scheduled donation long enough for a safe and pleasant procedure. . it seems beneficial to provide constant training for the medical staff involved in the process of donation regarding active observation of donors, proper conduct in the situation when the adverse reactions occur during the blood donation, ways to minimize the fear of donors, effective communication with the donors (explaining the process of blood donation, proper behaviour after the donation e.g. avoiding physical exercise or straining the arm). blood products -blood processing, storage and release background: the accumulation of microvesicles (mvs) in rbc concentrates during storage may be responsible for clinical symptoms such as inflammation, coagulation, and immunization. aims: our aims was to determine whether any of cd molecules responsible for important functions are present on the microvesicles, and if their expression level is dependent on the storage period of rbc units. additionally, by using cytometric analysis and phagocytosis visualization in a confocal microscope, we examined the interactions of donor monocytes with erythrocyte microvesicles, depending on their time of storage. methods: erythrocyte microvesicles were isolated from "fresh" ( nd day) and "old" ( nd day) stored rbc units. qualitative and quantitative cytometric analysis of these membrane structures was performed using the annexin v-fitc, anti-cd a-pe antibody, and calibrated beads. the microvesicles were also visualized under a confocal microscope. the expression of the molecules cd a, cd , cd , cd , cd , and of phosphatidylserine was analysed using flow cytometry. measurements of microvesicle phagocytosis by human monocytes were carried out using a flow cytometer and a confocal microscope. results: the analysis of the microvesicles with calibration beads allowed us to identify these structures with a diameter of about . lm in the "fresh" and "old" blood samples. we observed a statistically significant increase in the number of microvesicles in the "old" units ( ae mvs per ll), as compared to the microvesicles in the "fresh" ( ae mvs per ll). at day , the microvesicles had elevated expression levels of cd and reduced expression levels of phosphatidylserine. significant changes were also observed in the case of cd and cd molecules. the expression of these molecules of vesicles isolated from "fresh" rbcs was lower than in the case of -day vesicles. the phagocytosis index was significantly higher ( . %) for the microvesicles isolated from -day stored rbcs than for microvesicles from the - background: platelet concentrates (pcs) are conventionally stored at room temperature with a limited shelf-life of - days. alternative storage methods, such as cold storage and cryopreservation are attractive options due to the potential for extended storage, reduced bacterial growth and improved hemostatic function. cryopreservation of human pcs has been associated with formation of more microparticles and elevated procoagulant activity compared to liquid-stored (room temperature-and cold-stored) pcs. microparticles are submicron plasma membrane particles that have been postulated as potential mediators of adverse transfusion outcomes. similarities in the size and storage-related changes up to days suggest that sheep may be a suitable model in which to investigate the effects of pc transfusion. previous research has established that room temperature stored sheep pcs contain fewer microparticles than human pcs. however, nothing is known of the effect of other storage conditions. aims: this study aimed to determine whether cold storage and cryopreservation contribute to variation in concentration and size of sheep platelet derived microparticles compared to conventionally stored sheep pcs. methods: sheep buffy coat derived pcs in % plasma/ % ssp+ were prepared with minor modifications to standard procedures for preparation of human pcs. sheep pcs were split into units (n = of each) on day and stored either at room temperature (rt; - °c with agitation) for days, cold stored for days ( - °c no agitation) or cryopreserved (À °c with the addition of - % dimethyl sulfoxide) for - days and sampled post-thaw. platelet supernatant, prepared by double centrifugation, was stored at À °c. the mean size and concentration of microparticles were measured using nanosight ns nanoparticle tracking analysis system (malvern instrument). results are mean ae standard deviation. storage associated changes overtime were determined using a one-way analysis of variance with bonferroni's post-test. paired t-tests were applied to determine the effect of cryopreservation. a p-value of < . was considered significant. results: at day , sheep pcs had a microparticle concentration of . ae . microparticles/ml with a mean size of . ae . nm. storage duration at rt sheep pcs was not associated with significant changes to microparticle concentration or size. cryopreservation of sheep pcs significantly increased the concentration ( . ae . microparticles/ ml; p = . ) and the mean size ( . ae . nm; p = . ) of microparticles post-thaw. the mean size and concentration of microparticles in the cold-stored pcs at day was comparable to room temperature pcs stored for days ( . ae . nm vs. . ae . nm; p = . and . ae . microparticles/ml vs. . ae . microparticles/ml; p = . respectively). summary/conclusions: cold storage of sheep pcs did not impact formation of microparticles over the days storage period; however, cryopreservation increased microparticle concentration and the size post-thaw. further investigation is required to determine whether these findings are influence hemostatic function. a pre-clinical sheep model of cold-stored and cryopreserved pc transfusions can facilitate mechanistic studies and complement clinical trials. background: during storage, the properties of rbc in storage solution change ("storage lesion"). for instance, ph, atp and , -dpg concentrations decrease upon prolonged storage. these changes can affect oxygen delivery by the cells. the capacity to deliver oxygen is defined as p : the oxygen tension (po ) at which % of the hemoglobin is saturated with o . an oxygen dissociation curve (odc) represents the non-linear relationship between saturated hemoglobin and po . this relationship is dependent on temperature, ph, pco and , -dpg. due to changes in these factors, the curve will shift along the x-axis. in whole blood, p is at a po of about mm hg. not much is known about p of rbcs in storage solution, and the changes during storage. aims: to determine the oxygen dissociation of rbcs stored in standard red cell additive solution sagm and in pagggm (an experimental red cell additive solution, transfusion. ; : - ). methods: rbcs were prepared in sagm (n = ) or pagggm (n = ). pagggm is designed to better maintain both atp and , -dpg during storage. rbcs were stored at - °c and sampled on day , and for (internal) ph, atp, , -dpg and p . p was determined by hemox analyzer (tcs scientific corp.). the principle of the hemox is based on the measurement of spectrophotometric properties of hemoglobin at different oxygen pressure. rbc samples were brought from oxygen-rich environment to oxygen-poor environment ( %) using n gas. p was determined from the obtained odc. results: the whole storage period, ph i of pagggm-rbcs was higher compared to sagm-rbcs. , -dpg content of sagm-rbcs decreased during storage and was below the detection limit after day . , -dpg content of the pagggm-rbcs increased the first days of storage and slowly decreased from day on. at day , pagggm-rbcs still contained . -dpg ( . lmol/g hb). p values decreased during storage from mmhg at day to mmhg at day for sagm-rbc and from mmhg to mmhg for pagggm-rbc. p values of pagggm-rbcs were higher during the entire storage period. summary/conclusions: during storage, the p decreased in all rbcs. the p was higher for the pagggm-rbcs during the whole storage period. the higher p in pagggm-rbcs seems to correlate with the higher , -dpg content in these cells. background: in belgium % of the platelets are pathogen inactivated (pi) and legislation requires a minimum platelet content of . per platelet concentrates (pc). therefore routine pools are produced with buffy-coats (bc). facing increased demand of pc and stable to slightly declining red blood cells (rbc) demand, production of whole blood (wb) derived platelets must be adapted to switch flexibly from to bc per pool. this dual pooling strategy should allow alignment between wb collection forecast, pc inventory, pc demand and pc production. aims: first develop a pooling procedure with bc and ml platelets additive solution (pas) instead of ml for bc, without changing the settings of our wb separators and platelets separators. maintain a content of ≥ . platelets with a ratio plasma/pas between to % required for pi. after validation, deploy a dual pooling strategy ( or bc/pool). methods: wb is collected with top and bottom kit (composelect; fresenius kabi) and separated (macopress; macopharma) to produce ml bc with % haematocrit (htc) and > % platelets recovery with average platelets content of . random bc are pooled with ml or bc are pooled with ml of pas-e, platelets are then extracted on tacsi pl (terumo bct) and pc are treated for pi (intercept blood system; cerus). each pc is sampled and platelet content is determined (abx pentra xl ; horiba). results: during the study bc were processed into pools ( ( . %) with bc and ( . %) with bc). before tacsi separation, bc mixture with pas-e had volumes of ae ml ( bc) and ae ml ( bc) with respectively htc of ae % and ae %. the plasma/ pas ratio was ae % in both cases. tacsi separation was performed with one same program for both types of pools. after pi, platelets content of the pools was . ae . with bc and . ae . with bc (average ae standard deviation). pools below the limit of < . were / ( . %) with bc and / ( . %) with bc. the platelets concentrations ( /ll) were ae ( bc) and ae ( bc). platelets recovery was % ae for bc and % ae for bc. summary/conclusions: bc could theoretically produce pools of bc or pools of bc. this means a maximum potential gain of + % pc. in practice during shortage periods we switched from to bc when dictated by the actual inventory levels and hospital needs. the advantage of this dual pooling strategy was a gain in production capacity to cover these shortage periods ( pc, + %). the disadvantage of pooling randomly bc is that pools contained less than . platelets per pool potentially limiting their usage to low weight or paediatric patients. a preselection of the bc based on platelet count could optimize the bc pooling procedure. background: apheresis-derived platelet concentrates (apcs) is a standard medical therapy indispensable to contrast bleeding or hemorrhage. however, bacterial infection caused by storage at room temperature (rt) still remains the major drawback. recently, we showed that cold-stored apcs are associated with better plt functionality but with accelerated clearance (haematologica , pmid: ). cold-induced apoptosis was identified as a potential mechanism of the shorter plt survival aims: to investigate the protective effect of apoptotic inhibitors during cold storage of apcs methods: apcs were collected and stored at rt and °c in the presence or in the absence of caspase- inhibitor. the phosphatidylserine exposure and the mitochondrial membrane potential (mmp) (tetramethylrhodamine ethyl ester perchlorate [tmre ] staining) were measured using flow cytometry. the protein expression was quantified by western blot results: a higher expression of the apoptotic marker phosphatidylserine was detected in cold-stored apc compared to rt (% apoptotic events meanaesem: ae % vs. ae % p = . ). to verify if the apoptotic signal, observed with phosphatidylserine, specifically involved the intrinsic pathway, the mmp was analyzed as a marker of alive cells. interestingly, after cold storage a decrease of the mmp was observed compared to rt indicating the activation of the intrinsic pathway (mean fluorescence intensity tmre meanaesem: . ae . vs. . ae . , p = . ). accordingly, a decrease of the procaspase- level after cold storage was detected by western blot analysis. however, when plts were stored in the presence of caspase- inhibitor a significant rescue of the cold-stored cells viability was observed (tmre staining: % alive cells meanaesem: ae % vs. ae %, caspase inhibitor vs. ionomycin, p = . ). this indicates that the activation of the apoptotic pathway, induced during cold storage, can be prevented using caspase inhibitor summary/conclusions: our results show that the reduction of cold-stored plt viability can be prevented by a specific caspase inhibitor. consequently, cold storage, associated with a better plt functionality, may become an efficient strategy for apc storage in combination with apoptotic inhibitors background: gamma-irradiation is used to treat red blood cell (rbc) concentrates (rccs) for patients who are immunosuppressed. this treatment is known to damage rbcs and to increase storage lesions. one of the causes of the storage lesions is the presence of oxygen. several studies have shown, based on different strategies to reduce o , a reduction of storage lesions related to metabolism, protein modifications and cell morphology. aims: the present research work investigated the effect of gamma-irradiation on rccs stored under normal condition and hypoxia/hypocapnia. methods: saturation of o (so )-and abo-matched rccs from whole blood donations, leukoreduced and prepared in paggsm (macopharma, france) were pooled and split in two identical rccs within h post-donation. one bag (treated) was submitted to oxygen and carbon dioxide adsorption (oxygen reduction bag, hemanext, usa) for h on an orbital shaker ( rpm) at °cae and then transferred to a storage bag impermeable to gas. the other one (control) was left as it is. the two bags were then stored at °c. a g-irradiation treatment ( gy, gammacell elan, theratronics) was applied at day or and the rccs (expiry dates at day or day , respectively) were stored until day . hematological parameters, glycolytic metabolites, extracellular potassium level, antioxidant power, morphology and deformability were measured. results: starting so values were of . %ae . (n = ) in control and of . %ae . (n = ) in treated bags, and reached . %ae . and . %ae . at day , respectively. as expected, an increase in glycolysis rate was observed during deoxygenation without any influence from the irradiation. potassium levels were identical in treated and control, and reached around mm at expiry with an irradiation-dependent kinetic release. antioxidant power and deformability were identical in both conditions. no difference in hemolysis was observed after irradiation on day and the values stayed equivalent through end of storage (at day , hemolysis (control) = . %ae . , hemolysis (treated) = . %ae . , p-value > . ). when irradiated at day , hemolysis was lower (p-value = . ) in treated rccs at the end of storage (day , . %ae . ) compared to control ( . %ae . ). seven days post-irradiation, two-third of the control rccs were above the limit of . % whereas all the treated rccs remain below the limit. quantification of microvesicles and morphological analysis confirmed these data. summary/conclusions: the storage under hypoxia has a beneficial effect on rbc storage thanks to a decrease in o content and to an improvement of metabolism. this benefit provided equivalent storage when rccs were irradiated at day and was an advantage when irradiated at day . importantly, the results show that combining irradiation with hypoxia/hypocapnia retained the improved hemolysis profile of o depleted rbc. in summary, the reduction of o level in rccs enables a better storage of rcc when a late irradiation is applied. background: in vitro blood circuit machines require a constant monitoring of blood flow rate which have to be maintained at a constant value. also, measuring the hematocrit of flowing blood in such machines is essential for performing real-time diagnostics. recently, acoustophoresis has emerged has a promising blood separation technology capable of replacing centrifugation for the preparation of platelet concentrate. to avoid damaging blood cells, the technique is used without infusing pumps thus increasing the need of flow monitoring. however, acoustophoresis chips performs at low flow rates, outside the range of available commercial flow meters. in addition, hematocrit measurement is of a particular interest for acoustophoresis since it is a direct indicator of the separation efficiency. aims: in this study, we present a straightforward doppler ultrasound system designed for measuring blood flow rate and hematocrit in an acoustophoresis chip [bohec et al, platelets, ] . we show that the stability of the in vitro environment can be used to obtain high level of accuracy of the doppler method using a basic and low-cost experimental set-up. this improvement allows a precise measurement of flow rates as low as . ml/min in sub-millimeter tubing. furthermore we evaluate the capability of the system to measure hematocrit of human blood samples coming from different donors. methods: the experimental set-up was constituted of an ultrasonic continuous wave doppler probe mounted on a d printed support. the accuracy of flow rate measurements between . ml/min and . ml/min was evaluated as well as the optimal measurement time. for different blood bags, the relationship linking the total energy of doppler signals and hematocrit was derived. hematocrit in a range under % was estimated from doppler signals for each blood bag. results: the system is able to acquire exploitable doppler signals for the whole flow rate and hematocrit range. flow rate estimation from the signals shows a high accuracy with a mean measurement error under % for a measurement time of s. the mean error is still under % for a measurement time of . s. hematocrit estimation from doppler signals shows a good linear correlation with reference measurements for bags , and . hematocrit estimation for bag diverges from reference for values above %. summary/conclusions: the proposed doppler ultrasound system is capable of measuring low blood flow rate in narrow medical tubing with a high accuracy. it is particularly suited for an acoustophoresis device but the versatility of the system makes it easily applicable to any in vitro blood circuit. we furthermore demonstrated that the system can be used for measuring hematocrit under % without additional developments. this finds interesting applications in blood sorting technologies but also demonstrates that doppler ultrasound is a potential simple and low cost method for measuring hematocrit of flowing blood in vitro. background: hereditary hemochromatosis (hh) is the most common genetic disorder in populations of northern european descent manifesting with high levels of storage iron (ferritin) in blood and tissues. the standard treatment is serial therapeutic phlebotomy to decrease iron overload. the collected blood is frequently discarded but some blood banks allow "healthy" hh patients to donate blood for patient use. red cell concentrates from hh donors have been reported safe for transfusion, but little or no data is available on platelet concentrates from hh donors, including the potential contribution of surplus iron to the "platelet storage lesion". aims: the aim of this study was to compare platelet quality, activation and aggregation over seven-day storage in platelet-rich plasma from patients with newly diagnosed hh and from healthy controls. methods: whole blood ( ml) was drawn into compoflow blood bags containing cpd and sag-m from healthy controls and newly diagnosed hh patients. platelet-rich plasma (prp) was prepared from whole blood and split into four compo-flex bags each containing ml prp (range - platelets/l). platelet quality tests were performed on days , , , and of storage. platelet aggregation was tested using a chrono-log aggregometer and four agonists (adp, arachidonic acid, collagen, and epinephrine). platelet expression of cd , cd b, and cd p was measured with flow cytometry while ph and metabolites were measured with a blood gas analyzer. scd l and scd p in the supernatant were quantified using enzyme-linked immunosorbent assays. results: both hh and control groups included males and females. the mean age was significantly lower in the control group, years ( - years), than in the hh group, . years ( - years) (p = . ) while ferritin levels were significantly higher in hh patients (median . , range - ) than in controls (median . ng/ml, range . - ng/ml) (p < . ). in the hh group, each had the c y/c y and c y/h d genotypes. results of prp quality control tests were comparable between the two study groups over seven days of storage (p < . ) with the exception of glucose (higher in hh patients on all time points, p < . ). platelet aggregation and the expression of activation markers (cd p and cd b) on platelets and in the supernatant (scd p and cd l) were comparable between hh and control prp units over all seven days of storage. the analysis revealed comparable and expected alterations in metabolic and platelet activation markers over seven-day storage in both groups. ph increased, glucose decreased, and lactate increased over time while cd b expression decreased and cd p increased. platelet aggregation responses decreased during storage but to a varying degree depending on the agonist, however, the decrease was comparable in cases and controls. summary/conclusions: these results suggest that high iron stores in hh do not adversely affect the quality of platelet units produced from hh patients. furthermore, the data also suggest that blood from hh patients, including platelets, can be donated for patient use. background: platelets are often shipped over long distances from collection centres to blood processing centres and subsequently to hospitals. platelet agitation facilitates oxygen transfer, thus promoting aerobic metabolism, and maintaining platelet ph. during shipment, platelets cannot be agitated continuously, which may promote anaerobic metabolism. previous studies have examined the effects of prolonged periods without agitation on apheresis platelets collected in plasma, but not platelets in platelet additive solution (pas). it is therefore important to determine whether platelet quality and function are maintained during prolonged transport or hold time in a shipper. aims: the aim of this study was to evaluate the effects of prolonged storage without agitation on the in vitro quality of apheresis platelets in pas. methods: triple dose apheresis platelets (n = ) were collected using a trima accel platform in % plasma/ % pas (ssp+). after resting for h, platelets were split equally into three components, packed into a shipper and transported immediately to the blood centre. upon arrival, one of the platelet components was removed (< h; t ), and the others remained within the shipper, without agitation. the second component was removed at h post-collection (t ), and the third was removed at . h post-collection (rounded up to h; t ). platelets were tested on day , and post-collection and in vitro quality and function were monitored. data were analysed using a two-way repeated measures anova, where a p-value of < . was considered significant. results: platelets held without agitation for h consumed significantly more glucose than those removed at h or immediately upon arrival (p < . ), even on day post-collection. this was accompanied by increased lactate production (p < . ), indicating increased anaerobic glycolysis. consequently, the ph was significantly lower in t platelets (p < . ), and on average it was . ph units lower than in platelets held in the shipper for h or less. however, the ph remained above . in all components. mean platelet volume was also reduced in t platelets (p < . ), suggesting acceleration of the platelet storage lesion. phosphatidylserine exposure, surface expression of cd p and microparticle generation were significantly higher in the t platelets throughout the storage period (all p < . ), suggesting platelet activation. release of scd p was also increased in t platelets (p = . ), whereas extended storage in a shipper did not affect release of rantes (p = . ). adp-induced activation of glycoprotein iib/iiia, measured by pac- binding, was decreased in t platelets (p < . ), indicating reduced platelet responsiveness to agonist stimulation. additionally aggregation in response to collagen (p = . ) and adp (p = . ) were significantly lower in t platelets, suggesting a decrement in platelet function after prolonged storage without agitation. summary/conclusions: significant in vitro changes were observed in platelets held without agitation for h. these results suggest that the length of time that platelets are held in a shipper should be minimised where possible. background: the shelf-life for platelet products has been restricted to days. this very limited window of time is intended to sustain the quality of platelet and to reduce the risk of bacterial growth. we have recently demonstrated that in suitable platelet bags, the platelet product quality remains high after days of storage. this was proved by examining in vitro, the quality parameters of platelets such as platelet concentration, glucose, ldh, and ph (alexopoulos k. et al., haema, , ) . our new target is to extend this research in extra days of storage. we also want to determine if there is any bacterial development in this period. aims: the goal is to investigate the capability of storage period for platelet units, from to days. methods: in this study, platelets were collected from normal blood donors in the blood bank department of general hospital of patras "agios andreas". a total of ae ml of whole blood was drawn into triple cpd/sag-m top-top bags blood container systems, lmb technologie (gmbh). the platelet concentrates were prepared by platelet rich plasma (prp) method and then they were placed in a platelet incubator with agitator (helmer pc ). samples were drawn aseptically with a needless access coupler (cair-lgl) on days , , and . platelet count was done by ceeldyn ruby (abbott all data shown are reported as mean ae standard deviation (sd). the swirling effect remained positive (+) during the seven days storage period. the bacterial screening was found negative. summary/conclusions: platelet concentration in the bag remained constant between day and day , maintaining platelet yield. the decrease in glucose and increase in lactate, along with the decreased ph, show that the platelets remain metabolically active between days and of storage. the ph remained well within the acceptable range. no bacterial contamination was reported. thus, we conclude that platelet concentrates in these specific bags may be used with an extended shelf life of days. further studies are needed with other platelet bags to confirm our hypothesis. abstract withdrawn. aims: we introduce rt-dc as a fast, robust and unbiased quality control tool for pc, rcc and hpsc. utilizing the interdependency between cell deformation and the molecular state of the cytoskeleton, we demonstrate that rt-dc is capable to assess the quality of blood products. methods: by rt-dc we assessed: i) platelets after storage at °c or room temperature (rt) over days for apheresis pcs in addition to standard in vitro platelet function assays; ii). red blood cells before and after gamma irradiation in addition to hemolysis; and iii) hpsc after cryopreservation with % or % dmso in addition to cell count, and in vitro viability. in addition we compared the regeneration time of patients' platelets and leukocytes after transplantation of hpsc products containing either % or % dmso. results: for pcs standard quality assurance tests did not show a major difference between °c and room temperature storage while rt-dc showed a highly significant difference between both start conditions (day - , p < . and day , p < . ). for red cells, we found by rt-dc no impact of gamma irradiation with gy over the entire storage period of days assessing different rcc. for hpsc, rt-dc showed that cryopreservation in liquid nitrogen resulted in a significant increase in deformation ( . for % dmso versus . for the control without dmso; p < . ). however, this did not differ to high extent whether % or % dmso were used for cryopreservation ( . and . , respectively; p < . ). hpsc viability was lower after cryopreservation using % dmso in comparison to using % dmso. overall, blood cell regeneration is comparable between % and % dmso. summary/conclusions: studying platelet and red blood cell concentrates as well as hematopoietic stem cells under different, clinically relevant, storage conditions our results demonstrate that intrinsic material properties reveal insights into cell function and allow to predict cellular state in a robust way and using small sample volumes. in order to offer more flexibility to the production process, the storage of bcs overnight ( h) has been validated in our blood center. aims: the aim of the study was to assess the platelet quality in platelet concentrates derived from overnight stored buffy coats. methods: whole blood collected at day was separated into plasma, bc and red cell concentrates either at day or at day . bcs were then stored until the pooling step at °c without agitation and pcs were prepared at day by pooling isogroup bcs. seven " h-pcs" were prepared from bcs stored for h (whole blood separation at day ) and six " min-pcs" from bcs stored for min (whole blood separation at day ). standard quality control measurements were performed during the process and the storage. in addition, the quality of the platelets into the prepared pcs was assessed throughout the period of storage by measuring the hypotonic shock response (hsr) and by measuring by flow cytometry the proportions of platelets in apoptosis (marked with annexin v), of functional platelets (marked with cd ) and of activated platelets (marked with cd the changes observed during the -h storage period appear to be limited and compatible with a further pr process using a photochemical treatment (amotosalen and uva) with intercept. summary/conclusions: leukocyte-depleted "double dose" buffy coat platelets with a high platelet content and ready for pathogen reduction can be obtained with the ipp pooling and leukodepletion set developed by kansuk. a storage period of h before applying the photochemical treatment is feasible without significantly altering the biological quality of platelets. methods: dd-bc-pc were prepared with bc and ml of pas (intersol, fresenius kabi (germany) are sterile docked to the octopus harness and combined into a ml pooling bag. the pool is centrifuged and the pc supernatant expressed through a bioflex cs leukodepletion filter into a temporary platelet storage container. the obtained dd-bc-pc were tested within h of preparation and after storage for h in the platelet storage container for volume, platelet content, residual leukocytes (wbc), plasma ratio and biological parameters, ph, po , pco , glucose, lactate, mpv, ldh, p-selectin and swirling. results: the platelet content of dd-bc-pc (n = ) was on average . ae . . in a volume of ae ml. the mean of plasma ratio was % [min: . max: . ]. all pc contain < . wbc [min: <lq; max: . ]. po decreased from ae mmhg after separation ( h) to ae mmhg after h, ph (+ °c) and pco was stable during the same time period. glucose decreased from . ae . mmol/l ( h) to . ae . mmol/l ( h) while lactate increased from . ae . mmol/l ( h) to . ae . mmol/l ( h). the vpm was stable with . ae . at h and h. ldh increased from . ae . u/l at h and . ae . u/l at h as p-selectin . ae . ng/ml at h and . ae . ng/ ml. all units have maintained swirling. the changes observed during the -h storage period appear to be limited and compatible with a further pr process using a photochemical treatment with intercept. summary/conclusions: leukocyte-depleted "double dose" buffy coat platelets with a high platelet content and ready for pathogen reduction can be obtained with the platelet pooling and leukodepletion set developed by fresenius. a storage period of h before applying the photochemical treatment is feasible without significantly altering the biological quality of platelets. background: the irish blood transfusion service (ibts) is the statutory body with the responsibility for ireland's national blood supply. in the ibts collected , whole blood units and performed , platelet apheresis procedures. blood is collected in three fixed and six mobile sites and is returned overnight in temperature controlled vans to a single processing site. in september , the ibts implemented the tacsi automated system for the preparation of buffy-coat derived platelets as an alternative to the orbisac system. aims: the aim of this study is to compare operational aspects and quality data of buffy-coat derived platelets prepared by the tacsi (t-pcs) and orbisac (o-pcs) automated systems. methods: qc data of t-pcs and o-pcs from years to were analyzed. in , the ibts prepared , orbisac platelet pools of which , were qc tested. in , orbisac and , tacsi platelet pools were prepared and tested. in , tacsi platelet pools were prepared of which were qc tested. qc data comprised pc volume, platelet content ( /unit), residual leucocyte content ( /unit) and ph at expiry. feedback from the processing laboratory operators was collected comparing operational aspects of preparation of t-pcs and o-pcs. results: from the , o-pcs tested in and , mean pc volume was ae ml. initially the t-pcs mean volume was ae ml but more recently the volumes were increased by addition of a larger volume of additive solution to ae ml. platelet content ( /unit) was significantly improved in t-pcs ( ae ) compared to o-pcs ( ae ) [p < . ] as well as residual leucocyte content ( /unit) which was lower in t-pcs ( . ae . ) compared to o-pcs ( . ae . ) [p < . ]. ph at expiry was lower in t-pcs ( . ae . ) compared to -pcs ( . ae . ) but remained within the quality requirements. from an operational perspective with two tacsi devices, five operators produce approximately t-pcs per hour compared to a lower throughput of o-pcs per hour with five orbisac devices. the tacsi system is more compatible with batch processing which aligns with our staffing arrangements in routine production and has resulted in greater productivity since its introduction. with tacsi implementation, we reverted to manual pooling of buffy coats and new staff had to undergo training to achieve optimal platelet recovery. once staff were trained during validation, we observed a % increase in platelet recovery. processing laboratory staff indicated that tacsi devices were easier and simpler to maintain in comparison to orbisac, but highlighted that some improvements to tacsi system boxes could be made to make the system more robust. summary/conclusions: pcs prepared with tacsi and orbisac automated systems both met national and european quality requirements, however we observed a significant improvement in quality markers of pcs prepared with tacsi. processing staff reported easier maintenance and processing with tacsi compared to orbisac. throughput is higher with tacsi and there is greater additional capacity to increase production in the future if required. a perez aliaga , f puente , a aranda , j domingo , l call en and a bah banco de sangre y tejidos de arag on, aragon, spain terumo bct europe n.v., zaventem, belgium background: the blood bank and tissues of arag on (bsta) is responsible for the collection, processing and distribution of blood in the region of aragon in spain. with five fixed and five mobile sites, the bsta collects and processes , whole blood units per year. to improve quality of processed units and working conditions of personnel, the bsta decided to implement the reveos automated system. validation studies were carried out in november and routine use started in july . in parallel, the bsta initiated pathogen inactivation of platelet concentrates (pc) in november to improve transfusion safety. in november , the mirasol prt system was implemented due to simplicity of this platform. aims: the aim of this abstract is to (i) describe the results of the validation studies carried out during reveos implementation (ii) present routine use data of products processed with reveos and (iii) provide information on mirasol implementation. methods: in , whole blood units were processed using reveos. quality parameters for red cell concentrates (rcc), such as: hemoglobin (hb), hematocrit (hct) and volume; plasma: volume and residual platelet content; and pcs: volume and yield, were analyzed. a control group consisting of units processed with a semiautomated platform was used as comparison. a survey was sent to the collection and processing staff for feedback on operational aspects of the use of reveos. from to , qc data of rccs (n = ), plasma (n = ) and pcs (n = ) processed with reveos were collected. number of mirasol treated pcs and hemovigilance data from to were collected. results: volume, hb and hct of rccs processed with reveos were significantly higher compared to control rccs (volume: ae ml vs ae ml; hb: . ae . g/ unit vs . ae . g/unit; hct: . ae . % vs . ae . %). control plasma units had higher volume ( ae ml) and lower residual platelet content ( ae /l) compared to reveos plasma units (volume: ae ml; residual platelet content ae /l). for pcs, volume was higher for units processed with reveos compared to control ( ae ml vs ae ), but no statistical difference was observed in platelet content (reveos: ae /unit; control: ae . /unit). we observed either an increase or stabilization in qc parameters of rccs, plasma and pcs during the years routine use of reveos. for example, percentage of rccs units hemolyzed dropped from % to % between and and platelet content in pcs increased from /unit (first six months in routine) to /unit. plasma volume increased from ml during validation to ml in . survey results from staff highlighted the user friendliness of the reveos device. number of mirasol treated pcs increased from % in to . % in with no pathogen transmission nor serious adverse events reported following transfusion of these products. summary/conclusions: with implementation of two user-friendly systems, the reveos whole blood automation system and mirasol prt system, we observed an increased standardization of our processes enabling us to provide higher quality and safer blood products to hospitals and the patients they serve. background: white blood cells (wbc) may be regarded as contaminants in blood components and potentially reduce transfusion safety. there is currently enough evidence showing that wbc reduction through pre-storage filtration reduces the incidence of three major complications of allogeneic blood transfusions: febrile nonhemolytic transfusion reactions (fnhtr), refractoriness to random-donor platelet transfusions and transmission of cmv. leukodepletion is now mandatory in canada and several european countries. aims: the aim of this study was to evaluate leukoreduction performance and the quality of the resulting red blood cell concentrate (rbc) produced with new quadruple system top & bottom imuflex crc with an integrated red blood cells filter which was used in whole blood fractionation under routine conditions of san paolo asl blood bank methods: twenty-seven whole blood donations ( ml) were collected with using quadruple blood bags top & bottom system with an integrated rbc filter (imuflex crc, terumo bct). centrifugation and processing (using t-ace ii + -terumo bct) of whole blood units followed the blood bank sop to obtain rbcs, plasma and buffy coat. rbcs were diluted with sagm ( ml) and then filtered by gravity in average - h after blood collection to obtain leukoreduced rbc. average temperature during filtration was °c. samples were collected before and after leukoreduction for calculation of hemoglobin loss through the filtration process. filtration time was recorded. final hb, hematocrit (hct), residual platelets and white blood cells were determined after filtration using standard laboratory methods (blood cell counter) results: wb donations (n = ) were performed. rbc characteristics post-filtration and separation were as follows: volume ( . ae . ml), hematocrit ( . ae . %) hemoglobin ( . ae . g/dl) and hemoglobin per unit ( . ae . g); residual platelets ( . ae . x ³/ll); residual wbcs ( À . ³/ll). the mean filtration time was ae min and no filter blocks were observed summary/conclusions: the usability and performance of the new quadruple system top & bottom imuflex â crc with integrated rbc filter was evaluated. all quality parameters complied with italian and european guidelines and requirements. in conclusion, the set was found to be a reliable and efficient collection and separation system that performs consistently background: novel devices for automated whole blood processing (reveos tm terumo bct) have been installed in regional center for blood donation and blood treatment in katowice to modernize and automate production of blood components. this system allows to separation of four whole blood units into four buffy coat depleted red blood cell concentrates (rbc), four units of plasma and four interim platelet concentrate (ipu) units in one automatic cycle. an ipu is the starting blood component for the production of pooled, leucoreduced platelet concentrates (lpc). residual leukocytes (wbc) are obtained as a byproduct and discarded. the use of this system shortens production time because it combines otherwise two separate steps: centrifugation and blood separation in press. aims: to evaluate the quality of the blood components obtained with the newly developed reveos nlr kits, which are a whole blood collection kits containing no leucocyte reduction filter for the rbcs. methods: blood [wb] was collected into nlr reveos set (terumo bct), and processed between and h from collection using the c protocol. quality control was performed on rbc, plasma and ipu. rbc were tested for hemoglobin (hb) content, hematocrit (ht), residual white blood cells (wbc), volume and hemolysis level on the last day ( nd day) of storage. the content of wbc and platelet count (plt), protein, factor viii on the day of production and after one month of storage were determined in plasma. for ipu, platelet and leucocyte counts, volume and average platelet yield index (pyi) were displayed at the device after processing was recorded. furthermore, a comparison between fully automated and semi-automated whole blood processing was done, by comparing the amount of time necessary to fractionate whole blood units using the two different processes. background: direct, single step automatic blood separation devices (reveos tm terumo bct) was installed in regional center in katowice in . the system allows for full automation of whole blood fractionation. one of produced blood components is an interim platelet unit (ipu), containing most of the platelets and limited of white blood cells (wbcs). it is then pooled through a filter to form a therapeutic unit of leucoreduced platelet concentrate (lpc). a rough estimate of the platelet yield in the ipu, the so-called platelet yield index (pyi) is calculated and displayed by the device after the end of the separation phase. it is a useful tool to optimize selection of ipu for pools to produce lpc. aims: to determine the quality of polled lpc obtained on the basis of ipu from whole blood processed up to h after collection and the usefulness of this method in daily practice. methods: ipus used for production of lpc were obtained using fully automated whole blood processing single step system -reveos tm (terumo bct). from the beginning of the application of the method, therapeutic units of lpcs were produced after overnight hold: pools of ipus and of ipus were made using platelet pooling set (terumo bct), using ml ssp+ solution (macopharma). results: therapeutic units of lpc were analyzed. the mean volume of lpc was ae ml, platelet content was . ae . x , and white blood cells (wbc) count was . ae . x , % all lpcs had wbc below . ph measurements were made on the fifth day of storage, the ph was determined in units of lpc and was . ae . . summary/conclusions: the use of interim platelet units in daily practice increases the possibility of producing high quality blood components for patients and is a great alternative to the laborintensive manual methods of lpc's production. background: the development of cold-stored platelets has been hampered by the rapid removal of blood after transfusion by apoptosis and desialylation due to platelet storage lesions caused by refrigeration. previous studies have shown that antioxidants inhibited the activation and desialylation of cold-stored platelets for days and also inhibited rapid elimination after transfusion in animal models. aims: it was tried whether in long-term ( days or longer) storage conditions, antioxidants showed similar effects inhibiting the activation and desialylation of cold-stored platelets. methods: platelet-rich plasma (about ml) were obtained from a healthy blood donors of type o blood group and divided into a ml platelet storage bag manufactured by the manufacturer, and the conditions including room temperature and refrigerated condition and various kinds of antioxidants were prepared, (ph, glucose, lactic acid) and activation index (cd p, gpiba (cd b), annexin v), degree of reactive oxygen species and sialidase activity on the th, th and th day, and phagocytosis using the hepg cell line and platelet recovery after in vivo transfusion using scid mice were compared and compared. results: cold-stored platelets showed autoaggregation on the nd day of storage, and apparent aggregation on the fifth day of visual observation but not in the antioxidanttreated group. as expected, the ph, glucose and lactate levels of the cold platelets were maintained and the platelets at room temperature changed significantly. nac (n-acetylcysteine) -treated platelets were less active on day and sialidase activity was maintained lower than that of control group on day . the degree of phagocytosis by the hepg cell line remained at the same level during the storage period, and the in vivo recovery rate in the animal model was superior to that of the antioxidanttreated cold platelets for h and h after transfusion. summary/conclusions: cold platelets could be developed as clinically effective agents for up to two weeks if appropriate preservatives were added, and antioxidants, especially n-acetylcysteine, were effective. background: the reveos c procedure produces the following three blood components for transfusion: plasma, rbcs, and a single interim platelet unit (ipu). whole blood is collected into the reveos blood bag set and held at room temperature a minimum of h before processing on the device. after processing on the reveos device, the plasma product is ready to freeze. the rbc product is ready to combine with sag-m additive solution and leukoreduce using the integrated leukoreduction filter. the ipus are rested and agitated for the recommended time. for example, when whole blood is processed within h of collection, the ipu is agitated overnight before pooling. because the ipu is made from one unit of whole blood, approximately to ipus are pooled together and leukoreduced by filtration prior to storage in a platelet storage bag. this leukoreduced platelet pool ( units) can be supplied to the demand of hospitals like a platelet apheresis product. aims: to assess the usability of the reveos automated blood processing system to collect units of whole blood and to process the units on the reveos device, producing blood components that meet product quality specifications. methods: this study will evaluate approximately units of whole blood using the reveos system and approximately units of pooled platelet products. a total of units of whole blood (wb) have been collected into the reveos blood bag set and then held at room temperature without the use of an active cooling system (or temperature control system), such as cooling plates, or in this case, ice packs. of the units, units have been processed on the reveos device using the fresh procedure (within h of collection). nine units have been processed using the overnight wbhold procedure. all units have processed successfully without alarms, resulting in three components (rbcs, plasma, platelets). we also evaluated four platelet pools created from eighteen interim platelet units (ipus). one ipu has been discarded due to a -min whole blood collection time. the leukocyte count on all component using the automatic sysmex-xn cell blood counter. results: the red blood cells meet the criteria for hematocrit, hemoglobin and residual wbc counts are less than million per unit. the plasma units meet the criteria for displayed volume accuracy compared to measured volume and also for factor viii levels. the average residual platelets in plasma levels meet the criteria. the platelet pools meet the acceptance criteria for platelet yield and volume. limited data (n = ) suggests that this criteria will be easily met, provided that wb hold conditions are suitable for platelets. summary/conclusions: final results indicate that products produced from the reveos system meet or exceed product quality expectations. staff report that the reveos system is very easy to use. abstract withdrawn. background: thorough manual mixing of overnight-held whole blood (wb) units prior to centrifugation to separate red cell (rc) from platelet-rich-plasma (prp) is currently practised at the hong kong red cross blood transfusion service (hkrcbts). the mixing step is crucial to maximise platelet yield but laborious, and may cause elbow and wrist injuries in operators. a laboratory shaker, reax (heidolph instruments, schwabach, germany), originally designed for mixing solvents, was modified to allow mixing source wb units by the supplier. to enhance the well-being of the operators in the context of occupation health and safety (oh&s) management, feasibility of the application of such blood mixer to replace the manual mixing steps in blood component preparation was explored. aims: to evaluate the in vitro quality control (qc) parameters of the blood components prepared with the use of the modified mixer. methods: fifty-eight wb collections, including units in ml quadruple bags ( q) with/without integrated leucofilter and units in ml quadruple bags ( q), were processed in accordance with hkrcbts' prevailing component processing protocols except using the motor-driven mixer in lieu of manual mixing. wb collections were divided into groups, mixed at revolutions per minute (rpm) for min (n = ) and min (n = ), then processed into rc, prp platelet and plasma components. in vitro qc assessments including haematocrit (hct), haemoglobulin (hb) and haemolysis at expiry for rc; absolute platelet count and ph for platelet concentrates (plt); volume and residual platelet count for plasma units were evaluated and compared. results: all components derived from both q and q processed with the blood mixer fulfilled the qc requirements stipulated by aabb standards and council of europe (coe) guidelines. there were no significant differences for all the qc parameters in rc and plasma components produced when mixed for or min. summary/conclusions: the overall performance of blood components processed with the motor-driven mixer met the acceptance criteria at the hkrcbts in accordance with the aabb and coe standards. higher platelet yield was observed with prolonged mixing for min. however, prolonged mixing will much delay routine component processing. further evaluation on intermediate mixing time such as , or min may help determine an optimal mixing duration to maximise platelet yield without compromising processing workflow. to conclude, using the modified blood mixer to replace laborious manual mixing in components preparation is promising to improve the oh&s for blood component preparation operators. background: leukocyte reduction is widely used to reduce the risk of non-hemolytic febrile transfusion reactions and alloimmunization by multiple blood transfusions. around and after year , universal leukocyte reduction was adopted in many developed countries. there are mainly two types of filter, one to filter whole blood and the other to filter red cell concentrate (rcc) used during pre-storage blood processing. aims: in this study, we conducted the filtration tests with sepacell tm rs for rcc in comparison with sepacell tm r-s and sepacell tm pure rc widely used in the world. background: the cardarelli hospital blood bank processes over , whole blood units yearly. in order to constantly cope with the huge demand for platelets from oncohematology and intensive care departments, a progressive review of the processing protocols for platelet concentrates (pc) from buffy-coat (bc) pools has recently been implemented to reduce the number of units assembled, from (routine in italy) to . the -bc pc units have slightly lower volume and plasma content, factors that further limit the transfusion risk. in addition, the -bc assembly allows to facilitate the production of the pc units obtained from the same blood type, in order to minimize both the adverse reactions related to the abo/rh incompatibility and the amount of bcs not used. finally, the described innovation also impacts on the workload, with reduction of assembly, centrifugation and separation time. aims: the aim of this work is to define an optimized protocol for the preparation of pc units from -bc pools, so that the platelet yield is always higher than the minimum value required by current regulatory ( . cells/unit). background: blood is a basic component for human life and hence blood transfusion is an integral intervention in the treatment of patients. the need of blood transfusion is increasing with decreasing blood supply due to limited blood donations. conversely wastage of blood products is also a topic for discussion. to ensure the availability of blood products when they are needed, wastage of blood products should be controlled and minimized. aims: the study was designed to investigate the quantity and reasons of wastage of blood products at our hospital. methods: this was an observational study based on the statistical data available from blood bank department of nibd and bmt, pechs campus, karachi, pakistan. the study period was from february to february . study was approved from institutional review board. for all the blood products wastage and reasons of wastage were evaluated. frequencies were calculated by using spss version . results: a total of blood products were available at our institute including each of platelets, pack red cells and fresh frozen plasma(ffp). the overall wastage rate was . %. pack red cells and platelets were fully consumed yet shortage of supply was observed. however, highest wastage was observed in ffp in our blood bank i.e. ( %). results of investigating the common causes of blood product wastage at the hospital revealed that it was highly associated with common causes, including the expiry of unused products ( %) followed by broken bags ( %). summary/conclusions: this study showed over all diminutive wastage rate. ffp wastage was highest among all the blood products. wastage of blood products is a genuine issue in a hospital setup, strategies and plan of action should be discussed and implemented including enhanced collaboration with other centres to outsource the blood products or even donate at times, education and training of staff for better clinical use of blood products and ensure the availability when and where they are needed most. background: in the early s, the blood service of the republic of kazakhstan functioned along the lines of the soviet period: donation of blood was approached to the place of its use (carried out at hospitals), screening of donor blood was carried out at one stage (enzyme immunoassay) on analyzers of semi-automatic type, there was no mechanism calculating the cost of blood components, the activity of blood centers was funded at the rate of liter of whole blood. donation was not popular in society, household fears of infection were common when donated. aims: research objective is to study the main stages of reforming of blood services of the republic of kazakhstan (rok). the research methods are based on the system analysis of the condition of the rok's blood services based on the indicators of production activity for the period of - . results: in order to effectively reform the blood services, the following steps were taken. the blood supply was centralized and optimized. blood collection at hospitals was terminated, more than blood collection subjects were closed. the result was a more efficient use of technical, human and financial resources, as well as ensuring the high quality of the blood components produced. today, there are blood centers in the republicone for each of the administrative territorial units of the republic. the screening of donor blood for transfusion infection markers has been transferred into a two-step principleimmunological analysis and nat testing. a fully automated analytical equipment of a closed type is used for screening, unified for all blood centers of the republic. unification of the equipment choice allowed to provide centralized service maintenance of complex equipment and its uninterrupted operation. since , the national reference laboratory has been operating in the blood service, which conducts an external assessment of the quality of laboratory research in blood centers, as well as research in controversial and complex cases. introduced pathogen inactivation of platelet concentrates in % of cases of platelets. erythrocytes are used only in the weighing solution and only after leukoreduction. the use of resource-saving blood harvesting technologies, as well as methods to further enhance the infectious and immunological safety of components, are expanding annually. the foundations for the development of applied scientific research in the field of transfusion medicine were laid, and an own school of transfusiologists was created. as a result of reforming the blood services, the mechanisms of reimbursement of blood services costs from the budget of the republic have been changed, uniform tariffs have been defined by type of blood components for all blood components suppliers in the country. summary/conclusions: the transformations made it possible to create a blood service in kazakhstan that corresponds to the best international practice and ensures the quality, efficacy and safety of transfusion therapy. further development of the blood service is aimed at deepening reforms, studying and developing cellular technologies, new properties of plasma blood components, and improving the clinical practice of using donor blood components. background: reconstituted platelet concentrate (rpc) is a component that contains platelets (thrombocytes) resuspended in plasma that is blood group compatible with the recipient. it is used when transfusion of platelet concentrate is necessary but the fresh platelet concentrates of the specific blood group are not available. group rh-(negative) platelets resuspended in the ab group plasma are of universal use as such components can be used for all recipients independently of their blood group. in the area of activity of regional blood center in poznan rpc is used most often for patients after stem cell transplant incompatible with their blood group. aims: the aim of the analysis is to evaluate the loss in the number of platelets in the reconstituted platelet concentrates in order to determine their quality and usage. methods: we used for the analysis units of pooled platelet concentrate derived from buffy coats and units of pooled platelet concentrate derived from the apheresis. for the reconstitution group ab plasma was used. we investigated the number of platelets prior to and after the reconstitution. following measures were calculated: number of platelets in pooled platelet concentrates derived from buffy coats, number of platelets in pooled platelet concentrates derived from apheresis; average values and the standard deviation as well as the loss in number of platelets due to the reconstitution. the number of platelets was calculated with impedance method using horiba pentra xl analyser. . pooled platelet concentrates derived from buffy coats the number of platelets before the reconstitution: . /unit ae . the number of platelets after the reconstitution: . /unit ae . the loss in the number of platelets: . % . platelet concentrates derived from apheresis the number of platelets before the reconstitution: . /unit ae . the number of platelets after the reconstitution: . /unit ae . the loss in the number of platelets: . % summary/conclusions: . reconstitution results in the loss of . % of platelets in comparison to the initial value of pooled platelet concentrate derived from buffy coats. . the average number of platelets after the reconstitution is . /unit, which fulfils the quality requirements. . reconstitution results in the loss of . % of platelets in comparison to the initial value of pooled platelet concentrate derived from apheresis. . the average number of platelets after the reconstitution is . /unit, which slightly deviates from the quality requirements. . the results that we obtained show that the process of reconstitution always results in the loss of number of platelets and that the quality of platelet concentrates that have not been reprocessed is always higher. because of that we recommend that the reconstitution should only be performed in special cases such as for patients after stem cell transplant incompatible with their blood group and that hospitals should be supplied with platelet concentrates derived from buffy coats and apheresis. methods: pf was extracted from human pcs by using immunoaffinity chromatography and specific anti-pf antibody on the column. hereafter, pf was purified with concentration tubes having kda molecular weight cut-off and dialyzed via dialysis tubing with . kda cut-off. pf concentration was measured by bradford method. specific enzyme-linked immunosorbent assay (elisa) and dot blot analysis were used to determine the pf specificity. molecular weight of obtained pf was determined by polyacrylamide gel electrophoresis (page). results: our data confirmed clearly that separated pf had kda molecular weight which is corresponding with a tetramer pf . in addition, elisa showed that the pf qualified true antigenicity. dot blot analysis helped us to assure the specificity of pf . summary/conclusions: we used and optimized a homemade protocol to isolate and purify the pf . nevertheless, there was no any scientific report among the databases that utilized the similar purification method. recombinant pf is more feasible and ready-to-use, but its price may discourage the researchers to study the biology of pf . unused human pcs and specific anti-pf antibody can considered as an alternative to separate the pf particularly in labs with the shortage of resources. background: whole blood is increasingly used in civilian hospitals as an alternative to blood components in trauma resuscitation with massive bleeding. however, the hemostatic effect of whole blood depends on the initial platelet content and decreases rapidly within the first weeks of storage at °c. consequently the problem arises of how to provide wb to trauma centers without losing valuable low titer group o units if the units are not used within the expiry date of use. aims: to assess the in-vitro quality of red cell concentrates (rcc) produced from days cold stored leucodepleted whole blood units filtered with a platelet-sparing whole blood filtration filter in order to save the rcc once the wb units has reached the expiry date. methods: units of whole blood were leucodepleted within h using a platelet sparing filter (imuflex wb-sp/terumo bct) and stored for days at ae °c. on the th day of storage, units are centrifuged and the rcc is supplemented with sag-m additive solution for an additional storage of days at ae °c. in vitro parameters such as hemoglobin, hematocrit, residual leucocytes, platelet content, hemolysis, glucose, lactate, atp, . dpg were tested during storage. results: the imuflex wb-sp provided satisfying leucodepletion of the wb units ( . ae . . e /u)) while maintaining % of the initial platelet content ( ae . e /u). mean volume ( ae ml), hemoglobin content ( ae g/u) and hematocrit ( ae %) was within conformance range. after days of storage, % of the initial platelet content at collection is maintained and mean hemolysis is . ae . %. rcc processing at day was uneventful, without loss of hemoglobin or noticeable hemolysis. mean volume ( ae ml), hematocrit ( ae %), hemolysis ( . ae . %) were in conformance with mandatory standards at day . after days of storage (i.e. day after collection), rcc quality parameters were maintained with however an increase in hemolysis ( . ae . %) which was above usual values routinely observed with rcc produced from day processed units. rcc out of were above the maximum limit of . % at day after collection such increased hemolysis was more pronounced at day after collection ( . ae . %) with a proportion of rcc with a non-conforming hemolysis ratio above the accepted threshold ( % of the tested units). summary/conclusions: rcc units can be readily obtained from leucodepleted wb units with spared platelet contents after days of cold storage. in vitro quality attributes of such rcc are within conforming ranges for hemoglobin, hematocrit, volume and hemolysis. hemolysis increases more rapidly than in standard rcc, thus limiting the possibility of use within days after collection. additional studies are being initiated to reduce hemolysis during storage. g hetland , , f mahmood , l nissen-meyer and i nentwich immunology and transfusion medicine, oslo university hospital immunology, university of oslo, oslo immunology and transfusion medicine, akershus university hospital, lørenskog, norway background: allergen-specific ige in donors' plasma can be transferred from blood donors to recipients via plasma-containing products and consequently sensitize recipient's effector cells bearing receptors for ige (mast cells, basophils, thrombocytes etc.). these cells can then degranulate after exposure to allergen. this can cause allergy symptoms of various degrees (johansson, allergy, ) . food allergen-specific ige antibodies, although causing mild or no symptoms in blood donors, can be of clinical importance to plasma recipients due to varying sensitization and activation grade of recipients' effector cells. aims: the aims of the study were ) to assess sensitization profiles against an array of allergens in randomly selected blood donors and ) to identify donors with high concentrations of food-specific ige antibodies that could bear risk of clinically important sensitization of plasma product recipients. methods: we tested serum samples from blood donors randomly selected on one donation day outside the pollen season. we used ll serum per sample in a multiplex ige line-blot enzymoimmunoassay for analytes (euroline atopy screen, euroimmun, germany), which comprised food allergen extracts and single allergens, inhalant allergen extracts, insect venom extracts and one carbohydrate allergen ccd. this high-throughput method enables scanning of serum samples for ige against allergens in less than h. results are expressed as east (enzymoimmunoassay) classes: class (no sensitization), - (weak sensitization), (moderate sensitization), - (strong and very strong sensitization). results: east class, allergen, number of samples. food allergens: class none detected. class , sesame seed: . class , apple ; hazelnut . class , apple ; almond ; hazelnut ; sesame seed ; soybean ; cow milk alpha-lactalbumin . class : donors weakly sensitized to one or more allergens as kiwi, apple, almond, hazelnut, sesame, soybean, wheat, mutton, beef, cow milk beta-lactoglobulin and alpha-lactalbumin. we did not find any donors sensitized to apricot, peanut, rice, rye, yeast, cow milk casein and carbohydrate allergen ccd. insect venoms: class , and none, class , wasp venom ; honey bee . lower classes ( - ) not reported in this abstract. summary/conclusions: we found considerable sensitization to inhalant allergens but such sensitization probably represents low risk of clinical allergies due to passive transfer of antibodies. sensitization to insect venoms was negligible. we disclosed only one blood donor ( %) with high ige to sesame seed with a potential to transfer clinically relevant ige antibodies via plasma products. the need for a broad screening of donors for ige sensitization remains still questionable. background: the platelet storage lesion (psl) is one of the key factors that limit the platelet shelf-life to days. the mechanisms mediating the psl are not well understood, but it is becoming increasingly evident that platelets from some donors do not store as well as others. similarly, assessment of many in vitro quality parameters has been used to predict transfusion outcomes, with varying degrees of success. donor attributes such as age, and body mass index (bmi) may contribute to these differences. aims: to characterise the variability in the quality and function of apheresis platelet donations and to examine associations between donor attributes and platelet characteristics. methods: apheresis platelets (n = ) were collected, stored at °c with agitation, and tested at day , day and post-collection. vwf and fibrinogen binding (indicators of platelet adhesion; ae ristocetin stimulation), phosphatidylserine (ps) exposure (annexin v binding) and microparticles (cd + /annexin-v + ) were measured by flow cytometry. platelet aggregation was initiated with collagen, thrombin or arachidonic acid. thromboxane a (txa ) was measured by elisa. the proportion of procoagulant platelets (% coated platelets) was assessed by fibrinogen binding following collagen/thrombin stimulation. platelet-attached glycans were measured using flow cytometry and lectins ricinus communis agglutinin- (rca- ; detecting galactose-residues) and wheat germ agglutinin (wga; detecting sialic acid and nacetyl-d-glucosamine, glcnac-residues) ae stimulation with ristocetin. donation time, donor age, blood pressure (bp) and bmi were recorded. linear regression was performed using graphpad prism software. results: for many of the parameters measured, there was high inter-donor variability. platelets from subsets of donors showed up to -fold higher vwf and fibrinogen binding, formation of coated platelets and microparticle numbers. binding of lectins was also highly variable between the donors, indicating variability in sugar cleavage. following ristocetin stimulation, binding of all lectins increased, and again there was high variability in the responses, with up to -fold higher binding in platelets from a subset of donors. of particular interest, aggregation in response to arachidonic acid was observed in only % of platelet donations tested; although platelets from non-responders aggregated in response to the collagen and thrombin. txa was also higher in the arachidonic acid responders (p = . ). there were few associations between platelet parameters and donor attributes, and these associations were typically weak. ph at day was weakly associated with donor age (p = . , r = . ) but not bmi (p = . , r < . ), with a trend towards lower ph in younger donors. summary/conclusions: these data indicate that apheresis platelet products are highly variable. whilst donor characteristics may have some influence on the quality of the donated platelet product, there is a high level of inherent inter-donor biological variability. a much larger sample size is required to confirm these findings, and determine whether they have clinical implications. background: the frequency of beta thalassemia mutations, and thus, of beta thalassemia heterozygotes (b-thal-het) is particularly high in certain geographical regions. it has been reported that a significant proportion of donors (occasionally more than %) are b-thal-het that meet the criteria for blood donation (hb > . g/ dl). red blood cells (rbcs) of b-thal-het donors are characterized, in vivo, by particular geometry and redox status. despite sporadic indications that the rbc storage lesion may be milder in b-thal-het, targeted research on this donor group is still missing. aims: the aim of this study was to investigate whether b-thal-het rbcs storage at blood banks leads to a distinctive hemolytic, physiological and redox profile, thus, making b-thal-het a unique blood donor group. methods: blood samples from healthy non-smoker donors ( b-thal-het carriers and controls) were analyzed before and after preparation and storage of leukoreduced packed rbc units in cpd/sagm at various time intervals. susceptibility in hemolysis (in the presence/absence of oxidative, mechanic and osmotic stimuli), redox status (lipid peroxidation, reactive oxygen species (ros) accumulation, antioxidant capacity), intracellular ca + and proteasomal activities were determined. for statistical analysis, significance was accepted at p < . . samples from the red cell units were collected aseptically, processed (dual centrifugation at , g for min) and stored at À °c. processed samples were thawed, and then analysed using the nanosight ns nanoparticle tracking analysis system (malvern instruments). samples from all time-points from each unit were analysed on the same day. data were analysed by one-way anova with bonferroni's multiple comparisons test. results: at d , red cell units contained an average of . ae . mvs/ ml. the mean size of these mvs was . ae . nm and the mode size was . ae . nm. the concentration of mvs increased gradually throughout storage (p = . ), reaching a maximum at d of . ae . mvs/ml. both the mean (p < . ) and mode (p < . ) size of the mvs increased during storage; however, this size increase primarily occurred in the first week of storage (d vs. d : p < . for both mean and mode). by d , mean and mode size of mvs was . ae . nm and . ae . nm summary/conclusions: nanoparticle tracking analysis demonstrated the presence of mvs smaller than nm in red cell units. both the concentration and size of mvs present in red cell units increased during the days of routine storage. the concentration of these mvs was approximately -fold higher than we had previously detected using flow cytometry (aung, pathology, ) indicating the advantages of more sensitive techniques in characterisation of mvs. background: the lack of availability of sterile saline in a format suitable for use in blood centers for manual washing has led to an urgent need for blood services to consider alternative methods. for operational flexibility it would be desirable to be able to produce a washed rbc unit that had a shelf life longer than h. aims: the aim of this study was to validate the manual method for washing rbcs using sagm solution both as wash and storage solution and to ascertain whether an extended storage period for washed rbcs may be feasible. methods: six day old leukocyte depleted red blood cells (ld-rbc) and six day old ld-rbcs were manually washed and stored in sagm, and half of the units were pre-stored irradiated ( gy). a volume of ml wash solution (sagm) was added to the ld-rbss by sterile connection. after mixing the units were centrifuged for . min at g at °c (hettich roto silenta rs) before removing the supernatant using compomat g extractor. wash procedure was repeated twice using ml sagm solution, and after removal of the last supernatant, ml of sagm solution was added. all units were immediately measured for volume, haematocrit, albumin, iga, potassium, haemolysis, haemoglobin, ph, glucose and lactate and tested again after h, days and days storage at ae °c. results: all washed ld-rbcs met european specification for haematocrit ( . - . ) and all but one for hb content (≥ g/unit). hemolysis increased during storage. the rate of hemolysis in irradiated ld-rbcs was greater over time than in nonirradiated units. all units, both irradiated and nonirradiated, met european specification for hemolysis (less than . %) days after washing. after wash, potassium levels were low and then increased during storage; increase was greater in irradiated than nonirradiated units. potassium concentration days after washing and irradiation did not exceed those levels found at the end of shelf life (day ) of standard ld-rbcs. ph decreased during storage due to the metabolic activity of red blood cells converting glucose to lactate. the ph level of the supernatant depends on the age of the unit and not on the irradiation. the glucose concentration of the supernatant after washing is high due to sagm solution. the concentration of glucose decreased and lactate increased due to the metabolic activity of red blood cells. there is currently no specification in europe or finland for iga in washed rbcs. aabb and american red cross rare donor program stipulate that level of iga should be less than . mg/dl ( . mg/l). our iga method s lower limit for detection is . mg/l and all results were below this level. total albumin were well below finnish specification (< mg/unit). background: room temperature has been the standard storage condition for platelets since the s, when it was shown that this improved in vivo survival compared to when stored at °c. however, storage at room temperature has several disadvantages, including risk for bacterial contamination and short outdating. recently, the interest in cold-stored platelets increased, especially for patients with a hemostatic need. using extensive analysis techniques, we evaluated the in vitro quality of cold stored platelets in additive solution. aims: investigation of the in vitro quality of platelets stored at - °c in pas-e. methods: three experiments were performed, in which two platelet concentrates, prepared from buffy coats and ml of pas-e (pcs) were pooled and split in equal pcs. pcs were stored for days at - °c, one of each pair with agitation on a flatbed shaker and the other without agitation. various parameters were analyzed to study the in vitro quality during storage and compared to routine room temperature storage. results: during cold storage, the swirling phenomenon disappeared within one day. due to the lower temperature, metabolism of the platelets was lower as compared to room temperature storage. the metabolic conditions were acceptable with ph d -d : . - . with platelet count /u and glucose still at mm at least until days of storage. platelet activation maintained acceptable levels with cd p expression < %, while ps exposure increased rapidly; > % after days of storage. aggregation tests showed functional platelets until days of storage. agitation during storage had no effect on any of the tested parameters. summary/conclusions: during storage of platelets at - °c, the hematological parameters and ph met routine requirements, while swirling phenomenon disappeared already at the first day. the functionality of the platelets did not decrease during cold storage, indicating that the swirling phenomenon is not a good surrogate marker under these conditions. the strong increase of ps exposure might be involved in the observed short survival of cold-stored platelets. platelet concentrates stored at - °c are potentially suitable as a hemostatic agent for patients with a bleeding in need of platelets, but more studies are needed. aims: the goal of the study is the reinforcement of platelet reserves for case of emergency events and increasing their availability for treatment, preferentially in patients with massive bleeding. methods: we performed a comparative study with cpp and fp in vitro. buffy coatderived pooled leukoreduced platelets rhd negative were frozen in - % dmso and stored at À °c for months. cpp were thawed at °c, then reconstituted in platelet additive solution ssp+ and compared to fp. we measured these parameters: platelet content, platelet concentration, platelet loss during preparation process, coagulation properties, volume, ph, dmso concentration, titres of anti-a and anti-b antibodies. results: the average platelet loss after the process of freezing and reconstitution was %. the amount of platelets and platelet concentration in unit was lower in cpp compared to fp, but high enough (amount /unit, concentration . /unit). both types of plts (either pcc or fp) maintained an acceptable ph during storage. swirl was on value in fp and on value in cpp. the average plasma content in fp was % compare to . % in cpp after reconstitution. measured titres of igm anti-a and anti-b antibodies were very low ( - : ). cpp had faster clot initiation (rotem clotting time (ct) in cpp . s, fp . s). cpp contributes to a sufficient clot (rotem maximum clot firmness (mcf) in cpp . mm, fp . mm). summary/conclusions: our results shows, that cpp have higher procoagulation activity and simultaneously lower clot firmness. thawing and reconstitution of platelets are easy and fast processes if platelet additive solution is used. this method helps to increase the availability of platelets in emergency medicine. low plasma content in cpp enables their use as washed platelet product in specific groups of patients. methods: after donation, the whole blood was stored in room temperature overnight before separating next morning by reveos â system. seven abo compatible ipus, each with a target volume of ml, were selected and then they were connected to the pooling set provided by terumo bct. prior to the pooling of ipus, ml of additive solution (t-pas+ provided by terumo bct) was added and distributed evenly between the ipu bags. the pooling set was then kept h on bench in room temperature followed by h on agitator at ae °c. after filtration, the pool might be manually adjusted if its volume exceeded the maximum of ml to meet the requirements by the intercept tm blood system. the final products were two pathogen-reduced platelet units with a shelf life of days. results: during validation of the method, pathogen-reduced platelet units were controlled, in addition to the platelet count, for ph, glucose, po , pco and lactate on day , and of storage. the platelet count was . ae per unit on day . the ph value was . on day , . on day , and . on day . the glucose concentration decreased from . to . and . mmol/l on day , and , respectively. the mean po level was . , . and . kpa while the mean pco was . , . and . kpa and the lactate concentration was . , . and . mmol/l on day , and , respectively. since routine implementation of the method in april , regular quality controls showed an average of platelet count of . ae (n = ) with a volume of ae ml per unit. summary/conclusions: the validation of the method and the following two years of experience in routine shows that the pooling of ipus processed in reveos â system meet the requirements needed for intercept tm ds processing set for pathogen reduction of platelets. the results from the quality controls of the final platelet units were in accordance with the local and eu guidelines. methods: data was analyzed from published and unpublished clinical studies that performed both primary and secondary testing of platelets using the bta system. the studies included apheresis and whole blood derived buffy coat platelets and tested - ml sample volume per culture bottle. the studies classified results based on aabb bulletin - definitions with some modifications. the following assumptions were made including: • data was summarized as total number of positive tests, observed by the total number of tests performed on each day post collection; • it was assumed that one test was performed per platelet unit; • all units eligible for secondary testing were negative by the primary test the data needed to demonstrate a benefit for the use of the bta d systems for detecting contamination that was not revealed by previous bacterial testing as well as clinical specificity. results: a total of , platelet units from the studies where secondary testing of platelets was performed were analyzed. platelets were tested on day , , or ≥ , and represented . %, %, and % of the units tested, respectively. true positives were detected in platelet units representing . % of the total platelets tested. the majority were reported from platelets tested on day ≥ with a total of . data showed the bta d system used for secondary testing detects the most prevalent contaminates reported, staphylococcus spp., in ≤ h with the majority detected in ≤ h after incubation, allowing for interdiction of the units prior to transfusion. instrument specificity was reported in of the studies for platelets tested at days and ≥ days with a total false positive rate of . % (range of - . %). instrument sensitivity when used for secondary testing could not be determined since subculture of negative bottles is not performed during routine use. during previous validation testing of lrap and lrwbpc, , culture bottles were confirmed true negatives by subculture. summary/conclusions: data from the studies that tested platelets at to days post collection provided evidence that the bta d with bpa & bpn detects contaminants missed in previously tested platelet units. the data supports that the bact/alert d system is an effective safety measure for secondary testing of platelet products to extend platelet dating beyond day and up to day when testing is performed using the test parameters described in the bpa and bpn bottle ifus and according to the fda draft guidance. background: magnetic nanoparticles have recently shown great potential in nonradioactive labeling of platelets. platelet labeling efficiency is enhanced when particles are conjugated with proteins like human serum albumin (hsa). however, the optimal hsa density coated on particles and the uptake mechanism of single particles in platelets remain unclear. aims: we characterize the interaction between single particles and platelets and determine the optimal hsa amount required to coat particles. methods: ferucarbotran iron oxide nanoparticles were coated with hsa in different amounts ( . - mg/ml) and we confirmed successful hsa coating by addition of a crosslinking hsa antibody (dynamic light scattering). we labeled platelets from pooled platelet concentrates with mm ferucarbotran coated nanoparticles and analyzed labeled platelets for iron content (atomic absorption spectroscopy) and particle localization (transmission electron microscopy). single-molecule force spectroscopy was used to determine binding forces of nanoparticles to platelet compartments. we applied hsa-particles via linkers of different length (i.e. short~ nm, medium nm and long~ nm) on the cantilever tip and let them interact with a platelet provided on a collagen surface. after interaction we determined the rupture force required for platelet retrieval. results: the iron content per platelet reached a maximum at . - . mg/ml hsa coated particles with . ae . and . ae . pg/platelet, respectively. however, the . mg/ml hsa coating resulted in~ -fold higher binding affinity to platelets than particles coated with . mg/ml hsa. depending on peg length between tip and particle, particles interacted differently with platelets as shown by one, two or three force distributions of , , and pn, which correspond up to three different binding pathways, respectively. the results indicate that a particle can interact with three targets including platelet membrane, open canalicular system, and platelet granules. summary/conclusions: our results reveal mechanism of platelet-particle interaction on a single particle level and provide an optimal hsa concentration coated on particles to gain maximal platelet labeling efficiency. labelling of platelets by magnetic nanoparticles may substitute radioactive labeling. results: the activation/lesions on total platelets and small and medium-sized platelets platelet population was detected on storage day , by the increased expression of cd . the percentage of cd -positive cells among the population of large platelets did not change during storage. on the day , increased expression of cd b and cd p was detected, but only on large platelets. small and medium-sized platelets had increased cd p expression only on day . the expression of cd a on total platelets increased significantly on day , and stayed unchanged until day . the same pattern of cd a expression was detected for small and medium-sized platelets, whereas on large platelets the expression continued to increase until the end of storage. a decreased percentage of cd -positive cells was detected among the total platelets and populations of medium-sized and large platelets. the storage induced externalization of phosphatidylserine on total platelets or on any of the platelet populations was not detected. the levels of tgf-b and p-selectin in the pc-bc supernatants were unchanged during the -day storage period. increased annexin and pf concentrations were detected on day . the concentration of b-tg increased on day of storage, and continued to rise until the end of storage. summary/conclusions: the evaluation of expression of activation markers on different platelet populations could be used as an additional analysis in quality control of platelet concentrates, and in the assessment of novel approaches to platelet concentrate manipulation i.e. for testing new additive solutions, cryoconservation protocols, and cryoprotectants. background: the primary goal of autologous blood transfusion is to reduce the risks related to allogeneic blood transfusion, including transfusion-associated graft-versus-host disease (ta-gvhd). although downward trends in rates of autologous blood transfusion have been reported in europe and the americas, it still plays a role in eliminating risks related to allogeneic blood transfusion in japan, especially ta-gvhd. since february , the transfusion service in our hospital has managed autologous blood conservation techniques and helped to prevent mistransfusion by employing a bar code-based electronic identification system. aims: the objective of this study was to determine the use of types of autologous blood components in a single institution over an approximately -year period. methods: between february and december , we retrospectively analyzed autologous blood transfusion, including perioperative autologous cell salvage (pacs), pre-operative autologous blood donation (pad), and acute normovolemic hemodilution (anh). we investigated the use of autologous blood components and the rate of complying with electronic pre-transfusion check at the bedside in the operating rooms. we also determined the adverse reactions to autologous blood transfusion, which were categorized according to the definitions proposed by the international society of blood transfusion (isbt) working party on haemovigilance. results: a total of , patients ( % of whom received operations) received blood transfusion, of which , ( %) received autologous blood transfusion alone, , ( %) both autologous and allogeneic blood transfusions, and , ( %) allogeneic blood transfusion alone. the rate of autologous blood transfusion among patients who received blood transfusion was %. pacs units were transfused to , patients ( %), pad units to , patients ( %), and anh units to patients ( %), and multiple blood conservation techniques were used for one patient. the overall compliance rate with electronic pre-transfusion check at the bedside in autologous blood components was . %. adverse reactions were observed only with pad transfusion and not pacs nor anh. the number and rate of adverse reactions to pad transfusion were and . %, respectively, of which the most common was febrile non-hemolytic transfusion reaction at ( %), followed by allergic reactions at ( %), and hypotensive transfusion reaction at ( %). the severity of adverse reactions to pad transfusion was grade (non-severe) in all cases, and no serious adverse reactions were observed. among pad units, the rate of adverse reactions to whole blood pad units was . %, that to frozen pad units was . %, and that to autologous ffp units was . %. summary/conclusions: our observations indicate that the rate of autologous blood transfusion among patients who received blood transfusion was %, when all types of autologous blood conservation techniques were included. to accurately determine the rate of autologous blood transfusion in a hospital, it may be better for the transfusion service to manage all types of autologous blood conservation techniques. they are now clinically available as a blood product. the residual plasma level of this product, which is prepared using the automated cell processor acp (haemonetics corp.), is approximately %. recently, a retrospective multicenter study was reported that this product was effective and safety for prevention of recurrent or severe transfusion reactions. plt products are generally stored with continuous agitation to maintain their quality. the interrupted agitation of plt suspended in additive solution (plasma carryover: - %) for up to h was previously found to have only a slight impact on in vitro plt properties. however, in some small hospitals with no agitator, if the initiation of transfusion is delayed by an emergent change in a patient's condition, the interruption of agitation may be prolonged. aims: the aim of this study was to evaluate the effects the interruption of agitation for h (shelf life of wpc in japan) on the in vitro qualities of plt. methods: leukoreduced apheresis platelet concentrates in % plasma were washed on day one after blood collection using the automated closed-system cell processor acp (n = ). wpc, which were rested h after preparing, were divided equally into control and test units using polyolefin containers on day one. control units were agitated from days one to seven. test units were stored without agitation from days one to three, and agitation was subsequently performed until day seven. both units were stored at - °c. in vitro plt quality was examined on days one, three, four and seven. results: the plt concentration of prepared wpc was . ae . ( /l) and the volumes of the control and test units after the division were ae and ae (ml). the ph values of the test units on day three were lower than those of the control units; however, the ph of both units were maintained at higher than . during the seven-day storage period. swirling was well maintained and no clumping was visible in both units during storage period. no significant differences were observed in plts concentrates, mpv, hsr, aggregation response. the pco , po , bicarbonate, glucose and lactate mean values of test units were slightly lower or higher than those of the control units on days three or four. the levels of cd p expression were significantly higher in the test units than in the control units on days three ( . % ae . vs . ae . , p < . ); however, this difference decreased in a time-dependent manner after agitation resumed. the levels of cd b expression of test units were relatively lower than those of the control units until day seven, but no significant difference between the two units. background: monitoring residual white blood cells (rwbcs) is a requirement for quality monitoring (qm) the production of leucocyte depleted blood components. although flow cytometry is widely used for monitoring rwbc, there are no widely accepted methods to accurately and consistently measure rrbcs in blood components. sysmex have developed a novel algorithm, termed the blood bank (bb) mode for their xn-series of haematology analysers which is specifically designed to quantitate the levels of rwbcs and rrbcs in blood components. aims: we have previously assessed the linearity, accuracy and reproducibility of the bb mode on spiked samples in an r+d lab. we sought to further assess the performance of the bb software in a routine, high throughput blood component manufacturing department. methods: units of plasma, platelets (pcs) and red cell concentrates (rccs) were produced according to standard uk specifications within nhs blood and transplant (nhsbt). qm of residual cells was tested using the bb mode whilst rwbc was additionally analysed by flow cytometry using bd leucocount kit. results: during a -month field trial over , data points were collected representing all types of manufactured component. for some pcs, bb mode results from some sample tubes that did not contain edta gave very high rwbc values, indicating a potential large number of ld failures. the results were significantly different from those obtained from pcs using edta samples (p < . ) which did not show the same high values. for rccs or plasma, the range of results from plain and edta tubes were not significantly different (p ≥ . ). the analyses of ld platelet and plasma concentrates by either bb mode or flow cytometry both show more than > % of ld components have less than rwbc/unit. for ld failures (n = ) there was a good correlation (r = . ) between flow cytometry and bb mode measurements. spiking studies suggested that the limits of detection and quantitation of rrbc were around and rrbc/ll respectively. residual red cell counts from manufactured components showed a wide variation in their numbers between units. as expected platelet production methods also showed a significant difference (p < . ) in rrbc contamination, with lower levels in apheresis platelets (median = rbc/ll, n = ) compared to those produced from buffy coats (median = rbc/ll, n = ) in our hands, although the time taken to analyse samples is similar for flow cytometry and bb mode, considerable time can be saved on manual handling and the processing of samples for flow cytometry (approximately - h for - samples). summary/conclusions: we have been able to embed the sysmex bb mode into a routine production environment and confirm that its performance in spiked samples is mirrored in routine use. for platelets, sample collection in edta is essential. the bb mode offers an opportunity to reduce operator time compared to flow cytometry whilst gaining additional information on rrbc. abstract withdrawn. results: in our experiment, the typical size of a spectrin matrix section (l) was to nm (without oxidation). the heights (h) of dips were to nm. due to oxidation, the junctional complexes between spectrin and membrane proteins can rupture. only % to % of the spectrin surface has the same structure as in the control group. the values of l and h vary significantly depending on the intensity and time of exposure. we observed significant changes in the spectrin matrix after exposure to uv radiation in a model experiment. the local topological defects in the membrane arise from the action of oxidizing agents on the red blood cells. the mechanism of their appearance is connected mainly with the distortion of the spectrin matrix. as a result of oxidation processes, the spectrin molecules can be damaged. there is a transformation of tetramers to dimers. additionally, it can be easily seen with the afm, that spectrin network structure was essentially destroyed. most parts of the spectrin matrix have damaged structures with mesh breaks and dips after uv irradiation. also the results of network distortions in response to temperature changes were obtained. there are presented preliminary results of spectrin matrix change during long-term storage of prbc. summary/conclusions: atomic force microscopy in direct biophysics experiment allows to observe and to quantitatively measure the disturbances in the spectrin matrix nanostructure in response to oxidation processes in rbcs. these studies are important for the fundamental research of interactions of rbcs on the molecular level during redox processes and the consequences to their structure and function on the cellular level. this is important for the advancement of transfusion medicine, intensive care medicine, and molecular and radiation biology. methods: blood samples were taken from donors during a prophylactic examination and collected with edta-filled microvettes (sarstedt ag and co., germany). all experiments were carried out in accordance with the institute guidelines and regulations. the polylysine-coated glass was used to perform the sedimentation method for formation of native rbc smears. it is important that any fixatives weren't used. the stiffness of rbc membranes was studied in native rbcs (control) and native cells after the application of modifiers: glutaraldehyde, hemin, zn + (heavy metal ions). local stiffness was studied by atomic force spectroscopy (afs) (ntegra prima, (nt-mdt, russian federation). results: experimental kinetic curves i(z) were measured. nonlinear fitting method was used to determine the young's modulus. the experimental dependences of membrane bending were approximated by the hertz model to a depth up to nm. the young's modulus e = ae kpa for control rbc. it was shown that some natural oxidants (hemin), membrane fixatives (glutaraldehyde) modifiers, heavy metal ions (zn + ) significantly increased the absolute value of the young's modulus of rbc membranes up - times. the biophysical parameter hertz depth (h hz ) was determined for each curve. under the influence of modifiers the hertz depth h hz was changed from nm to nm. there are presented preliminary results during long-term storage of blood. summary/conclusions: the blood rheology is determined by rbc deformability, associated with membrane stiffness. the young's modulus can be used as a quantitative criterion to estimate the membrane state of a native cell. the results of the work can be used in clinical practice, in assessment of the quality of donor blood during storage before transfusion, in biophysical studies of rbc state. abstract withdrawn. immunohemotherapy, centro hospitalar universit ario são joão, epe, porto, portugal background: transfusion of blood and blood components is an essential resource in modern medicine. a proper use of human blood, being an irreplaceable resource, is necessary in order to achieve minimal wastage. blood wastage may occur for a number of reasons, like expiry date, haemolysis, seroreactivity or low volume. monitoring wastage of blood product during collection, testing and processing of blood is used as a quality indicator. aims: to determine the annual rate of discarded blood components due to expiry date in a portuguese university hospital blood bank (bb) from january to december , in order to implement appropriate measures to minimize the number of discarded blood to a reasonable rate. methods: we retrospectively analysed the rates of blood components discarded after meeting their expiry date of a portuguese university hospital blood bank from january st to december st . results: a total of , whole blood units and , apheresis platelets were collected during the study period. of the , blood components (packed red cells, whole blood pooled platelets and apheresis platelets) prepared during the study period, a total of , ( . %) blood components were discarded, of those . % due to expiry date. the rate of discarded packed red cells, according to this component production, decreased considerably over the years, in was . %, in was . % and . % in . similar tendency was shown in the pooled platelets for consecutive years with . % ( ) and . % ( ), but with an increase in ( . %). the rate of apheresis platelets had a more variable behaviour from to with rates of . %, . %, and . % respectively. summary/conclusions: blood transfusion is an essential part of patient care. for this reason, the implementation of a quality system and continuous evaluation of all activities of the bb can help to achieve maximum quantity and quality of safe blood. we identified that date expiry was the main reason of discarded blood components, although there was a significant decrease in the rate of discarded packed red cells over these three years. properly implemented blood transfusion policies, donor screening and training staff as well as implementation of automation also helps to improve the process, reducing the discarding rates of blood and blood component. background: storage performance of platelets (plt) is associated with age of the donor. the risk for plt with poor storage performance, characterized by high lactate production and rapid acidification of a plt concentrate (pc), shows a positive correlation with age. we wished to explore whether high lactate production was associated with donor health issues. aims: to investigate high lactate production by stored platelets in relationship to donor health. methods: single-donor pc were collected by apheresis or prepared from buffy coat and donors were evaluated who could be marked as 'rapid acidifiers'. in total, apheresis pcs and pcs from whole blood were included in four studies. information about donor health was obtained either from the blood bank information system or using questionnaires. in some donors, the lipid profile was measured from plasma, and the diabetes marker hba c from red cells. triglyceride levels > . mmol/l and hba c levels > mmol/mol were defined as high. results: twenty two percent ( / ) of the donors were marked as 'rapid acidifiers' and % ( / ) of these donors had health issues. 'rapid acidifiers' were of age , - (median, range) years. three groups of donors can be distinguished: a) donors affected by metabolic syndrome, prediabetes and type diabetes, indicated by high cholesterol and/or triglycerides, high hba c and/or the use of medication to treat diabetes. b) donors affected by vascular diseases who reported or used medication to treat high blood pressure. c) "other" donors who used other medication to treat various other conditions. the remaining 'rapid acidifiers' ( %) did not have high triglyceride or hba c levels and did not report health issues. summary/conclusions: pcs with rapid acidification by high lactate production are mainly collected from older donors with health issues. we postulate that high lactate production by stored plts is associated with health issues, and we will combine detailed donor information (health and behavior) with in vitro quality for a significant number of donations. background: the development of applied biotechnologies requires a search and creation of new methods of cells' functional completeness analysis. the instrumental assessment of platelets quality for the selection of the most effective donors, quality assessment of platelet concentrates for short and long-term storage and for the selection of platelets for cryopreservation is in demand in blood service. assessment of platelets morphofunctional status is possible using morphological studies of various platelet granules fractions (makarov, med. alfavit, ). among the biologically complete platelets there is a special population of cells, the so-called granule-rich platelets (grp). these cells contain the largest number of cytoplasmic granules (more than visually distinct granules). it is established that grp have increased viability and functional activity. earlier we found a correlation between the grp level in blood plasma and shift of the redox potential value in blood plasma after cryodestruction of platelets (tsivadze et al., doklady physical chemistry, ). it was suggested that the shift of the redox potential may be partly due to the release of the low molecular weight antioxidants contained in functionally complete platelets outside the cell. in turn, the concentration of low molecular weight antioxidants can be estimated using the cyclic voltammetry. aims: the aim of the study was to estimate of cyclic voltammetry method possibilities for quality assessment of platelets. methods: the functionality of platelets was examined in platelet concentrate (pc) obtained by apheresis ( . ae . /ll). voltammetric analysis in pc before and after the platelets cryodestruction was carried out on platinum electrode in the potential range from À mv to + mv using a potentiostat ipc pro l and saturated ag/agcl electrode as reference. for the morphofunctional analysis platelets were vitally stained with fluorochrome stains trypaflavin and acridine orange. microscopic examination of platelets was carried out using confocal microscope nikon eclipse i. the following parameters were evaluated: concentration and percentage of platelets with granules and concentration and percentage of grp. results: voltammetric studies in pc show that there are two oxidation peaks of low molecular weight antioxidants on voltammogram at potentials + mv and + mv. analysis of pc before and after the cells cryodestruction showed that changes in the height of oxidation peaks occur, indicating an increase of antioxidant content in blood plasma. at the same time a correlation between the changes in the height of oxidation peaks and the grp content in the sample was found. in samples with reduced initial grp content (less than %) after the cells cryodestruction significant changes in the height of oxidation peaks were not observed, regardless of the total number of cells in the pc. summary/conclusions: in conclusion, voltammetric analysis allows to indirectly estimate the population of functionally active platelets that in combination with other methods of analysis can serve to assess the quality of platelet products. background: determination of hemoglobin derivatives in blood is one of the most important studies in clinical laboratory diagnostics, especially during the storage of donor blood and its transfusion. concentration of hemoglobin derivatives can be changed during redox process. aims: to show the possibility of using non-linear fitting method to calculate concentrations of hemoglobin derivatives during reduction-oxidation processes. methods: for this we performed model biophysical experiment, in vitro. blood samples were collected into edta microvettes from healthy donors (sarstedt ag and co., germany) during prophylactic examinations. all the donors gave their consent to participate in the study. a suspension of erythrocytes was prepared in pbs buffer with ph . . we used ultraviolet (uv) irradiation of blood or nano as oxidizing agent. the drug cytoflavin (stpf "polisan", russian federation) was used as an antioxidant. in our study we used digital spectrophotometer (unico , usa) to measure the absorption and scattering of light ( . nm step). the method of nonlinear fitting was used to find the concentrations of hemoglobin derivatives. the empirical spectrum d l (k) exp was approximated by the theoretical curve d l (k l ) theor , which fits the experimental curve in the best way. under approximation the light absorption by different hemoglobin derivatives was considered in model. simultaneously effects of rayleigh light scattering on structures with size d<< k (coefficient s) and light scattering on particles with size d≥ k (coefficient k) were taken into account: d l (k l ) theor = e hbo ,l c hbo l+ e hb,l c hb l+ e methb,l c methb l+ e hbno,l c hbno l+ e methbno -,l c methbno -l+ e methbno,l c methbno l+k+s/k l ( ), where e h,l is the molar absorption coefficient for each hb h derivative at given wavelengths k l , c h is the concentration of the derivatives hb h , l is the thickness of the solution layer, d l (k l ) is the optical density of the substance, k and s are the parameters of the model. results: we determined the concentrations of hemoglobin derivatives without any additional chemicals in blood. there were measured experimental spectra for different agents action on blood. it was shown that concentration of methb increased after uv irradiation and nano action (up to %). there were calculated c h for each hb h derivative. it was established that theoretical curves coincide with experimental data with good accuracy (r = . ). incubation of rbcs with cytoflavin leads to reduction of methb to hbo . summary/conclusions: the determination of hemoglobin derivative concentrations by the method of nonlinear fitting (without adding special chemical agents to blood) can be used for measurement of carboxyhemoglobin in blood during toxic state of organism. also it is important for assessment of rbcs quality before blood transfusion. background: the use of in line leukoreduction filters have been highly expanded in iranian blood transfusion centers within the last decade in order to provide sufficient leukoreduced blood fractions from healthy safe frequent blood donations to be supplied to the leukocyte sensitive patients. leukoflex lcr , the dominant brand of such filters procured by iranian blood transfusion organization, is the most updated generation of the filters used around the world. aims: in this study, it is tried to recover the trapped leukocytes from this novel filter by different buffering systems and having optimized the elution mode, the cell differential of the viable recovered white blood cells were determined by flow cytometry. methods: having passed the routine virological tests, eight leukoflex lcr leukoreduction filters freshly used in tehran blood transfusion center were daily collected and each were back flushed by a self-designed mechanical system (a peristaltic pump, a triple junction with regulator part and an air pump) using various conditions and additives for pbs buffer at different phs in order to find the highest recovery yield for leukocytes. the optimized elute was characterized by flow cytometry for subcellular profile to be determined. results: it was illustrated that a system consisting of pbs (without cacl and mgcl ) in ph . containing mm edta and %(w/w) dextran without additive amounts of triton x was the most optimized buffering system for lcr filter back flushing. total cell content was also determined as . * granulocytes, . * lymphocytes and . * monocytes using auto hemoanalysis and flow cytometric methods. summary/conclusions: in addition to partly compensating of the overhead expenses inflicted by application of leukoreduction filters on healthcare system, the results will assist blood organization system to be more classified in rational profile design, future cell therapy strategies and exceptional blood management. also, the recovered cells could be of significance in stem cell science, cellular interaction studies as well as novel molecular developments in drug discovery. vox sanguinis ( ) results: three lines of strategy are in place to pursue self-sufficiency of the largest number of pdmps. first strategy line: maximizing the yield of driving proteins, represented by immunoglobulins (ig) and albumin; this was assured by csl behring with a yield of . g ig ( % intravenous -privigenand % subcutaneous -hizentra) and g albumin (alburex) per kg plasma fractionated, corresponding to . g ig and . . g albumin; based on present demand, this represents % and % self-sufficiency, respectively, for naip regions. second strategy line: ensuring other products from plasma fractionation; the fractionator granted . g fibrinogen (riastap) and . . iu vwf/fviii (haemate p) per year, which corresponds to the present demand of naip regions for both products, but it is under the full potential of plasma, thus providing a high margin of safety in case of increased demand (now the case of fibrinogen). third strategy line: exchanging cryoprecipitate, fibrinogen and vwf with italian regions whose plasma is fractionated by other companies to obtain prothrombin complex concentrates (pcc -kedcom) and antithrombin (atked) as to satisfy naip regions demand; this strategy allowed a supply of . . iu at and . . iu pcc, capable of ensuring self-sufficiency for naip regions until . summary/conclusions: in italy, differentiation of plasma contract manufacturing among companies with different portfolios allowed naip regions to obtain a significant contribution to self-sufficiency from vnrd plasma for a variety of pdmps by different and complementary strategies consisting in maximizing the yield and the portfolio of proteins from the fractionator and exchanging products among regions for other pdmps at high demand but not included in the portfolio of a single fractionator. plasma check system: a valuable tool for plasma freezing validation and monitoring. background: the validation of plasma freezing processes may result problematic in the monitoring/control of critical process parameters (cpp). in in italy , litres of plasma were produced and frozen. aims: in order to assist plasma freezing validation and cpp monitoring, of the italian bes performing plasma freezing utilize the plasma check system (pcs), a system able to record, store and certify the temperature (t) detected at the core of "surrogate" bags during the entire freezing session, consistently with gmp requirements. pcs is patented and commercialized by expertmed srl, verona, italy (http://www.expertmed.it). methods: pcs consists of parts: a) "surrogate" bags (check-bags) of and ml corresponding to the average standard volumes of the real products, containing a fluid validated to simulate the thermal behaviour of plasma; b) a mobile probe (cryo-med) positionable at the core of the check-bags; c) a dedicated software (memo-track). plasma freezing session data are tracked via barcode/rfid and can be consulted by the pcs that associates blast freezer code, operator code, cryo-med and check-bag. data on plasma freezing are stored in a shared folder and transferred to the be information system. the pcs can also be used to check and monitor the out-of-storage variations of core t of frozen plasma unit, i.e. during labelling and packaging procedures, thus allowing to establish optimal timeframes and operations and suitably validate these procedures. in the period - , at the pievesestina be of emilia romagna region , plasma units were frozen so as to allow complete freezing within to a temperature below À °c, in , freezing sessions, using the pcs both for process validation, change control and for the systematic monitoring of core t at each freezing session. furthermore, at the bologna be tests on the out-of-storage conditions of plasma units were carried out to revalidate the procedures of labelling and packaging. results: out of , freezing sessions carried out at the pievesestina be, ( . %) were detected to fail to reach À °c at the core of the check-bags within . of the latter, in most cases ( %) a technical error in the activation of the cryo-med was identified. in addition, the pcs was systematically utilized for periodical revalidation of the freezing procedures. the tests performed at the bologna be to validate the out-of-storage procedures of frozen plasma labelling and packaging allowed to modify the operating procedures in place so as to establish optimal timeframes and operations. this prompted corrective actions regarding: i) number of units to be taken out of storage sites at each labelling session (< units), ii) labelling time (< ), iii) optimal storage t (À °c vs. À °c), iv) optimal time between two openings of storage sites (> ). summary/conclusions: the pcs is a valuable system for plasma freezing validation and monitoring, as well as to perform monitoring and control of the whole pathway of frozen plasma in the be. it is a technologically advanced, easy-to-use and costeffective tool that can efficiently replace other traditional methods commonly used for the above-mentioned purposes. assessment of blood group matching quality using six sigma metrics background: six-sigma metrics provides a general methodology to evaluate a process performance on a sigma scale. implementation of six-sigma for quality assurance can benefit the health care sectors. one of the most important health care sectors is blood transfusion service. for that reason, maintaining a high quality in blood transfusion service is required. pathogen in activated plasma is one of the main products that are provided by the blood transfusion service. the process of producing pathogen inactivated plasma involves blood group matching step. the quality of this blood group matching is extremely significant for the delivery of plasma that satisfies the recipient need. aims: the aim of this study is to assess the quality of blood group matching of pooled plasma units using six sigma metrics, and to clarify the potential implementation of six sigma metrics as a quality management tool. methods: this retrospective study was conducted in the component preparation lab of kuwait central blood bank. the twelve months (january -december ) data of pooled fresh frozen plasma units were recruited and examined. the data was separated to data without double check ( months) and data with double check ( months). data statistics and analysis were conducted by the use of six sigma metrics. results: in a sample size of from the first six months a mismatch was found which equals dpmo and . sigma metric. and in a sample size of from the second six months a mismatch was found which equals dpmo and . sigma metric. out of the whole pooled units were found to be mismatched. some of which were found to be discarded as abo discrepancy, broken, or expired. other was still available in the system, while the rest of the mismatched units were issued. summary/conclusions: using the six sigma principle the study presents a successful assessment of blood group matching quality. as a . sigma metrics obtained from the first months, were shifted to a sigma metrics of . in the second months, after the addition of a double-checking step to the blood group matching of pooled plasma process. the implementation of these metrics in our laboratory quality management has been shown to be very beneficial. in which six-sigma metrics were able to clarify the reduction in blood group matching errors. although six-sigma benefits in major quality improvements and helps to reach an error free laboratory services, yet it presents a new challenge to laboratory practitioners. currently, the hemophilia a patients treated with factor viii concentrated as the first line of therapy but it is more expensive and the supply is not sufficient so for now they have not used factor viii concentrate as prophylaxis therapy. for some cases, hemophilia patients in indonesia depend on subsidy from the world federation of hemophilia. the first handicapped concentrated case is just for therapy not for prophylaxis. big blood centers in indonesia produce routinely fresh frozen plasma (ffp) and cryoprecipitate-anti hemophilic factor (ahf) as replacement therapy for hemophilia a, but its content and safety of factor viii from ml ffp need to be improved. nowadays, there is an available kit for producing minipool cryoprecipitate (mc) that has better safety and quality but it is available as liquid products, stored in very strict and specific temperature (À °c). prophylaxis therapy for hemophilia patients needs a stable product, easy to use and convenient treatment for patients. aims: to analyze the content and safety of f viii with minipool cryoprecipitate (mc) and lyophilized mc for home therapy. methods: we produced mc; mc as the control, mc were lyophilized with excipient and mc without excipient. we analyzed the number of factor viii, the safety, and stability. we count the erythrocyte, leukocyte and platelet residual in mc using flow cytometry. we also measure the ph, osmolality, solubility to learn its stability after storage at days at room temperature ( - °c) and blood bank refrigerator temperature ( - °c) at central blood transfusion services (cbts). results: we found the content f viii with excipient is higher ( . iu/ml) than without excipient ( . iu/ml) and the storage at blood bank refrigerator ( - °c) is better than at room temperature ( - °c) . in both group, there were no residual cells and bacterial found in mc. no significant difference in the ph, osmolality and solubility in both groups. summary/conclusions: the lyophilized mc with excipient stored at blood bank temperature ( - °c) is better than room temperature. this experiment will be continued to know its stability in extended storage time. background: peptic ulcer disease (pud) is a multifactorial and complex disease, and it affects a wide range of people in the world. however, a perfect therapy for pud has not yet been available at present. therefore, we provided a novel therapeutic approach for pud patients and observed its effect in this study. aims: we provided a novel therapeutic approach for pud patients and observed its effect in this study. methods: in this randomized controlled trial, pud patients residing in chongqing were enrolled from to . they were randomly assigned to two groups: (a) a control group used only rabeprazole, and (b) a platelet-rich plasma (prp) group that received a combined therapy of autologous platelet-rich plasma (aprp) and rabeprazole. the aggregation rate of aprp was measured via aggregation remote analyzer module. the therapeutic effect was assessed via the ulcer size and the symptom score. all data were recorded and analyzed statistically using spss. results: a total of patients were included ( patients as control group) and ( patients as prp group) in the analysis. we found that the aggregation rate of aprp is not affected in ph . after treatment with pepsin. our results showed that there were no significant differences between the prp group and control group before the treatment, and there was also no significant difference in healing time between the two groups in different variables. however, regression analysis revealed that the healing time was . d less in the prp group than in the control group, and the patients with higher symptom scores in the initial examination need more time to heal in treatment. summary/conclusions: this study showed an encouraging preliminary result that aprp has a positive result in the peptic ulcer patients, and it seems to be a better choice for refractory pud patients. despite the further follow-up studies are needed to determine the duration of efficacy of aprp, the approach will be helpful for improving the pud treatment in clinical. background: the croatian institute of transfusion medicine (citm) collects, produces and distributes blood components in an area of . million habitants. annually, it collects about , whole blood and , apheresis donations. platelet concentrates (pcs) are more inclined to bacterial contamination due to storage conditions that favor bacterial replication. the citm decided to evaluate the mirasol pathogen reduction technology (prt) system as it offers the possibility to work with a non-toxic, non-mutagenic compound that upon uv illumination induce nucleic acid damage, reducing the risk of septic transfusion. aims: the study objective was to evaluate quality of pcs treated with the mirasol prt system for platelets and stored in tpas+ for days at °c on a platelet shaker. methods: pcs were produced according to the citm's s.o.p., either through pooling of bc with tpas+, "wbd", or through apheresis collection using two devices: the fresenius amicus, "ad" and haemonetics mcs+ system, "mcd". pcs were stored in % plasma and % pas and mcd were subsequently evaluated also in % of plasma and % pas. identical pcs were produced with a pool-split protocol to be prt-treated or serve as untreated control. pcs were treated with the mirasol system according to manufacturer's instructions. qc parameters, such as yield, ph and swirl were measured at days , and . bacteria sterility test was performed at day for a sample of all treated platelets. protein content of pcs produced routinely at the citm was determined to assess accuracy of plasma carry-over calculations for all processed pcs. results: mirasol-treated wbd (n = ) and ad pcs (n = ) stored in % plasma showed at day an average ph ≥ . ; swirl ≥ . and yield = . . their untreated counterparts showed average values for ph ≥ : , swirl ≥ . and yield . - . . mcd stored in % plasma (n = ) that underwent prt showed at day average values for ph = . , swirl = . and yield = . . control mcd showed average values for ph = . , swirl = . and yield = . . mcd stored in % plasma (n = ) that underwent prt showed average values for ph = . ., swirl = and yield = . . their untreated counterparts had average ph = . , swirl = . and yield = . . total protein content in pcs derived from wbd (n = ), ad (n = ) and mcd (n = ) was g/l, g/l and g/l, respectively. while the coefficient of variation of wbd and ad ranged from % to %, plasma products respectively, the one of mcd reached %. all prt-pcs were negative for bacterial growth at day . summary/conclusions: mirasol treated wbd and ad produced according to citm current s.o.p. were quite similar to untreated controls at expiry, on day and passed the requirements of the eu guidelines ( th edition). quality of mcd units met eu criteria at day ; swirl decreased significantly at day which might be explained by the variability in plasma content of mcs+ -derived platelets, challenging the accurate calculation of illumination index for the mirasol treatment. all mirasol treated pcs showed minimal platelet loss at the end of storage. as the implementation of pr had to be cost-neutral it could only be implemented for~ % of the annual produced buffy coat platelet concentrates (bcp) (~ . bcp/year) and required a change in the bcp production method. the primary aim of the implementation was to offer increased blood safety to our most vulnerable patients. the secondary aim was to ensure that we built-up enough routine experience with pr to enable us to quickly ramp-up the production of pr-bcp to % if there were an outbreak of an emergent pathogen in the madrid region. aims: to verify if we could produce~ % pr-bcp without increasing the overall production cost (opc) for bcp. also evaluate the impact of pr on overall scrap rates of bcp, outdate rates and usage of other safety measures. methods: we compared opc for bcp between the pre-pr period ( ) . this cost was offset by substituting a semi-automated production method for bcp, which was used in to produce . % of bcp-units. a manual double dose buffy coat production method (dd-bcp) in combination with pr enabled us to reduce the bcp-disposables cost by . %. despite the moves from a semi-automated to a manual production method the overall scrap rates during production decreased in by . %. the extension of max. storage time from to days for % of the bcp-units that were pr resulted in decreasing our overall outdating rates by % (versus ). this reduction in outdating rates reduced our opc in by . %. in we gamma-irradiated . % fewer bcp-units, but this had only a minimal impact on the opc. summary/conclusions: results of this study confirmed that we reached our initial objectives of producing~ % pr-bcp without increasing the overall production cost (opc) of bcp. it enabled us to offer increased blood safety to the most vulnerable patients. we built-up enough routine experience with pr so we could quickly rampup the production of pr-bcp to % if there were an outbreak of an emergent pathogen in the madrid region. background: irradiation of red cell units is undertaken to prevent transfusion-associated-graft-versus-host-disease (ta-gvhd) in immuno-compromised patients. while irradiators using radioactive c-ray sources are primarily found in blood establishments, they require regular recalibration and supplementary safety measures. xirradiation has been shown to have similar biological effectiveness to c-irradiation and does not require a radioactive source. there is international interest in moving away from gamma sources to reduce vulnerability to terrorism. although damaging, impacts of irradiation on red cells are well recognised. only a limited number of studies have compared red cell component quality following cand x-irradiation for both standard volume red cell concentrates (rcc) and neonatal red cell splits (rcs). aims: to compare the in vitro quality of rcc and rcs when subjected to cor xirradiation on day of storage then stored for a further days. rcs were also irradiated on day of storage as that is most common practice in nhs blood and transplant (nhsbt). methods: four rcc were pooled and split into arms on day of storage, with units in each arm. all units received an irradiation dose of . - . gy. two arms remained as standard volume rcc and were either cor x-irradiated on day of storage. the other two arms were both split into rcs on day of storage before being irradiated on day (early arm) or day (late arm) of storage. for each replicate in these arms, splits were c-irradiated and splits x-irradiated. all arms were tested a day prior to irradiation and , and days post-irradiation for red cell quality parameters: haemolysis, intracellular atp and , dpg, supernatant potassium, glucose and lactate, ph and red cell microvesicle release. the rcc arms were sampled over storage; while for the rcs arms, split was tested on each testing day post-irradiation. a -way anova was used to detect statistical differences over storage between cand x-irradiation for the same components. results: all components produced were within nhsbt specification for volume, haemoglobin and haematocrit. there were no significant differences in red cell in vitro quality parameters studied over storage between cand x-irradiated units, for standard volume arms or neonatal arms and whether rcs were irradiated early or late in storage. moreover, all arms were within haemolysis specification for the end of storage (> % of units with < . % haemolysis) and % of units had atp levels above the recommended minimum for acceptable post-transfusion survival ( . lmol/ghb). both haemolysis and potassium levels at the end of storage for the standard c-irradiated rcc were comparable to our laboratory's historic data for the same component. summary/conclusions: in summary, the storage quality of rcc and rcs post-xirradiation did not differ from c-irradiation in this study, providing reassurance that either method could be used in routine manufacturing. a pajares herraiz , c coello de portugal , m morales , f solano , c perez parrillas , a rodriguez hidalgo , t diaz rueda and m flores direccion, regional transfusion center toledo-guadalajara transfusion service, toledo hospital complex, toledo transfusion service, general university hospital of guadalajara, guadalajara transfusion service, hospital nuestra señora del prado de talavera de la reina, talavera regional transfusion center, regional transfusion center toledo-guadalajara, toledo, spain background: the regional transfusion center of toledo-guadalajara (rtc) manages the collection, processing and distribution of blood components for the hemotherapy area of castilla la mancha (spain) that serves general hospitals (hospital complex of toledo (hct), university general hospital of guadalajara (ughg) and hospital nuestra señora del prado de talavera (nspt)) and the needs of , inhabitants. by also managing the hct transfusion service, it facilitates the handling of stocks. since , rtc has initiated pathogen inactivation (pi) for a part of its platelet components(pc) with the intercept blood system (cerus) using a photochemical treatment with amotosalen and ultraviolet-a. this system allows the inactivation of a broad panel of pathogens and leukocytes, extending the shelf-life of the cp from to days. this affects the expiry and discards of this blood component, allows a better management of the inventory and has an influence on production costs. aims: the objective was to evaluate the influence of pi in the production of cp at rtc and the expiry in the hemotherapy area during the last years divided into four periods ( results: pc were predominantly obtained from whole blood collections with % of bc platelets/ % of apheresis platelets. % of the available bc were used in production for period a and % for periods b, c and d. after wastes of approximately . %, the distribution of pc was stable for the periods studied. pc were distributed for period a, pc for b, pc for c and pc for d. the % of pi platelets with -day shelf life available in the hospitals was limited to % during period a. it was then increased to . %, . % and % for periods b, c and d respectively. the percentage of wastes was stable at . - . % but the discards due to expiry went down from . % (period a) to stabilize at . % in periods b and c and . % in period d. in the general hospitals the expiry went down from % to . %(hct), . % to . % (ughg) and . % to . %(nspt) respectively. summary/conclusions: greater control of pc stocks through historical analysis and consumption projection, together with it tools and the use of pi pc with -day shelf life allowed reducing discards for expiry from . % to . % in the last period analyzed at rtc and the major hospitals of the hemotherapy area. this has a great value in cost-reduction and improves inventory management and the efficiency of the processes. background: blood centers are faced with many challenges including availability of concentrate platelets as well as ensuring highest quality of the product. overcoming the shortage of platelet apheresis by using pooled platelet derived from whole blood units separated using automated standardized system, which can assist blood banks to meet the increase demand in platelets. the pathogen inactivation (pi) technology can improve the quality of the product by mitigating the risk of transfusion-transmitted diseases (ttd) and residual white cells, resulting in minimizing non -hemolytic transfusion reactions. however, the pathogen inactivation treatment must not impact the platelet quality and functionality significantly, as well as the patient safety. aims: evaluate the quality of pooled platelets derived from whole blood (five interim platelet units), separated using reveos automated blood processing system (terumo bct), pooled in % donor plasma and pathogen inactivated by amotosalen/uva technology. methods: five interim platelet units (ipus) produced with reveos device (terumo bct) from single whole blood donations, were pooled with a platelet pooling set (terumo bct) and leucodepleted with a lrf-xl filter (haemonetics). thirty pools have been included in this study, the units were treated using a large volume cerus intercept processing set for platelets according to the manufacturer's instructions and stored until day . the swirling was determined by visual inspection. the volume and yield content were assessed preinactivation and after treatment by pathogen inactivation with a cell counter (dxh- , beckman coulter), rbc contamination was also measured preinactivation with a cell counter (beckman coulter), bacterial contamination was assessed by automated blood culture with a bact/ alert system (biomerieux). the ph of the platelet units was assessed with a phmeter (jenway), and residual amotosalen levels were assessed by an hplc assay. results: the impact of amotosalen/uva pathogen-inactivated pool platelet products quality were assessed. the pre and post-inactivation of the units showed a swirling score of - . the average volume per unit of the pre-inactivation was ml ( - ml) and post inactivation was ml ( - ml), with average volume loss during inactivation was ml ( - ml), corresponding to % ( - %). the average platelet yield per unit pre-inactivation was . ( . - . ) and post inactivation . ( . - . ) with an average platelet loss of % ( - %) . the average rbc contamination per unit ( . - . rbc/ml). the culture tests were negative, the average ph at day was . ( . - . ), average ph at day / was . ( . - . ). the average residual amotosalen concentration post treatment was . lm ( . - . lm). summary/conclusions: the quality of pathogen-inactivated pool platelets tested, met the criteria set by aabb guidelines. the volume and platelet loss were in acceptable range, in alignment with previously published data. a residual amotosalen concentration below lm is considered safe and acceptable by french and german authorities. the evaluated data support the reasonable assurance of quality and effectiveness of the device when used in accordance with indication for use. background: the implementation of a pathogen inactivation process (pi) allows the redesign of processes to obtaining safe blood components by reducing the need for additional testing for pathogens detection, minimizing the residual risks (such as the infectious window period for those pathogens that are detected as usual), eliminates the need for selective tests (eg cytomegalovirus serology test) and complements gamma irradiation given its ability to inactivate white blood cells. in addition, the routine implementation of pi reduces the incidence of bacterial infection in recipients of blood components and allows blood services to proactively protect the blood supply against future emerging infections. aims: to verify the functional integrity and viability of platelet concentrates after being inactivated of any pathogenic agent, to be used as safe and functional components for transfusions. methods: a total of independent platelet concentrates were studied. platelets are donated through a process called plateletpheresis according to the established norms, after the process, platelet concentrates were submitted to pi on the intercept blood system tm platform with uv-a illuminator; an immediate sampling of each donation of platelet concentrates was carried out taking a sample of ml pre-inactivation and another sample post-inactivation ( h after pi). the platelet viability of each sample was evaluated by demonstrating the cd p expression marker by flow cytometry. once processed, platelet concentrates were released as safe components for donation. compiled the experimental data of the platelet count with platelet activation marker with respect to the total platelet, a comparative, nonparametric test of wilcoxon was carried out between two measurements (pre vs post) and the platelet viability after pi was determined. results: a total of independent platelet concentrates were studied, where the average percentage of pre-inactivated platelets with expression of the cd p marker, was %, while the percentage of functional platelets post inactivation was %, this result only shows that the functionality of the platelets is not being altered after the inactivation process. the wilcoxon test confirms that there is no significant difference between platelet activity pre-and post-inactivation, with a % confidence level. summary/conclusions: the process of photochemical treatment with amotosalen hydrochloride and long-wavelength ultraviolet light (uva) applied to platelet concentrates provides functional products without alterations in platelet function to be transfused. background: treatment of platelet concentrates (pcs) with pathogen reduction technologies is widely implemented in blood establishments to reduce the risk of bacterial contamination and to face the presence of new emerging agents in blood components. aims: the reduction of antioxidant power (aop) could be a quality control test to prove the complete viro-inactivation treatment. this evaluation has the goal to study the feasibility of the method from "abonnenc et al., transfusion, " in another blood service, assessing the aop of platelet units treated by intercept technology. methods: the aop is expressed in edel value, one edel being equivalent to lmol/l ascorbic acid. repeatability, intermediate precision and accuracy were determined. linearity was evaluated using the linear regression and the calculation of pearson's coefficient (r²). limit of quantification (loq) was determined by measuring aop using nacl samples to define the background. roc curves were used to determine a threshold to discriminate pcs before and after treatment. a distinction was realized between men and women and between apheresis (a) pc and buffy coats (bc) pcs. a one-year evaluation was assessed on pcs before and after treatment on the routine production. results: the coefficient of variation for the repeatability was less than %. for the intermediate precision, the coefficient of variation was less than %, but for the pcs after treatment, this result rose up to %. the r² value for the linearity was . %. the detection limit corresponded to a result of edel and the loq (equal to xsd) is edel. concerning roc curves, the men apcs threshold was . edel compared to women apcs with . edel. the threshold for bcpc was edel. all of these results had % of specificity. below this threshold, intercept treatment was considered to be executed. about the one-year experience on routine pcs production, apcs ( women and men) and bcpcs were tested. all of the bcpcs and women apcs were under the threshold after treatment. concerning men apcs, . % of the pcs after treatment were not under the threshold. summary/conclusions: the device validation was satisfied. for the one-year evaluation and concerning men group apcs, the threshold found by abonnenc et al. was edel. our study showed a threshold with % specificity and % sensitivity at . edel which is much lower. specificity was favored compared to sensitivity but the analysis should be revised to adapt the threshold to get higher sensitivity. this can lead to reduce the non-conformity and allows measuring the aop only after treatment. for women, our threshold was found at . edel compared to . edel for abonnenc et al. concerning sex in apcs, results were statistically lower in women group than men group before and after treatment. and for bcpcs, the two populations (before and after treatment) were very distinguishable and our threshold ( edel) was lower than abonnenc threshold which was at . edel. in conclusion, edel threshold enables the segregation and depends on the preparation process adapted in each blood service. aims: this study has the goal of measuring antioxidant power (aop) level in plasma units treated by mb technology. the aim is to use such a test as a quality control assay for documenting the execution of pathogen inactivation treatments during the preparation of plasma units. methods: aop measurements were performed using a potentiostat electrochemical analyzer. a -ll volume of sample is deposited over the electrodes on a single-use microship. the aop is expressed in edel value, one edel being equivalent to lmol/l ascorbic acid and reflects the redox status of the plasma units. different protocols were established to understand the role of mb, the illumination and the filtration on the aop variation measure: ) complete treatment, ) plasmas with mb without illumination, ) plasmas without mb with illumination and ) plasmas without mb without illumination. ten dosages on men donor samples, except for protocol where n = , were realized during the viro-inactivation process, t corresponds to a dosage of plasmas before treatment, t the plasma after the mb dry tablet passage, t is the time after illumination and t corresponds to the final product (after filtration). results: in each protocol with mb, an increase was observed after addition of mb before illumination. after illumination, the edel values decreased for about less than %, which was expected because of the degradation of mb in its photoproducts during the illumination. in the series and , the illumination seemed to have an effect by itself, with or without mb because the aop increased. the final filtration has the goal to eliminate the residual mb and its photoproducts. after this step, the aop values fell down. the series was a confirmation of the efficacy of the filter to remove the mb as shown by the decreased aop in t ( ae edel at t and ae edel at t ). however, in the absence of mb (series and ), the results at t and t were not statistically different. summary/conclusions: the filtration decreases the aop rate, except when there was no mb. the results of non-complete viro-inactivation treatment allow concluding that the measure of aop rate may not indicate that the treatment was completed or not since significant differences before and after treatments were found in the non-complete treatment series. vox sanguinis ( ) background: the intercept blood system (ibs), a photochemical treatment with amotosalen and uva, is used to inactivate pathogens and leukocytes in plasma. the intercept tm plasma processing set (cerus bv, netherlands) was modified to incorporate plastic containers in non-pvc materials sourced from alternate suppliers and connecting parts and accessories in non-dehp pvc formulations, making the system dehp-free. the final storage container was modified with a higher contact surface with plasma to limit the thawing time. proportion of units with a fibrinogen concentration ≥ . g/l was % (> % required). mean recovery fviii fibrinogen after ibs treatment and frozen storage were % and %, respectively. residual platelets were < /l, leucocytes < /l and red blood cells < /l. all units had a protein content > g/l. residual amotosalen was below lm in all post-cad samples. the concentration of tat complexes was slightly reduced after treatment and frozen storage. concentrations of c a and c a were significantly reduced with the cad treatment. the plasma thawing time in a water bath at °c was consistently short ( - min). summary/conclusions: pathogen inactivated plasma units (ffp-a-ibs and ffp-wb-ibs) prepared with dehp free intercept processing sets retained in vitro characteristics which meet the quality standards for therapeutic plasma. the process did not activate coagulation or complement. reducing ffp thawing time from routine - to - min is an important benefit for emergency use. background: plasma coagulation factor concentrations usually differ for individual donors, therefore pooling of whole-blood derived plasma units moderates high or low coagulation factor concentrations and ensures transfusion of more standardized blood components. moreover, pooling contributes to dilution of reactive antibodies and may reduce the risk of non-hemolytic transfusion reactions and trali. additionally pathogen inactivation reduces the risk of transfusion-transmitted infections, and non-hemolytic transfusion reactions as well as gvhd through inactivation of residual lymphocytes. aims: assessment of the impact of plasma pooling and pathogen inactivation on the standardization of blood components and plasma quality. methods: the study included experiments. for each experiment male-donor, abo-compatible whole-blood derived plasma units (≥ ml) were collected from different donors and pooled using the donopack optipool plasma pooling set (cerus europe b.v.). each of the -unit pools were split into equal minipools which were subsequently treated with the in intercept blood system (cerus europe b.v.). then, each minipool was split into (≥ ml) therapeutic units. samples were collected before and after pooling as well as after inactivation to assess the coagulation factor content (fviii, fix, fibrinogen, vwf antigen using elisa) and coagulation time (aptt, pt). the study-analysis included samples from five pools from single plasma units respectively ( background: biotin (bio) is an alternative to radioactive red blood cell (rbc) tracers which allows one to concurrently track in vivo multiple cell populations labeled at different bio densities. in american clinical trials, multi-labeled biorbc have been transfused in man to assess their survival (mock et al, transfusion, ) . in these studies, the different biorbc populations were monitored by ex vivo flow cytometry analysis using streptavidin. so far, the biotinylation reagents biosulfonhs was not complying with good manufacturing practices (gmp). moreover biorbc, with bio ≥ lg/ml, have induced immunization of the recipient, in rare cases (schmidt et al, transfusion, ) . this represents an obstacle regarding the regulatory european authorities. aims: the aim of this study is to describe a procedure of biotinylation of rbc intended for clinical trials while refining the levels of bio ≤ lg/ml. methods: sterile status is met throughout the process. rbc are taken from standard rbc concentrates and treated with biosulfonhs of gmp-grade ( to lg/ml) recently commercialized. washing buffer is of injectable-grade. biotinylation efficacy is controlled by flow cytometry with streptavidin conjugated to different fluorochromes: phycoerythrin (pe) or brilliant violet (bv ). results: labeling with biosulfonhs of gmp-grade or non gmp-grade is comparable and populations of rbc could be easily distinguished between themselves and from unlabeled blood cells. biosulfonhs (lg/ml): (mfi . ), (gmp mfi ; non gmp mfi . ), (gmp mfi ; non gmp mfi ), (gmp mfi ; non gmp mfi ). streptavidin-bv brighter than streptavidin-pe is a promising tool because it amplifies by . the signal of fluorescence and allows a good differentiation of the populations of rbc treated with only , , and lg/ml biosulfonhs. summary/conclusions: this preliminary study explores the feasibility of multilabeled biorbc production for clinical trials. the benefits of this approach are to overcome the need for non-radioactive tracers, to follow simultaneously various populations of rbc and consequently to limit the number of volunteers, and to reduce the risk of immunization using bio ≤ lg/ml. background: rejuvenation is aiming to revert ageing-related disease development. heterochronic parabiosis studies revealed eotaxin in young and old murine blood as a regulator of brain aging and neurogenesis. umbilical cord blood (ucb)-borne factors including tissue inhibitor of metalloproteinases (timp ) and neonatal immune cells also contributed to rejuvenation in animal models. human platelet lysate (hpl) is commonly used by us and others for highly efficient cell propagation in vitro (burnouf et al., biomaterials, ) . published data indicate only limited differences between adult and ucb-derived hpl, partly questioning enigmatic rejuvenation effects. aims: to verify candidate regenerative factors in neonatal blood products we compared protein contents of neonatal and adult plasma and platelets, respectively. methods: heparinized ucb samples (n = ) were centrifuged within h to collect neonatal platelet rich plasma. aliquots from apheresis platelet concentrates (n = ) were used as adult counterpart. platelet concentration was adjusted to - / l. plasma supernatants and platelets were obtained by centrifugation and platelet pellets were re-suspended in saline. after two freeze/thaw cycles at À °c/ °c for platelet lysis (npl; apl) the platelet fragments were removed by centrifugation. the protein content was analyzed with a proteome profiler tm array. nine samples of each group were pooled to avoid individual donor variations. a threshold of , au spot density was defined as cut-off. data were analyzed by graphpad prism using two-way anova. results: semi-quantitative evaluation of analytes per array revealed significant differences. in plasma samples and platelets and analytes were detected above cut-off, respectively. in neonatal plasma we found more highly prevalent proteins (> , au spot density) compared to adult plasma ( / vs. / ). thirteen proteins were significantly elevated in neonatal plasma including growth/differentiation factor (gdf ), platelet derived growth factor aa (pdgf-aa) and serpin e (p < . ). more highly prevalent proteins were detected in npl ( / ) compared to apl ( / ), and proteins were significantly elevated including vascular cell adhesion molecule- (vcam- ), platelet factor (pf /cxcl ), epidermal growth factor and lipocalin- (p < . ). in adult samples only proteins were significantly higher in plasma and three proteins in apl compared to the neonatal groups (p < . to p < . ). summary/conclusions: we detected significant differences in regenerative growth factor and cytokine contents of neonatal and adult plasma and platelet samples, respectively. additional experiments are underway to further characterize their impact in distinct functional readouts. background: the production and storage conditions of platelet (pl) products intended for transfusion are constantly evolving and need sometimes in vivo evaluations in clinical trials to ascertain whether the platelets have retained their ability to survive in the circulation. this requires that the transfused platelets can be distinguished from the recipient's circulating platelets. labeling of platelets with biotin (bio) affords to track in vivo and concurrently, multiple cell populations covered with various biotin densities as already described for red blood cells (mock, transfusion, ) . surprisingly, there is only one study describing the transfusion of human biopl (stohlawetz, transfusion, ) . so far, the biotinylation reagent bio-sulfonhs was not complying with good manufacturing practices (gmp), which represents an obstacle regarding the regulatory authorities. aims: the aims of this study are ) to describe a procedure to label injectable human platelets with densities of biotin, ) to evaluate the impact of biotinylation on platelet functions, ) to track human biopl in the circulation of the mouse. methods: platelets are taken from standard platelets concentrates and treated with . and lg/ml biosulfonhs of gmp-grade, recently commercialized. main platelet functions are assessed in vitro. human biopl survival is evaluated in immunodeficient nsg-mice treated with liposome-clodronate to eliminate macrophages and to prevent rejection. circulating human biopl are detected ex vivo by flow cytometry with streptavidin phycoerythrin. results: using trap ( lm), p-selectin externalization reveals a normal capacity of secretion for all biopl. gpiba and gpiibiiia expression is not affected by the biotinylation process. biopl have the ability to aggregate: using arachidonic acid ( mm), amplitude of aggregation is . ae . % (bio ); . ae . % (bio . lg/ ml); . ae . % (bio lg/ml). using collagen ( . lg/ml), amplitude of aggregation is . ae . % (bio ); . ae . % (bio . lg/ml) . ae . % (bio lg/ml). the biopl populations could be easily distinguished between themselves and from unlabeled blood cells in the mouse circulation during more than h. after h, the mean fluorescence intensities are . ae . for unlabeled circulating mouse platelets, . ae . and . ae . for circulating human biopl covered respectively with . and lg/ml biotin. summary/conclusions: this labeling approach should be helpful to evaluate new platelet products in vivo and represents an alternative to radioactive tracers. it allows to follow simultaneously different platelet populations and consequently limits the number of volunteers in clinical trials. background: severe ocular surface diseases, dry eye syndrome, persistent and recurrent corneal epithelial defects and diabetic or neurotrophic keratopathy are mainly successfully cured by standard treatment protocols. however, not rarely does refractory to these usual treatments appear, especially with serious forms of disease. in military medical academy, autologous serum eye drops -auto seds and autologous platelet lysate -apl eye drops have been being applied in the treatment of ophthalmological patients in these categories, who were previously resistant to standard therapy. aims: to show the achieved results of therapeutic use of autologous blood products (auto seds and apl) in the treatment of ophthalmological patients who previously had not responded to conventional therapysingle center experience. methods: auto seds are prepared by taking autologous blood into tubes (bd vacutainer, cat, ml) and apl in tubes with anticoagulants (greiner bio-one, acd-a, ml). control on tti of every patient and sterility of every series has been conducted. before and after the treatment, subjective ocular discomfort (ocular surface disease index -osdi), objective parameters of the tear film (schirmer's test, rose bengal, tear breakup time -tbut) and measuring of epithelialization zone were analyzed. apl, obtained from platelet-rich plasma which had been frozen, unfrozen and diluted with nacl solution, up to %. auto seds were administered in the form of % eye drops. results: auto seds have been applied to ophthalmological patients ( men and women), previously resistant to standard therapy. in total treatments were performed (each lasted days). for successful curing, one or two treatments per patient, in average, were applied. apl has been used multiple times to one patient with sj€ ogren syndrome and severe multiple tropical corneal changes. all ophthalmological patients had subjective improvements (the average pre and post treatment osdi scores were . and . respectively). also, objective progress was present in % of all patients (p < . ). summary/conclusions: the use of auto seds and apl in the treatment of ophthalmological patients, previously resistant to standard therapy, is in constant increase, because of its simplicity and low expenses. apl has turned out to be better than auto seds for patients with severe trophic changes, because apl contains larger amounts of the nerve growth factor, tgf-b, vegf and platelet derived growth factor. however, a larger number of clinical cases is needed for future conclusions. background: whole blood (wb) has recently regained favor in treatment of massively bleeding patients in military and civilian settings. platelets (plts) are a vital component in clot formation. as a component of wb, it is critical that they maintain functionality throughout storage. red blood cells (rbcs) stored in hypoxic/ hypocapnic conditions preserve high level of , -dpg while reducing storage lesions stemming from oxidative stress. , on the other hand, effects of steady hypoxia (pco ~ - mmhg) on plts contained in leukoreduced wb is poorly characterized. aims: examine the effects of hypoxic conditions on plt function and microvesicle (mv) formation in wb stored hypoxically (h) and conventionally (c) for -week storage at - °c. methods: units of wb were collected at mayo clinic rochester blood donor center from normal healthy volunteers into ml cp d. wb was leukoreduced using plt-sparing filter (terumo wb-s) then split into control (c) and hypoxic (h). h-wb was processed by the oxygen-reduction bag (hemanext, lexington ma) and unit was stored in o -free bag. ml of wb were collected from each unit at day , weeks , , . plt counts, agonists (thrombin receptor agonist peptide (trap), adenosine diphosphate (adp) and collagen stimulated platelets aggregation, nonactivated and agonists activated plt surface expression of phosphatidylserine (ps, annexin-v binding), p-selectin, fibrinogen receptor (pac- binding), and microvesicles (mv) were measured by coulter counter and digital flow cytometer. paired student t-tests were used to analyzed differences in degradation rates; significance: p < . . results: h-plt counts declined to~ % by the o -reduction process, while similar decline was observed after week in c, and thereafter remained steady. plt activation (ps) increased over time (h >> c after processing; c increasing more rapidly during storage). p-selectin increased over time (h < c), while pac- showed large increase after week, then remained steady (h << c). plt activation by trap or adp declined modestly over weeks (~ %) while h-plt showed additional~ % reduction for all time points. collagen activation for c-plt increased after week ( %) and gradually increased to % after weeks (~ % reduction with h compared to c). plt-derived mv (cd and cd /annexin v) increased~ -fold over storage time; day mv levers were significantly higher for h, but subsequent increase rates were similar or lower. total number of plt-derived mv (cd a) in wb supernatant increased -fold after weeks for c, while h suppressed increase to -fold. (majority of the trends described above showed significant differences between h and c.) summary/conclusions: plts were activated over -week period when stored at - °c in leukoreduced wb, accompanied by a modest loss of agonist-induced activation. oxygen reduction treatment initially activated h-plts, while subsequent increase in activation rates were suppressed compared to c-plts. wb plts retained activatability, and hypoxic condition showed only modest further reduction on the activatability. hypoxic wb may provide higher quality wb for trauma patients if the levels of initial plt activation can improved during oxygen reduction procedure. methods: after informed consent, eligible patients were randomized to either first receive autologous followed by allogeneic seds or first receive allogeneic followed by autologous seds. each sed treatment phase was one month, separated by one month of patient's standard treatment (wash out period) between sed treatment phases. the patients each donated ml whole blood from which the autologous seds were prepared. allogeneic seds were prepared from blood from never-transfused male donors with blood group ab. all serum was diluted : by adding saline, and aliquoted in an eye drop dispensing system (meise, schalksm€ uhle, germany). at each visit, the osdi was determined using a validated questionnaire, with higher scores reflecting poorer outcomes. the results were analyzed intention-to-treat, and a random effects linear mixed model for cross-over design was used. results: in total, patients were enrolled, of whom were excluded because they failed the autologous blood donation. background: the following blood components for non-transfusional use (bcntu) are produced in our transfusional center (tc): ) allogeneic platelet gel (pg), derived from buffy-coats (bc) and human cord blood platelet gel (cbpg); ) autologous serum eye drops (sed). the creation of both types of platelet gel started in but only in we confirmed the process for daily production: these blood components are used to treat pediatric patients with epidermolysis bullosa. the sed, produced from , is dedicated to treat patients with dry eye syndrome. aims: production and storage bcntu. methods: the whole process production of bcntu is traced on the transfusional informatic system (emonet-insielmercato), under the same conditions of another blood transfusional components. the process takes place in closed circuit using the laminar flow hood. ) pg production starts from the bc resuspended in plasma that are not used for daily platelet concentrates, instead the cbpg is produced using cord blood units that are not used for hematopoietic transplant. both have a platelet concentration between - /ll and negative blood cultures, required by the italian law; the units are frozen at À °c and last -year. pg and cbpg must be activated with calcium gluconate or batroxobin to be used. ) the ophthalmologist's patients, with dry eye syndrome, donate ml of autologous blood; the serum is separated and after the dilution with a balanced saline solution ( %) are divided in boxes containing single-dose vials each: they are stored at À °c and they last one year. negative blood culture was evaluated. results : background: candida albicans is the most common pathogen detected in fungal infections. aims: in this study, we aimed to evaluate the in vitro antifungal activity of volunteerderived platelet rich plasma (prp) against c. albicans atcc strain and the possible effects of certain chemokines, kinocidins that might play a role in this activity. methods: prp from nine volunteers were derived by using magellan prp â kit. % calcium gluconate was used to obtain autologous thrombin. c. albicans isolates with a final yeast concentration of cfu/ml and cfu/ml were inoculated on sabouraud dextrose agar at the st , nd , th , th and th hours of incubation to reveal the antifungal activity of autologous thrombin-activated prp. the colonies were counted after - h of incubation at °c. chemokines and kinocidins (platelet factor- , interleukin- and thymosin-b ) were also measured simultaneously by elisa method. results: compared with the pbs-control group, the prp- group showed that the antifungal activity was still going on at the th hour. the difference in colony production between the two groups at th hour was statistically significant (p < . ). it was observed that the antifungal activity continued at the th hour, decreased at the th hour in the group prp- group. although the same amount of prp was used and the same amount of chemokine and kinocidins were released in both groups, the concentration of c. albicans was considered to be important in the detection of more effective prp- group. although there was an increase in il- levels by hours in the two prp groups by elisa method, no antifungal effect was detected against c. albicans. it was observed that decrease in tmsb values results from the antifungal activity on the advancing hours in the prp groups. whereas pf- did not act an antifungal activity on prp- and prp- . summary/conclusions: even in our study group where the highest platelet counts were obtained at the lowest concentration, c. albicans reproduction could not completely eliminated as mentioned in the literature. repeated doses of prp applications, such as drugs used in patients, may have longer duration of action and even complete repression of reproductive outcomes. background: generally, blood is available in developed countries for transfusion. sometimes, transfused or previously pregnant patients form alloantibodies to red cell antigens and rarely, to antigens of high prevalence. this case focuses on a twoyear-old girl, of pakistani descent, diagnosed with neuroblastoma stage iv with anti-in b and -e. although the publications indicate that % of the pakistani, indian or iranian populations are in(b-), it was discovered that this blood type is exceedingly rare. an international search was required to ensure blood product availability for chemotherapy and autologous hematopoietic progenitor cell transplants aims: illustrate the response of the public to a powerful story of a child needing rare blood for treatment and international collaboration for provision of very rare units. methods case report: a two-year-old patient's sample was referred for antibody identification. the patient had received four transfusions ( ml of red cells) in the preceding -day period. hgb level fluctuations were consistent with decreased transfused red cell survival. following the last transfusion of ml, the hemoglobin decreased from . to . . anti-in b , and a ficin-only reactive anti-e was identified in the serum and anti-in b in the eluate. the monocyte monolayer assay predicted the anti-in b to be clinically significant ( % reactivity). transfusion of antigen neg units once obtained, resulted in a stable transfusion response. although it was expected that in(b-) blood would be more easily sourced, only two donors in the usa were in (b-) e-. as - units of blood were requested for the post-transplant period, a national and international search was initiated, as was a robust media appeal to donors resulting in many donors for an intense domestic screening effort in the usa. the search of the who international rare donor panel by the international blood group reference laboratory revealed three known in(b-) e-donors; two british and one australian. they were contacted, recruited, collected and shipped to the usa with the work of the american rare donor program (ardp) staff and the isbt working party on rare donors (isbt wprd) members in each of the countries. results: the intense media coverage of oneblood (the florida blood center collaborating on treatment with the hospital) included online news outlets (youtube, facebook) resulted in over , responses from national and international potential donors to be tested for in b . isbt wprd members were sent the web information of potential donors identified in their countries by the ardp. over , samples from blood centers and associated laboratories tested with anti-in b by oneblood. two new in(b-) donors were discovered ( . %); but both typed e+, thus were not a match for the child. summary/conclusions: this intense media coverage and the overwhelming donor response was unprecedented in our experience. the coordination and cooperation among the numerous blood centers reflect the deep dedication of the blood banking community to the well-being of special patients in need. this case illustrates the response potential that a powerful story and a medical appeal for exquisitely rare blood utilizing social media and other online news outlets can generate. background: blood platelet units are generally stored in blood banks for - days, afterwards they are discarded. prepared infusible platelet membrane (ipm) from fresh or outdated human platelets correct the prolonged bleeding times in thrombocytopenic animals such as rabbits. infusible platelet membrane (ipm) as a platelet substitute may be the most feasible approach to reach the target market. our previous experiments have shown that ipm has a hemostatic efficacy to shorten bleeding time without any adverse effects in rabbits. aims: abnormal toxicity is the european pharmacopoeia standard for assessment of biological products which the test material is administered to the mice. in this study, abnormal toxicity of ipm was evaluated in experimental animal model such as mice to assure the safety of ipm without any evidence of serious toxicity. methods: in this experimental study, infusible platelet membrane (ipm) was prepared from outdated platelet concentrates. platelet concentrates were pooled, disrupted by freeze-thaw procedure, pasteurized for h to inactivate the possible viral or bacterial contaminants with a sodium caprylate stabilizer, formulated by sucrose and human serum albumin and finally lyophilized. at first, the test for sterility is carried out under aseptic conditions for ipm vials and then we injected . ml of ipm ( mg/kg) intravenously between to seconds into each health mice, weighing - grams. these tests were performed according to eu pharmacopeia monographs. results: in the sterility test no evidence of microbial growth in our product is found. the abnormal toxicity test will be passed if none of animals die during h after injection. if more than one animal dies, the preparation fails the test. if one of the animals just dies, the test is repeated. in our experiment all five mice were alive after h of ipm injection. summary/conclusions: in this research the results showed that ipm as a platelet substitute is free of abnormal toxicity with adequate safety and it may be used in human clinical trial studies as a feasible approach to develop a platelet substitute in the future. however, further studies are required to confirm the different aspects of its safety as well. the success of such investigations may affect patients' care in transfusion medicine in the future. a substantial number of infants, especially premature infants, are unable to receive adequate amounts of their mothers' milk for a variety of reasons. the world health organization recommends that infants, especially preterm and ill infants are fed with quality-controlled donor milk if they cannot be fed with their own mother s milk. due to the possible transmission of the human immunodeficiency virus many human milk banks closed in the s, therefore the availability of donor milk has decreased. aims: we analyzed the processing of donor milk and the required laboratory tests to establish a human milk bank within our blood donation service in cooperation with the department of neonatology at the frankfurt university hospital. methods: based on the recommendations for promoting human milk banks in germany, austria, and switzerland (efcni) we evaluated the manufacturing steps and the quality controls require to establish a human milk bank. background: for patients suffering from severe ocular surface disorders treatment with blood derived serum eye drops (sed) is a highly effective therapy. autologous sed, prepared from the patient's own blood, is used preferably. for this approach we have more than years of experience. if auto-sed cannot be manufactured due to medical reasons allogeneic sed present an alternative. since years, the allogeneic approach is well established in our center. aims: retrospectively evaluation of our experience with allo-sed. methods: in germany manufacturing of allo-sed is only possible as an "individual healing attempt". for each patient experienced regular ab -identical male donors without blood borne disease, who never received blood products and not taking any kind of medication are selected. additionally, donors must pass a questionnaire excluding any form of dry eye syndrome. allo-sed are manufactured directed for each individual patient according to the process for auto-sed in a closed system. patient files of our serum eye drops donors were screened for patients receiving an allogeneic treatment. data concerning indication for allo-sed, contraindication for phlebotomy, problems with donor selection and manufacturing, as well as serological and microbiological testing results were obtained. clinical results were evaluated © the authors vox sanguinis © international society of blood transfusion vox sanguinis ( ) (suppl. ), - by ocular surface disease index (osdi) and patient's questionnaire, asking for subjective benefit, symptom reduction, possible side effects, consumption and comparison with artificial eye drops or, if applicable, with auto-sed. furthermore patients are undergoing regular ophthalmologic examination within a special consultation for dry eye syndrome at our hospital. results: patients were identified receiving allogeneic sed, patients had been treated autologous previously. in total, allogeneic sed have been produced times since june . indications were ocular gvhd (n = . %), neurotrophic keratopathy (n = . %), mucous membrane pemphigoid (n = . %), sj€ ogren syndrome (n = . %) and secondary keratoconjunctivitis sicca by virtue of chemotherapy, meige syndrome, rosacea, morbus bruton (n = . %). contraindications for autologous donation were underlying disease (n = . %), poor venous access (n = . %), low haemoglobin (n = . %), low body weight (n = . %), very young age (n = . %), circulatory disturbances (n = . %) and lack of response to auto-sed (n = . %). some patients presented more than one contraindication. manufacturing problems were: lipemic donor plasma (n = . %), high donor haemoglobin (n = . %) and unspecific positive serological findings (anti-hbs n = . %). microbiological testing was sterile every time. as side effects one case of allergic reaction, suspected as serum protein allergy, appeared. clinical outcome can be considered equivalent to ased. subjectively, all patients benefited from the therapy and reported an alleviation of their symptoms. for some indications (highly active gvhd) allo-sed might even be the better option. summary/conclusions: considering our previous experience, allo-sed seem to be a safe and equally effective alternative to auto-sed for patients unable to donate blood. in case of urgent indication, timely supply can sometimes be difficult. to overcome this disadvantage licensing allo-sed as a new blood product with the possibility of production and storage in advance would be a desirable goal. in addition supply would become even safer by preparing allo-sed according to a quarantine principle like ffp. abstract withdrawn. background: vernal keratoconjunctivitis is a chronic, recurrent bilateral inflammation of the outer ocular layer. mostly affected are children and young people and the condition is more common in boys. the disease presents with eye pruritus (itching eye), photophobia (sensitivity to bright light), excessive tearing and foreign eye syndrome. severe cases manifest with diffusion of overgrown papillae usually of the upper eyelid, bursting of the connective tissue barriers and appearance of giant papillae that press on the cornea. corneal ulceration is a severe complication of vernal keratoconjunctivitis that may induce scarring, corneal neovascularization and occasionally perforation. treatment of keratoconjunctivitis mainly relies on steroids, mast cell stabilizers, antihistamines, immunosuppressive drugs (cyclosporine), artificial tears, contact lensdressing, cryotherapy and surgical papillae removal. we present the case of a year-old girl with corneal ulceration who was applied artificial tears after traditional methods of treatment proved unsuccessful. aims: the aim was to share our experience on artificial tears therapy applied in ophthalmic disorders. methods: autologous blood ( ml) was collected into disposable, sterile transfer bags used for routine blood component preparation (no anticoagulant) and incubated for h at °c. the clot was then removed by centrifugation and the serum containing erythrocytes was press extracted. centrifugation was applied again to obtain serum free of cellular components. the serum was then divided into . ml segments (capsules)and the artificial tears applied to the left eye daily. results: ulcer healing was reported after weeks of therapy with artificial tears. the dosage was reduced to daily. no recurrence of corneal ulceration was observed after subsequent weeks. summary/conclusions: artificial tears are a safe and effective therapy for ophthalmic disorders in children. background: arv non-disclosure among hiv-positive donors who tested hiv antibody (ab) positive but rna negative (ab+/rna-), so-called false elite controllers, was previously described by our group in south africa, with > % of ab+/rnadonations since testing arv positive. the extent of undisclosed arv use at time of donation represents a significant risk to blood safety in a country with a growing treated hiv population. aims: to establish the prevalence of arv non-disclosure among four subgroups of hiv-positive donors in south africa along with demographic correlates of non-disclosure. methods: south african blood donors are screened by a self-administered questionnaire, which includes questions on current hiv status and arv use, followed by a semi-structured personal interview. specimens for hiv, hepatitis b and c testing are collected at time of donation. based on id-nat (procleix, grifols) and antibody (prism, abbott; western blot) testing, hiv-positive blood donations were classified as acute (ab-/rna+), recent (ab+/rna+, limiting antigen avidity [lag] odn ≤ . ), longstanding (ab+/rna+, lag odn > . ) and potential elite controller (ab+/rna-) cases. stored plasma from these donations were tested for four arv drugs using qualitative liquid chromatography-tandem mass spectrometry (detection limit . lg/ml). chi-square tests were used to assess associations of hiv case type, gender, ethnicity, age, donor type, and donor clinic (fixed, mobile) type with arv non-disclosure. results: during , donors tested hiv-positive of whom had samples available that were tested for arvs. the overall prevalence of undisclosed arv use was . % (n = ) with efavirenz most frequently detected ( ), followed by lopinavir ( ) and nevirapine ( ) . potential elite controller cases had the highest proportion of detectable arv ( / ; %) (p < . ) followed by longstanding ( / ; . %) and recent ( / ; . %) infections. none of acute hiv cases tested positive for arvs. there were no associations between arv use and gender or ethnicity. however, older ( to years) hiv-positive donors ( / ; . %) were significantly more likely to test positive for arv than younger ( to years) donors ( / ; . %) (p < . ). arv use was more frequent among first time ( / ; . %) than in lapsed ( / ; . %) or repeat ( / ; . %) donors (p < . ). donors at mobile clinics had significantly higher arv non-disclosure than donors at fixed sites ( . % vs . %; p = . ). summary/conclusions: the . % prevalence of undisclosed infection and arv use among hiv-positive south african blood donors is alarming. higher rates of nondisclosure among first-time donors was expected, but non-disclosure among repeat and lapsed donors suggests failure in donor education and assessment. the . % prevalence among concordant ab+/rna+ cases may suggest sub-optimal viral suppression. lack of detection of arvs in acute cases should be qualified because the samples were not tested for tenofovir, the most common drug used in pre-exposure prophylaxis. donor motivation for non-disclosure of known hiv infection and arv use needs further investigation, since early arv initiation or infection while on prep could lead to low ab and rna levels, failure to detect hiv-infected donations and transfusion-transmission of hiv. blood bank, rotary blood bank, new delhi, india background: voluntary blood donation ensures safe blood transfusion. careful blood donor selection is of importance to provide safe blood to patients, although new methodologies have also been adopted by blood centers for blood safety and to minimize risk of transmitting infections through blood transfusion. the quality and the availability of blood components depend on the willingness to donate and reliability of the information given by the donors about their own health, including risk behaviour. blood donor history questionnaire is designed to evaluate donor's history in accordance with the guidelines laid down by the fda. donors, once deferred by the blood bank, will be less motivated to return for donation if he is not counseled effectively. it is important to reduce the number of deferrals by good donor comprehension and the centre should have a mechanism to recall temporarily deferred donors aims: the aim of the study is to analyse donor history and test results of those who donated blood with past history of jaundice. based on their history which suggested the type of viral infection they had, these donors were accepted or deferred. data was collected from voluntary blood donors who were screened for blood donation in the year . methods: in this study, donor history was analysed with reference to history of jaundice. jaundice in donors after the age of yrs, history of surgery, blood transfusion, body tattoos and acupuncture treatment within past one year of donation, history of multiple sex partners and related history and intravenous drug abuse history was taken into consideration. donors who revealed past history of jaundice were asked in detail about their illness and recovery. blood was donated by donors from whom the history of jaundice was elicited and it was understood that the type of virus which caused jaundice was not hepatitis b or c. those who could not give the correct history or were not sure of the cause of hepatitis, those individuals were deferred. aims: to assess the performance of this follow-up program in terms of donor participations, successful confirmed positivity rates, and potential reentry rates. methods: eligible donors were tested for hbsag, hcvab, hivab/ag, and tpab with two eias for each marker. samples reactive with at least one assay were tested further with electro-chemiluminescence assay (eca) and reactive samples were considered repeated reactive (rr). tpab reactive donations were re-tested with particle agglutination assay (tppa). samples eca or tppa non-reactive were considered non-repeatable reactive (nrr background: the blood donation service in suhl processes more than . samples annually from whole blood and apheresis donations, testing on average around samples per day. for the last years, serology screening was performed on the architect instruments (abbott) (arc), but will be changed to the alinity s system (aly) by middle of . although the design of the aly assays is based on those of the arc assays, we undertook a thorough evaluation of the four mandatory screening assays detecting hbsag, hiv ag/ab, anti-hcv and anti-hbc. aims: to validate the mandatory screening assays on the new aly system in our lab in terms of sensitivity and specificity, also including samples with known falsereactive results. determine the rate of false reactive results for hbsag, anti-hcv and anti-hiv that may lead to deferrals of donations and donors. methods: for sensitivity, we used known positive samples confirmed by immunoblot or nat. known unspecific positive samples for arc not confirmed by immunoblot or nat were testes for aly also. close to . unselected samples (edta plasma) from routine blood and apheresis donors were tested in parallel on both systems, arc and aly to determine the rate of initial and repeat reactive results. results: all known confirmed positive samples were identical detected by aly. samples with known unspecific reactive results were retested by aly with the following results: / anti-hcv, / hiv ag/ab and / hbsag were found reactive by aly to. one donation from an acute hiv infection in the early seroconversion period was detected by both methods in routine testing. there are no reactive results for aly not already known for arc. the specificity for the screening assays on aly versus arc assays were as follows: ) hbsag aly . % ( % ( / % ( ) vs arc . % ( % ( / ; ) hiv aly and arc . % ( / ); ) anti-hcv aly . % ( % ( / % ( ) vs arc . % ( % ( / . the number of anti-hbc reactive samples did not differ between aly and arc. summary/conclusions: while the switch to the new system is mainly driven by operational efficiency, obviously, the high specificity of the alinity s assay will reduce unnecessary deferrals of donations and donors. abstract withdrawn. background: blood donor selection is the cornerstone for blood transfusion safety, designed to safeguard the health of both donors and recipients. donor safety is targeted by reducing the risk of complications associated with blood donation and transfusion safety by reducing the risk of transfusion-transmitted infections (tti) and other preventable transfusion reactions. there is always a compromise on blood donor safety as well as blood safety during outdoor mega blood donation drives due to various reasons, mainly due to more number of donations within a stipulated time. aims: to compare the blood donor selection patterns between in house blood donations and donations at mega blood donation drives and its influence on donor safety and blood safety in a tertiary care hospital in india. methods: a retro prospective study was done to audit and compare blood donor safety and blood safety over a period of years from january to december . blood donor safety was analyzed by two indicators: donor health questionnaire (dhq) monitoring and blood donor reaction rates and blood safety through tti positivity rates. ( ) during mega blood donation drive. summary/conclusions: a good donor selection is a lengthy process which involves pre-donation information and advice: this is usually provided in a leaflet, especially about transfusion-transmitted infections (and the associated risk factors) and the potential risks of donation, filling of dhqs by the donor himself, donor interview: conducted by a qualified medical specialist trained in donor selection process and health assessment at the end of the interview to declare if the donor is eligible to give blood or deferred temporarily or permanently. it was observed that seroprevalence rates, number of donor reactions and incompletely filled dhqs were more among blood donations at mega blood donation drives when compared to blood donations during in house collections. this is mainly due huge number of blood donations with in a stipulated time where there is limited time spent on proper donor selection. stringent implementation of who strategy: "safe donor safe blood" is the only way for blood donor and transfusion safety. background: safety of blood transfusion is a great concern especially in crisis countries and during humanitarian emergencies. transfusion transmitted infections (ttis) are one of the major health problem in yemen that are associated with blood transfusion complications. aims: the aim of this study is to determine the prevalence of ttis among blood donors at national blood transfusion and researcher center (nbtrc this contributed to an additional reactivity of . %, thereby total reactivity being . %. % ( / ) of these were hcv reactive & % ( / ) for hbv. the nat yield was in and the viral loads of nat reactives ranged from - x iu/ml for hcv & all the hbv yields had an extremely viral load of < iu/ml. / nat reactive showed sero-conversion after - months with follow-up eclia screening, and of these were hcv reactive and hbv reactives. summary/conclusions: incidence rate indicate that the current risk of transfusion transmitted viral infections attributable to blood donation is relatively high in our country. parallel use of both serology and nat screening of donated blood in countries that have high seroprevalence can improve the blood safety. at our centre, by using best in class serology and nat technologies, we were would add an extra layer of safety to blood supply by interdicting samples from donor with recent infections. abstract withdrawn. abstract withdrawn. ( / , ) . the both hiv-rna and hcv-rna detected donors by nat were identified in the window period. summary/conclusions: in this study, we found that nat could detect infected cases with hbv-dna, hiv-rna and hcv-rna which were forgotten by serological methods therefore, nat is a sensitive screening method to detect low viral load and shorten the window period of the virus infection to ensure the safety of blood transfusions. service du sang, croix rouge de belgique, namur, belgium background: due to enhancement of kits specificity and machines throughput, roche elecsys â technology is a potential partner for blood donations screening laboratories. aims: the aim of the study was to assess the performance of the elecsys serology assays on a cobas e equipment for clinical specificity, analytical sensitivity and reproducibility. background: deceased donors are the primary source of organs and tissues for transplantation but the risk of infectious complications in the recipient is high and is the main cause of morbidity and mortality after transplantation. to minimize the risk of infections by organ or tissue transplantation, donors should be tested for anti-hiv- / , hbsag, anti-hbc, anti-hcv, and syphilis. further laboratory tests may be required depending on the history of the donor and on the tissue properties. certain grafts can be donated after circulatory death of the donor; however, the absence of the heartbeat may change dramatically the blood composition by e.g., haemolysis and proteolysis. this may have an impact on test performance and lead to false results. therefore, an assay validation is needed for testing of cadaveric samples. aims: a validation study was performed to demonstrate the suitability of elecsys hbsag ii, anti-hbc ii, anti-hcv ii, hiv combi pt, hiv duo, syphilis, htlv-i/ii, and chagas for the use in cadaveric samples from non-heart beating donors. methods: as the basis for validation, we followed the recommendations of the paul-ehrlich-institut (pei) "proposal for the validation of anti-hiv- / or hiv ag/ ab combination assays, anti-hcv assays, hbsag and anti-hbc assays for use with cadaveric samples". comparison of spiked samples from living donors and cadaveric donors was used to demonstrate accuracy. to determine precision, two cadaveric specimens were tested in several replicates. acceptance criteria were implemented according to the pei recommendations. results: results were found to be within specifications requested by the pei recommendations for all tested assays summary/conclusions: the evaluated results support the extension of the use of these assays with cadaveric specimens. background: in developed countries, blood donors are routinely screened for a range of blood borne viruses (hiv, hbv, hcv and htlv) using highly sensitive screening tests. this has dramatically improved the safety of blood supply. however, transmission by transfusion of unknown or unsuspected viruses remains a continuing threat. this is particularly relevant considering that a significant proportion of transfused patients are immunocompromised and more frequently subjected to fatal outcomes. in developed countries, blood donors are routinely screened for a range of blood borne viruses (hiv, hbv, hcv and htlv) using highly sensitive screening tests. this has dramatically improved the safety of blood supply. however, transmission by transfusion of unknown or unsuspected viruses remains a continuing threat. this is particularly relevant considering that a significant proportion of transfused patients are immunocompromised and more frequently subjected to fatal outcomes. aims: in this context, metagenomic analyses of viral content in blood donations collected in geographical zones recognized as "hotspot" for viral emergence represents a suitable approach without any a priori for the identification of a potential emerging viral risk that may compromise blood safety. methods: in the framework of a viral discovery program founded by the french national agency for medicine security (ansm in french), more than plasma samples collected in sub-saharan africa countries ( ) ( ) and the amazon region of brazil ( ) have already been analysed by metagenomics. results: although no viral sequence could be described as novel (i.e. new species or even a new genus), we unexpectedly identified a feline bocavirus in two donors from mauritania. a large diversity of known viruses that are not part of the regularly monitored agents were also observed, among which anelloviruses, hpgv- (formerly known as gbv-c), papillomaviruses, herpes viruses, parvovirus b , chikungunya virus, enterovirus, and various small circular viruses (circo-, cycloand gemycircularviruses). while no significative differences was observed in the higher classification of detected virus (above families/genera) between africa and brazil, we observed variations at the sequence level allowing better resolution of the genetic diversity for several viruses (for example characterization of hpgv- genotypes). summary/conclusions: overall, the absence of novel viruses in blood samples collected across countries of two distant continents is reassuring regarding threats emergence. however, continuous monitoring of prospective blood banks should be continued. summary/conclusions: after the high peak observed in during the first period, this study shows that the decrease in the seroprevalence of viral markers is continuous over the next five years. the second period is marked by an irregular evolution of seroprevalence but with lower levels than the first period. the recruitment of new donors allows a quantitative increase in donations. however, improving the quality of blood products essential condition of transfusion safety is achieved through retention of recruited blood donors. background: in blood screening laboratories, samples may be transferred between automated serological and molecular instruments, and the potential for sample contamination is a serious risk to the integrity of nucleic acid testing (nat) results. the sensitive limit of detection (lod) for hiv and hcv nat assays combined with the high viral titers encountered in specimens from patients with acute infections presents a challenge for maintaining the sample integrity of negative specimens. at additional cost per test, this risk can be reduced with single-use filter pipette tips. aims: we evaluate the efficacy of applying induction heated washes to a non-disposable pipettor on serology instruments-alinity s, alinity i, and architect i sr (abbott diagnostics)-to preserve the integrity of samples transferred to a downstream molecular instrument, the m realtime (abbott molecular diagnostics), which amplifies viral nucleic acid targets exponentially. methods: in this application of induction heating, the metallic pipettor warms under its own resistance to coil-induced electrical currents. by sweeping the pipettor through an induction coil, temperatures on the pipettor are elevated throughout its length. single donor high viral titer hiv genotypes a ( . log iu/ml), b ( . log iu/ml), c ( . log iu/ml), crf ( . log iu/ml), crf ( . log iu/ml), and urf ( . log iu/ml), as well as single donor high viral titer hcv genotypes a ( . log iu/ml), b ( . log iu/ml), a ( . log iu/ml), ( . log iu/ml), q ( . log iu/ ml), and t ( . log iu/ml) were used as potential sources of contamination; these genotypes account for the majority of hiv and hcv infections worldwide. on serology instruments, one high viral titer hiv or hcv specimen and three consecutive susceptible negative samples (hiv/hcv rna negative human plasma, abbott molecular diagnostics) were tested on an hiv ag/ab combo or anti-hcv immunoassay (abbott diagnostics), and this schema was repeated four times per positive specimen. induction heated washes occurred between all samples processed on the serology instruments. the first susceptible negative from each testing block, with approximately ml of residual sample volume, was then tested using the . ml abbott realtime hiv assay (lod copies/ml) or . ml abbott realtime hcv assay (lod iu/ml) and an hcv ag immunoassay (lod . fmol/l; abbott diagnostics). study acceptance criteria required that any susceptible negative sample had no detectable level of hiv or hcv rna. results: all first susceptible negative samples (n = per platform per virus schema) run on alinity s, alinity i, and architect i sr using induction heated washes after a high viral titer hiv specimen or hcv specimen were hiv ag/ab combo nonreactive (< . s/co) and reported no detectable level of the hiv rna target, or were anti-hcv nonreactive (< . s/co) and reported no detectable level of the hcv rna or core antigen targets. summary/conclusions: while precautions should continue to be taken for samples run on molecular instruments, the integrity of samples originally tested on the alinity s, alinity i, and architect i sr was preserved for downstream molecular testing through the use of induction heated washes. aims: increasing the safety of blood and blood products -motivating the blood donors to be regular donors methods: national reporting system showed the high prevalence of ttis among first blood donors in compares with the regular donors. in per . . donations, % % of confirmed positive hiv, % of hcv, and % of hbv cases has been reported among first blood donors. in the end of a national program named "pre-donation screening tests "has been developed and has been implemented in high prevalence provinces in whole country. based on this program, all first blood donors who accept in donation sites, if after donor selection process are eligible to donate blood, they refer to give just a blood sample for screening ttis tests. after months, the invitation letters and smss send to the donors who have negative results for all screening ttis tests, and they can be eligible to donate blood after another donor selection process. in , about . % of all donations have been rejected because of at least one of hiv, hcv, or hbv confirmed positive results, while this reject rate in was . %, which shows a significant decreasing the ttis prevalence among blood donation from to . the prevalence of hiv, hcv, and hbv among donations has been decreased significantly in compared with the . prevalence of hiv among donations reduce from . % in to . % in , for hcv and hbv the same results have been experienced, respectively from . % and . % in reduce to . % and . % in . it seems this applied study could effectively scale up the safety of national blood supplies. in addition this intervention could support iranian blood transfusion service to increase the proportion of regular blood donors from . % in to . % in . it means that with increasing the regular blood donor population sizes, the safety of iranian blood and blood products will be more and more scaled up. summary/conclusions: evidence based reports show there is a high rate of prevalence of transfusion transmitted infections (ttis) among first blood donors. so an effective intervention which can reduce the risk of unsafe first blood donation can effectively increase the safety of blood and blood products. pre donation screening tests program in iran can support the national program to decrease the rate of ttis among blood donations from . % in to . % in . abstract withdrawn. abstract withdrawn. background: despite the universal application of viral inactivation and elimination technologies during the preparation of plasma-derived products, the exclusion of infectious donations before any other procedure remains the first essential step as well as the major determinant for the safety of untreated labile blood products. current selection and screening techniques have reduced the risk of viral transmission to very low levels, but there is still a very low but quantifiable risk of transmission through donations beyond routine detection, particularly during the " seroconversion window". "of an infection in a blood donor that is to say during the period when the recently infected donor has not yet developed a serological response. the level of residual risk, which must be as low as possible, is mainly conditioned by the rates of the infections concerned (hiv and hepatitis b virus (hbv) and c (hcv)) to blood donors. summary/conclusions: the evolution of serologic markers is generally satisfactory with continued regression, which has improved particularly for hiv. on the other hand, hepatitis b is still a concern because of its still high rate among new donors. it is desirable to initiate a regular donor vaccination program to protect against hepatitis b. background: blood centres require high throughput assays with a high level of reproducibility to assure consistent results and minimize unnecessary retesting of samples and deferral of donors. in addition, continued economic pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. aims: evaluate the reproducibility of hcvab, havab igm and havab igg essays using abbott alinity s when compared to architect i sr. determine repeatability of these tests in alinity s essays. methods: during months a study was conducted where several samples (minimum samples per test) were randomly sorted and tested using alinity s and architect i sr, results were compared using ibm spss statistics â . in order to evaluate repeatability, at least samples with different reactive degrees (high, intermediate and low) per test were repeated, using alinity s, an average of times per sample and it was determined the percentage of coefficient of variation (%cv). results: a total of samples were tested ( for hcvab, for havab igm and for havab igg) using alinity s and architect i sr, and it was ensured that there were no statistically significant differences between results (p > . ). using samples and a total of essays we found the %cv hcvab ranged from to . %. samples were tested for havab igm in a total of essays and the %cv ranged from to . %. havab igg was tested in samples during essays and the %cv ranged from to . %. summary/conclusions: the new automated equipment alinity s system demonstrated no statistically difference when compared with architect i sr and repeatability was ensured. this demonstrates the precision of results generated by this fully automated blood screening analyzer, which helps assure consistent results for the testing and retesting of blood specimens for hcvab, havab igm and havab igg. background: blood centres require high throughput assays with a high level of reproducibility to assure consistent results and minimize unnecessary retesting of samples and deferral of donors. in addition, continued economic pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. aims: evaluate the reproducibility of hbsag, hbsab, hbcab, hbeag and hbeab essays using abbott alinity s when compared to architect i sr. determine repeatability of these tests in alinity s essays. methods: during months a study was conducted where several samples (minimum samples per test) were randomly sorted and tested using alinity s and architect i sr, results were compared using ibm spss statistics â . in order to evaluate repeatability, at least samples with different reactive degrees (high, intermediate and low) per test were repeated, using alinity s, an average of times per sample and it was determined the percentage of coefficient of variation (%cv). results: a total of samples were tested ( for hbsag, for hbsab, for hbcab, for hbeag and for hbeab) using alinity s and architect i sr, and it was ensured that there were no statistically significant differences between results (p > . ). using samples and a total of essays we found the %cv hbsag ranged from - . %. samples were tested for hbsab in a total of essays and the % cv ranged from - . %. hbcab was tested in samples during essays and the %cv ranged from - . %. using samples and a total of essays we found the %cv hbeag ranged from . - . %. samples were tested for hbeab in a total of essays and the %cv ranged from - . %. summary/conclusions: the new automated equipment alinity s system demonstrated no statistically difference when compared with architect i sr and repeatability was ensured. this demonstrates the precision of results generated by this fully automated blood screening analyzer, which helps assure consistent results for the testing and retesting of blood specimens for hbsag, hbsab, hbcab, hbeag and hbeab. background: blood centres require high throughput assays with a high level of reproducibility to assure consistent results and minimize unnecessary retesting of samples and deferral of donors. in addition, continued economic pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. aims: evaluate the reproducibility of hivag/ab, syphilis and htlv i/ii essays using abbott alinity s when compared to architect i sr. determine repeatability of these tests in alinity s essays. methods: during months a study was conducted where several samples (minimum samples per test) were randomly sorted and tested using alinity s and architect i sr, results were compared using ibm spss statistics â . in order to evaluate repeatability, at least samples with different reactive degrees (high, intermediate and low) per test were repeated, using alinity s, an average of times per sample and it was determined the percentage of coefficient of variation (%cv). results: a total of samples were tested ( for hivag/ab, for syphilis and for htlv i/ii) using alinity s and architect i sr, and it was ensured that there were no statistically significant differences between results (p > . ). using samples and a total of essays we found the %cv hivag/ab ranged from to . %. samples were tested for syphilis in a total of essays and the %cv ranged from to . %. htlv i/ii was tested in samples during essays and the %cv ranged from . to . %. summary/conclusions: the new automated equipment alinity s system demonstrated no statistically difference when compared with architect i sr and repeatability was ensured. this demonstrates the precision of results generated by this fully automated blood screening analyzer, which helps assure consistent results for the testing and retesting of blood specimens for hivag/ab, syphilis and htlv i/ii. , human immunodeficiency (hiv) and hepatitis c (hcv) viruses' infection in blood donors were . %, . % and . % respectively. consecutive positive results for hbv were . % ( / ), for hcv were . % ( / ) and nil for hiv. there was no sample carry over in this. out of consecutive reactive donors were donated for same patients and were related with infected patient which were statistically significant (p < . ). summary/conclusions: among all tti reactive donors . % ( / ) were consecutive reactive. the reason for the same may be process related like sample carry over or reagent carry over or donor related. donor related reasons may be, one of the close relative is reactive for virus and that is transmitted to other family members. in our study reactive donors either had close contacts with persons with history of infective disease or were their first degree family relatives. these findings were found statistically significant (p < . ). this study recommends that in analysis of consecutive positive results in elisa along with looking for procedure/sample error, there is also a need to take retrospective history of donors for close contact with infected patient. background: screening for transfusion-transmitted infections (ttis) is critical in ensuring safety of blood products. transmission of infections through transfusion remains a major source of viral hepatitis especially hbv and hcv. the effectiveness of rapid immunochromatographic test (ict) devices for screening of blood is a concern and needs validation through advanced methods like chemiluminescence immunoassay (clia) and polymerase chain reaction (pcr). aims: the current study was conducted to evaluate the performance and screening effectiveness of commercially available rapid screening kits in comparison with clia and pcr. methods: this single centre, cross sectional study was conducted at the department of blood transfusion services, shaheed zulfiqar ali bhutto medical university, islamabad, from january -june . a total of ten commercially available ict devices and one clia kit (liaisonr xl) were tested for their sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv) and accuracy using positive and negative samples each for hbv and hcv respectively, in comparison with the values determined by pcr. the ict kits included hightop, rightsign, wondfo, accu-chek, fastep, abon, immumed, insta-answer, biocheck and ctk. results: the sensitivities and specificities of ict kits for hbsag were % and % (hightop), % and % (rightsign), % and % (wondfo), % and % (accu-chek), % and % (fastep), % and % (abon), % and % (immumed), % and % (insta-answer), % and % (biocheck) and % and % (ctk) respectively. similarly the sensitivities and specificities of different ict kits for hcv were % and % (hightop), % and % (rightsign), % and % (wondfo), % and % (accu check), % and % (fastep), % and % (abon), % and % (immu-med), % and % (insta answer), % and % (biochek) and % and % (ctk) respectively. the sensitivity and specificity of diasorin liaison murex assay for both hbv and hcv were found to be %, when compared with pcr. the ppv, npv and accuracy were determined accordingly. summary/conclusions: rapid testing ict devices for both hbv and hcv available in pakistan were found to have a variable degree of sensitivity and specificity, when compared with pcr. comparatively expensive but quality methods are more reliable as compared to rapid devices. the data generated will help policy makers to prepare future plan of action and introduce the concept of quality control in blood centres. the analysis has shown that the population of blood donors also included people infected with syphilis. in reference to the number of the tested samples this number is quite significant. the analysis proved the increase in the number of syphilis infections among the blood donors which is consistent with the general trend in the population. summary/conclusions: we have proved that testing blood donors for the treponema pallidum infection increases the safety of recipients of blood and its components and that obligatory testing of donors is fully justified. , and , the use of third or fourth generation serological assays is mandatory for screening of blood donor units for hbv and hcv infection before transfusion. routinely, blood banks in india screen the units by the elisa testing. nat is not very common due to cost constraints. aims: the aim of this study is to determine the frequency and load of hbv dna and hcv rna in hbs and hcv reactive blood donors respectively, and hence it was intended to contribute to determining whether routine hbs and hcv screening of blood donors, using elisa method alone, provides any concrete benefits with regard to hbv and hcv risk reduction or whether the implementation of nat will be of great benefit to low-resource countries like india, which has high prevalence of hbv and hcv. abstract withdrawn. , donors were routinely tested for hbv dna by using cobastaqscreen mpx- and mpx- (roche) or procleix ultrio and ultrio plus id (grifols) assays. obi was confirmed by repeat dna testing and by performing additional serological and molecular investigations on index and follow-up samples. anti-hbs concentrations were determined and anti-hbc antibodies were tested with three distinct commercial clia assays (anti-hbc elecsys roche, architect anti-hbc ii abbott, and hiscl anti-hbc assay sysmex). hbv pre-s/s, precore/core and bcp regions were pcramplified after viral particle concentration and viral amplicons were sequenced. results: hbsag-/dna+ donors ( : , ) including confirmed obi were identified ( : , prevalence). among obi donors, ( . %) tested anti-hbc+/anti-hbs-, ( . %) were anti-hbc+/anti-hbs+, ( . %) were anti-hbc-/anti-hbs+, and anti-hbc-/anti-hbs-primary obi ( . %). anti-hbc-/anti-hbs+ obi donors were significantly younger (mean: years [range: - years]) than those with anti-hbc+/anti-hbs+ (mean: years [range: - years]) and anti-hbc+/anti-hbs-(median: years [range: - years]) profiles (p < . ). hbv vaccination was documented for ( %) of these donors and was reported in one donor but without definitive evidence. extremely low hbv dna loads (range: < - iu/ml) were transiently detected in seven donors during follow up. genotypes identified were genotype b (n = / ) and genotype c (n = / ). preliminary analysis of core protein (n = ) and bcp (n = ) sequences showed no particular genetic feature that could be associated with altered antigenicity or core gene expression. follow-up was available for / anti-hbc-/anti-hbs+ donors ( - samples/donor; range: - months). anti-hbc remained undetectable with all clia assays in these donors except one. low transiently detectable levels of hbv dna were observed overtime with anti-hbs levels fluctuating between and , iu/l. no significant difference in hla-a, -b (except hla-b* more frequently detected in anti-hbc negative obi), and -drb *. summary/conclusions: overall, the . % prevalence of anti-hbs-only in hbv dna positive obi carriers ( : , of total donors) in dalian blood donors confirmed previous reports from south east asia. this phenomenon was not related to core antigenic variations but was significantly associated with younger age of carriers. a particular route and natural history of the infection may be considered. the hypothesis of acute-phase vaccine breakthrough was ruled out in / donors by the over months stability of this serological profile. breakthrough in immunized donors may still be suspected. further studies are needed to evaluate the potential infectivity of anti-hbs-only/hbv dna+ obi carriers, and to characterize the potential viral and immunological mechanisms responsible for this unusual hbv infection profile. confirmatory laboratory, hungarian national blood transfusion service (hnbts), budapest, hungary background: vaccination against hepatitis b virus (hbv) is an effective tool to avoid the infection. in hungary, population born after is considered to be immunized, because inoculation has been mandatory for children as campaign vaccination since . hbv vaccine is strongly recommended for healthcare workers, moreover trips to endemic countries and awareness of individuals could also be reasons of vaccination in immunologically na€ ıve age-groups. since the hbv vaccine contains surface antigen, a recent inoculation can cause reactivity of hbsag screening assays and positivity of confirmatory tests for several days resulting in deferral of donors from blood donation. the former regulation of hnbts, which was valid until december , , allowed the re-entry of donors whose immunization records and negative hbv confirmation of the second blood samples proved that the previous vaccination had resulted in the hbsag confirmed positivity. aims: the aim of this study was to strengthen that vaccination against hbv before blood donation had resulted in the reactivity of hbsag screening and confirmatory assays between and . background: in brazil, the introduction of nucleic acid tests (nat) for hbv-dna detection in the routine screening at public blood banks is relatively recent. at fundac ßão pr o-sangue/hemocentro de são paulo (fps-sp), about , blood donors are submitted to serological screening tests (hbv, hcv, hiv- / , chagas disease, syphilis and htlv- / ) and nat for hiv, hcv and hbv per year. approximately % of the blood donations are discarded due to some reactive result; of these, the hbv discard rate was . % in . aims: our study aims to determine the potential infectious cases among samples that had one or more hbv-reactive screening results (anti-hbc, hbsag and mp-nat-hbv) and verify the different categories of hbv infection (acute, chronic, occult hepatitis b infection (obi) and immunological window). furthermore, to characterize the distribution of hbv genotypes, drug resistance and escape mutations and analyze the risk factors. methods: we carried out a cross-sectional study of roughly , donations from may to december . hbv antibodies and antigen screening were performed using cmia kits architect â -abbott/hbsag and architect â -abbott/anti-hbc. nat screening was performed in minipools (mp) of six samples using kit nat hiv/hcv/ hbv -bio-manguinhos (sensitivity % lod iu/ml for hbv). reagent samples (n = ) that presented one or more hbv-reactive screening results (anti-hbc, hbsag and/or mp-nat-hbv), were submitted to individual nucleic acid extraction and "in house" quantitative real-time pcr-hbv (id-pcr-hbv) targeting the hbsag region (sensitivity - ui/ml). the hbv genotypes and mutation analyses were determined by direct sequencing of the hbv pol-gene/surface-gene and use of the online analysis tool geno pheno [hbv] . . socio-demographic and epidemiological data were also analyzed. financial support: fapesp / - . results: among the hbv reactive samples, were reactive for anti-hbc only ( . %), for hbsag only ( . %) and were reactive for both markers and hbv dna ( . %). routine testing and id-pcr-hbv identified ( . %) samples of active infections that had all hbv reactive/positive tests results. no hbv dnayield samples or hbsagyield or obi were observed. viral loads for active infections samples ranged from . e+ to . e+ cop/ml (median, . e+ cop/ml). hbv sub-genotypes a , a , c , d and f were found in %, %, %, %, and % of the donors, respectively. no reverse transcriptase inhibitor-resistant variants were detected. escape mutations in small hbsag protein shb region were detected in % ( / ), with the following main substitutions c ( x), r, n and g. the mean age of donors with active hbv infection was years, mostly donors were males ( %), mixed ( %) or white ( %) and had concluded high school ( %). summary/conclusions: discard rate due to isolated anti-hbc is high but no obi was found in the blood donor population studied. in addition, no case of immunological window for hbv or hbsagyield was detected. there was a predominance of subgenotype a and mutations associated with escape were found in % of hbv-dnapositive samples. continuous research and surveillance about hbv prevalence among blood donors are needed to maintain and evenly increase blood safety in brazil. background: screening for anti-hbcore antibodies in blood donors is considered to contribute significantly to blood safety, since it reveals donors with occult or probable occult hepatitis b, with variable results in molecular screening, due to very low viral load. however, universal anti-hbcore testing in blood donors, might exclude a considerable number of blood donors in countries with high hbv prevalence and even in countries with low to moderate prevalence, like greece. aims: the aim was to investigate the percentage of blood donors with natural hbv infection (confirmed positive anti-hbcore) or hbv immunization due to vaccination (anti-hbs+ only, due to vaccination) and predict the impact of generalized anti-hbcore testing. methods: during the period - november , all blood donors were asked to give their consensus for additional screening for hepatitis b anti-hbcore and anti-hbs antibodies, besides the obligatory serological and molecular screening, the samples of few donors who disagreed, were not examined. all samples with repeated positive anti-hbcore results, were further examined for anti-hbcore igm and anti-hbe antibodies. furthermore, a new donor sample was requested, to confirm reactivity. the serology results were recorded in an excel spreadsheet. additional data, including age, sex, nationality, number of previous blood donations, abo blood group, family history of hbv infection, hbv vaccination, were also recorded and statistically evaluated. donors were informed of the positive results. results: a total of edta samples were tested using the architect anti-hbcore, anti-hbs, nti-hbcore-m and anti-hbe assays (chemiluminescent microparticle immunoassay (cmia). repeated anti-hbcore(+) occurred in ( . %) samples, among which ( %) were also anti-hbe(+), while anti-hbs was found > m iu/ml in ( . %), between and miu/ml in ( . %), and < miu/ml in ( %). among anti-hbcore positive donors, / were foreigners ( . %) and were greeks, while foreigners consisted , % ( / ) of donors examined. so, anti-hbcore was found positive in , % of foreigners ( / , all from countries with high prevalence for hepatitis b infection) and in , % of greeks ( / ). in total, ( . %) samples had anti-hbs > miu/ml (considered seroprotective for the donor). summary/conclusions: almost half of our blood donors ( . %) were immunized, by vaccination and ( . %) by natural infection. the incidence of natural infection was significantly higher in foreigners ( . % versus , %). if not all anti-hbcore+ donors, % with anti-hbs < iu/ml, might be potentially infectious, especially for immunocompromised patients. if we choose to screen all blood donors for anti-hbcore and reject those with positive results, regardless of the anti-hbs levels, we would probably lose a significant number of donors and jeopardize blood sufficiency. alternatively, we could reject only those with anti-hbs < or < , or choose to selectively screen pre-donation blood donors from countries with high prevalence of hbv infection. following this pilot study, the prevalence of immunization against hbv in large numbers of blood donors from various parts of greece, must be investigated, in order to decide whether to introduce such screening. aims: the aim of this study was to perform phylogenetic analysis of the donor samples with hcv found in the neighbouring villages to determine the nature of transmission. methods: altogether, approximately million blood donor samples were screened with anti-hcv immunoassay (architect anti-hcv, abbott gmbh, wiesbaden, germany) and reactive results were confirmed with anti-hcv line-immunoassays (inno-lia hcv score, fujirebio europe, gent, belgium). based on lia positivity, in samples an association of hcv infection was supposed, because the residence places of donors were in three neighbouring villages situated less than km to each other. pcr was positive in samples. from these samples, hcv sequencing and phylogenetic analysis were performed. fourteen hcv infected samples of general population and of ivd users were also included into the study. results: phylogenetic analysis detected genetic relationship among the hcv virus sequences in donor samples. the most abundant was the a subtype, and it formed two different groups on the phylogenetic tree. according to their genetic distance, a more distant mutual ancestor could be supposed. two samples with b subtype originated from the same village, and their difference was only nucleotides. three hcv from the ivd user control group showed close genetic relationship with the viruses detected in the donor samples. summary/conclusions: based on our phylogenetic analysis, hcv transmission in blood donors could be the consequence of the ivd use and the origin might be related to or primary human sources. during and , a significant increase in the hcv seroprevalence among the ivd users was observed, which was approximately threefold in the rural areas of hungary. our recent findings highlight the importance of the proper donor selection, which can identify the typical signs of the ivd use. moreover, enhancing awareness of blood donors with education is a further significant issue in order to reduce the risk of transfusion transmitted infections. abstract withdrawn. background: in china, the residual risk of transfusion-transmitted hcv has been declining since screening of blood donors for anti-hcv and/or hcv nat from . however, many high sensitivity reagent, using to test blood donors' samples, lead to false-positive results and donors loss. aims: this study intended to establish a donor reentry procedure for hcv screening reactive donors in china. methods: from march to december , there were blood donor samples which were screened reactive or belonged to "grey zone" by elisa and/or reactive by nucleic acid test(nat) at the local blood centers were collected from chinese blood centers. all these samples were sent to institute of blood transfusion (ibt) national reference laboratory where anti-hcv and hcv individual nucleic acid test (id-nat) were conducted. if the results were reactive for anti-hcv, then the samples were tested with a recombinant immunoblot assay (riba). results: based on this study, of donors in the study who could be classified into two categories for hcv status: ( . %) true positive and ( . %) false positive. a total of of donors lost to follow-up, their hcv status cannot be determined with certainty. based on these data, a reentry procedure for hcv screening reactive donors was proposed. summary/conclusions: based on our proposed donor reentry procedure for hcv screening reactive donors, a majority of screening false-positive donors ( . %) can re-entry safely. abstract withdrawn. background: providing safe blood for transfusion in sub-saharan africa (ssa) is a particular challenge due to a combination of factors; limited resources and infrastructure, suboptimal diagnostics and a high prevalence of the major transfusion-transmissible infections (ttis). average seroprevalence data estimates from the ugandan and kenyan blood transfusion services (bts) for hepatitis c (hcv) currently stand at . % and . % respectively. between january and december , in mbale (eastern uganda) the hcv prevalence amongst blood donors was an alarming . %. with no provision or funds for confirmatory testing, the bts are unable to confirm or refute a diagnosis of active hcv. this results in large quantities of blood wastage, unnecessary anxiety in potential donors and high donor deferral rates limiting the donor pool. aims: we aim to determine the true prevalence of active hcv infection amongst seropositive donors in bts in uganda and kenya. in addition, we aim to compare the performance of locally used serodiagnostics and best available alternative tests and to examine the feasibility of cost-effective additional or alternative tests to help provide accurate results on the infectious status of blood. methods: hcv seropositive blood samples from bts study sites (kampala, mbale, mombasa) will be re-tested using the local serology screening test (abbott architect anti-hcv), an alternative who pre-qualified rapid antibody test (sd bioline) and a confirmatory test (hcv core antigen test). where there is discrepancy in the results or need for clarification, samples will be tested on the cepheid xpert platform by reverse-transcriptase pcr to obtain a quantitative rna result. s/co (specimen to cut-off) values for false positive samples (by screening serology) will be analysed and presented. pre-analytical factors (centrifugation speed, haemolysis check, time delay between collection and testing) will be controlled for and documented. results: pilot data from re-testing quarantined hcv seropositive donor blood (mbale bts) in uganda demonstrated that / seropositive blood ( %) was rna pcr negative. in december , / ( %) of seropositive samples (by screening anti-hcv serology) in kampala bts had s/co values between . - . ( . is the cut-off indicating a positive sample). data from the re-testing of seropositive samples as true representation of active hcv will be demonstrated and s/co values for the study period concomitantly with a retrospective analysis of january to december . preanalytical factors, cost analysis comparisons of the diagnostic platforms coupled with costs of the donor deferral process in false positive cases will be presented. summary/conclusions: for the bts in ssa there are significant resource and financial implications, as repeat testing and donor deferral counselling is required. evaluating and introducing new and appropriate diagnostics and algorithms in the screening of hcv is crucial in improving the supply of safe blood transfusion services in east africa. background: in november , the blood services of england, scotland and wales reduced donor deferral to three-months for commercial sex workers and individuals with higher risk sexual partners, including sex between men. the change was recommended after a detailed review by an external expert committee (sabto) which recommended that a shortened deferral of months would allow detection of recently acquired infection and maintain residual risk (rr) at a tolerable level. recommendations were accepted by government but with a government commitment to explore a more individualised approach. aims: to assess the impact of a -month deferral on blood safety in terms of epidemiology of infections in blood donors and compliance with donor selection criteria, and to explore evidence required to develop a more individualised approach to donor selection policy methods: routine uk blood donation surveillance data for - ( : preliminary) were reviewed. annual prevalence and incidence of hbv and hiv infection were estimated, with a poisson regression models to test for trends. incidence was calculated from donors seroconverting within -months, and/or microbiological and clinical evidence of recent infection. for donors positive in , compliance with the -month deferral was determined. uk hemovigilance data were scrutinised for evidence of transfusion transmitted infections (tti) associated with newly eligible donors. results: from to among new donors, annual hiv prevalence decreased significantly by an average of . % each year (p = . ) to . / , donations in ; no significant trend was observed for hbv. annual hiv incidence among repeat donors also decreased significantly by an average of . % each year (p = . ) to . / , -person years (pyrs) in (based on seroconverters). there was no significant trend in hbv incidence over the study period, however between and incidence increased from . / , pyrs to . / , /pyrs (based on and seroconverters respectively). with the information available to date, none of the seroconverting donors were non-compliant, and there was no reported confirmed ttis associated with the policy change. summary/conclusions: hiv prevalence and incidence has continued to decline. hbv incidence in repeat donors increased in although initial analysis suggests this is not associated with the policy change. monitoring continues, and residual risks will be re-estimated as data post-change accumulate. these data are reassuring, and therefore it is appropriate to scope the evidence for, and feasibility of, a more individualised approach to selection policy. a multidisciplinary steering group has been convened including representation from patient and stakeholder groups. gaps in knowledge are being defined, and a package of work is in development under the project of fair (for the assessment of individualised risk), using the abo rdf for guidance. background: permanent deferral of men who have sex with men (msm), established in the s, primarily to minimise the risk of hiv transfusion-transmitted infections is increasingly challenged. accordingly, blood services in many countries have changed to time-based deferral. in canada, a -year deferral was implemented in , reduced to -months in ; a -month deferral is now being considered. aims: to estimate the risk of undetected hiv among screened blood donations under a -month deferral since last sex between men. methods: the applied model combines features of previously published english and canadian models to estimate hiv risk under a -month deferral. three scenarios varying hiv incidence, prevalence and non-compliance under a -month deferral were modelled. assumed constants were the hiv nucleic acid window period, testing procedure error rate and assay sensitivity. model inputs were incidence under the current -month deferral, calculated as hiv positive donors with a previous negative within months divided by number of person years, numbers of hiv positive donations, hiv positive msm, hiv msm incident cases and newly eligible msm donors (from donor surveillance and compliance surveys). the risk with a -month deferral was estimated for three scenarios, one determined "most likely", where msm donor non-compliance, hiv incidence and hiv positive donations do not change and msm newly eligible to donate are estimated from compliance surveys. this scenario is based on data from two sequential policy changes in canada. an "optimistic" scenario where non-compliance halves and a "pessimistic" scenario where msm hiv incidence, hiv positive donations, non-compliance and new msm donors double were also used. the median hiv residual risk was used as the final estimate. the uncertainty in this estimate was assessed with the . th and . th percentiles over the simulation ( % ci). results: incidence, per , donations, was estimated to be . , . and . for the "most likely" "optimistic" and "pessimistic" scenarios, respectively. for the month deferral "most likely" scenario, hiv residual risk was predicted to be in . million donations ( % ci: in , million to in . million). for the "optimistic" scenario, hiv residual risk was estimated to be in . million donations ( % ci: in , million to in . million). finally, for the "pessimistic" scenario, hiv residual risk was estimated to be in . million donations ( % ci: in , million to in . million). with these residual risk estimates, based on the number of donations in canada, one hiv infectious donation would be in inventory every years for the "most likely" scenario, every years for the "optimistic" scenario and every years for the "pessimistic" scenario. summary/conclusions: the risks of hiv entering the blood supply in canada for a -month msm deferral are predicted to be very low for all modelled scenarios, including a "pessimistic" doubling of hiv incidence post change. background: safety of blood and blood products is a major concern in pakistan. the prevalence of transfusion transmitted infections among multi-transfused thalassaemia patients is high (above %). the hiv epidemic in pakistan is following the asian epidemic model where after establishment among the high risk groups, its transmission to general public is rapid. fear, stigma and ignorance have contributed heavily to hiv transmission in pakistan. the hiv detection among blood donors is on the rise and reports occur in media repeatedly. aims: to investigate the possible transmission of hiv through blood transfusion in punjab, pakistan and to highlight the steps being taken to reduce further transmission of infections methods: in september , a report of hiv transmission through blood transfusion was reported in the media where a mother and her newborn acquired hiv after blood transfusion from a hiv positive donor (confirmed later). the case was referred to and investigated by the punjab blood transfusion authority (pbta). the pbta team took blood samples of both recipients (mother and her newborn) and the blood donor who was a family relative. the samples were tested by highly sensitive chemiluminescence immunoassay (clia). the clia results confirmed the presence of hiv in both recipients and the blood donor. due to maternal hiv antibodies transfer through the placenta, the infection status of the newborn was not re-confirmed as he died within two weeks. the donor informed that he had donated times in the past few years. the pbta was able to trace only one earlier donation three months ago. the recipient (a female) was found, tested by clia and was found to be hiv positive. all these cases occurred in unlicensed private blood banks that were screening for hiv on rapid manual devices. the blood banks were sealed by the authority and infected cases were registered by the provincial aids control programme and are being treated. summary/conclusions: the main reasons for hiv spread through blood transfusion is the use of sub-standard rapid screening devices which are not evaluated and validated at a national level. in addition, the existing system relies on the family/replacement donors. the national safe blood transfusion programme, is implementing blood safety system reforms as recommended by who. under the reform agenda, the blood transfusion authorities have been made functional and grant licenses to only those blood banks with proper systems to ensure quality and safety of blood products. the programme is developing a national system for the evaluation, selection and validation of all assays used for screening of blood in close coordination with the drug regulatory authority of pakistan. to promote the culture of voluntary blood donations, the programme has taken concrete steps initiating with the formulation of a national blood donor policy, interaction with celebrities, celebration of world blood donor day and more recently the launch of blood donation feature through 'facebook'. the promotion of voluntary blood donation concept along with regulation of blood sector will reduce the risk of hiv transmission through blood transfusions in pakistan. mianyang blood center, mianyang urumqi blood center, urumqi, china rti international, rockville national heart, lung, and blood institute, bethesda stanford university, stanford, united states background: the incidence of hiv infections has increased substantially over the past decade in china, especially among young people, who represent nearly half of the chinese blood donor population. this upward trend in hiv infections underscores the importance of monitoring hiv prevalence and incidence in chinese blood donors. aims: to estimate hiv prevalence and incidence rate (ir) among chinese blood donors using blood donation data from five geographically-disperse blood centers in - participating in the recipient epidemiology and donor evaluation study-iii (reds-iii) china program. methods: western blot confirmatory testing was done on samples of blood donations reactive for hiv- / on one or both rounds of routine elisa tests or positive by nucleic acid amplification testing (nat). multiple imputation was used for samples with missing confirmatory test results. hiv prevalence was calculated among first-time donors. to estimate hiv ir in first-time donors, single-well lag-avidity eia testing was conducted with first-time hiv recent (incident) infections defined as being infected within approximately days based on avidity of hiv antibodies. a novel model was derived to estimate hiv ir among infrequent repeat donors who had provided only one donation in the - estimation interval. to derive an overall hiv ir for repeat donors, this estimate was combined with the classical-model ir estimated for repeat donors who had given at least donations in the estimation interval. multivariable logistic regression model was used to examine factors associated with hiv infection. results: a total of , , whole blood and apheresis platelet donations with postdonation screening results were collected at the five blood centers between and , including , donations from first-time donors and , donations from repeat donors. hiv prevalence among first-time donors was . per , donors ( % ci, . - . ). hiv ir was estimated to be . per , person-years ( % ci, . - . ) among first-time donors and . per , person-years ( % ci, . - . ) among repeat donors. hiv prevalence and ir varied across regions with an increasing trend observed at some blood centers. among first-time donors, being male, older than years, minority ethnicity, less than college education, and certain occupations (commercial services, factory workers, retired, unemployed, or self-employed) were associated with positive hiv confirmatory testing results. summary/conclusions: although hiv prevalence and incidence remain low among chinese blood donors, it is important to monitor hiv epidemiology in blood donors on a continuous basis, especially among populations and regions of higher risk. further donor screening and education strategies need to be developed and evaluated to reduce these risks. the ir methods used in this study for first time donors as well as repeat donors who donate very infrequently is readily applicable to other countries who have similar donation patterns. background: in thailand, the national blood centre is responsible for blood donation service which includes follow-up and blood donor counseling in order to indicate the infection status, especially hiv-positive blood donors. currently, although the epidemic of hiv infection in thailand is in decline, the hiv-positive cases still have been found in blood donors screening. thus, monitoring of hiv infection status in blood donors and post-blood donor counseling are important for providing the hiv-positive infected donors lead to access the hiv treatment immediately. aims: to study the hiv follow-up cases on serological testing over years for assessment of the hiv infection in thai blood donors. the retrospective analysis of hiv follow-up cases on serological testing (cmia, ics and western blot) was conducted during to at thai national blood centre. results: a total of , , voluntary blood donations over years, the repeated reactive results on hiv serological screening were , ( . %) cases and only half of these hiv reactive donors returned to follow-up testing for ascertaining their hiv status. for hiv follow-up process, the hiv reactive screening donors must be followed for months and tested by using the different three principles of hiv serological testing. a total of , hiv reactive results were separated to three patterns including hiv positive results, inconclusive results and negative results which the number of each group was , ( . %) cases, ( . %) cases and , ( . %) cases respectively. out of , hiv positive results, we found that , ( . %) cases were positive with all hiv serological testing for the first-time follow-up and ( . %) cases were tested and become to positive results after follow-up more than one time. in cases of inconclusive results, ( . %) cases were reactive only or testing(s) which these donors did not return to confirm again leading to temporarily deferred donors in blood donor system. in addition, ( . %) cases of inconclusive results could not conclude the hiv result although they were repeated several times. for the last pattern, , negative results cases showed ( . %) cases were negative results after follow-up over months while ( . %) cases were inconclusive results before changing to negative results which almost cases of this group were reentry as blood donor after deferral period is over. summary/conclusions: the number of repeated reactive results on hiv screening was constant over years of which returned to follow-up only half of hiv reactive donors leading to accumulation of temporarily deferred donors in blood donation system. hiv follow-up positive cases were informed and counseled immediately then referring to anonymous clinic for treatment. the problem and challenges of hiv follow-up were inconclusive results that were unclear and some of these did not return to retest lead to loss of re-entry donor who might be changed to negative result afterward. hence, the effective counseling and follow-up system need to be taken urgently to encourage the temporarily deferral donors returned to retest for reducing stigma of deferred donors in hiv follow-up cases. . we only analyzed the information that had non-reactive results for infectious markers reported by blood banks to sihevi-ins©, because they represent a risk for blood recipients. results: when loading the information of sivigila in sihevi-ins©, donors were found ( % men); of these people donations were obtained ( % whole blood). donors ( %) had a reactive result for hiv being subsequently reported in sivigila. in addition, five of them were reactive simultaneously for hbv in blood banks and took on average ae days to be reported in sivigila. donors ( . %) had an hiv reactive result notified by sivigila and subsequently they were reactive in blood banks. this behavior may suggest an attempt to spread the disease. donors ( % men) despite being initially reported in the sivigila database, presented a non-reactive result in a blood bank for hiv; one of them was reactive for syphilis and hbv and only one for hbv. this pattern may suggest false positive or negative results in one of the two databases analyzed. fourteen donors had negative test in blood banks for hiv and in a range of up to months they were reactive by sivigila ( % of them donate whole blood). this conduct may suggest that accepted donations were in a window period and therefore warrant further investigation. considering that two blood components could be obtained on average from each donor, a potential risk is estimated for recipients. summary/conclusions: the donors reported first in the blood banks through sihevi-ins© and later in sivigila allow to estimate an adequate orientation to the health services. the information from general epidemiological surveillance programs could improve the selection of donors and transfusion safety. background: it is assumed that bacterial contamination of blood products most often takes place during the donation process. the number of bacteria at this time point is estimated to be around - cfu per bag. little is known about the growth behavior of different bacteria species in whole blood (wb) units during storage and the distribution of bacteria to the different blood products. aims: aim of the current study was to determine the growth of different bacteria species in contaminated wb units and to study the distribution of the bacteria to the different blood components. methods: whole blood (n = - per species) was inoculated with approximately cfu of different bacteria species (escherichia coli, klebsiella pneumoniae, pseudomonas fluorescens, staphylococcus aureus, staphylococcus epidermidis, streptococcus dysgalactiae, streptococcus pyogenes) and stored for to h at room temperature before centrifugation and separation into red blood cells (rbc), buffy coat (bc) and plasma. bcs from spiked wb were each pooled with random bcs to prepare plasmareduced platelet concentrates (pc). samples were taken from wb after storage and from the blood products (rbc, bc, plasma and pc) right after preparation, and the bacterial titer was determined. sterility of pcs was tested by bact/alert after seven days of storage. results: bacterial growth in wb varied remarkably between donations and bacteria species. the highest titers in wb were detected for the streptococcus species, whereas staphylococcus aureus, staphylococcus epidermidis, escherichia coli and pseudomonas fluorescens did not multiply. bacteria preferably accumulated in the bcs during separation, reaching titers of up to . cfu/ml in bcs and up to . cfu/ml in the corresponding pcs right after preparation. in total, out of pcs tested positive for bacteria at the end of storage. the results were dependent on the species used: e.g., / pcs tested positive after spiking with streptococcus pyogenes, while only / pcs tested positive after spiking with escherichia coli. bacterial contamination of rbc and plasma units was much less frequent and associated with higher bacterial titers in the parental wb units. summary/conclusions: the growth and distribution of bacteria during processing of wb into the different blood products is species-dependent and remarkably varies between donations. results: both patients were male ( yo and yo) with a history of acute myelogenous leukemia status-post haploidentical stem cell transplant. the patients were thrombocytopenic and underwent simultaneous transfusion of irradiated, non-pr, day platelets stored in platelet additive solution, from a single apheresis collection. the blood supplier's primary pre-release bacterial cultures were negative, and the on-site point of release secondary safety measure pan genera detection (pgd) testing was negative for both gram positive (gp) and gram negative (gn) organisms. both apheresis units also passed visual inspection prior to release from the blood bank. during transfusion, both patients displayed signs of septic transfusion reaction including rigors, fever, hypoxemia, tachypnea, tachycardia, and hypotension. transfusion reaction evaluations were initiated, and both patients were admitted to the medical intensive care unit and started on broad-spectrum antibiotics. gram stain of one platelet unit demonstrated gram negative rods (gnr) and gram positive cocci (gpc) in clusters, and the second platelet unit demonstrated gnr only. repeat secondary safety measure pgd testing of both units was negative for both gp and gn organisms. direct bacterial cultures of both platelet units grew both gnr and gpc identified as a. baumanii and s. saprophyticus after h of incubation. colonies on the initial bacterial plates were too numerous to count (tntc), and subsequent re-plating of the platelet units showed: unit : a. baumanii tntc and s. saprophyticus with . cfu/ml unit : a. baumanii . cfu/ml and s. saprophyticus . cfu/ml blood cultures collected from both patients became positive within h with gnr on gram stain, and both blood cultures ultimately grew both a. baumanii and s. saprophyticus. the primary pre-release cultures at the blood supplier remained negative. after days on antibiotics and pressors, both patients stabilized and were discharged home. the blood donor was interviewed, and he was well. no cultures were collected. summary/conclusions: this case documents failure of both primary pre-release bacterial testing and secondary on-site point of release pgd testing to identify two pathogenic organisms. a. baumanii and s. saprophyticus are unusual causes of septic transfusion reactions, and it is possible that these organisms have different limits of detection in the pgd assay compared to other organisms. rapid attention to clinical signs during transfusion and prompt initiation of antibiotics is critical for the management of septic transfusion reactions. we are currently evaluating ways to further reduce septic transfusion reactions, including increasing the utilization of pathogen reduced platelets. background: transfusion-associated infections due to the transmission of bacteria still represents a major risk in developed countries nowadays. despite the refrigerated storage of red blood cells (rbc), fatal reactions of patients receiving contaminated rbc units are repeatedly reported. in order to further increase the safety of blood transfusions, new strategies and measures have to be developed. in this context, transfusion-relevant bacteria reference strains can serve as a valuable tool for the validation, comparison and interpretation of these new developments. aims: conducting a collaborative study to establish the first repository for red blood cell transfusion-relevant bacteria reference strains. methods: six bacterial strains (serratia liquefaciens, serratia marcescens, pseudomonas fluorescens, listeria monocytogenes, yersinia enterocolitica a- and yersinia enterocolitica a- ) were distributed from the paul-ehrlich-institut to laboratories in countries for enumeration, identification and growth measurement in a -day interval for a total of days after low-count spiking of rbc bags ( - colony-forming units (cfu)/rbc bag). results: except for s. marcescens, all other strains showed good-to-excellent growth in rbc. s. liquefaciens, p. fluorescens, y. enterocolitica a- and y. enterocolitica a- achieved > cfu/ml at day and cfu/ml at day . growth of l. monocytogenes was lower reaching a maximum concentration of > cfu/ml at day . in out of laboratories, s. marcescens showed no growth at all. summary/conclusions: five of the six tested strains showed robust growth in rbc independent of donor variability and are promising candidates to be adopted as official rbc transfusion-relevant reference strains by the world health organization. background: the samplok sampling kit (ssk), itl biomedical, is used by nhs blood and transplant (nhsbt) for sampling of platelet components (pc) for bacterial screening using the bact/alert d system. inoculation of bact/alert bottles is performed immediately after sampling. validation of delayed inoculation, with retention of the sample within the ssk devices, would allow a contingency for transport to other screening sites in the event of an incident that prevented testing at the sampling site. ssk maintain a closed system for sampling of pc and are compatible with standard blood collection bags. a graduated chamber ( or ml) ensures that only the required sample volume is collected and an integrated needle allows inoculation into bact/alert bottles. aims: the national bacteriology laboratory, nhsbt, evaluated the impact of prolonged storage of pc samples in ssk devices with regard to bacterial viability and detection. methods: four reference species were assessed: staphylococcus aureus (atcc ), streptococcus agalactiae (atcc ), escherichia coli (atcc ), clostridium perfringens (atcc ). a pool and split method was used with apheresis pc suspended in plasma. units were screened using bact/alert d prior to spiking to prove the absence of contamination. pc were spiked with a single species (range - . cfu/ml) and tested on bact/alert with a ml inoculation into anaerobic and aerobic bottles (positive control). enumeration was performed to confirm the bacterial concentration. each unit was sampled using two ml ssk, which were held for a period of h at - °c. the process was repeated with a -h period. once elapsed, ml of each ssk was inoculated into an aerobic and anaerobic bact/alert bottle, one ssk per atmosphere per species and the remaining sample was enumerated. all bottles were incubated on the bact/ alert system for a maximum of days ( ae . °c) and subcultured if positive. results: positive controls had detectable growth by bact/alert, excluding aerobic bottles with c. perfringens. this was expected as it is an anaerobic organism. after the storage periods, all bottles had detectable growth by bact/alert. s. aureus showed an increase of . -log after h ( . to . cfu/ml) and . -log after h ( . cfu/ml to . cfu/ml). s. agalactiae increased by . -log after h ( . cfu/ml to . cfu/ml) and . -log after h ( . cfu/ml to . cfu/ml). c perfringens increased by . -log after h ( . cfu/ml to . cfu/ml) and . -log after h ( . cfu/ml and . cfu/ml). for e. coli, the concentration after h was reduced by . -log ( . cfu/ml and . cfu/ml), however this was possibly a result of inherent counting errors. at h, an increase in growth by . -log ( . to . cfu/ml) was obtained. summary/conclusions: storage of pc samples in ssk devices for up to h does not have a negative effect on bacterial viability and detection using the bact/alert d system. background: the intercept tm blood system for platelets efficiently inactivates pathogens and leukocytes in platelet concentrates (pc). the system utilizes amotosalen and uva light and is available for the treatment of apheresis and whole blood (wb) derived platelets (mostly buffy coat pools) in europe in plasma or platelet additive solution (pas), and the treatment of apheresis platelets in the us (trima tm in % plasma or amicus tm for % intersol pas/ % plasma). acinetobacter baumanii and staphylococcus saprophyticus strains were isolated from a saline flush taken h after successful and complete transfusion of an apheresis intercept-treated pc in % pas/ % plasma, from a patient with a suspected septic reaction that occurred h post transfusion. bacterial isolates, and a sample of a gram stain-negative and culture-negative sister split pc were submitted for evaluation. we report here the in vitro inactivation of the fast growing, gram negative bacterium a. baumanii and slower growing gram positive s. saprophyticus. the sister unit was assessed for amotosalen break down products as an indication of successful inter-cept treatment. aims: the objective of the study was to evaluate bacterial inactivation of a. baumanii and s. saprophyticus in apheresis platelets, assessed immediately after treatment and with re-culture at the end of a day shelf-life. methods: a double apheresis pc collected in % pas/ % plasma was split into three equal components, yielding approximately ml of platelets/pc. a. baumanii and s. saprophyticus were grown in lb broth and each pc unit was inoculated with either bacterial strain or the combination of both strains, each at~ log colony forming units/ml (cfu/ml). after inoculation, the contaminated units were treated in small volume (sv) intercept kits. samples were taken: pre and post-inactivation treatment, and at , and days of storage. the samples were analyzed by plating on lb plates ( ll- ml). residual amotosalen levels were assessed by hplc. results: initial bacterial titers were . - . cfu/ml. following the inactivation treatment, no viable bacteria were detected by plate culture. no bacteria were detected after , and days of storage, corresponding to > . log inactivation of both bacterial strains. performance of the intercept treatment process was confirmed in the sister pc unit as evidenced by levels of amotosalen and its byproducts characteristic of intercept treatment, as well as by review of the process documentation. summary/conclusions: amotosalen/uva effectively inactivated a. baumanii and s. saprophyticus individually and together below the limit of detection after days storage. no bacteria in the sister pc by gram stain and culture, and the presence of amotosalen byproducts suggested that the pc collection involved in the septic reaction was sterile at the time of intercept treatment and was successfully illuminated. the possibility of only one-of-two split pc being contaminated due to biofilm formation is minimized in the intercept system which decants platelets into virgin storage bags at the end of treatment. contamination of the source pc container likely occurred after intercept treatment, possibly at the time of spiking for transfusion. background: studies in sub-saharan africa have documented bacterial contamination of blood products for transfusion varying between , %> , %, up to times higher than in the north. published data from central africa are lacking. aims: the aim of this study was to determine the proportion of blood products contaminated with bacteria in three hospitals in the democratic republic of the congo (drc). to assure aseptic sampling, we used a closed system of sampling bags. in addition to the presence of contamination, we assessed semi-quantitative colony counts. methods: from july to december , a total of blood products were sampled, of which in hôpital provincial g en eral de r ef erence, kinshasa (hpgrk), in hôpital p ediatrique kalembe lembe, kinshasa (hpkll) and in hôpital saint-luc, kisantu (hslk). after compatibilization of blood products, ml of blood was transferred from the primary blood bag to an attached sampling bag. sampling bags were sealed off, stored in the fridge and transported once daily to the bacteriology laboratory. using the adapter connected to the sampling bag, ml of blood was inoculated in a blood culture (bactalertpf, biom erieux) and incubated at °c for days. cultures were checked daily for signs of growth. in addition, ml of blood was equally distributed on the cled and macconkey agar-coated sides of a dipslide (meus s.r.l.). dipslides were incubated h for semi-quantitative culture, expressed as colony-formingunits (cfu) per ml. in case of blood culture growth, bacteria were identified and a second blood culture was inoculated to exclude contamination during processing. bacteria grown on semi-quantitative culture were also identified. results: a total of . % ( / ) of whole blood and red cell concentrates were contaminated with bacteria. in hpgrk, . % ( / ) of blood products were contaminated, in hpkll . % ( / ) and in hslk . % ( / ) . the proportion of contaminated blood products was significantly higher in hpgrk compared to hslk (p = . ). there was no significant difference between the other sites (p = . and p = . ). majority of isolated bacterial species were coagulase-negative staphylococcus spp./micrococcus spp. ( . %) and bacillus spp. ( . %). the remaining % of bacterial isolates were identified as non-fermentative gram-negative rods, klebsiella pneumoniae, staphylococcus aureus, mould, listeria spp., corynebacterium spp./coryneform bacteria. the concentration of all isolated bacteria was lower than ³ cfu/ml, except for one coagulase-negative staphylococcus spp. found in hpgrk at ³ cfu/ml. summary/conclusions: to our knowledge, we were the first to reach a sample size of more than blood products for bacterial culture and the first to use a closed system of sampling bags in sub-saharan africa, which guarantees aseptic sampling of blood cultures. this might explain the low bacterial contamination rate ( . %) of blood products in three hospitals in drc compared to previous studies in other sub-saharan african countries. moreover, bacterial concentrations in the contaminated blood products were low (< ³ cfu/ml). the different proportions of contamination between study sites suggest that different environments and practices play a role in the risk for bacterial contamination. background: although the screening of the treponema pallidum (tp) is mandatory in blood donations, its necessity is controversial, because there have been no transmissions by blood products documented in the developed countries in the last few decades. aims: based on laboratory markers, active and early tp infected donors (aeid) were determined. the demographics of aeid and the frequency measures of cases were compared with that of early infected syphilis cases (syc) notified from the to -year-old general population registered at the nphc. methods: altogether, , to -year-old donors were screened with anti-tp immunoassay (architect syphilis tp, abbott, wiesbaden, germany) between and . reactive results were confirmed with immunoblots (viramed biotech ag, planegg, germany), which discriminated both specific anti-tp (igg, igm) and non-specific vdrl antibodies in five dilutions. meeting the criteria of anti-tp igg positivity with a vdrl titer of ≥ : and anti-tp igm positivity, donors were considered as aeid. they were stratified by age, gender and residence regions. the proportion of aeid (paeid) and syc (psyc) were calculated in first time (ft), and repeat tested (rt) donors and in the to -year-old general population, respectively, in each year studied. the period prevalence (pp) of aeid and syc was estimated in the populations at risk , across - . statistics: weighted proportions and one-way anova with tukey post-hoc test and z score test were applied. statistical significance was defined as p < . . results: anti-tp reactivity was confirmed in blood donors. aeid was proved in cases with ft and rt donors. in that period, syc were notified. both in aeid and syc, the age group of - years with approximately % and % of individuals was the dominant. the proportion of men was % and % (p = . ) in the aeid and syc, respectively. paeid estimated in ft donors was significantly higher ( . %; . %; . %, p < . ) than that of rt donors ( . %; . %; . %) and the proportion of syc ( . %; . %; . %) in the general population. pp of aeid showed a roughly homogenous distribution in the regions ( . %- . %), however, pp of syc had a significant ( . %; p < . ) central hungary dominance in relation to the other regions ( . %- . %). comparing the pp of aeid to syc, central hungary indicated a significant difference ( . % vs. . %, p < . ), however, other regions showed no substantial differences. summary/conclusions: donors with anti-tp confirmed positivity are referred to the healthcare system. based on the laboratory markers tested, aeid could be separated and their demographical characteristics are pretty similar to that of syc notified from the general hungarian population. the proportion of early and active infection in ft donors is significantly higher than that of rt donors and the proportion of syc in the general population. given the considerable number of tp infection in background: quality assurance and safety of hematopoietic stem cells (hsc) with emphasis on prevention of bacterial and fungal contamination are the prerequisites for any transplantation procedure. bacterial contamination is of particular significance as it occurs relatively more frequently and bacteria are gradually gaining more antimicrobial resistance. aims: the aim was to determine the incidence rate of bacterial and fungal contamination during processing of transplantation material at the institute of hematology and transfusion medicine (ihtm) taking into account the hsc sourceperipheral blood (pbsc), bone marrow (bm) or cord blood (cb). methods: analysis involved both autologous and allogenic components collected at ihtm and other hospitals and dedicated for ihtm patients. in all, the analysis comprised donations, including bm ( . %), pbsc ( . %) and cb ( . %) donations processed in our laboratory in the years - . bm was collected in operating theatre-conditions, pbsc with cell separators -cs- (baxter), cobe spectra (gambro) and trima accel (terumo bct) and cb was acquired from umbilical vein at obstetrics and gynaecology wards. aerobic and anaerobic bacteria contamination was determined at various incubation temperatures (room temperature and °c) using a variety of culture media. pbsc and bm were tested using samples with trypcase-soy broth (tsb-t) and with schaedler + vit k (biomerieux). cb was tested using bactec peds plus/f and bactec lytic/ /anaerobic/f (becton-dickinson). results: in the - period contaminated products were found: pbsc ( . % of all tested pbsc units) and cb ( . % of all tested cb units). no infected bm products were determined. the overall percentage of contaminated products was estimated at , %. in , three ( ) products were found contaminated with staphylococcus epidermidis; all came from one patient with central venous catheter and were collected on consecutive days. other products were contaminated mostly with staphylococcus epidermidis ( . %). detailed results to be presented on the poster. summary/conclusions: according to ihtm policy no contaminated product is admitted to clinical use. the outcome of our study identifies processing experience of the staff as the main indicator of product quality. important is also proper assessment of donor health and condition of the injection site as products are usually collected from central venous catheter. the closed system is an additional safeguard against contamination during processing. the sample collecting procedure should help to avoid false positive results. background: syphilis is considered a global public health problem. the world health organization (who) estimates that there are annually around million new cases of syphilis in the world, more than % occurring in developing countries. despite significant decrease in syphilis transfusion transmission. the recent increase in worldwide incidence associated with the risk of transmission through platelet concentrates (cp), which are stored at room temperature, have called attention to the potential residual risk of syphilis transmission by transfusion. between and we observed in our institution a significant increase of % in positivity of syphilis among blood donors from . % in to . % in and . % in (p < . ). aims: to determine the prevalence of active syphilis in blood donors and characterize the serological profile of syphilis positive donors. methods: each positive sample in a treponemic chemiluminescence assay (cmia, abbott architect) performed during blood donor screening in was submitted to a treponemic elisa anti-treponema pallidum igm (euroimmun) and a non-treponemic test (antigen-omega diagnostics). samples with positive results for one or two of these tests (indicating recent syphilis) were submitted to a real-time pcr for syphilis. the inno-lia syphilis-fujirebio immunoblot test was also performed for samples that presented a positive result for elisa-igm alone. financial support: fapesp / - . results: among , samples screened in , ( . %) presented a positive result for cmia -syphilis. of these, ( . %) were included in the study. a total of samples ( %) showed vdrl+/igm+; ( %) vdrl+/igmand ( . %) vdrl -/elisa igm+. the inno-lia syphilis test was performed as a confirmatory test in ( . %) samples that presented positive results for elisa igm and vdrl negative with ( . %) positive results, ( . %) undetermined and ( . %) negative. none of the samples showed the presence of treponema dna by real-time pcr. the prevalence was . %, the incidence was . % in the year , and the incidence in relation to the total positivity was . %. both, prevalence and incidence were higher in men, white, not married, aging - years and high school educational level. we observed a % a-hbc seroprevalence in the elisa igm-syphilis positive samples and a prevalence of . % htlv coinfection. summary/conclusions: we observed a significant increase in prevalence of syphilis in ( . %) with an incidence of . % of the total of cases initially positive in the cmia test. according to our data, we could identify a risk of syphilis transfusion transmission in blood banks that exclusively use the vdrl for donor screening, once we found ( . %) cases with negative vdrl and elisa igm and inno-lia positive. continuous monitoring of the profile of donors infected with syphilis at this time of reemergence of the disease is useful and important not just for blood banks, as it reflects the epidemiological situation of disease in community, and can contribute to the definition of health policies. background: transfusion related sepsis is a serious concern limiting platelet storage time to days at room temperature. while most units are screened for bacterial contamination when collected, bacterial monitoring methods can take up to days to detect contamination. thus, cold storage of platelets represents an attractive alternative for improving platelet safety. in this study, we assessed bacterial growth in platelets stored either at room-temperature (rt; °c) or refrigerated (cs; °c). aims: the aims of this study were to ) assess the effect of storage temperature on platelet function and bacterial growth in "contaminated" platelet units, and ) identify factors contributing to bacterial growth during rt storage. methods: apheresis platelets in plasma (plt) were obtained from healthy donors using the terumo trima accel automated blood collection system (terumo bct). fresh plasma (fp) was collected similarly. aliquots of plt or fp were transferred to ph safe minibags (blood cell storage, inc) and "contaminated" with acinetobacter baumannii, escherichia coli, pseudomonas aeruginosa, staphylococcus aureus, staphylococcus epidermidis, or pbs (uninfected control). minibags stored at rt were agitated using an orbital shaker set to rpm while cs aliquots were stored under static conditions. bacterial growth was monitored daily through dilution plating. lactate levels were assessed by istat (abbott) cg + test cartridges. plasma glucose levels were assessed using blood glucose testing strips (germaine laboratories). platelet activation and aggregation were assessed on days , , , and by flow cytometry and multiplate platelet aggregometry, respectively. results: bacterial growth progressed rapidly over the first - days post-collection in all plt aliquots stored at rt except those challenged with s. epidermidis. significant growth of s. epidermidis was not detected until day . bacterial numbers remained unchanged in refrigerated aliquots through day . rt storage resulted in significantly (p < . ) decreased platelet aggregation over time which was exacerbated by bacterial challenge. plt function was largely preserved with refrigeration regardless of challenge. bacterial growth was significantly reduced, or at least delayed, in fp. fp challenged with gram-negative pathogens exhibited a significant (p < . ) delay in bacterial growth at day . while growth of e. coli and p. aeruginosa recovered by day , growth of a. baumannii was significantly (p < . ) inhibited throughout. fp challenged with gram-positive pathogens exhibited significant (p < . ) reduction in bacterial growth relative to plt aliquots. bacterial growth correlated with plt lactate production. lactate levels in plts challenged with e. coli showed diminished significantly after day , indicative of lactate utilization. with exception of fp challenged with s. aureus, bacterial growth was restored in fp supplemented with lactic acid in all challenge groups. summary/conclusions: refrigeration preserved platelet function while both inhibiting bacterial growth and lactate production. conversely, the opposite was observed with rt storage. these data demonstrate that bacterial growth can be controlled through refrigeration without loss of function and rt storage may potentiate growth of certain bacterial strains through accelerated plt metabolism. background: bacterial contamination of peripheral blood progenitor cell (pbpc) for transfusion has been the cause of serious sepsis and life-threatening infections. however, a standard procedure or choice of test sample(s) has not been established to screen pbpc products for microbial contamination, because these products are not large enough to facilitate inoculation of the recommended volume for the automated blood culture systems. samples taken from by-product plasma and low volume pbpc product were cultured in routine sterility test. aims: to evaluate the residual risk of microbial contamination in pbpc products for transplantation, we cultured sufficient post-thaw inoculation volumes from pbpc products which were discarded for various reasons in our blood center. methods: in routine sterility test, a -ml sample of by-product plasma collected with pbpc product was inoculated into bact/alert bpa and bpn culture bottle ( ml each) within h after collection. the bottles were then placed in the bact/ alert system and incubated for at least days or when a positive reaction was indicated by the automated liquid-media culture system. moreover, a -ml postthaw sample would be cultured before transplantation performed. in the residual risk investigation, discarded pbpc products were thawed, and then a -ml and a -ml aliquot were taken and cultured with the same method. all positive bottles were subcultured for bacterial isolation and identification. results: in september and march , after maintaining in liquid nitrogen for to years, pbpc products collected from patients, which was preserved in a volume between and ml, were discarded. all of these products had been cultured negative in routine sterility tests with plasma samples. these final products were thawed and cultured with both the -ml and the -ml aliquot. one of these pbpc products had the positive culture result with the -ml retested samples. nevertheless, the same pbpc product had the negative result with the -ml post-thaw pbpc sample and the -ml by-product plasma sample. propionibacterium acnes was isolated from the bpn positive bottle. summary/conclusions: the residual risk of microbial contamination in pbpc postthaw products still exist after routine sterility test with the plasma sample and the -ml volume of pbpc sample. the bacterium isolated from pbpc product was normal skin flora bacterium. an optimal screening method of pbpc products merits further study to increase the safety of the blood supply. background: hospital hygiene tools that serve as a proxy for assessment of microbial contamination are increasingly used. they include adenosine triphosphate (atp) bioluminescence and air particle counting. however, their use for microbial monitoring of blood banks remains underexplored. they could be of particular interest in a sub-saharan african setting (temperatures, dust) to circumvent bacterial culture and provide direct results usable for monitoring over time. aims: the aim of this study was (i) to quantify environmental bacteria in the air and on surfaces that are regularly in contact with blood products, and (ii) to evaluate atp bioluminescence techniques and particle counts as a predictor for bacterial contamination, in three blood banks in the democratic republic of the congo (drc). methods: samples were taken in three blood banks in the democratic republic of the congo: hôpital p ediatrique de kalembelembe (hpkll) ( surfaces, air), hôpital provincial g en eral de r ef erence (hpgrk) ( surfaces, air) and the national blood transfusion centre (cnts) ( surfaces, air). surfaces that are regularly in contact with blood products were selected (sealer, fridge, donor chair,. . ..). regular surfaces were sampled using rodac contact plates ( . cm²) containing cled and macconkey agar, irregular surfaces using swabs (nrsii, medicalwire). atp was measured on the same surface (pd , kikkoman), expressed as relative light units (rlu) per cm². air was sampled by active sampling ( liter; spinair, iul) on cled and macconkey medium. in parallel, particles > . lm and > lm were counted using a particle counter ( , liter; metone a). culture media were incubated for h at °c before counting colony forming units (cfu). results: for regular surfaces, the median (range) viable bacterial count was ( - ) cfu/rodac, ( - ) cfu/rodac, ( - ) cfu/rodac for hpkll, cnts and hpgrk, respectively. at hpkll, highest viable counts were found in the sink (plain growth) and cool boxes ( and cfu/rodac). in cnts the blood processing bench, the donor chair arm support and washing basin showed the highest counts (plain growth). whereas in hpgrk, most bacteria were found in a fridge (plain growth), blood bag trolley (plain growth) and manual separator ( cfu/ rodac). gram-negative bacilli were isolated from water basins and sink in cnts and hpkll, but also surfaces close to donor chairs at hpgrk. the median (range) of atp per cm² was . ( - . ) rlu at hpkll, ) rlu at cnts and . ( . - . ) at hpgrk. atp results and total viable count were not correlated (n = , p = . ). median (range) bacterial count in the air was ( - ) cfu/ l for all sites together. there was no correlation found between total bacterial count and particles > . lm or > lm (r = . and r = . respectively; p < . ; n = ) summary/conclusions: total viable bacterial count of surfaces varies over blood bank sites. according to our results, atp and particle counts did not correlate with bacterial counts on surfaces and in the air, respectively. bacterial isolates from blood bank environments in drc need to be identified and seasonal variations need to be evaluated. background: the risk of transfusion-transmitted hepatitis e virus (tt-hev) infections in line with the question of the necessity of hev-nat screening of blood products is currently subject to an ongoing debate on the importance of timely introduction of hev screening of blood donors and the impact of blood safety. different countries have chosen different regulatory approaches. just recently, the german federal authorities have introduced mandatory testing of all therapeutic blood products beginning from january st . however, we already decided to voluntarily test all our blood products since january . aims: in this study, we present our results of a % screening of therapeutic blood products for hev rna including four years of active surveillance of hepatitis e infection among blood donors in germany. methods: from january to december , a total of , allogenic blood donations from , individual german blood donors were screened in a minipool format of samples of for the presence of hev rna (realstar hev rt-pcr kit, altona diagnostic technologies (adt), hamburg, germany). nucleic acids were extracted from . ml plasma using the chemagen msm-i extractor (viral k, perkin elmer chemagen gmbh). the % lod of the assay was determined to . iu/ml ( iu/ml per single donation). the presence of hev-specific igm and igg antibodies was determined using the anti-hev igm/igg elisa (euroimmun, luebeck). hev rna concentrations were quantified using the first who international standard for hepatitis e virus rna for nat-based assays. all hev rna positive donors were deferred from donation for months. follow-up samples were tested for the presence of hev rna and hev-specific antibodies. genotyping was performed by sequencing of the hypervariable region (hvr) and orf . results: in total, hev rna positive donors were identified. of these, hev rna-positive donors, were nat-only positive donations ( . %, negative for anti-hev igm and anti-hev igg), three donors had a positive igm titer ( . %), donors showed reactive igm and igg titers ( . %), donors already had isolated igg titers ( . %). median values of viral loads were approximately twice as high in index donations that were antibody negative. merely donors showed elevated alt levels ( . %), mostly within a double increase within the reference range ( . %), only . % of donors had even further elevated alt levels. significantly higher alt values were found in donors with a viral load > , iu/ml compared to the group with viral loads between and iu/ml. available follow-up samples confirmed igg seroconversion for all donors, however we also observed long-term igm positivity in some donors. genotyping revealed genotype in all cases. the month-dependent incidence ranges from : to : , blood donations with a peak in june and july. summary/conclusions: the high number of identified hev rna positive donors emphasizes the need for hev-nat screening to increase the safety of blood products. this study further confirmed that hev infection is common in german blood donors. background: zika virus (zikv) is a mosquito-borne virus that has caused outbreaks in central and south america in february , and has threatened the safety of blood transfusion globally. there is a high risk of zikv transmission by whole blood and blood components transfusion. it was reported that, zikv rna in infected patients plasma can only be detected within to weeks. however, in whole blood, zikv rna might present positive up to day after the symptoms appear in some patients, even if the clinical symptoms disappeared with zikv rna negative in plasma. this phenomenon suggested that the presence of zika is associated with red blood cells (rbcs). moreover, another report showed that viral load in whole blood of type a west nile virus (wnv) patients was higher than type o, implying that the binding of virus to rbcs may be related to blood group glycoprotein. both of zikv and wnv are member of the flavivirus genus. the study is intended to explore whether zikv have the same adherence mechanism to rbcs as wnv. aims: to investigate the distribution of zikv in blood components and adherence of zikv to different blood types of rbcs in whole blood. methods: five units for each blood type of a, b, o and ab whole blood were randomly selected. each unit of ml whole blood was divided into two half-unit. zikv was added to one half-unit in a certain proportion, and incubated at °c for days. each component of whole blood was collected for viral load detection. in the other half-unit,rbcs were suspended in the same type pools of plasma with equal volume after the plasma removed from the whole blood after centrifugation. zikv was added with the same certain proportion, and then incubated at °c for days. the whole blood samples and the upper plasma by centrifugation were collected detected for zikv rna. meanwhile, rbcs were washed and resuspended with normal saline followed by viral load detection. results: zika rna of these samples which extracted from whole blood, rbcs, and plasma were determined in a quantitative reverse transcription pcr, and viral rna of each component was all up to copies/ml. although, zikv rna loads did not show significant difference in distribution between rbcs and their corresponding plasma components, zikv rna quantification were significantly higher than those in plasma (p < . ) in type o rbcs and lower than those in plasma (p < . ) in type ab rbcs. summary/conclusions: in our study, we detected high viral rna loads in rbcs. it was demonstrated that zikv adheres to erythrocyte in whole blood, and the blood type may have influence on the adherence. background: hong kong is not endemic for dengue virus (denv) with most of the documented cases being imported. the presence of sufficient number of mosquito vectors, aedes albopictus, in the territory has led to two self-limiting indigenous outbreaks affecting residents from to . during august to september , another outbreak of confirmed cases of autochthonous dengue fever were reported to the department of health, linked to two epidemiological clusters, one in lion rock park near wong tai sin (wts) district ( cases) and the other in cheung chau, an outlying island ( cases). aims: we assessed the risk of dengue transmission from blood donors during the outbreak using a simplified version of the probabilistic model developed by biggerstaff and petersen (b-p) and the european up-front risk assessment tool (eufrat) model (oei, transfusion, ) . methods: patient demographic and general population data were obtained from the centre for health protection and the department of census and statistics of the hong kong government for the number of -to -year-old patients in the outbreak and residents of the same age range in hong kong and wts district as at mid- respectively ( - years old being the eligible age range for first time donation). to apply the b-p model, we estimated denv incidence among donors in hong kong territory and in wts with confirmed denv infection during august to september after correction for clinical:subclinical infections ratio, the mean length of asymptomatic viraemia and the probability of collecting blood from asymptomatic donors as described previously (seed, transfusion, ). to estimate the risk using eufrat model, outbreak and blood donation variables were entered into eufrat's web-based interface (https://eufrattool.ecdc.europa.eu/), which provided automatic calculation of risk-related output parameters. results: while using the b-p model, the estimated risk of collecting a denv viraemic donation was one in , ( , - , , ) territory-wide for the -day study period but increased to one in , ( , - , ) in wts. similarly while applying the eufrat model, the risk of encountering a viraemic donor was in , ( , - , ) territory-wide and in , ( , - , ) in wts during the same period. the eufrat also predicted a territory-wide issue of . unit of denv-contaminated labile blood component during the outbreak period. summary/conclusions: like many mosquito-borne infections such as denv, the risk is characteristically localised and varies geographically and seasonally during outbreaks. the average predicted risk of collecting a denv-viraemic donation territory-wide is low at in , during the outbreak based on the b-p model, which was generally considered as tolerable. however, the risk increased by folds when blood donations were collected from wts residents, who had higher chances of paying visits to lion rock park in close proximity. it was then justifiable to institute risk mitigation policies such as geographically-based deferral and/or fresh component restriction, enhanced post-donation reporting, etc. to protect against blood safety. background: hev is a developing threat to blood safety following the reporting of several cases of transfusion transmission hev (tt-hev). transfusion-related hev infection has been reported in several countries but its true frequency is probably underestimated because it is often asymptomatic and testing of blood donors is infrequent. pakistan is classified as a highly endemic region; with sporadic cases of hev occurring throughout the year, mainly affecting the adult population. to the best of our knowledge, no studies have been reported from pakistan on the epidemiology of hev in blood donors. aims: to assess the epidemiology of the hev specific antibodies and serum alt levels in blood donors of capital twin cities of pakistan. methods: this cross sectional study was conducted from july to december at three blood banks in the capital twin cities (rawalpindi and islamabad) of pakistan. the blood donors were equally distributed across the three blood banks. only donors who tested negative for hiv, hbv and hcv were included in the study. serum alt levels were analyzed by using automated clinical chemistry analyzer (selctra pro m) using merck kits. all samples were tested for hev-specific antibodies (igm and igg) by using enzyme linked immunosorbent assay (elisa) kits (adaltis, italy). statistical analyses were performed using spss software version . (ibm). results: in our study population there were ( . %) males and ( . %) females. the mean age of recruited blood donors was . (sd ae . ), with a range of - . younger donors were more common with a frequency of - year olds of ( . %). we found an overall hev igg prevalence of . % and an hev igm prevalence of . %. there were ( . %) blood donors who were positive for both igg and igm antibodies. our results revealed that the hev specific antibodies (igg, igm) prevalence increased with age. the mean value of serum alt was . (sd ae . ) with a range of - iu/l. the serum alt levels were elevated (> iu/l) in ( . %) blood donors. there was significant correlation (p=< . ) between serum alt level and hev specific antibodies for igg and igm. summary/conclusions: this study shows that a significant proportion of blood donors at our blood centers have been infected with hev and may be able to cause tt-hev. as we have not yet measured hev rna, we have used igm antibodies as a proxy for donors who have active infection. hev is generally asymptomatic, so it is debatable whether mandatory hev screening in blood donors should be required. results of this pilot study show that there is a need to conduct a larger study at national level with highly sensitive assays before making screening for hev mandatory in pakistan. background: hepatitis e virus (hev) is a zoonotic virus. who estimates that there are million hev infections, million acute hev cases and thousands hevrelated deaths worldwide each year. in recent years, the prevalence of hev in european and american countries has increased significantly. the survey results show that the positive rate of hev igg in blood donors is respectively . % in new zealand, . % in britain, . % in denmark, % in the united states and . % in the netherlands. hev has become a global public health concern. in addition to the food route of infection, several cases have been reported that hev can be transmitted via blood products. aims: to investigate the prevalence of hepatitis e virus (hev) infection among voluntary blood donors and potential impact on blood safety in guangzhou china. methods: blood samples from blood donors were collected from april to april at the guangzhou blood center and were tested for anti-hev igg antibody (hev igg), anti-hev igm antibody (hev igm) and hev antigen (hev ag)by enzyme linked immunosorbent assay (elisa). hev rna detection was performed on hev antigen positive samples by rt-pcr. the association of age, gender, ethnicity, occupation and alt with hev igg and igm were analyzed by chi-square test. multivariate logistic regression analysis was applied to identify the independent risk factors of hev infection. results: the positive rates of hev igg, igm and hev ag were . % ( / ), . % ( / ) and . % ( / ), respectively. no positive hev rna was detected. age and ethnicity were independent risk factors for hev igg and hev igm. the rate of hev antibody increased significantly with age (igg or = . , p < . ; igm or = . , p < . ). donors who were zhuang minority ( . %, . %) showed higher anti-hev than those who were han ethnicity ( . %, . %), and the difference was statistically significant (igg or = . , p = . ; igm or = . , p < . ). in addition, we found that occupation was an independent risk factor for hev infection, where students showed the lowest anti-hev rate. summary/conclusions: the results indicate that the positive rate of hev antibody among blood donors in guangzhou is high, and the infection status differs in different populations. our study provides basic data for the estimation of risk of transfusion-transmitted hev. background: human cytomegalovirus (hcmv) belongs to the viral family of herpesviridae. it is an enveloped double-stranded dna virus, widely distributed in the human population ( - % seropositive subjects worldwide) and cause of severe disease in immunocompromised patients and upon infection of the foetus. in normally healthy subjects, hcmv persists lifelong without clinical manifestation undergoing alternating phases of active viral replication and latency. since hcmv can be readily detected in blood, as free virus as well as associated to neutrophils and monocytes, hcmv transmission is a complication of blood transfusion. even though leukoreduction of blood products has been shown to significantly reduce the risk of hcmv transmission, higher inactivation standards may be required for high-risk, immunocompromised groups of patients. aims: in this study, murine macrophages infected with murine cytomegalovirus (mcmv) were used as a model to study the inactivation cell-associated cmv in human plasma using the theraflex mb-plasma system (macopharma). methods: mcmv expressing the green fluorescent protein was used to infect murine macrophages. infected macrophages were harvested h after infection, washed and used for spiking of plasma. plasma units (n = , ml) were spiked with infected cell suspension ( % v/v) and treated with the theraflex mb-plasma system according to the manufacturer's protocol using the macotronic-b illumination device (macopharma). samples were taken after spiking (load and hold sample), after illumination with different light doses ( after addition of mb, , , and [standard] j/cm ) and after blueflex filtration. mcmv titers were determined by endpoint titration and large volume plating on murine fibroblasts. infectious virus, which expressed gfp in infected cells, was detected using a fluorescence microscope. results: the results of infectivity assay showed that the treatment of human plasma by the theraflex mb-plasma system inactivated cell-associated mcmv in a dosedependent manner. after spiking with mcmv infected macrophages a mcmv titer of . (bag no. ) and . (bag no. ) log tcid /ml was achieved in the plasma units. in hold samples, a mcmv titer of . (bag no. and bag no. ) log tcid /ml was determined. the illumination step of the theraflex mb-plasma treatment procedure efficiently inactivated mcmv. already three-fourths of the standard light dose decreased infectivity of cell associated and remaining cell-free mcmv to infectivity levels below the limit of detection (≥ . log). further investigations would be needed to evaluate the log reduction capacity of the blueflex filtration step for cell-associated mcmv. summary/conclusions: the results with the murine model virus suggest that the theraflex mb-plasma system is an effective technology to inactivate cell-associated cmv in human plasma units. background: the use of pathogen inactivation (pi) technologies for platelet concentrates and plasma is slowly but steadily increasing. methods for treatment of red blood cells (rbcs), the most commonly used blood component, are still under development. aims: a novel approach for pi in rbc units employing uvc light was developed. methods: pi treatment was applied to full-scale rbc units after leukodepletion. the pi capacity of the uvc-based method was evaluated by bacteria and virus infectivity assays. a panel of in vitro assays to measure quality, metabolism, functional, morphologic, and blood group serology variables was applied to a pool-and-split approach in which pathogen-reduced rbcs were investigated in comparison to untreated rbcs. results: uvc treatment caused dose-dependent inactivation of bacteria and enveloped and non-enveloped viruses in rbc units. at a full dose, the mean log reduction factors ranged from . (bacillus cereus) to . (serratia liquefaciens) for the tested bacteria, and from . (emcv) to ≥ . (vsv) for the tested viruses. uvc treatment did not alter rbc blood group antigen expression. quality of uvc-treated rbcs was maintained during storage, e.g. hemolysis in uvc-treated and untreated rbcs were well below . % until day of storage. summary/conclusions: the data obtained until now show that uvc irradiation is a potential new method for pi in rbcs and justify further development of this process. background: histo-blood abh antigens are the mayor allogeneic antigens in human and they are widely distributed in almost all tissues. the expression of a- , -fucosyltransferase (fuct ), encoded by fut gene, determines the secretor status of an individual. about % of caucasian population have a functional copy of fut (secretor gene) expressing abh blood group soluble antigens in organic fluids such as saliva and seminal plasma. this individuals are known as "secretors". soluble abh blood group antigens have been associated with several metabolic and infectious diseases as well as reproductive failures. the incidence of infertility related of both male and female factors continues to rise despite many advances in reproductive technologies. it is well known that abo antigens are expressed on sperm membrane and in seminal fluid of secretors as well as abo antibodies are present in cervical mucus. in previous studies we observed significant loss in progressive motility of spermatozoa of non-secretors compared to secretor ones caused by specific cervical mucus antibodies in abo-incompatible couples. in addition, sperm cells are haploid cells, so that a heterozygous individual has two sperm subpopulations, each expressing the corresponding allele. the specific antibody of cervical mucus will attack only its complementary sperm. aims: to evaluate the prevalence of secretor character in men belonging to fertile and infertile couples in order to investigate a possible association with reproductive success. methods: samples of semen, from infertile men and from fertile controls were studied. comprehensive infertility evaluation was performed in all patients according to who criteria. secretor phenotype was evaluated in seminal plasma by inhibition of hemagglutination assay using saline erythrocyte suspensions, monoclonal antibodies anti-a, anti-b and lectin from ulex europaeus (anti-h). to distinguish between abo genes, genomic dna was extracted by an enzymatic digestion method. pcr was designed with two sets of oligonucleotides that allow to amplificate two different regions of the transferases without use of restriction enzymes. by comparison of bands of the pcr products, the individual genotype was determine. cervical mucus antibodies of their female partners were titrated with the corresponding red blood cells. results: results were analysed in both groups. in infertile couples with abo incompatibility, the frequency of non-secretor phenotype of male partners ( . %) were significantly higher than those from fertile couples ( . %) (p < . ) the results obtained by pcr in sperm cells correlated % with red cells phenotypes. summary/conclusions: incidence of infertility continues to increase. several factors have a negative impact on men's reproductive health. immunological implications are now being studied and considered as a cause of failure in sperm-egg interaction, even among normal gametes. secretor phenotype in male partners could help reproductive success by blocking cervical abo antibodies. furthermore, if the male is heterozygous, cervical mucus antibodies will only affect the corresponding sperm. we propose to evaluate abh antigen expression on sperm membrane and seminal plasma as well as abo antibodies in cervical mucus to contribute to the diagnosis and treatment of human infertility. background: the h blood group contains one antigen, the h antigen, which is present on virtually all red blood cells (rbc) and is the acceptor substrate of both a and b gene-specified glycosyltransferases. in blood group o the h antigen remains unmodified and therefore its rbcs show the highest and the rbcs of blood type ab the least amounts of h antigen. individuals with the so called bombay phenotype carry homozygous h null alleles (h | h) and do not produce any h antigen. the para-bombay phenotype retains some h antigen on rbcs either induced by a weakly active (h+ w | h+ w ) or completely silenced fut gene (h | h), mandatory linked with an active fut gene. aims: in this study, we aimed to develop an adapted flow cytometric method to quantify the relative amount of h substance present on rbcs in order to distinguish different abo phenotypes in routine diagnostics as well as to capture rare h-deficient phenotypes. methods: analyses were performed on a flow cytometer (facs canto ii, bd biosciences, ch) and measured with identical instrument settings. list mode data were evaluated and visualised using bd facsdiva software. rbcs were incubated with increasing concentrations of monoclonal anti-h antibodies (bric -pe and a : mixture of bric -pe/bric , ibgrl, uk). after rinsing the cells with pbs, micro-aggregates were mechanically dissolved. rbcs from blood donors with different abo phenotypes (o ( ), a ( ), a ( ), b ( ), a b ( ), a b ( )) and patients with genetically confirmed bombay and para-bombay phenotype were assessed. results: saturation of h antigen binding sites on type o rbcs was achieved only upon use of a : antibody mixture (bric -pe/bric ) covering approx. half of the h-binding sites by unconjugated bric . in contrast, non-o type rbcs reached saturation of h-binding sites using pure bric -pe. rbcs coated with bric -pe at saturation revealed a distinct pattern of mfi (mean fluorescence intensity) depending on the abo phenotype. in addition, mfis of rbcs upon staining with bric -pe did discriminate bombay-and para-bombay type rbcs, respectively. summary/conclusions: adapted flow cytometry is able to distinguish variant expressions of rbcs h antigen. thus, our flow cytometric method may complement traditional serological and genetic analyses in routine abo phenotype cases or, more intriguing, when the bombay or para-bombay phenotype is suspected. it will be of interest to further prove this method by investigating additional rare h-deficient phenotype cases. s chen , , x xu , , x hong , , k ma , , j he , , j chen , and f zhu , blood centre of zhejiang province zhejiang provincial key laboratory of blood safety research, hangzhou, china background: weakened a and b antigen expression results in abo typing discrepancies. h gene controls the development of h substance from which a and b antigens develop. depressed a and b antigen expression and strengthened h antigen expression are always simultaneously observed in abo subgroups. there are other possibilities for weak antigen expression of abo system such as leukemic change and pregnancy. it is undiscovered whether abnormal expressions of a, b and h antigen stand for abo subgroups in hemopathic patients. aims: the aim of this study is to explore the role of enhanced reactions with anti-h in direction to abo subgroups of hemopathic patients. methods: samples from blood donors and hemopathic patients with nonconcordant abo typing by serological tests were collected after consent information. the agglutination strength of these rbcs with anti-h reagent was recorded. enhanced reactions were determined by comparison with the results from normal abo groups. the genomic dnas of samples were extracted and genotyped for abo system. this work was sponsored by the medical science research foundation of zhejiang province ( rc ). results: samples in blood donors showed increased expression of h antigen, of which were identified as abo subgroups. there were enhanced reactions in hemopathic patients. however, were finally confirmed as normal abo genotypes. no statistical significance ( . % vs . %, p > . ) in the frequency of strengthened h antigen expressions was observed between donors and hemopathic patients. the total number of subgroups is and respectively in blood donors and hemopathic patients. extremely significant statistical differences ( . % vs . %, p < . ) existed in the frequency of subgroups with enhanced h antigen, which meant the possibility of subgroups in hemopathic patients samples was less. summary/conclusions: the expression of h antigen is comparably enhanced in subgroups and hemopathies. but most of hemopathic patients with strengthened h antigen expression present normal abo genotypes. as a result, the enhanced reaction with anti-h is necessary but not sufficient for serological identification of abo subgroups in hemopathic patients. background: although the use of automated blood bank analyzer with the advantages of speed and efficiency has recently increased, the abo discrepancies in automated blood bank analyzer have caused the reporting delays of the results and increase of the task. aims: we analyzed the causes of abo discrepancies in automated blood bank analyzer and suggested a solution strategy based on the causes. methods: from november to january , cases ( . %) of abo discrepancies among , abo blood type tests performed using the -min reaction mode of ih- in chonbuk national university hospital blood bank were identified. we compared the test results of -min mode with results of immediate mode using different red cell reagents, and analyzed the causes of discrepancies by performing additional tests such as microscopy, auto-control, antibody screening and identification, anti-a and abo genotyping. results: in the immediate reaction using different red cell reagents, cases ( . %) of discrepancies disappeared and cases ( . %) remained discrepancies. all abo discrepancies observed in the -min reaction were due to serum side causes, and one case ( . %) was due to both of serum and red cells side cause. nonspecific response ( cases, . %), cold antibody ( cases, . %), rouleaux formation ( cases, . %), cis-ab ( cases, . %), and abo subtype ( case, . %) were analyzed as causes of discrepancies. one discrepancy due to cis-ab was disappeared in the immediate reaction using different red cell reagents, abo subtype was changed to totally different blood group, a. on the other hand, in cases of the discrepancy corrected by the immediate reaction using different red cell reagents, the intensity of the positive results still observed in immediate reaction was not different from the -min reaction. summary/conclusions: ih- , an automated blood bank analyzer, was considered useful for automation of abo blood typing, and some observable abo discrepancies are expected to be mostly addressed by reexamining with immediate reaction mode using different red cell reagents. abstract withdrawn. background: abo blood group antigens mainly expressed on red blood cells, but along with that they also present on many organs and tissues like epithelia, platelets, vascular endothelia and neurons etc. the importance of abo antigens extends beyond transfusion medicine by association with various systemic diseases like cardiovascular diseases, gastric diseases, cancers, infectious diseases etc has been proven previously. previous researchers also tried to find out the involvement of abo antigens in neurological diseases like alzheimer's disease, parkinson diseases etc. but association with neurological tumours is less explored. aims: this study aimed to analyse the association of abo blood group antigens with neurological tumours. methods: a retrospective study in a tertiary care institute in india analysed the years data from jan to dec . the carcinoma patient's admitted in neurosurgical department during study period were included in our study. their diagnosis and abo blood groups were collected from hospital information system. data were analysed into microsoft excel and spss (version ). results: during study period a total of patients with neurological tumours were admitted in our hospital. the blood group frequency of these patients were . %, . %, . %, . % for a, b, o and ab respectively. the common neurological tumours found in our study were glioma ( . %) followed by pituitary adenoma ( . %), meningioma ( . %), schwannoma ( . %), cavernoma ( . %), neuroma ( . %) and space occupying lesions ( . %). the prevalence of abo antigens was almost similar in all neurological tumours except in neuroma. neuroma was found in . % o group patients as compared to other blood groups which was found statistically significant (p < . ). summary/conclusions: in this study we tried to analyse the association of neurological tumours with abo blood groups antigens. we found there is no association of neurological tumours with abo blood groups because the prevalence on abo group in general population is almost similar in patient with neurological tumours except neuroma. neuroma group of tumours like neurofibroma, neuroblastoma, nerve tumours etc. were more common in o group of patients while in our population frequency of b blood group antigen ( . %) is more common as compared to o blood group( . %). background: rhd and rhce represent homologous genes in head-to-head position on chromosome (chr , p . ). they encode for the proteins rhd resp. rhce which compose together with rhesus associated glycoprotein (rhag), band and ankyrin the ankyrin complex (ac) linking the red blood cell (rbc) membrane to aspectrin of rbc cytoskeleton (s.e. lux, blood, ). cooperatively, the proteins of ac are important for maturation and physiologic properties of rbcs. many proteins of the rbc membrane express blood group antigens on their extracellular surface and are therefore of concern in transfusion medicine. cepellini et al. described weakened hemagglutination reactions of rhd+ rbcs in the presence of an rhc+ antigen (cepellini et al, pnas, ) . we attempted to further elucidate the expression of rhd/rhag proteins in various rhce/rhce pheno-/genotypes using a sophisticated flow cytometry approach. aims: in this study, we investigated a flow cytometric method for measurement of the antigen-density of various rhce-phenotypes. methods: analysis was performed on a flow cytometer (facscanto ii, becton dickinson (bd)) using bd facsdiva software and identical instrument settings for all samples. optimized number of rbcs was incubated with saturating concentration of pe-conjugated anti-rhd antibodies brad- /brad- /fog- (ibgrl, bristol, uk). debris was excluded by rbc gating in fsc/ssc plot. quantibrite-pe beats (bd) were applied according to manufacturer's instruction to quantify the relative expression of rhd epitopes. in addition a representative number of samples from common phenotypes were assessed for expression of rhag using bric- pe (ibgrl). results: a total of samples from healthy blood donors with serologically defined rhcde phenotypes were included into this study (rr( ), r r( ), r r ( ), r r( ), r r( ), r r ( ), r r ( )). variant expression of rhd by different rhce phenotypes using brad- -pe was shown. rhd was weakly expressed in presence of rhc antigen (cepellini effect). effect of rhd gene dose on rhd protein expression is mitigated by rhc/c genotypes. when only samples with molecularly confirmed phenotypes were assessed, the rhdce genotype predicts consistently the strength of rhd protein expression. outlier samples ( ) were retrospectively genotyped and revealed rhdce genotypes as expected from the strength of rhd expression falsifying serological rhcde phenotypes. in contrast, rhe/e polymorphic site does not correlate with rhd expression. in addition, rhag protein is equally present across all rhcde phenotypes. similar results were obtained by using alternative anti-d antibodies such as brad- -pe and fog- -pe, although different antibody's avidity precludes quantitative comparison of antigen expression on rbcs. summary/conclusions: sophisticated facs methods reveal different expression of rhd on rbcs according to rhce/rhce phenotype/genotype. rhc/c polymorphic sites (c. g>c, c. a>g, c. a>g of exon , exon resp. and intron ) are in linkage with rhd expression, confirming the observation by cepellini et al. in contrast, rhe/e (c. c>g, exon ) is not in linkage with rhd expression. based on epigenomic signature it is conceivable that altered transcription factor binding sites (tbs) of rhd mirrored by homologous rhc/c may cause variant rhd expression. rhe/e snp mirroring the homologous sequence of rhd in exon is not recognised as tbs. in addition, although ac comprises all three rh proteins (rhd, rhce, rhag), their transcriptional regulations seem to be distinct. red cell reference laboratory, australian red cross blood service, perth, australia background: the rh antigen was first described when an antisera thought to contain a potent anti-c did not react with all c+ cells. these non-reacting c+ cells were classified as c+, rh:- , and the antibody specificity anti-rh . most polyclonal anti-c contain anti-c and anti-rh . previous studies have shown of monoclonal anti-c reagents are actually anti-rh . these reagents will not detect the c antigen where the red cells are rh:- . aims: the australian red cross blood service investigated a phenotype discrepancy in a blood donor. the donor's historic phenotype c+ (r r) was inconsistent with the current donation phenotype c-(r r ). we aimed to investigate the cause of the discrepancy so the donor could be assigned the correct phenotype, identify the root cause of the discrepancy and implement any corrective actions. methods: the donor's red cells were phenotyped with all available anti-c reagents as per the manufacturers product insert across both manual and automated testing platforms. following variable results and weaker reactions with some reagents, dna was extracted from the edta sample and was genotyped using immucor bioarray tm hea precise and rhce beadchip tm . targeted dna sequencing of rhd and rhce was also performed using the trusight tm one sequencing panel. a review of the historical phenotype results, including the testing platform and reagents used at the time was also performed. results: on the current sample the donor's red cells gave a + reaction by tube with bio-rad seraclone â ( ) [clone ms ] and immulab epiclone tm [clone anti-c reagents. the sample tested negative on the beckman coulter pk using beckman coulter anti-c [clone ] blood grouping reagent and tested positive ( ) reaction on the immucor neo using immuclone â ( ) anti-c [clone . immucor bioarray tm hea precise beadchip tm predicted a c+ phenotype and no variants were detected with the bioarray tm rhce beadchip tm . the trusight tm one sequencing panel genotyped the donor as rhd* /* n. and rhce* . /* with a predicted phenotype of c+, c+ w , d+, e-, e+, rh: (locr+), rh:- . a review of the donor's historical records indicated the donor tested as c+ on the pk , which at the time was being used with an in-house bromelain preparation (sigma-aldrich) and diagast olymp pheno anti-c reagent [clone ms ]. summary/conclusions: results indicated the phenotype discrepancy was caused by the c+ rh:- variant associated with the rhce* . allele. reagents containing clones ms- and ms correctly phenotyped the donor as c+, with the manual tube reagents showing a weaker reaction which may alert the operator to a possible variant which is important in the patient setting. the beckman coulter pk and associated anti-c [clone ] failed to detect the c antigen. this reagent appears not to detect the c antigen where it is associated with the rh:- phenotype, which is in contrast to the previous report by faas et al, transfusion, where it was demonstrated that clone reacted with c+ rh:- bromelain treated red cells. abstract withdrawn. background: although serological rhd typing has always been challenging due to variation of techniques and variable sensitivity of anti-d reagents, most individuals are unequivocally typed as either rhd positive or rhd negative. however, variants of d (weak d and partial d phenotypes) may present typing difficulties. individuals with partial d (missing epitopes of the d antigen) must be typed as rhd negative as blood receivers, but as rhd positive, as blood donors. aims: the aim of our study was to evaluate the algorithm used since at ahepa university blood center, to resolve rhd typing problems among first time donors. methods: since automatic analyzers may type variants of rhd as rhd+, our practice is to routinely perform two different typing methods in first time donors: an automated microplate method on the neo analyzer (immucor) and the slide test, using a potent reagent (anti-d blend-immunodiagnostika). in case of negative, weak, slow or mixed-field reaction, further testing with an automated microplate weak d method [immucor-modified indirect antiglobulin (anti-igg) test] follows. the next step of the protocol consists of testing with the commercial id-partial rhd typing kit (bio-rad) comprising a panel of monoclonal anti-d reagents, in an indirect coombs gel test assay. the patterns obtained with this kit can distinguish between d weak and partial d and can also differentiate between categories ii, iv, v, vi, vii dfr, dbt and dhar. the last step of our algorithm consists of molecular testing (immucor bioarray rhce and rhd beadchip assays) at the hellenic national blood transfusion center, in case of remaining uncertainty. results: we applied the above algorithm in samples: a) by using the partial d kit, samples were typed: four samples were characterized as "partial d" ( dfr, diii) and as "weak d". four of the weak d samples (all from women of reproductive age) were confirmed by molecular typing ("weak d type " three samples, "weak d type . or . " one sample). b) the nine ( ) remaining samples that showed atypical serological pattern, were sent for molecular testing, which characterized samples as "weak d type ", one sample as "weak d type " and another as "weak d type ". results are pending for samples. summary/conclusions: in our experience some partial rhds may be mistyped as rhd+ if the technologist does not inspect the pattern of the reactions and only takes into account the assignment by the automatic analyzer as d+ or d-. by use of our algorithm, serological characterization was sufficient to distinguish between weak d and partial d in , % of cases. molecular typing was necessary in the rest. the integration of molecular techniques improves the quality and accuracy of d typing of blood donors. if applied to patients, it also allows administration of d positive blood without compromising safety to those carrying prevalent weak d types that have not been reported to produce anti-d. furthermore, it permits withholding rhig in case of pregnant women carrying such weak d types. background: rhd antigen is one of the most clinically significant blood group antigens. except d positive and d negative phenotypes, there are over rhd variants, which represent as serologic weak d phenotypes (swd). patients with certain swd can make anti-d alloantibodies. by serology testing it is not possible to clearly distinguish among different swd. in croatian institute of transfusion medicine (citm) patients and pregnant females with swd are mostly reported as rhd negative and generally did not refer for confirmation, because molecular testing was not part of the algorithm. that remains the risk of shortages of rhd negative blood and overuse of anti-d immunoprophylaxis for pregnant females. according to uk guidelines patients with swd who are likely to require chronic transfusion support and females ≤ years are treated as d negative and refer for confirmation of d type. people who are rhd genotyped as weak d type , or are not susceptible for rhd alloimmunisation. one study showed that in croatian population the most frequent variants are weak d type , and . aims: the aim of this study is to estimate the prevalence of swd in patients and pregnant females and to find out serologic and molecular characteristics of swd referred for confirmation. methods: from / / to / / we analysed . samples of patients and pregnant females. rhd typing was performed by anti-d igm monoclonal reagents in direct agglutination micromethod on tango (bs , bs ) (biorad, dreieich, germany), swing maestro [lmh / (ldm ) + - and th- + rum- + ldm ] and ih- [lmh / (ldm ) + - ] (id-card, biorad, cressier, switzerland). cut-off value for tango was determined as ++ and for gel microtyping as +++. the samples with results below the cut-off were reported and treated as rhd negative, all except those which gave discrepant results at current testing or with historical data. these were sent to rhd genotyping for confirmation. dna extraction was done by qiaamp blood mini kit (qiagen, hilden, germany) and rhd genotyping by pcr-ssp kits ready geneweak d and ready genecde (inno-train, kronberg im taunus, germany). results: from . samples ( , %) were swd. / ( %) were referred to rhd genotyping. / ( %) samples were weak d type , or , while / ( %) were weak d type and partial d variants vii and va. serologic reactions with monoclonal igm anti-d reagents showed different pattern for weak d types , and . clearly negative serologic reactions were given in / samples with bs and bs , in / samples with lmh / (ldm ) + - and in / samples with th- + rum- + ldm . summary/conclusions: the prevalence of swd in this study is rather low ( , %). after rhd genotyping % of referred samples were finally reported as d positive. serologic determination of d variants is inconsistent and only rhd genotyping can resolve rhd status in swd. to define the permanent rhd status of swd female of childbearing potential and patients who are likely to be chronically transfused we will introduce rhd genotyping in the new algorithm. background: among all blood group systems, the antigens of the abo system are by far the most clinically significant. comes second in importance is the antigens of the rh system, which comprise d, c, e, c, and e antigens. another clinically relevant antigen is the k of the kell blood group system, which is known to be involved in both htr and hdfn. the distribution of the major blood group antigens, such as rh, and kell, is well-studied among populations of developing countries. in contrary, a relatively few studies have addressed their frequencies in saudi arabian population this is also the case in jazan province, where only two published studies have analysed the prevalence of abo and d antigens, while the frequency of other clinically important antigens, such as rh and kell antigens, is yet to be explored. aims: to determine the frequency of the following clinically relevant blood group antigens; rh(d, c, e, c, e) and k among saudi blood donors in king fahd central hospital in jazan province. methods: a retrospective, cross-sectional study was carried out in the blood bank of king fahd central hospital in jazan province. the red cell phenotyping records for blood donation of randomly selected saudi donors, who donated blood between january and june , were reviewed to identify the prevalence for the following antigens: d, c, e, c, e and k. the hospital blood bank routinely performs rh/k phenotyping for all blood donation using either bio-rad or ortho diagnostic column agglutination technology (cat) platforms. phenotype frequencies were expressed as percentages. results: this study included a total of saudi voluntary as well as family replacement blood donors. the d antigen was found to be positive in . %, while k antigen was positive in . %. among other studied rh antigens, e was the most common ( . %) followed by c ( . %), c ( . %) and e( . %). dce/dce ( . %) and dce/dce ( . %) were the most common phenotypes amongst d-positive and dnegative donors, respectively. surprisingly, dce/dce phenotype was significantly prevalent ( . %) with almost times higher frequency compared that reported in caucasians ( . %). the rare phenotype dce/dce was found in donors ( . %), while dce/dce and dce/dce phenotypes were found in only one donor each. summary/conclusions: this study is the first to determine the frequency of rh and k antigens in saudi blood donors in jazan province. determination of the frequency of these clinically significant antigens in our geographical area will facilitate the selection of antigen-matched red cell units for transfusion in recipients with multiple alloantibodies. it will also help in the management of blood donation processes and planning the estimated need of blood stock of different blood group phenotypes to meet the patient's needs. abstract withdrawn. background: the gerbich (ge) blood group system includes several high-frequency antigens located on glycophorin c and d. with only few reports published on the clinical significance of antibodies directed against these antigens, it is unclear whether blood transfusions have to be antigen negative in the presence of an anti-ge antibody. the monocyte monolayer assay (mma) is an in-vitro method used to estimate the clinical significance of alloantibodies. aims: to illustrate the role of the monocyte monolayer assay (mma) in the transfusion management of a patient with an anti-ge alloantibody. methods: the clinical and transfusion history was retrospectively retrieved from the patient's medical records. serological investigations were performed by indirect antihuman globulin test. papain and trypsin treated cells were also used. the clinical significance of the antibody was assessed by mma. genomic dna was isolated from whole blood and the samples were further characterized by pcr. results: a -year-old male patient with lung cancer without previous transfusions was admitted ( / ) for surgery. his hemoglobin was . g/l. an anti-ge antibody was detected and it was decided to transfuse ge-positive packed red blood cells (prbcs). however, no blood transfusion was needed. in july , the patient was admitted for colon cancer surgery with a hemoglobin of , g/dl. the anti-ge alloantibody was still detectable and a ssp-pcr revealed the genotype ge* .- . an mma performed on the pre-transfusion sample revealed a monocyte index (mi) of . % and the antibody was considered not to be clinically relevant. the mi was interpreted as following: - % not significant; - % inconclusive; > % clinical significant. however, due to the clinical background of the patient it was decided to transfuse ge-negative prbcs, which were obtained from etablissement francais du sang (efs), paris, france. two days after surgery, the patient received units of ge:- ,- prbcs without any transfusion reaction. one and a half year later ( / ), peritoneal carcinomatosis, as a complication of colon cancer, was diagnosed. the patient's hemoglobin was g/l and he had a passage disorder, symptoms of deterioration and an adynamia. based on the mma results from july indicating no clinical significance of the antibody, it was decided to transfuse ge-positive prbcs. in the following days the patient received a total of units of gepositive prbcs no immediate or delayed transfusion reaction were observed following these transfusions. two further mma's, performed on samples drawn on december th and th ( days after transfusion of a total of three and two days after two further prbcs respectively), showed a mi of . % und % respectively and the anti-ge antibody was considered still not to be clinically significant. summary/conclusions: we report the case of a patient with an anti-ge antibody transfused with ge-positive prbc. as ge-negative prbc are not available in switzerland and not easy to obtain internationally the mma can help in the decision on how to transfuse. in this case, the clinical course confirmed the mma-based prediction. transfusions of ge-positive prbcs were tolerated without signs or symptoms of immediate or delayed transfusion reactions. background: abo grouping discrepancies occur when the results of forward grouping are not corroborative to those of the reverse grouping. these may be due to weak subgroups of a and b, missing or weak abo antibodies or red cell alloantibodies. determination of correct abo blood group of a donor is essential for preventing abo incompatible transfusions and to avoid hemolytic transfusion reactions in the recipient. aims: to determine the frequency of abo discrepancies and their resolution to correctly identify the blood group of the donors. we also determined the frequency of 'weak d' positivity in rhd negative donors. methods: this was a retrospective study on donor samples collected from st april, to th september, (two and a half years). for discrepant samples, the abo and rhd grouping was repeated using tube technique using commercial antisera {anti-a, anti-b, anti-ab and anti-d (igm), anti-d blend (igm+igg), anti-h and anti-a lectins}. adsorption-elution testing was done for detecting weak subgroups of a and b. antibody screen ( -cell) and identification ( -cell) was done by gel technique (bio-rad, switzerland). 'weak d' testing in rhd negative donors was also performed by gel technique. antibody titration was done using tube technique. the donor details including name, age and the registration/unit number of the donation were also checked for all the discrepancies to avoid repetition while data analysis. results: we detected ( . %) abo discrepancies out of the total donor samples tested during the study period. out of these, ( . %) were rhd positive. the most common cause of abo discrepancies was weak anti-b antibody ( / ; . %), followed by weak anti-a antibody and weak subgroups of a ( / each; . % each) and weak subgroups of b ( / ; . %). the remaining . % ( / ) discrepancies were due to agglutination with o cells in reverse grouping. the overall frequency of weak subgroups of a and b collectively was . % ( background: detection of unexpected red blood cell (rbc) antibodies before transfusion is critical for prevention of hemolytic transfusion reaction. ideally, unexpected rbc antibody detection is carried out within days after receiving a patient's sample. however, in some cases, retests could be performed after more than days for evaluation of any transfusion reaction, quality control or research. therefore, it is necessary to determine the stability of antibodies after refrigeration or freezing for a certain period of time. aims: we carried out antibody identification test with fresh, refrigerated and frozen samples using automated analyzer ih- and manual tube methods to evaluate the stability of antibodies after storage and compare the results between the two methods methods: antibody identification tests were performed using ih- (bio-rad, cressier fr, switzerland) and manual tube methods. fifty samples showing positive results in antibody screening test by both methods were divided into three and tested immediately, week after storage at °c and month after storage at À °c. the specificities and reactivities of antibodies at each storage state were recorded and compared between the two methods. results: specificities of antibodies identified were concordant between ih- and manual tube methods irrespective of the storage state. the results were as follows: anti-e/e+c, ; anti-le a , ; anti-di a , ; anti-c+e, ; anti-m, ; anti-d, ; anti-c, ; anti-k, ; anti-jk a , : anti-xg a , ; unidentified antibody, ; autoantibody, cases. with regard to the changes in reactivity owing to storage, ( %) samples (anti-e+c, ; anti-m, ; anti-di a , ; anti-d, ; anti-c+e, ; anti-le a , ; anti-c, : autoantibody, ; unidentified antibody, ) showed identical reactivities after week and month storage by both ih- and tube methods. however, ( %) samples, comprising unidentified antibodies, anti-le a , anti-c+e, anti-e, anti-e+c, and autoantibody, showed decreased reactivities after storage in both methods. three samples, comprising anti-di a , anti-e+c and anti-k antibodies, showed increased reactivities after storage. one sample with anti-jk a showed increased reactivity only after month storage, while one sample with anti-xg a showed decreased reactivity only after month storage. higher reactivities were observed in all samples detected using the ih- analyzer than manual tube methods (p < . , wilcoxon rank sum test). summary/conclusions: the specificities of unexpected antibodies detected by ih- and tube methods were the same in all storage states; however, reactivities were higher in ih- than in the tube method. twenty-six ( %) of samples showed identical reactivities after week refrigeration and month freezing. nineteen ( %) samples showed decreased reactivities after storage; however, ( / , %) of them were nonspecific antibodies, unable to identify using commercial id panels. therefore, it is suggested that retests for evaluation of transfusion reaction, quality control or research could be reliably performed after more than days, if stored appropriately in refrigerated or frozen states. abstract withdrawn. t gleich-nagel , d huber-marcantonio , n rufer , g canellini and c niederhauser unit of transfusion medicine, interregional blood transfusion src, lausanne laboratory diagnostics, interregional blood transfusion src, bern, switzerland background: a positive direct antiglobulin test (dat) is mainly found in patients with warm/cold autoantibodies or alloantibodies directed against transfused erythrocytes. the identification of antibodies fixed on red cells is important for the clinician, allowing the further evaluation of a patient's clinical situation including their current medication. in immunohematology the elution of a positive dat remains a tedious and expensive procedure. the blood transfusion service src (bts src) has derived a flow chart that indicates in which situation an elution of dat positive samples should be performed. in order to follow the bts src guidelines, it is mandatory to obtain additional data related to the patient's condition, such as haemolytic parameters and recent transfusion history. currently, our laboratory is not always able to apply the recommended flowchart, since information is often unavailable. aims: here, we performed a comparative study between the algorithm provided by bts src and our in-house strategy, which is based on the qualitative changes of a positive dat, without the need for additional patient and biological information. methods: details of dat positivity and the patient's transfusion history was taken from the software eprogesa (mak-system) and analysed in excel. we analysed a total of ' dats and evaluated them for their positivity, whether an elution was performed or whether antibodies were detectable in the eluate. furthermore, we performed an additional analysis on those samples, that were derived from recently transfused patients (< days). results: a positive dat was found for igg and c d in out of ' ( . %) samples, a level similar to previous reports of positive dats for hospitalized patients. among these positive samples, ( %) were eluted because of a qualitative change in their positivity according to our in-house algorithm. identification of warm autoantibodies or alloantibodies occurred in only . % ( / ) of the cases. from the patients transfused within the last days and having a positive dat, ( %) were eluted according to our in-house algorithm. the same samples would have been analysed if the swiss transfusion guidelines had been applied. however, this comparative study reveals a significant discrepancy in regards to overall sample numbers that should have been eluted according to the two algorithms ( versus samples). this is mainly due to the fact that the swiss transfusion based algorithm does not recommend an elution of positive dats from patients who did not receive a transfusion within the last -days, except if there is a significant clinical suspicion (e.g. haemolysis). summary/conclusions: this comparative study indicates that our elution-based algorithm was performed on all clinically relevant samples as recommended by the bts src guidelines. qualitative changes in the dat positivity represent our main parameter for selecting those samples to eluate. besides ensuring that no clinically relevant samples were missed, this strategy also led to a large number of unnecessary elution analyses. in conclusion, a significant reduction in the laboratory workload and economical savings arises if the relevant clinical information and patients history is known prior to laboratory analysis. background: novel anti-cd monoclonal antibodies, such as daratumumab (dara) and isatuximab, used in treatment of multiple myeloma, interfere with routine blood bank serologic tests. as part of the strategies to manage these patients, it is recommended to perform extended phenotyping to provide matched units (aabb association bulletin # - ). many investigations have focused on the interference with iat for the screening and identification of underlying alloantibodies and how to overcome them, but less has been published on the potential interference with extended phenotyping techniques. aims: the purpose of this study is to compare different technologies to type the most important antigens in myeloma patients before and during the treatment with therapeutic anti-cd antibodies. vox sanguinis ( ) (suppl. ), - methods: edta-anticoagulated whole blood samples coming from patients in different stages of treatment with daratumumab and with isatuximab have been typed in parallel with dg gel microcolumn (grifols) and mdmulticard technology (grifols). the results are also compared with genotyping results obtained with id core xt (grifols). direct coombs, autocontrol and antibody screening has also been performed as complementary tests. results: the study provides that four patients had positive dat and/or ac before therapeutic cd antibodies treatment. in these cases, of negative antigens (fy / jk and/or s) turn to positive in gel technology but mdmulticard showed % agreement with genotype id core xt results. focusing in the data obtained during the treatment, negative antigens were type as positive in gel technology ( % of the tests). mdmulticard agreed with genotype in % of the analyzed antigens. as complementary data, of patient-treated samples had dat or ac positive and showed panagglutination. summary/conclusions: the results demonstrated that mdmulticard is an effective method to type cd -directed cytolytic antibodies treated samples in addition to dat and or autocontrol positive samples. background: antibody titration is a semi-quantitative method to estimate the strength and concentration of antibodies present in plasma or serum sample. titration methodology should be validated together with clinical data to evaluate the relevance of the titer value in each application. the titer of an antibody depends on different parameters: the antibody concentration in the sample, the density of the corresponding antigen expressed on the red blood cells used, the affinity constant of the antibody-antigen and other parameters regarding the technique used (e.g. gel cards or tube test). gel cards technology reduces the intra and inter-laboratory variation in titration studies comparing with the tube technique. aims: to evaluate the suitability of dg gel coombs, dg gel anti-igg and dg gel neutral (grifols) for titrations using two sample volumes ll and ll. methods: twenty frozen plasma samples containing unexpected antibodies from different specificities (anti-jk a , -fy a , -k, -d, -e and -c) were titrated in dg gel coombs and dg gel anti-igg cards and donor fresh plasmas with natural occurring antibodies (anti-a and -b) were titrated in dg gel coombs and dg gel neutral (saline technique). the titer of the antibodies was determined by testing two-fold dilutions of the plasma with selected red blood cells depending on the antibody tested. plasma samples were diluted in dg gel sol. selected red blood cells serascan diana, serigrup diana or donor blood were added into the card ( ll at . %). further, sample dilutions were dispensed into the card ( ll or ll). subsequently, cards were incubated min, °c (coombs technique) and min, - °c (saline technique), centrifuged in dg spin and the results read. agglutination intensity was graded visually according to the instructions for use of dg gel cards. the reciprocal of the highest plasma dilution that gives macroscopic agglutination was interpreted as the titer. results: titers obtained with dg gel coombs and anti-igg (n = titrations, titer ranged - ) were compared for each sample with unexpected antibodies. no differences were found between gel cards types (differences were ≤ . titer in the % of the cases). differences between dg gel coombs and neutral (saline technique) (n = titrations, titer ranged - ) were observed when anti-a and -b antibodies were titrated using the same sample. the titer was similar or higher in coombs in comparison to the saline technique. coombs titers may be a mix of igm antibodies reacting at °c and igg antibodies. differences were > titer in % of the comparisons and ≤ titer in the rest of the cases ( %). comparing sample volumes of ll and ll in all cards (n = titrations), higher titers were observed using ll, as expected. differences were titer in the % of the comparisons, < titer in % and > titer in the % of the cases. background: autoimmune haemolytic anemias (aiha) are characterized by production of antibodies directed against red blood cells and destruction by the mononuclear phagocytic system or complement system. aiha observed in paediatrics is usually self-limiting and often precipitated by viral infections. in some, the condition is secondary to autoimmune diseases, drugs, infections or underlying primary immune deficiencies. appropriate immuno hematological evaluation to characterise the underlying autoantibody can help identify the type of aiha to aid in diagnosis & treatment of these cases. aims: retrospective analysis of immune-hematological evaluation, treatment and outcome of aiha in paediatrics. methods: patients aged - years, diagnosed with aiha, between april -december ( months) were included in this analysis. aiha was defined as positive direct coombs' test (dct) with anemia associated with corroborative evidence of haemolysis in the form of raised indirect hyperbilirubinemia, raised ldh, raised reticulocyte counts or red cell agglutination on peripheral smear. further monospecific dct and evaluation for the specificity of autoantibody was done for all patients using biorad gel cards and panel cells. steroids were given as first line in all; second line agents included cyclosporine and rituximab. red cell transfusion was given in those with severe anemia with cardiac decompensation. results: patients were diagnosed during the study period with autoimmune haemolytic anemia. haemoglobin at presentation ranged from . to grams/dl. the initial presentation was severe anemia in children and mild-moderate anemia with thrombocytopenia (evan's syndrome) in . the trigger for haemolysis was infection in children. rheumatological evaluation was performed for children out of whom were diagnosed as evolving lupus. primary immune deficiency evaluation was advised for and one child was diagnosed as suffering from combined immunodeficiency. dat was positive in out of aiha patients as one of the infant had dat negative iga mediated aiha secondary to viral infection. two out of dat positive cases had igg & c d positivity on monoclonal dat testing whereas rest had only igg coating the red cells. dat titration was more than : in patients; where only of these patients had both igg and igg coating and rest had only igg . alloantibody screen was negative in all. specificity of autoantibody was found only in one case, which was against rh blood group antigen (anti e). all patients received prednisolone as the primary treatment. three children attained remission following a - weeks of steroids. in those who were steroid dependent, cyclosporine was used as the second line agent in and rituximab was used in . out of these children children are in sustained remission and off any medication, whereas the rest are on low dose steroids with cyclosporine. summary/conclusions: aiha is not an uncommon problem in children and can vary in its clinical severity. the proper diagnosis and management involves efficient immuno-hematological evaluation, as detailed characterization of the autoantibody coating the red cell is very important in guiding the clinician for management and prognosis. abstract withdrawn. background: drug-induced immune hemolytic anemia (diiha) is rare and has only been described once with dexchlorpheniramine (polaramine tm), an antihistaminic agent widely used in the treatment of a variety of allergic reactions. we report a case of diiha complicated with acute renal failure associated with antibodies to dexchlorpheniramine. a -year-old woman with no history of transfusion, was treated semimonthly with a combination of chemotherapy and targeted therapy for metastatic colorectal adenocarcinoma. her chemotherapy regimen consisted of oxaliplatin and -fu with leucovorin rescue (folfox). panitumumab (monoclonal antibody anti-egfr) was used as targeted therapy. premedication with dexchlorpheniramine iv was systematically given at the beginning of each cycle of treatment to reduce the risk of perfusion reactions mainly associated with panitumumab. the patient developed chills and febrile agranulocytosis during the first and second infusion respectively. the third infusion was not performed due to pyrexia, chills, general discomfort experienced by the patient at the beginning of chemotherapy. probabilistic antibiotherapy was administered and the patient recovered rapidly. during the next infusion (day ), following premedication with dexchlorpheniramine, a more "impressive" reaction including all the above mentioned symptoms occured along with back pain and dark colored urine. the infusion was halted and no chemotherapy was delivered. bacterial infection at the implantable port was first thought to be the cause of this adverse event but was not confirmed. additional laboratory findings revealed biological signs of inflammation associated with iha and acute renal failure. the patient was treated with hemodialysis (day ), two units of rbcs (day ) and was discharged one week later in stable condition. dexchlorpheniramine was then suspected and samples collected on day were sent for a diiha laboratory workup. aims: the aim of this study was to support a clinical diagnosis of diiha. methods: laboratory workup included direct and indirect antiglobulin tests (dat and iat). drug antibodies investigation was performed by incubating patient's serum and eluate from patient's rbcs in the presence of drug against normal donor rbcs that had not been previously treated with the drug (i.e., by the so-called "immune complex" method). control tests were performed in parallel. drug was diluted in pbs and tested at and mg/ml. results: dat was positive (anti-igg + , anti-c d + ) and no unexpected rbcs antibodies were detected by iat in patient's serum and eluate without the in vitro addition of the drug. an antibody directed against untreated (titer ) and enzymetreated (titer ) normal donor rbcs was demonstrated only in patient's serum in the presence of the drug tested at mg/ml by the gel method. the pool of normal sera did not react in the presence of the drug. summary/conclusions: the multi-drug treated patient described in this study was demonstrated to have dexchlorpheniramine dependent antibody detected by the "immune complex" method. the key to the diagnosis was the observation of positive dat with negative eluate tests which prompted a reexamination of the medications administered in temporal relationship with the hemolytic event. although rare, this case report should alert physicians to the need to investigate the possibility of dexchlorpheniramine induced hemolytic anemia in any patient who develop unexpected anemia after hematologic or oncologic procedures p- singapore, singapore, singapore background: daratumumab is a monoclonal antibody against cd used in the treatment of multiple myeloma and has been known to bind to cd on rbc's and interfere with indirect antiglobulin based serologic tests such as red cell antibody screens and crossmatch compatibility testing. in order to negate the interference of daratumumab, our reference laboratory follows the daratumumab protocol recommended by the aabb which uses dithiothreitol (dtt) treated reagent red cells in red cell antibody screening and identification test in patients known to have received daratumumab. aims: the objective of this study is to determine the impact of daratumumab in the turnaround time (tat) for red cell antibody screening and identification. methods: a retrospective review of the tat for red cell antibody screening and identification samples of patients known to be treated with daratumumab from october to december was performed. turnaround time is defined as the time the sample is received up the time the results were reported. the tat for routine red cell antibody screen and identifications were also reviewed during the same period and was compared with the tat of samples from patients treated with daratumumab. results: a total of patients on daratumumab had samples sent to our reference laboratory for red cell antibody screen and identification during the study period. information on daratumumab treatment was not provided to the reference lab prior to the start of testing in of the patients while the use daratumumab was mentioned in the serology request form of the other patients. the median tat for red cell antibody screen and identification is min (range: - ) if information on daratumumab was provided prior to start of testing and min (range: - ) if information was not provided prior to testing. the median tat for routine testing is min (range: - ). using wilcoxon rank-sum test, turn-around time for antibody screening and identification for daratumumab treated patients was observed as statistically not significant when compared to routine samples (p value . ). however, tat for serologic tests requests with appropriate medical history compared to the testing requests without relevant information was also observed to be significantly difference (p value . ). summary/conclusions: there is no significant impact in the tat of red cell antibody screen and identification in patients known to receive daratumumab as compared to routine testing. however, there is a significant difference in the tat if information on daratumumab treatment is not provided prior to testing. this highlights the importance of providing the relevant medication information in the request form in order to prevent delays in testing and provision of blood to patients on daratumumab, which can result in improved organizational efficiency and have positive impact on cost and resource savings. background: daratumumab, an anti-cd monoclonal antibody, has been shown to be highly efficacious in the treatment of multiple myeloma (mm). cd is a glycoprotein highly expressed on plasma cells and, to a less extend, on the surface of red blood cells (rbc). when bound to cd on rbc, daratumumab interferes with the pretransfusion tests, with positive antibody screening and crossmatch. anti-cd interference is an important challenge as many mm patients will require blood transfusions during their treatment. dithiothreitol is a reducing reagent with multiple applications in blood bank testing. treatment of rbc with dithiothreitol irreversibly removes cell surface cd tertiary structure, avoiding the binding and testing interference by the anti-cd daratumumab. aims: to demonstrate the efficacy, safety and celerity of the protocol between the blood bank (bb) and haemato-oncology of our institutions, using just the crossmatch. methods: a retrospective research was used for the evaluation of the results obtained from the implemented protocol. this comprehends a previous contact by haemato-oncology that leads to a study of the patient before the beginning of daratumumab treatment, and consists in: abo/rhd grouping; rh and kell phenotyping, and other clinically significant antigens; antibody screening; and direct antiglobulin test. genotyping may be required for some patients who received previous blood transfusions. before the beginning of the therapy, a blood sample of the patient is sent to the bb to perform laboratory tests and frozen after. this frozen sample is used for crossmatching in patients that already started therapy, did not have a blood transfusion in between, and have a positive antibody screening and/or crossmatch. in further transfusions, in case of positive tests, the dithiothreitol-treated donor rbc is applied. the donor rbc antigens are always selected accordingly to patients negative clinically significant antigens, when transfusional support is needed. the laboratory tests are executed in gel column agglutination technique. results: since , patients were studied, from which were transfused with blood units, according to the protocol. there were no immunizations or adverse reactions to transfusion registered within the transfused patients, neither delay on the availability of blood units. patient blood sample collected and frozen prior to the beginning of the treatment, has shown to be a good strategy by reducing significantly the waiting time for the blood unit in the first transfusion. summary/conclusions: this protocol, which defines the communication among the involved professionals, has shown to be a secure and effective way of reducing interferences caused by daratumumab. it ensures the previous study of the patients and their transfusion with rbc respecting the patients negative clinically significant antigens. if not adopted, the mitigation measures described in this protocol, delays in the availability of the rbc requested and alloimmunizations, may and will possibly occur. a good communication between the bb and the haemato-oncology is crucial for a good time management when a transfusion is requested for these patients. three methods were used to resolve this dara interference. reagent rbc's were treated with dtt, which know to denature cd and then tested with patient plasma. allo-adsorption study was performed using a certain ratio of red cells to plasma. in addition, a selection of phenotyped cord cells were used as an antibody screening panel. results: dtt treatment of reagent red cells was successful at eliminating dara interference and allowing for the presence of underlying antibodies to be identified. in this case, underlying antibodies were not detected by using reagent dtt treated red cells or phenotyped cord cells. adsorption technique was ineffective at elimination the reactivity. summary/conclusions: dara is the first commercial fda-approved therapeutic monoclonal antibody used in treating multiple myeloma patients. • since cd is weakly expressed on normal red blood cells, dara attachment to red blood cells can interfere with pre-transfusion iat testing. • dtt treatment of reagent red blood cells and cord cells can abolish the interference of dara to test for the presence of underlying alloantibodies. • to prevent delays in issuing red blood cell units to patients, hospitals should send patient samples to be tested before receiving dara treatment to ensure that clinically significant alloantibodies are not being masked. background: antibody screening (as)is considered superior to antihuman globulin (ahg) cross match during pretransfusion compatibility testing. in spite of knowing the utility and superiority of as, it has not been adopted uniformly in india. therefore, scarce data is available from this subcontinent in terms of optimisation of red cell antibody detection during pretransfusion testing in form of "type and screen" aims: the main objective was to study the benefits of performing simultaneous antibody screening along with the blood grouping during the first hospital visit to the hospital. other objectives were to study the prevalence of clinically significant antibody among the indian population and to follow up the patients who were transfused antibody screen negative but cross match incompatible blood. we also studied some other relevant quality indicators related to efficiency of blood transfusion services methods: this prospective study was carried out at a tertiary healthcare centre in india between july and dec ( months). the study protocol was submitted to institutional review board and permission was granted. blood grouping and as were done during patients' first hospital visit, which we called "type and screen". when the patient got admitted to the hospital and required blood transfusion, a blood request form was generated by the user and sent to blood bank. depending upon the results of antibody detection, further course of action was chosen. if patient was found to have no antibody, immediate spin test (ist) cross match compatible blood was issued and transfused. in such cases the procedure of ahg crossmatch testing was continued even after issue of blood. cases where ahg cross match test was found negative no further follow-up of the patient was done whereas when ahg cross match was found positive, patients were followed after the transfusion results: a total of patients were "type and screened". majority were from hemato-oncology, bmt, liver transplant, paediatric cardiac surgery, and medical icu units. clinically significant allo-antibody was detected in patients and autoantibody was detected in patients. alloantibody was detected mainly against rh and kell blood group systems. in diagnosed aiha cases, majority were in the form of warm aiha ( %) and % of aiha cases were having hidden single or multiple alloantibody. significantly higher proportion of patients in as positive group required blood transfusion than as negative group ( % vs %, p < . ). in both the groups, in planned cases, most of the time blood was issued immediately within the defined turnaround time except in where either transfusion was delayed or surgery was postponed. it happened only in trauma or surgical bleed cases. expiry of blood was decreased significantly due to no usage of blood ( . % vs. %, p < . ). during the period of study we obtained cases where the ist cross match was compatible but the ahg cross match was incompatible. during follow up none of the cases demonstrated any sign of hemolysis summary/conclusions: in developing countries like us, optimization of as during pretransfusion testing increases operational efficiency and significantly decreases the expiry of blood. results: during the period when absc was performed on pk , , donation samples were tested and , ( . %) were found absc positive. antibodies to red cells were identified in donations out of , ( . %) absc positive samples and in the rest, no irregular antibodies were detected. the prevalence rate for atypical antibody was . %. the top most frequent antibody specificities were: nonspecific cold antibodies ( . %), anti-e ( . %), anti-mi a ( . %), anti-m ( . %) and anti-le a ( . %). a total of , donations were screened for atypical antibodies by ih- and , ( . %) were screened positive. among these, anti-red cell antibodies were identified in , samples ( . %), which was significantly higher than those identified in pk screened positive samples (p < . ). the prevalence rate for atypical antibody as screened positive by ih- and with confirmed red cell specificities was . %, which was also significantly higher (p < . ). the top most frequent antibody specificities were: anti-mi a ( . %), anti-m ( . %), anti-le a ( . %), anti-e ( . %) and non-specific cold antibodies ( . %). anti-fy b was detected in cases, which would be missed detection by enzyme treated reagent cells on pk system. summary/conclusions: the performance of the ih- system using a -cell screening panel including one cell with mi(a+) expression and column agglutination technology with iat phase was superior in comparison with that of pk in the context of higher sensitivity in detecting more true positive results and higher specificity in detecting more true negative and less false positive results. this has translated into the advantages of reduction in workload of reference laboratory in performing less antibody identifications in those false positive samples as well as enhanced transfusion safety by removing more irregular red cell antibody positive plasma-containing components from the issuable inventory, which may potentially lead to haemolytic transfusion reactions. the prevalence of irregular red cell antibodies of . % in healthy blood donors in hong kong reflects more the true statistical figure. background: chronic red blood cell (rbc) transfusion is the upfront therapy for thalassaemia patients, however this therapy is featured by several adverse events including rbc alloimmunization. phenotype matched products transfusion policy can prevent alloantibody formation, but it makes routine transfusion more difficult for both the donor center and the transfusion service. a recent systematic review (franchini et al, blood transfus ) reported a rbcalloimmunization prevalence of . %, with a higher incidence against rh and kell systems in thalassemia intermedia patients. aims: the aim of our retrospective study is to evaluate the rbc alloimmunization prevalence in thalassemia patients transfused in a single center over a years period with limited phenotype matched rbc (rh and kell system antigens) units. methods: from to thalassaemia patients, with a minimum follow up of year and transfused with more than > rbc units, were included in our study. patients were studied for: blood group and rh / k phenotype determination, direct antiglobulin test (dat), irregular antibodies research (abirr). cross-match and detection of alloantibodies were performed using the indirect antiglobulin test by the column agglutination method. six-monthly dat and antibody screening were performed using the indirect antiglobulin test and enzymatic papain-treated rbc test. results: overall patients ( females, males) were included in our retrospective analysis: patients were affected by thalassaemia major and by thalassaemia intermedia. rbc alloimmunization prevalence was . % ( patients): patients were found to be positive for rbc alloantibodies, four with alloantibodies and autoantibodies. eleven alloantibodies were detected ( anti-h, anti-cw, anti-e, kpa, anti-jka, anti-jkb, anti-m and anti-lua). in out of alloimmunized patients we found an anti-e antibody reactive in enzymatic papain-treated rbc test only, in the third alloimmunized patient anti-kpa and anti-lua antibodies were detected, while in the remaining patients, in which auto and alloantibodies were detected, a severe autoimmune hemolytic anaemia (aea) requiring therapy was diagnosed. in these cases the appearance of alloantibodies is concomitant with the presence of autoantibodies. among the patients positive for alloantibodies, were affected by major thalassemia and one by intermedia thalassaemia summary/conclusions: in our experience a limited phenotype matched rbc transfusion policy showed a rbc alloimmunization prevalence similar to literature data: . % vs . %; we didn't find higher alloimmunization prevalence in thalassemia intermedia patients may be due to the low patients number. we believe that introduction, in our department, of an extended-phenotype matched transfusion, including antigens of the main group systems (fy, jk, mns) and the main rare antigens (cw, kp, lu), could reduce the risk of red blood cell alloimmunization in thalassemia patients. abstract withdrawn. background: undoubtedly, preventing alloimmunization has an advantage over overcoming its consequences. however, the high cost of technical and organizational aspects of preventive measures requires their scientific substantiation confirmed by clinical and laboratory data. selection of donors of the rhesus (d, c) and kell (k) antigens for the red blood cell transfusions to hematological patients has been regulated in the russian federation since . recipients with the phenotype c+c-transfuse red blood cell only with the same antigenic combination. for transfusions red blood cell obtained from k-negative donors are used. the compatibility of the donor and recipient with the antigens c, e, e, c w (rhesus system) and k (kell system) is additionally taken into account from april . that is, transfuse red blood cell that do not contain antigens in the phenotype that are not in the recipient's phenotype. aims: to evaluate the efficiency of red blood cell donor selection using antigens of rhesus (c, c, e, e, c w ) and kell (k, k) systems for the prevention of the recipient alloimmunization. methods: immunohaematological studies using equipment and reagents of biorad (usa) were performed in patients of the hematology clinic. non-hodgkin lymphoma was diagnosed in patients, acute leukemia in , multiple myeloma in , chronic lymphatic leukemia in , chronic myeloid leukemia in , aplastic anemia in , hemophilia in , myelodysplastic syndrome in , and other hematological diseases in . the frequency of detection of antibodies to antigen c ( . % vs . %) and to antigen e ( . % vs . %) decreased four times. the frequency of detection of antibodies to the c w antigen has not changed significantly ( . % vs . %, respectively). selection of antigens c (rhesus) and k (kell) has been carried out in the clinic since , therefore the immunization index for these antigens remained unchanged and amounted to . % vs . % for anti-c antibodies; . % vs . %for anti-k antibodies. alloantibodies to the antigens e (rhesus) and k (kell) were not detected for the entire observation period. summary/conclusions: research verified the effectiveness of alloimmunization prevention of recipients by selecting red blood cell for antigens c, c, e of the rhesus system and k (kell). the study concluded that selection of red blood cells for the antigens c w , e (rhesus) and k (kell) does not affect the level of alloimmunization of patients and is not clinically justified. background: in the russian federation, there is an order according to which patients requiring multiple transfusions, who are at high risk of immunological complications are to typed for red blood cell antigens: abo, d, c, c, e, e, cw, k, k. selection of erythrocyte-containing blood components is carried out taking into account the donorrecipient compatibility according to all the listed antigens. aims: analysis of results of immunological evaluation of patients of hematological clinic. methods: the study included first time patients of hematology clinic in - . typing of antigens of abo, rhesus, kell systems, screening and identification of antibodies were carried out using equipment and reagents from bio rad (usa). results: interpretation of results of immunohematological screening was complicated in ( . %) patients. the total number of complex cases was . the double population of red blood cell was most often determined in antigens of the rhesus system ( . % of the total number of patients) as a result of previous transfusion therapy. of those, chimera for the antigen e was detected in cases ( . % of patients with the chimera for rhesus and kell antigens), cin ( . %), sin ( . %), e - ( . %), cw - ( . %), k - ( . %). in such cases, donor red blood cells were chosen not carrying chimeric antigen for transfusions, in the presence of chimeras in both paired antigensred blood cell transfusion with the cc phenotype and / ee. chimera for abo antigens was detected in . % of the examined individuals. the discrepancy between the direct and reverse blood grouping of the abo system in patients ( . %) was due to a decrease in the production of antibodies - cases and the appearance of extra agglutinins - case. autoantibodies were detected in . % of all patients, including . % of patients, when they caused panagglutination phenomenon. upon detection of autoantibodies that complicate the individual selection of donors, transfused red blood cells that are compatible with antigens of abo, rhesus, kell, duffy, kidd, mns systems. alloantibodies were detected in . % of patients, including specific anti-din ( . %), anti-dcin ( . %), anti-kin ( . %); antibodies of unidentified specificityin ( . %), polyspecificin ( . %). summary/conclusions: the complexity of interpreting immuno-hematological tests in hematological patients is due to intensive transfusion therapy, changes in red blood cell antigens and appearance of nonspecific antibodies due to underlying disease. red blood cell for transfusion in these patients should be selected taking into account the expanded red blood cell antigen profile. abstract withdrawn. background: blood transfusion is an essential part of therapy for many patients. although life-saving for many patients, blood transfusion is not without risk. the main goal of blood transfusion services is that transfused blood should be compatible with the patient. the clinical and serologic evaluation, which allows for the transfusion of the most compatible (or "least incompatible") blood, requires a joint effort between the clinician and the transfusion medicine physician. aims: root cause analysis of incompatible cross matches in patients. methods: in this prospective study, total of , , crossmatches were performed over period of last four & half years, out of which units were found incompatible by column agglutination method-cat in polyspecific (anti-igg+ c d) gel media. a root cause analysis protocol was formulated to resolve incompatibility to ensure safe transfusion. results: on the evaluation of , , crossmatches, only units were found to be incompatible ( . %). the major cause for incompatibility found in patients was aiha-( . %). other causes of incompatibility were infections ( . %), multiple transfusions ( . %), trauma ( . %), evan's syndrome ( . %), rh negative mother ( . %), sca ( . %) & incompatibility due to dat positive packed red cells ( . %).the most common antibody found were anti-'c', anti-'s' & anti-'m'. summary/conclusions: the rca protocol involves a thorough evaluation of the patient's clinical condition and underlying pathology to identify the cause. a logical stepwise approach will enable provision of safe transfusion to the patient. background: antibodies to high-frequency antigens (hfas) are a transfusion hazard, as compatible blood is often very difficult to obtain. other clinically significant alloantibodies represent an additional transfusion risk. in patients treated with allogeneic bone marrow transplantation (bmt) recipient red cell alloantibodies may cause acute or delayed haemolysis of donor red blood cells (rbc) and contribute to morbidity and mortality. aims: the aim is to present the case of a patient with myelodysplastic syndrome (mds), multiple "common" alloantibodies and an additional alloantibody to a highfrequency antigen, treated with allogeneic bmt. methods: a forty-one-year-old caucasian patient with mds (raeb- ) was admitted to our hospital in january for unrelated allogeneic bmt. she previously received myeloablative conditioning therapy according to the flu / bu / atg protocol ( days of mg iv. fludarabine, days of busulfan mg iv, days of mg iv. antithymocyte globulin). the indirect antiglobulin test (iat), done in august and december of , was negative. according to anamnestic data, the patient had two pregnancies. she received red cell transfusions during childbirth and platelets in december . results: the patient's blood group was o rhd positive, iat positive. the donor blood group was a rhd positive, iat negative. phenotype of the recipient's rbcs, as well as the donor rbcs, was also determined. anti-e and -c w were found in the patient's plasma, but an additional alloantibody was suspected. the autocontrol was negative. column agglutination technology (cat) and tube technology were used to identify rbc antibodies. plasma was tested with pheno-matched rbcs, papain-and . m dithiothreitol-treated rbcs, as well as cord and autologous rbcs. adsorption and elution tests were done, excluding other "usual" clinically significant alloantibodies, and the patient received three incompatible (xm in iat, cat) yt(a+), e-, c w -, k-red cell units. the sample was urgently sent for an antibody investigation at the international blood group reference laboratory (bristol, uk). in the reference laboratory, anti-e, -c w and an alloantibody to a high-frequency antigen were confirmed, whose specificity was determined to be anti-yt a . anti-jk b was also suspected and later confirmed. before the patient was discharged from the hospital, she received eight more red cell units (yt(a+), e-, c w -, jk(b-)), during which she was serologically closely monitored. summary/conclusions: the results of the antibody investigation in this case study indicate the presence of multiple alloantibodies in a patient who has previously received immunosuppressive myeloablative conditioning therapy. in addition to the "common" alloantibodies (anti-e, -c w , -jk b ), an alloantibody to a high-frequency antigen (anti-yt a ) was detected in the patient. this patient was transfused with incompatible red cell units (yt(a+)) in an emergency, with no ill effects. although anti-yt a is rarely a clinically significant antibody, according to literature, it can cause immediate haemolytic transfusion reaction. additional risk were "common" clinically significant alloantibodies, especially anti-jk b , which was in this case extremely difficult to detect and had further complicated the selection of blood. background: the identification of an antibody against a high-incidence antigen always introduces a challenge due to the difficulty in finding compatible units of red blood cells (rbcs). in patients needing surgery it is important to minimize their transfusional needs by implementing patient blood management programs (pbm). tests that predict the clinical significance of antibodies, such as monocyte monolayer assay (mma) are also useful in guiding clinical decisions. kell blood group system contains highly immunogenic antigens. antibodies against these antigens are immunoglobulin g, and can cause severe hemolytic transfusion reactions and fetal anemia. results: case report we report the case of a -year-old female, with non-hodgkin lymphoma, chronic anemia and scoliosis with severe neurological compromise, proposed for lumbar spinal stabilization surgery. she had a total hip replacement surgery in , with unknown transfusion history. her obstetric history was g p a . the patient had no history of thromboembolic or hemorrhagic events. during pre-transfusional tests, she was typed as a rr and had a positive antibody screening test. the identification studies were suggestive of an antibody against a highincidence antigen, so the surgery was delayed until clarification of these results. she was also referred to a pbm appointment where her hemoglobin was improved from . g/dl to . g/dl by administration of ferric carboxymaltose iv and darbepoetin sc. the patient was phenotyped as kp(a+b-) with anti-kpb, an antibody against a highincidence antigen (> % prevalence worldwide). it is a rare antibody with variable reactivity, causing from none to moderate/delayed transfusion reactions. to access the clinical significance of this antibody, a mma was performed, resulting in a reactivity of . %, suggesting no clinical relevance, however it could be altered after transfusion of kpb+ blood. in order to find compatible rbc's, several family members were phenotyped, however they were all positive to the kpb antigen. in portugal there were no rr kp(b-) blood donors, as it is extremely rare, so we searched in the international rare donor panel (irdp) and two donors were found in spain. two units of compatible rbc's were requested prior to the surgery, which was performed successfully four months later without transfusional support. summary/conclusions: anti-kpb is a rare antibody that in some cases can cause hemolysis of the transfused kp(b+) red blood cells. the combination of kp(b-) and o rr, an extremely rare phenotype, presented a challenge in finding compatible rbcs. this case illustrates not only the complex transfusional and logistic problems that an antibody against a high-incidence antigen can pose, but also the importance of an efficient pbm programme to mitigate the transfusional needs in these patients. background: blood transfusion is an integral part of the supportive care for patients with sickle cell disease (scd). allo-immunization is a recognized complication to red blood cells transfusion (rbc) in those patients. this may result in difficulties in providing compatible blood, and may be associated with the risk of acute of delayed hemolytic transfusion reactions. aims: to describe transfusion management in a patient with scd who has multiple alloantibodies with difficulty in obtaining compatible blood, in order to highlight the importance and clinical consequences of this complication and suggest a possible management approach methods: an -years-old female patient with scd presented to our hospital with hemoglobin level of g/dl secondary to acute splenic sequestration. she had a history of multiple previous admissions and many previous rbc transfusions. blood grouping and pre-transfusion compatibility testing were performed in addition to phenotyping of the patient's red cells. screening was done using column agglutination technique by automated machine (ortho; usa) and antibody identification was performed manually using commercial cells identification panel. phenotyping for the patient was done using haemagglutination technique with mono-specific anti sera (bio-rad; switzerland). results: the patient was of group o rhd (positive). antibody screening was positive and antibody identification revealed probable anti-e and anti-fya with possible development of anti-k allo-antibodies, in addition to recent development of autoantibodies; giving pan-positive reactivity with the identification panels. phenotyping of the patient's rbcs was found to be r r and k-negative. other masked allo-antibodies of undefined specificities were suspected and no compatible blood was found. the clinical condition warranted a blood transfusion, so least incompatible phenotypically matched rbc unit was released. the patient developed acute hemolytic transfusion reaction with drop of the hb level to . g/dl. despite screening hundreds of rbc units, no compatible units were identified, and no transfusion was given. the patient was managed conservatively using hydration, analgesics, hydroxyurea, erythropoietin, intravenous immune globulin (ivig), steroids, and rituximab. hb level increased to g/dl in weeks, and the patient was discharged from the hospital. the sample of the patient was sent to a reference lab (institut fur klinische chemie und laboratoriumsmedizin-regensburg -germany) for further investigations, clarifications and advice for compatible transfusion in case of need. the report of the reference lab revealed the development of additional anti-m and anti-s with confirmation of the presence of anti-fya, anti-k and warm auto-antibodies. phenotyping of rbcs was confirmed by molecular diagnostic testing done in the reference lab; as r r, k-neg. summary/conclusions: finding compatible blood may be extremely difficult in patients with scd who develop multiple alloantibodies. it is therefore essential to perform an initial extended red cell phenotyping for the patients at diagnosis and to have on shelf ready phenotyped blood units for issuing to the patients, to minimize allo-immunization. transfusion may occasionally be avoided in allo-immunized patients, utilizing alternative options of treatment and reducing the risk of serious complications such as hemolytic transfusion reactions. background: red blood cell (rbc) antigens that are present on less than % of most populations are known as low incidence antigens and those present on more than % are known has high incidence antigens. the mns blood group system consists of antigens carried on glycophorin a (gpa), glycophorin b (gpb) or on hybrids of these glycophorins. there are low incidence and high incidence antigens in the mns blood group system. an individual that is homozygous for gp.mur will be negative for the high incidence jenu (mns ) antigen. anti-jenu was first described in a thai patient with thalassemia where only compatible units were found following screening of units. the jenu negative phenotype is a rare phenotype with an estimated frequency of . %. a male patient with a history of previous transfusion presented with an anti-e and a weak auto antibody with no apparent specificity. a donor unit selected for cross match (group o rhd positive, c+e-c-e+, k-) was incompatible with a reaction grade of + by column agglutination technology. the patient's sample and donor unit were referred to the red cell reference laboratory for investigation for a possible antibody to a low incidence antigen. aims: we aim to characterize the phenotype of the incompatible donor unit. methods: standard serological procedures were used to identify the antibody specificities in the patient's sample. blood group phenotyping of the patient and donor was performed by standard serological procedures. genotyping and zygosity testing was performed using polymerase chain reaction (pcr) high-resolution melting (hrm) assay. gp.mur is a gp(b-a-b) hybrid glycophorin resulting from a gene conversion event between gypa and gypb . this disruption to gpb impacts s expression. the donor was negative with anti-s moab (albaclone), positive with anti-s polyclonal (immulab) and negative with anti-s monoclonal antibody (immulab). this s and s phenotype was consistent with the previously reported examples of gp.mur homozygote jenu negative individuals. molecular testing was consistent with serology supporting gp.mur homozygosity and jenu negative phenotype. summary/conclusions: this donor has been added to our rare donor panel and their red cell donations are cryopreserved for future use in our rare donor frozen inventory. there is limited anti-jenu antiserum available to confirm the jenu negative phenotype. we currently rely on the serological profile of red cells presenting with the gp.mur phenotype, s negative and the discrepant s phenotyping to identify jenu negative donors. this case has highlighted the importance of following up unexplained serological incompatibilities. the development of a monoclonal antibody directed against jenu antigen would provide an opportunity to screen for suitable donors for this rare phenotype. background: molecules expressed on tumor cells are a target of interest for drug development by the use of monoclonal antibodies or blocking proteins. however these drugs have the potential to interfere in pretransfusion testing when the target molecule such as cd is also expressed on red blood cells (rbcs). recently, many drugs targeting cd have been developed but appropriate mitigation strategies and approach to selecting rbcs for safe transfusion is still an obstacle. aims: we describe a case of delayed hemolytic transfusion reaction (dhtr) by anti-jk a in a patient treated previously with cd targeted high affinity sirpa fusion protein alx . methods: a -year-old woman diagnosed with nasal cavity squamous cell carcinoma was enrolled in an alx clinical trial. her blood type was group ab, rhd positive, and the antibody screening test was negative for the past months. she had no previous transfusion history during the past two years. after two infusions of alx , two units of apheresis platelets were requested for transfusion. the blood bank noticed that the antibody screening was positive and further investigation was proceeded. results: antibody screening showed trace positivity in both panel cells (i & ii) at room temperature (rt) and °c albumin phase, and + at anti-human globulin (ahg) phase by tube method. the auto control was negative at rt and °c albumin phase, but + at ahg phase. antibody screening ( cells) and identification ( cells) all showed + at ahg phase using gel cards. direct antiglobulin test was + for anti-igg and + for anti-c d using gel cards. two units of rbcs were requested for transfusion after hemoglobin decrease to . g/dl. rbc genotyping was unavailable at the moment. as her previous antibody screening was negative (anti-jk a not detectable), e-, c-, fy b -rbcs were given as a second best option, considering the phenotype distribution of major blood groups in the korean population. the hemoglobin level was well sustained between . - . g/dl but it decreased again to . g/dl twenty days after rbc transfusion. further laboratory investigation was consistent with a dhtr. the patient was no longer being given alx , and antibody screening and dat decreased to - + reactivity. we presumed that antigen typing results would be reliable after chloroquine dissociation and cell washing using antisera that did not require ahg for testing. serologic phenotyping showed that the patient's cells were c+, e+, c+, e+, jk a -, jk b +, fy a +, fy b -, s-, s+, m+, n + . antibody identification using papainized panel cells revealed anti-jk a antibody. we concluded that the dhtr was due to anti-jk a , and jk a -, fy b -, s-rbcs were issued for further transfusion requests. the patient's hemoglobin level recovered to . g/ dl. the patient's genotype was later identified to be the same as serologic typing. summary/conclusions: communication with the physician and blood bank to perform adequate pretransfusion testing before administration of drugs targeted to cd is important to achieve safe transfusion for patients. serologic phenotyping using antisera which do not require ahg for testing can be used as a second option when genotyping is unavailable in a timely manner. background: transfusion is still a key treatment for sickle cell disease (scd) patients. as a result, these patients are much more exposed to transfusions' risks, the most feared one being a delayed hemolytic transfusion reaction (dhtr). we investigated a female scd pediatric patient with no known antibody, who was referred to us for a suspicion of two dhtrs. three transfusion episodes were reported (a total of four units collected from four donors). for the last transfusion, a premedication with rituximab was done. the patient was planned to undergo a bone marrow transplant with her brother as her donor. aims: to describe the molecular and serological workups needed to investigate a dhtr in a scd patient. methods: antibody identification and crossmatches were performed by iat gel testing with red blood cells/panels, which were used raw, papain-treated and trypsintreated. rbcs' phenotypes were determined by conventional techniques. semi-quantitative phenotypes were conducted by serial dilutions with a monoclonal anti-jk a (ms /seraclone â ). dna was extracted using the magna pure compact instrument (roche). sequencing of jk exons - was carried out by in-house techniques. results: the antibody identification showed a very weak anti-jk a , which was only reactive on papain-treated rbcs. autologous control was also only positive in this technique. dat and the eluate were negative. as the patient had recently been transfused (less than four months earlier), on this first sample we were neither able to perform autologous adsorptions, nor verify her jk a /jk b phenotypes. in order to rule out the imputability of an anti-lfa in the dhtr outcome, crossmatches with her donors' rbcs were undertaken. three out of the four donors were tested. apart from the anti-jk a reactivity, none of them was reactive. because the patient had previously been phenotyped as jk(a+b+), her jk gene was sequenced. her genotype was determined as jk* ( a, a, a, g)/jk* . to confirm this jk a variant allele, a family study was conducted. all her siblings were found to harbor the same genotype. her mother's and father's genotypes were jk* ( a, a, a, g)/ jk* and jk* /jk* , respectively. subsequently, autologous adsorptions were performed, which proved the anti-jk a to be an autoantibody. considering the weakness of this antibody, internal controls were used, in order to evaluate a possible dilution effect of this technique. finally, serial dilutions with the anti-jk a reagent showed a weakened jk a expression encoded by the jk* ( a, a, a, g) variant allele. this finding is consistent with the fact that the crossmatches between the proband's serum and her brother's rbcs were weaker than those performed with (jka+b+) rbcs. summary/conclusions: about a third of dhtrs are reported to happen in patients with no previous history of immunization. performing sensitive serological techniques in order to identify antibodies is necessary to select the most appropriate units. molecular work and extra serological testing can be useful to determine whether an antibody is an allo or autoantibody. even though in this case the anti-jk a was the only antibody identified, because it was proven to be an autoantibody, it is difficult to conclude if it was the cause of the dhtr. nevertheless, jk(a-b+) blood was issued, and no adverse events have been reported. luckily, the patient's bone marrow donor harbors the same variant allele. background: according to the aabb, a pre-transfusion sample must be obtained within days of transfusion if a patient has been transfused or pregnant in the preceding months. despite this safeguard, high risk patients (i.e. those recently transfused with a history of pregnancy or transfusion) may develop antibody during this day window. to avoid issuing incompatible red blood cells (rbcs) to these patients, a new antibody screen (abs) sample should be drawn and tested shortly before anticipated transfusion. aims: we report a case of a y/o man who presented to the ed (hospital day , hd ) with a post-fall intracranial hemorrhage and multiple fractures. anti-e and anti-jka were identified after admission on a new specimen prior to current specimen expiration (< days). methods: specimen # (s ) was sent on hd for type & abs (t&s) and crossmatch (xm) of rbcs. abs and immediate spin xm were negative; there was no patient history. by hd , he had negative t&s specimens (hd : s ; hd : s & ; hd : s ) and had been transfused rbcs (hd : ; hd : ) via electronic xm (exm). at hr on hd , rbcs were requested and could have been issued via exm since s was not expiring until midnight. however, given recent transfusions, bb staff first called the patient's nurse to review history. patient was uncommunicative, but had scars suggesting past trauma or surgery. s was requested and received at hr. results: s showed anti-e and anti-jk a in plasma and eluate. his hemoglobin/hematocrit (h/h) decreased from . ( . - . g/dl)/ . ( . - . %) on hd to . / . on hd . during this period, he underwent several surgeries without unexpected bleeding, documented jaundice or dark urine. two e-jk(a-) rbcs were transfused on hd , which he tolerated well with an increase of hemoglobin from . g/dl to . g/ dl. he did well post transfusion with stable h/h between . / . . to . / . . he was discharged on hd . repeat abs on s was negative. of the rbcs transfused before s , one was e+ and four jk(a+). the family reported that he was injured years prior and had been admitted to hospitals, but was unaware of transfusion. hospital # (h ) reported admissions years ago ( rbcs transfused) and years ago; all abs were negative. h admission was years ago with positive abs and inconclusive workup. h admission years ago showed negative abs. summary/conclusions: the patient developed a significant antibody response in less than days from the specimen collection, likely a secondary immune response to sensitization from a transfusion years earlier. a new specimen was requested prior to transfusion even though the existing sample (which was abs negative) had not expired. this approach identified new antibodies, preventing transfusion of incompatible rbcs, and a potentially serious hemolytic transfusion reaction. this case suggests that for high-risk patients, abs more frequently than every days may be beneficial. it is important to increase clinicians' and laboratorians' awareness of this issue. background: red cells with partial d antigen have historically been classified as such, based on the fact that the red cells type as d positive, but individuals make anti-d antibody when exposed to conventional d antigen. a definitive confirmation of the variant of d antigen is obtained after the rh d genotyping. aims: to present a case study of the patient's alloimmunisation with the present d partial antigen type dnb, most likely on previously received transfusions. methods: the patient's pretransfusion testing included the determination of the abo blood group and rhd type (id card diaclon abo/d dv+, dv-, reverse grouping, monoclonal antibodies, gel method), antiglobulin crossmatch, additional phenotyping (gel and tube methods), antibody screening, identification of the specificity of irregular anti-erythrocyte antibodies by commercially available red cell panels (id dia-panel bio rad gel method, panocell immucor, tube method) through an indirect antiglobulin test (iat) and enzymes. after routine rhd typing we continued further characterisation of the rhd antigen by serologic assay (bio-rad id-partial rhd typing),and finally by rhd antigen molecular genotyping (fluogene method on fluo vista machine). results: our patient is a year old woman with a diagnosis of tu mammae who was preparing for total mastectomy surgery. she had a history of blood transfusions twenty years ago, and she also had two births. the blood group typing was: o, ccdee, k-, fy (a-b +), jk (a+b +), ss, mn, le (a+b -). the agglutination reactions that we tested with anti d serums were strong ( +). the compatibility test with rhd positive donated blood units was positive. the presence of anti-d and anti-fya antibodies in the serum of the patient was determined. we prepared one compatible blood unit, rhd negative and fya negative, for a surgery. interpretation of the id-partial rh d typing set indicated that this is a diii category of d partial antigen. a sample of blood of our patient was sent to the blood transfusion institute of serbia, where molecular typing of d antigen was performed and the presence of partial form of antigen d, dnb type, was found. summary/conclusions: rhd positive patients or donors with anti-d antibody presents in their serum should be tested for d genotyping. the recommendation for further transfusions of our patient with dnb d partial and her alloimmunisation is to prepare d negative, fya negative erythrocytic blood components, and as a possible blood donor it would be labeled as rh d positive. background: the jr blood group system consists of jr a (jr ), a high frequency antigen expressed by the abcg gene. the individuals with jr(a-) phenotype are mainly found in the japanese population and may develop anti-jr a when stimulated by blood transfusion or pregnancy. anti-jr a is a dangerous antibody for pregnancy, but also could cause mild or moderate neonatal jaundice. aims: to conduct the antibody specificity identification of the high frequency antibody in a pregnant woman with history of pregnancy but no transfusion. methods: abo, rhd and some special blood group antigens were identified by tube method in saline. antibody screening and blood group specific antibody identification were performed by indirect antiglobulin test (iat) in gel column. the reagent cells treated with trypsin, chymotrypsin and papain, were used to test the antiserum to obtain the characteristic of antibody reaction. the antibody titer in the patient's serum was detected. dna sample was extracted and exons and adjacent intronic sequence of the abcg gene were sequenced. the sample of one family member was collected for testing. results: the blood groups of the patient were b, rhd(+), lu b (+) and kp b (+). the negative reaction of the serum reacted with all reagent cells were tested in saline, but positive ( +) in iat test, while the self-control was negative. the antiserums reacted strongly ( + in iat test in gel card) with the papain-treated cells, but kept the same reaction strength ( +) with trypsin-and chymotrypsin-treated cells, which indicated the possible existence of anti-jr a . the titer of igg antibody in serum was . in cross matching test, the red blood cell of the patient's brother with the same abo and rhd blood group with the patient was successfully matched with the serum of the patient. the sequencing analysis of the abcg gene in the patient and her brother revealed one homozygous nonsense mutation in exon (c. c>t, p.gln x). after the delivery of the pregnant women, no pathological jaundice was seen in the newborn. summary/conclusions: in the condition of the anti-jr a reagent was unavailable for the identification of jr a antigen in the patient, having an indication with anti-jr a by serological test, the alternative genotyping method was used. the most common silencing jr allele reported in asian population, especially in japanese population, was identified to indicate jr(a-) phenotype. immunohemotherapy, centro hospitalar vila nova de gaia/espinho, vila nova de gaia, portugal background: if the investigation of irregular/unexpected antibodies reveals a pattern in which all or most screen and panel cells are positive, with reactions in the same phase and with the same strength, along with a negative autocontrol, an irregular antibody to a high-prevalence antigen may be suspected. high-prevalence antigens are those that are present in almost all individuals ( % or more). fortunately, because these antigens do occur so frequently, it is not common to find a patient with an antibody to one of them. however, when it happens, it may become a troubling situation. aims: clinical case report of panagglutination in assessment of irregular antibodies. methods: collection of clinical data in scl ınico â and sibas â applications. results: woman, years old, o rhd+, previously transfused with red blood cells concentrates in , was proposed to a correction surgery of a periprosthetic hip fracture. pretransfusion serologic tests were requested and irregular antibodies were detected ( + in all the screening cells). in order to identify the specificity of the antibody, a panel of cells was tested; the result was considered inconclusive, due to positive reactions ( +) with all test cells in liss/coombs and atypical positivity with dragging in all cells in enzymatic environment. autocontrol and direct antiglobulin test were negative. it was decided to send two blood samples to the reference laboratory for a more complete immunohematological study. compatibilization of red blood cells to this patient was also requested. during the waiting period, haematopoiesis was optimized. although the patient did not present anaemia at admission, the analytical study revealed iron deficiency; therefore, supplementation with intravenous iron was performed. the reference laboratory also obtained a panreactive panel ( + with all cells) in liss/coombs and weak positivity in papain. after allo-adsorption, the search for irregular antibodies was negative. an anti-yt a , apparently without clinical significance (negative igg and igg ) was then identified. transfusion was not needed either during or after the surgery, with a good recovery of the haemoglobin value in the postoperative period. summary/conclusions: yt a , which belongs to cartwright system, is a high-prevalence antigen in all populations. anti-yt a , an igg antibody stimulated by pregnancy or transfusion, is not as uncommon as we may think, which suggests that it is reasonably immunogenic. these antibodies are not generally considered clinically significant, but there are reported cases of acute and delayed haemolytic transfusion reactions in which anti-yt a has been implicated. therefore, although the described pattern of panagglutination in assessment of irregular antibodies may suggest the presence of an alloantibody directed against a highfrequency antigen, it is very important to confirm that hypothesis, recurring to a reference laboratory if necessary, to identify the antibody and to determine its clinical relevance. even if the identified antibody is associated with rare haemolytic transfusion reactions, it is crucial to optimize haematopoiesis when it is not an emergent procedure, in order to minimize transfusion and its associated risks. both for emergent and elective procedures, the creation of a national database of patients with already identified irregular antibodies would facilitate the administration of red cells concentrates without the implicated antigen. aims: to investigate the frequency and explore the genomic characterization of jk (a-b-) phenotype in blood donors in harbin, china. methods: all samples were screened for jk(a-b-) phenotype using a direct urea lysis test. and the results were confirmed with by iat using anti-jka and anti-jkb with a standard tube test. additionally, polymerase chain reaction amplification and sequence analysis of the jk gene were performed. results: from blood samples, four donors with jk (a-b-) were selected, at a frequency of . %. among these four samples available for sequencing jk gene, a total of two genotypes were discovered: heterozygote of ivs - g>a combining with heterozygote of g>a (gly glu) and heterozygote of g>a (gly glu) combining with heterozygote of c>t(thr met). summary/conclusions: the frequency of jk(a-b-) phenotype in blood donors in harbin area was lower than the reported data from the populations in other areas of china and in finland, but higher than that in japan. ivs - g>a, g>a and c>t were common mutations in the before reports, while g>a was reported first time. in addition, it is an effective measure which establish the jk(a-b-) phenotype donors in this region, to solve the blood transfusion problem in patients with anti-jk . background: blood types, indicating the type of blood group antigen expressed in the red blood cells, is determined by the type of allele at the blood group gene locus. therefore, when allele frequency of each blood group gene is determined, it is possible to predict the frequency of a specific blood type donor with a homozygous allele. it is also possible to estimate the proportion of donors within a particular blood type through combination of specific alleles. and because the ratio of blood group allele differs between ethnicity and race, this can be used as basic data for population genetics and anthropology. therefore, we present a study that examined the allele frequencies of blood group systems in the korean population through blood group genotyping. aims: the purpose of this study is to determine the frequencies of blood group alleles in the korean population, to predict the proportion of homozygous donors, and to obtain the basic data of population genetics. methods: , blood donors from age to were recruited at korean red cross blood centers located nationwide. acquired samples were examined by blood group genotyping methods using the rbc genotyping system id core xt (progenika biopharma). for each donor, genotypes of blood group systems, excluding abo and rhd, were identified. calculation of the frequencies of blood group alleles in the korean population was done. results: we conducted molecular genotyping of the rhce, kell, kidd, duffy, mnss, diego, dombrock, colton, cartwright, and lutheran blood group systems. the allele frequencies of these blood group systems in the korean population were estimated as follows. -rhce*ce . %, rhce*ce . %, rhce*ce . %, rhce*ce . % -kel*k_kpb_jsb allele % -jk*a allele . %, jk*b allele . %, jk*b_null allele . % -fy*a allele . %, fy*b allele . % -gypa*m allele . %, gypa*n allele . % -gypb*s allele . %, gypb*s allele . %, gypb*mur allele . % -di*a allele . %, di*b allele . % -do*a allele . %, do*b allele . % -co*a allele % -yt*a allele % -lu*b allele % summary/conclusions: the significance of this study is accumulation of data on the allele frequencies of blood group genes through highly accurate genotyping method in the east asia region. this enables the prediction of the proportion of donors with a combination of specific blood group alleles in the korean population, which accounts for a decent percentage of the population in this region. background: in donors from arabian countries only little is known about blood groups other than abo and rhesus. during the last years increased migration to central europe has put a focus on the question how to guarantee blood supply for patients from these countries, particularly because hemoglobinopathies with the need of regular blood support are more frequent in patients from that region. aims: blood group allele frequencies should be determined in individuals from syria, other arabian countries, and iran by molecular typing. methods: as most blood groups are defined by single nucleotide polymorphisms (snps) we introduced a maldi-tof ms assay to detect alleles encoding blood groups including kk, fy (a/b), fy null , c w , jk(a/b), jo(a+/a-), lu(a/b), lu ( / ), ss, do (a/b), co(a/b), in(a/b), js(a/b), kp(a/b), rhce*c. c>g, and rhce*c. c>g. additional blood groups and polymorphisms like yt(a/b), s-s-u-, vel null , co null and rhce*c. g>t were tested by pcr-ssp. a total of probands including individuals from syria, from iran, from the arabian peninsula and from northern african countries were included. results: % of the donors were homozygous for the fy null (fy*- t>c, fy* n. ) mutation, . % carried the heterozygous mutation. . % of the syrian probands were heterozygous for the do* c>t mutation (both, do*jo and do*jo ; jo(a+/ a-)) that is virtually unknown in caucasian donors. . % of the syrian donors heterozygously carried the kel* . allele coding for js(a) (phenotype js(a+/ b+)) that is very rare in caucasians. however, no homozygous kel* . carriers were identified. . % of the syrian and . % of all donors were negative for yt*a, which is definitely more frequent than in europeans. one donor from northern africa homozygously carried the gypb*c. c>g, intron + g mutation, inducing the s-u+ w phenotype. . % of all and . % of northern african donors were heterozygous for the rhce*c. c>g substitution, . % of the syrian donors carried rhce*c. c>g (heterozygously) and . % of all donors were heterozygous for rhce* g>t. heterozygosity for vel deficiency (vel*- ) was detected in individuals ( %; of them from syria) whereas only one syrian donor carried the homozygous mutation. none of the donors carried the aqp *c. delg (co* n. ) mutation that induces the co null phenotype. summary/conclusions: the study provides a first overview on a number of different blood group alleles in blood donors from arabian countries. some blood group alleles that largely are lacking in europeans but had been described in african individuals are present in arabian populations at a somewhat lower frequency. in single cases it could be challenging to provide immunized arabian patients with compatible blood. methods: three unrelated individuals ( blood donors and one pregnant woman) of polish origin who were typed as ab group with a very weak a antigen and normal b antigen expression were subjected to extended abo typing. in one case family studies were performed (blood samples from donor's mother, father and sister). sequencing analysis of this donor dna was performed three times (from two blood samples and buccal swab). serologic investigations were performed with standard methods: /gel cards diaclon id abo/d (anti-a: clone a , anti-b: clone g / , anti-a,b: clone es , es + birma + es ; bio-rad) and diaclon id abd-confirmation for donors (anti-a: clone m / = la- ; bio-rad); /tube techniques with: anti-a (birma ; a- h , a s.pa m , c. d ), anti-b (lb- , b- f , c. a ). genotyping was determined by rbc fluogene abo basic kit (inno-train, germany) and by sequencing of + . -kb site of abo gene to cover sequences ranging from the end of intron to utr of the abo gene. additionally sequence of exon of the abo gene was analyzed. results: abo typing showed normal b and a very weak a antigens on rbcs of all three individuals ( blood donors and one pregnant woman). the a antigen was detected by tube technique only using anti-a clones: birma ( + to +), a- h ( + to +) and c. d (weak+ to +); negative reaction of a antigen typing by gel cards was observed. the sera of all individuals contained anti-a antibodies. commercial pcr-ssp kit revealed three heterozygous a/b genotypes (absence of delc typical for abo*a alleles). in all these individuals abo sequencing of . -kb fragment confirmed the heterozygous genotype with polymorphisms characteristic for abo*b. allele ( a>g; c>g; c>t; g>a; c>a; g>c; g>a) and detected a novel abo*a allele sequence with duplication-based insertion of bp after position (abo*a c.dup _ ; gcaggacgtgtccatgcgccg). as a consequence, the online protein translation predicts an in-frame duplication of seven amino acids after codon (p.dup_ _ qdvsmrr), with synonymous change of the repeated codon (cgc>cgg) and (cgg>cgc) but both coding arginine (r). inheritance of abo*a c.dup _ allele was confirmed by family studies of one donor: his father and sister had a/b genotype associated with normal a and b antigens expression; his mother had normal a antigen expression. she carried abo*a . allele and the same abo*a c.dup _ allele as a son. summary/conclusions: a novel a weak allele at the abo gene detected in three unrelated polish individuals is an in-frame insertion of seven amino acids to the wild-type glycosyltransferase a. the stability of the encoded protein may be affected causing the weak a phenotype. the inheritance of this mutation was confirmed in the family studies. background: since the cloning in of cdna corresponding to mrna transcribed at the blood group abo locus, polymorphisms and phenotype-genotype correlations have been reported by many investigators. although many subgroups have been explained at the genetic level, unresolved samples are still encountered in clinical practice. we report here the result of an abo investigation of a sample from a swedish blood donor that showed a very weak agglutination of rbcs with anti-a in routine forward typing. aims: to elucidate the genetic basis of the apparent weak a subgroup. methods: routine abo genotyping by pcr-asp and pcr-rflp including pcrbased analysis of the upstream cbf/nf-y-binding enhancer region was carried out. further genetic analysis was performed by dna sequencing of abo exons - (including base pairs of the adjacent introns) and the proximal promoter. flow cytometric testing of rbcs was performed with monoclonal anti-a, anti-b and anti-h. results: the weak agglutination of erythrocytes with anti-a was accompanied by the expected lack of anti-a and anti-a in plasma. abo genotyping gave the genotype abo*a . /o . usually consistent with normal expression of a antigen. enhancer analysis resulted in an amplification product corresponding to the expected single cbf/nf-y binding motif. flow cytometric testing of the sample showed a antigen expression with an almost chimeric pattern where the majority of the cells (approximately %) expressed the a antigen at a very low level, marginally distinguishable from the group o control. the remaining approximately % of the cells displayed an a antigen level ranging from normal to very weak. genomic abo sequencing showed an abo*a . -like allele except for a novel mutation located in intron , c. + g. the o allele had an additional snp, c. g>a, consistent with the abo*o . allele variant summary/conclusions: a previously unreported variant, c. + a>g, likely effecting the -donor splice site of intron was found in an a weak sample. this type of mutations is expected to decrease mrna stability and/or cause skipping of the preceding exon in the mrna. however, small amounts of full-length enzyme might still be made, being able to give rise to the weak a antigen expression seen in this individual. interestingly, this mutation is very similar to the genetic variant underlying the weak a subgroup a finn . in this case, however, the c. + a>g mutation is located in the -end of intron and is predicted to cause partial skipping of exon . strikingly, the a finn phenotype also results in a pseudochimeric pattern by flow cytometry but with only approximately % positively staining erythrocytes. due to the well documented lack of a-allele-derived mrna in peripheral blood, further transcript studies could not be undertaken. further studies are needed to investigate the exact mechanisms underlying the pseudochimeric pattern observed by flow cytometry in these two interesting genotypes/phenotypes abstract withdrawn. background: abo is the clinically most relevant blood group system in transfusion and transplantation medicine. abo genotyping is potentially useful in clarifying serologic blood grouping discrepancies. this scenario includes inherited subgroups alleles, temporary acquired variant abo phenotypes in disease or pregnancy, and chimerism due to exchange of progenitor cells early in fetal life or after blood progenitor cell transplantation. aims: to investigate the molecular basis for abo discrepancies detected in clinical samples, including donors and patients, sent to our reference laboratory during the past years. methods: if routine abo grouping showed weak agglutination or forward vs reverse typing discrepancy, further abo typing studies were performed manually. adsorption-elution tests were also performed in some cases with polyclonal anti-a and anti-b to confirm whether a or b antigens were weakly expressed on the rbcs membrane. a pcr approach using sequence specific primers for a , b, o and o alleles was used for initial genotype determination. the full abo coding region was analysed as previously described in selected samples for which abo discrepancy was still unexplained. allele specific fragments spanning exon , intron and exon were amplified using a forward primer targeting the g nucleotide (to exclude o alleles amplification) in combination with either b, a or a generic reverse primer. analysis was carried out by sanger sequencing. results: a total of samples with suspected inherited abo subgroup alleles were selected for further molecular studies by sequence analysis. a subgroup alleles: in out of samples with suspected a subgroup alleles, the c. insg insertion was detected corresponding to the abo*ael. allele. the abo*aw . - variant, a hybrid a -o v allele, was found in cases. in case we found the c. g>c change, previously reported associated with weak a antigen expression. finally, a novel c. c>g change was detected in an a allele. b(a) or cis-ab suspected alleles: the abo*b(a) variant carrying the c. a>g change was found in of samples with bo genotype but a weak antigen expression. in the remaining cases, a consensus b allele was detected, thus pointing to a potential chimerism as the cause of the results observed in abo grouping. finally, we have identified an abo*b . allele carrying the nucleotidic change c. a>g in the context of an abo phenotype vs genotype discrepancy. summary/conclusions: the sanger sequencing approach applied in this study have proved to be informative and helpful to determine the molecular basis of abo grouping discrepancies with suspected inherited subgroups. we found mutations, within exon of the abo gene, in out of samples, including novel alleles. chimerism was suspected in cases of a antigen expression in samples with b o genetic background carrying an apparent normal b allele. we are evaluating at the moment a deep sequencing approach by next generation sequencing to determine the presence of a small amount of a minor allele in the presence of a large surplus of the other two alleles. background: recently, the multiple pregnancy rate has been increasing due to advances in artificial fertilization including in vitro fertilization-embryo transfer. most dizygotic twins have dichorionic placenta, but % of them share the placenta. monochorionic dizygotic twins can have blood chimerism, leading to double rbc populations in routine abo serologic typing. recently, more sensitive and objective column agglutination tests with automated systems are being widely used. therefore, blood chimerisms in dizygotic twins can be detected more easily by routine abo blood typing. aims: we report congenital blood chimerism in monochorionic dizygotic twins of triplets, found incidentally during abo serological testing and confirmed by abo genotyping and str marker analysis. methods: a -year-old male (one of triplets) was admitted to the hospital for medical checkup. he did not have any history of transfusion or bone marrow transplantation. routine abo blood grouping test was performed using automated blood bank system ih- ; however, it showed abo discrepancy. the red blood cells showed double cell populations in a gel column with anti-a and anti-b. we carried out abo genotyping both from the blood and from a buccal swab. for the further evaluation, we performed abo serologic testing, abo genotyping, and str marker analysis in his family members. results: among the triplets, blood chimerism was demonstrated in the patient and his brother. they both showed a b phenotypes in the serologic test and tri-allelic abo genotypes in the blood, a /b /o . however, in buccal swabs, the patient showed a /o and his brother showed b /o . other members of the family (father, mother, and dizygotic sister) had regular abo blood types in the serologic test. we performed str analysis in the triplets and parents. eleven loci (d s , d s , d s , csf po, th , d s , d s , d s , d s , d s , and fga) revealed more than one additional allele in the blood sample, apart from those in the buccal swabs. str marker analysis showed that his brother too had blood chimerism. summary/conclusions: we found blood chimerism in monochorionic dizygotic twins of triplets during routine abo blood typing, and this was confirmed by str analysis. as the application of assisted reproductive technology increases, the incidence of blood chimerism will also increase. blood chimerism can often create confusion during abo serologic typing and microchimerism can be overlooked in routine methods. therefore, it is helpful to use an automated blood bank system to improve sensitivity and blood chimerism should be considered if abo blood grouping reveals double populations. background: expression of abo transferase genes can be affected by genetic variants located within the coding sequence, at splice junctions, in the proximal promoter and in the intron enhancer. here we describe five new alleles with singlenucleotide substitutions found in samples with discrepant or unusual abo serology. aims: to resolve serological discrepancies or unusual serological findings in the abo blood group system by molecular methods, in particular by sanger sequencing. methods: forward and reverse abo phenotyping was performed by the gel or tube methods. genomic dna extracted from whole blood was pcr amplified to cover the entire abo coding sequence, splice junctions, proximal promoter and intron enhancer. amplification products were sanger sequenced directly or after cloning in a bacterial host. results: case # is a patient with an unclear abo phenotype: forward type b, reverse type ab. sequencing of genomic dna and cloned abo exon detected variant c. - t>g in heterozygosity on an otherwise common a allele, and in trans an abo*b. allele. case # is a caucasian donor with an abo discrepancy: forward type aweak/o, reverse type a. sequencing also detected variant c. - t>g in heterozygosity on an a background, and in trans an abo*o. . allele. given that this variant is located near the intron splice acceptor site, abo* - g transcripts are postulated to undergo altered splicing, leading to an aweak phenotype. case # is a prenatal sickle-cell disease patient with an abo discrepancy: forward type aweak, reverse type a. dna sequencing detected variants c. c>t (pro leu) and c. t>a (tyr asn), both in heterozygosity on an otherwise common a allele, with an abo*o. . allele in trans. thus, the data establish an association of allele abo* t, a with an aweak-like phenotype. case # is a donor with an abo typing discrepancy: forward type o, reverse type a. sequencing detected variant c. c>g (pro arg) in heterozygosity on an a background, and in trans an abo*o. allele. an interpretation of the data is that variant c. c>g weakens the activity of the a transferase, with allele abo*a ( g) encoding the aweak-like phenotype detected by serology. case # is a year-old patient with an abo discrepancy: forward type o, reverse type ab. sequencing of genomic dna and cloned abo exon detected variant c. g>c (gly ala) in heterozygosity on an a background, and in trans an abo*o. . allele. the serology and molecular results suggest that allele abo*a ( c) encodes a cisab weak phenotype. case # is a caucasian donor with an abo typing discrepancy: forward type o with a weak agglutination with anti-ab, reverse type o. dna sequencing detected variants c. g>a (glu lys) and c. g>a (asp asn), both in heterozygosity, in trans, and on a backgrounds. variant c. g>a by itself constitutes allele abo*a . . the phenotype encoded by abo* a is uncertain. summary/conclusions: molecular characterization of abo alleles can help in their future identification and discrepancy resolution. background: expression of abo transferase genes can be affected by genetic variants located within the coding sequence, at splice junctions, in the proximal promoter and in the intron enhancer. here we describe five new alleles with singlenucleotide substitutions found in samples with discrepant or unusual abo serology. aims: to resolve serological discrepancies or unusual serological findings in the abo blood group system by molecular methods, in particular by sanger sequencing. methods: forward and reverse abo phenotyping was performed by the gel or tube methods. genomic dna extracted from whole blood was pcr amplified to cover the entire abo coding sequence, splice junctions, proximal promoter and intron enhancer. amplification products were sanger sequenced directly or after cloning in a bacterial plasmid vector. results: case # is a year-old pregnant female with an abo typing discrepancy: forward type o, reverse type a. pcr-rflp predicted abo*a /abo*o . sequencing detected variant c. insg (val gly>fs ter) in heterozygosity on an otherwise common a allele, and in trans an abo*o. . allele. it is unclear how the early truncation of the a transferase encoded by allele abo* insg still allows for some residual enzyme activity, as suggested by the reverse a type. case # is a recently-transfused year-old black patient with an unresolved abo type. sequencing detected variant c. a>g (silent) in homozygosity and variant c. c>t (ala val) in heterozygosity, both on an o background, with an abo*b. allele in trans. although variants c. a>g and c. c>t are likely of no consequence to the abo phenotype of this patient, they are reported here as components of a new abo*o ( g, t) allele. case # is a year-old prenatal female with a rhd typing discrepancy. failure to yield an abo genotype on blood-chip (progenika), a genotyping microarray that interrogates polymorphic positions in rhd and abo, prompted dna sequencing. sequencing of genomic dna and cloned abo exon detected variant c. c>t (arg cys) in heterozygosity on an abo*b allele background, and in trans an abo*o. . allele. the phenotype encoded by allele abo*b( t) is predicted to be b, as evidenced by forward typing on immucor neo and reverse manual typing. case # is a prenatal black patient with an abo typing discrepancy: forward type o in gel, a + mixed field (mf) in tube. reverse type on a cells + in gel, / + in tube. sequencing of genomic dna and cloned pcr products covering exons - detected variant c. g>c (asp his) in heterozygosity, and in trans an abo*o. . allele. case # is the newborn baby of case # , with a forward type a + mf in gel, a + mf in tube. sequencing of the baby's dna detected variant c. g>c (asp his) in heterozygosity, and in trans an abo*b. allele. from these results it is inferred that the phenotype encoded by allele abo* c is a -like. case # is an year-old hispanic donor with an abo typing discrepancy: forward type a, reverse type o. sequencing of genomic dna and abo exons - and - detected variant c. c>t (gln ter) in heterozygosity, and in trans an abo*o. . allele. the truncation of the a transferase at such a relatively late position is consistent with the retention of some enzyme activity, explaining the forward a type encoded by allele abo* t. summary/conclusions: molecular characterization of abo alleles can help in their future identification and discrepancy resolution. background: expression of abo transferase genes can be affected by genetic variants located within the coding sequence, at splice junctions, in the proximal promoter and in the intron enhancer. variants reported to date in the intron enhancer include large deletions, small deletions and single-nucleotide substitutions. here we describe four new alleles with single-nucleotide substitutions found in samples with discrepant or unusual abo serology. aims: to resolve serological discrepancies or unusual serological findings in the abo blood group system by molecular methods, in particular by sanger sequencing. methods: forward and reverse abo phenotyping was performed by the gel or tube methods. adsorption-elution by the heat elution method and testing for h and a substances in saliva were performed by following the procedures in the aabb technical manual. genomic dna extracted from whole blood was pcr amplified to cover the entire abo coding sequence, splice junctions, proximal promoter and intron enhancer. amplification products were sanger sequenced directly or after cloning in a bacterial plasmid vector. background: inactive alleles of the fut could be decreased or aborted the activity of the fucosyltransferase, which results in to form the bombay or para-bombay phenotype with weak or no h antigen expression on erythrocytes. now many para-bombay individuals have been found in the chinese population. according to names for h blood group alleles v . of red cell immunogenetics and blood group terminology working group of the isbt, fut alleles were identified for bombay or para-bombay phenotype around the world. aims: the study was explored the distribution of fut alleles for the chinese individuals with para-bombay phenotype. methods: the samples were come from the blood donors or the patients. the a, b, h antigens were determined using conventional serological method according to the manufacture's instruction. the sequences of the full coding region for fut was amplified, then amplicon was purified with enzymes digestion and used as template for sequencing bidirectionally. all nucleotide sequences obtained were analyzed and compared with standard fut sequence. results: nineteen chinese individuals with para-bombay phenotype were identified. ten of them were the donors and nine individuals were come from the hospital. the rbcs had a very weak agglutination reaction with anti-h in the most of the individuals. fut homozygous mutations were found in the individuals and fut heterozygous changes were existed in individuals after bidirectionally sequencing. . %, . %, . %, . %, . %, . %, . %, . % respectively in the individuals with para-bombay phenotype. according to our previously reports, the fucosyltransferase activity of fut * n. (c. _ delag), fut * w. (c. c>t) and fut * w. (c. c>t) were abolished in vitro assay, while fut mrna levels of them had no effect compared with wild type. summary/conclusions: the fut mutations in the para-bombay individuals were various. the most common fut allele in the chinese individuals with para-bombay phenotype was fut * n. (c. _ delag). background: the regulatory mechanism of the abo gene is complicated and has been investigated extensively.variation in a antigen expression was recognized very early in the twentieth century and the a blood group was divided into a and a . later the a blood group was subdivided further based on characteristic reactivity with human polyclonal antisera, i.e., strength of reactivity and presence of mixed field agglutination; presence of anti-a , and whether a or h blood group substance was present in the saliva of secretor subjects. mutations critical for abo blood group phenotypes have predominantly been found in exons and of the abo gene, both of which encode the catalytic domain of abo glycosyltransferase. in our case report we show how mutation ranging from single nucleotide in the intron enhancer element can alter the efficacy of enzyme and alter antigen expression. aims: this study aims to investigate the molecular basis of discrepant results of abo forward/reverse typing in blood donor. methods: the abo typing was performed using tube technique and column agglutination tests (bio-rad, grifols). standard tests were completed with adsorption-elution study using o plasma as a source of anti-a, and with saliva testing for presence of a and h substances. we performed quality control for these methods. abo group genotyping was performed using pcr with sequence-specific primer by commercial kit (abo-variant; bag healthcare, lich, germany). pcr-amplified exons and intron enhancer were subject to bi-directional dna sequence analysis using standard sanger dideoxy chemistry. seqscape software (abi) was used to analyze sequence data by comparing the obtained sequence to a reference sequence from ncbi. results: standard serological forward tests identified blood group o, however, only anti-b iso-agglutinins were present. anti-a in adsorption-elution study was successfully adsorbed and eluted from the investigated cells. a and h substances were detected in saliva. abo genotyping using pcr-ssp indicated genotype o v/a . dna sequence analysis showed result abo*a ( + a), abo*o. . . the specimen was revealed as an a subgroup, probably a m with an unusual genetic variant in the intron region of the abo gene, the enhancer of the gene expression. summary/conclusions: we report the first case of abo*a ( + a), the mutation located in the enhancer region of gene expression in allele a, that causes discrepant results not only in abo forward/reverse typing but also in molecular blood grouping tests. based on our serological findings, this subgroup is considered as a m . background: a chimera is a single organism composed of cells with distinct phenotypes and/or genotypes. several different types of chimeras are described: artificial, twin and dispermic. the artificial chimerism can be seen following hematopoietic stem cell transplantation, or more transiently following blood transfusion. the second type may also be inherited most commonly through blood exchange in utero between twins. dispermic chimerism is induced by the fertilization of two maternal eggs with two spermatozoa and their fusion into one body. this one is also called tetra-gametic chimerism. in transfusion medicine, chimeras are often detected when mixed field reactivity is observed in abo/d typing or, less commonly, when phenotyping for other blood group antigens. aims: this investigation was prompted by finding a double population of erythrocytes in a surgery patient with no transfusion history. our aim was to investigate the chimera and determine the underlying abo genotype of this patient. methods: routine blood grouping was performed by column agglutination. separation of the double cell populations was performed by differential agglutination with igm anti-d (immuclone, anti-d fast igm, clone: d - , immucor). initial abo genotyping was performed by pcr-ssp (fluogene; inno-train diagnostik gmbh); further resolution was performed using in-house pcr-asp and pcr-rflp methods. next generation sequencing (monotype abo; omixon using illumina sequencing platform) and sanger sequencing analysis were also performed. identification of reference alleles was investigated by fragment analysis of short tandem repeats (str) polymorphisms. results: double population was found in column agglutination in tests with anti-a and anti-ab, and subsequently when typing for d and c antigens, with approximately % of o d+c+ cells. the patient's genotype was identified as abo*o. /*a by ce-certified pcr-ssp kit (fluogene). routine pcr-asp and pcr-rflp could not resolve the patient's genotype possible abo*a /*o genotype was detected by pcr-rflp, but the pcr-asp analysis gave an apparent abo*a homozygote result. sanger sequencing of abo exons and also gave anomalous reactions: no abo*a allele was detected. homozygosity for c. delg was observed as well as heterozygosity for c c/a. this result therefore suggests the patient's genotype is abo*o. /*o. . . next generation sequencing (omixon) revealed the same result. however, when pcr amplification of the cbf/nf-y enhancer vntr -region was performed, possible heterozygosity was observed, i.e. a weak band representing a single copy, and one representing copies of the enhancer region were present. presence of a single copy of the -bp cbf/nf-y enhancer vntr region is unique background: del is a very weak form of d antigen with low density expression of d antigen on the surface of red blood cell, which is generally typed as d-blood group as couldn't form agglutination in routine rhd blood group testing and could only be detected by the non-routine adsorption-elution test. in the east asian and southeast asian population, - % of the individuals with serologically apparent d-phenotype are not these with truly d-phenotype, but del phenotype, which is very rare in caucasian and black ethic groups. and the rhd* el. (rhd* a) is most prevalent (> %) in del people in these regions, so the del carried this allele was commonly known as "asia type" del. in previous studies, no alloanti-d was observed in a large cohort of chinese "asia type" del pregnant women with d+ fetus to indicate no occurrence of alloanti-d immunization against d+ red cell in "asia type" del individuals. aims: to conduct genotyping analysis in the chinese patients having serologically apparent d-phenotype simultaneous with alloanti-d to confirm the existence of the "asia type" individuals to produce alloanti-d or not. methods: from to , the blood sample of the patients or pregnant women identified with alloanti-d in our reference lab were collected. d antigen was confirmed again using the blend anti-d reagent (clone th- /ms- , igm/igg) by tube method in saline and indirect antiglobulin test (iat) in gel card. the zygosity of rhd gene was detected by hybrid rhesus box pcr with psti digestion. for the samples with d or dd genotypes obtained by rhd zygosity analysis, multiplex ligation-dependent probe amplification (mlpa) genotyping was conducted for rhd genotyping analysis. results: a total of serologically apparent d-chinese patients (female, n = ; male, n = ) with alloanti-d were identified. different titers of alloanti-d from : to : (≤ : , n = ; > : , n = ) were detected including few cases with mixed antibodies (anti-d mixed with anti-c, n = ; anti-d mixed anti-e, n = ). serological rhd typing confirmed the serologically apparent d-phenotype. rhd* n. / n. (homozygous rhd gene deletion) genotype was identified in majority of them ( / , . %) by rhd zygosity analysis, while rhd* n. / n. genotype (n = ) and rhd* n. / n. genotype (n = ) carried the rhd non-functional hybrid alleles were detected by mlpa. summary/conclusions: compared with the distribution of average % frequency of "asia type" del in serologically apparent dpopulation in guangzhou of china, no one case of "asia type" del was identified in the cohort of serologically apparent d-patients with alloanti-d in this study. this also provides evidence to confirm no occurrence of alloanti-d immunization in "asia type" del individuals. aims: a serologically rhd-negative donor was found to be rhd-positive in the routine rhd screen. to solve the discrepancy between serology and molecular screen, the sample was sequenced on dna and rna level. methods: phenotyping on id/iat-cards (bio-rad) was done using commercial anti-d antibodies. the adsorption-elution analysis was performed using an in-house pool of polyclonal anti-d antibodies. furthermore an antibody d-screen was performed (diagast). for rhd genotyping rh-type and partial d-type assays (bag health care) were carried out. the sample was further characterized by exon sequencing including flanking intronic regions. rna was extracted from whole blood, reverse transcribed and the cdna sequenced. for amplification and sequencing, both published (gassner, transfusion, ; legler, trans. med., ; richard, transfusion, ) and in-house primers were used. results: repeated phenotyping of the sample with commercial as well as, in-house anti-d antibodies confirmed the rhd negativity. in addition, the adsorption-elution analysis showed a negative result. however, genotyping, using commercially available kits, yielded a rhd positive result and no variants were detected. to investigate this discrepancy, all rhd exons were sequenced. the sequencing data revealed the mutation c. + delt in the splice donor site of exon . to confirm the effect of the splice site mutation on transcription, rna from a fresh whole blood sample was analysed. as a positive control, gypb was amplified and sequenced from the same cdna. wild-type gypb (mns ) was found. with rhd specific primers, no product could be amplified. summary/conclusions: we present a serologically rhd negative case, that was identified as rhd positive by standard commercial genotyping kits. sequencing revealed the new splice site mutation c. + delt. rna sequencing yielded no detectable product. the donor was classified as rhd negative. this case of a discrepant result between serology and genetics shows the importance of a profound and highly sophisticated genetic investigation of conflicting laboratory results. j stettler, s lejon crottet, h hustinx, c von arx, f still, j graber, c niederhauser and c henny interregional blood transfusion src berne ltd., berne, switzerland background: one of the most immunogenic and clinically significant blood group antigens in transfusion medicine is the rhd antigen. variant rhd phenotypes with weakened or absent antigen expression pose a challenge for rhd status assignment in blood donors. to ensure patient safety, it is necessary to fully characterize these variants at the molecular level. aims: samples from two donors were investigated in our laboratory due to discrepancy in rhd typing. methods: rh blood group phenotyping was done by standard serological column agglutination testing (id-system, biorad). further rhd characterization was performed by an anti-d antibody panel containing monoclonal antibodies (d-screen, diagast) and an adsorption-elution test using an in-house pool of polyclonal anti-d antibodies. molecular investigation was initially performed by ssp-pcr detecting common rhd variants (rbc-ready gene cde inno-train; rh-type bag health care). rhd sequencing was done on either dna or rna using published and inhouse primers for amplification and sequencing. results: by tube testing, the rbcs of donor were predicted to be rh:- ,- ,- , , . however, all ten exons of the rhd gene could be detected by routine genotyping. sequencing of rhd revealed a homozygous mutation c>g at position which is the second last nucleotide of exon and thus might have an influence on exon splicing. by cdna analysis a transcript with a correctly spliced exon was identified. the mutation c. c>g leads to the amino acid substitution t r located in the twelfth transmembrane domain of rhd using the model of flegel (transfus apher sci., ) as reference. adsorption-elution testing using a pool of polyclonal anti-d showed a weak positive reaction, re-classifying the donor as rhd positive. this novel allele, rhd* g, could thus be categorized as a del allele. serological results displayed an almost normal rhd antigen expression for donor . further serological determination of the rhd antigen with different antisera, however, showed a reaction pattern typically observed with a weak d variant. with commercial available kits no rhd variant could be detected. rhd sequencing revealed a novel homozygous mutation c. g>c in exon . this mutation causes a p.a p exchange in the sixth membrane-spanning domain of rhd. based on serological data, the donor is rhd positive and in case of transfusion the patient would be treated as rhd negative. summary/conclusions: here we report two novel rhd missense mutations c. c>g and c. g>c harbouring an amino acid substitution within a transmembrane segment. the c. c>g variation displayed an unusual low rhd antigen reactivity and would have been mistyped as rhd negative without extensive genotypic testing. molecular analysis of variant c. c>g suggests that the t r exchange causes a del phenotype rather than a miss splicing event. this was also confirmed by adsorption-elution testing. interestingly, variant c. g>c could only be detected due to comprehensive serological and genetically investigation. background: the rh blood group system is highly polymorphic and one of the most clinically relevant systems in transfusion. actually d antigen is of critical importance due to its involvement in hemolytic transfusion reaction and hemolytic disease of the fetus and newborn. rhd gene variants are common in africans and mostly related to partial d phenotype. aims: rhd gene sequence was investigated in two african brazilian samples. we further attempted to take advantage of combining the molecular data and the available in silico tools for the functional interpretation of the variations, in order to get insights into the clinical phenotype that may be predicted a priori from genotyping. methods: sample #id is a d-negative donor self-declared as african descent. sample #id is a patient with sickle cell disease (scd) typed as d-positive with anti-d in his serum. serologic d typing was determined by manual gel test and by microplate in an automated instrument. sample #id was also submitted to adsorption/elution test. after genomic dna extraction, all ten rhd exons and flanking intronic regions from sample #id were pcr-amplified with rhd-specific primers and analyzed by sanger sequencing. sample #id was investigated by next-generation sequencing on the miniseq platform (illumina) by using a previously published, custom (selected blood group genes) ampliseq panel. a reported three-dimensional ( d) structural model of the rhd-rhd-rhag heterotrimer was used to visualize the position of variations and predict their putative functional/clinical effect. results: in sample #id , a single nucleotide missense change, i.e. c. c>g in exon , was identified. this transversion is thought to replace a threonine by an arginine residue at amino acid position (p.thr arg) of the rhd protein. analysis in the d model clearly suggests a dramatic impact of the p.thr arg substitution occurring in a functionally-critical, conserved motif in terms of interhelix interaction, which is supposed to be highly deleterious to the stability of the protein, and potentially impairs totally its expression at the red blood cell plasma membrane. this predicted functional effect is definitely in accordance with the d-negative phenotype reported in sample #id . in sample #id , the single c. a>g transition was found in exon leading to a threonine-to-alanine substitution at amino acid position (p.thr ala). amino acid is located in rhd protein extracellular loop , and is thus thought to alter d antigen structure, resulting in a partial d phenotype. this hypothesis is in accordance with anti-d found in the serum of sample #id . summary/conclusions: for the past years, due to the advent of next-generation sequencing and the subsequent identification of numerous rare variants, bioinformatics prediction and modelling tools have evolved and currently help physicians in diagnostics, clinical management and genetic counselling. we took advantage of some of those in silico methods to predict retrospectively the effect of two novel variant rhd alleles, including one d-negative and one partial d alleles. although phenotype and clinical symptoms remain definitely the standard determinants to assess the effect of genetic variations, use of those approaches may soon become valuable for guiding subsequent investigations in immunohaematology. abstract withdrawn. alleles of the weak d type and diva cluster. in africans, the most frequent were typically associated with alleles of the weak d type (including dol and rhdpsi), diva and dau clusters with f v occurring in > % of alleles; in addition the key mutations of weak d type and dii and two inactivating mutations (c. _ inst and c. delg) not reported in rhb were among the first polymorphisms. in east asians, rhd( g>a) at . % was most frequent, followed by dfv, weak d type , dbo- , key mutations of diva and weak d type cluster as well as rhce-like substitutions and the mutations of weak d type , type , type , rhd(a v), dvl- , weak d and rhd(n s). weak d type and rhd(t r) were frequent in south asia but not elsewhere. summary/conclusions: data from tgp and gnomad add relevantly to the knowledge on rhd alleles; tgd discloses linked intron polymorphisms, gnomad frequency data not biased by the likelihood of serologic detection. current typing strategies usually start with serology later complemented by molecular typing. in the future, molecular methods will gain importance and frequent alleles currently not distinguished from "standard rhd" may need a rational transfusion strategy. in this respect, the high frequency of weak d type and type in europeans was surprising, might warrant confirmation by alternative methods and should trigger discussion on rational transfusion strategies for these alleles. consistent with an r haplotype and probable dc-. two siblings that were abo compatible including the dc-sibling were incompatible at iat phase. reactivity could be completely adsorbed from the serum using r r , r r , and rr rbcs indicating the antibody is probably a single specificity. the donor returned in and to continue autologous donations. the aim of this case study was to examine the genetic framework of the rhd and rhce genes and to characterize the rh epitope recognized by the antibody. aims: the donor returned in and to continue autologous donations. the aim of this case study was to examine the genetic framework of the rhd and rhce genes and to characterize the rh epitope recognized by the antibody. methods: serologic testing was performed by manual tube testing using ahg in the indirect antiglobulin phase. rbc phenotyping was performed by standard tube hemagglutination testing from edta anticoagulated blood. rhd and rhce exons were sequenced using genomic dna and standard sanger dideoxy method with the bigdye terminator v . cycle sequencing kit. sequence data was aligned to rhd_ng_ . . rhd zygosity was performed using pcr-rflp with mspi. background: according to recent findings in molecular immuno-hematology, rhd genotyping is strongly indicated in rhc+ and rhe+ donors classified in routine as d-negative. among these, one could find a non-negligible share of entirely new genetic alterations or even del alleles, which are often not identifiable with routine serological methods due to the low number of antigenic sites. aims: the present study reports the genotyping data of rhd on rhc+ and rhe+ caucasian donors classified serologically as d-negative, all enrolled by a single transfusion center in italy methods: rhd serological typing was carried out in microplate direct agglutination tests (iris, immucor) by using different anti-d igm clones (clone , dvi+: ldm +esd m; clone , dvi-: rum- , th ) and different anti-d igg clones (clone : ms ; clone : d e ). all donors with d-negative results (n = , divided into subjects with rhc+, with rhe+ and with both rhc+ and rhe+) were addressed to genotype analysis with rhd beadchip molecular test (immucor), pcr-ssp (bagene, inno-train) and/or rbc-fluogene (inno-train). the discrepant results between serology (d-neg) and molecular biology (wild-type or full-length rhd gene) were further investigated by bi-directional sequencing of the rhd coding regions. results: one-hundred donors have been analyzed retrospectively, as part of a pilot study. following the data obtained in this first phase, the analysis methods described above have been implemented in routine, allowing to include further donors, studied prospectively. in . % of donors (n = ), the molecular analyses showed the complete deletion of the rhd locus, while in cases ( . %) a genetic status was found with "non-deleted" rhd. over all, bi-directional sequencing on these donors revealed the presence of negative and weak-d variants. the list of rhd alleles we have identified at the molecular level is as follows: rhd* n. ( cases), rhd* n. ( ), rhd* n. ( ), rhd* n. ( ) , rhd* n. ( ), rhd* el. ( ), rhd* el. ( ), rhd* el. ( ), rhd* w. ( ) . moreover we found a donor with a lack of signal encompassing exons - of the rhd sequence (bioarray rhd beadchip), while additional cases are currently under investigation. summary/conclusions: our study confirms that a non-negligible number of caucasian subjects, classified serologically as d-negative, present rhd gene alterations that differ from the common total deletion. in line with the literature data, we also found a frequency of about in cases ( subjects out of ), in which a donor re-classification as d-positive (weak d type) was necessary. hence, a wider use of molecular typing methods is desirable in order to achieve the correct genetic characterization and the appropriate phenotypic classification of "apparently" d-negative donors. background: without evidence of abnormal serological d antigen expression there will be no quest for weak d, partial d or d variant on the red blood cells. according to our blood donor registry we found that out of serologically typed donors, . % were d+, . % d-and . % weak d. aims: to compare different weak serological reactions of the d antigen to the rhd genotyping. methods: molecular rhd typing using isolated dna and rbc-ready gene cde and rbc-ready gene d weak kits was performed in blood donors, who were serologically typed as weak d using monoclonal blended igm/igg and dvi-and dvi+ anti-d reagents by slide and microplate (mp) technique respectfully, as well as by the antiglobulin test (iat) in gel and with the set of monoclonal partial d typing reagents (biorad). in addition, rhccee phenotyping and genotyping was also performed. results: all of the donors with serologically weak reactions were confirmed to be weak d variants by genotyping except one donor whose iat was false positive due to rbc autoantibodies. the frequency of d variant genotypes was as follows: % weak d type , % weak d type , one donor was typed as weak d type and another one as weak d type . these weak d types were associated with different degrees of serologically determined weakness ranging from negative to weak positive reactions concerning slide and mp. all of them gave positive reaction ranging from + to + with iat, except for the weak d type with the score of < + which gave negative reaction by slide and mp and inconclusive result with the set of monoclonal anti-d reagents for partial d typing. the percentage of donors, who, at serological typing were only found to be d positive in the iat was %. one of the weak d type donors was negative with dvi-and positive with dvi+ reagent in the mp. the additional rh phenotype (genotype) was ccee in all of the donors except in the one who was genotyped as weak d type , as well as in the d negative donor, being ccee. summary/conclusions: further rhd genotyping is required to estimate the actual frequency of d variants in our blood donors. in practice, current serological methods are sufficient to detect almost all variant d phenotypes. there is a consensus that routine molecular d antigen screening in d negative donors in order to detect del variant when ddccee phenotyped red blood cell transfusion is practiced in all d negative patients does not seem to be cost-effective. background: rh null or rh mod -the so-called rh-deficiency phenotypes-are characterized by a null or severely reduced rh antigen expression (including d, c/c and e/ e), respectively. molecular genetic studies showed that these phenotypes are transmitted in an autosomal recessive manner. rh null phenotype originates from two different molecular events giving rise to the amorph type and the regulator type. the former is caused by homozygosity for silent genes at rhd and rhce loci, caused by inactivating mutations in rhce and deletion of rhd. on the other hand, the regulator rh null type as well as the rh mod phenotype are attributed to mutations in rhag gene when in homozygous state or when in heterozygosity with another rhag allele containing an inactivating mutation. a functional rhag is essential both for the correct rh complex assembly and rh antigen expression in the erythrocyte membrane. aims: the aim of this study was to investigate the molecular genetic basis of an argentinean proband with no detectable d, c, c, e and e antigens by standard serological techniques. methods: blood samples were collected from the proband, her parents and sister. the proband was a year-old young woman with parameters of hemolytic anemia: low hemoglobin level ( g/dl), reticulocytosis ( %), hyperbilirubinemia, increased ldh and marked spherocytosis. the d, c, c, e and e status was determined by standard serologic hemagglutination techniques using specific monoclonal antibodies. genomic dna was isolated using a modified salting-out method. dna samples were initially screened for the presence of intron and the untranslated region of the rhd gene using pcr strategies. rhc/c, and rhe/e alleles were studied by allele-specific pcrs to determine the rhce genotype. rhd zygosity was analyzed by pcr-rflp. rhd exon polymorphisms were studied by rhd exon scanning procedure based on pcr-ssp. rhag gene was investigated by exon-specific pcr amplification and sanger sequencing. results: no d, c, c, e and e antigens were detected in the proband's erythrocytes. the father and sister rh phenotype was: d+, c+, c+, e+, e+ whereas the mother rh phenotype was: d+, c+, c-, e-, e+. rh genotyping confirmed the rh phenotypes for all family members except for the proposita who genotyped rhd+, rhc+ and rhe+. all samples showed an homozygous status for the rhd gene and all rhd exons were detected by exon scanning. sequencing analysis revealed an homozygous c. c>t mutation in rhag exon in the proband whereas the rest of the family showed an heterozygous state in the same nucleotide position. the c. c>t mutation is responsible for the p.ser phe amino acid substitution predicted to be in the th rhag glycoprotein transmembrane segment. summary/conclusions: this study described the molecular background responsible for an rh-deficiency phenotype in an argentinean proband. we identified the novel missense mutation c. c>t in the rhag gene which results in the ser to phe single amino acid substitution that shows to be critical for rh antigen complex assembly within the erythrocyte membrane. further studies are being performed in order to determine whether the proband is rh null or rh mod . background: rh blood group system is the most immunogenetic blood group system and blood donor typing should account for all expressing antigens in order to prevent anti-d alloimmunization. aims: the objective of this prospective study was to investigate rhd alleles among blood donors who typed d-by serologic methods and positive for c and/or e. for this reason we developed an easy-to-perform dna-based screening method for the detection of rhd gene and positive samples were further characterized by two commercial pcr-ssp kits. methods: of individual blood donors within a month period, ( . %) typed as d-with standardized immunohematologic methods including the indirect antiglobulin test (iat). residual edta-anticoagulated blood samples were used to isolate genomic dna using the qiaamp dna blood kit (qiagen, germany) from out of ( . %) c/e+ and serologically d-donors. all dna samples were tested individually for the presence of rhd-specific dna sequences in the rhd promoter, intron , exon and exon by a multiplex pcr-ssp method. the reaction was conducted in a final volume of ll with primers that were applied as described by f. wagner et al. (bmc genetics, ) except antisense primer for exon and the two primers amplifying an hgh gene fragment as internal control, designed by our laboratory. pcr products were visualized by electrophoresis on a % agarose gel with ethidium bromide staining. in case of a positive reaction the sample was analyzed by pcr-ssp d weak and pcr-ssp cde (inno-train, germany). results: out of d-individuals analyzed, were ddccee, ddccee, ddccee and one had a ddccee phenotype. molecular analysis showed that ( . %) were negative for all four rhd dna regions. among the other samples, all of ddccee phenotype, three were found to be positive for rhd promoter, intron , exon and exon , three for rhd promoter and exon , and two for exon alone. further genotyping revealed five hybrid rhd-ce-d alleles [ rhd-ce( - )-d and rhd-ce( - )-d], one allele represented the del(m i) genotype, while the remaining two samples did not show an allele that could be determined with the pcr-ssp kits. summary/conclusions: serotyping is the standard method to assign transfusion strategies but it is not always capable to correctly define all samples that show weak reactions in d. a rhd genotyping strategy is needed to confirm d-blood donors and thus to avoid anti-d immunizations. for these reasons we suggest the implementation of an easy and possible cost-effective method. background: more than weak d types have been described to date. transfusion recipients with weak d type , , or are not at risk for forming allo anti-d when exposed to conventional rh d-positive rbcs. molecular analysis of weak d offers a more reliable basis than serotyping to determine the prevalence of weak d types and optimal d transfusion strategies. background: the d antigen, which consists of a mosaic of epitopes, is determined in all the blood donors and patients. most people are either rhd-positive or rhdnegative, but there is a certain number of people who have a variation of the d antigen, which are called weak d, partial d and del phenotypes. aims: the objective is to use molecular methods to determine whether blood donors in republika srpska (with whom a serological weak d antigen has been detected) really have the weak d antigen. in addition, determine whether blood donors, who have been determined as persons who are rhd-negative, with the phenotypes c and/ or e, who have the rhd gene and d antigen on the erythrocyte membrane, so weak that it could not be determined by serological techniques. methods: blood samples were used from regular blood donors, who have been determined as persons with a weaker d antigen, as rhd-negative or as c and/or e positive (based on the agglutination strength) using serological techniques, the test tube method, the microplate method and the gel method. gp.mur was also modelled and shown to closely resemble the tertiary structure of glycophorin a. the predicted structure is anti-parallel b sheets arranged in a "b barrel" also referred to as an ob-like-fold. the regions in which blood group antigens were identified in the predicted stable dimeric structure. summary/conclusions: ob-like-fold structures typically to bind oligonucleotides or oligosaccharides and are associated with cold shock proteins. further modelling is in progress to predict the structure of gpa/gpb heterodimers as a basis for understanding the presentation of blood group antigens. of interest, this finding is consistent with a previous report showing that this gpa binds to carbohydrates. this model serves as a foundation for future work regarding the properties of gpa, which includes identifying locations of specific interactions between gpa and other rbc surface proteins such as gpb and band , as well as identifying structural features of antigenic regions on gpa. . even though no significant differences were found among the groups studied, haplotypes containing the mcc b and sl polymorphisms were identified in d samples but were not found in tb and l groups. summary/conclusions: this preliminary data obtained suggests that cr polymorphisms and haplotypes, especially those containing mcc b and sl snps, could be involved in the disease pathogenesis of tuberculosis and leprosy. the entrance of mycobacteria into macrophages is mediated by complement receptors that facilitate their uptake by host cells so the combined haplotypes could be enhancing parasite phagocytosis and inflammation. further studies are being carried out to establish whether cr polymorphisms are risk or protective factors and whether other genetic variations in this receptor are also involved. abstract withdrawn. background: the dombrock blood group system consists of two antithetical antigens, do a and do b , and three high-prevalence antigens, gregory (gy a ), holley (hy), and joseph (jo a ). the rare do null or gy(a-) phenotype lacks all dombrock antigens, and the do null alleles vary with both do* and do* backgrounds. here we report the molecular basis of a novel do null allele in a gy(a-) brazilian patient with anti-gy a . aims: case presentation: an alloantibody to a high-prevalence antigen was detected in the serum of a year old woman from the northeast brazil with a history of pregnancies but no history of previous transfusion. she required transfusion because of a schedule for total thyroidectomy surgery due to a large compressive nodular goiter. the antibody did not react with the autologous rbcs but reacted by the indirect antiglobulin test in liss with all panel rbcs and other rbc samples tested except with the gy(a-) phenotype. the corresponding antigen was resistant to treatment with papain but sensitive to dtt and trypsin. these results suggested that the antibody recognized an antigen in the dombrock blood group system. the purpose of this study was to identify the antibody specificity and to determine the molecular basis of the phenotype detected. methods: the red cells phenotype and the presence of the dombrock related antibody in the serum were detected by standard hemagglutination techniques. rbcs and antibodies were from our in-house collection of rare samples. genomic dna was prepared from peripheral blood of the patient. dombrock genotyping was performed by id-core xt platform (grifols, spain). the exons of the do gene were amplified by pcr and directly sequenced. experimental immunohematology and diagnostic immunohematology diagnostic immunohematology experimental immunohematology, sanquin, amsterdam, netherlands background: typing of blood group antigens is essential to prevent transfusion reactions or haemolytic disease of the foetus and newborn. to date, the isbt recognises blood group antigens. most antigens ( ) belong to one of the blood group systems. since the genetic basis of these systems is known, genotyping of these antigens is possible. the molecular background of antigens is unknown and can only be determined serologically. one of these antigens is sd a (sid), first reported in .~ % of the population carry sd a on erythrocytes, but this frequency might be higher since identification is difficult due to variability in expression. in % of individuals sd a is present in urine. cells with a high expression of sd a (cad/sda++) are used for detection of antibodies. recently, a -cells antibody detection panel of bio-rad contained a sda++ cell and many individuals with anti-sd a were detected. the b galnt gene has been implicated in the synthesis of sd a . we collected individuals with and without anti-sd a to elucidate the genetic background of the antigen. aims: elucidation of the genetic basis responsible for loss of the sd a antigen on red blood cells. methods: routine diagnostics to identify antibodies in patients was performed using a bio-rad -cells panel, containing donor with high expression of sd a . additionally, pregnant women were screened for anti-sd a . dna of eight samples with anti-sd a and eight samples without anti-sd a was isolated for further analysis. sanger sequencing was performed on b galtnt exon - . results: sequencing of b galtnt revealed two homozygous mutations which are present in all eight individuals with anti-sd a , but not present in controls. the remaining two controls are heterozygous for these mutations. the first mutation within exon , c. t>c (enst . , rs ) changes a cysteine to arginine at position of the protein. the second mutation in exon c. a>g (rs ) does not change an amino acid. both snps have a maf of . and therefore we expect that . % of the population is homozygous for the minor allele. genotyping of a large population of pregnant women and the serological detection of anti-sd a in women with a homozygous mutation is in progress. summary/conclusions: the high frequency antigen sd a has not been linked to a blood group system because the molecular basis for loss of the antigen has not been elucidated. the b galtnt gene has been associated with sd a synthesis and therefore we analysed this gene for mutations in individuals with antibodies against sd a . a single homozygous mutation within exon causing an amino acid change was found in all individuals with anti-sd a , and no individuals without antibodies were homozygous for this snp. from population studies we expected~ % sd a -negatives, but either this frequency is an overestimation because of difficulties to detect low expressed antigens or mutations in other genes are interfering with sd a synthesis. a larger study of individuals with homozygous mutations in b galnt and linkage to sd a -negativity and presence of antibodies will be performed before sd a can be assigned to a new blood group system. abstract withdrawn. abstract withdrawn. background: erythrocyte duffy blood group antigen can scavenge chemokines in whole blood. duffy blood group gene consists of two major alleles: fy*a and fy*b. however, little is known regarding the association of duffy blood group polymorphisms with the red blood cell (rbc) chemokine scavenging. aims: the aim of this study was to determine the association of duffy blood group polymorphism with the rbc chemokine scavenging. methods: the duffy blood group were genotyped by ˊ-nuclease assay in healthy chinese han individuals, while erythrocyte chemokine scavenging function and duffy antigen expression from the same samples were measured using erythrocyte chemokine binding assays and quantitative flow cytometry respectively. results: rbc chemokine scavenging of cxcl was significantly lower in the individuals with the fy*a/fy*a genotype compared to those with fy*a/fy*b genotype (p = . ). similar result was also observed in rbc chemokine scavenging of ccl (p = . ). the expression of duffy antigen on rbc surface in the individuals with the fy*a/fy*a genotype was significantly higher compared to those with fy*a/ fy*b genotype (p = . ). summary/conclusions: duffy blood group polymorphism is associated with the differential rbc chemokine scavenging. it is probable that a change in duffy antigen structure caused by duffy blood group polymorphism is responsible for the differential rbc chemokine scavenging. background: individuals with p-phenotype can develop a naturally occurring anti-pp pk and has clinical significance, causing hemolytic transfusion reactions or hemolytic disease of the fetus and newborn. finding and procuring blood units of pphenotype is a challenge because of its rarity throughout the world. therefore, acute normovolemic hemodilution (anh) can be an on hand tool in the perioperative successful management of patient with rare blood group. however, this approach has not been commonly used aims: n/a. methods: n/a. results: a -year-old korean woman was referred to samsung medical center for surgical management for gallbladder malignancy. her blood type was group a, d-positive. the patient had no known history of transfusion. however, antibody screening and identification test using the column agglutination method (bio-rad, cressier, switzerland) showed panagglutination with negative reactions to autologous red blood cells, indicating the presence of alloantibodies to high frequency antigens. the specimen obtained from the patient was sent to the central laboratory of the swiss red cross (bern, switzerland) and confirmed as anti-pp pk. at first, the transfusion team of our hospital recommended the surgical team to postpone the surgery. however, anh was planned because postponing surgery was not preferred and the patient's preoperative hemoglobin was . g/dl. ml of blood was withdrawn through a radial arterial catheter in two ml blood bags containing citrate-phosphate-dextrose-a solution after anesthetic induction. equal volume of % hydroxyethyl starch solution was infused during the procedure. the patient underwent radical cholecystectomy and liver wedge resection with lymph node dissection, and two units of autologous blood were returned to the patient during surgery. she was then discharged h later with a hemoglobin level of . g/dl. later, the family study was performed with the standard serologic method using the proband's plasma containing anti-pp pk and sequencing of the a galt gene, which were conducted according to the protocols by koda et al.(transfusion. ) . the proband and her brother were homozygous for c. dupc, indicating a rare p phenotype. summary/conclusions: we experienced that autologous blood transfusions via anh is an alternative to allogenic rbc blood transfusion in patients who have no blood available because of high alloimmunization antibodies against rare blood groups. " and the third sample as "gypb*s_gyp*[ a], gypb*s_null(ivs + t)" with a predicted phenotype: s-s+ mi a + and s+s-mi a +, respectively. the gypa specific primers used for discrepancy resolution detected the nucleotide substitution, gyp.c. c>a, in gypa-b-a hybrid associated to gp.hut allele, thus confirming the id core xt result. the expression of mi a for one of these samples was confirmed using non-commercial anti-sera. hence, these three samples were not gp.mur but gp.hut phenotype. both alleles codify for the expression of mi a antigen since it is expressed on several hybrids between the usual forms of glycophorin a and b. two of these three gp.hut samples are african-american donors. gp.hut was reported in white people with a frequency about . % and in thais with . %. these three gp.hut cases found by id core xt in this study point to a higher frequency of this glycophorin variant and also to the presence in african american population. summary/conclusions: id core xt was able to detect two glycophorin phenotypes, gp.mur and gp.hut, which codify for the expression of mi a antigen. standard molecular methods should be implemented in pre-transfusion testing and obstetrical care routine to detect the most clinically relevant glycophorin variants in mns system. background: serf(+) is a high prevalence antigen in the cromer blood group system, which is encoded by a crom* allele. the lack of the serf antigen, serf(À) on red cells is caused by a single nucleotide polymorphism, c. c>t in exon of the decay-accelerating factor, daf gene. alloanti-serf has been found in thai pregnant woman with serf(À) and a serf(À) individual was found among thai blood donors. anti-serf is not a marketed product; hence, a molecular technique has to be implemented to genotype for the crom* allele among blood donors. aims: this study aimed to identify the crom* allele among thai blood donors leading to predicted serf(+) and serf(À) phenotypes. methods: dna samples obtained from , central thai blood donors were genotyped for serf allele detection using in-house pcr with sequence-specific primer (pcr-ssp) and confirmed by dna sequencing. results: the allele frequencies of crom* (+) and crom* (À) among , central thais were . ( , / , ) and . ( / , ), respectively. the homozygous of crom* (À/À) alleles was not found in this study. additionally, the pcr-ssp technique was validated by dna sequencing using randomly chosen samples together with heterozygous crom* (+/À) samples and the results were in agreement. summary/conclusions: our results confirm a high frequency of the crom* (+) allele in the thai population and their frequencies were similar to those formerly reported among thai blood donors. this study would be beneficial to predict the serf antigen from genotyping results due to unavailability of commercial antiserum. background: there is increasing interest in the use of molecular methods for predicting abo grouping. though nextgen and sanger sequencing have both been used to predict abo type, predicting abo type from buccal swab-derived dna and from deceased donors benefits from a quick and reliable method. besides a pcr-rflp that has been used by many labs for more than years, there is a commercially-available research use only (ruo) kit, and both interrogate nucleotides associated with o , o , a and b with a representing the ancestral allele. aims: the aim of this report is to compare two low-resolution polymerase chain reaction (pcr)-based methods, for investigation of samples submitted to a reference molecular immunohematology laboratory for abo typing discrepancies. fifty-six peripheral blood samples were tested, from patients and from blood donors. methods: genomic dna was isolated from peripheral blood mononuclear cells. background: del is the weakest known d positive phenotype in the rh blood group system and detectable only by adsorption and elution tests. the rhd g>a change is an important marker for del phenotype in east asians. a rapid and efficient pcr method for rhd gene g>a genotyping is useful in east asian countries. aims: the aim of this study was to develop a method for rhd g>a genotyping by using single-tube pcr with melting temperature(t m )-shift primers. methods: two allele-specific primer for rhd g>a and a common primer were designed and synthesized. two gc-rich tails of different lengths were attached to ends of the allele-specific pcr primers. single-tube pcr with t m -shift primers was carried out with the three primers. after pcr, melting curve analysis was performed. rhd g>a could be genotyped by differences of the t m s of the pcr products. all of genotyping results were compared with those obtained from conventional pcr-ssp. for the discordant results, rhd exon sequencing was performed to determine rhd g>a genotype. results: a total of samples were genotyped for rhd g>a by pcr with t mshift primers. samples were typed as a+/g-, samples were typed as a-/g+, samples were typed as a+/g+ and samples were typed as a-/g-. two samples typed as a+/g+ by pcr-ssp but a+/g-by pcr with t m -shift primers were confirmed as a+/g-by rhd exon sequencing. summary/conclusions: the single-tube pcr with t m -shift primers for rhd g>a genotyping is simple, rapid, accurate, and it is superior to conventional pcr-ssp. abstract withdrawn. background: the rh blood group system has numerous variant alleles, which may affect rh antigen expression, including rhd-rhce (d-ce) hybrid genes. these variant alleles are frequently found in people of african descent, and typically result in either d-negative (d-) phenotype, or partial d antigen expression, including silencing of high-frequency antigens and/or expression of low-frequency antigens. patients carrying those alleles are particularly at risk of alloimmunization, suggesting that their identification is important in diagnostics. quantitative multiplex polymerase chain reaction (pcr) of short fluorescent fragments (qmpsf) has proven successful for genotyping those dna samples carrying d-ce hybrid genes by assessing both qualitatively and quantitatively rhd and rhce gene exons. aims: the aim of this project was to genotype both rh genes in a cohort of brazilian patients with sickle cell disease (scd), which are known to be of african descent, by using the qmpsf approach and report hybrid gene variability in this population. methods: one-hundred fifteen dna samples were selected for the study and analyzed prospectively by the rhd-qmpsf and rhce-qmpsf approaches to investigate the copy number of all exons in both rh genes. genotypes were further confirmed or investigated by sanger sequencing and conventional pcr-rflp assays. results: in the dna samples, ( . %) exhibited a "wild-type" profile by qmpsf analysis. hybrid genes involving exon , which is functionally not relevant as reported before, was found in samples, including and samples carrying respectively rhd-ce( )-d and rhce-d( )-ce (two homozygous each). except two samples that require additional studies ( . %), rhd zygosity was resolved successfully: (n = rhd gene copies; . %), ( ; . %) and ( ; . %). clinically relevant, i.e. partial d, genotypes were identified in four hemizygous samples ( / , . %) carrying rhd*dau , rhd*dv. , a rhd*diiia-like allele, and a novel rhd*d-ce( :g h-y s-n i)-d allele, as confirmed by sequencing. other hybrid alleles, such as rhd* n. and rhd*diiic, were also found in trans with a normal rhd* allele. in rhce, c/c genotype could be resolved. the rhce*ce (rhce*ce ( c)-d( )-ce) allele, which is commonly cis-associated with rhd*Ψ, was observed in four samples. however the clinically relevant polymorphisms in variant rhce alleles, such as those involved in cemo, cear, ceag, and ceti, were mostly identified by other standard methods. summary/conclusions: although most of the brazilian patients with scd investigated in this study did not carry rhd-rhce hybrid genes, qmpsf analysis has been shown to be an efficient tool in the whole genotyping process to investigate rh gene variation. as previously reported, it has been conclusive for characterization of rhd zygosity and identification of rare, as well as novel, variant alleles. additionally, our results show a large diversity of hybrid genes among the brazilian patients with scd. therefore, we suggest that qmpsf may be used as a complementary screening approach for assessing rh genotype in selected patients and donors. = ) vs. non-bleeding (n = ) patients. platelet, pmp and cp phenotype and function were evaluated by flow cytometry: activation and granule release were examined by antibodies against granulphysin (cd ), p-selectin (cd p), activated gpiib/iiia (pac- ) and phosphatidylserine (ps) (lactadherin) unstimulated and adp, trap or collagen stimulated. coated platelets were identified as a highly granulated independent cell population appearing following collagen stimulation, gated on side scatter and gpiba (cd b). normal healthy reference levels were available. results: the platelet count in bleeding ( /l) and non-bleeding ( /l) patients was comparable (p = , ). bleeding patients had a higher bat score compared to non-bleeding patients ( vs. , p < , ). the proportion of cps was normal in all patients. however, in non-bleeding patients the proportion of ps+cps and per cell ps expression (mfi) ( , % and , mfi) were higher, compared to bleeding patients ( , % and , mfi, both p < , ), and the proportion of ps+cps correlated negatively with bat score (r = , , p < , ). cd + cp was higher in non-bleeding ( , % and , mfi) compared to both bleeding patients ( , % and , mfi) and significantly higher than the reference level ( , % and , mfi, both p < , ). finally, the proportion of ps+pmps was normal in bleeding patients, but their pmps expressed higher than reference ps per cell, both unstimulated and for all agonist ( , mfi unstimulated vs , mfi reference, p < , ). summary/conclusions: patients with it exhibited different bleeding tendency despite comparable thrombocytopenia. in non-bleeding patients the proportion and per cell level of ps+ were higher, indicating that generation of cps with high ps expression is a critical factor determining bleeding phenotype. the finding of high pmp ps per cell level in bleeding patients could represent an inadequate compensation for lack of cp function, indicating that procoagulant pmps may be less important than cps for thrombocytopenic bleeding. quantification and characterization of cps may be a useful tool for future assessment of bleeding risk as well as a therapeutic target in it and other conditions with bleeding diathesis and/or thrombocytopenia. more studies investigating this field are warranted. background: alloantibodies against human platelet antigens (hpas) and human leukocyte antigen (hla) are implicated in several immune-mediated platelet disorders. detection of these antibodies is crucial in the diagnosis and management of these disorders. aims: to establish a method detecting hpa- , hpa- , hpa- , hpa- and hla antibodies using luminex bead technology. methods: monoclonal antibodies specific for platelet glycoproteins and hla class i molecules were separately coupled to the luminex microbeads. positive anti-hpa- a, anti-hpa- b, anti-hpa- a, anti-hpa- a samples were used to validate the specificities of the luminex assay. the anti-hpa- a, anti-hpa- a standard samples were used to evaluate the sensitivities of the luminex assay by serial dilutions (from neat to / ). results: samples collected from patients or isbt platelet workshop were tested by the luminex assay. the results showed that luminex assay could detect antibodies against hpa- a, hpa- b, hpa- a, or hpa- a successfully from the known samples. the sensitivities of the luminex assay detecting anti-hpa- a, and anti-hpa- a were : and : , respectively, using the standard samples. no cross-reactivity was observed in the samples containing multi-platelet antibodies, or mixture antibodies against hpa and hla. the results of samples with platelet disorders were agreement with those of monoclonal antibody immobilization of platelet antigens (maipa) assay. summary/conclusions: luminex beads coupled with monoclonal antibodies could be successfully used to detect hpa and hla antibodies with high sensitivity. background: platelet transfusion is important in clinical treatment. the expression of abo antigen on platelet surface is differential, so it is usually need to ensure the consistency of the abo antigen in clinical transfusion. but in many cases, it is difficult to find the platelets that the abo blood type matched between the recipient and donor, and abo-incompatible platelet infusion is required in these cases. to data, the expression of abo antigens on platelets in normal blood group individuals is rarely reported in chinese population. aims: to understand the differential expression of abo antigen on platelet surface in population of zhejiang province, china. methods: total of individuals with normal abo groups ( group a, group b and group ab individuals, and group o as negative control of abo antigens on platelets) were analyzed. the expression of abo antigens on platelets was determined by flow cytometry using monoclonal antibodies: fluorescein isothiocyanate (fitc)-conjugated mouse antihuman blood group a and pe-conjugated murine igg anti-b antibody ( pe bgrl ). flow cytometric parameters were statistically analyzed by the mann-whitney test or the kruskal-wallis test to observe the difference in two or more groups using graphpad software v . . the correlation and regression analysis between a and b antigen in the platelets and rbcs were also performed by the software. population studies were reported as the mean and standard deviation (sd), and p values less than . were considered statistically significant. results: according to mfi values of abo antigens expression on platelets, the samples were divided into three groups: low expression (le), high expression(he) and moderate expression (me) according to the background mfi observed in group o samples. it was found that about . % of the individuals had a weak expression of abo antigen on the platelet surface in zhejiang province. there was a significant difference in the intensity of antigen expression between these three different groups of the same blood group. for each blood group, there was a positive correlation between the intensity of abo antigen expressed on the platelet membrane and red blood cells of the individuals. results: cases were found with antibody positive. among them, cases ( %) were only anti-hla-i positive, cases ( %) were only anti-hpa positive, cases ( %) were both anti-hla-i and anti-hpa positive. cases were found without anti-hla-i or anti-hpa. among the cases with anti-hpa positive, the distributions of anti-gpiib/iiia, anti-gpia/iia, anti-gpib/ix, anti-gpiv were . %, . %, %, . %, respectively., hla antibody positive rate in the female patients was higher than that in the male and hpa antibody positive rate in the female was lower than that in male, but there was no significance difference between them (p > . ). summary/conclusions: in ptr patients, the platelet antibody was mainly hla-i antibody combined with hpa antibody. background: human neutrophil antigens (hna) are polymorphic structures located on surface membrane of human neutrophils. alloantibodies against hna are implicated in a number of clinical conditions, including immune-mediated neutropenia and transfusion reactions. genotyping for human neutrophil antigen (hna) systems is an important in the diagnosis of disorders involving alloimmunization to hna. aims: the aim of this study was to investigate the hna allele frequencies among blood donors and hematological patients undergoing blood transfusions and to estimate possible hna incompatibilities and risk of hna alloimmunization. methods: a total of blood donors and hematological patients from the north-west region of the russian federation were recruited. dna samples were obtained and typed for hna- , - , - and - systems using polymerase chain reactions with sequence-specific primers (pcr-ssp). specific primers for hna were designed and the polymerase chain reaction amplification conditions were optimized. the v test was used to test for the hardy-weinberg equilibrium for the hna systems. the probabilities of the incompatibility and the potential risk for alloimmunization against different hna systems after random transfusions were estimated based on the hna allele and genotype frequencies. results: in blood donors, the frequencies for the fcgr b* (hna- a), fcgr b* (hna- bd), and fcgr b* (hna- bc) alleles were . , . and . ; for the slc a * (hna- a) and slc a * (hna- b) alleles, . and . ; for the itgam* (hna- a) and itgam* (hna- b) alleles, . and . ; for the itgal* (hna- a) and itgal* (hna- b) alleles, . and . , respectively. in hematological patients, the gene frequencies for hna- a/ bd/bc, - a/ b, - a/ b, and - a/ b were . / . / . , . / . , . / . , and . / . , respectively. no statistic significant difference between genotypes in these groups was observed. since the allele frequencies of hna - , - - for hematological patients and donors did not have statistically significant differences, possible hna incompatibilities and risk of hna alloimmunization were estimated based on the obtained data on the allele and genotype frequencies of hna in a group that combines donors and hematological patients (n = ). the predicted risk of hna- , - , - , - incompatibilities in this cohort were . %, . %, %, and . %, respectively. the possible risk of hna- a, - bd, and - bc alloimmunization were . , . , and . , respectively; of hna- a and - b alloimmunization, . and . ; of hna- a and - b alloimmunization, . and . ; of hna- a and - b alloimmunization, . and . , respectively. summary/conclusions: the information about hna gene frequencies can be used not only in blood services for detection and identification of hna alloantibodies in donors and assessment of alloimmunization risk but also for anthropological studies. background: non-invasive fetal rhd genotyping is performed using circulating cell-free fetal dna from maternal plasma sample and real-time polymerase chain reaction. this antenatal routine dna test is used to target rh-ig administration to prevent hemolytic disease of the newborn. aims: the aim of this study is to characterize maternal rhd variants responsible for indeterminate results during fetal rhd genotyping due to early amplification of at least one of the exons ( , or ) of the rhd gene. methods: samples were tested from / / to / / using free dna fetal kit â rhd. samples ( , %) yielded a premature signal for one or more exons of the rhd gene. after extraction of maternal cellular dna, the maternal rhd was characterized using rhd beadchip assay (immucor/bioarray). rhdiiia-ce( - )-d summary/conclusions: greater diversity is observed in the caucasian population rather than in the afro-caribbean. % of the identified variants are rhd negative alleles including alleles leading to partial rh antigen expression. unexpected alleles are found such as weak d type , , or . these data underline the benefits of maternal rhd genotyping when abnormal early signals are detected during noninvasive fetal rhd genotyping. background: a considerable number of rhd alleles responsible for weak d phenotypes have been identified. serologic determination of these phenotypes is often doubtful and makes genetic analysis of rhd gene highly desirable in transfusion recipients and pregnant women. dna-based methods are useful for enhancing immunohematology typing in doubtful d phenotypes at pregnant women. aims: determination of the rhd gene in a cohort of pregnant women with doubtful d phenotypes. methods: determination of the rhd phenotyping was performed with microagglutination technique biorad and ortho diagnostic simultaneously. rhd genotyping was performed on cases with d typing serological discrepancies with ready-to-use inno-train rbc-ready gene cde and rbc-ready gene d weak test kits based on polymerase chain reaction with sequence-specific priming (pcr-ssp) to unclear serologic findings. results: molecular analyses showed of ( %) pregnant women were rhd*weak d type and not at risk for anti-d. rhd*weak d type were typed in cases ( %) and case was rhd*weak partial . and potentially at risk for being alloimmunized producing anti-d allo-antibodies. summary/conclusions: appropriate classification of rhd phenotypes is recommended for correct indication of rhig in pregnant women. however, the serologic differences between rhd-negative and rhd-positive pregnant women is a real problem for unnecessary application of rhig prophylaxis in pregnant women with d variants. conclusion: antenatal rhig prophylaxis is useful in rhd negative pregnant women. with genotyping we found that % of serological doubtful rhd negative women was d variants that not produce anti d antibodies. in that cases those rhig prophylaxis was unnecessary and harmful as a product of human origin. on other hand there is a save up of a stock of rhig which is any way in deficit. is it time to think about cost benefit of rhig prophylaxis and genotyping in pregnant women. background: in may , uk neqas (btlp) created an external quality assessment (eqa) sample designed to mimic a feto-maternal haemorrhage (fmh) bleed of ml. all material used passed pre-acceptance serological testing; samples were dispatched to participants in countries. post-dispatch testing by flow cytometry (fc) using an anti-d marker showed a bleed volume of . ml so an investigation was initiated. aims: to determine the cause of the unexpectedly low bleed volume and what lessons could be learnt. methods: production methodology and results of pre-acceptance testing were reviewed. fc testing was repeated, plots examined, and the fmh scientific advisory group consulted for advice. further fc testing was performed at wbs using alternative markers, and the material used was investigated at ibgrl. participant results were examined to determine if the sample should be withdrawn from scoring. a questionnaire on how results were managed was sent to the participants using fc with an anti-d marker. results: a material production methodology review showed no obvious cause of the erroneous in-house result. review of pre-acceptance testing images showed no issues, further d-typing of the cord showed + reactions vs. two reagents by tube, cf. + with two different reagents by column agglutination technology. repeat fc testing using the anti-d marker gave similar results; however, closer examination of the plots showed a left shift in the positive peak, indicating reduced fluorochrome binding, possibly due to reduced d antigen density on the cord cells. further fc testing at wbs demonstrated a marked reduction in fluorescence intensity with an anti-d marker. further investigation using an anti-hbf marker showed a bleed volume of . ml, indicating the correct proportion of cord material had been used during sample production. additional serology at ibgrl on the cord material showed reactions which were weaker than the control with / anti-d reagents. overall, the investigation supported the hypothesis that the cord material was d variant. a review of results submitted by participants mirrored the fc investigation and the sample was withdrawn from scoring, as the fc median result is used to calculate scores and the d variant cord was clearly affecting testing with an anti-d marker. the questionnaire showed that all respondents examine fc plots and the gating used, but not all act on them before reporting results, and not all have a back-up plan for anti-d ig dosing in a similar situation. later sequencing of the d gene revealed the cord donor to be dvii which can have a lower than normal d antigen density. summary/conclusions: the use of a d variant cord in an eqa sample was not planned, but allowed uk neqas to highlight some important learning points: -thorough examination of fc plots is essential to avoid underestimation of fmh; a controlled procedure should be in place if modification of gates is required -access to cord/neonatal blood to allow serological investigation may be useful in a similar clinical situation -it is important to have a back-up plan for issuing anti-d ig in the event of an uninterpretable fmh result background: allo-antibodies against fetal blood group and platelet antigens produced by antigen-negative pregnant women can cause hemolytic disease of fetus and newborn (hdfn) and fetal and neonatal alloimmune thrombocytopenia (fnait). prediction of the fetus antigen status in immunized women is important for making decisions concerning further management of pregnancy. nipt is widely used for determination of fetal blood groups but determination of proper specificity in the real-time amplification of a single nucleotide polymorphism (snp), such as k or hpa- a, requires modified protocols. droplet digital pcr (ddpcr) permits detection of low-grade fetal chimerism in maternal plasma dna with higher specificity using allelic discrimination pcr protocols. aims: to establish ddpcr protocols for non-invasive prenatal diagnostics (nipd) of clinically important blood group antigens. methods: dna was isolated from plasma samples of pregnant women and donors with known genotypes (easymag, biomerieux). allelic discrimination protocols for determination of k/k (n = ), s/s (n = ), hpa- a (n = ), hpa- (n = ), hpa- (n = ), hpa- (n = ) genotypes were performed using ddpcr method with droplet digital tm (biorad). the results of allelic discrimination performed using ddpcr were concordant with the already known phenotype/genotype of donors and pregnant women. ddpcr enabled the detection of - , reads for total dna from plasma in tested samples. all fetal results were in agreement with antigen positive genotype of the neonates and the fetal chimerism was from , % to , % (one case was for advanced pregnancy - week of gestation). in / tested samples false positive results were detected at the level of or unspecific reads. summary/conclusions: the implementation of allelic discrimination protocols for ddpcr allowed detection of fetal-maternal incompatibility in k/k, s/s and hpa- a, - a/b, - a/b, - a/b antigens encoded by snp. background: in france, for pregnancies complicated by anti-d (rh ) and anti-c (rh ) allo-immunization, the tests currently used to quantitate maternal antibodies are tube method titration and continuous flow analysis determination of the antibodies concentration. recently, an automated assay was developed using the column agglutination technology on the ih- system (bio-rad â). aims: we wanted to evaluate the score, calculated from the agglutination profile of the antibodies on the ih- system, as a quantitative data to appreciate the level of maternal antibodies. methods: titers from samples containing anti-d and containing anti-c have been established using the semi-automated tube method performed since decades in our lab and the fully automated gel method on the ih- system. scores were calculated manually in both cases. antibodies concentrations were also determined for all samples by continuous flow analysis on our auto-analyzer device (evolution iii ams alliance). we looked for a possible correlation between anti-d and anti-c scores and the corresponding concentrations using the spearman correlation test. results: anti-d tube and gel scores were significantly correlated with the anti-d concentration values (p < . , r = . and p < . , r = . respectively). anti-c scores were also significantly correlated with anti-c concentration values (p < . ) but gel scores have a better correlation coefficient than tube scores (r = . versus . ). it was easier to extrapolate gel score thresholds than tube score thresholds from the autoanalyzer values, with the aim of triggering fetal monitoring by ultrasounds and measurements of the peak systolic velocity in the middle cerebral artery only for risk pregnancies. the determined gel score thresholds were and , corresponding respectively to ui/ml ( uchp/ml) of anti-d and . ui/ml ( uchp/ml) of anti-c. conclusions: calculating the score from the hemagglutination profile displayed by the ih- system provides added values compared to the sole reading of the titer. for anti-c immunization, gel scores are more discriminant than tube ones and better correlated to the concentration values established by continuous flow analysis. the proposed score thresholds to trigger fetal antenatal monitoring need, however, to be confirmed on more samples and to be clinically documented. background: hdnf is due to maternal igg alloantibodies directed against fetal antigens that cross the placenta during pregnancy, causing hemolysis in the fetus, anemia that can lead to edema, ascites, hydrops and, in some cases, death. the diagnosis and management of hdnf is based on maternal screening, and middle cerebral artery (mca) doppler monitoring. in severe hdnf intrauterine blood transfusions (iuts) and or exchange transfusion (et) after birth are necessary to correct anemia, to prevent and treat fetal hydrops. aims: we report eight years of experience in our immunohematology reference laboratory (irl) to highlight the importance of red cell antibody detection as a fundamental parameter to identify pregnancies with high fetal risk and to drive a correct treatment. methods: we report laboratory data from pregnant women with a positive indirect antiglobulin test (iat) referred to our irl from january to december . we performed antibody screening and identification by indirect antiglobulin test (iat) in microcolumn method with biovue system (ortho-clinical diagnostics, raritan, usa), and the title of antibodies in iat by tube method without additive. follow-up tests were also performed in the presence of significant red cell antibodies in order to check antibody title and begin clinical monitoring. threshold values were ≥ : for anti kell antibodies and ≥ : for other specificities. results: out of women, ( . %) displayed clinically significant antibodies, ( . %) clinically insignificant antibodies and ( %) natural antibodies of different specificities. among women with clinically significant antibodies the most frequent was anti-d ( . %) also in combination with other rh antibodies ( . %), while anti-k accounted for %, anti-e for % and antibodies against high-incidence antigens for . %. anti-m and anti-le a antibodies were also found ( . % and % respectively) but they were not clinically significant. among women with clinically relevant antibodies, showed a critic antibody title and they underwent gynecological and obstetric monitoring. fetuses resulted affected by hdfn, displaying anti-d in cases and anti-kell in . fetuses with severe hdfn (anti-d in and anti-kell in ) required iuts, were treated with et, received red blood cells units at birth. summary/conclusions: the mother screening program led to important improvements in the outcomes of hdfn. the identification of women with clinically significant antibodies allowed an appropriate monitoring program and therapy. background: the hemolytic disease of the fetus and newborn (hdfn) is a severe disease, resulting from maternal erythrocyte alloantibodies directed against fetal erythrocytes. alloimmunization in pregnant women has been found to range from , % to , % worldwide. there are over erythrocyte surface antigens, of which more than have been reported to be associated with hdfn. although anti-rhesus d was once the major etiology of hdfn, the universal introduction of antenatal and postpartum rh immunoglobulin has resulted in a marked decrease in the prevalence of alloimmunization to the rhd antigen in pregnancy. consequently, alloantibodies other than anti-d emerged as an important cause of severe hdnf, in particular anti-k and anti-c. however, there are other antigens that have also been found to be associated with hdfn. aims: retrospective identification of erythrocyte antibodies in pregnant women in hospital de braga in and . methods: this study was planned to assess the prevalence of erythrocyte antibodies responsible for alloimmunization, excluding abo-immunizations, in pregnant women attending the antenatal clinics of hospital braga during years, from january to december . in this study, we retrospectively evaluated the erythrocyte antibody screening results of pregnant women. women with positive erythrocyte antibody screening also underwent identification with gel card system following the manufacturer's instructions (diamed â ). the outcomes of infants, whose mother's indirect antiglobulin tests were found to be positive, were examined. direct antiglobulin tests, jaundice and phototherapy history, transfusion and mortality of the newborns were recorded. results: during the study period, pregnant women were attended in hospital de braga. the laboratory registered positive erythrocyte antibody screening tests. the prevalence of positive erythrocyte antibody screening was , %. anti-d was the most common antibody found ( , %). anti-d prophylaxis given during pregnancy was responsible for of cases and maternal antibody titer levels did not exceed among these cases. the prevalence of non-rhd immunization was %. anti-e ( , %) was the most frequent alloantibody other than anti-d followed by anti-m ( , %) and anti-c ( , %). multiple maternal antibodies were found in pregnant women. four women had types of alloantibodies: anti-c and anti-e; anti-c and anti-d; anti-k and anti-cw; anti-e and a non-identified antibody. one pregnant had types of alloantibodies: anti-d, anti-c and anti-e. of all cases of newborns whose mothers had a positive antibody screen tests, icterus occurred in % of them and phototherapy was given in %. summary/conclusions: the prevalence of positive erythrocyte antibody screening in hospital de braga was , %. the erythrocyte antibody screening showed that anti-d was the most common antibody found ( , %) in most of the cases because of anti-d prophylaxis. the prevalence of non-rhd immunization was %. the other most frequent alloantibodies were anti-e ( , %), anti-m ( , %) and anti-c ( , %). an increasing prevalence of non-anti-d alloimmunization was found and there are currently no preventive strategies. in contrast to rhd alloimmunization, the main risk factor for non-anti-d alloimmunization is a previous transfusion therapy. thus, it is important to minimize the exposure of women to incompatible erythrocyte antigens through unnecessary transfusions when possible. background: the mns blood group system is one of the most complex blood group systems. although alloanti-m is a common antibody observed in pregnant women and could also be found in the serum of individuals who have not been exposed to m positive erythrocytes, it is rarely clinically significant and has been regarded as an unimportant antibody to cause hemolytic disease of the fetus and newborn (hdfn), especially in caucasian and black ethnic groups, for a long time. however, an increasing number of cases of severe hdfn resulting in fetal hydrops and recurrent abortion caused by alloanti-m have been reported mainly in the asian population, especially in the japanese and chinese populations. aims: to summarize the characters of serological testing in preterm twins newborns suffered with severe hdfn. methods: the blood sample of two newborns with severe hdfn and the mother, who had the history with three hydrops fetus, were collected. abo, rhd, rhce, and mn blood group typing of the twins newborn and their mother were performed in saline with tube or gel card. direct agglutination test (dat), elution test, antibody specificity identification and antibody titer detection were conducted by iat method in gel card. results: o, rhd(+), and ccee blood groups were identified both in the mother and the twins newborn. background: in france, since may , the legislation does not promote anymore the use of the reference tube method for titration of anti-red blood cells antibodies. this opened the way to the use of newly developed automated anti-red blood cells antibodies quantitation by column agglutination technology. aims: we wanted to assess the performance of titration and scoring by the id-gel test on the ih- system (bio-radâ) and to compare it with the performance established for the reference tube method, used in our lab since decades. another objective of the study was to determine titer thresholds for the gel method, to trigger fetal monitoring by ultrasounds and measurements of the peak systolic velocity in the middle cerebral artery. methods: an home-made internal quality control (iqc) prepared and calibrated using the international anti-d standard ( / ) was used to determine the intraassay and interassay imprecisions, regarding the score and the titer results. patients samples for testing were chosen during the -months assay period, regarding the specificity of the antibodies and the tube titer in order to cover a wide range of have lower values. the highest differences (more than to dilutions higher) were seen for antibodies directed against rh system antigens. among the other specificities, anti-k (kel ) and anti-m (mns ) antibodies show the most samples with equal or lower titers compared to the tube method. conclusions: automated anti-red blood cell antibodies titration by column agglutination technology on ih- system shows better intra and interassay cvs compared to the tube method. it is explained by the fully automated process that includes the reading step. titer results are almost always higher with the gel technology. thus, it seems possible to safely extrapolate the titer thresholds defined for anti-red blood cells antibodies by the tube method to the gel method. however, based on future clinical studies and fetal/neonatal outcomes, it would probably be necessary to increase these thresholds, at least for anti-rh antibodies, in order to avoid heavy, expensive, stressful and useless monitoring of some pregnancies. results: the first case was a -day-old female infant, yellowish skin developed the next day after birth. her capillary bilirubin level was mg/dl, the evidence favored neonatal hyperbilirubinemia and the clinical manifestation revealed hemolysis symptoms. her laboratory findings showed elevated reticulocytes ( . %), ldh ( iu/l) and g pd ( . u/ghb); dat (+/-), iat (-), anemia (hb . g/dl, hct %), and blood smear showed anisocytosis, spherocytes, and polychromatic rbc. her mother blood typed o, d positive, while her blood type was b, d positive and anti-b was found from her elution rbcs ( + ). due to rarely severe anemia with abo incompatibility, maternal plasma was analysed for abo igg antibodies and showed high antibody a and b titre with : and : . the female infant received one unit washed-prbcs for anemia and intensive phototherapy for hyperbilirubinemia. her clinical condition improved significantly, hb rose to . , bilirubin level was within normal range, she was discharged. another -days-old male infant was our second case. on the third day after birth, yellowish skin discoloration developed and bilirubin level was mg/dl. two days later, his transcutaneous bilirubin (tcb) measurement data was high and laboratory findings also showed raised reticulocytes ( . %), dat (+/À), iat (À), hb . background: anti-indian b is a rare alloantibody against the high frequency antigen in b . individuals with the in: ,- phenotype (in(a+b-)) are observed with a frequency of < . % in the indian population and have not been described in caucasians. the majority of anti-in b antibodies have been reported in individuals without previous transfusions, indicating the possibility of a naturally occurring antibody. anti-in b is considered clinically significant and haemolytic reactions after in b -incompatible transfusions have been reported. haemolytic disease of the foetus and newborn (hdfn) due to anti-in b has not been described. however, a positive direct antihuman globulin test (dat) may be observed. aims: to describe the challenges of managing a pregnancy and childbirth of a woman with an anti-in b . methods: serological investigations were performed by iat (tube and column agglutination). papain and trypsin treated cells were also utilised. soluble recombinant in blood group proteins (in-rbgp) (inno-train, germany) were used in neutralization tests. the clinical significance of the anti-in b antibody was determined by monocyte monolayer assay (mma). genomic dna was isolated from whole blood and the samples were further characterized by pcr amplification and sanger sequencing of exon of cd . results: in a -year-old pregnant (para ) woman of indian origin without previous transfusions, an alloantibody of the specificity anti-in b with a titer of : was detected by iat (negative with papain-treated cells) at gestational week (gw) and . the mma, performed in duplicate on samples taken at these dates, showed a mi of . %/ . % and . %/ . % respectively. the mi was interpreted as follows: - % not relevant; - % inconclusive; > % clinical significant. the patient's parents were typed heterozygous, in: , whereas her husband was homozygous, in:- , . due to the husbands phenotype, the fetus was predicted to be in b positive. doppler flow measurement of the peak systolic velocity in the middle cerebral artery of the foetus was normal. delivery took place at gw without increased bleeding. the neonate presented no clinical manifestation of hdfn. neither the mother nor the baby required blood transfusions. summary/conclusions: we report the case of a pregnant woman of indian origin with an anti-in b alloantibody. the first mma, performed in gw , was inconclusive whereas the second mma, performed in gw , indicated that the antibody was clinically significant. if the mi-increase is only due to the pregnancy or has also a clinical significance, cannot be stated. in b negative blood components were not available and the patient's relatives were all in b positive. therefore, measures to avoid transfusions, including optimised peripartal management of haemostasis, was of utmost importance. with only few cases published, the risk of hdfn could not be excluded with certainty. an intrauterine investigation by doppler was performed to exclude relevant anaemia of the fetus. no transfusion was needed at delivery as there were no haemorrhagic complications. the neonate presented no clinical signs of hdfn. background: hemolytic disease of the fetus and newborn (hdfn) is a disease which if untreatedcan cause perinatal mortality and morbidity with a substantial risk for long-term sequela. in albania we lack of studies in this field. aims: the aim of this study is to determine the predictive value and the reliability of the "critical titre" during the evaluation of red cells alloantibodies ability to cause the hemolytic disease of fetus and newborn. methods: we conducted a descriptive, cross-sectional study. the data were collected in the university hospital for obstetrics and gynecology in albania. in the study were included immunized pregnant woman for anti-d antibodies and their newborns which were affected from the hemolytic disease of fetus and newborn. the data belong to the period and . results: the "critical titre" in our study was , meaning that this was the minimal value of the titre antibodies that could cause hemolytic disease of fetus and newborn. our study concluded that only newborns were born without the hemolytic disease of fetus and newborn and the titre values were less than . moderate hemolytic disease of fetus and newborn were caused between the titre values - . the summary/conclusions: the titre values of the mothers are a predictive option of the high risk of giving birth to a child with the hemolytic disease of fetus and newborn. it is recommended that in this cases the mother should be followed with doppler ultrasonography to measure the blood flow of the middle cerebral artery. also the doctors should recommend in pregnant women with positive coombs test not only the identification of the anti-d antibodies but also the identification of the other antibodies such as anti-e, anti-c, anti-k. background: rhd-negative pregnant women with allo-anti-d are at risk of having a fetus affected by haemolytic disease of the fetus and newborn (hdfn) where the fetus is rhd-positive. the rhd allele is highly polymorphic and many rhd variants give rise to an array of partial d phenotypes. the clinical significance for many partial d phenotypes is not well-established. rhd genotyping by non-invasive prenatal testing (nipt) to assess the fetal rhd status determines whether the fetus is at risk for hdfn. nipt tests also include strategies for detecting maternal rhd variants to provide for accurate reporting. however, the presence of a paternal rhd variant, while having the potential to confound nipt interpretation, is often not recognised. we report a "trio" family study triggered by a request for nipt for an rhd-negative pregnant mother, weeks gestation, who presented with allo-anti-d and anti-jk a antibody. subsequent paternal and fetal rhd genotyping was conducted and revealed a novel variant rhd allele. aims: we aim to characterise the paternal rhd allele and review clinical case features. methods: rh phenotyping was performed by standard serological procedures. nipt tested for fetal rhd exons , and . rhd genotyping on whole blood/cord blood dna was performed on the immucor bioarray rhd beadchip kit which predicts a rhd phenotypic variant of best fit. dna sequencing was performed using the illumina trusight one sequencing panel. copy number variation (cnv) analysis was used to assess the rhd exon structure and zygosity. results: the paternal red cells typed as group o rhd+c-c+e-e+, (ror). nipt genotyping detected fetal rhd signals for all exons, predicting rhd-positive. no maternal rhd sequences were detected consistent with homozygosity for the rhd deleted haplotype. for both paternal and cord genomic dna (gdna), beadchip genotyping predicted a rhd variant "diiia/cehar". furthermore, signal drop out was observed at nucleotide positions (c. , c. , c. ) located in rhd exon suggesting exon was either deleted or rhce-replaced. paternal and cord gdna sequencing detected out of snps (c. g>t, c. c>t, c. a>c, c. c>g) associated with diiia phenotype plus additional snps (c. g>a, c. g>c) on the rhd gene. both were rhd hemizygote by cnv analysis. no rhce variants were detected. clinical case features: the maternal anti-d quantitation increased from . iu/ml ( weeks gestation) to iu/ml ( weeks gestation). the fetus required intrauterine transfusions during the pregnancy to manage the hdfn. summary/conclusions: both father and fetus carry an rhd allele that does not align with alleles encoding diii phenotypes. this putative novel rhd variant allele comprises snps associated with diiia and with a possible exon deletion/rhcereplaced. a similar allele was reported in literature, although based on sequence analysis only, with no phenotype data. the variant allele here encodes rhd-positive phenotype and we predict that there may be a loss of d-epitopes. notwithstanding, the clinical presentation shows that maternal anti-d against this rhd phenotype (presumed partial) is associated with a severe hdfn and that such rhd blood group phenotypes are of clinical significance for alloimmunised pregnancies. abstract withdrawn. background: cd is a glycosylphosphatidylinositol (gpi)-anchored protein with apparent molecular mass of kda. in addition to being expressed on human plts, cd is expressed on activated t-cells, endothelial cells, cd + hematopoietic stem cells as well as on progenitor cells. in the chinese population, the calculated allele frequencies of hpa- a and - b are . and . , respectively. based on these data, the risk of alloimmunization against hpa- alloantibodies due to incompatible plt transfusion or pregnancy is expected to occur in relatively high frequency. however, until today there is no report of hpa- alloimmunization in the chinese population. in this study, we analyzed sera from hydrop fetus cases by maipa technique and icfa. aims: to detect the anti-hpa b alloantibodies by maipa and icfa. methods: a -year-old mother, gravida /para . the mother in the first pregnancy was diagnosed hydrop fetus at pregnancy weeks by ultrasound. in the second pregnancy, fetal hydrops was observed by ultrasound at pregnancy weeks. the mother's irregular antibody test was negative. the maternal platelet specific antibodies and hla antibodies were negative. blood routine and morphological examination of fetal umbilical cord blood showed that plt count dropped to . /l, wbc count dropped to . /l, including neutrophil %, lymphocyte %, mononuclear %, eosinophil %, basophil %, red blood cells were normal, hb was g/l. screening for hla and plt-specific antibodies was performed using a elisa-based plt antibody kit (pakplus, gti diagnostics) as recommended by the manufacturer. plt antibodies were detected by icfa and maipa.hpa genotyping was detected by cpr-ssp. results: the fetus's genotype was hpa- a/a, - a/a, - a/a, - a/a. - a/a, a/a, a/a, a/b, naka (+) and the maternal was hpa- a/a, - a/b, - a/a, - a/a. - a/a, a/a, a/ a, a/a, naka (+). the paternal genotype was hpa- a/a, a/b, a/a, a/a, a/a, a/a, a/a, a/b, naka (+), which was the only incompatible antigen compared with the maternal hpa. samples were tested using the fresh plt panels consisting of hpa- aa and - bb homozygous donors. the reactivity of the negative control and the mother's sera with the plts from hpa- a/a (donors ), hpa- a/b (donors ) and hpa- b/b (donors ) donors by maipa. the mother's serum showed no reactivity against a/a plts, weak positive reactivity against a/b plts (od values . ), but strong reactivity against b/b plts (od values . ).this finding could be confirmed by one of the reference plt laboratories (japanese red cross kanto-koshinetsu block blood center, japan) using freshly isolated plts from hpa- genotyped donors (anti-hpa- b average value . ). summary/conclusions: in this study, we found anti-hpa- b in a case of fnait (patient hpa- aa, blood group o) using the maipa technique. we were able to detect the presence of hpa- b alloantibody in one case of nait. background: fetal and neonatal alloimmune thrombocytopenia (fnait) occurs in : live births in caucasians. serological and molecular human platelet antigens (hpa) genotyping tests are performed to investigate and conclude to fnait diagnosis. however, in few cases and particularly in case of suspicion of private platelet antigen, some specialized analyzes must be performed in the laboratory (lab). these analyzes can range from sanger or ngs sequencing to platelet serology with transfected cells. aims: the aim of our study was to explore where the frontier between research and care takes place in the field of platelet immunology through the prism of the fnait investigations carried out by the platelet immunology laboratories. methods: a two-part electronic survey have been sent to foreign platelet immunology experts (pie) from platelet immunobiology working party (piwp) members and espgi board members (n = ). the first part focused on the lab practices and regulatory environment regarding to accreditation, contact with patient, informed consent and patient results. the second part stressed on the investigations performed to discover new platelet antigen and more precisely on the perceived status of these analyzes ( background: haemolytic disease of the fetus and newborn (hdfn) can occur when maternal red cell antibodies, directed against red cell antigens present on the fetal red blood cells, cross the placenta and enter the fetal circulation. in a "traditionally" conceived pregnancy, when hdfn occurs, it is as a result of maternal antibodies directed against fetal red cell antigens in the heterozygous state, whereby the antigen is inherited from the father only. with the advent of donor oocyte (do) in-vitro fertilisation (ivf), the addition of a third person into the reproductive equation allows for the possibility of a more severe form of hdfn when fetal red cell antigens are present in the homozygous state (one copy from father and one copy from donor) and maternal antibodies are directed against these. antigens expressed in the homozygous state will have more antigens sites per red blood cell and therefore are at an increased risk of red cell destruction from the maternal derived cognate antibodies. aims: to raise awareness of increased severity risk of hdfn in donor oocyte conceived pregnancies. methods: we describe two unusual cases of hdfn in our institution of two women whose pregnancy was induced using a donor oocyte and their offspring requiring transfusion support in the postnatal period to treat hdfn. results: the first is a case previously reported (doyle, quigley, fitzgerald et. al. transfusion medicine, ) of protracted hdfn due to anti-c, managed with phototherapy initially, then intervention with red cell top-up transfusion at weeks post-delivery. the second is an unusual case of severe abo hdfn requiring exchange transfusion therapy (pre-publication). summary/conclusions: given the increased number of pregnancies conceived using do we recommend that antenatal guidelines are reviewed to create awareness regarding the potential increased risk of hdfn in do pregnancies complicated by allo-immunisation. critically, antenatal testing guidelines should highlight that the predicted outcomes associated with quantitation/titres can only be used when do has not been used to obtain the pregnancy. it is also essential that clinicians inform the blood transfusion laboratory when do has been used. abstract withdrawn. %) are deceased due to organ rejection, and / patients ( %) are deceased due to disease not related to rejection. summary/conclusions: the use of therapeutic plasma exchange for the treatment of antibody mediated rejection in solid organ transplant is safe and effective when used along with other treatment modalities. further studies will help determine whether it can be reproduced in larger cohorts and whether it is more effective in certain organs. background: extracorporeal photopheresis (ecp) is an important cellular therapy for the treatment of several (auto-)immune diseases such as graft-versus-host disease. the international standard for the ex vivo treatment of the leukapheresis product is the application of -methoxypsoralen ( -mop) and irradiation with uv-a light. however, the addition of -mop to the illumination bag is associated with a potential risk of contamination. aims: the basic principle of the ecp is the induction of apoptosis in the leukocytes. our aim was to find an alternative for the conventional apoptosis induction without the need of external substance application. the objective of the study was the investigation of the apoptosis levels and kinetics in leukocytes after treatment with -mop+uv-a compared to uv-c treatment without additional -mop. methods: we used an in vitro h cell culture approach with human mononuclear cells from healthy blood donors. untreated control cells were compared with , lg/ ml -mop plus j/cm uv-a treated cells and j/cm (effective dose) uv-c treated cells. apoptosis in several leukocyte sub-populations was detected daily with annexin v and -aad flow cytometry standings. results: the apoptosis analysis of cd cd t-helper cells, cd cd cytotoxic tcells, cd b-cells, cd monocytes, cd neg cd nk-cells and cd cd nkt cells revealed no statistical differences in almost all of these cell types after treatment with -mop/uv-a or uv-c light. the apoptosis kinetic as well as the final apoptosis after h were similar in both treatment groups. summary/conclusions: the addition of -mop to the photopheresis irradiation bag is a risk for potential infections. the main effect of the -mop/uv-a treatment is most probably the induction of apoptosis in the leukocytes. here, we provide information that this induction of apoptosis can also be achieved with uv-c irradiation without the need of -mop addition. the apoptosis patterns in most leukocyte subpopulations are very similar after treatment with uv-c compared with -mop/uv-a treatment. future in vivo studies are needed to prove the therapeutic effect of uv-c treated cells in the ecp setting. abstract withdrawn. background: therapeutic plasma exchange (tpe) is performed to remove the implicating substances from the plasma causing the disease. a periodic appraisal of tpe data is important to get insight into the procedural related effects and toxicities and overall outcome in order to have a guided future approach. aims: the purpose of this study is to observe the overall profile and outcome of the patients receiving the tpe in the medicine intensive care unit (micu) of a tertiary care hospital in south india. methods: a record based audit was conducted for the all the patients who were admitted to our tertiary care hospital of south india with bedded micu and received tpe therapy between june, and december . all the tpe procedures were performed using haemonetics multicomponents system (mcs) + ln apheresis system based on intermittent flow centrifugation. we audited our tpe for: number of treatments, clinical indications, treatments prescribed and administered, any procedural or patient complications, and adherence to current best practice recommendations. results: sixty nine patients had undergone tpe procedures. among them, thirty were female patients ( %). the median age ( - ) years. guillain-barre syndrome (gbs) was the most common indication ( %) followed by cases of thrombotic thrombocytopenic purpura, diffuse alveolar hemorrhage, myasthenia gravis, autoimmune encephalitis and hypertriglyceridemia respectively. the tpe regimens received by patients in this icu were not always prescribed in accordance with current best practice recommendations. there were ( %) episodes of patient related complications during the tpe treatments. in ( %) procedures, technical error in the machine was encountered. summary/conclusions: the findings of this audit have identified differences between the current prescription recommendations for tpe and those applied. the infrequency of the therapy and the different indications may present a challenge for medicine intensive care clinicians to provide best care in all cases. background: microangiopathic hemolytic anaemia (maha) encompasses a spectrum of disorders characterised by widely disseminated thrombosis in small blood vessels resulting in formation of schistocytes and concomitant thrombocytopenia. plasma exchange (pe) needs to be considered as empirical and urgent life saving therapy in these disorders irrespective of waiting for specific testing like adamts levels in thrombotic thrombocytopenic purpura (ttp) or complement levels or factor h antibodies in atypical hemolytic uremic syndrome (ahus). aims: to assess the efficacy and safety of plasma exchange in patients diagnosed as having microangiopathic hemolytic anaemias. methods: a retrospective analysis of all pe procedures performed in patients diagnosed as having maha was done over a period of years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . procedures were done on apheretic device (cobe spectra, terumo bct, lakewood co. usa). patients' pre and post procedural hematological and renal parameters were analyzed by applying paired t test. adverse event if any was recorded. results: pe was performed in patients with diagnosis of maha ( -ahus, -ttp, each of post stem cell transplantation drug induced thrombotic microangiopathy (tma), post thyroidectomy tma and post-partum tma). the mean age of patient was . ae . years with m:f as . : . number of procedures per patient varied from to . post pe recovery was observed within - days with statistically significant increase in mean platelet count from . ae . to . ae . /l (p = . ) and significant decline in mean lactate dehydrogenase level from . ae . to . ae . lkat/l (p = . ). there was also significant decline in mean percentage of schistocytes in peripheral smear from . ae . % to . ae . % (p = . ). the mean serum urea changed from . ae . to . ae . mmol/l and creatinine from . ae . to . ae . lmol/l (p = . and . respectively) with significant increase in urine output from . ae . to . ae . ml/kg/h (p = . ). adverse events were observed in patients ( %), allergic reaction to replacement fluid (n = ) being the commonest followed by hypotension (n = ), rigors and chills (n = ). overall survival rate at months was %. summary/conclusions: pe had proven its safety and usefulness as life-saving first line treatment modality in maha. prompt and aggressive treatment helps in achieving early and complete remission in these patients. background: neuromyelitis optica (nmo) also known as devic's disease or devic's syndrome is a rare demyelinating disease of the central nervous system that most often results in selective involvement of the optic nerves (optic neuritis) and spinal cord (myelitis)and has female preponderance. neuromyelitis optica (nmo) attacks are poorly controlled by steroids and evolve in stepwise neurological impairments. assuming the strong humoral response underlying nmo attacks, therapeutic plasma exchange is an appropriate technique in severe nmo attacks. aims: to study the effect of tpe in neuromyelitis optica. methods: a year old female in the medicine department, civil hospital, ahmedabad admitted with chief complains of weakness and numbness in the arms and legs, blurred vision, reduced sensation, difficulty in controlling bladder and bowels, uncontrollable vomiting and hiccups since - days in the medicine department, civil hospital, ahmedabad. attacks were treated with short courses of high doses of intravenous corticosteroid -methylprednisolone intravenous. but there was no clinical improvement. results: clinician advised for the trial of tpe in this patient. the procedure was performed by automated device with continuous flow centrifuge machine fresenius kabi-com.tec using double lumen femoral catheter. after obtaining informed consent from the relative of the patient, cycles of tpe were performed on daily basis. after cycles, both subjective and objective clinical response to tpe was estimated by three different sources (the patient, a transfusion medicine physician, and the treating neurologist). [ ] for motor performance, patient was assessed on a disability scale ( = healthy; = minor symptoms; = able to walk meters without support; = able to walk meters with support; = confined to bed or wheelchair; = requiring assisted ventilation; = dead).patient's motor performance was increased to scale (upper limb) and (lower limb) from scale , deep tendon reflexes were normal. visual function began to improve week after the treatment. visual acuity was / after weeks. summary/conclusions: assuming the strong humoral response underlying nmo attacks, therapeutic plasma exchange is an appropriate technique in severe nmo attacks. this suggests that tpe is beneficial in nmo patients during acute attack if there is no response to corticosteroid treatment. background: babesiosis is a tick borne infectious disease caused by the protozoa babesia. while most infections with babesia are asymptomatic, some patients present with a symptomatic infections and rarely this can be a severe life threatening illness. treatment is primarily with antibiotics but red cell exchange (rce) has been used in the more severe cases which are characterized by high grade parasitemia, evidence of severe hemolysis and or multi-organ failure involving the kidney, lung or liver. a threshold parasite level of % has arbitrarily been applied as an indication for rce, however, this threshold is not evidence based. aims: to report on patients with babesiosis and high grade parasitemia who were treated with antibiotics only without rce methods: data were collected from july to july . a case was defined as a patient diagnosed with babesiosis for whom rce was requested on the basis of a parasitemia of > % but on clinical evaluation it was considered that rce could be withheld and the patient monitored awaiting response to antibiotics. results: three cases of severe babesiosis in which the use of rce was requested on the basis of a parasite level of greater than %, but was not performed. the rce was deferred on account of the good clinical state of the patient and the absence of renal failure. levels of parasite at diagnosis were . %, % and %. all patients were followed daily until discharge. two of these patients had been splenectomized and each received a single unit of red blood cells during the hospitalization. the third patient had a long history of refractory lymphoma and was pancytopenic requiring multiple transfusions during the years before the diagnosis of babesiosis. she had transfusion transmitted babesiosis from a red blood cell transfused days prior to the diagnosis. all three patients responded well to antibiotics and were discharged between - days with undetectable parasites. summary/conclusions: this small case series suggests that requests for rce solely on the basis of an arbitrary level of parasitemia should be questioned and the clinical state and evidence of organ failure considered in the decision to perform rce. abstract withdrawn. chronic transfusion program (ctp) remains the gold standard therapy for stroke prevention and for patients with a severe disease who have inadequate response to hydroxyurea treatment. aims: to evaluate the safety, efficacy and cost between scd patients on ctp that underwent both aet and partial manual exchange transfusion (pmet) procedures. methods: retrospective observational cohort study of patients with scd on ctp that have switched between pmet and aet. this study was carried out from / / to / / in a hospital in portugal. data on patient history, haematological values, duration of the procedure, intervals between them, adverse events as well as the cost of material and working hours were collected and compared between both procedures. results: a total of patients met the inclusion criteria described. however, patient was excluded from our study because of the lack of attendance to the ctp. during the study, we recorded exchange procedures ( pmet and aet), both on peripheral venous access. from all those procedures the major concern was the poor venous access, which was the reason why patients had returned to pmet. no major complication or alloimmunization was observed. the indications for ctp were cerebral vasculopathy (n = ), stroke (n = ) and recurrent vaso-occlusive crisis with multiorgan failure (n = ). for both procedures, target values were to obtain a pre-exchange hbs level ≤ % for stroke and cerebral vasculopathy and ≤ - % for other indications. the median hbs level before pmet was , % ( , - , ) and , % ( , ) before aet. we documented a higher hbs level prior to the next procedure in , % of patients (n = ). despite that all patients remained stable without any major scd related event. both procedures were well tolerated and iron overload was well controlled (median ferritin level pmet: , vs. aet: , ng/ml). the duration of the exchange procedure was longer and the intervals between procedures were shorter with pmet (median pmet: vs. aet: min and pmet: vs. aet: weeks, respectively). annual rbc requirements per procedure were superior (median vs. units) and the overall costs related with aet were , times higher - . , € and . , € aet and pmet, respectively (estimated cost per session aet: , € and pmet: , €). summary/conclusions: our study shows, that the hbs level before both procedures, performed during the same interval, was similar. we verified that pmet has a comparable efficacy with aet in terms of preventing the development or progression of chronic complications and that the cost per procedure is significantly higher with aet. however, in a clinical situation where it is important to rapidly reduce the hbs level, and/or where the control of the target hbs is stricter so that the patients are clinically controlled without an increase in hospital visits, aet is preferred. we conclude that aet is more effective in the rapid reduction of hbs and ferritin levels, as well as being less time consuming. despite this, for the reasons described above, it is more cost-effective to maintain both aet and pmet procedures. background: erythrocytapheresis/red blood cell (rbc) exchange, involves removing of a large number of rbcs from the patient and returning the patient's plasma and platelets along with compatible allogenic donor rbcs. typical indication for rbc exchange is sickle cell disease and its related complications. however, one of the miscellaneous indications of rbc exchange is for the patients of methemoglobinemia who are refractory to treatment by methylene blue. acquired methemoglobinemia is more common than any genetic causes. acquired methemoglobinemia is caused by toxins that oxidize heme iron, notably nitrate and nitrite-containing compounds. for patients failing to respond to standard treatment with methylene blue or in whom its use is contraindicated; hyperbaric oxygen or rbc exchange is indicated aims: case reports on use of rbc exchange in methemoglobinemia are few and indications are based on anecdotal reports. methods: exchange was performed on the cell separator machine, com tec by fresenius kabi. results: we report a case of acquired methemoglobinemia where patient was admitted with peripheral capillary oxygen saturation (spo ) of % on air. the patient did not show improvement in spo level with effective emergency treatment of methylene blue. since, the patient was refractory to treatment with methylene blue, the decision was made by clinician to proceed with rbc exchange. the patient improved significantly after two cycles of one rbc volume automated rbc exchange, and was discharged with spo of % on air. summary/conclusions: automated rbc exchange can be used in patients of acquired methemoglobinemia successfully when methylene blue is ineffective, and may be superior to manual one. background: therapeutic plasma exchange (tpe) is known to disturb the ph and electrolyte status. patients with compromised liver functions may be at a higher risk of electrolyte imbalance due to metabolic abnormalities. aims: the aim of this study was to analyze the variation in ph, ionized calcium, sodium, potassium, and bicarbonate in liver disease patients undergoing tpe. methods: patients with liver disease undergoing tpe during the period from july to august were included in the study. data on patient demographics, details of the tpe procedure, blood gas analysis report and adverse effects of tpe (if any) were collected and analyzed. results: one hundred and seven procedures were done during the study period; of these ( %) were done on the mcs plus (haemonetics corporation) and rest ( %) were done on the spectra optia (terumo bct). the percentage change in ionized calcium, sodium, and potassium due to the procedure was found to be statistically significant (p = . ). the systolic (p = . ) and diastolic ( . ) blood pressure also changed significantly with the procedure. the predictors for the change in ionized calcium were found to be pre-procedure ionized calcium (p < . ), the age of the patient (p < . ) and the pre-procedure ph (p = . ). procedurerelated complications occurred during procedures of which complications ( . %) were categorized as features of hypocalcemia. no association was found between hypocalcemic manifestations and pre-procedure calcium, change in calcium, age or gender of the patient. summary/conclusions: the tpe procedure in liver disease patients causes remarkable changes in ionized calcium, sodium, potassium and bicarbonate ions. the decrease in ionized calcium during the procedure is predicted by pre-procedure ionized calcium levels, ph and age of the patient. monitoring of these parameters and appropriate corrective measures are imperative to patient safety. background: therapeutic plasma exchange (tpe) in pediatric age group is technically demanding because of low blood volume, difficult venous access and poor cooperation of the patient during the procedure. we here present our experience of tpe in pediatric patients from our centre. aims: to assess the challenges during tpe in pediatric patients and formulate appropriate strategies. methods: we did retrospective analysis of all tpe procedures performed in pediatric patients over a period of years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . tpe procedures were done on two different apheretic devices (cs plus, fenwal usa and cobe spectra, terumo bct lakewood, colorado) daily or on alternate days depending on clinical condition of the patient. for all procedures, kit was primed with compatible packed red cells. adverse events during the procedure were noted and analyzed. results: a total of tpe (range - /patient with mean of . procedures) were performed for pediatric patients with different indications like atypical hus (category i as per american society for apheresis (asfa) in total patients, neuromyelitis optica (category ii) in patients, rapid proliferative glomerulonephritis (category i), c glomerulopathy in patients each and one patient of infective hemophagocytosis. the average age of patient population was . yrs ( . - years) . the male:female ratio was : with an average weight of . kgs. adverse events were observed during ( . %) procedures. most commonly observed adverse events were allergic reaction to replacement fluid ( . %) followed by hypotension ( . %), line occlusion ( . %), vasovagal, endotracheal tube blockage and symptomatic hypocalcemia was observed in one procedure each ( . %).there was no corelation observed between physical parameters of patient with adverse events. all adverse events were managed as per departmental standard operating procedures (sops) and procedures were completed successfully except in one where the procedure was abandoned. no mortality was observed during the procedures. background: the hemoglobin (hb) content of packed red blood cell (prbc) units is heterogenous. the patient's blood volume is also variable which can be calculated based on the weight, height and body surface area (bsa) of the patient. the efficacy of a transfusion episode can be assessed if the hb content of prbc is known and the patient's post-transfusion hb increment is determined. aims: this prospective study was performed to compare the efficacy of the transfusion of prbcs based on hb content versus the standard transfusion practice in thalassemia major patients. we also determined the correlation between hb increment and the hb content of prbc units transfused. methods: a total of registered thalassemia major patients of our institute were included in the study after excluding the patients who had allo-or auto-antibodies. the study was approved by the institute ethics committee. the enrolled patients were randomly divided into two groups: group i (n = )they received abo/rhd identical prbcs suspended in additive solution (saline, adenine, glucose, mannitol: sagm-prbcs) after determining its hb content (units with hb content ≥ g); and group ii (n = )they received randomly selected abo/rhd identical sagm-prbcs. the hb estimation of the randomly selected units in group ii was blinded. following tests were done on pre-transfusion sample: hb estimation using the hematology analyzer (orion , ocean medical technologies, india), blood grouping using tube technique, anti-human globulin (ahg) crossmatch and direct antiglobulin test (dat) using gel technique (biorad, switzerland), antibody screening (abs) using a fully automated immunohematology analyzer (neo, immucor, usa). on the posttransfusion sample collected h after transfusion, hb estimation and dat were performed. results: there was no significant difference among the patient characteristics of the two groups. the mean hb content of the sagm-prbc units was significantly higher (p = . ) in group i (mean ae standard deviation: . ae . g; range: . - . g) than group ii ( . ae . g; range: . - . g). the mean hb increment in group i patients ( . ae . g/dl) was significantly higher (p = . ) than the group ii patients ( . ae . g/dl). in both the groups i and ii, there was a significant negative correlation between hb increment and weight (p = . in groups i and ii), age (p = . for group i; p = . for group ii), body surface area (bsa) (p = . for group i; p = . for group ii) and blood volume (p = . for group i; p = . in group ii). in both the groups i and ii, there was a significant positive correlation between hb increment and hb dose adjusted for bsa and the hb dose adjusted for blood volume (p = . in both groups i and ii for both the parameters). summary/conclusions: the efficacy of transfusion is more when patients are transfused with sagm-prbcs having hb content of g or more as compared to those who are transfused with randomly selected units. for optimal hb increment in thalassemia major patients, the transfusion strategy should be based on the hb content of the sagm-prbcs. background: in male transfusion recipients under years of age, receiving red blood cells (rbcs) from an ever-pregnant blood donor has been associated with increased mortality, compared to receiving a product from a male donor. although it has been suggested that older units of rbcs could be associated with increased mortality, there are significant methodological challenges in these studies. other studies indicated the freshest units of rbcs could be associated with increased mortality among transfusion recipients. we hypothesize both the association between ever-pregnant donors, and fresh units, with mortality could be caused by passenger leukocytes in the transfused rbc units, which decay during storage. aims: to quantify modification of the effect of ever-pregnant donors on mortality in young male rbc transfusion recipients, by storage time. methods: data on transfusion recipients receiving their first-ever rbc transfusion in one of six major dutch hospitals between / / and / / was collected. for the current study, male transfusion recipients under years receiving only transfusions from one donor sex exposure category were selected and followup was censored at three years after transfusion. differences in storage time between groups were estimated by linear regression, adjusted for total number of transfusions, patient age, blood group, transfusion year and month. in a single-unit, single-transfusion cohort, cumulative mortality was estimated separately for patients receiving transfusions from ever-pregnant or male donors and for 'fresh' (< days storage) or 'old' (> up to days storage) rbcs. results: for recipients of only blood from male donors, the storage time of the freshest unit was . day shorter when comparing the patients who died, to , patients who survived (ci: À . to . ). for recipients of only blood from ever-pregnant donors, the storage time of the freshest unit was . day longer when comparing the patients who died, to patients who survived (ci: À . to . ). in the single-transfusion cohort, , patients received a fresh rbc transfusion from a male donor, of whom died; patients received a fresh transfusion from an ever-pregnant female donor, of whom died. patients received an old transfusion from a male donor, of whom died; patients received an old transfusion from an ever-pregnant female, of whom died. the -years cumulative incidence of death among young male recipients was . % (confidence interval (ci): . % to . %) after a fresh transfusion from a male donor and . % (ci: . % to . %) after a fresh transfusion from an ever-pregnant female donor. the -years cumulative incidence of death was . % (ci: . % to . %) after an old transfusion from a male donor and . % (ci: . % to . %) after an old transfusion from an everpregnant female donor. summary/conclusions: prolonged storage of rbcs from ever-pregnant donors was not associated with decreased mortality at years. contrary to our expectations, our results indicate older units may potentiate the effect of ever-pregnant donors. however, due to limited sample size the observed differences were not statistically significant. background: according to the literature review, there was limited impact of premedication (antipyretics, antihistamines and steroids) before transfusion on the prevention of adverse transfusion reactions (atrs). however, the necessity of premedication remains controversial. the premedication before transfusion is still a common clinical practice in pacific-asian countries, along with the premedication rate ranging from to %. in our previous investigation, we found that premedication rate was . % in the outpatients in , which was much higher than the reported rate in asia. aims: to investigate the incidence of atrs and decrease premedication rate without increasing the rate of atrs via education and evidence-based clinical practice. methods: the incidence of atrs from april to december, was retrospectively surveyed. evidence-based clinical practice was initiated since january, . clinical data of the outpatients receiving transfusion therapy were requested and analyzed from january to september, . the incidences of atrs and premedication rates in and were compared using chi-square test. a p value less than . was statistically significant. besides, feedback of the incidence of atrs and premedication rate was given quarterly to the clinicians during the investigation. results: from april, to september, , a total of , blood units were transfused in the outpatients with , transfusion events. of these, cases of atrs, including febrile nonhemolytic transfusion reactions (fnhtr) and minor allergic reactions were reported. the overall premedication rate in the outpatients was . % in , and was significantly decreased to . % in (p < . ). it was reported that the incidences of atrs in and were . % and . % per unit, respectively. there was no remarkable difference between the incidence of atrs in and (p = . ). summary/conclusions: via education and evidence-based clinical practice, we successfully reduced premedication rate without increasing the rate of atrs in the outpatients. furthermore, introduction of computerized provider order entry (cpoe) and clinical decision support system (cdss) could be considered and be expected to prevent unnecessary premedication before transfusion, increasing the compliance with optimized transfusion strategies in the future. methods: a retrospective analysis was done over a period of one year to evaluate clinical efficacy of granulocyte transfusions in hemato-oncology patients with febrile neutropenia. mobilization of granulocyte donors was done as per standard protocol, which included subcutaneous injection of granulocyte colony stimulating factor (g-csf) - lg/kg and tablet dexamethasone mg, - h prior to granulocyte harvest by apheresis. all granulocyte products were gamma irradiated before transfusion. patient parameters like white blood count (wbc), absolute neutrophil count (anc), hemoglobin and platelet count were recorded pre-and post-granulocyte transfusion. infection related mortality (irm) within days of granulocyte transfusion was also recorded. results: minimum adequate granulocyte yield of per unit was fulfilled in % of granulocyte harvests. clinical indications for granulocyte transfusions were fever, an absolute neutrophil count (anc) < /ll, evidence of bacterial and/or fungal infections (i.e. clinical signs of infection, positive cultures and radiological evidence) and unresponsiveness to appropriate antimicrobial therapy for at least h. effects of clinical, microbiological and granulocyte transfusion related variables on infection-related mortality were investigated. the post transfusion anc (within h) increased significantly (median value: /ll) as compared to baseline levels (median value: /ll) (p < . ). infection related mortality was observed in only % ( out of ) of patients. patients became afebrile within - days and culture negative within - days after granulocyte transfusion. for analysis purpose granulocyte transfusion episodes were grouped according to doses of granulocyte transfusions, based on european guidelines (standard dose: . - . cells/kg and high dose: > . cells/kg background: hsa's blood services group (bsg) is singapore's national blood service. in , we conducted our pilot national pbm audit to promote pbm practices. it was agreed that the audit would be performed annually with incorporation of a new indicator to continue promotion of pbm and sharing of good practices. aims: to provide an update on the second national pbm audit for . results are compared to the pilot audit and summarized below. methods: we collected data on performance indicators from acute public care hospitals for weeks each in march and august (the pilot audit covered weeks in ). the performance indicators were: ). percentage compliance to documentation of red blood cell transfusion indications ). percentage of patients screened for pre-operative anaemia, to days before surgery ). peri-operative transfusion rates ( days before to days after surgery) for commonly performed surgeries: coronary artery bypass graft surgery (cabg), total knee replacement (tkr), total hip replacement (thr), nephrectomy, colectomy and hysterectomy. the first two indicators assess pbm efforts and were measured in the pilot audit. indicator ) was added to the second audit to assess impact of pbm practices on transfusion in surgical patients. it was an appropriate time to incorporate this indicator as the hospitals would have been familiar with pbm since its introduction in . results and recommendations were shared with the senior management and hospital transfusion committees of the participating hospitals. results: for indicator ), hospitals had a compliance of - %, the remaining had a compliance of - %. all hospitals incorporated electronic blood ordering but the usage was not compulsory in some. hospitals which mandated electronic ordering performed better as doctors could only order blood products after entering the transfusion indication. we saw compliance increase from % in to % in a hospital that had newly mandated electronic ordering. for indicator ), results ranged from % to %. hospitals made notable improvements when compared to , achieving % and % respectively. they had implemented pre-operative workflows screening all elective surgical cases for anaemia at least weeks before surgery. one hospital also started an outpatient intravenous iron service which reduced pre-operative anaemia rates. for indicator ), mean number of transfused units for each surgery ranged from . to . units per patient, lowest being thr and highest being cabg. this suggests that some transfusions were potentially avoidable with more robust pbm practices. the rate of perioperative transfusions was highest for cabg at % and lowest for tkr at %. summary/conclusions: the annual national pbm audit increases pbm awareness, allowing hospitals to share and learn good practices and implement measurable improvements. based on this audit, a recommendation to mandate electronic ordering of blood products to improve adherence to red cell transfusion indications and implementing pre-operative workflows with consideration for intravenous iron support was made. this audit was more representative than the pilot, with a longer duration of data collection and incorporation of indicator ) showing impact of pbm practices. background: autoimmune haemolytic anaemia (aiha) is a decompensated acquired haemolysis caused by the host's immune system acting against its own red cell antigens. aiha is a rare disorder and although british society of haematology (bsh) guidelines for diagnosis and treatment were published in february , there is little evidence for clinical practice in the united kingdom. aims: to investigate the approach to the diagnosis, investigation and management of patients with autoimmune haemolytic anaemia (aiha) in english nhs trusts. methods: we designed and distributed a survey to the clinical transfusion leads at all english nhs trusts between november and march . the survey requested information on detailed, simulated clinical scenarios. the first simulated scenario described a young patient with active aiha months after an allogeneic stem cell transplant, who has received multiple transfusions in the last weeks and is hypotensive, tachycardic, with a falling haemoglobin (hb), currently g/l. the second scenario describes a young man with a new diagnosis of warm aiha who has an initial hb of g/l and returns to clinic at a -week interval with symptoms of fatigue. he is actively haemolysing and commenced on mg/kg prednisolone. results: there was a % ( / ) response rate by trusts. faced with a - h delay for allo-adsorption studies, % ( / ) of respondents would instead transfuse acutely with abo, rh and k matched red cells negative for any previously detected alloantibodies, % ( / ) would transfuse with o rh d negative red cells and % ( / ) would wait for completion of allo-adsorption studies before transfusing. in this first scenario, a quarter of respondents appeared to delay a potentially lifesaving blood transfusion. british society of haematology guidelines recommend that when anaemia is life-threatening in the time required for full compatibility testing, abo, rh and k matched red cells should be transfused. in the serious hazards of transfusion (shot) report, the most serious and fatal of cases of preventable delayed transfusion was a patient with aiha who died untransfused with an hb of g/l, while awaiting alloadsorption studies. a key shot message was that if clinical harm to patients from withholding blood outweighs safety concerns over a possible delayed haemolytic transfusion reaction, emergency blood is essential and should be offered. the second scenario also identified considerable variation in transfusion practice. it can take several weeks for patients with aiha to respond to prednisolone so a transfusion threshold < g/l after an hb fall of at least g/l in the previous weeks is perhaps overly conservative. summary/conclusions: the overall findings support a need for studies to explore barriers to uptake of guidelines, and to identify areas for further audit and research to guide safe and appropriate transfusion practice in aiha. background: balance between supply and demand of o d negative red cells remains a challenge for almost every blood service. with this re-audit, we wanted to collect objective and comprehensive information regarding usage of o d negative red cells supplied by nhs blood and transplant (nhsbt) to private and nhs hospitals in england. aims: the aim was to understand hospital practices, actual needs and possible avoidable usage of o d negative red cells. where possible, comparisons were made with two previous audits ( ) ( ) ( ) . methods: participating hospitals were asked to determine the fate of all group o d negative red cells they received between th and th may excluding substitutions and complete an organisational survey regarding activities, policies and stockholding practices with respect to o d negative blood. participating hospitals were asked to provide (if available) the prevalence (as a percentage) of o d negative patients in their population. this information, in conjunctions with hospital activities, will be used to estimate appropriate o d negative stockholding levels. background: o rhd-negative (neg) red blood cells (rbcs) are a precious resource, are often in short supply and transfusion of these units in emergency settings carries the potential risk of transfusion-related adverse outcomes such as haemolytic reaction due to minor blood group incompatibility. as such, their use should be closely monitored within health services. most recent australian guidelines ( ) for their use in emergency settings include pre-menopausal females of unknown blood group (mandatory indication) or while the blood group is being established; use should be limited to or less units where possible before a switch to group-specific rbcs (acceptable indication). aims: audit of use of emergency uncrossmatched o rhd-neg rbcs against national guidelines in our institution (an australian tertiary metropolitan public hospital providing acute medical and surgical, emergency and critical care services). methods: use of emergency uncrossmatched o rhd-neg rbcs units over a six-year period was retrospectively reviewed. we collected information about rbcs transfused and discarded, adverse outcomes, patient characteristics, clinical indications and whether use met national guidelines or could have been avoided. results: episodes of emergency uncrossmatched o rhd-neg rbcs were identified, encompassing transfusion of rbc units to patients and the discard of rbcs (due to incorrect transport). of the episodes, episodes ( %) involved an eventual switch to group-specific rbcs (range of emergency units, - units). the main requester was the emergency department ( %). the most common clinical indication for transfusion was acute gastrointestinal bleeding ( %). of the episodes, episodes ( %) did not meet the guidelines for emergency use because > units of emergency uncrossmatched o rhd-neg rbcs were issued. episodes ( %) were flagged as potentially inappropriate as the patients were clinically stable according to documentation in the medical records. episodes ( %) were identified as potentially preventable due to delay in pre-transfusion sample collection (defined as > h elapsed between patient arrival and group and screen sample collection) in the setting of acute bleeding ( %), receipt of an unsuitable pretransfusion sample requiring sample recollection ( %), delay in pre-transfusion sample processing ( %), no valid pre-transfusion sample being available at the time of the bleeding episode despite having a planned elective procedure or being an inpatient with recent clinical bleeding ( %). only one patient was investigated for potential transfusion-related adverse outcome ( %) which was thought likely due to concurrent sepsis. summary/conclusions: over six years, episodes utilising emergency uncrossmatched o rhd-neg rbcs were identified with rbcs issued and rbcs discarded. a significant proportion of episodes ( %) were potentially avoidable if there had been a valid pre-transfusion sample available in the transfusion laboratory at the time of the episode. efforts to minimise use of this precious resource are ongoing, and include feedback to clinical units regarding importance of valid pretransfusion samples prior to applicable invasive procedures and in bleeding patients, ongoing education to medical and nursing staff, and continuing audit of use of this blood component in the hospital haemovigilance programme. abstract withdrawn. abstract withdrawn. background: platelet transfusions are often given prophylactically to thrombocytopenic hematology patients. to which extent platelet function improves after transfusion, and how this improvement correlates with an increase in platelet count, is not well studied. flow cytometry has been used to evaluate platelet function after transfusion in a few studies and can be performed even at low platelet counts. rotational thromboelastometry (rotem) represents a more physiological measure of platelet function in whole blood that has not been extensively used in transfusion settings. we used these methods to investigate if platelet transfusion improves platelet function in hematology patients and if improvement correlates with increased platelet counts. aims: the aim was to evaluate the relationship between response to platelet transfusion, measured as corrected count increments (cci), and platelet function in thrombocytopenic patients with hematological disorders. methods: blood samples (sodium-citrate anticoagulated) were collected from unselected hematology patients receiving prophylactic platelet transfusions, after informed consent had been obtained. samples were taken at three time-points: within h before transfusion, h after and - h after transfusion (via a central venous catheter or a subcutaneous venous port). for each time-point, platelet response to adenosine diphosphate (adp) and thrombin receptor-activating peptide (trap- ) was assessed by flow cytometry by measuring p-selectin and pac- expression on single platelets. rotem analysis was also performed on all samples, using intem and extem reagents. results: an interim analysis was performed after inclusion of patients. the mean platelet count before transfusion was /l (range - /l). h cci was /l and - h cci was /l, but response was highly variable. pselectin expression after stimulation with adp and trap was significantly higher at h after and - h after transfusion compared to before transfusion (p < . ). pac- expression after stimulation with adp was significantly higher at - h after transfusion (p < . ), but not at h after transfusion. in rotem, clot amplitude at and min (a and a ) as well as maximum clot firmness (mcf) improved after transfusion (p < . ). a significant correlation between absolute platelet count and p-selectin expression after trap and adp stimulation was found (r s = . and . respectively, p < . ). absolute platelet count was also significantly correlated with mcf (r s = . , p < . ), where % of patients with a platelet count of more than /l reached mcf values within the reference interval. summary/conclusions: platelet function generally improves after transfusion and was in our patient population correlated to the absolute platelet count, but was also seen at the single platelet level in flow cytometry. a post transfusion platelet count of more than /l might be sufficient to significantly improve coagulation in heavily thrombocytopenic patients, but larger studies are needed to confirm this conclusion. abstract withdrawn. abstract withdrawn. background: sickle cell disease (scd) is a genetic disorder that is frequently referred to as a hypercoagulable state. hydroxyurea (hu) is known to decrease the frequency of vaso-occlusive complications and need for blood transfusions in severely affected individuals. although cross-sectional studies show that treatment with hu is associated with decreased coagulation activation, there are no prospective studies evaluating the effect of hu on coagulation activation. aims: to assess the effect of hu on markers of fibrinolysis (d-dimer) and endothelial activation (soluble vascular cell adhesion molecule- [soluble vcam- ]) in patients with scd in their non-crisis, "steady state." methods: patients, at least years of age, with documented hbss or hbsb-thalassemia, eligible for treatment with hu were studied in this prospective, observational study. laboratory investigations were obtained at baseline, prior to commencement of therapy with hu, with repeat evaluations at three and six months of therapy. non-parametric test was applied to observe the association between hu therapy and the biomarkers of interest. results: twenty-five patients with scd (hbss: , hbsb thalassemia: ) were enrolled (females: [ %]), with a median age of years (iqr: ). following months of hu, median values for wbc count ( . /l vs. . /l, p = . ) and d-dimer ( . ng/ml vs. . ng/ml, p = . ) were significantly lower than baseline values, while the mean corpuscular volume ( . fl vs. . fl, p = . ) was significantly higher than the baseline value. no significant differences from baseline were observed in the median values for hemoglobin ( . g/ dl vs. . g/dl, p = . ), platelet count ( /l vs. . /l, p = . ), lactate dehydrogenase ( u/l vs. . u/l, p = . ) or soluble vcam- ( . ng/ ml vs. . ng/ml, p = . ) following months of hu therapy. summary/conclusions: this exploratory study confirms that treatment with hu is associated with decreased coagulation activation in patients with scd, although no effect on endothelial activation was observed. by decreasing coagulation activation, hu may decrease the risk of thrombotic complications in scd. abstract withdrawn. abstract withdrawn. transfusion medicine, apollo gleneagles hospitals, kolkata, india background: reduction of immune responsiveness through blood transfusion has been documented by previous authors. breast cancer is considered as one of the commonest cancer globally and the second main cause of death in females transfusion of allogeneic blood in breast cancer surgery is variable and differences of transfusion incidence have been observed in the literature. where the maximum surgical blood ordering schedule (msbos) dictates cross matching and reservation of blood before surgery, factors deciding their utilization are varied and numerous. our hospital protocol guides that every patient planned for elective breast cancer surgery should routinely have a blood sample sent for reservation of one unit of compatible packed red blood cell (prbc) in the blood bank. aims: in this prospective study we aimed to audit the blood utilization in patients undergoing elective breast surgery and thereby optimize the blood ordering schedule, economic burden and loss of clinical resources. methods: the study included confirmed breast cancer patients planned for elective breast surgeries from january to december . patient and disease details like age, stage, tnm status, estrogen receptor (er) and progesterone receptor (pr) status, human epidermal growth factor receptor (her - ) expression, triple negative breast cancer (tnbc) status, reproductive and treatment status were documented. patients were divided into younger group [≤ years] and older group (> years). before surgery blood samples for compatibility testing were sent to blood bank for blood reservation. details of test, blood issue and blood transfusion were documented in the blood bank. approximate loss of time in minutes and wastage of resources in terms of money (inr) in the blood bank were noted. all results were calculated as mean ae sd and a 'p' value of < . was considered statistically significant. results: of the total patients most underwent wide local excision of the breast and modified radical mastectomy. a total of patients received units of blood and blood components in all categories of surgeries. only were younger women (≤ years) with mean age of years. non-transfused patients were significantly more than transfused ones (p < . ). frequency of blood transfusion was more in young patients ( . %). seven ( . %) of the total stage iv patients received blood transfusions. frequency of blood transfusion was more in patients undergoing surgery after chemotherapy ( . %). a significant loss of time and loss of revenue was observed. summary/conclusions: we conclude that routine compatibility test is not justified for all patients undergoing breast surgery. a more targeted approach is needed to reduce blood demand and associated cost to patient and blood transfusion services. background: blood transfusion guidelines are not only essential for the optimal use of blood products, but also help reduce transfusion-related adverse reactions and improve patient outcomes. the korean national transfusion guidelines were developed in and fully revised in by the korean centers for disease control and prevention and the korean society of blood transfusion. in our hospital, which is a -bed university hospital, a transfusion-indication data-entry program based on the national transfusion guidelines was developed in . it was applied to the electronic medical record system and all transfusion orders, except emergencies, have been performed through this program since then. aims: we planned to record and analyze the reasons for transfusion in order to monitor blood product usage and provide feedback to clinicians. furthermore, we intended to contribute to patient safety through the appropriate use of blood products. methods: we classified transfusion-indications by the blood product requested and created a pop-up window listing these indications, which would appear at each regular transfusion order. indications for transfusion with each blood product were as follows: red blood cells (rbcs)acute blood loss, chronic disease (sub-classified as hb ≤ g/dl, cardiovascular disease, cerebrovascular disease, peripheral vascular disease, respiratory disease, age ≥ years, age ≤ months, chemotherapy), surgery/ procedure, transplantation and 'other'; platelets (plts)present bleeding, bleeding prevention (sub-classified as hematologic disease, solid tumor, peripheral blood stem cell transplantation, disseminated intravascular coagulopathy, infant), surgery/procedure, massive transfusion and 'other'; fresh frozen plasma (ffp)bleeding in coagulopathy, bleeding prevention in coagulopathy, massive transfusion, plasma exchange and 'other'. transfusion indications entered into the data-entry program from sep to feb were analyzed. results: the number of transfusion-indications analyzed was for rbcs, for plts and for ffps. the most common indications for transfusion were chronic disease for rbcs ( / , . %), bleeding prevention for plts ( / , . %) and 'other' for ffp ( / , . %). 'hb ≤ g/dl' was the most frequent sub-indication of chronic disease ( / , . %), and hematologic disease was the most frequent sub-indication of bleeding prevention ( / , . %). many clinicians entered transfusion indication as 'other': rbcs ( / , . %), plts ( / , . %) and ffp ( / , . %). however, the free-text supplied by the clinician when 'other' was selected, often corresponded to an indication already categorized in the transfusion-indication data-entry program; . % of rbcs and % of plts. of the indications entered as 'other' in ffp, . % were surgery/procedure-related. summary/conclusions: in our hospital, the release of blood products has been dependent on the data-entry of transfusion indications (except in emergencies) since sep . transfusions of rbcs and plts were most common for chronic disease and bleeding prevention, respectively, but many cases entered as 'other' could have been categorized as existing indications in our data-entry program. therefore, we conclude that additional training is needed for clinicians regarding the determination of transfusion-indications and correct use of the transfusion-indication dataentry program, in order to use blood products more appropriately. methods: this was a prospective cohort designed study. subjects were children aged - years with indication of platelet transfusions in sardjito hospital yogyakarta indonesia. the patient samples were collected before and h post-transfusion, the expression of cd p on platelet was determined by flow cytometry method. results: there were subjects who were divided into two groups. fifty-one subjects received non-leukodepleted pcs and the other fifty-one transfused by pre-storage leukodepleted pcs. the mean of pre-transfusion platelet cd p for nonleukodepleted and leukodepleted groups were . % and . %, and the mean increase of post-transfusion platelet cd p for non-leukodepleted was . % and the mean decrease of leukodepleted groups was . %. it was shown the increase of post-transfusion platelet cd p for non-leukodepleted group, and it was significantly (p < . ) higher than in the leukodepleted groups. summary/conclusions: there was an increase of post-transfusion platelet cd p expression in patients received non-leukodepleted, but a decrease in leukodepleted pc transfusions. background: preoperative anaemia is a common finding in patients undergoing surgery and often neglected in our country. aims: the objective of this study was to evaluate hb(values and the identification of cardiac patients who entered operation with anaemia. and also to study the correlation between hb values and the number of rbc (red blood cell) transfused unit methods: this is a retrospective, descriptive and analytical study. the data for this study was collected from the files in the statistic's service at qsut (university hospital center "mother teresa"). the object of our study were the files of patients hospitalized in the period january -may in the cardiac surgery ward, which were subjected to cardiac surgery. from the files were collected data on age, gender, primary diagnosis, accompanying diseases. we also collected hb, rbc, htc (hematocrit), mcv (mean corpuscular volume), mch (mean corpuscular hemoglobin), mchc (mean corpuscular hemoglobin concentration). from the transfusion service at qsut and from the files were pulled out the transfused patients and the number of transfused units. results: based on the who definition for anemia (females < g/dl and males < g/dl), from the patients included in the study, ( %) were anaemic. from males in the study, ( %) of them were anaemic based on hb lab values, whereas from women in the study anaemic were found to be ( %) of them. from the anaemic patients in the study, ( . %) of them with mild anaemia, ( . %) with moderate anaemia and ( . %) with severe anaemia. in the total of anaemic female . % are under , while . % are over/or years old. in the total of anaemic males, % are under , while % are over/or years old. it is noticed that most of them are with normochromic normocytic . %, normocytic hypochromic anaemia . %, hyperchromic microcytic anaemia . %, macrocytic normochromic anaemia and macrocytic hypochromic anaemia respectively . % and microcytic normochromic anaemia . %. the average value of preoperative hb decreased from . g/dl before surgery to . g/dl after surgery, so there is a decrease of approximately . g/dl of hb value. in our patients, % ( ) were transfused and the remaining % ( ) were not transfused. from transfused patients ( %) patients were anaemic. the correlation between the values of hb, rbc, htc and the number of transfusions shows that with the decrease of these values the number of transfused units increases. summary/conclusions: the diagnose of anaemia is underestimated before surgical intervention in our country and investigation of hb low values do not take the proper importance to find probable cause and correct it before surgical intervention. the lower the hb values, the greater the chance to be transfused and the number of rbc transfused units. failure to correct hb values before surgery results in unnecessary transfusions for the patients or which could have been avoided, eliminating also the risk of transfusion complications. background: alloimmunization after red blood cell transfusion is affected by various factors. it is known that the incidence of alloimmunization increases in certain diseases. extended red blood cell matching can be used to prevent the development of alloimmunization in diseases which the rate of alloimmunization is increased. in asia, extended red blood cell matching is not actively implemented. aims: we tried to investigate whether there is a difference in the disease categories between unexpected red blood cell antibody positive and negative groups. methods: from january, to december, , the diseases of the patients who had undergone unexpected red blood cell antibody identification test at dong-a university hospital was examined through medical records. from january to december , the diagnosis was made on patients who had two or more unexpected antibody screening tests. we analyzed the frequency difference of disease category between two groups. results: a total of patients were performed with unexpected antibody identification tests. of patients who underwent more than screening tests, ( . %) were positive. were consistently unexpected antibody negative. the patients with solid tumors (n = , . %) and those with hematologic diseases (n = , . %) had a higher incidence in unexpected antibody positive group. the patients with myeloid malignancy had a significantly higher frequency than lymphoid malignancy (p = . ). the frequency of patients with liver cirrhosis was significantly higher in the unexpected antibody positive group ( / , . %) than in the negative group ( / , . %) (p = . ). the incidence of non-hodgkin lymphoma was significantly higher in the unexpected antibody negative group ( / , . %) than in the positive group ( / , . %) (p = . ). summary/conclusions: there was a difference in the distribution of diseases between unexpected antibody positive group and negative group. the patients with liver cirrhosis were more frequent in unexpected antibody positive group, suggesting that extended red blood cell matching would be considered. background: in hematological patients with multiple platelet transfusions (pc) often develop immune response to human leukocyte associated antigens (hla-i) and human platelet-specific associated antigens (hpa). besides, platelet associated immunoglobulins (paig) and complement components (pac) are found on platelet. this leads to increased platelet destruction and development of refractoriness to transfusions of donors' platelets. transfusion therapy using an individual selection of platelets and plasmapheresis, contribute, in the majority of cases, to the realization of efficient transfusion by pc. but, in difficult cases, there is a need to use intravenous immunoglobulin, which may promote the efficient transfusion of pc. aims: evaluate the algorithms of using the complex therapy of refractoriness to transfusions of donors' platelets with additional application of intravenous immunoglobulin (ivig). methods: in there were three female patients in the clinics of the centre for observation, age between and years (me = ) with the ineffectiveness of complex therapy for overcoming refractoriness to transfusions of donors' platelets due to selection and plasmapheresis. the diagnoses were as follows: aplastic anaemia (aa)- , acute myeloid leukemia (aml)- . individual selection of platelets was carried out by the adhesion method on the solid phase (immucor "galileo neo"). paig and pac / were evaluated by the method of flow cytometry (bd facscanto ii) by the method of double staining with cd a. the density of fixed paig, pac was © the authors vox sanguinis © international society of blood transfusion vox sanguinis ( ) (suppl. ), - evaluated by the median fluorescence intensity (mfi). the two patients with aa received ivig-igg therapy in the standard dose , g/kg per day, for days. one patient with aml received ivig-iggam therapy in the standard dose , ml/kg/day for . results: under pressure of the complex therapy with the use of ivig in the standard dose there was are decrease in mfi over time in the case of two patients: aa- mfi-paigg reduced from to ; while the patient with aml: paiga reduced from to , and paigm from to , pac from to , pac from to . the patient with aa- over time, regardless of the treatment, there was an increase of mfi, but the effect of pc transfusions was achieved under pressure of complex therapy. under pressure of complex therapy all the patients also reduced the frequency of reaction of alloantibodies when resorting to an individual selection and increasing the frequency of compatible couples "donor-recipient". summary/conclusions: delivery of complex therapy and the additional application of ivig enables an adequate transfusion therapy of pc, neutralize hemorrhagic syndrome and continue the treatment of the main disease. detection and monitoring of paig/pac during the development of refractoriness to transfusions of donors' platelets are additional markers for prescription of ivig therapy. anaesthesia, tan tong seng hospital, singapore, singapore background: blood transfusion is quite prevalent in paediatric cardiac surgical procedures. we hypothesized that the routine use of rotational thromboelastography (rotem) to guide transfusion decisions would reduce the overall proportion of patients receiving transfusions in paediatric cardiac surgery aims: the aim of the study was to find if the use of blood and blood products in pediatric cardiac surgical cases in a single centre is affected due to rotem. methods: sixty paediatric cardiac surgical patients undergoing cpb were included in this study. thirty patients (study group) were prospectively included and compared with thirty procedure and age-matched control patients (control group). in the study group, rotem, performed during cpb guided intraoperative transfusions. perioperative transfusions of blood and blood products, postoperative blood loss and hemoglobin levels were compared between the two groups. results: the patients in the control group received fewer transfusions of packed cells ( % vs %) and fresh frozen plasma ( % vs % p<o.oo ). more patients in the study group received platelets ( % vs %) and cryoprecipitate ( % vs %). the postoperative blood loss was lower in study group compared to the control group. the postoperative hemoglobin did not differ between the two groups. summary/conclusions: the results suggest that the routine use of rotem in paediatric cardiac surgery to guide transfusions is associated with reduced proportions of patients receiving transfusions and is evidence based practice. abstract withdrawn. abstract withdrawn. abstract withdrawn. background: mycoplasma pneumonia (mp) infection has often been implicated in respiratory tract infections. although this agent has also been associated with other non-respiratory diseases, hemolytic anemia is the most common hematologic complication of mp infection. episodes of sudden onset of severe anemia are rarely seen in beta thalassemia. we report a -years-old female with beta thalassemia major who was diagnosed to have severe anemia secondary to autoimmune hemolytic anemia induced from mp infection aims: to report a case of patient with beta thalassemia major who was diagnosed to have severe anemia secondary to autoimmune hemolytic anemia induced from mp infection and how it was managed with minimal transfusion. methods: a -year-old female case of beta thalassemia major who developed autoimmune hemolytic anemia following mycoplasma infection. the patient is on monthly blood transfusion since the age of years at dubai thalassemia center. she was admitted to the hospital with days history of dizziness, severe low back and joint pain and her travel history indicated a four-week visit to pakistan. initial investigations showed a hemoglobin level of . g/dl the direct and indirect coombs test were positive. patient was transfused with two units leuko-depleted compatible prbc (o, rh +, negative for e and kell antigens.) and discharged next day. three weeks later, the patient was still with lower limbs pain and the hemoglobin was . g/dl with a positive dat with both igg+ and c + , patient was not transfused as it was difficult to find matching blood; therefore she was given one week follow up. four days later, patient reported to the center with fever, generalized body pain and fatigue. she had significant drop in hemoglobin . g/dl, mcv . , platelets count , crp . , retic count . , blood culture no growth, total bilirubin . , malaria parasite smear was negative, urine culture and microscopy were normal. mycoplasma pneumonia antibody showed positive with igg . and igm . , she was started on azithromycin for days and received units prbc least incompatible leuko-depleted (o, rh +, negative for e and kell antigens.). after which her hemoglobin increased to . g/dl. she did not show any improvement in her condition over the following weeks and repeat mycoplasma pneumonia antibody showed an increased titer, which denoted resistance to azithromycin; hence, we started her with second line of treatment levofloxacin for days. screening for collagen disease were all negative apart from high esr of mm/hr. patient remained afebrile and transfused with least incompatible available blood, post transfusion hb was . g/dl. three weeks later, during her routine follow up, she was doing well with esr dropping to mm/hr and hemoglobin . g/dl, which indicated gradual settling of hemolysis, although the last dat remained positive. subsequent visits showed hb drop of . g/dl/week which is acceptable for transfusion dependant thalassemia. results: with conservative management patient condition improved. summary/conclusions: hemolytic anemia associated with mycoplasma pneumonia is usually self-limited and resolves spontaneously after mycoplasma infection elimination. packed red cell transfusion in transfusion dependent patient may be troublesome and can aggravate the condition; therefore it should be utilized and limited to significant symptomatic anaemia background: early plasma transfusion in women with severe postpartum hemorrhage is often instituted to prevent and treat coagulopathy, but whether maternal outcomes improve with this treatment is unclear. aims: to quantify the association of plasma transfusion within the first min after diagnosing persistent postpartum hemorrhage and adverse maternal outcome. methods: we performed a retrospective cohort study of women with persistent postpartum hemorrhage, defined as postpartum hemorrhage refractory to first-line measures to control bleeding. women were enrolled from january , to january , in dutch hospitals. in a time-dependent propensity score-matched analysis, women with transfusion of fresh frozen plasma within min following the diagnosis of persistent postpartum hemorrhage were matched to women without plasma transfusion or plasma transfusion at a later time point during hemorrhage. plasma transfusion was not guided by coagulation tests. the main outcome measure was adverse maternal outcome, defined as a composite of mortality, hysterectomy and arterial embolization to control bleeding. we performed sensitivity analyses with initiation of plasma transfusion within and within min following diagnosis persistent postpartum hemorrhage, compared with other plasma transfusion strategies. results results: the cohort consisted of women with persistent postpartum hemorrhage, with uterine atony as cause of hemorrhage in women ( . %). in this cohort, seven maternal deaths ( . %), hysterectomies ( . %) and arterial embolizations ( . %) were observed. plasma transfusion within min in women was matched on time-dependent propensity scores with women with no or later plasma transfusion. rate of adverse maternal outcome was similar between women with and without early plasma transfusion, . % versus . %, adjusted odds ratio . ( % confidence interval . - . ). results of sensitivity analyses were comparable to the primary results. summary/conclusions: among women with persistent postpartum hemorrhage, initiation of plasma transfusion within min following this diagnosis was not associated with improved maternal outcomes, compared with no or later plasma transfusion. whether other transfusion strategies or identification of women with high risk of coagulopathy will improve maternal outcomes remains to be studied. background: preoperative evaluation of increased risk for perioperative bleeding is essential for cardiac surgery patients. platelet aggregation, as a laboratory test for assessment of platelet function, is very efficient for optimal antiplatelet treatment and also for assessment of the increased risk of postoperative bleeding and perioperative application of allogenic red blood cell transfusions. aims: the aim of this study was to establish whether preoperative platelet function testing for the presence of residual effect of acetylsalicylic acid (asa) on platelet aggregation can be correlated with an increased risk for intraoperative bleeding during cardiac interventions. methods: a retrospective study included patients who underwent surgical procedures (cabg ii and cabg iii) at the department of cardiovascular surgery, clinical center in ni s in period november -july . patients were previously taken asa at a dose of mg per day, but therapy was discontinued days before surgery. platelet aggregation was measured on the day of surgery using impedance aggregometer multiplate (multiplate platelet function analyzer, roche), using trap and aspi tests. patients were divided into two groups: control group (cg), which included patients with preserved function of platelets (aspi - au*min), and examined group (eg), which included patients with inhibited platelet aggregation in aspi test (< au* min background: hemophilia b is an x-chromosome-linked inherited bleeding disorder resulting from reduced levels or an absence of factor ix clinically represented by recurrent prolonged bleeding. mutations can be inherited or acquired de novo. de novo mutations arise in about one-third of patients with haemophilia. the disease affects primarily males, but approximately % of carrier females have factor ix clotting activity lower than % and are at risk for bleeding. aims: case report of a hemophilia b carrier. methods: the clinical history of the patient was thoroughly studied by analyzing medical records and analytical results using the software available in the health institution and paper records. results: year old woman, with no history of abnormal haemorrhage, healthy, up to when, after a dystocic delivery, presents with subcutaneous and ocular haemorrhage and dispersed bruises. a basic coagulation study is performed and a level of % fix is found. genetic analysis reveals a mutation in fix gene and she is diagnosed as a carrier of hemophilia b. except for a son, no other direct family members carry the mutation. in , after total hysterectomy with bilateral adnexectomy due to an invasive carcinoma in the uterine cervix, the patient suffers a haemorrhagic shock with multiple transfusion support and around six months later undergoes an ureteronephrectomy also with the need for post-surgery transfusion support. the patient is referred to the immunohemotherapy department where she has regular appointments as an outpatient since . in , she requires surgery for the removal of a thyroglossal duct cyst, which is performed under prophylactic treatment with iu recombinant fix (rfix) daily, for four days, and up to h after discharge maintaining basal levels of fix of % and with no major complications reported. in , the patient is admitted to the er in haemodynamic shock and a history of black stools and syncope. at admittance, she receives a bolus of iu of rfix and requires severe transfusion support due to active bleeding. she is diagnosed with colonic angiodysplasia and undergoes surgery. daily doses of iu rfix are administered from day (d ) and up to d maintaining fix levels around - %. the patient is operated at d under the cover of iu of rfix, twice per day, and up to d after surgery reaching fix levels of around - %. at d the dose was diminished to iu of rfix daily and at d she is discharged with no rfix replacement therapy necessary in ambulatory. since then, no complications or new occurrences have been reported. the patient is under prophylactic administration of rfix prior to minor invasive procedures (nodule biopsy, dental extractions and colonoscopies). summary/conclusions: hemophilia b carriers usually do not require any major health care for their daily routine or invasive procedures. however, in the case reported, basal fix levels conditioned any minor intervention to be performed. thus, this carrier must be considered as a moderate hemophilia b patient and mandatory prophylaxis with rfix must be performed prior to any invasive procedure. background: blood transfusion is a life saving procedure but transfusion associated complications are equally important that need to be addressed. with limited resources of blood donations and screening, excessive transfusions must be avoided to prevent risk and economic burden on patients. on the other hand discussion on appropriate use of blood product is a matter of debate in medical literature. it is recommended to restrict the liberal use of transfusion. aims: in this regard we aimed to observe the frequency of genuine and non genuine transfusion at our hospital and also to compare the outcomes of liberal and restrictive transfusions. methods: it was a cross sectional study carried out at nibd and bmt, pechs campus, karachi, pakistan, from february to january . the study was approved from institutional review board. pack red cells (prc) transfusion in case of < g/dl hemoglobin (hb) with cardiac history and < g/dl hb with symptomatic anemia was considered genuine. platelets transfusion in case of sepsis and count < /l, sepsis with bleeding and < /l, patients on active chemotherapy without bleeding but platelet count < /l and in patients presented with bleeding was considered genuine. patients who were presented with bleeding, deranged coagulation profile and with sepsis + bleeding considered genuine for fresh frozen plasma (ffp) transfusion. spss version . was used for descriptive and inferential statistics. results: a total of transfusions were evaluated for genuine and non genuine transfusion. male predominance was high in our data ( %). out of , ( %), ( %) and ( %) prcs, platelets and ffp were transfused respectively. out of platelets, ( %) were platelet apheresis. / ( %) prcs and / ( %) platelets were non genuinely transfused as per the criteria described in methods. however, ffp and platelet apheresis were genuinely transfused. in non genuine group of platelet transfusion, all patients received more than unit platelet and the increment of platelet count post transfusion was found statistically non significant (p = . ). thirty six ( %) of transfusions were done with more than units of prcs in non genuine group. the mean hb level of patients received unit and more than units prcs was statistically same (p = . ) and it was found out that there was same increment in hb in both the groups post transfusion. (p = . ). summary/conclusions: we concluded that although blood transfusion is an integral procedure for saving life yet correct use of blood products is necessary in the era where blood donations are scarce and blood transfusion has its potential associated hazards. the approach towards the appropriate use of blood products will not only minimize the risk of transmission of infectious diseases but also will reduce the economic burden. longitudinal studies on large sample size are needed to validate this study. uncertain. an ovine model enables comparisons of; (a) invasive and non-invasive methods to measure oxygen delivery and utilisation at a tissue level, and of (b) the efficacy of various resuscitation fluids and transfusion protocols in treating haemorrhagic shock. aims: to develop an ovine model of haemorrhagic shock. methods: sheep (n = ) were anaesthetised, ventilated and instrumented. instrumentation included blood flow, perfusion, and microdialysis probes placed in the brain, kidney, liver and skeletal muscle. haemodynamic, tissue oxygenation, tissue flow and respiratory data were recorded continuously by data capture software. non-invasive assessments, including brain and muscle oxygen saturation by nirs, and visualisation of sub-lingual microvascular perfusion, as well as arterial blood gas measurements and plasma/serum/urine collections were made at specific timepoints. after a baseline period ( h) sheep were bled~ % of their estimated blood volume (estimated at ml/kg) to a mean arterial blood pressure (map) of - mmhg. sheep were then resuscitated with either plasmalyte â (up to ml/kg/ hr; n = ) or transfused with sheep red cells (n = ) to achieve a map > mmhg. sheep were euthanised h after resuscitation. data are presented as mean ae standard deviation. results: sheep were haemorrhaged an average of . ae . ml blood which combined with iatrogenic blood loss (~ ml) corresponded to an average . ae . % blood loss. two out of the four sheep met clinical criteria for haemorrhagic shock (map = - mmhg, lactate > mm, svo < %). across all four sheep the nadir map averaged . ae . mmhg, lactate peaked at . ae mmol/ l, and nadir svo was . ae . %. all sheep survived to the end of the experimental protocol. summary/conclusions: these data demonstrate the successful induction of haemorrhagic shock in an ovine model. further experiments are planned to improve the protocol and to achieve % incidence of haemorrhagic shock, and then to compare invasive and non-invasive measures of oxygen delivery and utilisation as well as the efficacy of different resuscitation fluids and red cell transfusion. adverse events, including trali p- bilirubin were recorded within the -day period. the clinical parameters were compared against the reaction strength of the antibody reactions. the automated strength was measured by solid phase. the manual testing consisted of a -min incubation using liss and adding monospecific igg. the dat was performed manually by adding poly-specific igg and then testing with monospecific igg and c d. the rh group and non-rh group had and cases performed manually, and results were + or weaker further indicating the manual strength did not correlate with the clinical hemolysis. likewise, in / ( %) the dat was negative, and did not show any correlation with clinical hemolysis. however, when ldh and bilirubin were measured, the two parameters increased as the automated strength of the antibodies increased. summary/conclusions: most of the dshtr investigation was not associated with overt accelerated red cell destruction. a strong correlation was observed only between the automated immunohematology testing results and other laboratory markers of hemolysis. in our experience, the direct antiglobulin test and manual strength showed no correlation. background: numerous transfused patients present severe, sometimes critical clinical conditions. the occurrence of adverse transfusion reactions (atr) may induce deterioration in the clinical condition with a worsened clinical course and a lifethreatening or fatal outcome as is the case with nervous system impairment. in france, in , out of , notified atrs, ( . %) and ( . %) were life-threatening and death respectively. aims: our aim was to evaluate the notified atrs with neurological signs that occurred in transfused patients over a period of six years and six months in hospitals in the auvergne rhône alpes area. the study included patients with reported atrs in hospitals in this area from january st to june th . each atr was registered in the national haemovigilance database system. two signs observed at the time of the atr were analyzed: unconsciousness and convulsions. stroke was excluded. the type of atr, its severity, the blood product involved and its imputability were studied. results: during the period under study, , atr were reported, of which included unconsciousness and/or convulsions ( . %). of these patients, were females ( . %) and males ( . %). unconsciousness alone was frequently observed ( reports, . %). convulsions were notified in reports ( . %) and were associated with unconsciousness in of them. the diagnosis of seizure, with no other clinical signs, was established in cases ( . %). unconsciousness and/or convulsions were present in allergic reactions ( . %), cases of transfusion-associated circulating overload ( . %), cases of suspected transfusion-transmitted bacterial infections and hypertensive reactions. in allergic atrs, unconsciousness was notified in cases and unconsciousness associated with convulsions in one. twelve atrs were severe ( . %), were life-threatening ( . %) and in cases, they resulted in the death of the recipient ( . %). of the allergic atrs, were severe and life-threatening. red blood cell concentrate was involved in atrs ( . %) and platelet concentrate in ( . %), including cases with apheresis platelet concentrate and cases with pooled platelet concentrate. fresh frozen plasma was involved in atrs ( . %). nevertheless, the imputability of the blood product was excluded or unlikely in atrs ( . %). in the suspected transfusion-transmitted bacterial infections, the imputability of the transfusion was ultimately excluded after a negative result was obtained in the bacterial culture of the blood product. the imputability of the blood product was probable or possible in and atrs respectively, but was certain in only atrs. summary/conclusions: unconsciousness and/or convulsions were rarely observed in atrs notified in transfused patients. nevertheless, the presence of these signs highlights the seriousness of the atr ( ars, . %). lastly, the imputability of the blood product was often excluded or unlikely. in the multivariate cox model for the effect of lpi on overall survival, adjusted for age and ipss-r category, elevated lpi levels were associated with inferior overall survival (hr . , % ci . - . , p = . ). this effect was most pronounced in the td-rs subgroup (hr . , % ci . - . , p < . ). similarly, elevated lpi levels were associated with inferior pfs (hr . , % ci . - . , p < . ) for the whole study population and the td-rs subgroup (hr . , % ci . - . , p < . ). in total patients received iron chelation during the sample collection period ( patients deferasirox, patients desferrioxamine). lpi levels were normal in out of the samples collected during deferasirox treatment and in out of samples collected during desferrioxamine treatment. summary/conclusions: transfusion dependency is associated with the presence of toxic iron species and inferior overall and progression-free survival in lower-risk mds patients. in td-rs patients the effects were most pronounced indicating ineffective erythropoiesis leading to additional iron toxicity. background: post-transfusion immunomodulation has been reported to contribute to poor patient outcomes. clinically relevant transfusion models are needed to improve our understanding of underlying mechanisms. sheep transfusion models are of increasing importance in blood transfusion research as they provide several advantages over small animals, including their size, anatomy, physiology and similar blood volume compared to human. a current limitation of sheep transfusion models is the lack of characterisation of the sheep immune system. understanding the sheep immunology is necessary to advance sheep transfusion models, identify mechanisms that contribute to post-transfusion immunomodulation and facilitate the translation of findings into clinical settings. aims: to characterise the sheep leukocyte inflammatory responses to in vitro lipopolysaccharide (lps) challenge in edta and heparinized whole blood. methods: edta and heparinized sheep whole blood (n = of each) was cultured with rpmi media ( °c, % co ) alone or with the addition of lps ( - lg/ml; derived from escherichia coli : b ). the inflammatory response was assessed after h (h), h, h, h, h and h. supernatant was harvested at each time point and stored at À °c. inflammatory cytokine/chemokine production was determined using sheep specific in-house elisa (il- b, il- , il- and il- ). twoway analysis of variance with bonferroni's post-test was used to measure the effect of incubation time and concentration compared to no lps matched samples. results: when edta was used as an anticoagulant, addition of lps resulted in production of sheep il- b and il- but not il- or il- . il- b production was significantly increased following stimulation of lg/ml lps for h (p = . ) and declined following h incubation. release of il- was significant h post-lps stimulation with lg/ml (p = . ) and reached a maximum at h. the use of heparinized blood resulted in a different immune profile as all inflammatory markers tested were detected following stimulation with much lower concentrations of lps ( lg/ml), although the incubation times differed. il- b was significantly increased following h incubation (p = . ), with increasing levels observed up to h post-lps stimulation. il- production was evident from h and reached significance at h post-lps stimulation (p = . ). il- was significantly increased following stimulation of lg/ml lps for hr (p = . ) with lower concentrations of lps resulting in il- production at h (p = . ). release of il- was significant after h of lg/ml lps stimulation (p = . ), with lower concentrations of lps resulting in il- production at h (p = . ). in heparinized whole blood an lps concentration-dependent effect was evident for all cytokines. summary/conclusions: using a time-and concentration-approach our findings indicate that sheep are more tolerant and have a delayed response to lps stimulation compared to previous research using similar human in vitro whole blood culture models. in addition, data suggest that sheep have greater immune responses using heparin as anticoagulant for the collection of blood samples. improving our understanding of sheep immunology and development of relevant sheep transfusion models will provide a bridge between sheep models of transfusion and clinical settings. . rhdig inappropriately administered (unnecessary exposure) (n = , %) administered to: -rhd positive woman (n = ) -rhd negative mother with rhd negative neonate (n = ) -woman with immune anti d (n = ) -administered in error (instead of other ig) (n = ) rhdig delayed/omitted/wrong dose (risk of sensitisation to the d antigen) (n = , %) -omitted (n = ) -delayed (n = ) -inadequate dose (n = ) administration without correct patient identification (n = , %) storage & handling (n = , %) failure to check the maternal and neonatal blood groups prior to administration was identified as a source of error. misinterpretation of blood results also led to women receiving product inappropriately. e.g. reading a negative antibody screen as the mother being rhd negative. patient identification was raised as an issue. rhdig is often stored in satellite blood fridges for easy access. collection from these areas did not always require confirmation against patient identifiers and there was no register of women who received product or link to the batch number to ensure traceability. two incidents involved the administration of rhdig when the prescription for other immunoglobulin products was not clear, leading to a child and a baby receiving rhdig instead of the intended immunoglobulin. summary/conclusions: these incidents indicate problems with the processes of appropriate identification of women who need rhdig, the use and interpretation of pathology tests and requirements for prescription and administration. these resulted in omitted and inappropriate doses of rhdig. blood matters has made a number of recommendations regarding rhdig administration: -all health professionals involved in rhdig administration should be appropriately trained in the use of rhdig -confirmation of the maternal rhd status is essential prior to prescription or administration -positive patient identification must be used prior to administration of rhdig -health services should consider regular auditing to identify areas for improvement relating to rhdig blood matters continues to work with maternity care providers to improve practice. centro comunitario de sangre y tejidos de asturias, oviedo agencia gallega de sangre, organos y tejidos, galicia banco de sangre y tejidos de cantabria, cantabria banco de sangre de la rioja, la rioja banco de sangre y tejidos de navarra, navarra banco de sangre y tejidos de arag on, aragon fundaci on de hemoterapia y hemodonaci on de castilla y le on, castilla y leon fundaci on banco de sangre y tejidos de las islas baleares, islas baleares, spain terumo bct europe nv, zaventem, belgium background: hemovigilance, a long-term monitoring process made mandatory by national and supranational regulations, begins with a systematic whole blood or blood component collection and ends with an examining period after transfusion of blood components into the patients. in spain, organized in autonomous regions, the hemovigilance system is structured in three levels: ( ) the local level comprised of transfusion centers and hospital based transfusion services that monitor and collect all transfusion related adverse events (ae) and level them up to ( ) the regional hemovigilance coordinator, who communicates all the region's data to the ( ) spanish ministry of health which issues an annual report and corresponds with european institutions. to ensure safer blood supply, pathogen reduction technology (prt) was approved and implementation started in spain in . the mirasol prt system for platelets and plasma was introduced in and is currently being used in of the spanish regions. aims: to monitor the safety of the system, a passive hemovigilance study on mirasol treated products was initiated in the region of asturias and collaboration was extended to other regions (baleares, galicia, la rioja, cantabria, navarra, castilla y leon and aragon). methods: collected data included allergic and febrile reactions, trali and all other adverse event observed. severity of the event and level on imputability of the transfusion were also assessed using the who grading scale. hemovigilance data of mirasol treated products (platelets or m-pc and plasma or m-p) are included from to as blood centers started to apply the technology in routine. results: increase adoption of the mirasol system is observed between , when , mirasol treated blood products were issued to hospitals and with , mirasol products issued. due to low number of transfusions of mirasol-treated blood components in and , notification rates began to be analyzed in , showing ae rates of . %, similar to reports at the national level. stable transfusion reaction rates were observed with m-pc (around . ). rate of ae after transfusion of m-p is fluctuant between . and . . this fluctuation could be due to the inconsistent numbers of m-p transfused from one year to the other. most of transfusion reactions (around %) were of grade i severity and grade ii level of imputability. allergic reactions accounted for most of the adverse events, with g&i > reactions in and of respectively . and . no bacterial nor viral transfusion transmission was recorded on mirasol products during the study period ( ) ( ) ( ) ( ) ( ) ( ) . at the national level, nine cases of bacterial transfusion transmission (with g&i > ) were reported. these transmissions were probably due to transfusion of non-pathogen reduced products. summary/conclusions: the observed notification rate of ae is similar to the national rate but allergic reactions with g&i > is inferior with mirasol treated products. also, we found no reports of transfusion transmission infections nor cases of transfusion associated graft-vs-host disease, demonstrating safety of mirasol treated products. were attributed to human error ( %) with the lowest frequency in equipment failure ( %), compared to % and %, respectively, in the following three years. root cause analysis demonstrated failures in the quality management system including failures in administration, inadequate staffing for blood collection as well as in distribution and processing, and failures arising from institutional constraints and system failures in hospital management. high numbers of "other" aes ( %) in distribution and whole blood collection call for further investigation to indicate measures necessary for prevention and correction. errors related to incorrect blood component transfused (ibct) in - were in , , blood units ( / , ) issued for transfusion. these resulted in serious reactions ( %) ( fatal, life-threatening) . another ( %) were related with ibct that did not cause a reaction. near misses (component not transfused) were ( %) summary/conclusions: our data demonstrate increasing compliance with reporting requirements. questions about the initial factors for deviations in certain activities specifying failures in equipment and materials due to system as well as human errors, highlight the need for further specifications beyond "other" and "human error". background: the weakest link in the transfusion chain currently is the handling of blood components after their issue and the bedside blood administration practices. aims: to evaluate compliance with standard procedures for bedside blood transfusion practices by analysis of the "transfusion feedback forms" in a tertiary care multi-specialty hospital setting. methods: during the study period of months, the transfusion feedback forms received from various clinical areas of the hospital were studied with special reference to the transfusion times. the data was categorized based on the patient's location as well as the time of transfusion, whether done in routine or emergency hours. results: , blood components were issued during the study period, while transfusion feedback forms for , components ( . %) were received in the transfusion medicine department. delay in starting the transfusion (more than min after issue) was observed in transfusion events ( . %). the component transfusion time exceeded the permissible limits for component ( . %).the overall total permissible time for completion of components exceeded permissible limit in ( . %) of transfusion events. the pediatric ward ( . %), icu and ot complex ( . %) were found to be the most non-compliant delay in transfusion, transfusion time and total transfusion time. amongst the delayed transfusions after issue, ( . %) were during the routine hours i.e. between am to pm and ( . %) were in the non routine hours i.e. between pm to am. summary/conclusions: the audit of bedside blood transfusion practices has given us a good insight into various areas of noncompliances as well as the predominant locations in the hospital where the practices need to strengthened further. focused training program on safe blood administration practices for all staff involved in handling and transfusion of blood components is now planned to combat this issue. background: the international surveillance of transfusion adverse reactions (ars) and events (aes) (istare) of the international haemovigilance network (ihn) collects aggregate data from member national haemovigilance systems (hvs) in order to estimate the morbidity and mortality of blood transfusion in a holistic approach. the ultimate goal is to contribute to improving the safety of transfusion by close monitoring throughout the chain "from vein to vein". aims: we analyse recent istare data on suspected transfusion transmitted infections (sttis) for - in comparison to previous years of surveillance, [ ] [ ] [ ] [ ] [ ] [ ] [ ] methods: annual aggregate data from ihn member hvs on transfusion associated bacterial, viral and parasitic infections collected online in istare are analyzed by incidence in blood components (bcs) issued for transfusion, by severity and imputability as well as by blood component. ars with definite, probable or possible imputability were included in the analysis. trend analysis is performed to allow comparisons and to collect information on established and newly emerging infectious threats of blood transfusion. results: for - sets of annual aggregated data from countries covering , , bcs issued were analyzed. all ars totalled , and infectious ars amounted to ( . %). the overall incidence of the infectious ars was . / , units of bcs issued. bacterial infections were the most frequent ( , %), next viral ( , . %) and then parasitic ( , . %). serious were % and there were fatalities ( . %, incidence . / , ). nine deaths were attributed to sepsis and the other two were associated with non-malarial parasitic pathogens. one geotrichum clavatum fungal infection associated with apheresis platelets was reported as a free text comment. this very rarely recognized fungal pathogen caused a very severe infection in a patient but the route of transmission is inconclusive. the viral sttis included hbv ( %), hcv ( %) and hiv ( . %). the recorded as "other" ( . %) including cases of hev, one case of parvovirus b , one cmv and one ebv. no case of tt-malaria was reported. other stt-pi were (two fatal). the prevailing bcs were in general rbcs followed by platelets. comparison with corresponding data for - shows a consistent overall incidence in total sttis ( . vs . / , ). however, considerable differences were seen in separate categories, such as bacterial infections (significantly increased rate in - , p < . ) and an almost doubled rate of parasitic infections (p < . ). compared to the earlier period, there were many fewer hbv infections ( vs ) and many more hev. a similar reduction in the rate of hcv and hiv was observed in - in comparison with previous years. this may be explained by the fact that nat testing for hcv/hiv/hbv has been implemented in many countries in the last decade. summary/conclusions: the infectious risk of transfusion overall remains very low. the rate of bacterial cases has increased and among other viral sttis the frequency of hev is increasing. the mortality of transfusion due to sttis is lower than in the previous period of surveillance. abstract withdrawn. background: one of the main aspects of haemovigilance system in hospitals is following of adverse events and reactions related to blood transfusions. aims: it was intended to analyse the adverse reactions related to transfusion of blood components in pediatric patients. methods: over a four year period (january -december ), the haemovigilance records of all patients receiving blood transfusions procedures were reviewed and transfusion reactions were analysed. statistical analysis of data was performed by spss software (version . , spss inc., chicago, il, usa). majority of blood components were provided by regional blood center organized by national red crescent society. but granulocytes collected by apheresis after donor mobilization and reconstituted whole blood for exchange transfusions were prepared in the transfusion center of the hospital. results: the median age of patients who developed transfusion reactions was months (interquantile range-iqr ). the median for the numbers of individual transfusions in children in a year was (iqr ). the median for the numbers of blood components individually transfused to patients was (iqr ). patients, anaphylactic transfusion reactions in patients and transfusion-related lung injury (trali) in a patient. the overall incidence of transfusion reactions was estimated at a rate of . per units. summary/conclusions: it was reported that adverse effects related to blood transfusion, especially allergic reactions and fnhtrs are common in pediatric patients than adults. in a multinational study concerned about the transfusion reactions related with red cell concentrates, allergic transfusion reactions and fnhtrs were reported at a rate of and in units and in units, respectively. while the incidence of transfusion reactions in children was found . % in a study from the u.s.a., the overall incidence of transfusion reactions in our study which was estimated at a rate of . per units represents a lower rate. hospital gran canaria dr. negr ın, gran canaria hospital general universitario, ciudad real, spain hospital nostra senior de meritxell, andorra, andorra banco sangre y tejidos, santander banc de sang i teixits, barcelona, spain fundaci on hematol ogica colombia, bogot a, colombia centro regional de transfusi on de almer ıa, almeria complejo hospitalario de navarra, pamplona fundaci on banc de sang i teixits illes balears, palma de mallorca hospital de cabueñes, gij on, spain background: root analysis cause is defined as the cause of an error that, if it is treated, eliminates the repetition of the error aims: describe types of human and latent errors detected by a work group in the root analysis cause of transfusion incidents, analyze the concordance between the individual responses of the members and propose recommendations in order to improve transfusional safety. methods: in fifteen participants (nurses and hematologists dedicated to transfusion and component preparation) studied some incidents of administration of nonirradiated components and tried to approach the root causes by applying the classification of errors in mers-tm transfusion medicine. they transferred the answers to a questionnaire (simple or chain error, initial process affected, human and latent errors and measures derived from the analysis to correct the errors). the communication was made by mail and by the spanish transfusion society web forum, which contained the consultation documents. data and percentages are exposed for each type of error and the answers of the participants are tabulated. results: cases corresponded to patients. two patients of years of age diagnosed of acute myeloblastic leukemia (case and ) and chronic lymphatic leukemia (case ). in one case, the hematologist of the transfusion service canceled an irradiation prescription; in another, a patient with fever was transfused in the emergency room without the irradiation requirement and it was later discovered that he had received a transplant of hemopoietic progenitors month earlier; in the last case, neither the requesting doctor nor the laboratory technician nor the following doctor (prescriber) detected the alerts located in their respective computer applications. in all cases, the story was judged as sufficient for analysis. the majority of reviewers ( %) diagnosed a chain of errors. there was agreement of % with respect to the initial process affected. the initial error was communication ( %), monitoring ( %) and compliance ( %), in cases , , and . - human errors were detected per case (average: . , . and . errors respectively) and - latent errors per case (average: . , . and . , respectively). the latent errors most punctuated were: failures in the quality of the protocols ( %), in the transfer of important knowledge ( %), in the available technology ( %) and in the information to the patient ( %). all the participants contributed feasible measures of improvement according to root causes: ) improve the quality and drafting of work procedures and their compliance, including procedures of effective communication between professionals, ) train staff in knowledge important for safety, ) communicate with computer application providers to improve the effectiveness and visibility of the alerts and ) involve the patient with essential information to ensure transfusion safety. the measures were processed later as recommendations. summary/conclusions: the root analysis shows agreement between participants and allows the elaboration of useful recommendations to increase patient safety. this strategy can contribute to the comprehensive prevention of errors. background: in transfusion-associated circulatory overload (taco), pulmonary oedema develops primarily due to volume excess. data from the uk haemovigilance scheme, serious hazards of transfusion (shot) suggest that either the incidence of taco, or the recognition and reporting of taco, has increased over time. from to , reports of taco increased from to ; deaths from to , major morbidity from to . known risk factors include pre-existing cardiac and/or renal dysfunction, low body weight, extremes of age (eg, < years, > years), concomitant fluid administration, positive fluid balance, peripheral oedema and hypoalbuminemia. in a small subset of cases reported to shot, taco developed following transfusion for severe anaemia in the absence of other risk factors. this may be an under-recognised independent risk-factor. aims: to raise awareness of severe anaemia as an under-recognised risk factor for taco and is potentially life-threatening transfusion. methods: cases of taco submitted to shot over the last years were reviewed to identify cases where transfusion for severe anaemia was a key identifiable patient risk factor. results: the following are illustrative cases: -case : a patient in their s weighing kg was prescribed six units of red cells for iron deficiency anaemia after being admitted with hb g/l. the patient had no risk factors for taco except for profound anaemia. during transfusion of the fifth unit the patient became dyspnoeic, hypoxic and hypertensive. the patient recovered after diuretic therapy and had a post-transfusion hb level of g/l. -case : a patient in their s presented with a -week history of weakness and dizziness and had felt unwell for months. the hb was g/l, ferritin lg/l and ecg showed cardiac ischaemia. two units of red cells were transfused. after the second unit oxygen saturations fell despite supplemental oxygen, post-transfusion hb of g/l. a third unit was transfused over min and the hypoxia worsened with dyspnoea and crackles on chest auscultation. the chest x-ray showed an enlarged cardiac silhouette and pulmonary congestion. the patient improved with diuretics. -case : a patient in their s with severe megaloblastic anaemia, hb g/l and peripheral oedema developed taco after transfusion of units and recovered with diuretic therapy. summary/conclusions: chronic and acute anaemia are associated with compensatory cardiac changes irrespective of the aetiology of anaemia. this is further compounded by the underlying cause of anaemia particularly haematinic deficiencies (iron/b deficiency) that independently affect myocardial function. hyperdynamic circulation related to anaemia increases the load on the heart, causing myocardial ischaemia and hypoxia and if the anaemia is not corrected, eventually leads to heart failure. clinicians need to make an accurate diagnosis and avoid excessive transfusion in patients with severe anaemia with or without other additional risk factors. patients with chronic iron/folate/b deficiency without haemodynamic instability should be given the appropriate haematinic replacement. haematinic deficiency responds rapidly to appropriate vitamin/mineral. blood transfusions are to be given only when clinically indicated and even then, only the minimum volume needed for symptomatic relief transfused with consideration for diuretic therapy. methods: legal forms for reporting transfusion reactions were used in the retrospective analysis, which were adjusted by the department of quality assurance and quality control in the electronic form and distributed to clinics using blood components. clinicians were trained to report transfusion reactions through the hospital's transfusion board and through the "service for improvement of the quality and safety of health services" at the clinical center of sarajevo. analysis of the reported reactions in the institute include immunohematological and microbiological examination based on which the guidelines for further treatment with blood components are being made. users of registered services are obliged to report since . results: total of , different blood components were applied in the period between - . department for quality assurance and control has received serious adverse reactions, serious adverse event, reports of transfusion reactions, of which ( %) were inadequately filled, in the same period. from the above, ( . %) were transfusion reactions to erythrocyte blood components which were applied, ( . %) to platelet components and ( . %) were transfusion reactions after the application of fresh frozen plasma. the analysis has shown that the most frequent were febrile non-haemolysis reactions ( or . %), followed by allergic reactions ( or . %). two transfusion reactions ( . %) were characterized as circulation overload. summary/conclusions: the frequency of serious adverse reactions and events was . % ( of , ) and . % were reported transfusion reactions ( of , ). with the establishment of the hospital transfusion board and with the increase of collaboration with the clinical center, significant progress has been made. it is necessary to increase awareness among clinicians in regards to the safe transfusion practice. reporting transfusion reactions should be a mandatory procedure, a path to the proper selection of blood components, monitoring adverse reactions, and for us, transfusiologist, guide to the safest, most efficient blood components. j garc ıa-gala, e martinez-revuelta, a caro-g omez, c castañ on-fern andez and i fern andez-rodriguez hospital universitario central de asturias, oviedo, spain background: elderly patients are the main group of transfusion recipients in our country. given their comorbidities are a risk group for the development complications related to transfusion. aims: analyze the incidence of adverse effects related to transfusion in the elderly population and to assess what factors may influence its appearance methods: transfusions were reviewed in patients > years old. the variables analyzed were: sex, age, diagnosis/reason for transfusion, pre-transfusion hemoglobin (hb), number of transfused units, infusion rate and transfusion side effects, as well as the measures used to prevent or treat the transfusions. effects of circulatory overload results: a total of patients were analyzed ( women, men), with a median age of years ( - ). in total, ch were transfused. patients received ch, patients ch, patients received ch. patients were transfused at two different times. the median hb prior to transfusion was . g/dl. in the patients who received ch was . g/dl, those who received ch: g/dl and those who received ch: . g/dl. the infusion time could be estimated in % of the patients. in those who received ch was . min; . min in those who received ch and . min in those who received ch. patients ( % of the total) suffered some type of adverse effect related to the transfusion. in patients there was an increase in posterior ta, in an increase in hr, in an episode of hypotension and in another one episode of acute respiratory failure. % of those who had an adverse effect were older than years. patients with aht after transfusion, % received ch and the remainder ch. among their background, % had a history of ischemic heart disease. % also had a positive balance. the average previous bp was / mmhg and the subsequent one was / mmhg. % of patients did not receive diuretic treatment. in the case of the patient with acute respiratory failure was in oligoanuria, with positive balances. ch was transfused in total. she was treated with oxygen therapy and with intensification of the diuretic treatment, recovering later. summary/conclusions: -patients > years have a higher risk of suffering some type of adverse effect related to transfusion because they have pre-existing risk factors such as ischemic heart disease or heart failure. -we see that the risk of suffering some type of adverse effect in the elderly population is greater when we transfuse ch than ch. -we have appreciated that in those patients receiving ch, the infusion rate is higher. -the study highlights the lack of methods to prevent the development of circulatory overload. background: iron deficiency anemia is the commonest cause of anemia worldwide. weakness, fatigue, reduced physical activity and difficulty in concentration are the symptoms which are associated with its deficiency. the forefront treatment available is oral iron replacement therapy which is convenient, cost effective and has substantial outcome. another option is intravenous (i/v) iron when oral is not tolerable. despite of potential transfusion associated hazards and limited availability of blood due to shortage of voluntary blood donations, it is insisted by the patients prior to iron therapy. aims: the aim of conducting this study was to observe the impact of administration of oral iron, i/v iron and transfusion on hemoglobin levels in patients presented with iron deficiency anemia. methods: this was an observational study carried out at nibd and bmt, pechs campus, karachi, pakistan from february to december . the study was approved by the institutional review board. diagnosed ida patients presented at our hospital were recruited for analysis who were given oral iron, i/v iron and transfusion for the correction of anemia. informed consent was taken from the participants. descriptive and inferential statistics was applied by using spss version . . results: a total of ida patients were analyzed in which ( %) were females and ( %) were males. the most common symptom in females and males was fatigue followed by body aches in females ( %) and pallor in males ( %). menorrhagia was present in ( %) of females of reproductive age. surgical history was present in ( %) of females while there was no surgical history in males. mean hemoglobin, mch and mcv of females at baseline was . ae . , . ae . , and ae . while in males it was . ae . , ae . and . ae . respectively. sixty two ( %) females were advised oral and i/v iron and ( %) received transfusion. however, in males ( %) received transfusion and ( %) were advised oral and i/v iron therapy. it was observed that the increment of hemoglobin after oral/iv iron at average of months follow up in males and females was same as that the transfusion (p > . ). summary/conclusions: in our society where blood donations are scarce especially voluntary blood donations that are considered to be the safest type of blood donation. we would like to draw attention towards the alternatives to correct anemia such as oral and i/v iron replacement therapy as our results revealed that there was no difference in the increment of hemoglobin between the two groups. we need to educate our society especially the older age adults and young women who are more vulnerable of getting ida to opt oral and i/v iron therapy. it will be cost effective, convenient and also has less risk than transfusion. cellular therapies -stem cell and tissue banking, including cord blood background: the differentiation of megakaryocytes plays an important role in the production of platelets. however, the underlying mechanisms regulating megakaryocytes differentiation have rarely been studied. aims: to identify candidate genes involved in megakaryocytes differentiation and investigate the potential regulatory mechanisms of megakaryocytes differentiation from human cord blood hematopoietic stem cells in vitro. methods: cb-derived cd + cells were isolated using density gradient centrifugation and magnetic activated cell sorting (macs). cultures were stimulated with only recombinant human tpo ( ng/ml). after , and days, the mk fraction was selected by immunomagnetic sorting from the non-mk fraction using an anti-cd a monoclonal antibody. rna-seq-derived gene expression data was performed on uncultured samples (day ), cultured but unselected samples (day ), and cultured, selected samples (day , and ) by using the next-generation sequencing (ngs) platform, and rq-pcr technology was used to verify the expression of transcription factors. results: the comparison of the transcriptome profiles among the five stages showed that a massive gene expression change occurred in megakaryocytes differentiation. a total of genes were detected, of which showed up-regulation and down-regulation. among these genes, differentially expressed genes (degs) (fold change ≥ ; false discovery rate < . ) were selected were further validated with rq-pcr, including gabre, cdhr , wasf , pkhd l , thbs , pf v , lrrc and lgals . the rq-pcr result indicated that the mrna expression level increased with the prolongation of culture time. however, pf v mrna expression level was highest at day , lgals was highest at day . summary/conclusions: conclusion: our study identified a series of genes that may participate in the regulation of megakaryocytes differentiation. these results should serve as an important resource revealing the molecular basis of megakaryocytes differentiation and thrombocytopoiesis. preoperative anemia and blood transfusion requirement during hip and knee surgery rambam health care campus, haifa, israel background: blood transfusion (bt) is independently associated with increased morbidity, mortality and hospitalization length across different patient populations. due to bt-related risks, the concept of "patient blood management" (pbm) has been introduced to clinical practice. the three pbm pillars are: optimizing red cell mass, minimizing blood loss and optimizing physiological reserve. bt indications during orthopedic surgery include excessive bleeding or hemodynamic instability and not the hemoglobin (hb) level. in most clinical scenarios, a restrictive transfusion threshold (hb level: - g/dl) appears to be non-inferior to the liberal transfusion strategy in terms of blood use, morbidity and mortality. similar results are observed in highrisk patients after hip surgery. we hypothesize that preoperative anemia may lead to blood product overuse and its complications. aims: evaluating potential correlation between preoperative anemia and bt requirement during hip or knee surgery. methods: we reviewed medical files of patients who underwent hip or knee replacement surgery at rambam between - . patients with hb level measurement within days pre-surgery were included. receiving > blood unit was considered a surgery complication and such patients were excluded. patient demographic and clinical data, including comorbidities, surgery type, length of hospital stay, were collected. we created a synthetic data cohort using mdclone healthcare data sandbox, an environment enabling fast data extraction and producing synthetic data for analysis that does not require irb approval. results: during the evaluated period, patients underwent hip or knee surgery; were excluded from the analysis due to receiving > blood unit. hb measurement within days pre-surgery was available for patients. hip or knee surgery was performed in ( %) and ( %) patients, respectively. women comprised % (n = ) of patients who underwent hip surgery. in the hip-surgery group, . % of patients required bt, with this need being slightly higher among women ( . % vs. . %; p-value=ns). only ( %) patients were transfused during knee surgery and this cohort was not further analyzed. patients receiving bt had a significantly lower mean hb level than those who didn't require it ( . g/dl versus . g/dl for women and . g/dl vs. . g/dl for men; p-value < . ). hospitalization was longer in transfused patients compared to non-transfused ones (mean . vs. . days, p-value = . ) and in patients with a low hb level (female < , male < . ) than in those with a high hb level, irrespective of receiving bt (p-values < . ). patients with at least one of the following diagnoses: diabetes, renal failure, ischemic heart disease, were significantly more likely to have a lower preoperative hb level (p-value < . ). no other factors (e.g., patient's weight, rdw value or blood pressure) were predictive of transfusion need. the probability of a need for blood unit was . in the hb g/dl group and . in hb g/ dl group ( %>reduction). summary/conclusions: anemia presence before elective hip surgery is a risk factor for bt requirement and longer hospitalization. diagnosis and management of anemia using timely pre-surgery consultations may minimize intraoperative bt, particularly in women and patients with comorbidities. real-patient data and prospective trials are warranted. abstract withdrawn. abstract withdrawn. background: cd , known as platelet glycoprotein iv, belongs to type b scavenger receptor and is related to the pathogenesis of many diseases. type i cd deficiency was cd not expressed on platelets and monocytes. individuals with type i deficiency can produce homologous antibodies and cause related immune diseases. in recent years, it has been reported that cd deficient individuals cause fetal immune thrombocytopenia with fetal edema syndrome in asia. cd is not expressed in mature rbc, but exists in hematopoietic stem (progenitor) cells. anemia is an important cause of edema. in view of the phenomena of clinical and animal experiments, cd + hematopoietic stem (progenitor) cells were cultured in vitro to observe the effect of anti-cd monoclonal antibody on cd + hematopoietic stem (progenitor) cells. aims: to investigate the effect of anti-cd monoclonal antibody on proliferation and differentiation of human cd + hematopoietic stem (progenitor) cells in vitro. methods: choose healthy full-term maternal women without various obstetric complications, take cord blood ml. after density gradient centrifugation of ficoll cell separation solution, cd + hematopoietic stem (progenitor) cells were sorted by flow cytometry and cultured for - generations. mtt was used to examine the effect of anti-cd monoclonal antibody on the growth of hematopoietic stem (progenitor) cells. flow cytometry analysis was used to detect the apoptosis and cell cycle of cd + hematopoietic stem (progenitor) cells. the effect of anti-cd monoclonal antibody on the formation of cfu-e/bfu-e in hematopoietic stem (progenitor) cells was analysis by cfu-e/bfu-e account after - days culture. results: after umbilical cord blood was isolated by ficoll to obtain mononuclear cells, the hematopoietic stem (progenitor) cells of cd + were sorted by flow cytometry, and about . % of cd + hematopoietic stem (progenitor) cells were isolated. different concentrations of anti-cd monoclonal antibody and hematopoietic stem (progenitor) cells were cultured in vitro. the od value of value ( . ae . ) of anti-cd monoclonal antibody group ( mg/ml) was decreased than normal group ( . ae . ) (p < . ), and the od value ( . ae . ) was significantly decreased at the cd monoclonal antibody concentration of mg/ml (p < . ). there was no significant difference between the hematopoietic stem (progenitor) cells culture group and the igg control group (p > . ). in the annexin v flow detection, the apoptotic rate of anti-cd monoclonal antibody group ( mg/ml) was statistically increased than the normal group (p < . ). anti-cd monoclonal antibody significantly induced hematopoietic stem (progenitor) cells to undergo s phase cell reduction, g phase cells increased, and g /s phase cell arrest occurred. the number of cfu-e/bfu-e clones in the normal group was ae , the number of cfu-e/bfu-e clones in the control group was ae , and the number of cfu-e/bfu-e clones in the anti-cd monoclonal antibody culture group was ae . the number of colonies formed by hematopoietic stem (progenitor) cells in the anti-cd monoclonal antibody culture group was significantly lower than that of the other groups (p < . ). summary/conclusions: anti-cd monoclonal antibody can reduce the proliferation of human cd + hematopoietic stem (progenitor) cells and reduce the ability of erythroid differentiation. background: recently the new modern collection techniques were introduced in the apheresis procedures. cobe spectra system was replaced with spectra optia, and it was necessary to verify the efficiency of spectra optia in pbpc collections. aims: the aim of the study was to evaluate and optimize the new cmnc protocol spectra optia v. (terumo) for pbpc collections in patients with haemato-oncological malignant diseases. methods: the results of autologous pbpc collections were evaluated in: (a) well mobilized patients with precollection cd + cells concentration in blood higher than /ll, (b) from only the first collections, which were performed either by the use cmnc spectra optia v. or cobe spectra v. , v. , terumo (c) collections were performed in the standard and large volume leukapheresis regimen, lvl. engraftment data in transplanted patients were assessed. results: standard collections were performed in patients. the yield of cd + cells was high, and no significant differences were found between the numbers of cd + cells prepared from spectra optia , ( , - ) and cobe spectra , ( , ) /kg b. w. (a = , ; pval , ). the dependence of cd + cell yield on the precollection concentration of cd + cells in blood can be considered as linear with high correlation coefficients in cmnc spectra optia r = , , and cobe spectra r = , . lvl collections were performed in of patients, and there were no significant differences between the numbers of cd + cells prepared by cmnc spectra optia , ( - , ) and cobe spectra , ( , - ) /kg b.w. (a = , ; pval , ). the relations between the precollection cd + cells concentration in blood and the numbers of cd + cells from collections can also be considered as linear with the correlation coefficients in cmnc spectra optia r = , , and cobe spectra r = , , respectively. in lvl, the median platelet loss was significantly lower in cmnc spectra optia ( %) than in cobe spectra ( %). a group of patients was transplanted by means of pbpc prepared in the standard regimen. median time in the neutrophil reconstitution was in cmnc spectra optia as well as cobe spectra days, while in platelets from cmnc days, and from cobe spectra days, respectively. the number of patients obtained pbpc from lvl. the median time in neutrophils and platelets reconstitution was in cmnc spectra optia as well as cobe spectra the same, and corresponded with and days, respectively. summary/conclusions: cmnc protocol spectra optia is a modern, efficient and the safe system, which can be used for both standard and lvl procedures. in well mobilized patients the sufficient dose of cd + cells for transplantation could be prepared from one standard or one lvl procedure. no serious adverse reaction have been observed. background: peripheral hematopoietic stem cells are collected from patients/donors after mobilization with g-scf. the aim of the collection is a fixed number of cd + cells/kg. this number depends on the pre-apheresis cd + number, the blood processed and the collection efficiency of the procedure. the aim should be to collect all the requested cells in day, whenever possible. this is in order to reduce the dose of g-csf given to donor/patient and the resources used in the collection centre. the only parameter that can be adjusted is the volume of blood processed, if this is increased, the likelihood of collecting the requested amount of cells is increased, but only if the pre-apheresis cd number is high enough. therefore, you need to know, when it is feasible to increase the volume and thereby increasing the time of the procedure with the intention to collect all the requested cells in day. it can also show if it is possible to reduce the volume of blood processed, thereby reducing the time of the procedure. aims: to develop an easy tool to calculate the volume of blood processed in order to collect the requested cells in day. methods: the mean collection efficiency (ce) was calculated. ce is calculated as cd + cells collected/(pre-apheresis cd + number*processed volume)* %. based on the mean ce, an excel sheet was generated to calculate the volume of blood that should be processed in order to collect all the requested cells. the excel sheet is designed so the user enters the pre-apheresis cd + number, patient weight and the requested number of cd + cells. the ce is fixed according to the mean ce calculated. the result is the volume of blood processed in order to collect the requested yield. based on that result, the apheresis machine will provide time for the procedure, thereby it is possible to evaluate if the collection can be finished in day or not, e.g. by increasing the volume of blood processed. spectra optia â was used for all collections, cmnc for allogeneic donors and mnc for autologous patients. results: mean ce = % (n = ). a ce of % was chosen as the cut-off for the cd calculation tool. using the cd calculation tool: allogeneic donors (n = ): mean ce = %, mean blood volume processed = . tbv, mean time: min, donors were finished in day collection ( %) autologous patients (n = ): mean ce = %, mean blood volume processed = . tbv, mean time = min, patients were finished in day ( %). the calculation failed in only case ( . %). in this case the volume of blood processed was reduced according to the calculation, but because of unexpected low ce, the requested number of cells was not achieved. summary/conclusions: the cd calculation tool based on an excel sheet has shown to be simple and easy to use in order to personalize the stem cell collection. immunotherapy products: blood product, pharmaceutical, or a new category all together? from till . all donors were hla typed and matched; they were fully informed on the donation procedure and signed an informed consent for donation. minimum dose required to ensure successful and sustained engraftment was /kg cd + cells and /kg mono-nucleated cells (mnc). pbsc harvesting was performed with continuous flow cell separator baxter c , cobe spectra and spectra optia using conventional-volume apheresis processing the - . total blood volumes per apheresis. a femoral catheter was used for harvesting and acid citrate dextrose formula a is used for anticoagulation. recombinant human granulocyte colony-stimulating factor (g-csf) is used to mobilize pbpc for collection. harvesting of pbsc is usually performed after to days of g-csf subcutaneous administration at a dose of lg/kg body weight. results: all the donors were siblings of the patients treated at the university hematology hospital. there were apheresis procedures performed in healthy sibling donors. there were males and females, aged - . one to two apheresis procedures were required to collect adequate graft. the single procedure usually took - h and the volume of collected stem cells was - ml. the needed number of mnc and cd + cells was successfully collected by . apheresis. there were abo incompatible donors. procedures for mobilization and collection of pbpc from healthy donors are generally well tolerated. the only adverse effects of the apheresis procedure were bone pain as reaction of g-csf and numbness of the extremities as reaction of acd-a (hypocalcemia), which occur rarely and were very mild. the collected pbsc were used in allogeneic stem cell transplantation in patients with: acute myeloid leukemia - patients ( . %), acute lymphoblastic leukemia - patients ( . %), chronic myeloid leukemia - patients ( . %), myeloproliferative disorders - patients ( . %), myelofibrosis - patients ( . %), severe aplastic anemia - patient ( . %), non-hodgkin lymphoma - patient ( . %), multiple myeloma - patient ( . %), chronic lymphoblastic leukemia - patients ( . ), hodgkin disease - patient ( . %). summary/conclusions: the apheresis collection of pbsc in healthy donors is an effective and safe procedure. we are developing our national stem cell donors registry as a part of bone marrow donors worldwide. in that way we hope we will help widen the world network of stem cell donors and enlarge the possibility for each patient to find the right match. background: leukocyte-removing filters for blood are being used widely as a universal leukocyte reduction policy is being adopted progressively throughout the world. filtration is one of the most effective methods for preventing various adverse transfusion effects caused by leukocytes included in blood components, such as febrile reaction, alloimmunization, and transmission of leukotropic viruses. aims: the goal was to evaluate whether the new domestic blood filter finecell, developed by kolon industries, gumi, korea, is appropriately suited to the international standards. and to reveal its efficacy and safety in the settlement of leukocyte reduction system in korea. methods: thirty-two units of packed red blood cells obtained from ml whole blood collected from healthy donors were used. this was done by analyzing the filtration time, residual leukocyte count, rbc recovery, and hemolysis rate during a storage period of days after leukoreduction. results: the standards commonly used for the evaluation of leukocyte-removing filters are set by the food and drug administration of the usa and the council of europe. the results of our study satisfied these international standards. summary/conclusions: the newly developed domestic leukoreduction filter was, thus, found to be efficient and will contribute to the improvement of the quality of isolated blood components used in korea. faculty of science, humanities and education, technical university of liberec, liberec, czech republic background: as polymeric fibrous scaffold fabrication techniques strive to create structures that more closely replicate tentative extracellular matrix form and function, the need for increased scaffold bioactivity becomes more pronounced. the fibrous structure made from biocompatible and nontoxic polymers ensures mechanical stability, however cell proliferation requires further stimulation. platelet-rich plasma, which has been shown to contain over bioactive molecules, has the potential to deliver a combination of growth factors (gfs) and cytokines capable of stimulating cellular activity. aims: the presented work deals with the preparation of nanofibrous materials with platelet growth factors incorporated into the internal fiber structure. polyvinyl alcohol (pva) was used for the preparation a material providing a progressive release of native gfs without need of subsequent crosslinking. methods: materials were prepared from pva (mw , , % of hydrolysis) using electrospinning technology (nanospider tm ws u). platelet lysate (pl) was prepared from thrombocyte rich solution (obtained from regional hospital in liberec, the concentration of - x plt/ml, freeze-thaw method with subsequent centrifugation). nanofibers were electrospun from % pva solution using water: ethanol ( : ) solvent system. materials with proteins were electrospun from solution containing % of pva and % of pl. morphological analysis was performed by scanning electron microscopy. protein release was monitored using spectrophotometry (bradford method) and chromatography. results: the prepared fibrous materials consisted of random oriented end-less fiber with smooth surface with minimal defects in structure. the morphology of materials was not altered by the addition of proteins. the average fiber diameter was: ae nm for pristine pva fibers and ae nm for pva with incorporated proteins (pva/pl). pva/pl layers contain - mg of protein per gram of pva. % of the proteins are released during the first day (burst release) followed by a gradual release of up to weeks. summary/conclusions: nanofibrous pva-based nanofiber materials were prepared with native growth factors. the process used for the preparation of solutions and subsequent spinning does not affect the activity of the incorporated proteins, which are being gradually released. therefore, we believe that the developed material has great potential for use in tissue engineering e.g. to promote healing of chronic wounds. acknowledgements: supported by the czech health research council, project no nv - - . background: human a-defensins are small cationic peptides with antimicrobial and anticancer activity. up till now, six a-defensins have been described in humans. they include the human neutrophil peptides (hnp) , and which present in large amounts in neutrophil azurophilic granules and differed from each other only in the first amino acid. a fourth defensin, termed hnp- , comprises less than % of the total defensins in neutrophils and has a distinct sequence from hnp - . the other two, human defensin and , are synthesized mostly by intestinal paneth cells. neutrophil defensins (hnp - ) are . kda peptides that are characterized by three disulfide bridges. the pattern of disulfide bonds in the mature forms is crucial for the functional properties. due to this structural feature, synthesis of defensins using the chemical and recombinant approach presents quite a challenge. moreover, purification from the natural source can be very difficult because the large number of neutrophils is needed to obtain a sufficient amount of protein. in blood banks, leukocyte reduction filters are used to remove leukocytes from blood components in order to prevent adverse transfusion reactions. leukofilters contain high numbers of normal human cells and discard after use. aims: the aim of this study was to purify a-defensins from neutrophils trapped in leukocyte reduction filters. methods: blood bags from healthy blood donors were collected after written consent. all donors were screened for infectious diseases (hbv, hcv and hiv) and negative samples were included in the study. blood bags were filtered at °c by leukoflex lst- filters. the cells were extracted from the filters by back-flushing with cold phosphate buffered saline (pbs), ph . , without mgcl and cacl , containing mm edta and . % sucrose. the pbs was homogenized with the filter content and then collected in a sterile tube. neutrophils were separated from mononuclear cells by ficoll. isolated neutrophils resuspended in pbs x at a concentration of cells/ml. for degranulation, cells were stimulated with nm of formylmethionyl-leucyl-phenylalanine (fmlp) for min followed by stimulation with lm of cytochalasin b for min. supernatant was collected by centrifugation at g for min. supernatant was incubated with mouse monoclonal antibody to hnp - and purification of hnp - was performed by lmacs protein g microbeads system. the presence of protein was confirmed by western blot. results: the presence of the . kda band was confirmed by western blot, which corresponded to the size of the a-defensins. summary/conclusions: the development of defensins as therapeutic products requires access to a steady supply of neutrophils. our results indicated that lst- filters are economical source for purifying a-defensins. anatomical sciences, abadan school of medical sciences, abadan, iran background: epigenetic reprogramming of terminally differentiated cell can modify somatic cells to a pluripotential state. there are several approaches that induce pluripotency in somatic cells. exposure the cells with the embryonic stem cell extract is an easy way, and some investigations were done on fibroblast cell line. however, its efficiency was low aims: the purpose of this study was to increase the number of reprogrammed granulosa cell as a full differentiated cell into pluripotential state methods: the human granulosa cells were cultured in the medium containing -aza-deoxycytidine and trichostatin a. then, the cells were exposed to mouse escs extract and co-cultured with mouse embryonic fibroblast in the presence of leukemia inhibitory factor (lif). alkaline phosphatase test and also immunohistochemistry staining for oct , sox and nanog were performed after and h and week results: the results indicated that after h the granulosa cells were revealed a round and expanded morphology. the cells in all groups except in negative control, were showed alkaline phosphatase activity. the cells that were cultured in medium containing -aza-deoxycytidine and trichostatin a and exposed to the extract had the most numbers of alkaline phosphatase positive cells. immunocytochemistry showed the granulosa cells that were cultured in medium containing -aza-deoxycytidine and trichostatin a with extract expressed oct with weak intensity after h. no expression of oct , sox and nanog were observed in other groups at the same time. after h, oct , sox and nanog were over expressed in the cells that were treated with -aza-deoxycytidine, trichostatin a and extract. furthermore, there was high expression of oct in the granulosa cells that were cultured in medium containing dmso and exposed to the extract. after one week, the expression of oct and sox in the granulosa cells that were cultured in medium containing dmso and exposed to the extract was continued while its expression ceased in the other groups. the expression of nanog were ceased in all groups after one week summary/conclusions: present study revealed that the inhibitors of the methyl transferase ( -aza-deoxycytidine) and histone deacetylase (trichostatin a) could delete the epigenetic markers and improved cells reprogramming by administration of the extract abstract withdrawn. abstract withdrawn. abstract withdrawn. background: mesenchymal stem cells (mscs) are adherent spindle shape cells expressing different surface markers. they show special criteria including, paracrine effects, differentiation to several tissue cells, migration, immunomodulatory and regenerative potentialities. mscs are isolated from different sources and employed as therapeutic tools to treat several diseases and injuries. however, some of mscs properties including secretion of growth factors and migration ability are controversial especially during remission or in presence of tumor. interestingly, msc-derived compartment could be used as practical tools in term of diagnosis, follow up, management and monitoring of disease instead of intact mscs. exosomes are kind of extracellular vesicles (evs) characterized via their size and releasing mechanism. usually they defined as less than nm in diameter vesicles. they secreted from different cells and are also found in urine, blood, breast milk, cerebrospinal fluid and other body fluids. exosomes contain genetic material including dna, mrnas, micrornas (mirnas) and other biomolecules. mirnas are single stranded non-coding rnas transcribed from dna. immature mirnas are subjected to two known cleavages to modify to mature mirna that involve to either mrna degradation and gene expression process or cell-cell interaction and communication via secretion as the part of exosomes. aims: this study was aimed to discuss some aspects of exosomal micrornas derived from mscs in progression, diagnosis and treatment of some diseases. methods: different scientific data bases including pubmed, google scholar and scopus were used to find and review related articles. results: evs play important role either in intercellular communication related to pathological and physiological situation or intracellular communication, angiogenesis, immune system modulation and metastasis progression. mirnas could regulate expression of multiple mrnas then they play important role in different biological processes and contribute cell-cell interaction as well as influence in the progression of different disease. exosomal mirna-derived mscs are involved in cancer procession, tumor growth, angiogenesis and metastasis. they are used as diagnosis and therapeutic tools to treat different diseases such as renal failure, liver fibrosis, myocardial infarction. summary/conclusions: due to controversial aspect of using of intact mscs especially during remission or in presence of tumor, msc-derived exosome could be used as practical tools in term of diagnosis, follow up, management and monitoring of disease instead of intact mscs. aims: the aim of study try to use sybr green i based real-time pcr to identify homozygous, heterozygous, gene deletion or wild type for rhd exon , , and a. methods: for this study, we used real-time pcr with high resolution melting curve mode, and matrix mix containing sybr-green i were used for sequence specific primers of g>a and rhd exon , , . samples with rhd gene deletion homozygous/heterozygous, g>a heterozygous with rhd gene deletion and normal rhd, normal rhd homozygous/heterozygous and rhd -rhce( - )-rhd homozygous/heterozygous were enrolled in our study. all samples were screened using rhd exon genotyping, sanger sequencing and rhesus box analysis. concentration and mass of dna samples were in alleles of normal rhd/rhd gene deletion. the tm ratio of rhd exon ( °c) to internal control ( °c) were . in alleles of normal rhd/rhd -rhce( - )-rhd , . - . in alleles of rhd gene deletion/normal rhd, . - . in alleles of normal rhd and < . alleles of rhd gene deletion. the tm ratio of rhd exon ( °c) to internal control ( °c) were . in alleles of normal rhd/rhd -rhce( - )-rhd , . - . in alleles of rhd gene deletion/normal rhd, . - . in alleles of normal rhd and < . alleles of rhd gene deletion. the tm ratio of rhd exon ( °c) to internal control ( °c) were . in alleles of normal rhd/rhd -rhce( - )-rhd , . in alleles of rhd gene deletion/rhd -rhce( - )-rhd . - . in alleles of rhd gene deletion/normal rhd, . - . in alleles of normal rhd and < . alleles of rhd gene deletion. summary/conclusions: using the tm ratio of sequence specific primers to internal control is an effective way to detect the rhd gene deletion or rhd weak d types , and not detected") were tested with a method based on next generation sequencing (ngs) using the illumina miseq platform to detect a possible rhd variant not interrogated by id rhd xt. results: in total dna samples were tested in pools. fifteen ( ) pools ( samples) gave rhd deletion genotype and seventy two ( ) pools ( samples) resulted to the presence of rhd gene. the positive pools were also analyzed individually. the genotype results obtained were: rhd exon no amplification ( ), rhd exon and the genotype results obtained with id rhd xt (in pools and individually) were concordant with the results provided by the centers. hence, % accuracy was obtained using id rhd xt with dna pooled samples. the results of rh ngs for the samples with inconclusive results by id rhd xt showed rhd variants previously described: sample rhd* - inst (del), sample rhd*ivs + g (del), samples rhd*weak d type (partial d), sample rhd*weak d type (weak d), sample rhd*weak d type (weak d) and not described: sample rhd*del - (unknown) summary/conclusions: id rhd xt is a high accurate tool for genotyping the most common rhd alleles associated to weak d and d negative phenotype in up to pooled dna samples. use of rhd genotyping improve rhd typing in blood donations variant rhd alleles generate qualitative/quantitative alteration in serological expression of d antigen such as weak and partial rhd phenotypes which are clinically important in transfusion setting. population studies have shown varied distribution of the variant d alleles in caucasians, africans, east asians and indians. many countries have developed their own population-specific strategy for identifying d variants. our previous study in indian population showed absence of weak d type , , and which are commonly found in caucasians d variant individuals. instead, a novel population-specific pattern i.e.~ -kilobase duplication event, including exon , was predominantly identified in . % d variant samples. functional analyses showed that this genetic variation results in the expression of several transcripts, including a wild-type product. commercial genotyping assays available, mainly detect common d variants found in caucasians and africans, thus limiting its usefulness in india. hence, based on our findings we have designed a multiplex pcr assay specific for indian population that can be easily implemented at the laboratory level for genotyping variant rhd. aims: to characterize rhd variants using "indian-specific, rhd genotyping assay". methods: seventy samples referred to our laboratory for molecular characterization of rhd variants were included in this study. all rhd variant samples were serologically typed for results: out of the rhd variants included in this study, samples ( %) showed presence of indian specific allele i.e. exon duplication. seventeen rhd variants samples showed presence of both exon and . qmpsf analysis of these samples excluded involvement of rhd-rhce-rhd hybrids. sixty of the seventy d variant individual had r r genotype this assay thus can be used routinely in indian laboratories to identify and characterize rhd variants. - non-invasive fetal kel genotypes from allo-immunized anti-kel women were done ( positive confirmed fetuses, undetermined, positive non-confirmed, negative non-confirmed and negative confirmed). - non-invasive fetal rhc genotypes from allo-immunized anti-rh women were done non-invasive fetal rhe genotypes from allo-immunized anti-rh women were done ( positive foetuses, undetermined for , % of the allo-immunized women, the pregnancy was compatible and no specific antenatal monitoring was necessary summary/conclusions: non-invasive fetal red blood cell genotype is a powerful tool to diagnose a feto-maternal red blood cells incompatibility and allows to legitimize a costly and heavy specific antenatal monitoring s purchla-szepioła , m krzemienowska , m pelc-kłopotowska , m jurkowska , m debska , m uhrynowska and e brojer the test developed by ihtm has been offered to clinicians and pregnant women since but it is not covered by the health care system. rhd nipt is not informative for mothers with rhd variant. in such cases further analysis of the molecular background is offered to exclude from immunoprophylaxis the women with weak rhd type , and . aims: summary of a -year period of routine rhd nipt available at ihtm. methods: cffdna isolated using easymag, biomerieux from plasma of pregnant women determined with standard serology as rhd-negative (in - week of gestation) was examined for the presence of exons and of rhd and ccr by realtime pcr using lc ii (roche). maternal dna from whole blood was tested for identification of rhd variant using rbc fluogene rbc-dweak/variant (inno-train, germany) or the home-made protocol. results: in cases the rhd gene was not detected in cffdna and the administration of rhig was not recommended. in seven cases ct-values for rhd and ccr indicated a maternal d variant (d ct ccr -rhd > ); the genetic follow-up of six of them identified: rhd* w. in cases, rhd* w. and rhd* . in cases the rhd nipd results indicated that a fetus is rhd positive and rhig administration was recommended it was recommended in the remaining % of mothers. in . % cases with maternal d variant rhd nipt was not possible. however, in / such cases the test is unnecessary because follow up analysis revealed maternal rhd variant of the weak d type and in switzerland extended antigen-matching for duffy, kidd and mnsbesides rhesus and kell -is recommended for sickle cell disease (scd) patients. the ethnic diversity of red blood cell (rbc) antigen polymorphism engender that these patients are often transfused with rbcs from donors of african origin. this strategy, however, increases the likelihood of being exposed to certain low-prevalence antigens, such as rh (d w ), as these are almost exclusive to african populations. rh is encoded by several types of rhd*dv as well as by dau- . anti-rh is associated with delayed hemolytic transfusion reactions (htr) aims: here we report a specific low-prevalence antibody newly formed by the same patient, meanwhile gravida , para , causing positive crossmatches with the rbcs of two of the four selected donors. subsequently, advanced serologic and genetic workup and close international collaboration enabled optimal patient care. methods: standard serological methods were used for antibody specification (biorad, cressier, ch and in-house). crossmatches were carried out by indirect antiglobulin test at °c. molecular typing of donors' and parental blood group antigens was performed by further serological analysis (institute national de transfusion sanguine, paris) revealed an anti-rh in addition to anti-fy , anti-e and anti-jk a . genotyping of the two donors causing positive crossmatches presented heterozygosity for rhd* . which encodes rh . the newborn's phenotype was a r r k-, fy(a-b+) and most likely rh -and jk (a+b+), considering both maternal and paternal (a r r, k-k+, fy(a-b+), jk(a+b-), rh -) predicted phenotypes. the neonatal serum contained maternal anti-a , anti-rh and anti-e. the direct antiglobulin test was positive but elution only showed nonspecific reactions with papain-treated cells. latter might have been caused by anti-fy during her present pregnancy we were able to demonstrate that two positive crossmatches of two former compatible donors were caused by a new alloantibody against a low-prevalence antigen, namely anti-rh , derived from several rh + rbc transfusions during the previous pregnancy. despite this challenging blood supply we were able to support the patient with a total of ten antigen compatible and crossmatch negative rbc units from french and swiss donors until delivery with increasing age, the relative number of women in the study population raise from % in the patients younger than years to % in the patients older than years. our study showed that cardiovascular diseases were the commonest indications for warfarin use in older patients with %. only , % achieved target therapeutic range while the risk of thromboembolism and the subsequent need for proper anticoagulant therapy increases sharply with age, the bleeding risk rises as well. older patients are more sensitive to any given dose of warfarin and need a significantly lower total weekly dose. a well-informed patient provides one of the best defenses against bleeding complications. recent data demonstrate doacs advantages over warfarin, especially for older population: more predictable dosing, fewer drug interactions and reduced risk of intracranial bleeding although vast majority of fh cases are caused by mutations in ldl-r gene %- % patients do not harbor genetic cause in the known loci. patients with homozygous/severe heterozygous fh are unresponsive (ldlc above mg/dl with diet and drug therapy) and require additional extracorporeal therapy to reduce ldlc concentrations to prevent the development/progression of cad. ldl apheresis techniques remove apolipoprotein b-containing lipoproteins from blood and include heparin-induced extracorporeal ldl precipitation(help), immunoadsorption, dextran-sulfate adsorption methods: a y iraqi male visited cardiac-opd. ct coronary angiogram showed cad-dvd. he had multiple tendinous xanthomas and xanthelasmas. family history was significant for death of elder brother from coronary event at y, a sister with similar profile age y and one sister apparently normal. he was taking medical treatment for dyslipoproteinemia (ecosprin mg od, ticagrelor mg bd, rosuvastatin mg od). despite dietary and medical treatment his dyslipoproteinemia was refractory. therefore cascade-filtration was planned with evaflux a plasma fractionator. one procedure of cascade plasmapheresis was done on com.tec apheresis system (fresenius kabi, germany) separating patient's plasma as the first step and passing it through a pore sized based filter column a (evaflux, kawasumi, japan) as the second step. a total of . x plasma volume( ml) was processed. the patient was given continuous calcium infusion. the flow rate of ml/min was maintained immunoglobulins) were not assessed. summary/conclusions: the procedure successfully met the requirement of reduction of cholesterol by %. the patient became responsive to the medical treatment. follow up of the patient up to a year has been uneventful with no additional procedure requirement actions included development of major haemorrhage protocols with improved communication and required instances of delayed transfusion to be reported to the uk national haemovigilance scheme (serious hazards of transfusion, shot) methods: delayed transfusion data have been collected from . hospitals identify incidents and report them via an online database. mh may also result in avoidable or overtransfusion. reports are analysed and collated data published in the shot annual reports in july each year. results: the total number of reports of delayed transfusion has increased with time: , , in the last years. delayed transfusion in relation to mh was reported for cases - contributing to death in patients %) miscommunication was noted between clinical different teams, between emergency departments, porters and the transfusion laboratory, failure of bleeps, failure to communicate the urgency, failure to confirm the patient location. failures to follow mhp correctly occurred in / ( . %): incorrect activation including failed alerts to porters, wrong contact telephone details and wrong components in the mhp packs most transfusions included red blood cells (median, units); % of women were transfused with fresh frozen plasma (median, units) and % with platelets. mean pre-and post-transfusion hemoglobin levels were . g/dl and . g/dl, respectively, representing an increment of . g/dl per rbc unit transfused ( . g/dl in soweto and . g/dl in durban). indications for transfusion included obstetric hemorrhage ( %), chronic anemia ( %), surgery or anesthesia ( %), other ( %) and not specified ( %). transfusion for chronic anemia (vs. hemorrhage) was associated with gestation ≥ weeks (odds ratio = . , % confidence interval . - . ). surgical blood loss was a common indication in trimester ( %) that declined to % then % in trimesters and . summary/conclusions: hemorrhagic complications accompanying spontaneous abortions and ectopic pregnancies in the first and second trimesters were the most common reasons for antenatal transfusion surveillance and analysis of blood transfusion reactions represents inseparable part of hemovigilance. aims: summarization of data on reported cases of transfusion reactions. methods: analysis of serious undesirable reactions to blood products administration in the czech republic (cr) during period - . results: there were evaluated , of blood products administrations in , patients in the cr during defined three years period. announced , ( , %) transfusion reactions including severe transfusion reactions ( adjudged with grade ). the most frequent types of severe transfusion reactions: anaphylaxis , trali x, taco x, hcv x, hbc x, bacterial infection x, delayed hemolysis x. transfusion reactions incidence according to administered bp: red blood cells products: , administrations, transfusion reactions (fnhtr x, allergy x, circulatory overload x, anaphylaxis x, trali x, hbv x, hcv x) platelets: , thrombocyte administrations, including transfusion reactions (allergy x, fnhtr x, anaphylaxis x, circulatory overload x, delayed immune hemolysis x, acute circulatory overload x. granulocytes: administrations, transfusion reactions plasma: , administrations, reactions reported (allergy , fnhr , circulatory overload , anaphylaxis x, trali x, hbv x, ards x. summary/conclusions: conclusions: comprehensive analysis and data processing help to appropriate prospective setting of blood products (bp) production and hemotherapy. concrete outputs from processed data triggered undermentioned changes in many departments in the cr: . plasma for clinical uses from male blood donors, . prestorage of leucocyte reduced blood products, . production of platelets in additive solutions, . implementation of pcr testing method for blood donors screening. background: skae's basic activities include epidemiological surveillance of all adverse events (aes) associated with deviations in the collecting, testing, processing, storage and distribution of blood and blood components that may affect quality and safety near misses" and "uneventful transfusion errors" are collected to identify preventable causes. incorrect blood component transfused (ibct) events are reported following ihn instructions. results: a total of they were mainly associated with deviation in processing ( . %) and attributed to equipment failure and materials ( %) whole blood collection, materials and distribution, as a result of product defect, equipment failure, human error and other. trend analysis showed a significantly increasing (p < . ) annual rate of total aes by % ( % confidence interval - ) ) % fibrinogen-depleted phpl or ( ) % fibrinogen-depleted phpl plus heparin. internalization of fluoresceinamine-labeled heparin in stcs was investigated by flow cytometry and immunocytochemistry. all stromal cells were subjected to whole genome expression analysis (affymetrix human gene . st array) and data were analyzed using r/bioconductor and panther analysis tools. confirmative qrt-pcr was performed and protein levels of selected pathways were analyzed by a bead-based western blot system (digiwest â ). immunophenotyping, in vitro differentiation, longterm proliferation and colony forming units (cfu) assays were done for all cell types. results: in vitro exposure of heparin induced differential internalization and lysosomal accumulation in stromal cells, as well as regulation of distinct gene sets, both in a tissue-source dependent manner. affected signaling cascades were mainly involved in proliferation, cell adhesion, apoptosis, inflammation and angiogenesis. the influence of heparin on protein expression and phosphorylation of four pathways (wnt, pdgf, notch and tgfbeta) was further analyzed, revealing most alterations in bm-stcs. independent of origin and medium composition, flow cytometry analysis revealed the characteristic fibroblastoid phenotype profile (cd +/ +/ + and cd -/ -/ -/ -/hla-dr-). in addition a comparable osteogenic and adipogenic differentiation capacity was found summary/conclusions: internalization of heparin in lysosomes by stromal cells, differential gene and protein expression and phosphorylation changes were observed in a tissue-source dependent manner. however, stromal cell characteristics as immunophenotype pattern, long-term proliferation, clonogenicity and in vitro differentiation were unaffected, putatively by post-translational protein modifications. in this respect, application of porcine heparin is compatible with efficient manufacturing of stromal cell based medicinal products abo incompatibility may have no effect on the clinical outcome after allogeneic hematopoietic stem cell transplantation. however, it carries additional risks of hemolytic reactions, delayed red blood cell (rbc) engraftment and incidence of graft-versus patients were categorized according to abo compatible and mismatched groups; these were further sub-categorized into major, minor and bidirectional. direct coombs test (dct) was performed when hemolysis was suspected in the post-transplantation period along with serum lactate dehydrogenase (ldh) %) were male and ( . %) female. mean age of abo matched and mismatched groups were ( . ae . ) years. most common indications for transplant included beta thalassemia major ( . %), aplastic anemia in ( . ) and pure red cell aplasia ( . %). source of stem cell was bone marrow in and peripheral blood patients abo matched while abo mismatched group comprised of ( . %) patients with further subdivision into major (n = ), minor (n = ) and bidirectional in the post transplantation period, packed red blood cell and platelets were transfused in matched group (n = ) and (n = ) comparably(n = ) and (n = ) in mismatched group. primary and secondary graft failure in matched group was . % and . % patients while in mismatched group graft failure was observed in ( . %) patients respectively. positive dct in abo matched group in ( . %) patient, whereas ( . %) patients with major and minor abo mismatch group with raised ldh levels and deranged lfts were found. episodes of acute and chronic gvhd in abo compatible and incompatible groups were insignificant. overall survival in abo summary/conclusions: these results indicate that abo incompatibility does not seem to influence outcome of the patients undergoing allogeneic hematopoietic stem cell transplantation. careful monitoring of patients can help detect problems early and treat them efficiently, thus, reducing the number of life threatening events a picascia , c sabia , f cavalca , g nicoletti and c napoli in our routine work with one lambda sab class ii reagents, we observed non-specific reactivity with some beads bearing dr and dr in patients without sensitizing events. this pattern was not confirmed by testing same sera with screening-and pra-beads suggesting non-specific reactions. aims: here, we sought to determine if fetal bovine serum (fbs) treatment would be effective in reducing/eliminating non-specific reactivity. methods: we tested sera pre-treated with fbs from non-sensitized patients that showed the dr /dr pattern. in particular, ll of fbs was added to ll of patient serum; incubated for min at °c; centrifuged and subsequently tested in the sab assay. as controls, we treated sera from patients with documented dsa including dr /dr and patients without hla antibodies. results: dr /dr non-specific reactivity was eliminated or significantly reduced after fbs treatment. we found that patients with dr and dr dsa had no change in mfi values and additional reactivity was not observed in negative fbs treated sera transfusion medicine, national blood transfusion centre transfusion medicine, national blood transfusion center transfusion medicine, national blood transfusion centre, tirana, albania background: abo blood group, has been associated with many diseases, although the explanation for abo's blood group association and some illnesses is still unclear. aims: to find the distribution of cases by blood groups in patients with malignant pathology compared to donors in order to assess the presence of the abo blood group as an epidemiological indicator to identify populations exposed to different malignant pathologies methods: we conducted a case-control study. abo blood group and diagnosis of all patients have been studied. the control sample was collected from , healthy donors from which group a ( , %), group o ( , %), b ( , %) and group ab ( , %) resulted. the study was conducted in patients who have been transfused and submitted a request to determine the blood group at the blood bank at qsut during the period - results: among the patients, when all malignant pathologies were taken together, the highest frequency was seen in blood group a ( . %), followed by ( . %), b ( . %) and ab ( . %). group a frequency was higher and o was lower compared to controls. a high incidence of blood group a is seen in: pancreatic cancer a ( %), in gastric cancer a ( %), colorectal cancer a ( , %), breast cancer a ( %), cervical cancer a ( %) and ovarian cancer a ( %) versus a ( . %) in the control group. a high incidence of blood b is seen in multiple myeloma b ( %) and cervical cancer b ( %) versus b ( . %) in the control group. blood group ab has a high incidence in malignant lymphoma ab ( %) versus ( . %) in the control group summary/conclusions: it appears that individuals with blood groups a, b and ab are more at risk of developing malignant pathologies and individuals with blood group o are more protected. background: the high homology and opposite orientation of rh genes promote many rearrangements between them and generate a large number of rhd and rhce variants which can be inherited together. several studies have shown that those rh variants in patients with scd represent an additional risk for alloimmunization and delayed hemolytic transfusion reactions (dhtrs), but little clinical or biological evidence related to alloimmunization and dhtr are presented for all the rh variant alleles. it is well established that transfusion recipients with the most common weak d types , and , are not at risk for forming alloanti-d when exposed to conventional rhd-positive rbcs. aims: we report here a case of a -year-old patient typed as weak d type , receiving d+ rbc units who presented anti-d in his plasma detected three weeks after the last transfusion. methods: rhd beadchip (immucor, nj, usa), was performed to identify the rhd variant allele associated with the weak expression of d. rhce genotyping was performed by laboratory developed tests. sequencing of rhd, rhce and rhag were performed to determine if there were other mutations that could explain the production of alloanti-d. serologic testing was by standard hemagglutination methods. the clinical significance of the antibody was evaluated by monocyte monolayer assay (mma). results: serological analysis showed a negative dat and the presence of anti-d in plasma ( + by gel). anti-lw was ruled out. rhd genotyping revealed the patient was rhd*weak d type . rhce genotyping predicted the d+c+c+e-e+ phenotype. sequencing of rhd, rhce and rhag found no additional changes and confirmed the presence of rhd*weak d type . mma showed the anti-d was clinically significant (> %). summary/conclusions: we report the production of alloanti-d in a scd patient with rhd*weak d type allele. weak d type patients are not considered to be at risk for allo anti-d but our results show that there are exceptions and that these anti-d can be associated with clinically significant rbc destruction. background: the mns blood group system is located on glycophorin a (gpa), glycophorin b (gpb) and hybrid glycophorins on the surface of the red blood cell (rbc). these glycoproteins are involved in complex structures interacting with other rbc surface proteins including the band /diego protein. the glycophorins are heavily glycosylated and contains multiple clinically significant blood group antigens. it has proved difficult to model the gpa extracellular structure due to its heavy glycosylation, and lack of homology with existing modelled proteins. aims: to develop an in silico model of gpa as a basis for improved predictions of structure function relationships methods: prediction of secondary structure and disorder: . . predictprotein (https://predictprotein.org); . . spider (http://sparks-lab.org/server/spider /); . . dsc (discrimination of protein secondary structure class): using an in-house implementation; . . jpred (http://www.compbio.dundee.ac.uk/jpred /); . . raptorx (http://raptorx.uchicago.edu). prediction of secondary structure: . . robetta (http://robetta.bakerlab.org/submit. jsp); . . falcon (http://protein.ict.ac.cn/treethreader/); . . itasser (https://zha nglab.ccmb.med.umich.edu/i-tasser/) threading methods to evaluate the quality of protein structures: . . verify d (http://servicesn.mbi.ucla.edu/verify d/); . . prosa (https://prosa.services.came.sb g.ac.at/prosa.php) protein-protein docking: . . gramm-x protein-protein docking web server (http://vakser.compbio.ku.edu/resources/gramm/grammx/); . . gramm (http://va kser.compbio.ku.edu/main/resources_gramm . .php) results: using in silico modelling we derived a stable tertiary glycosylated structure for gpa both as an individual protein and a homodimer. the hybrid glycophorin background: non-invasive prenatal testing of fetal antigen using cell-free fetal (cff) dna from maternal plasma of immunized women is widely implemented into clinical routine but the sensitivity and specificity of the method, especially for genotyping antigens encoded by single nucleotide polymorphisms such as k antigen, is limited by low proportion of cffdna in maternal plasma dna. according to literature reports detection of circulating tumour (ct)dna can be improved by selection of short ctdna fragments using automated electrophoresis methods. aims: the aim was to assess the feasibility for enrichment of cffdna fraction in maternal plasma dna by size selection using the pippin prep gel selection system. methods: plasma dna isolated using easymag (biomerieux) from rhd negative and k-negative pregnant women (n = ) carrying fetuses with known genotype was loaded into % agarose gel casette ( % df marker q , sage bioscience) and size selection of fraction was performed on a blue pippin tm (sage bioscience) with the elution from min to h min of electrophoresis. results for real-time pcr detection of fetal rhd, kel* and ccr (as a marker of total plasma dna) in dna fraction after gel selection were compared to results obtained from non-processed plasma dna. results: the total dna level (measured by ccr ) was significantly lower in dna samples tested after gel selection (from . to . geq/pcr) versus the level obtained from non-processed plasma dna (from to geq/pcr). the results for fetal fraction (measured by rhd) from dna samples of rhd-negative pregnant women carrying rhd positive fetus tested after gel selection were from , to . geq/pcr versus . - . geq/pcr for non-processed plasma dna. results for kel* detection in plasma dna from k-negative pregnant women carrying k-negative fetus were kel* -negative in dna samples tested after gel selection comparing to nonprocessed dna samples were false kel* positive amplification was observed. however, kel* detection in plasma dna from two k-negative pregnant women carrying k-positive fetus gave false kel* -negative results in dna samples tested after gel selection comparing to non-processed dna samples were kel* positive genotype was obtained. the total dna level in samples from k-negative women was from . to . geq ccr /pcr after gel selection versus from to geq ccr / pcr in non-processed dna samples. summary/conclusions: using the pippin prep gel selection system increases the proportion of cffdna fraction in total plasma dna by retaining long maternal dna fragments in the gel cassettes, but the protocol of gel separation dilutes the separated material decreasing the concentration of fetal dna and leading to false negative results of nipt. anti-rh quantification assay using ih- (bio-rad â ): promising results for monitoring rh:- pregnant women j beaud, h delaby, c toly-ndour, a mailloux and s huguet-jacquot centre national de r ef erence en h emobiologie p erinatale (cnrhp), hôpital saint-antoine, paris, francebackground: the generalization of immunoprophylaxis by anti-rh immunoglobulins since complicates the interpretation of the anti-red blood cell antibodies screening during pregnancy. to distinguish an alloantibody from a passive one, many laboratories in france use anti-rh microtitration. it is a column agglutination technology using red blood cells rh: , - , - , , (r r) . it permits to quantify low levels of anti-rh in comparison to a range of an anti-rh standard. performed since at the cnrhp and automated on evo clinical base tecan in (dilutions and distribution), anti-rh microtitration is well adapted to rh prophylaxis. aims: the aim of this study was to evaluate this technique on the ih- system from bio-rad â . methods: on ih- , the reactivity of the bio-rad â reagents was compared with the cnrhp reagents (red blood cells r r, anti-rh standard). the performances of the method were evaluated using three internal quality control (icq) ( cnrhp home-made at and ng/ml and bio-rad â at ng/ml) on papainized r r (plc) and native r r (nlc). a comparison of results from patient sera ranging from . to ng/ml was done between ih- and evo clinical base tecan. results: the results of the qci are similar between the different reagents used. there is no significant difference between the types of red blood cells except for the limit of detection: . ng/ml in plc - ng/ml in nlc. for the qci, the intra and interassay imprecision based on the dilution degree show coefficients of variation between and %, similar to those found with the evo clinical base. the correlation with the cnrhp technique performed on samples in plc and samples in nlc was satisfactory (deming plc: r = . y = . x + . -nlc: r = . y = . x- . ). summary/conclusions: the anti-rh microtitration on the ih- offers similar performances to the method conducted at the cnrhp. the ih- allows automated reading of gel cards. however, it does not have a calculation or interpretation algorithm and does not directly give the concentration of anti-rh . this final part remains manual and requires trained staff. background: haemolytic disease of the foetus and newborn (hdfn) due to maternal-foetal incompatibility has been perfectly framed for decades from the etiologic, pathogenetic and therapeutic point of view. the anti-d alloantibody is most frequently responsible for the most serious form of hdfn due to rhd incompatibility (rhdi hdfn). although immunoprophylaxis (ip) has reduced the number of cases of rhdi hdfn, this disease continues to occur and red blood cell alloimmunization still remains the most common cause of foetal anaemia. hdfn due to abo incompatibility (ab i hdfn) is currently the most common neonatal haemolytic disease in the western world. however, only in about . - % of cases haemolytic disease demands transfusion support. aims: analysis hdfn from to . methods: the hdfn's transfusional support is: intrauterine transfusion (iut) in the antenatal period; exchange transfusion (et) for severe hyperbilirubinaemia and neonatal transfusion of small volumes red cells for the newborn's late anaemia in the postnatal period. our policy for iut, for et and for the neonatal transfusion requires the use of a concentrated blood cells (ec) preferably group rh negative (cde/cde) or negative for any red cell antigens if the mother has antibodies, fresh (< days), preferably cmv safe. for iut, the ec must be compatible with mother's plasma, must have hematocrit + %, and irradiated. the unit for et must be compatible with the newborn's plasma, whit hematocrit % - % and irradiated. the ec used in post-natal transfusions is usually divided into rates of ml, hematocrit ae %. results: in last years, we calculated neonates with hdfn ( males and females): with rhdi hdfn, with ab i hdfn and with hdfn due to incompatibility for other red blood cell antigens. we have produced iut: for our hospitalized patients and for patients located in other hospitals. of these patients, who received iut, were immunized: showed anti-d antibody and antibodies different from anti-a and anti-b. , of the infants with rhdi hdfn, were transfused in utero. neonates on ( . %) have performed et: with ab i hdfn and with rhdi hdfn; the latter had also been transfused in utero. neonates on were transfused after birth: with rhdi hdfn, with ab i hdfn and with hdfn due to incompatibility for other antigens. summary/conclusions: our case studies reflect the literature data. neonates with rhdi hdfn are the most numerous ( . % of the total) and are those who have requested the highest blood supply both in the antenatal period ( . %) that postnatal ( . % performs et, . % performs postnatal transfusions). neonates with aboi hdfn are . %: nobody has received iut, only one has been subjected to et, and % has transfused after birth. patients with hdfn due to other antigens are %, have undergone iut . % and were transfused after birth . %. background: according to british guidelines on neonatal transfusion, since we shared with neonatologists a transfusion protocol for preterm babies. patients are anemic premature newborns with a gestational age ≤ weeks and/or a birthweight lower than g, until months of age. aims: reduce the incidence of iatrogenic anemia. methods: pre-transfusion tests were based on ab direct test, rh phenotype, direct and indirect antiglobulin test (dat, iat). a second blood sample was required for ab /rh confirmation. blood transfusions were performed with negative kell negative ( cde/cde/kk) cmv negative irradiated erythrocyte concentrates (ec) of less than days. ec were subdivided in ml aliquots with a hematocrit of ae %. according to the definition of "small volume transfusions", our protocol established that further four transfusions had to be delivered free of testing. after the fifth ec transfusion the supplementary release of ec was provided of type and screen (t&s) test with h of validity. serological investigation and full compatibility testing were applied in the presence of a iat and/or dat positivity and in the case of mother alloimmunization. results: from october to the end of , premature newborns received ec transfusions within their first months of life. in % of cases (n = ), transfusion requirement was comprised within the 'small volume transfusions'. another % of cases (n = ), requiring further ec administration, was requested of a blood sample for t&s determination and % (n = ) for a cross-match test. in . % of newborns (n = ), being transfused within the " small volume transfusions", blood requirement of ec was fulfilled by the initial blood test ( blood samples). . % of newborns (n = ) received more than transfusions ( - ; median = ) accounting for ec released and for this group blood samples were required. summary/conclusions: with the exception of babies requiring crossmatch test, blood tests were performed to sustain infants transfused with units. the alternative option of omitting crossmatch test (otherwise suggested by italian directives), allowed a reduction of % of blood drawn without any adverse effect or incident reported. due to the relevance of anemia in premature babies, we suggest the application of this transfusion policy in all newborns in the first months of life. background: glucose- -phosphate dehydrogenase deficiency (g pdd) is a sexlinked enzymopathy which is usually asymptomatic unless individuals are exposed to oxidative stress agents. the g pd genotype is the most common g pd genotype in sub saharan africa (ssa). some studies have linked blood from g pdd donors to poor outcome of a transfusion. however, there are no genetic screening programmes for blood donors in the region hence the contribution of g pdd to the donor pool in the ssa setting had not been described.aims: this study aimed to describe the prevalence of g pdd genotype among donors in two regions in uganda. it also described the effect of g pdd and the coinheritance of haemoglobin s and a-thalassaemia on the haematological quality of blood. methods: , blood samples from donor packs were utilized in a transfusion trial conducted in uganda, were genotyped for g pd , haemoglobin s and a-thalassaemia. haemoglobin and haematocrit measurements for the donor units (packs) at the time of transfusion were used to describe the effect of g pd and co-inheritance with a-thalassaemia (n = , ) and haemoglobin s (n = , ) on the haematological quality of blood packs. a subset of donor blood packs was utilized to determine the sensitivity and specificity of the carestarttm rapid diagnostic kit (rdt) for g pdd. results: based on g pd genotyping, . % (n = ) of the blood samples used in the trial were deficient for g pd enzyme while . % (n = ) were heterozygous. significant lower hemoglobin values were observed in red cell concentrates (p = . ) and whole blood (p = . ) donations of heterozygous g pd genotype. co-inheritance of g pdd and a-thalassaemia resulted in significantly lower haemoglobin levels. the carestarttm rdt test was . % sensitive and . % specific for detecting donor blood packs with g pdd. summary/conclusions: the prevalence of g pdd among ugandan blood donors was similar to that in the general population. the heterozygous genotype resulted in lower haemoglobin concentration of the blood units. the use of carestarttm rdt for screening of stored blood units was not as efficient in this study hence further testing for the determination of g pdd needs to be done on fresh samples from donors. transfusion medicine, jaypee hospital, noida, india background: during last two decade there has been a continuous remarkable improvement in desensitization therapy in high risk hla sensitized kidney recipients. in india there has been a tremendous increase in the number of kidney transplantations in patients having anti-hla antibodies (hla sensitized) with excellent success rate. aims: in present study, we are describing successful role of desensitization in hla sensitized patients having preformed donor-specific hla antibody (dsa). methods: all patients were preconditioned with combined modality of a standard dose of rituximab, therapeutic plasma exchange (tpe) and low dose ivig. tpe was started using com. tec (fresenius kabi, germany) after days of administration of rituximab. complement dependent cytotoxicity cross match (cdc-xm), luminex cross match with donor lysates (lm-xm, immucor inc., ga, usa) and flow cytometry cross match (fc-xm, bd facs canto ii).) was done in all cases. if any of the three tests was positive, single antigen bead assay (sab) was performed. desensitization therapy was given in all cases where dsa was detected. pretransplant tpe procedures were done until dsa (mfi < ) and cdc-xm became negative. cdcxm labeled positive at ≥ %. t-cell fcmx was considered positive above mfi and b-cell fcmx was considered positive above mfi. lmxm was considered positive above mfi. sab was performed using lifecodes single antigen (lsa) class i and class ii kits (immucor, usa). if the specificity of anti-hla antibodies was against donor hla antigen(s) it was called as donor specific antibody (dsa). results: present study demonstrated the diagnostic and clinical superiority of adding fc-xm and lm-xm in pretransplant compatibility testing algorithm over cdc-xm. cdc-xm alone was not able to detect anti-hla antibody in patients ( . %). among the three pretransplant compatibility tests, fcxm demonstrated highest sensitivity. among the cases initially screened showed dsa positivity in sab. desensitization was done in those cases only. in our study, sab was positive for class ii alone in ( %) while in remaining ( %) cases it was positive for both class and class ii. the number of pre transplant tpe procedures required was . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the mean number of post-transplant tpe sessions required was . (range, - ). during pretransplant and post transplant tpe procedures, five ( . %) patients presented with allergic or hypotensive reactions which were managed conservatively. most of the patients were discharged after seven days of hospital stay whereas patients who required post-transplant tpe were discharged after a relatively longer hospital stay (mean- . , median- days). after three months, protocol biopsy was done in those cases only where post transplant tpe was required. protocol biopsy showed normal findings. in present study, the mean duration of follow up was approx months with the longest duration of follow up of months. summary/conclusions: in a country like india where there is a huge gap in the demand and supply of kidney and a large no. of patients waiting for a suitable organ, transplant across hla barrier could a good doable option. thorough pretransplant compatibility and tpe are essential tools to make these transplants program successful background: most transfusion-dependent chronically anemic patients are managed by simple red cell transfusions. however, some patients are not able to tolerate the additional volume associated with simple transfusions and are at a high risk of developing transfusion associated circulatory overload, if transfused with multiple red cell units. plasma-to red cell exchange (prx) is a modified procedure wherein an apheresis machine is used to remove patient's plasma, while simultaneously replacing with donor rbcs. this procedure allows for a rapid euvolemic transfusion of rbcs to patients that are severely anemic and intolerant to excess fluid volume. others as well as our group have previously described this procedure. we now summarize our institutions nearly seven years of experience performing this procedure on a routine basis. aims: to document patient experience with prx. methods: we performed a retrospective chart review of all patients that underwent prx at our institution in the last seven years. our protocol for prx has evolved during this period. currently, we perform the procedures using spectra optia (terumo bct, lakewood, co) machine using the plasma-exchange program and tubing set. if the patient's pre-procedure hematocrit (hct) is < %, we custom prime the tubing set with % albumin. the number of red cell units transfused to the patient depends on their pre-procedure hematocrit and is individualized to the patients. results: we have treated four patients with prx procedure. patient # is a -year-old transfusion-dependent male with beta-thalassemia major. the patient had experienced multiple congestive heart failure exacerbations secondary to simple transfusions and we consequently performed prx procedure, every weeks, starting in . the patient has completed procedures with - units of washed red cells transfused to achieve a target hct goal of to %. he tolerated all procedures without any volume overload issues. he continues on this transfusion regimen. patient # was a -year-old female who had symptomatic anemia secondary to sickle cell disease (hb ss complicated by end-stage renal disease (esrd). she had progressively become intolerant to simple transfusions, including an episode of severe dyspnea, which required intubation. she underwent prx procedures with - units of washed red cells. patient tolerated the procedures without any significant complications. however, during a different surgical procedure, she experienced cardiac arrest and subsequently passed away. patient # is a -year-old transfusion-dependent male with severe anemia secondary to sickle cell anemia (hb ss). he was intolerant to excess fluid because of esrd and congestive heart failure. he has undergone prx procedures with - red cell units transfused to achieve a hct goal of %. he tolerated all procedures without any volume overload issues. he continues on this transfusion regimen. patient # is a -year-old male with a sickle cell disorder (hb ss) complicated by esrd, heart failure and chronic hypoxemic respiratory failure. the patient has undergone two prx procedures with - red cell units. other than an episode of non-bloody emesis that was symptomatically treated, he tolerated both procedures. he continues to be managed on this regimen. however, the patient remains noncompliant with treatment. summary/conclusions: prx is a safe and efficient method to transfuse multiple red cell units to volume-intolerant anemic patients. background: transplanted organ failure due to antibody mediated rejection in abo-compatible organs is a serious complication with a bad prognosis. the goal treatment in these cases encompasses the following strategies: adjustment of the immunosuppressive medications, ivig infusion, antibody removal by therapeutic plasma exchange, and/or the use of target-specific monoclonal antibody medications to lymphocytes, plasma cells, and/or complement. the american society for apheresis has assigned a category i to the use of therapeutic plasma exchange for the treatment of abo-compatible antibody mediated rejection in kidney, but a category iii to all other abo compatible organs: liver, lung, and heart. at our institution, a standardized approach for the use of therapeutic plasma exchange as a supportive intervention for abo-compatible immune mediated rejection, regardless of the organ type, has been in place since . aims: a retrospective review was performed to evaluate our patient outcomes using therapeutic plasma exchange for the treatment of antibody mediated allograft rejection in abo-compatible solid organ transplantation. methods: patients used for the retrospective review were selected from an existing therapeutic apheresis list. the therapeutic plasma exchange protocol consists of: adjustment of the immunosuppressive medications, ivig infusion, antibody removal by therapeutic plasma exchange, and/or the use of target-specific monoclonal antibody medications to lymphocytes, plasma cells, and/or complement. it is performed as follows: one plasma volume exchange is performed on days , , , , , along with one or more of the above strategies followed by an ivig infusion. cases with allograft rejection in which plasmapheresis was not used were excluded. and t devos aims: this study aimed to explore the possible causes of the decreased transfusion rate for all adult cardiac surgery patients. methods: data were collected from adult cardiac surgery patients during the mentioned time frame and were extracted from electronic patient files and a database of the department of cardiac surgery. a set of variables was defined as possible confounders by a panel of experts. after discussion, global variables (age, gender, duration of surgery, use of cpb (cardio-pulmonary bypass), american society of anesthesiologists (asa) risk score, type of surgery, urgency, attending cardiac surgeon and attending anesthesiologist) and cpb-related variables (administration of cardioplegia yes/no (cpg), duration of cpb, circulatory arrest, hypothermia, duration of aortic cross-clamp, baseline hemoglobin and cpb-priming volume) were retained. negative binomial models for counts were used for data analysis. all analyses were performed with spss. results: patients were extracted from databases and further analyzed. the mean age of this group was , years (sd +/- , years) and . % of them were male. the mean duration of surgery was min (sd +/- , min). the decrease of perioperative rbc transfusion rate over four years was statistically significant (p < . ). in , the mean use was , units per operation (sd +/- , ), which changed to , units (sd +/- , ) in . three variables (urgency, attending cardiac surgeon, attending anesthesiologist) changed significantly over years and were used in a multivariable model as confounders together with rbc transfusions and year. even after adjustment for these factors, the decrease in rbc transfusion rate was still statistically significant (p < . ). in the specific group of patients undergoing cardiac surgery with cpb (n = ), the use of rbc was also significantly reduced (p < . ). in , the mean use was , units per operation (sd +/- , ) and this changed to , units (sd +/- , ) in . after correction for the cpb variables that notably changed over the years (cpg, priming volume and hypothermia) and the three previously defined confounders (urgency, attending cardiac surgeon and attending anesthesiologist) the reduction of rbc transfusions over years still remained statistically significant (p < . ). summary/conclusions: our study shows evidence for a decreased rbc transfusion rate in adult patients undergoing cardiac surgery between and . this tendency was also seen in the subgroup of patients undergoing surgery with cpb. possible explanations of the decrease are implementation of various established parts of patient blood management. however, a unique reason could not be identified in this study. background: growing worldwide demand for immunoglobulin products such as intravenous immunoglobulin (ivig) and subcutaneous immunoglobulin (scig) is driving plasma collection. patients with primary immunodeficiency (pid) or secondary immunodeficiency due to haematological malignancy or its treatment (sid) rely on these products to maintain therapeutic serum igg levels to minimise recurrent infection. efficacy of immunoglobulin replacement therapy (irt) in pid is well established but information on sid is limited. the different aetiologies of hypogammaglobulinaemia between pid and sid raised the question of whether sid patients on irt experience similar clinical and quality of life (qol) benefits as reported in pid patients. aims: to assess whether sid patients experience similar clinical and qol benefits while on irt as pid patients. methods: following ethics approval, data on dosage, serum igg trough levels and infection (bacterial, viral and fungal requiring treatment such as antibiotics) was collected from adult pid and adult sid patients from medical records and pathology reports, for their last months of ivig and their first months of scig. the starting and maintenance dose was . g/kg/month for ivig, transitioning immediately to . g/kg/week for scig without a washout period. a study specific questionnaire was developed to gather data on patient perceived side effects, treatment satisfaction and impact of irt on social/family life, work/study and their overall qol. paired t-test was used for parametric data and the wilcoxon signed-rank test for non-parametric data. results: sid patients were significantly older with a mean age of . years versus . years in pid patients (p = . ). a mean of three training session was required to reach competency in scig administration in both cohorts. there was a trend of reduced side effects on scig for pid and sid patients compared to ivig, with a significant reduction of headaches in the pid cohort (p = . ). the majority of patients experienced infusion site reactions, which were predominantly perceived as manageable. % of infections were respiratory tract infections. pid patients had slightly higher mean serum igg trough levels with scig ( . g/l) compared to ivig ( . g/l), and fewer infections on scig than ivig (mean annual infection rate of . vs . respectively). sid patients had higher mean serum igg trough levels on scig ( . g/l) than ivig ( . g/l) (p = . ) but experienced more infections while on scig versus ivig (mean annual infection rate of . vs . respectively). the number of hospitalisation due to infection decreased in both cohorts with scig. pid patients perceived that switching from ivig to scig improved their health and qol. in contrast sid patients perceived no improvements in health and qol. summary/conclusions: data from this pilot study suggests that the clinical and qol impact of irt in sid patients is different to that of pid patients. to support evidence based irt management and effective use of this limited and expensive blood product in sid, larger studies which account for different stages of malignancy and associated treatment regimes are required. background: there is an increasing platelet transfusion for treatment and prophylaxis of bleeding in patients with hematologic disorders and malignancies. because of limited resources, leukoreduced platelet concentrates is not yet implemented in most indonesian hospitals. in vitro platelet activation may cause morphology, functional, and ultrastructure changes. those changes will reduce the platelet viability, in vivo functions, and clinical efficacy. high platelet cd p expression is the cause of faster platelet destruction in the reticuloendothelial systems. post-transfusion in vivo hemostatic efficacy can be determined by the measurement of corrected count increment (cci), recovery, and platelet cd p expression. aims: to analyze the increase of platelet cd p expression in patients of non-leukodepleted compared to pre-storage leukodepleted pc transfusion.background: haemorrhage is a leading cause of preventable death not only in the military trauma care, but also for civilian population suffering accidents or bleeding injuries in regions with low population density where health services should reach people in remote areas. resuscitation using blood products and limited infusion of normal saline improves survival for critically bleeding patients. nowadays there are hems programs (helicopter emergency medical system) carrying blood products around the world. the hems in castilla-la mancha, with physician and nurse, is the first out-of-hospital emergency service in spain that provides packed red blood cells (prbc) transfusion where the accidents happen without delaying the transport to the proper hospital for definitive treatment. this program has been developed between the blood center of ciudad real and the hems team ('gigante ', emergency service castilla-la mancha). the goal of the designed protocol was to preserve the properties of the product to be transfused in out-of-hospital environment by hems teams. aims: to describe the process for out-of-hospital prbc transfusion in hems of ciudad-real. the protocol for out-of-hospital blood transfusion was developed according to criteria of medical indications and security, monitoring, and tracking of the product. methods: data for the observational retrospective study were collected from june to august . the medical helicopter (ec t ) was provided with two prbc o rh(d) negative. the shock index was selected for the indication for transfusion according to the literature revised and as a simple rate to obtain out-of-hospital data. to achieve the feasibility and preservation of the prbc a prospective monitoring of volume was established, haematocrit, haemoglobin, leucocytes, coulter, hemolysis and microbiological culture. blood center established two groups: the case group for the prbc kept in the hems base and helicopter and the control group for the units remaining in the blood center with standardized blood conservation. for both groups, control and comparison of immediately obtained hematologic analyses, and days after collection, were performed. the statistical analysis used spss . version (significance p < , ). results: prbc samples were evaluated, , % ( ) from case group and , % ( ) from control group. analyses were tested day and day after collection. haemolysis was not observed. all cultures were negative. although significant differences were found between the parameter in the value of before-after in the value of the hematocrit, leukocytes and coulter, there are no differences between the prbc that flew and those conserved in the transfusion-service. all results comply with current legislation and blood transfusion standards. there have been administered prbc transfusion to patients during out-of-hospital advanced medical assistance. no post-transfusion reactions have been registered. prbc units have a -day rotation to allow the use of the units in the hospital after achieving their optimal status. summary/conclusions: the out-of-hospital transfusion protocol designed to transport blood (prbc) in the helicopter for hems has demonstrated to keep the standard conditions and properties of the product to be considered useful in the treatment for critically bleeding patients in the out-of-hospital. background: early and adequate treatment of major bleeding is important for survival and a good outcome. blood and plasma are given increasingly early including before hospital admission in trauma based on successes reported from combat experience. in the national patient safety agency issued a rapid response report requiring national health service hospitals in england to take actions to improve provision of blood in an emergency including provision of major haemorrhage protocols (mhp) and drills. the national reporting and learning scheme had identified reports of deaths and instances of harm due to delay over a -year period. aims: the aim of the study was to monitor the acid-base status of the patient by means of abg and to administer the blood component therapy based on teg results. methods: this study was a prospective observational study of adult patients over a period of months. serial monitoring of the abg in the intra-operative period was done. teg guided resuscitation was performed in all cases. results: the abg analysis of all patients showed decrease in the ph, increase in pco , decrease in serum bicarbonate level and elevation in negative base excess. these components of metabolic acidosis can be attributed to massive transfusion. increased lactate, an independent parameter, which reflects poor tissue perfusion or shock and predicts need for massive transfusion was observed in all patients. all the cases showed a decrease in ionized calcium levels which could be a result of citrate related toxicity. increased glucose was observed in all patients which may be due to increase in the catecholamine release as a response to haemorrhagic shock. electrolyte correction was given depending on results of the abg analysis wherever appropriate. two out of cases showed an increase in r time indicating deficient coagulation factors, which was corrected with fresh frozen plasma (ffp). three cases showed elevation in k time indicating deficient fibrinogen levels, which was corrected by ffp. fresh frozen plasma was also given in cases, which showed decrease in the alpha angle, indicating deficient fibrinogen, and cryoprecipitate was given in cases. platelets were transfused in patients showing a decrease in the maximum amplitude (ma), which indicates deficient platelets. summary/conclusions: teg as poc testing is an important tool in appropriate blood component therapy in massive transfusions. serial monitoring of abg helps in monitoring acid-base status of the patient and therefore is a guide in the correcting electrolyte level in patients undergoing massive transfusion. background: massive blood loss is encountered in various situations like trauma, major surgeries, gastrointestinal bleeds and obstetric haemorrhages. haemorrhage is an important cause of mortality and morbidity in massively bleeding patients. early recognition of haemorrhage and intervention is essential for survival. massive transfusion (mt) of blood is required to replenish blood losses and is a lifesaving treatment in these patients. a variety of haemostasis and pathophysiological changes occur during massive haemorrhage and massive transfusion. all of these changes contribute to the vicious cycle of progressive coagulopathy due to the 'lethal triad' of refractory coagulopathy, progressive hypothermia and persistent metabolic acidosis. aims: the aims of the study included understanding management of cases of massive blood transfusion in surgical patients, impact of mt of blood components on patient outcome, evaluating post-operative complications of massive transfusion and the development of institutional massive transfusion protocol (mtp).methods: this prospective observational study commenced after institutional ethics committee (iec) approval. it comprised of adult surgical oncology patients who received massive transfusions and was conducted for a period of months. every case of a massive transfusion was studied under the following headings ( ) patient's details ( ) patients base-line laboratory tests ( ) resuscitation with transfusion ( ) intra-operative laboratory tests ( ) thromboelastography (teg) ( ) post-operative complications ( ) duration of stay in the hospital ( ) day mortality rate. results: complete blood count, serum electrolytes, arterial blood gases, coagulation profile and teg were used to monitor transfusion therapy in the intraoperative period. intraoperative laboratory parameters of patients showed dilutional coagulopathy, metabolic acidosis, hypocalcaemia, hypomagnesaemia, hyperkalaemia and hypokalaemia, increased lactates and glucose. electrolyte correction was done based on the derangement. the derangements were on a decreasing trend in the postoperative period and returned to baseline level by nd or rd post-operative day with no requirement of correction in the post-operative period. the post-operative outcomes were evaluated in terms of the surgical site infection (ssi) as per the centers for disease control (cdc) criteria, surgical complications as per modified clavien-dindo classification and respiratory complications. a total of ( . %) patients had ssi, ( %) had surgical complications and ( %) patients had respiratory complications. the length of the stay in the hospital was longer for patients who had postoperative complications. despite complications, owing to excellent peri-operative care, ( %) patients were discharged alive. summary/conclusions: surgeries associated with massive transfusion are at an increased risk of ssi as well as morbidity and mortality. complications associated with rapid transfusions of blood, acute haemorrhage and associated risk of the surgery lead to a prolonged icu stay and increased length of stay in the hospital. a well-developed massive transfusion protocol optimizing the ratio and dose of the blood component therapy results in excellent patient outcome with minimal postoperative morbidity and mortality. background: despite the introduction of new oral anticoagulants (dabigatran, rivaroxaban, apixaban), vitamin k antagonists (vka), such as warfarin and acenocoumarol are still the most widely used oral anticoagulants for the treatment of non-valvular atrial fibrillation (nvaf). the use of vka must be regularly and often laboratory controlled in order to ensure the adequacy of therapy and to avoid subdosing or drug overdose. the most commonly used test for the control of oral anticoagulant therapy is the prothrombin time (pt), expressed in inr system, which provides an internationally standardized monitoring of the treatment. time in therapeutic range (ttr) represents a measure of the quality of the anticoagulant effect of vka and estimates a percentage of time a patient's inr is within the desired therapeutic. aims: the aim of this study was to evaluate of the effectiveness of vka therapy in patients with nvaf and to identify factors affecting the anticoagulation efficacy. methods: a retrospective study was conducted on a population of outpatients with nvaf, treated with vka and followed in blood transfusion institute of ni s from january to december . laboratory control of inr was done from capillary blood of patients on thrombotrack solo (axis shield, norway) and thrombostat (behnk elektronik, germany). targeted ae . %, but . % of patients had a ttr less than %. patients were at high risk of thrombosis in . % of time (inr < . ) and high risk of bleeding in . % of time (inr > . ). the most significant independent factors affecting the quality of vka therapy are gender, arterial hypertension, diabetes mellitus and the use of amiodarone and antiplatelet drugs (aspirin, clopidogrel). summary/conclusions: the ttr is undoubtedly useful indicator of the effectiveness of vka treatment. the most important predictors of poorer efficacy of vka therapy are arterial hypertension, diabetes mellitus, patients' gender and the use of amiodarone and antiplatelet (aspirin, clopidogrel) drugs. to improve the quality of vka therapy, education of patient and better collaboration with them, as well as a successful teamwork with clinicians are also imperative. background: an estimated . million deaths per year result from haemorrhagic blood loss. at a cellular level, haemorrhagic shock develops when oxygen delivery is insufficient to meet oxygen requirements to maintain aerobic metabolism. successful resuscitation prevents further oxygen debt and repays the prior oxygen debt. this includes the administration of fluids and blood components (e.g. plasma, red cells and platelets). measurement of oxygen delivery and utilisation at a tissue level requires invasive monitoring not possible clinically, meaning that surrogate markers such as lactate and venous oxygen saturation (svo ) are used instead. new technologies such as incident dark field imaging and near-infrared spectroscopy may offer a non-invasive alternative; however their utility in haemorrhagic shock remains background: transfusion-induced red cell alloimmunization is still a major challenge in transfusion practice. besides logistic problems for the transfusion laboratory, it may compromise available blood supply, and when undetected and unanticipated, it may risk haemolytic transfusion reactions. knowledge about risk factors can help to optimize preventive matching strategies. severe renal failure and subsequent renal replacement therapy influence the immune system and could therefore modulate the risk of alloantibody formation against foreign red cell antigens subsequent to transfusion. aims: this study aims to quantify the association between renal failure, according to its degree and its treatment with renal replacement modalities, and transfusioninduced red cell alloantibody formation. methods: we performed a multicenter case-control study within a source population of patients receiving their first and subsequent red cell transfusion between and in the netherlands (risk factors for alloimmunization after red cell transfusion, r-fact study). using a conditional multivariate logistic regression, we compared first-time transfusion-induced red cell alloantibody formers (n = ) with two similarly exposed non-alloimmunized control recipients (n = ) during a five-week alloimmunization risk period. degree of renal function was categorized as: 'no renal failure' i.e. glomerular filtration rate (gfr) > ml/min/ . m , 'moderate renal failure' i.e. gfr ≥ - ml/min/ . m during a continuous period of minimally seven days, 'severe renal failure' i.e. gfr < ml/min/ . m and/or use of any type of renal replacement therapy during at least one day of the alloimmunization risk period. odds ratios were interpreted and presented as relative risks (rr). adjusted rrs were conditioned on the matching variables and identified confounders. results: no renal failure was observed among ( . %) cases versus ( . %) controls; moderate renal failure among ( . %) cases versus ( . %) controls; and severe renal failure among ( . %) cases versus ( . %) controls. among the latter, cases and controls underwent renal replacement therapy. moderate renal failure and severe renal failure without renal replacement therapy were not significantly associated with red cell alloimmunization (adjusted rr . , % ci . - . and adjusted rr . , % ci . - . , respectively). however, patients undergoing renal replacement therapy had a two-fold lower alloimmunization risk (adjusted rr . , % ci . - . ) as compared to transfusion recipients without renal failure, unrelated to type and duration of renal replacement therapy. summary/conclusions: these findings suggest that patients undergoing renal replacement therapy have strongly diminished red cell alloimmunization risks. further research should confirm these results and elucidate the underlying pathophysiological protective mechanism. background: the ability of allogeneic hematopoietic stem cell transplantation(allo-hsct) to prevent relapse depends partly on donor natural killer (nk) cell alloreactivity. nk effector function depends on specific killer-cell immunoglobulin-like receptors (kir) and hla interactions. thus, it is important to identify optimal combinations of kir-hla genotypes in donors and recipients that could improve hematopoietic transplantation outcome. aims: to obtain the optimal combinations of inhibitory kir and its ligand between donor and recipient which is helpful for the guidance of selecting donors and recipients in hsct. methods: the pcr-sbt method was used for kir dl , kir dl /kir dl , kir dl , kir dl and hla-a, -b, -c, -drb , -dqb genotyping. pairs of hla / identical donor/recipients matching samples were retrospectively analyzed. three different models of kir were established. there were kir-kir gene model, kirligand model and haploid model. in kir-ligand model, patients were divided into three groups: c /c homozygote group ( cases), c /c heterozygote group ( cases) and c /c homozygote group ( cases). according to the expression of dl , cases were dl positive and cases were dl negative. there were cases of bw /bw , cases of bw /bw and cases of bw /bw in the dl positive samples. according to the expression of a /a , they were divided into three groups: a /a negative group ( cases), a /a heterozygous group ( cases) and a / a homozygote ( cases). according to kir genotyping, kir haploidentical group ( cases) and kir haploid mismatched group ( cases) were divided. the clinical data on neutrophil and platelet remodeling time, gvhd and os of cases were statistically analyzed by the mann-whitney test or the kruskal-wallis test using graph-pad software v . . results: there was no significant difference in the time of neutrophil and platelet remodeling, the incidence of agvhd and the survival time after transplantation in the kir genotype model. in haplotype model, there was no significant difference in neutrophil and platelet remodeling time and survival time after transplantation. the incidence of agvhd was low when the kir haploid mismatched and kir dl was positive. it was conducive to neutrophil and platelet remodeling when bw /bw and a /a was heterozygosity. summary/conclusions: it is important to establish the three different models of kir genotypes, haplotypes and receptor-ligand mismatches for analyzing the effect on the prognosis of allo-hsct. kir-ligand model plays an important role in hla unre-background: transfusion of platelet concentrates (pcs) has been associated with adverse outcomes including transfusion-related acute lung injury (trali). the underlying mechanism of trali has been related to the accumulation of immunomodulatory mediators (e.g. lipids, cytokines/chemokines) present in pcs. current room temperature storage limits the shelf-life of conventional pcs to - days. alternative storage conditions, including cryopreservation, offers extended storage and a solution for blood banking logistics. cryopreservation of human pcs has been associated with higher concentrations of immunomodulatory mediators compared to room temperature stored pcs and it has been suggested that cryopreserved pcs may be immunomodulatory. to investigate the effects of cryopreserved pcs, a transfusion sheep model would be a beneficial approach. aims: to characterize immunomodulatory mediators in supernatants of sheep conventional and cryopreserved pc and to investigate whether storage duration and cryopreservation impacts the accumulation of these mediators. methods: buffy coat pooled sheep pcs (n = ), prepared in % plasma/ % ssp+ with minor modifications to standard human procedures, were stored room temperature (rt) for days (d) and sampled on d , d and d . cryopreserved sheep pcs (n = ), prepared by the addition of - % dimethyl sulfoxide, were stored at À °c and sampled pre-freeze and post-thaw. supernatant was prepared at each time point with double centrifugation and stored at À °c. concentrations of pro-inflammatory cytokines (interleukin (il)- , il- b, il- a), anti-inflammatory cytokine il- and chemokines (il- , monokine induced by gamma interferon (mig) and interferongamma induced protein (ip)- ) were measured using sheep specific in-house and commercial enzyme linked immunoassays (elisa). levels of non-polar lipid mediators, such as arachidonic acid (aa), -hete and -hete were assessed in the stored sheep pc-and cryo-pc supernatant using commercial elisa. results shown as mean ae standard deviation. the effect of storage was determined at p < . using paired t-test. results: in rt stored sheep pc supernatant il- , il- b, il- a, il- , il- , mig, ip- , -hete and -hete were detected at d , d and d . storage duration significantly increased accumulation of ip- at d ( . ae . pg/ml compared to . ae . pg/ml, p = . ) and further increased at d , and il- at d ( ae . pg/ml compared to ae . pg/ml, p = . ). cryopreserved sheep pc supernatant pre-freeze and post-thaw contained equivalent or higher concentrations of il- , il- b, il- a, il- , il- , mig, ip- , -hete and -hete than rt stored d pcs. however, cryopreservation did not impact levels of any of the platelet derived mediators. summary/conclusions: several platelet-derived cytokines/chemokines, including high concentration of il- with neutrophil priming activity, and non-polar lipids were found in stored sheep pc supernatant. these immunomodulatory mediators may contribute to adverse outcomes associated with pc transfusion. storage at rt, but not cryopreservation was associated with increased accumulation of immunomodulatory mediators in sheep pcs. most importantly, similar to human pcs, sheep cryopreserved pcs contained at least if not higher concentrations of majority of cytokines as pcs stored at rt, therefore making sheep a suitable model in which to investigate immunomodulatory effects of cryopreserved pc transfusion. background: transfusion, despite being a lifesaving therapy, has been associated with adverse transfusion outcomes. transfusion related acute lung injury (trali) remains one of the leading causes of transfusion-related mortality. accumulation of immunomodulatory mediators (e.g. lipids, cytokines/chemokines) present in blood products, including packed red blood cells (prbcs), have been implicated with the development of non-antibody mediated trali. however, how specific mediators contribute to the underlying mechanism is yet to be defined. during routine storage of human prbcs fewer than cytokines/chemokines and several biologically active lipids have been identified. a sheep model of trali has successfully been developed using human prbc supernatant, however transfusing sheep prbc has not been investigated. to support the use of sheep prbc in the trali model and to better understand the precise mechanism, characterization of the potential mediators in sheep prbc is required. aims: to characterize immunomodulatory mediators in sheep prbc supernatants and to investigate whether storage duration impacts the accumulation of these mediators. methods: sheep prbcs (n = ), prepared according to standard human procedures with minor modifications, were stored ( - °c, days (d) ) and sampled at d and d . supernatant was prepared by double centrifugation and stored at À °c. concentrations of pro-inflammatory cytokines (interleukin (il)- , il- b, il- a), antiinflammatory cytokine il- and chemokines (il- , monokine induced by gamma interferon (mig) and interferon-gamma induced protein (ip)- ) were measured using sheep specific in-house and commercial enzyme linked immunoassays (elisa). levels of potential non-polar lipid mediators (arachidonic acid (aa), -hydroxyeicosatetraenoic acid (hete) and -hete) were assessed in the sheep prbc supernatant using commercial elisa. paired t-test was used to compare fresh and stored prbc supernatant (p < . ). results are mean ae standard deviation. results: at day , aa ( , ae , pg/ml), -hete ( . ae . pg/ml), -hete ( . ae . pg/ml) and il- b ( . ae . pg/ml) were detectable in sheep prbcs supernatant. at day , storage duration significantly increased concentrations of aa ( , ae , pg/ml, p = . ) and -hete ( . ae . pg/ml, p = . ) in sheep prbcs supernatant. summary/conclusions: similar to reported findings of human prbcs, the predominant type of immunomodulatory mediators present in sheep prbcs were non-polar lipids. the concentration of these non-polar lipids increased during storage. these immunomodulatory mediators may contribute greatly to adverse outcomes associated with prbc transfusions. further investigation is required to determine whether stored sheep prbcs supernatant induce immunomodulation in sheep in vitro and in vivo transfusion models. background: dshtr incidence is reported as in , transfusions, presenting days to months after the transfusion. the published data addressing the correlation between the strength of the antibodies detected after a dshtr has taken place and the corresponding clinical symptoms as measured by laboratory parameters that assess the presence of hemolysis is limited. aims: the aim of this study is to evaluate the correlation between the results of the dat, automated and manual antibody reactivity strength with the corresponding clinical parameters of hemoglobin, lactate dehydrogenase (ldh), bilirubin, and haptoglobin. methods: a dshtr is defined as discovering a new antibody within days of a transfusion. for all positive antibody screens, a work-up is initiated consisting of identification panels, dats, antigen typing of the red cells transfused, and eluates at the discretion of the transfusion medicine physician. additional laboratory testing for hemolysis is requested when indicated. a retrospective review was conducted of patients who were identified as having a dshtr. levels of hemoglobin, ldh, and transfusion safety background: rhd immunoglobulin (rhdig) has been available for years in australia. since its introduction for routine antenatal and postpartum prophylaxis, alloimmunisation has decreased from % to . %, reducing the number of australian deaths from haemolytic disease of the newborn over a hundred-fold, to approximately . deaths per . blood matters serious transfusion incident reporting (stir) system has been collecting transfusion incidents and adverse events across four australian jurisdictions since . since january , rhdig administration errors have been reported. aims: to understand incidents relating to the administration of rhdig and increase safety and awareness of risks. methods: health services registered with stir (n = ) were notified of the inclusion of reporting rhdig incidents. when an incident is identified, the reporter sends an online notification to stir, prompting the appropriate investigation form to be sent for completion. the completed incident data are reviewed and validated by an expert group. data is de-identified and collated for reporting. results: during the period january -december , reports were received; reports were validated, with reports excluded (reactions rather than administration errors). reports were categorised as below: background: following the nice transfusion guidelines, recommending offering iron before and after surgery to patients with iron-deficiency anaemia (ida), we worked collaboratively with the anaesthetic and pre-operative team to implement a clear and robust anaemia pathway for pre-operative haemoglobin (hb) optimisation. oral iron was started, where appropriate, and our anaemia pro-forma was sent for review in a virtual clinic to assess eligibility for intravenous iron. we performed a retrospective evaluation of the patients who received iv iron during the anaemia pathway. aims: the aim of this retrospective evaluation was to look at the cohort of patients who had received iv iron in and assess the effect of iv iron on haemoglobin levels for different defined groups. methods: we classified patients, as described in munting and klein, , depending on their iron parameters as having either: -idaserum ferritin < mg/l -chronic inflammation with idaserum ferritin - mg/l with transferrin % of < %/crp > mg/l -anaemia of chronic inflammationserum ferritin > with transferrin % of < %/crp > mg/l patients were considered eligible for iv iron if the following criteria were met: . an inadequate response to oral iron, or were unable to tolerate oral iron or the interval between diagnosis and surgery was short . the anaemia pro-forma was completed . hb was ≤ g/l . they were classified as either having ida or chronic inflammation with ida or anaemia of chronic inflammation hb was measured prior and on average, days following the iv iron infusion. we excluded patients who had their post iv iron follow up blood tests done after surgery. results: this retrospective evaluation included patients. patients were classified as having ida and patients classified as having chronic inflammation with ida. those classified with ida had a mean hb of g/l ( - ), a mean mcv of . fl and a mean serum ferritin of lg/l. those with chronic inflammation with ida had a mean hb of g/l ( - ), a mean mcv of . and a mean serum ferritin of lg/l. follow-up hb was measured on average twenty days post iv iron infusion in both groups. the average hb post iv iron infusion in the ida group was g/l ( - ) with an average increment of g/l and in the group with chronic inflammation with ida the average post iv iron hb was g/l ( - ) with an average increment of g/l. summary/conclusions: in conclusion the group with ida had, on average, a lower starting hb that the group with chronic inflammation with ida and the average increment in hb days post iv iron infusion was greater in the group with ida. however, the group with chronic inflammation with ida cases also responded to iv iron and therefore we strongly consider the use of iv iron in both groups. further studies to evaluate the ongoing effect of iv iron would help assess whether the same level of increment seen with ida can also been seen for the group with chronic inflammation with ida over a longer period and how long the increment was sustained. background: the expansion of personalized genomic medicine has led to the development of targeted therapeutic approaches for patients. one example is sipuleucel-t, an autologous cellular immunotherapy product used to treat prostate cancer manufactured from the patient's white blood cells. this study describes our experience with incorporating autologous cellular immunotherapy products into the workflow of the blood bank. the policies supporting the workflow are outlined and compliance with them is assessed. aims: this study aims to evaluate the process and method used to dispense and track the infusion of sipuleucel-t. methods: this is a retrospective analysis of the dispensation and administration of sipuleucel-t from january -august , which was handled exclusively by the blood bank. standard operating procedures and hospital policies were reviewed and compliance with these policies evaluated. included were patients who had the sipuleucel-t product dispensed and administered. information collected included the total number of products dispensed, patient age, adverse reactions/incidents, premedication, and patient outcome. descriptive statistics were used for data analysis. results: there were products dispensed to patients. the recipients were male patients diagnosed with prostate cancer with a mean age of years. there were doses (a complete course) administered to / ( %) recipients and a partial course ( - doses) administered to / ( %) recipients, for a total of products. the blood bank workflow treated sipuleucel-t as a derivative in the computer system, listing the manufacturer (dendreon corporation) as the supplier. health care providers were instructed to follow the nursing policy for the administration of blood products and derivatives for the infusion of sipuleucel-t. this policy required documentation of the infusion in a transfusion nursing note and reporting adverse events to the blood bank as transfusion reactions. there were no adverse events reported to the blood bank, yet there were adverse events described in provider notes; of them necessitating transfer to the emergency department, and requiring hospital admission. of the infusions, infusions were documented in a chemotherapy note rather than a transfusion note ( %), and ( %) were documented as both a transfusion and a chemotherapy administration. there were additional deviations from the blood product administration policy: cases where the consent check was not performed, case where the product was infused with ringer's lactate rather than normal saline, and cases where the -person -way check erroneously indicated the product was irradiated. summary/conclusions: this study describes one approach to managing cellular therapy products as an extension to existing blood products dispensed by a blood bank. the findings demonstrate noncompliance with hospital policy with this new product as evidenced by failure to report adverse events and failure to follow hospital practices regarding administration. although sipuleucel-t is a product manufactured from an autologous blood product donation, the administration and perceptions of this product may be more similar to a pharmaceutical. as the field of immunotherapies derived from blood product donations continues to expand, these products may necessitate an entirely new approach to ensure proper management. abstract withdrawn. (ref ) . while the mnc procedure is fully automated, cmnc requires frequent interface checks to ensure the collection of the correct cell layer. at the rambam health care campus, a tertiary care center, solely the mnc procedure had been employed till , at which point, the cmnc has been introduced for the use in patients with a white blood cell (wbc) count of ≥ , /ll on the collection day. aims: the current study aimed to compare various parameters of peripheral blood stem cell (pbsc) collection, using the cmnc protocol in allogeneic donors and patients undergoing autologous stem cell (autosc) transplantation. additionally, data on autosc collection using mnc (n = ) and cmnc (n = ) procedures were compared. methods: data were retrospectively obtained from pbsc collection reports in consecutive cmnc procedures, including autologous and allogeneic donors. the following comparisons were made: cmnc results of allogeneic versus autologous donors, a sub-analysis of cmnc results for autologous donors with a pb cd + count ≥ /ll versus allogeneic donors as well as mnc versus cmnc results in autologous donors. the collection efficiency- (ce- ) was defined as the total cd + amount in the collection bag divided by the amount of cd + cells in the pb processed by the collection apparatus. results: in the cmnc, the following parameters significantly differed between autologous and allogeneic donors: mean collection time ( ae and ae min, respectively; p = . ), the total blood volume processed ( . ae . and . ae . , respectively; p = . ) and the final volume in the collection bag ( ae and ae ml; p = . ). the mean ce- in autologous versus allogeneic donors was ae and ae , respectively (p = . ). using cmnc, the collection was effective in % of allogeneic and % of autologous donors. in autologous donors, a significantly lower collection bag volume ( ae and ae , respectively; p < . ) and increased total wbc in the collection bag ( ae versus ae , respectively; p < . ) were obtained using cmnc compared to mnc protocol. thirteen patients were treated with plerixafor due to a low pb cd + count following g-csf therapy; of them achieved a cd count ≥ and their collection was considered effective. summary/conclusions: the cmnc protocol is highly effective in terms of the cell yield in both allogeneic and autologous donors with a pb cd + count ≥ /ll. significantly superior collection results are obtained in allogeneic donors versus autologous ones. cmnc provides a significantly higher wbc and a lower final collection volume than mnc. similar total cd + cell counts are obtained with both methods. . tbv processed ranged from - . tbv with mean of . , average was . tbv for females and . tbv for males mean pre-apheresis cd + count was . cells/ll (range . - . ). mean postapheresis cd + count was . cells/ll ( . - . ). mean cd + cells x / kg recipients body weight was . (range: . - . ). our target yield was ≥ cd + cells/kg body weight of the recipient and in only / ( %) cases, the yield was < . / ( . %) procedures were lvl and / ( . %) were svl. summary/conclusions: most of our pbsc were done for haematological indications ( . %) and the target dose was cells/ll in single leukapheresis. in cases ( %), target yield was achieved, only cases had < but > yield. in our study donors < years have shown to mobilize better than the older children. hematocrit (hct) and weight showed correlation with cd + cell yield but they cannot be taken absolute predictors. wbc count cannot be taken as a predictor for cd yield as high wbc count did not convert into high cd yield or vice versa. high prepheresis cd + count gave higher postpheresis cd + count. large volume leukapheresis (lvl), > tbv gave higher yield as compared to standard volume leukapheresis (svl). blood volume processed related to prepheresis cd + count and/or the weight difference between the donor and recipient. other parameters like hematocrit, wbc count, age etc did not show correlation to the volume processed. in our study, younger age and prepheresis cd + count were found as the most relevant predictors for stem cell yield. background: allogeneic hematopoietic stem cell transplantation is an established therapy for many hematologic disorders. since the discoveries of the potential of peripheral blood stem cells (pbsc) in the hematopoietic reconstitution mid s and early s pbsc gradually replaced bone marrow as the preferred source of stem cells. the introduction of hematopoietic cytokines that can mobilize large number of progenitors into circulation accelerated pbsc usage. aims: the aim of our study is to present our year experience with apheresis collecting of pbsc in donors. methods: this is a retrospective study performed in the institute for transfusion medicine of republic of macedonia and university hematology hospital for period background: obtaining unambiguous results of hla typing plays an important role in the transplantation of hematopoietic stem cells. appropriate selection of alleles in the level of hla between recipients and unrelated bone marrow donors reduces the risk of transplant rejection and graft-versus-host disease. new generation technology ensures the highest possible resolution and obtaining unambiguous genotyping results due to the high complexity of the hla system. currently, this is the selection method for obtaining hla test results at the high resolution level. aims: the aim of this study was to determine hla loci (hla-a, -b, -c, drb / / / , dqb , dpb , dpa , dqa ) in potential bone marrow donors from poland. the research included , potential bone marrow donors registered between and . a novelty of this paper was that the amplification of all hla loci was performed by using multiplex pcr primers in a single tube. that solution completely eliminated the need to pool amplicons. methods: the typing of the hla loci (hla-a, -b, -c, drb / / / , dqb , dpb , dpa , dqa ) of potential bone marrow donors was made by using the alltype tm ngs -loci amplification kit (one lambda). genomic dna was isolated from peripheral blood of , donors. hla genotypes were determined according to the manufacturer's protocol on the miseq illumina platform. the obtained sequencing data was evaluated by using the typestream tm visual ngs analysis software. results: the ngs method allowed to obtaining unambiguous results of genotyping of potential bone marrow donors, and also provided the identification of rare alleles, such as: c* : , c* : , c* : , c* : , drb * : , c* : , b* : , c* : , dqb * : , drb * : , drb * : . summary/conclusions: . new generation sequencing technology (ngs), which is based on pcr, ensures the highest possible resolution. . the ngs method allows to obtain more accurate sequencing results compared to the conventional methods. . the research has confirmed the superiority of the ngs method over conventional methods in obtaining unambiguous hla genotyping results at the high resolution level. background: the accurate results of hla typing are significant for ensuring the success rate of hematopoietic stem cell transplantation. currently, hla typing is mainly based on sanger sequencing, which has a high proportion of ambiguous combination results indicating potential errors for hla typing. it is necessary for finding a more accurate typing method to reduce the risk. next-generation sequencing (ngs) method could provide clonal sequencing of single molecules, which has been used for hla genotyping and improved the scope and precision of hla study. aims: to establish a full-length precision sequencing platform for hla-i gene (hla-a, -b, -c) based on ngs technology and be evaluated by classical sangersequencing method, which can effectively improve the accuracy of hla typing for donor and recipient in hematopoietic stem cell transplantation. methods: hla-i (hla-a, -b, -c) gene-specific primers were screened, and the amplification parameters were optimized to obtain full-length sequences of hla-i gene under the same condition. the sample library for the amplicon was prepared with transngs tn dna library prep kit and the sequencing step was carried out with illumina miseq platform according to the manufacturer' protocol. all the sequencing data in fastq format were analyzed by typestream visual software version . . (one lambda inc.)with the default setting. cord blood samples were collected for hla typing with the mentioned above next-generation sequencing method in our study. in parallel, all the sample were also tested with the sanger sequencing method according to the previous study in our laboratory. results: samples were successfully tested with two methods and the coincidence rate between two sequencing methods was %. with the next-generation sequencing method, the probability of ambiguous results among samples in our study is . %( / ) for hla-a, . % ( / ) for hla-b and % ( / )for hla-c. however, the probability of ambiguous results with the sanger sequencing method is . % for hla-a, . % for hla-b, % for hla-c. summary/conclusions: the full-length precision sequencing platform for hla-i gene (hla-a, -b, -c) based on ngs technology was established, which could greatly reduce the probability of ambiguous results and effectively improve the accuracy of existing hla typing techniques. key: cord- -t x gknd authors: nan title: abstract presentations from the aabb annual meeting san diego, ca ctober ‐ , date: - - journal: transfusion doi: . /trf. sha: doc_id: cord_uid: t x gknd nan background/case studies: zika virus (zikv) is associated with severe neurological consequences in fetuses and adults and potential for transfusion transmission (tt). rna persistence has been reported in whole blood (wb) long after clearance of viremia in plasma, raising concerns over the risk of tt with plasma based nucleic-acid amplification testing (nat). the dynamics of zikv persistence in asymptomatic infection are not well understood and are needed for understanding of the natural history of zikv infection. we sought to characterize the dynamics of infection through prospective enrollment of zikv rna blood donors. study design/method: donors identified through investigational zikv nat screening were enrolled into longitudinal follow up and assessed for viral and serological persistence and clinical outcomes. plasma and rbc were obtained from index donations and blood, urine, saliva and semen samples were collected prospectively at weeks , , , and following index donations from donors and detailed symptom questionnaires were administered at each study visit. blood compartments and body fluids were tested for zika rna by real time rt-pcr. plasma samples were tested for zika specific igm and igg antibodies results/finding: the percent of zikv rna samples, followed by the number of samples tested in parenthesis, for each sample type during each sampling interval is summarized in the table. plasma viremia declined rapidly after index donations whereas rbc-and wb-associated viral rna persisted for up to months and peripheral blood mononuclear cell (pbmc) associated virus was detected intermittently at low levels and waning by months. urine and saliva detection decreased significantly after weeks and was undetectable by months. of donors who were enrolled in the acute pre-seroconversion stage of infection % ( / ) developed multiple zikv related symptoms week post index donation, compared to only % ( / ) for donors detected post-seroconversion. conclusion: zikv rna persists in cellular blood compartments for several months following clearance from plasma and body fluids, with higher rates of symptoms than previously reported. the persistence of zika rna in rbcs has unknown implications for blood screening, which currently relies on plasma testing; infectivity studies are in progress. wb testing may be of value to extend detection of acute infection and for diagnostics and monitoring of pregnant women. iron status and novel risk factors for iron depletion in a diverse donor population bryan r. spencer* , yuelong guo , ritchard g. cable , joseph e. kiss , michael paul busch , grier page , stacy endres-dighe , steve kleinman , simone glynn , alan mast and for the nhlbi recipient epidemiology and donor evaluation study-iii (reds-iii) . american red cross, rti international, american red cross blood services, blood systems inc., blood systems research institute, university of british columbia, nih/ nhlbi, blood research institute, nhlbi background/case studies: blood centers and regulators in the united states (us) are evaluating strategies for minimizing iron depletion in blood donors. the logistics of donor management might differ across blood centers, but the optimal approach may also vary according to biological or behavioral differences across sub-populations of donors. studies donors have been conducted in predominantly caucasian populations, which may differ from racial/ethnic minority donors in iron metabolism and capacity to undergo repeat phlebotomy. study design/method: over , donors were enrolled from us blood centers for ferritin testing. the study population was enriched for racial minorities [ african-american (aa), asian (as), hispanic (hisp)] and for "super donors" ( , who had completed donations in two years without low hemoglobin deferral). the minority donors and the remaining non-hispanic white (nhw) donors were an unselected population with no specific eligibility criteria. subjects completed questionnaires on risk factors for iron depletion. logistic regression was used to identify demographic and behavioral predictors of absent iron stores (ais, ferritin < ng/ml) and low ferritin (lf, ferritin < ng/ml). results/findings: across all subjects, % had ais and % had lf, with a high degree of variability based on demographic factors and donation behavior. in models stratified by race, expected patterns common to all groups included a sharp increase in risk with increasing donation intensity, and a large decrement in risk for females > years old. in models including all subjects, race was an independent predictor of both ais and lf controlling for age, sex, body weight, donation frequency, and other factors (table) . aa and as donors showed % % decreased risk for ais compared to nhw, while hisp donors had % higher risk. daily use of exogenous iron reduced risk for lf and ais by to %, respectively, while the estimated benefit from less-than-daily use was lower ( to % protection). regular use of antacids was associated with a % or greater increment to risk. reported use of hormone supplements showed opposing effects in males and females. use of oral contraceptives or estrogen in females reduced risk by % - %, while males who reported current use of supplemental testosterone had twice the estimated risk for ais. conclusion: this large study confirms the high prevalence of lf and ais in us donors and the principal risk factors of age, sex, and donation frequency. the diverse population studied and the questionnaire data from donors identify additional demographic and behavioral risk factors of secondary importance. in developing iron mitigation strategies, practices based on age and gender could be further refined depending on a given blood center's operational context and donor population. data are reported as mean ( sd) *p < . compared to batf / , ul hod rbcs mfi, median fluorescence intensity background/case studies: during storage, red blood cells (rbcs) undergo multiple morphological, biochemical and molecular modifications, collectively called the storage lesion. the proportion of cleared rbcs is correlated with storage duration, which may be responsible for the rapid clearance of up to % of transfused rbcs, reducing transfusion yield. it has been shown, using imaging flow cytometry that a subpopulation of morphologically altered rbcs accumulates during storage. the reduced surface area of these small rbcs (srbcs) suggests their rapid elimination by the spleen in the hours following transfusion. this hypothesis remains to be clarified, since the physiological mechanisms of rbc clearance remain to be precisely identified. study design/method: murine "young" and "old" rbcs (respectively on d and d of storage) were transfused into different models including splenectomized or macrophage-depleted mice. flow cytometry was used to determine the kinetics of clearance, the transfusion yield and to quantify rbcs retention in organs. the accumulation, during storage, and the posttransfusion disappearance of srbcs were analyzed by imaging flow cytometry. results/finding: using a murine model of transfusion, we confirmed that the post-transfusion yield decreases with storage duration ( % on d vs % on d of storage). a clearance of the storage-damaged rbcs mediated by spleen and macrophages is shown by significant improvements in post-transfusion yield observed in the splenectomized ( %) and macrophage-depleted ( %) groups. as in humans, we observed the accumulation of a subpopulation of small rbcs (mouse small rbc: msrbc) of reduced projected surface area with altered morphology. these msrbcs disappear rapidly from the circulation in control or splenectomized mice with a decrease of more than % at h post-transfusion. in contrast, in macrophage-depleted mice, msrbcs are kept in circulation at h posttransfusion. at h, these msrbcs completely disappear in all models, suggesting the importance of their elimination and the presence of compensation clearance mechanisms. in control mice, storage-damaged rbcs are mostly retained in the spleen but also in the bone marrow (bm) . no retention is observed in the liver, kidney or lung. in macrophage-depleted mice, retention is decreased in the spleen and bm. conversely, elevated retention is observed in the bm of splenectomized mice, associated with a transient retention in the kidney and liver. conclusion: during storage of murine rbcs, damaged rbcs accumulate, and are eliminated following transfusion via spleen/macrophage-mediated mechanisms. they include, as observed in humans, a subpopulation of small rbcs which undergoes a rapid macrophage-mediated clearance. the increase in transfusion yield in the absence of spleen or macrophages suggests that the recipient's functional state is one of its determining factors. age dependent relapsing and remitting autoimmune hemolytic anemia in a murine model andrea sut ling wong* , amanda l richards and krystalyn e hudson . background/case studies: breakdown of tolerance to rbc antigens may result in development of pathogenic autoantibodies (autoab) and lead to autoimmune hemolytic anemia (aiha), a severe and sometimes fatal disease. aiha in humans has a number of known features, including increased frequency with age, and tendency to relapse and remit. however, the mechanisms behind such observations are not understood. to gain insight into tolerance (or loss thereof) to an rbc autoantigen, we utilized the hod mouse, which expresses an rbc-specific triple fusion protein consisting of hen egg lysosyme (hel), ovalbumin (ova), and, duffy (hod). hod mice were bred to a transgenic mouse that expresses a t cell receptor specific for an ova peptide in hod presented by mhcii (otii mice). thus, hod otii mice are predisposed to have autoreactive cd t cells. study design/method: four cohorts of hodxotii f mice ( - mice/ cohort) were bled monthly for months to assess for autoab production. peripheral rbcs were stained with anti-complement (c ) and mouse immunoglobulin ab. spleens were weighed and splenocytes were stained with anti-cd and ter to assess for the presence of rbc progenitors. statistical analysis between hod otii autoab vs. hod otii autoabvs. hod -otii was performed using kruskal-wallis test and corrected for multiple testing with dunn's test. results/finding: otii cd t cells were not deleted in the thymus of hod otii mice; rather, they matured to the periphery. despite these peripheral autoreactive t cells, no detectable autoab were observed in hod otii . however, as they aged, - % of hod otii were positive for rbc autoab by months. thereafter, $ % of the autoab mice stopped producing autoab within two months after onset and remained autoab free throughout the study. in of the cohorts, - % of autoab mice were female. hod otii autoab mice also had enlarged spleens compared to hod otii autoaband hod -otii mice ( . g vs. . g and . g, resp., p< . ). this may due to rbc consumption, extramedullary erythropoiesis, or both. consistent with increased erythropoiesis, elevated numbers of rbc progenitors (cd hi ter inter ) were observed in the spleens of hod otii autoab mice but not in hod otii autoaband hod -otii ( . % vs. . % and . % resp., p< . ). moreover, autoab and c deposition were found ( . - % and - %, resp.) on ter rbcs in all of the hod otii autoab mice analyzed. conclusion: several features known to exist in human aiha were observed, including age-dependant autoab production, relapsing of autoimmunity after onset, and an increased frequency in females. this model may serve as an experimental system to investigate the mechanisms of aiha. b -a a reduction in neutrophil numbers is a risk factor for rbc alloimmunization amanda l richards , christopher a tormey and krystalyn e hudson* . background/case studies: red blood cell (rbc) alloimmunization occurs in up to % of transfusion recipients (excluding abo and rhd). the underlying factors that influence alloimmunization are poorly understood; thus, there is currently no reliable way to predict who will make an alloantibody and who will not. patients who receive multiple rbc units or several separate transfusions are at higher risk of alloimmunization; likewise, certain disease states have higher rates of alloimmunization, such as myelodysplasctic syndrome (mds) and sickle cell disease patients. however, despite chronic transfusions, some patients never develop rbc alloantibodies. it has been recently reported that poly (i:c)-elicited inflammation leads to enhanced alloimmunization rates and is correlated with increased splenic neutrophil (pmn) numbers. additionally, rbc transfusion into an inflamed recipient leads to enhanced erythrophagocytosis by pmns. here, we test the hypothesis that pmns regulate rbc alloantibody generation. study design/method: mice: c bl/ (b ) mice were treated with pbs, or anti-ly g to deplete pmns, followed by poly (i:c) to elicit inflammation, and finally a transfusion of allogeneic dio-labeled rbcs expressing a synthetic antigen, hod (hel-ova-duffy). multiple splenic cellular subsets were evaluated for dio fluorescence, an indirect measure of rbc consumption, at - hours post-transfusion. anti-hod alloantibody generation was assessed days post-transfusion by flow cytometry. humans:retrospectively, mean white blood cell (wbc) and pmn counts were collected on chronically transfused mds patients at va connecticut healthcare. for alloimmunized patients (n ), wbc and pmn counts were assessed on the day of exposure to the alloimmunizing rbc unit, whereas counts were averaged for the entirety of rbc therapy for non-alloimmunized patients (n ). patients were matched for numbers of rbc transfusions. results/finding: mice: the mfi of anti-hod antibodies was significantly increased in pmn-depleted mice, compared to controls ( / experiments, p< . ). while many control mice made no alloantibody (non-responders), all pmn-depleted mice made detectable anti-hod. pmn depletion also led to a significant reduction in dio leukocytes, suggesting a lack of compensatory mechanism(s) for rbc consumption. absence of pmns also shifted rbc consumption from macrophages to immune-stimulating dendritic cell subsets. flow cytometric analysis revealed that pmns with internalized rbcs upregulated expression of co-inhibitory molecules (e.g. pd-l ), compared to pmns (without internalized rbcs) from the same mouse; thus, pmns may regulate alloimmunization through antigen presentation and/or inhibitory signals. humans:. alloimmunized mds patients had a significant decrease in pmns, compared to non-alloimmunized (p< . ); no significant differences were detected in mean wbc counts between the two arms. conclusion: these data demonstrate that in both murine and human settings, pmns may play a significant role in regulating rbc alloimmunization and may provide key insights into predicting which patients will become alloimmunized. b -a b cxcr pd and ccr expressions characterize responders to rbc immunization benoît vingert* , , , marie tamagne , , , sadaf pakdaman , , , anoosha habibi , , , philippe bierling , , , , , rachid djoudi and france pirenne , , , . efs ile de france, laboratory of excellence gr-ex, imrb u -eq , ap-hp, universit e paris est background/case studies: post-transfusion alloimmunization can induce life-threatening hemolytic transfusion reaction. in human, mechanisms responsible of rbc alloimmunization are not fully defined. cd t cells are major for antibodies production. we have already shown in responder patients that the majority of anti-rbc cd t cells have a th profile. in contrast, in whole blood of non-responder patients, there is an unexpected expression of circulating cd t cells with a cxcr pd phenotype. this phenotype is usually associated with the presence of tfh cells, specialized in the production of antibodies. it has been suggested that some of the activated circulating tfh could have a cxcr pd hi profile, with a differentiated expression of ccr . ccr is essential for t cells domiciliation in lymph nodes where the encounter t and b cells is major for b cell differentiation and antibody production. others chemokines receptor like ccr and cxcr can also differentiate circulating tfh subpopulations. in this study, we were interested in the phenotype and function of these cxcr pd lymphocytes which were paradoxically highly represented in non-responder patients. study design/method: the membrane and functional phenotype of the circulating cxcr pd cells were compared in groups of transfused sickle cell patients : alloimmunized (n ) and non-alloimmunized patients (n ). the analysis was also performed in non-transfused healthy controls (n ). all assays were performed on whole blood without separation procedures that are known to alter the expression of chemokine receptors results/finding: the cxcr pd hi subpopulation expression was identical between transfused groups and controls. ccr and cxcr expressions show no difference between the transfused groups or the controls. however, in non-responder patients, ccr expression was very strong independently of the expression of pd . in the aim to determine the help of the circulating cxcr pd cells in the production of antibodies, these cells were purified by flow cytometry and co-cultured for days with b cells, and in the presence of seb protein. the levels of antibodies after seb stimulation were identical with the cxcr pd subpopulations from transfused groups or controls. conclusion: the paradoxical presence of circulating cxcr pd cells in non-responder transfused patients do not appear to have any particular functions that can promote the absence of a humoral response. however, in responder patients, the high expression of ccr on circulating cxcr pd cells suggests remarkable migratory properties towards secondary lymphoid organs, and could facilitate allo-immune responses. in conclusion, the study of the cxcr pd profile and the ccr expression in these cells could help to differentiate responder and non-responder patients to rbc immunization. primed cd t cells to one rbc alloantigen can enhance subsequent alloimmunization seema r patel* , ashley bennett , kathryn girard-pierce , connie arthur , amanda mener , patty zerra , christopher a tormey , jeanne hendrickson and sean stowell . emory university, yale-new haven hospital, yale university, emory university school of medicine background/case studies: while red blood cell (rbc) alloantibodies can increase the probability of transfusion-related complications, not all patients become alloimmunized following transfusion. however, individuals that do generate alloantibodies appear to experience an increased rate of additional alloantibody formation following subsequent transfusion. however, how immunity to one rbc alloantigen primes immunization to a completely distinct alloantigen remains unknown. though cd t cell help classically occurs through direct recognition of a peptide that resides within a target b cell antigen, individuals who develop antibodies toward one rbc alloantigen experience increased rates of antibody formation against completely distinct rbc alloantigens. these observations suggest that cd t cells that respond to one alloantigen may directly facilitate immunity to a completely distinct rbc alloantigen. study design/method: b recipients were transfused with kel rbcs in the presence or absence of poly i:c (pic), followed by transfusion of hod rbcs, kel rbcs, rbcs expressing hod and kel (hod x kel), or a mixture of hod and kel rbcs (hod kel). to examine the role of cd t cells, pic/kel primed b recipients were cd t cell depleted prior to transfusion. in addition, b recipients were adoptively transferred with cd t cells from na€ ıve or pic/kel primed donors, followed by transfusion of hod rbcs or (hod x kel) rbcs. anti-hod and anti-kel alloantibody formation was evaluated using indirect immunofluorescence staining. results/findings: kel rbc transfusion in the presence of pic (pic/kel) not only enhanced anti-kel antibody production through a cd t celldependent process, but this same priming event directly facilitated anti-hod antibody formation following subsequent (hod x kel) rbc transfusion (p < . ); pic/kel primed recipients transfused with (hod kel) rbcs or hod rbcs alone failed to impact anti-hod antibody formation. the ability of immunity to kel to boost a humoral response to the hod antigen following (hod x kel) rbc transfusion required kel priming in the presence of pic. cd t cell depletion prevented pic/kel primed recipients from boosting an anti-hod antibody response (p < . ) and transfer of cd t cells from pic/kel primed recipients likewise directly facilitated anti-hod antibody formation following a (hod x kel) rbc transfusion (p < . ). conclusion: these results demonstrate that cd t cells primed to one rbc alloantigen can directly enhance the immune response to a completely distinct rbc alloantigen, suggesting a mechanism whereby alloantibody responders may exhibit an increased rate of additional alloantibody background/case studies: platelet refractoriness remains a significant clinical problem, yet the mechanisms by which it occurs are incompletely understood. immune-mediated platelet clearance by anti-platelet alloantibodies plays a significant role, and patients with detectable alloantibodies can be managed with transfusion of hla-matched platelets. still, many patients are refractory even after receiving hla-matched platelets. it was shown previously that cd t cells can play a direct role in platelet clearance, as allogeneic platelets are cleared within hours post transfusion in b celldeficient mmt recipient mice (ie in the absence of anti-platelet alloantibodies) and depletion of cd t cells prevents such clearance. since minor antigenic differences still exist between donor hla-matched platelets and a recipient, we hypothesized that minor antigens alone may mediate clearance of otherwise hla-matched platelets. study design/method: to test whether minor antigens can stimulate cd t cell-dependent platelet clearance we examined platelet refractoriness using mova and oti transgenic mice. leukoreduced donor platelets from mova mice, which express a membrane-bound form of chicken ovalbumin and thus present ovalbumin peptides complexed with murine mhc class i h kb, were labelled in vivowith the fluorescent dye cfse and transfused into wildtype (wt, c bl/ ) mice or oti mice, whose cd t cell receptors recognize a specific ovalbumin peptide in the context of mhc class i h kb. in some experiments oti mice were primed with mova or wt splenocytes one week prior to mova platelet transfusion, and in others wt mice were adoptively transferred with oti splenocytes hours before mova platelet transfusion. platelet recovery was measured immediately after transfusion as well as after , , , , and hours and on days - . results/finding: transfusion of mova platelets into oti mice results in significant platelet clearance as compared to transfusion with wt platelets. clearance kinetics demonstrate platelet loss starting after hours and peaking at hours, and are similar whether oti mice are na€ ıve or previously primed with mova splenocytes. specifically, mova platelet recovery in oti recipients is - % versus > % in wt recipients at hours (p< . ), whereas transfusion of wt platelets into either oti or wt recipients is approximately % at hours after transfusion. adoptive transfer of oti cd t cells into wt mice recapitulates the effect, with significant mova platelet clearance at hours compared to wt platelet clearance (p< . ). conclusion: this work extends the ability of cd t cells to mediate platelet clearance to a minor antigen, providing insight into the potential etiology of platelet refractoriness in patients receiving hla-matched products. this study also holds implications for the clinical management of any nonantibody-mediated platelet refractory patient, as therapies directed toward immunomodulation of t cell responses may prove beneficial. background/case studies: alloimmunization against major histocompatibility (mhc) antigens is a common complication of transfusion, and can negatively impact subsequent transfusions and transplants. we have previously demonstrated that pathogen reduction with riboflavin and uv light (uv r) is effective both at rapidly killing donor white blood cells (wbcs) and at blocking their ability to stimulate an allogeneic response in vitro. furthermore, uv r treatment of allogeneic platelet rich plasma (prp) prevents alloimmunization in mice, and provides partial antigen-specific tolerance to subsequent transfusions. as cells that die through different pathways can be either tolerizing or inflammatory, we sought to determine which cell death pathways are triggered by uv r, as well as evaluate the immunogenicity of prp containing wbcs killed by other methods. study design/method: wbc-rich prp was prepared from c bl/ mouse blood and treated with uv r, and wbcs prepared in parallel from the same blood were treated with known inducers of either apoptosis or necrosis. membrane integrity, phosphatidylserine exposure, caspase activity, and chromatin condensation were evaluated by flow cytometry. balb/c recipients were transfused with either uv r treated wbc-rich prp, or uv r treated wbc-poor prp either alone or with added untreated, apoptotic, or necrotic wbcs, all generated from allogeneic c bl/ donor blood. a second transfusion of untreated wbc-rich c bl/ prp was given weeks later, and alloresponses were compared against mice given no transfusion or only the second untreated transfusion. results/finding: uv r treated wbcs have a pattern of phosphatidylserine exposure and loss of membrane integrity consistent with early apoptosis, but fail to demonstrate significant caspase activity or clear chromatin condensation. alloantibody responses to transfusion were significantly higher in mice previously exposed to untreated (p< . ) or necrotic (p< . ) wbcs, but not those given uv r treated or apoptotic wbcs. ex vivo cytokine responses to stimulation with c bl/ wbcs were reduced in recipients of either uv r or apoptotic wbcs, and enhanced in recipients of untreated or necrotic wbcs. conclusion: the mechanism of wbc death following uv r treatment shares some membrane characteristics of early apoptosis, but is distinct from classic apoptosis. however, both uv r treated and apoptotic wbcs fail to trigger an alloresponse, and offer some protection against subsequent alloexposures. background/case studies: in mitochondria-less red blood cells (rbcs), oxygen is the main substrate for oxidative reactions and resulting oxidative damage is considered as one of the major causative factors in the development of rbc storage lesion. oxygen saturation (so ) of venous blood is generally assumed to be around - % as measured from a central venous line. however, a recent investigation of so levels in freshly prepared leukocyte-reduced red cell concentrates (lr-rccs) revealed unexpectedly wide so distribution (mean . % . % [yoshida et al. ; blood transfusion , ] . the present study was undertaken to determine the distribution of so in lr-rcc produced at a medium-size blood center using a novel non-invasive so probe. additionally, quantitative metabolomics were carried out to examine the redox status of the stored rbc under various so levels. study design/method: the so from units of lr-rcc were examined on five consecutive days representing % of the collected units during the period at a regional blood center where all the units were processed at room temperature within hours of blood collection. so was measured noninvasively through the pvc bag immediately prior to refrigeration by employing a resonance raman spectrometry (pendar microvascular oximeter a u ; pendar technologies, cambridge ma). in addition to so , process methods, rcc volumes, blood types, gender and process times were recorded for analyses. in a separate study, lr-rcc (n ) from human volunteers were stored in as- under normoxic, hyperoxic, or hypoxic conditions for up to days (so ranging from < to > %) prior to uhplc-ms metabolomics analyses in presence of c, n or deuterated internal stable-isotope labeled standards for absolute quantitation. results/finding: measurements of so carried out non-invasively at a blood center yielded a similar wide distribution as previous study from units of lr-rcc procured and sampled invasively within hours after blood collection [yoshida ibid]. the shape of the so distribution appeared near normal with the mean of . % . %, median . %, range < % to > % and inter-quartile range (iqr) of . %- . %. male donors showed higher so compared to female donors (p< . ). no correlations were observed between so levels and processing time, donor age or blood types. metabolomics workflow indicated that lower so levels ameliorate the energy and oxidative metabolic lesion. lower so levels yielded higher rate of gsh synthesis, higher nadph concentration, higher gsh / gssg and nadph/nadp ratios, lower supernatant urate consumption and lower purine oxidation. the surprisingly wide distribution of starting %so levels was observed from lr-rcc manufactured at a blood center using -hour room background/case studies: cellular prion protein (prp c ) is a gpi-anchored cell surface glycoprotein that is expressed mainly in the brain but also in peripheral organs including blood, bone marrow (bm), and lymphoid tissue. prp c can be converted post-translationally into scrapie-prp (prp sc ), which is involved in the pathogenesis of neurodegenerative diseases including creutzfeldt-jakob disease, kuru in humans, and scrapie and bovine spongiform encephalopathy in animals. however, biological functions of prp c have yet to be conclusively elucidated. study design/method: in this study, prp c knockout mice (ko) are utilized to investigate the role of prp c in the hematopoietic system with controls of age and sex-matched prp c transgenic mice harboring a slightly augmented prp c expression. peripheral blood was examined by hematology analyzer to establish counts. bone marrow, thymus, spleen, lymph nodes, and peripheral blood were harvested and analyzed by flow cytometry using a comprehensive panel of fluorochrome-conjugated antibodies specific for all hematologic cell precursors/ lineages. histology of bone marrow, spleen, thymus and lymph nodes were evaluated by light microscopy. results/finding: complete blood count (cbc) showed a significant increase of wbc in ko mice. closer analysis of wbc differential revealed that the elevated number of wbc in ko mice was due to lymphocytosis. specifically, ko mice had a -fold increase in the absolute lymphocyte count (ko . . x /l vs. wt . . x /l, p . ), as well as a higher lymphocyte percentage compared to controls. ko mice also had a trend toward higher hemoglobin, rbc, and hematocrit compared to wt mice. additionally, platelet count in ko mice was higher than control mice. of interest, the mean platelet volume indicating platelet size was significantly increased in ko mice compared to controls (ko . . fl vs. wt . . fl, p . ). a comprehensive flow cytometric analysis of all cell lineages revealed no significant differences in the numbers of rbc and megakaryocyte in bm, and of lymphocytes in the thymus, spleen and lymph nodes. histological analysis of bm, thymus, spleen and lymph node tissue from ko and wt animals failed to show morphological differences between the two groups. conclusion: absence of prp c resulted in significant leukocytosis and specifically higher absolute count and percentage of lymphocytes, as well as larger platelets in peripheral blood, but does not appear to affect hematopoiesis and lymphopoiesis. our findings indicate that prp c might be critical in the survival and trafficking of lymphocytes in peripheral blood. the molecular mechanisms underlying the observed changes in lymphocytes and platelets, and whether these involve functional changes in these cells will be subject of future studies. potential role of cd foxp regulatory t cells derived exosomes in their immune modulation yiming yang*, rufeng xie and jie yang. blood engineering laboratory, shanghai blood center background/case studies: exosomes are defined as one type of membrane vesicles secreted into extracellular space by most types of cells and are reported to involve in intercellular communications, mediate biological process. human periphery blood cd foxp tregs cells are reported as more stable regulatory cells with greater inhibition effects. however, cd foxp tregs derived exosomes and their functions involved in cd tregs mediated immune-modulation were seldom reported. study design/method: cd t cells were freshly purified from pbmcs, cultured with anti-cd /cd antibody packaged beads and il- , and then polarized with tgf-b and rapamycin into cd foxp treg cells. the harvest cells were co-cultured with cd /cd beads stimulating cd cd effector cells in the transwell plate. the supernatant derived from cd tregs was collected and ultrafiltrated by centrifugation and the remaining solution was precipitated with peg. the harvest precipitation was resuspended in pbs and exosomes were analyzed by sem and nta. exosome surface marker cd , cd , tsg and other proteins expression were evaluated by flow cytometry and western blot. microrna was isolated with mircute mirna kit and mir- , let- b, let- d were measured by qpcr. the precipitated exosomes were further purified by cd immunoaffinity capture and co-cultured with effector cells to investigate their function in immune modulation. results/finding: as compared with direct contact co-culture, separated cd treg cells could suppress the proliferation of effector cells with a small decline (p> . ), which means some non-contact factors involved in the cd treg mediated immune modulation. a total number of . . / cells exosomes were harvest. electron microscope analysis demonstrated a kind of round-shaped membrane vesicle - nm in diameter ( . . nm by nta). cd and cd were expressed on these background/case studies: regulatory t cells (tregs), containing cd and cd subtypes, play an essential role in immune regulation and autoimmune disease prevention which makes it a potential candidate for cell therapy on autoimmune disease (aids). unfortunately, due to the instability of natural cd foxp regulatory t cells (ntregs) in inflammation conditions (including instability of foxp , conversion to pro-inflammatory effector cells and was unable to modify established disease), thus, it is needed to investigate cd regulatory t cells stability both in vitro and in vivo. in our previous works, we found that cd treg has an effective therapeutic function on cia mice. in this study we aim to investigate the stability of induced polyclonal human cd regulatory t cells in inflammation and transfusion. study design/method: human cd tregs were induced with tgf-b and rapamycin from cd t lymphocytes in vitro. collagen-induced arthritis (cia) mice were induced with type-two collagen as an autoimmune disease model. in vitro the stability of cd tregs when encountering with inflammation were test by foxp expression, th and th cells conversion in inflammations conditions (il tgf-b il il and il tgf-b il b il ) on day , day and day . in vivo, cd tregs were transfused into cia mice and then their survival in mice and foxp express were evaluated to reveal the stability of cd tregs in an inflammation condition model. additionally, we also investigate the stability maintenance of cd tregs when induced factor tgf-b and rapamycin were removed by testing the foxp expression on day , day and day . results/finding: ex vivo induced human cd treg were foxp ( . . %) and did not secret il a (both in supernatant and % of cells). foxp express in cd tregs were maintained after induced factor tgf-b and rapamycin were removed on day , day and day . in vitro, foxp , il and ifn-c expression has no significant difference when compared with controlled tregs on day , day and day and did not secret il a when encounter with inflammation conditions (il tgf-b il il and il tgf-b il b il ). in vivo, cd treg cells were transfused into cia mice on the peak of disease onset ( days after the first collagen immunization, has inflammation condition in vivo) to test cd tregs survival. cd tregs were found in cia mice foot ( . . %), blood ( . . %) and spleen cells ( . . %) hours after transfusion and their % of foxp were remained. conclusion: the results revealed that ex-vivo induced and expanded human cd tregs are stable in inflammation and transfusion and can maintain foxp expression when induced factor were removed, these make cd treg a novel and stable cell for potential cell therapy on aids. this research can provide some instructive reference and improve the utilization of blood components. tolerogenic dendritic cells induced by mtor suppression and control inflammation in chs model through s k related proteins translation inhibition. li gao*. shanghai blood center background/case studies: tolerogenic dendritic cells (tdcs) adoptive cellular immunotherapy is a cutting edge strategy for treating hypersensitivity response disease, in which immune responses are directed against selfantigens, such as atopic dermatitis, systemic lupus erythematosus (sle), rheumatoid arthritis (ra),et al. however, the traditional strategy base on the tdcs was usually unstable and inconspicuous through cytokines inducing processing so that might be the limitations on tdc adaptive cell therapy in future clinical use. study design/method: human tdcs were derived from fresh purified monocytes from pbmncs isolated from buffy coat and induced by mtor inhibitors (rapamycin and temsirolimus) in safe concentrations confirmed by apoptosis assay when the cells were completely differentiated. the mature markers and endocytisis were detected by flow cytometry. the production of cytokines and chemokines was measured using elisa. mechanism investigation was analysis by real-time pcr and western blotting. contact hypersensitivity (chs) model, an atopic dermatitis animal model, was treated with tdcs induced via mtor suppression and analyzed by ear thickness and tissue leukocytes number calculating. results/finding: human tdcs treated with mtor inhibitors had a lower mature marker cd /cd /cd expression after tlr signaling activation, accompanied with a set of cytokines and chemokines remarkably downregulated in a concentration dependent manner but not the lps absent group. moreover, mtor suppression extremely reduced the capacity of lps treated human dcs to stimulate autogenic na€ ıve t cell proliferation, which is one of the most important characteristics of tdc. beyond expectation, the common signal transduction pathway, mapk and nf-jb pathway, were not the signal target so that it could hardly be the explanation for the tolerogenic performance of tdc when exposure to lps stimulation. however, the p s k and its downstreanm proteins, especially the protein s , which controls the protein translation, were shown in charge of the tolerogenic induction mechanism. the data were also supporting the suggestion that rare difference on mrna transcription of the related functional proteins in tdcs induced by mtor inhibitors when exposure to lps stimulation from the non-induced cells, although there was more transcription of ido induced by mtor inhibitors. more important, edema responses of ears were clearly weakened in the chs model and recruited less leukocytes to the tissue when co-sensitized with mtor inhibitors or with tdcs induced by mtor inhibitors suggested that the tdc induced by mtor suppression were able to control hypersensitivity inflammation response in vivo. conclusion: accordingly, tdc induced by mtor suppression is a potent adoptive cellular immunotherapy strategy for treating hypersensitivity response disease and the induction mechanism of it might be through suppressing systematically effective function proteins by mtor-s related protein translation inhibition. xiaoyun fu* , , mikayla anderson and james c zimring , . bloodworksnw research institute, university of washington school of medicine background/case studies: red blood cells (rbcs) undergo many changes when stored under blood banking conditions, collectively known as the storage lesion. bioactive lipids generated during rbc storage have been implicated in certain adverse outcomes. recently, we reported that bioactive lipids, especially polyunsaturated fatty acids (pufas) and their oxidized products (oxylipins) accumulate during rbc storage despite leukoreduction. to evaluate the extent of membrane lipid degradation and oxidation in stored rbc units among the donor population with different blood groups, we quantified pufas and lysophospholipids (lpls) in leukoreduced rbc units. study design/method: rbc units from different donors were acquired and processed on day (one day past their expiration). bioactive lipids including common fatty acids, oxylipins, and lpls were analyzed by liquid chromatography-tandem mass spectrometry with multiple reaction monitoring (lc-ms/ms-mrm). total fatty acid concentrations of selected units were also analyzed. a one-way anova test was used to determine significant difference of analytes amongst the different blood groups. results/finding: we observed a wide distribution in concentration of major pufas in stored rbc units. for example, arachidonic acid (aa) ranges from . - . mm, linoleic acid (la) ( . - mm), dihomo-c-linolenic acid (dgla) ( . - . mm), eicosapentaenoic acid (epa) ( . - . mm), docosahexaenoic acid (dha) ( . - . mm), and alpha-linolenic acid (ala) ( . - . mm). ten oxylipins including hetes, hodes, and dihomes, and lpls including lpcs, lpss, and lpes all showed a large variation in concentration among donors. of analytes quantified, showed a significant difference in concentration among different blood types by one-way anova testing (fdr< . ). the ab rh blood group consistently exhibited the lowest concentration of major pufas, while the o rh-blood group showed the highest, averaging a two-fold difference in concentration (o rh-/ab rh ). the fold increase of o rh-/o rh among pufas ranges from . to . , suggesting the rh blood group, independent of the abo blood group, correlates with donor to donor variation in lipid metabolism. conclusion: the wide distribution in the concentration of bioactive lipids among stored rbc units suggests that lipid degradation is highly donor-background/case studies: to ensure availability of biological products to hospitals, blood banks have developed and validated multiple storage conditions for each of their products to maximize shelf life and quality. in the case of labile products, their metabolism is known to remain active during storage, leading to storage lesions. micrornas (mirnas) levels are modulated by these storage-related damages, which makes mirnas ideal candidates as potential biomarkers of quality monitoring. lately, nanoparticles have been widely studied and used for biosensing applications. the objective of this work is to develop biocompatible gold nanosensors for sensitive, selective and direct detection of biomarkers to characterize and assess the quality of blood products delivered to hospitals. study design/method: gold nanoparticles (gnps) surrounded by a fluorescent silica shell were prepared using a wet chemistry method. mirna- was chosen as a potential target, since it is strongly expressed in platelet concentrates and its concentration fluctuates according to storage lesions. custom rna and dna molecular beacons were designed and used as a probe for the specific detection of mirna- targets in pbs and human plasma. these fluorescent transducer probes were conjugated at the surface of fluorescent silica shell-gnps using an edc/nhs cross-linking reaction. the hybridization reaction between the target and the probe initiates an energy transfer mechanism which can be recorded by fluorescence. results/finding: gnps ( nm) surrounded by a thick fluorescent silica shell ( nm) were prepared and used as nanosensors because of their optimal luminescence properties and long-term stability. conjugation of the probe onto the nanoparticles was confirmed by fluorescence spectroscopy and microscopy, as well as nanoparticle tracking analysis. the fluorescent response of the molecular beacons was studied and showed a reproducible and linear relationship (r rnaprobe . and r dnaprobe . ) with mirna- concentration, down to a -nm limit of detection. hybridization assays in % human plasma appear to demonstrate denaturation of rna probes and targets. conclusion: biocompatible fluorescent gnps were prepared and used as tools for blood product characterization. the conjugation of a molecular beacon at the surface of nanoparticles was achieved and characterized using spectroscopic and microscopic techniques. the functionalization of the probe is still being optimized. the fluorescence response of the molecular beacon was characterized for the detection of a model mirna target in pbs and in % human plasma. energy metabolism profile of erythrocytes during storage suping ren*, qun yu, yanbing wang, changlan li and yu wang. background/case studies: the moment the mature red blood cells (rbcs) leave the bone marrow, it is optimally adapted to perform the binding and transport of oxygen and its delivery to all tissues. red blood cells modulate oxygen transport, protect hemoglobin from oxidant-induced damage, and maintain the osmotic environment of the cell. glycolysis is the only energetic metabolic pathway for mature rbcs to obtain atp which is the energy for rbcs to maintain a number of vital cell functions. generally, the current methods used to measure rbcs glycolysis are not in living state in realtime, or are destructive to cells or require radioactivity.xf technology can be applied to different types of cells, in which the red blood cells are suspended and the cell shape and size are different from other cells, and more importantly, rbcs have no nucleus, mitochondria and other organelles, so application of the xf technology in erythrocytes and exploration of the assay conditions are necessary. . . a . . . . a . . . . a . . total atp,lm/ghb . . a . . . . a . . . . a . . extracellular lactate,mm a extracellular glucose,mm a a a extracellular na ,mm a extracellular k ,mm a a a a p< . , paired t-test b intercept blood system for red blood cells is not approved for commercial use. c this project has been funded in whole or in part with federal funds from the dhhs; aspr; barda; contract no. hhso c. background/case studies: pathogen inactivation methods for platelet concentrates are increasingly being used in blood banks worldwide to make transfusion safer. in vitro studies have demonstrated the effects of pathogen inactivation on storage lesion, but little routine quality control data on blood banking outcomes have been reported. study design/method: swirling of distributed products was monitored one year before and one year after implementation of intercept pathogen inactivation. metabolic parameters like ph, glucose and lactic acid were determined in a random sample of expired pathogen inactivated products. furthermore, indicators of platelet storage lesion were measured in apheresis concentrates with premature low swirling and compared to controls with normal swirling. results/finding: in an experimental phase on a limited number of products (n ) to validate the intercept pathogen inactivation method, ph and glucose levels decreased faster in apheresis platelet concentrates with high platelet content than with low platelet content or than in pooled buffy coat derived products. once pathogen inactivation was implemented, routine products showed glucose exhaustion more often when prepared by apheresis compared to buffy coat derived platelet concentrates despite more plasma carryover in the former. furthermore, the number of apheresis products with premature low swirling increased by % ( / , ) compared to the previous year without pathogen inactivation ( / , , p . , chisquare) . in contrast, the incidence of premature low swirling in platelet concentrates prepared by the buffy coat method decreased ( / , vs / , ). of note, apheresis concentrates with premature low swirling had a significantly higher median platelet count ( . x ) than unaffected controls ( . x ) and showed signs of increased storage lesion compared to controls expiring on day five without swirling defects. these signs included lower ph, higher lactic acid concentration, increased mean platelet volume, phosphatidylserine exposure and alpha-degranulation. conclusion: the risk of increased storage lesion rates following intercept pathogen inactivation is higher for apheresis than for buffy coat derived platelet concentrates, especially when platelet content is above . x . in vitro quality of single dose amotosalen/uva treated platelets in % plasma/ % pas- after days of storage crystal stanley , marguerite kelher , nero evero , melissa vongoetz , betsy donnelly and anna erickson* . belle bonfils memorial blood center, university of colorado, cerus corporation background/case studies: the interceptv r blood system for platelets is fda approved for the ex vivo preparation of pathogen-reduced amicus o apheresis platelet components (pc) in pas- to reduce the risk of tti, including sepsis, and to potentially reduce the risk of transfusion-associated gvhd. registration studies (clinicaltrials.gov nct ) are in progress to support approval of the trima o apheresis platform for collection of platelets components (pc) suspended in pas- and plasma. the objective of this study was to evaluate in vitro function of platelets suspended in % plasma/ % pas- , collected using the trima platform, after treatment with the intercept blood system for platelets. study design/method: double dose apheresis pc, . . platelets in ml, were collected on the trima apheresis platform in % plasma/ % pas- . a sample was taken from each donation prior to dividing the donation to produce intercept treated apheresis pc (t), using the small volume (sv) set, and an untreated control pc (c). input volumes for replicates, n , were ml (t) and ml (c) with doses of . . (t) and . . (c). all pc were stored under the same conditions and evaluated on day and day for physical/metabolic characteristics. results/finding: on days and all t and c pc had ph c ! . . the dose recovery for t was % %. on day , t had lower count, volume, dose, bicarbonate and glucose compared to c pc; however, parameters predictive of in vivo function (atp, morphology score, hsr, and esc) were equivalent between t and c (table ) . conclusion: trima pc in % plasma/ % pas- treated with the inter-cept blood system for platelets using the sv set and stored for days retained in vitro metabolic and functional properties consistent with in vivo functionality. induction of pluripotent stem cell-derived cardiomyocyte toxicity by supernatant of long term-stored red blood cells in vitro feng-yan fan , , yang yu , li-ping sun , shu-fang wang , rui wang , lei-ying zhang and deqing wang* . the department of blood transfusion, the pla general hospital, the department of blood transfusion, air force general hospital, pla background/case studies: recently, multi researches have reported that longer term-stored red blood cells(rbcs) units were associated with increased risks of clinically adverse events, especially in critically ill patients. however, other studies have concluded the negative results. whether rbcs storage duration was associated with increased risks of clinically adverse events is uncertain and had become a popular topic. to study the adverse effects of longer term-stored rbcs directly, we aim to look at the pluripotent stem cell-derived cardiomyocyte toxicity induced by supernatant of suspended red blood cells(ssrbcs), and study the possible mechanism. study design/methods: five doses of leuko-reduced rbcs were prepared, and supernatant was isolated by centrifugation on d , d and d . we looked at the cardiotoxicity of ssrbcs on human-induced pluripotent stem cell-derived cardiomyocytes (hips-cms). hips-cms were treated with ssrbcs in % final volume simulating the large volume blood transfusion. using real-time cellular analysis (rtca) technology the beating of hips-cms was recorded in real time in detail. levels of k and lactic acid (la) were tested using automatic biochemical analyzer. k and la solution with concentrations being consistent with ssrbcs were prepared and cocultured with hips-cms. we analyzed the cardiotoxicity of k and la solution on hips-cms. treated hips-cms with d ssrbcs, d k and cell culture media for h. the nuclear shape and integrity of filament and sarcomere was examined by immunofluorescence. total rna of hips-cms was isolated and mrna analysis microarray was implemented. screened for toxic effects related signaling pathways through bioinformatics analysis. results/findings: d ssrbcs had no obvious influence on beating state of hips-cms-hips-cms treated with d ssrbcs stop beating, but beating patterns restored at h. hips-cms treated with d ssrbcs stop beating, and beating patterns did not restored at h. levels of k and la in ssrbcs changed most obviously. only d k solution made hips-cms stop beating and can restore in h; d k, d k and la solution did not influence the beating pattern in at the end of the treatment for h, hips-cms treated with d ssrbcs show obvious shrinkage. at the end of the treatments for h, cells treated with d k and d ssrbcs both show obvious shrinkage, the shrinkage in d ssrbcs group was more serious. the immunofluorescence results show the integrity of filament and sarcomere was complete and no nuclear pyknosis was detected. gene expression array results show a total of genes were differentially expressed in d ssrbcs group compared with naive group. there was no consistent separation within the d k and naive group. fifteen differently expressed genes were selected with bioinformatics method which were likely to play an important role in the cytotoxic effect. under the condition of simulating the large volume blood transfusion, ssrbcs of long term-stored rbcs have toxic effect on myocardial cells. in addition to high potassium that induced cardiotoxicity, there must be other elements are involved in the toxic effects. further study should be applied to signal pathways on ssrbcs induced cytotoxicity. large volume transfusion of long term-stored rbcs may be a risk factor for adverse clinical outcomes, and clinical should pay attention to it. background/case studies: processing thawed, deglycerolized red cell concentrates (rcc) in a functionally closed system allows for a prolonged storage after thawing. thawed cells are better maintained in as- as compared to sagm. the presence of citrate in as- seems to be necessary to prevent hemolysis of thawed cells. during storage in as- , atp and , -dpg levels rapidly decline. recently developed additive solutions like pag m and as- have shown to better maintain , -dpg and atp levels during storage of normal, unfrozen, rcc. however, most probably due to the absence of citrate, these solutions are not suitable for storage of thawed cells. we therefore designed pag c in which the mannitol of pag m was replaced by citrate. the aim of this study was to investigate the in vitroquality of thawed, deglycerolized rbc during storage at - c in pag c. study design/method: leukoreduced rcc (n ) in pag c (phosphate, adenine, glucose, guanosine, gluconate, citrate) were stored at - c. on day , rccs were glycerolized using acp (haemonetics v r , braintree, ma) to a final concentration of % (w/v), frozen and stored for at least two weeks at - c. after thawing and deglycerolization using acp , rcc were resuspended in pag c. during storage at - c, stability (hemolysis), atp and , -dpg levels were determined. results were compared with thawed rcc (prefreeze storage in sagm, n ) resuspended in or sagm (n ). results/finding: pre-freeze storage in pag c resulted in increased , -dpg levels at day as compared to storage in sagm, resp. . . mmol/g hb and . . mmol/g hb. hemolysis during post-thaw storage in pag c remained below . % for days and was comparable with storage in as- . in sagm, hemolysis remained below . % for days. during the first weeks of post-thaw storage in pag c, both atp and , -dpg levels increased, followed by a gradual decline during prolonged storage. during the whole postthaw storage period, rccs in pag c showed significantly higher atp and , -dpg levels compared to as- or sagm. while in sagm and as- , , -dpg levels were undetectable after days post-thaw storage, in pag c, , -dpg levels only decreased to . lmol/g hb after days of storage. conclusion: pre-freeze storage in pag c resulted in increased , -dpg levels. as compared to as- , post-thaw storage in pag c showed comparable hemolysis while atp and , -dpg levels were much better maintained. based on a maximum allowed hemolysis of . % and an atp content of > . mmol/g hb, thawed rcc can be stored at - c for days in pag c. background/case studies: platelets (plts) are vital for effective treatment of hemorrhage. cold ( c, c) storage of plts in platelet additive solution (pas) is a promising alternative to conventional storage at room temperature (rt) due to a lower risk of bacterial concerns, preservation of plt function, and mitigation of plt activation. currently only apheresis (ap) and pas systems are fda-approved for use in the us: trima and isoplate-pas (iso; terumo) and amicus and intersol (int; fenwal) . the goal of this study was to assess the adhesive function of long-term cold-stored plts collected by fda-approved ap/pas methods. study design/method: plts were collected (n - ) in % iso using a trima or in % int using an amicus and stored for days at rt and c. samples were tested on day (baseline, bl), , , and of storage to assess plt adhesion under shear flow (bioflux). acd vacutainer tubes were collected from donors and centrifuged to obtain red blood cells (rbcs) for all bioflux runs. simulated whole blood was created by combining plts labeled with calcein-am with rbcs at % hct. labeled blood was perfused through microfluidic channels (fluxion) coated with ug/ml type- collagen at s - shear rate. images were acquired every sec for min using a fluorescent microscope and % surface coverage was reported. data were analyzed using two-way anova and posthoc tukey test with significance at p< . . results/finding: both rt-int and rt-iso plts showed significantly decreased adhesion by day of storage compared to bl (bl: . . %, rt: . . %; p< . ). c-int samples showed no difference in adhesion at any timepoint compared to bl-int but significantly enhanced adhesion compared to both rt-int and rt-iso. in contrast, c-iso plts showed significant enhancement of surface coverage compared to bl-iso by day (p . ) and compared to c-int by day (p< . ). conclusion: our work suggests that c storage of plts collected with a trima ap system in iso for up to days offers a significant enhancement in adhesive function compared to plts collected with an amicus system in int and stored at c. these results are surprising since both c-int and c-iso have been shown to express similar levels of cd p, pac- , and phosphatidylserine and may suggest differences in pas plt intracellular signaling. as expected, storage at c of plts collected on either platform demonstrated superior function to rt storage. a plt product with superior hemostatic function and a shelf-life x longer than the current standard-ofcare provides the potential for shipment of products to underserved areas and may bolster plt availability for trauma care in the us. table . comparisons of white blood cell counts and percentages of apoptotic cells in whole blood components after -week storage between unirradiated and irradiated groups (n ) tang, is an anti-inflammatory agents and has a good safety records in clinic. it could reduce the severity of experimental autoimmune encephalomyelitis (eae), asthma, colitis, systemic lupus erythematosus(sle) and other immune diseases.however,its potential in inducing transfusion tolerance remains to be explored.the aims of our study are to find if baicalin could inhibit red blood cell (rbc) immunization and to elucidate the possible mechanism of yin-chen-tang in preventing hdn. study design/method: we used human red blood cells with adjuvant lipopolysaccharide (lps) and transfused mice to induce antibodies, as an experimental system to study the effect of baicalin on rbc immunization. mice were divided into a normal control group, a human rbc transfused positive control group receiving human rbc and lps intravenously weekly for five weeks, a control group receiveing dexamethasone ( mg/kg/day) intraperitonealy daily for five weeks,a treatment group receiving baicalin ( mg/kg/day) intraperitonealy daily for five weeks. assessment of human rbc immunization was performed by measuring serum immunoglobulin g (igg) and immunoglobulin m (igm) against human rbc weekly. and the lymphocyte changes in spleen are also monitored by flow cytometry. results/finding: we found that baicalin treatment decreased serum igg but not igm production significantly since the second week, with a concomitant reduction in th cells and increase in cd regulatory t cells in both spleen and mesenteric lymph nodes. and there are no significant differences in the percentage of th ,th ,tfh and tfr cd subpopulation among all groups.in addition, baicalin treatment didn't decrease the size of spleen and the percentage of cd positive cells in spleen in baicalin treatment mouse but in dexamethasone treated mouse. our results indicate that baicalin could inhibit rbc immunization especially igg production without the damage to the function of spleen,while dexamethasone as a wildly used immune-suppressive drug in blood transfusion could damage the function of spleen.considering its good safety records in clinic, it may be exploited for suppressing transfusion immunization events. in addition, our results elucidate the inhibitory effect in antibody production of baicalin may be a possible mechanism for yin-chen-tang as a widely used chinese herbal medicines in preventing hdn. comparison of immucor's pak plus and pak lx assays for the detection of human platelet alloantibodies randy m schuller* , sarah kloss , sara crew and sandra j nance . american red cross, american red cross and american rare donor program background/case studies: alloantibodies directed against human platelet membrane glycoproteins (gp) ia, iia, iib, iiia, ib, ix, iv, and cd have been implicated in several clinically significant disorders such as fetal and neonatal alloimmune thrombocytopenia (fnait), post-transfusion purpura (ptp), refractoriness to platelet transfusions, and passive transfer of antibodies in donor plasma. polymorphic epitopes on these gps give rise to unique human platelet antigens (hpa). identification of the specific platelet alloantibody is crucial in diagnosing and treating these bleeding disorders. currently the only k fda approved test permits the identification of these hpa antibodies to the glycoprotein level. immucor has recently released pak lx, a research use only (ruo) assay in the united states that has the ability to identify hpa antibodies to a single nucleotide polymophism (snp). we compared the performance of pak lx to the fda approved immucor pakplus. study design/method: we compared pakplus and pak lx results from plasma and serum clinical specimens. group contained a single hpa alloantibody specificity with or without hla antibodies (n ). group included specimens with hla antibodies alone and group consisted of patient samples that were negative for both hpa and hla antibodies. pak lx utilizes a luminex bead based assay which allows the user to report antibodies to the platelet specific antigen (hpa- , hpa- , hpa- , hpa- , hpa- , gpiv) and hla class i. pakplus uses an elisa method and results can only be reported to the glycoprotein location (gpiib/iiia, gpia/ iia, gpib/ix, gpiv) along with hla class i. however, based upon the pattern of reactivity observed in the pakplus and pak lx assays it is possible to determine the most probable hpa antibody specificity to the hpa snp. results/finding: conclusion: when analyzing hpa antibody specificity, there is % concordance observed for hpa- a, hpa- b and hpa- b antibodies. the pak-plus assay had difficulty discriminating hpa- b from hpa- a antibody when hpa- a antibody was present ( false positive samples) although the pak-plus signal od to cutoff od ratio was significantly higher for hpa- a when compared to hpa- b in these samples. the discordant hla class i antibody results between the assays was isolated to very weakly positive antibody (within % of the cut-off for pakplus and < . adjusted ratio for pak lx). we conclude that pak lx is an easy to use platelet alloantibody screening method that has the ability to differentiate hpa antibodies to the allele level. histo-blood group antigen lewis y promotes cell migration via regulation of microtubule acetylation huijun zhu* and ping lu. shanghai blood center background/case studies: blood group antigens are critical for transfusion practices as antibodies raised against them can cause severe transfusion reaction. beside this, blood group antigens themselves are composed of sugar chains, proteins, lipids, etc, which may be involved in various biological processes. lewis y is a histo-blood group antigen belonging to abh family. ley consists of carbohydrate chains which may play important roles in cell recognition, adhesion as well as migration, which are all critical steps in tumor progression and thus attracts wide researches focusing on its relevance in tumor biology. ley is demonstrated to affect cell mirgration via various mechanisms. however. although changes in cytoskeleton organization is the basis for cell motility, little is known about the association between cytoskeleton and ley. as microtubule and its construction unit tubulin participate in various steps of cell migration, we aim to explore the role of ley in microtubule and cell migration using breast cancer cells, which may provide reference to clinical study of other histo-blood group antigens and change the way of thinking in transfusion practice. study design/methods: we first manipulate ley expression in breast cancer cells by overexpression or sirna knockdown of fucosyltransferases, and block ley activity in mda-mb cells using anti-ley antibody, to verify the effect of ley on cell migration. then, we detect acetyl-a-tubulin level change as microtubule acetylation is a sign for stability. to establish the role of ley in cell migration via microtubule modification, we use hdac specific (tubacin) and nonspecific (tsa) inhibitors to minimize deacetylation of acetyl-atubulin and test again the effect of fut overexpression on cell motility. results/findings: fut overexpression increases both ley expression and cell migration, while fut knockdown leads to the opposite. ley activity blockade by anti-ley antibody also significantly inhibits cell migration. western blot and immunostaining results show a-tubulin acetylation level is negatively related with ley expression. tubacin or tsa treatment increases the acetyl-a-tubulin level while inhibits cell migration; in the meantime, the significance of fut overexpression in promoting cell migration is eliminated. conclusion: it can be concluded from the results above that ley can promote cell migration via regulation of a-tubulin acetylation, wherein ley may have interaction with deacetylase hdac . as tumor promoter, hdac becomes the target of many anti-cancer drugs. we demonstrated the potential association of ley and hdac function in this study. many blood group antigens are also carbohydrate chains, which are not only critical in blood group determination, compatible transfusion and immunological reaction, but may also have an effect in the initiation and development of diseases as tumor, similar to ley; they can even be components in a network with other important molecules and contribute to the destiny of diseases. transfusion of blood products is frequently needed by tumor patients. most attention is focused on the search of compatible blood for reducing transfusion reaction. however, it may lower the chance for the disease to advance to take account background/case studies: reducing the risk of bacterial contamination in platelet (plt) products is of great concern since plt storage occurs at room temperature (rt). pathogen reduction technologies (prt) were developed to inactivate pathogens prior to transfusion; however, studies have shown that prt may damage plts over the course of extended storage at rt resulting in a greater loss of function than what is normally concomitant with platelet storage lesion. storage of plts in platelet additive solution (pas) at c helps to preserve plt function and reduces the risk of contamination. in this study, we established the impact of prt performed after long-term coldstorage of plts in pas, instead of before storage, on plt function, mitochondrial respiration, and cell death parameters. study design/method: plt units were collected in pas (n ) and stored at c for up to days. after this time period, the bag was treated using mirasol prt (riboflavin and uv). samples were obtained and tested on the day of collection (baseline, bl), pre-mirasol (pre), post-mirasol (post), and minutes post-mirasol . aggregometry (adp, collagen, trap), rotem, flow cytometry (cd p [p-selectin] , lactadherin [ps] , , and gpib), high-resolution respirometry (oroboros), and imaging flow cytometry (amnis) were used for analysis. data are reported as means sem, and paired student's t-tests were used to determine statistical significance (p< . ). results/finding: on day , p-selectin levels were significantly higher in pre than bl (p . ). mirasol treatment caused a significant increase in pac- expression compared to pre (pre: . . %, post: . . %; p . ), which remained after incubation. a significant drop in both collagen and trap aggregation was observed in post samples compared to pre, but adp aggregation response was preserved. no differences in p-selectin, gpib expression, and mitochondrial respiration were observed between pre and post samples. post- samples displayed significantly less function, higher activation levels, and lower mitochondrial respiration compared to pre and post. conclusion: prt treatment of plt units in pas after day storage at c presents a unique alternative to prt treatment of plts prior to rt storage. in addition to providing a lower risk of bacterial contamination, c-stored pas plts may provide better preservation of hemostatic function than standard-of-care rt plts, even after mirasol prt treatment. however, we show here that mirasol prt of day c-stored pas plts followed by incubation ( minutes or more) results in widespread cell damage and should be avoided. safety evaluation of lyophilized canine platelets in a model of coronary artery bypass graft (cabg) todd m. getz* , arthur p. bode , anne s hale , michael stanton , mark johnson and g. michael fitzpatrick . cellphire, bodevet, inc, cellphire, background/case studies: cellphire has completed a micro dose clinical safety trial using lyophilized human platelets. cellphire also evaluated the safety of lyophilized canine platelets (lcp) in comparison to liquid stored canine platelets, following intravenous administration in a model of on-pump coronary artery bypass graft (cabg) in the canine. this safety study was in support of a future phase ii human clinical trial in cardiac patients. study design/method: three groups of eight mixed breed hounds underwent cabg to create an anastomosis and were administered lcps equal to , , and . % of the total circulating platelet count (tcpc). one group of four animals served as the vehicle group which received lyophilization platelet-formulation buffer, and another group of four animals received control ( -day old liquid-stored platelets). safety was assessed through the collection of blood loss data, evaluation of blood flow through the bypass graft, evaluation of the development of acute thrombosis, and maintenance of patency through the graft over the hr evaluation period. full necropsies with complete tissue analysis were also performed. efficacy signals were evaluated through the collection of blood loss data and coagulation endpoints (pt, aptt, fibrinogen, and teg). the results demonstrated that administration of the test article at doses up to % of the tcpc was not associated with any unexpected mortality, adverse changes in hematology or coagulation parameters, development of thrombosis at the anastomosis sites, or evidence of adverse thrombosis formation either clinically or microscopically regardless of group. the mortality noted on study was considered to be related to the surgical model and not a result of test article administration. the results also demonstrated that administration of doses of % and % of the tcpc produced a significant decrease in blood loss. the lcps at % and % tcpc were as effective in mitigating blood loss as -day old liquid-stored platelets and trended towards being more effective. no appreciable differences in coagulation parameters were observed between groups. conclusion: the results of the study demonstrate that administration of lcp up to % of the tcpc was safe in a canine cabg model. the data also demonstrate that administration of lcp at doses of % and % of the tcpc reduced blood loss. these results suggest a starting dose above . % tcpc may be required to achieve an effective dose in future human phase ii trials in cardiac patients. although the study was not powered for efficacy, these data indicate a level of safety, as % tcpc had similar efficacy signals as % tcpc with no observable severe adverse events. the starting effective dose may vary depending on the clinical indication. future studies will be required. this study was funded under barda contract hhso c. the study on pcr-ssp technique for the genotyping of cd - del.ac mutation and the genetic polymorphism of cd - del.ac in chinese population lilan li* and guoguang wu. nan-ning institute of transfusion medicine background/case studies: cd (platelet glycoprotein iv, scarb ) is an important and characteristic platelet antigen implicated in immune-mediated thrombocytopenia in chinese population. except anti-hla, anti-cd is the most common antibody of clinically relevant platelet antibodies in chinese population, which is associated with the high frequency of cd deficiency in china. cd gene mutation is the main reason that leads to cd deficiency. cd - del.ac (frameshift at aa ) mutation is one of the cd mutations that causes cd deficiency. have had natural mumps, measles and rubella infections, resulting in lower antibody levels in their blood. the recommendations may thus be unfounded and outdated, and prevent valuable vaccination opportunities for children with frequent blood transfusions. this places an already highly vulnerable pediatric population at risk for acquiring preventable infections. the primary aim of this project was to determine mmr vaccination immunogenicity in patients chronically transfused with rbc. study design/method: medical charts were reviewed for vaccination and transfusion histories. mmr-specific antibodies were quantified in pediatric patients who received both doses of the mmr vaccine at and months of age while they were on a chronic rbc transfusion program for sickle cell disease, b-thalassemia major, diamond-blackfan anemia or pyruvate kinase deficiency. there was no formal control group; long-term immunity rates in the literature are ! % for all mmr components. results/finding: table shows immunogenicity to vaccine components. delays between vaccination and serology testing averaged . years ( . to . years). thirteen patients ( %) were chronically transfused at the time of serology. twenty-three patients ( %) seroconverted to at least one of the vaccine components. conclusion: to the best of our knowledge, this is the first study designed to measure the effect of rbc transfusions on mmr vaccine immunogenicity. although lower than the rates reported in the literature, the results suggest a high rate of immunogenicity to each component of the mmr vaccine in chronically transfused patients immunized prior to months posttransfusion. weighing the risks and benefits of disease prevention in a highly vulnerable population, and taking into account the aforementioned results, a reevaluation of immunization delays post rbc transfusions is called for in chronically transfused infants. post-vaccination serology should be considered. cold stored uncrossmatched whole blood can be safely administered to pediatric trauma patients christine m leeper , , franklyn cladis , richard saladino , darrell triulzi , barbara a gaines and mark yazer* . university of pittsburgh, children's hospital of pittsburgh of upmc, institute for transfusion medicine background/case studies: the use of uncrossmatched cold stored whole blood (wb) is becoming increasingly popular in the initial resuscitation of trauma patients without a current abo group. wb has advantages over conventional component therapy including greater platelet and factor concentrations, as well as less saline and additive solution compared to an equivalent volume of reconstituted whole blood. this report details the initial use of wb in pediatric trauma patients. study design/method: pediatric trauma patients ! years old and ! kg with evidence of hemorrhagic shock were eligible to receive up to cc/kg of cold stored, leukoreduced group o negative wb during their initial resuscitation. all wb units had a low titer of anti-a and -b (< ) to reduce the likelihood of hemolysis in non-group o recipients. biochemical markers of hemolysis were measured on the day of wb transfusion and the following two days. admission thromboelastograms were obtained and repeated as necessary during the resuscitation. after receipt of the maximum quantity of wb, conventional components were utilized. results/finding: in approximately months, trauma patients received wb: group o and group a recipients, % male, median (iqr) age was ( . - ) and % blunt trauma mechanism. patients were severelyinjured with a median (iqr) injury severity score of ( - ) and % mortality rate. the median (iqr) quantity of wb transfused to group o recipients was . ( . - . ) ml/kg versus . ( - ) ml/kg to non-group o recipients. no transfusion reactions were reported. the mean standard deviation haptoglobin concentrations for non-group o recipients was . . mg/dl on day , . . mg/dl on day , and . . mg/dl on day ; the corresponding haptoglobin concentrations for group o recipients were . . mg/dl, . . mg/dl, and . . mg/dl, respectively (p> . for all comparisons). similarly there were no significant differences in total bilirubin, ldh, creatinine, and potassium at any time point. regarding evaluation of cold platelet function, we compared the subset of patients who received wb but no warm platelets (n ) to a historical group of pediatric trauma patients who received conventional components including warm platelets (n ). the mean standard deviation platelet volume administered was cc for whole blood recipients versus cc for warm platelet recipients. when pre-and posttransfusion teg and platelet counts were analyzed, there was no difference in median platelet count or teg maximum amplitude (ma) between cold and warm platelet groups. conclusion: use of cold-stored uncrossmatched whole blood for the resuscitation of pediatric trauma patients is feasible, acceptable, and appears to be safe. receipt of low titer group o wb did not lead to detectable hemolysis amongst the non-group o recipients. given this finding, the maximum quantity of wb per patients will be increased to ml/kg. identification of red blood cell antibodies in human breast milk by novel adaptation of serological method philippe p pary*, alexis leonard, lauren hittson, naomi lc luban, deepika s darbari, yunchuan delores mo, cyril jacquot, valli criss and jennifer webb. children's national medical center background/case studies: human breast milk contains immunoglobulins that are present in maternal serum and secretions. data in mice has demonstrated the potential for kell antibodies to be absorbed enterally from breast milk and impact the survival of transfused kell positive cells; however, methods to test and titer human breast milk for red cell antibodies are lacking. a two week old infant with a history of rh-d hemolytic disease of the fetus and newborn (hdfn), previously treated with intravenous immunoglobulin and phototherapy, was referred for anemia and reticulocytosis. patient was o positive, positive direct antiglobulin test (dat) with anti-human igg only, and a positive antibody screen by gel method. antibody identification showed anti-d in both the plasma and eluate. patient was transfused o negative red cells and discharged. over several weeks, the patient returned twice for persistent anemia requiring additional transfusions. at eight weeks of age, evaluation showed a persistent dat igg reactivity concerning for continued antibody exposure. maternal breast milk was evaluated as a potential source. study design/method: based on similar properties of human breast milk and plasma, testing to identify igg antibodies using a stantard tube saline method was performed with a minute c incubation, followed by automated washes prior to the addition of anti-human igg reagent. as a control, breast milk from an o positive, antibody screen negative mother was used to assess for interference by milk proteins. antibody screens were performed on the plasma of the patient, the patient's mother and the control concurrently using the same method. antibody identification and titers were also performed when indicated. only freshly collected breast milk stored at room temperature for less than days was found suitable for this technique. results/finding: the patient's mother showed plasma anti-d with a titer and the breast milk showed anti-d with a titer between and . the patient had a consistent plasma anti-d titer of . the patient's mother chose to stop breast feeding after weeks, and the patient's hemoglobin was improved at and weeks of age. using this method, we identified two additional cases of breast milk induced hemolysis: another anti-d and an anti-jka. conclusion: testing showed that it is possible to identify red cell igg antibodies in human breast milk using a standard tube saline method. we identified implicated antibodies in the breast milk received by infants with persistent anemia due to hdfn. breast milk titers were generally lower than maternal serum titers, but titers varied depending upon the timing and frequency of breast feeding. cessation of breast feeding correlated with improved hemoglobin in affected infants. background/case studies: red blood cell (rbc) transfusion is lifesaving for patients with sickle cell disease (scd), but is commonly complicated by rbc alloimmunization. despite transfusion protocols serologically matching for c,e, and kell antigens, alloimmunization to rh antigens continues. scd patients often exhibit a hybrid rhd-ce-d gene which is often characterized by the production of a partial c antigen. it has been previously documented that % of c scd patients from the west indies and west and central africa are partial c and at ( %) risk for alloimmunization to the c antigen through transfusion of c rbcs. this study sought to determine the prevalence within a cohort of children with scd at a u.s comprehensive scd center. study design/method: rbc genotyping results performed on all scd patients using precisetype hea array (immucor, norcross, ga) at children's healthcare of atlanta were reviewed and compared to the serologic type for rh (c/c, e/e) antigens. the prevalence of c-antigen positive patients (serologically) was determined overall, and compared to the prevalence partial c antigen based on the detection of the rhce*ce( g, t) allele in the absence of an rhce gene encoding a conventional c antigen in trans, since this allele is commonly linked to the hybrid rhd*diiia-ce( - )-d gene which encodes the partial c antigen. review of the blood bank information system was performed to identify the number of c-antigen positive transfusion exposures and frequency of alloimmunization to the c antigen. results/finding: out of a total of patients with genotype/rh phenotype data available, ( . %) were c antigen positive serologically. the allele frequency of rhce*ce( g, t) was . . in total, ( . %) patients possessed rhce*ce( g, t) in the absence of conventional c gene in trans. of the c antigen positive patients, individuals ( . %) were predicted to be partial c based on four molecular profiles [rhce*ce( g, t)/rhce*ce: ; rhce*ce( g, t)/rh*ce: ; rhce*ce( g, t)/rh*ce( g): ; rhce*ce( g, t)/rh*ce( g, t): ]. in these partial c patients, no anti-c alloantibodies (or other rh antibodies) were detected after transfusion exposures ( c-antigen negative units; mean: , range: - ), likely from placement of a c-negative rbc restriction upon detection of the rhce*ce( g, t) allele. conclusion: this report confirms previous data of a high prevalence of the partial c antigen in scd patients historically typed as c-positive serologically, and demonstrates the benefits of rbc genotyping to prevent alloimmunization to a highly immunogenic rh antigen by identifying individuals who should receive c-negative blood. all patients with scd should have rbc genotyping performed for determination of their rbc phenotype, preferably prior to receiving transfusions. investigational detection of zika virus rna in us blood donors paula p sa a* , megan l nguyen , melanie c proctor , david e krysztof , gregory a foster , erin k sash , sandy s dickson , joua yang , jeffrey m linnen , kui gao , jaye p brodsky and susan l stramer . american red cross, grifols diagnostic solutions inc., grifols diagnostic solutions, inc, quality analytics, inc background/case studies: zika virus (zikv), an emerging flavivirus, is primarily transmitted by infected aedes aegypti mosquitoes, but recent outbreaks have revealed non-vector transmission routes including the unprecedented sexual transmission of an arbovirus. acute zikv infection is mainly asymptomatic or presents as a self-limited disease but also includes severe congenital defects and neurologic disorders. the large proportion of asymptomatic cases, high numbers of returning travelers from zikv-active areas, severe clinical consequences to developing fetuses, the detection of rna in asymptomatic donors during the french polynesia epidemic, and suspected cases of transfusion transmission in brazil led fda to release guidance documents to minimize the risk of zikv transmission via blood/ blood components. study design/method: investigational testing by mini-pool (mp)-nat using the procleix zika virus assay (tma) was implemented on collections from five presumed high-risk us states on / / (fl, ga, sc, ms, al). following revised guidance on / / , testing was extended to all blood donations; conversion from mp-nat to individual donation (id)-nat was implemented in phases and completed on / / . travel history questions were discontinued on / / . confirmatory testing included repeat tma; in addition, rt-pcr, serology and red cell (rbc) tma were performed. estimates of viral loads were performed by end-point tma on plasma and rbcs. results/finding: as of / / , , , donations were tested including , ( %) in , mps. no reactive donations were identified by mp-nat. of the , , id-nat donations, were initial reactive (ir) of which ( %) confirmed positive (cp) by subsequent testing (cp rate of : , ; positive predictive value of %; specificity of . %). five ( %) cp donations were id-nat repeat reactive (rr); ( %) donations were id-nat ir only, igm positive and rna positive in rbcs. cp donors resided in ma, tx, ca, ny, wv and in fl, of which were local transmissions. six donors had traveled to a zikv-active area returning to the us from to days prior to donation. two donors with a travel risk reported clinical symptoms; cp donors ( %) remained asymptomatic. zikv rna was detected in rbcs from all cp index donations with estimated levels varying from less than copies (c)/ml to about Ê c/ml. at the time of writing, the longest period of detection in rbcs was days vs. days in plasma from the same tma-rr donor. zikv rna levels in plasma were obtained from ir and all rr donors, ranging from to c/ml. study design/method: plasma from blood donors were screened by individual donation (id-nat) for the presence of zikv rna with the cobasv r zika test. id-nat samples were repeated in duplicate and further tested by a second nat to confirm infection and estimate vl, and for anti-zikv igm. simulated mps of were prepared by diluting nat plasma : and tested to discriminate id-nat only detectable donations. nat yield samples for which simulated mp and conclusive igm results were available (n ) were sorted into categories corresponding to sequential stages of acute zikv infection: igm-/low vl; igm-/high vl; igm /high vl; igm /low vl. results/finding: of , donations collected april -december , were reactive for zikv rna. igm-index donations had higher vls (mean . x vs . x iu/ml) and higher proportions of simulated mp-detectable results ( % vs %) than igm donations. the distribution by stage of infection was evaluated as the epidemic evolved. over the course of the epidemic, the rates of id-nat only detectible and igm donations increased (table ) . conclusion: this study demonstrates how the viral and immunological profiles of zikv infection in the index donations shifted through the course of the pr epidemic. categorization of index samples into stages of infection is important for blood safety considerations, since infectivity and utility of mp vs id-nat screening likely correlate with vl and serological stages of infection. staging of infections also has implications for diagnostic testing and understanding the durations of zikv viral and immunological markers in blood and persistence of zikv in body fluids and tissues. cobasv r zika is not commercially available for blood screening. data generated under the cobasv r zika ind is preliminary and has not been reviewed by fda. this project has been funded in whole or in part with federal funds detection of zika virus rna in united states blood donations using cobas v r zika on the cobas v r / systems lisa lee pate* , phillip c williamson , michael paul busch , susan rossmann , scott jones , ann butcher , john duncan , jean stanley and susan a galel . roche molecular systems, inc., creative testing solutions, blood systems research institute, gulf coast regional blood center -sugar land, qualtex laboratories background/case studies: in february , the us fda recommended that all blood donations in areas with active zika virus (zikv) transmission be tested with an fda approved nucleic acid test (nat) for zikv rna or treated with an fda approved pathogen reduction technology. the cobasv r zika test was approved under an investigational new drug application on march , and testing of puerto rico donations began on april , . as a precautionary measure some blood centers in the us states also began nat testing for zikv. in august , the fda recommended universal screening of all blood donations. the aim of this study is to describe the detection of zikv rna in blood donations collected in us states between april , -february , using the investigational cobasv r zika for use on the cobas v r / systems. study design/methods: donations were screened with cobasv r zika by individual donation testing. all initial reactive (ir) results were repeated in duplicate. supplemental testing included an alternative nat (altnat) assay which is less sensitive than cobasv r zika and serology testing for anti-zika igm and igg. reactive donors were invited to enroll in follow-up, which included cobasv r zika and serology testing. a donor was considered to be zika confirmed positive if at least one replicate of the repeat testing by cobasv r zika was reactive on index donation or follow-up, reactive by altnat on the index donation, or positive for anti-zika igm on index or follow-up. all ir donations were also retested at a : dilution to simulate mini-pool testing. results/findings: a total of , , blood donations were screened using cobasv r zika. of ir donations, were repeat reactive (rr), non-rr and had no repeat testing. of the rr donations, were positive by altnat; of these were igm positive. all altnat negative donors were igm positive. one donor was alt-nat equivocal and igm negative. of the rr donors that were not igm positive on index, enrolled in follow-up and all seroconverted. of non-rr donations, were altnat negative and is pending supplemental testing. / donors were igm positive on index. donors were igm negative on index; / enrolled in follow-up; remained igm negative and was gm inconclusive. of donations without repeat testing results, met criteria for positive ( was altnat positive, igm negative and altnat negative, igm positive). donation is pending additional testing. altogether, / ir donations met the criteria for true positive on the index donation. / ( %) true positive donations were reactive when retested in a simulated minipool. / were igm positive. conclusion: . % of the , , donations in us states screened for zikv rna were confirmed as true positives. cobas v r zika is not commercially available for blood screening use. using monte carlo simulation luiz amorim* , marc germain , gilles delage , maria esther lopes and yves gr egoire . hemorio, hemaquebec, h ema-qu ebec background/case studies: zika virus was implicated in very large and recent outbreaks, in french polynesia ( ) , and in brazil ( / ), which was followed by outbreaks in south america, central america and caribbean. four probable transfusion transmitted cases were reported in brazil; since % of zika cases are asymptomatic, the actual transfusion rates can be much higher than reported. in this study, we used a monte carlo simulation for risk estimation during the brazilian outbreak. study design/method: the data feeding the monte carlo simulation were collected from january st , through november, th , , from brazil (the whole country) and for rio de janeiro state, one of the outbreak epicenters. the data came from brazilian epidemiologic bulletins and from brazilian blood donation figures. the risk assessment was performed separately for whole blood (wb) donation and for apheresis platelets (ap). the model took into account the following parameters: zika incidence in brazil and in rio; lognormal distribution symptomatic viremia (period: days, with % of the values lower than days); % of infected donors with symptoms lasting days; . donation/donor/year for wb and . for ap. the formula for transfusion risk calculation was: incidence x infectious period x average donation number per donor per year (wb, x/y; aph, z/y) x ( -proportion of refused donors) x ( proportion of discarded donations due to post donation -pd -information). results/finding: the table below shows the results. the estimated risk of transfusion transmitted zika is very important in brazil and in rio de janeiro, where it can attain : , , for apheresis platelets. the severe consequences of zika in vulnerable populations -pregnant women and newborn -indicate that interventions to reduce this unfavorable outcome, such as donor testing and pathogen inactivation, should be considered in brazil dengue (denv) arboviruses in the population are not available in brazil. the objective of this study was to assess the contemporaneous incidence of these agents in donors at large geographically dispersed blood centers located in the southeast and northeast of brazil. study design/method: in the brazil public blood bank system, nat screening for hiv, hcv and hbv is performed on minipools (mp from donations). the residual volume of mp plasma, . - . ml, is routinely discarded. beginning in april each blood center saved $ mps/week for retrospective testing using the triplex zikv, chikv, denv transcription mediated amplification (tma) assay developed by grifols/hologic. mps were shipped to the usa and batch tested at grifols. in the first two weeks (april - ) mp were combined into pools of donations; thereafter mp were tested without additional pooling. to estimate the percent positive donors, the denominator was adjusted to account for the number of donations included in each pool each month and % confidence intervals (ci) calculated using the method developed by biggerstaff. results/finding: the triplex assay performance was shown to have very high sensitivity ( % limit of detection < copies/ml for zikv/chikv/ denvs) and to accurately discriminate each of the arboviruses. testing of the first months of samples is complete for , mp, comprised of , donations collected from april to october , . a total of pools were positive, with detected between april-june . the table summarizes the highest monthly estimated percent positive donors for each virus in each city. months with highest percent postive donors were april or may. at the peak over . % of donors in belo horizonte and rio were viremic for zikv, whereas zika was not evident in donors in recife, but over . % of donors in that city were viremic for chivk during the peak. conclusion: during the latter part of the arbovirus outbreak season in brazil in , zikv, chikv, and denv were being transmitted by mosquitoes to donors with asymptomatic donors donating, indicating that blood recipients in brazil were extensively exposed to viremic blood components. the use of donor mps for surveillance may be one of the most efficient approaches for public health monitoring of the onset and magnitude of arbovirus infections. universal zika screening for blood donors in singapore sally lam* , sze sze chua , mars stone , michael paul busch and ai leen ang . health sciences authority, blood services group, blood systems research institute background/case studies: singapore reported its first locally transmitted zika case on august . the numbers rose rapidly to cases by the end september, with eight clusters (hotspots) of cases island-wide. zika virus (zikv) shares the same mosquito vector, aedes aegypti, as the dengue viruses and can caused microcephaly in unborn fetuses of infected pregnant women and guillan-barr e syndrome, which hastened singapore's blood services group (bsg) to look into securing the safety of blood supply from the zika threat. we aimed to assess the assay performance of usa-fda investigational (ind) procleix zikv nucleic acid technology (nat) assay for universal blood donation screening in singapore to prevent transfusion-transmitted zika infection. study design/method: all blood donations were screened for zika with the procleix zikv nat assay since october . zika nat reactive samples were tested at blood system research institute (bsri) for zika rna in plasma and red cells by pcr and for zika and dengue igm and igg antibodies. a zika confirmed case was defined by the presence of zika rna by pcr and/or zika antibodies. the analytical sensitivity was evaluated using blinded frozen samples consisting of replicates of half log dilutions of the who international standard for zikv and replicates of negative controls prepared by bsri. probit analysis was performed to determine the % and % limits of detection (lod) . clinical performance of the procleix zikv assay was also assessed with local patient samples obtained from institute of infectious disease and epidemiology, singapore and a member blinded zikv reference panel from the usa-fda. results/finding: a total of , donations were screened from october to march , with false positive case and zika confirmed donation detected. alternative zikv pcr tested positive in both the plasma and red cells with an estimated plasma viral load of . x copies/ml. zika igm was negative in the index donation sample but present in the -day post-donation follow up sample.. the donor reported no clinical symptoms. the analytical sensitivity for the procleix zikv assay was determined to be . copies/ml at % lod and . copies/ml at % lod. the procleix zikv assay detected rna in out of patient samples and provided . % agreement to the results of the usa-fda zikv reference material. conclusion: the investigational procleix zikv assay showed good analytical sensitivity and clinical performance, suitable for blood screening of zika infection especially in asymptomatic donor populations. bsg commenced universal zika nat screening by individual donation testing following the zika outbreak with confirmed zika donation (high-titer and seronegative) interdicted, which translates to a risk incidence of in , donations in singapore. background/case studies: a cap/aabb work group suggested that steps be taken to phase in rhdgenotyping for patients with a serologic weak d phenotype. weak d types , and express all the major rhd epitopes and these patients can be managed as rhd-positive, which may lead to a reduction in unnecessary rh immunoglobulin (rhig) administration and conservation of rhd-negative rbcs. study design/method: rhd genotyping was performed on all patient samples with weaker than expected or discrepant rhd typing results, utilizing a commercially available genotyping kit manufactured by immucor (rhd beadchip). initially, testing was performed at a reference lab while the rhd beadchip was validated and implemented at this institution. a serologic weak d phenotype is defined as weak to reactivity on initial gel testing. if genotyping demonstrated weak d types , or , the intent was to manage the patient as rhd-positive. if weak d types , or were not detected, the patient is considered at risk for alloimmunization and treated as rhdnegative. while rhd genotyping results were pending, rhd-negative rbcs were used and if pregnant, the patient was eligible for rhig. results were generally available in to weeks. results/finding: rhdgenotyping was performed on patient samples over months. of these patient samples, ( %) were weak d types or . the remaining samples demonstrated a variety of alleles including known partial d variants (see table) . one patient identified as weak d type required multiple transfusions over the study period, and refused rhd-positive rbcs. the remaining weak d types and patients have not received transfusions at this institution since they were genotyped. four of obstetric weak d types and patients received rhig while genotyping was pending. conclusion: testing and management of patients with serologic weak d phenotypes is not standardized. rhd genotyping may lead to more consistent, personalized patient care and appropriate management of resources. in this month study period serologic weak d patients were identified who could be managed as rhd-positive, however this did not result in withholding any doses of rhig nor conservation of rhd-negative rbcs. genotyping results pertaining to the management of an obstetric patient were discussed with each obstetrician and it is possible this information may impact management of future pregnancies. these outcomes highlight the limitations of current genotyping processes, including long turn-around-time background/case studies: the rh blood group is highly immunogenic and the most clinically significant blood group secondary only to abo. currently, in the united states, blood donors who type rhd-negative by serology undergo weak-d testing to identify some weak and partial states of rhd expression. however, not all rhd expression can be detected serologically. it has been suggested that investigation of serologic rhd-negative blood donors using genotyping methods can more accurately identify units that may lead to alloimmunization in rhd-negative recipients. study design/method: rhd genotyping of all serologic rhd-negative blood donors presenting to our blood donor center was implemented to identify units with altered rhd alleles that should be characterized as rhdpositive. repeat donations were not tested. initial serologic testing of blood donors was performed using fda approved anti-d reagents. when reactivity with all reagents was negative, rhd genotyping was performed using a commercially available genotyping kit manufactured by immucor (rhd beadchip). this assay detects over rhd variant alleles and additional dna sequencing was performed in selected cases. to maximize efficiency samples were batched for testing; testing was generally performed once a month. if an rhd variant known or suspected to be associated with an increased risk of alloimmunization was detected, recipients of previous donations were investigated for evidence of alloimmunization, and all future donations were restricted to rhd-positive recipients. results/finding: over a period of months we tested rhd-negative blood donors. there were ( . %) partial-d, weak d ( . %), and ( . %) del donors. in one donor sample a novel rhd allele was identified through dna sequencing (rhd*ivs - _ deltctc). the phenotype associated with this allele variant is unknown. investigation of previous donations from these donors showed that rhd-negative recipients received rbcs from of these donors. five of these recipients underwent antibody screening after an average follow-up period of months; anti-d was not detected in any sample (see table) . conclusion: serologic testing occasionally fails to identify some rhdpositive donor units, which could place rhd-negative recipients at risk for alloimmunization. dna-based testing can be used to identify donors who have the potential to sensitize rhd-negative individuals. in this limited study period a small number of serologic rhd-negative donors, whose genotype indicated potential to sensitize recipients, were found. however, review of recipient transfusion records indicated that prior exposure to these donors' rbcs did not lead to detectable immunization to date. future potential sensitizing events will be avoided by restricting these units to rhd-positive recipients. grifols diagnostic solutions labs, grifols immunohematology center background/case studies: pregnant women with rhd variants may be candidates for rhig prophylaxis if molecular analysis reveals a genotype associated with possible anti-d formation. proposed testing algorithms advocate molecular characterization of weak d types but if a patient types as rhd-positive, no further action is proposed. women with partial d variants who may also be at risk of anti-d formation have not been included in algorithms proposed to date yet molecular testing may unmask this hidden subpopulation of women who type as d-positive but who may be candidates for rhig prophylaxis. our hospital is in an urban setting in which % of deliveries are to african-american patients. we initiated routine, full-gene rhdsequencing for obstetric patients whose serology demonstrated not only weak d, but also those who were categorized as "d " with reactivity to determine the prevalence of partial d patients in an ethnically-mixed population who may be at risk of anti-d formation. study design/methods: from october to march , we performed routine d typing (neo, immucor) on obstetric specimens followed by rhd sequencing on samples with either a serologic weak d phenotype or anti-d testing strength of using at least antibody. solid phase and manual testing used the series and series reagents. four additional anti-d reagents manufactured by grifols (dg gel anti-d), quotient (anti-d blend), biorad (anti-d (rh ) blend), and ortho (bioclone anti-d) were also used for supplemental testing. rhd sequencing was performed by sanger methodology using routine clinical protocols. results/findings: rhd polymorphisms or variations were identified in all samples. two of ( . %) were d with an rhd gene with only common, known intronic variants that is predicted to produce the "reference" rhd protein (ivs - c, rs ; ivs c, rs ; and ivs a, rs ). two ( . %) were d and heterozygous for two apparently new rhd coding variations which we are confirming by further testing. four ( . %) patients had rhd alleles with known potential to make anti-d (rhd*dol , rhd*dar . , and with weak d type . ). one had weak d type , which has uncertain susceptibility to alloimmunization and one was weak d type , which has not yet been associated with anti-d. interestingly, two ( . %) had variable d expression associated with apparently new alleles, pending ongoing confirmatory testing and cloning. one patient background/case studies: a weak d type is a variant of the rhd protein that comprises an amino acid substitution located in the th transmembrane segment and expresses a reduced amount of the d antigen. this variant is known to be associated with the missense mutation c. g>c which is the first nucleotide of the exon of the rhd gene and thus could be implicated in exon skipping when it is mutated. when performing ngs (next generation sequencing) analysis to fully genotype known patients, we identified an additional variant. study design/method: dna samples were studied by beadchip technology (immucor/bioarray solutions) and ngs using the sureselect human all exon v (agilent) and the nextseq platform. in silico analysis with different bioinformatic tools was used to predict splicing events. furthermore, a functional splicing assay was performed to determine the impact of the nucleotide variations on exon skipping of rhd gene. this study was completed by the comparative modeling between the wild type and the weak type rhd proteins. results/finding: by a targeted analysis of full exome sequencing, we have confirmed the blood group genotype of patients previously characterized by beadchip technology. interestingly, out of carry the c. - c>t intronic variation on the rhd gene, already described and associated with a del allele. among these last patients, one has been previously characterized as rhd weak type carrying the c. g>c (p.gly ala). independently, sanger sequencing on unrelated rhd weak type samples pinpoint to a linkage disequilibrium between c. g>c (exac, maf . ) and the c. - c>t (exac, maf . ). in silico analysis of both mutation located close to the splice acceptor site of the exon does not predict a significant reduction of its strength score. with minigene vectors harboring rhd wildtype exon , mutant rhd c. g>c, mutant rhd c. - c>t and double rhd mutants c. g>c plus c. - c>t, we showed no influence on skipping of exon due to these mutations. comparative modeling of rhd proteins pointed out an additional hydrophobic interaction on the rhd weak type between ala (transmembrane helix ) and val (transmembrane helix ) hampering membrane insertion. conclusion: the c. - c>t variation is always associated in cis with the missense mutation c. g>c on the allele rhd weak type . the c. - c>t can be found alone on the rhd gene as a neutral polymorphism. we assess that these two mutations isolated or combined do not lead to abnormal rhd transcripts. our results clearly demonstrate that the weak d antigen reactivity observed with rhd type red blood cells is due to the substitution of alanine at amino acid position to glycine. topology of jk-weak or jk-negative single-nucleotide missense variants in the kidd protein glenn ramsey*. northwestern university background/case studies: the human urea transporter-b (hut-b) protein carrying the kidd blood group has transmembrane (tm) and tilted ureapore a-helices, a long extracellular connector segment, and cytoplasmic segments at each end. numerous single-nucleotide missense variants (snmvs) weaken or abolish expression of jk a/b antigens determined at p. . we mapped all reported jk-weak or jk-negative (jk-neg) snmvs onto the hut-b structure to explore topological correlates of jk antigen expression. study design/methods: jk*a and jk*b snmvs affecting jk expression were compiled from dbrbc and isbt registries, literature searches and - aabb, isbt and british blood transfusion society meeting abstracts. snmv locations were correlated with the human homolog of the x-ray-crystallographic structure of mammalian ut-b derived for analysis of ut function (levin ej, ) . results/finding: seven snmvs located within amino acid (aa) from the exofacial or internal end of a tm helix are mostly weak variants (table) . all at the exofacial ends (p.a t, p.w r, p.v d) are jk-weak; the two jkneg exceptions p.g e and p.g e are at the internal end of the tm helix bearing jk a/b . four snmvs in the cytoplasmic n-terminal segment are mostly weak variants. in contrast, snmvs within membrane helices are mostly jk-neg variants. three jk-weak snmvs (p.v m, p.e k, p.v i) have been associated with allo-anti-jk a/b to the antigen on their alleles ("weak partial"). six of the jk-neg variants are within aa (p. -p. ) of jk a/b at p. . none of these snmvs are in the long extracellular connector region or the cytoplasmic c-terminal segment. jk-neg variants p.n s and p.s p are adjacent to p. f and p. l which line part of the urea transporter pore. conclusion: in the transporter-structured rhd and rhce proteins, snmvs with weak d, c, c, e or e expression are mostly within the rbc membrane, and non-canonical antigen-negative snmvs are unusual. in the structurally similar kidd hut-b, most jk-weak snmvs are at the ends of the tm helices or in the n-terminal cytoplasmic segment. among jk-neg snmvs, most are in membrane helices. however, whether a variant appears jk-weak or jk-neg may depend on the extent of testing. next-generation sequencing may provide more complete structure-antigen correlations. background/case studies: the kidd-null blood group is most often inherited as a recessive genetic trait due to biallelic mutations in the slc a gene, which encodes the urea transporter ut-b . the kidd-null phenotype is associated with transfusion risk and also is associated with abnormalities in the ability to concentrate urine. the cause of the identical kidd-null phenotype with dominant inheritance [in(jk)] has not yet been defined, though it was first described in . in contrast to recessively inherited kidd-null phenotype, this is not associated with mutations in the slc a gene. the aims of the studies was to identify and characterize the causative gene for dominant kidd-null red blood cell phenotype (injk). jk-weak (bold)/ jk-neg expression n within aa from tm a-helix end v i, a t, w r, w r, g e, g e, v d* cytoplasmic n-terminal v m, g s, e k, l p in membrane tm and urea-pore a-helices r w, r q, g d, i t, a v, l r, a t ‡, a a §, l f, n s, s p, t m / * second nucleotide variant in this allele is synonymous (p.p p). ‡reported as jk-neg but considered jk-weak by isbt. §near splice point. study design/method: we identified several families with dominant inheritance of the kidd-null phenotype in multiple kindreds in spain. we performed whole-genome linkage analysis, exome sequencing, expression (rt-pcr and western) analyses, and urea lysis using patients' cells. in addition, two probands underwent urine concentration tests. results/finding: using molecular approaches, we mapped the affected locus to a mbp region in q . - . with an lod score of . . using deep sequencing, we identified a potential deleterious mutation in the znf gene, which deletes bp resulting in loss of an entire zing finger domain. the identical del -znf mutation is present in all affected individuals, and is absent from all controls tested (n> ). in addition, two adult individuals who are homozygous for the entire haplotype including the deletion within the znf locus, thus completely lacking the common allele, were identified. we also obtained dna from an unrelated injk individual reported from japan. in this individual, there was a similar, though not identical, znf del . none of the other potential genetic variants identified in the spanish kindreds was present in the dna from the injk individual from japan. consistent with the fact that the kidd antigen, encoded by the slc a gene, is a urea transporter that has been associated with renal function, we found that people with the znf del in spain had an inability to concentrate their urine. conclusion: a predicted zinc finger deletion at znf , prevalent in southern spain due to a founder mutation, leads to ut-b dysfunction and underlies the dominantly inherited kidd-null blood phenotype. the phenotype associates subnormal urine concentrating ability. in background/case studies: di-( -ethylhexyl) phthalate (dehp) makes pvc film flexible and useful for blood products. during storage, dehp can leach from the bag film into solution and be metabolized. studies in rodents have suggested that exposure to dehp may be associated with adverse health effects, albeit at high dosages. attempts to find dehp alternatives for blood bags have been difficult due to the rbc membrane-stabilizing effect of dehp. bis( -ethylhexyl) terephthalate (deht) a non-ortho-phthalate is structurally and functionally similar to dehp, but distinct from a metabolic and toxicological standpoint. deht can undergo complete hydrolysis and has an excellent safety profile; it is not classified as a carcinogen, mutagen, reproductive toxicant or endocrine disruptor. the study objective was to evaluate the quality of fresh frozen plasma (ffp) stored in deht containers versus ffp stored in dehp containers at days and year. study design/methods: thirty-six wb units were collected into cpd solution, leukoreduced, centrifuged, and separated into rbc and plasma. abo identical plasma units were pooled together in groups of three. the pools included group a, group o and group ab. each plasma pool was weighed, mixed, sampled, divided into dehp and deht pairs, and frozen at less than - c within hours of collection. in vitro plasma testing (pt, aptt, factor v, factor viii, fibrinogen, protein c, and protein s) was done on day (pool), day , and year of storage. dehp and deht paired plasmas were thawed and tested at the same time. plasticizer concentrations were determined on day , day , and year of ffp storage. dehp and deht and their monoesters were analyzed by liquid chromatography-mass spectrometry. internal standards were deuterated-dehp, mehp, deht and meht. the lower limits of quantification (lloq) were: dehp . ppm; mehp . ppm; deht . ppm; and meht . ppm. results/findings: mean and standard deviation (sd) for key clotting factors and plasticizer results are summarized in the table. there was no statistical difference in any plasma parameter between dehp and deht bags at the same time period. factor viii retained greater than % of its initial value. plasma stored in deht bags had an average plasticizer content % lower than that of the dehp bags. background/case studies: plasma prevents dilutional coagulopathy in trauma victims by replacing coagulation factors and substrates during resuscitation with red blood cells (rbcs) and/or crystalloid solutions. spray-dried plasma (spdp) is lightweight and can be reconstituted in minutes making it ideal for use in combat and pre-hospital settings to rapidly provide plasma in situations where it is impractical to administer fresh frozen plasma (ffp). the spray-drying process preserves coagulation proteins, but high molecular weight multimers (hmwm) of von willebrand factor (vwf) are decreased. the objective of this study was to compare spdp and ffp in reconstituted whole blood (rwb) to test the hypothesis that spdp is not inferior to ffp in facilitating platelet adhesion and thrombus formation. study design/method: under an irb-approved protocol, whole blood from healthy volunteers was collected into sodium citrate and centrifuged at g to separate rbcs from platelet-rich plasma (prp). prp was diluted -fold in pipes-saline with . mm pge and centrifuged at g. the platelet pellet was resuspended in either spdp or ffp and recombined with the packed rbcs to create rwb with hematocrit of - % and , - , platelets/ml. in addition, two rwb pairs were reconstituted with spdp diluted : (spdp %) with plasma from a patient with type vw disease (t vwd). samples were fluorescently labeled with a gpiibiiia-specific antibody and the sample was flowed through a type i collagen-coated microchannel at a shear rate of s - for seconds. still images of adherent platelets and thrombi were captured in order to calculate surface area coverage (sa) along the length of the channel. ratio paired t-test was used to compare sa in samples reconstituted with spdp vs. ffp. the margin of noninferiority was % (spdp/ffp > . ). results/finding: six batches of spdp/ffp were evaluated using subjects. there was no statistical difference between the spdp/ffp pairs (p . ). the mean ratio of spdp/ffp was . with a % ci of . - . . comparing spdp vs. spdp %, there was no difference (median ratio . , range: . - . ) in sa. two-way anova demonstrated that batch did not significantly affect ratio of sa in spdp vs. ffp. conclusion: spdp, despite a decrease of vwf hmwm, was not inferior to ffp in ability to support platelet adhesion and thrombus formation. on average, sa in samples reconstituted with spdp was % greater than in samples reconstituted with ffp. the lower limit of the th % ci is a difference of %, which is less than the a priori determined margin of noninferiority of %. even with % dilution with t vwd plasma, there was no reduction in platelet adhesion and thrombus formation in the spdp rwb samples. these data support the development of in-human studies to evaluate the efficacy and safety of spdp in preventing and reversing trauma-related coagulopathy. spray-dried plasma deficient in high molecular weight multimers of von willebrand factor retains hemostatic properties michael a. meledeo* , qiyong peter liu , grantham c. peltier , ryan c. carney , ashley s. taylor , colby s. mcintosh , james a. bynum and andrew p cap . u.s. army institute of surgical research, velico medical inc background/case studies: restoring coagulation factors is key in acute resuscitation after traumatic hemorrhage, but blood products are frequently unavailable in emergency response due to shelf-life restrictions and storage needs. a single unit spray dried plasma (spdp) process has been developed that produces a long-lived and readily stored product that has a reduction in high molecular weight multimers of von willebrand factor (vwf) and an increase in low molecular weight multimers. vwf is critical in platelet adhesion and thrombus formation. following work demonstrating enhanced function with use of glycine-based reconstitution solutions for spdp, this study examines two different spdp pretreatment conditions. study design/method: the samples were: ( ) ffp; ( ) ffp with mm glycine; ( ) regular spdp without pretreatment (rspdp), rehydrated with glycine-hcl:glycine; ( ) spdp pretreated with glycine-hcl ( mm); and ( ) spdp pretreated with glycine-hcl:glycine ( mm: mm; both pretreated were rehydrated in water). six donor-matched plasmas of each type were tested. vwf activity was measured by ristocetin cofactor assay. fibrin polymerization kinetics were analyzed by turbidimetry. thrombin generation (tg) was observed by thrombogram. chemistry was evaluated by i-stat. residual cell material was quantified by flow cytometry. coagulation properties were measured by thromboelastography (teg) in plasma and reconstructed whole blood ( % hct with platelets/nl from typematched donors). platelet adhesion to collagen under shear was measured by bioflux. results/finding: pretreated spdp showed enhanced vwf activity over rspdp (p < . ). fibrin polymerization density was slightly diminished in rspdp vs. ffp ( . vs. . o.d., p < . ), but tg was unchanged. bicarbonate/base excess were lower in spdp samples vs. ffp (p < . ). residual cellular material (especially platelet-derived) was reduced threefold in rspdp vs. ffp (p < . ) and an additional twofold in pretreated spdps vs. rspdp (p < . ). teg results were unchanged in plasma-only samples; in reconstructed wb there was a reduction in amplitude (clot strength) in all spdp samples vs. ; p < . ). platelet adhesion was equivalent in pretreated spdps and ffp, while rspdp was improved vs. all other samples ( . % surface coverage vs. . - . %, p < . ). conclusion: spdp has a longer shelf life and easier storage requirements than ffp and was equivalent or superior to ffp in most of these in vitro assays. spdp pretreated with glycine solutions was similar to ffp in most assays and showed superior vwf activity and fewer residual cellular materials but inferior support for platelet adhesion to collagen while under flow compared with untreated spdp. clinical significance of these findings is unclear, but overall in vitro outcomes suggest clinical studies are warranted. the interaction between red blood cell transfusion and lung injury: the influence of blood component manufacturing methods mathijs wirtz* , anita tuip-de boer , ruqayyah almizraq , jason p. acker , philip j. norris , jennifer a muszynski and nicole juffermans . academic medical center, university of alberta, canadian blood services, blood systems research institute, nationwide children's hospital background/case studies: red blood cell (rbc) transfusion is associated with acute lung injury, in particular in patients on mechanical ventilation. the causative factor is not known but may include residual cells or extracellular vesicles (evs) . in this study we investigated the functional effect of different manufacturing methods of rbc products on the response of pulmonary cells in an in vitro model of mechanical ventilation. study design/methods: groups of rbc products (whole blood filtered [wbf] , red cell filtered [rcf] , apheresis derived [ad] and whole blood derived [wbd]) were manufactured from donors (blood type a or b). supernatants were prepared after - (fresh) and - days of storage (stored) for measurement of thrombin generation and ev analysis. a type ii alveolar cells were seeded onto flexible membranes and incubated with rbc supernatant. cells were subjected to % stretch using a cellstretcher. control cells were not stretched. after hours, il- and il- production were measured. results/findings: both fresh and stored supernatants from ad products significantly increased pulmonary cell il- and il- production compared to incubation with other rbc products and non-incubated controls, which was further exacerbated by cell stretching. ad products also had significantly increased thrombin generating ability compared to other rbc products, as well as a significantly increased number of rbc-derived evs compared to rcf and wbd products (p< . ) . incubation of stretched cells with stored wbf products resulted in higher il- production compared to other blood products and stretched controls. rcf products did not activate pulmonary cells, had an absence of tg and had low levels of evs compared to other products. conclusion: manufacturing methods markedly influence the interaction of rbc products with lung cells. ad products activate lung cells, which is further aggravated by cell stretching. this may in part be mediated by rbc-background/case studies: investigators previously demonstrated immunosuppressive effects of rbc supernatant on monocytes in vitro, with greater effects seen in response to older units. recent clinical data suggest that rbc manufacturing method may influence immunomodulatory potential, but this has not been directly measured. we used in vitro models to test the hypothesis that rbc supernatants obtained by different manufacturing methods will have differential effects on monocyte function. study design/method: rbc products were manufactured by different methods from individual donors, each: (whole blood filtration [wbf] , red cell filtration [rcf] , apheresis, and whole blood derived [wbd] ). rbc products were stored in sagm (wbf and rcf) or adsol-containing preservative solution (apheresis and wbd). supernatants were obtained after - days (fresh) and - days (expiry). monocytes were co-cultured in media plus % rbc supernatant or media only (control) followed by lps stimulation. experiments were performed in replicates, each with a distinct monocyte donor. comparisons between groups by anova with dunnett's post-test for multiple comparisons. data are mean sd of % of control values. results/finding: exposure to apheresis or wbd rbc supernatants suppressed monocyte lps-induced tnfa production capacity compared to controls (table ) . this was true for fresh units and those at expiry. for monocytes exposed to rbc supernatant alone without lps, interleukin- production was higher after exposure to fresh wbf ( % control, p . ) or wbd at expiry ( % control, p . ). conclusion: manufacturing method and/or storage solution significantly alters immunomodulatory effects of rbc supernatant on monocytes in vitro and may confound analyses of clinical effects of rbc storage duration, particularly within international multi-center studies. a magnetic levitation system to study the impact of donor gender, age and blood storage conditions on red blood cell density profile gozde durmus* , alessandro tocchio , anita howell , kaushik sridhar , jason p. acker and utkan demirci . stanford university, canadian blood services, centre for innovation, background/case studies: the amount of hemolysis in red blood cell units increases as the product ages and has been shown to be lower in female blood donors than in males. it is hypothesized that female donors possess, on average, a younger population of red cells, which results in the lower hemolysis that is observed in the pre-menopausal population. it is also hypothesized that the differences between donor populations are mitigated by lysis of older cells when whole blood units undergo processing steps to produce red cell concentrate (rcc) units. as red blood cells (rbcs) age in circulation, they undergo characteristic changes in density and membrane composition that allows for them to be separated from younger cells. study design/method: our aim is to study the effect of donor factors and method of manufacturing and storing conditions on the average rbc age and density of red cell units. we have recently developed a powerful yet simple and inexpensive magnetic levitation-based platform, which allows realtime, high-resolution imaging and monitoring of various cell populations. this label-free system allows density profiling for individual red blood cells, with an unprecedented resolution of - g/ml. first, to determine the effect of rcc storage on the density profile of rbcs, levitation and single-cell density profiles were measured at , , , , and days. in addition, to determine the effect of donor age and sex on the rbc density profile, blood samples from volunteers with four different age and sex categories (male, - years; male, > years; female, - years; female, > years) were profiled. results/finding: first, we observed that the levitation and density profiles as well as morphology of rbcs within rcc units change significantly during storage. in addition, rbc density was significantly different between young ( . g/ml) and older female donors ( . g/ml) (p < . ). moreover, rbcs from young males ( . g/ml) were significantly less dense compared to rbcs profiled from older female donors ( . g/ml) (p < . ). conclusion: we have developed a magnetic levitation system for the point-of-care, real-time evaluation of rbc and red cell concentrate (rcc) quality. we envision our results might inform decision makers about impact that donor deferral criteria may be having on the quality of red cell concentrates available in the blood banks, for the optimal clinical outcomes. cytokine production of pulmonary cells il- (pg/ml) il- (pg/ml) background/case studies: oxidation reduction potential (orp) or redox is the ratio of activity between oxidizers and reducers. redox imbalance caused by a higher production of reactive oxygen species (ros) and reactive nitrogen species or a decrease in endogenous protective antioxidants results in oxidative stress (os). while os can cause cellular injury and death, it is also important in the regulation of a healthy immune response to injury or disease. in the present study we investigated changes in hemoglobin, free heme, and orp as red blood cells (rbc) age and the effects of red blood cell age on icu patient morbidity and mortality. study design/method: icu patients were enrolled in this prospective observational trial investigating the effect of transfused rbc age on icu patient morbidity and mortality. all rbcs were pre-storage leukoreduced and abo identical. citrated blood samples were collected from each rbc unit prior to issue. the rbc supernatants were tested for free hemoglobin/ heme and orp. the patients were followed prospectively. results/finding: a total of rbc units were transfused. patients and rbc characteristics are shown in the table. significant reductions were detected in orp values over storage duration (p< . ). substantial correlations were also found between orp and free hemoglobin (p< . ) and orp and free heme (p< . ). interestingly, there was a statistically significant difference between the average orp values of the transfused rbc in patients who developed infection with higher orp values measured in rbc units given to patients who developed post-transfusion infections vs (p< . ). no significant differences were observed between orp and patient mortality, hospital/icu days, or thrombosis. also, no correlations were detected between free heme/hemoglobin or rbc age and infection development. conclusion: these data demonstrate that older blood has lower orp values as well as increased free heme/hemoglobin. there were no differences in orp values between the different blood groups once rbc age was controlled for and there were no statistically significant differences in patient mortality associated with orp, free heme/hemoglobin, or rbc age. the decreased orp values observed in the older blood are likely attributable to the "storage lesion". higher transfused rbc orp values were associated with subsequent development of infection, and younger rbcs were found to have higher orp values. thus, this data supports that young/fresher blood may predispose to subsequent development of infection in critically ill patients. further studies are needed. background/case studies: no randomized trials in humans have addressed whether only exposure to red blood cells (rbcs) that have been stored for a long time is associated with harm. we explore the effect on inhospital mortality of transfusing rbcs stored for more than days compared to rbcs stored for days or less. study design/method: data from a multi-national randomized controlled trial were used for this exploratory analysis. the patients were hospitalized adults who required transfusions and were randomly allocated to receive the freshest rbcs in inventory or the oldest (standard issue) rbcs providing a large cohort of patients receiving rbcs with storage durations along the entire rbc storage continuum of to days. using a time dependent variable patient exposure was defined by the maximum storage duration of rbcs received. this was then used to classify individuals on each day of hospitalization into one of three mutually exclusive exposure categories: freshest (exclusively exposed to rbcs less than or equal to days storage duration -reference group), medium age (at least rbc of - days storage), and oldest (at least rbc greater than days storage). the primary outcome was all-cause in-hospital mortality. cause-specific cox regression models of in-hospital death assessed the effect of exposure of rbcs in each category to exclusive exposure to rbcs stored for days or less. the effects of fixed and time-dependent confounders were dealt with through stratification and regression. sensitivity analyses were conducted with a) weekly partition with cut-points every days, and b) a finer partition using cut-points every days. results/finding: , patients receiving , rbcs were included in the analysis. exposure to rbcs stored for more than days was not associated with increased risk of in-hospital death compared with exposure exclusively to the freshest rbc units (stored for days or less) after adjusting for several fixed and time-dependent potential confounders (hr . ; % ci: . , . ; p . ). exposure to blood stored for at most - days yielded a similar hazard ratio (hr . ; % ci: . , . ; p . ). in the sensitivity analyses using weekly partitions, exposure to rbcs stored for greater than days compared to exclusive exposure to rbcs stored days or less was not significant (hr . ; % ci . , . ; p . ). the confidence intervals around the hazard ratios for the other -day intervals all include . similar findings were obtained with partitioning exposure data into day intervals where exposure to rbcs stored for - days was not associated with increased risk of death compared with exclusive exposure to rbcs stored for - days (hr . ; % ci . , . ; p . ). the confidence intervals around the hazard ratios for the other -day intervals all include . conclusion: individuals exposed to rbcs stored for more than days were not at increased risk of in-hospital death compared to individuals exposed exclusively to rbcs stored for days or less. transfusion of anaerobically stored red blood cells improves recovery in experimental rat hemorrhagic shock model alexander williams* , cynthia walser , tatsuro yoshida , andrew dunham and pedro cabrales . university of california san diego, new health sciences inc. background/case studies: hemorrhagic shock (hs) severely decreases oxygen (o ) delivery and induces cardiovascular collapse. in parallel to controlling the hemorrhage, clinicians respond by infusing large volumes of red blood cells (rbcs) to restore blood volume, o carrying capacity, and hemodynamic stability. the quality of the transfused rbcs determines the recovery from hs, and extent of clinical sequelae prompted by the hs. this study compares the ability to recover from hs with conventionally stored rbcs, anaerobically (o saturation < %) stored rbcs, or anaerobic/hypercapnic (o saturation < % and pco (@ c) $ mmhg) stored rbcs. study design/method: packed red blood cells (prbcs) stored in as- after leukorfiltration were created from donor sprague-dawley rats. prbc units were randomly stored under either ) conventional; ) anaerobic; or ) anaerobic/hypercapnic conditions. rats ( - g) were hemorrhaged to % of blood volume, held in hypovolemia for minutes, and resuscitated to recover blood pressure to % pre-hemorrhage with prbc stored for either or weeks. systemic hemodynamics, cardiac function, and blood gas parameters were monitored during shock and resuscitation; and vital organ inflammation, oxygenation, and function were evaluated post resuscitation. data were analyzed using two-way anova, followed by the appropriate post hoc analyses. ( %) neg patient showed short term response and ( %) patients showed progressive disease. at the neg group standard eval ( %) patient showed response and ( %) had progressive disease. ( %) neg patient had long term response compared to ( %) pos patients. at the pos short term eval ( %) patients showed response and ( %) patients had progressive disease. at the pos group standard eval, ( %) patients showed response and ( %) patients had progressive disease. overall, ( %) pos patients responded compared to ( %) neg. conclusion: there is a trend in lower response rate in patients with negative antibody screens compared to positive controls. these findings suggest that an anti-cd neutralizing substance could play a role in treatment response. alternatively, reduced cd expression may also contribute. the low response rates seen in both groups may result from biased selection. the need for repeat t&s and presumed repeat transfusions may be preselecting patients with more aggressive disease. also, only a small number of patients were suitable for review. a larger prospective study that controls for such variables is needed. a review of blood utilized during provider-activated and critical administration threshold-triggered massive transfusion events patrick ramos* and john hess. division of transfusion medicine, harborview medical center background/case studies: traditional definitions of massive transfusions -e.g., the transfusion of ten or more units of red blood cells (rbcs) in a -hour period -are limited in prospectively identifying patients requiring massive transfusions, excluded patients who may not survive long enough to meet criteria, or ignored the acuity of the event. to address these issues, a level i trauma center adopted the critical administration threshold (cat) as an additional indication for activating its massive transfusion protocol (mtp). this study reviewed blood utilized during massive transfusion events based upon whether the mtp was provider-activated versus cat-triggered. study design/method: all massive transfusion events between january and april were reviewed to identify the start time, termination time, number of components transfused, and the start time of each component transfused. the transfusion of three or more blood components in an hour defined cat. a massive transfusion was any event in which the concern for hemorrhagic shock either necessitated a provider to activate the mtp or blood components were transfused at a rate that met cat criteria. the massive transfusion start time is based on either the time the provider activated the mtp or the time the first blood component was transfused, whichever came first. unless the patient expired first, the termination of the massive transfusion event was determined by identifying the point in time in which the patient went three or more hours without the transfusion of any additional blood components. this information was tabulated to determine the monthly number of provider-activated mtps, cat-triggered mtps, and average blood component transfused per massive transfusion. conclusion: blood utilization is lower within the cat-triggered mtps even though it outnumbered provider-activated mtps. however, the mode for both groups suggests that most massive transfusion require less blood components than the average rate. using the mode provides an approximate % replacement of blood volume. this should be enough to counter the early signs and symptoms of hemorrhagic shock. though this study did not review the appropriateness of provider-activated mtps, using cat as an indicator ensures clinicians are prepared for a potential massive transfusion. further investigation is needed to determine the factors contributing to the downward trend of the average blood components transfused. the mode would suggest optimistically that patients are being stabilized faster and resuscitated more efficiently. if this is the case, defining massive transfusion should include the rate of components transfused in addition to the total volume transfused. the long term storage effect of . m dithiothreitol on red cell antigen integrity in reagent red blood cells heike carrel* , laurie sutor , , germ an leparc , marjorie doty and william crews . carter bloodcare, ut southwestern medical center, oneblood background/case studies: anti-cd drugs, such as daratumumab, pose a problem for the transfusion service. they may cause a number of false positives, including positive direct antiglobulin tests (dat), indirect antiglobulin tests (iat), and panreactivity in eluates. such results can prolong compatibility testing and delay delivery of blood products for patients. treating reagent red cells (rrbcs) with . m dithiothreitol (dtt) removes drug interference due to daratumumab and allows for the detection of underlying alloantibodies. this study aimed to investigate the effect of dtt-treatment on rrbc antigen integrity over a day period. study design/method: twelve aliquots of human plasma, each containing an antibody of a single, known specificity (anti-d, -c, -e, -c, -e, -m, -s, -s, -fy a , -fy b , -jk a , and -jk b ), were tested against untreated and . m dtttreated rrbcs (immucor panoscreen i, ii, iii; dtt from acros organics). dtt treatment of rrbcs was performed using the methodology described in the aabb technical manual ( th edition). each of the plasma aliquots was further separated into aliquots and stored at - c until day of use. fresh aliquots were thawed each day to avoid unintended antibody integrity degradation. a polyethylene glycol (immucor) enhancement technique was used and reactions were read at the iat phase. hemolysis, if present, was observed in the diluent each day prior to mixing the cell suspension and given a grade based on the haemonetics color comparator chart. serological antibody reaction strengths were observed and documented each day. ( ) a monthly breakdown for both groups also displayed a downward trend in the average use of blood components. results/finding: there was noticeably more hemolysis with the dtttreated cells over time compared to the untreated cells. red cell antigens remained serologically detectable on the dtt-treated cells throughout the study, despite a greater degree of observed hemolysis. there was minimal difference in reactivity strength between untreated and dtt-treated cells for antigens not affected by dtt. in most instances, the dtt-treated cells reacted slightly more strongly. none of the antibodies produced reactivity strengths of less than with the untreated or dtt-treated cells during the study. conclusion: long term storage of . m dtt-treated rrbcs does not compromise antigen integrity. advance dtt-treatment and storage of a large aliquot of rrbcs may serve to increase efficiency in the transfusion service. background/case studies: monocyte monolayer assay (mma) is a cellular bioassay used to evaluate the hemolytic significance of blood group antibodies and aid in the selection of rbcs for alloimmunized patients. the requirement for fresh auto/allogenic monocytes for mma is highly restrictive due to tedious processing of fresh peripheral blood (pb). our previous study described processing and cryopreservation of buffy-coat (bc) derived and fresh pb-monocytes for mma assay. the aim was to evaluate the functional properties of cryopreserved bc-monocytes as substitute for fresh pbmonocytes in mma in evaluation of previously reported clinically significant rbc alloantibodies. study design/methods: peripheral blood mononuclear cells (pbmcs) were isolated from buffy-coats (histopaque- ), pooled, suspended in cryopreservation media ( % dmso; : ) and stored in liquid nitrogen. pbmc membrane integrity post-thaw was determined by trypan blue exclusion. pbmcs were cultured on poly-l-lysine-treated coverslips ( c, % co , h) and monocyte monolayers incubated with fresh or cryopreserved antigen positive (o ) rbcs sensitized with either anti-d (positive control), anti-scianna- (sc ) or anti-anwj or lipopolysaccharide stimulated for h. aliquots of the sensitized rbcs were tested for opsonization by indirect antiglobulin test (iat). phagocytosis index (pi) was determined microscopically as the number of fully phagocytosed rbcs/ monocytes. supernatants were analyzed for cytokines using luminex technique. results/findings: cryopreserved pbmcs showed . % viability postthaw. we report no significant difference in phagocytosis of anti-d sensitized rbcs by cryopreserved monocytes vs fresh monocytes. we show a significant increase in tnf-a, il- b, il- , il- , mip-a (p < . ), mip-b and gro (p < . ) secretion from cryopreserved bc monocytes vs both fresh bc and pb-monocytes. sc -and anwj-sensitised rbcs resulted in a pi of . % and . . % respectively vs anti-d sensitized rbcs (pi: . %). a weak ( ) reactivity by iat was observed for anti-anwj sensitized rbcs while anti-d sensitized rbcs resulted in iat reactivity. these results correlated with previously reported results for clinical significance and mma when using freshly obtained autologous or healthy donor monocytes. conclusion: this study shows that cryopreservation preserved monocyte viability and phagocytosis function for mma. as previously reported with fresh monocytes mma assay, the two alloantibodies tested with cryopreserved bc monocytes were shown to have a phagocytic index of clinical significance (pi> %). the use of cryopreserved bc-monocytes has the ability we describe antigen typing discrepancies in patients, involving antigens (c, jk a , s), revealed when serologic results differed from the phenotype predicted by dna testing. all patients had - positive dat with anti-igg and warm autoantibodies identified in the plasma. investigation of the antigen typing discrepancies showed both false negative and false positive results using monoclonal reagents. study design/method: standard tube hemagglutination methods were used for antigen typing. rbcs were treated with edta glycine-acid (ega) using gamma ega kit. genomic dna was isolated from wbcs and hea precisetype performed. results/finding: the rbcs of patients and typed c-on initial testing with immucor gamma-clone anti-c, but were predicted c by hea precise-type. ega-treated rbcs gave reactions with the same anti-c reagent. patient rbcs gave variable reactivity (vw- ) with bio-rad seraclone and ortho bioclone anti-c. patient rbcs gave reactivity with all anti-c reagents when incubated for the maximum incubation time allowed. patient rbcs were jk(a ) with immucor gammaclone anti-jk a , which the manufacturer states is suitable for testing dat rbcs, but predicted jk(a-) by hea. ega-treated rbcs tested jk(a-) with the same reagent. rbcs from patients and tested s with bio-rad seraclone anti-s ( - ), but predicted s-by hea. further testing with immucor gammaclone anti-s showed rbcs from both patients were s-. ega-treated rbcs from both were non-reactive with both anti-s reagents. conclusion: commercial monoclonal reagents are valuable resources, especially when phenotyping dat rbcs but not all manufacturers include reagent limitations regarding testing of dat rbcs. we describe cases of false negative tests with monoclonal anti-c due to antigen blocking by igg, and cases with false positive tests with anti-s (n ) and anti-jk a (n ) typing. false positive tests would potentially be anticipated, but false negative results due to antigen blocking are unexpected. extended incubation as indicated in the reagent insert may reveal weak reactivity when antigen blocking is involved. results concordant with dna testing were obtained with ega-treated rbcs, but it is generally accepted that this is not necessary when using a direct-agglutinating monoclonal reagent. these cases caution the potential for both false negative and false positive results for samples with - positive dat and supports testing to dissociate igg from rbcs strongly dat before antigen typing. in addition, this report highlights the benefits of dna testing as part of the routine reference laboratory workup. background/case studies: sensitization to antigens expressed on transfused cells, by triggering premature antibody-mediated clearance, diminishes the therapeutic effectiveness of transfusion and may also lead to serious delayed hemolytic transfusion reactions. accepted us clinical practice, while providing that sensitized patients receive only cells lacking "offending" antigens, nevertheless ensures continued alloexposure, and thus possible sensitization, to additional antigens, thereby complicating patient management. to mitigate sensitization risk, especially in an era of increasingly cost-conscious procurement, a quantitative assessment of the immunogenicity of specific antigens will be desirable. giblett, long ago, introduced a relative scale relating the rbc antigen immunogenicities to (an assumed) immunogenicity of "k" (http://bit.ly/ opqfew ). here, we show that an absolute estimate of immunogenicities may be extracted directly from observed antibody counts provided these are properly normalized to the fraction of recipients at risk (namely those lacking a specific antigen) and the expected fraction of donors expressing that antigen. study design/method: we define immunogenicity, or sensitization risk, r, for any antigen ("ag") of interest, as the conditional probability of alloantibody ("ab") formation, given allo-exposure to ag, i.e. r : prob(ab|al-loexp), so that prob(ab) prob(ab|alloexp)*prob(alloexp) and r ; rewriting prob(alloexp) prob(recipient, "r", lacks ag)*prob(donor , "d" has ag); and estimating prob(ab) nab/nr, nab denoting the number of ab in nr recipients, we obtain: nab/(nr*prob(r lacks ag)) r * prob(d has ag), the left-hand side representing the observed sensitized fraction, u, i.e. the number of observed ab in relation to the number of recipients at risk. conclusion: several antigens, though corresponding antibodies may be rare (e.g. "jsa", "e", "u"), nevertheless are highly immunogenic, requiring only a single exposure (on average) for sensitization; in contrast, others (on average) will require many exposures and thus pose a relatively low risk. in conjunction with patient genotypes, our r -scale will facilitate the selection of patient-specific cells so as to minimize the risk of (proliferating) alloimmunization even when perfectly matched cells are not available. our approach may be readily extended to additional rbc antigens and other antigen systems. background/case studies: aabb and fda require a month deferral of donors with a tattoo applied using non-sterile needles or reusable ink. we review state regulations to ascertain if tattoo establishments are licensed and required to use sterile or single-use needles and single-use ink. we recently added two large states in which we collect blood to the acceptable states list (asl). we compared the rates of donors deferred before and after the addition of these states to determine potential donor gain with changes in state tattoo licensing regulations. study design/method: we analyzed allogeneic interview responses to the screening question, "in the past months have you had a tattoo?" and if 'yes', whether the tattoo was applied by a state regulated entity. blood centers in states were selected for the analysis before and after state tattoo regulation. in state a, a comparison period of similar months before ( / - / ) and months after ( / - / ) was selected; for state b, a similar months before ( / - / ) and months after ( / - / ) was selected. frequency and rate of responses were compared in before and after periods. among those who responded to having a tattoo in a regulated state, donations were reviewed for presence of infectious disease markers including hiv, hbv and hcv. results/finding: a higher proportion of donors presenting to give blood admitted to having a recent (< months) tattoo in the post period in both states. this increase occurred immediately following the addition of states a and b to the asl (data not shown). among those who responded yes to having a tattoo, in states a and b respectively, there was a -and -fold increase in accepted donors (table) . the absolute number of accepted donors with tattoos increased from to (state a) and to , (state b), which annualized, represents a potential gain of , (state a) and , (state b) additional donations. all donors who had a tattoo in regulated states (asl) tested negative for hiv, hbv and hcv. conclusion: to counter rising numbers of ineligible donors resulting from recently added deferrals, we considered recovery of donors deferred for tattoos as a way to enhance our donor base. the immediate rise in the number of donors reporting a tattoo following the addition of the states may reflect a decline in self-deferrals based on having had a recent tattoo. we demonstrated an increase in the potential number of donations without compromising safety. background/case studies: transgender donors represent a small fraction of blood donors. determining their eligibility to donate has been challenging for blood centers. to assess behavioral risk, the donor is required to answer gender specific questions. the same is true when assessing trali risk where the donor is asked about a history of prior pregnancies. prior to the implementation of the fda's final rule, blood centers asked donors for their birth gender and determined eligibility based on that gender. if the donor changed their gender they were asked to answer both the male and female questions. the final rule now allows blood centers to accept the donor's stated gender and to determine eligibility based on that gender. in order to assess the risk of failing to ask a transgender male donor (birth gender female) the pregnancy question, a review was done to determine the number of transgender males who were actively donating with a large blood center. and tracked. donors were contacted to resolve any descrepancies. donors who had changed their gender from female to male and who had answered yes to prior pregnancies were identified. hla antibody test results were reviewed for these donors to see if they had been tested and whether they had tested positive or negative. results/finding: from - , there were donors identified who had changed their gender from their birth gender; female donors changed their gender to male and male donors changed their gender to female. there were ( %) transgender male donors, birth gender female, who had answered yes to the pregnancy question at one of their donations. three of these donors were apheresis donors who had been tested for hla antibodies. one tested positive and the other two tested negative for hla antibodies. the four other donors were whole blood donors and had not been tested. an hla test was added to these donors' records so that the test could be performed the next time they presented to donate. conclusion: transgender male donors may have had prior pregnancies and are also choosing to become pregnant after having transitioned from female to male. six percent of transgender males that we identified reported a prior history of pregnancy. at our center, when a donor requests a gender change from female to male, an hla test is requested for the next donation. first time donors are qualified based on their stated gender so transgender donors with a history of pregnancy will not be identified unless they volunteer this information. consideration should be given to using educational materials to prompt the donor to reveal a history of pregnancy at the time of donation so that hla antibody testing can be performed. effect of variable volume scale introduction in a large multi-site blood center ralph r vassallo*, marjorie d bravo and hany kamel. blood systems, inc. background/case studies: regulations allow whole blood donation [wbd] of up to . ml/kg or % of estimated blood volume [ebv] . traditional measuring/mixing devices are set to halt blood flow at fixed volumes which, with testing samples, are consistently below the % limit. variable volume scales [vvs] can be programmed to vary unit volume (up to ml) by donor ebv. this maximizes transfusable rbcs and plasma and recovered plasma [rp] volume. rp from wbds is a small but important source of derivatives and blood center cost recovery. we report the effect of introducing the hemoflow vvs on donor reaction rates and rp volume in a large blood center. compared to previous fixed settings, variable collection volumes were expected to decrease by ml at ebvs < . l in donors ! yo, but increase by - ml for all others. study design/method: donor vasovagal reaction [vvr] rates (prefaints, prolonged/offsite reactions, and loss of consciousness [loc]) for successful wbds were obtained from the center's hemovigilance database for the mos. before a mo. phased implementation of the vvs, and the subsequent mos. multivariable analysis [mva] by -mo. periods was performed in a model incorporating donor sex, age, first-time [ftd] vs. repeat status, ebv and donation site. both the volume and number of units of plasma sent for fractionation were available for the same time periods from the blood center's data warehouse. results/finding: compared to the baseline period, a significant increase in prefaint reaction rates were noted in pre-implementation (impl) periods & , continued during impl and post-impl periods & , returning to the baseline rate in post-impl periods & (table) . more severe reactions showed an increasing trend that only became significant in post-impl periods & . the mva showed the vvs as independent factor contributing to the increased prefaint and more severe reactions. however, its contribution, as measured by odds ratios, was consistently lower than those exerted by known donor determinants of reaction rates: young age, low ebv, ftd status and collection site (not shown). plasma unit volume increased an average of . ml during post-impl periods & from the temporally matched baseline & pre-impl period . conclusion: following an initial increase in mild vvrs during and immediately after implementation of the vvs, vvr rates fell back to baseline, suggestive of transient staff distraction from usual donor care, or a minor effect of increased blood loss with a superimposed improvement trend. the subsequent increase in prolonged/offsite reactions and loc after prefaint reactions had already returned to baseline suggests that staff training, work load, donor compliance with mitigation strategies and other determinants of donor reactions have a far greater effect than the small additional blood loss due to the vvs. small but significant increments in rp volume improve derivative availability and offset the cost of the vvs. comparison of vasovagal and citrate reaction rates in donors according to type of apheresis procedure pierre robillard* and yves gr egoire . hema-quebec, h ema-qu ebec background/case studies: apheresis procedures expose donors to various volumes of citrate depending upon type and length of procedure and type of machine used. citrate reaction (cr) results from various degrees of hypocalcemia in donors. blood volumes taken from donors vary according to type of procedure and use of volume replacement. loss of blood volume is in part responsible for the occurrence of vasovagal reactions (vvr). this analysis was conducted to estimate the incidence of cr and vvr according to various types of apheresis procedures performed at our blood center. (yfv) were reported in some brazilian states -rio de janeiro, sao paulo, minas gerais and espírito santo, mainly. the vectors of those cases were mosquitoes from the haemagogus and sabethes genders, whose habitat is the tropical forests. since many brazilian urban areas are very close to rain forests, there is an outbreak risk in those areas, where the infection is transmitted by the aedes mosquitoes. in order to minimize this risk, rio de janeiro health authorities decided to promote a mass vaccination in late march, . the vaccine is produced with live and attenuated yfv, which can circulate for at least weeks after vaccination. in some individuals, the vaccine can elicit viscerotropic effects and sometimes severe diseases. due to that, brazilian blood regulation authority established a week deferral period after yfv vaccination. this action could dramatically affect the availability of blood donors. this study shows the measures taken by rio de janeiro blood center to circumvent this risk and attract more donors. study design/method: the strategy consisted in offering the population, at a single place -the blood center -the possibility to donate blood and, immediately after donation, to get vaccinated against yfv. there were no financial advantages to the donors, since yfv vaccine is completely free of charge for any brazilian citizen. the vaccine was administrated by trained nurses, in an office close to the donors session. if, for any reason, the prospective donors were not able to donate, the vaccine was also offered to them, provide there were no contraindications. the blood center annnounced just before the mass vacination campaign launching that it would vaccinate people who came to the blood center to donate blood. if, for any reason, the prospective donors were not able to donate, the vaccine was also offered to them, provide there were no contraindications. results/finding: during the five days of campaign, we received , blood donors candidates; from those, , were accepted as a blood donor, after medical interview. the deferral rate was . %. at the same period of the year , there were , prospective donors, and blood donations. the deferral rate was . %. the "get vaccinated against yfv . . .but give blood before" campaign was able to attract, in a five day period, , additional donors, compared to same dates. that represents a . % increase in the number of blood donations, without deferral rate increment. there was a slight increase in the proportion of first-time donors, from . % in to . % in . conclusion: the strategy was more than successful, and it allowed the blood center to build a blood inventory large enough to avoid risks of shortage due to mass vaccination against yfv. dose loss which must be accommodated when collecting plt donations to ensure the us plt dose of ! . x is met. currently, triple set kits for pr are only approved in europe. plt loss, and adjusted apheresis targeting parameters may impact split rate (sr) or products per apheresis procedure. inventory suitable for pr without impacting us blood center srs warrants evaluation and optimization. study design/method: , apheresis collections from centers with different srs were analyzed. a baseline sr for conventional pc was calculated assuming i) a minimum dose (allowing for production loss) of . x for single (s), . x for double (d), and . x for triple (t) conventional pcs, ii) concentration and volume requirements from apheresis device manufacturer were used. for each collection, dose, volume, and concentration were assessed for pr kit compatibility, based on storage medium (pas or % plasma) assuming i) a minimum dose (allowing for production loss) of . x for s and . x for d for pr units, ii) removing small quantities from units with excess volume or dose to meet pr specs., iii) if all or part of an out of parameter d or t collection could be divided into one or more kits for pr, eligible parts undergo pr, and the remainder treated conventionally, iv) collections unsuitable for pr specs. or would decrease sr if treated would be counted as conventional pcs. results/finding: conclusion: blood centers today can adopt pr for a significant percent of their current supply (as high as %) without affecting their sr. compatibly increases further by dividing t and large d donations. percent achievable depends on their current s, d, t proportion of collections and practices. changes to d and t collection parameters, optimized donation and counting accuracy, and volume reduction will improve pr compatibility further. individual analysis is warranted for each blood center. rbc rbc plt/p plt plt/rbc/p plt/rbc plt plt/rbc plt/p #donations citrate exposure (mls) - study design/method: a randomized ( : ), placebo-controlled, single blind, subject, single-site study of ascending microdoses of autologous (apheresis-derived) thrombosomes was conducted. subjects were divided into cohorts, receiving increasing doses, ranging from / , - / of the lowest effective dose found in the above rabbit model. cohorts and received the / th dose, but cohort received two / th doses one hour apart. the primary end points were safety and tolerability. subjects were monitored in-hospital for hrs post infusion and followed for up to days for adverse events, global neurological assessments, abbreviated physical exams, and laboratory tests. results/findings: there were no serious adverse events (saes) or subject discontinuation post-infusion due to a significant decrease in platelet count from baseline. there were a total of aes: were treatment emergent (teae), of which were treatment-related ( thrombosomes and control). all teaes were mild or moderate in severity. in cohorts and , / thrombosomes subjects had treatment related adverse events. one cohort subject developed an upper respiratory infection and elevated wbcs within hours post infusion, which resolved by hours, and an elevated d-dimer at hours post infusion, which resolved by day . this subject also had an elevation of prothrombin fragment at baseline, which increased post transfusion and peaked at hours with resolution by day . one cohort subject developed non-specific t-wave changes at and hours following her nd infusion that resolved by day without clinical symptoms. troponin levels and echo stress tests were normal. ekgs were considered possibly a normal variant or related to placement of the ekg leads. another cohort subject developed an igg platelet autoantibody on days - , which was undetectable on days - ; there was no change in platelet counts. the thrombosomes autoantibody assay was positive at baseline, days - , and negative on days - . background/case studies: cryopreservation of platelets (plts) could extend the shelf life from - days to over two years. cryopreserved plts (cryoplts) appear to have a greater in vivo hemostatic effect than liquidstored plts. plts have been shown to require protein synthesis capabilities for certain functions such as clot signaling and immune responses. this study was designed to assess whether reconstituted cryo-plts carry out protein synthesis upon thawing and short term storage. study design/methods: apheresis plts were cryopreserved with % dmso and stored at c. after thawing, the unit was reconstituted in thawed ffp spiked with either lm puromycin (pm) or nm biotinlabeled pm. plts were stored at room-temperature with agitation. samples were drawn immediately after reconstitution as well as after , and hours to assess pm incorporation as a measure of protein synthesis, and for in vitro assays to determine platelet activation by cd p binding, phosphatidylserine exposure by annexin-v binding and microvesicle count in the supernatant. plt microvesicles (pmv) were prepared from the supernatant by ultracentrifugation. plts and pmv were lysed in a triton x- containing buffer and qualitative proteomics was performed on samples following affinity-purification with streptavidin beads. results/findings: in vitro parameters of reconstituted and subsequently stored platelets were in line with previously published results, with high surface levels of cd p and phosphatidylserine. pmvs were generated during cryopreservation and the count increased by -fold during hour storage. immunoblot analyses of the plts showed a -and -fold increase in pm incorporation after and hours of storage, respectively. massspectrometry revealed unique proteins that were synthesized after hours of storage, which was confirmed for gtpase and gtpase-regulatory proteins rac , rap and rhogdi by immunoblot analyses. analyses of the pmv translatome also revealed the presence of synthesized proteins; however, these did not change throughout storage. this finding suggests that a defined panel of proteins is packaged into pmvs upon freezing and thawing. additionally, the pmv translatome profile comprised a smaller subset of synthesized proteins compared to the cryo-plt translatome, including the proteins rac , rap and rhogdi. conclusion: this study has demonstrated that cryo-plts can synthesize proteins upon reconstitution in ffp and subsequent storage. discovery of a subset of these proteins in the pmv suggests their encapsulation, possibly in a selective manner. this observation provides novel insights into the capacity for protein synthesis in cryo-plts and the potential regulation of protein packaging into pmv. background/case studies: in , the authors' hospital-based blood bank received variances from the fda and aabb for the use of cold stored platelets (csps) with a shelf life of days. these group a csps, stored in a refrigerator in the emergency department, were used to support the trauma program for use in massively bleeding patients. the placement of the csps on the air ambulances, stored in coolers, was the next logical step in providing platelet therapy sooner to these patients. study design/methods: eight double unit csps were collected using the trima accelv r . two double csps were pathogen reduced using the inter-ceptv r pathogen reduction system. half of the csp pairs were subjected to flat storage in a refrigerator; the other half were loaded into a credov r - cooler with units of ffp, units of rbcs, and unit of whole blood. three to ml of platelets were collected via syringe from each unit at min (before storage in cooler or refrigerator) and after . , , , , and hours of storage for functional validation of platelets. the platelet count, agonists (thrombin receptor agonist peptide (trap), adenosine diphosphate (adp) and collagen stimulated platelets aggregation), non-activated and agonists activated platelet surface expression of phosphatidylserine (ps, annexin-v binding), p-selectin, fibrinogen receptor (pac- binding) were measured by coulter counter, channel aggregometer, and digital flow cytometer. paired wilcoxon rank sum tests were used to analyze differences in degradation rates with p< . deemed significant. conclusion: platelets, including pathogen reduced, stored in an oxygendeprived environment, (cooler), do not lose functional capabilities when compared to those platelets stored in a refrigerator with adequate oxygen for hours. therefore, cold stored platelets transported in a cooler are a viable option for providing timelier platelet intervention for severely injured patients prior to hospital arrival. c -a h molecular sieving: beyond genotyping ghazala hashmi , reinhard klemm and michael seul* , . biomolecular analytics, immunoinformatica background/case studies: more than a decade after its commercial introduction (hashmi http://bit.ly/ ohlehe), blood group genotyping, though available in several formats, has remained a tool for special tasks, e.g. the profiling of difficult patient samples or the identification of rare antigen combinations, while serology has remained the tool of choice for routine antigen typing. here, we introduce molecular sieving as an alternative to the current approach of managing special donor unit inventories. this novel process for dna analysis combines the "multiplexing" of markers offered by existing genotyping methods with the pooling of multiple samples in manner permitting the step -wise refinement of candidate sets by molecular attribute patterns. study design/method: molecular sieving is a special format of leansequencing, a proprietary process that permits the simultaneous analysis of up to four samples for alleles encoding rbc antigens in mns,rhce, lu,kel,fy,jk, di,yt,do and co, including the identification of rhce alleles. molecular sieving extends these capabilities to the analysis of pools to attain large scale. thus, in one format of the process, * * samples are accommodated in a single run. following the completion of the sieving step, candidates may be directly assigned to requests, or may be selected to enrich a subsequent profiling step for samples with rare or otherwise desirable attributes. here, molecularsieving was used to identify suitable donor units for sensitized sickle cell anemia ("sca") patients (tb in cas-tro , http://bit.ly/ oplxhr, excluding le and e(variant) and assuming request per patient), presenting with up to allo-antibodies ("ab") in multiple combinations. proprietary "greedy" algorithms were invoked to optimally pair candidate units with requests. results/finding: sieving of only = plate holding * candidate units from actual black donors, followed by profiling of samples selected to enrich for "e neg" and "c neg" and "c-e-k-fya neg", produced assignments for of requests ( . %), as indicated by colors, and shown in the row "assigned" below: thus, the number of assignments substantially exceeded the number of wells processed. moreover, the remaining pooled samples produced additional assignments to a second set of requests, for a total of assignments from only wells. in another scenario, sieving of a full plate of * samples, produced $ assignments for two successive batches of requests from sca patients, a yield exceeding . x. sieving alone typically fills - % of requests of moderate complexity ( ab). conclusion: molecularsieving, by widening the "funnel" while focusing the search for candidate donor units, attains a new level of efficiency in procuring suitable units for patients with hemoglobinopathies. molecular sieving for identifying red blood cells with special phenotype attributes kristopher fernandez , monica kalvelage , ghazala hashmi* and michael seul . biomolecular analytics, lifeshare blood centers background/case studies: providing transfusion support to patients with sickle cell anemia and other hemoglobinopathies remains a challenging logistical task that must accommodate pre-existing allo-antibodies in multiple combinations preferably while minimizing the risk of (continued) transfusion-related sensitization. the allelic diversity of the predominantly black patient population, especially at the rh locus which encodes a variety of "partial" phenotypes further complicates the problem (chou http://bit. ly/ ppvfeq ). study design/method: molecular sieving is a proprietary new process that, in order to rapidly probe candidate donor units in large numbers for multiple phenotype patterns, permits the analysis of pools and pools of pools of samples for a multiplicity of alleles (including at the rhce locus) that encode mns, rh, lu, kel, fy, jk, di, yt, do and co antigens. based on sieving, samples may be grouped by molecular attribute patterns ranging from single "ag " (e.g. e ,c ,e ,c ) to specific combinations of "ag " (e.g. c e k fya and c e jsa ) or combinations of alleles such as those encoding partial rh phenotypes. sieving, optionally, may be followed by profiling of samples selected for desirable attribute patterns. genomic dna from (predominantly) black donors, independently genotyped by one of two commercial methods were provided by lbc. at bmx, pools were prepared prior to amplification, and analyzed by a novel leansequencing method. results/finding: all pool genotypes were consistent with available individual sample genotypes. antigen patterns of particular interest included two groups, namely: several for which pools were homozygous and certain others t for which pools were heterozygous. illustrative of the former pattern type are these: appropriate pool queries revealed that sieving alone identified, among the c samples, that were also v and vs and, among the e samples, that were also negative for any partial_e phenotype. illustrative of the latter pattern type are pools identified as heterozygous ("het") for alleles encoding antigens of high or low prevalence. by segregating het pools into subpopulations, we were able to select specific "ee" pools of which were demonstrated (in subsequent profiling) to contain an e-sample. we also identified pools "het" for alleles indicating the possible presence of a rare donor, for example yta|b ( pools), co a|b ( ) and others. conclusion: molecularsieving of a single -well plate identified many desirable "antigen-negative" phenotypes and permitted selection of pools for combinations of "ag-neg" patterns including "partial:" rh phenotypes and combinations of c , e and jsa . these samples are thus confirmed "ag neg" and available for assignment. sieving also facilitated the enrichment of subsequent refinement of molecular attribute profiles in accordance with pending or anticipated demand. "antigen-neg" pattern partial_c partial _c, _e samples available after sieving background/case studies: sequence information generated from next generation sequencing (ngs) is often computationally phased using haplotype-phasing algorithms. utilizing experimentally derived haplotype information improves this prediction, as routinely used in hla typing. among the blood group systems, however, experimentally derived haplotypes are known for short genes only, such as icam (landsteiner-wiener) and ackr (duffy). for longer genes, such as abo of > kb, most haplotypes are only statistically derived. we recently established a large dataset of long ermap haplotypes, which code for the scianna blood group system. study design/methods: the nucleotide sequence of > kb each was used for all physically confirmed ermap alleles that we previously published. full-length sequences were aligned and variant sites were extracted manually. the bayesian coalescent algorithm implemented in beast v . . was used to estimate a coalescent phylogeny for these variants and the allelic ancestral states at the internal nodes of the phylogeny. results/findings: we found at least clades representing clusters of to alleles. for each clade, one observed allele was identified as the ancestral allele for its cluster of alleles. using the alleles, we were able to predict alleles with high posterior probability, which were ancestral to the observed alleles and, while not yet observed, may be extant. conclusion: we explored the phylogenetic structure and evolutionary events underlying the origin of different ermap alleles and predict ancestral alleles. in the present study, we show means to predict alleles and to calculate the distinct probabilities of correctness for such predicted alleles. the probabilities can be instrumental in defining a cut-off value to determine which computationally predicted alleles are worth confirming by physical evidence. the alleles identified by studies like ours may be utilized in designing of microarray technologies, imputing of genotypes and mapping of ngs data. the new alleles with nucleotide insertions would be predicted to cause complete loss of expression of the corresponding antigen from a bioinformatics perspective and to encode group o. rather very weak expression of the respective antigen and lack of the corresponding antibody in the plasma was found, confirming these represent subgroups of a and b and suggesting that transcriptional slippage, which has been observed before, is responsible for low level antigen expression. abo genotyping is powerful when both serology and molecular results are evaluated together, and these studies are needed to inform development of bioinformatics tools to accurately associate abo genotypes with phenotypes. background/case studies: evolutionarily related abo and gbgt genes encode a and b glycosyltransferases (at and bt) and forssman glycolipid synthase (fs), which catalyze the biosynthesis of a and b, and forssman (fors ) oligosaccharide antigens responsible for the abo and fors blood group systems, respectively. human at and bt possess leuglygly and metglyala, respectively, at codons - , and these tripeptides are important in determining the sugar specificity of enzymes, n-acetyl-d-galactosamine (galnac) for at and galactose for bt. functional fss possess gly-glyala at the corresponding codons, and exhibit galnac specificity. it has been recently shown that human at gained weak fs activity when the leu-glygly was substituted by glyglyala, suggesting that the tripeptide is involved in the recognition/binding of acceptor substrates, in addition to donor nucleotide-sugar substrates. study design/methods: we have searched for additional mechanisms that might enable human at to express fors . a variety of amino acid substitution constructs of human at were prepared. additionally, exon deletion constructs of at mrna transcripts were also prepared. dna from those expression constructs was transfected into cos (b galnt ) cells, and cell-surface expression of fors antigen was immunologically monitored with a monoclonal anti-fors antibody. results/findings: we found that met thr/ser substitutions also conferred human at with weak fs activity. we also found that the deletion of exon or of human at transcripts bestowed weak fs activity. because altered rna splicing is frequent in cancer, this mechanism may explain, at least partially, the appearance of fors antigen on certain cancer cells and tumors in forssman antigen-negative human species. furthermore, the co-introduction of one of those changes together with the glyglyala substitution synergistically conferred strong fs activity, in addition to strong at and bt activities. conclusion: the substitution of the glyglyala tripeptide codon in the catalytic domain may modify the acceptor specificity of the enzyme. met thr/ ser or exon / deletion may alter the intra-glogi localization of the enzyme. and those mechanisms function in synergy. the overlapping usage of acceptors by glycosyltransferases encoded by abo and gbgt genes is reminiscent of common ancestral origin of alpha , -gal(nac) transferase genes. the finding that at can synthesize fors implicates that the boundary between abo and fors systems may not be as strict as was previously delineated due to the crosstalk in-between. rh typing is required by the fda and fact/aabb for identity testing. since most antibodies in cb plasma are maternal in origin, the abo/rh phenotype relies only on the red cell typing. a and b antigens are not fully developed at birth, presenting about one third of a or b antigen expression levels compared to adult cells. this can result in indeterminate abo results for some cb products. we evaluated the use of dna-based methods for abo typing to aid the resolution of inconclusive ("indeterminate") or discrepant serologic typing results. study design/methods: a total of , cb units (cbu) were typed for abo/rh (beckman coulter pk system blood grouping and phenotyping) during the period / / - / / . abo genotyping targeting specific snps for groups a, a , b, o , and o and, if needed, gene sequencing was conducted in cases with indeterminate results, and in cbu that were provided for transplantation with abo discrepancy found at the transplant center. results/findings: sixty-two ( . %) cb samples had no reportable abo/ rh phenotype on initial testing, and therefore the cbu could not be used clinically. molecular abo/rh typing resolved all but one. all cases were heterozygous (a/o, b/o, or a/b); in % the predicted abo phenotype was a rh neg (table a ). the predominant donor race was caucasian ( %). four cbu with abo discrepancy were also evaluated by genotyping (table b) . in of those, abo typing performed at the hospital on the day of transplant differed from that reported by the cb bank; the fourth was identified by posttransplant abo typing of the recipient. molecular genotyping resolved the discrepancies. cbu identity was always verified by confirmatory hla typing. conclusion: there is currently no fda approved dna-based abo assay. however, abo genotyping is a useful method for samples where antibody tests alone cannot be conclusive, and can "rescue" cbu that could not be used otherwise. further, genotyping can help resolve abo discrepancies. abstract cobas v r hev for use on the cobasv r / systems is a qualitative pcr test for the detection of hev rna in human plasma. the purpose of this study was to evaluate the prevalence of hev rna among us blood donations collected in the midwest, a region reported to have a higher prevalence of hev infection, and the eastern us. study design/methods: , fresh and , frozen edta plasma samples from american red cross donors, collected from february - , were de-identified and screened by individual donation testing (id-nat) using cobasv r hev for use on the cobasv r system under a research protocol. samples were primarily from midwestern and eastern regions of the us. samples reactive on cobasv r hev were further tested by an alternate hev nat, hev rna quantitation, hev genotyping, and for hev antibodies. results/findings: of , valid results, a total of donations were reactive on cobasv r hev and all were confirmed positive. the confirmed donations were from a -year old male in indiana, a -year old male in california, and a -year old female in kentucky. all donations were positive by hemi-nested pcr and alternative hev nat; however, only the kentucky donation had a high level of hev rna ( iu/ml), and was strongly positive for both igm and igg hev antibodies. the indiana donation was genotyped as a, the california donation genotype b, and no genotype determined for the kentucky donation (see table) . the clinical specificity for the cobasv r hev test in id-nat was % ( % exact ci: . % to %). conclusion: based on the confirmed-positive donations of , tested, the hev prevalence was . % ( % exact ci: . % to . %) with a detection rate of : , ( % ci, : - : , ). to date, no cases of tt-hev have been documented in the us. however, based on the prevalence observed, immunosuppressed transfusion recipients may be at increased risk for transfusion-transmitted hev. background/case studies: monitoring the epidemiology of ttis within the donor population is critical to provide an ongoing assessment of infection risks associated with fda policy changes such as the msm deferral criteria. ttims is a multi-center, federally-funded program intended to derive hbv, hcv and hiv prevalence, incidence, viral genotypes, and donor risk factors for greater than % of blood collected in the us. ttims is supported by two distinct coordinating centers (laboratory and risk factor, lrcc, and donation database, ddcc). here we report months of prevalence along with demographic trends from the ddcc. study design/methods: four blood providers and their respective testing laboratories participated. standardized consensus-positive (cp) monitoring definitions were established for donor test results for hbv, hcv and hiv. these results, along with demographics for each donor and donation status (first-time vs repeat) were assembled into a single data set. rates of nucleic acid test (nat) yield (seronegative) and concordant positives (serologic plus nat positives) were combined to comprise cps, were computed overall for donors and donations and by demographic, geographic and temporal characteristics. where appropriate, rates were compared for differences using % confidence intervals. this analysis contains data from / / - / / . results/findings: among , , donations reported ( . % from firsttime and . % from repeat donors), there were respectively , and cp results for hbv, hcv and hiv with corresponding rates of . , . and . per , (pht) donations. prevalence among firsttime donors was, as expected, higher than among donations from repeat donors with ratios of : , : and . : for hbv, hcv and hiv. rates (pht) among males were higher than among females for all markers (hbv . vs . ; hcv . vs . ; hiv . vs . ). in general, higher rates for all markers were seen among minority donors, those in the - -year age group (also - year for hiv), and those from the southeast (and south central for hiv and hcv, and southwest for hbv). no trends were noted over time when -month periods were compared. conclusion: data from major us blood systems were successfully combined and are a baseline for monitoring purposes. demographic trends are similar to those observed in other donor studies and generally agree with community trends. changes in rates will require analyses in the context of potential changes in the demographic structure of the donor population. screening donated blood from babesia endemic regions of the united states using a transcription-mediated amplification assay on a fully automated system vanessa bres* , melanie c proctor , deanna self , monique portugal , adrian gurrola , laura tonnetti , sonia bakkour , cheryl lobo , michael paul busch , susan l stramer and jeffrey m linnen . grifols diagnostic solutions inc., american red cross, blood systems research institute, new york blood center background/case studies: the procleix v r babesia assay on the procleix panther v r system is a qualitative in vitro nucleic acid test currently under development. the assay, which is based on transcription-mediated amplification (tma), detects four clinically relevant babesia species (b. microti, b. divergens, b. duncani, and b. venatorum) in human whole blood specimens. this test is intended to screen blood donations individually and in pools of up to donations. whole blood samples are lysed and then pooled on the automated procleix xpress v r system prior to testing on the procleix panther system. these studies evaluated the preliminary analytical and clinical performance of the procleix babesia assay on the panther system. study design/method: analytical sensitivity was determined by diluting in vitro synthesized rna transcripts for the four babesia species. fresh b. microti-infected hamster whole blood, cryopreserved b. duncani-infected hamster whole blood and fresh b. divergens-infected human erythrocytes were tested to determine the limit of detection (lod) of parasites/ml (p/ml) by probit analysis. clinical sensitivity and specificity were determined by screening , unlinked whole blood donations collected from august th to april th in the northeastern united states. initial reactive donations were confirmed by repeat testing, pcr, and/or igg immunofluorescence assay (ifa). reactive individual donor lysates were tested in pools of . results/finding: the procleix babesia assay detected all four babesia species with a % lod ranging from . - . copies/ml. the preliminary % lod in parasites/ml ranged from . - . p/ml for b. microti (n ), from . - . p/ml for b. duncani (n ), and from . - . p/ml for b. divergens (n ). of the , donations screened, initial reactive and confirmed positive donations were identified for specificity of . % ( %ci: . - . %). of the confirmed positive specimens, were reactive by both ifa and pcr, by ifa only and by pcr only. all confirmed positive samples were reactive in lysate pools of . donors of reactive donations resided in ct ( ), nj ( ), nh ( ) and me ( ) for an overall incidence of : , , and : , in ct. conclusion: the procleix babesia assay on the procleix panther system demonstrated high clinical specificity and sensitivity and detected all four babesia species with similar sensitivity. all confirmed positive donations were also detected in pools of thus demonstrating the effectiveness of pooled lysate screening. conclusion: use of the lag avidity assay shows that in both first-time and repeat hiv-positive us blood donors, newly-acquired (i.e., incident) hiv infections are more frequent in younger donors. the use of this approach provides an additional monitoring tool to assess changes in characteristics of donors whose risk exposure was proximate to the date of donation and will also complement traditional incidence methods by allowing derivation of incidence by donor type. epidemiology of hepatitis b virus, hepatitis c virus and human immunodeficiency virus in united states blood donors lauren a crowder* , whitney r steele , ed p notari , james haynes , roger y dodd and susan l stramer . american red cross, american red cross (retired) background/case studies: from - , the prevalence of hbv and hcv in us blood donors decreased, while hiv rates remained constant. however, incidence has not been recently calculated. here we report the prevalence, incidence and residual risk (rr) of hbv, hcv, and hiv in a large us blood system from - . study design/methods: prevalence was calculated in -year intervals. incidence was measured as the number of positives among repeat donors divided by the total time at risk, in person-years (py). rr was calculated using the window periods of . , . and . days for hbv, hcv and hiv, respectively. linear regressions were calculated with p< . (*) as significant. results/findings: from / / - / / , there were more than million donations from , , donors ( . % female, % first-time (ft), . % caucasian). there were significant decreases in donation prevalence for hbv and hcv (p . and . ), but no significant decrease in hiv during the years (see table for f and r values). a significant decrease was seen in ft donor prevalence for hbv and hcv (p . and . ). prevalent ft donors were significantly more likely to be male ( . % -hbv, . % -hcv, . % -hiv; p< . ). incidence for all agents declined (significant only for hbv; p . ). the decrease in hcv incidence was not significant, but there were fewer incident donors in the last -year period ( in - vs. in - ) . hcv incident donors in - were more likely to be male ( . % vs . % in - , p< . ) and were younger ( . % vs. . % in - < years, p . ). overall, incident donors were more likely to be caucasian males (p< . ). rrs for all agents decreased over time with rrs in - of in , , ; in , , ; and in , , for hbv, hcv and hiv, respectively. conclusion: prevalence, incidence and rr of hbv, hcv and hiv have generally decreased within this blood system over the -year time frame. as donor screening and deferral regulations evolve, it is important to monitor these risks. it is critical to note that even in a large population, small changes to the number of positives can have a significant impact on prevalence and incidence rates. furthermore, in , mayv was isolated from a patient in haiti, suggesting the virus is already circulating in the caribbean. the extent of mayv transmission could be underestimated due to limited surveillance and diagnostic capabilities; therefore, it is necessary to be prepared for mayv emergence and the potential risk for the blood supply in case it can be transmitted through blood transfusion. study design/method: platelet components (pc) prepared in pas were spiked with mayv and treated with amotosalen and uva illumination. samples were collected pre-uva and post-uva illumination for infectious titer determination. as- rbcs were spiked with mayv, mixed with glutathione (gsh)/processing solution, dosed with lm amustaline, and incubated for hrs at room temperature. samples were collected prior to the addition of amustaline (pre-treatment) and following the hr incubation (post-treatment) to determine infectious titers. infectious titers for all samples were determined by plaque assay on vero cells. the extent of inactivation was determined by comparing the infectious titers (plaque forming units (pfu)/ml) in pre-vs. post-treatment samples. results/finding: mayv was inactivated to the limit of detection in both pc and rbcs. in platelets, > . log , or > . log pfu/ml, inactivation of mayv was achieved. in rbcs, inactivation of mayv was > . log , or > . log pfu/ml. conclusion: this study demonstrates robust inactivation of mayv by both amotosalen/uva treatment in pc and amustaline/gsh treatment in rbcs. these systems are efficient at inactivating alphaviruses that have demonstrated or have the potential for transfusion-transmission, including mayv, chikv and rrv. prt offers potential as a mitigation strategy for maintaining blood component availability in areas where multiple alphaviruses are epidemic or endemic, and testing is not feasible. (data have not been submitted for fda review and intercept for red blood cell is not approved for commercial use). thrombotic thrombocytopenic purpura with high adamts- inhibitor may represent a distinct disease subset in response to therapy based on immature platelet count (a-ipc) dynamics hamza n gokozan* , , hollie m reeves , and robert w maitta , . case western reserve university school of medicine, university hospitals cleveland medical center background/case studies: thrombotic thrombocytopenic purpura is a lifethreating consumptive thrombocytopenia and microangiopathic hemolytic anemia causing diffuse ischemic damage to tissues. early therapeutic plasma exchange (tpe) initiation has improved survival. absolute immature platelet count (a-ipc) has been found to aid in diagnosis and follow-up of ttp patients. a-ipc changes in response to therapy in patients with low adamts activity and high inhibitor have not been analyzed in a patient cohort. we analyzed a-ipc response to therapy in five patients with adamts deficiency and high inhibitor at a large tertiary academic medical center. study design/method: patients had adamts activity of < % and high inhibitor ( . - ). mean age of cohort . years (range - ). four patients were female and one was male. patients presented with microangiopathic hemolytic anemia, thrombocytopenia (mean . x /l, range - x /l) and low a-ipc (mean . x /l, range . - . x /l). patients were initiated on daily tpe and prednisone; additional immunosuppression during hospital stay for cohort consisted of rituximab mg/m ( patients) and cyclophosphamide mg/m (one patient). tpe continued until platelet count reached x /l for at least two consecutive days. immature platelet fraction (%-ipf) and a-ipc (%-ipf x platelet count) were obtained with daily pre-tpe cbc. a-ipc ratio was calculated from baseline. results/finding: patients responded rapidly to daily tpe (mean of . days [range - days]) when they achieved a three-fold increase in a-ipc from baseline (mean . x /l, range . - . x /l) and a rapid improvement in platelet count. however, this improvement in platelet count was not accompanied by expected decreases in a-ipc, suggestive of recovery from disease. all patients experienced platelet (mean . x /l, range - x /l) and a-ipc (mean . x /l, range - . x /l) decreases that occurred concurrently while receiving daily tpe so that after a mean of . days (range - days) mean platelet count was . x /l (range x /l) and mean a-ipc . x /l (range . - . x /l). patients were initiated in either rituximab or cyclophosphamide therapy in conjunction with tpe after a mean of . days of a-ipc and platelet count instability. a-ipc trended to levels indicative of restoration of a negative feedback after this time. conclusion: rapid decreases in platelet counts after a good response in ttp patients may raise suspicion for presence of high adamts inhibitor. patients with a high inhibitor have similar a-ipc dynamics during which initial high a-ipc production is followed by unexpected decreases in a-ipc concurrent with platelet counts. recovery occurs once negative feedback between platelet and a-ipc production is re-established. patients with a high inhibitor may represent a distinct subset of ttp as suggested by a-ipc responses. benchmarking the centralized urgent plasma exchange service for patients admitted with a diagnosis of thrombotic thrombocytopenic purpura at a multi-hospital healthcare system jansen n seheult* , michelle n stram , joan sevcik , alesia kaplan , and joseph e. kiss , . department of pathology, university of pittsburgh medical center, blood systems inc., university of pittsburgh background/case studies: consensus guidelines recommend that therapeutic plasma exchange (tpe) must be started as early as possible and within - hours after the diagnosis of thrombotic thrombocytopenic purpura (ttp) has been made; however, there are limited data documenting actual practice. there are several operational facets of delivering a centralized urgent tpe program in a multi-hospital healthcare system, including: central venous (cv) access, ordering, release and delivery of thawed plasma, and transportation of personnel and equipment to perform the procedure. this study analyzes the time elapsed between major steps from diagnosis to initiation of tpe in patients admitted with ttp. study design/method: a retrospective review of the electronic medical record and laboratory information systems from january , to november , was conducted to identify all ttp patients undergoing urgent tpe. demographics, comorbidities, and other pertinent laboratory tests (such as adamts- activity levels, complete blood count, biochemical markers of hemolysis and coagulation studies) were reviewed on all identified patients. temporal data for tpe request, cv access placement, plasma product release (which usually happens after cv access), arrival of tpe team and initiation of the procedure were extracted from procedure notes and the blood bank information system. descriptive and summary statistics were generated using stata version (statacorp, tx). group comparisons were made based on hospital location, level of care and history of ttp using a wilcoxon rank-sum test. results/finding: of the ttp patients identified, were excluded due to missing temporal data for important variables. the majority ( %) of patients were treated at central academic centers, with the remainder being treated at peripheral sites. fifteen patients ( %) had a prior history of ttp and % had severe adamts deficiency on admission. the median time from tpe request to initiation was . hours (interquartile range: . - . hours). there were non-significant trends to shorter time intervals from request to cv access and request to tpe initiation in patients admitted to the intensive care unit (icu) versus non-icu patients (table ) . treatment was not started within an -hour window in patients; the median time to cv access was significantly longer in these patients ( . vs . hours, p< . ). two of these patients had a prior history of ttp and only four patients had severe adamts- deficiency. the majority (more than %) of the time interval between tpe request and tpe initiation was spent obtaining cv access and plasma products. there were no significant differences in time intervals comparing patients with a new diagnosis of ttp versus patients with recurrent/ relapsed disease (table ) or between patients treated at a central academic center versus a peripheral hospital. conclusion: the consensus - hour target window from tpe request to initiation appears feasible for a centralized tpe program servicing a multi- a transfusion vol. supplement s hospital healthcare system. addressing limitations in availability of cv access would likely yield the greatest improvement in timeliness of urgent tpe. cytoreductive therapy for cellular hyperviscosity: utility of cytapheresis treatment for chronic myelogenous leukemia and essential thrombocythemia. jan c hofmann* and dobri d kiprov. california pacific medical center background/case studies: several retrospective, case series have suggested that cytoreductive therapy to treat cellular hyperviscosity and prevent thrombotic events in patients (pts) with chronic myelogenous leukemia with accelerated transformation (cml-at) or essential thrombocythemia (et) may improve short-term outcomes. however, no randomized controlled trial (rct) assessing the efficacy of cytapheresis treatment in this group of pts has been performed. study design/method: from january, through january, , we performed cytapheresis (cy) treatments (txs) for pts with either cml-at or et, and clinical and/or laboratory evidence of cellular hyperviscosity. pts ( %) had cml-at and received leukapheresis (lp) txs; pts ( %) had et and received thrombocytapheresis (tc) txs. cml-at pts presented with median wbc x /l (range - x /l), of which % had blast percent > % or blast count > x /l. median age was years ( - years); % were male. cns symptoms (sxs) of leukostasis (lks) were defined as: headache, cognitive decline, confusion, somnolence, visual abnormalities, or seizure; pulmonary (pulm) sxs of lks were defined as: dyspnea, hypoxia, or bilateral chest infiltrates. % of cml-at pts had no sxs of lks; % pts had sxs of either cns or pulm lks ( sxs), and % pts had sxs of both cns and pulm lks ( sxs). et pts presented with median platelet (plt) count of: x /l ( - x /l)and % pts had sxs of thrombosis (evidence of cva or tia, mi, or dvt). median age was years ( - years); % pts were male. results/finding: all pts received a course of cy tx with following objectives: ) decreasing the risk of thrombotic/ hemorrhagic complications related to hyperviscosity, and ) stabilizing cml-at pts for induction chemotherapy (ind chemo). wbc (or plt ct) tx goals were: wbc count (ct) < x /l for cml-at pts, and plt ct < x /l for symptomatic et pts and < x /l for asymptomatic et pts. cml-at pts received median of lp txs (mean . txs/pt; range - txs). et pts underwent median of tc txs (mean . txs/pt; - txs). outcomes were evaluated by percentage of pts who: ) reached wbc (or plt ct) tx goal, and ) received ind chemo. "improved" outcome was defined as pts who reached their wbc (or plt ct) tx goal during cy tx; "stabilized" were pts who achieved > % reduction in wbc (or plt ct) without reaching goal; and "unchanged" were pts who achieved neither. in cml-at cohort, % pts improved, % pts stabilized; and % pts worsened. in et cohort, % improved, % stabilized, and % were unchanged. for cml-at pts, median final wbc ct x /l (range - x /l); % pts received ind chemo. for et pts, median final plt ct x /l ( - x /l); % pts had resolution of thrombotic a transfusion vol. supplement s symptoms. % of cml-at pts and % of et pts expired within - days after course of cy tx. of expired pts, pts had both blast crisis and sxs of cns/ pulm lks; pt had intracranial hemorrhage or cva; and pts were hypotensive, intubated, or unable to tolerate ind chemo. conclusion: pts with cml-at or et and evidence of impending thrombosis may benefit from cytoreductive therapy. a limited number of cytapheresis treatments (median - txs) can enable a high percentage of pts to receive definitive treatment and may improve short-term clinical outcomes. a rct to assess efficacy of cytapheresis treatment versus induction chemotherapy (or platelet inhibitor tx) alone in this subset of pts would be very useful. background/case studies: partial normal saline replacement during plasma exchange procedures is common practice. benefits of using normal saline as a replacement fluid include reduced procedure costs and possible reduction of the hypothetical hyper-oncotic effects of standard albumin formulations. however, the use of normal saline may increase the risk of undesired, and potentially costly, adverse events, such as hypotension and citrate reactions. the goal of this study was to compare the frequency of reported adverse outcomes for patients that received all albumin versus albumin/ saline as replacement fluid for plasma exchange at our institution. study design/method: a four year retrospective chart review was done of all therapeutic apheresis procedures performed by our apheresis service that used % albumin or % albumin- % normal saline ( / ) as replacement. patients who received plasma entirely or partially as replacement were excluded. the procedure type ordered ( % albumin vs / ), the percent of normal saline actually used during the procedure, age, gender, and any noted adverse events during the procedure were recorded in all cases. repeated procedures were modeled using a generalized linear mixed model to examine the risk of having hypotension and/or citrate toxicity where % albumin was used versus those that used / . covariates included were fluid types, age and gender. odds ratios (or) and % confidence intervals (ci) were used as a measure of risk. we used the term significant for a two-sided p-value < . . results/finding: during the study period, procedures were documented for subjects ( % female), age range - years, of which , ( . %) received / . the type of fluid used as replacement had a significant effect on the risk of having either hypotension or citrate toxicity. replacement with % albumin had a significantly lower risk of having either event than by using / , [p . , or (ci): . ( . , . )] , and also had a significantly lower risk of causing hypotension [p . , or (ci): . ( . , . )] in addition to a lower risk of causing citrate toxicity [p . , or (ci): . ( . , . )]. age had a significant effect on having a hypotensive event [p . , or (ci): . ( . , . )] but no effect on citrate toxicity or the combined outcome. gender had no effect on frequency of any event. conclusion: partial saline use as a replacement fluid with albumin during plasma exchange significantly increases the risk of hypotension and citrate toxicity during the procedure. age also increases the risk of hypotension. use of saline as replacement fluid during plasma exchanges should be minimized to maximize patient safety especially in older patients. background/case studies: therapeutic apheresis (ta) is a complex procedure that is mostly well-tolerated and rarely associated with adverse events (aes). there are few studies published on aes associated with ta but they lack uniformity of data. moreover, there is no common database in the united states (us) to report ta-associated aes. we evaluated the annual incidence rates of aes associated with ta at a large tertiary academic medical center over a year period and compared it to published literature. study design/method: we conducted a -year retrospective study of ta procedures performed and aes were classified according to criteria described in table . during the study period, ta were performed using cobe spectra (software versions . and . ) and since the spectra optia apheresis system (version . ). literature search was conducted for data published on aes associated with ta. four studies from us and non-us studies (canada, europe and japan) were analyzed. trend for ae rates from - was also analyzed. statistical analysis was performed using chi square and spearman rho tests. results/finding: the overall ae incidence was . % ( of , procedures) during year period. frequency of aes associated with therapeutic plasma exchange (tpe) was significantly higher ( . %, p< . ) compared to other ta procedures. we found significant correlation between number of tpe and aes (spearman rho . , p . ) over the years and significant down trend of moderate and severe aes with a spearman rho of - . (p . ) and - . (p . ) respectively. there were no fatalities during the study period. majority of aes were grade i ( %) and grade ii ( %): / ( . %) procedures were not completed due to aes. comparison of aes [ . % ( / , )] to both european [ . % (n , , / , ) ] and other us studies [ . % (n , / , )] showed a statistically significant difference (p< . ). conclusion: overall incidence of aes was significantly lower than current published literature. incidence of aes published in other countries is significantly lower than rates published in us. differences in incidence of aes in literature emphasizes need for uniform reporting and stratification of aes and development of a common database to report ta-associated aes. we propose a grading rationale in order to standardize reporting of ae (table ) . variations in biochemical markers of bone metabolism during plateletpheresis: impact of socio-demographic and lifestyle factors? markus dettke*. akh vienna university hospital background/case studies: plateletpheresis is associated with short-term variations in biochemical markers of bone turnover. socio-demographic factors and lifestyle behaviors are recognized factors which influence mineral metabolism and bone health. in the present study we analyzed the influence of demographic and lifestyle factors on the observed changes in bone markers in a large cohort of routine platelet donors. study design/method: altogether platelet donors with a donation activity of up to platelet donations participated in the study. after a detailed anamnesis all participants underwent a standardized questioner asking for several lifestyle factors known to affect bone metabolism. blood was sampled before and after plateletpheresis and was analyzed for the bone formation marker osteocalcin (oc) and the bone resorption marker cross-linked telopeptides of type i collagen (ctx), among other parameters. the effect of calcium supplementation on bone metabolism was tested in a placebocontrolled crossover study involving ten donors. results/finding: plateletpheresis resulted in an increase in the serum levels of the bone resorption marker ctx and the bone formation marker oc. both parameters returned to base levels within hours after the end of the collection. multiple regression analysis including the parameters sex, age , positive family history of bone disease, but also individual factors like hormonal contraception, smoking, regular alcohol consumption or sportive activity revealed no influence of socio-demographic or lifestyle factors on the observed variation in ctx or oc. there was no association between individual donor career or the number of previous donation and the observed increase in bone turnover. the only predictive parameter we could identify was the amount of citrate exposure during plateletpheresis. increase in serum ctx, showed an inverse correlation to changes of serum ionized calcium. continuous iv supplementation of calcium-gluconate throughout plateletpheresis reduced the variations in bone markers, although this effect was more pronounced for ctx compared to oc. conclusion: the amount of citrate infused during routine plateletpheresis is a predictive parameter for the transient increase in serum markers of bone metabolism. known risk factors for bone diseases, including sex, age, smoking or alcohol consumption, seems to have a low impact on the observed citrate-related variations in serological biomarkers of bone turnover. transfusion with optimized blood products versus transfusion with standard products in a trauma-transfusion rat model mathijs wirtz* , jordy jurgens , jacoline buchner-doeven , joris roelofs , philip spinella , jennifer a muszynski , carel goslings and nicole juffermans . academic medical center, washington university school of medicine, nationwide children's hospital background/case studies: transfusion is associated with nosocomial infection and organ dysfunction in trauma patients, which may be mediated by soluble bioactive substances in blood products. we hypothesized that removing these bioactive substances improves host immune response and reduces organ dysfunction. study design/methods: blood products were prepared from syngeneic rat blood according to blood bank standards. soluble mediators were removed from red blood cells ( days old) and platelets ( days old) by washing. plasma was filtered through a . um filter. rats ($ grams) were poly-traumatized by crush injury to the small intestines, the liver lobes, and by fracture of the right femur and hemorrhaged $ % of their estimated blood volume, which was calculated to be ml/kg. hemorrhage continued until a mean arterial pressure of mmhg was reached. rats were randomized to resuscitation with standard blood products, washed/filtered blood products or sham. blood samples were taken up to h after trauma to assess biochemistry and coagulation status. ex vivo whole blood stimulation tests with lps were performed after sacrifice, and organ damage was assessed by histopathology. blood products were sampled to assess for biochemical changes. comparisons between groups was done by anova and dunnett's post-test for multiple comparisons. results/findings: filtering or washing of blood products significantly stabilized ph, sodium and potassium concentrations and decreased lactate levels in the products compared to standard products. both resuscitation groups received an average of ml/kg of blood products in a : : ratio. however, use of washed/filtered products did not improve organ failure, as assessed by histopathologic score and levels of creatinine, asat and alat. the coagulation status as assessed by thromboelastometry was deranged in all groups and normalized during transfusion, showing no significant differences between washed/filtered products and standard care. immune response to lps was decreased following trauma compared to healthy controls but did not differ between groups. conclusion: filtering or washing of blood products reduces some aspects of storage lesion of blood products, without affecting the hemostatic capacity of the products, but does not improve organ injury in a rat trauma and transfusion model, nor does it improve the immunosuppressive host response. these results suggest that washing or filtering of blood products may have no relevant clinical effects in a rat polytrauma model. safety and efficacy of tranexamic acid during cardiovascular surgery: a single center before-and-after study takuma maeda* and shigeki miyata. national cerebral and cardiovascular center background/case studies: tranexamic acid (txa), an antifibrinolytic agent, has been widely used in cardiovascular surgery, since several studies have shown that prophylactic use of txa is effective in reducing blood loss after cardiovascular surgery. however, there is concern about the risk of thromboembolic events and adverse neurological effects such as seizures, which might worsen patient outcomes. consequently, we stopped using txa in april , which enabled us to conduct a before-and-after study. the present study aimed to examine the association between txa and adverse effects (seizures, thromboembolism, and renal dysfunction) in patients undergoing cardiovascular surgery using a propensity score matching model. we also assessed the association between txa and other clinical outcomes (reoperation for bleeding, transfusion volume, blood loss, ventilation time, intensive care unit stay, and -day mortality). study design/method: this single center retrospective cohort study involved patients who underwent cardiovascular surgery with cardiopulmonary bypass or offpump coronary artery bypass grafting between january and july (n ). because of missing data on patient characteristics, patients were excluded. the incidence of adverse effects associated with txa and other clinical outcomes were evaluated before (january to march , n ) and after (april to july , n ) using a propensity score model. we estimated propensity scores using a logistic regression model for txa use as a function of baseline variable, generating pairs of patients who received or did not receive txa. we also evaluated the adverse effects of txa using segmental regression analysis. results/finding: propensity-matched analysis showed that seizures were more common ( . % vs . %, p< . ) and ventilation time was longer ( h vs h, p . ) significantly in the txa group than in the non-txa group. in contrast, transfusion volume and blood loss were significantly lower in the txa group than in the non-txa group ( ml vs ml, p . ; and ml vs ml, p< . , respectively). however, -day mortality was not statistically different between the groups ( . % vs . %, p . ). none of the other outcomes were significantly different. segmental regression analysis yielded similar results. conclusion: even though txa may be associated with an increased rate of seizures and longer ventilator time, it does not increase mortality. the use of txa is significantly associated with decreased blood loss and transfusion volume, providing social benefit by reducing the need for blood transfusion because the supply of blood components will be limited with the aging of japanese society. it seems to be advantageous to use txa because decreased blood loss and transfusion volume and the associated social benefit outweigh the disadvantages of an increased rate of seizures and longer ventilator time. sustained impact of blood management strategies in orthopedics: continuous quality improvement linda levinus* and michele deeney. new england baptist hospital background/case studies: transfusions are one of the most over-utilized treatments performed in any hospital setting (choosing wisely campaign, april , www.choosingwisely.org/societies/american-association-of-bloodbanks). costs and risks associated with transfusions are high and may have a significant impact on patient safety. in our institution we perform over , joint replacements and spine surgeries per year, making transfusion-associated costs very high. since our last formal evaluation of the metrics used post implementation of patient blood management (pbm) strategies, questions regarding the feasibility of continued transfusion reduction and sustainability of the program were raised by administration and key stakeholder physicians. the objective of this study is to determine what, if any, sustainable improvement to our blood utilization dashboard table ). the data collected show that there has continued to be a reduction in transfusion rate, and blood expenditures through fy . length of stay has also shown a continued reduction, which is an indicator that the pbm strategies implemented have not compromised quality outcomes. further, continued review and monitoring of the chosen metrics, evaluating changes to policy and practice related to transfusion medicine, and communication of findings to providers/administration upon immediate restrospective analysis, are integral to the continued success and sustainability of our pbm program. going forward, these practices, along with investigating use of additional pbm strategies, will provide the basis for an effective continuous quality improvement program in transfusion medicine for orthopedics. safety and efficacy of -factor prothrombin complex concentrate: a retrospective review of outcomes at an academic hospital stephanie jalaba*, hollie benson, nan zhang, jill adamski and theresa kinard. mayo clinic arizona background/case studies: -factor prothrombin complex concentrate (pcc) contains factors ii, vii, ix, x, proteins c and s and is used for reversal of vitamin k antagonists in acute major bleeding or urgent, invasive procedures. occasionally, it is used off-label when plasma is not optimal for achieving hemostasis. this study compares the efficacy of on-label and off-label use of pcc in correcting coagulation parameters and reducing allogeneic blood transfusion. study design/methods: a retrospective chart review was performed for pcc use at our institution in . marginal modeling (gee method) was used to account for within patient correlation and assess changes in lab values and products transfused. logistic regression (gee method) was used to evaluate potential risk factors for unsuccessful hemostasis (uh rate of transfusion after pcc ! rate before pcc) or thrombotic complications. results/findings: the reduction in pt (p . ) and ptt (p . ) was significantly greater in on-label than off-label use. interestingly, transfusion reduction in rbc (p . ) and plasma (p . ) after off-label use was significantly greater than on-label use. cases, both on-label and off-label, with uh were associated with cell saver, acute normovolemic hemodilution (anh), or cardiopulmonary bypass (cpb). the odds of having uh were . times (p . ) more with cell saver or anh, and . (p . ) times more with cpb. post-pcc thromboses were identified in cases, but no association was found with potential risk factors: use of antifibrinolytics, vitamin k, factor viia, or extracorporeal support. background/case studies: when a pregnant woman with high risk pregnancy (diagnoses such as abnormal placentation, multiple gestation) is admitted to inpatient bedrest the obstetrical team would like to assure ability to crossmatch red blood cells (rbc) at all times by always having an in-date type and screen specimen. per current aabb standards, this necessitates a new sample every days. this can lead to excessive iatrogenic blood loss and increasing difficulty with obtaining intravenous access in the patient, to the point that an invasive catheter such as a picc line may be placed. in order to mitigate these issues, we chose to extend the type and screen specimen to expire after days in patients without rbc alloantibodies other than passively acquired anti-d due to rh immune globulin administration. study design/method: patients expected to have an antenatal hospitalization of at least days with high risk for transfusion need are identified by the obstetrical service, which submits a request to the transfusion service for extension of pre-transfusion specimens to days. the transfusion service medical director reviews the case and gives final approval. we observed only patient did not have an in-date specimen when the extended out-dating was requested. thirty-eight ( ) patients were in-patients continuously until delivery. five patients were discharged prior to delivery- moved to another state, was admitted later at another local hospital, and three were readmitted for later deliveries. the mean interval from approval to delivery was days (range - ). six ( ) patients delivered within days of approval. after approval, the mean number of additional specimens per patient was . (range, - ). no patient required transfusion prior to delivery. five patients received transfusion of at least rbc at the time of delivery, and none had evidence of transfusion reaction. conclusion: since no new antibodies were identified prior to discharge or delivery and no transfusion reactions were observed, the process appears safe. with only patients delivering within days of approval for extended specimens, patients avoided collection of at least specimen each, and patients avoided at least collections each. since new antibodies are not detectable for at least days after immunization, even longer extension of pre-transfusion specimen out-date may be considered. although this requires further study, we believe our practice of extending the pre-transfusion testing sample expiration date to days is safe and is justified, when weighed against the risk of excess iatrogenic blood loss and placing an invasive line for blood sampling in a pregnant patient. iron metabolism in critically ill patients developing anemia of inflammation margit boshuizen* , , jan m. binnekade , benjamin nota , pieter r tuinman , kirsten van de groep , olaf l cremer , janneke horn , marcus j schultz , robin van bruggen and nicole p juffermans . academic medical center, sanquin research and landsteiner laboratory, vu university medical center, university medical center utrecht background/case studies: anemia due to inflammatory processes (anemia of inflammation, ai) frequently occurs in critically ill patients. in ai, inflammation-induced hepcidin decreases iron availability, a process that is thought to be regulated by erythroferrone, which impact erythropoiesis. knowledge on changes in iron metabolism during the course of ai is limited, hampering the development of strategies to counteract ai. this study aimed to investigate the dynamics of parameters of iron metabolism during the development of ai in critically ill patients. study design/methods: a case control study was performed in tertiary icus in the netherlands comparing patients who developed ai during icu stay with control groups: non-anemic patients with sepsis, non-anemic patients without sepsis, and patients with anemia due to acute blood loss. patients were matched on age and sex. a linear mixed model was used to assess differences in parameters of iron metabolism between groups and over time. results/findings: in patients with ai, levels of iron, transferrin and transferrin saturation decreased already prior to the development of anemia, with lower levels compared to controls (table) . ferritin and hepcidin were increased in ai compared to controls. in the course of ai development, erythroferrone decreased. differences in iron metabolism between groups were not influenced by disease severity. patients with ai differed from patients with anemia due to acute blood loss, the latter was characterized by high iron ( . vs. . mmol/l, p< . ) and transferrin saturation ( vs. %, p< . ), and low ferritin ( vs. mg/l, p< . ). conclusion: in critically ill patients with ai, iron metabolism is already altered prior to the development of anemia, suggesting a potential window of opportunity for therapy. iron metabolism in ai is more disturbed than in non-anemic septic controls, irrespective of disease severity, indicating that ai is not solely determined by severity of inflammation. iron metabolism in ai patients differs from patients with acute blood loss, suggesting that efforts to modulate iron metabolism in anemic icu patients should take the cause of anemia into account. clinical oral abstract session: novel approaches to processing and assessing cell therapy products a paradigm shift in stem cell isolation and storage jeffrey drew*. cells life group llp background/case studies: widespread use of umbilical cord blood is limited by processing yield and post-thaw recovery of viable nucleated cells. the recommended therapeutic cell dose is approximately . x cells per kg body weight indicating that a single cord unit may be insufficent to treat larger individuals. cell isolation methods were developed to remove erythrocytes whilst recovering the white cell fraction (wcf). however, all current methods result in significant loss of the wcf, some up to %, whilst leaving % of the starting volume of erythrocytes. additionally, there is an almost total loss of potentially important, low abundance cellular subsets. the use of cord blood for hematopoietic reconsititution and in regenerative medicine would be widened if processing methods improved postprocessing and post-thaw viable cell recovery. study design/methods: we have developed a solution consisting of a defined concentration of reagents routinely used in blood therapy. on combination with blood, this solution results in the selective sedimentation of erythrocytes by gravity within minutes. the wcf remains in solution and can be easily separated from the erythrocyte sediment. the wcf can then be concentrated by gentle centrifugation into a small volume containing less than % of the original erythrocyte content. the addition of dmso for cryogenic storage and controlled freezing using standard procedures then completes this simple process. results/findings: we have clearly demonstrated that this method allows almost the entire wcf to be isolated and/or concentrated with only modest loss of any of the cellular sub-sets thus far examined. in addition to improving pre-freeze yields, post-thaw recoveries of viable cells are markedly increased, with a yield of approximately % of the cd fraction post separation and freeze thaw (table ) . possibly more important, the cfu assay results reproducibly yield higher counts of cfu-gm, cfu-gemm and bfu colonies (table ) which is a strong indicator that this method will improve patient outcomes. in addition, our separation method isolates and preserves the megakaryocyte-like cells (cd cd ) and early projenitor cells expressing oct and nanog (markers for vsels) which are two examples of cellular subsets usually lost using current separation techniques. conclusion: these results demonstrate that our method achieves: . routine recovery of the wcf at levels higher than current methods, independent of volume. . higher percentage recoveries of all cell types tested than can be achieved with existing methods. . markedly higher post-thaw recovery of viable nucleated cells than any current methodology. . almost complete removal of hematocrit. as a result units of cord blood separated using this new method will contain cell yields that could only otherwise be achieved through pooling multiple separate units. therefore, this new method has the potential to increase the demand for cord blood in therapy, expanding to larger individuals and adults, where up until now, it has been suppressed due to limited cell yields delivered by existing methods. effects of implementation of an absolute lymphocyte count target, in addition to cd target, for hematopoietic progenitor cell collection edwin a burgstaler*, luis f porrata, dennis a gastineau, eapen k jacob and jeffrey l winters. mayo clinic background/case studies: lymphoma patients receiving > . x lymphocytes(lymph)/kg during peripheral blood stem cell transplant have superior survival. in addition to a cd cell target of . x /kg, a lymph target was also implemented. fifty patients before (no alc) and after (alc) implementation were retrospectively evaluated. study design/method: lymph and cd yields, number of collections, lymph target reached, and days to engraftment were examined. mobilization was g-csf (g) or g-csf plerixafor (g pl). consecutive no alc and alc procedures were examined. the mann-whitney and chi square tests were used for statistical comparison, p< . considered significant. results/finding: no alc and alc collections occurred among the patients. fenwal amicus was used for % of the no alc and % of the alc collections (terumobct spectra optia cmnc used for remaining). diagnosis was hodgkin's and non-hodgkin's lymphoma (no alc); hodgkin's and non-hodgkin's lymphoma (alc). pre procedure wbc and lymph counts were significantly higher for no alc (wbc . , lymph . x /l) than alc (wbc . , lymph . x /l). equivalent whole blood (corrected for ac) was processed for no alc ( . l) and alc ( . l). for alc group, extra collections beyond cd target were: days: %, day: %, days: %, days: %, and days: %. significantly more patients were mobilized with g pl in no alc group (n ) than alc group (n ) and collections in alc group had mobilization discontinued after cd cell target reached. there was no significant difference in g ( . x lymph) compared to g pl mobilized collections ( . x lymph); both were significantly higher than the collections where mobilization had been discontinued ( . x lymph). days to wbc engraftment ( . no alc vs . alc) and platelet engraftment ( . no alc vs . alc) were not significantly different. median number of collections for no alc ( ) and alc ( ) were not significantly different. data (medians) in the table. conclusion: not all patients achieved the . x lymph/kg or even the . x lymph/kg targets. implementation of a lymph target increased patients obtaining . x lymph/kg from % to %. only % had < . x lymph/ kg. discontinuation of mobilization once cd cell target was reached significantly reduced lymph yield. the median increase of one collection per patient following implementation was less than had been expected. extended preprocessing storage impairs cord blood hematopoietic stem cell activity suria jahan* , and nicolas pineault , . canadian blood services, university ottawa, canadian blood services, centre for innovation background/case studies: large distances between collection and processing sites combined with staff availability can result in long processing delays of umbilical cord blood (ucb) unit. current net-cord-fact standards specify that units can be stored for almost hours at room temperature (rt) as long as units are cryopreserved by -hours post-collection. the impact of such delay on hematopoietic stem cell (hsc) function is unclear since most studies have not used transplantation assays that measure hsc key properties and activities. we hypothesized that such processing delay reduces the engraftment activities of ucb units. we set out to measure the loss in engraftment activities associated with preprocessing storage. study design/method: ucb units (n ) were split with one half processed immediately (baseline - hours) and the second after hours storage at rt. ucb were then processed with hetastarch and buffy coat maintained cryopreserved in liquid nitrogen until use. viability was assessed post-thaw, and thawed ucb buffy coat cells were transplanted into nsg mice. serial transplantation was used to test the self-renewal and differentiation activities of hsc, while limiting dilution (ld) assay and poisson statistic were used to estimate the frequency of scid repopulating cells (src) in thawed units. results/finding: storage before processing had no significant impact on the recovery of viable post-thaw cd cells and cd cell (n ). primary nsg mice were transplanted with a ucb cell dose that contained a total of , annexinv neg viable cd cells. the latter was done to avoid any bias towards one group or another. short term platelets ( vs. hplt/ml, p . ) and leucocytes ( . % vs. . % hcd , p< . ) engraftment at -weeks were significantly reduced in stored mice vs. baseline (n ), and similar results were observed long-term at -weeks. long-term human bone marrow (bm) engraftment was also reduced in primary transplants from stored samples ( myeloid engraftment was however confirmed in both groups. bm cells from primary mice were transplanted into secondary recipients and human engraftment investigated months post-transplant. strikingly, the frequency of human cd bm cells was -fold greater in baseline vs. stored mice (p< . , n ). hence, storage at rt of ucb units is associated with a deficit in engraftment activity likely due to a loss in hsc activity and/or numbers. to distinct between both possibilities, the net number of src in baseline and stored samples for two units were calculated by ld transplantation assay. the net number of src measured -weeks post-transplants were reduced by % in unit , and by % in unit . conclusion: prolonged preprocessing rt storage significantly impairs the engraftment activities of ucb units. the reduced engraftment in secondary transplants coupled with the results from the ld assays suggest that this engraftment deficit origins from loss of hsc numbers. our results stress the importance of rapid ucb processing to avoid loss of engraftment activity. acoustic microfluidic separation of blood components charles lissandrello, ryan dubay, kenneth kotz and jason fiering*. draper background/case studies: new cell therapies require efficient and automated methods for purification of target cells prior to subsequent processing. while apheresis, density gradient centrifugation, and magnetic separation achieve some of the requirements, no method is currently available that fully meets clinical needs for a closed, automated, and scalable process. continuous acoustic separation in microchannels is emerging as a versatile method for sorting, separating, and concentrating cells from blood. it has advantages over centrifugation because it is scalable to small or large quantities and can discriminate cells by size as well as density. meanwhile, unlike magnetic methods, acoustophoresis is "label free" and adds no reagents to the therapeutic cells. it has been shown previously that acoustic separation can separate blood components including purification of lymphocytes. however, these studies used devices that were constructed from silicon or glass and have limited potential for scale-up or production as disposable cartridges. in contrast, we report the first ever demonstration of acoustic lymphocyte enrichment along with rbc and platelet depletion in a disposable plastic chip, and we present a cartridge concept that enables clinical scale throughput by linking microchannels in parallel. study design/method: acoustophoresis uses ultrasonic waves to oscillate a rectangular microchannel having a cross section on the scale of the ultrasonic wavelength ($ mm). this results in an acoustic force across the channel that drives cells toward the axial center stream. because the force increases with a cell's size and density, lymphocytes experience a weaker force than rbcs and other classes of wbcs. thus, as blood product flows through the device, the lymphocyte population is enriched at the sides of the channel and can be captured in a branching outlet. likewise, platelets can by separated from lymphocytes. initial and output cell counts are measured by a standard hematology analyzer. results/finding: in our acoustic system, lymphocyte purity (% of total wbcs) was enriched up to %, using leukapheresis product as the starting material. this enrichment was achieved in a single pass through the device (residence time of sec). total lymphocyte recovery was % and monocyte concentration was reduced %. furthermore, in a two-pass process platelets were reduced by %. in a -fold parallel system we tested rbc separation from plasma and achieved % separation at ml/hr. conclusion: acoustic lymphocyte enrichment along with platelet depletion from standard blood product was demonstrated for the first time in plastic microchannels. such disposable devices are suitable for scale up to clinical bioprocessing systems. lymphocyte purity is comparable to existing methods with the advantage of monocyte and platelet depletion and potential for an automated instrument. background/case studies: the use of natural killer (nk) cells as a cellular immunotherapy has increased over the past several years, specifically their use in patients with hematologic malignancies. nk cells have been used at our institution for the past years. most patients have a reaction with nk cell infusion with some reactions being quite severe. we retrospectively analyzed the reactions associated with nk cell infusions to help address why some patients have more severe reactions than others. study design/method: retrospective chart review of nk cell infusions performed at our institution from clinical protocols from - . an infusion reaction was defined as any symptom from the time of nk cell infusion up to hours afterwards. a severe reaction was defined as any symptom with grade or higher severity (graded on common terminology criteria for adverse events-ctcae). preliminary data was analyzed using r . . . two major endpoints of interest were: ) infusion reaction with any symptom and ) severe infusion reaction. to numerically summarize the association of continuous variables with our endpoints, the median, (range) and interquartile range (iqr) were used. a wilcoxon test was performed to test the association between the continuous variables and our end points. a chi-square test was used to test the association between categorical variables and our endpoints of interest. results/finding: there were a total of nk cell infusions. there were ( %) patients with an infusion reaction of any symptom and there were ( %) patients with a severe reaction. infusion rate (ml/min) was similar among those with any reaction (median . , p . ) and those with severe reaction (median . , p . ). infusion rate (ml/min/kg) was also similar among those with any reaction (median . , p . ) and those with severe reaction (median . , p . respectively). incubation of nk cell product overnight in il- vs il- had similar reaction rates for those with any symptom ( % had reaction with il- , % had reaction with il- , p . ) and those with severe reaction ( % had severe reaction with il- , % had severe reaction with il- , p . ). patients with severe reaction had a higher calculated monocyte dose (monocytes/kg) in the nk cell product (median . x ) versus those without (median . x , p . ). conclusion: our preliminary data analysis reveals that a higher number of monocytes in the nk cell product may contribute to severe infusion reactions, causing patients to have a grade or higher symptom. limitations to this study include this was a retrospective review at a single institution. a streamlined mixed lymphocyte reaction (mlr) assay for evaluation of human mesenchymal stem cell immunomodulation activity christopher p delavan , maryanne c herzig* , barbara a christy , james a. bynum and andrew p cap . us army institute of surgical research, u.s. army institute of surgical research background/case studies: mesenchymal stem cells (msc) have been investigated for treatment of acute respiratory distress syndrome (ards), graft versus host disease (gvhd), wound healing and trauma. a consensus is building that the immunomodulation by mscs is key to their therapeutic potential. mscs suppress peripheral blood mononuclear cells (pbmc) proliferation in vitro, suggesting a correlation for suppressing pbmc inflammatory responses in vivo. current mixed lymphocyte reaction (mlr) assays generally rely on either direct co-culture or indirect culture using transwell systems for monitoring the proliferation of isolated pbmcs in the presence of mitotically inactive mscs. in the study detailed here, mscs are analyzed in a direct co-culture with pbmcs using a luminescent atp assay. study design/method: blood was obtained from an in house blood bank and pbmcs were separated by centrifugation over ficoll-paque in leuco-sep tubes as specified by the manufacturer. the pooled donor pbmcs were stored at - . mscs derived from bone marrow, adipose tissue or umbilical cord (bm-msc, ad-msc, uc-msc, respectively) or human umbilical cord endothelial cells (huvec) were serially diluted starting at - , cells/ well and cultured in well plates for - h in their respective medias. on day , mscs were washed, resuspended in pbmc media and incubated with or without , freshly thawed pbmcs/well, in the presence or absence of phytohemagglutinin a (pha, - lg/ml). proliferation of both mscs and pbmcs was assessed in triplicate wells by quantitation of atp levels using the bioluminescent reagent cell titer-glo (promega). results/finding: pbmc proliferation in response to pha gave a robust atp signal by h, with > fold increase over control pbmcs. no increase in atp response or proliferation was seen in the absence of pha. co-culture with mscs inhibited pbmc proliferation dependent upon msc passage, source, msc media additive. intra-assay variance of triplicate samples was . %. inter-assay variation of msc preps run under identical conditions was . %. inhibition of pbmc proliferation was graded from - % over the range msc concentrations therefore an ec of msc cell number resulting in % suppression of pbmc could be determined for each msc prep. this ec however was dependent upon pbmc donor pool. conclusion: direct co-culture of live mscs with freshly thawed pbmcs give a robust determination of immunosuppression by mscs. graded responses can be determined, allowing comparison of potency between msc preparations. this streamlined assay can be performed within h, without irradiating cells and with minimal equipment outlay. background/case studies: a high prevalence of iron depletion (id) in blood donors has been documented by recent studies, but none targeted high school aged donors, who consistently contribute % or more of the us blood supply. differences between donors - years old (yo) and adults in baseline and donation-altered iron status are important to understand because teenagers need increased iron for physiological growth and development and may be more susceptible to harm from iron depletion. study design/method: donors aged - were eligible for ferritin testing if they donated at a high school (hs) blood drive at the start of the / academic year at two blood centers. samples from return donations over the remainder of the school year were also tested. the prevalence of absent iron stores (ais, ferritin < ng/ml) and low ferritin (lf, ferritin < ng/ml) were estimated for , , and - yo groups separately for both genders. linkage to operational databases established first-time (ft) vs repeat (rpt) donor status. linear regression analysis tested for differences in natural log of enrollment ferritin values by age. multiple logistic regression assessed whether young age independently predicts iron depletion controlling for donation frequency and other factors. results/finding: a total of donors contributed donations. donors were evenly split by gender, % were ft donors, and % were - yo. ft and rpt - yo donors had on average lower ferritin values at enrollment (p<. ), and a greater percentage were iron-depleted than donors - yo (table) . in repeated measures logistic regression analysis using data from all visits, female sex, greater number of previous donations, shorter interval since last donation, and lower body weight were risk factors for both ais and lf. controlling for these covariates, donors aged - have sharply higher risk for iron depletion than donors - yo. odds for lf were to times greater in the younger donors, and for ais were -to fold higher. preliminary statistical models indicate yo donors may have greater risk for lf than or yo by to percentage points, controlling for other factors (p . ). conclusion: the prevalence of iron depletion varies markedly by age, sex, and donation frequency, but was considerably higher in - yo donors than in adult controls. logistic regression analysis confirms lower age as an independent risk factor for iron depletion. blood centers should implement measures to mitigate higher risk for iron depletion and the potential adverse consequences for this population of vulnerable donors. mitigation of iron deficiency in young donors -a preliminary report ralph r vassallo*, marjorie d bravo, mary townsend and hany kamel. blood systems, inc. background/case studies: iron deficiency is observed in blood donors who meet regulatory hemoglobin (hb) requirements for blood donation. frequent donations result in negative iron balance and eventually lead to anemia. young donors may be at risk for adverse health consequences (cognitive dysfunction, pregnancy-related complications, fatigue, decreased exercise endurance and pica) even before anemia occurs. study design/method: serum ferritin testing was implemented on / / by a large blood collector. testing was performed on successful - y/o whole blood and apheresis donations. low ferritin (lf) was defined as a value < ng/ml in females (f) and < ng/ml in males (m). donors with low ferritin were notified of deferral from red blood cell (rbc) donations ( months for f and months for m) and counseled to take - mg of elemental iron daily for days. for m and f, a ferritin < ng/ml indicated absent iron stores (ais) and < ng/ml indicated iron deficient erythropoiesis (ide). ferritin levels ! ng/ml in f and ! ng/ml in m were considered as indicating an iron-replete state. conclusion: ferritin testing of young donors identified individuals with lf who would benefit from risk mitigation, e.g., delaying subsequent rbc donations and/or taking iron supplements. lf is more common in f than in m donors. lf is more prevalent in m and f donors with any rbc donations in the prior months. an appreciable number of donors with no rbc donations in the prior months presented with lf. these data may be useful in conducting a riskbased decision making exercise to establish recommendations for risk mitigation which could be different for m than for f, e.g., universal iron replacement in teen male donors may not be warranted above a certain hb value. ferritin blood screening in minor or young adult donors jennifer l ritter* , joan williams , michelle humphries , nancy haubert , ben reynolds , michael phillips , randall spizman , ralph r vassallo , hany kamel , sally caglioti , german leparc , and phillip c williamson . abstract completely investigated. the adolescent growth spurt, poor nutrition and onset of menses increase the risks of iron depletion in young donors. new studies show that teenage donors who give blood frequently may be more susceptible to becoming iron deficient than older repeat donors. study design/methods: over , serum samples from donors aged , and years were analyzed for ferritin levels using the beckman coulter au instrument and reagent kit. the anti-ferritin reagent is a suspension of polystyrene latex particles, of uniform size, coated with polyclonal rabbit anti-ferritin antibody. immune complexes formed in solution scatter light in proportion to their size, shape and concentration. the decrease in light intensity is measured spectrophotometrically. results/findings: background/case studies: the risk of cardiovascular (cv) disease in adults can often be identified during adolescent years. the presence of even borderline levels of multiple risk factors increases the likelihood of a cv event. our blood program routinely provides a total non-fasting cholesterol (tc) and blood pressure (bp) measurement for all blood donors. we added glycated hemoglobin (hba c) determination and performed analyses of the prevalence of abnormal (borderline or elevated) levels of multiple risk factors among , adolescents (ages - ; . % female) who donated blood from to . study design/method: abnormal risk factor levels were defined as hba c ! . %, sbp/dbp ! / mm hg and tc ! mg/dl, as suggested by the american heart association for adolescents. the presence of isolated risk factors was defined as one single abnormal risk factor per individual. clustering of risk factors was defined as the presence of or more abnormal risk factors in the same individual. donor sex was recorded at the time of donation. results/finding: table shows the prevalence of isolated abnormal risk factors and the prevalence of abnormal risk factor clustering in the study cohort. overall, , ( . %) adolescents had at least one abnormal risk factor ( . % of males, . % of females). of these, , adolescents had isolated abnormal risk factors, and , adolescents had clustering risk factors. higher proportions of males were in the abnormal bp alone, background/case studies: pre-donation determination of hemoglobin (hb) level in candidate blood donors is a pre-requisite in the majority of blood services and is used to ensure donor safety and blood product quality. however, a variety of hb testing strategies are used across blood services to satisfy this selection criterion. this study aimed to identify how hb screening practices vary across blood donation services and to what extent they influence deferral rates for low hb. study design/method: an online survey was performed among members of the biomedical excellence for safer transfusion (best) collaborative. additionally, data from literature were used to extend the dataset. the survey involved a detailed assessment of hb screening practices, numbers of donations and low hb deferrals for male and female donors separately. multivariable negative-binomial regression models were built to estimate the adjusted effects of minimum donation intervals, hb cutoffs (high/low with high defined as ! . g/dl for men and ! . g/dl for women), iron monitoring (y/n), iron supplements (y/n providing or prescribing), and geographical location on deferral rates due to low hb. results/finding: data were included from blood services worldwide and complete data were available for blood services. deferral percentages for low hb varied from . % to . % among male donors and . % to . % among female donors. hb deferral rates were notably higher in asian blood services. overall, iron monitoring was associated with % lower hb deferral rates in men ( % confidence interval [ci] % to %) and % lower rates in women ( %ci % to %). iron supplementation was associated to % lower hb deferral rates among women ( %ci % to %) but there was no evidence of such an effect among men (p . ). each one-week increase in minimum donation intervals resulted in % lower hb deferral rates among women ( %ci % to %) but not among men (p . ). at the % level of significance, higher hb cutoffs do not appear to have an effect among men or women. conclusion: the variation in hb deferral rates across blood donation services can be, particularly in female donors, explained by differences in hb screening and deferral practices. mitigation strategies should consider the variable response among men and women. these insights can help improve both blood service efficiency and donor care. were: characteristics of donors (age, sex, size, weight, region); hb levels, date and volume of donation for index application and previous donation; and number of previous donations (in the previous years and the lifetime). data were analyzed using logistic regression stratified by sex. results/finding: . % of all candidates for wb donation were deferred in continental france in . deferral was significantly more frequent in women ( . %) than in men ( . %), due to anemia in . % of deferred women and . % of deferred men. plotting mean hb recovery against time showed mean recovery times ranging from to weeks. analysis (table) identified main factors associated with a higher likelihood of hb recovery: higher logarithm of time since previous donation, lower levels of hb at previous donation, higher number of blood donations in the previous years. conclusion: the main factors associated with higher likelihood of hb recovery after wb donation are probably linked with hematopoiesis stimulation and selection bias among high-frequency donors. mean times required for hb recovery were long enough to require further studies to assess interdonation intervals in france. background/case studies: red blood cell (rbc) transfusion has been related to thrombo-embolic events. microvesicles in the rbc product may support coagulation, which in part may depend on storage time because microvesicles have procoagulant effects in vitro and the amount of microvesicles increase with storage duration. study design/method: we investigated whether transfusion of rbcs containing microvesicles promotes coagulation in human recipients. as transfusion is mostly administered to ill patients, we used a model of mild endotoxemia. eighteen healthy volunteers were randomized to receive either saline, days stored or days stored autologous rbc transfusion two hours after infusion of lipopolysaccharide (lps, from e.coli, ng/kg). blood was sampled every hours up to hours after lps infusion. results/finding: lps resulted in a mild increase in thrombin generation. during storage, the total number of microvesicles increased from . e (iqr . e - . e ) /ml in the fresh product to . e (iqr . e - . e /ml; p< . ) in the stored product (p < . ), which were mostly rbc derived vesicles. after transfusion, microvesicles from stored rbc products, but not from fresh products, could be detected in the circulation of healthy volunteers and were cleared within hours. however, infusion of stored rbc microvesicles did not augment thrombin generation. levels of d-dimer and thrombin-antithrombin complex were also unaffected. conclusion: transfusion of autologous rbcs containing high levels of microvesicles does not enhance coagulation in human volunteers with mild endotoxemia. background/case studies: transfusion-associated circulatory overload (taco) is characterized by hydrostatic pulmonary edema related to blood transfusion. we sought to examine contemporary risk factors and outcomes for taco during a period where patient blood manaement has led to declines in blood utilization. study design/methods: at four academic hospitals, cases of taco were detected by active surveillance of all adult hospitalized patients who received a blood transfusion, and transfused controls were matched to cases by transfusion intensity. taco incidence was calculated, and clinical characteristics were compared with control patients. odds ratios (or) were calculated using multivariable logistic regression. hospital mortality and length of stay were modeled using cumulative incidence functions in proportional hazards regression. results/findings: cases of taco and matched controls were enrolled from , transfused patients who received , blood components from may until july . taco incidence was case per patients transfused. in addition to well described cardiac and renal comorbidities, multivariable analysis identified the following independent predictors of taco: number of plasma units, emergency surgery, pre-transfusion diuretic use, and higher post-transfusion hemoglobin levels (see table) . compared to controls, taco cases were more likely to require mechanical ventilation ( % vs. %; p < . ), experienced longer intensive care ( vs. days; p . ) and hospital length of stay following transfusion ( vs. days; p< . ), and had higher mortality ( % vs. %; p . ). conclusion: the incidence of taco was lower than what has been reported by prior active surveillance studies. despite declines in its incidence and the number of blood components transfused per case, taco remains a complication of transfusion with significant associated morbidity and mortality. in addition to risk factors for cardiovascular and kidney disease, plasma transfusion and higher post-transfusion hemoglobin levels were associated with taco after controlling for other covariates in the model. additional research is needed to examine the utility of these risk factors in the development of real-time predictive algorithms and the benefit of reduced erythrocyte or plasma exposure in patients at high risk for taco. background/case studies: the residual risk of bacterial contamination of single-donor apheresis platelets (ap) was recently addressed by the march fda draft guidance to enhance the safety of platelet transfusion. this document also describes an existing pathway for ap outdate extension from to days using an fda cleared rapid test (rt). our hospital based transfusion service has used this rt to enhance the safety of ap transfusion since july and to routinely extend ap outdate to day since february . this study reports a month experience of secondary screening of ap using a rt. study design/methods: all ap were obtained from our hospital-based donor center or one of four external suppliers. ap were screened by culture based methods post-collection and prior to entry into our inventory. from july -january , ap underwent rt on day . day and units were transfused with physician approval when deemed medically necessary. any units remaining in inventory on day had a second rt performed. from february -january , ap underwent rt on day with routine outdate extension to days by performing a second rt on day and a third rt on day , as per manufacturer instructions. any positive rts were repeated in triplicate. repeat rt positive units were quarantined and cultured to identify true positives. false positives (fp) were defined as repeat rt negative (type ) or repeat rt positive with negative confirmatory culture (type ). all rt results were reviewed during both study periods. ap transfusion and outdate rates were also summarized. results/findings: since july , , ap were entered into inventory. of these, , ( %) were transfused prior to rt testing. the remaining ( %) underwent rt on day or day . of these ( . %) were rt positive ( type fp, returned to inventory; type fp, discarded), leaving a total available inventory of units tested by rt. of these, ( % of original inventory) were transfused before the end of day and the remaining ( % of original inventory) reached a day outdate. a total of ( % of original inventory) were transfused on day or day . of these, underwent a second rt on day ( rt positives; fp type one and fp type ) and underwent a third rt on day (no positive results). a total of ( % of original inventory) outdated on day . of these, underwent a second rt on day (no positive results). conclusion: to date we have performed rts on ap at our hospital. no true positives have been identified. use of rt over the study period decreased our outdate rate from a predicted % to only %. a total of ap have been tested twice by rt ( on day and ; on day and ) with ( . %) positive results, both of which were deemed fp by repeat testing or culture. a total of units have been tested times (day , day and day ) with no additional positives identified. we have not yet identified any units with an initial negative rt result that subsequently converted to a true positive. there is a low fp rate which should also be expected when performing repeat testing on the same unit. these data suggest that the yield for repeating the rt every hours, as currently specified by the manufacturer instructions, is quite low. additional studies are needed to clarify how rt can optimally be used to enhance detection of ap bacterial contamination. survival of trypanosoma cruzi in human blood components laura tonnetti*, aaron thorp and susan l stramer. american red cross background/case studies: trypanosoma cruzi, the agent of chagas disease, is associated with to million infections worldwide, mostly in latin america. despite the extensive immigration from endemic areas, only cases of transfusion-transmission (tt) t. cruzi have been reported in the us, before blood donor screening was implemented in . contributing factors to the low number of tt cases are a possible association between parasite lineage and tt, and high numbers of unreported cases. platelets are almost exclusively involved in t. cruzi tt cases; however, during preparation of components a large fraction of the parasites can be found in red blood cells (rbcs). we investigated if blood component preparation and storage time affect the survival of the parasite and thus play a role in tt of t. cruzi. study design/method: whole blood (wb) units were spiked with t. cruzi trypomastigotes to a final concentration between - , parasites/ml. each parasite concentration in wb was tested x . an aliquot of contaminated wb was used to prepare hemocultures to detect live parasites before preparation of components. rbcs were separated and half of the components leukoreduced (lr) by filtration. platelets and plasma were separated, along with one aliquot of plasma collected before lr. rbcs were stored at c for up to days; platelets were stored at c (rt) under agitation for days and plasma was frozen at - c. aliquots for culture were removed weekly from rbcs, daily from platelets and after days from frozen plasma. all samples were cultured in liver infusion tryptose (lit) media at c for detection of live parasites for up to weeks. results/finding: hemocultures from spiked-wb were positive at all concentration of parasites. lr'd and non-lr'd rbcs cultured before storage were positive at all concentrations. after storage at c, rbcs from all units spiked with , parasites/ml were positive for up to days; all further times yielded negative results. at lower concentrations, only non-lr'd rbcs spiked with parasites/ml were positive for up to days. plasma samples cultured before freezing were positive at the highest concentration in one non-lr'd sample, while all others were negative. platelets obtained from wb spiked with , and parasites/ml were positive up to days at rt. no parasites were observed in plasma or platelets prior to storage at lower concentrations. molecular analysis to determine the presence of parasite dna in each component is on-going. conclusion: platelet storage conditions offer a suitable environment for t. cruzi survival; however, high concentrations of parasites also survived in rbcs at c for up to weeks. leukoreduction offers partial protection, while freezing conditions appears unsuitable for t. cruzi survival. hemovigilance monitoring of platelet septic transfusion reactions (str) after treatment with intercept tm pathogen reduction or large volume, delayed bact/alert tm bacterial culture screening richard benjamin* , marion lanteri and larry corash . cerus corporation, scientific affairs department, cerus corporation background/case studies: amotosalen/ultraviolet a (uva) light (inter-cept tm blood system, cerus corporation) pathogen reduction (pr) and delayed, large volume, bacterial culture with the bact/alert tm system (dlvbc) (biomerieux, inc) represent respective best-in-class systems to reduce the risk of str associated with platelet concentrates (pc). where implemented, hemoviligance (hv) programs continue to receive reports of suspected str, most of which have low imputability as other causes are more likely or insufficient information is available to impute system failure. study design/methods: united kingdom ( - ), french ( - , swiss ( - ), and belgium( - hv reports, and cerus corporation's adverse event records were reviewed to assess the residual risk and imputability of str with amotosalen/uva-treated or dlvbc-screened pc. results/findings: approximately . million dlvbc-screened were issued with a day outdate after release into inventory days after collection, and $ . million amotosalen/uva-treated pc were released into inventory on day or , with a to day shelf-life. no septic fatalities were reported with either technology. the french, belgium and swiss hv programs monitored > . million conventional, non-dlvbc-screened pc and recorded str and fatalities. concurrently, zero definite and possible str were reported with , amotosalen/uva-treated pc, significantly fewer than with conventional pc (table ) ( . str per million vs. . per million, p< . ). one definite, possible, undetermined/indeterminate non-fatal str and contaminated "near miss" pc were reported with . million dlvbc-screened pc between and , for a reduced falsenegative rate compared with the prior five years ( . str per million vs. . per million, p < . ). hv programs highlight a major weakness when reporting str. stringent criteria are used to determine definite imputability, including evidence of patient infection, pc contamination and irrefutable evidence of a donor source, with confirmation of strain identity. reports with incomplete investigations are considered undetermined or indeterminate, or possible sepsis. some of these cases are almost certainly due to bacterial contamination of pc, suggesting that the actual rates of sepsis are considerably higher than that reported by hv programs. conclusion: best-in-class pathogen reduction and bacterial culture systems reduce str risk, although underreporting and inadequate clinical data may result in underestimation of the true rates. pathogen reduction of background/case studies: despite extant mitigation measures (e.g. diversion pouches and primary platelet culture at the collection facility), bacterial contamination of platelets and associated septic transfusion reactions remains a leading cause of transfusion-associated fatalities in the united states (us). consequently, the us food and drug administration has recommended adoption of additional measures such as point of release testing (port) and/or pathogen reduction to safeguard against transfusionassociated sepsis. however, port poses logistical challenges, particularly in institutions with high-volume platelet utilization, while pathogen reduction is a high cost intervention. we evaluated a second bacterial culture to contend with residual risk. study design/method: phased implementation of secondary bacterial culture testing (bact/alert tm ,biomerieux, inc., durham, nc) was initiated in october for all platelets received at our institution. at time of receipt at the blood bank (day post collection), products were sampled using a sterile connection device (tscd tm , terumo, elkton, md) and a sampling kit (sam-plok tm sampling kit, ml, itl biomedical, malaysia). five mls of product was transferred aseptically to bact/alert bpa (aerobic) culture bottles using the same sampling device. inoculated culture bottles were loaded into the bact/alert incubator modules and incubated at c for three days. results/finding: a total of / , ( . %) platelet products were successfully cultured ( / [ . %] and / [ . %] in october and march respectively). over the -month period, two true positive cultures were obtained (incidence of in platelet products). the cultures grew acinetobacter species (case a) and coagulase negative staphylococcus species (case b); both positive results were obtained four days following collection. repeat testing of cases a and b grew the same organisms identified in the initial cultures. there was a co-component in our inventory (case a) with negative initial and repeat cultures. none of the products were released for transfusion. the initial post-collection product cultures remained negative at the collection facility. over the same time period, no false positives were detected. implementation required hiring one additional dedicated fte; the total cost (technologist time, equipment and related supplies) was calculated to be $us . per product tested. the cost per averted case was $us , . conclusion: we demonstrate the feasibility of implementation of a secondary bacterial culture test of apheresis platelets to interdict bacterially contaminated units and prevent septic transfusion reactions. this presents a low-cost strategy (as compared to pathogen reduction) to mitigate risk of septic transfusion reactions. importantly, it offers a viable alternative to port in high volume institutions where logistic (e.g. time and personnel) constraints impede practical adoption of port. an increase in cases of blood culture positive transfusion reactions (bcptr) was noted at our hospital; bcptr was defined as bacterial culture positivity in the transfusion recipient and/or associated transfused blood product during investigation of a transfusion reaction. we sought to characterize the risk and clinical presentation of bcptr at our institution. study design/method: an analysis was conducted of all reported transfusion reactions at johns hopkins hospital (jhh) between january and december . the data, extracted from hemovigilance records, were evaluated to determine the incidence of bcptr; the severity and symptoms were evaluated in concordance with recipient data, including patient diagnosis, medications and clinical manifestations of the reaction. bacterial culture results were evaluated for both patients and associated blood products (i.e. partially transfused or residual product in blood bag). results/finding: in the -year study period, a total of transfusions reactions were reported, of which were bcptr ( . % of transfusion reactions). of the bcptr, ( %) were associated with apheresis platelets, ( %) with red blood cells, and ( %) with plasma. recipient diagnoses spanned hematologic/oncology (n ), renal (n ), cardiac (n ), autoimmune (n ), and obstetrics (n ). an organism was identified in both the blood product and recipient in ( %) cases; in ( %) cases an organism was grown in the blood product but not the recipient; and in ( %) cases an organism was isolated from the recipient only, due to inability to culture the product. the transfusion recipients in of the cases that did not isolate organisms in the recipients were on broad-spectrum antibiotics at the time of transfusion. symptoms of bcptrs included fever ( %), chills ( %), nausea and vomiting ( %), pain ( %) and dyspnea ( %). blood pressure (bp) decreased in %, increased in %; % of reported bcptrs had no change in bp. conclusion: the signs and symptoms of bcptrs are not specific and overlap both with underlying disease as well as other types of adverse transfusion associated events, thus contributing to delayed diagnosis and under-reporting. furthermore, high rates of antibiotic use in transfusion recipients can mask symptoms of true septic transfusion reactions. hospitals should consider expanding the clinical indications for culturing blood components that are implicated in transfusion reactions. furthermore, excessively stringent criteria (cdc/nhsn blood safety surveillance) for transfusion-transmitted infection, may contribute to misclassification of septic events in some recipients, particularly if on antibiotics. clinical oral abstract session: immonohematology and genetics --sickle cell disease and beyond blindspots and cross-reactivities of anti-human globulin specific for igg subtypes heather howie , jenna lebedev , linda kapp , xiaohong wang , meghan delaney , lay see er and james c zimring* . bloodworksnw research institute, bloodworks nw, university of washington school of medicine background/case studies: there are four different subclasses of human igg (igg -igg ), each with different effector function. essentially all existing data on the effect of igg subclass on hemolytic transfusion reactions and hdfn, were generated using ahg specific for igg subclasses. in recent decades, it has become appreciated that there are at least natural human variants of igg. in this study, the reactivity of igg specific ahg was tested against all known variants. study design/methods: the heavy and light chain variable regions of an anti-k monoclonal antibody were sequenced and cloned into expression plasmids that fused variable regions (in frame) with each of the known igg variants. plasmids were expressed by co-transfection into cho cells. the resulting panel of antibodies were pre-incubated with k rbcs and were then subjected to testing with currently available igg subtype specific ahg (monoclonal ahgs from southern biotech and sanquin, polyclonal ahgs from sanquin and the bindingsite). all testing was carried out by flow cytometry. results/findings: polyclonal reagents against igg , igg , and igg had cross-reactivity with variants found in other igg subclasses, and specific amino acids responsible were identified by site directed mutagenesis (table ). titrations of the ahgs did not identify a dilution at which crossreactivities were lost, but authentic targets were still detected. however, cross-reactivity could be neutralized by pre-incubating ahg with the crossrecognized igg forms (against a third party antigen); the remaining reactivity recognized the intended igg subtype without detectable cross-reactivity. no cross-reactivity was detected for polyclonal anti-igg or for any of the monoclonal ahgs tested. monoclonal anti-igg had a blindspot for igg - , due to the shorter hinge region on igg - . no blindspots were detected in other monoclonal or polyclonal ahg. conclusion: the relative quantitation of different igg subtypes has been studied in multiple immune settings, and plays important roles in diagnosis and research of human disease, including immunohematology. herein, we demonstrate that the reagents used to generate this body of knowledge suffer problems of cross-reactivities and blindspots. as such, the existing data regarding igg subtype biology may have some inaccuracies as a result of these defects in igg specific ahg. genotype matching for pediatric sickle cell disease patients nancy robitaille* , yves dominique pastore and maryse st-louis . chu sainte-justine, hema-quebec background/case studies: among the different treatment modalities available for sickle cell disease (scd), blood transfusion is frequently used. however, alloimmunisation remains a significant problem, even if prophylactic antigen matching is performed for c, e and kell antigens. this is partly explained by different antigen frequency among caucasian blood donors and african-american recipients, and by variants in the rh blood group of people of african-descent. blood group genotyping has been proposed as a potential way to alleviate this problem. the scd cohort of a pediatric academic hospital was genotyped for rhd, rhce and fy genes. the primary objective of our study was to evaluate whether compatible genotyped blood donors presenting similar rh variants could be identified. study design/methods: since , our local blood provider intensified recruitment of african-descent blood donors. these donors were phenotyped and genotyped for clinically relevant antigens by different means: genomelab snp stream, laboratory-developped assays and idcorext. as of , scd children were genotyped by sequencing rhd, rhce and fy cdnas after obtaining informed consent. extended red blood cell phenotypes were done at diagnosis at the hospital. patients' genotypes were compared to h ema-qu ebec's donor database to attribute blood donors to specific patients. results/findings: from diagnosis until september , ( %) patients had been transfused and had antibodies with known blood group antigen specificity: anti-c, anti-e ( ), anti-hrb, anti-fya, anti-jka, anti-jkb ( ), anti-s, anti-m, anti-sc , anti-leb ( ). seventeen patients ( . %) were either d or partial d. rhce results showed that patients expressed a normal c antigen and expressed partial c. as for e antigen, had a normal antigen, bore a partial antigen and were weakly expressed. fy(a b ) phenotype was found in ( %) patients. a total of genotyped blood donors of african-descent were available. the table below indicates the compatibility with these donors. conclusion: this study shows that several patients have rhce variants difficult to match, even with available genotyped blood donors from their community. although this measure is probably beneficial to decrease alloimmunisation, a larger donor pool is still needed to fulfill the patients' needs. the continued effort put towards recruitment and pheno/genotyping should improve the situation. using genetic markers to select responders and non-responders sickle cell disease (scd) patients for transfusion with rh haplotype matching red blood cell (rbc) units tamires delfino dos santos , emilia sippert , mayra dorigan de macedo , sheila fatima perecin menegati and lilian castilho* , . hemocentro unicamp, university of campinas background/case studies: rbc alloimmunization has been associated with several factors and with individual characteristics of each patient. we recently found that tnfa- a, il b- t cytokine polymorphisms, rhag g>a and hla-drb * alleles may predict a good responder phenotype (sippert et al, transfusion ) and that rhag a and hla-drb* alleles are closely linked to rh alloimmunization. based on this and considering the challenge to fulfill the transfusion needs of the patients with rh variants, we used these genetic markers to select responders and nonresponders scd patients for transfusion with rh haplotype matching rbc units and evaluated the risk of alloimmunization. study design/method: our study included non-alloimmunized patients with scd, homozygous for hbs, receiving a range of - rbc units. rbc antigen phenotypes of each patient and history of rbc antibodies were obtained from the medical records and transfusion service computerized database. rbc genotyping was performed using whea, wrhd and wrhce beadchip arrays (bioarray solutions, immucor) in accordance with the manufacturer's instructions. cytokine gene polymorphisms (tnfa- g>a, il b- c>t) and the rhag g>a gene polymorphism were analysed by pcr-rflp and taqman assays. hla class ii genotyping was performed using pcr-sso. results/finding: among non-alloimmunized patients, were homozygous or compound heterozygous for rh variant alleles. from those, had rhag a and/or hla-drb* alleles and at least one cytokine polymorphism (tnfa- a or ilb - t) associated with risk of alloimmunization and were transfused with extended and rh haplotype matching rbc units. the other patients with no risk factors associated with rbc alloimmunization were considered non-responders and were not transfused with extended and rh matching units. all patients were followed for one year and did not develop rbc antibodies. conclusion: these findings contributed to the development of a transfusion strategy for non-alloimmunized scd patients as typing for these polymorphisms could potentially help in the classification of responder and nonresponder scd patients, allowing blood with high level of compatibility to be five discrepant samples required sequencing. id core xt identified three rhce*cear samples encoding a partial c, and a partial e (predicted phenotype: vweak, vs-) and were confirmed by sequencing. the third sample was found to be rhce*cevs. ,rhce*cebi on sequencing (predicted phenotype v ,vs ). the samples were typed as v (or ce s ) and vs (or e s ) by hea. in addition, id core xt accurately identified rhce*ce[ g]in samples. this snp has been linked to various allelic variants affecting c and e antigenic expression. both samples were predicted to be c by hea. conclusion: blood group genotyping platforms vary depending on the specific snps that are included in each assay. such variations may be clinically significant when genotyping is used as a tool for providing matched blood. discrepancies leading to differences in the predicted phenotype could affect unit selection. despite the discrepancies between the methods, the high concordance rate and the limitations of serology warrant further reconsideration for the need for serologic confirmation of extended phenotypes. background/case studies: over three decades ago, two independent groups published work suggesting a novel categorization of warm autoimmune hemolytic anemia (waiha) on the basis of dat scores of agefractionated rbcs: type i waiha, comprising % of patients, showed increased binding of autoantibodies to aged rbc, whereas type ii waiha autoantibodies ( % of patients) bound young and old rbcs with no apparent prejudice. band- is a ubiquitously expressed rbc transmembrane protein which plays a vital role in maintenance of rbc structural integrity, cellular hemostasis, and regulation of senescence; and, has been suggested to be targeted by autoantibodies from patients with waiha. band- is regulated through phosphorylation of key residues; its hyperphosphorylation is a hallmark of normal rbc senescence, which causes band- to disengage from the cytoskeleton, increasing its lateral diffusion, thereby permitting the formation of band- aggregates forming new epitopes which are recognized by natural igg autoantibodies causing phagocytosis and destruction of senescent rbcs. type i waiha has been postulated to be caused by an exacerbation of normal rbc senescence. study design/methods: in an effort to confirm and characterize the two waiha subtypes we age-fractionated whole blood samples from patients with waiha on discontinuous percollv r gradients and looked for differences in dat results between less (young rbcs) and more dense (aged rbcs) fractions, fractionation patterns and band- tyrosine phosphorylation. results/findings: we confirm that two distinct types of waiha can be identified based on autoantibody reactivity with the youngest and oldest autologous rbcs. further, comparing type i and type ii patients, we found that type i is characterized by percollv r fractions (similar to healthy storage-matched controls) but increased band- tyrosine phosphorylation compared to healthy storage-matched controls, with phosphorylation occurring during younger stages of rbc development. type ii patients were characterized by - percollv r fractions, lacking the fraction containing the oldest rbcs, and showed a complete lack of, or dramatic decrease in, band- tyrosine phosphorylation compared to healthy storage-matched controls. conclusion: these results confirm the two distinct types of waiha. in type i waiha, the increased binding of autoantibodies to older rbcs coupled with increased tyrosine phosphorylation of band- suggests that rbcs from type i patients are aging faster than rbcs from normal healthy controls; this may represent an accelerated and pathogenic form of normal rbc senescence. in contrast, type ii waiha where autoantibodies bind strongly to either young or old rbcs coupled with a lack of fractionated bands that represent the oldest rbcs and a dramatic diminution in tyrosine phosphorylation of band suggests faster destruction of rbcs, consistent with the early published data, and metabolic changes that could affect rbc function. microbial pathogen primary sequence correlates with blood group antigen immunogenicity ian baine* , burak bahar , jeanne hendrickson , krystalyn e hudson and christopher a tormey . yale-new haven hospital, yale university, background/case studies: it is known that specific groups of patients immunologically respond more readily than others to rbc antigens. while rbc antigenic differences between donors and recipients are required for humoral immune responsiveness, other variables are also involved. studies have shown that there is significant primary sequence identity between common rbc antigens and microbes, and that cross-reactivity is possible between antigens in experimental models. we hypothesize that responder populations may be immunologically primed to form rbc alloantibodies via environmental exposure to cross-reactive microbial antigens, and that such a correlation may be linked to observed blood group antigen immunogenicity. study design/method: we performed peptide homology searches of the most immunogenic rbc antigens, based on previously published antigenicity findings. thirteen amino acid peptides containing the polymorphic residues of k, jk a , lu a , e, c, m, c, fy a , and s antigens were queried for identity with microbial peptides using the blast database (blastp, pam abstract algorithm, e value x - , word size , gap costs: existence exten-sion ). search results were restricted to bacteria and fungi, with a selective threshold of > % identity set for inclusion criteria. to corroborate with observed patient data, we also examined preceding cultures from alloimmunized patients to explore agreement between specific pathogens and rbc alloantibodies. results/finding: significant peptide identity was found between rbc antigens and pathogenic organisms including b. fragilis, p. aeruginosa, candida spp. among others. linear regression analysis of the number of genuses in microbial kingdoms meeting inclusion criteria showed a statistically significant inverse trend in predicting the degree of immunogenicity when fy a (an outlier) was removed (b - . , r . & p . ); that is, lower immunogenicity antigens were associated with larger number of kingdoms. k-medoids cluster analysis comparing immunogenicity and kingdoms showed that antigens clustered to low (c), moderate (e, c, s, m) and high (k, jk a , lu a , fy a ) immunogenicity groups, suggesting that an antibody response is inversely associated with environmental antigenic prevalence. of alloimmunized patients reviewed, were culture-positive. of these, % of the anti-c/c group ( of patients) and % of the anti-k group ( of patients) had microbe-antibody agreement. remaining microbe-rbc antibody agreements ranged from - . %. overall, . % ( of patients) demonstrated agreement. interestingly, we observed a particularly strong agreement between infection with klebsiella species and anti-k, despite the lack of > % sequence identity. while . % ( of ) patients reviewed had positive cultures for klebsiella species, . % of these ( of patients) demonstrated an anti-k. conclusion: our study highlights the potential connection between microbial infection and rbc alloimmunization, based on shared epitopes. we speculate that low-level antigenic exposure to highly prevalent microbial antigens such as commensals may promote immunotolerance, providing a model for the inverse relationship between rbc antigen immunogenicity and prevalence of microorganisms. longitudinal studies of microbial carriage (or acute microbial infection) and rbc alloimmune responses in larger patient cohorts may be informative. background/case studies: thromboelastogram (teg) has been incorporated into many hospital armories to manage transfusions during cardiovascular (cv) surgeries. some institutions use well-defined protocols for teg utilization at different stages of surgery (baseline, rewarming, postprotamine, and post-operative). on the other hand, at some institutions teg utilization is driven mainly by clinical judgment. when teg is ordered based on clinical judgment (clinical bleeding in most cases), some patients receive blood transfusions before teg is performed. there is no published literature on how pre-teg transfusions impact teg results and guide further transfusion requirements during cv surgeries. in this study, we have tried to address this issue. study design/method: we retrospectively reviewed tegs performed on patients undergoing cv surgeries at our institution from jan to dec , . no specific teg protocol was used to direct transfusions (plasma, platelets, and cryoprecipitate) during that period. only the first teg performed during surgery was included in the analysis. we excluded the patients that received only red blood cell (rbc) transfusions during the surgery because rbc transfusions are usually not based on teg results. for the tegs analyzed, teg results were divided into three categories: "normal" (reaction time (r), kinetics (k), angle (a), maximum amplitude (ma), and lysis at minutes (min) all within reference range), "hypocoagulable" (r> min, k> min, a< degrees, ma< mm) and "hypercoagulable" (r< min, k< min, a> degrees, ma> mm). fisher's exact tests and z-scores for two population proportions were used to identify statistically significant differences in teg results and blood product utilization. results/finding: out of tegs analyzed, patients ( %) received pre-teg transfusions. we found significantly fewer hypocoagulable teg results in pre-teg transfused patients than nontransfused patients ( % vs. %, p . ). the data also reflected a trend suggesting that there may be more normal teg results in pre-teg transfused patients compared with nontransfused ( % vs. %, p . ). there was no statistically significant difference in transfusions after obtaining teg results in both groups. however, there was a trend suggesting that hypocoagulable state was more likely to be corrected by transfusion in patients who were already transfused pre-teg compared to nontransfused ( % versus %, p . ). conclusion: pre-teg transfusions impact teg results (transfusions correct/normalize coagulopathy) but do not significantly impact further blood product utilization during cv surgeries. the decreased threshold (more transfusions) for correcting hypocoagulable state in patients who already received pre-teg transfusions may be due to more clinical significant bleeding in these patients to begin with. background/case studies: orthotopic liver transplantation (olt) is associated with significant blood loss, due to the complexity of the procedure and extensive liver vascularity, demanding blood transfusion. in this setting, cell salvage autotransfusion (cs) is been used as an alternative to decrease allogeneic red blood cell transfusion. however, as long as some studies have shown that cs in olt decreases allogeneic blood transfusion, others reported that cs presented little benefit or might have been associated with increased blood loss through fibrinolysis. in this study, we evaluate cs efficacy in reducing allogeneic blood transfusion in the intraoperative period. study design/method: we retrospectively evaluated data from liver transplants, performed from to in a single-center. patients were divided in two groups: one with cell salvage (cs) and another without cs (ncs). study endpoint included the requirement of allogeneic blood components transfusion during intraoperative period in both groups. cs was used in all liver transplant recipients but patients with malignancy and sepsis. blood transfusions were indicated based on clinical and hemodynamic criteria. clinical data included age, gender, diagnosis, body weight, height, warm and cold ischemic time and model for end-stage liver disease (meld) score. statistical analyses were performed using t-test, chi-square test, mann whitney test. results/finding: in this study period, olts were performed. a total of patients was submitted to cs. the median age was years (range - yo). cirrhosis caused by chronic hepatitis c virus infection was the main etiology of liver disease. hepatocellular carcinoma (hcc) was found in , % of the patients. the average meld score was , , and it was slightly higher in the cs group ( , vs , , p< , ) . there was no statistically significant difference in other variables such as body weight, height and cold ischemic time. the mean salvaged blood volume was ml and mean reinfused blood volume was ml. allogeneic blood transfusion was required in , % patients in the cs group, compared to , % patients in the ncs group. however, average red blood cells (rbc) and fresh frozen plasma (ffp) units transfused were lower in the cs group. the threshold for rbc transfusion was significantly lower in the cs group ( , units vs , units, p< , background/case studies: hemorrhage is a leading cause of mortality in trauma patients and morbidity in non-trauma patientsaddin en.cite.data. massive transfusion protocols (mtp) reduce mortality in trauma and nontrauma settings; however, this may be at the cost of blood product wasta-geaddin en.cite.data. blood product wastage benchmarks are loosely established, and data on wastage associated with mtps especially sparse. with a redesign of mtp and obstetric massive transfusion protocols (obp) which have different blood product preparation schedules, we assessed wastage, delivery method, and product utilization to identify differences in wastage during these protocols. study design/method: following institutional review board approval, a retrospective study on blood product wastage associated with the mtp and obp between july -december was performed. data on numbers of products dispensed and wasted were manually collected from transfusion service paper and electronic records and an automated data report from the electronic medical record. results/finding: the mtp resulted in higher total number of wasted products than the obp ( and products, respectively) however, obp wastage occurred more frequently in the month period. this reflects automatic thawing of cryoprecipitate in the first round of deployed products in the opb. mtp-trauma activations contributed higher wastage than non-trauma activations ( versus products). this is skewed by one month when products were wasted due to expiration of product on the floor. cooler-related issues ( ) and products dwelling too long out of a controlled environment ( ) were common reasons reported for wastage. the overall product wastage rates for mtp: trauma, mtp: nontrauma, and obp were . %, . %, and . %, respectively, with a total exsanguination protocol waste rate of . %. the difference between the overall proportion of waste between the mtp and obp protocols was insignificant (p . ). conclusion: wastage associated with both protocols was low and there is no statistical difference between mtp versus obp wastage. coolerrelated issues accounted for most product wastage, allowing for targeted waste reduction strategies including educational outreach and improved product delivery methods. better documentation of waste events identifies wastage trends for further product utilization optimization during these protocols. a year old female with multiple gun shots was admitted to a level one trauma center and received uncrossmatched group o, rh negative (d-) red blood cells (rbcs) through a rapid infuser during resuscitation. transfusion of uncrossmatched products before sample collection can lead to errors and confusion in blood typing, as can the venipuncture site used for collecting the patient's blood sample. the current fda guidance and aabb standard of two samples for determination of blood type to prevent cases wrong blood in tube (wbit) or electronic identification systems do not always catch or clarify these errors. study design/methods: patient was tested by manual tube method. two different technologists using two different reagent racks performed initial testing with matching results. results/findings: two samples were collected during resuscitation from the patient and typed as o d-. patient was transfused with units of o d-rbcs before stabilizing. two days later another sample was collected and typed as o rh positive (d ) with mixed field being seen on the anti-d. a weak d testing was performed to see if the negative result with anti-d could be strengthened through incubation. both original samples still resulted as d- (table a) . after consulting the patient care team it was discovered the samples were collected above the iv site after one unit had been completed and while the second unit was being transfused. it was also discovered all other clinical laboratory samples were rejected due to possible line contamination when results for the sodium, potassium, and glucose appeared inaccurate. the transfusion service laboratory is in a different area of the hospital and was unaware those samples had been rejected. conclusion: the initial samples were collected above the iv site and were contaminated with the d-blood product being rapidly transfused during resuscitation. the samples collected during the initial trauma response should have been rejected and a request made for samples drawn below the iv site. because both samples were collected while the unit was being transfused, contamination was in both. use of a handheld barcode system would not have caught this error because the patient had been correctly identified. future prevention of the above anomaly would be the education of transfusion testing staff to recognize an abnormal high hematocrit: secondly reminding the staff collecting samples to be aware of the proper collection procedures for laboratory testing, which would include type and screen. facilities also should strive to perform collection of the confirmatory sample from a completely different venipuncture site. impact of cell saver usage during solid organ transplants at a major institution holly ross* , edward smith , thomas brown , foeks jeremy , metcalf suzanne , james johnson , peter davis , karafa sw badjie and abba zubair . department of laboratory medicine and pathology, transfusion medicine, mayo clinic, department of anesthesia, mayo clinic background/case studies: our institution performs an average of solid organ transplants (sots) yearly. transfusion support for transplants can be tremendous, accounting for a large percentage of red blood cell (rbc) transfusions annually. even the best practices for allogeneic transfusion are not without risk. transmission of pathogens is possible with even the strictest screening methods, and each transfusion increases the risk of alloimmunization. the advent of intraoperative blood recovery has reduced the need for allogeneic donor rbcs during surgeries expected to bleed heavily. with the cell saverv r (haemoneticsv r , braintree, ma), patients' own blood shed during surgery is collected, washed, concentrated, and reinfused, lessening the need for transfusion support. this study sought to examine the amount of allogeneic donor rbc units saved during sots through the use of the cell saver for intraoperative blood recovery. study design/methods: data was collected for sots which utilized the cell saver. these included liver, liver/kidney combination, lung, and heart transplants. data a y.o. female was admitted to the trauma department after a motor vehicle collision (mvc) and transfused o( ) rbc units from the kiosk. her blood type was determined as o(-) with a negative rbc antibody screen (as). she was transfused more units of o(-) rbc. two months later, a repeat as identified two new rbc alloantibodies, anti-d and anti-e. the anti-d formation resulted from the o( ) rbc transfused from the kiosk, but the source of the anti-e was undetermined since e antigen is expressed in % of rh(-) individuals. the trauma department staff was notified of delayed serologic transfusion reaction and asked to investigate further since a y.o. female patient should not have received o( ) rbcs. study design/method: an investigative plan was developed by the trauma staff involving a patient census, review of the chart and kiosk inventory, obtaining feedback from clinical providers, and review of information provided by emergency services (ems). results/finding: the trauma unit was busy with admissions during the hours preceding the patient's arrival. the chart review found the following physical attributes; patient was overweight ( kg) with obvious facial deformities from the mvc, that compromised age assessment. it was determined that the kiosk was fully stocked with both o(-) and o( ) rbc units. one clinical provider recalls that the patient identification (id) might have been unknown. review of the ems communication states "patient is a y.o. female." conclusion: use of visual examination to determine age was significant in the selection of o( ) rbc for this patient. the trauma staff proposed and implemented a change in policy to prevent future incidents. any female patient that arrives without id or written confirmation of age will be transfused o(-) uncrossmatched rbc until a blood type can be determined. after being notified of the incident, the trauma staff took the lead in investigating and providing a process improvement resolution. this is credited to the excellent collaborative relationship between the transfusion service and trauma department on ensuring patient safety during emergent, uncrossmatched rbc transfusions. rate of abo/rh confirmation in outpatient pelvic organ prolapse surgery alexis r peedin*, taylor brueseke, yara park and jay s raval. university of north carolina background/case studies: approximately , surgeries for urinary incontinence or pelvic organ prolapse (pop) are performed annually. for abdominal pelvic floor disorder (pfd) surgeries, transfusion rates historically range from - %, whereas transfusion rates for vaginal and robotic pfd surgeries range from . - . % and . - . %, respectively. since the implementation of college of american pathologists (cap) requirements for abo/ rh confirmation, approximately % of patients who receive a transfusion in our hospital required a second abo/rh specimen to be drawn; however, limited data are available regarding the impact of this new requirement on patients preparing to undergo outpatient surgery that currently require preoperative type & screen (t&s). the primary objective of our study was to assess the rate of abo/rh confirmation in women who underwent outpatient pop surgery. study design/method: this was a planned secondary analysis of a retrospective cohort study of consecutive patients undergoing pop surgical repair from may -may in our academic tertiary care institution. among this sample, patients were excluded if their first t&s was drawn before our institution implemented the abo/rh confirmation requirement. fisher's exact test was used, and statistical significance was defined as p< . . results/finding: we identified patients for analysis, of whom ( . %) had a preoperative t&s ordered. two ( . %) of these patients had positive antibody screens; one patient had an anti-k and one had a warm-reacting autoantibody. fifty-nine ( . %) of the patients required a second abo/rh specimen per hospital protocol; ( . %) of these actually had a second specimen drawn. in patients for whom abo/rh confirmation was indicated, there were no differences between those who did and did not have abo/rh confirmed when comparing age, body mass index (bmi), pre-operative hemoglobin (hgb), or surgical approach (table ) . no abo/rh discrepancies were identified. one patient received unit of red cells after abdominal pop surgery. conclusion: the rate of requiring abo/rh confirmation before pop surgery was markedly higher than that seen in all patients receiving transfusions at our institution ( . % vs. %, respectively). because the vast majority of women undergoing vaginal or robotic pop surgery are not transfused perioperatively, hospital transfusion services should consider eliminating routine pre-operative t&s for this low-risk population in the maximum surgical blood ordering schedule, avoiding this unneeded test and subsequent abo/rh confirmation. volume reduction of red cells to reduce transfusion-associated adverse events related to hyperkalemia maressa t pollen*, laura knicks, linda van tol and c. michael knudson. background/case studies: one attribute of older blood is an increase in supernatant potassium level which can contribute to transient hyperkalemia. this problem is exacerbated in conditions of massive transfusion and in patients with renal failure. washing rbcs can effectively remove free potassium but is time consuming and can often only be performed on one unit at a time. here, we estimate the amount of potassium that is removed by volume reduction of red cell units. we also examined whether this technique would be feasible in the setting of massive transfusion in a patient with hyperkalemia. study design/method: expired or over temperature units (n ) that had been removed from inventory were utilized for these studies. each unit was weighed and a volume reduction procedure was performed. the supernatant was weighed and the potassium of the supernatant was measured using routine laboratory assays. for all formulas, weight was converted to volume using a specific gravity of . g/ml. the hematocrit (hct) of the volume reduced rbc was measured using a sysmex xs- i instrument. the percentage of supernatant removed was calculated by dividing the residual supernatant in the volume reduced unit (rbc hct x rbc volume) by the total supernatant prior to the procedure (residual supernatant removed supernatant). the remaining free potassium (meq) was calculated as the (concentration of potassium in the supernatant (mmol/l) x the estimated red blood cell residual supernatant volume. to simulate the process that would occur in the setting of a massive transfusion protocol (mtp), units were subjected to the volume reduction while recording the time needed to process all units. this was performed twice for a total of units processed in this manner. results/finding: the volume reduction procedure reduced the supernatant volume by an average of % (range %- %). in units between and days (n ), the estimated mean residual k was . meq (range . to . ). in the two mock mtp trials, the time to complete the procedure was approximately minutes and we estimate an additional - minutes would be required to modify and issue the units in our lis/emr. conclusion: a manual volume reduction protocol in red cell units significantly reduces the amount of potassium administered in a unit of red cells. this procedure may be useful when only older red cell units are available for a patient at risk for hyperkalemia. the procedure can be performed in less than one hour and may be useful under the conditions of massive transfusion. processing, cryopreservation, and non-specialized hospital collection. preliminary studies of three shipping conditions after collection were tested using sterile containers with sterile normal saline (ns) alone, ns plus antibiotic/antimycotic (ab/am) and a dry container. prolonged exposure to ab/am solution retarded outgrowth of mscs, but control of microbial growth in cultured tissue samples was needed. these findings were used to construct a validation study. study design/methods: a validation study designed to test procedures to collect, transport, process, and store umbilical cord tissue was measured by post-thaw outgrowth. collected uc tissue from consenting mothers was transported to the distant lab in validated shipping containers in a dry, sterile cup from vaginal ( ) and caesarian ( ) births. uc collections were divided into segments to test conditions. segment explants were placed on . % gelatin-coated gridded tissue culture plates ( explants per plate) in enriched medium specified for msc outgrowth containing antibiotic only with an endpoint of days. growth was scored as the number of squares with explants exhibiting outgrowth compared to the total planted explants. one segment (fresh control) was dissected and planted without further processing. the remaining tissue segments were soaked in (ab/am) saline solution for hr and hrs at c, respectively. tissue segments were frozen in cryo bags with a proprietary % dmso/large molecular weight sugar solution. background/case studies: it has been the practice in our institution to process or times the total blood volume (bv) of the patient, up to a maximum of liters (l) per procedure, to obtain peripheral blood cd stem cells. as a consequence, a patient often would need to spend hours or more on the machine. it would be desirable to be able to specify the exact volume of blood to process to achieve the desired cd cell yield, thus minimizing the patient's time on the machine, the nurse's time performing the procedure, and the number of bags that have to be submitted for cryopreservation and storage. study design/methods: our institution recently implemented the new spectra optia cmnc collection protocol, a continuous flow and continuous collection procedure that uses the automated interface management (aim) system to precisely manage the separation interface. an analysis of our collection data suggested a highly reliable collection process, so a prediction algorithm (pa) based on the linear regression between the patient's cd pre-count and cd yield, normalized per liter of blood processed, was derived utilizing the patient's cd pre-count, the patient's weight in kilograms (kg), and the target cd dose/kg. this pa calculated the exact volume of whole blood to be processed to achieve the requested dose of peripheral cd stem cells. the initial equation was modified to add an additional % to the predicted volume, to account for the natural variability of the process. this pa was then tested prospectively in the clinical setting. results/findings: in patients, representing both allogeneic and autologous donors, the average blood volume processed was . l. the range was . l - . l. the target dose was achieved in all patients. our previous practice for these patients would have required, assuming a standard bv procedure, processing an average of up to l per patient, with a range of - l. to quantify how well the new pa works, it was decided to evaluate the ratio between actual and predicted volume vs. the ratio between the actual and expected cd yield. the result was a high correlation between these two ratios (r . ), indicating that the algorithm produces very consistent results. conclusion: the predictability of our collection process during the time period analyzed was a robust r . , confirming the findings in the first data analysis. the blood volumes processed and patient time on the machine decreased substantially, with some patients only needing hours or less to achieve their target dose. nurses and lab medical technologists have seen a dramatic change in their workflow. the number of bags to process has dropped for the lab, with the consequent freezer space savings and the shorter collection times allowing the lab medical technologists to finish with their work earlier in the day. all in all, implementation of this pa has produced huge increases in patient and provider satisfaction. important factors that likely contributed to the success of the protocol included the precision and consistency of the aim system of the apheresis device, as well as the small number of nurses ( - ) who performed the procedures, resulting in less variability. the economic impact of this pa has not been quantified, but might be an interesting area for future studies. background/case studies: zarziov r , a biosimilar granulocyte colonystimulating factor (g-csf) has recently been introduced into clinical practice. its use has stimulated a certain debate regarding their possible less efficacy and security on cd mobilization. the aim of this study is to evaluate if there are differences between good and bad mobilizers and assess the need for plerixafor when a biosimilar as g-csf is used. study design/method: we retrospectively evaluated autologous mobilization processes performed between june and march . patients (n ) evaluated were diagnosed with malignant lymphoma (n ), multiple myeloma (n ) and primary amyloidosis (n ) and were mobilized according to standard protocols. collection cd cellularity target was established ! x e /kg. two groups, good and bad mobilizers, have been determined. predictors of unsuccessful mobilization were defined by > years old, previous fludarabine, lenalidomide, or bendamustine treatments or ! previous regimens, present peripheral cytopenias, active disease and previous mobilization failure. mann-whitney u test was used to compare means and comparisons of medians were performed by the median test. cd count was performed according ishage protocol. adverse events (ae) were analysed according to ctcae v . . results/finding: the media (range) general collection parameters were: cd (day ) . /ml ( . - . /ml), blood volume processed ml ( - ml) and . ( - . ) exchanged volemias. seventeen patients were considered bad mobilizers, needed plerixafor and had to undergone a collection procedure twice. there were statistically significant differences between both groups on mobilization characteristics and product cellularity [mean (sd) ); p . ]. there were no significant differences on mobilization characteristics and product cellularity between both groups. five mobilization ae were observed [muscle pain (n ), fever (n ) and flu syndrome; all grade ]. two patients could not undergo hematopoietic stem cell transplantation due low cd cellularity. conclusion: there are differences between products collected from the good mobilizer (rich in gm and cd ) versus poor mobilizer (with plerixafor) rich in cn and cmn. the mobilization with zarziov r could be smaller than expected since there are no significant differences if we compare the good mobilizers versus the bad mobilizers although the number of cases studied can be limiting. background/case studies: mesenchymal stem cells (mscs) have been widely studied and have shown beneficial effects on tissue regeneration, immunomodulation, and improvement of multiple organ failure caused by infection, sepsis, and trauma. however, mscs express tissue factor, which may be a risk factor for thrombosis especially if administrated systemically following trauma when coagulopathies are common. before applying mscs in a preclinical animal model, we sought to determine the procoagulant properties of rat mscs in vitro. study design/methods: bone marrow and adipose derived mscs (bmsc and amsc) were isolated from bones (femur and tibia) and visceral fat tissue in normal young sprague dawley rats respectively. both bmscs and amscs were cultured and passaged using dmem medium with % fetal bovine serum. bmsc and amsc at passage - were used in this study. the tissue factor expression of mscs was determined by immunohistochemistry. citrated whole blood collected from normal rats was treated with rat bmscs and amscs at low, medium and high doses ( . /ml, /ml and . /ml respectively). the prothrombin time (pt), coagulation properties and platelet aggregation (response to adp, collagen and par ) were measured by hemostasis analyzer, rotational thromboelastometry (rotem) and impedance aggregometry (multiplate) respectively within min and hr after incubation. results/finding: tissue factor was significantly expressed among both bmsc and amsc at all passages in vitro. bmsc and amsc at any dose and time of treatment neither shortened nor elongated pt in whole blood. however, both bmsc and amsc significantly shortened the clotting time (ct) (none: seconds, versus low, medium and high doses of amsc ( , , and seconds), and bmsc ( , , . seconds), p< . ), clot formation time (cft, p< . ) and increased alpha angle (p< . ) by natem measurement, but did not significantly affect the ct, cft and alpha angle by extem. maximum clot firmness (mcf) and fibrinolytic index were not affected by mscs. there was no significant impact of both bmsc and amsc on platelet aggregation simulated by adp, collagen and par . no significant differences of hemostatic and platelet function were found between the treatments of bmsc and amsc. conclusion: consistent with reports from human derived msc, both rat bmsc and amsc significantly expressed tissue factor in both early and late passages, which led to a significant decrease in clotting time at various dose and time of treatment. however, mscs had no direct impact on platelet aggregation in vitro. as considering the procoagulant capability of mscs, future study will be necessary to determine the optimal dose and safety of using mscs for systemic application in vivo. comparison of the terumo bct mnc and cmnc protocols for peripheral blood stem cell collections lindsey westbrook* , neil bagamasbad , reynold dilag , melissa nasser , nicole bauer , jennifer wheeler and mary berg . department of pathology, university of colorado -anschutz medical campus, department of medicine, division of hematology, university of colorado hospital, scientific support, terumo bct background/case studies: terumo bct recently offered a new method of peripheral blood stem cell (pbsc) collection using the spectra optia, an apheresis instrument. the new protocol, continuous mononuclear cell collection (cmnc) collects cells continuously as opposed to the older protocol, the mononuclear cell collection (mnc) protocol, which is batch collection or dual stage collection, involving an additional step where platelets are separated from mnc within a cell separation chamber. our institution has used both protocols and the purpose of this study was to compare pbsc product characteristics and run times between the cmnc and the mnc protocols. study design/method: a retrospective review and comparison of parameters from collection procedures using the mnc protocol and collection procedures using the cmnc protocol was done using the t-test. data from patients/donors (including allogeneic donors) as well as procedure details including run time, flow cytometry marker for stem cells (cd )-positive (cd ) throughput, cd collection efficiency (ce%), platelet loss a transfusion per total blood volume processed (plt loss/tbv), and collection product characteristics were included in the analysis. results/finding: numerical results are summarized in the table. the mnc and cmnc donor groups included and allogeneic donors, respectively. donor weight was not significantly different between the two groups. pre-procedure wbc values were also similar between the two groups. run time was found to be significantly shorter using the cmnc protocol compared to the mnc protocol. product volume was also significantly lower in the cmnc group compared to the mnc group. although the volume was lower, the cmnc product had significantly higher percentages of mononuclear cells (mono%) and lymphocytes (lymph%) collected when compared to the mnc product. the cd throughput was significantly higher in the cmnc group than the mnc group. the cd ce% was found to be slightly increased in the cmnc group, though not significantly. the platelet loss was not significantly different between the protocols when normalized for total blood volume. product hematocrit (hct%) was significantly higher using the cmnc protocol; however, the red blood cell volume never exceeded ml due to the lower product volume with the cmnc protocol. the cmnc protocol collects a smaller volume of a purer product when compared to the mnc protocol with comparable platelet and red blood cell loss. staff members who perform apheresis procedures are pleased by the shorter run time. background/case studies: hematopoietic stem cell (hsc) donors and their recipients need not have a matching blood type. eventually, the hsc recipient will become the blood type of the hsc donor. this scenario can become quite a conundrum if the hsc recipient becomes a patient in need of an organ transplant. in order for a patient to receive a donor organ, the patient and donor's blood type and hla typing must be compatible. study design/methods: blood type was determined using gel test cards. hla typing was determined by using sequence-specific oligonucleotide (sso), sequence-specific primer (ssp), and sequence based typing (sbt) technologies. hsc sources were bone marrow and umbilical cord blood. results/findings: patient # , originally typed as an a , had bone marrow donor and cord blood transplants. one of the cord blood transplants successfully engrafted. the engrafted unit was from a type o donor. patient # is now typing as type o. patient # was originally typed as a and received a bone marrow transplant from a type b donor. patient # is now front-typing as a b and backtyping as an ab. since the patient's abo front and back-type do not match, a note must be made, that when confirming abo during crossmatch, the abo will not match. the patient now has an hla and abo identical kidney match (his father who is a type b). previously, the patient and his father were abo incompatible. the abo and hla results on both patient # and patient # indicate that the hsc transplants have engrafted. results also indicate that the abo and hla now match that of the donor and differ from the recipient's original abo and hla type. due to various reasons, for example, a side effect of the immunosuppression, both patients now need a kidney transplant. both patients will be entered into the unet system according to their "new" abo and hla types, as unos regulations require patients to be listed as per the results of two separate abo typing tests. the patients' antibodies will be monitored as per lab policy and communication with the transplant centers and blood banks is crucial. background/case studies: mesenchymal stem cells (msc) are beneficial for tissue regeneration, immunomodulation and improvement of multiple organ failure caused by infection, sepsis, and trauma. mscs express tissue factor (tf) that activate the clotting cascade and interfere hemostasis. hypoxia is a condition that occurs after trauma globally during shock or at the site of injury, and is known to change or influence the phenotypes of cells, including mscs. in this study, we want to determine if hypoxia changes the expression of tissue factor and the pro-coagulant properties of rat msc in vitro. study design/method: bone marrow and adipose derived mscs (bmsc and amsc) were isolated from bones (femur and tibia) and visceral fat tissue in normal young sprague dawley rats respectively. both bmscs and amscs were cultured using dmem medium with % fetal bovine serum under either normoxia ( % o ) or hypoxia ( . % o ). msc growth curves were measured by cell counter. the tf expression was determined by immunohistochemistry. cd /cd and cd were measured as positive and negative markers of msc respectively by flow cytometry. the citrated rat whole blood was treated with msc ( . /ml) either from normoxia or hypoxia. the coagulation properties were measured by hemostasis analyzer and rotational thromboelastometry (rotem). results/finding: hypoxia potentiated the growth of bmsc by %, but depressed the growth of amsc by % at day in comparison to normoxia. both bmsc and amsc equally expressed cd and cd but not cd under any culture condition. tissue factor was significantly expressed among bmscs and amscs from both normoxia and hypoxia. whole blood treated with bmscs and amscs from normoxia significantly shortened the clotting time (ct: (control), versus (bmsc), and (amsc) seconds) by natem. hypoxia also significantly shortened ct ( (bmsc), (amsc) seconds, p< . as compared to control), but the changes in ct were not significantly different between bmscs and amscs. maximum clot firmness (mcf) and fibrinolytic index did not change after treatment with bmsc and amsc regardless of the normoxia or hypoxia conditions. conclusion: tissue factor is constitutively expressed in rat bmscs and amscs. adjustment of the msc culture condition to hypoxia did not affect tissue factor expression or the procoagulant properties of msc (bmsc and amsc). this study also suggests that the procoagulant properties will not be affected if mscs are recruited into injured tissues with hypoxic environments. future study will be necessary to determine the optimal dose msc and whether it is safe to use mscs for systemic application in trauma. effect of double-end cryopreservation on gene-transduced human hematopoietic stem and progenitor cells sandeep k srivastava*, jiaqiang ren, steven highfill, narda theobald, suksee deravin, andre larochelle, david f stroncek and sandhya r panch. national institutes of health background/case studies: current early-phase clinical gene therapy trials use freshly collected or cryopreserved cd cells as the starting fraction prior to gene manipulation. following gene-transduction and culture, the end product is infused fresh into recipients. for wider applicability and scale-up, gene therapy manufacturing protocols would benefit from double-end cryopreservation (dec) of cd cells during manufacture (i.e. immediately post-collection and again, post-gene modification). dec helps delink patients' preparative conditioning phase from cell manufacture, eases logistics of inter-facility cell transportation, and ensures fulfillment of regulatory product release criteria before infusion. our objective was to study the effects of dec on gene transduced mobilized peripheral blood (mpb) cd cells. study design/method: cryopreserved cd cells from healthy adult donors were thawed and transduced (tr) in retronectin coated tissue culture bags with an ef -alpha-yfp lentivirus ( . % concentration) and media (x-vivo- , human serum albumin(hsa), ng/ml each of cytokines (scf, tpo and flt -l) over days. untransduced (utr) cells were cultured as controls. tr and utr fractions were re-cryopreserved. a standard freeze-mix of % dmso, % pentastarch, hsa, plasma-lyte a was used for cryopreservation. viability, hematopoietic stem cell (hsc) (cd cd -cd ra -cd cd f cells) phenotyping and cfu assays were done following first thaw (pt ), post-transduction (ptxn) and second cryopreservation-thaw (pt ). results/finding: tnc recovery decreased gradually in the donor samples at each step. transduction efficiency, cd %, cfus were similar before and after pt . hscs ranged from to cells/ cd cells in the pt -tr arm compared to a range of to / cd cells after pt . viability, % cd and cfus were lower in the tr compared to the utr arm. this difference was not altered after pt (table) . conclusion: dec of mpb human cd cells decreases tnc recovery, but has minimal effects on cd cell phenotype, transduction efficiency and cell function. hsc numbers were within acceptable range after recryopreservation. lower viability and cd % in the tr arm compared to the utr arm is likely due to vector toxicity. this was unaffected by recryopreservation. additional studies to assess dec mediated changes on cd cell early apoptotic markers, telomere lengths, gene expression and engraftment potential in nod/scid mice will inform clinical trials. background/case studies: autologous peripheral blood stem cell (pbsc) transplantation has been used as a powerful resource during the treatment of some hematological malignancies. cryopreservation of these cells is routinely performed to allow for patient adequate conditioning and chemotherapy. in some cases, pbsc are harvested as a backup option and remain stored for several years, although effect of storage lesion in this product is still controversial. our work presents retrospective data on pbsc infusion after long-term storage. study design/method: all products were harvested after patient mobilization with g-csf by apheresis with cobe spectra v r . flow cytometry analysis of cd cells was performed prior to cryopreservation. the cryoprotective solution was freshly prepared by addition of % hydroxyethyl starch, % human serum albumin and % dmso at final concentration. pbsc were cryopreserved by direct immersion on - c mechanical freezer (dump freeze) and stored until transplantation. post-thaw viability was determined from stored cryotube samples by trypan blue exclusion minutes prior to infusion. cells were thawed and infused on bedside. engraftment was defined as the first day of consecutive days of neutrophil count > . x /l and platelet count > x /l after days. with g-csf for four days and patients with g-csf for five days with use of mozobil when cd was below x cells/l on the fourth day. hpc collection was performed on the fourth day of mobilization for healthy donors and on the fifth day for patients. all procedures were realized based on a prediction algorithm using pre-cd on the day of the collection and estimating wbc liters to be processed to obtain sufficient stem cells for the transplant. this algorithm was designed using linear regression of peripheral blood cd on the day of the collection versus collected cd per liter of blood processed. there was no distinction between patients and donors, once the efficiency coefficient was used for both. collected material was sent to analysis and total cd was calculated. final laboratory count of cd per kilogram was compared with the number predicted by the algorithm with spearman's correlation to evaluate whether the formula is effective. calculations were made using ibm spss software. results/findings: among patients collecting hpc for autologous transplantation, , % needed only one day of hpc harvesting, while , % needed two days and , % needed three or more days. our collection efficiency (ce) and standard error of the mean (sem) was - , %. after comparing predicted values with cd collected in the final product, we found a very strong correlation of . (p< . ) for patients and a strong correlation . for healthy donors (p< . ). conclusion: the use of a mathematical model with a prediction algorithm is safe, has low cost and provides a good tool to estimate wb liters to process and avoid unnecessary procedures in both patients and healthy donors. this study evaluated the phenotypic characteristics of uc-mscs derived from fresh and cryopreserved cord tissues (ct), as described in isct's position paper on minimal characteristics of mesenchymal stem cells (plastic adherent; ! % cd , cd , cd and % cd , cd , cd , cd , hla-dr) study design/method: umbilical cord tissue (n ) was washed, blood vessels removed, cut into . - mm pieces, and washed twice in saline. fresh tissue was immersed in . % saline for same day culture, while frozen tissue was cryopreserved for at least hours prior to culture. for colony forming unit (cfu) testing tissue was plated directly in a cm tissue culture flask following a wash in pbs with antibiotic/antimycotic. the tissue was allowed to adhere for minutes prior to the addition of cell culture media. media was changed several times a week. cells were passed when robust colony growth was observed and in subsequent cultures > % confluence. all cells were tested on an msc flow panel at passage just prior to confluence. results/finding: both fresh and cryopreserved tissue showed excellent colony forming capabilities. average time for cellular emergence of days (fresh . , frozen . ), and days (total) for the msc's to reach passage (fresh . , frozen . ). all cells were ready for flow analysis in approximately weeks time. there was no statistical difference between fresh and frozen tissue in their colony emergence (p . ), or their growth rates (p > . for all). flow cytometry showed average ! % for positive markers and % negative markers. there was no statistical difference between fresh and frozen flow result (p > . ). conclusion: uc-msc's show excellent adherence to plastic in both fresh and frozen explant cultures, with a consistent fibroblast-like morphology. flow cytometry analysis showed strong msc phenotype in both fresh and frozen samples. the data show that the cryogenic process does not appear to have any detrimental effects on the ability to obtain msc colonies. studies have shown that hsct improves survival and disease-free survival rates when compared to conventional chemotherapy treatments. the increase in the number of hscts over the last years has demanded quality and safety improvements of cell processing and cryopreservation services. cell recovery and viability are crucial parameters to assess ucb quality as a viable hsct graft source. study design/method: twenty-five ucb units cryopreserved for periods of up to years ( to ) were analyzed. units underwent red cell and plasma depletion and then subjected to controlled rate freezing and subsequent cryopreservation using dmso (dimethylsulfoxide) cryoprotectant with % concentration. informed consent and the unit discard terms for all units were obtained. units were thawed in a c water bath and . ml aliquots were diluted at a : proportion with % human albumin solution and plasmin were prepared, enabling dmso stabilization and concentration reduction. the following analysis were performed: nucleated cell count (tnc) in an automated hematologic counter and cell viability using flow citometry. post-processing (pre-cryopreservation) cell viability was tested using trypan blue as exclusion dye, while post-thaw cell viability was assessed using -aad marker through flow cytometric analysis. results/finding: ucb storage period was . years (mean) and cell recovery was . % (mean). there was no statistically significant correlation between storage period and post-processing cell recovery (p . ). post-thaw cell viability of . % (mean) showed no statistically significant correlation with unit storage period (p . ). post thaw cell viability results are within parameters defined in other studies. background/case studies: umbilical cord (uc) tissue is a rich source of mesenchymal stem cells (mscs) that can be collected noninvasively at birth and stored for potential future use. as such, a growing number of stem cell banks have established uc storage programs based on mounting preclinical evidence of its therapeutic potential. however, little has been reported on the ability to isolate msc-like cells from uc tissue after extended periods of cryopreservation. this work describes and characterizes the isolation of mscs from uc tissue cryopreserved as a composite material at a family stem cell bank for years. study design/method: donated uc units from consenting mothers were evaluated. units had been cryopreserved as composite tissue pieces in ln vapor in a dmso-based cryoprotectant for yrs. ( . . ; n ). units were rapidly thawed and rinsed in dpbs, then pieces were excised from each using a biopsy punch. pieces from each unit were explanted in a x grid pattern in msc-supportive medium and incubated for days, after which the tissue was discarded and media exchanged. cells were isolated on the th day, counted, and subcultured for two passages. at the end of each passage, cells were collected, counted and population doubling time was calculated. isolated cells from each unit were also evaluated for msc immunomarkers. results/finding: small, proliferative cells with fibroblastic morphology were obtained from all explants, yielding a % success rate. cells were positive for the msc markers cd , cd , and cd ( . . %, . . %, and . . %, respectively) and negative for the hematopoietic markers cd / ( . . %). passage and passage doubling times were . . days and . . days, respectively, which are in line with values reported for mscs isolated from fresh uc tissue. conclusion: due to their immature status, ease of collection, and potential therapeutic value, uc mscs are an appealing candidate for future clinical a transfusion vol. supplement s research and treatment. the present work demonstrates that the long-term cryopreservation of uc tissue does not disrupt the ability to isolate functional mscs from the tissue at a later date. importantly, growth characteristics of isolated mscs appear to be comparable to those reported for mscs from fresh uc tissue. based on the consistent isolation and lack of apparent impact on proliferation kinetics, it is reasonable to expect cell yields in the range anticipated for therapeutic requirements and more than sufficient for moving to clinical grade bioreactors for expansion. these results support the feasibility of storage of uc as a composite material for future potential cell isolation and expansion to clinically relevant doses. large volume leukapheresis with spectra optia cmnc protocol in adult and pediatric patients: performance and determination of cd yield prediction algorithm ines bojanic* , nelly besson , ivana vidovic and branka golubic cepulic . department of transfusion medicine and transplantation biology, university hospital centre zagreb, terumo bct background/case studies: large volume leukapheresis (lvl) have shown to enhance cd cell yield collected. this study evaluated performance and safety of the spectra optia cmnc protocol (version ) in adult and pediatric lvl. a prediction algorithm for cd cell yield was also tested. study design/method: we evaluated retrospectively lvl performed in adult patients, and lvl in pediatric patients treated in uhc zagreb from march till september . mobilization regimen combined chemotherapy and filgrastim; poor mobilizes received plerixafor additionally. a combination of acd-a and heparin was used as anticoagulant (acd-a:whole blood ratio : ). in patients weighting kg (n ), a rbc prime was performed. cd , lymphocyte(ly) and monocyte(mo) collection efficiencies (ces) were calculated. a customized prediction algorithm was determined on linear regression between pre-cd cell count and cd cells collected / blood volume processed. prediction accuracy was evaluated by comparing predicted cd values to real cd yield. results are presented as median (iqr). results/finding: in both groups, cd , ly and mo ces were high. target cd dose was successfully reached in procedure in ( , %)adults and in ( . %) children. all procedures were well tolerated: adverse reactions were restricted to mild citrate toxicity symptoms in ( . %) adults, while all pediatric apheresis went uneventful. no bleeding episodes occurred, and no transfusion was needed. product and procedure characteristics* a high correlation between precd cells and cd cells collected/ blood volume was observed in both groups (r . and . in adults and children respectively, p< . ) suggesting cd yield could be predicted based on precd cells and blood volume to process. linear regression equations served as prediction algorithm. the high correlation between predicted cd yield and observed cd yield (r . and . in adults and children respectively, p< . ) showed accuracy of the algorithm. implementation of the algorithm could have allowed sparing a median of . ( . - . )l of blood in adult procedures, and . ( . - . )l in pediatric procedures. conclusion: lvl performed using spectra optia cmnc protocol is safe and efficient in adults and in low body weight children. high cd , ly and mo ce were observed in both groups. implementation of a predictive algorithm can reliably minimize blood volume processed, shorten procedure duration, reduce anticoagulant volumes infused, and improve patient comfort. mesenchymal stem cell therapy in steroid refractory graft-versus-host disease (gvhd) emese molnar* , aniko barta , arpad batai , zoltan csukly , zita farkas , laszlo gopcsa , gabor tatai background/case studies: steroid refractory acute graft-versus-host disease (gvhd) is a serious complication of allogeneic hematopoietic stem cell transplantation (hsct). more experience accumulates in the immunomodulatory effect of mesenchymal stem cell (msc) infusion in numerous immunopathological disorders -such as gvhd -and signals. mscs have a hlarestrictive and non-immunogenic nature. study design/method: we have evaluated the efficacy of msc transfusions in cases of acute gvhd refractory to conventional immunosuppressive treatment. the patients with steroid-resistant gvhd had received third-party mscs (derived from wharton's jelly and bone marrow) times per case weekly at a dose of million cells/kg. clinical response was assessed days after administering the first dose. complete remission was defined as the complete disappearance of symptoms. partial remission was assessed by the significant relief of symptomsand by the general improvement of the patient's condition. results/finding: in all patients had received cycles of msctreatment ( dose per cycle). the median age was years old ( - ) with a male/female ratio of : . distribution of the original malignancies (n): acute myeloid leukemia: ; acute lymphoblastic leukemia: ; myelofibrosis: ; myelodysplastic syndrome: ; multiple myeloma: ; t-cell lymphoma: . nine patients had undergone allogeneic hsct with matched unrelated donors, the other three had stem cells derived from hla-identic relatives. the first episode of gvhd after hsct was started on the median rd day ( - ). the involved organs were skin ( ), gut ( ), skin and gut combined ( ) and even lung in cases. the median time of msc's first infusion was days after the stem cell transplantation (hsct) and ( - ) days after the first episode of gvhd. of the cycles of msc-treatment led to complete remission ( . %) and resulted inpartial remission ( . %). conclusion: we have evaluated msc-therapy as an effective treatment of gvhd in the majority of the observed cases with % overall cumulative response rate. the application of third-party mscs offers a promising alternative in the therapy of gvhd and other gvhd-associated complications after hsct. further research is needed to determine the optimal start of the treatment, along with the issue of long-term safety. background/case studies: stem cell collection by leukapheresis for transplantation is a significant endeavor for the patient and the clinical team. whether the collection is allogenic or autologous, the patient undergoing the collection and the physicians caring for the patient are always concerned whether they will be able to harvest enough cells for transplantation and engraftment. a typical goal for most adult procedures is million cd cells/kg. if a patient does not reach this goal on the day of the procedure, they will likely have to return the following day to undergo a second procedure to reach the desired goal. given the logistical challenges in planning transplantation, it is reasonable to attempt to optimize the number of cells collected while minimizing the number of collections. measuring a patient's cd cells/ml in their peripheral blood before the leukapheresis procedure has been used to predict if the collection will successfully reach the million cells/kg goal. the ideal minimum cd cells/ml that will lead to successful harvest has not been conclusively identified. study design/methods: we analyzed the collection data from patients to evaluate the predictive value of the cd cells/ml level. data was collected over months from every patient who underwent a stem cell collection. four patients were allogenic donors and were autologous donors. the patients' weight, diagnosis, and pre-procedure cd cells/ml level were all collected. the run time, amount of volume processed, and the absolute viable cd cells collected were recorded. the collection efficiency and the cd cells/kg were calculated for each patient. results/findings: our data showed a strong linear correlation between pre-procedure cd cells/ml and post-procedure cd cells/kg (r . ). any patient who had a pre-procedure cd cells/ml count of or greater had a collection of at least million cells/kg. any patient who had a pre-procedure cd cells/ml count of or less collected less than conclusion: the pre-procedure cd cells/ml level in the peripheral blood has a very strong predictive value for the post-procedure cd cells/kg level. to confidently know that a patient will be able to produce the desired million cells/kg, a pre-procedure cd cells/ml count of at least should be obtained. for any patient with a count below , they should be counseled that their collection is likely to take at least a second day and a second procedure. further studies, including potentially lengthening the run time and the volume processed, to evaluate how to handle the patients who fall between and cd cells/ml should be conducted. heidi elmoazzen , antonio giulivi , michael halpenny* , lisa martin , donna perron , chris bredeson , lin yang , locksley mcgann , paul birch and jason p. acker . canadian blood services, ottawa hospital background/case studies: a critical aspect of hematopoietic progenitor cell processing is the cryopreservation method. our program uses a "dump" freeze method consisting of product placement directly into liquid nitrogen vapour after addition of a cryopreservation solution containing dmso ( % final concentration) and hes (hydroxyethyl starch). pentastarch (hes source) a critical component of the cryoprotectant formulation was discontinued by the commercial vendor. this required that an alternative cryoprotectant formulation be validated to minimize the risk to patient safety without compromising engraftment quality. study design/method: the validation study consisted of phases; firstevaluation of the efficacy of four different cryoprotectant formulations, second -evaluation of full scale production and crypreservation and third -a concurrent validation for clinical transplant. phase i -samples from four different cryoprotectant formulations were tested for tnc, cd , viability and cfu at three points during manufacturing (fresh, post processing and post thaw). phase ii -mock hpc, apheresis units were used for a side-by-side comparison of freezing curves for the control and replacement formulations. phase iii -five clinical transplants were performed with hpc, apheresis products cryopreserved using the recommended replacement (hetastarch). results/finding: phase i -results indicate that aliquots cryopreserved in % dmso and . % hes (hetastarch) did not behave significantly different than cells cryopreserved in the control in terms of cell recovery, viability or cell proliferation assay (cfu). phase ii -the majority of freezing profiles displayed typical or expected bulk freezing profiles for both formulations. phase iii -transplants performed resulted in a mean engraftment time of . days for anc with no adverse patient reactions observed. engraftment times using the new hetastarch formula were compared to the previous engraftment times with no significant difference. conclusion: a change in the formulation of a cryoprotectant solution represents a major change that could have a significant impact on quality. in addition, maintaining the current % dmso final concentration was critical as post thaw washing is not performed at the clinical site, history demonstrating a very low toxicity rate with the existing formulation. this study demonstrated the acceptability of the hetastarch formulation using % dmso and . % hetastarch to replace pentastarch in the cryoprotectant formulation used for cryopreservation of hpc, apheresis products. background/case studies: autologous stem cell transplantation is usually performed with mobilized peripheral blood stem cells (pbscs). traditional mobilization regimens include granulocyte colony stimulating factor (g-csf) with or without chemotherapy, but have failure rates ranging from % to %. plerixafor is an adjunct agent used to improve mobilization in many clinical settings. however, its high cost is a significant concern. the manufacturer-recommended dose is . mg/kg, therefore patients weighing > kg would require a second vial, thus doubling the drug cost. in we implemented a policy of capping plerixafor at mg for patients weighing > kg. this retrospective study compares the mobilization of patients > kg who received capped doses ( ) ( ) ( ) ( ) , with historical control patients ( - ) who received full or uncapped doses. study design/method: patients weighing > kg with crcl > ml/min who received capped and full doses of plerixafor were identified in the pharmacy database. electronic medical records were used to collect baseline characteristics and cell collection data. results/findings: a total of and consecutive patients were included in the capped and full dosing groups, respectively. they showed comparable baseline distributions of age, weight, gender and diagnoses. plerixafor was given upfront, or as a rescue agent due to suboptimal mobilization in both groups. in the capped dosing group, fewer patients received chemomobilization or plerixafor upfront. when compared to historical controls, they used half of the number of vials of plerixafor, but collected similar numbers of cd /cells kg and achieved a comparable collection success rate. the strategy dose capping plerixafor at mg for patients > kg is cost-effective and achieves comparable mobilization outcomes while decreasing the drug cost by half. mean and range of %cd in peripheral blood were calculated. the data show that in the non-hispanic group, the youngest donors (< yrs) have a higher pre-apheresis %cd level than any of the other groups, reaching statistical significance when comparing the %cd pre-apheresis between the youngest group (< yrs) and the oldest group (> yrs). hispanic donors show statistically similar %cd pre-apheresis levels over all age groups. moreover, the hispanic older age group (> yrs) had a statistically higher %cd pre-apheresis level than the non-hispanic older age group. conclusion: in this analysis of sequential unrelated pbsc donors, hispanic donors maintain a similar pre-apheresis %cd level even as the donor ages, while non-hispanic donors show a decreasing pre-apheresis %cd level as they age. if proven, this data would suggest there are genetic factors that modulate a person's ability to mobilize stem cells as they age and that these genetic factors differ between ethnic groups. this small data set would suggest that people of hispanic ethnicity maintain a more robust and quickly responsive stem cell pool, even as they age. further studies of larger cohorts are needed to validate this observation. if proven, this has far reaching implications within the stem cell research and therapy arena. background/case studies: an update in hpc apheresis collection software led to higher collection volume in the organization's human progenitor cell (hpc) products without a corresponding increase in total cellular counts. incorporation of a volume reduction step was therefore warranted as larger product volumes require additional time to transfuse and lead to a larger dmso load to the recipient, often resulting in the need to transfuse over several days. the objectives of this study were to develop suitable mock hpc (mhpc) products and evaluate the effectiveness of the biosafe pericell volume reduction technology on white blood cell (wbc) recovery and viability. study design/method: hpc products are not readily available for development. mhpc were created from whole blood buffy coats (bcs). fresh abo compatible bcs were pooled and concentrated using centrifugation and manual extraction of supernatant and red cells. the mhpc products were then diluted in plasma to produce an appropriate concentration and volume. hpc collection data from last years was analyzed to determine the th percentile, median and th percentile values for both hpc volume and wbc concentration. six mhpc products were tested; three high wbc ( x cell / ml) and three low wbc ( x cells / ml) concentrations, each at high ( ml), low ( ml) and median ( ml) volumes. each unit was processed sequentially from high, median and low volumes. hence, the highest mhpc volume was processed for volume reduction first with a sepax (pericell protocol, cs. . kits), analyzed and then reconstituted and volume adjusted to the next volume target before being volume reduced again, and so forth. one additional mock product was prepared for a reproducibility study and was volume reduced three times. wbc concentration and -aad viability was determined before and after each volume reduction. a control sample was removed from the product prior to processing and sat on the bench top until the end of the protocol to assess the change in cell concentration and viability over time. results/finding: mock hpc products had a mean starting -aad viability of % [range - ]% and a hematocrit of % [ - ] which is well below the maximum allowable limit of the pericell. no significant differences in wbc recovery or change in viability were seen between the mhpc products. aggregate data showed that the mean wbc recovery of the volume reduction process was % [ - ] with a % [- - ] change in viability. the recovery protocol used to salvage product after each volume reduction gave a recovery of [ , ] % and a change in -aad viability of [ , ] % from the input product. the method was found to have a cv of . %. the change in wbc concentration and wbc viability of the test products was not significantly different from the unprocessed control samples. conclusion: mock bc products are a suitable alternative where hpc products are not available for development and are a good use of product otherwise directed for rejection and disposal. the volume reduction protocol evaluated had minimal impact on the wbc concentration and wbc viability in the mock products and was found to be highly reproducible, giving confidence that it will be a valuable processing step with hpcs and will facilitate transfusion of hpc products into the recipient. the protocol is now in use with patient hpc products and engraftment kinetics will be tracked in a postimplementation study. validating a transfusion clinical assessment. in the first phase, cryopreserved pbsc products were tested. two aliquots were thawed simultaneously for each product: one was passed through a pre-set infusion pump and a second control aliquot was drained by gravity. each aliquot was tested for baseline total nucleated cell (tnc) count and viability, and for final tnc recovery, trypan blue (tb) viability, cd -aad viability, and potency (cfu). the effect of longterm exposure to dmso was assessed by visually inspecting the product for aggregates and measuring viability up to hours post thaw. the second in vivo phase included use of an infusion pump for consecutive autologous patients, with comparison of infusion and transplant outcomes to previous infusions by gravity drip. comparison variables included infusion rate, adverse events (ae), and engraftment time. results/finding: no significant differences were observed between infusion pump and drip for the products tested in vitro, including tnc recovery, cell viabilities, and potency. for both methods tnc tb viability decreased by more than % within hour, while cd cell viability remained stable up to hours post thaw. small aggregates appeared after hour for both methods and increased by a similar rate over time. comparison of infusion and transplant outcomes between drip and infusion pump patients showed no significant differences for all measured variables. engraftment time was similar for both groups. anc days to engraftment for pump and drip were . . and . . , respectively (p-value . ). platelet days to engraftment for pump and drip were . . and . . , respectively (p-value . ). infusion rates were slightly higher for the pump group. for control patients, required transfer of products to syringes due to slow infusion rate and others experienced allergic and hypotension infusion adverse events. conclusion: no significant in vitro or clinical differences were observed between thawed pbscs infused by gravity or an infusion pump. these results demonstrate that the use of a pump for pbsc infusion is safe, provides consistent infusion rates, eliminates the need to transfer products to syringes, and results in comparable engraftment times. donor racial distribution among the zikv ineligible cbus was: caucasian %, asian %, black/aa %, and multi-race %. racial distribution of all clinical cbu donors was caucasian %, asian %, black/aa %, and multi-race %, suggesting there is no race correlation for this risk factor driven by cultural habits such as family travel. there were no cases in which onlythe sexual partner's potential exposure determined donor's ineligibility. conclusion: our study indicates that currently the leading risk factor for ineligible cb donors is potential exposure to zikv: % of all ineligible cbus and % of all banked cbus in the study period. we anticipate the number of cases to decrease following maternal education and travel warnings. recognizing the importance of zikv in public health, and its potential transmission via hct/p products, an fda approved screening test for hct/ p donors becomes a timely necessity. acknowledgments: funded by zimmer biomet, a zimmer biomet company, ibgrl red cell reference and nhsbt reagents background/case studies: during storage, red blood cells (rbcs) become less deformable, deplete , -diphosphoglycerate ( , -dpg) and adenosine triphosphate (atp), release pro-coagulation phospholipids, accumulate pro-inflammatory molecules, free iron and haemoglobin and increase their potential for adhesion to a recipient's vascular endothelium. longer rbc storage may impair transfusion outcome due to impaired oxygen delivery, promotion of oxidative stress, increased pro-inflammatory state and coagulation. a sterile, non-pyrogenic rejuvenation solution, containing pyruvate, inosine, phosphate, and adenine (citra labs, llc, braintree, ma), is approved by the u.s. food and drug administration for the rejuvenation of stored rbcs. the solution acts by restoring , -dpg and atp in stored rbcs to levels equivalent to those in the circulation. the aim of the study was to investigate the effect treatment with this rejuvenation solution had on the crossmatch reaction profile and phenotypic state of stored rbcs. study design/method: a ml aliquot was removed from abo/rh grouped, leucocyte depleted rbc units (n ), which were stored in sagm for days, to act as untreated controls. the remainder of each unit ($ ml) underwent treatment with the rejuvenation solution ( ml, minutes at o c), followed by cell washing twice in sagm ('manual' centrifuge-based process). to represent current transfusion laboratory practice, units were crossmatched against plasma from random donors, using both diamed gel column and glass tube technique. phenotype investigation with commercial antisera was performed to identify the effect the rejuvenation solution treatment exerted on rbc surface antigens (a, b, d, c, c, e, e, k, m, n, s, s, p , lu a , k, kp a , kp b , le a , le b , fy a , fy b , jk a , and jk b ), including whether it exposed crypt antigens (t, tn, tk*, th, tx*, and cad). crossmatch and phenotype agglutination scores observed for the untreated and treated rbcs were then compared. results/finding: crossmatch findings were defined as compatible, suitable, and incompatible. the study identified no difference between the crossmatch reaction profiles of untreated and treated rbcs. furthermore, no difference was observed in the phenotypic state between untreated and treated rbcs. conclusion: treatment of day old stored rbcs with the rejuvenation solution had no effect on crossmatch reaction profiles or phenotypic state when compared to matched untreated samples. background/case studies: cryopreserved platelet production is burgeoning worldwide. currently, there are no automated platelet cryopreservation methods. by contrast, red blood cell cryopreservation using the acp (haemonetics corp., baintree, ma) has automated the processing within a closed system, increased labour productivity and provided high quality blood components. purpose: to automate platelet cryopreservation procedure. study design/method: apheresis platelet concentrates (pc) were collected on the trima accel system. platelet counts were performed using an abx micros . pc were centrifuged at g in a sorvall rc c centrifuge (sorvall, usa) for min. the combination cryoprotectant dmso dextran (cryosure dex , germany) was used for pc cryopreservation. cryopreserved pc (cpc) were frozen and stored in a kelvinator chest freezer. cpc were thawed at degrees c (barkey plasmatherm) for min. cpc osmolality was measured with an osmomat osmometer. results/finding: staged platelet cryopreservation technology has been developed. platelets were cryopreserved in a closed system (patent no.: ru u ). during the first stage, cpc were spun to separate a plateletrich plasma (prp) fraction from platelet-poor plasma (ppp). the second step was to resuspend the prp by adding a combination of dmso dextran (cryosure dex ) , as a cryoprotectant, to obtain a final concentration of % dmso in the platelet suspension. the injectomat mc agilia and npbi compomixer m were instrumental in automating that phase. pc to be frozen had an osmolality of no less than mosm/l. prp and ppp were frozen at a cooling rate of - c/min and stored at - in the chest freezer for up to months. pre-transfusion defrosted platelets were also processed in a closed system (patent no.: ru u ). our transfer set made it possible to automate platelet resuspension in plasma through the agency of the exadrop v r . post-thaw prp was resuspended in plasma, which lowered the osmolality to mosm/l. freeze-thaw recovery of platelets was % or more of the original population. defrosted pc were stored at - with continuous gentle stirring from a helmer platelet agitator for no longer than hours before transfusion. it took no more than min to cryopreserve pc and process pre-transfusion thawed platelets. the automated processing accounted for the bulk of the time (over min). conclusion: the automated technique developed reduced the workload while offering reproducibility of the procedure and high cpc quality. the use of closed systems ruled out bacterial contamination. employing the infusion pump, platelet stirrer and precision flow regulator enabled adequate osmolality monitoring. bacterial detection in leukoreduced apheresis platelets on day and day evelyn c. oyler*. suncoast blood bank background/case studies: the recently published fda draft guidance describing bacterial testing to enhance the safety and availability of platelets outlined the steps for blood collection establishments and transfusion services to extend apheresis platelets dating for up to days. this evaluation will compare culture based and rapid based test methods for detecting bacterial contamination in apheresis platelets. study design/method: a large community blood center and transfusion service collects leukoreduced apheresis platelets (lrap) using amicus separator system (fenwal, lake zurich, il) and trima accel system (terumo bct, lakewood, co). previously-cultured lrap units were sampled on day for secondary culture using bact/alert (biomerieux, durham, nc) and rapid bacterial tests using bactx (immunetics, boston, ma) and pgd (verax, marlborough, ma). if lrap unit is still available, it is also sampled and tested for rapid testing on day . a total of lrap units were tested over a -month period: were cultured and rapid tested on day ; were rapid tested on day . the rapid test methods were also evaluated based on cost, ease of use, incubation time and indication for use. results/finding: of the lrap units evaluated for this study, there were true negatives (tn) and false positive (fp) on day when tested by bact/alert, with tns on day . bactx testing results showed tns on day and tns on day . testing using the pgd kit showed tns on day ; and tns and fps on day . fp results were confirmed by performing a secondary culture, which were found to be negative. bactx requires a specific analyzer and minutes are required for result interpretation. there is no instrument requirement for pgd and reactions can be read within minutes. conclusion: the results of this evaluation makes pgd the best fit for this blood center based transfusion service. pgd offers a shorter time for reading of results, does not need an initial investment for an analyzer and is indicated for lrap in % plasma and lrap in pas/plasma. its ease of use allows for testing of lrap on day and day during the night shift to be accomplished without additional staffing and allows to extend outdate to day storage of lrap. change in growth factor content of human serum for use as eye drops during frozen storage for year jos lorinser , pieter f van der meer , hans van der heiden and dirk de korte* . department of product and process development, sanquin blood bank, mu-drop background/case studies: growth factors are thought to be among the active components in serum used for treatment of dry-eye syndrome. stability of growth factors during frozen storage in mini containers ( ml) is unknown. if these products can be stored at - c it will be feasible to store this product in -star household freezers, making the product available for patients in need of serum eye drops. the purpose of this study is to demonstrate stability of growth factor content in human serum during longtime storage at - c or <- to - c packed in a new micro dose device for single use as eye drops. study design/method: serum produced from ml whole blood donations from non-remunerated healthy donors was quickly frozen. after frozen storage at <- c for - months and controlled thawing, six different sera were used to fill a large number of mini ( ll) containers, which were refrozen and stored at either - c or <- c. during storage at months intervals, samples were tested for several growth factors, using magpixv r luminex multiplex assays and compared to control samples stored at <- c. growth factors tested were pdgf-aa&ab/bb, tgf-ß / / , vegf, a transfusion vol. supplement s egf, fgf . the study was a fact-finding study, without preset acceptance criteria. results/finding: pdgf-ab/bb and tgf-ß were the most abundant growth factors, on average , resp. ng/ml. also pdgf-aa was detected at relatively high concentration in human serum, on average ng/ml. tgf-ß , egf and vegf were detected at relatively low values, resp. ng/ml, . ng/ml and . ng/ml. average levels of fgf and tgf-ß were close to detection limit (< . ng/ml). the controls stored at <- c showed for all growth factors close to % of the initial values in samples at t (moment of filling mini containers). for serum stored at <- c for up to months, most factors showed less than % decrease, except for pdgf-aa and tgf-ß , showing % resp. % lower values. for serum stored at - c the values for tgf-ß , egf and vegf were stable, whereas pdgf-ab/bb, pdgf-aa and tgf-ß showed a decrease of resp. , and %. conclusion: human serum eye drops can be stored in the new micro dose device at - c ( -star household freezers) or <- c (professional freezers) for at least one year after preparation without large decreases in growth factor content. the maximum decrease was found for pdgf-aa in serum stored at - c. it is yet unknown if the tested components add to the in vivo effectiveness of serum eye drops and what the minimal concentration is to ensure in vivo effectiveness. further stability testing in combination with in vitro and in vivo application is required to extend the shelf-life beyond year. ruqayyah almizraq* , heather inglis , phillip norris , , jennifer a muszynski , nicole juffermans , jelena holovati and jason p. acker , . university of alberta, blood systems research institute, university of california, san francisco, nationwide children's hospital, academic medical center, canadian blood services background/case studies: different blood manufacturing methods can influence residual cell numbers and membrane vesiculation, which may affect quality and safety of blood components. the aim was to identify, quantify and characterize residual cells and extracellular vesicles (evs) in stored rbc products produced by different blood manufacturing methods. study design/methods: thirty-two rbc units produced using whole blood filtration (wbf), red cell filtration (rcf), apheresis, and whole blood derived (wbd) methods were examined (n per method). residual platelets and white blood cells (wbcs) were measured on day using flow cytometer (fc). on storage day and , number and cell of origin/surface markers of evs were assessed with fc, and concentration and size-profile of evs were examined using tunable resistive plus sensing (trps). results/findings: on day , apheresis and wbd units had significantly greater residual platelets in comparisons to rcf (vs: apheresis p< . , wbd p< . ) and wbf (vs: apheresis p< . , wbd p< . ) methods. while rcf units yielded the lowest count of platelet-evs (cd a ) on day and , the highest number of platelet-evs were in apheresis (day ) and in wbd (day ). similarly, there was significant difference among methods in the number of wbc-evs (cd , cd , cd , cd , cd b ) and rcf contained the smallest concentration. moreover, both trps and fc showed an increase in the total number of evs on day vs day in all of the processing methods. noteworthy, trps showed that the number of small evs/exosomes (< nm) was greater than large evs (! nm) in all of the products on day and , and the highest level of evs < nm were in apheresis units. trps results also showed a significant difference in the evs size-profile amongst all rbc products (p< . ). conclusion: this study shows that the method of manufacturing significantly affects rbc and non-rbcs evs characteristics throughout storage, which has the potential to impact quality and safety of rbc products. the differences in the evs cell-of-origin, concentration, and size-profile observed between manufacturing methods, warrants further examination of their potential immunomodulatory effects and clinical consequences. coagulation and complement assays in whole blood stored at centigrade maryanne c herzig* , crystal lafleur , chriselda g fedyk , sherrill j. slichter and andrew p cap . us army institute of surgical research, u.s. army institute of surgical research, university of washington background/case studies: whole blood has been demonstrated to retain hemostatic activity, including platelet aggregation function, over at least weeks of storage at c without agitation. it may be possible to extend the preservation of platelet function by agitating wb. in order to more fully characterize the quality of wb stored at c with or without agitation, we evaluated complement activation as a marker of inflammatory potential. study design/method: subjects donated one unit of wb collected in cpd-a (citrate phosphate dextrose anticoagulant with adenine). the wb was not leukoreduced nor was it separated into components. units were stored under refrigerated conditions for , , , or days after collection. units were stored for days without agitation. units stored for , or days were agitated during storage with a model hybridization incubator at c set for end over end rotation at - rpms. at the appropriate time point, platelet free plasma was obtained from the wb sample and stored at - c. the frozen plasma was analyzed by elisa assays to determine: thrombinantithrombin complex (tat) as a marker of coagulation; soluble cd l as a measure of platelet activation and granule release; plasmin anti-plasmin complex (pap) as a marker of fibrinolysis; plasminogen activator inhibitor (pai- ) as another fibrinolytic measure; and complement activation markers c a, c d, c a and c b- . data was analyzed by one way repeated measure anova. results/finding: only % of the platelets were recovered in units stored for days without agitation. these levels did not meet fda requirements of . x platelets per wb unit. subsequently, wb was agitated and platelet recovery was - %. no difference was seen in elisa analysis for agitated or non-agitated samples. no change was seen in tat or pap levels between t (day of collection) and t , , , or measurements. significant elevations of pai- and scd l indicate activation of platelets and inhibition of fibrinolysis (p< . ). activated complement peptides c a, c a, and c d were all elevated over time (p< . ) while sc d- was not. however, only c a and c d levels at t were above normal reference ranges at . and . times maximum reference, respectively. conclusion: whole blood agitation appeared necessary to recover platelets at or above fda requirements. whole blood stored at c for - days did show some activation of complement proteins. in contrast to studies in stored red blood cells with elevations of sc d- reported, wb showed elevation of c a, a and c d and not sc d- . complement was gradually and modestly activated with most levels remaining within reference ranges over whole blood shelf life. meredith lummer* and christian todd . cerus corporation, community blood serivces background/case studies: the interceptv r blood system for platelets (cerus, concord ca) is used for the pathogen reduction (pr) of platelet collections, and replaces irradiation, cmv testing, bacterial culture and point of issue bacterial testing. to better understand pr compatibility and impact to split rate, data were analyzed from a mid-size blood center with roughly . x . x . x . x rcf . x . x . x . x apheresis . x . x . x . x wbd . x . x . x . x platelet collections must meet specific volume, concentration, and dose ranges to qualify for intercept pr. changes made to apheresis devices included adding the following collection targets: . x in ml, . x in ml, . x in ml, and . x in ml. study design/methods: four months of collections were retrospectively analyzed. platelet collections were evaluated to determine eligibility for pr treatment, and all products meeting pr processing specifications (unless intended for an hla matched recipient at a hospital not able to accept pr products) underwent pr treatment regardless of potential impact to split rate. a minimum post-treatment dose of . x or . x was required to classify collections as singles or doubles respectively. volume/dose mitigation (removal of volume to increase the number of products eligible for pr) was not utilized during this study. thus units were treated conventionally if volume, dose, and/or concentration did not meet pr specifications without further manipulation. results/findings: % of all single and double collections were eligible for and underwent pr treatment. split rate for single and double collections was . . conclusion: it is possible to treat % of single and double platelet donations with intercept pr at the blood center's current state with only a slight impact to split rate if centers are willing to make alterations to their targeting practices. platelet collections that fall outside of the specifications for pr are processed and distributed as conventional products. strategies to increase eligibility toward % while minimizing impact to split rate are being investigated, including incorporating new collection settings, splitting triples, and volume/dose mitigation. further evaluation is needed to determine the additional quantity of pr eligible products resulting from such changes. monique p gelderman* , andrey skripchenko , fei xu , ying li , stephen j wagner , pamela h whitley and jaroslav g vostal . fda/cber/ obrr/dbcd/lch, american red cross holland laboratory, american red cross mid-atlantic research facility background/case studies: platelets (plts) stored at room temperature (rt) can support bacterial proliferation in contaminated units and therefore septic transfusion reactions may occur. storing plts at cold temperature ( - o c [ct]) limits bacterial growth but results in rapid clearance upon transfusion. the development of alternate storage conditions usually involves costly radiolabeling human studies but success in these studies is difficult to predict based on in vitro studies. thus, an animal model of plt circulation that could predict performance of human plts in human volunteers would positively impact the development of alternate storage conditions. study design/method: we designed an immunodeficient (scid) mouse model to evaluate recovery of human plts and compared this side by side to a radiolabeling study in human volunteers that was conducted for evaluating a new plt storage condition: thermocycling plts ( hrs ct: hr o c [tc]). autologous apheresis plts stored for -days at rt, tc and ct were radiolabeled and infused into healthy human volunteers (n ) and the same non-labeled plts were also infused into mice (n ). blood samples from humans and mice were collected over time to generate survival and clearance curves of the plts in circulation. flow cytometry was used to detect and analyze the human plts in the mouse samples to generate such curves; counts < % were considered background. results/finding: the mean recoveries of infused plts were . . % for rt, . . % for tc and . . % for ct in humans. in mice, mean recoveries of the same plts were . . % for rt, . . % for ct and . . for ct (mean sd). to compare performance of the plts in humans and mice we expressed all recoveries as a percentage of the rt recoveries. in humans tc was $ % and ct was $ % of rt. in mice tc was $ % and ct was $ % of rt. the area under the survival curve (auc) was calculated for the individual mouse study and human trial data sets. the results of both auc were normalized to % for rt plts. human tc plts had % auc while ct plts had % auc compared to rt plts in humans. in comparison, the same tc plts had % auc and ct plts had % auc of the rt auc in the mice. the calculated ratios of the auc between the tc plts and ct plts of the human data set and mouse model data set are . and . , respectively. conclusion: the scid mouse model differentiates between rt plts and ct plts similar to humans based on auc and plt recovery data. however, the mouse model cannot differentiate between ct plts and tc plts as occurs in humans. even though the mouse model cannot differentiate between ct plts and tc plts, it may still be a useful tool to screen other novel storage conditions for human plts. converting the component manufacturing from a manual process to automation nicole peters* and geeta paranjape , . coastal bend blood center, carter blood care background/case studies: initiatives focused on improvements to donor collection processes drove us to investigate opportunities in our component manufacturing processes. our goal was to maintain blood quality while streamlining manufacturing and automating the in-process documentation. the compomat g was evaluated using a multi-team approach including component manufacturing staff, equipment management, qa, regulatory affairs and it. study design/method: after a comprehensive evaluation, the team decided to purchase the compomat g with the compomaster net software for data management. implementation was planned for a november go-live. . to centralize processing, new work counters were installed. fresenius kabi installed the compomat g s and compomaster in june . training and validations were successfully completed and a full launch occurred mid-march . device and sop training was performed. training qualification checklists were completed for each technician with a required number of successful units processed and completed december . validation was completed and signed off in march of . manufacturing data was collected using the compomaster net data management system and our quality control software for platelet (plt) parameters, including plt count, plt weight, and plt yield from before implementation (bi) and after implementing (ai) of the compomat g system. data points were collected from units bi and units ai. results/finding: upon initial implementation, staff training and use, the compomat g was found to be easy. plt weight spread was reduced from an average of gm to an average of gm. actual plt weights were reduced from an average of gm to gm, resulting in an average increase in recovered plasma of . ml per unit. plt count on average increased from a count of to ( /mm ) with a negligible change in plt yield. conclusion: plt weight spread was reduced by . % after implementation of the compomat g and our plt concentrations increased on average by %. we were able to consistently produce a smaller volume plt (average gm), which gave us . ml more plasma per unit for recovered plasma. the team intends to review a dryer cryo as a next step for potential additional plasma yields for recovered plasma. deglycerolization of manually glycerolized, frozen rccs using a closed system cell processor anita howell , angela hill , brandie dennis and jason p. acker* , . canadian blood services, centre for innovation, canadian blood services, university of alberta background/case studies: upon implementation of a closed system cell processor for glycerolization and deglycerolization of red cell concentrates (rccs), many rare rccs frozen using the current manual, open system glycerolization method will remain in the organization's frozen inventory. a study was undertaken to assess the feasibility of deglycerolizing this existing inventory on the closed cell processor and to evaluate how the change may impact post-thaw red blood cell (rbc) in vitro quality. as the closed cell processor uses a fixed centrifuge bowl for deglycerolization and rbc resuspension, both large and small units were assessed to determine the impact of cellular loss and variability in hematocrit on the post-thaw product. study design/methods: abo/rh matched lr sagm rccs were pooled and split to produce large ( ml) and small ( ml) rccs. the rccs were stored to d and glycerolized manually by mixing ml of glycerol with the rcc in a ml freezing bag. units were frozen at - c for ! h before being removed from frozen storage and thawed in a c water bath. large rccs and small rccs were deglycerolized using the organization's current procedure on the cobe cell processor prior to re-suspension in . % saline, . % dextrose. the remaining rccs were transferred into a l bag, spun to allow removal of excess glycerol by manual extraction to achieve a hematocrit of %, and deglycerolized in a ml centrifuge bowl on the acp- with re-suspension in as- . rbc quality was tested at h post-deglycerolization. results/findings: large rccs had significantly higher hemoglobin per unit (cobe: p . , acp : p . ) and lower cell recovery (cobe: p . , acp : p< . ) post-deglycerolization than smaller rccs on both cell processors. large rccs deglycerolized on the cobe had higher hemolysis (p< . ) and supernatant potassium (p . ) than did small volume rccs. large cobe rccs had higher hematocrits (p . ), hemoglobin (p . ), and recovery (p . ) than did large acp- rccs. however, all cobe rccs had higher (p< . ) hemolysis ( . . %) levels than did acp- rccs ( . . %). cobe rccs failed to meet regulatory hemolysis standards of . %. conclusion: addition of a ml bolus dose of glycerol to rccs of different volumes results in different concentrations of glycerol in the frozen rcc product and may lead to differences in frozen rcc quality. additionally, the size of the rcc impacts quality for rccs processed on the closed cell processor due to centrifuge bowl volume limitations which result in lower recovery, hemoglobin, and hematocrits. use of the closed cell processor with resuspension in as- and storage for h, met in vitro quality standards for recovery, hemoglobin, and hematocrit, and drastically reduced hemolysis levels in rccs glycerolized manually. the acp- cell processor can therefore be used to deglycerolize rccs glycerolized using a manual, open system glycerolization method. background/case studies: washed platelets may be indicated for thrombocytopenic patients who experience severe allergic/anaphylactic or febrile reactions to conventional platelet transfusions. platelet washing process is time-consuming which may delay transfusion. this study was conducted to evaluate the manual platelet washing method (mm) using . % saline and centrifugation and the semi-automated washing method (sam) using the cobe blood cell processor. study design/method: in this study, units of single donor platelets were evaluated ( washed using the mm and washed using the sam. the collected data included product weights (pre-and post-wash), platelet counts (pre-and post-wash), total plasma protein (pre-and post-wash), presence/absence of platelet clumps, calculated % protein removal, and calculated % platelet recovery rate. the platelet counts were measured on the sysmex exn and the total plasma protein samples were measured on the roche cobas . results/finding: table shows that the average platelet recovery for the sam ( %) was significantly higher compared to the mm ( %). the mm had a slightly higher average protein removal compared to the sam. no platelet clumps were observed in either the mm or the sam. it was observed that the hands-on time for the mm took - minutes longer than the sam. background/case studies: the interceptv r blood system for platelets is currently licensed for pathogen reduction (pr) of amicus platelets in inter-sol (pas- ) for input platelet doses of . to . platelets in to ml of to % plasma and - % pas. a new platelet processing set was designed with three storage containers (ts) to process apheresis platelet components in pas- containing doses of . to . platelets in a volume of to ml. study design/methods: apheresis pcs (amicus v r ) were collected in % plasma and % pas- . one study was performed at the nominal dose ( . - . x platelets), volume ( - ml) in % pas/ % plasma using single donor apheresis collections. two studies were performed to evaluate the high dose and high volume condition ( . - . x platelets in - ml) using either single or pooled donations. input pcs (n ) were treated with the intercept ts set by the end of day post collection; the incubation time in the compound adsorption device (cad) container ranged from to hours and the intercept treated pcs were stored in containers (n ). day and post-donation pcs were evaluated using a panel of in vitro platelet function assays results/findings: in vitro function data for apheresis pcs in pas- treated in the intercept ts set demonstrated acceptable in vitro function (table ). all intercept treated pcs had ph( c) ! . . platelet dose and volume recovery post-treatment ranged from % to % and % to %, respectively. conclusion: pathogen reduced platelet components processed using the intercept ts set from either single or pooled apheresis donations maintained acceptable in vitro quality through days of storage. intercept blood system for platelets ts set is currently not approved for use in the us. background/case studies: the possibility of transmitting infectious organisms via blood products, plasma and their derivatives is a major public health concern. while current screening measures have considerably improved transfusion safety by reducing the risks associated with known pathogens, they cannot protect from emerging infectious threats. the pathogen reduction technology (prt) represents a proactive strategy to further reduce transfusion-transmitted infectious risk. however, the scientific community broadly agrees over the fact that prt has negative impacts on the product's quality markers. this study aims at evaluating the impacts of the mirasol prt on platelet (plt) quality and plt processing. study design/method: two abo-compatible platelet concentrates (pcs) containing % plasma obtained from either apheresis or sagm whole blood (wb)-derived processing were paired, pooled and then split into two equal units. one unit was used as a non-treated control (ctrl) (n ). riboflavin was added to the other pc unit and then exposed to uv light according to the manufacturer's instructions for the mirasol prt (teru-mobct) (test) (n ). numerous in-vitro quality markers (plt concentration, atp, po , pco , ph, glucose, lactate, sodium, and potassium) were measured for both mirasol-treated and non-treated pcs on days , , and for apheresis pcs, and on days , , and for wb-derived pcs. two flow cytometry assays were used to evaluate cd p expression with and without thrombin activation, and to measure the percent annexin vpositive plt. transfusion vol. supplement s results/finding: platelet recovery was % and % for apheresis and wb-derived pcs, respectively. mirasol-treated pcs showed higher levels of annexin v-positive cells ( % (test), vs. . % . (ctl) on day ) and a higher rate of cd p expression than control pc units ( % (test), vs. % (ctl)) on day ). the mirasol treatment generates changes in ph, glucose and lactate for pcs during storage. conclusion: the mirasol treatment induces a loss in the net number of plts/unit and elevated platelet activation. changes in ph, glucose and lactate suggest that prt affects plt metabolism. finally, prt has numerous impacts on logistic, storage and processing time constraints of blood bank operations. nevertheless, the mirasol prt is routinely used in europe with acceptable clinical outcomes. evaluation of a test method to detect bacterial contamination in platelets; bactx tm assay ji hye park sexton* , lorraine blagg , christi e marshall , herman woodson , sean erony , krishna patel and eric gehrie . the johns hopkins hospital, johns hopkins hospital transfusion medicine dept, johns hopkins university school of medicine background/case studies: bacterial contamination of platelets (plts) is the leading infectious risk of platelet transfusion therapy and it is the most significant infectious cause of transmission-associated morbidity and mortality. therefore, detecting various potential bacterial contaminants in platelets in a timely manner is critical. the bactx assay is a rapid colorimetric assay that detects peptidoglycan, a cell wall component of both gram-positive and gram-negative bacteria. here, we report an analysis of the bactx assay at our hospital. study design/method: we aimed to determine the sensitivity and specificity of the bactx assay. intact leukoreduced apheresis plt (lrap) units were tested by bactx at storage day . as a control, each intact lrap was also cultured by an automated bacterial detection system (bact culture) on storage day . the results of the bactx test were compared to the results of the bact culture system. results/finding: a total of lrap were tested. lraps initially tested negative by bactx, while lraps initially tested positive by bactx. all initial positive bactx tests were negative when subjected to repeat testing. in contrast, all lraps tested negative with the bact culture system. the specificity of the bactx test was . %. we did not have any true positive test results; therefore, the sensitivity of the bactx could not be determined. conclusion: this is a small study of only platelet units. the expected rate of bacterial contamination of platelets is less than per units. the . % initial positive rate was therefore higher than expected, but given the small sample size, it is clear that further study is needed to more rigorously assess the true sensitivity and specificity of the bactx assay. in vitro quality of rejuvenated and washed cpd/as- and cp d/as- rbc alan d. gray* , matt landrigan , pamela whitley , michael wellington , sherrie sawyer , shalene hanley , emily rondeau , louise herschel , neeta rugg , patricia a.r. brunker , shawnagay nestheide , jose cancelas-perez , larry dumont and zbigniew m. szczepiorkowski . and , -dpg to fresh levels. the objective was to demonstrate that in vitro quality measures are maintained for rbc when stored for > hours after treatment with an fda approved rejuvenation solution. study design/method: whole blood ( - ml) was collected and processed at sites into leukocyte-reduced rbc (a total of n cpd/ as- and n cp d/as- ). ml of rejuvenation solution (citra labs) was added to each rbc on day (d- ), incubated for minutes with agitation at c water bath (helmer dh ), washed (haemonetics acp ), and stored in as- at - oc for days (d- through d- ). in vitro recovery (%) was calculated and hemolysis, atp, and , -dpg were determined on day , d- , d- after rejuvenation and washing (postrjv), d- , d- , d- , and d- . all units were cultured on d- postrjv and on d- , and then concentrated by centrifugation on d- . results/finding: in vitro rbc recoveries were . % and . % (as- and as- , respectively) and no bacterial growth was observed. hemolysis on d- was maintained < % in / ( %) as- units and / ( . %) as- units. all as- and as- units ( %) had hemolysis < % following concentration by centrifugation. morphology score was reduced to % (as- ) and % (as- ) by d- , restored after rejuvenation ( %, %, respectively) and maintained through d- (> %). atp was restored and maintained above fresh levels after rejuvenation. , -dpg was restored above fresh levels and was maintained ! % of fresh levels through d- . all values were significantly different compared to d- except as noted (p< . , paired ttest) ( table ) . conclusion: rejuvenation of stored rbc restores atp and , -dpg above fresh values and morphology to near fresh levels while maintaining improved in vitro rbc quality measures through d- when compared to nonrejuvenated rbc on d- . this study is funded by zimmer biomet. storage > hours is not fda approved for use at the time of this publication. liposomes and rejuvenation: new approach for improving quality of stored red blood cells luciana da silveira cavalcante , jason p. acker* , and jelena holovati . background/case studies: liposomes have been shown to minimize rbc membrane damage occurring during -day hypothermic storage (hs), while rejuvenation solutions have been shown to restore rbc metabolism by maintaining atp and , -dpg levels. this study aimed to evaluate the effect of combining liposomes and rejuvenation on the quality of stored rbcs. study design/methods: five leukoreduced packed rbc units obtained were pooled and split. the units produced were segregated into four experimental groups: sham control (s), liposome-treated (l), rejuvesol-treated (r) and liposome rejuvesol-treated (l r). the prbcs were incubated for h at c with hepes-nacl (sham), liposomes (dopc:chol, : mol%, mm lipid), rejuvesol or liposomes plus rejuvesol. the in vitro quality was accessed by hemolysis, deformability, aggregation, atp and , -dpg at day hs. results/findings: hemolysis was significantly decreased in all treatments compared to sham control ( . . %): l ( . . %, p . ), r ( . . %, p . ), l r ( . . %, p . ). ektacytometry analysis showed an increase in maximum elongation (ei max ) in r ( . . , p . ) and l r ( . . , p . ) treatments compared to s ( . . ) but not l ( . . , p . ). rbc rigidity (kei) increased in all treatments compared to sham ( . . ): l ( . . , p . ), r ( . . , p . ) and r l ( . . , p . ). aggregation amplitude was significantly increased by r treatment only ( . . au vs. . . au, p . ). atp levels were significantly higher in all treatments compared to sham ( . . mmol/g hb): l ( . . mmol/g hb, p . ), r ( . . mmol/g hb, p . ), l r ( . . mmol/g hb, p . ). the levels of , -dpg were no longer detectable in s and l treatments at day . the combined treatment was comparable to r ( . . mmol/g hb vs. . . mmol/g hb, p . ). conclusion: both rejuvenation and liposome treatments improved the quality of stored rbcs compared to sham control. the combined treatment (l r) did not have a greater impact in improving in vitro quality of stored rbcs compared to rejuvenation alone. step toward a unique and adaptable thermoregulation system lucie boyer , eric ducas , patricia landry , nathalie dussault , jacques bernier , danny brouard* and anne maltais . h ema-qu ebec, institut de technologie des emballages et du g enie alimentaire background/case studies: h ema-quebec (hq) is facing major logistic challenges in the transportation and distribution of blood components over a large geographic area. in collaboration with the institut de technologie des emballages et du genie alimentaire, our applied research group is working on the development and optimization of a transport packaging for the -ml whole blood leukotrap rc system (haemonetics corp.). the objective is to design a packaging system for the rapid cooling (t < c) of one to six -ml whole blood units (wbu) within h from collection. moreover, the insulating and thermoregulation system must maintain the internal temperature of wbu between c and c for h under extreme external conditions (- c to c), including the initial blood cooling period. study design/method: the proposed packaging design is based on an external coroplast box containing six vacuum insulated panels (vip) for increased insulating efficiency. preservation of the initial cooling period and extended thermoregulation properties were ensured by an assembly of preconditioned c phase change material (pcm). the number of pcm, their position and conditioning were optimized and tested in order to meet the expected performance criteria. preconditioned pcm were stored into vip boxes for h at - c before each test to mimic a worst-case scenario for remote blood drives. for the experimental testing, -ml wb bags were filled with ml saline . % at t c to mimic freshly collected wb. probes were positioned inside the saline-filled bags to monitor temperature profiles of wbu under extreme winter (- c) and summer ( c) conditions. shipping boxes were filled with either one or six bags (n ). results/finding: the results showed that the thermoregulation box prototype is able to cool wbu bags under c in . . h and maintain their internal temperature between c and c for h with final values ranging between . c and . c for the extreme summer scenario. similar results were obtained for the extreme winter scenario; units reached the c threshold value in . . h and the bags' internal temperatures were within the acceptable range for h. conclusion: the insulating and thermoregulation system met hq performance criteria. preliminary results showed that pcm could be conditioned at temperatures higher than - c without any significant impact on the system performances. hq is currently validating the shipping box prototype performances. additionally, we are working on reducing the pcm conditioning time to optimize logistic operations. as this packaging has many advantages in terms of durability, price and convenience, hq intends to evaluate this system for the packaging and transport of other lines of blood products. stuart weisberg* , christopher c. c silliman , beth shaz , marguerite kelher and claudia s. cohn . new york blood center, bonfils blood center, department of laboratory medicine and pathology, university of minnesota background/case studies: platelets collected and stored in platelet additive solution (pas) reduce recipient exposure to donor plasma components. to better define the effects of pas on platelet supernatant composition, we compared total protein, isohemagglutinin titers, hla antibodies and in vitro neutrophil (pmn) priming activity in supernatants of pas-c platelets to plasma platelets. study design/methods: apheresis platelets from group o blood donors were collected into either % donor plasma (n ) or % pas- / % donor plasma (n ). within hours of collection, samples of the product supernatant were frozen, assayed for total protein concentration, anti-a and anti-b titer, and pmn priming activity within the total and lipid extractable fractions. all samples were screened for hla antibodies. screen-positive samples were tested using luminex single bead assays for antibody strength and specificity. soluble cd ligand (scd l) was measured using solid-phase elisa. results/findings: supernatants of pas-c platelets had significantly lower total protein concentration, anti-a and anti-b titers compared to plasma platelets. there was no significant difference in the number of hla-antibody screen positive pas-c ( / products) compared to plasma platelets ( / products); however, the hla-antibody screen-positive supernatants of pas- a transfusion vol. supplement s abstract c platelets had fewer hla specificities ( specificities) compared to those of the plasma platelets ( specificities). pmn priming activity was significantly increased in the supernatant of pas-c platelets. the lipid extractable fraction was not affected; however scd l levels were increased in the supernatant of pas-c compared to plasma platelets (table ) . conclusion: decreased plasma proteins likely underlie lower rates of allergic and febrile non-hemolytic transfusion reactions seen with use of pas-c platelets. decreased anti-a and anti-b titers may prevent hemolysis from minor abo mismatch. lower hla-antibody specificities may mitigate transfusion related acute lung injury (trali). increased pmn priming by pas-c platelets is likely due to platelet membrane release of scd l and not bioactive lipids. although scd l has been associated with trali, only pmn priming with lipid -not cytokine -agents has been causally linked with trali. the mechanism and clinical impact of increased scd l in pas-c platelets remain to be elucidated. background/case studies: current guidelines require a reduction of residual white blood cells (rwbc) below x wbc in us and x wbc in europe, per unit. the established reference method for testing rwbc in platelet (plt) and red blood cell (rbc) products is flow cytometry. alternative technologies have been developed including hemocytometry and microfluorometry. study design/methods: this study compared performance and workflow efficiency of the facsvia, a flow cytometer with a simplified workflow and automated loader to the adam automatic microscopic cell counter based on imaging technology. nonfiltered whole blood (wb) samples, apheresis platelet units (n ) and leukoreduced (lr) rbc units (n ) were used to generate spiked samples. apheresis platelets and lr rbc were filtered to deplete wbcs and were used as a diluent. nonfiltered wb samples were the source of wbcs to prepare a sample of wbc/ul. the spiked samples of , . , , , and wbc/ul were prepared from the source sample of wbc/ul and filtered platelet and rbc units. to evaluate linearity, wbc concentrations ( , . , , , , wbc/ul) were measured using adam and facsvia. samples were stained and run in triplicate on each analyzer. data was analyzed using linear regression. the results were proportional to the wbc concentration in the spiked samples. reproducibility of the two systems was measured by running spiked samples ( , , , wbc/ul). tubes of each sample were stained and run per system. the %cv and %diff were calculated. a batch of samples (plt and rbc) were run on both analyzers, repeated for days. workflow efficiency was assessed observationally by measuring the time of tasks performed. tasks recorded were instrument qc, assay controls and sample testing and analysis. results/findings: the wbc concentration results for plt and rbc samples on facsvia correlated well with adam (r-plt . , slope . ), (r-rbc . , slope . ). the %diff-plt at , , wbc/ul were . , . and , respectively. the %diff-rbc at , , wbc/ul were . , . and . , respectively. the average total testing time was similar on both instruments; min for the facsvia and min for the adam. of the total testing time, adam required continuous hands-on time, while facsvia demonstrated % ( of min) hands-off time. conclusion: both instruments showed comparable precision, linearity and accuracy. while the average total testing time was similar on both instruments, facsvia offered a significant workflow efficiency advantage. users saved an average hands-on time of minutes that could be used on other tasks. platelet rich plasma and quality control: is there a role for the blood bank? claudia s. cohn* and mickey koh . department of laboratory medicine and pathology, university of minnesota, st george's hospital and medical school background/case studies: autologous platelet-rich plasma (aprp) is a poorly regulated blood component often produced at the patient's bedside and used for indications such as chronic and acute orthopedic injuries, wound and incision-healing and rheumatologic diseases. prp isolation can be done by apheresis, which yields a consistent, platelet-rich fraction; however, most aprp is made using small bench-top centrifuges with cartridges that deliver uneven platelet enrichment. thus, the consistency and quality of aprp is questionable and the lower yielding prp may have decreased efficacy. study design/methods: a survey was designed to assess aprp manufacture, usage and quality control (qc) measures taken prior to its use. a survey was developed with input from content experts. the survey was sent to members of best and isbt. survey respondents were encouraged to forward the survey to colleagues, thus a true denominator is unknown. a total of completed and partially completed surveys were received. results/findings: responses came from countries, but the majority of responses came from the united states (us). of the respondents, % reported aprp use in their hospital. aprp was used predominantly for outpatients, though > % of hospitals also used aprp in the in-patient setting. in most hospitals, aprp was used by - mds; however, hospitals had > mds using aprp. the aprp was used for orthopedics, wound/incision repair, rheumatology and other indications. in the us the aprp was manufactured outside of the blood bank, while outside the us aprp was isolated by blood bank personnel. nearly all the aprp manufacturing was done with no quality control (qc) measures ( %); however, respondents assessed the final product prior to release. these qc measures included a platelet count to measure the enrichment of the platelet fraction, culturing the product and infectious serology testing. in some cases, if the aprp failed qc it could still be used, pending an md's approval. in the hospitals conducting qc on the final aprp, the testing was done by the blood bank. a subset of respondents from african nations also used allogeneic prp (allprp). in contrast to the patterns of use with aprp, allprp was used primarily for inpatients for indications including orthopedics, wound/incision repair and 'other'. the allprp was manufactured in the blood bank or the donor center with no qc other than a regular check of the centrifuge used to isolate the prp fraction. conclusion: prp is used in hospitals throughout the world for a wide variety of indications. the blood bank is involved in its manufacture in some countries, but in the us aprp is made outside of the blood bank. quality control of aprp production and the final product is not done in most hospitals. to improve the consistency and efficacy of prp, more stringent qc measures need to be in place. background/case studies: the morphology of donated red blood cells (rbc) change with storage, along with a loss of deformability, increased surface exposure of phosphatidylserine (ps), and decreased intracellular atp. these changes have been associated with increased rbc clearance within hours of transfusion. analysis of morphological alterations of stored rbc with imaging flow cytometry (ifc) has identified a subpopulation of small rbc that accumulates upon storage. this rbc subpopulation has a reduced projected surface area and undergoes a spherocytic shift which is expected to induce their retention in the spleen (roussel, dussiot et al, ) . some of the storage alterations are reversible when the rbc metabolism is reestablished. as such, treatment with a rejuvenation solution (citra labs) before transfusion is expected to restore some of the rbc properties and thus potentially increase their capacity to stay in circulation and operate effective tissue oxygenation following transfusion. study design/methods: a multi-parametric analysis of rbc alterations was performed to evaluate the effect of rejuvenation on rbcs stored in sagm (n ) under blood bank conditions at day (d ), at day (d ), after rejuvenation (r), and after rejuvenation and washing (rw). morphological alterations of stored rbcs were evaluated with ifc (imagestream x mark ii, amnis v r ). results/finding: rejuvenation increased the level of intracellular atp, confirming the metabolic effect of this process. population distribution as per rbc projected surface area measured by ifc depicted a well-demarcated subpopulation of small rbc that increased with storage from . - . % at d to . - . % at d . rejuvenation markedly reduced this storage-induced spherocytic shift ( . - . %) and partially restored rbc morphology, an effect confirmed by differential interference contrast microscopy. the restoration effect of the rejuvenation process did not correct the storage-related loss of rbc elongation but was associated with a decrease in ps exposure (table) . conclusion: our multi-parametric analysis shows that some but not all storage-related alterations are therefore corrected by metabolic rejuvenation. the impact of these effects while generally positive at the cellular scale requires further analysis by specific clinical studies assessing transfusion yield and tissue oxygenation. red cell concentrate volume and manufacturing method impact post-thaw quality in cryopreserved products processed using a closed cell processor anita howell , angela hill , tracey turner , april xu , brandie dennis and jason p. acker* , . canadian blood services, centre for innovation, canadian blood services, university of alberta background/case studies: the blood service uses both top/top with whole blood filtration (wbf) and top/bottom with red cell filtration (rcf) methods to prepare cpd/sagm lr red cell concentrates (rccs). mean volume (ml) is higher in wbf units ( ) than in rcf units ( ), with similar hematocrits. a closed system cell processor is currently being implemented for cryopreservation of rccs. post-deglycerolization re-suspension in as- additive solution is performed on-instrument to a defined total end volume, as dictated by the centrifuge bowl size. the impact of the resulting variation in hematocrit on post-thaw in vitrorbc quality was evaluated to ensure that regulatory standards can still be met for rccs at the extreme edge of the input volume range. study design/methods: small rcf ( - ml) and large wbf ( - ml) rccs were stored for d before being glycerolized and frozen at - c for ! h. large rccs whose red cell mass exceeded the capacity of the ml deglycerolization centrifuge bowl were volume reduced prior to glycerolization. rccs were thawed in a c water bath, deglycerolized and re-suspended in as- . rccs were stored d and then tested for in vitrorbc quality. results/finding: small rcf rccs had lower (p< . ) hematocrit, specific gravity, hemoglobin per unit, supernatant k and na concentration, deformability (ei max ), and higher (p< . ) recovery than did large wbf units. no significant differences in hemolysis, atp, , -dpg, p , rbc indices, rbc morphology, or residual glycerol were seen between groups. the majority of units met acceptance criteria (table ) , however of large wbf units had rbc recoveries < % due to pre-glycerolization volume reduction, and of the small rcf units had hemoglobin values < g per unit. when the recovery and hemoglobin failure rates are analyzed against the organization's rcc production volume distribution, the mean recovery is projected to be well above % and the hemoglobin failure rate would be below % of units tested; compliant with regulatory standards. conclusion: the differences between groups in the cryopreserved rcc physical characteristics were expected due to the re-suspension method and differences in the input product red cell mass. the lack of significant metabolic differences between groups indicates that the differences in postdeglycerolization hematocrits are not adversely affecting product quality. . . . . . . . . elongation index ( pa) . . . . . . . . this study is funded by zimmer biomet. (hasan ) . the objective was to determine the effect of rbc rejuvenation on rbc oxygen release capacity (orc) and estimated oxygen consumption (vo ) after simulating a single unit transfusion of either standard or rejuvenated rbc stored for days. study design/method: oxygen dissociation curves (odc) (hemox analyzer, tcs scientific) were generated from fifty-two ( ) rbc units (leukocyte-reduced), cpd/as- or cp d/as- , on day , day , and after rejuvenation and washing (pw). the odc for each sample was used to determine orc (ml o /g hb) and total releasable oxygen (tro) of the unit (ml o ). orc was determined by assessing the change in % o saturation from mm hg po (e.g., lung) to mm hg po (e.g., venous blood) multiplied by . ml o /g hb (li ). a simulated baseline pretransfusion vo of ml o /min was estimated using the day orc and assuming a g/dl transfusion trigger with a cardiac output of l/min and l blood volume. paired student's t tests were used for comparative statistical analyses. results/finding: rbc rejuvenation on day restored orc and tro to levels greater than day ( table ) . orc of the rejuvenated unit was . . times and . . times greater than rbc on day and day , respectively (p< . ). vo increased after a simulated single unit transfusion of rbc (day , day , and pw) by . %, . %, and . % over the pre transfusion vo , respectively (p< . ). conclusion: these results suggest a transfusion with rejuvenated rbcs has the potential to release . times the volume of o compared to standard, untreated rbcs stored for days. inferior oxygen delivery to tissues (vo max) has been observed during exercise in healthy human volunteers after transfusion of two autologous rbc units stored for days vs days which seem dependent on genetic variability and storage time (bennett-guerrero ). therefore, transfusion practices to correct anemia may be less effective than intended due to the variable orc of standard stored rbc units. transfusion strategies should consider whether the use of rbc with increased orc may be physiologically advantageous. disclosure: this study was funded by zimmer biomet. rejuvenation solution as an adjunct storage solution maintains physiological hemoglobin oxygen affinity during rbc unit storage andrea ansari* , jay srinivasan , gustaaf de ridder , alan d. gray , matt landrigan , keaton charles stoner , angela crabtree , jessica poisson and ian welsby . duke university school of medicine, duke health pathology, citra labs, a zimmer biomet company, zimmer biomet, duke university, department of pathology, durham veterans affairs medical center, duke university hospital, duke university medical center background/case studies: deleterious changes develop during the storage of packed red blood cells (rbcs) collectively called the "storage lesion". these include altered membrane composition and decreased deformability, increased in-bag and post-transfusion hemolysis, loss of atp, snitrosohemoglobin, vasodilatory capacity, and cell surface ps expression, and depleted , -diphosphoglycerate ( , -dpg). the loss of , -dpg increases the oxygen affinity of hemoglobin, resulting in lower p (partial pressure of oxygen at % hemoglobin saturation). decreased p may negatively impact the ability for transfused rbcs to release oxygen to peripheral tissues. an fda-approved rejuvenation solution (citra labs) can restore normal levels of atp and , -dpg, normalizing membrane function and oxygen affinity, respectively. this process requires incubation at c for an hour, an impractical step in time-sensitive situations, followed by washing of the rbcs. we tested the hypothesis that rejuvenation without the incubation step ("cold rejuvenation") could prevent or reverse changes in oxygen affinity, deformability, and susceptibility to hemolysis of rbcs. study design/method: eight units of group a , leukoreduced prbc stored in as- were obtained from our local blood center. after days of storage, units were divided into separate aliquots: control (ctl), wash (w), standard rejuvenation (sr), and cold rejuvenation (cr). the rejuvenation solution ( ml) was added to the cr group, and all groups were then stored for another days at - c. on day of storage, the sr group was incubated for hour at c with rejuvenation solution, after which the w, sr, and cr groups were separately washed on a c.a.t.s v r (fresenius kabi) using the high quality wash setting. hemoglobin p was measured by tonometry using a hemox analyzer (tcs scientific). deformability (elongation index or ei) was measured by ektacytometry (lorrca mechatronics). supernatant plasma free hemoglobin (pfhb) was measured using visiblelight spectrophotometry. cell surface ps expression (ps ) was measured by annexin v flow cytometry. all group results were compared using nonparametric wilcoxon signed-rank tests with a . . results/finding: significant differences in p were noticed between all groups (table ) . ei, ps , and pfhb did not differ between groups. conclusion: cold rejuvenation prevents the increased oxygen affinity (lower p ) seen over days of rbc storage without adverse effects on deformability or hemolysis. this offers an alternative to incubated rejuvenation to provide clinicians with ready access to rbcs with a high/normal p that may better release oxygen to the tissues. cause transient and potentially fatal cardiac arrhythmias upon transfusion, particularly in infants, and massively-transfused patients, and those with compromised renal function. reactive antibodies and other inflammatory agents in rbcs can also elicit life-threatening reactions, potentially causing high fever, transfusion-related acute lung injury (trali), anaphylaxis, and even death. in this study, a multifunctional bead-based filter was evaluated for removal of k , along with free hemoglobin (hb) and other prbc contaminants that can contribute to transfusion related adverse events. study design/method: ten leukocyte-reduced prbc ( ml) units stored in as- , obtained from a regional blood donor center at expiration ( days), were passed by gravity through sorbent-devices containing ml of multifunctional polymer bead, at a flow rate of ml/min. supernatants were analyzed for k removal as well as free hb, antibodies and cytokines ( -plex, biorad). rbcs were analyzed for viability and integrity via flow cytometry and osmotic fragility assay, respectively. results/finding: filtration of the aged prbc units through the sorbent device reduced [k ] from . . to . . meq/l; equivalent to an . % reduction. free hb was reduced by . % from . . to . . mg/ml. antibodies, specifically igg, iga, and igm decreased from . . to . . mg/ml ( . %), . . to . . mg/ml ( . %), and . . to . . mg/ml ( . %), respectively. inflammatory cytokines were significantly reduced, specifically: ip- from . . to . . pg/ml ( . %), mip- b from . . to . . pg/ml ( . %), and pdgf from . . to . pg/ml ( . %). filtration had no significant impact on cell surface markers of rbc viability (< . % decrease) or sensitivity to osmotic changes. values listed represent mean sem (p < . for all analytes tested). a paired ttest was used to assess significance. conclusion: the sorbent filter was highly effective in reducing the levels of extracellular k as well as free hb, antibodies, and cytokines from prbcs without impact on rbc viability or integrity. this study demonstrates the viability of a multifunctional sorbent filter for removal of k along with other detrimental components from stored prbcs that can readily be incorporated into transfusion practices to minimize adverse effects. background/case studies: platelets carry no rh antigens, but residual red blood cell (rbc) in platelet products can immunize d negative recipients if the donor is d positive. current recommendation is to give rh immunoglobulin (rhig) to rh negative patient if they receive rh positive platelet unit to avoid potential alloimmunization to d antigen. a recent study has shown a very low frequency ( . %) of d alloimmunization when a rh mismatch platelet is transfused. restricting d negative patients to receive only d negative platelets could create shortage and cause inventory challenges. higher yields of platelets with minimum to none residual rbcs are obtained with new generations of apheresis machines. as a consequence, the need for prophylactic rh immunoglobulin (rhig) may be unnecessary with the use of apheresis derived platelets. the accurate determination of residual rbc in a platelet unit is important for patient safety to prevent rh alloimmunization. hemocytometer is considered the gold standard for cell counting. however, the rapidity and convenience offered by automated methods resulted in widespread use of automated hematology analyzers. currently there are no standardization and/or guidelines to advise what system to use for rbc quantification in platelet products. study design/method: we designed this study to quantify the residual rbc in apheresis platelets and whole blood derived platelets comparing hemocytometer and automated methods. we measured the amount of red blood cells per microliter in apheresis and whole blood derived platelet units using hemocytometer and two different automated hematology analyzers, namely, sysmex (sysmex america, lincolnshire, il) and advia (siemens healthcare diagnostics, tarrytown ny). the whole blood derived platelet units were produced using acrodose tm system technology. we conducted non-parametric permutation test based on permutations to compare sysmex and advia between apheresis and whole blood derived groups. abstract collection) rbcs to rbcs stored for days and after treatment with an fda approved rejuvenation solution. study design/method: the addition of a rejuvenation solution to stored red blood cells (rbcs) has been shown to increase atp and , -dpg profiles to fresh levels. the objective was to compare % hemoglobin-oxygen saturation (p ) and morphology profiles of fresh(day of collection) rbcs to rbcs stored for days and after treatment with an fda approved rejuvenation solution. results/finding: in vitro rbc recovery (overall) was . . %. hemolysis (%) was similar on day before and after dry-air incubation with the rejuvenation solution ( . . % vs . . %). percent hemolysis (%) decreased after washing ( . . %) and was maintained below < % for all units during storage for hr ( . . %). average atp and , -dpg were restored above the average fresh values. the morphology score decreased $ % by day , which was restored to near fresh values following rejuvenation and washing and storage hr ( . % and . %, respectively). rbc oxygen affinity, as assessed by p , was restored above fresh values. all values were significantly different compared to day (p< . , paired t-test) ( table ) . conclusion: rbc morphology was restored to near fresh and average atp, , -dpg, and p were restored above fresh values when incubated with a rejuvenation solution using the dry-air incubation process. rbc morphology, atp and , -dpg were maintained during storage hr. rejuvenation of refrigerated rbcs may offer avenues to improve rbc quality prior to transfusion. vandi ly*, dimath alyemni, warren r korn, matthew j brune and julie katz karp. thomas jefferson university hospital background/case studies: blood donors are screened with a donor history questionnaire that includes questions regarding behavioral risk factors, but none that specifically screen for the use of marijuana. therefore, there is the theoretical possibility of transfer of active cannabis metabolites through transfusion. donor plasma collected at an urban, hospital-based blood donor center was examined for the presence of active cannabis metabolites, d tetrahydrocannabinol (thc) and -oh-d -tetrahydrocannabinol ( -oh-thc). study design/method: de-identified donor plasma segments were sequestered and stored frozen until time of testing. testing for thc and -oh-thc was performed by liquid chromatography-tandem mass spectrometry (lc-ms/ms) based on a method modified from lacroix and saussereau. in summary, this method used dabsyl chloride derivatization of thc and -oh-thc to produce samples for lc-ms/ms analysis. lc used a c column. post-column detection by ms/ms used positive ion electrospray with q :q ion pairs of m/z . : . (internal standard (is), d -thc), m/ z . : . (thc), and m/z . : . ( -oh-thc). quantitative results for thc and -oh-thc were obtained from a standard curve (ratio of analyte integrals to integrals of internal standard) ranging from - ng/ ml for both thc and -oh-thc. limits of quantitation, defined as standard deviations above background, were . ng/ml for thc and ng/ml for -oh-thc. results/finding: a total of donor plasma samples were tested for thc and -oh-thc. no samples tested positive for either thc or -oh-thc. theoretical calculations according to statistics of a poisson distribution indicated that there would be a % probability of one or more positives at a prevalence of . % positive samples, and a % probability of one or more positives at a prevalence of . % positive samples. results thus indicated a boundary of prevalence of the presence of active thc-metabolites in plasma samples to be less than % among this donor population. standard pharmacokinetics of cannabis metabolism in previous studies indicate a likely time window of less than hours for post-exposure detection of thc and/or -oh-thc in plasma. conclusion: testing of donor plasma samples for active metabolites of cannabis at one urban, hospital-based blood donor center produced no testpositives. statistically, results indicated that prevalence of positivity, if greater than zero, is at most less than %. probability of occurrence of cannabis metabolites in blood donor samples is likely to be highly variable across donor centers and is largely dependent on blood donor demographics. elisabeth maurer-spurej* , ruqayyah almizraq , daniel millar and jason p. acker . university of british columbia, university of alberta, lightintegra technology inc., canadian blood services background/case studies: the controversy around the quality and clinical impact of aged red blood cell concentrates (rcc) is ongoing. current studies are limited by the lack of quality measures suitable for routine screening of rcc. based on evidence that fragments called microparticles (mp) or extracellular vesicles are markers of cellular activation or degradation, this study investigated the utility of mp screening to characterize the effect of rcc production methods and storage. study design/method: red blood cell concentrates were prepared by whole blood filtration (wbf; top/top) or red cell filtration (rcf; top/bottom) methods, centrifuged to prepare a supernatant and tested for mp content (as measured with dynamic light scattering or a tunable resistive pulse sensing technique), hemolysis, atp and red cell deformability on days , , and of storage. one rcf rcc was tested on days , , , , and and six ml aliquots were stored in parallel and tested on days , , and . all samples were tested for mp content and compared to the other quality indicators. results/finding: mp content showed a linear increase with storage time with statistically significant differences between days , and (p< . ) and correlated with supernatant hemoglobin, and inversely with atp or rbc elasticity. both mp testing methods agreed with respect to total mp content. starting levels of the quality indicators varied between donations, preparation methods (wbf rcc contained much higher levels of mp), and storage time. mp content in the aliquots were consistent at each time point but statistically higher than in the original rcc on and after day of storage. conclusion: mp content correlates with measures of hemolysis and other rbc quality indicators and could be implemented as a routine screening tool. differences in mp content between donors, processes and age could be monitored and used to inform component production decisions. measuring mp content would allow % screening of rcc products in studies and pragmatic qc initiatives which are needed to settle the controversy about the clinical effect of rcc age. single donor spray-dried plasma: the future of plasma therapy? qiyong peter liu*, jihae sohn, ryan c. carney, sruthi sundaram and mark a popovsky. velico medical inc background/case studies: frozen plasma is integral to hemostasis management in many situations but logistically cumbersome because of frozen storage and long thawing time. spray-dried plasma (odp, on demand plasma) is potentially superior because it may be stored under refrigeration near the patient and reconstituted in minutes at the point-of-care. the objective of this study is to determine if odp can be consistently manufactured at a blood center with key proteins and coagulation function comparable to ffp. study design/methods: units of never frozen plasma collected at a blood center were processed on-site at a fixed volume into odp using velico's spray dryer. odp (n ) and paired ffp aliquots were stored for - days at - c and - c, respectively, reconstituted with a fixed volume of rehydration fluid (sterile water for injection), and extensively characterized with respect to the levels of hemostatic proteins, coagulation and complement activation markers, and clotting performance. the volumes of processed plasma and rehydration fluid were pre-determined ensuring similar total protein concentration in reconstituted odp and ffp for direct comparison. results/findings: compared to ffp, odp had ! % levels of functional clotting factors (fibrinogen, factors ii, v, vii, viii, ix, x, xi and xii), plasminogen, and protease inhibitors (antithrombin iii, protein c, protein s; plasmin, c esterase and alpha -proteniase inhibitors). the level of factor xiii in odp was slightly lower, about % of ffp by both activity and antigen assays. odp was identical to ffp in the levels of albumin, immunoglobulins (iga, igg and igm), lipoproteins, calcium, citrate, and coagulation proteins evaluated by antigen assays except for factor xiii. the levels of the markers for coagulation (thrombin-antithrombin, prothrombin fragments i ii and ddimer) and complement (c a and c a) activation in odp remained similar to ffp. odp was equivalent to ffp when assessed by aptt, pt and thrombelastography. transfusion vol. supplement s abstract spray-drying fragmented a substantial number of high molecular weight von willebrand factor (vwf) multimers into smaller ones, leading to a net increase of vwf multimers in odp. the size re-distribution reduced the vwf ristocetin cofactor activity (vwf:rco) to % in odp relative to ffp, but had no impact on vwf antigen and factor viii function (stabilized by vwf). vwf-specific studies have shown that odp retains hemostatic function in supporting platelet adhesion and aggregation (see abstracts by meledeo et al/us army institute of surgical research and bercovitz et al/blood center of wisconsin). conclusion: odp can be manufactured at a blood center with a quality comparable to that of ffp. future studies will determine if the product is bioequivalent to ffp and comparable in safety and efficacy. background/case studies: the collection time of whole blood is, according to european guidelines, limited to minutes. in addition, donations with collection times between and minutes should not be used for preparation of platelet (plt) concentrates (pc) because of the chance of too much activation of plt. it seems justified to re-evaluate the quality of plt from these donations because new generations collection systems and mixers were introduced, including a more efficient needle. the aim of this study was to investigate the in vitro quality of pc prepared from - minutes buffy coats (bc) with the aim to prevent unnecessary discarding of bc and to simplify the total blood bank process. study design/method: single-donor pc (spc, n ) were prepared from one - minutes bc and ml of autologous plasma in a ml pvc-dehp container. as a reference, spc from donations with collection times of < minutes were prepared (n ). in addition, pc were prepared from bc, of which at least bc were from - minutes donations (n ). after pooling of the bc, ml of pas-e was added and a standard pooling set with a pvc-bthc storage container was used for storage of pc. all pc were stored for days at c and sampled at regular intervals for determination of the in vitro quality. aggregation tests were performed with chronolog (adp or collagen) and multiplate (arachidonic acid) aggregometers. thromboelastography (teg), using kaolin as an activator, was applied for assessment of the overall clotting capacity. values are expressed as mean sd. a non-paired t-test or a mann-whitney u test was applied for statistical analyses of normal or non-normal distributed data respectively. results/finding: volume ( vs. ml) and platelet content ( vs. x ) were similar in both groups. at the end of storage, both groups showed comparable in vitro quality (day , ph( c): . . vs . . , other data not shown). no differences in aggregation response after stimulation with arachidonic acid, adp or collagen were measured. teg parameters in both groups were also comparable. the five-donor pc fulfilled all requirements of european guidelines, aside from occurrence of small aggregates at day and/or in / pc (possibly because sometimes ab incompatibility was accepted). on day , plt showed low cd p expression ( . . %) and phosphatidylserine exposure (annexin v binding, . . %). hypotonic shock response of platelets was comparable with historical data. conclusion: single-pc in plasma as well as five-donor pc in pas-e, prepared from - minutes whole blood donations had a normal composition and showed good in vitro quality during day storage. to substantiate that the exclusion of - minutes donations for pc preparation could be stopped, further studies will be performed. the effects of a pneumatic tube system on red blood cell units amy mata* , jessie miller , ranee marie wannarka-farlinger , sandra bryant , scott a hammel , sherry stern and camille van buskirk . mayo clinic, mayo clinic rochester background/case studies: the use of pneumatic tube systems (pts) has become commonplace in many healthcare facilities throughout the world. the purpose of these systems is to transport products and specimens, resulting in reduced turnaround time for laboratory testing and to aid in the timely delivery of patient care. a downfall of ptss is that they have the potential to play a role in increased hemolysis. while several studies have been published on the effects of ptss on blood specimens, there are very few that address the effects on blood products, specifically red blood cells (rbc). the objective of this study was twofold: to determine if the pts that is in use at our facility contributes to an increase in hemolysis of rbc units and to evaluate how the pts system affects red cell microparticle (rmp) levels. study design/method: forty-one units of as- rbcs, irradiated and non-irradiated, were selected for the study. the units varied in age, ranging from to days old. specimens were obtained from each unit both prior to and after being transported through the pts, which runs underground and spans the length of a mile and a half. specimens were spun down and the plasma supernatant was removed. all specimens were evaluated for plasma hemoglobin (hgb), potassium (k), hemolysis index (hi), and rmps. the wilcoxon signed-rank test and p value were used to compare the pre and post values. additional statistical analysis was performed to compare the values after adjusting for age and irradiation. results/finding: after sending the rbc units through the pts, hgb, hi, and rmps were statistically (p< . ) higher than before. when adjusted for irradiation, the same analytes remained statistically higher, however when adjusted for age, the p-value was only significant for hgb and hi. the k values did not significantly change. rmps significantly increased, but only if the units were irradiated (p . ). (table) conclusion: the use of a pts provides an effective means to transport blood products; however, it can contribute to biological changes within rbc units. it is uncertain at this time how those changes can affect the outcome of patients who receive these products. each pts system is different in its specifications and should be validated prior to being used to transport blood products. validation of factor viii levels of thawed fresh frozen plasma after days of storage pei lun karen lim* , erma sofia sumardi , isamar eduardo ancheta , susan lim , christina yip , lip kun tan and shir ying lee . national university hospital singapore, national university hospital, national university hospital, singapore background/case studies: plasma transfusion is indicated in patients with coagulation factor deficiencies and active bleeding, or who are about to undergo an invasive procedure. fresh frozen plasma (ffp) has to be placed in the freezer within hours of processing and stored at - c or colder in order to preserve its coagulation factors. thawed ffp has an expiration period of hours hence to reduce wastage, this study aims to investigate factor viii (fviii) activity in thawed plasma stored for days and kept at to c. fviii was chosen as it is an important coagulation factor in correcting coagulopathies. arbitrary fviii level acceptance limit was set as not less than iu/dl. study design/method: randomly selected units of ffp (n ) were measured for fviii concentration based on clotting assay (stav r -deficient a transfusion vol. supplement s viii diagnostica stago). fviii levels were measured at five time points: prefreezing, , , and hours post-thawing. ffp were thawed using helmer plasma thawer (helmer scientific) at to c for minutes. an aliquot of thawed ffp from each unit was removed and measured for fviii before refrigeration ( hours post-thaw). thawed plasma (tp) units were kept in a refrigerator at to c for days for subsequent testing. results/finding: results obtained were listed in table . units to were not tested for fviii at post thaw- hour due to operational issues. the overall fviii concentration decreased at an average of % from pre-freezing to post thaw hour. after further storage of tp post thaw- hour and - hour, residual fviii level remain to be above iu/dl except unit which had a lower initial fviii concentration. at post thaw- hour, out of units tested had residual fviii activity within the pre-set standard of iu/ dl. the average decline from -hour post-thaw to -hour, -hour and hour post-thaw was . %, . % and . % respectively. there was no observed trend of any blood group having higher or lower pre-freezing fviii and this is likely due to small sample size. conclusion: decrease of coagulation factor such as fviii in ffp is expected due to its diminishing stability. nevertheless, our data showed that majority of the tp retained at least iu/dl of fviii. typically patients with factor levels below iu/dl may start to show abnormal coagulation profile. while tp is not used for specific factor replacement therapy, it may be indicated for patients with general coagulopathies and active bleeding. further study extending to measurement of other labile factor such as fv may add value to the validation study. validation of the pathogen reduction method using amotosalen/ uva: comparing pathogen-reduced pooled prp-platelets and conventional single prp platelets for quality and bacterial inactivation efficacy lubna ahmed almenawi , ayman mohamad sabri , ali abdullah alajeafi , ashwaq hasan alhekri , saleem bin mahfouz , ali hasan alkhodari , rawya saeed shealy , marcus picard-maureau* and hussain bana almalki . king abdulaziz hospital and oncology center, cerus europe bv background/case studies: the growing number of transfusiontransmitted infectious (tti) risks, including emerging and endemic pathogens, is a constant challenge for blood centers in saudi arabia. while for a limited number of these pathogens tti risk can be reduced using blood screening assays, alternative solutions are anticipated. pathogen reduction (pr) technology was identified as a potential solution. validation of amotosalen/uva photochemical treatment in our blood center was performed by comparing the platelet component (pc) quality of the standard "control" single-donor prp-concentrate in % plasma over a day storage period and the new "test" pathogen-reduced, pooled (pools of ) prp pc in % plasma over a day storage period. the efficacy of the bacterial inactivation was also assessed in our setting. study design/method: the quality parameters of leucoreduced test pcs were assessed at day of storage and compared to leucoreduced control pc at day of storage. the test pcs were pathogen-reduced with the intercept blood system (cerus corporation, concord, u.s.a.) at day ; the process was completed by day post-collection. samples were taken daily for quality analysis from test and control pc until day and day , respectively. for bacterial spiking, additional pc were spiked with each receiving ml of mcfarland ($ . x cfu) s. aureus, s. epidermidis, e. coli, p. aeruginosa or s. viridans, respectively, to challenge pr efficacy. results/finding: the average platelet loss in the test pc post pr treatment was . % . , the total average platelet loss at day was . % . . the average platelet loss in the control units at day was . % . . the average ph of the test units at day was . . and in the same range as the control pc, ph . . . glucose concentration in test pc at day ( . . mmol/l) was lower than in the day control units ( . . mmol/l). lactate levels increased during the course of storage; lactate levels at days and were outside the range of the assay (> mmol/l). cultures inoculated with pathogen reduced, bacterially spiked units were negative after days of incubation, in contrast to those inoculated with nonpathogen reduced samples from the control units, which were positive for bacterial growth. conclusion: the quality parameters of the pathogen reduced test pc were within specifications and comparable to the conventional control pc. the high efficacy of bacterial inactivation together with comparable quality parameter values suggests the use of amotosalen/uva pathogen reduction is safe and efficient to enhance pc transfusion safety. keaton charles stoner* , jay srinivasan , jessica poisson and ian welsby . duke university, duke university school of medicine, duke university hospital, duke university medical center background/case studies: the coagulation cascade relies on a complex interaction between proteins known as clotting factors. cryoprecipitate (cryo) is a plasma-derived blood product that contains several of the proteins central to the clotting cascade and is typically used as a fibrinogen replacement in bleeding patients. however, cryo contents tend to be variable, and little quantitative evidence exists regarding the exact therapeutic effect of cryo on coagulation. my study aimed to better characterize cryo for consistency across and within sources in terms of its functional effect on in vitroclot formation. study design/method: the duke proteomics core conducted a semiquantitative liquid chromatography-mass spectrometry/mass spectrometry transfusion developed an in vitromodel for a coagulopathic patient using serial dilutions of pooled normal plasma with saline and then added the equivalent of one, two, and three cryoprecipitate doses. a tissue factor-activated test on the rotemv r delta hemostasis analyzer (extem) was performed on each condition. for each source, dose-response curves for clotting time (ct), alpha angle, and maximum clot formation (mcf) were generated using linear regression models. inter-source unit variability was determined by anova and tukey's hsd post-hoc analysis (rstudio inc.). results/finding: lc-ms/ms identified proteins in cryo; of the most abundant, only fibrinogen was relevant to coagulation. notably, the american red cross (arc) single donor source had the steepest slope for mcf ( . mm/dose), indicating a greater per dose potency than the other sources. the arc single donor source had the highest mean mcf across all dosing levels, but also the highest standard deviations and response variability. the arc single donor source was significantly more potent than the australian source. conclusion: paired with our estimates regarding the variability of clot formation responses to cryo, the quantitative dose-response curves provided in this study for ct, mcf, and alpha angle can provide physicians with more information regarding cryo dosing. future studies that evaluate the therapeutic effect of cryoprecipitate versus fresh frozen plasma or fibrinogen concentrate would be of clinical importance and give us further insight into the relative utility of and dose requirements for cryo to correct dilutional coagulopathy. viral inactivation and enrichment of factor viii, factor xiii, fibrinogen and von willebrand factor (vwf) multimers from fresh frozen plasma (ffp)using, "vips plasma, virus inactivation treatment system". background/case studies: the solvent/detergent (sd) process used for plasma can safely inactivate all lipid-enveloped viruses. the method proved effective in the processing of coagulation factor concentrates by disrupting the membranes of lipid-enveloped viruses, cells and most protozoa, while leaving the labile coagulation factors intact. this study is done to assess viral inactivation and, factor viii, factor xiii, fibrinogen and von willebrand factor (vwf) multimers enrichment capacity of, "vips plasma, virus inactivation treatment system". study design/method: "vips plasma, virus inactivation treatment system" comprise of interconnected bag system where the s/d reagents are removed by filtration and the final products subjected to bacterial ( Á lm) filtration. cryoprecipitate mini-pools ( ml) were subjected to doublestage s/d viral inactivation, followed by one oil extraction and a filtration on a s/d and phthalate [di( -ethylhexyl) phthalate (dehp)] adsorption device and a Á lm filter. the initial and the final products were compared for visual appearance, blood cell count, factor viii, factor xiii, fibrinogen and von willebrand factor (vwf) multimers. initial and final products were also checked for hiv, hbv, hcv, dengue, malaria and bacterial contaminations. results/finding: our analysis showed that the treated cryoprecipitate were very clear, with negative blood count and the protein content of factor viii, factor xiii, fibrinogen and von willebrand factor (vwf) multimers were well conserved (table ) . kit ensured bacterial sterility (table ) and most importantly, final product was free of hbv, hcv and hiv (table ) . conclusion: it's the first time, "vips plasma, virus inactivation treatment system", is used in south asia for product enrichment and viral inactivation. results showed effective product enrichment and viral inactivation in our conditions. but further investigation is needed to characterize functional activity of the enrich component. irrespective of that the process may offer one additional option to blood establishments for the production of virally inactivated plasma components especially in low income countries. background/case studies: buffy coats (bc) from donors who used pain medication like aspirin and ibuprofen up to days prior to the donation are discarded, because a known side effect of these non-steroidal anti-inflammatory drugs (nsaids) is inhibition of platelet (plt) aggregation. these nsaids inhibit the enzyme cyclooxygenase- , thereby blocking synthesis of thromboxane a from arachidonic acid. however, the quality of platelet concentrates (pc), prepared from this bc is not known. the aim of the study was to investigate the in vitro quality of pc prepared from nsaid-bc and autologous plasma during storage. study design/method: single-donor pc (spc, n ) were prepared from a nsaid-bc and ml of autologous plasma. information about the type of pain medication was extracted from the anamneses form. the spc were stored for days at c and sampled at regular intervals. aggregation tests were performed with chronolog (adp or collagen) and multiplate (arachidonic acid) aggregometers. thromboelastography (teg, kaolin) was applied for assessment of the overall clotting capacity. spc in plasma from normal controls (n ) were investigated as a reference. values are expressed as mean sd or as median & iqr. a non-paired t-test or a mann-whitney u test was applied for statistical analyses of normal or nonnormal distributed data respectively. results/finding: volume ( vs. ml) and plt content ( vs. x ) were similar in both groups. on day , both groups showed comparable ph and changes in plt content (data not shown). phosphatidylserine exposure on day was significant higher in a subset of donors who had used ibuprofen (n ). aggregation tests with arachidonic acid revealed in general a low or absent response for spc with aspirin ( , - , p< . ), diclofenac ( , - ) and naproxen ( , - , p< . ), compared to normal controls ( , . no differences were detected in aggregation with adp or collagen. with teg, slightly longer r-times (initiation phase) were measured on day in spc with aspirin, diclofenac and naproxen, compared to the normal controls (only significant for naproxen). these differences disappeared during storage. conclusion: storage properties of spc prepared from nsaid-bc were comparable with spc from normal controls. main differences were observed in aggregation and coagulation properties for donors who used aspirin, diclofenac or naproxen. plt from donors who used ibuprofen showed little or no deviations. this is most likely caused by the fast (< hour) disappearance of ibuprofen from the blood circulation and the reversible binding to plt. the use of bc from donors who used ibuprofen will be further investigated in a 'worst case' (pc in plasma) and 'best case' (pc in additive solution) scenario. the effects of ibuprofen on aggregation and coagulation properties will be further investigated in a dose-response study design adding different levels of ibuprofen to plt. background/case studies: previously it was shown that donors could be classified as having platelets (plt) with good, average or poor storage properties [bontekoe, transfusion, ] . a main difference between 'good' and 'poor' storage properties involved metabolic activity, resulting in a faster decline of ph during storage of 'poor' plt concentrates (pc). this might be caused by a different functionality of the plt mitochondria and there are indications that donors with a history of 'poor' pcs are more likely to have health issues, pointing towards metabolic syndrome and type diabetes (t d). because of the strong rise of people with t d in the dutch population, the aim of this study was to characterize plt from whole blood donors diagnosed for t d, but accepted as donor. study design/method: twelve whole blood donors with t d, not using insulin, were selected and buffy coat (bc) and plasma were, after overnight hold, used for preparation of a single-donor pc (spc). an equivalent number of spc was prepared from age and sex matched control donors, derived from the same collection sessions. spc were stored for days at c and sampled on day , or and . the diabetic marker hba c was determined in red cells and cholesterol and triglyceride levels in plasma. from both groups 'good' (ph day > . ) and 'poor' (ph day < . ) storing spc were selected and analysed in more detail. results/finding: donors were of age year and primarily men ( %). donors with t d had a higher mean bmi ( . . vs. . . kg/m ) and higher hba c than controls. the spc of both groups had the same volume ( vs ml) and plt content ( vs x ) but on day glucose concentration was higher in the diabetic group ( . . vs . . mm, p< . ). on day , the average in vitro quality was comparable in both groups (data not shown). when combining a transfusion vol. supplement s the selected 'good' and 'poor' storing plt from both groups, a large difference in lactate production was observed ( . . vs . . mmol/ day/ plt). the 'poor' plt showed a faster decline of the mitochondrial membrane potential (as measured with jc- ) during storage than 'good' plt. remarkably, a difference in triglyceride levels was detected on day ('poor': . . vs 'good': . . , p< . ). conclusion: bc from donors with t d who did not use insulin and fulfilled all donor criteria, were comparable with bc from age and sex matched controls, and seem suitable for preparation of pc. when selecting the 'good' and 'poor' storing plt from the combined groups, the results of our previous study were confirmed, with significant differences in glycolysis rate and functionality of mitochondria. metabolic syndrome and t d are still suspected as health issues involved in 'poor' storage of plt because donors were of high mean age and because of the observed differences in triglyceride levels between 'good' and 'poor' stored pcs. whole blood leukoreduction failures --following manufacturer's instructions may not be enough karen klinker*, nancy m. dunbar and zbigniew m. szczepiorkowski. background/case studies: our hospital based blood donor program uses a blood collection system which leukoreduces the unit at room temperature prior to centrifugation. the manufacturer recommends minimum wait time of minutes prior to filtration. anecdotally, the vendor states waiting an hour improves the leukoreduction. we experienced leukoreduction failures in january and february of detected by our routine qc. we initiated an investigation as to the cause of these unexpected failures. study design/method: for each of the leukoreduction failures, the following factors were analyzed: collection time, length of filtration, length of wait time prior to filtration, platelet count, staff performing the process, the lot number of the collection system bag, and whether or not units collected from the same donor failed leukoreduction in the past. hemoglobin s determinations were not sought out as no repeat donor failures were noted and our donor population would suggest a minimal number of donors would be found to be hemoglobin s positive. results/finding: a relationship was established between the length of time the product rested or waited prior to filtration and leukoreduction failure. we found that shorter wait times increased the percentage of leukoreduction failures (see table ). all units that failed had wait times less than one hour. a similar trend was noticed for the previous year. the investigation showed no relationship between length of collection time, or the length of filtration time and leukoreduction failure. staff performing the filtration was ruled out as possible cause as the failures were spread out among numerous personnel and observation of their technique displayed no sample collection issues. platelet counts on the donors involved were available and none were outside of the normal range. various lot numbers of the collection sets were involved, and no donors were repeat failures. conclusion: in our small study, we found that following manufacturer's recommendations for the resting or wait time prior to filtration was insufficient to avoid excessive leukoreduction failures. we extended our minimum wait time to minutes based on our data. we have not experienced any leukoreduction failures after this change. absolute immature platelet count in diagnostic algorithm and management of pediatric thrombotic microangiopathy hamza n gokozan* , , katharine a downes , , hollie m reeves , and robert w maitta , . case western reserve university school of medicine, university hospitals cleveland medical center background/case studies: prior studies highlighted the utility of absolute immature platelet count (a-ipc) and a-ipc ratio once therapeutic plasma exchange (tpe) is initiated to differentiate thrombotic thrombocytopenic purpura (ttp) from other thrombotic microangiopathies. this can be helpful to determine those who may benefit from prompt initiation of tpe when tests such as adamts are not readily available. we report a young pediatric patient presenting with diarrhea in the setting of laboratory results suggestive of a microangiopathic thrombocytopenia suspicious for ttp in which a-ipc measurement was clinically useful. study design/methods: previously healthy month old unvaccinated girl presented with history of diarrhea for days which was bloody at onset, accompanied by fever and dehydration. laboratory results showed: white blood cell count: x /l, platelets: x /l, bun: mg/dl, creatinine: . mg/dl, lactate dehydrogenase u/l. hospital course was complicated by tonicclonic seizure episodes that stopped with anti-convulsants and acute kidney injury requiring hemodialysis. peripheral blood smear revealed schistocytes. on third day of hospitalization, platelet count decreased to x /l, adamts sample was sent out and tpe was initiated for clinical suspicion of ttp versus hemolytic uremic syndrome, atypical versus shiga-toxin mediated. immature platelet fraction (%-ipf) and calculated a-ipc (%-ipf x platelet count) were obtained with daily pre-tpe cbc. a-ipc ratio was calculated from baseline. results/findings: platelet count began to increase prior to tpe initiation ( x /l and a-ipc of . x /l). two consecutive tpe were completed which resulted in a platelet count decrease to x /l and a-ipc of . x /l. a-ipc ratio was . below the ratio of which has been reported for ttp patients. similarly a-ipc count was not below x /l threshold reported in setting of ttp with severe adamts deficiency. at this time stool culture obtained prior to start of tpe came back positive for e. coli o :h toxin. testing of c , c , factor h, factor h autoantibody, factor i and factor b were normal. adamts activity was %. patient was treated for the infection and platelet count improved within days to x /l, with resolution of her renal failure: bun: mg/dl, creatinine: . mg/dl. no additional seizures were observed during follow-up. conclusion: measurement of a-ipc can be used to aid clinical decisions in pediatric patients suspected of ttp especially when adamts testing and those for other etiologies are still pending. tpe did not seem to have a significant effect in a-ipc but decreased platelet counts in this patient. a-ipc is rapid to obtain and can provide helpful information in the setting of potentially overlapping etiologies in the setting of other testing with longer turnaround time. background/case studies: thrombotic thrombocytopenic purpura (ttp) is a thrombotic microangiopathy characterized by low adamts activity. many patients with severe autoantibody-mediated adamts deficiency at initial disease presentation may suffer from one or more recurrent episodes over the following months or years. it is unclear if disease course and characteristics of recurrent/relapsed ttp may be different from that seen at initial presentation. since absolute immature platelet counts (a-ipc) have been shown to be useful in the diagnosis and to follow response to therapy of ttp patients, we proceeded to evaluate if a-ipc pattern was different in relapsed verse initial presentation. study design/methods: our study cohort consisted of three patients (two female and one male) with acquired ttp (adamts activity < %) who underwent daily therapeutic plasma exchange (tpe). clinical course and laboratory values were reviewed. platelet count (plt), immature platelet fraction (%-ipf) and a-ipc (%-ipf x platelet count) were analyzed during treatment course. a-ipc values at presentation and peak, a-ipc peak time (days), and plt count recovery time (days) were compared between initial onset and relapse episode for each patient. a-ipc percent change in relapse episodes compared to initial presentation was calculated. results/findings: all patients had an increased %-ipf, and decreased a-ipc and plt count at presentation in both initial and recurrent episodes. once tpe treatment was initiated, a-ipc rapidly increased and reached a peak value - days prior to plt count recovery, consistent with that previously described in ttp patients. however, compared to first onset, recurrent episodes featured lower a-ipc at presentation (results shown as percent decrease, column ), increased peak a-ipc value (results shown as percent increase, column ), delayed a-ipc peak, and delayed plt recovery (table ) . moreover, recurrent episodes required more procedures compared to initial presentation (table ) . conclusion: recurrent/relapsed ttp demonstrate lower a-ipc at presentation and a delayed and increased a-ipc peak value in response to tpe compared to initial presentation. a longer treatment course was observed in recurrent patients. future studies of more relapsed ttp patients are needed. donors undergoing frequent plateletpheresis and its effect on the hematological parameters sweta nayak*, poonam coshic and r.m pandey. all india institute of medical sciences background/case studies: frequent plateletpheresis donors are assets for the blood banks. the well-being of these donors has been a matter of concern. in our study we intend to analyze the effect of plateletpheresis on the hematological parameters of these donors assessed prior to each subsequent procedure. we also try to compare the effect cell separators used for plateletpheresis on the post donation hematological parameters. study design/method: the study was conducted during february to march on all the repeat plateletpheresis donors coming to the department of transfusion medicine for the nd time within a month of the first plateletpheresis. the values of the hematological parameters including red cell and platelet indices tested prior to each plateletpheresis were entered into the excel sheet and gap between each donations were calculated. the plateletpheresis were done either on hemonetics mcs separator (hemonetics corporation, braintree, massachusetts, usa), fresinius separator (com.tec), dn (fresinius hemocare gmbh, bad homburg v.d.h, germany) and gambro trima accel, software version . after taking consent from the donors. the target collection of each procedure was a dose of x platelets in - ml of plasma. to compare the effect of the cell separators on the hematological parameters due to the plateletpheresis, parameters at consecutive donations within days were considered. data was analyzed by stata . within change in the continuous variables were assessed by paired t-test and between two groups comparison was done by independent t-test or wilcoxon rank sum test. the comparison among the cell separators was done by kruskal-wallis test or one way anova. results/finding: of the donors, repeated the plateletpheresis within a week (group i) and underwent nd plateletpheresis within - days (group ii). no significant alteration was found in the red cell or the platelet indices within either group but a significant difference in the variation of platelet counts of the groups (p . ). though above the eligibility cutoff of . lakhs/ml, platelet counts were lower than baseline in group i donors whereas it was higher at nd plateletpheresis in group ii donors. there were donors who presented to us for the rd time for plateletpheresis with a mean gap between st and rd plateletpheresis being days. no significant difference in the parameters assessed prior to any of the plateletpheresis was found except the platelet distribution width (p . ). plateletpheresis through all the cell separators had similar effects on the hematological parameters. conclusion: there was no significant change in the hematological parameters in the plateletpheresis donors who underwent frequent plateletpheresis. post donation follow-up hematological parameters were not affected by the cell separators used for plateletpheresis. efficacy of therapeutic plasma exchange on angiotensin ii type receptor antibodies in two kidney transplant recipients chisa yamada*, silas p. norman, milagros samaniego and laura cooling. background/case studies: some kidney transplant recipients develop antibody mediated rejection (amr) without detected hla donor specific antibodies (dsas) in sera. in recent years, angiotensin ii type- receptor antibody (at rab) has been reported to cause amr, especially refractory amr, possibly by contraction of renal arteries. at our institution, therapeutic plasma exchange (tpe) followed by ivig every other day has been applied to reduce at rabs in kidney transplant recipients, and we here report efficacy of tpe treatments in two cases. study design/methods: two kidney transplant recipients who received tpe treatment followed by ivig to decreased at r ab are reviewed. results/findings: case : the patient is a currently -year-old female with focal segmental glomerulosclerosis who received her first kidney transplant from a living related donor at age , and a second deceased donor transplant due to a rejection of the transplanted kidney at age . three years post-transplant, her creatinine (cr) started to rise from . to . mg/dl and a biopsy showed banff criteria grade amr, grade a t-cell mediated rejection (tcmr) and grade interstitial fibrosis and tubular atrophy. hla dsa had been negative in serum, but high level at rab was identified at > u/ ml (high: > u/ml, intermediate: - u/ml, negative: < u/ml). she received tpe treatments every other day and started losartan. after a course of tpe, at rab decreased to u/ml and histology showed improvement of amr and tcmr, however, cr kept increasing slowly to . ml/dl. in one month, her at rab increased again to > u/ml, therefore, she received more tpe treatments with a decrease in her at rab to u/ml. although at rab level increased slightly to u/ml after months, her cr has been stable at . - . ml/dl. case : the patient is a -year-old mean /-se - . /- . % * . % /- . %* * p< . a female with malignant hypertension who received a deceased donor kidney transplant at age . her cr started to rise weeks post-transplant from . to . mg/dl without detectable hla dsa. although biopsy showed no amr or tcmr, there was focally severe arteriopathy. she was found to have high at rab level at u/ml. she received tpe procedures every other day and at rab decreased to u/ml with a decrease of cr to . mg/dl and improved arteriopathy in histology. because her at rab level slightly increased to u/ml over the next weeks, she started weekly tpe treatment. after weekly tpe, tpe treatment was stopped because her at rab level remained relatively unchanged. her cr has been stable at around . ml/dl to date. conclusion: we present kidney transplant recipients who received tpe treatments for high at rab levels. a course of tpe procedures followed by ivig every other day was effective to decrease at rab levels; however, weekly tpe had no effect on reducing at rabs. tpe treatment may be also beneficial to improve histological amr and clinical kidney function. experience in management of thyroid storm by plasmapheresis tatiana belousova*, vanya jaitly, brian castillo, hlaing tint, kimberly klein and yu bai. university of texas health sciences center at houston background/case studies: thyroid storm (ts) is an extreme manifestation of thyrotoxicosis that is a serious complication occurring primarily in patients with graves' disease. clinically they may present with a wide range of hypermetabolic symptoms which may be fatal if not managed appropriately. we report two cases where ts with severe cardiac complications was managed by plasmapheresis (plex) with excellent effect. study design/method: a year old man (patient a) with a medical history of hyperthyroidism present with ts complicated with cardiogenic shock [ejection fraction (ef) < %], renal and hepatic dysfunction as well as coagulopathy. patient was persistent tachycardic while being intubated, sedated and requiring tandem heart support. a year old man (patient b) with a medical history of hypothyroidism (on synthroid for years), end stage renal disease and non-ischemic cardiomyopathy (ef of - %) presented for evaluation of dual kidney-heart transplant. he subsequently developed ts with multiorgan failure. standard steroid medication treatment showed little response. results/finding: both patients underwent urgent plex along with standard medication administration as soon as the clinical suspicion of thyroid storm was raised. a - . plasma volume, iso-volumic procedure using fresh frozen plasma as replacement was performed in the intensive care unit where the procedure associated hemodynamic impact could be easily managed. both patients showed significant clinical improvement within hours of the procedure completion. their total t , t and free t levels trended to normal or near normal range within hours (table) . in addition, the plex effect on hormone and the associated antibody removal seemed remained and no "rebound" phenomenon was observed in both cases, making repeated plex unnecessary. both patients had total thyroidectomy - weeks after the event with great clinical outcome. conclusion: our cases demonstrate that plex is a safe, effective treatment option in managing ts patient with severe cardiac dysfunction. the procedure can not only lead rapid decrease in thyroid hormone and its associated antibody levels, but also lessen the severity of tissue injury by moderating the inflammatory process and correcting complications. extracorporeal photopheresis in s ezary syndrome treatment: hospital-based blood bank experience sandra ortega s anchez* , laura martínez molina , cristina muniesa montserrat , octavio servitje bedate , silvia cosano navarro and maria isabel gonz alez medina . banc de sang i teixits, dermatology service. background/case studies: extracorporeal photopheresis (ecp) is an immunomodulatory therapy widely used since years in cutaneous t cell lymphoma, several autoimmune diseases and organ transplant rejection, and in the last years, also used in graft versus host disease treatment. the use of ecp in cutaneous t cell lymphoma (ctcl), mycosis fungoides (mf) and s ezary syndrome (ss) in their erytrodermic form are recently categorized by the american society for a pheresis (asfa) , as first line treatment alone or in combination with other therapies, with a strong recommendation: grade ib, category . since mf and ss are incurable diseases current therapies are focus in controlling skin symptoms and minimizing immunosuppression. the objective of this observational study is to assess outcomes of patients diagnosed with ss and compare them in their first evaluation once the th procedure is been performed. study design/method: ecp is a leukapheresis-based therapy, ex vivo exposition to a photosensitizer drug ( -methoxypsoralen, -mop) and uva light, and subsequent reinfusion of the treated cells which are now induced to apoptosis. volume treated varies from . to total body volume (tbv) and the schedule for ss disease is one cycle (two daily ecp procedures) twice per month. the venous access was peripheral in all cases except in where central catheter was needed. the procedures were performed with optia or amicus devices for the aphaeresis and external uva irradiation for off-line system (in / patients) and with online system (therakos) just in . main parameters for evaluation were cutaneous response rate, number of s ezary cells, previous treatments, duration of the response and possible complications during ecp treatment. results/finding: global response rate is ' % (partial remission . % and complete remission . % with maintained response). no severe side effects related with the procedure were found. the patient outcomes analyzed are similar to results in published literature. conclusion: cases treated in our hospital confirm the efficacy of ecp in ss treatment, with a good safety profile. another great advantage of ecp is the relative lack of immune suppression. many questions remain still unanswered about ecp: which schedule is the most suitable one, how we must continue or stop when partial or complete remission is achieved; and the number of leukocytes to be treated, as techniques as mini-photopheresis are also getting good results. all these questions and more make prospective studies necessary to be performed. : u/l) requiring transfusions, mild thrombocytopenia ( x /l), acute kidney injury (bun mg/dl, creatinine . mg/dl). by the third hospitalization day hgb improved to g/dl, however with worsening thrombocytopenia ( x /l) that led to clinical concern for ttp. peripheral smear showed many red cell fragments. patient was transfused with platelets day prior to first tpe. immature platelet fraction (%-ipf) and a-ipc (%-ipf x platelet count) were obtained with daily pre-tpe cbc. a-ipc ratio was calculated from baseline. results/finding: four tpe in five days were performed (hospital days - ). platelet count and a-ipc improved to x /l and . x /l respectively just prior to first tpe. response to four tpe led to a decrease in both platelet count ( x /l) and a-ipc . x /l. these dynamics did not resemble those which had been described for ttp patients with adamts deficiency. adamts obtained prior to tpe initiation was resulted at this time and was %. no causative organism or toxin was identified after urine, blood, and stool examination and culture. based on these results, tpe was discontinued which led to an immediate increase in a-ipc ( . x /l) that preceded platelet count increase to x /l three days later when patient was discharged. other laboratory values at this time were ldh of u/l, hgb: . g/dl in the setting of recovery of renal function. conclusion: timely diagnosis of ttp is essential to start of tpe. a-ipc dynamics differ in ttp compared to other thrombotic microangiopathies. in our patient a-ipc failed to improve despite tpe and improved once procedures were discontinued and were followed by increases in platelet counts three days later. when ttp is not the causative etiology, a-ipc can help adjust therapy and lead to clinical improvement. further research is needed to characterize immature platelet dynamics in non-ttp microangiopathies. infection and its role in the clinical course of idiopathic thrombotic thrombocytopenic purpura associated with severe adamts deficiency eiman hussein* and jun teruya . department of clinical pathology, cairo university, texas children's hospital background/case studies: ttp is a life threatening disease, defined by microangiopathic hemolytic anemia, thrombocytopenia and severely deficient adamts . since the introduction of therapeutic plasma exchange (tpe) as a treatment modality for ttp, its prognosis has improved dramatically. nonetheless, some patients may develop relapse or refractoriness, with potentially fatal outcomes. despite the notable progress that has been made with studies that emphasized the pivotal role of adamts , the epidemiology of ttp remains uncertain. previous studies have suggested that many factors appear to influence its pathogenesis. some studies point toward infection as a possible trigger which may contribute to the development and can ultimately influence its clinical course. one of the theories to explain this association is the possible cross reactivity between antibodies targeting infectious pathogens and those directed against adamts . the aim of this study was to prospectively examine the potential association between infection and the clinical outcome in a cohort of patients with idiopathic ttp. study design/method: patients with idiopathic ttp who underwent tpe from january through march were studied. sessions were performed daily until platelets and reticulocytes had been normal, then sessions were gradually tapered. we only included patients with adamts activity of less than %. data on infections that occurred at or within a week prior to the development of ttp were analyzed. results/finding: thirty-two patients were categorized as idiopathic ttp with severe adamts deficiency. eight patients ( %) were associated with suspected bacterial infection. four of the patients ( %) showed acute relapse coincident with bacterial infections. central line associated staphylococcus aureus infections occurred in three patients and acinetobacter urinary tract infection was reported in one patient. one patient had symptoms of respiratory infection before the development of ttp, on his initial as well as his relapsing episode. refractoriness to treatment was demonstrated in patients. it was associated with dental abscess in one patient. the other two were associated with mycoplasma pneumonia. tpe sessions were continued in all refractory patients until their death. conclusion: in patients with idiopathic ttp refractory to conventional treatment, a serious consideration should be given to non-idiopathic causes, particularly the presence of a remote source of infection, which can be an additional triggering factor for their initial and / or recurrent episodes. sandra satoe kayano*, marcos paulo colella, rafaela guerra maciel, ingrid priscila ribeiro paes ferraz and rafael colella. a c camargo cancer center background/case studies: therapeutic leukapheresis (tl) has become an ordinary procedure in low body weight children with cancer, and its use over the time has been replacing exchange transfusion. leukodepletion preceding chemotherapy helps preventing leukostasis and hiperviscosity, and aims to reduce metabolic and renal complications associated with cell lysis. the objective of this study is to evaluate the efficacy and safety of leukapheresis procedure in pediatric patients with less than kilograms using a single apheresis procedure. study design/method: in october and june , two children with possible leukemia were submitted to tl procedure. they were and months old, and weighted , and , kilograms. central venous catheters were placed, and apheresis were performed using a continuous flow apheresis system. the device was primed with ml of abo, rh and kell compatible, leukocyte-reduced, irradiated, % hematocrit packed rbcs, and the anticoagulant used was acd-a plus heparin ( ml of acd-a and , units of heparin), at a blood to anticoagulant ratio of : . a complete blood count was determined before and after apheresis. the room was heated to avoid hypothermia, and ionized calcium was measured every minutes to prevent hypocalcemia. during the collection, changes in blood pressure, oxygen saturation and heart rate were observed. net fluid balance was calculated as the sum of the volume of anticoagulant, cation and nondiverted apheresis prime solutions minus the product volume. when the procedure was completed, the blood that filled the apheresis tubing was discarded. the patients were in the intensive care unit (icu) under the supervision of a pediatric physician and icu nurse who were aware of potential adverse events, and the procedure were performed by two hematology physicians and the nurse practitioner. results/finding: the white blood cell (wbc) in blood was counted immediately before apheresis in both subjects, and were . and . / mm . the formula "collection pump flow , x inlet flow x preapheresis wbc count" was used with the goal of removing up to x leukocytes/ml. a single leukapheresis procedure was performed with total blood volume processed per patient. immediately after the -hour procedures, wbc count were . and . wbc/mm , and -hour post tl, wbc count were respectively . and . /mm . net fluid balance was zero in both procedures, and the patients required no transfusion. conclusion: tl was safe and efficient. experience with leukodepletion in infants is limited, and a procedure in children weighing kg or less needs forethought and a multidisciplinary effort, hence operators need to customize procedures for safe collection. however, despite the potential complications that may occur (placement of adequate vascular access, management of low extracorporeal blood volume, anticoagulant-related toxicity with metabolic and hematologic issues), remains an excellent source for leukoreduction in hematologic malignant diseases. background/case studies: nationwide apheresis registry can give us information on the current status and trend regarding apheresis procedures. data can be compared with other regions to find and understand differences in perspectives, indications, technology, and clinical practice. the korean society for apheresis (ksfa) has launched an online web based registry system for apheresis procedures since . we report the data from the year . study design/method: the registry is consisted of two sub-registries. one addresses the overall aspects of apheresis procedures performed at each institute, and the other is focused on therapeutic plasmapheresis procedures. data is registered by voluntarily participating hospitals in korea. results/finding: a total of , apheresis procedures were performed at hospitals. therapeutic plasmapheresis was the most frequent procedure ( . %) followed by autologous peripheral blood stem cell (pbsc) collection ( . %), allogeneic pbsc collection ( . %), donor leukapheresis ( . %), and therapeutic leukapheresis ( . %). cobe spectra ( . %) and amicus ( . %) were the most widely distributed instruments. centrifugation was the dominant technique ( . %) for therapeutic plasmapheresis. detailed information was given for , therapeutic plasmapheresis procedures performed on patients (some items were not completely filled out). spectra optia ( . %) and cobe spectra ( . %) were the most frequently used instruments for therapeutic plasmapheresis. fresh frozen plasma (ffp) was used most frequently ( . %) as the replacement fluid followed by % albumin ( . %), % albumin ( . %), and % albumin ffp ( . %). most of the procedures were performed for plasma volume ( . %). acd ( . %) and heparin ( . %) were used for anticoagulation. central venous catheter ( . %) was the dominant type of vascular access. major clinical indications were desensitization for abo incompatible renal transplantation ( . %), antibody mediated rejection in renal transplantation ( . %), thrombotic microangiopathy ( . %), desensitization for abo compatible renal transplantation ( . %), neuromyelitis optica spectrum disorders ( . %), and hyperviscosity in monoclonal gammopathies ( . %). adverse reactions were observed in . % of the procedures. allergic reaction ( . %), hypocalcemic symptom ( . %), and hypotension ( . %) were frequently reported. therapeutic effect was achieved in . % of the patients. our apheresis registry has been well run for years. recent data reflects the increase of abo incompatible transplantation in korea. revision and update of the registry planned this year will help us achieve better understanding on the apheresis status of our region. plasma exchange may not always be necessary in patients with severe hypertriglyceridemia and acute pancreatitis. jan c hofmann* and dobri d kiprov. california pacific medical center background/case studies: hypertriglyceridemic pancreatitis (hp) is characterized by severe hypertriglyceridemia (shtg: triglyceride > - mg/dl), acute pancreatitis (ap), and absence of other causes. hp is a potentially fatal complication of acute pancreatitis with an incidence of $ deaths/ , cases/year. complications of shtg include: abdominal pain (nausea/vomiting), acute pancreatitis, hepatosplenomegaly, eruptive xanthomas, lipemia retinalis, memory loss, dementia, and peripheral neuropathy. we report on the effective use of plasma exchange (pe) to treat patients (pts) with hp refractory to conventional medical therapy (lipid-free diet plus pharmaceutical interventions). study design/method: we reviewed the medical records of pts who were diagnosed with hp from january, through january, , and referred for immunotherapy evaluation. / ( %) pts received conventional therapy (ct) and pe (pe group), and / ( %) pts received ct alone (ct group). mean age was years (range - ), and % were female. baseline mean triglyceride level (normal < mg/dl) for pe group was , mg/dl ( , - , ) versus , mg/dl ( , - , ) for ct group. baseline mean lipase level (normal < u/l) for pe group was , u/l ( - , ) versus u/l ( - , ) for ct group. results/finding: all pts were treated with dietary restriction (lipid-free diet, or nothing by mouth) and aggressive lipid lowering protocols involving - medications. / ( %) of pe group and / ( %) of ct group received insulin therapy to manage symptoms (sxs) of hyperglycemia and/or diabetic ketoacidosis. / ( %) of pe group and / ( %) of ct group received heparin therapy to stimulate lipoprotein lipase release. the pe group underwent an average of . pe treatments (txs) (median of , range - daily txs) using % albumin; / ( %) required ffp to treat dilutional coagulopathy. in most cases, we did not perform pe txs when baseline triglyceride levels were < - mg/dl and lipase < - u/l ( . - . x upper limit of normal). mean triglyceride levels after pe txs were , mg/dl ( - , ) for pe group (mean decrease %); mean triglyceride levels after additional hours of ongoing ct were , mg/dl ( - , ) for ct group (mean decrease %). while the pe group achieved a greater mean decrease in triglyceride levels after pe txs (compared to the ct group after hours of ct), both groups experienced marked improvement in clinical sxs of pancreatitis and hyperglycemia (p> . ). limitations of the retrospective cohort study include lack of long-term follow-up. conclusion: this small study adds to the literature which demonstrates that plasma exchange is very effective in rapidly lowering triglyceride levels in pts with acute pancreatitis and hypertriglyceridemia. it suggests that there may be a threshold (or range) of triglyceride and lipase levels below which conventional therapy may be nearly as effective in achieving clinical resolution of symptoms. randomized controlled trials would further elucidate the appropriate use of adjunctive plasma exchange in the setting of hypertriglyceridemic pancreatitis. role of plasma replacement in therapeutic plasma exchange for hypertriglyceridemia: a single patient study geoffrey wool* and angela treml. university of chicago background/case studies: our apheresis service performs chronic therapeutic plasma exchanges (tpe) for a -year-old man with a chronic history of hypertriglyceridemia > mg/dl, diabetes mellitus type ii, and chronic abdominal pain. his abdominal pain is severe and persistent, but there is not overt evidence of chronic pancreatitis on imaging or fecal elastase testing. targeted sequencing has not revealed a pathogenic mutation to explain the patient's hypertriglyceridemia. hypertriglyceridemic pancreatitis is a category iii indication for tpe by asfa guidelines, in a patient unresponsive to optimal medical management. asfa guidelines for this disorder state that "some have used plasma as it contains lipoprotein lipase and could enhance triglyceride (tg) removal. no direct comparisons of replacement fluids have been reported". there are three apheresis physicians on our service and use of partial plasma replacement has been variable. we undertook a retrospective study of the efficacy of partial plasma replacement in this patient. study design/method: we have performed tpe on this patient. we performed a chart review to capture replacement fluid use and pre-and post-tg levels, if drawn. tpe was performed using spectra optia (terumo, lakewood, co) exchanging approximately one plasma volume, using entirely % albumin for exchange fluid ( % albumin procedures) or partial plasma replacement ( - units of thawed plasma). twenty-six tpe had pre-and post-procedure tg values available. we determined the percent tg reduction achieved by the tpe. we also determined the daily rate of tg increase until the next tpe appointment (to assess any long-term effects of plasma preventing tg rebound). significance was assessed by student's t-test (one-tailed, heteroscedastic). results/finding: twelve tpe were performed with partial plasma replacement, while were performed with % albumin replacement. table shows that partial plasma replacement was associated with significantly greater % tg reduction. the rate of subsequent daily tg increase was also lower with partial plasma replacement, but this did not meet significance. one mild allergic reaction has occurred during partial plasma replacement which responded quickly to additional iv diphenhydramine. conclusion: we have performed an ad hoc cross-over study on the efficacy of partial plasma replacement in tpe for hypertriglyceridemia. in this patient without lipoprotein lipase mutations, plasma was significantly associated with improved % tg reduction, but not with prevention of post-tpe tg rebound. safety and efficacy of local albumin replacement for therapeutic plasma exchange phandee watanaboonyongcharoen* , , metha apiwattanakul , sompis santipong , jutaluk jaipian , jettawan siriaksorn and ponlapat rojnuckarin . chulalongkorn university, king chulalongkorn memorial hospital, prasat neurological institute background/case studies: therapeutic plasma exchange (tpe) with albumin replacement has been used to treat a variety of diseases. however, there had been rising cost and supply shortage of imported albumin in our country. to solve the problem, our national blood centre had established a plasma fractionation plant to manufacture plasma derivatives including albumin. the objective of the study was to evaluate the safety and efficacy of local albumin as a replacement for tpe. study design/method: all tpes using local albumin as a replacement from two tertiary care hospitals performed from june through february were included. complete blood count and serum calcium were tested before tpe. serum albumin was tested before and after tpe. local albumin is available as a % solution. before using, it was diluted to a % albumin concentration with normal saline. all the patients were hospitalized and received oral calcium before tpe to prevent hypocalcemia. the adverse effects were recorded. results/finding: the total of tpes in patients were included as shown in the table. neurologic disorders were the most common indication for tpe, followed by autoimmune diseases. the median total plasma volume was , (range , - , ) ml. although the corrected calcium level was low (< mg/dl) in . % ( / ) before the procedure, no clinical manifestation of hypocalcemia was detected. adverse effects were observed during the tpe procedure in patients. the first patient had events of mild symptomatic hypotension. he previously took angiotensin converting enzyme inhibitor. the second patient complained nausea after finishing tpe. all reactions were mild. the incidence of adverse effects was . % ( / ). in , the incidence of tpe adverse effects was . % ( / ) when commercial albumin was used. the difference was not statistically different (p . ). median serum albumin levels pre-tpe and post-tpe were . ( . - . ) and . ( . - . ) g/dl. the increase in serum albumin after tpe was statistically significant (p< . ). eighty-two percent of pre-tpe serum albumin levels were lower than . g/dl explaining the rises of albumin after the procedures. we demonstrated that local albumin was safe and effective in maintaining albumin levels in patients undergoing tpes. safety, efficancy and cost-effectiveness of mononuclear cell collections for autologous immunotherapies: experience from a private outpatient collection facility within the eu markus dettke*. akh vienna university hospital, cyto-care.eu background/case studies: within the eu the collection of mononuclear cells (mnc) as starting source for the manufacturing of autologous cell therapies are mainly performed in hospitals or hospital-associated apheresis centers. we report about the challenges to perform the leukapheresis procedure (la) at a private held medical practice, with specific emphases on safety, cell collection efficiency, and cost-effectiveness. study design/method: we reviewed the records of altogether outpatients who underwent a total of la procedure at cyto-care, a private held medical practice/ certified cell collection facility located in vienna, austria. all patients participated in various industry-sponsored clinical p i-iii trials; the study sponsors were responsible for the manufacturing of the active cell product. disease entities were mainly prostatic cancer ( %) and ovarian cancer ( %). based on differences in the study protocols la was performed either one-time ( %), two-times ( %) or three-times ( %), with an interval of at least weeks between repeated collections. results/finding: all patients successfully completed the apheresis course. because of poor venous access, out of patients ( %) required a shortterm femoral catheter insertion. there were no serious side effects in patients who required a femoral catheter, or in patients with repeated la procedures. side effects of the la procedure mainly consisted on mild hypocalcaemia-related symptoms in % of patients. a follow-up survey one week after completion of the la revealed no infectious complications, and no patient required hospitalization. median cell yield collected per single apheresis was . x wbc consisting of . x mnc. mnc cell yields remained stable even in repeated la collections. all cell products were successful transformed into an active cellular product. analysis of the cost structure showed that the total cost of care was % lower in the setting of a private collection center compared to hospital-based apheresis centers. conclusion: leukapheresis performed in a private medical practice/ certified cell collection facility is safe and effective, with low rates of complications and high levels of patient satisfaction. this service model is costeffective and can help to reduce the cost of manufactured goods in the production of innovative cellular products. although typically associated with monoclonal gammopathies (e.g. waldenstrom's macroglobulinemia and multiple myeloma), hvs has rarely been reported in patients with disorders of immune system such as rheumatoid disease, sjogren's syndrome, hiv and igg -related diseases. therapeutic plasma exchange (tpe) is indicated in hvs due to monoclonal gammopathy (asfa category indication). however, there are limited data for the utility of tpe in hvs due to polyclonal gammopathy. study design/methods: a year old female patient with a medical history significant for seropositive erosive rheumatoid arthritis, hypertension, diabetes mellitus, cutaneous lupus and diffuse parenchymal lung disease, presented to our institution with complaints of progressive fatigue, muscle weakness, poor appetite, headache and epistaxis for a few months. fundoscopic examination showed dilated and tortuous vasculature as well as bilateral retinal hemorrhages (mixed flame-shaped and dot-blot patterns). pertinent laboratory findings included a positive anti-nuclear antibody screen with anti-histone antibodies and anti-ro antibodies. serum rheumatoid factor was markedly elevated to , iu/mls (ref. range < ) and anti-cyclic citrulline peptide antibody was elevated to , units (ref. range < ) . serum protein electrophoresis and immunofixation demonstrated a polyclonal hypergammaglobulinemia; protein precipitates were noted at the point of application, suggestive of circulating immune complexes. serum igg, igm and iga were , and mg/dl respectively. a cryoglobulin screen was negative. serum free kappa to lambda ratio was . . peripheral blood flow cytometry did not identify any monoclonal bcell population. plasma viscosity was noted to be . centipoise (cp) at admission (ref. range . - . ). pet-ct imaging was negative. the patient was treated with high dose steroids; a single tpe procedure was performed using the following parameters: volume treated - total plasma volume; replacement fluid - % albumin and normal saline in a : ratio; replacement fluid volume: % of the total volume processed. the procedure was tolerated without complication. results/findings: immediately post-tpe her plasma viscosity level dropped to . cp. serum igg, igm and iga levels decreased to , and mg/dl respectively. her rf had decreased to , iu/ml. the patient reported subjective improvement in strength. she subsequently received two infusions of rituximab separated by two weeks. her plasma viscosity has remained less than cp since tpe. conclusion: polycolonal gammomathy (e.g. secondary to ra) is a rare cause of hvs. tpe can provide transient relief of symptoms in unusual cases of hvs and may facilitate therapy to prevent recurrent hvs episodes. therapeutic plasma exchange in neuromyelitis optica spectrum disorders -experience from tertiary care centre in north india ratti ram sharma*, rekha hans, satya prakash, naveen sankhyan and neelam marwaha. postgraduate institute of medical education and research background/case studies: neuromyelitis optica spectrum disorder (nmosd) is an idiopathic inflammatory demyelinating disorder of central nervous system preferentially involving optic nerve and upper segments of the spinal cord leading to optic neuritis and myelitis. tpe is indicated in acute phase or as a maintenance therapy to treat or prevent relapses in chronic phase. study design/method: to assess the efficacy of plasma exchange in patients of nmosd not responding to high dose intravenous steroids. we did a retrospective review of tpe records for patients with nmosd over a period of three years (jan -dec ). tpe was done using, cobe spectra (terumo bct, lakewood co. usa), replacing one to one and half patient plasma volume with % human serum albumin or fresh frozen plasma on alternate days. the improvement in clinical signs and symptoms was recorded after each tpe procedure and at the end of the therapy. adverse reactions if any were also recorded results/finding: eleven patients of nmosd between to years age (m: f; : ) underwent tpe procedures with an average of . per patient. all the patients were on high dose immunosuppressant therapy without much clinical improvement. three ( %) patients had only visual symptoms, ( %) had both visual as well as muscular symptoms whereas ( %) patients had muscular symptoms only. three ( %) out of the seven tested, were positive for aqp -igg. all the patients showed significant improvement in their visual symptoms post exchange, from no vision/light perception to finger counting in two patients, recovery of colour vision and diplopia in six patients. post exchange recovery in the muscle power was observed in patients with grade- , in patient, and by grade- , in seven. adverse events were observed in % ( / ) of the procedures with allergic reactions to replacement fluid as most common event (n- ) followed by hypotension (n- ). follow up was available in % ( / ) of patients and are doing well on immunosuppressive therapy. one patient died due to respiratory failure after months and another had relapse for which he underwent second tpe cycle and continue to do well. conclusion: tpe is a safe and effective adjunct therapy to high dose immunosuppression in nmosd. trima accel software upgrade from . to . for platelet collections rachel m beck*, kimberly j duffy, sandra bryant, audrey e traun, mary m benike, james r stubbs and justin d kreuter. mayo clinic background/case studies: terumobct released trima accel software version . as an enhancement to allow for the collection of platelets (plt) with platelet additive solution (pas) and provide additional improvements to increase overall reliability. additionally, the manufacturer identified a slower centrifuge speed at low draw flow rates. this software was expected to function similarly to version . . the objective of this retrospective study is to identify any variances with the software upgrade influenced the plt products collection process or products collected. study design/methods: prior to / / , plt collections were performed on nine trima accel machines operating with version . . upgrading and validating all nine machines to version . occurred from / / to / / . the trimas were programmed with the same plt configurations both before and after software update. platelet collection data from version . ( / / to / / ) was compared to version . ( / / to / / ). incomplete collections, runs identified as having possible leukocyte contamination, duration of collection, and plt split rate were evaluated for each time period. generalized estimating equations (gee) were used to assess differences between plt collections with version . and . , adjusting for multiple visits per donor, with significance defined as p-value < . . results/findings: following the upgrade to version . , staff observed a number of changes including an increased centrifuge recovery time on a donor with a low flow and a notable increase in possible leukocyte contamination products. version . of the trima accel showed a statistically significant increase in possible leukocyte contamination from % to % of collections as compared with version . . both the duration of collections and the plt split rate remained constant even with centrifuge speed adjustments in version . . conclusion: due to fda limitations not allowing for the implementation of trima accel pas plts with the currently available pathogen reduction system, the institution decided to implement only the pathogen reduction system at this time. subsequently, the version . software is no longer required. with the noted slight increase in possible leukocyte contamination as well as the lack of enhancements for plt collection, the upgrade to version . currently does not provide added value over version . for plt collection. pulmonary and neurologic symptoms due to leukostasis. therapeutic leukocytaphersis (tl) is used as an adjuvant therapeutic modality in these patients with symptoms suggestive of leukostasis. tl procedures are performed using cell separators where anticoagulated blood is subjected to centrifugal force resulting in separate layers of cells and plasma depending on their density. there are two programs in the cell separator, a mononuclear (mnc)program which has greater centrifuge speed and efficiency for the collection of mncs and a polymorphonuclear (pmn)cell program with lower centrifuge speed for the collection of pmns. hydroxyethyl starch(hes) is preferred for the collections of granulocytes for transfusion from healthy donors. use of hes facilitates the sedimentation of the granulocyte layer and increases the efficiency of collection. though use of hes in tl was not associated with adverse events with its use as a volume expander (pagano) its use in tl varies and no reports are available on the efficiency of leukodepletion using hes for tl. study design/method: we received a request for leukoreduction in yearold lady with chronic myelogenous leukemia (cml) who had a good response to imatinib. she is weeks pregnant with an increased wbc count due to the discontinuation of imatinib. we performed tl with the cobe spectra using a replacement fluid of ml % albumin. wbc counts were monitored pre and post tl in the patient and in the collected product. we modified the collection based on these results using the mnc program with acd-a or the pmn program with acd-a . as leukodepetion was not adequate with these programs we elected to use hes after discussion with the patient and her physician. tl was performed using ml of hes with citrate and the pmn program. wbc pre procedure, immediate post procedure and the product was obtained and the efficiency of leukodepletion with the different programs was calculated. results/finding: the efficiency of % wbc depletion was calculated by product wbc to patient wbc based on blood volume and also pre to post wbc the patient tolerated the procedures well and there were no adverse reactions in the patient and in fetal monitoring during the procedures conclusion: therapeutic leukocytapheresis in cml patients is safe and more effective in reducing the wbc count with the use of ml of hydroxyethyl starch with anticoagulant. post procedure patient wbc counts sometimes may not provide the data on the efficiency of leucodepletion. background/case studies: early recognition of hypertriglyceridemia (htg) in the setting of acute pancreatitis (ap) is critical to initiate effective therapy. the role of plasmapheresis as an early/adjuvant approach in acute htg-induced pancreatitis is controversial. currently, there are no consensus guidelines in optimal therapy and is asfa category iii. reported here is a case where the tg level as well as clinical symptoms improved after one therapeutic plasma exchange (tpe). study design/method: a years old male with history of hypertension, htg, and diabetes mellitus (dm) presented to our emergency department with excruciating abdominal pain. the patient was diagnosed with htg at years old. he was treated initially with diet and lifestyle modification. however, his clinical course has been compromised after developing pancreatitis with acute episodes requiring prolong hospital admission of approximately months each which were successfully treated medically. however, the recurrent episodes resulted in chronic pancreatitis which was complicated with pancreatic pseudocyst and pancreatic insufficiency. since the first episode of pancreatitis, he was then medically managed with fenofibrate, lovaza, lisinopril, levemir and novolog. during evaluation on current admission, he was found to have a tg level of mg/dl, lipase u/l, glucose mg/dl, bicarbonate mmol/l, anion gap . ct findings were consistent with ap without evidence of necrosis and stable pancreatic pseudocyst. medical therapy was started with omega fatty acid, fibrate, statin, hydration as well as pain control. statin therapy was suspended on day of hospitalization, because he was noted to have elevated liver function tests (lft) and tpe was requested and started on day after admission. results/finding: the patient tg decreased by % ( mg/dl) with medical therapy, followed by additional % ( mg/dl) after one volume of tpe. his symptoms significantly improved and was discharged with medical treatment on day after admission. compared to previous episodes, his hospital stay was significantly decreased. tg levels remained below mg/dl at days follow up after discharge. conclusion: early tpe may be of value in treating patients with elevated tg associated with recurrent pancreatitis. plasmapheresis might be an effective early adjuvant therapy to mitigate length of hospital stay, improve cost-effectiveness and patient safety. background/case studies: from to , a national blood donor center in southeast asia conducted a program to monitor the ferritin levels of platelet blood donors. the aim of this study was to explore the trend of changes in ferritin. study design/method: in this study, we collected , cases whose ferritin levels have been monitored more than twice with an interval of detection in - days. the collected plasma samples were tested for ferritin by chemiluminescence using a commercial assay. inclusion criteria included apheresis platelet blood donors with over two results of ferritin, and first time ferritin test result was over lg/l. and the upper limit was set to be lg/ l in male and lg/l in female as described in manufactures insert. the impact on ferritin from gender, age, and the blood donation frequency were examined with anova test. the blood donations frequency was categorized into five groups: times, to times, to times, to times and more than times. the high frequency (more than times group) blood donors were analyzed ferritin changes in longitudinal data. results/finding: there were , donors included in the study, of which , were male ( . %) and were female ( . %). the mean ferritin was . lg/l in male ( % ci: . - . lg/l) and . lg/l in female ( % ci: . - . lg/l). the result of anova indicates that the group with the highest frequency (more than times) has the significant lowest ferritin level (p< . ). the average change of ferritin if donation over times would up to . and . lg/l in younger and elder y/o male and and lg/l in female. and then for high frequency (half a year more than times the group of blood donors) for longitudinal analysis and found that the long-term sustained high frequency of blood donation caused a significant decline in ferritin. the average change about ferritin in high frequencies donors (over times in $ days) was reduced from . lg/l in the first period to . lg/l in the third period ( period $ days). along with the more and more period, the decline of ferritin decreased. conclusion: this analysis revealed that frequent apheresis platelet donation would decrease ferritin of donors. but the high frequency of platelet blood donors who continue to donate after a year, the decline of ferritin slowed down. a rare case of blood donation precipitating acute delirium joseph griggs* , mary townsend and lizabeth rosenbaum . university of new mexico hospital, blood systems, inc., blood systems inc. background/case studies: we report a case of whole blood (wb) donation that precipitated a transient agitated delirium. a year-old first time male donor presented to the local blood center, completed the donor health questionnaire, mini-physical exam, and hemoglobin check, and was deemed eligible for blood donation. approximately minutes after an uncomplicated wb donation, the donor had an observed, brief loss of consciousness in the post-donation area. no fall or injury was seen. shortly after regaining consciousness, the donor became agitated, confused, and was not oriented to month or year; was unable to remember the names of friends and family members; was unable to read an analog clock; and had difficulty with word finding. the donor was transported to the local university hospital where he was noted to be combatively delirious and had altered mental status; he had to be forcibly restrained. he ultimately was sedated and intubated, and transferred to the intensive care unit. study design/method: an extensive laboratory investigation was performed including standard hematologic and chemistry panels; serologic and pcr-based studies for multiple organisms including west nile, herpes, hiv, varicella zoster, and syphilis; aerobic and anaerobic blood cultures; and a urine drug screen for multiple drugs of abuse. radiographic imaging was performed including a chest x-ray, and a ct and mri of head and spine. in addition, an eeg was performed. the inpatient neurology and psychiatry services were consulted for this patient. results/finding: after the sedation was discontinued, the patient was successfully extubated and rapidly improved. he completely returned to baseline within hours of onset of the event. laboratory investigation revealed no signs of infectious organisms or evidence of drugs of abuse. radiographic imaging and eeg studies showed no abnormalities. in addition, infectious disease marker testing performed by the blood center laboratory was negative. investigation revealed that the donor was experiencing high levels of stress at school, had an aversion to the sight of blood, and was coerced into donating by his girlfriend and peers. a week following hospital discharge, the blood center medical director contacted the donor by phone; the donor had resumed his normal routine and was attending his graduate level classes. conclusion: to our knowledge, this is the first report of blood donation precipitating a transient acute delirium. at the time of donation, the health status of all potential blood donors is assessed to help ensure the safety of the donor and the recipient. the health questionnaire, physical exam, vital signs, hemoglobin level, and infectious disease testing help to identify overt signs of medical illness that may disqualify a donor. however, routine donor screening does not explicitly evaluate mental health issues, both diagnosed and undiagnosed. although exceedingly rare, this case highlights the limitations of donor screening to identify donors who may be at risk for mental health adverse reactions when donating blood. a targeted approach to increasing the african american blood donor pool arnethea sutton* , william korzun , teresa nadder , susan roseff and elizabeth ripley . virginia commonwealth university, virginia commonwealth university medical center background/case studies: a continuous need for blood products for those who require frequent transfusions, such as individuals with sickle cell disease who could benefit from products collected from african american donors, warrants the need for targeted interventions to increase blood donations from underrepresented populations. one population in particular, african americans, only account for % of blood donors in the united states. literature indicates numerous reasons why this population is underrepresented amongst donors, including fear, lack of knowledge about the blood donation, and specific to this population, lack of trust in the medical community. study design/method: african americans in richmond and norfolk, virginia were recruited through churches and local universities. the study's aims were to develop, implement, and assess a targeted educational approach incorporating the theory of planned behavior and various teaching methods, to develop and implement a survey to evaluate participants' feelings, attitudes, and intent to donate, and to motivate african americans non-donors to attempt to donate blood. participants attended a -hour educational session where they were educated on the importance of red blood cell donations from african americans. participants completed three surveys -one before the session, one directly after the session and one, two months after the session. a two-proportion z-test was used to compare the known proportion of african americans who present to donate in the study areas to those who presented to donate in this study, while regression analysis was used to estimate the relationships among survey variables. results/finding: a total of subjects were included in the data analysis. sixteen percent of the study participants presented to donate as a result of attending the educational session. this resulted in a statistically significantly higher proportion of african americans presenting to donate than the current proportion in the areas of the state where this study was conducted. results from the first two surveys indicated that subjective norm and attitude were significant predictors of one's intent to donate blood, while perceived behavioral control was not a factor. the educational session increased survey scores related to intent to donate in comparison to scores obtained prior to the session. conclusion: this study shows that a targeted educational program can change attitudes toward blood donations in african americans resulting in an increase in new blood donors. additional studies are needed to see if this behavior will continue and whether african americans can influence their community to increase awareness and motivation for life-long blood donation. were from female basic trainees conclusion: the significant increase in hemoglobin deferrals at basic training site a from to could be a result of a change in the blood drive timing of the training schedule of that location. in , basic trainees at site a were scheduled at day of . in january , the blood drive date changed to day of . the extra three days in the basic training atmosphere, and its associated diet changes and increased physical activity may have had an effect on the hemoglobin levels in that population. at basic training site b, the significant increase from to of hemoglobin deferrals can be attributed to a larger male population presenting at this site for basic training. additionally, the percentage of female recruits donating at the blood drives decreased in . these observations support the hypothesis that the increase in hemoglobin deferrals in resulted from the implementation of the male hemoglobin standard change from . to . g/dl at basic training site b. when planning for blood drives at basic training site b, screening of an additional % of recruits must be considered when performing these blood drives, in order to meet the same collection goals set prior the implementation of the change in the male hemoglobin standard. blood donation in the donor with spinal cord injury joan-ramon grífols* , eva alonso , oscar bascuñana , monica romero , teresa vich , elena castaño , laura carbonell , eva palomas , saray almerge , francesc carpio and xavier curia . banc de sang i teixits, institut guttmann background/case studies: donation of blood components (bc) in donors with spinal cord injuries (sci) is poorly studied. paralysis is a state, not a disease, after a reasonable time since its acquisition these people should not be differentiated from the rest of the non-paralytic population in terms of bc donation. the literature reviews of blood donation suitability criteria among these people are scarce and the vegetative lability that they may present depending on the type of their sci it's obvious. in daily practice these potential donors are often rejected for donation with no specific criteria related to their sci. the objectives of this study are to establish the selection criteria for bc donation in people with sci based on medical criteria. to evaluate the rate of adverse donation blood reactions of these donors against a donor control group without sci. study design/method: our organization regularly organizes a donation campaign at a rehabilitation center for patients with sci. in this campaign some donors with sci as donors without (professionals of the center, relatives, etc.) donate blood. from january to december we analyzed the number of donors who came to give blood, the number and reasons for exclusion of those who could not make the donation, whether or not they had sci and number and typology of adverse reactions to the donation detected in both groups. donors with sci higher than t due to the high risk of autonomic dysreflexia were excluded for donation. donors with sci below t and less than one year of evolution were set as temporary exclusion criteria. the presence of neurogenic bladder was not considered a reason for exclusion. results/finding: in the analyzed period, donors came to give blood, of these, ( %) were excluded for donation for various reasons. two of the donors excluded suffered sci higher than t excluding them due their high risk of dysreflexia. another one donor excluded suffered sci lower than t but his hemoglobin levels were lower than our selection criteria. of the donors selected for donation ( . %) had sci lower than t and t . adverse reactions to donation ( . %) were recorded in our haemovigilance program, none of them in donors with sci. conclusion: according to our experience donors with sci lower than t have not had any type of adverse reaction to the blood donation. there should be selection / exclusion criteria based on the donor's paralytic conditions. the vagal syndrome that could appear as a complication to the donation in these sci donors should be approached differently to the usual protocols that we use. blood donor center's experience with changing from manual to automated blood pressures kimberly j duffy*, sandra bryant, audrey e traun, kristine i borth, mary m benike, james r stubbs and justin d kreuter. mayo clinic background/case studies: blood pressure (bp) is important for determining the health and suitability of blood donors. the manual method of reading bp can result in variability due to minor variances in the way staff perform the manual procedure. automated bp devices are able to reduce the variability in bp determination. in december of , automated bp devices were validated and replaced the manual bp method in our blood donor center. the objective of this retrospective study is to determine if the change from a manual to an automated bp process has impacted the average systolic and diastolic pressures and, additionally, if a differences in the deferral and reaction rate can be observed. study design/methods: data for the manual bp process was accumulated for an month period from january to november . the same information was assembled for the automated bp process for the month period of january to november . the automated bp process implemented in mid-december ; so the december data for both and has been excluded from the study. bp, bp deferrals, reactions, donor weights and demographics were evaluated for each time period. a donor may be included multiple times in each year and could be in both sets of data. generalized estimating equations were used to assess differences between automated and manual bp with significance defined as p < . . results/findings: significantly more people were deferred using automated bp compared to manual bp readings (p . ). both systolic and diastolic bp measured significantly higher by automated bp method than by manual method. although donors in the automated bp group experienced fewer reactions than those in the manual bp group, the reduction was not large enough to reach statistical significance. even after adjusting for gender, weight and age at donation, bp deferrals, systolic and diastolic bps all remained significantly higher (all p < . ) with the automated bp while and reactions remained non-significantly lower (p . ). conclusion: automated bp devices have improved convenience for both staff and donors. with a statistically significant increase in deferrals and marginal decrease in reactions, the use of automated bp devices may play a minor role in the safety of blood donors. for the purpose of this study, only the hemoglobin values that were below . g/dl will be compared as a surrogate for deferral. to adjust for multiple visits per donor, generalized estimating equations were used to assess significance between lancet a and lancet b, using the appropriate distribution for the data type, defining statistical significance as p-value < . . results/findings: the average hgb was slightly lower with lancet b but there was a larger change with the number of donors under . . statistically more visits with hgb less than . g/dl used lancet b than lancet a. additionally, fewer first time donors were seen during the lancet b time than during the lancet a time. after adjusting for the effects of both gender and first-time donation by using logistic regression, the risk of hgb under . was . % higher with lancet b than with lancet a. conclusion: donor's hgb was slightly lower with lancet b than lancet a, but not clinically different. slightly more lancet bs were used per visit than lancet as. in addition, more hgb deferrals were obtained using lancet b than lancet a. even after adjusting for the effects of gender and repeat donors, we saw more potential deferrals with lancet b than lancet a. the slight difference in the gauge of the lancet may have some association to free-flowing amount of blood and may affect hgb levels. prior to implementing materials at a lower cost, an evaluation of downstream consequences would be recommended. blood donors' acceptance and response towards implementation of automatic appointment booking yi lin ang*, ching lian toh and william choon hong sim. health science authority background/case studies: with surges in demand for blood due to an aging population and more hospitals being built, it is becoming increasingly important to be able to ensure that donors return on a regular basis to improve blood supply and blood stock management. disliking the obligation imposed by appointments, singaporean donors generally prefer "walk-ins" as opposed to appointment bookings. blood services group (bsg) singapore, has made a move to change donors' mindset by introducing automatic appointment scheduling. this paper aims to study donors' level of acceptance towards this initiative. study design/method: to determine the donors' acceptance rate, data was collected from january to march . after completing their donation, donors were automatically given the next earliest eligible date for their next donation. those who do not wish to accept the recommended appointment can either decline this arrangement or log into the blood bank's donor appointment booking system (donor-care) to make changes to the appointment offered. a reminder will be sent to their phone via sms and/or email to their account three days before the appointment date. data was collected from donor-care and was used to measure the number of appointments made and declined over the three months period. donors who declined appointment scheduling were verbally interviewed for their reasons. results/finding: a total of donors who has donated blood in the blood bank's main branch were used as the baseline for this study. % of donors (n ) accepted automatic appointment booking, whereas some donors (n ) were not comfortable with it. % of those who declined still preferred walk-ins (n ) based on their own time schedule, the rest decided that variable situations (n ), donation frequency (n ) and choice of preferred donation locations (n ) were reasons for declining automatic appointment booking. prior implementation of appointment booking at other blood bank branches showed that donors who booked appointment through donor-care was %. a comparison was made and found that this study shown a significant increase of acceptance rate by %. conclusion: generally, the results were positive and the automatic appointment booking system enabled bsg to predict donor attendance, ensure better manpower management to reduce donor turnaround time and thus hopefully improve donor retention. bsg is still monitoring this automatic appointment system and future study are still required to determine the effectiveness of automatic appointment booking, donor return and retention rate. currently bsg has collection centers, each managing its own appointment system. the eventual aim is to be able to have a centralized appointment booking system whereby donors can book appointments and still be able to donate at any collection site. ) , . . poisson distribution, normal distribution, logistic distribution, lognormal distribution a transfusion (p> . ) in donor and reference populations except in younger ( - yrs) male donors (p< . ; donor . %, reference . %). mean donor sbp, dbp, and pulse were . mmhg, . . mmhg, and . . bpm, respectively. screening blood pressure levels consistent with hypertension ( . % male; . % female) in the - year donor group, significantly (p< . ) higher than the reference population ( . % male; . % female). no differences were observed in the - year groups. conclusion: normal source donor demographic and physiologic characteristics often paralleled those of the reference usa populations. however there were differences including lower cholesterol levels and a higher rate of high blood pressure in younger donors and higher weights in - year old females. developing blood donor educational materials gay wehrli* , susan rossmann , louis m. katz and dan a waxman . university of virginia health system, gulf coast regional blood center -sugar land, americas blood centers, indiana blood center background/case studies: donors must have sufficient information to make a decision, time to consider options before making a decision and an opportunity to make a choice of whether to proceed with or decline donating. donor education (de) materials must address mandates set forth by regulatory agencies. these materials must be accessible and understandable by the general population. the goal of this non-experimental, qualitative design study was to evaluate knowledge acquired through standardized de materials. this study was irb approved as an exempt protocol. study design/method: we developed a de document written at an th grade comprehension level. a convenience sample of volunteers was identified for this two-part study. a focus group (fg) incorporated a pre-and post-quiz for knowledge acquisition from reading the four-page de document. the quiz was followed by a group discussion for feedback. the preand post-quiz contained the same multiple choice questions with single best answers including the option to answer, "i don't know." the de document was revised based upon the fg feedback and quiz results. the revised, . page, de document was then tested using the same pre-and post-quiz during individual interviews (ii). results/finding: demographics and quiz results are summarized in table . results from the fg and ii revealed a lack of knowledge in four areas: a donor might be asked not to donate at any time during the donation process, the need for photo identification to donate, iron helps increase a low red blood cell level, and not to donate for the sole purpose to obtain hiv testing. post-quizzes from the ii group revealed an improvement in knowledge acquisition for all four areas. feedback from both groups reiterated that the document was too long. conclusion: developing de materials requires a complicated balance of providing critical information, concisely and at an appropriate comprehension level ( th grade). testing de materials is an essential step in the development process to ensure the intended knowledge is acquired by the end user population. the next steps for this group will be to pilot the further revised, two-page de document at donation sites. effect analysis of the 'rh(-) blood supply program' establishment hyesung han*, deokja oh, buja hur and chulyong kim. korean red cross blood services background/case studies: the rh(-) blood supply program was developed in for the purpose of prompt and stable blood supply. based on the computerized system, the program operates the emergency contact/ communication. this program has major functions such as the request of the emergency blood, the recruitment and management of the rh(-) blood donors for the emergency blood donation, real-time blood supply status monitoring program and statistics program. the aim of the research is to validate the effect of rh(-) blood supply program operations and the responsiveness of the emergency blood supply under the rh(-) blood supply program. study design/method: researchers investigated the database from to after the rh(-) blood supply program was developed. investigators analyzed and compared the recruitment and blood donation of the rh(-) blood donors for the emergency blood donation and securing the blood supply upon request. results/finding: the data shows that the number of voluntary blood donors who pledge to give blood for the emergency blood donation has increased from . % to . % in and , respectively. also, the actual participation rate of rh(-) blood donations among the group who pledge to give blood for the emergency blood donation has increased from . % in to % in . moreover, the data has indicated that the blood supply has fully met the demand for the emergency blood request. conclusion: the result showed that the rh(-) blood supply program was effective for the recruitment/management of the rh(-) blood donors for the emergency blood donation. this system contributes to recruiting and managing rh(-) blood donors who pledge to donate blood and securing rh(-) blood in emergency situation . the institution that needs to meet the demand of rare blood type could possibly use the rh(-) blood supply program which leads to securing special type blood. hanwei chen*. wuhan blood center background/case studies: in china, volunteer blood donors can donate platelets by apheresis (ap) up to times per year. however, the awareness and knowledge of ap donation is much lower than whole blood donation among the chinese population. there are approximately . million doses of ap transfused within . billion people each year in china; it is one challenge to recruit new ap donors and retention them as frequency ap donors in china. study design/method: one stratified recruitment and retention strategy established and applicate at wuhan blood center since . firstly, "one-to-one" telephoning model for whole blood donors instead to donate platelet; secondly, group message for permanent ap donors and had not donated with an interval of more than days in low inventory. thirdly, specific recruiter telephone for those ap donors who had donated aps for more than times and had not donated for more than days or less than times with an interval of more than days from the last donation; the last one is preparing one letter of thanks for those ap donors who gave more than times annually which advise them to voluntarily come to the blood center for ap donation when they were available. results/finding: over the past decade, the overall donation time of ap donors increased by . times from to and the doses of ap increased by . times from to within years. the aps collected fulfilled the clinical needs. according to the donation frequency, ap donors were divided into groups: those who donated ap once, those who donated - times, - times, - times, and those who donated more than times, respectively. it was found that the number of permanent ap donors who donated ap more than times was only ( . %), but they denoted a total of doses of ap ( . %) from to . conclusion: aps increased at a rapid and steady pace in wuhan blood center from to , which not only met the clinical needs but also were supplied to other region outside wuhan. and in addition, the permanent ap donors who gained more attention donated the greatest percentage of platelets. in conclusion, stratified recruitment is one effective approaches to meet clinical needs for platelets and worth to popularize to other region. years were evaluated at sites on consecutive donations for finger stick (fs) hemoglobin (hb) per site policy. venous (ven) and capillary (cap) zpp and ven ferritin (fer) were performed per manufacturers' direction. donors were assessed for subclinical iron deficiency using ranges (fer < ng/ml and zpp levels > umol/mol heme) at hb levels. participants completed an online survey between donations to collect data on symptoms of anemia. univariate linear regression analysis was used to determine relationship between tests. results/finding: subclinical iron deficiency was present among first-time and repeat blood donors at all hb levels with both genders and all age groups. (table) there was a highly significant correlation between fs zpp and ven zpp . % (r . ) at first and . % (r . ) at second donations. at first donation when compared to fs hb, only . % (r . ) of variation could be explained by variation in fs zpp, . % (r . ) by ven zpp and . % (r . ) by ven fer. at second donation, when compared to fs hb, only % (r . ) of variation could be explained by variation in fs zpp, . % (r . ) by ven zpp and . % (r . ) by ven fer. for each donation, variation among tests (fs hb, ven fer, ven zpp and fs zpp) was significant (p< . ) suggesting strong evidence against correlation. % ( ) responded to the survey of which % ( ) reported not feeling well after donation. it should be noted that noted that % ( ) female study participants reported feeling unwell after the first donation and had ferritin levels below ng/ml but the zpp levels were less than umol/mol heme. of the % ( ) male participants that reported not feeling well none had ferritin levels below ng/ml nor ven or fs zpp levels above umol/mol heme. conclusion: subclinical iron deficiency was present at all hemoglobin levels. there was insufficient correlation with fs hb and ven fer to support use of fs or ven zpp analysis as measurement of iron stores for blood donors. symptoms reported by study participants were not consistent with laboratory results. the minimum male hb was raised from . to . gm/dl. fda imposed specific vs ranges for acceptable pulse (p) and blood pressure (bp), removing center-by-center discretion. a survey of members of america's blood centers (abc) was performed to assess the impact on donor deferrals resulting from these changes. study design/method: online survey software (surveygizmo, boulder, co) was used to solicit collections and deferral information from blood centers over two intervals, july-dec. and july-dec. (i.e., before and after the implementation deadline for the final rule respectively). information on deferral at presentations for whole blood (wb) donations and apheresis platelet (ap) donations was requested for hb thresholds and vs. the information was stratified by gender (male m, female f), and abo type. statistical analysis included t-tests for numerical and chi-square for categorical data (minitab . , chicago il). p <. was considered significant. results/findings: data were provided by of centers invited, representing , , and , , wb donations and , and , ap donations in aggregate during the two intervals respectively. gender and abo distributions appeared representative of the us donor base. among m wb donors the rate of deferral rose from . % to . % in the two intervals among aggregated donation attempts (p<. ), and for m ap from . to . % (p<. ). the mean "by center" deferral rates (table) were similar to that and significant (p<. ). mean by center hb deferral rates among f donations during the two intervals were . and . % (p . ) for wb, . and . % (p . ) for ap, respectively, absent any change in their acceptable hb thresholds. data on vs deferrals were much sparser. for p deferrals, only centers could provide specific high vs. low vs. irregular pulse deferrals; provided only a summary (i.e total pulse deferrals), and could provide none. for bp, provided detail (high vs. low), summary and none. p deferrals increased in the successive intervals among f wb donors from a center mean of . to . % (p . ) and for m wb donors from . to . % (p . ). where details were available, high and irregular pulses were responsible for most of the changes for both genders. bp deferrals were not significantly increased among wb donors, regardless of gender. the data sets and deferral rates re: vs in ap donors were quite small, possibly reflecting culling during their prior donation experience. conclusion: substantial additional donor deferrals attended the increased hb thresholds for m in the final rule, for both wb and ap. changes were more modest among female donors, consistent with the absence of changes in allowable hb levels. modest but significant changes attended more stringent requirements for vs, though data limitations restrict this aspect of the analysis. background/case studies: diabetes mellitus is reaching potentially epidemic proportions in india. given the disease is now highly visible across all sections of society within india, there is now the demand for screening of diabetes and urgent research and intervention -at regional and national levels -to try to mitigate the potentially catastrophic increase in diabetes that is predicted for the upcoming years. due to its ease of use, several studies have found that hba c testing can identify patients in the community who might otherwise go undiagnosed. we took an initiative to find out the incidence of diabetes by random blood sugar (rbs) measurement among indian blood donors and measure the hba c levels among those with rbs > mg/dl study design/methods: a prospective study was done at department of transfusion medicine and department of biochemistry from st march to st march . total of , blood donors were tested for rbs. those with rbs > mg/dl were further tested for hba c by gold standard hplc method using variant ii biorad. blood donors with > mg/dl rbs and hba c > . % were advised to consult a physician for further evaluation. results/findings: of the , donors tested, ( . %) donors showed a rbs of > mg/dl. forty two ( . %) were males and ( . %) females with a mean age of . years ( - years). of these, ( . %) were known case of type-ii diabetes mellitus (dm) on oral medications and were excluded. of the remaining , ( . %) of them had a family history of dm. of these donors, donors did not give a consent for testing for hba c. among the donors tested for hba c levels, ( . %) had hba c > . %. all the donors were counselled and referred to a physician for further management. the overall incidence of donors having dm in the population is . % ( of donors). conclusion: screening for blood glucose level by targeting the blood donors can go a long way in curbing the diabetes burden on the society. incidence of low ferritin levels in regular male blood donors with acceptable hemoglobin levels in singapore ramir alcantara* , hwee huang tan and ai leen ang . health sciences authority blood services group, health sciences authority, blood services group background/case studies: iron deficiency is a known complication of regular blood donation. in order to protect the donor's health and prevent iron deficiency, aabb increased the minimum acceptable hemoglobin level for male whole blood and apheresis donors from . to . g/dl last may . the current minimum acceptable hemoglobin for male donors in singapore is . g/dl. the aim of the study is to determine the incidence of low ferritin levels in regular whole blood and apheresis male blood donors with acceptable borderline hemoglobin levels ( . - . ) and in donors with hemoglobin g/dl and above. study design/method: during a month period, serum ferritin testing was performed on regular male whole blood and regular male apheresis donors who made at least donations in the last two years with an acceptable hemoglobin level. the donors were divided into groups according to donation type and hemoglobin range; group a (whole blood with hemoglobin . - . ) group b (whole blood with hemoglobin ! , group c (apheresis with hemoglobin . - . ) and group d (apheresis with hemoglobin ! ). the serum ferritin levels of the four donor groups were compared and analyzed. a ferritin level below ug/l is considered low and levels below < ug/l are considered having absent iron stores. results/findings: . % of donors in the study have ferritin levels below ug/l. there were more donors with low ferritin in group a compared to group b, % and % respectively (p< . ). in apheresis donors, low ferritin rates were higher in group c donors compared with group d, % and % respectively (p . ). ferritin results for the groups can be seen in table . conclusion: more than half of the donors in the study have low ferritin and of the donors with low ferritin, more than half or . % have absent iron stores. donors with low ferritin were immediately informed of their result, given iron supplements and advised to come back for donation after months or more. since donor health and safety is of paramount importance, measures to limit and prevent iron deficiency in blood donors must be implemented. due to the high incidence of low ferritin levels in whole blood and apheresis donors with hemoglobin . - . g/dl, it is recommended that the minimum hemoglobin level cut off for male blood donors in singapore be increased to . g/dl. other measures to be implemented includes better donor education on the risk of iron deficiency and the need for iron supplementation using our website and social media. background/case studies: safe blood is a crucial and irreplaceable component in the medical management of many diseases. the voluntary nonremunerated blood donation is the ideal sources of quality blood, which forms less than % of the demand of the blood in pakistan. motivation among the youth, particularly students, is essential to make voluntary blood movement more successful. to assess the knowledge, attitude and practice regarding the voluntary blood donation among the young student population of karachi so that an effective approach can be made regarding motivation enrolment of voluntary non remunerated blood donors in future in pakistan study design/method: a cross sectional prospective study was conducted among students from different universities and colleges of karachi. a well-structured and pre-tested questionnaire, in english, was used to access the knowledge, attitudes and practices about voluntary blood donation. a scoring mechanism was used to understand overall knowledge level. obtained data was analyzed. results/finding: the sample population consisted of % male and % female students in the age group of - years. only % of the students have heard about voluntary blood donation and % of the students have given blood once in their lifetime and among them % are blood donors at the moment. % of the participants believed that there is a specific reason why they don't donate blood and % believed that there is a risk involved for the donors, when donating blood. % students wanted to promote voluntary blood donation. fear and lack of awareness on blood donation are the reasons for not donating blood. students gather information about voluntary blood donation from several sources mostly schools, colleges, family and friends. ( ); miscellaneous effects were reported in courses. side effects led to interruption of supplementation in instances. ferritin levels (mgt sd) at entry into the program and at the last visit were . and . . mg/l in participants, vs . . and . . mg/l in controls. the positive impact of iron supplementation on ferritin levels was observed only in those who took ! % of the tablets. ferritin levels< mg/l were found in , % of participants and . % of controls. deferral for low hemoglobin was below % in both groups. conclusion: an iron supplementation program in a drbcd program is feasible.however, when taking into account acceptance to participate and compliance with supplementation, only % of donors obtain full benefit from such a program. using an iron preparation which is better tolerated may increase compliance. background/case studies: hereditary hemochromatosis (hh) patients are permitted to donate blood for the allogeneic blood supply as long as they are eligible for donation under cfr . and the collection is a physician-ordered therapeutic phlebotomy. blood collections establishments do not need an exception or alternative under § . to make a collection under this provision if the requirements set forth in § . (a)( ) are met. the objective is to describe current hh donors and long-term contributions of to our hospital-based donor center and hospital blood supply. study design/method: in , an irb protocol was approved for the enrollment and therapeutic phlebotomy of hh patients/subjects. this required filing an fda variance to permit hh donor blood for use in our allogeneic supply without disease labeling. the frequency of therapeutic bleeds are guided by routine clinical assessment, mcv/hemoglobin, serum ferritin, and transferrin % saturation monitoring. serum ferritin levels of - ng/ ml are targeted for maintenance phlebotomy. operationally, a custom, computerized database application is employed to ease phlebotomy management. results/finding: since inception, the cumulative number of hh subjects enrolled in the hemochromatosis protocol reached , of whom ( %) are c y homozygotes. without active recruitment, accrual rate is about per quarter, with % of subjects qualifying as allogeneic donors. the mean current age is . years, % male, % caucasian. the majority of hh donors ( of an active cohort of ) are in the maintenance phase of therapy with an average of . donations/year and a % deferral rate. over the last years, hh donors contributed approximately - % of the hospital's allogeneic blood supply, averaging whole blood units for transfusion per year. moreover, hh donor's whole blood (wb) donations provided - % of blood for in vitro research at our institution with an average of wb research donations/year. there have been no hh donor-derived transfusion-transmitted infections over years. since / / , with an increase in male hgb deferral threshold to g/dl, there has been only hh male deferral from blood donation. conclusion: a simple, safe system for donor evaluation, phlebotomy management, and transfusion of blood drawn from hh subjects was established. blood donated by hh donors remains an important resource at our hospital. hh donors benefit from careful medical follow-up of their iron status. this mutually beneficial relationship is feasible and sustainable. testing for accuracy of non-invasive blood hemoglobin methodology in a blood donor setting michele walker*, sharon garcia and mythili ram. gulf coast regional blood center background/case studies: the objective of the study was to assess the accuracy of hemoglobin (hb) levels measured on the orsense nbm- non-invasive occlusion spectroscopy device by comparing them to hb levels measured on venous samples with a laboratory hematology analyzer. in addition, the study examined operator ease of use and donor satisfaction with a finger stick-free method. study design/method: study procedures and protocol, including acceptance criteria, were defined in conjunction with the device manufacturer to determine the standard deviation (sd) of the difference between the nbm- non-invasive sample results and the sysmex hematology analyzer venous sample results. staff were provided training on the use of the nbm- non-invasive occlusion spectroscopy device. over a span of days, eligible blood donors, both male and female, were first screened by the nbm- non-invasive occlusion spectroscopy device followed by performance testing utilizing a capillary blood screening method. a venous sample was collected from each of the blood donors for the performance of hb measurement on the sysmex hematology analyzer within - hours of collecting the venous samples. results/finding: the sd of the difference between the nbm- non-invasive sample results and the sysmex hematology analyzer venous sample results was not to exceed . g/dl. the hb measurements obtained from the nbm- and the sysmex hematology analyzer were analyzed using the statistical software minitab and the sd of the difference was reported to be . g/dl. the precision of the nbm- yielded a co-efficient of variation of . g/dl and a standard deviation of . g/dl. conclusion: the operators found the nbm- easy to install, maintain, and operate with minimal training. the nbm- non-invasive occlusion spectroscopy technology showed accurate performance compared with the venous sample results. it was comparable to the capillary finger stick method and deemed suitable for screening donors. donors were satisfied with the process and appreciated the safe, painless methodology. ronel swanevelder , ravi reddy , dhuly chowdhury , don brambilla and edward l. murphy* . sanbs, rti international, ucsf/bsri background/case studies: to maintain an adequate blood supply, south african blood centers need to collect more blood from their majority black african population. success in recruiting first-time black blood donors has been tempered by lower suboptimal return rates. study design/method: we performed a prospective cohort study of firsttime, black blood donors donating during a four-month period in and followed them for one year. within days post donation, a questionnaire including questions on blood donation motivators and deterrents was administered by telephone. questions used -point likert scales to assess agreement with statements relating to domains of altruism, collectivism, selfesteem and marketing derived from local focus groups (muthivhi et al. ) . linking questionnaires to a blood donation database allowed logistic regression analysis to predict return for a second donation within one year. results/finding: we included , first-time black donors with median age and female predominance ( %). within one year, , donors ( %) attempted at least one additional donation. when likert scales were analyzed as an ordinal variable ( strongly agree to strongly disagree), donor return was associated with the following motivators "blood donation is an easy way to make a difference" (odds ratio for each likert increment (or) . , % ci . - . ), "i donated in response to adverts/campaigns on the radio, tv or newspapers" (or . , % ci . - . ). responses to altruism-associated statements were not associated with return. among deterrents, donors were less likely to donate if they agreed with the statement "i am afraid of the sight of blood" (or . , % ci . - . ) and "i wasn't treated well by the <blood center> staff" (or . , % ci . - . ). surprisingly, donors were more likely to return if they agreed with the statement "i was afraid of finding out about my hiv status" (or . , % ci . - . ). a secondary analysis treating the likert scales as -level categorical variables revealed generally similar results, with the additional finding that donors who disagreed with the statements "if i give blood then blood will be available when i need it" and "i don't know where the nearest blood collection point is" were more likely to return. conclusion: this novel design allowed us to study the link between donation motivators and deterrents and actual rather than intended return for donation. it is interesting that self-esteem and marketing predicted return better than altruism. fear and poor customer experience are recognized deterrents which could be addressed. we plan to use these data to construct black donor recruitment interventions which may be tested using randomized trial designs. willingness to donate blood during the summer christopher d bernard , ramya ghantasala , obhijit d hazarika , nicole leonard , cori a polonski , zachary b wunrow , michelle heleba , jan k carney and mark k fung* . university of vermont larner college of medicine, american red cross blood services background/case studies: each year donation rates fall in the summer months straining blood banks' capacities to meet local demands. in hopes of identifying factors to increase summer donations, our study investigated donor reported barriers which influence summer donations habits. study design/method: an anonymous question survey investigating various donation factors was administered across multiple blood donor centers in a state-wide region. questions addressed donor demographics, frequency of blood donation, preference in appointment making modalities including smartphone app use, summer travel habits, willingness to donate during vacation, and factors that deter donors from donating on vacation. results/finding: a total of surveys were received. survey respondents across multiple demographic groups cited similar barriers to summer donation, namely "too busy" ( . %) and "traveling is a time for me to relax." ( . %). of the respondents who travel in the summer, very few reported donating while traveling ( . %). summer donation rates between summertime travelers ( . %) and non-travelers ( . %) were essentially equivalent. the most preferred methods of scheduling appointments were via the regional blood donor center website ( . %) and phone ( . %). willingness to use a regional blood donation smartphone app was highest among respondents ages of to ( - %) and lowest among ages and older ( - %). of respondents with no prior knowledge of summer seasonal shortages ( %), / rds indicated newfound motivation to donate. background/case studies: viral infections (adenovirus, ebv, cmv, bk, hhv , and rsv etc.) have been implicated as major contributors to posttransplant morbidity and mortality in hematopoietic stem cell transplantation (hsct) from unrelated donors. investigators have shown that in-vitro expanded virus specific cytotoxic t lymphocytes (ctls) generated from donors with specificity for one or more viruses are safe and effectively treat viral infections in the hsct setting in recent clinical trials. present clinical trials have shown that ctls can be rapidly produced by a single stimulation of donor peripheral blood mononuclear cells (pbmcs) with a peptide-mixture spanning the target antigens in the presence of potent prosurvival cytokines interleukin- (il- ) and il . others have used banked third party epstein barr virus (ebv)-specific ctls generated from third party ebv-seropositive blood donors with encouraging results. study design/methods: eligible and consented blood donors were tested for cmv antibodies by serology. cmv-seropositive whole blood (wb) units underwent buffy coats processing from non-leucocyte reduced wb units collected in fenwal triple blood-packs tm that underwent hard spins at rpm for minutes with separation after each spin on a compomatev r g . plasma and buffy coat was separated from red cells after the first spin. the second spin lead to the separation of the buffy coat from plasma. the buffy coats were submitted to the gmp stem cell lab for processing of cytomegalovirus-specific ctls. hla typing at high resolution for hla-a/-b/-drb loci was obtained for all donors. results/findings: forty five eligible healthy blood volunteers ( m [ %]: [ %] f); median age years (range - ) donated a unit ( ml) blood from which buffy coats (average volume ml) were processed. the buffy coat process was previously validated on wb units. the mononuclear cells (lymphocytes and monocytes) recovered from the buffy coats are listed in figures and . all of the buffy coats received by the gmp stem cell lab were adequate in cell numbers to be processed. the processing of buffy coats from whole blood is a viable option for the concentration of pbmcs specifically for production of viral specific ctls as third party off the shelf products as well as use in other research projects that require pbmcs from healthy adults. background/case studies: the goal of this presentation is to describe the journey and challenges towards tjc, patient blood management (pbm) certification. transfusion-related health risks and increasing economic pressures have driven hospitals to recognize evidence-based blood management as an important cost-saving strategy. providence holy cross medical center (phcmc), as the providence california region alpha site, has embarked on this journey. our goals are pbm certification and reduction of the number of unnecessary transfusions by % within months of the program launch while improving patient outcomes. this paper will discuss our journey toward certification and the various hurdles being overcome. study design/method: tjc, aabb, and the society for the advancement of blood management have served as our primary resources for identifying current evidence-based transfusion practices and management methods. we needed to identify our organizational gaps in data gathering and analysis. then we could determine baseline performance and set improvement targets. from our internal assessment, we learned we had to start from scratch as we had no easily accessible data metrics and gaps in education to our staff. we took the following steps to develop our pbm program: formed an interdisciplinary pbm team consisting of physicians, nurses, blood bank staff, and data analysts constructed a report on rbc transfusions to help identify outliers and opportunities background/case studies: the maximum surgical blood ordering schedule (msbos) is a list of surgical procedures performed at a hospital along with a recommendation for pre-transfusion testing and rbc allocation before each surgery. the extent to which hospitals have an msbos and its design was explored in this survey. study design/methods: the survey was designed, piloted and refined by members of the best collaborative and invited colleagues. it was then encoded in online survey software and the link distributed to best members and colleagues who were encouraged to respond and to further distribute it. the survey was open for days. results/findings: there were completed responses, of which ( %) indicated that their hospital had an msbos and ( %) did not. the majority of hospitals without an msbos were academic centers ( / , %) from oceania ( / , %) or europe ( / , %), had between - beds ( / , %); the majority of these hospitals transfused between , - , rbcs ( / , %) per year. / ( %) are going to implement an msbos in . of those with an msbos, the majority / ( %) were from north america. the majority were academic hospitals ( / , %) with - beds ( / , %) that transfused ! , rbc units per year ( / , %) offering a wide range of surgical services. on average there were procedures listed in the msbos'. the msbos recommended no pre-transfusion testing for a mean of % of the procedures listed, a pre-operative type and screen for %, crossmatching rbc units for %, and for % of procedures a different recommendation was made. most ( / , %) of the msbos' were created by a combination of obtaining consensus between the surgical services and blood bank and use of procedure-specific transfusion data; only / ( %) of msbos' were created solely by using procedure-specific data, and most ( / , %) do not use patient-specific data in making a testing recommendation. most msbos' are updated less frequently than annually ( / , %), and the hospital transfusion committee is often ( / , %) involved in updating it. the msbos' are generally available electronically in both the operating rooms and in the blood banks. it was the opinion of the majority of respondents ( %) that the msbos was used regularly by only a limited number of surgeons and anesthesiologists, % of respondents felt that it was regularly used by all surgeons and anesthesiologists; % felt that it was not used at all at their hospital, % did not respond. conclusion: an msbos was available in only about half of the respondent's hospitals and in only the minority of cases was it felt to be regularly used. however, % of the hospitals currently without one indicated that it would be implemented in suggesting that these hospitals perceive the value of having one in place. implementing and following an msbos can be an important step in peri-operative patient blood management and in streamlining the operations of the blood bank vis-a-vis pre-operative testing. blood management -one hospital system experience leana serrano rahman*, mallika gupta, susan solometo, ronald walsh and joan uehlinger. montefiore medical center background/case studies: our system, a pioneer aco, is a -bed tertiary-care referral center dedicated to serving patients from across the new york city area and beyond. the comprising four hospitals see , hospital admissions and nearly , emergency department visits annually. we have active programs in high risk ob, stem cell transplant, solid organ transplant (heart, liver, and kidney), ct surgery, ecmo, oncology and critical care. transfusion medicine plays a key role in the support of these services. blood product spending in was approximately $ . m. in nov. , an interdisciplinary committee was created in an effort to improve patient care (by reducing blood product exposure) and reduce blood product expenditures. the vice president-sponsored multidisciplinary committee was composed of representatives of: surgery, anesthesia, blood bank, pediatrics, perfusion, cardiothoracic surgery, critical care, medicine, and emergency department. study design/method: first important step: "know your numbers"-although the committee had multiple sources of data, there was no "one report" that could display all of the pertinent information. baseline numbers were imperative to the committee's ability to effect change. a home grown one time only report revealed which services and clinicians were the highest volume users. the initial plan was to target their use with education. an initial goal was set to reduce expenditure by $ . m. the journey continued with regular bimonthly meetingsto brainstorm strategies and monitor utilization. utilization was analyzed using a home grown crystal report "transfused patients by location". this report was further compared to utilization patterns ( and ), by "dollars spent" and "total units per patient" by the project manager using excel. key initiatives developed by the committee . development of evidence based transfusion triggers. . education on evidence based transfusion triggers across multiple campuses, specialties and resident programs . clinical information system (cis) "soft stops" when ordering blood products outside guidelines. rbc order set defaulting to " " unit instead of " " units. . updated guidelines posted to easy to find internal intranet spots results/finding: despite higher patient volumes and a more complicated patient mix in , we were still able to reduced blood product expenditures by $ , when compared to . conclusion: in spite of limited resources, the committee was able to effect change by capitalizing on current stakeholders fully supported by leadership and project management. cord blood pathway to reduce iatrogenic blood loss in neonatal intensive care patients tracy shachner* , anna w rains and christopher t clark . university of tennessee graduate school of medicine, univeristy of tennessee medical center, univeristy of tennessee graduate school of medicine background/case studies: anemia due to iatrogenic blood loss in preterm and low birth weight infants is a major contributory factor leading to red blood cell transfusion in this patient population. methods to reduce phlebotomy for laboratory testing can reduce iatrogenic anemia. at a universitybased teaching hospital, a pathway to collect cord blood samples on all newborn deliveries was established. the cord blood sample is used for initial blood bank laboratory testing on newborn patients transferred to the neonatal intensive care unit (nicu), preventing need for additional blood draw. the blood tubes are saved for week post-delivery, with cost of $ . per delivery tray for sterile tubes. with an initial negative antibody screen on cord blood sample, no additional phlebotomy is required for blood product selection or compatibility testing in this population until four months of age. study design/method: labor and delivery data from our facility in was analyzed, and the gestational age and birth weight of all infants transferred to the nicu was collected. from this data, we were able to calculate the total blood volume of these infants using medcalc system. by using the blood volume values, and assigning a value of . ml as the minimum amount of blood that would be drawn to perform an antibody screen, we calculated the percent of an infant's blood that would have to be drawn if the cord blood pathway was not established. transfusion results/finding: in , there was a total of , infants delivered at our facility. out of all the deliveries, ( %) infants were transferred to the nicu. of those infants, % received at least one red blood cell transfusion and % received at least one platelet transfusion. of the infants transferred to the nicu, ( %) had a percentage of blood volume that would have had to be drawn for blood bank testing greater than or equal to % (which we considered to be significant), had the cord blood pathway not been in effect. the percentage of blood volume preserved in these infants ranged from . % all the way up to . %. in those infants, the birth weight ranged from - grams, and the gestational age ranged from weeks to weeks and days. conclusion: the established cord blood pathway has proven to be a relatively cost-effective method to prevent iatrogenic blood loss secondary to blood bank testing in a population of nicu infants who are most susceptible to iatrogenic anemia. the infants that were most likely to benefit from this policy are premature infants who are low birth weight (less than grams). development of a standardized response team for massive hemorrhage events outside of an operating room setting james burner* , shannon davis , suzan new , vaishali patel and oren guttman . university of texas southwestern medical center, ut southwestern medical center background/case studies: managing a massive transfusion protocol (mtp) in an operating room (or) is a relatively frequent occurrence with team members well trained in their specific roles. however, in the event of mtp activation outside of an or, sufficient and/or appropriately trained individuals may not be present. this can lead to a scene of confusion and chaos with potential for patient harm. study design/method: a failure mode effects analysis was performed to develop a standardized process for managing mtp outside of an or setting. with participation from anesthesia, surgery, transfusion medicine, patient safety and quality and nursing, every step of the hospital's mtp was analyzed for potential errors. the results were used to create a "code hemorrhage" team trained to respond to any massively hemorrhaging non-or patient. results/finding: code hemorrhage represents a multi-system team critical event requiring coordination of different sub-teams (primary resuscitation, surgical/interventional, transfusion services, blood preparation, equipment management, medication management, and lab requisition/monitoring). our code hemorrhage protocol utilizes critical care trained nurses from the hospital's rapid response team who play two key new coordination roles: hemorrhage coordinator and electronic medical record (emr) coordinator. their combined roles serve to reduce the cognitive load of the various teams, prevent duplication of resources/efforts during mtp and enable enhanced closed loop task performance. the hemorrhage coordinator establishes reliable : communication between the primary resuscitation team and transfusion services, and aids in multi-team on-site coordination. the emr coordinator enters all orders into the emr, sends/communicates laboratory results and ensures blood products are available to the resuscitation team. the primary resuscitation team includes a team leader (medical decision making and cardiac life-support management); a proceduralist (establishing venous and/or arterial access), event documenter (real-time documentation of actions, medications, events, etc.), medication manager (registered nurse who prepares and administers medications) and equipment technologist (managing rapid blood product infusion devices). additional secondary roles will also be assigned, such as blood product checker(s) (verifies blood product prior to transfusion) and blood bank runner (courier sent to retrieves blood product shipments). conclusion: the code hemorrhage protocol is designed to ensure timely, efficient delivery of blood products to massively bleeding patients outside of an or setting. future work will assess its overall effectiveness by comparing blood product utilization/wastage and patient outcomes before and after implementation. background/case studies: preoperative anemia affects up to % of surgical patients and increases the risk of red blood cell (rbc) transfusion. both preoperative anemia and perioperative rbc transfusion are associated with increased risk of adverse outcomes following surgery. preoperative treatment of anemia includes oral and intravenous (i.v.) iron and erythroid stimulating agents (esa) such as erythropoietin (epo); however, the optimal treatment strategy for preoperative anemia remains to be established. our objectives were to evaluate the efficacy and safety of esa and iron therapy based on their effects on the prevalence of rbc transfusions and adverse thrombotic events. study design/method: we searched the cochrane central register of controlled trials, medline and embase from inception to july ; reference lists of published guidelines, reviews and associated papers, as well as conference proceedings. no language restrictions were applied. we included randomized controlled trials in which adult patients undergoing surgery received either an esa and/or iron before surgery, versus iron or no intervention. three authors independently reviewed the studies and extracted data from included trials. risk of bias was assessed for all included studies. where applicable, we pooled risk ratios of dichotomous outcomes and mean differences of continuous outcomes across trials using randomeffects models. our primary outcome was the number of patients transfused with red blood cells. secondary outcomes included risk of mortality and other thrombovascular events (stroke, myocardial infarction, deep vein thrombosis, and pulmonary embolism). results/finding: a total of randomized controlled trials ( , conclusion: amongst patients undergoing surgery, the administration of an esa in addition to oral or i.v. iron was associated with a reduction in patients requiring rbc transfusion. intravenous iron was less effective at reducing rbc transfusion. neither treatment was associated with any clear increase in risk of adverse thrombotic events. additional large prospective randomized controlled trials are required to determine the optimal management strategy for patients undergoing surgery with iron restricted anemia. evidence based blood therapeutics scott neeley* and stephanie rogers . dignity health st joseph's medical center, dignity health background/case studies: over million units of packed red blood cells (prbc) are transfused annually in the united states and there is no clinical basis for as many as half of these transfusions. no randomized prospective trial has ever demonstrated a clinical benefit for transfusion in mild to moderately anemic patients and yet there is a large body of evidence which has shown that due to a variety of reasons including an immunomodulatory effect and the storage lesion, blood transfusions can cause considerable harm, including higher risk of hospital acquired bacterial infections, transfusion related acute lung injury/acute pulmonary edema, acute myocardial infarction, higher recurrence of rebleeding and higher cancer recurrence. study design/methods: a system wide goal was launched across hospitals to decrease the number of prbc transfusions given to clinically stable patients with hemoglobin (hgb) levels > . g/dl. the numerator consisted of all prbc units transfused to patients with a hgb of . g/dl or greater prior to transfusion and the denominator consisted of all prbc units transfused. exclusions included cardiac surgery, nursery, nicu, pregnancy, post-partum hemorrhage, massive transfusion protocol and transfusions in which or more prbc units were transfused in one episode. data was extracted directly from the electronic medical record and hospitals received patient level detail every month for all prbc units transfused to patients with a hgb of . g/dl or higher prior to transfusion. an extensive educational campaign re: evidence-based transfusion practice was launched for physicians and nurses, including the development of a blood therapeutics toolkit, development of standardized dignity health blood therapeutics guidelines, a one day blood therapeutics advanced training symposium, on-site visits to hospitals including cme presentations, online physician and nursing educational videos, communication tools including infographics and " is the new " buttons, development of a patient education resource and bi-monthly webinars with various educational topics and speakers. additionally, the ehr powerplans were revised to ensure available selections for "transfusion indication" (required field) were aligned with evidence based guidelines. facilties were encouraged to develop multi-disciplinary blood therapeutics committees to review all transfusions given to patients with pre-transfusion hgb > . g/dl on a routine basis, providing feedback to providers whose transfusions were deemed not in accordance with current evidence-based guidelines. results/findings: from fy to fytd , there was a % reduction in prbc units transfused to patients with hgb > . g/dl, starting at a baseline of % down to %. this represents an fy annualized savings of $ . m, from a baseline of units per , patients days down to an average units and approximately , fewer units transfused per month. conclusion: blood transfusions, while life saving, should be regarded as an organ transplant and as such they carry considerable risk. transfusions to stable, non-bleeding patients with hgb levels > . g/dl are not in accordance with evidence-based guidelines and should be avoided due to the associated potential harm. furthermore, this potential harm is dose dependent, so if the decision to transfuse is made, one unit of prbc should be transfused rather than two. three af studies (sdm - . ) reduced rbc units and two studies decreased the percentage of patients transfused (or . ). forty-three studies showed that intravenous tranexamic acid reduced the percentage of patients (or . ) and rbc units transfused (sdm - . ). qualitative/meta-analyses were translated into recommendations by an expert panel and approved by the lmbp workgroup for reducing rbc transfusion. recommendations are: early assessment and effective am; rt, hb alerts in cpoe/cds; reduction of blood loss and af assessing the percentage of patients and rbc units transfused across cases, physicians and service areas over discrete periods of time with feedback to physicians for continuous quality improvement. conclusion: conclusion: the lmbp a- method led to evidence-based recommendations for reducing transfusion. critical laboratory support is needed to achieve continuous quality and patient safety. background/case studies: reducing the inappropriate use of blood products via the implementation of evidence based guidelines is a main tenet of patient blood management. the use of electronic decision support tools such as best practice alerts (bpas) to enforce red blood cell (rbc) transfusion thresholds have been shown to reduce use by informing ordering providers when or when not to transfuse. the tools in use to date have not provided a dose of rbcs to transfuse, so in fact providers can continue to over-transfusion based on the number of units of rbc given. a therapeutic hemoglobin/hematocrit (hgb/hct) targeted approach to rbc indications/ orders allows for the calculation of a dose of rbcs to achieve the desired target and could further reduce the use of rbc units. our group has developed a computer algorithm to calculate rbc dose based on patient specific data drawn from the electronic medical record (emr) that has been used in select patient populations but has not been prospectively applied to hospital wide clinical practice. this study describes our initial experience with the use of this algorithm in non-surgical rbc transfusion. study design/method: the blood utilization calculator (buc) is a mathematical formula that draws patient specific information including index hgb/ hct and calculates a dose in number of units of rbcs to transfuse in order to achieve a selected target hgb/hct. hgb/hct target based indications for rbc transfusion were designed and used as the basis for rbc order set with in the ethe buc was embedded within the emrs rbc order set to provide a recommended transfusion dose in number of units when any nonsurgical rbc indication was selected. the target hgb/hct for these indications was g/dl/ % or g/dl/ %. the number of rbc units ordered and transfused were tracked prospectively for each of the orderable indications. comparison of units transfused per month before and after the buc implementation was performed using student's t-test. results/finding: historically, the three non-surgical rbc indications represented approximately % of the total rbc transfused. prior to the buc the mean number of non-surgical rbc units transfused was units/ month. after the first months of buc activation the mean number of units was units/month a reduction of units/month or % of nonsurgical blood use (p . by t-test). non-surgical rbc use now represents approximately % of the total rbc use hospital wide a % reduction. this change represents a significant cost savings in rbcs over time. conclusion: the use of target based transfusion indications and an electronic decision support algorithm to calculate a recommended transfusion dose can significantly reduce the non-surgical rbc transfusion rate providing enhanced patient blood management and potential cost savings. implementation of patient blood management at a community hospital - month report card richard gammon*. oneblood, inc. background/case studies: a collaboration between blood center between (bc) as consultant and three hospital ( beds) healthcare system (hcs) to implement a patient blood management (pbm) program was undertaken. this is a review of the first months. study design/method: during year one pbm working group was established. achievements included physician engagement programs, creation of transfusion committee and providing nursing education. auditing processes were implemented with nonconformance letters sent to physicians and nurses when compliance with informed consent, transfusion tags and thresholds and discharge instructions was not achieved. in year two, it created best practice alerts (bpa) when an order did not meet transfusion threshold criteria. bpa showed first line of associated procedure, link to the full procedure, three most recent lab results (e.g., hemoglobin & hematocrit for red blood cells (rbc)) and allowed ordering physician to cancel order after review. a blood administration video was created. it was mandatory that all physicians granted privileges complete within six months. low vital sign compliance required action that included reducing requirement from five to three during transfusion and formation of working group (wg) to address knowledge and practice gaps. in year three, as historically at this hcs very few jehovah's witness patients (jwp) presented, pbm wg was involved with implementation of a bloodless medicine program. all steps of care were addressed including identifying jwp at registration, creating a transfusion special arm bands, forming a bloodless medicine physician group, implementing nursing bpa in the electronic medical record, creating advanced directives and marketing to the public. results/finding: the following were monitored for compliance ( q vs. q ): present and completed consents ( vs. %), present and completed nursing flow sheets ( vs. %), transfusion thresholds supported ( vs. %), discharge instructions provided ( vs. %); ( q vs. q ) vital sign compliance ( % vs. %). jwp increased from to ( / - / ). cost savings were realized by decreased utilization and implementation of bpa. (table - q ) conclusion: pbm implementation at a hcs is a continuous and multiyear process. even with a robust program challenges such as vital sign compliance remain. improving patient outcomes in the golden-hour beatrice lebeuf*. medical city plano background/case studies: in emergency medicine, "the golden hour" refers to the critical one-hour time period following traumatic injury in which the patient has a higher likelihood of survival. nearly half of all trauma related deaths occur in the first hour after injury -half of those deaths are the result of major hemorrhaging. rapid administration of blood products is vital to the survival of these patients. we implemented bloodtrack emerge (haemonetics, braintree, ma) in our trauma emergency department (ed) as part of a quality improvement initiative to more efficiently provide group o rbcs and thawed/liquid plasma for incoming trauma patients to support ratio-based transfusions and ensure the proper handling and traceability of this regulated resource. study design/methods: we treat approximately - trauma patients monthly. an assessment of our current blood supply chain revealed a multistep, manual process that took about minutes to prepare and physically transport a cooler from the blood bank to the ed. coolers of blood were provided for incoming trauma patients, whether they ended up needing transfusions or not. this practice worked to ensure available blood supplies during critical moments, but resulted in inefficiencies and unnecessary inventory tie-ups, with only percent of coolers fully used. it also consumed valuable staff time as technologists typically made - trips per month from the blood bank to the ed. plus, there was no effective way to maintain traceability, control access to coolers or monitor usage. results/findings: since our november implementation, bloodtrack emerge has freed up technologists to perform important tasks, tightened traceability and inventory control procedures and contributed to the medical city plano's verification as a level trauma center. rather than preparing coolers of blood in case they may be needed in emergency situations, bloodtrack emerge provides ed staff ready access to emergency units whenever they're actually needed -and frees up an estimated - hours of tech time per month during which they can perform other tasks. audio and visual alerts notify the blood bank when emergency units are removed, allowing a quick response. plus, by stocking emergency blood supplies in the ed, the blood bank isn't unnecessarily tying up group o rbc units. today, the blood bank stocks and maintains - units of group o rhd negative, units of o rhd positive, and units of group a thawed plasma/ liquid plasma in bloodtrack emerge. conclusion: implementing bloodtrack emerge has enabled us to more effectively provide blood products for incoming trauma patients to support ratio-based transfusions, improve staff efficiencies and proactively respond to emergency situations. background/case studies: platelets are a limited resource for which the benefits of transfusion must be weighed against the risks. in , the aabb published platelet transfusion guidelines to assist providers. at our academic medical center, a computer provider order entry (cpoe) system combines institutional transfusion guidelines with a patient's most recent lab results to guide transfusion decisions. discordant information activates an "override" system, in which providers are prompted to select a prefixed indication for transfusion (e.g. count < k/ml [prophylaxis]) with the option to add a free-text comment. the order is placed and data is stored for later review. study design/method: override platelet orders placed from june -october were reviewed using the following data: prefixed indication, most recent platelet count, free-text comment, and ordering service/department. one of five "codes" was assigned to each order: i-indicated or ni-not indicated (based on institutional/aabb guidelines); nmi-need more information; p-protocol (e.g. liver transplant), and nic-non-indication comments (e.g. reserve for or). free-text comments were categorized and assigned one or more keywords in order to determine the common reasons for overrides. results/finding: over a -month period, , cpoe override platelet orders occurred. the percentages of code assignments by month are provided in table below. overall, ( %) were assigned as not indicated (ni). the top keywords assigned to free-text comments were "platelet count less than. . ." ( ), "active bleeding" ( ), "platelet count of . . ." ( ), and "downtrend" ( ), many with specified platelet count goals. certain platelet count goals and reasons for transfusion (e.g. "downtrend," "anticipate drop," or "per service,") are not included in institutional or aabb guidelines. of note, ( %) of overrides were placed by hematology-oncology providers. conclusion: a majority of override platelet orders were determined to not be indicated based on institutional and aabb guidelines. of concern were keywords such as "downtrend" and "anticipate drop," as these are not indications for transfusion and expose patients to unnecessary transfusions. it is unclear whether trainee progression throughout the year had any effects on ordering practices and associated override patterns. this review suggests the potential benefits of provider education initiatives at all levels of experience (with particular emphasis on hematology-oncology) in order to improve blood product utilization practices. background/case studies: early diagnosis of iron deficiency anemia (ida) by clinical laboratories (cl), with effective prevention and treatment in primary care may have an impact on packed red blood cell (prbc) transfusion, as well as intravenous iron therapy and, most importantly, applying lower transfusion triggers. they all help to avoid not essential transfusions, but also promote health and wellbeing by improving iron status in the population. results are described after implementing a process to prevent ida, its early detection and treatment for years - . study design/methods: performance measure after educational and organizational intervention. setting: public integrated healthcare system located in north africa bordering morocco, isolated by km sea distance to nearest continental spain airport, with a general hospital blood transfusion service and a establishment for blood donation and component production. cl involved in anemia detection and diagnosis receives four primary care centers and hospital based samples, and shares common leadership with both blood establishments. process: guidelines for first step cl diagnosis of ida and call for attention, primary oral iron prevention and treatment in first level care, and early intravenous iron complex for inpatients (sucrose) and outpatients (carboxymaltose). transfusion was avoided for stable ida patients without active bleeding or coronary heart disease, with a safety hemoglobin (hb) threshold of , g/dl. severely anemic patients were closely followed to asses hb increase and referred for etiology studies when hb> g/dl. background/case studies: bedside nurses are critical in safeguarding the delivery of appropriate patient care. more recently, nurses have also begun to play an important role in patient blood management (pbm) programs at the administrative level, although to our knowledge little has been published on the influence nurses may have on transfusion practice at the bedside. the goal of this study was to evaluate the impact nurses have on patient expectations and physician ordering practice. study design/method: a short electronic survey ( questions) was prepared to assess how often bedside nurses discussed transfusion necessity and the persons (patient or physician) with whom they discussed it with, as well as what was discussed, and what they felt were appropriate lab thresholds for transfusion. the survey was distributed to all registered nurses via email from floor leaders. responses were also solicited by hospital volunteers and lab staff with electronic tablets and included coverage of the night shift. results/finding: there were a total of complete responses ( %). the nurses had a range of experience from less than one year to forty years. ninety percent stated they discussed transfusion necessity with patients, % with physicians, and of these, % reported doing so proactively before an order was placed. ninety-six percent said they would discuss transfusion to suggest their patient required a blood product; only % responded that they would suggest product was not needed. nursing perception of acceptable transfusion thresholds had a wider distribution, with the most commonly reported values being hemoglobin of - g/dl ( %), platelet count of - , ( %), and inr of greater than . ( %). conclusion: this study demonstrates that nurses are willing to discuss transfusions with both patients and providers, although they appear to be most comfortable doing so in the setting of perceived transfusion necessity. the limited number of survey responses suggests a discomfort with their level of education in transfusion practice. this, along with the distribution of perceived thresholds and the reluctance to recommend against transfusions, presents an opportunity for education to further empower nurses in providing appropriate patient care within the guidelines of pbm programs. background/case studies: the use of red blood cell per , inhabitants may vary folds between european countries, revealing that there may be substantial room for blood optimization strategies. patient blood management (pbm) is an evidence-based, multidisciplinary approach aiming to preserve and optimise patients' own blood in order to improve clinical outcomes. the objective of our study was to assess the effect of a nationwide pbm program on public health in portugal. study design/method: the first phase of this research project involved a group of key opinion leaders (kol) in a stated preference inquiry to assess the relative value of specific pbm strategies, grouped in pbm pillars, to highlight the need for strategy prioritization in the implementation of a nationwide pbm policy. adaptive conjoint analysis techniques were used to elicit kol preferences. in the second phase a decision analysis model was used to estimate the impact of pbm implementation in the following therapeutic areas: surgery (orthopaedic, cardiac and urologic), cardiology, oncology, gastrointestinal bleeding, abnormal uterine bleeding, haemodialysis, inflammatory bowel disease and pregnancy. model inputs included effectiveness data regarding transfusion utilization, health resource consumption and mortality obtained from portuguese national health databases and literature review. the public health value of pbm implementation in portugal derives from the comparison of two scenarios: "current clinical practice" and "with pbm implementation". results/finding: kol elicited iron administration followed by restrictive transfusion of red blood cell as the most preferred pbm strategies ( . % and . %), for the remaining strategies weights varied between . % and . %. we estimate that , patients would be eligible for pbm strategies in one year time horizon, resulting in premature death avoided ( . % reduction) corresponding to a gain of approximately , life years and a reduction of , ( . %) disability adjusted life years (daly) relative to the current clinical practice. a decrease of , in-hospital days is expected mainly due to a . % reduction in hospital length of stay and a . % reduction in -day readmission rate. in this population the overall transfusion rate could decrease to . % from the current . % ( . % reduction) implying , blood transfusion avoided and , red blood cells units spared. conclusion: we anticipate that the implementation of a nationwide patient blood management program will represent a paramount improvement in clinical outcomes in terms of morbidity and mortality and may have a substantial public health impact while contributing a more efficient use health resources. results/finding: adult liver transplants were performed during the evaluation period. preoperative hemoglobin, creatinine, meld score, spontaneous bacterial peritonitis (sbp), preoperative hemodialysis, gender, and portal vein thrombosis (pvt) gave the strongest model predicting rbc usage. if the model predicted < ml of rbcs, all cases with ml transfused were captured and only . % of the time > ml were used. if - ml rbcs were predicted to be transfused, > ml were used % of the time. if predicted usage was > ml, % of the time it exceeded ml. conclusion: a model using specific preoperative factors can be used to predict intraoperative rbc usage. patients at risk for > ml of rbc transfusion can be identified with reasonable accuracy using this model at our institution. use of this model might help improve preparation and utilization of the blood bank. review of blood ordering practice for elective surgeries in a maternity hospital qi raymond fu*. kk women's and children's hospital background/case studies: pre-operative over-ordering of blood is common, resulting in waste of blood bank resources. blood units are withdrawn from the pool, leading to constraints in allocating the limited blood resources to meet the needs of other patients. the cross-match to transfusion (ct) ratio is often used in benchmarking efficient blood utilization within the hospital blood transfusion service. according to the american association of blood banks (aabb), a ct ratio of less than . is favorable, and anything above indicates over-ordering and cross-matching of blood. to achieve this, it is necessary to review pre-surgical blood ordering practice in a maternity hospital. study design/methods: data on elective surgeries requiring blood for standby was collected retrospectively over a month period (jan to mar ). details of total blood cross-matched, issued, transfused and returned were analyzed along with the ct ratio. results/findings: during the month period, there were patients undergoing obstetrics and gynecology procedures requiring blood on standby. a total of units of blood were requested. units were crossmatched, of which units were sent to the operating theatre (ot). only . % of blood issued to ot were transfused (n ) while the rest were unutilized. the observed ct ratio was . . conclusion: although only % of total blood requested was crossmatched, the ct ratio remains above the recommended guideline of ! . , with almost % of cross-matched blood unutilized. there is a need to improve and standardize the blood ordering practice to achieve costeffectiveness and reduce unnecessary workload. establishing and adhering to a maximum surgical blood order schedule (msbos) could help in conserving blood and prevent over-ordering of blood. background/case studies: total knee arthroplasty (tka) is a major orthopaedic procedure with increased perioperative blood loss. this perioperative blood loss could be more significant in patients undergoing bilateral tka in a single stage. the increased blood loss in bilateral tka often requires blood transfusion which results in high post-operative morbidities. study design/methods: in this retrospective study patients who received tranexamic acid (txa) (study group) and patients who did not receive txa during surgery (control) were evaluated for blood loss and transfusion requirement. the study group received a single bolus dose of txa gm iv before tourniquet deflation on first side knee. statistical background/case studies: blood product utilization is an increasing concern for hospital systems attempting to reduce transfusion-associated risks. one strategy to optimize utilization is to employ clinical decision support in the form of alerts to clinicians ordering blood products. we investigated whether an alert targeted to a patient's transfusion indication could alter provider ordering behavior. study design/method: this retrospective, observational study over the course of seven months included the inpatient adult medicine floors and intensive care units at a large academic hospital. each time a crossmatch for packed red blood cells (prbcs) was ordered via the hospital's electronic ordering system, an indication (e.g. "hemodynamically stable with hemoglobin < . g/dl") must be selected. if the indication selected contains a threshold hemoglobin concentration, and the patient's most recent hemoglobin on record was greater than this threshold, an interruptive alert displaying the patient's hemoglobin was activated. ordering providers were then given three options: cancel the order, select a more appropriate indication from a list, or provide an explanation via free text as to why transfusion was being requested outside of approved indications. an alert encounter was defined as all activations on a patient within a six hour period without an intervening transfusion results/finding: over seven months, there were unique alert encounters. of these, ( . %) led to a crossmatch being ordered while ( . %) led to the order being canceled. providers were more likely to cancel transfusions in response to alerts for hemodynamically stable patients with lower hemoglobin thresholds ( . g/dl) than for more complicated patients (bleeding, cardiovascular disease, or preoperative) with higher hemoglobin thresholds ( . or . g/dl background/case studies: the maximum surgical blood ordering schedule (msbos) is a list of surgical procedures performed along with a recommendation for the extent of pre-transfusion testing to be completed before the surgery begins. with improved patient data management systems it is now possible to create an msbos based on actual red blood cell (rbc) utilization data on a per-patient basis. this study investigated the transfusion patterns at academic hospitals with data-derived msbos. study design/method: the hospitals were in groups, with one shared msbos for each group. three of these hospitals were large academic centers while one was a children's hospital. at each center the msbos recommended no pre-transfusion testing if % of patients had been transfused for a specific procedure in the previous year, a pre-operative type and screen (t&s) if - % of the patients had been transfused, and a crossmatch of the median number of rbcs transfused if ! % of the patients had been transfused. data were collected at each center over a month period between january to march and included a maximum of cases per hospital during that one month to ensure equal representation between centers results/finding: between these centers there were a total of cases analyzed. some of the more frequently performed surgeries included orthopedics ( % of cases), general surgery ( %) and cardiac surgery ( %). there were t&s ordered for these cases, of which were positive for antibodies on the day of surgery. of all the t&s ordered, % were ordered in accord with the msbos recommendation, % were ordered when the msbos did not recommend one, and in . % a t&s was not ordered when the msbos recommended one. background/case studies: peripartum blood transfusion is more common in south africa than in the usa and recent studies have demonstrated that antenatal anemia is a strong risk factor for such transfusion (odds ratio . for prenatal hemoglobin (hgb) - . ). we therefore analyzed the etiology and characteristics of antenatal anemia according to hiv status at a large hospital with a hiv prevalence of % among obstetric patients. study design/method: we studied a sample of anemic (hgb< . g/dl) pregnant women who were referred to an antenatal anemia clinic at a large hospital in south africa. clinical information was abstracted and blood was sent for laboratory studies. t-tests were used to compare continuous variables between groups. results/findings: a total of women were enrolled, with median age (interquartile range - ) years, median gravida / para and median gestational age weeks. mean hgb before referral was . g/dl and most were already taking oral iron therapy. a total of women were hiv positive with mean cd lymphocytes counts of cells/ul; ( %) of hiv positive subjects were on anti-retroviral therapy (art) prior to the pregnancy and ( %) were on art during the current pregnancy. iron deficiency anemia was the overwhelmingly prevalent diagnosis, present in ( %) of women. there was concurrent chronic disease (n ), infection (n ), vitamin b deficiency (n ) and antenatal hemorrhage (n ); had other/unknown/missing causes of anemia. there were few pregnancy related complications. hiv positive women had higher levels of c-reactive protein but slightly lower levels of transferrin, soluble transferrin receptor and rbc folate than hiv negative women (table) . conclusion: iron deficiency is the overwhelming cause of antenatal anemia among south african pregnant women. compared to hiv-negative women, hiv-positive women had evidence of increased inflammation, relatively little differences in iron studies after early treatment with iron and lower red cell folate. a high proportion of hiv positive women were receiving art, consistent with national guidelines. future studies will examine longer-term responses to iron therapy to assess its potential in decreasing the incidence of peripartum blood transfusion. background/case studies: a month old boy presented to our institution after a month hospitalization in japan. he was admitted there, several weeks after his unremarkable term birth to an ab rh positive woman, with lethargy, failure to thrive, bloody mucoid stools with eosinophilia, and an elevated serum white count. he was found to be anemic and thrombocytopenic and required multiple transfusions. also, he had a diffuse, scaling, erythematous rash over his inner thighs. study design/method: initial workup was suspicous for an allergic/necrotizing enterocolitis. the patient had an elevated ldh and potassium, and concern was raised for leukemia with possible tumor lysis syndrome. a sample sent to our blood bank showed an anti-e, with a positive dat (igg and complement), and was positive for e, e, and c antigens. concern for a maternally-induced antibody was raised, as was the possibility of a red cell antigen passively transfused from blood products administered at the japanese hospital; both possibilities were excluded. further workup revealed no infection or hematologic proliferation. biopsy of his rash showed spongiotic dermatitis. his clinical course deteriorated, and he developed hepatomegaly and jaundice. a concern for wiskott-aldrich syndrome was raised, and workup showed normal immunoglobulin levels, but with elevated ige ( ku/l; rr: - . ). anti-platelet antibodies were identified. three days after admission, testing was sent for genetic alterations of foxp , while a japanese-speaking physician at our institution read a prior flow cytometry study showing a deficiency of foxp cd lymphocytes. the majority of these indications are seen in adults and for which a reported plasma wastage is $ . %. fortunately in pediatrics the incidence of these indications is low despite the heterogeneity of the patient population. during the utilization review process at our primary pediatric institution, we noted a mean wastage of . % over the last years. with recent changes in clinical practice (liver transplants and increased trauma) and recent evidence that faster plasma improves massive transfusion protocol (mtp) outcomes, our facility decided to implement the use of thawed plasma and benchmark mtp plasma wastage. study design/method: blood utilization review revealed an increase in the overall percentage of plasma wastage from to , with a peak of . % (range . %- . %). a single cause could not be readily identified prompting us to query children's hospital association (cha), as our initial external pediatric benchmarking, to determine if our wastage was comparable to other children's hospitals in addition to reviewing our "time of plasma availability" for mtps. results/finding: in , mtp was activated times. in cases the patient did not receive any blood product and in cases plasma was already available at the time of rbc allocation/issue. this left cases to evaluate. the median time to plasma availability was minutes (range minutes - minutes). the mean plasma wastage for mtp activations was % (range - %). of the cha replies, were using thawed plasma and their wastage was </ %. conclusion: increasing clinical evidence supports the prompt transfusion of plasma in the setting of mtp to decrease morbidity and mortality. our brief review suggests that implementing thawed plasma will allow a potential decrease in plasma availability of minutes. our implementation began with thawing a single unit of plasma for "level neuro trauma" alerts, and we are now keeping a single unit of ab plasma thawed at all times. plasma is now available at the same time as rbcs thus providing more effective and balanced blood product support while reducing wastage (preliminary estimates are . %) to a level consistent with external benchmarking. prospective evaluation of this practice is ongoing at our institution and includes collaborative clinical assessment with the trauma team. ultimately prospective, multi-institutional studies in pediatric institutions are necessary to define best clinical practice and effectively benchmark blood bank practice. background/case studies: bacterial and fungal infections remain a significant cause of morbidity and mortality in severely neutropenic patients with hematological disease receiving high-dose chemotherapy and hematopoietic stem cell transplantation (hsct). granulocyte transfusions (gtx) have been used for over years, although effectiveness, indications, and both patient and donor safety remain debated, particularly in children. to contribute to this discussion we demonstrated cases of gtx in pediatric patients with age from months to years old, neutropenic, with severe infection resistant to antibiotics and/or antifungal therapy, undergoing hsct and chemotherapy. study design/method: donors: data concerning a total of granulocytes donations from to were collected from health donors ( male/ female). donors had matched blood type and serology status for cytomegalovirus when the patient was negative. granulocytes were mobilized with a single dose of rhu-g-csf (filgrastim) subcutaneously, mcg/kg/dose (donors up to kg, maximum of mcg) and oral dexamethasone ( mg), h prior to apheresis. apheresis was performed using cobe spectra v r or spectra optia v r with citrate as anticoagulant. all products were irradiated with gy. results/finding s: granulocytes number increased times from basal levels and the median of cells collected were . x (range . - . ). in general donors reported no significant adverse reactions. from donations, only in was reported light paresthesia during the procedure. patients: all patients were medicated prior to transfusions with diphenhydramine and acetaminophen. the product was transfused within hours after collection, with efforts to transfuse as soon as possible. details about the transfusions are described on table . adverse reactions for patients were minor and not frequent ( in gtx) including vomiting, hypotension and headache, which resolved without serious or lasting complications, assuming that gtx is well tolerated. conclusion: our study provides further evidence that gtx transfusions can be safely performed on pediatric patients. irina kumukova* , elena kurnikova and pavel trakhtman . russian institute for paediatric haematology, oncology and immunology, instituteffor pediatric hematology, oncology and immunology background/case studies: infections cause major mortality among persons with prolonged neutropenia related to hsct and chemotherapy and among patients with granulocyte disorder. the granulocyte transfusion therapy, a logical approach in treating patients with infections, who are refractory to antibiotics. we want to demonstrate our granulocyte transfusions experience in children who have neutropenia or defects of the immune system, with severe infections study design/method: we analyzed the retrospective data for the period / - / . donors underwent granulocyte mobilization with g-csf in a dose - mg/kg s.c. - hrs prior to donation; granulocytes were collected with cobe spectra, caridianbct. the analysis was performed through microsoft excel, nonparametric mann-whitney's and spearman tests results/finding: was performed granulocytes collections in donors ( f, m), ages to . the mean increment of wbc after stimulation was , x /l ( , - , x /l; f- , x /l; m- . x /l); in the age groups - years (n ) and over years (n ), the mean increment of wbc was respectively , x /l ( , - , x /l) and , x /l ( , - x /l). the mean volume of treated blood was , a , ) . the mean number of total wbc in the product was , x /l ( . - x / l; f- , x /l, m- , x /l). only three donors ( , %) had apheresisrelated adverse effects the analysis included granulocyte transfusions in cases of infectious complications in patients. the mean number of transfusions was . ( - ). each patient received transfusions from mean donors ( - ); the granulocyte transfusions started at the mean days ( - ) after infection; the mean dose of wbc on the transfusion was . x /kg ( - . x /kg). wbc increment was able to estimate after transfusions. wbc increment was recorded after transfusions ( . %); the mean increment was , x /l ( , - , x /l). efficacy was determined by the number of patients who survived an infection episode and amounted to . %. in the cases of severe sepsis, the efficacy of transfusions was . %. the frequency of post-transfusion reactions was %, (n ): febrile nonhemolytic reactions , % (n ); pulmonary complications , % (n ); the anti-hla antibodies formation , % (n ) conclusion: no significant differences in the mobilization of granulocytes and products' volume, between men and women, or between age groups and we did not find significant relationship between baseline wbc and their increment after stimulation. the mean total wbc in the collected product and the mean volume of treated blood from men and women were significantly different. perhaps the reason for lower cell products from women is to treat smaller blood volume. the lack of increment wbc after transfusion is not equivalent to lack of its efficacy. we found a significant association between transfused dose and increment of wbc. we deliberately did not estimate our data on the treatment of patients with sepsis and other severe infections between patients receiving and not receiving granulocyte transfusions because the need for transfusions of granulocytes indicates more severe patients, when they have infections in a neutropenia or dysfunction of the immune system, and refractory to antibiotics cp hemolytic disease of the newborn due to anti-rh keegan barry-holson* and jennifer andrews . stanford university, dept of pathology, stanford university, dept of pathology & pediatrics background/case studies: anti-rh is a rare antibody against a high incidence red blood cell (rbc) antigen (ag) present in people with common rh phenotypes. this ag is missing in individuals who are rh null or have rh deletion phenotypes, including d--/d--. d--individuals strongly express d and lack c, c, e, and e ags. the clinical relevance of anti-rh has primarily been reported in pregnant women, causing mild to fatal hemolytic disease of the newborn (hdn). we present a rare case of hdn due to anti-rh alloimmunization during pregnancy in a d--mother. study design/methods: an o-positive full term infant was born to an opositive g p > mother with a negative st trimester antibody screen and no prior transfusions. she had two prior pregnancies, the first resulted in a normal term singleton, and the second resulted in a spontaneous miscarriage during the st trimester. father's blood type is unknown but presumably he has rh antigens. the infant was transferred to our institution at hours of life because he was found to have anemia (hemoglobin . g/dl), severe hyperbilirubinemia (total bilirubin (t bili) . mg/dl), reticulocytosis ( %) and a positive direct antiglobulin test (igg ). he was admitted to our neonatal intensive care unit for potential need for exchange transfusion given concern for hdn. he was treated with intravenous immunoglobulin and triple phototherapy on the day of admission, temporarily blunting his hemolysis. t bili rose to a maximum of . mg/dl on day of life and phototherapy was restarted. his t bili subsequently stabilized and he was discharged home and followed in clinic. meanwhile, his mother donated blood given there were no compatible red blood cells available in the united states via rare donor query. nine days after discharge, he was readmitted for worsening anemia (hemoglobin . g/dl) and was given steroids and washed maternal red blood cells. he was discharged and followed in clinic for several months with ultimate resolution of his anemia and hyperbilirubinemia. results/findings: at delivery, the mother's antibody screen was positive and anti-rh was identified; no other alloantibodies were detected. antibody identification was performed using polyethylene glycol, low ionic strength solution and ficin enhancement. maternal serum was pan reactive against panel cells and non-reactive against d--cells. anti-rh sera did not react against maternal rbcs. phenotyping of the mother revealed that she was d c-e-c-e-. molecular testing confirmed her d--genotype; molecular beadchip test yielded no type due to low signal for e, e, v and vs ags. genotyping for rh variant and targeted genomic rhce testing failed to detect several rhce exons. father was unavailable for further testing. conclusion: we report a rare case of hdn due to anti-rh antibody in a d --mother. we hope to obtain further laboratory studies in maternal relatives given the rarity of this phenotype in the general population. these studies have important implications for genetic counseling for mother's sisters. management of severe autoimmune hemolytic anemia: a case report of an infant treated with manual whole blood exchange with rapid clinical improvement yunchuan delores mo* , cyril jacquot , valli criss , philippe p pary , jay greenberg , naomi lc luban and edward cc wong . children's national medical center, quest diagnostics background/case studies: management of severe autoimmune hemolytic anemia (aiha) presenting with life-threatening anemia is challenging, particularly in the pediatric population. mortality rates in aiha are typically low; however, in children, the rate may be as high as - %. although corticosteroids and immunomodulatory therapies are first line modalities, several case reports describe the use of manual whole blood exchange (wbex) to successfully treat aiha in older children and adults refractory to first line treatment. to our knowledge, this is the first case report in which an infant with severe aiha has been successfully treated with manual wbex in an acute care setting. study design/methods: case report format. results/findings: a month-old previously healthy female patient presented to the emergency department with hemodynamic instability and a nadir hemoglobin (hb)/hematocrit (hct) of . g/dl/ . %. wbc counts ( x /l) were mildly elevated and platelet counts ( x /l) were within normal limits. her history was notable for upper respiratory tract infection days prior to the onset of anemia. laboratory studies on admission showed hyperbilirubinemia (total . mg/dl, direct . mg/dl), normal ldh ( u/l), and undetectable haptoglobin (< mg/dl) indicative of ongoing hemolysis. clinical symptoms included diffuse jaundice, hemoglobinuria, lethargy, and emesis. she was admitted to the pediatric intensive care unit for further management, including right internal jugular central venous catheter placement due to poor peripheral vascular access. the patient's blood group was o, rh (d)-negative with a positive antibody screen and panel demonstrating a strong panagglutinin ( - reactivity) with positive autocontrol. dat was positive for anti-igg and negative for c despite a positive cold antibody screen. the patient weighed . kg with an estimated total blood volume of ml. she initially received simple transfusions totaling ml/kg of least incompatible group o rh(d)-negative rbcs with no incremental response. manual wbex was then performed with ml of reconstituted whole blood consisting of o, rh(d)-negative rbcs and ab fresh frozen plasma (ffp) to an hct of %, utilizing the central venous catheter. no adverse events took place over the course of the hour exchange. her one hour post-exchange hb was . g/ dl and a subsequent antibody screen demonstrated reduced intensity of the panagglutinin ( ). after initiation of steroid therapy (methylprednisolone, mg/kg/day), she continued to improve clinically. one week later, the patient was discharged home with a hb of g/dl. one month later, she experienced recurrent hemolysis requiring re-hospitalization, at which time she had normal igm and iga levels with markedly elevated igg levels ( mg/dl). at a subsequent follow-up visit months after her initial presentation, her anemia had resolved and she had been completely weaned off steroids. conclusion: we demonstrate a case of severe neonatal aiha successfully treated with manual wbex. the main advantages of wbex include removal of both autologous rbcs and plasma as well as infusion of allogeneic rbcs. in this case, manual exchange transfusion avoided the need for an automated apheresis procedure requiring citrate anticoagulation. in summary, manual wbex is a potentially safe procedure that may be performed in young children with severe aiha. abstract operating room, each experienced blood-colored urine, laboratory evidence of hemolysis, and acute kidney injury. clerical and serologic investigations revealed no cause for hemolysis. mechanical hemolysis from transfusion rate, catheter gauge, or a recently introduced one-way valve was considered. study design/methods: in vitro simulated transfusions were performed via syringe. measurements included hematocrit (hct), free hemoglobin, and visual hemolysis index. washed and unwashed red blood cells (rbcs) were tested with or without a one-way valve, using a or gauge (g) intravenous (iv) catheter. each one-way valve was used to test three identical samples. constant pressure was applied manually (rapidly, . /- . ml/ second) or with a mechanical syringe pump (slowly, ml/min). a subset of the manual transfusions was timed. control samples for baseline measurements were collected by gravity drip, without passing through the one-way valve or catheter. results/findings: the one-way valve increased hemolysis markedly during rapid transfusion using both catheters as well as both washed and unwashed rbcs (see table) . with the g catheter, the mean change in hct was - . /- . % with the one-way valve and . /- . % without (p< . ). comparing the one-way valves tested, differences in hemolysis were observed (change in hct; p< . ). during rapid manual transfusion with a g catheter and unwashed rbcs, hemolysis was greater for samples that took longer to transfuse . ml when using a one-way valve (change in hct versus time: r - . , p< . ) compared to a significantly different (p . ) slight increase in hemolysis for samples that took less time to transfuse . ml when not using a one-way valve (change in hct versus time: r . , p . ). correlations between time and hemolysis were similar, but insignificant using g with washed rbcs and the g iv catheter. conclusion: mechanical hemolysis should be considered when investigating possible hemolytic transfusion reactions, especially with high rates of transfusion and use of a one-way valve. during rapid manual transfusion with the one-way valve, greater resistance was associated with increased hemolysis. background/case studies: gerbich (ge) antigens expressed on glycophorin c are present in . % of the population. ge antibodies cause delayed hemolytic transfusion reactions and hemolytic disease of the fetus and newborn (hdfn). ge antibodies also suppress erythropoiesis resulting in late-onset anemia. we report a case of hdfn due to anti-ge . study design/methods: a woman of paraguayan origin with prior terminated pregnancies presented at weeks gestation with passive anti-d and an anti-ge titer of . she was d-and ge:- ,- , by antigen typing. her obstetrician scheduled maternal blood collection near her due date for possible neonatal transfusion, but the woman went into labor at weeks. cord blood was dat positive for igg; the eluate confirmed anti-d and anti-ge . the birth hemoglobin (hgb) was . g/dl, reticulocyte (retic) was . %, bilirubin (bili) was . mg/dl; the infant was discharged. on day of life, the infant was referred to pediatric hematology for lethargy and poor feeding, with hgb . g/dl, retic . %, and bili . mg/dl. ge -blood was not available from the blood center or rare donor registry. the mother was b rh-and baby was b rh . obstetrics had to authorize maternal blood donation due to her hgb of . g/dl. maternal blood collection and rbc washing was expedited and the infant received ml of maternal rbcs within hours, at which time his hgb was . g/dl. post-transfusion hgb was . g/dl. one week later, the infant was symptomatic with hgb . g/dl, retic . %, bili . mg/dl. a nd aliquot of ml washed maternal cells was transfused. two weeks thereafter, the infant had hgb . g/dl, retic . %, anti-ge titer , and needed another transfusion. the maternal blood stored for just weeks had hemolyzed necessitating a nd maternal donation for baby's rd transfusion. at weeks, the infant's anti-ge titer was , hgb . g/dl, retic . %; no transfusion was necessary. at weeks of life, hgb was . g/dl, retic was . %, and the baby was thriving. results/findings: serologic studies at the hospital and reference blood center confirmed the antibodies and risk of anti-ge hdfn. molecular analysis revealed that the mother was homozygous ge -negative ge* .- , the father had homozygous wild type ge* , and the infant was heterozygous ge* /ge* .- . conclusion: the infant had hdfn due to antibodies to the high prevalence ge antigen. the continued need for transfusion was consistent with hemolysis and suppression of erythrocyte production caused by anti-ge . hemolysis of stored maternal blood was consistent with the absence of glycophorin c. this case demonstrates that cooperative multidisciplinary care among the blood bank, donor center, obstetrics, and hematology in a rare case of hdfn resulted in a successful neonatal outcome. background/case studies: patient blood management is a collaborative approach to optimize transfusion therapies to improve patient outcomes. in pediatrics, blood management is not 'one size fits all' given the paucity of clinical trials to guide evidence-based practice. in addition, pediatric care encompasses a very heterogeneous patient population such that applying one set of guidelines is difficult. because there are no standard, evidence-based clinical best practices regarding blood product usage in all children, unnecessary variation is occurring at our institution. we designed a robust analytics process to study baseline clinical practice and examine blood product usage, and plan to target the three pediatric sub-specialties with highest usage to establish standards in order to decrease variation/unnecessary transfusions. study design/methods: a data base encompassing all admissions and outpatient visits to a large, tertiary care academic children's and women's hospital was established, and included all relevant patient demographics, diagnostic and procedural codes, attending physician and specialty for each visit/admission, relevant hematology/coagulation laboratory results and blood product orders. we focused on rbc orders given the tripicu randomized clinical trial results ( ) supporting a hemoglobin trigger of g/dl in stable critically ill children and ffp since anecdotally we noted many children receiving this product for only minimally elevated international normalized ratio (inr) values without bleeding. results/findings: in , , rbc orders occurred and the top three patient groups were: % in congenital heart disease patients, % in hematology/oncology patients and % in neonates in the neonatal intensive care unit (nicu). average hemoglobin of every patient was . g/dl as measured in the hours prior to rbc order placement. in , ffp orders occurred and the top three patient groups were: % in neonates in the nicu, % in congenital heart disease patients and % in pediatric intensive care patients. average inr of every patient was . as measured in the hours prior to ffp order placement. conclusion: we have designed a robust data base that is continually updated for children in a large, tertiary care academic children's hospital. this serves as an important benchmark in pediatric blood utilization, and we plan to leverage usage patterns to make relevant practice changes in the care of children with a heterogeneous set of illnesses. background/case studies: bacterial contamination of plts remains an ongoing threat to transfusion recipients. recently, a psoralen-based pr technology that reduces the replication potential of pathogens in stored plts was fda approved. we describe our approach to phasing pr-plts into our inventory, including preliminary results of an ongoing qa study of neonatal and pediatric (peds) recipients of pr-plts. study design/methods: before the arrival of pr-plt, we undertook an educational campaign for hospital administrators, it staff, laboratory staff, clerical/clinical aides, nurses, and physicians. we also contacted risk management and the hospital ethics committee. phototherapy devices used at our hospital were confirmed to be compatible with the psoralen-based pr-plt product. shortly following the arrival of pr-plt, we introduced day bacterial "safety measure" testing of our conventional (c-plt) supply. a peds qa study monitored plt utilization and adverse transfusion event reporting relating to both pr-and c-plt transfusions. this study evaluated neonates ( - months of age), infants (> - months of age) and children (> months- years of age) who received at least one transfusion of pr-plts. results/findings: risk management and the ethics committee agreed that both pr-plts and bacteria tested c-plts would be the hospital standard of care. pr-plts were phased in and transfused to patients based on abo compatibility and expiration date, per routine, without regard for patient age or medical condition. after months, pr-plt represented % of our platelet inventory (average daily plt inventory: units). we encountered no complications with the pr platelet phase-in, either from a clinical, informatics or logistical perspective. due to the dual inventory, many peds patients in all age groups were transfused with both pr-and c-plts (table) . two potential transfusion reactions (trs) were reported over the study period in teenage recipients, one associated with a c-plt and the other with a pr-plt. in both cases, the symptoms were ultimately attributed to an underlying medical condition. no rashes were observed among transfused neonates ( - m) who received any pr-plts and phototherapy. background/case studies: packed red blood cell (prbc) transfusions are believed to improve oxygen delivery particularly in vulnerable patients such as neonates and children. however, evidence shows that hemoglobin (hgb) in prbcs has increased oxygen affinity and thus reduced oxygen delivery to tissues due to decreased , dpg levels. standardization of prbc transfusion practices in this population and the scientific evidence on which current practice is based is limited. additionally, due to small transfusion volumes, infants may be exposed to multiple blood donors, increasing their potential for adverse events. study design/method: medical records of pediatric patients receiving prbc transfusion over a month period were retrospectively reviewed. a total of patients were identified as receiving allogeneic prbc transfusion. patients who received autologous blood (cell salvage) were excluded. patient characteristics, length of stay, prbc transfusion volume, pre-and post-transfusion hgb, and adverse events were collected. results/finding: the average pre-transfusion hgb was . g/dl with post-transfusion hgb rising to . g/dl. the mean prbc volume transfused was . ml using a dose of ml/kg for all patients. complications noted were; volume overload, thrombosis, fever/infection, hemolysis, necrotizing enterocolitis (nec), and death (table) . conclusion: evidence based transfusion guidelines are lacking in neonates and infants. a typical dose of - ml/kg in a kg patient, for instance, would translate into full prbc units (about ml) in an average size adult. the current standard dose of - ml/kg yields very high increases in hgb and may put these patients at risk of adverse outcomes, especially thrombosis due to increased blood viscosity. additionally, many of these patients received volume reduced products which delivers a higher hgb concentration per transfusion. dosing should be based on goal hgb and patient condition rather than weight based, though the hematocrit level at which the benefits outweigh the risks remains unclear. pneumoniae has rarely been associated with warm autoimmune hemolytic anemia, with only case reports suggesting this association. however, each of these cases is confounded by other findings in addition to a mycoplasma infection. we describe a unique case in which a pediatric patient has clear evidence of severe hemolysis, a very strongly reactive warm autoantibody, and clinical and laboratory evidence of a mycoplasma infection without a detectable cold agglutinin. study design/methods: the patient is a month-old, previously healthy female infant who presented to the hospital with a -week history of fever, fatigue, decreased appetite, and pallor. she was only treated with acetaminophen. she also developed clear rhinorrhea the day before hospital admission. at the time of her admission, laboratory testing (outside hospital) revealed a hemoglobin and hematocrit of . g/dl and . %, respectively, platelets of , , and a reticulocyte count of . %. all other elements of the complete blood count were within the normal reference range for age. a complete metabolic panel revealed no abnormalities except for a total bilirubin of . mg/dl with a direct fraction of . mg/dl. a filmarray respiratory panel (biofire diagnostics; salt lake city, ut) detected mycoplasma pneumoniae, while all other pathogens ( total) were non-detectable. the patient was started on a -day course of azithromycin (zithromax). results/findings: prior to rbc transfusion, blood bank evaluation revealed that the patient was o-positive and had a stronglyreactive antibody screen. further testing demonstrated an antibody reactive with all reagent red blood cells. the dat was strongly reactive for igg but very weakly reactive for c . an eluate was reactive with all reagent red cells tested. finally, a cold agglutinin study was negative with undiluted serum. in addition to starting azithromycin, the patient was given iv methylprednisolone. during her -day hospital course, the patient received rbc transfusions on the day of admission and several rbc transfusions thereafter (see table ). despite transfusion, her hemolytic process persisted, so she was infused with a dose of iv immunoglobulin on hospital day . her hemoglobin rose to . g/dl on hospital day and increased to . g/dl on hospital day . at that time, the patient was discharged from the hospital with instructions to wean her oral steroid dose over the next weeks. she was followed closely by the hematology clinic and was found to have a stable hemoglobin (up to . g/dl on day after her hospital admission) with no recurrence of her hemolytic process. conclusion: m. pneumoniae infection is a typical cause of cad and has only rarely been associated with warm autoimmune hemolytic anemia. our case demonstrates clear evidence of severe warm autoimmune hemolysis in a previously healthy infant. with the increasing use of multiplex respiratory viral and bacterial pathogen detection systems, the once rare phenomenon of a m. pneumoniae infection associated with warm autoimmune hemolytic anemia may become a more recognized entity. ) and may serve to more reliably reflect when the neonates at risk for hyperbilirubinemia. the difficulty in eliminating the cord blood testing is the neonatologists' reliance of using abo incompatibility as part of the neonates risk assessment rather than using the point of care bilirubin testing. currently the ts requires all positive dat tests to be communicated to the nursing staff immediately. given that the dat strength positively correlates with the percentage of neonates diagnosed with hyperbilirubinemia, the ts staff may also consider notifying nursing staff only for those patients whose dat is or . platelet and leukocyte immunohematology, testing and genetics table . of pairs, pairs were complete match ( / ), pairs were partial match ( / ), pairs were complete mismatch ( / ). the matching rate of hla-dpb in our study is %. conclusion: the matching rate of hla-dpb in / hla matched unrelated hematopoietic stem cell transplantation is low and the gene frequency of hla-dpb in unrelated hematopoietic stem cell transplantation was obtained ,which will help to study on the relationship between hla-dpb and unrelated hematopoietic stem cell transplantation. this work was sponsored by national science foundation of china ( ) background/case studies: thrombotic thrombocytopenic purpura (ttp) is caused by severely reduced activity of the von willebrand factor-cleaving protease adamts . therapeutic plasma exchange (tpe) as well as immunosuppression minimize the morbidity and potential mortality of this presentation. absolute immature platelet counts (a-ipc) have been shown to help diagnose and follow ttp patients' responses to therapy. we report the case of a man with relapsing ttp, low adamts with high inhibitor, treated with mycophenolate mofetil in which a-ipc-indicated an unexpected response to therapy. study design/method: a year old male with a -year history of ttp, presented with status epilepticus complicated by acute respiratory failure admitted with suspicion for relapsing ttp. patient had been treated in prior admissions with tpe, prednisolone, rituximab, and cyclophosphamide with clinical improvement. he was on mycophenolate mofetil maintenance therapy which he last received just prior to day of admission due to consistently low platelet counts, adamts < % and inhibitor of . . on day of admission platelet count was x /l which decreased within five days to x /l leading to initiation of daily tpe along with mycophenolate mofetil discontinuation just prior to tpe start. immature platelet fraction (%-ipf) and calculated a-ipc (%-ipf x platelet count) were obtained with daily pre-tpe cbc. a-ipc ratio was calculated from baseline. abstract results/finding: a-ipc and platelet count were x /l and x /l respectively. counts improved rapidly post-tpe initiation and after one tpe his a-ipc tripled to . x /l achieving the ratio of previously shown to be diagnostic of ttp. on day his a-ipc and platelet counts had improved to . x /l and x /l respectively. absence of anti-pf antibodies ruled out heparin-induced thrombocytopenia at this time. on day he had an unexpected decrease in both a-ipc and platelet count to . x /l and x /l respectively, worsening by day to . x /l and x /l respectively despite daily tpe. patient received additional tpes that failed to improve a-ipc or platelets which on day were . x /l and x /l respectively. a-ipc had remained at this level for days suggesting that the observed decrease was irreversible. adamts activity remained < % low with a high inhibitor. patient's clinical condition continued to deteriorate and family placed patient on comfort care. conclusion: ttp patients have low a-ipc and plt counts at presentation, with the former improving first post-tpe initiation. despite appropriate therapy leading to early improvement of platelet count, patient's counts declined rapidly leading to suspicion for platelet production suppression as indicated by the sustained very low a-ipc. in the setting of ttp, or relapsing ttp use of immunosuppression should be closely followed and a-ipc may aid in establishing early if therapy is affecting platelet production. application of luminex bead technology to detect hpa- a, hpa- a, and hpa- a antibodies su-dan tao*, ying liu, yan-min he, ji he and fa-ming zhu. blood center of zhejiang province, key laboratory of blood safety research, ministry of health background/case studies: detection of antibodies against human platelet antigens (hpas) is crucial for patients' refractory to platelet transfusion therapy. in the text, luminex bead coupled with anti-gpiib/iiia and anti-gpia/iia monoclonal antibody was implied to detect hpa- a, hpa- a, and hpa- a antibodies, and the sensitivity of luminex bead technology was compared with monoclonal antibody immobilization of platelet antigens (maipa) assay. study design/method: monoclonal antibodies p and gi , specific for platelet glycoproteins gpiib/iiia and gpia/iia, were separately coupled to luminex xmap beads. four standard sera, containing anti-hpa- a, anti-hpa- a, anti-hpa- a and anti-hpa- b respectively, were bought from nibsc; three negative sera without hpa antibodies were prepared from ab type blood donors. platelets (containing hpa- aa, hpa- ab and hpa- aa) were collected and reacted with anti-hpa- a, anti-hpa- a, anti-hpa- a and anti-hpa- b standard sera respectively, then the antigen-antibody reaction complexes were lysed and the lysates were incubated with luminex beads to specifically capture antigen-antibody complexes via the epitopes on platelet glycoproteins. the beads-antigen-antibody complexes were then subjected to flow cytometric analysis on a luminex . the hpa- a serum was diluted to serial dilutions (from neat to / ) to test the sensitivities of maipa and luminex beads assay. the two methods were then used to test five blinded samples which were collected from fmait patients. results/finding: luminex bead technology showed that the mfi values of hpa- a, hpa- a, hpa- a standard sera samples reacted with the coupled beads were significantly higher than the negative controls ( . vs . ), which implied that the luminex bead technology could specifically identify negative and positive sera of anti-hpa- a, anti-hpa- a, anti-hpa- a. furthermore, because the platelet was hpa- aa, the hpa- b serum did not react with the coupled beads with mfi was comparable to negative control ( . vs . ). the sera were re-tested by maipa and the results of which were comparable to luminex bead technology, illustrating that detecting hpa antibodies by luminex beads technology was successful. the sensitivity of luminex bead assay and maipa to detect anti-hpa- a was / ( . iu/ml) and / ( . iu/ml), respectively. no cross-reactivity was observed with the samples containing hla, abo or other platelet antibodies. all results of five blinded samples tested by luminex assay showed that four sera were positive for gpiib/iiia antibodies which were consistent with maipa results. conclusion: the luminex beads coupled with gpiib/iiia and gpia/iia monoclonal antibodies could be successfully used to detect hpa- a, hpa- a and hpa- a antibodies via the epitopes on platelet glycoproteins. the sensitivity of luminex technology was higher than maipa technology. (ahus) is a thrombotic microangiopathy (tma) characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia and renal failure in the absence of infectious toxin. the literature suggests the presence of pathogenic mutations in complement proteins in % of cases of ahus. there is a lack of well-defined recommendations regarding testing for genetic ahus. complement pathway mutation analysis is an expensive test so appropriate utilization is crucial to prevent undue health care costs. we reviewed the indications for genetic testing to understand physician ordering practice and determine the frequency of pathogenic mutations in the population. study design/method: we performed a retrospective review of all cases referred for complement pathway mutation analysis to a national reference laboratory from january to december . clinical history was solicited by genetic counselors. cases were classified by the authors as primary ahus (tma and renal failure without identifiable cause), secondary tma (tma and renal failure with identifiable cause previously associated with tma) or non-tma. the test panel identified variants in complement proteins (cfh, cfi, mcp, factor b, c , c bp, thbd, dgke, cfhr , cfhr , cfhr and cfhr ) that were classified as vus (variances of uncertain significance), pathogenic or benign by the american college of medical genetics. chi square analysis/fishers' exact test was used to determine differences in proportion of patients with pathogenic mutations and primary ahus versus secondary tma. independent sample t-test was used to compare differences in continuous variables between primary ahus and secondary tma. results/finding: of patients tested, pathogenic mutations were detected in % ( / ) and vus in % ( / ). % ( / ) of patients did not fulfill criteria for tma; no pathogenic mutations were found in this group and ( %) had vus. % ( / ) of patients had primary ahus; of these, % ( / ) had pathogenic mutations and % ( / ) had vus. % ( / ) of patients had secondary tma; of these, % ( / ) had pathogenic mutations and % ( / ) had vus. in patients with pathogenic mutations, % ( / ) were children, . % ( / ) had a positive family history of ahus and % ( / ) had recurrent disease. patients with primary ahus had a significantly lower age at presentation ( vs. yrs; p-value: . ) and a higher proportion of pathogenic mutations ( % vs. % p-value: . ) compared to patients with secondary tma. gender distribution, hemoglobin nadir and serum creatinine levels were similar between the two groups. conclusion: we found a lower frequency of patients with pathogenic mutations compared to reported literature. our data suggests that patients with secondary tma should be carefully evaluated prior to ordering genetic testing and those without tma should not undergo this test. counting of platelets in platelet concentrates on hematology analyzers pentraxl and sysmex xn compared with a flow cytometric method farshid ezligini , kjersti roen eriksen , annette vetlesen , thomas larsen titze and geir hetland* , . oslo university hospital, university of oslo background/case studies: hematology analyzers are made for counting of whole blood samples but are often used for quality control of blood components such as platelet (plt) concentrates (pcs). a flow cytometric method for counting of plt in pcs has been developed as validation tool (van der meer et al, transfusion ). therefore, it is pertinent to evaluate plt counting in bcs on hematology analyzers with this validation method in a flow cytometer. study design/methods: samples from ten apheresis pcs and buffy coat-derived pcs were subjected to plt counting on hematology analyzers pentraxl (horiba abx, montpelier, france) and xn sysmex toa (kobe, japan) (both impedance score), and additionally, diluted and stained with anti-cd a fitc in truecount tubes (bd biosciences)(internal bead standard) for measuring in a gallios flow cytometer (beckman coulter, indianapolis in, usa). results were analyzed by paired samples test and shown in bland-altmann plots. results/findings: mean plt values x /l sd were , (<) , (<) and for counting by sysmex toa, pentraxl , and the gallios flow cytometer, respectively. sysmex count was the very lowest a transfusion vol. supplement s abstract ( . % less than for flow cytometry), but all plt counts were significantly different (p< . ), although least so ( . %) between pentra and flow cytometry. conclusion: as validated by the flow cytometric method, pentraxl seems suitable for routine quality control of pcs both because of the small difference and lower counts compared with flow cytometric method, which is too cumbersome in a routine setting. the much lower plt count on sysmex may reflect its optimization for plt counting in whole blood rather than in pcs. fast, precise & easy hpa typing with real-time pcr jonathan downing , arishma lata , roland russnak , zachary antovich , heather dunckley and thierry viard* . new zealand blood service, linkage biosciences background/case studies: the interaction of membrane-bound plateletspecific glycoproteins with the extracellular matrix plays a significant role in hemostasis. human platelet antigens (hpa) found within these glycoproteins can stimulate production of antibodies in recipients of transfused platelets or in fetus of mothers with incompatible hpa. thus, platelet incompatibility is associated with various forms of thrombocytopenia, posttransfusion purpura and other blood disorders. the new zealand blood service performs hpa typing on a pool of platelet donors to provide compatible transfusions where the need arises. the molecular basis of most hpas has been characterized as generally caused by a single-nucleotide polymorphism (snp). hpa typing has typically been performed using pcr-ssp, a method that utilizes time-consuming post pcr analysis steps. the aim of this study was to evaluate the use of real-time pcr-based techniques in a transfusion laboratory setting. study design/method: we evaluated a commercially available solution which consists of reactions that identify both variants of relevant snps located within hpa genes (hpa- through hpa- , and hpa ). genomic dna purified from blood samples, previously genotyped for hpa- ,- ,- ,- ,- and - by our in house pcr-ssp method were used in this study as validation samples. results/finding: results of the validation samples were % concordant with typing obtained by pcr-ssp. the real-time pcr approach overcomes the major challenges of hpa molecular typing by providing an automated solution resulting in increased laboratory productivity and decreased turn-around time. the analysis is facilitated by a software which generates the results. with less than minutes of hands-on set-up and no further operator intervention with the reagents, complete molecular genotyping results are provided in approximately minutes. further, since amplified products are never handled, the risk of laboratory contamination is significantly reduced. the real-time pcr approach with automated analysis was implemented by the new zealand blood service tissue typing laboratory in late and to date has tested dna samples from blood donors ( donors were tested in duplicate). concordance between the sample replicates was %. there were occasions where the assay had to be repeated, giving a repeat rate of . %. occasionally a reaction peak was insufficient to trigger the software automatic allele call and a manual interpretation was required. this occurred most commonly with the hpa- ( . %) and hpa- ( . %) assays. conclusion: real-time pcr with automated analysis provides an effective, robust an accurate method for molecular hpa genotyping. with its minimal hands-on time workflow, it is also very easy to implement and offers a cost effective alternative to classical methods used in a transfusion laboratory setting. genetic variation of cd antigen deficiency expression in jiangsu chinese han population qing chen* , jianyu xiao and chengyin huang . jiangsu province blood center, jiangsu province blood center background/case studies: cd has been implicated in the platelet refractoriness, neonatal alloimmune thrombocytopenia, and posttransfusion purpura, especially in the non-caucasian. cd deficiency varies widely among different ethnic populations, with the frequency of - % in asians and . % of african americans, respectively. however, there is little information on the molecular basis of individuals with cd deficiency in jiangsu chinese han population. study design/method: to investigate platelet cd expression levels and to determine the molecular basis of cd deficiency on the platelet surface of the han population in jiangsu region. cd expression levels on platelets were detected by flow cytometry among blood donors in jiangsu region. donors without cd antigen expression on their platelet surface were further to be determined the expression of cd antigen on their peripheral blood monocyte cells. the coding exons of cd gene and adjacent introns were amplified and sequenced in cd deficient individuals. results/finding: among these blood donors, cd -deficient and cd -expression individuals were . % ( / ) and . % ( / ), respectively. the frequencies of type i and type ii cd deficiency among the study population were . % ( / ) and . % ( / ), respectively. among individual with platelet cd expression, according to mean fluorescence intensity (mfi) value, , and individuals showed low, moderate and high expression levels of cd , respectively, and their mfis were . . , . . and . . (p< . ), respectively. the type i cd deficiency individual were heterozygous for - a>g and - c>g, respectively. among type ii cd deficiency individuals, two harbored a t insertion at position in exon which caused frameshift at codon ; one has a t>c exchange at position in exon which resulted in a tryptophan to arginine substitution at codon ; one has a a insertion before the th bp of the start codon atg in the promoter region; one were heterozygous for t>c and t>g, respectively. conclusion: platelet cd surface expression levels were diversified in the jiangsu chinese han population. the frequency of the type ii cd deficiency was higher than that in type i. the study findings indicated that the frequency of cd deficiency in the chinese population is slightly lower than that in other asian countries. background/case studies: cd -deficient phenotype can be immunized by pregnancy or transfusion, and involved in neonatal alloimmune thrombocytopenia, platelet transfusion refractoriness and other disorders. the frequency of platelet cd -deficient individuals widely varies among ethnic groups, with % to % in japanese, % in sub-saharan africans, . % in african americans, and . % in caucasians. although some studies of cd deficiency are focused on the asian populations, relatively little information has been reported in the chinese population. here we investigated the cd expression on platelets in large samples of the eastern chinese donors. study design/methods: peripheral blood samples were collected from unrelated platelet-apheresis donors in the eastern china. the expression of cd antigen on platelets was determined by flow cytometry using fluorescein conjugated monoclonal antibodies (fitc-anti-cd and peanti-cd ). the isotype control (fitc-mouse igg) was also analyzed to calculate a reference range of cd -nagtive phenotype. for those donors with cd -negative platelets, cd antigen expression on monocytes was analyzed further to distinguish between cd type i and type ii deficiency. flow cytometric parameters were statistically analyzed by mann-whitney test. the work was supported by national natural science foundation of china ( ) and zhejiang high-level innovative health talents. results/findings: the mfi (mean fluorescence intensity) of platelet cd in all samples showed a continuous distribution profile, and no obvious fluorescence-gap could be utilized to distinguish negative from positive phenotype. on account of this limitation, we classified the cd phenotypes using the (mean sd) of the background mfi observed in isotype controls. forty-three samples were detected as cd deficiency on platelet, in which one sample was cd negative both on platelet and monocyte. the frequency of cd type i and type ii deficiency in the eastern chinese donors was . % and . %, respectively. the average mfi of cd deficiency samples was significantly lower than cd positive samples ( . . vs . . , p< . ). conclusion: the frequency of platelet cd deficiency in the eastern chinese donors was close to japanese and african americans. it means that the possibility of cd antibody occurred by pregnancy and transfusion in this population is existed. it is useful to find and register cd -deficient donors by large-samples screening for potential immune thrombocytopenia patients with cd antibody. background/case studies: cd (gpiv, chromosome q . ) is an kda glycoprotein expressed on multiple cell types including platelets (plts), monocytes (mono), & erythroblasts. although rare among whites, cd deficiency (cd -n) is observed in - % of africans (t g) & is classified as either type i (cd -n plt, cd -n mono) or type ii (cd -n plt, cd mono). an acquired type ii cd -n phenotype can also be observed in the setting of myelodysplastic syndrome (mds). type cd -n individuals can develop anti-cd alloantibodies with plt refractoriness & neonatal alloimmune thrombocytopenia. we report a case of profound plt refractoriness caused by anti-cd in a patient with newly diagnosed mds. study design/method: hla antibody testing was performed with a commercial bead-based fluorescent assay. cd phenotyping (plt, mono) of patient & family members was performed by flow cytometry (fc). cd staining of bone marrow was performed by immunohistochemistry. plt crossmatching (plt-xm) was performed by the american red cross. pltspecific alloantibody testing & cd dna sequencing were performed at a commercial reference laboratory. results/finding: the patient was an year-old, group o african-american male who presented with blurry vision & lightheadedness. complete blood count findings were significant for hemoglobin . g/dl & plt count k/ml. bone marrow biopsy & cytogenetic analysis revealed multilineage dysplasia, - % blasts & a complex karyotype with del( )(q q ) consistent with mds. plt refractory work-up was initiated after repeated plt transfusion failures with corrected count increments (ccis) < . hla antibody testing was negative (class i panel reactive antibody (pra) %). the patient was plt-xm-incompatible with most donors ( / ). a trial of group o, plt-xm-compatible plts was unsuccessful (cci ). subsequent testing for plt-specific alloantibodies identified anti-cd . fc-phenotyping showed no cd on patient's mono or plt, consistent with type i cd -n. preliminary dna results show that the patient is heterozygous for t g. because cd -n apheresis plt were unavailable from blood suppliers, the patient's children & grandson were screened as possible donors: all showed normal cd expression on plts. trial of eltrombopag & romiplostim was attempted with no improvement in plt count. repeat hla antibody testing (day ) demonstrated new class i alloantibodies (pra %) in response to transfusion ( apheresis plts, rbcs). given his plt refractoriness & poor prognosis, the patient opted for hospice. conclusion: we describe a patient with cd -n & severe plt refractoriness in the setting of new mds, and q-chromosomal abnormalities. the absence of cd on plt & mono support congenital type cd -n although a contribution by the patient's underlying mds cannot be excluded. rapid platelet donor classification: hla & hpa profiles by "leansequencing" without dna purification dipika patel , kristopher fernandez* , eric senaldi , pascal george , michael seul and ghazala hashmi . biomolecular analytics, central jersey blood center background/case studies: prophylactic platelet transfusion is the standard of care for managing thrombocytopenia. in the emerging paradigm of personalized medicine, the selection of cellular products in accordance with patient immunomolecular signatures has the potential to reduce the rate of antibody-mediated platelet clearance and thus to improve treatment efficacy. while the benefits of customizing transfusion therapy have long been recognized (gmur http://bit.ly/ q heq), the routine, real-time selection of platelets by immunogenetic profile has remained impractical by current methods of dna analysis. to address this issue, we evaluated a process of platelet donor classification using buccal swab samples from apheresis platelet donors for determining the combined hla class i and hpa signature without dna purification using a novel "leansequencing" process. study design/method: under a study protocol and informed consent, we evaluated a process for collecting and classifying buccal swab samples from $ adult donors who had made ! donations in the previous months. samples (labeled with study barcodes) were shipped weekly to biomolecular analytics ("bmx") for preparation of "crude extracts" for leansequencing: this novel process combines a proprietary sample pooling strategy with a protocol that eliminates many traditional sample "clean-up" steps. briefly, after preparation of crude extracts, samples were amplified, pooled and analyzed (in separate runs) for , , , , , , , , , and for hla class (a,b,c) , the latter using a proprietary design that limits analysis to informative alleles in the hla sequence; this "information-theoretic" design permits direct allele and haplotype reconstruction using bmx-proprietary software. a subset of crude extracts was purified and analyzed side by side with positive and negative controls. results/finding: crude extracts from buccal swabs produced viable profiles for hpa as well as hla class i with significant savings in time-to-result. as an illustration, the table reports allele frequencies for platelet-antigens ("hpa") that are consistent with a predominantly caucasian or hispanic platelet donor population (http://bit.ly/ pdplf ) in hw equilibrium. similarly, hla-class i haplotype frequencies were determined. conclusion: leansequencing lends itself to the rapid determination of hla-class i and hpa signatures of platelets; the process with its streamlined lean protocol achieves additional time (and cost) savings by accommodating crude extracts produced from buccal swab samples collected and handled in accordance with the process validated in this project. the process could be readily implemented to another site using the elements and process developed. the "pool & plex" process and the early donor recruitment enables economies of scale for matched donor procurement. the serological characteristics and heritage background of a novel hla allele, hla-a * : chuan-fu zhu*, yong-hong song, xiang-min nie and wen-ben qiao. blood center of shandong province background/case studies: there are , hla alleles documented according to the imgt / hla sequence database in janury , and more than % of them were identified in the last years. besides sequences many of the novel hla alleles have not been analyzed their serological reactivities. hla-a * : allele was fist detected in our laboratory during our hla typing for china bone marrow donor program(cmdp). for further study, the serological characteristics and heritage investigation were performed. study design/methods: the routine hla tying for the potential donors from cmdp were performed by bi-allelic sequence-based typing method,using a commercial kit (rose europe gmbh, frankfurt, germany). in the case of no full matched hla typing results, group specific hlassure-se sbt typing kit (texas biogene inc., taipei, taiwan) was employed to identify the nucleotide sequences of the novel allele. fresh blood samples were collected of the proband and his family members with the consent, in order to nanalysis the serological reactivities and the possible haplotype associations to the novel allele. the hla serological specificity was indicated by one lambda(asn d)hla kit. results/findings: no full matched result was obtained at hla-a locus in hla typing for a donor,which suggested the possible existence of a novel allele. the latter nanalysis indicated that the proband have a nove nucleotide sequences at hla-a locus, the new sequences was most close to those of hla-a * : : : , but nucleotide substitution in exon , by nt c-a (codon acc-aac), which resulted in one aminoacid substitution ,thr-asn. the novel hla-a allele was officially named as hla-a background/case studies: anti-d is a frequent cause of hemolytic disease of the fetus and newborn (hdfn). as a rule, immunization occurs in d negative pregnant women, but occasionally anti-d is also observed in carriers of d variants. currently, maternal plasma analysis for determination of the fetal rhd status became an exciting new tool for the management of d-negative pregnant women, but one of the challenges in non invasive fetal rhdgenotyping is the presence of d variants in the pregnant women. we present a case of a year-old pregnant woman typed as ab , who delivered a baby affected by severe hdfn. the newborn was typed as b and presented a positive direct antiglobulin test (dat) with an anti-d identified in the eluate. the baby was treated by exchange transfusion and the mother's sample was investigated. study design/method: serologic testing was done by hemagglutination in gel cards. genomic dna was extracted from whole blood by spin column and all rhd exons were sequenced by sanger sequence method. results/finding: the mother's rbcs reacted with the four monoclonal anti-d used (igm clones p x and rum and the blends clones th ms and d d ) and were typed as c-c e-e . an anti-d was identified in her serum. molecular analysis showed the c>t and a>c in exon , the snp t>c changes in exon and the t>g nucleotide change in exon . the set of snps found is similar to the molecular background of dol , except for a>c change. conclusion: this novel set of snps found in this mother is related to a novel rhd allele leading to a partial d antigen involved in the production of an anti-d that can cause severe hdfn. this finding shows the need to elucidate the clinical significance of different rhd genotypes in various ethnic backgrounds. the and erytra v r (the routine reference platform) was performed. a total of immuno hematological tests ( abo/d grouping (including newborn samples), extended erythrocytic phenotype, antibody screening, antibody identification, dat) and crossmatches were performed on patient's whole blood samples. the erytra eflexis v r performance was evaluated according to a protocol that was designed to simulate the routine workload using the system in its two different configurations. concordance between systems was assessed and discrepancies were analyzed. the following performance metrics were assessed: time to first result (ttfr), turn-around time (tat) for the total workload from first result to last result (throughput, results/h), and manual "handson" time required as well as walk-away time, considering the two different configurations of the system. for the ease of use evaluation, different usability features were ranked and the number of steps and timing of the following activities were tracked: sample sort and loading, routine testing, post-run procedures, consumables used, and space requirements. a threshold for in vitrodetection of anti-d gamma globulin was also determined. v r analyzer and the reference method were obtained in . % of the abo/d tests (n ), , % of the antibody screening tests (n ), , % of the antibody identification tests (n ) and % of the dat tests (n ). there were discrepancies ( abo/d for the same patient, for antibody screening and antibody identification: in both cases, the erytra eflexis v r could conclude whereas erytra could not due to a poor reaction. use of the stat mode (incubator is reserved for urgent tests) proved its usefulness when testing several samples (time saving was more than min). detection threshold of the d antibody was assessed at . ng/ml ( . ui/ml) whereas the french recommendations are ng/ml. the possibility of interchanging the trays (reagents/sample) makes also possible to optimize the analyzer operation. the impressions of the technical staff were positive regarding esthetic and functional design, intuitive and easy use, as well as flexibility. v r results demonstrated velocity, sensitivity, as well as the ability to easily perform the routine workload of a medical analysis laboratory. erytra eflexis v r meets both the requirements for french regulatory in immunohematology and for iso accreditation. background/case studies: kell system antibodies inhibit erythropoiesis causing severe anemia in hemolytic disease of the fetus and newborn (hdfn). we report a case of hdfn secondary to anti-kpb that resulted in multiple intrauterine transfusions of kp (b-) donor cells and hemolytic anemia upon birth. case: a year old g p presented during her fifth pregnancy with anti-kpb with an initial titer measured of . by history, the anti-kpb developed during her third pregnancy which ended in a spontaneous abortion before antibody titers could be initiated. the patient's antibody titers peaked at during the fourth pregnancy which resulted in a healthy male without anemia or jaundice. . in the latest pregnancy, ultrasound was initiated with elevated middle cerebral artery doppler exams ( . moms) peaking at weeks. this resulted in three intrauterine transfusions. due to potential labor and the finding of reversed diastolic flow on middle cerebral artery doppler studies, a finding that has been associated with impending intrauterine fetal demise, caesarean delivery was performed at weeks gestation. the baby boy required phototherapy for hyperbilirubinemia. the indirect bilirubin at birth was . mg/dl with . g/dl hemoglobin. the baby typed as o positive, kp (b ) with a micro positive dat. the antibody workup revealed an anti-kpb. continued hemolysis required one more transfusion at weeks of age. the positive dat and passively acquired anti-kpb were no longer detected by weeks of age. his hemoglobin recovered to . g/dl with an indirect bilirubin of . mg/dl at weeks of age. all clinical signs of hemolytic anemia were resolved. study design/method: serologic testing included peg iat by tube methods. acid elution was performed using immucor gamma elu-kit ii. molecular testing was performed using immucor bio-array hea platform. results/finding: antibody identification on the mother was performed as well as alloadsorption studies to rule out other underlying alloantibodies. a new weakly reacting anti-s was detected on the day of the delivery. the baby typed as s positive however the anti-s was not detected in an eluate prepared from the baby's red cells. all of the intrauterine transfusion units were s negative. conclusion: to our knowledge only five case reports have been described for anti-kpb which resulted in moderate to severe hdfn. pregnant mothers with anti-kpb detected should be monitored closely. background/case studies: in some clinical cases, the c d-specific dat may be too insensitive to detect low, but significant levels of c d, or it may be inconclusive due to spontaneous red cell (rbc) aggregation. further, the dat is not well suited to quantify the number of immunoprotein molecules on rbcs, since a " " reaction corresponds to about molecules/ cell. a number of flow cytometric methods for the detection of rbc-bound c d have been published. however, these are mainly designed to quantify the fraction of rbcs with c d-sensitization. the aim of this study is to present a flow cytometric method for the quantification of the level of rbcbound c d. study design/method: ten microliters (ul) of : (after documenting experimentally that this amount ensured maximum binding of anti-c d) mouse monoclonal anti-human anti-c d (abcam, clone c ) were added to ul of a . % rbc suspension. after incubation for minutes at c, samples were washed x , and ul of : diluted anti-mouse-f(ab) -pe (ro , dako) were added. after incubation at c, samples were washed and resuspended before being acquired on a flow cytometer (becton dickinson facscanto ii). to enable calibration of fluorescence signals in antibody binding capacity (abc), a calibration standard (dako qifikit) stained with ro was run in parallel with all experiments. background fluorescence (in abc) was subtracted to yield net abc values corresponding to specific staining with anti-c d. the assay, in parallel with our routine dat (dc-screening i, id-card, gel card, biorad) was applied to a series of a rbcs stained with levels ( fold dilution, : - : ) of o serum with high titer anti-a. to estimate the normal range of rbc-bound c d, edta-stabilized samples from healthy donors were tested. finally, the assay was applied to a sample from a patient with clinical aiha with an inconclusive dat due to unspecific dat polyreactivity. results/finding: the correlation of the net level of rbc-bound c d (values ranging from to , abc) with level of -serum dilution (used to sensitize a rbcs) proved to be highly linear (logarithmic vs. logarithmic plot; r . , p < . ). compared with dc-screening , the sensitivity of the flow cytometric assay was superior. it detected c d sensitization at least dilution steps further. the median normal level of rbc-bound c d was abc (range - abc, n ). the assay enabled demonstration of specific c d-sensitization in the patient; the level of rbc-bound c d in the sample was significantly elevated ( , abc). conclusion: the presented flow cytometric assay is capable of quantifying the level of rbc-bound with a high degree of linearity and analytical sensitivity. further, it is capable of quantifying the level of rbc-bound c d in dat polyreactive samples. background/case studies: abo blood group system of red blood cells (rbcs) consists of a and b oligosaccharide antigens and anti-a and anti-b antibodies against these antigens, which are present in the sera of individuals who do not express the antigen(s)(landsteiner's law). because of the expression of those antigens on some epithelial and endothelial cells in the body, the abo matching is critical not only in blood transfusion, but also in cell/tissue/organ transplantation. in spite of the fact that both antigens and antibodies are involved, these genetic traits are specified by a single genetic locus of abo. forssman (fors) system is another rbc blood group system which consists in a glycosylation polymorphism specified by the gbgt gene. in humans, the abo and gbgt genetic loci are located on chromosome q , and the functional alleles encode a and b glycosyltransferases (at and bt) and forssman glycolipid synthase (fs), which catalyze the last biosynthetic steps of a and b, and forssman (fors ) oligosaccharide antigens. the molecular genetic bases for allelism of those two systems in humans have been well-elucidated. the abo and gbgt genes are also present in some other species in addition to humans. however, the presence/absence and functionality/non-functionality are species-dependent. molecular mechanisms/forces that created this species divergence, including human polymorphism, were unknown. study design/methods: utilizing genomic information available from gen-bank and ensembl databases, the gene maps of the chromosomal region surrounding the abo and gbgt genes have been constructed of vertebrate species. results/findings: extensive similarities were observed in the kinds, numbers, and orders of genes, as well as their chromosomal locations. however, numerous differences were also identified. these include chromosomal rearrangements, as well as the insertions and amplifications of specific genes. interestingly, the abo and gbgt genes were found located at the boundaries of chromosomal fragments that seem to have undergone frequent inversions/translocations during species evolution. conclusion: genetic alterations, such as deletions and duplications, are known to be prevalent at the ends of rearranged chromosomal fragments. therefore, the species-dependent divergence and polymorphism within species of those clinically important glycosyltransferase genes may have been resulted, at least partially, from unstable chromosomal structures neighboring those genes. alloimmunization despite phenotype matching in a patient with sickle cell disease and a complex rhce genotype jessica kneib* and emily coberly. university of missouri health care background/case studies: red blood cell transfusion plays an important role in the treatment of patients with sickle cell disease. sickle cell patients have a significantly increased risk of alloimmunization compared to the general population, and the standard of care is to provide phenotypically matched units for at least c, e, and k antigens to reduce this risk. unfortunately, the genotype and true alloimmunization risk may not always be accurately represented by the red blood cell phenotype, particularly in patients with complex partial rhce variants. study design/method: a year old female with a history of sickle cell disease, stroke, and iron overload presented for routine exchange transfusion. transfusion vol. supplement s the patient's blood type was o positive and her red cells had been previously phenotyped as c-, c , e-, e and k -. an antibody screen was positive, and antibodies against c and e antigens were identified in the plasma. the patient had only received phenotypically matched units negative for c and e antigens for all previous transfusions at our institution, based on her known red blood cell phenotype. blood samples were sent to a reference laboratory for molecular testing to look for partial rhce variants that might explain the antibody development. results/finding: molecular testing was performed to reveal the presence of two different partial rhce alleles, resulting in a predicted phenotype of d , c-, e-, partial c , partial e . the probable rhce genotype, rhce*ce-jal/rhce*ce g, results in partial expression of both c and e antigens. in addition to the known risk of alloimmunization against the absent c and e antigens, this result indicates that the patient is also capable of forming alloantibodies against the absent portions of both c and e antigens. based on these results, the patient's anti-e was determined to be an alloantibody and not an autoantibody. conclusion: although phenotypically matched units are standard of care for patients with sickle cell disease, the red blood cell phenotype may not accurately represent the alloimmunization risk in patients with complex partial rhce genotypes. in this case, molecular testing confirmed that the patient is at risk of developing alloantibodies against c, c, e, and e antigens. as the patient had already made alloantibodies against c and e antigens, it was determined that she would require units that were molecularly matched to her rhce variants for all future transfusions. this case demonstrates that phenotype matching for sickle cell disease patients may not be adequate to prevent alloimmunization in individuals with partial rhce variants. altered splicing in the rhd*weak d type allele associated with the skipping of exon in a pregnant woman and her newborn carolina bonet bub* , maria giselda aravechia , thiago costa , marilia sirianni , eduardo bastos , leandro santos , lilian castilho and jos e kutner . hospital israelita albert einstein, hemocentro unicamp background/case studies: rhd*weak d type is a variant commonly found in caucasians associated with a weak d phenotype. as previously reported (vege et al, transfusion ) the c. g>c change (p.g a), which characterizes the rhd*weak d type allele is a splicing variant that induces skipping of the whole rhd exon . we report an altered splicing in the rhd*weak d type allele associated with the skipping of exon in a pregnant women and her newborn with weak d expression. study design/method: the d antigen expression was evaluated with commercially available monoclonal anti-d reagents: blended igm/igg (clones th- /ms- ), igm (clones ms and p x ) and igg (ms ) in tube and on gel cards. c, c, e and e phenotyping were performed in gel. rhd genotyping was performed with the rhd beadchip platform from immucor. direct automated sequencing of the rhd exons and flanking intron regions was performed by the sanger dideoxy method. results/finding: both pregnant women and newborn samples were phenotyped as d w c-c e e . the samples showed weak hemagglutination reactions ( / ) with all anti-d clones used. rhd beadchip results showed the ls* signal indicating a possible deletion of exon in both dna samples. sequencing showed the c. g>c change and the intronic c. - t>a and c. - t>c substitutions, which are associated to the rhd*weak d type allele. conclusion: our results showed that c. g>c associated with c. - t>a and c. - t>c variations had probably a functional impact on splicing inducing exclusion of exon in both dna from mother and newborn. this finding is important to develop assays and interpret genotyping results, as current guidelines do not recommend anti-d igg prophylaxis for women with weak d type . background/case studies: sickle cell disease (scd) patients require red blood cell (rbc) transfusions to minimize disease-specific symptomatology. previous studies have shown that more than % of children with scd receive at least one rbc transfusion in their lifetime. both simple transfusions and erythrocytapheresis are associated with increased risk of rbc alloimmunization. published literature is lacking on the frequency of alloimmunization and geographical associations in pediatric populations, which is made difficult to compare due to lack of standardized categorization of what represents a pediatric patient population across studies. therefore, we looked at the alloimmunization rates of pediatric patients with scd in the unites states (us) and other countries. study design/method: a literature search was performed for studies published on alloimmunization rates of scd pediatric patients including hbss, sickle beta-thalassemia and hbsc. we evaluated the overall alloimmunization rates as number of alloantibodies per transfused patient and alloantibodies per transfused units across world literature and compared them using chi-square analysis. results/finding: fourteen studies reporting data to derive alloimmunization rates of pediatric scd patients were found. these included eleven us studies with , patients and studies from other regions (brazil, egypt and france) with patients. majority of patients included in the studies had hbss disease. patients received either episodic, chronic simple transfusions or erythrocytapheresis. age range for the us studies was to years and for the other countries to years. available data from us studies included a total of alloantibodies, the most frequent of which were antibodies to c, e, kell, m, s and kidd antigens ( . %, . %, . %, . %, . % and . % respectively). alloimmunization rates were calculated as antibodies per patient in some studies and antibodies per transfused units in other studies. we evaluated rates using both approaches as per available data. us had an alloimmunization rate of . % ( . to . , % ci) vs. . % for non-us studies ( . - . , % ci) (p . ) and a transfusion vol. supplement s more alloantibodies per transfused patient ( . vs. . , p . ). similarly, the number of alloantibodies per transfused units in the us, evaluated from five studies, was higher compared to a large french patient cohort ( Á vs. . , p Á ). average number of rbc units transfused per patient in the us was also higher compared to data from france ( vs. , p . ). conclusion: despite limited studies available to compare alloimmunization rates in pediatric scd patients in the us and other countries, the overall rates are higher in the us. though no definitive reasons could be concluded from the available data, limiting the number of rbc exposures, i.e. units transfused in non-critical conditions could lead to lower alloimmunization rates. results/findings: a post-transfusion sample was referred to the irl for a trxn investigation. there were no clerical errors; however, hemolysis was present in the post-transfusion plasma/serum. abo/rh and crossmatches using lo-ion tm were repeated on the pre-and post-transfusion samples with no discrepancies. the post-transfusion dat was positive with a negative eluate. the hospital requested another unit before the investigation was complete. antibody identification on the post transfusion sample with lo-ion tm was negative. suspecting a weak antibody, additional investigation using peg tm on both samples revealed an anti-c. no additional clinically significant alloantibodies detected in the pre-or post-transfusion samples using peg tm . conclusion: the patient experienced an acute hemolytic transfusion reaction due to anamnestic interaction of anti-c in the patient's plasma/serum against c antigen on the transfused cells. anti-c was not detected by our routine antibody identification techniques. the mma confirmed anti-e, -m and -c were clinically significant. laura bailey* , melissa grohotolsky , lisa deblass , bala carver and kip kuttner . health network laboratories, miller keystone blood center background/case studies: the en a antigen is a high prevalence antigen in the mns blood group system. the antigens of the mns system are carried on glycophorin a (gpa) and glycophorin b (gpb). anti-en a is a rare immune igm/igg antibody made by individuals who lack all or part of the gpa protein. anti-en a has been implicated in fatal htr and hdfn. the en(a-)phenotype can result from either a rare deletion of the gpa protein or the even rarer m k phenotype. because individuals with the m k phenotype lack both the gpa and gpb protein their red blood cells type as m-, n-, s-, s-, u-, en(a-), wr(b-) and have reduced sialic acid. study design/method: year old white mennonite female g ,p presented to her midwife for prenatal care with the intent of home delivery. she had a positive antibody screen by solid phase at the hospital transfusion service. an antibody identification panel was done in gel. testing for antibodies against selected cells (u-and u var ) in tube with peg enhancement and phenotyping was done. based on mns phenotype, anti-en a was suspected. the specimen was referred to an immunohematology reference laboratory (irl). the testing included phenotyping with unlicensed antisera, ficin treated panels by tube technique, allogeneic adsorptions for antibody exclusion and identification and antibody titration. following identification of anti-en a by the irl the midwife was advised to refer the patient to a maternal fetal medicine specialist at an academic center close to the patients' home. the midwife was also advised to consider autologous blood donation and /or testing of siblings. results/finding: testing by the hospital blood bank demonstrated positive reactivity in the antibody screen. the gel antibody panel ahg phase resulted in panagglutination and a negative autocontrol, suggesting a high prevalence antibody. the phenotype was performed and determined to be m-, n-, s-, s-, u -. outdated u variant reagent cells reacted in peg igg phase ruling out anti-u. anti-en a was suspected and the sample was referred to the irl. allogeneic adsorptions were performed to rule out antibodies to common red cell antigens. lack of reactivity on a ficin panel eliminated the presence of anti-u,-wr b . phenotyping with unlicensed anti-u was negative and unlicensed glycine soja demonstrated reactivity, suggesting that the patient is en(a-). the patient's phenotype is consistent with the m k phenotype. based on the lack of reactivity on the ficin panel, the antibody was identified as anti-en a fs. since anti-en a is extremely rare, this specificity could not be confirmed due to the lack of en(a-) cells and appropriate antisera. the baseline antibody titer was at igg phase without enhancement. conclusion: this case study describes the workup of a rare antibody in a prenatal patient at a tertiary care hospital. studies performed after the patient was transferred closer to home confirmed the anti-en a (fs) and genotyping was performed. three titers were performed for the remainder of the pregnancy and held at . although anti-en a has been implicated in hdfn, a healthy infant was delivered without complications. this patient should be monitored closely through future pregnancies. autologous donation and/or sibling testing should be considered in order to provide compatible blood for intrauterine transfusion or transfusions at or after delivery. background/case studies: a year old caucasian male diagnosed with hemolytic anemia and no previous transfusions was referred to the immunohematology reference laboratory (irl) for antibody identification and rbc genotyping. initial serologic testing by the referring facility and the irl demonstrated anti-d, anti-c and/or anti-g specificity with a positive auto control and igg dat. anti-g has an anti-d, -c specificity and is most frequently found in rr individuals exposed to r'r cells. the g antigen is present on rbcs expressing either rhd and/or c and very rarely on d-c-g (r g r) cells. both rhce*c and rhd genes encode ser which determines g expression. rare rhd variant antigens lacking ser are g-. study design/methods: serologic evaluation included tube testing using gamma lo-ion tm (immucor, inc., norcross, ga) enhancement, elution studies (gamma elu-kitv r ii (immucor, inc.)), edta glycine acid treatment (gamma ega tm kit (immucor, inc.)), allogeneic adsorptions with papain treated intact rbcs, reagent and patient-derived rbcs and antisera. molecular testing was performed with bioarray precise type ivd hea assay (immucor, inc.). results/findings: molecular testing revealed an rhce*ce genotype (with a c-e c e-predicted phenotype) and an otherwise unremarkable rbc typing report. serologically, the antibody(ies) demonstrated an anti-d, -c, -g specificity in the serum and eluate using r o r, r r , r'r, r g r and rr cells. this patient is predicted to be r r (dce/dce) therefore, anti-c is possible but an allogeneic anti-d or -g is exceptionally unlikely. allogenic adsorptions using papain treated r o r and r'r cells excluded anti-c and anti-d, leaving anti-g as the only explanation of the initial findings. reactivity with the patient's ega treated (dat negative) cells against the "neat" serum, eluate and anti-g antisera confirmed auto anti-g. conclusion: warm autoantibodies are common findings and often have an rh specificity; however, these antibodies usually demonstrate a broad but weaker specificity in the eluate or in the serum when enhancements are used. this anti-g had no reactivity with g-cells. the differentiation of anti-g from anti-d and anti-c is generally academic as transfusion recommendations are the same: provide rhd-, c-units. it is relevant and clinically important to determine the presence or absence of anti-d in rhd negative women of childbearing age who present with an anti-g specificity. if anti-d is a transfusion vol. supplement s excluded these women should receive rhig as part of their prenatal care. in this case differentiating anti-d, -c from an auto anti-g was necessary to provide transfusion recommendations. providing rhd-and c-units to give serologically compatible rbcs could result in formation of an allogeneic anti-e. automated eluates: comparison of solid-phase red cell adherence and gel automated eluate testing jayanna slayten* , christa voliva , kathy fletcher , heather vaught and tracie ingle . indiana university health, indiana university health (iu health) background/case studies: acid eluates (elu kit ii. immucor. norcross, ga) are to be tested via tube iat method in parallel with the recovered last wash per the manufacturer's package insert. finck et al (immunohematology ; : - ) demonstrated acid eluates may be tested in other platforms such as manual gel microcolumn assay (id-mts.igg card. ortho clinical diagnostics. raritan, nj) and automated solid-phase red cell adherence systems (echo. immucor. norcross, ga). our study looked to compare the use of the automated gel microcolumn analyzer (vision, ortho clinical diagnostics. raritan, nj) to the solid-phase red cell adherence analyzer (echo, immucor. norcross, ga) for the testing of acid eluates in a regional midwestern transfusion service. study design/methods: twenty patient samples, less than days from collection and drawn in edta, were used to prepare acid eluates (elu-kit ii. immucor. norcross, ga) while retaining the last wash to be tested in parallel. two samples were > dat positive, were weakly dat positive and were dat negative. the prepared eluates were observed for color (bluegreen/bg, blue-brown/bb, blue-purple/bp), and the ph was documented for the prepared eluate (whatman . - . ph. whatman international. maidstone, england). the prepared eluates and last washes were tested on the vision and echo against an antibody screen. if the antibody screen was positive, the sample was tested against an antibody panel to determine specificity/pan-reactivity. prior to the eluates being tested on the automated platforms, they were spun for minutes twice to remove any rbc debris which could cause false positive reactions. results/findings: the eluates prepared ranged in color: bb, bg and bp. the ph of all eluates ranged from . - . with the highest percentage of eluates at a ph of . ( %). sixteen of the eluates tested yielded the same results in both automation platforms (concordance of %). four eluates with different results are summarized in table . conclusion: the study demonstrated that both analyzers may be used for eluate investigations. both methods yielded apparent false positive results on samples which were initially dat negative. the echo was more sensitive, yielding false positive results ( ) when the vision was negative, while the vision was false positive with one eluate with echo negative. there was no apparent association in the non-correlating eluate results in relation to color of eluate, age of sample when eluate was prepared, or ph of the eluate. a larger study may be able to better elucidate the apparent false positive results noted in this study between echo and vision eluate study. background/case studies: blood agglutination observed by landsteiner in led to the discovery of human blood groups. in the abo system > alleles have been described. the glycosyltransferase encoded by most results in weakened expression of a or b or the null (group o) phenotype. as testing methods and reagents improve, donors may appear to change their abo type. here we describe a frequent group o blood donor ( units over years) who is actually a w . study design/methods: donations were tested with the pk instrument (beckman coulter inc.). routine forward and reverse abo testing was used to investigate the discrepancy. molecular studies were performed by dna sequencing of abo introns , and and exons and . specific primers located in the flanking intron regions of the blood group gene were used to amplify relevant exons by pcr. the template used is genomic dna extracted from whole blood collected in edta. pcr-amplified exons are subjected to bidirectional dna sequence analysis using standard sanger dideoxy chemistry. seqscape software (abi) was used to analyze sequence data by comparing the obtained sequence to a reference sequence from ncbi. results/findings: serologic results are shown in table . tests with anti-a, -a , -b anti-a,b were negative as were the a cells in reverse testing. the results of dna sequencing of abo introns/exons are shown in table . the significant changes were found in exons and . in exon there was a nucleotide (nt) deletion of g which resulted in a shortened transcript due to a stop codon, and another nt substitution lead to the amino acid change gly ala. mutations in exon included a nt substitution causing a pro -leu change and a nt deletion c resulting in shortened transcript. conclusion: serologic testing of the donor plasma with a cells was nonreactive revealing the abo discrepancy. molecular testing confirmed the donor genotype is heterozygote a/o [abo*o. . /abo*aw. ] which predicts a w phenotype. normally, donor rbcs are tested with anti-a and -b and the reverse type confirmed by testing the with a and b cells. this abo discrepancy was caused by the presence of anti-a in the plasma causing the forward and reverse type to be interpreted as group o. according to fda guidelines, the donor is technically group a, and as such all donations need to be labeled as group a. the donor was contacted and instructed to cease donating blood for transfusion. if donations continue, the unit labeled group a would likely test as group o at the transfusion facility resulting in an fda reportable error. there are numerous reports in the literature of the relative insusceptibility of a cells to destruction by anti-a, however, there is one hemolytic transfusion reaction to a x blood transfused to a patient with a potent anti-a titer > : . (schmidt, nacarrow et al. ) . a review of transfusion recipients of the donor reported here did not reveal any untoward reaction after transfusion. a transfusion vol. supplement s extraction of gdna from edta-anticoagulated whole blood from pilot tubes derived from the unit. dna extraction from whole blood is performed on up to blood tubes using the biorobot universal system (qiagen). there is no information on the maximum acceptable age of the blood for this purpose, either from the vendor or in peer-reviewed literature. we set out to assess if blood up to days post collection yielded suitable gdna for downstream rbc genotyping. study design/method: edta blood tubes collected from random blood donors were used to extract dna from microliters of whole blood on day , and days post collection. blood samples were stored at - c before and after extraction. tubes were brought to room temperature and rocked before loading on the biorobot. extraction was performed using the mdx blood minikit (qiagen). resulting dna samples were assessed for gdna yield and absorbance a /a using a nanodrop (thermo scientific). the extracted gdna was tested using precisetype hea molecular beadchip ("hea", immucor) and failure rates on both the biorobot and the hea were assessed. results/finding: all three extractions were successful with no invalids (result ) on the biorobot universal report. no evidence of visible clots or splatter during extraction was noted by the technologist. out of the samples, samples were chosen at random and concentrations were measured using nanodrop for each of the extracted plates. dna concentrations ranged from . to . ng/ul. all readings with the exception of ( . ng/ ul) had concentrations > ng/ul. interestingly, the one that was < ng/ ul on day , yielded > ng/ul on day and post collection. over the next months, sets of samples were extracted and tested by hea. eighty-three ( . %) failed extraction and ( . %) failed hea. none of the samples that failed extraction were or days post collection; none of those that failed hea were days post collection; . % were > < days post collection. conclusion: based on these results it can be concluded that edta blood tubes up to days post collection can be used as a source of gdna for rbc genotyping without negatively effecting the concentration of the resulting dna samples and the validity of the resulting genotyping. case study: investigation of persistent negative antibody screens on patients receiving daratumumab raeann thomas , carlos villa , rachel davis-rauser* , helen carpenter and vrunda patel . university of pennsylvania, hospital of the university of pennsylvania background/case studies: daratumumab is an anti-cd monoclonal antibody therapy that received fda approval for treatment of multiple myeloma in . communications suggest all patients receiving therapy would have a positive antibody screen because cd is a common antigen expressed on red blood cells. currently, patients have been treated with daratumumab at a large academic medical center. a wide variation of reactivity was observed, including patients who were found to have consistently negative antibody screens. while there are several potential causes, neutralization of anti-cd antibodies could easily be tested by applying established techniques used for neutralizing antibody reactivity. study design/method: samples received were drawn as a standard of care. indirect antiglobulin testing was performed using solid phase red cell adherence and gel. neutralization was performed by adding equal volumes of negative daratumumab treated patients' plasma with positive daratumumab treated patients' plasma. a dilution control was made by adding saline to each positive patient's plasma. samples were incubated for hour at room temperature and antibody screens were repeated. serial two-fold dilutions were also tested to determine if the neutralization could be titered. testing was repeated using various positive patient samples to determine if negative/positive combinations resulted in different reactivity. results/finding: all control samples remained positive. positive/negative samples were negative in solid phase testing across all patient combinations at : dilutions. variable reactivity was observed in gel. serial dilutions showed that neutralization for negative patients was observed up to a : dilution. conclusion: results suggest that patients' plasma may have a substance that neutralizes the antibodies. there is a possible correlation with patients who have persistent negative antibody screens and patient response to daratumumab. additional studies are necessary to uncover how this correlates to patient outcomes. further studies using a standardized daratumumabspiked sample will be conducted. background/case studies: the mns blood group is a red cell antigen system located on glycophorin a (gypa) and glycophorin b (gypb). individuals lacking gypa or both gypa and gypb on their red blood cells may develop a rare antibody against the en (a) antigen. the en (a) antigen is a highprevalence antigen, located on gypa. we present a case with a rare red cell phenotype and alloimmunization to the en (a) antigen. a y/o g p at approximately weeks gestation was discovered to have an anti-en (a) antibody in her plasma on a prenatal type and screen. this was worrisome for both mother and fetus, as the en (a) antibody is of igg isotype and has been implicated in both acute and delayed hemolytic transfusion reactions and hemolytic disease of the fetus and newborn (hdfn) [ , ] . further testing with red cell antisera revealed that the patient lacked m, n, s, s, and u antigens. a multiplex, allele-specific, pcr platform we commonly use to detect the presence or absence of red cell gene sequences failed to amplify genes specific for the m, n, s, s, and u antigens. these findings were consistent with a null phenotype for both gypa and gypb antigens, i.e. m (k) m (k) phenotype. the patient's husband and father of her unborn baby demonstrated a m n-s s phenotype by the same serological and molecular means. given the exceedingly rare incidence of en (a-) individuals (positive frequency > . ), clinical encounters with alloantibodies to this antigen are limited in our experience and in the literature [ , ] . however, the existing data gives credence to its association with transfusion reactions and hemolytic disease of the fetus and newborn (hdfn). the consensus in this case was to work her up as a high-risk pregnancy with frequent intensive monitoring which involved frequent monitoring of antibody titers. if transfusions were required for the mother or fetus, our options were to either search for rare units lacking the en(a) antigen via rare blood donor registries or directed donations from family members who match the patient's phenotype. at term, the patient underwent induction of labor and successfully delivered a health baby boy by vaginal route. the delivery was without event. no transfusions were necessary antepartum or postpartum. study design/methods: n/a results/findings: n/a conclusion: anti-en(a) is a rare antibody and there is limited data about its potential clinical sequelae, which is concerning in a pregnant woman. providing this patient with rare en(a) negative red cells via national or international blood donor registries would have been an arduous task if needed. this patient had many compatible family members available and willing to donate blood. the m(k) null allele (s) within this family is likely due to a genetic recombination among the gypa and gype genes rather than a mutation in both the gypa and gypb genes [ ] . this results in the absence of glycophorins a and b and the constitutive antigens of the mns blood group system. our patient was exposed to the en(a) present on glycophorin a on her unborn baby's red cells (inherited from father) in utero with subsequent alloimmunization. in conclusion, this case report demonstrates a clinical approach in identifying a rare anti-en(a) antibody in a prenatal sample. the clinical finding of a rare antibody in which there is limited data requires leveraging every resource available in order to predict its behavior and provide safe blood products to patients who may require it. background/case studies: transfusions are essential for patients with scd and thalassemia to maintain growth and development during childhood and to sustain good quality of life during adulthood; however, the development of red blood cell (rbc) alloantibodies and autoantibodies complicates transfusion therapy in such patients. routine phenotyping of blood recipients and the use of phenotype-matched blood units for transfusion has been useful to lower the occurrence of red cell alloantibodies in chronically transfused patients with thalassemia and scd. nevertheless, extensive phenotyping is expensive, laborious and cannot be performed in certain situations. the molecular understanding of blood groups has enabled the design of assays a transfusion vol. supplement s that are being used to better guide matched red blood cell transfusions and to maintain an inventory of units dna typed. based on this, our aim was to evaluate the clinical outcomes of molecular matching performed at different levels during years for patients with scd and thalassemia. study design/method: blood group genotypes were determined in dna samples from chronically transfused patients with scd, in patients with thalassemia and in dna samples from blood donors. laboratory developed tests (ldts), hea beadchip tm , rhd beadchip tm , rhce bead-chip tm , and sequencing were used to determine the genotypes among patients and donors. molecular matching was performed in levels: ( ) rh and k matching; ( ) extended matching and ( ) extended matching including rh variants. we considered the total of red blood cell units requested for each patient and a number of donations per year for the compatible donors. results/finding: according to the patients needs we performed molecular matching for % of our thalassemic and scd patients at level , % for scd patients and % for patients with thalassemia at level and % for patients with scd and % for patients with thalassemia at level . the patients were transfused with a median of . rbc units. after three years of molecular matching, we observed that this transfusion strategy avoided new alloantibodies development and hemolytic transfusion reactions in all studied patients. conclusion: molecular matching has shown clinical benefits to the patients with scd and thalassemia, contributing significantly to reduce the rates of alloimmunization to - % with c e k matching and < % with extended matching. improvements in the clinical outcomes of the patients have also been observed as shown by an increase in their hb levels and reduction in the % of hbs in scd patients, better in vivo rbc survival and diminished frequency of transfusions. allahna lilly elahie* and sandra fazari. hamilton regional laboratory medicine program background/case studies: the ideal manual backup method for an automated antibody detection system is an important choice. currently, our backup method is saline tube ( drops plasma, minutes incubation). the change to either a low ionic strength solution (liss) or polyethylene glycol (peg) method would reduce incubation time to minutes and specimen volume to drops, both important laboratory considerations. objectives of this study were to compare the relative sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of peg and liss, and to determine the most appropriate manual backup method for the existing automated solid phase system. study design/method: a total of specimens were compared utilizing: automated solid phase red cell adherence assay (sprca) with manual tube peg and liss, some samples were not sufficient quantity to test in liss. identification panels were used to determine: clinically significant antibodies, warm autoantibodies, and nonspecific reactions. calculations were based upon comparison to sprca. results/findings: a total of clinically significant antibodies were detected using sprca technique, as well as warm autoantibodies and nonspecific reactions. peg demonstrated the highest sensitivity and lowest specificity while liss was least sensitive and most specific for clinically significant antibodies. for warm autoantibodies, liss was more sensitive than peg with both being % specific. both reduced the detection of nonspecific reactions. while peg had more nonspecific reactions ( versus ), it identified more clinically significant antibodies ( ) than liss ( ). (table) conclusion: ultimately, the decision to choose a manual backup method must be based upon the highest sensitivity for clinical significant antibodies so as to minimize failure to detect one. peg was selected as the backup manual method even though peg has a higher sensitivity to nonspecific reactions. this study clearly demonstrates the interplay and tradeoffs between methods, which are important to understand and consider when making method choice decisions. comparison of thiol reagents in denaturing cd on rbcs patricia a arndt* , anthony salazar and regina m. leger . american red cross blood services, long beach memorial medical center background/case studies: monoclonal anti-cd , e.g., daratumumab (dara), which is used to treat patients with multiple myeloma, causes positive indirect antiglobulin tests (iats) due to expression of cd on red blood cells (rbcs). this serologic reactivity cannot be removed by adsorption so other methods have been developed to detect/identify underlying alloantibodies. one popular method is to denature the cd antigen by treatment of rbcs with thiol reagents, e.g., dithiothreitol (dtt) or aminoethylisothiouronium bromide (aet). chapuy et al described ( ) and validated ( ) ), and % aet (ph . ) as per the aabb technical manual, th ed. these treated and untreated rbcs were stored in alsevers at c and tested on days , , , and by two methods: ) polyethylene glycol (peg) iat using plasma from two myeloma patients who had received dara (plasmas from total dara patients were tested with reactivity - ), and ) flow cytometry using phycoerythrin (pe)labeled anti-cd . rbcs were also tested on days and or with a serum containing anti-k by peg iat. results/findings: the . m dtt in ph . pbs had a final ph of . and the ph of the commercial . m dtt was . . results are in table ; flow cytometry results from days , and (data not shown) were similar to those from days and . rbcs treated with . m dtt (both sources) or aet were nonreactive with anti-k and plasma from all dara patients and gave very low results (% positive events) with pe anti-cd by flow cytometry for up to days after treatment. rbcs treated with . m dtt reacted similarly to untreated rbcs with anti-k and dara plasmas, and showed only some weakening ( - %) of reactivity with pe anti-cd . background/case studies: clinically significant hemolytic disease of the fetus and the newborn (hdn) is often caused by feto-maternal rhd incompatibility. with the discovery of cell-free fetal dna (ccfdna) in maternal plasma, it became possible to determine the rhd genotype of the fetus using non-invasive techniques. however, the reliability of the non-invasive prenatal rhd test (nip rhd) is dependent on sufficient amounts of cffdna in the maternal plasma sample. recent studies show that the fraction of ccfdna in maternal plasma varies significantly between pregnant women and is inversely related to maternal body mass index (bmi). thus, high maternal bmi, may impair the validity of nip rhd. the aim of this study was to examine the effect of maternal bmi on the correctness of nip rhd and the correlation of maternal bmi with fraction of ccfdna to total free dna in the sample. study design/method: measurements of body height and weight of pregnant rhd negative women in gestational week were obtained from patient records and used for the calculation of maternal bmi. data on bmi were combined with the results from nip rhd (real-time pcr targeting rhd exon and ) and sample fraction of ccfdna (measured as threshold cycle [ct] value of rhd) to total free dna (measured as ct of ccr ) in gestational week . the correctness of nip rhd was determined by correlation with postnatal serological rhd determination. results/finding: a total of pregnant women were included. nip rhd was positive in / ( %), negative in / ( %) and inconclusive in / ( . %). compared to the postnatal rhd type, / ( . %) of nip rhd results were false positive (fp) and / ( . %) were false negative. in / ( %) of inconclusive nip rhd, the postnatal rhd type was positive. mean bmi (n ) at gestational week was . ( -and -percentiles: . - . ). there was no difference in mean bmi between individuals who tested inconclusive or false negative by nip rhd compared to the remainder (p , ). the fraction of ccfdna was calculated for randomly selected nip rhd true positive cases. median ccfdna ratio was . (the distribution had a highly positive skew, -and -percentiles: . - . ). there was no statistical correlation between bmi and fraction of ccfdna to total free dna (r , ; p . ). conclusion: neither the correctness of nip rhd test result nor the fraction of cffdna to total free dna appear to be correlated to maternal bmi with regard to maternal plasma samples drawn in the th gestational week. delayed hemolytic transfusion reaction due to anti-lan antibody: a case report. adla dh angelina*, suneeti sapatnekar and suzanne bakdash. cleveland clinic background/case studies: lan is a high-prevalence antigen and the sole member of the lan blood group system. anti-lan is a very rare igg antibody, with conflicting information regarding its clinical significance and potential for hemolysis. we report a case of delayed hemolysis in a patient with anti-lan antibody. study design/method: the patient's medical record and available literature were reviewed. results/finding: an year old man, o-positive, with a history of heart disease and bladder cancer was admitted for radical cystectomy. the antibody screen and panel were panreactive by multiple test methods (gel, liss, peg) with negative autocontrols and dat and a saline antibody titer of , suggestive of an antibody to a high-frequency antigen. anti-lan antibody was identified by a reference laboratory. only in , donors are lan-, but two frozen rbc units were locally available and transfused postoperatively. the patient's siblings were tested; one o-positive, lan-sibling was identified. nine months later, the patient was admitted for surgical management of metastases. at this time, the antibody screen was weakly reactive with cell and new antibodies were ruled out. blood conservation measures were instituted, including limited blood draws and cell salvage for surgery. due to bleeding during and after surgery, lan-rbc units were transfused over days, including rare donor units and units from the sibling donor. another surgical procedure was then performed; by post-operative day , the patient had symptomatic anemia with hemoglobin (hb) . g/dl and serially increasing troponin. no lan-rbc units were available. four rbc units untested for lan were transfused without adverse event; the units were presumed lan but crossmatch compatible and phenotypically matched for the patient's other antigens. a post-transfusion hb of . g/dl was maintained for days. the antibody screen was negative on day post-transfusion, but strongly panreactive on day , with a positive dat (igg , c ) and anti-lan antibody identified in the plasma and eluate. there was also evidence of extra-vascular hemolysis, including a progressive decrease in hb from . g/dl on day to . g/dl by day with no bleeding identified, and increase in total bilirubin and ldh (peak . mg/dl and u/l on day ) with normal haptoglobin. the patient was febrile with leukocytosis, but had negative cultures and no other evidence of infection. a lan-rbc unit was transfused on day with good response (hb . g/dl). the patient remained stable and was discharged to a skilled nursing facility days later. conclusion: transfusion of lan rbcs caused a resurgence of anti-lan antibody and a delayed hemolytic transfusion reaction days after transfusion. the rarity of lan-units may require a patient with anti-lan to be transfused with lan units, but close monitoring for delayed hemolysis is necessary even if the antibody is not demonstrable at the time of transfusion. delayed serologic transfusion reaction caused by auto-anti-f. karen yunker* , andrea gerner , lynne stewart , carol sostok , mollie bell and gregory r halverson . st. elizabeth healthcare, hoxworth blood center background/case studies: anti-f was first described in by rosenfield and coworkers in the serum of a hemophiliac who had been multiply transfused. the f antigen is comprised of the c and e antigens alligned in cis on the same chromosome, and is the th antigen assigned to the rh blood group system (isbt rh ). it is capable of causing significant transfusion reactions and mild hdfn. we report in this case a year old caucasian male, admitted for evaluation of suspected t-cell lymphoma, who appears to have had a delayed serologic transfusion reaction (dstr) due to auto anti-f. abstract study design/method: antibody screen and compatibility testing was performed by automated solid phase (echo and neo, lmmucor, inc). red cell phenotyping was done by standard tube testing with commercial reagents following the manufacturers instructions. molecular genotyping was performed using the bloodchip assay (grifols, san marcos tx). elution studies were performed using the elu-kit ii (lmmucor, inc.) results/finding: the initial antibody screen (as) was negative and the patient was transfused unit o-rbcs. two weeks later the patient received an additional o-rbc. within days the hgb had decreased from . to . g/dl, the as and direct antiglobulin test (dat) were now positive, and ounits were incompatible. anti-f was identified in the patient's plasma and eluate. three additional units were requested for transfusion. due to the rarity of o-f-rbcs, the patient was transfused r r (dce/dce) rbcs with no reported complications. the patient was discharged to follow up in clinic. molecular genotyping showed the patient was rhd deleted (rho* del) and had normal rhce (rhce*ce/rhce*ce) genes which predict a d-c-e-c e f phenotype. the rh phenotype and as was repeated on a sample collected days later. the c typing was micro positive, mixed field only after minute incubation. the other rh antigens were not mixed filed, and the as was non reactive. however, the dat was weakly positive with anti-lgg. no elution study was performed. conclusion: the expected post hour hgb increment from the receipt of a standard unit of blood should be near g/dl (or % hct.) throughout this patients hospitalization, the post-transfusion increments did not fully achieve this expectation. the first transfuion resulted in a . g/dl increase, and the second unit was only . g/dl. the last transfusion of units increased by only . g/dl. less than three weeks later, the rhc antigen typing was microscopic/mixed field only after extended incubation, indicating the removal of r r units was nearly complete. in a case from , ohto and kariyone (transf. ; vol , no. ) reported a cr Ásurvival study of f rbcs in a patient with anti-f. they showed that the initital survival of f cells was fairly normal, however, after days, there was a sudden increase of red cell destruction, and by day all f cells were cleared from the circulation. it is not unusual to find auto-anti-f as many have been reported, however, it is unusual to find the auto-antibody has caused the clearance of three units of f-negative blood. this patient will be monitored to see if the autoantibody recurs and determine if it still has anti-f specificity. background/case studies: use of dithiothreitol (dtt) treated reagent red cells (rrbc) is increasing in blood banks as an effective way to negate the interfering panreactivity caused by daratumumab, an anti-cd drug for treatment of multiple myeloma. daily preparation of dtt-treated rrbc for testing of individual patients is burdensome for the laboratory and may delay patient care. we evaluated the effectiveness of batch-prepared dtt-treated rrbc, stored up to days after treatment, in antibody detection tests. study design/methods: in-date rrbc (ortho clinical diagnostics, raritan nj) were selected based on phenotype to match the antisera to be tested. rrbc were treated with . m dtt (sigma-aldrich, st. louis mo) and stored in reagent red cell diluent. rrbc were tested with commercial antisera (ortho clinical diagnostics, raritan nj and immucor, norcross ga) per the manufacturer's instructions for specificities from the rh, duffy, kidd and mns blood groups (see table ). patient source antibodies (anti-d, anti-c) were also tested. testing was performed before dtt treatment, on the day of dtt treatment and up to days following the dtt treatment of rrbc. reactions were graded using standard serological grading of (negative) to (positive) reaction strength. stored dtt-treated rrbc were also observed for hemolysis during the storage period. results/findings: see table for a summary of results. commercial monoclonal and human source antisera, and patient source antibody, were reactive with the dtt-treated rrbc throughout the storage period. reactivity decreased by less than one reaction grade for all antisera and patient source antibodies tested. mild to moderate hemolysis was noted in the dtttreated rrbc's during the storage period. conclusion: dtt-treated rrbc showed adequate reactivity with various red cell antisera after storage for up to days. this suggests that dtttreated reagent red cells can be stored for at least days and used for the detection of alloantibodies with minimal effect on detection ability. batch preparation and storage of dtt-treated rrbc can increase testing efficiency and decrease turn-around-time when performing pre-transfusion testing for patients receiving anti-cd therapy. interference: more than just kell? marilyn stewart*, angela treml and geoffrey wool. university of chicago background/case studies: daratumumab (dara) is an anti-myeloma and anti-lymphoma agent that is known to interfere with routine blood bank antibody screening tests. dara is an igg monoclonal antibody that binds cd that is present on the red cell surface. at the university of chicago blood bank, we have seen many patients treated with dara and were showing this interfering reactivity. it has been well described that cd is a disulfidelinked molecule and its immune epitopes are disrupted by reducing agents such as dtt. we performed a validation of dtt-treatment of reagent rbc to abrogate dara interference. study design/methods: the validation was done to prove that dtt treated red cells could be used to screen patients receiving dara and still detect clinically significant allo-antibodies. screening cells and panel cells selected for dtt treatment were those rbc homozygous for clinically significant antigens, therefore allowing rule-outs of clinically significant antibodies in patient plasma. several patients that had received the dara drug protocol were selected for testing as well as many patients that had allo-and auto-antibodies (but not dara treatment). reagent screening cells and panel cells were treated with . m dtt prepared using the sop from judd's methods in immunohematology and the aabb technical manual. the treated cells were preserved between testing episodes using alsever's solution, stored at abstract - c, and observed for hemolysis (none was seen) for up to days. all immunohematology testing using dtt-treated cells was performed using gel methodology. untreated and dtt treated cells were tested with anti k before any patient testing was done. the untreated cells reacted - with the anti k, and the treated cells were negative. these controls were run and tested each time dtt treatment was done. thirty eight patient samples, including six dara patient samples were tested. results/finding: of the six patients who had dara interference in their untreated antibody screens, all samples had negative reactions with the dtt treated cells except one patient, which had weak reactions in one cell. this specimen was repeated three times and all repeats had weak positive reactions in the same cell. this sample was sent to the arc reference lab for dtt treatment and all clinically significant antibodies were ruled out. patients with allo-antibodies present in their plasma did react with the dtt treated cells as would be expected based on the underlying alloantibody, with the exception of newly formed anti-e antibodies in patients. plasma from these four patients with a nascent anti -e all showed no reactivity with dtt treated cells. plasma from fourteen patients with a long history of anti-e (greater than months) did react with the dtt treated cells. conclusion: dtt treatment eliminates dara interference as previously described, but also unexpectedly lessens the ability of treated cells to react with nascent anti-e. because of the negative testing with some of the alloanti e antibodies, dara-treated patients at ucm will be given both kell and e negative blood if they have immunohematology testing performed using dtt reagent cells. mahboubeh rahmani* , monique scott , garcia curtis , ellice wong , alexa j siddon and christopher a tormey . yale-new haven hospital, va connecticut healthcare background/case studies: benign ethnic neutropenia (ben) seen in approximately % to % of persons of african descent is characterized by neutrophil count of < . x /l with no obvious cause and no increased susceptibility to infection or any other adverse effect. at present, there is no laboratory assay used to identify this condition and it is generally diagnosed on a clinical basis. in this study, we investigated whether duffy (fy) blood group phenotyping would be a potentially useful modality to help identify patients with ben; such testing could potentially be used as a surrogate test to prevent unnecessary further work up including bone marrow biopsy in the correct ethnic and clinical setting. study design/method: cases included patients clinically diagnosed with ben; and controls were chosen randomly from the pools of patients from whom a cbc and type and screen were checked for any other reason. cases and controls were tested for the rbc antigens fy a and fy b phenotype using serologic methods. the fy phenotype, absolute neutrophil count (anc), white blood cell (wbc), hemoglobin level, platelet count, and medical diagnoses were extracted from the medical record. where appropriate, data were compared statistically using the mann-whitney u test with significance set at p< . . results/finding: subjects who were clinically identified as having probable ben included patients (mean age . ; all self-identified as african-american; / were male) and controls included patients (mean age . ; self-identified as african american; ( / male). all of the cases ( %) diagnosed with ben had fy(a-b-) phenotype. mean anc ( . x /ul) and wbc counts ( . x /ul) were significantly lower in the cases with ben and fy(a-b-) phenotype (p . and . , respectively) compared with controls (mean anc . x /ul ; mean wbc count . x /ul). there was no significant difference in mean platelet counts ( x /ul vs x /ul; p . ) or mean hemoglobin levels ( . g/dl vs . g/dl; p . ) between the two groups. none of the patients with ben had an accompanying marrow-suppressive hematologic disorder based on record review; however, subjects in the control group had accompanying conditions that were potentially marrow-suppressive including hepatocellular carcinoma, acute myeloid leukemia, and myelodysplastic syndrome. conclusion: testing for fy phenotype could potentially be used as a surrogate test in patients with chronic neutropenia in a correct ethnic and clinical setting for the diagnosis of ben. further studies regarding fy phenotyping comparing controls with neutropenia for any reason to our ben population are in progress to better determine the positive predictive value. these tests were compared to the provue for concordance. additional samples tested with anti-igg,-c d were correlated against tube testing for the dat and antigen typing for: c, c, e, e, and k. results/findings: the ih- had % concordance for all blood grouping assays. for ahg assays, the ih- detected an anti-jka e, anti-fya warm antibody, antibody to a high incidence antigen and a warm antibody that were missed by the provue. the ih- identified one additional anti-e not identified on the provue. discrepancies were also noted with the non-cord dat results. five samples were positive on the ih- with anti-igg,-c d vs. tube testing; reflecting the increased sensitivity of gel methodology over tube. the table below summarizes the results. conclusion: this study demonstrated that the ih- analyzer and associated ih-system tm gel cards are equivalent to the ortho provue. with random access capability, minimal operator touchpoints, broad test menu and excellent assay performance, the ih- is an ideal immunohematology system for the hospital transfusion service environment. chris elliott*, susan barnes, fiona lisle, debra smith and whitehouse natalie. background/case studies: the erytra eflexisv r (grifols) is a new fully automated, mid-size analyzer that performs pre-transfusion compatibility testing using dg gelv r technology. erytra eflexisv r analyzer performance, usability and adaptability to different workflows was evaluated in the routine environment of a large uk acute hospital transfusion laboratory. study design/methods: a comparison study was performed between the erytra eflexisv r and erytra (our routine system providing the reference platform). a total of tests were performed on , adult patient samples and donor red cell units. erytrav r eflexis performance was evaluated according to a series of scenarios designed to simulate routine workload using the system in different configurations. concordance between systems was assessed and discrepancies analyzed. time to first result (ttfr), overall turn-around time (tat) total workload from first result to last result (throughput, results/h), manual "hands-on" time and walk-away time were all recorded. for ease of use evaluation, we ranked usability features with number of steps and timing of activities including sample sort and loading, routine testing, post-run procedures, consumables used, and space requirements. fault recognition and messaging was assessed by simulating failures e.g. reagent absence. results/findings: blood grouping, antibody screening, antibody identification (using panels), direct antiglobulin test, red cell phenotyping and serological crossmatching were successfully tested. concordant results between the erytra eflexisv r analyzer and reference method were obtained in . % of samples tested. there were discrepancies, all antibody screening ( false positives, failure to detect a very weak prophylactic anti d and positive reaction not detected on the erytra but panels on both systems suggested a genuine anti cw). ttfr and tat depended significantly on a number of factors including; number and variety of tests requested and whether the stat functions were activated. the analyser seemed to prioritise antibody screening prioritization of the group, especially for stat samples, was considered preferable the laboratory team found the software easy to use with some improvements over existing ertyra software. physical design of the analyser was considered good with easy access to almost all areas. probe changing was quick and simple. while the analyser successfully flagged all error scenarios some messages were considered misleading and could be better phrased. conclusion: results showed the erytra eflexisv r offered a robust automated solution for routine transfusion testing. the device could comfortably deal with a medium laboratory (processing - group and screens per day). it is very flexible being able to deliver grouping, antibody screening and identification, dat, phenotyping and serological crossmatching ,compensating for its' single probe and wash station by clever use of incubators, centrifuges and design features. this allows a compact design with maximum flexibility without compromising on turnaround times cp evaluation of two monoclonal anti-e as reagents for the detection of the rh e antigen and its variants gregory a. denomme* , kathleen bensing , michael schanen , cindy piefer , randall w. velliquette , christine lomas-francis and connie m. westhoff . immunohematology reference laboratory, versiti/bloodcenter of wisconsin, immunohematology and genomics laboratory, new york blood center background/case studies: monoclonal antibodies are used as reagents for automated and manual phenotyping. false negative phenotypings have implications for variant antigens; e.g. altered c antigen mistyped as a cblood unit stimulating anti-c in a c-recipient. the development of new / / / cecf / / / rhce*ce or rhce*ce compound heterozygotes ce g ce g or ce c, g or ces or ceti / / / ce g ce c, g or c, g / / / ce g ces or cemo or ceek or ceek(var) or cern / / / ce c, g ce c, g or cemo or ceti / / / ce c, g/ce g/ g; ces/ceti; cear/ceek; ceek/cejal; cemo/cebi / / / total / / / a transfusion vol. supplement s reagents should include an evaluation of antigen variants to confirm fidelity. we evaluated two monoclonal anti-e reagents with comparator reagent using a large panel of molecular confirmed rh e variants. study design/method: two monoclonal anti-e clones, rd / and rd / , and a licensed comparator anti-e (p gd ms ), all from diagast (loos, france), were evaluated. rbc samples were either recovered from frozen storage (n ) or edta blood from donors (n ) and were tested using a manual tube method or on a pk automated platform. a score ( ) or greater was deemed acceptable for manual tube and a positive call for automated testing. results were tabulated by complexity of rhce*ce alleles (table ) . results/finding: the specificity of the monoclonal anti-e were confirmed using common rhce haplotypes: r r , r r , r r, and rr. twenty-one different rhce*ce alleles were included in the extensive panel: were rhce*ce that were in trans to rhce*ce; were various rhce*ce plus rhce*ce c compound heterozygotes; were rhce*ce or rhce*ce homozygotes; were various rhce*ce and rhce*ce compound heterozygotes. the comparator reagent was negative or unacceptably weak for rhce*ce alleles in trans to rhce*ce (rhce*cear, rhce*cemo, rhce*-cejal, rhce*cehar), with rhce*cear/rhce*ce c compound heterozygote, and with rhce*cecf homozygote. rhce*cear, rhce*cemo, rhce*cejal, and of rhce*cecf homozygotes were detected using the comparator reagent. rd / and rd / failed with and e variants, respectively (table ) . failure to detect the e variants was observed using both manual tube and automated methods for the comparator and the rd / clone. none of the reagents detected e antigen variant expressed on example of rhce*cehar/rhce*ce. conclusion: rd / and rd / anti-e reacted with more e variants than the comparator reagent. the e antigen encoded by rhce*jal and rhce*ar is not always detected when in trans to rhce*ce. however, double-dose expression was detected suggesting that the monoclonal reagents bind weakly to the respective altered e antigen epitopes. the e antigen encoded by rhce*cehar continues to be a challenge to detect. meihong liu*, teresita mercado, orieji illoh, maria rios and zhugong liu. obrr, cber, fda background/case studies: extended molecular typing of a large number of blood donors can increase the likelihood of identifying donor red blood cells (rbcs) that match those of the recipient. this is especially important in the management of chronically-transfused patients and patients with rbc alloantibodies. several high-throughput multiplex blood group molecular typing platforms have been developed to determine blood group antigen phenotypes. targeted next-generation sequencing (ngs) provides comprehensive sequence information focusing on specified genomic regions, and allows the simultaneous detection of genetic variants from multiple genes in a large number of samples. we developed and evaluated targeted ngs assays using two different target enrichment platforms for extended blood group genotyping. study design/method: two custom design platforms sureselect and halo-plex were used independently for preparation of probes that target the entire genes of blood group genes associated with the expression of blood group antigens from blood group systems. we used the illumina's hiseq / system to perform next generation sequencing first on sureselect-enriched genes from dna reference samples with average target design coverage of . %, and then on haloplex-enriched genes from dna reference samples with average target design coverage above . %. twelve samples were enriched and sequenced in both methods to allow a direct comparison. all reference samples were previously characterized for blood group genetic variants in these genes using taqman snp assay and sanger sequencing assay. serological data were also available for these samples. the ngs data were analyzed by clc genomic workbench. sequencing variants were detected and annotated using dbsnp database. blood group genotype calls by the two targeted ngs methods were compared with the reference results. results/finding: for the two targeted ngs methods, we evaluated and compared the target enrichment efficiency, off-target enrichment, quality of ngs, sequencing coverage, and genotype concordance. a higher percentage of the haloplex reads ( . %) were mapped to the target regions relative to the sureselect reads ( . %). the mean sequence coverage depth of the targeted bases was around x for sureselect method and x for haloplex method. some exons, such as rhd exons and , , rhce exon , ermap exons and , cd exons and , cr gene (most exons) and gypb exon , are consistently covered with less than x coverage by both sureselect and haloplex targeted ngs methods. both methods detected rhd gene deletion in a few representative samples. the genotype call concordance on blood group genetic variants was assessed by comparing ngs results to taqman genotyping and sanger sequencing results, and more than % concordance was obtained for both targeted ngs methods. incorrect calls were restricted to four complex blood group genes: mns, rhd, rhce and abo, and involved mainly heterozygous variants and indels. conclusion: using two targeted ngs methods, we have correctly detected more than % blood group genetic variants in selected genes. evidence rhce*cehar does not encode for rh (hr b ) antigen debra j bailey* , trina horn , paul mansfield , najmi qazi , pamela nickle , jessica keller , margaret a keller and jan r hamilton . background/case studies: the rhce gene has many variant forms, yet for many, the phenotypes encoded by these variant alleles is unknown or incomplete. new information can be elucidated when two altered alleles or haplotypes are expressed in an individual with subsequent alloantibody formation. the rhce*cehar allele was first described in and has a phenotype of c e c e w f w , g , hr w , hr , hr s , rh: , rh: with a partial d antigen expression. we describe new information regarding an rh haplotype that includes an rhce*cehar allele and its apparent rh: (hr b ) expression. study design/method: rbc typing was performed by standard tube methods with polyclonal and monoclonal antisera. antibody identification studies were performed by standard tube hemagglutination methods by published techniques. molecular immunohematology testing was performed on genomic dna extracted from whole blood and included hea, rhd and rhce beadchips (immucor) and pcr-rflp analysis for rhce c. c>g and rhd c. c>t. results/finding: a sample from an african american female with a history of an anti-e and anti-k was evaluated for unexpected antibodies. her red cell serologic rh phenotype on an untransfused sample was d c e c e . her plasma contained an alloanti-s and an antibody that reacted strongly with all random e k s reagent red cells except her own. the unidentified reactivity persisted following ficin and dtt pretreatment of reagent red cells. only d and dc red cells were non-reactive in initial tests. differential adsorption studies excluded antibodies to all other common antigens and hr b except e, s and k. when subsequent examples of e s k red cells homozygous for the rhd*diiia-ce( - )-d, rhce*-ce c, g, t haplotype (i.e., r' s /r' s ) and rhd*diiia, rhce*-ce c, g, t/ rhd*diiia-ce( - )-d, rhce*ce c, g, t (i.e., bastiaan genotype) were found to be non-reactive with the patient's plasma, the antibody specificity was determined to be anti-hr b . the patient's red cell antigen genotype identified the following probable rh haplotypes: rhd* , rhce*cehar and rhd*diiia-ce( - )-d, rhce*ce c, g, t. additional antigen typing of the patient's red cells with unlicensed antisera indicated an hr ( of sources) and hr b ( of sources) phenotype. conclusion: the rhd*diiia-ce( - )-d, rhce*ce c, g, t haplotype is one of the rh haplotypes expressed by the original hr b individual bastiaan. the hr b antigen status of red cells of individuals with the rhce*-cehar allele has not been described. we report an individual with the probable rhd* , rhce*cehar and rhd*diiia-ce( - )-d, rhce*ce c, g, t rh haplotypes and production of alloanti-hr b . the specificity of the alloantibody produced and the red cell hr b serologic antigen type supports the conclusion the variant allele rhce*cehar does not encode for the hr b antigen. excluding clinically significant alloantibodies in the presence of interfering antibodies with high-titer, low-avidity characteristics. background/case studies: high-titer, low-avidity antibodies (htla) are a group of clinically insignificant antibodies (ab) directed against highprevalence red cell antigens. they interfere with the exclusion of clinically significant red cell ab and crossmatch testing, leading to long work-ups and potential transfusion delays. we often use automated solid phase red cell adherence assay antibody panels (sp) when htla interference is seen by other methods, and undertook this study to determine its efficacy. study design/methods: a search of the laboratory information system database was conducted for patients with htla between / / and / / . all patient samples with available records of the full serological investigation were reviewed for testing method and results, with specific attention to the value of a given test method in permitting exclusion of clinically significant ab (rule out). results/findings: over approximately years, patients had htla established at least once by titration studies. serological investigations on a total of samples using a combination of gel, sp, and peg and liss tube methods, and occasional dtt and ficin panels, found that htla interference noted most frequently in gel (primary method) was, indeed, less often seen with sp. however, the proportion of cases achieving rule out on sp was no greater than that with peg testing (table) . for samples where rule out could not be performed with a combination of methods, patients were assigned to phenotype-matched transfusions, or testing was referred to a reference laboratory. reference testing on samples was successful in rule out in % of cases. in an additional patient samples, with negative antibody screens, htla were identified upon work-up for incompatible crossmatches. conclusion: sp is useful in avoiding interference from htla, but this conclusion is limited because sp was performed in only % of samples, and the inability to use select cell panels with sp made it difficult to complete rule out on samples containing multiple ab. peg testing was available for % of samples, and was at least as effective. further, manual testing allowed flexibility in selecting test cells when other ab were present. both sp and peg testing may be used alone or in combination to avoid interference due to htla, and can potentially decrease the number of patients requiring phenotype-matched units due to incomplete serological evaluations. background/case studies: the dau family of rhd alleles is characterized by c. c>t (p.thr met). the dau allele harbors only this change, is not associated with depressed or altered d antigen expression, and is the ancestral allele from which other dau alleles are purported to have evolved. srivastava et al (transfusion , : ) recently summarized serologic characteristics and associated anti-d alloimmunization for dau family alleles. we investigated two samples with the c. c>t change referred with weak d antigen expression. study design/method: serologic testing was performed by standard tube methods using licensed anti-d reagents and the albaclone partial rhd typing kit. genomic dna was isolated from wbcs and used in manual and array assays and for amplification and sequencing rhd. results/finding: sample was from a yo multiracial female. her rbcs reacted s at immediate spin (is) and in iat with immucor gammaclone and series and , and mi at is and in iat with ortho bioclone anti-d. rbcs did not react with of (lhm / & / ) anti-d in the partial d typing kit. this pattern did not match any of the defined partial d epitope patterns. rhd beadchip found no changes but rflp detected c. c>t characteristic of dau. rhd sequencing confirmed c. c>t and identified two adjacent changes, c. g>t and c. g>t (c. _ delinstt), in exon encoding p.gly leu. sample rbcs reacted w at iat with both ortho bioclone and quotient albaclone delta, but were non-reactive with immucor gamma-clone, series and , and quotient albaclone blend and alpha anti-d. papain treated rbcs were s in iat with ortho bioclone. these results suggested a d el like phenotype. rhd beadchip found no changes but rflp detected c. c>t. sequencing confirmed c. c>t and found a new c. c>t change (p.ser -leu) in exon . the c. t has not been reported, but c. g encodes a stop codon (p.ser stop) in japanese (vox sang , : ). conclusion: we report two new alleles: rhd with c. _ delinstt (p.gly leu) and rhd with c. c>t (p.ser leu), both also carrying the c. c>t (p.thr met) characteristic of the african dau cluster. d antigen associated with p. leu is a partial d antigen with a novel epitope pattern. the p. leu change is associated with a del-like phenotype, the first observed to our knowledge for a dau allele, and d antigen on the rbcs is not detected in iat by / commercial anti-d. the rhd nucleotide changes reported here are not in dbsnp database. this study brings the dau family of alleles to . the number and diversity of alleles in the dau cluster supports that the c. c>t change is a major ancestral african background allele (wagner et al, blood , : ). tae eun kim*. krc btri background/case studies: there have been the cases of anti-d alloimmunization caused by the transfusion of serologically d negative blood component. by analysis of genotype of the blood component, all of them were confirmed as asian type del. for that reason, the application of genetic analysis for the blood donor has been required in addition to serological assay. we established the algorithm for the genetic analysis of rhdin blood donors. in this study, we would introduce the experience of the application of the algorithm and the results in the preliminary test. study design/method: from september to present day we got samples of repeated blood donors who are known to be d negative, c positive and/or e negative from blood centers. we obtained the consent for the test from all of the donors who provided samples. as a genetic analysis, we accomplished polymerase chain reaction with sequence-specific primers (pcr-ssp) for the region of promoter, exon , exon and exon in rhd gene. based on the results of pcr-ssp, we discriminated the results into total rhd deletion, rhd-ce-d hybrid and rhd variant. when the results were discriminated to be rhd variant, we additionally analyzed the sequence of exon to confirm the existence of c. g>a and c. t>a variations. for the sample with indeterminate results, we performed sequencing for the full region of exon. when the result was confirmed to be rhd deletion or rhd-ce-d hybrid, the blood components were regarded as rhd negative. when the result was confirmed to be rhdvariant, the blood components were regarded as rhd positive. blood components were not supplied until the final results were obtained. results/finding: for the sample, we identified cases ( . %) of total rhd deletion, cases ( . %) of rhd-ce-d hybrid, and cases ( . %) of rhd variant. of rhd variant were determined to be asian type del with c. g>a variation. cases of rhdvariant were regarded to be unknown variation. conclusion: the frequency of rhd variant in this study was % higher than that of the general d negative donors not considering rhce phenotype in a previous study. for that reason, we considered that the genetic analysis of rhd targeting the donors of d negative, c positive and/or e negative is more efficient approach to identify rhd variant and better way to improve blood safety in the transfusion medicine related with rhd negative blood donors. lei fang tsai*, ping chun wu, shu hui feng, yi wen tsai, ming hung chen and shun chung pai. taipei blood center, taiwan blood services foundation background/case studies: certain abo subgroups or physiologic conditions may lead to mixed-field agglutination on abo typing among blood donors. the b phenotype was found to be the most common subgroup in taiwanese. however, it is hard to distinguish the b phenotype from other b subtypes also with mixed-field agglutination using routine serology without the genotype. this study aimed to evaluate if flow cytometric method could alternatively differentiate different b subtypes with mixed-field agglutination rather than using molecular genotyping. study design/method: blood samples from taiwanese blood donors exhibiting known common abo phenotypes were included to establish normal flow cytometric patterns and genotyped. blood samples (n ) from b subtype donors with mixed-field agglutination by routine serology (tube method and gel card) were further analyzed by flow cytometry and genotyping. flow cytometric method was performed by facscalibur flow cytometry using the gamma-clone anti-a and -b. for genotyping, exon and exon of the abo gene were amplified and sequenced. the abo*b . allele was confirmed by pcr-rflp analysis. results/finding: among subjects with b or ab phenotypes, were genotyped as abo*b . . the abo*b . group performed similar characteristic flow cytometric pattern and the profile was reproducible over time. the pattern showed the main population of cells expressed no b antigen, while a percentage ( . . ) of the rbcs exhibited b antigen levels diminishing with increasing of fluorescence. other subjects with b or ab subjects, genotyped as abo*b . (n ), abo*bw. (n ), abo*bw. (n ), abo*bw. (n ) and abo*bw. (n ), displayed flow patterns differed from the abo*b . group. the abo*bw. , abo*bw. and abo*b . subjects also showed a main population of cells expressed no b antigen and, however, less percentage of rbcs exhibited b antigen levels (< % in abo*bw. and abo*bw. subjects and < % in abo*b . subject). both abo*bw. and abo*bw. displayed a wedge-shaped pattern. conclusion: the flow cytometric method for the detection of b antigens on rbc might be useful in discriminating between b subtypes with mixed-field agglutination, especially abo*b . genotype. this approach could assist the serological abo subgrouping in clinical reference laboratory. frequencies and specificities of "solid-phase only" detected erythrocyte antibodies: is solid phase testing worth the headache? karen finegan*, karen gray, jill adamski, theresa kinard and qun lu. background/case studies: an effort to re-evaluate automated testing platforms (automated solid-phase red blood cell adherence vs automated gel column agglutination) was recently initiated due to the perception of excessive equivocal reactions from the solid-phase resulting in "unnecessary" workup at one site of a hospital system. the data available from parallel testing on solid-phase, gel, and peg performed at another cite of the same hospital system was collected and evaluated to determine the frequencies and specificities of "solid-phase only" detected erythrocyte antibodies and to see if solid-phase only antibody workup is necessary for patient care. study design/methods: throughout , the transfusion service used automated solid-phase red blood cell (rbc) adherence as the primary method for antibody screening and identification. all solid-phase antibody screen positive samples were re-tested using both gel column agglutination and peg method manually in order to determine which method should be used for antiglobulin phase crossmatch of rbc products. all antibody screen results on three methods and final antibody identification results were transcribed into a spread sheet and analyzed. results/findings: a total of patients were positive on solid-phase antibody screen and re-tested on gel and peg antibody screen. in % (n ) patients antibody reactivity observed in solid phase only and the concurrent gel and peg testing were completely negative. of them clinically significant rbc alloantibodies, warm autoantibodies, clinically insignificant antibodies were identified in % (n ), % (n ), and % (n ) of the cases, respectively. rbc alloantibodies identified in solid-phase only included anti-e (n ), anti-jka (n ), anti-k (n ), anti-jkb (n ), both anti-e and anti-c (n ) (see table ). conclusion: solid-phase only rbc antibodies are clinically important in a significant portion of cases (roughly in cases). workup for solid-phase only antibodies is not "unnecessary" workload. transfusion of corresponding antigen negative rbcs to these patients prevented possible hemolytic transfusion reactions. full-length nucleotide sequence of ackr alleles encoding duffy (fy) antigens in africans of ethiopia qinan yin*, kshitij srivastava, addisalem taye-makuria and willy a flegel. background/case studies: the human ackr gene (previously known as darc), comprising two exons and a single intron, encodes a multi-pass trans-membrane glycoprotein expressing the duffy blood group antigens (fy). the duffy protein acts as a chemokine receptor for various proinflammatory cytokines and for the malaria parasites plasmodium vivax and p. knowlesi. the study of fy variants in the low altitude and tropical gambela region is important, as malaria is endemic and the endogenous population is living in this region for a long time. in the present study, we determined the full length nucleotide sequence of the ackr gene encoding fy antigens in donors from ethiopia's southwestern gambela region. study design/method: edta-anticoagulated whole blood was collected from study volunteers in the gambela region (nct ). the whole ackr gene was amplified in one reaction covering , base pairs (bp). this primary amplicon was re-amplified using nested primers covering nucleotides. nucleotide sequence was obtained by sequencing reactions and manually annotated using ncbi refseq ng_ . . the sequencing covered bp of both exons, bp of intron, bp of '-flanking region, bp of '-utr, bp of '-utr and bp of '-flanking region and encompassed all the variations present in dbsnp and nhlbi esp databases. results/finding: among the samples, a total of snps, including one novel snp in '-utr were observed. snps occurred in the exons, in 'and 'flanking region, in '-utr and in the intron. all individuals carried the snp indicative of the common fy: phenotype; while individuals were homozygous and was heterozygous for the gata box mutation. no splice site mutation was detected. as individuals were observed as being homozygous or heterozygous for snp, we could unambiguously assign distinct alleles. in the remaining individuals with or more heterozygous snps, allele specific pcr is required to identify the alleles. conclusion: we sequenced more than . kb of the ackr gene and identified at least different alleles. the present study found that the vast majority of alleles ( / ) in the gambela population as defined by snps, were similar to the clinically relevant fy* n. allele, which in turn is defined by only snps at positions c. - t>c and c. g>a. out of the remaining alleles, were similar to fy* with the fy(b ) phenotype and was similar to fy* w. with the fy x phenotype. the high frequency of fy* n. ( %) in this study is similar to other studies conducted in western, central and south-eastern regions from gambia to mozambique ( %- %). a more detailed analysis, including other regions of ethiopia, will be useful to support transfusion care in the us for ethiopian-americans, the majority of whom may be of mixed ethiopian ethnical background. judith aeschlimann*, sunitha vege, christine lomas-francis and connie m. westhoff. immunohematology and genomics laboratory, new york blood center background/case studies: the homology, proximity, and inverted orientation of rhd and rhce on the chromosome favor gene conversion events. regions of rhd are transferred into rhce and conversely, resulting in hybrid alleles that encode novel or the absence of high prevalence antigens. rhd*diiia-ce( - )-d is the most common hybrid and is found in african blacks. it arose by conversion of exons - of rhce*ces into rhd*diiia and no longer encodes d antigen, rather (somewhat confusingly) encodes partial c antigen from the rhd locus. this hybrid allele is in cis to rhce*-ces, together known as the r's haplotype. we investigated atypical rh genotyping results in three samples; two associated with weak d typing and one patient with sickle cell disease (scd). study design/method: serologic testing was by standard methods. genomic dna was isolated from wbcs. all samples were investigated by hea precisetype, rhd and rhce beadchip, rflp, and rh-cdna sequencing. snp-specific sequencing was used to establish linkage/phasing. results/finding: sample (male) and sample (multiracial female), both c c e e (presumed r r ), presented with weaker than expected d typing; is and / at iat. rhd beadchip identified the common african rhd*diiia-ce( - )-d hybrid encoding partial c antigen with apparent conventional rhd in trans. these results did not provide an explanation for weak d antigen. hea indicated rhce*ce /ce, concordant with the rh phenotype, but c. c>g and c. g>t (heterozygous) was also detected. as rhce*ce with g and t has not been reported, rh-cdna analysis was done. transcripts from the rhce locus included one conventional rhce*ce in trans to rhce*ces with exons and replaced with rhd*diiia, and from the rhd locus, one conventional rhd and the hybrid rhd* diiia-ce( - )-d were found in both samples. sample (scd male), d c e c e , by rh beadchip had one conventional rhd and rhd*diii type , and rhce*ce g/ces. as rhd*diiia type has never been found with either of these rhce alleles, rh-cdna analysis was performed. transcripts representing a unique conversion event at the rhd locus, specifically rhce*ce( c) exons and had replaced those exons in the common hybrid rhd*diiia-ce( - )-d and expression of partial c antigen was lost these unique hybrid alleles have been deposited as genbank#: ky and ky . we report two different and novel complex rh rearrangements: two samples thought to be r r had a unique rhce locus representing a gene conversion into rhce*ces, designated rhce*ces-diiia( - )-ce. in kind, a sample genotyped as diii type rather had a novel rhd locus representing a gene conversion into the common hybrid, designated as rhd*ce c( - )-diiia( )-ces( - )-d . these represent novel events on the r's haplotype that can confound rh genotyping interpretations. interestingly, samples and have weaker than expected d antigen typing, despite the presence of a conventional rhd with rhce*ce [r haplotype (dce)]. it is important to further investigate samples with unconventional results when interpreting rh genotypes. high-frequency antibodies anti-lu(b-) and anti-yt(a-) in a multi-transfused patient: a case study nadia baillargeon*, carole ethier, cynthia parent, jessica constanzo-yanez, maryse st-louis, marie-claire chevrier and andre lebrun. hema-quebec background/case studies: a -year-old caucasian female was referred to our immunohematology reference laboratory (irl) for serological investigation. she was diagnosed with anemia, renal failure and cardiac history. her hemoglobin level was recorded at g/l. her pregnancy history was not provided. she had received units of packed red blood cells (rbcs) in the past including unit within the last months. none of the transfused unit was phenotypically-matched. the referring hospital obtained panreactivity in gel with liss-suspended rbcs and ficin-treated rbcs and negative direct antiglobulin test (dat) and autocontrol (at). study design/methods: abo/rh, dat and antibody identification were performed by h ema-qu ebec's irl according to approved techniques. in addition to liss-suspended rbcs and papain-treated rbcs, trypsin-treated and chemical-treated reagent rbcs such as dithiothreitol (dtt) were tested. alloadsorption were done using papain-treated allogeneic rbcs (r r , r r , rr). id core xt platform (progenika biopharm / grifols, vizcaya, spain) was used to analyse polymorphisms which determine antigens including carthright and lutheran blood groups. pcr-ssp (sequence specific primer) and pcr-rflp (restriction fragment length polymorphism) were also performed to verify the absence of the high frequency antigens yt a and lu b . sibling samples were also requested to conduct a family study. results/findings: initial serologic testing showed strongly reactive panels in gel with liss suspended rbcs, papain-treated rbcs as well as trypsintreated rbcs and dtt-treated rbcs but negative at in each media leading to a probable antibody directed against high-frequency antigen. alloadsorption procedure allowed the identification of an anti-jk a . a select panel of high frequency antigens absent in caucasian population was tested. the patient's sera react weakly with one jk(a-), lu(a-b-) reagent cell. in the meantime, genotyping results confirm the probable phenotype of the patient as jk(a-) lu(b-) yt(a-). additional testing in gel using trypsin and dtt differential effects on antigens lu(b) and yt(a) were performed to confirm antibody specificities. no rbcs unit jk(a-) lu(b-) yt(a-) were available for transfusion. selected units were jk(a-) and lu(b-) as alloanti-yt a are known to cause none to moderate transfusion reactions. her daughter' sample were types as yt(a ) and lu(b ). conclusion: serological study showed the presence of an anti-jk a in addition to two antibodies directed against high prevalence antigen namely anti-lu b and anti-yt a . the association of various selected serologic procedures combined with ethnic clues and genotyping results serves to solve this uncommon antibody combination. background/case studies: the kel blood group system, consisting of antigens encoded by the kel gene, is organized into exons. there are approximately kel alleles associated with a kell null phenotype (k ) in which no kell antigens are expressed, and alleles associated with a kell mod phenotype (k mod ). individuals with the k mod phenotype express very weak amounts of antigen on the surface of the rbc, and expression levels vary based on the allele present. here we describe the molecular and serologic testing that was performed in the case of a year-old hispanic male blood donor whose rbcs phenotyped k-k-js(b-) kp(b-). study design/method: the blood donor was phenotyped for k, k, kp b and js b antigens using standard tube agglutination methods. adsorption and elution studies of the donor red cells were performed using commercial anti-k antisera (american national red cross). genomic dna (gdna) was isolated from an edta blood tube using standard techniques. dna was genotyped for human erythrocyte antigens using the precisetype tm hea molecular beadchip (immucor). exons , , , and and flanking intron sequences were amplified and sequenced. total rna was extracted using rneasy lipid tissue mini kit (qiagen) and kel cdna was amplified and the resulting pcr product was subjected to sanger sequence analysis and aligned using sequencher (genecodes). results/finding: precisetype tm hea molecular beadchip testing predicted the sample to be k-k kp(a-b ) js(a-b ). kel-cdna sequence analysis was performed and detected a single transcript species with c. c, c. c, t, and missing the sequences corresponding to exons , and . amplification of the exons from gdna did not identify any nucleotide changes when compared to the reference sequence and the splice sites were intact. cdna analysis was repeated and the same aberrant transcript was detected. adsorption and elution studies of the k antigen demonstrated weak anti-k reactive after c incubation at the peg-igg-agt phase. conclusion: here we describe a donor homozygous for a novel kel* allele. this donor was presumed to have a k phenotype based on serology, but after molecular testing, has been reclassified as a k mod phenotype with extremely weak expression of k. the discovery of the aberrant transcript led to adsorption and elution studies to confirm the presence of weakly expressed k antigen on the red cells. the variant alleles reported to date (http://www.isbtweb.org/working-parties/red-cell-immunogenetics-and-bloodgroup-terminology/) are associated with missense mutations. in contrast, the allele reported here is associated aberrant mrna transcript. we propose that this allele be named kel* m. . here we report a case of a possible novel b subgroup observed in a pregnant black female. the patient specimen was referred to our reference laboratory to investigate a possible abo discrepancy. the referring facility reported the patient's red blood cells were nonreactive with reagent anti-a and anti-b and the patient's plasma was reactive with a cells, but nonreactive with b cells using automated gel methodology. study design/methods: serological testing of the patient's red blood cells was performed using routine and enhancement methods. molecular testing by pcr-rflp was performed to determine the patient's genetic abo typing and predicted abo phenotype. results/findings: serological testing of the patient's red blood cells is summarized in table ; similar results were obtained with multiple sources of antisera. enzyme treatment failed to enhance reactivity. patient sera strongly agglutinated a and a cells, but failed to agglutinate multiple sources of b cells at all phases of testing. molecular testing by pcr-rflp resulted in an uncommon banding pattern and indicated the presence of c. deleted g, characteristic of o alleles, c. t, characteristic of a and some uncommon o alleles, and c. a and c. a, characteristic of b alleles. genomic sequencing of exons and confirmed the presence of an o allele, abo*o del g, t, t), and the presence of a b allele ( g, g, t, a, a, c, and a), but did not reveal any changes associated with previously reported weak subgroups of b. conclusion: while serologic abnormalities in pregnancy have been reported due to decreased antigen expression, the unusually weak reactions observed when testing this patient are unlikely due to pregnancy alone. additional abo gene sequencing is required to determine the specific allele mutation responsible for this weakened antigen expression. carine arnoni* , tatiane vendrame , janaína muniz , diana gazito , afonso cortez , lilian castilho and flavia latini . associa, associac¸ão beneficente de coleta de sangue, hemocentro de são jos e do rio preto, hemocentro unicamp background/case studies: after the elucidation of the molecular basis of vel, molecular tools have been used to explain the reduced expression of vel antigen in different populations. negative or weak reactions are generally related to the -bp deletion in smim in homozygous or heterozygous status. however, other nucleotide changes have been described to reduce the vel expression, as for example, the major a allele of the snp rs located in the second intron of the gene, a regulatory region in erythroblasts. this study aimed to characterize the genetic changes related to atypical vel expression in a brazilian population. study design/method: a total of blood donor samples from the southeast region of brazil were typed for vel with an anti-vel serum from our inventory in gel-iat. samples typed as vel-negative were further analyzed by adsorption-elution. molecular study was performed in samples with negative results, in samples reacting and in samples with reactivity of . dna was isolated from peripheral blood and smim was sequenced. results/finding: from donor samples studied, were serologically vel negative by gel-iat but positive by adsorption-elution, presented a reaction and the remained samples showed a reactivity of . genotyping results showed that the samples with negative results and of samples that presented reaction were heterozygous for the bp deletion and presented the a allele rs in homozygous status. from the of remaining samples with reactivity of , ( %) had the a allele of rs and ( . %) had the a allele of rs . in contrast, in the samples with stronger reactions we found the a allele of rs in ( . %) samples and the a allele of rs in ( . %) samples. conclusion: the molecular changes rs and rs are located in intron distancing nucleotides. this study reinforces the association of the a allele of rs with reduction of vel expression and suggests the involvement of a new rs change in vel expression. in conclusion, the several patterns of vel expression found in different populations can be influenced by different molecular changes. background/case studies: the d antigen is the most immunogenic antigen after abo. consequences of misclassification of the d-antigen in patients or donors can be severe. some persons inherit mutations resulting in quantitative reductions of d antigen on the cell surface (weak d), some inherit rh haplotypes that result in biochemical effects that reduce the availability of the d antigens to reagent anti-sera (ceppellini effect), and others inherit d genes which are qualitatively different than wild type d. these latter individuals are often not identified until after they have formed anti-d. we hypothesize that some of these persons at risk of forming anti-d might be uncovered if they have weak and/or disparate d typing results with reagents that recognize different epitopes of the d antigen. study design/methods: all testing was performed using microtiter-well direct agglutination on the galileoneo or galileoecho (immucor, norcross,ga). any specimen that did not react as (rh negative), or ! on the neo or ! on the echo (rh positive) for both series and series anti-d antisera were included. patients with discrepant historical types also were evaluated. any specimens meeting the inclusion criteria were tested on the neo, echo, and by saline tube method using series and series anti-d antisera. genotyping was performed from whole blood samples sent to immucor genotyping laboratory in warren, nj using an algorithm of: rhd beadchip, rhdxp (prototype assay), rhd zygosity, and rhce beadchip. results/findings: patients met inclusion criteria for molecular testing for the d antigen. weak or rhd variants were identified in of ( . %) of the samples. ceppellini effect (i.e. c in trans to rhd) resulting in weak d reactivity was seen in of ( %) of samples. of ( . %) of the samples that resulted in weak or discrepant reactivity had some type of genetic cause that was resolved by using our algorithm. of ( %) of tested samples had results indicating weak/variant d proteins with the potential to cause alloimmunization to the d antigen. the remaining of ( . %) samples did not have identified genetic cause for the weak and/or discrepant d test results and were presumptively classified as wild type d. conclusion: transfusion services that use the galileoneo or galileoecho to perform rh typing should consider molecular testing of patients whose rh typing results are discrepant, or positive but < on the galileoneo or positive but < on the galileoecho, as about half of these patients can develop anti-d. this is particularly relevant for females of child-bearing potential where avoidance of d-positive transfusions and administration of rhig during pregnancy is prudent until their d typing can be confirmed by molecular testing. carine arnoni* , tatiane vendrame , janaína muniz , rosangela person , lilian castilho , afonso cortez and flavia latini . associa, associac¸ão beneficente de coleta de sangue, hemocentro de são jos e do rio preto, hemocentro unicamp background/case studies: rhd and rhce, are major protein constituents of red blood cell membrane, composing a complex together with rhag. many variant rh proteins have been described and most of them affect the integration of rh proteins in the membrane. d antigen expression can be affected by several molecular changes and also by the rhcehaplotypes. the present study investigated the score of reactivity of samples presenting a strong reduction in d expression. study design/method: a total of samples were included in the study, being previously genotyped as rhd*dar . , rhd*dar . and rhd*dau . the samples were phenotyped in neov r (immucor) to d, c/c and e/e antigens by direct agglutinationin microplate. results obtained in neov r were expressed in a score from - corresponding to the reaction intensity. zygosity assay was performed by a multiplex real-time quantitative pcr using a set of rhd-specific primers in rhd exon . rhce genotyping was performed by pcr-rflp and ssp-pcr. the presence of a d-cehybridexon was identified by amultiplex pcr. sequencing and identification of rhce variants were also performed when necessary. results/finding: zygosity results showed that of samples ( dar . , dar . and dau ) had rhd genes, were phenotyped as c e-c e and genotyped as rhce*ce/rhcece. rhd and rhce genotyping in these samples showed the presence of the d-ce-d s hybrid gene. rhce variants investigated in dar . samples showed the rhce*-cear/ce s genotype, in dar . samples the rhce*cevs. /ce s genotype and in the dau sample the rhce*ce s /ce genotype. table describes the differences found in the reactivity of d among the samples carrying the (c)ce s allele and in the samples homozygous for rhce*ce. the results showed that the presence of rhce*(c)ce s significantly reduces the expression of d antigen, probably due to the expression of the partial c partial antigen in trans to rhd. additionally, the samples with reduction on d expression carrying rhce variant alelles phenotype can be useful to provide compatible blood to some patients with rarerh variant alleles. background/case studies: drugs are known to interfere with routine blood bank testing. a novel monoclonal humanized f antibody (hu f -g ) that binds human cd has been entered into clinical trials for patients with acute myeloid leukemia, non-hodgkin lymphoma and solid tumors. we describe two cases of patients treated with hu f -g (anti-cd ) who had abo discrepancy with extra-reactivity in the reverse typing and a panaggutinin in the plasma. study design/method: this is a retrospective review of two cases with immunohematology work-up showing abo discrepancy and plasma panagglutinin. the first case is of a year old female with progressive follicular lymphoma who was enrolled in phase b/ trial of hu f g in combination with rituximab designed for patients with relapsed/refractory b cell nhl. she had no prior transfusion history and her historical blood type was not known. two rbc units were requested in anticipation for a surgical procedure. the second case is of a year old male with refractory diffuse large b cell lymphoma enrolled in hu f -g clinical trial. his historical blood type was a rh d positive with a negative antibody screen. he received three rbc units within the past month prior to testing and receiving the anti-cd therapy. results/finding: the abo typing in the first case showed a discrepancy between the forward typing ( with anti-a, non-reactive with anti-b) and the reverse typing ( with both a cells and b cells). rhd typing was positive. the extended reagent rbc panel tested with the patient's serum reacted with all cells tested at the immediate spin (is) phase ( to ), at liss- c ( to ), at liss-polyspecific ahg (m ), and at peg-anti-igg (m to ). plasma reactivity at is persisted with dtt or ficin treated red cells and was not removed by cold autoadsorption, cold alloadsorption, or rest adsorption. repeat testing, which avoided the is and c readings, was non-reactive in the antihuman globulin (ahg) phase using both liss and peg enhancements, ruling out clinically significant alloantibodies directed toward common red blood cell antigens. the direct antiglobulin test (dat) and autocontrol were negative. the rbc units issued to the patient were crossmatch compatible at o c ahg phase. the abo typing of the second case performed after anti-cd administration showed a discrepancy between the forward ( with anti-a) and the reverse ( with both a and b cells). rhd typing was positive. the antibody screen performed in solid phase technology was positive with all reagent red cells. his plasma reacted with all reagent red cells at is ( ), at c in liss ( ), and liss-polyspecific ahg (m ). the dat and autocontrol were negative. his genotype was determined to be a /o and full rbc phenotype by dna analysis was obtained. repeat testing which avoided the is phase did not show reactivity at peg-ahg excluding all alloantibodies directed toward common red blood cell antigens. conclusion: anti-cd therapy interferes with blood bank testing by causing abo discrepancies and panagglutinin reactivity in the plasma at is, c liss, but not at ahg phase using gamma-clone anti-igg, unlike the anti-cd interference. knowledge of patient's blood type and phenotype before starting this therapy is critical for providing safe blood. background/case studies: a middle-aged male with discrepant abo typing results was investigated. initial forward typing was group o but no anti-b was seen in the reverse typing. an unexpected reaction was noted with an anti-a,b reagent. genotyping surprisingly showed abo*o. . / o. . , consistent with group o. after initial testing at the referring center, samples were sent for extended analysis. study design/method: standard serological methods and flow cytometry were used. a panel of abo reagents (n ) and lectins were tested with both native and papain-treated red blood cells (rbcs). lewis phenotyping was performed, as was genetic testing for abo, gbgt and a galt. papain-treated patient rbcs were used to screen donor plasmas (n ) and two reactive plasmas were dtt-treated. results/finding: positive reactions were obtained with polyclonal anti-a,b and a monoclonal anti-b (clone g / ) when tested with the patient's papain-treated rbcs. a panel of lectins gave negative results. genetic testing confirmed the predicted group o and ruled out the presence of fors or nor antigens. the patient was le(a-b ) and thus a secretor. a positive crossmatch was seen with % of group o plasmas, while no reactivity was obtained with a or b plasmas. dtt treatment of crossmatchpositive plasmas indicated the antibody to be mainly of igg type. this was confirmed by positive flow cytometry cross match using anti-human igg secondary antibodies. reactivity remained after b-zyme treatment, thus excluding the normal (type or ) b antigen to be the underlying reason. inhibition with lewis substance significantly decreased reactivity. enzyme activity assay showed the patient's plasma to contain a fully functional b glycosyltransferase. on the suspicion that the patient had non-erythroid cells producing breactive type chains, a sample from a hematopoietic stem cell transplant (hsct) patient (group b secretor receiving group o donor cells) was included as a control and gave the same type of reactions. conclusion: the medical history of the patient was queried and he had indeed undergone an hsct $ years earlier. the reactions are likely due to uptake of recipient-derived ble b (type ) antigen (isbt no. ), which is the dominant lewis antigen in the recipient's original blood group, b le(a-b ). interestingly, b-zyme did not affect ble b . anti-ble b is not simply anti-b plus anti-le b but an inseparable and rarely reported specificity, which appears to be common among group o donors. the phenomenon reported here has unknown clinical implications but highlights the complexities of carbohydrate blood groups. background/case studies: the provuev r and visionv r (ortho scientific, raritan new jersey) automated analyzer use mts-gel tm card technology to perform immunohematology testing. benefits of automated testing include improved efficiency and enhanced reliability. after eight years of using the provuev r our transfusion medicine service switched to the ortho visionv r analyzer in january of . shortly after implementation, technologists reported increased time spent performing manual resolution of indeterminate (designated as "?") results. additionally, some test columns were noted to be visually negative but called positive ( ) by the analyzer. the objective of this study was to investigate the cause of "?" and apparent false positive results on visionv r three-cell antibody screens. study design/methods: with assistance from ortho diagnostics, analyzer archives were queried to identify the number of gel card columns used for screens, the number of columns with "?" results, and the gel card lot numbers used for testing from / / to / / . reactivity was determined to be false positive based on supervisory review of digital images and antibody panel results. investigation also included review of daily qc records, instrument maintenance, instrument diagnostics, and camera calibration. results/findings: of , columns run as part of antibody screens, , ( . %) columns generated "?" results. assuming seconds of technologist time per "?", we estimate that . hours were needed to resolve and update these results. among all potential causes investigated, only the gel card lot number was associated with the number of "?" generated (table ) . in cases, all three columns were visually negative but the analyzer reported reactivity with of cells. all cases had mts-gel tm antibody identification panels performed, of also had a mts-gel tm ficin panel. the yield for the panels performed was two routine panels with weak reactivity against hla cells, and four ficin panels with weak reactivity with no apparent specificity. fourteen patients coincidentally had a subsequent type and screen; were negative. one patient newly demonstrated anti-jka. fifty percent ( / ) of visually negative but analyzer positive samples were tested with gel card lot number , % ( / ) with lot , and % ( / ) with lot . conclusion: the incidence of "?" and visually negative analyzer positive results is dependent on the specific lot of mts-gel tm cards used. the difference between the lots is being investigated by ortho diagnostics, and remains to be explained. to avoid unnecessary waste of technologist time and other resources, with assistance from ortho diagnostics, we have results/finding: of the methods evaluated, the dtt method proved the most useful for mitigating dara interference. cord cells were effective but in limited supply and alloadsorption was ineffective. of the three different dtt methods evaluated, the tube method initially failed which led to re-evaluation with the addition of liss (passed). the gc method was the most sensitive method. following release of dara, samples from patients ( cross-match samples, units issued) were tested using both liss tube and gc iat methods. despite dtt treatment, the gc method remained positive by iat in / patients. further testing was performed in / . eight were tested for the presence of antibodies at c and confirmed in / . rouleaux formation was observed in / patients, / had reactivity detectable at c. no transfusion reactions have been reported to date nor has alloantibody formation been observed to date. conclusion: as previously reported, the dtt method was the most useful for mitigating dara interference. the observed interference seems to be due to rouleaux and/or cold reactive antibodies -seen least in the liss tube iat. this may be due to the washing phase in this technique which dissipates rouleaux formation. reactivity due to cold reactive antibodies can be eliminated by performance at strict c. our practice is now to use both dtt iat methods on initial patient referral, if residual reactivity in gc is observed use liss tube in preference thereafter in these patients. a further observation is that investigation of pan-agglutination could include the use of cord cells to confirm/exclude dara use if suspected. wendy beres* , sandra nance , david moolten and p. dayand borge . ( ): - ). our laboratory tested random allogeneic blood donors, and autologous donors (which were intended to represent a hospitalized patient population), to determine a mean and range of "normal" levels. this . year retrospective study was performed to assess levels of rbc-bound igg, iga and igm in normal donors. study design/method: residual edta-anticoagulated aliquots from random allogeneic and autologous blood donors were sequestered and tested per institutional review board approved protocol. the samples were tested by fc with fluorescein isothiocyanate (fitc)-labeled anti-human igg and iga (jackson immunoresearch lab, west grove, pa) or fitc-labeled anti-human igm (life technologies, carlsbad, ca) at optimized dilutions in dulbecco's pbs containing . % bsa. the becton dickinson facscalibur tm or facscan tm (san jose, ca) fc analyzed k rbcs from each sample. edta-anticoagulated samples and ig coated control rbcs were tested to determine fc settings and control for validity and cross-reactivity. controls reacted as expected. there were less autologous donors tested and with a mean age of these donors could have been older than the allogeneic donors, but the mean age of the allogeneic donors was not captured. despite the relatively small number of samples tested there was a higher than expected instance of allogeneic donors having elevated rbc-bound iga, igg, and igm levels. this emphasizes the need to include testing of normal donor populations in establishing expected reactivity, thus normal and abnormal ranges for flow cytometric testing. long range pcr reveals the genetic basis of an antibody in pregnancy to a high prevalence mns antigen judith aeschlimann* , anna burgos , virginia lew , sunitha vege , susan veneman , christopher j gresens , jonathan hughes and connie m. westhoff . immunohematology and genomics laboratory, new york blood center, blood centers of the pacific, bloodsource background/case studies: recombination events have generated many gypa and gypb hybrids giving rise to glycophorin (gp) variants that express low-prevalence antigens (e.g. mia, miny, mur). in rare individuals who are homozygous these alleles are associated with lack of highprevalence antigens (e.g. enkt, eneh, enav). complex hybrid recombination events can make it challenging to elucidate specific alleles present in samples, particularly heterozygotes. we investigated samples from a pregnant asian (hmong) woman with an antibody to an unidentified highprevalence mns antigen, and samples from her sister. study design/method: standard methods were used for rbc typing with licensed and unlicensed reagents and for antibody identification. dna was isolated from wbcs, and hea precisetype, exon-specific amplification and sequencing gypb exons - , and long range sequencing of exon - ( . kb amplicon) were performed. snp-specific primers were used to associate changes (phasing) to specific alleles. results/finding: rbcs of the pregnant proband typed s-s-(gammaclone anti-s), and the plasma reactivity was consistent with an antibody to a high background/case studies: the rhd antigen is clinically significant and immunogenic and therefore individuals who develop anti-d are at risk of haemolytic transfusion reaction. rhd polymorphism shows substantial ethnic variability and at least rhd variants associated with weak d alleles have been reported. in this study, we report two new rhd alleles in brazilian blood donors associated with weak d antigen expression. study design/method: the d status was evaluated with commercially available monoclonal anti-d reagents: blended igm/igg (clones th- / ms- ), igm (clones ms and p x ) and igg (ms ) in tube and on gel cards. c, c, e and e phenotyping were performed in gel. most common weak d and partial d alleles were investigated by allele specific (as) pcr and with the rhd beadchip platform from immucor. direct automated sequencing of the rhd exons and flanking intron regions was performed by the sanger dideoxy method. in order to determine rhd allelic combinations, we also performed rh-cdna cloning and sequencing. background/case studies: donors negative for multiple common antigens or lacking a high prevalence antigen are efficiently identified using a red blood cell (rbc) genotyping panel. when serology is used to confirm antigen negative status, discrepancies are identified, albeit rarely. investigation of the discrepancy often leads to identification of variant antigens. it is known that the set of gyp variants associated with expression of the st a antigen can also be associated with n typing discrepancies in m n-individuals (meyer et al. br j haematol. ; : - ) . the st a allele, also described as gyp* , is a hybrid gypb-gypatranscript with the crossover in intron . we sought to investigate five n typing discrepancies for which alternative genotyping methodology was performed and found to be concordant with the initial panel. background/case studies: a sample from a years old pregnant, african american female g p was sent to the blood bank for abo/rh and antibody screen. the sample was analyzed using the provue analyzer (ortho diagnostics). the patient was typed as o pos with no reverse type discrepancy. a retype of the same sample was performed using tube method with biorad reagents per hospital policy due to no previous abo/rh history on file. the retype showed that the patient was a subgroup with anti-a antibody present in the plasma. the sample was referred for genotyping, with the suspicion of a like phenotype. genetic testing did not support the serological findings of a subgroup and a new abo allele, abo* c that has never been reported in correlation with an a like subgroup was detected study design/method: the patient rbcs were typed with anti-a (immucor) and anti-a,b (biorad and grifols dg gel). an anti-a antibody work up was performed using three different lots of a cells and three lots of a cells, as well as a type o screening cell and auto control . the tubes were read at is and also incubated at rt and c for min. the patient 's initial antibody screen using ortho gel was negative. conclusion: the patient delivered a healthy baby boy at weeks of gestation. the baby cord was sent to the laboratory. the baby serological type showed an a b phenotype and it was referred for genetic testing. the baby rbcs showed the same abo* c found in the mother. the previously reported abo* a allele encoded an aspartic acid to asparagine change at position p. consistent with an a weak phenotype. also, at least five other alleles encoding an a phenoytpe consisted of polymorphisms at positions c. through c. , giving special characteristics to this new and unreported abo allele. from the data collected, it can be concluded that this a / aweak phenotype is encoded by the variant allele abo* c. this highlights the clinical relevance of confirming the serology of abo subgroups by molecular methods. philip berardi*, jacqueline cote, gwen clarke, vito scalia, robert liwski and mindy goldman. canadian blood services background/case studies: elucidation of the molecular basis of blood group expression has led to the development of high throughput molecular methods for predicting blood group antigens. the commonly used single nucleotide polymorphism (snp) arrays require nucleic acid isolation which is typically achieved by extracting genomic dna from whole blood. this method requires venipuncture and may not be an ideal approach for severely anemic patients or potential donors that are unable to provide a sample of whole blood due to their remote location. dna extracted from buccal swab samples offers a noninvasive alternative to venipuncture and may provide a safe and efficient means of transporting samples from remote locations to reference laboratories for extended blood type prediction. canadian blood services (cbs) has performed large scale dna extraction and hla genotyping for the onematch stem cell and marrow registry using buccal swabs since ; buccal swabs are also used by other unrelated donor stem cell registries, such as the us nmpd. we sought to assess the accuracy and reliability of using dna extracted from buccal swabs in predicting blood group antigen expression. study design/method: we performed parallel red cell genotyping on an automated typing platform, the progenika/grifols idcorext assay (progenika biopharma-grifols, bizkaia, spain) using dna extracted from blood and buccal tissue from volunteers. for antigen systems with available serologic reagents, we also compared results with serologic typing. we evaluated three different methods of dna extraction and performed testing regardless of dna yield or purity. two buccal swabs (puritan medical products, guilford, maine) were used for each test. swabs were stored at room temperature, and dna extraction was performed within six days of collection. in the initial phase of the study, buccal swab samples (n ) were processed with the automated biorobot m robot using the magattract dna mini m extraction method (qiagen, venlo, the netherlands). extracted dna had a mean concentration and purity of . ng/ml and . respectively. in the second phase of the study (n ), dna extractions from buccal swabs were performed using methods available in our national red cell immunohematology reference laboratory: the qiaamp dna mini kit, using either manual or an automated qiacube robotic workstation (qiagen, venlo, the netherlands). results/finding: the manufacturer's recommended analytical range for dna concentration was - ng/ll and the recommended purity was an absorbance ratio of . - . (a / ) for use of the id corext platform. dna extraction from buccal swab samples did not meet these specifications in several cases. however, in most cases, a lower concentration of dna was adequate for prediction of phenotype. the dombrock system was the most susceptible to failure of interpretation in the samples with a low dna concentration, with "no call" results reported. there was % concordance in genotyping results when source dna was extracted from whole blood or buccal tissue; there was also % concordance between predicted phenotype and serologic testing results. conclusion: this study supports the use of genomic dna extracted from buccal tissue on the id corext for predicting rbc phenotype with high accuracy. extraction methods may require optimization to achieve dna yields within the recommended analytical range of the assay. performance evaluation of id rhd xt, a genotyping assay for the detection of high-prevalence rhd negative and weak d types araitz molano , izaskun apraiz , maría azcarate , miguel angel vesga , montserrat rubia , mercedes piedrabuena , fernando puente , barbera veldhuisen , ellen van der schoot and m onica l opez* . progenika biopharma, a grifols company, centro vasco de transfusi on y tejidos humanos, banco de sangre y tejidos de arag on, sanquin blood supply research background/case studies: it is well established that weak d , and phenotypes are not at risk for forming allo-anti-d, whereas a few weak d and all partial d and negative phenotypes are. routine serologic d typing does not distinguish among them, consequently rhd genotyping is recommended, especially in patients. id rhd xt (progenika, grifols) is a qualitative, pcr/luminex v r xmap hybridization-based genotyping test for the identification of the following rhd gene allelic variants: rhd*weak d type , rhd*weak d type , rhd*weak d type , rhd deletion, rhd*pseudogene and rhd*diiia-ce( - )-d and itgb gene: hpa a and hpa b, in genomic dna extracted from whole blood specimens. in this study the performance of id rhd xt genotyping assay was evaluated in terms of whole system failure rate, call rate and accuracy for rh and hpa- blood group typing. study design/method: a cohort of previously serotyped samples for d antigen obtained from three european blood centers were analyzed with id rhd xt at progenika. samples were distributed as recommended by the annex of the common technical specifications / /ce for a ivd product of list a (! % clinical samples, > % neonatal specimens and ! % weak d donors). for the intended use of the product, weak d serotyped donors were enriched (n , %). commercial serology tests for d antigen predicted phenotype and bi-directional-sequencing (bds) for weak d type confirmation and hpa- predicted phenotype were used for comparison. transfusion results/finding: no system failure, % call rate and no inconclusive results were obtained. discrepancies were found for d antigen between serology and id rhd xt predicted phenotype results, although a % concordance was obtained when analyzed by bds, considering id rhd xt result correct. concordance between id rhd xt and bds results for the weak d type was %. the following id rhd xt predicted phenotype results were obtained: d negative (n ), no amplification variant (n ), weak d type (n ), weak d type heterozygous (n ), weak d type (n ), weak d type heterozygous (n ), weak d type (n ), weak d type heterozygous (n ), weak d types , or not detected (n ). regarding hpa- blood group, the predicted phenotype results obtained by id rhd xt were % concordant with bds results: hpa- a positive (n ) and hpa- a negative (n ), hpa- b positive (n ) and hpa- b negative (n ). conclusion: id rhd xt genotyping assay performed as a reliable and accurate method for predicting the genotype and phenotype of high prevalence rhd negative and weak d types ( % specificity and % sensitivity for d antigen, hpa- a and hpa- b antigens). that makes it a useful tool for the implementation of the rhdgenotyping recommendation on patient blood transfusion and anti-d prophylaxis. background/case studies: scd patients form red blood cell (rbc) antibodies at higher rates than other transfused populations. multiple predictors of alloimmunization have been reported but not well replicated in large scd cohorts. we investigated the clinical, laboratory and genetic predictors of alloimmunization. study design/method: a large scd cohort was established in brazil to investigate disease outcomes. at participating sites, patients are currently transfused with abo/d/cc/ee/kell matched rbcs prophylactically and extended phenotypically matched rbc after first antibody forms. policies for matching are center-specific and evolved to increased levels of matching over the exposure period included in this study. transfused subjects with rbc alloantibody of defined specificity within the cohort were compared to transfused antibody negative subjects using chi squared to compare categorical variables and t-test or wilcoxon rank-sum tests as appropriate to compare continuous variables. backward elimination multivariable logistic modeling was used to generate odds ratios (or) and identify independent predictors of alloimmunization using results of univariate analyses. all subjects had peripheral blood whole genome snp typing performed using an affymetrix array, which included enhanced content for blood related snps. genome wide association (gwa) analyses were conducted using a logistic model to identify additive genetic effects associated with alloimmunization. a p value < . (clinical analysis) or < x - (gwa) was considered statistically significant. results/finding: of the cohort patients, ( . %) transfused subjects were included with alloimmunized children < years ( . % of ) and alloimmunized adults ( . % of ). in multivariable logistic regression models, age (or . , p . , for age compared to - ), gender (or . , p . , for female compared to male), transfusion history (or . , p< . , for transfusions compared to - ), site, hemolysis (or . , p . , for log transformed lactate dehydrogenase) and presence of autoimmune disorders (or . , p< . ) were independent predictors of alloimmunization. gwa identified a single snp of unclear biologic significance associated with alloimmunization (eefsec gene responsible for incorporation of selenocysteine into proteins). conclusion: rbc alloimmunization is primarily driven by transfusion burden in this scd cohort. hemolysis remained significantly associated with alloimmunization after controlling for transfusions. presence of an autoimmune disease was also associated with rbc alloimmunization, indicating more systemic immune dysregulation may be present in scd patients who develop rbc alloantibodies. however, the gwa did not identify snps in immunoregulatory genes significantly associated with rbc antibody formation in the study population. background/case studies: physiologic anemia is more severe in preterm infants and worsened by the blood loss required for laboratory tests. to reduce iatrogenic anemia, placental blood, which otherwise would be discarded, can be used for laboratory testing. mother and infant blood are mixed in the placenta during delivery and pre-transfusion test results potentially can be altered due to fetal-maternal hemorrhage. there has been no published study to show if pre-transfusion test results of placental blood give the same result as the heel stick samples, which is the standard of practice. study design/methods: transfusion service tested sample pairs from newborns less than , gr birth weight. one of the samples was collected from the newborn as a heel stick sample, the other from the placenta. the following tests were performed on the sample pairs: abo, rh, antibody screen and direct antiglobulin test with igg (dat). results/findings: abo, rh and dat tests were performed on sample pairs. dat test was negative on sample pairs and two were positive. there was % concordance with the abo, rh and dat tests performed on these sample pairs. antibody screen was performed on placental blood samples and heel stick samples. twenty eight sample pairs were negative with the antibody screening test. there was one positive heel stick sample, which was also positive using the placental sample. one heel stick sample was negative for the presence of an antibody but found to be positive with the placental blood sample. this antibody which was detected only in the placental sample was a passive anti-d mother received during pregnancy. this discrepant result indicates that the placental blood sample was more sensitive to detect a weak antibody. conclusion: this study shows that placental blood sample is not inferior to heel stick sample regarding abo, rh and dat testing. based on this comparison study placental blood can be used for pre-transfusion testing for < , g birth weight newborns. o-( . %), ab ( . %), b-( . %), and a-( . %). among the tested donors, . % were d positive with r r being the most common rh phenotype. in the kell blood group system, . % of the donors were k positive, while the k antigen was found to be . %. the most common phenotype in the duffy blood group system was fy(a-b-), while the fy(a b ) was found at a higher frequency compared to what has been reported in the black population. (table) the commonest phenotypes for the kidd and mns blood group systems were jk(a b ) and m n-s s at % and . % respectively. the le a and le b alleles were seen in . % and . % of donors respectively, while lu b -phenotype was found in . % of the donors. the frequencies of the rare phenotypes jk(a-b-), le(a b ) and lu(a-b-) were . % , . % and . % respectively, while the m n-s-s-and m-n s-s-phenotypes were not found. the frequency of the p antigen was found to be at . % similar to what has been reported in caucasians. conclusion: this is the first study to examine the frequencies of rbc blood group phenotypes among the omani blood donors. the results show higher frequencies of the rare null phenotypes fy(a-b-), jk(a-b-) and lu(a-b-) compared to what has been reported in caucasians. the frequencies of the duffy blood group system resemble what has been reported in the black population. this data is helpful in understanding the influence of the arab ethnic background on the rbc blood group systems and warrants large genotype-phenotype studies in the region. quantitation of anti-d in serum using flow cytometry amanda whitelonis*, izekial butler, karen leighton, scott jones and anand srinivasan. qualtex laboratories background/case studies: rh(d) antibodies (anti-d) are developed in rhnegative individuals when exposed to d antigens. this scenario is commonly observed in alloimmunized antenatal and volunteer immunized patients. quantitation of anti-d in serum is important in the clinical setting to predict the risk of hemolytic disease of the newborn. quantitation of anti-d is also performed in quality control operations of organ procurement organizations and plasma fractionators. it is a common practice to report the strength of anti-d in serum as antibody titer values but quality control operations require a quantitative value. we have developed a screening assay using flow cytometry to quantitate anti-d in serum. study design/method: we have developed a method to quantitate anti-d in serum using flow cytometry, by modifying the protocols of christensson et al., and hilden et al.. red blood cells from rh-positive blood samples were washed three times in phosphate-buffered saline (pbs) at ph . and the supernatant was discharged. a dilution buffer containing % human serum albumin (v/v) in phosphate buffered saline was prepared. serum samples or who anti-d standards, suspended in dilution buffer were mixed with ll of washed red cells. the cell suspensions were incubated for min at c. following incubation, fitc-labeled anti-igg diluted in buffer was added and the mixture was incubated for an additional min at c. the samples were then analyzed by flow cytometry using gates for a typical red cell based on the forward and side-scatter signals. green fluorescence was collected using a band-pass filter set for - nm. events were recorded at a frequency of cells. results/finding: multiple dilutions of who anti-d reference standard were tested against rh-positive red blood cells from five different donors. the reproducibility of the assay was determined by measuring the change in coefficient of variance due to dilution procedure, machine variation and sample storage condition. after optimizing these factors, a linear regression was calculated to establish the standard curve. the fluorescent intensity emitted by probes demonstrated a linear correlation with the concentration of rh(d) antigens in reference standard. serum from thirty rh(d)-immunized volunteers were analyzed for concentration of anti-d and the results were benchmarked with antibody titer values. conclusion: based on our study, we conclude that the quantitation of rh antigens by flow cytometry can be used as a reliable assay to measure the concentration of anti-d antibodies in serum. the method is reproducible and advantageous over reporting antibody titer values. the operations of this platform can be translated to a well-plate based high-throughput flow cytometry. sarah k harm* , mark yazer , nancy m. dunbar and biomedical excellence for safer transfusion (best) collaborative . university of vermont medical center, university of pittsburgh, dartmouth-hitchcock medical center background/case studies: the use of emergency issued group a plasma and uncrossmatched group o whole blood (wb) in patients without a valid abo group is becoming increasingly common in the usa. it is unclear if low titer products should be provided in this situation and indeed a universally agreed upon threshold that would qualify as "low titer" has not been established. this study was designed to determine the rate of high titer donors using a titer threshold of . study design/methods: three academic hospitals that routinely issue group a plasma units for emergency issue participated in this study. before issuing this plasma to patients, a : dilution of the donor's plasma in saline was produced and added to group b reagent red blood cells (rbc). if any degree of macroscopic agglutination after immediate spin was observed, the unit was considered high titer and it would only have been issued to group a or o recipients. at these three centers no temperature, plasma volume or time enhancements were performed in the titer procedure, and anti-human globulin was not added. at one center samples were taken from the plasma of group o wb units and the same procedure was followed using a and b reagent rbcs; if at least one antibody demonstrated macroscopic agglutination after immediate spin, the wb unit was considered high titer and it was then centrifuged into an rbc unit for transfusion while the plasma and platelet components were discarded. two centers provided plasma testing data for a -year and -year period, respectively. one center provided plasma and wb testing data for a -year period. results/findings: in total there were group a plasma units tested and ( . %) had a high titer anti-b. the range of high titer group a plasma units between these three centers was . %- . %. of the wb units tested, ( . %) units had a high titer; / ( . %) of the units had a high titer anti-a, / ( . %) had a high titer anti-b, and / ( %) had high titers of both anti-a and anti-b. background/case studies: dithiothreiol (dtt) is a sulfhydryl reagent that denatures selective blood group antigens. reagent red blood cells (rbcs) treated with . m dtt is used as a tool in identifying antibodies to high frequency antigens. recently, dtt has become widely used in destroying cd on reagent rbcs and render them free from plasma anti-cd drug interference. procedures for the preparation of . m dtt has been published advocating the use of buffered saline at different ph levels. in this study, an effect of ph on . m dtt treatment time is investigated. study design/methods: non-buffered saline (nbs, thermo fischer scientific inc, middletown, va), used in the preparation of . m dtt, was adjusted to ph . , ph . , ph . using sodium phosphate dibasis (sigma aldrich, saint louis, mo). reagent rbcs (immucor, norcross, ga)(n ) were treated with the . m dtt solutions in parallel by mixing : ratio of packed rbcs to . m dtt solution followed by incubation at c. for up to minutes during treatment, the expression of k antigens was measured every minutes by tube method using different sources of anti-k. to assure uniformity, all reactions were graded by the same investigator. each reaction grade (in each rbc and each antiserum) is converted into a semiquantitive score and an average score was calculated every minutes for each ph level. the reduction in average scores between different phs were also calculated at every minutes to measure the impact of . m dtt reagent ph on the rate of k antigen destruction. results/findings: the expression of k antigen, measured by agglutination grades with two different k antisera, is significantly weakened (by ! ) after minutes of dtt treatment at ph . ; minutes at ph . and minutes at ph . . complete loss of k expression was seen after minutes of dtt treatment at ph . ; minutes at ph . and minutes at ph . . the reactivity patterns of k antigen tested with sources of anti-k correlate with each other. the reductions in average scores were seen between to minutes range of dtt treatment time when ph . was raised to ph . ; to minutes range when ph . was raised to ph . ; and to minutes range when ph . was raised to ph . . conclusion: the use of higher ph buffered saline may shorten the treatment time it takes to weaken or destroy k antigen. based on the comparison of reaction scores between different ph levels, the ph levels did not have an impact on dtt treatment up to minutes and/or beyond minutes of incubation. the ph of the . m dtt reagent relative to the treatment time is a factor to consider during the validation of dtt-treatment process and qualification of . m dtt reagent in a laboratory. background/case studies: data on the characteristics and frequencies of clinically significant red cell antibodies within the prenatal population have not been well established in the united states. the aim of this study was to determine if frequencies of red cell antibodies differed between geographically distinct regions within the continental united states. study design/ method: the aim of this retrospective study was to evaluate a cohort of prenatal patients (n , ) drawn between july , and june , . these patients were divided into united states census bureau regional and divisional categories according to their place of residence. prenatal blood work was collected which included an abo, rh(d) and a screen for unexpected alloantibodies. samples found to be positive for red cell antibodies were sent to one of nine regional laboratories for identification. results/ finding: in total, , patients were found to possess clinically significant red cell antibodies for an overall incidence of . percent. the three most commonly encountered antibodies were anti-d (n ) . %, anti-m (n ) . %, and anti-e (n ) with a frequency of . %. a total of ( . %) prenatal women were found to possess two or more antibodies. in general, the combination of anti-d and anti-c proved to be the most common, with instances ( . %) followed by anti-e and anti-c with ( . %), and anti-c, anti-e with ( . %). of the multiple antibodies identified, ( . %) included at least one antibody from the rh blood group. the south region had the largest number of antibodies identified with or . % of the total. the west had ( . %), the midwest ( . %) and the northeast with ( . %). a contingency table, using the two-sided fisher's exact test, was performed comparing the northeast, south, midwest and west regions. the p value of anti-d was calculated to determine nonrandom associations and values of . and below was deemed significant from a region-to-region perspective. with regard to anti-d, the pacific division comprised of california, oregon, washington, and alaska, had p values below the . thresholds when compared against seven of the eight other divisions. the west south central division (texas, oklahoma, arkansas, and louisiana) did not show statistically significant results when compared against the pacific division (p . ). conclusion: depending upon the antibody, statistically significant variations between geographical regions and divisions within the united states were observed. this relationship between antibody and locality requires further investigation but may be attributed to the presence or absence of red cell antigens among different racial and ethical populations. reduction in repeat testing using gel technology amy mata* , lindsy rich , sherry stern , sharon wangen and camille van buskirk . mayo clinic, mayo clinic rochester background/case studies: our institution currently uses the immucor neo (immucor, inc., norcross, georgia) to perform abo/rh and antibody screen (absc) testing utilizing solid phase technology. when results are unable to be obtained from the immucor neo, testing is repeated on the manual testing bench using tube agglutination. this repeat testing can lead to significant expenses including reagents, supplies, and technologist time. it was decided by leadership in our laboratory that it would be beneficial to observe how other methodologies perform in this regard. a side-by-side evaluation was performed between the immucor neo and the ortho vision (ortho clinical diagnostics, rochester ny) to determine if there was a significant difference in the amount of repeat manual tube testing that needed to be performed. the evaluation looked at abo/rh and absc testing as those are the only tests that are currently automated in our laboratory. study design/method: thirty specimens that were processed on the immucor neo and resulted in no type determined (ntd) for abo/rh testing were selected to be tested on the ortho vision. twenty-three specimens that were processed on the immucor neo and produced positive results for absc testing were selected to be tested on the ortho vision. all specimens were edta tubes and were collected within the previous days. the timeframe between when the specimen was tested on the immucor neo and the ortho vision was to days. results/finding: of the ntd specimens from the immucor neo, resulted in valid abo/rh typings on the ortho vision. three results were flagged indicating possible extra reactivity. upon performing a visual review of all results, it was determined that there was no reactivity and a valid result was present. the other samples required manual tube testing to interpret the abo/rh and were due to mixed field, weak isoagglutinins, unexplained extra reactivity, and hemolysis. of the absc specimens that were resulted out as positive on the immucor neo, specimens produced a negative result on the ortho vision and were confirmed to be negative with manual tube testing using peg as the enhancement media. one specimen was flagged for fibrin, but upon performing a visual review, was determined to be negative. nine specimens that were positive on the immucor neo were also positive on the ortho vision. one specimen proved to be an anti-m that was seen in gel but not in tube and one specimen displayed unexplained reactivity in gel as it was negative in tube and all clinically significant antibodies were ruled out. all showed discrepant results with monoclonal anti-c reagents, with a similar pattern of reactivity: - with ms (n ), - s with ms (n ), no reaction with ms , dgc , p x (n ). samples tested with a polyclonal anti-c showed a - reactivity. d c e c e cases tested with a polyclonal and monoclonal anti-e (ms , ms , ms , ms ) showed no weakened reactivity. rhce sequencing (genomic dna or cdna) showed a c. g>a mutation in exon , predicted to encode the p.gly ser substitution. for apparent r r donors, a f-negative type allowed the prediction of a rhce*ce a/rhce*ce genotype. altogether, our results are consistent with the presence of a very likely rhce*ce a allele (c and e in cis) in all samples. d c e c e individuals were reactive s with the original source of anti-rh , slightly weaker when compared to rhce*ce a/rhce*ce rbc samples available from our cryobank ( ). conclusion: our results confirm that the c. g>a mutation alters the conformational properties of the rhce protein, either on a ce or ce background, and encodes the low-prevalence locr antigen (rh ). the locr reactivity appears to be rather similar when coded by rhce*ce a or rhce*ce a alleles. this was quite an unexpected finding, since the p.gly ser substitution is close to the critical amino-acid for c/c expression (p.pro ser). none of our cases made anti-c and/or anti-e but few were subject to a potential alloimmunization background. however, as rhce*-ce a was reported to code for a partial c (rh:- ), we consider that rhce*ce a likely encodes partial c and e, this being also supported by the predicted localization of the p.gly ser change on the second extracellular loop of the rhce protein. background/case studies: weak d genotyping is recommended for transfusion recipients, pregnant women, and newborns who had a rhd typing discrepancy, or a serological weak d phenotype, to determine if they carried the weak d genotypes , or . the purpose of this study was to analyze the underlying rhd genotypes of the patient samples received for weak d genotyping since published recommendations, in particular those found to not carry the weak d , , or genotypes. study design/methods: between / and / samples were received for weak d genotyping. testing was performed using pcr-rflp targeting the sequence variants in the rhd gene that have been previously defined. samples that did not have weak d types , , or genotypes, but a transfusion vol. supplement s had evidence of rhd genetic sequences in exon and/or intron in preliminary testing were evaluated by sanger sequencing for rhd and rhce exons - to determine the underlying rh genotype. when provided, the patient's ethnicity and presence of anti-d was recorded. results/findings: the majority of the samples were from obstetrical patients ( %) followed by transfusion patients ( %); % had no clinical indication provided. samples ( %) were found to be weak d type , , or ( , , and samples, respectively). samples ( %) appear to be genetically rhd negative. genetic sequencing was performed on samples; had rhd genetic variants that were not weak d types , , or (table) . all of these variant rhd samples also showed some variation in the rhce gene. two samples ( %) had wild type rhd alleles; further evaluation is ongoing. conclusion: most samples tested by weak d genotyping were found to be weak d types - . of the samples that had evidence of an rhd gene and did not carry the known weak d types - polymorphisms, ( %) of were found to have other rhd variants, and ( %) did not have underlying genetic variation detected in the rhd gene. the majority of the non weak d types - variants were dar alleles, which are often associated with anti-d production. background/case studies: rhd genotyping has been recommended to guide transfusion of d-negative rbcs and administration of rh immunoglobulin to patients with discordant or weaker than expected d typing, particularly for females and ob patients . the recommendation is based on observational evidence, primarily from europe (flegel , curr opin hematol : ) , that individuals with weak d types , , and are not at risk for clinically significant anti-d. the implications and utility of this approach for the diverse u.s. population are not yet clear. here we report months experience with rhd genotyping on samples referred with discrepant or weak d typing investigated from january to april . study design/method: serologic testing was performed by standard tube agglutination with licensed reagents. dna isolated from wbcs was used in manual rflp and rhd beadchip assays and rhd sequencing for some. ethnicity was known for samples ( . % caucasian, . % african american/african, . % multiracial, . % hispanic, % asian, and . % other). results/finding: rhd genotyping identified weak d types , , and in / ( %) and alleles known to encode partial d phenotypes in / ( . %) (table) . uncommon or rare weak d alleles including types , , , , , , (n ), , , , , and were found in ( . %). the partial d alleles found were diverse, but the largest number included partial rhd*d . (n ) and *dar ( conclusion: in a multiracial cohort of individuals with weaker than expected d typing % were due to weak d types , , or and would not be considered at risk of clinical significant anti-d, but for % there is potential or unknown risk. these studies are important to gain insight into the prevalence of specific alleles in the u.s. multiethnic population and to continue to evaluate and refine rhd genotyping for clinical practice. cp rhd* . allele causes discrepant genotyping results for rhce small c sabine scholz* , sandra schneider , sabrina k€ onig , susanne helmig and vicky van sandt . inno-train diagnostik gmbh, rode kruis vlaanderen background/case studies: in the human rh blood group system the c, c, e, e and d antigens are expressed by the two highly homologous genes rhce and rhd. after d, c is the most immunogenic rh antigen. the difference between c ( c) and c ( t) is caused by the snp on position on the rhce gene. the rhd* . allele (also known as rhd cat vii type ) carries the snp t>c on the rhd gene and additionally the snp t>c. this rhd* . allele has been described to partially express rhc on the d polypeptide (faas, transfusion, ) . aims: genotyping was performed to clarify the cause of the weak c expression. serology of a patient sample (male, ) indicated a partial c phenotype with a cde. study design/method: rhd and rhce phenotyping was done by accredited routine protocols (monoclonal ab id card: diaclon rh subgroups, seraclone anti-c). genotyping was performed with a taqman probe assay (rbc-fluogene veryfy, inno-train diagnostik gmbh), sso (rbc-lifecodes, gen-probe inc.), in-house ssp-pcr (hila, rode kruis-vlaanderen) and commercial ssp-pcr (rbc-ready gene cde, inno-train diagnostik gmbh). sanger sequencing of the rhd gene was performed using an inhouse method (inno-train diagnostik gmbh). results/finding: discrepant genotyping results were generated by different test systems: the taqman probe based assay showed in repetition a ccee genotype, while the sso system rbc-lifecodes predicted in repetition a ccee phenotype. in ssp-pcr the sample showed a weak c band with the in-house method, while there was no band visible with the commercial test kit. the parallel analysis of the rhd gene with rbc-ready gene cde test system revealed a variant d cat vii rhd allele. sequencing of the dna sample identified two snps on one of the rhd alleles ( t>c, t>c) confirming a rhd* . and one rhd* allele. hispanic female in preparation for surgery resulted in variable reactivity and weakly positive d reactions when using microtiter-well agglutination versus tube testing. determination of whether the d antigen expression represented a weak d or a variant d could not be resolved by serologic testing alone. here we report the characterization of a novel rhd gene mutation identified by rhd gene sequencing. study design/method: serologic typing was initially performed by microtiter-well agglutination by automated analyzer platforms galileo neo and galileo echo (immucor, norcross,ga) and by standard tube testing using the immucor series and anti-d reagents. further immunohematologic evaluation was performed by standard tube testing (immediate spin -is, and indirect antiglobulin -iat) using orthobioclone, immucor gammaclone, immucor series and series , and albaclone anti-d reagents. dna isolated from wbcs was used in manual rflp and rhd beadchip assay (immucor, bioarray) and rhd sequencing. results/finding: rbc reactivity is summarized in the table. dna testing detected a hybrid rhesus box associated with the rhd gene deletion, indicating the patient was hemizygous for rhd. rflp assay and rhd beadchip did not identify any changes. rhd gene sequencing identified a new c. a>g change in exon encoding an amino acid change p.met val. the predicted location of this change is within the fourth transmembrane segment of the rhd protein. conclusion: we identified a novel rhd allele with c. a>g (p.met val) change in exon . several snps, deletions, and insertions have been reported with changes in exon . phenotypes of these genetic variations result in rh negative, weak d types, and variant d. since this change has not been previously identified, we are unable to determine if this confers a risk of anti-d alloimmunization, but the rhd c. a>g snp results in serologically weak phenotypic expression of d antigen when tested by microtiterwell agglutination on the neo/echo platforms. in this case the combination of microtiter-well agglutination and dna sequencing helped identify a new allele which would be missed by standard tube serologic testing and the current commercially available array assays. serologic and molecular detection of an antibody to a high incidence antigen in patient with history of chronic transfusions georgia spanos* , juan merayo-rodriguez , christopher lough and nancy eckert . lifesouth community blood centers, life south community blood centers, lifesouth community blood center-headquarters background/case studies: the jo a antigen is one of three high incidence antigens in the dombrock system. the prevalence of this antigen is % in most populations and greater than % in the black population. the jo a antigen can be resistant or enhanced with enzyme treatment (ficin/papain) and typically variable with dithiothreitol (dtt), w.a.r.m. tm (immucor) and zzap treatment. anti-jo a is an igg antibody that demonstrates at ahg phase. hemolytic transfusion reactions to the jo a antigen vary from none to moderate/severe. hemolytic disease of the fetus and newborn (hdfn) has not been observed with any antibody associated in the dombrock system. there are two common phenotypes present in the black population:hy negative/ jo a negative and hy weakly expressed/jo a negative. study design/methods: an antibody identification and red blood cell (rbc) units were requested for an o positive, year old, african-american female with a history of sickle cell disease and no history of pregnancy. the patient was not recently transfused, however, had a history of chronic transfusions. last reported transfusion was three years prior to the current specimen. there were no known rbc antibodies at the time of the request. facility reports that the patient's hemoglobin(g/dl)/hematocrit(%) (hgb/hct) is . / . and does not appear to be in sickle cell crisis. a request for phenotypically matched units, as per hospital policy, for c, e, k and s was received by our immunohematology reference laboratory (irl). results/findings: anti-jo a was detected in patient plasma reacting with liss and peg (tube method) and manual gel-iat. the antibody was resistant when tested with dtt treated red cells. in-house frozen reagent rbcs negative for the jo a antigen (positive for hy) were used to serologically prove the presence of the antibody to this high incidence antigen. an allogenic peg adsorption was performed to rule out other common clinically significant antibodies. anti-kp a was identified using this adsorbed plasma. further testing with molecular genotyping (grifols idcore xt ) confirmed the patient's genotyping as antigen negative for the jo a , kp a and positive for hy. conclusion: molecular testing is frequently performed on patients and retained donor samples from our local community donor pool throughout florida, georgia and alabama. staff is able to search our database for any combination of antigen negative phenotypes using the internal (k) blood establishment computer software (becs) integrated blood bank information system (ibbis). this enabled us to locate one refrigerated and three cryogenically preserved jo a negative rbc units. we found eligible blood donors that could be recruited via an automatically generated call list. the request for rbcs was cancelled. patient's clinical symptoms improved without transfusion and repeat hgb/hct increased to . / . the patient's sibling is historically negative for the jo a antigen and should future transfusions be required, it was recommended that a directed donation be made on the patient's behalf. in order to continue having blood components available to meet all our patient's needs, irl staff is consistently screening and searching our inventory for blood components that are negative for rare antigens to retain for patients needing antigen negative units in a timely fashion. rbcs of two females whose samples were referred for rhd genotyping with previously reported alleles for which serologic reactivity had never been investigated. study design/method: serologic testing was performed by automated analyzer, galileo echo and neo (immucor, norcross, ga), and by standard tube testing with licensed anti-d reagents and the albaclone advanced partial rhd typing kit. genomic dna isolated from wbcs was used for immucor rhd beadchip assay, pcr-rflp, and rhd sequencing. results/finding: patient was a yo female, c e c e , whose rbcs reacted by echo and by neo with anti-d , and '?' with anti-d . testing with d and d by tube gave and w on initial spin (is) respectively and by indirect antiglobulin test (iat). rbcs were non-reactive at is with ortho bioclone and biorad seraclone, and w with immucor gammaclone anti-d, and all were at iat. rbcs did not react with two (lhm / & / ) of anti-d in the alba partial d kit. this pattern did not match any partial d identified by these clones. rhd beadchip detected an inactive rhd pseudogene in trans to rhd. gene sequencing confirmed the presence of the pseudogene, but rhd had a c. c>a change encoding p.his gln. patient was a yo pregnant female, c e c e , whose rbc were w at is and at iat with immucor series and and gammaclone, and moderately reactive, is and iat, with alba alpha, alba blend and delta anti-d. rbcs did not react with two (lhm / & / ) anti-d in the partial d kit with no known partial d pattern. dna testing predicted she was rhd hemizygous and rhd beadchip detected markers for rhd*dar but exon gave low signal (ls). sequencing found a hybrid dar with ce-specific nucleotides in exon from c. to c. encoding amino acid changes p.ile leu and ser asn. conclusion: we found two previously reported rare alleles: rhd with a c. c>a (p.his gln), previously found in france (lefloch et al. genbank ku ), and rhd*dar with part of exon replaced by rhce, reported in sub-sahara africa (granier et al. transfusion : ) designated rhd*dar(ce :v v-s n) with an allele frequency of . to . . blood samples were not available to test for alterations in d expression for either allele. we provide serologic evidence that these alleles, found in two females evaluated by rhd genotyping, inform transfusion and rh immune globulin prophylaxis, as they encode partial d phenotypes with novel epitope expression patterns, meaning these patients are at risk of forming allo anti-d. background/case studies: hu f -g is a human monoclonal igg antibody recognizing cd that is in clinical trials to treat hematologic or solid malignancies. cd is a transmembrane glycoprotein that binds to signalregulatory protein a (sirpa) on macrophages and functions to regulate phagocytosis. blocking cd is thought to enhance phagocytosis and promote anti-tumor responses. cd is also highly expressed on rbcs, and the purpose of this study was to evaluate anti-cd drug interference in blood bank testing. study design/method: serologic testing was performed by standard methods. serial samples (n ) from patients were tested over the course of month treatment. plasma was tested at immediate spin (is) and by iat with r r , rr, d--, rh mod and rh null rbcs, as cd expression levels vary depending on rh phenotype. dtt and enzyme treated rbcs were also tested. both immucor gamma-clone anti-igg (does not detect igg ) and ortho bioclone anti-igg (total igg) were used. for titration plasma was diluted in pbs. allo-adsorptions were performed with papain treated rr rbcs and eluates were made using gamma elu-kit ii. results/finding: anti-cd was observed in plasma as soon as hour post infusion. plasma reacted to at is and with all panel cells in peg iat using ortho anti-igg. d--, rh mod and rh null rbcs were nonreactive at is and weaker ( and ) in peg iat with ortho reagent. reactivity with all panel cells by ortho igg gel card was . in contrast, iat reactivity using gamma-clone anti-igg was only w to , and this reactivity was confirmed to be carry-over agglutination. d--, rh mod and rh null were non-reactive in peg iat using gamma-clone anti-igg . the anti-cd titer was at is and peg iat with gamma-clone anti-igg, but was ! with ortho anti-igg. plasma reacted with dtt, trypsin, papain, a-chymotrypsin or w.a.r.m. treated rbcs. somewhat unexpected, autocontrols were negative and dats were non-reactive or microscopic only. acid eluates (n ) were reactive with ortho, and non-reactive with gamma-clone anti-igg. plasma reactivity was removed after x allo-adsorption with papain treated rr cells, but in some samples low level (micro- ) reactivity remained. peg adsorption was invalid due to precipitation/complexing of antibody. robust plasma reactivity interferring in abo reverse typing was observed, and weak spontaneous agglutination of the rbcs in the abo forward and rh typing. conclusion: hu f -g anti-cd therapy interferes with routine pretransfusion testing, not only antibody screening and crossmatch, but abo and rh typing. high levels of cd expression on rbcs results in plasma agglutination at is, mimicking reactivity observed with igm antibodies although hu f -g is igg . reactivity was observed in all phases and with all test methods. cd is not cleaved from rbcs by dtt, trypsin, papain/ ficin, dtt with ficin (w.a.r.m.) or a-chymotrypsin, and treatment of rbcs with these does not mitigate interference. numerous adsorptions with papain treated rr rbcs were required to remove anti-cd reactivity from plasma. use of immucor gamma-clone anti-igg, which does not detect igg , can mitigate interference in iat although carryover reactivity may be observed. due to blocking by anti-cd on the patient rbcs, dat and autocontrols were weak or non-reactive; however eluates prepared from the dat rbcs were strong and pan-reactive using ortho anti-igg. background/case studies: a caucasian woman with history of a caesarean section and a rbc tx in . in august , she was admitted to hospital for trauma surgery, ab screening was negative and two units were transfused without transfusion reactions. five days later she was referred to a tertiary care trauma center due to a severe postop infection and need for a reoperation. ab screening was now positive, with an antibody reacting with all panel cells detected. because of the urgent need for rbc tx, two weakly cross-match positive rh k matched units were transfused with a warning of possible alloantibodies. the patient got acute hemolysis. study design/method: a gel technique was used in the hospital transfusion laboratory. in addition, various antibody identification panels and special serological and genotyping methods were used in the reference laboratory. kel sequencing was done by the international immunohematology center. results/finding: the hospital transfusion laboratory results were o rhd neg, dat neg, and the ab identification was with untreated and with enzyme-treated cells, with weakly positive autocontrols. a sample was submitted to the reference laboratory for additional investigation. dat was weakly positive, while ab identification results were similar to the hospital results. different pheno-and genotyping methods were used in addition to several identification panels to exclude rare blood groups. after pk, vel neg, jk:- etc. had been excluded, k-phenotyping revealed a k -phenotype. a total of silencing mutations are known for the kel gene and the genotyping kits used did not recognize these. the anti-ku antibody reacts with all cells apart from the k -phenotype. the presence of dtt-sensitive anti-ku was confirmed with dtt-treated panel cells. anti-ku may cause immediate and delayed hemolytic transfusion reactions. samples were taken from the patient's two siblings and daughter. kel sequencing revealed kel* n. with c. t encoding p. ter (reported in an individual from austria in ). there are two known k -patients in our country, both homozygous for c. t. the daughter was a c. t heterozygote, while the siblings did not have this variant. a new operation is necessary but no k -donors are available in our country. with the help of the isbt rare donor working party, a k o rhd neg donor was found in japan and one unit was delivered to us for use in the next operation. conclusion: an alloantibody should always be suspected when autocontrol is weaker than panel cell reactions, even if the direct coombs is positive. a combined serological and genotyping approach offers the best solution for problematic antibody cases. compatible blood is not always available in rare blood group cases, but international co-operation may be of help in finding a suitable donor. transfusion strategy for the serologic weak d phenotype in tunisia based on rhd alleles and rh haplotypes mouna ouchari* , kshitij srivastava , houda romdhane , saloua jemni yacoub and willy albert flegel . nih, dtm/cc/nih, regional blood transfusion center sousse, regional blood transfusion center sousse, tunisia background/case studies: d antigen variants have been studied molecularly in many arab populations, including gaza, tunisia, egypt and libya, a transfusion vol. supplement s since . the tunisian population has the largest known prevalence of weak d type . alleles, occurring in of rh haplotypes, compared to in , or less in europe. a systematic study was missing for samples with the serologic weak d phenotype routinely found in blood donor and patient testing in tunisia. the study was designed to obtain data on weak d type . in a population known to harbor the greatest prevalence of such allele worldwide. study design/methods: a total of , random blood donors were serologically screened for the d antigen using routine techniques. samples with weak reactivity were tested with a panel of monoclonal anti-d (partial rhd-typing set) to identify partial d phenotypes. the rhd gene was sequenced in all samples with serologic weak d phenotype. the rhce gene was also tested molecularly by either direct sequencing or using the rhce beadchip kit to ascertain the rhce allele linked to the rhd allele. results/findings: a total of discrepant samples ( . %) were observed and expressed the serologic weak d phenotype. among them, carried an allele of the weak d type cluster ( . %), of which samples ( . %) showed the weak d type . allele. only sample each was found for the weak d types , and and the dvii, while samples showed the consensus rhd sequence. no mutation in any of the rhd exons was detected in another samples. the molecular analysis of the rhce gene showed that out of samples with serologic weak d phenotype ( . %) had a variant rhce allele and the most common associations were: weak d type . linked to rhce*cevs. . ; weak d type . . with cear; and weak d type . to rhce*cevs. , while the other rhd alleles were linked to one of the common rhce alleles. conclusion: almost % of the weak d phenotypes in tunisia were caused by alleles of the weak d type cluster, of which % represented the weak d type . allele. based on established rh haplotypes for variant rhd and rhce alleles and the lack of adverse clinical reports in tunisia, we recommend d positive transfusions for patients and no rhig administration for pregnant women with weak d type . in tunisia. we propose this strategy as a pragmatic clinical decision, even if eventually a rare allo-anti-d immunization would occur in tunisia associated with weak d type . phenotype. there is a possibility that the rhce*cevs. . allele, typically associated in tunisian individuals, may protect from allo-anti-d immunizaton and other rhce alleles, such as rhce*ce more often associated in individuals of other ethnic groups, may not. however, we conclude that this conjecture has not much evidence in support at this time and would need corroboration by experimental and clinical data, before used to guide clinical recommendations. martha rae combs* , heather simmons , christine lomas-francis , gayane shakarian , sunitha vege , lauren hutelmyer , sandra nance , jessica poisson , nicholas bandarenko and connie m. westhoff . duke university hospital, immunohematology and genomics laboratory, new york blood center, arc pennjersey, american red cross, immunohematology reference laboratory, biomedical services background/case studies: plasma from a transfused, a , year old white female, post liver transplant with rbc aplasia, reacted at rt and in peg iat with all rbc samples tested except her own. study design/method: standard hemagglutination methods were used for antibody id and antigen typing. acid eluates were prepared using gamma elu-kit ii (immucor). genomic dna was isolated from wbcs and used for hea precisetype array and kel and sc gene sequencing. samples from the proband and her mother were tested, as applicable. results/finding: the patient's dat was negative. her plasma reacted with . m dtt-treated and papain-treated rbcs, all available rbc samples lacking high-prevalence antigens, and with phenotypically similar rbc samples [c , k , fy(a ),s ]. reactivity was detected to a titer of ; it was not removed by prewarm technique or by x peg alloadsorption. the adsorbed plasma reacted with . m dtt-treated rbcs. extensive rbc phenotype results were unremarkable except for the following: k , k , js(b ), kp(a b ) and sc: , . her plasma reacted with k o , mcleod, sc: , rbc samples and dtt-treated sc: rbcs at rt and peg iat but her diluted plasma and pretransfusion eluate showed relative kp b specificity. the patient was transfused aliquots of crossmatch incompatible kp(b ), s rbcs. her post-transfusion dat was with anti-igg, with anti-c d. the eluate reacted with all rbc samples except kp(b ) sample. she tolerated additional aliquots from phenotypically similar rbcs untested for high-prevalence kell or scianna antigens. the hea precise-type predicted k , k , kp(a b ), js(a b ) and sc: , , discordant with her rbc phenotype. kel gene sequencing identified a homozygous change, c. a>t (p.glu val) (kel* . ) encoding the low prevalence antigen, ul a , but no changes associated with lack of kell system antigens; however, her rbcs typed ul(a ). sc sequencing found heterozygosity for a '- g>a change (rs , to % prevalence) and conventional sc* , predicting sc: , , . kel and sc results on the mother were kel* /kel* . , heterozygous for the sc change '- g>a, and her rbcs typed k k kp(a b ), sc , ula , consistent with dna predictions. plasma collected months later was nonreactive at rt and in peg iat. her rbcs were dat and now typed k , kp(a b ), ul(a ) sc and sc ,concordant with predicted kell and sc phenotypes. conclusion: we report an example of kell and scianna antigen suppression or blocking in the presence of autoantibody or an alloantibody in the kel system. to our knowledge, this is the first report of a ul a kel* . homozygote. the rbcs may lack a high-prevalence antigen antithetical to ul a . without dna testing and gene sequencing, the patient would be presumed to have kell null and sc null phenotypes, a search for k o , and/or sc: , rbc units would be performed and we would not have been prompted to re-type her rbcs when the dat was negative. background/case studies: anti-jka is a common antibody identified in the blood bank and providing phenotypically characterized red cells lacking this antigen is important in avoiding an acute or delayed hemolytic transfusion reaction. in nearly all cases, this antibody is identified in the context of a phenotypically homozygous jkb patient, jk(a-b ). other scenarios are quite rare. we present two cases of anti-jka in which this phenotype was not observed. study design/method: patient a is a -year-old multiparous female with no known transfusion history. her blood typed as o positive with a positive antibody screen, negative dat, and a clearly identified anti-jka in plasma. the patient phenotyped as jk(a-b-). genotyping revealed the presence of the jk*b allele, but not the jk*a allele. complete sequencing of the jk gene showed an intron polymorphism in homozygosity. specifically, the patient showed a jk*b(ivs - a)genotype, associated with a jkb null phenotype. anti jk was not identified. the conclusion was an allo-anti-jka in a jk null patient. the patient did not receive any transfusions. patient b is a multiply transfused old female. her blood typed as a positive with a positive dat and antibody screen. both the plasma and eluate revealed an anti-jka. despite the recent transfusion, the patient phenotyped as jk(a ) and jk(b ) . genotyping showed the presence of both jk*a and jk*balleles. whole gene sequencing was not performed. there was no hematologic or biochemical evidence of hemolysis. the patient was considered to have an auto-anti-jka and jka negative cells used for transfusion. results/findings: patients a and b both developed anti-jka while having uncommon phenotypes/genotypes. conclusion: it is common for jk null patients to develop anti-jk . however, we speculate that expression of the kidd glycoprotein with the jkb epitope was below the threshold of serological detection, but enough to prevent the formation of anti-jk or anti-jkb. auto-anti-jka is usually reported in the context of an active hemolytic process, but patient b illustrates an auto-anti-jka without hemolysis which is more commonly observed with autoantibodies exhibiting specificity for rh epitopes. these rare cases of anti-jka require phenotypic and genetic analysis for the jkb epitope and jk*b allele respectively, and in more complex cases whole gene sequencing. background/case studies: donor genotyping for red blood cell antigens has become common practice in many blood bank laboratories. package inserts for commercial assays indicate false negative results may be generated when unexpected rare mutations affect primer or probe binding and cause allele dropout or failed amplification. these outcomes may go unrecognized unless serological results are available for comparison. study design/method: a routine blood donor, self-identified as african american, was selected for red blood cell genotyping. dna was extracted and genotyping was performed using two commercial platforms a transfusion vol. supplement s (precisetype, bioarray, warren nj; idcore xt , grifols, emeryville, ca). genotype results were compared to historical serological results. discrepancies were resolved by sanger sequencing (grifols ih, san marcos, tx). results/finding: genotyping results showed variants in both the duffy (fy) and kell (kel) blood group systems. the donor's genotype was concordant on both platforms, fy*a/fy*b_gata, kp*a/kp*a, for a predicted phenotype: fy(a b-); kp(a b-). when genotype results were compared to historical serology, it was noted that the donor previously typed fy(a-) on separate donations. no previous kpa or kpb serotyping was available. sequencing of fy exon revealed a g>a mutation, fy *n. , known to silence fya. sequencing of kel exons - exposed a silent polymorphism in exon , g>c. this polymorphism causes a dropout artifact yielding a false negative kpb interpretation. conclusion: the discrepant fy*a result, as well as the unlikely kp(b-) type prompted the request for sequencing. the rare fy *n. mutation has been reported in people of caucasian descent. this is the first example of this fy mutation identified in this regional population. the kpb antigen is present in nearly % of all populations. however, kp(b-) is most frequently seen in people of caucasian descent. to date, self-identified african american donors have been genotyped as kp*a/kp*b at this blood center. given the diversity of regional heterogeneity, it is feasible to identify a kp(b-) donor, self-reporting as african american. red blood cell genotyping offers an abundance of information, but cannot replace serology as the sole means of red cell antigen characterization. donor ethnicity continues to play a key role in selection for genotyping and the search for rare and unusual red cell types. in this case, a donor selected for genotyping based on ethnicity was initially thought to have genetic variants not previously reported in those of african descent. only was proven to be present. this case acts as a reminder that genotype limitations must be considered even when using licensed methodologies. this case report presents two group o pediatric patients who had been on enteral feeds and had absent/weak anti-b that became strong over time in patient . study design/methods: patient was a year-old male born prematurely with short gut syndrome who underwent a small bowel and liver transplant at years of age. anti-b changed from undetectable/weak to strong at the age of years. patient was a month-old female with a metabolic urea cycle disorder who underwent a liver transplant. anti-b was / . both patients were on total parenteral nutrition (tpn) since birth and had strong anti-a and normal immunoglobulin testing. abo typing with enhancing techniques is presented in table . results/findings: both patients typed as group o on forward typing. anti-a was strong in both patients. anti-b varied in strength in patient with - reactions up to years of age. thereafter, abo typing showed mainly strong anti-b. patient had / anti-b. conclusion: intestinal bacteria stimulates production of anti-a and -b. unexpected changes in anti-b that caused abo discrepancies are reported here for children on long-term tpn. patient had absent/weak anti-b since birth up to years of age, then developed strong anti-b with no change in feeding regiment and medications. patient had consistently strong anti-a and absent/weak anti-b. these findings support the notion that normal colonization of the gut is important in the development of anti-a and -b and suggests that microflora of the gut in patients on prolonged tpn is different leading to the delayed formation of these antibodies compared to individuals on normal enteral diet. difference in strength of anti-a and-b could be due to stronger a than b antigen expression on gut bacteria. results/finding: a daratumumab protocol was established that incorporated use of the cord panel. multiple myeloma patients selected as candidates for daratumumab treatment were baseline tested for blood type and antibody screen, dat and genotype. after daratumumab infusion, a two unit crossmatch was order as a precaution in the event the patient developed a reaction to the medication. repeat of the antibody screen demonstrated panagglutination which served as a positive control for the medication. the cord panel ruled out underlying alloantibodies. selected red cell units were crossmatched at immediate spin phase to avoid expected indirect antiglobulin reactivity. conclusion: the cord panel was used times over a five month period to rule out underlying alloantibodies. tests for the daratumumab protocol consisted of a routing antibody screen followed by a cord panel for resolution. the daratumumab protocol significantly reduced testing time and allowed for the provision of compatible blood products in an efficient and cost effective manner. teresa gorey* and elizabeth hart . brigham and women's faulkner hospital, university of massachusetts-dartmouth background/case studies: the purpose of performing a pre-transfusion antibody screen is to detect clinically significant unexpected antibodies and to decrease the probability of detecting clinically insignificant antibodies. several antibody detection methods (polyethylene glycol (peg), liss, and albumin) are routinely used in small transfusion services. the utility of peg is to enhance the sensitivity of detecting clinically significant antibodies by the indirect antiglobulin procedure. the code of federal regulations, title , cfr part . (a), states the manufacturer's instructions are followed when testing for unexpected antibodies. the package insert for gamma peg tm (immucor inc., norcross, ga), states that negative reactions may be examined with an optical aid. based on these directions, our institutional policy is to confirm all negative reactions using the microscope. study design/method: a one-year retrospective document review was performed on all patient samples in which a positive antibody screen (absc) triggered the antibody identification (abid) to be performed in . a total of samples were evaluated. each abid was subcategorized; ( ) as being a new antibody for our facility or in the patient's shared electronic health record within the partnersv r healthcare system and ( ) whether a microscopic absc result triggered the abid. also, patients with known antibodies were grouped according to a microscopic absc result. a comparison of the new patients and the previously known antibody patients with microscopic results were reviewed to determine if the antibodies were clinically significant. results/finding: a total of abids were performed on new patient samples. of the new abid samples, ( %) had microscopic absc results. for the previously known antibody patients, there were which accounted for % of the total abids performed. when reviewing the total abid workups, a total of ( %) of the abscs had microscopic results which resulted in an abid being performed. the antibodies identified in the new antibody samples were: conclusion: a total of % of the new antibodies identified based on a microscopic absc were clinically insignificant. the manufacturer's directions were followed but they do not state that an optical aid is required to confirm all negative results. due to the results of this study, a decision will be made to: ( ) discontinue the use of the microscope, ( ) switch to a peg manufacturer whose directions indicate to observe macroscopically for agglutination, or ( ) define the use of the agglutination viewer as the optical aid. decreasing the number of abids will save time and money while providing potential rbcs for transfusion in a timely and efficient manner. anton") has a prevalence greater than % in all populations. hereditary absence of anwj has only been described once (in a single family). however, red cell expression of anwj may be markedly decreased to near undetectable levels in blood donors of the in(lu) (or "dominant lutheran inhibitor") phenotype. similarly, anti-anwj antibody formation is rare, with only cases reported in the literature. the antibody developed in the context of hereditary absence of anwj (i.e., a true alloantibody) in only one of the cases. in the other nine cases, the antibody occurred in the context of autoimmune or lymphoproliferative disease, where, in this context, it is believed to have developed secondary to transient anwj antigen suppression. most of the reported cases lacked clinical or laboratory evidence of hemolysis. however, in the most recently reported case, involving a -yearold woman with aplastic anemia, the antibody was associated with acute hemolytic reactions after rbc transfusions, necessitating transfusion support with anwj-negative and in(lu) rbcs. the case was also unique in that the anti-anwj resulted in a direct antiglobulin test (dat) that was positive for complement only, rather than igg like all previous cases in which the dat was performed and was positive. study design/method: a -year-old woman with severe aplastic anemia experienced acute hemolytic transfusion reactions (ahtr) with development of a panagglutinin on indirect antiglobulin test (iat) screens. prior to identifying the specificity of the panreactive antibody, the patient received rbc transfusions and showed signs of hemolysis with six of them. the first three transfusions were prior to her positive iat and were electronically crossmatched. the next seven transfusions were incompatible by antihuman globulin (ahg) phase crossmatch, but were extended phenomatched for clinically significant antigens. the patient's ahtr signs and symptoms included fever, rigors, nausea, vomiting, dark urine, flank pain and "impending doom" anxiety; while her laboratory findings included hemoglobin decreasing below pre-transfusion levels, and increased total bilirubin and ldh. the dat, while initially negative during the immediate posttransfusion workup of the transfusion reactions, eventually became positive for igg only ( - ), and negative with anti-c b, c d reagent. the antibody showed a peak gel-igg iat titer of . results/finding: the antibody was identified as having anwj specificity. the patient's pre-transfusion sample showed weak anwj expression (w ), altogether suggesting an auto-anti-anwj. monocyte monolayer assay testing using the patient's plasma and rbcs from the ahtr-implicated units yielded monocyte indices ranging from to %, consistent with the clinical hemolysis observed. given the patient's group o, rh d negative blood type and continuing transfusion dependence, in order to avoid further ahtrs, international collaboration was necessary in order to procure and provision group o, rh d negative rbcs that were also serologically negative for anwj. the patient was successfully transfused three such units without further incident. conclusion: this is the second documented case of anti-anwj in a patient with aplastic anemia and, overall, the third anti-anwj case associated with ahtr. this case also underscores the importance of international collaboration. cold auto-antibody anti-p anti-m anti-sd a anti-le b anti-jk a anti-k anti-e anti-c results/finding: three hundred and ninety weak d genotypes have been determined to this day with frequencies of % (type ), % (type ), % (type ), % (type ) and % other than , , or . further investigation was conducted to determine the molecular identity of the «others». out of samples, ( %) were confirmed to be legitimate serological weak or partial d, mainly deletions of exon or both exons and . a surprising amount of samples were discovered to be normal rhd. conclusion: along with sandler et al. ( ) data, our findings highlight the difficulties hospitals face in interpreting serological weak d. trend analysis was conducted regarding the reagents and technologies used by each hospital, the origin of the request and the ethnicity of the concerned patient, but no significant correlation could be identified at this point. altogether, our findings allow to share the frequency of weak d types , , and obtained in serological weak d, years old quebec's women, and also highlight the need for further investigation of standard practices amongst hospitals regarding the management and interpretation of atypical d typing. were classified as fnhtr. taco incidence was , %. no trali happened in the period. prophylaxis were used in % of patients. conclusion: fnhtr is described as the most common adverse event related to transfusion, but our data showed a higher incidence of allergic reactions. fnhtr occurred times less than allergic reactions. this might be explained by universal leukoreduction and universal prophylaxis adopted at our institution. further studies are necessary to evaluated the benefit of this approach. that cannot be associated with a specific rbc unit or were deemed unrelated to transfusion, rbc transfusion aes were analyzed. chi-square test and logistic regression were used to compare the ae incidences among transfusion groups. results/finding: univariate and multivariate logistic analyses showed that irradiated rbcs were associated with a significantly increased incidence of transfusion-related aes (p < . ). there was a significant difference in febrile non-hemolytic transfusion reaction (fnhtr) ( . % vs . %, p < . ) or aes with a non-allergic type inflammation etiology ( . % vs . %, p < . ) including transfusion-related acute lung injury, transfusion-associated dyspnea, but not transfusion-associated circulatory overload, infections or hemolytic transfusion reactions, between irradiated rbcs and non-irradiated rbcs. in contrast, the incidences of allergic aes ( . % vs . %, p . ) were similar between these two groups. the incidences of inflammation aes after transfusion of irradiated rbcs that were stored for , , , and weeks were . %, . %, . % and . %, respectively (p . , logistic regression) but there was a significant difference in the incidence of inflammation aes caused by irradiated rbcs stored for a week ( . %) and longer than a week ( . %) (p < . ). conclusion: irradiated rbcs associated with a higher incidence of transfusion inflammation aes compared to non-irradiated rbcs and this risk increased when rbcs were stored longer than week after irradiation. while it is likely the patient population is a factor in ae caused by irradiated rbcs, it is also possible that rbc radiation damage, as shown in previous studies, contributed to this increased ae incidence. a list of patients with one of these icd codes was generated. the emr was searched to find the clinical scenario in which trali was mentioned. these patients' records were then searched within our laboratory information system (copath), to determine if they had a transfusion reaction reported to our transfusion medicine service. results/finding: the search of our electronic medical record found patients from - , who had trali mentioned in their chart as a diagnosis or possible/likely diagnosis. one patient was excluded from our study because trali was mentioned as a past medical history from an outside hospital. only the patients who had trali listed as a diagnosis or possible diagnosis were included in this study. these patients had clinical scenarios in which a transfusion of a blood product occurred which was followed by various forms of respiratory distress. the clinical teams caring for these patients were either giving a diagnosis of trali or considering trali as a possible diagnosis. of these cases, only of them were reported to our transfusion medicine service as transfusion reactions. of the reported cases, one was determined to be trali and the other one was consistent with taco. eight out of those cases were never reported. background/case studies: despite diligent efforts to transfuse the safest product available to patients, undetected alloantibodies may cause delayed hemolytic transfusion reactions (dhtr). this transfusion reaction is seen in as many as out of transfused products. therapeutic plasma exchange (tpe) may be employed to mitigate ongoing immune mediated hemolysis, but few reports in the literature describe tpe for clinical management after profound hemolysis. study design/method: case review of a patient was performed after diagnosis and treatment of severe dhtr. results/finding: a man with a history of gastrointestinal bleeding presented to the emergency room with shortness of breath and "hematuria". he had a known history of anti-d and anti-c, and was transfused two units of crossmatch compatible rbcs seven days prior during a previous admission. readmission hemoglobin (hb) was . g/dl but declined to . g/dl the next day. an antibody screen was consistent with anti-d, anti-c, and direct antiglobulin test (dat) was negative. he received three units of crossmatch compatible rbcs over days and with poor responses. on day , routine labs could not be reported due to marked hemolysis, he had "worsening hematuria", creatinine rose from . mg/dl to . mg/dl (reference . - . mg/dl), and lactate dehydrogenase was above reportable linearity, > u/l (reference - u/l). testing revealed additional anti-e, anti-jkb, dat c , plasma free hb . mg/dl (reference - . mg/dl), and hemoglobinuria. four of five transfused rbc units were jk(b ), one of which was also e . one volume tpe was performed to remove free hb on days , , and using fresh frozen plasma as replacement fluid for haptoglobin supplementation. creatinine peaked at . mg/dl on day , decreased to . mg/dl before discharge on day results/findings: twenty three cases were identified, of which had medical records available for analysis. ten ( %) patients were male, the mean age was . years (range - years), ( %) had an underlying hematologic malignancy or bone marrow disorder, and ( %) had a history of coronary artery disease (cad). the implicated units included ( %) red blood cells and ( %) platelets; ( %) patients received a single unit, and ( %) received two or more within the previous hours; the mean volume transfused was . ml (range - ml). the mean time to onset of chest pain was . minutes (sd minutes), with % of patients presenting within . hours and % within hours of starting the transfusion. chest pain was present as the only symptom in % of the cases, and for the other cases the accompanying symptoms included dyspnea ( %), fever ( %), back pain ( %), and hypo-and hypertension ( %). a post-transfusion chest x-ray was performed in % of cases, and all showed no evidence of pulmonary edema to suggest possible volume overload/transfusion associated circulatory overload (taco). electrocardiogram was performed in % of cases and showed no findings to suggest acute ischemia. three ( %) patients had a minimal increase in their troponin levels, although had a history of chronically elevated troponin due to stress cardiomyopathy. fourteen ( %) patients received some form of treatment, including increased oxygen supplementation, metoprolol, acetaminophen, morphine, and oral calcium carbonate; the pain resolved after more than minutes in the majority of patients ( %). no cases resulted in new admission to the icu or procedure cancelation. conclusion: chest pain associated with transfusion was infrequent, but several such cases were identified during the review period. this symptom is not a diagnostic criterion for any of the other hemovigilance categories and merits further characterization to determine whether blood product transfusion could be the cause of the chest pain. larger observational studies to power clinical characterization could help to further inform hypotheses regarding a transfusion-related mechanism, which could be interrogated by translational research studies. background/case studies: thrombotic microangiopathy (tma) in children is most commonly seen in the form of hemolytic uremic syndrome (hus). however, tma may be seen in the presence of streptococcus pneumoniae (spn). the action of bacterial neuraminidase of spn results in exposure of the normally "hidden" thomsen-freidenreich antigen (t-antigen) found on erythrocytes and other tissues. ultimately, this may lead to spn induced hemolytic uremic syndrome (phus) with subsequent hemolysis and end organ damage by naturally occurring anti-t antibodies against the exposed t antigen. specific lectins or anti-sera can confirm exposure of the t antigens in phus. alternatively, phus can be identified by minor crossmatch incompatibility resulting from agglutination of exposed t antigens on recipient's erythrocytes to anti-t antibodies in the plasma portion of blood products. we present a case of suspected phus that resulted in a compatible minor crossmatch leading to concern and eventually diagnosis of atypical hus (ahus). study design/method: a months old boy presented with respiratory failure. he was found to have blood cultures positive for spn as well as hemolytic anemia, thrombocytopenia, and acute renal failure. he was shiga toxin negative and had normal levels of adamts . based on the findings, the clinical team was concerned for phus. therefore, he received washed erythrocytes. for his thrombocytopenia, our institution does not routinely provide washed platelets due to decrease quality of the platelet product. as a result, a minor crossmatching was suggested and performed to determine if t activation was present. results/finding: minor crossmatch was performed with patient's erythrocytes and plasma of abo-identical platelets to be transfused. no agglutination was seen at immediate spin, degree, or anti-human globulin phase. check cells were found to be . these findings were conveyed to the clinical team and platelets were issued without washing. due to the lack of identification of t activation by minor crossmatching and poor clinical response despite appropriate antibiotic treatment, additional studies were performed by the primary team for complement mutations and found to be consistent with ahus. the patient was then treated with eculizumab with clinical and laboratory improvement. we present a case clinically consistent with phus. confirmation of this diagnosis is done with lectins or anti-sera that are not readily available. an alternative means of identifying phus is by minor crossmatch incompatibility. by demonstrating minor crossmatch compatibility, we further elucidated a definitive diagnosis of ahus with appropriate management. background/case studies: orthotopic liver transplantation (olt) is a complex and technically challenging procedure that can be complicated by severe intraoperative bleeding. we report a case of massive transfusion in an olt patient necessitating an abo blood group switch (from o to a ) to sustain transfusion support and minimum group o rbc inventories. study design/methods: type & screen (ts, gel) and anti-a titers (tube) were performed using routine methods. a chart review was performed for pertinent medical and laboratory findings. results/findings: the patient was a -year-old o man with cirrhosis secondary to nonalcoholic steatohepatitis and alpha- antitrypsin deficiency who presented for olt (donor o ). during olt, the patient endured substantial bleeding from retroperitoneal collateral vessels complicated by post-transplant coagulopathy. he required rapid high volume rbc and plasma support, which strained hospital inventories. after receiving units of o rbcs and units of o plasma with ongoing severe hemorrhage, he was switched to group a products. ten units of a plasma were transfused to wash out anti-a antibody prior to transfusion of a rbcs. due to difficulty controlling the bleeding, biliary reconstruction and fascial closure were delayed for hours post-transplant. the patient's total estimated blood loss was > l. he received a total of units of rbcs (including a ), units of plasma (including a ), units of cryoprecipitate, and units of platelets. towards the end of the second procedure, the patient's hemorrhage was stabilized and the final two rbc units he received were o . on postoperative day (pod) , a ts showed predominantly a rbcs with trace o rbcs, as well as very low anti-a igm and igg titers (table ) . he received two additional o rbc units ( each on pod and pod ) with increasing o rbcs on ts and rising anti-a titers. his blood type was unequivocally o by pod . the patient showed recovery of liver synthetic function on pod (factor activity %) complicated by cholestasis. conclusion: this study shows successful switching of a group o patient to group a in the setting of rapid hemorrhage and massive transfusion. by pod , the patient had reverted to o with recovery of anti-a titers. at months post-olt, the patient is alive with signs of improving biliary graft function. a new rfid transfusion safety system anna millan* , alfred mingo , maria isabel gonzalez , antoni mena and juan pedro benitez . bst, at-biotech background/case studies: a new transfusion safety system (tss), based on processes and technologies, especially, identification by radio frequency (rfid), is currently implemented in two hospitals, a general one (h ) and an oncology center (h ). the tss is fully effective in protecting against incidents, and specifically offers mechanisms to detect near misses (nm) by using procedural and physical barriers, assuring that the pretransfusional sample extraction (pse) and the blood components administration (bca) only take place at bed side, using a location control and interacting with the clinical and transfusion information systems (tis). the tss allows to analyze the transfusional activity information in real time to project organizational changes in both transfusion services and hospital units, and to create a new classification of nm. study design/method: retrospective analysis of transfusion activity in both h and h shows pse and bca, out of and respectively, since the tss deployment in . retrospective analysis and classification of security events has been done. results/finding: activity results for both hospitals are shown in the table below. the safety events have been classified in pretransfusion sample extraction (pse), blood component assignment (bcas) in the transfusion service and blood component administration (bca) near misses (nm). for h , nm related to pse accounted for . % of all, being the mistake in concordance between patient identification and prescription order the most frequent ( . %). the nm detected in bcas were . % of all and mostly ( . %) occur when the patient information in the tis does not match the one registered in the tss. the nm detected in bca are . % of all and mostly ( %) the systems detects a not assigned bracelet. for h , nm related to pse accounted for the . % of all, being the error in concordance between the transfusion security number in the bracelet and in pretransfusion sample the most frequent ( . %). the nm detected in bcas accounts for . % of all and in . % occurs when the patient information in the tis does not match with the one registered in the tss. the nm detected in bca are . % of all and in . % of them the blood components were assigned to another patient. ( , , , , , , , , , , , , , ) were analyzed via a commercially available elisa. comparison of adequate response to ppv , defined as ! mcg/ml for > serotypes, was perform based on alloimmunization status. statistical significance was determined by comparing means of subgroups using paired and non-paired t-tests. results/findings: pre-vaccine sp titers were available in patients (alloimmunized, ); pre-and post-vaccine titers were available for patients (alloimmunized, ). of the patients, were on chronic transfusions, were on hydroxyurea, were surgical splenectomized, patients had no history of surgical splenectomy or status was unknown. forty-four patients had a previous history of ppv in the previous years; / also reported previous history -valent sp conjugate vaccine within the last years. baseline pre-vaccination titers (n ) showed no difference between alloimmunized and non-alloimmunized patients (all p-values > . ). in the group with pre-and post-vaccination (n ) titers available, out of ( %) non alloimmunized patients had an adequate response versus out of in the alloimmunized group ( %, p ns background/case studies: blood transfusion is the most common procedure performed in the hospital setting and the transfusion process is monitored to ensure regulatory compliance. to safeguard safety, efficacy and regulatory compliance, transfusion services actively benchmark transfusionrelated errors (tres) as they occur from "vein-to-vein", i.e. from collection of pre-transfusion sample to final infusion of product -with the goal of ensuring that the right product/dose goes to the right patient at the right time. multiple over-lapping error documentation processes are needed to capture and report tres from within and outside of blood bank (bb). we present a comprehensive error management program along with data on five years of benchmarking tres at a large academic medical center. study design/method: tres were detected by capturing and reporting of sample suitability, testing variances and biologic product deviations. in addition, tres as observed and reported by providers and clinical staff (i.e. blood delays/undertransfusions, transfusions without consent, infusions with wrong fluids) were reported to the bb and hospital quality through the veritas system, a hospital based reporting system that enables reporting any occurrence with potential for causing patient harm. all serious errors were reviewed daily and summation of tres was discussed on a monthly basis. mapping tres within the "vein-to-vein" was performed by reviewing the fiveyear of transfusion medicine quality records (from to ). patient harm events recorded within the veritas system from january to july were investigated in depth. transfusion reactions were excluded in this analysis. results/finding: an average of tres per month and per year were found over five years. % of tres are associated with pre-bb activities, % occur within bb, and % are post-bb events. sample collection and handling represent % of total tres. most tres ( %) were reported by bb staff, % were reported by non-bb staff. patient harm analysis revealed an average of four level (near miss), three level (no known harm), and . level (patient harm) per month. no deaths related to tre were detected over the seven month january to july period. patient harm was associated with tres occurring in the bb ( %) and post-bb ( %). these events were reported externally ( %) and by bb staff ( %). conclusion: although most tres were detected in the pre-bb phase, no patient harm was associated with these events indicating an efficient capture prior to causing patient harm. the tres causing patient harm, including near miss events, were mostly reported externally and they occurred entirely in the post-bb and bb phases. these results suggest that significant opportunities for quality improvement may be achieved in two areas: the pre-bb phase aimed at reduction of waste associated with sample collection and handling, and the post-bb and bb phases aimed at improving tre detection and decreasing patient harm. background/case studies: uncrossmatched red blood cells (rbc) and emergency issued platelets (plt), plasma and cryoprecipitate (cryo) are lifesaving in a bleeding patient without a valid type and screen. collectively termed "emergently issued products" they are issued as a bridge until pretransfusion testing is completed. this study evaluated the utilization and wastage rates of blood products during pregnancy-related hemorrhage where the first products issued were emergently issued. study design/methods: a list of patients on whom blood products had been emergently issued between january , and march , was obtained from the blood bank at a regional maternity care hospital. patients who were not experiencing a pregnancy-related bleed (e.g., postpartum hemorrhage or bleeding relating to a complication of pregnancy such as a ruptured ectopic pregnancy or bleeding post spontaneous or therapeutic abortion) were excluded. the total number of products (emergently issued plus crossmatched or non-emergently issued products) that were transfused, returned back into the blood bank's inventory, and wasted within hours of the first emergently issued products were enumerated. apheresis plt units were multiplied by and added to the number of individual whole blood plts; apheresis plasma units were multiplied by and added to the number of whole blood plasma units. results/findings: seventy women who received emergently issued blood products during a pregnancy-related hemorrhage were identified. average age was . the majority of these patients with pregnancy-related hemorrhage who received at least one unit of emergently issued blood products received at least one unit of the product that was issued to them and few units were wasted. that plt wastage was higher than the other products was likely due to the -hour post-pooling room temperature shelf life. keeping wastage rates low while meeting the clinical needs of these patients is the ideal situation for the blood bank. . patient blood platelets were higher before prophylactic than therapeutic transfusions ( [ /l vs. [ /l, p . ). there were no significant differences in the frequency of effective therapeutic ( % vs. %, p . ) and prophylactic ( % vs. %, p . ) transfusions between the prcs and gypcs. we did not find significant differences between prcs and gypcs in cci after prophylactic ( . . vs. . . ) and therapeutic ( . . vs. . . ) transfusions, in cc after prophylactic ( . . vs. . . ) and therapeutic ( . . vs. . .) transfusions. there were no significant differences between prcs and gypcs also in ma after prophylactic ( . . vs. . , p . ) and therapeutic ( . . vs. . . , p . ) pc transfusions. reduction of the severity of bleeds was obtained in ( %) of the cases after prpc transfusions and in ( %) of cases after gypc transfusions. there were no significant differences in the frequency of adverse post-transfusion reactions between the groups (respectively, and cases). background/case studies: an 'end-to-end' electronic transfusion management process including a bedside administration system was developed and implemented in this large multi-site academic center in . it enables the safe administration of blood components at the patient bedside and provides an audit trail for all blood components. an error was identified in the electronic bedside transfusion process which was reported to our national hemovigilance scheme in under the category 'errors relating to information technology'. this error was the incorrect use of the emergency transfusion process for non-emergency transfusions. the standard (non-emergency) process requires a scan of the barcode on the patient's wristband containing their identification details which is verified against the same details from the barcode on the compatibility label attached to the blood bag. the emergency transfusion option is only intended for use with 'emergency group o rhd negative blood units' which, unlike non-emergency units allocated to specific patients, do not have a compatibility label. the emergency transfusion option skips the compatibility label barcode scan as the emergency units can be transfused to any patient needing urgent transfusion. it was found that the emergency blood option was being misused for non-emergency transfusions, leading to blood units not being checked to ensure they were for the correct patient. study design/method: this center worked with the software supplier to develop a solution which corrects the weakness in the process. the revised process involves providing a universal compatibility label for emergency units so that all units (emergency and non-emergency) require a scan of the compatibility label on the blood bag and the patient's wristband at the bedside before transfusion. the use of the emergency process was audited pre and post implementation of the new process to determine whether it was being used correctly or not. results/finding: there were units administered using the emergency transfusion process in the months before the change was implemented. it was found that / ( %) units were non-emergency units administered incorrectly without a bedside compatibility check. following the implementation of the change there were no instances of incorrect administration of non-emergency units in the next month ( components administered), / ( %) were emergency units which were administered correctly. users of the system reported the revised process was quicker, safer and unified with other functions on the device. conclusion: the improved process for the administration of blood in an emergency now prevents users from following the incorrect procedure for non-emergency transfusions and missing the essential final bedside electronic check. this report indicates the need for continued vigilance of the functionality of electronic transfusion processes, and the correction of any weaknesses compromising patient safety. background/case studies: recent recommendations indicate one red blood cell (rbc) unit should be transfused at a time with reassessment after each transfusion to determine the need for more. however, the practices of canadian transfusion medicine (tm) experts and what constitutes a reassessment are unknown. therefore, we conducted a survey of tm experts across canada to gather information on their practices and criteria for reassessment. study design/method: tm experts were identified and contact information obtained from the canadian national advisory committee (nac) and from contacting least one tm expert per province. each respondent was assigned a unique study id after consenting to the survey, allowing for anonymity on analysis. the survey contained demographics, general practice questions, and questions regarding transfusion in: ) a stable anemic inpatient, ) a stable anemic inpatient to be discharged, and ) an asymptomatic post-operative inpatient. results/finding: we identified canadian tm experts: ( . %) provided a response and most had a primary place of practice in a laboratory setting ( / ; . %). for a stable, non-bleeding, anemic inpatient, . % of respondents recommended transfusing one rbc unit, then reassessing. recommendations were more variable in outpatient settings, with . % generally recommending transfusing two rbc units then reassessing. recommendations for reassessment were mainly functional status/symptoms and vitals within a short time period ( - hours), a repeat hemoglobin > hours later dependent on the clinical scenario, and a search for an underlying cause of anemia in outpatient settings. lab practitioners emphasized volume status, cardiac examination, and transfusion at lower hemoglobin thresholds. with an asymptomatic patient to be discharged, fewer respondents chose to transfuse ( . %) compared to an inpatient potentially symptomatic due to anemia ( . %). none of the respondents suggested transfusion in an asymptomatic post-operative patient who had a hemoglobin trending down. conclusion: tm experts generally recommend transfusing one unit at a time in stable inpatients. assessment for transfusion should focus on patient symptoms, pertinent physical exam, hemoglobin levels, and an underlying cause. "top-up" transfusions were not recommended. these recommendations may help guide clinicians, but further research is needed to generate higher quality evidence around the clinical benefits and cost effectiveness of these practices. background/case studies: current evaluation of red blood cell (rbc) post transfusion recovery is based on ex vivo labeling of stored rbcs with radioactive chromium- ( cr). this method has several limitations including the risks associated with radioactivity, and the inability to evaluate multiple rbc populations in the recipient. rbc labeling with s-nhs-biotin (bio-rbcs) overcomes many of these limitations and offers safe and longitudinal tracking of multiple transfused rbcs in vivo. the purpose of this study was to scale up and optimize the biotinylation procedures to the current good manufacturing practice (gmp) environment. study design/method: packed rbc units (n ) were divided into two ml aliquots, which were labeled with selected concentrations of s-nhsbiotin ( and lg/ml) in a cgmp closed system (average bio-rbcs hematocrit of . . %). optimization of labeling efficacy was determined by flow cytometric analysis of bio-rbcs using fluorochrome-conjugated streptavidin (sa). approximately million rbcs were measured in triplicate. quantum simply cellular beads were used to quantify fluorochrome (molecules of equivalent soluble fluorescence, mesf) and infer number of biotin molecules per rbc. the lower limit of detection was determined for rbc labeled with varying amounts of biotin. product quality and safety were evaluated by endotoxin and sterility testing, and by determining the levels of spontaneous hemolysis before and after rbc biotin labeling. results/finding: investigation of different fluorochromes, laser excitation wavelengths and laser power to maximize the signal to noise ratio of labeled and unlabeled rbcs revealed that nm excitation of phycoerythrin (pe)-sa and high laser power ( mw) provided the best separation between the two bio-rbc populations, and between labeled and unlabeled rbcs. labeling with lg/ml of biotin resulted in $ , mesf/rbc, and were detectable among unlabeled rbc at a lower limit of detection (lld, % ci) of in , ( . %). the lld for rbc labeled with biotin at lg/ ml was $ in million ( . %). biotinylation was not associated with increased levels of hemolysis ( . . % before labeling versus . . % after labeling; p . ) or bacterial contamination. conclusion: the resulting manufacturing process produces large volumes ( ml/transfusion) of bio-rbcs with low risk of contamination or hemolysis. the flow cytometry assay can detect bio-rbc in unlabeled blood at very low frequency. we plan to use this technology to study the impact of donor characteristic on rbc storage stability and post-transfusion survival. background/case studies: blood products offer resuscitation benefits in trauma over crystalloid/colloid volume expanders (which provide no hemostatic benefit or oxygen delivery), but usage is often hampered by supply or storage needs. hemoglobin-based oxygen carriers (hbocs) are not red cell replacements but may supplement oxygen delivery and expand volume during transport until blood is available. since hemostasis is critical in resuscitation, this study evaluated bovine hemoglobin glutamer- (hboc- ) effects on coagulation parameters alongside freeze-dried plasma (fdp) in an in vitro model of hemorrhage/resuscitation. study design/method: whole blood (wb) was collected from healthy donors under an approved institutional standard operating procedure. in the first study (limited resuscitation), samples were: ( ) wb, ( ) wb % hboc volume (model of two units in an adult), ( ) wb % fdp, and ( ) wb % hboc % fdp. samples ( )-( ) simulated autoresuscitation by adding % plasmalyte to - . susceptibility to lysis was tested with ng/ml tissue plasminogen activator (tpa). follow-up studies were performed with severe resuscitation simulations of %, %, %, and % volume replacement with hboc and/or fdp, with or without prior % plasmalyte dilution. coagulation parameters were obtained with a coagulation analyzer and thromboelastography (teg). rbcs/hemoglobin were measured on a hematology analyzer. thrombin generation was quantified by thrombogram. platelet aggregation was measured in multiplate and adhesion to collagen under shear in bioflux. viscosity was evaluated by rheology. results/finding: a limited resuscitation model with hboc and/or fdp had no effects on fibrinogen, pt, aptt, ph, hct, or hemoglobin. in teg, wb, wb hboc, and wb hboc fdp had reduced clot strength with dilution and tpa. there was increased susceptibility to tpa-induced lysis between wb and wb hboc in autodilution simulation (mean lysis . % vs. . %; p<. ). hboc and fdp had no statistically significant impact on thrombin generation. no effects on platelet aggregation were observed; no significant differences within diluted v. undiluted groups were seen in platelet adhesion under flow. hboc ( %) did not significantly change viscosity. severe resuscitation simulations had increased pt/ptt and reduced clot strength, particularly in hboc-only resuscitation; however, even % hboc volume replacement produced clots with acceptable teg parameters. conclusion: in a limited resuscitation model with hboc- , there were no significant in vitro effects on hemostatic parameters (except increased susceptibility to lysis); more severe resuscitations impacted coagulation parameters but did not prevent clotting. considering the large impact healthy platelets have on coagulation function, further in vitro studies with impaired platelets are warranted alongside in vivo studies of hboc plasma as initial resuscitation of hemorrhagic shock. therapy in patients with acute major bleeding. while published literature has largely focused on the efficacy and safety of pcc, actual usage practices are less characterized. our aim was to describe the pcc usage practices within a tertiary care center. study design/method: we conducted a retrospective review of the electronic medical records of patients who received pcc between its addition to our institution's formulary in / and / . we compiled information about the usage of pcc in these patients. descriptive statistics were generated with microsoft excel. results/finding: of patients, were on warfarin. pcc was most frequently prescribed for hemorrhage due to surgery ( %). pcc was given for warfarin reversal in % of cases. a subset of patients received plasma within hours prior to pcc ( %) or hours after ( %). pcc was most frequently ordered in the or/perioperative service ( %). conclusion: the majority of pcc usage was "off-label" in terms of being prescribed for indications other than warfarin reversal. the most frequent indication was hemorrhage due to surgery, and pcc was most often ordered in the or/perioperative service. although guidelines recommend the use of pcc as a plasma alternative, plasma was administered within hours of pcc in a notable subset of patients. background/case studies: in emergent situations, when a patient's life may be jeopardized by delaying transfusion, a physician may decide to transfuse blood emergently. however, in some cases, poor communication and lack of clear expectations between the blood bank and patient care areas can lead to frustration and delays in the timely provision of blood products. an incident prompted an appraisal of our emergency release protocol (erp), which revealed gaps in communications and expectations by both the blood bank and nursing personnel. thus, it is imperative that there is a standardized er protocol with clear communications for both the blood bank and nursing personnel. reported here is the outcome of a process improvement that resulted in improved communication, expectations, and turnaround (tat) for our er protocol. study design/method: in , several meetings were conducted with stakeholders (critical care units (icu), emergency department (ed), internal medicine, interventional radiology (ir) etc.) in an effort to identify process gaps, improve communications, and expectations for er episodes. the goals was to design a process for emergent blood product request and release in life threatening situations that will; ) simplify and expedite the process; ) improve communication and expectations to decrease tat; ) improve patient safety and meet compliance. in order to achieve these goals, a series of activities were conducted. these included meetings with all stakeholders to ensure process improvement meet the needs intended. a series of training sessions with nurse educators in icu, ed, ir and surgery managers were conducted. during the meetings, communication goals, and expectations were defined and agreed upon. training sessions included powerpoint presentations to educate staff members and performance of dry runs, to identify weaknesses and strengths with the process flow. the impact on the current process was analyzed and, as a result, led to the revision of the current sop, addition of pre-labeled emergency pack blood ( units of o neg rbc's) and implementation of an electronic emergency blood order set. results/finding: in the ten months post implementation of our improved, standardized er pack protocol, a total of er episodes were received. the average tat from order to delivery at the bedside was reduced by % ( . minutes compared to minutes previously), while the compliance rate for er orders and physician documentation was % ( / ), with no current wastage of blood products. conclusion: the implementation of the improved standardized er protocol significantly improved communications and expectations, decreased tat and delays in transfusions while ensuring patient safety and compliance to regulatory requirements. background/case studies: massive transfusion (mt) in the trauma setting has been extensively studied. yet, the literature in non-trauma areas, especially oncology is rather sparse. the following study was conducted to understand the background and outcomes of mt in cancer patients. study design/methods: this was a single center retrospective study performed at a large cancer center between february -february . mt was defined as the transfusion of ! rbc units in a -hour period. the following data were collected included: age, gender, primary diagnosis, surgery or acute care type, amount and type of blood components transfused, whether or not a massive transfusion protocol (mtp) was activated, and survival at days. results/findings: thirty mts occurred during a one year period. a total of , blood products were transfused during that time period. gender distribution was / ( %) males, and the average age of all patients was with a range of to years of age. surgical patients accounted for / ( . %) mts, and / ( . %) were critical care patients. tumor categories included carcinomas ( / ), sarcomas ( / ), leukemias ( / ) and lymphoma ( / ). resection of tumor followed by complex reconstruction was the cause of the majority of mts. metastatic renal cancer ( / ) was the most common disease seen followed by sacral chordoma ( / ). mtps were activated in only / ( . %) cases. thirty-day survival was seen in / ( . %) patients. only of mortalities was a surgical case (peritoneal mesothelioma), and the remainder were caused by gi hemorrhage ( / ) or perisplenic hematoma ( / ). the overall ratio of rbc:ffp in the entire patients ( background/case studies: plasma is a straw-colored supernatant of blood that is used for type and screen (t&s) and crossmatch. in the analytic phase of testing, plasma is examined prior to processing. plasma occasionally becomes discolored, interfering with crossmatch procedures. timely identification of the etiology allows for corrective actions and minimizes delay in transfusion. study design/method: during the analytic phase of blood bank testing, samples were evaluated for t&s and crossmatch; this identified three samples with discolored plasma. we present a series of cases that illustrate the testing process. results/finding: a -year-old woman diagnosed with breast cancer presented for mastectomy with sentinel lymph node biopsy. a preoperative t&s specimen contained bright green plasma. review of her preoperative case revealed exposure to intravenous methylene blue. this dye is known to alter the color of urine, tears, and blood with no known pharmacologic effects. alternative causes of green plasma include other dyes used to locate sentinel nodes and oral contraceptive use. although not ideal, this sample could be used for crossmatch by tube method, but not automated gel technique. a specimen drawn one week later contained clear plasma. a -year-old woman diagnosed with a warm autoimmune hemolytic anemia was refractory to blood transfusions secondary to alloantibodies. administration of a synthetic blood product resulted in dark maroon colored plasma. the most common cause of a dark red color is hemolysis of the sample, which is usually discarded. in this instance, the hemoglobin color was due to the infused product, an experimental bovine pegylated carboxyhemoglobin that affects colorimetric evaluation of blood samples. with this in mind, the sample was not discarded and testing was completed by tube method. a -year-old woman admitted with acute stroke was treated with a thrombolytic. her t&s revealed cloudy white plasma that could not be used for the crossmatch procedure. common causes of white plasma include purulence, hypertriglyceridemia, and sampling of blood drawn proximal to administration of radiopaque agents such as propofol. although an etiology could not be identified a repeat specimen drawn several hours later was clear. conclusion: these cases highlight the importance of an appropriate evaluation of discolored plasma. once a discolored sample is identified, a repeat sample is required to confirm the change in color. in the first two cases, the discoloration persisted, prompting further clinical investigation. once the etiology was identified, need for further testing and eligibility for further transfusion was determined. testing by tube method could be performed in two cases. in the third case, repeated sampling revealed a clear sample and the transfusion process continued without delay. decisions regarding the analytic phase of testing must include reevaluation of the sample, identification of the etiology, and comprehension regarding how to proceed when discoloration persists. caleb wei-shin cheng* , , rebecca ross , christopher a tormey , , and amit gokhale , . yale university school of medicine, yale-new haven hospital, va connecticut healthcare background/case studies: daratumumab (dara) is a igg monoclonal antibody therapy that specifically targets cd , a glycoprotein highly expressed on plasma cells, where it has been successfully used in patients with refractory or relapsed multiple myeloma. dara interferes with blood bank testing as it binds to cd expressed on red blood cells, causing pan reactivity. the dara interference can be overcome with the use of dithiothreitol (dtt) treated reagent red blood cells. to minimize alloimmunization and to provide crossmatch compatible blood to treated patients, we instituted a dara protocol in our blood bank. the purpose of this retrospective study was to identify the outcomes of our protocol, with a particular focus on the development of de novo alloantibodies during dara treatment at our institution. study design/method: all dara patients' antibody workups were completed using dtt pre-treated reagent red blood cells. if the antibody screen was negative, k antigen negative rbc products are provided. if an antibody is identified, k negative along with that particular antigen negative blood is provided. our electronic medical record (emr) was searched for patients who received dara over the past eight months. study subjects were examined to see if they had pre-existing alloantibodies before dara treatment and whether they formed new alloantibodies during dara treatment. the age, gender, type and screen pre-dara treatment, type and screen post-dara, intervening blood transfusions, and the date of first dara treatment was recorded. results/finding: overall, subjects were identified for analysis. their mean age was . years, with male and female subjects; all were diagnosed with multiple myeloma. we found an alloimmunization rate of % ( / ) prior to administration of dara. of these patients, were transfused with red blood cells (rbcs) after initiation of dara therapy. following our testing/matching protocol, none of these ( %; / ) patients formed a confirmed, new alloantibody during dara treatment; each of these patients underwent at least one follow-up screen after their first rbc unit. we also found no complications in providing crossmatch compatible units to any of the patients. conclusion: to our knowledge, this is the largest case series reporting on results of overcoming dara interference with blood bank type and screen testing. the protocol implemented in our laboratory appears to be successful in providing compatible units and preventing alloimmunization in patients receiving dara therapy. it is possible that the drug, targeting antibody forming cells, may have an immunosuppressive effect on the humoral response; further studies of this effect may be warranted. background/case studies:a multi-facility transfusion service began stocking liquid plasma in september of for use in massive transfusion and trauma situations. due to the infrequent occurrence of these incidents, the liquid plasma would outdate before use. a policy to use liquid plasma in nonemergent situations when the units were nearing their expiration dates was implemented. this study evaluated the effects of that policy on inr values of plasma recipients. study design/methods:a retrospective analysis was developed to compare the effectiveness of fresh frozen plasma (ffp) and liquid plasma (lqp) in changing inr values of recipients. all plasma units transfused within the facility from september , through april , were identified. the following data was obtained from the hospital and laboratory information systems for each unit: the recipient, primary reason for transfusion of plasma, number of plasma units transfused, type of plasma transfused, preand post-transfusion inr values, and whether or not vitamin k was administered. patients were divided into groups based on the type of plasma units transfused and were evaluated based on primary reason for transfusion, number of units transfused, and administration of vitamin k. the change in inr for each recipient was calculated, along with the average change in inr for each group. background/case studies: in gynaecological settings, most but not all relatively young anaemic women are iron deficient due to blood loss associated with menstruation. transfusion could generally be avoided in those without haemodynamic instability. the oral antifibrinolytic drug tranexamic acid is an effective and well tolerated treatment for menorrhagia. besides, iron replacement is often necessary for a prolonged period of time after normalization of haemoglobin (hb). the present study attempted to look into transfusion appropriateness and the use of iron and tranexamic acid in transfused women in hong kong. study design/methods: anonymous data of gynaeological patients age was retrieved from a central database of public hospitals which included age, number of units of red cell transfused, pre-and posttransfusion hb, the use of iron and/or tranexamic acid during hospitalization and upon discharge. all transfusion episodes associated with surgical operations during same admission are excluded. results/findings: in , , unique women receiving a total of , units of red cells (rc) in , transfusion episodes were identified. their median age was (range - ). the distribution of pre-and post-transfusion hb and units of rc transfused were summarized below: in this cohort, pre-and post-transfusion hb were absent in ( . %) and ( . %). ( . %) transfusion episodes were associated with the use of units or more rc. as a result, ( . %) episodes resulted in a post transfusion hb ! g/dl. parenteral iron or tranexamic acid was uncommon during hospitalization and was given (< . %) and ( . %) women respectively. upon discharge, ( . %), ( . %) and , ( . %) women were prescribed with oral iron alone, oral tranexamic acid alone or both respectively. however, neither were given to ( . %) women. conclusion: in the present study, it is observed that . % transfusion episodes were given at hb ! g/dl. a substantial number of episodes ( . %) were transfused with multiple units and resulted in almost half having a post transfusion hb level (! g/dl). for iron replenishment and bleeding control, up to . % transfused women were not given iron or tranexamic acid at discharge. the results indicate that awareness of both transfusion appropriateness and iron deficiency anaemia management have to be improved. it is recommended that in-depth education and training should be provided for a better gynaecological patient blood management. background/case studies: granulocyte transfusions may be utilized to boost the immune response in patients with life-threatening neutropenia or neutrophil dysfunction and evidence of treatment-refractory bacterial or fungal infection. however, granulocytes are rarely administered due to uncertainty regarding efficacy, difficulty in collection, and increased propensity for adverse reactions. we report a case of granulocyte transfusion therapy following chimeric antigen receptor t-cell (car-t) therapy in a patient with severe neutropenia and multiple infections in the context of relapsed b-cell acute lymphoblastic leukemia (b-all). study design/method: granulocytes ( . - . x per unit) were collected from abo-identical unstimulated donors at a regional blood center. each unit was irradiated with gy and transfused over - hours within hours after the time of collection. the patient's response and laboratory data were reviewed in the medical record. conclusion: this data suggests that a diagnosis of aml is associated with anti-hla antibodies. an increased frequency of blood group a in patients with aml has been reported, but here no statistically significant difference between abo blood group frequencies was found in any category except the patient's with hla antibodies. blood group b has a significant association with hla alloimmunization in the studied patients. it has been reported in a large study of female blood donors that no difference in hla antibody frequency was observed based on abo blood group at centers using the flow-based assay. although the reasons for the higher rate of group b blood type among patients with anti-hla antibodies and hematologic malignancies is unknown, this could be due to variation in immunizing events (pregnancy vs transfusion) or immune dysregulation related to the hematologic malignancy, especially aml. females with aml who are blood group b appear to be most likely to have hla alloimmunization among patients with hematologic malignancies. implementation of electronic solution to reduce risk of mistransfusion in a regional transfusion service debra lane* , lee grabner , brenda herdman , robert fallis , amin kabani and charles musuka . canadian blood services, kenora rainy-river regional laboratory program, diagnostic services manitoba background/case studies: patient misidentification and improper sample labeling has been an ongoing risk for the safety of blood transfusion. the rate of mistransfusion has remained unchanged in over years. attempts have been made to reduce mistransfusion including barrier devices, barcoding and rfid. within a regional background/case studies: the role of donor age and sex on hemoglobin content and susceptibility to hemolysis during storage of red blood cell (rbc) units is receiving increased attention. however, the impact of donor characteristics on efficacy of rbc transfusion has not been studied in largescale donor-recipient outcomes databases. study design/methods: we conducted an analysis using blood donor data routinely collected by a blood center and transfusion recipient data from a large community hospital network between and before patient blood management initiatives. linkage was performed between blood donor characteristics and hospitalized rbc transfusion recipients who received a single rbc unit. studied exposures for this analysis were blood donor sex and age in addition to rbc storage age. the wilcoxon test was used to examine changes in hemoglobin level following rbc transfusion, and , and % were male. recipients of rbc's from male and female donors had similar pre-transfusion hemoglobin levels ( . g/dl; p . ); however, transfusion recipients of male donor rbc units had higher post-transfusion hemoglobin levels and larger increments in hemoglobin compared to those of female rbc units ( . vs . g/dl; . vs. . g/dl; both p . ). female recipients had a larger rise in hemoglobin per rbc unit compared to male recipients ( . g/dl vs. . g/dl; p< . ). female sex of the recipient remained a significant predictor of change in hemoglobin after accounting for recipient age and estimated circulating blood volume in multivariable analysis (p . ). rbc storage age and the age of the donor were not significant factors in changes in hemoglobin levels in multivariable analysis, p . and p . , respectively. conclusion: rbc units from male donors resulted in a larger rise in hemoglobin levels compared to those from female donors, and these changes were more apparent in female recipients even after accounting for effective circulating blood volumes. this suggests that the dose of hemoglobin is lower in female than male rbc units. this analysis demonstrates the feasibility of using this approach to study the association between donor characteristics and rbc efficacy, hemolysis and other donor-component-recipient interactions. background/case studies: people who identify as jehovah's witnesses (jw) comprise less than % of the population of the united states. however, as a group they can present a special challenge in medicine due to a religious aversion to blood products, based on biblical readings. the degree of this religious refusal can vary from individual to individual, but as institutional policy, a conservative approach is warranted. however, in large institutions where multiple teams manage a single patient, blood refusal information can be lost or poorly communicated from provider to provider. as such, a system to alert providers of patient blood refusal was recently implemented through the electronic medical record in a large west-coast institution. study design/method: the electronic medical record (emr) utilized in this study in an institutionally modified version of epic ea best practices alert (bpa) was designed to trigger each time an end user attempted to place orders related to blood transfusion, transfusion-related lab testing, or human-derived pharmacy items on patients with blood refusal codes in their history, problem list, or religion (jehovah's witness) discrete data fields. the alert constitutes a "soft-stop" in which the ordering provided is prompted to either cancel the triggering orders or acknowledge the blood refusal/religious history and override the warning with an option to select a reason for the override. data on the triggers are automatically collected through the emr systems and generated into a report by informatics personnel. results/finding: the available data covers triggers in the two month postimplementation of the bpa. the bpa triggered times in total, affecting patients and users. stratified by location, the majority of triggers occurred in the perioperative areas ( times) and the liver icu ( times) with a minority occurring on the regular hospital floors and emergency department. nurses, attendings, residents, pharmacists, and nurse anesthesiologists were the users affected. orders that triggered the bpa included type & screens, human albumin % iv solution, human albumin % iv solution, immune globulin (human) solution. conclusion: despite the limited and very preliminary data, the user action findings seem to indicate that the bpa is effective in halting up to half of the contraindicated orders for blood-derived products and type & screens orders. given the limited types of orders that the bpa is triggering on, the pattern suggests that the bpa is potentially alerting some previously unaware providers of the patient's religious status and/or the fact that certain pharmacy items are blood-derived, and therefore unacceptable to many jw patients. despite these positive initial findings, this is an ongoing study to track the efficacy of the bpa and more data needs to be collected for better metrics of the institutional sensitivity to patient blood refusal. intervention to address inappropriate cryoprecipitate-ahf orders at a tertiary medical center sirisha kundrapu* , , mahmut akgul , , hollie m reeves , , robert w maitta , , marcie pokorny , anne capetillo and katharine a downes , . background/case studies: although introduced for the management of hemophilia a, now cryoprecipitate is primarily indicated for low fibrinogen levels. at our institution the transfusion medicine service (tms) reviews and makes recommendations to clinicians for all inappropriate cryoprecipitate orders. we aimed at analyzing the effectiveness of this intervention in reaching target fibrinogen levels in under-estimated and over-estimated orders. study design/method: we conducted a -month retrospective study (january-july ) of adult cryoprecipitate order quality assurance forms. the reference range for fibrinogen was - mg/dl with critical value of mg/dl. cryoprecipitate orders for massive transfusion protocol, from operating rooms and for extracorporeal membrane oxygenation were not reviewed by the tms. during the study period, tms evaluated orders for appropriateness of dosing and agreement with estimated required doses. post-transfusion fibrinogen levels due to intervention were compared with hypothesized no intervention levels. statistical analysis was performed using chi-square and t-tests. results/finding: there were adult (> years) orders reviewed by tms out of which were approved. of the approved orders, ( . %) were in agreement with tms's estimated dose. of ( . %) orders that were not in agreement with the tms's estimate, ( %) were underestimated and ( %) were overestimated. seventeen of orders had no post-transfusion fibrinogen levels. without intervention, there would have been a median deficit of . mg/dl (range . to mg/dl) and a median excess of . mg/dl (range . to mg/dl) of fibrinogen from the target. median difference between target and actual post-transfusion fibrinogen level was mg/dl above target, which is significantly higher with intervention than without (which could have been mg/dl below the target; p< . ). median differences between target and post-transfusion fibrinogen levels for the group with agreement between approved and requested units was not significantly different from possible differences without intervention ( vs. . mg/dl, p . ). median differences between target and post-transfusion fibrinogen levels for the group with non-agreement between approved and requested units was significantly different from possible difference without intervention ( vs. - . mg/dl, p< . ). seven of ( ) ( ) orders were for critically low fibrinogen (< mg/dl) and of these were under-estimated requests and reached target fibrinogen with tms's estimate and approval of required units to be transfused. overall most frequent orders were and units ( . % and %) i.e. and pools and the most frequent orders in the disagreement group were , , and units ( %, %, % and %). there is a significant difference between agreement and disagreement groups based on clinical service ordering the units (table) . conclusion: intervention by tms to review and approve cryoprecipitate orders was associated with increased accuracy of orders and achievement of desired target fibrinogen levels. further studies are needed to develop multidisciplinary strategies for accurate cryoprecipitate dosage. patient characteristics, medical records, vitamin k administration, and adverse events, were collected (table) . results/finding: the average pre-transfusion inr was . and posttransfusion was . . only % of patients had their inr corrected to . , while % had no change, or had increased inr. (table) . the majority ( %) of patients received units of plasma. the mean plasma dose was ml/kg. there were transfusion reactions reported, non-hemolytic and transfusion associated circulatory overload reactions in which required admission to the icu. two patients experienced bleeding during ir procedures (tips) and developed a hematoma (tunneled central line). the median of inr correction in this study was . with no relationship to the number of units of plasma transfused and/or if vitamin k was administered. this study suggests it may not be beneficial and may be harmful to transfuse plasma for correction when inr is . . randomized trials are needed to assess whether the inr is a rational tool to measure bleeding risk, and whether prophylactic treatment with plasma yields any benefit. of the patients experienced bleeding complications indicating that inr of . may be considered safe in some lower risk procedures. current practices may provide little or no benefit, with substantial risk of life threatening complications. background/case studies: group ab plasma, which lacks anti-a and anti-b antibodies, is considered to be the universal plasma donor and is used in the emergency setting before the patient's blood group is available. approximately % of the population is group ab, which limits the available inventory of group ab plasma. of group ab population, only plasma from male donors are considered suitable for transfusion since females, especially multiparous female donors, have a greater propensity to develop antibodies that can cause transfusion related acute lung injury (trali). this makes type ab plasma a limited resource. our hospital is a level one trauma center, where a significant amount of plasma transfusion is required for severely bleeding patients before their blood type is known. group o individuals make up % of the population and have no a or b antigens on their cells. group a is the second most prevalent blood group in the us population ( %) and has no b antigen on their cells. so, group a plasma is compatible with both group o and a patients, approximately % of the patient population. before patient's blood type is known, type o red cell units are transfused with a plasma, which decreases the chance of hemolysis. to conserve ab plasma, we instituted a policy effective july , as follows: units of group a plasma and units of group ab plasma is provided for the massive transfusion protocol (mtp) along with units of o negative rbc until patient blood type is known. study design/method: this prospective study is designed to monitor the use of group a plasma in mtps at our institution and to evaluate the risk and severity of hemolysis in patients transfused with incompatible plasma. direct antiglobulin test (dat) is performed if patient received incompatible plasma. if dat is positive, lactate dehydrogenase (ldh), haptoglobin and bilirubin levels are obtained to detect possible hemolytic transfusion reaction. results/finding: we reviewed mtps at our institution between july and march . twenty patients ( . %) were transfused with incompatible group a plasma ( group ab and group b patients). five patients died due to severe injury, and follow-up testing of these patients could not be performed. the remaining patients had negative dat, indicating the lack of significant amount of antibody coating their red cells, which could lead to hemolysis. none of these patients developed acute hemolytic reaction, or any other adverse effects of incompatible plasma transfusion. conclusion: our study adds more evidence of the safety of group a plasma transfusion in trauma patients requiring emergent massive transfusion before the patient blood type is known. based on this and other recently published studies, starting in april , our institute will provide only group a plasma for emergency release and mtp cases before the patient blood type is known. average ( background/case studies: in , bonfils immunohematology reference lab (irl) sent out approximately special platelets for patients with hla antibodies. by , hla platelet orders increased dramatically and the irl sent out over special platelet products. the purpose of this abstract is to illuminate the methods used to fulfill increased client need that occurred in a short period of time. study design/methods: bonfils blood center has over , donors in the database with historical hla typing. however, only approximately of those donors actively donate. in the denver area, one of the most common hla types is a a b b . only of the , donors have this type ( . %). therefore, to fill an hla platelet order request for a common hla type, only donors in the system would be a perfect hla match. with that low number of donors, it is not likely that there would be a platelet on the shelf ready to fill the order. after a donor is recruited and donates, it takes at least two days to fill an order. for a less uncommon hla type like a a b b , there is only out of , donors ( . %) that match perfectly. in those cases, there are no donors to recruit to fill such an order. in some complicated cases, the irl was provided with an hla antibody list or panel reactive antibody test (pra). in order to find product for these patients, lists of platelets in inventory with corresponding hla types were printed. if a patient had an antibody to a for example, all of the a positive platelets were crossed off the list. this cross-out process would continue manually until the only platelets on the list were the ones positive for hla antigens to which the patient did not have antibodies. these platelets are pra matched to the patient. in order to automate this process a report linked to the donor database was created to find both pra platelets in inventory and donors for recruitment. the blood center medical director began suggesting that hospital clients order a pra for each patient with platelet refractoriness. the pra test is fast and it is a definitive method to discern hla antibody mediated refractoriness from platelet refractoriness due to other causes. results/findings: in all but the most complicated cases with rare hla patient phenotypes, it was much easier to find a pra patient matched platelet on the shelf than an hla match donor. in , approximately % of these special order platelets were pra matched and the remaining % were hla matched by donor recruitment. by , approximately % of special platelets sent are pra matched. this change resulted in a . fold increase of finding product in inventory to fill orders quickly. conclusion: developing a system to provide pra matched platelets is a faster alternative to finding hla matched platelets thus contributing to better patient care. background/case studies: in urgent cases where large amounts of blood products are needed quickly, maintaining a standard massive transfusion protocol (mtp) is critical to the timely delivery of these products. each mtp pack at ucm contains packed red blood cells (prbcs), fresh frozen plasma (ffp) units, and plateletpheresis pack; a unit of prepooled cryoprecipitate is also given if the patient is in labor and delivery (l&d) or if one is requested. at ucm, blood products are generally transported through the pneumatic tube system (pts). we undertook a review of our mtp issuing practices and efficiency patterns over the last three and half years. study design/method: the electronic archives of the blood bank laboratory information system and electronic medical record at our institution were queried for patients who had mtp activations. the archives were correlated to paper copies of these activations to collect data pertaining to the relevant information such as where the order originated from, how quickly the first product was sent out, how many products were transfused, and so on. results/finding: between august to march mtps were activated at ucm, of which orders could be traced to the origin: on inpatient floor (including icus), in the operating rooms, in the emergency department, in labor and delivery, and in other procedure rooms. of the prbcs that were issued, were transfused ( % utilized); of the units of ffp that were issued, were transfused ( % utilized); of the platelet packs that were issued, were transfused ( % utilized); of the units of cryoprecipitate that were issued, were transfused ( % utilized). since march , the time of first product issue after the initiation of an mtp has also been tracked. of the events that fall within this time period, ( %), had the first product issued in minutes or less. another ( %) were issued between - minutes, resulting in over % of patients being issued their first blood product within the first minutes. only of ( %) events had an initial time greater than minutes and none were greater than minutes. conclusion: the majority of our activations currently come from inpatient floors (primarily icus). as our institution anticipates the introduction of an adult level trauma center, we anticipate this balance will shift. in addition, the data shows that (with the exception of cryoprecipitate) the utilization rate is nearly identical among the blood products sent during mtp activations ($ - %). again, we anticipate utilization rate of issued mtp products to increase with the introduction of a new adult trauma center. we have recently begun tracking time to last product issued during an mtp, but cannot report on that variable at this time. overall, our data show that our transfusion service is generally performing adequately to issue the first product within minutes of mtp protocol activation. this data only reflects time to issue in the pts; patient care areas can experience additional minutes delay in pts delivery and arrival of product at bedside. we must continue to collaborate with our clinical colleagues to collect accurate data to provide the best and most efficient mtp care. mehreen yasin* , shailesh macwan , arline stein , jane fischman , nancy nikolis , matthew bank , lennart logdberg , alexander indrikovs , sherry shariatmadar and vishesh chhibber . north shore university hospital, northwell health background/case studies: massive bleeding is generally defined as any patient who requires blood volume replacement within hours and/or receives transfusion of greater than or equal to units in one hour with a transfusion vol. supplement s ongoing bleeding. our mtp was officially implemented in in preparation for an initial verification as a level trauma center by acs. our mtp has the following packages: st pack has a ratio of : : (rbcs, plasma & platelets) and subsequent packs a ratio of : : . our mtp also includes prothrombin time (pt), activated partial thromboplastin time (aptt) and fibrinogen testing after each pack is transfused. this data is used to assess the patient and allows the transfusion service and clinical team to identify coagulopathies. however, attempts to supplement mtp packs with cryoprecipitate (cryo) and prothrombin complex concentrate (pcc) were challenging to accomplish in a timely manner. study design/methods: due to challenges in timely supplementation of mtp packages with cryo and pcc, the protocol was modified in march to add cryo and pcc at a defined point in the mtp (cryo is included in the rd pack and pcc in the th pack). in order to validate this modification of adding these products at defined intervals regardless of laboratory data, we decided to review all patients that received > rbc at our institution as these massively hemorrhaging patients would receive pcc based on our current protocol. we reviewed the blood products received by these patients and their available laboratory data. results/findings: we had patients who received > rbc in and . mtp had been activated for all patients and all patients received between . to unit of plasma for each rbc unit transfused. despite receiving these ratios of blood products, all patients had elevations of their pt > seconds and many had elevations of the aptt and fibrinogen levels less than our institution's target of mg/dl (table ) . as anticipated, improvement in the coagulation parameters was noted with cryo and pcc supplementation. conclusion: our data on massively hemorrhaging patients supports a role for supplementation of our mtp with cryo and pcc in patients who require transfusion of > rbc. our current protocol with the addition of cryo and pcc at defined intervals has streamlined the process and improved timely provision of these products in bleeding coagulopathic patients. background/case studies: red blood cell hemolysis is a key finding for a diagnosis of transplant-associated passenger lymphocyte syndrome (ta-pls). however, whether a hematopoietic stem cell or organ transplant recipient experiences hemolysis when a transplant contains unintended antibody-forming passenger lymphocytes depends, by chance, on the recipient's blood group phenotype. a living donor liver segment transplant resulted in a case of ta-pls with donor-derived anti-d that had the potential for causing a clinically significant hemolytic event. the donor's plasma contained anti-d. anti-d was absent in the recipient's pre-transplant plasma, but present in the recipient's -day and -day post-transplant plasma. although these findings established a diagnosis of ta-pls, hemolysis did not occur because the recipient's blood group phenotype was d-. the conventional focus on hemolysis, rather than on the transfer of antibody-forming lymphocytes, is a diversion from the primary pathophysiology of pls and limits capturing the true scope of the syndrome. study design/method: to determine the standard of practice for detecting and diagnosing ta-pls, a retrospective -year pubmed search for peerreviewed english-language journal articles was conducted using key words "passenger lymphocyte syndrome." cases were categorized according to the presence or absence of hemolysis and whether there was a routine antibody screen to detect donor-derived, passenger lymphocyte-formed blood group antibodies. results/finding: of published cases ( reports) of ta-pls, ( reports) were stem cell and ( reports) were organ transplants. all ( %) stem cell transplants and ( %) organ transplants were associated with hemolysis, reflecting an overwhelming bias for identifying ta-pls associated with hemolysis. of the reports of stem cell ta-pls, actively screened for antibodies in the immediate post-transplant period, and of the reports of organ ta-pls, actively screened for antibodies. these screens detected cases of stem cell ta-pls before hemolysis became apparent and cases of organ ta-pls with antibodies without hemolysis. it can be inferred that ta-pls is currently under-diagnosed, because hemolysis is not consistently present and/or antibody screens are not performed routinely. conclusion: a new category of "non-hemolytic ta-pls" is recommended to capture otherwise undiagnosed cases where ta-passenger lymphocytes form blood group antibodies in the recipient, but hemolysis does not occur, as in our aforementioned case. to ensure including the full scope of ta-pls, an antibody screen should be performed routinely one week after transplant and repeated as clinically indicated. occult hemolytic anemia due to anti-mur in a patient receiving blood from a region with a prominent asian donor population jean oak* , rosario mallari , marc de asis , elaine shu , jonathan hughes and tho pham , . stanford university, stanford health care, stanford blood center, bloodsource background/case studies: mur antigen is present in - % of individuals in southeast asia, taiwan, and parts of southeastern china, but is rare elsewhere. antibodies against mur antigens are clinically significant, hence many countries in asia routinely screen for it while other countries, including the us, does not include mur in the standard screen. we describe a case of an occult anti-mur antibody causing anemia and donor ethnicity distribution in a regional blood center with a large asian donor population. year old hispanic male with chronic myelomonocytic leukemia and plasma cell dyscrasia developed anemia. initial antibody screen and dat were negative, and the patient received - rbc units every - weeks to maintain a hemoglobin (hb) level of g/dl. the patient remained stable for months when his hb level acutely dropped to . g/dl. the antibody screen remained negative for an additional months when it became positive for anti-jka and anti-mur. donor ethnicity data was available for of the rbc units he received. units were from an asian donor, and a unit transfused days prior to the hb drop was from a caucasian/chinese donor. study design/method: we reviewed the ethnicity data of , donors at a hospital-associated blood center located in a region where asians comprise approximately % of the population. results/finding: . % of donors identified as chinese, vietnamese, filipino, or other southeastern asian. these donors account for of ( . %) rbc collections. conclusion: identification of anti-mur in this patient was triggered by the presence of a concurrent anti-jka alloantibody. since over % of the rbc supply in the local blood center was collected from chinese or southeast asian donors, chronically transfused patients are at risk of developing anti-mur-mediated hemolysis that could be missed on a standard screen. this finding raises a possible need for blood banks located in regions with a prominent asian population to implement screening for anti-mur. brian adkins* , princess maynie , carol chandler , shelia garret and pampee young . vanderbilt, vanderbilt university medical center, department of pathology, microbiology and immunology background/case studies: antibody titration is a testing modality vital to both obstetric and transplant services. manual direct tube testing is associated with variability in results (poor reproducibility/precision) and is also time and resource intensive. in fact, studies have shown a three-to eightfold inter-institutional difference between the antibody titers from the same samples using manual tube method. the orthovision automated analyzers offers automated titering of patient plasma using gel technology. although there is intense interest in adopting automated testing technology for titering, it is well-appreciated that titers obtained in manual gel testing are much higher than those obtained by manual/direct tube testing. the higher titer results lack clinical fetal anemia and outcome correlations, which is a barrier to their implementation. moreover, despite the increased sensitivity of gel testing, prior studies have found variable results with regard to reproducibility and precision. [ ] [ ] [ ] there is minimal information on the comparisons of tube titers to orthovision automated titers or assessment of the reproducibility of this automated method. study design/method: rh and non rh minor rbc antibody titrations were performed by manual direct tube method on clinical samples and the same samples were analyzed on three different ortho vision analyzers to assess precision and inter-instrument reproducibility. results/finding: a total of samples have been analyzed (table) , rh and non-rh antigens. titers via automated testing on orthovision resulted in a mean titration being . (range - ) times higher. the average fold change for rhd/c/e antibody titers were . , whereas the average fold change for non rh titers was . (range - ). the range for anti d titers was particularly variable, - , whereas for c/e, it was - . the overall reproducibility/precision of the automated analyzer was $ %. to correlate the a transfusion vol. supplement s increased titers observed with some classes of antibodies, particularly anti d, we will be performing parallel testing of obstetric samples and correlating with pregnancy outcome/fetal testing the obtained values. conclusion: automated titration of antibodies using the orthovision analyzers resulted in highly reproducible results between different instruments using the same sample. however, the automated analyzers consistently yielded higher values, particularly with rh d, with results $ times higher than in manual tube testing. interestingly, the difference in titers of non rh antibodies between manual tube and automated testing was not statistically significant, although our n thus far is small. in order to leverage the efficiency and reproducibility benefits of automated titering we will need to establish "critical titer ranges" which require active monitoring of the fetus. platelet additive solution reduces the isoagglutinin titer in apheresis platelet units maxim tynuv*, elizabeth j furlong and willy a flegel. dtm/cc/nih background/case studies: isoagglutinins in the plasma of apheresis platelets are a concern during transfusion, as high titer anti-a and/or anti-b may cause a hemolytic transfusion reaction (htr) in a recipient with cognate antigen. apheresis platelet collections are usually reconstituted with donor plasma, however most facilities do not test for high titer of isoagglutinins, exposing recipients to the risk of htr due to plasma incompatibility if given based on short outdate and not abo type. at our facility testing is performed on all apheresis platelets with a cutoff titer of . units above the cutoff are marked as "high titer" and only given to abo plasma-compatible recipients or washed with saline to reduce plasma. however, washing platelets is a time consuming process that results in a loss of up to % of the platelets. platelet additive solution (pas) is used as an alternative collection and storage solution, replacing approximately % of donor plasma in the final product. the goal of this study was to determine what affect pas has on isoagglutinin titers and whether using pas could lead to a revision of one facility's procedure for management out of group platelet transfusions. study design/method: isoagglutinin titers of whole blood edta samples were compared to the final apheresis platelet unit collected in pas (intersol, fresenius kabi, lake zurich, il). using two-fold dilution steps, plasma was tested with pooled red cells (equal mix . % suspension of a and b cells, ortho, raritan, nj) in a gel matrix test (mts buffered card, ortho, raritan, nj) with min incubation (room temperature) prior to centrifugation (mts ortho workstation). fifty two donors were group o, group a, and group b. results/finding: of the whole blood edta samples tested, ( group o and group b) exceeded a high titer threshold of . when the pas samples of these donors were tested, only one (group o) exceeded the same threshold. pas specimens showed a consistent two-fold decrease in titer compared with whole blood specimens. nearly half of the group o donors exceeded a titer of when whole blood specimens were tested. conclusion: only one sample from apheresis platelets collected in pas exceeded our clinically applied titer threshold of , a % decrease from the number of whole blood specimens exceeding the threshold. testing the platelet bag collected in pas instead of plasma from whole blood specimens would lower the number of units exceeding the high titer threshold, and reduce products needing to be washed. furthermore, facilities not collecting platelets on site or without access to whole blood specimens from donors could implement the process described here and screen platelet apheresis collections for potentially clinically adverse isoagglutinin titers, whether collected using pas or not. other components. the majority of blood components in israel are collected and distributed by magen david adom (mda), from main locations. several hospitals in israel also collect platelets in-house. as part of an effort to understand plt utilization, a nationwide survey of plt transfusion and expiration was conducted. study design/methods: data on the disposition of all plt units, acquired from mda and collected in-house, during the calendar year was requested from all hospitals in israel. the number of plt distributed to hospitals by mda was also collected. plt wastage was defined as the sum of plt that were returned and not reissued from the hospital blood banks and plt that expired on blood bank shelves. results/findings: sixteen of the ( %) hospitals in israel, along with mda, participated in the survey, listed as a to p. the results are presented in the table along with each hospital's distance from the mda facilities. for some hospitals, the sum of transfused and wasted plt was slightly less than the number of plt supplied by mda; this is likely due to the small number of plt that had not either been transfused or expired by the time the data collection period ended. three of the largest hospitals (c, b and a) collected plt in-house in addition to acquiring units from mda. these hospitals had a lower overall rate of wastage including their own donations than the other hospitals that did not collect in-house plt. the other hospitals had wastage rates ranging between - %. no correlation was apparent between the hospital's distance from the mda facility or its number of beds and the plt wastage rate. conclusion: there is considerable platelet wastage in israel. large hospitals in israel with in-house donations had the lowest overall wastage rates in comparison to the other hospitals. factors known to affect plt utilization and wastage such as patient diagnosis mix, policies about how plt are issued and accepted back into hospital inventory, plt inventory size and the time of pooling of whole blood platelets relative to the time they are issued and returned to the blood bank need to be investigated and optimized in order to reduce wastage rates. possible immune-mediated hemolysis due to platelet transfusion masked by underlying hemolysis in a patient with blast crisis sirisha kundrapu* , , christopher j gresens , anne capetillo , hollie m reeves , and katharine a downes , . case western reserve university school of medicine, university hospitals cleveland medical center, bloodsource background/case studies: transfusion-related hemolysis with abomismatched platelets is rare with a reported incidence of < . %. most commonly in such cases group o platelets having high titer anti-a result in clinically significant hemolysis when transfused to a group a or ab recipient. we present a patient with a possible hemolytic reaction following transfusion of abo mismatched platelets presenting in the setting of underlying disease associated hemolysis. study design/method: a -year-old male with chronic myelogenous leukemia in blast crisis was evaluated for possible transfusion reaction to a single donor platelet (sdp). two hours post transfusion he developed chills, rigors, and increased blood pressure ( / mm hg to / mm hg) followed by hematuria ( ml). chills and rigors resolved; blood pressure stabilized after min with diphenhydramine, solumedrol, and acetaminophen. negative. patient abo group, rh (d) type and antibody screen on pre-and post-transfusion specimens showed no discrepancies. laboratory indicators of hemolysis are summarized in table. notably, while total/ indirect bilirubin increased and hemoglobin decreased after transfusion other tests were indeterminate for hemolytic transfusion reaction with abnormal pretransfusion levels. despite underlying disease associated hemolysis, the blood supplier of the unit was contacted to investigate into the possibility of high titer donor anti-a. this revealed donor anti-a titer results of (igm) and , (igg); donor was deferred from future platelet donations. conclusion: while the post-transfusion sample had no visible hemolysis and a negative dat, increased total/ indirect bilirubin after transfusion and high titer donor anti-a are supportive of immune mediated hemolytic transfusion reaction. the key unique aspect in this case is baseline underlying hemolysis, which may mask needs for further investigation of donor for high titer anti-a. ana paula hitomi yokoyama* , leila patricia de sousa fontenele , isabel nagle reis , carolina bonet bub , araci sakashita , raffael zamper , cristiane nakazawa , tatiane almeida omura paula , patricia silva batista , marcio dias almeida , fernanda loureiro de andrade orsi and jose mauro kutner . hospital israelita albert einstein, hemocentro unicamp-universidade estadual de campinas background/case studies: orthotopic liver transplantation (olt) is a high complex procedure, fundamental to therapeutic approach for end-stage liver disease. despite improvements in hemostatic , surgical, and anaesthetic techniques, liver transplantation is still associated with massive blood loss and high rates of transfusion requirements. peri and intraoperative transfusion of red blood cells (rbc) have been previously reported as major predictors of post -operative mortality . identifying predictive factors for transfusion requirements may help optimise patient blood management strategies in olt. we conducted a single center retrospective analysis of cases of olt performed between and in brazil in order to identify predictive factors for red blood cell transfusion study design/method: a retrospective analysis in a single institution was performed, and charts of consecutive patients submitted to liver transplantation between and were reviewed. the following variables were collected for each patient: gender, race, primary diagnosis, presence of hepatocellular carcinoma, age, body mass index, corrected model for end-stage liver disease (meld), duration of warm and cold ischemia. categorical variables were analysed using pearson chi-square test. continuous variables were analysed using t-student test. a forward logistic regression model was used to analyse data in a multivariate fashion, to identify independent contribution of variables previously found to be significant. results/finding: in univariate analysis, female patients, absence of hepatocellular carcinoma (hcc), primary diagnosis, corrected meld and warm ischemia time were significantly associated with consumption of rbc use in the intraoperative period. multivariate logistic regression of these factors showed that female patients (or , - % ci: , - , , p: , ), absence of hcc (or , - % ci: , - , , p: , ), cirrhosis of any cause (or , - % ci , - , -p: , ), miscellaneous diagnosis (auto-immune, metabolic diseases, familial amyloid polyneuropathy, vascular complications) (or , %ic , - , ) and retransplantation due to primary non function of the graft (or , %ci , - , , , p: , ) were independently associated with rbc transfusion requirements. conclusion: in this study, female patients, absence of hcc, specific primary diagnosis and retransplantation due to primary non function of the graft were significantly associated with rbc consumption in intraoperative period. determination of rbc transfusion predictors before surgery might provide important information regarding management of blood components and help optimise utilisation of resources for blood conservation strategies. prevalence of high-titer anti-a /b in group o platelet products. charles k. childers* , mark destree , ashley rose and theresa nester , . madigan army medical center, bloodworks northwest, bloodworks nw, dept of laboratory medicine, university of washington background/case studies: with platelet substitution policies, minor aboincompatible platelets (where donor's plasma may contain antibodies to recipient's red blood cells) are often issued in an effort to best utilize the community supply. however, rare reports of acute intravascular hemolysis have been reported from such transfusions, and can be attributed to high anti-a or anti-b titers, typically in a group o donor. one method to reduce the risk of hemolysis is to identify high titer platelet units prior to transfusion with a subsequent intervention. the percentage of high titer anti-a /b in group o platelet products is presented from a large regional blood center collected over - months. data from both pre-storage pooled platelet units (pspp) and apheresis derived platelet units (aplt) is shown. study design/method: platelet component samples were collected in ml edta sample tubes. a single : dilution of plasma was prepared using a hamilton microlab series dilutor using . ml saline diluent and . ml platelet component sample. using a standard transfer pipette, two drops of diluted sample were transferred to each reaction tube along with one drop of a or b red blood cell reagent. reaction tubes were centrifuged immediately in a serological centrifuge at rpm for seconds. reactions were read using a lighted agglutination reader. the presence of macroscopic agglutination (weak or greater) with either the a cells or b cells was recorded as a positive reaction, indicative of a high titer anti-a or anti-b. retesting of samples was performed to confirm high titers. results/finding: the above results indicate that, when a titer cut-off of is used, approximately % of group o apheresis platelets will have a high titer, most commonly with anti-a . less than half of a percent of pspp units will have a high titer. testing units for the titer can help to change abo out-of-group platelet substitution policies. in our example, the bloodworks transfusion service was able to change from a policy of volume reducing any group o apheresis platelets being issued to a group a or ab patient, to giving high titer products to only group o patients. the subsequent decrease in episodes of volume reduction helped to improve overall availability of apheresis platelets, by maintaining their day outdate. after months of testing pspp units and verifying that the products rarely had a high titer ( . %), the blood center stopped performing this testing for pspp units. rh ) ] started complaining of worsening back pain two and half hours after receiving one unit of rbc for a drop in hematocrit to % (from % on the previous day). his hematocrit did not increase ( %), and over the ensuing hours, he became anuric and jaundiced. clerical checks confirmed that his forward type was a positive, which was also the type of the rbc unit transfused, but revealed anti-a at a titer of in his plasma. furthermore, the direct antiglobulin tests (dat) were positive for c in the pre-and post-transfusion blood samples. anti-a was not detected in his plasma collected three days earlier, however. although his plasma color was amber, he had signs of intravascular hemolysis: undetectable haptoglobin, increased lactate dehydrogenase (ldh) and total and indirect bilirubin results/finding: the positive dat in the pre-transfusion sample pointed to ongoing hemolysis prior to the transfusion of the a rbc unit. in the setting of recent abo-mismatched transplant, his picture was consistent with hemolysis from newly formed anti-a by proliferation of donor lymphocytes, or pls. we performed an emergent rbc exchange using o rbcs with a goal hematocrit of % while reducing the number of a rbcs in his circulation by approximately %. his pain improved rapidly thereafter, and he had complete recovery of renal function. conclusion: pls should be in the differential diagnosis when suspecting/ investigating clinically significant hemolysis in abo-mismatched hpc transplant recipients, especially when the hpc source is from peripheral blood. as in our patient, it usually takes - days for antibodies to develop and they are short-lived ( - weeks). due to the severity of his manifestations, we performed an emergent rbc exchange successfully. furthermore, this patient's event exposed a vulnerability in our system of issuing the proper blood type for abo-mismatched transplant recipients, which has since been remediated electronically background/case studies: group o rhd negative (oneg) red blood cells (rbcs) are a precious resource. to conserve the oneg inventory while minimizing the risk of rhd alloimmunization in oneg females of childbearing age, transfusion services may automatically provide group o rhd positive (opos) rbcs to rhd negative males and/or rhd negative postmenopausal females during bleeding emergencies. despite these conservation strategies, shortages of oneg rbcs occur. the goal of this study was to determine how the utilization of oneg rbcs can be optimized using agebased opos switching for routine transfusions in oneg patients. study design/methods: recipient age and abo/rhd group were obtained for all allogeneic rbc transfusions during the calendar year from hospitals. an additional hospital* provided data for august-december . rbc transfusions in patients < year of age, and in patients whose age and/ or abo group were unknown, were excluded from analysis. the abo/rhd group of each rbc unit was compared to that of the recipient to determine the number of oneg rbcs transfused to all patients, the number of rbcs transfused to oneg patients and the number of oneg rbcs transfused to oneg patients. the number of oneg rbcs transfused specifically to oneg patients >/ years was also determined. results/findings: see table . the fraction of all transfused rbcs that were oneg ranged from - % (row f). the percentage of oneg rbcs transfused to oneg patients ranged from - % (row g); thus, non-oneg patients received - % of the oneg units transfused (row h). hospitals differed widely in the practice of issuing oneg rbcs to oneg patients ( %- %; row i). overall use of oneg rbcs could have been reduced by %- % if opos units had been given to all oneg patients >/ years old (row j). conclusion: during times of oneg shortage, age based opos switching rules may be applied for routine transfusions. this would help to ensure the availability of oneg rbc units for oneg females of childbearing age. rasha eldeeb mohammed* , nehad mohammed , marwa aly and nashwa fahmy . national blood transfusion services, nbts background/case studies: sensitization to the transfused red cell may complicate further transfusion& make it increasingly difficult to find compatible blood components for those patients. splenectomy has been shown to increase human leucocyte antigen immunization. the aim of the study is to evaluated the effect of splenectomy on the occurrence of red cell alloimmunization in humans. study design/method: this study was conducted on multitransfused patients who received blood transfusion chronically at our central blood center. they were thalassemia patients ( bthalassemia patients, one patients with a thalassemia), sickle cell anemia patients and immune hemolytic anemia patients ( auto immune hemolytic anemia patients, one paroxysmal nocturnal hemoglobinemia patient, one immune thrombocytopenic purpra patients). oncology patients, chronic diseases patients. history and demographic data were documented. all the patients who received blood are examined for the presence of the spleen.our patients were subjected to direct & reverse blood grouping (abo& rh) tests, alloantibody screening and detection. results/finding: statistical study is done to determine what is the effect of splenectomy in increasing the rate of red cell sensitization in chronically transfused hemolytic patients. the study revealed that: out of ( %) alloimmunized patients and out of ( %) non alloimunized patients(p< . ) . statistical analysis show that there is high statistical significant difference between patients who performed splectomy& who did not perform splenectomy as regard form conclusion: patients who had splenectomy had a higher alloimmunization rate removal of the spleen is not recommended in those patients who are periodically in need of blood and blood components. restrictive transfusion triggers rather than specific evidence. therefore, two systematic reviews of a) rbc transfusion guidelines and review articles to determine if single or multiple unit transfusion strategies are recommended and b) to identify studies comparing strategies were performed. study design/method: methods medline, embase, cinahl, web of science, national guideline clearinghouse, and the trip database were searched from inception to june . screening and data abstraction were done independently by two assessors. for review a, the proportion of articles with recommendations and articles recommending single unit strategies were assessed; stratified by guidelines, systematic reviews, and other review articles. for review b, the primary outcome was rbc utilization. secondary outcomes included proportion of units transfused using a single unit strategy, length of stay, and mortality. meta-analysis was done using the mantel haenszel random effects model. results/finding: review a identified articles for data abstraction, where articles were transfusion guidelines. there were guidelines ( %) that made a recommendation, for a single unit and for multiple unit transfusion strategy (table ) . review b identified retrospective cohort studies that were eligible and data abstraction was performed. all utilized a policy encouraging single unit transfusion strategies and compared a pre-implementation period to a post-implementation period. meta-analysis could only be performed on the secondary outcome of the proportion of units transfused using a single unit strategy, which was higher after the policy intervention (or . , % ci . - . ), although heterogeneity was high (i %). conclusion: our systematic reviews demonstrated a lack of recommendations amongst guidelines pertaining to transfusing single units of rbcs and only a few retrospective cohort studies to support benefits of the use of single unit transfusion strategies. additional high quality studies are needed to identify the benefits of a single unit transfusion strategy and when it should be used. guidelines groups should review research in this area to determine if a recommendation can be made. background/case studies: platelets made with platelet additive solution c (pas c) and treated for pathogen reduction (pr) have been shown to have decreased post transfusion platelet counts from platelets stored in all plasma. with the advent of multiple types of platelets, we are evaluating whether a mixed platelet inventory has had an effect on component use. the literature from europe has shown that platelet and red cell use does not increase when pr and pas products are used. evaluation of rbc use at our institution has shown no change in the number of products transfused per patient per month. we are evaluating whether the mixed inventory has led to more platelet transfusions. study design/method: we looked at occasions when patients received all of their platelet transfusions on a single day. by doing this we were able to exclude refractory patients from the analysis. the information obtained from routine quality management audits of transfusions between december and february was used for this analysis. the information included the ordering service, product release time, product code, pre and post counts. statistical analysis was performed using minitab. results/finding: during the months, units of platelets were transfused to recipients. over the months, a median of units was given to each patient with a range of to . the overall distribution of products used was % plasma, % pr, % pas f and % pas c. thirty percent of patients (n ) received all of their products on a single day. single units were given to patients while , and received , , and units respectively. the distribution by product type was % plasma, % pr, % pas c and % pas f. this same percentage was present for single and multiple products and was not statistically significantly different from the overall distribution of the products given during the month period (p . ). the distribution by service was different for the groups receiving multiple units. for single units the distribution was % hematologic malignancy, % infusion clinic (nos), % solid tumor medicine, % surgery, and % pediatrics. for those receiving multiple units the distribution was % surgery and % each for solid tumor, hematology and infusion (nos). the chi-square test for associations showed the increase in multiple units to surgical patients to be significant with a p value of . . conclusion: the distribution of the type of platelets given during a single event of transfusion was not significantly different from the overall distribution of platelets given during the month period. the patient's clinical service was a better predictor of the use of multiple products than the type of product given. this suggests that surgical losses or the need to have a higher platelet count during a procedure was the leading factor in the use of multiple products in this transfusion scenario. the effect of red blood cell transfusion on iron metabolism in critically ill patients margit boshuizen* , , yvemarie b.o. somsen , maike e. van hezel , marleen straat , robin van bruggen and nicole p juffermans . sanquin research and landsteiner laboratory, academic medical center background/case studies: anemia of inflammation (ai) has a high prevalence in critically ill patients. in ai, iron metabolism is altered, as high levels of inflammation-induced hepcidin reduces the amount of iron that is available for erythropoiesis. ai is treated by red blood cell (rbc) transfusions. it is known that rbc transfusions increase iron level in neonates and thalassemia patients, but the effect of rbc transfusion on iron metabolism during inflammatory processes is unknown. since one unit of rbcs contains mg of iron and % of the rbcs are cleared by macrophages within hour following transfusion, rbc transfusion could increase iron levels and iron availability for erythropoiesis. we investigated the effect of rbc transfusion on iron metabolism in icu patients, and additionally compared the effect in septic patients to non-septic patients. study design/method: in a prospective cohort study in icu patients who received one rbc transfusion, different iron parameters were measured before and hours after transfusion, to determine the effect of a rbc transfusion over a period of time. next, the impact of a rbc transfusion on plasma iron parameters in septic patients compared to that in non-septic patients was analyzed. plasma iron concentration, transferrin (saturation), ferritin, haptoglobin, hepcidin and il- levels were determined. results/finding: in this cohort, serum iron levels were low and did not change following transfusion ( . vs. . mmol/l, p . ). also, the transfusion had no effect on transferrin saturation ( vs. %, p . ), ferritin ( . vs. . mg/l, p . ) and il- levels ( . vs. . pg/ml, p . ). hepcidin levels increased in these icu patients after rbc transfusion ( vs ng/ml, p . ). in septic patients, rbc transfusion induced a decrease in haptoglobin levels compared to baseline, which did not occur in non-septic patients (- . vs. . % change, p . ). other iron parameters did not differ between septic and non-septic patients. conclusion: transfusion of one unit of rbcs does not increase iron levels in icu patients. the increase of hepcidin suggests rbc transfusion induced upregulation of hepcidin, despite the absence of a significant increase in il- or plasma iron levels. this increase in hepcidin levels after transfusion can potentially further hamper iron availability for erythropoiesis. in sepsis, rbc transfusion decreases haptoglobin levels, suggestive of hemolysis. in conclusion, rbc transfusion might have a negative effect on erythropoiesis, due to the increase in hepcidin levels that are observed after transfusion. the effects of pas and pr on platelet use barbara mendez, judith delmonte, elizabeth mccabe and joanne becker*. roswell park cancer institute background/case studies: with the anticipated release of the fda guidance: bacterial risk control strategies for blood collection establishments and transfusion services to enhance the safety and availability of platelets for transfusion, the use of pathogen reduced platelets (pr) which are often produced from products made with platelet additive solution (pas) may become more common. our institution has been transfusing platelets made with additive solutions since and pathogen reduced platelets have been available since . in our data validating pas and pr, the post counts from transfusion of pas-c and pr products have been statistically lower than platelets in all plasma (pp) or pas f products. our study looks at whether this difference has led to a corresponding increase in the number of units of platelets transfused. study design/method: the data was obtained from the routine quality reports produced for the blood utilization committee at our facility between and . during this time pas c, pas f and pr went from % to % of all platelet products given. all recipients had an oncology diagnosis. the data collected included the service, unit number and product code. the number of unique recipients was determined monthly. the data was converted to plt/month/recipient for analysis. statistical analysis was performed using the two sample t-test results/finding: the data was normalized to plt/recipient/month. in patients received an average of . units/recipient/month and in the average was . units/recipient/month. the intervening data points for , , and were . , . , and . respectively. the year average was . . the slope of the graph for all points was y - . . . the two sample t-test showed that the plt/recipient/month from to was not statistically different with a p value of . . conclusion: the implementation of pas and pr platelets in the oncology environment has not increased in the number of platelet transfusions given. in additional analysis, the red cell use has decreased (data not shown). this can be interpreted as indicating that patients have not had increased episodes of bleeding. although the post platelet count from pas/pr platelets may be lower, we do not have evidence from our platelet transfusion data that this is leading to clinical outcomes necessitating additional products to be given. background/case studies: it is reported that the incidence of alloimmunization in aml patients is unrelated to the number of transfusions the patient receives and most patients who have hla antibodies do not exhibit platelet refractoriness. many cases are also found not to have any anti-platelet antibodies detectable by standard laboratory tests. recent data in leukemia and hematopoietic stem cell (hsct) recipients transfused exclusively with leukoreduced products show that % to % develop alloimmune platelet refractoriness. objective: to determine an improvement in platelet count with the match grade and/or the abo blood group of the hla matched platelets in highly alloimmunized patients with concomitant non-immune causes for platelet destruction. study design/method: clinically documented platelet refractory patients, who received hla matched irradiated sda platelets with their hla typings for hla-a/-b and hla antibody identification were reviewed. there were two strategies utilized, the hla strategy (matching recipient and donor hla-a/ -b types) and the antibody specificity prediction (patient provided with platelets from donors lacking only those hlas to which the patient had antibodies) strategy. statistical analysis: a one sample t-test using minitab statistical software was performed comparing the mean against a platelet increment of a hypothetical difference of at least k/ul. the analysis revealed that the mean of . k/ul (n ) had a percent lower bound confidence interval platelet increment of k/ul (p< . ) results/findings: (median range [ - ]) hla matched leucoreduced irradiated sda platelets were transfused to ( m/ f) patients, median age years (range - ). / ( %) patients showing broad alloimmunization to hla class i/class ii antigens. / ( %) patients had anti-hpa antibodies (gp iib/iiia and gp iib/iiia and gp ia/iia). the majority / ( %) had a diagnosis of hematologic malignancy (aml/mds/mpn/ cmml/mm); / ( %) female patients had prior exposure via pregnancy and / ( %) had a history of hsct. ( %) platelets were abo identical-platelet increment median k/ul (range - to ), ( %) were abo compatible -platelet increment median of k/ul (range - to ) and ( %) were abo incompatible with platelet increments median k/ul ( range - to ). platelet counts were performed within hours in ( %) transfusions. the hla match grade of the transfused platelets were as follows: the use of massive transfusion protocol (mtp) in a community hospital rohini patel* , renee leblanc , dongfu xie , alice cabe and yanyun wu . overlake hospital, bloodworks northwest the use of massive transfusion protocol (mtp) in a community hospital background/case studies: the establishment and use of massive transfusion protocol (mtp) have become common practice, especially in trauma centers and tertiary hospitals due to significant number of patients with massive bleeding. however, it is not well established if the use of mtp also has value in small hospitals and community hospitals, and how mtp is used in fig. these settings, such as indication for mtp, blood products used, and the outcomes of these patients. study design/method: retrospective review of transfusion data from a community hospital with a bed size of about for years (from to ) was performed. patients with mtp requested are included in this study. results/finding: please see the table below for the summary of data. notably, patients with gi bleed and ob bleed are the two most common indications for mtp, and % of patients survived with the support of mtp. in one case, no blood product was used. the establishment and readiness of mtp can be very important in supporting patients who experience massive bleed in small hospitals and community hospitals. in these settings, mtp is most commonly used for patients with massive gi bleed and ob bleed. if the patient develops antibodies to a high incidence antigen, finding compatible units may become impossible. included in the mns system, and residing on glycophorin b (gpb), the u antigen is absent in less than . % of the black population. those with altered forms of gpb, known as u variants, can produce a diverse group of antibodies capable of causing mild to severe hemolytic transfusion reactions and hemolytic disease of the fetus and newborn (hdfn). this case illustrates the balance between the need to transfuse and avoiding complications thereof. a -year-old ghanaian woman with scd and history of chronic transfusion presented with diffuse pain and a hemoglobin value of . g/dl (baseline - g/dl). she is known to be e, c, k, fya, jkb, s, s negative, u variant, and has anti-e, c and u antibodies. there were no eligible family donors and a nationwide search for compatible blood yielded four crossmatch compatible u variant units. the decision to transfuse was made. the patient had no change in symptoms or vital signs during transfusion but post-transfusion hemoglobin was . g/dl. a transfusion reaction work-up was ordered. post-transfusion serum sample was negative for hemolysis and no new antibodies were identified. the post-transfusion dat was weakly positive only with complement and laboratory data revealed a decrease in total bilirubin ( . to . mg/dl). two additional u variant, crossmatch compatible units were transfused over the next two days restoring her hemoglobin to . g/dl. the patient was discharged to home in stable condition and follow-up hemoglobin levels continued to rise back to baseline. study design/methods: molecular genotyping was used in donor unit selection prior to compatibility testing by transfusion services. conventional methods were used to monitor the patient's condition pre and posttransfusion. results/findings: each donor unit came from a different donor but all were the same gpb genotype as the patient. the patient did not experience an acute or delayed hemolytic transfusion reaction and genotype matching successfully facilitated donor unit selection in this case. conclusion: transfusion of u variant red cells to a u variant patient should be undertaken with great caution due to epitope and antibody heterogeneity. this case highlights the importance of genotype compatibility in selecting donor units for a chronically transfused, scd patient with anti-u. sound transfusion management of such patients requires planning and good communication on the part of clinicians and the laboratory staff. background/case studies: patients with decompensated waiha may require transfusion with red blood cell (rbc) products that are cross-match incompatible due free autoantibodies. the feasibility of blood transfusions in waiha patients is controversial because of difficulty in cross-matching and increased risk of transfusion reactions, since transfused rbcs may be destroyed more rapidly in patients with active hemolysis. to study the actual vs. theoretical risk of increased hemolysis in waiha patients, we investigated the post-transfusion (post-tfn) hematocrit (hct) change in waiha patients who were transfused compatible rbcs compared to those who received li blood. we further hypothesized that a post-tfn hct would be inversely related to the degree of ahg-phase incompatibility. study design/method: we reviewed all transfusions to patients in our quaternary-care hospital with a history of waiha from october to march . patient hcts were ordered by prescribing physicians for clinical purposes. a transfusion episode was defined as all units released in the interval before a post-tfn cbc. ahg-phase crossmatch was tube tested in saline per clinical procedure. transfusion medicine physicians determined the release of least-incompatible units. statistical tests were performed with statcalc (epiinfo, cdc) and www.socscistatistics.com. results/finding: there were rbc products transfused to waiha patients. twenty-three ( . %) patients received at least incompatible unit. the mean age was . years (range - yrs) with % women. ethnic composition was % african-american, % caucasian, and % patients of mixed/other ethnicity. one hundred fourteen ( %) of these products were released as li products and ( %) were compatible. ninetythree ( . %) of the li product transfusions had a post-tfn hct change of < % whereas only ( %) of the compatible product transfusions resulted in a post-tfn hct change of < % (p . , v ( ), exact methods). the mean hct increase in the compatible group was . % per unit vs. a slightly lesser per-unit increase of . % in the li group (p . , t-test, -tailed) within the li group, there was no difference in the per-unit hct change according to strength of incompatibility (table) . strength of ahg incompatibility was not available for units. units that were incompatible had a lower mean post-tfn hct rise compared to all other li units ( . % vs. . %); however, this difference was not statistically significant (p . ). conclusion: the post-tfn hct change for transfusions of li units to patients with waiha was less than the expected % per unit more frequently than it was for waiha patients who received compatible products ( . % vs. %). however, likely due to our small sample size, the mean differences were not statistically significant. interestingly, there was no difference in the per-unit post-tfn hct according to differing strengths of incompatibility in our sample, although the mean increase for the li products was less than all other li products combined. the increase was unexpectedly low for weaklyincompatible units, which we are further studying. future work includes consideration of inpatient vs. outpatient clinical status, effect of co-incident alloantibodies, comorbidities, and medications. transfusion management was summarised by individual hospital, type and total cases. in-hospital mortality (adjusted for age, sex, comorbidity, bleeding context and number of rbcs in the first -hours from mt onset) was calculated with % and . % control limits to indicate potential outliers. data were analyzed using statistical software (stata). results/finding: there were mt cases from hospitals ( tertiarylevel, smaller/medium sized acute-care and specialist women's). number of mt cases per hospital ranged from to . patient median age was years (iqr , ), % were male and % required admission to intensive care. the most common clinical groups were cardiac surgery ( % cases), trauma ( %) and gastrointestinal hemorrhage ( %); however there was marked variation between hospitals. ratios of transfused products, analyzed according to bleeding context, varied between hospital types. the pooled average adjusted in-hospital mortality for the tertiary-level hospitals was % (range % to %) and / ( %) were within the % control limit. cb that required ! rbcs within -hours of mt onset occurred in % of cases. comparison of transfusion management for this subset of mt cases showed that patients treated in smaller/medium sized acute-care were less likely to receive cryoprecipitate than patients treated in tertiary-level hospitals ( % versus %; p . ). conclusion: patient characteristics and transfusion practice varied between hospitals and hospital types, however in-hospital mortality outcomes were comparable. results are made available to participating hospitals in the anz-mtr to initiate discussion, practice review, and examination of compliance with national standards, patient blood management guidelines and to highlight areas for further investigation. data are also available for review by governance and policy bodies at state and national level to support practice improvement activities and highlight priority areas for future research. background/case studies: in hospitals and medical centers, in case of big traumas often an intraosseous entrance via a bone needle is combined with a fast flow fluid warmer. with this, infusion fluids, including blood products, are administered under pressure. this is done because veins of trauma patients are often not suitable for infusion of fluids. suppliers of pump and needles describe the possible transfusion of blood products, but this is mainly limited to plasma and erythrocytes. there is no information available concerning transfusion of platelets under pressure via a bone needle. the aim of the study was to investigate the effects of warming and administration of a platelet concentrate (pc) under pressure via a bone needle on the in vitro quality of platelets. study design/method: pools of bcs and ml of platelet additive solution iii (pasiii) were used to produce pcs (n ). pcs were stored on a flatbed agitator ( cycles/min) in a temperature-controlled cabinet at c for - days. to mimic hospital conditions, pcs were warmed using a blood warmer and transfused via a bone needle to a transfer bag. on the pcs a pressure of mm hg was applied. using clamps, a flow velocity of - ml/minute was realized. platelet quality before and after pressurized simulated transfusion was determined by means of various in vitro parameters. results/finding: due to priming of the transfusion disposable with saline, the pcs were diluted - %, resulting in a significantly increased pc volume and decreased platelet concentration after simulated transfusion. because of loss of platelets in the disposable set, also the total number of platelets was decreased after simulated transfusion. after simulated transfusion, the pcs still fulfilled the requirements for platelet concentration ( . - . x /l) and number (> x /unit). simulated transfusion had no effect on the percentages of cd p and annexin v positive cells, indicating no activation or induction of apoptosis. ph was not influenced by simulated transfusion. due to the dilution effect, glucose and lactate concentrations were slightly lower after simulated transfusion. conclusion: warming and simulated transfusion of pcs under high pressure via a bone needle has no negative effect on the in vitro quality parameters of platelets. transfusion of warmed pcs via an intraosseous entrance via a bone needle is not expected to have a negative effect on the in vivo functionality of platelets. it is recommended to study the in vivo effects in a limited clinical study. alesia kaplan* , , joan sevcik and joseph e. kiss , . university of pittsburgh, blood systems inc. background/case studies: low titer a plasma has been safely used as a substitute for ab plasma in trauma patients. low inventories of ab plasma can cause a delay in life saving therapeutic plasma exchange (tpe) procedures in ab patients needing plasma replacement. here, ab non-bleeding patients are presented who safely received ab and low titer a plasma for tpe. one ab patient who received ab plasma only was used as control to compare hemolysis laboratory data over tpe course. study design/method: a retrospective review of tpe procedures for patients was conducted from medical records. number of procedures, volume replaced, total number of plasma units, number of a plasma units, quantity of a plasma and hemolysis laboratory data were recorded. average quantity (ml) for a plasma and % of a plasma out of total volume of plasma used were calculated. all a plasma units were low anti-b titer units. in the laboratory, plasma dilution : is prepared and tested with reagent b cells. if agglutination is not observed, the unit is labeled as "low titer anti-b". hemolysis laboratory data was traced with linear graphs and trends were compared between patient and and (control). results/finding: all patients were ab blood type. patient , a year old female with recurrent adamts deficient ttp, received courses of tpe (total tpe procedures) for relapse and exacerbation. ten out of procedures were performed with ab and a plasma (average ml of a plasma or % of total plasma volume for tpe procedures). patient , a year old female with thrombocytopenia, schistocytes and presumed ttp, received a total of tpe procedures. four out of procedures were performed with ab and a plasma (average . ml of a plasma or % of total plasma volume for tpe procedures). patient , a year old female with adamts deficient ttp who served as a control, received a total of procedures with ab plasma only. haptoglobin, ldh, hemoglobin and total bilirubin were graphed and compared between patients. the trends of hemolysis laboratory data for patient and were comparable with patient . all patients had negative dat. only patient received rbc transfusions. all patients had a favorable clinical outcome with tpe treatments and adequate platelet recovery. conclusion: in this study, tpe was effectively performed without evidence of increased hemolysis using up to % of low titer a plasma. this approach can reduce strains on limited supplies of ab plasma while providing a vital treatment alternative for ab patients undergoing tpe who require plasma replacement. when cd negative platelet unit is not available for a patient with anti-cd antibodies sameer khatri* , charles harmon , brian r curtis and chisa yamada . background/case studies: refractoriness to platelet (plt) transfusion can be caused by antibodies (abs) against human leukocyte antigen (hla) class i antigens (ags) or less frequently against plt specific ags (psas). glycoprotein iv (cd ) is one of the identified plt surface ags and deficiency is rare, but found in asians ( - %), sub-saharan africans ( - %) and also in some people from mediterranean descent. two types of cd deficiency have been described. type deficiency is the complete lack of cd on both plts and monocyte-macrophages whereas type deficiency lacks cd on plts with variable expression ( - %) on monocytemacrophages. transfusing plts in a patient with cd deficiency is challenging given the rarity of cd negative phenotype and risk of further immunization when giving ag non-matched platelets. study design/method: a patient with cd negative phenotype who received multiple plt units was reviewed in the electronic medical record. results/finding: a year old man developed aplastic anemia following liver injury possibly due to a supplement for body building and required multiple plt and rbc transfusions. he received more than units of apheresis plt units over a week period without any significant increase in plt count. cross-match compatible plt unit found in of units and hla matched units were tried without success. at that point, a cd ab was identified in the serum and the patient's type cd deficiency was confirmed by flow cytometry. his hla class i panel reactive ab (pra) was % due to multiple plt transfusions, although all abs were low levels. the patient initially received high-dose prednisone and thymocyte immune globulin infusions without significant improvement in plt increase. following three doses of ivig, he received a cd- negative (but blood type different and hla a transfusion vol. supplement s unmatched) plt unit from his relative with only a slight increase in plt count. however, he started to respond to cd non-tested apheresis plts after receiving a fourth ivig and two rituximab infusions. since then, he has received ivig every weeks. other medications include filgrastim, eltrombopag, and cyclosporine for treatment of aplastic anemia. the mean corrected count increments (cci) when post-transfusion plt count was available are shown in table. with desensitization therapy, his cd antibody positive reactivity in serial dilutions has reduced from : to : dilutions and his hla class i pra has decreased to %. he is currently receiving apheresis plt units twice a week and rbc units periodically. his bone marrow (bm) has been slowly recovering evidenced by increased wbc count from zero to up to . k/ml and slow increase of reticulocyte counts. current plan is rbc/plt transfusion support until bm recovers or a haplo-identical transplant if bm recovery fails. conclusion: we report a case with anti-cd abs that received multiple plt transfusions. this case demonstrates that decreasing ab level with immunomodulation can be an alternative option for successful plt transfusion when compatible plts are not available for patients with rare or multiple abs to plts. table: mean available cci for plt transfusions a blood center's experience screening donations for babesia microti using enzyme-linked immunoassay methodology nancy van buren*, jed gorlin, vanessa reynolds and deborah anderson. background/case studies: our blood center, located in an area considered to be moderately endemic for babesia microti, implemented universal screening of red cell collections from minnesota and wisconsin under an investigation new drug (ind) study in oct utilizing the immunetics investigational enzyme-linked immunoassay (elisa) performed by creative testing solutions (cts). this test was selected as the most cost-effective approach for universal screening of blood donors, as opposed to the investigational ifa/pcr test combination. study design/methods: we performed a retrospective analysis of our screening test results and deferral rates for to evaluate for seasonality, donor abo bias, deferral rates, and outcomes of lookback investigations. since an opt-out of this research test was originally offered, we report donor opt-out rates. results/findings: from jan through dec , , blood donations were screened for b microti by immunetics elisa. of those, ( . %) were positive. the percent of positive donations was evaluated monthly revealing a variable reaction rate between . % and . %. no patient babesia transmission has been reported since implementing this test, but we only had documented babesia ttd cases from - . donors who previously tested negative demonstrated an increased seroconversion rate during the summer months, consistent with historical seasonal variation corresponding with tick season in minnesota and wisconsin. test performance characteristics were analyzed by abo group with no demonstrable differences in positive rates. the opt-out rate of donors who chose not to be tested significantly decreased over time, reflecting an increased acceptance of this test. of positive test results, lookback investigations were initiated representing % of positive donations. lookbacks were only performed when there was a donation within months of the new positive screening test, according to ind protocol. no confirmatory testing was performed per ind protocol or for donor counseling, so the true positive rate is unknown. in the prior ind trial, up to % were unlikely to transmit infection in our region, i.e. were pcr and blood smear negative. although a small number of antibody positive, pcr negative donors may be actively infected, no transfusion-transmitted babesia infections were identified by lookback investigations. notification of blood donors with positive screening results was also performed and information provided for healthcare provider followup. overall, donor deferral represented . % loss of eligible donors during this follow-up period. deferred donors were invited to participate in other research collections not requiring volunteer donor eligibility. conclusion: testing for b microti may help improve blood safety, particularly in endemic regions. although only . % of donors have a positive reaction, this represents a significant loss of eligible donors over time, most of whom are unlikely to transmit infection. a direct test capable of detecting babesia in individuals with very low levels of organisms without the need for concurrent antibody testing would be ideal. a reinstatement protocol for donors who test positive should also be considered. nonetheless, the current method of screening is inexpensive compared to pcr-based methods. background/case studies: human anelloviruses are the smallest in particle size, smallest in genome size, and least complex in genetic organization of all human pathogens. they establish a chronic persistent infection in infancy or early childhood and produce a constantly detectable load in plasma thereafter. some studies suggest they are ubiquitous, present in > % of the human population, and that immune surveillance is required to control the level of the virus load. study design/methods: we have developed a quantitative dna pcr assay for the most conserved region of the anellovirus genome that detects all known genotypes of the virus. we used this assay to examine viral loads in the plasma of us blood donors and transplant recipients pre-transplant and three months post-transplant. results/findings: for blood donors, were positive with an average load of . x copies/ml of plasma, a median value of . copies/ml of plasma, ranging from to . x copies/ml. pre-transplant viral loads were similar. for transplant candidates, were positive with an average of . x copies/ml of plasma, a median value of copies/ml of plasma, ranging from to . x copies/ml. post-transplant viral loads were remarkably different. for transplant recipients, all were positive with an average of . x copies/ml of plasma, a median value of . x copies/ml of plasma, ranging from to . x copies/ml. conclusion: these results validate the pcr assay that was developed and confirm that detectable viral loads of around - copies were present in > % of the blood donors surveyed. in addition, the effect of post-transplant immunosuppressive therapy has caused an increase in the viral load of at least orders of magnitude above that of non-immunosuppressed individuals. background/case studies: the screening of blood donors and travelers returning from endemic/epidemic areas has highlighted the importance of multiplex diagnostic approaches for the simultaneous analysis of various pathogens. furthermore, in the context of similar clinical signs, the differential diagnosis of arboviruses during acute infection is essential to discriminate the causative agent for patient management and epidemiological surveillance. the development of a flexible diagnostic approach is a key challenge to face the continuing emergence of arboviruses, belonging to flavivirus and alphavirus, such as dengue virus (denv), west nile virus (wnv), zika virus (zikv), yellow fever virus (yfv), usutu virus (usuv) and chikungunya virus (chikv). study design/method: an innovative diagnostic approach combining generic rt-pcr amplification and identification on low cost microarrays has been developed. we have patented original polythiolated probes grafted on maleimide-activated microplates for the robust, sensitive and specific mean cci pre-ivig: all plt ( ) . post-ivig: all plt ( ) . post-ivig: cd -negative plt from relative ( ) . post-ivig: single donor apheresis ( ) . post-ivig: cross-match compatible ( ) . post-ivig: flow cross-match compatible plt ( ) . a transfusion vol. supplement s detection of the viral genomes. analytical performances of the test were evaluated on viral standards and on clinical samples: denv ( / / / ), wnv, zikv and chikv. forty human plasmas from blood donors with no history of contact with arboviruses were used as negative controls. we have designed two sets of degenerated primers for the generic rt-pcr amplification of all flaviviruses and for chikv. biotinylated amplicons were captured on complementary grafted polythiolated probes on microplate. after addition of streptavidin-europium label, the molecular hybridization events were detected by time-resolved fluorescence using a microplate reader. results/finding: one original generic probe for denv and specific probes designed for each of the four denv serotype, wnv, the two zikv lineages and for chikv, were validated. the use of our methodology combining the amplification of the viral genomes and their identification using polythiolated probes shows % of specificity, with no false positive results on the control samples, and no cross reactions. using viral reference standards, we have observed sensitivities of tcid /ml for denv- , denv- and chikv and of tcid /ml for denv- , denv- and zikv. finally, the first results obtained on denv( ), zikv( ) and chikv( ) clinical samples show %, % and % correlation respectively between our approach and commercial or in house real time rt-pcr methods. conclusion: this innovative strategy allows the development of flexible, highly sensitive and easy to handle platforms dedicated to the multiplex screening and identification of emerging viruses. this methodology is adapted for the easy inclusion of additional molecular targets to improve the surveillance and the prevention of arboviral infections. babesia microti serological testing with pooled samples: a feasibility study laura tonnetti*, aaron thorp, letitia dixon and susan l stramer. background/case studies: blood donation screening for babesia microti, a tick-borne intraerythrocytic parasite endemic in the northeast and upper midwest us, is performed under an investigational study using nucleic acid and immunofluorescence assays (ifa). however, ifa is a time consuming and labor intensive procedure. with the possibility of an fda licensed screening assay(s) in the near future, we investigated if b. microti testing by ifa in pools of plasma or serum could be a feasible screening approach. study design/method: to test if the increased amount of plasma or serum interferes with background fluorescence, pools of , , and were prepared from plasma or serum samples determined to b. microti-negative by individual ifa screening. the pools were tested by ifa with or without a blocking step using bovine serum albumin (bsa) and goat serum to minimize background fluorescence. potential interference from multiple pooled plasma or serum samples on the endpoint titer of positive samples was investigated by including positive samples with endpoint titers from : to : ( -fold dilutions) in the pools. results/finding: non-specific fluorescence was visible in pools of or higher and was not eliminated by the addition of a blocking step. pools of or samples did not show significant increased background. there was no difference between testing of pooled serum or plasma samples. when one single positive sample was included in the pools of or samples, the pool tested positive and the final titer was the same as the positive sample tested individually. when two or more positive samples were included in the pools, the final titer of the pools was equal to the sample with the highest titer. conclusion: this study represents a proof of concept that serological testing for b. microti by ifa in pools of up to plasma or serum samples does not increase false positivity while maintaining the sensitivity of the test. background/case studies: the rapid detection of bacterial contamination in platelets is key to reducing the risk of infection in transfusion of blood components. the bact/alert virtuo* is an advanced, next generation system with improved automation, connectivity and with data management systems. the virtuo's new algorithm significantly reduces the time to detection (ttd) of microorganisms during quality control testing of platelet preparations using bact/alert (bta) bpa (aerobic) and bpn (anaerobic) bottles. as plasma is known to be bactericidal, a study was completed to evaluate plasma susceptibility/resistance for organisms considered for virtuo studies. study design/method: human plasma (thawed and pooled) and saline controls were seeded with $ cfu/ml of organisms associated with platelet contamination and incubated at room temperature for - hours. colony counts were performed initially and after incubation. plasma resistance was determined if the colony count of the seeded plasma was equivalent or higher ( log) than the colony count of the seeded saline after incubation. results/finding: the serially diluted strains and all bioball tm strains except p. aeruginosa, nctc , were determined to be plasma resistant. the bioball tm p. aeruginosa was susceptible to the antimicrobial effects of human plasma, but when spiked into ml of leukocyte reduced apheresis platelets (lrap) and inoculated into bta bpa bottles and loaded into the bta d and virtuo the organism was recovered % . conclusion: results confirm that previously tested organisms and additional strains are plasma resistant with the exception of p. aeruginosa, nctc . however, the bpa bottles still recover p. aeruginosa in the presence of lrap. bpa/bpn bottles inoculated with select organisms from this panel in the presence of ml lrap demonstrated % recovery when loaded onto the virtuo and d ( table ) . further studies may be required to determine if higher test volumes of lrap could affect the recovery of plasma sensitive strains. * virtuo is not fda cleared for platelet testing a. notoscriptus, identified as a major urban vector of rrv, is also capable of transmitting dengue virus - , and has recently been found in los angeles, illustrating an expansion in range. with the growing geographical distribution of aedes species mosquitoes, the potential for rrv to enter local transmission cycles outside of australia is significant. in , a probable transfusiontransmission (tt) was confirmed as the cause for an rrv infection in australia, validating the reality that rrv tt can occur. rrv morbidity leads to clinical manifestations that are similar to chikv infection, with varying degrees of arthralgia, which can become debilitating. various asymptomatic to symptomatic infection ratios have been reported, but this further increases the risk of additional tt in endemic areas and could mask the spread of the disease globally. study design/method: platelet concentrates (pc) prepared in pas were inoculated with rrv, amotosalen was added to final concentration of mm and the units were treated with uva light. pre-and post-treatment illumination samples were collected for titration. as- rbc units were contaminated with rrv, mixed with processing solution/glutathione (gsh) and treated with amustaline at a final mm concentration. pre-and post-treatment samples were removed prior to amustaline treatment and hrs after amustaline addition, respectively, for titration by plaque assay on vero cells. log reduction was calculated as the difference between the mean infectious titer in pre-vs. post-treatment samples. results/finding: inactivation of rrv was achieved to the limit of detection in pc and rbc. in pc, > . log or log /ml of rrv was achieved, with > . log or > . log /ml of rrv inactivated in rbc. conclusion: these studies illustrate that amotosalen/uva and amustaline/ gsh treatments are effective at inactivating rrv in pc and rbc, respectively. these data corroborate previous results achieved with other alphaviruses, including chikv and mayaro virus which are inactivated at high titers in pc and rbc, demonstrating the ability for these systems to mitigate tt potential and maintain safe blood component availability in endemic areas. (data have not been submitted for fda review and intercept for red blood cell is not approved for commercial use). background/case studies: the interceptv r blood system for platelets is designed to inactivate pathogens and contaminating leukocytes. this photochemical treatment process utilizes amotosalen and low energy ultraviolet a (uva) light. the current available sets include small volume (sv; - ml), large volume (lv; - ml) and dual storage containers (ds; - ml) designed to treat platelet doses between . and . x . the new triple storage (ts) set was designed to expand the dose range to . x and the maximum volume to ml, generating either or doses of pathogen reduced platelet components (pc). the objective of this study was to evaluate the effectiveness of the system by performing log reduction assays using representative gram positive and negative bacteria and enveloped and non-enveloped viruses in platelets suspended in pas, or % plasma using ts set. study design/methods: for each experiment, a platelet pool was prepared either in % plasma/ % pas or % plasma with a final volume of $ ml and a dose of - platelets. these conditions represent inactivation using the lowest amotosalen concentration ( mm) and highest concentration of platelets. platelet units were inoculated with high titers of viruses, or bacteria and treated. control (pre-uva) and test (post-uva) samples were serially diluted and cultured. plates with suitable media were used for bacteria, whereas viral titers were determined using plaque assays. log reduction was calculated as the difference between the log titers in control (pre-uva) and test (post-uva) samples. conclusion dromedary camels were identified to be the reservoir of mers cov, transmission to humans occurs through direct and indirect contact. mers cov has been detected with high genomic titers of - logs in respiratory secretions of mers patients, and with lower genomic titers of - logs in blood. the presence viral particles in the blood of acute patients gives rise to concerns, especially in endemic areas. the high mortality rate, especially for critically ill patients, which often require blood transfusion, raises the need for a method to safely exclude mers cov contamination of blood products. pathogen reduction with amotosalen/uva technology is a widely established technology with a broad range of data supporting clinical efficacy and safety of amotosalen/uva treated blood products. the aim of the study is the assessment of the mers cov inactivation efficacy in human plasma with amotosalen/uva pathogen inactivation technology to safely exclude the presence of infectious virus in human plasma units. pre-uva titer post-uva titer log reduction/ml (log /ml) %plasma/ % pas e .coli . <- . > . e. cloacae . <- . > . k. pneumoniae . < . > . s. aureus . <- . > . blue tongue virus . <- . > . bovine viral diarrhea virus . <- . > . adenovirus- . <- . > . %plasma k. pneumoniae . - . > . s. aureus . <- . > . adenovirus- . <- . > . n a transfusion vol. supplement s abstract study design/method: four therapeutic human plasma units were spiked with a fully characterized mers cov clinical isolate followed by pathogen inactivation with amotosalen/uva (intercept blood system, cerus corporation) at four different days. pathogen reduced samples were taken preand post-pathogen reduction after various processing steps to assess the infectious titer by plaque assay titration and the genomic titer by real-time-pcr. samples post pathogen reduction have been passaged times up to days, assessing the infectious titer and genomic titer every rd day to exclude the presence of low-titer infectious particles. results/finding: all viral particles in the plasma units were completely inactivated with an average efficacy of ! . log infectious titer. no viral replication was observed after days of passaging post inactivation. the genomic titer was only slightly affected by pathogen inactivation, which is designed to target the infectious titer, but not the physical titer. conclusion: amotosalen alone had a slight effect on the infectious titer while amotosalen/uva effectively inactivated all infectious mers cov viral particles in the plasma units with an inactivation efficacy above logs infectious titer, giving evidence for improved blood safety of amotosalen/uva treated plasma in mers cov endemic regions. estimating the prevalence and incidence in a national blood service in taiwan for hcv eradication program yun-yuan chen* , jen-wei chen , chi-ling chen , sheng-nan lu and pei-jer chen . department of research, head office, taiwan blood services foundation, graduate institute of clinical medicine, college of medicine, national taiwan university, division of hepatogastroenterology, department of internal medicine, kaohsiung chang gung memorial hospital background/case studies: world health organization (who) has set a goal to eliminate hcv by , and the epidemiological indicators generated from a national blood service is useful to monitor the effectiveness. this study aimed to evaluate the prevalence and incidence of hcv infection in taiwan. study design/method: in taiwan, anti-hcv (since ) and -sample mini-pools triplex nucleic acid test of hcv, hbv and hiv (since ) have been used in the routine blood screening. prevalence of anti-hcv and hcv rna were estimated in the first-time donors during - and - , respectively. age-standardized prevalence and its % confidence interval ( % ci) were calculated with adjustment of who world standard population - . for the incidence study, donors who have donated blood two or more times during - and who were without a history of anti-hcv positive before the follow-up period were included. the incidence and its % confidence interval was estimated from the number of new hcv rna positive cases divided by the person-years of follow-up. results/finding: the crude prevalence of anti-hcv in the first-time donors was dramatically decreased from . per , donors ( % ci: . - . ) to . per , ( % ci: . - . ) during - , and the agestandardized prevalence was also decreased from . per , donors ( % ci: . - . ) to . per , ( % ci: . - . ). the agestandardized prevalence of anti-hcv was generally higher in female donors before , but it was significantly higher in male donors at (p-value . ). a total of , hcv rna positive cases, . % of them were anti-hcv negative, identified from , first-time donors during - , and the crude and age-standardized prevalence of hcv rna was . per , ( % ci: . - . ) and . per , ( % ci: . - . ), respectively. crude prevalence of hcv rna was significantly higher in female donors (p value < . ), but no significant difference was found after age standardization (p value . ). both the prevalence of anti-hcv and hcv rna were increased with age (p for trend< . ). in the incidence study, a total of new hcv rna positive cases, . % of them were anti-hcv negative, found from , , donors followed for , , person-years. the incidence of hcv rna was . per , person-years ( % ci: . - . ), and no significant difference was observed between both genders (p-value . ) and between age groups (p for trend . ). conclusion: the prevalence of hcv infection has been dramatically decreased by . % during - . it becomes significantly higher in male donors and that needs to monitor in the future. incidence of hcv rna is low in repeat blood donors and it needs to identify more incident cases to observe the epidemiological characteristics. dalia ashour* , sahar muhmmad and dalia el dewi . national blood transfusion services, azhar university background/case studies: blood safety is a challenge in egypt because of the high prevalence of hcv and hbv. nucleic acid amplification test (nat) technologies have the potential to detect viremia earlier than current screening methods, which are based on seroconversion. the primary benefit of nat is the ability to reduce residual risk of infectious wp donations. the estimated reduction of the wp utilizing nat for hcv is - days, hiv from to days, and hbv from - days. study design/method: this cross sectional study was conducted in national blood transfusion center (giza, egypt) from to , the total number of donor samples to be screened is , the age of the donors ranged from to years, and they were of both sexes (m: f : ).screening by nat ulterio assay (grifols diagnostics; formerly novartis diagnostics) was done in parallel with eia testing for hbsag, hcv-ab and hiv ag/ ab. using individual donation nat (id-nat). multiplex nat yield samples are further tested using the discriminatory assay in order to ascertain which viral nucleic acid is present in the donor sample. statistical analysis chi-square (v ) test was used to measure the association between two qualitative variables. results/finding: nat screening detected a total of nat yield donations among ( . %) seronegative donors. among these nat yields cases, ( . %) were reactive for hbv, ( . %) were reactive for hcv and ( . %) were reactive for hiv- . we stratified the age of the donors into groups; group a ( - years), group b ( - years) and group c ( - years). the prevalence of nat yield to the three viruses was significantly higher in either group b or c, compared to group a (p . ; with % confidence interval (ci) . - . & p . ; with % ci . - . respectively). prevalence of nat-hbv; was significantly higher in age group b, as compared with group a (p . ; with % ci . - . ). on the other hand, there was no statistically significant difference between groups c and a and between groups b and c. comparing groups b and c combined with group a found a significantly higher prevalence of hbv in the former (p . ; with % ci . - . ). nat-hcv; did not differ significantly between the three groups (p . ; with % ci - . to . between groups a and b & p . ; with % ci - . to . between groups a and c & p . ; with % ci - . to . between groups b and c). nat-hiv; did not also differ significantly between the three groups (p . ; with % ci - . to . between groups a and b & p . ; with % ci - . to . between groups b and c). in either group a and c, no nat-hiv detected. nat yield to the three viruses was significantly higher in males than in females (p . ; with % ci . to . ). nat hbv was significantly higher in males (p . ; with % ci . - . ), but the prevalence of either hcv or hiv did not differ significantly between males and females (p . ; with % ci - . - . & p . ; with % ci - . - . ; respectively). conclusion: in this study the nat yield of in assumes more significance when one considers the fact that single donation is used for generating components that can be used by recipients. hence, in effect the nat yield becomes times that is, in . saving recipients from tti out of ( . %) is indeed very significant. results/finding: of the , donors who were tested by our donor center, , ( . %) were repeat reactive. a seasonal pattern in the prevalence was observed with the highest number of donors being positive in summer, and then progressively declining during the fall and winter months and increasing again in spring. there was a single case of transfusion transmitted babesiosis reported from our center during this period. a patient who was transfused with two units of packed red blood cells (rbcs) from two donors in the beginning of july presented in august for further transfusion and was found to have parasitemia in the peripheral blood smear and was subsequently diagnosed with babesiosis. the donors were called back, however one of them could not be tracked. samples were sent to the state for further testing: an immunofluoresence assay was performed (combination of igg, igm and iga). the test was positive at : titer. the screening elia s/co of this donor was . . both donors were indefinitely deferred as blood donors. conclusion: our data confirm a decreased risk in transfusion transmission with the use of a screening assay. prior to implementation of the screening there were - transfusion transmitted babesia cases per year from - (table ). in the months after implementation of pre-transfusion babesia screening, one break through case of transfusion transmitted babesia was observed ( in , donors tested). thus the babesia eia screening test effectively prevents ttb. however, there was a substantial loss of donors due to being screen positive. four years of experience with id-nat at a tertiary care centre in north india: implications for transfusion transmission and donor screening. jasmeet singh*, amarjit kaur, gurpreet kaur, rajesh kumar and sonia gupta. dayanand medical college and hospital background/case studies: transfusion transmitted diseases are a challenge for transfusion medicine specialists and patient care providers around the globe. blood safety is a formidable task especially in a high population country like india. newer technologies like id-nat equip us to screen and prevent transfusion transmitted viral infections and prevent their transmission by improving over the sensitivity and specificity of conventional methods. this study aims at examining the effect of id-nat as an additional test on the safety of blood supply. study design/method: a retrospective observational study was conducted to analyze the data of years of additional nat testing at blood bank, dmch, ludhiana from september to december . results/finding: results . % ( of ) units were initially nat reactive. these units were further tested, of which . % were discriminated ( hiv, hcv, hbv and co-infections). the remaining . % ( ) were repeat non-reactive and . % ( ) could not be discriminated. overall, nat yield rate was one in , whereas virus-specific nat yield rates were one in , for hiv, one in for hcv, one in for hbv and one in , for hbv/hcv coinfections, respectively. conclusion: id-nat screening of all blood donations at our institution over past years has increased the screening sensitivities to check viral load and prevented transmission of probable transfusion transmitted viral infections. assuming % component preparation it saved transfusion recipients from harm. implementation of nat along with routine serological tests for screening of the blood donations definitely improves the transfusion safety and should be mandated across all transfusion centers. min xu , , wei mao , tao he , yashan yang , , zhan gao , , chunhong zhang , hongmei liao , jingxing wang , and miao he* , . institute of blood transfusion, chinese academy of medical sciences & peking union medical college, sichuan blood safety and blood substitute international science and technology cooperation base, chongqing blood center background/case studies: many emerging infectious pathogens are known to be existed in heathy blood donations, and could be transmitted via transfusion with potential hazardous consequences against recipients. with more convenient application of high through put sequencing, it becomes much easier to investigate uncultured microbiome in qualified blood donations. therefore, metagenomics analyses were used to reveal emerging and re-emerging infectious diseases in healthy donations which might potentially threat the blood safety. study design/method: pooled plasma sample were collected from , voluntary blood donors from chongqing, china. total dna and rna were extracted and amplified with random primers pcr respectively in order to construct a pe library to peform deep sequencing by illumina miseq. all reads were trimmed to remove low quality bases and adapter sequences. the fully overlapping paired-end reads passing the quality filter were concatenated using pear. we classified the final reads using kraken and a kraken database made from complete refseq bacterial, archaeal and viral genomes, along with the grch human genome. the unclassified reads by kraken were aligned to ncbi nt database using blastn with cut-off evalue as e - . the best alignment hits were used to classify the reads. krona was used to generate all taxonomic distribution plots. finally, the potential emerging and re-emerging infectious pathogens were identified out of the classified microbiome by experience. abstract results/finding: . gb raw data with , , reads were generated in the dna library. meanwhile, . gb raw data with , , reads were generated in the rna library. after cleaning the human background, reads from bacteria, reads from viruses, and reads from parasites were identified (table ) . no hazardous viruses were identified as potential threats to blood safety. except for viruses and bacterias which would do limited hazards to blood safety, plenty of parasites were identified in which some were already considered as threats to blood safety in some developed countries were also discovered such as plasmodium sp. and leishmania infantum (table ) . conclusion: the investigation has revealed the metagenomics of the qualified blood donations in chongqing, china. the results showed a thoughprovoking discovery of genomic fragments of some microbes which might threat the blood safety. the displayed serious results let us have to think about regulating some reasonable screening methods as well as donor recruitment strategy in certain epidemic areas or seasons to ensure the blood safety. however, on the contrary, the results should be considered more cautiously because the existing of genomic fragments could not represent the existing of infectious pathogens. the validity of the metagenomics hints were suggested to go through epidemiological investigations and specifically tested under laboratory ways such as bacteria or virus culturing to ensure the vitality of those pathogens. background/case studies: the caribbean has become an endemic region for several emerging viruses in the last decade. after a chikungunya outbreak in most recently zika was shown to be endemic on the caribbean island of curacao. to effectively provide safe blood products in an endemic region the conventional international recommendations of donor exclusion and testing do not seem a viable option and could severely affect the local blood supply. pathogen reduction (pr) is considered an important new approach with potential benefits. the introduction and experience of use of pr platelets in the dutch caribbean over a period of one year is presented. study design/method: pathogen reduction of thrombocyte concentrates by use of riboflavin and ultraviolet treatment (mirasol prt, terumo, belgium) was introduced. all thrombocyte concentrates provided to the general hospitals on the dutch caribbean islands of curaçao, bonaire and sint maarten were pr and data collected over the period of february to february . thrombocyte concentrates are prepared out of single donation units by the buffycoat method. results/finding: over the period platelet concentrates were provided to adult and pediatric patients. these included patients on the intensive care and neonatal intensive care departments. no adverse events were reported and the cci for each transfusion was within the expected outcome. introduction of pr had minimal impact on the logistics of thrombocyte concentrate preparation and availability. furthermore no transfusion related bacterial contaminations were reported. conclusion: pr of platelet concentrates seems viable and safe for use in a small scale caribbean setting with endemicity for emerging viruses like chikungunya and zika. it offers a realistic alternative for conventional recommendations of donor exclusion and testing, thereby helping to maintain sufficient labile blood product availability. michael phillips* , germ an leparc , phillip c williamson , lani palmer , ben reynolds , maria noedel and lindsey houghton . creative testing solutions, oneblood background/case studies: due to the risk of travel and sexually transmitted zika infections, the food and drug administration issued a guidance document on february , recommending that blood centers in puerto rico cease distribution of locally collected blood products unless donors are tested or products are pathogen reduced by march , . with the high incidence of zika virus (zikv) in puerto rico and uncertainty of the impact to the continental u.s. blood supply, there was intense pressure to implement a donor screening test for zikv. the project was initiated on february , and included clinical trial requirements, client onboarding and laboratory operations. stakeholders consisted of clients, the manufacturer, institutional review boards (irb), informational technology (client and lab based), the food and drug administration (fda), the centers for disease control cdc, and the florida department of health. clinical trial requirements included development of instrument and assay validations, sop creation, result reporting, assay and clinical trial training, deviation management, donor notification, and follow up sample handling. client onboarding began with confidentiality agreements between the client and the sponsor. a zika based webinar was created to provide an overview of the sponsor protocol, lab test system and client responsibilities. the complexity of the project increased when mosquito borne zika transmission was identified in two counties in florida. this required zikv testing to be performed on collections in both florida and puerto rico. the zikv-nat is performed in singlet, unlike the mpx and wnv assays which are run in minipools. this had a significant impact on instrument capacity. despite these obstacles and the changing regulatory requirements, the zikv screening test was implemented within six weeks. study design/method: one metric used to measure client service levels is our ability to meet established upload time goals for individual clients. the percentage of samples released on time is evaluated daily with a running monthly total. our upload time goals were negatively impacted from july through september due to the unexpected increase in zikv testing, the requirement to perform testing in singlets and the resulting instrument capacity issues. additional instruments were sourced in october and operations stabilized. conclusion: on february , , the project to implement a zikv ind test was initiated. six weeks later, testing was performed on the first batch of samples. despite the changing regulatory requirements over time, the implementation was extremely successful. initiating a new ind testing within weeks is unprecedented and required exceptional collaboration between all participants and stakeholders. background/case studies: plasmodium falciparum (pf), an intraerythrocytic protozoan parasite, is accountable for nearly all malaria mortality in africa. in , who reported $ million new cases worldwide, resulting in > , deaths. malaria prevalence is highest in sub-saharan africa, home to % of all infections accounting for % of mortalities. both the incidence and prevalence of malaria in africa significantly increase the potential for transfusion-transmission (tt), with little to no screening of products in developing countries. the objective of this study was to evaluate the inactivation of pf in whole blood (wb) using a system specifically developed for the realities of the developing world and in support of the swiss red cross humanitarian foundation for whole blood pathogen inactivation for africa. the inability to consistently supply blood components leads to routine wb transfusion, and as transfusion-transmitted diseases are prevalent in the developing world, the establishment of a robust wb pathogen inactivation system is desirable. the approach uses the small molecule amustaline to form covalent adducts and crosslinks within nucleic acids of leukocytes and contaminating pathogens to prevent replication. the process includes addition of . mm amustaline and mm glutathione (gsh) and a h at room temperature (rt) incubation after which the treated wb unit is suitable for storage up to days at rt. study design/method: for each experiment, a wb unit was spiked with ring-stage pf-infected red blood cells (irbc). a pre-treatment sample was removed prior to addition of amustaline and a post-treatment sample was removed h after amustaline addition to determine the pre-and posttreatment titers to calculate the level of inactivation. these samples were serially diluted in flasks containing medium with % fresh rbcs. the diluted samples were used to inoculate flasks in quadruplicate and monitored for parasitemia by counting irbc in blood smears and by flow cytometry. pretreatment cultures were terminated after reaching > % parasitemia, while no residual pf was detected in post-treatment cultures. log reduction was calculated as the difference between the mean titer in pre-and posttreatment samples. results/finding: robust inactivation of pf in wb was achieved to the limit of detection, at > . log or > . log /ml. conclusion: pf was inactivated to the limit of detection in wb after treatment with amustaline/gsh, illustrating that the system has potential to mitigate the risk for pf transfusion transmission in endemic regions that lack testing capacity and operate under the constraint of a very limited blood component supply and rely on wb transfusion. (this system for wb is not approved for commercial use). increased patient safety and improved inventory management with day apheresis platelets nancy m. dunbar* and zbigniew m. szczepiorkowski. background/case studies: a pathway currently exists for apheresis platelet (ap) outdate extension from to days using an fda cleared rapid test (rt). in february , our hospital based transfusion service implemented the use of rt on day , and to routinely extend ap shelf life to days. prior to this, we tested aps by rt on day and transfused day or day units with physician approval when deemed medically necessary. this report describes changes observed in transfusion practice and platelet inventory management one year following routine use of day platelets. study design/methods: data were obtained for two -month study periods: october -september (pre-implementation) and february -january (post-implementation). the interval transition period was intentionally excluded. for each study period, we determined the total number of aps transfused, rt status on the day of transfusion, total number of rts performed, expired ap units, and aps obtained from suppliers using ad-hoc ordering. we also obtained hospital data including inpatient admissions, surgical volumes, average length of stay and case mix index. results/findings: data are shown in table . the number of ap transfusions increased by % post-implementation, comparable to a % increase in inpatient admissions and an % increase in surgical volumes. the hospital length of stay and case mix index were similar for both periods. the average number of platelet transfusions per patient was not statistically different ( . pre; . post, p . ). the number of rts performed increased by %. the percentage of transfused units tested at least once by rt prior to transfusion increased by % (p< . ). the outdate rate decreased from % to % (p< . ). ad-hoc ordering decreased from % to % (p< . ). conclusion: use of an approved rt for routine ap outdate extension to day was associated with increased patient safety as more transfused units underwent secondary testing prior to transfusion. increased cost of rt was offset by reduced ap waste and less frequent need for ad-hoc ordering. sheila o'brien* , vito scalia , carla osiowy , michael carpenter , anton andonov and margaret fearon . canadian blood services, public health agency of canada background/case studies: the rates of hepatitis b (hbv) and hepatitis c virus (hcv) positive donations are low ( . and . per , donations, respectively) and most are among first time donors. we aimed to determine the frequency of various genotypes of hbv and hcv in canadian blood donors confirmed positive for hbv and hcv. study design/methods: in the roche multiplex assay (hcv/hiv/ hbv) was implemented in minipools of units. hcv nat was in place since (using minipools of ) but this is the first time donors have been screened by hbv nat. hbsag, anti-hbc and anti-hcv were tested using the abbott prism assay. confirmatory testing for hbsag was by the prism neutralization assay. anti-hcv repeat reactivity was confirmed by the inno-lia hcv score line immunoassay. since march all samples testing hbv nat positive, or confirmed positive for hbsag and all hcv nat positive or anti-hcv confirmed positive samples were considered positive and samples were sent to phac for sequencing. a sample from each positive donation was aliquoted and frozen at - o c. genotyping was carried out by sequence and phylogenetic analysis of the hbv surface antigen coding region. hcv viral rna was extracted and subjected to reverse transcription and pcr amplification in the ' ntr-e and ns b regions. sanger sequencing of these regions represents approximately % of the genome. results/findings: all confirmed positive donations were whole blood donations. there were hbv positive donations. of these, had tested hbv nat positive. genotypes were type a, b, c, d and e. there were samples hbv nat negative but hbsag positive ( were anti-hbc reactive). of these, could not be sequenced and one was genotype a (also anti-hbc reactive). there were samples considered hcv positive. of these, samples were hcv nat positive. genotypes were type a, b, c, b and a. there were also samples hcv nat negative but anti-hcv positive. none of these could be sequenced. conclusion: the first months of molecular surveillance show a range of genotypes for hbv and hcv for samples identified as nat positive. to date no samples that were nat negative anti-hcv reactive could be sequenced, however one nat negative sample that was positive for hbsag and anti-hbc reactive was hbv genotype a. surveillance over a longer period is background/case studies: the bact/alert d microbial detection system (bta d) is currently fda cleared for the quality control testing of leukocyte reduced apheresis platelets (lraps). the bact/alert virtuo microbial detection system (virtuo) (biom erieux, st. louis, mo) is a new generation of bact/alert instrumentation. the underlying colorimetric technology used in previous generations of bact/alert is used in the vir-tuo and incorporates new instrument architecture to improve temperature stability, workflow improvement via automation of processes that are currently performed manually, an improved user interface and an enhanced algorithm to shorten time to detection. the objective of this study was to compare the performance of the virtuo and bact/alert d (bta d) instruments, using bact/alert bpa (aerobic) and bact/alert bpn (anaerobic) bottles, for the detection of a range of typical bacterial contaminants seeded into leukocyte reduced apheresis platelets (lraps).* study design/method: the study was performed at two institutions, one in the us and the other in the uk. aliquots of lraps were seeded with low levels ( - cfu/ml) of bacterial species commonly associated with platelet contamination, and replicates ( per instrument) of ml aliquots per bottle were inoculated into bpa and bpn bottles. one set of bottles was loaded into bta d and the other into virtuo and incubated until signaled positive by the instruments or for up to days. overall detection rates and time to detection of bacterial contaminants between instruments were compared. additionally bottles were tested in each instrument (lraps only, no organism) to evaluate differences in the overall negative agreement rates (detection of false positives) between instruments and to serve as sterility controls for the platelet preparations. background/case studies: the implementation of nucleic acid testing (nat) blood screening is still a challenge in resource-limited countries. at the same time, in these countries, higher to similar proportions of replacement to voluntary blood donors are recruited. a higher prevalence of infections is observed in relation to developed countries. as a consequence, more incident cases of infections can be expected. in our country, some hospital blood banks could not afford nat due to high costs, but belong to a net that centralizes nat in a reference blood center. the process to consolidate small blood banks in regional blood centers, which will be able to implement nat, is not yet complete. although efforts to reduce replacement /familiar blood donations are in progress, these goals have not been completely achieved. the aims were to compare the prevalence of hiv, hcv and hbv by nat screening in a blood center recruiting only voluntary blood donors with the prevalence in centers recruiting replacement and voluntary blood donors, and describe the nat yield rates for hiv, hcv and hbv in a period of three and a half year experience. study design/method: a regional blood donor center (rbdc) has centralized nat screening from centers in different regions of the country due to since august . this process required to achieve adequate laboratory conditions and staff qualification and a development of software to assure sample traceability and interface for transmission of results. when a window period was suspected, the nat screening was repeated from the plasma unit and a second sample of the blood donor was required to confirm nat results. this rbdc have also been developed a % voluntary donor program since and is the only center in the country that has achieved this goal. results/findings: a total of , blood donations were studied from august to december . in the rbdc, where only voluntary blood donations are recruited, the prevalence was per , donations for hiv (ic % - : , ); per , for hbv (ic % - : , ) and per , for hcv (ic % - : , ). in all other centers together, where voluntary and replacement blood donations are recruited, the prevalence was per , donations for hiv (ic % - : , ); per , for hbv (ic % - : , ) and per , for hcv (ic % - : , ). window period infections were detected only in centers recruiting voluntary and replacement blood donations, giving nat yield rates of : , for hbv; : , for hiv and : , for hcv. conclusion: the hiv, hbv and hcv prevalence was lower in a center where the tasks to sustain a voluntary blood donor program were developed. nat yield rates could be reduced in the region if this program could completely be applied in all centers. mechanisms leading to obi include various factors such as imperfect host's immune response and viral variation factors. this study was to determine the viral loads of obi under currently recruitment and screening among blood donors in five blood services of zhejiang province, china. study design/method: before donation, the donors were screened and precluded with hbsag preliminary test positive and alt level abnormal. following, the samples were detected for hbsag twice using different elisa reagents and hbv dna using tma or qt-pcr techniques. then, the samples with hbv dna positive and elisa negative were tested for the viral loads using taqman technique in cobas s system. hbv s region was also sequenced. results/finding: obi were found in the , donations. in the viral loads assay, samples were negative and samples' viral loads were lower iu/ml. the mean viral loads was . . (log ) iu/ml in other samples,while the mean viral loads with hbsag /hbv dna samples was . . (log ) iu/ml. samples of obis have analyzed the hbv genotype, which b was the most prevalent subtype ( . %) and the other was hbv c genotype( . %). compared the samples with hbsag /hbv dna ,we found two obi samples carrying with t>c mutation, which could cause an amino acid s f. conclusion: in this study, the viral loads of obi infection in donors was much low than hbsag /hbv dna , and some unique variation was identified in the obi individuals. a transfusion in general population. screening of blood donors for hbv in india is primarily based upon detection of hepatitis b surface antigen (hbsag) in donor's sera. the current study was undertaken to determine the prevalence of occult hbv infection (obi) in voluntary blood donors and to analyze the burden of hbv window period donations. study design/method: this is a prospective, observational, mono-centric study performed in a national accreditation board for hospitals (nabh) accredited apex blood bank, located in maharashtra state, india. monolisa hbsag ultra (bio-rad, france)sandwich type elisa using monoclonal and polyclonal antibodies was used for hbsag detection in donor's sera. all the elisa non-reactive samples were also tested by an additional real time multiplex polymerase chain reaction (mpx-pcr) by cobasv r taqscreen mpx test. the donors which were found to be positive for hbv dna were followed upat th days, month, months& months by monolisa hbsag ultra (bio-rad, france) to analyze interval of window period and to delineate the window period donations (wpd) & true obi. background/case studies: occult hepatitis b infection (obi) is characterized by hepatitis b virus (hbv) dna-positive, but hbv surface antigen (hbsag) -negative. since may , we have been testing apheresis donors for hbv nucleic acids and improvements in laboratory testing have reduced the risk of transfusion-transmitted infection. the number of apheresis collections increased significantly year by year, however, data on hepatitis b virus marker rates among these donors continue to be lacking. the aim of this study is to evaluate the epidemic characteristics, incidence and estimate the risk factors of obi among apheresis donors in a region of central china. study design/method: apheresis donors' data from may to dec was retrospectively analyzed. all samples were tested for hbsag, hbv dna, and other markers. nucleic acids testing (nat) was performed on the roche cobas s platform using pools of serologically negative samples and any pools positive would undergo nat again individually. hbsag negative, but hbv dna positive were further tested for hbv dna quantitative pcr, antibody to hepatitis b surface antigen (hbsab), antibody to hepatitis b core antigen (hbcab), hepatitis b e antigen (hbeag) and antibody to hepatitis b e (hbeab). results/finding: in the evaluation, seronegative donations were screened by nat and a total of hbv dna-reactive/hbsag-negative donors were detected. no hiv rna -reactive or hcv rna -reactive sample was detected. complete serologic screening of the index donations indicated that the majority of these donors had an occult hbv infection and the majority of which were married men and the fixed donors with many whole blood or apheresis donations. age distribution of the age group - years old showed a large proportion, who accounted for % of reported infections. most of the hbv dna cases (about . %) reached senior high school education. the average hbsag dna positive rate was . % ( / ). incidence among apheresis donors in this period for hbsag dna were . / . these estimates were comparable to those among repeat whole blood donors. we developed pathogen reduced (pr) cryo derived from ffp and pf with day stability at c. study design/method: six replicates of type-matched pools of whole blood derived (wbd) and apheresis (aph) plasma were split to produce conventional control ( ml) and test components ( ml ml). test components were pr with amotosalen and uva light. aph and wbd ffp were produced by freezing plasma within hr and wbd pf within hr. cryo was manufactured according to site sops and frozen at - c (test ml, control ml ). test and control cryos were thawed at c, and characterized immediately post thaw (t ), and after d storage at c and tested for fb and fviii function, thromboelastography (rotem) and thrombin generation (cat). results/finding: pr cryo retained sufficient fb and fviii activity post thaw and over d at c (table) for hemostatic capacity. rotem (extem) showed retention of fibrin formation (a angle) and clot quality (mcf) (table) . thrombin generation was robust as demonstrated by multiple parameters (lag time, peak thrombin, endogenous total thrombin potential (etp), and time to peak (tt) despite lower fviii levels. these parameters were maintained through d storage at c. conclusion: pr cryo can be processed from plasma sources, including pf , and stored at rt for days. pr plasma provides adequate levels of fb with hemostatic capacity equivalent to control as demonstrated by rotem and cat. use of pf with stability over days can increase the availability of cryo with a reduced risk of transfusion-transmitted infection. cryo produced with psoralen-treated (pr) plasma is not approved for use in the us. performance of a new automated alinity s assay for antibodies to t. cruzi darwin smith* , ed bakker , anton van weert , jane bryant , mark paradowski , lynne fleischmann , mirjana sarac , george chen , george schlauder and gregg williams . abbott diagnostics, sanquin diagnostics, abbott gmbh & co. kg background/case studies: the parasite, trypanosoma cruzi (t. cruzi), is the cause of chagas disease which is endemic to the americas and infects - million people. in order to prevent transfusion mediated transmission of this parasite in endemic countries, blood collection centers require high throughput anti-t. cruzi assays with good specificity and sensitivity. in nonendemic countries, selective testing of at risk donors is a strategy to avoid temporary donor deferrals. in addition, continued pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. study design/method: the performance of the new automated chemiluminescence immunoassay for the detection of antibodies to t. cruzi was evaluated on the alinity s automated platform and compared to another onmarket chemiluminescent immunoassay. precision was assessed over days using a panel of positive and negative samples. sensitivity was evaluated on presumed antibody positive specimens and specificity was evaluated on random blood donor samples. results/finding: precision was % cv or less for positive samples over days. the overall specificity in a blood donor population was . % ( / ). sensitivity was . % for presumed antibody positive samples. conclusion: these results indicated that the new automated alinity s chagas assay provided very good performance in sensitivity and specificity, comparable to the current on-market anti-t. cruzi assay, and is equally suitable for use of universal screening in endemic and selective donor screening in non-endemic countries. performance of a new automated alinity s assay for hepatitis b surface antigen and hepatitis b surface antigen confirmatory randal makela* , anton vanweert , ed bakker , jane bryant , mark paradowski , lynn martin , daniela kaleve , george chen , gregg williams and george schlauder . abbott laboratories, sanguin diagnostics, abbott gmbh & co. kg, abbott diagnostics background/case studies: despite the development of sensitive nat methods, blood transfusion in many parts of the world relies on serologic screening for hepatitis b surface antigen (hbsag) to prevent transfusion transmitted hbv infection. sensitive hbsag assays must be capable of coping with a wide range of mutants while exhibiting an uncompromised specificity. in addition, continued pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. study design/method: the performance of a new automated chemiluminescence immunoassay for the detection and confirmation of hbsag was evaluated on a next generation automated platform, abbott alinity s. precision was assessed over days. sensitivity was evaluated using known positive samples, commercially available seroconversion panels, the who standard, hbsag mutants, and hbsag genotyped specimens (a through h). specificity was evaluated on random blood and plasmapheresis donors. results/finding: precision was less than % cv for positive samples over days. the blood donor specificity was . % ( / ). sensitivity was % for presumed positive samples. sensitivity was % for all genotypes. % of the mutants were detected vs % for the comparator assay. seroconversion detection was equivalent to the comparator assay with reactive samples detected with the alinity s assay and reactive samples detected by the comparator assay. analytical sensitivity ranged from . to . iu/ml. the alinity s hbsag confirmatory assay confirmed all known positive hbsag specimens, including hbsag mutant samples that were not confirmed by the comparator hbsag confirmatory assay. conclusion: the new automated alinity s hbsag assay provided precision, specificity, and seroconversion sensitivity comparable to the current onmarket comparator assay. however, the alinity s hbsag assay demonstrated a gain in sensitivity over the comparator assay through the detection and confirmation of a wider range of mutants. performance of a new automated alinity s immunoassay assay for hiv darwin smith* , ed bakker , anton van weert , jane bryant , mark paradowski , kevin callear , susan sullivan , george chen , george schlauder and gregg williams . abbott diagnostics, sanquin diagnostics background/case studies: blood donations are commonly screened to detect the presence of antibodies (or antibody and antigen) to human immunodeficiency virus types and (anti-hiv- / ). blood centers require very high throughput anti-hiv- / assays with high specificity and sensitivity to prevent unnecessary donor deferrals while maintaining a safe blood supply. in addition, continued pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. in the response for the need for such screening assays, we have evaluated an improved automated assay for the detection of anti-hiv- / antibodies and hiv- p antigen. study design/method: the performance of the new chemiluminescence combination immunoassay for the detection of anti-hiv- / antibodies and hiv- p antigen was evaluated on the abbott alinity s system. precision was assessed over days evaluating positive samples. specificity was evaluated on samples obtained from random blood donors and plasmapheresis donors. sensitivity was evaluated using presumed positive samples for hiv- , hiv- and hiv group o antibodies and hiv- p antigen. seroconversion sensitivity was evaluated with commercial seroconversion panels. results/finding: precision was less than % cv for positive samples over days. the blood donor specificity was . % ( / ). sensitivity was % for presumed antibody positive samples comprised of hiv- , hiv- and hiv- groups o, n, p, crf and urf samples. also, sensitivity was % for antigen positive viral isolate samples comprised of hiv- , hiv- and hiv- groups o, n, p, crf and urf samples. seroconversion detection was equivalent to the comparator assay with reactive samples detected with the alinity s assay and reactive samples detected by the comparator assay. conclusion: these results indicate that the new automated alinity s hiv ag/ab combo assay provided acceptable performance in specificity, sensitivity and precision, while providing similar seroconversion sensitivity as the comparator assay. performance of a new automated alinity s immunoassay for the detection of anti-hbc antibodies randal makela* , anton vanweert , ed bakker , jane bryant , mark paradowski , joyce siregar , angela vockel , george chen , gregg williams and george schlauder . abbott laboratories, sanguin diagnostics, abbott gmbh & co. kg, abbott diagnostics background/case studies: in countries with a low prevalence of hepatitis b, blood donations are commonly screened to detect the presence of antibodies to hepatitis b core antigen (anti-hbc) alongside hbsag and hbv nat to detect donors with occult hepatitis b infections (obi). blood centers require anti-hbc assays with high specificity and sensitivity to prevent unnecessary donor deferrals while maintaining a safe blood supply. in addition, continued pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. in the response for the need for such screening assays, we have developed an improved automated assay for the detection of anti-hbc on the alinity s system. study design/method: the performance of a new chemiluminescence anti-hbc assay for the detection of anti-hbc antibodies was evaluated on the next generation automated abbott alinity s system. precision was assessed over days evaluating positive samples. specificity was evaluated on samples obtained from random blood donors. sensitivity was evaluated using specimens characterized as anti-hbc positive by means of serologic methods. analytical sensitivity was assessed using the who st international standard. seroconversion sensitivity was evaluated using commercial seroconversion panels. results/finding: precision was less than % cv for positive samples over days. the blood donor specificity was . % ( / ). sensitivity was % for samples presumed to be anti-hbc positive. analytical sensitivity results on the alinity s anti-hbc assay ranged from . to . iu/ml. seroconversion detection was equivalent to the comparator assay with reactive samples detected with the alinity s assay and reactive samples detected by the comparator assay. conclusion: these results indicate that the new automated alinity s anti-hbc assay provided good performance in specificity, sensitivity and precision versus the comparator assay. performance of a new automated alinity s immunoassay for the detection of htlv i and htlv ii antibodies melanie anderson* , anton vanweert , ed bakker , mark paradowski , jane bryant , tuan bui , joyce siregar , george chen , george schlauder and gregg williams . abbott laboratories, sanguin diagnostics, abbott diagnostics background/case studies: in endemic countries, universal blood screening is necessary to prevent transfusion transmitted htlv infections (anti-htlv i/htlv ii). in non-endemic countries, selective testing may avoid unnecessary temporal deferrals for donors at high risk, such as returning travelers from or donors born in countries with a high htlv prevalence. blood centers require high throughput anti-htlv i/htlv ii assays with high specificity and sensitivity to prevent unnecessary donor deferrals while maintaining a safe blood supply. in addition, continued pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. in response for the need of an assay with high specificity on a high throughput instrument we have developed a new assay for the detection of antibodies against htlv-i/ii antibodies for the alinity s system. study design/method: precision was assessed over days using htlv i and htlv ii positive samples. specificity was evaluated using , blood donor specimens from europe and diagnostic samples obtained from the united states. sensitivity was evaluated using preselected htlv i and htlv ii positive samples. sensitivity and specificity samples were split across reagent lots during testing. confirmation of repeatedly reactive samples was done using the mp diagnostic htlv blot . . results/finding: imprecision was less than . % for positive samples over days. clinical sensitivity was . % ( / ) on preselected htlv i and htlv ii positive samples. the specificity was . % ( , / , ) on a blood donor population and . % ( / ) on diagnostic samples. conclusion: these results indicate that the new alinity s automated htlv i/ ii assay provided very good performance in specificity, sensitivity, and precision. sensitivity and specificity were comparable to the comparator assay. claudia ramirez , michel garcia* , fernando palomino and guillermo orjuela-falla . national blood bank colombian red cross, universidad del rosario, fuats background/case studies: current hepatitis c virus (hcv) supplemental testing algorithm for blood donations in colombia, requires that an immunoblot assay be performed on every hcv enzyme immunoassay (eia) repeatreactive sample. a higher proportion of indeterminate (ind) results by immunoblot assays has been documented for non-us donor samples, affecting donor counseling and eventually increasing costs and opportunity for the notification of infected donors. this work aimed to establish the distribution of immunoblot results in colombian repeat-reactive samples, as well as the frequency of band detection in both positive and indeterminate blots. study design/method: in total, anti-hcv-reactive donor samples (signal-to-cutoff (s/co) ratio greater than . ; abbott architect i sr) underwent supplemental testing by immunoblot (either chiron riba hcv . sia or hcv blot . test, mp diagnostics). negative (neg), indeterminate (ind) and positive (pos) blot results were grouped by s/co ranges as follows: - . , - . , > . band detection and intensity were independently analyzed for indeterminate and positive results. results/finding: immunoblot results were negative in . % ( / ) of samples, indeterminate in . % ( / ) and were positive in . % ( / ). a direct relationship was observed between positive immunoblot and increased s/co. the proportion of ind results were higher in the s/co group - . ( . %) compared with the - . ( . %). in samples with indeterminate results, ns _ was the most frequent band detected ( , %). in contrast, the most frequent band in the group of positive results was core ( , %). only one sample from the indeterminate group ( . %) had a strong band intensity ( ), compared with samples from the positive group ( . %). conclusion: the proportion of indeterminate immunoblot results in this sample of colombian donors is one of the highest ever reported, being twice as much as the proportion found in larger samples of us donors. the high proportion of ind results found in the s/co group ( - . ) suggests that the optimal s/co ratio for predicting a confirmed anti-hcv result in this population should be higher than the one recommended by the cdc for us population (> ). overall, these results suggest that the supplemental testing algorithm for blood donations in colombia could be improved not only by using high s/co ratios as an alternative to immunoblot, but also by introducing hcv genomic assays instead of immunoblots, at least for samples with intermediate s/co ratios. ns _ and ns _ cross-reactivity in colombian population warrants further investigation. performance of the alinity s immunoassay for the detection of syphilis antibodies melanie anderson* , ivanka mihaljevic , manuela miletic , miljana stojic vidovic , irena jukic , jane bryant , mark paradowski , angela vockel , george chen , gregg williams and george schlauder . abbott laboratories, croatian institute of transfusion medicine, abbott gmbh & co. kg, abbott diagnostics background/case studies: blood donations are commonly screened for syphilis in order to detect the presence of antibodies to the bacterium treponema pallidum. in addition, continued pressures on laboratory operations demand that the full panel of ttid assays perform on a single platform capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. in response to those needs, we have evaluated a new automated immunoassay for the detection of antibodies to t. pallidum. study design/method: performance of the new automated chemiluminescence immunoassay for the detection of antibodies to treponema pallidum was evaluated on the alinity s system. precision was assessed over days using positive samples. specificity was evaluated on samples obtained from , blood and plasmapheresis donors from the united states and europe and diagnostic samples obtained from the united states. sensitivity was evaluated using preselected positive samples. sensitivity and specificity samples were split across reagent lots during testing. confirmation of repeatedly reactive samples was done using a testing algorithm with confirmatory assays, inno-lia tm syphilis score, and mikrogen recomline treponema igg and igm blots. results/finding: imprecision was less than . % cv for positive samples over days. clinical sensitivity was . % ( / ) on preselected syphilis positive samples. the specificity was . % ( , / , ) for blood donor specimens and . % ( / ) on diagnostic samples. conclusion: these results indicate that the new automated alinity s syphilis assay provided good performance in precision, specificity and sensitivity in line with data found for the comparator assay. performance of the new automated alinity s assay for anti-hcv melanie anderson* , ed bakker , anton vanweert , jane bryant , mark paradowski , tuan bui , lynn martin , george chen , gregg williams and george schlauder . abbott laboratories, sanguin diagnostics, background/case studies: serological screening for antibodies to hepatitis c virus (hcv) often in conjunction with nucleic acid testing (nat) is used worldwide to prevent transfusion transmitted hcv infections. while nat provides improved sensitivity and detection of hcv in the pre-seroconversion window, serological testing provides continued detection of hcv in infected individuals and individuals with resolved infections with no detectable hcv rna. blood and plasma centers require very high throughput anti-hcv assays with high specificity and sensitivity to prevent unnecessary donor deferrals while maintaining the safety of the blood and plasma supply. in addition, continued pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. study design/method: the performance of a new automated chemiluminescence immunoassay for the detection of antibodies to hcv was evaluated on the alinity s system. precision was assessed over days evaluating positive samples. sensitivity was evaluated using preselected positive samples and seroconversion panels. specificity was evaluated on samples obtained from , blood and plasmapheresis donors from the united states and europe and diagnostic samples obtained from the united states. sensitivity and specificity samples were split across reagent lots during testing. confirmation of repeatedly reactive samples was done using a testing algorithm consisting of the inno-lia tm hcv score and nat/hcv discriminatory nat assays. results/finding: imprecision was less than . % cv for positive samples over days. overall clinical sensitivity was % on preselected anti-hcv positive samples. seroconversion sensitivity was better than the comparator as evidenced by the new anti-hcv assay identifying more bleeds than the comparator assay. the specificity was . % ( , / , ) for blood donor specimens and . % ( / ) background/case studies: zika virus (zikv), which has been outbroken in south america and the united states since middle of , was declared as the public health emergency of international concern by who in feb . in addition to mosquito, zikv can be transmitted via maternalneonatal relationship, sexual intercourse or blood transfusion. the potential for transfusion-transmitted zika virus was shown in french polynesia where . % of asymptomatic blood donors tested were positive for zika virus rna using nucleic acid test (nat). several case reports have confirmed that zikv can be transmitted by transfusion. it has been shown that among blood donors, . % of the zikv infections were asymptomatic and the ratio of symptomatic to asymptomatic patients observed in micronesia was approximately : to : . thus zikv has raised a great challenge to transfusion safety. measures should be taken to prevent transfusion-transmitted zikv, including temporary deferral of blood donors in epidemic locations, donor self-reporting of zikv symptoms after donation with or without quarantine of blood components, supply by blood collected from non-endemic areas to epidemic regions, nat of blood donations, and pathogen inactivation of blood products. in this study, we evaluated zikv inactivation in plasma by using methylene blue photochemical treatment (mbpt). study design/methods: plasma units from randomly selected healthy donors were collected and spiked with zikv. samples were added by mb at a final concentration of lm and assayed after illumination with visible light from both sides for , , and min. viral infectivity and zikv rna loads (reverse transcription pcr) were measured in spiked plasma before and after mbpt and confirmed using repetitive passages in cell culture. control was zikv spiked plasma without photochemical treatment. results/findings: zikv titer of control sample was . log % tissue culture infectious dose (tcid )/ml. no viral infectivity was detected after mb photochemical inactivation treatment for min, min or min and the losses of the infectivity were further demonstrated by repetitive passages of cell culture. meanwhile, zikv rna loads decreased significantly during the initial min of treatment whereby ct-value jumped from . (control) to . (mbpt for min) (table ) . conclusion: it showed that mb photochemical treatment could effectively inactivate zikv in plasma. rna lesions were induced during mbpt process so that nucleic acid reverse transcription and amplification were inhibited. mbpt is proved to be an efficient method to prevent plasma transfusiontransmitted zikv infections. gilles delage* , margaret fearon , susan l stramer , megan l nguyen , france bernier , sheila o'brien , vito scalia , sakina smith , yves gr egoire and boris hogema . h ema-qu ebec, canadian blood services, american red cross, sanquin background/case studies: hepatitis e virus (hev) is known to be transfusion-transmissible. as part of the risk assessment for this infection, a study was carried out in , canadian blood donors in . in a subset of , donor samples the seroprevalence was . %. however, no donor samples were positive for hev by an in-house nucleic acid test (hev-nat). since that study suggested exposure to hev in canada but used an hev-nat with a limit of detection of iu/ml, a larger study was performed using a more sensitive hev-nat assay. study design/method: donors were informed about the study in the predonation reading materials. linked samples from approximately , canadian whole blood donors including , from canadian blood services (cbs) and , from h ema-qu ebec (hq) were collected. clinics were selected to ensure representative sampling of the donor population. all a transfusion vol. supplement s donations with available plasma samples were tested by individual donation nat at the american red cross laboratory in gaithersburg, md, using the cobas v r hev test ( % lod . iu/ml, % ci . - . ) for use on the cobas v r / system. this test is not currently approved in canada or the usa, but is available as a ce marked test. all nat-reactive donors are questioned concerning risk factors for recent hev infection (travel, animal contact, food and water exposure), undergo confirmatory testing (alternate nat, viral load, genotyping and igm/igg serology), are notified by letter, and deferred from donating for months; in-date products collected from the donor, and any frozen red blood cells or plasma from the previous months are destroyed. recipients will be traced in the event of any products transfused in the previous months. results/finding: as of april , , of , ( , cbs, , hq) tested samples with valid results have been found hev-nat reactive: donors have been confirmed by further testing to date. confirmation is pending in donor. of the donors, were from quebec, and one each from nova scotia and alberta ( male, female). ages ranged from to years. only two donors reported non-specific symptoms (fatigue). in terms of risk factors: ate pork (including who ate pork liver), ate shellfish, ate venison, and drank well water. one donor had no identifiable risk factor. viral loads ranged from to iu/ml, of which were < , were - , and were > iu/ml; were anti-hev igm positive and anti-hev igg positive at index (wantai assay). conclusion: the prevalence rate of acute hev infection in this donor population appears to be around / . the data from this study will contribute to the ongoing risk assessment of transfusion-transmitted hev infection in canada. prevalence of malaria parasite in donated blood at nakasero blood bank, uganda gerald nsubuga* and musiisi ezra. uganda blood transfusion service background/case studies: introduction infectivity of donated blood with malaria is a significant health problem facing humanity. in uganda, screening for malaria parasite is neither routinely done in blood banks, nor stipulated in the current uganda national blood transfusion service (ubts) guidelines by the ministry of health. as a result, the proportion of donated blood that is infected with malaria is largely unknown. malaria infection places more than half of the world's population at risk and in majority of the tropical and sub-tropical regions of the world and about to million cases and to million death occur per year. however the study aimed at determining the prevalence of malaria parasites in donated blood at nakasero blood bank, kampala, uganda study design/method: a cross sectional study was carried out in nakasero blood bank, kampala, uganda in four hundred and seventy randomly selected donor samples at the blood bank between june and august . both thin and thick glass stained blood smears of blood samples with giemsa was examined using microscope. results/finding: of the donated blood samples, ( . %) tested positive for malaria parasite (p. falciparum), although there was no significant difference in occurrence of plasmodium in relation to sex, age and blood group (p> . ), majority of the blood donors that tested positive belonged to blood group o ( . %). the prevalence of malaria parasite in the study was . %. regardless of the prevalence, the presence of malaria parasite (plasmodium falciparum) in donated blood from donors that were presumed to be healthy raises a serious concern on the safety of donated blood in uganda. the ministry of health should review the existing guidelines for screening malaria and mandatory universal blood donor screening policy for malaria, for exclusion of blood donors with plasmodia parasitaemia. using methods like pathogen inactivation compared to tedious microscopic procedure to screen donated blood to be introduced to further enhance blood safety in our communities. components. the bact/alert virtuo* (virtuo) is an advanced, next generation system with improved automation, connectivity, and with data management systems. most importantly, the virtuo's new algorithm significantly reduces the time to detection (ttd) of microorganisms during quality control testing of platelet preparations using bact/alert bpa (aerobic) and bpn (anaerobic) bottles. bpa and bpn bottles were tested on virtuo and bact/ alert d (bta d) to evaluate repeatability to detect growth in seeded leukocyte reduced apheresis platelets (lrap) without platelet additive solution (pas), throughout platelet shelf life ( , and days after collection). study design/method: pooled lrap were seeded with low levels of organisms commonly associated with platelet contamination at , and days post collection. the seeded lrap were inoculated into bpa and bpn bottles on different days (not consecutive) alternating between teams of people each. seeded bottles were loaded into a virtuo and a bta d and incubated until declared positive or negative (up to days). additionally, bpa and bpn bottles inoculated with ml of unseeded lrap were tested on the virtuo and the bta d ( and bottles respectively), to serve as negative controls, sterility controls, and to evaluate the risk of false positives caused by lrap results/finding: the repeatability of the virtuo to detect organisms in lrap was demonstrated by a recovery rate of seeded bottles of . % for the virtuo and . % for the bta d. the virtuo demonstrated an average improved ttd of . hours, when compared to the bta d in the presence of ml lrap platelets. the lrap did not cause false positives. additionally, the age of the lrap units (within day expiry),did not impact the ttd when seeded with organism background/case studies: zika virus (zikv) is an emerging flavivirus that is transmitted by the aedes aegypti mosquito and sometimes a. albopictus mosquito. most infections are asymptomatic. zikv nucleic acid testing (nat) became a required test for blood donors per the fda guidance entitled, "revised recommendations for reducing the risk of zika virus transmission by blood and blood components". based on our geographical location, implementation of this testing began weeks after this guidance was issued. we performed zikv nat for donors of whole blood and blood components under an investigational new drug (ind) study (sponsored by hologic, inc.). we performed a retrospective analysis on all nat results as there is a potential to defer donation due to false positive screening results. study design/method: donors that consented to donate blood and be tested for the zikv were obtained from three blood banks in colorado and nebraska. nat was performed using the procleix virus assay which is a qualitative in vitro nucleic acid assay system that detects zikv rna in plasma specimens. the assay was performed on the automated procleix panther system. all testing was performed according to the manufacturer package insert. results/findings: in the event of a reactive result, donors would be retested by nat in addition to other testing (igm antibody testing, neutralization test). donors are deferred for days barring continued zikv testing and nonreactive results. a total of , donors were screened for zikv. all donors screened for zikv were nonreactive by nat. no invalid test results were obtained. in addition the number of failed test runs due to instrument or assay issues were experienced were quite low ( . %). this data indicates that both the assay and instrument are robust. there was a low frequency for additional testing which allows the laboratory to publish timely infectious disease results for our blood bank customers. conclusion: the reactive rate data presented here demonstrate that there is a low/zero incident rate in our region for whole blood and blood component discard due to reactive results. this screening is important to continue to ensure blood safety in the united states. robust inactivation of the yellow fever virus d strain can be achieved using amotosalen and uva light for pathogen reduction treatment (prt) of platelet components andrew laughhunn , felicia santa maria , yvette girard , peter bringmann , marion lanteri* and adonis stassinopoulos . microbiology department, cerus corporation, scientific affairs department, cerus corporation background/case studies: yellow fever virus (yfv) is known to cause explosive outbreaks, such as the one in angola in . the rapidly increasing number of infections in brazil, with hundreds of fatalities since december , is of concern. yfv is a flavivirus transmitted by aedes mosquitoes and could spread, like zika virus, to other parts of the americas where the vector is endemic. with no effective antivirals and only supportive therapy available, the best mitigation strategy is through vaccination with live attenuated vaccine strains, like the d-yfv strain. yfv vaccine is considered an effective and safe vaccine; however major adverse events have been reported including neurologic and visceral adverse effects. in addition, transfusion transmission (tt) of live attenuated yfv has been reported with severe clinical outcomes, especially in immunosuppressed patients. in order to prevent tt by yfv vaccine strain, the aabb recommends a weekperiod deferral after yfv vaccination. yfv outbreaks and vaccination campaigns may therefore reduce blood availability. this pilot study evaluated the ability to inactivate d-yfv using amotosalen (s- ) and uva light prt of platelet components (pc). study design/method: pc in %pas (n ) or % plasma (n ) were spiked with high titers of d-yfv and treated with s- /uva prt. samples were taken pre-and post-uva illumination and infectious titers were determined, by plaque assay using vero cells. the extent of inactivation was quantified by comparing titers before and after inactivation. results/finding: pre-prt infectious titers were . . log pfu/ml for pc in % plasma and . log pfu/ml for pc in % plasma while titers in post-prt samples were <- . . log pfu/ml for pc in % plasma and <- . log pfu/ml for pc in % plasma. inactivation to the limit of detection of > . . log or inactivation of > . . log pfu/ml was achieved for pc in % plasma. inactivation to the limit of background/case studies: the use of biotin as a supplement has increased in recent years and many health care professionals may not be aware of the high dosage intake by their patients. this high dosage has resulted in an increased prevalence of individuals being exposed to biotin levels much greater than the recommended daily dose and as a consequence, has led to inaccurate lab results for assays that utilize the free capture biotin-streptavidin methodology. although abbott's alinity s assays do not utilize this free capture biotin-streptavidin methodology, eight assays developed for blood screening on the alinity s system were evaluated for biotin interference to ensure there are no unknown consequences of high biotin levels. study design/methods: the purpose of this study was to determine if the eight developed abbott alinity s assays would be susceptible to biotin interference by evaluating their performance in the presence of a high concentration of biotin. for each of the alinity s assays evaluated (hiv ag/ab combo, htlv i/ii, anti-hcv, chagas, hbsag, anti-hbc, syphilis, and cmv igg), samples spiked with a concentration of biotin at approximately ng/ml were tested against a control (unspiked) sample preparation to determine if there was a difference between the control and biotin containing samples. two samples, one negative and one positive, were tested with all assays, except the hiv and htlv assays, which each tested two positive samples ( hiv- antibody and hiv- p antigen, and htlv-i antibody and htlv-ii antibody, respectively). results/findings: for the negative samples, the sample to cutoff (s/co) differences between the biotin spiked and control were . for hcv, hbc, syphilis, cmv igg, and chagas, . for hiv ag/ab and htlv i/ii, and . for hbsag. for the positive samples, the mean s/co % differences between the biotin spiked and control were . % (antibody sample) and . % (antigen sample) for hiv ag/ab combo; . % (htlv i antibody sample) and . % (htlv ii antibody sample); - . % for anti-hcv, - . % for chagas, - . % for hbsag, - . % for anti-hbc, - . % for syphilis, and - . % for cmv igg. conclusion: eight abbott alinity s assays were evaluated to determine if they were susceptible to biotin interference. these results indicate that the eight alinity s assays do not show susceptibility to biotin interference at an approximate concentration of ng/ml. robustness of the abbott prism methods to biotin interference c fischer , r schneider , w leonard , m cobb , g schlauder , g williams , m zuske m janulis* . transfusion medicine, abbott diagnostics, wiesbaden, germany, add diagnostics, transfusion medicine, abbott laboratories, chicago, united states background/case studies: the use of biotin as a dietary supplement has increased significantly in recent years and many health care professionals do not realize their patients are taking high doses. the increase has resulted in an increased prevalence of people being exposed to biotin levels much higher than the recommended daily dose and as a consequence, potentially inaccurate lab results for assays that utilize the free capture biotin-streptavidin methodology. the purpose of this study was to identify any abbott prism assays that may be susceptible to biotin interference based on assay design and then evaluate the performance of those assays with high concentrations of biotin. after a comprehensive review of abbott's current on market prism assays, no assays were identified that utilize biotin-streptavidin capture; however, assays were identified for subsequent testing as they contain biotin in their assay design. background/case studies: bacterial contamination of platelets is the highest residual infectious risk in transfusion despite the current preventive strategies. while bacterial contamination may affect any blood component, the ambient storage temperature conditions for platelets make them most likely to facilitate bacterial growth. based on all the precautionary measures, the final platelet concentrates include in the worst cases a very limited viable bacteria number estimated from to colony forming units (cfus)/bag (i.e. . to . cfu/ml). one major difference between viruses and bacteria is that bacteria have the ability to grow up to a concentration of - cfu/ml over the days product shelf-life. moreover, a large diversity of strains is found in contaminated platelets representing a key challenge for the development of a generic bacterial test. the aim of this study was to develop an economic and easy diagnostic approach for the early, rapid, sensitive and generic detection of bacteria in platelet concentrates. the adaptability of the process with the blood transfusion services requirements was of major concern. hence, attention was focused on an easy to automate technique able to deliver results on day after collection. study design/method: a large panel of bacteria involved in transfusion reactions including clinical isolates and reference strains was established and used for mouse immunizations, antibody screening and platelet spiking steps. an original approach was used to produce and select monoclonal antibodies directed against bacteria to develop our generic immunoassay. as recommended, hours (day ) after collection a sampling volume of spiked platelets ( . - cfu/ml) was tested after a short generic culture, lysis and capture of bacteria on magnetic microparticles in a microplate format. an immunoassay was performed for the detection of the captured bacteria. results/finding: this approach was tested on a panel of bacterial strains involved in transfusion reactions. the pre-analytical steps and the capture of bacteria on microparticles were improved to avoid false negative results and to enhance the sensitivity of detection. the full test developed in this study combining a pre-analytical culture step followed by an there are many stakeholders are involved in hcv eradication program, including government authority such as centers for disease control and prevention, national health insurance and health promotion administration, and private property like hospitals, medical societies, pharmaceutical and vaccine industries, npos and academia. results/finding: tbsf is a private nationwide single blood services program in taiwan, and performs anti-hcv screening test and nat confirmatory test on every collected blood, which is a large-scale population screening of hcv in taiwan because of its high blood donation rate ( . %). tbsf confirmed positive test result of repeated blood donors, and can identify hcv rna seroconversion cases as recently-infected hepatitis patients. those infected patients would be referred to physician for further medical care and deferred permanently by tbsf to secure blood safety. by interviewing the newly-infected cases, the risk factors of hcv patients can be studied and then help identifying and eliminating sources of hcv infection. tbsf also contribute to health education by teaching our donors being aware of potential risks of hcv infection and keep monitoring every parameters of hcv epidemiology to evaluate the efficacy of hcv eradication program. conclusion: in hcv eradication program, tbsf can not only secure blood safety but also participate in health education, disease screening, etiology finding and prevention, surveillance and evaluation. thus, among all stakeholders, tbsf is particularly important and can play a pivotal role in eradicating hcv by in taiwan. the theraflex uv-platelets technology efficiently inactivates transfusion-relevant bacteria species in contaminated platelet concentrates ute gravemann , frank tolksdorf , wiebke handke , thomas h. m€ uller and axel seltsam* . german red cross blood service nstob, maco pharma international, gmbh background/case studies: the theraflex uv-platelets system (macopharma) is a uvc-based pathogen inactivation system for platelet concentrates (pcs). inactivation efficiency has been shown for a broad range of viruses, bacteria, and protozoans. previous studies with the first set of bacteria species of the who international repository of platelet transfusion relevant bacterial reference strains revealed a high inactivation capacity for clinically relevant bacteria. aim of the current study was to investigate the bacteria inactivation efficacy of the theraflex uv-platelets system for enterobacter cloacae, pseudomonas fluorescens, staphylococcus aureus and streptococcus bovis which have recently been added to the who international repository. study design/method: pcs were produced from buffy coats using the additive solution ssp (macopharma) with a residual plasma content of %. for inactivation kinetics, pcs (n ) were spiked with bacteria to a final concentration of approx. colony forming units (cfu)/ml and irradiated with increasing doses until the full uvc dose was achieved. samples were taken for the bacterial titer determination after each irradiation step. for sterilization studies, two pcs were pooled and inoculated with bacteria to a final concentration of approximately . cfu/ml. bacteria were allowed to grow for h in the pcs at c under agitation. after splitting, one pc remained untreated (growth control) while the other one was uvc-treated. after storage for seven days, samples were taken from both bags for sterility testing by bactalert (biomerieux) and for determination of the bacterial titer in the untreated control units. results/finding: bacteria in pcs were inactivated in a dose-dependent manner by treatment using the theraflex uv-platelets system. mean log reduction factors ranged from to for enterobacter cloacae ( . . , pei-b-p- ), pseudomonas fluorescens ( . . , pei-b-p- ), staphylococcus aureus ( . . , pei-b-p- ), and streptococcus bovis ( . . , pei-b-p- ). pcs (n for each species) spiked with these different bacteria species were efficiently sterilized ( out of ). treated pcs remained sterile during storage for days, while bacteria in non-treated pcs grew to high titers of - cfu/ml. the theraflex uv-platelets system efficiently inactivates a broad range of different bacteria species, including the who reference strains. sterility is maintained over a storage period of days. these results suggest that the uvc-based pathogen inactivation technology will significantly improve the bacterial safety of platelet transfusions. transfusion transmissible infections among blood donors and strategy on direct laboratory testing cost of blood screening at national blood bank center, addis ababa, ethiopia abraham zewoldie*. national blood bank service background/case studies: blood and its components are life saving; however, they are also associated with life threatening hazards such as transfusion transmitted infections (ttis). hepatitis b virus (hbv), hepatitis c virus (hcv), human immunodeficiency virus (hiv) and syphilis are the most serious infections transmitted during blood transfusion. serious of blood shortages especially in developing countries and reliance on unsafe family replacement or paid donors also contribute to an increased risk of ttis. knowing the current prevalence of ttis among blood donors will be crucial in donor program strategy development and cost effective alternative strategies of blood screening are highly required especially in resource limited setup. study design/method: a retrospective analysis of blood donors' record covering the period from july , to july , was conducted. the data was collected from the nation al blood bank (nbb) center donor data base. in addition, direct laboratory costs of parallel versus sequential strategy of blood screening were compared using the current price of the laboratory costs. data was first exported to spss version software for analysis. data analysis was performed using scores and odds ratio using same software to look for an association between dependent and independent variables. p values less than . were considered significant. results/finding: a total of , consecutive blood donors were screened between and . the overall seroprevalence rate of hbv, hiv, hcv and syphilis of blood donors was . %, . %, . % and . % respectively. the hiv-hbv co-infection was higher among blood donors ( . %) followed by hbv-hcv co-infection whish accounts about ( . %). significantly increased sero-prevalence of ttis was observed in among family replacement donors, factory workers, daily labors and the age group of - . in this study the difference in cost between the current in use strategy (parallel) versus the newly proposed designed sequential testing algorism was , . ethiopian birr. conclusion: a significant percentage of the blood donors harbor ttis. the nbb center should work on voluntary blood donor mobilization and develop culture of voluntarism. the direct laboratory cost analysis using current in use strategy (parallel) was higher than the newly designed sequential testing algorithm. thus, the new strategy can be implemented to make screening of ttis cost effective in nbb center. transfusion transmitted malaria in a month old infant patricia davenport* , geeta paranjape and laurie sutor , . carter bloodcare, ut southwestern medical center background/case studies: in at a large pediatric hospital, a month old infant was supported for days by extracorporeal membrane oxygenation (ecmo). over this time blood products were transfused. about days after end of ecmo support, a routine blood smear examination revealed inclusions in some of the patient's red cells. the patient had also been having intermittent fever. malaria was confirmed by pcr as plasmodium ovale (p. ovale). because the patient had no other risks, the infection was suspected to be transfusion related and was reported to our blood center which had supplied all transfused products. study design/method: the investigation began by focusing on donors of red cell products, since the chance of an apheresis platelet product transmitting malaria is relatively small, and that of a frozen product is remote. we identified donors of red cell products. each donor was contacted and was asked four questions. additional questions were asked for clarification if needed. based on donor response, risk for active malaria infection was assessed. we also considered areas where p. ovale is, or is not found. donors identified as having possible risk were tested for antibodies and parasitic dna. results/finding: the five donors who had been ill all had common cold or bronchitis like symptoms. donors who traveled went only to non-risk areas. three donors were former residents of another country and may have risk because they lived in malaria endemic countries since birth and came to the u.s. as adults. it was discovered that one of these three did not meet all donor criteria. the donor had failed to disclose that he had not completed years stay in the u.s. after emigrating from cameroon, an area endemic for p. ovale. he had not travelled anywhere after coming to the united states in october and answered "no" to travel. antibody tests on this donor were positive for p. ovale and p. falciparum, but pcr tests were negative. another possible at-risk donor, a former resident of iran was tested and was pcr and antibody negative. the third donor has not yet been tested but the country of residence does not have p. ovale malaria. conclusion: while it could not be definitively proven that the donor with antibodies to p. ovale had active malaria at the time of donation, the donor was indefinitely deferred and referred to an outside physician for treatment. transfusion-transmitted babesiosis outside an endemic area: a case report german felix leparc*. oneblood background/case studies: an y.o. male patient was admitted to the emergency room for severe acute gastrointestinal bleeding, caused by an arterio-venous malformation later located in the proximal jejunum that was clipped endoscopically. during this admission, he received a total of units of red blood cells. approximately weeks later, he was re-admitted due to another episode of gi bleed manifested by melena. as part of his routine evaluation, a cbc was performed in which a blood smear revealed the presence of intraerythrocytic parasites consistent with babesia sp. study design/method: upon notification of a suspected case of transfusion-transmitted babesiosis, lookback of all donors involved in prior transfusion event was initiated. results/finding: to confirm the presumptive diagnosis of babesiosis, pcr was performed and babesia microti dna was detected. an evaluation of the patient's risk factors revealed that prior to the gi bleed episode for which he received transfusions, eight months earlier he was also transfused during open heart surgery. no travel history to the us midwest, and while he travelled to new england two years ago he did not spend time outdoors. he was splenectomized in his mid 's. donor lookback identified a donor who lived in new london county, connecticut but spent the winter season in central florida, where the blood donation (double rbc collected by apheresis) took place. he had never been diagnosed with babesiosis, but participated regularly in outdoor activities in connecticut that put him at risk for tick bites (although he never noticed being bitten or showing signs of it). upon testing, he was found to be negative for b. microti on pcr as well as igm antibodies, but had igg antibody titers of : . the recipient of the other rbc unit collected in the same donation was deceased within hours of transfusion, so no follow up could be performed. during phone interviews, none of the remaining donors had risk factors for babesiosis, and all but four were tested and found serologically negative. conclusion: while transmission of babesiosis through the zoonotic route is confined to regions were the appropriate hosts and vector coexist, people from areas where it is endemic may establish temporary residency and donate blood in non-endemic locations facilitating transmission through transfusion as illustrated in this case. once licensed assays for babesia microti become available, testing schemes will have to be formulated through policies that take this issue into consideration. transfusion-transmitted stenotrophomonas maltophilia from a red cell unit: a case report ashley c gamayo* , andrea j linscott and donny dumani . background/case studies: transfusion-transmitted bacterial infections (ttbi) are rare, but serious complications of blood product transfusions. from - , % of transfusion-associated fatalities reported to the fda were attributed to bacterial contamination. red cell units are rarely implicated in severe and fatal ttbi. when present, contaminants are often gram-negative rod (gnr) bacteria with psychrophilic properties. we present a case of a sickle cell patient who developed definitive sepsis after receiving a red cell unit contaminated with stenotrophomonas maltophilia (s. maltophilia). study design/methods: a -year-old female with sickle cell disease was admitted to the hospital for possible pain crises. pre-transfusion blood and urine cultures collected on day of hospitalization showed no growth after five days. on day , the patient required a blood transfusion for which she was issued a cmv-safe, irradiated, hbs-negative, crossmatched, o-negative red cell unit. the ml unit had been aliquoted via sterile connecting device days prior for a pediatric patient. all ml of the pediatric aliquot were transfused without adverse effects. the patient's pretransfusion temperature was . c. within minutes of starting the transfusion, the patient's temperature increased to . c and subsequently reached a maximum of . c. the transfusion was stopped and the blood bank notified immediately. gram stain of the remainder of the transfused component revealed gnr bacteria. blood was collected from the patient for culture and antibiotic treatment initiated. results/findings: initial transfusion reaction work-up revealed no evidence of clerical errors with negative post-transfusion antibody screen and direct antiglobulin test. blood cultures from both the patient post-transfusion and the implicated red cell unit grew gnr bacteria identified as s. maltophilia. further microbial testing revealed the cultured pathogen was able to proliferate at - c; a finding not characteristically observed in s. maltophilia. conclusion: this is the first definitive case of ttbi with s. maltophilia. this bacterium is a globally emerging gnr that is widely spread in the environment, causing both community-acquired and nosocomial infections in immunocompromised and debilitated patients. contamination was unlikely due to an asymptomatic donor. there was laboratory evidence of the pathogen in both the transfusion recipient and the transfused component. the patient was not infected with the pathogen prior to transfusion, and no other potential exposures could be identified. the patient recovered following appropriate antibiotic treatment, but endured prolonged hospitalization. the transfusion reaction was classified as definitive, severe tti of definite imputability. validation of commercial immunoassays for detecting hbsag and hiv antibodies in production pools karen leighton, izekial butler and scott jones*. qualtex laboratories background/case studies: plasma fractionators test plasma production pools for hbsag and hiv antibodies as a qualitative limit test for the control of impurities, to safeguard against errors in donation testing or pooling. the european medicines agency (ema) has published guidelines for the validation of immunoassays for the detection of hbsag and hiv antibodies in production pools. the aim was to validate commercial immunoassays for the testing of production pools for hbsag and hiv antibodies utilizing the ema guidelines. study design/method: a lower calculated cutoff value for the abbott prism hbsag and hiv o plus assays was determined by calculating the mean signal-to-cutoff ratio (s/co) plus standard deviations of four different types of plasma production pool samples. the calculated cutoff values were utilized for the rest of the validation. the detection limit was determined by testing in triplicate, serial dilutions of who hbsag and hiv antibody standards diluted in plasma. a normalized detection limit was calculated for the hbsag assay using production pools containing low, typical and high anti-hbsag titers. intra-assay variability was determined by testing a minimum of determinations of a low positive control in run. inter-assay variability was determined by testing at least representative negative production pool samples, at least low positive sample (about s/co) and a titration series of who standard spiked into plasma production samples. runs were performed on six separate days using two different instruments and two different lots of assay reagents. results/finding: the lower calculated cutoff values for the hbsag and anti-hiv assays were both below the manufacturer cutoffs of . and were . and . respectively. the hbsag assay detection limit was . iu/ ml for source plasma and . iu/ml for recovered plasma samples. the normalized detection limit study demonstrated that one and a half hours was the maximum amount of time the pool samples could sit at - c where all samples were still reactive for hbsag. the anti-hiv lowest positive dilution for all replicates varied between : , to : , , depending on subtype and group. the % cv of the s/co values of the replicates of the intra-assay variability validation were less than % for both assays. the %cv of the s/co values of the panel of samples of the inter-assay variability validation were less than %. conclusion: a lower calculated cutoff value could be determined for commercially available immunoassays for hbsag and anti-hiv. these immunoassays could meet all of the recommendations in ema validation guidelines. the abbott prism hbsag and hiv o plus assays can be utilized to test production pool samples. was performed on donors ( - days after the index donation) - donors in the follow up study and tested by the doh. no donors tested by the doh participated in the follow up study. follow up testing was negative for all donors. denv antibodies were negative in donations and equivocal in . our initial reactive rate is higher than that reported to date for the procleix zikv tma of per , [p. williamson, et al transfusion, in press] . conclusion: universal testing under ind was successfully implemented and incorporated into blood center operations. we have noted an initial reactive other demographics that should be analyzed for their potential to be used to predict cmv seroconversion rate include gender, age, race, ethnicity or a combination of these. background/case studies : growing the geographic footprint has been a priority for the organization since . over a four year period, the organization doubled the number of blood centers, with continued growth expected. with the current challenges in the blood industry, the audit program needed to be flexible, maximizing efficiency and capacity utilization, and without increasing compliance risk. the internal audit function was centralized in late , for which the program consisted of types of audits, an operational compliance audit and a support systems compliance audit. each type was performed twice per year at each main center. this model was no longer serving the changing organization. study design/methods: lean six sigma concepts were applied to this project. survey results and brainstorming aided in capturing the strengths of the current program, opportunities for improvement, and ideas for a redesigned program. this information was the primary input to the swot analysis (strengths, weaknesses, opportunities, and threats) for the purpose of understanding performance of the current program, as well as elements that could impact the future design. potential solutions were placed into a pugh matrix, which was used to facilitate a disciplined, team-based process for concept generation and selection. each potential solution was compared to criteria for evaluation and selection of the best solution. results/findings: the program was re-designed to perform internal audits annually as a single, team-based comprehensive audit. remote auditing was incorporated to require less on-site time, less disruption, improved auditor work/life balance, and cost savings. a formula was created to determine on-site audit time that included adjustable risk factors. the audit reporting process was also automated for simplification, efficiency, and to meet stakeholder needs. the team-based approach leverages auditor strengths, fosters a learning environment, and increases detectability of organization-wide concerns. conclusion: the comprehensive team-based approach, and other program improvements, has been effective in responding to organizational growth without sacrificing quality or increasing compliance risk. external inspection performance has achieved record performance levels the past year. diversity of auditor skills led to a stronger skill presence, which was consistently applied across system. auditing is more efficient and effective. stronger collaboration among audit team members provided stronger objectivity, fairness, and consistency across the system. auditors and auditees have increased in knowledge, and the internal quality audit program has improved. background/case studies: in many places, blood banking is using semiautomated systems to perform fractioning in different blood components (red blood cells, platelets and plasma). banc de sang i teixits (bst), adopted the fully automated reveos system (terumo bct inc, lakewood, co) few years ago to manufacture blood components. in june , bst started a validation of new blood bags manufactured by terumo bct with different variables on platelet volume after processing and a kit to perform platelets pools with a new filter. study design/method: to perform this validation, blood donations were used under different conditions (see table below ). the current filter evaluated for the platelet pool (lrf-xl, haemonetics corporation) was compared to a new filter (terumo bct inc.). the new blood bags were manufactured using a new vinyl supplier. a portion of these processed blood components (red blood cells, platelets and plasma) was used for different quality control (qc) tests (routine qc performed at bst following european directorate for quality of medicines & healthcare; cytokine analysis, such as p-selectin and platelets recovery through the filter). results/finding: the results are very similar between both bags, current and new one, as well as filters. all the analysis done to evaluate the quality of the blood components were similar in all conditions. also, it was shown a better performance on platelets pools, when they came from bags centrifuged with ml of plasma, vs. ml of plasma and additive solution. conclusion: these new bags and filter have shown a similar behavior when using them for manufacturing blood donations with reveos system in our blood bank. regarding the new platelets pooling kits, a better manipulation by the operator was observed; although the tubing is shorter and it meant being more difficult when manipulating the pools. no issues should be found if they are implemented in routine use. it's planned to start this implementation during this year, ; so then there will be larger results in order to have a proper procedure qualification. conclusion: patients requiring rare blood products are rare, and those lacking high prevalence antigens are the most challenging for whom to obtain antigen negative blood. it is clear that some requests for exquisitely rare types are not able to be filled with current donors. molecular testing of large numbers of donors has likely helped to identify more rare donors in recent years. it is recognized that commercial platforms do not include many of these making these rare types even more challenging to find. consideration should be given to testing more donors of all ethnicities to identify more rare donors. recommendation # : updating donor educational material to provide more comprehensive information on risks of iron deficiency and recommendations on iron supplementation. updating our educational materials will likely have a minor impact. recommendation # : implementing strategies such as iron supplementation, ferritin testing or increasing interdonation intervals for all donors or those groups most at risk for iron deficiency. initial implementation would likely be either iron supplementation or ferritin testing for at risk groups only and implementation of either one of these strategies would potentially affect over , donors. the recommendation to limit the number of donations would have a substantial impact. for this analysis, the focus was on - year olds and premenopausal women (ages - ) donors. on average, - year olds donate . times a year and premenopausal women donate . times a year. if both of these groups were limited to donating once a year, a total of , donations from - year olds and , donations from premenopausal donors would not be collected. conclusion: after analyzing the impact of the aabb association bulletin # - , the bulletin will have a significant impact on both donors and our local blood supply. more than half of donors would receive either ferritin testing or iron supplementation. if the only measure employed is limiting the number of times a donor could donate for - year olds and premenopausal women, this recommendation would have a substantial impact on our ability to provide blood products to local hospitals. background/case studies: transfusion medicine knowledge deficits are apparent among medical students, residents and practicing physicians. these deficiencies may be due to the frequency and type of education. the majority of medical students in the united states receive four or fewer hours of transfusion medicine education. the transfusion medicine academic award group published educational content guidelines for medical school, residency and fellowships. however, the frequency and educational methods remain poorly evaluated and with little guidance. we investigated the effects of different educational techniques on transfusion medicine knowledge acquisition in novice learners. study design/method: three educational pathways were developed to teach principles of transfusion medicine while allowing learners to recognize problems and develop solutions for transfusion medicine complications. the simulation group received all educational activities within a . hour inperson, high-fidelity live session. the hybrid group received some educational component online and also attended an in-person high-fidelity simulation session. the online only group received all educational materials online, including a pre-recorded-video simulation session. the learners were second year medical students enrolled at one institution. the same faculty members taught all live sessions and developed all online materials ensuring the content was the same. a pre-and post-test was created to address blood groups, blood donation, blood testing, blood component indications and transfusion complications. the educational session was evaluated by the likert scale survey which ranges from zero (poor/unsatisfactory) to five (outstanding). results/finding: % ( / ) of the simulation group students improved their post-test scores and had an average likert scale rating of . (very good). % ( / ) of hybrid group students improved their post-test scores and had an average likert scale rating of . (very good). % ( / ) of online only students improved their post-test scores and had an average likert scale rating of . (good). the average changes in scores were statistically significant within all training groups (p value < . ). additionally, the simulation group had a larger increase in average post-test scores when compared to the online only group (p< . ) and the hybrid group (p< . ). conclusion: our study demonstrated that a faculty taught high-fidelity transfusion medicine simulation curriculum consisting of an in-person didactic session and simulation session for second year medical students produces greater knowledge acquisition compared to an online only or hybrid curriculum. the high-fidelity simulation curriculum is also preferred over the online only education as indicated by the likert survey results. aaron j wyble*, yeon mi kim and barbara j bryant. university of texas medical branch background/case studies: diagnostic management teams (dmts) are an innovative way to bridge the communication gap between the laboratory and clinical services thereby facilitating the delivery of improved patient care. dmts employ a multidisciplinary approach which integrates clinical and laboratory data into succinct interpretations and recommendations. the interpretations must be of moderate to high complexity in order to be clinically valuable. recommendations are made regarding future testing, timing of testing prior to blood component needs, and other pertinent concerns to allow for improved coordination of patient care. the timeliness of the dmt reporting is vital to patient management. the inherent design of a dmt also provides an educational opportunity for trainees at academic centers. study design/method: the transfusion medicine service at a large university-based academic medical center implemented a dmt in . all cases involving complex antibody identification workups, transfusion reactions, deviations from standard operating procedures, consultations for blood component utilization, and massive transfusion protocols from july through january were evaluated by transfusion medicine residents. the electronic medical record (emr) of each patient was also reviewed to determine relevant clinical history. all significant findings were presented at the transfusion medicine dmt conferences. the dmt was comprised of physicians from transfusion medicine, hematology/oncology, anesthesiology, transfusion service technical staff as well as visiting clinical staff from surgery, obstetrics and gynecology, transplant services, and pediatrics. the dmt integrated the clinical and laboratory data to formulate relevant interpretations and recommendations. the final dmt reports were placed into the emr for access by health care providers. financial benefits of a transfusion medicine dmt were also evaluated. results/finding: in a -month period, cases of complex antibody identification workups ( %), transfusion reactions ( %), consultations for blood component utilization ( %), and deviations from standard operating procedures and massive transfusion protocols ( %) were presented at the transfusion medicine dmt conferences. the placement of dmt narratives in the emr as progress notes and laboratory reports provided informative and timely communications. residents participating in dmts demonstrated improved clinical and laboratory correlation skills. as a result, resident competency in transfusion medicine was enhanced. over $ , of revenue was generated utilizing the standard professional component cpt codes. conclusion: dmts encompassing multiple aspects of transfusion medicine improved patient care through enhanced communication between laboratory and clinical services. additional benefits of a dmt program include resident, clinician, and technical staff education and the generation of revenue for the institution. streamlining a blood center and hospital transfusion service supply-chain with an informatics vendor-managed inventory solution hamilton c. tsang* , david lancaster , dianne geary , robert scott , anh thu nguyen , adam garcia , raina shankar , leslie buchanan and tho pham . stanford health care, stanford blood center background/case studies: inventory management is both a major challenge and an integral part of hospital transfusion service (hts) and blood centers (bc) operations. the current process at our institution involves twice-per-day shipments from the bc to the hts, with each shipment predicated upon current stock levels at hts. manually obtaining inventory levels for each product is time-consuming. the manual determination is also errorprone. we aim to enhance inventory management operations by developing an informatics solution to ( ) streamline the ordering process to accurately reflect inventory status and transfusion practices and ( ) re-allocate valuable hts tech time. study design/method: at our hts, the general inventory accounts for over product categories broken down by component, blood type, irradiated status, and cmv-serology status. we therefore sought to establish an electronic method to reliably infer the general inventory level. since the raw electronic inventory report comprised both the general inventory and physically sequestered units (e.g. special antigen units, cross-matched units), over a -month calibration period we performed linear regression between electronic and the gold-standard manual count to impute from the electronic census the number of units of each product category in the general inventory. once we had a reliable electronic method to determine inventory levels, we implemented a -month pilot period. we analyzed various metrics pre and post pilot implementation to ensure non-inferiority of our electronic system: ( ) the ratio of units transfused per week to the number stocked (t:s), ( ) the number of products ordered as stat, and ( ) the number of expired products. we created in-house programs on visual basic for applications (microsoft, redmond, wa) for both the calibration and pilot periods. lines of code were written for both programs, including class modules and distinct subroutines. results/finding: during the pilot period, we investigated our system's noninferiority. the average weekly t:s ratio for cryoprecipitate, plasma, and rbc, respectively, were . , . , and . before the pilot period compared with . , . , and . during the pilot period. these differences did not reach statistical significance (p . ). we also monitored the number of stat ordered products before and during the pilot period, which were and stat units per week, respectively (p . ). lastly, we also monitored the number of monthly wasted products due to expiration as an indicator of inventory mismanagement before and during the pilot period, which were and units, respectively (p . ). an estimated hours per week of technologist time was reallocated to other tasks once the electronic census was adopted. this translates to . fte and $ , per year saved from labor costs per year if permanently adopted. conclusion: we created an in-house electronic ordering system to enhance information fidelity, re-allocate technologist time, and further standardize ordering. our system showed non-inferiority to the labor-intensive manual system, by not changing the number of stat orders, having the same t:s ratio, and not increasing the number of expired products. this is achieved while freeing up over hours of staff time per year. future directions include full automation with involvement from hts informatics department. transfusion practice improvement: gaining traction through the use of a provincial transfusion quality improvement plan denise evanovitch* , yulia lin , troy thompson , allison collins and sheena scheuermann . ontario regional blood coordinating network, sunnybrook health sciences centre background/case studies: a provincial regional blood coordinating network (prbcn) held a "quality focus day" (qfd) in to explore transfusion quality indicators to be included in a province wide quality improvement plan (qip). the plan's main goal is to reduce patient harm by improving transfusion practice in hospitals through the reduction of inappropriate use. the following recommendations were made: select a blood component that most hospitals could monitor display progress in a public forum so that hospitals could compare themselves to peers strike a province-wide transfusion qip committee to guide the development of the plan, supporting resources and ongoing improvement initiatives study design/method: a provincial transfusion quality improvement plan (ptqip) committee was formed and included broad representation: the provincial patient blood management coordinators, physicians, technologists, nurses, administrators, clinicians, quality/risk managers from all regions of the province and the provincial blood advisory committee, the blood supplier and a patient. there was further collaboration with other organizations such as the provincial health quality division, choosing wisely after the launch, an informal survey indicated that of the province's hospitals were interested or had already adopted portions of the ptqip. to further assist hospitals in advancing their qips, a technologist prospective screening educational module was developed in addition to an electronic tracking tool with which hospitals can enter their baseline data and subsequent audit data and track their success. both hospital and provincial reports can be generated from the tracking tool. a more formal survey conducted in indicated that % plan to implement or already have implemented the ptqip and % of the respondents already have put prospective order screening by technologists in place. conclusion: helping hospitals through the development of standardized templates, instructions, education and other tools for transfusion quality improvement increases the ability of hospitals to uptake quality improvement initiatives. taking a standardized approach across the province allows for both aggregate and hospital data comparison analyses. background/case studies: military and civilian trauma-based studies have demonstrated the advantages of transfusing blood products prior to a patient's hospital arrival, a process known as pre-hospital transfusion (pht). helicopter emergency medical services (hems) worldwide have implemented this protocol with great success, despite a current lack of guidance or advisory publications. there is a need for literature that addresses the regulatory requirements and logistical challenges associated with developing a pht program. herein, we report our experience as a large hospital system embarking on the development of a multi-state pht service. study design/method: in october a work group was formed to establish pht services for the hems providing care to over thirty regional hospitals. composed of flight care staff, emergency physicians and transfusion medicine specialists, the group identified the major tasks to be addressed: federal/state regulations; inventory structure/management; product storage/testing; tracking/traceability; emergency release protocol; and staff training. while there are no specific regulations governing pht, the regulations pertaining to blood product storage, validation, and monitoring apply. the fda, aabb, and state agencies were each consulted to ensure compliance with all directives. results/finding: the largest hospital within this system, already acting as a reference site, was designated to perform all confirmatory testing on products supplied to the multi-state hems. similarly, this hospital was tasked with remote monitoring of all blood refrigerators at the helipad sites. the system's fda licensed blood supplier was deemed responsible for product consignment and transport between the four hems sites. the blood inventory at each site was designed to contain: group o positive rbcs, group a low anti-b titer liquid plasma, and four-factor prothrombin complex concentrate. a military-tested in-flight medical record system will be used to transfer transfusion information to non-affiliated hospitals as needed. validated inflight coolers, protocol for product emergency release, inventory tracking system, and re-stocking schedule were also requisite to this plan. staff competencies regarding emergency release guidelines, transfusion reactions, and the handling/storage of products are maintained by the hems medical director with additional oversight provided by transfusion medicine physicians. conclusion: our work group successfully identified the challenges associated with a multi-state pht helicopter based service, which spans blood product management, adaptation of existing transfusion procedures and operating policies, licensing requirements, and personnel training. our pht service will go live in . publishing this experience may benefit future sites as they launch similar pht initiatives. blood transfusion during humanitarian emergencies yetmgeta e. abdella* , rana hajjeh and cees th. smit sibinga . world health organization regional office for the eastern mediterranean, international quality management (iqm) consulting background/case studies: more than million people are affected by humanitarian emergencies in the eastern mediterranean region of the world health organization (who), where some of the most affected countries in the world are located. in these countries, the health systems have been weakened or destroyed and health workers provide health services under difficult circumstances. humanitarian emergencies increase the demand for blood transfusion and make its delivery challenging and complex. despite these obvious needs, across the region, there is a lack of information on the emergency preparedness and response capacity of blood transfusion and on the challenges countries and health responder's face in meeting the needs of the patients during emergencies. study design/method: we searched pubmed and index medicus for the who eastern mediterranean region for data on availability and safety of blood transfusion in humanitarian emergencies. we conducted a structured survey of blood transfusion services (bts) in all countries in the region to identify the following: type of humanitarian emergencies between and ; current strategies to ensure availability and safety of blood transfusion during emergencies; coordination and collaboration between countries; and gaps and challenges. additional information was collected during a regional consultation (eastern mediterranean region) held in may in tunisia. results/finding: we found publications on disaster from five countries in the region and publications on disaster preparedness and blood transfusion in casualties and severe trauma outside the region. however, none dealt with the questions of availability and safety of blood transfusion during emergencies. twelve countries ( . %) responded to the survey. armed conflicts and terrorism are the commonest types of emergencies with estimated - % of the injured requiring blood transfusion. nine countries have emergency preparedness and response plans for bts. potential blood donors are mobilized through public calls, besides a direct appeal on regular and replacement donors. seven of the responding countries keep an emergency blood stock. collaboration between the different stakeholders exists in seven countries. lack of adequate and competent human resource, transport and cold chain deficits, shortages in supply of consumables and maintenance of equipment, lack of reliable power supply, and shortage in finances are the gaps identified. conclusion: there is a need to integrate bts in the overall national emergency preparedness and response, collect and disseminate updated information on factors affecting provision of blood transfusion in humanitarian emergencies, provide technical and financial assistance to affected countries, strengthen mechanisms for coordination and collaboration among different parties, and develop a regional emergency blood services system and management expertise. ( , , and for - ) . the number of collections per registered trt donor varied significantly, ranging from to therapeutic draws/donor per year. excluding those that didn't present for a therapeutic blood collection, the average number of trt collections/donor per year decreased from . to . between and . conclusion: our blood center has experienced an increasing number of therapeutic phlebotomies, as well as individuals on trt referred for therapeutic phlebotomy due to elevated hemoglobin values from through . it is not clear from information provided by the ordering physician whether this is intended as a temporary measure to decrease the hemoglobin while the patient is on trt, or whether the dose was being adjusted or discontinued due to the known risk factor of cardiovascular disease in patients with polycythemia; however, the average number of donations per trt donor decreased during this timeframe. the percentage of men on testosterone who present as regular blood donors at our blood center is not known, since this hormone is not reason for deferral. our findings raise the concern, however, that regular phlebotomy is necessary to reduce the risk of testosterone-associated polycythemia in this population. as it is our duty to provide a safe and adequate blood supply, our blood center also has concerns about perpetuating the misperception that repeat phlebotomy, particularly if required more frequently than days, is sufficient to mitigate the risks of testosterone therapy. hence, we have made the decision to discontinue offering phlebotomy services to this population of donors other than for those on testosterone that meet all donor eligibility requirements. approaches involving the use of a vein illumination device in a blood donor center sara matheson*, kimberly j duffy, audrey e traun, mary m benike, james r stubbs and justin d kreuter. mayo clinic background/case studies: venipuncture is a critical step in blood collection and locating a suitable vein for this procedure can be a challenge. unacceptable vein selection or incorrect needle placement can lead to incomplete collection or infiltration. in a blood donor center, the primary selection of a vein is done by palpation within the antecubital area. prior to needle insertion, the skin at the site must be prepared and contact avoided until after needle is placed. vein illuminator (vi) devices are available to aid in visual display of potentially suitable veins. such a device was made available to staff in march of . after an initial testing and instructional period, the vi has since not been used by staff. the objective of this study is to discover reasons why staff does not use the vi to identify potentially suitable veins. study design/method: a staff survey was developed and distributed to staff in march to inquire about usage of the vi and obtain feedback about the device. at the time that the survey was sent, the device had been available for several years. the survey included questions involving frequency of use, adequacy of training, comfort with using the device, knowledge of the device's storage location, willingness try the device, and general feedback. results/finding: the survey had a % response rate (n ). of these, . % have never or very rarely utilized the vi. self-reported reasons for low utilization focused on two dominant themes. first, that the device is not needed and second that it doesn't accurately show veins. . % of respondents are aware of where the vi is stored and a more accessible location to share the device was not identified. although . % of respondents have been provided training on using the vi, the group was mixed regarding their comfort level in using the device independently. only % of the group was willing to try vi. conclusion: infiltration and incomplete collection account for approximate % ( units/year) of qualified blood donors, yet vi does not appear to be a viable solution for our blood donor program. there seems to be both an opportunity and challenge with vi implementation. the opportunity is to create critical awareness of problems with vein cannulation. the challenge is to identify a device that is more effective at visualizing deeper veins necessary for blood donation. benefits of converting from mcs to alyx penny schroeder* and elizabeth parker. indiana blood center background/case studies: in , apheresis red cells (arc) represented . % of total red cell collections at our center. hae mcs ln was utilized to collect arc. due to the age of the instruments, challenges with collections on mobiles as well as the need to increase collection of right type products, the decision was made to change technologies. study design/method: fresenius kabi demonstrated the fenwal alyx technology as well as the business case to the primary stakeholders. all implicated departments were involved in the initial impact assessment. a multidepartment kick off meeting was held and project team formed. due to product demands, the decision was made to validate arc and plasma apheresis. the primary departments affected were blood collection and production. fresenius kabi provided sample validation plans, sops, training and training materials for use. four mobile-carts were purchased for easy transportation of alyx and quick-connect feet for installation on mobile buses. the lead trainer and the bc technical administrator traveled to an affiliate blood center to observe their alyx program and identify best practices. a team of blood collection trainers and preceptors were the initial group trained and validation performed. this team also served as the subject matter experts and field preceptors. fresenius kabi returned for advanced alyx operator training. the training plan targeted previous mcs operators first and then operators new to apheresis with a training goal of % of mobile staff. validation of the alyx began / / and took approximately days to complete. during this time, fresenius kabi conducted alyx education and apheresis recruitment training to all collection and recruitment staff. the mcs machines were removed from service / / . alyx go-live occurred / / . additional operator training continued through september . results/finding: due to ease of mobility and use of alyx, reduced procedure time compared to mcs and donor conversion training we increase components collected. alyx disposable kit includes pre-attached solution containers reducing ancillary items required to pack and carry to mobiles. this decreased kit cost by $ . each providing an estimated annual savings of $ , . conclusion: with the multiple alyx donation types we were able to increase our collection of right type procedures by approximately . % and decrease our kit costs by %. with alyx the collection plasma on mobile blood drives is now possible. due to ease of use, operators have embraced this technology and we have consistently met our monthly collection goals from october -march . background/case studies: high frequency of donation is a risk factor for iron deficiency. because females' iron stores are generally lower than males' before they start their donation career, females who donate frequently are particularly high risk. minimum hemoglobin (hb) has long been the same for males and females at g/l, but for males this falls below the normal limit. as a first step to mitigate iron deficiency, criteria for whole blood donors were modified for males (minimum hb increased to ! g/l) and for females (minimum interdonation interval increased from to days). the longer interdonation interval in females was gradually implemented, starting with donor messaging in october , changes in rebooking of donation appointments in december and culminating with eprogesa criteria changes on march , . both these changes are expected to initially result in donation loss, but may be partly counteracted by a decrease in hb deferral rates in female donors. we aimed to assess the impact of these changes on hb deferral rates. study design/method: percentages of hb deferrals were calculated as the number of donation attempts that resulted in hb deferral divided by the number of successful donations plus hb deferrals multiplied by . percentages were calculated for male and female donors before and after changes were made. results/finding: the percentage of hb deferrals increased in male donors from . % in the weeks pre-implementation to . % in the weeks post-implementation of the change in the hb criterion. hb deferral rates for female donors were . % in september, . % in october/november, and . % from december to march, . conclusion: hb deferral was more frequent in male donors after the minimum hb was increased to g/l. the gradual implementation of increased interdonation interval for females resulted in a reduction in deferrals, thus the initial donation loss associated with this change may be partly offset over time by decreased hb deferrals. a longer observation period is necessary to confirm these findings and assess impact on phenotyped blood and donor retention. in the past years, , blood products, derived from , procedures, were distributed to different investigators in over laboratories. whole blood was the most common product ( . %), followed by unmanipulated mononuclear cell collections ( . %), and elutriated monocytes or lymphocytes ( . %). less common requests included platelets ( . %), plasma ( . %) and granulocytes ( . %). adverse donor reactions were infrequent ( . % of procedures). conclusion: we report the feasibility of a program for collecting and distributing blood for investigators to obtain blood components for in vitro research use, utilizing the staff and resources of a hospital-based blood bank. research blood donation is essential to support laboratory research and to maintain positive relationships with donors who have been deferred from allogeneic transfusion. hospital-based blood donor center's experience with implementing platelet pathogen reduction system kimberly j duffy*, mary m benike, james r stubbs and justin d kreuter. background/case studies: the safety of platelet products has been continually improving due to testing despite the continued emergence of microbial threats. the recent fda approval of platelet pathogen reduction technology will protect transfusion recipients regardless of the new microbial dangers. in order for platelet products to use the pathogen reduction technology, the volume, platelet yield (dose), and concentration must be collected within tight specifications. the objective of this study was to determine the optimal collection settings to enable % collection of pathogen reduced platelets while limiting the loss of products. study design/methods: the collection instrument evaluated for this study has fda approval for platelets suspended in % plasma. the corresponding pathogen reduction system used for the study has kits with different collection specifications. all apheresis collections occurred at a fixed site and pre-platelet counts were performed on a hematology analyzer. the yield scale factor has been established for correlation between the hematology analyzer and apheresis collection device. in order to determine the optimal collection targets, the apheresis collection instrument had a variety of multiple yields and volumes established for collections. staff was instructed to collect the highest available yield per donor. after collection, volume, platelet yield, and concentration data was obtained. this data was used to determine if the product met the specifications for one of the available kits, and if the actual platelet yield was higher than . x , thus meeting the criteria for a double product. results/findings: a higher platelet concentration product is ideal to produce a double product, but targeting products with a platelet concentration greater than x /ml was more likely to be outside the specification of the pathogen reduction kit. the platelet concentration target of x / ml results in discarding products and was quickly removed from instrument settings. collections with a platelet yield as low as of . x and platelet concentration of x /ml were more likely to produce a product that was not within the specification of the pathogen reduction kit. abstract conclusion: the loss of both triple platelet products and lowered postprocessing platelet recovery requires the collection of platelets to be far more precise. the goal of platelet collection has shifted from simply maximizing each platelet collection to an approach that considers optimal collection within the limits of kit specifications. final collection instrument configurations are platelet yield of . x and . x at the volume of mls and platelet yield of . x , . x , and . x at the volume of mls. moving from subjective to objective donor eligibility screening platforms: a blood center's journey angela dirr* and steve cihura . bonfils blood center, bbc / bsi background/case studies: in , the device used by bonfils blood center to determine donor hemoglobin and donor eligibility was reaching its end of life, and bbc needed to define a path forward for a reliable replacement device. study design/method: bbc evaluated devices with the following criteria in mind: ) device disposable costs, ) reagents/controls/quality control, ) objective hgb/hct measurement, ) portability and durability for a mobile environment, ) ease of use, ) donor experience, ) battery life, ) validation requirements plans, ) blood center suitability, and ) ability to link to becs. multiple departments including donor care, equipment management and validation, quality, and regulatory affairs were involved in the evaluation and product selection. bbc tested donors per each device at both a fixed and a mobile site. bbc also considered donor feedback for the choice of replacement technology. the project started february with a targeted implementation date of july . after creating necessary sops and adopting existing sops, bbc successfully completed the validation of the devices, and chose the compolab technology from fresenius kabi as the new device for bbc blood bank. results/finding: the compolab was selected as it met project scope and selection criteria. it was important for bbc to reduce paperwork and daily tasks. the compolab eliminates daily qc reducing paperwork, time and improves error management. after converting to the new technology, bbc donor deferral rates increased by approximately %. as a consequence to this increase, bbc conducted reminder training with bbc staff to ensure proper sampling technique and higher sample quality. over time, bbc deferral rates stabilized to . % in and . % in . during this time period, bbc also successfully recruited new blood donors to bbc program, which may have contributed to an increase in deferral rates. in , the deferral rate increased again, probably due in part to the fda final rule "requirements for blood and blood components intended for transfusion or for further manufacturing use", which went into effect in may . conclusion: during the evaluation for new equipment, bbc learned that it is critical to understand the equipment's life cycle and the effect the equipment has on all aspects of the business. after comprehensive evaluation of multiple donor eligibility screening platforms, the compolab device was selected at bbc facility. it met the majority of all aspects of the project scope and qualifying criteria. bbc also learned that continuous refresher training of the staff ensured optimal device performance, and how external factors such as changes to the regulatory environment may impact deferral rates. flowmetry on platelet apheresis. tetsu yamamoto* , ayumi araki , hiromi sanyoshi , hiromi kanai , hiroya kikuchi , katsushi tsukada and kazuhide mure . hokkaido red cross blood center, japanese red cross hokkaido blood center background/case studies: vasovagal reaction (vvr) is known to be the most common adverse reaction to blood collection, but effective measures for preventing vvr have not yet been developed. effective timing of interventions during apheresis donations in particular should hold the key to predicting vvr, but no research has been done on the topic. study design/methods: this study investigated the potential to predict vvr from fluctuations in peripheral blood flow measured by laser doppler flowmetry in platelet apheresis donors, a population highly likely to experience vvr. data were collected from individuals who donated platelets during the -month period between february and august , and data from the donors who experienced vvr were analyzed. to calculate the level for issuing vvr alert, the percent decrease in blood flow (dbf) and the percent decrease in heart rate (dhr) were calculated, the time from alert to vvr was estimated for three dbf levels, and the detection performance of each alert level was calculated. results/findings: eight of the men ( . %) and of the women ( . %) experienced vvr. one donor did not experience vvr during blood collection, but had a delayed reaction while resting afterward. mean maximum dbf in the donors in the vvr group was . . %, which was significantly higher than the . . % in the non-vvr group. at a maximum dbf threshold of %, sensitivity for discriminating between vvr and non-vvr donors was . % and accuracy was . %. when % dbf was used as the alert level, alerts were issued for donors, including in the vvr group. therefore sensitivity for predicting vvr was . % and specificity was . %. mean time from alert to diagnosis in the vvr group was . . minutes, and accuracy of the alert was . %. some of the vvr could not be predicted even the value of maximum dbf exceeded %. the reason was supposed to be the difference of donor susceptibility on dbf. conclusion: we investigated whether vvr in platelet apheresis donors can be prevented by prediction and found that it is possible to predict vvr early enough before onset to intervene by monitoring dbf in real time during blood collection using laser doppler flowmetry. future research must also investigate whether the incidence of vvr can actually be reduced by interventions such as adjusting extracorporeal circulation. the risks of alloimmunization in sickle cell patients using c, e, k negative blood: experience of a hospital apheresis and transfusion service grace banez sese* , , salam abdus and shabrina shah . inova blood donor services, inova fairfax medical campus, inova fairfax medical campus transfusion services background/case studies: red blood cell (rbc) transfusion is often a lifesaving measure for patients with sickle cell disease (scd). it is critical in the management of scd complications such as splenic sequestration, stroke, priapism, iron overload and acute chest syndrome. a wellrecognized complication of chronic transfusion in scd patients is alloimmunization to rbc antigens. to prevent alloimmunization, transfusion with rbcs negative for c, e, and k antigens has been advocated. this has led to reports of reduction in the rate of alloimmunization and a decrease in hemolytic transfusion reactions. we report a summary of our three year experience with the prophylactic transfusion of rbc units negative for c, e, k antigens for scd patients during red blood cell exchange transfusions (rbcx). study design/method: retrospective review of scd patients with a history of stroke, refractory sickle pain crisis and priapism was done. rbcx was performed every to weeks from december to march . blood bank work-up used the mts gel method for antibody screen and identification. our hospital-based donor center proactively works with the hospital blood bank in preparing these units in a timely manner. results/finding: a total of patients, females and males, who underwent a total of rbcx from october to march , using an average number of rbc units per rbcx. rbc units negative for c, e, and k antigens were used during rbcx for patients. two patients positive for c antigen underwent rbcx, using e and k antigen negative rbc units. review of the antibody screen test results performed prior to each of the rce showed that no new clinically significant alloantibodies were formed after exposure to multiple rbc units. conclusion: although there is no consistent standard of care in transfusion practice related to the extent of antigen matching for scd patients, studies suggest that the standard of care for transfusion of all patients with scd is to provide rbc negative for c, e, and k antigens. this ability to find these rare units is also affected by the characteristics of one's institution and blood supplier. it is an advantage to have a hospital based donor center to work with, as we proactively collaborate with them to provide these rare units. the approach by our institution to transfuse rbc units negative for c, e, k or study design/method: venous blood specimens of healthy volunteers were collected before blood donation and after blood donation immediately, day, week, weeks, and weeks among men and weeks among women. immunoglobulin g (igg), immunoglobulin m ( igm) , immunoglobulin a ( iga)and complement component ( c ) , red blood cell (rbc), white blood cell count ( wbc) , hemoglobin (hb), hematocrit (hct), and serum iron (fe) , were measured to monitor he dynamic changes of these biomarkers and blood quality. results/finding: the level of igg slightly decreased after blood donated immediately, iga and c decreased significantly but still within their normal ranges, igm did not change after blood donation. the level of iga significantly decreased at weeks among men and weeks among women, while c significantly increased at the same time period. igg, rbc, hb, hct and fe started to recover week after blood donated and reached their levels before blood donated within weeks among men and weeks among women. conclusion: the biomarkers mutually changed over the course of weeks among men and weeks among women. donating ml blood will not significantly affect overall blood quality. utilizing amicus dxt relay data managment solution to increase platelet split rate and improve amicus productivity janelle wilhelm* and jennifer kaluza. memorial blood centers background/case studies: with the increase in platelet demand and the opportunity to export products we set an initiative to increase the platelet products collected form our existing donor base. we also faced the challenge of managing multiple collection sites in multiple states. the decision was made to implement amicus dxt relay data management solution to provide us insight into procedure details to make data driven decisions. day to day variability previously dipped as low % split forcing reactive planning. study design/method: incorporate dxt to strategically plan our day to day operations. dxt reports were monitored by management and with the fresenius kabi team for productivity by site, phlebotomist and device. reports measured target vs actual yield, donor parameters, and procedure events to perform a donation opportunity analysis. this allowed us to adjust configuration settings when appropriate to improve the accuracy of the yield prediction. reports by phlebotomist were utilized for training on how to optimize the donor's gift to donate an additional platelet or plasma product(s) and increase procedure success rate. results/finding: the monthly dxt report analysis resulted in device configuration improvements, phlebotomist and center manager accountability, effective training, and donation optimization we increased our overall platelet split rate percent and increased concurrent plasma collections by percent. with utilization of the dxt reports we are able to take a proactive approach allowing us to predict product availability, with day to day variability dropping no lower than percent split. phlebotomist qns rates were easily monitored regularly (daily, weekly monthly) resulting in a decrease in our overall qns rate to consistently below percent. conclusion: dxt was easy to implement, is very user friendly and will continue to help improve our platelet collection and process improvements between donor centers. dxt provides invaluable tools for the operational supervisors to monitor their staff and improve productivity at their multiple sites. next step is to develop the plan for implementation of paperless documentation with dxt and healthcare-id. the ability to immediately review data directly from amicus was key in the productivity improvements realized. evaluating the impact of a background/case studies: as blood and blood products are limited and expensive resources, they are prescribed, handled, stored and transfused according to hospital guidelines established to ensure that the best practice standards are maintained for patient safety. it is a prerequisite for all registered nurses (rns) involved in blood and blood product administration to possess fundamental knowledge of transfusion practice. aim: the aim of this study is to evaluate the impact of a hospital-based transfusion practice training program among registered nurses, through administration of a knowledge-based questionnaire before and after implementation of the program. the results gathered would identify gaps in assimilation of knowledge and suggest improvements to the design and implementation of specific content in the nurse-led transfusion training programme. study design/method: all rns from various units and departments were invited to participate in the blood transfusion knowledge questionnaire in october . after which, a formal transfusion practice training programme was introduced, consisting of an online learning platform and in-service training sessions. the same questionnaire was administered to the rns one year later in september for post-training programme evaluation. individual item scores and proportion of nurses with perfect scores was compared pre-and post-implementation. results/finding: in and , a total number , rns and rns completed the questionnaires, giving a response rate of . % and . % respectively. the overall mean score in was . points (range to ). the mean score in was . points (range to ). the percentage of rns having perfect scores of increased from . % in to . % in . table i below shows the results for each question item. the implementation of a hospital-based, nurse-led transfusion practice training programme has led to encouraging improvement in blood transfusion knowledge amongst rns. further training may be needed in the preparation of blood sets and management of fever. background/case studies: clinical use of blood has shown to be the least developed part in the vein-to-vein transfusion chain. this global survey was therefore carried out in order to investigate the level of awareness, accessibility and utilization of e-continuous learning and quality of blood use among blood prescribing clinicians and nurses. study design/methods: a descriptive 'ex-post facto' survey design was used; purposively selected blood prescribing clinicians and nurses from hospitals in countries of the human development index (hdi) groups (low, medium, high, and very high) participated. three research questions were answered, while seven null hypotheses were tested at . level of significance. descriptive statistical tools (frequency counts and percentage) were used to analyze the demographic backgrounds, while inferential statistics -pearson product-moment correlation coefficient (ppmc), analysis of variance (anova), were used to analyse the hypotheses. results/findings: quality of clinical use of blood was positively and significantly correlated with levels of awareness (r . ; p . ; df ) and accessibility (r . ; p . ; df ) to e-continuous learning among blood prescribing clinicians/nurses. there was significant difference in levels of awareness [f( , ) conclusion: today e-continuous learning has become a conditio sine qua non to effective and quality clinical use of blood. the higher the hdi level the better the awareness, accessibility and utilization of continuous education, both through e-learning and conventional programs. there is a better awareness among clinicians routinely prescribing blood as compared to others involved only incidentally in blood transfusion. accessibility of e-learning depends highly on the presence of a sustained societal infrastructure which is less guaranteed in the low and medium hdi countries; reliable power supply, maintenance of hardware tools and updated software programs, together with the necessary knowledge and skills of e-technology are prominent factors. the results are used for policy and strategy recommendations to improve knowledge and clinical practice through continuous e-learning programs eg, starting at undergraduate medical and nursing schools and continuing at postgraduate vocational medical specialization institutes, principles of clinical transfusion practice should be comprehensively included through appropriate and timely curricula; creation of a technical climate to guarantee access to e-learning courses and materials; stimulation of national and international exchange of e-learning programs focused on continuing education; creation of an e-learning mentoring network through professional societies, associations and education institutes. background/case studies: transfusion medicine (tm) didactic teaching materials for pathology residents are not widely available to share among residency training programs. the advancing blood knowledge (abo) leaders project is a novel approach wherein education materials are created collaboratively through a community of practice (cop). educational theorist etienne wenger defined cops as groups of people who share a concern or passion for something they do and learn how to do it better as they interact regularly. study design/method: as a pilot project, junior faculty co-investigators from west coast institutions each had months to create a minute powerpoint presentation on a fundamental tm topic, after which other members had months to review and edit. therefore, each member created and reviewed presentations (three total steps). during each step, members wrote multiple-choice questions for those particular topics. in the end, each topic would have quiz questions to assess learning. at completion, evidence-based, peer reviewed presentations would be available for all members to use for teaching pathology residents. three methods were planned to measure effectiveness of these materials: ) pre and postlecture abo leaders exam using the questions made for each topic to assess learning; ) pre and post-lecture question validated examination (best collaborative) to assess learning; ) resident in-service examination trends specific to tm. results/finding: six presentations were developed as of the abo leaders members continue to participate in this cop for tm education. abo leaders and best pre-test results are shown in tables and . abo leaders pre-test data could not be obtained for institution b, and trainees declined to participate in the examinations at institution a. challenges experienced by the cop have included heterogeneity between institutionsÕ resident schedules, balancing time dedicated to the group given busy schedules, and difficulty in giving all presentations during the defined institution-specific teaching period. post-test results will be included when assessments are complete. conclusion: despite logistical and organizational challenges, it is feasible to create a multicenter cop for tm education. the impact of such a group on resident learning will be assessed and plans for growth will be evaluated. background/case studies: the traditional educational curriculum for the pathology residency program is primarily based on didactic lectures, casebased presentations, and discussion of on-call cases. the use of dramatic vignettes has proven to be an effective educational tool to illustrate complex and multidisciplinary topics in medicine. our goal is to use and evaluate the relevance of this approach in resident education. study design/method: a clinical vignette based on a placenta accreta case was written by a pathology resident during the transfusion medicine rotation. during a two-week laboratory management course, residents prepared for the dramatic vignette performance with a focus on transfusion medicine and laboratory management topics. each resident completed a question preand post-test on topics related to the vignette. several meetings for review and adaptation of the script, topic discussion, and rehearsals were held. there were several commonly encountered problems and deviations from the standard operating procedures that the residents in the audience were asked to identify prior to the performance. during the skit, each resident presented at least one major transfusion management teaching point. results/finding: the educational activity, including the minute vignette performance and the minute discussion, was completed with a focus on: communication between the operating room and the blood bank during surgery, maximum surgical blood order schedule, pre-transfusion testing, transfusion safety, informed consent, massive transfusion protocol, emergency release blood products, thromboelastometry interpretation, patient safety, adverse events, and root cause analysis. all performers significantly improved their scores in the post-test (mean %) when compared to the pre-test scores (mean %) ttest p< . . during the vignette discussion, residents together identified all the intended non-conformances and answered related questions. residents in the audience actively participated in the post skit discussion and % reported a satisfactory learning experience. conclusion: dramatic clinical vignettes can illustrate multidisciplinary complex interactions that are of pivotal importance in the daily activities and professional development of pathology residents. with specific structured goals, clinical dramatic vignettes can be used as a complementary educational tool to illustrate challenging topics in an integrative way that is enjoyable and easy to understand and remember. the skit performers benefit from the activity further by preparing and extensively studying the topics to deliver a multifaceted and coherent presentation with emphasis on the integral role of the laboratory and transfusion medicine in patient care. hannele sareneva*, susanna sainio, inna sareneva, tiia kivipuro and taru jaske. finnish red cross blood service background/case studies: the finnish red cross blood service (frcbs) is the nationwide blood service provider in finland, responsible for collection, testing, processing and distribution of blood products to all hospitals and health care providers. the frcbs serves as the national blood group reference laboratory and provides a wide range of other laboratory services e.g. tests for hemostasis and tissue typing for possible donors as well as patients waiting for organ or stem cell transplantation. frcbs also performs antenatal blood group and rbc antibody tests covering whole country. as a sole national operator we are providing educational services to ensure the safe use of blood products as well as accurate use of our laboratory services. study design/methods: we have performed customer surveys to healthcare professionals to assemble the needs for education. based on these results and continuous feedback frcbs provides hospital customers in blood banks and clinics the following additional services: * regular education * e-learning application of transfusion medicine * handbook for blood products on the web site * reports to hospitals for their use of blood products * annual national blood safety reports regular elements of our educational program are the practical, problem solving course for blood bank personal and safe transfusion training day for clinicians. for every education we collect numerical feedback as following: "how did the education responded your expectations" and "can you utilize the knowledge in practice". we also inquire "how likely you would recommend the training for your colleges" indicating net promoter score (nps). results/findings: more than healthcare professionals participate training days at frcbs annually. in addition our experts give tens of lectures at hospitals across finland. feedback from educations has been very good, varying between . to . (in the range of - ). nps varies between and . according to customer surveys frcbs provides appropriate education to healthcare professionals. this score has increased - from . to . . conclusion: feedback, nps scores and surveys ensure that education and training program of frcbs responses to customer needs. hospitals can utilize annual courses of frcbs in their own initiation programs. together with clinical contact persons in hospitals our aim is to ensure patient blood management (pbm) and to optimize use of blood products. we also have plans to increase e-learning applications and the courses of transfusion medicine for nurses and medical students. educational outreach and effect on reporting septic transfusion reactions kathleen m grima* , anne eder , beth a. dy and mary o'neill . american red cross, georgetown university background/case studies: hemovigilance programs to monitor adverse events after transfusion depend on clinicians' ability to recognize and report reactions to the blood center. about in , apheresis platelet donations are implicated in septic transfusion reactions (strs), but this could underestimate the risk because of the difficulty in recognizing delayed or mild reactions. a large blood center designed an educational outreach program to increase awareness of strs and assessed its effect on the rate of str reporting to its national hemovigilance program. study design/method: in dec. , a large blood center developed a web based course on strs for cme/ceu credit. letters were sent to , hospital customers about recognizing and reporting strs, and alerting them to the availability of the course. blood center physicians and staff in sales and marketing also engaged hospital customers directly in discussions about recognizing and reporting strs, using the online educational content. the physicians tracked their interactions. the blood center's national hemovigilance program compared the number of strs reported in the months before and after launching the educational outreach. results/finding: the web based course was completed by more than participants; were physicians. based on a review of the evaluations, the course was highly valued with % of participants rating it excellent or very good. the blood center physicians gave over presentations to hospital customers. reporting of suspected strs in increased by % compared to the prior year. the increased reporting came from specific regions. the total number of strs that met the hemovigilance definitions for definite (culture-confirmed) and probable strs in the nationwide system increased but did not change significantly compared to the previous years. the educational initiative was designed to deliver a consistent message on the risks, recognition and reporting of strs. while the number of reports of suspected strs in two regions increased, there was no meaningful change in the overall reporting of suspected or confirmed strs across the national blood system. this finding could reflect that hospitals already recognize and report medically significant reactions or that the target audience was laboratory personnel and physicians in transfusion medicine, but not the clinicians closest to patient care at the bedside. more targeted educational efforts provided by personnel who interface with hospitals could be used to address identified professional practice gaps in transfusion medicine. implementation of subscription-based cgmp e-learning laurie mcgraw*, courtney saphier, helene belton, sallie bittner and ward scott. gulf coast regional blood center background/case studies: previous cgmp e-learning courses we developed required - minutes for learners to complete. while feedback was positive, manufacturing areas struggled to schedule time for staff to complete courses within their assigned schedules. at the same time, a shift in design trends suggest that subscription-based learning is more effective (thalheimer, .) subscription-based e-learning utilizes - minute modules, delivered at regular intervals. this changes the learning process from a singular event to a regular interaction that reinforces learning and keeps the content at the top of the learner's mind. study design/method: we began developing cgmp subscription-based elearning in by selecting our first five series topics: equipment, personnel, labeling, sops, and records. the first topic, equipment, was divided into modules on selection, validation, calibration, quality control, and maintenance. these modules, and pre-and post-quizzes for the equipment series, were developed and assigned to employees in manufacturing-related jobs using our learning management system. the pre-quiz was assigned to employees in june , with a new equipment module assigned each month for the following five months. the series concluded in december with the post-quiz. results/finding: using surveys, assessments and incident reports, we evaluated the training effectiveness using three of the four kirkpatrick levels. while our previous cgmp courses received good ratings from learners, the equipment series received the highest rating of . on a -point scale. of employees who completed all versions of our cgmp courses, the majority preferred the equipment series over all previous courses combined. comments clearly demonstrated that learners preferred the short, subscription format over the previous courses with positive and negative comment. level : learning the average score of users increased % from the pre-test to the posttest, with the greatest improvements noted in the scores from laboratory employees. a two-sample t-test determined the result to be statistically significant with a t-critical value of . and a t-stat value of . . level : results while equipment-related errors decreased by % after training, there is not enough data to demonstrate a statistical significance. conclusion: our level and evaluation data validated that the subscription approach was effective. knowledge increased from the pre-to postquiz, learners reported that they appreciated the shorter training, and they completed the modules without special scheduling requirements. as a result, we are continuing development of the remaining series. background/case studies: the interdisciplinary nature of transfusion medicine requires the collaboration of multiple work units for efficient patient care, but departmental "silos" impede collaboration between transfusionrelated care teams. we hypothesized that regular educational meetings would improve knowledge and awareness of each department's role, so in october , a multidisciplinary educational meeting called friday blood conference (fbc) began as a collaborative, interprofessional forum involving frontline staff of our transfusion practice. during these monthly meetings, which are also broadcast online for those unable to attend in person, presenters from different work units share background information and patient cases before opening the floor to constructive discussion. study design/method: a survey was sent to fbc participants (n ) to retrospectively capture the effect of fbc on interdepartmental collaboration. the survey was structured to obtain formative feedback using the published interprofessional collaborative practice competencies (icpc) as a guide. these core competencies target maintaining a climate of mutual respect, communicating within and between departments, fostering teamwork, and understanding everyone's role in patient care. results/finding: our survey response rate was %. of those, % endorse that fbc creates a climate of respect within our transfusion practice, % believe it has improved communication between work units, and % feel that fbc leads to increased understanding of interdepartmental processes. notably, laboratory scientists and transfusion nurses have the highest attendance rate. furthermore, those attending via the online broadcast report the lowest satisfaction, with only % responding positively. the main reasons individuals attend fbc are to increase knowledge about transfusion medicine, interact with and learn from other departments, hear about patient case studies, and understand the "big picture" of one's role in patient care. suggestions for improvement include preparing questions to help initiate discussion, increasing representation of other areas for broader perspectives during interdepartmental dialogue, and posting recordings of fbc for later viewing. conclusion: the application of icpc in transfusion medicine was an effective lens to assess the value of interprofessional collaboration. although there is room for improvement, the results support that fbc has contributed to better communication between transfusion-related care teams and has increased understanding of interdepartmental processes within our transfusion practice. novel approach to curriculum development: demystifying transfusion medicine ritcha saxena* and ananya saxena. all saints university school of medicine background/case studies: transfusion medicine is an essential element of education required for the future physicians in various disciplines like surgery, internal medicine and anesthesiologists to work effectively with the blood bank personnel. transfusion carries considerable advantages as well as risks. consequently, educational initiatives are required to identify the particular knowledge deficits in transfusion medicine and subsequently, bridge the gaps. and the challenge is to update the undergraduate medical curriculum to reflect the latest enhancements in transfusion medicine. study design/methods: students of undergraduate semester and students of semester participated in the study. self-directed learning resources combined with modules of interactive instruction were implemented in a tbl course design. five education modules focusing on quality management, blood collection, transfusion reactions, precise utilization of blood products and innovations in component safety were designed for the students. the students' reaction to tbl in transfusion medicine was evaluated using qualitative and quantitative assessment tools to analyze knowledge attainment and critical thinking development along with team continuity. the participants were first assessed with readiness assurance testing (rat) to guarantee that they understood the concepts and their application followed by case study based test questions. results/findings: students' reaction to tbl was primarily positive, with % of students giving a positive feedback. evaluation through readiness assurance testing (rat) illustrated improved team knowledge acquisition in implementation of effective quality management systems over knowledge acquired through individual study. students grasped a conceptual knowledge of principles of transfusion medicine and achieved confidence in dealing with transfusion-related complications. anecdotally, students significantly attained perception in blood component preparation, storage and their optimal utilization along with developments in safety techniques in blood donation. conclusion: our study suggests that reforming the medical curricula for undergraduate medical students, with specific educational modules designed to focus on blood banking and blood transfusion principles and latest advances in transfusion medicine, is much required in the interest of patient care and safety, by the future physicians. tbl is an interesting and efficient way to deliver the key aspects of transfusion medicine to the students. results/finding: open house attendees were given tours of the bb, led by a bb attending, bb residents, bb supervisor, or bb quality coordinator. the patient blood management nurse was also in attendance to answer attendee questions and educate about patient blood management. light refreshments were offered to the attendees in the bb break room. the first bb open house was held on wednesday, / / from - am. there were attendees, including a second-year medical student, four regular blood donors at the hospital blood donor center (who were also employees in facilities management and the university office of admissions, respectively), a hospital senior vice-president, six apheresis nurses, two clinical laboratory staff, two medical laboratory science students, and one additional staff member from the university office of admissions. the second bb open house was held on thursday, / / from - am. there were attendees, including regular blood donors (who were also employees in the office of international affairs and supply chain, respectively), a hematology/oncology fellow, and surgical residents. background/case studies: simple, partial, and exchange transfusions are routinely performed in patients with sickle-cell disease (scd) with the goal to increase the oxygen carrying capacity of the blood and reduce the relative percentage of sickled cells. it is essential for clinicians to be able to rapidly estimate the effects of the available therapeutic modalities using clinical information to minimize the risk of red blood cell exposure. given that the formulas for these calculations are complicated, we developed and validated an online calculator to assist physicians with such tasks. study design/method: a web application was generated (www.phamcalcs.com). the performance of the simple transfusion and partial manual exchange calculators were validated by comparing the predictions to clinical data. the performance of the automated and depletion rbcx calculators was validated using the terumo bct (lakewood, co) calculator up to a fraction cells remaining (fcr) % as patients with fcr % may benefit from delaying the procedure for performance in the future. validation process included ( ) a deming regression to globally assess the predicted vs. actual results and ( ) an individual comparison wherein validation was contingent on the (predicted-expected results)/(expected results) demonstrating |d| %. validation was performed for hematocrit (hct) and hemoglobin s (hgbs) level post-transfusion for simple and partial manual exchange and volume of replacement fluid for automated and depletion rbc exchange. results/finding: see table background/case studies: with the focus on new technologies the modern medicine requires more expenses. despite the increase in the target impact on patients there is still a risk of adverse reactions to medical treatment. the issues that are currently under discussion: the use of standardized or personalized approach, for doctors -being multidisciplinary or having a narrow specialization, integration of new technologies, the need for more trainings resulted from knowledge deficiency. in russia, the development of insurance medicine creates the demand for more intensive and cost-effective treatment programs. as a multidisciplinary approach, pbm optimizes the transfusion practice reducing the risk of adverse effects and improving the financial performance of a health care institution. however, the prosperous implementation of pbm also requires supplemental medical competencies that provide harmonization of dialogue logistics: administrator -clinician -transfusiologist. study design/method: at the medical simulation centre of hospital there has been a unique opportunity to launch an educational program for the medical specialists practicing blood components transfusion. the main innovative features of the training course are an interdisciplinary approach, intensive learning performance, comprehensiveness of learning methods. during days ( academic hours) the trainees can attend lectures, discuss the methodical materials, participate in seminars, interactive clinical discussions, a master class and a game that presents the modelling of working processes. since initiating the project in june, with the group capacity a transfusion vol. supplement s of up to people the number of medical specialists who have attended the training is nearly . results/finding: the medical competencies gained: knowledge of modern recommendations on the use of blood components the ability to interpret all parameters of the haemogram, coagulogram and tromboelastogram the ability to unveil the indications and contraindications for urgent and scheduled blood component transfusion personalization of the blood transfusion risks using a personalized approach on selecting the type and the dosing of transfusion habitat predicting the efficacy of transfusion the correction of anemia and hemostasis system malfunctions using the medicinal treatment performing the macroscopic assessment of blood component before the transfusion procedure performing the differentiated diagnostics and ability to prescribe the adverse effect treatment ability to carry out the auditorial check of health cards conclusion: the launch of the program "guidance for safe and effective blood use in adult patients of multi-field hospitals" is aimed to meet the educational and professional needs of medical specialists, develop the algorithmic thinking and a range of useful motivations in case of patient blood management and reach the compliance in practice. the effect of emergent situation drills on technologist teamwork and comfort levels abigail neils*, raeanne stensgard, rebecca wren, elisabeth greer, amy mata and camille van buskirk. mayo clinic rochester background/case studies: teamwork and composure are essential for technologists when dealing with emergent situations in a large hospitalbased blood bank where multiple situations can occur simultaneously. in an effort to reduce errors and improve emergency response, a group was formed to evaluate the effectiveness of emergency situation drills (esd). the esd were based on common emergent situations encountered in the lab and were run once per month per shift. the main goal of esd was to improve teamwork and comfort level during real emergent situations; therefore reducing the amount of unplanned standard operating procedure (sop) deviations. study design/method: prior to esd implementation, a survey was sent to all technologists to determine baseline comfort levels associated with various emergent situations. one year post esd implementation the same survey was sent to all technologists to reassess the comfort levels for the same situations. the surveys asked employees to rate satisfaction and comfort level on a grading scale of - ; being least satisfied/comfortable and being most satisfied/comfortable. the pre and post survey results were evaluated by calculating lab average comfort levels per situation and survey. in addition, unplanned sop deviations related to emergent situations were counted for one year before and one year after esd implementation. results/findings: out of total technologists, technologists took the pre esd survey and technologists took the one year post esd implementation survey. table shows the lab averages from the pre and post surveys as well as the percent difference. out of the employees who responded to the post survey, ( . %) answered "true" to the statement "esd have improved my comfort level with emergent situations." in the year prior to esd implementation there were unplanned sop deviations; in the year after esd implementation there were only deviations. conclusion: all but one area increased in comfort level post esd implementation. also most technologists agreed that the esd helped improve their overall comfort level with emergent situations. the goal of implementing esd has been met based on the unplanned sop deviation decrease and technologist satisfaction increase; therefore esd were deemed effective. monthly esd will continue to be run with the hope of continual improvement in teamwork, comfort levels and deviation levels. therapeutic background/case studies: category i indications for red blood cell exchange (rbc exchange) in children with sickle cell disease include following acute stroke and for stroke prophylaxis, as well as for iron overload prevention. as described in the first installment of this series about therapeutic plasma exchange (tpe), the challenges of access, volume management, and instrumentation persist, as along with the need to address the psychological and emotional well being of this population. rbc exchange is a complicated procedure to explain to adults and becomes an even more intimidating task when translating into the language of childhood. nevertheless, pre-treatment education is shown to decrease the anxiety associated with medical care. providing age appropriate specific treatment information to pediatric patients decreases negative behaviors, reduces stress and promotes faster recovery. a previous project explaining tpe to the pediatric population revealed the lack of age specific literature for apheresis procedures in general, including tpe and rbc exchange. study design/method: in collaboration with a child life specialist, an ageappropriate story-driven explanation of the rbc exchange procedure was adapted from a previously implemented project related to tpe. artwork was produced with the aid of a medical illustrator to complement the story-line. results/finding: the story board addresses why rbc exchange is performed, the steps involved in preparing for and performing the procedure, and strategies for coping before, during and after the procedure. the idea of long-term therapy is also briefly addressed, to prepare these children for the concept of ongoing therapy. the booklet is in production in concert with our hospital's medical illustrator and will be available on our hospital website for patient use. conclusion: using the previously illustrated story as a guide, an explanation of red cell exchange was created to provide education and reduce anxiety. this second installment continues the pediatric series helping to explain apheresis procedures to pediatric populations in the hopes of reducing patient stress and promoting age appropriate coping strategies. transfusion safety officer resource manual leonor de biasio*. it is also intended to be utilized by hospitals that do not have a formal tso position but which have delegated the responsibilities to other staff. the resource provides helpful information to assist with education in transfusion safety, adverse event investigation and reporting, product administration guidelines or monographs, and links to information about the equipment used for infusion of blood. the resource manual will serve as a useful reference tool to assist with a healthcare professional's transition into the tso role. turning on pathogen reduction: a case of flipping the switch kassandra poffenberger*, darla wendt, jennifer vrieze and james r stubbs. mayo clinic background/case studies: a critical aspect of implementing a new method in manufacturing blood products is to develop a training plan that adequately prepares staff but doesn't interfere with production or cause delays in patient care. with the implementation of pathogen reduction technology (prt) using interceptv r blood system for platelets it was understood that we would need more collections to make up for the loss of products, specifically our triple collections. our institution collects the majority of its blood products and supplements inventory from a major blood collection center. it was crucial for the component laboratory to maintain daily processing levels while learning the new method in order to sustain optimal platelet inventory levels without relying on purchasing additional platelets from external vendors. our approach in introducing prt for apheresis platelets was to "flip the switch" and process all products with the new method rather than a step wise roll out with a dual inventory. study design/method: it was essential to prioritize who would be trained first. collections occur monday through friday from to . the first group to be trained was those who would be performing training (a two person team) and product validation; they were trained by cerus deployment team. the second group was those who would process platelets on weekends and evening hours without direct management support. the last group was the technologists who would be working during normal hours with direct management support. prt processing for platelets in % plasma is broken up in to two days. on day platelets are treated with amotosalen and placed in a compound adsorption device to remove residual amotosalen for - hours. on day products are removed from the cad and modified into final product codes and labeled. each technologist was trained one on one, over a one week period. the trainers alternated training processing days for day and day . in the weeks following training it was important that each technologist rotated back thru prt processing to maintain proficiency. results/finding: of employees were trained in a two month time period. prior to "flipping the switch" the daily average of products collected was . for the two month training period the daily average rose to . conclusion: our "flip the switch" training plan for implementing prt platelets in % plasma has been highly successful for our laboratory; training while implementing the new technology did not create a bottle-neck in the process. it was imperative to prioritize who would be trained first to insure complete coverage during off hour shifts. technologists were able to become proficient with the new process while maintaining daily processing expectations and sustaining an optimal platelet inventory. accepted depending on each individual's conscience. due to these unique medical challenges, it is important for caretakers to have an understanding of their beliefs in order to provide optimal care. we describe the process of identifying jw in our hospital and communicating treatment needs to staff. study design/methods: proper treatment of jw requires the ability to identify the patient and his/her needs. when a jw is admitted to our hospital, our electronic medical record (emr) triggers several processes based on the patient's listed religion. one process creates an order that reminds caretakers to complete the declining blood consent (dbc) with the patient. the dbc contains language declining mabf and reviews the mibf with the patient to identify any that would be accepted. the emr order regarding the dbc provides educational links that include a bloodless policy, step-by-step instructions on obtaining the dbc, and information on alternatives to transfusion. a second emr process triggers a stop-gate to prevent the completion of any mabf order or mibf order for a product that the patient has declined. a third enrolls patients in the minimal blood volume labs protocol which uses microtainers, partial-fill vacutainers, and blood reservoir sets to reduce blood loss during draws. additionally, at registration, a bloodless packet is added to the patient's paper chart. this packet contains the dbc, a glossary of dbc terms, a bloodless sign to be placed over the patient's bed, a bloodless wristband to be worn by the patient, and two bloodless chart stickers that are added to the outside of the chart. these steps remind the caretakers of the patient's special requests. finally, the patient blood management (pbm) department receives emr developed reports which identify jw presenting to the hospital. these patients are followed by the pbm nurses and medical director during the duration of care. treatment plans to optimize hemoglobin, oxygen carrying capacity, and hemostasis are discussed with the bedside caretakers and implemented as needed. results/findings: nearly % of jw that enter our hospital have a dbc completed. this has resulted in increased education of the medical staff. in addition, patients have reported better communication with caretakers leading to a more inviting environment for the patients. conclusion: our hospital has found success by using an education-based team-oriented approach involving emr, pbm, and caretakers when caring for the jw patient. this approach has set up a foundation for treating other bloodless medicine patients. background/case studies: transfusion services should provide safe blood components from vein to vein with donors acting as suppliers and patients as final customers. this process involves labor-intensive activities, critical materials, human resources, facilities and highly coordinated processes. cost management has a great impact on technical processes guiding decisions upon supplies and technical staff. activity-based costing (abc) is a method to determine cost drivers within activities and determine process or product final cost allowing managers to take precise decisions. we demonstrate how an effective abc approach can result in financial savings without compromising process quality in a mid-size transfusion service. study design/method: materials costs can represent as far as % of an activity. in we had a central storage supplying satellite storages at each department and replacement was done independent of residual stock. purchases were performed on demand. at the end of we performed a supply inventory on all departments to plan future purchases and control residual stocks. in , we implemented annual purchases and satellite storages were supplied only to replenish programmed stock. cost drivers were defined upon activities on standard operational procedures (sops) resulting in a cost estimate. technical staff was involved in cost driver calculations to indicate possible changes to sops, supplier and deliveries. to minimize seasonal fluctuations we compared last quarter (q / ) with last quarter (q / ). in this work we present activity data from blood collections to illustrate abc method. results/finding: in q / blood bags were used compared to in q / , demonstrating an activity " . %. price negotiation resulted in . % readjustment. both indicated an estimated cost " . % with a possible impact of over us$ , . we have identified a real cost # . % in q / , representing an overall # . % and us$ , . (r$ , . ) savings. conclusion: economy had deteriorated in our country in with higher inflation and exchange rate variations, directly impacting imported materials, most of them critical. even with adverse economy, abc showed to be an effective tool that allowed cost decrease without significant changes in critical materials and processes. cost drivers calculations demanded review of sops and suppliers by technical staff resulting in optimization of activities. also, staff involvement reduced discharged materials since costs were wellknown to area supervisors and satellite stocks were reviewed briefly. automated verification of immunohematology results and the impact to donor testing barbara j bachman* , candace williams , carmen meyer , paul lamonby , anne cleverley and silke milbradt-pohan . bio-rad laboratories, diamed gmbh title: automated verification of immunohematology results and the impact to donor testing background/case studies: staffing challenges in today's blood banks require instrumentation with minimal operator intervention. technology advances have developed where every immunohematology result does not necessarily require operator visual review. this study evaluates the impact of automated result verification on the bio-rad ih- tm immunohematology system through the ih-com tm data management system (dms) for donor processing laboratories. study design/method: a multi-center study was performed on donor samples as shown in table a evaluating two of the most commonly used ih-system gel cards available in the us. workflow data was analyzed using process modellar app (ipad). this study focused on post-analytical steps of result verification, evaluating with and without automated result verification to determine the impact on quality (# operator touchpoints, visual result review occurrence), result accuracy, and speed (time from result interpretation to lis data transfer). operator touchpoints during the post-analytical phase are only required when doing visual result verification and are software defined. speed metrics were analyzed using minitab v , statistical the transfusion team collaborated with multiple user groups to educate them regarding the new processes. a gap analysis was performed to determine the optimal delivery process for blood products, with key stakeholders invited to review the options. the use of the pneumatic tube system to deliver blood throughout the entire campus was investigated to determine whether it would be a viable option given the expanded size of the new campus. results/finding: user groups requested additional training sessions as questions arose regarding use of the ehr for blood ordering. because the pneumatic tube system would be heavily used, and due to concerns that blood products could become "lost", it was decided this would not be the best route for delivery of blood. department educators requested support to create job aids specific to workflow changes impacting their departments, such as how to order rh immune globulin, a cord blood workup, etc. conclusion: leadership was challenged to provide a stable and positive environment during a complex set of changes. the simultaneous hospital move/merger and implementation of a new ehr constituted an arduous task that would not have been possible had substantial preparations not been initiated a year in advance. training is essential to the success for a scope of change this big and should not be minimized. while training was thorough prior to the move, gaps were nonetheless discovered following the move. abstract conclusion: strategic development partners funding and support based on newly developed government strategy on blood service with commitment of the government has brought a positive impact in establishing sustainable and safe national blood service program in ethiopia. even though the identified positive impacts mentioned are achieved, the bts remains with multiple challenges and needs continuity of funding and more partner support and government commitment. pilot implementation of a comprehensive hybrid performance management system at national blood service zimbabwe blessing mukwada*, judith j parirewa and tonderai mapako. national blood service zimbabwe background/case studies: the national blood service zimbabwe (nbsz) introduced its first performance management system (pms) in . in the - nbsz strategic plan it was noted that the current pms lacked objectivitety and there was no relationship between perfomance and remuneration. in order to revise the pms, the nbsz set up a three membered committee at the executive management level to spearhead the revamp of the nbsz pms. the aim of the new pms was to achieve a shared vision of the purpose and objectives of the organization, helping each staff member to understand and recognize the contribution to the strategic plan. in this paper, we share how nbsz revamped and implemented its new hybrid pms that derived its inputs from established pmss and nbsz monitoring and evaluation (m&e) process that have been linked together. one-selected departmental results for one quarter are shared to demonstrate how the system works. study design/method: pms committee developed and shared with executive management a pms conceptual and implementation framework. consultations including field visits were done on three established pms to assess suitability for nbsz adoption. a hybrid pms was adopted for nbsz and a pilot application for one quarter on selected department was done. review of policy, procedures to including hybrid pms templates and forms were done. pms committee trained all staff on how to implement an integrated scorecard, how to conduct appraisal, how to develop scorecards, how to measure performance using the new pms, how weighted performance reward systems based on all layers of performance for bonus payments works using standardised tools. throughout the process risk assessment were done. results/finding: the nbsz hybrid pms is based on five levels of planning namely strategic, departmental, branch, sectional and individual. the fourcoloured traffic light reporting system is central in uniformly assessing performance at all levels. the levels of accountability were properly defined for each level of planning. a weighted overall integrated individual scorecard (iis) is determined based on % individual and % for the other four levels ( % for each). the bonus (%) is calculated based on the iis as follows; category a: % (iis > %), category b: % (iis: -< %), category c: % (iis: -< %) and category d: % (iis < %). on the pilot implementation, the individual scores for staff ranged from % to %. the iis were % to %. the number of staff in each bonus categories were , % (category a) and , % (category b). conclusion: the new hybrid pms was generally accepted by all staff and it was easily implemented at various staff levels. this provides a basis for the full implementation of the new pms and this simplified pms can be easily be adapted in similar settings to ensure all staff contribute sufficiently and objectively to the realisation of the organisation strategic vision. rare donor engagement with american rare donor program (ardp) margaret c manigly* , deborah r fludd and sandra j nance . background/case studies: rare donors are defined as a blood type occurring in less than in people in a given population. these donors are discovered by testing new donors in a random or targeted way and require testing many donors to find one rare donor. once found, if the facility is a member of the american rare donor program (by being an aabb accredited or american red cross accredited irl), the donor is registered in the ardp database as a rare donor. in , there were , active rare donors in the ardp. with the mobility of the population in the usa, it is important that as donors relocate, that they are recognized as a rare donor when they donate and their unit can be identified and used for a patient with a rare blood need. in addition, when recruitment is needed for a patient need, correct contact information on the donor is required. study design/method: the ardp procedure for ardp members requires that donors be contacted every six months to ensure that ardp (or the facility) has their latest contact information. the timing is determined by the postal service time limit of six months to forward mail to a new address. this contact ensures that if recruitment is required to obtain blood for a patient with a rare blood need, the donor can be contacted by the collecting center to donate. this contact is achieved by ardp sending a contact card by postal mail twice yearly to all donors for whom the ardp has address demographics. results/finding: the ardp reports on the information obtained from the contact cards returned in the ardp annual activity report to the ardp members at the aabb annual meeting. of the ( . % of total active donors) returned contact cards alerting ardp of changes in calendar year , ( . %) were donors moving from one ardp facility to another, ( . %) were donors no longer eligible to donate, and an additional ( . %) were address changes. other changes were ( . %) reactivated donors and ( . %) donors who we were notified were deceased, or did not want to be listed in the ardp. in , new rare donors were submitted to ardp for registration. the number of donors that could potentially be lost to follow-up in was ( ), which would be . % of the new donors submitted. conclusion: with nearly a % response rate for donors receiving the mailed contact cards, it is clear that rare donors (and their families) are responsive to the ardp contact card, and inform ardp of address changes and changes in their health status that affects their ability to donate. this is evidence of the importance of the card in ensuring correct donor contact information. in , donors changed their addresses which often are not known to the collecting facility until the donors donates again, after their move. the ardp contact card is effective in retaining the relationship with the ardp registered donors and keeps the address information of rare donors current. workflow comparison of two gel analyzers in a large transfusion service j peter pelletier* , barbara j bachman , mike leamy , susan olson and candace williams . university of florida college of medicine, bio-rad laboratories background/case studies: vendor-assisted workflow studies are becoming more popular as analyzer choices and capabilities vary in the market. the purpose of this study was to evaluate the provue (ortho clinical diagnostics) against the ih- (bio-rad laboratories, inc.) in a large volume transfusion service using lean process flow. study design/method: twenty-two ( ) runs of one to six ( ) samples per run were observed for two ortho provues alternating testing at a large transfusion service performing , types, screens, type & screens (t&s) annually. the workflow patterns observed were then repeated on the ih- and compared. each process was mapped in detail by direct observation using process modellar app (ipad). the evaluation started at sample centrifugation completion and ended with results sent from analyzer to lis (lab information system). each was evaluated for quality (testing process steps, biohazardous exposure episodes, and maintenance tasks), speed (operator/analyzer time) and cost (testing/maintenance personnel hours recaptured). time studies were analyzed using minitab v , and statistical significance was assessed using the paired t-test, with p values of < . considered significant. regardless of quality or speed metrics evaluated, the ih- demonstrated a significant reduction (improvement) in process steps and associated times when compared against the ortho provue (p < . ). ih- process steps and time studies addressed in the table below did not account for the ih- reagent storage capacity. in reality, the improvements would be greater than what was displayed here in a real-life operation. evaluating the total number of maintenance tasks required annually, as well as the times associated with maintenance performance, there was a significant reduction on the ih- ( % reduction, a difference of hours/year). conclusion: this study verified the ih- provided significant efficiencies and cost avoidance over the ortho provue for a large volume transfusion service. workflow comparison of two high volume, high throughput analyzers aaron samson* , kimberly monnin , barbara j bachman , kyla warren , susan olson and candace williams . clinical pathology labs, bio-rad laboratories background/case studies: few workflow studies have been performed on high volume, high throughput blood bank analyzers in large volume testing facilities. the purpose of this study was to evaluate the galileo v r neo (immucor) against the ih- tm (bio-rad laboratories, inc.) using lean process flow. study design/method: a total of separate test runs of or samples per run were observed over a three day period on the galileo neo at a reference laboratory annually performing approximately , type & screens (t&s). the workflow patterns observed were then repeated on the ih- and compared. each process was mapped in detail by direct observation using process modellar app (ipad). the evaluation started at sample centrifugation completion and drop-off in testing area and ended with results sent from analyzer to lis (lab information system). each was evaluated for quality (process steps, biohazardous exposure), speed (operator/analyzer time) and cost (testing/maintenance personnel hours recaptured). time studies were analyzed using minitab v , and statistical significance was assessed using the paired t-test, with p values of < . considered significant. results/finding: detailed process steps, biohazardous exposures, and published analyzer maintenance tasks were evaluated/compared (table, part a) . time studies focused on operator time, analyzer time, and maintenance time (table, part b). regardless of quality or speed metrics evaluated, the ih- demonstrated significant reduction (improvement) in process steps and associated times when compared against the galileo neo (p < . ). evaluating the total number of maintenance tasks required annually, as well as the times associated with maintenance performance and downtime, was a significantly reduced on the ih- (difference of hours/year). conclusion: this study verified the ih- provided significant efficiencies and cost avoidance over the galileo neo for high volume/high throughput testing facilities. workflow impact of automated result verification for patient and donor blood typing barbara j bachman* , candace williams , carmen meyer , paul lamonby , anne cleverley and silke milbradt-pohan . bio-rad laboratories, diamed gmbh background/case studies: immunohematology facilities face many challenges including standardization, process control, productivity, staffing and patient safety. to alleviate these challenges, the ih- tm instrument and complementary ih-com tm data management system (dms) were designed to provide lean automation to enhance blood testing facility workflow. the purpose of this study was to focus on the lean functionality of automated result verification on the ih- and ih-com dms and determine its impact on workflow. study design/methods: internal and external studies using the ih- with the ih-com dms were performed with patient and donor samples. assays included abo/rh blood grouping and antibody screening (abs) as shown in table a . workflow data was analyzed using process modellar app (ipad). the evaluation focused on post-analytical steps of result verification, evaluating with and without automated result verification to determine the impact on quality (operator touchpoints, visual result review occurrence, result accuracy), and speed (time from result interpretation to lis data transfer). operator touchpoints during the post-analytical phase are only required when doing visual result verification and are software defined. speed metrics were analyzed using minitab v . statistical significance was assessed using the paired t-test, with p values of < . considered significant. results/findings: using automated result verification, only . % out of , samples evaluated for abo/rh testing would require visual verification, resulting in a % reduction in operator touchpoints (p < . ) and a labor saving of minutes ( : hh:mm) for abo/rh testing. for , antibody screens, automatic validation of results would result in . % reduction in operator touchpoints (p < . ) and a labor savings of minutes ( : hh:mm). no false positive or false negative typing results or false negative screenings occurred with results auto-verification. (rbc) has remained, and in fact is proportionally increasing while blood usage has notably declined in the era of patient blood management. over the past years a steady increase in demand for o neg rbc compared to other blood types has been observed at our blood center. utilization metrics for hospital customers are monitored monthly for overall trending and forecasting and the data shared with them during regular visits. despite heightening awareness, percent o neg rbc sales continued to rise by % annually and peaked at % in mid . to better understand this increased demand a survey was conducted to gather insight for improved utilization. we speculated that during the survey an observer effect, or change in the staff behavior, would result in reduction of o neg rbc sales. study design/methods: a tie tag was designed as a survey tool and attached to each o neg rbc distributed to hospital customers for an week period in late . hospital transfusion service staff were asked to record the final disposition of the o neg rbc (transfused, wasted, returned) on the tie tag. information on the survey objective and instructions for tie tag completion were communicated via customer meetings, emails and reminders sent by blood center drivers. completed tags were returned to the blood center. customers are allowed to return rbc units with greater than day shelf life remaining. units with tie tags attached were in hospital inventories for up to months due to the shelf life of rbc. return rates and percent of net sales (gross sales minus returns) by abo/rh type were tracked monthly before, during and after the survey. results/findings: participation was % of the hospitals surveyed. mean percent o neg rbc gross sales for a month period before, during, and after the survey was . %, . % and . %, respectively. mean percent o neg net sales during the -month survey fell to . % compared to an average of . % in the months prior. during the -month survey period o neg rbc monthly return rate increased to an average of . % compared to an average of . % in the months prior. for the months after the survey the average o neg rbc return rate further increased to . % while mean percent o neg rbc net sales trended slightly upward to . %. when customer hospitals were queried whether any process changes occurred, no major changes to policy or inventory levels were reported. conclusion: during and after the survey percent o neg rbc gross sales was fairly constant indicating that target inventory levels and transfusion service staff ordering practices remained unchanged. however, during the same period the increase in o neg rbc return rate and corresponding decline in percent net sales suggests improved o neg rbc utilization. increased awareness from participating in the survey and staff knowing they were being observed likely played a role in the lowering of percent o neg rbc net sales. tracking of monthly metrics will provide ongoing review to determine if the effect is transient or sustained and identify other opportunities for improving o neg rbc utilization. acoustophoretic separation of platelets from whole blood: a relevant and practical alternative to centrifugation pierre bohec* , jeremie gachelin , veronique ollivier , thibaut mutin , xavier telot , benoit ho tin noe and sandra sanfilippo . aenitis technologies, hôpital bichat, inserm u background/case studies: shear-induced platelet activation is an unwanted side effect of the centrifugation-based procedure currently used in blood banks to prepare platelet concentrates. transfusion of partly activated platelets could indeed increase the risk of adverse transfusion reactions. aims: here we evaluated the effectiveness of an innovative acoustic-based fractionation device by carrying out a qualitative and functional in vivo analysis of isolated human platelets. study design/method: whole blood was obtained from donors and fractionated using an acoustic-based device. platelet recovery and purity were determined by quantifying blood cell subpopulations in the microchannel outlet samples. quality of isolated platelets was evaluated using the surface expression of two activation markers (p-selectin, pac ) using flow cytometric methods while their procoagulant ability was investigated using in vivo experimentation. platelets isolated using a soft-spin protocol, were used as inactivated control. results/finding: fractionation using the acoustic-based device led to a red blood cell clearance ratio from whole blood greater than % (p< . ) and a purity of platelets close to . %. we did not find any difference in terms of quality and functionality of platelets from the same donors isolated using the acoustic device versus the soft-spin protocol. conclusion: this acoustic-based blood processing method led to excellent preservation of platelet quality and functionality providing a novel promising technique for whole blood fractionation in clinical settings. automation in blood bank processing: where we go? robert fernandez, lluis puig, pilar ortiz, joan ovejo, nuria martinez, elena valdivia and susana g gomez*. banc de sang i teixits background/case studies: nowadays, blood banking is requiring new strategies to manufacture blood components, due to the increase on their production. at banc de sang i teixits (bst), we have implemented during the last years automation manufacturing, including lean management methods, to be able to process our needs of over . blood donations for an area with more than million people. study design/method: the automation of blood donations process, bst has done different changes on the equipment. in , orbisac (terumo bct) was the equipment to obtain buffy coats and from this product, we got platelets concentrates. it was in , when we moved from this equipment to atreus c (terumo bct), to get red blood cells, buffy coat and fresh frozen plasma. then we did some updated on atreus; in we changed to atreus c (terumo bct) and finally in , we moved to reveos system (terumo bct). since the changes in , our blood components were red cell concentrate, plasma, platelets and a leukocyte residue. while all these changes in processing equipment, we added also some automation in our registration (donation id, weight and temperature) and labeling steps, implementing two homemade robots. and finally, to get better results and more efficacy in our production, in , bst incorporated an engineer to introduce lean manufacturing methods. these methods are based on the identification and analysis of problems, and then chose all these activates that add some value to the procedure. results/finding: once all these changes have been updated, we have evaluated the quality of blood components, such as red cells and platelets, also the number of donations that we were missing and working hours that were necessary to process our blood donations. this evaluation was done for processes during and . conclusion: with these results, it's obvious that automation in blood banking makes more efficient the manufacturing of blood components, getting better quality of them and also in a cheaper way. we encourage maintaining lean philosophy in order to keep improving our methods and identifying those activities that add value to our processes and get rid of those ones that are not necessary. in a globalized and industrialized world, where everything changes very fast, these improvements are necessary to be on top of the field and be a state of the art blood bank. background/case studies: the laboratory envisioned an automated blood product delivery system that extended blood access to the bedside through the use of remote blood allocation devices, or "smart blood refrigerators" to improve patient safety, provide timely access to blood products, and potentially reduce laboratory workload. as part of this initiative, bloodtrack haemobanks (hb) (haemonetics, braintree, ma) were installed and interfaced to the existing safetrace tx (haemonetics, braintree, ma) laboratory information system. one hb was installed in the methodist hospital (rmh) campus which includes a busy outpatient infusion therapy center (itc). study design/method: an assessment of the current blood supply chain revealed improvement opportunities for both nursing and blood bank staff. frequent daily trips to and from the blood bank take nurses away from the patient beside and can create congestion at the blood bank window during peak times. for the itc, with a daily outpatient volume of - patients and an average, round-trip travel time of approximately -minutes, even small delays waiting in line at the blood bank window would produce profound ripple effects. itc nurses faced the additional challenge of maintaining nurse-to-patient ratios and providing timely patient care. about % of patients in the itc have same-day transfusion orders, adding to the blood bank workload and creating unpredictability in workflow. often for patients in the itc, nurses had to repeat pre-transfusion vital signs because too much time had elapsed between gathering vitals and obtaining the blood. these inefficiencies resulted in longer patient wait times and, ultimately, a longer stay in the itc. results/finding: hb devices allow nursing staff to access red blood cells (rbc) for the majority of their patients at the point of care. since implementing in november , the hb has significantly improved the turnaround time of rbc issue -from -minutes to less than -seconds-and helped maintain nurse to patient ratios and reduced traffic at the blood bank issue window. prior to hb implementation, blood bank staff at rmh were issuing approximately rbc per month out of the window for non-surgical patients. this has been reduced to approximately rbc per month, a % average monthly reduction. conclusion: having the hb located in the itc has helped to expedite the care of patients and more easily manage blood products for patients with same-day orders. the use of hb devices has not resulted in a reduction in blood bank fte, but rather a shift in workload; from issuing products to monitoring inventory and restocking. consists of registered paramedics that are pararescue specialists and helicopter personnel. when in combat, the squadron conducts personnel recovery operations and rescues downed airmen. when stationed in the us, they mitigate in state emergencies and perform aeromedical evacuations. in , they supported a civilian medical emergency and the patient needed a transfusion in the field. they procured blood products from a distant air force base with adjacent medical facility. at the debriefing, members of the st rescue squadron ( rqs) decided to find a local civilian blood supplier. the master sergeant contacted our blood center and set up a contract for blood supply. study design/method: blood center representatives met with the rqs master sergeant in january . we asked what rqs's order and delivery expectations were. he said sporadic use and the blood order would be rbcs. we wrote a procedure for consignment and packaging, using standard blood transport boxes. we developed a communication template for staff to anticipate the rqs needs. staff was trained based on data from january meeting. we contacted the rqs in september to perform a trial run. at that time, we learned the master sergeant was shipped out to military theater. we invited his replacement to the blood center. this pararescue senior airman had just returned from syria and was assigned to civilian duty. he had no prior knowledge of the rqs association with a civilian blood center. based on his field experiences, he changed the blood order from to rbcs. he introduced blood transport containers, used in military operations, saying they were easier to carry during water and land pararescue missions. we rewrote the procedures, incorporated his transport containers, and made a pictorial job aid to assist staff on packaging blood using these containers. the blood center and rqs performed a mock run on october , and we felt prepared for any future events. results/finding: on november , , the rqs was deployed to a civilian aeromedical evacuation. we anticipated a rbc order. the actual order was rbcs and ffp. staff was preparing frozen ffp to ship, as was their norm for filling hospital orders. realizing that they could not thaw plasma in flight, we contacted the rqs and offered liquid plasma instead, which they accepted. product was consigned and picked up at : am by the rqs. the patient was transfused in the field and then taken to a nearby hospital. at our joint debriefing on november th , we established a maximum blood order of rbc and liquid plasma, noting future orders may request fewer products, yet meet the preferred rbc; plasma transfusion ratio. conclusion: military personnel are adapted to instantly adjust to an ever changing environment. regulated blood centers are not as adaptable. with clear and comprehensive communication and anticipation on the blood center's part, we now supply civilian blood products to the air national guard. (table ). the highest mean fib concentration was mg/donor unit; lowest mean fib concentration was mg/donor unit. all sites had a mean fib concentration at least mg/donor unit above the fda minimum requirement of mg/donor unit. fifteen of blood centers completed the manufacturing process survey. one used a leukocyte reduction filter with ahf destined plasma. all blood centers manufactured single donor cryoprecipitate; manufactured pooled donor cryoprecipitate. most froze plasma in a - c or colder blood bank freezer. one froze plasma using dry ice, and one used a blast freezer. two blood centers method of thawing frozen plasma took longer than hours. conclusion: blood centers consistently met the overall fib minimum requirement with a mean of mg/donor unit, over double the fda requirement. however there is variability in fib levels amongst blood centers. in general, manufacturing processes were similar with a few exceptions. blood centers should inform their hospital customers of their average fib level in cryoprecipitate in order to most appropriately care for patients receiving this product. compliance & productivity improvement via engineered-staffing/ scheduling calculator application (app) mary deck, mark angelelli and kevin lee*. american red cross background/case studies: the healthcare industry, particularly the blood banking industry continues to experience tremendous pressures not only with ensuring patient safety and quality daily, but managing and maintaining an efficient operation with a cost competitive structure. applications of basic industrial engineering tools, coupled with lean-six sigma techniques such as time study analysis, bottleneck elimination & process standardization to transfusion reduce variation has been transformed into an application (for short "app"), which can be utilized to determine process and staffing optimization and provide flexibility to the dynamic nature of changing needs in blood banking. study design/methods: a time study analysis offers valuable data about the process requirements. once this baseline has been established, translating the data into a user-friendly app would enable ease and practical use to facilitate business decision-making as well as effectively manage daily operations. important concepts such as lean-pull production system, bottleneck elimination, work-load balancing together with basic development of the app using ms excel software will be demonstrated. results/findings: successful rollouts and implementations of the staffing/ scheduling calculator app across pilot facilities, then onto facilities nationwide, has yielded improved productivity together with a sustainable compliance scorecard. the app interactive-based approach, programmed via a commonly used software, ms excel, was used to analyze how to optimize staffing requirements together with staff-scheduling (i.e. match incoming volume/work content to staffing availability). the staffing/scheduling calculator app has been utilized by executives to evaluate "what-if" scenarios (sensitivity analysis) as well as a planning toolkit to proactively manage the changing demands of blood banking. conclusion: besides providing a key mechanism for increased productivity and sustained compliance -a top priority for blood banks -the staffing/ scheduling calculator app will highlight continuous improvement opportunities and spring-board to system-wide acceptance and standardization. all coolers were prepared in a walk-in refrigerator. two scoops of wet ice or two ice packs were placed at the bottom of large/medium or small coolers, respectively, with rbc units on top of the ice. a quality-controlled thermometer was placed on top of the rbc units. a control thermometer was place at the interface between the ice and the rbc units in one large and one medium cooler. the start temperature was recorded and then the temperature was recorded every minutes for a hour period or until the temperature exceeded c. results/finding: the temperature recorded from the thermometer on top of the units in all five coolers reached > c in minutes as shown in table . the control thermometer recorded temperatures maintained at - c for the entire hour observation period in both the large and medium cooler. conclusion: when units are placed on top of the ice in a cooler, the temperature is not reliably maintained at - c for more than minutes. these data support a policy of wasting units that are returned to the blood bank with rbc units on top of the ice. background/case studies: an fda draft guidance has highlighted the need to reduce the risk of bacterial contamination of platelet components (pc) via pathogen reduction (pr) or secondary rapid testing (rt). hospitals must understand the cost implications that may result. our objective was to create an interactive model to analyze the budget impact for different pc types across the range of existing us hospitals. study design/methods: an excel model was built and populated with base case costs and probabilities identified through literature search as well as through a survey administered to us hospital transfusion service directors. the model was reviewed and refined by a panel of seven transfusion medicine physicians. the model allows base-case assumptions to be overwritten with values specific to the institution. three scenarios were generated to compare annual costs of plt acquisition, testing, wastage, dispensing /transfusion, adverse events (ae), shelflife, and reimbursement for a hospital that purchases all of its pcs: % conventional (c-pc), % pr-pc, and mix of % c-pc/ % pr-pc. the model predicts a modest ($ %) cost increase for pr-pc compared to c-pc depending on the degree of pr conversion; this takes into account cost offsets such as elimination of bd and irradiation, decreased waste due to increased shelf-life, and outpatient reimbursement. the effective pc shelf-life is potentially increased with pr due to elimination of bd, and is dependent on nat turnaround time. benefits not captured by the model include transfusion-transmitted infectious risk mitigation from emerging pathogens, which may impact cost/benefit analyses. future iterations of this model will also enable hospitals to consider scenarios in which rt is used. this model can serve as an important tool for hospitals considering pr adoption. in january . a report was created to identify donors previously classified as rare according to the american rare donor program (ardp) criteria. donors are classified as rare by meeting one of the following: highprevalence antigen negative, multiple common antigen negative, or iga deficient. the new process utilized the report and involved sending a letter to the donors notifying them of their rare donor status and encouraging them to continue to donate. a database was created to track the letters sent to rare donors. in august , inventory reduction efforts were implemented to gradually decrease the number of allogeneic red blood cells (rbc) collected to minimize unit age at transfusion. the inventory reduction occurred in phases and was completed by january . a study was performed to determine the impact of the inventory reduction on the number of rare donor donations. study design/methods: the total number of allogeneic rbc donations, rare donor donations, and number of rare donor letters sent was analyzed from to (see table) . the percentage of rare donor donations per year was calculated. background/case studies: blood centers (clients) often carry low inventory of blood and blood components. laboratories performing donor screening therefore, have limited time to determine the presence or absence of infectious disease within these products. in order to measure and ensure expedited donor screening we implemented a daily performance metric consisting of upload time goals for release of results to clients. in , zkv-nat testing was implement for travel deferral donors (july), followed by universal individual donor screening in september and november in response to the fda recommendations for "reducing the risk of zkv transmission by blood and blood components". per the fda guidance we implemented mandatory zkv testing for clients with proximity to areas with locally acquired mosquito-borne cases of zkv within weeks (sept. phase ) and nationwide within weeks (nov. phase ). zkv testing is performed on individual samples, unlike all other nat tests that are performed in minipools ( -donations). therefore zkv testing has a disproportionate impact on the turnaround times for testing, which we analyzed in this study. study design/method: within two regional testing labs, participating in the same clinical trial, lab had % and lab had % of clients requiring universal zkv testing. we evaluated a -month test result upload performance period to determine the impact of zkv test implementation. results/finding: during , lab upload time performance ranged from % to . % from january to july; upload time performance fell between august through november, returning to . % performance in december. lab upload time performance ranged from . % to . % january to august. performance fell september through december . % - . %. lab experienced a low of % upload time performance during phase when there was a rapid implementation; % clients required zkv nat. improved performance was observed during phase , with a % increase in zkv clients. for lab : phase experienced a modest decline of upload performance ranging from . % to . % with . % of clients implementing zkv nat. performance was . % in phase , when an additional . % of clients implemented zkv testing. conclusion: with an unprecedented rapid implementation of zkv testing our laboratories experienced a short period of reduced ability to maintain our upload time performance metric. enhanced platelet bacterial screening in an eight-hospital system robin larson* and colleen a. aronson . advocate lutheran general hospital, acl laboratories/ advocate hospitals background/case studies: in response to two platelet-related septic transfusion reactions and the draft fda guidance released in march regarding bacterial risk control strategies for transfusion services, an eight-hospital system implemented the verax pgd enhanced platelet bacterial screening test in of the hospital transfusion services. the sites that did not implement the test arranged for fresh platelets to be rotated in from the blood supplier. the sites which implemented the verax pgd test perform testing on all day and day platelets to be issued for transfusion. this abstract summarizes the data collected for the first weeks of testing. study design/methods: platelet bacterial testing logs were reviewed over the entire time period studied for platelets tested on day , day , and those that were tested twice. inventory reports were reviewed for platelets issued on day or day that did not require testing, and for the total number of platelets issued over the time period studied. results/findings: in the month of february ( week of performing the test), . % of all platelets issued by the participating transfusion services were day or day platelets. in march that number dropped to . %. it is expected that this number will level off at some percentage at or below . % with further data collection. in february . % of platelets were tested twice prior to final issue from the transfusion services. in march conclusion: the percent of platelets issued fresh (day or day ) will likely level off at some number at or below . % due to inventory management from both the blood supplier and the individual transfusion services. testing platelets twice is undesirable. ideally, no platelets would be tested twice as this represents a high cost for both the test reagents as well as the staff time to complete the testing. in addition, of the sites performing testing are level trauma centers and need to have tested platelets available at all times. this will require some amount of double testing, but the goal is to have this number be as low as possible, so that the percent of tested vs issued platelets does not exceed %. as the transfusion service staff becomes more comfortable with judging inventory levels and performing testing, it is expected that the amount of double testing will decrease. background/case studies: in order to make up for the deficiency of the apheresis platelets in clinical application, and also to improve the comprehensive utilization of blood, we investigate the feasibility of preparation of pooled platelet concentrates(pcs) for providing a reliable source for clinical application. to speed up the storage research of pooled pcs in china, we evaluate the changes in platelet function after filtering leukocytes with leukocytes filter for pcs and the quality changes during storage in pvc-bthc blood bags. study design/method: pcs were prepared from ml virus free whole blood by platelet-rich plasma (prp) method. five or six bags of abomatched pcs were pooled and filtered with leukocytes filter for pcs(n ). the swirling phenomenon, ph, automatic blood count, platelet aggregation, hypotonic shock response (hsr), the extent of shape change(esc), cd p expression, atp level in platelet, glucose and lactate concentration were detected before and after filtering, and on days , , and of storage, respectively. results/finding: the platelet recovery ratio of a therapeutic dose of pooled platelet concentrates after filtering leukocytes was ( . . )%, relative change rate of hsr was ( . . )%, the residual leukocytes were ( . . ) . the ph, hsr, and the cd p expression of pooled platelet concentrates before and after filtering were ( . . ) vs ( . . ), ( . . )% vs ( . . )% and ( . . ) % vs ( . . )%. there is significant change for wbc after filtering (p< . ). during storage in pvc-bthc blood bags, the biochemical parameters of pooled platelet concentrates changed with increasing storage time, as shown in table . conclusion: storage in pvc-bthc blood bags for five days, the quality of pooled pcs met the requirements of chinese standards (gb - ) . it can be a complementary source for apheresis platelets supplement in china. evaluation of samplokv r segment sampler to obtain and measure samples from blood component tubing segments abbejane blair*. ajblair laboratory consulting background/case studies: current methods used to obtain samples from blood component tubing segments are cumbersome and present a significant risk for exposure to biohazards, sharps injury and cross contamination. itl biomedical has developed samplokv r segment sampler (ss), a device for obtaining measured samples from sealed tubing segments that is less cumbersome and offers improved safety, eliminating the need to manually cut and squeeze tubing segments. ss was evaluated with the goals of reducing the number of steps required to obtain a measured sample, and, reduce biohazards and sharps exposure. study design/method: ss obtains fluid samples from sealed tubing segments into a needleless syringe. it consists of two chambers with recessed internal needles located at the top of the device and a female port located at the bottom of the device. a needleless syringe is attached to the female port, the sealed tubing ends are then aligned with the ss chambers and, gently pushed onto the needles to pierce each end of the segment. the sample from the segment is then withdrawn into the syringe. the study was performed at rhode island blood center (providence, ri) using tubing segments from three bag manufacturers to demonstrate ease of use on the following processes: segment alignment over needles and piercing, ability to draw sample into syringe, ability to expel air bubbles from syringe, fluid leaks, ease of transfer of sample from syringe to tube and to collect user feedback. two lengths of tubing segments were filled to contain sample volumes of ml and ml. two users then evaluated the ss tubing segment types with ml or ml samples for a total of data points. samples were collected into the attached ml or ml syringe then a measured sample was transferred from the syringe into a test tube or microcentrifuge tube. results were tabulated as pass or fail. results/finding: a total of ss were evaluated by two users. all samples were successfully collected and transferred into tubes. insertion of the segment edge requires observation to ensure placement onto the needles. any air bubbles collected into the syringe could easily be moved to the top by background/case studies: the management of platelet inventory is crucial due to a number of factors including the day product outdate, the allocation of staff due to the lengthy donation process, the increasingly small donor pool, and the high cost of production (e.g. platelet collection kits, testing, product processing). the use of a platelet inventory management tool has the potential to enhance the understanding of units transfused, optimize inventory, increase efficiency, and reduce waste. the objectives of this assessment were to decipher if the platelet inventory management tool has reduced the amount of outdated platelet products, total cost of platelet production, and full time equivalent (fte) allocation. study design/method: in january , a platelet inventory management process was implemented which uses a spreadsheet based tool to predict the amount of platelet collection procedures needed to be scheduled each day. the tool uses daily historical transfusion data from the last five weeks. additional calculations are included to account for deferrals, no shows, incomplete collections, and product split rate. the number generated from the calculations correlates to how many platelet collection procedures to schedule for the specific day of the week considering testing release and historical daily transfusion trends. the effectiveness of the tool was verified by comparing platelet collections, platelet products outdated, and fte information for a one year period prior to the implementation of platelet inventory management to one year period following implementation. results/finding: by implementing a platelet inventory management tool, collections have been lowered or shifted to accommodate the transfusion needs. the staffing adjustments and targeted collections have lowered fte and outdate cost by %. the platelet outdate rates dropped after implementing the platelet inventory tool from % ( units) to % ( units); a % decrease. fte was able to be monitored closely with the donor schedule and lowered from a yearly average of fte to . fte, lowering fte by %. conclusion: considering historical transfusion data for potential platelet demand has had a positive impact on scheduling platelet collections. staffing requirements and outdating products have decreased since implementation of the platelet management spreadsheet tool, leading to less waste both in terms of staffing and platelets. given these positive results, we are beginning to develop a similar tool for our whole blood collections. identifying opportunities to right-size hospital inventory using compotrace radio frequency id inventory management system nanci fredrich* , jaclyn mckay , jennifer curnes and rowena punzalan , . bloodcenter of wisconsin, children's hospital of wisconsin background/case studies: the ability to track inventory of blood components in real time is challenging for both hospital transfusion services (ts) and blood centers (bc) using current blood bank information systems (bbis). in addition, determining if established par levels of individual components meet or exceed daily transfusion needs is difficult to ascertain. a pilot was designed to track and monitor all blood components from distribution at the bc to issue in a hospital ts using fresenius kabi compotrace radio frequency id (rfid) enabled inventory management system. the objectives were to determine feasibility of the compotrace system and analyze compotrace data for real-time usage and optimal inventory levels. study design/method: a month pilot was conducted at a pediatric hospital and its bc using both bbis and compotrace systems to track all adult-size blood components. staff were trained on use of compotrace system. upon receipt of order from pilot hospital, bc staff applied rfid tags to all component bags and scanned components into the compotrace system. components were transported and delivered to ts following established procedures. upon receipt at the hospital, components were scanned into inventory using both the ts bbis and compotrace systems. dual scanning of components occurred upon issue to or return from floor, component modification or return to bc. products for emergency use or at time of high demand were not rfid-scanned. a priori, the pilot would stop if the compo-trace system hampered current workflow, component issue was delayed or if ts errors increased. no inventory changes were made during the pilot. results/findings: real-time data from compotrace system provided actual usage for all blood components including component disposal and shipment to and from bc. average daily rbc inventory levels and usage for selected blood types is shown in table. lessons learned related to equipment and workflow: ( ) use of smaller irradiation canister may damage rfid tag, which was resolved by relocating tag, ( ) ts workflow and stat orders challenged consistent use of dual processes to track component status. however no increase in ts errors or delay in issue of components occurred. conclusion: use of rfid to track blood components from bc to final disposition is feasible. real-time data from compotrace system identified optimal inventory levels for rbc at the pilot ts. use of real-time rfid to track inventory and adjust target levels based on actual daily usage over time may reveal seasonal influences that affect target inventory. background/case studies: physicians expect blood to be available at all times. following a national appeal in july for donors based on a predicted summer shortage with high likelihood of extending into the fall, our transfusion service (ts) recognized a potentially dire situation given the institution's patient acuity. our hospital-based ts supports a full range of services: a level i trauma service; stem cell and solid organ transplant services; a brisk cardiothoracic surgical program; a high risk obstetrical service; and high acuity medical/surgical services. a regional donor center supplies our blood products. to insure appropriate response to patient needs, the ts created a management plan, with input from multiple stakeholders, to assist with product management in times of extreme shortages. the approach is described herein. study design/method: at the direction of the transfusion committee (tc), ts directors presented the concern for impending shortages to the hospital quality directors (qd) committee. the qd committee consists of clinicians and non-clinicians trained in health care quality/regulatory affairs who are responsible for institutional health care quality (hcq) activities. the qd recommended creation of a multidisciplinary team: "the blood shortage task force (bstf)", analogous to an existing task force started for management of drug shortages. results/finding: with hcq and tc support, the ts created the bstf and blood shortage management algorithm (bsma). standing members of the bstf include ts medical director (chair), senior vice president (svp) of hcq, svps of clinical services director of regulatory affairs, legal counsel, and representatives from ethics, social work, pharmacy, patient referrals, and communications. ad hoc members include those whose patients would be most impacted by the specific shortage. the bsma designed by the bstf provides a framework for ts's to conduct operational and therapeutic assessments of potential impact and defines criteria for convening the bstf. trigger criteria include: marked ts concern; essential product; high likelihood of inventory depletion; broad patient impact. once convened, the bstf is responsible for situational assessment and formulation of a management plan, with a goal of maintaining quality patient care. conclusion: faced with the potential for limited blood supply, the ts reached beyond the laboratory and engaged the tc and members of hcq to assemble a robust, multidisciplinary task force. this resulted in an inclusive plan which can be activated at any time to address shortages, and assist in management of impacted patients. abstract background/case studies: cryoprecipitate (for short "cryo") plays a critical role in clotting and controlling hemorrhaging, and is often used in the treatment of massive trauma and major diseases, including metastasized cancers, cardiac diseases, hepatic failures, and organ transplants. the collection process of cryo is particularly challenging; due to fact to be processed into cryo units, the collected whole blood has to be shipped to the production facility and be processed within -hours after collection. this tight hour time constraint between collection and production can only be satisfied with precision collection planning and extra courier services; which makes the collection for cryo units more costly than other products. study design/methods: the american red cross (arc), in partnership with researchers from the georgia institute of technology (gt), has developed a blood collection model to increase the amount of whole blood that can be processed into cryoprecipitate. after reviewing blood collecting and processing schedules, collection locations, and other factors, arc-cryo subject matter experts together with gt researchers were able to analyze the problem structurally with several analytic/dynamic programming properties, and developed a near optimal solution algorithm or mathematical model. results/findings: to facilitate implementation, a decision support tool (dst) was developed to systematize the selection of the collection sites; determining when and from which mobile collection sites to collect blood for cryo production and how to schedule the courier services such that the collection targets are met and the total collection costs are minimized. the implementation of the dst led to an increase in the number of whole blood units satisfying the tight -hour completion time constraint for cryo production (capacity expansion). in particular, during the th -quarter of , a blood processing region was able to process about more cryo units/month (an increase of %) at a slightly lower collection cost (cost avoidance), resulting in an approximately % reduction in the per unit collection cost for cryo. conclusion: by utilizing operations research toolkits, a mathematical model or near-optimal algorithm could be developed to optimize the cryoprecipitate collection process, ensuring the time constraints and product consistency levels are achieved. this interdisciplinary improving cryoprecipitate collections collaborative project has been selected as a finalist on the -the franz edelman award, recognizing outstanding achievements and practices in operations research. inventory management and transfusion practice before and after -day apheresis platelets sarah k harm*. university of vermont medical center background/case studies: the shelf life of apheresis platelet (ap) units stored in plasma may be extended from to days in the usa using an fda cleared rapid test (rt). in august , our hospital based transfusion service began using a rt on day and to routinely extend ap shelf life to days. this report describes changes in platelet inventory management and transfusion practice six months following routine use of -day ap. study design/methods: data were obtained for two study periods: september -february (pre-implementation) and september -february (post-implementation). the study periods were intentionally made to span the same months of the year due to seasonal variability in platelet transfusion rates in our region. the transition period from -day to -day ap inventory was excluded. the following data was collected for each study period: the total number of ap transfusion recipients, ap units transfused, expired ap units, ap units ordered ad-hoc from suppliers, inpatient admissions, surgical volumes, and average length of stay. results/findings: data are shown in the table. the number of ap transfusions decreased by % post-implementation while inpatient admissions and surgical volume increased by % and %, respectively. the hospital length of stay was similar for both periods. ap inventory decreased by % post-implementation and the outdate rate decreased from % to % (p< . ). ad-hoc ordering was not statistically different between study periods (p . ). the average number of ap transfusions per patient between pre-and post-implementation periods was not statistically different ( . and . , respectively, p . ). furthermore, a new "rejection threshold" for lipaemic products will be implemented. this threshold represents the tg concentration above which viral marker testing for donor screening will be affected. in kcbb abbott's prism assays are used for: hbsag, anti-hcv ab, anti-hiv ab, anti-htlvi/ii . results/finding: using data management system and file records in kcbb as regard discarding blood components due to lipaemia during the last five years ( ) ( ) ( ) ( ) ( ) , it was demonstrated that number of discarded rbcs due to lipaemia during the whole period was units. number of discarded different plasma, platelets, and cryoprecipitate components during the last two years due to lipaemia was , , and units respectively. the mean number of discarded rbc units of the five years of the study exceeds % of the tested ones. literature about guidelines on the management of lipaemic donations were reviewed in order to minimize donation loss, and establish an accurate rejection threshold for lipaemic donations. by reviewing sample requirements for viral marker testing in kcbb, the accepted level for tg in blood samples is below mg/dl, and so the rejection threshold for lipaemia is level equal to or more than mg/dl. conclusion: many blood product units are discarded needlessly in kcbb due to lipaemia in the last five years (including rbcs, plasma products and apheresis platelet units). in an effort to reduce the waste of potentially lifesaving products, the rejection threshold for lipaemic products is recommended to be changed from mg/dl to mg/dl which does not affect blood safety. a follow up study is recommended after applying the new threshold to evaluate the new policy. logistical management of the incorporation of pathogen reduced single donor platelets (pr-sdp) into inventory at a u.s. tertiary care medical center eric gehrie* , , rebecca ross , debra mraz , anne baker , zenna neal , melanie champion and edward l. snyder , . johns hopkins university school of medicine, yale university, yale-new haven hospital background/case studies: the approval of pr-sdp by the fda provided an opportunity to improve the safety of our platelet inventory across all patient demographics. we outline our approach and address issues we faced during the first months of pr-sdp availability. study design/methods: our nursing education team provided presentations to the nursing and clinical unit support staff. a company-sponsored trainer staffed sessions for the evening/night shifts on the clinical wards. presentations to physicians were made by the blood bank medical staff. information technology personnel created a new product type in the blood bank computer system, tested the abo/rh truth tables, and ensured that billing codes were in place. the necessity for transiently supporting a dual inventory of pr-sdp and conventional platelets led to consultation with the ethics committee and risk management, to confirm that pr-sdp and conventional platelets (c-plts) tested for bacteria ("safety measure" testing) could both be considered the hospital standard of care. we chose to not gamma irradiate any unit of pr-sdp, consistent with the package insert. results/findings: the ethics committee and risk management confirmed that informed consent was not needed for transfusion of pr-sdp. pr-sdp available from our blood supplier incremented monthly. over the first four months of pr-sdp availability, pr-sdp were transfused at our hospital (out of a total of platelets transfused). after months of scale-up, pr-sdp were approximately % of inventory. questions received during the nursing and medical conferences related to: the risk of bacterial contamination with c-plts vs. pr-sdp; toxicology of the pr process; scanning pr-sdp labels into the electronic medical record; and the need to irradiate pr-sdp. our use of a "safety measure" addressed concern over bacterial contamination of c-plts. published pr-sdp toxicology data comparing the content of psoralens in food products such as grapefruit ($ mg per g) to the content in pr-sdp (< ng per ml) addressed toxicology concerns. nursing/it allayed concern over scanning issues with a simple demonstration. finally, we ensured that all parties were aware that fda did not require irradiation of pr-sdp. presentations at the medical conferences were also used as an opportunity to provide transfusion-transmitted disease training and information on platelet utilization. company personnel did not present at medical or nursing conferences per institutional policy. no background/case studies: ensuring platelet supply capability represents a challenge in terms of donor recruitment and inventory management operations. in september , the apheresis collection process (acp) was completely revised to increase the number of products per donation by maximizing the rate of double-platelet donations (dpd). the process review has led to several changes, including the substitution of the pre-donation platelet (plt) count measurement before donation type allocation, in favor of the use of the donor's past donation records. multiple processing steps were eliminated, and the evaluation of plt concentration as a function of time, deduced from complete blood count (cbc) measurements, allowed the centralization of the analysis at the qc department. finally, introducing the concept of non-optimal donations has led to an increase in the proportion of dpd. study design/method: at the donation centers, whole blood (wb) from donors was collected in k edta tubes. plt concentrations were determined at the qc department using the coulter act diff hematology analyzer (beckman coulter). sample tubes were stored at - c and measured at , and hours post-collection. single platelet donations (spd) or dpd were collected using the trima accel. units were pooled and split in elp (extended life platelet, terumo bct) storage bags to mimic spd ( ml; n ) or dpd units ( ml; n ). plt pools were stored at - c under mild agitation for seven days except for dpd, which were split in two -ml bags after h. samples were taken on days and . ph, po and pco , hypotonic shock response (hsr), extent of shape change (esc), cd p expression, atp content, lactate and glucose concentrations were used as in vitroquality markers. results/finding: plt concentration as a function of time, determined from wb cbc measurements, showed no significant difference at h ( pltx /l), h ( pltx /l) and h ( pltx /l) postdonation. dpd can be stored in the same collection bag for h after donation without any significant impact on plt quality markers. plt concentrations were within the manufacturer's acceptable limits ( - pltx / l) before splitting. on day , lactate and pco concentrations increased, and po decreased in dpd. however, these values normalize to those of control units at the expiration day. conclusion: this project was approved by health canada and implemented in our organization in march . there are numerous operational and cost benefits from this process optimization initiative, without significant impact on safety and quality. post-implantation efficiency data will be compared to the targeted % increase in the targeted number of plt units per donation ratio. phased implementation of pathogen-reduced platelets in a health system elizabeth s. allen* , colleen vincent and patricia kopko . university of california -san diego, american red cross background/case studies: pathogen reduced platelets (prp) provide improved safety compared to conventional apheresis platelets, but collection and manufacturing are complex. early evidence shows only - % of double platelet collections meet requirements for pathogen reduction treatment. blood centers need hospitals to implement prp to start manufacturing, but hospitals may not wish to use prp until they can provide the product to all patients. scaling up manufacturing at the blood center and phasing in prp across patient populations meets both parties' needs. we evaluated this strategy at our university health system (transfusion volume: , apheresis platelets annually), which includes two hospitals ( inpatient beds) and an outpatient cancer center. study design/method: before initiation, approval and funding were obtained from the hospital quality council and administration, and stakeholder groups such as hematology/oncology were educated and consensus gained. live training was provided for nurses in the outpatient cancer center (week ) and the bone marrow transplant (bmt) ward (week ). an e-mail communication explained the change to all physicians and nurses. in phase , we implemented prp in the outpatient cancer center. these patients are immunocompromised and do not have access to the immediate advanced critical care of the inpatient environment should a septic reaction occur. in phase , we expanded usage to include the inpatient bmt ward. in phase , we lifted all restrictions so prp could be used throughout the health system, with the goal to reach % prp within months. results/finding: in phase (weeks - ), we requested prp products weekly, based on typical usage in the outpatient cancer center. our blood supplier provided an average of prp weekly (range - ), and prp constituted % of platelet transfusions in the cancer center. in week , excess prp inventory required use of prp in the inpatient bmt ward ahead of schedule, a practice which continued throughout phase . in phase (weeks - ), we formally expanded issuing of prp to include the inpatient bmt ward and requested prp products weekly. our blood supplier provided an average of prp weekly (range - ), and prp constituted % of platelet transfusions in the phased-in areas. in phase (weeks - ), we began issuing prp throughout the health system. our supplier provided an average of prp weekly (range - ), and prp constituted % of all platelet transfusions. scaling-up is ongoing. conclusion: phased implementation of prp by patient group prioritizes patients who stand to benefit most from the product, and allows time for the blood center to scale up manufacturing. background/case studies: maintaining adequate inventory of platelets without significant outdating and waste of product is a constant challenge for many institutions, especially for smaller community hospitals. our health system comprises hospitals including smaller community hospitals (sch) and larger tertiary care medical centers (tcmc). for several years, we have been using a limited internal process of platelet sharing between some of our institutions to successfully reduce platelet wastage. this encouraged us to analyze platelet usage throughout our health system and devise an expanded novel concept of platelet distribution, in partnership with our blood supplier that would allow us to maintain an inventory of apheresis platelet (ap) units at our smaller community hospitals without significantly increasing platelet waste and the associated cost. study design/methods: a "round robin" (rr) transportation system for platelet delivery and pick up was strategically developed with the regional blood center to align with routine delivery of red blood cell (rbc) standing orders. an efficient delivery system was implemented so that the regional blood center would realize reduced supplemental and emergency deliveries of blood components to our hospitals. platelets are transferred at the time of rbc standing order delivery based on a predetermined route schedule. each day, ap are delivered to the sch and the previous day's platelets retrieved (if not transfused), packed in blood center transport boxes, and then picked up by the blood center driver. these platelets typically have a hour shelf life remaining. the same process occurs at the next sch on the route. all retrieved platelets from the sch are delivered to the tcmc which is the last stop on the route. thus, the sch has adequate number of units available for regular transfusion and massive transfusion protocol. results/findings: review of our rr process revealed a significant benefit to our smaller community hospitals as we were able to routinely maintain an ap inventory for patients requiring urgent platelet transfusion. an additional benefit was further decrease in ap waste (table ) resulting in a cost savings of $ k. an additional cost savings of approximately $ k was noted due to decreased cost of emergent platelet transportation. conclusion: our novel rr process of platelet distribution has resulted in improved platelet availability at our smaller community hospitals while maintaining the reduced level of ap waste at our health system from our previous platelet sharing process. we anticipate additional decreases in ap waste as a transfusion vol. supplement s we further streamline our process. with the trending merge of health delivery systems, we predict that other health systems will adopt similar processes to improve platelet availability and reduce waste. post implementation adjustments of our pathogen reduction process jacqueline carlson* , james r stubbs , scott a hammel and manish gandhi . mayo clinic, mayo clinic-rochester background/case studies: the implementation of pathogen reduction for apheresis platelets using cerusv r intercept system for apheresis platelets was a substantial endeavor encompassing many different areas. as with any process change, adjustments and modifications can occur along the way. after implementing % pathogen reduction technology (prt) for apheresis platelets, we made two additional adjustments to our sampling processes to ensure accurate labeling/categorization/branding of our final products. study design/method: our prt validation consisted of apheresis platelet products. each product was tested pre-processing for white blood cell (wbc) content and platelet yield, along with post processing platelet yield. this data was used to calculate our yield and volume retention during processing. we anticipated products with preprocessing yields of . , . , and . x may end up below a . in the final storage bag and would need a post-processing sample to ensure the product met criteria at ! . x platelets. results/finding: during the validation, we discovered one collection was not leukoreduced and two collections started at a . yield but ended with a yield below . . these two discoveries led to adjustments in our prt platelet process. with the wbc failure, we reviewed the wbc count on the sysmex xe- d preprocessing report to see if it would alert us to a potential wbc failure. the review discovered that of results were . or . x / mcl with the exception being the wbc failure with a count of . . further monitoring of the wbc counts discovered a result of . which was tested on the adam r-wbc for wbc count and determined to not be leukoreduced. we decided all sysmex wbc results from the pre-processing sysmex report would be reviewed prior to processing and a wbc result of . will be tested on the adam to confirm a leukoreduced product. we also discovered of ( %) of the . preprocessing yields products ended with a post processing yield < . . we decided to increase the yields requiring post processing samples to include the . . conclusion: we are continuing to sample all collections for a post processing yield so we can be confident that we are releasing products into inventory with a yield of ! . x platelets and to have enough data to accurately determine our volume and yield loss during processing background/case studies: the university of kentucky medical center (ukmc), a large academic hospital with level i trauma center, is supplied with blood products by the kentucky blood center (kbc) on a consignment agreement-based contract. ukmc is kbc's largest consumer of blood products. as platelet usage can vary widely day to day platelet usage projections are provided to kbc by the ukmc blood bank, thereby allowing kbc to act accordingly with a given day's stock (i.e. import vs export). daily platelet projections are based on phone calls asking clinicians working in high-demand locations to estimate their needs. this process can be easily confounded by multiple factors and has undergone multiple adjustments to improve its accuracy. study design/method: daily platelet projection forms from / - / were retrospectively reviewed and compared to actual usage data over that same time. the prediction system used in the ukmc bb up to that time (estimated clinical need ) was evaluated for effectiveness based on: total number of days under-predicted, number of days with large underprediction, average number of units under-predicted, and average difference between prediction and usage. the prediction system was subsequently changed based on this data in ; the revised prediction method (estimated clinical need ) was then evaluated retrospectively using the same data sources covering / - / and then compared to the prior method. results/finding: the average number of platelets transfused from / - / was . u/d with a standard deviation of . u/d; the predicted amount was . u/d. the difference between the predicted amount and the number of units used was - . u/d. % days ( d/month) were under-predicted (average: u/d). % of days ( ) were under-predicted by ! u (average: u; max: u ( x)). the average number of platelets used from / - / was . u/d with a standard deviation of . u/d; the predicted amount was . u/d. the difference between the predicted and units used was a . u/d. % days ( d/ month) were under-predicted (average: . u/d). one day ( %) over this period was under-predicted ! u ( u). conclusion: review of clinical platelet usage over this time identified a relatively stable average daily clinical demand. adjustment of our prediction system to ensure that no, or as few as possible, days were projected for less than that average has markedly reduced catastrophic shortages ( % a %), reduced the number of days under-predicted ( % a %), and decreased the discrepancy on those under-predicted days ( . u a . u). these improvements in estimating usage allow for an increased ability to handle unpredictable events without suddenly straining kbc's supply flexibility or severely limiting ukmc clinical settings. rapid implementation of zika virus (zkv) nat blood donor screening joan dunn williams* , maria noedel , nancy haubert , kenneth hudson , larry morgan , robert shaw , tracy fickett , jamie jue , valerie winkelman , sally caglioti , german leparc , and phillip c williamson . background/case studies: on / / , fda issued a guidance document for "reducing the risk of zkv transmission by blood and blood components". in response, a plan was implemented for mandatory zkv testing for all clients with locally acquired mosquito-borne cases of zkv within weeks; nationwide in weeks. this organization performs testing for clients (blood centers, hospitals) across the country. we report on of manufacturers' (sponsor) provided investigational new drug (ind) protocols. a single project management (pmo) system was used to control all required processes. study design/method: project focus included: clinical trial requirements, client onboarding, lab operations (labs). our objectives were to implement zkv testing for clients within weeks, and an additional clients within weeks. to minimize the impact to labs a staggered implementation was used with tracked/streamlined communications from stakeholders: vendors, institutional review board (irb), it (client and lab based), client services and labs. results/finding: clinical trial requirements increased the complexity of implementing an unlicensed test. documents included donor notification, informed consent, protocol training, staff certification, deviation management, and result reporting. multiple irb documents were required. to ensure accuracy in ind commitments a principle investigator was assigned to labs with client sub-investigators. deliverables were multiple including client requirements, vendor responsibilities and labs. client onboarding included confidentiality agreements between client and sponsor. an immediate zkv based webinar provided materials and understanding of sponsor protocol, lab test system, and client/donor based responsibilities. to facilitate and ensure effective communication, twice weekly conference calls were held. clients sent questions which were facilitated by labs and directed to sponsor. specific to clients were irb documents, it updates/validation for zkv test ordering and result receipt. labs were multifaceted: vendor instruments, assay materials, package inserts, staff training. assessments included: zkv sample volume, throughput, instrument capability/capacity. work requirements included vendor installation, equipment, assay and reagent qualifications, staff training, competency assessments, result reporting. all clients were provided with zkv testing within required timeframes. conclusion: the success in meeting a rapid implementation of zkv testing was largely due to a centralized pmo system which provided a controlled process for sponsor, client, vendor and labs. within lessons learned strength was found in a multi-client onboarding process. a weakness was in understanding instrument test volume capacity throughput which was exceeded during the -week period but overcome during the -week cycle. red blood cells baby units traceability and discard in kuwait central blood bank and five hospitals marwa moemen al deeb* , hala samuel boules , fatemah saleh al matroud , rabab hussien ali dashti , hanan alawadhi and reem al radwan . kuwait central blood bank, kuwait central blood bank, kuwait central blood bank background/case studies: ill children are more likely to receive red blood cells (rbcs) transfusion than any other patient age group. rbcs are the component most often transfused during neonatal period. small volume aliquots are used to limit donor exposure, prevent circulation overload and decrease donor related risk. traceability is the ability to trace each individual unit from donor to recipient or disposal. blood component should be fully traceable from collection to final disposition. the kuwait central blood bank (kcbb), is preparing baby units and distributing it to all hospitals all over the country. kcbb, being accredited by the american association of blood banks (aabb), is following the aabb's regulations in tracing every component. study design/method: this is a retrospective study to assess final deposition and the percentage of discard of prepared packed rbcs baby units in the kcbb and five hospital blood banks (hbb). also, to assess the levels of traceability as a reflection of the improvement in the efficient use of these blood products. methods: a total of rbcs baby units were randomly chosen to be traced to their final deposition from the year till . half of them ( units) were traced in kcbb. tables showing the numbers of the chosen units were distributed to the five governmental hbb ( units for each year of the study period). results/finding: preliminary results show that the tracing of rbcs baby units in the kcbb is % efficient. results from other hospitals are under process. statistical analysis of the traceability will be done as soon as the data is collected. the study will analyze the usage of the baby units in different departments and the percentage of discarded units. the traceability of rbcs baby units in the kcbb is excellent, this is due to good management and training of the working staff and the use of an electronic system in registration and issuing. most of the kuwait governmental hospitals are using electronic systems, so the traceability should be up to the recommended levels. the percentage of discard of the baby units in the hospitals is very high. this may be due to the practice of using fresh blood (< days of donation) and the reservation of the baby units of the same donor to the same baby to reduce the hazards of multiple donor exposure. the creation of a national policy for using rbcs baby units is highly recommended to reduce the discard of such units. we also calculated the number of false positive results. the study traced all products through mid-march . results/findings: a total of products were tested. fifteen units ( %) had a false positive result and could not have their life span extended. of the fifteen reactive units, two repeat donors were identified and their charts were marked to not test subsequent donations. cross-reactive antibodies were identified in all by the vendor and none were true positives by re-culture. of the units that were successfully tested, were tested again on day for use on day ( %). there were platelets transfused ( %) and expired after day ( %). the cost to test the products including controls was $ , and our calculated cost to produce products would be $ , . if we had needed to import products to meet needs, the cost would be roughly $ , without shipping costs which are estimated at $ , . . we averaged expired platelet products per month (range - ) before verax testing and (range - ) after implementation. conclusion: using verax point-of-care testing saved platelet products from discard. the cost savings were $ , . from importing and $ , from producing a replacement for those products. the average discard rate per month went from to after verax implementation. extending platelet shelf life to days more than paid for the cost of testing and ensured products were available for patients who needed them. secure text messaging in transfusion medicine: can texting decrease wastage? melanie estrella* and elsie lee. george washington university hospital background/case studies: secure text messaging in hospital settings allows for quick, easy, and hipaa compliant communication between members of patient care teams. it works on a mobile phone or computer, and provides read-receipt confirmation and a temporary record of team communications. secure texting has potential to be a useful management tool in transfusion medicine in reducing blood product wastage. for example, it provides a relatively low-burden means for busy clinicians to provide feedback to the transfusion service about scenarios of potential wastage. this information can be used to identify areas in which management strategies could be developed. it also allows for personalized educational opportunities between clinicians and the blood bank about usage guidelines and how to reduce future wastage. the goal of this study is to use secure texting to investigate wastage, evaluate the responses from clinicians, and evaluate the potential effects on reducing wastage. it is hoped that the results will identify secure texting as a useful management tool in transfusion medicine. study design/method: wastage records that were investigated without the assistance of secure texting from july to december were reviewed to identify the most common scenarios of preventable blood product wastage. wastage records from january to april were reviewed, and wasted products that were considered preventable were investigated using secure texting to communicate with the ordering physician. results/finding: for data, units were investigated without the use of secure texting. of these, units were identified as preventable wastage, and wasted units were considered beyond the control of the clinician. the categories for preventable wastage were defined as follows: ) product not released after procedure/ or when patient stabilized ( ) ) product returned outside of appropriate temperature range ( ) ) clinician unaware product was assigned ( ). thus far in , wastage records have identified units of preventable wastage. secure texting was used by a transfusion service physician to investigate. twelve responses provided useful feedback for future management strategies, responses thanked the transfusion service for the information, and in instances, the message was read with no reply. conclusion: secure text messaging has the potential to improve communication in transfusion medicine. it is easy to use, hipaa compliant, and helps identify strategies for reducing wastage by improving communication and allowing personalized educational opportunities between ordering physicians and the transfusion service. sequence of reagent adding for cryopreservation freezing solution guoling chen*, xu zhao, andrew tiss, sasha turner, devin emerson, manijeh shemirani, sharon novak, david garvin, john eng and wanxing cui. medstar georgetown university hospital background/case studies: dimethyl sulfoxide (dmso), plasmalyte-a (plas-a), human serum albumin (hsa) are widely used to prepare cryopreservation freezing solution. some use autologous plasma instead of plas-a and hsa. this study is to identify the choice of reagents and the optimal sequence of adding these reagents when making freezing solution. study design/methods: materials: . % dmso, plas-a, % hsa, autologous plasma extracted. containers: transfer pack (bag) and polystyrene tubes. the freezing solution recipe used in this study is (volume ratio) . %dmso: plas-a : %hsa : : . plas-a and hsa are kept at room temperature ( - c, rt) and refrigerated at c, plasma at rt (to simulate the end-of-centrifuge temperature), dmso at rt (due to high freezing point . c). different combinations of the reagents choice, storage temperature, adding sequence, are tested with photo taken. total tests. at least minutes cooling after dmso, before adding the next reagent. see table: ( ) after directly adding . % dmso alone to bag, the bag turned from transparent to white, so dmso should not add first. ( ) in tube, autologous plasma first, dmso next, powder-like precipitates. ( ) in tube, dmso first, hsa next, precipitated instantly, a layered appearance. ( ) & ( ) in tube, plas-a first, then hsa, dmso at last, precipitates formed; rt plas-a and hsa combination formed a thicker precipitate than those kept at c. ( )&( ) in tube, hsa first, dmso next: precipitation formed heavily, sculpture shape. precipitation in the c group is slightly milder/slower than rt group. so hsa should not be added first. ( )&( ) trace of hsa(< ml) was mixed into the plas-a bag ( ml). in tube, such "hsa-contaminated" plas-a was added first, then dmso, small fragments of precipitates formed, so dmso should not add last. background/case studies: maintaining a robust blood product supply is an essential requirement to guarantee optimal patient care for all major hospitals. however, daily blood product use is difficult to anticipate. platelet products are the most variable in daily usage, have short shelf lives, and are also one of the more expensive products to produce, test, and store. due to the combination of absolute need, uncertain daily demand, and short shelflife, platelet products are also frequently wasted due to expiration. sophisticated data analysis has the potential to accurately predict hospital wide platelet needs and therefor reduce wastage. study design/method: we have investigated platelet usage patterns at our institution, and specifically interrogated the relationship between platelet usage and aggregated hospital-wide patient data over a recent consecutive -month period. using a convex statistical formulation, we have found that platelet usage is highly dependent on several factors. these include day of week, number of abnormal cbc, location-specific hospital census data, and other less important factors. we exploited this relationship to develop a mathematical model to guide collection and ordering strategy. results/finding: this model minimizes waste due to expiration while never allowing for a shortage; the number of remaining platelet units at the end of any day never drops below in our model. compared with historical expiration rates during the same period, our model reduces the expiration rate from . % to . %. with an annual platelet usage of approximately , units, this reduction equates to approximately units saved from expiration annually. depending on platelet pricing in different regions, this accounts for annual savings between $ , to $ , , per institution. conclusion: to our knowledge our research is the first such use of hospital wide data to inform real-time donor recruitment strategies based on anticipated patient demand. thawed plasma implementation: signficant cost savings and decreased plasma wastage morvarid moayeri* , russell thorsen , rosaline ma , antonio g insigne , amy decourten , florence panganiban , patricia mckean , cyril jacquot , sara bakhtary and ashok nambiar . ucsf health, children's national medical center background/case studies: plasma (ffp, pf , pf rt ) stored at - c outdates hours after thawing. if collected in a functionally closed system, it may be relabeled as thawed plasma (tp), extending expiration to days from the thaw date. although coagulation factor levels decrease over this period, they remain above hemostatic levels. as tp can be safely used for the vast majority of patients requiring coagulation support, we implemented use of tp in our multi-site tertiary care system, with the aim of decreasing costs and minimizing wastage. study design/methods: the massive transfusion protocol at our instiution already allowed the use of group ab tp. following a review of literature and practice at other large centers, the transfusion committee extended the approval of tp to all patients. neonates (< months), patients undergoing plasmapheresis and those with factor deficiency or other disorders for which we also noted a significant decrease (not quantified) in technologist time and effort, as less time was expended on the following: thawing units, printing inventory reports and reporting/record-keeping for discarded units. conclusion: in many large facilities, providers frequently order more plasma units than are ultimately transfused, leading to high plasma wastage rates due to limited ( hr) shelf-life. tp has an extended shelf-life, and can be used interchangeably with ffp and pf for most patients. implementing tp in a multi-site tertiary health care system resulted in sustained decrease in plasma wastage, saving thousands of dollars and helping conserve a precious resource. the merging of immunohematology reference lab's (irl) inventories-using technology to create advanced search functions alexander delk and richard gammon* . oneblood, oneblood, inc. background/case studies: immunohematology reference labs (irls) must maintain diverse inventory of antisera to aid in antibody identification, antigen type rbc units, and meet regulatory requirements. when our current organization was established, two irl sites had independent inventory management systems. although the purpose of maintaining the antisera inventory was the same, organization, storage, & access to instructions for use (ifus) were not. our irl developed a synergistic method to organize and store antisera coupled with in-house designed custom excel spreadsheet to organize and search antisera and view ifus. study design/method: a list of similarities and differences was constructed. best practices of both methods were identified. we determined that our antisera could be broadly classified/organized into two main categories: rare and bulk for screening. sequential lab assigned numbers were given to antiserum for each category: s (rare sera) and b (bulk sera). a dynamic/static freezer box storage system that was inter-box static and intra-box dynamic was determined to be best option to combine two inventories while conserving elements of each allowing for library growth. antisera assigned to a box remained in that box, but may be moved within the box. the box itself may be moved among freezers. to track boxes, location and movement within the box, a custom excel spreadsheet was created. its location tracking feature allowed for two different storage methods to function in one spreadsheet. the spreadsheet had a tab for s and b antisera categories. abo group, desired and unwanted antibodies filters allowed quick search for appropriate antisera. the spreadsheet also had hyperlinks to scanned ifus. results/finding: sequential lab s and b numbers were assigned to new additions using a dynamic/static storage system. an excel spreadsheet with scanned ifus (hyperlinks) was used. pre-merger systems, it took on average - minutes to choose an antiserum and obtain the appropriate ifu. post-merger system was reduced to on average - minutes. (table) conclusion: the merging of two irl's antisera inventories resulted in a need for innovation to create an inventory management system with an advanced search function and hyperlinked ifus. this process saved valuable technologist time and organized the antisera more efficiently. abstract continue to flash until they are removed from shelf and their status updated in our database. 'units allocated' tab includes truncated patient name (to protect privacy), unit number, component type, allocation and expiration date/time, and time since allocation, with a flashing alert for units expiring in < hours. the xm/hla platelets tab provides patient names and status of units allocated. a 'trxn/xmplat' tab lists pending transfusion reactions and platelet cross match reports. dashboard eliminated the printing (several times/shift) of lengthy computer-generated reports, simplified thawed plasma inventory management and helped decrease plasma wastage (from % to %). conclusion: using in-house talent and minimal capital expenditure, we designed and implemented a dynamic web-based dashboard for managing blood product inventory across a multi-site transfusion service. the dashboard is stable, customizable and requires little maintenance. initially built to optimize inventory display for thawed plasma implementation, the dashboard was expanded to include all allogeneic blood products. over the past year, this tool has replaced manual processes for monitoring and rotating inventory and directly helped decrease plasma wastage. use of deglycerolized red blood cells for hospital transfusion service inventory management ronnie l. hill*, jason corley and lizabeth ostiguin. us army background/case studies: regional blood shortages have been documented across the united states during the winter holiday timeframe. deglycerolized red blood cells (drbcs) have been shown to be an effective alternative though more expensive to manufacture. this study looks into the fiscal and inventory efficacy of using drbcs to meet the needs of transfusion services during times of blood shortage. study design/method: on three separate occasions, a medium sized dod donor center used its frozen blood inventory to produce type o drbcs to meet the needs of two regional transfusion services. all frozen red cells were manufactured by an offsite facility with the haemonetics acp- using the low glycerol ( %) freezing method and frozen at - c within six days of collection. thawing occurred in a c water bath in the following order: o positive and o negative on january ; o positive and o negative on february ; and o negative on february . deglycerolization occurred on site using the acp- with all units passing internal qc requirements. drbcs were shipped the same day to a hospital transfusion service, allowing for days of shelf life prior to expiration. results/finding: during the three events, all supported transfusion services and the blood center were below minimum inventory requirements for standard type o red blood cells (rbcs). o positive rbcs were only available through nbe at $ - and had the limitation of arrival on the next business day. collection and processing time of liquid rbcs takes approximately two days including: donor screening, phlebotomy, component processing, testing, and labeling. drbcs cost the dod on average $ per unit to produce and distribute. drbcs have a shorter shelf life, days versus the days for other rbcs, but are washed during deglycerolization and thus produce fewer transfusion reactions. one tech can operate up to four acp- 's and deglycerolize four units at a time. in january and february , it took one tech four hours per iteration of eight units to include thawing, labeling, and packing for shipment. conclusion: while not as readily available as traditional rbcs, drbcs can be an effective product to bridge the inventory gap when small numbers of units are needed due to reduced inventory. collection and processing of whole blood into components takes approximately two days, but can produce greater numbers of units in that timeframe. based on this, drbcs can be ready faster than freshly collected units of blood. there is an increased cost associated with manufacturing frbcs which is compensated for by the longer available shelf life of years. having a small contingency supply of frozen red cells and deglycerolization equipment has been effective on three occasions in ensuring availability of type o red blood cells for hospital transfusion services. validation of a human anti-tetanus toxoid immunoglobulin assay performed on the abbott c izekial butler* , karen leighton , scott jones and rachel beddard . qualtex laboratories, biobridge global background/case studies: plasma fractionators require anti-tetanus quantitative testing to be performed on plasma samples collected from individual donors or plasma production pools. this testing serves as a quality control test and helps estimate the antibody potency of the product. the binding site, human anti-tetanus toxoid immunoglobulin liquid reagent kit is for use on a turbidimetric analyzer. the aim was to optimize and validate the human anti-tetanus toxoid immunoglobulin liquid reagent kit for use on a photometric analyzer. study design/method: experiments were performed in order to determine the optimal amount required of reagent buffer and latex reagent from the anti-tetanus toxoid immunoglobulin kit utilizing the abbott c instrument. precision of the new assay parameters was determined by testing replicates of a panel of samples at three concentrations of tetanus antibody in a single testing run. the panel samples were created by spiking appropriate amount of a who tetanus antibody standard into sodium citrate plasma. accuracy was determined by testing a series of samples ranging from iu/ml to iu/ml of tetanus antibody. the samples for the accuracy study were created by diluting an appropriate amount of a who tetanus antibody standard with sample diluent from the reagent kit. linearity regression was determined by using the accuracy study values within the range of . to . iu/ml. stability of samples was determined by testing samples stored at - c and - c in triplicate at various time intervals. results/finding: the %cv for the optimized anti-tetanus assay for all antibody levels determined in the precision study varied from . to . . so, precision was acceptable since the %cv for all samples tested was %. the mean values for the samples tested in the accuracy study were all % of the expected value which was much lower than the acceptance criteria which was % of the expected value. the linearity of the assay was acceptable with a r ! . %. the linearity study established that the known tetanus concentration was a statistically significant predictor of the observed concentration. the sample stability studies demonstrated the ability to quantitate tetanus antibody concentrations in samples stored up to days at - c and up to month at - c. conclusion: the data presented shows the successful optimization of the human anti-tetanus immunoglobulin reagent kit for use on a photometric analyzer. validation studies of this optimized assay demonstrate excellent accuracy, precision and linearity using samples stored for days at - c and stored up to one month at - c. a deep dive audit of intravenous immunoglobulin use for immune thrombocytopenia: is its use inappropriate? jiajia liu*. university of toronto background/case studies: intravenous immunoglobulin (ivig) is a generally safe and effective therapy for immune thrombocytopenia (itp) but is only suggested for scenarios when a rapid increase in platelet count is desired or as first line therapy if steroids are contraindicated. due to concerns regarding adverse effects, cost and resource availability, an ivig request form was implemented in our jurisdiction in to track utilization and appropriateness. a recent audit of these request forms from four academic institutions found a lack of compliance with form requirements and inadequate documentation of efficacy which led the authors to conclude that the use of ivig was broadly inappropriate (shih et al, ) . as such, we aimed to conduct an extensive chart review of patients who received ivig for itp at our institution to assess appropriateness of use. study design/method: we conducted a retrospective chart review of all patients with itp who received ivig in our institution from april , to march , . local research ethics board approval was obtained. results/finding: patients received ivig for itp at smh over the study period for a total of unique ivig infusions. the most common indications for ivig within currently accepted guidelines were: active bleeding ( , %), pre-operative or antepartum care ( , %), a platelet count of less than and contraindication to corticosteroids ( , %). additional indications that still fell within accepted guideline recommendations included: patients with arterial/venous thromboembolism or risk thereof requiring initiation of antithrombotic therapy; and patients requiring myelosuppressive chemotherapy. indications that fell outside of guidelines included: use of ivig as a diagnostic challenge where the etiology of thrombocytopenia was unclear and use prior to international travel for patients with difficult-to-treat chronic itp despite a platelet count between - x /l. patients received ivig for a likely diagnosis itp while a transfusion being investigated for alternative explanations for thrombocytopenia. three patients were refractory to all other therapy for itp and were dependent on regular ivig infusions. / ( %) of infusions consisted of g/kg over days; the remainder of infusions consisted of g/kg. of those who received g/kg, of patients ( %) had evidence of partial remission after a first g/kg dose. ivig was generally well tolerated and infusion reactions were mitigated with use of corticosteroids, antipyretics and/or antihistamines. conclusion: we found, at our institution, that use of ivig for itp was generally appropriate and carefully considered even in cases that did not meet current guideline recommendations. we believe that ivig remains an important treatment for itp particularly in the aging population where prevalence of conditions complicating bleeding risk is increasing. detailed utilization/ knowledge data inquiries are required to develop tools and policies to enhance appropriate ivig use in multiple settings. we believe that there is an opportunity to promote administration of a single g/kg dose to minimize unnecessary utilization of ivig amongst hematologists who manage itp. a process for improving crossmatch bench ergonomics janet dornfeld*, sheng-chung cheng, ann eggebrecht, beth greer, savannahsue rondeau, brian rognholt and beth taylor. mayo clinic background/case studies: a mission of our institution is to reduce the risk of work-related injuries. accordingly, each year an ergonomic survey is undertaken as a component of a general department of laboratory medicine and pathology safety audit. our survey identified potential musculoskeletal risks that suggested a redesign of our crossmatch benches. study design/methods: a seven item ergonomics survey of the working environment was sent to staff members in early february of . twenty-two technologists responded for a % response rate. the below table below reports the survey items and responses. results/findings: the most problematic area was the available workspace. of the respondents, % indicated that workspace size was insufficient and % that the chairs at the fixed height benches were problematic. problems noted were difficulty with climbing up into a chair and backing down and with the chairs holding the chosen height. our laboratory lean team operational support group was tasked to aid with the bench redesign and to choose products for improving the workspace. our goals were to design a layout to streamline testing workflow and better utilize lab space, including our plasma thawing and sink space, eliminating dead space. the configuration of the new workspace was guided by the survey findings. adjustable height workstations were recommended to replace our fixed height bench. we worked with our facilities design contactor to purchase adjustable benches and plan add-on cabinet shop work. the benches were assembled off site, which allowed a bench top layout to be determined and installation of cabinet shop add-ons of a drawer for supplies and a pull out breadboard as a writing surface. the opportunity to assemble off site streamlined the process of installation, resulting in minimal disruption of testing. conclusion: the survey was effective in identifying working areas for improvement. employee comments have been positive for the new workstations. an effectiveness assessment will follow, using the original survey, to assess the success of the project. a retrospective study of emergency department initiated type and screen testing: were patients transfused after testing? sandra lamm* , neil bangs and kimberly sanford . vcu health system, virginia commonwealth university background/case studies: type and screen (t&s) testing is often ordered on patients presenting in the emergency department (ed). if the patient does not have a historical type, a second sample is drawn with an additional phlebotomy for type confirmation. if the patient does not need a transfusion of red blood cells (rbcs), the testing and second phlebotomy is an inefficient use of resources and time. study design/method: as part of a performance improvement initiative in transfusion medicine, we performed a retrospective study of all t&s orders that were initiated in the ed from / / to / / to determine if testing was subsequently followed by transfusion of blood products. patients were stratified by ed department, time from t&s draw (tsd) to transfusion (< hours, > hours < hours), and if a second sample was required. results/finding: a total of t&s orders were initiated from the ed in this time period. ( . %) patients were not subsequently transfused any type of blood product within hours of tsd and ( . %) patients were not subsequently transfused any type of blood product within hours of tsd. a total of ( . %) patients required a second sample. of these patients requiring a second sample, ( . %) were not subsequently transfused any type of blood product within hours of tsd and ( %) were not subsequently transfused any type of blood product within hours of tsd. conclusion: routine ordering of t&s testing is not an efficient use of resources and time as many patients are not subsequently transfused. ultimately unnecessary t&s and second sample collection and testing for those patients not subsequently transfused within hours of tsd amounted to an estimated $ , in unnecessary patient charges and approximately . nursing hours for phlebotomies in a six month period. anti-d from alloimmunization versus rh immune globulin: detective work in the blood bank and transfusion medicine services (bbtms) margaret diguardo* , debra berry , yunchuan delores mo and gay wehrli . university of virginia health system, children's national medical center background/case studies: the institute for healthcare improvement triple aim incorporates enhancing patient satisfaction by providing high quality, safe care. towards these goals the bbtms is charged with communicating to obstetric physicians (obs) a patient's antibody specificity with associated hemolytic disease of the fetus/newborn risk. thus, when anti-d is detected in a female of childbearing age, it is critical to determine whether this represents rh immune globulin (rhig) or alloimmunization (alloanti-d). review of a patient's electronic health record (ehr) helps quickly identify rhig administration, but if this documentation is missing, then it is easy to assume presence of alloanti-d. rhd alloimmunization impacts mom, fetus, newborn and future pregnancies. therefore, without a national, comprehensive health information exchange (hie) system, it is imperative to investigate beyond the on-site ehr whether a patient received rhig at an outside hospital (oh). we report an irb approved (exempt) case series where detective work revealed rhig administration at ohs. study design/method: over a two month time period, anti-d was identified in four pregnant women. review of their ehrs did not reveal a history of abstract rhig administration; nor did subsequent direct communication with their obstetricians (ob) reveal a history of rhig. based on each patient's home address, the bbtms of any nearby ohs were contacted as was a primary care physician if listed in the ehr. results/finding: investigations beyond the ehr and obs revealed each of the four patients received discontinuous prenatal care with presentations at multiple sites. through phone calls to the bbtms of ohs, a history of one or more rhig administrations within the preceding three months was found for each patient. our bbtms records and ehr were amended to reflect the presence of a passive anti-d due to rhig, rather than alloanti-d. the changes were also directly communicated with the ob caring for each patient. conclusion: when a new anti-d is identified in a pregnant female, investigation is required to determine whether it is passive rhig versus alloanti-d. when neither the ehr patient history or ob reveal a rhig history, it remains in the patient's best interest to investigate further. through phone calls to oh we revealed a history of rhig administration in four patients. finding and communicating this critical information helps enhance the quality and safety of patient by ensuring subsequent rhig administrations when indicated, at our institution. future strategies for avoiding similar situations include expanding our national hie for critical information such as bbtm history and allergy history and expanding use of wallet-size patient identification cards with rhig and alloantibody histories. auditing massive transfusion protocol colleen a. aronson* , elizabeth halperin , sharon breining and mona papari . acl laboratories/ advocate hospitals, advocate health care, itxm background/case studies: a large midwest hospital system with level i trauma sites evaluated how to audit the massive transfusion protocol (mtp). the possibility of real time audits is impractical due to the unpredictability of these events. a search of the internet found an example from new zealand for post process evaluation. this was shared with a team as a starting point and then adjusted for system specific priorities. to start the audit, the initiation of the mtp needed to be determined as events are often started as a verbal request but then followed up with either downtime or computer orders. study design/method: the transfusion service (ts) was determined to be the source of truth for all of the mtp events. a tracking sheet was created to capture the patient demographics, start and stop time, number and type of products issued and wastage. this was then passed onto nursing quality staff that used the tracking form and the patient chart to enter an event into the error management data base as a focused event. the focused event was built to include patient demographics and other information from the tracking form as well as where the event was called (surgery (or), emergency (ed), labor and delivery (l&d), etc.), type of event, use of tranexamic acid (txa), calcium chloride (cacl), temperature monitoring and pre/ post lab results. a trial was started and months of data were evaluated that contained events. results/finding: there was an equal number of events that were initiated in the ed and the or ( ). male patients were involved % of the time and % of time the patients expired. trauma of some type was the majority of the cause but . % of the cases involved gi bleed and only . % were obstetric cases (see chart). the lowest hemoglobin (hgb) was found to average . with the post hgb average of . . ratios of : for red blood cells (rbc) to plasma as well as rbc to platelets (plt) and cryoprecipitate (cryo) were also determined with a target of : . it was found that the rbc: plasma was . : , rbc: plt was . : and rbc to cryo was . : . use of txa was only . % and cacl was utilized in . % of cases. conclusion: although this data is for a short period of time it has pointed out several opportunities for improvement. the use of mtp in gi cases was not previously understood but opens up a new group of people for which education and understanding of the mtp process is needed. the low use of txa needs to be evaluated and already has started conversations about how this drug should be stored and accessed for the mtp process. the product ratio numbers were suspected of being off but now that data is available, it is much easier to speak to this issue and look for improvement. the process will now be expanded to the level ii trauma sites in the system and routine evaluation will be shared with all sites. automated report significantly reduces turnaround time for rbc antibody alert jessica l dillon* , jody a barna , donald e ulinski and nancy m. dunbar . dartmouth hitchcock medical center, dartmouth-hitchcock medical center background/case studies: clinically significant antibodies should be promptly and clearly communicated to the patients' healthcare team to avoid potential transfusion delays in blood availability or complications of incompatible transfusion. at our institution, all newly identified clinically significant antibodies are immediately resulted in the electronic medical record (emr). an interpretative comment is also entered by the transfusion medicine service (tms) physician after the antibody work-up has been reviewed (this may be up to weeks after the antibody is identified). this comment describes the antibody(ies) identified, indicates the need for crossmatch compatible blood and alerts clinicians of possible delays in providing crossmatched units. since clinicians may not always review these results, the tms physician also simultaneously adds an "allergy to red blood cells" alert in the patient emr at the time the interpretive comment is entered. study design/methods: in july , we implemented an automated report to reduce the turnaround time (tat) for entry of the allergy alert. the report contains all detected red cell antibodies in the prior hours and is provided to the tms physician during daily morning rounds (monday through friday) for manual entry of allergy alerts. this study describes a three month comparison both before and after the automated report intervention, to evaluate the tat for allergy alert entry into the emr. age ( abstract results/findings: between august and november (pre-implementation) , newly identified clinically significant antibodies were resulted for patients compared to patients between the months of august and november (post-implementation). the tat for allergy alert entry for both periods is shown in table . we observed that % of allergy comments were performed within hours in the post-implementation period versus only % pre-intervention (p . ). using the new process, nearly all of the alerts were entered into the emr within hours of antibody resulting and none of the entries were missed. conclusion: there was a significant improvement in the tat for allergy comment entry following implementation of an automated report. this project illustrates how information technology can be leveraged to facilitate timely communication of antibody identification. blood bank verbal tool implementation for cardiovascular surgery rita louie* , shailesh macwan , nancy nikolis , arline stein , janelle richardson , manju bagu , lennart logdberg , alexander indrikovs , vishesh chhibber and sherry shariatmadar . north shore university hospital, northwell health background/case studies: our institution is a tertiary care facility performing over cardiovascular surgeries (cvs) in , an increase of % after the healthcare system cvs integration in . transfusion support of these patients includes preoperative preparation of prbcs according to a maximum surgical blood order schedule. additional blood components are issued as orders are placed. until december , the additional written orders were submitted to the blood bank via the pneumatic tube system without further communication. after reported events in q that resulted in delays in blood transfusion, we examined our process very closely and identified opportunities for improvements. in collaboration with cvs, the blood bank implemented a new workflow process to enhance communication with the cvs team, reduce turnaround time and improve patient safety. study design/method: . open discussions and collaboration between blood bank and cvs nursing teams . mapping the process using flowcharts for additional blood orders from cvs. . identify bottlenecks and brainstorm solutions. . a verbal cvs order process and form was implemented to improve communication between cvs and blood bank, which solidified communication by including the time of the order, patient identifiers, caller identification, ordering prescriber, staff receiving order, the quantity and kinds of products ordered, the mode of order delivery, and anticipated future orders. a read back was also documented for verification of the order. . the blood bank staff immediately processes this order while waiting for the written order to arrive. upon receipt of the written order the blood is issued to the or. . follow plan-do-check-act. the transfusion safety officer reviews each order for the following parameters: number/type of products, turn around times (tat), wastage/returned products and overall efficacy since implementation of this process. results/finding: a significant improvement was noted in communication and tat after implementation of the process described above. for the period / / - / / the blood bank has received verbal orders with varying product combinations. the table below represents average turn-around times to issue blood products: conclusion: the introduction of the verbal order tool for cvs has streamlined the blood ordering process leading to increased efficiency and lower tat. effective communication between the or team and transfusion service is the key to timely provision of blood products for these critical patients. challenge of blood type testing for multiply transfused sickle cell disease patients jayanna slayten* , tracie ingle and heather vaught . indiana university health, indiana university health (iu health) background/case studies: we report our midwestern, university transfusion service challenge of obtaining the correct blood types in rbc exchanged sickle cell disease (scd) patients tested by our primary testing method, solid-phase red cell adherence analyzer echo (immucor. norcross, ga). the echo operation manual in chapter - and appendix d it states: "warning: the galileo echo cannot reliably detect hemagglutination reactions that are graded as or less in tube methodology. the galileo echo does not generate as interpretation of mixed-field. such a mixed-field reaction will be interpreted as positive, negative, or equivocal." we report of a challenge with this analyzer limitation which impacts the assignment of the correct blood type for multiply transfused scd patients. study design/method: two scd when initially tested by the echo as o, d negative; however, each patient was historically o, d positive. both patients had received a rbc exchange transfusion with - o, d negative red blood cells over days previously. repeat testing of the samples was completed by the vision (ortho clinical diagnostics. raritan, nj), neo (immucor. norcross, ga), and by standard abo/rh manual testing (anti-a, anti-b, anti-d series , anti-d series , a cell and b cells. immucor. norcross, ga). the repeat testing was compared to verify the patient's abo/rh typing and the results were entered into the computer system to allow for assigning the patient's abo/rh typing and electronic crossmatch. results/finding: table summarizes the initial and repeat testing with the two patient samples. although the echo failed to interpret or flag the blood type as mixed-field, the other methods identified the transfusion of o, d negative blood with the detection of mixed-field in the d typing or by failing to interpret the abo/rh as not type determined (ntd). the vision and manual abo/rh typing yielded the easiest mixed-field to interpret macroscopically. conclusion: our results agree with the findings of summers et al (trans-fusion ; : - who reported the challenge detection of mixed-field with the use of the echo compared to improved detected with automated gel column agglutination. when the samples were tested by multiple automated and manual abo/rh methods, the expected mixed-field was detected. the failure of the echo to detect the mixed-field is acknowledged by manufacturer, but there is a risk that a facility may mistype the abo/rh when there is not a historical abo/rh to compare. to avoid this risk, it may be appropriate to re-type first time scd patients by other methods rather than the echo to avoid this challenge. consistent with summers do not account for regional distribution. many large hospitals acting as regional hubs for redistribution may appear to have optimized inventory based on odr and bsr, but we hypothesized that these are crude key performance indicators (kpis) requiring redevelopment. study design/method: kpi redevelopment occurred in a large tertiary care hospital blood bank in canada, responsible for % and % of transfusions in the region and province respectively. rbc supply, inventory, and disposition data were retrospectively assessed from february -june as the baseline period. a "demand-driven inventory planning policy" (ddip) was instituted to assess and implement the optimal rbc reorder quantity based on the difference between the historical maximum and minimum rbc inventories during weekdays; that would not lead to blood shortages. shelflife inventory (sli) was chosen as the main surrogate marker for the assessment of efficiency of the supply chain process, calculated by the differences between age of blood transfused (abt) and received (abr). iterative simulation modeling (r statistical software) was then performed to optimize sli in a post-implementation period from june -october . results/finding: modeling predicted observed rbc disposition. through simulation, optimization of sli was found to occur by optimizing a set of kpis for each abo blood group (table ) . this led to a reduction in observed overall sli ( . . days vs . . days, p< . ) and odr ( . % vs . %). the bsr was not significantly increased during the postimplementation period. conclusion: optimization using simulation modeling of multiple factors other than bsr and odr led to further efficiency gains in a large tertiary care hospital blood bank. hospital blood banks should use an integrative approach with a set of kpis to optimize the supply chain. this approach requires validation in other blood banks and jurisdictions. ( )) requires that the hospital make reasonable attempts to notify the patient (or the patient's physician), counsel the patient, and offer testing. the hospital must maintain records of this lookback notification as part of the patient's medical record. paper records of lookback notifications are less accessible than electronic records and are at greater risk of being damaged or lost. to facilitate the lookback process and reduce paper documentation we sought to use the electronic medical record (emr) to perform and document notifications. study design/method: representatives from transfusion medicine (tm) and information technology (it) worked together to define minimum and optimal emr solutions. minimally, a completed paper packet could be scanned into the emr. this solution had no advantages in terms of ease of use, process control, or transparency. desired optimal functionality includes the ability to send letters in the emr, document control so that original communications may not be altered, opportunity for patient's physician to electronically sign and return responses, letter and form templates that can be individualized, and the ability to track when and by whom notifications were sent and received. the emr system at our institution, epic (epic systems corp., verona, wi), has a function called "letters" with the capacity to do all these tasks. a series of five templates were developed: hiv and hcv letters to physicians, response forms for physicians to return to the transfusion service, and a blank letter template to be used for specially tailored letters. templates are opened within the patient's emr and demographic information is automatically populated by epic (eliminating many possibilities for clerical errors), the blood product transfused (e.g. rbcs or plasma) is selected from a drop-down menu, and the date of transfusion is manually entered by the sender. the completed letter is then routed to the patient's physician; it shows up automatically (and instantly) in their electronic in basket as well as in the patient's emr. physicians may electronically complete and return the response form within epic, or print it and return the form by fax. results/finding: between january and december thirty-five ( ) notifications were sent to physicians using epic letters and of those, fourteen ( ) responded to the epic notification and five ( ) used the provided electronic response form. for these cases the time to mail or handdeliver paper notifications was avoided. the remaining cases required follow-up paper notification, but the electronic letter remains as permanent, easily accessible documentation of when the transfusion service first notified the physician. conclusion: lookback notifications within the emr makes compliance with government requirements more transparent and records more accessible to caregivers, patients, and assessors. secondarily, efficiency may be improved by reducing the need to print and mail/deliver letters. evaluation of ordering practice in the operating rooms and its impact on product wastage alexandra budhai* , denden benabdessadek , annu george and alexandra jimenez . westchester medical center, new york blood center background/case studies: blood product wastage is an issue that many hospitals aim to address. the or was identified to have the highest rate of wastage within our hospital. in this study, we assessed the appropriateness of the product order and utilization by the or to understand its impact on wastage. study design/methods: data on product orders, issue, and return for two months were analyzed. the hospital cpoe and product requisition forms were used to collect this data. the surgical procedures and number of ordered units were compared to the hospital's maximum surgical blood order schedule (msbos). trends for inappropriate orders for products by physicians were evaluated. results/findings: a total of orders were reviewed. approximately, % of these products were issued to the or. we found that the physician orders were within the guidelines of the msbos for most cases ( %), but of the issued products, all were returned to the blood bank in % of cases. we observed that the percentage of products ordered and used compared with the products ordered and returned in cardiac surgeries are nearly equal. in addition, all of the products ordered for c-sections were not used; albeit ordering frequency being significantly lower than for cardiac cases. conclusion: the data analyzed demonstrates that the majority of surgeons are adhering to our institutional msbos guidelines. it was noted that surgeons are requesting products be issued for invasive procedures where rapid exsanguination is possible. our analysis revealed that the hospital's msbos does allow for an excess in blood ordering for some surgical procedures. the msbos should be updated to reduce the suggested maximum product order. in general, the data does not imply that the blood product wastage in the or is due to the ordering practices of the surgeons. a larger period of surgical blood ordering practices should be analyzed to detect blood product ordering, utilization and wastage trends in other subspecialties. background/case studies: the visionv r and visionv r max (ortho diagnostics, raritan new jersey) are id-mts tm gel card-based automated immunohematology analyzers marketed for small to medium, and high-volume [> type and screens (t&s) per day] blood banks , respectively. our laboratory which serves a large -bed multispecialty academic hospital and receives - t&s specimens per day needed to replace three provue analyzers prior to the availability of the visionv r max. we implemented three visionv r analyzers to work with our existing neov r and echov r (immucor inc, norcross georgia). a recent multicenter field application trial of the visionv r reported a mean turnaround time (tat) for t&s and abo, rh typing (abo/rh) of . . and . . minutes , respectively. the objective of this study was to determine visionv r tats under routine daily high-volume practice. study design/methods: one visionv r was in operation during a five-week period (phase i), and then two additional analyzers were brought into service (phase ii). tats are defined as the time when the order is received by the instrument to when the test is completed and available for review. three-cell screen and abo/rh tats, and number of visionv r antibody panels were collected for a nine-week period. the tat for the screen was used as the tat for the t&s because the screen is the rate determining step. all testing was performed using in-service analyzers on routine patient samples by trained technologists. samples were not deliberately batched but were placed on the analyzer based on the volume and flow of work at the time. results/findings: under the high volume conditions of our laboratory with three visionv r analyzers, the mean t&s tat was % longer and had a larger standard deviation (s.d.) than the published trial result of . . . transfusion vol. supplement s abstract during phase i visionv r performed panels. during phase ii visionv r performed of the visionv r panels. conclusion: our visionv r analyzers are used under high volume conditions more suitable for the visionv r max. when balanced with the testing menu, including ability to perform select cell panels, our tats using three analyzers were satisfactory. the large standard deviation indicates that opportunities remain for improving tats through workflow improvement. from west nile virus to the emergence of zika virus: a nationwide survey of how regulators are keeping the blood supply safe and available falisha atwell* , john roback , ronald arkin , michael bartlett , robert geiger and jaxk reeves . university of georgia, emory hospital background/case studies: with the emergence of zikv in the united states, it is important to assess the fda's response time in providing guidance to ensure the safety and availability of blood products in the face of newly emerging infectious diseases. this research compares the responsiveness of the fda during west nile virus (wnv) and zika virus (zikv) outbreaks to evaluate our current preparedness. study design/methods: the literature review was conducted to analyze fda's response time during the wnv crisis and determine if it was effective and efficient. the research survey was performed to determine if the donor history questionnaire (dhq) adequately screens donors for zikv as the sole preventive method (as per the february guidance for industry: recommendations for donor screening, deferral and product management to reduce the risk of transfusion-transmission of zika virus) and to determine if the current regulatory practices (including the august guidance for industry: revised recommendations for reducing the risk of zika virus transmission by blood and blood components) are perceived to be effective and efficient in the face of the current zikv outbreak. survey monkey was used and participation was anonymous. over , emails and web-links were sent to members of aabb, scabb, seabb, and personal network with a % target response rate. participants self-selected or deselected based on the inclusion and exclusion criteria listed in the consent letter. results/findings: the literature review revealed that the fda's response was slow during the wnv outbreak, while the zikv response is efficient thus far. a total of participants responded to the survey ( . % response rate). statistically, participant agreement with fda's decisions was performed by "t" test (with n- - df) of the null hypothesis that the mean vs. the alternative that the true mean is> . overall participants had favorable opinions of the fda's decisions. statistically, whether participants in different levels of the demographic variables (region, profession, and years of experience) answer significantly differently, one way anova models were used with likert-scale question responses as if they were continuous. the f-statistic and p-value are for the null hypothesis that all levels of the explanatory variable have the same mean for the response variable. there were no significant differences in the years of experience and profession variables for participants. region was determined to be unreliable due to undefined states for each region listed. conclusion: the research revealed that industry experts conclude that the current system of dhq and fda guidance documents, if issued timely, are adequate. background/case studies: when evaluating a new instrument solution for pre-transfusion testing, it is important to consider the operational impact of the system on the lab. there are a variety of operational, performance and system metrics that can be evaluated to determine this impact including: test workflow, hands on time, and automation time. study design/methods: the study involved a current state to a future state comparison of testing processes with an instrument ortho provuev r (pv) and manual testing vs. an instrument ortho visionv r (ov). data collection methods included direct observation, time studies, and interviews. the pv bench performs type & screens (ts) on the pv and manual abid/selected cell panels in the gel test. all other testing; cord blood(cb), dat, unit confirm(uc), patient type confirm(pc) and crossmatch(xm), etc. are done manually in tube. the future state incorporated the ov. ts, abid and uc were evaluated in both states. cycle time(ct) was averaged based on run cycles. ct was comprised of metrics; instrument time(it), standby time(st) and labor time(lt). st may be comprised of components, time that could be utilized as "walkaway" time or vigilant time (vt) which requires operator presence but not operator action. for automated instruments, vt for each cycle was measured as instrument access unavailable. instrument daily maintenance (dm) ct was evaluated as well. similarly, timing of manual tube test processes used these metrics. for repetitive activities within a process, such as uc or xm, a time per individual process was captured and then multiplied per unit. results/findings: table provides details about the metrics of current state and future state processes. tube based test timing is as follows: pc ( : ), xm ( : ), cb ( : ) and dat ( : ). by implementing the future state, an average $ . min. lt and vt is saved on each sample loaded for ts equating to a % labor reduction over the current state. a % improvement in tat on the ts was achieved in the future state. moving from manual abid to automated processing resulted in a % lt reduction. on average, a min. continuous walk-away time is achieved for each automated abid. uc had less impact on labor time with minimal difference however allowed for focus on consistency and quality metrics. conclusion: based on the metrics evaluated and compared between current state and future state, the ov has demonstrated improvement in lab operations to both the labor required and result tat delivery. opportunity exists to automate workflows on other tests that are still manually performed. background/case studies: high throughput and efficient automation of serologic tests is crucial in the workflow of a blood bank that tests $ type and screen samples per day. the erytrav r (grifols) is a fully-automated walkaway analyzer utilizing -column gel cards for pretransfusion testing. the blood bank validated and implemented the use of erytrav r for abo/d typing, antibody screening and identification of patient samples as a replacement for a solid phase testing platform. the blood bank also validated automation of donor unit retypes. the instrument has bidirectional interface to the blood bank lab information system (lis), hcll tm (hemocare life line, mediware). instrument validation and implementation were done in conjunction with the software version upgrade of hcll tm and an interface system change to maestro tm . study design/method: correlation testing of the erytrav r results with the manual tube testing (peg iat; reference method) was performed on patient samples for abo/d typing and antibody screening; of which at least had a positive antibody screen. out of the , had known antibody specificities. forty-two rbc units were also tested for abo/d confirmation; of which were d(-) and were d( ). calculations of concordance, sensitivity, and specificity were performed. precision studies were also done. interface testing of erytrav r , hcll and the hospital's information system using the maestro tm interface system was performed and validated. results/finding: concordant results between both methods were obtained in all of the patient and donor samples tested ( % concordance). all samples with positive antibody screens were obtained by both methods. all clinically significant antibodies were detected by both systems. erytrav r gave % sensitivity and specificity. the precision studies showed that both methods gave the same type and screen results for samples at different testing events. after validation of the lis upgrade and interface system change, a bidirectional interface with hcll tm was established. the instrument has been operational in our lab for over months. conclusion: erytrav r was found to be reliable and accurate and can handle the high workload of our lab. users found the instrument easy to use; hence training, proficiency, and competency of the users are achievable and manageable. the validation of the the instrument is straightforward. the major challenge and delay in the implementation experienced by this blood bank were attributed to the concurrently occurring lis upgrade and migration of the data integration system. a post-implementation workflow assessment would be ideal to perform to ensure that the instrument is being used at its full potential. implementation of a system-wide platelet inventory report optimizes platelet utilization and reduces unit wastage elly landolfi* , craig fletcher and peter millward . beaumont hospital, beaumont health system background/case studies: a sufficient number of blood components should be available to meet routine and emergent hospital needs. this must be assured while minimizing outdating of scarce and expensive blood components -an inherent challenge with platelet units which have a short -day shelf-life. we report the results of a quality improvement project implementing a custom computerized platelet inventory report designed to mitigate the most common cause for platelet wastage at our institution: high platelet outdate rates. the report includes blood type, product code, unit number, respective product attributes, supplier and availability status of all platelet units for each hospital location. all system blood banks receive a morning fax of the report which facilitates transfer of units prior to expiration and adjustments are more readily made for product orders to the supplier. study design/method: the study was conducted in the hospital-based blood bank and based on available platelet inventory and wastage quality data. the report went live october and quality data was reviewed from august to december . the collected data was then analyzed using descriptive statistical methods. results/finding: data from indicates platelet wastage comprised % of total received platelets and % of these wasted platelet units were due to expiration. other reasons included failed visual inspection, blood dispensed but not used and wasted on the floors, potential tube station problems or short-dated units transferred into our blood bank from another facility. the mean of monthly wasted platelet units months preimplementation of the report was units, compared to units months post-implementation and units months post-implementation. wastage rates improved from % (wasted yearly platelets/total received yearly platelet units) in , the year of report implementation, to post-implementation rates of % in and % in (see table) . importantly, this occurred despite a greater than % increase in platelet inventory between and and resulted in cost savings of over $ , in this period. conclusion: study limitations included restricting data collection to one campus. the option to transfer expiring platelet units to another blood bank was available to all participating sister hospitals. it would have been interesting to see the effect of the report on those hospitals which have lower transfusion rates and different ordering practices. aside from lowering platelet wastage within years of implementation, additional benefits to the report included facilitating ordering from the blood supplier. cornerstones of a successful inventory management plan include daily inventory monitoring and, ideally, coordinated system-wide efforts to share platelet units. we have shown achievement of this end is facilitated by a customized daily platelet inventory report -an efficacious and easily adaptable tool with demonstrable gains. valerie halling* , lisa marie button , lori scanlan-hanson , karen koch , janet finley , deepi goyal and camille van buskirk . mayo clinic-rochester, mayo clinic, mayo clinic rochester background/case studies: transfusions in the emergency department of a level i trauma center were ordered using a handwritten order form. the transfusion lab's (tl) management team and medical director met with emergency department (ed) leadership and it resources in to define the needs of a successful electronic blood transfusion system. the handwritten order forms had several potential error sources which could lead to a delay in filling the order pending correction (in the best of circumstances) or could lead to transfusing the wrong patient or the wrong product if the error was not detected. the potential error sources included clerical errors involving the patient's name or medical record number (mrn), writing two different names on the order form (because there were two locations to record patient name), two product types ordered on one form when the requirement is for one product type per order, no priority indicated (stat or routine), or not including the prescriber call-back information. the number of ed reported transfusion related events in and were / (events/ed transfusions - ). study design/method: electronic ordering for the ed was implemented march st . any transfusion orders generated from the ed are now electronic, unless in the case of electronic downtime. the system electronically fills in the patient's name and mrn, controls for the type of blood product being ordered, requires an order priority and provides service contact information. it was designed to accommodate transfusion ordering needs for adults, pediatric patients < kg and pediatric patients > kg. a transfusion orders had three critical fields identified that are required for the order to be processed including patient weight, product volume, and infusion rate. the electronic system was designed so that an order cannot be submitted unless all critical fields are completed. results/finding: the electronic ordering system has been in place for years (april -march ), and during that time there was instance of blood being ordered for an unintended patient . % ( / ). this was because a previous patient's medical record was accessed rather than the intended patient's medical record. there have been no instances of clerical errors (name misspelled or mrn transposition etc.), missing service contact information, missing order priority information, more than one product type ordered on a single order, or two patient names on one order. electronic ordering also provided a place for the transfusionist to chart against, leading to increased transfusion documentation compliance. prior to electronic order implementation, in , / ( . %) units were transfused in the ed but not charted in the patient's medical record. in , / ( . %) transfusions were not charted. however, in , the first full year of electronic transfusion order capability, only / ( . %) transfusions were not charted in the patient's medical record. conclusion: electronic ordering in the ed has essentially eliminated ordering errors in this area resulting in less rework for both technologists and physicians. it allowed the order to be processed more quickly by tl, resulting in a faster turnaround time. improvement in the overall quality of transfusion ordering through electronic ordering reduced the influence of human factors in order placement and provided an added benefit of having a specific order to chart against. implementation of blood bank automated attendant lok tse*, gerald motta and maria aguad. brigham and women's hospital background/case studies: the blood bank receives numerous nonemergent phone calls on a daily basis. these calls not only occupied valuable time but also made the lines unavailable when a real emergency occurred. the hospital is categorized as a level trauma center, with over inpatient beds and over operating rooms. a proposal to implement a blood bank automated attendant was recommended to decrease phone calls, minimize errors due to distraction from phone calls, free team members to perform other duties and have a direct line designated for requesting trauma coolers, massive transfusion protocol (mtp) and emergency release of blood products. study design/method: the first step was to categorize the types of phone calls received by the blood bank by creating a phone log. data were collected and analyzed for four weeks. the blood bank collaborated with nursing, hospital administrative staff and telecommunication team to evaluate the possibility of implementing an automated attendant to minimize phone calls. it was very important to maintain patient safety and quality of service at the same time. the automated attendant consist of: option (urgent) for trauma, emergency release, mtp and obstetric hemorrhage emergency release; option (verbal) for verbal orders and coolers set up; and option (staff) to speak with staff member. instructions were also given for specimen inquiry and product availability in the hospital information system. results/finding: the data in table showed that most of the incoming calls fall into three categories (specimen inquiries, product order inquiries, and other inquiries). most of the calls were from nursing staff inquiring about the length of wait time for blood products and specimen availability. there was an overall decrease in phone calls by % with the implementation of an automated attendant. conclusion: with the implementation of an automated attendant, the blood bank team was able to identify and respond accordingly and efficiently to urgent requests and verbal phone orders. the decrease in phone calls freed up team members to perform other critical tasks in the department. improved detection of wrong blood in tube errors: implementation of a two-sample blood type verification process ariana king* , steven zibrat , geoffrey wool and angela treml . university of chicago medicine, university of chicago background/case studies: our organization used a blood bank identification (bbid) band system for pre-transfusion testing and detection of wrong blood in tube errors (wbit). additionally, type & screen results were compared to patient's historical records; the specimen was retyped by a second technologist if historical results were not available. the bbid bands were prone to clerical errors and excessive specimen rejections, and believed to miss some wbit errors. in , blood bank accounted for % of all rejected clinical laboratory samples, yet comprised only % of total laboratory volume; % of rejected blood bank samples were due to bbid band issues. the wbit error rate detected by bbid-based system was . %. study design/method: a multidisciplinary workgroup was formed to review data and best practices. the decision was made to discontinue bbid bands and implement a two-sample verification process, in keeping with standards. a new laboratory test order was created in the emr system and embedded into the existing t&s order. providers are prompted to order the abo verification test only when no previous abo/rh typing results are found. education was provided to all clinical staff in the form of in-services, emails, and annual competencies completed electronically. the new process went live in september . results/finding: in the five months following implementation, four wbit errors were detected with the second sample. these may have been missed using the bbid band system. improved detection revealed a wbit error rate of . %, three times the national average of . %. under the new system, rejected blood bank samples decreased from an average of % to % of all rejected laboratory samples, a % decrease. implementation of the new process produced a net savings of $ . k. conclusion: replacing the bbid band system with two-sample verification successfully improved our ability to detect wbit errors among patients who lacked historical blood bank results. additionally, discontinuation of the bbid system decreased the incidence of clerical errors and unnecessary specimen rejections, and also saved money for the organization. next steps are for blood bank and laboratory quality leaders to partner with nursing leadership to drive down wbit error incidence. a addendum with the final culture results. we used a student's t test to determine whether there was a statistically significant difference in the mean tat for result addendum entry in the post-implementation period compared to the pre-implementation period. results/findings: in the pre-implementation period, we cultured residual products for suspected str. the tat for final culture result entry into the patient's emr was - days (mean days, sd ). in the postimplementation period, we cultured residual products for suspected str. the tat for final culture result entry into the patient's emr was - days (mean days, sd ; p . ). there were no positive cultures during either study period. conclusion: our study demonstrates that tat for documentation can improve with the use of information technology to notify the transfusion medicine physician when results are available for documentation in a patient's emr. improved turnaround time of type and screen samples michaelene hultman* , marcus holme , johnathan bakst , gunta musa and angela treml . university of chicago medicine, university of chicago background/case studies: the primary test performed in the blood bank with regard to pre-transfusion testing is the type and screen (tys). the current target for this institution's blood bank is an minute turnaround time (tat). in april of , the blood bank was forced to move to a temporary location due to building construction, which necessitated a switch from automated solid phase methodology to manual gel method. the average number of outliers increased %. tat analysis of a representative one week sampling per month showed an increase in outliers from per month to per month. average monthly tys samples performed is . these numbers did not improve even upon returning to the original facilities. study design/method: two ortho clinical diagnostics visionv r analyzers (raritan, n.j.) were purchased for the blood bank. the instruments were set up with a bi-directional interface allowing for samples to be continuously loaded without manually ordering the tests. batch testing was eliminated allowing samples to be run as received. the results were auto interpreted, and transmitted to the laboratory information system (lis) based on predetermined rules. only results in need of manual review or interpretation were held back. final verification of results was performed by the technologist within the lis. reagents and other needed consumables could be preloaded on the instruments eliminating the need to repeatedly load consumables with each sample run. key quality indicators including tat continued to be monitored throughout implementation. data was monitored for significant changes and improvements in patient care. the go-live date was / / . results/finding: the average number of outliers decreased % from per month to . further benefits include a reduction in the number of technologists needed to perform tys testing. additionally, reduced waste due to better utilization of supplies by the instruments along with less repeat testing has resulted in projected cost savings of $ , for fiscal year . conclusion: the use of gel technology, in combination with a two way interface and a continuous load instrument can result in a significant decrease in tat over manual gel method. improvements in the timely reporting of final product culture results in the patient's emr. barbara a. hewitt*. dartmouth hitchcock medical center background/case studies: in certain transfusion reactions it is required that a culture of the returned blood product be performed. these cultures are reported in our cerner operating system but those results do not cross over to the patient's emr . the finalized product culture results are entered into the patient's emr as an addendum to the transfusion reaction clinical note. a review of the transfusion reaction database revealed that there were occasions when the final product culture results were not entered into the patient's emr in a timely manner. it is important to the patient's care for the transfusion medicine service and the patient's primary provider to know if a transfusion reaction is related to a contaminated product or the patient's general overall health. this information is also crucial to the supplier of the product to determine if others have received components of the affected unit and to possibly determine if there are any quality control issues at the donor facility. study design/methods: a review of a specific month period revealed that the timeframe in which the finalized product culture results were entered into the patient's emr ranged from - days with a mean of . days. it was determined that this was not in the interest of improving patient care. in collaboration with laboratory information services a report was created in which once product culture results were finalized an email would be generated notifying the medical director and the transfusion safety officer that results were available. results/findings: data was collected for months following the implementation of this report and it was noted that timeliness of finalized product culture results being entered into the patient's emr improved to a range of - days with a mean of days. conclusion: improvements in patient care require diligence and timely reporting of finalized culture reports to determine potential causes of transfusion reactions. this process can be made easier when the correct tools are used. omer ilyas* and randy levine . northwell health, lenox hill hospital background/case studies: transfusion of non-irradiated blood in patients with hematologic malignancies and those receiving cytotoxic chemotherapy can result in life-threatening graft versus host disease (gvhd). after noting several instances where non-irradiated blood was transfused in patients requiring irradiated blood, we designed a quality improvement project with educational sessions involving the oncology unit and blood bank. study design/method: the project was separated into three parts. in the first part, data on transfusion practices was retrospectively collected over a four month period on the oncology unit. the variables collected included date and time of transfusion, pre-and post-transfusion hemoglobin, patient diagnoses, and whether or not blood was ordered to be irradiated and if so, whether or not irradiated blood was issued by the blood bank. all patients with hematological malignancies and all patients receiving cytotoxic chemotherapy were candidates for irradiated blood. the second part of this project was an educational intervention. residents, oncology floor nurses, and blood bank staff were given lectures on the importance of transfusing irradiated blood on the oncology floor. residents were also instructed to order irradiated blood for all patients on the oncology unit. in the third part of this project, repeat data was collected over a two month period to assess whether the intervention was successful. results/finding: pre-intervention, units were transfused on the oncology floor with units ( %) requiring irradiation and only of those units ( %) ordered as irradiated. since the blood bank occasionally issues irradiated blood without a specific order, additional irradiated units were issued ( / ; %). post-intervention, units were transfused on the oncology floor with units ( %) requiring irradiation and all of those units ( %) ordered irradiated specifically to prevent gvhd. eight additional irradiated units were ordered with no requirement for irradiation; thus of the ( %) total units were ordered as irradiated. again, additional irradiated units were issued ( / ; %) without a specific order by the blood bank. the results are summarized in the accompanying table. conclusion: this quality improvement project demonstrates that educational intervention can succeed in changing clinical practices. continued monitoring of ordering practices will ensure that compliance continues. we plan to expand the quality improvement project to other settings, including the emergency department and surgical floors. we expect that adherence to transfusion guidelines in this patient population will reduce the incidence of adverse events. samantha ngamsuntikul* , charlotte van dyke , dina garza van hoose and rachel beddard . biobridge global, south texas blood and tissue center background/case studies: at our blood center, apheresis platelets and red cells are collected on trima accels and double red cells on haemonetics s. in addition to routine quality control (qc), qc is performed for instrument flags on collection instruments. quality control for apheresis platelets includes: volume variance and rwbc; quality control for apheresis red cells includes: product volume, volume variance, hemoglobin and red blood cell mass. study design/methods: during the period of january , to april , , , total collections were flagged for additional qc by our trima accels and haemonetics instruments. quality control at our center is tracked by our quality control software management system, hematerra's hemacomply which allows the ability to track and retrieve this information. the majority of products flagged for instrument qc pass and are released for distribution. a small percentage, however do fail qc leading to loss of product. quality control data can be retrieved and monitored for trends using a quality control software management system. background/case studies: in , the centers for medicare & medicaid services (cms) rolled out a plan for implementing iqcp (individualized quality control plan) as a new quality control option based on a risk management plan for clia laboratories performing non-waived testing. this plan was meant for clia approved tests, but serves as a good tool for labs performing non-traditional and traditional tests on non-traditional samples. study design/method: clia clinical laboratories can either follow traditional clinical clia qc requirements according to the regulations or implement iqcp. while we perfrom traditional qc assessments on all the tests we perfrom on our cellular products we did decide to implement the iqcp program within in our quality control laboratory. we followed the iqcp process for assessing some of our qc tests used to assess the safety, purity and potency of our cell based products. one test in particular where we applied this tool was in the review of our qc sterility testing method and found it to be a very useful in improving the overall process. the tool walks you through three process requirements: ) risk assessment, ) quality control plan and ) quality assessment for the preanalytical, analytical and post analytical phases of testing. abstract conclusion: the integration of the iqcp into the quality control laboratory was determined to be a success. the iqcp tool was successful in identifying gaps within the sterility testing process. this tool will be used on additional quality control tests and manufacturing processes. the implementation of the iqcp program ensure regulatory qc requirements appropriate for testing performed. we were able to revise our procedures, reeducate those involved in the process and hopefully minimize potential sources of error. objective performance of massive transfusion protocols at a single institution gustaaf de ridder* , rachel jug , kimberly ingersoll , nicholas bandarenko , nicole guinn and jessica poisson . duke health pathology, duke university hospital, duke health anesthesiology background/case studies: hemorrhage is both a leading cause of mortality in trauma patients and morbidity in non-trauma patients. using a balanced : : transfusion ratio (tr) for massive resuscitation is recommended based on trauma data. objective performance during massive transfusion protocol (mtp) activations is poorly studied and there may be differences based on site or medical service of mtp initiation. with the impending release of a unified, redesigned exsanguination protocol (exp) at our institution, we established baseline performance characteristics for our existing mtp and obstetric massive transfusion protocol (obp). study design/method: following institutional review board approval, we performed a retrospective study on blood product utilization and outcomes of mtp and obp activations from july -december . data were manually collected from transfusion service paper records, electronic (safe-trace) records, and an automated data report from the electronic medical record (epic). conclusion: we observed considerable variability in transfusion practices during acute hemorrhage depending on the service and location of activation. trauma activations demonstrated the sharpest deficit in platelet transfusion, whereas all groups lagged somewhat in transfused plasma relative to packed red blood cells. los and mortality varied among groups, likely reflecting underlying medical conditions and indications for massive transfusion. we have identified an opportunity for improvement in mtp transfusion ratios observed in trauma cases, the specific environment from which the : : ratio was derived, and in which the impact of protocol-driven blood resuscitation is most efficacious. patient identification improvement strategy to help reduce unacceptable specimens arline stein* , nancy nikolis , linda benison , ruthmire thelusca , renee liberty , sherry shariatmadar , alexander indrikovs and vishesh chhibber . north shore university hospital, northwell health background/case studies: our blood bank (bb) processes approximately , specimens per year. bb specimens are unacceptable when they are unlabeled, unsigned or missing necessary documentation. in such cases, a new specimen is requested to be drawn as per protocol. our investigation of unacceptable specimens previously included generation of a report by the blood bank staff that was subsequently submitted to the bb supervisor for completion. following completion, the report was sent to the nurse manager of the patient care unit (pcu) for follow-up and investigation with the staff members involved. this process was cumbersome, taking a few days before the staff member of the pcu was alerted to the deviation in protocol. at times, residents or float staff involved were difficult to identify and it was often challenging to track down the staff and do the necessary investigations and in-services. study design/method: in june , a patient identification improvement strategy was implemented jointly by the department of nursing and the bb to address mislabeled, unlabeled and unsigned specimens as part of a patient safety initiative. currently, following this strategy, when an unacceptable specimen is received, the nurse manager (nm) of the pcu is immediately notified by bb staff. the nm promptly initiates a debrief process with the staff involved in drawing the specimen. a debrief form (tool) was created to guide the discussion. this process is followed / . the nm will also engage other available staff in a huddle to review the incident and reinforce the policy. the debrief form is then submitted to hospital qa and the bb with preventative actions included. we believe in using the just culture model to help us understand the reasons why the staff did not label the specimen according to policy. just culture helps promote shared accountability to ensure we have the proper systems and processes in place to deliver high quality care. results/finding: the table below represents the percentage of unacceptable specimens identified by the bb since the second quarter of . the implementation of this new process has led to a decrease in the number of unacceptable specimens up to % quarterly following its implementation. the opportunity for direct intervention by the nm with the staff involved has risen from % to %, due to the immediate debrief process. abstract conclusion: the patient identification improvement strategy allows for real time engagement of the bb and pcu staff to promptly investigate and institute corrective/preventive actions when there is a deviation from policies related to specimen collection. the heightened awareness of correcting patient specimen labeling errors can only improve patient safety and the patient experience. platelet transfusion practices among pediatric oncology patients: a single institutional experience nicole m crews* , , morgan rockwell , joseph hagan , jun teruya , and shiu-ki hui . texas children's hospital, baylor college of medicine background/case studies: despite advances in adult platelet transfusion (ptx) literature, questions persist regarding pediatric transfusion thresholds, dosage and responses. therefore, ptx are commonly guided by local institutional recommendations (ir). the aim of this study was to determine the degree of adherence of ptx practice to ir at a pediatric tertiary institution. study design/method: retrospective review of ptx practices including transfusion thresholds, responses and dosages were collected. platelet counts within hours pre and post transfusion were evaluated. patients ( - years) receiving prophylactic ptx from july to december admitted to the oncology acute care unit with diagnosis of leukemia or lymphoma were included. for prevention of volume overload, the ir for ptx were < ml/kg for patients < kg and one apheresis unit (au) for patients > kg; therefore, patients were separated into groups: < kg and > kg. a significant proportion of orders for both < kg and > kg did not meet patient platelet threshold criteria (p< . ). conclusion: ptx threshold above ir for both groups were ( kg) and % (> kg). most common reason for above ir threshold was an invasive procedure or low molecular weight heparin therapy. greater than % of ptx dosage in both groups were above ir, however the platelet response did not increase significantly (p> . ) with a higher dose vs. ir dose. this study demonstrated that there were still considerable deviations from ir in ptx practice among pediatric oncological patients. in addition, the false assumption that a higher dose will yield a better response can put patients at increased risk for transfusion related adverse events. each institution should conduct a quality assurance review to determine ptx practice. pre-surgical sample process improvement to enhance patient safety and compliance lisa marie button*, stephanie saathoff, jered luedke, benjamin colvin, umalkair amare and james r stubbs. mayo clinic background/case studies: our institution provides the option for presurgical samples (pss) to be drawn up to days prior to surgery as long as the patient reports not being transfused with a blood or blood component containing allogeneic red cells and they have not been pregnant in the preceding months from the date of pss collection. when pss patients returned for surgery, the patient's service was required to ask the patient again about their transfusion and pregnancy history to determine if there had been any new opportunities for allogeneic red cell exposure, however, there was no process to capture the information the patient reported for the time between the pss draw to the day of surgery/possible transfusion. study design/method: an electronic fix was designed that was applied to the surgical intake process. a new set of questions was added to the a.m. admit questionnaire that must be completed prior to the patient's surgical procedure. the questions ask the patient if they have been pregnant or transfused in the preceding three months and if the answer is affirmative, the computer system runs a blaze rule causing an alert in the blood bank. the blood bank techs review the alert and inactivate the patient's pss based on the new transfusion/pregnany information. one year post-implementation of the electronic fix, transfusion lab performed a retrospective review of all pss alerts generated during a three-month period. results/finding: the results of the review were analyzed and are displayed in the table. it was determined that only . % of patients with a pss alert had an active sample requiring inactivation. conclusion: implementing an electronic solution that requires documentation about pss eligibility upon return for surgery has resulted in an estimated ( x ) pss alerts in the blood bank each year. of these alerts, it is estimated that approximately patients ( x ) per year are identified as no longer eligible for pss status. once this retrospective review was performed, it was shared with the project stakeholders to determine if the electronic questionnaire could be further tailored to patient's based on age, gender, and pss status. while the benefit of having fewer false positive pss alerts ( . %) was recognized as an ideal future state, it was not compatible with the institution's current it project of implementing a new electronic medical record (emr) system. the safety enhancement provided by the current electronic fix will remain as is and the improvement suggestions were shared with the team creating the parameters for the new emr with the intention of targeting only patients with an active pss in the blood bank, rather than all surgical patients. weill cornell medicine, columbia university school of medicine background/case studies: blood ordering is a complex, high-risk process with multiple steps that have the potential for errors and delays. risks associated with this process, from ordering through pick-up, require evaluation and strategies for mitigation. given the complexity and high-risk nature of blood ordering a proactive risk assessment (pra) for blood product ordering using the fmea methodology was conducted. the goal of the project was to proactively assess the effect of a redesigned electronic order set on the quality and safety of blood ordering study design/method: to evaluate the electronic blood ordering redesign process, a pra was completed using the fmea methodology. the team identified each step and sub-step of the electronic blood ordering process, all failure modes and causes, and then scored each by severity occurrence and detectability to determine the risk priority number (rpn). all rpns with a score above the threshold were reviewed and rescored based on mitigation strategies designed to address the failure mode. results/finding: the group scored the identified failure modes by categories used in root cause analyses. the electronic blood order process has internal logic and alerts that improve communication and reduce the risk score. several mitigation strategies that will reduce the risk of the identified failure modes include type and screen status within the rbc order, streamlined alerts when the order does not meet the laboratory threshold, a nursing task list for transfusion, and a change to the pickup process that is linked to the product ready status in the laboratory information system. a transfusion history will be available to providers when ordering blood products to further reduce communication risks. categories for failure modes included clinical,communication,equipment people,process and system. the average overall failure mode rpn was reduced by % with the communication category average rpn having the greatest reduction of %. conclusion: an fmea of an electronic blood ordering process can proactively improve quality and patient safety by preventing transfusion delays and errors in blood product administration. accurate and timely information in the blood ordering process has the potential to reduce risks associated with ordering,preparing and dispensing blood. reducing turn around time for type and screens in the blood bank kimberly ouellette* , karen king and joseph sweeney . rhode island hospital, lifespan academic medical center background/case studies: expeditious turn-around times (tat) in the blood bank are critical to provide fully tested and crossmatch compatible blood in a timely manner. the blood bank at rhode island hospital, a level trauma center and teaching hospital associated with brown university, was originally designed to accommodate tube testing by all technologists. the original setup of the lab was split into three sections allowing for preparation and issuing of units in the first section, bench testing in the second, and the receipt of components in the third. as technology changed, the blood bank adopted first the manual gel station and then the automated gel system (ortho provuev r ) but did not adapt the space. the second section of the blood bank contained the manual and subsequently automated gel stations with no other changes. the process of sample receipt through completion of testing and issuing of units remained segmented and inefficient. the average tat for type and screens was minutes. study design/method: the blood bank design was remodeled to make for a more open concept to allow for collaboration amongst technologists as well as the best use of space and technology. the first section of tables were removed and replaced with a center console to allow for movement about the entire front of the laboratory. a wall was constructed to separate the main work flow, automated gel testing and issuing units, from the area for complicated workups and inventory receipt. the third section remained, but was repurposed for teaching medical technology students and residents. in addition to the remodel, the blood bank retired the ortho provuev r for the ortho visionv r , which is considered a true continuous feed machine. although the inter-device tat is not significantly different ( minutes for the provuev r and for the visionv r ) the visionv r is built with a scheduler that effectively handles the system and processes samples efficiently. the visionv r is also equipped with two centrifuges to process samples, which further reduces tat when multiple samples are onboard. a bi-directional interface was designed to allow for test orders (type and screens) to go to the visionv r and test results to go directly from the visionv r to the lis without the need to manually order the tests or transmit the results. data on tat were collected and analyzed using independent t tests and chi square. results/finding: the mean tat pre-and post-reconfiguration and implementation of the ortho visionv r and a fraction of samples with tat over minutes are shown in the table. the results show a reduction in tat by minutes with a % reduction of tat greater than minutes. conclusion: a combination of new technology and space remodeling can lead to a significant reduction of tat of testing in the blood bank. caleb wei-shin cheng* , , lorna orengo , monique scott and christopher a tormey , , . yale university school of medicine, yale-new haven hospital, va connecticut healthcare background/case studies: the type and screen (t&s) is a fundamental laboratory test that allows the blood bank to provide compatible blood for patients. despite this, erroneous blood product administration may occur as much as in , blood transfusions. to prevent errors, adequate specimens such as those lacking hemolysis and those with proper specimen labeling are necessary; otherwise the specimen is rejected, leading to a second blood draw and a delay in medical/surgical management. hemolysis rates for t&s specimens are reported to be as high as % prior to interventions, but may potentially be reduced to as little as . %. however, there is little published data on non-hemolysis-related type and screen rejections. an initiative was undertaken to reduce the rejection rate in the blood bank to a sustained rate of < %, with a particular emphasis on non-hemolysisassociated forms of rejection. study design/method: a root cause analysis (rca) was performed over the preceding months to obtain a baseline understanding of the errors involved. t&s submission at our facility involves standard completion of the specimen label plus completion of a unique witness form to confirm the identity of the patient from whom the specimen was collected; specimen and witness form must be submitted simultaneously. when a specimen was rejected, we recorded the patient name, medical record number, and the reason for rejection. following rca, an intervention was created to resolve the most common issues documented that resulted in rejection. approval for the intervention was granted by the department chair, transfusion committee, forms committee, and the medical executive committee. after implementation, prospective data will be collected for several months in the same manner as before to determine the effectiveness of the intervention. results/finding: over the study period, the t&s rejection rate averaged . %. reasons for specimen rejection were divided into groups: ) hemolysis, ) blood bank witness collection form errors, ) quantity not sufficient, abstract ) duplicate sample, and ) specimen tube labelling errors. the highest percentage of rejections was due to improperly-filled witness forms (table ) . after multiple form redesigns and approval by appropriate committees the new form was implemented. preliminary data collected thus far demonstrates a . % rejection rate with only rejection relating to witness form errors. conclusion: rejected t&s specimens are an impediment to safe clinical care as it may delay medical/surgical management. rejection rates could be reduced through simplification of blood bank specimen collection forms. care providers have multiple tasks that need to be performed in a short amount of time, therefore, simplification is often times necessary to reduce human error. future quality initiatives will aim to simplify complex healthcare processes without compromising patient care. reduction of failed whole blood donor testing runs on the roche cobas s system christopher shahan* , christina dejesus , mosi mccall , fallon hampton , tangi herring , judy davis , anjali patel , sonya gomillion and bonnie maltby . qualtex laboratories, qualtex laboratories background/case studies: as part of our quality control program, we track the number of technician related failed runs observed on the roche cobas s system. this system is used to test whole blood donor samples for human immunodeficiency virus (hiv) rna, hepatitis c virus (hcv) rna, hepatitis b virus (hbv) dna and west nile virus (wnv) rna. technician related failed testing runs can cause the laboratory to report results outside of the contractual - hour turnaround time. failed runs also cause retesting which increases reagent utilization for the system. currently % of whole blood donor testing turnaround time delays are due to issues and failed runs on the s system and we have technician related failures per week. a lean six sigma approach for process improvement was utilized to identify root causes and develop countermeasures in order to decrease the number of technician related failures on the s system. study design/method: the number of technician related failed runs on the s system were tracked from / / thru / / . a pareto chart was used to determine that technician related errors was the largest controllable factor causing run failures. the whys were performed to determine root causes of technician related failed runs. a gemba walk was performed on all of the lab testing processes to help identify areas for improvement. the process improvement team talked, met, observed, and worked directly with staff that operate the s system. roche was also contacted to provide guidance on how to help decrease technician related failures. results/finding: the main root cause determined was that there was no current process flow map for whole blood donor testing using the s system. counter measures implemented included creating a two phase process map. one phase was related to the processes related to start-up of the system and the second phase was related to the processes involved in processing of samples. roche provided a job aid for the technicians which provides clear steps technicians should take when handling and cleaning up crashes and failed runs on the s system. after counter measures were implemented, the number of technician related failed runs decreased from to . failures per week, which was a % decrease. conclusion: a lean six sigma approach for process improvement was utilized to identify root causes and develop countermeasures in order to decrease the number of technician related failed runs on the cobas s system. this lean six sigma approach and counter measures significantly decreased the number of technician related failed runs by %. patients who were transfused for pre-transfusion hgb > g/dl with resulting post-transfusion hgb > g/dl were reviewed. demographics, medical history, provider identity, indication and transfusion complications were abstracted & compiled individually by volunteer internal medicine residents. group discussion for each case ensued before determination of transfusion appropriateness occurred. principal investigator/attending physician then made final determination of appropriateness of rbc transfusion. results/finding: patient charts were reviewed. were excluded for bleeding and cardiovascular instability. / ( . %) were determined to be transfused inappropriately. there was no difference in appropriateness of transfusion with respect to age or sex. patients with solid tumors ( . % vs . %, p . ) and anemia of chronic disease ( . % vs . %, p . ) were more likely to be inappropriately transfused. patients who had higher pre-transfusion hemoglobin were more likely to be inappropriately transfused (median hgb . g/dl vs . g/dl, p< . ). inappropriately transfused patients also had higher median post-transfusion hemoglobin ( . g/dl vs . g/dl, p< . ). moreover, lab evalutions revealed association with lower folate levels (median . nmol/l vs . nmol/l, p . ). / ( . %) patients were inappropriately transfused at least in part because they received more than one unit without an interval hemoglobin check in between. / providers were responsible for . % of all inappropriate transfusions. / appropriately-transfused patients experienced an fnhtr. deaths unrelated to transfusion occurred ( in appropriate, in inappropriate group). conclusion: physicians in training are interested in promulgating optimal rbc transfusion practice. this study identified patient factors (such as solid tumors and anemia of chronic disease) that correlate with a higher likelihood of receiving an inappropriate transfusion. beyond cpoe, educational intervention at individual level should be designed for specific providers responsible for more inappropriate transfusions. successful implementation of a blood bank information system in a small-scale caribbean blood bank: a structured step-wise approach. luigi sille* , willem martin smid and ashley john duits . red cross blood bank foundation, sanquin consulting services background/case studies: an important tool for complying with gmp quality standards is the effective use of a blood bank information system (bis). validation and implementation of a bis is described for centralized large blood bank and literature and guidelines are lacking for the nonautomated small scale blood bank environment. . small-scale blood banks face specific challenges for computerization in relation to economies of scale and existing processes requiring special attention. for the introduction of a bis at the blood bank of the dutch caribbean island of curaçao a specific procedure was designed based on existing guidelines and adapted to the local setting. study design/method: the red cross blood bank foundation curaçao is the sole provider of labile blood components for the dutch caribbean islands of curaçao, bonaire and sint maarten. after selection of the bis provider for implementation isbt and bcsh guidelines for validation of information systems in blood establishments were carefully analyzed to prepare the design of local procedures. these procedures were meant to evaluate and validate the features of a bis (e-delphyn, hemasoft america, miami, usa) before introduction. the outcome of the approach was entered in worksheets that were evaluated by the implementation team and management. from this the implementation plan was designed and implemented. an external auditor (sanquin consulting services, amsterdam, netherlands) was invited to evaluate the implementation and validation plan and its practical implementation. the evaluation was performed according to risk assessment of critical process steps. results/finding: based on the isbt and bcsh guidelines a process flow chart describing the relevant phases and critical steps for introduction and validation of a bis was designed. comparison of the current processes and procedures were compared to the bis characteristics making use of worksheets. with these worksheets the existing gaps with the bis procedures were carefully described. these gaps and the appropriate procedural changes for bis or blood bank were effectuated. the worksheets also provided the basis for staff training in a separate training environment before bis introduction. during the early validation phase all procedures and processes were audited by an external auditor. with the feedback of the expert several improvements were added for the validation and subsequent implementation processes. conclusion: with the use of existing international guidelines a validation and implementation plan was designed to prepare for successful introduction of a bis in a small scale caribbean blood bank. the program as designed seems well suited for small scale blood banks contemplating introduction of a bis. time and cost savings through implementation of a remote blood fridge jessica peters* , dee dee cassidy , jed b gorlin , and nancy l van buren , . hennepin county medical center, innovative blood resources background/case studies: rapid delivery of emergency release group o red blood cells (rbc) are vital to patient care. commercial remote blood fridge packages are available but have large upfront and maintenance costs. we implemented a remote blood fridge directly in our emergency department (ed) using an under counter fridge requiring id access, and a selfdeveloped ios application that scans, tracks and real-time alerts transfusion service (ts) to products used and to whom they were dispensed. prior to ed fridge implementation, rbc units were verbally requested and an ed blood runner would pick up and return the cooler. given that our ed is located in a separate building from the ts, this meant or more minutes may be required for transit of units often released in less than minutes. the net effect was that providers would routinely order products to ensure they were at the bedside for patient arrival as a precaution, only to return them when not required. implementing a blood fridge at bedside resulted in the predicted outcome of delivering emergency release rbcs more quickly, with the observed benefit of decreasing wasted staff time. study design/method: the remote blood fridge was implemented in july . data for rbc requests in coolers, rbc returns and rbc transfusions from the ed was collected and compared. baseline data included january -june , and post change included august -december . july data was excluded as it included both the pre and post processes. results/finding: baseline data shows that the ed requested an average of rbc/month in coolers. post change this dropped to rbc/month, thus less blood was requested from the transfusion service in coolers as units were being used from the fridge. baseline data also shows that an average of rbc/month were returned ( %). post change, the average rbc/ month returned was ( %), this represents an absolute % reduction in number of returned products. each rbc dispensed and returned takes approximately minutes to complete paperwork and transport, therefore this change saved an average of minutes per month. it was also noted that the average rbc/month transfused was for baseline and post change. this confirms that the decreased requests and returns were not due to decreased patient volume or severity. the fridge was also successful at decreasing delivery time of blood to patient bedside, as baseline delivery time of - minutes (estimated) was reduced to - minutes. conclusion: implementing a remote blood fridge and moving blood access closer to patient bedside ensures a faster delivery of blood to the patient. this change has an additional benefit of decreasing wasted time, and hence cost, by decreasing unnecessary product requests and returns. implementing a blood fridge can also be done at a reduced cost through homegrown processes. transfusions are everyday procedures and over patent-applications have been filed related to "transfusion medicine" and over related to "transfusion alarm", during the last years, employing numerous technical settings, aiming to support automated supervision of the mentioned actions. the aim of this contribution is to present a developed low-cost real-time individual intravenous blood-transfusion monitoring system, based on the internet of things. study design/method: the designed system is based on a commercially available pan-tilt-zoom (ptz) camera, employing an / inch color cmos sensor, providing effectively . mp, a . mm lens, ir-cut, day/night minimum illumination . lux/f and viewing angle. the camera is focused on the droplets and acts as vis/ir detector with a hz sampling-rate. custom-developed software supports droplets' ratemonitoring, causing acoustic alarm-signals if necessary (e.g. clotting, blood a transfusion vol. supplement s abstract or other suspensions depletion etc.) and enables, if necessary, wide-angle image-capturing. the video image-audio settings provide for compression h. , video frame rate (fps) - /s, refresh rate hz and audio input, through bidirectional built-in microphone. the acquires an ip-address, the connection mode is wireless, the network interface is wi-fi/ . /b/g, the supported protocols include dhcp, tcp/ip, upnp, http, smtp and p p is provided. typical v power-supply, sized x x mm and weighing g. client software is required. the ir range is - m; ir-cut filters, remote access, dual stream, motion detection, day/night and ir night vision distance of m are offered. two-way radio-link is provided, as well as, trans-flash (tf) recording and storage on a gb sd-card. pan/tilt-horizontal o and pan/tilt-vertical o movements can be performed. the system facilitates, if needed, also patient's position monitoring and readings of other monitoring displays, such as nibp, ecg, and spo , if present. results/finding: the system and is being presently tested in a laboratory (non-clinical) environment, by simulating the virtual patient, with a custommade "phantom", combining flow-rate, negative pressure and viscosity resistance regulation. conclusion: the system can measure infusion-speed with a deviation lower than %. the developed iot-system takes advantage of the existing hospital wi-fi networked environment and offers a low-cost solution, under $ for each monitoring-set. it allows for even multi-platform (ios, android, windows) smart-phone, short-range connectivity, for up to participants, for example nurse, physician etc. two potential approaches for the quality control of bact/alertv r culture media using various bioball tm organism preparations patricia rule*, michelle keener and christine crawford. biomerieux inc. background/case studies: the bact/alertv r bpa and bpn culture bottles are used with the bact/alert microbial detection system for rapid screening and detection of microbial contamination in leukocyte reduced apheresis platelets (lrap). recent changes in the clia quality control guidelines and aabb accreditation program will require additional quality control of manufactures media that is both lot specific and shipment specific to ensure recovery of bacterial growth. a study was conducted using commercially prepared organisms evaluating both a comprehensive organism panel as well as a streamlined method utilizing only two organisms from the panel. study design/method: the general protocol consisted of three replicates each of each organism inoculated into two lots each of bpa and bpn by two different analyst. the study was two part in that aspergillus brasiliensis, candida albicans, bacillus subtilis subsp. spizizenii, pseudomonas aeruginosa, escherichia coli, clostridium sporogenes, staphylococcus aureus and streptococcus pyogenes were prepared from bioball singleshot ( cfu), multishot cfu or highdose k organism preparations at a low level (< cfu) and evaluated on the same day of preparation as method validation. the second part of the study utilized escherichia coli and staphylococcus aureus prepared and frozen at a higher level and then evaluted over a day study as a stream line approach to routine quality control testing of the bact/alert culture bottles. inoculation preparations were enumerated in duplicate to confirm the level at each inoculation time point. inoculated bpa and bpn bottles were loaded into the bact/alert microbial detection system at c for automatic monitoring of growth. negative bpa and bpn bottles were included in duplicate at each day of testing. results/finding: escherichia coli, staphylococcus aureus, streptoococcus pyogenes and bacillus subtilis subsp. spizizenii were positive in both the bpa and bpn culture bottles. the aerobic aspergillus brasiliensis, candida albicans, and pseudomonas aeruginosa grew and were reported positive in only the bpa aerobic culture bottle as expected. while the obligate anaerobe, clostridium sporogenes was positive only in the anaerobic bpn culture bottles. bacterial cultures were positive in the bact/alert bpa and bpn bottles < days and the fungal organisms in < days. the overall agreement was . % in bottles tested here. no significant differences were observed in the time to detection between the different lots or between the different analyst. conclusion: the bioball prepared organisms demonstrated a reproducible method as both a comprehensive and streamline approach for the quality control of bact/alert bpa and bpn culture media. the method was simple and did not require additional microbial preparations or storage of live organisms by the laboratory. use of an electronic patient identification system for blood banking specimen labeling found to be superior over historical armband approaches annie newton* , diane schafer , debra brown , jesse cox , scott koepsell and sara shunkwiler . nebraska medicine, the nebraska medical center, university of nebraska medical center background/case studies: anticipating the implementation of the new ( th addition) aabb standard concerning the confirmation of patient abo blood typing of type and screen (crossmatch) specimens performed prior to the issue of crossmatched blood products, laboratory and organizational leadership evaluated the practical application of an electronic patient identification system to label blood bank specimen collections versus the traditional use of blood bank armbands. continued use of the armbands would require a second sample for abo confirmation of patients that did not have a historical blood type on file. concern was raised regarding the amount of increased workload of staff and delayed results availability based on the number of increased specimens that would be generated, as well the potential for increased iatrogenic blood loss and patient dissatisfaction. moreover, nd sample collection alone would not improve the rate of mislabeled specimens observed, which is of supplementary concern. study design/method: current organization employment of an electronic patient identification system for the labeling of other laboratory specimen collections made it feasible for applying this technology to the blood bank as well. an in-depth evaluation, including a failure modes and effects analysis (fmea) spanning several days, was completed to ensure that the use of the electronic system would produce comparable or superior safety results to its armband counterpart. an alternate process for specimen labeling and abo confirmation (which would satisfy the new standard) was established to support care areas that did not have the capability of using the electronic system. extensive education was provided to all staff (physicians, advanced practice providers, phlebotomist and nurses) to ensure comprehension as well rational for the new process. alerts were congruently built into the electronic health record (ehr) to supplement any information regarding crossmatch testing expiration that may not be readily available by the elimination of the armband use. results/finding: within days of implementing the new process (september , ), there was a noticeable reduction in the amount of mislabeled blood bank specimens received, totaling in months post implementation compared to in the months prior. in addition, the vast majority of specimens received into the blood bank are henceforth collected and labeled using the electronic system and thus have reduced the amount of potential nd specimen collections needed for abo confirmation. conclusion: use of an electronic patient identification system for labeling blood bank specimen collections in lieu of traditional blood bank armbands has proven to improve patient safety and department efficiency by substantially reducing the occurrence of mislabeled specimens and negate the need for nd specimen collections, reducing potential iatrogenic blood loss and improving patient satisfaction. background/case studies: based on a few small randomised controlled trials (rcts) performed in the late ' s and in early , intravenous immunoglobulin (ivig) use has been suggested as a potential treatment to avoid exchange transfusion (et) for rh hemolytic disease of the newborn (hdn). this treatment modality is now routinely used for rh-hdn and has been extended to hdn caused by abo incompatibility or by other red blood cell antibodies. however, larger rcts performed since have shown that prophylactic ivig did not reduce the need for et, the duration of hyperbilirubinemia, the maximum bilirubin levels nor the need for top-up red blood cell transfusions. the primary objective of this study was to describe the usage of ivig for hdn at a tertiary academic referral hospital. study design/methods: a retrospective chart review was performed of all neonates who received ivig for hdn in the neonatal intensive care unit (nicu) from january , to june , . data collected included patient demographics features and diagnosis, indications for ivig, neonatal laboratory results, treatment details, adverse events and patient outcomes. results/findings: ninety-seven neonates received ivig during the study period: % were female and % were less than weeks of gestational age. none had co-existing g pd deficiency, pyruvate kinase deficiency or spherocytosis. all neonates received phototherapy prior to ivig treatment. indications for ivig were abo-hdn ( %) and rhesus-hdn ( %). antibodies most often implicated in rh-hdn were anti-d ( / ), anti-d and anti-c ( / ) and anti-c ( / ). sixteen infants with rh-hdn had received intrauterine transfusions. the mean cumulative dose of ivig was g/kg (range from , g/kg to , g/kg). neonates received one to four ivig administrations. table shows the number of patients receiving ivig during two time periods. three adverse reactions were noted during ivig administration: cutaneous rash, hypotension and fever. of all neonates, required an et for rh-hdn and for abo-hdn. forty-five ( %) patients needed top-up transfusions during hospitalisation and until three months of age: with abo-hdn and with rh-hdn. the mean number of transfusions was three (range: to ). conclusion: although initially described for rh-hdn, abo-hdn is now one of the most frequent indications for ivig in neonates. the optimal use of ivig in abo-hdn needs to be better characterized. our study shows a wide variation of ivig dosing and a significant proportion of neonates requiring top-up transfusions. further research is required to evaluate whether anemia in abo-hdn might be exacerbated by hemolysis from ivig isohemagglutinins and if it is dose-dependent. background/case studies: background: one of the most serious adverse reactions to transfusion is the development of graft versus host disease. symptoms include the development of a characteristic cutaneous rash, enteritis often resulting in watery diarrhea, elevated liver function tests and ultimately pancytopenia. the clinical course is rapid with an over % case fatality rate. the patient population at risk is reasonably well-defined including patients who are immunocompromised due to disease process or therapy, the fetus and low birth-weight neonates, recipients of hla-matched cellular blood products and the recipients of cellular blood products donated by blood relatives. the basic etiology of ta-gvhd is the inability of the transfusion recipient to mount an effective immune response against donor t-lymphocytes. treatment options for ta-gvhd are ineffective, making it imperative that cellular blood components be irradiated prior to transfusion which virtually eliminates the risk of the complication. study design/methods: most transfusion service information systems have mechanisms to alert transfusion service staff to patients who have been previously identified as needing irradiated blood components. however, if these patients are not identified to the transfusion service at the time of the initial hospital visit or the time at which the qualifying diagnosis, these patients can erroneously receive non-irradiated blood components. following a "near-miss" situation, our hospital information department developed a -part program to minimize the risk that the transfusion service is not notified of patients newly requiring irradiated blood components. results/findings: our blood products ordering system has been redesigned to include specific queries to identify those patients who required irradiated cellular blood products. first, physicians have been notified to include the need for blood product irradiation in the patient problems list. once this is included in the list, the transfusion service will be notified of the need for irradiation on all subsequent transfusion orders until the problem list is modified by the clinical staff. second, if irradiated blood components have ever been requested on a patient, an alert will be generated for the ordering physician even if the requirement for irradiated products has not been included in the problem list. finally our system will automatically default to request irradiation on all cellular products ordered for children less than months of age to comply with local irradiation policies. conclusion: we believe that our approach can be further enhanced by including a list of specific diagnoses typically requiring blood product irradiation within our computer algorithm. we believe that this list will provide an additional level of safety in insuring that patients receive irradiated blood components when appropriate. using lab information system and a dynamic dashboard for labeling and tracking coolers russell thorsen, rosaline ma, peter suslow, gina giannarelli, sara bakhtary, ashok nambiar and morvarid moayeri*. ucsf health background/case studies: our tertiary-care transfusion service routinely issues blood products in validated coolers to high acuity areas such as ors, icus, cath-lab, etc. coolers are also used for emergency release and massive transfusion protocols, and for shipping products between our different hospital sites. a robot that can hold one cooler delivers products to locations not served by the pneumatic tube. on average, coolers are issued every day. cooler set-up is a multi-step, labor-intensive process. transfusion service staff track cooler location and elapsed time-in-use and notify clinical teams to return/recharge coolers to avoid product wastage. we developed a lab information system (lis)-based solution to manage cooler labelling and tracking more efficiently. study design/method: nine cooler test batteries were built; the batteries for rbc, plasma, platelet and cryoprecipitate ( each) are identical, whereas the final battery designated for the cooler delivered by robot (containing plasma and rbcs with variable expiration times) is slightly different. the second battery in each pair was built to avoid duplicate test cancellation by lis when a second cooler (for same component type) is being set up for the same patient. each battery consists of tests capturing the following information: cooler location, cooler id, number of units issued, and expiration. custom barcodes representing each test battery and different locations can be scanned from a 'quick-pick list', avoiding need for manual entry. when coolers are returned, a final entry is made in the test battery, updating lis. a dynamic cooler tracking dashboard with live-feed from lis displays data captured in the test battery. elapsed time, starting from cooler set-up (which is identical to time cooler battery is ordered in lis) is captured automatically. color codes alert users to coolers that have less than hour before expiration. a flashing alert pops up for coolers that have expired. results/finding: we replaced our manual process (hand-write patient information and expiration time on separate tags; affix one tag to cooler and retain second one to track cooler location and expiration) with a novel lis-driven labeling and tracking system. each time a cooler is set up, a test battery is ordered and resulted in lis by scanning the related custom barcodes. a single lis-generated label is printed and attached to each cooler. cooler expiration is defaulted to hours (per our current cooler validation) from the time the test battery is ordered during cooler set up. techs pay attention to expiration of each product they place in a cooler. if an individual product outdates before the cooler expiration time, this information is entered in the test battery and gets displayed on the dashboard as a cooler expiration time, distinct from the system-driven countdown. color-coded visual display and alerts greatly simplify cooler monitoring, and the elimination of some manual steps has improved staff satisfaction. conclusion: using lis for cooler set-up and deploying a linked dynamic dashboard to display cooler locations and expiration time makes cooler management more efficient. these tools reduce manual steps and decrease likelihood of wastage by aiding cooler tracking. improving cryoprecipitate collection operations using operations research and analytics-based methods american red cross, georgia institute of technology ap reduction in unnecessary use of type o-negative rbcs in a level i bellevue hospital-nyulmc our hospital is a level i trauma center serving a diverse predominately non-caucasian population. historically we stocked our trauma blood bank monitored refrigerator with o-negative rbcs. trauma requested that we stock additional rbcs to be able to initiate a mtp for multiple patients at the same time. believing that most of our trauma patients are male, elderly, or rh-positive, we agreed add type o-positive rbcs to the stock. rules for determining which units to use were established. o-positive rbcs are to be given to a) all adult males (am), b) women of non-childbearing age (wncba), and c) if both o-negative rbcs were used but not yet restocked, and o-negative rbcs are to be given to a) women of childbearing age (wcba) and b) children until the patient's aborh type are determined. we sought to assess the impact of this change on our usage and purchases of o-negative rbcs. study design/method: all patients issued emergency release trauma rbcs following the addition of o-positive rbcs were assessed %) would have needed to be o-negative. the addition of o-positive rbcs to our trauma refrigerator will enable us to markedly reduce our purchases of o-negative rbcs. ap saving apheresis platelets through use of verax point of care testing jennifer rhamy* and rebecca wride . st. mary's regional blood donor center, st. mary's regional medical center background/case studies: our rural hospital-based blood center serves hospitals and a diverse patient population including acute trauma. because of the varying need for platelet products (varies between and per day in ), we investigated the use of the verax point-of-care test to better manage our valuable inventory barrett lawson and jun teruya , . texas children's hospital, baylor college of medicine ap vision titers --easier or problematic? (table ) . results/findings: post intercept, t had volumes of - ml, with % hemoglobin (hb) recovery. t had -fold less extracellular protein than c. after days of storage t had higher atp and na than c while lactate and hemolysis were lower. hct, ph, k and glucose were equivalent between t and c on d . d hemolysis for t was . - . %, while for c it was . - . %. t and c atp was > mmol/g hb, the level of atp associated with effective rbc viability, throughout storage (table ) . hematocrit (hct, %) . . * . . . . . . hemoglobin (g/unit) not measured hemolysis (%) . . * . . . . * . . ph ( c) . . * . . . . . . total atp (mmol/g hb) . . * . . . . * . . k (mm) . . * . . . total tested total plts issued feb mar totals table: . resident reports to the intranet "drop box" increased from . % to . % to %, each over month time spans. conclusion: safe transfusion ordering requires a team approach to ensure the right information is available to the ordering provider at the right time. safe ordering prevented recurrent allergic reactions in our patient population. the tso plays a pivotal role in ensuring the full circle of communication occurs. processes that integrated the pathology resident improved with pdsa cycles and impacted the quality and timeliness of hand off. finally, the data provided from the residents enabled efficient participation in hemovigilance. decreasing results/finding: the main root cause determined was that there was no standard work process. sops were being followed but there was no standard work process that included the details so testing was not following the most efficient work flow. counter measures implemented included implementing a standard work process, visual cues were added to the work process, and a samples awaiting testing report was created for the batch release department. specific locations were identified within the work cells in the lab to place samples based on their phase/stage of testing. after counter measures were implemented, the number of exceptions decreased from . per day or , dpmo to . per day or , dpmo. this is a statistically significant difference since the p-value calculated was . . conclusion: a lean six sigma approach for process improvement was utilized to identify root causes and develop countermeasures in order to decrease the number of exceptions related to the testing of whole blood samples in the laboratory. this approach and counter measures statistically significantly decreased the number of exceptions seen in the whole blood testing process. background/case studies: our blood bank processes approximately , specimens per month. since , the requirement of having a second blood type on record was met by: . utilizing the historical blood type and the current specimen, or . having second type performed on same specimen by different technologist, and . each type and screen specimen signed by staff, one being a licensed practitioner attesting the identification of the patient was done accurately at bedside.to comply with the aabb standards th edition, # . . . a decision was made to change our practices. we considered challenges encountered at other hospitals and collaborated with nursing and it to create a streamlined and safe process. in april , the second specimen procedure was implemented addressing the following: ii. extensive education was provided to all involved in the process prior to implementation including a learning module prepared by blood bank and nursing collaboratively. results/finding: . there was a minor adjustment period with more phone calls made to blood bank to explain the process. . there was minimal impact on turn around times for release of components. . aborh retype workload decreased from to ( % to % of t&s volume) per month. . unnecessary blood draws minimized, improving patient experience. . no emergency release requests due to absence of a second specimen. the second specimen process with the conditional order has been beneficial to our blood bank as well as patient care services. overall feedback from staff on the process has been positive. our workload has decreased which results in cost savings and increased efficiency allowing us to devote more resources to the growing services at our institution. background/case studies: the hazards of transfusion are well recognized and in certain cases restrictive transfusion strategies compared to liberal transfusion strategies may be associated with better clinical outcome. with this in mind, aabb and others published guidelines for transfusion, but even with guidelines in place, rate of inappropriate blood transfusions is reported to be as high as to %. computerized provider order entry (cpoe), is a process of electronic medical order entry for medical practitioners with instructions and guidelines for treatment. the objective of this study was determination of transfusion practice quality by thorough chart and electronic medical record review, with measures in place to avoid inappropriate transfusion. additionally, factors associated with inappropriate transfusion were examined. study design/method: in our bed hospital, a retrospective chart review was performed ( / / - / / ) on hospitalized internal medicine patients. cpoe with hospital guidelines for rbc transfusions were in place. transfusion thresholds in different clinical settings were determined by a thorough literature review of studies analyzing restrictive transfusion strategy, and transfusion guidelines by various medical societies. charts for background/case studies: our midwestern university-based transfusion service (ts) evaluated the appropriateness the automated platform vision (ortho clinical diagnostics. raritan, nj) for prenatal titration studies. it has been established from previous publications that the micro-column assay, of which the vision is based, may lead to higher titer results compared to standard tube titrations. this study sought to evaluate the transition from manual to automated titer studies from a sensitivity as well as cost perspective. study design/method: twenty-three prenatal retention plasma samples were tested as part of the evaluation of titration studies of the vision. the samples were manually tested with a standard two-fold serial dilution. the titer was reported as the last tube to demonstrate a reaction by macroscopic observation. the titer studies were then repeated using the vision. the results of the manual and automated processes were compared and categorized as "< grade" or "> grade" difference between endpoints. this analysis is similar to the acceptable ranges used for evaluating college of american pathologists (cap) proficiency survey challenges. a cost analysis was completed based on the direct and indirect cost for each method, excluding the cost of an analyzer. results/finding: table demonstrates a summary of the samples tested by manual titer study and vision titration method. the vision titer results (mean, median, and mode) were higher than the manual tube titer results. less than half of the samples ( %) were > titer results higher, while the majority was titer results different ( %). the cost analysis is summarized in table . the indirect cost (labor) was significantly lower with the use of the vision. the reduction in pre-analytical technical time for manual preparation of the titration is eliminated with the vision completing the titration as part of the profile of the titer study of the analyzer. conclusion: with an estimated % decrease in the cost of a vision titer compared to manual tube method, the change in practice would clearly be a cost and efficiency measure in the blood bank. however, the vision demonstrated the expected increase in titer results compared to manual tube titer results. this would impact the critical values currently utilized. an impact assessment for clinical staff would be necessary to adequately implement the change in method. consideration must be given to changes in the computer logic for critical values on titer studies and training of physician and nurse obstetric practitioners for changes in the critical values. in addition, as part of changing to the vision an implementation period will be necessary to ensure that manual titers are compared to previous manual titers and not to vision titer results which would be higher and may be interpreted as a significant change for clinical care of the patient. what is the best practice for testing residual white blood cells in blood components for monthly routine quality control? janja pajk*. general hospital celje background/case studies: we wanted to discover what is the best routine quality control practice for testing residual white blood cells in blood components. our aim was to validate the adam device for counting thne number of residual white blood cells (wbc) in leucocyte depleted and in non-leucocyte depleted blood components (bc) and to compare with standard counting method by microscopy in fuchs rosenthal chamber (frc) used in ghc and with flow cytometry (fc). study design/method: after samples of red blood cells (rbc), platelets (plt) and fresh frozen plasma (ffp) (leucocyte depleted in top and top (t/ t) bags and non-leucocyte depleted in top and bottom (t/b) bags) were stained with propidium iodide (pi) on r-slides; adam -rwbc device was messured fluorescent images of stained wbc nucleus. data were analised by image analysis software and later compared with results of testing samples in frc by microscopy and with fc. samples of bc were microscopic tested in frc at department of laboratory medicine in ghc; another samples were measured with fc in ucc maribor. results/finding: samples ( rbc, plt, ffp-all leucocyte depleted and non-leucocyte depleted ffp) were tested in triplicates on adam and with frc once.coefficient of variation of (kv%) of samples measured on adam for leucocyte depleted bc varied for: rbc from , - , ; plt from , - , ; ffp from , - , ; and for non-leucocyte depleted ffp from , - , (table ) . samples ( rbc, plt, ffp -all leucocyte depleted and nonleucocyte depleted ffp) were tested in triplicates on adam and with fc once.kv% of samples measured on adam for leucocyte depleted bc varied for: rbc from , ; plt from , , ffp from , ; and for non-leucocyte depleted ffp from , - , (table ) .high percentage of kv was noticed in samples with low numbers of wbc (in leucocyte depleted bc; low percentage of kv in non-leucocyte depleted ffp, with higher amount of wbc was observed. conclusion: all samples tested with adam met expected criteria for wbc in bc in european union (less than x /unit for leucocyte depleted or x / unit for non-leucocyte depleted) and were comparable with those tested with fc; the correlation with microscopy in frc was worse.with use of disposable r-slides, the risk of exposure to the potential hazardous blood samples is grately reduced, the method is more precise and not time consuming.from january we changed our protocol for testing residual wbc in bc with adam device and we advise it as the best practice for monthly routine quality control. key: cord- -ezrn cva authors: nan title: physicians – poster session date: - - journal: bone marrow transplant doi: . /bmt. . sha: doc_id: cord_uid: ezrn cva nan hematopoietic stem cell transplant unit, hematology department, hospital universitario de donostia, donostia/san sebastián and informatics and automatics department, university of salamanca, spain the immature platelet fraction (% ipf) is a relatively new parameter that measures young (reticulated) platelets in peripheral blood (pb). ips rise as bone-marrow (bm) production of platelets increases. several clinical utilities of the %ipf have been already proved, as the treatment response monitoring in aplastic anemia or immune thrombocytopenic purpura. in this study, we aimed to found if ip measurement might be useful during the grafting phase of hsct. this study includes patients who underwent allo-hsct in our center during the last . years. were male ( %) and female ( %). median age was years (range: - ). baseline diseases were: acute leukemias ( ), lymphoproliferative disorders ( ), myelodysplastic syndromes ( ), chronic myeloproliferative diseases ( ), multiple myeloma ( ) and bone marrow failures ( ) . donor was unrelated in cases, and related in (including haplo-identical). conditioning regimen was: busulphan-based ( ), melphalan-based ( ), tbi-based ( ) and others ( ) . progenitors source was pb in , and bm in . platelet count, %ipf and absolute ip count (aipc) from day + to the day of stable graft were analyzed. . % patients reached plat ⩾ /mcl at day + , . % at day + and . % at day + . median first day of plat ⩾ /mcl was day + (range: . median %ipf was . % (range: - . ), . % (range: - . ) and . % (range: - . ) at days + , + and + , respectively. median aipc was /mcl (range: - ), (range: - ) and (range: - ) at days + , + and + , respectively. among the time points analyzed, aipc at day + showed the best positive correlation with platelets counts at day + (r = . ). interestingly, patients with lower aipc at day + showed a delayed platelet graft (see table ). contrarily, patients with higher aipc at day + had an earlier platelet graft. absolute immature platelet count before the graft seems to predict the precocity of the platelet graft for the majority of patients undergoing allo-hsct. this finding might help physicians for the patient management (anticipation of hospital discharge and so on). disclosure of conflict of interest: none. [p ] p analysis of genetic polymorphism for cardiovascular diseases (cvd) in placental and maternal blood in hypertension and hypercholesterolemia c khalil , a azar and a ibrahim , reviva stem cell research and application center, lebanese university, middle east institute of health hospital and faculty of medical sciences, lebanese university, lebanon cardiovascular diseases are the world's leading cause of death representing % of the total global mortality. the genetic polymorphism of the cvd genes, especially the ace: angiotensin converting enzyme gene risky alleles (ins/del) which are associated with a high and inappropriate level of ace can be considered as a genetic model in the development of hypertension and its complications in cvd. we evaluated the mutation impact of the cvd genes in the lebanese population, based on samples derived from placental blood (pb) and samples derived from peripheral blood of postpartum mothers. adult females (age ⩽ years) were divided (n = per group) into group (normotensive, normocholesterolemia: nn), and group (hypertension, hypercholesterolemia: hh). buffy coat were extracted from the pb. all tests on pb and maternal blood were done by using the test strip assay to identify the most relevant genetic variations to estimate the risk for cvd. the presence of a double mutation (ins+/del+) related to the ace gene in the hh group was %. the presence of a single mutation (ins − /del+) was only associated to the hh by %. (ins − /del − ) was absent in % of the pb and nn. despite the presence of double mutation ins/del for cvd in maternal blood, pb was free of this mutation. therefore, beyond genetic mutations, other factors can play a major role in the occurrence of cvd. disclosure of conflict of interest: none. s b e mt automated red blood cell depletion in abo incompatible grafts in the pediatric setting c del fante, l scudeller, s recupero, g viarengo, f compagno, m zecca and c perotti fondazione irccs policlinico san matteo red blood cell (rbc) depletion by apheresis is employed to reduce the rbc content from abo major or bidirectional mismatch bone marrow (bm) grafts mainly to avoid severe haemolysis . rbc depletion results in a significant volume reduction (due to both rbc and plasma depletion) and buffy coat concentration . . in pediatric setting, both rbc depletion and volume reduction before transplantation or cryopreservation can avoid fluid overload and renal impairment, especially in low/very low body weight recipients. the aim of this study was to evaluate the quality of the graft and immediate post infusion complications in rbc depleted bm in major and minor abo mismatch recipients using an automated device. patients and methods: bm aspirates for transplantation in pediatric setting were processed at our centre using the spectra optia (terumo bct) automated device. the initial collection preference was set at level and then was adjusted in order to maintain a haematocrit of % (colorgram) in the collection bag. flow speed was set at ml/min for cycles. mean recipients' body weight was kg (range: - ). pre and post procedure bm bag volume, hct%, mononuclear cells (mncs) count, (including b and t lymphocytes), cd + cell and cell viability were calculated. moreover, post procedure rbc volume and procedure time were registered. on the patient's side, post infusion complications (renal impairment, fluid overload, fever and haemolitic reactions) and time to engraftment were evaluated. results: a total of rbc depletion procedures were consecutively performed on bm grafts ( major and minor abo incompatibility, mud and related donors). data about pre and post procedure graft composition are reported in table . mean time to engraftment for pmn was . days (range: - ) and for plt was . (range: - ). pre and post-procedure cell viability were always %. mean procedure time was . minutes (range: - ). no bacterial or fungal contamination was detected. no infusion complications were recorded. one graft failure was observed. conclusions the spectra optia automated system is efficient in rbc depletion of abo mismatched grafts, permitting an effective volume reduction and an excellent mncs and cd + cell recovery in pediatric setting. automated rbc depletion may be proposed in low/very low body weight recipients both in abo major and minor incompatibility setting to minimize graft infusion side effects. building up a stem cell transplantation program in an emergent country, in the public setting, with limited economic resources, is not an easy work to do. international cooperation may be essential for the development of the program, in training, technological support and implementation of international guidelines. after years, we show an experience of international cooperation between a highly developed center in france (institut paoli calmettes, marseille) and the stem cell transplantation department of hospital maciel, a public assistance service in montevideo, uruguay. fourteen persons between doctors and nurses have been trained in france in stem cell collection and processing, patient's clinical handling, nursing, outpatients care and quality management. french missions of experts have been also received in hospital maciel every year since for in situ human resources training. in last years we developed a program for optimizing transplant results and reducing transplant related mortality (trm), based on several measures: improvement of patients selection, applying the sorror comorbidy index; adjustment of conditioning regimen doses, in order to reduce toxicity; development of a program to improve interaction with the intensive care unit; protocolization of the standard proceedings treatments; and initiating a program of quality and safety at the national institute of quality of uruguay inacal. adult patients have been treated with autologous (asct) ( ) or allogeneic (allosct) ( ) sct, with hematological malignancies. different modalities of allosct have been included progressively, becoming the only center accredited by the national regulation authorities (fnr) to perform unrelated donor sct and the haploidentical donor sct. this increased the proportion of allogeneic transplants from the historical % until % in last years. regarding patients health coverage, % comes from the private assistance system and % from the public health system. the major indications are lymphoid malignancies and acute leukemia, for asct and allosct, respectively, showing the same trend than cibmtr. three-year overall survival (os) for acute myeloid leukemia after allosct is %. considering asct for diffuse large b cell lymphoma, years os after autologous sct is % and % for chemo sensitive and resistant disease, respectively. threeyears os after asct for hodgkin disease is and % for sensitive and resistant disease, respectively. asct in multiple myeloma shows an os of and % at and years, respectively. in trm, results during the last years (after the described strategy) are shown in figure . the development of the-program of continuous improvement in quality-and the impact of results was locally recognized by two annual prices from inacal in (bronze) and (silver) in the category ‛commitment to public service.' a successful mirna- and the level of proangiogenic cytokines: angiopoietin- (angpt ), matrix metalloproteinase- (mmp- ) and vascular endothelial growth factor (vegf) in patients with lymphoproliferative malignancies prior to autologous hematopoietic stem cell transplantation (hsct) and in early posttransplant period. twenty-four patients were enrolled to the study ( f, m). the median (me) age was years. the investigated group consisted of multiple myeloma and lymphoma patients. the plasma samples were collected on time points: before chemotherapy-‛bc', on the day of hsct -‛ ', days after hsct-‛+ ' and days after hsct-‛+ . ' the cytokines were evaluated using elisa method, while mirna levels were estimated by qpcr method. the wilcoxon matched-pairs test was used to compare groups of dependent continuous variables: mirna's relative quantification (rq) levels or cytokines expression at two different time points. spearman rank correlation coefficient (r) was used to compare independent variables. we observed continuous decline of cytokines and mirnas level after conditioning treatment. the deepest decrease of expression was marked on ‛+ ' day ( table ) . we noticed a positive correlation between mirna- , mirna- cells in pbsc product. among the autologous transplanted patients between march and october , we have selected according to diagnosis, conditioning regimen and number of infused bags of cryopreserved pbsc. this group included females and males with median age of (range: . most of them, ( . %), had multiple myeloma (mm), ( . %) had non-hodgkin's lymphoma (nhl) and ( . %) had hodgkin's disease (hd). after harvesting, cd + cell and leukocyte number in pbsc product were enumerated on flow cytometer and blood cell counter, respectively. pbsc were cryopreserved with % dymethil sulfoxide (dmso) and cell viability was measured with trypan blue exclusion test before and after adding dmso, and as well after thawing in water bath on °c. as a conditioning regimen for the mm patients, melphalan was used and for the nhl and hd patients we used beam regimen. all received one bag of cryopreserved pbsc and pegfilgrastim mg on the first or the second post-transplant day. time to hematopoietic recovery was measured; for neutrophils . × /l, leukocytes × /l and platelets × /l with at least days without platelet transfusion. the median number of total leucocytes infused was . × /l (range: . - . × /l) of which cd + cells were - . × /kg of patient's body mass (median . × /kg). pre-freezing cell viability before and after adding dmso was with a median of % ( . - ) and , % ( . - ), respectively, and post-thaw viability . % ( . - ) . the average time to engraftment was . days ( - ) for neutrophils, days ( - ) for leucocytes and . days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) for platelets. our results confirmed the known correlation between the number of infused cd + cells and engraftment of neutrophils (po . ), leukocytes (p o . ) and platelets (p = . ). we found inverse correlation between the infused leukocytes and cell viability with dmso (p = . ) and after thawing (p = . ). no correlation was found between prefreezing and post-thaw viability with hematopoietic recovery, and also between the cd + number and these viabilities. no differences were found considering patients' age, gender, diagnosis, conditioning regimen or day of applying pegfilgrastim. we can indirectly infer good survival of cd + cells and higher sensitivity of other nucleated cells to preparation of pbsc product. trypan blue exclusion assay, due to its inability to distinguish type of stained cells, is not relevant for cd + cells survival determination. disclosure of conflict of interest: none. chronic granulomatous disease (cgd) is a kind of primary immunodeficiency disorder of phagocytic cells which resulting in failure to kill a defined spectrum of bacteria and fungi and in concomitant chronic granulomatous inflammation. allogeneic hematopoietic stem cell transplantation is the only treatment proved to be potentially curative in cgd. unrelated umbilical cord blood (ucb) is increasingly used as an alternative to bone marrow. methods: unrelated ucbt was performed consecutive cgd children at our center between and . median age was . months (range: - months), median body weight was . kg (range: - kg). all patients received myeloablative conditioning regimen consisting of busulfan, fludarabine, cytarabine, cyclophosphamide and g-csf. all patients received tacrolimus as prophylaxis for graft-versus-host disease (gvhd). median nucleated cells were . × /kg (range: . - . × /kg), and median cd + cells were . × /kg (range: . - . × /kg). median follow-up time was . months (range: - months) results: of patients engrafted. median time to neutrophil engraftment was days, and median time to platelet engraftment was . days. / patients were alive, and / had full donor engraftment. overall survival rate was . %. disease-free survival was . %. of patients had grades iii-iv acute gvhd. no patients developed chronic gvhd. only one patient died from multi-organ failure related to adenovirus infection. conclusion: unrelated ucbt should be considered as potential curative methods in children with cgd. myeloablative conditioning regimen has improved the engraftments of the ucb. disclosure of conflict of interest: none. reduced muscular mass and excess visceral fat in patients undergoing hsct are associated with higher mortality, longer hospitalization, longer use of immunosuppressive drugs, graftversus-host disease (gvhd) and comorbidities leading to shorter survival time. a recent study of patients undergoing allogeneic hsct showed that occurrence of enlarged areas of visceral and peripheral fat is inversely associated with the disease-free interval after the transplant. reduced muscle mass has also been associated with higher prevalence of chronic gvhd and low rates of success following allogeneic hsct. objectives: to investigate whether amount muscle mass and muscle strength (ms) as well as the amount of visceral fat (vf) of patients undergoing hsct would influence the duration of the engraftment time (en). we evaluated hsct patients (⩾ years) at hospital israelita albert einstein, são paulo, brazil, on their first day of hospitalization, before hsct. the thickness of the right femoral quadriceps muscle (rfq), measured at cm from the top edge of the patella was measured using ultrasound (us) in b-mode. the dominant upper limb strength of the patients was evaluated by the hand grip test. the vf was measured in the abdominal region, by the thickness of the fat layer between the linea alba and the anterior wall of the aorta. most patients were women ( %) with a mean age of years (± years) and % of our patients were elderly (⩾ years). the haploidentical ( %) was the predominant hsct, autologous ( %) and allogeneic ( %). most patients were overweight, with body mass index (bmi) of kg/m (± kg/m ). the average time en was days (± days). rfq was . cm (± . cm), ms was kgf (± . kgf) and the vf was . cm (± . cm). patients with lower rfq had a longer engraftment time that was statistically significant as the negative correlation between rfq and en was rs = . , p o . ), independent of the age and the hsct type as analyzed by linear regression. no significant correlation between vf or ms with en was found. in this cohort of patients we found that longer engraftment times were significantly correlated to reduced muscle mass but no positive or negative correlation was found with superior limb muscular force or with the amount of visceral fat. disclosure of conflict of interest: none. hematopoietic stem cell transplant unit, hematology department and pharmacy department. university hospital of donostia. donostia/san sebastiań introduction: lymphocytes are the cells responsible for the cellular and humoral immunity and, consequently, critical for hematological patients. the aim of this study was to analyze the eventual conexion between lymphocyte recovery and survival (srv) after allogeneic hematopoietic stem cell transplantation (allo-hsct). patients and methods: we retrospectively analyzed data from consecutive patients who underwent allo-transplants in our unit. in total, patients were male ( . %) and female ( . %). median age was years old (range: . baseline disease was: acute leukemia ( . %), lymphoma ( . %), myelodysplastic syndrome ( . %), chronic myelogenous leukemia ( . %), multiple myeloma ( %), aplastic anemia ( . %), chronic lymphocytic leukemia ( . %) and others ( . %). . % of allo-hscts were from an unrelated donor, and . % from a family donor ( % of them haplo-identical). the sc source was pbsc in . %, and bm in , %. a variety of conditioning regimens were employed, including: busulphan-based ( . %), melphalan based ( . %), tbi-based ( . %) and others ( . %). evolution of absolute lymphocyte counts (alc) and subpopulations during the first year after allo-hsct were analyzed. results: as shown in table , alc decreased abruptly during conditioning therapy and recovered up to baseline at days + and + ; at day + median alc had clearly improved compared with admission values. median cd + cells were lower than /mcl in two thirds of pts at day + and in only one third at day + . as shown in table , we found a significant link between alc at day + and srv, as well as between cd + cells at day + and srv. in our series, immunity recovery was a late event for the majority of patients undergoing allo-hsct. in addition, in our experience, the precocity and quality of the alc and cd + recovery was clearly linked with long-term survival. disclosure of conflict of interest: none. although there is experimental evidence suggesting the presence of a common mesoderm cell as origin of both hematopoietic (hsc) and mesenchymal progenitor cells (msc) in an animal model, it is still controversial if durable engraftment of native donor-derived mscs without ex vivo treatment can occur in the recipient of allogeneic hsct. to assess the presence of donor-derived msc following hsct. between july and july , a total of recipients of hsct were analyzed for hsc and msc chimerism. eighteen patients received bm grafts ( %), patients had peripheral blood as stem cell rescue ( %) and finally patients had a cord blood transplantation ( %). patients received myeloablative ( %) or reduced intensity conditioning ( %) for malignant ( %) or nonmalignant disease ( %). bm aspirate cells were plated and expanded in α-mem with % human platelet lysate at cells/cm . after - days, nonadherent cells were removed, while the adherent cells were expanded until they reached confluence. after weeks we quantified msc precursors as colony forming unit fibroblast (cfu-f). finally the amplified sequences were resolved by capillary electrophoresis ( ruo genetic analyzer, applied biosystems) and analyzed by comparing genotypes of bmt recipell detachment, nuclear dna was extracted (dneasy blood and tissue kit-applied biosystems) and specific polymorphic tandemly repeated regions (strs) were amplified by means of the polymerase chain reaction(pcr) following the specific manufacturers' instructions. (ampfℓstr identifile kit, applied biosystems following hsct (hsc and msc) to those of donors. we cultured whole bm aspirates from patients following hsct with a median time of day (range: - ). cfu-f/ × growth was observed in a majority of bm the prevalence of human pegivirus in recipients of allogeneic hematopoietic stem cell olga koroleva , e parovichnikova , l kuzmina , m drokov , v vasilyeva , z konova , ekaterina mikhalcova , d dubnyak , n popova , tamara romanova , d tikhomirov , t tupoleva and v savchenko bone marrow transplant department, national research center for hematology and virology department, national research center for hematology human pegivirus (hpgv; previously named as gb virus c/hepatitis g virus) was discovered more than years ago. it is an rna virus referred within the genus pegivirus of the family flaviviridae. hpgv rna is found in liver, spleen, bone marrow and peripheral blood mononuclear cell, including t-and b-lymphocytes, nk-cells and monocytes. despite of the fact that it is a molecular structure, mechanism of replication and transmission routes are very well understood but the clinical significance of hpgv is still not determined. recipients of allogeneic hematopoietic stem cell have a high risk infection of hpgv. it is known, that hpgv is a nonpathogenic virus, however, it may play a role in immunocompromised individuals. to investigate the frequency of occurrence of hpgv and its clinical significance in recipients of allogeneic hematopoietic stem cell. blood samples were obtained from patients who underwent allogeneic hematopoietic stem cell transplantation (allo-hsct): all n = , aml n = , mpn n = , cll n = , mm n = , lpd n = , aa n = , mds n = . a median of age was years ( - years) . forty five patients were males and patients were females. conditioning regimen was ric in cases, mac in . bone marrow as a graft source was used in , pbsc- . all patients received multiple transfusions of blood components at the previous stages of treatment. hpgv rna had been assayed by polymerase chain reaction real time (rt-pcr) on plasma samples before started pre-transplantation conditioning. despite the diagnosis incidence of hpgv was high . % (rna-hpgv was positively in patients). patients with piercings and tattoos had incidence of hpgv in % that was not statistically significant (p- . ). hpgv is known as nonhepatotropic virus. in our study there was also no statistical reliability of specific changes in liver function test such as elevating the levels of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and total bilirubin due to the rna-hpgv. liver enlargement was also not statistically significant according to ultrasound scan results in patients infected with hpgv. we also analyzed the co-infection with hepatitis b and c virus. results are presented in table . coinfection was not statistically significant. however, only one patient with hepatitis c was coinfected hpgv. leukocytes recovery median was days ( - ). thrombocytes recovery median was ( - ). the presence of rna-hpgv did not affect the recovery of peripheral blood cells in patients after allo-hsct. according to our study the frequency of hpgv infection in recipients of allogeneic bone marrow was quite high ( . %), and it did not depend on the presence of any other hepatotropic viruses. clinical significance of hpgv infection in recipients of allogeneic hematopoietic stem cell has not been revealed, it is possible due to the short follow-up. it needs further clinical research. disclosure of conflict of interest: none. quantification of cd + recent thymic emigrants and t cell receptor excision circles (trecs) in umbilical cord blood transplanted patients v devlia , , j gridlestone , m raymond , s tulpule , d tewari , , r hough , c navarrete , a madrigal , , b shaw , , r danby and a saudemont , anthony nolan research institute, london, uk; ucl cancer institute, london, uk; nhsbt colindale, london, uk and ucl, london, uk reconstitution of t lymphocytes is a limiting factor in the regeneration of an effective immune system in adult patients following hematopoietic stem cell transplantation. cd (pecam- ) is a transmembrane glycoprotein expressed on naive t-cells that have recently emigrated from the thymus into the periphery. in peripheral blood, cd + t lymphocytes also contain high numbers of t-cell receptor excision circles (trecs); excision loops of dna excised during t-cell receptor gene rearrangement during t cell maturation within the thymus ( ) ( ) ( ) . however, quantification and correlation of cd and trec has not been formally investigated in patients following umbilical cord blood (cb) transplantation. quantification of cd and trecs post cb transplant will provide an insight into the immune reconstitution of t cells from the thymus. we therefore sought to measure cd and trecs in patients after cb transplant and assess whether these markers provided evidence of thymic recovery. we followed adult patients (median age . years) who underwent cb transplant in the uk. patient samples were collected , , , , and days post transplant. using flow cytometry, we determined absolute counts of cd +cd +cd ra+ and cd +cd +cd ra+, and quantified the copy numbers of trec genes in peripheral blood mononuclear cells (pbmcs) via real time pcr. results: at the six time points, the number of samples collected were the following: , , , , and . in all of the samples, the overall median number of cd +cd +cd ra+ was cells/μl (range: - cells/μl). the median level of cd +cd +cd ra+ cells increases from to cells/μl from day to day . absolute counts of cd +cd +cd ra+ at all of the six time points is -fold lower compared to healthy controls (median: cells/μl, range: - cells/μl). the overall median number of cd +cd +cd ra+ cells is cells/μl (range: - cells/μl). there is an increase in the median number of cd +cd +cd ra+ cells between days and posttransplant from to cells/μl. however, the absolute median counts of cd +cd +cd ra+ cells in patients are twofold lower, years post transplant, compared to healthy controls (median: cells/μl, range: - cells/μl). in the majority of the patient samples throughout all time points the trec gene copy numbers were undetected (n = ). in a few patient samples (n = ) trec gene copy numbers were quantified but with this limited sample size no correlations can be made between the absolute counts and trec gene copy numbers. our data suggests that cord blood transplant patients within the uk have reduced levels of cd +cd introduction: common variable immunodeficiency (cvid) is a highly heterogeneous group of primary immunodeficiency characterized by defective antibody production, recurrent infections, lymphoproliferation and autoimmunity. autosomal recessive mutations in lrba, encoding lps-responsive beigelike anchor protein were first described as a cause of cvid-like disease in . although hsct is accepted as a standard treatment modality for long-term resolution of severe primary immunodeficiencies, its role is less established in patients with lrba deficiency. patients and methods: whole exome sequencing of patient's genomic dna obtained prior to the hsct revealed a homozygous deletion in lrba (c. delt:p. c fs). immunological analyses including serum immunoglobulin levels, flow cytometry analyses of lymphocyte subsets, cytotoxicity/proliferation assays, vaccine responses were studied at several time points throughout the disease course, prior to and after hsct. a -year-old boy, born to consanguineous healthy parents of turkish origin became symptomatic at the age of months. he hospitalized several times due to recurrent pulmonary infections. he developed pancytopenia, lymphadenopathy, hepatosplenomegaly and autoimmunity (autoimmune hemolytic anemia and thyroiditis) with low serum immunoglobulin levels at the age of . as a result, he received several courses of steroid and prophylactic immunoglobulin and wide-spectrum antibiotics. over time he manifested growth failure and diagnosed with ibd-like colitis. due to the cumulating severe cvid-related complications, a hsct was performed at the age of years with the bone marrow stem cells from his hla identical brother after a conditioning regimen including fludarabine, busulfan and atg. severe intractable colitis with hypoalbuminemia continued till the engraftment despite vigorous fluid-electrolyte replacement therapy and accompanied with severe episodes of acute gastrointestinal bleeding. after the achievement of full donor chimerism, diarrhea episodes resolved. he received three doses of abatasept because of persistent cytopenia thinking about unresolved immune dysregulation. he is in complete remission at -year post-hsct with no signs of graft versus host disease. allogeneic hsct should be considered in patients with lrba deficiency prior to the development of disease-related severe cumulative manifestations. disclosure of conflict of interest: none. inflammatory bowel disease (ibd) is a chronic disorder of the gastrointestinal tract. very early onset ibd (veo-ibd) represents those severe children with disease onset occurring before -years-old. interleukin- receptors (il- ra, il- rb) mutation are considered to be one of the very important genes for veo-ibd. currently variant treatment, such as steroid medication, immunosuppressive agents and biological agents could not get complete remission. allogeneic hematopoietic stem cell transplantation (allo-hsct) was reported to induce remission in those with veo-ibd. we performed unrelated umbilical cord blood transplantation (ucbt) in five consecutive children with veo-ibd due to il- receptor mutation between and . median age of five children was months (range: - months), and median body weight was kg (range: . - . kg). all patients received reduced intensity conditioning (ric) regimen consisting of busulfan, fludarabine and cytarabine. prophylaxis for graft-versus-host disease (gvhd) was tacrolimus. most patients ( %) received a or hla alleles-mismatched cord unit. median nucleated cells of the cord blood were . × /kg (range: . - . × /kg), and median cd + cells were . × /kg (range: . - . × /kg). median follow-up time was months (range: - months). all patients engrafted, median time of neutrophil engraftment was days, and median time of platelet engraftment was days. four of five patients were alive with continuous donor engraftment, and achieved complete clinical remissions. colonoscopy at months after transplantation in two children revealed the mucosa healing. two children had grade iii acute graft-versushost disease (gvhd). one child developed severe chronic gvhd of both lungs and died of ards at months after transplantation. it is the first clinical trial that unrelated ucbt was performed in veo-ibd children in china. our data should unrelated ucbt with ric should be considered as a potentially curative therapeutic option in children with veo-ibd. disclosure of conflict of interest: none. patients with refractory primary induction failure and resistant relapse are poor candidates for hematopoetic stem cell transplantation (hsct) . additional attempts at remission induction with various combinations of chemotherapy will unlikely improve the outcome and will contribute to excess toxicity. a major goal of sct has been to develop strategies to reduce the risk of gvhd while maintaining or enhancing gvl. tcrαβ+/cd +lymphocytes depletion is a technology of graft manipulation with a potential to increase gvl effect and improve gvhd control and immune reconstitution in this group of patients. a total of pts with refractory aml (primary induction failure (n = ), refractory relapse (n = )), female/ male, median age . years ( . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , underwent allogeneic sct between may and august , median fu . years ( . - . ). pts were transplanted from haploidentical donors and from mud. all pts had active disease (ad) at the moment of sct and received treosulfanbased high-intensity conditioning regimen. three regimens of gvhd prophylaxis were used. regimen (n = ): atgam mg/kg with (n = ) or without (n = ) post-transplant tacro/ mtx; regimen (n = ): thymoglobulin mg/kg, rituximab mg/m and post-transplant bortezomib on day+ ,+ (n = ); regimen (n = ): tocilizumab mg/kg on day- and post-transplant bortezomib (n = ), pts receive additional abatacept mg/kg on day+ , + , + , + . tcrαβ+/cd +-depletion of sct with clinimacs technology was implemented in all cases. the median dose of infused cd + cells was × /kg (range: . - ), tcra/b- × /kg (range: - ). all engrafted pts received additional post-transplant courses of low-dose chemotherapy, including hypomethylating agents and dli. primary engraftment was achieved in of pts(three pts had disease progression, one died at the moment of engraftment), the median time to neutrophil and platelet recovery was days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . early mortality within days was . % (one pt with aml had acute lung injury after engraftment on day + ), . -years ptrm- . % ( %ci: . - ) . there were no allergic or infusion-related adverse events associated with tocilizumab or abatacept. ci of gvhd grades ii-iv and iii-iv was . % ( % ci: - ), and . % ( %ci: . - ), respectively. ci of cgvhd was % ( % ci: - ). ci of acute gvhd was lower in a group with prophylaxis regimen without serotherapy: % ( % ci: - ) vs . % ( % ci: - ) in atg group. no correlation between graft composition, donor type with the incidence of agvhd and cgvhd was noted at . years ppfs (event = death or relapse or progression) was % ( % ci: - ), . -years pos - % ( % ci: - ). median time of fu for survivors is . years (range: . [ ] [ ] . we confirm that the depletion of tcrαβ +/cd +lymphocytes from the graft ensures high engraftment rate and low transplant-related mortality in pediatric pts with refractory aml. we suggest that tocilizumab and abatacept can be safety administered to children with acute leukemia in the context of treosulfan-based conditioning regimens. long-term follow-up will demonstrate if the gvhd prophylaxis without serotherapy and combined administration of tocilizumab, abatacept and bortezomib post-tcrαβ+/cd +depleted grafting will improve gvl effects without extensive gvhd-related morbidity and mortality in pts with refractory aml. disclosure of conflict of interest: none. the jacie experience at the university hospital of amiens l marie-noelle , w brigitte , f isabelle , g bérengère , h muriel , h anne , v elsa , m jean-pierre and c amandine lacassagne; oncopôle, chu amiens picardie; hématologie clinique et thérapie cellulaire-chu amiens picardie; oncopôle-chu amiens picardie and the jacie (joint accreditation committee of isct and ebmt) accreditation aims to improve the management of patients benefiting from autologous or allogenic hematopoietic stem cell (hsc) transplants. usually, candidates' centers for jacie accreditation have already existing clinical activity when they have willingness to comply with jacie standards. here, we present our new experience in the implementation of jacie quality process, at the same time as allograft clinical activity. implementing process autograft clinical activity existed at amiens hospital, since , but in lack of center cellular therapy laboratory and hsc collection that were outsourced. the collection activity for autologous transplant was set up in , the cellular therapy laboratory in november and then the allogenic transplant was started in july . as early as march , we set up a steering committee with hematological clinicians, managers of each sector, a transplant coordinator nurse, the head of the processing laboratory and a part-time quality engineer recruited part-time. each actor had to become familiar with standards to obtain information from accredited centers in order to evaluate objectives and their prioritization. steering committee decided on deadlines and established a roadmap including the following: the list of jacie required standard operating procedures and their writing; assignment of the tasks for each actors in order to evaluate, writing and approval each document; organization of documents diffusion; information to all staff on the approach; creation of feedback committee for adverse events management; establishment of morbidity and mortality review; formalization of initial and continuing training for medical and paramedical staff; and organization of cross audits with external teams. at the same time, we assessed requirements for starting activity: training for medical and paramedical staff; training for the transplant coordinator nurse; circuits for taking care of donors; the organization of the in-patient department; the organization of follow-up of post-transplant patients; and authorizations of the national regulation agencies for processing facility on manipulations and cellular qualifications and for regulatory collection and transplant. allogenic transplant clinical activity started in july . accreditations jacie visit occurred on and june and our center has been officially accredited since march . neither quality approach, nor clinical activities were easy to implement. medical and paramedical staff had to get acquainted with a new organization and restrictions. despite difficulties, implementing jacie quality process, concomitantly with allograft activity allowed to create a true team dynamics with a common reflection on the means to be implemented. moreover, quality approach has assured us best ensure to care graft patients. the result is true satisfaction, which be credited to all. disclosure of conflict of interest: none. previously published p three-dimensional co-culture of peripheral blood monocytes supports and expands functional hematopoietic stem/progenitor cell without immobilization y xu , x li , b wang , w shan , h chen , s liu , r tie , y long , s cai , h xu , x yu and h huang bone marrow transplantation center, the first affiliated hospital, school of medicine, zhejiang university very low numbers of circulating hematopoietic stem/progenitor cells (chspcs) are found in normal human peripheral blood (pb) without mobilization. here, we developed a three dimension co-culture system to seize and expansion chspcs from pb monocytes without mobilization. flow cytometry analysis was carried out to identify chspc phenotypes. multipotential properties of chspcs were determined using colonyforming unit assay in methylcellulose and reconstitution ability in the compromised animals. the critical regulation mechanism underlying chspcs was identified with transcriptome analysis based on next-generation sequencing technology at total or single cell levels. loose cobble stone colonies (lcs), round or vessel-like compact colonies (rccs or vccs) were presented in three dimension co-culture system after about weeks. the colonies lasted for at least six passages with no obvious apoptosis sign, and expanded more than~ fold during the period. we studied the niche-mediated regulation mechanism of chspc fate at molecular level compared to the conventional method of two dimension culture. furthermore, chspcs were capable of forming all types of hematopoietic colonies, including cfu-gemm, and especially held short term engraftment capacity for compromised nogs by radiotherapy. transcriptome analysis by deepsage identified genes significantly associated with regulating the function of chspcs. figure : the cellular morphology in three dimension culture system for peripheral blood monocytes without mobilization during the culture for - weeks. figure : short transplantable potential analysis of chspcs. figure : (a) static of differentially expressed genes between three-and two-dimensional culture systems for peripheral blood cells. (b) go functional analysis classifies those genes by biological process, cellular component and molecular function. (c) the significant differences between the molecular phenotypes of three-and two-dimension chspcs indicating that chspcs from three dimension culture hold stem properties. our system may provide a more ideal and balanced approach which not only seizes circulating chspcs, promotes selfrenewal and expansion of chspcs, but also holds phenotypic and functional attributes of chspcs. . to wash or not to wash? comparison of neutrophil and platelet engraftment after infusion of cryopreserved autologous stem cells before and after the implementation of bedside thawing am halldorsdottir , s atladottir , m thorsteinsdottir, na arnason , g runarsson , t jonsson , oe sigurjonsson , and s reykdal the blood bank, landspítali, the national university hospital of iceland; department of hematology, landspítali, the national university hospital of iceland and school of science and engineering, reykjavik university cryopreserved autologous peripheral blood stem cell (pbsc) grafts are widely used after high-dose chemotherapy in the treatment of patients with myeloma or lymphoma. prior to infusion, cryopreserved grafts can be thawed at the bedside, or thawed and washed at the cell therapy laboratory. at our institution the practice of routine washing of stem cell grafts in the laboratory was discontinued in april and bedside thawing implemented instead. this was done to minimize the time thawed cells are exposed to toxic dmso. this study was performed at a single center, at landspítali-the national university hospital of iceland, which is the only transplant center in iceland. autologous pbsc transplants have been performed in iceland since . the study compares outcome for two groups of patients, who received either; (a) thawed and washed autologous pbsc cell grafts from january to [p ] april , or (b) autologous pbsc grafts thawed at the bedside from april to november . the following outcomes were compared; days to neutrophil engraftment (absolute neutrophil count (anc) . per μl), and platelet engraftment ( and × e /l). data on mean cd + cell content/kg of the infused grafts, measured prior to cryopreservation, were also compared. all patients have received premedication with solucortef, clemastine and ondansetron prior to infusion of the graft. from january to april a total of patients received thawed and washed autologous pbsc grafts, and between april and november patients received autologous pbsc grafts thawed at the bedside. majority of the patients were diagnosed with either multiple myeloma or related disorders (n = ) or lymphoma (n = ) whereas the remaining patients (n = ) had miscellaneous diagnoses. days to engraftment and the dose of cd + cells infused are compared in table . there was no significant difference in the mean cd content of infused autologous stem cells in the two groups ( . vs . × e cd +cells/kg, p = . ). there was also no difference in the mean number of days to engraftment of neutrophils ( . vs . days, p = . ), platelets at days ( . vs . days, p = . ) or platelets at days ( . vs . days, p = . ) after transplant. one hundred day mortality was comparable in the two groups or . %. additional data on transfusion requirements, infections and use of granulocyte-colony stimulating factor will be presented. [p ] there was no difference in neutrophil or platelet engraftment after changing the autologous stem cell graft thawing procedure from post-thaw washing in the laboratory to bedside thawing. bedside thawing of stem cells is a safe procedure that results in acceptable cellular engraftment. disclosure of conflict of interest: none. the procedure of autologous hematopoietic stem cell (hsc) transplantation requires cryopreservation of hscs. addition of dmso (dimethyl sulfoxide) is necessary to secure the viability of such cells, but this cryoprotectant causes adverse reaction during infusion into patient. the concentrations of dmso in cryopreservation mixture vary strongly between different transplant centers. usually, the hscs are stored in mixtures containing % dmso, however, many centers successfully use lower concentrations. the main aim of the study was to evaluate the clinical impact of different dmso concentrations in cryopreservation mixture ( %, . %, %) on reconstitution of hematopoiesis after autologous hsc transplantation. the project was approved by the local bioethics committee. written informed consent obtained from all of patients. the study is registered to clinicaltrials.gov (identifier: nct ). between january and july , consecutive patients with hematological malignancies or solid tumors, referred for autologous hsc transplantation, were recruited in the study. the patients were randomly assigned to one of three study arms ( patients each). hscs obtained by leukapheresis were cryopreserved in three concentrations of dmso: %, . %, %, respectively. study groups did not differ significantly with regard to the diagnosis (mostly mm, nhl or hl), age or conditioning regimen (chemo-or radiotherapybased). all patients received granulocyte-colony stimulating factor (g-csf, filgrastim) starting from day + after transplantation to support neutrophil recovery. in case of patients, the transplantation was cancelled due to progression or other medical reasons. four patients died shortly after transplantation, due to refractory infections. data for patients were subjected to statistical analysis. the viability of nucleated cells on the day of transplantation was similar in all groups (median %, range: - % for % dmso group; %, range: - % for . % dmso; %, range: - % for % dmso; p = . ). the dose of transplanted cd + cells was comparable in all group: (median . × /kg of recipient body weight for % dmso, . × /kg for . % dmso and . × for % dmso, p = . ). the median time to leukocyte recovery, defined as the first day with wbc count exceeding . × /l was days in all groups (ranges: - for % dmso; - for . % dmso; and - for % dmso; p = . ). similar results were obtained in case of neutrophil recovery-the median day, when the anc exceeded . × /l, was in all arms (ranges: - ; - and - , respectively; p = . ). the day when the platelets level were greater than or equal to × /l (sustained without transfusion within days) was similar in all groups: medians were days in %, . % and % dmso (ranges: - ; - ; - ; p = . ). no serious adverse effects were observed during hscs infusion and during h after transplantation. reduction of dmso concentration from in cryoprotective mixture % to . % and % has no negative impact on cell viability during cryopreservation and engraftment after auto-hsc transplantation. disclosure of conflict of interest: none. a real-world cost-effectiveness analysis demonstrates that introducing plerixafor to improve mobilization in multiple myeloma patients who behave as poor mobilizers is cost-effective considering the whole mobilization and transplant procedure r touzani , , a-m stoppa plerixafor, a cxcr -antagonist, is efficient to improve cd + cell mobilization and collection in candidates for autologous transplantation who behave as poor-mobilizers. the cost of the drug is however of concern. published medico-economics studies were mostly conducted in the us, and few including detailed and comprehensive micro-costing of the collection and transplantation process; conclusions may thus not apply to european countries where cost structures are different. to compare costs and effectiveness of plerixafor-free and plerixafor-replete management strategies for multiple myeloma patients who behaved as poor-mobilizers after adequate administration of a standard rhg-csf mobilization regimen. sixty patients diagnosed with multiple myeloma were consecutively identified during years - , immediately before and after ema granted marketing authorization for plerixafor. poor-mobilizers were defined as having circulating cd + cell counts below /μl. plerixafor was introduced or not as a result of the attending physician's decision, reflecting progressive changes in medical practices over this transitional period. the historical and study groups were matched over four criteria: disease stage at diagnosis, age, gender and number of chemotherapy treatments received before mobilization. two cost-effectiveness analyses (cea) were conducted; the primary cea looked at the criterion ‛collecting at least × cd + cells'; a secondary cea looked at the criterion ‛successful autologous transplant administered'. detailed micro-costing evaluations ( figures) did not or did include transplantation costs for the first and second cea, respectively. the two groups were similar in terms of age, sex distribution, disease characteristics or previous treatments. / and / patients proceeded to high-dose melphalan and autologous transplantation in the study and historical groups, respectively. there was a trend to a higher number of collected cd + cells in the control group; however, the proportion of patients who met the minimal target number of × collected cd + cells/kg was identical ( / ). length of hospitalization, times to neutrophil and platelet recoveries, numbers of prbc and platelet transfusions were identical in the two groups. mobilization and collection costs per patients were more important in the plerixafor group that in the historical group ( . vs . €, p o . ), and proportionally higher in patients who received plerixafor as part of a remobilization treatment rather than pre-emptively ( . vs . €, respectively). the main cea concluded to a . € increase in costs for the same number of patients achieving a minimal target number of × collected cd + cells/kg. the second cea found a decrease in the cost of transplant, with . € in the study group vs . € in the historical group (ns). in total, the . € increase for the complete procedure cost ( . € per successfully autografted patient in the study group vs . € in the historical group) was not statistically different. cost-effectiveness arguments should not been used against the administration of plerixafor in multiple myeloma patients in the european context. future prospective researches looking at patients reported outcome criteria and labour organization in apheresis facilities are needed. disclosure of conflict of interest: this work was supported by a grant from sanofi s.a.; cc: research support, honorarium & hospitality from sanofi s.a. administration of plerixafor for peripheral blood cd + stem cell content of o × /l for autologous stem cell mobilization leads to decreased apheresis days and increased total yield m kamdar , s abebe , gr gonzalez fontal, l gates , a hammes , d abbott , j gutman , b haverkos , d sherbenou and c smith division of hematology and transplantation and department of biostatistics and informatics, university of colorado, denver, colorado, usa autologous stem cell transplantation (asct) is an effective treatment for lymphoma and plasma cell neoplasm (pcn) (multiple myeloma and amyloidosis). granulocyte-colony stimulating factor (g-csf) is the most commonly used upfront mobilizing agent with plerixafor-based higher cost approaches reserved for poor/unsuccessful mobilizers. several mobilization algorithms utilizing g-csf and plerixafor have been published however the most efficient and cost effective strategy is yet to be determined. most transplant centers administer plerixafor for peripheral blood (pb) cd + stem cell content of o × /l on day (d) of g-csf mobilization. at the university of colorado (uch) we changed our programmatic approach in and administered plerixafor for pb cd + count of o × /l on d of g-csf mobilization. in this study we evaluate the impact of this novel mobilization algorithm on apheresis days and total stem cell yield. patients (pts) with lymphoma and pcn who underwent asct at uch until / received plerixafor if pb cd + cells on d of g-csf mobilization was o × /l. based on our institutional review of poor/unsuccessful mobilizers and using logistic regression analysis this algorithm was revised in / . in the new algorithm all pts received plerixafor if pb cd + cells on d of gcsf mobilization was o × /l. demographics were compared between pts with lymphoma and pcn before (group : / - / ) and after (group : / - / ) the new algorithm was implemented. the primary goal of this analysis was to assess the total days of apheresis and total stem cell yield between the two groups. we also sought to analyze days to wbc engraftment and platelet engraftment. a total of pts were included in this analysis. group consisted of pts ( pts had lymphoma and pts had pcn). group consisted of pts ( pts had lymphoma and pts had pcn). we found that there was a significant increase in total yield (p = . ) in group as compared to group . on further disease subtype assessment we noted that pts with pcn in group had a significant increase in total yield (p = . ). in lymphoma pts on univariate analysis group showed a significant decrease in apheresis days ( . days, p = . , % ci: (− . , − . )). on multivariate analysis there was still a marginally significant decrease in group ( . days, p = . , % ci: (− . , − . )) compared to group . in pcn pts on univariate analysis group showed a significant decrease in apheresis days ( . days, p = . , % ci: (− . , − . )). on multivariate analysis group continued to show a significant decrease in apheresis days ( . days, p = . , % ci: (− . , − . ) compared to group . we found no significant difference between the two groups in days to neutrophil engraftment and platelet engraftment. our analysis showed that a mobilization algorithm of administering plerixafor for a pb cd + stem cell count of o × /l on d of g-csf mobilization led to a decrease of roughly . days in the lymphoma cohort and a significant decrease of . days in the plasma cell neoplasm cohort. we also noted a significantly increased total yield of stem cell collection in group . overall our programmatic approach led to decreased chair-time for apheresis and better resource utilization. pharmacoeconomic impact of this approach will be updated at the meeting. disclosure of conflict of interest: mk: speakers bureau, seattle genetics; remaining authors declare no conflict of interest. administration of stem cell boosts (scbs) from the original donor offers a therapeutic option. we report on pediatric patients with pgf who received a total of boosts with cd + selected peripheral blood stem cells (pbsc) after transplantation from matched unrelated (n = ) or mismatched related (n = ) donors. median time between hsct and infusion of the scbs was days ( - ). boosts contained a median number of . × cd + progenitor cells/kg body weight (range: . - . × ) with a median number of /kg (range: - ) residual cd + t cells. within weeks after application, a significant increase in median neutrophil counts ( vs /mm , po . ) and a decrease in erythrocytes and thrombocytes transfusion requirement (median frequencies and vs , p o . and o . ), were observed, and . % of the patients resolved one or two of their initial cytopenias whereas . % had a complete hematological response. additionally median lymphocyte counts for cd +, cd +cd +, cd + and cd + increased . fold, . fold, . fold and . fold, respectively. the rate of de novo acute gvhd grade i-iii was only % and resolved completely after treatment. no gvhd iv or chronic gvhd occurred. patients who showed a response to scb displayed a trend toward better overall survival (os) (p = . ). administration of cd + selected scbs from alternative donors is a safe and effective procedure. we hypothesize that the cd + progenitor boosts may have an enhancing effect on maturation of committed lymphoid precursors already present in the host or generate another wave of thymic seeding with accelerated t-cell differentiation process in the absence of any immune suppression. further studies are warranted to better define the impact on immune reconstitution and survival. disclosure of conflict of interest: none. plerixafor plus granulocyte-colony stimulating factor (g-csf) has been shown to mobilize more cd + cells than g-csf alone for autologous hematopoietic stem cell transplantation (hsct). however, there are few studies that analyze the impact of this strategy in engraftment. the aim of our study is to compare mobilization and engraftment between patients who received a combination of plerixafor plus g-csf and patients (pts) who mobilized with g-csf alone. a retrospective casecontrol analysis was performed in pts with myeloma who mobilized with plerixafor plus g-csf (group p/g-csf) and was compared with matched for sex and age controls who mobilized with g-csf alone (group g-csf). all pts underwent hsct between and . mobilization with g-csf at dose of μg/kg/day was used in all pts. the aphaeresis was scheduled on day + . plerixafor ( . mg/kg) was added if the number of cd +cells on day + was o /μl for × cd +/kg requested (or o /μl for × cd +/kg), or if the number of cd +cells collected in the first apheresis was o % of cd + requested. conditioning and supportive care were similar in both groups. in p/g-csf group, were male and female. median age was . years (range: - ). in group g-csf, were men and female. median age was . years (range: - years). there were no differences between both groups. disease status at time of mobilization was different between groups (p = . ). in p/g-csf group: ( . %) pts were in complete remission (cr), ( . %) very good partial responses (vgpr), ( . %) partial response (pr) and ( . %) had no response to treatment. in g-csf group: ( . %) pts had reached cr, ( . %) vgpr and the remainder in pr. sixteen ( . %) pts in p/g-csf group had received ⩾ lines of treatment vs ( . %) pts in g-csf group (p = . ). no difference was seen on mean day-dose of g-csf ( μg/kg/ h in p/g-csf group vs μg/kg/ h) (p = . ). there was no difference on cd +/kg requested ( / pts in p/g-csf were requested × /kg vs / in g-csf group) (p = . ). p/g-csf group needed more apheresis sessions, ( . %) pts required ⩾ sessions against ( . %) pts in group g-csf (p o . ). we obtained enough cd + cells to carry out hsct in all patients, although mean number of cd + cells obtained in p/g-csf group was lower than in g-csf group ( . × /kg vs . × /kg, respectively) (p o . ). also, mean number of cd + infused in p/g-csf group was lower ( . × /kg vs . × /kg) (po . ). however, engraftment results were similar in both groups, as represented in table . patients who required mobilization with plerixafor plus g-csf got an engraftment as good as patients who do not require the combination despite of worse baseline parameters. given that the number of cd + infused in the p/g-csf group has been lower than g-csf group, these results might suggest that the different composition of graft cell with plerixafor plus g-csf mobilization, described in some studies, could impact on engraftment outcomes. high-dose chemotherapy following autologous hematopoietic stem-cell transplantation (autohsct) is an effective method of treatment both recurrent and primary refractory lymphoma patients. however, some patients have mobilization failure (‛poor mobilizers') with inadequate collection of peripheral blood stem cell (pbsc). aim: to evaluate the efficacy and factors influencing pbsc mobilization and collection for the autohsct in patients with lymphomas. thirty patients were included in this study: -with hodgkin lymphoma, -with non-hodgkin lymphoma, -with multiple myeloma; women and men of them. the median age of patients was years ( - years). the mobilization of pbsc with only colony-stimulating factors (csf) was carried out for patients, chemotherapy (cyclophosphamide, etoposide) in combination with csf-for patients. only one patient had plerixafor mobilization. the concentration of cd + in peripheral blood (pb) was studied on the day of the intended cytapheresis. cytapheresis was commenced when cd + concentration had been greater than . × cells/ml. twenty-four patients ( %) from had collection of pbsc. the collection was not performed in six patients ( %) because the concentration of cd + in pb on the day of the intended cytapheresis was lower than . × cells/ml. there was no possibility to use plerixafor in these cases for economic reasons. the median concentration of cd + in pb on the first day of the intended cytapheresis in the group of patients that had cytapheresis was . × cells/ml whereas in the group of failed- . × cells/ml (p o . ). fifty-nine tests of cd + in pb were done. distribution and test results by days from the first day of the intended cytapheresis are presented in table . the total number of the cytapheresis was . the majority of patients had procedure of pbsc collection (n = ), patients had procedures and only had . the last patient had had two previous failed cytapheresis procedures and the adding of plerixafor helped him to collect necessary number of cells. the median of cd + cells on patient's kilo was . × cells/kg. sex, age, mobilizing regimen, previous radiation therapy, the count of lines of chemotherapy before autohsct were not significantly associated with poor pbsc mobilization and collection. only tumor response before autohsct (complete/ partial response or stabilization) was significantly associated with cd + cell count in the product of cytapheresis. patients with complete or partial response had significantly better cd + count. [p ] disclosure of conflict of interest: none. factors associated with failure in mobilization of peripheral blood hematopoietic progenitor cells in autologous transplantation je dulon-tarqui, bl acosta-maldonado, l rivera-fong, sa sánchez-guerrero, jf zazueta-pozos, ja padilla-ortega, wj ladines-castro and lm valero-saldaña high dose therapy followed by autologous stem cell transplantation (asct) obtained from peripheral blood is currently the standard model for treatment consolidation in various hematologic malignancies. a global incidence of - % of failure to mobilization is reported, and some factors associated with poor mobilizers in hodgkin's lymphoma (hl), non-hodgkin's lymphoma (nhl) and multiple myeloma (mm) when the yield in peripheral blood stem cells (pbsc) collection is unsatisfactory, the effects for the recipient can be serious. the donor's age, gender, body surface area (bsa), processed blood volume and the method of g-csf dose calculation may affect the cd + yield. as g-csf has a low distribution volume in the peripheral blood (pb), it might be appropriate to calculate the doses by using the bsa instead of per kg body weight. consecutive allogeneic pbsc donations performed in healthy donors at the karolinska university hospital in stockholm were included. a complete medical history, physical examination, electrocardiogram, chest x-ray and laboratory testing were done before pbsc donation. relevant data for analysis were collected from the institutional quality database for a retrospective review. the total blood volume was calculated using the formula by nadler et al. the bsa was calculated using the formula by du bois and du bois. the concentration of cd + cells in the pb and the processed volume of blood were significantly correlated to cd + cells yield (po . and po . , respectively, see table ). the g-csf dose per m was significantly correlated to the concentration of cd + cells in the pb (p = . ) and in the product (p = . , see table ). smaller bsa (p o . ) and less processed volume (p o . ) were found among female donors, who were given lesser g-csf dose per m (p o . ) and showed lower yield compared to men (po . ). however, multivariate analysis of the yield showed that only the concentration of cd + cells in the pb and the processed volume remained independent significant (see table ). [p ] in this study, we found the concentration of cd + cells in the pb and the processed volume of blood to be independent predictors of yield. we recommend to get a high concentration of cd + cells in the pb, and to process adjusted volumes of blood when needed. an evaluation if the calculation of g-csf dose per m is more appropriate than per kg body weight should be done in future studies. autologous stem cell transplantation (asct) has been widely used in the treatment of hematological malignancies over the last two decades. despite its broad use, some characteristics that might influence engraftment have not been exhaustively investigated, particularly graft purity with respect to contamination by platelets (plts) and white blood cells (wbc). here we report collection characteristics and engraftment kinetics of a single center consecutive series of asct. we retrospectively collected clinical records of patients who underwent leucapheresis procedures (la; followed or not by asct) and data on asct at our institution over years ( - ) ( table ). the impact on engraftment kinetics of conditioning chemotherapies, amount of infused cd + cells and wbc/plts graft contamination were analyzed. absolute neutrophil count (anc) engraftment was defined as the duration of neutropenia (from day to the first of consecutive days of anc /μl post asct). regarding cd + cell collection, no impact of mobilizing regimens and wbc count during la was observed. on the other hand, we observed a difference in the number of total cd + cells collected among different diagnoses: the median overall collection was . ( . - . ) × /kg cd + cells for nhl patients, . ( . - . ) × /kg for mm patients, . ( . - . ) × /kg for hl patients and . ( . - . ) × /kg for aml patients) (p = . ). considering cd + cells/kg harvested on the first day of la, . % of nhl and hl, . % of mm patients and % of aml patients harvested ⩾ × /kg cd + cells. of note, among aml patients, . % collected o . × /kg. the differences were statistically significant (p = . ). moreover, an inverse correlation between collected cd + cells and age was shown (p = . ). anc recovery after asct was not influenced by conditioning regimen whereas diagnosis impacted on the duration of neutropenia (aml patients displayed a longer aplasia, po . ). we observed that the median days with anco /μl were , and in patients who received . × /kg, . - . × /kg and o . × /kg cd + cells, respectively (po . ). furthermore, the same finding was observed considering the duration of thrombocytopenia (median number of days with plts o /μl: , and in patients who received . × /kg, . - . × /kg and o . × cd + cells, p o . ). looking at the apheresis product, we analyzed the impact of harvest contaminating wbc and plts on engraftment kinetics. notably, when the asct collection contained × /μl wbc, anc engraftment (days with anc o /μl) lasted longer (median days ) compared to patients who received a graft with lower wbc count (po . ). a faster anc engraftment was also observed in patients receiving harvests with plts levels × /μl compared to those who infused a collection bag with plts o × /μl (p = . ). herein, we confirmed that the disease and the amount of infused cd + cells significantly influence time of anc and plts engraftment; furthermore, we observed for the first time that quality and purity of the graft have a substantial impact on engraftment kinetics. a combination of chemotherapy with growth factor is a commonly used strategy for hematopoietic stem cell (hsc) mobilization. the collection of timely and adequate numbers of hscs is a prerequisite for proceeding to transplantation. a variety of mobilization strategies are currently used. the knowledge of efficacy, safety and predictability of different hsc mobilization strategies might help blood and marrow transplantation (bmt) programs to effectively schedule patients for mobilization. given the many variables associated with the mobilization of hsc, collecting an adequate stem cell dose in a timely and effective manner is an art and science. factors that might affect the process includes type of disease and mobilization protocol, financial clearance, availability of chemotherapy beds, scheduling various diagnostic procedures and transplant urgency. to evaluate the effectiveness and related coordination efforts of ‛just-in-time' strategy of hsc mobilization and collection, we performed a retrospective study comparing all patients in whom peripheral hsc mobilization was attempted at khcc from january through november . data collected included the disease type, mobilization protocol, days to and number of collections, cd + cell dose, calendar of the mobilization and collection. the records of a total of mobilizations were reviewed. were of healthy allogeneic donors, and the remaining were of patients undergoing autologous transplantation. table depicts the overall summary of number of days and collection procedures per each protocol. detailed mobilization kinetics per disease type and mobilization protocol were also captured and evaluated. [p ] s [p ] detailed analysis of mobilization kinetics comparing different mobilization strategies aids in prediction of number of days of mobilization and anticipated number of collections. this helps in proactively scheduling patients based on collection predictability. a seamless communication through a shared calendar between key parties, primarily bmt physicians and nurse coordinators, bmt and flow cytometry laboratories and chemotherapy unit can be achieved. autologous stem cell transplantation is still a standard of care in the treatment of multiple myeloma. lenalidomide-based regimens are commonly used in both transplant-ineligible as well as -eligible patients. prolonged lenalidomide-exposure is known to affect mobilization of cd + cells, although the basic mechanisms are poorly understood. limited prospectively collected data is available on the effect of lenalidomide in the capacity to mobilize cd + cells for transplantation as well as graft cellular composition and post-transplant hematological recovery compared to the lenalidomide-naive patients. this prospective study included newly diagnosed myeloma patients who received mobilization with low-dose cyclophosphamide + g-csf, were successfully apheresed and transplanted before the end of . twenty-six patients had received a median of three cycles of lenalidomide-based induction ( %), whereas patients were lenalidomide-naive and served as the control group. both baseline characteristics and collection targets were similar between the groups. cd + mobilization and apheresis yields were analyzed and compared between the groups. blood graft cellular composition was analyzed from the thawed cryopreserved samples with a flow cytometry. graft function was evaluated by collecting engraftment data as well as by total blood counts at day + and at , , and months after post-transplant. the patients in the lenalidomide group had both lower median peak b-cd + counts and about % lower cd + yields of the first apheresis but without statistical significance ( table ). the median number apheresis was significantly higher in the lenalidomide arm ( . vs . , p = . ). the number of cd +cd +cd -, cd +cd +, cd +cd + cells and nk cells in the cryopreserved grafts were comparable between the arms. time to neutrophil engraftment was days in the both groups. the median time to platelet engraftment was d in the lenalidomide group and d in the control group. hematological recovery was comparable between the groups within months post-transplant. lenalidomide-based induction therapy seems to have an impact in the number of apheresis needed, but not in the total yield of cd + cells in the graft. neither the graft cellular composition nor posttransplant recovery in myeloma patients was affected by the limited duration of lenalidomide used before mobilization and collection of blood grafts. between september and november . siemens hematek system was used for luc count. luc numbers and percentage was measured before leukapheresis. we used pearson test for the correlation and roc curve for cut off value. patients' characteristics were shown in table- . there was not a correlation between luc number and mobilized cd positive stem cell number. but luc percentage was positively correlated with mobilized stem cell number (p: . ). a count of × /kg collected stem cells are optimal for autologous stem cell transplantation. we found % luc percentage as a cut-off value for prediction of collecting optimal number of stem cells with % sensitivity and % specificity. as expected luc percentage was negatively correlated with white blood cell count. there was no correlation between mobilized cd positive stem cell number and age. both luc percentage and mobilized cd positive stem cell number did not differ with underlying disease. we found only one study in the literature that evaluated luc percentage as a tool for the prediction of successful stem cell collection. they found that baseline luc numbers negatively correlated with stem cell mobilization in healthy donors ( ) . but we measure luc on apheresis day and found a positive correlation between luc percentage and stem cell mobilization. and we found a cut-off value for optimal stem cell mobilization with acceptable sensitivity and specificity. in our study we demonstrate that luc percentage measurement on apheresis day may be a very simple and cheap tool for the prediction of optimal stem cell mobilization. the spectra optia (so) apheresis system performs a wide range of therapeutic procedures, including peripheral blood stem cell (pbsc) collection in mobilized donors and patients (pts). the device was studied to evaluate the cellular composition of pbscs harvested in pts with multiple myeloma (mm), non hodgkin's lymphoma (nhl) and hodgkin's lymphoma (hl) planed for autologous peripheral stem cell transplantation (apbsct), and to optimize the collection of pbscs using the cd + precount and collection efficiency (ce ) of apheresis device which is calculated as follows: ce = total cd + cells collected × /kg; cd + precount/ μl × blood processed (liters). the blood volume processed is calculated as follows: desired cd + × /kg × recipient weight (kg): ce × cd + precount/μl in our study enrolled pts undergoing pbsc mobilization and planed for apbsct. we evaluated so system's mononuclear cell (mnc) collection performance, with respect to cd + cells and mnc collection efficiency, platelet reduction pre to post apheresis, and product purity in view of using prediction algorithms to optimize the procedure and predict the cd + yield, blood volume processed and platelets loss. we also evaluated neutrophil and platelet recovery in pts who underwent apbsct. results: between / / and / / , pts underwent pbsc harvesting by so device. median age was years ( - ). there were females and males. diagnosis was mm in pts, hl in pts and nhl in pts. the number of ahereses procedures was . mobilization consisted in g-csf alone in pts, chemotherapy and g-csf in pts, and g-csf + cxcr inhibitor in one patient. median count of cd + cells pre-collection was /μl ( . - ) . median total blood volume processed was . l ( . - . ). median count of cd + cells collected was . × /kg ( - . ). median mnc collection efficacy was % .median cd + cell collection efficacy was . % ( - %). median platelet reduction pre to post apheresis was % ( - %). median product hematocrit and granulocytes product was % ( - ) and % ( - ), respectively. twenty-six of the pts underwent myeloablative high dose chemotherapy followed by apbsct which was performed for mm in pts, hl in pts, and nhl in pts. the median count of cd + cells infused was . × / kg ( . - . ). all the pts received g-csf post-apsct until neutrophil recovery. the median day for neutrophil recovery was ( ) ( ) ( ) ( ) ( ) ( ) ( ) . median duration of severe neutropenia (anc o . × /l) was days ( - ). the median day for platelet recovery was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . median duration of severe thrombocytopenia (platelets o × /l) was . days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . conclusion: the study results confirm that the so apheresis system's mnc collection protocol is safe and effective. the neutrophils and platelets recovery in pts auto-transplanted was not inferior compared to historical controls. in addition, this system help to use prediction algorithms for whole blood processing to achieve a desirable and optimal yield based on cd + precounts and ce of the apheresis device. disclosure of conflict of interest: none. peripheral blood stem cell apheresis in small children is difficult! aa hedayati-asl , m emam-jome, p dinarooni, v fallah, a mehrvar and r zangooei in low-weight children with cancer and healthy donor children, peripheral blood progenitor cells (pbpcs) have largely replaced bone marrow as source of autologous and allogeneic stem cells in part because of their relatively easy collection. however, there is a concern regarding medical, psychosocial and technical difficulties in small children. we retrospectively analyzed peripheral blood stem cell apheresis in collections. patients were with cancer ( patients = neuroblastoma, patients = retinoblastoma, patients = germ cell tumor, patient = hepatoblastoma, patient = wilm's tumor) and healthy children donors. the study was conducted between and . peripheral stem cell apheresis was performed in the mahak cancer children's hospital in a nice room for children where the patients stayed with their families. patients s were not routinely sedated. pbpc were collected by a cobe spectra cell separator (cobe, denver, co, usa). harvesting was performed after days mobilization. mean body weight was . kg (range: - kg) for a median age of years (range: months- years). mean duration of harvesting was min (range: - min). mean volume of stem cell collection was ml (range: - ml). the mean number of total nucleated cells collected was . × /kg (range: . - . × /kg recipients). no side effects occurred. children didn't require an additional haematopoietic progenitor mobilization or additional apheresis in other day. pbsc collection was without transfusion in healthy donor children. pbsc collection may be difficult in small children owing to the large volume apheresis compared to the child's weight. various problems, such as metabolic or haemodynamic disorders may be were seen. peripheral stem cell harvest can be performed in low-weight children under safe and effective conditions even when systematic priming by blood is avoided. processing with increase of blood volume may to increase in the yield by recruiting progenitor cells. disclosure of conflict of interest: none. peripheral blood stem cell collection in low body weight children: a single centre experience g del principe*, g leone, s lazzaro, a meschini, k feri, p marchitelli, d carasso, f locatelli and m montanari department of pediatric hematology/oncology and transfusion medicine, irccs bambino gesù children's hospital, rome, italy pbsc became preferred source for autologous transplantation because of easier collection and faster engraftment. however apheresis for low body weight children ( o . kg) is affected by some issues: venous access, extracorporeal volume, metabolic and hemodynamic complications, citrate toxicity, so is crucial to standardize harvesting procedure both maximizing stem cells collection and reducing adverse events. a dual lumen central venous catheter was used to obtain a minimal blood flow of - ml /min and pbsc collection was performed with spectra optia mnc v . apheresis system, starting with cd + cell ⩾ μl in peripheral blood. the priming of extracorporeal circuit was made with compatible, irradiated, leucodepleted packed red cell to avoid hypovolemic state. citrate dextrose solution a(acd-a), with a ratio of : to whole blood, and a bolus of heparin ui/kg were used as anticoagulants. all patients, treated without sedation, were monitored by ecg, pulse oximetry and non invasive blood pressure; electrolytes panel (na, k, ca) and act (activated coagulation time) were assessed at the beginning, minutes after and then every hour during apheresis. hypocalcemia was managed by mg calcium gluconate slow infusion. we report our experience of pbsc collection in low body weight children ( o . kg) treated in our apheresis department between january and november . a total of pbsc collections were performed in children ( m/ f, median age months, median weight . kg) affected by medulloblastoma (n = ), germ cell tumor (n = ), neuroblastoma (n = ), retinoblastoma (n = ), brain cancer (n = ). total blood volume processed ranged from . to . tbv (median . ) and median count of cd + collected was . × /kg(range: . - ). all procedures were performed with a median duration time of minutes (range: - min) and no serious adverse events occurred. in our experience pbsc collection is safe and feasible also in low body weight children using a tailored apheresis procedure. disclosure of conflict of interest: none. plerixafor on demand in the first or in the second attempt of cd mobilization j romejko-jarosinska, e paszkiewicz-kozik, l targonski, m szymanski, z pojda and j walewski high-dose chemotherapy and autologous hematopoietic cell transplantation (auto-hct) is a recommended strategy for patients with relapsed, refractory or high risk lymphoma. mobilization failure of cd + cells after granulocyte colonystimulating factor (g-scf) with or without chemotherapy is a factor limiting patient access to this potentially curative procedure. the use of plerixafor with g-csf may improve cd + cell harvest in poor mobilizing patients. we evaluated the clinical effectiveness of plerixafor and g-csf ± chemotherapy administered on demand in the first and second attempt of mobilization in lymphoma or myeloma patients who were eligible for auto-hct. we evaluated data on consecutive patients with hodgkin lymphoma ( ), dlbcl ( ), mantle cell lymphoma ( ) , myeloma ( ) and other lymphoma subtypes ( ) who were mobilized with plerixafor between january and october . median (range) age of patients was ( - ). patients received a median of ( - ) chemotherapy lines. radiotherapy was applied in patients. all patients received g-csf ( μg/kg/day) ± chemotherapy and plerixafor ( μg/kg/day) on demand in the absence of increase in the number of cd + cells in peripheral blood above /μl on the day of the scheduled apheresis (within days following the chemotherapy and after at least days of g-csf). plerixafor was given to patients in the first attempt of mobilization and to patients during the second mobilization. the mobilization was considered effective if the harvest cell dose was × /kg cd or more. after plerixafor administration circulating cd + cells increased to /μl in patients ( %) and in patients ( %) in the first and in the second mobilization, respectively (p = . ). the cd + cell collection was performed in / patients ( %): in / ( %) patients in the first and in / patients ( %) during the second mobilization cycle. the median number of apheresis was (range: - ), for both mobilizing cycles. the median (range) cd cell dose collected in the first and second cycle was . (range: . - . ) × /kg and . (range: - . ) × /kg, respectively (p = . ). the harvest was successful in / patients ( %) in the first and in / patients ( %) in the second cycle (p = . ). three patients ( %) who failed the collection with plerixafor in the first attempt, succeeded in the second cycle. additional second mobilization with plerixafor was successful in five patients ( %) who failed the first mobilization. in total, / ( %) and / ( %) of patients given plerixafor in the first or in the second mobilizing cycle harvested at least a minimum cd cell dose for auto-hct (p = . ). these results show that plerixafor administered on demand is an effective rescue strategy for poor mobilizing patients. each mobilization cycle with plerixafor resulted in the increase of circulating cd cell count. successful harvest is more frequent if plerixafor is administered in the first than in the second mobilization attempt. the evaluation of the prognostic factors for mobilizing failure with plerixafor is necessary to identify the poor mobilizers precisely. disclosure of conflict of interest: jr-j, ep-k, lt and jw: sanofi (travel grants); ms and zp: none; jw: lecture, honoraria cryopreserved stem cell grafts are still widely used both in the autologous or allogeneic settings. cryopreserved grafts can be thawed at the bedside or thawed and washed at the cell therapy laboratory. we recently reported that post-thaw washing did not impair hematopoietic engraftment, in a cohort of autologous transplanted patients receiving either unwashed or washed grafts (calmels b et al, bone marrow transplant. ). post-thaw washing can be implemented using various methods such as manual centrifugation, automated centrifuge-based (sepax , biosafe) or spinningmembrane devices such as lovo (fresenius kabi). we here report a step by step implementation of the lovo biomedical device (bmd) for washing thawed stem cell grafts. having defined a washing program, we aim to compare this protocol to our routine process, using the sepax bmd. we took advantage of apheresis products intended for destruction and cryopreserved in identical bags; after dry-thawing (plasmatherm, barkey), bags were connected to the sepax or to the lovo bmd, diluted volume to volume with + - °c % hydroxyethylstarch / . (voluven, fresenius kabi) and processed using the smartwash program (sepax ) or a cycles standard wash protocol on lovo (a cycle referring to one pass through the spinning membrane). the lovo settings were customized for this application: reduction retentate pump rate ml/min, desired inlet pcv %, and automated volume to volume dilution. after processing, cd and cd absolute counts and viability were evaluated by single platform flow cytometry (stem-kit, beckman coulter) and dmso was quantified by capillary zone electrophoresis (p/ace, beckman coulter). post-wash data show comparable cd + cell recovery, viability and effective dmso depletion. we conclude that lovo enables high efficiency dmso depletion while preserving optimal cd viability and recovery. comparison with sepax , a widely used automated centrifugebased device, reveals comparable efficiency. moreover, the length of the procedure when using the lovo does not significantly delay the process as compared to bedside thawing. we are currently evaluating lovo for the processing of multiple bags and higher cell contents, due to its ability to concentrate large volumes of cells suspension. post-thaw washing using automated cell processing systems have thus to be preferred over bedside thawing, since they provide multiple benefits including a short processing time, efficient dmso and cell debris removal, precise determination of infused cd + cell dose, and improved cellular stability. [p ] disclosure of conflict of interest: none. using bone marrow (bm) as the graft source results in lower graft-versus-host disease incidence, which is particularity important in haploidentical (haplo) stem cell transplantations (sct). nonetheless achieving adequate cd + cell count might be complicated in cases of donor-recipient weight differences. priming with g-csf may partly solve this problem. also there are reports of immunomodulatory effect of bm priming. in the retrospective study we have evaluate the effect of priming on stem cell yield and the outcomes of sct. patients and methods: patients with primed bm graft were matched in the ratio : to non-primed grafts. the criteria for matching were type of the donor, age of the recipient, underlying disease and disease status at the time of sct. priming was performed with three injections of filgrastim - mcg/kg daily for days prior to bm harvesting. median recipient age was years (range: - ). % of patients received the graft from haplo donor, % from matched related donor (mrd). % had acute lymphoblastic leukemia, % had acute myeloid leukemia, % had aplastic anemia, % had other malignancies. % were classified as salvage patients. % received myeloablative conditioning, % received reduced intensity. post-transplantation cyclophosphamide (ptcy) was used as graft-versus-host disease prophylaxis in % of patients. results: the yield of cd + × cells /kg of recipient weight was only non-significantly higher in the priming group: . ± . vs . ± . , p = . . the yield of cd + cells per kg of donor weight was also not different: . ± . vs . ± . , p = . . there was no difference in the incidence of primary graft failure ( % vs %, p = . ). median time to neutrophil ( vs days, p = . ) and platelet ( vs days, p = . ) engraftment was shorter in nonpriming group. there was no differences between priming and non-priming groups in the incidence of acute grade ii-iv gvhd ( % vs %, p = . ), moderate and severe chronic gvhd ( % vs %, p = . ), -year non-relapse mortality ( % vs %, p = . ), relapse incidence ( % vs %, p = . ), overall survival ( % vs %, p = . ), event-free survival ( % vs %, p = . ) and gvhd-relapsefree survival ( % vs %, p = . ). conclusions: priming of the bone marrow with reported schedule did not result in higher cd + cell yield and was not associated with any differences in the outcomes of sct. nonetheless, these results should be interpreted with caution, because our study included large proportion of pediatric patients, patients with active disease and ptcy as gvhd prophylaxis, and they may not translate to the other groups of patients. disclosure of conflict of interest: none. priming with granulocyte-colony stimulating factor preserves the contents and abundant ifn-γ production capacity of γδ t cells z bian , q fu , m huo , xj huang and j liu peking university people's hospital the increasing evidences indicate that removal of αβ t-cell and b-cell from grafts was efficient and reproducible in allogeneic hematopoietic stem cell transplantation (allohsct). γδ t cell is one of the functional subpopulations preserved by this graft manipulation and supposed to play a role in improving the transplant outcomes. thus, comprehensive understanding the subsets and functional capacities of γδ t cells in graft becomes important. although there is increased attention paid on this special t-lymphocyte subpopulation, the contents and cytokine production capacities of peripheral γδ t cells before and after granulocyte-colony stimulating factor (g-csf) mobilization for allohsct have not been reported. peripheral blood (pb) before g-csf treatment, g-csf-primed pb and bone marrow (bm) grafts were obtained from healthy donors. the proportions of total γδ t cells and various γδ t-cell subsets were detected by flow cytometry. furthermore, effects of g-csf on the contents and cytokines production by γδ t-cell subsets were also determined. the percentages of most γδ t-cell subsets including cd +, cd -, vδ +, vδ +cd +, vδ +cd -, vδ +, vδ +cd +, vδ +cd -, and non-vδ /δ were preserved in the g-csf-primed pb grafts compared with those before g-csf mobilization. interestingly, we found that peripheral γδ t cells and various subsets all predominantly expressed ifn-γ in response to stimulation. this abundant ifn-γ production capacity of peripheral γδ t cells were maintained after g-csf treatment. in contrast, production of il- by γδ t cell and its subsets were decreased in the same context. priming with g-csf preserved the contents and abundant ifn-γ production capacity of γδ t cells. our data suggests a reasonable role of γδ t cells in preventing from allohsct associated complications and may help establish an effective γδ t cell-based immunotherapeutic approach to improve the overall survival of allohsct. disclosure of conflict of interest: none. processing of hematopoietic stem cells grafts: towards automation of cryopreservation/thawing steps a-l chateau , j gaude , c malenfant , a autret , c lemarie , c chabannon and b calmels centre de thérapie cellulaire-institut paoli-calmettes and unité de biostatistiques-institut paoli-calmettes autologous hematopoietic stem cells (hsc) support is still widely used to allow for high-dose chemotherapy in the context of myeloma and lymphoma treatment. in the autologous setting, mobilized aphereses are systematically cryopreserved. currently, cryopreservation and subsequent thawing rely on manual and largely operator-dependent processes such as manual addition of dmso for cryopreservation or thawing in standard water baths. these operations are thus hampered by significant intra-and inter-facility variability and have to be replaced whenever possible with automated and harmonized processes. the aim of our study was to evaluate a recent, versatile device: smartmax (biosafe, eysins, switzerland), based on the peltier-seebeck effect, for its ability to automatically add the dmso-containing solution to the cell product and to thaw hsc bags. we thus compared three different cryopreservation/thawing protocols ( figure ). we first evaluated the use of the smartmax at the thawing step by comparing cryopreserved apheresis products thawed using our routine device: the plasmatherm (barkey), an automated dry-thawing device that contains water (protocol a), with products thawed with the smartmax (protocol b); after thawing, all products were washed using the smartwash program of the sepax (biosafe). we then evaluated the smartmax for its ability to automatically add the dmso solution: autologous grafts were processed with the smartmax, both for cryopreservation and thawing (protocol c); we compared these ‛fully automated processes' to apheresis processed with protocol b. absolute cd + and cd + cell counts and viability were measured before cryopreservation and after washing using single platform flow cytometry. for all three protocols, the quality of the collected product was comparable in terms of median cd + cell and neutrophil contents. when comparing protocols a and b, viable cd + cell recovery after thawing and washing was slightly lower in the smartmax group ( %) as compared to the plasmatherm group ( %, p = . ). when comparing protocols b and c, viable cd + recovery was comparable (p = . ) when the cryopreservation solution was automatically added by the smartmax ( %), as compared to the manual technique ( %). these preliminary data need to be validated on larger numbers of procedures, however suggest that smartmax use can safely be substituted both to the manual addition of the cryoprotectant and to the traditional thawing step in water baths; potential advantages include complete water removal from sensitive clean rooms and gmp environments. full automation of previously manual and operatordependent technical processes will ultimately allow for improved standardization and reproducibility across cell processing facilities. [p ] disclosure of conflict of interest: none. reduced efficacy of mobilisation using gdp compared to ive a hunter, w merrison, am martin, k hodgson, f miall, r moore and r lewin university hospitals of leicester, nhs trust the use of ive ± rituximab for relapsed/refractory disease in lymphoma is well established. stem cell mobilisation using g-csf post ive administration has been the standard of care in our unit for years. recent interest in cisplatnin-based treatments has seen a change in practice with the use of gdp ± rituximab increasingly common. we have assessed the success of stem cell mobilisation post gdp and compared it to ive using g-csf. patients were eligible for augmentation with plerixafor if their peripheral blood cd levels were between - × cells/l at the time of collection. from sept to oct patients with progressive or relapsed lymphoma underwent stem cell collection. patients characteristics: dlbcl, follicular and t-cell nhl. had a median age ( - years). received gdp, ive. overall % patients failed to mobilise a sufficient cd cell dose to proceed to hdt. all the patients who received ive mobilised successfully but / ( %) patients receiving gdp failed to mobilise. of the patients who did mobilise the average cd collection was higher in the patients who received ive . ( . - . ) and the number of apheresis procedures was lower, median ( - ) compared to . ( . - . ) and ( ), respectively, in the gdp group. patients in the gdp group who failed to mobilise were not eligible for plerixafor because cd levels were below × /l. taking age into account the median age in the ive group was higher ( - ) than the gdp group ( - ) and the lines of previous therapy were not different. patients who had successful stem cell collections went on to receive hdt with leam and all patients engrafted. in this small collection of patients we have experienced a higher failure of mobilisation post a cisplatnin-based protocol compared both to our historical controls pre plerixafor usage (data not shown) but also to current patients. further investigation is needed to ascertain the impact of cisplatnin on stem cell mobilisation and its impact of treatment strategies. disclosure of conflict of interest: none. single centre experience of zarziotm biosimilar granulocyte-colony stimulating factor (gcsf) for the mobilisation of healthy donors demonstrates good leukapheresis yields and safety profile at month median follow-up jg taylor , , t seddon , k alizadeh , c agrawal , l kempster , jg gribben , and sg agrawal , centre for haemato-oncology, barts cancer institute, dept. haemato-oncology, st bartholomew's hospital, london, uk and experimental pathology, blizard institute, queen mary university of london, uk biosimilars have led to significant improvements in the affordability of growth factors such as granulocyte-colony stimulating factor (gcsf). data has shown similar performance and efficiency to parent drugs but concern has been raised about their use in healthy donors due to lack of data examining adverse effects in this setting. we conducted a retrospective analysis investigating mobilisation and adverse effects in healthy sibling donors of adults undergoing an allogeneic haematopoietic stem cell transplant at st bartholomew's hospital from to . harvest data were gathered from hospital records. adverse effects data were gathered from hospital records and telephone follow up. % of donors were male with a median age at harvest of ( - ). all donors were mobilised using zarziotm biosimilar gcsf at a dose of μg/kg/day. median number of apheresis required was ( ) ( ) ( ) . median cd + cell count was . × /kg bodyweight ( . - . ) with × cd +/μl ( - ) in peripheral blood. the target cd + count ( × /kg) was achieved in % of donors and an adequate yield ( - × /kg) in %. in four donors ( %), the harvest was deemed to have been unsuccessful as the cd + count was o × /kg. the patients with donor harvest yields o × /kg proceeded to transplant; all four patients engrafted and one patient had mixed chimerism at day but was fully donor by day . median cd + cell count was . × /kg bodyweight ( . - . ) . median days to neutrophil engraftment ( . × /l) was . median days to platelet engraftment ( × /l) was ( - ) with one patient never engrafting. forty ( %) of donors were contacted at a median of months ( - ) post mobilisation to establish incidence of adverse effects. three donors were uncontactable as they had moved overseas. eight donors were not contacted to avoid distress as their sibling had died since transplant. among contacted donors . % reported side effects including bone and lower back pain controlled with analgesia, constipation and low mood. other side effects included chest pain which was considered to be musculoskeletal in origin on day of gcsf administration associated with taking an increased dose due to patient error (n = ) and abdominal contractions like labour while receiving gcsf (n = ). three ( . %) reported side effects lasting beyond one month post mobilisation: lower back pain lasting months (n = ), fatigue of months duration (n = ), and cough of months duration (n = ). our data demonstrates good mobilisation using μg/kg/day zarziotm biosimilar gcsf without significant adverse effects at years median follow up. this supports its ongoing use for the mobilisation of healthy donors. disclosure of conflict of interest: sga has received honoraria from sandoz and grant support from sandoz and amgen. stem cell mobilization in poor mobilizers with multiple myeloma (mm) or non-hodgkin lymphoma (nhl) before and after introduction of plerixafor: single center comparative analysis using a cost-efficient single fixed-dose schedule r wäsch , c greil , c kiote-schmidt , s hildenbeutel , k kühbach , r bosse , j duyster and m engelhardt department of hematology, oncology and stem cell transplantation, university medical center, freiburg, germany collection of hematopoietic stem cells (hsc) from the peripheral blood (pb) is routinely conducted prior to highdose chemotherapy and autologous transplantation. despite safety and efficiency of current apheresis procedures including mobilizing chemotherapy and granulocyte colony-stimulating factor (g-csf), there is a significant rate of mobilization failures due to different patient-dependent factors necessitating additional agents like plerixafor. while plerixafor is approved for patients with mm or nhl based on prospective studies using steady state mobilization with g-csf − /+ plerixafor, prospective studies using chemo-mobilization are lacking. here we compared the outcome of poor mobilizer from the pre-plerixafor era with poor mobilizers who received additional plerixafor in a real world analysis. we analyzed consecutive patients with mm or nhl who were mobilized at our academic center between and and received plerixafor, because they were expected to be poor mobilizers, due to . low counts of cd + cells in pb samples prior to apheresis, . after a first apheresis day with insufficient yield or . as a rescue strategy after insufficient harvest with previous mobilizing chemotherapy (greil c,…engelhardt m, wäsch r. leukemia & lymphoma , in press). we examined cd + cell counts in pb and in apheresis products to identify those patients who were able to collect a sufficient cd + cell count for transplantation after application of plerixafor. we compared these data with consecutive poor mobilizers from the pre-plerixafor era, who were mobilized between and without plerixafor. the median pb cd +/μl count at first apheresis was significantly higher after the first dose of plerixafor when compared to the pre-plerixafor group with . vs . (p o . ). accordingly, the median collected cd + cells/d (× /kg bw) and total cd + cells (× /kg bw) were significantly increased with . vs . (p o . ) and . vs . (p o . ), respectively. the rate of × cd + cells/kg bw in first apheresis (%) increased from % in the pre-plerixafor era group to % after the first dose of plerixafor in the plerixafor group. consistently, the successful transplantation rate increased from % in the preplerixafor group to % in the plerixafor group. successful stem cell mobilization could be achieved with only a single fixed-dose of plerixafor in % of poor mobilizers as previously reported by our group. the addition of plerixafor to chemomobilization in poor mobilizers with mm or nhl significantly increased pb cd +/μl counts, apheresis yields and transplantation rates when compared to poor mobilizers from the pre-plerixafor era. these favorable apheresis results can be obtained using our cost-efficient, single fixed-dose plerixafor schedule in the majority of the patients leading to a % transplantation rate in poor mobilizer. disclosure of conflict of interest: rw received research funding, advisory and speaker's honoraria from sanofi-aventis. high-dose chemotherapy followed by autologous peripheral blood stem cells transplantation (pbsct) is the standard of treatment for patients with hematological malignancies. recombinant granulocyte colony-stimulating factors (g-csfs) are widely used alone or in combination with chemotherapy, in order to mobilize patient's stem cells (cd +) for autologous and allogeneic peripheral blood stem cells transplantation. aim: the aim of our study was to compare effectiveness and safety of different biosimilar products of filgrastim used in autologous pbsc mobilization in patients with hematological malignancies. our retrospective analysis included patients ( women and men) with median age years ( range: ,who underwent the procedure of autologous pbsct in years - in the haematology, blood neoplasms, and bone marrow transplantation clinic of medical university in wrocław. there were three different biosimilar products of filgrastim used: tevagrastim (teva) in patients, nivestim (hospira) in patients and zarzio (sandoz) in patients. ( %) patients were diagnosed with plasma cell neoplasms, ( %) with hodgkin's and non-hodgkin's lymphomas, ( %) patients had acute myeloid leukemia and ( %) had other hematological malignancies. statistical analysis was conducted using statistica (statsoft polska) statistical software. for quantitative variables arithmetic means and standard deviations were calculated for the estimated parameters in the studied groups. distribution of variables was tested using w-shapiro-wilk test. p . ). there were also small variations in the mean number of leukapheresis necessary to obtain the minimum cd + cell count: . in zarzio group, . in nivestim group and . in tevagrastim group. however, there were no difference between biosimilar g-csfs. the highest rate of successful mobilizations (defined as × /kg cd + cells collected) was observed in . % patients received zarzio, in . % received nivestim and in . % patients received tevagrastim. the safety profile was comparable between the biosimilar g-csf and included bone pain in ( %) patients and headache in ( %) patients. the results are shown in table . all three used biosimilar g-csfs demonstrated similar efficacy and safety in stem cell mobilization in patients with hematological malignancies. therefore, it seems that all the analyzed products can be used interchangeably. presented observations should be verified with wider prospective research. [p ] disclosure of conflict of interest: none. use of g-csf stimulation of bmt donors might prove to be beneficial in many respects, improving tnc yield but also through immunomodulatory effect on donor t cell function and apcs . we analyzed outcomes of consecutive patients receiving bone marrow transplants from hla-haploidentical related donors that received g-csf stimulation prior to harvest. fourteen patients received hla-haploidentical bmt with pt-cy between / and / . five donors were siblings, children, mothers and father. donors received g-csf at the dose of mcg/kg bw sc. on days − , − and before bm collection. twelve patients received nonmyeloablative conditioning according to baltimore protocol , while two patients received myeloablative conditioning (bucy). along with post-transplantation cyclophosphamide, all patients received tacrolimus and mmf form day + , as described earlier . median age was years (range: - ), female and male patients. eight patients had aml, cml, mh and one all. ten of them were in remission, while mh patients were in pr, and aml patients had residual disease as evident by immunophenotyping. median number of infused tnc was . × /kg bw (range: . - . ); cd + cells . × /kg bw (range: - . ) and cd + cells . × /kg bw (range: . - . ). median follow up was days (range: - ). eleven patients engrafted ( %), one patient had primary rejection, one had overt disease relapse at day + and one patient died in aplasia due to sepsis. median day to neutrophil recovery (anc . × /l) was (range: - ), median days to platelet recovery (plt × /l) was (range: - ). in all patients mmf was discontinued at d + . two patients developed acute gvhd in our cohort ( %), one after receiving dli for falling chimerism at day + . one patient ( %) developed chronic gvhd, after having received dli due to disease progression. at the time of analysis patients are evaluable; patients had disease relapse/progression ( %), patients are alive and in remission. one patient died due to sepsis in aplasia (accounting for % non-relapse mortality). one patient that rejected the graft was transplanted again from the same donor, using myeloablative conditioning and peripheral stem cells as graft source and engrafted. overall survival median is . years, with significantly shorter survival if patient was not in complete remission at time of transplant (p o . ). even though the experience with g-csf mobilized bm graft in the hlahaploidentical setting with pt-cy is relatively small, in our series it has been beneficial in terms of tnc yield. also, the incidence of acute and chronic gvhd in our patients has been low, particularly agvhd with one case developing only after dli. whether the observation is the result of limited number of patients, or it reflects the immunomodulatory effect of g-csf on bm graft as previously suggested remains to be seen as further studies are warranted. autologous transplantation of haematopoietic stem cells (ahsct) is usually perceived as a fully standardized and safe procedure; however, a minority of patients experience a delayed engraftment and seldom even an engraftment failure, possibly related to a poor quality of the graft. therefore the current policy in many centers is aimed to increase the target dose of collected cd + cells up to an ‛optimal' level of × /kg. plerixafor was introduced in the clinical practice to maximize the mobilization of hsc, in order to collect an optimal number of cd + cells in a limited number of collections also in poor and slow mobilisers. we carried out a retrospective analysis of our case series aimed to individuate mobilization predictors optimize the ‛on demand' use of plerixafor. we analyzed patients who underwent mobilization with cyclophophamide ( g/sqm) and filgrastim mcg/kg from + in our unit from and . diagnosis were multiple myeloma (mm) ( . %), non-hodgkin lymphoma (nhl) ( . %), hodgkin lymphoma (hdg) ( . %) and ( . %) autoimmune disease (ms . %; ssc . %). median age (range) was years ; male/female ratio / . circulating cd + cell count was started at white blood cells (wbc) recovery, which was defined as the first day when their count exceeded × /l. the primary goal was to identify at wbc recovery one or more factors predicting a suboptimal mobilization, which was defined as the failure to exceed cd +/mcl circulating cells in the day after the wbc recovery. patients were excluded from this analysis if ) showed a cd + count /mcl at wbc recovery (very good mobilizers) and/or ) had received plerixafor and/or ) did not proceed to another cd + count the day after wbc recovery. binary logistic regression was used to obtain the factors that increased the odds for an optimal mobilization. overall out ( . %) patients were shown as very good mobilisers as their cd + count exceeded /mcl at wbc recovery. on the remaining , were excluded for the lack of a second assessment and for the lack of data. among the remaining patients, the threshold of cd +/mcl cells on the second day was reached by ( . %) of patients (group a) while the remaining ( . %) failed the goal (group b). median (range) wbc × /l and cd +/mcl counts in group a and b at wbc recovery were . ( - . ) and . ( . - . ) and . ( - ) and . ( - ), respectively, with a statistically significant differences among group (mann-whitney u test with p = . and p = . , respectively). wbc (or = . ; % ci: . - . ) and cd +/mcl (or = . ; % ci: . - . ) in first day count, but not gender, disease category and time from mobilization chemotherapy to first cd + count, were predictors of optimal mobilization. combining these two predictors we found that wbc/cd + ratio has a sensitivity of . % with an auc . in roc analysis. assessment of circulating wbc, cd + and their ratio at wbc recovery in a chemo-based mobilization strategy can predict sub-optimal mobilization of hsc and support the decision of adding plerixafor. these data will be prospectively validated in a broader set of patients. disclosure of conflict of interest: none. human platelet lysate (hpl) is rich in growth factors (gf) and nutritive elements and represents a powerful xeno-free alternative to fetal bovine serum (fbs) notably for mesenchymal stem cell (hmsc) proliferation. however, there is a large variability in hpl preparations (various sources, use of different and non-standardized production protocols, with variable and limited number of donors), resulting in discrepancies in product quality, low management of product safety and poor batch-to-batch standardization. we describe here the development and the characterization of a standardized hpl prepared from outdated transfusional grade screened normal human donor platelet concentrates (pcs), manufactured on an industrial scale (batch size of donors) and following a highly qualified process (clean room, trained operators, validated aseptic filtration). pcs were frozen at − °c and thawed at + °c to lyse platelets. cell debris were removed by centrifugation and the supernatant (hpl) was recovered. clinical grade l batches of aseptic filtered hpl were characterized. first, we showed that hpl prepared from a limited number of donors displayed a variability in terms of gf contents. on the contrary, we observed a robust standardization between industrial batches of hpl ( donors) in terms of gf contents (bfgf, egf, vegf, pdgf-ab, tgf-beta and igf- ), biochemical analyses (total proteins, albumin, fibrinogen, vitamins and iron) and efficacy on bone marrow (bm)-hmsc proliferation. secondly, we compared expansion and functional characteristics of bm-hmscs grown in clinical grade hpl vs msc-screened fbs batches. we showed a reproducible increase in cell growth kinetics using hpl, a maintenance of bm-hmsc clonogenic potential and membrane marker expression (with however a strong overexpression of cd ). we observed a similar adipogenic and osteogenic differentiation potential and finally that immunosuppressive properties of bm-hmscs (inhibition of t-cell proliferation) cultivated in parallel in both conditions also remained identical. finally, we demonstrated the stability over time of hpl stored at − °c and − °c. in conclusion, we demonstrated the feasibility to use a standardized, characterized, efficient and clinical grade hpl for research and cell therapy applications. disclosure of conflict of interest: sv, se, lc, pb, tb, al, fg and bd are employees of macopharma. previously published p alpha/beta t cell depleted donor lymphocyte infusion m karakukcu, e Ünal, l kaynar, s Özcan, g tezcan karasu and mb acar the main objective of this project is to improve a safe and efficient new donor lymphocyte infusion (dli) with depletion of αβ+ t cells which cause graft versus host disease (gvhd), and enrichment of anti-leukemic γδ+ t cells, nk cells and dendritic cells to build an effective and permanent anti-tumor effects for patients relapsed hematological cancers after allogeneic hematopoietic stem cell (hsc) transplantation who have blasts and mixed chimerism. this study is conducted with collaboration of erciyes university pediatric and adult hsct units, and bahcesehir university, medical park hospital pediatric hsct unit. the tcr αβ+ t cell depleted dli product that is used in the study was collected and separated at erciyes university apheresis unit. the cell contents obtained for tcr αβ+ t cell depleted dli used for patients were cd cells were reduced to . - . × cells/kg, γδ+ t cells were reduced to . - . × cells/kg, αβ+ t cells were reduced by . %, and were obtained at - cells/kg. a total of patients ( female, male) were included in the study, consisting of an adult and children. nine patients had hematological malignancies. five patients were referred for all, three for aml, one for mds and one for griscelli syndrome. efficiency: the clinical response to the αβ+ t cell depleted dli treatment was achieved in / patients ( %). in these patients, although the increase of chimerism was limited in patients, no recurrence was occurred. one of the two patients who previously responded to the treatment but experience of decreasing chimerism had relapsed after months, and months later. one of these two patients died after relapse. the other was managed by the second transplant. the most important objective of this study was to show that αβ + t cell depleted dli treatment is reliable. none of the patient showed severe gvhd except one patient with mild grade ii gvhd. despite the presence of severe gvhd after hsct in two patients, reactivation for gvhd was not observed after treatment with αβ+ t cell depleted dli. none of the patients had a bone marrow aplasia. as a result, αβ + t cell depleted dli treatment seems to be highly safe, and effective in selected patients. disclosure of conflict of interest: none. hematopoetic stem cell transplantation (hsct) is associated with several potentially lethal complications; for example, relapse of the malignant disease, graft rejection, infectious complications and graft versus host disease (gvhd). higher levels of cd + cells in the graft have clearly been associated with increased risk of gvhd, but also superior gvl effect and less infectious complications. to tackle post-transplant complications such as graft failure and relapse, donor lymphocyte infusion (dli) have successfully been used for decades but with an associated risk of gvhd. to decrease the risk of gvhd but still use facilitating cells in the cell product we performed αβ depletion of grafts for use as stem cell booster after allogeneic hsct to treat infections or poor immune reconstitution. in this study, patients were infused post-hsct with αβ t-cell depleted grafts. the indication for infusion of αβ t-cell depleted graft in all patients was poor immune reconstitution with associated infectious complications. for all patients, the original hsct donor was used for the αβ t-cell depleted boost. to characterize the αβ-depleted stem cell grafts, samples were stained for various cellular subsets and analyzed by flow cytometry. we could show a median log depletion of αβ cells of . and a median yield of γδ t-cells (%) of . . the median cd + cell dose (× /kg) was . . all patients were alive months after infusion. after year only one patient succumbed. despite that the majority of patients suffered from agvhd grade or before infusion of αβ t-cell depleted graft none showed increased symptoms afterwards. in more than % of the patients there was a increase in granulocytes, thrombocytes and white blood cells months after infusion. in conclusion, we describe the use of αβ t-cell depleted grafts as stem cell booster in patients suffering infectious complications due to graft failure after hsct with encouraging results. disclosure of conflict of interest: none. delayed engraftment or graft failure still remains a concern in bone marrow transplantation (bmt). graft composition may predict engraftment after infusion. this study aims to determine which quality control parameters used for the characterization of bone marrow grafts are the most predictive in order to minimize the risk of engraftment delay or graft failure. we conducted a multicenter retrospective study in pediatric patients who underwent first allogenic bmt at two centers in barcelona (catalonia, spain) between and . quantitative variables considered for the study were: total nucleated cells (tnc), mononucleated cells (mnc), cd + cells, cd + cells and granulocyte-monocyte (gm) colonies enumeration. qualitative variables considered for the study were viability assessed by flow cytometry and clonogenic efficiency of the cd + cells (clonegm) which is the ratio between gm colonies and cd + cells. patients were included (median age (range) were years old ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ). the median tnc(range) was . e /kg ( . - . e /kg) and . e /kg ( . - . e /kg) for mononuclear cells (mnc). on the other hand, the median (range) cd + cell dose was . e /kg ( . - . e /kg) and t-cell dose (cd +) was . e /kg ( . - . e /kg). the median (range) colonyforming unit granulocyte macrophage (gm/kg) dose was . e /kg ( . - . e /kg). the median (range) of cd + cell viability, was % ( - %) and the median(range) of the clonogenic potential of cd + cells (clonegm) was . % ( . - . %). the median (range) of engraftment was days for neutrophils and ( - ) days for platelets. patient was considered as primary graft failure. in the univariate analysis, cd + (p = . ) and mnc (p = . ) cell dose predicted a faster neutrophil engraftment and female donor a slower neutrophil and platelet engraftment (p = . and p = . ). cell viability also correlated to a better platelet engraftment (p = . ). in the multivariate analysis we observed a trend for a faster neutrophil recovery according cd + cells infused. again, female donor was associated with slower engraftment. in order to establish a safety threshold, we did a quartile analysis of cd dose and found . e /kg (quartile ) discriminates a faster neutrophil engraftment [median days vs days for those with higher cd + cells (p = . )]. in conclusion, we found an association between mnc and cd + cell dose and time to engraft, and established a safety threshold of . e cd +/kg. also, bm grafts from female donors were associated with slower engraftment. no other qualitative parameters were predictive of engraftment. disclosure of conflict of interest: none. plasma cell myeloma (pcm) is currently treated with chemotherapy and autologous stem cell transplantation (asct) but relapse rates remain high. adoptive transfer of mature haploidentical natural killer (nk) cells is a promising approach to provide pcm patients with highly immunocompetent effector cells with anti-myeloma function early post transplantation. here we report on the current clinical phase i/ii trial of multiple preemptive infusions of good manufacturing practice (gmp) expanded nk cells to pcm patients (clinicaltrials.gov nct ). ten pcm patients were recruited (seven males, three females, median age: y). all patients received four cycles of vtd chemotherapy (reaching cr: × , vgpr: × and pr: × ) before high dose therapy with melphalan mg/m and asct. after successful stem cell mobilization and cryopreservation of patients' stem cells after the third vtd cycle, nk cells from haploidentical family donors were purified from unstimulated leukapheresis by t cell depletion and nk cell selection using clinimacs. highly pure nk cells (mean: . × cells) were obtained with a minimal t cell contamination corresponding to a . log t cell depletion. nk cells were expanded ex vivo for days in gmp-medium containing autologous irradiated feeder and interleukin- and - . nk cell numbers increased -fold (range: - -fold). in three nk cell products t cell contents were × cells/kg body weight (bw: × above limit of clinical trial) and were successfully reduced by °cd -depletion to . × cells/kg bw. nk cell products were cryopreserved in escalating doses ( . × , . × and rest as multiple doses of maximal . × cells/ kg bw). the pcm patients received - × expanded nk cells (median: . × cells/kg bw, range: . - . × cells/ kg bw) as - infusions (median. dlis). the nk-dlis were administered between day and after asct and were well tolerated without any acute adverse events. no signs of acute or chronic graft-versus-host disease were observed in any of the patients after a total of nk-dlis. engraftment occurred between days - (median: days). infused donor nk cells were monitored by short-tandem repeats pcr. donor nk cells were detected in peripheral blood one and h post infusion (% donor nk of enriched blood nk cells: mean: %, range: - %, and mean: %, range: - %, respectively) indicating significant nk cell survival in recipients in the absence of il- support in vivo. clinical responses at last follow-up compared to a retrospective cohort of matched control patients will be presented. these results demonstrate the feasibility of large-scale gmp expansion and safety and immunotherapy with third-party leukemia-specific t cells (leuk-sts) represents an attractive approach for acute leukemia (al) patients lacking a fully matched donor or relapsing after allogeneic hematopoietic cell transplantation (hct). its application however, is limited by the demand for high numbers of antigen presenting cells (apcs), capable to produce clinically relevant numbers of leuk-sts. low volume, non-transplantable cord blood units (cbus) could theoretically serve as an easily accessible source to generate high numbers of dendritic cells (dcs) and subsequently leuk-sts, providing also the advantage of reduced alloreactivity, even in cases of partial matching. our goal was to generate clinically relevant doses of leuk-sts targeting al-related antigens, the wilms tumor protein (wt ) and the preferentially expressed antigen in melanoma (prame), through the exploitation of non-transplantable cbus. to generate dcs, immunomagnetically enriched cd + cells from cbus ⩽ ml were cultured in g-rex devices in the presence of scf, gm-csf and il- . dcs matured by toll-like receptor ligand and / were immunophenotypically characterized by flow cytometry (fcm). secreted cytokines were measured with elisa. matured dcs were activated with a peptide-mix of wt and prame and used as apcs to repeatedly stimulate naive t-cells (derived from the cd fraction of the same cbu). the phenotype and the specificity of generated leuk-sts were determined by fcm and ifn-γ/ elispot, respectively. starting from mean . × ± . × cd + cells, from non-usable cbus, we generated . × (range: . - . × ) myeloid dcs (cd +/cd c+: . ± . %) in days (fold change~ . ). the produced cells highly expressed maturation markers (cd +/cd +: ± %; cd c+/hla-dr+: ± %) and secreted high levels of th cytokines (Ιl- : ± pg/ml; il- : . ± . × pg/ml, tnf-α: ± pg/ml) and low levels of the th -cytokine, il- . the average number of cd -cell-derived leuk-sts after week-culture was . ± . × (~ logs above clinical doses). the produced cells were enriched in cd + polyclonal cells ( ± %), comprising of cd + ( ± %) and predominantly cd + cells ( ± %), expressing effector memory (cd ra − /cd l − : . ± %) and effector memory ra markers (temra: cd ra+/cd l − : ± %), while containing insignificant numbers of cd +/cd +cells ( ± . %). specificity was seen after the second stimulation at the earliest and was increasing after each stimulation [mean spot forming cells (sfc)/ × cells at second, third, fourth stimulation: ± ; ± ; ± ; respectively]. in particular, produced cells were highly specific for both targeted antigens (prame: ± , wt : ± ), while they expressed low the programmed cell death protein- (cd +/pd- +: ± %), implicating absence of cell exhaustion after repeated stimulations. we report a paradigm of ‛circular economy' in science, by the exploitation of non-usable cbus, towards scalable generation of cb-cd +-cell-derived dcs and cb-cd -cellderived leuk-sts from the same cbu and establishment of leuk-sts banks. whether similarly produced leuk-sts could significantly advance the treatment of al or leukemic relapse after hct, will be ultimately determined in vivo. disclosure of conflict of interest: none. comparison of two different methods to generate antifungal-specific t-cells under pre-clinical-scale conditions r geyeregger , s tischer , invasive infections with aspergillus fumigatus constitute a major cause of morbidity and mortality in immunocompromised patients after haematopoietic stem cell transplantation. although adoptive immunotherapies against viral pathogens are already in phase i/ii trials, clinical-grade methods for the generation of aspergillus-specific t-cells (asp-t-cells) from healthy transplant donors or even related or unrelated thirdparty donors are still under development. in this study, two different strategies interferon-gamma (ifn-g) cytokine capture system (ccs) vs short-term in vitro expansion (ste) were performed from the same healthy volunteers in order to evaluate the most suitable approaches for the in-time generation of clinical applicable asp-t-cells. pbmcs from leukapheresis of healthy donors (n = ) were first prepared in hannover for the ifn-g-ccs and then sent to vienna to prepare the ste. all donors belong to the allocell registry (www.allocell.com) of hannover medical school and the frequency of asp-t-cells was pretested by high-throughput ifn-g elispot assay. for the ifn-g-ccs, × cells were stimulated for h with gmp-conform aspergillus lysate followed by magnetic selection of ifn-g-producing t cells. cells were characterized for phenotype and function by multicolour flow cytometry. for the ste, × cells were cultured in g-rex devices and stimulated for days with either the aspergillus lysate alone or with pooled overlapping pepmixes (catb, crf , f , gel , pmp , shmt and sot) and il- . to further characterize the final cell products, multicolour flow cytometry, ifn-g elispot and ifn-g/granzyme b flurospot analyses were performed. ifn-g-ccs: frequency of ifn-g positive asp-t-cells pre-magnetic enrichment ranged between . and . %. recently we defined t-cell donors as eligible if ⩾ . % specific ifn-g+ t cells are detectable. the purity of asp-t-cells among cd + cells, obtained from three donors after magnetic selection was in mean % ± (range: - %). the absolute number of selected ifn-g+ cd + t-cells was ± . this could be approximately multiplied by a factor of , if × pbmcs are used for the generation of clinically applicable t cells using the ccs and the prodigy device. ste: after days, asp-t-cells (n = ) showed highly specific activity against the lysate (in mean ± spot forming colonies (sfc)/ cells) and pooled pepmixes (in mean ± sfc/ cells). in both methods (lysate vs pooled pepmixes), predominantly cd + t-cells were expanded ( % ± . vs % ± . of cd +) compared to cd + t-cells ( . % ± , vs . % ± . ). interestingly, whereas after ste, cd + t-cells include mainly central memory t-cells (mean %; cd l+cd ra − ), cd + t-cells include mainly effector memory t-cells ( %; cd l − cd ra − ). generated t cells were highly functional and cytotoxic as determined by the secretion of effector molecules granzyme b and ifn-g. based on the purity of up to % after the ifn-g-ccs and the high number of sfc received after ste with lysate and pepmixes, both methods seem to be suitable for clinicalscale productions. for patients who are in need for high asp-tcell numbers the application of first in-time ccs-purified asp-t-cells followed by the administration of ste cells might be a promising way to boost antigen-specific t-cell response. disclosure of conflict of interest: none. complete computerization of cell therapy product files (‛zero paper') in the qap software o christéle , r catherine , r aline , k mathias , m lavinia , d vincent , m jean-pierre and l marie-noelle , hematologie clinique et thérapie cellulaire-chu amiens picardie, simedia-ver, hématologie clinique et thérapie cellulaire-chu amiens picardie, simédia-ver, direction système informatique-chu amiens picardie, hématologie clinique et thérapie cellulaire, lacassagne and the computerized management of cell therapy products (ctp) is an obligation for processing laboratories to meet regulatory requirements. the software used is often independent of institutional systems in view of the specificity of cellular therapies and do not always allow the implementation of the ‛zero paper' policies that are being put in place. we report here our experience with the qap software (quality assurance partner) developed by the company simédia (www. qap .com) in open source (mit license) allowing the management of fully computerized ctp files. the qap software has been developed to ensure the traceability of ctp for both preparation and quality control by combining the product preparation environment (personnel, premises, reagents, consumables, equipment). initially, with the help of the company simédia, we parameterized the software in accordance with our procedures for the preparation and quality control of ctp. we built a file that we printed out for archiving on paper. it soon seemed necessary to reverse this mode of operation to add to the software the documents papers to obtain a file completely computerized and to avoid paper archiving. the close collaboration between the cell therapy laboratory staff, the software referent within the information system department of the amiens hospital and the company simédia enabled: set up a document backup server sufficiently proportionate in memory. have simedia carry out the necessary developments so that all documents can be integrated into the software, set up a coherent working circuit, organize the registration of documents, put in place a rigorous verification of the mandatory elements of the file. the reflection on the computer file made it possible to evolve the software to widen its use to all documents of management of the laboratory: maintenance of equipment, control of premises, housekeeping, staff training, quality control of automatons, reagents and consumables, process, reception, distribution. rigorous formalization was mandatory to ensure that the record was organized in a uniform manner. an intermediate paper record is still necessary for a period of about month: from the programming of the graft to the final validity of the injected product. this folder consists only of transient elements that cannot be integrated into the qap software immediately. the transition from the paper file to a computer file took place in several stages, calling into question our functioning. the difficulties of this implementation are of several natures: the heterogeneity of the documents components a cell therapy product file, the impossibility of benefiting from an interface between all computer software used on the hospital, the psychological barrier prompting us to keep a paper copy, work habits, the guarantee of computer backup quality as well as its verification. but the complete computerization of the ctp file has the following advantages: easy and secure accessibility of information, resolution problems archiving paper files, a single backup media folder. disclosure of conflict of interest: none. conditioned media from allogenic mesenchymal stem cell culture (msc-cm) enhances wound healing in an allogenic d skin model moyasasr al-shaibani, x wang , p lovat, a tulah and a dickinson newcastle university migration of the epidermal layer towards the wound centre is an important step in the healing process. full thickness in vitro skin models can be used to investigate epidermal migration towards an injury site. since wound healing therapies often require allogenic transplantation of primary keratinocytes, an allogenic d skin model was developed to investigate epidermal migration. the effect of mesenchymal stem cell conditioned media (msc-cm) was assessed for wound healing using this in vitro human d skin model. human mscs were derived from human hip joints, and characterised using standard protocols. at % confluence, msc secretions were collected in serum free medium and referred to as msc-cm which were then analysed for protein content using elisa. fully humanised allogenic d skin models were developed (n = ) and a mm punch was induced into each model followed by daily treatment with msc-cm to investigate the migration of the epidermal layer towards the punch centre over the dermal layer at different time points ( week, weeks, and weeks). intact and wounded models were characterised structurally by haematoxylin/eosin (h&e) staining and immunofluorescence (if) was used to validate the dermal and epidermal biomarkers such as collagen (col ), cytokeratin (k ), keratin (k ), loricrin and involucrin. mscs were characterised as stipulated by the international society for cell therapy, that is, fibroblast like cells with the ability to differentiate into tri-lineages (adipocyte, chondroblast and osteoblast). phenotypically, over % of the cells were able to express phenotypic markers for variant stem cells such as cd , cd and cd . over % of the cells were negative for the expression of cd , cd , cd , cd and hla-dr (p = . ). msc-cm contained different concentrations of a variety of growth factors such as keratinocyte growth factor (kgf), hepatocyte growth factor (hgf), platelet-derived growth factor (pdgf), stromal-derived factor- (sdf- ) and macrophage stimulating protein- (msp- ). h&e staining showed that the models had distinct dermal and epidermal layers similar to that of real skin. additionally, if showed that the models expressed dermal and epidermal biomarkers, for example, col , k , k , loricrin and involucrin. after treatment with msc-cm, the epidermal multilayers of the punched models started to migrate towards the punch centre and covered the whole punched area after weeks of treatment with recovered expression of the epidermal biomarkers, for example, k , k , loricrin and involucrin. a fully humanised allogenic d skin model is a useful tool to mimic the in vivo environment and evaluate the wound healing process. it could also be used as a screening method to test candidate wound healing drugs. allogenic keratinocytes could be used as a cellular sheet to cover the wound area with the ability to migrate towards the wound centre and promote wound healing. a possible explanation for promoting epidermal migration at the injury site is that msc-cm contains cytokines which accelerate cell migration such as kfg, sdf- and msp- , in addition to other cytokines which promote both migration and proliferation of epidermal cells, for example, hgf and pdgf. disclosure of conflict of interest: none. before each freezing and after each thawing, a quality control is performed including a minima: (i) cd + quantification; (ii) estimation of the percentage of hsc cd + viability, via aminoactinomycin-d ( -aad) staining and (iii) evaluation of hsc functional ability to form colony ‛cfu-gm' (colony forming unit-granulocyte macrophage). apoptosis, or programmed cell death, involves complex pathways in part the path fas-fas ligand (fasl), mitochondrial components and caspase enzymes. the involvement of apoptosis dependent on caspases activation pathway in hsc cd + after thawing remains unknown. here, we assess the extent of apoptosis caspase-dependent before and after cryoconservation of hsc cd +, using a fluorescent labeled inhibitor of caspases ‛flica. ' we tested the induction of apoptosis caspasedependent, before and after hsc cd + cryoconservation from patients with different hematological malignances: multiple myeloma (n = ), lymphoma (n = ). caspases pathway activation status was evaluated by flow cytometry, using a fluorescent labelled inhibitor of caspases ‛flica' staining test, in hsc cd +, lymphocytes cd +, monocytes cd + and natural killer cells cd +. in order to assess cell viability, cells were stained in parallel with -aad. we determined positive cells %, that is, showing caspase activation in viable cells (flica+ cells), before and after cryoconservation. caspase pathway activation level was then correlated with hsc functional ability to form colony ‛cfu-gm,' and day's number of clinical aplasia. in our cohort, we showed a significant caspases pathway activation, with . % cd + flica+ cells after thawing, compared with the . % described in fresh cd + cells (p o . ). moreover, caspases pathway was significantly activated in thawing cd +, cd + and cd + cells: flica+ cells % in thawing cells were, respectively, . %, . % and . % vs %, . % and o % in fresh cells. we also report a significant increase of apoptosis caspasedependent in lymphoma patients ( . % of cd + flica+) in comparison to myeloma patients studied ( . % of cd + flica+) (po . ). in contrast, no correlation has been established between observed caspases pathway activation and hsc cd + capacity to form cfu-gm, or still day's number of clinical aplasia. our results show substantial cell death, induced by the increase in caspases pathway activation, secondary to the thawing process, and across all study cell types. this advance of apoptosis caspase-dependent may affect the immune response quality during recipient aplasia, without detecting a clinical impact. moreover, caspases pathway activation through cd + and cd + subpopulations could modify the therapeutic result of donor lymphocytes infusion dli, though yet untested. thawing process in autologous graft induces apoptosis caspase-dependent in all apheresis product cells, particularly in hsc cd +, without clinical impact in graft fate. disclosure of conflict of interest: none. donor-derived nk cell infusion combined with hla halpoidentcial blood stem cell transplantation to decrease leukemia relapse for high risk acute myeloid leukemia patients b wu, y huang, j xu, y he, jxm zhang*, z wu* hematology department, zhujiang hospital of southern medical university, guangzhou, china *shenzheng hank biologoical engineering co.ltd. hla halpoidentcial blood stem cell transplantation have solved the donor deficiency for patient who need to treat by transplantation. the high relapse of leukemia especially for high risk patient post transplantation affect the outcome of haploidentical stem cell transplantation. natural killer (nk) cells are part of the innate immune system and play a scavenger role to detect targets marked by ‛missing self' induced by viral infection or malignant transformation. infusion nk cells into receipt prior to stem cell transplantation could decrease the gvhd in mouse bone marrow transplantation model. in an effort to decrease the leukemia relapse and gvhd after halpoidentical stem cell transplantation for high risk acute myeloid leukemia patients, we evaluated the addition of donor-derived nk killer cells before halpoidentical stem cell transplantation in high risk acute myeloid leukemia patient. here we report interim results for five patients enrolled last year. five high risk acute patients received halpoidentcial stem cell transplantation combined with donor-derived nk cells infusion. all patients received an fbca conditioning regimen, which consisted offludarabine ( mg/m /day, intravenous) on days − to − , busulfan ( . mg/kg/day, intravenous) on days − to − , cyclophosphamide( mg/kg/day, intravenous) on days − to − and rabbit antilymphocyte globulin (atg . mg/kg/day, intravenous) on days − to − . donor-derived nk cells were infused into patient prior to stem cell transplantation. gvhd prophylaxis was a combination of cyclosporine a (csa) and short term methotrexate. five high risk patients ( patients with aml m cr , patient with aml m nr, patient with aml m cr and patient with aml m cr ) enrolled from jan to nov. ; the donors are parents and sibling. hla were mismatched between donor and patients. median cd + dose infused was . /kg (range: . - /kg) and the nk cell dose infused was × /kg ( . - . × /kg). all five patients got hematology recovery and achieved hematology cr. only one patient occurred grade ii agvhd post transplantation and controlled by methylprednisolone. at a median time of months (range: - months) post peripheral blood stem cell transplantation, the incidence of acute gvhd grade ii is % ( / ) . no chronic gvhd observed. four patients are still cr and survival with event free survival with median year follow up. one patient with aml m who had not achieved remission before transplant relapsed after months and got cr with second nk infusion and still survival. nk infusion prior to transplantation was found to be safe and feasible. there was no increase acute gvhd or chronic gvhd risk. there was a trend towards increased -year survival for high risk leukemia patient. the potential benefit on overall survival remains to be further evaluated with additional patient enrollment and longer follow up. however, given the favorable safety profile of nk cells, future strategies to enhance efficacy such as repeat dosing or modification of nk cells are worth potential exploration. disclosure of conflict of interest: none. donor lymphocyte infusion (dli) is a therapeutic option in the treatment or prevention of relapse after allogeneic stem cell transplantation (allohsct).of note, the risk of graft-versus-host disease (gvhd) associated with the graft-versus-tumor (gvt) effect may be influenced by the level of hla disparity between donor and recipient. data on use of dli after unmanipulated haploidentical hsct (haplohsct) with post-transplant cyclophosphamide (pt-cy) are still currently limited. we report patients (pts) receiving dli between and for prevention or treatment of relapse after haplohsct. seven pts were given haplodli doses, as treatment for relapsed disease (n = ) or as preventive therapy of relapse for high risk disease (n = ). four pts had acute myeloid leukemia (aml), had acute lymphoblastic leukemia and lymphomas - hodgkin (hl) and non-hodgkin dlbcl. pt had intermediate risk disease features, adverse risk and pts had refractory disease at time of haplohsct. pts had a previous hsct ( allogeneic and autologous). of the pts received a ric regimen and the source of stem cells was peripheral blood s (n = ) and bone marrow (n = ). gvhd prophylaxis was cyclosporine and mycophenolate mofetil (mmf), atg and pt-cy. median follow-up after haplohsct was (range: months. median time to neutrophil and platelet ( g/l) recovery were and days, respectively. after haplohsct, pts developed acute gvhd (agvhd) of grade i (n = ) or ii (n = ), at a median of days after haplohsct. the median time from haplohsct to first dli was days (range: - ). all pts had full donor chimerism at time of dli. before dli pts relapsed at a median time of days (range: - ), of whom pts had aml and received salvage chemotherapy and pt with hl being treated by dli alone. of the relapsed pts, showed progressive disease after first dli dose and achieved a sustained cr (with duration of cr of and months at last follow-up). the remaining pts were given dli in cr, in case (of aml) associated with azacytidine. pts received dli dose and pts were given dli injections with escalating doses. the first dose of dli was × cd /kg in pts, × in pt and × in pts. the pts who received dli doses (lymphomas) were given: ( ) × - × - × ; ( ) × for doses followed by dose of × . four pts developed chronic gvhd (cgvhd, %) in a median time of days (range: - ) after dli ( of them had presented previously agvhd grade i-ii). cgvhd was limited in case, moderate in pt and severe in pts. of these pts presented features of an overlap syndrome (acute/chronic gvhd) with signs of agvhd de grade i,ii and iii in pt each. involved organs were skin/mucosal (n = ), liver (n = ), gastrointestinal tract (n = ), lung (n = ) and joints (n = ). all patients experiencing gvhd after dli were treated by systemic corticotherapy, extracorporeal photopheresis and cyclosporine or weekly low dose methotrexate. median follow-up after first dli was months (range: . none of the pts receiving prophylactic dli relapsed during the follow-up period. pts died, of relapse and of severe cgvhd. pts were in cr at last follow-up, with no signs of gvhd and with limited cgvhd. despite the limited cohort, dli after haplohsct appears to be a therapeutic option in high risk pts allowing enhancement of gvt in the setting of haplohsct with post-cy infusion. disclosure of conflict of interest: none. previously published p early and sequential ctla ig primed donor lymphocyte infusions (dli) following post-transplantation cyclophosphamide (ptcy)-based haploidentical pbsc transplantation for advanced hematological malignancies promote proliferation of mature natural killer (nk) cells with cytotoxic potential and markedly reduces relapse-risk without increase in gvhd sr jaiswal, s zaman, p bhakuni, s bansal, s deb, s bhargava and s chakrbarti we have earlier shown that cd enriched cell infusion following ptcy resulted in rapid proliferation of mature nk cells with attenuation of gvhd and early use of prophylactic g-csf mobilized dli resulted in improved disease-free survival. ctla ig has been shown to be effective in attenuating t cell activation and induce transplantation tolerance in preclinical models. it has recently been employed to induce transplantation tolerance and reduce early alloreactivity in patients with nonmalignant disorders undergoing ptcy-based haploidentical hsct. nk cells on the other hand are resistant to ctla ig and in fact might demonstrate better anti-tumour effect in presence of ctla ig as cd is a putative activation receptor. to explore this phenomenon, we employed sequential ctla ig primed dli following ptcy-based haploidentical hsct in patients with relapsed/refractory hematological malignancies. patients ( - years; aml- , all- , nhl- ) received abatacept (ctla ig) as a part of gvhd prophylaxis at mg/kg on day − followed by pbsc and sequentially on days + , + and + followed h later by dli of × cd cells/kg containing . - × /kg cd + cells. ptcy was administered on days + and + with cyclosporine from day + to day + and subsequent rapid tapering. the immune reconstitution of the study group (ctla ig-dli) was compared with the cohort of patients with both malignant and nonmalignant diseases who received abatacept but not dli (n = ; ctla ig group) and those receiving cd enriched donor cell infusion on day + (n = ; nki group). results: there were no acute infusion related toxicities. all patients engrafted at a median of days ( - days). the incidences of acute and chronic gvhd (all mild) were % and %, respectively. three patients reactivated cmv and there was only one non-relapse mortality ( . %). only patients relapsed ( . %) with a disease-free survival of . % at year. these cells had greater expression of cd a compared to normal healthy donors. the recovery of cd +, cd + + and cd + − cells were similar in the ctla ig-dli and nki groups at days , and post-transplant and this was significantly higher than the ctla ig group ( figure ). in contrast to ctla ig group, nk cells recovered at day + with predominantly cd dim cd + phenotype with significant population of cells expressing kir+nkg a phenotype in both ctla ig and nki groups with higher expression of cd a. interestingly, the patients who relapsed had attenuated recovery of cd + + cells at and days( /μl and cells/μl) without cd a expression, in contrast to the rapid and sustained recovery of this population of nk cells in those not experiencing relapse (cd + + cells /μl and /μl). however, the recovery of tregs was prompt and sustained in the comparator groups, which remained low in the ctla ig-dli group until day + . there were no differences in the recovery of other t cell subsets between the three groups. the study demonstrates the unique ability of ctla ig to augment nk cell proliferation, maturation and cytotoxicity and reduce relapse with attenuation of t cell activation and gvhd in the context of the early use of ctla ig primed dli following ptcy-based haploidentical hsct without ex vivo selection or expansion. we hope this novel strategy might offer less expensive and yet a viable alternative in the field of nk cell therapy. [p ] disclosure of conflict of interest: none. enhanced cytotoxicity of γδ-cytokine induced killer cells against hematologic malignancies n bloom, s eldror, s caspi, s teihuman,h vernitsky, e jacoby, b bielorai and a toren cik cells are ex vivo expanded by scheduled addition of anti-cd mabs and a cytokine cocktail that contains ifn-γ, il- or il- . cells represent an in vitro generated heterogeneous population consisting of different effector cells-cd poscd pos, cd negcd pos and cd poscd neg-t cells that mainly ( %) express α/β t-cell receptor (tcr) s and to a lesser extent (o %), tcr γδ phenotype. these nklike t cells product show a dual functional activity, retaining their original t cell specificity and nk cytotoxic capacity via marked up regulation of the nk cell receptor, nkg d. pre and clinical studies showed that the optimal cytotoxic effect of cik cells against different malignancies (target cells) is achieved at : e:t ratio, which means high numbers of αβ t-cells that might increase the risk of gvhd. here we produced ciks from αβ tcr depleted cellular products (defined as γδcik) and tested their phenotype expression and in vitro cytotoxic activity against hematological malignancies. fresh apheresis products were processed using the clinimacs depletion reagent, according to manufacturer instructions. target product was cultured with rpmi supplemented with % fcs and ex vivo expanded by scheduled addition of cytokine cocktail that contains ifn-γ ( iu/ml), anti-cd mabs ( ng/ml) and iu/ml il- . the cells were cultured for days. cytotoxic activity of the γδcik was evaluated against various target hematological malignant cell lines (k , reh, jurkat, and u ). after days, the αβ depleted cik cultures resulted in . % γδ t-cells ( folds expansion) compared to . % of γδ t-cells immediately after depletion, and compared to only . % in non-selected cik cells. the percentage of αβ t cells in γδcik cell cultures started from . % (immediately after depletion) to . % compared to . % αβ t cells were found in non-selected cik cells cultures. γδcik cells produced robust cytotoxic activity at a : e:t ratio against reh cells ( . ± . %), jurkat cells ( ± . %); u ( . ± . %) and k ( . ± . %), compared to nonmanipulated cik cell activity against the same targets ( ± . %; . ± . %; . ± . %; . ± . %, respectively). we found higher degranulation capacity of γδcik cells compared to non-selected cik cells against reh ( . ± . % vs . ± . %), jurkat ( . ± . % vs . ± . %), u ( . ± . % vs . ± . %) and k ( . ± . centre de thérapie cellulaire, institut paoli-calmettes; unité de transplantation et de thérapie cellulaire, institut paoli-calmettes; centre d'immunologie de marseille-luminy and laboratoire d'immunomonitoring, institut paoli-calmettes during the past years, the major improvements in the field of allogeneic hematopoietic stem cell transplantation (hsct) (reduced intensity conditioning regimen, high level hla typing, alternative donors, gvhd prophylaxis…) significantly extended the feasibility of this procedure. in contrast, disease recurrence after hsct remains a main issue. thus, many post-hsct prophylactic interventions are under investigation. unmanipulated donor lymphocyte infusion (dli) remains one of the most frequently used post-hsct treatment, but its potential benefit in increasing gvl effect may be counterbalanced by the induction of gvhd. in this setting, the use of adoptive transfer of ex vivo enriched and activated nk cell infusions from the same donor (dli-nk) may induce gvl effect without causing gvhd. we therefore report on a single-center phase clinical trial (nct ) evaluating the safety of ex vivo activated allogeneic nk cells infused between days and after hsct. the aim was to determine the maximum tolerated dose (mtd) of ex vivo highly purified and activated dli-nk after matched related donor hsct. the schedule plan a first phase of + dose escalation method using dose levels ( . e /kg, . e /kg and . e /kg). grade - secondary adverse events according to nctci classification and severe gvhd occurring within days after dli-nk were considered as dose-limiting toxicities (dlt). a second step allowed enrolling patients at the mtd. over a period of . years, patients with various hematological malignancies (aml, all, hl, nhl, mds) were infused with activated nk cells at a median time of days (range: - ) post-hsct. apheresis products were collected from the hsc donor, cd -depleted and cd -selected by immunomagnetic separation using clinimacs. selected nk cells were cultured for days in medium supplemented with % fetal calf serum in the presence of u/ml of il- in air-permeable cell culture bags. after immunomagnetic separation, cd enriched products had a median cd + cell purity of % (range: - ) and viability of % ( - ). after il- activation, the median cd + cell dose was . × e /kg ( . - . ) , with a viability of % ( - ) and a residual cd + cell content of . × /kg ( - . × /kg). all release criteria to be met were fulfilled for the preparations infused : viability %, negative microbiological testing, cd + cell count ⩾ × /kg, and cd + cell content o × /kg. standardized quality controls were employed at all steps of the manufacturing process, adding a level of consistency to the product testing before release. activated-nk cells were well tolerated in all patients, with no occurrence of dlt. thus, mtd was not reached. two patients presented with a moderate chronic gvhd, both of them during cyclosporine a dose reduction. relapse occurred in patients with aml. one patient died from idiopathic pneumoniae, without evidence of relapse, gvhd or infectious disease. with a median follow up of months ( - ), year os was % ( figure ). therefore, infusion of highly purified, activated-nk cells of donor origin as a substitute to standard dli does not induce gvhd nor other side effects after hsct: the demonstration that modulation of nk cell activity can achieve disease control after hsct deserves to be investigated in larger trials. [p ] disclosure of conflict of interest: none. feasibility, safety, rapid production and efficacy of institution-produced cd car staff were trained on site for collection, processing and cryopreservation by regional experts. a total of units were collected and processed as part of the initial validation of the project. ucb units were processed on either axp or sepax systems, and all cryopreserved in bioarchive (an automated, robotic cryopreservation system that can archive up to units). the characteristics of which as well as the post processing data are depicted in table . [p ] we shared a successful story of establishing the first public cord blood bank in jordan. the first units collected showed excellent sterility, viability, collection volume and total nucleated cells. a very good recovery of both nucleated and cd + cells were obtained using axp and sepax cell separation systems. the process of validation of equipments and methodology is complete. we anticipate moving to permeant facility of the cord blood bank in the new expansion in early . we look forward for steady progress in ucb recruitments, hla typing, cryopreservation and adherence to netcord-fact standards as well as participation in international registries. functionally active ifn-gamma secreting cmv pp specific t cell therapy as an alternative for clinically urgent cmv related diseases n kim, y-s nam , k-i im , j-y lim, y-w jeon , y song and s-g cho the catholic university of korea, seoul cytomegalovirus (cmv) related diseases are a serious cause of morbidity and mortality following hematopoietic stem cell transplantation (hsct). it has been reported over the last two decades that cmv-specific cytotoxic lymphocytes (cmv-ctls) can provide long-term cmv-specific immunity without major side effects as an alternative to antiviral drugs. however, its application has been limited by prolonged manufacturing process of cell therapy. in this study, we apply the ifn-γ cytokine capture system (ccs) using the fully automated clinimacs prodigy device to rapidly produce cmv-ctls that may be applicable in clinically urgent cmv-related diseases. five validation runs were performed using apheresis samples from randomly selected cmv-seropositive healthy blood donors. then, clinimacs prodigy automatically performed successive processes including antigen stimulation, anti-ifn-γ labelling, magnetic enrichment, and elution which took~ h. the original apheresis samples consisted of . % ifn-γ secreting cd + t cells in response to cmv pp antigen (cd +ifn-γ+ cells) which were mainly cd ra+cd l+ naive t cells. following ifn-γ enrichment, the target fraction contained . % cd +ifn-γ+ cells with reduction in naive t cells and the selection of cd ra − cd l − and cd ra +cd l − memory t cells. furthermore, extended culture of these isolated cells revealed functional activity including efficient proliferation, sustained antigen-specific ifn-γ secretion and cytotoxicity effect against pp pulsed target cells. therefore, we suggest ifn-γ ccs by clinimacs prodigy as a simple and robust approach to produce cmv-ctls, which may be highly feasible and applicable in clinically urgent cmvrelated diseases. disclosure of conflict of interest: none. in vitro generation of tumor antigen-specific t cells from patient and healthy donor stem cells s bonte , s snauwaert , g goetgeluk , b vandekerckhove and t kerre hematology, ghent university hospital, ghent, belgium and department of clinical chemistry, microbiology and immunology, ghent university, ghent, belgium acute myeloid leukemia remains a therapeutical challenge, as many patients relapse after chemotherapy. allogeneic stem cell transplantation is in most of these patients the only option for cure, but carries a high risk of morbidity and mortality and a suitable donor may be lacking. recently, advances are being made in the field of t cell immunotherapy. the classical protocol, in which peripheral blood lymphocytes (pbl) are transduced with a tumor antigen-specific t cell receptor (tcr), can generate t cells with low and possibly hazardous specificities (due to mispairing of the endogenous and introduced tcr α and β chains). therefore, we have developed a novel protocol in which we generate tumor antigen-specific t cells from cd + hematopoietic stem cells. we have already succeeded in generating large numbers of tumor-specific, naive and resting t cells that only carry the introduced tcr, starting from postnatal thymus and cord blood cd + cells. now we are optimizing this protocol for clinically more relevant samples, such as mobilized peripheral blood from healthy stem cell donors and from patients in remission after chemotherapy and/ or other treatments, and leukapheresis samples from patients at diagnosis. in our protocol, cd + cells were isolated from hla-a + fresh patient and healthy donor samples and cultured on op -dl in the presence of scf, flt l and il- , until t cell commitment. subsequently, the cells were transduced with a tumor antigen-specific tcr and again co-cultured until cd + cd + double positive cells were abundantly present. at that point, agonist peptide was added, which induces maturation. finally, cells were polyclonally expanded on feeder cells. for hla-a negative samples, cd + cd + double positive cells were co-cultured with a cell line (t pulsed with the agonist peptide or a cell line with endogenous expression of the agonist peptide) which can present the agonist peptide to the maturing t cells. using the above protocol, we were able to generate tumor antigen-specific t cells from out of healthy donor samples, / sample from a patient in remission and / samples from patients at diagnosis, who were all hla-a +. for most samples, multiple rounds of agonist peptide stimulation were necessary to obtain further maturation. in contrast, generation of mature t cells from cd + cd + double positive cells in postnatal thymus or cord blood co-cultures, requires only round of agonist peptide stimulation. for the hla-a negative samples, we were able to generate an adequate cd + cd + double positive population from / healthy donor sample, / samples from patients in remission and / sample from a patient at diagnosis. agonist selection using a cell line seems inefficient as cd is not upregulated and cells did not mature to cd + or cd + single positive mature t cells. we are currently co-culturing more samples using our protocol. furthermore, we are investigating the effect of freezing and thawing on the in vitro t cell generation process (cell numbers and efficiency). finally, we are also working on optimizing the protocol for generation of tumor antigen-specific t cells from hla-a negative patient and healthy donor samples. disclosure of conflict of interest: none. increase of polyspecific immune responses against leukemia-associated-antigens (laa) and reduction of regulatory cytotoxic t-cell (ctl) responses against malignant cells play a major role in maintaining remission and prolonging overall survival in patients with hematologic malignancies after allogeneic stem cell transplantation (allo-sct) and/or donor lymphocyte infusions (dli). graft versus leukemia (gvl) effects after allogeneic stem cell transplantation and/or dli are considered to be t cell-mediated. many groups described specific t-cell responses against several leukemia associated antigens (laa) in different hematological malignancies. however, t cell responses after allo-sct and dli are not well characterized. in this study, we analyzed laa-specific t cell responses after allo-sct and dli. to this end, we assessed the frequency and diversity of laa-specific cd + t cells using elispot analysis and tetramer assays in patients ( patients (pts) with acute myeloid leukemia, pts with chronic myeloid leukemia, pts with multiple myeloma and pts with chronic lymphatic leukemia) before and after dli. epitopes derived from prame, npm mut, rhamm, wt- and other laa were tested. moreover, the frequency of regulatory t (treg) cells was measured and the course of cytokine profiles before and after dli was analyzed. these immunological findings were correlated to the clinical course in the respective patients. in elispot and tetramer assays, an increase in frequency and diversity of laaspecific t cells was observed in all patients. importantly, there was a significant increase from a median of to laa-derived t cell epitopes (p = . ) in clinical responders (r) when compared to non-responders (nr). these positive results in r vs nr where s confirmed by tetramer-based flow cytometry assays, where an increase in frequency from . to . % in the r group of laaspecific t cell/all cd + t cells was observed. interestingly, the frequency of tregs in clinical responders decreased significantly from a median . % to . % (p = . ) while the frequency of tregs kept stable over time in non-responding patients. t cell subset analysis did not reveal significant differences before vs after dli administration. in cytokine assays using elisa for the detection of more than cytokines before and after dli we found a shift towards proinflammatory and t cell stimulating cytokines. taken immunologic surveillance of leukemia is employed for the prevention and treatment of relapse post allohsct. to augment this effect donor lymphocytes are infused (dli) in patients at risk. this procedure is associated with a high risk of agvhd and we believe that this route of administration may not make the direct contact between infused cells and blasts the optimal one. to address these issues, we started delivering donor lymphocytes directly to the bone marrow cavity (ib-dli) in patients post allohsct at relapse. three with aml and one with cll, all relapsed post allohsct: allosib: -year-old female aml patient (relapsed years post hsct), -year-old aml male q del (relapsed in years, traumatic brain injury), -year-old male aml flt itd+ received mud hsct (relapsed months) and -year-old cll male, tp del, ebv reactivation (progressed years). two patients ( % and % blasts in the marrow) received ib-dli up-front and two others due to higher proportions of leukemic cells received either flag (aml case) or anti-cd moab (cll case) followed by ib-dli. tcr clonotyping revealed in all patients the presence of the prevailing oligoclonal response on the polyclonal background (characteristic for each individual) which was identified in the marrow and in the blood. however, in two out of patients a distinct oligoclonal peak was seen at first in the marrow and then in the blood. microarray analysis of the transcriptome in the marrows of patients who received three ib-dli courses revealed in all patients preferential use of genes associated with lymphocyte or lymphocyte activation pathways. the patients who responded favorably (cr or pr) clustered with the transcriptomes of normal individuals, but those who failed to respond clustered separately. ib-dli was safe and not associated with gvhd. selective accumulation of cd +cd + as well as the presence of a distinct oligoclonal peak in the marrow suggest that tcrbeta clonotypes may be private to leukemia cells recognition. the response may result in cr or pr and the patients were in a good physical shape during the treatment, which makes it possible to deliver the salvage chemotherapy if required. broad spectrum antibiotics were started. after the orthopedic consultation, the fourth finger was amputated and amputation from the left ankle was recommended. a stem cell transplantation option was offered to patients and their relatives as one of the therapeutic approaches. upon acceptance by patient, μgr/kg of colony stimulating agent was started to patient. when the stem cell was /μl, the stem cells were collected. the obtained stem cell product was injected intra-lesionally (picture b). granulation tissue began to develop from the second week in the foot floor of the patient. after from th week, the necrotic tissue was disappeared and the granulation tissue was appeared. at weeks, % of the lesion healed. at th week, there was normal tissue instead of necrotic tissue on plantar surface at left leg (picture c). this case report suggests that diabetic foot/ulcer can be healed with intralesional application of stem cells in patients with diabetes mellitus. [p ] disclosure of conflict of interest: none. and third (n = ) cell infusions were cryopreserved. cells were infused following conventional chemotherapy (ia, mec, hdac) in cases ( %), chemotherapy plus hypomethylating agents in cases ( %) and hypomethylating agents alone in cases ( azacytidine, decytabine; %). the procedure was well tolerated, with mild and transient ‛haploimmunostorm syndrome' (fever %, rash %, diarrhea %). only the two patients with cmml received corticosteroid. one patient suffered early infusional reaction that was resolved with support treatment. none of the patients showed acute or chronic gvhd or persistent donor engraftment in chimerism tests. four patients had bacterial infections, but no other significant invasive fungal or viral infections were observed. all aml/raeb patients treated achieved complete remission with microhct treatment ( ; %). only one patient, with cmml, died during microhct induction ( %). four patients relapsed at , , and months after the infusion; two of them achieved a second sustained complete remission with another micro-hct from a different donor (one of them had developed anti-hla antibodies). as described in figure , median overall survival is months and overall survival at years is %. microhct is a well tolerated procedure in elderly aml/mds patients who are not candidates to allogeneic hct. infectious complications are insignificant and the remission rates are very encouraging in very high risk cases, with no evidence of gvhd. patients can undergo a second microhct from a different donor. in addition to the experience by ai et al, we have also shown that microhct can be safely administered following a hypomethylant agent course instead of conventional chemotherapy. a large, international, randomized clinical trial will address the safety and efficacy of microhct for elderly aml/ mds patients (nct ). [p ] disclosure of conflict of interest: none. wilms tumor protein (wt ) is expressed in a variety of solid tumors and is found in more than % of patients with acute myeloid leukemia which makes it an attractive target for immunotherapy. previously it was shown that t cells recognizing wt are suitable for adoptive t-cell therapy by increasing the graft versus leukemia effect. however, the efficiency of this therapeutic strategy is still limited due to the low precursor frequency and specificity of wt -specific t cells in the peripheral blood of healthy donors. the ubiquitous antioxidant inducible enzyme heme oxygenase- (ho- ) and its products have immunomodulatory effects, which render it as a potential target for the modification of t-cell responses. recently, we found that inhibition of ho- enzyme activity via tin-mesoporphyrin (snmp) results in activation and proliferation of antiviral t cells from healthy donors. in this study we aimed ( ) to identify the mechanism of ho- modification in the generation of wt -specific t cells and ( ) to develop strategies for the sufficient generation of wt specific t cells from healthy donors to augment effective t-cell immunity in leukemia patients and to broaden the applicability of adoptive t-cell therapy to the majority of patients. the frequency of wt -specific t cells in peripheral blood of healthy donors (n = ) was examined before and after snmp treatment via ifn-γ elispot using the wt -overlapping peptide pool (ppwt ). enrichment efficiency of wt -specific t cells after ho- inhibition was verified in response to ppwt and the hla-a* : -restricted wt peptides (vldfappga, wt ) and (rmfpnapyl, wt ) by ifn-g secretion assay and expression analysis of the t-cell activation marker cd . phenotypic and functional characterization of wt specific t cells were further assessed by multicolor flow cytometry, luminex assays and elisa with respect to t-cell subsets, cytotoxicity, proliferative capacity and secretion of effector molecules. in % of donors we found specific t cells against ppwt by ifn-γ elispot ( spots/ . pbmcs). the frequency of wt -specific t cells in these donors could be increased fivefold after inhibition of the enzymatic activity of ho- via snmp. to assess the possibility that ho- modulation might be clinically applicable in conformity with good manufacturing practice, enrichment of snmp-treated wt -s specific t cells was evaluated based on ifn-g secretion and cd expression. compared to snmp-untreated cells there was a . -fold higher response of ho- modified wt -specific t cells pre-enrichment and an up to -fold higher enrichment efficacy, while snmp treatment did not affected the t-cell functionality. in conclusion, modification of the enzymatic activity of ho- resulted in a more effective generation of functionally active wt -specific t cells suitable for adoptive t-cell therapy. this makes ho- a promising therapeutic target to boost antigen-specific t-cell responses for treatment we recently developed and characterized a standardized and clinical grade human platelet lysate (hpl) that constitutes an advantageous substitute for fetal bovine serum (fbs) for human mesenchymal stem cell (hmsc) expansion required in cell therapy procedures, avoiding xenogenic risks (virological and immunological) and ethical issue. because of the progressive use of pathogen reduced (pr) labile blood components, we evaluated the impact of the novel procedure theraflex uv-platelets for pathogen reduction on hpl quality (growth factors content) and efficacy (as a medium supplement for hmsc expansion). this technology is based on short-wave ultraviolet light (uv-c) and has the main advantage not to need the addition of any photosensitizing additive compounds (that might secondary interfere with hmscs). we applied theraflex uv-platelets procedure on fresh platelet concentrates (pcs) suspended in platelet additive solution and prepared hpl from these treated pcs. we compared the quality of pr-hpl with the corresponding non-pr ones, in terms of growth factor contents. then, we evaluated the efficacy of pr-hpl, in comparison with hpl and msc-screened fbs. we performed large scale culture of hmscs during passages and evaluated the proliferation of cells and the maintenance of their properties: profile of membrane marker expression, clonogenic potential, immunosuppressive properties (inhibition of t-cell proliferation) and potential to differentiate in adipocytes and osteoblasts. we showed no impact on the content in growth factors tested (egf, bfgf, pdgf-ab, vegf and igf) and a significant decrease in tgf-b (− %, n = , p o . ). a large scale culture of hmscs during passages showed that hpl or pr-hpl at % triggered comparable hmsc proliferation than fbs at % plus bfgf (n = ). moreover, after proliferation of hmscs in hpl or pr-hpl containing medium, their profile of membrane marker expression, their clonogenic potential and immunosuppressive properties (inhibition of t-cell proliferation) were maintained, in comparison with hmscs cultured in fbs conditions. the potential to differentiate in adipogenic lineage of hmscs cultured in parallel in the conditions, evaluated using oil red o and nile red stainings and the measurement of triglyceride accumulation, remained quantitatively identical. we also showed that the potential to differentiate in osteoblasts (quantified using alizarin red s and von kossa stainings and alp activity measurement) of hmscs grown in hpl or pr-hpl was not impaired, in comparison with fbs. in conclusion, we demonstrated the feasibility to use uv-c treatment to subsequently obtain pathogen reduced hpl, while preserving its optimal quality and efficacy for hmsc expansion for cell therapy applications. although it is still not used widely in clinical practice. in this paper, we demonstrated a case of ada-scid who received hsct as an adolescent from matched unrelated donor (mudd) after termination of her peg-ada treatment due to severe intractable thrombocytopenia induced by peg-ada. patient showed good engraftment and incremental clinical improvement. her post transplantation course was complicated with multiple complications including: grade i gut gvhd as well as hemorrhagic cystitis (btk related) and ebv infection, additionally, she developed several cns complaints like headache, vomiting and dizziness which were found to be due to increased intracranial pressure with multiple enhancing cerebral lesions found on brain imaging. further investigations for the brain lesions confirmed the diagnosis of malignant diffuse large b cell lymphoma (dlbcl) involving the brain. the lymphoma was highly suggested to be originated from donor cells giving the timing relationship between transplant and establishment of the diagnosis. this lymphoma was successfully treated with full recovery and good final immune reconstitution but with lack of b cell engraftment and need for monthly ivig. we conclude that, peg-ada can rarely induce thrombocytopenia in an autoimmune manner by forming antibodies against platelets and good recovery of thrombocytopenia can be achieved after discontinuation of peg-ada. hsct can be considered as modality of treatment even in older patients with scid due to ada deficiency keeping in mind high possibility of complications including, autoimmunity and malignancy. disclosure of conflict of interest: none. ( ) ( ) ( ) ( ) . based on the pre and post-apheresis cd + cell counts, the collection efficiency of the apheresis amicus device was median . % ( - ) and of the comtec median % ( - ). in mm the apheretic collections were started on median day ( - ), while in lymphoma patients, due to chemotherapy, the day of apheresis start was ( - ). after cryopreservation and thawing, viability ( -aad, bd) was median . % ( - ). with these cell products, up to now we engrafted patients following high-dose chemotherapy ( mm autografted after mel , hl and nhl autografted after beam). engraftment was prompt and stable in all with anc . and . × /l on median day ( - ) and . ( - ), respectively, and with platelet count and × /l on median day ( - ) and . ( - ), respectively. these results are similar to those obtained by most experienced centers in europe and us, and confirm the fact that autologous transplantation may be implemented also in developing countries when appropriate technology and application of standard procedures are employed. with this experience our center is also developing allogeneic transplantation, and the initial results in thalassemia will be reported in a separate abstract. disclosure of conflict of interest: none. extracorporeal photopheresis (ecp) is a safe and effective immunoregulatory therapy for steroid-refractory graft-versushost disease (gvhd) but its mechanism of action is poorly understood. ecp is a non-immunosupressive therapy whose modulating mechanism is thought to result in an increase in t-regs in the patient and in inversion of the cd /cd ratio at the end of treatment. in this study, we evaluated the effect of ecp on t cell response in a cohort of steroid-refractory gvhd patients. from november to november , patients ( con acute gvhd and with chronic gvhd) treated with ecp in our unit, were retrospectively evaluated. patient characteristics are shown in table . we performed an ‛off-line' system ecp using a cell separator (spectra optia, teruno bct) for the cmn apheresis; after -methoxypsoralen was added, the product was photoinactivated in the ultraviolet a irradiator (uvamatic-g , macopharma). ecp procedures were performed for two consecutive days, initially weekly (agvhd), or every two weeks (cgvhd) and afterwards monthly according to clinical response. anthracycline-induced cardiotoxicity (aic) is irreversible, which has limited the use of this anthracycline in cancer chemotherapy. to explore the therapeutic effect and its possible mechanism of bone marrow derived mesenchymal stem cells (bmscs) on cardiac damage induced by anthracyclines in a rat model. study selects sd rats aged - weeks to isolate and culture bmscs, and flow cytometry was used for phenotypic identification of bmscs. female sd rats were first randomly divided into groups: the sham control, bmscs control, . mg/kg daunorubicin (dnr), dnr with bmscs, dnr with dexrazoxane (dzr), dnr with bmscs and dzr. left ventricular (lv) function before, during and after chemotherapy were assessed by echocardiography. at the end of weeks, animals were euthanized and organs were collected in % buffered formalin for histopathology using hematoxylin and eosin staining and immunohistochemical analysis was used to identify the cellular subpopulations that infiltrate the cardiac tissues. after the construction of microrna- (mir- )modified bmscs with lentiviral vector, sd rats were randomly assigned into groups: the normal control, the empty vector control, dnr, dnr with bmscs, dnr with mir- -modified bmscs. the density of new blood vessels of rats in each group was detected by immunohistochemical method. mir- , bcl- , bax and vegf mrna expressions were detected by qrt-pcr. bcl- , bax and vegf, cx , troponin t and bnp protein expressions were detected by western blotting. all procedures performed in studies involving animals were in accordance with the ethical standards of the institutional. an animal model of drug-induced cardiomyopathy was built in the dnr treated rats.lv ejection fraction (lvef) and lv fractional shortening (lvfs) were significantly decreased compared to that of the sham control (p o . ), and the signs of the myocyte injury (myocytolysis, vacuolization and disruption) in paralleled with the inflammatory infiltrates, marked by cd and hla-dr, were observed in the dnr group, while bmscs alone or synergistic with dzr facilitate the anthracycline-induced lv dysfunction returning to the baseline values and the recovery of myocarditis (p o . ). in the mir- -modified bmscs transplant group, mir- expression, cell migration and proliferation ability were higher than that in the bmscs and empty vector groups (p o . ). the cardiac regenerative capacity of bmscs following significant myocardial injury were further enhanced by mir- compared to that of the dnr group and the control groups (all po . ), revealed by the significantly higher density of new blood vessels and upregulation of vegf expressions, during which the pro-apoptotic protein bax were down-regulated and the anti-apoptotic protein bcl- function were upregulated in the mir- overexpression group compared to that with the bmscs, dnr group and the control groups (all po . ). western blotting demonstrated that the expression of c × were significantly decreased, while expressions of troponin t and bnp were significantly increased in the mir- overexpression group in contrast to that with the dnr group (all p o . ). these results showed that bmscs could reverse cardiac damage induced by anthracycline, and the cardioprotective efficacy was further enhanced by mirna- -mediated regulation of apoptosis and angiogenesis. disclosure of conflict of interest: none. effective adoptive t cell therapy against cancer is dependent on long-lived tumor-specific stem cell-like t cells with the ability to self-renew and differentiate into potent effector cells. however, current protocols for ex vivo generation of tumorspecific cd + t cells result in terminally differentiated effector t cells. it was found that minor histocompatability antigen (miha)-specific cd + t cells with an early memory-like phenotype and long-lived memory transcription profile could be expanded from naive precursors using akt-inhibitor viii . importantly, these akt-inhibited tumor-specific cd + t cells showed a superior expansion capacity and anti-tumor effect multiple myeloma bearing mice. for the clinical exploitation of ex vivo generated akt-inhibited tumor-specific cd + t cells, we tested the effect of potential clinical grade akt-inhibitors azd , gdc , gsk , gsk , mk and triciribine in polyclonal stimulations, allogeneic mixed lymphocyte reactions (mlr), and antigen-specific t cell assays. polyclonal stimulation with anti-cd /cd beads on cd naive t cells was used for a first screening of the akt-inhibitors. for all inhibitors, a dose dependent effect on the naiveassociated receptors ccr , cd l and cxcr was observed. this had limited effect on viability, activation and proliferation except for triciribine, which was therefore excluded for further assays. moreover, in the mlr, treatment of naive cd + t cells with remaining akt-inhibitors resulted in a dose dependent effect associated with higher ccr , cd l, cxcr and cd expression. furthermore, the akt-inhibited cd + t cell products showed a - fold increased expansion capacity upon restimulation in vitro. when expanding miha-specific cd + t cells from the naive repertoire in the presence of one of the akt-inhibitors, the miha-specific cd + t cells showed a more early memory phenotype compared to controls. this was displayed in higher levels of the naive-associated receptor cd l ( figure ). in addition, these miha-specific cd + t cells were shown to be functional, as antigen-specific restimultation resulted in degranulation (cd a) and ifn-γ production. based on this ifn-γ production, the akt-inhibited antigenspecific cd + t cells can be selected using the cytokine capture assay (miltenyi, for enriched infusion in patients suffering from hematological malignancies. using aktinhibition in the generation of tumor-reactive t cells results in a more early memory tumor-specific cd + t cell product. this adoptive immunotherapy product retains superior proliferation capacity upon infusion, and its potential selfrenewal capacity could result in a long-term anti-tumor effect in patients suffering from a hematological malignancy. chimeric antigen receptors (cars) are composed of an extracellular domain-derived from a tumour-reactive monoclonal antibody, linked to one or more signalling endodomains. in early clinical trials, cd car-t cells have demonstrated impressive anti-tumour activity against different b-cell malignancies, including chronic lymphocytic leukaemia, acute lymphoblastic leukaemia (all) and non-hodgkin lymphoma. conventional alpha-beta car-t cells are however hla-restricted and could cause graft-versus-host disease (gvhd) when used across major mismatches, as expected in the highly anticipated setting of off-the-shelf car-t cells from third-party donors. besides being non-hla restricted, gammadelta t cells possess intrinsic anti-tumour reactivity, making them attractive effectors for next-generation car-t cell therapies. so far, however, attempts at exploiting gammadelta t cells in patients have been largely disappointing, possibly because of sub-optimal ex vivo culture conditions. the aim of our study was to optimise the generation of gammadelta car-t cells and to test their anti-tumour potency both in vitro and in vivo. starting from peripheral blood mononuclear cells of healthy donors, we stimulated gamma-delta t cells with zoledronate and il- /il- , and transduced them with retroviral vectors encoding for cd cars carrying either cd .z or - bb.z signalling endodomains. we assessed antitumour activity in vitro by measuring killing, secondary expansion and cytokine production after co-culturing gamma-delta car-t cells with different cd + all cell lines, and in vivo in nsg previously engrafted with a b-all semi-cell line. although allogeneic hematopoietic stem cell transplantation (allosct) is a curative option to treat hematologic malignancies, disease recurrence remains a concern in the setting of high risk diseases. thus, post allosct therapeutic strategies are needed to treat and/or prevent disease progression. in this setting, donor lymphocytes infusion (dli) is an option as post allosct immunotherapy aiming to enhance graft versus leukemia (gvl) effect. although dli may induce persistent remission, graft versus host disease (gvhd) is a potential complication following dli. because of the suspected higher incidence of gvhd in the presence of hla mismatches, few series focused on dli following haploidentical stem cell transplantation (haplosct) so far. we therefore report our experience of dli following haplosct using post-transplantation cyclophosphamide (pt-cy) platform. we included in this single center study all consecutive adult patients with hematological malignancies who received dli after haplosct with pt-cy as part of gvhd prophylaxis from to (n = ). conditioning regimens were non-myeloablative (low dose tbi-based) or with reduced toxicity (various dose of busulfan according to disease and patient characteristics). ciclosporine a and mycophenolate mofetil were given as additional gvhd prophylaxis in all cases. dli were given at escalating doses, expressed as cd +cells/kg, without gvhd prophylaxis, and ranged from × our study suggests that dli following haplosct with pt-cy is feasible. gvhd is frequent but with a relatively low incidence of severe forms. no response rate was achieved in the context of hematological relapse, underlining that preemptive or prophylactic strategy might be preferred. indeed, the overall good outcome in patients receiving prophylactic dli is promising taking into account the poor prognostic of the diseases indicated for alternative donor transplantation. further prospective studies are needed in specific disease settings to assess the benefit for using such post allohsct immune-intervention. [p ] disclosure of conflict of interest: none. dual specific cytokine-induced killer cell therapy as a treatment option for life-threatening ptld-a case report of the frankfurt experience l-m pfeffermann infection with epstein-barr virus (ebv) is a frequent complication after allogeneic hematopoietic stem cell transplantation (hsct) and besides relapse remains a significant cause of morbidity. prolonged immunosuppression or delayed t-cell recovery may favor ebv reactivation after transplantation, which under these circumstances can lead to life-threatening lymphoproliferative disease (ptld). consensus is lacking on the optimal treatment of ptld. adoptive immunotherapies with both anti-tumor capacity and restored virus-specific cellular immunity may represent optimal treatment options especially when considered in the context of ptld. in this case report we applied in vitro activated t-cells namely cytokineinduced killer (cik) cells with dual specific cytotoxic capacities transferring both anti-cancer potential and donor t-cell memory against ebv infection for the treatment of ebvassociated ptld which progressed to highly proliferative large b cell lymphoma during delayed t-cell recovery after allogeneic hsct. the reported patient had received an allogeneic hsct for secondary myelodysplastic syndrome following acute myeloid leukemia, and due to delayed t-cell recovery had developed ebv-related ptld two months after transplantation. treatment with rituximab, conventional ebvspecific t-cells and wildtype cik cells failed, therefore the patient was offered ebv-specific cik cells on a compassionate use basis. ebv-specific cik cells were generated from peripheral blood mononuclear donor cells. cells were activated and expanded in the presence of ifn-γ, il- , anti-cd antibody and il- . on day and of culture an ebv peptide pool was added for additional priming. follow-up analysis included in vitro and in vivo monitoring of ebv-specific cik cells. with above mentioned protocol we were able to generate cik cells containing × cd + ebv-specific t-cells/kg body weight of the patient. infusion of ebv-specific cik cells resulted in rapid clearance of plasma ebv dna level and sustained disappearance of large (vol. cm ) ptld-malignant lymphoma. during one-year follow-up analysis we were able to detect ebv-specific cik cells (cd + and cd + ) in vivo by flow cytometry using specific mhcdextramers. facs-monitoring of the patient´s blood revealed besides cd bright t-cells also an increasing cd dim t-cell population with a remarkable percentage of t emra cells within this compartment (up to %) indicating virus-specific t-cells. no cytokine release syndrome appeared after ebv-specific cik cell treatment, but cytokine secretion patterns, analyzing serum of the patient, reflected cytotoxic and anti-virus capacity provided by this treatment. cytotoxic potential, as well as t h cell differentiation and function offered by ebvspecific cik cell treatment were further confirmed by in vitro analysis. ebv-specific cik cells revealed an . s hematologic disease. the global survival ratio in the follow-up was . % (with . %, . % and . % survivals in , and months, respectively). the variables significantly associated with greater survival were: type of gvhd (cgvhd), number of affected organs (an organ had to be moderately or severely affected to be included in this category) and steroid dependence as the main reason to initiate ecp (see figure ). there was a trend towards significance for the degree of gvhd and cutaneous involvement to be factors associated to enhanced survival ratios. extracorporeal photopheresis is a safe treatment option for patients with gvhd, generating a response and decreasing immunosuppression in an important percentage of them. the presence of cgvhd rather than agvhd, a lower severity degree of the condition, having a lower number of affected organs, skin as main affected organ and steroid dependence as the reason to start the ecp treatment were all factors associated with greater survival in our sample. disclosure of conflict of interest: none. tx) . we report the case of a patient refractory to chemotherapy treated with ibrutinib as debulking therapy before allo-tx. in june , a years old woman was diagnosed with mcl. the staging performed by whole body ct scan, colonoscopy, egds and bone marrow (bm) biopsy was conclusive for stage iva with bulky lymph node over and below the diaphragm, bm, enteric and peripheral blood (pb) localization. the planned treatment included cycles of r-chop, cycle of high dose (hd) cy, cycles of hd arac and autologous sct. after completion of hd cy, the restaging showed progressive disease, with a thyroid involvement and histologic switch in a blastoid variant. disease continued to progress even after cycles hd arac, so we tried to control the disease with r-bendamustine ( mg/mq on days - of -d cycle), but after the first cycle the neck circumference increased. we shift to lenalidomide ( mg on days - of -d cycle) without any response after two cycles. we excluded patient from autologous sct programme because of chemo-refractoriness and we searched matched unrelated donor because no hla identical sibling was available. we started a therapy with ibrutinib ( mg/die on days - of d cycle). after the first cycle we observed a rapid response with decrease of neck size and the disappearance of superficial lymphnode; we performed cycles of ibrutinib, and we reached a good partial remission with lymphnode of max cm, and a bm and pb involvement of %. meantime an unrelated donor with / hla matching was identified, so in december we performed allo-tx with reduced-intensity conditioning (thiotepa mg/kg-fludarabine mg/m -melphalan mg/m ) and cyclosporine and short term methotrexate as gvhd prophylaxis. engraftment was at day + . in the first days after allo tx she experienced a clostridium enteritis, transient cmv reactivation and acute gastrointestinal gvhd on day + with rapid response to steroid therapy. main complication happened on day , when sudden fever and stupor, progressive to coma, occurred; subsequently pneumococcal encephalitis was diagnosed, with positive csf microbiological exam and two signal alteration in the right cerebral hemisphere at mri. the patient was treated with ampicillin and ceftriaxone with a favourable outcome. the mcl revaluations performed at , and months showed complete remission with disappearance of all pathological lymph node and pb involvement. currently the patient is at year post asct, she is enrolled in a rehabilitation program and mcl is in complete remission. our experience seems to indicate that ibrutinib is safe and can be used as bridge to allo-tx therapy in refractory mcl. we will investigate side effects of this platform of therapy, and, given the early occurrence of pneumococcal infection, we will consider to perform capsulated bacteria vaccination before allo-tx. disclosure of conflict of interest: none. [p ] pt was diagnosed with c-all in and received a mud-hsct (tbi gy, cyclosphosphamide) in / due to persistend mrd. following early rel / , cycles of blina led to mrd+ cr, for which a nd hsct from a haploidentical family donor (busulfan, thiotepa, fludarabine) was performed in / . molcr lasted months and rel was treated with cycles of weekly io followed by one dli ( x - cd + cells/kg), resulting in mrd+ cr and complete donor chimerism. five weeks after the last io cycle, the pt was admitted with ascites, hyperbilirubinemia and reduced general condition. vod was suspected, but diagnostic paracentesis revealed malignant ascites demonstrating fatal progressive disease. conclusion. our data suggest that the sequential use of io and dli is feasible even for heavily pretreated patients with r/r all after hsct and can induce molecular remissions. we observed an unusual case of late onset, severe vod responding to defibrotide and one all relapse manifesting itself with ascites in our patients. we therefore suggest close monitoring of liver function tests in the setting of this therapy and extensive diagnostic work-up for any developing liver abnormalities or ascites. disclosure of conflict of interest: ng: advisory board (pfizer, amgen); research support (amgen); gb: honoraria (amgen). [p ] p while allogeneic hematopoietic stem cell transplantation from matched related and unrelated donors has become a standard of care treatment for patients with hematological malignancies, transplantations from mismatched or haploidentical family donors remain challenging. currently t-replete and t-deplete transplantation strategies are applied aiming to improve the outcome after haploidentical transplantation. despite high rates of relapse many centers regard post-transplant cyclophosphamide, a t-replete strategy, as a standard of care approach. we have developed a t-depleted transplant approach where donor lymphocytes selectively depleted of alloreactive t-cells (atir ) using th , arhodamide-like dye, are infused after cd -selected haploidentical hsct, to overcome the challenges of infectious complications, gvhd and relapse. in phase i (cr-air- ) we have demonstrated safe infusion of these lymphocytes at doses up to × viable t-cells/kg. recently, we reported a promising -year grfs was % from a phase ii trial (ash ),that is awaiting final results soon. here, we introduce a randomized, multicenter phase study (cr-air- ), where patients with acute myeloid leukemia (aml), acute lymphoblastic leukemia (all) or myelodysplastic syndrome (mds) are planned to undergo a haploidentical hsct with either a t-cell depleted graft and adjunctive treatment with atir , or with a t-cell repleted graft and use of posttransplant cyclophosphamide. inclusion and exclusion criteria are listed in table . all patients will undergo myeloablative conditioning consisting of either tbi ( gy) or melphalan/ busulfan, in combination with thiotepa and fludarabine. patients in the atir study group will receive atg ( . mg/ kg once daily for days) during conditioning and atir infusion at a dose of × viable t-cells/kg is given between and days after the hsct. patients in the ptcy group will receive cyclophosphamide ( /mg/kg) on day and (or ) with subsequent use of immune suppression up to months post-hsct. the primary endpoint of the study is gvhd-free, relapse-free survival (grfs). grfs is defined as time from randomization until grade iii/iv acute graft-versus-host disease (gvhd), chronic gvhd requiring systemic immunosuppressive treatment, disease relapse, or death, whichever occurs first. this endpoint captures both safety and efficacy. additional secondary endpoints are overall survival (os), progression-free survival (pfs), relapse-related mortality (rrm) and transplantrelated mortality (trm). patients are planned to be randomized in study centers in europe and north america. a number of - sites are planned to participate in the study. enrolment is expected to continue until mid- with initial results being available first half . results of this study will determine which transplant regimen provides most clinical benefit in haploidentical donor transplantation, with the promise of an effective regimen without the use of post-transplant immune suppression. disclosure of conflict of interest: jr is an employee of kiadis pharma. multipotent mesenchymal stromal cells (mscs) are used for prevention and treatment of graft versus host disease after allogeneic hematopoietic stem cells transplantation due to their immunomodulatory properties. mscs fate in vivo after infusion is unknown. the aim of this study was to analyze the changes in mscs and allogeneic lymphocytes properties when co-cultured in vitro to simulate their interactions in vivo. the bone marrow from donors ( male and female aged - years, median years) was used. mscs were cocultured with allogeneic lymphocytes in a ratio of about : for days and their basic properties were analyzed over time. lymphocytes were activated by adding to the culture medium mg/ml of pha (pha-lymphocytes). some mscs were treated for h with u/ml ifnγ (γmscs). determination of gene expression levels was performed by reverse transcription polymerase chain reaction in real time (modification of the taq-man) and of antigen expression on mscs and lymphocytes by flow cytometry. significant reduction in the proportion of viable cells was observed in mscs co-cultured with pha-lymphocytes. in γmsc co-cultured with pha-lymphocytes no reduction in the proportion of living cells was revealed. this indicates the sensitization of mscs by ifnγ to factors secreted by pha-lymphocytes. in mscs co-cultured with pha-lymphocytes and lymphocytes mean fluorescent signal intensity level (mfi) of cd gradually decreased. ifnγ treatment and co-cultivation with lymphocytes led to significant increase of hla-dr mfi on mscs. co-cultivation with lymphocytes increase the hla-dr mfi on mscs much stronger than ifnγ treatment. relative expression level (rel) of ido gene increased dramatically in both mscs and γmscs when co-cultured with lymphocytes. at a day in γmscs rel of ido increased fold, and then gradually declined. in mscs cocultured with lymphocytes il- rel increased almost -fold and then decreased -fold at the fourth day. the csf rel in γmscs showed twofold increases, upon incubation mscs and γmscs with lymphocytes csf rel increased fourfold and sevenfold, respectively. co-culture of msc and γmscs with lymphocytes led to decrease in the proportion of cd , cd , cd , hla-dr, and pd- positive cells (both cd and cd ) after one day, compared with pha-lymphocytes without mscs. proportion of cd +, hla-dr+ and pd- + cells also decreased after days of co-culturing with msc or γmscs (compared with pha-lymphocytes without mscs), but anyway number of activated cells increased . - folds compared with first day. number of cd + lymphocytes after days of co-culturing with mscs or γmscs did not vary significantly from control and decreased in comparison with first day. main inhibition of activated lymphocytes by co-culturing with mscs occurs during the first day of their interaction, and then the inhibition became less effective, moreover in mscs decreased the rel of the main immunomodulating factors, and most of them were eliminated. mscs treatment with ifnγ resulted in improved survival and resistance of these cells to lymphocytes action. the results indicate that the effect of mscs injected intravenously to patients is limited to several days. disclosure of conflict of interest: none. autologous adipose-derived mesenchymal stem cells (admscs) embedded in platelet-rich fibrin (prf) promote healing in different types of wounds. by avoiding the needlerelated complications, prf-embedded autologous admscs graft provides a new effective stem cell-based therapeutic strategy for wound healing. adult male (age ⩽ yo) were equally divided (n = per group) into group (prf only), and group (prf+admscs). regular dressing (without any agent) was used for both groups with a frequency of changing every days. rpf with or without admscs was patched on the wound (maximum surface area cm ). all patients were followed up until complete healing. a complete healing was noted in both groups; however, the healing in group was very slow (after weeks), compared to a quicker one in group (after weeks). control of the moisture was very well noted in group , less in group . group showed a lot of exudates on the wound; less exudate in group were noted. infections were absent. both groups had a colonized wound. signs of inflammation were very well noted in group ; no signs of inflammation in group . admscs embedded in prf offered rapid wound healing responses then prf alone. keywords: mesenchymal stem cells, platelet-rich fibrin, engineered tissue wound healing disclosure of conflict of interest: none. stem cell source p additionally cryopreserved g-csf primed pbsc can substitute the second transplantation for the patients with acute leukemia who lately relapsed after hematopoietic stem cell transplantation y lee , j moon , ih lee and s sohn department of hematology, kyungpook national university hospital; department of hematology,kyungpook national university hospital and kyungpook national university hospital although allogeneic hematopoietic cell transplantation (allo-hct) is a potentially curative therapy for acute leukemia, survival outcomes of the patients relapsed after transplantation remains poor with high early mortality and a small percentage of second remission. this study evaluated the efficacy of dli using g-csf primed pbsc additionally cryopreserved for the patients who relapsed after allo-hct. we retrospectively reviewed the medical records of the patients who received allo-hct for acute myelogenous leukemia (aml), myelodysplastic syndrome (mds), and acute lymphoblastic leukemia (all) between and in kyungpook national university hospital. among the patients who had relapsed after allo-hct, the patients received dli using the additionally harvested cells. at the time of harvest for the first hct, collecting targeted pbscs (greater than × /kg cd + cells) allowed us to cryopreserve surplus pbscs, including cd + cells with dimethylsulfoxide in a nitrogen tank. then, we analyzed the efficacy of dli for the patients who were classified into early relapse or late relapse group by the median time of relapse after transplant. the median age at transplant was . years (range - years) and male was patients ( . %). primary diseases for allo-hct were aml/mds (n = , %) and all (n = , %). one hundred forty three patients ( . %) were in cr (complete remission), ( %) in further cr, and ( . %) in relapsed and refractory status. one hundred seventy one patients ( . %) received myeloablative conditioning regimen. the median dose of cd + cell was . × /kg (range: ~ . × /kg). almost % of patients achieved the neutrophil engraftment with a median time of days (range: - days). the -year overall survival (os), relapse free survival (rfs), non-relapse mortality (nrm) and graft-versus-host disease (gvhd)-free/relapse-free survival (grfs) since hct was . ± . %, . ± . %, . ± . %, and . ± . %, respectively. there was no significant difference according to s the infused cd + cell dose (lower o × /kg vs higher ⩾ × /kg). the incidence of chronic gvhd was more frequent in higher cd + group ( . % vs . %, p = . ). median time from hct to relapse was days (range: ~ days). after relapse, patients ( . %) were treated with salvage chemotherapy, patients ( . %) with second allo-hct, and patients ( . %) with dli. the median number of cd +t cell was . × /kg (range: . ~ . × /kg). fourteen patients ( . %) achieved dli induced cr, patients progressed, and patients were not evaluable for response. dli induced acute gvhd was observed in patients ( . %) and chronic gvhd developed in patients ( . %). in late relapse group, the -year os since post-transplant relapse was significantly higher in dli group than non-dli group (figure , . ± . % and . ± . %, p = . ) but, early relapse group had no difference. the patients treated with dli showed significantly survival benefit in late relapse group (median days vs days, p = . ). the incidence of dli-induced gvhd does not differ between two groups. dli for the patients who lately relapsed after allo-hct can be a feasible and an effective option in terms of response, donor convenience and it's cost. in the late relapse group, g-csf primed dli may replace second transplantation. disclosure of conflict of interest: none. cord blood transplantation- years of experience c alves , f amado , f bordalo , s ferreira , s lopes , c pinho , t rodrigues , l antunes and s roncon serviço de imuno-hemoterapia; serviço de terapia celular and registo oncológico do norte, instituto português de oncologia do porto francisco gentil, epe allogeneic haematopoietic stem cell transplantation (hsct) is a well-established treatment for patients with malignant and non-malignant haematological disorders. cord blood transplantation (cbt) has extended the availability of hsct to patients that would not otherwise be eligible for this curative approach because of the lack of human leucocyte antigen (hla) identical donor. the aim of this retrospective study was to analyse and characterize years of cbt activity in our institution ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . we examined patient electronic files and created a database in excel to register cord blood unit (cbu) parameters and patient characteristics. after thawing, cbu was washed/diluted with validated procedures; the cellular content was evaluated by immunophenotyping and followed ishage recommendations; sterility was assessed by bacterial/fungal cultures, viability by trypan blue exclusion assay and functionality by clonogenic capacity. the transfusion of blood products after transplant was quantified and the hematological recovery (hr) established using cibmtr criteria. correlation between continuous variables was assessed with spearman coefficient. overall survival (os) was determined according to cellular content and hla-disparity by the kaplan-meier estimator. survival between groups was compared using the log-rank test. a total of cbu were administered to patients (table ) : / female, the main diagnosis was acute leukaemia ( / ). a sibling cbu was used for patients; the unrelated were imported from europe ( %), usa ( %) and oceania ( %). hla-matching was / , / , / and / for , , and patients, respectively; % were abo-identical. after thawing, % were washed and presented no microbial growth. the majority of patients were submitted to a bussulfan-based myeloablative conditioning regimen; graft versus host disease prophylaxis was performed with a calmodulin inhibitor+mycophenolate mofetil. complete and mixed chimerism was verified in % and % of patients; % had graft failure; the rest were unknown results ( %). at the moment, we reported patients alive ( in complete remission, with evidence of disease relapse) and dead at a median of ( . - ) months after cbt; the most frequent cause ( %) was recurrence of the initial clinical condition. the correlation between nucleated cells (nc) and cd + cells per kg/hr (p = . ; p = . ) and number of cd + cells per kg/os (p = . ) was not statistically significant. however, the engraftment and os was associated with hla-mismatch (p = . ; p = . ) and os was related to nc per kg (p = . ). our clinical results suggest that despite increased hla disparity, ucb offers promising results. ucbt is feasible in patients when the unit contains a high number of cells. there are several strategies for the future, related to cbu expansion and homing techniques, nurturing procedures, selection of optimal cbu unit and enhancement of immune recovery, in order to improve the application of cbu. s received sirolimus and mmf. median time to neutrophil and platelet engraftment was days ( - ) and days ( - ), respectively. one patient died from parainfluenza pneumonia (d ), one patient from ptld (d ), one patient from late pulmonary vod (d ), and one patients from relapse (d ). with a median follow up for survivors of months, one year survival is %. three patients had grade - gvhd and none of the survivors have chronic gvhd. though unrelated donor chimerism was dominant early after transplant and contributed to early count recovery, definitive engraftment was dominated by ucb chimerism in all but one patient. conclusion: among older adult patients with hematological malignancies,~ % lack haplo-identical relatives. for these patients, double or single ucb transplant is challenging because of delayed engraftment. cd selected partially matched grafts from unrelated donors hasten hematopoietic recovery and are over time outcompeted by ucb grafts which provide robust hematopoiesis with low risk of chronic gvhd. the combination of mismatched unrelated hematopoietic progenitors and ucb grafts provides an attractive alternative for older patients lacking hla-idental donors or haploidentical relatives. in planned trials, mismatched donors may be selected based on kir type to further enhance gvl effects. disclosure of conflict of interest: partially supported by miltenyi biotec. haploidentical stem cell transplantation (haplo-sct) is an attractive option for patients who do not have an hlamatched donor. historically it has been associated with high rates of graft rejection, relapse and low incidence of graft versus host disease (gvhd). to decrease these issues we have considered the use of primed bone marrow as stem cell source, early withdrawal of immunosuppressive therapy and the use of donor lymphocytes infusions (dli) in haplo-sct with high-dose post-transplantation cyclophosphamide (ptcy) as main gvhd prophylaxis. to analyse our incidence of acute and chronic gvhd and overall survival (os) in patients with haplo-sct with short course of inmunosupressive therapy. we retrospectively analyzed a cohort of patients who underwent haplo-sct with primed bone marrow as stem cell source, between years and in our centre. gvhd prophylaxis consisted in ptcy ( mgr/kg on days + and + ) and tacrolimus plus mycophenolate (mmf) from day + as recommended by baltimore group. mmf was stopped on day + . tacrolimus was tapered off from day + with withdrawal on day + in patients without gvhd or with active disease. dli were considered if mixed chimerism, relapse or disease progression appeared. the characteristics of the patients are shown in table . results: there was no primary graft failure. eight of patients ( . %) developed agvhd (grade ii-iv) and it was severe (grade iii-iv) in patients ( . %). cutaneous agvhd location was the most common presentation ( patients ( %)) and it was associated with intestinal gvhd in patients. twenty two patients were evaluable for cgvhd. thirteen patients ( %) developed chronic gvhd that was mild, moderate and severe in: ( . %), ( . %) and ( %) patients, respectively. the median time of onset cgvhd was months (range: - ) and it was related with previous withdrawal of the immunosuppression in ( . %) patients, tapered off immunosuppression in ( . %) patients and dli in ( %) patients. systemic treatment was required in / patients but only patients were treated with high doses of steroids ( mg/kg/day). the median days of is therapy in patients who developed gvhd was days (range: - ). dli were used in ( %) patients because of: relapse/disease progression in ( . %) and secondary graft failure in ( . %). two patients achieved complete remission and patients developed cghvd. the median number of dli per patients were ( - ) with a median cd +cell of × /kg (range: × - × /kg). with a median follow-up of months (range: - ), the estimated os at and years after haplo-sct were % and %, respectively. at the moment of this study patients ( . %) were alive, patients in complete remission, in partial response and in progression. eleven ( . %) patients died due to: disease ( ), infections ( ), pleuropericarditis ( ), hepatic veno-occlusive disease ( ) and refractory gvhd. five patients ( . %) are without is therapy and without gvhd symptoms. in our experience, early withdrawal of immunosuppression following haplo-sct with primed bone marrow and posttransplantation cyclophosphamide facilitates the development of chronic gvhd and can decrease the relapses in patients with high-risk hematological malignancies. it is necessary more follow up and more studies to confirm this preliminary results. [p ] disclosure of conflict of interest: none. s myeloid malignancy (n = except patient with saa) received fludarabine (flu)/busulfan ± tbi gy, while lymphoid malignancies (n = ) received flu/tbi gy or cy/ tbi gy. all patients received g-csf-mobilized t-cell replete pbsc from a haplo donor. gvhd prophylaxis was ptcy mg/ kg on day + /+ , tacrolimus (d+ to + ), and mycophenolate (d+ to ). the median duration of follow up of surviving patients is months. median age was ( - ) years, patients ( %) were male, ( %) were african american, and patients ( %) had comorbidity index (hct-ci) ⩾ . all patients had hematological malignancy (except patient with saa) including patients ( %) not in cr. disease risk index was high/very high in ( %) and intermediate in ( %). on the day of transplant, patients ( %) did not receive steroid premedication ( = no-steroid group), while patients ( %) received mg of methylprednisolone minutes prior to pbsc product infusion ( = yes-steroid group). all the following outcomes are described in the ‛no-steroid' vs ‛yessteroid' group, respectively. cumulative rate (ci) of anc engraftment (⩾ /μl) on day + was % ( % ci - %) and % ( % ci - ) (p = . ). ci of platelet engraftment (⩾ /μl) on day + was % ( % ci - %) and % ( % ci - %) (p = . ). primary engraftment failure was observed in patients; in yes-steroid and in no-steroid. no primary engraftment failure was observed with myeloablative tbi ( - gy) (n = ). ci of agvhd gii-iv (day+ ) was % ( % ci: - %) and % ( % ci: - %) (p = . ). ci cgvhd ( year) was % ( % ci - %) and % ( % ci - %) (p = . ). ci of relapse ( year) was % ( % ci - %) and % ( % ci - %) (p = . ). ci of non-relapse mortality (nrm) ( year) was % ( % ci - %) and % ( % ci - %) (p = . ). post-infusion noninfectious fever (d to + ) was observed in / ( %) and / patients ( %). median tmax was f and f (p = . ). only patient in the no-steroid group developed life-threatening cytokine release syndrome and survived. no difference of viral reactivation was noted between groups. cmv reactivation occurred in ( %) and patients ( %), bk reactivation in % (in both groups), hhv in % and %, ebv in % and %. the -month overall survival was % ( % ci - %) and % ( % ci - %) (p = . ). the -month disease-free survival was % ( % ci - %) and % ( - %) (p = . ). t-cell replete haplo pbsc transplant is effective therapy for patients with high-risk hematological malignancies. high-dose steroid premedication with pbsc infusion neither influences transplant outcome nor prevents post-infusion febrile reaction. disclosure of conflict of interest: as discloses grant support (american porphyria foundation), consultation (medpace inc), research support (astellas and fate therapeutics), honoraria (alxion, and spectrum), and royalty for licensing of intellectual property (incysus biomedical). intrabone transplant of unwashed cb in hematological malignancies: engraftment and safety f giglio , s marktel , r greco , m morelli , mt lupo-stanghellini , e xue , l lazzari , m marcatti , m zambelli , c parisi , r milani , s piemontese , a assanelli , c corti , m bernardi , f ciceri and j peccatori unit of hematology and bone marrow transplantation, irccs san raffaele scientific institute, milano, italy and immunohematology and transfusion medicine unit, irccs san raffaele scientific institute, milano, italy cord blood transplant (cbt) in adult patients (pts) is limited by the risk of graft failure or delayed engraftment due to low cell counts. to improve the capacity and speed to engraft, intrabone (ib) cbt technique has been investigated, showing high rate of engraftment and low acute gvhd, also when compared with double cb transplant. cb units washing procedure has been suggested to remove dmso toxic potential effect. we report our experience in adult pts with hematological malignancies receiving ib unwashed cb in an attempt to reduce the loss of progenitor cells and the risks associated with cell-washing procedure. between and we performed allogeneic hematopoietic stem cell transplant (hsct) using unwashed cbu as a source and infusing them ib. all pts were adult and suffering from hematological malignancies. this population was characterized by very high-risk and advanced phase disease. all pts received a cb hsct because of unavailability of sibling or matched unrelated donors. eleven pts received a treosulfanbased myeloablative conditioning regimen and a sirolimusbased ghvd prophylaxis; four pts received busulfan-based myeloablative conditioning and a cyclosporine-based ghvd prophylaxis. cb units were thawed and diluted with albumindextran solution immediately before the transplant. this ‛nowash' dilution was implemented to reduce product manipulation that may results in cell loss. furthermore, graft manipulation risks potential contamination, requires increased technologist time, and delays time to infusion. the ib infusion was performed under local anesthesia and with short conscious sedation, at bedsite in the bmt ward. the infusion was preformed monolaterally or bilaterally according to the volume to be infused. starting from a % dmso concentration in the cb units before the dilution, the graft products contained a median of . % dmso (range: . - . ) at ib-hsct. the median cd + cells infused were . × /kg b.w. (range: . - . ). the median mono-nucleated cells were . × /kg b.w. (range: . - . ). the median cd + t-cells were . × /kg b.w. (range: - . ). the median infused volume was ml (range: - ). no procedure-related adverse events were observed, nor related to the ib technique, neither to the sedation. of the transplanted pts, were evaluable for engraftment ( patient rejected the graft and patients died before day + because of severe infections). all achieved anc . × /l after a median of days (range: - ) and achieved plt × /l at a median of days (range: - ). three patients developed grade iii-iv acute gvhd grade. according to extreme heterogeneity of the population no correlations with relapse incidence and diseasefree survival could be evaluated. ib infusion of unwashed cb is feasible, safe, easy to perform. no adverse events related to the procedure were documented. no dmso toxicity was documented. engraftment was obtained in all evaluable pts. our data confirm that direct ib cbt overcomes the problem of graft failure even when low numbers of cb cells were transplanted, thus leading to the possibility of using of this technique in a large number of adult pts, for whom this approach represents the sole possibility of long-term survival. the ‛no wash' cb dilution can also help the implementation of ib transplant thanks to the easier graft manipulation. [p ] disclosure of conflict of interest: none. lower incidence of cgvhd after cord blood transplantation for hematological malignancies in comparison with hematopoietic stem cell transplantation from other donors: years' experience in a single institute m yoshino, m obiki, m osakie, s ikeno, t sato, m nasashima, y kagaya, n kawashima, t morishita, y ozawa and k miyamura department of hematology, japanese red cross nagoya first hospital the outcome of cord blood transplantation (cbt) for hematologic malignancy was investigated. however the incidence of gvhd is not accurately known. the goal of this study was to compare the outcome of cbt with allogenic hematopoietic stem cell transplantation (allo-hsct) from other sources, mainly unrelated bone marrow (urbm). patients' characteristics: patients who underwent allo-hsct, between and in our hospital were retrospectively analyzed. donor sources were cord blood cell (n = ), urbm (n = ), hla matched sibling bone marrow (sibling bm) (n = ), and hla matched sibling peripheral blood stem cell (sibling pbsc) (n = ). in cbt, the median age was . ( - ), and the diagnosis included aml ( ), all ( ), mds ( ), cml ( ) and other ( ). the disease risk was good in and poor in . disease risk was slightly higher in comparison with other sources. prophylaxis of acute gvhd was tacrolimus, short-term methotrexate ( ), cyclosporine, short-term methotrexate ( ) and others ( ) . the -year overall survival (os) rate after cbt ( cbt ( - . %, engraftment failure . %, acute gvhd . %), relapse . % and other . %. in cbt cases, engraftment failure after allo-sct was observed in cases ( . %) which is higher than that among urbmt ( . %), out of . cbt cases underwent the second allo-hsct and patients achieved engraftment and patients were alive at days after allo-hsct. of them survived at years after allo-hsct. our results suggest that the outcome of cbt has improved in recent years. moreover, cbt has an advantage in the least cumulative incidence of acute/chronic gvhd. cbt may well create the best outcome in the future. disclosure of conflict of interest: none. chronic active epstein-barr virus (ebv) infection is a major type of ebv-associated t/nk-cell lymphoproliferative disorders (lpd) in childhood. however, young adults rarely develop chronic active ebv infection (caebv), and shows more aggressive features than that of childhood. umbilical cord blood transplant (ucbt) is a possible treatment option for caebv patients who have no hla-matched donor, but there is little information available about the efficacy and safety of ucbt for adult patient with caebv. we analyzed six adult patients with caebv who underwent a single-unit ucbt between and at our institute (including a case reported in [ ] ). the diagnosis of caebv was made according to the criteria proposed in [ ] ; persistent infectious mononucleosis (im)-like symptom and detection of increased ebv genomes in peripheral blood mononuclear cells (pbmc). ebv-dna load was measured using real-time quantitative pcr. median patient age at diagnosis was ( - ) years. target cells of ebv-infection were cd +t cells (n = ) or nk cells (n = ). median ebv-dna load was . × copies per microgram of dna in pbmc (range: . × - . × ) at the diagnosis. all patients were given prednisolone and cyclosporine, and then etoposide (n = ) or combination chemotherapy (n = ) before transplant. ebv load has slightly decreased to a median of . × copies (range: . × - . × ), but disease status was active at ucbt in all. median time from the diagnosis to ucbt was days (range: - ). one patient received total body irradiation (tbi) gy + cyclophosphamide (cy) mg/kg + cytosine arabinoside g/m , and the other five patients received fludarabine (flu) + melphalan (lpam) - mg/m or cy mg/kg with tbi gy before ucbt. umbilical cord blood (ucb) was / hla-matched to the recipients. median number of infused ucb cd + cells was . × /kg (range: . - . × ). gvhd prophylaxis was consisted of tacrolimus + methotrexate or mycophenolate mofetil. neutrophil engraftment and complete donor chimerism were achieved in four patients, but two of them developed secondary graft failure (gf) early after engraftment. the other two patients developed primary gf. second ucbt was successfully performed in the patients with gf a median of . days (range: - ) after the first ucbt. ebv genomes in pbmc became undetectable immediately after ucbt. at a median follow-up of days (range: - ), ebv-dna was undetectable or very low, and im-like symptoms were resolved in all cases. however, at - months after ucbt, two patients developed ebv+ b-cell lpd derived from donor cells, that was successfully treated with rituximab therapy. this study suggested that ucbt could eradicate ebv-infected cd + t cell-or nk cell-clones. ucbt can be a treatment option for adults with caebv. rituximab monotherapy was effective for post-transplant lpd from donor b cells. however, a high incidence of gf was observed in patients receiving reduced-s intensity conditioning of flu/lpam or cy /low-dose tbi. further studies are needed to find more optimal regimens for stable engraftment of ucb in adult patients with caebv. there is an increased incidence of ab incompatibility- - %, in allogeneic hematopoietic stem cell transplantation (allohsct) in patients who are russian citizens as a result of the variability of genetic polymorphism in the multi-ethnic population and a significant number of unrelated donors from international bone marrow registries. ab incompatibility in different types of allohsct may be an additional aggravating factor for the development of immunological complications and decrease effectiveness of treatment, but the data is still controversial [ ] . from may to december in raisa gorbacheva memorial institute for children oncology, hematology and transplantation patients with leukemia, malignancies and hereditary diseases were included to the study, who were performed hsct: allogeneic unrelated - ( %); allogeneic related- ( . %); haploidentical - ( . %); umbilical cord blood in patients ( . %). age was - , median- years. patients were predominantly with acute myeloid leukemia- % (n = ), acute lymphoblastic leukemia- % (n = ) and chronic myeloid leukemia - % (n = ). results: in . % of cases (n = ) АВ incompatibility was determined: major- . % (n = ); minor- . % (n = ); combined- . % (n = ). АВ incompatibility in allohsct did not influence overall survival (p = . ) and frequency of acute graft versus host disease (gvhd) (p = . ). also there was no difference in overall survival depending on combination of condition regimen and ab incompatibility: reduced intensity (ric) or myeloablative (mac) (p = . ). an increased frequency of acute gvhd was observed in ric and АВ incompatibility ( . %) compared to mac ( . %, p = . ). ab incompatibility was not a major factor (log worth . ) which influenced the fact and speed of donor's transplant engraftment in comparison to level of hlacompatibility ( . ), hematopoietic stem cell source ( . ) and type of hsct. but the presence of major ab incompatibility increase the period of erythroid recovery (p = . ) as reflected in the higher amount of blood transfusions. complications caused by ab incompatibility were identified in . % of all cases (n = ) including acute and delayed hemolysis, partial red cell aplasia and immune thrombocytopenia. conclusion. the presence of АВ incompatibility is not a limiting factor to perform allohsct, however, it demands high quality prophylaxis and accurate transfusion therapy depending on ab incompatibility type to prevent immune complications. keywords: allogeneic hsct, ab -incompatibility. poor graft function or graft failure have become common indications for infusion of immune-selected cd + cells (‛boost') or second unprocessed allo-hsct, creating the need for remobilization of the same related or unrelated. we retrospectively compared the results of two consecutive cycles of rh-g-csf treatment and peripheral blood progenitor cell collections in related donors cared for at our institution between and . mobilization consisted of the administration of rh-g-csf at a dose of μg/kg per day injected in the evening, and apheresis was started in the morning of the fifth day after the fourth dose of rh-g-csf. collection was performed with a spectra or spectra optia cell separator (terumo bct). eleven out of were haplo-mismatched donors and were hla matched donors. four donors were re-collected because of recipient graft failure and because of poor graft function; in the latter situation, immunomagnetic selection of cd + cells was performed on the collected cell product prior to infusion into the recipient, using the clinimacs medical device, as previously published. median donor age was years (range: - ) at time of first donation, median weight kg ( - ) and bmi ( - ). median delay between mobilizations and was days ( - ). interestingly, the median delay between collections was days ( - ) in the haplomismatched setting and ( - ) in the matched setting. median number of circulating cd + cells/μl after the first injections of rhg-csf was vs at the first and second mobilization cycles (po . , table ). seven out of donors ( %) requested more than one apheresis session to obtain the target number of collected cd + cells during the first cycle, as compared to out of ( %) for the second cycle: this is largely due to the higher target of cd + cells for the second collection, expecting that the median cd recovery after immunomagnetic selection is % in our experience. our study shows that a second cycle of mobilized peripheral blood progenitor cell collection from related donors is associated with a significant reduction in response to hematopoietic growth factors and mobilization capacity. this information allows planning the number of aphereses at the second cycle-and subsequently the number of immunoselection procedures to be carried out-taking into account the higher cd + cell dose target needed for subsequent immunomagnetic selection. cmv reactivation remains one of the main complications after allogeneic stem cell transplantation (hsct), requiring antiviral therapy, causing myelosuppression, prolonged hospitalization, higher treatment costs and mortality. cmv seronegative donors are recommended for cmv seronegative recipients. however data about donor selection for cmv positive (cmv-pos) recipients is not conclusive. some studies showed that selecting cmv-pos donors for cmv-pos patients might be beneficial. cmv-seropositivity is very high in lithuania among healthy blood and bone marrow donors ( %) and even higher among hsct recipients (up to %), so donor selection for cmv-pos recipients is an object of interest. retrospective analysis of cmv reactivations in cmv-pos allogeneic hsct recipients (transplanted during - year in vilnius university hospital) who survived at least months post hsct was performed. data about cmv reactivation frequency, time post hsct, duration, maximal cmv dna copy number at each reactivation collected. cmv reactivation was considered when cmv dna copies detected /ml in patient's blood. statistical analysis conducted using sas . ; student's tests for statistical significance; kaplan-meier methods for overall survival. among allogeneic hsct recipients ( . %) were cmv-pos. cmv-pos allo-hsct recipients were further analysed. of them received graft from cmv-pos (pos/pos group) and -from cmv-seronegative donors (pos/neg group). more patients in pos/neg group experienced cmv reactivation in first months post hsct in comparison to pos/pos group ( . % vs . %, p o . ). pos/neg group patients had more cmv reactivations ( . vs times in months post transplant period, po . ), reactivations were diagnosed earlier post transplant ( . vs days post hsct, p o . ), had longer duration ( . vs . days, po . ) and larger maximal cmv dna copy number ( , vs . copy/ml, p o . ) in comparison to pos/pos group patients. pos/pos group patients showed tendency for better survival than pos/neg group patients, however did not reach statistical significance. in a univariate analysis only hla mis-match and donor cmv seronegativity were factors statistically significantly associated with cmv reactivation. donor cmv serostatus is significant factor selecting donor for allo-hsct recipients. according to our findings, selecting cmv-pos donor for cmv-pos recipient may reduce cmv reactivation frequency and duration. disclosure of conflict of interest: none. selection of the best hsc donor when a matched donor is not available is still a matter of debate, and reports in pediatric population are scarce. this is a retrospective study conducted by brazilian society of hsct (sbtmo), including centers, aimed to compare matched unrelated (matched-urd), mismatched unrelated (mm-urd) and unrelated cord blood (ucb) hsct. all or aml/mds patients o y/o who have received first unrelated hsct between - were included. hla -digit typing was available for urd; for ucb, hla class-i -digit typing. overall survival (os), and cumulative incidence (ci) of agvhd, cgvhd, nrm and relapse were analyzed. on an unplanned analysis, we fitted a lognormal bayesian survival model with random effects, imputing the probabilities of ucb matching at loci. a total of patients were included ( matched-urd, mm-urd and ucb). median age was . y/o. most patients had all ( %). proportion of early disease in matched-urd was higher ( %, against and %). matched-urd were / -digit hla matched (except one, for whom dq was not available), while most of mm-urd ( %) were / hla matched. ucb were loci ( %) or -loci typed ( %). based on previous report on extending -loci hla typing to -loci ucb, we estimated that ucb were - mismatched at loci, had mismatches and had or more mismatches. conditioning regimens were mainly myeloablative, tbi-( %) or bu-( %) based. grafts were in vivo t-cell depleted in % of the patients, not balanced between groups (p = . ). with median follow-up of . years, y os was %, % and % for matched-urd, mm-urd and ucb, respectively (p = . , log rank test). for matched-urd, mm-urd and ucb, ci of grades iii-iv agvhd at months were %, % and % (p = ns); moderate/severe y-cgvhd, %, % and % (po . ); y-relapse, %, % and % (p = ns); and y-nrm, %, % and % (p = . ). we found out that primary graft failure occurred in ( %) of ucb, compared to % in mm-urd and % in matched-urd. when ucb matching probabilities at loci were imputed and analyzed in a bayesian model (controlled for age, gender, disease status and diagnosis, and t-cell depletion), survival was inferior in ucb with + mismatches ( . -times lower median survival, ci . - . ), but not with up to mismatches ( . -time higher median survival, ci . - . ). of note, in vivo t-cell depletion marginally impaired survival ( . -times decrease, ci . - . ). discussion: in our population, overall survival achieved with mm-urd was not different to / matched-urd, despite higher incidence of moderate/ severe cgvhd. on the other hand, survival with ucb was significantly lower. recent report have shown excellent os with ucb compared to / hla-matched urd. ucb cohort inferior results may have been due to hla disparity degree, since survival in ucb with up to mismatches (out of ) was not worse. one limitation of our study is that tnc and cd from ucb units were not available, impairing primary graft failure analysis. we have also found that in vivo t-cell depletion might have a detrimental effect on survival and should be studied further in prospective trials. in conclusion, mm-urd, especially hla / , is a suitable option when a fully hla / matched-urd is not available. ucb matched at least / may also be a good option. disclosure of conflict of interest: none. allogeneic hematopoietic stem cell transplantation (hsct) is a proven treatment for patients with high risk or relapsed hematological malignancy. the probability of having a hla matched family donor is about %. in populations with high consanguinity rates, the probability of having non-sibling matched family donor(mfd) is much higher. to explore the impact of msd vs non-sibling mfd on outcome of hsct recipients, we undertook a single center retrospective analysis of pediatric patients transplanted with the diagnosis of hematological malignancy at our center in the last five years. a retrospective cohort from to current included pediatric patients with hematological malignancies transplanted from family donors, of which were from msd and from non-sibling mfd. hla matched family donors were identified by high resolution allelic typing and were matched of hla loci. diseases were all (n = ), aml (n = ), mds (n = ), jmml (n = ), kml (n = ), nhl (n = ) and hodgkin's disease (n = ). conditioning regimens were tbi or busulphan-based myeloablative in all patients. the median age of the patients was . years (range: month- . years). although peripheral stem cell seemed to be used more commonly in non-sibling mfd recipients ( % vs %), the difference was not statistically significant. the median follow up time for alive patients months ( - months) . two year overall survival and leukemia free survival did not differ between patients with transplantations from msd or nonsibling mfd ( % ± . vs ± . , p = . ) similarly, leukemia free survival was not different between msd and non-sibling mfd transplants ( . % ± . vs . % ± . , respectively). the incidences of grade ii-iv acute gvhd in msd and nonsibling mfd transplants were % and % , respectively. the incidences of relapses were % in msd transplants and % in mfd transplants and the difference was not significant (p = . ). these data show that the results of hsct from nonsibling mfd is comparable to hsct of msd in children with hematological malignancy. our data emphasize the need for extended high resolution family typing for patients in regions where there is high rate of consanguinity. disclosure of conflict of interest: none. [p ] p donor-recipient rh incompatibility is a risk factor for mortality after pediatric matched related allogeneic hematopoietic stem cell transplantation k ghanem , n hariss , z merabi, n kreidieh , n tarek, r saab , s muwakkit , h el-solh and m abboud american university of beirut, department of pediatrics and adolescent medicine and american university of beirut, optimal donor selection is critical to achieve the best outcome after allogeneic hematopoietic stem cell transplantation (allo-hsct). there is no consensus regarding the effect of donor-recipient rh incompatibility on survival after matchedrelated donor (mrd) allo-hsct in children and adolescents. this abstract aims to study this effect in a single-institution cohort over a period of years. this is a retrospective chart review for all patients aged o years who underwent allo-hsct at the american university of beirut medical center between august and june . a total of patients with a median age of years (range: . - years) underwent allo-hsct from mrd for the following diseases: leukemia (n = ), bone marrow failure (n = ), thalassemia (n = ), scid (n = ), metabolic diseases (n = ) and lymphoma (n = ). the stem cell source was bone marrow for patients ( %) and mobilized peripheral blood stem cells for patients ( %). the grafts contained a median of . × /kg total cd cells. tbi was used in patients ( %). all but patients achieved sustained neutrophil and platelet engraftment. after a median follow-up of months (range: - months), the -year overall survival rate was % ( % ci: - %). by multivariate analysis using cox proportional hazard regression model looking at the following factors for overall mortality: diagnosis, recipient's age, donor's age, the use of tbi, stem cell source, cd count, donor-recipient abo incompatibility, donorrecipient rh incompatibility, and donor-recipient sex-mismatch, the only statistically significant risk factor for mortality was donor-recipient rh incompatibility (hr: . , p: . ). this risk was not statistically significant when looking at transplantrelated mortality (hr: . , p: ) and relapse-related mortality for malignant diseases (hr: , p: . ). there was no association between the incidence of acute or chronic gvhd and rh incompatibility. donor-recipient rh incompatibility was associated with an increased risk of mortality in children and adolescents undergoing mrd allo-hsct. further studies with larger number of patients are needed to confirm this finding. disclosure of conflict of interest: none. effect of iron or vitamin b deficiencies on in vitro colony forming capacity of peripheral blood-derived hematopoietic stem cells in children ny Özbek, mm zabun, y köksal and m Özgüner iron deficiency (id), id anemia (ida)and vitamin b deficiency (vit-b d) are common disorders in developing countries. in urgent situations, children with these disorders could be donors before treatment. in this study, we investigated capacity of peripheral blood-derived hematopoietic stem cells to develop colony-forming units (cfu) in children with id and vit-b , in vitro. patients and methods: we included children (age months- years) in the study in groups: children with id (n = ); children with ida (n = ); children with vit-b d (n = ); children with both id and vit-b d (i/ vit-b d; n = ); and control children (n = ) who has normal peripheral blood findings, and normal ferritin and vit-b levels. from each child complete blood counts (cbc), and levels of ferritin, vit-b , and cero-reactive protein (crp) have been obtained. who criteria, adjusted for age and sex, have been used for definition of anemia, id, ida and vit-b d. four ml peripheral blood drawn into tubes with edta has been used for cfu analysis. mononuclear cell suspension ( . × cell/ml), obtained from peripheral blood by ficoll-hypaque density gradient separation method, has been cultured in dishes containing semi-solid agar culture medium (methocult, h classic, stem cell technologies, canada) in appropriate conditions. after weeks, number of cfu colonies [burst forming erythroid (bfu-e); colony forming unitgranulocyte macrophage (cfu-gm); colony forming unitgranulocyte-erythrocyte-monocyte-megakaryocyte (cfu-gemm)] have been investigated by an inverted microscope. results: statistical analysis showed no difference between groups for age, sex, crp levels, and cfu-e, cfu-gm and cfu-gemm numbers. however, expected differences between groups were present concerning mean values of hemoglobin, ferritin and vit-b levels, mean corpuscular volume (mcv), and red cell distribution width (rdw) ( table ) . discussion: this study shows in vitro proliferation capacity of peripheral stem cells has not been influenced by id, ida, vit-b d, or i/vit-b d. our results may indicate normal grafting ability of peripheral stem cells obtained from donors with iron, vit-b or i/vit-b deficiencies for hematopoietic stem cell transplantation. however, in vivo analysis should also be performed in order to reach a definite conclusion. [p ] disclosure of conflict of interest: none. efficiency of day compared to day stem cell mobilization in allogeneic donors h al-gaithi , s al-mamar , m al-huneini , d dennison , s al-kindi , k al-farsi and m al-khabori hematology residency training program, oman medical specialty board; hematology department, sultan qaboos university hospital granulocyte colony stimulating factor (g-csf) given for - days is commonly used for mobilization of allogeneic stem cell donors. the optimal days of g-csf administration is still debatable. the primary objective of this study is to compare the yield of stem cell mobilization, assessed using cd + cell count, between day and day . secondary objectives include the assessment of the impact of donor's age, weight, mean corpuscular volume and blood group on the difference in the cd + cell count. in this retrospective study we included all allogeneic stem cell donors mobilized with g-csf for days from january till october in the bone marrow transplantation unit at sultan qaboos university hospital. of donor records reviewed, were with available data and selected for the study. descriptive and analytical statistics were performed using stata . . we included donors with median age and weight of years and kg, respectively. the median day wbc and cd + cell count were . × /l and × /l respectively; while the median day wbc and cd + cell count were . × /l and × /l, respectively, (figure) with a statistically significant difference from day (p o . ). in the multivariable model, there were no significant impact of donor's age (p = . ), weight (p = . ), height (p = . ) and mean corpuscular volume (p = . ) on the difference in cd + cell yield. however, donor's blood group ab predicated a significantly higher difference (p = . ). six days of g-csf mobilization achieves higher cd + cell count than days in allogeneic stem cell donors especially in donors with blood group ab. however, cd + cell count on day is high enough to allow for successful mobilization. appropriately designed prospective trial is needed to confirm these results. disclosure of conflict of interest: none. there are known differences between individuals on an unrelated hsc donor register who decide to proceed with verification typing (vt) vs those who choose not to. in the anthony nolan registry, white british donors are more than twice as likely as other ethnic groups to continue with testing at vt (or . ; po . (unpublished data)). the purpose of this study was to explore differences in key characteristics between white british donors and british donors from other ethnic groups with a view to developing interventions to reduce vt stage attrition. study recruitment occurred april -may . all donors not proceeding at vt were invited to participate, and a stratified random sample of those proceeding at vt were recruited to meet pre-determined targets for each ethnic group. data were collected via structured interview (telephone or online). broad categories of participant characteristics were assessed: demographic, culturally related, psychosocial, and donation-related. measures were previously validated scales with established psychometric properties either created for, or used in other donation-related settings. for analyses donors were divided into two groups based on ethnicity: white british (wb), and non-white british (nwb). results: wb donors and nwb donors completed interviews donors proceeding at vt were more likely than their counterparts to participate in the study ( % vs %, p o . ). mean donor age was . with no difference between ethnic groups and % of donors in both groups were female. nwb were statistically more likely to have completed higher education, and have a stronger religious affiliation. in contrast they were less likely to be blood or organ donors. nwb also described greater mistrust of the medical system and of hsc allocation. nwb donors were more likely to have joined the register at a recruitment event (p= . ) or a place of worship (p= . ), while wb donors were more likely to have joined online (p= . ). wb donors reported significantly higher scores regarding feeling well informed about donation both at the point of joining, and at the point of vt and were more likely to remember joining the register and the two donation methods. this study highlights important differences in demographics, culturally related variables and donor interaction with the register between white british donors and donors from other ethnic backgrounds. given the higher rate of vt attrition in nwb donors, these findings could be used to tailor interactions/information given to donors on the register to ensure their priorities are addressed. disclosure of conflict of interest: none. data on mismatched family donor transplants for myelofibrosis are scarce due to the risk of poor engraftment, gvhd and exclusion from trials. outcomes from such transplants performed between and reported to the ebmt are presented. sixty-nine patients, median age ( - ) years; ( %) male, ( %) had primary, ( %) had secondary myelofibrosis ( from et, from prv and others) and unknown ( %). jak v f was mutated in / . karnofsky performance status was % in %; median time from diagnosis to allograft was . (range: . - ) months. the donors were predominantly male ( %), median age ( - ) years, hla mismatched at locus in ( %) and or more loci in ( %). donor-recipient serology was cmv − / − in ( %) ± in ( %), − /+ in ( %) and +/+ in ( %) missing ( %) . bone marrow was used in ( %) and peripheral blood in ( %). the median total nucleated cell count (tnc) was . × /kg (range: . - × /kg) (n = ). the median cd + cell dose was . × /kg [p ] s (range: . - . × /kg)(n = ). patients. conditioning was myeloablative in ( %) and ric in ( %). predominant conditioning regimes were fludarabine, busulphan, atg (fbatg) and thiotepa, busulphan, fludarabine (tbf n = ). tbi was administered in ( %) and t cell depletion in vivo in ( %) and ex vivo in ( %) patients. gvhd prophylaxis varied with post transplant cyclophosphamide administered in / ( %) and atg in / patients ( %).neutrophil engraftment occurred in ( %) patients at a median of days (range: - ). primary graft failure ensued in ( %) and secondary graft failure in ( %) patients at a median of (range: . - ) months. eleven patients had a second allograft at a median interval of ( - ) months. responses to the first allograft censoring for a second allograft, data available in patients, showed that complete remission was achieved in patients ( %), ( %) were never in cr and ( %) were not evaluable. relapse occurred in ( %) of patients at a median interval of ( . - . ) months. the cumulative incidence (ci) of grade ii-iv acute gvhd (agvhd)was % ( % ci - %) and for grade iii-iv agvhd at was % ( % ci - %). data for chronic gvhd (cgvhd) was valid in patients of whom % developed cgvhd. the ci of cgvhd at years was % ( % ci - %):ci of limited cgvhd was % ( % ci - %) whereas the ci of extensive cgvhd was % ( % ci - %). median follow-up was ( % ci - ) months. the and year os was % ( % ci - %) and was % ( % ci - %). the and year rfs was % ( % ci - %) and % ( % ci - %). the -year ci of relapse was % ( % ci - %). the year nrm was % ( % ci - %), which increased to % ( % ci - %) at years. thirty patients died due to infection ( , %), gvhd ( , %), organ damage or failure ( , %), relapse/disease progression ( , %) and secondary malignancy or ptld ( , %) unknown . there was no significant effect (univariate analysis) of recipient or donor gender, degree of hla mismatch, cmv matching, primary or secondary mf, chronic vs advanced disease at transplant, conditioning intensity or regimen, gvhd prophylaxis with atg or post transplant cyclophosphamide or stem cell source on overall survival. the data are encouraging for patients with myelofibrosis, with engraftment, pfs and os being attained with limited severe chronic gvhd from family mismatched donors. disclosure of conflict of interest: none for all other authors, fc consulting with molmed. feasibility of salvage second allogeneic stem cell transplantation for disease relapse or graft failure: a single centre experience g battipaglia , , d salvatore , , r dulery , f giannotti , f malard , e brissot , s sestili , f isnard , s lapusan , a-c mamez despite high rates of toxicity and mortality, a second salvage allogeneic stem cell transplantation (second allohsct) might be an option to consider in patients experiencing disease relapse or graft failure after first allohsct. we retrospectively analyzed outcomes after second allohsct in a cohort of patients ( males and females) transplanted either for disease relapse (group , n = ) or graft failure (group , n = ) between and in a single centre in france. median age at second allohsct was (range: - ) years. diagnoses were acute myeloid leukemia (group : n = ; group : n = ), acute lymphoblastic leukemia (group : n = ; group : n = ), myelodysplastic syndrome (group : n = ; group : n = ), myeloproliferative neoplasm (group : n = ; group : n = ), bone marrow failure (group : n = ; group : n = ). median time from first allohsct to second allohsct was (range: . - ) months in group and . (range: - ) months in group . graft source for the second allohsct were: haploidentical bone marrow (group : n = ; group : n = ), haploidentical pbscs (group : n = ; group : n = ), cord blood (group : n = ; group : n = ), matched unrelated pbsc (group : n = ; group : n = ). at time of second allohsct, patients were in cr and presented active disease in group . conditioning regimen was myeloablative in patients (group : n = ; group : n = ), reduced intensity (ric) in cases (group : n = ; group : n = ). a sequential schema consisting of a combination of thiotepa, etoposide and cyclophosphamide followed by a fludarabine and busulfanbased ric was used in out of patients with active disease in group . sixteen patients received atg as part of the conditioning regimen for second allohsct (group : n = ; group : n = ). all but one patient engrafted, at a median time of (range: - ) days. cumulative incidence of acute and chronic gvhd were ± % and ± %, respectively, - ) months, non-relapse-mortality (nrm) and relapse incidence (ri) were ± % and ± %, respectively, while disease-free (dfs) and overall survival (os) were ± % and ± %, respectively, for the entire cohort. in all, patients died of infections (n = ), hematological disease (n = ), gvhd (n = ), hemorrhage (n = ) and for unknown causes (n = ). main outcomes of patients in group were: ri ± %, nrm ± %, agvhd ± %, cgvhd ± %, dfs ± %, os ± %, respectively. main outcomes of patients in group were: ri ± %, nrm ± %, dfs ± %, os ± %, agvhd ± %, cgvhd ± %. historically, a second allohsct was hampered by significant morbidity and mortality. however, the advent of reduced-toxicity conditioning regimens and improved supportive care allowed to significantly improve the results of patients receiving a second allohsct as suggested from the above results. therefore, a second allohsct could be considered as an option to rescue a certain number of patients experiencing disease relapse or graft failure, for which prognosis is very poor. decision is to be discussed on a case-by-case basis. disclosure of conflict of interest: none. haploidentical hematopoietic stem cell transplantation with post-transplant cyclophosphamide for patients with high-risk hematologic malignancies am carella department of oncology and hematology, irccs casa sollievo della sofferenza, san giovanni rotondo allogenic hematopoietic stem cell transplantation (sct) has been increasingly used for treatment of adult with high risk hematologic malignancies. for patients lacking an hlamatched related or unrelated donor, unmanipulated haploidentical (haplo)-sct is a potential alternative. haploidentical transplantation performed with post-transplantation cyclophosphamide (ptcy)-based graft-versus-host disease (gvhd) prophylaxis has been associated with favorable outcomes for patients with acute leukemia and lymphomas we analyzed outcomes of patients with hematologic malignancies who received t-cell-replete haematopoietic stem cells and posttransplantation cyclophosphamide after myeloablative or nonmyeloablative hla-haploidentical donor transplantation. the median age was years ( - ); twelve patients were in first remission (cr ), in second remission (cr ) and had an active disease. ). the diagnosis was acute leukemia (n = ), myelodisplastic syndrome (n = ), hodgkin disease (n = ) non hodgkin lymphoma (n = ) and multiple myeloma (n = ). median follow-up was days. stem cell source was bone marrow (bm) for patients, and peripheral blood (pb) for . myeloablative conditioning (mac) was used in patients and reduced intensity regimen (ric) in patients. thirty one patients were first grafts, the others underwent previous autologous sct (n = ) or mud (n = ). gvhd prophylaxis s consisted in pt-cy on days + and + , cyclosporine (from day + ), and mycophenolate (from day + ). the median day for neutrophil engraftment was day + ( - ). no graft failure was observed. chimerism was evaluable in patient; on day + all patients had % donor chimerism on marrow cells median follow-up was days. the cumulative incidence of acute gvhd grade ii-iv was %, grade iii-iv % and chronic gvhd %. one-and -years os was . % and . %, respectively. with a median follow-up for the surviving patients of days ( - ), the cumulative incidence of transplant-related mortality (trm) is %, and the relapserelated death is %. thus, we demonstrate excellent rates of engraftment, gvhd, and trm in adult patients treated with haploidentical hematopoietic stem cell transplantation with post-transplant cyclophosphamide. this approach is a widely available, safe, and feasible option for adult patients with high risk hematologic malignancies, including those with a prior history of myeloablative bmt and/or those with co-morbidities or organ dysfunction, also for patients with active disease at the time of transplant. disclosure of conflict of interest: none. it has recently been shown that t-replete allogeneichematopoietic stem-cell transplantation (allo-hsct) from a haploidentical donor (haplo-id) could be a valid option when a matched donor is not available. unfortunately, the worldwide donor registries comprise mainly donors of caucasian origin and patients of non-caucasian origin have a much lower chance of finding a matched unrelated donor (mud). the lengthy period of international search when required and the financial burden of this process are considered as additional significant limitations. at the american university of beirut medical center (aubmc) in lebanon, we started the mud program in and haplo-id hsct program in . we report here our experience in this two groups of patients. patients and methods: we have transplanted patients from a haplo-id donor since and compare their outcome with the patients transplanted from a mud since . the patients and transplant characteristics are listed in the table . the groups were comparable except for conditioning. patients in haplo-id group received two days of posttransplant high-dose cyclophosphamide (pt-hdcy) followed by cyclosporine a (csa) and mycophenolate-mofetil while patients in the mud group received pre-transplant antithymocyte-globulins and csa starting on day- . all patients engrafted in the mud group, while one patient did not engraft in the haplo-id group, the patient had refractory all transplanted with progressive disease, and died on day + . the median of anc /mm was days ( - ) vs days ( - ) in the haplo-id and mud groups, respectively. fourteen patients from the haplo-id group developed grade acute graft-versus-host disease (agvhd) vs one after mud-hsct. two patients haplo-id group developed limited cgvhd and none after mud grafts. six patients relapsed in the haplo-id group vs three patients in the mud group. two and three patients died from non-relapse mortality in the haplo-id and mud group, respectively. at the last follow-up, patients are still alive in the haplo group vs patients in mud group and all of them are in cr. we conclude that t-replete haplo-id hsct followed by pt-hd cy is associated with promising results or at least comparable to patients transplanted from mud. haplo-id hsct seemed to be safe and feasible in patients with high risk hematological malignancies. finally, because of the obvious advantage in rapidly finding a donor ( haplo transplants in three years vs mud transplants in years), development of haplo-id hsct is warranted to satisfy the regional needs. [p ] disclosure of conflict of interest: none. haploidentical hematopoietic stem cell transplantation (haplo-hsct) using t-cell-replete (tcr) grafts and posttransplantation cyclophosphamide (ptcy) provides a curative approach for patients with high-risk mds/aml lacking a conventional hla-matched donor. in children and adults haplo-hsct using ptcy as gvhd prophylaxis seems to be safe with low treatment related morbidity and mortality (trm). however, few data are available for elderly patients with advanced disease. we retrospectively analyzed the outcome of patients with mds (n = )/aml (n = ) age - years (median age years; patients - years, patients ⩾ years; male), who underwent tcr haplo-hsct with high-dose ptcy at our institution between january and november . disease was active in patients while had achieved cr. patients failed previous allo-hsct. pretransplantation risk factors were scored using the hematopoietic cell transplantation-specific comorbidity index (hct-ci) which was ⩾ in patients (median hct-ci = , range: - ). a sequential therapeutic concept using either flamsa (n = ) or clofarabine (n = ) as cytoreduction was used prior to reduced intensity conditioning (ric) in all but patients. ric consisted of fludarabine/cyclophosphamide combined with either melphalan (n = ), busulfan (n = ) or gy tbi (n = ). post-grafting immunosuppression consisted of cyclophosphamide, tacrolimus and mmf in all patients. % received a bone marrow graft. one graft rejection occurred. neutrophil and platelet engraftment was achieved in % and % of evaluable patients, respectively at a median of ( - ) and ( - ) days. acute gvhd grade i-iii occurred in % of the patients whereas no grade iv agvhd was observed. chronic gvhd presented in %. it was most frequently assessed as mild to moderate ( pts). only patients developed severe cgvhd; no gvhd related death was observed. cmv reactivated in of patients at risk, one patient developed cmv disease (pneumonia). no ebv reactivation or ptld occurred. one-year trm was %. / ( %) patients relapsed, three within the first days after haplo-hsct. at a median follow up of months (range: - months) estimated one-and two-year overall survival (os) was / %, respectively. when stratified by age, estimated one-and two-year os was / % in patients o years and / % in patients ⩾ years (p = . /p = . ). one-and two-year progression-free survival (pfs) was / %, respectively. stratified by age estimated one-and two-year pfs was / % in patients o years and / % in the elderly (p = . /p = . ). unmanipulated haploidentical allografting using ptcy-based gvhd prophylaxis in high-risk mds and aml patients aged over years is safe and well tolerated resulting in acceptable trm. a remarkable survival outcome can be achieved in elderly high-risk aml/mds patients with significant comorbidities. disclosure of conflict of interest: none. key performance indicators to assess the quality of a collection facility: experience of a single center s roncon*, c pinho , f bordalo , s lopes , s ferreira and f amado allogeneic hematopoietic stem cell transplantation (allo-hsct) has evolved into an effective immunotherapy for the treatment of a variety of disorders. when patients do not have a familiar matching donor, transplant centers (tc) search for an unrelated and volunteer donor. this one must be previously evaluated by the collection center (cc) to donate peripheral blood stem cells (pbsc) or bone marrow (bm); lymphocytes can also be asked after allo-hsct. this work aims to evaluate our performance as cc, ensuring donor safety, quality of cell therapy products (ctp) and the accomplishment of tc requirements. we retrospectively analyzed all the requests of ctp collections sent by the portuguese registry from to . countries of destination, number and type of ctp were determined. we established eight key performance indicators (kpi) classified into four categories: response time; product quality; satisfaction of patients and donors; and on-site donor motivation. the intended target was defined by the mean result obtained in the first half of (excluding kpi- ). written comments from donor center (dc) and tc were received by email or written in the local notebook. the donor's answers were obtained through a survey given on the collection day. a total of requests were assessed: pbsc, bm, lymphocytes and cancellations; % were sent to europe ( / to portugal), % to america and % to oceania; / were withdrawn by tc ( patients died, presented progressive disease and had a better hlamatched donor) and / by dc ( donors not cleared and refused). the results obtained with kpi- , - , - and - exceeded the intended target (table ) . after the first kpi- results, we verified a positive evolution. we took an average of days of delay in sending donor clearance. however, there is no holdup in the ctp delivery, as demonstrated by kpi- . regarding kpi- it is important to notice that % of ctp with a cell number less than requested were bm and lymphocytes; when pbsc was considered separately, the result increased ( % vs %). analyzing kpi- , % (n = / ) of the contaminated ctp were bm. concerning kpi- , - acknowledgments and - commitment, we recognize that our initial targets were too ambitious ( %). the kpi- shows a low number of complaints (n = ): one due to a misreading of the request and three to communication failures; all were properly examined and rectified. a good general status was guaranteed in almost all the donors (kpi- ). the decrease of kpi- is due to the fact that one donor refused to proceed after three postponements of the collection date by tc. table -key performance indicators of the quality of our activity as a cc. the overall good level of our results reflects an extremely professional performance as a cc. we consider that these kpi should be continuously monitored with the purpose of earlier detect any deviation of the stated goals and assess the progress against settled strategies. we further suggest the establishment of universal indicators in order to standardize [p ] practices, share expertise and improve the quality of services and products provided to patients and donors. two year later, the patient had a genoidentical allogenic stem cell transplant (from the bone marrow stem cell of his sister, who was years old, hla compatible). he had a reduced intensity conditioning, associating busulfan, fludarbine and antilymphocyte serum. months from the asct, he was in complete remission with % donor chimerism. years after the asct, the patient presented a progressive thrombocytopenia without any other peripheral causes. the bone marrow aspiration initially showed a refactory cytopenia with multilineage dysplasia. the patient was followed up during months, and then a second bone marrow aspiration has shown a refractory anemia with excess blasts raeb . a cytogenetic study has every time demonstrated a female karyotype ( ,xx) on mitoses out is , and chimerism was % donor. the diagnosis of the myelodsplastic syndrome of the donor cells was approved. the patient was treated by azacitidine ( mg/m , from j to j , j = j ). after cycles, the patient was in complete hematologic response (normalization of the platelet count) and a partial bone marrow response (normalization of the blasts rate but persistence of the signs of dysplasia). he received more cycles, and presented hematologic relapse (reemerging of thrombopenia). a phenoidentical allogenic stem cell transplantation was suggested. conclusion the occurrence of mds on the donor cells is rare. these anomalies are secondary to intrinsic factors (of donor) or extrinsic factors )of the transplant recipient). the treatment is not definitely determined. disclosure of conflict of interest: none. nk-cell alloreactivity based on kir/ligand mismatch in the donor vs recipient direction provides better graft-versustumor effect in patients with active hematological malignancies undergoing allogeneic t-replete haploidentical transplantation followed by post-transplant cyclophosphamide a wanquet , , s bramanti , , s harbi , s fürst , f legrand , c faucher , a granata , p-j weiller , , c picard , b calmels , c lemarie , c chabannon , , , l castagna , , d blaise , , and r devillier , haplo-sct have been developed in the past years with very interesting results in high risk patients. gvhd prophylaxis using post-transplant cyclophosphamide (pt-cy) recently allowed extending the use of unmanipulated haplo-sct. it was shown that nk alloreactivity, triggered by donor-recipient inhibitory kir gene-gene mismatches, could lead to better outcomes and survival in the setting of in t-cell-depleted haplo-sct. however, few data is available on the impact of kir-ligand mismatch on the outcome after t-replete haplo-sct with pt-cy. we thus assessed the impact of nk alloreactivity on the outcome of patients who received haplo-sct followed by pt-cy. we retrospectively collected the data from patients from two centers who were treated for various high risk hematological diseases and underwent a haplo-sct with pt-cy from december to december . we assessed the kir-binding epitope in hla-c and hla-b molecules for all patients, and we predicted nk cell alloreactivity in the donor vs recipient direction via the immune polymorphism database kir ligand calculator, based on the kir-ligand mismatch between donors and patients. because disease status at the time of haplo-sct is one of the most important predictor of outcome, we separately analyzed two cohorts of patients: those transplanted in complete remission (cr group) and those transplanted with active disease (no cr group). using a multivariate cox model (adjusted by disease type, age and conditioning), we therefore evaluated the impact of nk alloreactivity on outcome in both cr and no cr groups. we analyzed patients with a median age of y ( - ). they were mostly transplanted for lymphoma (n = , %) or aml/ mds (n = , %). patients mostly received a tbi-based nonmyeloablative conditioning regimen (n = , %) and pbsc as graft source (n = , %). eighty one and patients were transplanted in cr and in no cr, respectively. nk alloreactivity was found in / cr patients ( %) and / no cr patients ( %). with a median follow up of months ( - ), cr patients had a significantly better outcome than those in the no cr group ( -year pfs % vs %, respectively, p o . ). in no cr patients, multivariate analysis showed that nk alloreactivity was significantly associated with reduced the risk of relapse (hr = . , p = . , figure a ) with no increase of both acute (hr = . , p = . ) and chronic gvhd (hr = . , p = . ), and nrm (hr = . , p = . ). this led to significantly better pfs (hr = . , p = . , figure b ) and a trend for better os (hr = . , p = . ). in contrast, in cr patients, we found no difference in outcome according to nk alloreactivity for all end points (acute gvhd: hr = . , p = . ; chronic gvhd: hr = . , p = . , nrm: hr = . , p = . , relapse: hr = . , p = . , figure c ; pfs: hr = . , p = . , figure d ; os: hr = . , p = . ). our results suggest that nk alloreactivity provides better disease control with no increase of gvhd, especially in patients transplanted with active disease. thus, donor selection should rely on the prediction of nk alloreactivity. this may contribute to improve outcome of these patients with high risk of relapse after transplantation, underlining the need of a specific strategy of donor search, and the promising perspective of early post-transplant nk-cell-based immunotherapy. haploidentical bone marrow transplantation (haplo-bmt) with post-transplant cyclophosphamide (pt-cy) is being increasingly used, in the last five years, for patients lacking a suitable hla-matched donor. genoa study (eudract number: - - ) provides for a modified gvhd prophylaxis platform compared to the original baltimora protocol. aim of the study: in this study we assessed outcomes in consecutive patients transplanted from a haploidentical donor for haematological malignancies. all patients received a uniform gvhd prophylaxis: cyclosporine (csa) starting on day , mycophenolate (mmf) starting on day + , and post transplant cyclophosphamide (pt-cy) mg/kg, on days + and + . all patients received a myeloablative conditioning consisting of thiotepa, fludarabine, busulfan (three doses n = or two doses n = ), or tbi, fludarabine (n = ). the median age was years ( - ); at transplant ( %) patients were in remission of disease (cr and cr ), and had an active disease ( %); all patients were first grafts. the diagnosis were acute myeloid leukemia (n = ), myelodisplastic syndrome (n = ), acute lymphoblastic leukemia (n = ), myelofibrosis and myeloproliferative diseases (n = ), non hodgkin lymphoma (n = ), chronic lymphocytic leukemia (n = ) and multiple myeloma (n = ). the median follow up was days (range: - days). the median infused mononucleated cells was . × e /kg (range: . - . ). seven patients died before engraftment, and ( %) had autologous recovery: ( %) after conditioning with doses of busulfan. full-donor chimerism on day + was reached in ( %) patients. the median day for neutrophil engraftment was day + (range: - days). the cumulative incidence of grade ii-iv and iii-iv acute gvhd (agvhd) was % (n = ) and % (n = ), respectively. two years cumulative incidence of moderate-severe chronic gvhd (cgvhd) was % (n = ).sixty one ( %) patients experienced haemorragic cystitis. at years the cumulative incidence of non relapse mortality (nrm), relapse and relapse related death was % (n = ), % (n = ) and % (n = ), respectively. causes of death were infections (n = ), hemorrhage (n = ), gvhd (n = ), secondary neoplasia (n = ) and relapse (n = ). at years of follow up overall survival and disease free survival was . % and %, respectively. at the same time overall survival rate was % for patients in remission and % for patients with active disease at transplant(p o . ). in conclusion, a modified pt-cy as gvhd prophylaxis and ma conditioning regimen followed by haploidentical bmt results in a low risk of agvhd and cgvhd and encouraging rates of trm and dfs. disclosure of conflict of interest: none. the italian bone marrow donor registry (ibmdr), in collaboration with admo (associazione donatori di midollo osseo) since has implemented, as part of the donor enrollment strategy, public enrollment events (pe). our donor center (dc) has taken part to those events since the first years. one or more clinician (or trained biologist) has been present to pe to inform the potential donors, evaluate the candidates and supervise the collection of biological fluids. all the local permission where obtained. aim: aim of this study was to compare the compliance of the donor enrolled in pe with donors enrolled at our dc institutional site. we prospectively evaluated all the donors recalled for further evaluation and/or for requalification in the years and at our dc itmi . we defined possible results for the call: ‛success' (the donor was eligible and accepted to be evaluated, or only temporarily ineligible) ‛not eligible' (the donor was definitively ineligible) and ‛consent denied'. results: a total of donors were called back in the years and ( not found). eightyfour recalled donors had been enrolled after . among them ( . %) had been enrolled at the dc and during pe ( . %). the two populations were not different for age at the call, age at enrollment and gender (table ) . [p ] when evaluating the probability of obtaining a "success", no significant difference was found between the two populations: . % vs. . % (chi square p= . ). no significant difference was also found for the "not eligible" and the "consent denied" categories. of note, when we turned to the whole donor population we had called back (median age , range - ), the probability of "success" and "consent denied" were not related to donor age, and time from enrollment to recall, whereas donor ineligibility was (spearman test p= . and . ). public events with the presence of an adequate trained medical team represent a valid option for the enrollment of new unrelated donors. disclosure of conflict of interest: none. the search for hematopoietic stem cell unrelated donors in patients with malignant hemopathies with not-sibling matched family donor: the experience of a center a pérez , r goterris , m gómez , s blanco , a segado , c arbona , jch boluda , m poch and c solano hematology department, hospital clínico universitario, valencia unfortunately, as few as - % of patients will have an hlaidentical matched sibling donor available for hematopoietic stem cell (hst) donation. the search for an unrelated donor (urd) (adult or cord blood) is often the best option for those patients lacking a suitable matched donor. below we describe the experience with the search for an unrelated donor in our center. between september and march the search for urd was activated for patients. the median age of the patients was years (range: . - ), % were under years and % were males. acute myeloid leukemia (n = ), acute lymphoblastic leukemia (n = ), non-hodgkin's lymphoma (n = ), chronic/prolymphocytic lymphocytic leukemia (n = ), hodgkin's lymphoma ((n = ), multiple myeloma (n = ), chronic myeloid leukemia (n = ), philadelphianegative myeloproliferative neoplasms (n = ), myelodysplastic syndrome (n = ), aplastic anemia/paroxysmal nocturnal hemoglobinuria (n = ), others (n = ). the disease status in hematological malignancies was: first cr (n = ), second cr (n = ), pr (n = ) and refractoriness (n = ). the donor type requested at the activation of the search was an adult (n = ), umbilical cord blood (n = ) and two options (n = ). results: a compatible donor was found in patients ( % of the series) after a median of days (range: - ) from the activation of the search. the degree of adult donor compatibility (not available in cases) was: complete hla identity ( / : n = , / : n = ); an hla difference ( / : n = , / : n = ); lower degree of compatibility (n = ). the degree of umbilical cord blood compatibility: identity ⩾ / (n = ). a total of patients ( %) were transplanted, from adult donor and from umbilical cord blood. the median time between the activation of the search and the hst transplantation was months (range: . - ), being . months for acute leukemia and . months for other pathologies, and between the location of the donor and the hst transplantation days (range: - ), being days for umbilical cord blood and days for an adult donor. there were cancellations of the urd search ( % of the total) for the following reasons: clinical status of the patient (n = ), performing a haploidentical transplant (n = ), transplant center does not consider (n = ), norms of the registry (n = ) and loss of indication of transplantation (n = ). the median time from the beginning of the search to its cancellation was . months (range: . - ). at the time of analysis, the median follow-up of the patients is months. the survival of the series in the years is % and % for patients transplanted from urd. % of the searches activated in our center allowed the localization of a urd with an adequate degree of hla compatibility. however, only % of the patients for whom the search was activated were finally transplanted. the most frequent cause of cancellation of the procedure was the clinical deterioration of the patient. disclosure of conflict of interest: none. the leukemic transformation of otherwise healthy donor stem cells provides a useful in vivo model to study the mechanisms involved in leukemogenesis. we report two cases of donor cell-derived haematological malignancy in which wholeexome sequencing (wes) was performed in bone marrow (bm) samples from recipient at different times after allogeneic hematopoietic stem cell transplantation (allo-hsct) in order to study the dynamics of emergence of mutations that precede the development of donor cell leukemia (dcl) and donor cell myelodysplastic syndrome (dc-mds). case : a -year-old female diagnosed with lymphoblastic leukemia-b t( ; ), who developed acute myeloid leukemia (aml) with normal karyotype, npm +of donor origin months after unrelated cord blood transplantation (ucbt). case : a -year-old male diagnosed with mantle cell lymphoma, who developed mds ,xx,- ,del( )(p ) of donor origin, months after allogeneic bm transplantation from his hla-identical brother. the donor also developed mds several months later. wes (sureselect-xt human-exon mb) was performed by next generation sequencing (hiseq) on donor stem cells (scs) infused as well as on bm samples from recipient after allo-hsct. the exome of donor scs and bm samples, from case , were aligned to the human reference genome (grch /hg ) and donor scs and bm samples were aligned to grch / hg in the second case. in both cases non-synonymous variants in the coding regions or synonymous variants in splice regions of genes related to leukemia were selected. in addition, bm samples were matched to their scs and to prior bm samples to identify the acquired variants. variants meeting such criteria were evaluated with functional predictor software's (sift, polyphen and mutation taster). wes analysis revealed progressive emergence of multiple somatic mutations probably related to the development of leukemia in bone marrow samples post allo-hsct ( figure ). both scs showed alterations that may be involved in leukemogenesis. (case : sh b and case : kmt c, kmt a, arhgap and monosomy ). somatic mutations, acquired over time, fall into genes that play well-established roles in signalling pathways (ras-mapk, pre-mrna splicing factor, apoptosis, dna doublestrand break repair, dna replication and so on). mutations in leukemic subclones that disappear after chemotherapy were indentified, as well as the acquisition of new mutations in resistant subclones. we propose a possible model of leukemogenesis in these cases ( figure ). the present study reveals a process of sequential clonal expansions, promoted by the acquisition of additional somatic mutations in donor hematopoietic cells. detection of heritable or acquired gene mutations in donor associated with predisposition to haematological malignancies could have clinical implications for the patients undergoing to allo-hsct. although the cause of donor cell-derived haematological malignancy onset seems to be multifactorial, the infusion of a scu with pre-leukemic potential in a context of residual toxicity in recipient as a result of pre-transplant chemotherapy, a post-transplant environment characterized by a decreased immune surveillance may well have played role in these cases. the study of a greater number of dcl cases by next generation sequencing could help to understand this process and to detect new mutations involved in the emergence of aml. disclosure of conflict of interest: none. the impact of donor and recipient sex in allogeneic stem cell transplantation-single center experience (cic ) y petrov , p ganeva , g arnaudov , s lozenov , y davidkova , v stoeva , i tonev , m guenova and g mihaylov national hospital for active treatment of hematological diseases allogeneic hematopoietic stem cell transplantation (hsct) has been one of the most effective therapeutic modalities for patients with hematological malignancies and bone marrow failure syndromes. optimal donor selection is one of the key factors to enhance the success rate of this procedure. we [p ] s retrospectively investigated whether and how donor-recipient sex affects transplantation outcomes of patients transplanted between and in our center. the median age of the patients was years (range: - ). thirty-nine of the patients ( %) received a pbsc from a hla-identical sibling, and patients ( . %) received pbsc from matched unrelated donor. forty-six percent were male recipients with male donors (m-m), . % were female recipients with male donors (m-f), . % male recipients with female donors (f-m), and . % female recipients with female donors (f-f). we performed a crosstab analysis and χ tests to observe whether the donor sex affects our study population. patients with male donor had superior overall survival and progression-free survival compared to those with female donor ( . % vs . % p = . for os, and . % vs . % p = . for pfs; cramer`s v = . ). we further investigated how the disparity of the donor in the four groups (m-m, m-f, f-m and f-f) affects the os, pfs and nrm. the f-m group had a worse overall and progression-free survival comparing the other groups ( % -year os and % pfs; p o . ).this group had % relative increase in the non-relapse mortality compared with m-m group (p = . ). for m-m group there was a % relative increase in the subdistribution hazard of nrm compared with m-f group (p = . ). the f-f group and m-f group had similar subdistribution hazard of nrm ( % vs % p = . ). the incidence of acute gvhd and chronic gvhd for the groups was: % and % (m-m), % and % (m-f), % and % (f-m), % and % for the (f-f) group. the appearance of either acute or chronic gvhd did not show statistical significance regarding the os and pfs in the groups (p = . ). we examined the effect of donor-recipient sex incompatibility on the outcome of hsct in out center. our results showed inferior os and pfs for f-m group and a higher incidence of nrm compared with other groups. these effects might be associated with allogeneic immune responses against h-y antigens. key words: stem cell transplantation, donor sex, recipient sex, overall and progression-free survival [p ] disclosure of conflict of interest: none. from to , % of the patients affected by hematological malignancy searching for an unrelated donor through the italian registry successfully identified a suitable donor. this proportion increases up to % when searching for a cord blood unit was considered, corresponding to total transplant efficiency of %. from april , the rome transplant network adopted a unique policy for the identification of a potential alternative donor, following a hierarchical selection that considered as first choice a volunteer unrelated donor, secondly a cord blood unit and last a haploidentical related donor. before starting the unrelated donor search, a preliminary query through the bone marrow donor worldwide database was performed for all the patients referred to the rome transplant network. based on the low resolution hla typing (a, b and drb ) it was possible to arbitrary assign a good or poor score that might predict the identification of a full matched ( / a, b, c and drb ) donor. therefore, aims of the present study were to assess the utility of the preliminary query and the impact of the use of high resolution hla typing since the starting of donor search on the timing for the unrelated donor identification. moreover, the final aim was of comparing donor identification and transplant efficiency between the national registry, that considers only the unrelated donor and the rome transplant network, whose policy includes also haploidentical donor as third choice in the donor search process. at rome transplant network % out of adult patients met criteria of a good preliminary query corresponding to a matched unrelated donor identification in % of cases vs only . % for patients with poor preliminary query. our policy led to % and %, respectively, of alternative donor identification and transplant efficiency, significantly higher than the corresponding data of % (p = . ) and % (p o . ) reported by the national registry. moreover, the median duration of search process for mud identification has been significantly reduced by the use of hr hla typing patient at the start of the formal search activation from (range: - ) to (range: - ) days at ibmdr (po . ) and from to days ( - ) at rtn (po . ). in conclusion, the preliminary query represents a useful tool to address the search towards the best donor choice and to perform transplant in adequate time. moreover, the timing of donor identification has been significantly reduced with the use of high resolution typing at the start of donor search. a search and selection donor policy should be basically established and should include the haploidentical donor to improve the transplant efficiency. disclosure of conflict of interest: none. the long term prognosis of elderly acute myeloid leukemia (aml) patients remains poor. advances in the uses of alternative donors and reduced intensity conditioning regimens have extended the use of allogeneic hematopoietic stem cell transplantation (hsct) to a wider number of patients. however, few studies have reported data on the efficacy of hsct from alternative donors in elderly aml patients. we retrospectively analyzed the transplantation outcome in consecutive elderly aml patients aged years who received hsct ( hsct ( - at the catholic blood and marrow transplantation center. donor types were autologous (n = ) or hla matched related (mrd, n = ), unrelated (mud, n = ), or haploidentical (n = ). for graft-versus-host disease (gvhd) prophylaxis, methotrexate and cyclosporine (mrd) or tacrolimus (mud/haploidentical donor) were used. mud and haploidentical donors were given antithymocyte globulin. the median age was years, with patients ( %) years. intermediate-or adverse cytogenetic risk was observed in % of patients. with a median follow-up of . months, overall survival (os) and disease-free survival (dfs) at years after transplantation were % and % for autologous, % and % for mrd, % and % for mud, and % and % for haploidentical hsct, respectively. the -year relapse was significantly higher for autologous hsct compared to allogeneic hsct ( % vs %, p = . ), while it was similar among allogeneic donors: mrd, %; mud, %; haploidentical, % (p = . ). the -year non-relapse mortality (nrm) for mud ( %) or haploidentical donor ( %) hsct was comparable to that of autologous hsct ( %), while it was relatively higher for mrd hsct ( %, p = . ). of the patients receiving allogeneic hsct, the -year cumulative incidence of moderate to severe chronic gvhd was significantly increased for mrd ( %) compared to alternative donor hsct ( %, p = . ). in multivariate analysis, patient age (hr . , % ci . - . , p = . ) and donor type (hr . % ci . - . , p = . for mud; hr . , % ci . - . , p = . for mrd compared to haploidentical donor) were significantly associated with the cumulative incidence of moderate to severe chronic gvhd, while female-to-male hsct showed a borderline significance (hr . , % ci . - . , p = . ). incidence of acute gvhd was similar according to donor type. in the multivariate analysis for nrm, patient age (hr . , % ci . - . , p = . ), mrd (hr . , % ci . - . , p = . ), and hematopoietic cell transplantation-comorbidity index high risk (hr . , % ci . - . , p = . ) were significantly associated. in conclusion, our results showed significantly higher relapse rate for elderly aml patients receiving autologous hsct compared to allogeneic hsct, responsible for the lower survival rate in autologous hsct. we observed that nrm rate for mud and haploidentical donors for elderly aml patients were lower than expected and similar to autologous hsct. relatively higher incidence of nrm for mrd hsct seemed responsible for the low long term dfs. these results suggest a need for strengthening of gvhd prophylaxis in mrd hsct for elderly aml patients. our results suggest a potential role of alternative donor hsct to improve long term survival rates in elderly patients with aml. disclosure of conflict of interest: none. for patients with saa, transplantation from an unrelated donor (ud) is usually considered after failure of at least one course of immunosuppression. this strategy is based on a relatively high risk of complications for ud transplant recipients, such as graft rejection, graft-versus-host disease (gvhd) and infections. however, the outcome of unrelated donor transplants has significantly improved in recent years, due to better donor selection, conditioning regimen optimization and better supportive care. the authors describe results from patients with saa who receive unrelated allogeneic transplants in a single reference institution from to . data was retrieved from the center databasis and there were females and males. median age was years old . median total number of cells infused was . × /kg. % of the patients have received more than transfusions previously. conditioning regimen were: cy + tbi ± atg in ( %) patients, bu mg/kg+ cy + atg in ( %), and fludarabine + cy+atg in ( %), fludarabine, cy+tbi in ( %) patients. stem cell source was marrow in %, cord blood in % and peripheral blood in % of patients. transplants were full matched in ( %) patients, had one mismatch (out of ) in ( %) and mismatches in ( %) patients. engraftment was complete as evaluated by donor chimerism at day and post transplant in patients ( %), partial in ( %) and graft failure was observed in ( %) patients. acute gvhd grade ii-iv was seen in patients ( %) and nih moderate to severe chronic gvhd was seen in ( %) patients. median overall survival was days ( - ) and estimated years overall survival was %. risk factors for survival identified were: hla mismatch and stem cell sources other than marrow. unrelated transplants are a feasible salvage therapy for patients with saa refractory to immunosuppression, being hla compatibility and marrow stem cell source factors with a positive impact on survival. disclosure of conflict of interest: none. use of haploidentical stem cell transplantation continues to increase, the european society for blood and marrow transplant activity survey report jr passweg , h baldomero , p bader c bonini , rf duarte , c dufour , , a gennery , n kröger , j kuball , f lanza , s montoto , a nagler , ja snowden , j styczynski and m mohty for the european society for blood and marrow transplantation (ebmt) hematopoietic stem cell transplantation (hsct) is an established procedure for many acquired and congenital disorders of the hematopoietic system, including disorders of the immune system, and as enzyme replacement in metabolic disorders. the annual activity survey of the ebmt describes the status of hsct in europe and affiliated countries and has become an instrument used to observe trends and to monitor changes in technology use. teams were invited to report their transplant activity for by indication, stem cell source and donor type using a single paged survey. a record number of ' hsct in ' patients ( ' allogeneic ( %), ' autologous ( %)) were reported by centers in countries in . trends include continued growth in transplant activity during the period and , with the highest percentage increase seen in middle income countries (allo %, auto %), and the lowest in very high income countries (allo %, auto %), for both allogeneic and autologous hsct. in contrast the absolute growth is highest in the very high income countries (growth allo rates transplants per × inhabitants, auto rates for very high income countries; allo rates , auto rates for middle income). main indications for hsct were myeloid malignancies ' ( %; % allogeneic); lymphoid malignancies ' ( %; % allogeneic); solid tumors; ' ( %; % allogeneic); and non-malignant disorders; ' ( %; % allogeneic). remarkable is a decreasing use of allogeneic hsct in cll from patients in to in and is most likely due to the development of potentially very effective cll drugs. use of haploidentical donors for allogeneic hsct continues to increase ' in ; a % increase since . the highest growth is seen in myeloid malignancies ' , with lymphoid malignancies , nonmalignant disorders and others. in aml, haploidentical hsct increases similarly for patients with both advanced disease and those in cr . both marrow and peripheral blood is used as stem cell source for haploidentical hsct with higher numbers reported for the latter. this year's activity survey shows continued increase in the use of haploidentical hsct across europe within the main indication groups and cell source. it reflects in a timely manner current trends in stem cell transplantation and is an essential tool for health care planning and health policy makers. human bone marrow mesenchymal stromal cells derived exosomes (hbmmdes) are small membrane vesicles secreted from mesenchymal stromal cells that may serve as a vehicle for protein, mrna and microrna (mirna) transfer to distant cells; affecting gene expression, proliferation, and differentiation of the recipient cells. therefore, mdes may possess some of the immunoregulatory properties of their parental cells. in the present study we aim to explore the immunomodulatory function of mdes and understand the molecular mechanisms enabling it. for this purpose, we co-cultured hbmmdes with activated human lymphocytes. using ultracentrifugation, hbmmdes were isolated from expanded human bone marrow derived mesenchymal stromal cells (hbmmscs). using em and zeta sizer, particles were shown to be in the range of - nm. pha activated human peripheral blood lymphocytes (pbls), r- /il activated b cells and anti cd /cd activated t cells were co cultured with purified mdes. cell proliferation was tested using thymidine incorporation assay. we found that exosomes derived from × to × mscs exhibited a dose-dependent inhibition of lymphocyte proliferation. exosomes derived from × mesenchymal stromal cells co cultured with pha activated pbls, activated b cells and activated t cells showed proliferation inhibition of %( p ⩽ . ), . % (p ⩽ . ) and . % (p ⩽ . ), respectively. in order to understand the molecular mechanism behind the immunomodulatory effect of mdes, we have profiled mde's mir content using illumina hiseq platform and we are currently profiling co cultured activated lymphocytes mrna content using next-generation sequencing system, illumina. preliminary results demonstrate some higher abundance of specific mscs derived mirs in the mdes. hbmmscs have been shown to serve as immune modulators in patients with acute and chronic graft versus host (gvhd). in the future, mdes may provide an alternative therapy for gvhd. compared with bmmscs, mdes are more stable, have no risk of aneuploidity or ectopic proliferation and have less probability of immune rejection. additional studies are needed to explore the applicability of mdes to serve as modulators of the immune response. disclosure of conflict of interest: none. graft-versus-host disease (gvhd) is the major complication after allogenic haematopoietic stem-cell transplantation s (hsct). extra virgin olive oil (evoo) is a source of phenolic compounds such as glycoside oleuropein, hydroxytyrosol and tyrosol. olive oil polyphenols have shown antioxidant, immunomodulatory, antiproliferative, anti-apoptotic and antiinflammatory properties that might be useful in the prophylaxis and treatment of gvhd. polyphenolic extract (pe) of evoo was obtained by the method described by vazquez roncero et al. with some modifications. briefly, fifty grams of evoo (oleoestepa, seville, spain) was extracted with methanol/water ( : , vol/vol, ml ). the mixture of evoo, methanol and water was decanted and the methanolic extract was concentrated and lyophilized. then, the effect of pe in cell viability and activation of t lymphocytes from healthy donor's buffy coats either resting or activated with anticd plus anticd was analyzed by flow cytometry after staining with aad, anexin-v and cd . proliferation assays were performed with pkh and the quantification of il- , il- , il- , il- , tnf-α and ifn-γ cytokines in cell culture supernants with bd cytometric bead array (cba). signaling pathways were analyzed by western blot. finally, in a mouse model of acute gvhd (c bl/ in balb/c), mice were randomized into two experimental diet groups: standard diet ( s harlan laboratories) and standard diet ( s harlan laboratories) supplemented with ppm of pe obtained of evoo. the severity of gvhd was assessed by a scoring system described by cooke et al. that incorporates five clinical parameters: weight loss, posture (hunching), activity, fur texture, and skin integrity. pe did not affect t cell viability. by contrast, pe decreased t-cell activation and proliferation of t-lymphocytes stimulated with anticd plus anticd . in addition, there was a decreased production of th (ifnγ, il- and tnf) and th cytokines (il- , il- and il- ) in the presence of pe. regarding the signaling pathways analyzed, pe inhibited phosphorylation of akt and nuclear translocation of nfkb in activated t cells. in the mouse model of acute gvhd, animals which received the pe supplemented diet had an increased survival as compared to mice receiving a standard diet. also, gvhd incidence was significantly lower among mice receiving the pe supplemented diet as assessed by both the presence of gvhd signs as well as pathological examination. polyphenols obtained from evoo are an important immunomodulatory agent capable to reduce the proliferation and activation of activated t cells and the production of proinflammatory cytokines. in a mouse model of acute gvhd, pe supplemented diet reduced the incidence and severity of the disease and increased the survival of mice. disclosure of conflict of interest: none. graft-versus-host disease (gvhd) is a leading cause of postallogeneic haematopoietic stem cell transplantation (hsct) morbidity and mortality ( ) . extracorporeal photopheresis (ecp) is an alternative therapeutic strategy that appears to act in an immunomodulatory fashion, potentially involving regulatory t lymphocytes and dendritic cells in patients who are refractory to steroids. dendritic cells (dcs) are the most important antigen-presenting cells, playing a pivotal role in t-cell function and in the link between innate and adaptive immunity. moreover, dcs are also critical mediators of immune tolerance and energy. they can be divided into two major subsets, plasmacytoid dcs (pdcs) and myeloid dcs (mdcs) which have distinct functions. pdcs play a pivotal role in peripheral tolerance through generation of regulatory t (treg). on the other side mdcs promote, as well as pdcs, th and th /tr responses ( - ). our study was performed to understand the mechanism of action involved in immunomodulatory effect of ecp. as the modulation of dcs and tregs number and function ( , ) may be a central mechanism of ecp in maintaining self-tolerance, down-regulating immune responses, and limiting inflammation ( ). eight patients affected by gvhd were included in this pilot study. in ecp apheresed mononuclear cells are exposed to methoxypsoralen and uva radiation. after this photoactivation, which induces dna damage and apoptosis, the cells exposed are re-infused into the patient inducing an immunomodulatory effect. all patients or their legal guardians gave their consent for this study. a sample of peripheral blood (pb) (basal condition), a sample of apheresis pre-uva photoactivation (pre-pa) and a sample of photoactivated apheresis (pa) were collected at the first day of ecp and every week for the first month of treatment. circulating dcs, mdcs (cd / -cd +cd +), pdcs (cd / -cd +cd +) and tregs (cd +cd +foxp +) were directly enumerated and phenotypically characterized. the assays were performed at day+ ,+ , + ,+ ,+ data are expressed as mean ± s.d. of absolute number of cells/μl. at day + there were no differences in the absolute number of both mdcs and pdcs between pre-pa and pa. consequently there were no differences between pb and pa. from day + till + we observed an increase of these two cellular populations at every date of treatment. comparing the basal pb of day + vs day + we observed an increment of % and %, respectively for mdcs and pdcs (mdc from cell/μl to cell/μl; pdc from cell/μl to cell/μl). comparing the basal pb of day + vs day + we observed an increment of % of tregs (from cell/μl to cell/μl) while we observed a median increment of % calculated between pre-pa and pa of each day of treatment from day to day + . no firm conclusions can be drawn from a clinical point of view, however a biological effect has certainly highlighted. in particular no substantial differences in basal pb mdc or pdc emerged during the first month of treatment while a significant increase of mdc and pdc can be observed since day + following uva photoactivation. regarding tregs we observed an increment of % of tregs between pb from day + to day+ and a median increment of % calculated between pre-pa and pa of each day of treatment. disclosure of conflict of interest: none. [p ] p impact of th cells on xenogeneic graft-versus-host disease l delens, s servais , g ehx , l vrancken , g fransolet , c gregoire , m hannon , s dubois , c daulne , f baron and y beguin giga i : hematology, university of liege acute graft-versus-host disease (gvhd) is a severe complication of allogeneic hematopoietic stem cell transplantation. its pathophysiology is complex and not yet fully understood. in particular, the impact of th cells on murine acute gvhd has yielded conflicting results, while demonstration of increased levels of th cells at the site of acute gvhd provided only indirect evidence of their involvement in humans. here, we assessed the potential implication of th cells in a humanized mouse model of xenogeneic gvhd (x-gvhd). methods: x-gvhd was induced by infusing human peripheral blood mononuclear cells (pbmcs) into nod-scid il- rγnull (nsg) mice given . gy total body irradiation day prior transplantation. th cells were generated by culturing naive cd + t cells with anti-cd /anti-cd coated beads under th -skewing cytokines (tgf-β , il -β, il- , il- , il- , neutralizing anti-il- and anti-ifnγ antibodies) in hypernatremic conditions (nacl mm). results: after days of culture, a median of . % of il- a+ cells was obtained. we confirmed the expression of il- a, rorc and il- r by these cells by rt-qpcr. we next assessed the co-injection of human pbmcs ( . ) with in vitro differentiated cells under th skewing conditions ( × ) (co-injection group, n = ), in comparison with the injection of pbmcs alone ( × cells, pbmcs group, n = ). we observed higher x-gvhd score (p %) of cells expressing both il- a+ and ifnγ+ cells (th / th -like phenotype) among cd + il- a+ cells while coinjected mice had higher blood concentration of il- a (p = . ) than pbmc mice. these results demonstrate that addition of th cells worsened x-gvhd confirming their role in acute gvhd pathogenesis. disclosure of conflict of interest: none. although survival from allogeneic stem cell transplantation (hsct) has significantly improved, acute graft-versus-host disease (gvhd) remains a major cause of death. intestinal dysbiosis has been associated with acute gastrointestinal gvhd and poor outcome after hsct. we reported a correlation between microbiota (gm) composition and short chain fatty acid (scfa) production and gvhd in transplanted children. to assess how the metabolic pathways of gm change during transplantation and identify modulators of immune response, we perform first longitudinal metagenomic analysis in children undergoing hsct. patients (pts) ( male; mean age: y) with hematologic malignancies ( all, aml), who received busulphan-based myeloablative conditioning and t-cell replete bone marrow graft were enrolled. pts were prospectively enrolled in a protocol with at least specimens fecal samples collected: one before and two after hsct, in order to build a proper trajectory. gvhd prophylaxis was cyclosporine for pts receiving a matched related donor and cyclosporine, short-term mtx and atg for pts receiving a matched unrelated donor. non-gvhd and gvhd patients had similar exposures to antibiotics during the stool collection. of these pts, % developed gvhd within the first days. we applied shotgun metagenome sequencing to total fecal dna from samples collected. functionalities were assigned by reads mapping at different levels of the kegg database. relative abundance was calculated and statistical analysis was performed. according to our findings, core functional profiles were overall conserved through the time-points in all patients ( figure a ), in contrast to the phylogenetic profiles behavior, this finding confirming the overall redundancy of gut microbiome core functionalities. analyzing the single metabolic pathways in subjects who developed gvhd, we found in the pre-hsct period a higher relative abundance of nucleobasis (purine and pyrimidine) metabolism (p o . ) and branched-chain amino acids biosynthesis (p o . ). functions related to the production of branched-chain amino acids are involved in the biosynthesis of the cell wall of gram-negative bacteria, microorganisms including subgroups with well know opportunistic pro-inflammatory. in addition, post-hsct samples of gvhd patients showed a lower abundance of genes involved in polysaccharides metabolism, as glycan biosynthesis and glycosaminoglycan degradation (p o . ) ( figure b ). glycosaminoglycan degradation activity gets bacteria able to survive during extreme situations, as fasting using mucus polysaccharides as energy source, contributing to maintain a mutualistic composition of gm and scfa production by the saccharolytic functions of the endogenous mucus polysaccharides. this study detects functional peculiarities in the gm of non-gvhd pts. the gut metagenome configuration of non-gvhd patients is structured to derive scfa after hsct. the production of these metabolites promotes peripheral regulatory t-cell generation , potentially explaining the protective role of gm from gvhd. although intestinal epithelial cells (iecs) are crucial regulators of barrier function and immune homeostasis, they also facilitate inflammation in exaggerate responses to proinflammatory mediators by pretransplant conditioning regimen, which plays a critical role in amplifying graft-versus-host disease (gvhd). thus inhibition of the converting to pathogenic iecs by conditioning may represent a novel approach to inhibit gvhd. aryl hydrocarbon receptor (ahr) is the ligandactivated transcription factor which has the ability to mediate the biochemical, metabolic, and toxic effects of environmental chemicals. recently, it has been demonstrated that ahr is an important regulator of cell development, differentiation, and function of both innate and adaptive immune cells. the ability of ahr is induced by respond to endogenous ligands generated from the host cell, diet, and microbiota. here, we investigated the regulatory role of ahr in iecs under inflammatory responses and its therapeutic activity for modulation of gvhd. ahr and cyp a expression in mouse iecs were determined by real-time pcr. mouse iecs were pretreated with endogenous ahr ligands l-kynurenine (l-kyn, mm) or pbs for h and then stimulated with lps or il- b for h. cytokine levels were measured using the mouse flex-set cytokine bead array or real-time pcr. b d f (h- b/d) recipients were administrated l-kyn daily by i.p. injection for days. then the recipients were lethally irradiated and transplanted with × tcd-bm plus × t cells from b (h- b) donor. mice were monitored every other day for survival and clinical score. colons were collected and stained with hematoxylin and eosin (h&e) for histopathological scoring. we found that ahr was constitutively expressed in the mouse iecs. cyp a (an ahr target gene) was significantly increased by treatment of l-kyn under un-stimulatory condition. we further observed that l-kyn completely abrogated il- β-mediated il- or lps-mediated tnf-a expression in iecs. administration of bdf recipient mice with l-kyn before transplantation significantly reduced the lethality and severity of gvhd. histopathology clearly revealed that treatment of l-kyn inhibited intestinal gvhd. our results demonstrate that ) ahr is constitutively expressed in iecs, ) treatment of endogenous ligand l-kyn induce ahr activation in the steady status, ) ahr activation blocks conversation of the epithelial cells into pathogenic cell type, and ) pre-administration of ahr ligand reduces gvhd. our study suggests that activation of ahr pathway in iecs before allogeneic hematopoietic stem cell transplantation (hsct) is a possible strategy to reduce intestinal gvhd. disclosure of conflict of interest: none. [p ] s relating with acute graft-versus-host disease (gvhd) after allogeneic hematopoietic stem cell transplantation (allo-hsct), protecting endothelial cells (ecs) from damage may be a potent prophylaxis and therapeutic strategy of acute gvhd (agvhd). conventional agvhd therapies may cause many adverse side effects because of their multiple targets. therefore, we explored the therapeutic efficacy of simvastatin, a lipid-lowering drug, which has been demonstrated endothelial protection. our previous clinical observation has found patients with agvhd had lower angiopoietin- (ang- ) level at day but higher ang- level at day than those without agvhd. in this study, we explored changes in ang- and ang- expression in an agvhd mouse model and determined whether simvastatin prevents gvhd through regulating ang- and ang- expression. we preincubated ea.hy ecs with simvastatin ( mmol/l) h before stimulated with tnf-a, then ang- and ang- concentration in the cell supernatant was measured by elisa. ang- and ang- mrna and protein level of treated and untreated cells were examined simultaneously. in vitro simvastatin increased ang- production and release but conversely inhibited ang- release from ea.hy ecs. donor mice spleen cells were injected along with bone marrow cells into recipient mice after lethal irradiation to induce agvhd. simvastatin was administered orally once daily to mice ( mg/kg) for days after allo-hsct and started − day after allo-hsct. then mice survival time was monitored and organ damage was evaluated. the plasma level of ang- and ang- was measured by elisa, expressions of ang- and ang- in aortic endothelium were assessed by immunohistochemistry. simvastatin improved the survival and attenuated the histopathological gvhd grades of agvhd mice. plasma levels of ang- were significantly decreased, while plasma levels of ang- obviously increased in agvhd mice after transplantation. simvastatin reduced plasma levels of ang- , elevated the plasma levels of ang- as well as the aortic endothelial levels of ang- and ang- . in summary, simvastatin represents a novel approach to combat gvhd by increasing ang- production while suppressing ang- release to stabilize endothelial cells. there is a growing evidence of safety and efficacy of posttransplantation cyclophosphamide (ptcy) in stem cell transplantations (sct) from different donors and graft sources. still the optimal combination of immunosuppressive agents with ptcy should be elucidated for different types of scts. we report the -year update of the prospective nct single-center trial that evaluated risk-adapted graft-versushost disease (gvhd) prophylaxis with ptcy in related, unrelated and haploidentical scts. adult patients (median age y.o., range: - ) with hematologic malignancies, including aml ( . %), all ( . %), cml ( . %), mds ( %), and lymphomas ( . %), were enrolled in the study. % of patients were classified as salvage. % received the graft from matched related (mrd), % from matched/mismatched unrelated (mud/mmud), and % from haploidedntical (haplo) donor. % received bone marrow graft (bm) and %peripheral blood stem cell (pbsc) graft. . % had myeloablative conditioning and . %-reduced-intensity conditioning. gvhd prophylaxis for matched bm grafts consisted of single-agent ptcy mg/kg days+ ,+ , for matched pbsc graft-ptcy+ tacrolimus+ mycophenolate mofetil (mmf) mg/kg days - , and for any mismatched graft-ptcy+ tacrolimus+ mmf mg/kg days - . median follow-up was months (range: - ). grade ii-iv ( % vs % vs %, p = . ) and grade iii-iv acute gvhd ( % vs % vs %, [p ] p = . ) were not different in mrd, mud/mmud and haplo groups, respectively. moderate and severe chronic gvhd was infrequent in all groups with slightly lower incidence after mud/mmud graft: and % vs % vs %, p = . . nonrelapse mortality (nrm) was not different after mrd, mud/ mmud and haplo sct ( % vs % vs %, respectively, p = . ), while relapse incidence was higher after mrd and haplo grafts: ( % vs % vs %, p = . ). -year overall survival (os), event-free-survival (efs), and gvhd-relapse free survival (gfrs) were % vs % vs % (p = . ); % vs % vs % (p = . ); % vs % vs % (p = . ) for mrd, mud/mmud and haplo groups, respectively. in the multivariate analysis only disease risk index (hr . %ci . - . , p = . ), severe sepsis (hr . %ci . - . , p = . ) and chronic gvhd (hr . %ci . - . , p = . ) were predictive for efs, while type of donor was not a significant factor (hr . %ci . - . , p = . ) (figure ). the incidences of complications were: hemorrhagic cystitis- %, sepsis- %, severe sepsis- %, invasive mycosis- %, cmv reactivation- %, veno-occlusive disease- . %, transplant-associated microangiopathy- . %, grade - liver toxicity- %, grade - kidney toxicity- %. more than one third of patients experienced poor graft function during days after sct, and in % of them cmv, hhv and bk virus reactivations were identified as the cause. the reported risk adapted strategy alleviates the risk of gvhd and nrm after mmud and haplo grafts. the observed differences in the relapse incidence, os and efs were predominantly due to unbalanced disease risks in the groups. the relapse of underlying malignancy with this prophylaxis still significantly influences the outcome. substantial number of patients experience poor graft function, which doesn't translate into nrm. disclosure of conflict of interest: none. a high migratory capacity of donor t-cells in response to the lymph node homing receptor ccr increases the incidence and severity of graft-versus-host disease vg garcía de soria , ip sainz , e jiménez , a arriero , c fernández-arandojo , c cuesta , b colom , a marcos , a rosendo and cecilia muñoz calleja department of hematology hospital universitario de la princesa and department of inmunology. hospital universitario de la princesa graft-versus-host disease (gvhd) pathogenesis involves migration of the donor t-cells into the secondary lymphoid organs (slo) in the recipient, which is steered by two homing molecules: cd l and ccr . therefore we investigated whether the migratory capacity of donor t-cells is associated with gvhd. this single center prospective study included donor-recipient pairs. in vitro chemotaxis assays of the lymphocytes of the apheresis product were performed in parallel with the analysis of cd l and ccr by flow cytometry. the potential of activation of ccr + t-cells was assessed through ex vivo activation assays with peripheral blood monuclear cells (pbmc) from healthy donors using anti-cd and anti-cd mabs. the migratory index to the ccr ligands, ccl and ccl , was higher in t-cells from donors whose recipients will develop gvhd. these data indicated that the migratory capacity of the donor t-cells is clearly related to the development of gvhd. this prompted us to study the relationship between gvhd and the expression of two of the most relevant molecules in the trafficking of lymphocytes towards slo, cd l and ccr ,as a subrogate index of the migratory potential of t-cells. consequently, we quantified the numbers of cd l+ and ccr + t-cells in the graft. the initial transversal analysis of our data revealed that the percentage of cd l+ lymphocytes in the apheresis product was very low compared to healthy lymphocytes. the analysis also confirmed that cd l undergoes plasma membrane shedding after g-csf mobilization thus making it a non-valid biomarker. the analysis of ccr molecule revealed that the acute gvhd group received higher percentage of cd +ccr + t-cells, whereas chronic gvhd patients were transplanted with higher percentage of cd +ccr + t-cells compared to the non gvhd group. these results were confirmed when patients were subdivided into degrees of severity. a multivariate analysis was performed to investigate the real value of ccr to predict the development and severity of gvhd, and confirmed that ccr expression is a risk factor for the development of gvhd. thus, the percentage of ccr +cd + t-cells increases the probability of developing acute gvhd (or = . , c.i ( %) = . - . , p = . ) and suffering a higher degree (or = . , c.i ( %) = . - . , p = . ). similarly, the or of the percentage of ccr +cd + t-cells was . (c.i ( %) = . - . , p = . ) and . (c.i ( %) = . - . , p = . ) for the development of chronic gvhd and its degrees, respectively. finally, to study the potential of activation of ccr + t-cells, we carried out ex vivo activation assays with pbmc from healthy donors using anti-cd and anti-cd mabs and the expression of cd l on cd + t-cells and of cd on cd + t-cells as markers of activation, demonstrating that ccr + t-cells exhibited higher potential of activation than ccr -t-cells. to our knowledge this is the first analysis of the influence of the migratory capacity of the donor t-cells on clinical outcome following allogeneic hsct. our data show that ccr could be considered a subrogate biomarker of the migratory capacity of the donor lymphocytes for predicting the risk of suffering gvhd. based on the previous findings, we propose that the selective depletion of ccr expressing cells could be an effective preventive therapy for gvhd. disclosure of conflict of interest: none. previously published p a single center research for outcome in patients receiving imatinib for steroid-refractory chronic gvhd after allogeneic stem cell transplantation l ni, y luo, y tan, y hu, y zhao, j shi and h huang despite of major progress in allogeneic stem cell transplantation over the last decades, steroid-refractory chronic graftversus-host disease (sr-cgvhd) remains a leading cause of late morbidity and mortality. pre-clinical evidence confirms cgvhd has antibodies activating the platelet-derived growth factor receptor (pdgf-r) pathway. since this pathway can be inhibited by imatinib, we performed a study including patients with sr-cgvhd given imatinib at a dose of mg per day. all patients with a median age of years (range: - ) underwent allogeneic hematopoietic stem cell transplantation in our single center between and , and chronic gvhd occurred at a median time of months (range: - ) after transplantation. patients had active cgvhd with measurable involvement of skin, lung or other districts and had previously failed in first-line immunosuppressive therapy. the major organs involved were lung (n = ), skin (n = ) and mouth (n = ), including cases involving both lung and skin, cases involving or more organs. according to the national institutes of health (nih) criteria and nih global severity, patients were evaluated as severe cgvhd, and the other three were moderate. meanwhile, the nih working group had updated its recommendations for overall responses, consisting of complete remission (cr), partial remission (pr), and lack of response (unchanged, mixed response, progression). cr was defined as resolution of all manifestations in each organ or site, and pr was defined as improvement in at least organ or site without progression in any other organ. after months treatment, patients receiving sufficient dose of imatinib revealed overall response rate (orr) at . %, and orr remained unchanged at months assessment, but with cr rate increased to . %. two patients couldn't meet the response of cr or pr were considered as a lack of response, including one evaluated as unchanged and one mixed response because of pr in lung accompanied by progression in eyes. with a median follow-up of months, patients were alive, with a year estimated overall survival was . %. patients eventually died of pneumonia. except patient discontinued imatinib because of grade toxicity as gastrointestinal discomfort at the first month, no one had imatinib-related grade to toxicity. this study suggests that imatinib is a promising and better tolerated treatment for patients with sr-cgvhd. disclosure of conflict of interest: none. acute graft-versus-host-disease (agvhd) is a major complication after allogenic hematopoietic transplantation (allo-sct). in recent years, a number of tissue-specific proteins have been described as biomarkers that could contribute to anticipate and/or diagnose this complication earlier and more accurately. reg α (regenerating-islet-derived- -alpha) has been directly related to gastrointestinal (gi) agvhd. our objective was to analyze plasma levels of reg α at days + and + in patients who underwent unmanipulated haploidentical transplantation with reduced conditioning regimen (haplo-ric), and to correlate the results with the development of agvhd. we retrospectively analyzed consecutive patients ( - ) who underwent haplo-ric with post-transplant cyclophosfamide (days + , + ), mmf and csa as gvhd prophylaxis. seven cases were excluded due to early death (before day + ) and cases due lack plasma sample. characteristics of the patients included in the analysis are described in table . reg α detection was performed by elisa (mbl international corp, woburn, ma) according to manufacturer's instructions on μl of plasma obtained at day + and + . the association of the incidence of agvhd with known clinical variables and plasma reg a levels were performed by cox regression and mann-whitney u-test, respectively. the determination of the best cut-off of reg α levels to stratify patients with gi agvhd was performed with roc curves. the stadistical program used was r v . . . the cumulative incidence of grade ii-iv and grade iii-iv agvhd was % and %, respectively. characteristics of agvhd are shown in table . no association was found between agvhd and usual clinical variables (stem cells source, age, sex, conditioning regimen, donor/recipient sex and number of infused cd + cells), and with plasma reg α levels at day + .plasma reg α levels at day + were higher in patients who devolved gi agvhd compared to patients who did not showed gi agvhd (median [p ] s and range: ( - ) vs ( - ) pg/ml, p = . , figure ).the best cut-off selected on day + was pg/ml (s %, e %). patients with levels higher than pg/ml at day + had a significantly higher incidence of gi agvhd grade ii-iv (hr . , p = . , figure ). plasma levels of reg α at day + after haplo-ric correlated with the occurrence of gi agvhd grade ii-iv. therefore, plasma levels of reg α could be use for the prediction and/or diagnosis of gi agvhd. disclosure of conflict of interest: none. anti-fibrotic treatment with pirfenidone in patients with gvhd-associated bronchiolitis obliterans syndrome ke hostettler, s gerull, g nair , j passweg , m tamm and j halter hematology, university hospital basel, switzerland and pneumology, university hospital basel, switzerland prognosis of lung gvhd remains poor due to progressive decrease of lung function and repeated infections. pirfenidone exhibits anti-fibrotic effects and has been shown to reduce disease progression in patients with idiopathic pulmonary fibrosis. five patients with established bos (nih criteria ) and stable or deteriorating lung function under standard immunosuppressive treatment without active infection were treated with pirfenidone ( mg/d) in addition to their current therapy. clinical assessments and pulmonary function tests were performed every three months. five patients ( m, f), median age y (range: - y) that were diagnosed with bos at a median time of . months post-transplant started pirfenidone at a median time of months ( - ) after diagnosis of bos. two patients are currently still under treatment after and days. two patients had to stop treatment due to financial reasons after and days of therapy. one patient never reached more than % of the planned dose due to gastro-intestinal symptoms and was excluded from further analysis. at the start of treatment median fev was . l ( . - . ); . % predicted (range: - %) and median fvc . l ( . - . ); - % predicted. median fev trajectory was − . % predicted/ month during median months before start of pirfenidone (median − ml/month) and + . % predicted/month (+ . ml/month) during treatment with pirfenidon. the treatment was well tolerated except in one patient with gastrointestinal complaints, no phototoxic reactions or serious drugrelated adverse events occurred. in our small number of patients pirfenidone was rather well tolerated and generally safe. the observed, albeit small trend in change of fev trajectory justifies further studies of anti-fibrotic therapy as a new therapeutic option in bos after allogeneic hsct. disclosure of conflict of interest: none. anti-thymocyte globulin has been widely used for the prevention of severe graft versus host disease in patients undergoing hsct from unrelated donor. however, the optimal dose remains to be defined. in samsung medical center (seoul, korea), institutional strategy for the atg use has been changed since april , and we hypothesized that the incidence of chronic gvhd may differ by atg strategy. before april , atg . mg/kg was routinely used in allogeneic hsct from unrelated donor, whereas, the dose of atg was escalated to . mg/kg since april . in this study, a total of patients who underwent allogeneic hsct from matched or unmatched unrelated donor between jan and dec were retrospectively analyzed. peripheral blood was used as the source of stem cells in all patients. after a median follow up of . months, the cumulative incidence of moderate to severe chronic gvhd was . % ( % confidential interval [ci], . to . ) in the low-atg group and . % ( % ci, . to . ) in the non-atg group (p = . ). the rate of year overall survival (os) was not significantly different between the groups ( . % in low-atg group vs . % in high-atg group, p = . ), as was the rate of disease free survival (dfs) ( . % in non-atg group vs . % in atg group, p = . ) and cumulative incidence of relapse (cir) ( . % in non-atg group vs . % in atg group, p = . ). in allogeneic hsct from unrelated donor, larger atg dose ( . mg/kg) did not reduce the incidence of chronic gvhd when compared to lower atg dose ( . mg/kg). disclosure of conflict of interest: none. allogeneic hsct provides a curative chance for patients with hematological fatal disease. however, substantial risks remain for morbidity and mortality caused by disease relapse and graft-versus-host disease. in samsung medical center (seoul, korea), institutional strategy for the atg use has been changed since april , and we hypothesized that the incidence of chronic gvhd may differ by atg strategy. before april , atg was not routinely used in matched sibling donor (msd) transplantation, whereas, atg mg/kg has incorporated into hsct process in transplantation from msd thereafter. in this study, a total of patients who underwent allogeneic hsct from msd between jan and dec were retrospectively analyzed. peripheral blood was used as the source of stem cells in all patients. after a median follow up of . months, the cumulative incidence of moderate to severe chronic gvhd was . % ( % confidential interval [ci], . to . ) in the atg group and . % ( % ci, . to . ) in the non-atg group (p = . ). the rate of -year overall survival (os) was not significantly different between the groups ( . % in non-atg group vs . % in atg group, p = . ), as was the rate of disease free survival (dfs) ( . % in non-atg group vs . % in atg group, p = . ) and cumulative incidence of relapse (cir) ( . % in non-atg group vs . % in atg group, p = . ). in allogeneic hsct from msd, atg use was significantly associated with less occurrence of chronic gvhd, but not linked to increasing risk of relapse, with showing similar os and dfs between atg and non-atg group. disclosure of conflict of interest: none. long-term follow-up from the prospective randomized phase iii multicenter trial comparing a standard gvhd prophylaxis with cyclosporine a and methotrexate with or without additional pretransplant atlg (grafalon, previously atg-fresenius s) (given mg/kg/day, days − to − ) in unrelated donor hematopoietic cell transplantation after myeloablative conditioning resulted in a significant reduction of acute and chronic gvhd without compromising relapse rate and survival [ , , ] . here we report on a subsequent prospective non interventional observational study evaluating the outcome of patients receiving atlg in unrelated donor transplantation in day to day clinical practice without the selective measures of a clinical trial (german clinical trials register drks ). thirteen transplant centers included patients with haematological malignancies (median age years, iqr - years, range: - years) in early (n = , %), intermediate (n = ; %) or advanced (n = ; %) disease status receiving marrow (n = ) or pbsc (n = ) from / matched ( ; %) or mismatched ( ; %) unrelated donors (n = related) after myeloablative (n = , %) or ric (n = , %) conditioning. gvhd prophylaxis consisted of calcineurin inhibitors, mainly csa (n = , %) with mtx or mmf and atlg. different dosing regimens were allowed according to current practise of centers. median total atlg dose was mg/kg (iqr - mg/kg, range: - mg/kg). median follow-up was months (range: - months). as compared to patients in our randomized phase iii multicenter trial [ , , ] , patients in this study were older; advanced disease status, / match, pbsc transplantation were more frequent, and given median atlg dose was lower. acute and chronic gvhd, nrm, relapse risk, dfs and os at one year were similar to the results obtained in our randomized trial: incidence of°ii-iv agvhd: %, iii-iv agvhd: %; moderate/severe cgvhd: %; nrm: %; risk of relapse: %; relapse mortality: %; os: %. the experience in day to day clinical practice confirms the results shown in our randomized trial, namely the gvhd protective effect of atlg without compromising nrm or relapse rates. baseline calprotectin as a predictor for acute gastrointestinal graft versus host disease (gvhd)-a prospective study n schmidlin , a holbro , , jp halter , d heim , l infanti , , a plattner , r plattner , c rothen , a buser , , c bucher and jr passweg division of hematology, university hospital basel, switzerland; blood transfusion center, swiss red cross, basel, switzerland and rothen medical laboratories, basel, switzerland graft versus host disease (gvhd) is a major complication after allogeneic stem cell transplantation. so far there is no good validated predictor for the incidence and severity of gvhd. fecal calprotectin (cpt) is a protein in leukocytes with antibacterial properties. it has been shown to be elevated in acute gastrointestinal gvhd. additionally, cpt may be predictive for treatment response. the aim of the current prospective study was to investigate the role of baseline cpt in predicting incidence and severity of intestinal gvhd. in this prospective study conducted at the university hospital basel, switzerland, we included all adult patients undergoing hsct. the institutional review board approved the study. data were collected prospectively. cpt was measured twice before conditioning and at transplantation. fecal samples for cpt were obtained before conditioning and on the day of transplantation and assessed twice by standard elisa. between march and april a total of patients ( % males, patients with both baseline and transplant cpt values) were included. patient, disease and transplant characteristics are described in table . median age at transplant was years (range: - years). most patients had myeloid neoplasia and % received myeloablative conditioning. gvhd prophylaxis consisted mainly of cyclosporine containing regimens ( %). cpt levels ranged from to μg/g both at baseline (median: μg/g) and at transplantation (median: μg/g), with a good consistency between the two measurements performed (internal quality control). on the other hand, cpt did not correlate with c-reactive protein. the two measurements were taken in median days apart, depending on the conditioning regimen. eighty-five patients had an increase of at least μg/g between baseline and transplantation. overall ( . %) patients developed acute intestinal gvhd (grade : ; grade : ; grade : , and grade : patients, respectively). cpt both at baseline and at transplantation was not predictive for the incidence of gvhd, acute intestinal gvhd, and for acute intestinal gvhd grade - ( figure) . additionally, we did not find a significant association between cpt levels and the above mentioned endpoints for patients showing an increase of cpt of at least μg/g between baseline and transplantation. in the current prospective study, we didn't find any correlation between baseline cpt values and the incidence and severity of gvhd and intestinal gvhd. further studies identifying early markers and predictors of gvhd are urgently needed. [p ] disclosure of conflict of interest: none. calcinuerin inhibitor (ci) free graft-versus-host disease (gvhd) prophylaxis: its effects on resource utilization, renal function, and the cost of care m muilenburg , k cole, m abidi , , s williams and as al-homsi , spectrum health blood and marrow transplantation and michigan state university, college of human medicine effective gvhd prevention following allogeneic hematopoietic stem cell transplantation (ahsct) is vital to reducing transplant morbidity and mortality and improving overall outcomes. several strategies are currently utilized for gvhd prophylaxis including mtx, mmf, cis, post-transplant cyclophosphamide (cy), and proteasome inhibitors. recently, we described the results of a phase i-ii trial of cyclophosphamide (cy) and bortezomib (bor) where patients (pts) received cy ( mg/kg) on days (d) + & + and bor on d & + . the incidences of grade ii-iv and grade iii-iv acute gvhd were % and %. the incidence of chronic gvhd was %. in addition to gvhd, there are other factors that affect patients' quality of life and cost of care and that should be considered. it is well documented that cis have an unfavorable toxicity profile. this includes nephrotoxicity and electrolyte disturbances. furthermore, the cis need serial level monitoring. thus, we endeavored to compare the effects of cybor combination against ci-based regimens by focusing on electrolyte requirements, specifically mg, and renal function. we also sought to better understand financial considerations surrounding the need for ci drug level monitoring. sixteen pts were randomly selected from the cybor group and patients from an internal control group of patients who received mmf and cyclosporine or tacrolimus following reduced-intensity ahsct. the groups were well matched in regards to age, sex, disease status, pam score, and baseline renal function. on each pt, mg results from d to + were compiled. based on institutional protocol, a mg replacement value was assigned as well as the corresponding drug and infusion charges. next, the number of immunosuppressant (is) trough levels from d to + was tallied and the internal lab charges calculated. to compare renal function, gfr was calculated at baseline, d , and d + . χ tests and wilcoxon rank square tests were used to analyze the data. for the cybor group, median mg value was . mg/dl (iqr . ) vs . ( . ) in the control group (po . ). cybor pts required a median of grams ( ) vs grams ( ) in the control group (p = . ). the cost of mg replacement and infusion was significant (p = . ) ( table ) . for is checks, drug levels were checked a mean of . times per patient in the cybor group compared to . times in the control group (po . ), which also translates to significant savings ( table ) . considering these costs, the cybor group saved~$ . for gfr, cybor pts and control pt had reduced gfr at baseline. on d + , cybor pts had better renal function in comparison to the control group (p = . ) ( figure ). in summary, cybor significantly reduced the use of resources post-transplant and thereby the associated cost related to mg replacement and need for drug level monitoring. furthermore, cybor preserved renal function at d + . these findings could also impact patient's quality of life. although our cost analysis was restricted to certain aspects of care and did not take into account other factors, it highlights specific important benefits of ci-free gvhd prophylaxis and supplicates further study. a formal prospective comparison of cost and qol is warranted. . related donor n = and unrelated donor n = (compatibility / n = ), with conditioning regimen: myeloablative n = and non-myeloablative n = . median interval between transplantation and diagnosis of cgvhd of months( . - . ); and between cgvhd diagnosis and sativex months ( . - . ), with a median of prior treatment lines ( - ). at the time of beginning, the cgvhd was extensive in all patients, severe cgvhd n = and moderate cghvd n = . all patients except one had cutaneous involvement (n = with sclerodermal features). in addition, other organs were affected: digestive n = , pulmonary n = , hepatic n = , ocular n = , oral n = , genital n = and muscular n = . drug was started because of pulmonary affectation in patients and due to sclerodermal/muscular involvement in patients. concomitant therapies during treatment were: topical cutaneous treatment n = , topical ocular treatment n = , pulmonary n = , sirolimus n = , tacrolimus n = , oral corticosteroids n = , extracorporeal photopheresis s n = , ruxolitinib n = , imatinib n = , mesenchymal stem cells n = . the mean dose were three puff/day ( ) ( ) ( ) ( ) , with good tolerance, only two discontinuations of treatment because of adverse effects. median time of treatment days ( to ). at the time of the analysis patients were still under treatment. responses mainly occurred within the first days, s with a median time of duration of days ( in ). responses after two months of treatment were: partial organ response, mixed responses, unchanged and organ progressions; at th day ( / ) only two patients maintained their responses (one pr and one mixed response). it must be pointed out that one patient who reached pr with sativex in monotherapy maintain response after months of treatment. in addition, cramps were resolved in patients. sativex appears to be an effective treatment option in patients with chronic gvhd, particularly in those having cramps, sclerodermal features and pulmonary affectation. as seen in multiple sclerosis context, the main issue with its use is the loss of response in the long-term follow up. the median dose is inferior to the one described in ms, leaving the question if higher doses can deepen the response. these results should be confirmed in prospective trials. disclosure of conflict of interest: none. several risk factors associated with acute and chronic graftversus-host-disease (gvhd) have been identified in multiple studies. most commonly associated factors are human leukocyte antigen (hla), mismatch between recipient and donor, as well as several other characteristics such as age, conditioning regimen and prior acute gvhd. objective: the aim of this study was to evaluate the characteristics of acute and chronic gvhd in patients who underwent an allogenic hematopoetic stem cell transplantation (hsct), identify differences in the profile risk factors for acute and chronic gvhd and their impact in post-transplant morbidity and mortality. this retrospective study included mexican adult patients who received an allogenic hsct between january and march , at instituto nacional de cancerologia. we analyzed patients with a median age of years ( - ), from which, % were male patients. among the participants with hematologic malignancies, were previously diagnosed with acute lymphoblastic leukemia, acute myeloid leukemia, chronic myeloid leukemia, lymphoblastic lymphoma and with myelodysplastic syndrome. because bone marrow transplants are not performed at this institution, all transplants were from peripheral blood stem cell harvest. acute gvhd prophylaxis consisted in a triple immunosuppressive drug regimen for all patients. . % of the patients had high risk disease prior to hsct. myeloablative conditioning represented % of the applied regimens, which consisted of iv busulfan in . % of the cases. . % of patients, were transplanted within months from diagnosis. the cumulative incidence of acute gvhd at days was . % ( patients). patients with acute gvhd had % grade a, % grade b and % grade c, according to the ibmtr grading system. patients had skin involvement, with grade - acute gvhd in % of the cases, patients developed liver involvement and patients had gastrointestinal tract disease. % of the patients developed chronic gvhd, from which, % were classified as severe, . % as moderate and . % as mild. % of the patients who developed chronic gvhd had a single organ involvement, while . % had or more organs/sites. prior acute gvhd was associated with de development of chronic gvhd. the multivariate analysis identified hla unrelated donor as the only risk factor associated with the development of acute gvhd (hr, . ; % ci, . - . , p = . ). the overall survival at years was of % poor patients who developed acute gvhd and of % for those who didn´t (p = . ). our analysis showed that the incidence of acute and chronic gvhd at our center is lower than the reported at other centers, but we were not able to identify risk factors usually associated with the development of gvhd, perhaps due to the small population that we evaluated. graft versus host disease (gvhd) remains one of the main obstacles to broader application of allogeneic stem cell transplantation (sct). despite the routine use of prophylactic therapies, chronic gvhd (cgvhd) occurs in to % of patients undergoing allogeneic sct. ciclosporin a (csa) remains the backbone for gvhd prophylaxis in both myeloablative (mac) and reduced intensity conditioning (ric) sct. however, in a significant proportion of patients, csa causes important side effects and needs to be discontinued. in this study we have evaluated the impact of substituting csa for mycophenolate mofetil (mmf) as immunosuppression (is), on the incidence of cgvhd. we have compared the outcome of consecutive patients that underwent allogeneic sct from march to november at the bmt unit of the hammersmith hospital and received csa as part of the gvhd prophylaxis. of them, patients ( %) remained on csa prophylaxis for the duration of the planned post sct immunosuppression period and patients ( %) required a switch to mmf before day + . the reason for changing the is was nephrotoxicity in the majority of cases (n = , %), neurological toxicity (n = , %), disease relapse (n = , %), intolerance (n = , %) or not determined (n = , %) . we excluded from the analysis those patients whose is was changed due to the presence of acute gvhd. both groups had similar patient and transplant characteristics (see table ). [p ] however, distribution according to diagnosis showed a predominance of aml ( %) in patients that remained on csa and mds ( %) for those that switched to mmf. the mean survival rate of the entire cohort was . days (± ) . the mean survival of each group was: csa . days (± . ) and mmf . (± . ). this difference in survival reached statistical significance (p: . ). we graded cgvhd using the nih scoring system as mild, moderate and severe. out the patients that continued with csa, . % (n = ) had no cgvhd; . % (n = ) had mild cgvhd; . % (n = ) had moderate and . % (n = ) had severe cgvhd. in patients that switched to mmf . % (n = ) did not develop any cgvhd; . % (n = ) developed mild; . % (n = ) moderate cgvhd and . % (n = ) developed severe cgvhd. (p: . ). the cumulative incidence of any cgvhd at years post sct was % for the csa/mmf group and % for the csa only group (p = . ). csa is one of the standards of care for gvhd prophylaxis in both ric and mac sct. in our cohort of patients, those who remained on csa had a better overall survival and a reduced incidence of chronic gvhd compared with those patients that stopped csa and replaced it by mmf. csa toxicity should be prevented to avoid gvhd-related complications. disclosure of conflict of interest: none. although the outcome of allogeneic stem cell transplantation (sct) from an unrelated donor (ud) has considerably improved over the recent years, graft versus host disease (gvhd) still represents a severe and potentially lethal complication. in vivo t-cell depletion with anti-thymocyte globulin (atg) has been shown to significantly decrease the risk of both acute and chronic gvhd without compromising survival, however the optimal dose has not been defined yet. aim of present retrospective study was to evaluate the impact of two different doses of rabbit atg (thymoglobulin) on gvhd incidence, infectious complications and outcome of patients undergoing sct from ud. between february and september , patients received thymoglobulin mg/kg (atg- group) and received thymoglobulin mg/kg (atg- group) in addition to cyclosporin and short course mtx as gvhd prophylaxis. the two groups were comparable regarding sex, age, diagnosis and disease phase at transplant, comorbidity index, stem cell source and antimicrobial prophylaxis. conditioning treatment was myeloablative in % of atg- group patients and in % of atg- group patients. donor and recipient pairs were / hla matched in % of the cases of the atg- group and in % of the cases of the atg- group (p . ). netrophil engraftment occurred in ( %) patients at a median of days post transplant (range: - days); six patients ( in the atg- group and in the atg- group) died before engraftment. overall, patients ( %) developed grade ii-iv acute gvhd, without significant differences between the two groups (atg- % and atg- %, p . ). similarly, chronic gvhd was not significantly different between the two groups: moderate to severe chronic gvhd occurred in % of the patients in the atg- group and in % of the patients in the atg- group (p . ). univariate logistic regression analysis didn't show any significant differences between the two groups respect the incidence of bacteremia, invasive fungal infections acute and chronic gvhd. with a median follow-up of . months, patients ( %) are alive, in complete remission and after disease relapse. transplant related mortality was superimposable in the two groups (atg- % vs atg- %). kaplan-meier estimates of overall survival and event free survival were % and %, respectively, without statistically significant differences between the two groups and between hla matched and hla mismatched sct. the results of our study suggest that different doses of atg tailored on hla compatibility might be effective for preventing gvhd with any detrimental effect on overall survival and incidence of infectious complications. a prospective randomized study is mandatory to confirm our preliminary results. disclosure of conflict of interest: none. c-reactive protein levels at acute gvhd diagnosis predict steroid-resistance, treatment related mortality and overall survival after allogeneic hematopoietic stem cell transplantation l minculescu , ls friis , bt kornblit , sl petersen , i schjødt , ns andersen and h sengeløv department of hematology, rigshospitalet, copenhagen, denmark acute graft versus host disease (agvhd) remains an excessive cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (hsct). primary treatment consists of high-dose corticosteroids, but a small group of patients are steroid-resistant and their prognosis is especially poor. a predictor of patients at risk of steroid-failure would aid the decision of additional immunosuppressive treatment at an early stage. there is experimental evidence that co-existing inflammation aggravates agvhd. since c-reactive protein (crp) is a systemic inflammatory marker, we aimed to investigate whether crp levels at agvhd diagnosis could predict the risk of failing first-line therapy and developing steroid-resistance. we retrospectively studied patients transplanted between and , table . acute gvhd was diagnosed in patients, of whom had grade ii-iv. crp, total white blood cell-, lymphocyte-and neutrophil counts were available for all patients at the time of agvhd diagnosis. according to local protocol, patients with failed response to high-dose steroid ( mg/kg) were treated with the tumor necrosis factor (tnf) alpha inhibitor infliximab and categorized as steroid-resistant. of grade ii-iv agvhd patients ( %) developed steroid resistant disease. crp levels at diagnosis among these where between o and mg/l. crp levels where significantly higher in patients who developed steroid resistance compared to patients responding to high-dose corticosteroids, p = . , hr . ( % ci . , . ). this translated into significantly increased transplant-related mortality (trm) and decreased overall survival in patients with high crp levels, figure . total white blood cell-, lymphocyte-and neutrophil counts were not associated with steroid resistance in agvhd patients. cxcr is chemokine receptor expressed on activated t lymphocytes, in particular on th cells, nk cells, dendritic cells, and subsets of epithelial and endothelial cells. cxcr ligands attract th cells into inflamed tissues and concomitantly block the migration of th cells. furthermore, inhibitory functional autoantibodies against cxcr occur in humans which play an important role in cxcr -dependent immune regulation. in addition, cxcr regulates endothelial cell homeostasis. there are two variants of cxcr : cxcr -a and cxcr -b. overexpression of cxcr -a on endothelial cells is associated with an increase in cell survival, whereas overexpression of cxcr -b dramatically reduced dna synthesis and up-regulated apoptotic endothelial death. here we have studied if a dysfunctional cxcr axis might be involved in gvhd pathogenesis and could link endothelial and t cell pathology in acute gvhd. we assessed concentrations of the cxcr ligands cxcl , cxcl and cxcl as well as anti-cxcr autoantibodies in patients with high grade ( ) ( ) acute intestinal gvhd for whom serum was available at gvhd onset. furthermore, anti-cxcr autoantibodies and cxcl levels were measured in sera stored before conditioning therapy. all variables were tested for influence on post-gvhd survival using cause-specific cox regression analysis. at gvhd onset, we observed a strong inter-correlation of cxcr ligands, but no correlation with anti-cxcr auto-antibodies. compared with pre-conditioning probes, cxcl levels strongly increased (median to pg/ml, p o . ), whereas anti- these results suggest crp levels at diagnosis as a valid predictor of developing steroid resistant disease in agvhd grade ii-iv and survival in allogeneic hematopoietic transplant recipients. [p ] s cxcr decreased (median . to . u/ml, po . ). anti-cxcr levels before conditioning and at gvhd onset correlated (coeff. . , p o . ), whereas cxcl levels did not. in multivariable analyses, low anti-cxcr and high cxcl measured at disease onset were strongest predictors of survival after acute gvhd. notably, high levels of the proinflammatory chemokine cxcl were particularly prognostic of an adverse outcome of gvhd in the presence of a high endothelial risk as assessed by the previously published easix score, while high anti-cxcr levels were most protective in patients with low easix score (that is, low endothelial risk). a score based on cxcl , anti-cxcr , and easix allowed an effective prediction of acute gvhd outcome ranging from mortality % (high cxcl + high easix) to mortality o % (low cxcl , low easix, high anti-cxcr . our data suggest a strong role for the cxcr axis in the pathology of acute high grade gvhd. the opposing effects of cxcl and anti-cxcr indicate a functional, attenuating role for these auto-antibodies. the overall prognostic impact of the immunemodulating cxcr axis appears to depend on the underlying integrity of the patients' endothelial homeostasis. despite some progress in acute lymphoblastic leukemia (all) treatment including modern chemotherapy modalities, monoclonal antibodies and newer tyrosine kinase inhibitors (tki) for ph positive cases, the final success is still difficult to reach. allogeneic hematopoietic stem cells transplantation (allohsct) has remained an essential approach in attempts to cure all. tki routinely used for all ph(+) pre-and post-transplant treatment are also described as an alternative and adjunctive approach for chronic gvhd especially with fibrotic features due to their antifibrotic activity targeting the platelet-derived growth factor receptor (pdgfr) pathways. in this study we have tried to estimate the potential influence of pretransplant tki treatment on gvhd occurrence comparing all ph(+) and all ph(− ) cases treated with allohsct. a cohort of all patients consisted of all ph( − ) and all ph(+) cases treated with allohsct was retrospectively analyzed. all patients were transplanted from sibling or unrelated donor (no haploidentical procedures were included). all ph(+) patients achieved pretransplant treatment with imatinib and chemotherapy, and ph( − ) patients with chemotherapy alone. the median age in ph( − ) and ph(+) group was vs (p = . ), the percentage of hla mismatched transplantations - ,. vs . (p = . ), the percentage of acute gvhd cases- . vs . (p = . ) and extensive chronic gvhd cases- . vs . , respectively. there were no significant difference between groups in patients sex (f/m- / vs / respectively), ric/mac conditioning, unrelated/sibling donor, donors age, bm/pbpc transplantation, number of cd cells and chronic gvhd incidence. all patients received cyclosporine-and methotrexate-based gvhd prophylaxis. gvhd occurrence was analyzed in subgroups as previously described: all ph( − ) and all ph(+). as mentioned above the incidence of acute gvhd was higher in ph(+) group (higher number of hla mismatched transplantations in this group) but the incidence of extensive chronic gvhd was higher in ph (-) group. cox proportional hazard model analysis revealed death risk caused by gvhd higher in ph negative group (hazard ratio = . ; ci % = . - . ; p = . ). the analysis of competing events was performed to estimate the probability of death caused by gvhd vs other complications (transplant related mortality, infections and relapse). the impact of conditioning was not significant on gvhd related deaths vs other complications (p = . vs . , respectively- figure ). the same results were achieved with donor cmv status (p = . vs . - figure ). we have not found any significant difference either in gvhd or other complications related deaths taking into account patient s sex/age, donor sex/age, patients cmv status, number of cd cells transplanted. on the other hand, the influence of agvhd and chgvhd on deaths related to other complications was not significant (p = . vs . ). cumulative probability of overall survival was higher in ph(+) group but the difference was not significant. the impact of pretransplant treatment with imatinib on gvhd occurrence has not been estimated so far. we are aware of our results to be preliminary and variety of data is still to be evaluated. however our results, if confirmed, may suggest the influence of imatinib on decreasing the extensiveness of chronic gvhd. disclosure of conflict of interest: none. seta-tsukinowa, otsu, - , japan; department of pathology and laboratory medicine, emory university hospital, atlanta, ga, usa; department of biostatistics and bioinformatics, rollins school of public health, emory university, atlanta, ga, usa; pathology and pediatrics, emory university school of medicine, atlanta, ga, usa, aflac cancer center and blood disorders service, children's healthcare of atlanta, atlanta, ga, usa and bloodworks northwest research institute, seattle, wa, usa more than % of allogeneic hematopoietic stem cell transplant (allo-hsct) patients receive red blood cell (rbc) and platelet (plt) transfusions in the peritransplant period. preclinical models indicate that rbc and plt transfusions trigger inflammation, raising the question of whether such transfusions are associated with development of severe acute graft-versus-host disease (grade iii/iv agvhd) and mortality in allo-hsct recipients. we conducted a retrospective analysis of rbc and plt transfusions, agvhd incidence, and mortality among consecutive adult patients receiving non-t celldepleted allogeneic bone marrow ( %) or g-csf-mobilized blood stem cell grafts ( %). common underlying diseases were acute myeloblastic leukemia ( %), myelodysplastic syndrome ( %), and acute lymphoblastic leukemia ( %) . underlying disease risk was ranked as low ( %), intermediate ( %) or high ( %). allografts were obtained from / hlamatched sibling donors ( %), unrelated donors ( %), or from donors mismatched at - hla alleles ( %). graft sources were bone marrow ( %) or mobilized pbsc ( %). the cumulative incidences of grade iii-iv agvhd and mortality prior to day without developing grade iii/iv agvhd were estimated using the cumulative incidence function and a cox proportional hazards regression model. covariates included in multivariable analysis was limited to baseline covariates associated with grade iii/iv agvhd at the p median number of rbc or plt transfusions ( figure ). univariate analysis showed a lower hematocrit on admission (median of rbc units transfused (p = . ) were significantly associated with the risk of developing grade iii/iv agvhd, while a longer time to neutrophil engraftment was inversely associated with grade iii/iv agvhd ( ⩾ median of days, hr . , p = . ). multivariate cox regression analysis showed only larger numbers of rbc units transfused and hla mismatch independently associated with severe agvhd (p = . and p = . , respectively), while underlying disease risk and larger numbers of transfused rbc units were independently associated with overall survival in a multivariate analysis that excluded agvhd grade. overall mortality rate was lowest for the group with fewer rbc and plt transfusions ( %), and greatest for the group with more rbc and plt transfusions ( %). groups that received more rbc units had higher rates of mortality due to gvhd, while patients who received more plt transfusions and fewer rbc transfusions had greater mortality from relapse ( figure ). these data support the hypothesis that peritransplant rbc transfusions are associated with the risk of developing severe agvhd and worse overall survival following allo-hsct. prospective studies are warranted to whether rbc transfusions promote t-cell activation and inflammation in allo-hsct recipients, leading to increased severe agvhd. disclosure of conflict of interest: none. early high umbilical cord blood cd chimerism associated with acute gvhd at time of onset in haplo-cord transplantation h choe , j hsu , s mayer , u gergis , a phillips , t shore and k van besien department of hematology/oncology, weill cornell medicine, new york, ny , usa introduction: haplo-cord transplantation is a combined haploidentical and cord blood transplant that allows for more rapid engraftment by the haplo with eventual loss of the haplo graft upon engraftment of the cord. haplo-cord transplants are associated with an approximate - % incidence of agvhd. reported, using chimerism assessments at approximately day after transplant for aml and mds, that lower umbilical cord blood (ucb) chimerism in the cd or cd lineages were associated with increased rates of relapse. we did not find a statistically significant association between day chimerism and risk for acute gvhd.( ) here we report our analysis of chimerisms at the onset of agvhd. patients and methods we retrospectively reviewed all patients who underwent haplocord sct for all hematologic malignancies between july and march . ucb for haplo-cord transplants were selected based on hla-typing and cell count. grafts were matched for at least of hla loci by the standard criteria and contained a minimum cell count of × nucleated cells per kilogram (kg) of the recipient's body weight before freezing. the haploidentical donor was a relative in the large majority of cases. we identified patients evaluable for agvhd (onset before day ) without preceding relapse or early death. of the total patients, patients were diagnosed with agvhd of any stage and grade. fractionated chimerisms including cd and cd components were routinely sent to evaluate for engraftment of the recipient vs haplo vs ucb. chimerism data was collected for both agvhd and no agvhd patients. the two-sided student's t-test was used to compare the agvhd cohort to the no agvhd cohort. chimerisms collected on patients with agvhd were within median ± days of onset of agvhd. the median time to onset of agvhd was days (range: - days). the median post-transplant chimerism recorded for comparison with the no agvhd patients was days. the agvhd cohort had significantly lower cd recipient (p = . ) and higher cd ucb engraftment (p = . ). all other fractions, including the cd chimerisms, were not significantly different between the two cohorts. the agvhd vs no agvhd cohorts were further compared by degree of hla mismatch ( - out of vs - out of ). the frequency of agvhd was similar in the - out of ( / , %) and the - out of ( / , %) groups. within these subgroups, cd ucb chimerism was higher for those with agvhd (p = . and p = . , respectively). conclusion the onset of agvhd in haplo-cord transplantation is associated with a significantly higher cd ucb chimerism and lower cd recipient chimerism. higher ucb chimerism may indicate that full ucb chimerism poses a higher risk of agvhd development. vice-versa persistent recipient chimerism may protect from acute gvhd. il- is a pleiotropic cytokine with both pro-and antiinflammatory properties (scheller ). the proinflammatory properties are mediated through trans-signaling that depends on the soluble il- receptor. il- trans-signaling is involved in several autoimmune diseases and in regulation of tissue regeneration of the gi-tract. specific snps in the il- receptor have been associated with increased baseline crp levels, severity of autoimmune diseases and response to interleukin- inhibition in rheumatoid arthritis. so fare little is known about the role of trans-signaling in graft-versus-host-disease (gvhd). in this study we investigated how specific snps in the il- receptor influence pretransplant levels of crp, il- sil- r and the risk of grade ii-iv acute gvhd in allogeneic stem cell transplantation (asct) in patients with family donor. dna was available for patients ( male, female median age , range: - ) and donors, that underwent asct with a matched related donor ( sibling) at haukeland university hospital in the period - . the majority received conditioning with either bycy ( ) or flubu ( ) and only patients were transplanted with tbi-based conditioning. four different snps in the il- r gene (rs , rs , rs , rs ) were chosen on the basis of (i) documented or suspected roles in autoimmune disorders; and (ii) allele frequency between . - . and r o . between the different snps. genotyping was done using kaspar assays with viia instrument (life technologies). the overall genotype call rate was %. no departures (p-values o . ) from hardy-weinberg equilibrium were observed. pretransplant serum levels of il- , sil- r and were analyzed with bio-plex kits (bio-rad, hercules, usa). both serum and dna analyses were performed in duplicates. patients being homozygous for the rs minor allele had significantly higher pretransplant serum sil r levels but lower crp levels compared with patients homozygous for the major allele. the overall incidence of agvhd requiring high-dose steroid treatment (grade ii gastrointestinal, grade iii-iv liver and skin) in the cohort was %. when analyzing the conventional clinical and laboratory parameters only transplantation with a non-sibling donor was associated with increased risk of agvhd (p-value o . hr , confidence interval . - . ). the presence of the rs in donor or recipient was associate with a significant increase in the rate of aghvd (p-value . hr . confidence interval . - . ). the snp rs (p-value . hr . , confidence interval . - . ) was also significant in an adjusted model including both donor type and rs . none of the evaluated snps were associated with an increase in early or late trm and did not influence os either. this study suggests that snps in the il- r influence pretransplant biochemical characteristics and clinical outcomes after asct. future studies investigating the effect of il- inhibition as gvhd prophylaxis or treatment should include analyses of il- receptor snps to investigate their possible influence on treatment outcomes. graft-versus-host disease (gvhd) continues to be the major cause of morbidity and mortality in allogeneic hematopoietic stem cell transplant (allo-hsct). the prophylaxis scheme varies according to the center and the country. in ours institution we use triple-prophylaxis based on cyclosporin a (cya), metrotexate (mtx), and mycophenolate mofetil (mmf). this scheme has been used for more than one decade in asian centers where it has proven adequate effective and safe to prevent gvhd. we evaluated patients undergoing allogeneic hematopoietic stem cell transplantation treated at the national cancer institute from january to december . the triple-prophylaxis scheme consists in cya (adjusted serum levels, mtx ( mg/m days + , + , + , + ) and we evaluated different doses of mmf, one of them includes mg bid × days and the other has high doses ( mg/kg bid × days), as gvhd prophylaxis. the response characteristic was analyzed using the pearson test, fisher's exact test on categorical variables and student's t-test, mann-whitney u on continuous tests. kaplan-meier method was used to estimate the probabilities of os, sle with the differences compared by the log-rank test. we analyzed patients with median of age of years (range: - ), % male gender, all were transplant with peripheral blood progenitor cells as a source. . % were acute lymphoid leukemia and . % acute myeloid leukemia, . % chronic myeloid leukemia, . % myelodysplastic syndromes, . % aplastic anemias, . % non-hodgkin's lymphomas and . % hodgkin's lymphomas. myeloablative conditioning was used in % (bucy, cfm-gat) and % reduce intense conditioning (flubu, flucy, flucy-gat), . % related hla compatibility. mmf mg twice daily (bid) for days (group ) and of mmf mg/kg bid for days (group ), in the group the . % developed febrile neutropenia vs . % in group (p = . ). the frequency of gvhd was . % group vs . % group (p = . ), chronic gvhd was . % vs . % respectively (p = . ). at the moment of analysis . % vs . % were free of disease (p = . ). there no difference at -year overall survival was % (group ) vs % (group ) (p = . ), neither free-survival disease (p = . ). the mmf regimen shows noninferiority scheme for gvhd. the low doses and for shorter administration did not show differences in the incidence and severity of acute or chronic gvhd, os, dfs compared to the mmf regimen at days with high doses. the high doses shows higher incidence of febrile neutropenia, but there were no differences in documented infections. disclosure of conflict of interest: none. a protein-losing enteropathy can develop due to conditioning regimen related gut toxicity and can cause albumin decline during peritransplant period in allogeneic stem cell transplantation (allohct). damaged intestinal mucosal barrier results in alloactivation of donor t cells and this situation is considered a primary event in the pathogenesis of acute graft-versus-host disease (agvhd). peritransplant albumin decline, as a result of conditioning regimen related protein-losing enteropathy, may predict agvhd ( ) . in this retrospective study we tested this hypothesis. we evaluated patients who received allohct between and . albumin decline from the day of conditioning initiation until its nadir in the first weeks of post-transplant period was calculated as delta albumin. acute gvhd was proven by biopsy in all patients. chi square and mann-whitney test were used for statistical analysis. patients' characteristics were shown in table- . acute gvhd was developed in patients and severe agvhd was developed in patients. delta albumin was not different between agvhd patients and no agvhd patients. delta albumin was not related with severe agvhd. delta albumin was not different between patients who received myeloablative and reduced intensity conditioning regimens. when we used a cutoff value of . gr/dl for delta albumin, we could not find a relation between delta albumin and development of both agvhd and severe agvhd. we repeated the analysis for acute myeloid leukemia (aml) and myelodysplastic syndrome (mds) patients who receive myeloablative conditioning regimen and we found the same results, there was no difference between agvhd patients and no agvhd patients in terms of delta albumin. there was a number of studies that used albumin as a predictive and prognostic marker in the setting of agvhd. but albumin may decrease in patients due to many reasons like malnutrition, proteinuria, enteropathy, liver disease or being negative acute phase reactant. because of albumin value can show variability between patients, albumin decline may be a more objective criterion. rashidi et al. showed that . gr/dl decline in albumin may be a predictor of severe agvhd in patients who was diagnosed with aml and mds and received myeloablative conditioning regimen. we repeat this analysis in our mds and aml (n = ) patients but we couldn't find this relation. when we evaluated all our patients, again there was no relation between delta albumin and development of both agvhd and severe agvhd. in conclusion, our study did not support rashidi et al.'s findings. because serum albumin level shows variability due to many reasons, it is hard to use albumin as a predictor of agvhd. sclerodermatous chronic graft-versus-host disease (scl-cgvhd) in its severe manifestation affects the patient quality of life and, due to complex pathomechanism, does not respond to standard immunosuppressive therapy-calcineurin inhibitors (cni) with corticosteroid. methotrexate (mtx) and rituximab appeared to be effective in some patients but the novel strategies, including extracorporeal photopheresis (ecp), imatinib, m-tor inhibitors (for example, sirolimus) and ruxolitinib seem to become the real breakthrough. we retrospectively analysed data of patients with scl-cgvhd, who underwent allogeneic hematopoietic cell transplantation (hct) between - in transplant centres. the study group consisted of patients with haematological malignancies and one with aplastic anaemia, female and male, with the median age ( - ). donors' median age was , with predominance of matched sibling donors ( donors) and even distribution of the donors' gender. in patients ( %) acute gvhd (agvhd) was diagnosed with skin involvement observed in ones. acute gvhd directly progressed to cgvhd in cases. in patients ( %) cgvhd developed ‛de novo' and in cases cgvhd was induced by dli. median time from hct to cgvhd diagnosis was months and to scl-cgvhd diagnosis- months. seven patients ( %) were scored as moderate cgvhd and patients ( %) as severe cgvhd according to nih- cgvhd activity classification. in patients sclerotic features had superficial form and in ones deep sclerosis was observed. chronic gvhd manifestation in other organs includes: mouth ( %), joints and fascia ( %), liver ( %), eyes ( %), gi tract ( %) and lungs ( %). patients were treated with ecp and/or sirolimus and /or imatinib with % response rate (complete-cr, partial-pr or minimal-mr). median duration of ecp therapy, sirolimus and imatinib treatment was months ( - ), months ( - ), and months ( - ), respectively. sirolimus was added more likely ( patients) as the first in case of suboptimal response to ecp after median weeks and in patients was subsequently replaced by imatinib with no favourable outcome in cases. in patients imatinib was initially used in combination with ecp therapy, leading to pr or mr. mtx without novel therapies was effective in patients with limited skin involvement, patients responded to mtx plus imatinib and patient to mtx plus sirolimus. two patients, after failure of other therapies, have been receiving ruxolitinib with improvement. only patient ( %) were nonresponsive to ecp (progressive or stable disease), patients ( %) to sirolimus and patients ( %) to imatinib. toxicity incidence was equally observed in case of sirolimus and imatinib and lead to the therapy discontinuation in altogether patients. infectious complications were observed in patients ( %). ecp confirms to be the most effective therapeutic strategy in severe forms of scl-cgvhd with favourable safety profile. imatinib and sirolimus, targeting different fibrotic pathways, both play important role in nonresponsive patients, improving the outcome in ecp and non-ecp group. in case of limited access to ecp, mtx remains to be beneficial in combination therapy of moderate scl-cgvhd and an alternative to cni. disclosure of conflict of interest: none. post-transplant morbidity and mortality are majorly determined by gvl effect counter-balanced by gvhd. treatment with systemic steroids represents the first-line therapy for gvhd, but is associated with increased incidence of infection and relapse. ecp can reduce the extent of gvhd while preserving anti-virus/-tumor activity. to elucidate this clinical phenomenon on an immunological level, we correlated clinical data with immunological findings in patients under ecp treatment. nine patients with acute gvhd (agvhd) of the gut ii-iv suffering from severe diarrhea were treated by ecp in addition to triple-drug immunosuppressive therapy. furthermore, patients with chronic gvhd (cgvhd) of the skin or lung despite triple-drug received ecp treatment. patients were evaluated according to their individual response and clinical condition. phenotypical analysis of different cellular subsets of patients and healthy donors was performed by multicolor flow cytometry. functional properties of virus-specific cd + t and nk cells were evaluated by inf-γ-elispot and cr-release assay. about patients were treated by ecp in this study. however, two agvhd and two cgvhd patients had to be withdrawn from ecp treatment after a few ecp cycles due to pancytopenia or poor clinical condition. for patients with agvhd up to ecp cycles were needed for response. all patients achieving a complete response (cr) were still alive year after initiating ecp therapy. overall response, that is, cr or partial response (pr) according to nih criteria, was obtained in of patients with agvhd ( . %) including cr in of ( . %). out of cgvhd patients ( . %) reached pr, and ( . %) remained stable under ecp treatment. after year, overall survival (os) was % for agvhd patients responding to ecp, while only % for non-responders. os for cgvhd patients was %. during intensive ecp treatment for patients with agvhd of the gut, the average stool volume and frequency decreased and consistency changed from loose to formed stool. steroids could be tapered down to a mean of % of the initial dosage. cgvhd patients were stabilized under ecp treatment and steroid dosage could be reduced to a mean of %. clinically responding patients showed increased numbers of regulatory cells including mdscs, foxp +cd + and foxp +cd +cd + tregs, as well as cd − cd − cd + t, vδ + t cells and regulatory b lymphocytes. furthermore, loss of cd l expression on effector cells like cd + te, cd + te, nk and nkt cells was observed under ecp treatment. interestingly, ecp treatment did not dramatically influence the frequency of cd +cd +cd + t, γδ t cells and nkt cells, which possess anti-virus/-tumor function. elispot and cr-release assays revealed stable anti-viral activity of cd + t cells as well as functional cytotoxicity of nk cells. moreover, cd + t, cd + tem, cd l+cd + temra, cd +cd − nk and cd brightcd − nk cells could serve as reliable biomarkers for prediction of response to ecp. conclusion: ecp treatment might stabilize or even improve clinical situation of patients suffering from gvhd. in clinically responding patients an immunomodulation was observed in terms of increasing numbers of regulatory cells with loss of migratory capacity of effector cells while anti-virus/-leukemia t-cell function was preserved. disclosure of conflict of interest: none. extracorporeal photopheresis affects dendritic cells by reducing total numbers and blunting cytokine production in patients with graft versus host disease tj altmann , , m bickerton , am flinn , u cytlak , p milne , s pagan , m collin , , v bigley , and ar gennery , institute of cellular medicine, newcastle university, newcastle upon tyne, united kingdom and newcastle upon tyne hospitals nhs foundation trust, newcastle upon tyne, uk graft versus host disease (gvhd) and concomitant immunosuppression is a leading cause of morbidity and mortality post hematopoietic stem cell transplantation (hsct). the pathophysiology of gvhd is complex, involving presentation of histo-incompatible antigen by activated recipient dendritic cells (dcs), activation and proliferation of donor t cells and resultant tissue damage. extracorporeal photopheresis (ecp) is a second-line treatment for steroid refractory or dependent gvhd that facilitates the reduction of immunosuppression. ecp's mechanism of action is unclear and is likely to be multifaceted. apoptosis of lymphocytes, induction of a th favoured environment and increased numbers of regulatory lymphocytes have been implicated . although ecp has been shown to modify the function of in vitro monocyte-derived dcs , its effect on primary (non monocyte-derived) dcs has not been studied. our aim was to determine whether ecp had immediate or long-term affects on primary dc numbers or function. we enumerated monocyte and dc subsets (cdc , cdc myeloid dcs and plasmacytoid dcs) in whole blood before, during and after ecp cycles, and developed a novel dc function assay, suitable for use on clinical samples. four adults with immunosuppression withdrawal gvhd and four children with acute gvhd, received ecp during the study. all received ciclosporin gvhd prophylaxis and corticosteroid treatment at onset of gvhd. children received ⩾ dose of infliximab prior to starting ecp. adults received two ecp treatments (one cycle) every weeks and children received two ecp treatments (one cycle) weekly. whole blood was taken before and after each cycle of ecp. trucount flow cytometry analysis of whole blood was used to enumerate mononuclear leukocytes. to assess function, peripheral blood mononuclear cells were isolated by density centrifugation and stimulated with toll-like receptor agonists. cell-specific cytokine production was then analyzed by flow cytometry. samples were compared to healthy controls and pre-ecp samples. median time to first ecp treatment from gvhd diagnosis was . days. no gvhd flares were experienced during study period. ( ) adult had a cycle of treatment delayed due to intercurrent pneumonia. numbers of cdc , pdcs and classical monocytes were significantly reduced after each ecp treatment in the adult group. dc numbers followed the same trend after ecp in the paediatric group but were not significantly different before and after ecp. this is perhaps due to initial lower dc count compared to adults in the children before the first ecp cycle. functional analysis showed a reduction in cytokine production in dcs and monocytes in both groups over the course of ecp treatment. our data support a cell-intrinsic effect of ecp on monocytes and dcs, with numerical and functional consequences. this may contribute to the beneficial effect of ecp both through reduction of inflammatory effector function and through modulation of interactions with other immune cells. correlation with immunosuppression withdrawal and clinical events during treatment may provide further insight into the role of monocytes and dcs in gvhd and ecp, which may aid in the development of novel targeted therapies for gvhd. extracorporeal photopheresis as early second-line treatment for patients with steroid-dependent or refractory acute graft-versus-host disease: a single-centre experience i sakellari , i batsis , e gavriilaki, a-k panteliadou, a lazaridou, k leontopoulos, d mallouri, a bouinta, v constantinou, e yannaki, c smias and a anagnostopoulos department of hematology bmt unit, g. papanicolaou hospital, thessaloniki, greece acute graft-versus-host disease (agvhd) remains a severe complication of allogeneic haematopoietic cell transplantation (allohct). corticosteroids as the backbone of initial therapy for agvhd result in varied complete responses ( - %). traditional secondary treatments lead to profound immunosuppression without improved survival. on the basis of our experience in chronic gvhd, we aimed to prospectively assess the role of extracorporeal photopheresis (ecp) as early secondline treatment in steroid-dependent and refractory agvhd. we enrolled consecutive patients with steroid-dependent or refractory grade (gr) ii-iv agvhd post allohct from january to august . all patients with unrelated or haploidentical donors received thymoglobulin (atg) mg/kg as prophylaxis. post-transplant gvhd prophylaxis included cyclosporine-methotrexate in myeloablative and cyclosporine-mycophenolate mofetil in reduced toxicity or intensity regimens. ecp was commenced after assessment of response to days of steroid treatment according to our protocol: two sessions per week for month, one session per weeks for months, evaluation of response and one session per month for months. we studied patients, aged ( - ), post allohct with myeloablative ( ), reduced toxicity ( ) and intensity ( ) conditioning, from sibling ( ), matched ( ) or one locus mismatched ( ) volunteer unrelated and haploidentical ( ) donors. disease risk index was high ( ), intermediate ( ) and low ( ). acute gvhd was observed at day + ( - ) in patients, late onset at + ( - ) in patients and induced at + post donor lymphocyte infusion in a relapsed aml patient. skin, intestine and liver involvement was evident in patients, skin and intestine in and skin only in patients. nine patients ( with grii, with griii agvhd) were steroid-dependent and ( with griii, with griv) steroidrefractory. atg was administered simultaneously with ecp initiation in six refractory patients that further developed ebv reactivation (p = . ) treated pre-emptively with rituximab. ecp was commenced at day + for ( - ) sessions. the majority of patients ( / ) presented partial ( ), very good ( ) or complete ( ) response to ecp. with . ( . - ) months of follow-up, immunosuppression was reduced in / and ceased in patient. clinically significant bacterial infections were found in patients, fungal in , cmv and ebv reactivation in and , respectively, and other viral in patients. cumulative incidence (ci) of chronic gvhd was . at year. one-year ci of agvhd-related mortality was %. one-year overall survival (os) was % and significantly increased in steroid-dependent vs refractory patients ( % vs %, p = . ). reduction of immunosuppression (p = . ) and response to ecp (p = . ) were associated with improved os, irrespectively of other factors. our data indicate that ecp should be considered early in the course of steroiddependent or refractory agvhd, before irreversible end organ damage has been established. optimal timing of intervention, frequency, duration and tapering schedule of ecp remain important unanswered questions. [p ] disclosure of conflict of interest: none. extracorporeal photopheresis for treatment of chronic graft versus host disease m lanska, a zavrelova, j radocha and p zak faculty of medicine, th department of internal medicine-hematology, university hospital hradec kralove, czech republic allogeneic stem cell transplantation represents a curative approach to many hematologic disorders. graft versus host disease (gvhd) is a complication with significant morbidity, mortality and decreased quality of life. extracorporeal photopheresis (ecp) represents possible treatment approach. mononuclear cells (mnc) collected by apheresis are photosensibilized with -methoxypsoralenem ex vivo, irradiated with uva and transfused back to the patient. aim of the study: evaluation of patients treated with ecp for gvhd at our center. thirteen patients ( females and males, median age years) were treated with ecp. about patients (pts) had matched sibling donor and patient had unrelated donor. about pts had sclerodermic form of gvhd, had concomitant pulmonary gvhd, had pulmonary gvhd alone. one pts had mild, seven moderate and five severe gvhd according to nih. about patients were treated with steroids. mnc separation was prepared on cobe spectra and spectra optia (terumo bct, usa). -methoxypsoralen was added, irradiation was done on macogenic g (macopharma, mouvaux, france). about procedures in pts were performed (median procedures, - procedures). the schema was as follows: ecp on consecutive days every - weeks first months with subsequent increase in interval. median follow up was months. in sclerosing form two pts reached cr, six pts pr, one is stable and one patients progressed. in pulmonary gvhd one reached cr, two partial improvement, one is stable. seven pts are still alive, six died (two due to relapse, one secondary malignancy and three infections). it was possible to withdraw steroids in pts. adverse events were clinically negligible. ecp is an effective treatment for chronic gvhd. especially sclerodermic form responds to ecp very well. it is safe and well tolerated procedure with minimal toxicity. supported by prvouk p- . disclosure of conflict of interest: none. allogeneic haematopoietic stem cell transplantation (hsct) is a potentially curative treatment option for children with a variety of haematological, oncological and immunological diseases. graft versus host disease (gvhd) represents a major cause of post-transplantation mortality and morbidity affecting multiple organs including skin, gut, liver and lungs. gvhd is considered a succession of inflammation and donor t-cell activation initiated by translocation of gastro-intestinal microorganisms through impaired mucosal barriers after chemotherapeutic conditioning and/or infection. diagnosis of gvhd is based on clinical symptoms and histological findings, necessitating invasive and potentially harmful procedures including endoscopy and biopsy. as yet, no non-invasive markers are available for diagnosis or treatment monitoring in children with gvhd. faecal calprotectin (fc) reflects intestinal mucosal inflammation of any origin. in the setting of allogeneic hsct in adults, fc has shown to be a marker for acute (steroid-resistant) gvhd. we aimed to evaluate the feasibility of prospective fc measurement as a non-invasive marker for diagnosis and treatment in children with gvhd. a prospective, observational, single centre study was started in july . by december , paediatric allogeneic hsct patients (age - years) were included after informed consent. faecal samples were collected from weeks before to months after hsct. fc levels were measured by elia, according to manufacturer's instructions. clinical symptoms were prospectively evaluated and managed according to local guidelines. if gvhd was suspected on clinical grounds, histological confirmation was obtained. first-line therapy for gvhd consisted of corticosteroids. in case of steroid-resistant disease, more advanced immune modulation was applied. a total of five patients developed histologically confirmed gvhd: acute gvhd of skin and gut (n = , one patient with steroidresistant disease), acute gvhd of skin only (n = ); chronic gvhd of lung only (n = ) and acute gvhd of skin followed by chronic oromucosal gvhd (n = ). without exception and regardless of gut involvement, gvhd occurrence was accompanied by rises in fc levels to values μg/g (range: - μg/g). fc levels correlated with clinical and histological grading. moreover, adequate response to therapy was consistently reflected by return of fc levels to values o μg/g. sensitivity of fc levels to diagnose gvhd was poor due to increased fc levels in patients with posttransplant complications other than gvhd such as viral reactivation and pulmonary or gastro-intestinal infections. fc levels reflect gvhd occurrence and correlate with clinical and histological grading in paediatric allogeneic hsct patients. fc levels increase in case of gvhd regardless of gut involvement, supporting a central role for (subclinical) intestinal inflammation in gvhd initiation. although, in this interim analysis, fc lacks sensitivity to diagnose gvhd, fc may serve as a noninvasive marker for monitoring therapy response and, thereby, reduce the need for repeated invasive procedures including endoscopy and biopsy. acute graft-versus-host disease (agvhd) is a major complication of allogeneic hematopoietic cell transplantation (hct), and glucocorticoids are typically used as first-line treatment. the aim of our study was to evaluate the effect of first-line ecp +/ − steroid therapy in order to reduce the incidence of infections and toxicity. from december to january , of pts ( %), were diagnosed with agvhd grade ⩾ following allosct. pts were treated with ecp +/ − steroid as first-line therapy. about ( %) pts were treated with ecp only and ( %) with ecp + steroid - mg/kg/day. we compare this cohort with an historical group of patients, transplanted between and , who were treated with steroid only for grade - agvhd (n = out of ). the two cohorts were well balanced in terms of median age (p = . ), disease type (p = . ), disease status (p = . ), graft source (p = . ), conditioning regimen (p = . ) and hct-ci (p = . ). there were more female patients (p = . ) and more haploidentical transplant (haplo-sct) (p = . ) in the cohort treated with ecp+/ − steroid. ecp was performed using the offline technique, and was started as soon as possible with a treatment schedule consisting of four rounds of two procedures per week, three rounds of two procedures every other week and finally two procedures every month. steroid was tapered as soon as possible after starting ecp. the clinical response was evaluated at day + . median follow-up for alive patients was months for ecp group and months for control group. there was no difference in terms of median time of agvhd onset ( vs days) and number of pts with grade or - agvhd ( figure ). ecp was started after a median of ( - ) days from agvhd diagnosis. every patient underwent a median of ( - ) ecp procedures, during a median time of months. on day after starting agvhd treatment with ecp+/ − steroid, pts ( %) achieved cr or pr, pts did not respond and experienced agvhd relapse to front-line therapy. one year cumulative incidence (ci) of agvhd relapsed/refractory was . % for ecp+/ − steroid. these percentages were not different from the cohort receiving steroid alone. ci of moderate-severe cgvhd was lower in the ecp group, probably due to the higher frequency of haplo-sct with pt-cy in the ecp group. about days after agvhd onset, ci of infection ( % vs %), especially cmv reactivation ( % vs %), was lower in the ecp group, but was not statistical significant. ecp allowed a faster taper of steroid: ( - ) vs days ( - ) (p o . ). overall survival, progression-free survival, non-relapse mortality and ci of relapse rates did not differ in the two groups. in multivariate analysis, visceral involvement by agvhd was associated with an increased risk of failure to front-line therapy (hr: . ; range: . - ; p = . ). this observational study suggests that the overall response rate of ecp +/ − steroids is similar to steroid alone for front-line treatment of grade - agvhd, but is potentially associated with lower incidence of infection, and in particular of cmv reactivation. a prospective phase clinical trial is warranted to address whether augmentation with ecp may be beneficial for agvhd frontline treatment. [p ] a -year-old girl with neuroblastoma received autologous stem cell transplant (asct), followed by antibiotic prophylaxis and filgrastim. her transplant preparative regimen consisted of busulfan and melphalan. engraftment of neutrophil took place on day after asct. twentieth day after asct, she experienced nausea and diarrhea. there was neither skin rash nor elevation in liver enzymes. the diarrhea continued to worsen day by day and reached to a daily volume of ml/ m . infectious studies for stool and blood including testing for influenza a and b, parainfluenza, adenovirus, epstein-barr virus, amebiasis, cryptosporidium parvum, cytomegalovirus, clostridium difficile, salmonella, campylobacter, yersinia and shigella were all negative. colonoscopy and endoscopy were performed by an experienced pediatric gastroenterologist and findings were suspicious for severe graft versus host disease (gvhd). colonoscopy and rectoscopy revealed severe inflammatory changes, friability and patchy dark exudates on the mucosa of rectum. endoscopy revealed erosions, ulcers in the esophagus and a pale mucosal surface with reticulated submucosal vessels accompanied with erosion and erythema in the antrum of stomach. grade gvhd was confirmed by pathologic analysis that revealed diffuse crypt dropout and mucosal erosion on rectal mucosal biopsy. mucosal erosions, apoptosis of epithelial cells and small lymphocytic infiltration of the lamina propria were found on duodenal biopsy. after these results, we started methylprednisolone intravenously at a dosage of mg/kg/day. on the fourth day of treatment we increased the dosage to mg/kg/day and added cyclosporine to treatment. because of unresponsiveness to treatment we decided to administer thirdparty mesenchymal stem cells (msc) ( × cd +/cd + cells per kg). these were given intravenously at day + asct as single infusion. the second dose was given at day + . within days after first application of mscs, the frequency of diarrhea decreased to one-third. at day + after second dose of mscs, the patient's stool became nearly normal. we tapered the steroids first and stopped cyclosporine at + th days after asct. discussion and conclusion: to our knowledge, this is the second case report of spontaneous severe autologous gvhd in a child with a solid tumor malignancy. regarding the pathogenesis of autologous graft-versus-host disease, there may have multiple causes for the loss of tolerance to self because of disrupted immune system. alteration of t regulatory cells by previous chemotherapy may be key point. endogenous cells that survive conditioning and assist in post-transplant maintenance of self-tolerance may be affected. microchimerism due to maternal cells transmitted during fetal development and persisting throughout adult life has also been postulated as a cause. however it is not very clear for factors that may contribute to the pathogenesis of this rare disease. autologous gvhd has the potential to cause critical illness in the hematopoietic stem cell transplantation patient population. in patients with multiple myeloma some experts report pathologically verified gastrointestinal gvhd as high as %. responses to steroids are variable. however, a significant proportion improve dramatically after early therapeutic intervention. so clinicians and pathologists should be aware in suspecting and recognizing gvhd in patients with diarrhea to guide therapy as soon as possible. disclosure of conflict of interest: none. haplosct patients did not receive additional gvhd prophylaxis aside from the ex vivo t-cell depletion (tcd) with clinimacs system. of the bud bmts out of patients engrafted, % of which had gvhd. the % who did not have any gvhd, relapsed. eighty one percent had agvhd, of which majority ( %) were grade ( table ) three patients did not have agvhd ( / mud and two cord blood grafts), but developed cgvhd. one of the patients who had grade agvhd died and one still has intermittent cgvhd years post bmt. there were % who had cgvhd. currently, all of our haplosct receive a cd /cd ra tcd grafts (n = ). the depletion techniques for the others were either cd tcd, cd / cd ra /tcrab tcd+cd +/cd ra tcd; tcrab tcd. all patients who received haplosct engrafted and % had agvhd ( % grade ) ( table ). we noted that some of the patients presented with nonclassical agvhd signs (upper gut gvhd, oral gvhd, blood). there were no patients who presented with grade agvhd. cgvhd in the cohort was %. of note, % of patients did not have any gvhd and did not receive any form of immunosuppression post bmt. only eight patients received further immunosuppression for agvhd, median duration (range: - ) days. at the time of this report, there are four patients with agvhd still receiving immunosuppression all o days and all on tapering doses. haplosct using ex vivo tcd techniques has a lower risk of gvhd with comparable, if not superior outcome to bud. the degree and duration of immunosuppression is also much less. this may translate to earlier immune reconstitution and less viral reactivation. [p ] disclosure of conflict of interest: none. allogeneic hematopoietic stem cell transplantation (allo-hsct) offers a potential cure for several hematological diseases, but it is burdened by severe life-threatening complications, being gvhd the major cause of morbility and mortality. recently, more have been understood of the physio-pathologic relationships between endothelium and graft-versus-host disease (gvhd), showing that vascular endothelium is an early phase target of gvhd. in recent years, the direct count of circulating endothelial cells (cec) has emerged as a valuable biomarker of endothelial damage in a variety of disorders. however, due to their rareness and complex phenotype, different published techniques have showed variable degrees of uncertainty, reporting a wide range of cec values in healthy subjects. by means of the commercially available rare cell isolation platform cellsearch system, for cec identification and count, we correlated cec count changes to gvhd onset and response to treatment in allo-hsct patients. cec were analysed in allo-hsct patients ( aml, all, hd, nhl, cll, mds, cms, mm, saa) at the following time points: t (pre-conditioning), t (pre-transplant), t (engraftment), t (day+ or onset of gvhd), t ( week after steroid treatment). the median cec/ml at t was (range: - ), in comparison to a value of (range: - ) in healthy controls (p %: or . , % ci . - . ; p = . ). we confirm that cec count represent a valid biomarker to monitor endothelial damage in patients undergoing allo-hsct and can be a valuable tool in supporting the diagnostic definition of gvhd and in monitoring responsiveness to treatment. moreover, the use of the cellsearch system can be crucial in order to move routinely cec monitoring into clinical practice of allo-hsct. reference clinicaltrials.gov nct . disclosure of conflict of interest: this research was conducted with the support of the investigator-initiated study program of janssen diagnostics, llc to ca. kb is employee of janssen diagnostics. results of hla mismatched unrelated donor (mmud) hematopoietic cell transplants (hct) are worse than results of fully matched hct due to higher risk of gvhd, infection and graft failure. atg during conditioning reduces incidence of gvhd but can increase risk of infection and relapse. high doses posttransplant cyclophosphamide ( × mg/kg) prevent gvhd in haploidentical hct. we initiated this approach instead of atg in hct from one alelle or antigen mismatched unrelated ( / )mmud-hct in . here we present outcome of patients (cy-group) transplanted between and , comparing it with outcome of patients transplanted between and from / mmud with atg-f (fresenius) mg/kg given during conditioning. patients in cy-group ( males, females) were transplanted from mmud mismatched for hla ( a- , b- , c- , dr- ). about patients had aml, mds, cll, cml, all and mps. med. age of patients was years ( - ). about patients received myeloablative (flu- mg/m + iv bu . mg/kg) and nonmyeloablative(flu- mg/m+mel - mg/kg +-tt mg/kg) conditioning. about patients received pbpc and bm as a graft. graft versus host prophylaxis consisted of cyclophosphamide ( mg/kg aibw) on d+ and + , cyclosporine a from d and mmf from d+ . all patients received antibacterial, antifungal, hsv and pcp prophylaxis. historical control (atg) group consisted of patients ( males, females), med. age y ( - ) who had mmud-hct for aml- , mds- , nhl- , mf- , all- , cll- , cml- , h.d- , saa- , mps- and mm- . there were mismatches for a, for b, for c and for dr. myeloblative conditioning was used in and nonmyeloablative in patients. all patients received atg-f mg/kg × given d- and- . cyclosporin was initiated d- and mmf d- . all patients received anti-infectious prophylaxis as described previously. three of patients from cy group died so far. two of them due to relapse and one due to toxicity and infection during aplasia. five patients relapsed . two achieved cr after dli and one is alive in relapse expecting second hct. about patients are alive, of them in cr. eight patients experienced agvhd (gr.i- , gr.ii- ,gr.iii- , gr. iv- ) and eight developed clinically mild cgvhd). about patients from atg group are alive - m (med. m) posthct. about patients died - m postransplant (med. m) due to vod, gvhd, infections and relapse. -day mortality is % ( / ) in cy group and % ( / ) in atg group. one year mortality is % ( / ) in cy and % ( / ) in atg group. patients from cy group have % probability of os at months posthct vs % from atg group. cyclophosphamide × mg/kg instead of atg fresenius( mg/kg) for gvhd prophylaxis reduced -day and -year mortality, and improved probability of m os significantly in our cohort of patients. this approach seems to be safe and effective in / mmud-hct. disclosure of conflict of interest: none. high transplanted cd + cells are not associated with beneficial effect on graft-versus-host disease-free, relapse-free survival (grfs) after allogeneic hematopoietic cell transplantation y lee and ih lee department of hematology, kyungpook national university hospital and inhee lee the success of allogeneic hematopoietic cell transplantation (allo-hct) is comprehensively assessed by individual comorbidity, relapse, graft-versus-host disease (gvhd) and death. besides, inconsistent results have been reported regarding the dose of cd + cells. in the current study we have addressed the issue of the potential effect of stem cell dose on the of gvhd-free/relapse-free (grfs) associated with cd + cells doses. we retrospectively reviewed the medical records of the patients who received allo-hct for acute myelogenous leukemia (aml), myelodysplastic syndrome (mds) and acute lymphoblastic leukemia (all) between and in kyungpook national university hospital. the grfs included grade - acute gvhd, systemic therapy-requiring chronic gvhd, relapse or death. the patients were reclassified into two groups according to the targeted cd + cell doses ( × per kg) by knuh protocol. a lower cd + group (n = , . %), patients who underwent allo-hct with cd + cell dose o × per kg; and a higher cd + group (n = , . %) patients who underwent allo-hct with cd + cell ⩾ × per kg. the median age at transplant was . years (range: - years) and male was patients ( . %). primary diseases for allo-hct were aml/mds (n = , %) and all (n = , %). one hundred forty-three patients ( . %) were in cr (complete remission), ( %) in further cr and ( . %) in relapsed and refractory status. one hundred seventy-one patients ( . %) received myeloablative conditioning regimen. gvhd prophylaxis consisted of methotrexate and cyclosporine a or mtx and tacrolimus. the median dose of cd + cell was . × per kg (range: . - × per kg) in lower cd + group and . × per kg (range: . - . × per kg) in higher cd + group. there was no significant difference in neutrophil, platelet engraftment between two groups. the incidence of chronic gvhd was more frequent in higher cd + group ( . % vs . %, p = . ). the median follow-up duration was . months, with a range of . - . months. the -year overall survival (os), relapse free survival (rfs), nonrelapse mortality (nrm) and graft-versus-host disease (gvhd)free/relapse-free survival (grfs) since hct was . ± . %, . ± . %, . ± . % and . ± . %, respectively. there was no significant difference according to the infused cd + cell dose (figure ). the relapse rate was not proportionally affected by the cell dose ( . % vs . %, p = . ). and there was no significant correlation between the number of cd + and cd + cells infused (spearman correlation coefficient: p = . ). in a univariate analysis, patients transplanted with the higher cd + cell doses and higher cd + cell doses had no increased grfs (p = . and p = . ). an independent factor associated with worse grfs was risk status at transplant (hr = . , % ci: . - . , p = . ). these results suggest that careful assessing the cd + and cd + graft content and tailoring the cell dose infused may help in reducing cgvhd risk without negative impact on grfs. a large and prospective study in a homogenous population will be needed to confirm the effect of stem cell dose. disclosure of conflict of interest: none. imatinib associated with extracorporeal photopheresis can fully reverse severe sclerotic-type lesions in patients with chronic graft-versus-host disease: the lille university hospital experience l magro , j gauthier, b catteau , l mannone , a lionet , v coiteux and i yakoub-agha lille university hospital and nice university hospital severe sclerotic-type chronic graft-versus-host disease (cgvhd) is difficult to reverse and can dramatically alter the quality of life of patients after allogeneic hematopoietic cell transplantation (allo-hct). imatinib or extracorporeal photopheresis (ecp) used separately yield sustained responses in s only about % of patients with steroid-refractory cgvhd. given their respective modest efficacy we hypothesized that the combination of imatinib with ecp could lead to higher response rates. we are reporting here on seven patients with severe steroid-refractory sclerotic-type cgvhd treated at our institution using this combination. we retrospectively analysed all patients treated at our institution (n = ) with the combination of imatinib with ecp for severe steroidrefractory scgvhd. imatinib was started at mg/day and increased to mg/day if well tolerated. the cellex closed system was used for ecp. ecp was initiated twice weekly during weeks. after this « induction » period, ecp sessions were scheduled less frequently according to the response to treatment. additional immunosuppressants were tapered gradually in responding patients. initial grading and response evaluation was determined according to the nih criteria. steroid-refractoriness was defined as progression of gvhd on high-dose steroids (⩾ mg/kg) or progression during corticosteroid tapering. patient characteristics are displayed in table . patients received an allo-hct between may and april . median age at allo-hct was (range: - ). a variety of myeloablative (n = ) and non-myeloablative conditioning regimens were used (n = ). antithymocyte globulin was used before allo-hct in one patient. gvhd prophylaxis consisted of ciclosporine and methotrexate in six patients. one patient received tacrolimus and methotrexate. five patients had prior history of acute gvhd. nih global severity grade was severe in all patients (n = ) due to severe sclerotic features. the median number of previous therapies was (range: - ). all patients were steroid-refractory. after a median follow-up of months (range: - months) the overall response rate was %. the complete response rate was %. median time on ecp associated with imatinib was months (range: - months). median time to best response was months (range: - months). corticosteroids could be discontinued in all patients after a median time of months (range: - months). patients # , # and # received maintenance therapy with ecp upon discontinuation of imatinib. in four patients, both ecp and imatinib led to complete response and could be discontinued after , , and months for patients # , # , # and # , respectively. patient # and # passed away after due to a myocardial infarction and the development of a solid tumour, respectively. patient # was off therapy while patient # remained on maintenance with ecp. both remained in complete response. patient # remained in response during months before progression of cgvhd while on imatinib and ecp. none of our patients experienced adverse events related to either imatinib or ecp. despite the limited number of patients in this report, we observed that the combination of imatinib and ecp can lead to complete and sustained reversal of severe steroid-refractory sclerotic-type cgvhd. these encouraging results should be confirmed in a larger cohort. disclosure of conflict of interest: lm: therakos (honorarium). allogeneic hematopoietic cell transplantation (allo-hsct) is an established treatment modality that is potentially curative for many patients (pts) with acute myeloid leukemia (aml). aml itself is the most common indication for pts undergoing hsct nowadays. for pts with high-risk disease, allo-hsct is, perhaps, the most effective curative treatment and is considered the standard post-remission therapy in first complete remission (first cr). this is a retrospective study to analyze those variables which were associated with patients' overall survival (os) after allo-hsct. the study population consisted of pts who were diagnosed of aml from january to july at the hospital universitario central asturias, and submitted to allo-hsct in first cr. risk status based on validated cytogenetics and molecular abnormalities following recommendations of european leukemianet was performed. sixteen ( . %) were male. median age was years old (range: - ). clinical characteristics at transplantation are represented in table . median follow-up was months ( - ). considering the donor type, os at year was higher in pts receiving sd ( . %) compared to % in those who received urd (p = . ). regarding graft source, os at year was . % who received pbsc compared to % in pts receiving bmsc (p = . ). gender also showed significant association with os, which was higher among men, os at year was %, compared to . % for women) (p = . ). the presence of minimal residual disease (mrd) detected using multiparametric flow cytometry was performed prospectively after induction and consolidation, and before transplantation. thirteen pts had negative mrd before transplantation. median os was greater in pts with negative mrd before transplantation compared to the group with positive mrd ( vs months, respectively) (p = . ). this difference did not reach statistical significance probably because the low number of the sample. thirteen pts developed agvhd. only ( . %) pts receiving sd developed agvhd compared to ( %) pts among those who had an urd; however this association was not statistically significant (p = . ). also, we observed higher incidence of agvhd in bmsc group ( pts; %) whereas only ( . %) in pbsc group developed agvhd. this tender did not reach significant association (p = . ). one year os was . % in pts who developed agvhd and . % who did not (p = . ). all factors that had a significant influence on pts survival were included in a multivariate analysis (cox regression model): graft source, donor type, pts gender and agvhd development. developing agvhd kept an independent association with mortality (or . , % ci . - . , po . ) and male gender also persisted as an independent protective factor (or . , % ci . - . , p = . ). in our series, agvhd has shown a significant and independent association with os over other parameters such as graft source, type of donor or mrd before transplantation. identifying reliable predictors for agvhd development, controlling well known risk factors for this disease, as well as improving management of immunosupressors should still be the key to potentiate longer os in our patients. larger studies are needed to confirm our results. acute and chronic graft-versus-host diseases (gvhd) are associated with increased morbidity and mortality after allogeneic hematopoietic stem cell transplantation (allo-hsct). older patients undergoing allo-hsct may experience a high degree of transplant-related complications and this concern has historically limited the use of allo-hsct for some older patients. in many studies, age has been shown to be a negative prognostic factor for survival and associated with higher transplant-related mortality (trm). however, in others, age was not shown to be a significant factor if appropriate adjustments for other comorbidities are incorporated in the analyses. there are very few studies that evaluated the relationship between patient's age, the presence of gvhd and long-term transplantation outcome. the aim of this study is to evaluate the impact of age in patients who develop acute and/or chronic gvhd after allo-hsct for hematological malignancies on the trm incidence. we included in the study patients with hematological malignancies who received allo-hsct and were followed in our center between january and january . for the purpose of this study, only patients who developed grade ii-iv acute gvhd and/or limited or extensive chronic gvhd where considered for analysis (n = ). patients were split into three homogeneous groups according to age at transplantation taking into consideration the underlying disease, type of conditioning and disease response at transplantation. group (younger) included patients aged o years (n = ), group (intermediate) included patients aged between and years (n = ) and group (older) included patients older than years (n = ). gvhd evolution over time was followed as well as the cumulative incidence of trm was calculated in case of acute or chronic gvhd in each group. thirty seven percent of grade ii gvhd occurred in the younger group (n = ), % (n = ) in the intermediate group and % (n = ) in the older group; majority ( %) resolved in the younger group as well as in and % in the latter two groups, respectively, while trm rates at year were %, % and %, respectively, sdhr = . , p = . . among patients who had acute gvhd grade ii, , and % in the three respective groups developed chronic gvhd later. grade iii-iv gvhd occurred in % (n = ) in the younger group, % (n = ) in the intermediate group and % (n = ) in the older group; with a respective resolution in %, % and % of patients and were associated with comparable trm rates at year of %, % and %, respectively, p = . . among patients who had acute gvhd grade iii-iv, , and % in the three respective groups developed chronic gvhd later. de novo chronic gvhd was observed with a higher rate in the intermediate and in the older group (table) while patients with extensive chronic gvhd older than years had significantly higher trm at years ( %) compared to % in those younger than years, sdhr = . , p = . . patients who develop acute gvhd grade iii-iv could incur over % of trm at year independently of age. resolution of acute gvhd grade ii was significantly better in younger patients while older patients with grade ii acute gvhd or with extensive gvhd had higher mortality compared to younger ones. in addition to an adapted prophylaxis, a better preemptive gvhd strategy should be warranted in older patients. [p ] disclosure of conflict of interest: none. in vivo effects of nilotinib on lymphocyte subpopulation and function following allogeneic stem cell transplantation e marinelli busilacchi , a costantini , j olivieri , n viola , s coluzzi , e pirro , g mancini chronic graft versus host disease (cgvhd) is a major complication of allogeneic stem cell transplantation and is characterized by frequent multiorgan involvement resembling autoimmune diseases; its pathogenesis is still incompletely defined and a standard treatment is lacking. donor-derived cd + and cd + t lymphocytes have been considered the main effector cells mediating cgvhd pathogenesis; however, recent studies suggest that b cells might also play an important role. in vitro data indicate that tyrosine kinase inhibitors (tkis) such as imatinib and nilotinib affects both innate and adaptive immune response by interacting with different cell populations (t cells, b cells, dendritic cells, mast cells and macrophages). we sought to evaluate the impact of different doses of nilotinib on the distribution and function of lymphocyte subpopulations. we analyzed samples obtained from patient with steroiddependent/refractory cgvhd enrolled in a phase - study with nilotinib in steroid-refractory cgvhd (nct ): triplets of patient were treated with escalating doses starting from mg/die ( ), mg/die ( ), up to mg/die ( ) . blood and plasma were collected at baseline and at day and of therapy. trough plasma nilotinib concentrations had been previously determined by hplc (abstract c , haematologica: evaluation of nilotinib safety in patients with steroid-refractory chronic graft-versus-host disease: a phase i-ii gitmo study). peripheral blood mononuclear cells were isolated by density gradient centrifugation using ficoll biocoll. six color flow cytometry analysis (facs canto ii) was performed using conjugated antibodies (anti-cd , cd , cd , cd , cd , cd ). inflammatory cytokine analysis was performed on plasma samples according to the instruction of bioplex pro human cytokine plex assay (bio-rad). statistical analysis was performed by -tailed student's t-test; differences were considered statistically significant for po . . flow cytometry analysis showed that nilotinib did not exert any significant impact neither on the proportion of t lymphocytes subpopulation (cd +cd + t helper, cd +cd +cd + t regulatory, cd +cd − t cytotoxic), nor on b lymphocytes and nk cells. on the contrary, a statistically significant and dose-independent decrease of pro-inflammatory and th- cytokine production was observed ( figure ): reduction of il (po . ), il (po . ) and ifnγ (po . ) were already significant after days; decreases of il (po . ) and tnfα (po . ) become significant after days. interestingly, after days of therapy, among the patients enrolled (according to the itt criteria) ten patients showed cgvhd improvement and the other five remained stable. this study shows that therapeutic doses of nilotinib can reduce plasma levels of inflammatory cytokines without affecting the proportions of lymphocyte subpopulations. these findings correlate with clinical response and suggest that besides the previously demonstrated anti-fibrotic effects, nilotinib has also potent anti-inflammatory and immune regulatory properties, supporting its role in patients with cgvhd. disclosure of conflict of interest: none. [p ] previously published p infectious gastro-enteritis after allogeneic hematopoietic transplantation after reduced intensity conditioning (allo-ric): incidence and possible role in gastro-intestinal acute gvhd i garcía-cadenas , r martino , a esquirol , a bosch , n rabella , s saavedra , c muñoz , j briones , s brunet and j sierra hematology and microbiology departments and hospital de la santa creu i sant pau, autonomous university of barcelona, spain enterotoxigenic c. difficile-associated associated disease or infection (cdi) is a common cause of diarrhea after hematopoietic stem cell transplantation (sct). recent studies have suggested the relationship of cdi with gastro-intestinal (gi) graft-versus-host disease (gvhd). the possible role of other types of infectious gastro-enterocolitis (g-ec) in gvhd development has not been studied. as a prior investigation to a national prospective observational study on this issue, we conducted a single-center retrospective analysis including all adult patients who received an allo-ric sct between january and march . the aim was describing the cause(s) (if known), timing and outcomes of recipients with possible g-ec (defined as new onset acute diarrhea grade ⩾ ) in the first year after sct. of the patients studied (median age: years, % male, % aml or mds as underlying disease), ( %) had a total of episodes of acute diarrhea, with ( %) developing more than one event. these acute diarrheas occurred at a median of days (range: - ) after sct. overall, a g-ec causing pathogen was identified in of stool specimens ( %) and included: cdi ( ), c. jejuni ( ), rotavirus ( ), adenovirus ( ), norovirus ( ), b. hominis ( ), s. stercoralis, g. lamblia, a. caviae, salmonella enterica and cryptococcus (one in each case). most postransplant diarrheas ( / ; %) occurred during the weeks after infusion and were attributable to mucosal damage caused by the ric (negative microbial screening and no evidence of gvhd).the rate of infectious g-ec among the diarrheas occurring after day + was % ( / ). the overall incidences of enteric infection were . % ( % ci: . - . ) and . % ( % ci: . - . ) at + and + months after sct, respectively. all the infected patients had mild to moderate disease, and no deaths were attributable to this complication. there were no differences in year-os and nrm between the infected and uninfected patients ( % vs %, p = . and % vs %, p = . , respectively). in univariate analysis age o years, prior sct, donor type, atg administration and prior grade - agvhd were associated with development of infectious gastro-enteritis. in multivariate analysis, unrelated donor and grade - agvhd were the only factors significantly associated with gastrointestinal infection (hr . ; % ci: . - . , p = . and hr . , % ci . - . , p = . ; respectively). acute gvhd occurred in % of patients (n = ), with a median onset of days (range: - ). the cumulative incidences of - acute gvhd at days and months post-sct were % ( % ci: . - %) and . % ( % ci: . - %), respectively, and there was a trend toward a higher risk of - gvhd in the group of patients with an enteric pathogen ( . % vs % at year, p = . ). more importantly, an enteric infection occurred just before the onset or aggravation of gvhd in / infected patients in our study ( %) at a median interval of days after the infection (range: - ). in summary, our results confirm that enteric infections are a common complication after allo-ric, representing at least % of the episodes of acute diarrhea during the first year post-sct. a possible interplay between infectious g-ec and gvhd was observed in this study. disclosure of conflict of interest: none. long-term efficacy of extracorporeal photopheresis in chronic graft versus host disease m nygaard , t karlsmark , n smedegaard andersen , i schjødt , s lykke petersen , l smidstrup friis , b kornblit and h sengeløv department of dermatology, bispebjerg hospital, copenhagen, denmark and department of hematology, rigshospitalet, copenhagen, denmark chronic graft versus host disease (cgvhd) activity is known to fluctuate over time, so we evaluated cgvhd continuously throughout the extracorporeal photopheresis (ecp) treatment course and after stopping ecp. patients with at least year follow-up, who were treated with ecp at department of dermatology, bispebjerg hospital between and were evaluated. a single investigator retrospectively evaluated response to ecp monthly for months, every months until years and every months until years. prednisolone doses were recorded every months. responses were defined as complete remission (cr) if no symptoms of cgvhd were present, partial remission (pr) as improvement in cgvhd or stationary cgvhd with more than % reduction in prednisolone, no change (nc) as no difference in symptom burden and o % reduction in prednisolone. progressive disease (pd) was defined as worsening of symptoms with unchanged or intensified immunosuppressive medication. ecp was performed with therakos uvar xts or cellex. there were evaluable patients with moderate (n = ) or severe (n = ) steroid-refractory, dependent or -intolerant cgvhd. the median age was years (range: - ) and there were females and males. conditioning regimen was myeloablative (n = ) and non-myeloablative (n = ). seventeen had related donors and had unrelated. stem cell source was peripheral blood (n = ), bone marrow (n = ) or umbilical cord blood (n = ). number of organs affected by cgvhd was one (n = ), two (n = ), three (n = ), four (n = ) or five (n = ) and involved organs were skin (n = ), eyes (n = ), mouth (n = ), lungs (n = ), genitals (n = ), liver (n = ), musculoskeletal system (n = ) or gastrointestinal tract (n = ). time from diagnosis of cgvhd to first ecp was median days (range: - ) and time from referral to ecp and the first ecp procedure was median days (range: - ). at the time of the first ecp procedure patients were also treated with prednisolone (n = ), sirolimus (n = ), calcineurininhibitor (n = ), mycophenolate mofetil (n = ), imatinib (n = ), methotrexate (n = ) or rituximab (n = ). one patient received no immunosuppression. total number of ecp cycles was median (range: - ). responses over time are shown in figure . overall response to ecp was seen in ( %) of the patients. most responses were seen after more than months ecp treatment. in univariate analysis of possible baseline predictors of response, no significant associations were found. prednisolone dose was significantly reduced at every months after start of ecp (p o . ). additional cgvhd treatment was administered to ( %) patients during ecp treatment (sirolimus n = , calcineurininhibitor n = , uva n = , methotrexate n = , rituximab n = , mycophenolate mofetil n = ). about ( %) patients had more than additional treatment. prednisolone dose was increased at least once in ( %) patients during ecp treatment. overall survival at years was %. follow up was median days (range: - ). more than half the patients with cgvhd ( %) improve overall after treatment with ecp, but flares in cgvhd activity still occur. prednisolone dose is significantly reduced at all time points after starting ecp, but short term increased doses or additional immunosuppression was necessary in more than one-third of the patients. larger prospective studies with long-term end points are warranted. disclosure of conflict of interest: marietta nygaard has received a travel grant and speaker's fee from therakos/ malinckrodt. chronic graft versus host disease (cgvhd) remains a major cause of morbidity and mortality after hematopoietic stem cells transplantation despite the improvement of the immunosuppressive prophylaxis. skin, buccal, lacrymal and hepatic disorders are the most frequent. sclerotic gvhd remains a severe form and often refractory to standard treatment lines such as corticosteroids and calcineurin inhibitors. the antifibrotic activity of imatinib by the inhibition of pdgf-r and tgfb-β pathways has been used in the treatment of refractory gvhc with sclerotic features and systemic scleroderma. here, we report the results of imatinib treatment in patients (pts) with refractory cgvhd. over a period of years (january -december ), pts received allogeneic stem cells transplantation from related donors, of whom were treated with imatinib for refractory cgvhd: pts for malignant diseases ( cml, aml, nhl) and pts for aplastic anemia. the median age is years ( - ), the sex ratio m/f: . . conditioning regimen used with chemotherapy alone: myeloablative ( pts with gvhd prophylaxis combining ciclosporin and methotrexate), reduced intensity ( pts with prophylaxis combining ciclosporin-mycophenolate mofetil). all pts received peripheral blood stem cell transplant with an average of cd cell count: . × /kg ( . - . ). the median duration of the cgvhd is months ( - ). the firstline treatment consisted of the combination of steroidsciclosporin with or without mycophelonate mofetil. imatinib was administered to these pts after median treatment duration of months ( - ) for moderate ( pts) and severe ( pts) cgvhd according to the nih classification. treatment with imatinib, at doses ranging from to mg/d, was introduced in the second line for all pts. the evaluation is conducted in october after a median follow-up of months ( - ). tolerance was good except in a one pt with severe thrombocytopenia that led to a transient cessation of treatment. after months, analysis of pts who received imatinib according to couriel criteria and nih criteria: complete remission (cr): pt ( %), partial remission (pr): pts ( %), stable disease (sd): pts, failure: pts ( %). a long-term evaluation performed after a mean duration of treatment months ( - ) finds similar results with a cr: pts ( %), pr: pts ( %), sd: pts ( %) and failure: pts ( %). corticosteroids were tapered or discontinued in pts (cr or pr). at october , pts ( %) were alive and pts ( %) died of severe infections. treatment with imatinib seems to be a good therapeutic option in the treatment of cgvhd in its moderate or severe form refractory to a minimum of two immunosuppressive agents according to the nih criteria as shown by our results in terms of response and survival with good tolerance. disclosure of conflict of interest: none. atg significantly reduces the risk of cgvhd both in unrelated and in hla identical sibling. the finke's study randomised pts undergoing an allogeneic unrelated stem cell transplant (sct) after a myeloablative regimen to receive or not mg/kg atg-grafalon reporting a significant reduction of cgvhd without increase of relapse and no os and dfs effect. however a successive study didn't confirm those results (significant reduction of acute and chronic gvhd but poorer survival mainly due to higher relapse probability in the atg arm). the conflicting data reported on urd sct have several explanations, one is about the dose and the timing of atg. the timing of atg infusion has been demonstrated to be crucial for cb transplant : an earlier administration is still active in preventing gvhd while ensuring engraftment and low hampering of immune reconstitution. here we report a large ( sct) retrospective monocentric analysis on low atg doses (and - mg/kg for bm according to the degree of hla matching and mg/kg for all pbsc sct) given early (from day − to − ). pts in the study were aml (n = , %), all (n = , %), hr mds (n = , %), cr (n = , %) cr or (n = , %), active disease (n = , %) for al; median age was (range: - ). myeloablative conditioning were bu-cy (n = , %), bu-flu (n = , %), edx-tbi (n = , %), other (n = , %); pbsc was used in % (n = ); sct were performed between and at the bologna transplant center. sct were performed from hla / identical urd (n = , %), or from / (n = , %), / (n = , %) and o / (n = , %). median follow up was months. overall, grade - agvhd was %, grade - agvhd %; cumulative incidence (ci) of cgvhd of any severity was %, for moderatesevere cgvhd %. ci of relapse and nrm was % and %, respectively. the -year overall and disease-free survival were % ( % ci: - %) and % ( % ci: - %). the gvhd (agvhd grade - and moderate-severe cgvhd) and relapse free survival (grfs) of the entire population ( figure ) was % at years ( % ci: - %). restricting the analysis to patients in cr - , we found that cgvhd (any severity), gfrs and os at years were %, % and %, respectively. comparing transplants with / urd to mismatched ones ( / or less) we found a trend for increased mod/sev cgvhd in pts undergoing transplant with mismatched urd (shr . , % ci: . - . , p = . ); agvhd grade - and cgvhd overall were not significantly increased; relapse incidence according to hla mismatches resulted % and % in / and ⩽ / , respectively; grfs was % in / and % in ⩽ / . the data reported show that low and early administration of atg is able to effectively prevent acute and chronic gvhd without increasing relapse thus ensuring really convincing grfs, even for o / matched urd transplants. graft versus host disease (gvhd) is one of serious complications in patients after allogeneic hematopoietic stem cell transplantation. the application of mesenchymal stem cells (msc) represents a promising method for the treatment of severe steroid refractory gvhd. we present the data from an interim analysis of clinical trial, within which we applied msc in patients with acute or chronic gvhd after allogeneic transplantation. the diagnoses included aml ( pts), mds ( pts), all ( pts), cll/nhl ( pts), mpn ( pts). the patients underwent sibling hla-compatible ( ), haploidentical ( ), unrelated hla-compatible ( ) or hla-mismatched ( ) transplants. the median interval between the transplantation and msc was months ( - ). the indications for msc infusion were steroid resistant acute gvhd ( pts), steroid-dependent gvhd (agvhd pts, cgvhd pts) or chronic gvhd with the need for long-term immunosuppression and corticosteroid intolerance ( pts). msc were applied as a single infusion at a median dose of . ( . - . ) × /kg. response to treatment was assessed on day , , and . the severity of gvhd prior to msc was graded as clinical stage ( - ) in acute and stage ( - ) in chronic gvhd, respectively. the median dose of corticosteroids was . ( . - . ) mg/kg/day in agvhd and s . ( . - . ) mg/kg/day in cgvhd patients. on day + the partial response (pr) was achieved in % of patients with agvhd, the stabilisation of gvhd (sd) was found in % of patients with cgvhd. the dose of corticosteroids was reduced in most patients with agvhd (to % of the starting dose; - %), while the early reduction was possible only in % of cgvhd patients. on day+ only patients were evaluable. the agvhd patients ( pts) achieved a significant clinical response: pr, cr and dose of corticosteroids was reduced in all of them (to %; - %). the minor responses were achieved in cgvhd patient ( pts.) with pr and sd. however the dose of corticosteroid was reduced in % of these cases (to % of the initial dose; - %). a total of patients died because of infectious complications. most of them ( / ) were agvhd patients who expired early up to day + . there were observed no side effects of msc application neither during the infusion nor later during the follow-up of ( - ) months. the analysis of lymphocyte reconstitution revealed the changes of kinetics of some subsets as compared to the day + benchmark. the b-lymphocyte count tended to decrease in % of patients from chronic gvhd subgroup (vs % in agvhd). conversely nk cells declined in most agvhd patients ( % vs % in cgvhd). also the pro-inflammatory th cell was affected especially in agvhd (decrease in % pts vs % pts in cgvhd). the counts of myeloid/plasmocytoid dendritic cell increased in %/ % agvhd and %/ % ccvhd patients. the screening testing of cytokines (raybiotech, cytokines, pts, day + to + ) revealed changes of some analytes after msc infusion, including a decrease of proinflammatory cytokines such as ifn-γ, tnf-α, il- . our experience with the treatment of gvhd using msc confirmed the safety of this immunotherapy. the favourable clinical effect with reduction of severity of gvhd and steroids dose was observed, especially in patients with acute form of gvhd. methotrexate day + omission is not associated with higher incidence of acute graft-versus-host-disease mm rivera franco, e leon rodriguez and a campos castro allogeneic hematopoietic stem cell transplantation (allo-hsct) remains a high-risk procedure due to its related morbimortality, limiting the broader application of this important treatment modality. despite extensive research over the years, acute graft-versus-host-disease (agvhd) affects the majority of patients undergoing allo-hsct, and up to % will develop clinically significant grades (ii). over the years, several methods for gvhd prophylaxis have been implemented, including immunosuppresive agents. methotrexate (mtx) is one of the earliest drugs used for gvhd prophylaxis. frequently, a short course of intravenous methotrexate (given on days + , + , + and + after hsct) is combined with a -month tapered course of cyclosporine. there is no consensus on which drugs and schedules for prevention of gvhd are best and clinical practice varies by institution. further, it is not clear whether omission of the day + dose of mtx has a negative effect on outcome in terms of morbidity. to describe the frequency of acute and chronic gvhd, mucositis and engraftment in patients receiving methotrexate (plus csa) as prophylaxis, omitting day + . ninety-five consecutive patients who underwent allo-hsct from to september , and received mtx as immunosuppressive prophylaxis were included. all patients received three doses of mtx, always excluding day + . mtx was administered iv, either mg/m day + , + , + or mg/m day + , and mg/m during days + and + . we included patients ( % male). the most frequent underlying diseases were aplastic anemia ( %) and acute lymphocytic leukemia ( %). ninety-nine percent of patients had a matched related donor. forty patients ( %) had gender disparity with their donor, and % presented abo incompatibility (major in %). most of the patients received myeloablative conditioning regimens (n = , %). the median of cd + infused cells were × (range: . - . ). the median neutrophil and platelet engraftment was ( - ) and (range: - ) days, respectively. from all the cohort, only patients ( %) developed acute gvhd ( % grades i-ii) ( figure ). thirty patients ( %) developed chronic gvhd, which was limited in %. most of the patients, % (n = ), presented acute toxicity after the conditioning regimen, from which % (n = ) corresponded to superior mucositis ( % grade i-ii and % grade iii-iv. the -year overall survival was % and the -year relapse free survival was %. our results showed a low incidence of acute gvhd, mostly grades i-ii, and similar survivals compared to previously reported studies, proposing that the administration of day + mtx as gvhd prophylaxis is not mandatory, however, prospective studies might be necessary to test our results. [p ] disclosure of conflict of interest: none. outcome of refractory graft versus host disease (gvhd) treated with extracorporeal photopheresis (ecp) as second line: a single-center experience j cornago navascues, b aguado bueno, av arriero garcía, edc jimenez barral, i vicuña andres and a alegre amor hematology department, university hospital la princesa, madrid, spain gvhd is a common and, sometimes, life-threatening entity related to hematopoietic stem cell transplantation (hsct). steroids remain the first-line therapy but they are not always enough to control it, or their side effects are simply unacceptable. both acute and chronic gvhd are responsible of impairment occurred in different organs that can lead to increase morbidity and mortality in our patients. different options are available as second line, but it is a well known fact that ecp, due to its inmunomodulatory mechanism, yields satisfactory response rates and presents excellent safety profile. from may to october , patients with steroid-dependent or refractory gvhd have been treated in our centre with ecp. we have performed ecp procedures with the therakos cellex device, an integrated 'on line' system. the transplant was from a sibling donor in cases and from an unrelated donor. the median of cd + infused was . × cd /kg. eight patients ( . %) presented agvhd, ( . %) cgvhd and finally, ( . %) had an overlap gvhd syndrome. most of patients ( . %) with agvhd had a severe intestinal involvement as the main manifestation of the disease. however, all patients with cgvhd had a multiorgan involvement with a median of four organs affected, being skin, mouth, eyes and lungs the most common implicated. ten patients in our series have died, for gvhd complications or infections and due to relapse of aml. as firstline treatment they all received steroids and cyclosporine or mycophenolate mofetil. median ecp per patient has been ( - ). ecp procedures were performed for consecutive days, in initial phase weekly (in those with agvhd), or every weeks (cgvhd) and then monthly according to clinical response, evaluated by clinical assessment and reduction in immunosuppression. about % of patients with agvhd had a significant clinical response to ecp so that steroid doses could be tapered and even in . % of them withdrawal was possible. in the cgvhd group overall response rate (orr) to ecp was . %. in % of these patients steroids could be suspended after a median of . ecp procedures. all patients who responded to ecp in cgvhd are still alive. independently of gvhd type, . % of patients responded to ecp and % of them even could stop steroid therapy. those who had no response are dead. in cgvhd, . % of patients remain alive, in contrast with agvhd or overlap syndrome patients whom survival is around %. about adverse events, % of patients did not present any complication associated with ecp. complications were mostly related to central venous catheter, with cases of bacteremia and thrombosis, easily recovered. in our experience, ecp is effective as second line treatment in gvhd, obtaining the best results in the chronic gvhd group. in fact, cgvhd patients with a good clinical response to ecp, specially when steroid doses can be tapered, have the better outcomes and longer survival. the tolerance to the procedure is excellent without severe adverse events. more experience is required to determine the best scheme of ecp and its role as prophylactic treatment. mesenchymal stromal cells (mscs) possess immunomodulatory properties and may play important roles in graft-versushost disease (gvhd) and engraftment. this study examined co-transplantation of mscs and hscs (hematopoietic stem cells). we investigated co-administration of ex vivo expanded mscs along with hla-identical sibling-matched hscs in β thalassemia major patients. we recruited patients from january to january in our study. all participants received cyclophosphamide-based or fludarabine-based conditioning regimens and short-course methotrexate and cyclosporine as gvhd prophylaxis. mscs were administered intravenously ( . - . × /kg) into patients (n = ) h before infusion of hscs. the outcomes were then compared to those of patients transplanted with hscs alone. the median follow-up in the msc and non-msc group was . and . years, respectively. median time to wbc engraftment . × /l was . days (range: - days) in both groups (p-value = . ) and median time to platelet engraftment × /l was . days (range: - days) in the msc group, while it was . days (range: - days) in the non-msc group (p-value = . ). fifty-six percent of patients had acute gvhd in the msc group compared to the non-msc group where . % developed acute gvhd (p-value = . ). meanwhile, chronic gvhd was % in the msc group and % in the non-msc group (p-value = . ). although the incidence of acute and chronic gvhd was lower in co-transplantation of hscs and mscs, no statistically significant difference was noted between the two groups. three-year overall survival rate was % and % in the msc and non-msc group, respectively (p-value = . ). three-year thalassemia-free survival rate was % in the msc group and % in the non-mscs group, showing no statistically significant difference (p-value = . ). the -year rejection incidence in the msc and non-msc group was % and %, respectively (p-value = . ). there was no statistically significant difference between the two groups in terms of -year transplant-related mortality (pvalue = . ). this study indicates that co-transplantation of hla-identical sibling hscs with mscs does not inflict harm on bone marrow transplantation procedure and seems to be safe and secure. on the other hand, differences between the two groups in acute and chronic gvhd, engraftment, overall survival, thalassemia-free survival and rejection incidence did not reach statistical significance. therefore, despite the immunomodulatory activity of mscs and their role in gvhd amelioration and engraftment improvement resulted from in vitro studies, their efficacy in the clinical setting has not been conclusively proven which indicates further multicenter randomized clinical trials are required. keywords: β-thalassemia major, co-transplantation of mesenchymal and hematopoietic stem cells, engraftment, graft-versus-host disease. hematology-oncology and stem cell transplantation research center, tehran university of medical sciences, shariati hospital, tehran, iran. disclosure of conflict of interest: none. a number of studies were published with contradictory results comparing tacrolimus (tac) and cyclosporine a (csa) for graftversus-host disease (gvhd) prophylaxis, but there are only few that accounted for pharmacokinetic (pk) parameters. in this retrospective study we have identified pk parameters that affected gvhd incidence and incorporated them in the s multivariate comparison of tac-and csa-based prophylaxis. the retrospective study included consecutive patients with csa and consecutive patients with tac prophylaxis. % were grafted from matched related donor (mrd) and % from unrelated donor (ud). about % received busulfanbased myeloablative conditioning (mac) and % reducedintensity conditioning (ric). second agent for gvhd prophylaxis was short-course methotrexate (mtx) - mg/m on days + , , , in % of patients and mycophenolate mofetil mg/kg days − to + in %. unrelated graft recipients also received antithymocyte globulin (atgam, pfizer, ny, usa) mg/kg. the pk parameters analyzed were mean and median concentrations, pk variability parameters and number of concentrations below the targeted limit (nlow) within , and days after hsct. for tac the highest predictive value for acute gvhd was observed for median concentration during first days (auc = . ), and for absolute skewness (auc = . ) of concentration data. for csa parameters with highest predictive value were median concentration (auc = . ) and variability coefficient (auc = . ) during first days. nlow was also a significant parameter for tac current gvhd prevention regimens are partially effective, delay immune reconstitution, impair graft versus tumor effect and are cumbersome to use. therefore, there is a pressing need to develop innovative approaches for the prevention of gvhd. we completed a phase i-ii study employing a calcineurin and mtor inhibitor-free regimen based on a combination of post-transplant cyclophosphamide and bortezomib (cybor) in patients receiving fludarabine and busulfanbased reduced-intensity conditioning followed by peripheral blood, matched related or unrelated transplant. patients receiving grafts from unrelated donors also received ratg. we reported that the regimen was feasible and safe and yielded promising outcomes. ( , ) herein, we compare the results to those of a quasi-contemporaneous matched group of patients receiving a calcineurin-based gvhd prophylaxis. the experimental and control groups were well-matched in terms of age, sex, donor type, disease status, renal function and pam score. the cybor group (n = ) was treated during a timeframe spanning from to and the control group (n = ) from to . gvhd prophylaxis for the control group was mmf and csa (n = ) or tacrolimus (n = ). both groups received supportive care according to standard institutional protocols. median follow-up for the cybor group was . months as opposed to . for the control group. median times to neutrophil engraftment for the cybor and control groups were days ( - ) and ( - ), respectively (p = . ). two patients from the cybor arm died before achieving platelet engraftment. for the remaining s patients, median time to platelet engraftment was days ( - ). for the control group, five patients never dropped their platelet count below × /l. for the remaining patients, median time to platelet engraftment was days ( - ) (p = . ). there was no primary or secondary graft failure in either of the two groups. the incidences of acute grade ii-iv and grade iii-iv for the cybor group were . and . %. for the control group, the incidences were (p = . ) and % (p = . ). the incidence of chronic gvhd for the cybor and control groups were % and . %, respectively (p = . ). treatment-related mortality was . % and % for the cybor and control groups, respectively (p = . ). the incidences of cmv, ebv and bk reactivation for the cybor group were . %, . % and . %, respectively. for the control group, the incidences were . % (p = . ), . % (p = . ), % (p = . ). the -year progression free survival and overall survival were . % and . % for cybor group and . % and . % for the control group ( figure ). the year gvhd and disease-free survival (grfs) were . % and %, respectively. despite the limitations of our study that include its size and its design and the delayed neutrophil and platelet engraftment associated with the cybor regimen in comparison to calcineurin-based prophylaxis, our data confirm the promising outcomes previously reported with the cybor combination and reaffirm the need for a large randomized study comparing cybor to a standard calcineurin-based regimen. clostridium difficile infection (cdi) causing enterocolitis may represent a serious clinical problem in patients undergoing allogeneic hematopoietic cell transplantation (allo hct). the reported prevalence varies substantially among heterogeneous patient cohorts. although cdi has been proposed as a risk factor for the development of gastrointestinal (gi) acute graft-versus-host-disease (agvhd), limited knowledge on the prevalence of cdi, occurrence of gi agvhd in cdi patients, relapse incidence and mortality of cdi patients in large patient cohorts is available. the aim of this analysis was to study the implications of cdi in a homogenous cohort of patients with either aml or mds undergoing allo hct. at our center all patients undergo stool test once a week for clostridium difficile antigen while in aplasia until discharge, irrespective of clinical symptoms for enterocolitis. patients with positive stool antigen tests (that is, toxin test) in the absence of clinical symptoms were referred to as cd+, in contrast to patients without a positive test and without clinical symptoms which were referred to as cd − . we retrospectively analyzed the data of a total of n = patients with either aml or mds undergoing allo hct in our institution between and . overall survival (os) was measured from allo hct to the date of death or last follow-up. after hsct, relapse and nonrelapse mortality were considered as competing events. eventprobabilities were calculated according to kaplan-meier for os and using competing event statistics for the cumulative incidence of relapse (cir), non-relapse mortality (nrm) and agvhd. % confidence intervals (ci) were provided for major endpoints. statistical analyses were performed using the r environment for statistical computing version . . (r core team , vienna, austria, www.r-project.org). from a total of n = patients with either aml or mds who underwent allo hct, we identified n = ( %) who were cd − , n = ( %) who were cd+, and n = ( %) who had cdi. interestingly, n = ( %) of patients with cdi were diagnosed having gi agvhd as compared to n = ( %) of patients who were cd+ and compared to n = ( %) of patients who were cd − , p = . . the three groups harbored no differences when comparing incidences of liver and skin agvhd or chronic gvhd, respectively. when dissecting gi agvhd according to ctcae criteria, only n = ( %) of cdi patients vs n = ( %) of cd+ patients, and n = ( %) of cd − patients had grade - gi agvhd, p = . . with regard to os and trm, no statistical differences were observed between the three groups. the cir was % for patients with cdi, % for cd+ patients and % for cd − patients, p = . , respectively. this analysis represents the largest published analysis of clostridium difficile in patients with aml or mds who underwent allo hct. the prevalence of cdi in this patient cohort was %. patients with cdi developed significantly more often gi agvhd as compared to patients who were either cd+ or cd − , respectively. however, this did not translate into differences in os or trm. disclosure of conflict of interest: friedrich stölzel has received research funding from astellas. the majority of studies on cytokines in allogeneic hsct were performed with classical gvhd prophylaxis, consisting of nonspecific immunosuppressive agents. with this type of prophylaxis almost in all studies published, higher levels of proinflammatory cytokines are associated with development of acute gvhd, while lower levels indicate the success of immunosuppressive agents in abrogation of alloreactive response. currently, there is no data, whether the dynamics of cytokines after ptcy is similar to the situation of classical gvhd prophylaxis. out of adult patients transplanted at first state medical university with ptcy between and we have identified cases with acute gvhd and plasma samples available. these patients were matched in the ratio : to patients who did not develop acute gvhd. the study group was comprised of adult patients with hematological malignancies who underwent hsct. all patients received ptcy-based gvhd prophylaxis. five plasma biomarkers were studied by elisa: il- a, il- , il- , tnf-α and ifn-γ. blood samples were obtained from patients on days − , , + , + . the fifth time point varied between day + and + to represent the sample after engraftment, but before onset of acute gvhd. about ( %) out of gvhd patients had a grade i, ( %) grade ii, ( %) grade iii agvhd, ( %) patients developed multiorgan agvhd. about patients ( . %) had chronic gvhd. there was no difference between gvhd + and gvhd − groups in any of the clinical parameters. the median of engraftment for all patients was ( - : range). the median agvhd was days ( - : range). neither of the cytokine levels was significantly different in patients with agvhd grades i − iv and without gvhd. however, for patients with agvhd grade ii − iv we found that low levels of il- on day + ( . ± . vs . ± . pg/ml, p = . ) and ifn-γ on day + - ( . ± . vs . ± . pg/ml, p = . ) were associated with increased risk of gvhd. the roc analysis was performed to determine the cut off values for il- - . pg/ml (auc = . ) and ifn-γ - . pg/ml (auc = . ). the incidence of agvhd grade ii-iv was significantly higher in patients with levels of cytokines lower than cut off ( % vs . %, p = . and . %, p = . for il- and ifn-γ, respectively). the same pattern was observed for patients with agvhd grade iii-iv. low levels of il- ( . ± . vs . ± . pg/ml, p = . ) and ifn-γ ( . ± . vs . ± . pg/ml, p = . ) on day + were especially predictive. the cut off values for il- was . pg/ml (auc = . ) and for ifn-γ- . pg/ml (auc = . ). the incidence of agvhd grade ii-iv was also significantly higher in patients with levels of cytokines lower than cut off (p = . and p = . for il- and ifn-γ, respectively). for chronic gvhd only higher level of il- at day + ( . ± . vs . ± . pg/ml, p = . for patient with and without gvhd, respectively) was significantly predictive. in this pilot trial we have demonstrated that dynamics of cytokines after gvhd prophylaxis with ptcy may be different from conventional one, and well-known predictive biomarkers might not work after ptcy. further large prospective trials are warranted to elucidate reliable biomarkers for gvhd after this type of prophylaxis. disclosure of conflict of interest: none. graft versus host disease (gvhd) remains one of the main obstacles to broader application of allogeneic transplantation. gvhd prevention and treatment techniques are poorly standardized. the st-line treatment of newly diagnosed chronic (c) gvhd is corticosteroid. there is no standard ndline treatment for cgvhd. approximately - % of patients (pts) with cgvhd require secondary treatment within y after initial systemic treatment. recently the jak / inhibitor ruxolitinib emerged as an efficacious treatment for corticosteroid-refractory (sr) acute and c-gvhd with a % of sr-cgvhd patients reporting a long lasting immunosuppression-free complete response. the current study seeks to analyse the efficacy and safety of ruxolitinib in highly pre-treated sr-cgvhd pts in our centre. ruxolitinib treatment was given off label after provision of an informed signed consent and in the absence of alternative therapeutic options including clinical trials. we analysed data prospectively collected at our long-term follow-up clinic between and . a written consent was given by pts allowing the use of medical records for research in accordance with the declaration of helsinki. overall pts (median age y-range: - years; mean karnofsky score %) with sr-cgvhd were treated s with ruxolitinib. median time from transplant was months (range: - ). ruxolitinib was initiated at a starting dose of mg twice daily-median time on ruxolitinib months (range: - )- / pts increased the dose up to mg twice daily. four pts had a classic and an overlap sr-cgvhd. all of them had skin sclerodermatous involvement and / joint and fascia involvement with significant decrease of range of motion and limitation of adl. all pts were previously treated with several lines of immunosuppression ( - ) including high-dose prednisone in st line ( / ), rapamycin ( / ), tk-inhibitor imatinib ( / ), extracorporeal photopheresis ( / ). all pts were pre-screened for risk of infection and regularly checked on a fortnightly basis. all pts were under active prophylaxis according to recommendation for gvhd pts and ruxolitinib therapy. after a cumulative follow-up of days we reported only one serious adverse event represented by a cmv pneumonia requiring hospitalization with complete recovery. early time point evaluation ( / pts evaluable) at + month underlined how all pts were reporting subjective improvement at the patient global ratings according to nih . data were confirmed at the health care provider global ratings. month evaluation ( / ) confirmed meaningful responses (partial responses / ) according to nih , with both patient and health care provider global ratings improvement and concomitant enhancement in lee skin symptoms score and sf- health-related qol. at last followup no evidence of myelosuppression, infections, pml, nonmelanoma skin cancer was registered. considering the concomitant treatment (with reference to azoles and rapamycin or cyclosporine) no cases of toxicity due to drug-druginteraction was reported. ruxolitinib is well tolerated in highly pre-treated sr-cgvhd. its safety profile seems to be reassuring. the efficacy data observed also at this early time point is preliminary but promising in this subset of pts with a long history (⩾ lines) of treatment for cgvhd. confirmatory study in a larger number of patients is underway on a multicentre basis. disclosure of conflict of interest: none. severe acute enteral graft-versus-host-disease (gvhd) is a lifethreatening complication of allogeneic bone marrow transplantation. in case of resistance to corticosteroids as the firstline treatment severe enteral gvhd harbors a high morbidity and mortality. retrospective analyses indicate efficacy of the jak / -inhibitor ruxolitinib in the treatment of acute or chronic gvhd in adults, but experience in paediatric patients is limited. here, we report a small cohort of paediatric patients with stage steroid-refractory gvhd of the gut who received ruxolitinib as salvage therapy within a multimodal immunosuppressive regimen. we retrospectively analysed four patients aged - years with severe, steroid-resistant acute gvhd of the gut who were treated with ruxolitinib in our institution. all patients were transplanted for non-malignant haematologic disorders, graft source was × mmud, × mud, × msd. the conditioning regimen consisted of treosulfan, fludarabine and thiotepa. serotherapy with thymoglobuline was administered in all patients transplanted from unrelated donors. all patients received mtx and cyclosporine as gvhdprophylaxis. gvhd was staged according to the glucksberg-scale. ruxolitinib was added to the immunosuppressive regimen when acute stage gvhd was reached and became resistant to treatment with methylprednisolone ( mg/kg/day) as well as infliximab and mycophenolate (mmf) as second-line immunosuppressants. acute stage enteral gvhd developed at a median of days after transplant ( - days) and ruxolitinib was started at a median of days post-transplant ( - days). the starting dose varied between mg/day and mg/day, that is, . - . mg/kg/day, taking into account the expectedly low bioavailability of the oral drug during severe diarrhea. upon improvement of gvhd symptoms and/ or increasing side effects the dose was gradually tapered and ruxolitinib was discontinued after a median of treatmentdays ( - days) . after addition of ruxolitinib to the immunosuppressive regimen, the symptoms of acute gut gvhd gradually improved in all four patients with decreasing abdominal pain and stool volumes. immunosuppression with steroids and mmf could slowly be tapered. all patients are alive after a median follow-up of days ( - days) from diagnosis of acute stage gut gvhd. the most prominent side effect attributable to ruxolitinib was thrombocytopenia with a nadir in platelet counts after days of ruxolitinib treatment in / patients. platelets recovered within weeks after ruxolitinib was discontinued. neutropenia was observed in one patient with anc dropping o . /nl after days of ruxolitinib treatment. mild to moderate elevation of liver transaminases was observed in all four patients during ruxolitinib treatment. one patient developed imminent acute renal failure, another patient showed symptoms of hemolytic uraemic syndrome. however, due to the multimodal treatment of these critically ill patients, these complications could not clearly be attributed to ruxolitinib. ruxolitinib is potentially beneficial in severe acute enteral gvhd in children refractory to corticosteroids as well as second-line immunosuppressants. however, randomized trials are warranted to verify safety and efficacy of ruxolitinib in this patient cohort. disclosure of conflict of interest: none. steroid refractory acute gvhd is a major cause of mortality after allogeneic stem cell transplantation. until date, no agent or treatment strategy has demonstrated superior efficacy in this patient group. the dose and duration of steroid treatment is associated with several short and long-term side effects, therefore concepts facilitating rapid steroid taper may be beneficial. both ruxolitinib and ecp have been reported to be effective in treatment of steroid refractory (sr) agvhd. we analyzed data from consecutive adult patients who received ruxolitinib for sr agvhd between march and august in our institution overall, patients (male n = ; female n = ) with a median age of years (range: - ) were included. donors for allogeneic sct were msd (n = ), mud (n = ) and mmud (n = ). median time to gvhd onset after stem cell transplantation was days (range: - days). about patients had agvhd grade iii or iv (all with gi involvement), while patients had skin grade involvement. sr agvhd was diagnosed if agvhd manifestations were progressive after days or persistent and without improvement after days or no partial remission after days of treatment with mg/kg bw of systemic steroids. patients received additional ecp (n = ), if response to ruxolitinib was lacking or slow (n = ) or instead of ruxolitinib due to cytopenias (n = ). ruxolitinib was first-line treatment for sragvhd in patients ( %). median initial dose of ruxolitinib was mg (range: - mg) twice daily. steroids were tapered and stopped, even if agvhd was still active. primary end point was non-relapse mortality at months. secondary end point was response on day after initiation of ruxolitinib. response occurred relatively slowly, resulting in a day overall response rate of % (cr = , pr = ). however, a total nine patients ( %) attained a complete response (cr), five with ruxolitinib alone and four others in combination with ecp. about patients ( %) required dose reduction or interruption of ruxolitinib mainly due to cytopenias. after a median follow-up of days, patients are alive. causes of death were relapse of malignant disease (n = ), gvhd (n = ), infections (n = ) and other (n = ). median survival from diagnosis of sr agvhd was days for non-responders and days for responders ( figure , p = . ). in univariate analysis, non-response was associated with higher risk of nonrelapse mortality (rr; . , % ci: . - . , p = . ). ruxolitinib and ecp are two effective promising treatment options, which may be complementary in patients with sr agvhd. cytopenia is the most frequent side effect of ruxolitinib while infections remain the major cause of death. [p ] disclosure of conflict of interest: ayuk-therakos: honoraria; kröger: novartis: honoraria, research funding. steroid-refractory acute graft-versus-host disease (sr-agvhd) is associated with a dismal outcome. janus kinase (jak) / signaling has been shown to be instrumental in multiple steps leading to inflammation and tissue damage in gvhd. jak / inhibitor ruxolitinib was studied in the treatment of sr-gvhd by zeiser et al. (leukemia ) , and the overall response rate was reported to be . %. we have now studied ruxolitinib in the treatment of six adult patients with steroid-refractory, grade iii-iv, intestinal agvhd. all the patients were male. the median age of the patients was (range: - ) years. three of the patients were transplanted for aml, one for all, mds and mm each. all the patients had been given a myeloablative conditioning treatment (cytbi , treosulfan+fludarabine ). two patients had a sibling donor and four a matched unrelated donor. the graft was from peripheral blood in all the patients. gvhd prophylaxis consisted of cyclosporine and a short course of methotrexate, and in addition antithymocyte globulin in the unrelated donor setting and methylprednisolone in one sibling recipient. agvhd of the intestine manifested on days + , + , + , + , + and + with diarrhea. in two patients it was preceded by agvhd of the skin by and days, respectively. gi-biopsy showed acute gvhd of grade iii and of grade iv in three patients each. treatment of intestinal gvhd was started with methylprednisolone mg/ kg/day, tapering the dose to and mg/kg after doses each. gastroduodenoscopy and colonoscopy were performed at the onset of symptoms indicating intestinal gvhd. biopsy confirmed the diagnosis in all cases. because the diarrhea continued in spite of methylprednisolone treatment, ruxolitinib was started , , , , and days from the first day of diarrhea. the dose of ruxolitinib was mg × per day orally. four patients showed a clear response to ruxolinitib, normalization of bowel function, after , , and days from the start of ruxolitinib treatment. the healing of the intestinal lesions was verified by biopsy. two of these patients had received extracorporeal photopheresis simultaneously. two patients did not benefit from ruxolinitib treatment. one of them had continuous infectious complications and therefore ruxolitinib was only started after days from the start of diarrhea. the other patient died of fulminant diarrhea after weeks of ruxolitinib treatment. cmv reactivation was detected in three of the responders, and two of them had also polyoma virus cystitis. one patient developed a pulmonary aspergilloma, which is under control with drugs. corticosteroid-resistant gastrointestinal acute gvhd was treated in six patients, out of whom four showed a good response. disclosure of conflict of interest: none. although methotrexate (mtx) is commonly used in the prophylaxis of graft-versus-host disease (gvhd) after allogeneic hematopoietic stem cell transplantation (allo-hsct), some small studies have also reported its use in the treatment of chronic gvhd. the aim of this study was to evaluate the efficacy and safety profile of low-dose mtx for treatment of sclerodermatous chronic gvhd (sgvhd) after the failure of first and second line treatments. we retrospectively evaluated adult patients who received low-dose mtx as salvage treatment of sgvhd during the period elapsed between june and june in a tertiary referral university hospital in spain. there were ( %) males and ( %) females. the median age was years (range: - ). all had received an allo-hsct for hematologic malignancies. the median time from allo-hsct to sgvhd was days (range: - ). thirteen patients ( %) had presented previous acute skin gvdh. superficial skin lesions mimicking lichen planus (lichenoid gvhd) were diagnosed in ( %) patients, while lesions resembling lichen sclerosus, morphea or fasciitis (sgvhd) where seen in all ( %) patients. the total body surface area was affected by more than % in patients ( %). besides the skin, other organs/tissues involved were the eyes ( %), mouth ( %), nails ( %), lungs ( %), liver ( %) and gastrointestinal tract ( %). treatment lines prior to mtx administration were: prednisone (pdn) in patients ( %), phototherapy (pht) in ( %), cyclosporine (cya) in ( %), mycophenolate mofetil (mfm) in ( %), pht + pdn + cya in ( %), pdn + mfm + cya in ( %), extracorporeal photopheresis + pdn in ( %). the median time from sgvhd onset to mtx treatment was days (range: - days). mtx was administered subcutaneously in patients ( %) and orally in patients ( %). median dose of mtx was . mg/week (range: . - . mg/week) and median length of treatment was weeks (range: - weeks). in two patients ( %) early withdrawal of mtx occurred (one due to early death secondary to septic shock and other due to rapid disease progression). mtx-related toxicity occurred in three patients ( %): megaloblastic anemia, asymptomatic increase of liver enzymes and mucositis, respectively. response to mtx was evaluated in the patients ( %) s who did not suffer early mtx discontinuation. seventeen patients ( %) presented a partial response; of them, two are still under mtx treatment for and weeks, respectively. fourteen patients ( %) received pdn concomitantly to mtx (median dose mg/day, range: - ); year after mtx treatment, only four patients were receiving pdn (median dose mg/day, range - ). seven patients have finished mtx treatment without reappearance of symptoms, receiving only topical treatment with emollients, tacrolimus or corticoids for short periods. in four patients ( %) sgvhd progressed despite mtx administration. our data suggest that mtx is a safe, inexpensive and effective alternative for refractory sgvhd. its potential used in earlier phases of sgvhd deserves further investigation. disclosure of conflict of interest: none. severe chronic gvhd has a major influence on late morbidity and mortality after hematopoietic stem cells transplantation (hsct). ecp is a good approach to treat refractory-gvhd: leucocytes are obtained from peripheral blood by apheresis, incubated with -mop, irradiated and then infused to the patient where they undergo apoptosis and induce tolerance. it is a promising alternative that reduces doses of immunosuppressive therapy and their side effects in the treatment of gvhd. this study shows its efficacy in persistent refractory cgvhd. the procedure was applied to three patients (pts) aged , and years (two aml and one cml), sex ratio ( m/ f) who underwent allogeneic-hsct with myeloablative conditioning regimen based on chemotherapy alone from a peripheral blood stem cells with cd levels: . , . and . × /kg respectively. prophylaxis of gvhd combined ciclosporin and methotrexate in short cycle. severe extensive cgvhd (according to nih criteria) was observed in the three cases after an average delay of . months ( - ) with involvement of - organs (mouth, eyes, skin, liver, joints and lungs). all pts are refractory to three lines of immunosuppressive agents (ciclosporin-corticosteroids, mmf and imatinib), with an average of thrusts/pt ( - ) over an average period of months ( - ). ecp was performed under the open system or dissociated system (macopharma) for two sessions per week for weeks, one session per week for weeks, one session every weeks for weeks and one session per month for months. after a median period of months ( - ), an average of sessions/pt ( - ) was performed. in terms of tolerance, a red blood cell transfusion was required in one pt, spontaneously resolved lymphopenia was observed in another pt, and a poor venous approach led to the pause of a central catheterization in one pt. the month and -month evaluation according to the couriel response criteria shows a partial response observed as of the first month with net improvement especially on skin sclerotic features and joints retractions initially refractory to all therapeutic lines. this allowed gradual reduction doses of corticosteroids. pce is recommended in the curative treatment for refractory chronic gvhd from the second line. this encouraging study on a small series shows its efficacy in persistent and late refractory forms. it is nevertheless necessary to evaluate it on a larger number of pts. disclosure of conflict of interest: none. successful treatment of steroid-refractory acute gastrointestinal graft-versus-host-disease by fecal microbiota transplantation p neumeister steroid-refractory acute gastrointestinal (gi) graft-versus-host disease (agvhd) is a severe complication of allogeneic hematopoietic stem cell transplantation (allo-hsct) associated with a high mortality rate. loss of intestinal bacterial diversity is thought to be associated with severity of gi-agvhd and an impaired intestinal microbiota with reduced diversity is an independent predictive factor for mortality. fecal microbiota transplantation (fmt) is the application of a fecal suspension derived from a healthy donor into a patient's gi tract. it has been successfully applied in recurrent clostridium difficile associated diarrhea including patients who underwent allo-hsct. we report the complete resolution of lower gi-agvhd following colonoscopic fmts in three patients that had been refractory to - lines of immunosuppressive therapies. microbiota analysis by s rdna before fmts revealed a severely depleted microbiota in all patients. donors (different persons for each patient) were healthy adult subjects. repetitive ( - ) colonoscopic fmts were necessary to permanently establish the donor's microbiome. all patients responded clinically by reduction/normalisation of stoll volumes, stopping total parenteral nutrition and tapering of steroids. a possible causative relationship of fmt in the reversal of severe intestinal dysbiosis and subsequent resolution of gi-agvhd can therefore be hypothesized. the establishment of donors' microbiota and increase in bacterial richness was associated with disease control. no immediate procedure-related infections or other side effects were observed. besides restoration of an initially severely reduced microbial richness by fmts, response of gi-agvhd was sustained despite reduction and discontinuation of concomitant immunosuppressive treatments. restoration of dysbiosis by fmt might represent a promising novel therapeutic approach for refractory lower gi-agvhd. disclosure of conflict of interest: none. tear film proteomics reveals important differences between patients with chronic ocular gvhd and healthy controls k plattner , n gerber-hollbach , s moes , p jenoe , d goldblum and j halter ophthalmology, university hospital basel, ch- basel and proteomics core facility of the biozentrum, university of basel, ch- , basel chronic gvhd frequently involves the eyes, leads to important decrease of quality of life and may threaten visual capacity. sicca syndrome is one of the hallmark of ocular cgvhd. analysis of tear protein composition may help to identify biomarkers for early diagnosis and prognosis of ocular cgvhd. tear fluid of patients with ocular cgvhd were compared with healthy individuals in this single center study. results of the first patients are reported here. tryptic digests from schirmer strips were analyzed on an orbitrap mass analyzer. clinical examinations included slit lamp examination, fluorescein staining, schirmer test, break-up-time (but) and a quality of life questionnaire (osdi). outcome measures were differences and consistency of proteins in human tear fluid s between patients with ocular gvhd and healthy controls. statistical analysis was performed by one sample wilcoxon-tests, p-values o . was considered significant. ten patients (eight males, two females) with a median age of years (range: - ) were analyzed. all underwent pbsct, eight from an unrelated donor. cgvhd overall score was moderate in three and severe in seven. eye organ score was in six and in four patients. all patients had more than one organ manifestation of cgvhd. eight were under systemic immunosuppressive therapy at the time of analysis, two had topical treatments only. in total different proteins were detected in tears analyzed. compared to controls, were differentially expressed in ocular cgvhd. expression was highly significantly different in proteins. compared to controls, expression of proteins was at least -fold increased, representing different categories. among them, more than % of all proteins belong to one of three categories: cytoskeletal proteins, nucleic acid binding or structural proteins. albumin, cluster or keratin (keratin type i-iii) and cluster of pyruvate kinase were most highly overexpressed. expression of proteins was decreased to o to %, belonging to different protein classes. half of them belong to defense/immunity proteins, enzyme modulators, hydrolases, nucleic acid binding and carrier proteins. expression of lactotransferrin, proline-rich protein and prolactin-inducible protein was most profoundly decreased. compared to healthy controls, a high number of protein is found to be differentially expressed in tears in ocular cgvhd. among them high expressions are observed for proteins that may indicate disturbed integrity of ocular surface and leakage of conjunctival capillaries. most profoundly decreased proteins include proteins with important functions in host defense and immunomodulation. more detailed pathway analysis is necessary to identify biomarkers for ocular cgvhd. disclosure of conflict of interest: none. steroid-dependent chronic gvhd after allogeneic peripheral blood stem cell transplantation is a great problem. nonresponders to corticosteroid therapy are at high risk of mortality. we hypothesized that such patients could benefit from treatment strategy using in patients with primary severe autoimmune diseases like multiple sclerosis and crohn's disease. patient z., y.o. was diagnosed in july with myelomonocytic leukemia (jmml). initially he was treated with low-dose of cytarabine and epigenetic agents. in september , jmml progression was observed with leukocytosis, thrombocytopenia, splenomegaly. bone marrow aspirate showed . % monocytes and . % blast cells. splenectomy was performed in november due to refractoriness to blood components transfusions. in december unmanipulated haploidentical peripheral blood stem cell transplantation from mother with . × /kg cd + and . × /kg cd + was performed. the conditioning regimen was myeloablative including melphalan mg/m day − and treosulfan mg/m days − , − , − . no organ toxicity grade was observed. gvhd prophylaxis consisted of hatg mg/kg on days − , − , − , + , i.v. tacrolimus from d − and mmf mg/kg from d . engrafted was fast and prompt ( % donor) with wbc . × /l on d + , plts × /l on d + . acute gvhd of stage ii was observed in early posttransplant period and treated with steroids and tnf-α inhibitor (infliximab). patient also received five procedures of ecp. all attempts of immunosupression tapering failed and the patient was staying on high dose of tacrolimus, mmf and courses of steroids till october . in october , gvhd stage ii flare with blood eosinophilia occurred after another attempt of steroids withdrawal. clinical examination showed that the patient was in complete remission with full donor chimerism. mild response of gvhd to steroids was observed. in april and may patient received two doses of rituximab mg/m with no significant response. in order to restore naive immune system first course of chemotherapy with cyclophosphamide mg/m was performed in the end of may . no toxicity grade was observed. the patient recovered wbc . × /l on d + , plts × /l on d + . in the phase of hematological recovery he was mobilized with g-csf and two leukaphereses of pbscs were performed. in june our patient was transplanted with previously collected . × cd +/kg following nonmyeloablative regimen including cyclophosphamide mg/m on day − and fludarabine mg/kg, on days − , − , − . second dose of cyclophosphamide was not administered because of severe hyponatriemia with seizures due to the cpm administration. no other significant toxicity was observed. the patient did not require either blood product or i.v. antibiotics. doses of tacrolimus and mmf were picked on months late and no more steroids were given. the patient is well in cr with no signs of gvhd for months. we speculate that pbsc collection from patients under massive immunosupression underwent allogeneic transplant is difficult but feasible. the nonmyeloablative regimens in such group of patients could be well tolerated and ensure the restoration of naive recipient immune system. this option could be discussed as an attractive alternative for treating resistant gvhd in steroid resistant patients. disclosure of conflict of interest: none. severe acute gi-gvhd is a serious early complication of allotransplants, and still remains a clinical diagnosis.( ) endoscopic biopsies provide the best supportive evidence, but are invasive and morbid in patients who are already medically compromised. f-fdg pet/ct may be able to stratify patients who require endoscopy and biopsy. to evaluate the performance of fdg pet/ct in differentiating moderate to severe gi-gvhd from no or mild disease in pediatric patients with suspected gi-gvhd. retrospective chart review of all paediatric allo-transplant patients referred for f-fdg pet/ct with suspected gi-gvhd from to . clinical follow-up, endoscopy and biopsy findings were correlated with f-fdg pet/ct. regional suv parameters were extracted by placing rois around stomach, duodenum, distal ilium, caecum, ascending, transverse, descending colon, recto-sigmoid colon and rectum. regional, and average large and small bowel suv data were statistically compared between patients with no or mild git-gvhd vs moderate to severe disease. the clinical and biopsy-supported diagnosis of acute gi-gvhd was taken as the true positive diagnosis for acute gi-gvhd. roc curves were generated for whole bowel suvmax values. about scans in patients, median age of years ( mths to y), were performed at a median of days post bmt. there were stage , stage - and with no acute gi-gvhd. transverse colon suvmax was significantly higher in the stage - gi-gvhd compared to no or stage disease (mann-whitney-u-test p o . ). there was a non-significant trend for average large bowel suvmax to be higher in the stage - group than the no or stage disease group (mean suvmax . compared to . , p = . ). a cut off whole bowel suvmax . had a sensitivity of % and specificity of % for detecting moderate to severe gi-gvhd. f-fdg pet/ct is a feasible and potentially useful non-invasive tool in the diagnosis and monitoring of therapeutic efficacy in acute gi-gvhd ( ) . large bowel suvmax may be higher in patients with stage - gi-gvhd, and transverse colon suvmax could have the ability to differentiate children with no or stage gi-gvhd from those with stage - disease. a negative fdg-pet/ct could serve as a criteria to avoid invasive endoscopic procedures and observe for the persistence of gastrointestinal symptoms before subjecting these patients to an imageguided biopsy. in patients too unwell for endoscopy, suvmax (roc curve specificity %) and a high suvmax in the transverse colon could serve as supportive evidence for moderate to severe acute gvhd, in the absence of biopsy findings. a major advantage of a pre-endoscopic f-fdg pet/ ct is to guide the procedurals to sample areas with the best diagnostic yield. prospective controlled studies are needed. oral mucosal progenitor cells (omlp-pcs) possess immunomodulatory and antibacterial properties, suggestive of their in vivo function in healthy tissue and their potential contribution to scarless wound healing in the buccal mucosa ( , ). our aim was to establish whether the function of oral stromal progenitors is impaired in chronic graft versus host disease (cgvhd) and restored with response to treatment. a patient with grade oral cgvhd was treated with systemic thalidomide for weeks ( mg/day). punch biopsies of buccal mucosa were taken before and after treatment. oral progenitor cells were isolated and expanded in vitro. numbers of progenitors was assessed using colony forming unitfibroblast (cfu-f) assays. stem cell markers (cd , cd , cd , cd , cd , cd , hla i and ii) were evaluated by flow cytometry. wound healing and antibacterial potential were assessed using a collagen gel lattice assay and bacterial cocultures as previously described ( , ) . secreted levels of relevant cyto-and chemokines associated with wound healing were assessed by elisa. significant clinical improvement with reduced inflammation in the oral mucosa and healing of ulcers was seen after weeks of thalidomide treatment, with continued improvement after weeks. cell surface expression of cd and cd on omlp-pcs was elevated postthalidomide; markers correlated with stemness and angiogenesis in mesenchymal stromal cells. this correlated with a restoration of wound healing potential and antibacterial function after thalidomide treatment ( figure ). figure : antibacterial testing demonstrated a loss of antibacterial function against (a) gram positive and (b) gram negative micro-organisms in the cgvhd omlp-pcs that could be completely or partially restored to levels comparable with healthy controls after thalidomide treatment. *p ⩽ . , **p ⩽ . , ***p ⩽ . . we demonstrate, for the first time a correlation between clinical improvement of oral cgvhd with thalidomide treatment and restoration of endogenous progenitor cell function. this study highlights the importance of a dysfunctional oral mucosal stroma in the pathogenesis of cgvhd. further studies should focus on the role of the stroma in promoting cgvhd and the precise mechanisms by which thalidomide is able to restore its functions. chronic graft-versus-host disease (cgvhd) is a major cause of late morbidity and treatment-related mortality in patients undergoing allogeneic hematopoietic stem cell transplantation (hsct). cgvhd is driven by a th biased t-cell mediated alloreactive immune response that leads to chronic inflammation and fibrosis in various organs. thymic stromal lymphopoietin (tslp) is an epithelial cell-derived cytokine that mainly affects myeloid cells. upon stimulation with tslp, dendritic cells are polarized towards a dc phenotype driving th biased immune response. we hypothesized that tslp is involved in the pathogenesis of cgvhd and that elevated levels of tslp post-transplant may lead to an increased risk of cgvhd. in the present study, we measured plasma tslp levels during hsct to study associations with clinical outcomes including cgvhd. about adult patients undergoing myeloablative hsct at rigshospitalet, denmark, from to were included. diagnoses included aml (n = ), all (n = ), myelodysplastic syndrome (n = ), other malignancies (n = ) and anemias (n = ). donors were either hla matching siblings (n = ) or mud (n = ). grafts were either bmsc (n = ) or pbsc (n = ). conditioning included tbi (n = ) or high-dose chemotherapy alone (n = ). plasma tslp was measured by elisa (abcam) before transplantation, at the day of transplantation and at day + , + , + and + post-hsct. monocytes were counted daily, and t, b and nk cells were measured at day + and + using flow cytometry. about ( %) patients engrafted; acute gvhd grade - was seen in ( %) patients, and ( %) patients developed severe cgvhd. oas was . %, trm . % and relapse rate . %. median plasma tslp levels increased from before conditioning ( pg/ml) to reach a peak at day + ( pg/ ml, p = . ), followed by a gradual decline. the plasma levels of tslp at day + were positively correlated with same-day monocyte counts (ρ = . , p = . ). approximately half of the patients (n = ) experienced an overall rise in tslp from baseline ( pg/ml) to day + ( pg/ml). this increase in tslp was not significantly associated with any transplantrelated baseline characteristics. however, patients, who had an increase in tslp levels from baseline to day + , had a significantly higher risk of extensive cgvhd compared to those in whom tslp levels at day + were similar or below baseline levels (cumulative incidence of cgvhd: % (increased tslp at day + ) vs % (normal/low tslp at day + ), p = . ). development of cgvhd was also associated with the nucleated cell dose infused (p = . ) and transplant using pbsc (p = . ). tslp plasma levels were not associated with acute gvhd, oas, trm, relapse rate or numbers of t cell, b cell or nk cells posttransplant. we have found that increased levels of tslp from baseline to day + were associated with an increased risk of extensive cgvhd. this association may be due to the ability of tslp to polarize the immune system toward a th response. importantly, the increase in plasma tslp levels was not associated with any transplant-related characteristics suggesting that tslp may be an independent predictor of cgvhd. these findings indicate that anti-tslp treatment may be a new approach to fight severe cgvhd. disclosure of conflict of interest: none. thymopoiesis following hct: a retrospective review comparing interventions for agvhd in a paediatric cohort c roberts , am flinn , ma slatter , , r skinner , h robson , j lawrence , j guest and ar gennery , institute of cellular medicine, newcastle university and great north children's hospital, newcastle-upon-tyne, uk acute graft-versus-host disease (agvhd) is a life threatening complication of allogeneic haematopoietic cell transplantation (hct), treated with topical and/or systemic corticosteroids. in steroid-refractory agvhd extracorporeal photopheresis (ecp) can be effective. ecp exposes apheresed mononuclear cells to -methoxypsoralen and ultra-violet radiation. systemic corticosteroids and agvhd are damaging to thymic tissue. delayed immune reconstitution, especially of the t lymphocyte compartment, is associated with increased morbidity and mortality. therefore, management strategies must be effective in treating agvhd but endeavour to minimise resulting thymic damage. we compare the effect of topical steroid therapy, corticosteroids and ecp on thymic reconstitution following hct in paediatric patients. statistical analysis was performed using the kruskal-wallis test. about paediatric allogeneic hcts were performed between june and april , at the great north children's hospital, newcastle for malignant and non-malignant disease. we reviewed computerised records to categorise patients into four groups: no agvhd, mild agvhd treated with topical steroid, agvhd treated with systemic steroid, agvhd treated with ecp. laboratory data were reviewed to provide values of naive (cd + and cd − )cd ra+cd + t-lymphocytes at , , and months post-hct. values for thymic output for the ecp group were additionally recorded at , , and months during ecp. excluded were patients with no available data, those with o months follow-up, those with chronic gvhd, recipient of hct or received dli post-hct. about patients were included, ( . %) had no agvhd, ( . %) had agvhd treated topically or systemically, ( . %) had agvhd and received ecp. for analysis, the group treated with steroids were divided into those treated with topical therapy and those given systemic steroids. the median values of all groups at each time point ( , , and months) are shown ( figure ). there was a significant difference between the rate of thymopoiesis (measured by the addition of cd + and cd − cd +cd + cells) between all groups (no agvhd, agvhd treated with topical or systemic steroids, and agvhd treated with ecp) at , , and months post-transplant (p = . , p o . , p o . , p = . respectively). further analysis excluded those treated with ecp (so including the no gvhd (n = ), topical treatment (n = ) and systemic steroid treatment group (n = )). at each time point p = . , p = . , p = . and p = . , respectively, demonstrating a statistically significant difference in time to thymopoiesis between those that had developed agvhd and those that had not. acute graft-versus-host disease (agvhd) is a significant cause of morbidity and mortality following allogeneic hematopoietic stem cell transplantation. which despite first line treatment is well-established (esteroids), second line is not well defined. evaluate the results with different second line treatment used and the risk factors associated with of sr-agvhd. we review the clinical records of consecutive patients undergoing allogenic hsct from to in our hospital. about % presented agvhd. sr-agvhd was defined as progression after days, no clinical change in days or incomplete response after days of treatment. about patients ( %) met s criteria for sr-agvhd. there were no significant differences between both groups (sr-agvhd vs no sr-agvhd) respect to age (recipient/donor), unrelated donor, prophylaxis of gvhd, cd lymphocyte and cd cell. the median time between transplantation and agvhd diagnosis was days ( - ). patients who did not respond on fifth day of steroid treatment have an % rate mortality vs % on no sr-agvhd group (p = . ). sr-agvhd: patients presented sr-agvhd and this was related to: hla mismatch ( % sr-agvhd vs % no sr-agvhd, p = . ), male recipient/female donor ( % sr-agvhd vs % no sr-agvhd, p = . ) and advanced underlying disease ( % sr-agvhd vs % no sr-agvhd, p = . ). second line: basiliximab ( . %); extracorporeal photopheresis (ep) ( . %), timoglobulin ( . %) and others therapies ( . %). two patients ( %) obtained complete response (cr) and patients ( %) partial response (pr). global response (cr, pr) after second line (mainly basiliximab) showed better overall survival (p = . ). third line: basiliximab ( . %); ep ( . %), mesenchymal cells (msc) ( . %), ruxolitinib ( , %) and others ( . %). ruxolitinib improve gvhd cutaneous and hepatic but not intestinal. the best results were achieved with ep ( cr, pr) and basiliximab/msc ( pr, respectively). only patients who achieved cr survived. fourth line: msc ( %)/ ruxolitinib ( %) does not improve the prognosis. no serious adverse effects were observed with msc therapy, basiliximab and ep. about % of patients showed cmv reactivation with basiliximab. about patients died ( %), patients with early mortality ( o months) due to refractory agvhd ( %) or secondary infections ( %). overall survival at months and year was ± % and %, respectively. in multivariate analysis the main factor for trm was the steroid-refractory vs steroidsensitive (hr . , % ci . - . ; p = . ) and was unfavorable the association of hepatic and intestinal agvhd (hr . , % ci . - . ; p = . ) no sr-agvhd: patients. trm- was % (n = ), mainly due to infection ( %). trm- year was % (n = ), mainly by gvhd ( %) and infections ( %). median follow-up of months, os- months and year were ± %/ ± %, respectively. trm was associated with not obtained cr/pr after second line (p = . ), no cr after third line (p = . ) and relapse of gvhd despite achieving cr initially (p = . ). in our series only the patients that obtained cr/pr after second-line or cr after third-line improved os. the best results in sr-agvhd were obtained with basiliximab and extracorporeal photopheresis. trm was associated with relapse of gvhd and advanced disease to the transplant. randomized clinical trials are needed to assess different treatment modalities for sr-agvhd. [p ] disclosure of conflict of interest: none. extracorporeal photopheresis (ecp) is a therapy for steroidrefractory chronic graft versus host disease (cgvhd). therapeutic response to ecp has been linked with a progressive increase in circulating granulocytic myeloid-derived suppressor cells (g-mdsc) in acute gvhd, but not in cgvhd . low density neutrophils (ldn) phenotypically resembling g-mdsc (putative g-mdsc) show marked flux in cgvhd patients receiving ecp, and a reduction in their frequency is associated with a sustained therapeutic response to ecp . recent data has identified lectin-type oxidized ldl receptor- (lox- ) as a specific marker of ldn with t-cell (tc) suppressive activity . using this marker we have conducted a cross-sectional study to assess whether putative g-mdscs in this patient cohort have suppressive activity. about patients with steroid refractory or steroid-dependent cgvhd (mean treatment duration of months) receiving ecp and healthy controls were recruited. patients had gvhd affecting skin ( / ), liver ( / ) and gut ( / ). pbmc were isolated and immunophenotyped by flow cytometry for markers of g-mdscs (cd − ve , cd , cd b, hla-dr − ve , cd int ) and lox- expression. suppressive function was determined by measuring the inhibition of proliferation of anti-cd /cd -activated purified cd tc from healthy donors by -day co-culture with g-mdscs from patients. statistical analysis was conducted using graphpad . ecp patients had substantially greater frequencies of circulating putative g-mdsc than healthy controls (p o . ; median: % and iqr %- % vs . % and iqr . %- . %, respectively). while there were substantially greater frequencies of circulating lox- + cells in pbmc from ecp patients than healthy controls (p o . ; median: . % and iqr . %- % vs . % and iqr . %- . %, respectively), these were mainly the minority population within the putative g-mdsc fraction with no significant difference between ecp patients and healthy controls in the proportion of lox- + cells ( % ± % vs % ± %, respectively). ecp had no significant effect on circulating putative g-mdsc frequency measured before and the day after treatment (median: . % and iqr %- % vs % and iqr %- %; n = , respectively) nor on lox- frequency (median: % and iqr . %- % vs . % and iqr . %- . %; n = , respectively). at a tc:g-mdsc ratio of : , isolated g-mdscs from ecp patients suppressed cd tc proliferation (mean ± sd: % ± %; n = ). however, the potency of suppression was highly variable (min-max: - %). the pattern of lox- expression suggests that only a subset of putative g-mdscs in ecp patients are suppressive and may explain why suppressive function in this cell fraction is so highly variable. however, the relatively high frequency of lox- cells in this patient cohort might contribute to immunosuppression resulting in increased susceptibility to opportunistic infections. according to the revised eortc/msg criterion, patients were diagnosed with cns-ifd. among those patients without cns-ifd ( patients), cns-ifd were matched in a : ratio for analyzing the risk factors of cns-ifd. and among ( . %) patients who occurred pulmonary ifd without cns involvement, patients were selected as control group for analyzing the risk factors associated with involvement of cns in pulmonary ifd. we selected the control group using a : ratio matched-pair method with the variates of ( ) age; ( ) sex; ( ) underlying disease. we retrospectively reviewed patients complicated with cns-ifd after hsct in our single center during a years period. most patients received haploidentical stem cell transplantation. the median onset time of cns-ifd was ( - ) after hsct, and most ( . %) of them have prior pulmonary ifd. the most frequent pathogen was aspergillus, while no crypoccosis and candidas were found. the most common clinical presentation was space-occupying symptoms and signs. brain abscess were the most common imaging finding. prior pulmonary ifd (po . , hr . ( % ci, . - . )) was the only risk factors associated with occurrence of cns-ifd. while poor response at weeks (p = . , hr . ( % confidence interval: . - . )) was the only risk factor predicting the involvement of cns in pulmonary ifd. the response (complete and partial response) at weeks and last follow-up was . % and . %, respectively. the overall survival was . % at the last follow-up with a median ( - ) days after transplantation. in conclusion, patients with pulmonary ifd had higher risk of cns-ifd, especially in those with poor response after weeks of treatment. and the prognosis of cns-ifd was very poor after hsct. disclosure of conflict of interest: none. adv may cause severe infections in hsct recipients, especially from unrelated donors or cord blood particularly in pediatrics. disseminated infections usually occur after digestive reactivations. at mo.post-hsct, the incidence of adv digestive infection and viremia in pediatric hsct is about % and %, respectively. therapeutic strategies to control adv infections are limited to the use of infusion of cidofovir (cdv) or ex vivo anti-adv selected cytotoxic lymphocytes (ctl). however cdv is not labeled for adv treatment, presents a renal toxicity and has shown limited efficacy. specific-ctl remain difficult to produce. brincidofovir (cmx , bcv, chimerix, usa) is an orally-available lipid conjugate of the nucleotide analog cdv that has demonstrated broad clinical antiviral activity against double-stranded dna viruses (that is, herpes-, adeno-, orthopox-and polyomaviruses. the drug has an increased bioavailability compared to cdv and has shown encouraging results. we report here the results obtained with this compound in patients treated in six centers from january . there were pts ( m/ f), median age at hsct: mo. ( - ). hsct indication was all in nine, pid in six, aml in two, fa in two and ibmf in one. donor was / or / mud in four and six pts, respectively; haplo-identical familial donor in ; / or / unrelated cb in two and three pts, respectively; msd in one. stem cell source was bm for pts, cb in and pbsc in . two pts underwent a second hsct. cond' regimen were mac in pts. all pts received either ex vivo or in vivo t-cell depletion. three pts presented with adv-disseminated disease, seven pts with blood + other site (throat, urine or stools) adv infection, three with adv-related gut disease, three with blood infection and three with gut infection. the remaining patient received bcv for jc viremia with fever. median time for virus infection diagnosis was d post-hsct (range: d- to d+ ). about pts experienced other viral infection episodes after hsct (cmv: ; ebv: ; bk: ; hsv: ; hhv : ; influenzae: ( ). about pts received - injections of cdv prior to bcv treatment. one pt received specific-adv ctl before bcv without efficacy. the reason to switch from cdv to bcv was uncontrolled adv infection (n = ) or cdvinduced renal failure (n = ). two additional pts experienced renal impairment after cdv. about pts received - lines of immunosuppressive therapies (including ecp) in addition to calcineurin inhibitor at time of bcv therapy due to grade iii and iv acute gvhd in seven and seven pts, respectively. median adv load at time of bcv initiation was . log copies/ ml (range: - ) in blood and log copies/ml ( . - . ) in stools. median duration for bcv therapy was weeks (range: - ). about seven pts with blood adv infection or disseminated disease experienced adv disappearance as well as four pts with gut disease or infection. three of them experienced adv infection relapse and received thereafter cdv, bcv or advspecific ctl. five pts presented with grade - diarrhea during bcv treatment. about were alive at end point where seven died from septis (n = ), multi-organ failure (n = ), gvhd (n = ) and adv disseminated infection (n = ). adenovirus infections occur often in immunocompromized pts receiving concomitant nephrotoxic drugs that may avoid cdv use.bcv appears as efficient therapy against adenovirus infection in such pediatric pts since here out of pts where alive after adv infection and bcv treatment. in this study we retrospectively analyzed cmv reactivation determined by pcr and response to pre-emptive therapy in patients receiving an haplo (n = , %) comparing them with a control group of non haplohsct ( mrd and mud) (n = , %). median age was years (range: - ), for haplohsct and for control group. conditioning regimen was myeloabaltive (mac) in . % and reduced intensity (ric) in . %. haplohsct characteristics: haplo conditioning was fludarabine ( mg/m or mg/m × days in ric or ma regimen) and busulfan ( . mg/kg × in ric or days in ma) ( . % mac, and . % ric). cyclophosphamide-post was used for gvhd prophylaxis in %. median of days to reach more than × granulocytes and more than × platelets were ( - ) and ( - ), respectively. incidence of acute gvhd was % (grade i-ii . %, and iii-iv . %), with two steroid-refractory cases. cmv reactivation: . % of haplohsct patients presented cmv reactivation, vs . % in control group (p = . ). median number of cmv reactivation episodes was in both groups. median time to cmv pcr detection was days ( - ) and ( - ) in haplohsct and control group respectively (p = . ). average maximum cmv iu by pcr was . in haplo vs . in the control group (p = . ). first antiviral pre-emptive therapy (valganciclovir in . %) was effective in % in haplohsct vs % in control group (p = . ). main reason for antiviral treatment switch was failure in cmv iu reduction, and foscarnet was the most used therapy in refractory cases. twenty patients developed cmv disease ( in haplo and in control group) (gi disease % and pulmonary disease % in both groups). in a multivariate cox-regression model, receiving an haplohsct, serological cmv status (positive patient/negative donor), mac regimen and development of acute gvhd grade i/ii or grade ii/iv were variables associated with a higher risk of cmv reactivation. based on these results, haplohsct is associated with a higher cmv reactivation compared to non-haplohsct, despite a lower incidence of all other risk factors as agvhd or mac in the haplo group. although it is not statistically significant, response to pre-emptive therapy is higher in haplohcst and no differences in cmv disease were observed. disclosure of conflict of interest: none. although a number of patients with hiv infection and hematological disease have successfully undergone allogeneic hsct together with combination anti-retroviral therapy (cart), short and long-term outcomes remain not well known. we report the spanish experience treating hiv-infected adult patients with high-risk hematological malignancies with allogeneic hsct. we retrospectively reviewed hiv-positive patients who received allogeneic hsct in three institutions in spain within geth (grupo español de trasplante hematopoyético y terapia cellular). seventeen patients have been transplanted between and . median age was ( - ), % male. diagnosis and transplant characteristics are summarized in table . cumulative incidence of neutrophil and platelet engraftment were % at days (median days), and % at days (median days), respectively. with a median follow-up of months ( - ), os and efs were %. trm was % at months and % at months. grade ii-iv agvhd rate was %, and moderate/severe cgvhd rate was %. all patients received cart. two patients showed severe toxicity related to interaction of immunosuppressive s drugs and protease inhibitors. about % of patients showed infectious complications. viral infections were the most frequent cause: cmv ( ), bk ( ), adv ( ), hhv- ( ), hcv ( ), hhv- ( ), parainfluenza ( ). two patients had invasive aspergillosis and one patient presented disseminated tuberculosis. causes of death were: relapse ( ), infection ( ), gvhd ( ) and toxicity ( ). all surviving patients showed undetectable hiv load after hsct. allogeneic hsct is an effective therapy for high-risk haematological malignancies in patients with hiv infection, and long-term hiv suppression with cart is feasible. however, interactions between immunosuppressive agents and anti-retroviral drugs, high rates of significant gvhd, and frequent infectious complications account for a complex procedure in this population. selected hiv-infected patients with hematologic malignancies should be considered for allo-hsct when indicated, in experienced centers. disclosure of conflict of interest: none. clostridium difficile infection (cdi) is one of the most common causes of nosocomial infectious diarrhea in europe and usa, which results in high morbidity and mortality among hospitalized patients. allogenic hematopoietic stem cell transplant (hsct) recipients remain at high risk for cdi. incidence rate ranges from to %. numerous risk factors including acute graft-versus-host disease (agvhd), hla matching status, conditioning-intensity, use of total body irradiation (tbi) may play an important role in the course of cdi in these patients. the aim of this study was to evaluate the prevalence of cdi in children, and to assess the influence of such factors as gender, age, diagnosis, hla matching status, conditioning-intensity, use tbi-containing regimen, source of graft (bone marrow/bm/ vs peripheral blood/pb/)or agvhd on course, duration of treatment and outcome in children undergoing hsct. between and a total of hscts were performed in five polish pediatric transplant centers, including allogeneic and autologous. all patients were followed up to months post hsct. we analyzed retrospectively episodes of cdi infection in the group of children. twenty-one of children were diagnosed with hematological malignancies: acute lymphoblastic leukemia (all), acute myeloblastic leukemia (aml), myelodysplastic syndrome (mds), two were diagnosed with severe aplastic anemia (saa), one with chronic granulomatous disease (cgd) and of them-with solid tumors. the median age was . years (range: . - . years). majority of patients underwent myeloablative conditioning protocol ( / ). in allogeneic setting / patients underwent mud-hsct, / pts msd-hsct and one patient was given a haploidentical pbsct. in this series, in out of cases bm was a transplant source, and pb in out of . cdi was defined as having diarrhea that tested positive for c. difficile via pcr, cytotoxin assay, or dual enzyme immunoassays. kruskal-wallis test, wilcoxon test and χ -test were used to estimate the influence of risk factors on severity of disease, duration of treatment and outcome. we observed episodes of cdi ( . %) in hsct recipients: in allotransplant recipients ( . % of all transplants) and in autotransplant recipients ( . % of all auto-hsct). nine patients responded to therapy with metronidazole, seven patients responded to vancomycin alone, and in two patients rifaximine was administered. six children required adding second drug: vancomycin or metronidazole, five patients were not given any medications. there was no significant correlation between such factors as diagnosis, gender, age, conditioning regimen, hla matching, agvhd and severity of disease, and duration of treatment. recurrence rate was difficult to assess due to lack of data. we observed three deaths. one of them was connected with cdi. there was one -year-old boy with saa (mud-pbsct, hla / ) with no agvhd. the other two deaths were due to progression of s disease. cdi occurred in nearly % of pediatric patients undergoing hsct, surprisingly often in autologous hsct too ( . %). almost all patients experienced mild cdi with adequate response to antibiotic therapy. cdi is a rare cause of death among transplant recipients. disclosure of conflict of interest: none. antifungal prophylaxis in high-risk paediatric patients with haematological malignancies: a monocentric experience k perruccio, i capolsini , a carotti , n albi , l pitzurra , a velardi and m caniglia pediatric haematology oncology section; haematology and clinical immunology section; transfusion medicine and the choice of antifungal prophylaxis in high risk paediatric haematological patients (according to the latest ecil /seifem guidelines) remains an open question. a recent retrospective survey from associazione italiana ematologia oncologia pediatrica (aieop) showed that, in these patient categories, the only variable which significantly impacted on invasive fungal infection (ifi) occurrence was the presence or not of antifungal prophylaxis at the ifi onset (unpublished data). from january , in our pediatric hematology oncology unit, allogeneic hematopoietic stem cell transplantations (hsct) were performed (median age: years; range: months- years), mainly for acute leukaemia (median follow-up: months; range: - ). patients received liposomal amphotericine b (n = ), micafungin (n = ), or fluconazole (n = ) as primary antifungal prophylaxis until neutrophil recovery ( × /l). seven patients developed acute gvhd ( %) which evolved in gvhd in ( %). as outpatients, they continued with posaconazole (n = ), voriconazole (n = ), or micafungin (n = ) until cd +t-cell recovery ( /cmm) or gvhd immune suppressive prophylaxis/treatment withdrawn. during the last year, according to ecil /seifem guidelines , we administered primary antifungal prophylaxis also to / high risk (hr) acute leukaemia patients. two patients with aml were treated with posaconazole, four patients with hr-all received micafungin, four relapsed all patients received micafungin (n = ), or liposomal amphotericine b (n = ), or posaconazole (n = ). one aml patient was then transplanted; all relapsed patients are waiting for transplant. no differences were observed in terms of breakthrough proven/probable (pp)-ifi incidence, according to antifungal prophylaxis in the various patient groups. in particular, in the early phase, we observed a pp-ifi incidence of % in both treatment arms (micafungin vs liposomal amphotericine b, p = ns). in the late phase, we observed case of pp-ifi who were receiving posaconazole as prophylaxis. overall survival (os) was %, with % mortality rate. in hr leukaemia patient group, we observed pp-ifi in the only two patients who were not receiving any antifungal prophylaxis at the ifi onset. antifungal prophylaxis is strongly recommended in paediatric patients with haematological malignancies who are at high risk of ifi. the choice of antifungal drug depends on the treatment phase, drug interactions (particularly for azoles), patient compliance and clinical conditions which interfere with intestinal absorption. in our experience, as no differences were observed in term of efficacy, micafungin resulted the best choice in terms of tolerability, toxicity, compliance and cost saving. antifungal prophylaxis with micafungin and bridging to inhaled liposomal amphotericin b after engraftment in patients undergoing allogeneic hematopoietic stem cell transplantation d rivera* , , c de ramon , a avendaño , j carrillo , d caballero , l lopez , i ormazabal , a navarro , a martin micafungin is an effective antifungal for prophylaxis, active against candida spp. including those resistant to other antifungals (c. glabrata and c. krusei) and also active against aspergillus spp. guidelines focused on antifungal prophylaxis, recommend its use during preengraftment and early postengraftment period in allogeneic hematopoietic stem cell transplant (allo-hsct) recipients. moreover, its profile of low drug interactions and side effects, makes it a suitable alternative for patients who need concomitant treatments, present hepatic insufficiency and in those who do not tolerate oral drug administration. the addition of inhaled liposomal amphotericin b (lamb) after engraftment, provides an alternative way to effectively prevent mold infections, that are acquired mainly by inhalation. inhaled lamb has good tolerance with absence of drug interactions and low toxicity. the aim of this study was to describe the experience in the hsct unit of the university hospital of salamanca with micafungin and lamb as primary prophylaxis in patients undergoing allo-hsct with reduced intensity conditioning (ric) and graft-versus-host disease (gvhd) prophylaxis with tacrolimus and sirolimus. thus evaluating efficacy and tolerability in our population. retrospective observational study from january to august , including all adult patients undergoing allo-hsct with ric and gvhd prophylaxis with tacrolimus and sirolimus, in whom an azole derivative is not indicated, due to drug interactions. therefore received prophylaxis with micafungin during the preengraftment period and bridging to lamb after engraftment at discharge, and continuing it during the first days post-transplant. data from patients from our hsct unit. ten ( . %) patients who had invasive fungal infection before undergoing allo-hsct, and ( . %) patients who received prophylaxis with drugs other than micafungin-lamb were excluded. underlying disease was grouped by leukemia in ( . %) patients, lymphoma in ( . %), myelodysplastic syndromes in ( %), multiple myeloma in ( . %) and other diseases in ( . %) patients. eighty patients underwent peripheral blood allo-hsct, of whom were related donor in ( %) patients and unrelated donor in ( %). prophylaxis with micafungin in ( . %) patients, dose of mg per day, with a mean of days (± days) with postengraftment bridging with lamb mg weekly, continuing it during the days posttransplant. days of neutropenia during preengraftment, o days in ( . %) patients, - days in ( . %), more than days in ( . %). during follow-up there were three cases ( . %), two catheter related candida infection, and one esophageal candidiasis. there were no reported aspergillosis cases (possible, probable or proven), according to the european organization for research and treatment of cancer (eortc) criteria. finally, prophylaxis with micafungin and inhaled lamb, was considered an effective and safe strategy in ( . %) patients, with no side effects reported. according to our experience with micafungin and the addition of inhaled liposomal amphotericin b, the results indicate that, this is an appropriate alternative for antifungal prophylaxis, in patients undergoing allo-hsct, because of their efficacy, few side effects and drug interactions. disclosure of conflict of interest: none. recipients of allogeneic hematopoietic cell transplantation (allohct) are at high risk of developing invasive fungal infections (ifi). in the early phase (o days) after allohct, the use of antimold prophylaxis has been generalized, although there is no consensus on the best therapeutic strategy. the use of nebulized liposomal amphotericin b and fluconazole has been shown to be effective, safe and associated with low economic costs in lung transplantation . however, the use of this prophylactic strategy in the early phase of allohct setting has not been evaluated. we included all consecutive patients who received their first allohct in our center from january to august and who underwent antifungal prophylaxis according to the prospective ambineb protocol (nebulized liposomal amphotericin b mg administered three times per week as loading dose and once per week and fluconazole mg per day until day + ). patients with a previous ifi were excluded. patients with graft-versus-host disease (gvhd) receiving high dose corticosteroids were allowed to be changed to voriconazole or posaconazole at physician's discretion. the primary objective of the study was the incidence of ifi at day + . the secondary objectives were to assess adherence and toxicity of the ambineb protocol. only cases with proven or probable ifi according to eortc-msg criteria were considered. a multidisciplinary team of experts in hematology, infectious diseases, microbiology and radiology prospectively evaluated and categorized each case. we included patients with a median age of years (range: - ) and a median follow-up for survivor of months (range: - ). patients received allohct mainly for acute leukemia ( %), non-hodgkin lymphoma ( %) and myelodysplastic syndrome ( %) . patients received allohct from hla unrelated ( %) or related donors ( %) mostly using a reduced intensity conditioning ( %). graft-versushost disease (gvhd) prophylaxis was performed with calcineurin inhibitors mainly in combination with sirolimus ( %) or methotrexate ( %). after the comprehensive review, only one case of proven or probable ifi at day + was diagnosed. prophylaxis with ambineb was completed in patients ( %) while ( %) stopped the treatment. the most frequent causes of discontinuation were possible ifi ( %), gvhd ( %), admission in intensive care unit ( %) and toxicity ( %) (figure) . ninety-four patients ( %) did not have adverse advents associated with ambineb. eight patients presented organ toxicity which was at least partially attributed to ambineb, including gastrointestinal symptoms (n = ), liver function test abnormalities related to fluconazole (n = ) and cough (n = ). of the patients who discontinued ambineb, ( %) were switched to other antifungal drugs including (echinocandins ( , %) posaconazole ( , %), voriconazole ( , %) or others ( , %)). overall survival and non-relapse mortality of all patients at median follow-up were % ( % ci - ) and % ( % ci - ), respectively. the combination of nebulized ambisome and fluconazole is effective in preventing ifi in the early phase of allo-hct and is associated with high adherence and low toxicity. neutropenia-related infections is a common complication of apsct in patients (pts) with mm and dlbcl. our study aims are to: ( ) assess antibacterial susceptibility patterns of isolated organisms, to guide antibiotic prophylaxis ( ) identify the epidemiology of bacteremia with susceptibility patterns to direct empiric therapy of febrile neutropenia ( ) assess the interval between the occurrence of neutropenia and the isolation of resistant bacteremia to identify the best timing to start prophylaxis ( ) identify contributing factors for the development of bacteremia and mortality. our retrospective study included adult pts who underwent apsct for mm and dlbcl between and . we recorded the following: age, gender, basic illness, comorbidities, number of cd + cells infused, a central venous catheter, duration of neutropenia, diarrhea and mucositis, mechanical ventilation, positive bacterial cultures with susceptibility profiles and history of broad-spectrum antibiotic intake for more than h for the past months on hospital setting, and mortality. statistical analysis was carried out using spss (version ). about isolates were obtained: urine ( . %), blood ( . %), sputum ( %), wound ( %), venous catheter ( %) and stool ( %). gram-negative (gn) species were predominant ( . %) with e. coli ( . %), klebsiella (k) ( %) and pseudomonas (pseudo) ( %). isolates sensitive to third generation cephalosporins ( gc) represented % of the enterobacteriaceae (entero) including % in e. coli and % in k. all entero isolated were susceptible to carbapenems (carba), pipercillin/ tazobactam (pip/taz), amikacin and ciprofloxacin (cipro). all pseudo (n = ) and acinetobacter (n = ) isolates were susceptible to carba, pip/taz, amikacin, cipro, colistin and tigecycline. as for gram-positive (gp) bacteria ( . %), coagulase negative staphylococci (cns) were predominant ( %) . oxacillin susceptibility reached % and two isolates methicillin resistant s. aureus were identified. all gp were susceptible to glycopeptides. a total of bacterial isolates were identified ( episodes of bacteremia) from pts. gn were predominant ( . %) with e. coli being most common ( %). all gn were susceptible to gc, carba, pip/taz, amikacin and cipro. as for gp ( . %), cns predominated ( %) including % oxacillin-susceptible causing seven episodes of bacteremia with six central line-associated. no glycopeptide resistance was identified. none of the clinical features and pts' characteristics reached statistical significance as risk factor for bacteremia. however, the need for mechanical ventilation and mortality were higher in bacteremic vs non-bacteremic pts ( . % vs %, p = . , and . % vs %, p = . , respectively). all bacteremic episodes occurred after developing neutropenia (median = . days, range: - ) except for one case of clabsi caused by e. coli occurring day before neutropenia. pip/taz was prescribed in % of bacteremia episodes followed by quinolones ( %) and carbapenems ( %). no previous use of third and fourth generation cephalosporins was observed. we recommend quinolone prophylaxis in apsct pts. for empiric therapy, antibiotics recommended by international guidelines including, cefepime and pip/taz still fit. thus, we could spare the use of carba and other last-resort antibiotics to other conditions. we also recommend continuous surveillance of resistance. disclosure of conflict of interest: none. fever is an almost universal complication in patients undergoing autologous stem cell transplantation (asct), however, microbiological documentation is only achieved in - % of such febrile episodes (fe). this low diagnostic efficiency makes epidemiological assessment in transplant units difficult, and may lead to a suboptimal empirical treatment. we have studied the utility of strict blood culture (bc) extraction as a mechanism to improve microbiological documentation of fe in these patients. we conducted a retrospective study over consecutive asct performed in our centre between june and may ( year). about patients were male and female, with age between and years (mean . ). diagnosis was hodgkin lymphoma, non hodgkin lymphoma and multiple myeloma. ascts were performed in reverse isolation conditions, in rooms equipped with hepa and pall filters. prophylaxis against herpes virus and p. jirovecii with acyclovir and pentamidine was used. no prophylaxis against gram negative bacteria or filamentous fungi was performed. bc were extracted at the beginning of every fe and every - h if fever persisted (or more frequently, following clinical criteria). blood samples from intravascular devices and peripheral blood were collected in two bactec bottles each (for aerobic and anaerobic microorganisms). complementary diagnostic techniques and empiric antibiotic therapy were performed following our institution's guidelines. fe were classified in microbiologically documented infections (mdi), clinically documented infection (cdi) and fever of unknown origin (fuo) following his criteria. fe were studied (average . fe per patient, . days of fever duration per fe). about % of fe were classified as mdi, % as cdi and % as fuo. mdis were cause by gram positive bacteria ( %), gram negative bacteria ( %) and polymicrobial infections ( %). no viral or fungal infections were observed. an average of . bc per fe and . per patient were extracted. the proportion of fe classified as mdi was related to the number of blood cultures extracted during the episode. only % of fe with three or less bc extracted were classified as mdi, % if - bc were extracted, and % if - bc were extracted (p o . ). no significant difference in proportion of mdi classified fe between the extraction of or more bc and - . all patients were discarded in good clinical conditions. according to our experience, a strict - blood culture extraction is related to a high rate of microbiological documentation of febrile episodes. moreover, we have not observed the rise in gram negative bacteria reported by other studies and gram positive cocci persist as the main infection cause in our centre. candida which has been traditionally related to duration of neutropenia, emerges as a pathogen beyond the aplastic period in allogeneic haematopoietic cell transplantation (allohct). in the setting of alternative transplants and aggressive immunosuppressive therapy, these infections are a challenging problem. there is scarcity of data regarding the significance of breakthrough candidaemia in allohct. to that end, we aimed to determine the incidence, clinical and microbiological characteristics and outcome of candidaemia in allohct recipients. we studied consecutive allohct recipients from january to june . blood cultures were obtained from peripheral vein or central venous catheters (cvcs) routinely and on febrile patients. well-known risk factors for candidaemia were studied: neutropenia, type of transplant, moderate to severe graft-versus-host disease (gvhd) and coexisting infections. among allohct recipients, we identified seven patients with candidaemia: five post matched unrelated (four myeloablative and one reduced intensity conditioning) and two post haploidentical transplant. in median time of . ( . - ) months, episodes of candidaemia were noted, despite antifungal prophylaxis with echinocandins or azoles. infections with non-albicans candida spp. occurred more frequently ( / ) and c. parapsilosis was the predominant microorganism ( / ). other species were isolated: c. famata ( ), c. krusei ( ) and c. haemulonii ( ). all candida spp. isolates were phenotypically susceptible to antifungal agents already administered to patients. there was no resistance to echinocandins indicated by minimum inhibitory concentrations (mics). all patients had severe acute or late-onset gvhd with intestinal involvement and cvcs prior to candidaemia. although cvcs were removed in / and patients were treated with echinocandins, new cvcs were re-contaminated in / with the same or other species. all patients presented well known risk factors for candidaemia (use of broad spectrum antibiotics due to severe bacterial infections, total parenteral nutrition due malnutrition, long-term high-dose corticosteroids and other immunosuppression), but no neutropenia. one patient survived, whereas five patients succumbed to gvhd and multi-organ failure and one patient to sepsis due to bacteremia. candidaemia was observed in non-neutropenic patients with agvhd and cvcs on antifungal prophylaxis, despite difficulties in diagnosis due to poor sensitivity of blood cultures. the epidemiology of candidaemia has changed in the last decade and its risk is more diverse and complex. the irreversible intestinal gvhd lesions might be the main source of candida in patients receiving antifungal prophylaxis. our data show that candidemia remains an important issue in profoundly immunosuppressed patients contributing to excessive morbidity. our aim was to compare the rate of neutropenic sepsis, defined as fever of o c and a neutrophil count of o . × /l, before and after the introduction of ciprofloxacin prophylaxis. one hundred and eight adult patients, of which had acute myeloid leukaemia, had acute lymphoblastic leukaemia, had lymphoma and had other haematological malignancies, were identified through our admission database. of these patients, received oral ciprofloxacin during their neutropenic phase. the median duration of neutropenia was days in both the no-prophylaxis and ciprofloxacin groups. there was a significant reduction in the rate of neutropenic sepsis from . % ( / ) in the no-prophylaxis group to . % ( / ) in the ciprofloxacin group (p = . ). prolonged infection, suggested by the use of broad-spectrum antibiotic treatment for more than days, was more common in the group which did not receive prior ciprofloxacin prophylaxis ( . % vs . %, p = . ). rate of intensive care admission ( . % vs . %, p = . ) was also reduced by the use of ciprofloxacin. however, there was no significant difference in the length of stay (mean of vs days, p = . ), or in the -day infection-related readmission rate ( . % vs . %, p = . ) between the two groups. in terms of the cause of neutropenic sepsis, escherichia coli, klebsiella pneumoniae and pseudomonas aeruginosa were the most common bacteria isolated from cultures in the no-prophylaxis group. eighty percent of these organisms showed sensitivity to ciprofloxacin. in the ciprofloxacin group, staphylococcus epidermidis was the most frequently found bacteria. with regards to treatment related adverse effects, none of the patients who received ciprofloxacin prophylaxis developed clostridium difficile diarrhoea. in conclusion, ciprofloxacin is still an effective antibacterial prophylaxis during neutropenia following allogeneic stem cell transplantation. clinicians should have a high suspicion of a gram-positive infection in patients who develop neutropenic sepsis on ciprofloxacin prophylaxis. disclosure of conflict of interest: none. s hematopoietic stem cell transplantation (haplohsct) to cure leukemia, malignancy and some inherited diseases, different additional reasons interfere microbiota metabolism and integrity. among them are radiation and chemotherapy, mucositis, infection and graft versus host disease (gvhd). the curative mechanism of fmt is based on the ability of donor intestinal microbiota to substitute and to provide all necessary functions of altered patient's microbiota. three patients ( , and years old) after haplohsct, who observed pseudomembranous colitis (toxin b-positive) as gvhd of intestine outcome, were enrolled to the study and performed fmt. relatives (mother, father and brother) were used as microbiota donors. donor and patient examination have included routine clinical and biochemistry laboratory data, microbiota cultural methods, pcr of most common intestinal microorganisms. additional for patient-level of fecal calprotectin by elisa was tested, identification of drug resistant bacteria and histology of intestine were made. patient's preparation for fmt included-probiotic (inulin) administration h prior procedure, discontinuation of all antibiotics h prior procedure and antiemetics ( ht agonist), prokinetics and proton pump inhibitor. delivery of donor's microbiota was performed in two consecutive steps under total intravenous anesthesia: with esophagogastroduodenoscopy-to the duodenum; with colonoscopy-to the caecum. all patients observed complete clinical response in - days after fmt (table ). in days we have revealed significant quantitative and qualitative changes in microbiota composition, which was matched to donor's microbiota. in days after fmt we identify microbiota changes in oropharynx and urogenital tract similar to donor microbiota. this leads to substitution of multidrug resistant klebsiella pneumoniae strains by drug sensitive microorganisms and helps to treat severe infection complications after haplohsct. platelet aphereses were carried out in donors ( males and females with median age . years) using haemonetics instrument with simultaneous leucoreduction. quantitative detection of cmv, ebv and hhv- dna was performed by multiplex real-time quantitative pcr kit (interlabservice, russia) in donors' whole pb, plasma and platelet aphereses at the time of platelet collections. viral load in hsct recipients was monitored weekly after hsct and days before hsct by the same pcr kit. lower limit of detection (llod) of the applied kit for all viruses was copies/ml. in specimens of platelet donors we additionally performed ultra-sensitive pcr with llod copies/ml. only one patient ( . %) was cmv-positive by pcr prior to hsct. cmv reactivation after hsct ⩾ copies/ml was noted in whole pb of patients ( . %) with median time of days (range: - ). donor source in cmv-reactivated patients was as follows ( mud, msd, haplo). cmv viremia ⩾ copies per ml was detected in seven patients ( . %). cmv disease was found in five cases ( . %). none of patients were positive by pcr for ebv or hhv- prior to hsct. ebv reactivation ⩾ copies/ml was found in six cases ( . %), ⩾ copies/ml in ( . %) with median time of days (range: - ). no signs of ptld or other ebv-dependent clinical symptoms were observed. hhv- level after hsct ⩾ copies/ml was detected in patients ( . %), ⩾ copies/ml in ones ( . %) with median time of reactivation days (range: - ). hhv- disease was observed in one patient. none of platelet donors were cmv-positive in plasma, whole blood or platelet aphereses products. ebv ⩾ copies/ml was detected in whole pb specimens of five platelet donors ( . %). application of ultra-sensitive pcr revealed low level of ebv-viremia in additional pb cases with median ebv level copies/ml (range: - ). none of platelet donors have any clinical signs of ebv disease. there is no any ebv-positive case among platelet concentrate specimens. in two cases low levels of hhv- was found in a whole pb ( and copies/ ml). none of hhv- -positive case was observed among plasma and platelet concentrate specimens. despite high incidence of cmv, ebv and hhv- reactivation after hsct in pediatric patients we could not show that source of viral reactivation was contamination of platelet apheresis products by donorderived herpes viruses. disclosure of conflict of interest: none. conventional respiratory virus (crv) infections are known to be major causes of morbi-mortality after stem cell transplantation (sct) due to the increased risk of progression to lower respiratory tract infection (lrti) in this setting. risk of developing severe lrti is mostly related to factors specific to the patient and the underlying disease, although the intrinsic virulence of crvs may also determine their outcomes. we conducted a single-center retrospective study including all adult sct recipients who had crv disease (defined as patients with symptomatic respiratory disease and crv identification) during a -year period ( - ) with the main objective of evaluating epidemiological changes over time and their association with infection outcomes. during the study period episodes of crv disease were diagnosed in patients (median age: years, % male, % aml or mds as baseline disease). patients ( %) received an allogeneic-sct (allo-sct) ( % had a prior sct) and ( %) an autologous sct. crv disease was diagnosed at a median of days after sct (range: - ), with cases ( %) occurring before day + . during the infectious episode of allo-sct recipients ( %) had active gvhd and ( %) were under s prednisone (pdn) mg/kg. most of the patients ( %) had symptoms compatible with an upper respiratory tract infection (urti), with of them ( %) progressing to a lrti, while ( %) had a lrti only. hospital admission was required in episodes ( %) with a median duration of hospitalization of days (range: - ), % required supplemental oxygen, % were transferred to the intensive care unit and % required mechanical ventilation. the most commonly identified pathogens over time are shown in figure . twenty-four cases ( %) had concomitant bacterial or fungal infections. influenza a virus was the most frequent crv detected ( episodes, %) followed by human respiratory syncytial virus ( episodes ( %) and human parainfluenza virus type ( episodes, %). during the flu pandemic, only of the crv infections diagnosed in sct recipients ( %) were associated to influenza a virus h n . antiviral treatment was started in episodes ( %), antibiotics in % and combined therapy in % during a median of days (range: - ). the rv resolved in cases ( %) at a median of days ( - ) from onset, with crv being considered the leading cause of death in only patients ( % of all cases and / ( %) in those with a lrti). predictors of severe crv infection (including icu admission, need for supplemental oxygen, need for mechanical ventilation requirement or death) in multivariate analysis were lymphocyte count o cells/μl (hr: . , % ci: - , p = . ) and co-infection with other pathogens (hr: . , ci %: . - , p = . ). no specific crv nor period post-sct of the infection influenced the risk of severe infection. our results confirm that crv infections are a frequent cause of morbidity after sct with a high need for hospital-based care. temporal changes in the principal circulating crvs has been identified during the -year study period, with influenza a virus being the most common. profound lymphocytopenia and presence of co-pathogens are associated with infection severity. [p ] disclosure of conflict of interest: none. the consecutive hsct performed from to are being analysed retrospectively. out of them ( %) performed in hepa filter room and ( %) in non-hepa filter room, criterion was purely financial to make this decision. / ( %) were allogeneic and / ( %) were autologous hscts. blood cultures both bacterial and fungal were taken at onset of fever and with every change of antibiotics till patient became afebrile. chest x-ray and if required hrct chest was done for all patients who had respiratory complaints. we did not use antibacterial prophylaxis; however, antifungal prophylaxis was administered along with conditioning; and at the onset of fever systemic antibiotics were started. antifungal agents were added if fever persisted for days pre empatively. extremely well trained nurses were looking after both the groups. all treatment protocols, antibiotic/antifungal policies were same in both the groups. median time for neutrophil engraftment was days in hepa filter room and days in non-hepa filter room. total / ( %) patients did not engraft till days. out of them / ( %) were in hepa filter room and / ( . %) in non hepa filter room. blood cultures were positive in total / ( %) patients, were positive for bacterial and for fungal organisms. in hepa filter hsct / ( %) were positive and in non-hepa filter hsct were / ( %) positive. total / ( %) patients developed pneumonia, out of them / ( %) were in hepa filter and / ( %) hsct were in non-hepa filter room. statistically not significant. no central venous access cather issues or infections were documented in any groups gr - agvhd : hepa rooms / ( . %),non hepa rooms / ( . %) :was not statistically significant the -day mortality was / ( %), / ( %) patients were from hepa filter rooms and / ( %) were from non-hepa filter rooms. cost : average cost of allogeneic hsct in hepa room : usd . average cost of allogeneic hsct in non hepa room: usd . average cost of auto hsct in hepa room: usd . average cost of auto hsct in non hepa room : usd . incidence of blood culture positivity & incidence of pneumonia was not different. these are two very important issues in outcome of hsct. agvhd incidence did not depend on the room type. these are significant findings from this study. results were slightly better in hepa filter rooms compare to non-hepa filter rooms, which was statistically insignificant. our study had few confounding factors hence we could not be concluded that hepa-filtered rooms are not necessary. nevertheless, our experience suggests that availability of dedicated hepa units with special air-handling equipment should not be considered a critical and essential precondition for providing allogeneic hsct to patients even in developing world with financial constraints. these would otherwise succumb to potentially curable hematological illnesses with background of financial constraints and wait list of hepa filter rooms. early hsct in a clean patient in non hepa rooms is extremely cost effective with comparable outcomes. nursing care, experience of the team, experience in hsct program & well established protocols are more important in outcome of hscts. disclosure of conflict of interest: none. we present five cases of cytomegalovirus (cmv) pneumonitis occurring in patients after recent allogeneic stem cell transplantation (allohsct). these cases were complicated by an organising pneumonia (during the recovery period) with a predominantly central peribronchial pattern. all patients presented with evidence of active cmv pneumonitis which was treated successfully with anti-viral therapy but was followed by persistent severe dyspnoea, cough and hypoxia. high resolution computed tomography (hrct) imaging showed widespread central peribronchial consolidation with traction bronchiectasis. in most cases there was a marked clinical and physiological improvement after treatment with systemic corticosteroids. however, in all patients the lung function remained abnormal and in some cases imaging revealed a fibrosing lung disease. these cases represent a previously undescribed central peribronchial pattern of organising pneumonia complicating cmv pneumonitis that can result in chronic lung damage. disclosure of conflict of interest: none. cytomegalovirus reactivation in pediatric acute leukemia after stem cell transplantation has an effect on relapse and survival in aml but not in b-precursor all j-s kühl , l sparkuhl and s voigt department of pediatric oncology/hematology/sct, charité universitätsmedizin berlin, berlin, germany several studies have indicated better survival after stem cell transplantation (sct) for acute leukemias, especially acute myeloid leukemia (aml), in case of cytomegalovirus (cmv) reactivation. here, we investigated if cmv reactivation had an impact on survival after sct for aml or acute lymphoid leukemia (all) in children. pediatric allogeneic stem cell transplant recipients from our institution who received myeloablative conditioning were included. transplant indications included aml, t-all and b-precursor all. cmv reactivation was correlated with relapse, mortality as well as acute graft-versus-host disease (gvhd) and was analyzed by fisher's exact test or χ -test (if n ). from the patients included, were transplanted for aml ( %), for t-all ( %), and for b-precursor all ( %). mortality and relapse rates ( - % and - %, respectively), cmv reactivation rates ( - %) as well as numbers of negative cmv serology status ( - %) of donor and recipient were comparable between different acute leukemias. when patients were analyzed altogether, cmv reactivation had no effect on relapse rates or mortality. however, a tendency towards fewer relapses after cmv reactivation was observed in aml patients (no relapse ( %) with cmv reactivation vs relapse cases ( %) without cmv reactivation; p = . ). in those leukemia patients capable of reactivating cmv (that is, donor or recipient cmv seropositive prior to sct), cmv reactivation had a protective effect on relapse rates in aml (no relapse ( %) with cmv reactivation vs relapse cases ( %) without cmv reactivation; p = . ). a similar tendency could be seen in t-all whereas no effect in patients with b-precursor all was documented. numbers of acute gvhd cases grade i between aml and t-all with or without cmv reactivation were similar. different effects of cmv on relapse rates and mortality in aml vs b-precursor all were noticed in patients who were either not capable of cmv reactivation or who did reactivate cmv post sct. in aml patients, there were no relapses ( %) and deaths ( %) in contrast to relapse cases ( %) and deaths ( %) in children with b-precursor all (p = . and p = . , resp.). latently cmv infected aml patients without documented cmv reactivation after sct have a significant worse prognosis compared with all other aml patients. this is also likely to be the case in patients with t-all, however, patient numbers in our cohort were too few. the protective effect of cmv reactivation in aml and possibly t-all does not appear to be gvh-related since the rate of relevant acute gvhd cases was comparable. cmv reactivation after sct for b-precursor all lacks significance. disclosure of conflict of interest: none. infections are among the most frequent and relevant complications of hematopoietic stem cell transplantation (hsct). little is known about the role of dental foci for the prevalence of infections in hsct. dental status was prospectively evaluated in all patients at our center before undergoing hsct. a total of different patients before undergoing hsct ( allogeneic and autologous), with a median age of years (range: - years) were evaluated. for evaluation a panoramic x-ray evaluation was performed. dental findings included the status of third molars and root fillings as well as caries, periodontitis, destructed teeth and apical bone loss. as non-dental parameters we used age, sex, type and status of central venous line, mucositis, and type of transplantation. these were correlated with neutropenic fever, bacteremia and pneumonia in a bivariate manner before a multivariate analysis was performed. no correlation of initial dental status to neutropenic fever, bacteremia or pneumonia was found. however, bacteremia and suspected infection of central venous lines was a significant predictor of neutropenic fever. in conclusion, dental surgery should only be performed prior to hsct if urgently required and limited to those individuals with overt infection. disclosure of conflict of interest: none. [p ] early experience with clinimacs prodigy ccs method in generation of virus-specific t-cells for pediatric patients with severe viral infections after hematopoietic stem cell transplantation k kallay viral reactivation especially in children is a frequent complication of allogeneic hematopoietic stem cell transplantation. most of these episodes can effectively be controlled by an antiviral or antibody therapy; in refractory cases a novel virusspecific t-cell therapy could be a promising management option. in our pediatric cohort of allogeneic transplantation during year patients fulfilled criteria for virus-specific t-cell therapy ( boys, girls, median age of ( . - ) years). six patients were transplanted because of hematological malignancies and for inborn errors. donor distribution was the following: matched unrelated, sibling and haploidentical donor. in cases bone marrow, cases peripheral blood and case cord blood was used as a stem cell source. the underlying viral illness was cmv in , ebv in and adenovirus in case, while more than one virus was detected in cases (cmv+adenovirus cases, cmv+ebv cases). viral diseases necessitating a t-cell therapy were cmv pneumonitis and colitis, adenovirus enteritis and cystitis and ptld. patients initially received cidofovir for adenovirus, rituximab for ebv and a combination of gancyclovir and foscarnet for cmv infections. the indication for t-cell therapy was progressive viral disease in of the cases and uncontrollable viral load in case. the procedure was performed on a median of ( - ) day post transplant. donors were st degree relatives in cases, nd degree relatives in cases and an unrelated person in case, the best hla match was haploidentical. the median age of the donors was ( - ) years. cells were produced by the clinimacs prodigy cytokine capture system (ccs) method after mononuclear leukapheresis. the system produced a median of . ( . - ) times /kg cd + and a median of . ( - . ) times /kg cd + interferon producing cells while the non-interferon producing cells were far below gvhd limit with a median of . ( . - . ) times /kg cd + and a median of . ( . - . ) times /kg cd + cells. the t-cell products were administered uneventfully in all but one case. we observed a manageable cytokine storm in one patient. glucocorticoid treatment was ongoing due to acute gvhd in children; however we could manage to keep the steroid dose below mg/kg in all cases. eight patients became completely asymptomatic, while also cleared the virus. we experienced decreasing viral load in all cases, the first negative viral results were achieved on a median day of ( - ). six patients are alive without viral illness or sequale, and complete viral dna clearance in peripheral blood with a median follow up of ( - ) days. one patient with cmv pneumonitis improved during the first week but deteriorated on the second week and died of respiratory insufficiency despite of mechanical ventilation. in cases the viral illness improved or cleared, but the patients died of invasive aspergillosis. no cases of gvhd, rejection, organ toxicity or recurrent infection were noticed. virus-specific t-cell therapy produced by the clinimacs prodigy ccs is a feasible, fast, safe and effective way to control resistant viral diseases after pediatric hematopoietic stem cell transplantation. this treatment can be implemented within a week in most cases. in order to define the appropriate place of this approach for patients with viral reactivations more data should be collected. disclosure of conflict of interest: none. central venous catheter (cvc) is essential for the treatment of recipients of stem-cell transplant. it is usually placed for the administration of conditioning regimen, stem cell infusion, intravenous antibiotics, immunoglobulins, electrolyte and nutritional support and blood concentrates. this patient group is at high risk for catheter-related bloodstream infections that can result in substantial morbidity and mortality. the neutropenia secondary to the conditioning regimen determines the risk of catheter-related infections, which may serve as an entry into the blood circulation, leading to bacteremia, fungemia, and consequently to septic shock and death. the risks of infection and the spectrum of infectious syndromes differ according to the type of transplant, conditioning regimen, type of implant of stem cells and therapies used after the procedure. gram-positive bacteria, particularly coagulase-negative staphylococcus spp, remain the leading cause of catheter-related bloodstream infection, although an increase in gram-negative bacteria as the causative agent has been noted. aim of the study: to evaluate the impact of the early cvc removal on the frequency of febrile episodes and infections in our group of patients. during a years period we have treated patients with hematologic neoplasm with high-dose chemotherapy and stem cells transplantation. patients were treated in sterile room conditioned with hepa filtration. in every patient was introduced double-lumen cvc ( subclavia, jugular, and femoral). % were febrile ( % fuo), catheter-related infection was present in %, while positive culture from cvc was present in %. the most frequent isolated bacteria from cvc were gram positive-staphylococcus coagulasa negative. the catheter was removed on the day of discharge. trm is . %. from january to november we have transplanted additional patients. to aim to decrease infection related mortality we perform strategy to remove cvc on day + after stem cell transplantation. the febrile episodes decreased on % ( / ), there were no early post-transplant mortality due to infection. early removal of the cvc and adequate handling from the nursing staff is essential for outcome of this patient population in regard of infective complications efficient prevention, early diagnosis, and effective treatment of catheter related infection are essential to providing the best care to these patients and can minimized morbidity and mortality. disclosure of conflict of interest: none. fever in patients with agranulocytosis during autologous hematopoietic stem cell transplantation (autohsct) can be associated with non-infectious causes due to g-csf, vancomycin, engraftment syndrome. in this case biochemical markers, such as presepsin (psp), procalcitonin (pct) and c-reactive protein (c-rp), can help in differential diagnosis of fever of infectious and non-infectious genesis. psp, pct and c-rp were assessed on the day of admission to the hospital (da), on d+ , on d+ , on d+ and on the day of discharge (dd). if patients developed neutropenic fever (nf), the markers were assessed at the beginning of the fever, h after, then on the second, third, fourth days after. if patients developed nf immediate empirical antibiotic therapy (at) was implemented with meropenem. in cases of ineffective st line ab, nd line at was added or totally changed. there were patients included in the study: patients with hodgkin lymphoma, with non hodgkin's lymphoma, with multiple myeloma, out of patients there were women and men. the median age was years ( - years). the conditioning regimens were cbv, beeac or hd melphalan. patients developed infectious complications (ic): of them had sepsis and others-nf. the median of nf development was . days. depending on the efficiency of at therapy patients were divided into two groups: group : patients that have had effective at (they 've had fast clinical response and they haven't needed to change medicine (n = )); group : patients that have had ineffective st line at, they haven't had response to st line at and they've needed to change another at (n = )). there were significant differences in psp levels on the third day after ab had been admitted: . pg/ml in group and . pg/ml in group (p = . ). similar differences between the analyzed groups were observed on the fourth day: . and . pg/ml, respectively (p = . ). pct and c-rp didn't show any significant changes between group and on each day of the study (table ) . disclosure of conflict of interest: none. enterovirus related immune reconstitution inflammatory syndrome (iris) following haploidentical stem cell transplantation in an mhc class ii deficient child r shah , s waugh , k foong ng , z nademi , t flood , m abinun , s hambleton , a gennery , m slatter and a cant paediatric immunology and bmt, great north children's hospital, newcastle upon tyne, uk and department of virology, great north children's hospital, newcastle upon tyne, uk immune reconstitution inflammatory syndrome (iris) has been described after hsct in association with fungal, viral and bcg infections. we describe a case of post-hsct iris associated with enterovirus infection. case: a girl with mhc ii deficiency (rfxp c. mutation) underwent treosulfan/fludarabine/ thiotepa/atg conditioned tcrαβcd + depleted haploidentical hsct at . years of age. pre-transplant work up did not reveal any viral or fungal infections except norovirus in stool. cyclosporine (csa) was given as gvhd prophylaxis. neutrophil and platelet engraftment occurred on d+ and d+ , respectively. on d+ , her stool was tested positive for enterovirus (taqman pcr), however; she was asymptomatic. the child started having fevers and irritability from d+ which persisted despite the use of antimicrobials. no evidence of fungal or bacterial infection was found. enterovirus pcr in blood was found positive on d+ (cycle threshold value, ct . ) and further typing showed it to be echovirus . at this time, symptoms progressed with diarrhoea, developmental regression and signs of radiculopathy. mri (brain and spine) was normal and csf showed pleocytosis ( wbc/mcl- % lymphocytes, protein . g/l) with positive enterovirus pcr (ct ). subsequently, immunoglobulin prophylaxis was increased to . g/kg bi-weekly, and with supportive measures, the patient slowly recovered. blood enterovirus pcr remained positive. with no evidence of gvhd, csa was tapered off by day+ and child was discharged on d+ on a bi-weekly ivig replacement. she presented days later with signs of raised intracranial pressure. mri showed hydrocephalus, and vp shunt was placed and broad spectrum antibiotics administered. csf showed wbc o /mcl, protein . g/l and enterovirus positive. methylprednisolone mg/kg/day was started suspecting iris. in subsequent csf testing days later, enterovirus was negative. enterovirus pcr remained positive in blood during this period. patient's clinical deterioration correlated with a rise in cd /cd counts and c reactive protein with clearance of enterovirus from csf, blood and stool ( figure ). subsequently, the child showed gradual but marked improvement and discharged home. discussion: the clinical features of index case fits into criteria for iris . markedly raised crp suggests high il- levels without any bacterial or fungal pathogens being isolated. in addition, iris occurs at the site of prior active infection (brain in index case) and viral clearance and clinical recovery demonstrated with the continuation of steroids. the incidence of enterovirus infection in hsct recipients is around % . iris, in this case, had a temporal correlation with discontinuation of csa, and it has been shown that discontinuation of immunosuppression is associated with higher risk of iris. a high index of suspicion for iris is necessary during immune recovery post-hsct especially when immunosuppression is being tapered in a patient with pre-existing infection. aggressive antiviral treatment (when available) and judicious immunosuppression are the keys to managing iris complications. posttransplantation lymphoproliferative disease (ptld) is a significant cause of morbidity and mortality in allogeneic stem cell transplant patients. identifying high risk patients, routine pcr screening, early diagnosis and therapy are crucial for successful management. patients and methods primary objectives of this study were to describe epidemiology of ebv associated ptld and to assess risk factors in our paediatric cohort. additionally, role of immunoglobulin (ig) levels as a possible diagnostic/prognostic marker was analyzed. between january and june , allogeneic transplantations were performed in pediatric patients ( boys and girls) at our center. median age was . years ( . - ). underlying diseases were hematological malignancies ( %), nonmalignant hematological conditions ( %), immunodeficiencies ( %) and others ( %). stem cell source was bone marrow ( %), peripheral blood ( %) and cord blood ( %). donors were unrelated ( %), sibling ( %), haploidentical ( %) or other matched family donors ( %). routine ebv pcr screening and ig level detection were performed weekly. rituximab prophylaxis was given only in nine cases. results ebv dnaemia was found in / patients ( . %), while ptld was diagnosed in / patients ( . %). all ptld cases were related to ebv infection, median of highest viral load was copies/ml ( - ). diagnosis was confirmed by biopsy in / cases, further five fulfilled criteria of probable ptld (positive pcr with appropriate clinical symptoms). ptlds occurred at a median of day + ( - ) after transplantation. all patients received rituximab treatment along with a reduction of immunosuppressive therapy. four patients died of ptld (mortality %), all confirmed by autopsy. a higher incidence of male gender ( / ; . % vs . %), bone marrow graft ( / ; . % vs . %), hematological malignancy ( / ; . % vs . %) and second transplantation ( / ; . % vs %) could be detected among ptld patients when compared to the non-ptld group. elevated igg, iga or igm levels were observed in / patients. nine out of had positive ebv pcr testing, eight of them developed ptld. five of the ptld patients had monoclonal or biclonal immunoglobulin elevation, two of them died. in cases, elevated ig level preceded the positive ebv pcr results by at least week. conclusion: at our centre incidence and mortality of ptld was similar to published data. we observed a tendency that a higher representation of male gender, hematological malignancy, bone marrow graft and second transplantation could be confirmed in the ptld group however due to small number of patients, a correlation and statistical significance could not be calculated. elevation of immunoglobulin levels do not seem to be specific for ptld but in selected cases it could predict ebv disease earlier than pcr testing. disclosure of conflict of interest: none. autologous peripheral hematopoietic stem-cell transplantation is a procedure of a stem cell rescue with patients' own previously collected hematopoietic stem cells, after myelotoxic therapy. the purpose of stem cell reinfusion is to ensure adequate recovery of hematopoiesis, shorten the period of profound neutropenia and to reduce the risk of infections. the transplantation itself carries a moderate risk for infection but some patients have higher risk due to the nature of underlying disease, earlier treatment and in case of severe mucositis. for these reasons, all treated patients are in isolated clean rooms and receive ciprofloxacin, fluconazole and acyclovir prophylaxis. in the . -year period, autologous transplantations were performed. the patients were - years old, with median of . years. of all transplanted patients, or . % had multiple myeloma, or . % had lymphoma and or . % had acute myeloid leukemia. all of the patients received pegfilgrastim mg on the first or the second posttransplant day. febrile neutropenia (ne o . × /l) was reported if patient's temperature was above . °c in one measurement or above °c in two consecutive measurements. these patients were treated empirically with piperacillin/tazobactam . g four times a day with the addition of vancomycin in the case of severe mucositis or pulmonary infiltrates. in all cases blood and urine cultures were performed, as well as testing for seasonal flu. time to neutrophil recovery (ne . × /l) was - days, with a median of days, and average of . days. febrile neutropenia was reported in patients ( . %) and in ( . %) patient's samples pathogen was isolated. gramm negative bacteria caused sepsis in . % of patients. we had to change empirical therapy according to antibiogram in . % patients. in month follow-up period, there were two ( . %) infection related deaths. our data on incidence of infections is consistent with literature data but large number of papers show satisfactory results of safety of patients discharged from hospital immediately after the autologous stem cell transplantation and who were treated at home during the phase of profound neutropenia. there is still an ongoing debate whether it is possible to conduct this procedure in such manner in our health system. disclosure of conflict of interest: none. fluconazole was equal to mold-active drugs in preventing early invasive fungal disease after allogeneic stem cell transplantation regardless of transplantation type y sun, j hu, h huang, j chen, j-y li and x-j huang there are still controversies that whether mold-active drugs is better than fluconazole in preventing invasive fungal disease (ifd) after allogeneic stem cell transplantation (hsct). we hypothesis that the optimal prophylaxis might be different in patients with different risk profile, such as in different time period after hsct or received alternative donor transplantation. in the prospective china assessment of antifungal therapy in haematological disease (caesar) study database, out of patients received primary antifungal prophylaxis were analyzed. the ifd incidence of different time period after transplantation (early, late and very late) and survival were compared among different drug groups. in patients with fluconazole, itraconazole, voriconazole or micafungin prophylaxis, the overall incidence of ifd after transplantation were . %, . %, . % and . %, respectively (p = . ). however, there is no difference in early ifd (o days post hsct) among groups of patients. the risk factors associated with occurrence of ifd were neutropenia duration days (po . , or . ( . - . )), adult (p = . , or . ( . - . )) and alternative donor (unrelated donor or haploidentical donor) transplantation (p = . , or . ( . - . )). in the sub-group analysis with only alternative donor (unrelated donor and haploidentical donor), it also demonstrated that fluconazole is equal to other mold-active drugs in preventing early ifd. patients received fluconazole prophylaxis has even better overall survival. the overall survival in patients with fluconazole, itraconazole, voriconazole or micafungin prophylaxis were . %, . %, . % and . %, respectively (p = . ). our current [p ] study suggests that fluconazole is equal to mold-active drugs to prevent early ifd in hsct patients, even in high-risk patients received transplantation from alternative donors. however, further prospective randomized study was warranted to confirm this conclusion. disclosure of conflict of interest: none. ( . %) received autologous hsct and ( . %) allogeneic hsct. sixty-five out of patients ( . %) were affected by different haematological diseases: by lymphoma, by multiple myeloma, by chronic lymphocytic leukaemia and by others diseases including mastocytosis, amyloidosis and essential thrombocythemia. hbv reactivation prophylaxis prescribed was entecavir for hbsag+ inactive carrier patients and prolonged lamivudine (lmv) course for ( %) patients. in patients ( . %) lmv prophylaxis was withdrawn - months after the end of immunosuppressive therapy. eight out of patients ( . %) experienced hbv reactivation: of them during lmv treatment and then they were switched to entecavir or tenofovir therapy, patients reactivate hbv after lmv interruption ( . %). in these patients reactivation was observed after an average time of months (range: - ) after discontinuation of lmv prophylaxis. median duration of prophylaxis was months (range: - ) after the end of immuno-suppression. three out of patients ( %) underwent allogeneic hsct and patients ( %) received rituximab. one out of ( %) seroreverted in hbsag positive and hbsab negative status, with hbv-dna ui/ml (table ) . two patients out of ( %) experienced hbv-dna detection below ui/ml. disclosure of conflict of interest: none. [p ] [p ] the severity is measured on grades (grade : microscopic hematuria to grado : clots cause urinary tract obstruction). the treatment is based on support measures: hyperhydration, continuous bladder irrigation, instillation of topical agents and in severe cases must be performed a cystoscopy for clot evacuation. in the case of the presence of poliomavirus virus (bk virus) the use of cidofovir had been demonstrated in vitro studies to have activity against bk virus. we performed allogenic transplants of which are haploidentical from to october . we realized a retrospective case study to analyses the experienced in the management of hc. results: of a total of allogenic transplants realized, developed a hc: patient received an identical hla transplant and the patients remaining haploidentical allotrasplant. all cases were male, with an age range of - years. the status of the disease was: were in complete remission and had visible disease. of the patients received cyclophosphamide as immunosuppressive therapy and all patients received cyclosporine and mofetil micofenolate also. the onset of the symptomatology was between day and day post transplant and the range of duration was from to days. the four patients precised continuous bladder irrigation but because of the poor response they received instillation of hialuronic acid ( doses). two patients required the use of cidofovir ( doses). one of the four patients required urinary tract catheterization because of hydronephrosis and renal impairment. in our review we confirmed that this entity is more frequent in the haploidentical transplant and bkv is the most prevalent cause in the late hc. -the three patients received doses of cidofovir ( mg/kg) without probenecid and had a good response. -three patients present acute renal failure associated to hc. the four patients needed bladder instillations with saline but they had poor response and received at least doses of hyaluronic acid. disclosure of conflict of interest: none. hsv infection in allo-hsct setting is mostly reactivation of latent virus. hsv disease commonly presents as mucocutaneous lesions of the oral cavity. however some patients develop serious fatal visceral dissemination. prophylactic use of acyclovir has markedly reduced the incidence of hsv disease during the period of neutropenia after allo-hsct. in this study, our aim is to demonstrate the incidence, clinical outcome and risk factors for hsv disease in adult allo-hsct. between and , patients who underwent allo-hsct in our center were included to the study. all hsct candidates and donors were tested for hsv- / immunoglobulin g (igg) antibodies prior to transplantation. all patients received acyclovir prophylaxis (related transplants mg tid, unrelated transplants mg tid) during conditioning and after allo-hsct up to months. chlorhexidine oral solution as well as bioadherent oral protective gels was used for oral hygiene. all patients were followed for symptoms of reactivation. hsv / igg seropositivity was detected in recipients ( %) and donors ( %). the distribution of hsv status was as follows: recipient and donor seropositive in ( %), recipient and donor seronegative in ( %), recipient seropositive and donor seronegative in ( %), recipient seronegative and donor seropositive in ( %) transplants. the median age of the patients was (range: - ), patients were male ( %) and ( %) had malign disease. the stem cell source was peripheral blood in ( %) patients and ( %) received grafts from related donors. sixty four patients ( %) received myeloablative conditioning regimen. the most common graft-vs-host disease (gvhd) prophylaxis administered was cyclosporine (csa) and methotrexate (mtx) in patients ( %). acute graft vs host disease was detected in patients ( %).four patients from seropositive patients ( %) had hsv reactivation, the patient characteristics are given in the table. all patients had hsv reactivation within month of allo-hsct except one patient had symptoms at sixth month posttransplant when he suffered from oral gvhd. all patients s and donors were seropositive prior to allo-hsct and responded well to antiviral treatment. the incidence of hsv reactivation in allo-hsct was detected as % which is lower to previous studies. successful primary prophylaxis and oral hygiene might reduce the incidence. all patients were responded to antiviral treatment and no visceral dissemination was detected. disclosure of conflict of interest: none. patients who have received hematopoietic stem cell transplantation (hsct) may suffer, to some extent, losses in humoral and cell immunity against antigens to which they had been previously exposed naturally (infection caused by wild microorganisms) or artificially (through vaccination). the conditioning regimen for hsct replaces the patient's immune system and involves the loss of previous immunity. this study analyzed patients included in the vaccination program for hsct recipients in the salamanca health care complex during the period - . we assessed the serological status prior to hsct for the following immunopreventable diseases (hepatitis b, hepatitis a, varicella), and the study after hsct also included measles, rubella and parotitis, prior to their inclusion in the hsct vaccination program. the study included patients, . % of which (n = ) were men. . % of the patients (n = ) were allogeneic hsct recipients with an average age of ± years, and . % ( ) were autologous hsct recipients with an average age of ± years. prior to hsct, % of the patients showed immunity against hepatitis b (hbv antibodies ui/l), . % against hepatitis a (positive for hav igg) and % against varicella (positive for varicella igg). no statistically significant differences were observed regarding this variable hepatitis b anti-hbs ui/l, hepatitis a, igg positive, varicella igg positive, measles igg positive, rubella igg positive, parotitis igg positive. table compares the serological status before and after transplantation. in the pre-transplant serological study we observed that less than half of the patients are protected against hepatitis b, while over % of them are protected against hepatitis a and varicella. regarding the diseases in which we know the serological status before and after transplantation (hepatitis a, hepatitis b and varicella), we observed that most patients maintain immunity. in the case of rubella, measles and parotitis we only have access to the serological status after transplantation, and we observed that parotitis is the disease with the lowest seroprotection. therefore, vaccination would be indicated, just as in the case of hepatitis b. the clinical results support the need to adapt the vaccination schedule to the immunological status of the patients after hsct individually. disclosure of conflict of interest: none. impact of cumulative steroid dose on infectious diseases after allogeneic hematopoietic cell transplantation m watanabe , j kanda, t kitano, t kondou, k yamashita and a takaori-kondo after allogenic hematopoietic cell transplantation (hct), highdose steroids are used to treat transplantation-related complications such as graft-versus-host disease (gvhd). however, the use of high-dose steroids is associated with an elevated risk of infectious diseases. information on the association between cumulative steroid dose and infectious diseases after hct is scarce. a total of patients who underwent their first hct in kyoto university hospital from to and survived at least days after transplantation were included in this study. we analyzed the association between cumulative steroid dose used within days after transplantation and the occurrence of infectious diseases, including invasive fungal infection (possible/probable/proven cases), cytomegalovirus (cmv) antigenemia, and bacteremia through days after transplantation. sixty-three patients received transplantation from a related donor, received unrelated bone marrow grafts, and received unrelated cord blood units. their median age was (range: - ) years and median day of neutrophil engraftment after transplantation was . patients were categorized into groups according to their cumulative steroid dose within days: no steroid administration (n = ), low-dose cumulative steroid administration under mg of prednisolone in total (n = ), and high-dose cumulative steroid administration over mg of prednisolone in total (n = ). reasons for steroid administration were treatment for gvhd in patients, engraftment syndrome in , and other reasons including lung complications in . the rate of invasive fungal infection was % ( possible cases with pneumonia and proven case of candida blood stream infection) and we found no apparent association between fungal infection and steroid use regardless of dose. cmv antigenemia was diagnosed in %, % and % of patients in the groups respectively, and both low-dose and high-dose steroid groups were significantly associated with a high risk of cmv antigenemia (low-dose group, adjusted hazard ratio (ahr), . , p = . ; high-dose group, ahr . , p = . ). bacteremia was diagnosed in . %, % and % of patients in the groups, respectively. high-dose steroid use was a risk factor for bacteremia (ahr . , p = . ). seven patients died from infection (fungal, ; viral, ; bacterial, ). two of three bacterial infection-related deaths occurred in the highdose steroid group, although the number of events was too small to analyze. our data confirmed that steroid administration is itself a risk factor for cmv antigenemia and close observation to detect cmv antigenemia is mandatory for patients using steroids regardless of its cumulative dose. high-dose cumulative steroid use is a risk factor for bacteremia. contrary to our expectations, steroid administration showed no apparent association with invasive fungal infection in our study, perhaps because of its generally low incidence in our hospital. disclosure of conflict of interest: none. impact of different t-cell depletion techniques on the incidence of infectious complications after allogenic hematopoietic stem cell transplantation k aikaterini , s federico , d-l vu , e boely , c dantin , a pradier , y tirefort , a-c mamez , o tsopra , c stephan , y beauverd , e roosnek , s masouridi-levrat , c van delden , y chalandon department of oncology, hematology unit, university hospital of geneva and department of medicine specializations, infectious diseases, university hospital of geneva t-cell depletion (tcd), obtained by either in vivo antithymocyte globulin (atg) administration or ex vivo depletion, is a well-established strategy for graft-versus-host-disease (gvhd) prevention after allogeneic hematopoietic stem cell transplantation (hsct) - . however, the prolonged lymphopenia associated with tcd can result in increased incidence of disease relapse and infections. although many studies investigated the impact of tcd on disease relapse - , little is known about the impact of tcd strategies on the incidence of infectious complications after allogeneic hsct. we retrospectively evaluated the incidence of infectious complications in consecutive patients who underwent allogeneic hsct at our center from september to december . patients received tcd grafts obtained by in vivo atg administration as part of the conditioning regimen (atg group). patients received partially tcd grafts obtained through incubation with alemtuzumab in vitro washed before infusion followed on day + by an add-back of donor t cd + cells (ptcd group). patients received grafts tcd by both methods combined. patients did not receive any form of tcd (no-tcd group). cumulative incidence estimates of infectious complications were calculated and compared using the gray test. given the increased risk of infection associated with gvhd and its treatments, gvhd or death from other causes were defined as competitive events in the analysis. we didn't observe any significant difference in the -year cumulative incidence of bacterial infections in patients receiving tcd by atg ( % ( % ci - . %)) ptcd ( . % ( % ci . - . %)) or both ( % ( % ci . - . %)) compared with patients receiving no tcd ( . % ( % ci . - . %)). similarly, the -year cumulative incidence of viral infections or reactivations was comparable in patients receiving no-tcd grafts ( . % ( % ci . - . %)) compared with patients receiving tcd grafts (atg: . % ( % ci . - . %); ptcd: . % ( % ci . - . %); atg+ptcd: . % ( % ci . - . %)). finally, no significant impact of tcd was observed on -year cumulative incidence of fungal (no-tcd: . % ( % ci . - . %); atg: . % ( % ci . - . %); ptcd: . % ( % ci . - . %); atg+ptcd: . % ( % ci . - . %)) and parasitic (no-tcd: . % ( % ci . - %); atg: % ( % ci . - . %); ptcd: . % ( % ci . - . %); atg +ptcd: . % ( . - . %)) infections. image/graph: -year cumulative incidence estimates of infectious complications depending on the tcd strategy employed. the results of our retrospective analysis indicate that the cumulative incidence of bacterial, viral, fungal and parasitic infectious diseases are similar in patients receiving tcd grafts compared to those receiving no-tcd graft, suggesting a favorable toxicity profile of different tcd strategy in respect of infections. these results should be confirmed by similar analysis in large scale, prospective clinical trials assessing the potential benefits of tcd on transplantation outcomes. patients with aml were considered eligible for hsct, died before transplantation. patients ( %) underwent transplantation from hla-identical sibling, ( %) from haploidentical family donor and ( %) from matched unrelated donor, while patients ( %) received unrelated cord blood cells. twenty ( %) out of eligible patients have had an ifi episode before transplant: were proven, probable and possible; ( ( %) pneumonia, ( %) gastroenteritis, ( %) sinusitis, ( %) candida sepsis, ( %) meningitis and ( %) cutaneous abscess were registered). five ( %) out of patients with a previous ifi and ( %) out of without previous ifi did not receive hsct (or . % ci . - . , fisher test p: . ). the majority ( %) of patients with a previous ifi waited hsct more than months from the date of eligibility in comparison with those without a previous ifi ( % vs %; or . , % ci . - . , p-value . fisher test) overall a post transplant ifi episode was diagnosed in ( %) of transplanted patient; ( %) had a relapse of a past ifi vs ( %) of the patients without a previous ifi who had a new episode. (or . , % ci . - . , p-value . yates test).a higher number of patients with ifi ( out of , %) respect to those without a previous ifi ( out of , %) died in a median time of days(range: - ) after hsct. furthermore, those who had a previous ifi had a lower median survival ( days (range: - )) compared to patients without a previous ifi ( days period (range: - )) (student's t-test p: . )). a previous ifi episode in the pre transplant period slows and limits the accessibility to hsct, and is significantly associated with an increased mortality. disclosure of conflict of interest: none. s delayed immune reconstitution has been described for haploidentical hematopoietic stem cell transplantation (hsct) compared to conventional hsct, nevertheless the incidence of invasive aspergillosis infections (iai) in haploidentical sct and the efficacy of primary prophylaxis are not well defined. our objective is to describe the incidence, risk factors and mortality of iai in our patients, using as prophylaxis micafungin during the conditioning and neutropenia period, switched to posaconazole or voriconazole when oral intake is feasible. we retrospectively analyzed consecutive patients from to who received haploidentical grafts: unmanipulated for adults, tcrab depleted in children and cd ra depleted in children. the stem cell source was peripheral blood in all cases. adults ( - yo) were treated for aml/mds (n = ), all (n = ) and lymphoma (n = ). children ( mo- yo) were treated for aml (n = ), all (n = ), aplastic anemia (n = ) and immunodeficiencies (n = ). conditioning regimen was bu-flu-cy (n = , adults), thio-bu-flu (n = , adults), flu-mel-thio for all pediatric patients; atg was used in children and tli in children. median follow up was months ( - ) for adults and months ( - ) for children. we used eortc criteria for iai and analyzed probable or definite as cases. there were events of iai, with a bimodal presentation: events ( . %) during neutropenia period and ( . %) after months of hsct ( figure ). five of them were probable and one definite (aspergillus niger). site of infection was mainly pulmonar; cns was suspected in two adult patients and skin was proven in one adult patient. all patients at the late period had chronic gvhd at diagnosis. one patient had primary graft failure. severe cmv disease (hepatitis and colitis) was present in one adult. mortality related to iai was high ( / ), patients died at a median of days. figure . iai patients characteristics the global incidence of iai in haploidentical hsct is similar to conventional hcst. primary prophylaxis with micafungin switching to oral triazole is successful ( . %) during the early period. late cases ( . %) had clearly known risk factors (chronic gvhd, steroids and cmv), and primary prophylaxis had been modified due to toxicity or interactions. iai mortality in our patients is very high ( %) despite effort in prophylaxis, diagnosis and treatment. visceral intractable abdominal pain prior to skin lesions from herpes zoster can be misdiagnosed as gvhd post stem cell transplantation which may lead to initial increase in immunosuppression and hence high mortality if we don't suspect. case report and literature review through pubmed results: year-old male with relapsed all post mud pbsct ( / ) transplant in following cy tbi atg conditioning presented at day + with intractable diffuse abdominal pain with constipation. no history of nausea, vomiting or skin rash. on physical examination his abdomen was soft, diffuse tenderness but no rigidity, muscle guarding and rebound tenderness. laboratory tests including liver function test, amylase, lipase were normal. usg abdomen and mri abdomen showed no abnormalities, except for presence of fecolith. during the stay his pain worsened needing morphine infusion, pca and later ketamine. he had previous history of acute gut gvhd controlled on budesonide and cyclosporine which was later being weaned once his symptoms were controlled. in view of previous history of gvhd, gi consultation was sought and he underwent ugi endoscopy and biopsy which was non-significant. on day of his admission he developed a pustular skin lesion on thigh and scrapping from that showed vzv and his blood pcr was also positive, he was started on intravenous acyclovir. his lesions improved and crusted and his abdominal pain subsided after h of acyclovir and was discharged on oral acyclovir after days of intravenous therapy. review of literature illustrated in table . severe abdominal pain in patients who received an allogeneic stem cell transplant has a broad differential. here we describe a case of vzv presenting with intractable abdominal pain needing opioids. because of the poor prognosis and life-threatening nature of disseminated vzv disease, it should be considered and included in the patient's workup. intravesical cidofovir ( mg/kg, diluted in ml sterile water) was once weekly applied until symptom control for min. via a transurethral catheter, i.v. cidofovir was initiated if no symptom control was achieved after local applications. in patients with hc or a lavage catheter was added. bkv cystitis (dysuria (n = ) or dysuria combined with hematuria (n = )) developed in out of transplants ( %). median age was years, % were female and % received a mismatch transplantation after mac or ric conditioning regimens. in % of bkv cystitis cases also cmv reactivation within the first days could be detected. % had acute gvhd ii°-iv°at the onset of bkv cystitis and % received steroid medication. the median time to symptom occurrence was day + after hsct (iqr - : - ). patients ( with dysuria and one either hc °and °) didn´t require therapy due to self limiting symptoms. ( %) of treated patients showed only dysuria, ( %) hc °, ( %) hc °, ( %) hc °and ( %) hc °. the first patient was treated with i.v. cidofovir twice and symptoms relieved. all the following patients were exposed to intravesical cidofovir as st line therapy. patients ( %) achieved a complete remission with a median of intravesical procedures (range: - ). patient showed symptom improvement and all patients didn´t require further therapy. patients had to be switched to i.v. application due to bladder spasms during intravesical application (n = ) or to insufficient symptom control (n = ). out of these responded to i.v. treatment, whereas patient receiving nd transplant didn´t respond at all. in patients with spontaneous symptom relieve the median bkv concentration at the time of symptom onset was log lower compared to those requiring antiviral therapy. local therapy reduced bkv viruria by log. pain during cidofovir instillation in % of patients was the only significant side effect of local therapy compared to creatinine increases by % in . % of i.v. treated patients. intravesical treatment of symptomatic bkv cystitis with cidofovir ( mg/kg) is safe and effective with an % symptom improvement rate and no systemic side effects. in patients without sufficient symptom or bleeding control i.v. cidofovir is still an option, which however induces significant renal toxicity. we therefore recommend intravesical cidofovir as st line therapy in case of dysuria or hematuria induced by bkv after hsct. disclosure of conflict of interest: none. haemorrhagic cystitis is a recognised complication of stem cell transplant (sct), with a reported incidence of - % of cases ( ) . the majority of cases are associated with bk polyomavirus (bkv), and less often adenovirus and cytomegalovirus. there are a lack of high quality studies on the optimal prevention and management of haemorrhagic cystitis. treatment options are restricted by conditioning toxicity, immunosuppression and other co-morbidities such as renal impairment. cidofovir has an inhibitory effect on bkv replication and has been used extensively in the treatment of haemorrhagic cystitis. however, severe nephrotoxicity limits routine intravenous use in sct patients. alternative options include using low dose intravenous cidofovir or intravesical administration. we conducted a retrospective case review of post sct patients presenting with bk virus associated haemorrhagic cystitis in our institution between january and november . we identified patients in total ( male, female). the indications for stem cell transplant were as follows: severe aplastic anaemia high risk aml relapsed aml relapsed all onset of symptoms (haematuria and painful micturition) ranged from day − to day + , and the time to resolution of symptoms varied from days to days. four of the patients were treated with intravesical cidofovir only, with the number of doses required varying from to . one patient received combination treatment with both intravenous ( doses), and intravesical cidofovir ( doses). all patients had a good clinical response with complete resolution of symptoms and no major complications. however, the level of bk virus in the urine did not always correlate with clinical response. some of the patients did not tolerate urethral catheterisation and required a general anaesthetic for the placement of the urethral catheter; patient required a supra-pubic catheter. currently out of patients are alive and well; patients died from causes not related to bk virus associated haemorrhagic cystitis. our experience shows that intravesical administration of cidofovir is a safe and effective option for the treatment of bk virus associated haemorrhagic cystitis. an allogeneic stem cell graft from a cytomegalovirus (cmv) seronegative donor puts recipients at high risk of cmv reactivation which can lead to cmv disease and mortality. based on the immunogenicity of cmv phosphoprotein (cmvpp ) we initiated a clinical phase i trial with a novel vaccine designed by our group: a cmvpp -derived peptide in water-in-oil emulsion (montanide) plus administration of granulocyte-macrophage colony stimulating factor. ten patients received four vaccines s.c. at a biweekly interval after allogeneic stem cell transplantation. we monitored the patients for their clinical outcome and cmvpp antigenemia. multi-color flow cytometry test were performed to assess cmvspecific cd + and gamma-delta t cells. novel neutralizing anti-cmv antibody assays were established and correlated to clinical parameters. findings: in general, patients tolerated the peptide vaccination well, no drug-related adverse events others than rash or induration at the site of injection were detected. seven of nine patients with cmvpp antigenemia cleared the cmv after four vaccinations and were hitherto free from antigenemia. two patients with cmv reactivation showed persisting cmv antigenemia. one of these two refractory patients received additional four injections and remained hitherto free from cmv antigen. another patient obtained a prophylactic vaccination and did not develop antigenemia. an up to six-fold increase in frequency of both cmv-specific cd + t cells or vdelta -gamma-delta t cells was detected in five patients. moreover, titers of neutralizing antibodies increased in four patients up to -fold over the time of vaccination. humoral and cellular immune responses correlated with clearance of the cmv load. cmvpp peptide vaccination was safe and well tolerated in patients after allogeneic stem cell transplantation at high risk for cmv reactivation. the vaccine showed encouraging immunological and clinical results. a prophylaxis study using the vaccine in solid-organ transplant patients is ongoing. disclosure of conflict of interest: none. sporopachydermia cereana is a rare yeast found in necrotic cactus tissue, predominantly in the americas. infection in humans has only been reported in neutropenic patients with fatal course, either directly from the pathogen or other complications of immunosuppression. treatment is complicated by difficulties in pathogen-identification with conventional diagnostic techniques and by resistance to echinocandins. here we present a patient with acute myeloid leukemia (aml) and s. cereana infection. this is the first patient who was successfully treated with antifungal therapy and who survived s. cereana infection. case presentation we present the case of a -year-old female patient who was diagnosed with normal karyotype aml with dnmt a and idh mutations in december . she achieved complete remission after two cycles induction chemotherapy. during the nd induction cycle the patient developed persistent fever in neutropenia despite broad-spectrum antibiotics and the replacement of prophylactic fluconazole to caspofungin. blood cultures showed growth of s. cereana, shown to be sensitive to azoles (mic fluconazole o mg/l, mic voriconazole o . mg/l) as well as amphotericin b (mic o . mg/l), but resistant to caspofungin (mic mg/l). following the susceptibility profile the treatment was changed first to liposomal amphotericin b, and with the availability of mic results to voriconazole. metastatic fungal infection (that is, endocarditis, endophthalmitis, hepatosplenic candidiasis) was excluded. after regeneration of peripheral blood values the treatment was switched to oral voriconazole. a ct scan of the chest and abdomen prior to allo-hsct after weeks of treatment with voriconazole revealed new multiple necrotic mesenteric lymph nodes. an ultrasound-guided biopsy of a node revealed no growth on fungal cultures, a grocott stain revealed no hyphae or spores. a panfungal pcr of an its (internal transcribed spacer) fragment revealed fungal dna, which could be confirmed as s. cereana. at this time the level of voriconazole in serum was found to be sub-therapeutic ( . mg/l), and the dosage was increased accordingly. subsequent ct scans and weeks later revealed a regression of the affected abdominal lymph nodes. in the further course non-myeloablative conditioning with fludarabine and busulfan prior to allo-hsct using pbsc from her hla-matched brother was performed. under prophylaxis with cyclosporine, methotrexate and antithymocyte globulins (atg) graft-versus-host disease (gvhd) remained absent. the allo-hsct was performed under voriconazole treatment with no further complications and the patient engrafted at day . the treatment was changed to fluconazole mg daily before discharge. due to the complete radiological regression of the infection in follow-up scans and excellent general condition of the patient months after hsct, fluconazole was discontinued. the patient remains in morphological complete remission months after hsct and has a % donor chimerism. the first published case of survival of infection with s. cereana exemplifies the continual progress made in treating infections in the severely immunocompromised patient. diagnosis via its sequence-analysis seems reliable but a high index of suspicion is required for neutropenic patients who do not respond well to standard antimycotic therapy. the increased availability of the technology may lead to more frequent diagnoses in the future. disclosure of conflict of interest: none. neutropenic enterocolitis (ne) is a clinical syndrome characterized by fever and abdominal pain in patients who received chemotherapy for hematological malignancies and who treated with stem cell transplantation (sct). the aim of this study was to determine the incidence, risk factors and outcome of ne after autologous sct (auto-sct). we retrospectively evaluated patients with non-hodgkin lymphoma (nhl), hodgkin lymphoma (hl) and multiple myeloma (mm) who underwent auto-sct between january and december in our center. patients with lymphoma were conditioned with carmustine, etoposide, cytarabine, melphalan (beam) or thiotepa, etoposide, cytarabine, cyclophosphamide, melphalan (tecam). patients with multiple myeloma were treated with melphalan as conditioning. diagnosis of ne was established in case of neutropenic fever, abdominal pain or diarrhea, and bowel wall thickening mm on abdominal ultrasonography. febrile neutropenia was seen in ( %) patients of all. the median time from transplantation to neutropenia was . days (range: - days). ne occurred in ( . %) in all neutropenic patients. the median time to ne after auto-sct was days (range: - days). the median neutrophil engraftment time was . days (range: - days). abdominal pain was seen in all patients with ne. twenty one patients ( %) had diarrhea. ileus was seen in ( . %) patient and septic shock was developed in ( . %) patients. five ( . %) of patients had bloodstream infection. klebsiella pneumoniae in , pseudomonas aeruginosa in , escherichia coli in , staphylococcus aureus in and coagulasenegative staphylococcus in patient were documented in patient's blood stream. early diagnosis was made by abdominal ultrasonography in all patients at a day of median days (range: - ). twenty ( %) patients were resolved completely with good supportive care and proper antibiotherapy. two ( %) patients died of septic shock and ileus. ne is a rare but serious complication in patients underwent high dose chemotherapy followed by auto-sct. gramnegative bacteria are the main causative pathogens. abdominal ultrasonography is the simple, cheap, fast diagnostic and noninvasive procedure that allows the early diagnosis and effective treatment. disclosure of conflict of interest: none. [p ] neutrophil transfusions in the treatment of neutropenic patients submitted to allogeneic hsct: possible role on graft failure s giammarco, p chiusolo , l laurenti , f sorà , n piccirillo , l teofili and s sica hematology department, università cattolica del sacro cuore and hematology departement, università cattolica del sacro cuore granulocyte transfusions (gtx) from g-csf-stimulated donors have been shown to increase the absolute neutrophil count (anc) before expected haematopoietic recovery in neutropenic patients after chemotherapy or haemopoietic sct. thus gt offers a therapeutic option along with antimicrobial agents and growth factors to improve clinical outcome of neutropenic patients with severe infections. the primary limitations of gt include low component cell dose and leukocyte incompatibility. the transfusion of g-csf-mobilized, hla-matched granulocyte components resulted in sustained anc increments, but the efficacy of this procedure has not been established by convincing randomized control trials. aim: we focused our attention on gt in the setting of allogeneic hsct, in particular on the feasibility and safety of this procedure on the rate of engraftment. between and our centre performed allogeneic hsct. we analyze data from transplanted patients receiving gt at some point during their disease. indication for gt was severe sepsis mainly due to mdr gram-bacteria. patients received a median of gt ( - ), in different phase: patients during induction therapy, during hsct, at diagnosis and during hsct and after hsct. patients' characteristics are summarized in table . median cd + cells dose was . × /kg (range: . - ). donor source was in patients g-csf mobilized peripheral blood, bone marrow and cord blood. median neutrophil recovery ( /mmc) was days and platelet recovery ( / mmc) was days. sepsis were documented in pts and pts developed fuo. relapse was documented in pts ( %). twenty-two pts are still alive and in complete remission ( %), death occurred in pts: due to trm and the remaining for disease relapse. graft failure occurred in of the pts submitted to hsct. among the patients ( %) who experienced graft failure, six ( %) received gt before hsct, because of sepsis during the induction therapy, and the remaining after hsct, during aplasia period. in the remaining group ( pts) not receiving gt, only ( %) graft failure were observed. thus a statistically difference (p = . fisher's exact test) increase in the rate of graft failure was detected in patients receiving gt. the role of gt in the treatment of infections in neutropenic patients remain still unclear for several reasons including the lack of clinical trials convincingly and consistently demonstrating efficacy, by availability of gt donors and by center's experience. gt has been successfully used in our center in patients with severe sepsis from mdr gram-bacteria during severe neutropenia but an increase number of graft failure has been registered in patients subsequently receiving hsct. alloimmunization to hla antigens in patients receiving gt might lead to an excess of graft failure requiring hla antibodies detection and attempt to reduce titer prior to hcst and maximizing stem cell dose. disclosure of conflict of interest: none. viridans streptococci are microorganisms frequently isolated from blood cultures of patients undergoing myeloablative allogeneic hematopoietic cell transplantation (allohct). poor dentition status has been associated with an increased risk of streptococcal bacteremia in the immediate post-allohct neutropenic period. the objective of this study was to evaluate the impact of oral health status on bacteremia risk in a cohort of patients undergoing therapy for acute myeloid leukemia (aml). a retrospective study was conducted in patients with aml treated at dana-farber/brigham and women's cancer center (df/bwcc) from to . there was no formal dental assessment prior to aml induction therapy. all patients underwent protocol directed pre-allohct dental evaluation that included a standardized examination, comprehensive dental radiographs, and detailed treatment planning guidelines. poor oral health status was defined as presence of acute or chronic odontogenic infection, and it was assumed that oral health status at the time of induction therapy was the same as the pre-allohct evaluation findings. oral health status at the time of allohct was determined by the completion of required dental treatment. positive blood cultures were recorded from aml induction to day + post allohct. organisms that caused bacteremia were classified as 'of possible oral source' by a blinded microbiologist. two-sided fisher's exact test was used to compare the oral health status of the entire cohort to patients with blood cultures of potential oral source. from january to january , patients with aml underwent myeloablative allohct at df/bwcc and were s followed through today + , and of these, patients met the inclusion criteria and were included in the cohort. the median age was years (range: - ) and there was similar distribution of genders. the most common aml induction regimen was daunorubicin and cytarabine ( / ; %) and of those that received consolidation therapy ( / ; %), almost all patients were treated with cytarabine. nearly all patients ( / ; %) received cyclophosphamide and total body irradiation for allohct conditioning and the majority of patients ( / , %) received tacrolimus/methotrexate (n = ) or tacrolimus/sirolimus (n = ) for gvhd prophylaxis. over half of patients ( / , %) experienced mucositis during their course of therapy for aml. pre-allohct dental evaluations were completed in / ( %) of patients. of the / ( %) patients identified as having poor oral health status, / ( %) completed all required dental treatment prior to allohct. bacteremias occurred in / ( %) patients, and / ( %) had positive blood cultures of potential oral source. of the patients with positive blood cultures of potential oral source, / ( %) patient developed bacteremia during induction and / ( %) patients developed bacteremia during allohct. of the / ( %) patients identified as having poor oral health status, one patient ( / ; %) had a positive blood culture with a bacteria of potential oral source during induction/consolidation (p = . ). oral health status was not associated with risk of bacteremia of potential oral source at either aml induction/consolidation or allohct. risk of such bacteremia in the setting of myeloablative allohct may be related more to overall gastrointestinal translocation. disclosure of conflict of interest: none. is one of the main alternatives to trimethoprimsulfamethoxazole (tmp-smx) for prophylaxis of pneumocystis pneumonia (pcp)(maertens et al. jac ). ato is less effective than tmp-smx to prevent pcp but the reasons of this lower efficacy are not well understood. ato acts on pneumocystis, plasmodia and toxoplasma species by inhibiting mitochondrial pyrimidine biosynthesis. ato is highly lipophilic and its absorption in volunteers is improved by a fatty meal. there is a wide inter-individual variability in bioavailability and many drug interferences. the aim of this study was to assess the plasma concentrations of ato in patients under pcp prophylaxis with ato oral suspension and explore the factors which might impact its bioavailability. all adult patients receiving ato for pcp prophylaxis in the hematology and clinical immunology wards between may and september were included in the study. the prescribed dose was mg of oral suspension twice a day. blood samples were collected around h after the evening dose (cmin) and - h after the morning dose (cmax). plasma was immediately separated after each sample and frozen at − °c until proceeding to the assay. ato plasma levels were measured by uv-high-performance liquid chromatography. clinical and biological data, exact timing and modalities of intake (during a meal or not), and concomitant medications were collected. cmin and cmax results are presented as median (iqr - %) and compared by mann-whitney u-test or signed rank test when appropriate. patients: a total of measurements were performed in patients (allogeneic hsct patients: ; hematology non-transplanted patients: ; hiv-infected patients: ). the mean age (range) was years ( - ), the m/f ratio was / . only two patients were neutropenic. the median cmin was . μg/ml ( . - . ) and the median cmax was . μg/ml ( . - . ). thirteen of the ( %) patients had a cmin. disclosure of conflict of interest: none. presepsin as a marker of infectious complications during high-dose chemotherapy following autologous hematopoietic stem cell transplantation in lymphoma patients y dubinina, v sarzhevskiy and v melnichenko national pirogov medical surgical center lymphoma patients, who undergo high-dose chemotherapy following autologous hematopoietic stem cell transplantation (autohsct), are at high risk of developing infectious complica- tions (ic). mortality from ic during the transplantation, according to various data ranges from to %. thus the development of models of early prognosis of ic during autohsct has become more urgent. it's reasonable to include the dynamics of biochemical markers of inflammation in these models. presepsin (psp), procalcitonin (pct) and c-reactive protein (c-rp) were assessed on the day of admission to the hospital (da), on d+ , d+ , d+ and on the day of discharge (dd). if patients developed neutropenic fever (nf), the markers were assessed at the beginning of the fever, h after, then on the second, third, fourth days after. there were patients included in the study: patients with hodgkin lymphoma, with non-hodgkin's lymphoma, with multiple myeloma, out of patients there were women and . the median age was years ( - ). the conditioning regimens were cbv, beeac or hd melphalan. depending on the presence of ic, the patients were divided into groups: group patients without infectious complications (n = ), group patients with the development of infectious complications (n = ). the median of the nf development was . days. patients from group had no microorganism growth in blood stream, either in repeated studies. gram+ flora was detected in patients, patient had gram-, patients had mixed flora and patient had pneumocystis jirovecii infection with respiratory insufficiency grade . significant differences in psp level between groups and were determined on d+ , on d+ and the dd after autohsct. considering the median day of the nf appearance ( . days), it's supposed both the prognostic value (differences on d+ , that is, days before the clinical manifestation of infection) and the diagnostic value of psp (differences on d+ and on the dd) ( table , graph ). [p ] disclosure of conflict of interest: none. hc is often a serious complication and occurs in % of allo-hsct recipients. early bleeding is usually the result of chemotherapy toxicity however late occurring hc is multifactorial. bk virus infection has been shown to be related with hc. most studies demonstrate bk virus at the time of bleeding therefore not allowing the risk imposed by asymptomatic infection to be estimated. in this study, our aim is to show the effect of risk factors as well as pre-transplant bk viral load in asymptomatic recipients on development of hc in allo-hsct. between and , we prospectively evaluated allo-hsct. in order to detect the bk viral load, we performed quantitative bk virus pcr (altona diagnostics, germany) from blood samples at days , , and after allo-hsct. informed consents were obtained from all participants. bk virus pcr was considered positive if any number of copies were detected above the analytical sensitivity of the tests. the patients were monitored for signs and symptoms of hs. the risk factors for the development of hs were evaluated by univariate and multivariate analysis. p o . was considered statistically significant. the median age of the group was (range: - ), of the patients ( %) were aged . male to female ratio was . ( / ). fifty two patients ( %) had diagnosis of malign hematological disease. stem cell source was peripheral blood in ( %), bone marrow in ( %) allo-hsct. patients received stem cells from related donors ( %) vs ( %) unrelated or haplo donors. myeloablative conditioning was administered in patients ( %). forty-four of the conditioning regimens ( %) included cyclophosphamide. hc was diagnosed in patients ( %) at a mean of days (range: - ), early hc was detected in of patients ( %). the frequency of bk viremia and number of viral copies are given in detail in table. the frequency of bk viremia increases during transplantation in relation to clinical hc ( %, %, %, %; p = . ). acute graft vs host disease (agvhd) was diagnosed in patients ( %) at a median time of posttransplant day : grade i-ii gastrointestinal/skin/liver in ( %), grade iii-iv gastrointestinal/ skin/liver in patients ( %). the most common gvhd prophylaxis preferred was cyclosporine and methotrexate in patients ( %). in univariate and multivariate analysis (age , sex, diagnosis, stem cell source, donor type, conditioning regimen, agvhd, cy administration, bk virus pcr at days , , ) bk virus titer positivity at day , , (p = . , p o . , p o . ), myeloablative conditioning (p = . ), the presence of agvhd after day (p = . ) and conditioning regimen that includes cyclophosphamide (p = . ) are found to be related with increased risk of hs. patients with hc and clots were treated with continuous bladder irrigation as well as of patients with bk viremia received cidofovir and six of them responded to treatment ( %). our study showed that, bk titer positivity, myeloablative conditioning, presence of agvhd, cyclophosphamide containing conditioning are associated with hc. detection of bk viremia in later transplant period is more sensitive for clinically proven hc. prophylactic treatment might be considered in patients with asymptomatic bk viremia in pretransplant period. [p ] disclosure of conflict of interest: none. this project has been granted by ankara university scientific research committee numbered as b . high-dose chemotherapy with peripheral blood progenitor cell (pbpc) collection followed by a myeloablative conditioning and autologous stem cell transplantation (asct) is considered the standard of care of relapsed/refractory non hodgkin/hodgkin lymphoma (nhl/hl). a widely adopted conditioning regimen is the combination of carmustine etoposide cytarabine and melphalan (beam), whose feasibility and efficacy has been largely demonstrated. high dose fotemustine plus etoposide, cytarabine and melphalan (feam) has in some cases replaced beam conditioning. neutropenic enterocolitis (nec) is a life threatening complication of patients (pts) treated with chemotherapy (cht) with mortality rate up to %. it's a clinical syndrome in neutropenic patients (pts) characterized by abdominal pain (ap), fever (f) and diarrhoea (d). ultrasound (us) was used to evaluate bowel-wall thickening (bwt), and mm is considered diagnostic of nec. early diagnosis is crucial to start conservative medical management (cmm), which appears the optimal strategy for most cases. objective: . to evaluate if nec incidence and outcome differs in beam vs feam and . to evaluate prospectively if bed-side-us (bus) can detect early signs of nec and guide a prompt treatment (cmm or surgical) in order to reduce mortality. in the last years all pts with nhl/hl admitted in our bmt unit wards at university of pisa (italy), undergoing asct were prospectively enrolled. abdominal us was performed, baseline before treatment, and as only one symptom (or a combination) appeared within h from onset: f and/or d and/or ap in cht-related neutropenic pts. pts were conditioned with beam and pts with feam. nec was diagnosed in n = / feam and in n = / beam patients. incidence was % and % respectively, without a statistically significant difference (p = . ). two pts died/ in feam arm ( . %) and pts/ in beam arm ( . %), without a statistically significant difference (p = . ). at time of diagnosis (dx) symptoms were: f+ap+d %, f+d %, f+ap %, ap+d %,d %,ap %. f alone was never present at diagnosis of nec. at dx, f was absent in / nec episodes ( %). all pts were treated promptly as bus allowed diagnosis with cmm except one pts who underwent surgery, guided by us features, during neutropenia. the likelihood of nec dx in a discriminant st model (bayes theorem) for pts with bwt and ap = . %, ap+d = . %, ap+d+f = %, ap+f = . %, d+f = %. bus allowed to detect early signs of nec and to start prompt treatment in this life threatening complication, of nhl/hl pts undergoing asct. this is a prospective study thus the true incidence of nec in nhl/hl undergoing asct should not be underestimated. there is not a statistically significant difference in incidence and outcome of nec in pts conditioned with beam in respect to feam. with bus pts do not live the isolation room. fever is not a condition sine qua non for nec diagnosis. early diagnosis allows most of pts to be treated with cmm. images of bus and ct were superimposable with lower costs, and less radiation exposure. a low mortality rate in pts with a - % chance of developing this life threatening complication suggests that a prompt bus in neutropenic patients as just one symptom presents allows to make early diagnosis of this life threatening complication and guide prompt treatment (conservative or surgical), reducing mortality. disclosure of conflict of interest: none. quantiferon-cmv in the evaluation of cmv-specific immunity after autologous and allogeneic hsct j moreno , ltesta , l zanetti , l serra , b pereira , m souza , a carolina souza , mp souza , vr colturato and cm machado , hsct program, amaral carvalho foundation and virology laboratory, institute of tropical medicine, university of são paulo cytomegalovirus (cmv) is a major cause of morbidity and mortality after allogeneic hsct. the same is not observed in autologous hsct recipients who do not need to receive immunosuppression after transplantation. in the present study, we compared the reconstitution of cmv-specific immunity in autologous and allogeneic hsct recipients. patients were invited to participate in the study and signed the informed consent. cmv surveillance with the antigenemia (ag) test (cmv brite, biotest, germany) was done weekly in the first months of transplant in allogeneic hsct recipients. preemptive ganciclovir therapy was initiated whenever a positive antigenemia was detected. the presence or absence of cmvimmunity was determined by a commercial interferon (inf) gamma release assay (quantiferon cmv, qiagen) before hsct and monthly thereafter up to d+ . from january to october , hsct recipients ( auto and allo) were included in the study. ag was positive in ( %) of the allohsct recipients at a median of (range: - ) days. ag recurrences occurred at a median of . ( - ) days, in of the pts ( . %) who had at least one episode of positive ag. hsct recipients were included in the analysis of qtf-cmv. in the pre-hsct sample, qtf-cmv was reactive in of the allohsct ( . %) and in of the autohsct ( . %). significantly less allo hsct recipients recovered cmvimmunity at day + ( . %) and day+ ( . %) in comparison with autohsct ( % and %, respectively, p o . ). up to day + , all autohsct have recovered cmvimmunity, in comparison to % of the allohsct recipients (p = . , figure ). the qtf-cmv test performed at d+ , d + and d+ did not predict the risk of cmv reactivation in the following month. similarly, the test did not anticipate the risk of ag recurrences: % of the hsct recipients with undetermined or non-reactive qtf-cmv test at d+ had ag recurrence after this period, in comparison with % of the patients with a reactive result (p = . ). in the present study, the qtf-cmv test alone could not predict the risk of cmv reactivation or recurrences. [p ] disclosure of conflict of interest: qiagen. recovery of vδ + γδ t cells is critical to epstein-barr virus reactivation after haploidentical hematopoietic stem cell transplantation j liu, z bian, q fu, l xu, x zhang, y wang and x-j huang peking university people's hospital, peking university institute of hematology, beijing, china epstein-barr virus (ebv) reactivation and its related disease are life-threatening complications in patients undergone haploidentical hematopoietic stem cell transplantation (haplohsct). our previous studies found that impaired cd − cd − t-cell recovery correlated to the increased occurrence of ebv infection after haplohsct. γδt cells make up - % of cd − cd − t cells in the peripheral blood of healthy donors. expansion of vδ + γδt t cells after hsct has been reported and this subset could respond against autologous ebv-lcl in vitro. selective activation and expansion of vγ vδ -t cell could inhibit ebv-lpd development in humanized mice. however, the association of γδ t-cell recovery with ebv reactivation after allohsct remains unknown. this is a prospective cohort study including consecutive patients who were diagnosed as hematological malignancy and underwent haplohsct. recovery of t lymphocyte and a panel of subsets, including cd +, cd +, cd +, cd -cd -, tcrαβ+, tcrγδ+, vδ +, and vδ + t cells, were determined by flowcytometry at , , , days after haplohsct. all recipients and donors were tested negative for ebv dna in the peripheral blood before transplantation. recipients were monitored weekly for ebv dna load until day after transplantation. recipients with peripheral blood plasma ebv dna load copies/ml at least on two consecutive occasions were diagnosed as ebv reactivation (ebv +). ebv − cohort generally represents patients whose ebv dna loado copies/ml in peripheral blood. within days after haplohsct, of ( . %) recipients were diagnosed as ebv reactivation. compared to recipients with negative ebv dna load, the counts of cd +, cd +, and tcrαβ+ t cells were not statistically different in the ebv+ cohort from to days after haplohsct. in contrast, recoveries of cd + and cd -cd -t cells in ebv+ patients were significantly hampered at days after transplantation (p = . and p = . , respectively). although the tcrγδ+ t-cell counts were also decreased at and days in the ebv+ cohort, the comparisons did not reach the statistical significance (p = . and p = . , respectively). notably, recoveries of vδ + γδ t cells at , and days were continuously delayed in recipients with ebv reactivation (p = . , p = . and p = . , respectively). whereas the counts of vδ + γδ t cells were similar between the two groups from to days in this context. in this prospective and large cohort study, we showed that the occurrence of epstein-barr virus (ebv) reactivation was associated with the hampered recovery of vδ + rather than vδ + γδ t cells after haplohsct. our findings will help explore γδt subset-dependent therapeutic strategies to control the serious complications due to ebv infection post transplantation and improve the overall survival of haplohsct recipients. disclosure of conflict of interest: none. in particular, bloodstream infection (bsi)is a frequent complication in the pre-engraftment phase with an impact on the morbidity and mortality of these patients. objectives: to analyze the incidence of bsi in patients undergoing hsct in our center, and to identify predisposing factors for the development of bsi in pre-engraftment phase patients after hsct. fifty-one consecutive patients undergoing hsct were analyzed retrospectively in our center during the period of july and june . the characteristics of the sample are shown in table . we have reported all the bsi between day and day after stem cell infusion. . % ( patients) received antibacterial prophylaxis with ciprofloxacin, five patients with broad spectrum antibiotics and five did not received any drug. the average days of fever have been . days ( - days). a total of blood cultures has been collected ( . per patient). there have been bsi ( . % of the patients) with ( . %) of cases caused by gram-negative organism ( escherichia coli, klebsiella pneumoniae, acinetobacter baumanii, proteus vulgaris and delftia acidovorans) and ( . %) by gram-positives ( enterococcus faecium, enterococcus faecalis, staphylococcus epidermidis, streptococcus mitis and streptococcus viridians group). one patient presented different episodes of bsi, two patients independent episodes and the rest eight, only one microorganism isolated. we have identified two bsi by extended-spectrum betalactamases (esbl-producing organism) and one isolation of carbapenem-resistant gram-negative bacteria. the rate of quinolone-resistant is % in all the sample. in univariate analysis, several factors like presence of comorbidities, presence of severe mucosits, type of catheter and antibacterial prophylaxis modality don't increased the risk to develop bsi (p . ). the place where the procedure is performed does not influence the development of bsi. although the presence of previous infections is not a risk factor, hospitalization for infection in the days before hsct does influence the development of bsi with statistical significance (po . ). the crude mortality rate of the sample has been very low ( %), with only one death related to bloodstream infection. bsi are a common relative complication in the patient undergoing hsct but with an extremely low mortality in our sample. hospitalization for infection in the days before hsct does influence the development of bsi. it is important to note that outpatient model and conventional rooms don't increased the incidence of bsi. although the use of quinolones in prophylaxis does not result in an increase in infections caused by multiresistant micro-organisms (esbl and carbapenemias) with acceptable resistance rates ( %), it also does not reduce the incidence of bsi in our sample. according to our analysis, his routine employment still throws light and shadows. [p ] disclosure of conflict of interest: none. septic episodes with multiple bacterial strains during antithymocyte globulin (atg) therapy for conditioning for allogeneic stem cell transplantation under rifaximin gut decontamination d markel , c schultze-florey , t brockmeyer , v panagiota , c lück , a schwarzer , m beck , e dammann , a ganser , g beutel and m eder recent evidence demonstrates the importance of the enteric microbiome for the development of gastrointestinal graftversus-host disease (gvhd) and mortality after allogeneic stem cell transplantation (sct) ( , ) . accordingly, the usage of the non-absorbed rifamycin derivate rifaximin for gut decontamination has been reported to preserve the intestinal microbiota composition with a positive effect on overall survival in a single centre retrospective analysis ( ). we here report severe septicaemia requiring therapy at the intensive care unit (icu) during atg application for conditioning in three patients with rifaximin used as single agent for gut decontamination within months. after changing our gut decontamination from a chinolon-metronidazole regimen to rifaximin, three cases of severe septicaemia by gram-negative and gram-positive bacteria during atg treatment occurred within months. patient # was a -year-old woman with tmds/aml after breast cancer conditioned according to the flamsa-bu protocol. the second (# ) and third (# ) patient were and -year-old males with a complex karyotype secondary aml after omf and relapsed inv( ) aml with meningeosis leucaemica, respectively. patients # and # were treated with flamsa-bu and flamsa-tbi, respectively. all patients received rabbit atg (atg fresenius/grafalon) at a dose of × mg/kg body weight and rifaximin ( × mg) for gut decontamination. patient # developed severe escherichia coli and pseudomonas aeruginosa septicaemia on day − of the conditioning regimen and had to be transferred to the icu with septic cardiomyopathy for therapy with vasopressants and levosimendan. in patient # escherichia coli, klebsiella oxytoca, staphylococcus hemolyticus and staphylococcus epidermidis were simultaneously detected in blood cultures at day − . the patient was transferred to the icu and treated with vasopressants for septic shock. patient # developed septic shock due to klebsiella pneumoniae and enterobacter cloacae on day − under atg therapy. mechanical ventilation and vasopressor therapy were required. fortunately, all three patients survived and completely recovered without any sepsis related disabilities under escalated anti-infective and intensive care therapy. all were discharged from the hospital in the outpatient clinics. interestingly, all isolated gram-negative pathogens were found to be sensible for a chinolon based gut decontamination. the reasons for these septic complications under atg therapy are not exactly understood but raise a note of caution on the use of rifaximin as single agent gut decontaminant during atg application in conditioning for allogeneic sct. infections with mycobacterium genavense were described for the first time in . since then, several cases have been reported, but almost exclusively in patients with aids. most patients who underwent hsct have insufficient cellular immunity. here we report a mycobacterium genavense infection in a patient mimicking a lymphoma-relapse after hsct. a year-old female patient was diagnosed in july with stage ivb alk-negative anaplastic t-cell-lymphoma with cervical, retro-/supraclavicular, mediastinal, axillary and retroperitoneal lymphadenopathy as well as pulmonary manifestation. two chemotherapy treatment lines and autologous stem cell transplantation resulted in a partial remission. to improve remission prior to hsct the patient received courses of brentuximab-vedotin. after conditioning therapy with fludarabine, busulfan, cyclophosphamide and atg, hsct from a hla compatible unrelated donor was performed in april . a pet-ct-scan in november confirmed complete remission. after hsct the patient remained lymphocytopenic with cell count of cd + cellso /μl. after acute stage iii gastrointestinal graft-versus-host disease (gvhd) low dose immunosuppressive therapy was maintained due to mild chronic gvhd of the liver and the upper gastrointestinal tract. beginning in june the patient experienced increasing fatigue, general weakness, loss of appetite, nausea, night sweating and fever. abdominal ultrasound, urine and blood culture as well as ct scans revealed no focus of infection. different lines of empirical antibiotic therapy resulted only in short term improvement. several blood culture tests remained sterile. a fdg-pet-ct scan showed a paraaortal and parailiacal lymphadenopathy with a high fdg uptake (suv between . and . ), highly suggestive of lymphoma relapse. endoscopic evaluations revealed two polypoid lesions in the bulbus duodeni. histology of duodenal biopsies revealed a massive accumulation of weakly pas-positive bacilli. pcr analysis confirmed an infection with mycobacterium genavense. despite several attempts mycobacteria were not recoverable on solid media even by long term culture. treatment was started with rifampicin, ethambutol, ciprofloxacin and clarithromycin. lymph node manifestation responded to therapy with decreasing fdg-uptake (suv . ) in a control fdg-pet-ct scan months later. after months treatment was terminated due to therapy refractory nausea. lymphocytopenia was persisting with cd + cellso /μl. six weeks after stopping the antibiotic therapy, symptoms as fever and weakness reappeared. duodenal biopsy could not confirm persistent mycobacterial infection. fdg-positive intraabdominal lymph nodes (suv . ) and spleen (suv . ) were detected in a control fdg-pet-ct-scan. five lymphnodes were surgically removed. immunohistology detected histiocytic cell proliferation with no sign of lymphoma relapse. pcr confirmed the presence of mycobacteria-dna. consequently, antibiotic treatment was resumed. mycobacterium genavense can present with all the symptoms of a lymphoma relapse and should be considered in immune compromised patients. reliable diagnosis can only be obtained from lymph node biopsies and/or endoscopic evaluation. treatment has to be accompanied by restoring cellular immunity and should only be stopped after pcr-negative biopsies. disclosure of conflict of interest: none. stratification of patients with multiple myeloma and lymphoma undergoing autologous hematopoietic stem cell transplantation in term of antifungal prophylaxis r moghnieh, s khaldieh, l awad, d abdallah, n droubi, a youssef, a mougharbel, t jisr and a ibrahiim makassed university hospital, beirut, lebanon autologous hematopoietic stem cell transplantation (ahsct) is at intermediate risk for invasive fungal infections (ifi). the recommendations of international scientific societies are not homologous regarding prophylaxis against ifi in patients (pts) undergoing ahsct. the primary end point was to assess risk factors for the need of empiric/preemptive antifungal therapy in ahsct recipients, and to extrapolate to the subgroup of pts that requires antifungal prophylaxis in our population of ahsct pts. the secondary endpoint was to determine the fungal species distribution infecting or colonizing the pts. our study included adult pts ( yo) who underwent ahsct for lymphoma and multiple myeloma (mm) between and . all febrile neutropenic pts are being managed according to the infectious diseases society of america (idsa) guidelines regarding the use of antimicrobial agents in neutropenic pts with cancer. eligible pts were divided into two groups: those who received empirical antifungal therapy and those who did not need it. we recorded demographic and baseline clinical characteristics including: age, gender, comorbidities, stage, disease status at ahsct, high-dose therapy regimen, the presence of mucositis and its grade, the number of cd + cells transfused, the presence of central line or portacath, the need for mechanical ventilation, the presence of diarrhea, the duration of neutropenia, and the presence of bloodstream infections. pts who had lung infiltrates suggestive of ifi were analyzed separately. the causative fungal pathogens and colonizers were analyzed. univariate and multivariate analysis of potential risk factors to assess further significance was performed using spss. patients were included. pts ( %) had lymphoma and pts ( %) had mm. the need of empiric antifungal therapy was statistically more significant in lymphoma than mm pts (po . ).the presence of mucositis grade ⩾ showed a statistical significance for the need of antifungal therapy (p = . ). in the lymphoma group, remission status (pr vs cr) was not a significant factor for the need of empiric antifungal therapy (p = . ).the presence of mucositis grade ⩾ was at the limit of significance ( p = . ). in the mm group, remission status (pr vs cr) did not affect the need of empiric antifungal therapy (p = ). however, mucositis grade ⩾ was found to be a significant risk factor for the need of empiric antifungal therapy (p = . ). following factors: the number of cd + cells transfused, the presence of central line and portacath, the need for mechanical ventilation, the presence of diarrhea, the duration of neutropenia, and bloodstream infections did not show any significance for the need of antifungal prophylaxis in both groups. all recovered fungal isolates (n = ) were not from deep seated tissues biopsies or blood, and were identified as candida albicans in with lymphoma, and in with mm. they reflected the candida ecology in this pts series rather than deep seated fungal infections. we suggest to give antifungal prophylaxis to all lymphoma pts because of the higher need of empirical antifungal therapy, and give antifungal prophylaxis to mm pts having a predisposition for severe mucositis. fluconazole is the antifungal of choice for prophylaxis since all the fungal isolates were candida albicans. keywords: autologous hematopoietic stem cell transplantation, antifungal prophylaxis. disclosure of conflict of interest: none. a -year-old previously fit woman from a rural area of eastern europe was admitted to the hospital for severe aplastic anemia. steroids, csa, antinfective prophylaxis and supportive therapy were administered without response; therefore rabbit atg was then administered, with minor response; the year later, she underwent allogeneic-hsct (mud / , ric: tbi, cyclophosphamide and fludarabine; gvhd prophylaxis: atg, csa, mtx). several days after transplantation she developed left migraine with ipsilateral back-eye pain. brain mri and ct showed a diffuse opacification of paranasal sinuses, mainly in the sphenoid sinus. the symptoms gradually improved with a specific treatment. the patient achieved a quick and complete haematological recovery and she was discharged. at follow-up visits she complained a flare of the migraine, with a left-sided headache that did not improve with nsaids. the headache gradually intensified until vision in the left eye became blurred with conjunctival injection. after consultation with ophthalmologist, for suspected toxoplasma retinitis, administration of intravitreal steroids and clindamicine was begun with partial benefit. however days after (d + ) she was admitted in hospital because of worsening headache, irradiated in the occipital area, and weakness in the right hemibody. tests on csf were negative for neurotropic pathogens. an mri showed a complete occlusion of the intracranial tract of left internal carotid artery, with likely infectious material localized in the left lateral cerebral fissure. a chest tc showed a nodule with initial excavation in the right superior pulmonary lobe. for suspected tuberculosis she started antitubercular therapy. despite a second lumbar puncture confirmed pleocytosis compatible with acute purulent meningitis, microbiological research for bacteria, fungi and bk were negative. so antitubercular and antitoxoplasma therapy were stopped and the patient underwent surgical biopsy within the sphenoid sinus. pathological examination of the biopsy specimens showed acute and chronic inflammation of the respiratory mucosa, periodic acid. schiff and grocott staining ( figure ) highlighted several septate fungal hyphae. cultural analysis revealed colonies of scedosporium apiospermum so the patient started targeted voriconazole intravenous therapy. nevertheless, days later, she developed aphasia and right hemiparesis. a brain angio-mri confirmed the appearance of new lesions compatible with infectious localizations associated to an increased defect of left internal carotid artery vascularisation and complete left choroid detachment. after weeks of voriconazole a significant clinical improvement have been observed and she was discharged, continuing oral antifungal therapy with voriconazole. at the last follow-up she achieved a complete resolution of neurologic symptoms, with permanent left eye blindness. months later (d + ) she was asymptomatic, with normal haematological and neurological conditions and was able to stop the antifungal therapy. this case-report confirms that the risk of invasive fungal infection (ifi) is relevant in patients receiving hsct for aa, probably due to the prolonged neutropenia and association of other risk factors such as the immunosuppressive therapy and the iron overload. in this very poor prognosis infection, the early diagnosis of cns ifi remains challenging, but the administration of voriconazole was extremely effective. disclosure of conflict of interest: none. in this study, we aim to present the seroprevalence of ebv and incidence of posttranplant lymphoproliferative disease as well as to evaluate the relation with gvhd. between and , the ebv serology of patients that underwent allogeneic hematopoietic stem cell transplantation and their donors were evaluated in the study. ebv ig g (vca-igg, ebna ig g, ea-igg) and igm (vca-igm) antibodies were detected by chemolluminesance method (abbott, abd). all patients were followed for reactivation. ebv igg seropositivity was detected in patients ( %) and donors ( . %). there was no statistically difference in related vs unrelated transplants in seropositivity. the median age of the patients was (range: , patients were male ( %) and ( %) had malign disease. the stem cell source was peripheral blood in ( %) patients and ( %) received grafts from related donors. myeloablative conditioning regimen was received by of patients ( %) (table) . all patients received acyclovir prophylaxis (related transplants mg tid, unrelated transplants mg tid) during and after allo-hsct up to months. twenty six-yearold pretransplant ebv seropositive aplastic anemia patient had ebv ig m positivity after months of allo-hsct and developed lymphoproliferative disease. he was in complete remission after courses of rituximab and methylprednisolone. three patients were ebv igm seropositive in th, th and th months of allo-hsct and received symptomatic treatment. acute gvhd was detected in patients ( %) whereas patients ( %) had chronic gvhd. acute gvhd and chronic gvhd incidences were similar in comparison of donor ebv seropositive vs seronegative status ( % vs %, p = . ; % vs %, p = . ). ebv seropositivity was detected in . % of patients. the donor ebv serology was not related with acute or chronic gvhd. [p ] disclosure of conflict of interest: none. the umc utrecht pediatric experience with brincidofovir after allo hsct ca lindemans, m bierings and jj boelens pediatric blood and marrow program, dept. of pediatrics, university medical center utrecht, the netherlands viral reactivation with dna viruses form a considerable complication of allogeneic hematopoietic stem cell transplantation (hsct). there are little effective antiviral therapies and most have considerable toxicity. especially for adenovirus, there is no satisfactory therapeutic option. recently a new oral antiviral agent, the cidofovir prodrug brincidofovir became available to european patients only on the basis of urgent medical need and after a case by case approval by the health authorities. the aim was to describe our single center experience with brincidofovir in the pediatric allogeneic hsct setting. in the umc utrecht, pediatric patients receive t-replete bone marrow or unrelated cord blood (ucb) as the donor source after mostly myeloablative conditioning regimens (+ serotherapy in unrelated-hct). as gvhd prophylaxis patients receive cyclosporine a (csa) and mtx for bone marrow, csa and prednisone for ucb. patients are by standard weekly monitored for the presence of adenovirus, ebv, cmv en hhv viremia by rt pcrs in the plasma. extensive immune reconstitution measurements are performed every weeks. since , patients that developed viral reactivation with adenovirus, or a combination of other dna viruses (cmv, bk or hhv ) were offered brincidofovir if the viremia was progressive or in the context of poor immune reconstitution. brincidofovir was given in suspension ( mg/ml) at the dose of mg/kg biw, or mg biw for larger children. de drug was discontinued when the viral load was below detection level. in total, six pediatric patients (age range: - ) received brincidofovir ( patients tablets, the suspension). four received it for adenovirus reactivation, a th patient for cmv and bk and a th patient for cmv en hhv . the median day post-hsct of the first administration was days post hsct (range: − to ), the median day post detection of viral reactivation days . the median duration of administration was days ( - ) with two patients being discontinued because of death. in no patient the drug was discontinued due to toxicity issues. the patients that died had multi-organ failure due to a combination of severe agvhd and multiple infectious issues. the patients were discontinued when the viral load was low and when they had cd counts of at least /μl. none of the four alive patients reactivated after the drug was discontinued. urgent medical need administration of brincidofovir is feasible. in our limited series we found the drug was well tolerated. disclosure of conflict of interest: i am a medical consultant for brincidofovir (chimerix). reactivation of herpes simplex virus (hsv- ) or varicellazoster virus (vzv) occurs frequently after allogeneic stem cell transplantation (asct). here, we report three unusual cases, two with reactivation of hsv- and one with vzv. patients and methods: patient (pt) ( -year-old, male) was allografted for high risk acute lymphoblastic leukemia in first complete remission after conditioning with total body irradiation ( gy) and etoposide ( mg/kg). graft-versus-host disease (gvhd) prophylaxis was performed using cyclosporine a, short course methotrexate and anti t-lymphocyte globulin (atg). pts ( year-old, female) and ( -year-old, male) were allografted for acute myeloid leukemia in second and first complete remission, respectively. conditioning regimens used were flamsa-ric in pt and fludarabine/busulfan in pt . in both cases, gvhd prophylaxis consisted of cyclosporine a, mycophenolate mofetil, and atg. pts and had already experienced hsv- -positive oral mucositis following induction chemotherapy and had successfully been treated with acyclovir. both developed hsv- -positive oral mucositis again after asct. in both cases, initial therapy with acyclovir i.v. at a dose of up to mg/kg t.i.d. was ineffective. to explore the mechanism leading to clinical acyclovir resistance, the thymidine kinase genes of both viral strains were sequenced. pt presented with severe abdominal pain and nausea months after asct. in this case, acyclovir prophylaxis post asct had been stopped months before due to side effects. moreover, low dose prednisolone therapy was necessary for chronic gvhd. the hsv- -strain from pt showed a single base pair deletion in the region from nucleotide position to of the thymidine kinase gene (which consists of a guanosine repeat). in pt a single base pair insertion in the same region was found. both genetic alterations lead to a loss of enzyme activity and acyclovir resistance. in both pts treatment was changed to foscarnet which led to rapid improvement. in the case of pt , multiple mucosal erosions were found on endoscopy of the esophagus. in these vzv dna was detected by polymerase chain reaction (pcr). only days later, a vesicular skin eruption developed, which did not follow a dermatomal distribution. again, in the vesicular fluid vzv dna was detected by pcr. in this patient, acyclovir ( mg/kg i.v., t.i.d.) resulted in rapid improvement. reactivation of hsv- and vzv after asct is a frequent finding. usually, hsv- strains respond well to acyclovir. in some cases, resistance can develop, especially in patients that had been treated with acyclovir before. acyclovir resistance of hsv- caused by mutations in the thymidine kinase gene can be overcome by treatment with foscarnet which directly inhibits the viral dna polymerase. disseminated vzv reactivations after asct have been described. clinical presentation can be misleading, for example, beginning with severe abdominal pain that precedes the vesicular eruption by several days. disclosure of conflict of interest: none. toxoplasmosis is a rare but severe complication after hematopoietic stem cell transplantation (hsct) ( ) . it can involve the central nervous system alone or can manifest as a disseminated disease. in the paediatric population the mortality rate is high and sequelae are often severe. new diagnostic tools, such as the pcr assay, may allow for rapid diagnosis and preemptive therapy ( , ) . we retrospectively analysed all children who underwent allogeneic hsct in our centre between january and december . patients lost to follow up before day + were excluded. patients and donors were tested before transplant in order to assess their immunological status against t. gondii. a total of allo-hsct were analysed. before transplant, . % of recipients (r) were toxo-igg positive and . % were toxo-igg negative. among donors (d), serology was available only for / : % were toxo-igg positive, % were toxo-igg negative. we found a high number of not tested donors ( . %, / ) which included, in most cases, mud from foreign registries. the group at higher risk for toxoplasmosis, d − /r+, included . % pairs, whereas d − /r − were . %, d+/r-were . % and d +/r+ were . %. in our series the cumulative incidence of toxoplasmosis disease was . %, with cases out of transplants. two of them (case and ) had cerebral toxoplasmosis, one (case ) had disseminated toxoplasmosis and case had toxoplasmic chorioretinitis. mortality rate was %: two patients died because of multiorgan failure and disseminated toxoplasmosis respectively. in no case localized cerebral toxoplasmosis was the main cause of death. no complications were seen in surviving patients. all patients who developed toxoplasmosis were toxo-igg positive before hsct and three of them were transplanted from a toxoplasma igg negative donor (fourth donor not tested). in the two fatal cases the interferon-gamma releasing assay (igra) never became positive, confirming the absence of specific cellular immunity. toxoplasmosis disease can affect hsct outcome in paediatric recipients and pre-hsct seropositivity is the most important risk factor for toxoplasma disease in the post transplant period. in our cohort seroprevalence was higher than expected, probably due to the high number of patients coming from eastern europe. in order to reduce the burden of toxoplasmosis disease in our population we decided to implement a real-time pcr screening protocol for d − /r+ pairs, to provide rapid diagnosis and early therapy. all positive recipients with a seronegative donor will undergo real-time pcr screening starting on the day of stem cells infusion, and regularly until cd + t cell recovery. in the future we will analyse the impact of this strategy in this particular subset of immunocompromised patients. treatment with brincidofovir for adenovirus disease in pediatric hematopoietic transplants introduction adenovirus may cause serious morbidity and mortality after allogeneic hematopoietic transplants in children. severe lymphopenia is the main risk factor associated with progression to disseminated and often fatal disease. treatment with unlicensed cidofovir is based on monitoring of plasma viral load by pcr. however, cidofovir is only moderately effective at controlling adenovirus and it is associated with significant renal toxicity. brincidofovir is a lipid conjugate of cidofovir. it has a good oral bioavailability and achieves higher intracellular levels of active drug than cidofovir with a better safety profile. it is a potent inhibitor of viral dna synthesis so it could be indicated in immunocompromised patients with adenovirus disease. patients and methods we present three children of , and years old diagnosed of acute lymphoblastic leukemia (all) in nd complete remission (the first two patients) and severe aplastic anemia the last one. there were girls and boy. they underwent a peripheral blood hematopoietic stem cell transplantation using αβ/cd depletion with a haploidentical donor in the two patients with all and cd ra depletion with a matched unrelated donor in the other patient. patients that underwent haploidentical transplants developed early acute graft versus host disease grade iii with gut and skin involvement so immunosuppressive treatment with corticoids was started. they developed severe lymphopenia ( o / mm ). in the first month after transplant an adenovirus disease was diagnosed in the three patients from the weekly monitoring of plasma viral load by pcr. adenovirus was also tested in stools, urine and respiratory sample. in all patients adenovirus was also detected in urine sample. in one of them adenovirus was detected in nasal exudate too and in the other the virus was isolated in stools and in a skin biopsy. results: all of them were initially treated with cidofovir with poor results. foscarnet and gancyclovir was also used without improvement. finally they started a treatment by compassionate use with oral brincidofovir twice a week. with the first dose of brincidofovir plasma viral load started to go down until its complete disappearance. brincidofovir tolerance was good with only mild and limited diarrhea in two cases in the day they were taking brincidofovir. two of the three patients were alive without signs of adenovirus disease. in the other patient blood adenovirus load by pcr decreased below /ml, but remain high in urine. she died of respiratory failure due to pulmonary graft versus host disease. conclusion brincidofovir may be a promising therapeutic option for the treatment of severe adenovirus disease in immunocompromised patients with a good toxicity profile. disclosure of conflict of interest: none. table . all patients were transplanted with pbsc for haematological malignancy, and s received reduced intensity conditioning (ric) regimens with in vivo t-cell depletion. the proportion of patients with baseline and post-vaccination hi titres ⩾ : were . and % for a(h n )pdm , . % at both time points for a (h n ), and . and % for b/phuket. pre and postvaccination geometric mean titres gmt) were higher by mn than hi for a(h n )pdm and a(h n ), but lower for b/ phuket (p = . ). no post-vaccination seroconversions were detected by hi, while a single seroconversion to a(h n ) pdm was detected by mn in a patient vaccinated at - months. the mn assay did not detect any additional low-titre seroresponses (negative to detectable titre) below hi threshold. none of patient age, lymphocyte count, days from transplant to vaccination, donor type, and gvhd or ist at vaccination correlated with baseline or post-vaccination titres by either assay. response to iiv was virtually absent throughout the first year post-hsct, with a single seroconversion to a(h n )pdm detected by mn but not hi, although the sample size was small and half of patients were vaccinated at - months. there is a clear need for a novel, immunogenic seasonal iiv and/or novel vaccination regimens in this population. vaccination of recipients' relatives and close contacts, and hsct healthcare workers should be strongly encouraged. pre-and post-transplant iron overload (io) has been associated with considerable long-term morbidity and mortality in pts undergoing transplantation. classically, management of io in the post-allo-hsct setting has been based in the performance of therapeutic phlebotomies (tp), which are inconvenient for the patient and are often not feasible due to ongoing anemia. we recently published the first prospective study of deferasirox in adult allo-hsct pts with io (vallejo, et al. haematologica ). in this retrospective analysis, we analyzed the real-life management of io in the post-allotransplant setting. this study includes the last pts with a minimum follow-up of weeks, who underwent allo-hsct in our center (october -october ). pts were male ( . %) and female ( . %). median age was years (range: - ). baseline diseases were: aml ( . %), lymphoproliferative disorders ( . %), mds ( . %), all ( . %), chronic myeloproliferative diseases ( . %), mm ( . %), and bm failures ( . %). donor was unrelated in cases ( %; of them hla mismatched), and related in ( %; of them haplo-identical). conditioning regimen was: busulphan-based ( . %), melphalan-based ( . %), tbi-based ( . %), and others ( . %). progenitors source was pb in ( . %), and bm in ( . %). pre-hsct: pts had been transfused with a median of prbc (range: - ), and their median serum ferritin (sf) was ng/ml (range: - ). day + post-hsct: pts had died, and pts had not reached that day yet, so pts were evaluable. they had been transfused with a median of prbc (range: - ), and their median serum ferritin (sf) was ng/ml (range: - ). % pts had sf superior to ng/ml. liver mri (by sir method) to assess liver iron concentration (lic) was performed in pts at day + . seven pts ( . %) had no io (lic - mg/g), pts ( . %) had moderate io (lic . - . mg/g), and pts ( . %) had severe io (lic superior to . mg/g). median lic was . mg/g (range: . - . ). among the cases with history of more than prbc transfused and sf higher than ng/ml at day + , ( . %) were proved to have liver io by mri; the other pt had io in spleen. pts started some kind of therapy to treat the io: pts with severe io initiated a tp program and pts ( out of with moderate io, and out of with severe io) initiated chelation therapy with deferasirox. the drug was started at low dose ( . - mg/kg/ day), and was increased if tolerated up to a maximum of mg/kg/day. of note, the majority of pts were also taken a number of medications (immunosuppressants, statins, antimicrobials, etc). of those pts ( . %) did not tolerate the drug, and were changed to tp. for more details, see the table. ( ) the combination of the history of prbc transfusions and serum ferritin levels was, in the majority of cases, enough to assess the io in the post-allo-hsct setting. ( ) liver mri (by sir method) helped to assess io in doubtful cases. ( ) deferasirox, initiated at low doses and increased if tolerated, was safe and its use helped to avoid the need of therapeutic phlebotomies for the majority of patients. this study reproduces, in a real-life setting, our previous findings in a prospective clinical assay. [p ] disclosure of conflict of interest: none. a case-control study of risk factors of primary graft failure with a focus on associated early-onset severe infections v alcazer , a conrad , f-e nicolini , s ducastelle-lepretre , f barraco , x thomas graft failure (gf) is a rare but devastating event after allogeneic haematopoietic stem cell transplantation (ahsct), exposing the recipient to disease relapse, drawbacks of marrow aplasia, infections and death. the aim of this study was to analyse the risk factors associated with graft failure after ahsct, with a specific focus on early-onset severe infections (esi). we conducted a retrospective, observational, single-centre, matched case-control ( : ) study among adult s ahsct recipients transplanted at the haematology department of our institution between and , with a subsequent follow-up of months. engraftment was assessed at day+ post-ahsct. gf cases were classified as primary gf (pgf), defined as failure to achieve donor-derived absolute neutrophil count (anc) ⩾ . × /l or lasting more than consecutive days without evidence of disease relapse and early-secondary gf (esgf), referring to the loss by day post-ahsct of a previously functioning graft associated without evidence of disease relapse. each case was matched with two controls according to underlying haematological disease, hla matching, stem cell source, intensity of conditioning and temporal proximity of ahsct. demographics, haematological and graft characteristics as well as esi report were retrieved. esi were classified in invasive fungal infections, viral infections (cmv, ebv, hhv- , other viruses), toxoplasmosis and severe sepsis of bacterial origin. during the study period, ahsct were performed at our center. seventeen ( . %) gf cases were identified, of which pgf and esgf, and were matched with controls. in the descriptive analysis, gf and control populations did not significantly differ when considering demographics, haematological characteristics and hematopoietic stem cell source. regarding pretransplantation status and graft characteristics, only disease status (progressive disease) and cell dose (both cd + and cd + cells number/ kg) were associated with graft failure. the proportion of patients with ⩾ esi before day was significantly higher in cases than in controls ( / vs / , p = . ), with an overall number of esi events of and among cases and controls, respectively. five cases had ⩾ concurrent esi. the median time from ahsct to the first esi event for gf cases was days (interquartile range (iqr), - ) vs (iqr, - ) days for controls (p = . ). in the gf setting, the most prevalent infections were herpesviridae infections (n = including hhv- n = , ebv n = , cmv n = ), probable ifi (n = ), severe sepsis of documented bacterial origin (n = ), toxoplasmosis (n = ) among whom one patient developed haemophagocytic syndrome. when further analysing subsets of esi using logistic regression, only toxoplasmosis was a significant risk factor for gf (p = . ). death related to an infection was proven for gf patients vs control patients (p = . ). the overall survival probability at months was significantly lower in the gf setting than in control patients (hr = . ( % ci . − . ), p = . ). the survival rates at months were . % and . % for gf and control patients, respectively. at our center, graft failure is statistically associated with early-onset severe infections, and already known graft characteristics such as cell dose and disease status. however, our study would need more power to increase its significance. disclosure of conflict of interest: none. allogeneic stem cell transplantation (asct) is a curative option for hematological disorders, especially malignancies. in immunosuppressed women after asct, the progression from cervical dysplasia to invasive carcinoma is accelerated, and cervical cancer is likely a more aggressive disease. therefore, follow-up protocols after asct should include regular gynecologic evaluation with papanicolaou (pap) smears. we retrospectively evaluated pap smears in women who underwent asct and searched the risk factors for abnormal cervical cytology. the median age at transplantation was . years (range: - years). the most frequent indication for asct was leukemia ( %), and % of the patients received a transplant from a sibling hla-matched donor. stem cell source was peripheral blood in all patients. myeloablative conditioning regimen was used in % of patients. cyclophosphamide, busulfan and fludarabin were used in ( %), ( %) and ( %) patients, respectively. acute graft versus host disease (gvhd) occurred in patients ( %) and chronic gvhd in patients ( %). secondary cancer ( breast cancer) was reported in only one patient at months after asct. the follow-up time was months (range: - months). after asct, benign and abnormal pap smears were found in ( %) and ( %) women, respectively. the median time between asct and development of abnormal cytology was months (range: - months). four ( %) women had at least one smear with atypical squamous cells of unknown significance (asc-us), one ( %) had a low-grade squamous intraepithelial lesion (lsil), one ( %) had atypical squamous cells/high-grade lesion (asc-h) and one ( %) had asc-us and asc-h. one ( %) patient had malign smear. two patients with asc-h showed high-grade atypia mimicking cancer but had a negative follow-up. patient who had malign smear died because of aorta dissection. cervical biopsy showed cervical intraepithelial neoplasia (cin) i in ( %) women who had asc-us or asc-h. one patient was hpv-positive. we did not find any relationship between cervical cytological abnormality and clinical factors. after asct, patients are high risk for abnormal cervical cytology and secondary gynecological cancer. regular surveillance of patients is the most important factor for decreasing the risk of developing cervical and other secondary cancers. gynecologic examinations and cervical cytological testing after asct allows early diagnosis and effective management of cervical abnormalities. disclosure of conflict of interest: none. kidney dysfunction is a frequent complication of allogeneic stem cell transplantation (sct) and contributes to the morbidity and mortality of the procedure. incidence of severe acute kidney injury (aki) in patients undergoing nonmyeloablative allogeneic sct for malignant diseases ranges from to %. lymphoma patients are often heavily pretreated through both chemotherapy and autologous sct and may be at increased risk of developing kidney injury. we performed a retrospective analysis of consecutive patients with lymphoma undergoing nonmyeloablative allogeneic sct between and (table ) . acute kidney injury (aki) within days of allogeneic sct was diagnosed and staged according to rifle-criteria, and severe aki was defined as rifle stage i-e ( doubling of creatinine or % decrease of egfr). chronic kidney disease was defined as an estimated glomerular filtration rate (egfr) o ml/min/ . m year after allogeneic sct. we performed multivariate logistic regression to evaluate potential risk factors for severe aki. severe aki developed in patients ( . %). reduced overall survival was observed in these patients, although not statistically significant. no significant associations were seen with age at transplantation, baseline kidney function or prior autologous sct. severe aki was associated with acute graft versus host disease (gvhd) (or . , p = . ) and the use of an unrelated donor (or . , p = . ). chronic kidney disease was observed in ( . %) of patients alive after year. we report a substantially higher incidence of severe aki after nonmyeloablative allogeneic sct for lymphoma than has been reported for other malignancies. acute gvhd and unrelated donor stem cell s source were associated with severe aki, while prior autologous sct, age and baseline kidney function were not. [p ] disclosure of conflict of interest: none. patients with acute myeloid leukemia who are treated with conventional chemotherapy still have a substantial risk of relapse. we, therefore, retrospectively analyzed data to investigate the effects and some risk factors of allogeneic hematopoietic stem cell transplantation in relapsed and refractory acute myeloid leukemia patients, and to provide some suggestion for the clinical treatment. a total of refractory and relapsed acute myeloid leukemia patients receiving allogeneic hematopoietic stem cell transplantation in our center between february and december were retrospectively analyzed, including patients in no-remission (nr) and patients in second complete remission (cr ) at the time of transplant. the median age was years (range: - ). conditioning was myeloablative using cyclophosphamide, busulfan and total-body irradiation (bu/cy, n = ; tbi/cy, n = ), and others were underwent nonmyeloablative stem cell transplantation. patients had successful engraftment. acute-gvhd and chronic-gvhd appeared in and patients. the year overall survival (os), relapse rate and disease-free survival (dfs) of the cases was ± . %, . ± . % and . ± . %, respectively. the -year dfs were higher for patients in cr patients ( . ± . %) than in nr patients ( . ± . %), and the relapse rate in nr group and cr group were . ± . % and . ± . % respectively. there was no significant difference in treatment-related mortality compared cr group with nr group. sex, age, related-donor graft were not independent factors affecting os, dfs and relapse rate. it is concluded that allo-hsct is an effective salvage therapy for patients with refractory and relapsed aml. non-remission before transplant and severe agvhd are high risk factors of poor prognosis for allo-hsct. patients in cr group who accept reinduction chemotherapy before transplantation have better prognosis than those in nr. the overall outcome seems related to the disease status. hsct during refractory and relapsed can achieve long-term survival in selected patients with individual therapy. disclosure of conflict of interest: none. the incidence of most hematologic malignancies increases with age. aging is related with a greater prevalence of impaired functional status and comorbidities. although cure of malignant and non-malignant hematological diseases is potentially possible with allo-hsct, it could lead to significant transplant-related mortality. decision making about referral to allo-hsct in older adults is a challenging task. in this study we aim to present our geriatric allo-hscts. from to , [p ] patients (age ) underwent allo-hsct in our center included to this retrospective study. pre-transplant status as well as posttransplant toxicities, complications and outcomes were determined. the age distribution of the group: patients was aged and o , patients was aged and o , patient was years old. the median age of donors was (range: - ). the pre-transplant patients' characteristics are given in the table. remission was achieved in twenty-three ( %) patients. twenty-six patients ( %) had neutrophil engraftment ( . × /l) at a median day of (range: - ) and platelet engraftment ( × /l) at a median day of (range: - ). post-transplant complications are detailed in the table. acute graft vs host disease (gvhd) was occurred in patients ( %) and chronic gvhd in patients ( %). eight patients ( %) were diagnosed with a relapse and year relapse-free survival was %. the -year and -year os were detected as % and %. the most common reason for mortality was sepsis. the -year os was higher in patients who had reduced intensity conditioning regimen and remission status pre-transplant however they were not statistically significant ( % vs %, p = . ; % vs %, p = . ) (figure) . since increasing number of older patients being diagnosed with hematologic malignancies, this trend of increasing number of allo-hsct will continue. tolerability and effectiveness are lesser, toxicity is higher in older adults. although study population is relatively small, reduced-intensity conditioning and pre-transplant remission status may be related to better survival. comprehensive geriatric assessment may be considered prior to allo-hsct for global evaluation. disclosure of conflict of interest: none. allogeneic hematopoietic stem cell transplantation (asct) is a procedure with high morbidity and mortality ( - %) requiring a complex hospital infrastructure. improved support measures and development of homecare units has allowed that asct at-home programs may be possible. our center has launched a pioneering program in our country in patients with asct to perform at home the following of aplasia, control of immunosuppressive therapy (ist) and intravenous support from the d+ of asct until the engraftment and independent ambulatory patient. to evaluate the patient safety, we compared the group of patients at-home (asct-op) with a cohort of asct 'in patient' with similar characteristics (asct-ip). asct patients between january and october at the hospital clinic of barcelona. patients performed asct-op and had an asct-ip. all patients received conditioning (myeloablative-mac-or reduce intensity-ric-) in the hospital with fludarabine mg/m (d - ) and busulphan . mg/kg ( - doses), prophylaxis of gvhd was performed with tacrolimus/mycophenolate (mmf) in asct-op group and cyclosporine(csa) and methotrexate (mtx) or mmf in asct-ip group. in all patients, the infectious prophylaxis was conventional (levofloxacin, fluconazole and acyclovir). moreover, the asct-op group received prophylaxis with ceftriaxone g intravenous (iv) once daily and liposomal amphotericin b inhaled mg twice a week during neutropenia. the asct-op group from d+ received a nurse visit once daily and physician visits twice a week in the hospital. baseline characteristics were analyzed those related to toxicity and patient outcomes. the median age (range) was years ( - ), male/female / ; ( % male). the source of the progenitors was peripheral blood in all cases and analysis of the results detailed in the table: disclosure of conflict of interest: none. an increase in rdw-sd after allogeneic hematopoietic transplantation is associated with a poor prognosis s leotta, a cupri, a di marco, a spadaro, l scalise, g sapienza, mg camuglia, g avola, g moschetti and g milone istituto oncologico del mediterraneo red cell distribution width (rdw), is an erythrocyte index influenced by stress erythropoiesis, inflammation and antioxidants. rdw predict mortality in sepsis, chronic kidney diseases and in cardiovascular disease. no data are available on rdw after hematopoietic transplantation. in a retrospective study we collected data on changes of rdw-sd in a group of patients who received allogeneic hematopoietic transplantation. fortyeight patients were affected by acute leukemia, by lymphoma, by mm, and by other diagnosis. rdw was studied at baseline and monthly for the first months. a subset of patients were studied prospectively for clinical and laboratory signs of microangiopathy. at baseline before the transplant a rdw-sd higher than normal upper limit was observed in % of allogeneic candidates. a high co-morbidity score (htc-ci score - ) at the pre-transplant screening was a factor associated to high rdw-sd (χ p = . ). a value of rdw-sd higher than normal range, at baseline, was not associated to any other factors, such as age, diagnosis, phase of the disease, previous transplantation, c-reactive protein, bilirubin, creatinine and arterial hypertension. early after allogeneic transplant we noticed at day + a significant reduction of rdw-sd but subsequently (at day + ) the proportion of patients showing an abnormal rdw-sd increased to %. an abnormal rdw-sd at s day + was registered in % of allogeneic transplant patients who presented an acute gvhd while in only % of patients who did not presented during the first months an acute gvhd (χ p = . ). in allogeneic transplantation group, patient who, at day + , had a rdw-sd higher than normal value had a inferior outcome in respect to patients having a rdw-sd within normal ranges (os was % vs %; logrank: p = . ;), (ci of trm: % vs %).these two groups were not significantly different for pretransplant features in the subset of patients studied prospectively, abnormal rdw-sd was associated to presence of schystocytes in pb (chi test: . ) and patients having ⩾ % schystocytes had a median rdw-sd of (iqr ) vs a median rdw-sd of (iqr . ) in patients who did not show schystocytes in pb (mann-whitney u-test p = . ). rdw-sd was significantly correlated also to serum triglycerides (r = + . , p = . ) and to red blood cell mean corpuscular volume (r = + . , p = . ). abnormal rdw-sd is frequent after allogeneic transplantation. abnormal rdw-sd is associated to acute gvhd and its value obtained at day + marks a group of patients with poor prognosis because of high trm. this simple parameter warrant further studies to determine its clinical usefulness in monitoring of patients suffering acute-gvhd and in diagnosis and monitoring transplant associated microangiopathy. [p ] disclosure of conflict of interest: none. sickle cell disease (scd) poses a lot of psychological burden for the patient and the caregiver. it also poses a significant financial burden over the family. ohaeri et al. developed a point questionnaire to asses sickle cell disease burden called as sickle cell disease burden index (scdbi) and its impact on caregiver's quality of life (qol). we used this questionnaire to assess the impact of hematopoietic stem cell transplant (hsct) on caregiver's qol. point questionnaire was sent to set of parents whose child underwent hsct between january and june . scdbi contained questions in various domains ( :family finances, :family interactions, :routine family activity and :parental coping ability). answers were graded on a score of - ( :never occurred and :occurred regularly or had a severe impact on the family). the results were interpreted in two headings a. family finances and interactions ( : no impact; - : insignificant impact; - : moderate impact; - : severe impact) and b. routine family activity and parental coping ability ( : no impact; - : insignificant impact; - : moderate impact; - : severe impact). all these domains were assessed before and after hsct. ten parents replied with duly filled questionnaire. mean age at hsct was . years (range: - ), m/f: / . all were symptomatic for months before hsct with % having more than hospital admissions. majority of parents were from middle class with median family income of usd per annum (range - usd). median score for family finances and interactions (a) before hsct was (range: [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] which decreased to (range: - ) after hsct. median score for routine family activities and parental coping ability (b) before hsct was (range: which decreased to (range: - ) after hsct. our results suggest that before hsct there was a moderate impact on family finances and interactions which reduced to no impact after hsct. similarly there was severe impact on family activities and parental coping ability before hsct which changed to no impact after hsct. our study suggests that hsct not only improves the qol of the child but also of the caregivers. chronic graft versus host disease (cgvhd) is a late complication of allogenic hematopoietic stem cell transplantation (hsct) that affects many tissues and organs and manifests with polymorphic clinical features similar to autoimmune diseases. poorly understood pathophysiological mechanisms are implicated in inflammation and tissue fibrosis which is a hallmark of cgvhd. the affection of lachrymal glands is frequent and contributes to ocular manifestations presenting as dry eye syndrome. autologous serum eye drops (aesds) are used topically to facilitate tissue healing and ease the symptoms in a variety of ocular diagnosis. it is unclear if the serum of a patient with cgvhd is suitable for remedy preparation and if the transplanted patient himself can meet the criteria for autologous donation. aim is to show the safety, feasibility and efficacy of autologous serum preparations in ocular lesions after allogenic hsct. donors should meet criteria for autologous blood donation (infectious disease status, complete blood count hgb g/l, hct %, adequate venous access). aesds are prepared from ml of autologous blood left to clot, irradiated and centrifuged to separate serum which is diluted with saline in : ratio or : if requested. product is dispensed into . ml ampules, stored at − °c and a -month supply is released to the patient after receiving negative results of sterility testing. in period from to . in the aesds program patients ( female, male) with ocular symptoms were included. all met required predonation criteria. of collections performed, one failed due to venous access problem and one product had to be discarded due to hemolysis. cgvdh global nih score of the patients at start of the program was: severe, moderate, mild and not scored. all patients presented with moderate to severe dry eye symptoms. in ( %) patients aesds alleviated dry eye symptoms. in ( %) out of patients referred to aesd program, more than autologous blood collections were performed (range: - ) and aesds were used regularly through period of - months, which points to the beneficial effect of the long-term use of the serum. three patients dropped out because aesds showed no advantage compared to commercial lubricant eye drops preparations. one patient dropped out because of a venous access problem, patients had disease s progression and needed other therapies: cases of amniotic membrane application of which continued with aesds to facilitate the healing effect. one patient was recently included and the effect of aesd is still evaluated. autologous donations in cgvhd patients are feasible, safe and autologous serum preparations can help relieve symptoms of dry eyes. it needs to be further elucidated specifically in which patients and at what point of the disease course the effect of the aesds is the most beneficial to make optimal use of these preparations. disclosure of conflict of interest: none. idiopathic pneumonia syndrome (ips) is a non-infectious pulmonary complication with diffuse lung injury that develops in - % of patients who undergo hematopoietic cell transplantation (hct) and the mortality rate remains high at % . the major aim of this study was to identify prognostic biomarkers for ips and establish positive and negative predictive values (ppv and npv) of ips. in a case-control study, we compared patients with ips with available samples (transplanted between and at fhcrc) with hct control recipients who did not require bronchoscopic examination and who did not grow any bacterial or fungal blood cultures. for each subject, plasma samples at day post hct and onset of ips or matched time points for controls were analyzed. the 'onset sample' for controls was the sample closest to day (median day of onset for patients with ips). we measured six proteins by elisa: suppressor of tumorigenicity (st ), tumor necrosis factor receptor (tnfr ), interleukin- (il- ), lymphocyte vessel endothelial receptor (lyve)- , endothelial protein c receptor (epcr), and herpes virus entry mediator (hvem). multivariable logistic regression models were used to evaluate the association of each protein with ips vs controls. cytokine cutoff values that maximized discrimination between ips and controls were identified using receiver operating characteristic (roc) analysis. ppv and npv of ips were calculated using the identified cytokine cutoffs across a range of hypothetical ips prevalence values ( - %) day weighted kaplan-meier survival curves were estimated for high/low cytokine subgroups. similarly, a weighted log-rank test was used to evaluate p-values. a multivariable logistic regression model including six cytokines showed that st and il- were significantly important markers to identify ips at the onset (table ) . st value at day post hct was significantly associated with occurrence of ips and il- had a marginal association. predictive values for ips by a plausible percentage of the actual hct population (up to %) are shown in figure . of the six proteins, st showed the highest ppv both at onset and day post hct followed by tnfr , and il- . npv were high in all the markers. to analyze whether st and il- at day after hct can predict survival following ips, we dichotomized the patients into cytokine high and low groups (cutoff level: st , ng/ml; il- , pg/ml) and compared survival after downweighting the observations to represent a plausible percentage of the actual population (ips prevalence, %). day survival rate were significantly lower in st high value group than in st low value group ( % vs %, p = . ). similarly, il- high value was associated with high mortality (day survival rate, % vs %, p = . ). st , il- , and tnfr were good prognostic markers for occurrence ips. especially, st and il- at day after hct can be a predictor for both ips occurrence and survival following ips. these results require validation in an independent prospective hct population. body composition parameters are sensitive nutritional indicators that influence response to treatment and mortality in cancer patients. research is not conclusive on the changes in muscle attenuation and adipose tissue areas in the stem cell transplantation (sct) phases. objective is to assess the changes in adipose tissues, skeletal muscle index (smi) and waist circumference (wc) among stem cell recipients in the peri-transplantation phase. study design: institutional review board approved this retrospective study with adult patients (age years) having b and t lymphoma who underwent sct. each patient was imaged by pet/ct scan pre-sct and months post transplantation. a cross sectional image was analyzed at the level of the l to calculate total adipose tissue (tat), visceral adipose tissue (vat), intra-muscular fat (imf), smi and wc. data was analyzed by gender since body composition parameters differed significantly between the two categories in the literature. the study sample consisted of patients (mean age: . ± . years, ( %) males, ( . %) autologous sct, median overall survival in months: . in males and . in females). death was observed in ( . %) males and ( . %) female. patient characteristics were similar for males and females except for weights (kg) and body mass index (kg/m ): . and . vs . and . in males and females respectively. changes from pre-sct to months post sct revealed that tat, vat, smi and wc decreased with mean differences of ± . cm , . ± . , . ± . cm /m and . ± . cm, respectively in males (po . ). in females, tat and wc significantly decreased with mean differences of . ± cm and . ± . cm, respectively (po . ). in females, vat and smi decreased clinically but did not reach clinical significance. in multivariate analysis, no significant associations were shown with mortality and progression rates. this study fills a research gap by providing data on the evolution of body composition parameters in the peri-transplantation phase. tat, vat, smi and wc decrease months post transplantation. future studies should evaluate the associations of these parameters with major outcomes on larger sample sizes. [p ] disclosure of conflict of interest: none. . patients received tbicontaining preparative regimen. all these patients were exposed to calcineurin inhibitors for prevention and treatment of gvhd. patients suffered from cgvhd-grade moderate or severe. all patients required systemic corticosteroids, because of gvhd ( pts) or during basic treatment of lymphoma ( pts). all patients had deficient states of vitamin d initially and required replacement. all of them, except for patients, had balanced adrenal insufficiencies and patients had balanced hypothyroidism. all women had premature ovarian failure ( received hrt). according to measurements of bone mineral density (bmd), low bone mass was detected in patients; osteopenia ( pts), osteoporosis ( pts). bone loss of femoral neck ( -osteopenia, -osteoporosis) occurred more often than lumbar vertebral ( -osteopenia, -osteoporosis) or radius ( osteopenia, -osteoporosis). presence of avascular necrosis of bone (avn), confirmed by mri, was detected in patients and the most common site of involvement was the femoral head(all patients), knee( pts) and shoulder( pts). one of the first symptoms of avn was pain and functional limitation. all patients required intensive analgesic treatment, usually nsaids and patientsfentanyl. fractures occurred in patients. the femoral neck ( pts) and thoracic or lumbar vertebral ( pts) were two most common fracture sites. all patients were qualified for surgery; patients required hip replacement, patients still awaited to perform surgery or were disqualified because of severe, skin cgvhd. bone complications may occur in about % of allo-hct survivors (including % patients with gvhd, and up to % patients with severe or moderate cgvhd) within first years after allotransplantation. bone loss, particularly at the femoral head, is the most common complication. avascular necrosis usually requires surgical intervention because of fractures. exposure to higher doses of corticosteroids (during treatment of gvhd) increases risk of bone complications. early diagnosis by mri and dxa may help to detect bone complications. ( %) and (e) ( %). a total of ( %) pts failed to meet these criteria but remained alive on day and ( %) died before day . the overall survival (figure ) for the pts was % at years with an overall mortality in icu of % ( / ) compared to % ( / ) for those who did not meet our criteria. the overall survival for pts that met our criteria at fifth day and were discharged to the haematology ward (n = ), was % at years. in this study, % of patients survived their icu admission. patients could be stratified according to the reason for admission and given an individualized -day trial: those who met our criteria for successful icu trial ( %) had a low icu mortality ( %) and those who were subsequently discharged home had a overall survival of % at years. this study raises the possibility of offering a short-term icu stay to oncohematologic patients and perhaps allows for the ceiling of intensive care for those who fail these criteria. [p ] disclosure of conflict of interest: none. in contrast, only . % of patients without cgvhd showed a thromboembolic complication in the later time course, with one patient showing an additional thrombotic risk factor. in multivariate analysis cgvhd was an independent risk factor for thromboembolic complications after hsct. . % of patients with thrombosis before hsct showed one afterwards. thrombosis before hsct was not found as risk factor for thromboembolic complication after hsct. our retrospective analysis showed an increased risk for thromboembolic complications after allogeneic hsct, with substantial higher risk in patients with chronic gvhd ( . %). in ongoing studies we currently investigate a vascular screening procedure with additional biomarkers according to inflammation and endothelial damage in patients with cgvhd prospectively. we hope to identify patients at risk for thromboembolism and prevent future complications on an individualized basis. disclosure of conflict of interest: none. ( ). pts with cns involvement received intrathecal therapy with cytarabine and in one case additional cns irradiation was applied. / pts died after a median time of mts (range: - mts) due to resistant systemic relapse, infectious complications or extensive graft-versus-host disease following allohsct. patient remains alive and disease-free at + mts following secondary allohsct. conclusions: our data indicate that em disease following allohsct affects a significant proportion of pts with aml. sites of em relapses vary widely among the pts with skin and cns being frequently involved. an aggressive approach combined of local and systemic therapy including secondary allohsct may produce favorable response in a small proportion of pts, however, overall prognosis for pts with isolated em relapses still remains poor. due to the lack of effective treatment strategies, there is a need for novel approaches to manage isolated em relapses after allohsct. disclosure of conflict of interest: none. hematopoietic stem cell transplantation (hsct)-associated thrombotic microangiopathy (tma) is a multifactorial complication, and has variable incidence in study populations due to different diagnostic criteria. aim: our aim was to identify pediatric patients with hsct associated tma using different diagnostic tma criteria published in literature and to compare the various groups for tma parameters and outcomes. we enrolled pediatric patients who underwent allogeneic hsct using treosulfan based or reduced intensity conditioning therapy. different tma diagnostic criteria, the bmt ctn toxicity committee consensus definition ( ), the overall thrombotic microangiopathy grouping ( ), the diagnostic criteria created by city of hope ( ) and the criteria proposed by jodele et al. ( ) were used to startify the patients. we determined and registered the following tma activity markers: presence or development of increased ldh and decreased haptoglobin levels, new onset anemia, thrombocytopenia, fragmentocytes, coombs test, kidney function, proteinuria, hypertension and terminal complement complex (sc b- ). complement pathway activities, components and sc b- were measured during early hsct period. two/ ( ), / ( ), / ( ) and / ( ) subjects met the different tma diagnostic criteria according to the four different systems on day and ( ) and on median ( ), ( ), ( ) post-hsct days. all of the / patients who were defined with the first three criteria, met the forth definition. due to normal haptoglobin levels and kidney function, / patients fulfilled only the forth criteria. tma coexisted with acute graft-versus-host disease in / cases ( / vs / ; p o . ). patients who met any of the different tma diagnostic criteria had higher sc b- level on day ( vs ng/ml; p = . ) compared to those without. all of the / subjects defined with tma had elevated sc b- ( ng/ml) level during the early hsct period. two patient died before day after hsct, out of which one patient met all of the four tma diagnostic criteria. after a median . ( . - . ) year follow-up time, overall survival was / . / patients with tma survived, compared to / patients without tma. relapse related mortality was the most common cause of death (n = / , po . ), while tma was not a significant cause of mortality after reduced toxicity conditioning therapy. hsct-associated tma has a variable and complex pathophysiology. using the different diagnostic criteria may influence the incidence and the time of diagnosis of this transplant-related complication. monitoring all of the published tma activity parameters, including complement terminal pathway activation marker, may help to guide physicians to recognise tma after hsct. disclosure of conflict of interest: none. hematopoietic stem cell transplantation (hsct) is associated with a risk of non-relapse mortality (nrm). it's important to assess the risk of complications and mortality before the hsct. some indexes quantify the impact of patients' comorbidities on hsct outcome. the most frequency used is the hct comorbidity index (hct-ci) and the european group for blood and marrow transplantation score (ebmts). this study tried to determine which of the two indexes best predicts the outcome in a series of patients submitted to hsct in a single center. between and , hsct were performed in our center. a total of hsct have been analyzed (we excluded patients o years (yr), nd hsct, haploidentical donors and hsct for specific diseases with very low number ( o %) of hsct performed: aplastic anemia, cll, prolymphocytic leukemia, mycosis fungoides, sezary syndrome, dendritic cell neoplasia, plasma cell leukemia and poems syndrome). the hct-ci and ebmts were calculated retrospectively (yr - ) and prospectively (yr - ). overall survival (os), relapse incidence (ri) and nrm were analyzed in the overall series and separately according to the type of hsct: autologous hsct (auto-hsct) or allogeneic hsct (allo-hsct). male: ( %) patients. median age: yr (range: - ). diseases: aml ( %), all ( %), mm ( %), nhl ( %), hl ( %), mds ( %), cmpd ( %). disease status: st complete remission (cr) or st chronic phase ( %), ⩾ second cr ( %), first partial remission (pr) ( %), ⩾ second pr ( %), no response ( %) and without previous treatment ( %). auto-hsct in patients ( %) and allo-hsct in ( %) patients. related and unrelated donor were ( %) and ( %), respectively. the conditioning regimen was standard in ( %) cases and reduced intensity in ( %). hct-ci and ebmts grouped - , and ⩾ were ( %), ( %), ( %) and ( %), ( %), ( %) in auto-hcct and ( %), ( %), ( %) and ( %), ( %), ( %) in allo-hsct, respectively. median follow-up was . yr ( . ; . ) for the overall series, . yr ( . ; . ) for auto-hsct and . yr ( . ; . ) for allo-hsct. significant differences in os and nrm were found according to the ebmts in patients submitted to auto-hsct. one-yr-os and -yr-os were % ( % ci: %; %) and % ( % ci: %; %), respectively, in patients with ebmts - , vs % ( % ci: %; %) and % ( % ci: %; %), respectively, in patients with ebmts ⩾ (p = . ). one-yr-nrm and -yr-nrm were % ( % ci: %; %) in patients with ebmts - , vs % ( % ci: %; %) in patients with ebmts ⩾ (p = . ). no significant differences were observed for ri according to ebmts in patients submitted to auto-hsct. no significant differences in os, ri and nrm were observed according to ebmts in patients submitted to allo-hsct. no significant differences regarding os, ri or nrm were found when the hct-ci was assessed. in our series, only the ebmts was predictive of os and nrm in patients submitted to auto-hsct. failure to find statistically significant differences for the hct-ci and for ebmts in allo-hsct recipients could be due to an insufficient number of patients or to a partial retrospective collection of data. infertility is common after hct predominantly as a result of the chemoradiotherapy used in conditioning. nonetheless, some patients do retain or recover fertility. newer reduced intensity regimens may be less gonadatoxic. in addition, patients are increasingly encouraged to store gametes, or embryos before transplant. we sent questionnaires to ebmt centers requesting retrospective details of number of pregnancies and pregnancy outcome for all patients treated between - . centers responded from countries detailing patients who became pregnant/partners conceived. the most frequent underlying diagnoses were acquired bone marrow failure (n = , f) aml (n = , f), hd (n = , f), cml (n = , f), all (n = , f) and b nhl (n = , f). other diagnoses included mds, mps, solid tumours, autoimmune disease, cll, t-nhl, haemoglobinopathy. of females (f), ( %) involved assisted reproductive techniques (art). f had tbi ( seven o gy) of which ( %) had art. f had reduced intensity conditioning of whom ( %) had art. f were specified as having standard conditioning of whom ( %) had art. f had allogeneic ( art, %) and f had autologous transplants ( art, %). of men (m) whose partners conceived, ( %) had art. m received tbi of which ( %) had art. where specified, had reduced intensity hct ( art, %) and had standard conditioning ( art, %) . had had allogeneic hct ( art) and autologous ( art). men had reduced intensity transplants. men received tbi (two o gy) of whom ( %) had art compared to men without tbi, ( %)of whom had art. data on return of menstruation was available for . indicated yes and ( %) had art. indicated amenorrhoea of whom ( %) had art. specifying number of children had live births (lb) and ( %) patients had more than one child after hct. lb occurred in female patients ( art, %) and lb were in partners of male patients ( art, %). the median gestational age for female patients was weeks (range: - ) and the median birth weight was kg (range: . - . ). there were / congenital anomalies. the median follow up of the offspring was y (range: - ). developmental problems were indicated for / (fine motor skills) and learning difficulties in / (adhd). in partners of male patients the median gestational age for offspring was weeks (range: - ). the median birth weight for offspring was kg (range: . - . ). congenital malformations occurred in / . one infant died of pulmonary infection. in women, several methods of assisted conception were used including hormone stimulation, ivf, cryopreserved embryos, donor embryos and cryopreserved ovarian tissue. the most frequent method was use of donor embryos ( / ) in which a minimum of attempts led to lb. the median number of attempts was (range: [ ] [ ] [ ] [ ] [ ] . art were frequently used in this group of posttransplant patients particularly in male patients vs female, tbi vs non-tbi, amenorrhoeic vs menstruating women, standard conditioning vs ric. in patients who conceive after hct, successful pregnancy leading to healthy offspring is the likely outcome. disclosure of conflict of interest: none. reduction of trm after sct was observed over the transplant periods and supportive care with danaparoid was found to be significantly effective to reduce trm. therefore, prophylactic administration of danaparoid is considered to be a reasonable option to improve the transplant outcomes for children. [p ] disclosure of conflict of interest: none. the attainment of transfusion independence after transplant is sometimes hampered by a combination of factors, ranging from infections to the need of combined therapy for clinical complications, as well as control of gvhd. iron overload is frequently observed in hematological patients before and after hematopoietic stem cell transplantation (hsct). whereas several reports have focused on iron overload before transplant, up to now, this is the only report that show full recovery of hematopoiesis and correlate this to deferasirox chelation performed on this particular subset of patients. we report on patients, transplanted for hematological diseases ( acute leukemia, aplastic anemia, multiple myeloma) heavily transfused before transplant that, considering the iron overload, were treated with deferasirox after hsct. before starting deferasirox, the patients were fully engrafted and in complete remission, although transfusion dependent, and with incomplete hematological reconstitution after allogeneic hsct. patients were selected according to the following inclusion criteria: ( ) transfused pre-transplant with more than rbc units; ( ) incomplete hematological recovery; ( ) transfusion-dependence; ( ) serum ferritin ng/ml; ( ) normal creatinine value. the workup for other aetiologies resulted negative. all patients received an initial dose of deferasirox mg/kg/day, later adjusted according to side effects. all patients experienced an increase in hemoglobin levels, with a reduction in the frequency of rbc transfusions, followed by transfusion independence (median time: days from the first dose of deferasirox). in addition, it was promptly (median time: days) associated with hematological improvement, with sustained values and no further platelet support or growth factors administration. no relevant modifications with immunosuppressive or myelosuppressive drugs were made during deferasirox treatment. deferasirox was well tolerated. basing on our results, we think that deferasirox determined stimulatory, and/or depressive effects on hematopoiesis after allo-hsct. this clinical experience raises the possibility of a potential additive benefit on hematopoiesis after transplant following iron chelation therapy with oral deferasirox. further long term studies, in larger cohorts of patients are needed to confirm these data and to design an efficient strategy to reduce iron loading after transplant. disclosure of conflict of interest: none. supported in part by ail pesaro onlus. ( ) hypertension (n = ). all five patients had normal adamts levels and negative testing for shiga toxin. complement mutation genetic studies were obtained for four patients including genes (n = ) and genes (n = ) and were all negative. testing for complement pathway including c b- were obtained for patients and were normal. all five patients were treated with eculizumab with induction treatment at mg weekly × doses, followed by one dose of mg on the fifth week, and mg every weeks thereafter. patients had a recovery of hemoglobin and platelets and a rise in haptoglobin and a normalization of ldh within - weeks from the start of eculizumab. eculizumab was discontinued for of the patients without recurrence of their tma; they are now - months since the discontinuation of eculizumab. in summary, there is a subacute syndrome of thrombotic s microangiopathy that can occur late post transplant. this syndrome appears to be complement mediated as shown by its response to a terminal complement inhibitor. it also appears to be transient without recurrence following treatment discontinuation. disclosure of conflict of interest: none. transplant associated microangiopathy (tam) is a very severe complication occurring after allogeneic bone marrow transplantation (bmt), burdened by a high case-fatality rate. it is characterized by abnormal complement activation, triggered by various agents (calcineurin inhibitors, acute gvhd, infections) with subsequent endothelial damage. in the literature, cases of mutations in recipient complement genes are described, but none in donor dna. here we describe for the first time patients affected by tam, carrying mutations in donor complement genes. in our lab, we studied patients affected by tam; they were screened for cfh autoantibodies, adamts function and variants and macro-rearrangements in cfh (and related), cfi, cfb, cd , c , dgke, thbd genes and at-risk haplotype (cfh-h and mcpggaac) by means of next-generation sequencing (ngs) and multiplex ligationdependent probe amplification analysis (salsa mlpa p armd mix- ; mrc holland). ngs was used to sequence dna by haloplex kit (agilent) on a miseq (illumina) platform with -fold coverage of every target base. the bioinformatic analysis was performed using sophia genetics and the pathogenicity was assessed by means of in silico predictions (polyphen , sift, mutationtaster, aligngvgd). all of the predicted pathogenetic variants were confirmed using sanger sequencing. the same genetic screening was extended also to donor dna in all cases. the screening for known causes of tam revealed mutations in recipient complement genes in one case; no mutations were found neither in recipient nor in donor dna in two cases; instead, donor genetic alterations were found in patients whose characteristics are summarized in table s donor hematopoietic cells. in the three cases presented, tam was relatively delayed with respect to hsct, in particular in two cases ( months) and this timing is compatible with the concept of reticulo-endothelial 're-population' by donor cells of monocytic lineage, responsible for the production of regulatory proteins of the alternative pathway of the complement. we also underline the response to anti-c inhibition in the patients who were treated with eculizumab; this fact further supports the hypothesis that the disease was related to complement dysregulation. we therefore suggest that both the recipient and the donor should be screened for complement gene mutations, so that more cases could be identified and the pathogenesis of tam could be further clarified. among these we observed one autologous engraftment, one death due to septic shock before engraftment and two primary gf. we used a desensitization treatment based on plasma exchange procedures, intravenous immunoglobulin ( g/kg) and rituximab ( mg/sm) in patients. one of these patients (aml, haploidentical donor) had dsa against hla-b (mfi ). she experienced primary gf with increasing titles of dsa (maximum mfi ); so, on day , a second transplant from the same donor was performed after a desensitization treatment. a progressive decrease in dsa was documented (up to mfi ⩽ ). on day patient achieved neutrophil count over /μl and on day platelet count over /μl. the second patient (mds, haploidentical donor), instead, received a desensitization procedure before the first transplant. she had dsa against hla-a (mfi ), and after desensitization dsa levels decreased and reached . on day patient achieved neutrophil count over /μl and on day platelet count over /μl. dsa were detected in / of usct candidates ( %) and / of haplosct candidates ( %) and they were associated with failure to obtain allogeneic engrafment in cases. desensitization treatment achieved dsa clearance and engraftment in the patients in which it was performed, underlining the potential benefit of this procedure in the setting of hsct with dsa that has to be validated by prospective and controlled studies. disclosure of conflict of interest: none. early complications and late effects and quality of life at myeloma multiplex patients z trajkovska-anchevska, a pivkova, s genadieva-stavrich, l chadievski, z stojanoski, l chevreska and b georgievski university hematology clinic, skopje, macedonia the subject of this research is the quality of life at patients with myeloma multiplex at diagnosis and during therapy within - months. the research aims to analyze patients to be able to continue activities which will contribute for improving their quality of life as a priority task placed before the patient, his family, health institutions and social environment. this research was conducted at the university clinic for hematology skopje in the period from june to march . it covers patients infected with multiple myeloma, diagnosed and treated during this period. a total of patients analyzed, using the eortc qlq c ver. . standardized questionnaires for hr quality of life that analyzed the physical, cognitive, emotional, personal and social functions related to the patients. it also analyzed and general health and quality of life. analysis of physical functioning at diagnosis is . during treatment . , significantly improved. personal functioning at patients at the diagnosis is . , during therapy − . . analyzing emotional functioning in patients at diagnosis is . , during the therapy over . significantly improved. in examining the cognitive functioning is also a significant difference at diagnosis . , during treatment . . social functioning of the patients was . at the diagnosis; during the treatment grow to . . significant improvement was notices in these patients' symptoms like fatigue, nausea and vomiting, pain, dyspnea, insomnia, loss of appetite, constipation and diarrhea. the analysis of the financial difficulties of patients at diagnosis is . and . during treatment, meaning no significant difference in the time given. the analysis of the overall health and quality of life at patient has a value of . , and during therapy . . quality of life at patients with myeloma multiplex that makes the research group was significantly improved as a result of on time diagnosis and treatment with modern medicaments and the role of social worker with the application of certain social skills, continuous counseling, guidance and education for their reintegration in the community. installing the quality of life as a separate category and investigating the factors that affect its expression in the daily functioning of the patients within the changed framework of action, as like this example for malignant disease. the needs of clearly defined interactions patient illness and treatment, quality of life and specifying the segments where it can effectively act and improve in order to achieve positive progression towards improving the qualitative features of this category is a clear and primary objective that must be inserted into the current approaches to monitoring patients with malignant hematological diseases. acute graft-versus-host disease (agvhd) is a common and severe complication after allogeneic stem cell transplantation. since the current first-line treatment is based on treatment with systemic glucocorticoids (gc), steroid-induced hyperglycaemia develops frequently in patients with (agvhd) potentially impacting on their outcome. we performed a retrospective analysis on patients who received systemic gc for agvhd and thoroughly investigated the consequences of aberrant glucose metabolism. in particular, we focused on glucose parameters early after initiation of gc. with a median of (range: - ) blood glucose measurements during gc treatment, increasing mean, median and maximum glucose levels as well as the need for insulin treatment were associated with decreased overall survival (os) in simple and multiple survival analysis. early hyperglycaemia, as defined by mean blood glucose levels mg/dl during the first days of gc therapy, was also found to be highly associated with adverse outcome: in multivariate analysis, the hazard ratio (hr) for death was . ( % ci . - . , p = . ) in patients with early hyperglycaemia. while the risk of death due to relapse was not increased, the hr for death due to non-relapse mortality was . ( % ci . - . , p = . ) in a competing risk analysis. a score based on early hyperglycaemia and non-response to gc within days allowed the identification of three risk groups: patients with both risk factors had an inferior os at years of . % as compared to . % in patients with none. patients with one risk factor had a -year os rate of . % (p = . for trend). in this retrospective study, we identified early hyperglycaemia after gc initiation as a prominent factor predicting increased nonrelapse mortality in agvhd patients. in addition, a score based on early hyperglycaemia and lack of response to gc was highly predictive for overall survival in these patients. disclosure of conflict of interest: none. early toxicity because of infectious complications not relapse is the main cause of death after allogeneic transplantation in aplasia for patients with refractory or relapsed acute myeloid leukemia high-dose cytarabin was given in / pts with induction failure. the search for a stem cell donor was started immediately after results of high-risk cytogenetic, no achievement of bone marrow aplasia on day of induction therapy, or immediately after diagnosis of relapse. four patients had a related / donor, for patients a / matched unrelated donor was identified and patients received a transplant from a / unrelated donor. the interval between diagnosis of primary disease or relapse and tx was ( - ) months (mo) for both groups . in patients melphalan ( - mg/m ) was used to induce an aplasia before starting conditioning therapy. the interval between melphalan and conditioning therapy was ( - ) days. three pts started the conditioning therapy while in aplasia after previous chemotherapy. the conditioning therapy was of reduced intensity in all pts. and consisted of treosulfan ( g/m )/fludarabin(flu) in pts, tbi( gy)/flu in pts and busulfan( m/(kg)/flu in pts, respectively.atg was given to all pts with an unrelated donor. most pts ( / ) had a severe neutropenia with a median of . /nl ( . - . ) before starting melphalan because of refractory leukemia. after a median follow-up of ( - ) mo pts ( %) were alive without relapse. ( %) pts died because of a relapse after a median of ( - ) mo. the nonrelapse mortality was % ( / pts). most of these pts ( / , %) died because of infectious complications early after transplantation (med ; - mo). in pts graft versus host disease was the main cause of mortality. in this retrospective 'real-life' analysis, we showed that an early allogeneic transplantation is feasible for patients with primary refractory or relapsed aml. a reduced intensity conditioning after induction of aplasia with melphalan offers a chance of long-term relapse-free survival for about % of patients with an otherwise dismal prognosis. nrm is high, especially because of infectious complications early after transplantation, probably related to the long period of severe neutropenia. therefore, the focus has to be set on early recognition and intervention of infectious complications. disclosure of conflict of interest: none. recent evidence supports the effector role of complement activation in several types of thrombotic microangiopathythe atypical hemolytic uremic syndrome (ahus) as well as the transplantation-associated thrombotic microangiopathy (ta-tma). the blockade of the terminal complement complex formation by anti-c monoclonal antibody eculizumab provides an effective treatment option in severe and devastating cases of ta-tma. the experience with the use of eculizumab in this indication is slowly accumulating in the hsct community, however the published data originate from small case series or uncontrolled trials and sharing of emerging real-life observations may be valued. on case reports of two pediatric patients treated with eculizumab for ta-tma with very detailed followup of multiple complement parameters, including terminal complex sc b- and eculizumab drug levels we would like to demonstrate: ( ) achieving therapeutic levels of eculizumab ( μg/ml) may be unsuccessful even with initially intensified dosing interval. furthermore, we documented rapid eculizumab clearance from circulation which allowed only for short periods ( o h) of efficient drug levels during the weekly dosing. ( ) we did not observe tightly correlated sc b- and eculizumab levels within the dosing intervals; however the long-term sc b- formation suppression was achieved concomitantly with improved eculizumab levels and slowed drug clearance. ( ) classical complement pathway activity assay (ch ) may not reliably substitute for therapeutic efficiency monitoring in case of hypocomplementaemia due to protein losses (profound diarrhea, proteinuria, gi bleeding, catabolism). this holds true also for the alternative pathway activity which remained low during treatment in both patients. ( ) mycotic infections may represent serious therapy related risks in eculizumab treatment after hsct (both patients achieved control of complement activation after multiple doses of eculizumab, however suffered fatal infections subsequently). besides, we observed a significant increase in c a concentrations correlated with clinical onset of infection which invites for further investigation of this complement cascade product as early indicator of mycotic infection. in conclusion, we would like to highlight the great added value of timely available complement assay results, including sc b- and especially eculizumab drug level values-to be used together with detailed clinical parameters for directing effectively these highly personalized (and also costly) treatments. [p ] disclosure of conflict of interest: none. table . no difference in terms of drug-related adverse events was observed in the three patient cohorts with no reported serious adverse events. similar results were obtained performing two separate sub-analysis only for lymphoma or myeloma patients. despite the limitations due to the non-randomized nature of the study, from our data on a large cohort of patients s with a long-term follow-up biosimilar filgrastim (zarzio®) could be considered substantially equivalent in terms of efficacy and safety to lenograstim (myelostim®) and peg-filgrastim (neulasta®), when used for hematological recovery and febrile neutropenia prophylaxis after asct in adult patients with hematologic malignancies. disclosure of conflict of interest: none. we studied all adults who underwent allo-hsct during a -month period ( january to november ) in our center. a total of pts ( . %) received epag for pfg with thrombocytopenia. three pts were male, and three female. median age was years ( - ). the baseline diagnoses were: alm ( ), mds-raeb ( ), idiopathic myelofibrosis ( ), aa ( ), and cll ( ). three transplants were from family donor (all of them haplo-identical), and from unrelated donor (the three of them hla / ). sc source was pb in cases, and bm in . epag was started at mg/day and escalated each weeks to , and mg if platelet count was o × /l. we analysed the platelets, anc, and hgb at epag initiation and days after being with the maximum dose. median time between allo-hsct and eltrombopag initiation was days ( - ). median maximum dose used of epag was mg/day ( - ). median platelets, anc and hgb before starting treatment were × /l ( - ), × /l ( . - . ) and . g/dl ( . - . ), respectively. five patients ( %) were severely thrombocytopenic (platelet count ⩽ × /l), ( %) were anemic (hbg o g/dl), and ( %) were neutropenic (anc o . × /l). median platelets, anc and hgb at day + of maximum dose were: × /l ( - ), . × /l ( . - . ) and . g/dl ( . - . ), respectively. the thrombocytopenic pts ( %) responded to epag, with increases of , , , and × /l in the platelet count. three anemic pts ( %) responded and achieved increases of hgb of . , . and . g/dl. finally, the neutropenic pts ( . %) responded and achieved increases of anc of and × /l. at the moment of the analysis close, pts are at a median of + . months post-hsct ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , and all but one (who died from a septic shock) are alive and outpatient. this survival is striking for subjects who develop a complication with such a high expected mortality as pfg. pgf is a life-threatening complication, relatively frequent after alternative donor hsct, whose treatment has been very disappointed. we report our experience in pts who developed pgf during the last years. epag induced responses in platelets in all pts of the studied group. bilineal and trilineal responses were also seen. in our opinion, prospective studies are warranted in order to confirm epag as a new efficient treatment of post-hsct poor graft function. disclosure of conflict of interest: none. s ing patients who developed es with an equal number of patients who did not between january and november . we analyzed variables such as cd + cells per kg infused, use of granulocyte colony-stimulating factor (csf-g) and engraftment day. analytical data, including baseline and maximum determination of serum glutamic oxaloacetic transaminase (got) and glutamic pyruvic transaminase (gpt), c-reactive protein (crp) and procalcitonin (pct), as well as clinical data fever, weight gain, digestive and respiratory symptoms, pulmonary infiltrates were analyzed. sixty-eight patients were women. median age was years old (range: - ). patients were conditioned with beam ( %), melphalan mg/m ( %) and bcnu-tt ( %). nineteen patients developed es in our series, which correspond to eight percent of all asct. case and control groups were matched according to age, sex, diagnosis and conditioning regimen. the most prevalent baseline disease in the group with es was myeloma ( . %), followed by mantle cell lymphoma ( . %). all patients who developed es had fever, % skin rash, % respiratory symptoms, % pulmonary infiltrate an % digestive symptoms. a summary of the comparison of data analyzed in subgroups is shown in table . we found significant difference in the percentage of weight gain (p = . ), increase of tgo (p = . ), increase of tgp (p = . ) and increase the number of cd + cells per kg infused (p = . ), we found an inverse correlation between the number of cd + cells per kg infused and incidence of es. however, in terms of post-transplant csf therapy (p = . ) and crp and pct valor (p = . and p = . , respectively) we did not find significantly difference to develop es. in our series, weight gain and tgo and tgp rise were risk factors for es development. therefore, we should be aware of es in patients who develop fever, elevated liver enzymes and weight gain during graft phase. we did not find a significant difference in crp and pct suggested in other studies. further studies are required to better characterize risk factors of es development. busulphan-based ( ), melphalan-based ( ), beam ( ), tbi-based ( ), and others ( ). weight at hospital discharge was significantly lower than at admission ( . % in allo-hsct, and . % in auto-hsct). weight at day + was also significantly decreased compared with the admission ( . % in allo-hsct, and . % in auto-hsct). weight at day + was lower than the ideal for their sex and height in the allo-hsct setting. contrarily, among the patients undergoing auto-hsct, the weight at day + remained higher than the ideal for their sex and height in a high proportion of cases. regarding serum albumin, it was significantly decreased at discharge ( % in allo-hsct, and . % in auto-hsct), but recovered values similar to admission at day + . in the auto-hsct setting, prealbumin levels were significantly reduced at discharge ( %), and in lower proportion at day + ( %), compared with admission values. in the allo-hsct patients, prealbumin levels were significantly reduced at discharge ( %), but had been recovered at day + , compared with admission values. disclosure of conflict of interest: none. recently, blood and marrow transplant clinical trials network has proposed a composite endpoint: gvhd-free, relapse-free survival (grfs) for hsct outcomes. this endpoint includes as event: iii-iv acute gvhd (agvhd), relapse, death or chronic gvhd (cgvhd) requiring systemic treatment. in the last embt annual meeting a redefinition of this endpoint was proposed changing cgvhd event from those patients with cgvhd requiring systemic treatment (the original one) to those with just severe cgvhd (the redefined one). we retrospectively analysed patients consecutively transplanted ( - ) excluding non-malignant diseases, second allo-sct and those o years old age. we had generated two composite endpoints: in both iii-iv agvhd, relapse or death were considerated events but we defined grfs as the one with cgvhd event including those who required systemic treatment (as the original one) and in grfs just those with severe cgvhd (the ebmt redefined one). the median age was years ( - ) and % ( ) were males. other characteristics of patients are resumed in table . with a median follow up for patients alive of months , the median estimated survival in months and the % at + year and + years was: months, % and % overall survival (os); months, % and % event free survival (efs); months, % and % grfs ; months, % and % grfs . ( %) and ( %) hadn't any event in grfs and in grfs , respectively. in grfs , event's incidence was: ( %) for iii-iv agvhd, ( %) for cgvhd, ( %) for relapse and ( %) for death; in grfs was ( %), ( %), ( %) and ( %), respectively. considering those patients with cgvhd as event in grfs , of them hadn't the event as cgvhd at the same time in grfs (since they had cgvhd requiring systemic treatment but not severe cgvhd). for these patients, the alternative event in grfs was: without any event, relapsed and died. in the multivariate, the factors associated with better outcomes were: in grfs early ebmt stage (p o . with early as reference; intermediate p factor with more impact in both, but it is interesting to point it out that haploidentical donor had an advantage in grfs . these results are being validated in a large series and the definitive results will be available at the moment of the meeting congress. [p ] disclosure of conflict of interest: none. steroid refractory acute graft-versus-host disease (gvhd) remains a major complication of allogeneic hematopoietic stem cell transplantation (allo-hsct). affected patients have a very poor prognosis. gvhd has been associated with transplant-associated thrombotic microangiopathy (ta-tam). endothelial damage mediated by radiation, viral reactivation, drug exposure or alloreactivity results in exposure of subendothelial collagen, activation of coagulation and small vessel occlusion to a degree that results in organ failure. complement is thought to be a major mediator of endothelial damage. although a consensus exists about the exceedingly high morbidity and mortality of ta-tam and diagnostic criteria have been converging to a consensus, no biomarkers to diagnose tam and predict outcome have been established. we hypothesize that a ta-tma, related to dysregulation of the alternative complement pathway correlates with organ damage. a retrospective analysis of consecutive patients with hematological malignancies receiving an allo-hsct at the university hospital basel in the period from to was performed. data on the occurrence, risk factors and outcome of patients with ta-tma and the correlation with acute gvhd was collected. available biopsies of organs suspected to be affected by tam and/or gvhd will be performed. routine bone marrow biopsies for histological, immunohistochemical signs of ta-tam and complement activation will be analyzed. serum samples will be used to characterize markers of complement activation using plasma levels of c b- and c b- deposition in tissues biopsies. patients (aml n = ; all n = ; mds/mpn n = ; lymphoid neoplasm n = ; plasma cell disorder n = ; bone marrow failure n = ) underwent myeloablative (n = ) and non-myeloablative (n = ) allo-hsct at a median age of years (range: - years). forty-eight ( . %) patients matched the established diagnostic criteria for tam (increased ldh, platelet count o g/l or o % of normal baseline, schistocytes per high power field, creatinine increase). the median time to onset of tam was days post-transplant (range: - days). subjects with ta-tam had significantly higher -year nonrelapse mortality compared to those without ( . % vs . %, p o . ). grades - agvhd and cytomegalovirus viremia were independent risk factors for ta-tam, and serum ldh level u/l as well as arterial hypertension were early signs of ta-tma occurrence. patients with clinically relevant agvhd (⩾ grade ) had more ta-tam than patients without agvhd ( % vs %; po . ). tam correlated with agvhd severity; the higher the agvhd grade, the more the patients who suffered from tam. allo-hsct recipients with grades - agvhd or cytomegalovirus viremia should be closely monitored for the presence of ta-tma. at the meeting first results of histological, immunohistochemical and complement activation analyses will be presented. disclosure of conflict of interest: none. hemorrhagic cystitis (hc) after stem cell transplantation (sct) can cause significant morbidity and prolonged hospitalization. early bleeding occurs almost exclusively when using cyclophosphamide (cy) ( - % of cases), while late onset hc are classically attributed to bkv infection, and occurs up to % of patients (pts) receiving myeloablative haplo-sct who had positive bk viruria ( , ). we retrospectively studied hc cases among pts submitted to haplo-hsct in our department. thirty-eight pts receiving an haplo-sct with post-transplant cy (pt-cy) were included (table ) . prophylaxis for cy included hyperhydratation ( l/m of . % saline) and mesna administration ( mg for each mg of cy/daily divided into three doses). hematuria was graded as follows: grade i, microscopic; grade ii, macroscopic; grade iii, with clots; and grade iv, leading to urinary retention or requiring surgical intervention ( ). pts with hc and clots were treated with continuous bladder irrigation. twenty-three pts ( . %) developed hc at a median of . days post-sct (range: - ). clinical severity was grade i in cases ( . %), grade ii in cases ( . %), grade iii in cases ( . %) and grade iv in cases ( . %). at the onset of hc diagnosis, bk viruria was investigated in / pts. five pts ( . %) had bkv negative (bkv − ) hc and pts ( . %) bkv positive (bkv+) hc. bkv-hc occurred after a median of days (range: - ) while bkv+ hc after . days (range: - ), respectively (p = . ). among bkv+ pts, received iv cidofovir mg/kg once a week for weeks and then once every weeks. median number of administrations was (range: - ). oral probenecid was given at the dose of g h before and g and h after cidofovir administration. two pts obtained a complete response (cr) after and days, respectively, one patient reached a partial response after days and one pt failed to obtain a response. no pts developed renal toxicity during treatment. one pt received ganciclovir for concurrent cmv viremia and bkv+ hc resolved in days. three patients did not receive any treatment for mild or asymptomatic cystitis. all of them achieved remission after a median of days from the onset (range: - .) among bkv-hc, pts obtained spontaneous resolution after a median of days (range: - ), while two pts died early after sct. finally, among pts for whom bk viruria was not available, a remission was reached in of them after a median of . days (range: - ), while pts died early after sct. in our cohort of pts, hc occurrence was of . % and bkv was responsible for the . % of cases. contrary to its high incidence, hc showed a relative benign course, with an overall remission rate of . %, regardless of treatment. finally, we found a trend for a longer interval between sct and hc onset in pts with bkv+ hc, as compared to cy-related hc (p = . ). sos is a rare and serious complication of hematopoietic stem cell transplantation (hsct). it is diagnosed using the modified baltimore criteria of hyperbilirubinemia, weight gain or ascites % over baseline, hepatomegaly or right upper quadrant pain of liver origin. only defibrotide has been approved for the treatment of veno-oclusive disease. hdmp has been described as effective sos therapy in a few case series ( , ). we describe our experience of treating adult sos using hdmp. objective is to retrospectively analyze the treatment efficacy and overall survival of patients diagnosed with sos after hsct and treated with hdmp. we used vilnius university hospital data base to identify patients diagnosed with sos under baltimore criteria and treated with hdmp over - period. patient demographics, transplant and clinical data, response, survival (kaplan-meier survival analysis) and hdmp infusion related complications were analyzed. we identified patients ( males) of whom had had allogeneic hsct ( reduced intensity conditioning) and one had received a double autologous hsct. sos was diagnosed on the median day + (+ to + days). the median bilirubin value was . μmol/l ( . - μmol/l). all patients had liver enlargement of median mm ( - mm) on ultrasound. two patients had normal bilirubin values but displayed the remaining signs and symptoms of sos at diagnosis. patients received intravenous methylprednisolone mg/m every h for days. none received defibrotide. seven ( %) patients responded on median day + (+ to + days) after the start of hdmp. four responded by decrease in serum bilirubin by % and resolution of symptoms without the need of further treatment. the remaining three responders received maintenance treatment after one course of hdmp with reduced doses of methylprednisolone until resolution of symptoms. four patients failed to respond and died of multiorgan failure on median day + (+ to + ). the median observation time was months ( - months). the median overall survival for the sos group was months (range: - ) and it was months among the responders. no adverse reactions related to hdmp infusion were observed. hdmp therapy in adult sos results in clinically relevant response rate. further prospective trials are required to assess hdmp efficacy in comparison to defibrotide or as add on therapy. prevalence of hypertension (ht) in general pediatric population is~ %, while in children treated with hematopoietic stem cell transplantation (hsct) it is up to %. we assessed factors contributing to the development of ht in children treated with hsct and usefulness of ambulatory blood pressure monitoring (abpm) in this population of patients. the study included children ( boys, girls; mean age . years) treated with hsct for neoplasms (n = ; %) or non-neoplastic disorders (n = ; %). control group included children ( boys, girls; mean age years). abpm measurements (spacelab device) were performed before hsct and after a mean of months after hsct (in of the children). blood samples were collected from children treated with hsct and all controls. total rna extraction was performed and microarray analysis was conducted using genechip human gene . st arrays (affymetrix). in patients after hsct no antihypertensive treatment was used. mean systolic blood pressures (sbp) before and after hsct did not differ significantly from the control group. mean diastolic blood pressures (dbp) before and after hsct were . ± . mm hg and . ± . mm hg, respectively, and mean dbp percentiles were . ± . and . ± . , respectively; the differences between the study group and the control group were significantly higher before hsct. mean -hour arterial pressure (map) percentiles were . ± . and . ± . , respectively; the differences between the study group and the control group were significantly higher before hsct. before hsct and after the procedure, the european society of hypertension criteria for high normal blood pressure (bp) and ht were fulfilled in %/ % patients and %/ % patients, respectively. nocturnal bp decrease o % was found in %/ % patients and % nocturnal bp decrease in %/ % patients, respectively. in the control group o % nocturnal bp decrease was found in % of children and % nocturnal bp decrease in % of children. when the groups of patients before and after hsct were compared, highly significant differences were found in gene expression levels for mthfr ( in children referred for hsct a trend towards higher bp values was seen. in children assessed months after hsct more abnormalities in nocturnal bp measurements were seen, which may be a predictor of ht. in children treated with hsct significant differences in the expression of ht-related genes were found. abpm was useful in bp monitoring in children treated with hsct. hypothyroidism may complicate of allogeneic hematopoietic stem cell transplantation (allo-hsct); risk factors are analysed. we studied patients with aml who underwent an allo-hsct between and with different conditioning regimens (myeloablative, reduced-intensity, chemotherapybased, total body irradiation-based). thyroid stimulating hormone (tsh) and free thyroxin levels (ft ) were available in patients before and after allo-hsct. median age at transplantation (n = ) was years (iqr - ), ( . %) were female and overall mortality was . % (n = ) ( table ) ursodeoxycholic acid (udca) has been shown to have a protective effect in the liver complications after allogeneic stem cell transplantation (allo-sct), but it also has other immunomodulatory effects; it has been described also a potential benefice as graft-versus-host disease (gvhd) protection. we retrospectively analysed patients consecutively transplanted between - excluding second allo-sct and those o years old. we analysed the differences between those with and without prophylactic udca using spps v . results: the median age was years ( - ) and % ( ) were males. other patient characteristics are resumed in table objective of study was to evaluate the impact of disease status on the outcomes of allogeneic hematopoietic stem cell transplantation (allo-hsct) in the treatment of patients with refractory and relapsed acute lymphoblastic leukemia(all). patients with refractory and relapsed all, including cases in advanced stage (nonremission, nr) and cases in more than or equal to second complete remission(⩾ cr ), received allo-hsct after myeloablative conditioning regimen in our department. results: patients engrafted successfully. the transplantation-related mortality (trm) rate of nr and ⩾ cr was . % vs . % (p = . ). the incidence of agvhd was . % vs . % (p = . ), including . % vs . % (p = . ) with mild (grade i-ii) and . % vs . % (p = . ) with severe (grade iii-iv) agvhd. the incidence of cgvhd was similar also( . % vs . %, p = . ). with a median follow-up of ( . - . ) months, the cumulative relapse rate of nr and ⩾ cr was % vs . %(p = . ), respectively. the estimated year overall survival (os) and year leukemia-free survival (lfs) rate were . % vs . % (p = . ) and . % vs . % (p = . ), respectively. multivariate analysis results showed that cgvhd was independent favorable risk factor for os and lfs of r/r all. for relapsed patients, os was significantly better with first cr duration months and time to transplant ⩽ months. alio-hsct is an effective salvage treatment option for patients with refractory and relapsed all. our retrospective analysis showed that r/r all with different status prior transplant had similar outcome post transplantation. disclosure of conflict of interest: none. the deleterious effect of intensive care unit (icu) admission during hematopoietic stem cell transplantation (sct) on patient survival is well established. however, it is unknown whether admission into the icu during the chemotherapy for the underlying disease has any impact on survival after sct. we reviewed patients who had received a first sct between the years and in our institution, and we compared the overall survival (os), relapse incidence (ri) and non-relapse mortality (nrm) between patients who required icu admission during the chemotherapy prior to the sct (icu group) with matched patients ( : ) who did not need it (no-icu group). sixty-six patients were included, of them in the icu group and in the no-icu group. as shown in table , the main clinic-biologic variables and the sct procedure were comparable between the patient groups. the causes of icu admission for the icu group patients were: ( %) respiratory failure, ( %) septic shock, ( %) neurological disturbance, ( %) post-surgery and ( %) tumor lysis syndrome. seventeen patients ( %) needed mechanical ventilation. the median time between icu admission and the sct procedure was days (range: - ), and the median days of icu stay were . . with a median follow-up after sct of . years ( . - . ) for the icu group and . ( . - . ) for the no-icu group, the year os (ic %) probabilities were % ( - %) and % ( - %) in the icu and no-icu patients (p = . ), the -yr probabilities of relapse were % ( - %) and % ( - %)(p = . ) and the -yr probabilities of nrm were % ( - %) and % ( - %)(p = . ), respectively. there were no differences in either os, ri or nrm between icu and no-icu in the allogeneic or autologous subgroups considered separately. at the moment of the study, s ( %) of icu and ( %) of no-icu group had died. the causes of death in the icu group were: relapse in ( %), infection in ( %), gvhd in ( %) and gvhd plus infection in ( %). the causes of death in the no-icu group were: relapse in ( . %), infection in ( . %), gvhd in ( . %), gvhd plus infection in ( . %) and veno-occlusive disease and secondary malignancy, one each ( . %). in this series, admission to the icu before sct did not have an impact on outcomes after sct. these results suggest that these patients benefit from this treatment as much as the other patients, without expecting worse outcomes as a result of a previous icu admission. supported in part by grants rd / / (rticc, fejer), pi / , instituto carlos iii, and sgr (gre), spain. disclosure of conflict of interest: none. autologous stem cell transplant (asct) is a well established treatment for several haematologic and non haematologic malignancies, either as front-line or rescue therapy. however it is associated with toxicity and complications which might lead to treatment-related mortality (trm). although decrease in trm has been reported, data about the precise reduction and detailed analysis of causes of mortality throughout years are scanty. the aim of this study was to evaluate early trm and its causes in patients who underwent an asct in a single center along the last three decades. data of all consecutive adults ( years old) asct recipients were prospectively collected at a single center from december to august and then retrospectively analysed. trm was defined as mortality happened into the days post asct or during conditioning treatment due to any cause except relapse or progression of main diagnosis. demographic characteristics, diagnosis, conditioning regimen and cause of death were analysed. data were compared for two periods: from december to december and from january to august . a total of patients were included, median age was years ( - ) and . % were male. diagnoses were: lymphoma (n = ), multiple myeloma (mm) (n = ), acute myeloid leukaemia (aml) (n = ), amyloidosis (al) (n = ), acute lymphoblastic leukaemia (all) (n = ), solid tumours (including breast cancer and germ-cell tumours) (n = ), chronic myeloid leukemia (cml) (n = ), thrombotic thrombocytopenic purpura (ttp) (n = ) and autoimmune disease (n = ). the most frequent indication for asct was lymphoma ( . %) and mm ( . %). twenty patients died within d from asct (trm). demographic characteristics and causes of death for this patients are shown in table . the cumulative incidence of trm at day + was . % ( % ci . - . ). comparing both periods, trm cumulative incidence was . % ( % ci . - . ) in first period ( - ) vs . % ( % ci . - . ) in last period ( - ) po . . (figure ). according to main diagnosis trm cumulative incidence was higher in patients diagnosed with solid tumour . % ( % ci . - . ) and al . % ( % ci . - . ) followed by acute leukaemia (aml/all) . % ( % ci . - . ), mm . % ( % ci . - . ) and lymphoma . % ( % ci . - . ) p o . (figure ). sepsis ( %) was the main cause of death in both periods of time, and the only one cause of death in the last period. the second cause was sinusoidal obstruction syndrome (sos/vod) ( %), which only appeared in the first period. this study shows a low incidence of trm in asct recipients, with a significant decrease in the last period ( - ), despite the higher risk in some groups of patients such as those with amyloidosis and solid tumours. in our experience, infection is the main cause of early death in asct recipients and sos/vod has disappeared in last years as a cause of early transplant related mortality. disclosure of conflict of interest: none. incidence and risk factors for hepatic sinusoidal obstruction syndrome after allogeneic hematopoietic stem cell transplantation: a retrospective multicenter study of turkish hematology research and education group (threg) hepatic sinusoidal obstruction syndrome (hsos) is a potentially life-threatening complication of allogeneic hematopoietic stem cell transplantation (allo-hsct). the mean incidence of hsos was found to be . % ( - %) in the literature. we examined the incidence and risk factors for hsos after allo-sct. eight centers from turkey were enrolled in the study. we retrospectively evaluated the medical records of patients who were treated with allo-sct between january and december . a baltimore criterion was used for assessment of hsos. two hundred eighty three ( %) of patients who were treated with prophylaxis with defibrotide alone or one or more of the n-acetylcysteine, diuretics and heparin used defibrotide ( - mg/kg/day). the study included patients ( males/ females) with median age of ( - ) years. the demographic and clinical characteristics of patients were summarized in table . the incidence of hsos was . % ( ). prophylaxis for hsos was used in ( . %) of patients, who developed hsos. defibrotide as prophylaxis was received by of ( %) of patients. hsos developed in a median of ( - ) days after stem cell infusion. seventy-five ( . %) of patients who developed hsos had infection at the time of diagnosis. forty-five of them had ascites, had hepatomegaly and, had weight gain. seventy-two ( . %) of patients with hsos were treated with defibrotide after diagnosis. the median time of starting defibrotide in these patients was ( - ) days. thirty-six ( . %) of patients with hsos recovered completely and forty-seven ( . %) of them died as a result of multi organ failure. the incidence of hsosrelated mortality in allo-hsct cohort was found to be . %. in univariate analysis, statistically significant associations were not found between hsos incidence and age/sex of recipient, type of conditioning regimen, stem cell source and type of gvhd prophylaxis. on the other hand primary diagnosis of myelofibrosis, donor type, engraftment status and prophylaxis for hsos were significantly associated with hsos development. hsos prophylaxis was significantly decreased hsosassociated mortality (p = . ). hsos still remains a serious life-threatening complication of allo-sct. although the incidence is low, hsos is associated with increased -day nonrelapse mortality. hsos prophylaxis especially with defibrotide, seems to reduce hsos associated mortality in high risk patients. [p ] disclosure of conflict of interest: none. hemorrhagic cystitis (hc) is a serious complication occurring after allogenic hematopoietic stem cell transplantation (hsct) more frequent on haploidentical (haplo) hsct, with an incidence of - % associated mainly with the effect of cytotoxic agents such as cyclophosphamyde (cy). the conditioning regimen, bkpyv infection and graft versus host disease have an implication in the incidence. other authors related the reactivation of cmv and a previous transplantation as risk factors to hc development . with this study we aim to describe the hc incidence and risk factors in all haplo-hsct performed in the canary islands. we analyzed all consecutive haplo-hsct from family donors performed at our hospital between and . the conditioning regimen used for the transplant was the hopkins haplo protocol with high dose cy ( mg/kg on days and ) posttransplantation (ptcy). we used as hc prophylaxis intense hydratation on the cy administration day and the following h (using bladder wash only in patient with cardiac dysfunction) and perfused mesna at % of cy dose beginning min before the cy administration on pts and at % of the last dose at , and h on all pts. we used spss v. to determine the cumulative incidence (ci) of hc. we performed haplo-hsct, of which were males ( was transplanted times) and were women. the mean age was (range: - ). the pts presented the following diagnosis: aml ( ), all ( ), eh ( ), nhl ( ), am ( ). % of pts received the haplo-hsct in remission, % with refractory disease and % of pts did not receive previous treatment. pts developed hc ( . % ci at day + ) (figure a ) with a median time from haplo-hsct to onset of days (range: - ), ( %) was grade i, ( %) grade ii and ( %) grade iv. the grade i case did not received the mesna infusion like most of the other pts. no pts died due to hc and all cases resolved without sequelae. pts received cy pre-and post-transplant and only pts received ptcy. the ci at day + for the pts with ptcy was . % and for cy preand post-transplant . % (figure b) . we found no statistically significant difference on the ci of hc between these two groups. the development of hc was related to cy in patient, who suffered from this complication on the second and third haplo-hsct. for the rest of the pts (after day + ) the hc was related to bkpyv infection, as a consequence of the immunosuppression state of the patient, we also observed all these pts had positive serum viral load for cmv. the incidence of hc associated to post-hsct high cy dose in our series is % lower than other ones. most of them on grade or and without mortality associated. the risk of hc is high, particularly in the setting of highly pre-treated patients (especially those undergoing a nd transplant). the development of hc after day + is evidently associated to bkpyv as a contributing factor for continuous inflammation and cmv reactivation (as an immunosuppression marker). in our study, hc did not have an impact on mortality of high-risk patients after haplo-hsct. the hc remains frequent with a high morbidity in particular when it is severe, often causing prolonged hospitalization and resource use. we need further studies to recognize the at-risk population early. [p ] ta-tam is not a rare post-transplant complication and it is potentially fatal. in survivors, it was often associated with longterm morbidity and chronic organ damage, mostly to the kidney with poor renal prognosis. our retrospective study showed ta-tam associated risk factors included t reg haplo hsct as the incidence was highest in this group, tbi-based conditioning or tbi based conditioning plus cyclophosphamide. although acute gvhd and infection were associated with ta-tam in retrospective studies, no association emerged between acute gvhd or infection preceding diagnosis in our series of patients. in order to prevent ta-tam we need to understand its underlying biological mechanism so we are investigating its pathogenesis by means of cytokine assays, histology and murine models. disclosure of conflict of interest: none. mortality in children requiring invasive mechanical ventilation (imv) after allogeneic hematopoietic stem cell transplantation (hsct) is known to be high. little is known about the longterm outcome of those who survive imv. we therefore reviewed the medical records of children who survived s imv after they had received a hsct between and in the two pediatric hsct centers in the netherlands. retrospective multi-center cohort study in two university hospitals that perform all pediatric hscts in the netherlands. long-term survival of hsct recipients who had received imv was assessed. health status was reviewed more in detail for those who were still alive years after discharge from the pediatric intensive care unit (picu). in the absence of standardized use of quality of life questionnaires, health status was expressed as the number of affected domains (cardio-respiratory, motor and miscellaneous, regardless of the degree of dysfunction) and level of education. health status was categorized as follows: no health problems when all four domains were normal; mild health problem when there was an abnormal score in one of the four domains; moderate health problems when there was an abnormal score in two domains; severe health problem when there were abnormal scores in three or all four domains. between january and december , patients underwent a hsct in the two study centers together. a total of hsct recipients received imv within year after hsct ( % of all hsct recipients). median time between hsct and picu admission was days (iqr - days). the most common indication to start imv was respiratory failure ( %). median duration of imv was days (iqr - days). patients ( %) died during their picu admission. of the patients who were discharged alive from picu, patients were still alive years after picu discharge ( % of those who survived picu admission). health status of these long-term survivors was assessed in december by hospital database review, using the most recent hospital contact. follow-up time varied from to years (median . years) after picu discharge. two patients ( %) had no health impairment, eight patients ( %) had mild health problems, five patients ( %) had moderate health problems, and nine patients ( %) had severe health related problems. very little is known about long-term mortality and morbidity of hsct recipients who survived imv. survival of picu treatment in pediatric hsct recipients is limited. however, long-term outcome of those who survive picu treatment seems promising: a considerable proportion of them still is alive years later without obvious sequelae. this is the first study which assessed long-term outcome of imv after hsct. further studies in this population are urgently required to counsel parents and to optimize quality of life outcomes in these children. disclosure of conflict of interest: none. long-term surveillance data support lack of increase in mortality or cancer risk in brincidofovir clinical trial participants m morrison, k fitzgerald , t brundage, a harrison and wg nichols chimerix brincidofovir (bcv) is an orally bioavailable lipid conjugate of cidofovir (cdv), with broad-spectrum activity against doublestranded dna viruses, including cytomegalovirus (cmv), adenoviruses (adv), polyomaviruses (bk and jc viruses), and orthopoxviruses. bcv is being evaluated for prevention of cmv and other dna viruses in high-risk hematopoietic cell transplant (hct) recipients, and for the treatment of serious adv infection. bcv is also being developed for the treatment of smallpox under the us fda's animal efficacy rule. because bcv, cdv, and other marketed nucleoside analogs are reported to be carcinogenic in rodents, a registry was established to evaluate the long-term safety of bcv in subjects who have participated in bcv clinical studies. to date, the registry includes prior participants from study (a placebo (pbo)-controlled study of bcv for cmv prevention) and study (a single-arm study of bcv for adv treatment). subjects are encouraged to consent for long-term follow-up in the registry following participation in bcv clinical studies. registry participants are followed at -month intervals for a minimum of years from the time of completion of the parent study. development of malignancies (new or relapsed), lifethreatening or fatal adverse events (aes) assessed as potentially related to bcv, and subjects' vital status are collected. a total of subjects were enrolled in the parent studies ( bcv and pbo from study , bcv from study ). of these, are enrolled in the registry as of october ( bcv and pbo from study , bcv from study ). bcv recipients in the registry are % male, % white, with a median age of ( o - ) years, similar to the bcv recipients in the parent studies. the median duration of follow-up is ( - ) months, with % of subjects continuing in follow-up at the time of analysis. all-cause mortality from the time of first dose in the parent study through current registry follow-up is % for bcv vs % for pbo (p = . ) in study , and % for bcv in study . all-cause mortality in the registry since completion of the parent study is % bcv vs % pbo for subjects from study (p = . ) and % bcv for subjects from study (figure ) . the incidence of a new malignancy in registry subjects from study is % bcv vs % pbo (p = . ), and the incidence of relapsed primary malignancy is % bcv vs % pbo (p = . ). in registry subjects from study , % developed a new malignancy and % had a relapse of the primary malignancy. no bcv-related life-threatening or fatal aes have been reported to date in the registry. registry data collected to date support no increase in late mortality or increased risk for carcinogenicity in patients treated with bcv. long-term surveillance for cancer risk and other drivers of mortality is important for novel compounds undergoing development in hct and other immunocompromised patient populations, with high background risk for these outcomes. [p ] disclosure of conflict of interest: all authors of this abstract are employees and stockholders of chimerix. hematopoietic stem cell transplantation (hsct) is a medical procedure that allows the cure of many paediatric diseases. it has been described an increased risk of new malignancies in this population and it represents an important cause of late mortality. we analyzed the late evolution of patients submitted at pediatric age to hematopoietic transplantation (hsct) (allogeneic or autologous) in santa creu i sant pau hospital between and . a total of hsct was analyzed. it has been calculated the cumulative incidence of secondary malignancies at years of follow-up. it has been done univariate and multivariate analysis of risk factors through χ -test and binary logistic regression method (odds s ratio, or). it has been studied the relative risk (rr) for new malignancies through comparison of observed cases in our cohort with the expected cases in the general population. we observed cases of secondary malignancies with a cumulative incidence of % at years, % at years and % at years of follow-up. the risk was higher of expected in general population for each tumor type and in the different range of age, being the rr for malignancies in our cohort of . at years of follow-up. solid tumors were the most prevalent malignancies ( out of cases). the median time of latency from hsct to diagnosis of malignancy was years ( - years) . the thyroid tumors were the later ones and hematologic malignancies the earliest to be developed. chronic graft versus host disease was a statistically significant risk factor in univariate (or = ; p = . ) and multivariate analysis (or = . ; p = . ). total body irradiation of conditioning was a significant risk factor only in multivariate analysis (or = . ; p = . ). previous radiotherapy was a significant risk factor only in univariate analysis (or = . ; p = . ). mortality was % ( out of ) between patients with a new malignancy and it was the cause of death for all the cases. we observed an incidence of secondary malignancies after hsct of . % that is significantly higher compared to the expected in the general population (p = . ). the factors that have been related to an increased risk were chronic gvhd, tbi and previous radiotherapy. microalbuminuria defined, as urinary albumin: creatinine ratio (acr) of - mg albumin/g creatinine is a marker of endothelial dysfunction and inflammation. in general populations albuminuria predicts development of chronic kidney disease (ckd) and cardiovascular disease ( ). in the general population microalbuminuria is associated with the metabolic syndrome ( ) . in patients with hypertension, diabetes and the critically ill, it is a marker of adverse events and poor outcomes. following hematopoietic cell transplant (hct), microalbuminuria at day was associated with a four-fold increased risk of chronic kidney disease (ckd) at year in a single centre study; macroalbuminuria at day was associated with a . -fold increased risk of non-relapse mortality ( ) . international guidelines for adult and children survivors of hct recommend that proteinuria is assessed at least annually ( , ) . there is a paucity of data on the prevalence and implications of micro and macroalbuminuria in long-term survivors ( years) of adult hct, however. this was a single-centre retrospective study conducted in patients attending a dedicated clinic for long-term (minimum years) survivors of hct. we investigated prevalence of albuminuria and its association with renal disease, cardiac disease and the metabolic syndrome. of patients, were treated for acute leukemia, for aplastic anaemia and for cml. the median follow up time was years (range: - years) and the median age at follow up was years (range: - years). for / urinalysis was normal (group a) and ( %) had microalbuminuria (group b). none had macroalbuminuria. group b were significantly more likely to have ckd grade - (egfr o ) compared to those in group a (p = . ). group b patients were significantly more likely to have diabetes or impaired glucose tolerance / ( %) vs / ( %) in group a (p = . ). group b patients were also significantly more likely to have dyslipidaemia (p = . ) with / ( %) affected vs / ( %) in group a. cardiac disease and hypertension were more frequent in group b, / ( %) and / ( %), respectively vs group a / ( %) and / ( %) but these data were not statistically significant. the more features of the metabolic syndrome present, however, (elevated hba c, /glucose, dyslipidaemia, hypertension) the more likely a patient was to have microalbuminuria (p = . ). our data demonstrates that microalbuminuria is a frequent finding in long term survivors of hct. patients with microalbuminuria are more likely to have ckd grade or below. they are also more likely to have diabetes and dyslipidaemia. as this was a retrospective study we are not in a position to comment on whether microalbuminuria is predictive of the development of renal disease, metabolic syndrome or cardiovascular disease in this group of patients. this warrants further study as intervention, for example with ace inhibitors, may have the potential to reduce morbidity. the purpose of the study is the improvement of transplantation techniques and supportive care lead to an increasing number of long-term survivors after allogeneic hematopoietic stem cell transplantation (ahsct). recipients of ahsct have a higher prevalence of cardiovascular risk factors. ambulatory blood pressure measurement (abpm) is the 'gold standard' to diagnose arterial hypertension (ht). the prevalence and treatment control of ht by abpm is unknown in ahsct patients (pts). this prospective single center study at university hospital basel included all pts ⩾ year after ahsct in complete hematological remission during annual follow-up consultation. office blood pressure (obp) was measured on both arms after minutes rest. abpm by noninvasive continuous bp monitoring (pulse transit time method) was performed on the same day. ht was defined as obp ⩾ / mm hg, mean systolic bp ⩾ mm hg on abpm s (bp ) and/or current use of antihypertensive drugs. pts ( % female) were included with median age of years (range: - ) and years (range: - ) after transplantation. ( %) pts received total body irradiation-based conditioning, ( %) pts had chronic graft-versus-host disease, and ( %) required immunosuppression. mean bmi (kg/m ) (± sd) was ± , with ( %) pts . twenty-seven ( . %) pts were current smokers. fourty-three ( %) pts had chronic kidney disease (egfr o ml/min/ . m ) and ( %) diabetes. ( %) pts were on antihypertensive drugs consisting of ace/at-ii-inhibitors in ( %), calciumchannel blockers in ( %), beta-blockers in ( %) and diuretics in ( %) pts. thirty-nine ( %) pts were on ⩾ drugs. among our cohort ( %) pts were normotensive without antihypertensive treatment (mean age ± years, % female and mean bp (systolic/ diastolic bp) ± / ± mm hg). ( %) pts were hypertensive and/or on antihypertensive treatment. untreated ht was diagnosed in ( %) pts (mean age ± years, % female and mean bp of ± / ± mm hg), including ( %) with white-coat hypertension and ( %) masked hypertension (normal obp, high abpm). in the group of pts with current antihypertensive medication / ( %) were controlled (mean age ± years, % female, and mean bp ± / ± mm hg) whereas / ( %) were hypertensive on abpm (mean age ± years, % female, mean bp ± / ± mm hg). thirty-four ( %) pts with uncontrolled ht were already hypertensive at obp. although long-term survivors after ahsct are known to be at elevated cardiovascular risk, diagnosis of arterial hypertension was missed in every fifth patient. the proportion of controlled hypertension is poor with only %. disclosure of conflict of interest: none. myasthenia gravis (mg) is a rare complication of allogeneic stem cell transplantation (sct) and is often associated with graft-versus-host disease (gvhd). we report a -year-old man who presented with oculobulbar and neck weakness months after an unrelated donor, allogeneic sct for chronic myeloid leukaemia (cml). he was diagnosed in with chronic phase cml. this responded poorly to tyrosine kinase inhibitors (tkis) and he was found to carry the t i mutation with additional monosomy . he underwent a fully hla matched unrelated donor sct with y -anti cd targeted radiotherapy, fludarabine, melphalan and alemtuzumab conditioning. he had grade cutaneous gvhd on ciclosporin withdrawal but no other significant gvhd. he has an immune mediated neutropenia since months post sct and has reduced immune reconstitution as demonstrated by a sub-normal absolute cd level. he remains on pneumocystis prophylaxis and has not experienced increased infection. chemotherapeutic agents have a cytotoxic effect on the oral mucosa and is a major problem following cancer treatment. cooling the oral mucosa in conjunction with chemotherapy infusion, using ice chips, is known to reduce the severity of oral mucositis ( , ) . although effective, ice chips are perceived as uncomfortable. the aim of the present study was to determine the optimal cooling temperature to prevent adverse effect of chemotherapeutic agents using tissue engineered oral mucosal models (teom). teom were incubated at °c, °c, °c or °c for min followed by exposure to μg/ml of -fu for h (control models were incubated at °c). teom were then washed and further incubated for h at °c co . cell viability and inflammatory cytokine production (il- and tnf-α) were measured using (prestoblue) and (elisa), respectively this study demonstrates an increased capacity to restore cell viability with decreasing temperature (figure a ). teom treated with -fu further showed an increased secretion of the pro-inflammatory cytokines tnf-α and il- at all temperatures compared to un-treated controls. for il- , secretion increased markedly when cells were incubated with μg/ml -fu at °c and °c compared to cells incubated with medium alone at °c (figure b) . for tnf-α, secretion was significantly higher (p o . ) in cells treated with μg/ml fu at °c compared to untreated mucosal models and mucosal models treated with μg/ml fu but incubated at °c (figure c ). teom models incubated at °c has an increased capacity to restore cell viability following exposure to -fu. incubation at °c further reduces the release of pro-inflammatory cytokine compared to those incubated at °c. ( ) and one received fludarabine and cyclophosphamide. all patients received campath- h as part of the conditioning regimen. stem cell source: peripheral blood stem cells patients and bm. comorbidity was assessed using the haematopoietic cell transplantation co-morbidity index (hct-ci), with patients ( %) having no co-morbidities, ( %) a co-morbidity index of - and ( %) had a score ⩾ . follow up of survivors ranged from to months (median: months). at the specified end point patients had relapsed ( %) with an actuarial -year relapse rate of %. there were deaths ( %). relapse ( ) was the main cause of death with transplant related mortality of % ( ) at day , % ( ) at months and % ( ) at year. the actuarial os at years was %, with a -year dfs of %. of the surviving relapsed patients all received chemotherapy and donor lymphocyte infusions resulting in effective recovery of remission, showing the utility of this approach. in terms of co-morbidity, actuarial survival rates were % in those with an hct-ci index of , % with an index of - and % with an index ⩾ . the results of this retrospective study indicate that allosct using reduced intensity conditioning regimens can be an effective treatment strategy for older patients with high risk myeloid malignancies including those with significant co-morbidities. relapse remains the main cause of treatment failure and strategies to reduce relapse risk are required. patients that relapse post allosct may respond to further treatment such as azacytidine or intensive chemotherapy and donor lymphocyte infusions. ( ) whether patient-related variables were associated with disagreement. this is a secondary analysis of a cross-sectional multicenter study where patients and clinicians completed an identical qol questionnaire (fact-bmt) at day . clinical and demographic variables as well as anxiety and depression (hads) were collected. agreement was analyzed with the intraclass coefficient correlation (icc). rates of under-and over-estimation were calculated. logistic regression models identified predictors of disagreement. we analyzed pairs of questionnaires, filled in by patients and clinicians. patients' median age was years, ( %) were men, and ( %) received an allogeneic hct. clinicians' median age was years, were men and had worked on the transplant field for a median of years (range: - ). agreement on qol was moderate (icc = ). exploratory analyses revealed that agreement for emotional (icc = ) and social (icc = ) wellbeing was poor, whereas it was moderate for physical (icc = ), functional (icc = ) and bmt concerns (icc = ). patients' wellbeing was overestimated in - % of the categories of wellbeing parameters, and underestimated in - %. patient-related variables explained - % of the variance on disagreement across scales. specifically, anxiety contributed to disagreement in all subscales, except in social wellbeing, where non-significant univariate associations were observed (p . ). type of transplant (allogeneic vs autologous), performance status, and graft-versus-host disease were not associated with disagreement (p . ). patients and clinicians agreement on qol is suboptimal, particularly on emotional and social wellbeing. patients' wellbeing cannot be estimated from other sources than themselves. these results highlight the unmet needs of hct recipients with respect to qol-related issues; an outcome that must be addressed by hct programs since their wellbeing is as important as survival endpoints. disclosure of conflict of interest: none. . we wanted to test the function and the safety of picc device as alternative to standard cvc in patients submitted to autologous stem cell transplantation (abmt). the primary end point of the study was to individuate the cause leading to the failure of picc (its removal or the needing of another cvc during the abmt procedure). secondary end points were the correct function of the device and its praticity. twenty patients submitted to abmt for multiple myeloma ( ) or lymphoma ( ) experienced a double lumen picc device ( ) or a single lumen ( ) if the patient already carried a permanent single lumen cvc such as hickman or port-a-cath. we excluded from this experience patients with high risk of life-threatening situation or high risk of intensive care already before abmt. picc devices were placed from a specialistic nurse team by ultrasound identification of a deep venous vessel in upper arms. melphalan or ceam were the standard conditioning regimens employed in myeloma and lymphoma abmt respectively. we considered a failure all the causes leading to the removal of picc or requiring another cvc before the end of the transplant procedure. at last we collected nurses and clinicians opinions about the picc functionality. no complication has been recorded in positioning phase. / patients maintained the picc device for all the time of transplant procedure. only one patient needed to remove the device for infection. the opinion of nurses and clinicians about the picc device was a significatively slower speed of infusion and resistance to the flow; in fact, / patients needed an infusional pump. the idraulic resistance of the catheter was particular evident against cellular fluids (stem cells suspension, transfusions of blood and platelets). for this reason picc seems to be less indicated in patients requiring many endovenous infusions (nurses' opinion). the rate of infection of picc devices seems to be lower compared to cvc, but the number of cases tested in this experience is too limited for definitive conclusions about it. for other aspects picc is similar to other cvcs. picc seems to be a valid alternative to standard cvc in patients who do not require intensive care, and in particular in patients with low intensity abmt who do not present a high number of endovenous infusions. maybe picc is less burdened of infections respect to normal cvc. this fact, summed to the lower risk during the positioning of the device, leads to consider the use of this device in abmt setting for standard risk patients. disclosure of conflict of interest: none. there are only few algorithms for the selection of hlamismatched unrelated donors, when no fully matched donor is available. indirect recognition of hla-mismatches can be predicted using the model of 'predicted indirectly recognizable hla epitopes' (pirche). the pirche model is a recently developed computer-based strategy, which classifies hladerived epitopes that are potentially presented by patientdonor shared hla-molecules. we performed a multicenter retrospective study evaluating the impact of pirche on outcome after allogeneic stem cell transplantation from hla / matched unrelated donors. the study cohort included adult patients who had undergone allogeneic stem cell transplantation for aml or mds. pirche scores were computed for recipients of hla / matched unrelated donor transplants ( / mud) using a web-based tool. primary endpoint was overall survival at years. patients with a / mud were divided into groups according to the sum of pirche i+ii values (pirche score). eighty-five ( ) patients had a pirche score of (no pirche detected), a pirche score . km estimate of year os was higher for / mud with pirche score = compared to pirche score : % ( % ci: - %) vs % ( % ci - %), p = . . os was similar for / mud with pirche score = and / mud ( % vs %). cox regression analysis revealed poorer os for pirche scores (rr . , % ci: . - . , p = . ). cumulative incidence of nrm at years was lower for / mud with pirche score = compared to pirche score ( % vs %, p = . ). multivariate cox regression analysis revealed poorer nrm for pirche score (rr . , % ci: . - . , p = . ). cumulative incidence of agvhd grade - at months was not significantly different for / mud with pirche score compared to pirche score ( % vs %, p = . ). cumulative incidence of cgvhd at years was lower for / mud with pirche score compared to pirche score ( % vs %, p = . . our findings require confirmation, ideally in a large prospective cohort study. if validated, the pirche model would allow selection of permissible hla-mismatches that may be associated with an improved transplant outcome in terms of reduced nrm and better os. [p ] disclosure of conflict of interest: none. this study was supported by a research grant from pirche-ag to the university medical center, hamburg-eppendorf. pretransplant liver dysfunction has been recognized as a risk factor for complications and mortality after allogeneic hematopoietic cell transplantation (allo-hct). however, there is no consensus on the optimal way to evaluate liver function in hct candidates. transient elastography (te) is a noninvasive method for diagnosing liver damage and cirrhosis. while elastography is widely used in the setting of viral hepatitis, its possible role in allo-hct recipients has not been deeply evaluated. patients receiving allo-hct in our center from may are scheduled to receive pretransplant evaluation by a hepatologist under a prospective protocol. the evaluation includes a hepatologist consultation, liver function and infectious serology tests and te. all patients receive ursodiol from hct admission to day + . this study constitutes the first evaluation of the ongoing protocol for patients receiving their first allo-hct from may to august . sixty patients received a first allo-hct during the study period. sixteen patients did not undergo hepatologist evaluation due to timing issues (n = ), unstable medical condition (n = ) or other reasons (n = ). finally, patients received pretransplant evaluation by a hepatologist under the current protocol and constitute the study population. median age at transplantation was years (range: - ). most patients received a transplant for acute leukemia (n = , %) or non-hodgkin's lymphoma (n = , %) mainly from hla matched unrelated donors (n = , %). thirty-two patients received reduced-toxicity regimens ( %). graft-versus-host disease (gvhd) prophylaxis consisted of tacrolimus in combination with another agent. median follow-up for survivors of months (range: - ). median elastography was . kpa (range: . - . ). considering the hct-ci categories on hepatic dysfunction, , and patients scored , and points, respectively. there were two cases of veno-oclusive disease (vod). overall survival and non-relapse mortality of all patients at median follow-up were % ( % ci - ) and % ( % ci - ), respectively. in the univariate analysis, median elastography was not associated with a higher risk of nrm (p-value = . ), os (p-value = . ) or hepatic chronic gvhd (p-value = . ). the two patients with vod had normal pre-hct transaminase levels and te. this first analysis of an ongoing protocol with universal pre-hct evaluation of hepatic function indicates that increased values of transient elastography are not associated with higher nrm or lower os after the procedure. further studies including a larger number of patients are needed in order to clarify the possible role of elastography in the hct setting. disclosure of conflict of interest: none. allogeneic hematopoetic stem cell transplantation (hsct) remains associated with a high morbidity and mortality in spite of advances in hsct management. specifically, pulmonary complications account for a substantial proportion of deaths within the first days after hsct. therefore, identification of lung dysfunction and additional comorbidities are crucial for preventive strategies in hsct. given the inconsistent association of pretransplant lung function s parameters on mortality after hsct and the significant changes in hsct care over the last decades, the aim of our study was to assess the effect of pulmonary function and comorbid conditions on mortality in patients undergoing hsct for hematological disorders. we retrieved relevant clinical data of all consecutive patients at the hematology division of the basel university hospital with a transplant for hematological disorders between and . we examined the lung function at baseline and , and months after hsct-including the s forced expiratory volume (fev % of predicted), fev /vcmax and diffusing capacity for carbon monoxide (dlco, adjusted for hemoglobin concentration). in addition, we assessed pretransplant conditions such as age, sex, karnofsky performance status (kps), donor type and various risk scores in hsct (hematopoietic cell transplantation comorbidity index (hct-ci), european society for blood and marrow transplantation (ebmt), revised pretransplant assessment of mortality score (pam)). using uni-and multivariate cox proportional-hazards regression analysis, we evaluated patient-and transplant-related risk factors for all-cause mortality by including the following categorical candidate variables: fev (⩾ % vs - % vs o % of predicted), kps ( o % vs ⩾ %), age ( o vs ⩾ years), conditioning intensity and donor type (matched-related vs mismatchedrelated vs matched-unrelated vs mismatched-unrelated). within the study period, patients with predominantly acute leukemia ( %) or lymphoproliferative disorders ( %) underwent myeloablative (n = ) and non-myeloablative hepatic veno-occlusive disease/sinusoidal obstruction syndrome (vod/sos) is a potentially life-threatening complication of conditioning for hematopoietic stem cell transplantations (hsct). recombinant thrombomodulin (rtm) is a new drug for treating disseminated intravascular coagulation (dic) and is an endothelial anticoagulant cofactor that promotes the thrombin-mediated formation of activated protein c (apc). rtm has been used to treat vod/sos, but its ability to prevent vod/sos has not been established. we evaluated the cases of pediatric hematology and oncology patients ( ( %) acute myeloid leukemia, ( %) acute lymphoblastic leukemia, and ( %) neuroblastoma patients, and ( %) patient each with myelodysplastic syndrome, rhabdomyosarcoma, hemophagocytic syndrome (hlh), and wiskott-aldrich syndrome) who underwent hsct at our institution between and and had ≧ risk factors for vod/sos. these risk factors included previous treatment with gemtuzumab ozogamicin (go), receiving hsct, undergoing conditioning with busulfan (bu), and being diagnosed with hlh. the patients who received hsct after (n = ; rtm group) were treated with rtm as a prophylaxis against vod/sos ( u/kg per day for days; from days to ) together with ursodeoxycholic acid (urso) and low-molecular-weight heparin (lmwh), and the others (n = ; control group) were only treated with urso and lmwh. the incidence of vod/sos was evaluated, and various coagulation parameters and markers of endothelial injury (plasminogen activator inhibitor type (pai- ) and apc) were measured in both groups. the patients' median age was (range: - ) years, and ( %) were male. clinical characteristics, including vod/sos risk factors, were wellmatched in both groups. the risk factors possessed by the patients included receiving hsct ( / , %), previous go treatment ( / , %), conditioning with bu ( / , %), and a diagnosis of hlh ( / , %). although vod/sos occurred by post-hsct day + in ( %) patients in the control group, vod/sos was not seen in the rtm group. two of the former patients ( : previous treatment with go, : a diagnosis of hlh) suffered severe vod/sos, and (a diagnosis of hlh) died of the condition. no grade / adverse events involving bleeding or severe organ damage were reported in the rtm group. interestingly, the mean peak value of pai- and apc (markers of endothelial injury) were significantly lower in the rtm group (table ) . [p ] disclosure of conflict of interest: none. protective effect of early human cytomegalovirus reactivation on relapse of myeloproliferative disorders after allogeneic hematopoietic stem cell transplantation z peric , , j wilson , n durakovic , , l desnica , a ostojic , vv rezo , v marekovic , , r serventi-seiwerth and r vrhovac , school of medicine, university of zagreb, zagreb, croatia and university hospital centre, zagreb, zagreb, croatia there have been conflicting results regarding the association between early cytomegalovirus (cmv) reactivation and decreased incidence of relapse after allogeneic hematopoietic stem cell transplantation (allo-hsct). this prompted us to retrospectively evaluate the potential impact of cmv reactivation on transplantation outcomes in a study population of consecutive adult patients who underwent allo-hsct in our institution and were treated and followed in a homogenous manner. patients were monitored for cmv reactivation once weekly for the first days after allo-hsct. monitoring was done with a real time qpcr with lower limit of detection of genome copies per ml of blood. when cmv viremia was detected, all patients were treated with intravenous ganciclovir or oral valganciclovir untill two consecutive negative qpcr assays. univariate and multivariable proportional hazards models using the fine and gray approach were considered to evaluate the variables for relapse, treating death as competing event. between and , male and female patients underwent allo-hsct at a median age of years (range: - ). among them, most patients were treated for myeloid malignancies ( aml, mds and mpn with cml, mf and cmml), while the rest had lymphoproliferative disorders ( all, nhl, mm, mh and cll) and one patient had aplastic anemia. the donors were unrelated in cases, related in patients and haploidentical in patients. most of the patients ( %) received peripheral blood stem cells after a reduced-intensity conditioning regimen ( %). with a median follow-up of months, early cmv reactivation occured in % patients at a median of days after transplantation and did not affect relapse incidence in patients with lymphoproliferative disorders. on the contrary, the cumulative incidence (ci) of hematologic relapse in patients with myeloproliferative disorders (aml and mpn) at months after allo-hsct was % ( % ci, - %) in patients without, opposed to % ( % ci, - %) in patients with cmv reactivation (p = . ). however, cmv reactivation did not significantly affect (p = . ) overall survival between patients with ( %; % ci - %) and without cmv reactivation ( %, % ci - %). a striking and previously unreported correlation between cmv reactivation and relapse was found in patients with mpn; the ci of relapse was % ( % ci, - %) in patients without, opposed to only % ( % ci, - %) in patients with cmv reactivation (p = . ). a substantial and independent reduction of the relapse risk in myeloproliferative disorders (aml+mpn) associated with early cmv reactivation was confirmed by multivariate analysis using time-dependent covariate functions for high-risk disease, use of atg, chronic graft-versus-host disease (hazard ratio . ; % ci, . - . , p = . ), and cmv reactivation (hazard ratio . ; % ci, . - . , p = . ). in summary, this report supports an independent role of cmv reactivation on relapse in patients with myeloproliferative disorders. to our knowledge, we are the first to show a significant reduction of relapse incidence in patients with mpn, even though our findings are based on a relatively small number of patients. however, this putative virus-versus-myeloproliferation effect definitely warrants further research. [p ] disclosure of conflict of interest: none. final result of fact-bmt is score ranged - point (the higher the score, the better qol). for qualitative assessment of donor-recipient relationship, the adult sibling relationship questionnaire (asqr) in polish version was used. the asrq-s consists of items which are spread over eight scales designed to investigate three factors: warmth, conflict and rivalry. the questionnaires were given to both subgroups, donors and recipients of msd-hsct and the results were compared to each other. the overall result of the fact-bmt questionnaire was . ± . points, which means that the examined group generally described their qol as 'quite good'. the best results were found in functional well-being ( . ± . ), while the worst in emotional well-being ( . ± . ) dimension. statistically, the qol score was not influenced by age at hsct (p = . ), current age (p = . ) or gender (p = . ) of the respondents. the recipients scored highest on warm factor ( . ± . ), while donor respondents scored slightly higher rivarly ( . ± . ) than warm ( . ± . ). the second dimension scored by recipients was rivarly ( . ± . ). conflict scores were lowest, although donor respondents scored higher on these than recipient respondents ( . ± . in donors vs . ± . in recipients). statistical analysis revealed that the being a donor or recipient of msd-hsct determines the level of rivarly in the sibling relationship (p = . ) with no impact on warm and conflict dimension. health-related qol in transplanted patients is quite good. sibling donor-recipient relationship is unbalanced with recipient respondents being more likely to assess a warm relationship, while rivalry was more likely to be present among donor. further multicenter studies based on larger cohort of patients are necessary to assess sibling relationship after transplantation life experience. disclosure of conflict of interest: the authors have nothing to disclose. this work was supported by grant from poznan university of medical sciences ( - - - ). rate of re-admission in patients undergoing allogeneic transplants from identical siblings, unrelated donors or haploidentical donors f sora , s sica, l laurenti, p chiusolo, s giammarco, i innocenti, e metafuni, a corbingi and a bacigalupo department of hematology, catholic university of rome hla identical siblings (sib), unrelated (ud) and family hla haploidentical donors (haplo) are currently being used for patients undergoing an allogeneic transplant (hsct) for hematologic disorders. gvhd prophylaxis is usually different, and is commonly based on a calcineurin inhibitor (cni) and methotrexate (mtx) with or without atg for sibs and uds, wheres post-transplant cyclophosphamide (pt-cy)+a cni and mycophenolate (mmf) is used for haplos. we will refer as sib, ud, haplo platform, the combination of a given donor and a given gvhd prophylaxis. the outcome of these three different platforms is usually measured in terms of gvhd, non relapse mortality (nrm) and survival. days of admission and readmissions are important in terms of morbidity, but also of costs, and are usually not reported. aim of the study: assess the duration of the first admission and the incidence of a new re-admissions, in the first days after the transplant. we retrospectively analyzed patients from to . sixtyone received peripheral blood stem cell graft from an ud, and gvhd prophylaxis with cya+mtx+atg; received a peripheral stem cell graft from a sib and gvhd prophylaxis with cya +mtx; patients received bone marrow hsct from haplorelated donor and pt-cy+cya+mtmf. patients characteristics are shown in table . relapses were excluded from the readmission analysis. the median time from the transplantation to discharge was days for ud, for haplo and days for sib: there was no significant difference between haplo vs ud (p = . ), whereas the admission of both haplo and ud was longer than sibs (po . ). first readmission. fiftyone patient out of required of a new admission for complications after tranplant ( out of after mud ( %), out of ( %) using a sibling donor and out of using an haploidentical donor ( %)). there were significantly more re-admissions in the ud vs sib group ( . ) and a trend for more ud readmissions vs haplo (p = . ); siblings had the lowest number of readmissions. time to neutrophil engraftment was comparable in haplo vs ud patients (p = . ) and in sib vs ud (p = . ); the time was longer in haplo vs sibs (p o . ). the reason to re-admitted the patients in the hospital after tranplantation was fever in out of ( %) new admissions in ud setting, out of ( %) in sib and out of ( %) in haplo; acute gvhd was the cause for re-admission in out of ( %) ud, out of ( %) sib and none in haplo. the other causes for re-admission in the hospital were hemorragic cistitis, thoracic or abdominal pain. second re-admission. of hospitalization is registered in out of patients in ud ( for aghvd and fever), out of ( %) in sib ( episodes of fever) and out of ( %) patients in haplo ( for fever and progressive disease). also for second episodes, ud grafts had significantly more admissions compared to haplo and sibs. third re-admission was recorded only in ud patients ( out of - %). this study shows a comparable duration of admission for transplant for haplo and ud patients, both significantly longer than sib grafts. the number of re-admissions is comparable in haplo vs sibs and there is a trend for lower number of re-admission as compared to uds. we interpret this outcomes with caution given the relatively small sample size and heterogeneous disease population included. future studies need to confirme our results. disclosure of conflict of interest: none. prolonged thrombocytopenia (pt) is frequent event after allogeneic haematopoietic stem cell transplantation (hsct), especically in haploidentical transplantation, which could be up to % according to our previous report. pt has significant negative impact on long-term outcomes, mainly due to increased non-relapse mortality. however, there are no efficious treatment. in this study, we report the preliminary results of recombinant human thrombopoietin (rhtpo) in treating this kind of patients. from . to . , patients were enrolled under the following inclusion criterion: ( ) diagnosed with dpe or sfpr after allogeneic stem cell transplantion; ( ) no sign of minimal residual disease or recurrence of hematological malignancy; ( ) not using other tpo receptor agonist or il- within month of enrollment. pt include delayled platelet engraftment (dpe) and secondary failure of platelet recovery (sfpr). the former was defined as failure to achieve platelet counts ⩾ /μl for consecutive without transfusion until days after transplantation, while the latter was defined as a decline in platelet counts below /μl for consecutive days, or requiring transfusion support after achieving sustained counts without transfusions for consecutive days after hsct. the prescription of rhtpo was iu once daily for days, or if patients achieve platelet ⩾ /μl for consecutive days with a duration o days. response was defined as success of achieve platelet counts ⩾ /μl for consecutive days. the response time was defined as the first day achieve response from the start of prescription. the primary end point was response rate, and the secondary end point was reponse time. a total of patients were enrolled, including males and females. the median age was ( - ) years. all patients received haploidentical transplantation. among these patients, patients were dpe and were sfpr. all patients received a -day prescription. the overall response rate was % ( out of ) in the overall population, while % ( out of ) in dpe and . % ( out of ) in sfpr, respectively. among the patients with response, the median response time was ( - ) days from the first dose of rhtpo. after weeks of the last dose of rhtpo, none of the responsed patient lose response. since the followup time is too short, the impact of relapse, gvhd were not reported. this single-arm preliminary result suggest that rhtpo could be a efficious method to manage pt after stem cell transplantation. however, these result need further confirmation. disclosure of conflict of interest: none. reproductive health in long-term female survivors after allogeneic hematopoietic stem cell transplantation z peric , , a samardzic , n durakovic , , d tina , , l desnica , r serventi-seiwerth and r vrhovac , school of medicine, university of zagreb, zagreb, croatia and university hospital centre zagreb, zagreb, croatia most female recipients of allogeneic hematopoietic stem cell transplantation (allo-hsct) suffer from premature menopause, infertility and endocrine imbalance owing to gonadal damage from myeloablative conditioning. in order to evaluate ovarian recovery and long-term endocrine complications in our institution, we performed a retrospective study of female patients who received a myeloablative allo-hsct during their reproductive age. we identified female patients who underwent myeloablative allo-hsct in our institution between and and were still alive with available follow-up at the time of this study. among them, patients accepted to participate and responded to a query designed for this s purpose. the median age of our patients at transplantation was years (range: - years). they were interviewed at a median of years (range: - years) post allo-hsct. the majority of patients were transplanted for a myeloid malignancy ( acute myeloid leukemia, chronic myeloid leukemia, myelodysplastic syndromes and chronic myelofibrosis), while patients had aplastic anemia and had acute lymphoblastic leukemia. all patients received bone marrow transplant from a hla-matched related donor after a myeloablative conditioning. conditioning regimen consisted of cyclophosphamide with or without total body irradiation (tbi) or in combination with busulfan. only patients ( %) resumed a normal menstrual cycle after allo-hsct, without the need for hormonal replacement therapy (hrt). all these patients were transplanted for aplastic anemia and none of them received tbi in the conditioning regimen. eight patients ( %) remained amenorrheic indefinitely and never started hrt, even though most of these women were transplanted under the age of years. % of these patients were diagnosed with osteoporosis later in life. the remaining patients ( %) started hrt at a median of months after allo-hsct (range: - months). however, only seven patients on hrt ( %) resumed regular menstrual cycle. a median duration of hrt therapy was years (range: - years). none of the women receiving long-term hrt had severe cardiovascular complications or breast cancer. finally, five women gave birth to eight healthy children in our study population. three unassisted pregnancies were observed in two female patients after spontaneous recovery of ovarian function (both patients with aplastic anemia). the remaining two patients restored ovarian function with the use of hrt and gave birth after an assisted pregnancy (one woman gave birth to triplets after an in vitro fertilization (ivf), while other became pregnant with a donated oocyte). in spite of the fact that almost all women who undergo allo-hsct develop an ovarian failure, spontaneous recovery is sometimes possible, particularly following conditioning regimen without tbi. in patients without spontaneous recovery, hrt should be initiated promptly to prevent the early and late unwanted effects related to estrogen deficiency. moreover, recovery of normal ovarian function and even a viable pregnancy is a realistic possibility in patients placed on hrt, particularly with the use of potential therapeutic interventions as ivf or oocyte cryopreservation. it is therefore crucial to provide adapted pre-transplant counselling and recommendations for regular post-transplant follow-up in female patients who undergo allo-hsct. disclosure of conflict of interest: none. transplant-associated thrombotic microangiopathy (ta-tma) is a multifactorial disorder caused by systemic vascular endothelial injury leading to end-organ damage often involving the kidney. ta-tma occurs in up to % of patients undergoing hsct, and may be associated with poor outcome. although pathogenesis has not been fully clarified, activation of the complement system has been suggested to play a central role, and eculizumab, a monoclonal antibody (mab) that mediates terminal complement blockade, has shown therapeutic benefit in cases unresponsive to immunosuppression modulation. we report the case of a pediatric allogeneic hsct recipient with severe ta-tma, who did not tolerate treatment with eculizumab, now successfully treated with oms , a novel human mab targeted to the mannan-binding lectin-associated serine protease- (masp- ), a molecule central to the activation of the lectin pathway of complement. a -year-old girl received an allogeneic hsct from a hla-compatible unrelated donor for the treatment of diamond-blackfan anemia. at month + of the posttransplant course, she developed progressive deterioration of renal function, microhematuria and serositis, that prompted the cyclosporine discontinuation. from month + , the patient experienced progressive trilinear cytopenia, elevated ldh, schistocytes, undetectable haptoglobin, hypertension, increased serum creatinine, nephrotic range proteinuria, and serositis, and a diagnosis of ta-tma was established. laboratory investigations documented no abnormalities in the patient but identified a stop-codon heterozygous variant in cfhr c. _ dupaa (p.glu lysfs* ) in the donor's dna. the patient was initially treated with eculizumab, but she developed acute pulmonary edema soon after eculizumab administration as the consequence of a possible reaction to the drug which had to be discontinued. the patient was subsequently treated with plasma exchange, with only limited benefit. upon ta-tma relapse at month + , eculizumab was re-administered at lower doses, but she developed a new episode of acute pulmonary edema, preventing further eculizumab continuation. renal function progressively deteriorated and she was started on hemodialysis, reaching a times weekly regimen. the patient received oms , kindly provided on a compassionate use basis by omeros corporation, seattle, usa, starting with an iv dosing schedule. she did not experience any adverse events, and was able to tolerate the treatment well. at months from oms initiation, she has shown improvement in ldh and haptoglobin levels, and, more importantly, her creatinine levels have normalized, allowing for complete discontinuation of hemodialysis and partial outpatient management. anti-masp- mab oms is a promising new option for the treatment of ta-tma occurring after hsct, and seems to have a safe profile also in the pediatric/adolescent setting. disclosure of conflict of interest: none. severe cytokine release syndrome after t-cell replete haploidentical transplantation with post-transplant cyclophosphamide is associated with increased death rate d taurino , j mariotti , b sarina , l morabito , s bramanti , c carlo-stella , a santoro and l castagna bone marrow unit, humanitas cancer center, istituto clinico humanitas, rozzano, italy and hematology department, humanitas cancer center, istituto clinico humanitas, rozzano, italy haploidentical stem cell transplant (haplo-sct) represents a potential curative strategy for several hematological malignancies. haplo-sct may represent an alternative option when a hla matched-identical sibling (hlaid) or a matched unrelated donor (mud) is not available. the syndrome of systemic inflammation, characterized by fevers, vascular leak, hypotension, and respiratory and renal insufficiency, in the context of elevated inflammatory markers and cytokine levels was previously described as cytokine-release syndrome (crs) . recent publications have elicited the occurrence of crs after haploidentical transplant, especially after peripheral blood stem cell graft, and its high-related mortality - . here we report the experience of our institution with crs after haplo-sct. between march and october , we treated patients with haplo-sct with a graft source represented by peripheral blood stem cells. we monitored the occurrence of crs symptoms and utilize a previously described grading system , starting from day , up to day after transplant. severe crs is defined as grade or higher because it requires aggressive interventions and is characterized by oxygen requirement ⩾ %, l nasal cannula, hypotension requiring high dose or multiple vasopressors, grade renal toxicity or grade transaminitis. other characteristics comprise newonset altered mental status without other explanation and new cardiomyopathy without wall motion abnormality. results: out of patients experienced fever between day and day post transplant with most episodes ( patients) occurring between day and day . on day after transplant, patients had grade , grade and grade crs, respectively. by day post haplo-sct, patients had crs grade , grade and grade . overall, the incidence of crs any grade was % ( % ci - %). year after transplant patients died because of non-relapse related side effects. with a median follow-up for alive subjects of months, -year overall survival (os) was % ( % ci: - %). -year os was % for patients with a crs on day (p = . ). conclusions: crs represent an important complication after haplo-sct. crs score on day after hst apparently correlates with long-term survival. better strategies need to be implemented for an early detection of severe crs in order to develop effective treatments, such as tocilzumab, for this important side effect. further studies are ongoing at our institution in order to correlate post-haplo crs with graft composition, laboratory parameters and immunereconstitution. hematopoietic cell transplantation (hct) is associated with significant morbidity that impairs survivor's sexual functioning. however, few studies have specifically addressed it. thus, we examined ( ) sexual functioning during the first year post hct, ( ) differences between allogeneic and autologous hct, and ( ) whether demographic, clinical and psychological variables were associated with sexual functioning. this is a prospective multicenter study assessing patients before hct, at day , and . sexual functioning was assessed with the changes in sexual functioning questionnaire, which yields a total score, along with scores for the dimensions of frequency, pleasure, orgasm, desire and arousal. anxiety and depression (hads) were also collected. we included consecutive hct recipients: ( %) were men, with a median age of years (range: - ), ( %) received an allogeneic hct and ( %) an autologous hct. sexual functioning was significantly affected: % of the sample reported impairment at pre-hct, % at day , % at day and % at day . mixed model analysis indicated that sexual functioning was not associated with time from hct (p = . ) or hct type (p = . ). however, there was an interaction between these two variables (p = . ), particularly at day , since sexual functioning had improved among autologous survivors and worsened among allogeneic survivors leading to nonsignificant differences between hct type (p = . ). frequency of sexual functioning improved during the study period (po . ), and no differences were observed between hct type (p = . ). again, there was a borderline interaction between post-hct time and hct type (p = . ), since autologous survivors reached higher frequencies than allogeneic survivors, with significant differences at day (p = . ). pleasure significantly improved during the study period (p = . ), without observing differences between hct groups (p = . ). again, however, autologous survivors reported significant improvements in pleasure at day (p o . ) and a trend at day (p = . ) when compared with allogeneic survivors. orgasm did not improve during the study period (p = . ), and no differences were obtained between hct groups (p = . ). allogeneic survivors had higher orgasm scores at pre-hct (p = . ), which worsened during the study period, particularly at day (p = . ). in contrast, autologous survivors reported improvements in orgasm by day . non significant results were obtained in the sphere of sexual desire and arousal (p . ). bivariate analyses indicated that women, older age and depression were associated with impaired sexual functioning at all assessed time-points (p o . ). chronic graft-versus-host disease (gvhd) was associated with worse sexual functioning at day (p = . ) and (p = . ). no differences were obtained when considering diagnosis, having received previous hct, intensity of the conditioning regimen and whether patients lived with a partner (p . ). stepwise multivariate regression analyses indicated that gender (p = . ) and extensive chronic gvhd (p = . ) predicted for worse sexual functioning at day . sexual functioning should be routinely assessed and considered for eventual targeted intervention in both hct populations, particularly during the first year post transplant. additional clinical efforts should focus on patients more vulnerable to impaired sexual functioning. disclosure of conflict of interest: none. significant improvement of qol by using atg as part of the conditioning regimen followed by hla-identical peripheral stem cell transplantation in acute leukemia patients. results from a prospective, randomized phase iii study (atg family study) b francesca , s carlos , w christine , s mariarosaria , p massimo , s carmine , m giuseppe , b wolfgang , cm angelo , p francesca , m nicola cgvhd is a major complication after allogeneic sct. we previously demonstrated that the addition of anti-tlymphocyte globulin (atlg neovii, formerly atg-fresenius) to a myeloablative preparing regimen followed by peripheralblood sct from an hla-identical sibling for pts with acute leukemia resulted in a significant reduction of cgvhd, without increasing the risk of relapse or infection. the study protocol included quality of life (qol) questionnaires (eortc qlq- and hdc ) before and after sct (day+ , , and mos). the qlq-c includes a global qol scale, five functional scales (physical, role, emotional, cognitive and social function) and nine symptom scales (fatigue, nausea-vomiting, pain, dyspnea, insomnia, appetite loss, constipation, diarrhea and financial problems). the qlq-hdc includes six multi-item scales and eight single items that describe impairment through highdose treatment. mixed models for repeated measures (mmrm) and linear mixed models (lmm) were used to analyze the time courses and the slopes of the outcomes depending on treatment arm (atg vs non atg), age, country, sex, and cgvhd. (clinicaltrials.gov: nct ). pts with a qol form returned decreased by visit ( % pre-sct, % at days and % at mos after sct). forty-nine percent in the atg and % in non atg arm provided any qol forms after sct. return of any post-sct qol forms by country was % for germany, % for italy and % for spain. pts with cgvhd were more likely to return qol questionnaires ( % vs % w/out cgvhd) while neither age nor sex were closely associated with qol form return. the majority of subscales of the qlq- indicated an average improvement of qol and reduction of symptoms over time, notably in the atg group. in an mmrm model controlling for country, age, sex and cgvhd, pts treated with atg showed significantly more pronounced improvement of global health status/qol over time compared to non-atlg (p = . ), with a treatment group difference of . ± . points (marginal mean ± sem) at day and increasing to . ± . points at month favoring atg. significant superiority of atg (po . ) was also observed for four of the five functional scales as well as for several symptom scales scores including appetite loss, insomnia, nausea-vomiting and dyspnea. for the qlq-hdc , significant treatment effects favoring atg were observed for gi side effects and impact on family. lmm analyses of qol by country indicate that patients from italy generally gave more favorable ratings for all functional scales and lower scores for most symptom scales than those from germany while the time courses and slopes were similar for most scales. these results underline the importance of the habits and cultural environment which are distinctive of each country. males and females showed similar qol ratings at pre-and post-sct. patients up to years tended to provide more favorable functional ratings and less severe symptom scores than older patients and also showed more pronounced improvements of qol. pts receiving atg in a randomized study have significantly less cgvhd and improved grfs, resulting in an improved qol regarding global health status and most functional scales. notably, we also observed a significant difference in qol assessment between pts from germany and italy. oral mucositis (om) is a well-known side effect of high-dose chemotherapy and radiotherapy in hematological patients, which influences the health-related quality of life (hrqol) of the affected patients. the purpose of this study is to demonstrate the impact of om on hrqol in stem cell transplanted patients in routine care. prospective, noninterventional single-center observational study was performed at a german university hospital. inpatient allogenic and autologous stem cell transplant patients ⩾ years with high-dose chemotherapy. om was assessed with the who oral toxicity scale, pain using the numeric rating scale (nrs) and the performance status with the ecog score. hrqol was captured with the eortc qlq-c and the qlq-oh questionnaires ( days before hematopoietic stem cell transplantation (hsct); days after hsct; days after hsct). statistical significance was assumed p o . . a total of patients ( autologous and allogenic) was included from august to december . a total of ( %) patients developed om. of these patients, suffered from grade , from grade , from grade and from grade om. three days before hsct, the mean qol of all patients was %, the mean qlq-c summary score . % and the mean oral health related quality of life . %. most of the patients suffered from om around day after hsct. after days, quality of life (qol) was higher in patients with no om ( . %) than in patients with om ( . %). the qlq-c summary score was significantly (p = . ) lower in patients affected by om ( . %) than in patients who did not develop an om ( . %). om affected patients had significantly more limitations in emotional (no om . %; om . %; p = . ) and cognitive functioning (no om . %; om . %; p = . ) and in fatigue (no om . %; om %; p = . ), pain (no om . %; om %; p = . ) and insomnia (no om . %; om %; p = . ), they had a significantly higher rate of problems. oral health-related quality of life was significantly (p = . ) lower in patients who were affected by om ( . %) compared to patients who did not develop an om ( . %) and patients with an om had significantly more problems with a sore mouth (no om . %; om . %; p = . ), sticky saliva (no om . %; om . %; p = . ) and sensitive mouth (no om . %; om . %; p = . ). after days, qol was higher in patients with no om ( . %) compared to patients with om ( . %). patients with no development of om had a higher but not significant physical functioning, cognitive functioning and social functioning. patients affected by om had higher levels of fatigue and pain and more often suffered from a sore mouth. oral health-related quality of life was higher in patients without om ( %) compared to patients with om ( . %). comparing all assessed days patients with om had higher scores on the nrs increasing with a higher grade of om (mean nrs score grade ; - . , grade ; - . ), the ecog index was higher in om affected patients during episodes with om (mean ecog score- . ) compared to episodes without om (mean ecog score- . ). om has a major impact on the hrqol, health-related symptoms and functionality. in the future, there has to be a higher awareness from clinicians and patients of the prevention, assessment und causes of om. more research has to be initiated to ease the symptomatology and to improve patients' quality of life. disclosure of conflict of interest: none. according to ebmt data, chronic gvhd (cgvhd) occurs in - % of all patients after allogenic hematopoietic stem cell transplantation (allo-hsct). pulmonary cgvhd is the most severe form. but it is very unpredictable to use due to the fact that many factors can affect it (breath-dependent; need experience not only from physician but from patients also and so on). here we show that routine software-based image analysis algorithm can provide data that highly correlated with pft results and have excellent sensitivity and specificity in pulmonary cgvhd diagnosis. we blindly analyzed ct scans (made without additional expiration) in allo-hsct patients at different time points. all scans were performed on ct scanner aquilion , toshiba, japan. according to hounsfield units (hu) definition, − hu ('air') have approximate density at g/ml; hu ('water') have approximate density at g/ml. the analysis of ct scans (heart, vessels and bronchi were excluded from analysis) was based on automated software conversion (image-analysis algorithm providing by multivox software, msu, moscow, russia) of each ct-image pixel from hu to density units (g/ml). pft were performed using standard procedures at same as ct scans time points (spirolab iii, italy). all patients with hematological malignancies (acute leukemia- , aplastic anemia- , chronic myeloid leukemia- , t-cell lymphoma- , chronic myeloproliferative disorder- , myelodysplastic syndrome- ) were transplanted in national research center for hematology between and . median of age was . years (range: - years). eight patients were males, -females. seventeen received reduced-intensity and -myeloablative conditioning regimen. graft from match unrelated donor (mud) were used in cases, 'mismatch' mud- , match related donor (mrd)- , 'mismatch' mrd- . median follow-up is . months. we analyzed lung tissue experimental density in patients before and after allo-hsct at different time points. median of lung tissue experimental density were . (interquartile range (iqr), . - . ), . (iqr, . - . ) and . (iqr, . - . ) for patients before allo-hsct, after allo-hsct with cgvhd (except pulmonary cgvhd) and with pulmonary cgvhd, respectively. mann-whitney u test was used to reveal significant differences between these groups (see figure ). also, we found strong correlation between pft and experimental density (spearman's correlation coefficient r = . ) (see figure ). forty-five ct scans of patients with pulmonary cgvhd and ct scans of patients without pulmonary cgvhd at the time of ct scan as control subjects were included in roc analysis to assess the clinical values of our model. we generated an roc curve and found that the area under the curve (auc) was . ( % ci, . - . ) (p o . ) (figure ). standard ct scan is presented as easy to perform, breath-independent, standardized and wide spread method for every patient after allo-hsct. it can be performed many times during all their post-hsct life. ct scan with a simple software analysis allows to select a group with high probability of pulmonary cgvhd and who can be suspected of cgvhd development by this method with sensitivity- % and specificity- . %. disclosure of conflict of interest: none. the choice of effectiveness criteria affects conclusions of economic evaluation of newer allogeneic bone marrow transplantation modalities :example based on a randomised multicenter trial comparing two reduced intensity conditioning regimen (flu-bu-atg) vs (flu-tbi) for matched related allo-sct s le corroller*, anne-gaelle , c siani , , r tabrizi a re-evaluation of the per-diem hospitalization cost was performed in and included the utilization of hospital technical facilities and a more precise estimation of overheads costs. we performed three separated cost-effectiveness analysis, using, respectively, pfs, os and qaly as end point. when using pfs as effectiveness, relapse costs were not included. weighting coefficients for the cost per qaly analysis came from the literature. at years, os and pfs were % and %, respectively, and did not statistically differ between groups. the mean total cost per patient was not statistically different between groups ( € for fba vs € for ftbi, ns). using pfs as end point, the icer of fba compared to ftbi is € per year of pfs gained. using os, the icer became non-statistically significant, signifying that when handling uncertainty, no difference in term of cost-effectiveness was observed between fba and ftbi with os as end point. using s qaly, the icer was statistically ns again, showing no advantage in terms of cost per qaly of one conditioning regimen over the other. this result was obtained both considering three weighted health states (dfs, progression and death) and four weighted health states (dfs without gvhd, dfs with gvhd, progression and death) for the qaly calculation. using os and qaly, the two conditioning regimens were not different in terms of cost-effectiveness, while fba may be considered as more cost-effective using pfs as effectiveness criterion. using intermediary end points allows economic evaluation to be available earlier in the life cycle of an innovation. however, it implies strong hypotheses about the predictive value of the pfs over the os. longer period evaluation and qaly may reverse preliminary results. this situation is likely to exist in the hematology setting where alternatives between chances of cure and toxicities of treatment are often observed. research about allogeneic sct modalities is archetypical of such situations and decisions makers should be aware of the necessity of further economic re-evaluation along the development and diffusion process of innovative treatments. disclosure of conflict of interest: none. the impact of corticosteroids prophylaxis for the engraftment syndrome incidence during autologous stem cell transplantation in multiple myeloma and amyloidosis the es is a complication of asct characterized by an inflammatory response during peripheral blood recovery. the standard treatment is based on corticosteroid therapy. the incidence of es after asct increases in chemotherapy lowtreated patients such as those with multiple myeloma (mm) and amyloidosis (al).moreover, the es is associated with the use of g-csf after infusion of stem cells. therefore, our bmt team does not use g-csf since in this population reducing the incidence and severity of es. therefore, it makes sense to use low-dose prednisone to prevent this complication. in this study, we compared two consecutive cohorts of patients with mm/al that performed an asct while evaluating the corticosteroids prophylaxis (cp) in the es incidence and its effect on other clinical variables. we included patients with mm (n = ; %) and al (n = ; %) that performed an asct between january and november in a single institution. the median age (range) was . ( . - . ) years. during the procedure, all patients received melphalan as conditioning chemotherapy and none received g-csf. fortyseven patients ( %) received intravenous methylprednisolone or oral prednisone . mg/kg/day from day + until reaching a neutrophil count ⩾ per mm for consecutive days (cs group), and ( %) patients did not receive corticosteroids (noncs group). the characteristics of patients in both groups (age, gender, status performance and previous treatment were similar (p . )). the cs group, received higher doses of cd + than the noncs group ( . × /kg vs . × /kg, respectively, p = . ). the median (range) days of neutropenia ( o per mm ) was ( - ) days. es was diagnosed in ( %) patients. fifty-seven ( %) patients had fever, showing infectious focus or microbiological isolation in ( %) cases, whereas the incidence of grade iii-iv oral mucositis and relevant gastrointestinal toxicity was % and . %, respectively. the complete analysis between groups (cs versus noncs) for the whole series and in the mm/al subgroups is detailed in table . the administration of corticosteroids as prophylaxis seems to reduce the incidence of es in the overall series or in the analysis for the subgroups (mm and al) without increasing infection. [p ] disclosure of conflict of interest: none. chronic gvhd is a condition that might occur after allo-hsct and has been proved to impair long-term survival and quality of life of patients. graft failure is also a major potential complication for patients undergoing transplant for an aplastic anemia/bone marrow failure (bmf). partial in vivo t-cell depletion, employing anti-thymocyte globulin (atg) during conditioning, has been proved to successfully prevent the mentioned potentially life-threatening complications in highrisk patients. however, the possibility of developing epstein-barr virus (ebv)-induced post-transplant lymphoproliferative disorders (ptlp) has been a limiting factor to use atg. this study includes the last pts with a minimum follow-up of days, who underwent allo-hsct in our center (november -august ). a total of pts were male and female. median age was years (range: - ). baseline diseases were: acute leukemias ( ), lymphoproliferative disorders ( ), myelodysplastic syndromes ( ), chronic myeloproliferative diseases ( ), multiple myeloma ( ) and bone marrow failures ( ) . donor was unrelated in cases, and related in (including haplo-identical). conditioning regimen was: busulphan-based ( ), melphalan-based ( ), tbi-based ( ) and others ( ). progenitors source was pb in and bm in . patient/donor ebv pre-transplant serology was: +/+ in cases, +/ − in and − /+ in . rabbit atg (thymoglobuline) was employed in cases: at . - mg/kg (urd transplants) (low dose), and cases at . mg/kg (all of them pts with bmf) (intermediate dose). family donor (including haplo-identical) transplants of those pts with diagnosis different from bmf ( cases) did not receive atg. systematic monitoring of ebv using quantitative pcr was employed. ebv reactivation was considered when dnaemia was superior to copies per ml. a total of pts presented ebv reactivation: / ( %) in cases without atg, / ( . %) in cases with low-dose atg and / ( %) in cases with intermediate-dose atg. median time of reactivation was the day + (range: + to + ). there was one single case of ebv-induced ptld which belonged to the intermediate-dose atg group. all cases (including the one with ptlp) were successfully treated with rituximab at mg/m /week. median number of doses employed were (range: [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . mortality due to ebv was % in our series. limited donor availability in the form of either matchedrelated or unrelated donors drew attention to haplo-hct. donors of haplo-hct shares an exact haplotype with the recipient but is mismatched for hla genes on the unshared haplotype. most studies have shown promising results in terms of graft success and survival. in this study our aim is to present the early and late outcome of our haplo-hct patients. between and , we retrospectively evaluated haplo-hct in terms of post-transplant outcome, survival and complications who diagnosed and followed in our center. the median age of patients was (range: - ), ( %) of them were male recipients. the patient characteristics were given in table . thirteen patients ( %) had pre-transplant active disease. neutrophil and platelet engraftment was achieved in patients ( %) at a median day of (range: - ) and (range: - ). eight of patients ( %) died within month after transplant because of sepsis without achieving engraftment. haplo-hct is the second transplant in four of patients ( %): patient relapsed after full-matched related transplant, patient relapsed after / matched unrelated transplant, patient had engraftment failure after full-matched unrelated transplant, patient underwent haplo-hct in another center, followed in remission for years and relapsed. acute graft vs host disase (agvhd) was diagnosed in patients ( %), whereas chronic gvhd in patients ( %). four patients were relapsed ( %) during follow-up with median rfs of months. three patient had bk virus-positive hemorrhagic cystitis ( %). the distribution of infections is shown in figure, viral infections were detected later than fungal and bacterial infections. previous history of invasive pulmoner aspergillosis was detected in of the patients ( %) ( of them were re-transplanted) and received secondary prophylaxis. overall survival (os) of months and year were % and %, respectively. the choice between alternative graft sources depends on the urgency of the transplant on each institutional preference. higher complication and infection rates in addition to decreased survival compared with previous studies since our patient population consisted of refractory patients with comorbidities. preferable patient profiles undergoing haplo-hct may have better outcomes. disclosure of conflict of interest: none. the third month risk factor score: detection of disease at day + of allogeneic stem cell transplantation is the most important risk factor of worse prognosis m celis , c fernández , l yáñez , , a bermúdez , , a insunza , m colorado , m lópez-duarte , i romón , s garcía-Ávila , a cabero , a casado , m sánchez-escamilla , c richard and e conde , hematology department, hospital universitario marqués de valdecilla and university of cantabria before allogeneic stem cell transplant (sct), several index can provide prognostic information (ebmt risk score and hcti score). however, there is scarce data for the impact of the procedure during the first days of transplant, in which opportunistic infections and the acute graft versus host disease (gvhd) can induce harmful effects. our purpose is to create a risk factor score, measured at day + post sct, to give information about the prognosis of the patient. we retrospectively analyzed seven clinical (disease, fungal and cmv infection, acute gvhd, treatment with corticosteroids, karnosfsky status and length of hospitalization) and eight analytical (related to immune status, liver and lung function, nutritional status, iron overload and platelet count) risk factors in patients who underwent sct in our center between and and were alive at day + . data were collected as categorical variables and compared by χ -test. significant variables (p o . ) were evaluated in a multivariate logistic regression model. those who maintained statistical significance were then assigned a point value calculated with their β-coefficient. summation of the points resulted in a weighted risk score. median age was years (range: - ) and were males ( . %). the most frequent disease was aml, patients ( . %). the conditioning regimen was myeloablative in patients ( %) and bone marrow was the principal stem cell source ( %). donor was mrd in ( . %), mud in ( . %) and mmd in ( . %). the median followup was months (range: - ). the univariant model identified five prognostic variables: detection of disease by molecular, cytogenetic or flow cytometry asses in leukemias, myelodisplastic syndrome and multiple myeloma or image (ct scan ± pet) in lymphoma, dose of corticosteroids ⩾ . mg/kg/ day, ferritin ng/ml, albumin o . g/dl and platelet o per mm . table shows variables evaluated. in the multivariate model, the detection of disease (hr . , % ci . - . , p ng/ml (hr . , % ci . - . , p = . ), and platelet o per mm (hr . , % ci . - . , p = . ) were associated with higher risk of death and according with their-coefficient , and points were, respectively, assigned. the third month risk score (tmrs) was calculated in all patients and they were stratified into three groups: low risk of death (a, - points), intermediate risk (b, points) and high risk (c, ⩾ points). at years post sct, the estimated overall survival according with the tmrs was . % ± . in group a, . % ± . in group b and . % ± . in group c, po . . although the harmful effect of the first months of transplant can impact in the survival, the detection of disease at day + is the most determinant risk factor of death. this fact gives us the need of transplant in the best response and, in those who cannot, to plan promptly rescue strategies. the next objective is to confirm our risk score in a validation group. disclosure of conflict of interest: none. recombinant human soluble thrombomoduline alpha (rhtm) is a novel anticoagulant agent and approved for disseminated intravascular coagulation in japan. the aim of the study is to evaluate the therapeutic potential of rhtm for sinusoidal obstructive syndrome/hepatic veno-occlusive disease (sos/ vod). we retrospectively studied times of allogeneic hematopoietic cell transplantation in toranomon hospital from june to june . we extracted the patients who used rhtm for dic and satisfied the diagnostic criteria of sos/ vod around the same time, because the use of rhtm for sos/ vod alone is off-label. data on the patients who used rhtm for days within days after transplantation were analyzed. the patients who were already treated with rhtm before the emergence of the first symptom or sign of sos/vod, and who started rhtm over days after the emergence of the first symptom or sign of sos/vod, were excluded from the [p ] analysis. to diagnose classical sos/vod (⩽ days after transplantation), we used two classical criteria of the modified seattle and the baltimore. for late-onset sos/vod ( day of transplantation), we used the criteria of ebmt. we defined as severe sos/vod, if the patients had renal (cr ⩾ times of baseline), respiratory (spo ⩽ % or the need for positive pressure) or central nervous system failure until weeks after the diagnosis of sos/vod. complete response (cr) was defined as the resolution of all the symptoms and the signs in sos/vod diagnostic criteria. a total of patients were extracted. the median age was years (range: - ) and patients ( %) was male. donor cell sources were ucb (n = ) and ubm (n = ). most of the prophylaxis regimen was the combination of ursodeoxycholic acid and dalteparin in patients ( %). classical sos/vod was diagnosed in ( %) and patients ( %) by the criteria of the modified seattle and the baltimore at the median day of (range: - ) and (range: - ), respectively. twenty-eight patients ( %) were diagnosed as late-onset sos/vod at the median day of (range: - ). severe sos/vod developed in patients ( %) (renal, n = ; respiratory, n = ; central nervous system, n = ). the elevation of transaminase was observed in patients ( %). the median interval from the emergence of the first symptom or signs of sos/vod to rhtm administration was days (range: - ). the median duration of rhtm use was days (range: - ). rhtm was used alone in patients ( %), in combination with dalteparin in ( %), with atiii in ( %), with dalteparin and atiii in ( %), with atiii and pge in ( %), and with pge in ( %). corticosteroid was used concomitantly in patients ( %). finally, patients achieved cr of sos/vod. the cumulative incidence of cr of sos/vod was . % at year after the administration of rhtm ( % confidence interval, . - . %). the median interval from the administration of rhtm to cr of sos/vod was days (range: - ). at year after transplantation, overall survival was . % ( % confidence interval, . - . %). from the administration of rhtm to weeks after the cessation of rhtm, hemorrhagic adverse events were observed. seven out of events were at grade - , and out of events were fatal (intra-abdominal in , gastrointestinal in , lung in and brain in ). we concluded that rhtm had a therapeutic potential for sos/vod. disclosure of conflict of interest: none. thrombopoietin receptor agonists for delayed and prolonged clinically-relevant severe thrombocytopenia after allogeneic hematopoietic stem cell transplantation v bosch vilaseca , i garcía cadenas , e roldán , s novelli , r martino , p barba , a esquirol, l díaz polo , g orti , d valcárcel and j sierra hematology department, hospital de sant pau, barcelona, spain and hematology department, hospital de la vall d'hebron, barcelona, spain persistent thrombocytopenia is a common complication after allogeneic stem cell transplantation (allosct), which dramatically increases the patients' dependence on hospital-based healthcare. thrombopoietin receptor agonists (tpoa) increase platelet counts in other clinical settings; however, the experience regarding their use after allosct is limited. we retrospectively evaluated tpoa efficacy in consecutive adult allosct recipients who received tpoa as a compassionate use for severe thrombocytopenia post-engraftment. five patients ( %) had primary and prolonged failure of platelet recovery, while had secondary thrombocytopenia: in seven of these cases, gvhd and/or a viral infection were the 'attributed' cause, while three were classified as post-allosct itp. all patients were dependent on platelet transfusions (median: times per week, range - ), with severe bleeding episodes in nine cases ( %) before tpoa onset. tpoa was started at a median of days after allosct (range: - ). romiplostim was used in ( %) cases. the median starting dose was μg/kg once a week (range: - μg/kg), while the final dose identified as most beneficial was μg/kg (range - μg/kg). eltrombopag was used in cases ( %), with an initial dose of mg daily; while the final doses were and mg daily. overall, / patients responded to tpoa therapy (defined as a stable platelet recovery to ⩾ /μl without transfusion support). the -day cumulative incidence of successful platelet recovery to ⩾ /μl and ⩾ /μl was % ( % ci, - %) and % ( % ci, - %), respectively, which were reached at a median of and days from start of therapy. five of the patients ( %) with severe bleeding at onset responded to tpoa ( of them without further hemorrhages) at a median of days (range: - ). at a median follow-up of days from start of therapy, three patients who responded continue tpoa treatment, while four other responders were able to discontinue it without recurrence of thrombocytopenia. among these patients, s the median total duration of treatment was days (range: - ). one patient lost his response within months after tpoa onset when he developed thrombotic microangiopathy associated with progressive gvhd. the remaining responder experienced disease relapse on day + after allosct. among the non-responders, had leukemia relapse during tpoa treatment, switched from romiplostim to eltrombopag without success and the remaining cases had active severe infections at tpoa onset ( hemorrhagic cystitis and cmv colitis) or non-controllable intestinal bleeding due to progressive gvhd. tpoa were well tolerated, with only patients showing adverse events (grade liver toxicity and grade fatigue), which did not lead to any change in therapy. six patients ( %) underwent follow-up bone marrow biopsies that did not display any increase in marrow fibrosis, including the patient who had myelofibrosis prior to allosct. although six patients in the study had active gvhd when tpoa was started, no patients showed worsening of gvhd. our results support the safety and efficacy of tpoa for the treatment of persistent thrombocytopenia in allosct recipients. further studies should compare the efficacy of romiplostim and eltrombopag and identify surrogate clinical and laboratory variables that are predictive of response to one (or both) of these tpoa. disclosure of conflict of interest: none. . clinical response in both groups was defined as improvement of organ function (no neurological residues; normalization of kidney function) and independence of red blood cell and platelet transfusions. results: the median time of ta-tma onset was . months ( . - . ) after hsct. thirty-five of patients ( %) were under treatment with calcineurin-inhibitors or sirolimus at the time the ta-tma occurred. in all cases, the immunosuppressive drug was stopped promptly. in patients, classical treatment was the primary therapy with a response rate of % (including four patients who switched to ec), whereas the response rate to ec treatment was significantly higher with % (p = . ). all patients receiving ec showed sufficient blockade of the terminal complement pathway after the second ec application (ch o %). despite the increased response rate for ec therapy, there was no difference seen between these two groups according to overall survival in weeks: classical treatment ( % ci - . ) vs ec treatment . ( % ci . - . ) p = . . the main cause of death differed significantly between this two treatment approaches with a therapy-related mortality due to infection with % in the ec group during tma therapy and none seen in the classical treatment group (p = . ). progressive gvhd was identified as an adverse prognostic factor in both groups (p = . and p = . ). conclusion: in our analysis, we show that ec shows a significant higher response rate in severe ta-tma patients compared to the classical treatment approach. however, in both groups the outcome remained very poor. since most patients presented with advanced, severe ta-tma, especially in the ec group, we hypothesize that earlier diagnosis and treatment of ta-tma and more effective prevention and treatment of infections will improve the outcome of patients with this complication. however, randomized studies are essential for comparison of these two treatment strategies to identify patient groups that benefit from a treatment with ec. disclosure of conflict of interest: none. tocilizumab as an effective treatment in cytokine release syndrome as an early peri-transplant complications in patients subjected to allogeneic stem cell transplantationproinfammatory/autoimmune patient/donor hla haplotype life-threatening early allogeneic hsct complication risk factor hypothesis m-g patrycja , , p-j beata , , s marcin , k ksenia , s-k agnieszka and sb aleksander , bone marrow transplantation unit, department of haematology, krakow university hospital and jagiellonian university collegium medicum cytokine release syndrome (crs) is classical complication of car t cells therapy, but also can be connected with early peritransplant complications in patients subjected to allogeneic stem cell transplantation. it can be connected with atg infusion, but also with inflammatory response during periengraftmetnt period (pre-engraftment syndrome and engraftment syndrome) and septic infections. severity of these complication can differ depending on patient's performance status and therapeutic options from just observation and vigilance to mechanical ventilation need. we would like to present small patient series (n = ) subjected to msd (n = ) and mud (n = ) with early transplant-related complications treated with combination of steroids (dexamethason) and tocilizumab. in two of them, tocilizumab was used after second dose of atg. both patients present hypotonia with decreased urine output, prompt increase of creatinine level and presence of acute inflammatory parameters crp, beta microglonulin and procalcitonin level, fluid retention and decreased oxygen saturation. in another one patient, these symptoms were connected with pbsc infusion from unrelated donor. in later two patients, we observe almost the same clinical presentation in preengraftment phase. in every of patients infection was ruled out-blood cultures were negative. all these patients were treated with tocilizumab in a single dose of mg/kg. in all patients, we observed prompt response-normalization of clinical state, renal function, oxygen saturation and decrease of inflammatory factors-crp, procalcitonin and beta microglobuline. discussion: crs is a rare complication connected with early phase of allogeneic stem cell transplantation. there were no results of treatment with steroids, reduction of a dose of cyclosporine a according to decreased renal function, but all patient completely/fully recovered after single dose tocilizumab treatment. all our patients were subjected to reduced intensity protocols, what might be a risk factor to develop crs because non complete depletion of the patient origin monocytes/macrophages active population. we also analyzed other factor connected with crs in early peritransplant period finding possible connection with s proinflammatory hla phenotype. it was obvious in the patient one our patients with peri-engraftment phase crs-he was diagnosed previously with rheumatoid arthritis b pos, dr . in three of five, we have found sle predisposition in hla phenotype (drb * /dqb * or drb * / dqb * ), in later one-ra associated hla antigen drb .these patients were analyzed correlating with historical cohort of additional five patients with mortal and another three with very severe early peri-transplant complications and in all we have found the same 'sle or ra hla phenotype'. because small number of analyzed patients and documented high frequency of these haplotype in population, this is still an opened question is proinflammatory/autoimmune hla phenotype connected pathogenically with predisposition to develop severe transplant complications and are we able to treat all these patients with combination of steroids with tocilizumab. further analysis is needed. disclosure of conflict of interest: none. transplant-associated thrombotic microangiopathy (ta-tma) is a severe complication post haematopoietic cell transplantation (hct) leading to high mortality rates. however, outstanding questions regarding its diagnosis, pathophysiology and treatment remain in the literature. recent studies suggest evidence of complement activation, implicating that complement inhibition may be an effective alternative treatment strategy in refractory patients. therefore, we hypothesized that increased complement activation can be detected in ta-tma patients using a functional assay, the modified ham test. we enrolled consecutive patients with ta-tma according to the international working group criteria from january to june . as controls, we studied patients with graft-versushost-disease (gvhd). complement activation was detected using the modified ham test, a cell proliferation assay based on the susceptibility of a pnh-like cell line to complement activated serum. normal human serum was used as a negative control and lipopolysaccharides(lps)-incubated normal serum as a positive control. all samples were tested in triplicates and twice. we studied ta-tma patients transplanted from unrelated / matched ( ) or / mis-matched ( ) donors, identical ( ) and haploidentical ( ) siblings. all patients presented severe acute and/or chronic gvhd. ta-tma presented at median + ( - ) day post-transplant. in the control group, we studied two patients with steroidsensitive grii and two with steroid-refractory griv acute gvhd. we were able to detect significantly increased complement activation in the serum of ta-tma compared to gvhd patients (p = . ). based on previous studies and present controls, percentage of non-viable cells higher than % was considered a positive modified ham test, indicating increased complement activation in four ta-tma patients. regarding treatment outcomes, two patients with a negative modified ham test responded to cyclosporine cessation and steroid administration. plasma infusion with/without plasma exchange was initiated in seven patients. however, only three of them responded to second-line treatment. the modified ham test result was significantly increased in refractory patients (p = . ). the terminal complement inhibitor eculizumab was administered in one refractory patient with a positive modified ham test and renal failure at presentation. despite delayed initiation ( days post ta-tma diagnosis), response was observed after three doses of eculizumab including evidence of reduced hemolysis, schistocytosis and transfusion needs. however, the patient succumbed to complications of end-stage renal disease ( days post ta-tma diagnosis). among ta-tma patients, succumbed at a median + ( - ) day to transplant-associated complications, related to gvhd and infections from multi-resistant pathogens. ta-tma is associated with increased morbidity, mortality and severe complications, including gvhd. unlike gvhd, increased complement activation was observed in a significant portion of ta-tma patients. complement inhibition seems an encouraging therapeutic option in these patients. given the lack of robust functional assays for complement activation, the modified ham test may be useful for early recognition of patients that would benefit from complement inhibition. . this proposal includes, along with the 'classical sos' (cases diagnosed before day + ), the new type 'late onset sos' (cases diagnosed afterwards). new ebmt criteria for severy grading classify cases of sos into four grades (mild, moderate, severe, and very severe). the aim of this retrospective study is to analyze the cases of severe/very severe, both classical and late onset sos, occurred in our unit during the most recent period of time. we studied the last pts, with a minimum follow-up of days, who underwent allo-hsct in our center (november -august ). pts were male and female. median age was years (range: - ). baseline diseases were: acute leukemias ( ), lymphoproliferative disorders ( ), myelodysplastic syndromes ( ), chronic myeloproliferative diseases ( ), multiple myeloma ( ), and bone marrow failures ( ) . donor was unrelated in cases, and related in (including haplo-identical). conditioning regimen was: busulphan-based ( ), melphalan-based ( ), tbi-based ( ) , and others ( ). all patient received prophylactic [p ] s ursodeoxycholic acid. progenitors source was pb in , and bm in . five patients developed severe/very severe sos ( % incidence); were classical (at days + , + and + ), and were late onset (at days + and + ) (see table ). four cases had received conditioning with a busulphan (iv)-based regimen (doses from . to . mg/kg), and one case with tbi plus cyclofosfamide at high doses. all cases presented with right upper quadrant pain, jaundice, ascites, weight gain, hiperbilirrubinemia, and renal function impairment. all but one had increased transaminases. the five cases were treated with defibrotide, in spite of which all of them died. considering that overall day + mortality was %, severe/ very severe sos was the most important cause of death of the series. [p ] although milder forms of sos might resolves within weeks, the most severe forms are still associated with a very high mortality rate. prophylaxis with defibrotide (the drug currently licensed for treatment) for high-risk patients has not been sufficiently studied yet. therefore, a high index of suspicion, early detection and early therapy are the only ways to try to reduce mortality due to sos in the hsct setting. disclosure of conflict of interest: this research has been performed entirely with public financial support. the royal marsden hospital, sutton, uk; anthony nolan research institute, london, uk and university college london, london, uk secondary poor graft function (spgf) complicates up to % allogeneic hcts, and is associated with increased mortality and poor quality of life due to recurrent infections and the need for ongoing blood product support. potential interventions include a second allograft using further conditioning, however many patients with spgf have a reduced performance status and are at an increased risk of complications from this procedure. unconditioned haematopoeitic progenitor cell (hpc) top-ups are associated with a high risk of gvhd if unmanipulated cellular products are used. cd + selection offers an attractive alternative, but incurs a loss of up to % hpcs and is an expensive procedure, unavailable to many centers internationally. alemtuzumab, a monoclonal anti-cd antibody, is routinely used in allogeneic transplant conditioning in the uk to prevent gvhd. we report the results of a retrospective study examining the efficacy of alemtuzumab conditioned hpc top-ups for spgf. data pertaining to patients who had undergone a second infusion of hpcs from their original donor were identified from our hospital-specific promise database. those who met the criteria of spgf defined as ⩾ of hemoglobin × /l without support. patients ( pediatric, adult) who underwent initial allogeneic transplants for malignancy ( ) or bone marrow failure ( ) received an alemtuzumab conditioned hpc top-up for spgf at our center - . the diagnosis of spgf was made at a median . months post allograft (range - ) with trilineage cytopenias in patients and bilineage cytopenias in patients. all patients had received transplants from / ( patients) or / ( patients) matched unrelated donors. the median interval between initial transplant and top-up was days (range - ), and a median cd dose of . × /kg recipient weight (range . - . ) was infused. % patients achieved haematological improvement (hi) at a median days post-top-up (range - ), with the only failure to achieve hi seen in the patient who had received the lowest cd dose ( . × /kg). one patient developed grade i agvhd post top-up but no grade ii-iv agvhd was observed. year os was % and year os % following hpc top-up. deaths occurred due to infection at , and months post top-up, and one due to relapse of a prior non-haematological malignancy. patients had an aplastic or hypocellular bm trephine pre-top up, which was repeated at days post topup in patients, of whom had a normocellular bm trephine, while remained hypocellular. alemtuzumab conditioned hpc top-up appears an effective intervention for spgf with results comparable to those of cd selected top-ups, and therefore represents a feasible alternative. larger studies are needed to exclude complications including viral reactivation and to investigate immune reconstitution following this procedure. disclosure of conflict of interest: none. high dose chemotherapy (hdt) followed by autologous stem cell transplantation (asct) has shown to improve outcome in patients with relapsed/refractory diffuse large b cell lymphoma (dlbcl). in the rituximab era, the benefit of asct has been debatable as prior study (coral study) has shown that patients who received r-chop as induction chemotherapy & responded to salvage chemotherapy had a poorer outcome following asct compared with those who received chop alone. in addition, it remains unclear whether addition of rituximab to standard high dose beam regimen provides any additional benefit. we retrospectively analyzed dlbcl patients receiving high dose beam (n = ) or rituximab +beam (r-beam) (n = ) followed by asct for relapsed/ refractory dlbcl since . all patients who received chop (n = ) ± rituximab (n = ) as first line therapy and who received ⩽ lines of salvage chemotherapy before asct were analyzed. rituximab was given at the dose of mg/m on day + and + of asct. twenty-two ( %) patients in beam group and all the patients ( %) in r-beam group received rituximab-based salvage chemotherapy prior to asct. the year overall survival (os) was % and event-free survival (os) was % for the whole cohort. r-chop induced patients did not fare any worst after asct than chop induced patients ( year os vs %; p = . ). there was a trend towards better survival in patients with pre-transplant disease free interval (dfi) months compared to those with dfi /μl) time was days and days, respectively. median platelet recovery ( /μl) time was days and days, respectively (p = . ). ten year os ( % r-beam vs % s beam, p = . ) and efs ( % r-beam vs % beam, p = . ) were also comparable between both groups. hdt with beam and asct remains beneficial for patients with relapsed/ refractory dlbcl. it should be offered to all patients who respond to salvage chemotherapy with the expectation that they fare no worse than patients who do not receive rituximab in the induction chemotherapy. addition of rituximab following the standard beam for hdt and asct does not compromise haematopoietic recovery, but does not result in improved outcome in our study. prior use of rituximab during first-line or salvage therapy in most of the patients of r-beam group might have negated the beneficial effect of r-beam over beam. ( ) . in this study, we aimed to develop a cns targeted chemotherapy regimen, which has lower toxicity and higher complete remission rates, in combination therapy. eight patients with secondary cns lymphoma (scnsl) and two with primary cns lymphoma (pcnsl), followed between the years and , were included in the study, retrospectively. the patients were histologically diagnosed with biopsy and underwent autologous stem cell transplantation (apkht). all patients were treated with r-idaram/ rt (radiotherapy)/subsequently autologous stem cell transplantation (apsct) with r-beam protocol. the r-idaram regime consists of the following substances: rituximab mg/m , cc/h infusion, day ; cytosine arabinoside . gr/m i.v., h infusion, days and ; dexamethasone mg, h infusion, days , and ; idarubicin mg/m i.v., min infusion, days and ; methotrexate gr/m ( gr/m at years old-patients), h infusion, day ; and cytosine arabinoside mg plus methotrexate mg, intrathecally, days and . the patients included seven males and three females. the median age was years (range: - ). six scnsl patients were diagnosed in the application and two of them were diagnosed during r-chop chemotherapy (ct) protocol. five patients ( %) were stage ivb, and the others ( %) were stage iiib at diagnosis. after two or three chemotherapy cycles, patients were mobilized with growth factor support and median . cells per kg (range: - ) stem cells were collected. then, at a dose of - cgy cranial rt was administered for days. after the third cycle of r/idaram, the state of remission was evaluated by cranial mri and lumbar puncture (lp). all patients achieved complete remission. neutrophil engraftment occurred at a median of days (range: - ) and platelet engraftment occurred at a median days (range: - ). after apkht, three patients relapsed and died at the fourth, ninth, and thirteenth months. grade i-ii manageable neurological toxicity occurred in two patients. the median follow-up time was (range: - ) months. the five-year overallsurvival (os) was %. serious signs of infection were not observed in patients during transplantation. in pcnsl and scnsl, a standard treatment regimen has not yet been found. apsct with r-beam following modified r/idaram/rt is a curative and applicable therapeutic regimen with low toxicity, which can provide high rates of long-term survival and disease-free survival. despite the advent of novel therapies, autologous hematopoietic stem cell transplantation (ahsct) following melphalan (m)-based conditioning remains the standard of care for patients with multiple myeloma who are eligible. still, the majority of patients experience disease progression and ultimately succumb to their disease. we hypothesize that integrating novel agents in the conditioning is feasible and safe and may increase complete remission rates and overall survival. we completed a phase i, dose escalation study of carfilzomib (c) added to a backbone of bendamustine (b) and melphalan. all patients received a fixed dose ( mg/m ) of c on days (d) − , − , − , − , − and − . in addition, patients were conditioned as described in table . due to dose-limiting toxicity in cohort , the study was amended after the first patients. subsequently, the dose of m was reduced to mg/m and the d + dose of c was omitted, per oversight of a data safety monitoring board. fifteen patients were enrolled, males and females. median age was years ( - ). performance status was ⩾ % (kps) in all patients. per the international staging system (iss), patients had stage i disease, had stage ii, had stage iii, and had unknown staging. three patients had high-risk cytogenetics: with t( ; ) and with deletion p. four patients had undergone a prior ahsct. disease status at enrollment was stable disease (sd) (n = ), partial response (pr) (n = ), or very good partial response (vgpr) (n = ). median cd + cell dose infused was . × /kg ( . − . × ). median follow-up was . months ( . - . ). all fifteen patients are evaluable s for engraftment. median time to neutrophil engraftment was d ( - ). one patient died before achieving platelet engraftment. for the remaining patients, median time to platelet engraftment was d ( - ) . non-hematologic toxicities included grade acute mucositis (n = ), lower gi complications (n = ), electrolyte disturbances (n = ), transaminase elevation (n = ) renal insufficiency (n = ), atrial fibrillation (n = ), hypoxia (n = ), prolongation of the qtc interval (n = ), and grade acute sepsis (n = ), including death (cohort ) on d + . eight patients went on to receive maintenance therapy: with bortezomib, with lenalidomide, and with lenalidomide, dexamethasone, and c. posttransplant disease status was assessed per protocol by spep, spif, serum free light chains, and light chain ratio. twelve patients were evaluable on d + . two patients had sd, had vgpr, and had complete response (cr). eight patients were evaluable on d + . two patients had progressive disease, had pr, had vgpr, and had cr. the combination of cbm prior to ahsct appears feasible, with manageable toxicities, at the doses described in cohort b. a prolonged follow-up and a phase ii study are warranted to determine response rates and long-term outcomes. disclosure of conflict of interest: none. beam (carmustine, etoposide, cytarabine, melphalan) is the most frequently used high-dose chemotherapy regimen for patients with lymphoma referred for autologous hematopoietic cell transplantation (autohct). in recent years a novel conditioning protocol containing bendamustine instead of carmustine (beeam) has been proposed in order to potentially increase the efficacy. so far, however data on its safety are limited. the aim of this study was to retrospectively compare the safety profile of beam and beeam based on single center experience. consecutive patients with lymphoma treated with beam and patients treated with beeam between year and were included in the analysis. the median age was ( - ) years and ( - ) years, respectively (p = ns). clinical characteristics of both groups were comparable. patients with hodgkin's lymphoma constituted % in the beam group and % in the beeam. among those with non-hodgkin lymphoma the diagnosis of dlbcl predominated. beam treatment consisted of carmustine mg/m on day − , etoposide mg/m /d on days − to − , cytarabine mg/m /d on days − to − , and melphalan mg/m on day − . in the beeam regimen carmustine was substituted by bendamustine administered on days − , − at the total dose of mg/m i.v. peripheral blood was used as a source of stem cells. cd + cell dose was . ( . - . ) × /kg in the beam group and . ( − . ) × /kg in the beeam group (p = ns). time to engraftment and the rates of adverse events up to day + after autohct were the study endpoints. all patients engrafted in both study groups. median time to neutrophil . × recovery was ( - ) days after beam and ( - ) days after beeam (p = . ). median time to achieve platelet count × was ( - ) days and ( - ) days, respectively (p = . ). two patients died without progression before day + in the beam group, both due to bacterial infections. no early deaths were reported in the beeam group. the rates of grade or adverse events were comparable (see: table ). administration of bendamustine instead of carmustin as part of conditioning does not affect engraftment as well as toxicity profile of the regimen. therefore beeam may be safely used in patients with lymphoma undergoing autohct. its efficacy requires evaluation in prospective studies focused on homogenous patient populations. [p ] disclosure of conflict of interest: none. the baltimore group reported a low dose tbi-based nonmyeloablative conditioning regimen followed by t cell replete bone marrow, with post-transplantation cyclophosphamide (pt-cy) to control gvhd and graft rejection. based on the fact that in our facility conventional low dose tbi was not available, we wanted to explore whether tmi/tli could be a potential substitute the aims of our study was to explore if tmi/tli can be considered an effective substitute of tbi in terms of os, pfs and nrm. retrospective analysis was applied in cases of haploidentical hsct from april to october . all patients underwent baltimore conditioning associating fludarabine ( mg/m /day) day − to − , cy ( . mg/kg/day) on days − and − , and tbi gy in patients and tmi/tli gy in patient at day − . unmanipulated bone marrow graft was infused at day . postgrafting immunosuppression consisted of cy ( mg/kg/day) on day + and + , and mycophenolate mofetil for days, and tacrolimus or cyclosporine. no differences between the two groups was observed in term of age, gender diagnosis, disease status and donor type. % of patients engrafted in both arm ( / and / ). in tbi cohort vs tmi/tli cohort, the median time to anc /μl and platelet recovery /μl was not different ( and days vs and . days, p = . and . , respectively). in all tmi/tli evaluable patients, full chimerism was observed at days + . after a median followup of months in tmi/tli cohort and months in tbi arm, -year nrm was . % and . % (p = . ), respectively. the years os and pfs were not statistically different in the two groups % vs . %, p = . and . % vs . %, p . , respectively). the -year relapse incidence was % in tmi/tli group and . % in tbi group, p = . . no difference in incidence of both agvhd and cgvhd was observed between the two groups. this retrospective analysis suggests that tmi/ tli could be considered an effective substitute of low dose tbi, with a sufficient degree of immunesuppression of recipient, allowing engraftment and full chimerism. the gvhd both acute and chronic as well as the -y nrm were not different. disclosure of conflict of interest: none. comparison of the beeam conditioning regimen and the beam conditioning regimen in the autologous transplantation for hl and nhl s lozenov , p ganeva , y petrov , g arnaudov and g mihaylov the beam has established itself as a standard of care conditioning regimen in the autologous lymphoma hsct setting for most transplant centres in europe. yet however various other regimens are being compared with it in order to achieved better safety profile, better os and dfs, in order to improve results with chemoresistant and unfavourable patients. one such regimen is beeam (bendamustine, etoposide, cytarabine, melphalan).we aimed to compare the efficacy of the beam and beeam conditioning regimens and to compare their myelotoxicity profile. we evaluated retrospectively adult patients (mean age . with sd . ), receiving auto-hsct at the national specialized hospital for active treatment of hematological diseases in sofia, bulgaria for relapsed/refractory hl or nhl (of them mh - , dlbcl - , pmbcl - , fl - , lbl - , ptcl-nos - , aitl - , alcl - , mcl - , mzl - ) for the period from . . to . . with a follow-up of patients up to . . . ninety-two of the patients received the beam (as previously described -bcnu mg/m i.v. day − , etoposide mg/m i.v. days − to − , cytarabine mg/m i.v. days − to − , and melphalan mg/m i.v. day − ) regimen and received beeam regimen (bendamustine on days − and − ( mg/m ); cytarabine, mg/m intravenously daily, from day − to day − ; etoposide, mg/m intravenously daily, from day − to day − ; and melphalan, mg/m intravenously on day − ). the overall survival at the second and third years of follow-up (os- , os- ) and dfs at the third year, the cr rates and the average time periods to hematological recovery, were compared. the os at and years, respectively, was . % and . %, for beeam and . % and % for beam, the dfs at years was . % for beeam and . % for beam, provided that the differences did not have statistical significance (p . for os and p . for the dfs). the cr rate was . % in the beeam group versus % in the beam group. from the patients who received autologous hsct in stable disease or progression pre-transplant status (chemoresistnat patients), . % of the patients receiving beeam achieved cr at the first post-transplant evaluation versus . % respectively for the beam group. the mean time to hematological recovery for neutrophils was . ± . days (beeam) versus . ± . days (beam) and . ± . days (beeam) versus . ± . days (beam) for platelets. beeam appears to be a non-inferior alternative conditioning regimen to the standard beam, it shows a trend towards higher myelotoxicity, but also a trend towards better response rates in chemoresistant patients. [p ] disclosure of conflict of interest: none. autologous hematopoietic stem cell transplantation (asct) is widely used as a consolidation therapy in aggressive non-hodgkin's lymphoma (nhl) and recurrent or refractory classic hodgkin's lymphoma (hl). in mexico, the use of carmustine (bcnu) in the conditioning regimen of these patients is limited due to the lack of access to the drug and its high costs. this study aims to compare results in terms of toxicity, disease-free and overall survival between a group of patients treated with the standard regimen beam and another group treated with a scheme in which carmustine was replaced by cisplatin (peam regimen). a comparison of two groups with lymphoma was performed and the clinical aspects of cisplatin mg/m d . the characteristics were well balanced between the two groups. the mean time for neutrophil grafting ( per mm ) was significantly slower with beam than with peam ( vs days, p = . ), hospitalization time was longer with beam compared to peam ( vs , p = . ). on the other hand, proportion of patients who require red blood cell s transfusion was significantly higher in beam group ( %) versus peam group ( %) (po . ), but total amount of platelet transfusion did not differ between groups. about the toxicity, beam patients had significantly more frequent incidence and severity of nausea/vomiting ( % vs . %) and diarrhea ( . % vs %) compared to peam (p o . ). no significantly differences were observed in incidence of mucositis (p = . ). at the moment of the analyses, % of patient of the peam group were in complete response versus % of the patients treated with beam, but it did not represent a significant difference. disease-free survival and -year overall survival in the peam vs beam scheme were similar with % vs % (p = . ) and % vs % (p = . ) respectively but with less toxicity using the peam scheme. peam regiment is not inferior scheme compared with beam, because it shows similar outcomes in disease-free survival and overall survival. additionally, peam is a well-tolerated regime and beam scheme was associated with greater gastrointestinal toxicity such as nausea, vomiting and diarrhea, also greater hematology toxicity such as more requirement of red blood cell transfusion. [p ] disclosure of conflict of interest: none. cumulative busulfan exposure is associated with relapse following busulfan and cyclophosphamide myeloablative allogeneic stem cell transplantation for acute myeloid leukaemia e wong, d kliman , m chau , j szer , c nath , p shaw , d ritchie , d gottlieb and a bajel westmead hospital, new south wales, australia and royal melbourne hospital, victoria, australia the optimal busulfan exposure to reduce disease relapse in adult patients with acute myeloid leukaemia (aml) undergoing busulfan/cyclophosphamide myeloablative allogeneic stem cell transplant (allosct) is poorly defined. we retrospectively analysed busulphan pharmacokinetics (pk) and outcomes of patients who underwent busulfan/cyclophosphamide conditioned allosct for aml from to . busulfan was administered intravenously over days ( . mg/ kg/d for days followed by . mg/kg for days). peripheral blood was obtained for busulfan pk after the first dose. subsequent doses of busulfan were decreased if daily busulfan exposure (area under the curve; auc) was anticipated to exceed μm per min/day. cyclophosphamide was dosed at mg/kg. the primary outcome was the cumulative incidence of relapse (cir) accounting for non-relapse mortality (nrm) as a competing risk. independent variables analysed included age, sex, cytogenetic risk group, disease risk index (dri), donor type, stem cell source, t-cell depletion, and cumulative busulfan auc (cumauc) calculated as previously described. (figure ) . t-cell depletion was also associated with increased cir (hr . ; p = . ). patient age, sex, cytogenetic risk, dri and graft type were not significantly associated with cir. on multivariate analysis, cumauc μm per min remained significantly and independently associated with lower cir (hr . ; p = . ). cumauc was not associated with nrm, rfs, os, or the incidence of acute or chronic gvhd. figure . cumulative incidence of relapse in patients stratified by total busulfan exposure. [p ] cumulative busulfan exposure μm per min is independently associated with reduced relapse following busulfan/cyclophosphamide allosct for adults with aml. these findings support further evaluation of the optimal busulfan exposure to reduce aml relapse in a prospective clinical trial, whereby patients could be randomised to target cumauc μmol per min versus standard practice. hematopoietic stem cell transplant with busulfan and cyclophosphamide (bucy) based conditioning has a relatively high incidence of liver toxicity and sinusoidal obstruction syndrome (sos). busulfan and cyclophosphamide metabolites share the same glutathione conjugation in the liver metabolism. a small number of studies addressed different sequence of both drugs bucy vs cybu during conditioning. differences in liver toxicity, sos, transplant related mortality (trm), relapse incidence (ri) and overall survival (os) were reported favoring cybu conditioning. we decided to address the above issues at the umc ljubljana, slovenia. this was a retrospective study following patients with myeloid malignancies (aml, mds, mpn) with bucy (n = ) and cybu (n = ) conditioning through a three year period in a single institution. primary endpoint was detecting difference in liver toxicity by measuring levels of liver enzymes. secondary endpoints were incidence of sos, difference in trm, ri and os. patients characteristics between groups at the time of the transplant did not differ significantly. we observed significantly higher liver toxicity through elevated bilirubin and alt in the bucy . % than cybu . % patient group (picture ). the highest probability of liver toxicity was around d in the bucy group and in the second week after the transplant in the cybu group. the incidence of sos, trm and ri were comparable between the groups. there was no difference in os between the patient groups during the -month follow-up. bucy conditioning for hematopoietic stem cell transplant causes higher incidence of liver toxicity compared to cybu conditioning. there is no difference in sos frequency, trm, ri and os between bucy and cybu conditioning. prospective controlled comparison would be needed for further study of the subject. disclosure of conflict of interest: none. early monocyte recovery is associated with better overall survival after busulfan containing myeloablative conditioning allogeneic hematopoietic cell transplantation in patients with acute myeloid leukemia a lojko-dankowska the outcomes of allogeneic hematopoietic cell transplantation (allohct) in acute myeloid leukemia (aml) depend on different patient-, disease-and transplant related factors, including the dose and combination of agents used for conditioning. the aim of the study was to analyze the outcomes of allohct in patients with intermediate or high risk aml according to disease risk index (dri) who received myeloablative conditioning consisted of intravenous busulfan ( . - . mg/kg) combined with cyclophosphamide ( mg/ kg) or fludarabine ( mg/m ) between and in our institution. the published data indicate that the combination of busulfan (bu) and fludarabine (flu) seems to have more favorable toxicity profile than combination of bu and cyclophosphamide (cy), so bucy regimen has been substituted with buflu as the myeloablative conditioning for aml patients in our institution practice since . we evaluated the influence of type of regimen on transplant outcomes along with the impact of other potential prognostic factors, including age of patient, dri, donor type, hla and gender mismatches, stem cells source, and lymphocyte and monocyte recovery. the study group consisted of aml patients, median age years (range: - ), classified as intermediate (n = ) or high (n = ) risk according to the dri, who were conditioned with bucy (n = ) or buflu (n = ) followed by allohct from hla identical sibling (n = ) or - / matched unrelated donor (n = ). the stem cell were collected from peripheral blood (n = ) or bone marrow (n = ). gvhd prophylaxis consisted of calcineurin inhibitor combined with mtx plus atg in allohct from unrelated donors. engraftment was observed in all patients. the median time to neutrophil count ( . g/l) and platelet count ( g/l) recovery was shorter after buflu in comparison with bucy ( days vs days; p = . and days vs days; p o . ), however peripheral blood stem cells were used more often after buflu regimen than after bucy ( % vs %, p /mm on+ day after transplant ( -year os % vs %, p = . ) and intermediate vs high dri ( -year os % vs %, p = . ). in multivariate analysis higher amc after allohct remained the only independent favorable prognostic factor for os (rr . ( % ci . - . ), p = . ). our results suggest that early monocyte recovery after myeloablative bu containing conditioning allohct is significant favorable predictor of outcome. in our experience both bucy and buflu myeloablative regimens result in similar long-term survival after allohct in aml patients. [p ] disclosure of conflict of interest: none. the use of t-cell depletion as part of the conditioning protocol has the potential to improve the tolerability of allogeneic stem cell transplantation (hsct) through the reduction in graft versus host disease (gvhd). despite the wide spread adoption of this practice in many parts of the uk and europe, definitive recommendations regarding the most appropriate dose remain elusive. previous experience by our group with mg of alemtuzumab combined with fludarabine and busulfan based conditioning demonstrated good long-term outcomes with low rates of gvhd. however, due to concerns of high relapse risk especially in patients with high-risk myelodsypastic syndrome and acute myeloid leukaemia, we instituted a policy change in to reduce the dose of alemtuzumab in the conditioning protocol from a total of - mg. we conducted a retrospective analysis of all consecutive patients undergoing reduced intensity unrelated allogenic stem cell transplantation with fludarabine ( mg/m ), busulfan ( . mg/kg iv or . mg/kg iv) and alemtuzumab (fb c or fb c, respectively) conditioning for neoplastic myeloid disorders between and . patients were subsequently analysed in two cohorts; those receiving mg of alemtuzumab (n = ) and those receiving mg of alemtuzumab (n = ). apart from a decreased proportion of females in the mg alemtuzumab group, the cohort was balanced across the different dose levels ( table ). the longterm overall survival (os) of the entire cohort was good with a year os of %. no significant differences in overall outcomes across the two groups were observed with a year os of % in the mg group vs % in the mg group (p = . ). cumulative incidence of relapse (cir) and nonrelapse mortality (nrm) was % and % and % and % in the mg and mg groups, respectively. interestingly, age had a significant effect on nrm in the mg ( % age o , % age - and % age p = . ), but not in the mg group ( % age o , % age - and % age p = . ). the effect on relapse rate was not significant in either group (p = . and p = . , respectively). this retrospective analysis did not demonstrate an overall improvement in transplant outcomes with dose de-escalation of alemtuzumab from to mg. in particular, we did not see the anticipated improvement in relapse rate in this cohort. notably older patients seem to tolerate the mg dose better due to the lower nrm. prospective trials with accompanying translational work are required to determine the optimal dosing and schedule for this group of patients. disclosure of conflict of interest: none. bendamustine was given at mg/m /d for the first pts then mg/m /d for the subsequent pts and finally at mg/m /d for the remaining pts ( pts). among the beam group, % had non-hodgkin's lymphoma (nhl) and % hodgkin's lymphoma (hl) compared to % and %, respectively, in the beeam group (p = . ). hhv- detection was performed by pcr for symptomatic pts (fever, rash or prolonged cytopenia). patients were housed in single bedrooms with air filtration and received the same supportive care. median age was ( - ) and ( - ) in the beam and beeam groups respectively and median of previous chemotherapy regimens was (range: - ). fifty two out of patients were male ( / in the beam group and / in the beeam group). pts were in cr ( . % vs . %) or pr ( . % vs . %) at time of transplant. there was no difference in terms of hematologic recovery (median = days (range: - )), blood and platelets transfusion, mucositis toxicity. there was no statistical difference in the incidence of acute renal failure when comparing the two groups. however, there was a very striking difference when considering the highest dose of bendamustine when compared as well to the two others doses of bendamustine (po . ) as to the beam group (p = . ). additionally, we also observed a high incidence of symptomatic hhv- infections ( . % vs . %, p o . ), digestive toxicity ( . % vs %, p = . ) and a longer hospitalization duration ( days (range: - ) vs days (range: - ), p = . ) for patients in the beeam group overall. with a median follow up of . and . months for beam and beeam respectively, overall survival ( % vs %), transplant related mortality ( % vs %) and event free survival ( % vs %) were comparable. overall, beeam regimen was associated with longer duration of hospitalization, higher rate of digestive toxicity and increased risk of symptomatic hhv- infection as compared to the beam regimen. in addition, higher doses of bendamustine ( mg/m /d for two consecutive days) were associated with unacceptable high rate of acute renal toxicity. with a still short follow-up, the absence of benefit on disease control together with higher short term toxicity does not allow to recommend the use of beam instead of classical beam. should it be used, we suggest that pts should be carefully monitored for renal toxicity and for hhv- infection in case of symptoms. disclosure of conflict of interest: none. high-dose treosulfan and melphalan for consolidation therapy in high-risk ewing sarcoma me abate, a paioli, a longhi, m cesari, e palmerini and s ferrari musculoskeletal department, rizzoli orthopaedic institutes, bologna, italy common toxicities observed after high dose chemotherapy with busulfan and melphalan for high risk ewing sarcoma (es) are generally well managed by current supportive care but some patients can develop severe complications. treosulfan is an alkylating agent that has recently been used as a substitute of busulfan to prevent potential serious complications related to busulfan. medical records of es patients undergoing autologous peripheral blood stem cell (apbsc) transplantation after intravenous treosulfan (treo) and melphalan (mel) from / / to / / were analyzed with regard to toxicity and outcome. patients were included into the study if they were eligible for the protocols activated in our institution for es and presented reasons that did predict potential complications related to busulfan, such as previous radiotherapy on axial skeleton/pelvis or coexistence of high risk of epilepsy. as consolidation treatment patients received intravenous treo g/m over days and mel mg/sqm with support of apbsc transplant and use of granulocyte colony stimulating factor. in those patients with lung metastases total lung irradiation was performed at least months after treomel. frequency of toxicity for treomel was recorded with at least months of follow-up and was evaluated according to nci ctg common toxicity criteria. the median age at diagnosis of patients receiving treomel was years (range - years), males and females. patients had localized disease at diagnosis with poor radiological or histological response to standard chemotherapy; one patient had lung metastases at diagnosis and one patient had relapsed disease with lung metastases. before receiving treomel the primitive tumour underwent radiation therapy in cases ( pelvis, cervical vertebra, sacrum), surgical resection in one case(tibia) and surgical resection plus radiation therapy in one case (fibula). patients showed eeg abnormalities at high risk of developing epilepsy. the median number of infused cd + cells was . × /kg (range . - . ). febrile neutropenia occurred in / patients and lasted one day in patients and days in patients. median time to granulocyte engraftment was days (range - days); median time to platelet engraftment was days (range - days). only one patient needed red blood cells transfusions; patients needed platelet transfusion and patients needed platelet transfusions. none developed grade - stomatitis or grade - [p ] hematuria or grade - liver toxicity. surprisingly, a patient became pregnant after year and months from transplantation. with a median follow-up of months (range - months) patients are alive in complete remission, one patient is alive with relapsed disease and one patient died for disease progression. these results, related to a limited cohort of patients, confirm the lower toxicity observed for treosulfan with respect to busulfan. although more data are needed to clarify the role of treosulfan in es, the impact of potential severe complications observed with busulfan, including infertility, should suggest its replacement with treosulfan in selected cases. disclosure of conflict of interest: none. immunoadsorption procedures prior to haploidentical allogeneic pbsct could prevent graft failure in patients with hematological malignancies displaying anti-donorspecific hla antibodies donor-specific anti-hla antibodies (dsa) have been shown to be associated with a high risk of rejection in solid organ transplantation and with graft failure (gf) in allogeneic hematopoietic stem cell transplantation. a combination of anti-cd (rituximab), plasma exchange (pe), and ivig in patients with additional buffy coat infusion in among them prevented graft loss in all patients that became c q negative before sct. we addressed the question whether immunoadsorption in combination with rituximab can also be applied in patients with dsa to prevent graft failure in haploidentical pbsct. four patients with acute myelocytic leukemia or myeloma in second complete remission were enrolled. the presence of dsa was determined by luminex at pre bmt checking. immunoadsorption was performed with polyclonal sheep anti-human igg adsorbers (miltenyi biotec gmbh, germany) on life apheresis system. in addition all patients received rituximab mg/kg bw in a single dose. patients were conditioned with a reduced intensity regimen comprising tbi gy, cyclophosphamide mg/kg, and fludarabin mg/m . all patients received cyclophosphamide post bmt (ptcy) mg/kg. non-t-cell depleted pbsct were transfused in a sequential manner in doses each. the data of the patients and treatments is summarized in table . two patients had a normal hematopoietic reconstitution and are alive at + and + months post-transplantation, one with hepatic gvhd; chimerism was % in peripheral blood on last follow up. one patient died following a graft failure. by a combination of rituximab and repeated immunoadsorption prior to allogeneic pbsct the titer of dsa could be lowered sufficiently to enable engraftment. ia turned out to be a safe procedure without relevant clinical side effects. hematopoietic reconstitution was in the normal range in of evaluable patients. disclosure of conflict of interest: none. allogeneic hematopoietic stem cell transplantation (hsct) is the only curative option for patients with beta thalassemia major. however, the availability of hla-matched related donor remains the main obstacle for allogenic hsct. although, a few studies have been reported, experience with hla matched unrelated donors is limited. we present the result of children with beta thalassemia major who received allogeneic hsct from hlamatched unrelated donors with using a novel conditioning regimen. we retrospectively assessed unrelated hsct in children with beta thalassemia major. all patients received busulphan (bu) based myeloablative conditioning regimen. busulphan was used according to weight adjusted doses. in addition, all patients received fludarabine mg/m in days, cylophosphamide mg/kg in days, thiotepa mg/kg in one day and atg mg/kg in days. cyclosporin-a and mtx were used for graft versus host disease (gvhd) prophylaxis. donor chimerism was evaluated in the peripheral blood on days + , + and + . the median age of the patients was . years (range month- year). two of the patients were grouped in class i and rest of them were class ii. the median serum ferritin level was . ng/ml (range, - ). all of s the donors were matched / with high-resolution hla typing in gvhd direction but three of them / with graft failure direction. twenty-three of them received bm (median tnc: . x /kg) and pbsc (median mnc: . x /kg) with median cd + cell number . x /kg. the median neutrophil and platelet engraftment days were and days in pbsc and and days in bm group, respectively. grade i-iv acute gvhd was observed in patients ( %) and only one experienced limited chronic gvhd with only skin involvement. mild to moderate vod was seen in patients ( %) and treated with defibrotide successfully. all patients except one are alive with full donor chimerism (between - %) with a median months (range - months) follow-up. one patient died because of cmv pneumonia. these data show that the results of hsct from unrelated donors in selected low risk thalassemia patients may be comparable to hsct of matched sibling donors. however, it needs further studies with long term follow up and larger study population. disclosure of conflict of interest: none. table . data about cytogenetic risk of group patients were available only in individuals. differences between groups were analyzed by t-student and chi square tests. survival was analyzed by kaplan-meier method and differences in survival between groups were evaluated by log rank test. no differences were found between groups regarding gender, sc source, disease status at sct, type of donor and number of cd + cells infused. patients in group were significantly older (median age for groups and : vs , p = . ). gvhd prophylaxis protocols included atg in a higher frequency in group . no differences between groups and were observed in neutrophils recovery (median days to anc /μl: vs respectively, p = . ) and platelets recovery (median days to platelets /μl: vs respectively, p = . ). patients in group required more red cell transfusions (median packed rbc: vs , p = . ). no differences were observed regarding platelets transfusion requirements or length of hospitalization. post-sct os was significantly better in group ( years-os group : %; group : %; p = . ) (figure ). there were no significantly differences between groups regarding frequency of mucositis, diffuse alveolar haemorrage, sepsis, acute and chronic gvhd. vod was more frequent in group ( / vs / , p = . ). trm mortality was higher in group ( / vs / ), being this difference no statistically significant (p = . ). as it was reported by others, the use of fludarabine-based conditioning regimen was associated with a significantly better post-sct os and a reduced frequency of vod in aml patients. reduction in trm and differences in the frequency of described complications are not statistically significant probably due to the small size of this sample. since march , given the limited availability of melphalan, we administer the beac regimen (carmustine, etoposide, cytarabine, and cyclophosphamide), instead of the gold standard conditioning regimen beam, followed by autologous haematopoietic cell transplantation (ahct) in relapsed or refractory hodgkin (hl) and non-hodgkin (nhl) lymphoma patients. the primary goal of this analysis was to assess the immediate related toxicity of this alternative regimen. we used beac (carmustine mg/m , etoposide mg/m , cytarabine mg/m , and cyclophosphamide mg/kg) in consecutive lymphoma patients ( hl, nhl) who underwent ahct for relapsed or refractory disease. the median age of the patients was . years ( - ). they all received peripheral stem cell grafts with a median cd + cell dose of . × /kg cells ( . - . ). disease status post salvage treatment (at ahct) was complete remission (cr) in , partial remission (pr) in and progressive disease in . the disease was chemosensitive to salvage therapy in / patients. median follow up was days ( - ). toxicity was assessed according to the who toxicity scale grading. all patients engrafted successfully. median time for engraftment was day + (d+ ) for neutrophils ( /mm ) and d+ for platelets ( /mm , without transfusion within the previous days). patients were hospitalized for a median of days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . no treatment-related mortality occurred. two patients died due to disease progression (both nhl patients, on d+ and d+ ). toxicity assessment until d+ is presented in table : moreover, no hemorrhagic cystitis or macroscopic hematuria, and no cardiac events were encountered. febrile neutropenia was recorded in and bacteremia in patients ( gram+, gram-, / related to central venous catheter), with fever ≤ grade in all cases. during d+ - two patients presented fever of unknown origin, and patients had upper or lower respiratory infections, with no other adverse events being recorded. in terms of disease best response within months post ahct ( / patients evaluated), patients achieved or sustained cr, pr ( of these patients eventually died due to disease progression), relapsed and succumbed due to disease progression (no response). according to our preliminary results, the early toxicity profile of beac is very low, the regimen is easily tolerable for the patients, and without any treatment-related mortality. its use as an alternative conditioning regimen in ahct for lymphoma patients seems feasible. further investigation including more patients and comparative analysis to other conditioning regimens are warranted for reliable conclusions on the toxicity and efficacy of beac. disclosure of conflict of interest: none. veino-occlusive disease (vod) is a potentially fatal adverse event caused by intravenous (iv) busulfan used in bone marrow transplantation (bmt) conditioning. the objective of this study was to identify determinants of vod in children treated by iv busulfan. this was a retrospective analysis of data collected in children from two bmt centers over years. vod was diagnosed according to modified seattle criteria. individual pharmacokinetic data, including busulfan area under the concentration-time curve (auc) and maximal concentration (cmax) were estimated in all children by using a validated bayesian approach. we examined the relationships between the occurrence of vod and available data in a learning (n = patients) and validation set (n = patients) obtained by random splitting. logistic regression was used as a continuous statistical model. in addition, we used classification and regression tree (cart) analysis, a machine learning and binary partitioning technique, to identify determinants of vod and their optimal cut-off values. the predictive performance of variables within both models was assessed by these results are compared with historical data from our service using beam as conditioning followed by auto-sct in lymphoma patients. nine patients were enrolled to receive neam: mitoxantrone mg/m day - to - , etoposide mg/m every hours and cytarabine mg/m every hours day - to - , and melphalan mg/m day - , followed by auto-sct. the median age was years ( - ); five non-hodgkin lymphomas (nhl) and four hodgkin lymphomas (lh). six patients were in partial remission (pr), two in complete remission (cr), and one with progressive disease at time of auto-sct. neam patients were compared with a historical control group of patients receiving beam regimen (n = ). differences between groups were analyzed by t-student and χ -tests. median cd + cells infused in neam and beam groups was . × ⁶/kg ( . - . ) and . × ⁶/ kg ( . - . ), respectively (p = . ). the median time to neutrophil recovery ( /μl) was days ( - ) and days ( - ) (p = . ) and median time for platelets recovery ( /μl) was and days ( - ) and days ( - ) (p = . ) respectively, for neam and beam patients. median duration of hospitalization was days ( - ) with neam and days ( - ) with beam (p = . ). among neam patients, % had one or more febrile episodes during neutropenia. no case of grade iii or iv mucositis was described. there was no transplant-related mortality (trm: %) associated with the use of neam regimen. at the present, all neam patients are alive, two of them in relapse ( %). due the difficulties in obtaining carmustine in our region, neam can be considered as a feasible alternative to beam. however, despite the sample was small enough to draw conclusions, we find that neam presents prolonged aplasia of significant value, we are currently exploring conditioning regimens followed by auto-sct in hodgkin's and non-hodgkin's lymphomas based on bendamustine, etoposide, cytarabine and melphalan. disclosure of conflict of interest: none. at present, decision-making about conditioning regimens for allogeneic hsct is based on patient's and donor's features, and disease characteristics. during the last years, terms as 'myeloablative/non-myeloablative/reduced-intensity' have been frequently employed in a confusing and unequal way among the different centers. knowing the expected intensity and myeloablative effect from each regimen is very useful and constitutes the aim of this analysis. we have analysed the severe neutropenia (anc o per mcl), and thrombocytopenia durations (platelets o per mcl), the need for platelet concentrates transfusion and the duration of the inpatient period of the allo-hsct carried out during the last four years in our centre. these data are reported according to the conditioning regimen used and to the type of transplant performed. then, they are compared among them in order to stablish intensity ranks. results: population characteristics are described in table : conventional intensive regimens (bu-cy , cy-bu , tbi-cy) reported more days of severe neutropenia and greater need of platelet concentrates transfusion. the regimens with less days of severe neutropenia, less need of platelet concentrates transfusion and fewer days of admission were flu-bu and flu-bu . allotransplants carried out with stem cells from bm presented more days of severe neutropenia and longer hospital stay. similar platelet transfusion need was reported. haplo-identical allotransplants reported more days of severe thrombocytopenia, but were not asociated to longer neutropenia or longer hospital stay than the others. these data are described in detail in table . flu-bu: the number ( , or ) expresses the doses of busulphan administered at . mg/kg/day. pc: platelet concretates data is expressed in medians. within the analysed conditioning regimens, an intensity rank is stablished regarding the myelosupression induced (in descending order): conventional intensive regimens (cy-bu , bu-cy , tbi-cy), flu-mel, flu-bu , flu-bu and flu-bu . all of them induced severe neutropenia and thrombocytopenia, and for that reason they must be considered myeloablative regimens. disclosure of conflict of interest: none. myeloablative allogeneic stem cell transplant for aml and mds: the impact of advanced age in the outcome m sánchez-escamilla* , , s garcía-Ávila , l yáñez san segundo , , ma bermudez rodriguez , , mm colorado araujo , , a casado diez , m celis alvarez , a cabero martinez , c fernandez martinez , a insunza garminde , , c richard espiga , and e conde garcía , allogeneic hematopoietic stem cell transplantation (allo-hsct) is the only curative option in high risk myeloid hematological malignancies. myeloablative conditioning (mac) regimen has been proven to be effective in the control of high risk diseases in advanced age patients. objective: the aim of this study was to analyze the efficacy of myeloablative allo-hsct in two cohorts of patients considering their age at transplant. we also analyzed the incidence of acute and chronic graft versus host disease (gvhd) and procedure related outcomes who underwent to myeloablative allo-hsct were retrospectively analyzed. the median age was years (iqr - ). both groups were divided regarding their age at allo-hsct [group , age ⩾ years (n = ) and group , age o years (n = )]. patient´s characteristics are shown in picture . data were collected as either continuous data and compared by two-tailed unpaired t-test or mann-whitney test, or as categorical variables and compared by chi-square. the procedure related outcomes were analyzed with the kaplan-meier test. the incidence of acute gvhd grade ii-iv was similar in both groups ( . % in group and . % in group , p = . ). the mean day to acute gvhd (grade ii-iv) development was days in group and days in group . the most involved organs in both groups were skin (group : . % and group : . % [p = . ]) and gut (group : . % and group : . % [p = . ]). at day + post-transplant patients were alive and evaluable for chronic gvhd. the incidence of cgvhd development was similar between group and ( . % versus . %, respectively, p = . ). however, severe grade s of cgvhd was high in group patients ( . % versus . %). with a median follow up of months (iqr, - ) the probability of os was significantly low (p = . ) in group ( . % +- . ) compared with group ( . % ± . ). pfs was also significantly low (p = . ) in group ( . % +- . ) compared with group ( . % ± . ). trm at months was higher in group compared with group ( . % versus . %). mortality due to relapses was also higher in group ( . % versus . %). most of the patients died during the first month. comparing both groups at this time ( months post-transplant), trm was higher in group compared with group ( . % versus . %). deaths due to relapse were also higher in this group ( . % versus . %). in our series, myeloablative conditioning regimen provides good survival rates and disease control in high risk hematopoietic diseases, however in patients aged ⩾ years confers high toxicity. it may be necessary to evaluate other strategies in this group of patients. disclosure of conflict of interest: none. allogenic hematopoietic cell transplantation (hct) is reserved for a group of high risk multiple myeloma (mm) patients having relapsed after high-dose melphalan and autologous transplantation. in general, reduced-intensity conditioning (ric) regimen are applied in this patient group with the aim of reducing transplant related mortality (trm). however, relapse of disease remains a major challenge after allogeneic hct. to address this issue, we added radioimmunotherapy (rit) to a conventional ric regimen. we have used a rhenium anti cd antibody in combination with a ric conditioning regimen. this ß-emitter leads to a so called 'cross-fire' effect allowing for bone marrow doses of gy and in parallel may target cd on myeloma cells. we hypothesized that this strategy may decrease the incidence of relapse. so far, we have treated nine patients with high risk relapsed multiple myeloma. all patients had received one (n = ), two (n = ) or three (n = ) high-dose regimens and autologous hct. conditioning therapy was flu/mel (n = ), flu/ bu (n = ) or flu/treo (n = ). flu/cy and gy tbi were applied before haploidentical transplantation. patients received g-csf mobilized pbsc from unrelated (n = ) or haploidentical (n = ) s donors. either tacrolimus/ methotrexate/ bortezomib or cyclosporine a/ methotrexate were used for gvhd prophylaxis. early extramedullary toxicity was limited. neutrophil and platelet engraftment was timely and complete in time in seven of nine cases. all patients achieved full donor chimerism around day fifteen after hct. severe acute graft-versus-host-disease (gvhd grade iii-iv) occurred in two patients and was lethal in both cases. two patients have experienced extramedullary relapse, one of them in the central nervous system and the other in the soft tissue. in two patients, a transplantation-associated thrombotic microangiopathy (ta-tma) was diagnosed. four patients are alive and in complete remission. we conclude that the combination of a ric regimen with a rhenium anti-cd radioimmunotherapy is save and feasible. the incidence of gvhd, ta-tma and extramedullary relapse will be monitored closely and will be presented in a larger patient cohort. disclosure of conflict of interest: none. the sirolimus/tacrolimus (sir/tac) combination has been associated with a better outcome after allogeneic hematopoietic stem cell transplantation (allo-hsct) when compared with conventional prophylaxis for graft vs host disease (gvhd) as cyclosporine/methotrexate in the true reduced-intensity conditioning (ric) setting but not in the myeloablative setting. in moderate-intensity regimens as thiotepa/busulphan/fludarabine (tbf), the sir/tac combination has not been evaluated. from january to december , all consecutive ric-allo-hsct recipients who received sir/tac combination to prevent gvhd in three spanish institutions were included in the study. the reduced-toxicity regimens used in this study where: (a) intravenous busulphan ( . mg/kg) and fludarabine mg/ m (bf), or (b) thiotepa days - and - and mg/kg if yrs old or mg/kg if o yrs old) on days - and - added to the bf regimen (tbf). the gvhd prophylaxis with sir/tac was given as detailed elsewhere (cutler c blood ) and was consistent within the center. the outcomes of the procedure according to the conditioning regimen were analyzed. overall, patients were included: tbf and patients in the bf group, with a median follow-up of months (range - ) and no difference in the median age ( vs years old). there were more males ( % vs %, p = . ) and more female donors to male recipients ( % vs %, p = . ) and more patients with lymphoid diseases and previous asct in the tbf group ( % vs %, p = . ), whereas there were more unrelated donors in the bf group ( % vs %, p = . ). other baseline characteristics were balanced between the groups (table ) . sir/tac prophylaxis had to be discontinued in % and % patients in the tbf and bf groups, respectively. toxicity was the main reason for discontinuation in the tbf group. the most frequent toxicities were renal injury (tbf % and bf %) and neurologic impairments (tbf %, bf %). in the bf group, the main reason of discontinuation was relapse or a mixed chimera. patients who received tbf presented higher incidence of extensive chronic gvhd ( % vs %, p = . ), higher nrm at days ( % vs %) and at years ( % vs %, p = . ). there were no differences in os ( years) between both groups ( ± . % vs ± . %, p = . ) (figure) . there were no differences regarding to acute gvhd - ( % vs %, p = . ), acute gvhd - ( % vs %, p = . ), or relapse (up to years, % vs %, p = . ) between the groups, either. the combination of sir/tac as gvhd prophylaxis was associated with higher incidence of chronic gvhd and nrm in patients receiving conditioning regimen with tbf compared to those receiving bf. there were no differences in os between both groups. [p ] cr complete remission, pr partial remission, nr non remission, hct-ci hematopoyetic cell transplant comorbility index. disclosure of conflict of interest: none. reduced-intensity conditioning regimen with fractionated total body irradiation of gy and cyclophosphamide mg/kg for allogeneic hematopoietic stem cell transplant is well tolerated and offers a potential disease control as treatment of acute leukemia and lymphoproliferative disorders m adler, t girinsky , s koscielny, g ferini, s wittnebel, s mayeur, c chahine, m vanghele, s pilorge, c castilla-llorente and j-h bourhis the use of reduced-intensity conditioning regimens (ric) before allo-hsct is widely extended since it preserves the graft-versus-leukemia effect but reduces treatment related mortality. however, there exist different ric regimens with diverse outcomes and the choice of the ric regimen relies on the type of disease treated, experience of the center and previous therapies. this is a retrospective study of patients treated in our institution within / and / . the ric regimen consisted of fractionated total body irradiation (ftbi) of gy administered in consecutive days ( gy/day) and cyclophosphamide mg/kg given in days ( mg/kg/day). post-transplant immunosuppression consisted of csa started the day before allo-hsct and short mtx on days , and after transplantation. for patients receiving transplant from unrelated donors, anti-thymocyte globulin at a dose of mg/ kg ( . mg/kg/day for days at day - and - ) was used as part of the immunosuppressant therapy. patients (median age: years: range: - years) were included. the median hct-ci was . (range: - ). primary disease was multiple myeloma (mm) in ( %), al/mds in ( %), cll in ( %), nhl in cases ( %) . patients ( %) received transplant from matched related donors, ( %) from matched unrelated donors and ( %) from mismatched unrelated donors. female to male mismatch incidence was % (n = ). most of the patients (n = ) received a peripheral blood graft. patient received a second allogeneic transplant. mm patients were transplanted in a "tandem" autologous-allogeneic hsct program in cases. the median number of chemotherapy lines prior to transplant was . in cll, . in mm and . in nhl. patients ( %) engrafted by day post transplant. neutrophil engraftment occured at a median of days (range: - days) and platelet engraftment at a median of . days (range: - days). full donor chimerism was observed in out of patients ( %) having survived by day . primary graft rejection was observed in patients. treatment related toxicities consisted of grade / mucositis in patients ( %), grade (range: - ) cardiac toxicity in patients ( %), grade (range: - ) hemorrhagic complications in patients ( %) including cases of hemorrhagic cystitis and secondary malignancies in patients, this within a median follow-up of . years. infectious complications during aplasia included fever of unknown origin (n = ), bacteremia (n = ) with cases of bacteremia with severe sepsis and cases of infections defined by bacterial foci. incidence of agvhd was % with cases of grade / refractory agvhd. cgvhd occurred in pts ( %). the non-relapse mortality (nrm) at days was % including cases of septic shock, case of acute cardiac toxicity and case of agvhd. the nrm at year was %. -year survival rates were % in al, % in cll and % in nhl with extended survival benefit. in al patients, the relapse incidence was % comprising patients who progressed during conditioning. the -year survival rate in mm patients was %. in mm patients who were in complete response prior to transplant, median overall survival was . years. the used ric regimen resulted in durable donor engraftment with an acceptable toxicity profile permitting efficient disease control in the described cohort. disclosure of conflict of interest: none. graft manipulation using selective depletion of αβ-t cells provides a source for haploidentical hematopoietic stem cell transplantation (haplo-hsct) enriched in effector cells. initial reports demonstrated safety and rapid immune reconstitution using this method, in malignant and non-malignant disorders using several proposed conditioning regimens. no specific considerations were given to hematologic malignancies. we reviewed a total of twenty seven pediatric patients who underwent haplo-hsct using αβ-t cell depletion between - in a single tertiary referral center. we report the results of procedures performed in eighteen patients transplanted for malignancies. twenty two haplo-hsct were performed in eighteen patients. the indication for hsct was acute leukemia in sixteen (all = , aml = ) and neuroblastoma in two. median age at hsct was . years. six patients had failed a prior hsct, and the remainder had no matched donor. the initial reduced-toxicity conditioning regimen consisted of melphalan, fludarabine, thiotepa and atg, and resulted in a high rate of graft rejections ( of ). thus, a totalbody irradiation (tbi)-based regimen was implemented, with prompt engraftment in all the patients. we observed rapid neutrophil and platelet engraftment kinetics (median time to engraft, days and . days, respectively). significant treatment related complications were all due to graft failure in patients receiving reduced-toxicity conditioning, with two infection-related mortalities in the presence of prolonged neutropenia. none of the patients developed hepatic sinusoidal-obstruction syndrome, and no grade - acute graft-versus-host disease (gvhd) or chronic gvhd were observed with either regimen. importantly, the majority of patients with acute leukemia were free of immunosuppression in the first days post hsct. the -year actuarial event-free and overall survival of the entire cohort were % and % respectively, with results for tbi-based conditioned patients being % and %. overall, we demonstrated that a tbibased conditioning for haplo-hsct using αβ-t cell depletion for malignant diseases resulted in acceptable outcomes in these high-risk patients without increased toxicity. disclosure of conflict of interest: none. high-dose chemotherapy conditioning regimens followed by autologous stem cell transplantation (auto-sct) generally provide good results in relapsed and refractory lymphomas. we evaluated the efficacy and safety of tecam regimen as conditioning with autologous stem cell support in patients with relapsed/refractory lymphomas. thirty-two ( patients were refractory, patients were relapse and one frontline treated) patients ( m, f) with lymphoma at various stages (stage ii, %; stage iii, %; stage iv, %) who underwent asct were included in this retrospective study. the median age at transplantation was . years (range, - years). the diagnosis were as follows: diffuse large b-cell non-hodgkin lyphoma (nhl), hodgkin lymphoma (hl), mantle cell lymphoma, follicular lymphoma, marginal zone lymphoma and t-cell nhl. all patients received tecam as conditioning regimen that consist of thiotepa ( mg/m × days), etoposide ( mg/m × days), cyclophosphamide ( mg/ kg × day), ara-c ( mg/m × days) and melphalan ( mg/m × days). median cd (+) cells were . × /kg (range; . - . × /kg) which were infused at day , followed by recombinant human granulocyte colonystimulating factor (rhug-csf) at a dose of μg/kg/day. the median time between mobilization and auto-sct was months (range; - months). the median time to recovery of absolute neutrophil and platelet counts independent of transfusion were (range; - ) and (range; - ) days, respectively. the median stay in hospital was days (range, - days). bacterial, sitomegalovirus and invasive fungal infection were detected in ( %), ( %) and ( %) patients, respectively in first days of auto-sct. three s patients ( . %) died from transplant-related complications. the overall response rate was % ( cr, . %; pr, . %) after auto-sct. relapse developed in patients during median follow-up period of . months (range; - months) after auto-sct. the -year estimated dfs ( figure ) and os were % and %, respectively. no statistical significance was observed for os and pfs in terms of gender, patient age ( o and ⩾ years) and nhl and hl lymphoma group (p ⩾ . ). the tecam regimen for auto-sct in lymphoma seems to provide encouraging results in terms of response and its good tolerance with acceptable toxicity. [p ] disclosure of conflict of interest: none. allogeneic hematopoietic cell transplantation (allosct) is the only curative treatment for myelofibrosis. however, its widespread use is limited by early non-relapse mortality (nrm). the optimal modalities of the conditioning regimen are a major unmet clinical need. in an attempt to reduce early nrm, we used a tbf conditioning regimen (thiotepa, busulfan (bu), fludarabine (flu) and antithymocyte globulin (atg)). our aim was to reduce nrm and improve engraftment by using such tbf conditioning. thirty consecutive patients with a median age of years (range, - ) who underwent allosct for primary (n = ) or secondary (n = ) myelofibrosis were included. according to the refined dynamic international prognostic scoring system (dipss-plus), patients were stratified as intermediate- (n = ), intermediate- (n = ), and high (n = ) risk. five patients had blast transformation. ruxolitinib was given to patients ( %) prior to allosct. graft source was pbscs in patients ( %) and bm in patients ( %). donors were matched related (mrd, n = ), unrelated (n = ) and haploidentical (n = ). conditioning regimen was tbf in patients ( %). in our historical cohort patients ( %) received fb (flu, bu, atg). in addition, patients received a 'tec-ric' sequential conditioning (thiotepa, etoposide, cyclophosphamide, and after days rest, flu, bu and atg) for blast transformation (n = ) or refractory proliferative myelofibrosis (n = ). gvhd prophylaxis consisted of cyclosporine (csa) and mycophenolate mofetil in patients ( %), csa and short course methotrexate in patients ( %) with abo mismatch and csa alone in patient ( %) with mrd. high dose posttransplant cy (pt-cy) was added in haplo cases. no significant difference was observed between tbf, fb and tec ric patients in terms of age, gender, karnofsky score, comorbidity index, number of previous treatment line, history of ruxolitinib administration and source of stem cells. median follow-up was months (range, - ). two tbf patients died of septic shock before engraftment at day + and + after allosct, respectively. one fb patient died of graft failure at day + post allosct. median time to neutrophils and platelets ( g/ l) recovery was days (range, - ) and days (range, - ) with tbf, days (range, - ) and days (range, - ) with fb, and days (range, - ) and days (range, - ) with tec ric. grade ii-iv acute gvhd occurred in . % of tbf patients, . % of fb patients, and % of tec ric patients (p = . ). moderate chronic gvhd developed in / evaluable tbf, / fb and / tec ric patients. no severe forms of chronic gvhd were observed. at last follow-up, patient relapsed, died and are still alive. main causes of death were disease progression (n = ), infection (n = ) and gvhd (n = ). nrm at years was . % in tbf patients, % in fb patients, and % in tec ric patients. the -year os were . % in tbf patients, . % in fb patients, % in tec ric patients, respectively. cd +-selected stem cell boost without further conditioning allowed to patients for poor graft function, with significant hematological improvement in patients. tbf conditioning regimen seems to be efficient in allosct for patients with myelofibrosis and compares favorably with previously published fb regimens. these preliminary results give a rationale to support a prospective evaluation of this platform. disclosure of conflict of interest: none. we proposed here to compare the outcome of patients receiving either thymoglobuline (atg), a rabbit anti-human thymocyte immunoglobulin or campath, a recombinant dna-derived humanized monoclonal antibody directed against cd . campath and atg are both commonly used as in vivo tcd before hsct, respectively in united kingdom and france but very few comparing data are available. all consecutive patients with acute myeloblastic leukemia (aml), myelodysplastic syndrome (mds) or myeloproliferative neoplasia (mpn) who received a reduced intensity hsct from an unrelated donor transplanted between and were included in this study. a propensity score was used to identify and control potential confounding to relate the treatment group to the outcomes. in the matched sample, cox regression model was used to describe the association between treatment and outcomes. patients have been included. all patients received fludarabine and busulfan with either atg (n = ) or campath (n = ). patients treated by atg received cyclosporine plus mycophenolate mofetil or methotrexate and patients treated by campath received cyclosporine alone as gvhd prophylaxis. comparing patient and transplant characteristics, atg patients were older ( vs years), had less often aml ( vs %), had higher disease risk (adverse dri: vs %; poor cytogenetics: vs %; high cibmtr score: vs %), were less often in complete remission at time of transplant ( vs %) and were transplanted less often from a mismatched hla donor ( vs %). cumulative incidence of sustained engraftment was in % and % campath and atg patients. time to neutrophil engraftment was longer in atg patients ( vs days). acute gvhd ii to iv rate were higher after atg ( % vs %) as well as chronic extensive gvhd ( % vs %). relapse rate was higher after campath ( % vs %). disease-free survival (dfs) was higher after atg ( vs %) and the gvhd-free relapse free survival (grfs) was similar ( % vs %). according to the prognostic factors for outcome, a propensity score was developed selecting patients from the original cohort. the estimation of tcd effect was than studied. relapse risk was higher in patients treated by campath while there is a non-significant advantage for atg in dfs (table ) . [p ] tcd with atg or campath gives similar os, dfs and grfs. severe acute or chronic gvhd is lowered by campath but the higher relapse risk counterbalances the potential benefit of campath finally given similar os. nevertheless, lower risk disease patient might benefit from campath while higher risk patients might benefit from atg. disclosure of conflict of interest: none. high-dose chemotherapy (hdt) with autologous stem cell transplantation is the standard of care for relapsed/refractory (rr) or high grade non-hodgkin-lymphoma (nhl) and hodgkin-lymphoma (hl) . the standard hdt in autologous stem cell transplantation (asct) for lymphoma is carmustinebased hdt using a combination of carmustine, etoposide, cytarabine and melphalan (beam); this standard conditioning programme is used by most groups worldwide . we have designed novels hdt regimens in which carmustine was substituited by an equal dose of fotemustine (feam) or thiotepa (team) and we compared these two hdt regimens in terms of engraftment times, toxicity, tolerability and frequency of relapse after asct. from february to september we consider a total of relapsed/refractory patients affected by hl and nhl respectively hl and nhl with different grade of initial disease (grade i-iv) and different response to prior treatments. the all other drugs were administered according to a standard beam regimen . after a day of rest, autologous peripheral blood progenitor cells were infused on day , followed by s.c. g-csf ( mg/kg) from day of asct until consecutive days when the ancs were × /l . the primary objectives of the study were to assess the feasibility and safety of the feam and team regimens in terms of acute toxicity, grade of mucositis, hemopoietic engraftment and relapse after asct. acute toxicity include chemotherapy-induced nausea and vomiting, diarrhea, hepatotoxicity, nephrotoxicity and infection complication. in all patients cd + cells were collected from peripheral blood and the median number of infused cells per patient was . × e /kg. the median time of engraftment was days for neutrophil recovery (n × /l) and days for plt recovery ( × /l). acute toxicity occurred in total patients ( . %), mucositis grade - occurred in patients ( % of cases). frequency of relapse in all cases was . %. feam conditioning regimen was used in cases showing a median time of neytrophil recovery of days and a median time of plt recovery of days. acute toxicity occurred in of these cases ( . %), mucositis grade - occurred in patients ( . % of cases). frequency of relapse in feam group of patients was . %. team conditioning regimen was used in cases showing a median time of neytrophil recovery of days and a median time of plt recovery of days. acute toxicity occurred in of these cases ( . %), mucositis grade - occurred in patients ( . % of cases). frequency of relapse in team group of patients was %. relapse/progression of lymphoma and conditioning regimen toxicities remain limitations to treatment success. the two novels hdt regimens feam and team are safe and feasible and show similar engraftment times, tolerability and frequency of relapse. maybe the team regimen shows toxicity slightly higher than feam regimen but longer follow-up is needed to evaluate fully its efficacy and long-term safety. disclosure of conflict of interest: none. treosulfan is a prodrug of a bifunctional alkylating cytotoxic agent. there are few reports regarding toxicological side effects of treosulfan-based conditioning prior to hsct. here we report on incidence of early potential treosulfan-related toxicity in patients treated with treosulfan-based conditioning before hsct. treosulfan was given at a dose of g/m /d for days in combination with fludarabin mg/m /d for days prior to hsct. most patients (n = ) had a haematological malignancy, while patients had a non-malignant disorder as hsct indication. an hla-a, -b and -dr matched unrelated donor (mud) was used in cases, patients had a hla-identical sibling donor and received an hla-a, -b or -dr allele mismatched unrelated donor. as graft versus host-disease (gvhd) prophylaxis, most patients (n = ) received cyclosporine and methotrexate. patients medical records were scrutinized retrospectively to collect laboratory tests (aspartate aminotransferase (ast), alanine aminotransferase (alt), creatinine) before hsct and then weekly until weeks after hsct. levels of ast and alt were significantly increased week after hsct compared to before hsct. however, only a few patients had transaminase levels over or times the upper normal level (unl) levels decreased sharply after the first week. most of the cases with high levels of ast/alt at one week had normal or close to normal levels before hsct. creatinine levels increased after week but no patient had levels ⩾ × unl. clinical features of all oral mucositis (om) were recorded using the world health organization (who) scoring system. most patients ( %) had no or very limited (grade i) om, % had grade ii and % had grade iii or iv of om. according to our toxicological results this is low-toxic protocol. however, all patients became neutropenic, % already at the time of graft infusion, indicating that the protocol has a myelo-toxic effect comparable to conventional mac protocols. all patients engrafted, except three patients who died very early. median time to neutrophil and platelet engraftment was (range - ) and days ( - ), retrospectively, which is significantly later when compared to engraftment data for other ric protocols used at our centre (data not shown). median duration of neutropenia (o . × /l) was days , comparable to what is expected after conventional mac conditioning. secondary graft failure (gf) occurred in ( . %) patients, all having a nonmalignant disorder and / having a urd. non-relapse mortality (nrm) was . % ( % ci . - . %) at days and . % ( . - . %) at one year after hsct. causes of death within one year after hsct were: relapse , epstein-barr virus associated posttransplant lymphoproliferative disease (ptld) , other infections , organ failure , gvhd , hemophagocytic lymphohistiocytosis (hlh) . other infections occurring within days after hsct were cytomegalovirus (cmv) reactivation ( %), invasive fungal infection ( . %) and blood stream infection ( %). veno-occlusive disease of the liver or sinusoidal obstruction syndrome (vod/sos) occurred in one patient and haemorrhagic cystitis in two patients. this study shows that early regimen-related toxicity after hsct was low despite similar marrow toxicities compared to mac regimens. disclosure of conflict of interest: none. allogeneic stem cell transplantation from haploidentical donors (haplosct) is an increasingly adopted option for patients (pts) with high-risk hematological malignancies. in our institution, we previously described a platform for unmanipulated peripheral blood stem cell (pbsc) haplosct using a calcineurin-free gvhd prophylaxis with sirolimus, micophenolate and anti-human t-lymphocyte immunoglobulin (atg) after conditioning with treosulfan and fludarabine (trramm; peccatori et al., leukemia ) . as an attempt to decrease relapse rate, especially in advanced-phase diseases, we designed a new phase ii prospective clinical trial intensifying conditioning regimen with the addition of gy total-body irradiation (tbi) (trramm gy; eudract# - - ). we report results on pts. pts affected by aml (n = ), other myeloid (n = ) and lymphoid (n = ) malignancies were prospectively enrolled from may to june . median pts age was y (range - ). revised disease risk index (r-dri) was low or intermediate in pts, high in pts and very-high in pts. twenty-five pts had previously received an allogeneic stem-cell transplantation with a median time from st to nd sct of months . median hct-comorbidity index by sorror et al. was ( ) ( ) ( ) ( ) ( ) ( ) . pts received a myeloablative conditioning regimen consisting of treosulfan ( g/m /d from - to - ), fludarabine ( mg/m /d from − to − ) and tbi gy (fractionated in doses, from − to ). source of stem cells were unmanipulated g-csf-mobilized pbsc from haploidentical donors. gvhd prophylaxis consisted of atg-fresenius (grafalon, neovii) mg/kg/d from − to − , rituximab mg/m on − , mycophenolate mofetil mg/ kg from − to + and sirolimus (target concentration - ng/ ml) from − . median infused cd + and cd + cell doses were . × ⁶/kg and . × ⁸/kg, respectively. median follow-up for survivors was months ( - ). neutrophil engraftment occurred in % of pts with a median of d ( - ), platelet engraftment was reached in % of pts with a median of d ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the -d cumulative incidence (ci) of grade ⩾ acute gvhd (agvhd) was ± % and of grade ⩾ agvhd ± %; the years ci of chronic gvhd was ± %. the ci of transplant-related mortality (trm) at y and y were ± % and ± %, respectively. the ci of relapse at y and y were ± % and ± %, respectively, with a median time to relapse of d . interestingly, we did not observe any extramedullary relapse; loss of mismatched hla-haplotype occurred in % of relapses. among pts who were in active disease at time of haplosct and who were evaluable, % achieved complete remission (cr) and full donor chimerism at day+ . the y and y probabilities of disease-free survival (dfs) were ± % and ± %, respectively. at y, % of pts are alive, disease-free and immunosuppression-free minimal residual disease, tolerance, chimerism and immune reconstitution the number of human leukocyte antigen (hla)-mismatched hematopoietic cell transplantation (hct), including cord blood transplantation, has been increasing. hla-flow method can discriminate mismatched hla antigens between donor and recipient by using flow cytometry, and can evaluate minimal residual disease (mrd) or chimerism after hla-mismatched hct. by developing more simple methodology, hla-flow might be more widely applicable. we have developed modified -colorbased hla-flow method. the aim of this study is to evaluate the utility of the -color-based hla-flow for monitoring of mrd and chimerism after hla-mismatched hct in children. from june to november , serial monitoring of mrd or chimerism by the -color-based hla-flow was performed in twelve patients undergoing hla-mismatched hct ( tests). nucleated cells obtained from bone marrow were stained by immunofluorescent antibodies against hla antigens mismatched between donors and recipients. these cells were also stained by immunofluorescent antibodies against surface antigens such as cd , cd , cd , cd and cd /cd for determining lineage of the cells. these surface antigens were also used as a marker of leukemic blasts in the mrd study. we used -color-based flow cytometry (facs-navious) and the data were analyzed with flow jo. erythroblasts and dead cells were excluded from the analysis. in each study, at least cells were analyzed. for mrd analysis, we concurrently tested real-time quantitative polymerase chain reaction (pcr) of peripheral wt mrna or leukemia-specific fusion genes. pcr of polymorphic short tandem repeats or fluorescent in situ hybridization of x/y chromosomes was concurrently tested for chimerism study. age of patients ranged from to years. donor sources included bone marrow (n = ) and cord blood (n = ). for mrd monitoring of acute leukemia (n = ), the -color-based hla-flow could detect mrd in three patients. five patients have not experienced relapse. no discordance with other mrd markers was observed in these patients. hla-flow could not separate donor-derived cells from recipient-derived ones in one patient receiving bone marrow transplantation. as for chimerism testing (n = ), the -colorbased hla-flow could successfully evaluate quantitative lineagespecific chimerism in all patients. there is no discrepancy between hla-flow and other methods. we could complete evaluation of the -color-based hla-flow within two days in all tests. the -color-based hla-flow is a simple, quick and useful method for the quantitative evaluation of mrd and lineagespecific chimerism after hla-mismatched hct in children, irrespective of donor sources. it is thought that our method is applicable in all institutions owing -color-based flow cytometry. acknowledgement: we thank drs. nobukazu watanabe, eri watanabe and natsuko sato (university of tokyo) for their technical advices. we also thank drs. tomoko okunushi (chiba university), hidefumi hiramatsu and katsutsugu umeda (kyoto university) for their care of patients involved in this study. disclosure of conflict of interest: none. survival (pfs), cumulative incidence of relapse (cir) and acute/ chronic gvhd incidence in aml patients (pts) submitted to allo-hsct at our institution between january and december . this retrospective study evaluated aml pts submitted to allo-hsct from matched sibling donors (msd) and matched unrelated donors (mud) who provided bone marrow (bm) or peripheral blood as stem cell grafts.ir was evaluated at , and days post-transplant in all pts. cmv-dna copies were determined in peripheral blood by quantitative pcr twice weekly in the first days post-transplant and subsequently once weekly. cmvi/r was analyzed as a timedependent covariate.effect of cmvi/r on os and pfs was estimated by cox proportional hazard model. cir and gvhd incidence were analized with a competing risk approach, considering death from any cause as a competing event. effect of cmvi/r on cir and gvhd were evaluated by fine & gray model. median age at allo-hsct was . years ( . - . ). in our population % of donors were seropositive for a previous cmv infection and pts transplanted from these donors showed a significantly lower cumulative incidence of cmvi/r than pts transplanted with seronegative ones (shr = . , %,ci: . our study demonstrates that cmvi/r influences the success of allo-hsct by determining a better ir characterized by a higher cd + cell number that might exert an immune protective control on disease outcome by improving os,pfs and cir with no effect on gvhd. another factor of utmost importance to achieve this same goal might be constituted by the significantly increased nk cell number six months after allo-hsct. to assess the dynamics of molecular response to treatment in aml adult patients with concomitant flt and npm mutations. this retrospective single center studystudy was approved by the institutional review board of american university of beirut medical center. twelve consecutive newly diagnosed (n = ) or relapsed (n = ) aml patients received idarubicin/cytarabine induction and one or two consolidation (s) ( table ) . seven patients received allogeneic stem cell transplant (allo-sct) and had haploidentical-sct (hap-lo_sct); all followed by post-transplant sorafenib maintenance. median follow-up was . ( - ) months. all transplanted patients remain alive and disease free.flt mutation was tested on dna using a qualitative method with a sensitivity of . %. npm- mutation was tested on cdna using a qualitative or a quantitative rt-pcr with a sensitivity of . % and . ncn respectively. patients were tested at diagnosis, after induction, after each consolidation, before and s at days , and after allo-sct for kinetics of npm and flt molecular response. after induction, flt became negative in all tested patients (n = ). after first consolidation, flt- was not tested in patients who had a negative result after induction, was negative in patients including the patients who were not tested after induction, whereas a molecular relapse was noted in one patient who developed a hematological relapse and rapidly died. another patient died after the third consolidation, in complete remission, due to septic shock. no molecular positivity for flt- was noted later on, whether after second consolidation or post-transplant. conversely, npm- mutation became negative in out of tested patients after induction, in additional patient after first consolidation and in additional patients after sct, mostly after starting sorafenib. npm- mrd value remained elevated in out of patients with quantitative assessment at diagnosis and post induction (figure ). flt become negative early after induction while npm negativity lags behind. persistent npm- mrd does not seem to predict post-transplant outcome and may indeed become negative after sorafenib. these results need confirmation in larger studies. disclosure of conflict of interest: none. in allogeneic stem cell transplantation (allo-sct), an early detection of the transplant outcomes such as overall survival (os), event-free survival (efs), cumulative incidence of relapse (cir) and non-relapse mortality (nrm) is fundamental regarding the use in time of additional therapy after sct. therefore, we investigated the association between early immune reconstitution (ir) on day + after allo-sct and outcomes in children suffering from acute leukemia or myelodysplastic syndrome (mds). this study collected data from allo-sct from january until december in our institution. the median survival follow-up was months. indications of allo-sct were all (n = , %), aml (n = , %) and mds (n = , %). the median age was years (range, . - ). patients were transplanted in cr (n = , %) and pr/nr (n = , %). patients included in the study received st sct (n = , %), nd sct (n = , %) or sct (n = , %). grafts were from sibling (msd; n = , %), matched unrelated (mud; n = , %), haploidentical (n = , %) or mismatched unrelated (mmud; n = , %). conditioning regimens were tbi-based (n = , %) or chemo-based (n = , %). stem cells were from bone marrow (n = , %) or peripheral blood (n = , %). we analyzed the absolute count of lymphocytes (alc), monocytes, cd + t cells, cd +cd + t-helper cells, cd +cd + cytotoxic t-cells, cd -cd + natural killer (nk) cells and cd + b cells assessed on day ± after sct. we used the percentiles of the lymphocyte subsets of the same cohort to categorize the samples throughout the study. patients with alc over the th percentile of alc (alc o cells/μl) had a . -fold increased hazard ratio (hr) to develop relapse (p = . ). nk cell counts on day after sct were strong associated with os, efs, cir and nrm. patients with nk cell count over the th percentile (nk . cells/μl) had increased hr for os (hr = . , p = . ) and efs (hr = . , p = . ) compared to patients with nk count under the th percentile. patients with nk cells over the th percentile (nk o . cells/μl) had a hr = . (p = . ) for relapse and hr = . (p = . ) for nrm compared to patients with nk cell count under the th percentile. monocyte cell count on day correlated with os, efs and cir. patients with cd + cells count under the th percentile of cd + (cd + o cells/μl) has an increased hazard ratio for os, efs and relapse compared to patients with cd + cell counts over the th percentile. no association between absolute cell count of cd +, cd +, cd + and cd + on day + after allo-sct and any outcomes either os, efs, cir or nrm was found. the study confirms the strong association between early ir and outcomes after allo-sct in children. our study suggests that especially nk cell and monocyte cell count on day + may have significant prognostic implications. our findings suggest that the cells count of alc, nk cells and monocytes on day + after allo-sct could be useful to predict outcomes after allo-sct and should be taken into account in considering alternative treatment. disclosure of conflict of interest: none. early immune reconstitution (eir) has proven to be a significant determinant for the outcome of allogeneic hematopoietic stem cell transplantation. in the setting of unmanipulated haploidentical transplantation (haplo-hsct), some groups have identified the absolute leukocyte count on day + (alc ) as an independent prognostic factor in terms of overall survival (os), disease free survival (dfs) and infectious mortality (im). the aim of this study was to evaluate the impact of eir on os, dfs and im among patients who underwent haplo-hsct with postransplant cyclophosphamide (ptcy) at our institution. from july to april , haplo-sct were performed at our institution. threedied before day after haplo-sct, and patients had missing data. conditioning regimen consisted of fludarabine, cyclophosphamide and busulfan. twenty-nine patients received a reduced intensity conditioning regimen ( - days of busulfan) while a myeloablative regimen ( - days of busulfan). gvhd prophylaxis comprised ptcy, cyclosporine and mycophenolate mofetil. patients were assessed for eir by means of alc , cd + t lymphocyte count on + (cd ), nk lymphocyte count on + (nk) and nk cd bright percentage on + (cd br ). we analyzed pts, with a median follow-up of months ( - ). the median age of the pts was (range - ), %men. diagnosis were: aml( %), hl ( %)non-hl ( %), all ( %),mds( %), cml( %), others( %). % were in complete remission at the time of transplant, % in partial remission and % had overt disease. in terms of infectious complications, cmv reactivation was documented in % of the pts, % developed a proven invasive fungal infection and % suffered from bk+hemorrhagic cystitis. median os and dfs were ( - ) and months ( - ), respectively. im rate was % at the end of follow up. median follow-up was months ( - ). roc curves were used to determine the optimal cut-off values for each of the studied parameters: cells/μl for alc , cells/μl for cd , cells/μl for nk and % for cd br were chosen. pts with alc ⩾ /μl had better os (p = . ) and dfs (p = . ), than those with alc o /μl. median os and dfs were months vs not reached (nr) and months vs nr, respectively. pts with cd br ⩾ % had better os (p = . ) than those with lower values. median os was months vs nr; however no difference was seen in terms of dfs. we didn´t observe statistically significant differences in os or dfs, among pts with different levels of cd and nk on + . cumulative incidence of im was significantly lower in pts with an alc ⩾ (p = . ), pts with cd ⩾ /μl (p = . ) and pts with nk ⩾ (p = . ); patients with cd br ⩾ % showed tendency to have lower cumulative incidence of infectious mortality (p = . , non-significant). cumulative incidence of relapse was not affected by alc , cd , nk or cd br . our study supports the independent prognostic value of early immune reconstitution after unmanipulated haploidentical transplantation with ptcy, especially in terms of lower infectious mortality. os and dfs were better among patients with alc ⩾ cells/μl. pts with cd br ⩾ % also showed better os. no correlation was found between cd or nk on + with os or dfs. cumulative incidence of infectious mortality was affected by alc , cd and nk on + ; while cd br seems to have less impact. [p ] disclosure of conflict of interest: none. an early absolute lymphocyte count (alc) recovery after autologous stem cell transplantation (asct) for hematologic malignancies has been related with an improved transplant outcome due to a faster autologous immune restoration. in this retrospective study we analyze post-transplant survival of non hodgkin lymphoma (nhl) patients and its relation with alc at day + post-asct. we analyzed consecutive adult nhl patients who underwent asct at the hematology and sct department of hospital maciel (montevideo, uruguay). only individuals with at least months post-transplant follow up were included. all patients received beam (bcnu, etoposide, cytarabine and melphalan) conditioning regimen followed by peripheral blood stem cells previously collected by apheresis. median cd + cell dose was . × e /kg ( . - . ). median alc at day + was /μl. patients were divided into two groups: alc at day + inferior than /ul (group ) and alc at day + superior or equal than /ul (group ). differences between groups were analyzed using t-student and chi-square tests, with statistical significance determined at p o . . disease free survival (dfs) and overall survival (os) were analyzed by kaplan meier method. differences in survival between groups were determined by log-rank test. no differences were observed between groups regarding gender, histology, disease status at transplant and cell dose. patients in group were older and more heavily pretreated. neutrophils and platelets engraftment were significantly faster in group (table ) . after a median follow up of months, disease-free survival (dfs) and overall survival (os) were superior in group . median dfs was months and not reached (p = . ) and os was months and not reached (p = . ) in groups and respectively (figure ). an early alc recovery after asct was associated with a superior dfs and os in nhl patients. individuals with alc major or equal than /ul had also a shorter time to neutrophils and platelets recovery and a shorter hospital stay. in this study, cd + cell dose does not seems to be a determinant factor for lymphocyte recovery. the load of previous treatment may influence lymphocyte recovery after asct. these results support the association between early post-asct lymphocyte recovery and improved survival in nlh patients. [p ] disclosure of conflict of interest: none. t cell depletion (tcd) reduces the risk of graft versus host disease (gvhd) but also the graft versus leukaemia (gvl) effect, thus increasing the risk of relapse. donor lymphocyte infusions (dli) can be given to boost donor chimerism, with the intention of enhancing the gvl effect. it is not currently known whether giving dli based on bone marrow chimerism (bmc) influences survival, or whether certain groups of patients benefit more from dli than other groups. in addition, it is not known whether the overall aim of achieving % bmc associates with improved survival. we investigated whether day (d ) bmc was predictive of survival, and whether giving dli based on this result was associated with improved overall survival. data were retrospectively collected from case notes and laboratory reports for patients who underwent allogeneic stem cell transplant (allosct) for aml or mds at the northern centre for bone marrow transplantation between and . patients who died prior to d were excluded from the analysis. of the patients analysed (aml , mds ), % were male and % female. the median age was years (range - ). conditioning was with flu/bu/ alemtuzumab ( ), flu/mel/alemtuzumab ( ), cy/tbi alemtuzumab ( ), flamsa tbi/bu atg/alemtuzumab ( ), other ( ) . ( %) received a graft from an unrelated donor, ( %) a matched sibling donor and ( %) another source. ( %) received mobilised pbscs, ( %) bone marrow and ( %) cord blood. statistics were performed using graphpad prism. p values were calculated using the chi square test and taking po . to determine significance. bmc was divided into groups %, - % and o %. % bmc at d was associated with a significant increase in year overall survival (os) ( . % vs . % and . % for - % and o %, respectively, p o . ). patients with a d bmc o % had a year os of o % (with relapse the cause of death in %). in patients whose d bmc was o %, there was a significant improvement in year os seen in those who received dli ( . % survival at years vs % with no dli, po . ) (figure : os by d bm chimerism (with and without dli). attainment of % bmc at a subsequent time point also significantly improved survival in those with a d bmc of - % ( . % year survival vs . % who never attained %, p o . ) and o % ( % year survival vs . %, p o . ). we found d bmc to be predictive of os in this population. in addition, dli was associated with an improvement in os, especially in patients whose bmc at d was o %. there was also a statistically significant improvement in os seen in patients who subsequently attained a % bmc, where it was o % at d . the objectives of this analysis were to examine the optimal alc recovery cutoff utilizing receiver operator characteristics (roc) analysis and to examine infused allograft characteristics associated with early alc recovery. after due irb approval, patients (pts) with aml and all who underwent hct at our institution between - were identified. pts with t-cell depletion or maintenance post hct were excluded. data were collected retrospectively from the patient's records. cellular contents of infused products (cd , cd , tnc, mnc, alc and amc) in addition to alc post hct were analyzed and optimal cutoff, if present, was established using roc analysis for the end point of relapse. time to end point analysis was computed using the kaplan-meier with log ranks. for competing events, cumulative incidence was computed using grey's model. univariable and multivariable analyses were performed using cox proportional hazard regression. a total of pts met the inclusion criteria and were analyzed. optimal alc cutoff by roc analysis was established to be on day + (d ) with alc . × /l and was subsequently defined as early lymphocyte recovery (erl). pts with alc ⩽ . × /l were deemed to have delayed lymphocyte recovery (dlr). patients were subsequently stratified accordingly and patient, disease and transplant related factors were well balanced between the groups. median follow up of the entire cohort was ( - . ) months. graft characteristics: roc analysis established optimal cellular cutoff, if present to predict elr. pts in the elr group were more likely to receive cd × /kg o ( . ), cd × /kg ( . ) and alc . × /kg (p = . ). we did not find a significant threshold for other allograft variables i.e. (tnc, mnc or amc). post hct outcomes: at years, corresponding cumulative incidence of relapse (cir) and non-relapse mortality (nrm) was . % vs . % (p = . ) and . % vs . % (p = . ), for elr and dlr cohorts, respectively. there was a trend towards improved progression free survival (pfs) and overall survival (os) in favor of elr vs dlr at . % vs . % (p = . ) and . % vs . % (p = . ), respectively. median time to neutrophil and platelet engraftment was and days, respectively for both groups. incidence of acute graft vs host disease (agvhd) was similar (p = . ); however, chronic gvhd (cgvhd) was more prevalent in the elr group at % vs %, respectively (p = . ). on s multivariable analysis for relapse, elr retained its prognostic significance with hr . ( . - . ; p = . ). cgvhd and first complete remission (cr ) at the time of hct were also protective factors from relapse in multivariable analysis. we observed that elr is an independent predictor for relapse in patients receiving allogeneic hct for acute leukemia with a trend towards improved os. this is possibly related to higher incidence of cgvhd. elr was influenced by infused allograft characteristics particularly cd count. given the sample size and retrospective nature of the analysis, these important observations should be examined prospectively. disclosure of conflict of interest: none. allosct is the only curative option for the treatment of hematological disorders with depression of hematopoiesis and primary immunodeficiencies.non-myeloablative conditioning (mac) regimens lead to long persistence of mixed chimaerism (mc) in the majority of patients. purpose: to estimate the relationship between type of hematopoietic chimaerism and appearance of gvhd in patients with non-malignant diseases after allosct eleven patients ( boys and girls) with median age of years (range - ) were included in the current study. among them there were patients with severe aplastic anemia (saa), with fancony anemia (fa), with thalassemia, with nijmengen syndrome, treated in our center from to . donors' sources were as follows: siblings in cases, mud ( / ) in ones. in cases bone marrow aspirate were used, in mobilized peripheral blood hematopoietic stem cells. conditioning regimens included fludarabin, cyclophosphamide and horse atg for saa patients, in fa and nijmengen syndrome patients this scheme was augmented by low-dose busulfan. in thalassemia patient we used mac with busulfan, fludarabin and horse atg. in majority of case gvhd prophylaxis consisted of tacrolimus and methotrexate combination. when allosct was performed form mud patients were additionally administered with mycophenolate mofetil. median of follow-up period was mo (range - ). quantitative evaluation of chimerism was done by multiplex amplification of str loci with subsequent fragment analysis using «cordis plus» kit («gordiz llc», russia). we analyzed whole bone marrow and peripheral blood together with cd + and cd + lymphocyte subpopulations. presence of ⩾ % donors' hematopoietic cells was considered as complete donor chimerism (cc), less than % was considered as mc. all patients engrafted in time and all of them are alive at the time of current analysis. there were no severe life-threatening complications, infections or graft rejections. only patients achieved cc at day + . at day + only these patients stayed in cc. at this time point mc was mainly revealed in cd + lymphocytes. in year after hsct proportion of cc patients enlarged to % ( patients did not achieved this time point). there is no any correlation between time of engraftment and chimerism value at day + , either between the dose of transplanted cd + cells and chimerism level ((p . in both cases). severe gvhd was noted only in female patients with cc at day + . in the first case it was acute gvhd grade iii after hsct from mud, in the second case extensive form of chronic gvhd in year after hsct from sibling was observed. there are no other cases of grade iii-iv acute gvhd in the observed cohort of patients. localized form of chronic gvhd [p ] was revealed in ( %) patients. in other patients there were no signs of chronic gvhd. despite limited number of observations we assumed that fast achievement of cc corresponds to severe gvhd. and vice versa, long persistence of mc prevented emergence of gvhd. however our findings need to be confirmed in a larger group of patients and preferably in a multicenter setting. disclosure of conflict of interest: none. interest of quantitative assessment of hematopoietic chimerism by real-time quantitative polymerase chain reaction after hematopoietic cell transplantation for hematological malignancies: a retrospective analysis on adult patients from rennes university hospital g laure , c mathilde , b marc , n stanilsas , d charles , l christine , a mehdi , lb laetitia, s gilbert , l thierry and r virginie department of hematology, chu pontchaillou, rennes; immunogenetics and histocompatibility laboratory, etablissement français du sang, rennes and etablissement français du sang-bretagne chimerism (percentage of recipient versus donor-derived blood cells) is used to document engraftment after hematopoietic stem cells transplantation (hsct). detection of persistant host cells, - as well as an increase in recipient cells chimerism has been associated with impaired dfs and os. quantitative real time pcr (qrt-pcr) is a highly sensitive, reproducible method, which can detect very low levels of recipient cells. the aim of this study was to evaluate the prognostic impact of early chimerism days (d ) and days (d )) after hsct and the meaning of detection of an increase of chimerism, even at low levels, during follow-up. adult patients who underwent hsct in rennes between and were included in this retrospective study. all chimerism analyses were done with qrt-pcr using whole blood sample. complete chimerism (cc) was defined by less than . % recipient cells detected. with a median follow-up was days, patients relapsed with a median time of . days after hsct. both d and d mixed chimerism (mc) ( . % recipient cells detected) were associated with an increased relapse risk (p = . and p o . respectively) compared to patients with cc in univariate analysis. however, when looking at subgroups analysis, d and d mc vs cc was significantly associated with increased relapse risk in this cohort for myeloid diseases (p = . and p o . ) but not for lymphoid diseases (p = . and p = . ). no difference in os was observed (p = . and p = . ). more important, detection of an increased of mc (imc) was associated with an increased relapse risk in univariate and multivariate analysis (or = . [ . ; . ], or = . [ . ; . ]), (po . ), as well as impaired os (p = . ) and dfs (p o . ). among the patients with aml and at least chimerism analysis available, only relapsed without imc detected but the patients' last available chimerism analysis was , and days before relapse respectively. median levels of recipient cells detected was . %. altogether, these results indicate that serial analyses of chimerism with qrt-pcr are a useful tool for post-transplant monitoring and might help identify patients at highest risk to relapse after transplant, especially in myeloid disease. monitoring frequency is critical in order to obtain the highest clinical impact, and the timing of monitoring as well as the safety and type of pre-emptive interventions still need to be explored. considering the kinetics of the disease, frequent analysis in myeloid pathology might improve the detection of impending relapse. although an approximately -log higher sensitivity of quantitative pcr (qpcr) compared to short tandem repeat (str) has been documented in different studies, the latter remains the standard procedure for hc assessment to date. we hypothesized that qpcr could be superior to str for monitoring the molecular kinetics of donor cell engraftment, response to donor lymphocyte infusions (dli) and development of relapse post-hct. we analyzed patients (pts) who underwent mainly / hla-matched unrelated hct mostly for acute myeloid or lymphatic leukemia at the university hospital essen between and . transplant conditioning was mostly myeloablative and gvhd prophylaxis was by cyclosporin a and methotrexate without anti-thymocyte globulin (atg). median follow-up of pts was days (d) ( - ). cytomegalovirus (cmv) reactivation in the first d posttransplant was measured by pp (n = ) or pcr (n = ). a total of retrospective genomic dna samples from peripheral blood (pb; n = ) or bone marrow (n = ) collected between d and d post-transplant were available for hc analysis in parallel by str (mentype chimera, biotype) and qpcr (alleleseq, abbott). threshold for hc positivity in qpcr was set at . % following published protocols. concordance in hc analysis between qpcr and str was found in / ( . %) samples, with all discordant cases positive in qpcr but negative in str. engraftment could be assessed in samples drawn at d -d from pts without relapse in the first months post-hct. these samples showed concordant negative or positive qpcr and str results reflective of full donor engraftment or persistent mixed chimerism (pmc) in and pts, respectively. in pts, qpcr but not str documented delayed conversion to full donor chimerism until d . in the remaining pts, positive results in qpcr but not str during early engraftment were observed exclusively in bm, in particular those drawn before d post-hct. qpcr but not str was also able to document the kinetics of conversion to full donor chimerism which took d and d in pts receiving dli for treatment of pmc and relapse, respectively. informative relapses could be assessed in samples drawn at least d before onset. / bm and / pb were positive in qpcr, compared to / bm and / pb in str, with a sensitivity of / ( %) and / ( . %) relapses, respectively. consistent with previous reports on a protective effect of early cmv reactivation on relapse in gvhd prophylaxis regimens without atg, relapse occurred in / ( %) pts who experienced cmv reactivation in the first d post-transplant, compared to / ( %) pts who did not. no apparent associations were observed between early cmv reactivation and engraftment kinetics post-hct. hc assessment by qpcr is highly concordant with str, but markedly superior for molecular monitoring of engraftment kinetics and relapse. positive qpcr results in bm should be interpreted with caution during early engraftment, while both bm and pb were highly informative for relapse in our series. these results advocate the feasibility and clinical utility of qpcr for post-hct hc monitoring in routine use. disclosure of conflict of interest: the commercial assays for qpcr chimerism analysis were provided by abbott molecular free of charge. tyrosine kinase inhibitor (tki) has become the standard of care in patients (pts) with chronic myeloid leukemia (cml) and an unavoidable tool in the combined therapy for pts with philadelphia chromosome positive (ph+) acute lymphoblastic leukemia (all). nevertheless, allogeneic stem cell transplantation (hsct) remains the standard therapy of all ph+ and of cml pts failing st line therapy with tki, with failure or insufficient response or intolerance or mutations resistant to nd generation tki, or in the advanced phase at diagnosis. in the past decade the feasibility and safety of post-hsct imatinib administration as prophylactic or therapeutic strategy was confirmed. second and rd generation tki administration after hsct is under investigation. here we are reporting our experience in post-hsct treatment with the rd generation tki ponatinib in pts treated between and at our institution. pts data and information were collected from institutional database and chapters revision. a written consent was given by pts allowing the use of medical records for research in accordance with the declaration of helsinki. pts and diseases features are reported in table . pre-transplant treatment for the all ph+ patient consisted of chemotherapy combined with dasatinib, followed by a st mud hsct and dasatinib in maintenance. the patient relapsed year after hsct with documentation of mutation v l. ponatinib was introduced as salvage treatment to bridge nd haplo hsct. pre-transplant treatment for the cml patients consisted of tki therapy with combination of chemotherapy in case of uncontrolled progression of disease. two pts received a st mud hsct but relapsed respectively months and years later. ponatinib was introduced as salvage treatment to bridge nd haplo hsct. four pts received ponatinib mg daily before the last hsct: one patient achieved sustained major molecular response, pts obtained transient response. all pts were presenting nd generation tki resistant mutations (table ) . ponatinib was started at a median of days after hsct (range, - ) as salvage treatment in overt relapse ( cases), prophylaxis ( case) or preemptive therapy ( case). acute gvhd was diagnosed in pts before ponatinib administration, of them also experienced chronic gvhd. no new cases of gvhd were observed after initiation of ponatinib. immunosuppressive treatment and azoles treatment were discontinued before ponatinib in all but one patient who was under combined treatment for chronic gvhd: therapeutic drug monitoring was closely performed without evidence of drug-drug interaction. pts were regularly evaluated for toxicities and monitored for cardiovascular events. no serious adverse events were reported in our experience: we administered ponatinib at a median maximum dosage of mg daily (range, - mg), for a median of weeks (range, - weeks). at last evaluation one patient maintained the status of molecularly undetectable leukemia (follow-up post hsct: months) and one major molecular response (follow-up post hsct months). three patients who received therapeutic ponatinib in overt relapse did not respond and died for progressive disease. ponatinib is safe and well tolerated as bridge to hsct and to maintain disease control after transplant. prophylaxis targeted therapy and preemptive therapy with ponatinib may lead to the reduction of disease relapse for high-risk ph+ leukemia. disclosure of conflict of interest: none. at nuh singapore we have adopted the cd ra depletion to ameliorate graft versus host disease. materials and methods: we have transplanted leukemia patients with cd depleted hsct followed by cd ra depleted donor lymphocyte infusion. no additional gvhd prophylaxis or gcsf was used. results: % patients achieved primary engraftment. median time for neutrophil engraftment ( /μl without gcsf) was days (range - days), platelet engraftment ( ) was days (range to days). immune reconstitution was rapid with median cd and cd cell counts /μl at day . by day median cd count was /μl (range - /μl). no patient developed grade iv acute gvhd. there was a significantly reduced incidence of invasive viral infections as compared to conventional transplants. importantly, all patients achieved complete remission (cr) on day + and remained in cr for longer time as compared to conventional transplants. conclusion: our preliminary data suggests that rapid immune-reconstitution of nk cells and t cells with this strategy correlates with reduced infection related mortality without loss of graft versus leukemia effects. disclosure of conflict of interest: none. the use of post-transplantation high-dose cyclophosphamide (pt-cy) has overcome the need for extensive depletion of t lymphocytes from haploidentical donor grafts, which traditionally resulted in severe and prolonged immunosuppression. it is therefore relevant to investigate the degree and the tempo of immune reconstitution after t cell replete haploidentical stem cell transplantation (haplo-sct) by use of pt-cy. we prospectively monitored cellular immunity in consecutive adult patients (male/female: / ), who underwent haplo-sct with pt-cy for myeloid (n = ) or lymphoid (n = ) malignancies. the median age at transplant was (range, - ) years. the conditioning regimen was myeloablative in , reduced-intensity in , and non-myeloablative in case. the source of the graft was peripheral blood (n = ) or bone marrow (n = ). in addition to pt-cy, graft-versus-host disease (gvhd) prophylaxis included tacrolimus and mycophenolate mofetil. absolute counts of cd +cd +, cd +cd +, cd + and cd +cd + cells were measured by flow cytometry at , , , , , and months post transplant. the median doses of infused cd + and cd + cells were . (range, . - . ) × /kg and . (range, . - ) × /kg, respectively. neutrophil engraftment ( /ul) was achieved at a median of (range, - ) days, whereas platelet engraftment ( /ul) was observed at a median of (range, - ) days. seven patients developed acute gvhd (grade i/ii: , grade iii: ). chronic gvhd occurred in patients, and was extensive in the of them. cytomegalovirus infection was detected in / cases at a median interval of (range, - ) days post transplant. two patients were administered rituximab for epstein-barr virus reactivation at months, whereas one patient developed bk virus-associated hemorrhagic cystitis at . months following haplo-sct. there was death due to gvhd and infection at months post transplant. at a median follow-up of (range, - ) months, / patients remain alive and disease-free. the absolute counts of t and b cells were extremely low early post transplant, while nk cells recovered from the first month (mean count, /μl). the number of cd + t cells started to increase beyond the first month, and exceeded lower normal limit at months (mean count, /μl). cd + t cells remained in general low ( o /μl) for the first months, increased moderately by months (mean count, /μl), and approached lower normal values at months (mean count, /μl) [ figure ]. of note, cd +cd ra+ naïve t cells remained significantly impaired (absolute count range, - /μl) in all patients in which they were assessed beyond the st year from transplant. cd + b cells were suppressed for the entire first trimester (mean count at months, /μl), but increased rapidly between and months (mean counts, /μl and /μl, respectively). in haplo-sct with pt-cy, reconstitution of cellular immunity can be achieved at adequate levels by - months following transplant. the observed deficit in the recovery of naïve t-helper cells may be related to a possible effect of pt-cy on thymopoiesis and warrants further investigation. [p ] disclosure of conflict of interest: none. hematopoietic stem cell transplantation (hsct) is a curative therapy for patients with sickle cell disease (scd). hemoglobin a in scd ameliorates the manifestations of the disease and this could be achieved with stable mixed chimerism after a reduced intensity hsct. this study aims to estimate the proportion of patients who develop mixed chimerism after hsct for scd and to characterize its progression in patients who develop it. this is a retrospective cohort study conducted at sultan qaboos university hospital (squh) bone marrow transplant unit in oman. we included all patients with scd who received hsct over the course of years between may to may . patients who received second hsct were excluded. short tandem repeat polymerase chain reaction was used for chimerism assessment. mixed chimerism was defined as − % chimerism at months from hsct. the data was analyzed by r program . . . χ or student t-test were used to assess the impact of acute graft versus host disease (agvhd) prophylaxis, age at transplantation, gender, red blood cell antigen alloimmunization, preparative regimen, and ferritin on the development of mixed chimerism. we included eligible patients. the median follow-up time after hsct was months (interquartile range: . − . months). the mean age at transplant was . years (standard deviation: . ). fifty-nine percent of patients were male. most patients had s/s genotype ( %), followed by s/beta-thalassemia mutation ( %). the indications for bmt were: stroke in %, acute chest syndrome (acs) in %, recurrent vaso-occlusive crisis (voc) in %, stroke and acs in %, acs and voc in %, orbital compression syndrome in %, stroke and moyamoya disease in %, and moyamoya disease in %. the two most frequently used preparative regimens were busulfan/fludarabine/atg in % and thiotepa/treosulfan/fludarabine in %. twenty-five percent of patients developed mixed chimerism at six months after hsct. on follow up of patients with mixed chimerism, % rejected the graft, % developed complete chimerism, and % continued to be in mixed chimerism. preparative regimen and the development of agvhd were statistically significant predictors of mixed chimerism at months (p values: . and . respectively). age at transplant, gender, red blood cell antigen alloimmunization, and ferritin were not statistically significant predictors of the mixed chimerism (p . ). the study confirmed that mixed chimerism can commonly be achieved in patients with scd after hsct and in majority, it remains stable on long-term follow-up. reduced intensity preparative regimen and lack of agvhd predicts the development of mixed chimerism. larger prospective studies are needed to confirm these results. disclosure of conflict of interest: none. there was a majority of male patients ( %). the median hbf level was % ( - ), median monocyte count was . /l (range: - . ), median platelet count was . /l ( - ), median marrow blasts was % ( - ) above patients who were explored by marrow karyotype, % of them had a monosomy . mutations in ptpn were detected in patients. fifty patients ( %) were treated with the bu/cy/mel regimen, whereas patients ( %) received the bu/flu/mel regimen. at years, the overall survival (os) was % ( % ci: - ). nineteen and patients developed vod after bu/cy/ mel and bu/flu/mel conditioning regimen, respectively. the cumulative incidence of agvhd - was % ( % ci: - ). the -year cumulative incidence of relapse and non-relapse mortality was % ( % ci: - ) and % ( % ci: - ), respectively. the median delay of relapse was days (range - ). among relapsing patients, were transplanted twice and one underwent hsct. in multivariate analysis, female donor to male recipient sex-mismatch, cmv status, total body irradiation and ras-double mutation/other additional mutation predicted poorer outcomes. the bu/flu/mel conditioning regimen was associated with a decreased risk of relapse. however, there was no statistical difference for os between the two main preparative regimens, bu/cy/mel vs bu/ flu/mel. our results show that allogeneic hsct may cure approximately % of patients with jmml and are similar to the best results published by other groups. relapse represents the main cause of treatment failure and a second hsct should be proposed. despite a decreased risk of relapse with the bu/ flu/mel regimen, there was no statistical difference in terms of os between the two main conditioning regimens, bu/flu/mel vs bu/cy/mel. disclosure of conflict of interest: none. allogeneic hematopoietic stem cell transplantation (ahsct) is the only curative treatment modality for the majority of pediatric patients with myelodysplastic syndrome (mds) and myeloproliferative neoplasms (mpn). the purpose of this study is to evaluate overall (os) and failure (relapse or death from any cause) free survivals (ffs), non-relapse mortality (nrm) and relapse incidence in children who underwent ahsct for mds or mpn in a single center from turkey. we retrospectively analyzed ahsct carried out in patients (median age: . years; range: . - ; males). thirty four had primary mds and had secondary mds. according to the modified who mds and mpn classification, had refractory cytopenia (rc), , refractory anemia with excess blast (raeb), , refractory anemia with excess blast in transformation (raeb-t) and , juvenile myelomonocytic leukemia (jmml). amongst patients with secondary mds, had been treated for acute myeloid leukemia, had been treated for non-hodgkin's lymphoma and had been treated for acute lymphoblastic leukemia, retinoblastoma and osteosarcoma, each, previously. donors were related in transplantation ( haploidentical transplantation) and the stem cell resources were bone marrow (n = ), peripheral blood (n = ), cord blood (n = ) and bone marrow +peripheral blood (n = ). three-year ffs and os for patients with mds were % and . %, respectively; and for patients with jmml, % and %, respectively. crude incidence of nrm and relapse for entire group were % and %, respectively. ahsct offers durable ffs and os for a significant group of pediatric patients with mds and mpn. less toxic conditioning regimens could result in better results in some patients. disclosure of conflict of interest: none. allogeneic stem cell transplantation in children with autism z antonella, g alessandra, ma beatriz and r vanderson bone marrow transplantation unit, hospital sirio-libanes, são paulo, brazil autism spectrum disorders (asd) are severe heterogeneous neurodevelopmental abnormalities characterized by dysfunctions in social interactions and communication skills, restricted interests, repetitive, and stereotypic verbal and non-verbal behaviors. the etiology of asd remains unknown, but recent studies suggest a possible association with altered immune responses and asd. inflammation in the brain and central nervous system has been reported with microglia activation and increased cytokine production in postmortem brain specimens of individuals with asd. other studies have established a correlation between asd and family history of autoimmune diseases, associations with mhc complex haplotypes, and abnormal levels of various inflammatory cytokines and immunological markers in the blood. the paracrine, secretome, and immunomodulatory effects of stem cells would appear to be the likely mechanisms of application for asd therapeutics. we describe two cases of patients with asd who underwent hsct for acute lymphoblastic leukemia (all) and whose symptoms were markedly decreased like an improvement of social interaction, communication, and behaviors. the first patient is an -year-old girl with asd who was diagnosis with ph-positive all in october (at the end of treatment, bcr-abl remained positive). she underwent a matched sibling hsct in march . the conditioning regimen was total body irradiation (tbi) and cyclophosphamide. during the -month follow-up period, we observed improvement in social interaction, communication, and behaviors (according to the childhood autism rating scale-cars). the second case is a -year-old boy with asd, asperger syndrome, who was diagnosis with all in september . he presented with bone marrow and testicular relapse in may and underwent a matched unrelated hsct in november . the conditioning regimen used was etoposide, atg and tbi. during the -month follow-up period, we observed improvement in social interaction, communication, and behaviors (according to cars). there is no treatment for asd thus every effort to minimize the symptoms are valuable. in both cases, social interaction was significantly increased, and the aggressive behaviors decreased. clinical cases have reported responses in autistic children receiving cord blood cd + cells. several incurable neurological disorders have shown benefits with cellular therapy. thus, autism should be explored as an indication. clinical studies are an immediate need to fully explore its potential in autism. disclosure of conflict of interest: none. conditioning is the initial phase of hematopoietic stem cell transplantation, based on high dose chemotherapy, combined or not with total body irradiation, aiming to eradicate the disease and prepare the environment of the bone marrow for the new cells. conditioning regimens can be characterized as myeloablative or non-myeloablative. during the period of conditioning and immunological reconstitution, signs and symptoms of the gastrointestinal tract are frequent, negatively influencing oral food intake, and may require the use of complementary nutritional therapies, aiming at an adequate caloric intake with the objective of avoiding decreasing in the nutritional status. the study aims to describe the association between the regiment intensity and the nutritional aspects during hospitalization of children and adolescents undergoing allogeneic hematopoietic stem cell transplantation (hsct) at a tertiary hospital. a retrospective study with medical records of patients undergoing allogeneic hsct, aged between and years of age (incomplete) between january and december . data were collected (regimen intensity, clinical signs of mucositis and nutritional therapies used) during the hospitalization and analyzed by the relative risk (rr). sixty-three patients were evaluated, being % male, with a median age of years. nineteen types of conditioning protocols were used. of these, % were high intensive regimen and % were low intensive regimen. the four most applied ( % of cases) were bucy (busulfan + cyclophosphamide) with and without atg (thymoglobulin), as well as cytb (cyclophosphamide+total body irradiation), also with and without atg. mucositis were observed in % of patients, being % grade and grade . the association was positive when analyzed the regimen intensity (myeloablative) with mucositis (rr = . ( . - . )) as well with the use of parenteral nutrition (rr = . ( . - . )). patients showed high prevalence of mucositis during hospitalization decreasing food intake, being necessary to use the parenteral nutrition. myeloablative regimen needed more nutritional therapy intervention when compared to non-mieloablative regiment. results demonstrate that an appropriate nutritional screening tool considering these aspects could help to intervene earlier maintaining an adequate nutritional status. autoimmune cytopenia (aic) is a potentially serious complication of hematopoietic stem cell transplantation (sct). autoimmune hemolytic anemia (aiha) is the most common aic, followed by immune thrombocytopenic purpura and autoimmune neutropenia. aic after sct is considered difficult to treat and associated with high morbidity and mortality. the aim of this cohort study is to evaluate incidence, outcome, potential risk factors and current treatment strategies and to explore the immune dysregulation predisposing to aic. the ebmt-promise database was accessed to identify all pediatric scts between and complicated by aic at our center. potential risk factors (i.e., age, gender, diagnosis, donor type, stem cell source, conditioning regimen) for aic after sct were assessed using univariate and multivariate cox regression analysis. in addition, we summarized treatment decisions of all aic patients. a nested matched case-control study was performed to search for possible biomarkers for aic. of consecutive scts, were complicated by the development of aic (cumulative incidence . %) at a median of months post-sct (figure) . aiha was the most common aic ( %), followed by combinations of two or more aics (evans syndrome, %). non-malignant disease, young age, alemtuzumab serotherapy pre-sct, non-tbi based conditioning regimen and cmv reactivation were associated with aic in univariate analyses. using multivariate cox regression analysis, non-malignant disease (hr . , p = . ), alemtuzumab use (hr . , p = . ) and cmv reactivation (hr . , p = . ) were independently associated with aic (figure) . for patients with cmv reactivation, diagnosis of aic was made at a median of months (iqr [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) after detection of maximum viral load. in our nested case-control analysis, serum levels of individual anti-and proinflammatory, and regulatory cytokines did not differ significantly between patients and controls. however, the cytokine profile of aic patients appeared to skew towards a more pronounced th response, compared to controls. firstline treatment, usually with prednisone and/or ivig, or a waitand-see approach led to resolution of aic in ( %) cases. second and subsequent-line therapies, often in combination with continuation of other treatments, consisted of rituximab (n = ), bortezomib (n = ) or sirolimus (n = ) and eventually led to resolution of aic in %, % and % of cases, respectively. overall survival of aic patients was %. in this retrospective cohort study, we identified cmv reactivation post-sct, alemtuzumab use and non-malignant disease as independently associated clinical risk factors for the development of aic. treatment with first-line therapy was mostly insufficient. for patients with severe aic, rituximab, bortezomib or sirolimus can be regarded as promising step-up therapies. figure (bkv) may cause polyomavirus-associated nephropathy or polyoma virus-associated hemorrhagic cystitis in bone marrow-transplant patients.we present patients with bk polyoma virus (bkv) ascociated hemorrhagic cystitis and patients with bk polyoma virus associated hemorrhagic cystitis and nephritis. between and , patients received an allogeneic bmt at acıbadem adana hospital pediatric bone marrow transplantation unit. patients occurred bkv associated hemorrhagic cystitis and nephritis. bkv was detected in the urine analysis and blood by pcr (polymerase chain reaction) in all patients. we presented patients with bkv infection, age ranging from to with a average of . years. they underwent allogeneic bmt due to thalassemia major ( patients), aplastic anemia ( patients) and acute lymphoblastic leukemia ( patients). the patients were treated with hydration, continuous bladder irrigation, ciprofloxacin, and weekly intravesical hyaluronic acid instillation for four weeks, and cidofovir. fourteen patients showed complete resolution of hematuria. one patient with refractory above these therapy also received hyperbaric oxygen and recombinant factor viia (rfviia, novoseven; novo nordisk,bagsvaerd, denmark). hemodialysis was performed in two patients who developed renal failure due to nephritis. bkv is ubiquitously present in the general population. reactivation of infection occurs under conditions of immunosuppression, particularly hsct or renal transplantation, and causes late-onset hc. bkv the management of bkv cystitis and nephritis sometimes may be very difficult and refractory all treatments, we presented our experience of bkv infection and management in transplanted patients in our center. patients with high-risk hematologic malignancies (hrhm) are among those in the highest risk group for developing invasive fungal disease (ifd), especially mold infections. allogenic hematopoietic stem cell transplantation (alsct), acute myeloid leukemia (aml), refractory and relapsed acute lymphoblastic leukemia (all), myelodysplastic syndromes and chronic extensive graft-versus-host disease are considered hrhm. ifd are a major cause of morbidity and mortality in these patients, however, the optimal strategy for antifungal p s prophylaxis in this population is not well defined yet. we performed a retrospective, observational study to investigate documented ifd during antifungal prophylaxis in children with hrhm who were admitted in our unit between and . demographic and clinical data were collected from patient's electronic medical records. all patients were treated with prophylactic voriconazole (vcz) according to our local practice. oral administration was preferred when available. vcz therapeutic drug monitoring (tdm) was not available in our center until june . breakthrough ifd was defined as occurrence of a proven or probable ifd according to eortc/ msg criteria while on vcz prophylaxis (⩾ days of treatment) or within days after discontinuation of prophylaxis. during the study period, hrhm patients were treated with prophylactic vcz in our unit. patients out of developed a breakthrough ifd. patient's demographic characteristics, main diagnosis and treatment are collected in table . initial and maintenance vcz doses are adjusted by weight in all patients except in patient- (adjusted according to vcz plasma level). adherence and tolerance to treatment was excellent in all patients. disclosure of conflict of interest: none. ( ) stable mixed chimerism (smc) when fluctuations of ac were o %; and ( ) mixed progressive chimerism (pmc) when ac were ⩾ %. - hscts performed in patients (pts) were included: children with a median age of . yrs (iqr . - . yrs) at diagnosis and . yrs (iqr - yrs) at hsct received one hsct ( . %), pts two hsct ( . %), and pts three hscts. primary diagnosis were bone marrow failures in pts ( . %), primary immunodeficiencies in ( . %), inborn errors of metabolism in ( . %) and haemoglobinopathies in ( . %). the donor was match related in ( %) procedures, match unrelated in ( %), and haploidentical in ( %); stem cell source was bone marrow in ( %), peripheral blood in ( %) and cord blood in ( %). conditioning regimen (cr) included busulfan in hscts ( . %), treosulfan in ( . %), while hscts ( . %) were conditioned with reduced intensity crs (including low dose of tbi in ); pt did not received cr. gvhd prophylaxis was based on csa/mtx (or mmf) in association with atg ( ) or alentuzumab ( ) ; recipients of tcrαβ/cd depleted haploidentical graft did not received post transplant immunosuppression. engraftment was observed in hscts ( after st , after nd and after rd hsct) after a median of day (iqr - days). acute gvhd occurred in hscts at risk ( %), and it was severe (gr. iii-iv) in ( %), chronic gvhd in ( %). at last follow-up (median . yrs), ( %) pts were alive, while pts are dead for infections (n = ), vod (n = ), c-gvhd (n = ) and vascular event (n = ). figure reported the evolution of chimerism over time. in our experience in children with non malignant disease, cc increased from % to % at subsequent analyses. % of pts with mc at st evaluation became cc, % remained smc, % evolved in pmc, and % rejected. only pts with cc at first time point rejected the graft. this study highlight the extreme variability of chimerism in the early post transplant course of children with non malignant disease and confirmed the relevance of performing serial analysis to monitor and, if necessary, improve graft function. naive t-cells identified by cd ra expression are believed to cause graft-versus-host-disease (gvhd), while cd ra-t-cells are memory cells that provide anti-infection and anti-tumoral effects. depleting cd ra+ naïve cells and retaining memory t-cells in the graft is a novel approach to haploidentical hsct for children. children with high risk leukemia ( aml, all) received cd ra-depleted haploidentical hsct following non-myeloablative conditioning. cell-selection performed on g-csf-mobilized peripheral blood. two cellular products obtained using clinimacs device, infused to each patient: a cd selection and a cd ra depletion from the cd negative fraction. product infused contained a median of . (range . - . ) x /kg cd + cells and a median of . (range . - ) × /kg of cd + cells in the cd -selected s graft. the second product was the cd ra depletion, cd ra +/kg was a median of . × /kg (range - × /kg) and a median . (range . - . ) depletion log of cd ra + cells. median dose of cd ro+ cells (memory t-cells) infused was (range . - ) × /kg. seventeen patients achieved neutrophil engraftment at median of days (range - ) post-transplant. one patient could not achieve engraftment, died at day + due to sepsis. two patients presented secondary graft failure (day + and + ), both received a second hsct. three patients developed agvhd grade ii with gastrointestinal tract involvement, all steroids responsive. three patients presented clinical features of cgvhd. patients have an extensive skin involvement, with hepatic findings in one and pulmonary affection in other, at day + , + and + post. ten of patients ( . %) remain alive in remission with median follow-up (range - ) days post-transplant. eight patients died, due progression at day + , + , + ( presented positive minimal residual disease at hsct), due to infectious complications (days + , + , + , + ) and due to cardiogenic shock at day + . four patients relapsed, of them died afterward with progressive disease. t-cells led immune recovery, achieved values higher than , , and cells/mcl at day , , and respectively. most of t cells were cd +cd ra-(median of , and × /mm respectively on day + , + and + ) and cd +cd ra-t cells (median of , and × /mm respectively on day + , + and + ), while cd + ra+ and cd + ra+ cells remained low recapitulating the cd ra depleted graft composition. six patients presented cytomegalovirus reactivation, one progressed to cmv disease. five patients with hhv- encephalitis. probable aspergillosis in patient (aml-m with secondary graft failure) at day + after second hcst. two cases of toxoplasmosis ( cns, pulmonary). cd ra-depleted haplo-hct showed acceptable tolerability with rapid and sustained engraftment as well as a full donor chimerism, minimal risk of acute gvhd and accelerated inmunologic reconstitution. to note the high incidence of hhv- encephalitis seen. disclosure of conflict of interest: none. collection of peripheral blood stem cells in teenager sibling donors: a single center experience c carvalho , f amado, f bordalo, s ferreira, s lopes, c pinho and s roncon serviço de terapia celular, instituto português de oncologia do porto francisco gentil, epe human leukocyte antigen (hla) compatibility is important in allogeneic haematopoietic stem cell transplantation in order to reduce post-transplant complications; however, siblings only present a % chance of hla-match with the patient. the well-known advantages and the low risk of complications associated to peripheral blood stem cells (pbsc) collected by apheresis made this procedure the first option in teenagers. the aim of this retrospective study was to analyse and characterize the paediatric sibling pbsc donor population assuring safety during the collection procedure, providing a high-quality product and accomplishing patient needs. we consulted the clinical files of donors under years old since - ; a database in excel ® was created to register population characteristics, collection parameters and graft requirements. the informed consent was obtained from parents before procedure. the leukapheresis were performed with a cobe spectra system; since , we use a spectra optia apheresis system. the donor/patient weight ratio (proposed by styczynski et al.) was determined for each pair. the collection was programed based on clinical and analytical donor's features as well as transplant requirements. the analytical assays were done by a certified laboratory. we performed pbsc apheresis in healthy donors, females and males ( table ) . all of them started on the th day after mobilization with granulocyte colony-stimulating factor (g-csf) administered subcutaneously, bidaily. the weight ratio was o in eight situations. most of donations were performed by peripheral vein; a central venous catheter (cvc) was placed into a femoral vein in six adolescents. a median of ( ) ( ) ( ) blood volemias were processed during ( - ) minutes; the anticoagulation used was citrate+heparin (ratio : ). in general, one-collection day was enough to obtain the number of cd + cells required; six donors had to perform a nd collection. in cases, we cryopreserved the exceeding cells after graft infusion. the procedure was well tolerated, with only adverse reactions registered (one hematoma in the puncture local; one paraesthesia due to hypocalcaemia induced by citrate). no blood products were used after the procedure or needed for the priming of the extracorporeal circuit. so far, no serious long-term adverse events were observed. table . median (range) of donors and leukapheresis products data. our long lasting experience shows that pbsc collection in the teenage population is safe and feasible, allowing us to obtain a high-quality product for the patients. there were no adverse events associated with the g-csf mobilization or cvc placement which is different from the experience of other groups. we recognize that leukapheresis by peripheral vein is a lengthy procedure but no complaint was reported to the collection team. [p ] disclosure of conflict of interest: none. correspondence between clinical and hystological grading of gastro-intestinal grading acute graft versus host disease in children m faraci , a rizzo , p gandullia , s arrigo , , a barabino , e lanino , s giardino and c coccia hematopoetic stem cell transplant unit, institute g gaslini, genoa, italy; pediatric department, institute g gaslini, genoa, italy; gastroenterology and digestive endoscopy unit, institute g gaslini, genoa, italy; gastroenterology and digestive endoscopy unit, institute g gaslini, genova and department of pathology, institute g gaslini, genoa, italy diagnosis of gastro-intestinal acute graft versus host disease (gi-agvhd) is frequently confirmed by apoptosis findings on mucosal biopsies. aims of this single center retrospective study is to evaluate the correlation between clinical and histological grading of gi-agvhd in children undergoing allogeneic haematopoietic stem cell transplantation (allo-hsct), and to describe histological findings obtained by gi endoscopies in order to evaluate usefulness in the diagnosis of gi-agvhd. allo-hscts were performed in our department between january and december . gi biopsies were performed in pts ( . %) because of suspected gi-agvhd. pts were transplanted for malignant ( . %) and for not malignant diseases. the median age at hsct was . years ( . - . ). pts ( %) received myeloablative and ( %) reduced intensity conditioning regimen. pts ( . %) received an unrelated donor (ud), pts a related donor (rd) ( . %), and an haploidentical donor ( . %). at onset of diarrhea, microbiological examinations of stool were performed and pcr research for cmv, adenovirus, hhv , ebv were evaluated in blood and in mucosal biopsies. mucosal biopsies were obtained with esophago-gastro-duodenoscopy in pts ( . %),esophago-gastro-duodeno-colonscopy in ( . %), pancolonscopy in ( . %), flexible sigmoidoscopy in ( . %), and rectal suction biopsy in pts ( . %). all mucosal biopsies, except in case of rectal suction, were obtained under sedation. the interval between mucosal biopsies and onset of gi acute symptoms was days (from − to days). biopsies were taken from different sites in the gi tract, were stained using hematoxylin-eosin and evaluated using histological grading of agvhd. in these pts the maximum grade of agvhd was: grade in one ( %), grade in ( %), and grade in pts ( %). at time of histological evaluation, diarrhea was the most common gi symptom ( . %); children had also cutaneous agvhd and hepatic agvhd. pcr-cmv was positive in mucosal biopsies obtained with pancolonscopy, pcr-adenovirus in other obtained with upper and pancolonscopy, pcr-hhv in rectal biopsies, and pcr-ebv in one with upper and pancoloscopy. the comparison between clinical and histology grading of gi-agvhd is shown in table . mucosal biopsies were positive in / pts evaluated with esophago-gastroduodenoscopy ( %) (grade agvhd), in / pts undergone esophago-gastro-duodeno-colonscopy (grade in and grade in ), in / ( %) who received a pancolonscopy (grade in , grade in , grade in ), and / ( %) of rectal biopsy obtained by sigmoidoscopy or rectal suction biopsy (grade in , grade in , grade in , and grade in ). one patient developed duodenal intraparietal hematoma after upper endoscopy. in our experience, we did not demonstrated a overall correlation between clinical and histological grading of agvhd showing that hystological examinations underestimated the grade mild or moderate of agvhd. we confirmed , that rectal biopsies represent to be more effective and safe diagnostic method for the confirm of diagnosis of gi-agi. during the past few decades, hematopoietic cell transplantation (hct) as a treatment modality for primary immunodeficiencies (pid) has undergone remarkable advancement mainly due to better availability of alternate donors resulting in increase in not just matched unrelated donor (mud) but also increased haploidentical (haplo) and cord blood transplants (cbt). additionally, refinement of the conditioning regimens and better graft versus host prophylaxis have presumably led to better survival outcomes. however, a literature gap is identified in evaluation of these outcomes in general with respect to donor and conditioning regimens. we conducted a systematic review by performing a comprehensive search of the pubmed and ovid library from its inception to august . mesh terms included 'primary immunodeficiency (immunodeficiencies)', 'stem cell transplant', 'bone marrow transplant' and 'hematopoietic cell transplant'. all pid studies which used hct as a treatment modality were included. experimental cellular therapies were excluded. both cellular immunodeficiencies (e.g. scid, was, a-t), and innate immunity disorders (e.g. ifngr, cgd) were included in the search. reviews, case reports, meta-analysis and non-english language articles were excluded from our electronic search. publication bias was excluded by performing a methodological search of unpublished conference abstracts from the annual meetings of cis, aspho, asbmt, ebmt, and siop from to . the data were analyzed considering the outcomes -overall survival and gvhd. studies fulfilled the strict selection criteria for the electronic search comprising of pid patients. in majority of the hcts, a myeloablative conditioning regimen (mac) was utilized ( % of the evaluable) but a shift towards more reduced intensity conditioning (ric) was observed in the later years. cbts were identified. % of patients developed some degree of acute gvhd, whereas chronic gvhd was identified in % of the patients. total number of haplos was . overall survival was found to be % post-hct. a meta-analysis could not be performed due to the heterogeneity of both the predictor variable data (combined stem cell sources were also used for hct) and due to the extremely small number of the patients when categorized in subgroups (e.g. for omenn syndrome, rag deficiencies). this is the largest study of hcts in pid, and we observe that alternate donor hcts have increased significantly over the past decade for the treatment of pid. while the incidence of chronic gvhd was low, acute gvhd still remains a problem in about a third of the pid patients transplanted. disclosure of conflict of interest: none. hepatic veno-occlusive disease (vod) is a common and serious complication of hemotopoietic stem cell transplantation (hsct) in children. we aimed to assess prospectively the use of prophylactic defibrotide in pediatric patients undergoing hsct. in this study, patients who underwent hsct were given defibrotide prophylaxis as mg/kg per day in four divided intravenous infusions over h, starting on the same day as the pretransplantation conditioning regimen. the mean duration of use of defibrotide is days as a prophylaxis. in this study, patients were recruited, male patients and female patients, with the average of . years, range - ; % infants, % children and % adolescent. there were patients with thalassemia major, patients with leukemia, patients with aplastic anemia, one patient with diamond blackfan anemia, two patients with congenitale dyserythropoetic anemia, one patient with osteopetrosis, four patients with famial hemophagocytic lymphohistiocytosis, two patienrs with severe immune deficiency and one patient with kostman syndrome. all transplants were allogeneic. no serious side effects were seen. in eight patients developed clinical vod (seattle criteria). in these patients, defibrotide dose was increased to a treatment dose of - mg/kg per day. one infant patient with kostman syndrome died due to hepatic and pulmonary veno-occlusive disease. after months of follow up, patients who developed vod are being well and no patient have transplant related complications. hepatic veno-occlusive disease, which is caused by hepatocyte and sinusoidal vessel endothelium damage, can ocur early after hsct, and in its severe form, may lead to liver faillure, hepatorenal syndrome, portal hypertension, and eventually death from multiorgan faillure. in this prospective study, we demonstrated that the use of defibrotide is safe and effective in preventing and treating vod in pediatric patients at high risk. immune reconstitution (ir) is critical for clinical outcome after allogeneic hematopoietic stem cell transplantation (hsct). host and proceeding-related factors affect the ir dynamics and survival. isolated ir parameters are commonly correlated and proposed to predict clinical outcomes after hsct, but these approaches only confer prognostic value at single time points or for single markers. we aim to demonstrate an appropriate methodology to assess the capability of combined serial measurements of lymphocyte subsets to reflect the impact of infections on ir after paediatric hsct. retrospective data of patients receiving a first hsct for any indication with any cell source in the paediatric hsct program from to were included. to characterize the kinetics of immune reconstitution, cd +, cd +, cd + t-cells, b-cells, nk-cells and their naive and memory subsets were measured and analysed at various time points at years post-hsct to stablish a joint model for the evolution of cell subpopulations. slope per month (cellular increase or decrease) of each lymphocyte subsets were calculated and compared with clinical outcomes and cumulative risk of infections. a total of children (range from - y.o. median y.o.) were included, with cb (n = ) pb (n = ) and bm (n = ) as cell sources. the cumulative incidences after early period were % for viral infections (ebv %, cmv %, bk %, adv %) and % for bacterial infections. data on ir were available for %, of the diseasefree survivors. in a exploratory multivariate analysis we detected mainly differences in cd +, cd +cd ro+ memory and nk cells at year after hsct, with dependent tendency according on the cell source and hla compatibility. analysis of the slope tendency patterns were stablished for the analysis of the impact of infections in the ir. delay in cd + and cd +ra+ appearance (mean slope/m = − . % and − . % respectively) remarks the ir profile for bacterial infections, and delayed in nk, cd and cd ro+ (− . %, − . %, − % respectively) for overall viral infections. additional correlations allow differences in ebv (cd +ra+ high mean slope/m = . %), cmv (delayed in cd ro+ slope/m = %), and bk infection (cd +ra + plus cd ro+ and nk high mean slope/m = . %, % %). understanding the dynamics of reconstitution by integrating information from the monitoring of lymphocyte subpopulations allows the establishment of kinetic profiles that may help to evaluate the risk of infections and adjust infection prophylaxis in the follow-up of transplanted patients. mortality rate in hsct patients admitted to intensive care unit (icu) is still as high as % to %. this rate increases when respiratory complications progress to acute respiratory failure (arf) requiring mechanical ventilation (mv). the aim of this study was to determine the feasibility and effectiveness of early continuous positive airway pressure (cpap) delivered in a pediatric hematology-oncology ward to prevent occurrence of arf requiring mv. we retrospectively analysed children treated with cpap in our pediatric hematology-oncology ward between october and october . thirty-two patients received cpap delivered with helmet during the study period. data were available for patients, males and females, median age years [range - ]. eighteen patients underwent allogenic hsct: from sibling donor, from matched unrelated donor, from haploidentical family donor, from cord blood unit. seven patients had a malignant disease: all, aml, ewing sarcoma. infectious pneumonia was the main cause of arf in / patients ( . %): viral pneumonitis ( rhinovirus, parainfluenzae virus, respiratory syncitial virus and cmv). five patients had proven/ probable invasive fungal infection according to eortc criteria ( aspergillosis and mucormycoses). other causative agents were pneumocystis jiroveci ( ), bacillus of calmette and guerein ( ), toxoplasma gondii ( ) and st. mitis ( ) . non infective causes of arf were acute transfusion related lung injury ( ), hemorragic alveolitis ( ), cryptogenic organizing pneumonia ( ), tumor lysis syndrome ( ), and alveolar oedema due to renal failure ( ). according to chest imaging, / patients ( %) presented with pulmonary consolidations, while % had both interstitial infiltrates and pulmonary consolidations. at baseline median neutrophil count was . × /μl (range - . × /μl), mean heart rate bpm, pulsiossimetry saturation in room air %. h-cpap was applied in / patient with a curative aim, in / patients as palliative support to reduce respiratory distress. median positive pressure delivered was cmh o ( - cmh o), median fio was % ( - %). h-cpap was applied for a median of days . no patient failed h-cpap because of agitation or adverse events (skin breakdown, conjunctivitis, gastric distension or epistaxis). ten patients were transferred to icu ( . %), / because of hsct complications. median icu stay was . days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . only patients required mechanical ventilation, in cases associated to ecmo. nether psao in room air (p . ci %) nor cpap level (p . ci %) correlated with the need of icu admission. patients requiring higher fio during cpap demonstrated a not statistically significant trend to higher icu admission rate (p = . ).there was a higher rate of mv in patients with higher cpap fio level (p = . ). mv prolonged icu stay (p . ). cumulative mortality was . % ( / ); only patient died in icu ( %), because of post hsct parainfluenza virus pneumonitis requiring ecmo. helmet cpap delivery in pediatric hsct ward is feasible and safe, both for curative and palliative aim. if applied early, cpap could reduce icu admission rate for mv and icu mortality. veno occlusive disease (vod) and graft versus host disease (gvhd) are both dreadful complications of hematopoietic stem cell transplantation (hsct). although they have different clinical signs, it is suggested that they share similar pathophysiological pathway. defibrotide is used in the treatment of vod for a long time but it is very less known about its effect on gvhd. in this study, we analyzed a 'high risk' patient population in pediatric hsct to show the effect of defibrotide on acute gvhd. between june -august totally 'high risk' pediatric allogenic hsct procedures were enrolled in this study. 'high risk' definition involves busulphan/ melphalan usage in conditioning regimen, second myeloablative hsct, pre-existing liver disease, allogenic hsct for leukemia with second relapse and diagnosis of hemophagocytic lymphohistiocytosis (hlh) or osteopetrosis. defibrotide prophylaxis group (n = ) received mg/kg/day per day and continued for at least days after transplantation. the control group (n = ) received only continuous infusion of low-dose heparin until days after transplantation. for the comparison between groups, the fisher's exact test was used. all analyses were performed using spss and p-value of . was considered statistically significant. we analyzed totally hsct procedures with different diagnosis; beta thalassemia major, leukemia, hlh, primary immunodeficiencies, osteopetrosis, fanconi aplastic anemia (faa), myelodysplastic syndrome, neuroblastoma, congenital amegakaryocytic thrombocytopenia, krabbe disease, aplastic anemia, hypereosinophilic syndrome and sickle cell disease. all the procedures meet the 'high risk' definition; most of them (n = ) have busulphan for conditioning, also there are hlh and osteopetrosis patients, neuroblastoma patients had the second myeloablative regimen, faa and aplastic anemia patients had pre-existing liver disease, and of the leukemias had beyond second relapse. the mean age was . years old ( . - . ), hsct performed from match sibling donor (msd) ( %), hsct from match family donor (mfd) ( %), hsct from match unrelated donor (mud) ( %) and hsct from haploidentical mother ( %). we especially focused on gvhd and vod. totally vod cases ( %) in these hsct procedures were detected. only two of them detected in the prophlaxis group ( %) and cases in the control group ( %). there were cmv reactivation cases detected in hsct procedures ( %). in the prophlaxis group there were cases ( %) and in the control group cases ( %). we detected acute grade i-iv gvhd cases in hsct procedures ( %). only of them were in the prophlaxis group ( %) and cases were in control group ( %). the prophlaxis group's agvhd ratio was significantly lower than the control group (p = . ). defibrotide for vod prophylaxis is confirmed by several studies, but its benefits for agvhd is not clear. in this study, we show the significant effect of defibrotide on agvhd. we speculate that the protective effect of defibrotide on both vod and agvhd could be explained by the similar pathophysiology of these complications. we need larger studies on the pathophysiological pathways, then we could invent more effective interventions. disclosure of conflict of interest: none. conventional extracorporeal photopheresis (ecp) has proven efficient for the treatment of graft-versus-host-disease (gvhd) but is limited to patients with sufficient body weight. a mini buffy coat ecp (mini-ecp) 'off line' technique that allows treatment of small children has been developed, using various methods for mononuclear cell (mnc) separation from whole blood. we present treatment of low body weight child with mini-ecp 'off line' technique using sepax system for mononuclear cell (mnc) selection and macogenic irradiator. a toddler with juvenile myelomonocytic leukemia (jmml) developed acute gvhd, after a matched unrelated stem cell transplantation (sct) performed at the age of months. acute gvhd of the skin occurred three months after sct and responded to high dose steroids, but recurred six months after sct (biopsy of the skin confirmed acute gvhd) together with gvhd of the liver. because of the resistance to steroids and cyclosporine, mini-ecp was introduced as therapy. the patient weighed kilograms. blood was collected from tunneled central venous catheter, and collected volume was replaced with saline infusion. the cord blood collection bag (macopharma, france), which contains ml citrate phosphate dextrose (cpd) anticoagulant solution was used for whole blood collection. whole blood was processed using sepax system separator (biosafe, switzerland), and final volume of buffy coat was set on ml. extracted buffy coat was transferred into the uv-a illumination eva bag (macopharma, france) and diluted with saline solution up to ml. methoxypsoralen (gerot, austria) was injected directly into the uv-a illumination bag, and cells were irradiated by the uv-a illumination device macogenic (macopharma, france). irradiated cells and autologous residual blood were reinfused back to the patient. during the whole procedure patient's vital signs were monitored. ecp procedures were performed times per week for weeks, followed by times per week at weeks intervals for months. in month period mini-ecp procedures were performed. median of collected whole blood was ml (range - ). median of total nucleated cell (tnc), and mononuclear cell recovery after sepax separation were . % (range . - ), and . % (range - ), respectively. median of hematocrit in final irradiated product was % (range . - %). patient was reinfused with median of . (range . - . ) tnc × /kg bw, and median of . (range . - . ) lymphocyte × /kg bw. after one month of ecp together with steroids and cyclosporine, gvhd of the skin improved, and the steroids were gradually weaned, with no recurrence. gvhd of the liver showed no improvement, and other therapies had to be introduced, but without steroids. for the first time in croatia, mini-ecp was performed in a child with gvhd, in whom conventional ecp could not be used because of insufficient body weight. mnc separation using automated closed system sepax separator has proven efficient and safe. mini-ecp treatment was continued for three months, without technical difficulties. positive effect was experienced concerning the skin gvhd, but not the liver gvhd. after the first experience in our country, in future we plan to use this technique for low-weight patients or patients with contraindications for apheresis, which are in need of second-or third-line therapy for gvhd. disclosure of conflict of interest: none. gonadal failure represents one of the late effects of haematopoietic cell transplantation (hsct) with a negative impact on quality of life in young patients (pts) undergoing hsct , . the aim of this retrospective multicentre ebmt study was to assess gonadal function in untreated pts undergoing allogeneic hsct between to years (yrs) of age, after a preparative regimen with busulphan (bu) or treosulfan (treo). eighty-seven pts ( females, males) were reported from out of contacted ebmt centers: / ( %) received allogeneic hsct during pre-pubertal and / ( %) in pubertal phase. of the pts, ( . %) received bu in myeloablative dose [ pre-pubertal, (median age of . yrs) and pubertal, (median age of . yrs)] and pts ( . %) received treo ( in pre-pubertal and in pubertal period). underlying diseases were primary immunodeficiency ( . %), chronic myeloid leukemia ( . %), myelodisplastic syndrome ( . %), familial haemophagocytic lymphohistiocytosis ( . %) and shwachman-diamond syndrome ( . %). / of prepubertal pts ( %) developed spontaneous puberty ( . % in the bu group and % in treo group). / ( %) females undergoing hsct during puberty completed their pubertal development ( . % in bu group and % in treo group). none of females ( / ) with bu during pre-pubertal phase developed spontaneous menarche (sm), while . %( / ) of females who received bu in pubertal period had sm. all females (n = ) treated with treo during pubertal phase had sm ( %). for both conditioning regimens, the . % ( / ) s of females treated during the puberty experienced sm. among the remaining females (for pts the information is missing) who did not developed sm, received hrt . yrs after hsct and of them had ovarian recovery after a median of . yrs from hsct ( . - . ). the median age at last follow up was . and . yrs in bu and treo pre-pubertal group, and . and . yrs in bu and treo pubertal group respectively. in the pubertal group, females ( . %) are still receiving hormonal replacement therapy (hrt) ( in the bu group and in treo group). pts ( . %) had spontaneous pregnancy. no problems in newborns are reported. sperm analysis was performed in . % of pubertal pts ( / ) of males, and % (n = / treated with bu) were azoospermic (data regarding pts were missing). the sperm analysis was repeated in half of the males. until now no paternity was reported. in this experience, the pubertal development in pts who received treo (n = ) was normal, and in the bu group the majority of females ( %) had normal puberty. the rate of sm is higher ( %) in females after treo than bu ( %). the hrt is ongoing at last follow-up in % of females treated with bu and in % of those who received treo. our data suggests that treo may have a better outcome than bu in young girls receiving allogeneic hsct and larger studies are warranted. male patients require longer follow-up. prevention in patients transplanted from partially matched donors. we report the single centre experience in haploidentical sct. in years - in the department of pediatric bmt, oncology and hematology at wroclaw medical university, children underwent sct from partially matched, haploidentical parental donors. graft manipulation in patients consisted of cd sel, in patients the cd immunomagnetic depletion (tcd-cd ) was performed, and in -tcr alpha-beta depletion (tcd-ab). we analysed the impact of type of manipulation procedure, conditioning regimen, demographic factors, and kir genotype on survival and probability of neutrophil recovery. the probability of engraftment and neutrophil recovery was % vs % in cd sel group (p = ns). probability of year overall survival in the tcd group was similar to the cd sel group ( % vs %, p = ns). in the tcd patients, neither use of busulfan vs treosulfan, nor kir genotype, nor donor sex had noticeable impact on sct result and survival. patients transplanted after tcd due to non-malignant disease had higher survival probability, than those with malignancies ( % vs %, p = . ). the trm in tcd patients was reduced in comparison to cd sel ( vs %, p = . ). the trm after tcd resulted mostly from severe viral infections in tcd-cd patients. in / tcd patients spontaneous acute, skin (stage ) gvhd was diagnosed and successfully treated. two patients received unmanipulated donor lymphocyte infusions (dli) and developed severe acute steroid-resistant (grade ) gvhd, in one of them with fatal outcome. tcd methods are superior to cd sel due to significant reduction in treatment related mortality. haploidentical sct after tcd can result in durable engraftment, but warrants intensive post-transplant monitoring for infectious complications and cautious approach to dli therapy. disclosure of conflict of interest: none. median of days for neutrophils in both groups, for platelets ( in ptcy, in αβ+cd +/cd +depleted, p . ). donor chimerism was complete in patients ( . %). in αβ +cd +/cd +depleted group, patient rejected ( . %: primary and secondary reject, , , and days after haplo, respectively) and were rescued with a second transplant. seven patients ( %) developed acute (a-) gvhd in ptcy group (grade - in ; grade - in ), compared to one ( . %: grade ) in αβ+cd +depleted group (p . ). among patients at risk, out of in ptcy group developed chronic (c-) gvhd ( . %: score- , overlap, score- ), compared to / patients in αβ+cd +/cd +depleted group (p . ). the cumulative risk of cmv-reactivation was % and % in ptcy and αβ+cd +/cd +depleted groups, respectively (p . ). t-cell reconstitution was significantly different in the two groups,with a median absolute number of cd + +cd -and γδ+cd + higher in αβ+cd +/cd +depleted group on day + (p . ) and a median number of cd +cd + higher in ptcy group on day+ (p . ). length of hospitalization was shorter in the αβ+cd +/cd +depleted group, with a median time from haplo to discharge of days compared to days in the ptcy group (p . ). some children have not donor and an urgent need to proceed to transplantation because of disease status. we reviewed the role of haploidentical transplantation in children and report our single center experience. ten children were transplanted from haploidentical family members donors (median age: . years). we performed alfa beta t cell depleted transplantation in three patients and unmanipulated bone marrow transplantation with posttransplant cyclophosphamide in seven patients. the diagnosis were eight high risk leukemias (three all and five aml) and two severe aplastic anemia. patients were myeloablative conditioned with cyclophosphamide, fludarabine and total body irradiation in aplastic anemia received alfa beta t cell depleted grafts with a median cd cell dose of . × /kg (range: . - . ) and busulphan, cyclophosphamide in high risk leukemias received unmanipulated bone marrow grafts with posttransplant cyclophosphamide in rd and th day of posttransplant with a median cd cell dose of . × /kg (range: . - . ). median follow up of our patients months. six of patients are alive and in disease free follow up. four patients were relapsed and dead median . months of transplantation. the rate of relapse was % for leukemia patients in remission and % for patients with active disease. myeloablative conditioning regimen followed by haploidentical bone marrow transplantation with posttransplant cyclophosphamide may be an option in high risk leukemia patients need urgent transplantation because of desease status who have not donor. table . all patients received hd-cy mg/kg on d+ and d + . cyclosporine a mg/kg/d i.v., then mg/kg/d p.o. adjusting for blood levels - ng/ml and mycophenolate mofetil mg/kg times daily po were started on d+ . mmf was discontinuated on d+ , csa-after d+ . all pts received anti-microbial prophylaxis for bacteria, fungal, herpes infection and pneumocystis according to institutional practices. analysis for donor chimerism and mrd were performed at d+ , + , + , + . pts, donors and stem-cell harvest characteristics are described in table . pts had high risk hematological malignancies, and relapsed after auto-sct neuroblastoma (hr-nb). pt was transplanted in st cr (aml m ) and others in nd cr. pts had full engraftment (neutrophil engraftment at , and days). pt (hr-nb) was concerned as a primary failure for achieving neutrophil and platelet engraftment by d+ , despite of complete donor chimerism in bone marrow. he was transplanted additionally with the same donor at d+ after st transplant. pt died before engraftment at d+ (fulminant ps. aeruginosa-sepsis). pts remain alive in cr ( ndcr-aml and st cr-m aml) with follow-up of and days ( / / ) without cgvhd with complete donor chimerism. pts relapsed after d+ ( were transplanted in nd cr-flt aml and nd cr-nb) and died. pt died because of infectious complication at d+ (transplanted in d cr-all). / pts had grade acute gvhd. hla-haploidentical hsct with post-transplant t-cell in vivo repletion grafts by using hd-cy is feasible and effective in children with hr-haematological malignancies. [p ] who were match unrelated donor. thalassemic reconstitution occurred in three patients. acute graft-versus-host disease (gvhd) of grade ii-iv occurred in % and chronic gvhd in %. acute and chronic gvhd were seen more frequently in patients with class - compared to class . mortality rate was also higher in these groups. seven patients died. one patient died on post-transplant day due to intracranial bleeding. the other patients with chronic gvhd died between and days, on average days post-transplant. these data suggest that allogeneic bmt remains an important treatment option for children with beta-thalassaemia major, particularly when compliance with iron chelation is poor. the society to support children suffering from cancer, also known as mahak, was set up in as a non-governmental and non-profit organization. in the past two decades, the organization has attracted a vast public support and fulfilled a great part of its mission which is to support children with cancer, reduce the child mortality rate and create an appropriate environment that empowers families who have children with cancer. pediatric stem cell transplant also is used to treat many types of conditions affecting children and adolescent, including cancer and certain hematologic, immune reconstitution inflammatory syndrome (iris) is a clinical condition emerging after immune recovery of an immunocompromised status, mostly after the initiation antiretroviral therapy (art) in human immunodeficiency virus (hiv) infected patients, but also in several other settings, such as the recovery from the severe combined immunodeficiency (scid) status after hematopoietic stem cell transplantation (hsct). herein, we report a patient transplanted for scid who developed iris for two times, namely shortly after transplantation and after donor lymphocyte infusion (dli) ( table ) in our patient, t cells passing from the donor probably contributed to the immediate post-transplant increase in the size of granulomas. this inflammatory response waned after the institution of immunosuppressive and methylprednisolone therapy. however, immunosuppressives were stopped due to lowered chimerism at follow-up, and the inflammatory response re-appeared after administering stem cell support containing a large amount of t cell from the donor for dli purpose. although the mechanism by which dli results in clinical responses is unclear, it is presumed to be a t cellmediated process. several studies have been performed to strengthen our understanding of the immunopathogenesis of iris. while some of those studies put forth t cell-associated causes, others implicated cytokines and non-t cells. the reaction that developed in our patient is suggestive of t cellassociated causes. immune reconstitution inflammatory syndrome remains a poorly understood entity. the dli procedure in our case provides a unique clue supporting a t cell mediated process. pediatric transplant teams need to be s aware of the previous iris phenomenon of bcg-adenitis while making the decision of dlis. [p ] disclosure of conflict of interest: none. pediatric patients treated with a hematopoietic stem cell transplantation (hsct) often suffer from late side effects caused by the treatment. the aim of this study is to investigate the late effects of a hsct on dental development. in addition, patients and parents awareness on this topic was investigated. young adults treated and followed at the ghent university hospital who were under the age of y at the time of hsct were examined clinically and radiographically (planmeca promax d). transplants ( autologous/ allogeneic) were done for malignant disease in pts. eight patients received a hsct for a non-malignant disease. twelve patients underwent a conditioning regimen with total body irradiation (tbi), patients with busulfan and patients with other chemotherapeutic agents. patients were o y, patients were - years and patients were years at hsct. every patient was evaluated on dental agenesis, microdontia and rootcrown ratio. patients and their parents were asked about their knowledge and interest for dental screening at the follow-up clinic using a questionnaire. overall, the prevalence of agenesis and microdontia of one or more dental elements is respectively . % and . % in our study population. . % of patients have a strongly aberrant root-crown ratio of at least one element. patients treated o years of age show significantly more microdontia ( . %; po . ) as well as agenesis ( . %; p o . ) compared to patients treated at an older age. the first premolar of the mandible is the most vulnerable element for agenesis as well as for microdontia. more microdontia is found in patients treated with a busulfan conditioning regimen compared to the other conditioning regimens ( . % versus %). patients older than years, treated with busulfan have statististically more microdontia compared to patients y treated with tbi conditioning regimen (p = . ). there was no difference of the conditioning regimens on agenesis nor on root-crown ratio. almost all patients/parents find it important to receive information about the dental late effects of a hsct and are interested in dental screening at the follow-up clinic. treatment with hsct has an explicit negative impact on dental development. the degree of this effect depends on age at hsct and used conditioningregimen. dental follow-up of these patients is essential and should be incorporated in the follow-up program. disclosure of conflict of interest: none. importance of body composition in the outcome of hematopoietic stem cell transplantation in elderly patients l koch , n hamerschlak , r garcia , c prado , c silva and a pereira hospital israelita albert einstein the loss of muscular mass is a well recognized cause of the decline in muscle strength and functionality that accompany the aging process. in , irwin rosenberg proposed the term 'sarcopenia' to describe the decline in muscle mass associated with aging. changes in body composition after hematopoietic stem cell transplantation (hsct) have been the subject of previous studies. immunosuppressive therapy and corticosteroids are known to alter skeletal muscle metabolism. infections and graft-versus-host disease (gvhd) that can occur after hsct may also affect body weight and composition. therefore, both the treatment and complications after hsct exert large negative effects on lean muscle mass, especially in elderly patients. patients with hematologic malignancies are usually well nourished before undergoing hsct. objective: the aim of this study is to determine in an elderly population whether parameters of body composition could be correlated to outcomes after hsct. we performed a retrospective longitudinal study through review of medical records of patients ⩾ years old undergoing hsct at hospital israelita albert s einstein, from to , that were subject to tomography scans (cts) in a period ranging from days before and days after hsct. table . there were no differences between groups with respect to age, gender, diagnosis, stage of disease, and source of stem cells. in ly patients, the quantity of peripheral cd + cell dose (× /kg) infused was different between groups (group ly-ct the incidence of nf was significantly higher in group mm-g ( ( . %) vs ( . %); p = . ). no differences were observed in the incidence and severity of mucositis, first day and duration of fever, documented bacterial infections or readmission rate between mm patients groups. this study suggests that in at home asct, the use of piperacillintazobactam prophylaxis significantly reduces the incidence of neutropenic fever and hospital readmission in patients with ly, and also that no administration of g-csf in mm patients reduces significantly the incidence of neutropenic fever. disclosure of conflict of interest: none. [p ] allogeneic stem cell transplantation (sct) has been recognized as a curative treatment for patients with wiskott-aldrich syndrome (was). in sct for was, myeloaberative conditioning (mac) has been indicated to avoid a mixed chimera. however, risk factors for a mixed chimera in patients with was who have received sct have not been evaluated. here, we analyzed the outcomes of sct and risk factors for a mixed chimera in patients with was who underwent sct in japan since . we reviewed medical records of consecutive was patients who received sct since january who were registered with the japan society for hematopoietic cell transplantation. the age of the patients at transplantation ranged from months to years, and the mean age was . years. the origin of the stem cells was related bone marrow (bm) or peripheral blood stem cells (pbsc), unrelated bm or pbsc, and unrelated cord blood (cb) for , and patients, respectively. a preparative conditioning regimen consisting of mac was provided to patients, and reduced-intensity conditioning was provided to patients. fifty-one patients received prophylaxis against graft-versus-host disease (gvhd) with cyclosporine in combination with methotrexate (mtx) or a steroid, and patients received tacrolimus (tac) with mtx or a steroid. chimerism analysis had been performed in patients. neutrophil engraftment was achieved in patients ( . %). the engraftment rate was significantly higher in patients who received tac for gvhd prophylaxis, (p = . ) overall survival rate was significantly higher in patients with complete chimerism than in patients with mixed chimerism ( . ± . % and . ± . %, respectively, p = . ), though there was no significant difference in stem cell sources. using multivariate analysis, the rate of complete chimerism in patients who received mac including cyclophosphamide (cy) at more than mg/kg was significantly higher (p = . ) than the other conditioning. not only patients with mixed chimerism but also patients with complete chimerism were complicated with auto-immune diseases. in this study, achievement of complete chimerism after sct was important for survival in patients with was. we found that patients who underwent mac including cy at more than mg/kg had a higher rate of complete chimerism. we also found a higher neutrophil engraftment rate in patients who received tac for gvhd prophylaxis. thus, mac including cy at more than mg/kg and tac for gvhd prophylaxis are optimal conditions of sct for patients with was. disclosure of conflict of interest: none. adenosine deaminase (ada) deficiency is an inherited autosomal recessive immunodeficiency which represents about - % of scid. since we diagnosed patients affected by ada-scid: underwent hematopoietic stem cell transplantation (hsct), were treated with replacement therapy with peg-ada and received gene therapy; patients died before or after treatment. maternal t lymphocyte engraftment is frequently detected in scid patients, but this is never been found in ada deficient patients. a -months-old italian girl, from non-consanguineous parents, presented to our hospital with a history of frequent bronchiolitis associated with dermatitis, mycosis, hypogammaglobulinaemia, marked lymphopenia (t cells cd , /mmc; cd /cd , /mmc; cd / cd , /mmc, b cells . /mmc, and nk cells, /mmc) and in vitro absence of proliferative response to pha. level of immunoglobulins was almost normal (igg mg/dl, iga mg/dl, igm mg/dl). high levels of toxic metabolites were found: axp, . micromol/ml rbc; daxp, . micromol/ml rbc; %daxp, . . ada activity in rbc lysates was abnormally high for scid-ada ( . u/g hb). molecular analysis confirmed diagnosis: the sequencing of exon revealed two mutations: a missense mutation previously reported called p.ser leu (c. c t) and a new missense mutation defined p. leu pro (c. t c). t-cells str analysis of patient showed . % maternal t lymphocytes engraftment never reported before in ada-scid patients. the girl was transferred to the isolated bmt unit and the respiratory symptoms progressively improvement. replacement therapy with peg-ada was started immediately at a dose of u/kg/twice per week. ig therapy was started at a dose of mg/kg every two weeks. after three months of treatment patient showed an increase in t cells count (cd , /mmc), and a decrease of toxic metabolites: axp, . micromol/ml rbc; daxp, . micromol/ml rbc; %daxp, . maternal t-cell engraftment persists, despite a good response to the peg-ada therapy. the last examination before hsct reveals maternal t-cell engraftment of . %. patient underwent hsct from mud hlaidentical donor after a myelo-ablative reduced intensity conditioning regimen protocol d ebmt/esid guidelines. the number of infused cd + cells was . × /kg and . × cd /kg. she is actually at day+ post hsct, is doing well and shows % engraftment of donor cells. disclosure of conflict of interest: none. graft versus host disease (gvhd) is a frequent complication in patients undergoing haematopoietic stem cell transplantation. while the exact pathophysiology of gvhd is not known, the gut microbiome has been implicated in its development since it was shown that total gut decontamination (tgd) decreases the incidence of gvhd. with this study we aim to get insight into the diversity of the gut microbiota before, during and after total gut decontamination in comparison with selective gut decontamination (sgd). secondly, we want to identify changes in microbiota composition that relate to the occurrence of graft-versus-host disease. for this prospective cohort study we recruited children (o y) that were eligible for a stem cell transplantation at the leiden university medical center between january and december . of these, % (n = ) received tgd (consisting of piperacillin/ tazobactam and oral amphotericin b), whereas the other % (n = ) received selective gut decontamination with polymyxin /neomycin and oral amphotericin b. in total, fecal samples were collected, weekly during admission for the stem cell transplantation and monthly thereafter up to months after transplantation. also samples were collected from family stem cell donors as healthy controls. samples were processed within hours and stored in the - freezer, after which s v amplicon sequencing (illumina hiseq, rapid mode, bp read length) was applied. data analysis (taxonomy and shannon diversity) was primarily done using qiime (ref). compared to microbiota diversity in stem cell donors (mean shannon index (si) . ), we observed an overall lower mean si during tgd ( . ) and slightly higher mean si during sgd ( . ). microbiota diversity months after sgd ( . ) was similar to diversity during sgd ( . ), while diversity months after tgd ( . ) was higher than during tgd ( . ). further analysis of repopulation dynamics demonstrated no differences in repopulation duration after both decontamination strategies. however, we did observe differences in the type of bacteria that repopulated, with bacteroidales being more prominent in sgd and lactobacillales more prominent in tgd patients. actinomycetales (genus rothia) was exclusively present in tgd patients during decontamination. also, the clostridiales (blautia, lachnospiraceae and peptostreptococcaceae) were bacteria that appeared after the decontamination period. four patients ( %) in this cohort developed gvhd grade or more. in these patients we did observe individual compositional changes of the gut microbiota at the time of ghvd diagnosis, e.g very low diversity or dominance of enterobacteriales. considerable microbiota diversity is observed in patients that received tgd. different repopulation dynamics were observed between tgd and sgd. no common pattern was found in the gvhd cases. disclosure of conflict of interest: none. minimal residual disease (mrd) pre-and post-hct for children with aml is highly predictive of event-free survival: a pediatric blood and marrow transplant consortium study d jacobsohn johns hopkins all children's hospital, children's hospital los angeles, usc keck school of medicine multicenter data regarding the significance of mrd in children with aml pre-and early post-hct are lacking. we hypothesized that pre-and post-hct mrd assessments using wt pcr combined with multi-dimensional flow cytometry (mdf) would be predictive of disease relapse and event-free survival (efs) at -yrs post-hct. subjects were o yrs with aml in morphologic cr undergoing ma allogeneic hct. stem cell sources included bm, pbsc, or cb. bm and pb samples were collected at time points: baseline ( o weeks prior to preparative regimen); day+ (± days); and day+ (± days). bm samples were analyzed for both wt expression and mdf mrd (single reference lab using a 'difference from normal' approach without access to diagnostic phenotype); pb samples were analyzed for wt only. mdf detection limit was . %; however, we required that independent analysts certify that the abnormal population was aml. in addition, sorted mrd+ cells were tested for chimerism. wt positivity was defined as ⩾ copies for bm and ⩾ copies for pb. results were not available to the treating clinician. subjects were enrolled at centers in us and canada. enrolled subjects did not undergo hct and were excluded for progression prior to hct or other ineligibility. in eligible subjects, -yr efs and os were % and %, respectively. the -yr ci of relapse and trm were % and %, respectively. mdf identified subjects pre-hct having . - % residual disease. the -yr relapse rate in subjects with +mrd by mdf pre-hct was % vs % ( - %) in those who were negative. -yr dfs and os were % and % ( - %) for positive mdf pre-hct, and % ( - %) and % ( - %) for negative mdf. pre-hct mdf sensitivity for -yr dfs was %; specificity was %. mdf mrd at days and were similarly predictive of outcome. sorted mrd+ cells from post-hct samples were all noted to be of recipient origin. pb wt had no correlation with dfs or relapse; bm wt at day+ correlated with -yr os ( % ( - %) low/neg vs % ( - %) high). other wt cutoffs studied demonstrated no correlation with outcomes. figure : relapse probability by flow cytometry mrd at time points. mdf mrd pre-hct and at days + and + was significantly associated with lower efs and os in children with aml undergoing hct. mdf is specific but not sensitive, as many negative mdf patients relapsed. our goal was to define a reproducible assay that did not depend on having the initial aml profile. this would facilitate multi-institutional studies aimed at decreasing relapse. given that constraint, we were able to detect clear mdf mrd in a small percentage of patients that was highly predictive and can be used in trials. wt level was not predictive in this multi-institutional trial. the sensitivity of flow was significantly affected by not having the initial flow available. future attempts to improve sensitivity should include initial flow and/or test higher channel flow or molecular pcr techniques. in addition, we confirmed that mrd + cells obtained by cell sorting post-hct were of recipient origin. future testing of 'suspicious' sorted cells by fish, molecular, or comparative genomic hybridization could possibly increase mfd sensitivity. novel cellular or targeted therapies should be tested in clinical trials to improve outcomes in patients with mfd mrd noted either pre-or post-hct. [p ] disclosure of conflict of interest: none. novel mutations were identified with ngs and low intensity of conditional regimen succeeded in children with fanconi anemia who received allo-hsct s hu , h hou, j lu, p xiao, x bian, h liu, y hu, j ling, l li, l kong, z zhai and y yao children's hospital of soochow university to explore the possiblity of applying next-generation sequencing (ngs) to diagnose the disease of fanconi anemia (fa) and evaluate the efficiency and safety of low intensity conditional regimen on children with fa receiving allogenic hematopoietic stem cells transplantation (allo-hsct). five patients initially suspected as severe aplastic anemia were diagnosed as fa by the method of next-generation sequencing (ngs)-based genetic diagnosis panel. one patient received hla-identical sibling donor hematopoietic stem cell transplantation (mrd), three patients underwent unrelated donor matched (ud) hsct, and one patient received unrelated cord blood transplantation (ucb). the conditional regimen consisted of either cgy tbi or . - . mg/kg of busulfan with - mg/kg of cyclophosphamide. meanwhile, atg at mg/kg and fludarabin at - mg/m were included as well. cyclosporin or tacrolimus as well as mycophenolate mofetil (mmf) were used for the prophylaxis of graft versus host disease (gvhd). engraftment of neutrophil and platelet and complications followed transplantation such as infection, gvhd, and hemorrhagic cystitis (hc) were observed. of cases diagnosed as fa by ngs, only case showed the abnormality of chromosome fragility test which has been regarded as golden criteria in the diagnosis of fa. meanwhile, we found novel mutations in cases of fa which enriched chinese national database with data of rare diseases by ngs. the counts of mononuclear cells (mnc) were ( . - . ) × /kg for non-ucb and . × /kg for ucb. the counts of cd + were ( . - . ) × /kg for non-ucb and . × /kg for ucb. all cases succeeded in allo-hsct with the low intensity of conditional regimen. the median time for neutrophils engraftment was days (range ~ days), median time to platelets (plt) engraftment was days (range ~ days). one case occurred with grade i of agvhd, cases with hemorrhagic cystitis. after transplantation, all patients were monitored the copies of ebv-dna and cmv-dna of whole blood, and five case with ebv positive and cases with cmv positive. no patient suffered of ebv or cmv disease. the hepatic veno-occlusive disease (vod) and hc were observed in fa patients after transplantation. ngs showed much more specific and facilitated for the diagnosis of fa. low intensity of conditional regimen is efficient and safe which should be recommended for the treatment of fa patients. disclosure of conflict of interest: none. outcome of alternate donor stem cell transplantation in children: an indian experience sp yadav , , n rastogi , , d thakkar , , s kohli , , s nivargi , , r misra and s katewa in india due to lack of donor registries and cord blood banks very few alternate donor stem cell transplants (sct) are performed. haploidentical sct has become feasible with availability of post-transplant cyclophosphamide (ptcy) technique. here we present our experience of setting up alternate donor program for sct for children in india and report the outcomes of the same. we collected data retrospectively of all children who underwent alternate donor sct during jan to dec in two centres. a total of sct were performed for children; median age years ( - years) and were boys and girls. of these, underwent haploidentical ( ptcy and tcr alpha-beta/cd depleted), matched unrelated donors (mud) and unrelated cord blood (ucb) sct. the diagnosis was: primary immunodeficiency- , thalassemia major- , sickle cell disease- , inherited bone marrow failure- , acquired aplastic anemia- , acute lymphoblastic leukemia- , acute myeloid leukemia- , neuroblastoma- , ewings sarcoma- & leukodystrophy- . the conditioning was with fludarabine, cyclophosphamide and total body irradiation backbone in children (thiotepa added in ), fludarabine and treosulfan in , fludarabine and busulfan in , busulfan and cyclophosphamide in . serotherapy was part of conditioning, rabbit anti-thymoglobulin . mg/kg in and campath mg/kg in . graft vs host disease (gvhd) prophylaxis was ptcy along with tacrolimus and mycophenolate mofetil in patients ( haploidentical, mud & ucb) and ex-vivo tcr alpha-beta depletion in and cyclosporine and methotrexate in . all were transplanted after a signed informed consent. a median of million of cd cells/kg was infused (range - million/kg).graft source was peripheral blood in and bone marrow in and ucb in . five children died before engraftment. the remaining had neutrophil engraftment by median of days (range - ) and platelet engraftment by median of days (range - ). chimerism at day+ was available in cases; of them had full donor hematopoiesis. one had mixed chimerism and fully recipient. four children underwent a second haploidentical sct after rejection of which are alive and disease free. the median follow-up of remaining patients is months (range - ); the cumulative incidence of graft versus host disease (gvhd) acute and chronic extensive was % and % respectively. grade-iii-iv acute gvhd was seen in patients. a total of patients have died (sepsis- , stroke- , gvhd- , vod- , encephalitis- and progressive disease- ). among encephalitis deaths, one child had undergone ucb with ptcy and another tcr alpha-beta depleted second sct.; both had bk virus in the csf.there were / deaths in haploidentical (ptcy- / & tcr alpha-beta- / ), / in mud and / in ucb sct. overall survival is % and disease free survival is % at last follow up. alternate donor sct is an acceptable curative option for children lacking a matched sibling donor. haploidentical donor sct is more feasible in the setting of lack of donor registries having indian ethnicity donor. disclosure of conflict of interest: none. hematopoietic stem cell transplantation (hsct) from an unrelated donor (ud) is largely used for pediatric patients with all in second complete remission (cr) lacking an hlaidentical sibling. in this study, we retrospectively analyzed outcome of patients (pts) given ud-hsct in centers affiliated to the associazione italiana di ematologia ed oncologia pediatrica (aieop) network between and . three hundred fifty-six pts with all in second cr experiencing either bone marrow (bm), isolated extramedullary or combined relapse were included in the study; were males and females, median age at hsct being . years (range . - ). bm, peripheral blood (pb) and cord blood (cb) were the stem cell source in %, % and % pts, respectively. all children received a myeloablative conditioning regimen, either tbi-( pts) or chemotherapy-based ( pts). as gvhd prophylaxis, the combination of cyclosporine a, short-term mtx and atg was employed in most pts. according to the berlin-frankfurt-munster (bfm) classification of first leukemia recurrence, % and % of pts were assigned to the s +s and s +s groups, respectively. level of pre-hsct minimal residual disease (mrd), measured within days before hsct through flow cytometry (fcm) in the laboratory of padova, is available in children; more data will be presented during the s meeting. with a medium follow-up of . years (range . - ), the overall survival (os) was %, while the event-free survival (efs) was %. the cumulative incidence of transplant-related mortality (trm) and leukemia recurrence were % and %, respectively. the efs probability for children transplanted in the time period [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and - was %, % and %, respectively (p = ns). patients who received a tbi-based conditioning regimen had a significantly better outcome in comparison to children who received chemotherapy-based treatment, efs being % and %, respectively (p = . ). efs of pts belonging to s +s and s +s groups was % and % respectively (p = . ). the difference in efs is largely explained by an increased incidence of leukemia recurrence in s +s ( %) compared to s +s pts ( %) (p = . ). efs of pts who experienced grade ii acute gvhd was %, while that of pts with either absent/grade i acute gvhd or grade iii-iv acute gvhd was % and %, respectively (p = . ). pts with limited chronic gvhd had a better efs as compared to those with either extensive or absent chronic gvhd ( %, % and %, respectively; p = . ). the choice of stem cell source (bm, pbsc, cb) did not influence the probability of efs, which was %, %, % respectively (p = ns). importantly, among pts with evaluable mrd before hsct (n ), the group with detectable levels . % (n ), respectively % and % (p = . ). conclusions. outcome of children with nd cr all who underwent transplant from an ud is significantly influenced by the presence of tbi in the conditioning regimen, limited severity of acute and chronic gvhd and bfm classification at time of st relapse. notably, mrd level before transplant, namely with a cut-off of . %, influences efs. disclosure of conflict of interest: none. the median mononuclear cell dose was . × /kg. the median time to reach absolute neutrophil count . × /l was days, and the median time to platelet count × was days. grade and grade mucositis was seen in % of our patients. transplant-related mortality at days not occurred. only three patients relapsed , and months after transplant (mean . m.). with a median follow-up of months ( - months) after transplant the event free survival were %. only one patient had death, two years after transplantation. no significant different between cbv group vs ceam group in engraftment day. high-dose therapy with stem cell rescue can lead to durable remissions in children and adolescents with advanced hd. future investigations should focus on strategies designed to decrease relapse after auto-transplantation, particularly in patients at high risk for relapse. our analysis suggests that these regimens (ceam, cbv) are feasible in pediatric patients with acceptable engraftment and toxicity. pbsc collection may be difficult in small children owing to the large volume apheresis compared to the child's weight. various problems, such as metabolic or haemodynamic disorders may be were seen. peripheral stem cell harvest can be performed in lowweight children under safe and effective conditions even when systematic priming by blood is avoided. processing with increase of blood volume may to increase in the yield by recruiting progenitor cells. disclosure of conflict of interest: none. outcomes of children with hemophagocytic lymphohistiocytosis given allogeneic hematopoietic stem cell transplantation in italy allogeneic hematopoietic stem cell transplantation (hsct) is the only curative treatment for patients with familial hemophagocytic lymphohistiocytiosis (hlh) or relapsed/ refractory hlh. we analyzed outcomes of a cohort of patients ( m, f) with hlh given hsct between and . median age at hsct was years (range . - ). genetic testing was performed for / patients ( %). mutation of prf was found in patients ( %), of unc d in ( %), of stxbp in ( %), of rab a in ( %), of sh d a in ( %), of birc in ( %) and of lyst in patient ( %). no known gene abnormality was found in patients who had recurrent/ refractory hlh. central nervous system (cns) involvement at diagnosis was recorded for patients ( %) and was present in of them ( %). the primary endpoint was event-free survival (efs), defined as the probability of being alive and in continuous complete remission (cr) at last follow-up. in order to determine efs, death from any cause, relapse or graft failure were considered events. ninety-five patients received one transplant, while received more than one hsct, because of rejection in patients or disease relapse in (preceded by rejection in case): hsct were performed in cases, while and hsct were performed in case each. donor for first transplant was an hla-matched sibling for patients ( %), an unrelated donor for patients ( %) and a partially matched family donor for patients ( %). conditioning regimen was busulfan-based for patients ( %), treosulfan-based for patients ( %) and fludarabine-based for patients ( %). the -year probability of overall and efs were % and % respectively (fig. ) . twenty-six ( %) patients died due to transplant-related causes, while ( %) and ( %) patients experienced graft rejection and/or relapse, respectively (see also fig. ). twelve out of children ( %) given a nd hsct after graft failure/relapse are alive and disease-free. active disease at hsct was not statistically associated with adverse outcomes, while patients had a trend for a worse outcome if the interval between diagnosis and hsct was months. patients transplanted from partiallymatched family donors (pmfd) had a significantly worse efs ( %) than recipients of a matched family donor transplant ( %) or a matched unrelated donor allograft ( %, po . ). the main reason for the dismal efs of pmfd recipients was graft rejection, which, however, was largely rescued by a nd hsct. patients given peripheral blood stem cell transplantation had a lower efs probability ( %) as compared to bone marrow ( %) or cord blood recipients ( %, p = . ). children given hsct o o/u months from diagnosis had a better efs as compared to those transplanted months from diagnosis ( % vs %, p = . ). in multivariate analysis, only the use of a pmfd predicted a worse efs probability (relative risk: . , p = . ). these data suggest that in patients with hlh allogeneic hsct is able to cure / of patients. haploidentical hsct in patients with hlh is currently associated with unsatisfactory rate of engraftment, new approaches being needed to ameliorate this outcome. active disease does not preclude the chance of benefiting from transplantation, which should be ideally performed within months from diagnosis. [p ] defibrotide shows efficacy in the prevention of sinusoidal obstruction syndrome (sos) after allogeneic hematopoietic stem cell transplantation: a retrospective study on patients. disclosure of conflict of interest: none. standard gvhd prophylaxis regimens impair the graft-versustumor (gvt) effect, delay immune reconstitution and are associated with high rate of infections. high-dose posttransplantation cyclophosphamide (ptcy) targets alloreactive donor t cells proliferating early after bmt, promotes regulatory t cell and permits rapid immune reconstitution. in this pilot trial we evaluate the safety and effects of ptcy in unmanipulated haploidentical and matched unrelated transplantation (mud) in pediatric patients with all. fifteen pediatric patients with high risk all underwent unmanipulated allogeneic bone marrow (bm) (n = ) or peripheral blood stem cell (pbsc) (n = ) transplantation followed by ptcy between april and march with a median follow-up of months ( - ). eight patients were transplanted from haploidentical donors and from mud. the median age was . years (range . - ) and were in complete remission (cr) at the moment of bmt. in patients this was a second bmt. all pts. received myeloablative conditioning regimen (treosulfan-based n = , tbi based n = ) and ptcy on day + , + , posttransplant prophylaxis consisted of tacrolimus from day + (n = ), tacrolimus/mmf (n = ), atg (rabbit, thymoglobuline) at mg/kg without other posttransplant prophylaxis(n = , both from mud). primary engraftment was achieved in % of pts., the median time to neutrophil recovery was days and to platelet recovery was ( - ) days. all pts. had full donor chimerism on day + . causes of death included viral infections (n = ); gvhd and viral infection (n = ). cumulative incidence (ci) of acute gvhd grade ⩾ ii was % ( % ci: - ), grade iii-iv- . % ( % ci: . - ) and chronic gvhd- . % ( % ci: . - . ). two-year event-free survival (efs) and overall survival (os) were . % ( % ci: . - ) and were equal. median time of follow-up for survivors is years (range . - . ). we demonstrate that unmanipulated hsct and posttransplantation cyclophosphamide allows for high rate of engraftment with acceptable transplant-related mortality in pediatric patients with all. all major outcomes were equivalent between transplantation from unrelated and haploidentical donor. gvhd prophylaxis including ptcy was effective. event-free survival was high despite chemotherapybased conditioning in most patients. disclosure of conflict of interest: none. serotherapy with atg is frequently used in allogeneic hsct to prevent gvhd and rejection. however, the choice of the two most frequently used rabbit atg brands depends on country, disease protocol, national recommendations and/or physician's preference. atg-genzyme (atg-g, thymoglobulin) is prepared by immunizing rabbits with human thymocytes, whereas rabbits are immunized with a jurkat cell line for production of atg-fresenius (atg-f, recently named as antihuman t-lymphocyte immunoglobulin atlg, grafalon, noveii biotech). the recommended dose of both brands differs a factor - . we have previously reported the pharmacokinetics/ pharmacodynamics (pkpd) of atg-g in a large cohort of pediatric hsct recipients and concluded that the clearance of the active component of atg, which is the portion of atg binding to lymphocytes, had a major impact on immune recovery post-hsct, while total atg did not. both atg brands have frequently been compared according to disease outcome, without detailed analysis of composition and clearance of the active components. in the present study, we compared clearance of the active component and immune recovery after atg-g and atg-f, respectively. the serum concentrations of total and active atg were measured longitudinally after hsct in children ( atg-g, atg-f), transplanted with bm or pbsc of unrelated donors for all or aml between january and june in leiden (n = ) or copenhagen (n = ). atg-g treated patients received a total dose of - mg/kg and atg-f was given at a total dose of - mg/kg in both cohorts administration was divided over - days. serum samples (pre-conditioning, day of hsct, + ; + ; + ; + and + weeks and + and + months after hsct) were analyzed by elisa for total atg and by quantitative flow cytometry on hut cells for active (lymphocyte binding) atg. lymphocyte (sub-)populations were analyzed at + , + and + months post-hsct by flow cytometry. as reference group for immune recovery, children transplanted for all or aml with an hla-identical donor and not receiving serotherapy were included. the median serum concentration of total atg at the day of hsct was times higher for atg-f (atg-g μg/ml, atg-f μg/ ml; figure a) as the result of the higher dose of atg-f given. the active atg concentration was twice as high for atg-f (atg-g . au/ml, atg-f . au/ml figure b ). three weeks later at the expected time of engraftment, the total atg concentration was decreased with the same factor for both atg brands (atg-g from to μg/ml, factor . ; atg-f from to μg/ml, factor . ). however, the active atg concentration showed a much faster decline for atg-f (atg-g from . to . iu/ml, factor . ; atg-f from . to . iu/ml, factor ). correspondingly, the number of cd t-cells at month post-hsct was higher after atg-f than after atg-g (atg-g, atg-f and no-serotherapy , and cells/μl, respectively. figure c) . this is the first study to compare the pkpd of total and active atg-genzyme and atg-fresenius. active atg-f showed a much faster clearance than atg-g, which was associated with a significantly faster cd t-cell recovery at month post hsct. thus, atg-f is not only quantitatively but also qualitatively very different from atg-g, which will clearly impact hsct outcomes. reduced toxicity myeloablative conditioning regimen in pediatric hematologic malignancies not associated with improved outcomes s chaudhury , , i helenowski , r duerst , , wt tse , , m kletzel , , j schneiderman , and d jacobsohn ann and robert h. lurie children's hospital of chicago; northwestern university feinberg school of medicine, chicago and children's national health system, washington dc allogeneic (allo) hematopoietic cell transplantation (hct) is the only curative potential therapy in refractory and relapsed pediatric leukemias. poor outcomes in allo hct are associated with treatment-related mortality (trm), mostly due to regimen-related toxicities (rrt) and graft-versus-host disease (gvhd) after myeloablative conditionings (mac), but high relapse rate with reduced-intensity or nonmyeloablative regimens. to improve trm, without compromising conditioning intensity, we prospectively explored the feasibility and efficacy of a mac but reduced-toxicity conditioning (rtc) regimen, consisting of fludarabine mg/m /d (given first) × d, daily busulfan dosed to target an auc of microm*min/d × , ratg . mg/kg/d × and cgy of total body irradiation in patients (table ) with hematologic malignancies. gvhd prophylaxis was cyclosporine and mmf. all patients tolerated the rtc well, with no graft failures. rrt included moderate mucositis ( %), infections (bacterial %, viral reactivation %, fungal %) and cases of venoocclusive disease (vod). cumulative incidence d ⩾ gr acute gvhd was % ( % confidence interval [ci], - ), extensive chronic gvhd was . % ( % ci, . - ). mortality at days was . % ( % ci - ), due to infections with agvhd and vod. with a median follow-up of . y (range, . - ), the cumulative incidences of relapse at years was % ( % ci, - ). mortality due to severe agvhd was %. overall survival (os) and progression-free survivals (pfs) for year was % ( % ci, - ), and % ( % ci, - ) respectively. on univariate analysis there was no association of outcomes with donor type, graft source, disease or busulfan exposure except significantly higher cgvhd in unrelated donors, agvhd severity with peripheral blood. in summary, the use of the myeloablative rtc resulted in comparable trm, with high relapse rate was high, including in those developing chronic gvhd. this suggested a less robust graft-versusleukemia effect resulting in poor pfs and os. nonetheless, this regimen may be used as a lower-trm platform to combine with other strategies, intensive disease monitoring pre and post hct, addition of post hct maintenance therapy in combination with marrow as the stem cell source to decrease relapse or gvhd. specific immune response to vaccinations decline after hematopoetic stem cell transplantion (hsct). re-vaccination of all hsct recipients is recommended in all guidelines but bcg vaccination is not recommended due to safety concerns after hsct. mycobacterium tuberculosis can cause severe disease in children including meningitis and milliary tuberculosis (tb). the bacille-carmette-guerin (bcg) is a liveattenuated vaccine with documented efficacy against milliary disease and meningitis. routine vaccination of all infants residing in countries with high tb incidence is recommended by world health organization. however, there is no data in literature regarding its safety in post hsct setting. here, we report children who underwent matched related allogeneic hsct at ankara university pediatric bone marrow transplant (bmt) unit and received bcg -months post-transplant. all patients were free of graft versus host disease (gvhd) and immunosuppressive therapy (ist) and had negative ppd skin test prior to vaccination. none of the recipients developed local or disseminated tuberculosis as a complication of bcg with a median follow up of years. we conclude that the bcg vaccine is safe in the post hsct period when administered at least months out of transplant to a selected group of patients who are free of gvhd and ist. disclosure of conflict of interest: none. single centre experience of harvesting bone marrow from donors o years of age r raj, r uppuluri , d subburaj , d jayaraman , k mullanfiroze , v swaminathan and l vaidhyanathan department of paediatric blood and marrow transplantation, apollo speciality hospital harvesting bone marrow for allogeneic marrow transplantation from donors o kg presents special challenges. we present data on sibling donors from our institution between and . the mean age was months with a range between months to months. children less than one year accounted for % of our donors with the youngest being months of age and the smallest donor weighed . kg. all aspirations were performed from iliac crests and all donors were given general anaesthesia by a paediatric anaesthetist. irradiated blood was transfused in % of the donors during the procedure. the volume of marrow obtained ranged from to a maximum of ml/kg donor weight. the product contained an average cd count of . × /kg recipient weight with a range from . to × /kg. only on one occasion was a second harvest needed, where the donor weighed kg and recipient kg with major blood group incompatibility requiring red cell reduction. the yield of cd cells per ml of bone marrow was on average % higher than children above years of age. all recipients showed brisk engraftment in weeks. none of these donors experienced major difficulties following the aspiration procedure. thus, very young children may safely donate marrow for allogeneic transplantation and the yield of stem cells obtained is substantial. this data is particularly relevant in transplantation for haemoglobinopathies like thalassaemia major and sickle cell anaemia, where families are being counselled about a target of kg for the donor in order to plan transplantation. disclosure of conflict of interest: none. sinusoidal obstruction syndrome-veno-occlusive disease in pediatric patients given either autologous or allogeneic hematopoietic stem cell transplantation (hsct). a retrospective study of the aieop-sct (italian haematology-oncology association-stem cell transplantation) group m faraci , r luksch, e calore , f saglio , a prete , mc menconi , v trevisan , g de simone , v tintori , s cesaro , s santarone , mg orofino , e lanino , m zecca and a bertaina sinusoidal obstruction syndrome (sos), known as venoocclusive disease (vod), is a potentially life threatening complication that can develop after hsct. although sos progressively resolves within few weeks in most patients, the severe forms result associated with multi-organ dysfunction and high mortality rate ( %). aim of this survey is to evaluate incidence and management of sos in a large cohort of children receiving either allogeneic or autologous hsct. we retrospectively reviewed pediatric hscts performed in ( %) out of aieop affiliated centers, between january and april . new ebmt criteria have been used for the diagnosis of sos (serum total bilirubin ⩾ mg/dl and of the following criteria: painful hepatomegaly, weight gain %, and ascites) and for the classification of severity grading. , among a total number of hsct procedures ( autologous and allogeneic), we identified ( . %) patients with sos. this complication occurred in and cases after autologous and allogeneic hsct, respectively. fiftytwo pts ( %) received iv busulphan (bu) at myeloablative dose, ( %) oral bu, while ( %) were treated with different conditioning regimen. the median time of sos occurrence was days after hsct. details about prophylaxis and therapy are reported in figure . out of the children, ( %) fulfilled all sos-ebmt criteria. bilirubin ⩾ mg/dl, gain of weight %, ascites, and painful hepatomegaly did not occurred in , , and patients, respectively. thrombocytopenia was present in pts ( %), thickening of gallbladder in ( %) and abnormalities of coagulation parameters in ( %). according to sos ebmt severity grading, levels of transaminases were mild in pts ( %), moderate in ( %), severe in ( . %), and very severe in ( . %). notably, creatinine was mild in pts ( %), while ( . %), ( . %), and ( %) children showed moderate, severe and very severe grade of renal failure. thirty-three pts ( %) had respiratory failure, and ( %) of them experienced right pleural effusion. six out of the patients who developed acute kidney injury, required dialysis. severe encephalopathy occurred in pts ( . %) and ( %) out of the pts evaluated, were admitted in intensive care unit. as therapy of sos, pts received defibrotideâ (df); the dosage was mg/ kg/day in % of them. the median duration of df treatment was . days (range - ). thirty-three ( %) pts received methylprednisolone (median dose of mg/kg). fifteen pts ( . %) died due to mof ( in moderate, in severe, and in very severe group) at a median time of days from sos diagnosis (range - gg). our multicenter survey showed that, at least in our experience, there is a significant variability in the management approaches to sos/vod in children, while, diagnostic evaluations are more homogeneous. interestingly, in our cohort, the increase of bilirubin may be an absent criteria, while thrombocytopenia and abnormalities of coagulation parameters are more frequent. as expected, mof occurred mostly in patients experiencing severe sos. df represents first strategy to treat sos in the majority of patients, even if steroids and ursodeoxycholic acid are still used. the hyper-ige syndromes are characterized by marked elevations in plasma ige levels and eosinophilia with impairment in t cells which clinically results in combined immune deficiency. dock deficiency, the autosomal recessive form, brings about allergic/atopic manifestations and unusual susceptibility to infections with herpesvirus family members (herpes simplex virus, human papilloma virus) and molluscum contagiosum. symptoms in patients with dock deficiency typically emerge during childhood, and the majority results in death because of infections and malignancy by the third decade. hematopoietic stem cell transplantation (hsct) is now considered a standard of care for dock deficiency when an appropriate donor is available. in this study, we present the unrelated hsct results of children with dock mutation. the demographic and clinical data of the patients with transplantations studied are shown in table . hsct was administered between august and august at bahçeşehir university medical park antalya hospital and the clinical data of the hscts are presented in table . all patients were transplanted from unrelated donors with bone marrow, except one with cord blood. the cord blood transplantation´s regimen was non-myeloablative which resulted with rejection. despite existence of serious morbid problems before transplantation, all the patients engrafted successfully. majority of the complications mentioned in the table were improved and they are in the follow-up in an outpatient basis. discussion dock deficiency has high mortality, and hsct should be considered as early as possible before development of significant organ damage. despite myeloablative conditioning and high morbidity before the transplantation, survival was very good in our patients. myeloablative and nonmyeloablative transplants have been performed from related and unrelated donors and have reported successful results even without the preparative regimen. in our center, all transplants performed from unrelated donors by myeloablative regimen have been successful but have resulted in transplant rejection with cord blood transplantation after nonmyeloablative regimen. in all of our patients, stable full chimerism has been detected, however mixed chimerism have also been shown to be useful in several reports. whether hsct also cures the autoimmune complications and reduces the risk of cancers is as yet undetermined. however, a myeloablative conditioning regimen followed by allogeneic hematopoietic stem cell transplantation from unrelated donors in dock deficiency results in improvement of the clinical phenotype with a low incidence of regimen-related toxicity. disclosure of conflict of interest: none. successful bone marrow transplantation after myeloablative conditioning in a child with ipex syndrome b kuşkonmaz , d ayvaz , mh abur , fv okur , g karagüzel , f orhan , İ tezcan and du Çetinkaya immune dysregulation, polyendocrinopathy, enteropathy, x-linked (ipex) syndrome is a rare disorder. although most patients present in infancy with a clinical triad of intractable diarrhea, insulin-dependent diabetes, and eczematous dermatitis, some patients present with severe food allergies and other autoimmune manifestations. the disease is caused by mutations in the forkhead box p (foxp ) gene, a transcription factor that is essential for the development and function of regulatory t (treg) cells. this cells plays an essential role in controlling immune responses and preventing autoimmunity. patients usually die in the first years of life without treatment. the only effective cure is hematopoietic stem cell transplantation (hsct). here we report a patient with ipex syndrome who underwent hsct after myeloablative conditioning. months of age boy with the history of diarrhea, insulin-dependent diabetes, eczematous dermatitis, pneumonia, coombs positive hemolytic anemia, referred to our hospital for investigation of immunodeficiency. on admission physical examination showed eczematous skin rash, submandibular lymphadenopathy, hepatosplenomegaly. before hsct the patients treated with immunosuppressive agents including methylprednisolone, mycophenolate mofetil and monthly intravenous immunoglobulin. complete blood count revealed anemia (hb: . g/dl), and eosinophilia ( /mm ). serum immunoglobulins were: ig g: mg/dl ( - ), igm: mg/dl ( - ), iga: . mg/dl ( - ), ige : iu/ml. lymphocyte subset analysis showed cd %, cd %, cd %, cd + %, cd %. foxp gene analysis showed c. _ delaag mutation. at the age of year, patient underwent hsct from his hla matched sibling. myeloablative conditioning regimen including busulfan ( . mg/kg) and fludarabine ( mg/m ) was given to the patient. cyclosporine a and methotrexate (day + , day + , day + ) were used as graft versus host disease prophylaxis. bone marrow was used as the stem cell source and the number of cd + cells was . × /kg. neutrophil and platelet engraftment were achieved on day + and + [p ] s respectively. acute and chronic gvhd were not observed, but patient developed veno-occlusive disease treated with defibrotide, sepsis treated with broad spectrum antibiotics. chimerism analysis showed % donor profile at the third month of hsct. after hsct, autoimmune hemolytic anemia, eczematous dermatitis, food allergies, diarrhea and type diabetes resolved completely within two months after hsct. now the patient is in good clinical condition without any symptoms months after hsct. early hsct provides better outcome in patients with ipex, before the organ damage due to autoimmunity and/or adverse effects of immunosuppressive therapy. myeloablative conditioning is associated with substantial transplantation-related mortality whereas nonmyeloablative conditioning carries an increased risk of rejection because of dysregulated effector t-cell function. in this patients, myeloablative conditioning was preferred because of the risk of rejection. although the required levels of donor chimerism and conditioning intensity are unknown, engraftment of donor treg cells seems to be sufficient to control the disease. the patient is well without any symptoms of ipex after hsct with full donor chimerism. disclosure of conflict of interest: none. interferon gamma receptor deficiency (ifnr ) is a rare autosomal recessive immune deficiency disorder associated with very poor outcome secondary to severe and disseminated mycobacterial infections. hematopoietic stem cell transplantation (hsct) has been proposed as a curative option. however, hsct for these patients is particularly difficult owing to a high rate of graft rejection. the use of a non t-cell depleted transplant from an hla-identical sibling and fully myeloablative conditioning regimen has been shown to have improved outcomes. we report the first successful hsct with a t-depleted haplo-identical donor, performed in a girl with severe ifnr deficiency. we reviewed the medical chart of a -year-old hispanic girl with ifnr deficiency who was diagnosed at birth, since her brother had previously been diagnosed with the same complete ifnr deficiency. they were found to have a novel mutation variant detected at c. - g t. as expected with this disorder, she developed disseminated infection with mycobacterium abscessus infection at months of age and was subsequently found to have mycobacterium abscessus osteomyelitis. she was treated with multiple antibiotics including: amikacin, linezolid, meropenem and clarithromycin while tigecycline was added a few weeks prior to admission for hsct. she was continued on this therapy until day + following which antimicrobials were gradually weaned off. she was enrolled on the bp- trial, a multicenter, prospective phase i-ii trial (enrolling both malignant and non-malignant diseases) evaluating αβtcr +/cd + depleted haplo-transplantation followed by administration of bpx- t cells containing the ic suicide gene, (clinicaltrials.gov nct ). her conditioning regimen included busulfan ( mg/kg/day for days) and cyclophosphamide ( mg/kg/day for days). fludaragbne, tli ( cgy) . gvh prophylaxis with atg/rituximab. the patient received a graft with: tnc- . × cells/kg, cd + cells- × cells/kg, and αβtcr+ t cell content of . × cells/kg. as per protocol, since the αβ tcr+ t cells in the product was below threshold of × cells/kg, she did not receive any post-transplant immune suppression. bone marrow recovery occurred at day + with anc /mm and platelet recovery at day + . full engraftment with % donor chimerism based on cytogenetic analysis was observed at day + after transplantation and has remained stable. she is currently months post-transplant, and has done well without major complications and or signs of mycobacterial infection. there is limited data in patients receiving hsct for ifnr deficiency with very poor outcomes either relating to graft failure, transplant complications and progressive mycobacterial infection. to our knowledge, this is the first patient with ifnr deficiency transplanted successfully with a haploidentical donor and alive without any active mycobacterial infection. this report suggests that using a highly immunopotent graft depleted of only αβtcr+ t cells while retaining other immune effectors might offer a potential strategy to engraft these high risk patients using haplo-identical donors thereby allowing access to virtually all patients in need. disclosure of conflict of interest: none. tandem autologous stem cell transplantations for high risk pediatric embryonal central nervous system tumors: a single center experience k rosenfeld , r dvir , s constantini, j roth , s edelman , a tal , d levin , m manisterski , s achituv and r elhasid , department of pediatric hematology-oncology, tel aviv medical center; department of pediatric neurosurgery, tel aviv medical center and sackler faculty of medicine, tel aviv university pediatric embryonal central nervous system tumors are highly malignant tumors, which tend to disseminate through the cerebrospinal fluid to the brain and spinal cord and include: medulloblastoma, pinealoblastoma and primitive neuroectodermal tumors (pnets). the recommended treatment for these tumors is a complete surgical excision, craniospinal radiation and chemotherapy. the use of high dose chemotherapy with tandem autologous hematopoietic stem cell transplantation (hsct) has been advocated for high risk patients, and infants who could not be irradiated. between july and november , pediatric patients ( males, females) suffering from high risk medulloblastoma, pnet or pinealoblastoma underwent tandem autologous hsct. they were treated according to two protocols: group a consisted of ten patients with median age of . years (range . - . years) received the st jude sjmb protocol, while group b consisted of six patients with median age of . years (range . - . years) who received the children's oncology group -acns protocol. all patients engrafted with median time for neutrophil engraftment of days (range - days) and for platelets engraftment ( ) of days (range - days). median follow-up was . years (range week- years). neurological toxicity: two group a patients had convulsions episodes, one occurred during infusion of cryopreserved stem cells, and the other was a result of progressive disease during the last course of hsct. gastrointestinal toxicity: seven patients required total parenteral nutrition due to mucositis. diarrhea occurred in seven patients, two of them were diagnosed with rota virus and two with clostridium difficile. infectious complications: all patients suffered from at least one episode of neutropenic fever which was treated with broad spectrum antibiotics. there were documented bacteremia in patients. ( klebsiella pneumonia, proteus mirabilis, staphylococcus aureus, streptococcus viridans and staphylococcus epidermidis). metabolic complications: four patients in group a developed reversible syndrome of inappropriate anti-diuretic hormone secretion (siadh) during chemotherapy, and all group a patients developed hypomagnezemia. four patients died, one due to progressive disease, one due to early relapse months post treatment, one due to late relapse years post treatment and one due to sepsis months post treatment. another patient relapsed . years s post treatment, underwent surgery and radiotherapy and is now years post therapy. late effects: four group a patients developed endocrinological sequelae at a median of months (range - months) and require hormone replacement therapy. tandem autologous hsct is a feasible treatment for pediatric high risk embryonal tumors, with good engraftment and acceptable toxicities using sjmb and acns protocols, with overall survival of %. long follow-up is needed in order to diagnose and treat late effects. disclosure of conflict of interest: none. the diagnostic role of liver stiffness measurement in predicting hepatic veno-occlusive disease (vod) in pediatric hematopoietic stem cell transplantation (hsct) k kleinschmidt , f ravaioli , r rondelli , g marasco , r masetti , a prete , a colecchia , d festi and a pession pediatric oncology and hematology unit, department of pediatrics, university of bologna, sant 'orsola-malpighi hospital and department of medical and surgical sciences, university of bologna vod is a potentially life-threatening complication associated with hsct in which immediate therapeutic action is crucial for patients' outcome. liver stiffness measurement (lsm) using fibroscan represents a non-invasive method to detect the grade of liver fibrosis and portal hypertension as in case of vod. to evaluate the predictive potential of lsm in pediatric patients (pts) at risk for developing vod, a prospective, ongoing, single-center study has been performed at the university hospital of bologna. lsm was performed by using the fibroscan device, which consists of a . mhz ultrasound transducer probe that transmits low-frequency vibrations ( hz) to the liver tissue. the propagation velocity is proportional to the stiffness (elasticity) of tissue. lsm will obtain pathological high values ( . kpa) when the tissue is altered like in liver fibrosis, or post-sinusoidal portal hypertension. from november -september , pediatric pts ( male, female), aged - years (mean . ), affected by hemato-oncologic disease, eligible to allogeneic ( ) or autologous ( ) sct conditioned with busulfan-based chemotherapy, were enrolled. pts were scheduled for study examinations with lsm: at t (baseline) before chemotherapy, t (day - after sct), t (day - ) and t (day - ). the diagnosis of vod was defined according to modified seattle/baltimore criteria. twenty-five pts were enrolled in the protocol, of which were evaluable for the study (pts characteristics table ). out of pts ( %) developed vod. the cumulative incidence (se) of vod in our setting was % ( . ). baseline lsm values on t of all pts were normal ( . kpa at t (p = . ) and t (p = . ). from our observations, an anticipating pattern of pathological lsm in presence of clinical and laboratory parameters within normal ranges in patients who develop vod can be derived. preliminary data indicate a high predictive potential of lsm in the diagnosis of vod, however the number of cases is not sufficiently representative to draw definitive conclusions. to optimize the predictive potential of the method, more frequent (daily) measurement in the critical time frame are currently investigated. [p ] all= acute lymphoblastic leukemia, aml= acute myeloid leukemia, bu= busulfan, treo=treosulfan, fluda= fludarabine. disclosure of conflict of interest: none. [p ] the exact role of extra-corporeal photopheresis in children with gvhd: an unanswered question ss anak, h bilgen , , , , , , , y yaman, et saribeyoglu, k ozdilli, v hazar, m elli, am kokrek, h hizli and k payalan ecp continues to be a controversial treatment, probably due to the mechanism of action not being identified, the varying photopheresis procedures and treatment schedules, and the difficulty of conducting trials on relatively rare diseases with involvement of clinically heterogeneous organs. ecp was performed in our pediatric transplant center to patients mean age of years ( - ) diagnosed to have all ( pts), thalassemia ( pts), aplastic anemia ( ), blacfan diamond ( ), refractory hodgkin disease ( ) following our internal protocol for ecp sessions. five of the patients had mud, had hla id sibling transplants. chronic gvhd was diagnosed in of the patients had acute gvhd. skin was involved in all the patients, liver in of the patients, lung in , gut in and mucous membranes in patients. the ecp treatment consisted essentially of three steps: ( ) collection of mncs from the patient, ( ) processing of mnc buffy coat, and ( ) return of mncs to the patient. collection was performed using a cell separator (haemonetics mcs plus), processing two blood volumes. our protocol provides for a maximum final mnc volume to be collected at ml, with a hematocrit (hct) value below %. the maximum procedure time was set at min. the mncs collected were adjusted to a constant volume of ml by the addition of saline and ml of -mop in aqueous solution, to always obtain a final concentration of the drug of ng/ml. the diluted buffy coat was transferred into a special uv-a-permeable bag (pit-kit medtech solutions), and uv-a radiation at j/cm was performed (uva-pit irradiator). the photoactivated mncs were returned to the patient within minutes using a blood transfusion set. during ecp procedure, patients' vital signs were monitored. anticoagulation consisted in acidcitrate-dextrose formula a set at a variable ratio ( : - : ) according to the patient's characteristics (clinical conditions, body weight, coagulation values) and platelet (plt) count. prophylaxis of hypocalcemia consisted of the administration of calcium gluconate ( ml diluted in - ml saline) every to minutes. all procedure related side effects were recorded. during the reinfusion and postreinfusion phases, the patients were monitored for fever, chills, headache, rash, erythema, urticaria, itching and edema. no serious complication was detected. all the patients had also steroids, had concurrent mesenchimal stem cells. ecp was applied on consecutive days every - weeks which is continued for approximately months followed by a maintenance schedule tapered to an every -to -weeks. the mean session cycle was ( - ) between february to november . the most commonly involved organ was the skin which demonstrated a response rate of %, followed by liver ( %), lung ( %), gut ( %) and mucous membranes ( %) the concurrent immunosuppression could be reduced during ecp therapy, and no increase in opportunistic infections was detected. / patient died after a relapse, / are alive with chronic mild gvhd. however, despite our good response rates, our understanding of ecp remains limited. patients who suffer from acute and chronic gvhd have limited treatment options. ecp remains an important therapeutic option. future basic, translational, and clinical research studies will provide a better understanding of its mechanism of action and optimize its therapeutic potential. disclosure of conflict of interest: none. tolerability and responses to ex vivo il activated nk cells from haploidentical parental donors in paediatric patients with refractory leukaemia/lymphoma pl tan prognosis for patients with refractory leukaemia/lymphoma ineligible for transplants and those who relapse posttransplant is poor. in adult settings, adoptive transfers of ex vivo il activated natural killer ('ank') cells from nk alloreactive donors, especially for nk sensitive cancers, has been successful in bridging patients to curative transplants.( ) this approach has not been reported in paediatric patients. we report our experience in consecutive patients, of median age (range, - ) years, with refractory leukaemia/ lymphoma (aml, ; all, ; mixed phenotype acute leukaemia, ; lymphoma, ) who received treatments with 'ank' from haploidentical parental donors on institutional protocol, between aug and . parents/legal guardians/patients provided informed consents as per institutional guidelines for donors and patients procedures. donor lymphocytes harvested at steady state were cd depleted followed by overnight culture in il before being infused into patients lymphodepleted with fludarabine and cyclophosphamide. additional rituximab were given to patients and another received tbi gy. subcutaneous il injections at doses - mu/m /dose started on d- and were planned for doses, as tolerated. nk alloreactive donors (kir-ligand mismatch) and kir b/x genotype were available to all except patients. two patients were treated for post-transplant relapse; of whom also received 'ank' pre-transplant; other patients had failed best conventional therapy including cd /cd bispecific t cell engager (blinatumomab) in . lymphodepletion was well tolerated. a median tnc and cd + dose of . (range, . to ) × /kg and . (range, . - ) × /kg, respectively were administered. cytokine release syndrome (crs) was observed in of treatments ( grade , grade , grade ). the patient with dock deficiency, disseminated ebv+ cerebral lymphoma had grade crs and robust tumour lysis syndrome but succumbed to neurotoxicity. of the treatments, there were responses, including the given posttransplant. excluding the treatments given post-transplant and non-responders, median peak donor chimerism was % (range, - %) occurring at a median of (range, - ) days. five patients ( responders, non-responder) proceeded to transplants at a median of (range, - ) days after 'ank.' responders had longer survival time compared to nonresponders (median vs days). two responders ( %) achieved sustained minimal residual disease (mrd) remission after transplants and are alive and days from 'ank.' five eventually died of their primary leukaemia/lymphoma; from crs. our preliminary experience in a small cohort of paediatric patients with refractory leukaemia/ lymphoma showed that adoptive transfers of ex vivo il activated nk cells from haploidentical parental donors were tolerable; with responses seen in % of patients; and % achieving prolonged mrd remissions after transplants. patients with cerebral diseases might be at increased risks of neurotoxicity with this approach; and care must be taken in patient selection and the design of the lymphodepletion therapy. alternative donor choices are limited in multi-racial, multiethnic societies with small families such as singapore. unrelated cord blood transplant provides a feasible alternative to patients lacking adult stem cell donors in children with primary immunodeficiency diseases. method: we describe our experience using unrelated cord blood transplant (ucbt) for children with pid from august to november . during this period we performed hsct for children with pid: with unrelated cord blood ( %); with msd and i mud. out of cases of ucbt there were severe combined immunodeficency (scid), chronic granulomatous disease (gcd), hyperigm syndrome and wiskott aldrich syndrome (was). the median age of transplant was . months (range . to . months). all presented with multiple infections ranging from disseminated bcg infection to parainfluenza /rsv /rotavirus infection to pseudomonas sepsis, staphylococcal endocarditis to pulmonary aspergillosis for scid. hyper igm presented with pnemocystitis carini pneumonia while cgd conditions presented with perianal abscess and fungal pneumonia. the child with was had life threatening git bleeding and a hemorrrhage trachaebronchial cast removed after a failed initial extubation for gastroscopy. conditioning regimes consisted of reduced intensive (fludarabine based) conditioning regime for scid and myeloablative regime for the rest. the median tnc dose was . × ( )/kg (range . to . ) and median cd + cells dose was . × ( )/kg (range to . ). results: all engrafted well except for one graft failure in cgd. he refused nd transplant and died . years post transplant from fungal pneumonia. median engraftment time for neutrophil was days (range to ) and platelet was days (range to days). grade skin aghvd occurred in one patient while another patient died of agvhd of liver and lungs. chronic gvhd was found skin and liver in one patient. trm was % (due to agvhd). median follow up was days (ranged to ). overall years survival was %. post-transplant complication with life threatening puemonitis was not uncommon. one patient developed biopsy -proven idiopathic interstitial pneumonitis and required ecmo for one month. he received immunosupressive drugs including methylprednisolone, infliximab, oral imatinib (tk inhibitor), azithromycin and nebulised becotide. he was weaned off oxygen after - months. conclusion: our limited experience showed unrelated cord blood is good source of stem cell for transplant in pid in a multiracial population. one case of graft failure was likely due too low cell dose cd +cells dose × ( )/kg. the expertise in icu has enabled us to support several patients who presented with infective pneumonia pre-transplant and post -transplant. with better technology like alpha/beta depletion haploidentical transplant may be a better option to achieve engraftment earlier so as to avoid stormy post-transplant infections seen in unrelated cord blood setting. disclosure of conflict of interest: none. in spite of these recommendations, literature from developing countries suggest that pbscs are used more and more frequently without compromising the transplant results, as they seem to be preferred graft source for donors in many countries incl. poland. therefore we analyzed the efficacy of mud-hsct in children with saa transplanted in our centre. clinical data of saa and pnh children and adolescents ( boys and girls), who underwent mud-hsct between october and july were retrospectively analyzed. the median age was . years (range . - years) according to the graft source, the patients were divided into pbsct group ( patients) and bm group ( patients). four patients required second mud transplant due to graft rejection. overall survival for all patients was %. estimated -year overall survival (os) was not statistically different between pbsct group and bm group [( % vs % ) p = . ]. there was no significant difference in os between group who had ist before transplant and the group, who had an upfront transplant as a first line of therapy [ % vs %, p = . ].the time to neutrophil and platelet engraftment was statistically longer in bm group than in pbsc group [(anc vs days, plt vs days, respectively) p = . ]. the incidence of grade iii-iv acute graft-versus-host disease (gvhd) in pbsct group was similar to that in bm group [ % ( / ) vs % ( / )]. the incidence of chronic gvhd in pbsct group was similar to that in bmt group [ % ( / ) vs % ( / )]. other transplantrelated complications like heart failure, central nervous bleeding, incidence of infections were comparable within the two regimens. there were deaths in the whole group. the main reason of death were infectious complications or multiorgan failure (mof) in severely pretransfused patients in this historical cohort of patients. unrelated donor pbsct in children and adolescents with saa seems to be not inferior to unrelated donor bmt. the incidence of chronic gvhd was surprisingly low in saa recipients of mud pbsc. increased morbidity and mortality due to infections was due to individual poor clinical situation of patients before transplant (i.e. fungal infections, contamination with resistant bacteria, prolonged neutropenia). disclosure of conflict of interest: none. dyskeratosis congenita (dc) is characterized by the clinical triad of reticular skin pigmentation, nail dystrophy, and oral leukoplakia. the majority of patients with dc develop bone marrow failure (bmf), which is the main cause of death in dc patients. allogeneic hematopoietic stem cell transplantation (hsct) is the only curative treatment for bmf associated with dc. transplant-related morbidity/mortality is common, especially after myeloablative conditioning regimens. hsct has been introduced into the management of dc, which has had remarkable clinical results. we report our experience in children with dc who underwent allogeneic transplantation at a single medical center. patients received a fludarabine-based reduced intensity conditioning (ric), and the graft source was unrelated peripheral blood stem cells. median age at the time of hsct was . years (range, - years). the numbers of infused mononuclear cells and cd + cells were . ± . × /kg and . ± . × /kg, respectively. the median time of neutrophil and platelet recovery were . days (range, - days) and . days (range, - days). two patients experienced grade ii-iii acute graftversus-host disease (gvhd), and chronic gvhd was only observed in one patient. all four patients remained alive and transfusion independent at the median follow-up of . months (range, - months). correction of previously existing physical defects was observed in two patients. unrelated peripheral blood hsct can be a curative option for dc. ric based on the type of disease is important to s achieve successful hsct. a larger sample size and extended follow-up of this rare patient population are needed to determine whether the changes in therapy will improve longterm survival. disclosure of conflict of interest: none. autosomal recessive hyper-ige syndrome due to dock mutation is a combined primary immunodeficiency, characterized by severe eczema, recurrent infections, and susceptibility to autoimmunity, malignancy, and multiple allergies, in addition to unusual high serum ige level. dock patients tend to have a progressive severe clinical course with mostly fatal outcome during second to third decade of life without hematopoietic stem cell transplantation (hsct). in our center we have a large number of dock patients. during a period of years ( - ), we transplanted patients with documented dock- mutation confirmed by molecular genetics. one patient did not receive any conditioning because of poor clinical condition and he died from severe cutaneous and gut gvhd and another patient received cbt with bu/flu with zero engraftment. the rest of the patients received hsct from hla full matched donor with chemoablation with bu/cy for all with % lymphoid and myeloid engraftment (str). among those patients who received chemoablation, gvhd developed in patients mostly grade i and ii. in addition patients died: one died of severe gvhd and the other two died of sepsis. for dock patients we highly recommend early hsct if fully matched donor is available to prevent the high mortality associated with the disease. alloreactivity triggered by interactions between killer cell immunoglobulin-like receptors (kir) and natural killer (nk) cells plays a role in graft-versus-tumor (gvt) effects after hematopoietic stem cell transplantations (sct). in particular, kir-ligand mismatching between the donor and recipient might promote nk cell alloreactivity after unrelated cord blood transplantations (ucbt) in adult patients with acute myeloid leukemia (aml). recently, it has been suggested that allogeneic nk cells could be the effector cells that mediate gvt effects after mismatched allogeneic transplants for refractory childhood solid tumors. however, there are few reports about the efficacy of kir-ligand mismatched sct in pediatric cases. here, we report the excellent outcomes of kirligand mismatched cbt (kir-cbt) in pediatric patients with refractory malignant disease. we evaluated the cases of pediatric hematology and oncology patients [ ( %) aml, ( %) myelodysplastic syndrome [mds] , and ( %) neuroblastoma [nbl] patients] who underwent kir-cbt between and at our institution. among the aml cases, one involved refractory disease (induction failure), and the other three involved relapsed aml (one patient relapsed after the st sct because of q-). all nbl patients underwent kir-cbt followed by auto-peripheral blood stem cell transplantation (pbsct) because of stage disease. the mds patient underwent kir-cbt because of refractory anemia with excess blasts. kir mismatching was defined as incompatibility between the donor kir and recipient kir ligand, and only inhibitory kir that interacted with human leukocyte antigen (hla)-bw , -c , or -c group ligands were considered. the median age of the patients was (range - ) years. all of the aml patients were in complete remission (cr) at the time of the hsct (cr = one case, cr = cases). the mds patient was in a non-cr state, and all of the nbl patients were in their st cr at the time of the hsct. the aml patients received total body irradiation (tbi)-based conditioning ( gy tbi and mg/kg cyclophosphamide [cy]), and the mds patient received busulfan (bu)-based conditioning ( . mg/kg bu and mg/kg cy). the nbl patients received reducedintensity conditioning regimens ( mg/m fludarabine, mg/m l-pam, and gy tbi). the cb exhibited hla - locus mismatches (dna typing), including at least one inhibitory kir gene mismatch. the prophylaxis for graftversus-host disease (gvhd) consisted of tacrolimus and shortterm methotrexate. anti-thymocyte globulin (atg) was not used as a gvhd prophylaxis in any case. after the median follow-up period of months (range: - months), all patients were alive, and none of them had relapsed after the kir-cbt. although grade ii-iv gvhd was observed in patients ( %), it was controlled with prednisolone. chronic gvhd was not seen in any case. the present findings suggested that nk cell alloreactivity plays a role in preventing childhood myeloid leukemia and nbl relapse after kir-cbt. although our results are limited, this report provides novel data to support further investigations into the use of kir-cbt for the treatment of pediatric refractory malignant disease. disclosure of conflict of interest: none. impact of fcm-based minimal residual disease on transplant outcomes in patients with aml in hematological complete remission t oka, j kanda , k ohmori , m hishizawa , t kitano , t kondo , k yamashita it is reported that the presence of minimal residual disease (mrd) before hematopoietic stem cell transplantation (hsct) is associated with poor overall survival in patients with acute myelogenous leukemia (aml) in hematological complete remission (cr). we retrospectively analyzed the association between flowcytometry (fcm)-based detection of mrd and transplant outcomes. we included adult patients with aml in hematological cr, who underwent their first allogeneic hsct between april and may at kyoto university hospital. mrd of bone marrow before hsct was measured using fcm. to search for target antigens to detect mrd, threecolor fcm analyses were performed using a differential panel for every disease and patient, which allowed us to detect ⩾ . % of mrd. of the patients (median age: . , range: - ), patients were included in the mrd-negative group (mrd o . %), whereas were included in the mrd-positive group (mrd ⩾ . %). in the latter group, patients were included in the mrd-low group (mrd o . %), and were included in the mrd-high group (mrd ⩾ . %). there was no significant difference in the patient background between the mrd-negative and mrd-positive groups. the -year overall survival rates for the mrd-negative, mrd-low, and mrd-high groups were %, %, and %, respectively (p = . , figure ). in a multiple regression analysis, the mrd-high group was significantly associated with higher overall mortality than the mrd-negative group (mrd-low vs mrd-negative, hazard ration [hr] . , p = . ; mrd-high vs mrd-negative, hr . , po . ). the -year relapse rates for the mrdnegative, mrd-low, and mrd-high groups were %, , and %, respectively (p o . ). there were no significant differences in non-relapse mortality among the three groups. the analysis of fcm-based detection of mrd revealed that an mrd positivity of ⩾ . % was significantly associated with high risk of relapse and death even in patients with aml with hematological cr. the stronger consolidation or conditioning therapy before hsct based on mrd could improve transplant outcomes in these patients. [p ] disclosure of conflict of interest: none. post-transplant cyclophosphamide (ptcy) and megadose t cell depleted (tcd) haplohsct for tolerance induction f aversa , e bachar-lustig , n or-geva , y zlotnikov klionsky , l prezioso , s bonomini , a monti , i manfra , c schifano , s pratissoli , f lohr , r lamanna , v sgobba , n giuliani and y reisner hematology and bmt unit, university hospital of parma, italy; department of immunology, weizmann institute of science, rehovot, israel; neurology department, stanford school of medicine, stanford, california; radiotherapy unit, university hospital of modena, italy; radiotherapy unit, university hospital of modena, italy; genetic unit, university hospital of parma, italy and hematology and bmt unit, university hospital of parma, italy the use of ptcy is associated with reduced risk for gvhd in t cell replete nma haplo-hsct; however, this intervention is still not sufficiently safe to justify treatment of non-malignant diseases or as a platform for organ transplantation. experimental data: in a total of mice, we showed that combining the power of megadose tcd hsct with high dose ptcy (fig. a) , enables marked and durable chimerism following nma conditioning, while each modality alone was ineffective (figure a) . chimerism included all myeloid and lymphoid lineages, and lda analysis of alloreactive t cells revealed specific immune tolerance towards donor stimulators (fig. b) , also associated with acceptance of donor but not rd party skin. clinical trial: a similar protocol was developed for clinical use. the first patient, a yr old male with high-risk multiple myeloma in cr after autohsct, received megadose ( . x cd + cells/kg) cd /cd depleted ( . x cd +t cells/kg) haploidentical pbpcs after atg, fludarabine and gy single frcation tbi. ptcy was given to control both hvg and gvh reactions (fig. c) . hematopoietic engraftment was achieved at day + with over % donor type chimerism during the first months in the myeloid and b cell lineages. t cells during this period were predominantly of host type ( - % donor type), gradually increasing to - % at - months post transplant (fig. d) . the patient overcame cmv and subsequently ebv reactivation without any treatment (fig. e- g) . dextramer facs analysis revealed that cmv and ebv specific cd t cells were exclusively of host origin (fig. f- h) . at + months, cr and normal free light chain ratio were confirmed. the second patient, a year-old male with high risk heavily pretreated multiple myeloma (tandem auto-hsct, yr maintenance with lenalidomide, salvage therapy with vd) received a similar hsct ( . x cd + cells/kg, . x cd +t cells/kg). despite transient engraftment ( % donor cell on day + ), graft failure with autologous recovery ( . % donortype chimerism) was documented on day + . this may be due to the extended treatment ( yrs) with lenalidomide, but rejection cannot be excluded. after months, this patient tolerated a second haplo-hsct (different donor) after myeloablative conditioning (atg, treosulfan, thiotepa and fludarabine) and alfa/beta tcr/cd -depleted pbpcs. at month follow up, he shows no sign of gvhd, good immunological reconstitution, excellent quality of life, and remains in complete remission. collectively, our murine proof of concept data supported by clinical experience in the first high risk mm patient. the marked level of host t cells persisting over the first year after hsct can provide anti-viral immune protection until thymus-derived donor t cells are generated. avoiding additional post transplant immune suppression ensures a robust anti-viral immunity and a graft vs tumor effect. the rejection experienced by the nd patient, although corrected by a nd myeloablative tcd hsct, indicates that the conditioning must be fine-tuned to optimize engraftment in every patient. we are therefore testing, increasing tbi from gy to gy. further studies will determine the efficacy of this approach in elderly mm patients, in non-malignant hematopoietic diseases, or as a prelude for organ transplantation and cell therapy. over the last decade the addition of alemtuzumab to fludarabine-based reduced intensity conditioning regimen is common practice in the unrelated donor allograft setting. in recent years, however, its use has extended to reduced intensity hla-identical sibling donor allografts with the aim of providing an additional prophylaxis against gvhd. it is difficult to assess though whether this practice has any negative influence in the relapse rate or whether it has any net benefit or disadvantage in terms of overall survival. in this retrospective study we have analysed a historical cohort of patients [ males, females, mean age . ( - )] who s received a ric fully matched unrelated donor ( patients) or sibling donor ( ) hsct as consolidation treatment for hr aml in transplant centres in uk and greece. the conditioning regimen included fludarabine in all cases, together with melphalan and alemtuzumab( patients), busulphan and campath ( patients), busulphan and thiotepa ( patient), melphalan ( patients), busulphan with and without atg ( patients) total body irradiation ( cgy, patients). in total, patients received alemtuzumab ( mud mg alemtuzumab and sibling donor hsct recipients mg alemtuzumab) and patients ( mud and sibling donor hsct recipient) received atg with patients receiving t replete allografts. gvhd prophylaxis was ciclosporin for patients receiving alemtuzumab based or atg based regimen and ciclosporin with low dose methotrexate for t-replete allografts. the median follow up was . months (range - months).all but four patients were transplanted in cr overall, patients receiving conditioning without alemtuzumab suffered more frequent (po . ) and more severe (po . ) acute gvhd. this group, however, had a significantly (po . ) lower relapse rate. the overall survival remained unaffected. the subgroup of patients receiving allografts from mud had a clear benefit in terms of a lower incidence (p o . ) and severity (p o . ) of acute gvhd: none of the patientsreceiving alemtuzumab experienced grade iv agvhd, but up to / patients not receiving alemtuzumab suffered severe grade iv gvhd. however, the use of campath was associated with a significantly higher rate of relapse or progression of the aml (po . ), so that none of the mud recipients not having campath relapsed, while / patients having alemtuzumab relapsed. although none of these factors had a net impact on survival, there was a nonsignificant (p = . ) trend towards a higher survival in patients who received alemtuzumab. in the sibling donor allograft setting, alemtuzumab had no significant impact on the incidence of acute gvhd, relapse or survival. finally, in diseases where cytogenetic or molecular markers of high risk were available, our results showed a better overall survival (po . ) in ric alemtuzumab conditioning undergoing fully matched unrelated donor hsct, probably as a result of the protection against graft versus host disease while maintaining graft versus leukaemia effect. overall, alemtuzumab is a highly protective agent against agvhd in mud hsct recipients while it maintains the graft versus leukaemia effect.however it did not show any clear benefit of its use in the identical sibling donor setting. larger prospective studies are required in order to determine the need for this agent in this particular setting. disclosure of conflict of interest: none. blastic plasmacytoid dendritic cell neoplasm (bpdcn) is a rare disease which constitutes o % of all hematologic neoplasms annually. majority of bpdcn present with diverse skin involvement prior to leukemic dissemination, whereas a minority (~ %) have systemic involvement at diagnosis. there are no established therapies for bpdcn and most pts receive acute leukemia, myeloid or lymphoblastic, induction regimens; but responses are short-lived and prognosis is poor upon relapse. allogeneic hematopoietic cell transplantation (allo-hct) is offered to bpdcn cases based on small retrospective or registry case series. we retrospectively analyzed outcomes of bpdcn pts who received an allo-hct at transplant centers in the usa. a total of pts were eligible for analysis ( table ). the primary endpoint was overall survival (os). twenty patients (m = , %), median age of ( - ) yrs, received an allo-hct from a matched related (n = , %), matched unrelated (n = , %), mismatched-unrelated (n = , %), umbilical cord (n = , %) or haploidentical (n = , %) donor using myeloablative (mac) (n = , %) or reducedintensity (ric) (n = , %) conditioning. fifteen pts received hyper-cvad as pre-allograft therapy (front-line = , salvage = ). the majority (n = , %) were allografted in cr . median f/u for survivors was . ( . - . ) months. median time-to-neutrophil and platelet engraftments were ( - ) days and ( - ) days, respectively. five pts never dropped s platelet counts below /μl. three pts (mac = , ric = ) relapsed at , , and months, respectively. all relapsed with marrow involvement ( had also skin involved). mean os was . ( . - . ) months. one-year and -year os were % ( % ci = - %) and % ( % ci = - %), respectively. there was no difference in -year os when comparing mac versus. ric (hr = . ( % ci = . , . ), p = . ). median time to onset of acute gvhd was ( - ) days; grade ii-iv acute gvhd occured in cases. chronic gvhd was seen in cases (mild = , mod/severe = ). allo-hct is an effective therapy for bpdcn resulting in durable remissions. encouraging outcomes observed in this analysis may be explained by offering allo-hct early in the disease course and in the setting of complete remission. larger studies are needed to better understand risk factors for relapse to develop post-transplant strategies to improve outcomes. disclosure of conflict of interest: none. a risk-factor analysis for overall survival in patients with acute leukemia that relapse following t-replete haploidentical transplantation: on behalf of the acute leukemia working party of the european society for blood and marrow transplantation s piemontese , , m labopin , , f ciceri , , c schmid , , a ruggeri , , w arcese , z gulbas , y koc , j tischer , b bruno , w depei , d blaise , d beelen , g ehninger , a boumendil , , m houhou , , m mohty , and a nagler , relapse of acute leukemia is the leading cause of transplantation failure with devastating results. relapse post t-replete haploidentical transplantations (haplo-sct) is not well characterized. the objective of this study was to identify riskfactors for overall survival in patients with al that relapsed after a haplo-sct. from to , haplo-sct were performed in ebmt centers as first allogeneic transplantations for adults with acute leukemia. out of patients for whom we were able to receive updated data, relapsed and were included in this analysis. median follow-up among survivors was months after haplo-sct ( - ) and . months ( - ) after relapse. median time from haplo-sct to relapse was months ( d- m). diagnosis was acute myeloid leukemia (aml) in % and acute lymphoblastic leukemia (all) in % of the patients, respectively .fifty-two ( %) patients were transplanted in first complete remission (cr ), ( %) in cr or cr , while ( %) were transplanted in active disease. ric regimen was used in ( %) patients and ( %) received bone marrow as stem cell source. post-transplant cyclophosphamide (pt-cy) was used for graft-versus-host disease (gvhd) prophylaxis in patients ( %). fifty-two ( %) of the patients who relapsed post haplo-sct experienced previously acute gvhd and ( %) chronic gvhd post transplantation. treatment of relapse varied and included: none in ( %), ist withdrawal only in ( %), chemotherapy (ct) only in ( %), tyrosine-kinase inhibitor (tki) only in'( %), tki and ct in ( %), dli only in ( %), subsequent transplant in ( %), ct and dli in ( %), ct and subsequent transplant in ( %), tki ct and subsequent transplant in ( . %), dli and subsequent transplant in ( . %) patients. donors for second allogeneic transplant were unrelated (n = ), haploidentical (n = ) and cord blood (n = ). second transplant was performed in cr for patients and in relapse for patients. only patients who received a second haplo were alive at and months post second transplant. the majority of patients who received dli were in relapse at time of dli ( %), and % achieved cr after dli. os y after dli was %, patients being alive at a median time of mo ( - ) post dli. overall, the one-year overall survival (os) following relapse was % ( % ci: . - . ). in univariate analysis disease status at haplo-sct (cr vs active disease), cytogenetics (good/intermediate vs poor) and median time from haplo-sct to relapse ( or o . months) were associated to a higher os at one year after relapse: % (p = . ), % (p = . ) and % (p o - ), respectively. in multivariate analysis complete remission at haplo-sct (p = . ; hr . ; ci: . - . ) and time from haplo-sct to relapse higher than . months (p = . ; hr . ; ci: . - . ) were risk factors for a higher os after relapse. in the patients transplanted in cr and relapsing more than month after haplo, and y os were respectively % and %. these findings suggest that similar to other transplantation setting os for acute leukemia that relapse post haplo-sct is dismal. disease status at transplant and time from transplant to relapse are the two important prognostic factors that can predict somewhat better survival. indication for second transplant should be carefully evaluated. integrations with novel therapies are in unmet need to prevent and treat relapse post haplo-sct. disclosure of conflict of interest: none. patients (pts) with aml who relapse after autologous stem cell transplantation (asct) have a dismal outcome but some can be rescued with an allogeneic transplantation (allohsct). yet, available evidence presently stems from analyses of limited patient numbers. we decided to analyze the ebmt registry to evaluate the outcome and determine the prognostic factors in a large series of such pts. the ebmt registry was screened for adult pts with de novo aml (non-apl) who received an allograft in cr or first relapse ( - ) after being autografted in cr . pts receiving ex vivo t cell depletion (tcd) were included only if they received a haploidentical allohsct. inclusion criteria were met by pts ( % female, median age [range - ] years). median time from asct to relapse was (range . - , iqr . - . ) months. at allohsct, pts were in st relapse ( %) or cr ( %). donors were matched sibling ( %), unrelated ( %), haploidentical ( %), or cord blood ( %), respectively. conditioning was myeloablative in % and reduced intensity in % of the pts, respectively. the median follow up was months (range o - months). at years post allograft (figure), leukemia free survival ( - ] of the pts. all factors significantly associated with ⩾ endpoint in univariate analysis were entered in a multivariate cox regression model (table ) . ri was lower in pts transplanted in cr rather than in relapse ( . % vs . %; hr . , p = . ) and in pts who relapsed later ( months, median value) as opposed to those who relapsed early post asct ( . % vs . %; hr (per month) . , p o - ). ri was lower in pts transplanted with an unrelated donor (ud) in comparison to those transplanted from a matched sibling donor ( . % vs . %; msd, hr: . , p o - ). patient age, poor cytogenetics, transplantation in relapse, previous tbi for asct, myeloablative conditioning (mac) vs reduced intensity (ric) and ud, haplo or cbt vs msd all significantly increased nrm. lfs was significantly better in pts with good risk ( . %) than in pts with intermediate risk or poor risk cytogenetics ( %; hr . , p = . ) or in pts who relapsed late (per month: hr . , p = . ) post asct. lfs was worse in pts who previously had received tbi ( % vs %; hr = . ; po - ). the same prognostic factors were significant for os. haploidentical (hr . , p = - ) and cord blood (hr . , p = . ) transplants resulted in lower os than those from msd. finally, date of transplant significantly influenced os which was higher in pts transplanted after january vs those allografted before; . % vs . %, hr (per year) . , p = . ). about one third of adult patients with aml who relapse post asct can be rescued with an allogeneic transplantation, especially if the duration of persisting cr post asct is long and no tbi was received in the past. transplantation from an msd while in cr rather than at relapse offers the best outcome. disclosure of conflict of interest: none. high incidences of graft-versus-host disease (gvhd) and relapse have seriously impeded the widespread application of haploidentical hematopoietic stem cell transplantation (haplo-hsct) for high-risk acute leukemia lacking conventional hla-matched donors. one hundred and ten high-risk acute leukemia patients underwent haplo-hsct with idarubicin (ida) intensified conditioning regimen (ida intensified bucy for acute myelocytic leukemia (aml) and ida intensified tbi-cy for acute lymphoblastic leukemia (all)). for donor-recipient hla / or / transplant, we separately administered a total of mg/kg or mg/kg antithymocyte globulin (atg) and basiliximab for gvhd prophylaxis. all enrolled patients were observed longitudinally until death or lost to follow-up. the -day cumulative incidences of Ⅱ-Ⅳ and Ⅲ-Ⅳ agvhd for all patients were . %, . %, respectively. the -year cumulative incidence of extensive cgvhd was . %. the relapse rate was . %. the -year probability of overall survival (os) reached . %. the patients in non-complete remission (nr) showed significantly higher relapse and worse survival than complete remission (cr) minimal residual disease (mrd) (-) and cr mrd (+) patients. however, the relapse, y-os and disease-free survival (dfs) of cr mrd (-) did not differ from cr mrd (+) patients, indicating our intensified transplant technique could overcome the poor prognosis of mrd. for whatever aml or all patients, the relapse rates, agvhd, cgvhd and the estimated -year os and dfs between two atg group were equivalent, except that all patients in atg mg/kg experienced higher relapse ( . % vs . %, p = . ). although the incidence of cytomegalovirus (cmv) reactivation in atg mg/kg and mg/kg was . %, . %, the average episodes of cmv reactivation were remarkably [p ] higher in mg/kg. our ida intensified haplo-hsct technique could improve the outcome of high-risk acute leukemia and could be recommended as a good alternate for patients lacking hla-matched sibling donors. diagnosed secondary aml were randomized : to cpx- or standard + therapy. cpx- induction was units/m on days , , (first induction) and days , (reinduction); + first induction was cytarabine mg/m /day × days and daunorubicin mg/m on days , , , and reinduction was cytarabine mg/m /day × days and daunorubicin mg/ m on days , . a dynamic allocation procedure stratified patients by age group ( - or - years) for each study arm. patients with complete response (cr) or cr with incomplete platelet or neutrophil recovery were considered for allogeneic hct, based on institutional criteria. overall survival (os) landmarked at the time of hct was assessed. a total of patients were enrolled on the induction trial. . patient and aml characteristics in the hct age subgroups were generally similar between arms. in both age subgroups of patients receiving hct, median os was longer in the cpx- arm than in the + arm (table ). in the - group, serious adverse events (saes) prior to hct in the cpx- and + arms occurred in % and % of patients, respectively; in the - group, in % and %, respectively. the most common sae was febrile neutropenia (cpx- , . %; + , . %), occurring in all age groups. relapse after allogeneic haematopoietic stem cell transplant (allo-hsct) for acute myeloid leukaemia (aml) and myelodysplastic syndrome (mds) remains the main cause of treatment failure. it is associated with dismal prognosis and short survival. proposed salvage strategies are tapering of immunosuppressive therapy, re-induction with chemotherapy and consolidation with donor lymphocyte infusion (dli) or second allo-hsct, although, results remain disappointing. azacitidine (aza) and dli has proved to be an effective and well-tolerated outpatient approach in this setting, and results in at least temporary disease control in the majority of patients, thus, representing a valuable alternative to current treatments. between january and november , patients with relapsed aml or mds after allo-hsct were treated with subcutaneous aza mg/m days - every days and escalating doses of dli if feasible at manchester royal infirmary, uk. aza was continued until cr or disease progression. patients characteristics: median age (range - ) years, % males, diagnoses were aml (n = ) and mds (n = ). five ( %) patients had either monosomal or complex karyotype. fifty percent of patients were in cr before transplant, . % in cr , . % had a partial response and % did not receive any chemotherapy before the transplant. fifteen out of received fludarabine-base reduced intensity conditioning regimen and all but one had a t-cell depleted graft. at relapse % had mixed donor chimerism. median time to relapse was . (range - ) months after allo-hsct. with a median follow up of . (range - ) months a median of (range - ) courses of aza were administered and median of (range - ) dli were infused. doses of dli were administered starting at . x /kg and escalating by log . aza and dli infusions were well tolerated; only two patients withdrew due to intolerance. seven patients were admitted at least once due to infections ( %) or progressive disease. only two patients developed mild gvhd grade . complete remission was achieved in . % patients and stable disease in %. patients in cr had full donor chimerism. median overall survival for patients in cr was months compared to months for those who did not respond (p = . ). patients with more than % blasts on bone marrow at time of relapse after allo-hsct had a worse outcome than those with less than % blasts ( months and months respectively, p = . ). no differences were seen when compared time to relapse ( o months vs ⩾ months) s and outcome, or disease and overall response, although numbers in this series are small. image/graph: overall survival following azacitidine and dli, patients in complete remission, stable disease and disease progression. azacitidine and dli can provide long term remissions in patients with relapsed aml/mds post allo-hsct with low toxicity. lower disease burden at relapse carries better outcomes. low rates of gvhd are seen following azacitidine and dli most likely showing the immunomodulatory effect of azacitidine described by other groups. acute myeloid leukemia (aml) is a frequent complication in patients affected by telomere maintenance disorders ('telomeropathies') such as dyskeratosis congenita (dkc). treatment of aml in dkc patients by chemotherapy and hematopoietic stem cell transplantation is characterized by frequent remission failure, high organ toxicity and poor outcome. a -yearold patient with aml was admitted to our hospital in december . he had been treated with cycles beacopp for hodgkin´s lymphoma (hl) in . on admission, the patient presented clinical signs of premature aging with hair greying and lack of fully recovered hair growth after chemotherapy (cx) for hl. flow-fish analysis revealed tl below the % percentile within leucocytes in line with the suspected diagnosis of telomeropathy. retrospective tl analysis by confocal q-fish from bm at hl diagnosis confirmed short tl before the start of any chemotherapy. he received standard aml induction cx ( + ), but follow-up revealed persistence of aml. salvage cx with flag-ida was applied resulting in partial remission with only weak regeneration of normal hematopoiesis. the patient received an allogeneic stem cell transplantation (asct) after conditioning with mg/m melphalan and fludarabin from his hlamatched brother whose tl was found to be normal. after asct, he developed sinusoidal obstructive syndrome and progressive liver failure treated with defibrotide and he was admitted to icu for sepsis. leucocyte count showed sufficient engraftment on day ; however, liver function recovered only partially. during critical care treatment, the patient showed cardiomyopathy, renal failure and extensive wound healing problems without epithelial proliferation indicative of severe replicative exhaustion. finally, he died due to sepsis with acute liver failure on day after asct. aml arising from dkc is a rare event with substantial impact on patients´prognosis. therapy remains challenging due to poor bm function and high risk of organ toxicity, especially liver failure and lung fibrosis. dose reduction of alkylating agents and avoidance of total body irradiation are necessary in conditioning prior to asct in patients with dkc and aml, however no clear data or recommendations exist for the management of these patients. tl screening can help to identify patients with suspected dkc related bm failure or aml and to identify family donors without telomeropathy. physicians should be aware of possible dkc related aml, especially in familial cases of aml or bone marrow failure, impaired or prolonged recovery following cytoreductive treatment or coincidence of solid (e.g. oral cavity carcinomas) and hematological malignancies. disclosure of conflict of interest: none. chronic graft-versus-host disease and donor lymphocyte infusions in patients with non-de novo acute myeloid leukemia or advanced myelodysplastic syndromes after allogeneic stem cell transplantation pg hemmati , k pfeifer , lg vuong , cf jehn , p le coutre , b dörken and r arnold medizinische klinik mit schwerpunkt hämatologie, onkologie und tumorimmunologie, charité-universitätsmedizin berlin, campus virchow-klinikum, berlin, deutschland aml with myelodysplasia-related changes and therapy-related aml (taml), collectively termed secondary aml (saml) in daily clinical routine, represent distinct subgroups in the revised who classification of myeloid neoplasm and leukemias. as compared to de novo-aml, saml is associated with a poor survival when using conventional chemotherapy approaches. this is mainly due to unfavorable cytogenetics, older age and/or the presence of comorbidities as well as poor response to induction therapy. furthermore, cumulative organ toxicity resulting from treatment of the antecedent solid malignancy in patients with therapy-related disease has to be taken into account. allogeneic stem cell transplantation (allosct) represents the only option to achieve long-term disease control and definitive cure. we retrospectively analyzed patients with saml or advanced mds (eb- according to who) transplanted at our center between and . at the time of allosct, patients ( %) were in complete hematologic remission (chr), whereas patients ( %) had active disease. cytogenetic risk was categorized according to the swog/ecog classification and was favorable (n = ; %), intermediate (n = ; %), unfavorable (n = ; %), or unknown/undetermined (n = ; %). standard myeloablative conditioning (mac) using gy total body irradiation (tbi) and cyclophosphamide was used in patients ( %), whereas fludarabin/busulfan/atg-based reduced intensity conditioning (ric) was applied in patients ( %). grafts were from related (n = ; %) or unrelated (matched: n = ; % or mismatched: n = ; %) donors. the median follow-up of the surviving patients was ( - ) months. a graft failure occurred in / patients ( %). at last day of follow-up / patients ( %) were alive and in chr. relapse occurred in / patients ( %) after a median interval of . (range: . - ) months. cause of death were either relapse or nrm (gvhd and/or infections) in / patients ( %) or / patients ( %). at , , , and years after allosct overall survival (os) or disease-free survival (dfs) of the entire cohort was %, %, %, and % or %, %, %, and %, respectively. at the same time points, the cumulative incidence of relapse (ci-r) or non-relapse mortality (ci-nrm) was %, %, %, and % or %, %, %, and %, respectively. extensive uni-und multivariate analyses revealed a number of factors associated with inferior outcome, e.g. poor-risk cytogenetics, the presence of taml, advanced age, reduced physical performance, and comorbidities, whereas donor type (unrelated versus unrelated), and remission status had no significant impact on overall outcome. furthermore, the development of gvhd, especially the presence of cgvhd, and the use of donor-lymphocyte infusions (dli), either in a prophylactic or pre-emptive setting, were identified as independent predictors for a reduced relapse incidence, which in turn, led to an improved os and dfs. our results indicate that allosct represents an important treatment option for patients with saml. however, a relapse rate of % at months prompts the development of novel approaches to prevent early disease recurrence. strategies to augment the graft-versus-leukemia (gvl) effect of allosct may help to improve the results. disclosure of conflict of interest: none. myeloid sarcoma (ms) is a rare hematologic myeloid neoplasm that can involve any site of the body. it can occur as an exclusively extramedullary form or it can be associated with an acute myeloid leukemia (aml), a chronic myeloproliferative neoplasm (mpn) or a myelodysplastic syndrome (mds) at onset or at relapse. the rarity of ms does not enable prospective clinical trials and therefore a specific multicenter register can be useful for the clinical and biological studies of this rare disease. we report the clinical characteristics and outcome of histologically confirmed ms, diagnosed and treated in italian hematological centers in the last years. the patient's median age was years. there were / de novo extramedullary ms, / de novo aml-related ms and / were secondary aml-related ms. the most common extramedullary anatomic sites of disease were: skin, lymph nodes and soft tissues. forty-three patients ( %) underwent a program of intensive chemotherapy including flai, hdac-ida, hypercvad and mec schemes, with a cr rate of % ( / ). twenty-two ( %) patients underwent allogeneic sct, from a mud, from an hla-identical sibling donor and from an haploidentical donor. the median os of the whole population ( pts) was . months. the os probability at , and years was %, % and %, respectively. the os was better in patients that underwent an intensive therapeutic program (median os: months vs months). among the intensively treated patients, in univariate analysis, the os was better in young patients (p = . ), in patients that underwent allo-sct (p = . ) and in patients that achieved a cr during treatment (p = . ), and was worse in pts with secondary aml-related ms (p = . ). age, response to intensive chemotherapy and allo-sct were the only three variables that significantly influenced dfs (p = . , p = . and p = . , respectively). in multivariable analysis, allo-sct and response to intensive chemotherapy remained significant in predicting a better os (p = . and p = . , respectively), and response to intensive chemotherapy was the only significant variable in predicting dfs (p = . ). after allo-sct we observe a survival advantage in patients who achieved a pre-transplant cr (p = . ) and in those who developed a chronic gvhd (p = . ). patients with ms, both with de novo and secondary forms, still have a very unfavorable outcome and require an intensive therapeutic program, that includes allo-sct, whenever possible. the outcome after allo-sct is positively influenced by the development of chronic gvhd suggesting a graft versus ms effect. disclosure of conflict of interest: none. relapse of acute lymphoblastic leukemia (all) after allogeneic stem cell transplantation (sct) is associated with poor prognosis. blinatumomab may enhance the efficacy of donor lymphocyte infusions (dli) in this specific situation but data on the concurrent use of dli and blinatumomab are sparse. the patient presented here was diagnosed with standard risk pre-b-all (presence of t( ; ); bcr-abl and cd negative) at the age of . during treatment according to the german multicenter all-study group (gmall) protocol he presented with molecular relapse and months after initial diagnosis he received a tbi-based myeloablative sct from an unrelated hla-identical ( / ) donor. post sct he was negative for minimal residual disease (mrd) with % donor engraftment. given the high relapse risk he received prophylactic dli without occurrence of graft-versus-host disease (gvhd). one year after st sct he presented with an extramedullary (testes) and molecular relapse. after remission induction resulting in negative mrd he received a nd sct from an alternative, hlaidentical ( / ) donor after reduced intensity conditioning. this again resulted in negative mrd with % donor chimerism without any gvhd. six months after nd sct he presented with bone marrow relapse. we decided on the concurrent use of blinatumomab and dli. the first cycle of blinatumomab was initiated at standard dose including dose escalation without relevant toxicities. on day of the nd cycle, i. e. in the infusion-free interval before the rd cycle the patient received the first dli at x cd /kg. no toxicities or gvhd occurred. the rd cycle of blinatumomab was initiated and a second dli at . x cd /kg was applied on day of the rd cycle. on day of the rd cycle, i. e. day after nd dli the patient presented with signs of overlap gvhd (mouth, skin) and topical steroids were started. upon progression of clinical gvhd systemic steroids were initiated with immediate response. steroids were rapidly tapered and a th cycle of blinatumomab was started. gvhd did not recur. current staging after the th cycle blinatumomab, i.e. on day + after nd sct and months after initiation of blinatumomab treatment revealed complete remission with negative mrd, % donor chimerism and no signs of extramedullary relapse. counts of cd -cells at that time point were /μl. no relevant infections or relevant blinatumomab-associated toxicities were present during the entire course after the nd sct. in this case concurrent treatment of blinatumomab and dli resulted in the longest disease-free interval for our patient compared to preceding chemotherapy or dli alone. together with the small number of reported cases (ueda et al.) this supports the concept of concurrent blinatumomab and dli as an effective post sct treatment. the objective of the study is to evaluate the clinical efficacy and safety of decitabine (dac) in combination with haag regimen [homoharringtonine (hht), cytarabine (ara-c), doxorubicin (acla) and recombinant human granulocyte colony stimulating factor (g-csf)] for advanced patients with acute myeloid leukemia (aml). thirty-six patients with advanced aml receiving dac combined with haag chemotherapy in our center from december to august were enrolled in this study. eighteen of them were refractory or relapsed aml, and another patients were those who didn't achieve complete remission (cr) after a course of induction chemotherapy. the therapeutic responses, side effects and longtime survival were retrospectively analyzed. after a course of treatment, the rate of cr and partial response (pr) was . % ( / ) and . % ( / ) respectively, while the overall response rate (orr) was . % ( / ) in the cohort. for the patients with refractory or relapse aml, cr was . % ( / ), pr was . % ( / ), and orr was . % ( / ). while for the other not getting cr after a course of induction chemotherapy, cr was . % ( / ), pr was . % ( / ), and orr was . % ( / ). grade hematological toxicities were observed in all patients, and . % cases experienced infection. and all non hematological side effects were mild and well-tolerated. with a median follow-up of . ( . ~ . ) months, the -year overall survival (os) rate was . %, . % for the refractory or relapsed aml patients, and . % for those not achieving cr after a course of induction chemotherapy. the difference was significantly (p = . ). conclusion dac combined with haag regimen is safe and effective salvage treatment for advanced stage aml patients. disclosure of conflict of interest: none. aml patients harboring flt -itd mutation are associated with decreased survival compared to patients without flt -itd mutation. nevertheless, whether flt-itd mutation also has negative impact on the post-transplant survival is less clear. for flt -itd mutated aml, a decreased leukemia-free survival (lfs) after allogeneic hsct was observed in ebmt analysis but not cibmtr. in this study, unlike studies of ebmt or cibmtr which only pre-specified populations of patients were analyzed (cr in ebmt, cr +cr in cibmtr), we examined the prognostic impact of flt -itd mutation on post-transplant outcome of "all" the adult aml patients reported to taiwan bone marrow transplant registry (tbmtr). tbmtr is a research collaboration affiliated to the taiwan society of blood and bone marrow transplantation. it comprises all the transplantation centers in taiwan that contribute detailed data on hsct. adults aged ⩾ years with a diagnosis of aml and with known flt-itd mutation status in the registry were included. patient characteristics and transplant outcome following allogeneic hsct for flt -itd mutated and nonmutated aml were compared. kaplan-meier estimates were used to calculate the probability of lfs and overall survival (os). multivariable analyses for lfs and os were performed using cox proportional hazards model. patients who met the eligibility criteria were enrolled for analysis. the median follow-up of survivors was months. of the patients, ( . %) were positive and ( . %) were negative for flt -itd mutation. flt -mutated patients had significantly more transplantation at cr ( . %), shorter time interval between diagnosis and hsct ( . months), and higher wbc count at diagnosis ( . × /l) comparing to patients without flt mutation ( . % at cr , . months from diagnosis to hsct, and . × /l wbc count at diagnosis). significant more flt mutated patients had intermediate-risk ( . %) and normal ( . %) karyotype at diagnosis. the age, donor type, stem cell source, conditioning regimen, and atg use were not significant different between flt -mutated and non-mutated patients. of the whole population, flt mutation status did not negatively impact the transplant outcome ( years os for flt mutated and non-mutated patients: . % vs %, log rank p = . ; years lfs for flt mutated and non-mutated patients: . % vs . %, log rank p = . ). when different pre-transplant conditions (cr , subsequent cr, and no cr) were analyzed separately, flt -itd mutation status is still not a significant prognostic factor of os and lfs for patients in cr (equally good) and no cr (equally bad). however, for patients in subsequent cr, flt -itd mutation is the only significant factor predicting poor os and lfs in multi-variable analysis (median os and lfs for flt mutated and nonmutated patients: vs days, log rank p = . ; vs days, log rank po . respectively). the incidence of non-relapse mortality, grade / acute gvhd and extensive chronic gvhd is comparable between flt -mutated and nonmutated patients. flt -itd mutation is a significant and strong predictor of poor survival for aml patients in subsequent cr at hsct. for flt -itd non-mutated aml, a sizable portion of patients can have disease free survival after allogeneic hsct at subsequent cr. however, allogeneic hsct at cr should be strongly recommended for flt -itd mutated aml. [p ] disclosure of conflict of interest: none. allogeneic stem cell transplantation (asct) is a curative strategy in acute myeloblastic leukemia (aml) and myelodysplastic syndrome (mds). however, relapse keeps being the main cause of treatment failure. extramedullary relapse (er) is a rare event and its management is not well standardized. we retrospectively analyzed patients who received asct from to and developed er in our centre. we performed a descriptive study to analyze characteristic of these patients, post-relapse treatment and survival. statistic analysis was performed using spss v. . we found a total of patients with er, one of them with er after consecutive asct, so we analyzed cases of er. patient and transplant characteristics are summarized in table . at day + , % of patients were in complete response (cr). er occurred after a median of ( - ) months post-asct. eleven patients ( %) presented with a bone marrow relapse concomitant with the er. er affected central nervous system (cns) in patients ( . %), bone in patients ( %), skin or soft tissue in patients ( . %), mama in patients ( . %), ocular globe in patients ( . %) and teste in patients ( . %). two of them presented with multiple sites affected. between the patients who developed cns relapse, of them had received intrathecal prophylaxis. regarding post-er management, immune modulation was conducted in patients (immunosupression tapering in , donor lymphocyte infusions in and both strategies in ). all patients except one received systemic treatment (salvage chemotherapy in , azacitidine in , low dose arac in and atra in patient with a promyelocytic leukemia). together with systemic treatment, received radiotherapy and intrathecal therapy was used in all patients with cns involvement. response: out patients treated, ( . %) achieved cr and ( . %) progressed. two responding patients received a nd asct. after a median follow-up of months ( - ), patients are alive and disease free, with an estimated overall survival of % at years. patients receiving salvage chemotherapy followed or not by a nd asct experienced a significantly better os than those receiving other therapies (median os vs months; p = . ). patients with bone marrow involvement at relapse show a worse prognosis (median os vs months; p = . ) although not statistically significant due to small number of patients (image ). ten patients died due to disease progression. er must be considered in patients receiving an asct in case of organ symptoms. patients can be rescued with salvage chemotherapy followed or not by a nd asct achieving good results in terms of long term os. it seems that involvement of bone marrow at relapse confers a worse prognosis, what should be confirmed in a larger series of patients. [p ] disclosure of conflict of interest: none. flag-ida regimen as bridge therapy to allotransplant in refractory/relapsed aml patients: a single-center experience c pasciolla, m delia, d pastore, p carluccio, a ricco, a russo rossi, a mestice, f albano and g specchia university of bari, italy although treatment outcome in acute myeloid leukemia (aml) adult patient has improved over the past decade, relapse still occurs in up to - % of cases. furthermore, - % of patients fail to achieve complete remission (cr) because of treatment-resistance. the management of primary refractory and/or relapsed disease remainschallenging for clinicians. in our study, we reviewed the outcome of refractory and/or relapsed aml patients who underwent salvage therapy with the flag-ida regimen between and at our institution. the study aim was to determine the efficacy of the flag-ida regimen in order to clarify which variables (who ps, ldh, bone marrow, peripheral blood blasts and platelets counts, white blood cells (wbc), pmn, molecular-cytogentic risk, duration of response and relapsed or refractory disease), present before starting flag-ida treatment, might have an impact both on cr and on os. we analyzed consecutive adult patients ( males, females; median age years, range - ) with newly diagnosed acute myeloid leukemia refractory to standard induction regimens or relapsed after cr, who received the flag-ida protocol as salvage therapy between january and december . sixty-eight of the patients ( %) were in first relapse, forty-seven patients ( %) were refractory to conventional chemotherapy. median wbc count before salvage therapy was . x /l (range . - ). median bone marrow and peripheral blasts counts were and %, respectively; median platelets count was x e /μl. according to the fab classification, patients had m , m , m , m , m , m , had biphenotype acute leukemia. according to molecular-cytogenetic risk stratification ( %), ( %) and ( %) patients belonged to poor, intermediate and good risk group, respectively. sixty-nine of patients ( %) achieved complete remission (cr); forty-seven %) patients were refractory to the salvage therapy. in multivariable analysis, variables with positive impact on response rate were lower wbc counts (o e /μl, p = . ), higher platlets counts ( x e /μl, p = . ), molecular-cytogenetic risk (p = . ), duration of response in relapsed aml (p = . ) and relapsed rather than primary refractory disease (p = . ), respectively. median os was months (m). cox regression analysis confirmed that both higher platlets counts, p = . ( ( x e /μl) vs m (o x e ul), log rank, p = . ) and relapsed disease, p = . ( (relapsed) vs m (refractory), gehan-breslow, p = . ) correlated with better survival. of note, molecular-cytogenetic risk evaluated before starting treatment was associated with cr, while no correlation was found with os. our data seem to confirm the value of flag-ida in relapsed amland may suggest its best usage as bridge-therapy in patients awaiting allotransplantation. disclosure of conflict of interest: none. s leukemia relapse is the major cause of death in patients received allogeneic hematopoietic stem cell transplantation (allo-hsct). the precise etiological mechanisms of leukemia relapse remain unclear. both leukemia cells themselves and hematogenesis micro-environment are involved in the relapse event. in our previous study, we reported a case of donor derived relapse of acute myeloid leukemia (aml) after allo-hsct. the patient and his donor-sister both harbored a germline mutation(c. - dup) in cebpa gene. donor hematopoietic cells transformed to aml by developing two somatic cebpa mutations ( dupc and - dup) in the patient's microenvironment. hence we suspect that - dup mutation of cebpa gene may altered hematopoiesis microenvironment and increased the survival of aml cells. to conform our hypothesis, we transfected mesenchyme stem cells (mscs) with cebpa - dup or wide type and took vector as control. aml cell line hl cells were co-cultured with transfected mscs and then treated with ng/ml doxorubicin. apoptosis and cell cycle were detected at day . mscs protected hl cells from toxicity of doxorubicin. this protection was enhanced by overexpression of cebpa - dup . apoptosis rates of hl cells in group of msc-vector and msc-cebpa - dup were . ± . % vs . ± . % (p＜ . ). a larger part of hl cells remains quiescent with s higher rate of g /g phase in msc-cebpa - dup group, which may reduce the sensibility of hl cells to doxorubicin. to explore mechanisms involved in the alteration of microenvironment, we performed rna sequence with each group of mscs. we found that col a , col a and col a were upregulated in msc-cebpa - dup group compared with msc-cebpa wt group (col a :cebpa wt vs cebpa - dup was . vs . , p = . e- ; col a :cebpa wt vs cebpa - dup was . vs . , p = . e- ; col a : cebpa wt vs cebpa - dup was . vs . , p = . e- ). furthermore, we found that ddit and herpud genes, which were important factors in cellular unfolded protein response(upr) and to topologically incorrect protein, failed to augment in cebpa - dup group (ddit : vector vs cebpa wt the cure rate of childhood acute lymphoblastic leukemia (all) has improved considerably and approaches % today. however, the outcomes of patients who suffer from leukemic relapse remain unsatisfactory. despite the high cure rate of children and adolescents with all a subgroup of patients benefit from allogeneic hsct. allo hsct remains the standard treatment for intermediate/high risk aml patients. patients, all = and aml = age to years with median age years, m/f = / (m/f all = / , aml = / ) underwent sct in our hospital (from to ). fifty-eight patients transplanted allo hsct and pt aml auto hsct. conditioning regimens consisted of busulfan (iv) +cyclophosphamide for allo and cyclophosphamide + vp +cytarabine for auto hsct. peripheral blood (pb) was the source of progenitor cells in patients, bone marrow (bm) in patients and cord blood in one patient. in allo hsct, patient transplanted / matched and patients / matched. gvhd prophylaxis regimen was cyclosporine + mtx. all patients engrafted. in allogeneic pbsct all patients' median time to absolute neutrophil count (anc) . × /l was days, and the median time to platelet count × was days vs and days in allo bm all patients. in allogeneic pbsct aml patients median time to anc . × /l was days, and the median time to platelet count × was days. (all patients with aml transplanted with pb). at present pts are alive ( all, aml) and pts died due to ards, vod, hemorrhagic stroke, sepsis and relapse. trm was % at days. median time of death after transplantation was days in all and in aml. in allo pbsct all patients hospitalization period were days vs in allo bm all patients. acute gvhd appeared in % pts. chronic gvhd appeared in % pts. with a median follow-up of months ( - months) after transplant the event-free survival were % and four years overall survival % in all patients. a median follow-up of . months ( - months) after transplant the event-free survival were % and three years overall survival % in aml patients. hematopoietic stem cell transplantation can lead to durable remissions in children and adolescents with leukemia and increase in survival of children. pbsct in childhood all was consistent with significant faster anc and platelet recovery in allogeneic pbsct, hospitalization was shorter. longer follow-up is required to evaluate fully efficacy and long-term results. disclosure of conflict of interest: none. group hla-c /c subtypes were defined as previously practiced. median age of patients was , % of them were male. allo-hscts were performed from % unrelated donors vs % related donors. remission status was detected in % of patients whereas % had active disease pre-transplant. stem cell sources were as follows: % peripheral blood, % bone marrow, % cord blood, % bone marrow plus peripheral blood. the most frequent fab subtype was aml-m . patients were grouped by hla-c status: % c /c homozygote, % c /c heterozygote and % c /c homozygote. the frequency of hla c donor/recipient mismatch allo-hscts was %. relapse was detected in % of patients. the relapse risk was significantly lower in c /c homozygote patients compared to c /c homozygotes ( % vs %, p = . ). lfs was similar between c /c homozygote group and c /c homozygote group (p = . ) (figure ). in multivariate analysis (age, sex, remission status, related/ unrelated transplant, aml subtype), lfs was increased by pre-transplant remission status (p year). there was no difference detected between -years os in c /c homozygote group and other groups ( % vs %, p = . ) (figure ) . when similar analysis were repeated with donor hla type results were not significant. our results confirm two earlier published reports on aml and all. even in the absence of kir genotyping, hla group c has a protective effect. if hla matched donor is not possible a donor-recipient hla-c mismatch favoring c to c may be preferable. disclosure of conflict of interest: none. immunomodulatory kits do not induce aml-blasts' proliferation ex vivo: ipo- is an appropriate and reliable marker to detect and quantify proliferating blasts c plett, dc amberger, a rabe, d deen, z stankova, a hirn, y vokac, j-o werner, j schmohl, d krämer, a rank, c schmid and h schmetzer aml-blasts can be converted to dcleu by immunomodulatory 'kits' (ex vivo). t-cells' energy can be overcome after stimulation with dc/dcleu and results in antileukemic reactivity. a potential induction of blast-proliferation (e.g. by immunomodulatory kit-application in vivo) in aml-pts has to be excluded. kits containing combinations of gm-csf with - additional factors (pge- / , picibanil, ifnα, tnfα, calciumionophore) were studied with respect to the generation of dc/dcleu from blasts, mediation of antileukemic reactivity (after dc/dcleu-stimulation) and with respect to their potential to induce blast-proliferation in a whole blood (wb) culture-system. we studied different markers (ipo- , ki- , cd ) and quantified blast proliferation before/after culture. we correlated findings with (ex vivo) antileukemic functionality, with disease-entities and the course of the disease. dc-generation: we could generate dc/dcleu regularly from wb culture from aml-pts. detection of blast proliferation: Ø . % (range - %) of uncultured blasts expressed ipo- , . % ( - %) cd , . % ( - %) ki- . induction of blast proliferation: pooling all results we found lowest amounts of proliferating blasts after culture with kit i (gm-csf+picibanil, % ± . ), kit k (gm-csf+pge , . % ± . ), kit m (gm-csf+pge , . % ± . ). amounts of proliferating blasts were lower compared to uncultured cells. highest expression of proliferating blasts was found with ipo- followed by cd and ki- .we found few individual aml-samples with increased blast-proliferation after ex vivo kit-culture. antileukemic activity: t-cells stimulated with dcleu (generated with kits) improved antileukemic activity. correlations between blast-proliferation and antileukemic activity will be presented. clinical correlations: pts with bad (vs good) cytogenetic risk were characterized by higher proportions of proliferating blasts in uncultured blasts; in some pts with iron-deficiency anemia (ida) proportions of cd +unculured blasts were lower than of ipo- /ki- + blasts. ipo- is a stable marker to be used to quantify proliferating blasts in aml-pts. cd is also a good marker, although not suitable for some pts with ida, ki- is no reliable marker for every given pt. subtypes of pts correlated with proportions of proliferating blasts. in general kit treatment of blasts did only exceptionally induce blast proliferation ex vivo. in general lowest risk for blast proliferation was seen after culture with kit i, k and m. t-cellstimulation with dc/dcleu generated after kit-treatment resulted regularly in antileukemic reactivity. we conclude that an in vivo treatment of aml-pts with kits i, k or m might be safe (no induction of blast proliferation). disclosure of conflict of interest: none. the occurrence of additional cytogenetic abnormalities (acas) is common in philadelphia chromosome-positive acute lymphoblastic leukemia (ph+ all), but is of unknown significance in the tyrosine kinase inhibitor era. recent study [aldoss et al., ] has revealed the acas appear to have a significant deleterious effect on outcomes post-hsct in adult ph+ all patients only. we retrospectively analyzed data from adult and pediatric patients with ph+ all who had undergone allogeneic hematopoietic stem cell transplantation (allo-hsct) at our university between and . among patients with ph+ all, patients had available data on conventional cytogenetics before allo-hsct. all patients and transplant characteristics are listed in table i . thirty-three of patients ( %) had isolated t( ; ). acas were revealed in / ( %) pts, including / ( %) pts with ⩾ cytogenetic abnormalities (with complex karyotype, ck). the median follow-up was ( - ) days. overall survival (os) and event free survival (efs) were % ( % ci - ) and % ( % ci - ) at years, respectively. in univariate analysis, prognostic factors associated with increased os and efs were donor type (match related/match unrelated vs haploidentical; p = . for both), the disease status at transplant (cr vs beyond cr ; p = . , only for efs), acas (aca-vs aca+; p = . , only for os) and, especially, the complex karyotype (ck-vs ck+; p = . , only for os) (figure ). multivariate analysis showed that the independent prognostic factors for os and efs remained the complex karyotype (hr- . , % ci, . - . ; p = . ) and disease status at transplant (hr- . , % ci, . - . ; p = . ), respectively. the study demonstrates the acas and disease status at allo-hsct to be independent prognostic factors not only for adult, but for pediatric ph+ all patients too. up to % of newly diagnosed acute myeloid leukemia (aml) patients (pts) present initially with hyperleukocytosis consequently placing them at increased risk for morbidity and mortality during induction. , whereas early publications have indicated that hyperleukocytosis is an adverse prognostic factor associated with poor long term outcome, it is currently unknown whether hyperleukocytosis still retains prognostic value for aml patients undergoing allogeneic stem cell transplantation. furthermore, it is unknown whether hyperleukocytosis retains prognostic value when modern molecular markers such as flt and npm are accounted for. we hypothesized that hyperleukocytosis at initial diagnosis is still an independent adverse prognostic factor influencing long term outcome in aml pts undergoing allogeneic stem cell transplantation. we performed a retrospective analysis using the multicenter registry of the acute leukemia working party (alwp) of the european society for blood and marrow transplantation (ebmt). pts included in the analysis were over years of age, with de-novo non-m aml, a presenting white blood cell count of over k, with an hla matched related or unrelated donor, transplanted between and . clinical outcome indices of hyperleukocyotosis pts namely, non-relapse mortality (nrm), graft versus host disease (gvhd), relapse incidence (ri), leukemia free survival (lfs), overall survival (os) and gvhd-free/relapse-free survival (grfs) were compared to a cohort of pts without presenting leukocytosis. multivariate analyses were used to assess whether hyperleukocytosis was independently associated with ri, nrm, os, lfs, and grfs. age, gender, number of chemotherapy inductions, cytogenetics, donor type, fms-like tyrosine kinase- (flt ) status, nucleophosmin (npm ) status, and conditioning intensity were covariates for regression modeling. a cohort of pts with hyperleukocytosis ( patients with wbc over k and less than k, and patients with wbc over k) was compared to pts without hyperleukocytosis. pts with hyperleukocytosis were younger, had an increased rate of favorable risk cytogenetics, were more likely to be flt and npm mutated, and had an increased rate of myeloablative conditioning. on univariate analysis pts with hyperleukocytosis had an increased rate of ri ( % vs . %, p = . ), and decreased incidence of grfs ( . % vs . %, p = . ). in multivariate regression analysis, hyperleukocytosis was significantly associated with increased ri (hazard ratio [hr] of . , % confidence interval [ci], . - . ; p = . ), s poorer lfs (hr of . , % ci, . - . ; p = . ), decreased grfs (hr of . , % ci, . - . ; p = . ), and poorer os (figure ) (hr of . , % ci, . - . ; p = . ). image/graph hyperleukocytosis at initial presentation retains a significant prognostic role for aml patients undergoing allogeneic stem cell transplantation even in the current era of advanced molecular prognostication. outcome after hematopoietic stem cell transplantation for philadelphia-positive aml: relatively favorable outcome in patients allografted in first complete response; a survey from the acute leukemia working party of the european society for blood and marrow transplantation (ebmt) v lazarevic , m labopin , w deipei , i yakoub-agha , a huynh , p ljungman , n schaap , d blaise , jj cornelissen , n maillard , p pioltelli , t gedde-dahl , s lenhoff , m houhou , j esteve , m mohty and a nagler , aml with t( ; ) and bcr-abl rearrangement (ph-pos aml) is a very rare aml subtype, recognized as a new provisional entity in the recent who classification. the role of stem cell transplantation (sct) in the era of abl tyrosine-kinase inhibitors (tkis) is mostly unknown. we analyzed long-term outcome in patients ⩾ years after allogeneic or autologous sct performed between - in ebmt centers responding to a designated survey. patients with blast crisis cml and philadelphia-positive all were excluded. primary end-point was os. secondary end-points were nrm, acute gvhd, chronic gvhd, lfs, ri, and the effect of tki on outcome. patients (median age, years, range: - ; males and females) with ph-pos aml undergoing sct (allogeneic, ; autologous, ) were identified. median wbc count at diagnosis was x /l ( . - ) and % had splenomegaly (data missing on patients). translocation t( ; ) was the sole abnormality in patients ( . %). the majority of the patients received one or two courses of chemotherapy before transplant and % attained cr after one course. the majority ( %) received a tki (mostly imatinib, / ) before transplant, with a median period of exposition of days (iqr - ), while ( %) received tki after the transplant either as maintenance (n = ) or treatment for relapse (n = ). at time of transplant, patients were in complete response (cr - , including all autosct; cr - ) and the remaining patients were allografted in advanced phase. among patients with available information, achieved a mrd negative status at transplant (ratio bcr-abl/abl o ).regarding allosct, conditioning regimen was myeloablative (mac) in / ( %) patients o years, while in patients years received a reduced intensity regimen (ric) and mac. cell source was peripheral blood stem cells in and bone marrow in allogeneic transplants. the donor was a hla matched sibling (msd) in cases and unrelated (ud) in , amongst whom were / and were / hla matched, respectively. in the patients undergoing autologous sct the majority received busulfanbased conditioning (n = ) and peripheral stem cells (n = ). median follow-up was . . %, . %, . %, and . %, respectively. by the univariate analysis, age ( o vs ⩾ ) was associated with ri ( -yr: . vs %), lfs ( -yr: . vs . %, and grfs ( -yr: . vs . %), whereas mrd-negative status before allosct was associated with an improved grfs ( . vs . %). in the patients autografted, ri, nrm, lfs and os at -year was % ( . - . ), %, % ( . - . ), and . % ( - ), respectively. outcome of patients with ph-pos aml who received allosct in cr in recent years was relatively favorable, especially among younger patients, probably reflecting the beneficial effect of tki. disclosure of conflict of interest: none. outcome of allografting for aml-cr is equivalent across the bsbmt and ebmt and is associated with encouraging os and dfs across all age groups j byrne, j perry , k kirkland , r pearce and g jackson bsbmt and newcastle university and freeman hospital, newcastle relapsed aml has a very poor prognosis with a high mortality, even if a second cr is achieved. the only curative treatment is with an allogeneic hsct but allografts for aml in cr are considered to have a worse outcome compared to those performed in cr , especially in older patients for whom this therapy may not be considered. the bsbmt undertook a bench-marking study analysing the outcomes for all patients allografted for aml-cr from to . the uk outcomes from paediatric and adult patients were compared to non-uk patients transplanted for the same indication reported to the ebmt during the same period. allogeneic transplants for aml-cr represent an important part of any allograft program and numbers referred for allograft were stable between - in both programs. the median age of patients was . yrs and . years in the bsbmt and ebmt cohorts respectively, with % and % of patients aged o years and % and % aged years in the groups. the length of first remission was missing in many of the ebmt registrations so time from diagnosis to transplant was used as a surrogate for this and was similar in both cohorts ( m and m respectively). similarly the presence of comorbidities was poorly reported in both databases but was similar. the bsbmt cohort included fewer patients undergoing ric conditioning protocols ( % vs %), fewer sibling transplants ( % vs %) and more pbsc allografts ( % vs %). transplant related morbidity and mortality were similar across the two cohorts (bsbmt v ebmt) with rates of severe acute gvhd (grade iii and iv) % v %, limited chronic gvhd % v %, relapse at year % v % and death in cr at year % v %. chronic gvhd (both limited and extensive) appeared more common in the bsbmt cohort ( % v %) although reporting of cgvhd was more comprehensive and complete within the bsbmt registry and may be under-reported in the ebmt registry. outcomes were excellent in both cohorts with outstanding rates of leukaemia free survival in this high risk cohort at day (bsbmt v ebmt) % v %, at year % v %, at years % v % and at years % v %. although os and lfs was significantly shorter in patients aged years, at % and % the results in this high risk age group are acceptable and warrant its continued use. multivariate analysis of the combined cohorts showed that age at transplant ( o yrs/ - / yrs), time from diagnosis to transplant and the presence of agvhd were important factors affecting dfs. risk factors for relapse included the type of conditioning used, presence of agvhd and time from diagnosis to transplant, whereas those for trm included age, agvhd, source of stem cells and time to transplant. there was no significant difference in outcomes between the bsbmt and ebmt for this indication. outcomes for patients allografted for aml-cr are excellent and appear superior to those reported for patients not undergoing an allograft in both the bsbmt and ebmt cohorts. the os and dfs observed are comparable to those reported for allografts in aml-cr and, although this study has not considered outcomes for patients who did not achieve a nd cr, it nevertheless supports the practice of risk stratification of aml patients such that only high risk patients are offered an allograft in cr with the remainder being offered an allograft as salvage after relapse. disclosure of conflict of interest: none. to evaluate the efficacy and safety of intensive chemotherapy followed by allogeneic hematopoietic stem cell transplantation (allo-hsct) for atl. a total of evaluable atl patients treated at our center from to are retrospectively analyzed. the htlv-i proviral dna load in peripheral blood mononuclear cells using pcr assay was developed, in comparison with htlv- tax protein expression measured by western-blot, to confirm the diagnoses and monitor the disease control. patients were male and patients were female. median age was . (range - ) years. all obtained patient samples were subjected to flow cytometric examination and karyotype analysis. patients received chemotherapy as the induction therapy while quit at the time of diagnosis, with da-edoch regimen while with other regimens such as chop, vcap and amp. da-edoch regimen is a variation of dose-adjusted epoch regimen with the replacement of prednisone ( mg/m per day) by dexamethasone ( mg/m per day). before the conventional regimens bucy followed by prophylaxis donor lymphocyte infusion, both received a course of salvage chemotherapy including fludarabine and cytarabine for days registered on http://clinicaltrials.gov (nct ). the gvhd prophylaxis consisted of atg, csa and mtx. the patient characteristics, therapeutic effect and survival data were collected. all patients came from the coastal area in the south-east of china. subtype classification of these atll were acute, lymphoma and chronic type. the main manifestations were characterized with cutaneous and respiratory involvement, hepatosplenomegaly, lymphadenopathy and the laboratory abnormalities as leukocytosis with atl cells, hypercalcemia and elevated serum ldh. typical morphological characterisitic of "flower cells" were observed in . % cases and most of the atll cells are cd +cd -. chromosomal abnormalities were detected in cases. all patients who didn't receive da-edoch regimen died of disease progress, while among patients with da-edoch regimen, achieved cr, pr and died. with a median follow-up of . ( - . ) months, patients respond to da-edoch are still alive. patients in cr achieved successful engraftment with complete donor chimerism in one month post haplo-identical transplant. both were received prophylaxis donor lymphocyte infusion and the immunosuppressive agents were abruptly discontinued for induction of a graft-verus-atl (gvl) effect. they keep remain alive and disease free longer than years so far without severe graftversus-host (gvhd), and the htlv- proviral dna became undetectable after allo-hsct. conclusion: it shows great promise of da-edoch regimen followed by allo-hsct to the long-term cure of atl with apparent clearance of the virus. haplo-identical transplantation can be an alternative option for the atl patients without increasing non-relapse mortality. [p ] disclosure of conflict of interest: none. in the absence of an hla-matched related donor or a good matched unrelated donor in time, haploidentical stem cell transplantation (haplo-sct) is an option for patients requiring an allogeneic hematopoietic stem cell transplant. substantial progress has been made in the last two decades with a dramatic improvement in patient outcomes, with some groups reporting preliminary beneficial effects similar to the ones in hla matched unrelated donor and cord blood transplant. several strategies have been adopted through the years for the procedure. the two strategies used in haplo-sct are ex vivo t-cell depletion and t-cell replete transplantation. the latter can be done with a combination of immunosupressive drugs ( beijing approach) or with post-transplantation highdose cyclophosphamide (post-cy). due to of its lower cost, feasibility and practicality, post-cy has become the most often used platform for haplo-sct in the majority of allogeneic transplantation units worldwide. we analyzed our experience in haplo-sct, since the first one in march to the last one that has just been done in october . we collected all complications reported, also mortality related to treatment and to the disease. we analyzed the overall survival (os). transplants were treated, with different sct indications, the most common being acute myeloblastic leukemia (n = , %), the rest of indications are exposed in figure . all our patients, independent of the conditioning receive post-cy as t cell depletion measure and stem cells were collected from peripheral blood. age at the time of transplant was . years, % were males, % females, the rest of patient characteristics are listed in table . in our series the treatment related mortality (trm) was low with only patient ( %) that died before the day + . as complications, we reported % of hemorrhagic cystitis, % of sinusoidal obstruction syndrome, % reports systemic inflammatory response syndrome, % of citomegalovirus (cmv) reactivation. neutrophils graft is . days (r = - ) and the platelets graft is . days (r = - ). in our series we haven't reported any case of graft failure, one of the transplantes the patient had antihla antibodies, this was treated with a plasmapheresis previous the stem cell infusion, and was infused with a high number of cd + cells ( × /kg), no graft problems, and has had no complications since then with the graft. the os for the whole group is months, with a median not reach at months, with patient's dead at time of analysis. two patients had a relapse after the haplo-sct ( %), both of them received lymphocyte donor infusion, sadly, neither of them responded. the haplo-sct procedure is been adopted by many centers for high risk hematology malignancies, mainly because the fast availability of donors, and because of the preliminary results that have been reported place it as good as the unrelated donor or cord unit transplant. our center is getting experience in these types of transplants, and our results reflect similar outcomes as larger studies. with longer follow ups we will be able to keep the trend of good results both in procedure safety and disease efficacy. os, toxicity and trm are expected for these high risk malignancies. in overall, the haplo-sct seems a reasonable technique that is reflecting in our short series, the results being reported in studies worldwide at bigger scale. disclosure of conflict of interest: none. complex karyotype, the presence of flt- itd and losses of genetic material in chromosome , are all considered high risk markers in aml. patients bearing these abnormalities could undergo a myeloablative allogeneic transplantation in cr whenever this is possible, although this could significatly reduce the chances for cure in older patients due to increased transplant related mortality. ric allografts could be performed in older patients in order to overcome the deleterious effects of these individual abnormalities but its effect still remains controversial in the high risk group. between and , a total patients [ males, females, mean age . ( - )] received a ric allograft ( from fully matched unrelated donors, and from an identical sibling) for high risk aml in transplant centres. high risk disease was classified according to their response to treatment, the presence of complex karyotype, the presence of individual cytogenetic/molecular abnormalities or a combination of these. in particular, patients presented one single karyotype abnormality and presented three or more. ten patients presented alterations of chromosome and patients presented flt- itr. the conditioning regimes included fludarabine in all cases, together with melphalan and campath ( patients), busulphan and campath ( patients), busulphan and thiotepa ( patient), melphalan ( patients), busulphan with and without atg ( patients) total body irradiation ( cgy, patients). graft versus host disease prophylaxis was ciclosporin for patients receiving alemtuzumab or atg but for patients who had a t-replete allograft ciclosporin and low dose methotrexate was the preferred prophylaxis. all but four patients were transplanted in cr patients were followed-up for a mean . months (range - ). thirty-one ( %) patients remain alive. the causes of death ( cases) include relapse or progression of the original disease ( ), transplant-related causes ( ) and unknown in cases. the influence of the genetic abnormalities on survival was analysed, showing there were no significant differences between patients with normal karyotype, single chromosomal abnormalities and two or more abnormalities. likewise, the kaplan-meier survival analysis of patients bearing flt- itd was not significantly different to the rest of the cohort (p = . ; / died, with only one case being related to relapse). patients bearing chromosome abnormalities (with or without other chromosomal aberrations) had a comparable, not significantly (p = . ) different survival to the rest of the cohort: / patients bearing this abnormality died although, most interestingly, none of these deaths were related to relapse. our results indicate ric allografts can provide an adequate consolidating effect in hr aml with complex karyotype, alteration of chromosome or flt- itr, yielding clinical results that are comparable to those obtained in patients with aml allografted for other indications. this is particularly important as these alterations are more frequent in patients whose age prevents them from having myeloablative grafts. disclosure of conflict of interest: none. early detection of inapparent replicative human cytomegalovirus (hcmv) infection together with its preemptive antiviral treatment has led to a marked reduction of life-threatening hcmv disease after allogeneic hematopoietic stem cell transplantation (allosct). we first reported in a retrospectively performed study that hcmv reactivation is associated with a reduced risk for relapse in patients with aml after transplant. now, we evaluate the impact of early hcmv replication on the risk for leukemic relapse in patients with aml after t cell depleted transplantation in a prospectively performed observational study (registration trial drks ). between january and march we enrolled patients with aml in this trial who were consecutively transplanted at the university hospital of essen. patients received a myeloablative regimen (tbi based conditioning n = , chemotherapy based conditioning n = ) and patients a ric (n = chemotherapy based regimen). patients were transplanted in .cr (n = ), .cr (n = ) or more progressive disease stages (n = ) from hla-identical sibling donors (n = ) or hlaidentical unrelated donors (urd) (n = ) or mismatched unrelated donors (n = ). patients who received a second transplant were excluded from the study. the median age of patients was years (range - ) and that of the donors years (range - ). gvhd prophylaxis was performed with mtx and csa, or csa and mmf with (n = ) or without atg (n = ) ( - mg total dose). the incidence of acute gvhd grade - was statistically not different in both groups ( % versus %). hcmv-reactivation (hcmv-r) detected by pcr occurred between and days (median days) after allo sct. only patients surviving day after transplant were included in the study for estimation of relapse incidence (cir) or overall survival (os). hcmv status of recipients (r) or donors (d) were in % r-/d-, % r-/ d+; % d+/r-and % r+/d+. patients with a documented hcmv-r had a cir at -year after transplant of only % as compared to % in patients without a hcmv-r (p = . ). estimates for -year os were in favor for patients with hcmv-r ( % for patients with hcmv-r versus only % for patients without hcmv-r), but this did not achieve statistical significance. non-relapse mortality was greater in patients with hcmv reactivation ( % versus %, ns) a substantial and independent reduction of relapse risk associated with early hcmv replication was confirmed by multivariate analysis including competitive factors as unfavorable cytogenetics according to eln, advanced disease stages of aml, hla-identical donor versus mismatched donor, sibling versus unrelated donor, presence of acute gvhd grades ii-iv, chronic gvhd, and hcmv-r [(hazard ratio: . , % ci: . - . , p o . ) for occurrence of hcmv-r]. the final result of this first prospective performed study confirms an independent advantageous effect of early hcmv replication on the leukemic relapse risk in patients with aml after transplant. disclosure of conflict of interest: none. . primary engraftment of wbc and platelets was achieved in pts, one patient (pt) died at day + after hsct, and one had a secondary graft failure. a median time to wbc engraftment was days ( - ), to platelets - days ( - ). cumulative incidence (ci) of acute gvhd (agvhd) grade ⩾ ii was % ( % ci: - ): from haplo- %( - ), from mud % ( - ),p = . . ci of agvhd iii %( % ci: - ): haplo vs mud - % ( % ci: - ) vs %( % ci: - ), respectively,p = . . ci of chronic gvhd (cgvhd)- % ( % ci: - ). ci of agvhd was significantly lower in a group with regimen ( - ) of gvhd prophylaxis: % ( % ci: - ) vs %( % ci: - ), po . . regimen was also effective in prevention of cgvhd: ci at year after hsct was % vs %, p = . . Сi of trm was %( % ci: - ): haplo- %( - ), mud - % ( - ). early mortality (before + -day) was relatively low (n = ): pt died from bacterial sepsis; two pts died due to adv infection. thirteen pts died after days: pts relapsed and died due to complications of second hsct; bacterial sepsis in pt and viral infection (adv and cmv) in pts ( with extensive chronic gvhd). ci of relapse was % ( % ci: - ) at year: from haplo- % ( % ci: - ), from mud- % ( % ci: - ),p = . . event-free survival (efs) at years was % ( % ci: - ): haplo - %( % ci: - ), mud - % ( % ci: - ), p = . . os was % ( % ci: - ) at years: haplo- % ( % ci: - ), mud - % ( % ci: - ), p = . . relapse-gvhd-free survival at years was different among recipients of haplo and mud hsct: %( % ci: - ) vs % ( % ci: , p = . . we confirm that the depletion of tcrαβ+/cd + depletion from the graft ensures high engraftment rate and acceptable transplant-related mortality in pediatric aml pts. there is a trend towards better efs for haploidentical transplantation. gvhd prophylaxis including ratg/rituximab/bortezomib improves gvhd control s in recipients of tcrαβ+/cd +depleted grafts in comparison to hatg/tacro/mtx apparently without loss of anti-leukemic activity. disclosure of conflict of interest: none. results of t-cell depleted haploidentical stem cell transplantation in adults with acute leukemia improve with time: a study from the acute leukemia working party of the european society of blood and marrow transplantation (ebmt) s simona , , m labopin , a ruggeri , , , a velardi , f ciceri , j maertens , l kanz , f aversa , d bron , d bunjes , m mohty , and a nagler , t cell-depleted (tcd) transplants from haploidentical donors are increasingly used in the absence of a hla full-matched donor for patients (pts) with high risk acute leukemia (al). progress has been made in optimization of conditioning regimens and post-transplant cellular therapy to potentiate the graft-versus-leukemia effect with no graft-versus-host disease (gvhd). however, relapse incidence (ri) and non relapse mortality (nrm) remain the main obstacles for pts outcomes. we report adults with de novo al, given a tcd haplo from to . to analyze the effect of transplant period on tcd haplo outcomes, pts were analyzed in two separate groups: - (n = ) and - (n = ). tcd haplo were performed in ebmt centers. median follow-up was months with no difference according to transplant periods. median age was different between groups, being and years respectively (p = . ). the majority of pts had acute myeloid leukemia (aml) ( % vs %, p = . ) and disease status at haplo was first complete remission (cr ) in % and % of pts respectively (p = . ). pts transplanted before had more frequently a karnofsky performance status o % ( % vs %, p = . ). conditioning was myeloablative in % and % of tcd haplo before and after (p = . ), mainly based on fludarabine(flu)-tbi, flu-melphalan-thiotepa or cyclophosphamide-tbi. as for ric it was flu-melphalan-thiotepa, flu-tbi or cyclophosphamide-tbi. the cumulative incidence (ci) of neutrophil engraftment, grade ii-iv acute gvhd and chronic gvhd were not different according to transplant period, being % and %, p = . ; % and %, p = . ; % and %, p = . , respectively. in the whole population -year ri and nrm were % and %, with no difference before and after ( % vs %, p = . ; % vs %, p = . , respectively). ri was % before versus % after . the main cause of nrm was infection, with no difference over time ( % vs %, p = . ). in multivariate analysis, disease status was the only factor associated with ri (hr . , % ci . - . , p = . ). tcd haplo after (hr . , % ci . - . , p = . ), younger age (hr . , % ci . - . , p = . ) and ric (hr . , % ci . - . , p = . ) were independently associated with lower nrm. -year os was % with a marked improvement for tcd haplo performed after ( % vs %, p = . ), while lfs and grfs were % and %, respectively. according to disease status, -year lfs, os and grfs were higher for pts transplanted in cr ( % vs %, p o . ; % vs %, p = . ; % vs %, respectively p = . ). in multivariate analysis, tcd to further establish the role of haplosct in high-risk aml, we performed a retrospective matched-pair comparison of hlamatched sct vs haplosct/ptcy in two german centers. highrisk aml was defined by any of the following criteria: refractory or relapsed aml, secondary aml, or genetic aberrations classified as intermediate-high or adverse accordingly to the eln classification. all consecutive adults, who fulfilled ⩾ of these criteria before either hla-matched or haplosct/ptcy were included (n = ). recipients of haplosct were pair-matched with patients receiving a matched donor sct. matching variables were ( ) stage at sct, ( ) genetic subgroups accordingly to eln, and ( ) age (± y). patients (pts) undergoing haplosct/ptcy could be successfully pairmatched (p = . for stage and genetic subgroup, . for age) with recipients of matched sct ( family, unrelated sct). within the entire cohort, median patient age was y ( - ). at start of conditioning, % of patients were in cr, % had refractory, % had relapsed, and % had untreated disease. genetics were favorable ( %), intermediate i ( %), intermediate ii ( %) and unfavorable ( %). hla-matched sct was uniformly performed following flamsa-ric. recipients of haplosct/ptcy ( %) received cytoreductive chemotherapy with flamsa (n = ) or clofarabine (n = ) before ric was started. median follow-up among survivors was months. overall cr rate at d+ was %, patients suffered from refractory disease or early death, (n = each). overall-survival (os) for the entire cohort was %/ . % at y/ y from sct. the corresponding y/ y leukemia-free survival (lfs) was . %/ . %. median time to engraftment was . and . days after matched and haplosct, respectively (p = . ). with respect to outcome, no difference was observed between the two groups: os at y/ y was . %/ . % after matched sct, and . %/ . % after haplosct/ptcy (p = , , figure ). lfs at y/ y was . %/ . % within the hla-matched group and . %/ . % within the haploidentical group (p = , ). recipients of haplosct showed a higher incidence of agvhd ⩾ ii°( % vs %, p = . ), as well as a trend towards increased y-nrm ( % vs %, p = . ), whereas y-relapse rates were comparable ( % after haplosct/ptcy vs % after matched sct, p = . ). relapse was the most frequent cause of death in both cohorts, main causes of nrm were gvhd and infections (no difference between the two groups). allogeneic sct following sequential conditioning can achieve excellent results in high-risk aml. in our study, results after haploidentical transplantation were comparable to those obtained after hla-matched sct. hence, haplosct/ptcy following sequential conditioning can be considered as a reasonable option for patients with high-riaml. [p ] disclosure of conflict of interest: none. a significant proportion of patients with acute myeloid leukemia ( aml) will either be refractory to initial chemotherapy or will suffer refractory relapse. the role of allogeneic transplantation (hct) in active disease is contentious. there is a growing body of literature that sequential chemotherapy, pioneered by the german flamsa regimen, followed by ric hct is a safe and efficacious modality in these patients, and there have been numerous modifications of this regimen, especially as amsacrine is not widely available. fludarabine, cytarabine and etoposide (vp ) (flav) have been reported as an an effective salvage regimen. here we report on single center outcomes of a variation of the flamsa regimen, substituting amsacrine for etoposide with mainly myeloablative conditioning. patients were consented for a clinical protocol if they had aml that was refractory to cycles of chemotherapy, or cycle and considered to be at risk of complications of a second cycle, and if they had a matched related donor. patients with myelodysplasia received flav if they had high or very high risk cytogenetics. cytoreductive chemotherapy consisted of fludarabine mg/m / day × days, cytarabine g/m /day × days, etoposide mg/m /day × days, commenced simultaneously. after days of rest, conditioning chemotherapy consisted of fludarabine mg/m × days and and iv busulfan . mg/ m q hours; the number of busulfan doses varied between - , depending on patient comorbidity. ten patients ( %) received myeloablative doses of busulfan. patient received doses of atg at . mg/m /day on day - and - . patients received gcsf mobilized peripheral blood hematopoietic cells. post-transplant gvhd prophylaxis was csa and mmf. csa was tapered from day+ and stopped at day + in the absence of gvhd. mmf was discontinued between day + and day + . donor lymphocyte infusions were collected for planned prophylactic dli. thirteen patients received a flav-sct between march and october . the median age was ( - ); male:female ratio was( : ). patients ( %) had aml and ( %) pts had mds. all patients had detectable disease prior to flav. the median time for plt engraftment was days ( - ). the median time for anc engraftment was days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . cytogenetic cr rate on a day - bone marrow was %, and morphological cr was %. patients ( %) developed veno-occlusive disease. acute gvhd grade ii-iv occured in pts ( %). ( %) patients developed chronic gvhd. death was due to disease relapse in ( %) and nrm in ( . %) patients, resulting from h n pneumonia. patients ( %) received dli for post transplant relapse, and one of these is in molecular remission. at a median follow up of . months post transplant ( . - m), year dfs was %. the year and year os was % (± %) (figure ). our experience, consistent with published data, demonstrates that for patients with active aml refractory to chemotherapy, transplantation is an effective modality of disease control and may be the only curative therapy in a significant proportion. etoposide appears to be a suitable alternative to amsacrine. our patients tolerated busulfan at myeloablative doses, and this may be required for adequate disease control. our report is limited by small numbers and relatively short follow-up, but is encouraging enough for us to continue offering flav hct for these high-risk patients. [p ] disclosure of conflict of interest: none. sequential high-dose chemotherapy reinduction followed by haploidentical transplantation in acute leukemias l brunello , , cm dellacasa , l giaccone , , e audisio , d ferrero , , s d'ardia , b allione , s aydin outcomes after t-cell replete haploidentical stem cell transplantation (haplo hsct) have been encouraging and haplo hsct has become an alternative option for patients without a hla-identical related or unrelated donor. , as previously published, the sequential use of intensive chemotherapy and allogeneic transplantation represents a possible approach to the treatment of high-risk acute myeloid leukemia (aml). , between and , acute leukemia (al) patients received sequential therapy (s.t.) consisting of high-dose chemotherapy reinduction and haplo hsct during the chemotherapy-induced neutropenia. median age at transplant was years (range: - ); median number of previous therapy lines was (range: - ) and / ( %) patients had received a previous allogeneic hsct. twelve and out of patients had de-novo aml and secondary aml, respectively; furthermore two patients presented blastic crises of chronic myeloid leukemia. all patients had active disease at the time of s.t. and median marrow blast count before reinduction was % (range: - %). hematopoietic cell transplantation comorbidity index was ≥ in / patients ( %). all patients received high-dose cytarabine (≳ g/sqm) containing regimens as reinduction therapy. the conditioning regimen was started after a median of days from the end of reinduction (range: - ). sixty-eight percent of patients ( / ) were conditioned with a myeloablative regimen (thiotepa tot. mg/kg, busulfan tot. . mg/kg, fludarabine tot. mg/ sqm), while / ( %) patients received a non-myeloablative conditioning. bone marrow was used as stem cell source in / ( %) patients. graft-versus-host disease (gvhd) prophylaxis consisted of post-transplant cyclophosphamide with calcineurine inhibitors and mycophenolic acid. all patients engrafted but one, who was rescued with a second haplo-hsct with peripheral blood stem cells from the same donor. median day of neutrophil recovery was day + (range: - ). median follow-up of survivors was . years (range: . - . ); -year overall and event-free survivals were % and %, while -year relapse incidence and non relapse mortality were % and %, respectively. overall cumulative incidences of acute and chronic gvhd were % and % at day + and + . among patients who developed gvhd, grade iii-iv acute gvhd and moderate-severe chronic gvhd were observed. at . years post haplo-hsct, % of patients are alive and disease free. in our cohort of heavily pre-treated and high-risk patients, s.t. with a myeloablative conditioning was safely used to reduce leukemic burden pre-transplant and enhance graft-versus-leukemia effects. only the prompt availability of a haploidentical donor allowed to implement this treatment modality. though small the patient cohort, our findings suggest that transplant-related toxicity was acceptable and early relapse was the major treatment-failure. however, long-term survival and disease-free rates of % in these very poor prognosis patients are highly encouraging. in elderly patients with acute lymphoblastic leukemia (all) and kinase activating lesions allogeneic stem cell transplantation (allo-sct) is considered to be the only curative option. however, high risk of relapse and non-relapse mortality (nrm) often withholds elderly patients with existing comorbidities from definitive therapy. even though, age alone as the most important eligibility criterion for allo-sct has become less important. a -year old patient with a medical history of adipositas, hypothyreosis, arterial hypertension, hypercholesterolemia and coronary artery disease with stent implantation was diagnosed with common-b-cell-all based on immunophenotype. cytogenetic analysis showed two coexisting clones with an abnormal karyotype of ,xx; t( ; )(q ;q ), + [ ] and ,xx; t( ; )(q ;q ),der( )( ; )(p ;q ) [ ] and no evidence of bcr-abl positive disease using fluorescence in situ hybridization (fish) technique. rt-pcr and sequencing of the fusion transcript was performed to validate the rcsd -abl t( ; )(q ;q ) fusion between exon of rcsd and exon of abl . western analysis of phosphorylated abl and its downstream target crkl was performed to investigate the in vivo activity of dasatinib. clinical monitoring of minimal residual disease (mrd) levels has been performed via rt-pcr of the rcsd -abl fusion transcript followed by nested pcr of the amplicon to detect early relapse or mrd. as positive control the plasmid pcr . -topo_rcsd -abl ( bp) was synthesized encoding rcsd -abl amplicon with the fusion site. our patient was enrolled on gmall elderly ( / ) and treated accordingly. thereby, no sustained remission could be achieved. flag-ida re-induction and study treatment with an oral pi k/mtor inhibitor remained futile. cytogenetics and verification of the rcsd -abl fusion gene prompted salvage treatment with the tyrosine kinase inhibitor (tki) dasatinib as single agent. the in vivo activity of dasatinib was highlighted by a decrease of rcsd -abl amplicon and inhibition of phosphorylated abl and its downstream target crkl was shown. clofarabine and cyclophosphamide complemented treatment and mrd negative remission was achieved due to administration of the bi-specific t-cell engager blinatumomab. consolidation with allo-sct was performed. ongoing remission has been achieved for more than months now. we demonstrate that monotherapy with tki like dasatinib is effective in refractory rcsd -abl positive all. to the best of our knowledge, this is the first elderly patient with rcsd -abl positive all with a sustained and ongoing complete remission. thereby, we suggest allo-sct after successful tki even for elderly patients with existing comorbidities and uncommon cytogenetics. relapse is the most important cause of failure of allogeneic hematopoietic stem cell transplantation (hsct) for flt -itdpositive acute myeloid leukemia (aml). in those cases, treatment with flt tyrosine kinase inhibitors (tki) constitutes a promising clinical approach to induce remission without conventional chemotherapy. forty-eight-year-old woman was diagnosed of aml secondary to myelodisplastic syndrome with npm mutation and internal tandem duplications of the flt gene (flt -itd). after achieving complete remission (cr), she received a sibling allogenic-hsct. four months later, aml relapsed at the medullary level, without central nervous system (cns) involvement, treated with conventional chemotherapy and donor lymphocytes infusions (dli). she achieved second cr and developed chronic graft-versus-host disease (cgvhd). nine months later, she suffered the first extramedullary relapse, at the mammary, cutaneous and probably pericardial levels. there was not medullary involvement. disappearance of the lesions at all levels was achieved with conventional chemotherapy and radiotherapy, and full donor chimerism. eight months later, she referred atypical precordial pain irradiated to the back. cardiac mri was performed in which several masses were visualized in a pericardial sac up to cm in diameter (dec- ). bm was maintained in cr. in study of pericardial fluid, infiltration by leukemic flt positive cells was observed. the patient was not considered candidate for further systemic chemotherapy nor radiotherapy treatment. then, treatment with the flt sorafenib inhibitor was started, by compassionate use, at dosage of mg/ h, which maintains after one year. after first month with sorafenib, pericardial lesions decreased considerably, ranging from cm in diameter to . cm (jan- ). in the subsequent ct controls, progressive decrease of the lesions has been observed and no new lesions have appeared in other locations. in the last ct (oct- ) pericardial thickening is almost non-existent, without new lesions. after one year of treatment, she maintains cr at medullary and extramedullary levels images. in our patient, treatment with sorafenib has achieved sustained control of extramedullary disease, which had escaped the mechanisms of action of conventional chemotherapy, allotransplant and dli. further studies are needed to corroborate the efficacy of flt inhibitors in the control of aml extramedullary disease and in the treatment of relapses after allo-hsct. all pts with tbi-based regimen received rabbit atg. tcrαβ+/cd + depletion of hsct with clinimacs technology was implemented in all cases according to manufacturer's recommendations. the median dose of cd + cells in transplant was × /kg (range: . - . ), tcrα/β- × /kg (range: . - ). primary engraftment was achieved in of pts. ( pts died before engraftment, one received second hsct), the median time to neutrophil and platelet recovery was and days, respectively. early ( day) mortality was %( % ci: - ), -year ptrm- % ( % ci: - ). the three early deaths were due to bacterial sepsis (n = ) and viral infections(n = ), seven late: viral infection in pts (adv = , adv+cmv = , cmv = ), bacterial sepsis in pts and rhinocerebral mucormycosis in pt, all late deaths were associated with cgvhd and prolonged corticosteroid therapy. ci of acute gvhd grades ii-iv and iii-iv was . % ( % ci: . - ), and % ( % ci: . - ), respectively. ci of cgvhd was . % ( % ci: . - ). regimen was more effective in prevention of agvhd ii-iv: ci at year after hsct was % vs , % in regimen , p = . and in cgvhd % vs . %, p = . . ci of relapse at years was % ( %ci: . - . ). two-year pefs(event = death or relapse) was . % ( % ci: - ), -year pos- % ( % ci: - ). in patients, who received tbi-based conditioning pefs was % ( % ci: - ), as compared with treosulfan-based % ( % ci: - ), p = . . median time of follow-up for survivors was . years (range: . - . ). we confirm that the depletion of tcr-alpha/ beta and cd lymphocytes from the graft ensures high engraftment rate and acceptable transplant-related mortality in pediatric all patients. viral infections and leukemia relapse await further improvement of control. all major outcomes were equivalent between transplantation from unrelated and haplo donor. disclosure of conflict of interest: none. the prognosis of patients (pts) with relapsed/refractory acute lymphoblastic leukemia (all), especially after allogeneic hematopoietic stem cell transplantation (allo-hsct), is very poor. therapeutic options for these pts are limited. blinatumomab is a bispecific t-cell engager (bite) antibody construct with dual specificity for cd and cd . bite therapy may help to overcome the resistance to chemotherapy (ct) with minimal toxicity, and may be a bridge to allo-hsct. we analyzed data of pts from hematologic centers in russian federation with relapsed cd positive all, who received bite. the median age was (range: - ) years, ( %) pts o yrs, ( %) pts ≥ yrs. the diagnosis was all b-i (egil) subtype in pts, b-ii-in , b-iii-in pts, and patient had mixed phenotype leukemia (m (fab) and b-all). three ( %) pts had philadelphia positive (ph+) all. in pts it was the first relapse of all, in -second, in -third. thirty pts had isolated bone marrow relapse, pts-combined relapse (bone marrow and extramedullary sites). the bone marrow blast infiltration was o % in pts, % in pts. disease relapse was revealed after ct in pts ( ( %) pts received allo-hsct after the therapy of relapse), after allo-hsct ( -from related, -from unrelated, -from haploidentical donors)-in pts ( pts received second allo-hsct after the therapy). in pts with posttransplant relapse donor lymphocyte infusion (dli) was used in combination with bite. every patient received from to cycles (median ) of bite. complete remission (cr) was achieved in ( %) pts (in ( %) pts it was minimal residual negative remission): in ( %) pts with all relapse after ct, in ( %) pts-after allo-hsct. pts with less than % blasts in bone-marrow at baseline experienced substantially higher response rates compared with patients with % blasts or higher ( % ( / ) vs % ( / )). response rates were similar although the number of relapse- % ( / ) in first relapse, % ( / ) in second relapse and % ( / ) in third relapse. pts with posttransplant all relapse who received bite in combination with dli had higher response rate than pts, who received bite as monotherapy: . % ( / ) vs % ( / ), respectively. one-year os was % ( % ci - %). one-year dfs was % ( % ci - %). grade ≥ hematological toxicity (neutropenia, thrombocytopenia) was observed in ( %) pts, grade ≥ liver toxicityin ( %) pts. five patients ( %) developed toxic neuropathy during the therapy. cytokine release syndrome occurred in ( %) pts. one patient after allo-hsct (but not after dli) developed grade i agvhd. there were no fatal treatment related toxicity. tree ( %) pts who responded to bite had relapse. eighteen ( %) pts died: pts-of disease relapse/ progression. the treatment of relapsed/refractory all with bite is effective and has acceptable toxicity. we demonstrated high efficacy in therapy of posttransplant all relapses, especially when bite was combined with dli, perhaps, due to additional immunological effect of the transplant. disclosure of conflict of interest: none. the mechanism of sorafenib anti-leukaemic effect seen in aml patients relapsing post allohsct involves the augmentation of alloreactivity which includes infiltration of the affected marrow by cd + cells having pd- receptor which presence characterize lymphocytes with antitumour potential multikinase inhibitor (mki) sorafenib is clinically active in acute myeloid leukaemia (aml) patients, especially in those with flt itd who receive allohsct as a part of their primary treatment. to throw some light on the mechanism of this antileukemic post-transplant sorafenib effect we studied the fate of two patients (flt itd-positive, npm -positive) who relapsed ( -year-old male) and ( -year-old female) days post-transplant and their salvage treatment included sorafenib. the multikinase inhibitor ( mg twice daily) was given either together with flag or da + . the response was prompt. the patients became, after completion of the chemotherapy, leukaemia free. both patients continued the sorafenib ( mg twice daily) treatment together with the aml standard maintenance chemotherapy (female case) or without any chemotherapy (male patient, substantial comorbidity and liver toxicity). ( ) . the patients responded well to the therapy and were free of leukaemia for and + months after initiation of the mki treatment (flt itd negative, % chimerism documented in the blood and in the marrow). ( ) . in both patients, and months on sorafenib, skin lesions appeared either in the context of cgvhd, which progressed to a life-threatening level in a male patient or as a photodermatitis-like cheek eruption. histopathology revealed the presence of severe cd + cells infiltration in affected tissues in both patients. ( ) . cd positive lymphocytes colonized the marrow of both patients. these marrows infiltrating cells co-expressed cd (pd- receptor) in proportions which were higher than those seen in the blood ( . % ± . % vs. . % ± . %, p = . ). a similar observation was made for cd +cd + cells ( . % ± . % vs. . ± . %, po . ). . transcriptome analysis of the marrow cells, which addressed the genes involved in lymphocyte activation, revealed the presence of proinflammatory profile which included a higher expression of tlr and il- . ( ) sorafenib given with or without moderate chemotherapy was effective in two patients in maintaining the anti-leukaemic effect of salvage chemotherapy. ( ) this was associated with the presence of alloreactivity (affected tissues infiltration with cd + cells) clinically seen as a severe fatal cgvhd aggravated by sorafenib treatment associated unwanted effects in one cases and with rather mild skin lesions appearing later during the treatment. the outcome of elder patients with acute myeloid leukemia or high risk myelodysplastic syndrome treated with allogeneic hematopoietic stem cell transplantation ch tsai , , division of hematology, department of internal medicine, national taiwan university hospital; tai-cheng stem cell therapy center, national taiwan university and genome and systems biology degree program, national taiwan university allogeneic hematopoietic stem cell transplantation (hsct) is a curative-intent treatment for patients with high-risk hematologic diseases, including acute myeloid leukemia (aml) and myelodysplastic syndrome (mds). both the incidences of aml and mds increase with age and patients elder than years of age were traditionally excluded from hsct because of high possibilities of therapy related morbidity/mortality. recently, with the introduction of reduced intensity conditioning regimens and the improvement of hsct care, more and more elder patients could undergo hsct for consolidation or salvage purposes. however, literature regarding the treatment outcome of elder patients receiving hsct is scarce. patients diagnosed as aml or high risk mds aged equal or more than years were recruited consecutively at national taiwan university hospital. the high risk mds was defined to include myelodysplastic syndrome with excess of blasts- and according to the world health organization (who) criteria. the cytogenetic risk stratification was based on original medical research council classification. from to , a total of patients were enrolled consecutively. the median age was . (range: - ) years and the gender distribution was even. among them, ( . %) patients had high risk mds, ( %) had de novo aml, ( . %) had secondary aml, and three ( . %) had therapy related aml. at diagnosis, four ( . %) patients had extramedullary disease. nine ( . %) had unfavorable-risk cytogenetics, ( . %) had either unfavorable-risk cytogenetics or intermediate-risk cytogenetics but with flt -itd mutations. regarding the pre-hsct disease status, nine patients had the first complete remission (cr), had the second cr, and patients were treatment naive or had refractory disease. the graft-versushost-disease(gvhd)-free/relapse-free survival (grfs) in which events include grade - acute gvhd, chronic gvhd with moderate severity according to cibmtr criteria, relapse, or death of any cause. with median follow-up of months (range: . - . ), the median overall survival (os) for all patients was . months, the relapse-free survival (rfs) was . months, and the grfs was . months. in univariate analysis for os and rfs, high-risk mds was a favorable prognostic factor but secondary or therapy related disease (p = . for os and . for rfs, respectively), unfavorablerisk cytogenetics or intermediate-risk cytogenetics but with s flt -itd mutations (p = . and . , respectively), pre-hsct refractory disease (p = . and . , respectively), and grade - acute gvhd (p = . and . , respectively) were unfavorable prognostic factors. however, for grfs, only unfavorable-risk cytogenetics or intermediate-risk cytogenetics but with flt -itd (p = . ) and pre-hsct refractory disease (p = . ) were unfavorable prognostic factors. in multivariate cox proportional hazards regression analysis for os and rfs, grade - acute gvhd was a significant unfavorable risk factor; for gfrs, pre-hsct refractory disease status was a significant unfavorable risk factor. our results showed that the choice of hsct should not solely based on the age factor and pre-hsct disease status. incorporating cytogenetics and genetic mutation status could risk-stratify elder patients with hsct. further prospective trials are warranted to validate these findings. disclosure of conflict of interest: none. children affected with acute lymphoblastic t cell leukaemia (t-all) and relapse after allogeneic stem cell transplantation (sct) have limited treatment options and a poor prognosis. immune checkpoint inhibitors targeting the programmed death (pd- ) receptor pathway may enhance the graftversus-leukaemia (gvl) effect by blockade of inhibitory signals to t cells mediated by its ligand pd-l . we report a -year old girl with refractory t-all after allogeneic sct, who was treated off-label with the pd- inhibitor pembrolizumab. the girl was diagnosed with t-all ( . g/l wbc, % bone marrow infiltration, cns negative, t ( ; )) and underwent hlahaploidentical bone marrow transplantation from her mother with post-transplant cyclophosphamide since she failed to achieve molecular remission despite an intensified chemotherapeutic regimen. on day post sct, she had a % donor chimerism and decreasing minimal residual disease (mrd) marker (minimal × − ). days post sct she had a molecular relapse with an mrd of × − and a subsequent morphological relapse as well as mixed donor chimerism. further treatment regimens included chemotherapy, intrathecal therapy and four donor lymphocyte infusions (dlis). initially, she displayed a good morphological response to dlis but the leukaemic burden eventually remained stable with an mrd of × − . considering . % pd- expression on cd + t cells in the patient's bone marrow and the encouraging data in other hematologic malignancies an off-label therapy with the pd- inhibitor pembrolizumab - was initiated. the patient and her parents gave informed consent and she received a single dose of pembrolizumab at . mg/kg days after sct. one week after administration of pembrolizumab, the patient developed acute gvhd grade iv of the skin, mucosa, liver, lung, central nervous system and eyes. she had a severe generalized inflammatory reaction with high inflammatory markers, increased hepatic transaminases and lymphocytic infiltration of the liver, cerebrospinal fluid and bronchoalveolar lavage fluid. magnetic resonance imaging (mri) of the brain revealed periventricular white matter lesions and hyperintensities of basal ganglia and bilateral temporal lobe consistent with autoimmune encephalitis. treatment with high-dose corticosteroids, cyclosporine and the anti-interleukin receptor antibody tocilizumab slightly improved her clinical condition. her mrd value significantly decreased to × − two weeks after administration and she achieved a % donor chimerism in bone marrow. despite this promising response her medical condition deteriorated and the severe inflammatory reaction caused fatal multi-organ failure. this is to our knowledge the first report on a remarkable and fast response to pd- inhibition in a patient with pediatric t-all refractory to multiple lines of therapy including allogeneic sct. this case illustrates the potential risk of checkpoint inhibitors to trigger severe gvhd that is not responsive to steroids. induction of inflammatory gvl responses without causing severe gvhd by therapeutic checkpoint inhibition needs to be addressed in future clinical trials. in recent years, there is a remarkable trend in the use of haploidentical-related hematopoietic cell transplantations (haplo-hct) in patients who do not have a hla matched related or unrelated donor. here, we report our single-center experience, in patients who underwent haplo-hct for acute leukemia. between and seventeen consecutive adult patients, seven males and ten females, median age years (range: - years) with high-risk acute leukemia underwent unmanipulated, bm or pbsc transplantation from an haploidentical family donor. eleven patients transplanted for acute myeloid leukemia ( in cr , in cr , in minimal active disease after cr , second trasplant in cr , transformed mds in cr , aml secondary to myelofibrosis in cr ), for acute lymphoblastic leukemia ( in cr , in active disease) and mastcell leukemia (secondary to aml) in active disease. sixteen patients received myeloablative conditioning, and reduced intensity, respectively. in five patients stem cells source was bm, in were g-csf mobilized pbsc. the median infused cd + cell dose was . × (range: . × - . × ). conditioning regimens were: bu-flu-mac (n = ), tbf-mac (n = ), tbf-ric (n = ) the regimens for gvhd prophylaxis were: ptcy as sole gvhd prophylaxis (n = ), mtx-csa-atg (n = ), methylpred-atg-tacrolimus (n = ), atg-csa-mtx-mmf (n = ). sustained trilineage engraftment occurred in patients ( %), two patients died of transplantation-related complications before day after transplantation without myeloid recovery. for patients receiving bm or pbsc grafts, the median time to neutrophils recovery was days (range: - ), and , platelets recovery was days (range: - ). / patients ( . %) and / ( . %) had ii-iv and iii-iv grade of acute gvhd, respectively.the incidence of grade ii-iv cgvhd was %. after a median follow-up of months, / patients ( . %), out patients transplanted in cr , are alive and disease free at , , , months (inclusing the patient transplanted for aml after imf). the -year probability of overall and progression-free survival was % ( % ci, . - . %) and . % ( % ci, . - . %), respectively. causes of death were: sepsis (n = ), fatal agvhd (n = ), pneumonia (n = ), toxicity (n = ), progression (n = ) and relapse (n = ). in our experience unmanipulated bm or pbsc transplantation from haploidentical family donor is feasible approach with high engraftment rates and acceptable trm ( %) and rate of grade iii-iv agvhd, associated with durable remission in a proportion of patients with high-risk acute leukemia, specially in patients with aml transplanted in first remission. it is generally recognized that allogeneic hematopoietic stem cell transplantation (allo-hsct) should not be administrated to patients with severe aplastic anemia (saa) or very severe aplastic anemia (vsaa), when they got active infection. however, without neutrophil, severe infection is usually difficult to control and even fatal. under these circumstances, rapid recovery of neutrophil by allo-hsct might be an alternative to control infection. from january to december , there were young patients received allo-hsct for saa or vsaa at shanghai children's medical center in china. among them, patients ( males and females) with a median age of . years (range: . - . years) received allo-hsct with refractory active infections. refractory active infection was defined as persistent neutropenic fever with nonresponse to standard doses of broad-spectrum antibacterial agents and antifungal agents for more than three weeks, with or without definite focus of infection. prior to allo-hsct, four patients had persistent fever of unknown origin, patients with singlesite infection, and patients with multiple-site infections. sites of infection included lung, sinus, cellular tissue, peritoneum, liver, spleen and skin. the conditioning regimen consisted of fludarabine, cyclophosphamide and rabbit-antithymocyte globulin with or without total body irradiation (tbi) ( - gy). twelve patients were transplanted from mismatched unrelated donors, from matched sibling donors, and from haploidentical donors. sixteen patients received g-csf mobilized peripheral blood stem cells, three patients g-csf mobilized peripheral blood stem cells plus g-csf primed bone marrow stem cells, two patients bone marrow stem cells, and patient umbilical cord blood stem cells. a median of . × /kg mononuclear cells with . × /kg cd + cells were transfused, except the patient who underwent ucbt with a total of . × /kg mononuclear cells and . × /kg cd + cells transfused. eighteen patients achieved recovery of neutrophil and finally control of infections, including one patient who suffered primary graft failure and had autologous marrow recovery. three patients died of infection and one patients died of acute renal failure before recovery of neutrophil. one patient died of pneumonia months after allo-hsct. one patient become thrombocytopenia after allo-hsct. the other patients are all disease-free. there were five patients developing grade i-ii acute gvhd, and patient grade iii-iv acute gvhd. all were cured at last. three patients had localized chronic gvhd and one patient had extensive chronic gvhd. with a median of years follow-up, the overall survival rate and disease-free survival rate are . % ± . % and . % ± %, respectively. allo-hsct could be a feasible way to control infection for children with saa or vsaa in the present of refractory active infections. disclosure of conflict of interest: none. paroxysmal nocturnal hemoglobinuria (pnh) may present hemolysis isolated (classical pnh) or associated with aplastic anemia (aa; aa/pnh syndrome). while classical pnh patients require anti-complement treatment (eculizumab), the treatment of aa/pnh patients should target their underlying aa by immunosuppression (ist), or even bone marrow transplantation (bmt). however, in a few patients clinically meaningful aa and hemolysis may be concomitant, eventually justifying both ist and eculizumab. to date there is no standard treatment for s this rare condition. amongst a large cohort of pnh patients (between and ) at our reference centers, st. louis hospital (paris) and federico ii university (naples), we retrospectively assessed characteristics and outcomes of patients diagnosed with aa/pnh who received intensive ist during or immediately before ( - months) eculizumab treatment. nine patients were identified. eight patients fulfilled the criteria of severe aa, and one had an immunemediated isolated agranulocytosis. since no patient had a hla-matched related donor for bmt, all patients received intensive ist according to institutional guidelines. six out of patients were already on eculizumab treatment at the moment of starting intensive ist (concomitant treatment) whereas patients received ist in the - months (median time of months) before the introduction of anti-complement therapy (sequential treatment). for all patients already on treatment, eculizumab was not discontinued to minimize the risk of rebound intravascular hemolysis and thrombotic complications. eculizumab was administered at the standard dose of mg fortnightly in all but one patient, who needed an increased dose ( mg) because of pharmacokinetic breakthrough. six patients ( aa and agranulocytosis), including the three undergoing a sequential treatment, received standard ist with horse-antithymocyte globulin (h-atg, mg/kg for four consecutive days) combined with cyclosporine a (csa). the remaining three aa patients received alemtuzumab ( - - - mg subcutaneously in four consecutive days) and csa within the prospective trial nct ; one of these patients a few months later also received a second ist course with rabbit-atg ( . mg/kg for five consecutive days) and csa. all the patients completed the scheduled treatment without any side effect, including infusion-related reactions. lymphocyte depletion (o /μl) was observed in all patients irrespective of sustained therapeutic complement blockade. all the patients were available for response assessment at months. among the six patients receiving a concomitant treatment we observed one partial response (pr) and two complete responses (cr), whereas the three remain patients were non-responders (nr). of them one was rescued with an unrelated bmt, while two remained on eculizumab treatment. one of the cr relapsed at years showing clonal evolution and finally died. all the other patients are alive, keeping their hematological response. patients receiving a sequential therapy were one in pr and two in cr months after introduction of eculizumab. in conclusion, for patients diagnosed with severe aa/pnh syndrome intensive ist and eculizumab treatment, can be safely delivered either concurrently or sequentially, with an overall response rate of nearly %. this is the first systematic description of the management of severe aa in hemolytic pnh patients receiving eculizumab treatment. disclosure of conflict of interest: none. ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) in aa, ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) in rcc, and ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) years in rcmd. sixty-five patients underwent bmt from hla-matched (related , unrelated ) and from hla-mismatched (related , unrelated ) donors. conditioning regimens were used as follows; cyclophosphamide (cy)+antithymocyte globulin (atg) ± total body irradiation (tbi) (n = ), fludarabine (flu)+cy ± atg ± tbi (n = ), and flu +melphalan (mel) ± atg ± tbi (n = ). all patients got engraftment after bmt. however, late graft failure was found in patients with rcc, and with rcmd, but none with aa. out of patients who developed late graft failure, patients used flu+cy ± atg ± tbi, used cy ± atg ± tbi, and used flu +mel ± atg ± tbi for conditioning regimens. five-year cumulative incidence (ci) of graft failure was higher in rcmd ( ± . %) than in aa ( %) and rcc ( ± . %), significantly (po . ). five-year ci of graft failure tended to be higher in flu regimen ( ± . %) than in cy+atg ± tbi regimen ( ± . %), but not significant (p = . ). five-year ci of graft failure did not differ between with ( ± . %) or without tbi ( ± . %) (p = . ). multivariate analysis revealed that the morphological classification was a significant risk factor for graft failure (po . ). five-year failure free survival rate ( ± %) in rcmd was significantly lower than in aa ( ± . %) and rcc ( ± . %) (p = . ). graft failure, second malignancy, and death were considered as failure events. one patient with aa died of infection, four with rcc died of infection (n = ), bleeding (n = ) and myocarditis (n = ), and one with rcmd died of infection. five-year overall survival rates were not different among groups (aa, ± . %; rcc, ± . %; rcmd, ± . %) (p = . ). high incidence of graft failure in rcmd may be due to higher bm cellularity than in aa and rcc. the optimal conditioning regimen of bmt should be established for children with abmf based on the bm cellularity and morphological classification. disclosure of conflict of interest: none. recent studies have suggested inferior outcome of patients treated with rabbit atg (thymoglobulin, sanofi) as compared to horse atg (atgam,pfizer or lymphoglobulin, genzyme), and a higher early mortality with rabbit atg has been suggested to explain this difference. aim: to assess early mortality, response rates at , and months and long term outcome, in a large cohort of aa pts, treated in europe or asia with rabbit atg and cyclosporin, as first line treatment. eligible for this study were pts with aa, treated with thymoglobulin between and in europe (n = ) or asia (n = ). median year of treatment, was : characteristics were comparable : median age and years, interval diagnosis treatment ( and days) and severity of the disease ( % and % with vsaa). early mortality was analyzed for all patients.long term outcome was also analyzed for pts for who response data (no, pr, cr) were available. mortality o days was . % and . %, respectively, in the time period - and - (p = . ). in these time periods, early mortality for patients aged - , was reduced from . % to . % and for patients over , from % to %. overall response was recorded in patients. at months the cumulative incidence of response was comparable in the time periods: % vs %, and at year, % vs % (p = . ). response rates at months were age dependent: %, %, %, % respectively in patients aged - , - , - , (p = . ). when non responders at months were reevaluated at year, % had responded, % were non responders, % had died, and % had received other treatment. responses at months, were %, %, %, in pts with very severe, severe and non severe aa (p = . ). the actuarial year survival for the entire population was %, and %, when pts were censored as surviving at transplant. actuarial year survival in univariate analysis was as follows: % vs % for day responders vs non responders (p o . ), % vs % for males versus females (p = . ); %, %, %, % in pts aged - , - , - , years (p o . ); %, %, % in pts with neutrophils o . × /l, - × /l and . × /l (p o . ); %, %, % for pts with an interval diagnosis-treatment of o days, - days or days (p = . ). finally pts treated had a year survival superior to pts treated before ( % vs %, p = . ). survival at years, in the recent period ( - ), was % for pts aged - and % for pts over years. in multivariate cox analysis the following variables remained independent predictors of survival: patient age, year of treatment, severity of the disease, interval diagnosis treatment, and gender. thymoglobulin +csa is effective and safe in patients with aa. the outcome is mainly age dependent. the inrerval between diagnosis and treatment remains a strong predictor: the earlier the better. for pts o years old current early mortality. . for pts years of age, current early mortality is higher ( %), response rate ( %) and year survival ( %) are lower. . the actuarial year survival for the enire population was %. survival at years has improved from % (o o/u ) to % ( - ), especially for pts over years ( % vs %, p = . ). [p ] s disclosure of conflict of interest: we thank centers for providing up date follow up of their patients . this study was supported by a grant of sanofi-genzyme. both of the patients have extremely low anc o . × /l, reto . %, plt o × /l. both was given antibiotic treatment with carbapenem, vancomycin/linezolid, voriconazole or amphotericin b liposome and got no response. no pathogenic bacteria or fungus was found from either of the patients. both of them had no full sibling or matched unrelated donor and had their father as their haploidentical donor. bone marrow combined with peripheral blood stem cell (pbsc) was adopted. conditioning: fludarabine days − through − , ( mg/m × ), intravenous busulfan ( . mg/kg q h) on days − to − . gvhd prophylaxis: high-dose cyclophosphamide mg/kg on days + and + , mmf and tacrolimus since days + . rabbit anti-thymocyte globulin (thymoglobulin) . mg/kg on days − to − . stable neutrophil engraftment (anc . × /l) occurred on day + and day+ respectively. platelet achieved × /l on day + and day + , respectively. both transplant course was complicated by febrile neutropenia without detected etiology, while both children have no fever since the first day anc . × /l.the facial swelling was resolved in both patients except for palatal fistula and fistula of maxillary sinus as the sequela of severe nasosinusitis. no acute or chronic gvhd. case had hemorrhagic cystitis on day + which last for about days, and suspected thrombotic microangiopathy (tma) with hypertension, thrombocytopenia, elevated ldh and creatine on day + which was resolved soon after discontinue of tacrolimus. case had delayed engraftment of platelets and herpes simplex virus encephalitis on days + which was cured by ganciclovir and high dose intravenous immunoglobulin. now they are and months post-hsct respectively and are doing well with % chimerism and no gvhd. alternative donor hsct may be considered as the first line salvage therapy for patients of vsaa with extremely low anc and active infection. fast reconstruction of neutrophil helped to control the infection. hallo-identical hsct make sure nearly every patients can find a donor. ptcy is proved to be efficient and safety in gvhd prophylaxis and facilitating engraftment in these two challenging cases. disclosure of conflict of interest: none. long-term outcome of patients with severe aplastic anemia receiving allogeneic hematopoietic cell transplantation using nonmyeloablative conditioning with fludarabine and low dose total-body irradiation l cheryl xiu qi , l yeh ching , p michelle li mei , t lip kun , h william ying khee , g yeow tee , t patrick huat chye and k liang piu department of haematology-oncology, national university cancer institute, singapore and department of haematology, singapore general hospital, singapore allogenic haematopoeitic stem cell transplant (ahct) offers the best prospect of cure in patients with severe aplastic anaemia (saa). the use of myeloablative hct is however limited by the toxicity of preparative regimens, the lack of matched sibling donors, transplant related mortality and graft rejection. the introduction of non-myeloablative (nm) conditioning offers the possibility of extending this potentially curative treatment to patients in whom ahct was previously contradindicated. in , we reported the outcome of patients with saa who have received ahct using nonmyeloablative conditioning comprising of days of fludarabine at mg/m and total body irradiation at gy (flu + tbi gy). here, we report a longer follow-up, with additional patients who had recevied ahct with this regimen. fourteen patients with a median age of years old (range: - years old) received filgastrim-mobilised peripheral blood stem cell transplant from either hla identical sibilings (n = ) or matched unrelated donor (n = ) after receiving nm conditioning consisting of flu + tbi gy. the first two patients received cyclosporine (cya) and mycophenolate mofetil (mmf) for the post-transplant immunosuppessive therapy. the remainining patients received cya, mmf and a short course of methotrexate (mtx) for additional graft-versus-host dsease (gvhd) prophylaxis. results all patients achieved prompt engraftment. the median time for engraftment of neutrophils ( . × /l) and platelets ( × ) were days (range: - days) and days (range: - days), respectively. chimerism analysis on day and subsequently showed % donor cells in all patients except , who developed secondary graft failure at months and required salvage hct. none of the patients experienced grade and above regimenrelated toxicity. five patients developed grade ii-iv acute gvhd and patients developed limited chronic gvhd. with a median follow-up of . years (range: . - . years), the estimated overall survival and event free survival were % and % respectively. the two patients who did not receive mtx developed acute gvhd of the liver and succumbed to infective complications. the remaining patients who had received triple immunosuppressive therapy were well, with limited chronic gvhd seen only in . our results suggest that the nm conditioning regimen comprising of flu + tbi gy provides sufficient immunosuppression to allow prompt and stable engraftment with minimal regimen-related toxicity. it is an attractive option for patients with saa who require ahct but are at increased risk of regimen-related complications from more intensive cyclophosphamide-based regimens. disclosure of conflict of interest: none. paroxysmal nocturnal hemoglobinuria (pnh) is a rare acquired clonal disorder of hematopoietic cells characterized by the triad of hemolytic anemia, cytopenias and high risk of venous thrombosis. due to the rarity of the disease, most reported data derive from multicenter studies. we describe the natural history of the disease in a -year (yrs) long single center series of pnh patients (pts). we performed a retrospective analysis of consecutive pts followed at our center from to . since , the diagnosis was made by ham test; starting from , flow cytometry (fc) analysis was used to diagnose new pts and to confirm pnh in pts previously diagnosed by the ham test. at diagnosis, pts had classic pnh, aplastic pnh and intermediate form. the cumulative incidences of thrombosis, cytopenia and clonal neoplasm were %, % and %, respectively. except for pt with aplasia, no severe infections were diagnosed, nor renal failures or pulmonary hypertention. the yrs overall survival (os) was %. a nonsignificant better os was associated to the absence of thrombotic events ( % vs %) and to a diagnosis made during the last decade ( % vs % vs %).up to the treatment options were supportive care or allogenic bone marrow transplantation. since , eculizumab was used in transfusion-dependent patients and/or in case of a thrombotic history. overall, pts were transfusion-independent for the entire period of the illness, were transfusion-dependent and/or had thrombotic events( pts). six of the latter pts never received eculizumab but only transfusion support ( pts) or allogeneic bone marrow transplant ( pts), while pts received eculizumab (the first pts were included in the phase iii triumph and shepherd trials).considering the increased risk of meningococcus infection for pts on eculizumab, vaccination with conjugated anti-meningococcus serotypes acwy was employed and, since , conjugated antimeningococcus serotype b was added. overall, pts treated with eculizumab became transfusion-independent and four remained transfusion-dependent. no thrombotic event was observed after eculizumab, even if pts had recurrent thromboembolisms prior to receiving the drug. no severe infection was documented. one patient developed extravascular hemolysis and receive a successfully selective splenic artery embolization. the yrs os in the eculizumab group was %.no pnh-associated death occurred. our study confirms that thrombosis is a major complication in pnh pts not receiving eculizumab, influencing os. the better os in the last decade is probably due to the use of eculizumab and to lack of thrombotic events. in particular, for pts on eculizumab the year os was %, even though half of the pts had thromboembolism and diagnosis made prior to the last decade. although kidney failure and lung hypertension have been reported, we did not observe these complications in our long follow-up case series. we can assume that the availability of a dedicated emergency room at our center allows to perform, promptly, hyper-hydration or transfusion support in case of hemoglobinuria crisis, reducing the risk or organ damage. no infections have been observed after eculizumab, probably due to the vaccination program schedule recommended in the literature, plus the addition of conjugated anti-meningococcus serotype b. however, shared guidelines are needed. disclosure of conflict of interest: none. mortality following hsct in saa pts over the age of is reported to be in the order of %, without taking in to account long term sequelae such as chronic gvhd, known to be more frequent in older patients. this has prompted international guidelines to recommend first line immunosuppressive therapy above years of age. the question is whether this is still true in . the aim of the study is to assess whether trm in saa patients grafted - is reduced,as compared to the era - . we used the wpsaa ebmt registry, and identified pts aged years or more, with acquired saa, grafted between and . we divided pts in transplant eras: - (n = ) and - (n = ). in the more recent period ( - ) pts were older ( vs year, p o . ), were more often grafted from alternative donors (alt) ( % vs %, po . ), with a greater use of bm ( % vs %, p o . ), and with a longer interval dx-tx ( vs days, p . ), and more often received a fludarabine containing regimen ( % vs %, p o . ). the os year of pts grafted in - was %, compared with % for pts grafted - (p = . ). in multivariate analysis, including the interval diagnosis transplant, patient's age, donor type, stem cell source and conditioning regimen, the lack of improved survival in - was confirmed (p = . ). a very strong age effect was shown both in univariate and multivariate analysis: survival of pts aged - years, - years and years, was respectively %, %, % (p o . ) and this was confirmed in multivariate analysis. the conditioning regimen, also proved to be a significant predictor, with improved survival for alt transplants receiving flu containing regimens ( % vs %, po . ). in general pts receiving either cy or a flu containing regimen, did significantly better than pts receiving other preparative regimens ( % vs %, p = . ). the use of a sibling donor (sib) did not prove to predict survival in multivariate analysis. pts receiving campath in the conditioning,did significantly better than pts not receiving campath ( % vs % po . ); similarly survival of patients with atg was superior % vs % compared to patients not receiving atg (p o . ). when pts receiving either campath or atg (n = ) were compared to patients not receiving either (n = ), the difference in survival was % vs % (p o . ), and this was significant also in multivariate analysis. combined primary and secondary graft failure was reduced from % to % in the two time periods (p = . ), acute gvhd grade ii-iv was reduced from % to % (p = . ) and chronic gvhd was also reduced from % to % (p = . ) infections remain the leading cause of death in both transplant eras ( % and % respectively), followed by gvhd ( % and %) and graft failure ( % and %), whereas ptld have been reduced from % to . %. hsct in pts with acquired saa aged and over, continues to carry a significant risk of trm also in - , ranging from % in younger pts ( - ) to % in older pts ( years). survival is predicted in multivariate analysis, by two crucial predictors: patients' age and the use of either campath or atg,the latter giving a % survival advantage over no campath/atg. alt and sib donors produce similar survival. this study gives further support to current guidelines, suggesting first line therapy with atg+csa, in pts over the age of . [p ] disclosure of conflict of interest: none. autoimmune diseases p allogeneic haematopoetic stem cell transplantation as curative therapy for early-onset, refractory crohn's disease e groene , p bufler , k krohn , s immler , g marckmann , t feuchtinger , s koletzko and m albert dr. von hauner university children's hospital and institute of ethics, history and theory of medicine, lmu results of a recent randomized trial suggest that autologous hsct is an option in adult patients with severe, therapyrefractory crohn's disease (cd) with an associated mortality risk of %. however, relapse of the disease is frequent ( ). in contrast allogeneic hsct has resulted in long-term cure of cd in affected patients transplanted because of haematological malignancy ( ). we report a year old girl who was diagnosed with severe cd at age seven (paris classification l , l a, b ). neither next generation sequencing nor immunological work up identified a monogenetic cause of cd. progressive chronic inflammation manifesting ubiquitously in the gastrointestinal tract resulted in severe complications, such as perianal fistulas with rectal stenosis, intestinal abscesses, dysphagia, severe weight loss, failure to thrive, delayed puberty and the need for ileostomy and long-term exclusive enteral nutrition via tube feeding. despite multiple lines of therapy, including repeated nutritional therapy, steroids, immunosuppressants (methotrexate, azathioprine) and biologicals (infliximab, adalimumab, certolizumab) a lasting remission could not be achieved resulting in poor quality of life. after careful risk/benefit assessment including ethical counselling allogeneic hsct was offered. she underwent allogeneic hsct from a matched ( / ) unrelated bone marrow donor ( . × /kg total nuclear cells). conditioning was performed according to a protocol successfully applied in adolescents with chronic granulomatous disease ( ) with alemtuzumab ( × . mg/kg/d), targeted busulfan (tauc ng × h/ml) and fludarabine ( × mg/m ). cyclosporine a and mycophenolate mofetil were used as gvhd prophylaxis. neutrophil and platelet engraftment were observed on days + and + , respectively. the post hsct course was complicated by grade i acute skin gvhd treated with topical steroids and toxic megacolon secondary to scarring stenosis on both ends of the unused colon on day + requiring surgery and a colostomy. at months post hsct the patient is well, off immunosuppressive medication, without gvhd and exhibiting % donor chimerism. the cd is in complete clinical and histological remission as proven by endoscopy and biopsies. stoma reversal with restitution of intestinal continuity is planned for the next months. refractory cd can lead to life-threatening complications and severely reduced quality of life. although long-term outcome in our patient will need to be carefully assessed, allogeneic hsct may offer a curative therapy in children and young adults with severe cd, even in the absence of an identified monogenetic cause. current ebmt recommendations include consideration of ahsct in exceptional circumstances for patients with severe refractory cd. the only randomised trial of ahsct in cd (astic) confirmed substantial short-term benefits but failed to meet its primary year endpoint. to further clarify the longterm safety and efficacy of ahsct in cd we performed a retrospective analysis of patients undergoing ahsct for cd outside the astic trial using the ebmt registry. patients were identified from the ebmt registry. all adult patients undergoing ahsct for a primary diagnosis of cd from to were eligible for inclusion. patients who were enrolled in the astic trial were excluded. from a total of patients (across centres) on the ebmt registry, data were obtained from patients transplanted in centres in countries. median patient age was yrs (range: - ) and % were female. median age at first diagnosis of cd was yrs (range: - ). patients were heavily pre-treated, having failed or been intolerant to a median of previous lines of therapy (range: - ). % had received experimental therapy prior to auto-hsct. % of patients had undergone at least operation. the median time from first diagnosis of cd to auto-hsct was . years (range: . - . ). all patients received peripheral blood stem cells following conditioning with cyclophosphamide mg/kg and % received anti-thymocyte globulin (atg). the median cd + dose infused was . (range: . - . ) × /kg. twelve percent of patients underwent cd + selection. neutrophil and platelet engraftment occurred at a median of day (range: - ) and day (range: - ), respectively. sixety-one percent received post transplant g-csf. median length of follow-up following auto-hsct was months (range: - ). at days post auto-hsct, % of patients were in clinical remission (cr), defined as no abdominal pain and normal stool frequency. a further % experienced significant improvement, defined as improvement in abdominal pain and stool frequency. for % there was no appreciable change in disease and in % the disease worsened compared to baseline. at year post auto-hsct, % were in cr, % were improved, % were unchanged and % had worsened. at last follow-up, % were in cr, % were improved, % were unchanged and % had worsened. overall % restarted medical therapy post auto-hsct and % required further surgery. overall % developed an infection requiring treatment post auto-hsct ( % bacterial, % viral). ebv and cmv reactivation occurred in % and % respectively and herpes zoster occurred in %. a secondary autoimmune disease developed in %, most commonly thyroid disease ( %). malignancy developed in %, of which skin cancer accounted for % of cases. one patient died at days post auto-hsct due to cmv infection, sepsis and multiorgan failure. this large retrospective series further supports the safety and efficacy of ahsct in a population with severe and treatment-refractory crohn's disease, % of patients experienced complete remission or significant improvement in cd symptoms with long-term follow-up. trm observed was similar to ahsct for other indications. in summary, ahsct appears to be an extremely promising therapy for severe refractory cd. further follow up of astic patients and future randomised trials are warranted. disclosure of conflict of interest: none. memory stem t cells (tscm) are long living self-renewing memory t cells with long-term persistence capacity, which play a relevant role in immunological memory and protection against infectious diseases and cancer , , , , , . the aim of this work is to investigate the potential role of tscm as a reservoir of arthritogenic t cells in rheumatoid arthritis (ra). we analysed the dynamics of circulating tscm (here identified as cd ra+ cd l+ cd + t cells) and other memory t-cell subpopulations by multiparametric -color flow cytometry in patients with active ra and in of them also during treatment with anti-tnfα biological agents (etanercept). to analyse cytokine productions, functional assays were performed stimulating peripheral blood mononuclear cells (pbmcs) with pma/ionomycin and brefeldin a. after the stimulation, cells were stained for surface markers, fixed and stained for intracellular cytokines. we traced circulating antigen specific cd + t cells for the vimentine-derived citrullinated peptide (vimcit) savracitssvpgvr , in hla-drb × : ra patients before and during the anti-tnfα treatment using custom mhc class ii tetramers. viral antigen specific cd + t cells were traced using mhc class i dextramers. age-matched healthy donors (hds) were used as control for all the experiments. we found a significant expansion of cd + tscm in patients with active ra both in terms of frequency and absolute counts. notably, cd + tscm significantly contracted upon anti-tnfα treatment, suggesting a role of tnfα in tscm accumulation. in contrast to cd +t cells, cd compartment did not show significative alterations compared to (hds). furthermore, cd +tscm in ra patients displayed an enrichment in the th phenotype, largely implied in autoimmune disorders, while the other t cell subpopulation were not enriched in the th phenotype. at the antigen specific level, we were able to trace in hla-drb × : patients antigen specific cd + t cells, comprising tscm, specific for the vimentin-derived citrullinated peptide. of notice, citrullinated vimentin specific cd + t cells, including tscm, contracted during anti-tnfα administration, while viral-specific cd + t cells (ebvbhrf- ) and antiviral cd specificities (cmvpp , flump, ebvbmlf- ) were not affected by etanercept administration, thus suggesting a possible role of cd + tscm as reservoir of arthritogenic autoreactive t cells. overall, our results suggest that tscm, by representing a long-term reservoir of undesired specificities, might play a non redundant role in sustaining ra and possibly other t cell mediated disorders, thus representing novel biomarkers as well as therapeutic targets. ongoing experiments will characterize the tcr repertoire on sorted tscm and cd + memory subsets in order to identify a possible oligoclonality in tscm repertoire. in conclusion, the analysis of tscm dynamics in autoimmune disorders could have relevant clinical implications as new biomarkers and for devising innovative therapeutic strategies. ebv and cmv reactivation following autologous haematopoietic stem cell transplantation (hsct) for autoimmune neurological diseases resolves spontaneously and rarely requires treatment c mapplebeck , b sharrack , h kaur , y ezaydi , h jessop , l pickersgill , l scott , m raza and ja snowden departments of haematology, neurology and virology, sheffield teaching hospitals nhs foundation trust, sheffield, uk autologous haematopoietic stem cell transplantation (hsct) for severe autoimmune diseases involves immunosuppressive conditioning regimens and current guidelines recommend monitoring for viral reactivation of cytomegalovirus (cmv) and epstein barr virus (ebv) (snowden et al ) . however, the incidence, degree and management of viral reactivation are not established. we performed a retrospective observational service evaluation study of all patients receiving cyclophosphamide mg/kg + rabbit anti-thymocyte globulin mg/kg (atg, thymoglobulin) followed by autologous hsct for various autoimmune neurological diseases between and at our centre. data collected included the baseline serological status of the patient prior to transplant and serial blood pcr quantitation (copies/ml). if ebv and cmv reactivation occurred details of further management was collected and descriptive statistics were used to summarise outcomes. twenty-three patients received autologous hsct between january and october ; patients with multiple sclerosis (ms), with chronic inflammatory demyelinating polyneuropathy (cidp) and with stiff person syndrome. twenty-two patients had positive ebv igg serology prior to transplant and patient had an equivocal result. seventeen patients had evidence of ebv reactivation and a further patient had ebv dna detected post-transplant but with less than copies/ml. the average time to peak ebv pcr was . (range: - ) days post-transplant and a range: in ebv pcr peak level from to copies/ml. the patients who had ebv pcr results of over copies/ml had ct scans of chest, abdomen and pelvis performed which did not demonstrate significant lymphadenopathy or hepatosplenomegaly. in all patients monitored for a detectable ebv reactivation, the ebv pcr spontaneously began to fall within months (average days, range: - days) post-transplant and no specific treatment was required. one patient had late ebv reactivation of copies/ml at months post-hsct associated with chronic tonsillitis and tonsillectomy specimens showed follicular hyperplasia without evidence of post-transplant lymphoproliferative disorder (ptld) and ebv pcr levels normalised without other treatment. ( %) patients had positive cmv igg serology prior to transplant and one patient had an equivocal result. only of patients had a significant reactivation of cmv with copies/ml at days post-transplant, successfully treated with intravenous immunoglobulins and valganciclovir. two other patients had low level cmv reactivation with and copies/ml, respectively which resolved spontaneously without treatment. ebv reactivation in patients with neurological autoimmune disease undergoing autologous hsct is common and usually resolves spontaneously without treatment. asymptomatic cmv reactivation occurs in approximately % of patients in this setting and may require treatment. autologous hematopoietic stem cell transplantation (hsct) has been utilised for the treatment of severe multiple sclerosis (ms). it results in significant improvement of neurological function, although patients can experience exacerbations of ms-related symptoms during the procedure. we reviewed patients with ms who underwent stem cell mobilisation and collection from march to november . the median age was years ( - ). nine patients ( %) were male. the interval from diagnosis to hsct was . months (range: . - . ). patients ( %) had relapsing-remitting (rrms), six patients ( %) secondaryprogressive (spms) and two patients ( %) primary-progressive (ppms) multiple sclerosis. only patients ( %) had not received any prior treatment, whereas patients ( %) received two prior treatments, three patients ( %) received three treatments and two patients ( %) received four treatments. the median expanded disability status scale (edss) score was (range: - ). peripheral blood stem cells were mobilised with cyclophosphamide (cy) g/m on day + and daily gcsf ( μg/kg subcutaneously) from day + until the completion of the harvest. hsct was performed at a median of days after mobilisation (range: - ). the conditioning regimen consisted of cy ( mg/kg/day from day − to − ) and atg ( mg/kg/day from day − to − ). exacerbation of ms symptoms was defined as the appearance of new or worsening of old symptoms for at least h duration in a previously stable ( weeks) patient. of the total cohort, patients ( %) underwent mobilisation with cy+gcsf uneventfully. only two patients ( %) had an exacerbation of ms requiring hospital admission after collection (one with fatigue and increase of spasticity, other with worsening weakness). no patient required hospital admission during the mobilisation procedure. the median cd + cell dose was . × /kg (range: . - ). the median number of apheresis was ( - ). a total of patients have undergone hsct at the time of this analysis. during transplant a total of patients ( %) experienced an exacerbation of ms. of these, % (n = ) before day and % (n = ) between day + and + . symptoms of exacerbation were: muscle spasms in patients ( %), weakness and reduced power of limbs in patients ( %), increase instability and tremor in two patients ( %) and one patient ( %) with worsening of neuropathic pain. only three patients ( %) received treatment with methylprednisolone for ms exacerbation and symptoms had fully resolved by discharge in all patients. other transplant complications included neutropenic fever in all, invasive fungal infection in , fluid overload in ( %) and atg related complications in ( %) such as fever (n = ) and pericarditis/serositis (n = ). the median time to neutrophil engraftment was days ( - ) and the median duration of hospital admission was days ( - ). exacerbation of ms symptoms is common during hsct and can also occur during mobilisation. in our hands, after cy and gcsf mobilisation only two patients ( %) developed an exacerbation of ms symptoms compared with patients ( %) after ct and atg conditioned hsct. it is possible that the addition of atg to cy triggers an immunological response involved in this transient deterioration of the ms symptoms. further studies are required to confirm this hypothesis. disclosure of conflict of interest: none. inflammatory immune response syndrome (iris) is a noninfectious worsening of neurological condition during immune recovery and has been documented to occur in hiv and in multiple sclerosis following alemtuzumab. the manifestation of iris includes headache, nausea, weakness, neurologic deficits, and mri enhancing lesion. we report three cases of iris after autologous non-myeloablative hematopoietic stem cell transplantation (hsct) in patients for which the transplant indication was an inflammatory neurologic disease: neuromyelitis optica (nmo), chronic relapsing inflammatory optic neuritis (crion), and multiple sclerosis (ms). mobilization was with cyclophosphamide gr/m and gcsf. conditioned regimen was mg/kg cyclophosphamide ( mg/kg/d) and . mg/kg ratg (thymoglobulin). the conditioning regimen for nmo and crion also included mg rituximab. case . a years old african-american female with systemic lupus erythematosus (sle) and nmo was discharged day and readmitted on day for fever, headache, progressive altered mental status with dysarthria and legs. brain mri had numerous t /flair hyperintense and enhancing lesions in the subcortical and periventricular white matter. a lumbar puncture was negative for infection including jcv. complete recovery occurred after treatment included high dose of steroids and plasmapheresis. case . a years old female with crion experienced blindness, weakness and slurring of speech three months post hsct. mri showed a large enhancing brain stem lesion. lumbar puncture was jcv negative. complete recovery occurred after solumedrol and rituximab. mri months later demonstrated complete resolution of the enhancement with return of vision to baseline. case . a ten year-old boy diagnosed with paediatric ms developed hemichorea seven days after hsc reinfusion. brain mri revealed a gadolinium-enhancing lesion in the contralateral basal ganglia. lumbar puncture was negative for infection including jc virus. symptoms resolved spontaneously after seventeen days. the appearance of new neurologic symptoms and mri enhancing lesions early after autologous hsct is unexpected and may be related to lymphocytes in the graft, immune recovery post engraftment, and or persistent auto-antibodies. it is mandatory to perform a lumbar puncture to exclude the possibility of infections including progressive multifocal leukoencelopathy (pml) due to jcv. the timing of presentation, the negativity of jc viral load, and the complete recovery with or without immune suppression suggest the hypothesis of iris, as an epiphenomenon of the immune reconstitution following autologous hsct for neurologic diseases disclosure of conflict of interest: none. hematopoietic stem cell transplantation is the effective method of therapy for cns autoimmune disorders in children. long-term outcomes and late effects estimation required. the aim of the study is to estimate long-term outcomes and late effects at children underwent auto-hsct for multiple sclerosis (ms) and allo-hsct for neuromyelitis optica (nmo). twelve pts. with ms and pts. with nmo were included to the analysis. ms pts. gender: female - % (n = ), male - % (n = allogeneic haematopoietic stem cell transplantation (hsct) remains the sole curative option for patients with myelofibrosis (mf). although a spectrum of conditioning regimens has been used, the optimal preparative treatment before hsct remains to be defined. we did a phase ii randomized study at transplant centers in italy with the aim of comparing the reduced-intensity conditioning (ric) fludarabine-busulfan (fb) (conventional arm), that had been already tested in the prospective ebmt study ( ) with the ric fludarabine-thiotepa (ft) (experimental arm), that has been widely used in italy in the last two decades ( ) . eligible to this study were patients with primary mf or a mf subsequent to a previous essential thrombocytemia or polycyhemia vera, an age ≥ ≤ years, a karnofsky performance status , a comorbidity index o o/u and with at least one of the following unfavorable prognostic factors: anemia (hb o g/dl), leukocitosis ( × /l), circulating blasts % or constitutional symptoms. patients were randomized to receive intravenous busulfan . mg/kg for doses or thiotepa mg/kg for two doses associated to fludarabine mg/m for impact of pre-transplant ruxolitinib in myelofibrosis patients on outcome after allogeneic stem cell transplantation syed abd kadir, sharifah shahnaz, author , , zabelina, tatjana, co-author , christopeit, maximilian, co-author , wulf, gerald, co-author , wagner, eva, co-author , bornhaeuser, martin, co-author , schroeder, thomas, co-author , crysandt, martina, co-author , mayer, karin tina, co-author , stelljes, matthias, co-author , badbaran, anita, co-author , wolschke, christine, co-author , ayuk ayuketang, francis, co-author , triviai, ioanna, co-author , wolf, dominik, co-author ruxolitinib (rux) is the first approved drug for treatment of myelofibrosis. because spleen size and constitutional symptoms may influence outcome after allogeneic stem cell transplantation (asct), rux is recommended before stem cell transplantation in order to reduce therapy-related morbidity and mortality and improve outcome (ebmt/eln recommendation, leukemia ) the aim of this retrospective study was to evaluate the impact of pretreatment with rux in comparison to transplantation of rux-naïve mf patients with regard to outcome after asct. we included myelofibrosis patients (pts) with a median age of years (range: - ) who received asct between and from related (n = ), matched (n = ) or mismatched (n = ) unrelated donor. all patients received busulfan-based reduced intensity conditioning. while pts ( %) did not receive rux, pts ( %) received rux at any time point prior to asct. the median daily dose of rux was mg (range: - mg) and the median duration of treatment was days (range: - days). in pts rux was stopped before stem cell transplantation because of no response or loss of response, while in pts rux was given until start of conditioning. gvhd prophylaxis consisted of cni plus short course mtx or mmf and anti-lymphocyte globulin. according to dynamic ipss (dipss) (n = ) the patients were either low (n = ), intermediate- (n = ), intermediat- (n = ), or high risk (n = ). as the median follow up was shorter for patients treated with rux ( vs months, po . ). primary graft failure was seen in pts in the rux and three in the non-rux group. the median leukocyte engraftment was days (range: - ) in the ruxolitinib and days (range: - ) in the non rux group (p = . ). the incidence of acute gvhd grade i to iv was significantly lower in the rux group ( % vs %, p = . ), while agvhd grade ii-iv ( % vs %, p = . ) and grade iii/iv ( % vs %, p = . ), did not differ significantly. the ci of nrm at year was % ( % ci: - %) for the rux group and % ( % ci: - %) for the non-rux group (p = . ), and the ci of relapse at years was % ( % ci: - %) vs % ( %ci: - %, p = . ). the years rfs and os was % ( %ci: - %) and % ( %ci: - ) for the rux group and % ( % ci: - %) and % ( % ci: - %) for the non-rux group (p = . and p = . , respectively). within the rux group (n = ), pts responded to rux (more than % spleen size reduction), while pts did not respond or lost response prior to stem cell transplantation. here, no significant difference could be seen between the responding and non-responding group for nrm ( % vs %, p = . ), relapse ( % vs %, p = . ), rfs ( % vs %, p = . ) and os ( % vs %, p = . ). in a multivariate analysis including rux treatment as variable there was a non-significant trend in favor for in the tyrosine kinase inhibitor (tki) era, allogeneic haemopoietic stem cell transplantation (allo-hsct) has become the later-line therapy but still remains the only known curative treatment for chronic myeloid leukemia (cml). since the introduction of tki in our centre in , the trend of allo-hsct among our cml cohort has changed over time. the purpose of this study is to examine hsct outcomes of our cml cohort who was either tki naïve or has received tki therapy prior hsct. between may and december , cml patients in our center received allo-hsct with % were tki naïve. the time of diagnosis to transplant was significant shorter among the tki naive group as compared to those received tki prior hsct ( . ± . months versus . ± . months, respectively). there were no gender different ( % males) but the median age at hsct was younger among tki naïve group, . years (range: - years) versus . years (range: - years) respectively. malays remained majority ethnic group but the percentage was reduced among patients received tki prior hsct ( . % versus . % respectively). the disease phase at hsct was significant different whereby majority of tki naïve group was in first chronic phase (cp ) ( . %) as compare to patients with prior tki exposure ( . %). all the patients in the tki naïve group received hla-matched related siblings donor (mrd) with . % marrow stem cell source whereas only . % of patients who have prior tki exposure received mrd with . % were from peripheral blood stem cell (pbsc). all patients in the tki naïve group but only . % among patients who have prior tki exposure received full myeloablative conditioning regimen. there was slower neutrophil and platelet engraftment ( . ± . days versus . ± . days and . ± . days versus . ± . days respectively) among tki naive group. at june , the -year overall survival (os) of cml at all disease status was % in tki naive group versus % for patients who have prior tki exposure and transplanted in more advance disease stage. in general, patients in cp have the best os. there was higher incident of grade to acute graft-versus-host-disease (gvhd) among the tki naïve group ( . % versus . %, respectively) likely due to intensity of conditioning regimen with no significant different in chronic gvhd incident. similarly, there was higher relapse rate among tki naive patients ( . % versus . %, respectively) as upfront post transplant tki was not routinely given to this group of patients in the past. further multivariate analysis to ascertain predictors of transplant outcome among this cohort of patients included disease status, donor-recipient gender combination, ethnic difference will be presented. in conclusion, despite emergent of effective and potent next generation tki, hsct still has it role as curative modality for patients who failed tki. as showed in our data, the transplant outcome is excellent for patients who remain in cp at the time of hsct and it is important to identify patients earlier, before disease progression, especially young patients, in order to optimize transplantation outcomes. disclosure of conflict of interest: none. the purpose of this analysis was to provide -year follow-up of the gcllsg cll x trial which aimed at evaluating reducedintensity conditioning (ric) hsct in patients with poor-risk cll. the cll x trial included patients (median age ( - ) years), of whom patients were allografted with blood stem cells from related ( %) or unrelated donors ( %) using fludarabine-alkylator-based ric regimens. % had refractory cll at hsct, and % had a tp deletion and/or mutation. the -year follow-up of the trial including the observation that genetic risk factors such as tp lesions and sf b and notch mutations had no prognostic impact has been previously reported. survival and relapse information was requested for all patients who underwent hsct within the cll x trial in german centres (the canadian centre was unavailable for follow-up) and were alive at the -year followup. results: follow-up information was received for / patients ( %) alive at the -year follow-up. of these, patients had died ( cll, chronic gvhd, secondary cancer), and had experienced disease recurrence. with a median follow-up of survivors of . ( . - . ) years, -year nrm, relapse incidence (rel), event-free survival (efs), and overall survival (os) of all patients allografted was %, %, % and %, respectively, without significant effects of tp lesions on outcome. absence of minimal residual disease (mrd) at the -month landmark post hsct was highly predictive for a reduced relapse risk, in particular if mrd eradication occurred only after immunosuppression withdrawal, suggesting of effective graft-versus-leukemia activity (gvl; -year rel %). in the patients who were alive and event-free years post allohct, nrm, rel, efs, and os years after this landmark (or years after transplant) was . %, %, %, and % with a median follow-up of . years ( . - . ) after the -year landmark. notably, no relapse event occurred beyond years post hsct. of those who remained event-free beyond years, all patients who were available for mrd assessment at their most recent follow-up were mrdnegative. altogether of the allografted patients had cll recurrence after transplant; between and , and from onwards. whilst the median survival of those patients who relapsed during the earlier period was months, all patients with late relapse are currently alive - (median ) months after the event. conclusions: long-term observation of patients allografted in the cll x trial confirms that ric hsct can provide gvl-mediated sustained disease control in a sizable proportion of patients with poor-risk cll independent of the tp status. patients who are in mrdnegative remission one year after hsct have an % probability of remaining disease-free at least for years. however, late relapses do occur but may benefit from strategies involving innovative pathway inhibitors. hallek: consultancy and speakers bureau for pharmacyclics, llc and an abbvie company; speakers bureau for janssen; m. kneba: consultancy, honoraria, travel grants and research funding from gilead and roche; consultancy, honoraria and travel grants from abbvie and janssen-cilag; research funding from amgen; travel grants from glaxo-smithkline; p.dreger: consultancy for roche and janssen; consultancy and speakers bureau for novartis and gilead. no evidence for an increased gvhd risk associated with post-transplant idelalisib given for relapse of chronic lymphocytic leukemia or lymphoma: first results of a survey by the ebmt chronic malignancy and lymphoma working parties p dreger , , a boumendil, l koster , c scheid idelalisib is a kinase inhibitor (ki) approved for the treatment of cll and follicular lymphoma (fl). idelalisib has a specific adverse effect profile including immune-mediated inflammatory conditions such as colitis and pneumonitis, raising concern about the safety of this ki if administered for treatment of malignancy recurrence after allogeneic hematopoietic cell transplantation (allohct). the purpose of this ongoing study is to provide information on the safety and efficacy of idelalisib in this setting. we included in this study adult patients who had been registered with the ebmt for an allohct for cll or lymphoma and who received idelalisib for treating disease relapse or persistence at any time after transplant as indicated by participating investigators upon request by the ebmt study office in leiden. baseline patient, disease, and transplant data were collected from med-a forms. centers were requested to provide additional treatment and follow-up information. as of november , , a total of patients have been registered, of whom a full dataset as required for this analysis was available for patients (cll , fl , diffuse large b-cell lymphoma (dlbcl) , peripheral t-cell lymphoma , unspecified ) who had undergone allohct between july and april . all patients except one were male. median age at transplantation was ( - ) years and the median interval from diagnosis to allohct was . ( . - . ) years. prior to allohct, patients ( cll and lymphoma) had received an autohct and two other patients had been exposed to ki (idelalsib , ibrutinib ). disease status at allohct was sensitive in % of the patients. conditioning was reduced-intensity in % of the transplants and included in vivo t cell depletion in the majority of cases ( %). donors were identical siblings in % with pbsc being the stem cell source in all cases. the interval between hct and idelalisib commencement was ( - ) months in the cll group but only ( - ) months in the lymphoma group. prior to idelalisib, grade ii-iv acute gvhd and chronic gvhd had been observed in % and % of the patients, but was still active at the time of idelalisib commencement in only two cases ( %) . four patients with cll had already failed ibrutinib given for post-hct relapse prior to idelalisib. the median time on idelalisib until documented withdrawal or event (progression, retreatment, death) was ( - ) days. after start of idelalisib, one patient developed grade acute gvhd and subsequently chronic gvhd, however, in this patient idelalisib was started as early as days after transplant. efficacy of idelalisib in this high-risk patient sample was limited with only one pr in the cll group (stable disease , progressive disease , not available ; lymphoma not available), translating into a median event-free survival after start of idelalisib of days. five patients with cll underwent a subsequent treatment with an alternate ki (ibrutinib , venetoclax ). altogether, there were five deaths, all due to diease progression (cll , lymphoma ). median overall survival was days for the whole sample and not reached for cll. this preliminary data does not support concerns about the safety of idelalisib in the post allohct setting. updated results of this ongoing study will be presented at the meeting. tested patients ( %) achieved a ccyr and at least a mmolr, respectively. the response to transplant by day assessment correlated significantly with the disease status before transplant. a higher percentage of patients who experienced cytogenetic response before transplant experienced molecular response post-transplant ( %) compared with those who did not ( %; p = . ). for the entire group, the -year cumulative incidence (ci) of acute gvhd grade ii-iv and grade iii-iv were % and %, respectively; -year ci of extensive chronic gvhd was %. there was no significant difference in the ci of severe acute or chronic gvhd between donor types. the ci of nrm at days and year was % and %, respectively. the ci of cytogenetic and molecular relapse at years was % and %, respectively. overall the -year os, pfs and gvhd-free, relapse-free survival (grfs) were %, %, and %, respectively. in multivariable analysis for grfs, transplant in cp and the use of haploidentical donor significantly associated with better grfs. the -year grfs of patients in cp , ap and bp before transplant was %, % and %, respectively (p = . ). ( figure a ) patients receiving a haploidentical donor had a better -year grfs when compared with hla matched transplants ( % vs %, p = . ). ( figure b ) for pfs, transplantation in cp , using a haploidentical donor and mac regimen associated with better pfs while age, cytogenetic and molecular response before transplant did not predict survival. ahsct is curative for a proportion of patients with advanced cml. pfs and grfs are favorably influenced by percentage of bm blasts and donor type, with haploidentical donor having at least as good outcomes as hla matched donors, while molecular and cytogenetic response before transplant do not appear to correlate with survival posttransplant disclosure of conflict of interest: none. allogeneic stem cell transplantation (sct) has been considered as the treatment of choice for younger patients (pts) with high-risk chronic lymphocytic leukemia (cll). role of allogeneic sct in era of novel drugs is widely discussed. here we present our results after sequential use of chemotherapy and reduced-intensity conditioning (ric) in cohort of high-risk cll pts. high-risk cll was defined by one of the following: disease refractory to purine analogs, short response or early relapse (within months) after purine analog combination treatment, and/or progressive disease with unfavorable genetic abnormalities (del [ p]/tp mutation). we analyzed pts with high-risk cll undergoing chemotherapy and ric sct in our centre from august to june . the median of pretransplant lines were (range: - ), novel drugs (idelalisib, ibrutinib) were used in % of pts ( / ). fludarabine ( mg/m ) and cytarabine ( g/m ) for days (fc) were used for cytoreduction in all pts. after days of rest, ric consisting of gy tbi, anti-thymocyte globulin - mg/ kg/day for days, and cyclophosphamide - mg/kg/day for days followed. median age of pts was years (range: five-year overall (os) and relapse-free survival (rfs) was % and %. ci for cgvhd in pts surviving more than months post-hct was % after years and % after years. in a multivariate cox-regression model the occurrence of cgvhd independently improved os (p = . , hr . ; % ci . - . %) as well as rfs (po . , hr . ; % ci . - . ). high risk dipss plus score demonstrated significant inferior survival compared to intermediate- (os p = . ; rfs p = . ), int- (os p = . ; rfs p = . ) and low risk (os p = . ; rfs p = . ) which could be confirmed in multivariate analysis for os (p = . , hr . ; % ci . - . ) and rfs (p o . , hr . ; % ci . - . ). rfs additionally was improved by splenomegaly (n = ) vs. normal spleen size (n = ) at time of hct (p = . , hr . ; % ci . - . ). ruxolitinib (n = ) or none (n = ) pre-treatment compared to other drug therapy (n = ) resulted in improved os (p = . ) and rfs (p = . ) and was an independent factor for rfs in multivariate analysis (p = . , hr . ; % ci . - . ). non-relapse mortality (nmr) was significantly determined by high-risk dipss plus score (p = . ) or dipss high and int- (p = . ). relapse incidence was significantly lower in pts with splenomegaly compared to asplenic or normalspleensized pts prior to hct (p = . ). our data point out that pre-therapy and dipss or dipss plus score are relevant pre-transplant outcome factors while chronic gvhd is the most important independent hct-related factor. furthermore, splenomegaly at hct reduces risk of relapse and therefore improves rfs. [p ] disclosure of conflict of interest: none. thalassaemia major affects new babies in india each year and haematopoietic stem cell transplantation offers the only chance of cure. we present data on children with thalassaemia major aged between months and years using a uniform conditioning regimen consisting of thiotepa mg/kg, treosulphan gm/m and fludarabine mg/m . equine antithymocyte globulin at a dose of mg/kg was added to children who were undergoing transplantation from an unrelated donor source. there were eight deaths before engraftment due to sepsis or bleeding and two related to graft versus host disease. all patients showed complete chimerism on day . however, in children there was an acute drop in donor chimerism between day and post transplantation. immunosuppression was abruptly stopped when donor chimerism dropped below % in all children. seven children responded well and re-established complete chimerism with this measure. seven children progressed to develop complete graft loss. donor lymphocyte infusion (dli) in the form of small aliquots of peripheral whole blood from the donor was administered in seven children. dli was used in a graded fashion every weeks starting from × /kg of cd , followed by × /kg and × /kg. all of them continued to maintain their graft with these interventions. drop in chimerism was seen particularly in children less than years at the time of transplantation comprising out of children. older children with lucarelli class iii were also prone to rejection in our earlier series and this complication has now been eliminated with pre-transplant immunosuppression and hypertransfusion. children above the age of years were more prone to graft versus host disease and required on average months of immunosuppression. treosulphan based protocol has been equally well tolerated by all age groups, all lucarelli classes of children with thalassaemia major and different donor sources. the transplant related mortality and graft rejection rates have been low at . % and . %, respectively. however, children less than years need to be monitored carefully during the first months of transplantation as early withdrawal of immunosuppression can prevent graft rejection resulting in excellent outcomes. disclosure of conflict of interest: none. institute of cellular medicine, newcastle university, newcastle-upon-tyne, uk hemophagocytic lymphohistiocytosis (hlh; hemophagocytic syndrome) is a rare syndrome of potentially fatal, uncontrolled hyperinflammation. allogeneic stem cell transplantation (allosct) is indicated in familial, recurrent or progressive hlh. additional recommendations include central nervous system involvement and unknown triggering factor. while data for allosct outcome are available for the pediatric setting, information for adults is very limited. the aim of this study was to retrospectively analyze the information from the ebmt databases about adult hlh patients who underwent allogeneic stem cell transplantation. we obtained data of adult (≥ years of age) patients transplanted due to hlh. additionally, an hlh-oriented questionnaire was sent to the clinical centers, with responses received so far. median age at transplantation was (range: - ). there was a slight male predominance / ( %). the majority of patients were reported with secondary hlh / ( %), the familial disease was reported in / ( %) patients. in two patients triggering factor was attributed to malignancy. the majority of patients received stem cells obtained from the peripheral blood ( / ; %) while for the remaining ones it was bone marrow. reduced intensity conditioning was used since in / ( %) of patients. thirteen ( %) patients received tbi. donor choice was: matched unrelated ( %), mismatched unrelated ( %), identical sibling ( %). engraftment was observed in / ( %). the cumulative incidence of acute graft versus host disease (gvhd) at days was % ( % ci - %). the cumulative incidence of chronic gvhd at year after allosct was % ( % ci - %) and increased to % at years ( % ci - %). the -year probability of overall survival is shown in fig. . the median survival time was months. the -year os was % ( % ci - %). for patients who survived until months, this proportion was more favorable with an os of % ( % ci - %) at years after transplantation. among patients with observation times longer than months, only one patient died (in the th month after allosct due to relapse which occurred in the th month. after months no more relapses of hlh were recorded-the cumulative incidence reached %. the non-relapse mortality reached % after months. the familial disease was associated with a better prognosis than secondary hlh (p = . ). unlike the pediatric population, where reduced intensity conditioning (ric) was associated with higher survival, in adult patients there was no difference between the conditioning types. data form the questionnaires confirm clinical picture typical for hlh at the diagnosis: fever in / ( %), splenomegaly in / ( %), hemophagocytosis in / ( %) and hyperferritinemia with median concentration of ng/ml (range: - ). image fig. overall survival after allogeneic stem cell transplantation for adult hlh patients until months ( % confidence intervals are shown in grey). the number of patients at risk is indicated below the time axis at the corresponding time points. to our knowledge, this is the largest group of adult patients with hlh who underwent allogeneic stem cell transplantation. relatively low relapse incidence shows that allosct can effectively cure hlh. patients who survive the first period after this procedure can expect a long disease-free survival. disclosure of conflict of interest: none. allogeneic hematopoietic stem cell transplantation (hsct) is the only curative option for children suffering from various life-threatening inherited non-malignant diseases with best results using hla-identical family donor. hsct from unrelated or mismatched family donors is associated with increased risk of agvhd and graft rejection.use of post-transplantation cyclophosphamide (ptcy) with or without additional immunosuppression has been shown to be effective prophylaxis against gvhd in patients with hematological malignancies. there are limited reports of hsct using pt cy for patients with non-malignant disorders. we retrospectively analyzed results of hsct in patients with life-threatening non-malignant diseases using ptcy-based gvhd prophylaxis. patients characteristics are presented in table . thirteen patients ( . %) were transplanted upfront, patients ( , %) were rescued after primary or secondary graft failure after first hsct. donors were hla-matched (n = ) or mismatched ( - / ) (n = ) unrelated, haploidentical (n = ) or hla-identical family (n = ). bone marrow was used as graft source in ( . %) patients and peripheral blood stem cell in ( . %). median cd +/kg recipient weight- . × ( . - . ), cd +/kg- . × ( . - . ). the conditioning regimen was myeloablative in patients (conventional- , reduced toxicity- ), reduced intensity- . the gvhd prophylaxis consisted of a combination of ptcy at dose of mg/kg on days + and + with calcineurin inhibitors (tacrolimus- pts, cyclosporine a- pts) or sirolimus ( pt) and mmf ( pts) starting on day + . all but one patients received also serotherapy with rabbit ( pts) or horse atg ( pst) and rituximab ( pts). with a median follow-up of months (range: - ), the kaplan-meier estimates of os − . %. one patient with thalassemia died before engraftment on day+ from severe vod. / pts ( %) achieved engraftment. the median time for neutrophil and platelet engraftment was ( - ) and days ( - ), respectively. primary graft failure was observed in patients ( was successfully retransplanted from another haploidenticle donor, was not eligible for a second transplantation, but alive). at last follow up, ( %) patients had full donor chimerism, ( %) had stable mixed chimerism without signs of disease progression. one patien with wiscott-aldrich syndrome had secondary graft failure with progressive loss of donor chimerism and were successfully rescued with second haploidentical transplant from the same donor. of engrafted patients, agvhd ii-iv was seen in ( . %) patients. one patient developed grade ii (gut stage ii) agvhd, which resolved with systemic steroids. severe (griii-iv) agvhd was observed in pts after second hsct, both had calcineurin and mtor-inhibitors induced toxicity leading to discontinuation of this drugs, but responded on combined (steroids and ruxolitinib) therapy. one patient with was developed grade iii gvhd (gut stage ) after severe cmv-colitis and died on day from multiple organ failure (suspected tma). one patient developed extensive chronic gvhd of kidney (minimal change [p ] disease) after tapering of immunosupression. one patient with hurler syndrome had seizures, died on day+ from multiple organ dysfunction syndrome. conclusion: ptcy is a promising option for agvhd prophylaxis in patient with non-malignant disease, lacking an hla-matched family donor. disclosure of conflict of interest: none. an exploratory, open-label study to evaluate the safety and feasibility of atir , a t-lymphocyte enriched leukocyte preparation depleted ex vivo of host alloreactive t-cells (using photodynamic treatment), as adjuvant treatment to a t-cell depleted haploidentical hematopoietic stem cell transplantation in patients with beta-thalassemia major c selim , w rob , l sarah , f josu de la previous studies demonstrated that donor lymphocytes, selectively depleted of alloreactive t-cells (atir), could be given safely in adult patients receiving a haploidentical hsct. in patients a single dose of atir, at doses up to × viable t-cells/kg, was given and no grade iii/iv acute gvhd has been reported. this confirms the efficacy of the elimination method of allo-reactive t-cells and attributes to its beneficial safety profile. in an ongoing phase study, cr-air- (nct ), infusion of atir at days post-hsct results in a reduction of transplant-related mortality (trm) and improvement of overall survival and event-free survival. adjunctive treatment with donor lymphocytes in patients receiving a t-cell depleted, haploidentical hsct for nonmalignant diseases such as beta thalassemia major, could provide early immunological support and better immune reconstitution in the absence of gvhd. in an open-label, multicenter phase study (cr-bd- ; eudract - - ), patients age ≥ years and ≤ years with beta thalassemia major will undergo a haploidentical hsct with adjunctive administration of atir . patients will receive a t-cell depleted graft (cd -selected, or cd /cd depleted, or tcr-αβ depleted, depending on the experience of the study center) from a related, haploidentical donor, patient conditioning will be myeloablative following standard practices at the study center. atir infusion at a dose of × viable t-cells/kg is given between and days after the hsct. to assess safety, patients will be evaluated for the occurrence of dose limiting toxicity (dlt), defined as acute gvhd grade iii/iv within days post hsct. efficacy will be primarily evaluated by transfusion-free survival (tfs), occurrence of severe infections, and time to t-cell reconstitution, taking into account hematologic and sustained engraftment. all patients will be closely monitored for cmv, ebv and adenovirus titers, with initiation of pre-emptive treatment upon rising blood titers. regulatory authorities in the united kingdom and germany have approved this clinical study protocol. enrolment of the study is expected to continue during , with first report of safety of atir to be expected first half . disclosure of conflict of interest: j. rovers is employee of kiadis pharma, sponsor of the study. sickle cell disease (scd) can be cured with haematopoietic cell transplantation (hct), yet progress in the practice and research of hct for scd has not come without risks and uncertainty. the information and decisions that families and physicians encounter in this field are complex and hanging. in this hermeneutic study, we analyze the case of one family who advocated for hcts for two of their four children knowing the potential risks. these experiences have had a profound impact on both the family and the medical team. this study was conducted through the research method of hermeneutic phenomenology. hermeneutic inquiry is described as the practice and theory of interpretation and understanding in human contexts and aims to make sense of the particulars of these contexts and arrive at deeper understandings. data collection: in-depth interviews were conducted with the mother of the family, the hct nurse coordinator, and the hct physician. the interviews were audiotaped and transcribed verbatim. the transcribed interviews were later reviewed by the physician, who then wrote an additional reflection. this work culminated in approximately pages of single spaced data in textual form. in hermeneutics, interpretation takes place through a careful reading and re-reading of the data, looking for statements and instances that resonate with the researcher. initial individual interpretations of researchers are then raised to another level of interpretive analysis in the research team's communal attention to the data. particular criteria guide the analysis: agreement, coherence, comprehensiveness, potential, and penetration. the following excerpts and interpretations are provided as examples of the analysis, with names changed for confidentiality. "being heard" arose repeatedly in this family's experience, including at the time of their request for a transplant without meeting the traditional criteria for hct. they persisted in their belief that their children would benefit from hct. "they gave us options to see if there was a chance for a transplant...how life would look…. and then we figured…a transplant for him was better at the time…worth the risks…. and you wouldn't even know. he plays basketball now, he plays sports, he's active and he can exercise and run. i never had any regrets because i felt it was better and the most important thing is his organs were really intact; none of the organs were destroyed…so i think it's the right decision we made" (mother). "this family has changed my career, and my life as a result. they challenged my practice and way of thinking. they did so in a considerate way, out of a duty to advocate for their children. we worked through the tension of different viewpoints with respect and all of us grew in the process. at least i can say our team did. i certainly did... i am humbled by their trust and respect…i am grateful to them" (physician). patients and providers are deeply impacted by their interactions. dr. robert buckman stated that it was the individual case that changed his practice always. he claimed he could not walk into a new patient's room without his practice being forever changed. in presenting this hermaneutic analysis, we aim to remind ourselves of the opportunity for growth that can result from reflection on this sacred patientprovider relationship. disclosure of conflict of interest: none. defibrotide (df) prophylaxis and adjustment of busulfan schedule to prevent veno-occlusive disease and thrombotic microangiopathy in an infant with a membrane cofactor protein (mcp) gene mutation and metachromatic leukodystrophy undergoing hematopoietic stem cell gene therapy (hsc-gt) v calbi , , f fumagalli , , , r penati , g consiglieri , m migliavacca , , d redaelli , s acquati , v attanasio , r chiesa , f ferrua , , f barzaghi , , m cicalese , , a assanelli , , p silvani , s tedeschi, r arora , a soman , f ciotti , m sarzana , g antonioli , , c baldoli , s martino , gl ardissino , mg natali sora , l naldini , , f ciceri , , a aiuti , , and me bernardo hepatic veno-occlusive disease (vod) and thrombotic microangiopathy (tma) are life-threatening complications that can occur after hsc transplantation. expert consensus guidelines support use of df for treatment and prophylaxis of vod due to its ability to restore thrombo-fibrinolytic balance and protect endothelial cells. presymptomatic monozygous twins affected by late infantile metachromatic leukodystrophy (mld) underwent investigational hsc-gt after conditioning with busulfan. no comorbidities were evident at baseline. the dose of transduced cd + cells was similar in both patients ( . × cd +/kg for patient and . × cd +/kg for patient ). patient (p ): at months of age, received conditioning with iv busulfan mg/m /dose for doses (target auc mg × h/l). on day (d) + after gt, he developed severe vod and was treated with diuretics, fresh frozen plasma, paracentesis and df. on d+ schistocytes in peripheral blood, marked proteinuria, complement factor consumption, and increases ldh and bilirubin were observed. the patient's condition worsened, with reduced urine output and generalized oedema with pleural effusion. stool, urine and blood cultures were negative and adamts activity was %; anti-complement factor h (cfh) antibodies (ab) were positive ( ui/ml). these findings led to the diagnosis of atypical hemolytic uremic syndrome (ahus; a form of tma) and eculizumab ( mg/weekly dose) was started on d + . patient subsequently developed pulmonary oedema and needed non-invasive ventilation. molecular analysis revealed a heterozygous deletion of cfhr -r and ala val mutation in the mcp gene, a defect previously shown to be associated with ahus. due to the presence of ab anti-cfh and antiplatelet, weekly doses of rituximab ( mg/m ) were administered. after treatment, p progressively improved although he showed prolonged severe anaemia and thrombocytopenia and bone marrow (bm) hypoplasia, secondary bleeding which required reinfusion of unmanipulated autologous bm cells on d + . nine months after hsct-gt p has shown good hematopoietic recovery, stable engraftment of the transduced hscs, no signs of renal damage or complement activation, albeit with neurodevelopmental delay. patient (p ): given his twin history and genetics, this month old infant was considered at increased risk of vod, so prophylaxis with df ( mg/kg/d) was administered from d- to d+ and the busulfan conditioning was modified by adjusting the auc to a lower target ( mg/kg/dose for doses; target auc . mg × h/l). the child had a good clinical recovery and didn't develop signs of vod or tma after hsc-gt. on d+ and + , respectively, anti-cfh and anti-platelet ab were positive. considering the history of the twin, weekly doses of rituximab were administered. p is currently months after gt with persistent engraftment of transduced hscs and no signs of tma. data from this case-control report of monozygous twins diagnosed with mld, and subsequently shown to also harbor mutations in complement regulator gene, suggest that df prophylaxis and busulfan adjustment may have helped prevent systemic microangiopathic damage in the second twin. patients with rare disease may have mutations in genes in addition to those that cause their disease. patients at risk of post-transplant tma following hsc-gt for genetic diseases may require tailored df prophylaxis and treatment. disclosure of conflict of interest: a. aiuti is the principal investigator of the tiget-mld clinical trial of gene therapy. the mld gene therapy was licensed to glaxosmithkline (gsk) in and gsk became the financial sponsor of the trial. all authors declare no other competing interests. hematopoietic stem cell transplantation (hsct) using an optimized conditioning regimen is essential for the longterm survival of patients with inherited bone marrow failure syndromes (ibmfs). we report hsct in children with fanconi anemia (fa, n = ), diamond-blackfan anemia (dba, n = ), dyskeratosis congenita (dc, n = ) and shwachman-diamond syndrome (sds, n = ) from a single hsct center. the graft source was peripheral blood stem cells (n = ) or cord blood stem cells (n = ). fa, dc and sds patients received reduced-intensity conditioning, while dba patients had myeloablative conditioning. the median numbers of infused mononuclear cells and cd + cells were . × /kg and . × /kg, respectively. the median time for neutrophil and platelet recovery was and days, respectively. there was one primary graft failure. after median follow up years the overall survival was %. the incidence of grade ii-iii acute and chronic graft versus host disease (gvhd) was % and % respectively. in a multivariate analysis, the type of conditioning regimen was the only factor identified as significantly associated with grade ii-iii acute gvhd (p = . ). we conclude that hsct can be a curative option for patients with ibmfs. disease specific conditioning regimen was important to disease the transplant-related mortality. [p ] disclosure of conflict of interest: none. homozygous sickle cell disease (scd) patients suffering from end-stage renal disease (esrd) show a variable outcome after kidney transplantation as underlying disease can cause poor allograft survival and disease-specific problems. we present a case of a -year old patient with severe scd and esrd who underwent haploidentical bone marrow transplantation (bmt) with consecutive living kidney transplantion (lkt). the patient suffered from multiple complications of scd including stroke with secondary hemorrhage, symptomatic epilepsy, esrd and uncontrolled hypertension. the patient had been on hydroxyurea without success and required regular blood transfusion due to severe renal anemia. the rationale for bmt was uncontrollable iron overload. a reduced intensity conditioning regimen was used with (fludarabine, cyclophosphamide and gy of tbi, dose-adjusted to esrd). graft-versus-host disease (gvhd) prophylaxis consisted of post-transplant high-dose cyclophosphamide, cyclosporine a (cya) and mycophenolate mofetil (mmf). the donor was her -year old mother with hbs trait, the stem cell source was bone marrow, the cell dose . × nucleated cells/kg. during conditioning daily hemodialysis was performed to keep drug levels stable. neutrophil engraftment occurred on day + , chimerism at day + was %. hbs increased from . % pre-hsct to . % months after hsct. hemoglobin values increased from g/l pre-hsct to g/l post-hsct and reticulocytes from g/l to g/l. erythropoietin levels increased from . iu/l pre-hsct to iu/l months after hsct. during the follow-up, the patient did not show any sign of acute gvhd or vaso-occlusive crisis, hemolysis or sickling. relevant complications were disease-related (therapy resistant hypertension and epileptic seizure due to former brain damage). on day + a lkt from the same donor was performed. the initial immunosuppressive treatment with mmf was continued, cya was switched to tacrolimus and steroids were added for months. the post-transplant period was uneventful. currently, months after haploidentical bmt and months after lkt there are no signs of gvhd, the blood chimerism is %, the kidney allograft function is very good (gfr ml/min/ . m ) and immunosuppression is withdrawn. iron overload is being corrected by regular phlebotomies. the patient no longer requires antihypertensive medication and there is evidence of vascular remodeling. this is the first report of a successful haploidentical bmt followed by kidney transplantation from the same donor in a patient with scd. disclosure of conflict of interest: none. allogeneic hematopoietic stem cell transplantation (hsct) can cure non-malignant diseases, such as primary immune deficiency (pid), severe aplastic anemia (saa) and osteopetrosis (op). in the absence of a well-matched donor, transplantation from a haplo-identical donor maybe considered. post-transplant cyclophosphamide (ptcy) is a new strategy derived from the treatment of malignant diseases in adults that has been little studied in high-risk pediatric nonmalignant diseases. fifteen children ( . years, range: . - . ) underwent hsct in the pediatric immunology and hematology unit of necker hospital, paris, between december and september . these children were suffering from op (n = ), saa (n = ), hemophagocytic lymphohistiocytosis (hlh) (n = ), immunodysregulation polyendocrinopathy enteropathy x-linked (ipex) syndrome (n = ), combined immune deficiency (n = ) and leukocyte adhesion molecule deficiency (n = ). three patients received a low-intensity conditioning regimen (cr) (based on fludarabine, cyclophosphamide, and total body irradiation) whereas the other received myeloablative cr (based on busulfan auc targeted and fludarabine). fourteen patients received serotherapy before hsct. post-transplant cyclophosphamide ( mg/kg/ day) was given on d and d and graft versus host disease (gvhd) prophylaxis with cyclosporine and mycophenolate mofetil was initiated on d . the transplanted stem cells were obtained from bone marrow in all cases. engraftment with full donor chimerism was observed in patients. the median cd + cell dose was . × cells/kg body weight (range: . - . × ). neutrophils recovered after a median of days (range: - ), and overall survival (os) was % after a median follow-up of year (range: . - . ). three patients died due to graft failure (n = ) or infectious complications related to gvhd (n = ). grade ii acute gvhd occurred in of the patients displaying engraftment ( %), and chronic gvhd and/or autoimmune complications were observed in four patients ( %). viral complications were frequent, occurring in patients ( %) with cmv infection (n = ) /disease (n = ), adenovirus disease (n = ) and bk virus cystitis (n = ). haploidentical transplant with ptcy is feasible in high-risk patients with non-malignant diseases. chronic gvhd and autoimmunity were more frequent than for more conventional approaches in such patients. infection rates were high. disclosure of conflict of interest: none. sickle cell disease (scd) remains associated with high risks of morbidity and early death. even best of supportive care fails to improve quality of life. hematopoietic stem cell transplant (hsct) can be considered for selected group of patients. in long run it is not just economical but also substantially improves quality of life (qol). we report our experience with hsct for scd from india. seventy three consecutive patients suffering from scd who underwent hsct between january and november were included in the study. fifty two underwent matched sibling donor (msd), matched family donor (mfd), matched unrelated ( / or / ), cord blood transplant cbt ( matched sibling cord blood and matched unrelated) and patient underwent haploidentical transplant. different conditioning regimens were used and so was the graft versus host disease prophylaxis depending on institutional protocols as depicted in table . a total of patients underwent sct. the median age was years ( months- years). m/f ratio was / . majority of patients were either from african union or oman. all patients suffered from one or other severe symptoms making them eligible for sct. graft source was bone marrow (bm) in with median cd count of . x /kg ( . - . ), peripheral blood (pb) in with median cd count of . x /kg ( . - . ), cord blood in with median cd count of . x /kg ( . - . ) and combined bm & pb in with median cd count of . x /kg ( . - . ). of the patients, are alive and disease free with lansky/karnofsky scores of . there were deaths ( msd/mfd/mud; haploidentical and matched unrelated cbt). four patients rejected the graft ( haploidentical and msd/mfd/mud). at the last follow up, the probabilities of survival, scd-free survival, and transplantrelated mortality were %, . %, and %, respectively. outcome of hsct in scd has improved significantly. with better conditioning regimens, improved supportive care, the outcome of alternative donor transplant and adult scd has improved and matches sibling donor transplant. hsct should be strongly considered as a curative modality for selected patients suffering from scd. disclosure of conflict of interest: none. s staff jointly defined more than local standard operating procedures. patients with low-risk characteristics (age ≤ years, liver size ≤ cm below costal margin) and a hla matched sibling donor were considered eligible in this initial phase of activity. a downstaging protocol with hydroxyurea and deferoxamine or deferasirox was adopted. conditioning regimen included iv busulfan and cyclophosphamide. gvhd and rejection prophylaxis included atg from day − to − and csa, mtx and methylprednisolone. gcs-f primed bone marrow was chosen as stem cell source. the first allogeneic hsct of the whole iraq was performed in a child with thalassemia at hiwa hospital in october . up to now, patients ( females, male) underwent hsct; median age at transplantation was years; median infused tnc . × /kg, cd + . × /kg. all of them engrafted. no major complication were observed. one of them developed grade ii agvhd (skin only) which resolved after increasing the dose of steroids. a huge number of patients with low-risk thalassemia are now in the waiting list and some of them have already started downstaging having planned hsct in a short time. a matched sibling transplant program in children with thalassemia is feasible and safe in kurdistan. such a program can provide many advantages: far less psychosocial and financial burden for the families and significant saving for the government. the estimated costs of performing locally hsct are much less than in the countries where patients were previously referred. the continuation of cooperation is of paramount relevance for further implementing the activity and extending the transplant accessibility to patients with other hemato-oncological disorders of childhood. disclosure of conflict of interest: none. long term follow-up after reduced-intensity conditioning and stem cell transplantation for thalassemia major r rihani, a natsheh, sm abu, e khattab, r najjar, f sheab, s sharma, n hussein, a tbakhi and m sarhan bone marrow and stem transplantation program-king hussein cancer center, amman, jordan hematopoietic stem cell transplantation (hsct) is the only curative treatment for thalassemia major (tm). reducedintensity conditioning (ric) before hsct for high risk tm patients results in fewer complications, when compared with myeloablative regimens. one hundred and three tm patients received hscts from an hla-identical related donor at king hussein cancer center, between january and november . of those, were high risk tm ( %) who received ric hscts. in this report, we describe follow-up beyond years (median, ; . - months) post ric hscts. forty-four class ii-iii patients ( %) were identified ( % with hepatitis c); with a median age of ( . - ) years. females accounted for % (n = ). conditioning regimen consisted of oral busulfan mg/kg, fludarabine mg/m ,tli cgy and atg followed by pbsct. gvhd prophylaxis consisted of mmf and csa. median infused stem cell dose was . × /kg. all patients attained neutrophil and platelet engraftment (median, . and . days, respectively). persistent mixed donor or full donor chimerism were observed in . % (n = ) and . % (n = ), respectively. immune-suppressive therapy for gvhd treatment was required in ( . %) patients (agvhd, n = ; cgvhd, n = ). moreover, veno-occlusive disease occurred in patients ( %) that resolved completely. secondary graft failure was noted in ( %) patients. the -year overall survival was %, while the -year probability of thalassemia-free survival was . %. other factors evaluated include: growth parameters, endocrine and other organ functions, in addition to functional status. this report confirms the safety and efficacy of ric regimens in hscts for high risk tm patients. those regimens are associated with excellent engraftment and sustained mixed donor chimerism; and lead to excellent thalassemia-free and overall survival rates. [p ] disclosure of conflict of interest: none. in-time hsct for pts. with hurler syndrome (hs) can significantly improve the results. long-term follow-up and late effects estimation required to prepare a special observation and rehabilitation programs. aim. to analyze our experience with hsct for hs in the field of special observation and rehabilitation programs. forty hsct during the - were performed for pts. with hs. median age at the diagnosis was months ( - months), at hsct- months ( - months). bm used in . % (n = ), pbsc- . % (n = ), cb- . % (n = ). mac conditioning was used for hsct, ric-for . ric regimen: flu+mel+atg, mac: bu/treo +flu+thio/mel (bu was used in early ) and atg +rituximab (in case of mud hsct). all pts. with ric received mud hsct, pts. with mac mud- pts., mrd- pts. pts. received csa/tacro-based gvhd prophylaxis. mmf/mtx was additionally added in all cases. in ric hsct immunomagnetic Сd /Сd + depletion of pbsc (by clinimacs) was used. a special observation protocol including somatic and neurocognitive estimation was developed. all pts. engrafted with full donor chimerism on d+ . median of engraftment day- ( - days). thirty three pts. survived. reasons of death-mac: infections- pts., ric: trali- pt., agvhd- pt. trm improved, over the years, with improving of supportive care and donor selection as well as pre-transplant screening. no early severe toxicity revealed. pulmonary infection episodes was registered in % of pts. in our study. gvhd: grade iideveloped pts., grade iii-iv- pts. (after ric), local cgvhd- pts. (ric). no extensive cgvhd. pts. rejected (mac and ric rejection rate was same). at median follow up of months ( - months), the estimated years pos was %. best response correlated with early hsct (and better status before hsct) and higher level of aidu after. late effects estimation showed that . % (n = ) of patients experienced late effects: cardio-vascular- pts., skeletal- pts., endocrine- pts. all pts. with cardio-vascular effects received mac. skeletal effects affected patients of older age, pts. transplanted in younger age do not have such effects. median period of late effects arising after hsct was month ( - months). only pts. experienced serious pulmonary late effects (infections), all episodes was before . no pts. in our study have progressive retinal degeneration. % of pts. improved in the neurosensory component and all pts. improved in neurocognitive status and development after hsct. best response correlated with neurocognitive rehabilitation based on unique computer model used by our group in russian national rehabilitation center "russkoe pole." in-time hsct is an effective and safe way to stop neurodegenerative process for pts. with hs. both mac and ric regimens can be used with the same effectiveness. mac regimens associated with bigger number of cardiovascular late effects. long-time follow-up showed that these patients require the special observational protocol including estimation of cardio-vascular, skeletal, endocrine and neurocognitive risks. better neurocognitive response correlated with intensive rehabilitation using computer model. russian joint study showed effective cooperation for treatment pts. with hs in the national setting. disclosure of conflict of interest: none. little is known about pathogenesis of solid tumors after hsct but, intensive cytotoxic conditioning therapy with defective dna repair of persisting stem cells/stromal cells, viral infection, and immunosuppression may play a role. / patients with solid tumors had a melphalan-based conditioning. melphalan was linked to sarcoma and lung cancer in animal model. there are few data linking parotid mec to infection by cmv and hhv which can remain dormant in the salivary glands. both affected patients had hhv during the transplant period. p and p had a family history of solid tumor pointing to a possible genetic factor. whilst secondary malignancy post-hsct for patients with malignant disorders is well recognised, non-ptld malignancy post-hsct for pid has not previously been reported. a larger study is needed to evaluate incidence and risks. allogeneic hsct is a treatment of choice for the bone marrow failure in patients with sds. hsct from unrelated or mismatched family donors is associated with higher morbidity and mortality compared with matched sibling. combined pgd and hla antigen testing is a possible option to preselect a compatible donor for an affected sibling requiring hsct. we describe a case report demonstrating first successful hsct for years girl with sds by using preimplantation genetic diagnosis and hla matching. diagnosis of sds was suspected at m.o., based on clinical features, family history, laboratory studies. at m.o., bone marrow (bm) aspiration revealed hypocellular marrow with signs of dysplasia and expansion of blasts ( . % blasts). the sanger sequencing of sbds gene showed c. - ta ct and c. + t c mutations. the patient had recurrent infections, including bilateral pneumonia caused by phaeohyphomyces, bloodstream infection, cmvdisease. due to the lack of matched related or unrelated donors, hsct with ric (flu, mel, atg) from haploidentical father was performed at months of age. after the st allo-hsct, engraftment was achieved on d+ , initial str study showed full donor chimerism. post-transplant period was complicated with severe cmv-infection and signs of secondary hlh. at d+ , graft rejection was registered. the girl became dependent on regular rbc and platelet transfusions, bm examination revealed hypocellularity with moderate signs of myelodysplasia without elevated blast count. due to lack of available hla-compatible donors, an option of in vitro fertilization (ivf) with preimplantation selection of a normal hla-matched embryo was considered. after controlled ovarian hyperstimulation embryos were hla-compatible and healthy (first, wild-type; second, heterozygous for sbds gene mutation c. - ta ct). hence, the only unaffected hla-identical embryo was transferred resulting into full-term pregnancy. at the age of . years after st hsct, the nd s transplant was performed with a combination of cb and bm as a source of hematopoietic stem cells. the donors' age was years a reduced toxicity conditioning regimen (rtc) based on flu mg/m , treo g/m , thiotepa mg/kg with serotherapy (thymoglobuline . mg/kg) was used. because of neurotoxicity, arterial hypertension, since d+ csa was changed to sirolimus +mmf for gvhd prophylaxis. the total number of infused nc was . × /kg; cd +, . × /kg; cd +, . × /kg. engraftment was achieved on d+ . any signs of gvhd, severe infectious or toxic complications were not observed. eight months later, the patient is alive, has full donor chimerism in bm and is not transfusion-dependent. in the absence of hla-identical donor, ivf with preliminary pgd and hla-typing could be a chance for matched donor to cure patients with non-malignant genetic diseases. in case of low cord blood cellularity, a combination of cb and bm from the same sibling could be used. our experience showed a successful engraftment of sds patient and stable donor chimerism after second hsct of cb and bm from pgd-selected sibling with rtc. disclosure of conflict of interest: none. the safety and efficacy of familial haploidentical (fhi) stem cell transplantation utilizing cd enrichment and cd addback in patients with high risk sickle cell disease (scd) ( figure a ). probability of yr efs is . % (ci : - %) ( figure b ). immune cell reconstitution has been robust and similar to rtc and msd allosct in scd (table ). there have been deaths, vod, steroid refractory agvhd and cgvhd. mac followed by fhi utilizing cd enrichment and t-cell addback in patients with high-risk scd is safe, tolerable and results in long-term donor chimerism and absence of scd symptoms or complications. a larger cohort and follow-up will be required to confirm these preliminary findings. disclosure of conflict of interest: none. supported by r fd - a . [p ] s lymphoma p a clinical prognostic index for assessing patients aged being considered for high-dose therapy and autologous stem-cell transplant in relapsed or refractory high-grade non-hodgkin lymphoma d edwards , k kirkland , r pearce, s robinson and g cook bsbmt patients with relapsed high-grade nhl or disease refractory to first-line therapy can still be cured with high-dose therapy and autologous stem cell transplant if they respond to salvage chemotherapy. this aggressive algorithm is accepted in younger patients but is less well established in the elderly. age has a negative predictive score in the international prognostic index (ipi) and there are concerns that the outcomes of hdt in these patients are significantly worse. deciding which older patients will benefit from hdt is challenging and there are no established predictive tools to guide physicians. we present a clinical prognostic index derived from information readily available at the time a patient is being assessed for asct the bsbmt audited the outcomes for uk patients aged transplanted between - (n = ) and benchmarked against the european bone marrow transplant (ebmt) database for the same period (n = ). the primary outcome was progression-free survival (pfs) but data was also analysed for overall survival (os), relapse rate (rr) and non-relapse mortality (nrm). we included all patients with a diagnosis of high grade nhl and the following demographic features were also analysed: age at diagnosis; age at transplant; m/f; year of transplant; cr/not cr at transplant; no. of prior therapies; no. of cells infused; clinical staging; karnofsky status at transplant; histology; ipi at diagnosis; mobilising regime and conditioning regime. candidate prognostic indices were factors achieving significance in univariate and multivariate analyses of the main outcomes by regression analysis. the best prognostic index was selected based on the bsbmt dataset and then applied to the rest of the ebmt dataset (the validation dataset). there were no significant differences in patient characteristics between the uk and non-uk groups nor in outcomes of pfs, os, rr or nrm. (figure ). in both univariate and multivariate analysis the following features were associated with a significantly worse outcome for pfs, os, rr and nrm : age , karnofsky score. disclosure of conflict of interest: none. underwent an allo-sct at our center after a treosulfan-based conditioning regimen. eleven pts received a mrd, pts a mud, and pts a haplo unmanipulated pbsc allo-sct. at allo-sct pts were in cr, pts were in pr, and pts had sd/pd. hct-ci was evaluable for pts, had a score ≥ . the backbone conditioning regimen consisted of treosulfan g/m from day − to − , and fludarabine mg/m from day − to − ; twenty-five pts were treated with this reduced toxicity conditioning (rtc) regimen. intensification with other alkylating agent (melphalan, thiotepa, or cyclophosphamide) or radiotherapy ( gy total dose) was applied on the remaining pts (myeloablative conditioning, mac). gvhd prophylaxis was based on cyclosporine a and methotrexate ( pts) or rapamycin and mycophenolate mofetil ( pts), plus anti-thymocyte globulin or post-transplant cyclophosphamide accordingly to donor type. median numbers of infused cd +/kg and cd +/kg were . × (range: . - . ) and . × (range: . - . ), respectively. median follow-up was months (range: - ). thirty-nine pts were evaluable for engraftment; median time to neutrophil ≥ . × /l was days (range: - ), and days (range: - ) to platelet ≥ × /l. treosulfan conditioning provided a cr in and pts respectively in pr and sd/pd at transplant. no graft failure was observed. one and years overall survival (os) was . % and . %, respectively. progression free survival (pfs) and gvhd-free/relapse-free survival (grfs) were respectively . % and . % at year, . % and % at years. one and years relapse/progression incidence (ri) was . % and . %, respectively. transplant related mortality (trm) was . % at days, . % at year and for the entire follow-up. the -day cumulative incidence (ci) of agvhd grade ≥ was . %; ci of moderate to severe cgvhd was . % at years. the outcome of pts in cr at years was significantly better compared to that of pts with active disease in terms of both os ( . % vs . %, p o . ), pfs ( . % vs %, p o . ), grfs ( . % vs . %, p o . ), and ri ( . % vs %, p o . ). no statistical differences in os, pfs, and ri were found when pts were stratified according to donor type and [p ] the use of rtc or mac regimen. at last follow-up, patients are alive and disease free; of them obtained a durable cr using chemotherapy and/or dli for disease progression after allo-sct. treosulfan-based conditioning regimen is effective and well-tolerated in patients with advanced b-nhl undetgoing allo-sct. disclosure of conflict of interest: none. systemic anaplastic large cell lymphoma (salcl) is a very infrequent well-defined histological entity that comprises around % of all t-cell non-hodgkin lymphoma. in the absence of prospective clinical trials, autologous stem cell transplantation (autosct) is considered the standard of care as consolidation therapy after first line therapy for those patients not expressing the alk protein (alk neg salcl) and for patients with relapsed disease. the objective of this retrospective analysis was to analyse the long-term outcome of patients diagnosed with salcl and being treated with autosct during the course of the disease, making special emphasis on the potential impact of the administration of brentuximab vedotin (bv). eligible for this study were patients years or above with salcl who underwent autosct between to and were reported to the ebmt. baseline patient, disease, and transplant data were collected from ebmt med-a standard forms. centers with potentially eligible patients were contacted to provide additional treatment and follow-up information including a written histopathology report for central review. seventy-nine patients ( males) with a median age at diagnosis of years (range: - ) and at transplantation of years were included in the final analysis. thirty-nine patients were alk negative, alk positive and in patients expression of alk protein was unknown. at diagnosis, patients ( %) presented with advanced stage and ( %), with b symptoms. sixty-three patients ( %) received - lines of therapy before autosct. ten patients were treated with bv at some point before autosct; two patients as second line therapy, three as third line, one as fourth line and four as fifth line therapy. the median number of bv doses was (range: [ ] [ ] [ ] [ ] [ ] [ ] . the median time between diagnosis and transplantation was months (range: . most patients had chemosensitive disease at autosct [ patients ( %)] and in all but patients peripheral blood was used as the source of stem cells. conditioning regimen consisted on beam / beam-like protocols in patients ( %). all patients engrafted. with a median follow up for surviving patients of months (range: - ), patients are alive ( %), patients died ( %) and patients ( %) are lost for follow up. disease relapse after transplantation was the most frequent cause of death after the procedure. cumulative incidence of non-relapse mortality for the whole series was % ( % ci, . - ) at days, year and years. cumulative incidence of relapse was % ( % ci - ) and % ( %ci - ) at and years, respectively. and years progression free survival (pfs) was % ( % ci - ) and % ( % ci - ), respectively and and -years overall survival (os) was % ( % ci - ) and % ( % ci - ), respectively. there were no significant differences in any of the outcomes between bv treated and non-treated patients. autosct results in a promising pfs and os in patients with salcl. the potential impact of the administration of bv as salvage strategy before the procedure needs to be further elucidated. disclosure of conflict of interest: none. coeliac disease (cd) is a t-cell immune-mediated enteropathy to dietary gluten, characterized by small bowel villous atrophy resulting in malabsortion. the enteropathy is reversible with a gluten-free diet (gfd), however symptoms and signs which persist year are defined as refractory coeliac disease (rcd). rcd is divided into type i and ii, depending on absence/ presence respectively of clonal intra-epithelial t-lymphocytes (iels) with an aberrant phenotype (cytcd pos, membranous cd , cd and cd neg). rcdii patients have a year survival of . , plts ) was successful at a median of . (range: - ) days and no transplant-related mortality occurred. all patients achieved a clinical complete remission, with normalization of nutritional indices at days, but persistently abnormal iels and clonal t-cells on duodenal biopsy. with a median follow-up of . (range: - ) months, patients remain in clinical remission, patient relapsed with rcd and no patient progressed to eatl. chemotherapy and asct is a safe and effective strategy for the treatment of rcd offering the possibility of sustained clinical responses. clonal tcr in duodenal biopsy/blood and iel flow cytometry form part of the patient evaluation prior to the chemotherapy/asct program. most patients with hodgkin lymphoma (hl) are cured with conventional chemotherapy. however, approximately % of patients relapse after primary treatment. for those, high-dose chemotherapy (hdc) followed by autologous stem cell transplantation (asct) is the standard of care. fifty seven adult patients with relapsed or refractory hl submitted to asct between and were reviewed. variables examined were sex, age, ann arbor stage (i-ii vs iii-iv), b symptoms, bulky disease, extranodal involvement, nodal areas involved (≥ vs vs ≤ months) and response to the treatment prior to asct. log-rank test was used to compare differences in survival for each factor. patients median age was ( - ) years at diagnosis. ann arbor stage iii-iv in ( %) patients, b symptoms in ( %), extranodal involvement in ( %) and bulky disease in ( %). all patients were treated according to the abvd protocol in first line. indications for asct were relapsed disease (n = , . %) and lack of complete response (cr) or progressive disease with st line treatment (n = , . %). there were a median of ( - ) treatment-lines before asct (protocols eshap, ice, beacoop, gvd and others). the disease was chemosensitive in % cases: cr in and partial response (pr) in patients prior to asct. refractory disease (rd) in % (n = ). in . % patients, the hematopoietic cells mobilization was performed under stimulation with granulocyte-colony stimulating factor in hematologic recovery after the cycle of nd line chemotherapy, and most of which required ( - ) apheresis. conditioning regimens were beam ( %) and gmb ( %). the median time to hematologic recovery was days ( - ) for neutrophils /ul and days ( - ) for platelets , / ul. three months after asct, thirty-nine ( . %) patients had cr, one ( . %) patient maintained pr and ( . %) patients had disease progression. status unknown in patients and four ( %) patients died. relapse rate % (n = / ). with a median follow-up time after asct of ( - ) months, median disease-free survival (dfs) was ( - ) months and overall survival (os) was ( - ) months. there were deaths ( . %), four ( %) related to early infectious complications of asct, two ( . %) due to late infectious complications, eleven ( . %) due to disease progression and ( . %) in context of secondary acute myeloid leukemia. response to the treatment prior to asct was the only factor with survival influence. the dfs and os differed significantly in chemosensitive disease compared with rd (dfs mean: vs months,p = . , os mean: vs months, p = . ). the response to salvage treatment prior to asct is the main prognostic factor for survival after asct. prognosis remains poor in patients with rd or early and disseminated relapses. for these patients, the therapeutic approach should include intensive treatment with tandem hdc and stem cell transplantation, allogeneic transplant or early consolidation with brentuximab-vedotin after asct. hodgkin's lymphoma (hl), although considered a curable neoplasm in adults, could be associated with a very poor prognosis when refractory to primary induction therapy or when it relapses within months from an autologous stem cells transplant (auto-sct). the optimal treatment of patients with heavily pretreated/refractory hl is controversial. brentuximab vedotin (bv) is an active single agent in this context; unfortunately, there are no well established therapies when patients fail to respond or progress after bv. encouraging results were recently described with checkpoint inhibitors. similarly, data pertaining to efficacy of bendamustine (benda) shows encouraging activity in various refractory lymphomas. we included in this study adult patients with hl who relapsed post auto-sct and were refractory to or progressed after salvage bv and were treated with benda as salvage therapy with an intention to proceed with an allo-sct. this study was [p ] conducted in two major centers in lebanon, the american university of beirut medical center (aubmc) and makassed university hospital. we identified eligible cases. the primary study endpoint was objective response rate (orr). the secondary endpoint evaluated successful rate of bridging into an allo-sct. the median follow-up times from auto-sct and from benda salvage were ( - ) and ( - ) months, respectively. the median age of patients was years ( - ). all patients had bv as salvage therapy post auto-sct, and all of them progressed after a median of ( - ) cycles. clinical characteristics are outlined in table . patients received a median of cycles ( - ) of benda. the treatment was well tolerated, with rather infrequent adverse events and transient and manageable toxicities. the orr was %, in of patients, with % obtaining a complete response. eventually, of proceeded to allo-sct using a matched related donor, and the remaining patients are planned for allo-sct. only one patient died from disease progression after months post allo-sct. two of patients who progressed following benda received salvage therapy with nivolumab and are being planned for haplo-identical transplant while the third one is being planned for therapy with nivolumab. from the initiation of benda, the median duration of response for the patients was months ( - ); all these patients had maintained a continuous response at the last follow-up examination. conclusion: notwithstanding the limitations associated with our analysis, namely a small sample size and its retrospective nature, these results suggest a role for bendamustine in post bv failures. these findings also provide the basis to evaluate the concept of benda as a bridge to allo-sct in a large prospective study. [p ] disclosure of conflict of interest: none. brentuximab vedotin for relapsed or refractory hodgkin lymphoma, single center experience king faisal specialist hospital and research center, riyadh, kingdom of saudi arabia ms rauf , i maghfoor , a badran , mn zahir and s akhtar hodgkin lymphoma (hl) patients with relapsed or progressive disease after high dose chemotherapy (hdc) and auto-sct have limited curative options. fda granted approval of brentuximab vedotin (bv) for the treatment of hl and anaplastic large cell lymphoma (alcl) patients who fail auto-sct or have had at least prior multiagent chemotherapy regimens and are not candidates for auto-sct. we are reporting single center experience of bv usage in this "approved" setting. medical records were reviewed to collect required data. kaplan-meier (km) method was used to calculate overall survival (os) and progression free survival (pfs) from date of first dose of bv. from - , patients received bv. / had hl ( classic hl-nodular sclerosis, hl-mixed cellularity) and alcl. / ( %) pts were primary refractory or had early relapse after initial treatment. / ( %) pts received bv were refractory to the last treatment. all the baseline characteristics of patients are mentioned in table . median bv cycles administered were ( - ). overall response rate (orr) was % ( patients): cr in ( %), pr in ( %) ( / were primary refractory or early relapsed). median pfs for whole group was months ( % ci, . - . ). km estimated -year os was % and year was %, median os has not been reached yet. for patients who responded, pfs at months was % ( % ci, %- %), median pfs not reached. for / patients with progressive disease (pd) or non responders after bv, median pfs was only months ( % ci, . - . ). there was no difference in os between patients with responders and non responders. median os has not yet been reached in either group as mentioned in survival curves. at the median follow up of months (range: - months) patients are alive, patients are alive without disease, patients received consolidation bone morrow transplant ( auto-sct and allo-sct). patients completed courses and achieved cr. rest of patients who are alive without disease; they had pd on bv but achieved cr with other treatments. patients are alive with disease; patient is on bv and are on another treatment. patients have died, because of pneumonia while being on bv and due to pd. / patients who received bv, achieved cr after failing all previous treatments and are in cr. peripheral sensory neuropathy developed in patients; one required dose reduction. patient stopped treatment due to pulmonary toxicity. we are reporting largest single center data from middle east which confirms that bv as a single agent is effective and safe. overall response rate is lower as compare to pivotal trial but cr rate is comparable to other reported case series. this analysis also concludes that bv can be used as bridge to transplant in patients who don't respond salvage chemotherapy. disclosure of conflict of interest: none. was used to diagnose hiv infections. cox proportional hazards models were used to evaluate risk factors of overall mortality. fifty-six patients with nhl ( . %) and patients with mm ( . %) were positive for hiv antibody. in patients with nhl, overall survival was significantly lower in the hiv-infected patients than in the hiv-negative patients [ - year overall survival: hiv-infected patients, % ( % confidence interval, %- %) vs. hiv-negative patients, % ( % confidence interval, %- %), p o . )]. in a multivariate analysis, hiv infection was significantly associated with an increased risk of mortality (hazard ratio . , p o . ), and this effect was consistent regardless of transplant year. on the other hand, overall survival in patients with mm was similar between the groups [ % ( % confidence interval, %- %) vs. % ( % confidence interval, %- %), p = . ]. previous studies in europe and the united states showed comparable survival rates between hiv-infected and hiv-negative patients with nhl. however, our study showed that hiv infection was associated with a higher risk of mortality in patients with nhl in japan. suppression of t cell-mediated immunity or hiv related diseases might affect transplant outcomes in japanese patients. [p ] disclosure of conflict of interest: none. while beam and beac regimens (bcnu, etoposide, cytosar in both regimens and melphalan or cytoxan, respectively) are commonly used as conditioning high-dose therapy (hdt) in patients with non-hodgkin lymphoma (nhl), there have been few reports comparing these regimens. a retrospective analysis found the superiority of beam over beac in terms of overall survival (os) and event-free survival (efs). toxicities were similar, except that beam was associated with more frequent lower gastrointestinal (gi) mucositis. other studies reported that these regimens had similar efficacy and outcome. recently, a concern regarding cardiotoxicity of beac has risen. the current study aimed to compare efficacy and toxicity of beac and beam as consolidation hdt in young patients with mantle cell lymphoma (mcl) undergoing autologous stem cell transplantation (asct). this is a retrospective analysis of outcomes in mcl patients who received hdt with beam or beac followed by asct at bone marrow transplant centers in israel. os, disease-(dfs) and progressionfree survival (pfs) and regimen toxicity were compared. seventy seven mcl patients who were diagnosed between - / and received consolidation with beac or beam were included in the analysis. forty nine patients were treated with beam and patients-with beac. no significant differences between the groups were revealed in terms of age, sex, the mantle cell lymphoma international prognostic index (mipi) risk score, induction protocol and% of patients transplanted in first complete response (cr ) (mean age yrs in beam vs yrs in beac group; % of patients in beam group had mipi risk score - vs % in beac group; % of patients in beam group were transplanted in cr vs % in beac group). the amount of infused cd cells was significantly higher in the beam group (median cd cells/ kg: . in beam vs . in beac groups; p = . ); the number of days to platelet engraftment was significantly greater in the beac group (median days in beam vs days in beac group; p = . ). there were no differences in the number of blood transfusions or hospitalization days between the groups. the rate of grade - upper mucositis was significantly higher in the beam group ( % in beam vs % in beac group; p = . ); no other differences in toxicity (grade - lower mucositis, pulmonary congestion, infections) were observed between the regimens. non-relapse mortality by day posttransplant was % in both groups. a median follow-up was (range: - ) months. the -yr dfs in beam and beac groups was % and %, respectively (p = . ). there was no difference in the -yr os between the groups ( % in beam and % in beac group; p = . ). there was a trend to improved dfs and os in patients transplanted in cr receiving beam (p = . , figure) . in multivariate analysis, low-to-intermediate mipi and transplant in cr were found to significantly increase pfs (p = . and. , respectively), while the hdt regimen did not affect pfs. beac and beam hdt regimens followed by asct had similar efficacy in mcl patients. there was a trend to improved dfs and os in patients transplanted in cr and treated with beam vs beac. the toxicity profile was similar in both groups, except a significantly higher rate of grade - upper gi mucositis. [p ] disclosure of conflict of interest: none. early or refractory relapsed ( o year) diffuse large b-cell lymphoma has a very poor prognosis especially for those not responding to salvage chemotherapy. allogeneic stem cell transplantation is potentially curative. even though this is less likely in those not responding or having frank progression pretransplantation. methods: at our institution we identified all patients with aggressive b-cell lymphoma (diffuse-large b-cell lymphoma and blastoid mantle cell lymphoma) who were refractory or progressive to salvage chemotherapy with r-dhap and who had peripheral blood stem cells ( × cd +/kg body weight) collected after the st or nd cycle. after high-dose melphalane and autologous stem cell transplantation patients had a partial and a complete remission. patient died due to neutropenic infection, patients died due to progressive disease leading to a transplant related mortality of . %. median progression-free survival after autologous transplantation was . months. proceeded to allogeneic stem cell transplantation. patients had a matched related sibling, had a matched unrelated donor and had a mismatched unrelated donor. transplant related mortality was % in this heavily pretreated population. -year overall survival of all patients intended for treatment is %. one of these patients with relapsed mediastinal lymphoma after allogeneic transplantation was cured by salvage radiotherapy and is in long-term remission ( years). conclusions: salvage high-dose melphalane and autologous peripheral blood stem cell transplantation for diffuse large b-cell lymphoma as a bridge to allogeneic transplantation is potentially curative for a minor fraction of these patients. however, the remission rate of % ( % pr, % cr) and progression-free survival of . months after high-dose melphalane and autologous stem cell transplantation provides a window of opportunity to use new drugs and cellular therapies in these poor prognosis patients. high dose chemotherapy and autologous stem cell transplantation is the treatment of choice for patients with relapsed refractory hodgkin lymphoma. several factors including number of chemotherapy lines received before conditioning, time of relapse and remission status before transplantation can predict survival and pfs in patients undergoing autologous stem cell transplantation. in , we reported on a patients who underwent high dose chemotherapy followed by autologous stem cell transplantation from to . all patients with relapsed or refractory hodgkin lymphoma in the period of - , who underwent high dose chemotherapy followed by autologous transplantation were retrospectively analyzed. the main outcomes of the study were complete remission (cr) at day , overall survival (os) and relapse-free survival (rfs). the impact of the following variables on os and rfs: (a) disease status at the time of transplant, (b) number of chemotherapy lines prior to conditioning and (c) time of relapse months and (d) age. a total of patients were identified. the median age was year. there were . % females and . % males. complete remission (cr) was achieved in . % of patients and . % with chemotherapy sensitive disease at the time of transplantation. prior to conditioning regimen, . % received two chemotherapy lines, and . % received more than two lines. % relapsed in less than months and % relapsed more than months after completion of therapy cr at day was . %. the median os for the whole group was . months; the median rfs was , months. the number of chemotherapy lines significantly impacted os and efs. cr status before conditioning, favorably influenced os and efs with a trend toward better os in favor of those who underwent abmt while in complete remission. the time of relapse and the age did not affect survival outcomes. [p ] the outcome of patients with relapsed or refractory hodgkin lymphoma is favorable and the number of chemotherapy lines received before conditioning is the only factor that had a statistically significant impact on os and efs. since the identification of human immunodeficiency virus (hiv), a clear association between hiv and specific malignancies has been recognized. high-grade b cell lymphomas are the most common malignancy complicating hiv infection and one of three aids defining malignancies. diffuse large b cell lymphoma (dlbcl) accounts for % of cases. before , lymphomas were the cause of % of all deaths attributable to aids. after the introduction of highly active antiretroviral therapy (haart) overall incidence of adm declined, however longer survival and exposure to environmental risk factors have increased the incidence of non adm (adm) such as hodgkin's lymphoma (hl). since haart has improved overall survival substantially, the aim of chemotherapy should be complete remission rather than palliation with careful consideration of drug interactions and side of haart. between and a total of patients were detected hiv positive. twenty-one of these patients were diagnosed with a malignancy and patients referred to our department with a hematologic malignancy were evaluated retrospectively. diagnosis, stage, treatment, survival data were recorded. haart during chemotherapy, nadir cd count and cd count at diagnosis of malignancy was evaluated. four patients were diagnosed with high grade b cell lymphoma, patients with primary central nervous system lymphoma (pcnsl), patient with hl and patient with multiple myeloma (mm). all patients were male and median age at diagnosis was . ( - ). hiv seropositivity was identified during evaluation of malignancy in both pcnsl patients. median duration of hiv seropositivity before diagnosis of malignancy was months for the remaining patients. patient characteristics, treatment modification and cd counts are summarized in tables and . lymphoma was fatal in and the cause of death was identified as lymphoma progression in all patients including one patient diagnosed with hodgkin's lymphoma. a patient presented with multiple plazmositomas was diagnosed with multiple myeloma is currently receiving induction treatment together with haart. hiv related lymphoma patients frequently present with extra nodal disease, incidence of central nervous system involvement is also higher and prognostic score tends to be in the intermediate or high-risk groups. prognosis is also worse than hiv negative population. degree of immunosuppression is implicated and the duration of immunosuppression is directly correlated with the risk of developing lymphoma rather than hiv itself. haart allowed the use of aggressive chemotherapy since it improved immune system and decreased infectious complications. multiple myeloma is a rare neoplasm observed in hiv infection and the treatment is based on data obtained from hiv negative patients. treatment of such patients as well as lymphomas should take into consideration the toxic effects of haart combined with chemotherapy. since hiv positive [p ] patients are excluded from most studies, there are no guidelines to direct treatment and avoid toxicities. drug interactions should be monitored closely and modifications should be made accordingly. interruption of haart may not be mandatory since studies have shown safety of continuation of haart during chemotherapy. for newly diagnosed hiv and malignancy, careful clinical and laboratory evaluation should be made before postponing haart until after chemotherapy. disclosure of conflict of interest: none. the outcome of hdct and asct in refractory hodgkin lymphoma (r-hl) is not as encouraging as in relapsed hl. ten years ago we analyzed and reported outcomes of asct in our r-hl patients, however the follow-up was short. now we a reporting long term outcomes in r-hl after asct in one of the largest numbers reported to date. between and , patients with hl who underwent hdc and asct for r-hl in adult medical oncology (age years) were identified. r-hl is defined as partial response (pr), no response (nr), stable disease (sd), progressive disease (pd), relapsing within months (relapse o m) of finishing the planned (chemotherapy + radiation therapy (xrt)) treatment or refractory to salvage chemotherapy. kaplan-meier (km) method was used to estimate progression free survival (pfs) and overall survival (os) from the day of asct while progression is defined as progression of disease, relapse and death from any cause. all percentages are rounded to nearest. patients underwent hdc and asct during - and of them met the criteria of r-hl. male ( %), female ( %), median age at diagnosis was . years ( - years) and at asct was years ( - years). initial therapy was abvd in ( . %), mopp/copp alternating with abv or abvd in ( %) and others in ( %). ( %) had xrt after initial chemotherapy. response to initial chemo + xrt was pr in ( %), pd in ( %), cr in ( %) ( / relapsed within months and others have refractory relapse) and no response in ( %) and others in ( %). prior to salvage chemotherapy, ( %) had stage iii-iv, ( %) extra-nodal involvement, ( %) bulky disease and ( %) had b symptoms, spleen involvement in ( %), performance status , in ( %). eshap was used as first line salvage in ( %) or rd line ( %). post salvage / prior to hdc and asct disease status was pr in ( %), cr in ( %) and nr/sd in ( %). ( %) patients had a fdg-pet scan prior to asct, ( %) were in cr. beam was used as conditioning regimen. median follow-up for all alive patients is months ( - ) from asct. response rate post asct: cr in ( . %), pr in ( %), nr/sd in ( . %) and pd in ( . %) patients, others /unknown in ( . %). ( %) patients had xrt post auto-sct. type of first post hdc auto-sct event was no event in ( %), persistent disease in ( %), pd in ( %), relapsed disease in ( %), treatment related mortality in ( %) and died of other cause ( %). at last follow-up in november , patients ( %) are alive with no disease, ( %) alive with disease, ( %) died of disease and ( %) died of treatment related mortality or other causes. for entire group, km estimated median os is months, , , , and year survival is %: %: %: %: % respectively. median pfs is . month, , , , and year pfs is . %: . %: %: %: % respectively. we are reporting a very high risk group of patients with a very long follow-up. in patients with r-hl, eshap + beam combination resulted in high response rate ( . %). these remissions are durable. a year os survival of greater than % in our population is higher than most reports with similar numbers. although our cohort has a year os survival of %, % patients have either relapsed or died underscoring need for improvements in the management refractory hl. [p ] disclosure of conflict of interest: none. here we update the previously reported results of our reduced-intensity conditioning (ric) allo-hsct experimental program, initiated in . as of november , in our centre patients underwent ric allo-hsct. donors were hla-identical sibling in , fullymatched unrelated in , or -mismatch-unrelated in and haploidentical relative in . median age was years (range: - ). all patients ( m and f) had stage iib/iv refractory mf (n = ) or refractory ss (n = ). median number of previous treatment lines was (range: - ). source of stem cells was peripheral blood in patients and bone marrow in . median time from diagnosis to hsct was months (range: - ). conditioning included flu/ctx/tbi , pentostatin +tbi and flu/mel in case of hla-identical or unrelated donor, whereas the tt/flu/ctx/tbi regimen was used in the haplo setting. gvhd prophylaxis included csa/mmf in all patients, with the addition of atg in cases with unrelated donor and post-transplant ctx ( mg/kg giorni + e + ) in cases with haploidentical donor. full donor chimerism was obtained in / of the evaluable patients, in a median time of months (range: - ). grade ii-iv acute gvhd occurred in patients ( %), while grade iii-iv was observed in patients ( %). chronic gvhd occurred in patients ( %), being extensive in ( %), all transplanted from hla-identical sibling (no atg). following transplantation, a complete remission (cr) was achieved in out of the evaluable patients ( %), of whom experienced relapse at + and + months, respectively. transplant-related death occurred in patients ( %), of whom were in cr. out of the patients who did not achieve cr, died from progressive disease (median follow-up of months, range: - ), from a secondary malignancy and is still alive with disease months after transplant. of note, all pts who died in progression had chemoresistant disease at time of transplant. at the last follow-up, patients were alive and ( %) maintained cr after a median time of months (range: - ). in the whole population, the -year overall survival was % ( % ci - ) and the -year disease-free survival (dfs) was % ( % ci - ). however, when mf and ss were analysed separately, -yrs dfs were % ( % ci - ) and % ( % ci - ), respectively (figure) . apart from diagnosis, outcome appeared to be primarily associated with the disease status at transplantation, with a -yr dfs of % in the group of patients (n = ) who were in cr before starting the conditioning. after a median follow-up longer than years, we confirm the efficacy of ric allo-hsct as a powerful therapeutic strategy in inducing and maintaining remission in selected patients with chemosensitive advanced-stage ctcl, with results particularly encouraging in ss. [p ] disclosure of conflict of interest: none. outcomes of allogeneic hematopoietic stem cell transplantation for hodgkin lymphomas: a retrospective multicenter experience of the rete ematologica pugliese (rep) f gaudio , p mazza , am carella , d pastore , g pisapia , a mele , p galieni , n cascavilla , g specchia and v pavone hematology, university of bari, bari, italy; hematology, ospedale "san giuseppe moscati", taranto, italy; hematology, ospedale "casa sollievo della sofferenza", san giovanni rotondo, fg, italy and hematology, ospedale "cardinale panico", tricase, le, italy; hematology, ospedale "c. g. mazzoni", ascoli piceno, italy hodgkin's lymphoma (hl) is a potentially curable disease, and modern therapy is expected to successfully cure more than % of the patients. second-line salvage high-dose chemotherapy and autologous stem cell transplantation (sct) have an established role in the management of refractory and relapsed hl, leading to long-lasting responses in approximately % of relapsed patients and a minority of refractory patients. patients progressing after intensive treatments, such as autologous sct, have a very poor outcome. allogeneic sct represents the only strategy with a curative potential for these patients; this study reports a retrospective multicenter experience of the rete ematologica pugliese (rep) over the past years aiming to define the impact of patient, disease, and transplant-related characteristics on outcomes. patients with histologically confirmed diagnosis of hl who received allogeneic sct from to were retrospectively studied. the median age was years (range: - years) and ( %) were male. the majority of patients ( %) had had a prior autologous sct. at the time of allogeneic sct, ( %) patients had a chemosensitive disease and ( %) were chemorefractory. most ( %) patients received reduced-intensity conditioning, % received matched sibling donor and % matched-unrelated donor grafts. the disease status at day post-transplant was reported in out of evaluable patients. of the patients with chemosensitive disease, ( %) achieved a cr, ( %) had a pr or stable disease and ( %) had progressive disease. of the patients with chemorefractory disease achieved a cr ( %), had a pr or stable disease ( %) and ( %) had progressive disease. although the overall survival has improved significantly in mantle cell lymphoma (mcl) according to advanced treatment options, relapsed or refractory disease remains a challenge. recently, lots of targeted agents actively have been tried clinical studies and adapted to clinical practice in indolent lymphoma. however, the role of frontline autologous hematopoietic stem cell transplantation (auto-hsct) has not been fully understood in patients with mcl, compared with a few impressive published data about auto-hsct as salvage treatment option for patients with relapsed mcl. so, we retrospectively evaluated consecutive patients diagnosed mcl, and compared the clinical outcomes of high-dose chemotherapy followed by auto-hsct and conventional chemotherapy alone. between january and december , consecutive patients with newly diagnosed with mcl at catholic blood and marrow transplantation center in south korea were included in this study. all of the patients received high-dose cytarabine-containing regimen or chop with/without rituximab regimen for induction therapy regardless of transplant eligibility. the treatment approach in our institution for patients was based on the physician discretion for transplant eligibility or ineligibility that depend on patient age, comorbidities, and disease status. seventy patients were included in the analysis. initial chemotherapy regimens were consisted of chop (n = , %), r-chop (n = , %), r-hypercvad (n = , %), and hypercavd (n = , %). demographics and disease characteristics of both groups are shown in table . patients received auto-hsct were superior s overall survival (os; p = . ) and progression-free survival (pfs; po . ). the subgroup analysis according to high-risk of mcl international prognostic index (mipi) or bone marrow involvement was performed. between the two treatment arms among the high-risk mcl group, the clinical parameters were not different. the high-risk mcl patients with frontline auto-hsct showed superior os (p = . ) and pfs (po . ) compared with conventional chemotherapy alone. although mcl is classified within indolent lymphoma, frontline auto-hsct can be considered for patients diagnosed with mcl in the group of high-risk mipi or bm involvement with the favorable survival outcomes. disclosure of conflict of interest: none. nasal type extranodal nk/t-cell lymphoma (enktl) is a very rare and agressive malignancy characterized by a poor outcome. current standard therapy is not yet established. the role of high dose therapy followed by haematopoietic stem cell transplantation (hsct) is still controversial. we evaluated the outcomes of all the enktl patients undergoing hsct in a multicenter analysis on patients registered by the société francophone de greffe de moelle et de thérapie cellulaire (sfgm-tc) and compared them with a population of french patients who received chemotherapy alone. sixty four enktl ( males and females) received hsct, including allogeneic (allosct) and autologous transplantations (autosct). median age at the time of hsct was years (range: to years). overall, % of the patients presented with disseminated disease ( % and % in the allosct and autosct, respectively), % were in complete response (cr) at the time of hsct ( % and % in allosct and autosct groups, respectively) and % had received l-asparaginase regimen prior to hsct ( % and % in allosct and autosct groups, respectively). five ( %) and ( %) patients of the allosct and autosct groups underwent upfront hsct therapy, respectively. four patients received tandem autologous/ allogeneic transplants. in allosct, stem cell source was a matched related donor in patients, an unrelated donor in patients and an umbilical cord blood in patients. reduced intensity conditioning regimens (based on fludarabine-busulfan combination) and beam regimen were used in % and % of patients from the allosct and autosct groups, respectively. median overall survival for the whole cohort was . months (range: to months). the -year non-relapse mortality was . % and . % in the allosct and autosct groups, respectively (p = . ). the -year overall survival (os) and progression free survival (pfs) were . % and . % in the autosct and . % and . % in the allosct group, s respectively ( figure a) . the absence of cr prior to hsct was associated with a poor prognosis (p = . ). as compared to allosct, autosct resulted in a better outcome in patients who didn't achieve cr before transplant (p = . ) and tended to have better outcome in high pink risk score (figure b-c) . finally, at years pfs and os of patients who have been treated by chemotherapy alone (ct) (n = ) or followed by allosct (n = ) or autosct (n = ) in cr were %, % and %, % and %, %, respectively ( figure d ). in this french cohort, more patients received autologous hsct in upfront therapy than allogeneic hsct. in cr , there is no evidence suggesting that transplantation is associated to a better outcome than chemotherapy alone. however, a precise matching based on the pink score will be evaluated to ensure that patients who were intensified were not of worst prognosis. in refractory patients there is also no clear advantage to perform allosct when compared to autosct. however, in relapsing disease after ct or autosct allosct, allowed to obtained durable control of the disease. disclosure of conflict of interest: none. high relapse rate is one of concerns for allo-sct in pts with relapsed/refractory aggressive lymphoma. an optimal conditioning regimen designed for aggressive lymphoma may reduce relapse, especially during early post-transplantation period. however, it is not established yet. results of a german phase study of allo-sct with conditioning regimen of fludarabine, busulfan ( mg/kg po or . mg/kg iv), and cyclophosphamide with or without post-transplantation rituximab for relapsed/refractory aggressive lymphoma suggested the role of myeloablative busulfan-containing regimen in reducing relapse rate in pts with aggressive lymphoma. based on these results, we conducted a single institution prospective study to explore feasibility of the bmf regimen consisted of full-dose busulfan, melphalan, and fludarabine in pts with relapsed/refractory aggressive lymphoma (umin ). patients with aggressive lymphoma who achieved at least sd with salvage chemotherapy after experiencing either pd during first-line therapy, early relapse ( o mo) after firstline therapy, late relapse (≥ mo) but refractory to salvage therapy, relapse after auto-sct,; age - ; ecog ps of - ; and without severe organ dysfunction were eligible. donor source could be / matched related or unrelated donor pb/bm or cb with ≤ antigen mismatch; the bfm regimen was consisted of busulfan . mg/kg iv, fludarabine mg/m , and melphalan mg/m (yamamoto h. bbmt ). gvhd prophylaxis was csa + mtx (related pb), tac + mtx (unrelated bm), and tac + mmf (cb). primary end point of the study was survival with engraftment at day , and secondary end points were engraftment rate at day ; nrm and relapse rate at day and y; progression free survival (pfs), overall survival (os), and gvhd at y. protocol was approved by irb and written ic was obtained from all pts. twelve pts (male , female ) with a median age of y ( - ) were enrolled. ps was - in pts. diagnosis were dlbcl (n = ), transformed fl (n = ), enktcl (n = ), ptcl (n = ), and aitl (n = ). median number of previous line of therapy was . ( - ) and pts had failed previous auto-sct. diseases status at transplantation was cr (n = ), pr (n = ), and sd (n = ). donor source was cb (n = ), unrelated bm (n = ), and related pb (n = ). survival with engraftment at day , primary endpoint of the study, was achieved in %. neutrophil engraftment was achieved at a median of day ( - ). full donor chimerism at day was achieved in all of the pts evaluated. two pts developed vod which was manageable. with a median follow-up of mo, pts had progression of lymphoma at , , mo. five pts died and cause of death were progression of lymphoma in , interstitial pneumonitis in (at mo), systemic adenovirus infection in (at mo), and agvhd in (at mo). os and pfs at y were % and %, respectively. relapse and nrm rates were % and % (day ), and % and % ( y), respectively. agvhd of grade ii-iv was observed in / pts and pts developed limited cgvhd. this prospective study shows that allo-sct using myeloablative conditioning regimen with full-dose busulfan, melphalan, and fludarabine for relapsed/refractory aggressive lymphoma is feasible and deserves further evaluation. disclosure of conflict of interest: none. for patients with advanced ctcl, the allogeneic hsct seems to be curative with graft versus lymphoma effect playing a major therapeutical role. in this retrospective study, patients with a median age of years (range: - ) affected by ctcl underwent allogeneic hsct after a median of (range: - ) lines of chemotherapy, including autologous transplant for of them. the median time from diagnosis to hsct was months (range: - ). the diagnoses were: sezary syndrome (ss, n = ). mycosis fungoides (mf, n = ), primary cutaneous cd + lymphoma (n = ), panniculitis-like t-cell lymphoma (n = ), nk t cell lymphoma (n = ). at time of hsct, patients ( . %) were in complete remission (cr), ( . %) in partial remission (pr) and ( . %) had active disease. the patients were transplanted from an hla-identical (n = ), mismatched (n = ) or haploidentical (n = ) sibling, from matched unrelated donor (n = ) or from a single cord blood unit (n = ). different pre-transplant regimens were used as myeloablative (mac) in (th-bu-flu, n = ; bu-cy, n = ) or as reduced intensity (ric) in (th-flu-cy, n = ; th-bu-flu, n = ). al patients engrafted for neutrophils at a median of days (range: - ) and patients engrafted for platelets at a median of days (range: - ). acute gvhd was of grade -i in patients and ii-iv in ( . %). skin was the most common organ involved. five of evaluable patients experienced chronic gvhd which was mild in and severe in . at a median of months (range: - ), patients died ( mac and ric) because of gvhd (n = ), vod (n = ), pneumonia (n = ) or multiorgan failure (n = ). all patients surviving at months from transplant were in cr. only patients prepared with a ric (n = ) relapsed respectively at , , and months from hsct. these patients received dli associated or not to chemotherapy. three achieved cr, which remained stable in , while one patient died in cr from post dli acute gvhd. one patient (nk-t cell) not achieving cr is still alive with active disease. for all patients the median survival was months (range - ). with a median follow up of months (range: - ), patients ( mac, ric) are alive, in cr and with active disease. at years, the os was ± %; at years dfs was ± %. according with the median time ( months) from diagnosis to transplant, the -year os was ± % for patients transplanted early and ± % for the others (p o . ), while dfs was respectively s ± % and ± % (p o . ). despite the small number of patients, our results confirm the high susceptibility of ctcl to the graft versus lymphoma effect and point out the time to transplant as a crucial prognostic factors for the outcome. finally, the long-term follow up of our series strongly supports hsct for the cure of ctcl. disclosure of conflict of interest: none. recently, a new prognostic score, the nccn-international prognostic index (ipi) has been developed to stratify patients affected by diffuse large b cell lymphoma (dlbcl), and in high-intermediate and high risk groups the survival was equal or less than %. the aim of this analysis was to evaluate the outcome of a cohort of dlbcl patients undergoing high dose chemotherapy (hdc) as consolidation following first line chemo-immunotherapy, after their re-classification according to the nccn-ipi. we performed a retrospective study on patients diagnosed with dlbcl, with a high/intermediate or high-risk disease according to the ipi ( - ), who received upfront hdc with asct, in institutions. the patients were then re-stratified according to the nccn-ipi and arbitrarily classified in groups: low risk (nccn-ipi ≤ ) and high risk (nccn-ipi ≥ ). the pre-transplantation disease status was assessed by positron emission tomography (pet) or computed tomography (ct). the primary endpoints were non-relapse mortality, progression-free survival (pfs), overall survival (os) and relapse risk. the estimated -year pfs for all patients was . % ( % confidence interval [ci] . - . ) and the -year os was . % ( % ci . - . ). of these patients, had a low risk ipi score (ipi = ) and were considered high risk (ipi ≥ ). subsequently, the whole cohort was re-stratified according to the nccn-ipi: patients were allocated to the high-risk (nccn-ipi ≥ ) group, and to the low-risk group (nccn-ipi ≤ ). the analyses were then carried out for both groups. the -year pfs was . % ( % ci . - . ) in the low-risk group and . % ( % ci, . - . ) in the highrisk group (po . ), whereas the -year os was . % ( % ci . - ) in the low-risk group and . % ( % ci . - . ) in the high-risk group (p = . ). the significant difference in os and pfs between the two groups was mainly due to the cumulative incidence of relapse at years (graph ): . % ( % ci . - . ) in the low-risk group and . % ( % ci . - . ) in the high-risk group (po . ). non-relapse mortality was comparable in both cohorts: % ( % ci . - . ) for all patients. figure : cumulative incidence of relapse following hdc and according to nccn-ipi. patients affected by high-risk dlbcl still have an unsatisfactory prognosis after treatment with conventional therapy regimens, even in the rituximab era. the -year os and pfs in patients with nccn-ipi score ≥ range: from % to % and from % to % respectively . although this is a retrospective analysis subject to all related biases, our results suggest that upfront intensive therapy with autologous stem cell transplantation may significantly improve the outcome of these patients compared to conventional chemotherapy. the role of hdc in the treatment of dlbcl is controversial. however, new entities or new risk stratifications, as the one reported here, could allow to identify high risk subpopulations that could benefit from this approach. enteropathy-associated t-cell lymphoma (eatl) is an exceedingly rare and often rapidly fatal subtype of peripheral t-cell lymphoma, arising from intraepithelial lymphocytes. eatl type i is associated with celiac disease; type ii occurs in patients without inflammatory pre-conditions (according to who classification now called monomorphic epitheliotropic intestinal t-cell lymphoma (meitl)). surgical debulking and anthracyclinebased chemotherapy (ctx) followed by high-dose chemotherapy (hdctx) and autologous cell rescue (asct) are pursued when possible in this often malnourished and frail patient cohort. yet, even with intensive consolidation relapse occurs in - % of patients. the value of allogeneic hematopoietic cell transplantation (hct) is not clarified as of today due to limited reports. here, we report on a patient with meitl who was rescued with an allo-hct for his nd relapse following prior asct. moreover, we summarize the available literature on the use and outcomes of allo-hct for eatl and meitl. a y old man with spontaneous intestinal perforation was diagnosed with meitl following emergency partial resection of the small intestine. histology revealed infiltration by monotonous medium-sized lymphocytes with abnormal immunophenotype (cd +, cd +, cd +, cd -, cd -, tia- +) consistent with type ii eatl. post-surgical f-fdg pet-ct scan showed abnormal uptake in gastric antrum and pyloric region but no other manifestations. ctx with cho(e)p ( × ) followed by beam hdctx and asct was performed and achieved a complete remission (cr ). however, m post asct disease relapsed and was treated with × dhap, and × dhaox. cr was achieved after the rd cycle of salvage therapy. due to anthracyclineinduced cardiopathy allo-hct could not be performed at that time. m after completion of salvage therapy, disease relapsed again, and was progressive under pralatrexat treatment ( cycle, infusions). by then cardiac function had recovered and therapy was switched to dose-reduced mini-beam ( × ). in cr reduced intensity conditioning (ric; fludarabine, busulfan, atg) and allogeneic hct from a matched sibling donor was performed. ciclosporin a (csa) and mycophenolate mofetil (mmf) were given as gvhd prophylaxis. prompt engraftment in blood (day+ ) and full donor chimerism in the marrow (d+ ) were achieved. immunosuppression was tapered and discontinued on d+ (mmf) and d+ (csa), respectively. f-fdg pet-ct scan at m post-hct showed cr, but at m relapse was suspected (under work-up). only few cases of patients with eatl/meitl treated with allo-hct are reported in the literature (n = , table ), and the value of this highly aggressive therapy is not clear at this point. of note, the patients listed in table were given allo-hct instead of asct. long-term complete remission (cr) could be achieved in / patients, while patients suffered from early relapse and died of the disease (n = before d+ post allo-hct). asct following surgery and ctx appears to cure - % of patients in available series. no treatment concept is available for relapse following asct, and no published data are available for allo-hct for relapse post asct. the disease is exceedingly rare and is afflicted with very poor outcomes. therefore, patients given this aggressive treatment should be reported, even when treatment outcomes are not positive. disclosure of conflict of interest: none. strong graft versus lymphoma effects with low toxicicty of haploidentical hematopoietic stem cell transplantation comparing with hla-identical in t cell lymphomas: a retrospective multicenter study s bramanti, r devillier, s fuerst, b reda, a granata, s harbi, c faucher, i legrand, a santoro, d blaise and l castagna istituto clinico humanitas rozzano consolidation treatment of relapsed/ refractory t-nhl with allogeneic stem cell transplant (sct) is considered a curative options but few patients manage to undergo this procedure, due to the highly refractory nature of the disease. the primary aim of this work is to evaluate the gvl effects among t-nhl with both hla identical and haploidentical donors. we have retrospectively analized the long term outcome of consecutive patients affected by t-nhl, received hlaidentical or t-cell replete haplo-sct with pt-cy, in european centers, between february and october . the patients received nonmyeloablative (nmac) or reduced intensity (ric) conditioning regimen. gvhd prophylaxis consisted of mg/kg of pt-cy (day + and + ) in haplo setting and atg plus cyclosporine a in the hla identical setting. patients characteristics were reported in the table . no differences were founded in the two groups . most of the patients were transplanted in complete remissions but only as consolidation of first line. no graft failure occurred. the cumulative incidence of acute gvhd grade - was % in the haplo setting vs % in the hla id .extensive chronic gvhd was seen in % of haplo, and in % in the hla id . patients had cmv reactivation, hemorrhagic cystitis, and ebv reactivation. after a median follow-up of years os was % and % and pfs was % and % in the haplo vs hla id group see figure . nrm was % in haplo setting and % in hla identical one. the years cir is % and % in haplo and hla id setting respectively. this study confirm a strong anti-lymphoma effect of allo hsct without prohibitive toxicities. haplo-hsct with pt-cy shows low rate of cgvhd in a contest of poor prognosis t-nhl patients. [p ] disclosure of conflict of interest: none. ibrutinib is the first-in class bruton tyrosine kinase inhibitor that has been approved for the treatment of relapsed mantle cell lymphoma. however, despite the high response rate of % including % of complete response, the median duration of response is relatively short with an overall survival of % at months (wang ml, et al, n engl j. med ). we report a single experience of patients with relapsed mcl who underwent allogeneic stem cell transplant (allosct) after ibrutinib monotherapy salvage. all patients had previous autologous stem-cell transplantation (asct) before and were given ibrutinib at a dose of mg daily after the second or subsequent relapse. all patients had to be at least in pr according to cheson criteria before allosct. patients had an unrelated / ( ) or / ( ) allo-sct from peripheral hematopoietic stem cells after a reduced conditioning regimen with busilvex, fludarabine and antithymocyte globulin in association with zevalin according to our recent published phase study protocol (bouabdallah k, et al. ann oncol ). graft versus host disease (gvhd) prophylaxis consisted on ciclosporine and methotrexate. patients ( m/ f) were aged from to years and received between and previous chemotherapy regimens including asct in their last treatment strategy before introduction of ibrutinib. all patients had extensive disease with gastric involvement in patients and pulmonary localization in patient. median time between diagnosis and ibrutinib introduction was years ( - ) and the median time between asct and allosct was years ( ) ( ) . median duration of ibrutinib treatment was months ( - ) and it was stopped one week before proceeding to allo-sct. it was not planned to restart btk inhibitor after transplant. patients were assessed for response after at least months of treatment with ibrutinib. at time of evaluation, all patients were in complete ( ) or very good partial response ( ) before allosct. the patient in partial response had % tumor reduction with persistent gastric ulcer where histology examination shows cd + but negative cycline d lymphoid cells. all patients engrafted (median duration of pnn o g/l = days ( - ) and median duration of platelets o g/l = days ( - )) with fulldonor chimerism at month. one patient had a grade ii cutaneous chronic gvhd (cgvhd) with favorable outcome and developed months later a bronchopulmonary obstruction syndrome related to cgvhd. with a median follow-up of months ( - ) after allo-sct, all patients are alive in cr. one patient, in complete metabolic response before transplant had a gastric relapse months later but achieved again a cr months after reintroduction of ibrutinib. after the first case reported by furtado m et al (leuk lymphoma ), we report here additional cases with longer follow-up after allogeneic transplantation. the excellent tumor control after treatment with ibrutinib together with a very good outcome after allosct should drive to consider this approach in young patients with mcl relapse after asct. disclosure of conflict of interest: none. autologous hematopoietic stem cell transplantation (autosct) is considered the standard approach for high risk or relapsed/ refractory non-hodgkin and hodgkin lymphoma. although a large variety of conditioning regimens are available, including the widely used beam (carmustine, etoposide, cytarabine, melphalan), there is no consensus regarding a standard approach. in the context of carmustine shortage, we have chosen to replace it by thiotepa. however, clinical data about thiotepa-based autosct conditioning are still sparse, except some retrospective data for primary central nervous system lymphoma. thus, we designed a multicenter prospective study (nct ) to assess the efficacy and toxicity of a team (thiotepa, etoposide, cytarabine, melphalan) conditioning regimen. team regimen consisted in total dose thiotepa of mg/kg on day- ; etoposide mg/m / h and cytarabine mg/m / h (day- to - ); melphalan mg/m on day- . patients underwent autosct with team conditioning, and were included in this analysis if they have fullfilled the following criteria: age older than years, biopsy-proven hodgkin or non-hodgkin lymphoma, hiv seronegative, and first autosct. thirty-three male and nine female with a median age of years (range: - ) were analyzed thus far. karnofsky score was g/l was days (range: - ). of note, patients received thrombopoietic agents after engraftment because of persisting thrombocytopenia. the most significant regimen-related toxicities were mucositis in % of patients (median grade = , range: - ) and diarrhea in % of patients (median grade = , range: - ). other non-hematologic grade adverse events occurred in patients ( %) and no grade adverse events were observed. central line-associated bloodstream infection occurred in patients ( %). surprisingly, / evaluable patients ( %) developed human herpesvirus reactivation. only patients required intensive care unit transfer. the median duration of hospital stay was days (range: - ). after a median follow-up of months (range: - ), the non-relapse mortality (nrm) was %. only one patient relapsed of refractory aitl months after autosct and died month after. the estimated -year overall survival and progression-free survival were % and %, respectively. a team conditioning regimen seems to be a safe and valid platform in autosct for patients with high-risk or relapsed/ refractory lymphoma. although mucositis and diarrhea were frequent, there were no grade adverse events and no deaths related to the treatment. updated results with updated followup will be presented. disclosure of conflict of interest: none. the cell of origin has no prognostic impact on high-dose chemotherapy with r-beam and autologous stem cell transplant for diffuse large b cell lymphoma s lozano cerrada, r saliba, s srour, s ahmed, c hosing, r champlin and y nieto university of texas, md anderson cancer center, department of stem cell transplantation and cellular therapy diffuse large b-cell lymphoma (dlbcl) is a biologically heterogeneous disease that can be classified according to its cell-of-origin (coo). the germinal center b-cell (gcb) subtype has better outcome with frontline r-chop than the activated b cell (abc) subtype. however, the prognosis of these two types of dlbcl after high-dose chemotherapy and autologous stem cell transplant (asct) is less clear. the purpose of our study was to evaluate progression-free survival (pfs), event-free survival (efs) and overall survival (os) in a cohort of dlbcl patients treated with r-beam (rituximab, carmustine, etoposide, cytarabine, melphalan) and asct according to coo. we have the dicep regimen effectively reverses the poor outcome for lymphoma patients with suboptimal response or failure post st salvage treatment p kaloyannidis the outcome of patients (pts) with refractory hodgkin's (hl) and non-hodgkin lymphomas (nhl) post st salvage treatment (salv ) is considered poor. the published data, have shown extremely low survival rates ( - %) even after nd salvage treatment (salv ) followed by autologous stem cell transplantation (asct), due to the low response rates post salv and the high relapse rates post asct, confirming that the management of these pts remains a major challenge. we herein evaluated the dicep regimen [dose intesified cyclophoshamide ( gr/m ), etoposide ( mg/m ) and cisplatin ( mg/m ), days - ] as a salv treatment, in terms of safety and efficacy regarding disease response and stem cell mobilization/collection. moreover, we evaluated pts' long term outcome post asct. we retrospectively analyzed the data of ( hl, nhl) pts, with a median age of ( - ) yrs. twenty-one had suboptimal response ( % reduction): and minor response (≤ % reduction): ). three pts had stable disease while experienced progression. overall / pts underwent asct after a median of days (range: - ) post dicep. no pt was considered ineligible for the asct due to unacceptable toxicity post dicep; did not undergo asct because of progressive (n = ) or stable (n = ) disease. the -yr overall survival (os) was % for the whole cohort of pts ( % for hl and % for nhl, p = ns) while the -yr progression free survival (pfs) from dicep administration (± asct) was % ( % for hl and % for nhl p = ns). in particular, for the autografted pts, the -yr os was % ( % for hl, % nhl p = ns) and the -yr pfs was similar, % ( % for hl, % for nhl, p = ns) our data demonstrate that dicep is an effective salvage regimen with acceptable toxicity and no negative impact on the cd + collection. the promising response rates post dicep in combination with the very encouraging pfs rates achieved post asct, in this unfavorable and heavily pretreated group of patients, strongly support the rationale for using dicep as st line salvage regimen in selected pts in order to proceed to a successful asct. for the treatment of aggressive lymphoma, high dose chemotherapy followed by autologous stem cell transplant (asct) is an important component. however, the role of upfront asct in patients with diffuse large b cell lymphoma (dlbcl) is still controversial. furthermore, there is currently no consensus on a single best conditioning regimen for asct in patients with dlbcl. we retrospectively analyzed the records of patients with dlbcl who underwent upfront asct in state of complete remission (cr) or partial remission (pr) from institutions in korea. we evaluated the outcomes and prognostic factors of upfront asct in patients with dlbcl. we compared the outcomes of most widely used two conditioning regimens for asct; carmustine based regimens and busulfan containing regimens. total patients ( . %) achieved cr after asct and overall response rate (orr) was . %. with median follow up of months, patients ( . %) had progression or relapse. the -year overall survival (os) rates and progression free survival (pfs) rates were % and %, respectively. infection events were found in patients ( . %) and treatment related mortality was . %. these outcomes were comparable with the results of previous other studies. cox multivariate analysis for os showed that eastern cooperative oncology group performance status (ecog ps) ≥ (p = . ) and rituximab based induction therapy (p = . ) were significant prognostic factors. in addition, the following factors were significantly associated with pfs in multivariate analysis; female (p = . ), ps ≥ (p = . ) elevated β -microglobulin (p = . ), failure to achieve cr with induction chemotherapy (p = . ), carmustine based conditioning regimen (p = . ) and melphalan based conditioning regimen (p = . ). there were no significant differences in os and pfs according to stage, b symptom, bulky disease, high lactate dehydrogenase, bone marrow involvement, high or high-intermediate international prognostic index (ipi), absolute lymphocyte count and absolute monocyte count. therefore, it is considered that upfront asct can overcome the poor prognosis in patients with advanced stage or high risk ipi. in the analysis with conditioning regimen, neutrophil and platelet engraftment were slower in the carmustine group compared to the busulfan group. there were no significant differences in os between busulfan group and carmustine groups with -year os rates of . % and . %, respectively (p = . ). pfs at years was . % in busulfan group versus . % in carmustine group (p = . ). however, carmustine based conditioning regimen was poor prognostic factors for pfs in multivariate [p ] s analysis (p = . ). in subgroup analysis, busulfan group had significantly higher pfs compared to the carmustine group especially in female patients ( . months vs. months, p = . ), with b symptom ( . months vs. . months, p = . ) and abnormal serum ldh level ( . months vs. . months, p = . ). the outcomes of upfront asct in patients with dlbcl after induction therapy were acceptable. it is considerable in selected high risk patients who achieve cr with induction treatment, and have good performance status at diagnosis. in cases of conditioning regimen, busulfan based regimen resulted in improved outcomes compared with carmustine based regimen especially in patients with disseminated disease or female patients. disclosure of conflict of interest: none. no heavy chain was present in %). the predominant light chain was kappa ( %). patients had bence-jones positive myeloma. received bortezomib as induction therapy before transplant. we analyzed overall survival (os) and progression-free survival (pfs) in groups of patients. we separated the groups according to improvement in grade of response from preasct to postasct. the post-asct grade of response was measured months after asct. the os and pfs were estimated by the kaplan-meier method. pfs was measured from diagnosis to disease relapse and os was measured from diagnosis to death by any cause. results by subgroups of patients are detailed in table . median os and pfs of the whole group was years and months, respectively. if we analyze groups only by their grade of response before asct we find the following results: rc ( years os rate . %, median pfs months); pr/vgpr (median os . years and pfs months); sd/progression (median os . years and pfs months). according grade of response after asct, instead: rc ( years os rate %, median pfs: months); pr/vgpr (median os , years, and pfs months); sd/progression (median os . years and pfs months). in our experience, the grade of response before asct is a capital predicting factor for patients os and pfs. patient in cr before asct that preserve it after transplant, have a median pfs of months, the years os rate being . %. patients in situation of progression after asct have a very dismal prognosis (median os . years, pfs: months), however, patients who change from sd/progression to pr after asct have a median pfs of months and a os of . years. comparing these results we observe that this second group is particularly benefited by transplant. autologous peripheral blood hematopoietic stem cell transplantation in elderly patients with multiple myeloma as a standard therapeutic procedure. is it feasible? a single-center experience l cadievski, s genadieva stavric, z stojanoski, a pivkova veljanovska, d miloska, b kocoski, l cevreska and b georgievski university clinic of hematology, department for hematopoietic stem cell transplantation, university ss. cyril and methodius, skoje, republic of macedonia autologous peripheral blood stem cell transplantation (pbsct) represents a standard therapeutic approach in the treatment protocol of myeloma patients. it is known that multiple myeloma is a hematological disease that is a characteristic for the older population. autologous pbsct ideally should be performed in every myeloma patient, but with the elderly myeloma patients the procedure might be risky if know the possible comorbidities, or the possibility of the body to fully compensate the side effects of the conditioning regimen, the procedure or its possible complications. we present our experience in using high dose conditioning with melphalan mg/m followed by autologous pbsct for elderly myeloma patients, using the age limit od years. our retrospective analysis of our data during years of experience, shows that we have performed autologous pbsct on patients with myeloma at the age of or older. males ( . %), and female ( . %). patients ( %), were diagnosed with igg type myeloma, patients ( %) with iga myeloma, and patient ( %) with light chain myeloma. median age of the patients was . years ( - ). all patients were initially treated with cy-thal-dex regimen. in ( %) patients complete response (cr) was achieved, in ( %) very good partial response (vgpr), and in ( %), partial response (pr). in all patients the mobilisation of hematopoietic stem cells was performed with g-csf, and a median of apheresis procedures were performed, and the average number of collected cells was . × /kg tt mononuclear cells (range: . - . ). days to confirmed engraftment in our group of patients was . (range: - ). the number of blood transfusions was on average . (range: - ), and the number of transfusion of thrombocytes . units (range: - ). in the majority of patients, mainly after the year (that represents patients of the whole group), we used noncryopreserved hematopoietic stem cells, kept under the temperature of c, for median of days, thus avoiding the toxicity of dmso. additionally, we used central venous catheter inserted in the femoral vein for apheresis and application of the stem cells afterwards. the day after, the catheter was removed, thus avoiding catheter associated infections. all patients received standard infectious prophylaxis with fluconasole mg/daily, ciprofloxacin mg/ two times daily, acyclovir mg/ three times daily, cefixime mg/once daily, and ursodeoxycholic acid for vod prevention. no serious infectious complications were reported. our transplant related mortality was %. in the group with noncryopreserved stem cells no graft failure was reported. in two patients we even performed tandem autologous pbsct with no major complications. of the group of patients, the majority, patients ( %), had hta as comorbidity, ( %) with cardiomyopathy, and ( %) with inserted prosthetic aortic valves. three patients ( %) have died because of relapse of the disease. our oldest patents were and years old, and are still alive year posttransplant, in cr. we can conclude the performing autologous pbsct in elderly myeloma patients can be safe and effective therapeutic option, but with careful selection of the patients, balancing the risk profile of the patient and the benefit, or the risk of the procedure. affective supportive care, monitoring and reducing the risk of complications is an imperative to a good result. disclosure of conflict of interest: none. autologous stem cell transplantation program for patients with multiple myeloma in an outpatient setting k lisenko , s sauer , g egerer , j schmier , m witzens-harig , a schmitt , ad ho , h goldschmidt , , j hillengass and p wuchter , department of medicine v, heidelberg university hospital, heidelberg, germany; national center for tumor diseases heidelberg (nct), heidelberg university, heidelberg, germany and institute of transfusion medicine and immunology, mannheim, german red cross blood service baden-württemberg-hessen, medical faculty mannheim, heidelberg university, germany the first and second authors contributed equally. high-dose chemotherapy with melphalan and autologous blood stem cell transplantation (absct) for treatment of symptomatic multiple myeloma (mm) is performed in the usa and canada mostly on an outpatient basis, whereas in germany and western europe an inpatient setting is the standard. we report on a german single-centre program to offer the procedure on an outpatient basis to selected patients. major inclusion and exclusion criteria for eligibility were defined as follows: patients had to be able to reach the hospital within minutes, had reliable support from their family at home, had an ecog performance score of - and were willing and able to comply with the demands of the program. patients with severe co-morbidities were not included. all patients were treated on our outpatients' clinic and examined on daily visits by a team of physicians. feedback from patients was obtained by means of a questionnaire. from september to september , patients with mm stage iiia were enrolled. all engrafted within the expected time range: (median time to leukocyte , /μl and neutrophil recovery μ/l: days; median time to platelet recovery /nl: days, /nl: days). twenty patients ( %) had an episode of neutropenic fever but only in patients ( %) blood cultures were found to be positive. there occurred no cases of infection with multiresistent bacteria. although rather liberal criteria for hospital admission were applied, of patients ( %) could be treated entirely on an outpatient basis. eight patients ( %) were temporarily admitted for inpatient treatment with a median duration of . days (range: - days), mainly because of neutropenic fever. no severe adverse events occurred. feedback from patients revealed a high level of satisfaction with the outpatient setting. high-dose chemotherapy and absct on an outpatient basis is safe and feasible if conducted in a comprehensive surveillance program. the feedback from patients was very positive, thus encouraging further continuation and expansion of the program. disclosure of conflict of interest: none. high dose of melphalan (bor-mel). we retrospectively analyzed patients with mm who underwent asct between january and march . in these patients, conditioning regimen consisted of a high dose of melphalan ( - mg/ m ) intravenously on day - and two doses of intravenous bortezomib at . mg/m administered on days − and + . this cohort was compared with patients underwent asct between and , conditioned with high dose of melphalan alone. response rate was evaluated according to imwg criteria. all patients were evaluated after induction therapy and months after asct. all patients were followed until death or reference date (november, ). results: patients' demographics and baseline disease-related characteristics are shown in table . [p ] no difference was found in terms of neutrophil and platelet engrafment, hospitalization days (p= . ) and use of mechanical invasive ventilation (p= . ). bor-mel regimen did not enhance severity of preexisting peripheral neuropathy (pn) in any patients, and only one presented de novo grade pn. non relapsed mortality was . % and % in the bor-mel and mel cohorts, respectively (p= . ). complete response rate after transplant was significantly better in the bor-mel cohort than in the mel cohort ( . % vs. . %; p= . ) ( figure b) . when the analysis was restricted to patients who received bortezomib-based therapy, this difference was also statistically significant ( . % vs. . %; p= . ) ( figure d ). median of follow-up was months in the bor-mel vs. months in the mel cohort. no difference was found in terms of overall survival (os) and progression free survival (pfs) between both groups. for all patients, a post-transplant deeper response was associated with better os and pfs (p= . and p o . , respectively). our results are in line with previous studies demonstrating that bortezomib combined with melphalan is a well tolerated conditioning regimen and may enhance the response rate after transplant, even in patients receiving bortezomib in the induction therapy. these results should be confirmed in a randomized trial. for newly diagnosed patients (pts) with multiple myeloma (mm), the triple-agent induction treatment based on bortezomib plus dexamethasone in combination with cyclophosphamide (vcd) or lenalidomide (vrd) represent extremely reliable regimens, which in combination with early autologous stem cell transplantation (asct) result in high response rates and prolonged long-term outcomes. however, though both regimens are widely used, there are extremely limited studies that compare the vrd vs. vcd in terms of safety and efficacy. in the present study we compared the outcomes of newly diagnosed mm pts who received induction treatment vrd (n = ) or vcd (n = ) and proceeded early to asct. the vrd and vcd pts groups were similar regarding age at diagnosis ( vs. ys, p = ns), interval between diagnosis-asct ( , vs. , months, p = ns) and maintenance treatment post asct ( vs. pts, p = ns). per revised international scoring system (riss), the vrd-group had slightly more advanced disease (stage i: , stage ii: and stage iii: ), compared to vcd-group (stage i: , stage ii: and stage iii: ), however this difference was not statistical significant. the conditioning regimen consisted of single agent melphalan: mg/m . the t-test, kaplan-meir and cox regression were utilized for the statistical analysis. following a median of cycles of treatment (range: - for vrd vs. - for vcd, p = ns), in the vrd-group pts achieved complete remission (cr), pts very good partial remission (vgpr ≥ % reduction of m-band) and pt partial remission (pr: - % reduction of m-band) while in the vcd-group cr: , vgpr: and pr: pts (p = ns). the toxicities in terms of peripheral neuropathy, myelosuppression, liver and renal function were well tolerated and no patient discontinued treatment due to severe side effects. the -yr overall survival (os) was % for the vrdgroup vs. % for the vcd-group; nevertheless, the difference was not significant due to the size sample of the pt groups. the stage at diagnosis, the disease status pre-asct and the maintenance post-asct did not influence the os. interestingly, the -yr progression free survival (pfs) was significantly superior for patients who had been induced with the vrd regimen ( % vs. % p = . ) and for patients who achieved cr or vgpr before asct (pfs: %) while no pts with pr pre-asct was progression-free yrs post asct (p = . ). in multivariate analysis, only the cr or vgpr status before asct favorably affected the long term pfs. our results are in line with the limited published data from other studies with larger series of patients. in our study, very low disease burden before asct proven to be an independent factor for prolonged pfs. taking into consideration that vrd resulted in more cr or vgpr status, it is reasonable to conclude that vrd is a highly effective regimen and could be first treatment choice for newly diagnosed mm patients who are fit for early asct post induction. lenalidomide cohort and in the maintenance bortezomib cohort. baseline characteristics and outcome data were obtained via chart review. the primary outcome was pfs. the secondary outcomes were overall survival (os) and treatment-related toxicities. the median follow-up time was months. median time to death ( . years vs . , p = . ) and median time to progression ( . years vs . , p = . ) were not significantly different in the maintenance lenalidomide cohort compared to the maintenance bortezomib cohort. in the multivariate analysis, pfs was worse in patients at international staging system (iss) stage at diagnosis compared to those at iss stages and (hr, . ; % ci, . to . ; p = . ) and worse in patients with less than very good partial response (vgpr) to last prior therapy compared to those with a response to prior therapy of at least vgpr (hr, . ; % ci, . to . ; p = . ) [see figure ]. pfs was improved in patients with more than two years of maintenance therapy compared to those with less than two s years of maintenance therapy (hr, . ; % ci, . - . ; po . ), but this result does not account for patients who ended maintenance therapy due to disease progression. os was worse in patients at iss stage at diagnosis compared to those at iss stages and (hr, . ; % ci, . to . ; p = . ). peripheral neuropathy was more common in the bortezomib cohort ( % vs %, p o . ), while cytopenias were more common in the lenalidomide cohort ( % vs %, po . ). figure kaplan-meier curve for pfs for the maintenance lenalidomide group versus the maintenance bortezomib group by log-rank test (p = . ). lenalidomide and bortezomib maintenance after transplantation have equal efficacy in prolonging progression-free and overall survival in patients with multiple myeloma. iss stage significantly affects time to progression and overall survival, and response to last prior therapy affects time to progression. length of maintenance therapy may be a significant predictor and warrants further analysis. these findings suggest that both lenalidomide and bortezomib are acceptable maintenance therapy options for post-transplantation multiple myeloma patients. autologous stem cells transplantation (auto-hct) is an accepted method in multiple myeloma (mm) patients, but usually it is not curative. the issue of allogeneic hematopoietic stem cells transplantation (allo-hct) is challenging yet for myeloma. we investigated allo-hct in mm and compared with auto-hct. in this retrospective study, we recruited patients from january to january ( ( . %) patients in autologous group and ( . %) in allogeneic group). we performed allogeneic hct with peripheral blood stem cells source in our center for patients who are relatively young (less than years old) with good performance, have match sibling donor and accepted allogeneic hct. the conditioning regimens in autologous group was melphalan mg/m only and in allogeneic groups was fludarabine mg/m plus melphalan mg/m in consequent days. gvhd prophylaxis consisted of methotrexate and cyclosporine. the outcomes then compared between two groups using log-rank and gray tests and cox proportional hazard regression. the median follow-up in the autologous and allogeneic group was . months. three years disease-free survival of auto-hct was . % (ci: . %, . %) and . % (ci: . %, . %) for allo-hct patients (p value = . ). three years overall survival of auto-hct was . % (ci: . %, . %) and . % (ci: . %, . %) for allo-hct patients (p value = . ) showing no significant statistical difference between two groups. mortality rate was . % for auto-hct and for allo-hct was . %. the most common cause of death between two groups was relapse of primary disease. three year relapse incidence was . % (ci: . %, . %) for allo-hct and . % (ci: . %, . %) for auto-hct (gray's test p value = . ). the three year trm incidence was . % (ci: . %, . %) and . % (ci: . %, . %) in allogeneic and autologous patients respectively (gray's test p value = . ). despite there was no statistically significant difference between two groups in terms of os but dfs and relapse incidence was meaningfully better in allogeneic group. so, perhaps the reason of non-significant os improvement in allogeneic group is higher early death due to higher trm. we suggest that this study needs longer follow up to see whether allo-hct resulted in os improvement. disclosure of conflict of interest: none. myeloablative allogeneic hematopoietic stem cell transplantation from unrelated donors for patients with relapsed or refractory multiple myeloma n tsukada , s shingaki, m ikeda, t ishida and k suzuki division of hematology, japanese red cross medical center allogeneic hematopoietic stem cell transplantation (allo-sct) for patients with multiple myeloma (mm) is increasing in number despite in the era of novel agents, especially as a second line treatment and beyond. it has been reported that allo-sct for patients with mm resulted in high incidence of treatment related mortality (trm). high incidence of disease relapse is also a major problem especially after reducedintensity stem cell transplantation (rist). it is an important issue to reduce the incidence of trm while preventing disease relapse. the use of stem cells from unrelated donors is required for those without hla-matched sibling donors. the purpose of this study is to evaluate the feasibility of an intensified conditioning regimen incorporating both mg/ m of melphalan and gy of total body irradiation (tbi), followed by allo-sct from unrelated donors for patients with relapsed or refractory mm. we retrospectively analyzed eight consecutive patients who received allo-sct from unrelated donors with the conditioning regimen including gy of tbi, fludarabine mg/m for five days, and melphalan mg/m between april and july at the japanese red cross medical center. six patients received unrelated bone marrow transplantation (bmt) and two patients received cord blood transplantation (cbt). graft-versus-host disease (gvhd) prophylaxis was consisted of tacrolimus and short term methotrexate. the median age at allo-sct, the time from diagnosis of myeloma to allo-sct, and the numbers of prior treatment lines were . years (range: - years), . months (range: - months), and . lines (range: - lines), respectively. five patients are female. no episode of either grade ≥ iii toxicity or non-relapsed mortality was documented during the median follow-up period of over two years. cumulative incidence of grade ≥ ii acute and severe chronic graftversus-host disease were . % ( % confidence interval [ci] . %- . %) at days and . % ( % ci . %- . %) at days, respectively. probabilities of progression-free survival and overall survival were . % ( % ci . %- . %) and . % ( % ci . %- . %), at years, respectively. the results suggest that allo-sct conditioned with this intensified regimen may be tolerable for patients with relapsed or refractory mm. disclosure of conflict of interest: none. the role of allogeneic stem cell transplantation (allosct) in the era of novel myeloma drugs remains controversial. it is the only curative treatment option but non-relapse mortality makes the decision making difficult as opposed to achievements with autologous sct and new mm drugs by which the median survival is nowadays nearing years. aim of this study was retrospectively evaluate the outcome of allosct for mm performed at our institute, including evaluation of factors affecting survival. all consecutive patients allotransplanted for mm between and were included. the data were collected from our transplant registry. frequencies and medians were produced as appropriate. kaplan-meier method was used to calculate os and pfs and log rank test for comparisons. univariate analysis for factors affecting survival was performed with cox proportional hazard model. median age of all patients was ( - ) years. half of the patients had igg myeloma, % had iss score (score available for patients), and % had high-risk cytogenetics (data available for patients). response to treatment at sct was at least vgpr in % of patients, and transplant timing was early (within months from dg) in % of patients. sibling donors were used in % and muds in % of transplants, and conditioning was ma for % and ric for another % of patients. acgvhd grade - occurred in % and grade - in % of patients; % of patients had extensive chrgvhd. posttransplant cr rate was %. % of pattients have relapsed after allosct, and % are alive with the median follow-up of , years. non-relapse mortality has been % ( % until , % since then). the median survival of patients up to age of years is . years vs . years for patients years (n = ) with survival plateau after years at % level. transplant period, cytogenetics, donor type, conditioning intensity or occurrence of chrgvhd had no statistical impact on survival. significant differences in os were observed between disease status at scr vgpr vs o months from dg vs later), grade of acgvhd - vs - , and best resonse post-transplant cr vs not less than cr. the respective differences for pfs were in sct timing, grade of chrgvhd, and best post-transplant response. in univariate cox regression analysis the only significant factors for os were severity of acgvhd and cr vs other responses after sct, and for pfs allosct timing, severity of chrgvhd, and best response to sct. with allosct ca. % of mm patients can be cured but at the cost of high non-relapse mortality. the occurrence of grade - acgvhd and less than cr response to sct predict poor survival. considering the increasing survival expectations with modern standard therapy for mm, allosct may be recommended for younger patients with high-risk features, and allosct should be done early in the disease course. disclosure of conflict of interest: none. angiogenesis plays an important role in the pathophysiology of hematological malignancies including plasma cell myeloma (pcm). microrna- (mir- ) is overexpressed and displays oncogenic activity in cancers. however, little is known about the role of mir- in pcm. the aim of the present study is to examine the expression level of peripheral mir- in pcm patients and to determine its role in angiogenesis. vegf serum levels and mir- in pbmcs was measured in patients with pcm directly before melphalan mg/m followed by autologous hematopoietic stem cell transplantation (auto-hsct) and months after hsct; and healthy controls. the study population was divided into two groups after therapy: responders (stringent complete response, complete response, very good partial response, partial response) and nonresponders (stable disease, progressive disease). gene expression of mir- was quantified by sybr green real-time fluorescent quantitative pcr. further tube formation of huvecs and vegf secretion was measured in mir- mimic or inhibitor transfected human plasma cell myeloma cell lines h and rpmi- . the expression level of mir- was significantly increased ( . ± . versus . ± . ; p o . ) in pbmcs of pcm patients compared with healthy controls. further, serum vegf levels were increased in pcm patients ( ± pg/ml versus ± pg/ml in normal controls; p o . ). after auto-hsct, the expression level of mir- was significantly different in responders compared to nonresponders. responders had a lower expression of mir- compared to non-responders. further, serum vegf levels decreased in responders to auto-hsct compared to nonresponders. vegf expression was increased in the supernatant from mir- mimic transfected human pcm cell lines h and rpmi- compared with the negative control, while s vegf was decreased in the mir- inhibitor transfected cell lines. the angiogenic ability of huvecs was increased under pretreatment with the supernatant from h and rpmi- cells transfected with mir- mimic compared with negative controls and decreased when pretreated with mir- inhibitor transfected cells (fig. ) . this study demonstrated that mir- was upregulated in pcm patients. responders to auto-hsct had a decrease of mir- expression and vegf levels. further, mir- regulated angiogenesis. therefore inactivation of mir- or activation of its target gene may be a potential therapeutic approach in pcm. fig. : in vitro matrigel tube formation assay. (i), normal control (ii, iii), mir- mimic transfected h cells (iv), mir- mimic transfected rpmi- cells (v), mir- inhibitor transfected h cells. original magnification × . disclosure of conflict of interest: none. [p ] pilot study of busulfan/thiotepa as conditioning regimen followed by allografting and post transplantation cyclophosphamide in advanced relapsed myeloma patients c wolschke, e klyuchnikov, d janson, m heinzelmann, m christopeit, f ayuk and n kröger university medical center hamburg-eppendorf despite the significant improvement in outcomes has been observed for myeloma patients, the disease still remains incurable. due to limitations, such as trm and gvhd, the role of allogeneic stem cell transplantation as salvage therapy in this setting remains unclear. in present pilot study we provide data on the use of post cyclophosphamide (ptcy) as gvhd prophylaxis after a busulfan/thiotepa based conditioning regimen in patients who relapsed after autologous stem cell transplantation. between / and / myeloma patients (male n = , female n = ) with a median age of years (range: - ) (pts), who relapsed after autologous stem cell transplantation received allogeneic stem transplantation with with ptcy as gvhd prophylaxis after busulfan ( . mg/kg for age y and . mg/kg for age years) and thiotepa ( mg/ m )and for haploidentical and mmud additional fludarabin ( mg/m ). all pts. were relapsed after one or two autologous stem cell transplantations. donors were haploidentical (n = ), mmud (n = ), mud (n = ) and hla-identical sibling (n = ). stem cell source was pbsc (n = ) or bm (n = ). all patients received cyclophosphamide mg/kg of body weight on day + and + , which was in pts (n = mrd, n = mud) the only gvhd prophylaxis, while patients with mmud and haploidentical donor received also cyclosporine a from day + and mmf (until day ) and patients (mrd and mud) received additional cyclosporine. we observed no primary or secondary graft failure. the median time for neutrophil and platelet engraftment was (range: - ) and days (range: - ), respectively. major toxicities grade and were: renal (n = ) and mucositis (n = ). major infectious complications were: cmv: n = cmv-reactivations (n = ), sepsis (n = ), pneumonia (n = ) rsv-(n = ) and hsv (n = ). acute gvhd grade ii to iv and ii/iv was noted in % and %, respectively and mainly seen in patients with cyclophosphamide as single gvhd prophylaxis. remission rate were n = complete remission, n = vgpr, n = partial remission, n = n.a. after a median follow up of months pts progressed and patients (n = relapse, n = trm) died. the year pfs was % (n = ). busulfan/thiotepa is an active conditioning regimen for advanced relapsed myeloma patients. post cyclophosphamide might increase anti-myeloma activity, but as single gvhd prophylaxis it causes significant agvhd in mrd and mud and additional immunosuppressive agents such as cyclosporine should be added. disclosure of conflict of interest: none. magnetic resonance imaging (mri) for multiple myeloma (mm) is a sensitive, non-invasive and non-toxic method for detecting myeloma lesions. the goal of the study was to assess whether quantitative mri metrics can detect treatment response and replacement of neoplastic cells by fat marrow. the study was hipaa-compliant and irb-approved. we retrospectively identified all patients who achieved a complete response (cr) after induction therapy between and . inclusion criteria for the study was total spine mri imaging at diagnosis and after achieving cr. cr was determined using the imwg criteria. spinal vertebrae t through l were outlined with imagej software. fractures and lesions were excluded. images were analyzed using histogram-based (entropy, skewness, kurtosis) and texture-based statistics. a two-sided t-test was used to compare quantitative mri metrics from before therapy and after achieving cr. cox regression was used to explore the association between progression free survival (pfs) and change in each quantitative mri metric based on a median split. pfs was defined as the time from the second mri to death or progression of disease. nineteen patients met the above criteria. median age was . years (range: . - . ). majority of patients ( %) were male. majority of patients had iss stage disease ( . %) and standard-risk cytogenetics ( . %). an induction regimen containing an imid and/or a proteasome inhibitor was commonly used ( . %). all patients received an autologous stem cell transplant (asct) consisting of high dose melphalan followed by autologous stem cell rescue. three patients received a planned second asct. seven patients ( . %) were in cr before asct. nine patients ( . %) were treated with imid maintenance after planned initial therapy. median time to repeat mri imaging after cr was months (range: . - . ). mean change in measurements of kurtosis, skewness, entropy and texture analyses are shown in table . no significant change was detected between preand post-cr mri. furthermore, no significant association was seen between the change in any quantitative metric and pfs. [p ] despite promising results by other groups, we could not find a significant association between quantitative t image analysis and cr or pfs. there was heterogeneity in the time of repeat mri imaging which may have limited our ability to study interval change. although no definitive conclusions can be made from this small sample, correlation between pfs and kurtosis or texture d may be promising and should be investigated in a larger group prospectively. multiple myeloma (mm) treatment (tx) has evolved in recent years. solid data on the impact of new tx on patient (pt) outcomes outside clinical trials, however, is lacking. this study aimed at investigating tx practices, pt journeys, and outcomes in the real-world in countries with different access to new tx. the study was conducted between / and / in bulgaria, croatia, czech republic, poland, romania, and slovakia. it consisted of a cross-sectional (x) and a retrospective (r) phase. for the x-phase, investigators included all symptomatic mm pts seen during a -week counting phase to provide a snapshot of where in the pathway pts were at a given moment. for r-phase, investigators collected data on current and past tx, including symptoms, dosages, administration schedule, tx durations, tx interruption, reasons for change/discontinuation, and tx response. pts were selected in reverse chronological order with a quota of a maximum of pts who completed first-line ( l) tx within the past months (mo), pts in second-line ( l) and pts in third or higher lines ( +l). pts included in the x-phase could also be included in the r-phase, if they met the respective inclusion criteria. in total, physicians included pts in the x-and physicians included pts in the r-phase. in the x-phase, % of pts were o , % were - , and % were years; the median time since diagnosis was mo. % of pts were currently undergoing tx, % were previously treated and % had never been treated. of currently-treated pts, % received l, % l, % l and % +l. in the r-phase, % of pts were o years. of pts receiving l, % continued to l, % to l, % to l and % to l. of the % of pts eligible for stem cell transplantation (sct), % ( = % of all pts) received sct at l; these proportions were similar across countries. the most frequently-used regimens in l and l were bortezomib-based ( % and %, respectively), in l and +l lenalidomide-based ( % and %, respectively). median duration of l was mo, followed by a median disease-free interval (dfi) of mo. median dfi was longer in pts with sct than in those without ( . mo vs . mo). time to progression (ttp) decreased with later tx lines, from median mo at l to mo at l. depth of response, as assessed by the treating physician, decreased with each additional line of tx: % of pts achieved at least very good partial response (≥ vgpr) in l, while only % achieved ≥ vgpr at +l. ttp was longer in pts with better response levels: in l, median ttp for pts with ≥ vgpr was mo versus mo for pts with mo for pts with ovgpr. the most common ( ≥ %, all grades) adverse events (aes) and co-morbidities in l were anemia ( %), thrombocytopenia ( %), neutropenia ( %), neuropathy ( %), and fatigue ( %). these aes disrupted treatment in % in l, % in l and % in +l. the study found that of sct eligible pts, only slightly more than half were transplanted. poorer outcomes and increasing ae incidence with each tx line highlight the challenges of mm tx. information on real-world pt management may be valuable for physicians to plan their tx strategies and can provide input for health economic evaluations of existing and new tx. disclosure of conflict of interest: daniel coriu declares to have received consulting fees or other remuneration (payment) from novartis, amgen, pfizer, takeda, janssen. ivan spicka declares to have received research grants from celgene, consulting fees or other remuneration (payment) from bms, takeda, celgene, janssen-cilag, and amgen, and to be a member of the speakers bureau of celgene, janssen-cilag, amgen, and bms. zdenka stefanikova declares to have received consulting fees or other remuneration (payment) from amgen, celgene, and takeda and be a member of the speakers bureau of amgen, celgene, and takeda. daniela niepel, krisztian szabolcs toka, and paul schoen are amgen employees and hold amgen stock. dominik dytfeld, and georgi mihaylov have nothing to declare. safety and efficacy of autologous stem cell transplantation in elderly patients with multiple myeloma t maia , c marini , p medeiros , e aguiar , j cancela pires , r bergantim , f trigo and je guimarães , hematology department, centro hospitalar de são joão and faculty of medicine, university of porto autologous stem cell transplantation (asct) is considered standard treatment for multiple myeloma (mm) patients under the age of years, but its safety and efficacy still uncertain for patients over this age. retrospective analysis from one single centre concerning mm patients under, equal or over years who underwent asct between january/ and july/ . it was also compared to - years old mm patients diagnosed in this period of time who were not transplanted. we analysed a total of patients, of which underwent asct. onehundred-and-six of the transplanted patients were aged years or less (median , iqr years), patients were aged more than years (median , iqr years) and patients were non transplanted (median , iqr ). the conditioning regimen for younger patients who underwent asct consisted mainly of melphalan mg/m (mel ) while half of the elder patients received melphalan mg/m (mel ). regarding transplant-related myelotoxicity there were no statistical differences between patients aged years or less and over years old, however the first group needed less days of g-csf (p = . ). non-hematopoietic toxicity measured by infections and mucositis was not influenced by age. patients years conditioned with mel had more days of aplasia (p = . ), greater need of g-csf (p = . ) and transfusional support (p = . ) than patients ≤ years. there were no differences on non-hematopoietic toxicity. in the elderly group, patients conditioned with mel presented more aplasia days (po . ), higher grade of mucositis (p = . ) and more days of iv antibiotics (p = . ) than those transplanted with reduced dose of melphalan. comorbidities had no effect on transplant-related toxicity, either by age or by dose of melphalan. days of hospitalization and post-transplant complications did not differ according to age group. transplant related mortality was % at day posttransplant. survival after transplant in patients years old or under vs older patients (median follow-up time, months), was not influenced by age (os, mo vs mo, p = . ; pfs, mo vs mo, p = . ). regarding the non-transplanted elderly group, these are patients with more renal disease (p = . ) and poorer performance status (p = . ) than the transplanted cohort. there is also higher cytogenetic risk (p = . ). induction regimens were similar in transplanted group and non-transplanted group years old, and response to first line therapy (before asct of transplanted group) revealed no differences. infections were the most common complication in both groups. transplanted patients needed less days of hospitalization (p = . ). comparing the long term outcome of these two groups, survival curves of the elderly patients transplanted were clearly superior to the nontransplanted (os, mo vs mo, p o . ; pfs, mo vs mo, p o . ) although one has to consider that the non-transplant group has worse features than the elderly transplant group. transplantation in the elderly still debatable but this study shows that it might bring benefit. globally, transplant related toxicity is not influenced by age. regarding dose of melphalan, higher dose in elderly patients has higher toxicity, without apparent benefit in survival. therefore, age should not restrict the access to asct, but instead selection must be based on individual clinical and functional status. disclosure of conflict of interest: none. second autologous stem cell transplantation for relapse after allografting in multiple myeloma using cd + selected donor cells without immunosuppression p novak number of patients receiving a second allogeneic stem cell transplantation (sct) in europe is increasing despite high treatment related mortality (trm). in multiple myeloma only very few reports of second allogeneic sct exist with limited number of patients and substantial mortality. while in most hematological malignancies, the donor cell chimerism is dropping down if patients are relapsing, in myeloma donor cell chimerism remains complete despite relapse. to reduce trm we thought that full donor cell chimerism may allow us to perform a second high dose busulfan based chemotherapy followed by "autologous transplantation" after stem cell mobilization and collection. however, because two consecutive patients failed to collect sufficient cd + cells for an autologous transplantation even with plerixafor, we used donor t cell depleted cd + selected cells and transplanted those patients in an "autologous" fashion without any immunosuppression. to enhance graft-versus-myeloma effect, we added donor lymphocyte infusion (dli) at day . we report here on myeloma patients with a median age of years (range: - ) who relapsed after allogeneic sct and underwent a second "autologous" sct with cd + selected donor cells. all patients had received one (n = ) or two (n = ) autologous sct before . allografting. patients received an upfront auto-allo protocol and patients received . allogeneic sct as a salvage therapy. % of patients received a reduced intensity melphalan based conditioning regimen for . allogeneic sct and the median pfs was months (range: - ). before . allograft patients had received overall a median of (range: - ) treatment lines. at the time of . allogeneic sct all patients had a full or nearly full donor cell chimerism and remission status was very good partial remission (n = ), partial remission (n = ), stable disease (n = ), progressive disease (n = ). % of patients received a myeloablative busulfan based conditioning regimen and all received cd + selected stem cells with a median number of . × /kg cd + cells (range: . - . ) and × /kg cd + cells (range: . - ). engraftment was noted in % at a median of days (range: - ). no further graft-versus-host disease (gvhd) prophylaxis was performed and no acute gvhd (agvhd) was observed. according to treatment plan, patients received escalating dli around day + , starting with a median dose of × /kg (range: . - ) in combination with lenalidomide maintenance in patients. patients experienced agvhd ii-iv after dli. two patients had a severe gvhd (grade iii) which resolved completely after steroid therapy. no nonrelapse mortality after sct and dli was observed. after a median follow up of months (range: - ) the median pfs was months (range: - ) which translates into a pfs for all patients of % at year and % at years. median os was months (range: - ) and an os of % at years and % at years was observed. for patients with advanced multiple myeloma relapsing after allografting, a second "autologous" sct with cd + selected donor cells without immunosuppression followed by dli is an encouraging treatment option with low toxicity. disclosure of conflict of interest: none. second autologous stem cell transplantation as treatment option for relapsed patients with multiple myeloma: a single center experience (cic ) p ganeva, y petrov , m mincheff , i tonev , m guenova, l gartcheva , a michova , g arnaudov and g mihaylov ya. petrov; m. mincheff; i. tonev; l. garcheva; a. michova; g. arnaudov and g. mihaylov the use of modern therapies such as bortezomib, lenalidomide, thalidomide coupled with upfront high-dose therapy and autologous stem cell transplantation (asct) has resulted in improved survival in patients with newly diagnosed multiple myeloma (mm). the role of second asct as salvage therapy for relapse is unclear because of the availability of new agents to treat progression in multiple myeloma (mm). as the treatment options for management of patients with relapsed mm has become increasingly complex, physicians must consider both disease-and patient-related factors when choosing the appropriate therapeutic approach, with the goal of improving efficacy while minimizing toxicity. we retrospectively reviewed all mm patients who received a second asct as salvage therapy at our center from to december . for this period we performed transplants for mm patients. twenty five ( . %) patients received second asct ( patients were relapsed) and for patients asct was performed as tandem transplant. we analyzed only second asct for relapse. the median time to relapse after first transplant was . months (range: - months). all patients received reinduction therapy before the second asct. conditioning was performed with melphalan with two different doses ( mg/m and mg/m ). the median age at second transplant was . years (range: - years), and female/man ratio was / . median interval between first and second asct was . months (range: - months). we have no observed early deaths. until now ( %) patients are dead because of progression disease. response rate was assessed three months after asct, nine ( %) patients achieved vgpr, three ( . %) patients achieved at least a partial response, three ( . %) had sd and three ( . %) progressed despite salvage asct.median overall survival (os) was . months ( relapse ≥ months = . ; ≤ months = ). second asct is a feasible and safe option for salvage therapy in mm, especially in bulgaria where the possibility of using novel agents such as carfilzomib, lenalidomide, daratumomab for relapsed patients is limited to clinical trials, because of no reimbursement. the best results were observed in patients whose time to progression was more than months after first asct. advances in treatment of multiple myeloma (mm) has improved overall survival in these patients (pts). a steady increase in the risk of secondary malignancies has been reported over the last decades in mm survivors. estimated incidence of secondary acute myelogenous leukemia or myelodysplastic syndrome (t-mds/aml) after treatment with alkylating agents is %- . % per year - years after primary chemotherapy. no specific risk factor has been recognized, but genetic instability, natural history of the disease as well as induction therapy and autologous stem cell transplantation (hct) have been implicated. recently, novel anti-myeloma treatments have been linked with an increase in secondary malignancies, but no solid relationship has been established yet. in a retrospective study, we analyzed the incidence of secondary malignancies (t-aml/mds and solid tumors) in patients suffering from mm who had undergone autologous hct using high-dose melphalan conditioning regimen in our bmt unit. study population consisted of consecutive pts with median age of years ( - ), . % of them being male, who were transplanted during a period of years . type of myeloma was igg/a/d in %, . % and . % respectively, while . % was light chain and % nonsecretory. the majority of pts presented with k light chain myeloma ( . %). there was almost equal distribution between iss stages i and ii ( %/ . %) and only . % were diagnosed with advanced stage myeloma. most pts received two lines of chemotherapy ( %) and all of them more than one. treatment regimens before autologous hct included vad ( pts), bortezomib-based ( pts), dcep ( pts) and rd ( pts) and pts received radiotherapy. chemotherapy administration for mobilization was used in pts ( . %). conditioning regimen before autologous hct consisted of high-dose melphalan ( mg/m ) and in case of renal insufficiency mg/m . incidence of a secondary malignancy was . % after a median follow up period of months. t-aml /mds was diagnosed in ( . %) pts and ( . %) were diagnosed with breast and lung cancer respectively. pts diagnosed with secondary malignancy were previously exposed in induction therapy to melphalan ( ), vad ( ), bortezomib ( ), high-dose cyclophosphamide as mobilization treatment ( ) and radiotherapy ( ) . cytogenetic analysis was available in patients diagnosed with t-mds/aml and the majority ( / ) presented complex karyotype. abnormalities mainly observed were deletions and insertions in chromosomes , , . pts with secondary malignancies had an overall survival of months ( - ), however, after malignancy diagnosis, survival was very poor, four months only . secondary malignancies in pts with multiple myeloma after autologous hct occur with a substantial frequency and have a dismal prognosis. the role of novel treatment agents has to be elucidated. further studies are needed to identify new risk factors and develop better surveillance strategies. [p ] disclosure of conflict of interest: none. survival analysis after allogeneic hematopoietic stem cell transplantation in patients diagnosed with multiple myeloma: a single center experience p patricia hernandez* , r maria calbacho , a laura posada , g fabio augusto ruiz , r anabelle chinea hospital universitario nuestra señora de candelaria, santa cruz de tenerife (spain); hospital universitario ramón y cajal, madrid (spain) and hospital universitario cruces, barakaldo (spain) allogeneic hematopoietic stem cell transplantation (allohsct) may provide long term remission cures for patients diagnosed with high-risk multiple myeloma. however, its use is limited since it has a high rate of treatment-related mortality (trm), and because its efficacy compared to autologous hsct is not fully established. we studied patients that underwent allohsct between - . population characteristics are in table . all patients were treated at least with one prior therapy lines ( ) ( ) ( ) ( ) ( ) , all including autohsct ( . % underwent prior autohsct). % had or prior therapy lines. of them received bortezomib as part of treatment regimens. donor characteristics: non-related; hla-identical. gvhd prophylaxis: methotrexate plus a calcineurine-inhibitor: cyclosporine and tacrolimus. median follow-up . months ( . - . ), average was . months. seven patients died ( . %); because of progression ( . %), and ( . %) due to trm, including infections and immediate complications of transplantation, such as toxicities, icu admission and agvhd: infections: cmv reactivations, invasive fungal and bacterial infections. disease status: patients were in cr prior to allohsct. of them maintained it after. remaining patients died before disease was evaluated. seven patients were in pr prior to transplant, and reached cr after allohsct. one had progressive disease and reached cr after the procedure. two had stable disease and progressed after allo; one of them is in cr after additional therapy lines, and the other one died months after due to it. donor characteristics: hla-identical sibling donors: . % ( hla-mismatch, passed away . months after allo due to trm). one of the nonrelated donors, had an hla-mismatch, and died months after allohsct due to trm, the other one is alive after months. gvhd: ( . %) developed agvhd and of them maintained it chronically. two suffer from cgvhd, plus that initiated it as agvhd. were refractory to steroids. longterm survivors: patients had overcome three years after allohsct. they were among and years old at the time transplant was performed. none of them received bortezomib as part of therapy protocols for the disease. all had therapy lines prior allograft. were submitted to prior autologous hsct. relapse: patients relapsed after allohsct ( %, median time to relapse . months), being alive % at the end of the study. allogeneic hsct is associated with a high incidence of nrm and a low incidence of relapse. rates of acute and chronic gvhd are high. in our cohort, besides that more than % are alive until now, they suffer from extensive chronic gvhd and are in need of treatment. long-term survival may be related with patient factors such as young age, but also low tumor burden, or less prior therapy lines; in our group there are no differences in this aspect. studies including high-risk abnormal cytogenetics should help to define which patients are best candidates to allohsct. high-dose melphalan followed by autologous haematopoietic cell transplantation (ahct) remains the standard of care for eligible multiple myeloma (mm) patients. the majority of patients in clinical practice and trials receive a melphalan dose of mg/m (mel ), but a reduced dose of mg/m (mel ) is often used in patients perceived to be unable to tolerate mel . it remains to be determined whether this considerable dose difference results in different clinical outcomes. we therefore analysed patients with mm who underwent a first single mel or mel -conditioned ahct between january and december . all patients were included in the calm study, an analysis of a prospectively defined cohort of patients with data reported retrospectively to the ebmt, covering ahcts for mm and lymphoma. patients in the mel group were older than patients in the mel group at the time of ahct (median years [range: - ] vs years ; p o. ). compared to the mel group (n = , . %), fewer patients in the mel group (n = , . %) were overweight or obese ( . % vs . %; p = . ). compared to the mel group, more patients in the mel group had received proteasome inhibitor-containing induction therapy ( . % vs . %; p = . ), had a karnofsky score of ≤ ( . % vs . %; p = . ), and were transplanted in less than pr ( . % vs . %; p = . ). overall survival (os) from the time of ahct was not significantly different between the mel and mel group ( - significantly different between mel and mel ( days in both groups for neutrophil recovery; vs days for platelet recovery). however, late neutrophil recovery was noted in a small proportion of patients in the mel group. neutrophil recovery days post ahct was not observed in any engrafting patient in the mel group, but occurred in ( . %) engrafting patients in the mel group (p = . ). a cox proportional hazards model that included melphalan dose, age, and remission status at ahct showed that melphalan dose had no effect on os, pfs and relapse risk. the findings suggest that mel is not inferior to mel in younger and older mm patients and may reduce the risk of delayed haematological recovery in some patients. further analyses in relevant subgroups such as patients with high-risk features or renal impairment are required. disclosure of conflict of interest: none. high-dose therapy (hdt) followed by autologous stem cell transplantation (asct) remains the standard of care for patients younger than years of age with multiple myeloma (mm). different agents are being used to control the disease before asct, including the older thalidomide based combination or the newer bortezomib and lenalidomide based combination. the relation between the initial induction regimen and outcomes after asct is not completely clear. to evaluate the effect of different induction regimens on asct outcome, we retropsectively evaluated the outcomes of a low cost older regimen of thalidomide based combination in doublets or triplets with newer novel agents like bortizomib or lenalidomide based combination in a low resources country in transplant-elegible patients with multiple myeloma who underwent autologous stem cell transplantation at king hussein cancer center bmt program we retrospectively reviewed the files of patients diagnosed with mm from january till december , who received induction treatment followed by hdt and asct and followed up in a single institution. we compared the effects of different induction regimens, disease stage, and remission status before transplantation on over-all survival (os), event free survival (efs) and progression free survival (pfs) using kaplan meier curves. a total of patients were included, ( . %) of them received thalidomide based induction (group ) and ( . %) received bortezomib and lenalidomide based induction (group ). patients also offered no consolidation nor maintenance therapy. ( . %) patients were stage i, ( . %) stage ii and ( %) were stage iii. stage was not documented for ( , %) of cases. ( . %) were in complete remission (cr) and ( . %) were in partial remission (pr). the estimated -year os for the whole group was . %. there was no statistically significant difference between both groups in regards to initial iss stage of disease (p = . ) or cr status before asct. patients ( . %) in group achieved complete remission ( cr ) or very good partial response (vgpr), while ( . %) patient in group achieved cr or vgpr. there was no statistically significant difference between group and group in -years os ( -year os was % vs %, p = . ), efs ( . % vs . %, p = . ) or pfs ( . % vs . , p = . ). the use of an old, low-cost, thalidomide-based regimen in a low-resources country achieved a favorable transplantation outcomes in patients with multiple myeloma who received hdt and asct. double autologous stem cell transplantation (asct) is a useful treatment for multiple myeloma (mm) patients. we can make the second asct ( asct) without reinduction treatment (tandem regimen) or after a reinduction treatment after first asct ( asct) relapse (salvage regimen). we have conducted a retrospective study over mm patients undergoing a double asct performed in our centre from to . we have compared the different conditioning regimens used, and if there are any difference between tandem or salvage asct. we do not use maintenance treatment systematically. characteristics of patients and conditioning regimens in table . the overall survivals (os) of our patients are months (m) from treatment start till last control. the most important prognostic factors are the duration of the progression free survival (pfs) after asct (hr: . ( . - . ); p = . ), and the use of bumel like conditioning regimen at the asct or at the asct vs another conditioning regimens (hr: . ( . - . ); p = . ). today there are patients alive ( %), but only ( %) are free of mm now. the patients who were treated with tandem have a little better os than salvage patients ( m vs m; p = . . not significative). patients at tandem group who received different conditioning regimen at the asct and at the asct live more time than patients treated only with melphalan (mel ) at both asct. at salvage group the duration of pfs after asct is better than the pfs after asct ( m vs m). the use of the same conditioning regimen at the both asct has worse results than if we use different treatment. patients who were treated with s bumel at the asct or asct have better os than patients treated with cbv or mel . patients who not responded to reinduction treatment before asct have worst pfs after asct (rc: m, response; m and not response; only m). attention is drawn to the fact that patients who received bumel at asct have large os, but they are very few ( ) patients. only one patient has died during the asct, and was a patient of salvage group treated with bumel. double autologous transplantation continues to be a useful treatment despite the new mm treatments, and allows to prolonged the os. tandem asct probably is a useful treatment in high risk mm patients. salvage treatment is most useful in patients with a large pfs after asct, and good response to reinduction treatment. although mel continue to be the standard conditioning regimen for asct in mm patients, we have observed that patients treated with different conditioning regimen at asct and asct have better prognostic, and bumel has the best results in our serie. disclosure of conflict of interest: none. allogeneic haematopoietic stem cell transplantation (allo-hsct) is an effective treatment for myelodysplastic syndrome (mds) and acute myeloid leukemia (aml). the prognosis of elderly patients with mds and aml after chemotherapy is poor. allo-hsct is feasible in these patients; however the management of elderly patients with mds and aml for allo-hsct is difficult. we performed a retrospective survey of allo-hsct for elderly patients with mds and aml in our institution. we retrospectively analyzed the records of elderly patients ≥ years with mds and aml who underwent allo-hsct in our hospital between january and december . in this study, we assessed the ipss-r (revised international prognosis scoring system) cytogenetic score and the ipss-r score against the outcome of elderly mds and aml patients who treated with allo-hsct. fifty-one elderly patients with mds and aml were treated with allo-hsct in our institution, patients with mds ( with mds overt aml) and with de novo aml. ages ranged from to years (median ), patients were female and were male. there was a history of malignant disease in patients. according to the ipss-r cytogenetic scores of mds patients, patients fell in the good risk group, were in the intermediate risk group, were in the poor risk group, and were in the very poor risk group. regarding the ipss-r score, patient fell in the low risk group, in the intermediate risk group, in the high risk group, and in the very high risk group. sixteen patients were in st complete remission (cr), patient was in nd cr, patients were in partial remission, and patients were not in remission (nr) upon administration of allo-hsct. all patients received a reduced intensity conditioning regimen. patients [p ] were treated with fludarabine (flu), melphalan and low dose tbi-containing regimens; patients were treated with flu, intravenous busulfan and low dose tbi; and one patient was treated with flu, cyclophosphamide and low dose tli. graftversus-host disease (gvhd) prophylaxis consisted of tacrolimus plus methotrexate in patients, and tacrolimus, methotrexate and mycophenolate mofetil in patients. thirty-four patients received anti-thymocyte globulin (atg). the donor source was sibling bone marrow (bm) in patient, sibling peripheral blood stem cell in , unrelated bm in and unrelated cord blood in . relapse-free survival (rfs) and overall survival (os) were . % ( % confidence interval (ci): . - . %) and . % ( % ci: . - . %) at year, . % ( % ci: . - . %) and . % ( % ci: . - . %) at years, respectively (figure .) . in this study, patients died before engraftment. non-relapse mortality (nrm) was . % at day . twenty-five patients developed chronic gvhd ( patients limited and extensive). the causes of death were disease progression ( patients), treatment-related mortality ( patients), infection ( patients) and other causes ( patients). we suggest that many elderly allo-hsct patients with mds and aml were in the very poor risk group when the ipss-r cytogenetics score was assigned, in the very high risk group when the ipss-r score was assigned and nr upon administration of allo-hsct. rfs and os were . % and . % at years, respectively. there is a need for novel treatment strategies to manage elderly mds and aml patients for allo-hsct. [p ] disclosure of conflict of interest: none. counting bone marrow blasts as a percentage of nonerythroid cells provides superior risk stratification for mds patients with erythroid predominance a sun , y yu , t zhang , q wang , d liu and s chen the first affiliated hospital of soochow university, jiangsu institute of hematology, suzhou, china patients with erythroid predominance (≥ % erythroblasts, mds-erythroid) compose a significant proportion of patients with mds. the erythroid/myeloid subtype was divided from the aml category into mds-erythroid by the who classification of myeloid neoplasms. at that time, there was no consensus on a more appropriate way of enumerating bone marrow (bm) blasts from tncs or necs in mds-erythroid patients. to clarify these questions, mds patients were retrospectively analyzed in our center. mds-erythoid was observed in . % of patients ( / ), and these patients had similar clinico-pathological features and overall survival, with cases of mds with o % encs. by calculating the percentage of bm blasts from necs, of patients ( . %) with mds-erythroid who were diagnosed within who subtypes without excess blasts (eb) were moved into higherrisk categories and showed shorter os than those who remained in the initial categories (p = . ). recalculating the international prognostic scoring system-revised (ipss-r) by enumerating blasts from necs, of ( . %) mdserythroid patients with relatively lower risk were re-classified as higher-risk and had significantly poorer survival than those who remained in the lower-risk category (p = . ). this was especially true for the intermediate risk group that was stratified by ipss-r (unchanged patients vs. shifted patients, p = . ). however, the impact of enumerating bm blasts from necs on classification and prognostication was not evident in all mds patients. in conclusion, our results suggested that enumerating the percentage of bm blasts from necs significantly improved the prognostic assessment of mds-erythroid, especially for patients within the intermediate risk group stratified by ipss-r. disclosure of conflict of interest: none. myelodisplastic syndrome (mds) is a group of clonal and heterogeneous diseases, characterized by ineffective hematopoesis. the incidence of mds is about % of all blood disorders in children, approximately % of them develops acute leukemia. allogeneic hematopoietic stem cell transplantation (allo-hsct) is effective curative treatment of mds in children, but depends on disease status, type of clonal chromosomal abnormalities presented at the time of allo-hsct and graft quality. the aim of this study: to analyze the influence of graft quality on the outcome of childhood mds after allo-hsct. allo-hsct were performed in patients (pts) p hypomethylating agents vs. allogeneic sct in elderly patients with advanced myelodysplastic syndromes: a single center study j cermak, a vitek, m markova-Šťastná, j soukupova-maaloufova and p cetkovsky institute of hematology and blood transfusion, prague, czech republic a group of patients older than years of age with myelodysplastic syndrome (mds) raeb ii or with acute myeloid leukemia with multilineage dysplasia with less than % of bone marrow blasts (mds raeb-t according to the fab classification) was treated with hypomethylating agents (hma) and the results were compared to those obtained in an age and diagnosis matched group of patients who underwent allogeneic stem cell transplantation (sct). in the hma group, patients received azacytidine (vidaza) in the dose of mg/ m × every days and patients were treated with decitabine (dacogen) in the dose of mg/m × every days. median number of cycles administered was . (range: - ). in the transplanted group, patients were transplanted upfront and patients were pretretated with combination chemotherapy, patients received myeloablative conditioning and patients were transplanted after reduced conditioning regimen. a hematologic response to hma (cr,pr, hematologic improvement) was observed in patients ( . %), cr was achieved in patients ( . %). in sct group, engraftment was achieved in out of patients, patients died after sct ( on complications related to sct, patients relapsed). no difference in year survival was observed between both the groups ( . % for hma vs. . % for sct), however, median overall survival (os) was . months in hma treated group compared to . months in sct group (p = . ). in a recent analysis performed at months after starting the treatment, patients treated with hma ( . %) and transplanted patients ( . %) were alive, patients in hma group and patients in sct group relapsed. estimated years survival was . % in sct group and only . % in hma group (p = . ). no significant differences in results and adverse effects of treatment were observed between patients aged - years and those older than years in both hma and sct groups. our results confirm previous observations showing that despite a promising effect of hma resulting in hematologic response in more than % of elderly patients with advanced mds, allogeneic sct still represents the only potentially curative treatment connected with long-term survival in a significant number of patients even in this mds patients subgroup. disclosure of conflict of interest: none. immunophenotypic assessment of erythroid dysplasia by a simplified cocktail in myelodysplastic syndromes in taiwan c-c li , p-f weng , c-t lin , j-l tang hypomethylating agent (hma) is commonly used as a bridge therapy to prevent leukemic transformation prior to selection of a donor for allogeneic stem cell transplantation (sct) in patients with myelodysplastic syndrome (mds), and showed low toxicity. although its roles are known, the underlying genetics and clonal dynamics upon hma treatment has not been systematically examined using serial samples, especially in allogeneic stem cell transplantation (sct) setting. in this study, we performed targeted serial sequencing on bone marrow samples from mds patients treated with hma for bridging of allogeneic sct. to perform targeted deep sequencing, bm mononuclear cells before hma treatment and, and fractionated t-cell samples (cd + fraction) as controls were taken before hma treatment. analysis of genetic mutations were performed using targeted resequencing by illumina hiseq (sureselect custom probe set targeting [p ] entire exon regions of a myeloid panel consisting of genes). all patients received hma (decitabine: , azacitidine: ), and the median number of cycles was four (range: - ). the overall response rate for hma pre-treatment was %: there were four cases of complete remission (cr) ( %), six cases of marrow cr ( %), and two cases of hematologic improvement ( %). targeted sequencing revealed mutations in patients ( / , %) with median of mutations per patient (range: - ). mutated genes were then grouped into biological pathways, defined in the cancer genome atlas (tcga) aml study. the most frequent biological pathway at diagnosis was dna methylation ( %), followed by activated signaling ( %), chromatin modifiers ( %), tumor suppressors ( %), spliceosome ( %), cohesin complex ( %), npm ( %), and myeloid transcription factors (tfs) ( %). when assessing the difference in pattern of variant allele frequency (vaf), we found the significant reduction of vafs in four ( %) patients after hma. with a median follow-up of . months, -year overall survival (os) were . % ( % ci, . - . ). there was no significant difference in os according to the presence of mutations in each biological mutational pathway (all, p . ). to identify prognostic value of mutational dynamics, we subclassified the change of variant allele frequencies (vafs) after median fourth cycles of hma [no mutated or reduction of vafs ( patients) vs. stable or increased ( patients)]. however, there was no significant association between the dynamic of mutation and os (p = . ). these data show that hma using as bridge therapy for allogeneic sct in mds patients is insufficient to achieve the sufficient molecular responses and, mutational pathway and dynamics may not prognostic in this clinical setting. to clearly demonstrate the role of hma pre-treatment in mds, systematic assessment on a larger cohort is necessary. disclosure of conflict of interest: none. any role of high-dose chemotherapy in mediastinal nonseminoma germ cell tumors? p pedrazzoli, s secondino, a necchi , f lanza and g rosti istituto nazionale tumori, milano and ospedale santa maria delle croci, ravenna among germ cell tumors, primary mediastinal nonseminoma germ-cell tumors (pmnsgcts) have the poorest outcome with -year overall survival ranging from to %. indeed, the presence of mediastinal location defines per se a "poor prognosis" category according to the igcccg classification. this clinically and biologically distinct disease entity is associated with lower complete response rates to chemotherapy (ct), high rates of relapse and disappointing results from salvage ct. current standard first line treatment for patients with mediastinal primary location is still four cycles of peb, as for all igcccg poor-prognosis patients. we have reviewed available data present in the literature, including recommendations and expert opinions, on the use of high-dose chemotherapy (hdc) with autologous stem cell support in pmnsgcts. the use of hdc as both early intensification (that is, first-line setting) and at disease recurrence (salvage setting) have been reported in small cohorts of patients. according to the largest retrospective comparison, it has been suggested that hdc, given up-front, may produce a % to % absolute improvement in survival compared with standard dose ct. studies of the ebmt suggest that responsive disease after induction therapy may have a better outcome. mediastinal primary had salvage rates by hdct of less than % based on an international multicenter analysis and an ebmt study. the use of hdct in pmnsgcts warrants further investigation, preferably with the use of modern hdct strategies (that is, multiple carboplatin and etoposide courses). while hdc cannot be routinely recommended in pmnsgcts, selected patients with chemosensitive disease may benefit from early intensification. a retrospective analysis evaluating the large ebmt database is ongoing; results will be presented at the meeting. disclosure of conflict of interest: none. high dose therapy and autologous stem cell transplantation in gynaecological malignancies: a monocentric retrospective study m nderlita , i vergote and d dierickx university hospitals leuven, department of gynaecology; university hospitals leuven and department of hematology high-dose chemotherapy (hdt) followed by autologous stem cell transplantation (asct) has been established as a treatment option in many relapsed hematologic malignancies. however, in spite of many small trials, there still is no proven role for this treatment in solid tumors including most gynaecological epithelial carcinomas. however, in some recurrent non-epithelial ovarian cancers, such as sex cord stromal tumors, germ cell tumors, neuroendocrine gynaecological tumors and gestational trophoblastic disease, some studies suggest a possible role for hdt followed by asct. we performed a monocentric retrospective descriptive analysis of all patients diagnosed with gynaecological malignancies and treated with hdct followed by asct in our center. clinical, laboratory, pathological and imaging data were collected and analysed, together with information on treatment and outcome. eleven patients were included in this analysis, with a median age of years (range: - ) at time of diagnosis. eight patients suffered from ovarian neoplasia. at time of diagnoses patients showed metastatic disease. first line therapy consisted of surgery (n = ), chemotherapy (n = ) or a combination of both (n = ). median time to progression after first line therapy was . months (range: - ) with a median time between primary diagnosis and start hdt of . months (range: - ). three patients underwent single ast, whereas the other patients had a tandem ast, with a median time of months between first and second hdt (range: - ). treatment related toxicity was manageable, although there was treatment-related death. at last follow up patients ( %) were still alive with a median follow up of . years (range: . - . ) after last asct for all patients. of the deceased patients died with progressive disease. although the number of patients is very small, this retrospective study shows that hdt and asct is feasible in heavily pretreated patients with relapsed/refractory gynecological malignancies, although further studies are mandatory for optimal selection of patients, histological subtype and timing of hdt during the disease course. disclosure of conflict of interest: none. the human endogenous retroviruses (hervs) are remnants of ancient exogenous retroviral infections of the humans: they represent about % of the human genome . the basic genes of hervs are group-specific antigen (gag), polymerase (pol) and envelope (env); there are also two regulatory regions, long terminal repeat (ltr), located at ' and ' ends. several reports have shown that hervs may play a role in the development of autoimmune diseases, such as multiple sclerosis . additionally the existence of a strong relationship between hervs expression and cancer, based on the mrna expression profile of hervs in normal and cancer tissues has been suggested . the increased level of expression level of herv-h in colorectal cancer (crc), a major cause of cancer death worldwide has been already shown. the aim of the study was to analyse the expressions of env genes of herv-r, herv-h, herv-k and herv-p in the peripheral blood mononuclear cells (pbmcs), in the tumor and in the adjacent normal tissues of colorectal cancer patients. a group of control composed by pbmcs from healthy subjects was also included. rna was isolated from the biological samples and a reverse transcription assay was conducted. quantitative real time pcr was performed to evaluate the expression of the hervs env gene. all the env genes were related to the expression of an housekeeping gene, gapdh. the quantification was carried out using comparative ct method and the difference between the levels of env gene expression in pbmcs, cancer and adjacent normal tissue was given by fold difference. fold difference values were relative to a calibrator: first the pbmcs of patients and then pbmcs of control healthy group. Δct values were analysed using the paired sample t-test, followed by a bonferroni correction. higher levels of expression of herv-h, herv-k and in particular herv-p were found in tumor tissues, as compared to pbmcs and to adjacent normal tissues of patients, with an increase of -, -and folds, respectively. the Δct distribution of herv-h, herv-k and herv-p in cancer tissues were statistically significant (po . ) ( table ). the expression of herv-h, herv-k and herv-p env gene resulted increased in the colorectal tumor tissues also when compared with the pbmcs of the healthy controls ( -, -and -folds, respectively). the Δct distribution of herv-h, herv-k and herv-p in tumor tissues were statistically significant ( ρ < . ). no difference of expression was observed between pbmcs of healthy controls, pbmcs and normal adjacent tissues of patients (figure ). hervs env gene expression cannot be used as a diagnostic biomarker, but it is conceivable that hervs are directly involved in the pathogenic process of cell transformation and, if the protein expression will be demonstrated, the protein of hervs env gene could be the target for new immunotherapy strategies against colorectal cancer. [p ] disclosure of conflict of interest: none. a biosimiliar g-csf filgrastim is as effective as a reference drug however itis not as cost effectiveas it supposed to be and by the way no impact on the health care system m kurt yüksel, g pekcan, u sahin, s bozdag, s toprak, p topcuoglu, o arslan, g gurman and m beksac ankara university school of medicine biosimiliars are up to times the size of small molecule generic drugs and far more structurally complex. additionally biosimiliars are manufactured in living cell lines using processes that cannot be exactly replicated from one manufacturer to the next. a biosimiliar cannot be identical to its reference biologic drug. with billion dollars in global sales of biologic medicines anticipated to go off patent by .this lead to fast production of biosimiliar drugs. besides, it is expected that biosimiliar drugs will be more cost effective than the reference drugs and will have a meaningful impact on health care systems around the world. aim: to compare biosimiliarfilgrastim (leucostim) with two reference g-csf filgrastim (neupogen) and lenograstim(granocyte) in the context of safety, efficacy and cost effectivity. records of patients with multiplmyeloma(mm) whom underwent autologous stem cell transplantation(asct) and received g-csf sc mikrogram/kg/day from +day until engraftment were [p ] retrospectively evaluated mm patients were treated with high dose melphalan and asct at the ankara university school of medicine bone marrow transplantation unit between and . the median age was ( - years) with % male. patients were divided into three groups (n = ) whom received reference filgrastim (neupogen), lenograstim (granocyte) and biosimiliarfilgrastim (leucostim): groups a, b and c respectively. the total cost of each g-csf in dollars was calculated by one package of g-csf multiplied by total used days . chi-square, mann-whitney u and kruskal-wallis tests were used for analyses of variance. the percentage of patients who received melphalan mg/m were% , , in groups a, b, c respectively (p = . ).there was no statistically significant difference between the engraftment day of neutrophil and ; platelet and in the groups. (p = . , p = . , p = . , p = . respectively) themedian numbers of g-csf administered days were ( - ), ( - ), ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) in groups a, b, c, respectively .eventhough there was no statistical difference between the numbers of days( p = . ), the total cost in dollars was statistically difference between a vs b and c vs b (both p o . ) and there was no statistical difference between a vs c (p = . ), total cost in dollars as follows: $ ( - $), $( - $) and $( - $) for the group a, b and c respectively. our results demonstrate that biosimiliar gcsf leucostim is highly similar to existing licenced biologic products in turkey with no clinically meaningful difference interms of safety and efficacy. on the other hand it as a biosimiliardoes not have a meaningful impact on the cost savings to the health care system as expected when compared with reference filgrastim. disclosure of conflict of interest: none. in this study, we investigated the roles of prx ii, one of critical peroxidases besides catalase and gpxs, in cml primary cells at diagnosis and remission while patients were treated with sti (signal transduction inhibitor) and tested the same roles in imatinib(im) sensitive ph+ cell lines and resistant cell lines as well. newly diagnosed cml cells, im resistant k cells and parental k cells were treated stis and analyzed western blot assay to detect bcr-abl, phosphorylated bcr-abl and prx protein expression level. we added n-acetylcysteine ( - mm, hr) to k cells to show antioxidant effect of imatinib and analyzed dcf-da detection for intracellular ros level and western blot for prx protein level. mtt assay was performed to detect cell death by nac time-dependent treatment of mm nac( , , , hr). imatinib resistant k cells were established by treatment of gradual increment of imatinib. we also repeatedly investigated the effects of im therapy using prxii overexpressed k cells by transfection. at diagnosis of cml, ros level was elevated and prx ii was either absent or significantly suppressed. as ph chromosomes were decreased with stis, suppressed or absent prxs levels were restored to the level of normal individuals. these findings were also inversely correlated with the level of ph chromosomes in the cases of disease progression and re-remission with further treatment. when sti were treated in ph positive cell line, we found deceased cell survival and ros level by mtt assay and dcf-da methods respectively, but elevated prx ii by western blot. by the treatment of nac into ph+ cell lines, the level of dcf-da was decreased and mtt level was down, but prx ii level was elevated. interestingly, the level of bcr-abl oncogene were decreased in prx ii tranfected cells. meanwhile, we observed that prx ii restoration was mild or weak in imatinib resistant k- , which we established in our lab. the importance of the roles of ros and its prx ii, antioxydant enzymes in cml is further established by our work. our finding may contribute to find a new pathway on which tkis are working besides the mechanisms of atp binding competitively, blocking the binding of abl-bcr kinase to the substrate resulting apoptosis of ph+ cells. furthermore, our finding may be useful to overcome the stis resistant cml in the clinics in the future. disclosure of conflict of interest: none. allogeneic hematopoietic stem cell transplantation for the treatment of mucopolysaccharidosis f shunqiao, s xiaodong and l junhui department of hematology, capital institute of pediatrics, china mucopolysaccharidosis (mps) is a lysosomal storage disorder caused by deficient activity of the iduronate-sulfatase.this leads to accumulation of glycosaminoglycans(gags) in the lysosomes of various cells,which causes progressive multisystem involvement with ensuing death.the aim of this study was to exploit the effect of treatment with allogenic hematopoietic stem cell transplantation and administration of high doses of cyclophosphamide early after haplobmt in these cases. we retrospectively reviewed data from mps patients ( cases mps ii, and case mps i). the two mps ii patients were -month-old and -month-old boy and the mps i patient is a -month-old girl at the time of transplantation. the reduced-intensity of bu+flu conditioning regimen in allo-hsct for these patients was as follows: busulfan mg/kg at - days before transplantion,fludarabine mg/m at - days before transplantion.graft-versus-host disease(gvhd) prophylaxis:rabbit antithymocyte globulin . mg/kg daily at - days before transplantation,shortcourse methotrexate,posttransplantation high-dose cyclophosphamide on days + and + was followed by mycophenolate mofetil and cyclosporine.the donors all were their hlahaploidentical father. these three patients' neutrophil engraftment occurred on + d, + d and + d after transplantation respectively, platelet engraftment occurred on day + d, + d and + d after transplantation respectively.complete donor type engraftment was confirmed by short tandem repeat-polymerase chain reaction(str-pcr) on day after transplantation. no regimen-related toxicity occurred,gvhd and graft failure were not observed. month after transplantation, the activity of the iduronate-sulfatase was increased to normal. the motion of metacarpophalangeal joints ameliorated, regression of hepatosplenomegaly, the neurocognitive function improved. allogeneic hematopoietic stem cell transplantation is an effective measure to treat patient with mps at least mps ii and mps i. the reduced-intensity conditioning regimen was helpful to decrease the regimen-related toxicity. posttransplant cyclophosphamide approach successfully used and reduced the incidence of gvhd. this study aimed to evaluate the feasibility of alternative donor hematopoietic stem cell transplantation (hsct) using busulfan, fludarabine, and thymoglobulin conditioning for patients with chronic granulomatous disease (cgd) who lack an hla-matched familial donor. medical records of consecutive patients who received alternative donor hsct between may and may were reviewed, and the transplant-related outcome measures were analyzed retrospectively. the donor source was unrelated peripheral blood (pb) in , unrelated cord blood (cb) in , and haploidentical father in patients. only transplants ( / allele-matched unrelated pb) were hla-matched according to current standards relevant to the donor type. the conditioning regimen was uniform; fludarabine mg/m on days - to - , busulfan . mg/kg/d (or mg/m /d) on days - to - , and thymoglobulin . mg/kg/d on days - to - (or on days - to - in cb recipients). all but one patient were male and their median age at transplantation was . y (range: . - . ). one patient who received a cord blood graft suffered from primary engraftment failure, while the other patients were successfully engrafted with their chimerism levels ranging from % to % (median %) at month post-transplant. the median days to neutrophil and platelet engraftment were . (range: - ) and (range: - ), respectively. among the patients engrafted, one patient experienced secondary graft failure which was rescued by a second transplantation. the remaining one patient who failed to engraft was also rescued with a haploidentical graft from his mother. eight patients ( %) developed cmv antigenemia, and one of those patients developed cmv hepatitis. three patients developed grade acute gvhd which were manageable. one patient who developed grade hepatic gvhd eventually died. two patients developed extensive chronic gvhd, but became free of immunosuppressants after a complete resolution in one and with remaining stable mild joint contractures in the other. including patients who were rescued by additional transplantation, patients are alive with their latest chimerism levels ranging from . % to % (median %). the estimated -y overall survival rate was . % with a median follow-up of months (range: - ). even though the majority of our cohort underwent a mismatched transplantation, the survival rate was excellent. while conditioning with busulfan, fludarabine, and thymoglobulin seems feasible for alternative donor hsct in patients with cgd, special attention needs to be payed on cmv infection and severe gvhd which might offset the high survival rate. disclosure of conflict of interest: none. diarrhea is a common infectious complication in patients who had hematopoetic stem cell transplantation so, we aimed to detect entamoeba histolytica ratio before engraftment, amoung patients who had diarrhea after periferic hematopoetic stem cell transplantation (phsct) in our clinic. allogenic phsct patients had a median age of (range: - ) and autolog phsct patients had a median age of (range: - ). diarrhea is described as an abnormal increase in the frequency ( or more times per day), volume or liquidity of stools. we based upon this description in this study. we made stool examination in the first day of diarrhea. as stool examination, we used direct microscopic evaluation and adhesin antigen test specific for e.hystolytica with enzyme linked immunosorbent assay (elisa), e. histolytica ii, techlab, blacksburg, usa). we accepted e.hystolytica positivity as detecting cyst or/and trophosoit in stool and antigen test positivity at the same time. in our study, of patients had diarrhea in the first days of phsct. diarrhea was found in of in autologous phsct patients (% ), of patients in allogenic phsct with non-myeloablative conditioning regiment (% ) and of patients in allo phsct with myeloablative conditioning regiment (% ). diarrhea occured at + th day of transplantation and the median duration of diarrhea was days. e. histolytica positivity was found of patients ( %) who underwent phsct within first days of transplantation. infection is an important mortality and morbidity factor for patients who had hematopoetic stem cell transplantation, when especially before engrafment (between - days). autologous phsct patients were elderly, with poor self-care and low socioeconomic status individuals. e. hystolytica is a frequent pathogen in posttransplant diarrhea at endemic regions. prophylactic metronidasole treatment should be used routinely for autologous phsct as in allogenic phsct. patients and companions sholud be tested for e.hystolytica before autologus/allogenic phsct in endemic regions. prophylactic treatment for amebiasis and scanning patient/companions could be a part of solution for post phsct diarrhea. despite the emergence of disease modifying therapies (dmts) for multiple sclerosis (ms) a cohort of patients with aggressive disease have ongoing progression/relapse, associated with progressive disability. autologous haematopoietic stem cell transplantation (ahsct) has been used worldwide for aggressive ms with inflammatory changes on mri. we update on a uk single centre experience of ahsct in ms. a retrospective audit of ahsct performed for ms from to at uk centre (king's college hospital) was undertaken. patients were selected for transplantation based on persistent clinical relapses (relapsing-remitting ms) or secondary progressive neurological disability with mri lesion activity despite use of at least dmt. primary progressive patients were also eligible if new/active mri lesions were demonstrable. followup included clinical evaluation, edss assessment and mri scanning. we report our preliminary findings. as of november , patients ( female, male, rrms, spms, ppms) had received ahsct. mean age at transplant was . years (range: - ). the mean baseline edss was . (range: . - . ). patients underwent cyclophosphamide/atg conditioning, while received beam/atg. whilst conditioning and stem cell infusion were well tolerated there was a high rate of infections, with / patients developing a culture confirmed infection. reactivation of ebv and cmv were observed in a number of patients ( and , respectively) while a number of delayed herpes zoster infections were also seen ( cases of shingles and of disseminated varicella infection in patients who had previously experienced it in childhood). median follow-up was for days ( - ). of patients with a formal month assessment (n = ), had a stable edss, had an improved score (median improvement . , range: . - . ) and had a deterioration in their score (median . , range: . - . ). at months (n = ), had a stable edss, had an improved score (median . , range: . - ) and had a deterioration in score (median . , range: . - . ). at months, two patients assessed both had improvements in edss scores (median , range: . - . ). for patients who underwent mri at month follow-up (n = ), had a stable lesion load, demonstrated improvement in lesions and had a new lesion (the remaining mri was difficult to read due to a high baseline lesion load in this patient). patients had mri's at months; were stable and demonstrated a reduction in lesion load. to date, no patients have developed secondary malignancies or autoimmune diseases. of patients with followup data, / rrms patients experienced suspected clinical relapses following hsct-only one had a new lesion on mri (with no gadolinium enhancement). of the received steroids to treat these relapses (it is unclear if the remaining patient received treatment). patient tried a new disease modifying therapy ( dose of rituximab) following hsct. ahsct in this cohort was feasible with universal mobilisation and harvest. whilst conditioning and stem cell infusion were well tolerated, there was a high rate of infectious complications in the neutropenic phase. however, the transplant related mortality was % despite significant levels of disability amongst this patient cohort. ahsct remains a treatment option to be further investigated in this difficult cohort of patients. disclosure of conflict of interest: none. peripheral blood (pb) stem cells (scs) mobilized with g-csf are the first-choice source for allogeneic transplantation. we carried out a prospective study on healthy donors (hds), to identify donor characteristics that could influence the effectiveness of mobilization with special focus on the value of the basal cd + cell count. sibling hds were analyzed in a prospective study. we tested somatic variables (sex, age, weight, height, volemia) and, basal blood counts (white blood cell, peripheral blood mononuclear cell, platelets, hematocrit, hemoglobin, cd + cell). hds received g-csf subcutaneously at a dose of μg/kg day. two different determinations of cd + cells were done in each donor: baseline (before g-csf administration) and in pb on the morning of the fifth day (after g-csf administration). consecutive hds ( males) with a median age of years were enrolled. the mean value of cd +on day was . cells/μl, while the median value was . cells/μl. we performed two multivariate analyses either by using median regression (to predict the median value of cd +on day ) according to the values of cd + at baseline, the first adjusted by gender, age and blood volume and the second by gender, age and bmi. results of both models indicate that from basal cd + values o = to values ranging between and cells/μl, predicted median values of cd + on day significantly increase, from . to . cells/μl for model adjusted by blood volume, and from . to cells/μl for model adjusted by bmi. baseline, pb cd + cell count correlated with the effectiveness of allogeneic pbscs mobilization and could be useful to plan the collection. disclosure of conflict of interest: none. comparison of efficacy between chemotherapy plus granulocyte colony stimulating factor (g-csf) and chemotherapy plus g-csf and granulocyte-macrophage colony stimulating factor (gm-csf) for mobilization of peripheral blood stem cells (pbsc) and hematological recovery post-transplantation in patients with multiple myeloma (mm). a retrospective study of autologous peripheral blood stem cell (apbsc) mobilization data of mm patients who treated with chemotherapy plus g-csf or chemotherapy plus g-csf and gm-csf from may to july . the mobilization efficacy and hematopoietic recovery were analyzed. a total of stem cell mobilizations were performed in mm patients. in the univariate analysis, successful collection rate of single harvest in female and in patients at iss stage iii, r-iss ii/iii and chemotherapy plus g-csf was lower(po . ). however, age(≦ yrs vs yrs), subtype, d-s staging (i+ii vs iii), cycles of chemotherapy before mobilization (≦ cycles vs cycles), disease phase before mobilization (pr vs cr) and interval diagnosismobilization (≦ months vs months) were not correlated with the cd + cell collection and successful mobilization rate(p＞ . ). in the multivariate model, rate of successful mobilization in patients who received chemotherapy plus g-csf+gm-csf mobilization regimen was high (or = . , %ci . - . ). the effect of mobilization regimen remained significantly (p = . ). all patients successfully underwent hematopoietic reconstruction without transplantation-related mortality. chemotherapy plus g-csf +gm-csf mobilization regimen can significantly increase the effect of apbsc mobilization and ensure the reconstruction of hematopoietic function after transplantation. this mobilization regimen is a safe and effective method of mobilizing apbsc. disclosure of conflict of interest: none. clinical efficacy of bk virus specific t-cells in treatment of severe refractory hemorrhagic cystitis after hla haploidentical transplantation om pello , a bradshaw , a innes , s-a finn , s uddin, e bray , e olavarria, jf apperley and j pavlu centre for haematology, imperial college at hammersmith hospital, london, uk and department of clinical haematology, hammersmith hospital, imperial college healthcare nhs trust, london, united kingdom hemorrhagic cystitis caused by bk virus (bkv) is a significant complication of allogeneic hematopoietic cell transplantation (hct). it is particularly common in the setting of hla haploidentical transplantation and can be challenging to manage. here we present a post haploidentical hct patient who developed severe bkv haemorrhagic cystitis resistant to standard therapy and who responded to adoptive transfer of donor t cells enriched with anti-bkv specific cells. a year old man underwent hct for acute myeloid leukaemia with inversion of chromosome and monosomy of chromosome while in first complete remission. as he had no related or unrelated hla identical donor, cells from his hla haploidentical sister were used. on day + of this procedure he developed haemorrhagic cystitis. supportive treatment was initiated and cystoscopy showed diffuse bleeding from his urinary bladder with blood clots. urine pcr for bkv showed . billion copies/ml. despite bladder irrigation, local therapy to s bladder mucosa and intravenous hydration, he failed to improve, so treatment with weekly intravenous cidofovir was initiated on day + . his symptoms improved, but on day + he again deteriorated on weekly infusions of cidofovir. his immunosuppression was slowly tapered off without any graft versus host disease (gvhd) but without any significant effect on his hemorrhagic cystitis. he underwent bladder diathermy, was treated with intravesicular hyaluronate and with intravenous cidofovir, but continued to have frank haematuria with blood clots and significant lower abdominal pain. although there was no evidence of obstruction his renal function deteriorated on cidofovir therapy. hence we elected to trial adoptive anti bkv therapy. a leukoapheretic lymphocyte collection was used to prepare an anti-bkv t cell enriched product using the clinimacs prodigy and the cytokine capture system from miltenyi biotec. the eluted product contained % and % of cd + and cd + lymphocytes expressing ifng+ respectively and the cd +/cd + dose adoptively transferred on day + of transplantation was . × /kg. in vivo expansion of anti-bkv t cells in the patient was analysed weekly for the first month using the research grade peptivators bkv lt and bkv vp and the rapid cytokine inspector (cd /cd t cell) kit. bk viral load was monitored by pcr in urine samples twice weekly. ifng+ anti-bkv reactive t cells were undetectable in the patient for the first two weeks after adoptively transfer of donor t cells. twenty days after the adoptive transfer an increase in the cd + ifng+ population was observed, in response to the bkv vp peptivator. this observation correlated in time with a substantial decrease of the urine bkv viremia from . million copies/ml to copies/ml and a complete resolution of patient's symptoms. no gvhd, recurrence of urinary symptoms or any other problems have been observed to date (day + of transplantation, + days after the adoptive transfer). we are not aware of any other reports of successful adoptive anti bkv cellular therapy. our experience suggests safety and efficiency of the use of anti-bkv t cell enriched products using the clinimacs prodigy and the ifng capture system in hla haploidentical hct where bkv cystitis constitutes a significant complication. this opens the possibility of further clinical trials. disclosure of conflict of interest: none. haploidentical donor (hd) has been used as an alternative stem cell source when patients do not have a hla-matched related or unrelated donor. to overcome the hla barrier, haploidentical stem cell transplantation (haplosct) using post-transplantation cyclophosphamide (ptcy) has been conducted. here, we compared the clinical outcomes of haplosct using ptcy with those of unrelated donor transplantation. eighty-two patients ( from hd and from unrelated donor [ud]) who underwent allogeneic hematopoietic stem cell transplantation (hsct) in seoul national university children's hospital from january to june , were analyzed. there were no significant differences between hd and ud patients with respect to median age of patients, sex distribution, and diagnosis [ . %], p = . ). the conditioning regimen of haplosct included targeted busulfan, fludarabine and cyclophosphamide using ptcy, tacrolimus and mycophenolate mofetil for graftversus-host disease (gvhd) prophylaxis. all patients showed engraftment except for a patient who underwent unrelated hsct. neutrophil engraftment of ud was faster than hd (median days versus . days, respectively, po . ). however, there was no significant difference of platelet engraftment. incidences of complications, such as hepatic venoocclusive disease, cmv infection, and hepatic dysfunction, between both groups, were comparable, except hemorrhagic cystitis (hd: . %, ud: . %, p = . ). moreover, cumulative incidence of acute gvhd (hd: . %, ud: . %, p = . ), severe chronic gvhd (hd: . %, ud: . %, p = . ), relapse (hd: . %, ud: . %, p = . ) and non-relapse mortality (hd: %, ud: . %, p = . ) were not significantly different. the overall and event-free survival of hd and ud were . % vs . % (p = . ) and . % vs . % (p = . ), respectively. the clinical outcomes of haplosct using ptcy were comparable with those of ud, and a trend of lower cumulative incidence of severe chronic gvhd and non-relapse mortality was encouraging. it could be a promising alternative therapeutic option in pediatric hsct. disclosure of conflict of interest: none. , median number of apheresis procedures was , ( - ), median amount od dmso infused ml ( - ). time to engraftment was median days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . statistical comparison between cryopreserved pbsc grafts and bm showed benefit for pbsc in the terms (po . ) of faster engraftment, less infective complications, less transfusion support and less hospital stay. in patients ( %) dmso related events were not registered during graft administration. in patients ( %) mild to moderate dmso related events were registered, as nausea in patients ( . %), vomitus in patients ( %), tachycardia in ( . %), hematuria in patients ( %) and patients ( . %) with bradycardia, hypotension, fever and high temperature during graft infusion. cryopreservation of stem cells is a feasible procedure at our institution. there are some issues that have to be improved. the process is standardized with achieved engraftment in all transplanted patients. disclosure of conflict of interest: none. effectivity of a fludarabine based conditioning regimen in allogenic hematopoietic stem cell tranplantation for patients with severe aplastic anemia and over twenty years old p mustafa , , k melya pelin , s handan haydaroglu and g ilknur gaziantep university, faculty of medicine, department of internal medicine; hematology and bone marrow tranplantation unit, gaziantep, turkey severe aplastic anemia (saa) is an anemia with bone marrow hypocellularity and caused by hematopoietic stem cell failure ( ) . allogenic periferic hematopoietic stem cell transplantation (aphsct) is a curative treatment choice ( ) . although cyclophosphamide (cyc) and anti thymocyte globulin(atg) is accepted as standart conditioning regimen, especially for patients with high rejection risk, using fludarabin (fu) based regimens show increased successful engraftment ratio with minimal toxic side effects ( ) . to the study, saa patiens who were transplanted from hla matched sibling donors between the years - were included. the patients comprised of male (% ) and female (% ). median age was (range: - ). the median time from diagnosis to transplantation was (range: - ) months. conditioning regimen consisted of cyc ( mg/m ), fu ( mg/m ), atg (fresenius rabbit, mg/kg). the median dose of stem cells was × stem cell/kg (range: - ). methotrexate ( mg/ m given four days) and cyclosporine (cyca) ( - mg/kg given months) were applied for graft versus host disease (gvhd) prophylaxis. all patients ecog performance status were good ( - ). prior to transplantation only one of the patients received atg-csa, the others received only supportive treatment. after aphsct, neutrophil engraftment was occured at a median of days (range: - ) and thrombocyte engraftment was occured at a median of days (range: - ). posttransplant graft failure was observed in only one patient at tenth month and this patient had aphsct again from the same donor with the same conditioning regimen. acute gvhd didnot occur in any patient. the (% ) of patients had common chronic skin/oral mucosa gvhd. these patients received methylprednisolone (mp) and/or mycophenolate mofetil (mmf) in addition to the cyclosporine treatment. extracorporal photopheresis was applied to the two patients with chronic gvhd. all chronic gvhd patients had complete response to the immunsupresive treatment with a median follow up time months (range: - ). one patient died from sepsis. at year overall-survival rate was %. fu based conditioning regimen in aphsct with young saa patients has favorable results. fu based regimen might be a gold-standard treatment in the future. cgvhd; tgfb-induced factor homeobox , interleukin receptor gamma, tetra trico peptide repeat domain , carbonic anhydrase i, serpin peptidase inhibitor clade a and myod family inhibitor. we established a -gene model (myod family inhibitor, tgfb-induced factor homeobox , tetra trico peptide repeat domain ) to diagnose cgvhd. our -gene model showed . % sensitivity, . % specificity, . % precision, . % accuracy and . % roc area in diagnosing cgvhd. tgfb-induced factor homeobox increased in expression after rituximab treatment in responders. myod family inhibitor was found to be able to predict rituximab responses in steroid-refractory cgvhd patients. we could demonstrate that gene expression studies were useful in the diagnosis of cgvhd after allo-hsct. we developed a -gene model to diagnose cgvhd. hematopoietic stem cell transplantation (sct) is physically and psychosocially demanding. however, exercise interventions may have positive impact on sentiment and psychological well-being in patients undergoing sct. we report on a prospective, randomized study comparing the influence of a multimedia sensor-based practice with classical physiotherapeutic treatment (pt) on psychological aspects and quality of life (qol). patients undergoing sct were randomized into the control group (n = ) receiving pt or the experimental group exercising on the nintendo-wii (n = ). patients of both groups performed the exercises under the supervision of a physiotherapist and completed the functional assessment of cancer therapy -bone marrow transplantation (fact-bmt), hospital anxiety and depression scale (hads-d) and distress thermometer at the date of hospital admission (t ) and on day (t ), (t ) and (t ) after sct. questionnaires were completed by the participants independently and without supervision. groups were compared using the mann-whitney u-test. a p value o . was considered statistically significant. the median age of patients was years in the control group and years in the experimental group. results of fact-bmt generally showed a decline of the qol domains measured on t and t and a raise at t in both groups. physical well-being (pwb) showed the strongest fluctuation of all domains. it declined significantly between t -t in both groups (pt p = . , wii p = . ), followed by a significant increase between t -t (both groups p = . ). however, only in wii-group results of pwb at t ranked significantly above t (p = . ). highest scores were proved for social and emotional well-being (swb/ewb) in both groups. in wii-group ewb increased significantly between t -t (p = . ) and ranked above pt-group at all times. functional well-being (fwb) scored lowest in both groups at all times. the score of bone marrow transplant scale (bmts), the second lowest score in both groups, was always higher in wii-group. the level of distress was comparable between both groups. however, at t distress increased above the cut-off level of in both groups (wii-group p = . , pt-group p = . ). this was accompanied by an increase of anxiety (p = . ) and depression (p = . ) in the pt-group, while both parameters decreased in the wii-group (p = . and p = . ), respectively. anxiety in intervention group , / , / , /, at t /t /t /t stayed below standard group , / , / , / , at all times. depression averaged out at , / , / , / , in physiotherapy group and , / , / , / , in wii-group. to the best of our knowledge, this is the first study to show that exergaming using the nintendo-wii is feasible in the immediate phase after hsct. exergaming may be regarded as beneficial since our data indicate less psychological distress and higher qol in sct recipients exercising with nintendo-wii. therefore, it may be used in addition to pt. disclosure of conflict of interest: none. acute graft versus host disease (agvhd) is the most frequent and serious complication following haematopoietic stem cell transplantation (hsct), with a high mortality rate. a clearer understanding of the molecular pathogenesis may allow for improved therapeutic options or guide personalised prophylactic protocols. circulating micrornas are expressed in body fluids and have recently been associated with the etiology of agvhd, but global expression profiling in a hsct setting is lacking. this study profiled expression of n = mature micrornas in patient serum, using the nanostring platform, to identify micrornas that were dysregulated at agvhd diagnosis. selected micrornas (n = ) were replicated in independent cohorts of serum samples taken at agvhd diagnosis (n = ) and prior to disease onset (day post-hsct, n = ) to assess their prognostic potential. sera from patients without agvhd were used as controls. dysregulated micrornas were investigated in silico for predicted networks and mrna targets. profiling identified micrornas that were differentially expressed at agvhd diagnosis. mir- a (p = . ), mir- b- p (p = . ), mir- - p (p = . ), mir- a (p = . ), mir- a (p = . ) and mir- a (p = . ) were significantly verified in an independent cohort (n = ). mir- a (p = . ), mir- a (p = . ), mir- (p = . ), mir- a (p = ), mir- b ( . ) and mir- (p = . ) were differentially expressed days post-hsct in patients who later developed agvhd (n = ). high mir- b expression was associated with improved overall survival (os) (p = . ), while high mir- a and mir- b- p were associated with lower rates of non-relapse mortality (p = . and p = . ) and improved os (p = . and p = . ). pathway analysis associated the candidate micrornas with haematological and inflammatory disease. circulating biofluid micrornas are dysregulated at agvhd onset and have the capacity to act as prognostic and diagnostic biomarkers. their differential expression in serum suggests a role for circulatory micrornas in agvhd pathology, which warrants further investigation. disclosure of conflict of interest: none. factors associated with medication adherence amongst allogeneic hematopoietic stem cell transplantation recipients j lehrer , e brissot , , a ruggeri , , r dulery , a vekhoff , g battipaglia , f giannotti , c fernandez , , , m mohty , and m antignac ap-hp, hôpital saint-antoine, service de pharmacie, paris, f- ; service d'hématologie et de thérapie cellulaire, hôpital saint antoine, assistance publique-hôpitaux de paris; sorbonne patients with median ages of years (range: - years) between december and march , which including case of primary hlh (homozygous missense mutation in unc d: n = ; homozygous missense mutation in prf : n = ; heterozygous missense mutation in prf in the combination with hemizygous missense mutation in sh d a: n = ; mutation in rab a: n = ; mutation in itk: n = ). cases of unknown causes hlh, cases of lympgoma -hlh (nk/t-cell lymphoma: n = , primary γδt cell lymphoma in skin: n = ; subcutaneous panniculitis-like t cell lymphoma: n = ; primary t cell lymphoma in skin: n = ) and cases of ebv associated hlh. patients achieved cr+pr before hsct, and patients nr. patients were transplanted from hla-haploidentical family donors, from hla-identical sibling donors, and from a matched unrelated donor. conditioning regimen include tbi and non-tbi. the median overall survival rate was . % with a median survival time of months (range: - months). os of primary hlh is . %, os of unknown causes hlh is %, os of lymphoma-associated hlh is %, os of ebv-hlh is . %. os of cr+pr is . %, os of nr is . % patients without engraftment died because of graft failure and toxicity of conditioning regimen. patients with engraftment died. of those, patient died of hsct-associated tma, patient died of grade iv agvdh, patients died of relapsed hlh or organ failure as results from unsuccessful treatment of the progressively elevated ebv-dna load. patient died of tumor relapse, and patient died of infection. acute gvdh occurred in patients with grade i-ii agvdh in patients and grade iii-iv agvdh in patients; chronic gvdh occurred in patients. patients achieved completed chimerism, patients appeared with mixed chimerism,and patient presented with graft failure. of ebv-hlh with engraftment, reactivated ebv infection was found in ( %) with the whole blood ebv-dna load at - copy numbers per ml. ptld occurred in patients confirmed by pathology. after reduced immunosuppressors, negative result of ebv infection was obtained while patients developed gvdh. for ebv-hlh, patients who carry with ebv loading ebvdna ≤ copies/ml before transplantation, overall survival rate was significantly higher than that of ebvdna copies/ml (po . ); who achieved cr+pr os was significantly higher than that of nr (po . ); who range: from diagnosis to transplantion ≤ months os was significantly higher than that of months (po . ). allogeneic hematopoietic stem cell is an effective method for primary hlh and lymphoma-hlh, ebv-hlh,even haploid transplantation. the remission status before transplantation is decisive for the prognosis. disclosure of conflict of interest: none. hepatic veno-occlusive disease after allogeneic hematopoietic stem cell transplantation in a single centre: revised diagnosis and incidence according to new ebmt classification s santarone, a natale, p olioso, g papalinetti, t bonfini, p accorsi, s angelini, g iannetti, m di ianni and p di bartolomeo dipartimento di ematologia, medicina trasfusionale e biotecnologie, bmt center, ospedale civile, pescara, italy sinusoidal obstruction syndrome, also known as venoocclusive disease (sos/vod), is a potentially life threatening complication that can develop early after hematopoietic cell transplantation (hct). in this study we retrospectively investigated the incidence, risk factors and outcomes of sos/vod in transplants, performed in patients between march and may , on the basis of the new diagnostic criteria and classification of the ebmt. the patient's median age was years ( to ). of them, were males and females. patients received one transplant and two transplants. a diagnosis of hematological malignant and nonmalignant disease was present in and cases, respectively. the disease risk at hct was standard in cases, intermediate in and high in . an hla identical sibling donor was used in in cases, an unrelated donor in and a haploidentical family donor in . conditioning was myeloablative in transplants and at reduced intensity in . source of hematopoietic stem cells was bone marrow in transplants and peripheral blood in . we did not limit the diagnosis of sos/vod to the classical days after hct, but all suspicious cases appearing in the first days were evaluated. sos/vod was diagnosed in cases, of which in the first days after transplant and between day and (median day ). their main clinical characteristics are shown in table . the severity of sos/vod was mild in patients ( %), moderate in ( %), severe in ( %) and very severe in ( %). the cumulative incidence (ci) of sos/vod was . + . %. among the most relevant variables studied in univariate analysis (recipient age and gender, ferritin level at hct, type of hematological disease, disease risk at hct, type of donor, number of transplants, time of transplant, drugs used in the conditioning regimen, intensity of the conditioning regimen, source of stem cells), there was no factor with an adverse impact on sos/vod incidence. of patients with diagnosis of sos/vod, ( %) died. sos/vod was the main cause of death in patients and a relevant contributing cause of death in . of relevance, of patients ( %) with severe sos/vod and of patients ( %) with very severe sos/vod died, whereas only one patient with moderate sos/vod died and no patient with mild sos/vod died. among patients with sos/vod, received defibrotide therapy and the best supportive available therapy. defibrotide was given for a median of consecutive days (range: to ), starting at day post-hct (range: to ) with a median total bilirubin level of , mg/dl (range: . - . ). the -year overall survival (os) of patients treated with defibrotide was better as compared to that of patients who received the supportive therapy ( % versus %) although the difference doesn't reach the significance (p = . ). the occurrence of sos/vod does influence significantly the -yr os considering that it was + . % for patients without sos/vod and + % for patients with sos/vod (p = . ). in conclusion, the new ebmt diagnostic and severity criteria for sos/vod has been very useful in identifying patients with severe and very severe forms of this complication. if validated in prospective studies, these criteria will allow an earlier selection of patients requiring immediate therapeutic intervention. [p ] disclosure of conflict of interest: none. the prognosis of patients with newly diagnosed ewing's sarcoma family of tumors (esft) has improved significantly over the last few decades. nonetheless, the long-term survival is still below % patients with high risk features.the role of s high dose chemotherapy and autologous stem cell transplantation (hdct and asct) for high risk and relapsed esft was analyzed. a retrospective medical chart review was done on patients with efst who underwent hdct and asct between september and january at seoul national university children's hospital. indications for hdct and asct included metastasis at diagnosis, bulky primary tumor ( ml), axial/ central primary site, and relapsed disease. single hdct and asct was performed in the earlier period, and the regimen was changed from mec (melphalan, etoposide, carboplatin), to topothiocarbo (topotecan, thiotepa, carboplatin), and to bumel (busulfan, melphalan). tandem hdct and asct was performed in the recent period, st hdct with bumel and nd hdct with modified mec (melphalan, etoposide, carboplatin). twenty-one patients who were diagnosed with esft at a median age of . years old underwent conventional chemotherapy, radiation therapy and/or surgery and received hdct and asct in complete response (n = ) or partial response (n = ). the overall survival of the patients was . % at median . years and the event free survival (efs) of the patients was . % at median . years from the last asct. the efs of the patients who underwent single hdct and asct with mec (n = ), topothiocarbo (n = ), and bumel (n = ) was . %, . % and % respectively. the efs of the patients who underwent tandem hdct and asct (n = ) was . %. seven patients relapsed at median . months from the last asct. despite further treatment, patients died of disease and patients are currently alive without disease. one patient developed acute myeloid leukemia at . months from the last asct and is currently alive without disease after additional chemotherapy, hla-haploidentical stem cell transplantation and donor lymphocyte infusions. one patient died of transplantation-related mortality due to septic shock and lung infection. hdct and asct may be a promising treatment option for patients with high risk or relapsed esft. further refinements may be needed to identify the optimal regimen and number of hdct and asct. disclosure of conflict of interest: none. post transplant cyclophosphamide (pt-cy) has expanded the use of unmanipulated haploidentical grafts which have a high hla disparity between host and donor. one of the consequences of hla disparity is the development of engraftment syndrome (es). this is an immunological reaction characterized by non-infectious fever and skin erythema that develops after neutrophil engraftment. es resembles an infectious process but treatment involves the use of high dose steroids. our hypothesis is that pts undergoing haploidentical transplants (haplo) with pt-cy should have a high rate of es given the high hla disparity between donor and recipient. objectives: to determine the incidence, symptoms, morbidity and mortality of es in patients undergoing haplo with pt-cy at our institution. retrospective analysis of patients with highrisk hematological diseases undergoing haplo with pt-cy at clinica santa maria between november and august . es was diagnosed using the spitzer criteria ( ). es was diagnosed if pts met major criteria or major plus minor criterion. symptoms could occur prior to or after neutrophil engraftment (neutrophils over cells / ul). all patients signed informed consent and the study was reviewed by our institutional review board. patients received haploidentical grafts ( table ) . all patients had neutrophil engraftment at a median of days. / patients ( %) had symptoms that met criteria for es ( table ). / were transferred to icu due to hypoxemia and patient died after diagnosis of es. / pts were treated steroids. all patients received broad spectrum antibiotics during the febrile period and neutropenia. blood cultures, ebv and cmv pcr were negative in all es pts. there were no significant differences in hospital stay or one-year overall survival (os) between patients who developed and pts who did not develop es (median vs. days respectively, p = . ; one-year os % vs. %, p = . , respectively). es is a frequent complication in patients undergoing hsct haplo with pt-cy. the incidence of es in our study was higher when compared to historical full match related donors series and lower when compared to cord blood transplant studies ( ) there was no increased morbidity and mortality associated with es diagnosis. prompt institution of steroids is recommended in es patients after ruling out an underlying infectious process to avoid further complications. haploidentical allogenic hematopoietic stem cell transplants (haplo-hsct) is an alternative transplant procedure for patients with hematologic malignancies that are in need of transplant and do not have a compatible donor. due to the broad hla disparity, the haplo-hsct can be performed with t-cell depletion and megadose of cd +. alternatively haplo-hsct can be performed with non t-cell depleted transplants (t-replete) either in combination with anti-thymoglobuline serum (atg) or post-transplant cyclophosphamide (pt-cy) as gvhd prophylaxis strategy. center effect is a known risk factor for outcomes of haplo-hsct in both t-cell depleted (tcd) and t-replete settings. however, many centers tend to specialize in one gvhd prophylaxis strategy making it difficult to differentiate the treatment effect from the center effect. the objective was to investigate the role of center effects in gvhd prevention strategy, on leukemia-free survival (lfs) and overall survival (os) in a population of adult patients with acute leukemia receiving haplo-hsct. a retrospective multicenter study was conducted on patients reported to the ebmt registry. inclusion criteria were: age years, lymphoblastic or myeloid acute leukemia (all or aml) in first or second complete remission (cr or cr ), receiving a haplo-hsct between and . in this population (n = ), in order to assess the interaction between center and gvhd prevention treatment, we then included in the study selected patients from the centers that had performed more than % of both tcd and t-replete haplo-hsct during the study period. center effects on the outcomes consisted of ) center effect on the baseline risk of event and ) interaction between center and strategy of gvhd prevention. these center effects were estimated using cox mixed-effects models and tested using permutation tests. all models were adjusted on age, cmv statuses, disease (all or aml), secondary leukemia, previous autologous transplant, disease status (cr or cr ), peripheral blood vs. bone marrow transplant, conditioning regimen. after selection, patients were available across centers in europe. one hundred and one ( %) patients received tcd, t-replete haplo-hsct ( ( %) using atg and ( %) using pt-cy). overall, ( %) patients had aml. there were ( %) peripheral blood transplants in the tcd group and ( %) in t-replete. median follow-up was . years. in adjusted analyses, without accounting for center effect, t-replete tended to be associated with better lfs (hazard ratio (hr): . ( %ci . - . ), p = . ) and os (hr = . ( %ci . - . ), p = . ). when center effects were included, there was significant heterogeneity across centers on the baseline risk of both outcomes (lfs: p = . and os: p = . ). when accounting for interaction between center by strategy for gvhd prevention, the effect of t-replete vs. tcd on the outcomes did vary across centers (p = . and p = . for interactions in lfs and os, respectively) ( figure ). we found an interaction between center and strategy for gvhd prevention on outcomes of patients who received a haplo-hsct. the difference between the strategies (tcd or t-replete) varied across centers, in size and direction. this could be in part related to the increase in expertise with each technique in some centers and with the different management of complications, such as infections-related and relapse. disclosure of conflict of interest: none. adherence included recognition of spuriously high levels (typically from contaminated lines) and delayed dose adjustment due to late reporting of levels by the laboratory. the most common cause of unjustifiable non-adherence was failure to increase the dose in response to a low level. inadequate or excessive dose adjustments may be due to lack of experience or unfamiliarity with the sop. two interventions were launched with the aim of improving adherence to the sop for therapeutic tacrolimus dosing. firstly, to provide a rapid and user-friendly calculation method, we developed a mobile phone application (tacrocalc, a dose calculator based upon the sop algorithm) for android and ios devices using python and swift, respectively. secondly, to reduce the number of spuriously high levels, all nurses responsible for specimen collection participated in an educational module delivered by medical and senior nursing staff. key messages included the need to: use only the dedicated colour-coded tacrolimus lumen to infuse iv tacrolimus; avoid sampling from this lumen; sample peripherally when other lumens are known to be contaminated (reasons for this are being explored); suspend infusion of iv tacrolimus minutes before taking a level; send only immediately pre-dose levels for oral tacrolimus. initial re-audit of episodes post intervention (data collection is ongoing) demonstrated a % increase in sop adherence (p = . ; fisher's exact test), with no cases of unjustifiable non-adherence and a significant reduction in spuriously high levels. in conclusion, the use of tacrocalc by doctors and the implementation of targeted teaching for nurses dramatically improved adherence to the tacrolimus sop. this should ultimately improve therapeutic dosing whilst avoiding toxicity, which may result in better transplant outcomes. tacrocalc is now being adapted to include an option for paediatric dosing, with the potential to dose related medications such as cyclosporine. disclosure of conflict of interest: none. king's college hospital, imperial healthcare, charing cross hospital and imperial healthcare, hammersmith hospital managed with calcium and vitamin d alone in / cases ( %) and together with bisphosphonates in / ( %). osteoporosis was managed with bisphosphonates ± calcium/ vit d in / and with calcium/vit d alone in / . / indicated that they would give bisphosphonates in the absence of osteoporosis, if a patient with osteopenia was receiving long term steroids. dissemination and implementation of existing guidance on investigation and managing low bmd post hct appeared to be poor amongst respondents to our survey. routine dxa scanning was underused; the trigger for dxa in the context of steroids is inappropriately high at many centres at mg/kg daily for months; in established osteoporosis, bisphosphonates were used less frequently than would be anticipated. these findings may reflect the limited data on which current recommendations have been made, or the large number of non-transplant guidelines for investigating and managing low bmd which confound management of this post-hct patient group. hematopoietic stem cell transplantation (hsct) still remains as the most efficient therapy for adult patients with acute myeloid leukemia. for older patients and those lacking a hlacompatible donor, autologous hematopoietic stem cell transplantation (auto-hsct) is a valid therapeutic option. authors aimed for determining the effect of auto-hsct for acute myeloid leukemia patients and analyze group of patients who underwent auto-hsct. the study has been set as a retrospective single center study. clinical information included age, gender, aml type and cytogenetic risk. pretransplantation treatment, mobilization and conditioning were analyzed and thus subsequently authors used kaplan and meier method to calculate the actuarial overall survival rate. table describes patients' characteristics. majority of patients received similar induction therapy based on combination of cytarabine and anthracycline. timespan from the diagnosis to auto-hsct varied from days to days, median was days. seventy ( , %) patients received a preparative regimen consisting of busulfan at mg/kg orally, four times daily for days for a total dose of mg/kg administered on day - through day - and melphalan - mg/m intravenously for over hours on day - . patients achieved an absolute neutrophile count (anc) of ≥ . × /l in between to days; median was days. patients achieved not transfused platelet count ≥ × /l in between to days; median was days. median of patients' discharge from hospital was days (range: from to days) since auto-hsct. hundred day mortality after autologous transplant was at . % ( / ). on the date of our evaluation (april , ), patients were alive and in continued cr. the relapse rate was . % ( patients) and patients ( . %) were lost from follow-up. the -year overall survival (os) was . %, so the target median of overall survival has not been reached. [p ] the development of dyslipidaemia is commonly observed after haematopoietic stem cell transplantation (hsct). few data are available concerning lipid profiles over a long followup period or with regard to the different transplantation types (autologous vs. allogeneic) or the effect of multiple transplantations on the development of dyslipidaemia. a retrospective, single center cohort study including adult patients ( years) who underwent hsct at the university hospital basel s - and who survived ≥ days was performed. patients with at least a baseline lipid measurement were included (n = ) and grouped according to the type of their first hsct (autologous or allogeneic). for the examination of the effect of subsequent hscts, patients with consecutive transplantations of the same type were included and other patients were censored when a different transplantation type was performed. serial lipid profiles (total-, ldl-and hdl-cholesterol and triglycerides) before and after transplantation were examined. of the patients, underwent a first, and of these at least one subsequent autologous hsct. underwent a first, and of these at least one subsequent allogeneic hsct. median age of patients at autologous hsct was y (iqr - ) and y ( - ) at allogeneic hsct. % and % were males, median bmi pre-transplant was ( - ) and ( - ). the majority of patients underwent s intensive conditioning before hsct. median follow-up time was . years in the autologous and . years in the allogeneic group, with a maximum follow up time of . and . years, respectively. table shows the number and percentage of patients with dyslipidaemia ( st autologous and allogeneic transplants). the distribution of exact total cholesterol values along with comparisons with baseline measurements according to group are presented in the figure . *% based on number of measurements available total, ldl-and hdl-cholesterol and tg increased within months of transplantation, regardless whether autologous or allogenic transplantation or a first or a subsequent transplantation was performed. the percentage of patients with dyslipidaemia accordingly rose significantly within months of transplantation and persisted throughout follow-up. although patients undergoing an autologous hsct presented with higher baseline values of total cholesterol, a significantly greater increase post-transplant was observed after allogeneic hsct. first and subsequent transplantations seem to behave similarly with respect to changes in lipid profiles. disclosure of conflict of interest: none. nuremberg, erlangen, germany; department of cancer immunology, institute for cancer research, oslo university hospital, radiumhospital, oslo, norway; kg jebsen center for cancer immunotherapy, institute of clinical medicine, university of oslo, oslo, norway; department of haematology and oncology, university hospital of the goethe university, frankfurt, germany and childrens hospital, goethe university, frankfurt, germany natural killer (nk) cells are lymphocytes of the innate immunity with a potent anti-tumor capacity. in tumor patients, such as multiple myeloma (mm) patients, an elevated number of nk cells correlates with a higher overall survival (os) rate. our study adressed nk cells characteristics and anti-tumor ability in mm patients. especially cytotoxicity of patientderived, cytokine-stimulated nk cells against mm cells has been analyzed at various time points (at diagnosis, before/ after chemotherapy and/or auto-sct). nk cells from patients were analyzed by facs after pbmcs isolation via ficoll separation at different time points: tp , before the start of high dose chemotherapy (hdc)/auto-sct; tp , after early leukocyte recovery (leukocytes /μl) and tp : at least weeks after tp . for testing nk cell cytotoxicity against mm cells, nk cells were purified via negative selection and expanded in vitro for - weeks in low doses il- and il- . nk cells were divided into the cd ++ cd − or cd + and cd + cd ++ subsets. while the major nk cell subset at tp was the cd + cd ++ nk cell subpopulation ( . %), after leukocyte recovery at tp cd ++ cd − /+ nk cells were the main subsets (cd − : . %; cd + : . %). we further evaluated the nk cell function upon tumor interaction at the defined time points. cd ++ cd − nk cells were the main subset to produce ifn-γ upon interaction with k cells at all different time points. the percentage of ifn-γ-positive cd + + cd − nk cells was slightly decreased at tp compared to tp but significantly increased from tp to tp (p-value: . ). similarly, mip- β-and cd a-positive cd ++ cd − cells remained constant between tp and tp , whereas their percentages increased from tp to tp [p-values: . (mip β) and . (cd a)]. moreover, in a small group of mm patients, we isolated nk cells and expanded them for - weeks prior to the functional assays. as expected, the expansion rate was reduced after chemotherapy compared to nk cells from healthy controls, but the patients nk cells increased their ability to kill mm cells due to the ex vivo cytokine expansion. conclusion: our data demonstrate that nk cells have an altered phenotype and function after hdc/auto-sct. remarkably, these nk cells were able to secrete cytokines and still displayed cytotoxic capacity against different types of tumor cells. however, as the proliferative capacity of nk cells seemed to be reduced following chemotherapy, innovative nk cell therapeutic approaches further improve the patients nk cell activity by an ex vivo cytokine stimulation procedure. finally, we suggest that an additive cell therapy with cytokinestimulated autologeous nk cells might improve the outcome of mm patients. lymphoid and myeloid acute leukemia are the most frequent type of cancer and the most frequent cause of cancer related death in children. relapse and refractory disease are the main clinical problems that current therapies are still unable to solve. one of the main nk cell activating receptors is nk cell group d (nkg d). nkg d receptor recognizes human mica/ulbp - ligands. these nkg d ligands are expressed in leukemia cells and constitute suitable targets for immunotherapy. the expression of nkg d ligands was analyzed in peripheral blood mononuclear cells from pediatric patients suffering from acute leukemia ( acute myeloid leukemia, b cell acute lymphoid leukemia and t cell acute lymphoid leukemia), as well as in leukemia cell lines (k , rs - , jurkat, nalm- , molt- , reh and cem), by flow cytometry using specific monoclonal antibodies directed against mica, micab, ulbp- , ulbp- , ulbp- and ulbp- , and by quantitative pcr using taqman probes. peripheral blood mononuclear cells from healthy donors were labeled with cd ra microbeads and depleted using automacs device. the hl i r-mndanticd bbz lentiviral vector was derived from the clinical vector cl i r-ef a-hgcopt but contained the extracellular domain of nkg d, the hinge region of cd a and the signaling domains of - bb and cd -z. the cassette was driven by mnd promoter. viral supernatant was produced by transient transfection of hek t cells with the vector genome plasmid and lentiviral packaging helper plasmids pcagg-hivgpco, pcagg-vsvg and pcag -rtr . cytogenetic studies and array comparative genomic hybridization were performed to analyze the genetic stability of lentiviral-transduced memory t cells. the in vitro cytotoxicity of cd ra − t cells against leukemia cells, healthy pbmc and mesenchymal stem cells (msc) was evaluated by performing conventional -hour europium-tda release assays or by flow cytometry using cfse and aad labeling of target cells. nkg dl were heterogeneously expressed in leukemia primary cells and cell lines. for b cell all primary samples, we found expression of mica/b, mica and ulbp decreased in refractory disease compared to remission (p = . , p = . and p = . , respectively). lentiviral transduction of nkg d- - bb-cd z markedly increased nkg d surface expression in cd ra − memory t cells, which became consistently more cytotoxic than untransduced cells against leukemia cells. additionally, no chromosomal aberrations nor cytotoxic activity against healthy pbmc or mesenchymal stem cells was observed in nkg d car expressing t cells. our results demonstrate nkg d-car redirected cd ramemory t cells target nkg dl expressing leukemia cells in vitro and could be a promising and safe immunotherapeutic approach for acute leukemia patients. peripheral blood stem cell mobilization and collection from elderly patients (≥ years) with multiple myeloma: a single center experience g cengiz seval , sk toprak , s civriz bozdag , m kurt yuksel , p topcuoglu , o arslan , m ozcan , t demirer , g gurman , h akan , m beksac and o ilhan clinic of hematology, yildirim beyazit university yenimahalle education and research hospital and department of hematology, ankara university school of medicine high-dose melphalan followed by autologous hematopoietic cell transplantation (auto hsct) has become the standard procedure for patients with symptomatic multiple myeloma (mm). the ability to mobilize stem cells from healthy donors shows little deterioration with age, the influence of patients' age on auto hsct is uncertain and studies in patients' ≥ years are scarce. severe studies specific to mm have failed to show an independent effect of patient age on cd + mobilization. we retrospectively compared myeloma patients below the age of with patients above years of age, analyzing cd mobilization into peripheral blood and the number of leukapheresis needed to collect at least one single stem cell graft. material and methods: from february through april , data from myeloma patients below the age of were compared to myeloma patients above years of age. all these data were obtained from the ankara university faculty of medicine center for therapeutic apheresis and written informed consent was signed according to our institution regulations. most of the patients received only gcsf at a dose of μg/kg bw twice-daily s.c. until stem cell procurement. patients underwent further pbsc collections until we obtained the target dose cd + cells/μl blood. a maximum of collections were performed in the first mobilization; if the cell dose was not achieved, we submitted patients to a second mobilization. fifty two of patients were above years of age (median age , range: - ) and patients were below the age of (median age , range: - ). baseline characteristics of the older and younger patient cohorts are summarized in table . mobilization regimens for the younger patient population were cyclophosphamide based (n: ), g-csf only (n: ) and +plerixafor (n: ). mobilization in the older population was with cyclophosphamide based (n: ), g-csf only (n: ) and +plerixafor (n = ). the chemotherapy regimens were not statistically different between both age groups. there were no significant statistical differences in time from diagnosis to mobilization, number of prior therapies or disease status between both patient groups. the number of cd + circulating cells before scheduled leukapheresis was mean . cells/μl (median cells/ μl, range: - ; sem ± . ) in all patients (including patients who failed mobilization). our data support the observation that after a standard mobilization regimen with anti-myeloma chemotherapy and once-daily growth factor support, patients above years of age show an impaired cd mobilization into peripheral blood compared to a younger population. this can be overcome by an increased number of leukaphereses. still the number of progenitor cells in the actual graft is inferior compared to the younger population. [p ] disclosure of conflict of interest: none. donor and/or recipient citomegalovirus (cmv) seropositivity has been associated with a poor overall survival (os) in patients who have received an allogeneic hematopoietic stem cell transplantation (allohsct). in comparison with seronegative donors, hsct from seropositive donors has been associated with decreased disease-free survival (dfs) and increased non-relapse-related mortality (nrm). we analyzed the prognostic impact of cmv serology status (donor/ recipient) in patients diagnosed with acute leukemia (al) [p ] s who had received an allohsct in our institution. retrospective unicentric study of patients diagnosed with al between and who received allohsct.the following outcomes were studies: os, dfs, and cumulated incidences of relapse (ri), nrm, acute graft-versus host disease (agvhd) and chronic gvhd (cgvhd). the series included patients ( males, females), median age of years . al type: ( %) all, ( %) aml. type of transplant: ( %) related donor, ( %) unrelated donor and ( %) unrelated umbilical cord blood. the majority, ( %), received myeloablative conditioning. stem cells source: peripheral blood ( %), cord blood ( %) and bone marrow ( %). cmv serology status: positive receptor ( %), negative receptor cases ( %); positive donor ( %), negative donor ( %). serology status combinations (d/r): +/+ ( %), +/ − ( %), − / − ( %), − /+ ( %). patients developed agvhd and ( %) cgvhd. the impact of donor/recipient cmv serology status on os, dfs, ri, nrm and incidence of agvhd and cgvhd for the overall series is reported in table . no statistically significant differences were detected in any of the analyzed variables. in this study, donor/recipient cmv serology showed no influence on the analyzed variables os, dfs, al relapse, nrm, acute and chronic gvhd. however, the sample size limits the validity of the results. disclosure of conflict of interest: none. supported in part with the grants pi / from fondo de investigaciones sanitarias and rd / / from rticc, instituto carlos iii and sgr (gre), generalitat de catalunya, spain. petersburg, russia during the last two decades ahsct has been used as a treatment option for ms with promising outcomes. qol is an important outcome of ms treatment. its assessment gives the patient's perspective on the overall effect of treatment. we aimed to study qol in ms patients before and after ahsct and search the value of the data obtained for decision-making. a total of patients with different types of ms were enrolled in the study: mean age- (range- - ) years old; male/ female- / ; mean edss- . (range: . - . ). all patients were treated by ahsct. reduced-intensity beam-like conditioning was used (bcnu mg/m , etoposide mg/m , ara-c mg/m and melphalan mg/m ). mean follow-up was months (range: - months). qol was assessed using generic questionnaire sf- . for comparisons t-test for independent samples or mann-whitney test was used. qol parameters in ms patients at months after ahsct improved in comparison to base-line: physical functioning- . vs . , role-physical functioning- . . further qol improvement was registered at long-term follow-up: integral qol index exhibited . at long-term follow-up as compared to . at base-line. qol improvement was more dramatic in relapsing-remitting ms than in progressive ms. we found a significant increase of all eight sf- scales in a year posttransplant as compared with base-line in relapsing-remitting ms patients (po . ). in progressive ms patients statistically significant improvement was registered for six out of eight sf- scales (except bodily pain and role-emotional functioning) (p o . ). improved qol parameters were preserved over the entire study period in all the patients who did not have disease progression or relapse. in conclusion, qol monitoring in ms patients after ahsct provides clinicians with the unique information regarding the changes in physical, psychological and social well-being of patients who have been treated with this new treatment modality. it allows to evaluate risks/ benefits of ms patients undergoing ahsct and might influence decision-making. further studies are needed to examine the trajectory of qol changes in this patient population to better define treatment outcomes after ahsct. disclosure of conflict of interest: none. pediatric patients with leukocyte adhesion deficiency type-i (lad-i), a rare autosomal recessive primary immunodeficiency disorder, experience severe and recurrent lifethreatening bacterial infections. allogeneic haematopoietic stem cell transplantation (hsct) offers the possibility of curative therapy although the conditioning regimen used for hsct in lad-i is still a controversial issue. this study provides evaluation of outcome of the lad-i pediatric patients who underwent reduced-intensity conditioning (ric) hsct. twenty four patients ( female) with severe lad-i who received hscts between februay and september at our center were enrolled. the median age at hsct was months (range: months- years). patients received bone marrow (n = ), peripheral blood progenitor cells (n = ) or umbilical cord blood grafts (n = ) from hla-matched related donors (n = ), mismatched related or unrelated donors (n = ), unrelated fully matched donors (n = ) and haploidentical relative donors (n = ). ric regimen was provided with fludarabine, melphalan and anti-thymocyte immunoglobulin. cyclosporine a and prednisolon were used as graft-versus-host disease (gvhd) prophylaxis. engraftment occurred in / , of which one patient experienced graft rejection.the median times to neutrophil and platelet engraftments were days (range: - days) and days (range: - days), respectively. with a median follow-up of months (range: - months), overall survival (os) was . %.the main causes of death were gvhd and infection. acute gvhd occurred in ten patients ( grade i-ii, grade iii-iv) and patients also developed chronic gvhd. there were no significant differences in acute gvhd occurence and also os regarding to the stem cell sources. at this time, patients with full chimerism and patients with mixed chimerism are alive and disease free. conclusion: hsct offers long term benefit in lad- and should be considered as an early therapeutic option if a suitable hla-matched stem cell donation is available. as pretransplant infections in primary immunodeficient patients especially those affected by lad- lead to rise in mortality rate, ric regimen is found to be safe and mixed donor chimersim appears sufficient to prevent significant symptoms. disclosure of conflict of interest: none. tregs based immunotherapy may be beneficial in several immune mediated diseases including graft versus host disease (gvhd). the possibility of cryopreserving tregs might lead to the administration of multiple doses, thus potentially increasing their efficacy in chronic diseases. however, there are few and controversial data on the functionality of tregs after cryopreservation. here, we evaluated the phenotype and the inhibitory capacity of thawed tregs. tregs were purified from leukapheresis of normal donors (n = ) by double immunomagnetic depletion (cd and cd ) followed by cd enrichment using the clinimacs system (miltenyi biotec) under gmp condition. the cells were cryopreserved in saline solution containing % human serum albumin (hsa) and % dmso with a controlled-rate freezing. cell viability was assessed by -aad staining. number/phenotype and function were evaluated on fresh and thawed tregs. cryopreserved autologous t effector (teff) cells were used in mlr assays. before cryopreservation the tregs enriched product mean viability was ± % and the mean percentage of cd +cd +cd +cd low and cd +cd +cd +cd lowfoxp + cells was ± % and ± %, respectively. we then analysed the tregs enriched product after thawing. mean viability of thawed tregs, by -aad staining, was ± %. the viable tregs were almost totally cd +cd + ( ± %). the mean percentage of cd +cd +cd low and cd +cd +cd lowfoxp + thawed cells was ± % and ± % respectively. the contaminant cells present in the treg enriched product were mostly cd +cd +cd + (around %). we further characterized the phenotype of the cd +cd +cd low population. this population was almost totally foxp + ( ± %) and expressed selected markers at various degree (cd l ( ± %), cd s ( ± %), cd ra+ ( ± %), hla-dr+ ( ± %), ccr + ( ± %), cd d ( ± %), cd + ( ± . %), cd +cd + ( ± %). notably, viable thawed tregs were able to induce inhibition of autologous teff cells in a : tregs:teff ratio as freshly isolated tregs: ± % (thawed) vs ± % (fresh) of inhibiton (p . ). in conclusion, here we demonstrated that thawed tregs from healthy donors mantain a stable phenotype. in addition, in our hands tregs show good suppressive ability after thawing despite lower expression of cd l and cd s relapsed and refractory malignant b cell diseases: evidence for therapeutic efficacy via subcutaneous administration of anti-cd × anti-cd antibody lymphomun r buhmann, p ruf, j hess, h lindhofer, u jacob and m dreyling the trifunctional antibody anti-cd × anti-cd lymphomun represents a chimeric immunoglobulin scaffold (mouse igg a/ rat igg b) with promising treatment outcome in patients suffering from malignant b cell diseases. by changing the lymphomun administration route from intravenous (i.v.) to subcutaneous (s.c.) the proinflammatory cytokine-mediated side effects were considerably slighter and generally welltolerated. most importantly, s.c. lymphomun showed outstanding responses in b cell depletion even in the absence of elevated cytokine levels (e.g. il- ) that are required for cytotoxic t cell activation. in summary, the clinical tolerability of s.c. lymphomun may result in a considerable improvement of the subjective well-being and in enhanced mobility due to decreased pain symptomatology. intestinal microbiota disruption is associated with acute gastrointestinal (gi) gvhd and inferior outcome in patients after allogeneic stem cell transplantation (asct). the wide use of systemic broad spectrum antibiotics adds a further risk factor contributing to major microbiota shifts. here, in a retrospective analysis of patients undergoing asct at the regensburg university medical center we assessed the relative expression of paneth cell antimicrobial peptides (amps) in human intestinal biopsies in relation to acute gi gvhd and systemic antibiotic treatment. the relative expression of paneth cell amps was significantly higher in biopsies of the upper gi tract than in the lower gi tract for reg α (p ≤ . ), human defensin (hd) (p ≤ . ) and hd (p ≤ . ). regarding the distribution of paneth cell amps in the gi tract we observed significantly higher expressions of all three paneth cell amps in the duodenum, jejunum and ileum compared to the stomach, colon and rectum (po . , figure ). in the presence of acute gi gvhd, paneth cell amps reacted contrarily in the upper and lower gi tract: we observed a decrease of hd , hd and reg α in the upper gi tract (p ≤ . ), similarly paneth cell count dropped in case of severe gi gvhd stage - (po . ). however in the lower gi tract severe acute gi gvhd was associated with an increase of paneth cell amps (p ≤ . ). initiation of additional systemic antibiotic treatment prior to day after asct correlated with a significantly higher expression of hd (p = . ) and reg α (p = . ) in intestinal biopsies compared to patients without or with initiation of systemic antibiosis after day . however, no significant differences were found in terms of hd expression in intestinal biopsies and start of systemic antibiotic therapy. the expressions of hd , hd and reg α in intestinal biopsies seem to respond to major microbiota disruptions caused by acute gi gvhd or systemic antibiotic treatment. while observations in the upper gi tract seem to reflect paneth cell damage, the relative increase in the lower gi tract may indicate inflammatory induction of amps in colonic epithelial cells in the course of gvhd. [p ] disclosure of conflict of interest: none. patients ( %) were in complete remission at the time of pcy haplo-sct. hematopoietic cell transplantation-comorbidity index was ≥ in patients ( %). thirteen patients ( %) received non-myeloablative conditioning regimen (as baltimore schema, luznik et al. bbmt ) prior to haplosct while remaining patients received busulfan-based regimen. all patients were given pcy and both csa and mmf as gvhd prophylaxis. day+ cumulative incidence of grade to and to acute gvhd was % and %. -year cumulative incidence of chronic gvhd was %. the cumulative incidence of non-relapse mortality and relapse at years were % and %, respectively. with a median follow up of months (range: - ), -year progression-free and overall survivals were % and %, respectively. disease status at the time of haplosct was a major determinant for outcome. indeed, year nrm and os were % and % in patients transplanted with active disease, respectively, while corresponding values in patients transplanted in cr were % (p = . ) and % (p = . ), respectively ( figure a and b) . we can conclude that in selected patients who could be candidate for second transplantation, haplosct is feasible and may represent a curative option. the overall incidence of relapse of % is promising in this situation for which no alternative for cure is available, with relatively good survival in patients transplanted in cr. however, the very high nrm ( %) in refractory patients should make us consider second transplant with caution in this setting. for these patients, specific developments are needed to avoid procedure-related toxicity. [p ] disclosure of conflict of interest: none. secondary solid tumors following hematopoietic cell transplantation for thalassemia major a natale, s santarone, a meloni, a pepe, m di ianni, s angelini, p di bartolomeo dipartimento di ematologia, medicina trasfusionale e biotecnologie-ospedale civile, pescara, italy secondary solid tumors (sst) have been described after hct, in particular for patients affected by hematologic malignancies. there is limited information about the incidence of sst following hct for thalassemia major (tm). the aim of this study was to determine the incidence of sst in patients with tm who received hct in our center between and . patients survived more than years after hct and were enrolled in the study. of them, were males and females. their median age at time of hct was years ( - ). as conditioning regimen, they received busulfan ( mg/kg) and cyclophosphamide ( mg/kg). the gvhd prophylaxis included cyclosporine and methotrexate. all patients received bone marrow cells from an hla identical donor. at time of this report, patients were cured, whereas patients rejected their graft and are now under regular transfusion treatment. overall, the median follow-up after hct was years ( - ). seven patients developed a malignancy . to years (median . years) after hct including carcinomas of the tongue, oral squamous cell carcinoma, colorectal cancer, thyroid carcinoma, carcinoma of the uterine cervix, and parotid carcinoma. the -yr cumulative incidence (ci) of developing sst was + . %. all patients underwent surgical resection of the tumor and in addition of them received chemotherapy and/or radiotherapy. of relevance, the patients with cancer of the oral cavity were affected by severe chronic gvhd with buccal cavity involvement. patients ( with parotid and with tongue carcinoma) died of tumor progression and are living. we compared these results with case control populations. first of all, we investigated the occurrence of solid tumors in the individuals ( males, median age years at time of marrow donation), who served as stem cell donors for hct. one donor developed breast cancer years after marrow donation at age of . the -yr ci of developing solid tumor for donors was . + . % with a statistically significant difference (p = . ) as compared to that of transplanted patients. the second case control population consisted of patients affected by tm treated with transfusions and iron chelation. the matching technique applied was based on the variables age and sex. one control per case (transplanted patient) was randomly selected from the miot (myocardial iron overload in thalassemia) registry and matched by sex and age with the transplanted patient population. patients developed an hepatocellular carcinoma (hcc) at age of and years, respectively. one patient died and one is living. using the event rate measure, we observed an event rate of . at years for the transplant group and . for the nontransplant group (p = . ). this study shows that the magnitude of increased risk of sst is twofold to threefold for patients treated with hct as compared with an age-and sex matched nontransplant tm patients or with stem cell donors. notably, among the transplanted patients we didn't observe any case of hcc, which is one of the most frequent solid tumor in nontransplant tm patients, whereas we observed cases of head/neck cancers. in our series, cgvhd seems to be a strong risk factor in the development of new solid tumors. patients with cgvhd, especially those with involvement of the oral cavity, must receive a very long careful monitoring and surveillance in order to prevent the development of secondary cancers. disclosure of conflict of interest: none. sequential treatment with bortezomib plus thalidomide plus dexamethasone followed by autologous hematopoietic stem cell transplantation (hsct); consolidation and maintenance therapy in patients with multiple myeloma a bachiri , ma bekadja , s talhi , s abderrahmani , h ouldjeriouat and r bouhass department of hematology, hmru oran, oran, algeria; department of hematology and cell therapy, ehu st november, oran, algeria and department of hematology and cell therapy, oran, algeria the management of multiple myeloma (mm) has been significantly improved in recent years in young patients, where ahsct and advent of new molecules was introduced as first line treatment. the sequential treatment (induction followed by autologous hematopoietic stem cell transplantation; consolidation and maintenance therapy) has increased rates response (cr and vgpr) as well as the overall survival. our purpose was to assess the efficacy and adverse effects of sequential treatment with vtd chemotherapy and autologous hsct followed by consolidation and maintenance therapy. in a prospective multicenter study, we evaluated this mm management strategy at oran, in two hematology centers. patients aged under years with de novo mm, were treated with induction included: bortezomib ( . mg/m , d -d -d -d ), thalidomide ( mg/ m d -d ) and dexamethasone ( mg, d -d ; d -d ). a total of to cycles where delivered every days. autologous stem cell was mobilized using g-csf alone ( μg/kg/day for days). leukapheresis to harvest stem cells were performed on day - and - . the conditioning regimen consisted of melphalan mg/m . a consolidation phase was initiated two months later with the same protocol (vtd), followed by a maintenance treatment with thalidomide mg/day given orally for months. this study was done over a -years period (january -december ). fifty patients were included. they include women and men (sex ratio = . ). the median age at diagnosis was years ( - ). according to durie salmon staging, % of patients were in stage iii, while % were in stages iii according to iss staging. the monoclonal component was igg in % of patients. postinduction overall response rate in the eligible patients was %, including % vgpr and % cr/ and % pr rates. the median of cd + rate was . x /kg ( . to ). all patients had engraftment on the median of day (range; to ) and platelet transfusion independence on the median of day (range; to ). there was no graft failure. one patient died following the procedure (trm). posttransplantation on day , cr and at least vgpr remained significantly higher ( %). in the evaluable patients, the estimated os at months was %, the estimated dfs at months was % and the pfs at months was . %. at the / / , ( %) patients are alive and ( %) without disease activity after a median follow-up of months (range; - ). the main hematological toxicities post transpland (grade / ) were thrombocytopenia ( %), neutropenia ( %), and anemia ( %). the most frequently observed nonhematological toxicities (all grades) included peripheral neuropathy ( %). our experience suggests that the sequential protocol used in first line produce a better outcome with fewer adverse events and is an interesting therapeutic option in term of efficacy and tolerance. disclosure of conflict of interest: none. micrornas are small, non-coding single-stranded rnas and regulate approximately % of all genes by repressing translation. they are present in bodily fluids, where they are protected from rnase-mediated degradation by encapsulation into extracellular vesicles (evs) and demonstrate a novel capacity to regulate the cellular differentiation of blood cells and immune function. candidate micrornas mir- , mir-- , mir- * and mir- have previously been associated with acute graft versus host disease (agvhd) in posthematopoietic stem cell transplant (hsct) patient plasma. however, validation in independent cohorts is necessary, and their presence within extracellular vesicles (evs) has not been explored. microrna expression was evaluated in a prognostic cohort (n = ) of day (d ) post-hsct patient serum samples by taqman qrt-pcr. further assessment in an independent cohort of serum samples taken at the time of agvhd diagnosis was also performed. expression was also assessed in serum evs at sequential time points (pre-hsct, d , d and d ) and an independent verification cohort of d serum samples by ev isolation, rna extraction and taqman qrt-pcr analysis. this study replicated elevated serum expression of mir- (po . ), mir- (p = . ), mir- * (p o . ) and mir- (p = . ) in agvhd, in a prognostic cohort of d post-hsct patient samples (n = ). expression was also associated with disease severity. further analysis at agvhd diagnosis in an independent cohort (n = ) confirmed high expression of mir- (p = . ), mir- (p = . ) and mir- * (p = . ) at disease onset. investigation of microrna expression patterns during early hsct at sequential time points (pre-hsct to d ) identified elevated micrornas at d post-hsct in all transplant patients. in a novel investigation of microrna expression in serum evs (n = ), mir- (p = . ), mir- (p = . ) and mir- * (p = . ) levels were lower at d in patients who later developed agvhd, and this was replicated for mir- (p = . ) and mir- (p = . ) (n = ). comparing serum to circulating evs, at d patients remaining agvhd-free had significantly higher expression of mir- (p = . ), mir- (p o . ) and mir- * (p = . ) in the ev fraction. results validate the capacity for circulating serum mir- , mir- and mir- * to act as diagnostic and prognostic biomarkers for agvhd. novel findings of differential expression between whole serum and the ev compartment prior to disease onset suggest a role for ev micrornas in the biology of agvhd, which warrants further investigation. disclosure of conflict of interest: none. prior data indicate similar outcomes after transplants from hla-haplotype-matched relatives, hla-idntical siblings and hla-matched unrelated donors. we used our dataset to answer a clinically important question: who is the best donor for a person with acute leukemia. we analyzed data from persons with acute leukaemia in st complete remission treated in a prospective, multi-centre study. patients were randomly divided into training (n = ) and validation (n = ) sets. consecutive subjects received a transplant from an hla-haplotype-matched relative (n = ) or an hlaidentical sibling (n = ). -year leukaemia-free survivals (lfss) were % ( % confidence interval [ci], , %) and % ( , %; p = . ). the multivariate model identified major risk factors for transplant-related-mortality (trm): older donor/recipient age (donor years/recipient years; hazard ratio [hr] = . ; [ . , . ]; p = . ), female-to-male transplants (hr = . ; [ . , . ; p = . ) and donor-recipient abo major-mismatch transplants (hr = . [ . , . ; p = . ). a risk score was developed based on these three features. trms were % ( , %), % ( , %) and % ( , %) for subjects with scores of - , and (p o . ). year lfs were % ( , %), % ( , %), and % ( , %; p = . ). the risk score was validated in an independent cohort. in recipients years, lfss were % and % (p = . ) after transplants from identical-sibling or children. our data confirm donor source or degree of hla-disparity is not significantly correlated with transplant outcomes. selection of the best donor needs to consider donor-recipient age, sex-matching and abo-incompatibility amongst persons with acute leukemia receiving transplants from family members. [p ] disclosure of conflict of interest: none. synergistic effect of kir ligands missing and cytomegalovirus reactivation in improving outcomes of haematopoietic stem cell transplantation for treatment of myeloid malignancies d cardozo, a marangon, r da silva, fj aranha, j visentainer, s bonon, s costa, e miranda, c souza and f guimarães. the lack of one or more hla class i alleles, whose protein products are the ligands for kir receptors, has been exploited as a prognostic factor for the outcome of patients with haematological malignancies treated by haematopoietic stem cell transplantation (hsct). although it has been accepted that kir-hla interactions may influence the outcome of the hlamismatched hsct, there is no consensus regarding the settings of hla-matched transplantation. there are studies that have reported either benefits, or no effects, under the influence of inhibitory kir-hla interactions. additionally, certain activating kirs and/or reactivation of cytomegalovirus (cmv) infection have been reported to affect the outcome of hla-matched transplantation. the goal of this study was to evaluate the influence of kir-hla genotypes on the outcome of patients undergoing treatment for haematological malignancies by non-t-depleted lymphocyte haematopoietic stem cell transplantation (hsct) from hla-matched sibling donors. the prospective study was conducted at the center of hematology, university of campinas, and patients and their donors were followed up from to . kir and hla class i genes were genotyped and patients grouped based on the presence of kir ligands combined with kir genotype of their respective donors. patients with all kir ligands present (n = ) had a significantly higher (p = . ) incidence of acute graft-versus-host-disease (gvhd) than patients with one or more kir ligands missing (n = ). the overall survival following transplantation of patients with myeloid malignancies (n = ) was significantly higher (p = . ) in the group with one or more kir ligands missing (n = ) than in the group with all ligands present (n = ). presence of kir ds was associated with a worsening of hsct outcome while reactivation of cytomegalovirus (cmv) infection improved the outcome of patients with one or more kir ligands missing. our results indicate that kir-hla interactions affect the outcome of the hla-matched transplantation, particularly in patients with myeloid malignancies. disclosure of conflict of interest: none. p = . ), lower disease-free survival (p = . and p = . ) and lower overall survival (p = . and p = . ). one-year cir of the above two groups were . ± . % vs. . ± . % in mrd negative and positive patients, respectively (p = . ). in addition, those who had consistent positive mrd prior to hlamatched sibling hsct showed even worse outcomes compared to patients without pre-mrd. unmanipulated haploidentical hsct might have the stronger graft-versus-leukemia effect compared to hla-matched sibling hsct. it suggested that those who received unmanipulated haploidentical hsct with pre-mrd might not need more intensive relapse intervention after transplantation. disclosure of conflict of interest: none. the retrospective study of allogeneic hematopoietic cell transplantation for patients with mixed-phenotype acute leukemia in toranomon hospital, japan in the real clinical setting, however, there are substantial number of patients who can not achieve cr after chemotherapy. we conducted a retrospective study including such patients to elucidate the outcome of allogeneic hct in toranomon hospital, japan. we studied the patients with mpal diagnosed from july to september . mpal was diagnosed according to who classification in . from june , we examined cytoplasmic myelo-peroxydase (cmpo) routinely for flowcytometric analysis in all the patients, to distinguish mpal from acute lymphoblastic leukemia (all). we included the patients who were diagnosed as mpal in toranomon hospital, regardless of their diagnosis or clinical course in the previous hospitals. a total of mpal patients underwent their first allogeneic hct with related bone marrow or peripheral blood stem cells (r-bm/pb) (n = ), unrelated bone marrow (u-bm) (n = ), and unrelated umbilical cord blood (u-cb)(n = ). the median patient age was years (range: - ). the immunophenotype of leukemia cells included cases of b and myeloid (b/my) ( %) and cases of t and myeloid (t/my) cell lineage( %).eleven patients( %) harbored philadelphia chromosome. the remission induction chemotherapy was performed with all-type regimens in patients, and acute myeloid leukemia (aml)type regimens in of patients, patients( %) were not in cr at the time of transplantation. myeloablative conditioning (mac) regimens were used in pantients( %). the -year overall survival (os) rate was . % ( % confidence interval (ci), . - . %). to identify the factors that influenced os, we performed univariate analysis and compared the following pre-transplantation factors: age at the time of transplantation ( o vs. = years), committed immunophenotype (b/my vs.t/my), karyotype (philadelphia chromosome (ph vs.non-ph), disease status at the time of transplantation (cr vs.non-cr), donor cell source (r-bm/pb vs.u-bm vs.u-cb, cb vs.non-cb), and conditioning regimen (mac vs.reduced intensity conditioning). cr at the time of transplantation was extracted as a significant predictive factor for the better os( -year os; cr vs. non-cr, . % ( % ci, . - . %) vs. . % ( % ci, . - . %), p = . ). the cumulative incidence of relapse rate (rr) at years after transplantation was . % ( % ci, . - . %). to identify the factors that influenced relapse rate, we performed univariate analysis and compared pretransplantation factors same as above. harboring philadelphia chromosome was extracted as a significant predictive factor for lower relapse rate ( -year rr; ph vs.non-ph, . %( % ci, . - . %) vs. . %( % ci, . - . %), p = . ). the older patients(p = . ) and the patients in cr (p = . ) also showed a trend towards lower relapse rate. allogeneic hct provided . % of -year os for mpal patients in cr at the time of transplantation. on the other hand, for patients not in cr, year os was approximately %. the use of tyrosine kinase inhibitors along with chemotherapy before transplantation might prevent relapse after transplantation in mpal patients with ph chromosome. disclosure of conflict of interest: none. allogeneic hematopoietic stem cell transplantation (allo-hsct) is a standard of treatment for many patients with hematological malignancies. however, the disease relapse and graft failure after first allo-hsct ( st allo-hsct) lead to poor outcomes almost in all cases. second allo-hsct ( nd allo-hsct) is one of primary options that can decrease the mortality in this group of patients. here we report our experience of patients who underwent nd allo-hsct. the aim of the study was to estimate a clinical efficiency and practicability of nd allo-hsct. we included patients ( males/ females) with acute myeloid leukemia (aml, n = ), acute lymphoblastic leukemia (all, n = ) and myeloproliferative disease (mpd, n = ) who underwent nd allo-hsct for relapse ( , %) or graft failure ( , %) from the same (n = ) or another donor (n = ) between november and october . median age was years (range: - years). three ( %) patients had a matched related donor (mrd), nine ( %) patients had a matched unrelated donor (mud) and three ( %) patients had a mismatched unrelated (mmud) at the second transplant. to evaluate time gap affecting outcomes all patients were divided into two groups: who underwent nd allo-hsct in more/less than months after st allo-hsct. in "less than months" group three patients were re-transplanted for relapse and one-for graft failure, in other group there were seven patients who received nd allo-hsct for disease relapse and four-for graft failure. fisher's exact test were performed to exclude probability of imbalance between groups (p . ). median of overall survival (os) and disease-free survival (dfs) after nd allo-hsct was . months and . months respectively. (see figure a , c) two patients ( . %) developed graft failure and three relapsed ( %). acute graft-versus host disease (agvhd) incidence was extremely low as . % (n = ) even despite use of mud/mmud in % of cases. mortality rate were . % in a group of nd allo-hsct. it should be noted that only ( %) patients died because of disease progression. five patients ( . %) died in complete remission due to severe infections or previous toxicity (e.g. heart failure). the effect of donor change on dfs was not significant (p = , ). our statistical analysis reveal significantly differences in os in patient with long-term interval ( months) between st and nd allo-hsct. median of os in patients who underwent nd allo-hsct in more/less than months after st allo-hsct was , vs , months respectively. (see figure b , d) for hazard ratio (hr) estimation mantel-haneszel approach were used hr for group who were transplanted in less than months from st allo-hsct was . , ( % ci, . s to . , p = . ). as for dfs difference was not significant (p = . ). according to our analysis, performing nd allo-hsct in a period less than months after st allo-hsct seemed not very reasonable due to extremely high mortality even in young patients (hr- . , p = . ). as for "more than months" group it can be considered even despite hla-disparity between donor-recipient pair due to extremely low agvhd rate ( . %). donor change was not associated with better outcome (p = . ) disclosure of conflict of interest: none. hemopoietic stem cell transplantation (hsct) is an effective treatment for many hematologic disorders, and globally over procedures/year are performed in more than countries. however, not all the countries have enough resources and expertise to establish an hsct program, and patients are often forced to emigrate for transplantation, with heavy social and economic consequences. in the year the iuc (an italian ngo) identified the hiwa cancer hospital (hch) in sulaymaniya (iraqi kurdistan) as a possible site for the establishment of a new hsct transplant center. a hsct expert from italy (mi) following a visit to the hch, reported a positive conclusion on the feasibility of an hsct project. this was mainly due to the fact that many of the required technologies were already available at hch, including a -bed positivepressure, hepa-filtered-air clinical unit, last-generation cell separators and a well equipped hla laboratory. following this preliminary survey, a capacity building project was rapidly made and submitted to the italian agency for development cooperation, that approved and funded it in march with the specific aim to cure thalassemia patients either of kurdistan and of the refugees population from syria and other parts of iraq. in april , the joint italian and kurdish team started the project. a first autologous transplant was done in june followed by more autografts (overall, myeloma and lymphoma patients). in october, following appropriate downstaging, a first low-risk thalassemia patient was allografted from her hla-id sibling, followed by more patients. all the patients engrafted promptly, with one death occurring on day + with acute cardiac failure and a major toxicity recorded in a single patient (nhl, severe enterocolitis with perforation) that was successfully treated. the full process for the start-up included the following activities developed during -month time: ( ) s of transplants, the hch group also submitted to ebmt an application for full membership, that was promptly approved. in all this project, the italian counterpart provided over highly-experienced volunteer specialists (physicians, nurses, technicians and one physicist), each with a specific mission plan. despite the many difficulties and obstacles encountered, the clinical results obtained so far appear encouraging, though there is still need to furtherly support the hch in order to make it totally independent. following this intervention, the hch is the only one center performing both auto and allo hsct not only in the iraqi kurdistan region, but also in all the iraqi nation. we conclude that international cooperation may be fruitful also in the field of high-technology medicine, and may contribute to improve the capabilities of centers even in critical geographic areas, representing a valuable instrument also to implement nation-to-nation scientific exchanges. disclosure of conflict of interest: none. the use of plerixafor with g-csf in conditioning regimen for hematopoietic stem cell transplantations with tcr alpha/beta and cd depletion of graft in wiscott-aldrich syndrome patients: a single-center experience b dmitry , l alexandra , s larisa , g elena , s irina , t pavel , k rimma , n galina , m michael and m alexei grade acute gvhd (agvhd) was % ( pts). no pt experienced a grade agvhd. three patients presented a limited form of chronic gvhd ( %). incidence of oral mucositis and gastrointestinal/liver toxicity has been extremely low in this population of patients, even in those with active disease and heavily treated at the time of transplant. eight out of fifteen pts ( %) are alive with a median follow-up of months (range: - m). seven ( %) are in cytogenetic/molecular remission. six out the eight patients who were transplanted in cr or cr are alive ( %), while two out the seven patients who were transplanted in advanced phase are alive ( %). in this preliminary clinical experience, we find that unmanipulated haploidentical transplants with post-transplant cyclophosphamide are a valid alternative and have outcome comparable to unrelated and match sibling transplants, in pts with hematologic malignancies. advanced disease is the only adverse factor for diseasefree survival. we therefore consider this therapeutic option when a match sibling or a / ag mud donor is not immediately available. disclosure of conflict of interest: none. autism spectrum disorder (asd) is a group of neurodevelopmental disorders characterized by impaired social communication and interactions with restricted and repetitive behaviors. although asd is suspected to have either heritable or sporadic genetic basis, its fundamental etiology and pathogenesis are poorly understood. recently researchers have suggested that stem cells have therapeutic potential for asd. wharton's jelly-derived msc (wj-msc) from third-party donors (tpd) have high proliferation and differentiation potential. this cell population has also non-immunogenic and immunomodulatory properties, thus seem to be a promising treatment stem cell source. the polish stem cell bank (pbkm) has provided wj-msc for clinical application in a medical therapeutic experiment for children with asd. twenty-three patients (pts) with asd aged from to . / (median age: years and months), after bioethical committee approval, received intravenous injections of wj-msc, obtained from tpd. the cells were previously collected from healthy newborns, then processed, screened for bacterial contamination as well as endotoxin content, and frozen in liquid nitrogen vapour. wj-msc immunophenotype was confirmed using flow cytometry assay. the pts received from to injections in intervals from to weeks. the average cell dose per infusion was . × ^ /kg of body weight (bw). each pt was examined by the same neurologist at the day of infusion. comorbidities present in some patients: unspecified speech disturbances, flaccid paralysis, flaccid tetraplegia, unspecified encephalopathy, epilepsy, sensorineural hearing loss. one patient was diagnosed with comorbidities: conductive hearing loss and intellectual disability. almost % of pts, after their treatment with wj-msc, revealed positive changes in neurological examination. an improvement in speech was observed in pts and improvement of cognitive functions ensued in pts. what is more, % of children showed progress in self-reliance, social interactions and improved their ability to concentrate. there was a reduction of aggressive behavior in pts and pts have experienced better quality of sleep. there was only one adverse event after wj-msc infusions -psychomotor agitation occurred in hours after the administration. five follow-ups have not yet been completed. the administration of thirdparty donor wj-msc seems to be safe and efficient procedure with promising preliminary results in patients with asd. hematopoietic stem cell transplantation between red cell incompatible donor-recipient pairs red blood cell depletion from bone marrow and peripheral blood buffy coat: a comparison of two new and three established technologies human bone marrow processing using a new continuous-flow cell separation device disclosure of conflict of interest: none. references . zama d, et al. gut microbiota and hematopoietic stem cell transplantation: where do we stand? bmt the kyoto encyclopedia of genes and genomes-kegg metabolites produced by commensal bacteria promote peripheral regulatory t-cell generation disclosure of conflict of interest: none antifungal prophylaxis in hematopoietic stem cell transplant recipients: the unfinished tale of imperfect success guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective differences in aspergillus-specific immune recovery between t-cell-replete and t-cell-depleted hematopoietic transplants toxoplasmosis following allogeneic hematopoietic stem cell transplantation diagnosis of toxoplasmosis after allogeneic stem cell transplantation: results of dna detection and serological techniques implementation of molecular surveillance after a cluster of fatal toxoplasmosis at neighboring transplant centers management of high blood pressure genes for blood pressure a prospective studyon the predictive value of plasma bk virus-dna load for hemorrhagic cystitis in pediatric patients after stem cell translantation cidofovir for bk virusassociated hemorrhagic cystitis:a retrospective study hemorrhagic cystitis after bone marrow transplantation bcsh/bsbmt guideline: diagnosis and management of veno-occlusive disease (sinusoidal obstruction syndrome) following haematopoietic stem cell transplantation drug safety evaluation of defibrotide defibrotide for prophylaxis of hepatic veno-occlusive disease in paediatric haemopoietic stem-cell transplantation: an open-label, phase , randomised controlled trial safety and effects of prophylactic defibrotide for sinusoidal obstruction syndrome in hematopoietic stem cell transplantation disclosure of conflict of interest: none university children's hospital basel, division of paediatric oncology/haematology late complications subcommittee of translated related complications and quality of life wp; clinic of paediatric haemato-oncology, department of women's and children's health, university of padova, italy; department of surgery, division of transplantation division of blood and marrow transplantation, the children's hospital at westmead ovarian function after bone marrow transplantation during childhood pregnancies following high-dose cyclophosphamide with or without high-dose busulfan or total-body irradiation and bone marrow transplantation unmanipulated haploidentical bone marrow transplantation and posttransplantation cyclophosphamide for hematologic malignancies after myeloablative conditioning haploidentical hematopoietic transplantation:current status and future perspectives t-cell replete haploidentical donor transplantation using post-transplant cy: an emerging standard-of-care option for patients who lack an hla-identical sibling donor hematopoietic stem cell transplantation in thalassemia major and sickle cell disease: indications and management recommendations from an international expert panel allogeneic stem cell transplantation for thalassemia major killer-cell immunoglobulin-like receptors reactivity and outcome of stem cell transplant kir b haplotype donors confer a reduced risk for relapse after haploidentical transplantation in children with all kir/hla interactions negatively affect rituximab-but not ga (obinutuzumab)-induced antibody-dependent cellular cytotoxicity reduction of minimal residual disease in pediatric b-lineage acute lymphoblastic leukemia by an fcoptimized cd antibody diagnoses: hodgkin's lymphoma(hl)- pts (refractory ; relapsed ); non-hodgkin's lymphoma(nhl disease status before asct: st (after refractority prior radiotherapy to the mediastinum - / ( . %); heavily pretreated patients with advanced disease (x lines previous treatment) / ( . %). grafts: pbsc - / pts with median of cd +cells- ccnu dose: / pts mg/m ; pt mg/m . engraftment: anc> cells/mkl: median=d+ ( ÷ ), / pts. plt> cells/ mkl: median=d+ ( ÷ ), / pts. full engrafted / pts / pt required a short-term mechanical ventilation ( of them died because of lung infection ad d+ and d+ ) aeruginosa associated sepsis on a background of graft failure); pts ( . %)-d+ and d+ (pulmonary toxicities +infection; both had prior mediastinal radiotherapy). relapse/ progression after asct- / pts ( . %), of them died. pt achieved secondary mds (diagnosed . mo after asct). for this group of pts with relapsed/refractory lymphomas (n= ) -year os= for nhl(n= ) efs= . (se ± . ) lomustine-containing conditioning regimen cem (lomustine, etoposide, melphalan) is effective and feasible in autologous stem cell transplant efficacy and toxicity of a ccnu-containing high-dose chemotherapy regimen followed by autologous hematopoietic cell transplantation in relapsed or refractory hodgkin's disease champlin re reduced-toxicity conditioning therapy with allogeneic stem cell transplantation for acute leukemia idarubicin-intensified bucy conditioning regimen improved survival in high-risk acute myeloid, but not lymphocytic leukemia patients undergoing allogeneic hematopoietic stem cell transplantation: a retrospective comparative study comparison of outcomes of idarubicin intensified tbi-cy and traditional tbi-cy conditioning regimen for high-risk acute lymphoblastic leukemia undergoing allogeneic hematopoietic stem cell transplantation: a single center experience inhibition of cd (il- r alpha) expression and t-cell proliferation by polyclonal anti-thymocyte globulins csf-primed bone marrow transplantation for patients with high-risk hematologic malignancies in an exploratory analysis, os after hct appeared to be longer in the cpx- arm in both age groups. these results suggest that cpx- may provide an effective bridge to successful transplant for a high-risk subgroup of aml patients. support: celator pharmaceuticals, inc., a subsidiary of jazz pharmaceuticals plc consulting ambit biosciences, amphivena therapeutics, ariad, astellas pharma sunesis, tolero; institutional research funding abbvie chiarella and louie: employment celator/jazz; stock jazz pharmaceuticals plc. hoering disclosure of conflict of interest: none. inkt-/nk-/cik-cell (subsets) are important for immunesurveillance. antibody b targets the vα -jα -invariant-t-cell-receptor (tcr) in the cdr -region, which is semiinvariantly rearranged in inkt-cells. we characterized: i.) inkt-/nk-/cik-subsets in pb-samples from healthy donors (n = subsets under stimulation with dendritic-cells of leukemic origin (dc leu ), generated from aml-blasts in mononuclear cells(mnc) and whole-blood (wb, containing soluble/cellular components of pts' pb) with 'cocktails' (dc-generating-methods/kits). . ) compared to healthy mnc (significantly) lower proportions of inkt-cells comparable correlations were seen in adultall-and cll-pts. . ) we quantified inkt-/nk-/cik-subsets before/after mixed-lymphocytecultures (mlc) of t-cell-enriched immune-reactive cells stimulated with mnc/wb (with or without pretreatment 'cocktails' inducing blasts' conversion to dc leu ) from aml-pts. our findings show, that )inkt-/nk-/cik-cells increase after mlc independent of the stimulator-cells-suspension (under the influence of il- ); ) pretreatment of mnc/wb-blasts with 'cocktails' increases inkt-counts and induces a shift in the composition of inkt-/nk-/cik-subsets after mlc, that might correlate with an improved antileukemic potential; ) individual samples showed varying, however higher inkt-, cik-cell-counts after pretreatment with different (especially prostaglandin-containing) 'cocktails'; ) dc-/inkt-/nk-/cikcells-values after mlc were comparable in physiological hypoxia vs normoxia; ) in cases with antileukemic blast-lytic activity after mlc t-/inkt-/nk-/cik-cells were significantly increased-pointing to an involvement of these cells in antileukemic reactions. in summary: ( ) healthy mnc present with significantly higher inkt-/nk-/cik-cells compared to aml/all/cll-leukemic mnc. ( ) subtypes of inkt-cells differ in healthy vs leukemic samples, resembling a shift in the composition of inkt-cells. ( ) amounts of inkt-/ nk-/cik-cells in aml/all/cll-mnc-samples correlate with prognosis. ( ) 'cocktail'-treated aml-blasts (resulting in dc leu ) lead to a shift in t-,inkt-/nk-/cik-cell-counts/compositions, what correlates with improved antileukemic activity against aml-blastspointing to a cross-talk of these cells. proportions of inkt-/ nk-/cik-cells management of philadelphia chromosome-positive acute lymphoblastic leukemia (ph+ all) outcome of allogeneic stem cell transplantation for aml and myelodysplastic syndrome in elderly patients (⩾ years) comorbidity-age index: a clinical measure of biologic age before allogeneic hematopoietic cell transplantation high rate of hematological responses to sorafenib in flt -itd acute myeloid leukemia relapsed after allogeneic hematopoietic stem cell transplantation phase i trial of maintenance sorafenib after allogeneic hematopoietic stem cell transplantation for fms-like tyrosine kinase internal tandem duplication acute myeloid leukemia haematopoietic cell transplantation with and without sorafenib maintenance for patients with flt -itd acute myeloid leukaemia in first complete remission quantitative monitoring of minimal residual disease (mrd) after sct was performed by four-colour flow cytometry and/or real time pcr. the median time of neutrophil engraftment (above . × e /l) was days, % of pts ( / ) engrafted, one patient died in aplazia. non-relapse mortality (nrm) after year and years was % ( / ) and % ( / ). causes of death were refractory gvhd (n = ), infection (n = ) and multiorgan failure (n = ). incidence of acute gvhd was evaluated in pts: % ( / ) of pts had gvhd (grade i+ii in pts, grade iii in pts). incidence of chronic gvhd was evaluated in pts, % ( / ) of pts had gvhd with median follow-up from sct months (range: - ), % of all pts ( / ) were alive ( in remission of cll with mrd negativity, with relapse), pts died ( from nrm, from cll relapse/progression), relapses ( %; / ) occurred. sequential use of chemotherapy and ric regimen with allogeneic sct is safety and effective treatment of high-risk cll with reponse rate % and low nrm. progression-free survival and overall survival at years from sct were % and % department of hematology, hemostasis, oncology and stem cell transplantation hannover deutsche klinik für diagnostik helios klinik wiesbaden, germany; imperial college london at hammersmith hospital du cane road centre for haematology london disclosure of conflict of interest: none. references . sibon d, brice p. optimal treatment for relapsing patients with at our institution, pr-hl is defined as partial response (pr), no response (nr), stable disease (sd), progressive disease (pd), relapsing within months of finishing the planned treatment. progression free (pfs) and overall survival (os) from the day of auto-sct was estimated by kaplan-meier (km) method. from to , patients with aethera trial criteria were identified. male ( %), female ( %), median age at diagnosis: yrs ( - ), at auto-sct: . yrs ( . - )( % o yrs). initial chemo: abvd in ( %). ( %) had radiation therapy (xrt) after initial chemo. response to initial chemo + xrt was refractory disease: ( %), relapse between - months: ( %) and relapse after months: ( %) aethera had % stable disease before sct vs we have only %. aethera months pfs ( % control arm, % brentuximab arm, investigator assessment) and our . % is not much different. despite having similar selection criteria, our median pfs is higher than both aethera trial placebo and experimental arm. clinically, rate of progression in both studies are very high and comparable at months. given the very high cost of this drug and while waiting for survival fifty-nine ( %) and ( %) patients had relapsed and primary refractory chemosensitive dlbcl, respectively. secondary ipi was - in ( %) patients, in ( %) patients and - in ( %) patients. fifty-one ( %) and ( % patients had gcb and abc tumors, respectively. abc patients received more prior lines of chemotherapy than gcb patients ( % vs % received lines of chemotherapy, p = . ). the rest of characteristics were equally distributed between both groups (table ) disclosure of conflict of interest: none disclosure of conflict of interest: none. p upfront autologous stem cell transplantation in patients with diffuse large b cell lymphoma: focused on risk factors for survival and conditioning regimens ds kim association between complete response and outcomes in transplant-eligible myeloma patients in the era of novel agents e jantunen and v varmavuo department of medicine disclosure of conflict of interest: none. and hematology department lenalidomide after stem-cell transplantation for multiple myeloma bortezomib induction and maintenance treatment in patients with newly diagnosed multiple myeloma: results of the randomized phase iii hovon- /gmmg-hd trial disclosure of conflict of interest: none we performed a retrospective study to investigate survival outcomes and toxicities of l maintenance therapy compared with b maintenance in mm patients post-ahct. this study included patients who received ahct for mm between and after induction with l-or b-based therapy. all patients received ahct within months of mm diagnosis and received melphalan mg/m conditioning. patients who received tandem transplantations (autologous or allogeneic) were excluded. only patients initiating maintenance therapy within months post-ahct were included. maintenance therapy was defined as monotherapy with either l or b. the primary outcome was pfs. secondary outcomes were overall survival (os) and treatment-related toxicities. patients received l maintenance and b maintenance post-ahct. at baseline there were no differences in iss stage, ds stage or cytogenetic risk between maintenance cohorts. at time of analysis, % (n = ) receiving l maintenance and % (n = ) on b maintenance experienced disease progression. median time to progression ( . vs . yrs, p = . ) was not significantly different between cohorts. by multivariable analysis, choice of maintenance (l vs b) was not significant for pfs or os. variables significant for improved pfs were iss stage i disease response improved while on maintenance in % (n = ) with l and % (n = ) with b. median os was not statistically different between maintenance cohorts ( . vs . yrs, p = . ). iss stage i/ii vs iii while cytopenias were more common in the l cohort ( % vs %, p o . ). the median follow-up time for survivors was months. these findings suggest that both lenalidomide and bortezomib are equivocal maintenance therapy options for post-transplantation mm patients. choice of maintenance therapy post-ahct for mm did not demonstrate a difference in survival outcomes. based on these data, maintenance choice should be guided by patient specific anticipated tolerance rather than drug type alone. iss stage and post-ahct disease response continue to be significant predictors for outcomes. toxicities recorded on maintenance were as anticipated. length of maintenance therapy may be a significant predictor and warrants further analysis. the analysis was underpowered to disclosure of conflict of interest: none. p real-world multiple myeloma management practice patterns and outcomes in six central and eastern european countries d coriu , d dytfeld , d niepel , i spicka second autologous stem cell transplantation as salvage therapy for multiple myeloma: impact on progression free survival and overall survival second autologous stem cell transplantation: an effective therapy for relapsed multiple myeloma second auto asct for treatment of relapsed multiple myeloma the role of second autografts in the management of myeloma at first relapse moving beyond autologous transplantation in multiple myeloma ebmt data office bortezomib-based versus nonbortezomib-based induction treatment before autologous stem-cell transplantation in patients with previously untreated multiple myeloma: a meta-analysis of phase iii randomized, controlled trials first-line therapy with thalidomide and dexamethasone in preparation for autologous stem cell transplantation for multiple myeloma mechanism of action of bortezomib and the new proteasome inhibitors on myeloma cells and the bone microenvironment: impact on myeloma-induced alterations of bone remodeling boys; girls) with following mds types: refractory cytopenia of childhood- ( %), refractory anemia with excess blasts - pts ( %), refractory anemia with excess blasts in transformation- pts ( %), juvenile myelomonocytic leukemia in pts ( %). the median of age was years ( - years) mac consisted busulfan (bu) mg/kg + cyclophosphamide mg/kg. ric included fludarabine (flu) mg/m + melphalan (mel) mg/m , flu - mg/m + bu mg/ kg. the bone marrow (bm) was used in pts ( %), peripheral blood stem cells (pbsc) in pts ( %), combination of bm and pbsc in pts ( %). -years overall survival (os) was % os was in pbsc group - %; bm group- %, combination of bm and pbsc- % there were two cases of mds, eb- , although erythroid aberrancy can not be found, fc did disclose significant aberrancy on myelomonocytic lineages. on the other hand, all the normal control bm samples revealed no any erythoid phenotypic abnormality. our study suggests this simplified cocktail of -tube, -color, fc is very sensitive and useful in the assessment of erythroid phenotypic abnormalities in mds we analyzed consecutive patients ( % were female, median age of (range: - ) allografted for mds (median ebmt risk score of , median disease risk index of intermediate risk) over a -year period ( - ) with mac conditioning for % and ric for % pfs ± %, grfs ± %, ri ± % and trm similarly, there was not difference between tdep and non tdep patients for -years pfs ( ± % and ± %, p value . ), -years gfrs ( ± vs ± , p value . ) (graph), -years ri ( ± % and ± %, p value . ) and -years trm ( ± % and ± %, p value . ). finally, tdep had no significant impact on -years grade - agvhd when compared to the non tdep ( ± % and ± %, p value . ). it had not either on -years cgvhd ( ± % and ± %, p value . ). our study shows that tdep is feasible on patients undergoing hsct for mds disclosure of conflict of interest: none. p mutational pathway and dynamics may not be prognostic in patients with myelodysplastic syndrome receiving hypomethylating agent pre-treatment for allogeneic stem cell transplantation republic of korea; department of computer science; the donnelly center for cellular and biomolecular research amebiazis after bone marrow transplantation use of a five-agent gvhd prevention regimen in recipients of unrelated donor marrow impact of age on outcomes after bone marrow transplantation for acquired aplastic anemia using hla-matched sibling donors treatment of acquired severe aplastic anemia: bone marrow transplantation compared with immunosuppressive therapy-the european group for blood and marrow transplantation experience disclosure of conflict of interest: none. leukemia, myelodisplastic syndrome, juvenile myelomonocytic leukemia and chronic myelomonocytic leukemia s bondarenko hla-mismatched unrelated (n = , %), and haploidentical (n = , %) donors. response was achieved in % (n = ) of pts after - (median ) courses of hma therapy: complete remission (cr) in ( %), partial remission (pr) in ( %) of pts. stabilization (s) was documented in ( %) pts, in ( %) pts there was disease progression (p) after beginning of hma therapy mismanaging the gift of life: noncompliance in the context of adult stem cell transplantation l'adhésion thérapeutique et at. des lieux en allogreffe de cellules souches hématopoïétiques (csh) dans des services de pédiatrie et d'adulte. rapport de la sfgm-tc predictive validity of a medication adherence measure in an outpatient setting data is limited to small case series, transplant registries and a single prospective multicenter observational study. here we report our institutional experience with auto-hct in patients with hrl. twenty patients with hrl [non-hodgkin = ( %), hodgkin = ( %)] and treatable hiv infection underwent hdt consisting of carmustine, etoposide, cytarabine and melphalan (beam) followed by peripheral blood auto-hct from / to / . in cases rituximab was administered as part of the preparative regimen. patient-, disease-, and transplant-related characteristics are summarized in table . median age was years (range: - ). the median follow-up for surviving patients was months (range: - ) abbreviation: n: number of patients; m: male gender; auto-hct: autologous hematopoietic cell transplant; nos: not otherwise specified; dlbc: diffuse large b-cell lymphoma ara-c), melphalan; cr : first complete remission; cr :second complete remission disclosure of conflict of interest: none. p incidence of secondary primary malignancies (spm) in patients with multiple myeloma m curly , g laurent and k nicolaus city of hope igm ( . %), lines of induction regimens prior to hsct one in pts ( %), two in pts ( . %), in pts ( . %), and missing in pts ( %). induction regimens included imids and proteasome inhibitor (pi)s with alkylating agents in pts ( . %), imids and pis with no alkylating agents in ( . %), and alkylating agents with no imids or pis in ( . %) and missing data in ( %). radiotherapy was used pre hsct in pts ( . %), no radiation in pts ( %) and missing data in ( . %). plerixafor (p) was administered mostly for poor hsc mobilization as defined by the centers number of hsc collected o × in pts ( . %), - in pts ( . %), × in pts ( %), and data missing in ( %). the number of cd + hsc infused o × in pts ( %), - × in pts ( % , × in pts ( %), and missing in ( %). a total of pts developed spm with cumulative incidence of . % ( %ci . , . ) at mo. data are missing in pts ( %) use of radiotherapy, type of induction, hsc cell dose did not influence the cumulative conflict of interest: f. sahebi, none declared, s. iacobelli, none declared, l. koster none declared l. gardaret none declared, n. kroger received research fund from sanofi, curly morris, none declared p interaction between center effect and strategy for gvhd prophylaxis on outcome of t-cell depleted and t-cell replete haploidentical transplant inserm u ecstra team expanding transplant options to patients over years-improved outcome after reduced intensity conditioning mismatched-unrelated donor transplantation for patients with acute myeloid leukemia: a report from the acute leukemia working party of the ebmt nkg d ligands in tumor immunity comprehensive analysis of nkg d ligand expression and release in leukemia: implications for nkg d-mediated nk cell responses nkg d cars as therapy for cancer russian federation high incidence of mixed chimerism with impaired graft function remains a significant issue in patients with wiskott-aldrich syndrome (was) after hsct. simultaneous use of plerixafor with g-scf is efficient in inducing stem cell release and opening of bone marrow niches. the use of plerixafor/g-csf in conditioning demonstrates better levels of donor chimerism in patients with acute myeloid leukemia. we report our experience of plerixafor/g-csf usage in patients with was as an addition to myeloablateive conditioning to improve stem cell engraftment p = , . events were considered: death in patients, graft rejection in patients, mixed myeloid chimerism (less than % donor) in patients. median time of event was , months after hsct ( . - . ) all patients are alive, median fu is months, range: . - . . patients had acute gvhd: -grade (gut), -grade (skin), in both cases resolved after a short course of steroids. all patients had more than % donor chimerism monthly till the time of last fu. the comparison of peripheral blood chimerism (% of donor cells) in was patients transplanted with and without plerixafor/g-csf in conditioning is shown (figure ). the additional use of plerixafor with g-csf references . moratto et al disclosure of conflict of interest: none. is undesirable. fifteen pts ( males, females, median age , range: - years) with high risk hematologic malignancies ( acute myeloid leukemia n. , %; acute lymphoblastic leukemia n , % pretransplant conditioning regimen consisted of thiotepa mg/kg in two days, busulfan . mg/kg in three days, and fludarabine. source of stem cells was g-csf stimulated bone marrow in all. dose of marrow nucleated cells and cd + were . (range: . - . ) × /kg and . (range: . - . ) × /kg respectively. post-transplant cyclophosphamide at mg/kg/ day was given on days and after transplantation, together with cyclosporine (starting at day − until day posttransplant) and mycofenolate (from day + to day + ) modeling autism spectrum disorders with human neurons autism spectrum disorders neurobiology and genetics of autism: a developmental perspective. the development of autism: perspectives from theory and research wharton's jelly-derived mesenchymal stem cells treatment in children with cerebral palsy: our second preliminary results of the clinical application in poland a mucha , k kosterna , m chroscinska-krawczyk , m kotarska , k mitosek-szewczyk , m murzyn the polish stem cell bank cases application potential of bone marrow mesenchymal stem cell (bmscs) based tissueengineering for spinal cord defect repair in rat fetuses with spina bifida aperta sensory neuron differentiation potential of in utero mesenchymal stem cell transplantation in rat fetuses with spina bifida aperta: sensory neuron differentiation of in utero mscs analysis of post allo-hct relapse in acute leukaemia patients, a comparative on second allo-hct and donor lymphocyte infusions g orti , j sanz , i garcia-cadenas , i sanchez-ortega , mj jimenez , p barba , c ferra , r parody , j sierra , ma sanz , s querol and d valcarcel hospital universitari vall d´hebron; hospital universitario la fe; hospital de sant pau i la santa creu; hospital duran i reynals ico, hospital germans trias i pujol ico; hospital germans trias i pujol and banc de sang i teixits acute leukaemia relapse after allogeneic hematopoietic cell transplantation (allo-hct) associates poor prognosis. in this scenario, lowering the tumour burden prior to a second allo-hct ( nd allo-hct) or donor lymphocyte infusions (dli) is essential to improve survival. thus, patients that respond to chemotherapy and subsequently receive a dli or nd allo-hct appear to associate better outcomes compared to patients receiving only chemotherapy, but data regarding this particular group of patients is lacking. we retrospectively analysed a cohort of post allo-hct relapsed acute leukaemia patients, who, after tumour reduction, were treated with either a nd allo-hct or dli. data was collected from centers, patients were consecutively included from to . patients were treated to reduce the tumour burden and received the nd allo-hct or dli on morphological remission or postchemotherapy aplasia. patients ( %) were diagnosed with aml and ( %) with all. patients ( %) underwent nd allo-hct and ( %) received dli. median patient age was ( - ) years. the median follow-up was ( - ) days. since data regarding time from first allo-hct to relapse was unavailable, we calculated the time from allo-hct to nd allo-hct or dli (time to nd allo-hct or dli). median time to nd allo-hct/dli was ( - ) days, and was days and days for nd allo-hct and dli respectively (p = . ). regarding the dli group, the median dli dose was . x / cd + ( . - x ) cells and the mean number of infused dli was . /patient. one-year os was % (se ± %). in os univariate analysis, longer time to nd allo-hct/dli associated better survival rates (p = . ). the -year dfs was % (se ± %). a longer time to nd allo-hct/dli (p = . ) and nd allo-hct compared to dli (p = . ) (figure ) associated better dfs. the -year nrm was % (se ± %). univariate analysis identified pb as stem cell source as linked to better nrm (p = . ). the -year relapse incidence (ri) was % (se ± %). ri univariate analysis related longer time to nd allo-hct/dli (p = . ) to lower ri. on os multivariate analysis, longer time to nd allo-hct/dli was associated to better survival (p = . ). this association was also observed on dfs multivariate analysis (p = . ). table summarizes nd allo-hct and dli univariate analysis. grade ii-iv acute gvhd was diagnosed in ( %) and ( %) patients post nd allo-hct and dli, respectively. chronic gvhd was diagnosed in ( extensive) and patients after a nd allo-hct and dli, respectively. in this study, longer time to nd allo-hct/dli associated better dfs. nd allo-hct (compared to dli) associated better dfs on univariate analysis, but this association was not observed on multivariate analysis. of note, the nd allo-hct group included more patients with longer time to nd allo-hct/dli. this might be explained by nd allo-hct patients relapsing later or by the fact that the preparation of a nd allo-hct might require longer time than dli. results of this analysis warrant further study with larger number of patients.advancing age is associated with worse prognosis in acute myeloid leukemia (aml). intensive induction chemotherapy in patients aged ⩾ years results in lower aml remission rates with increased induction mortality vs younger patients. cpx- is a liposomal formulation of cytarabine and daunorubicin encapsulated at a : molar ratio. a phase iii, randomized, open-label study of cpx- vs + (cytarabine and daunorubicin) in newly diagnosed older patients with high-risk secondary aml showed superior survival in the cpx- arm (hazard ratio . ; p = . ). in that trial, eligible patients went on to allogeneic hematopoietic cell transplantation (hct). an exploratory analysis of those patients by age strata is reported here. patients aged to years with newly p number, composition and/or antileukemic activity of (dc-stimulated) invariant nkt-, nk-and cik-cells is predictive for outcome of patients with aml, all and cll cl boeck # , dc amberger # , f doraneh-gard , w sutanto , t guenther , j schmohl , f schuster , h salih , f babor , a borkhardt myelofibrosis (mf) is a hematolgic malignancy which is characterised by extramedullary hematopoiesis due to bone marrow fibrosis resulting in spleno-and/or hepatomegaly. allogeneic stem cell transplantation (allo-hsct) is the only curative treatment for mf but is associated with therapy related morbidity and mortality. retrospective studies suggested an increase of liver toxcicity in mf patients in comparison to other diseases following allo-hsct. the aim of this prospective study was to evaluate the impact of liver stiffness measured by transient elastography (fibroscan) on liver toxicity after allo-hsct. between and we included patients (male %, female %) who underwent allo-hsct due to primary mf( %), postpv/et-mf ( %) or mf in transformation ( %). the median age of the patients was y@@@ears (range: - ). conditioning regimen was mainly busulfan based reduced intensity. all patients received atg. gvhd prophylaxis was csa/mmf in all patients. stem cell source was peripheral blood in % and bone marrow in % of the patients. donor sources were as follows: mrd ( %), mud ( %) and haploidentical relative ( %). fibroscan was performed prior to conditioning. elevated liver enzymes, bilirubin above the normal value or the onset of veno-occlusive disesae (vod) from the time of conditioning start and within the first post-transplant days were considered as indicators for liver toxicity. the median stiffness of the liver measured by fibroscan on the day before conditioning treatment start was . kpa (range: . - . ). six patients ( %) had prior liver diseases such as cirrhosis (n = ), viral hepatitis (n = ), steatosis (n = ), or vod (n = ). the median onset of liver toxicity was day (range: − until + ). the median bilirubin level of all patients was mg/dl (range: - ). the median ap level was u/l (range: - ), the median ggt level was u/l (range: - ), the median alt level was u/l (range: and the median ast level was u/l (range: - ). the pearson-test revealed a positive correlation between liver stiffness and the elevation of the ap (r = . , p = . ) and ggt levels (r = . , p = . ). the comparison of the median maximum enzyme and bilirubin levels is shown in table . in two patients who developed severe vod requiering defibrotide, the liver stiffness level was . kpa and . kpa, respectively. the patient with the highest stiffness level ( . kpa) developed acute gvhd of the liver, which completely resolved after steroid treatment. only one of those five patients who had stiffness levels kpa died due to liver toxcity and concurrent septic shock, he suffered from viral hepatitis prior to transplantation. liver stiffness measured by transient elastography (fibroscan) positively correlates with the elevation of the cholestatic enzymes ap and ggt in myelofibrosis patients after allo-hsct and may predict liver toxicity. disclosure of conflict of interest: none.[p ]in the era of tyrosine kinase inhibitors (tki) as superior first line treatment in the therapy of cml, the concept of allogeneic hsct has been pushed to the role of salvage therapy. to date, data on allogeneic hsct after tki-therapy are scarcely available. in this study, we report single center data on the outcome of cml patients, for the most part pretreated with tki, who underwent allogeneic hsct between and with a follow-up of months to years. upon obtaining written informed consent patients diagnosed with bcr-abl-positive cml and patients with bcr-abl-negative atypical cml were included in this analysis. the majority of patients underwent myeloablative conditioning regimen. the median age at time of hsct was years with a range: from to years. twenty-one patients were transplanted from a matched related donor, and received stem cell grafts from an unrelated hla-compatible donor. / patients received tki-therapy before transplantation, patients received more than tki prior to hsct. / patients were treated with interferon prior to hsct. twenty-two patients were transplanted due to acceleration or blast crisis. twenty-six patients received an allogeneic hsct in chronic phase (cp, n = ) or complete hematologic (chr, n = ) or cytogenetic remission (ccyr, n = ). kinase domain mutations could be identified in seven patients including t i-mutation in four patients. seven patients showed "major route" cytogenetic aberrations. next to advanced disease status, tki intolerance (n = ) and tki resistance (n = ) were the main indications for hsct after . after a median follow up of years and months, those patients transplanted in cp, chr or ccyr showed an overall survival (os) of %. / patients died in remission and two patients died after cml relapse. after none of the patients transplanted in cp, chr or ccyr died or relapsed so far, with a median follow-up of days. all of these patients received tki therapy prior to transplant. twenty-two patients transplanted in advanced stage cml (bc and ap) had after a median follow up of years an os of %. the difference between survival curves is significant (log rank test p = . ; hr . , % ci of ratio . - . ). prior to transplantation of these patients received a tki-therapy. in this group, four patients died due to cml relapse, one died after development of donor cell leukemia and five patients died in remission. one patient with atypical cml was transplanted in bc and died of progressive disease shortly after transplantation. the other three patients with atypical cml were transplanted in cp-phase. with a median follow-up of days these patients are in ongoing remission. even in times of tkitherapy allogeneic hsct remains a successful and safe therapy option for cml patients with tki intolerance or resistance. patients transplanted in cp or complete remission had an excellent long-term outcome. allogeneic hsct should be considered in tki resistance or intolerance before the development of blast crisis. despite tki therapy, overall survival deteriorates in patients with advanced disease. however, this treatment modality can improve survival rates substantially compared to other available therapies. tkimaintenance therapy could be a possible strategy to prevent cml relapse, although randomized data on tki-maintenance therapy after allogeneic hsct are still lacking.[p ]disclosure of conflict of interest: none. use of first or second generation tki for cml after allogeneic hematopoietic stem cell transplantation: a study by the cmwp of the ebmt y chalandon, s iacobelli , j hoek , l koster , l volin , j finke , jj cornelissen , i yakoub-agha patients (pts) relapsing with cml after allogeneic hematopoietic stem cell transplantation (allohsct) may be treated with tki and/or dli. as nowadays the majority of cml pts would have received at least imatinib prior to transplantation, we were interested in analizing (a) the type of tki used after allohsct, (b) the indication for tki treatment, (c) the outcome of this treatment and d) the temporal relationship with dli if given. pts received tki after first allogeneic hsct for cml. transplants had been performed in cp , n = , ap, n = or for more advanced disease (bc/ cp , n = ) from hla identical siblings (n = ) or ud (n = ) between and . tki given prior to transplant was imatinib (n = ), dasatinib (n = ), nilotinib (n = ), bosutinib (n = ) and ponatinib (n = ). median age at transplant was ( . - ) years, pts ( %) were male. tki post allohsct were given between and . first tki given was either imatinib (n = ), dasatinib (n = ), nilotinib (n = ), bosutinib (n = ) or ponatinib ( ). the indications for tki therapy were the same as for transplantation (n = ), for relapse/progression/ persistent disease (n = ), for prophylaxis/pre-emptive (n = ), planned (n = ), others (n = ) and missing (n = ). median follow-up from start of tki was ( - ) months. the median time interval from transplant to tki was ( . - ) months. it was longer for tki given for relapse/progression with ( - ) months and shorter for tki given for prophylaxis/pre-emptive with . ( . haematopoietic cell transplant (hct) is the only curative approach for scd. due to concerns regarding the toxicities associated with myeloablative conditioning regimens in adults, a non-myeloablative protocol was developed by hsieh et al. (national institutes of health, nih protocol). the use of this novel regimen was able to achieve a curative degree of mixed donor chimerisms with minimal transplant-related complications. the alberta children's hospital (ach) has adopted this conditioning regimen in children due to the efficacy and low rates of toxicities published by the nih group. with generally lower rates of gvhd in younger recipients, our group had no reason to believe rates of toxicities would be greater in a younger population with fewer comorbidities secondary to scd than those described in the nih cohort. to our knowledge, there is no published literature describing the utilization of the nih protocol in a paediatric population. we describe our experience in children with scd who underwent matched sibling donor (msd) peripheral blood hct using nih protocol. this retrospective cohort describes outcomes of msd hct in children with scd who underwent hct with the nih conditioning regimen between - . a total of potential subjects were identified. eight subjects have consented to the analysis to date. msds with either normal haemoglobin or sickle cell trait were considered appropriate for donation. the transplant procedure: the conditioning regimen consisted of alemtuzumab . mg/kg/dose administered subcutaneously daily for five days (days − to day − ). patients received a tbi dose of cgy on day - , with testicular shielding for male recipients. gvhd prophylaxis consisted of a sirolimus load of mg/ m /dose (po) on day − , followed by mg/m /dose once a day starting on day . unmanipulated peripheral blood stem cells were infused on day . sirolimus was used for gvhd prophylaxis post-hct and continued until at least one year. weaning of sirolimus was initiated no earlier than year post-hct and if donor t-cell chimerisms were greater than %. institutional supportive care protocols for scd hct were followed. patients were eligible for early discharge post-hct even prior to neutrophil engraftment. eight patients ( f, m) have been registered on this retrospective study. follow-up ranges from to months post-hct. there were no failed stem cell mobilizations. all patients had donor neutrophil engraftment at a median of days. all patients are currently alive. there have been no cases of graft failure to date and no sickling crises post-hct. one patient has dropping myeloid chimerisms but still % donor. no cases of veno-occlusive disease, idiopathic pneumonia syndrome, cerebral hemorrhage, pres, or posttransplant lymphoproliferative disease were observed. three cases of cytomegalovirus (cmv) reactivation required pre-emptive therapy. only one patient did not initiate sirolimus weaning at year post-hct due to donor t-cell chimerisms of %; this patient is months post-hct and is likely to start weaning sirolimus soon. there have been no cases of acute or chronic graft-versus-host disease. nonmyeloablative conditioning regimen is safe and effective as curative therapy for scd. long-term follow-up of these children to assess organ function post-hct is underway. disclosure of conflict of interest: none.the number of new hiv/aids cases has been declining in developed countries, whereas it is still increasing in japan, with the cumulative number reaching , as of june , . hiv infection is associated with an increased risk of hematological malignancies such as non-hodgkin lymphoma (nhl). autologous hematopoietic cell transplantation (auto-hct) is a treatment option for hiv-infected patients with nhl and multiple myeloma (mm). however, the prognosis after auto-hct in hiv-infected japanese patients remains unclear. the aim of this study is to evaluate the effect of hiv infection on transplant outcomes after auto-hct in japan. using the national database of the japan society for hematopoietic cell transplantation, we retrospectively evaluated patients with nhl (n = ) and mm (n = ) who underwent their first auto-hct between and . presence of hiv antibodyperipheral t-cell lymphomas (ptcl) comprise a heterogeneous group of diseases among which ptcl-not otherwise specified (ptcl-nos) represents the most common histology. patients with ptcl are typically offered high-dose chemotherapy followed by autologous hematopoietic cell transplantation (auto-hct) as front-line consolidation. allogeneic hct (allo-hct) is generally offered in the relapsed setting; however, in selected cases it is also offered as front-line consolidation. no randomized controlled trial (rct) have been performed to date comparing offering an allo-hct versus other treatment modalities either in the front-line or in the relapsed setting. thus, we performed this systematic review/meta-analysis to assess the totality of evidence pertaining to the role of allo-hct in ptcl. search of the literature was undertaken via pubmed and web of science from inception until september , . no search limits were applied but studies presented only in abstract form were excluded. data were collected on treatment benefits (complete remission (cr), progression-free survival (pfs), overall survival (os)) and harms (non-relapse mortality (nrm), grade ii-iv acute graft-versus-host disease (gvhd), and chronic gvhd). the search identified references; however, only studies ( in front-line (n = pts), in relapsed/refractory setting (n = pts)) were eligible based on our inclusion criteria and had extractable data. three studies included both frontline and relapsed/ refractory cases but data for certain outcomes were reported separately. the median follow-up time for studies evaluating allo-hct in the front-line or relapsed/refractory setting ranged from - months and - months, respectively. in the front-line setting, allo-hct resulted in cr rates of % (( %ci = - %), studies, n = pts), pfs rate of % (( % ci = - %), studies, n = pts), and os rate of % (( % ci = - %), studies, n = pts). nrm rate was % (( % ci = - %), studies, n = pts). acute (grade ii-iv) and chronic gvhd rates were % ( % ci = - %), studies, n = pts) and % ( % ci = - %), studies, n = pts), respectively. in the relapsed/refractory setting, allo-hct resulted in cr rates of % (( % ci = - %), studies, n = pts), pfs rate of % (( % ci = - %), studies, n = pts), and os rate of % (( % ci = - %), studies, n = pts). nrm rate was % (( % ci = - %), studies, n = pts). acute (grade ii-iv) and chronic gvhd rates were % ( % ci = - %), studies, n = pts) and % ( % ci = - %), studies, n = pts), respectively. notwithstanding the need to perform a rct to compare the efficacy of allo-hct versus auto-hct as front-line consolidation in ptcl, the results of this systematic review/meta-analysis show very encouraging os rates of % following allo-hct. moreover, allo-hct also offers an encouraging os rate of % in patients with ptcl in the relapsed/refractory setting. the higher nrm rate in the relapsed/refractory setting probably reflects the adverse effect of a higher number of prior prescribed therapies. one of the limitations of our analysis is the inability to analyze outcomes for individual histologic subtypes due to the aggregate nature of the published data. disclosure of conflict of interest: none. high-risk patients with relapse or refractory hodgkin lymphoma do significantly better after hdc auto-sct compared to control arm of aethera trial. mature results from a cohort of patients s akhtar, s rauf, tam elhassan and i maghfoor king faisal specialist hospital and research center, riyadh, kingdom of saudi arabia brentuximab vedotin use in hodgkin lymphoma (hl) patients who had hdc auto-sct has been reported to improve progression free survival (pfs) but not the overall survival (os) in a phase trial (lancet ; : - ). in this trial, after hdc auto-sct, high risk hl patients were randomized to receive placebo (control gp) vs brentuximab (experimental gp) as consolidation therapy. we are reporting our experience of patients with similar selection criteria as control gp. hl patients z yrs who received hdc auto-sct with similar selection criteria as defined in aethera trial were identified that is, patients had at least one of the following risk advanced lymphomas still represent a therapeutic challenge and allo-hsct is among treatment options. between march and august , seventy-three patients (pts) affected by r/r lymphomas ( nhl and hl) underwent an allo-hsct after a treosulfan-based conditioning regimen and sirolimus as calcineurin-inhibitor-free prophylaxis of gvhd. six pts received a mrd, pts a mud, and pts a haplo unmanipulated pbsc. at allo-sct pts were in cr, pts were in pr, and pts had sd/pd; sixty patients underwent autologous sct before allo-hsct. hct-ci was evaluable for pts, had a score ≥ . thirty-three pts received treosulfan and fludarabine reduced toxicity conditioning regimen (rtc) and intensification with other alkylating agent or with gy total body irradiation was added on the remaining pts (myeloablative conditioning, mac). all pts received a backbone gvhd prophylaxis with sirolimus and mycophenolate mofetil; atg or pt-cy or both were added in , , and pts respectively. median numbers of infused cd +/kg and cd +/kg were . × (range: . - . ) and . × (range: . - . ), respectively. median follow-up was months (range: - ); median time to neutrophil ≥ . × /l was days, and days to platelet ≥ × /l. sixteen out of patients with pre-transplant active disease obtained a cr after treosulfan conditioning; nine of them ( hl and b-nhl) achieved durable cr without post transplant treatment. oneand -years os was % and %, pfs was % and % at and years respectively; cumulative incidence of relapse/ progression was % and % at and years. grfs was % and % at and years, respectively. transplant related mortality (trm) was % at days, % at year and for the entire follow-up. the -day cumulative incidence (ci) of agvhd grade ≥ was % and ci of agvhd grade ≥ was %; ci of moderate to severe cgvhd was % at years and for the entire follow-up. no differences in ci of agvhd or cgvhd were found if pts were stratified according to donor type, but ci of moderate-severe cgvhd was significantly higher in pts after mac regimens (p o . ). as expected, the outcome of pts in cr was significantly better compared with active disease, in terms of os (p = . ), pfs (p = . ), ri (p = . ). in multivariate analysis, intensity of conditioning regimen (rtc vs mac), gvhd prophylaxis (use of atg, pt-cy or none), donor sex and age at allo-sct did not impact the transplant outcomes; both os and pfs were reduced by active disease at allo-hsct (hr = . , ci % . - . , p = . and hr = . , ci % . - . , p = . , respectively) and by nhl histology (hr = . , ci % . - . , p = . and hr = . , ci % . - . , p = . , respectively); grfs and ri were impacted only by active disease (hr = . , ci % . - . and hr = . , ci % . - . , p = . , respectively). allo-hsct after treosulfan conditioning and sirolimus gvhd prophylaxis is feasible even in heavily pretreated pts affected by lymphomas. complete remission status before transplant remains crucial for better outcomes and in the era of new targeted treatments should be pursued. disclosure of conflict of interest: none.university of eastern finland, kuopio, finland and department of medicine, kymenlaakso central hospital, kotka, finland autologous stem cell transplantation continues to have an important role in the treatment of patients with multiple myeloma (mm). in mm patients the most commonly used mobilization method is granulocyte-colony stimulating factor (g-csf) ± cyclophosphamide (cy). generally, up to - % patients mobilize poorly with these methods and plerixafor may be used to enhance mobilization. the most important parameter of graft quality has usually been the number of cd + cells, but there are also significant numbers of other cell subsets in the grafts and they may also be of special interest in regard to post-transplant recovery and outcome. for example, a higher number of lymphocytes and nk cells in the grafts has been associated with improved lymphocyte as well as nk cell recovery, respectively. the mobilization methods used seem to affect the graft composition. however, there is currently no prospective data on the effects of plerixafor on the graft composition, post-transplant hematological and immune recovery or outcome in patients with mm. altogether eighty-seven patients with mm were included into this prospective study. seventy-seven patients were mobilized with g-csf ± cy (control group) and ten patients received also plerixafor due to poor mobilization (plerixafor group). in the control group / ( %) and in the plerixafor group / ( %) of patients were mobilized with g-csf+cy (p = . ). there were no statistically significant differences between the groups according to age, gender, paraprotein type, initial iss, induction therapy used or disease status at the time of mobilization. by imwg risk stratification, there were more high risk patients in the plerixafor group ( / vs. / , p = . ). cryopreserved graft samples were analyzed with flow cytometry for t and b cells (cd /cd /cd /cd ) as well as for nk cells (cd /cd +cd ). also, cd + cell subclasses were analyzed (cd /cd /cd ). complete blood counts were evaluated at + days, , , and months posttransplant. to evaluate immune reconstitution, flow cytometry of lymphocyte subsets (t, b, nk) was performed in a subset of patients at , and months after the graft infusion using the same antibody panel as for graft analysis. there were no significant differences between the groups in the number of cd + cells in the grafts. also, the median number of aphereses was two in the both groups (p = . ). the proportion of the more primitive cd + cells (cd + cd + cd -) was significantly higher in the plerixafor group (p = . ). in addition, the number of various lymphocyte subsets analysed was significantly higher in plerixafor group table ). there were no statistically significant differences in the course of hematological recovery. the recovery of blood cd +cd + t cells was significantly faster in the plerixafor group at one at three moths post-transplant. there was no significant difference in the progression-free survival (pfs) (log rank, p = . ) with the median follow-up time of days in the plerixafor group and days in the control group ( . ). in the present study plerixafor added to g-csf ± cy seemed to significantly alter the cellular composition of autologous blood grafts in poorly mobilizing mm patients. hematological recovery was comparable but the cd +cd + t lymphocyte recovery was faster in the plerixafor group. the pfs was comparable between the groups. disclosure of conflict of interest: dr. valtola has received honoraria from sanofi and jansen-cilag. dr. silvennoinen has received a research grant from celgene and janssen, honoraria from genzyme and sanofi and participated in advisory board organized by amgen, janssen and takeda. dr. siitonen has received honoraria from amgen and celgene. dr. jantunen has received honoraria from genzyme, amgen and sanofi and has participated in eu leadership meeting organized by genzyme as well as medical advisory board meeting organized by genzyme and amgen. dr. varmavuo has received consultancy fees from abbvie, roche, celgene, amgen and sanofi. the other authors declare no conflicts of interest. bortezomib after high-dose melphalan as conditioning regimen before autologous stem cell transplantation in patients with multiple myeloma: a comparison with the historical conditioning regimen with melphalan alone ga ferini; ja arbelbide; al basquiera; e nucifora; n schutz; v otero; d fantl hospital italiano d buenos aires, buenos aires, argentinahigh dose of melphalan followed by autologous stem cell transplantation (asct) is the standard of care for younger patients with multiple myeloma (mm). to enhance the efficacy of the conditioning regimen, the intergroupe francophone du myelome added bortezomib to melphalan showing improved response rates, without significant toxicity. bortezomib has shown synergistic effects with melphalan, mainly if the bortezomib is administered hours after the melphalan. since , we have changed our conditioning regimen for patients with mm undergoing asct by adding bortezomib toallogeneic stem cell transplantation (allosct) is a potencially curative option for patients with multiple myeloma (mm). despite the improvement of reduced-intensity-conditioning (ric), transplant-related mortality (trm) remains high. there is no consensus on which graft versus host disease (gvhd) prophylaxis regimen is superior. some studies have suggested that tacrolimus-based prophylaxis is more effective than cyclosporine (csa) in terms of lower incidence of severe acute gvhd (agvhd), with no impact on overall survival (os). herein, efficacy and toxicity between two gvhd prophylaxis regimens is analyzed. we retrospectively analyzed patients (pts) with relapsed mm who received allosct ric in the period from to in a single centre (table ) . population: age, years ( - ); median follow-up: months ( - ). conditioning regimen: allo-ric (fludarabine + busulfan or melphalan regimens) and % was bortezomib-based in the tacrolimus group. donor: matched related ( pts), unrelated ( ), mismatch unrelated ( ) and haploidentical ( ) donor. gvhd prophylaxis: all patients received a short course of methotrexate + csa ( pts, %) or tacrolimus ( pts, %). complete response at transplant was % at csa group and % at tacrolimus group. all pts underwent toxicity related to chemotherapy (mainly mucositis and neutropenic fever) with organ impairment (renal or liver) in % tacrolimus arm as well as pts in csa group. the incidence of agvhd was % and . % in tacrolimus and cyclosporine groups, respectively (p = . ). grade iii-iv agvhd were reported in pts ( %,tacrolimus) and pts ( %, cyclosporine), with severe gastrointestinal and liver involvement. glucocorticoid resistance was observed in % in both groups. patients with refractory agvhd received other immunosuppressive therapies: more than second-lines agents ( ) ( ) ( ) ( ) were necessary in fifty percent of pts in both groups to control gvhd. two patients had to interrupt tacrolimus due to neurological toxicity and suspected thrombotic thrombocytopenic purpura. no patients had to discontinue treatment in the csa arm because of toxicity. the -months os was . % ( % in tacrolimus vs . % in csa (p = . )) and the -months was . %. a total of pts died because of gvhd. during follow-up, only patients relapsed ( and months after allosct, respectively) in csa group. no relapse were seen in tacro group. in our experience, no significant differences were observed between both calcineurin inhibitor in terms of os, toxicity and gvhd incidence. an explanation could be our small number of patients. allosct is an effective therapy for selected patients but it is associated with high rates of gvhd and trm. a long-termsafety and effective prophylactic regimen is necessary as main objective.[p ]disclosure of conflict of interest: none. several parameters, including early lymphocyte, neutrophil, platelet recovery, and infused dose of cd + cells, have been associated with clinical outcome of patients with haematological malignancies. however, their prognostic significance remains uncertain. the aim of current study was to evaluate prognostic significance of clinical and laboratory parameters that might influence survival after autologous stem cell transplantation (asct) in hodgkin lymphoma (hl) and multiple myeloma (mm). this retrospective study included a total of with hl and mm patients (median age years, years, respectively) who underwent asct between november and june . hl patients were conditioned with beam ( . %) and cbv ( . %) regimen, while mm patients received conditioning with high dose of melphalan. high ips (international prognostic score) at diagnosis had . % hl patients and high iss (international scoring system) had . % of mm patients, of which . % had renal impairment. the average of transplanted cd + cells in hl patients was . × /kg (range: - . × /kg), and . × /kg (range: - . × / kg) in mm patients. after asct, favourable treatment response (partial/complete remission) achieved . % hl patients, of whom . % had infused o × /kg cd + cells. median time to recovery of absolute lymphocyte count × /l or greater (alc ) was days (range: - days), recovery of absolute neutrophil count ≥ × /l (anc ) was (range: - days), and platelet recovery ≥ × /l (plt ) was days (range: - days). after asct, . % mm patients achieved favourable treatment response, of whom . % had infused cd + cell dose . × /kg. median time to alc was days (range: - days), anc was (range: - days), and plt was days (range: - days). median follow up of patients with hl was months, while after asct, median event free survival (efs) was months, and overall survival (os) was months. treatment response after asct strongly influenced both efs and os after asct (po . ). in patients who achieved favourable treatment response, os and efs after asct were influenced by infused cd + cell dose (o × /kg vs. ≥ × /kg), prolonged recovery of alc by day+ , plt by day + , and achieving of anc by day + (po . ). multivariate analysis among significant variables showed that infused cd + cell dose was the most important parameter that influenced os and efs (po . ). median follow up of mm patients was months, while after asct, median efs was months and os was months. regarding patients who achieved favourable treatment response, os and efs after asct were influenced by the presence of renal impairment, infused cd + cell dose (≤ . × /kg vs. . × /kg) and plt recovery by day + (po . ). among these significant parameters, multivariate analysis pointed out infused cd + cell dose as the most important parameter that influenced both os and efs (po . ). these data suggest that number of infused cd + cells is an independent factor that may contribute to outcome of patients with hl and mm. disclosure of conflict of interest: none. high-dose therapy with autologous stem cell transplantation (asct) has become the treatment of choice for symptomatic eligible patients with multiple myeloma (mm). we studied an induction regimen of cyclophosphamide, bortezomib and dexamethasone (cybord) and showed rapid and deep responses after cycles in patients with newly diagnosed mm and we subsequently done asct with melphalan (mel) conditioning. cost is the major limiting factor in developing world.all the drugs used are generic brands manufactured in india. a total of mm patients (median age: . years, % male and % female) were transplanted between and . in all, patients had igg kappa- ( %), igg lambda- ( %), iga lambda- ( %), iga kappa- ( %), kappa light chain ( %), lambda light chain ( %) patients. prior to autograft, all cases had received cybord with generic medicines. median time diagnosis to asct was . months ( to months). stem cell mobilization was done with g-csf alone in ( %), g-csf plus plerixafor in ( %) and chemo mobilization in ( %) patients. all patients received asct support after conditioning with mg/m generic melphalan alone (dose adjustment was done according to renal status). all patients received thalidomide maintenance from march . bortezomib used was manufactured by dr. reddy's lab, hyderabad and melphalan used was manufactured by emcure pharmaceuticals, pune, india. patients from to received cyclophosphamide, vincristine, adriamycin and dexamethasone (cvad) protocol of originator medicines followed by originator melphalan conditioning and asct (cvad-mel-asct). at the time of autograft, ( %) of patients were in complete remission, ( %) in partial remission, ( %) very good pr. median day of engraftment was for neutrophils and for platelet. transplant related mortality was % ( / ) out of which died of infection and deaths of cardiac events. the pfs and os rates were % and % at median follow up of . months. patients who were treated with cvad-mel-asct had efs of % at yrs and % at yrs. cost of bortezomib showed significant difference, generic was usd where as for originator drug was usd for cycles of chemotherapy. cost of melphalan also showed difference with usd for generic and usd for originator drug. generic cybord showed excellent response rate and allows excellent stem cell collection and transplantation which can further consolidate response and improve outcome. cybord induction and melphalan conditioning with generic medicines can be considered a standard regimen for transplant-eligible patients with newly diagnosed mm in resource constraint situation. generic cybord-mel-asct is more cost effective than originator cvad-mel-asct. generic medicines produced in india are of good quality and cost effective. this study needs long term follow up to assess survival parameters at a median. disclosure of conflict of interest: none. and an extra copy of one or more odd-numbered chromosomes and as intermediate risk(ir) if they had t( ; ) or del( ) (q).overall survival (os) and relapse-free survival (rfs) were calculated from the time of allo hsct and auto hsct on day , from diagnosis to death or disease progression. the median age at presentation was . (range: - ) years, and ( . %) were men. at a median follow-up time of months, % were alive. of the patients with available fish samples underwent auto hsct. patients ( . %) achieved cr and patients ( . %) relapsed. of the patients who had received allo hsct, five patients ( . %) achieved cr and five patients ( . %) remained alive. in patients who received auto hsct, the risk of relapse was % less than those never transplanted (p = . ), but the difference was not significant in patients who received allo hsct. the relapse-free survival in hr patients was months (po . ), in ir was months (p o . ) and in sr was . months (p o . ). in transplant patients, rfs in hr patients was . times more than sr group (po . ) and in ir group was . times more than sr (p o . ). the survival time in transplant patients was significantly better than non-transplanted patients (p o . ). the median overall survival (os) in hr patients was . months, in standard risk group months and in sr patients was months. cytogenetic abnormalities detected by fish are of significant value in classification, risk stratification and management of patients with mm. we can use cytogenetic data to provide prognostic information and also to guide management and clinical practice. these data indicate that autologous stem cell transplantation could potentially be of benefit to myeloma patients. disclosure of conflict of interest: none. chronic graft-vs-host disease (cgvhd) is the most troublesome complication developing after allogeneic hematopoietic stem cell transplantation (allo-hsct). diagnosis of cgvhd has largely been based on clinical features only. we previously reported gene expression profiles in patients with cgvhd after allo-hsct. we extended our study to develop a molecular diagnostic method of cgvhd. we selected six most commonly expressed genes from the former dna expression study. and, a home-made -gene pcr array were used to evaluate gene expression profiles in the peripheral blood mononuclear cells of patients given allo-hsct ( cgvhd patients, non-cgvhd patients) and normal controls. the gene expressions of the allo-transplanted patients were compared to those of the stem cell donors. sybr green qpcr and multiplexqpcr were performed to confirm the usefulness of the selected genes in the diagnosis of cgvhd. infogainattributeeal and ranker were used to develop a gene model to diagnose cgvhd. k-nearest neighbor model and weka classifiers lazy ibk module were applied to evaluate the performance of the gene model. in another steroid-refractory cgvhd patients ( responders, non-responders), the gene expression changes were analysed using our -gene pcr array before and days after rituximab treatment. we identified six genes most accurately delineating cgvhd patients from those without treatments after allogeneic hematopoietic stem cell transplantation (hsct) are long and constraining for patients. medical adherence in hsct patients is of major concern in daily practice but it has been not yet described. , the aims of our study were to evaluate treatment adherence and to identify factors associated with adherence behaviors. an observational single-center study was based on self-reported questionnaires completed by patients in a hematology day hospital between november and july . the patientreported adherence was evaluated using the eight-item morisky medication adherence scale (mmas- ). , individual item scores were summed: patients with a score of / were considered as good adherents to medication whereas a poor adherence referred to a score under . among the latter, medium adherence ranged to a score of - , while a score of o was considered low adherence. socio-demographic and medical characteristics were collected by health records. a univariate model was used to evaluate if some of patients' characteristics were associated with adherence. statistical analysis was performed using r software (version . . - - rstudio, inc). fifty-six patients were included in the current study. median age at transplantation was years (range: - years). diagnosis were aml (n = ), all (n = ), myelofibrosis (n = ) and other hematological diseases (n = ). patients received a hsct from a related donor ( haploidentical). myeloablative conditioning was used in patients and reduced intensity regimen in patients. a total of . % ( / ) of the patients were poor adherent according to mmas- . among these patients, / were low adherent and / were medium adherent. the results of univariate analysis showed that a poor adherence was associated with a longer time since hsct and discharge at home. however elderly patients, patients treated with cyclosporine and patients with daily hydration at home were associated with a better adherence (po . ). our study presents the first data on adherence among patients undergoing hsct. risk factors associated with a poor adherence have been identified in order to determine patients' profiles that will benefit more from interventions to improve adherence. particular attention has to be paid to younger patients. efforts to establish a regular follow-up of these patients are needed in order to sustain patients in the treatment adherence to prevent the occurrence of severe complications. we studied the effect of basic fibroblast growth factor (fgfb) and dexamethason on expansion and immune modulation of mscs in patients with lymphomas. mscs were generated from bone marrow aspirates obtained from the patients with hodgkin's lymphoma (hl; n = ) and non-hodgkin's lymphoma (nhl; n = ). the adherent fraction of marrow aspirate was cultivated with/without the basic fibroblast growth factor (fgf-b, ng/ml) or dexamethason ( − М or − М) to reach - % confluence. then mscs were passaged with accutase and used for experiments after - passages. the number of msc precursors (cfu-f) in bone marrow of lymphoma patients was found to be significantly decreased both in patients with nhl ( ± , p o . ) or hl ( ± , p o . ). the time until - % confluence was significantly increased and took on average ± days (vs . ± . in donors). finally, the immunosuppressive ability of patient msc was significantly lowered and was only registered at the high concentrations of mscs ( : and : ). the expansion of patient mscs was significantly promoted with fgfb resulting in a significant decrease of primary cell cultivation (from . ± . to . ± . days; p = . ) and a statistically significant twofold increase in the number of cells received at the first passaging. in addition, in cultures with fgfb there was a decrease in the relative amount of resting mscs and a threefold increase of cycled cells in cd + mscs. dexamethasone has also provided a moderate stimulating effect on the msc growth. in fact, the use of − М of dexamethasone resulted in the increase of the cell yield by . times and of − М-by . times. however, fgfb and dexamethasone differed in their effect on the msc ability to inhibit the proliferative response of t lymphocytes upon stimulation with mitogens or alloantigens. indeed, fgfb failed to correct the impaired immunosuppressive activity of patient mscs, and median percentage of suppression still remained lowered- % vs % without fgfb. in contrast to fgfb, dexamethason could increase the immunosuppressive activity of patient mscs by . times (in dose of − М) and by . times (for − М). our data indicate that fgfb and dexamethasone used during the generation of mscs exert a stimulating effect on the msc expansion. in contrast to fgfb, dexamethasone, in the broad range: of doses, was able to enhance the suppressive properties of mscs that are initially reduced in patients with lymphoma. these findings suggest the existence of at least two mechanisms of impairments in immunoregulatory function of mscs in lymphomas-dependent and independent of the msc proliferation. disclosure of conflict of interest: none. free nonabsorbable antibacterial digestive decontamination is associated with a low incidence of gastrointestinal acute gvhd and better gvhd-free/ relapse-free survival (grfs) in the atg-based conditioning regimens nabil yafour commonly antibacterial prophylaxis based of oral no absorbable antibiotic such as (neomycin colistin, gentamicin, vancomycin) used before and after engraftment, other fluoroquinolone such as levofloxacine were recently used to prevent invasive infection. however the exact interaction with gastrointestinal acute graft versus host disease (gi-agvhd) remains unclear. the objective of this study was to evaluate a novel composite endpoint of gvhd-free/relapse-free survival (grfs), in which events include grades - gi agvhd, chronic gvhd requiring systemic therapy, relapse, or death in atg based-conditioning regimens, with free no absorbable antibacterial digestive decontamination prophylaxis. a total of evaluable consecutive patients with hematological disease were included in period of february to mai . patients with malignancies disease (n = ) received myeloablative conditioning regimens plus atg ( mg/kg); including once daily busulfan ( mg/m ,- d to - d, iv ) + fludarabine ( mg/m /d, - d to - d, iv) (aml = , all = , cml = ) or melphalan ( mg/m , d- , iv) (all = ). six patients received cy/atg for saa. gvh prophylaxis consisted to; ciclosporine a (csa) + mtx. csa was maintain levels between - ng/ml and tapered at the discretion of the treating physician. all patients were received peripheral blood stem cells (pbsc) graft from a matched related donor. since december levofloxacine and voriconazole was administered as antibacterial and antifungal prophylaxis. diagnostic, clinical grading and treatment of gi-agvhd and gi-cgvhd were performed according to established criteria and nih recommendations. probability of grfs was estimate by kaplan-meier method. median age was years (range: - ). median dose of cd + and cd + cell doses were . × (range: . - ) and . × (range: , - , ). the median time to neutrophil and platelet recovery were days (range: - ) and days (range: - ) respectively. at time of transplant / ( %) had an intestinal colonization with extended-spectrum betalactamase (esbl) producing bacteria. only / ( %) developed infectious diarrhea during the period of transplant. incidence of grade iii/iv gi-agvhd and gi-cgvhd requiring systemic therapy were % and % respectively. for patients with malignancies diseases (n = ), ( %) were alive at a median follow up of months (range: - ). incidence of relapse, disease free survival rates were %, % respectively. the grfs rate as defined previously was % at months. these results confirm that free no absorbable antibacterial digestive decontamination and atg-based conditioning regimens were associated with very low incidence of gi-gvhd and better grfs in patients with malignancies diseases. diverse bacterial populations of the gastrointestinal tract remain important factors to promote immune tolerance after allogeneic sct. disclosure of conflict of interest: none. g-csf primed hla haploidentical transplantation from maternal or collateral donor using atg plus reduced dose of posttransplantation cyclophosphamide: results of a phase ii prospective trial y wang , x-j huang peking university people's hospital, peking university institute of hematologythe transplantation milieu using granulocyte colony-stimulating factor (g-csf), and anti-thymocyte globulin (atg) for hlahaplotype-mismatched transplants from related donors has resulted in favourable outcomes with low transplant-related mortality (trm), without increased relapse rate. however, in this transplant modality, the poorer outcome owing to high incidence of graft-versus host disease (gvhd) related to maternal donor or collateral donor remains a concern. meanwhile the use of post-transplant cyclophosphamide (pt/cy) in recent years appears to be protective against severe acute and chronic gvhd. we performed a prospective pilot study of hla haploidentical stem cell transplantation (sct) from maternal or collateral donors with intensified conditioning including g-csf and atg, followed by two lower doses of pt/cy ( . mg/kg × doses). outcomes were compared with those of controls from matched-pair analysis who undergone haploidentical sct from other donors than mother or collateral relatives at the same time period. a total of patients with myelodysplastic syndrome (mds) or leukaemia undergoing haploidenticla sct from maternal or collateral donors were enrolled in the study. incidence of grade ii-iv and grade iii-iv acute gvhd at day were comparable between the study group and the control group ( . % vs. . %, p = . ; . % vs. . %, p = . ). incidence of cmv and ebv reactivation at day were also comparable between the study group and the control group ( . % vs. . %, p = . ; . % vs. . %, p = . ). after a median follow-up of days and days, the incidence of trm and relapse at year were comparable between the study group and the control group ( . % vs. . %, p = . ; . % vs. . %, p = . ); the probability of overall survival and lfs at year were comparable between the study group and the control group ( . % vs. . %; p = . ; . % vs. . %, p = . ). in conclusion, conditioning with atg and low-dose pt/ cy might be a feasible option for patients undergoing hla haploidentical, t-cell replete sct from maternal or collateral donors. trial registration: the study is registered at www. clinicaltrial.gov as nct . disclosure of conflict of interest: none. hematopoetic stem cell transplantation (hct) is a lifesaving treatment option for eligible patients with hematological malignancies. hct is inherently associated with a risk of nonrelapse mortality that varies greatly depending on transplant and patient characteristics. the assessment of the risk of complications and mortality before the procedure is extremely important. the hct comorbidity index (hct-ci) introduced by sorror m. is one of the tools proved to predict hct outcomes and was shown to be significant in various disease and hct settings. the objective is to evaluate hct-ci index of hct recipients, determine impact of different variables on ci score, particularly those, showing pulmonary and cardiac function. data of hct-ci of autologous (auto) and allogeneic (allo) hct recipients, transplanted during period january -october were analyzed. impact of pulmonary and cardiac function values on ci score was evaluated: dlco (diffusing capacity of the lung for carbon monoxide), fev (forced expiratory volume) and ef (cardiac ejection fraction) are parameters, reflecting pulmonary and cardiac function, which values are included into hct-ci score. the statistical data analysis was conducted using spss program. the differences were considered statistically significant at p ≤ . . records of allo and auto hct recipients, transplanted during . - . in vilnius university hospital were revised. median age of allo hct and auto hsc recipients was ( - ) and ( - ) years respectively. main indication for allo hct was acute myeloid leukemia ( %) patients and for auto hct -multiple myeloma ( . %) patients. hct-ci was completely calculated (no values missing) in allo and auto hct recipients. only patients with available complete hct-ci data were further analyzed. hct-ci in hct recipients was as shown in table . hct-ci score o was calculated in ( . %) and ≥ in ( . %) allo hct recipients. hct-ci score o was calculated in ( . %) and ≥ in ( . %) auto hct recipients. hct-ci score did not differ statistically significant between male and female recipients in both hct categories as well as in different age groups of patients (below and above years in allo and below and above years in auto hct). dlco was found to be below normal values (o %) in ( . %) allo hct and in ( . %) auto hct recipients. fev was less affected and found to be lower % in ( . %) allo hct and in ( . %) auto hct recipients. ef below % detected in ( , %) allo hct and in ( . %) auto hct recipients. low dlco was found to cause the greatest impact on hct-ci score and was statistically significantly associated with higher hct-ci (po . ). the most common hct-ci in both hct groups was score . dlco was found to be below normal ranges in relatively large patient group and had the greatest impact on hct-ci score. further studies on reasons of pulmonary function impairment and it's impact on hct outcomes are warranted.[p ]disclosure of conflict of interest: none. haemophagocytic lymphohistiocytosis (hlh), a life-threatening hyper-inflammation syndrome, is classified into primary and secondary forms. primary hlh is caused by gene mutations resulting in impaired cytotoxicity of natural killer (nk) cells and cytotoxic t lymphocytes (ctls). secondary hlh arises in the setting of autoimmunity, infection, malignancy, or less commonly, may be idiopathic. treatment of hlh has two major goals: halting the triggering event and controlling the overactive immune system. however, patients with primary or recurrent secondary hlh should subsequently undergo allogeneic hct for long lasting disease remission. we retrospectively evaluated hematopoietic stem cell transplantation (hsct) might be a valid treatment option for adults suffering from aggressive t-cell malignancies providing long term disease control. since a suitable hla-matched donor cannot be identified for all patients (pts) in need for transplantation, alternative donors graft sources such as related hla-haploidentical donors are considered. through introduction of t-cell-replete (tcr) hlahaploidentical transplantation (haplo-hsct) using post transplantation cyclophosphamide (ptcy) successful treatment with low non-relapse mortality rate (nrm) has been observed in lymphoma patients (luznik et al., bmt, ) . however, less data are available on the outcome of this haplo-approach in the treatment of t-cell malignancies, in particular when disease is refractory. we retrospectively evaluated the outcome of haplo-hsct using tcr grafts and ptcy in pts with peripheral t-cell lymphoma treated between and at our institution (t-nhl = , t-all = ; male n = ; median age: years). disease was refractory/active at time of transplantation in pts, while one had achieved second cr. all patients received at least prior treatment lines and one patient failed previous allogeneic transplantation. while fludarabine and cyclophosphamide served as backbone for conditioning, pts received a tbi-based and a drug-based conditioning regimen which was myeloablative in %. if disease was active at time of haplo-hsct, a sequential therapeutic concept was performed involving intensive chemotherapy (clofarabine n = ) shortly preceding conditioning (zoellner ak et al., bmt, ) . post-grafting immunosuppression consisted of cyclophosphamide, tacrolimus and mycophenolate mofetil in all patients. graft source was bone marrow in pts. no primary graft rejection occurred; / pts engrafted, one died early in aplasia. neutrophil/platelet engraftment was achieved at a median of (range: - ) and (range: - ) days, respectively. acute gvhd grade ii-iii was observed in pts, whereas no patient developed grade iv agvhd. mild chronic gvhd occurred in one patient. % of the pts developed grade ii-iii treatment-related toxicities most commonly diarrhea ( %) and mucositis ( %); grade iv toxicity (mucositis) was observed in one patient only. no vod occurred. cmv reactivated in / pts at risk, whereas no ptld was seen. proven invasive aspergillosis was diagnosed in one patient. at day + seven pts achieved cr. pts relapsed and died (relapse n = , infection n = ). -year nrm was %. at a median follow up of months (range: - ) the estimated -year and -year overall survival (os) and progression-free survival (pfs) were %/ % and %/ %, respectively. three pts received haploidentical dlt pre-emptively (n = ) and therapeutic (n = ), leading to sustained cr in two, while no severe gvhd occurred. sequential therapy in the setting of tcr haplo-hsct using ptcy as gvhd prophylaxis is feasible, well tolerated and shows low rates of gvhd and acceptable nrm in patients with relapsed/refractory t-cell lymphoma/ leukemia providing an effective anti-lymphoma/leukemic activity. thus, we suggest that intensified tcr hapo-hsct using ptcy should be considered as an alternative for patients suffering from aggressive t-cell malignancies, lacking hlamatched donors. disclosure of conflict of interest: none. tacrolimus is a calcineurin inhibitor increasingly used as immunosuppression following allogeneic stem cell transplantation; maintenance of therapeutic serum levels is essential to reduce the risk of graft rejection and graft versus host disease. however, tacrolimus can be associated with serious side effects and potential drug interactions. regular monitoring of serum levels and appropriate dose adjustment is essential to ensure therapeutic levels and to avoid toxicity. in our adult bmt unit, an established standard operating procedure (sop) provides a prescriptive dosing algorithm for: (i) initiation of tacrolimus therapy; (ii) conversion between iv and oral routes; (iii) dose adjustment based upon tacrolimus serum level and interacting medications. we performed an audit assessing adherence to the sop dosing algorithm. inpatient tacrolimus dosing episodes from five consecutive haploidentical transplants were retrospectively analysed. episodes were excluded due to insufficient records. for the remaining episodes, tacrolimus serum levels and corresponding doses were identified. the response of the medical team to each serum level was compared with the sop dosing recommendation. to account for sensible rounding of doses, a margin of error of ± % was permitted. adherence to sop dosing was %. non-adherence to the sop ( %) was subcategorised as justifiable ( %) or unjustifiable ( %). justifiable non-autologous hsct is currently being explored for its efficacy and safety in the treatment of multiple sclerosis (ms). as more experience is gained in treating this cohort, treatment related mortality has steadily improved although the procedure still carries a degree of risk. ebv reactivation is well described in allogenic stem cell transplants although less so in autologous transplantation. we investigated the frequency of ebv reactivation in patients with ms undergoing autologous hsct at a single uk site. patients underwent autologous hsct for treatment of ms at king's college hospital between feb and aug . all were mobilised with cyclophosphamide g/ m and g-csf. were conditioned with cyclophosphamide and atg, and one with beam/atg. previous exposure to ebv (ebv igg) was assessed prior to transplant and local posttransplant ebv monitoring was performed on whole blood samples by means of quantitative pcr in patients. data was collected retrospectively. all ( %) patients were positive for ebv igg pre-transplant. overall, samples were tested for monitoring post-transplant. ( . %) patients demonstrated positive pcr post-transplant on local testing with one further patient being negative on local tests but later becoming positive on testing in their parent hospital (full results unavailable). of these , the median time to positive testing post-transplant was days ( - ). maximal ebv dna titre was reached at a median time of days post-transplant ( - ) with a mean maximum titre of . log ( . - . ). patients experienced symptomatic reactivation with an associated large paraproteinemia. one of these developed hyper-viscosity requiring plasma exchange and developed neurological symptoms mimicking an ms relapse (max ebv titre of . log). this patient received rituximab and ebv level is declining, the other was observed carefully but developed right leg weakness which is slowly improving. the patient with raised ebv at their parent hospital also received rituximab (unclear if this reactivation was symptomatic). we have developed a protocol to pre-emptively treat ebv reactivation with rituximab once a log titre is reached and one patient has so far been treated according to this. of the patients with locally confirmed reactivation who did not receive rituximab, ( %) self-resolved at a median time of days ( - ), ( . %) have ongoing re-activation ( with improving, with stable titres) and ( . %) have not had any local bloods performed ≥ months. patient with selflimiting reactivation later had a further positive titre ( days post-transplant and days post initial resolution). ebv reactivation appears to be common in patients with ms in the first months post autologous hsct. unlike in other patient groups such as aplastic anaemia patients receiving allogeneic transplants it can cause significant neurological symptoms which may be confused with ms relapse. the mechanism of this reactivation is probably related to atg administration but may be exacerbated by prior immune suppression in this heavily pre-treated group, the majority of whom have received highly active disease modifying therapies in the past. these results demonstrate the importance of monitoring for ebv reactivation following autologous hsct and the consideration of pre-emptive therapy. disclosure of conflict of interest: none. reduced bone mineral density (bmd) is a well recognised complication of hct. guidelines recommend scanning by dual energy x-ray absorptiometry (dxa) one year after transplant in all hct patients or else specific groups of high risk patients. , it is recognised that both dose and duration of steroids are risk factors for low bmd and it is recommended that prednisolone doses greater than or equal to mg/day for more than months should prompt a dxa scan. for patients with osteopenia it is recommended that calcium/vitamin d supplements are given together with lifestyle advice including diet, smoking cessation and weight bearing exercise. in this survey we have investigated the current practise in investigating and managing bone health in the context of hct. a survey was sent to all centres including countries registered with ebmt as of november . centres replied from countries. response numbers to each question were variable and are indicated by the denominators. / used a national guideline to guide their practise, and / used an international guideline. no single guideline was quoted more than once. low testosterone has been demonstrated to be an independent determinant of endothelial (dys)function in men. graftversus-host disease (gvhd) is a major contributor to nonrelapse mortality (nrm) after allogeneic stem cell transplantation (allosct). vulnerability of the recipients' endothelial cell system is a novel concept to explain why a proportion of patients with acute gvhd fail to respond to escalating immunosuppressive therapy and ultimately succumb to gvhd and related complications. this retrospective study investigated the prognostic impact of pre-transplant testosterone levels on nrm after allosct in male patients. between and , a total of male patients undergoing allosct at heidelberg university (median age years) provided informed consent to participate in this observational study (training cohort). a total of patients ( %) received transplants from related donors (rd). diagnoses were aml ( %), mds ( %), lymphoid malignancies ( %) and multiple myeloma ( %) . a total of patients ( %) received statin treatment post allosct as per institutional standard policy. for validation, an independent patient cohort of men allografted for aml and mds (median age years, % rd, no statin treatment) at essen university was analysed. pretransplant serum samples were collected between and months before allosct and cryopreserved at − °c. testosterone and suppressor of tumorigenicity- (st ) levels were measured by radioimmunoassay and elisa, respectively. median pre-transplant testosterone level in the training and validation cohort was . nmol/l (range: . - . nmol/l) and . nmol/l ( . - . nmol/l), respectively. in the training cohort, lower pre-transplant testosterone as continuous variable was associated with shorter os (p = . ). lower testosterone levels showed a trend towards higher nrm (p = . ) and a significant association with nrm after onset of acute gvhd (p = . ). multivariate analysis confirmed lower pre-transplant testosterone levels as a significant predictor of an increased nrm risk after gvhd onset (p = . ). in the subgroup of patients not receiving statins post-transplant, lower testosterone levels were associated with increased incidence of transplant-associated microangiopathy (p = . ), and, in addition, with higher pre-transplant st levels indicating endothelial vulnerability. in the validation cohort, similar results with regard to overall survival (os, p = . ), nrm (p = . ), nrm after acute gvhd onset (p = . ) in univariate analysis, and to nrm after gvhd onset (p = . ) in multivariable analysis could be observed. the association of pre-transplant testosterone levels (in quartiles) and incidence of nrm after gvhd onset in the training and validation cohort is depicted in figure a and b, respectively. our study suggests that low pre-transplant testosterone is associated with serological and clinical evidence for endothelial damage and is an independent risk factor for a fatal outcome of gvhd. prospective studies in the allosct setting investigating testosterone and testosterone supplementation in deficient patients are highly warranted. disclosure of conflict of interest: none. nk cells anti-tumor ability in multiple myeloma patients s tognarelli , , b jacobs , , , i von metzler , h serve , p bader, t klingebiel , a mackensen and e ullrich , department of pediatric stem cell transplantation and immunology, childrens hospital, goethe university, frankfurt, germany; cellular immunology, loewe centre for cell and gene therapy, goethe university, frankfurt, germany; department of hematology and oncology, university hospital erlangen-busulfan is one of essential drugs for hematopoietic stem cell transplantation (hsct). because of its narrow therapeutic range: targeted busulfan using therapeutic drug monitoring (tdm) has been used. generally, the initial dose of busulfan is determined by patients' body surface area as mg/m except for infants ( mg/m ). however, pharmacokinetic evidence of these initial doses is scarce. therefore, we investigated the full pharmacokinetics of busulfan in infant and child, and attempted to validate that these initial doses are acceptable. one hundred ninety-five pediatric patients undergoing hsct using four-day targeted busulfan were enrolled. of them, patients received hsct when their age was ≤ year old (infant group [ig]), and patients received when - years old (toddler group [tg]). the remaining patients were defined as a child group (cg). busulfan was administered intravenously once daily for consecutive days. tg and cg received mg/m as the first dose, and ig received mg/m . using daily tdm, we adjusted the next dose of busulfan. target daily and total area under the curve (auc) were μg*h/l/day and - μg × h/l, respectively. median first-day busulfan auc of ig, tg, and cg were , and μg × h/l, respectively, which was significantly different (p = . ). however, there was no significant difference in median total busulfan auc (ig; , tg; , and cg; μg × h/l, respectively, p = . ). the coefficient of variance (cv) of four-day busulfan aucs in ig and cg was similar (median cv: . % and . %, respectively), whereas cv of tg was . %. in sub-analysis of tg and cg who received equally mg/m as the first dose, there was an inverse correlation between age and first-day busulfan auc (r = − . , p = . ), as well as between age and cv of four-day busulfan aucs (r = − . , p = . ). initial busulfan dose as mg/m for infant could be acceptable in aspect of first-day auc and cv of four-day busulfan aucs. however, higher first-day auc and cv were shown in tg. although target total busulfan auc could be achieved safely by tdm, we suggest that reduction of initial dose less than mg/m is also necessary to patients with - years old to lower the relatively higher first-day auc. taken together, tdm is highly recommended to reduce busulfan toxicity, especially in younger children. disclosure of conflict of interest: none. post-induction treatment strategy of acute myeloid leukemia (aml) is currently driven by european leukemia net (eln) risk assessment at diagnosis. if it is well established that patients belonging to favourable-risk group can be treated with chemotherapy and/or autologous stem cell transplantation (sct) and that those belonging to the unfavourable-risk group should be addressed to allogeneic (allo) sct, for patients included in the intermediate-risk groups the best post-induction treatment has not been established yet. we report here a years ( - ) allo-sct single center experience in aml patients. median age was years (range: - ), %, %, % and % were grouped in the eln favourable, intermediate-i, intermediate-ii and unfavourable risk category, respectively and % of the patients were allotransplanted in advanced disease-phase ( nd complete remission). half of the patients received a sibling hla compatible donor, % of the cases received peripheral blood stem cells and half of the patients received a myeloablative conditioning regimen. graft versus host disease prophylaxis was conventionally based on cyclosporine and shor-course methotrexate, with the addition of antilymphocyte immunoglobulin in case of matched unrelated donor. the clinical and transplant characteristics of the patients according to the eln-risk group were well balanced. with a median follow up of months (range: - months), the projected years overall survival (os) and disease free survival (dfs) is % ( % ci: - %) and % ( % ci: - %). the median os and dfs in favourable/intermediate-i vs intermediate-ii/unfavourable is . and . months ( figure a ; p = , ) vs and , months ( figure b ; p = . ). the relapse rate (rr) and the non relapse mortality (nrm) at two years are % ( % ci: - %), and % ( % ci: - %), respectively. non differences were observed comparing the years rr and the years nrm of patients in the favourable/intermediate-i vs intermediate-ii/unfavourable eln risk group ( % vs %; p = . and % vs %; p = . ). interestingly, the percentage of patients allotransplanted in advanced phase of the disease was higher in those included in low/intermediate-i with respect to intermediate-ii/unfavourable eln-risk group ( % vs %; p = . ). our data suggest that allo-sct can cure approximately - % of aml patients, with no difference within the eln risk groups. disease recurrence remains the major problem and this is highly correlated to the percentage of patients in advanced phase of the disease at transplant, particularly in eln favourable/intermediate-i patients. we are currently collecting the data on minimal residual disease (mrd) status of these patients during chemotherapy and before transplant using moelcular biology on target genes and/or multiparametric flow cytometry on leukemia associated immunophenotype, in order to assess if the prognosis of these patients may be refine by the prospective application of mrd data.[p ]disclosure of conflict of interest: none. outcome of allogeneic stem cell transplantation for patients with high-risk acute leukemia according to donor type and graft-versus-host disease prophylaxis s lindner, t berg , j riemann , s ajib , z jedlickova , s gueller , f lang , a sackmann , , n goekbuget , , h martin , a bacigalupo , h serve , and g bug department of medicine ii, hematology and oncology, university hospital frankfurt, goethe university, germany; s german cancer consortium (dktk), german cancer research center, heidelberg, germany and università cattolica del sacro cuore, fondazione policlinico universitario gemelli, roma, italyin high-risk acute leukemia (hr-al), allogeneic hematopoietic stem cell transplantation (hsct) is the only potentially curative treatment. increasingly, hsct is being performed utilizing alternative donors. we retrospectively analyzed the outcome of consecutive patients (pts) with hr-al (aml/all, n = / ) undergoing first allogeneic hsct in our transplant unit between / and / according to donor type and graft-versus-host disease (gvhd) prophylaxis: in the matched related donor group (mrd, n = ), hsct was performed with standard immunosuppression (is), that is, calcineurin inhibitor (cni) plus methotrexate or mycophenolate mofetil (mmf). for / hla-allele matched unrelated donors ( / mud, n = ) or / hla-allele mud ( / mud, n = ) we used is and anti-thymocyte globulin (atg fresenius/neovii). hsct with a haploidentical family donor or an / hla-allele mismatched unrelated donor was performed using is with cni plus mmf and post-transplant cyclophosphamide (pt-cy, n = ). a myeloablative (n = ) or reduced-intensity (n = ) conditioning regimen was applied in complete remission (cr, n = ) or active disease (n = ). pts had a median age of years (range: - ) and hematopoietic cell transplantation comorbidity index of (range: - ). patient and treatment characteristics were well balanced between the groups except for a higher percentage of pts transplanted in cr in the pt-cy group ( % vs. - %, p = . ). peripheral blood stem cells were preferred for mrd, / mud and / mud ( %, % and %, respectively) and bone marrow for % of pt-cy based hsct. all pts engrafted. with a median follow-up of months (range: - ), probability of overall survival (os) at years was ± % for the mrd, ± % for the / mud, ± % for the / mud and ± % for the pt-cy group, without significant differences (p = . ). however, the probability of achieving the combined endpoint gvhd-and relapse-free survival (grfs) at years varied significantly between the groups (mrd ± %, / mud ± %, / mud ± % and pt-cy ± %, po . ), reflecting the high cumulative incidence (ci) of chronic moderate and severe gvhd at year in the mrd ( ± %) as opposed to the other groups ( / mud ± %, / mud ± % and pt-cy ± %, p o . ). of note, donor type had no impact on ci of transplant-related mortality (trm) at years ( ± %), acute gvhd g - at day + ( ± %) or leukemic relapse at years ( ± %). overall, aml pts years of age had a significantly inferior relapse-free survival compared to younger pts ( ± % vs. ± %, respectively, p o . ) without a higher ci of trm (p = . ). median time to aml relapse was months. our results suggest that pt-cy-based alternative donor hsct is safe in hr-al pts and provides a solid basis for a randomized clinical trial comparing hsct from haploidentical family donors and / mud, currently in preparation. while os did not vary between groups, grfs was dismal after mrd transplants without atg, due to high rates of severe chronic gvhd, consistent with published data. as leukemic relapse remains the major cause for treatment failure especially in elderly pts, maintenance strategies using novel drugs or cellular therapies are warranted. disclosure of conflict of interest: none. relapse following hematopoietic stem cell transplant (hsct) is the leading indication for a second transplant in patients with malignant disease. hsct has been shown to be superior to chemotherapy alone or palliative measures in these patients. for non-malignant disease a second transplant may be considered for graft failure after first transplant. data regarding the outcome of a second hsct for non-malignant disease is scarce. we retrospectively analyzed patients who underwent a second hsct, for survival and toxicity data. twentynine patients (age - years) who received a second hsct at our institution during - were included in the analysis. thirteen patients had an underlying malignancy and patients were transplanted for non-malignant indications, including inborn errors of metabolism, non-malignant hematologic diseases and immune deficiency. median follow up was months (range: - ). there were deaths ( %) in the malignant group, ( %) were due to disease relapse and ( %) were transplant related. fifty percent of deaths occurred within the first year following the second hsct. in the non-malignant group there were deaths ( %), of which ( %) were attributed to the underlying disease and ( %) were transplant related. all deaths but one occurred within the first year post hsct. treatment related mortality following second hsct is higher compared to first transplant. the higher survival rate in the non-malignant group suggests that transplant following graft failure should be considered ins patients with otherwise incurable underlying disease. though the outcome for patients with relapse of malignant disease following hsct is poor, a second transplant may benefit a subset of these patients. attempts to achieve complete remission prior to transplant should be made to improve outcome. due to the small number of patients in our cohort, further multi-center trials are needed. disclosure of conflict of interest: none. disseminated bcg infection (bcg-osis) is a rare but most serious complication in vaccinized especially immunocompromised children. severe combined immunodeficiency disorder (scid) is probably the commonest primary immunodeficiency associated with bcg-osis, though there is no such definitive data as most of the cases described in literature are in the form of reports. hematopoietic stem cell transplantation (hsct) is a life-saving treatment for patients with scid, especially if therapy is instituted early, prior to onset of infections.as bcg vaccine is routinely given to all iranian children at birth, the likelihood of having an active infection at the time of transplant would be significantly high. the main objective of this study was to evaluate the outcomes of hsct in scid patients with disseminated bcg infection . sixteen scid patients underwent hsct in our center since to , of which nine patients ( male, female) were enrolled in this analysis. all the patients had received bcg vaccination according to the national vaccination protocol, and had undergone anti-tuberculosis (tb) treatment prior to transplant due to disseminated bcg infection. the mean age at hsct was . months (range: - months). patients received bone marrow (n = ), peripheral blood progenitor cells (n = ) or umbilical cord blood grafts (n = ) from hla-matched related donors (n = ) and mismatched unrelated donors (n = ). three patients received unconditioned matched sibling donor transplants and ric regimen was provided with fludarabine, melphalan and rabbit anti-thymocyte immunoglobulin (thymoglobulin) in others . cyclosporine a and prednisolon were used as graft-versus-host disease (gvhd) prophylaxis. they also continued to receive anti-tb treatment. all patients but one engrafted. the median times to neutrophil and platelet engraftments were days (range: - ), and days (range: - ), respectively. engraftment with full chimerism ( %) occurred in patients and the other patients had mixed chimerism. with a median follow-up of months (range: - months), overall survival was . %. the main cause of death was disseminated bcg infection.three out of patients who achieved engraftment, developed acute gvhd (grade i-ii), while one patient developed extensive chronic gvhd. although anti-tb treatment continued, tuberculous dactylitis occurred in patients post-hsct that were successfully treated. on last post-hsct follow-up, patients with full chimerism and with mixed chimerism are alive and disease free. scid is called as a pediatric emergency as it invariably leads to fatality in infancy without early aggressive therapy and hsct. in hsct recipients, the impaired cellular immunity renders these patients more susceptible to infection. as previous reports suggest, our study demonstrates that with appropriate anti-tb cover, immunological reconstitution with complete recovery from bcg infection can be achieved by early hsct. disclosure of conflict of interest: none. paraproteinemia occurrence after allogeneic hematopoietic stem cell transplant as a possible marker for chronic gvhd onset f monaco , s tamiazzo , f dallavalle , l calcagno , m pini and m ladetto hematology and transfusion medicine, azienda ospedaliera ss. antonio e biagio e cesare arrigo, alessandria, italy transient monoclonal gammopathy is commonly reported after solid organ or stem cells transplant (sct) for hematologic malignancies. however the clinical significance of a paraproteinemia appearance is not fully understood, because the attempts to correlate its effect on survival rates, graft versus host disease (gvhd) occurrence and viral reactivations have led to controversial results. starting from these reports we decided to evaluate among our allogeneic transplanted patients the incidence of m-component and its possible relationship with chronic gvhd. one-hundred and one patients undergoing allosct at the hematology unit of alessandria (italy) between and were evaluated. % of patients were male and % were females. pretransplantation diagnosis included: acute myeloid leukaemia/ high-risk myelodisplastic sindromes ( %), acute lymphoblastic leukaemia ( %), lymphoproliferative disorders ( %) and other less common malignancies ( %) . patients with multiple myeloma were excluded from the study. all patients had, at least, two pre-transplantation serum electrophoresis with no evidence of pre-existing monoclonal component. serum electrophoresis was scheduled to be performed at , and days and years after transplantation. forty-nine patients were submitted to allo-sct from a sibling donor and from a matched related donor (mud); in vivo t-cell depletion with anti-thymocyte globulin was used in patients. thirty-four patients relapsed after allosct, ( %) developed chronic gvhd and patients ( %) are currently alive at the last follow-up. posttransplantation follow up ranged from to days with a median of days. paraproteins were detected in out of patients ( %), being monoclonal in patients, and bi or tri-clonal in the remaining cases; the immunoglobulin subclass most commonly observed was igg. ten-year overall survival of the whole population was %; splitting the population in two cohorts (with or without paraproteinemia) we did not detect any statistical differences in overall survival, gvhd development and relapse incidence at + and + days posttransplant; viceversa, after days, a statistically significant difference was observed in chronic gvhd occurrence in patients with or without paraproteinemia ( % vs %, respectively, po . ). ten-year overall survival curves were significantly better in patients with paraproteinemia as compared with the paraprotein-free group ( % vs %, p = . ), and an even more evident significance was seen in ten-year relapse free survival curves ( % for patients with paraprotein vs % for patients without paraprotein, p = . ). monoclonal gammopathy, also in our experience, is frequent following allo-sct. we observed a strong correlation between the occurrence of paraproteinemia, chronic gvhd and a significantly better overall and relapse-free survival. recently many evidences showed that b cells are involved in the pathogenesis of chronic gvhd (cgvhd) and anti-b-cell therapy has been suggested for the treatment of cgvhd. we speculate that the presence of a monoclonal gammopathy after allogeneic transplant is expression of the activation of the b-cell compartment. a prospective study with a larger population should be considered, in order to confirm our results and assay post-transplantation monoclonal gammopathy as an early marker for gvhd development. disclosure of conflict of interest: none.inherited bone marrow failure (ibmf) syndromes are rare pediatric disorders that characteristically associate physical abnormalities, progressive bone marrow failure and predisposition to cancer. the most common of these disorders is fanconi anemia (fa). stem cell transplantation (sct) using related or unrelated donors are the only curative therapeutically approach when severe marrow failure is established. the aim of the study was to analyze the results of sct for patients with ibmfs in a single center. we performed a retrospective study in pediatric patients with ibmf admitted in pediatric hematology and bone marrow transplant department, fundeni clinical institute between january and september . diagnosis and severityof ibmfs were established based on hematological results, bone marrow biopsy and clinical findings. genetic testing for ibmfs is not currently available in our country. indication for sct was established when patients developed moderate/severe aplastic anemia and became transfusion dependent.in case of dba, sct indication was established for steroid resistant disease. the donors were selected from family members or unrelated donors, / matched.the conditioning regimens used were reduced intensity (fludarabine - mg/m , cy mg/kg, f-atg mg/kg) for af, dc and myeloablative (busulfan i.v., fludarabine mg/m , thiotepa mg/kg, f-atg mg/kg) for dba. gvhd prophylaxis consisted of standard methotrexate and csa/tacrolimus. all parents signed informed consent forms. in our center, between and , patients with ibmf were diagnosed: ( %) patients with fa, ( %) patients with diamond blackfan anemia (dba), ( %) patients with diskeratosis congenita (dc), and ( %) patients with not classifiable ibmfs. the patient data is available in table . seven out of patients ( %) performed sct procedures: sibling patients ( patients with af, patient with dc), mud patients ( patients with af, patient with dba). all patients ( %) engrafted for pmn (median = , range: - days) and platelet (median , range: - days). / ( %) presented reactivation of cmv and received valganciclovir, / developed cmv disease (encephalitis and pneumonia), / ( %) developed bkv cystitis and required extensive hydration and levofloxacin. / ( %) developed grade i-ii skin acute gvhd day + , which responded to topical treatment and low dose of corticosteroids. / ( %) developed grade iii intestinal acute gvhd, which responded to high-dose corticosteroids. / ( %) developed grade iv intestinal chronic gvhd (day + ), without response to high-dose corticosteroids, mmf and later died on day + , due to infectious complications (severe pulmonary and cerebral aspergillosis). / patients ( %) are alive, with % donor chimerism / ( %) or stable mixed chimerism / ( %). median follow-up for sct patients was days ( days- y mo). conclusions in our study we observed a low incidence of severe complications associated with low mortality rate ( %) . sct is a procedure that associates multiple risk situations, but it remains the only curative cytomegalovirus (cmv) infections remain a significant cause of morbidity and mortality in patients whose immune systems are compromised, including hematopoietic stem cell transplant (hsct) recipients. although the adoptive transfer of third party cmv-specific t cells has proven both safe and clinically beneficial in treating even drug-refractory infections/disease, broader implementation and commercialization of this strategy has been hampered by (i) the postulated need for extensive cell banks generated from donors representing diverse hla profiles, and (ii) lack of large scale t cell manufacturing processes. to address these limitations we have developed a proprietary decision tool (cytomatch™) to identify a small panel of healthy donors who should provide almost universal hla coverage; and optimized a simple, scalable manufacturing process to generate large numbers of cmv-specific t cells. to assess the robustness of our strategy we generated a bank of cmv-specific t cells (viralym-c™) from carefully selected healthy donors. the lines were polyclonal, comprising both cd + ( . ± . %) and cd + ( . ± . %) t cells, expressed central cd ro+/cd l+ ( . ± . %) and effector memory markers cd ro+/cd l-( . ± . %), and were specific for the immunodominant cmv antigens ie and pp (ie : ± ; pp ± sfc/ × , n = ). a fixed-dose ( × cells/m ) phase i clinical trial was subsequently initiated to test the safety and efficacy of these "ready to administer" t cells in pediatric and adult hsct recipients with drug-refractory cmv infections. using our bank of just lines, we have identified a suitable line for of patients screened. of these, patients have been treated with viralym-c cells; received a single infusion and patient required infusions for sustained benefit. there were no immediate infusion-related toxicities; and despite the hla disparity between the viralym-c™ lines and the patients infused, there were no cases of de novo or recurrent graft versus host disease (gvhd). based on viral load (measured by quantitative pcr) and/or symptom resolution, viralym-c cells controlled infections in all patients with complete (cr) and partial responses (pr) achieved within weeks of infusion. one patient with cmv retinitis had complete resolution of symptoms following viralym-c™ infusion. our results demonstrate the feasibility, preliminary safety and efficacy of "ready to administer" viralym-c™ cells that have been generated from a small panel of healthy, eligible cmv seropositive donors identified by our decision support tool. these data suggest that cost-effective, broadly applicable t cell anti-viral therapy may be feasible for patients following hsct and potentially other conditions. disclosure of conflict of interest: drs. juan vera, ann leen and brett giroir hold equity and drs. ifigeneia tzannou, sunitha kakarla are employed by viracyte. haploidentical stem cell transplantation (hsct) protocols utilizing ex vivo t-cell depleted grafts have been proven efficient in preventing graft versus host disease (gvhd), but cause a delay in early t-cell recovery that increases the risk of graft rejection, leukemia relapse and viral infections. conventional donor lymphocyte infusion (dli) after hsct transplantation is conditioned because of the high prevalence of gvhd even with low dose of t cells. here we present preliminary data of escalating cd ro+ memory t cells as dli in three patients that received a selective graft depleted of naïve (cd ra+) t-cells. three children that were transplanted following nonmyeloablative conditioning regimen with a graft consisting of cd + and cd ra-cells, with mixed chimerism, lymphopenic and viral/opportunistic infections and minimal residual disease positive before hsct received dose scalating cryopreserved haploidentical cd ra-memory t cell starting with a initial dose of × /kg, until a maximal dose of × /kg with a days interval. we infused products with a naïve ( ra+) t-cell dose less than × /kg with . % purity of cd + cd ro+ memory t-cells in all cases. all infusions were well tolerated without any side effect during infusions neither gvhd. following the dli, a progressive increase in t cell counts was observed. our preliminary data suggest that dose escalating of haploidentical memory t cells ( ro+) as dli provides a safety platform, even with high dose of t cells ( × /kg), for adoptive immunotherapy in haploidentical ra+ depleted grafts with no gvhd complications, and allows an increase in t cell reconstitution. however, efficacy of this strategy requires longer studies. relapse after allogeneic hematopoietic stem cell transplantation (allohsct) remains a major therapeutic challenge: outcome is very poor, without curative option in most cases. second allohsct may be considered in few selected patients because of anticipated limitations: ( ) donor availability; ( ) high toxicity due to previous treatments; ( ) low efficacy considering the very advanced disease situation. we hypothesized that the use of post transplantation cyclophosphamide (pcy) haplo-sct after relapse following allohsct may deal in part with these limitations. in particular, the presence of full haplotype hla mismatch could provide a decisive antileukemic effect relative to alloreactivity. in absence of large series in this setting, we report here the outcome after haplosct for patients who relapse after a first allohsct. we retrospectively studied adult patients, who received a second pcy haplo-sct for hematological malignancies. patients were treated between and . the objective was to assess both the feasibility and the efficacy of haplosct in this setting. twenty seven patients were included: median time between first allohsct and relapse was months (range: - ). median age at second transplantation was years old (range: - ). most of patients had acute myeloid leukemia (n = , %) or hodgkin lymphoma (n = patients, %). fifteen the impact of minimal residual disease and its kinetics prior to different types of allogeneic hematopoietic stem cell transplantation on clinical outcomes in patients with acute myeloid leukemia z xiao-su , , l yan-rong , yan-hong , p xu-ying , qian-jiang , hao-jiang , lan-ping, xu , xiao-hui zhang , , yu-wang , , h xiao-jun , and c ying-jun this study investigated the impact of minimal residual disease (mrd) and its kinetics prior to different types of allogeneic hematopoietic stem cell transplantation (hsct) on clinical outcomes in patients with acute myeloid leukemia (aml) in complete remission (n = ). patients who received unmanipulated haploidentical hsct and patients who received hla-matched sibling hsct were enrolled. mrd measured using -color flow cytometry (fcm) at fixed time points before transplantation was retrospectively analyzed. the patients were divided into four groups based on mrd kinetics before transplantation: consistent negative, positive to negative, negative to positive and consistent positive. during the follow-up, total twenty ( . %) patients underwent relapse. through unique variate analysis, none of mrd status at various time points before unmaipulated haploidentical transplantation was associated with clinical outcomes, as well as the dynamic change of mrd before hsct (p . ), although the patients with consistent positive mrd before hsct seemed to have a relatively higher incidence of relapse (p = . ). one-year cumulative incidence of relapse (cir) were . ± . % vs. . ± . % in mrd consistent negative and consistent positive groups, respectively (p = . ). however, patients with positive mrd after the second chemotherapy or pre-mrd before hla-matched sibling hsct showed a significant poor outcomes including higher cir (p = . and both neuroblastoma (nrb) and rhabdomyosarcoma (rms) in childhood are the aggressive malignant disease with higher mortality. this paper aims to study the efficacy of autologous peripheral blood stem cell transplantation (apbsct) in the treatment of high risk advanced nrb and rms. patients with high-risk stage iv nrb and patients with advanced childhood rms were treated by apbsct in our hospital from october of to may of . in the subgroup of nrb patients, patients got complete remission (cr) and patient got cru while patients had tumor residual disease after intensive induction therapy before asct. the median age was . ( - ) years old. primary sites of the tumors included submaxilla (n = ), cervical (n = ), adrenal gland (n = )and retroperitoneal (n = ). the conditioning regimen consisted of busulfan and melphalan (busulfan mg/kg × d, melphalan mg/m x d) or cem regimen (carboplatin mg/m × d, etoposide mg/m × d, cyclophosphamide mg/ m × d); the pathology of stage iii childhood rms patients was embryonal rhabdomyosarcoma. there were cases in cr and case in partial remission (pr). the median age was . ( - ) years old. primary sites of the tumors included bladder (n = ), left forearm (n = ), retroperitoneal (n = ), pelvic (n = ) s and talus (n = ). the conditioning regimen consisted of melphalan, cyclophosphamide and dactinomycin (melphalan mg/m × d, cyclophosphamide mg/m × d, dactinomycin . mg/kg × d).there were double apbsct cases (nrb n = , rms n = ). all the relapse patients were treated with chemotherapy and radiation therapy. all the patients successfully underwent mobilization, collection and reinfusion. the time of hematopoietic reconstitution was ( . ± ) days, no severe toxicity was observed, no transplant-related death was found. with a median follow-up of . ( - ) months, one of the patients was lost to follow-up. in the subgroup of nrb patients (n = ): the -year event-free survival and total survival rate of all patients were . % and . %, respectively. the survival time of no recurrence was significantly different between the double transplantation group and single transplantation group (p o . ). in the subgroup of rms patients (n = ), patient died, patients live without pd( patients had double apbsct), patients suffered recurrence but still alive. apbsct achieved good outcome in patients with high risk advanced nrb and rms. transplantation-related toxicities were tolerable. double apbsct significantly improved the depth of remission. disclosure of conflict of interest: none. transplantation outcomes of a once-daily intravenous busulfan and fludarabine conditioning for allogeneic hematopoietic stem cell transplantation in pediatric aml and high risk mds: single center experience in korea y-t lim, e-j yang and k-m park department of pediatrics, pusan national university children's hospital, yangsan, koreathere have recently been some reports suggesting that oncedaily intravenous busulfan as a conditioning regimen for hematopoietic stem cell transplantation (hsct) possibly reduces the toxicities without influencing the clinical outcome as compared with the traditional times daily dosage schedule. but until recently there has been little research and limited data available on the safety and efficacy of oncedaily intravenous busulfan and fludarabine in pediatric allogeneic hsct. we report the outcomes for allogeneic hsc recipients, evaluating engraftment status, regimen related toxicities (rrt), and event free survivals (efs) after use of oncedaily intravenous busulfan and fludarabine conditioning for allogeneic hsct in children with aml and high risk mds in a single pediatric center of korea. from january to december , aml and high risk mds children who received once daily iv busulfan/fludarabine based conditioning regimen for allogeneic hsct were reviewed, bu/flu ± atg consist of intravenous fludarabine ( mg/m ) and busulfan ( ~ mg/m , once daily iv) on days - to - , and antithymocyte globulin (atg) ( mg/kg) on days - to - . all patients received tacrolimus and mini-dose methotrexate ( mg/m( )) for graft versus host disease (gvhd) prophylaxis. boys and girls were enrolled with median age of . years (range: . - . years). the median period from diagnosis to transplantation was months (range: - months). more than half of the patients had a matched sibling donor (n = , %), % patients (n = ) had a matched unrelated donor, % patients (n = ) had a mismatched unrelated donor, and the remaining patient had a mismatched family donor. as a stem cell source, peripheral blood stem cells (pbsc) were cases ( %), bone marrow and cord blood were cases in each. the median follow-up for patients was months. the median number of infused total nucleated cells and cd + cells except cord blood transplantation were . × ( )/kg and . × ( )/kg. all patients including who received cord blood were successfully engrafted. the median time to absolute neutrophil count (anc) recovery (anc × ( )/l) and platelet recovery (platelet , × ( )/l) were days, days in each. the incidence of acute gvhd was . %, while severe grade iii/iv gvhd was observed in only patient ( . %). there were only two cases ( . %) of extensive chronic gvhd in this study. transplant-related toxicities were acceptable, there was no case with cns toxicity, eleven patients ( . %) developed grade ii,iii mucositis and grade i-iii hepatic toxicity in twenty four ( . %), but transient. there was clinically diagnosed veno-occlusive disease (vod), but most recovered by fluid restriction and diuretics. nine patients ( %) showed positive cytomegalovirus (cmv) antigen/pcr but only one patient developed cmv colitis. eight patients died: due to relapse/disease progression, due to extensive chronic gvhd. the -year efs and overall survival were . % and . % respectively. at year, the cumulative incidence of relapse was . %. overall, once-daily intravenous busulfan and fludarabine was less toxic and effective as conditioning regimen in aml and high risk mds patients undergoing allogeneic transplantation in children. disclosure of conflict of interest: none. haploidentical stem cell transplantation from unmanipulated graft has becoming a practiced option for high risk hematological malignancies who lack a matched related or unrelated donor. lack of a matched sibling or unrelated donor (mud) can be a significant barrier to allogeneic transplantation in patients who stand to benefit from this procedure. hlahaploidentical donors are readily available for nearly all such patients. haplo transplantation has inherent advantages over mud transplantation including the lower cost of graft acquisition, greater availability of donors for ethnic minorities, and immediate access to the donor in patients in whom delay cerebral palsy (cp) is a heterogeneous group of conditions that result in permanent motor disability. it may occur due to perinatal hypoxic insults, developmental brain abnormalities, genetic diseases, traumatic or infectious causes. in general the condition is non-progressive, but improvement over time is rarely seen. various treatment methods have been used for the management of this disorder. however, there has been no absolute cure for cp. the ultimate goal of stem cells therapy is to use the regenerative capacity of the stem cells causing a formation of new tissues to replace the damaged tissue. the polish stem cell bank (pbkm) has provided wharton's jellyderived msc (wj-msc) for medical therapeutic experiment application in children with cp. wj-msc from third party donors were administered to patients (pts) with cp aged from . / to . / (median age: years and month). twenty two pts have received infusions intravenously (i.v.), pt intrathecally (i.t.), and pts via both routes (first i.v., next i.t.). the cells were previously collected from healthy newborns, processed, screened for bacterial contamination as well as endotoxin content, and frozen in liquid nitrogen vapour. msc immunophenotype was confirmed using flow cytometry assay. the pts have received from to infusions in intervals from weeks to months. median i.t. dose was × cells per infusion, while median i.v. dose was × cells/kg of body weight per infusion. each patient has been examined by the same neurologist at the day of each infusion and the result of examination has been described in a follow-up. twelve patients were diagnosed with epilepsy as comorbidity. eighteen pts ( %) showed positive changes in neurological examination after their treatment with wj-msc. almost half of the children experienced improvement of cognitive functions ( out of pts). muscle tension was reduced in pts. improvement in the ability to concentrate, better contact with others and improved social interactions were observed in % of pts. correction of motility was noticed in pts, pts have experienced better quality of sleep. in cases there has been a reduction in the number of epileptic seizures ( pt even discontinued some of his medicines). there were no s noticeable changes in neurological examination of patients. seven follow-up forms have been not received yet. the experiment data provide evidence that third-party donor wj-msc are suitable and efficient stem cells for treatment in patients with cp. however further and more extensive examination, with a greater number of patients is needed, which will be beneficial for far-reaching results. spina bifida (sb) is a congenital malformation resulting from failure of fusion in the spinal neural tube during embryogenesis. despite surgical repair of the defect, most patients who survive with spina bifida have multiple system damage due to neuron deficiency in the spinal cord. it has been confirmed that the mesenchymal stem cells (mscs) have the ability to survive, migrate and differentiate into cells of a neural lineage. wharton's jelly-derived mscs (wj-mscs) from third-party donors have high proliferation and differentiation potential along with non-immunogenic features, thus seem to be a promising stem cell source. the polish stem cell bank (pbkm) has provided wj-msc for clinical application in a medical therapeutic experiment for children with sb. eleven patients (pts) were qualified for administration of wj-mscs. three pts have been waiting so far for their therapy after bioethical committee approval. seven pts were in the middle of stem cell therapy (after or injections), pt had finished one cycle of stem cell therapy ( injections -ijs) and resumed therapy by administering a first dose of wj-mscs. the cells were previously collected from healthy newborns, processed, screened for bacterial contamination as well as endotoxin content, and frozen in liquid nitrogen vapors. six pts have received infusions intravenously (median dose: . × /kg body weight per infusion), and pt was given injection of × cells intrathecally. each patient has been examined by the same neurologist at the day of each infusion and the result of examination has been written in a follow-up. there were pts, who received at least doses of wj-msc, and all of them showed positive changes in neurological examination. the important improvement, declared by pts, was in areas: pronunciation and/or self-reliance ( pts), movement of arms and/or legs ( pts), quality of life ( pts), core stabilization ( pt). only one adverse event occurred after third injection of wj-msc: pt had nausea and a fever. in case of other pts it was too early to provide reliable feedback. the transplantation of wj-mscs could stimulate the mscs to differentiate towards sensory neurons. this could be one of the reasons of observed improvement of many vital functions in patients, after mscs treatment. this approach might have value in the experimental treatment of sensory neuron deficiency in spina bifida. key: cord- - qib authors: nan title: the th annual meeting of the european society for blood and marrow transplantation: physicians – poster session date: - - journal: bone marrow transplant doi: . /s - - - sha: doc_id: cord_uid: qib nan background: allogeneic hematopoietic stem cell transplantation is routinely offered to patients with high-risk or advanced all in the hopes of improving outcomes. use of truly non-myeloablative (nma) conditioning reduces toxicity in other contexts but outcome data for all patients after nma transplants is lacking. we report the outcomes of patients with all transplanted using a nma conditioning without t cell depletion. methods: first transplant patients between october and june were reviewed. these were consecutive patients until then only those considered unfit for fmc conditioning as per the ukall protocol. all patients were conditioned with fludarabine mg/m /day for days and cyclophosphamide g/m /day for days. short course mtx and ciclosporin were used for gvhd prophylaxis. standard supportive care was employed. thirty-one patients with a median age of ( - ) met the criteria for this case review. had b-all and were philadelphia chromosome positive. patients ( %) had high risk disease by standard diagnostic criteria. ( %) were in first complete remission (cr ). matched sibling donors were used in instances with the remaining being fully matched unrelated donors. % of patients had a hct-ci score of , % a score of or with patients having a score of or higher. median cd dose was . x /kg ( . - . ) with a median cd dose of . x / kg ( . - . ) results: trm was low at % at year and % at and years respectively. no factors included in a univariate analysis (which included age, diagnosis, disease status, hct-ci, donor type, cmv risk and cell dose) significantly impacted trm. the incidence of classical acute (a) gvhd grade - and - was % and % by day and % and % by day if late onset agvhd is included. out of eligible patients developed chronic gvhd of any stage. relapse incidence was low ( % at years in all patients, % in cr patients) and was not impacted by any pre-transplant factors including positive mrd post phase induction (present in patients). notably, in univariate analysis relapse was significantly lower in patients who developed chronic gvhd. background: allogeneic stem cell transplantation (allosct) is the treatment of choice for many patients (pts) suffering from acute myeloid leukemia (aml). the graft vs. leukemia effect (gvl), applied by immunocompetent cells of donor origin, is the most important effector mechanism for the eradication of leukemia, the presentation of leukemic or allospecific antigens by malignant blasts is regarded as a crucial trigger for an effective allogeneic immune response. conversely, insufficient stimulatory capacity by the leukemic blasts is thought to be a relevant escape mechanism from cellular immunotherapy (allosct or donor-lymphocyte infusion (dli)). the purpose was to test, whether the ability of malignant blasts to differentiate in vitro towards dendritic cells of leukemic origin (dc leu ) is associated with response to allosct or outcome after immunotherapy (second allosct or dli) for post-transplant relapse in aml. methods: leukemic blasts were isolated from peripheral blood (pb) or bone marrow (bm) samples of aml patients before allosct (n= ) or at relapse after allosct (n= ). a panel of different assays was used to generate dc leu in vitro ( of them containing gm-csf). finally, in vitro results were correlated with clinical characteristics and outcome of patients treated with donor lymphocyte infusion and/or allosct. results: dc leu could be generated in vitro from all samples. when correlating proportions of dc-subtypes generated ex vivo with clinical data, significantly higher mean proportions of dc leu in the dc-fraction were found in responders vs. non-responders to immunotherapy ( . % vs . %,p= . , range: %- %). vice versa, the chance for response to immunotherapy was significantly higher, if a dc leu /dc ratio of >= % could be reached in vivo (p= . ). those patientswere characterized by a longer time to relapse (p= . ) and by a higher probability for leukemia-free survival (p= . ). similarly, generation of higher amounts (> %, p= . ) of dc leu in the mnc-fraction, and generation of more mature dc (> % cd +, p= . using the best gm-csf containing assay) were associated with a longer time to relapse in the respective patients. moreover, overall survival was improved, if > % dc leu /dc could be generated with the best gm-csf containing assay (p= . ). conclusions: in vitro generation of dc/dc leu from leukemic blasts obtained in active stages of aml before allosct or at relapse post transplant were associated with clinical outcome. this observation supports a role of antigen presentation by leukemic cells for an allogeneic immune response in aml. disclosure: nothing to declare background: the role of autologous hematopoetic cell transplantation (hct) in the treatment of aml is not clear. trials in the past have shown that autologous hct consolidation lowers the risk of relapse, however the magnitude of this effect is limited . autologous hct is advocated in patients with aml with lower genetic risk in cr .many of these patients will eventually relapse and will undergo reinduction followed by allogeneic hct in cr . methods: the aims of this study is to analyze outcome of allogeneic hct performed in cr comparing patients with prior consolidation by autologous hct vs. patients with chemotherapy consolidation. primary outcome is non relapse mortality (nrm) of allogeneic hct in cr in patients with, or without prior autologous hct in cr . secondary outcomes include leukemia free survival (lfs), relapse rate (ri), graft versus host disease free relapse free survival (grfs), overall survival (os), and treatment related toxicities. results: adult patients reigstered with the alwp of the ebmt with de novo aml were included, receiving a first allogeneic hct in cr , in cr , in - or without (n= ) prior autologous hct. patient and transplant characteristics are shown in the table. patient groups were not entirely comparable, patients with prior autologous hct were younger, had less often a favorable cytogenetic profile, had more commonly donors other than matched siblings and more often received reduced intensity conditioning (ric) as compared to mac conditioning. univariate outcomes are shown in the table with slightly higher nrm risks in patients with prior autologous hct consolidation. in multivariate analysis nrm risks in patients with prior autologous hct were . ( . - . ), p= . after adjustment for patient age, cytogenetic risk category, year of transplant, donor type, conditioning intensity, sex matching, time from diagnosis to relapse and time from relapse to allogeneic hct as compared to patients with chemotherapy consolidation. similarly, risks of events in lfs and grfs were higher with prior autologous hct, . ( . - . ), p= . and . ( . - . ) p= . , respectively, risk of death was also higher . ( . - . ) p= . but this was not statistically significant. conclusions: we may conclude that some of the advantages of potentially higher anti-leukemic activity of high dose chemotherapy and autologous hct when given to patients with aml in cr (as was shown in a randomized trial by vellenga e et al with lower relapse and higher lfs by approximately % but no significant differences in overall survival) may be lost by higher toxicity of allogeneic hct in cr in case of subsequent relapse. background: although relapse is a major cause of mortality in patients receiving allogeneic hematopoietic cell transplantation (hct) for acute leukemia, limited and conflicting data exist on extramedullary relapse (emr). we aimed to describe the incidence, risk factors, outcomes and prognosis in relapsed hct recipients. methods: we retrospectively reviewed charts of consecutive allogeneic hct recipients transplanted in our center with the indication of acute leukemia ( / - / ). we recorded: age, gender, disease, previous extramedullary involvement, phase at transplant, type of transplant, donor, conditioning, graft-versus-host-disease (gvhd), infections, treatment-related mortality and relapse mortality. in patients with extramedullary relapses, additional data on clinical manifestations, imaging, cerebrospinal fluid testing, histopathology and management were additionally documented. incidence of isolated emr (iemr) and bone marrow relapse (bmr) was calculated using cumulative incidence (ci) analysis, with each and treatment-related mortality considered a competing risk. results: among allohct recipients followed for . ( . - . ) years, ( %) patients presented with emr. the majority of emrs involved the central nervous system (cns, %). isolated emr was observed in patients at . ( . - . ) months. -year cumulative incidence (ci) of . % for iemr was associated only with pre-transplant advanced disease phase (p< . ). bmr was observed in patients at ( . - months), with a -year ci of . %. in the multivariate analysis, bmr ci was independently associated with fungal infections (p< . ), pre-transplant disease phase (p< . ) and lines of treatment (p= . ). -year trm of our whole cohort was . %. the majority of iemr and bmr ( % and %, respectively) patients received systemic treatment combined with local radiation for iemr ( %) and donor lymphocyte infusions (dlis, % and % respectively) when feasible. extensive chronic gvhd was recorded in % of iemr and % of bmr patients. outcomes were poor in iemr, with -year overall survival (os) of . %. favorable os in iemr was associated only with sibling donors (p= . ) and not with other factors, such as treatment with dlis or presence of chronic gvhd. similarly poor outcomes ( year os of . %) were observed in bmr. favorable os was independently associated only with the diagnosis of aml (p= . ) and absence of bacterial infections (p= . ). in the whole cohort, both iemr and bmr were independent unfavorable predictors of os (p< . ) along with extensive chronic gvhd (p= . ). conclusions: in a large population with long-term follow-up, incidence of iemr was relatively high, developed at the late post-transplant period and associated only with disease phase at transplant. furthermore, iemr and bmr conferred similarly poor outcomes despite systemic treatment or extensive chronic gvhd. these independent predictors of survival highlight the unmet clinical need of novel approaches either as maintenance or treatment to reduce extramedullary or systemic relapse post allohct for acute leukemia. disclosure: no competing financial interest. impact of t-cell depletion on outcome in patients undergoing allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia background: after a diagnosis of acute myeloid leukemia (aml) the majority of patients (pts) who achieve complete remission (cr) eventually relapse, with only approximately % of pts maintaining cr for years or longer. late relapses (after years in cr) occur rarely ( - %) in pts receiving hsct in cr and late effects are followed up by routine surveillance as well as preventative measures. the purpose of this study was to investigate long-term outcomes in pts with diagnosis of aml undergoing hsct at our institution in cr . methods: a standardized follow-up of hsct-survivors is applied at our center. we analyzed adult pts with aml in cr consecutively transplanted between january and december at our institution. a written consent was given for the use of medical records for research. a landmark analysis was adopted for patients in cr at -y after hsct (ltcr -long-term cr). results: ltcr was achieved after hsct in / patients (male , female ) transplanted in cr . the median follow-up was years and the median age at transplant years (r - ). the selected donor was a family haploidentical relative in cases, an hla identical relative in , a match unrelated donor in and a cordblood in . in this cohort of ltcr, the -year overall survival was % ( % ci - ). cumulative incidence of relapseevaluated in competing risk with transplant related mortality (trm) -and trm -evaluated in competing risk with relapse -were respectively % ( % ci - ) and % for the cr cohort. the event-free-survival (efs) was % ( % ci - ). the causes of death were relapse ( / pts), second cancer ( / pts) and sepsis ( / pts). the -year incidence of dyslipidemia -defined as cholesterol >/= mg/dl, and/or ldl >/= mg/dl, and/or triglycerides >/= mg/dl or need for specific treatment -was %. the -year incidence of osteopenia / osteoporosisdefined as t-score lower than - and greater than - . and t-score lower than . respectively -was %. the -year incidence of second cancer was %: nonmelanoma skin cancer, lung carcinoma, cervical intraepithelial neoplasm, thyroid cancer, gastric cancer and colon cancer. the -year incidence of chronic moderate-severe gvhd was % ( % ci - ), with the latest diagnosis performed on day . of note, / pts are still on active treatment at last follow-up. conclusions: relapse incidence is low for patient that reached ltcr: patients in cr at transplant can obtain excellent os and efs once reached the target of ltcr. a proactive long-term follow-up and strategy of counseling are essential to keep at best quality the survival advantage offered by hsct in patients with aml in cr . disclosure: chiara bonini has research contract with intellia therapeutics. the other authors declare that they have no conflicts of interest. background: relapse, graft-versus-host disease (gvhd) and gvhd-associated mortality are major obstacles to success of transplantation from unrelated (mud) donors in children with acute leukemia (al). negative depletion of αβ t cells and cd + b lymphocytes, conserves the mature donor-derived natural killer cells and γδ t cells in the graft, may improve gvhd control, immune reconstitution and prevent the relapse. we present a retrospect analyses of a cohort of pts with al in cr transplanted from mud with depletion. methods: a total of children with acute leukemia ( aml, all, female, male, median age , y) underwent allo hsct from matched unrelated donor between june and july . all pts were in complete remission (cr = , cr = , cr> = ). all pts, except one, received treosulfan-based conditioning. either melphalan (n= ) or thiophosphamide (n= ) or etoposide (n= ) were added as a second agent. fludarabine was used in all pts. two types of gvhd prophylaxis were used: type (n= ): hatg mg/kg and post-hsct tacro/mtx (n= ) or without prophylaxis (n= ); type (n= ): thymoglobulin(ratg) mg/kg, rituximab mg/ m with either bortezomib on days + , + (n= ) or tacro/ mtx (n= ) . aβ t cell depletion with clinimacs was used in all cases. the median dose of cd + cells was x / kg, aβ t cells - x /kg. median time of follow-up for survivors was , years (range, , - , ) . results: primary engraftment was achieved in % pts., the median time to neutrophil and platelet recovery was and days, respectively. all evaluable pts achieved sustained complete donor chimerism by day + . early ( day) mortality was , % ( pt -bacterial sepsis, pt -adv fulminant hepatitis), -years overall ptrm at years was , % ( %ci: - ). six late trm events were due to: viral infection in pts (cmv= , adv+cmv= ), bacterial sepsis in pts and pts had bacterial and viral infection, all late deaths were associated with cgvhd and prolonged corticosteroid therapy. ci of acute gvhd grades ii-iv was % ( % ci: - ), acute gvhd grades iii-iv , % ( % ci : , - , ) . ci of cgvhd was %( %ci: - ). regimen was more effective in prevention of agvhd ii-iv in comparison with regimen : % ( % ci: , - ) vs , %, respectively, p= , . all events with acute gvhd grades iii-iv had pts with regimen . ratg was also effective in prevention of cgvhd: ci at years after hsct was , % vs. %, respectively, p= , . cumulative incidence of relapse was % ( %ci: - ) without difference between ratg and hatg. event-free survival (efs) (event=death or relapse) at years was % ( %ci: - ), overall survival %( % ci: - ), there were no difference between age and diagnosis. conclusions: we confirm that the depletion of tcrαβ +/cd + t lymphocytes from the graft ensures high engraftment rate. transplant-related mortality is caused by infections, mostly associated with cases of chronic gvhd. gvhd prophylaxis including ratg/rituximab/ bortezomib improves gvhd control in recipients of tcrαβ+/cd +depleted grafts in comparison to hatg/ tacro/mtx apparently without loss of anti-leukemic activity. disclosure results: at baseline, r/r all with emd and lbl were diagnosed in and ino patients and and sc patients. median (range) age of the ino and sc patients was . ( - ) and . ( - ) years, with / ( . %) and / ( . %) males, respectively. the rate of cr/cri was significantly higher in the ino group ( / [ . %] , % confidence interval [ci] : . - . ) compared with sc ( / [ . %], % ci: . - . ; p= . ) (table) . allogeneic hematopoietic stem cell transplantation was carried out in / ( . %) ino and / ( . %) sc patients prior to any post-study induction therapy. the pfs hazard ratio [hr] was . ( . % ci: . - . ; p= . ), with median pfs of . ( % ci: . - . ) months among ino and . ( % ci: . - . ) months in sc patients. the os hr was . ( . % ci: . - . ; p= . ), with median os of . ( % ci: . - . ) months in ino versus . ( % ci: . - . ) months in sc patients (figure) . all patients had adverse events (aes). serious aes occurred in / ( . %) ino and / ( . %) sc patients; ( . %) ino and sc patients had grade ae. one ( / , . %) patient in the ino group died from veno occlusive disease. conclusions: among r/r all patients with emd and lbl, improvement in remission rates, transplant rates, and progression free survival was shown in the ino group versus the sc group. although patient numbers were small and limited the ability for a robust comparison, these results support the use of ino in patients in this difficult to treat population with r/r all and emd or lbl. background: bcr-abl-targeted tyrosine kinase inhibitors (tki) revolutionized the outcome of patients inflicted with ph+ b-all. moreover, addition of tki may be relevant strategy for ph-like all patients. methods: we hypothesized that overcoming the bm microenvironment-mediated protection of all cells from tki-mediated apoptosis may further enhance the responsiveness to tki therapy. results: in vitro treatment of bcr-abl-positive all cell lines nalm and nalm ) with dasatinib resulted in significant dose-dependent cell growth inhibition, with ic of - nm (p< . ). furthermore, dasatinib exhibited significant growth suppression of bcr-abl -negative all cells (nalm and reh), with ic of nm and nm, respectively. however, when cocultured with bone marrow stromal cells (bmscs), dasatinib-mediated effect was abrogated in both ph-and ph+ all cells. furthermore, dasatinib treatment promoted significant upregulation of chemokine receptor cxcr , on both mrna and cell surface levels. elevated cxcr expression was accompanied by increased responsiveness of all cells to cxcl stimulation, resulting in strong and sustained phosphorylation of erk / and akt and increased adhesion capacity to bmscs. therefore, dasatinib-induced upregulation of cxcr promotes stroma-mediated survival advantage of all cells upon tki therapy. next, in order to overcome the cxcr -mediated stromal protection, we choose to combine dasatinib with the histone deacetylase inhibitor panobinostat, for its known ability to deplete cxcr in aml cells. single-agent treatment with panobinostat demonstrated significant inhibition of ph-and ph+ all cell growth at low nanomolar concentrations (p< . ). importantly, combination of panobinostat with dasatinib synergized (ci< . ), effectively overcoming the protection provided by bmscs and inducing the apoptosis of ph-and ph+ all cells, as demonstrated by phosphatidylserine externalization, mitochondrial depolarization and dna fragmentation. furthermore, combining panobinostat with dasatinib significantly reduced cxcr surface levels in ph-and ph+ all cells. accordingly, cxcl mediated responses, including erk / and akt activation and adhesion to bmscs were significantly reduced upon combined panobinostat/dasatinib treatment. these data indicate that panobinostat effectively suppresses both basal and dasatinib-induced cxcr expression and function in all cells overcoming stroma-mediated resistance to dasatinib. to determine the molecular mechanism, we performed gene and protein expression analysis. panobinostat, alone or in combination with dasatinib, significantly down-regulated the protein levels of calcineurin, a serine-threonine protein phosphatase previously implicated in t-all and b-all pathogenesis, as well as of nfatc , a critical effector of the calcineurin signaling cascade, and nfatc -regulated target genes. it was previously found that calcineurin signaling positively regulates cxcr expression in t lymphocytes. additionally, cyclosporin a (csa) decreased both basal and dasatinib-induced cxcr surface levels in all cells, overcoming the protection of the bmscs which result in potentiation of the cytotoxic effect of dasatininb and panobinostat. combining csa with panobinostat resulted in deeper suppression of nfatc -regulated target genes. we thus link the effect of panobinostat with calcineurin-dependent downregulation of cxcr , blocking the ability of the leukemic cells to respond to cxcl mediated stromal support. conclusions: taken together, our results identify calcineurin signaling pathway as a novel target of panobinostat in all cells and indicate that hdac inhibition with panobinostat may be effective strategy for facilitating the anti-leukemic activity of tki therapy. disclosure: nothing to disclose background: the treatment of relapsed/refractory acute lymphoblastic leukemia (rr-all) remains a clinical challenge with a generally dismal prognosis. allo-sct using a sequential conditioning ("flamsa"-like regimen) has shown promising results in relapsed/refractory aml, but little is known about the efficacy of this procedure in rr-all. methods: we identified adult patients ( % females; median age: y; range, - ) with all in primary refractory phase ( %) or in relapse ( %), allografted between and from a matched sibling ( %), matched unrelated ( %) or haploidentical donor ( %) at ebmt participating centers. almost half ( %) of the patients had t-all and % had a positive philadelphia chromosome. six patients ( %) underwent a previous autotransplant. karnofsky score was above in % of patients. conditioning was myeloablative (mac) with high dose tbi in % of patients, reduced intensity (ric) including low dose tbi in %, or with chemotherapy alone in %. in vivo t cell depletion was performed in cases ( %). most patients ( %) and about half of the donors ( %) were cmv positive. % of patients were males who received a graft from a female donor. the median follow-up was (range, - ) months. results: overall, patients ( %) failed to engraft, ( %) died within days after allo-sct without relapse, and ( %) could achieve complete remission. at day , the cumulative incidences of grade ii-iv and grade iii-iv acute gvhd were % and %, respectively. the year cumulative incidences of chronic and extensive chronic gvhd were % and %, respectively. the -year relapse incidence (ri) and non-relapse mortality (nrm) were % and %, respectively. the -year leukemia free survival (lfs), overall survival (os) and gvhd relapsefree survival (grfs) were %, % and %, respectively. in a multivariable cox analysis, karnofosky score below negatively affected ri, lfs, os and grfs. also, conditioning with chemotherapy alone, compared to tbibased conditioning, negatively affected relapse rates (hr= . ; p= . ), lfs (hr= . ; p= . ) and os (hr= . ; p= . ). conclusions: allo-sct using a sequential conditioning regimen is proposed by different teams in rr-all, and could be an option, especially when considering a tbibased regimen. however, the overall -year lfs of % suggests that these patients still face extremely dismal outcomes, highlighting that other therapies (e.g. bite antibodies, inotuzumab, car t cells) need to be combined prior and/or after allo-sct in order to further improve outcome. disclosure: no conflict of interest, no funding received chemotherapy courses, only pts were not treated: pts for the worsening of the general status and the other for invasive fungal infection. results: forty-three pts ( %) were in complete remission (cr) and negative minimal residual disease (mrd) at the time of hsct; pts were in active disease ( %), and ( %) showed a morphological cr with positive mrd. pts ( %) developed chronic graft versus-host disease (cgvhd) as followed: pts ( %) mild, pts ( %) moderate, and only sever grade respectfully. only patient developed cgvhd after dli. the overall leukemia free survival (lfs) time was months, the absence of cgvhd (hazard ratio -hr: , ; p = , ) and the pre-hsct disease status (hr , ; p = , ) were the most important factors on lfs. all pts treated with chemo-based regimens died due to progression or infective complications. patient of aza/dli group is still alive with a extramedullary relapse; pts treated with bl/dli are in cr. os was better for the dli group compared to the chemotherapy group ( vs months respectfully; p < , ). conclusions: dli after allo-hsct has exhibited definite anti-leukemic effects in post-transplant patients. bl and aza were reported to increase dli's graft vs-leukemia (gvl) effect. although cgvhd could be the most important protective factor against the relapse but it remains the main cause of morbidity. maximising the gvl effect without putting the patient at risk of gvhd still represents an unmet need. our data show that the combination of either bl or aza with dli infusion is safe and might represent an improvement in disease control in the early phase of relapse. disclosure: nothing to declare p increased detection of (leukemiaspecific) adaptive and innate immune-reactive cells under treatment of amldiseased rats and one therapy-refractory aml-patient with blastmodulating, clinically approved response modifiers (pg-e ,kit-k) or +pge (kit-m),patent ) convert myeloid blasts into dendritic cells of leukemic origin (dc leu ). after stimulation with dc leu , antileukemic tcells can be generated ex vivo. the compounds are approved for clinical use and are therefore attractive tools for immunotherapy in myeloid leukemia. methods: dc/dcleu-culture from rats'/patients' wholeblood (wb) with kits, mixed lymphocyte culture (mlc) of tcells with kit-treated blood, functional blast-cytotoxicity and leukemia-specificity assays (csa/elispot/degranulation/intracellular cytokine-assays). in addition flowcytometric evaluations of cellular and (leukemia-specific) lymphocyte compositions were performed from rats'/pts' blood in the course of the disease. results: ) aml-diseased rats: each rats were treated with "i", "k" or "m" or were untreated (controls). a significant increase of dcleu could be detected in spleen/pb in kit-(esp. m) treated compared to untreated animals without induction of blasts' proliferation (ki positivity): a significant reduction of blasts was seen with "m" (p= . / . in spleen/pb) and "i", but not "k". successful treatment correlated with an increase of cd l+tcells, most likely representing tmem-cells, (p= . ) and a reduction of cd +treg (p= . ). ) therapy-refractory aml-patients (during the course of decitabine/ld-aractreatment): kit-m was shown to ex vivo generate dcleu, activate immunereactive cells and mediate leukemia-specific/antileukemic response. activated or leukemia-specific lymphocytes were monitored in low proportions in active stages of the disease as well as of two patients during the further course of persisting disease. one of these patients ( yo male), was offered an individual systemic salvage-treatment (kit-m, applied as continuous infusions) for refractory leukemia. after approval from the local ethical commitee,extensive information of the patient about the experimental nature of the treatment and obtaining his written informed consent. clinically the treatment was well tolerated and the patient improved clinically. neutrophils in wbc increased from % to %, thrombocytes reached g/l after days. after weeks of treatment, the patient was discharged in good clinical conditions. days later, progression of aml was seen with high blast counts in pb and bm. the patient developed severe sepsis and died few days later. immune monitoring showed (other than before treatment and in the patients without kit-m-treatment) a continuous increase of proliferating and non-naïve tcells, nk, cikand nkt-, th cells, bmem-cells and dc in pb. the production of ifnƔ producing t-, cik and nkt-cells was demonstrated, suggesting an in vivo production/activation of (potentially leukemia-specific) cells. immune stimulatory effects decreased after discontinuation of therapy. conclusions: treatment of wb as well as leukemically diseased organisms with blast-modulating kits (especially gm-csf and pge ) was well tolerated and induced clinical and immunological improvement (adaptive and innate immune system), whereas low counts of (leukemiaspecific) activated immune-reactive cells were found in non-kit-treated organisms. disclosure: nothing to declare p long-term outcomes after allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia with non-myeloablative and myeloablative conditioning: a single-center cohort study of consecutive patients lars klingen gjaerde, niels smedegaard andersen , lone smidstrup friis , brian thomas kornblit , søren lykke petersen , ida schjødt , henrik sengeløv rigshospitalet, copenhagen, denmark background: since , we have at our institution used a non-myeloablative (nma) conditioning regimen for older (> years) or significantly comorbid younger patients undergoing allogeneic hematopoietic stem cell transplantation (allo-hsct) for acute myeloid leukemia (aml). we aimed to compare the long-term outcomes of nma conditioned patients with myeloablative (ma) conditioned patients. methods: we studied nma and ma conditioned adult (> years) consecutive patients receiving their first allo-hsct for aml from to at rigshospitalet. nma conditioning consisted mainly of gy total body irradiation (tbi) and fludarabine mg/m ( % of cases). ma conditioning consisted mainly of cyclophosphamide mg/ kg and either gy tbi ( % of cases) or busulfan . mg/ kg ( % of cases), or fludarabine mg/m and treosulfan mg/m ( % of cases). five percent and % of nma and ma conditioned patients, respectively, received anti-thymocyte globulin. patients were followed until death or end-of-followup on october st , . cumulative incidences with % confidence intervals (ci) of acute graft-versus-host disease (agvhd) grade ii-iv, chronic graft-versus-host disease (cgvhd), relapse and non-relapse mortality (nrm) were calculated and compared between nma and ma conditioned patients using gray's test with death as a competing risk (or relapse when comparing nrm). overall survival (os) was estimated by the kaplan-meier method. results: nma and ma conditioned patients were comparable when regarding sex ( % and % female, respectively) and donor (matched related donor in % and %, respectively), but differed, as expected by indication, with regards to age (median of versus years, respectively) and karnofsky score (< in % and %, respectively). nma conditioned patients had generally a lower aml stage at transplant ( st complete remission in % versus % of ma conditioned patients) and a lower aml cytogenetic risk (adverse risk in % versus % of ma conditioned patients). patients were followed for a total of person-years (median follow-up in surviving patients was . years). agvhd grade ii-iv occurred less frequently in nma conditioned patients ( % [ci: %- %] versus % [ci: %- %] in ma conditioned patients, p < . ), while cgvhd occurred in similar rates ( % [ci: %- %] in nma conditioned patients and % [ci: %- %] in ma conditioned patients, p = . ). there was a trend towards a higher relapse rate in nma conditioned patients ( % [ci: %- %] versus % [ci: %- %] in ma conditioned patients, p = . ), and nma conditioned patients had, however not with statistical significance, lower nrm ( % [ci: %- %] versus % in ma conditioned patients, p = . ). os ( figure) was comparable, with -year os rates of % (ci: %- %) in nma conditioned patients and % (ci: %- %) in ma conditioned patients. conclusions: patients with aml undergoing allo-hsct with nma conditioning at our institution were older and frailer than ma conditioned patients, but their overall survival after transplantation was comparable. this might be explained by a generally lower aml stage and cytogenetic risk at transplant in nma conditioned patients. jedlickova , saskia güller , rosa toenges , juliane steinmann , hans martin , hubert serve , gesine bug background: allogeneic hsct is urgently indicated in patients with aml in first complete hematologic remission (chr) after intensive chemotherapy with increasing or recurrent minimal residual disease (mrd). these patients are at high risk of hematologic relapse (hr) during preparation of their transplant and hsct with active aml was found associated with poor outcome. azacitidine has recently been shown to substantially delay or even prevent hr in > % of patients (relaza trial, platzbecker et al., lancet oncology ) . we here present the outcome of a small cohort of consecutive patients with mrd-positive aml who received low dose cytarabine (ldarac) as bridging therapy prior to hsct. methods: mrd was assessed by quantitative polymerase chain reaction (qpcr) using mutated npm (n= ), runx -runx t (n= ), cbfb-myh (n= ) or kmt a-ptd (n= ). mrd negativity was defined as ratio of oncogene to control gene (abl ) ≤ , % while increased or recurrent mrd required a ratio > % (shayegi et al., blood ) . primary endpoint of our retrospective analysis was progression to hr (≥ % bone marrow blasts or extramedullary disease); secondary endpoints were achievement of molecular remission prior to hsct, neutropenia g according to ctcae, thrombocytopenia g , anemia ≥g , admission to hospital, os and rfs. os and rfs were calculated from the first dose of ldarac. ldarac was self-administered subcutaneously by the patients at home at a flat dose of mg bid over days and repeated after weeks if necessary. results: between / and / , nine patients (median age , range, - years) with low (n= ), intermediate (n= ) or high-risk cytogenetics (n= ) according to eln criteria were treated in continuous chr for increasing (n= ) or recurrent mrd (n= ) starting at a median of (range, - ) days after the last consolidation therapy, i.e., duration of chr was > months in all pts. patients received one (n= ), two (n= ) or three cycles (n= ) of ldarac prior to hsct. in three patients, neutropenia g occurred and one patient needed platelet transfusion. all patients were managed in the outpatient setting. in eight out of nine patients ( %), hr was successfully prevented and patients ( %) even became mrd negative prior to hsct. one patient (runx -runx t positive aml) progressed to hr after one cycle of ldarac and received salvage therapy with high-dose arac and mitoxantrone (ham) prior to hsct. all patients proceeded to hsct from a matched related (n= ), unrelated (n= ) or haploidentical donor (n= ) and are still alive (median follow-up of days). conditioning regimens included fludarabine (flu)/melphalan (mel)/tbi (n= ), flu/mel (n= ), flu/tbi (n= ), flu/busulfan (bu) (n= ) and thiotepa/bu /flu (n= ). after hsct, only the ldarac-refractory patient relapsed, resulting in a probability of rfs of % at years. conclusions: our data suggest that a bridging therapy with up to three cycles of ldarac prior to hsct is feasible and was associated with favorable outcomes in patients with npm -mutated or core binding factor aml and molecular relapse > months after achieving a first chr. the treatment has low costs, can be administered on an outpatient basis and is very well tolerated. clinical background: allogenic hematopoietic stem cell transplant (hsct) is the only curative treatment for all the patients with aml. high risk disease qualifies for upfront hsct irrespective of the presence of matched sibling donor (msd). in the absence of msd, haploidentical stem cell transplant is easier option with success rates as high as msd in a high volume transplant centre. we present our experience from a single centre. methods: we analyzed retrospective data of aml patients who have undergone hsct at our centre between january- and august- . for msd transplant we used fludarabine + busulfan or fludarabine + melphalan conditioning regimen, in matched unrelated donor transplant (mud) regime used was fludarabine + busulfan + atg. we followed john hopkins's protocol for haploidentical hsct. cyclosporine + methotrexate was used as gvhd prophylaxis in msd and unrelated donor group and cyclophosphamide + tacrolimus + mycophenolate was used for haploidentical post-transplant. day survival, overall survival (os), incidence of gvhd and cmv reactivation was computed. results: a total of aml patients underwent hsct during the study period, the basic and clinical characteristics of the study patients are presented in table . conditioning regime did not have significant impact on os. survival at day was %. the os function and relapse free survival (rfs) function did not significantly differ between msd and haploidentical transplantation ( . % vs . %; p= . ) and ( . % vs . %; p= . ) (graph ). disease status at latest follow up showed that % were in remission and % had relapsed. overall one year survival and five year survival in the entire cohort was % and % respectively. the average cost of msd transplant at our centre is inr , , (€ - ), haploidentical transplant is inr , , (€ - ) and mud transplant is inr , , (€ , + for stem cell procurement). conclusions: our study showed comparable outcomes in msd and haploidentical transplant with respect to day survival, os, and rate of gvhd. in a developing country like india where patients are not covered under state health insurance, the additional cost of procurement of stem cells in a mud transplant would add to the financial burden to the patients. haploidentical transplant is a feasible option in case of non-availability of msd, due to ease of donor availability and strong motivation from the family donor to donate the stem cells. background: allogeneic stem cell transplantation (allo-hsct) is not indicated as consolidation of first complete remission (cr ) in favorable-risk acute myeloid leukemia (aml) bearing mutations in nucleophosmin (npm ) in the absence of flt internal tandem duplication (flt -itd). nevertheless, a substantial proportion of patients eventually proceed to allo-hsct beyond cr or for chemoresistant minimal residual disease (mrd) while in cr , which might compromise transplantation outcomes. the study aimed at examining the characteristics and results of allo-hsct in aml cases with mutated npm and wild-type flt (npm mut/flt wt), with special focus on molecular monitoring of mrd following transplantation. methods: from / until / , patients (women/men, / ) underwent allo-hsct for npm mut/ flt wt aml. at transplant, median age of patients was . years (range, - ) , and disease phase was cr (n= ), cr (n= ), or primary refractory (n= ). among the patients who were transplanted in cr and had available molecular mrd assessments, had detectable mutant npm transcripts by real-time quantitative pcr (rq-rcr). also, patients fulfilled criteria of molecular relapse (increasing levels of npm -mutated transcripts in two successive bone marrow samples), with mutant npm load of - , transcripts/ , abl transcripts). the conditioning regimen was myeloablative in the majority of cases (n= ) or reduced-intensity (n= ). the type of donor varied, namely hla-identical sibling (n= ), matched unrelated (n= ), haploidentical relative (n= ), or double umbilical cord blood (n= ). results: engraftment was achieved in all cases, with a median time to absolute neutrophil count > /ul of days (range, - ) . among the patients with posttransplant monitoring of mrd by rq-pcr, exhibited a stable molecular remission whereas a rising level of npm mutated transcripts was observed in cases due to either hematologic (n= ) or molecular (n= ) relapse of disease. the cumulative incidences (cin) of hematologic relapse and non-relapse mortality (nrm) were . % and % at months, respectively. no events of relapse or nrm were encountered beyond months from allo-hsct. out of patients with hematologic relapse post transplant, died of disease whereas one achieved a stable complete remission after withdrawal of immunosuppression. at a median follow-up time of months (range, - ), / patients continue to be alive in cr. the estimated disease-free background: cpx- (vyxeos®) is an advanced liposomal encapsulation of cytarabine/daunorubicin at a synergistic : molar ratio. cpx- is approved by the us fda and ema for the treatment of adults with newly diagnosed, therapy-related aml or aml with myelodysplasia-related changes. methods: safety data were pooled from studies of cpx- in adults aged - years with newly diagnosed or relapsed/refractory aml. cpx- induction consisted of units/m (cytarabine mg/m + daunorubicin mg/m ) on days , , and (second induction: days and ) . cpx- consolidation consisted of or units/m (varying by study) on days and . cpx- was evaluated against standard-of-care controls. results: baseline characteristics were generally balanced between cpx- (n= ) and controls (n= ); the majority of patients were aged ≥ years ( %; %) and had secondary aml ( %; %). controls included + (n= ) and salvage therapy with mitoxantrone/etoposide/ cytarabine (n= ), idarubicin/cytarabine (n= ), other cytarabine-based chemotherapy (n= ), and mitoxantrone/ etoposide (n= ). the treatment-emergent adverse event (teae) profile of cpx- units/m was comparable to induction controls, but associated with a greater proportion of patients with teaes, grade ≥ teaes, and serious teaes during consolidation (table) . therefore, the cpx- consolidation dose was reduced to units/m in latter studies; this dose demonstrated an improved teae profile similar to consolidation controls. the most frequent system organ class was gastrointestinal disorders for both cpx- and controls; a lower incidence was reported for cpx- ( %) versus controls ( %), with this difference driven by the lower incidence of diarrhea for cpx- ( %) versus controls ( %). the most frequently reported grade ≥ teaes were febrile neutropenia (cpx- : %; controls: %), pneumonia ( %; %), hypoxia ( %; %), and bacteremia ( %; %). early mortality rates, both overall and by treatment period, appeared lower with cpx- versus controls at day and day ( table) ; the majority of early deaths were attributable to teaes. conclusions: across the studies comprising the cpx- clinical development program, cpx- demonstrated a safety profile comparable to conventional chemotherapy in adults with newly diagnosed or relapsed/refractory aml. background: haploidentical hematopoietic stem cell transplantation (hsct) with post-transplantation cyclophosphamide (pgcy) marked improved clinical outcome. recent studies comparing allogeneic hsct using unrelated donors versus haplo donors in patients with acute leukemia have suggested equivalent outcomes. the depletion of tcells with pgcy was subsequently applied for unrelated hsct setting for patients with unrelated donor. methods: we performed a retrospective study on patients with acute leukemia in order to compare the outcome after hla haploidentical (n= ) and unrelated hsct (n= ) with pgcy. the main characteristics of patients were similar in both groups. baseline disease were: aml ( %) and all ( %) for haplo group and aml ( %) and all ( %) for unrelated group. disease state at time of haplo and unrelated-hsct were following: and patients in cr ( % and %) and and non cr ( % and %). for aml recipients mainly received thiotepa, busulfan and fludarabine and for all recipients received tbi and etoposide conditioning. all patients who received pbsc graft were treated with rabbit antithymocyte globulin (atg) on days - and - . results: at the time of analysis, the os and dfs did not differ between the haplo and unrelated groups ( % vs %, and % vs %). incidence of severe (grade [ ] [ ] acute gvhd was the same in two groups ( % versus %). recipients of haplo-hsct transplant were statistical significance less likely to experience disease relapse ( % vs %) and chronic gvhd ( % vs , %). however, gvhd free relapse free survival (grfs) rate was slightly higher after haplo-hsct ( % vs %). addition, cumulative incidence of trm rate was higher after haplo-hsct ( % vs %).for haplo and unrelated groups who underwent hsct in cr , the os were % and % versus % and % for those in non cr . for aml, the os was same in two groups (haplo % versus unrelated %). however patients with all, the os was higher in haplo group compared with unrelated group ( % versus %). the impact of pretransplant disease state have a more powerfull effect on survival in the haplo-hsct setting (for aml cr % versus non cr % and for all cr % versus non cr %). viral reactivations were significant concern in both groups. conclusions: our retrospective analysis suggests largerly similar os and dfs with haplo versus unrelated transplants with pgcy for acute leukemia. our data indicate that haplo-hsct results in a lower incidence relapse and of chronic gvhd and higher grfs compared with unrelated hsct. in addtion, the pretransplant disease state have the important effect on the outcomes in both groups. allo-pbsc with atg can be used safely and effective as graft source in haplo-hsct with acceptable post-transplant outcomes and replaced bm in this settings. more statistical data for transplant related characteristics will be provided at the presentation.we emphasize that use the same pgcy gvhd prophylaxis for all types of allogeneic transplant. based on our results, we recommend haplo-hsct with pgcy against unrelated transplant for patients with acute leukemia. disclosure: disclosure of conflict of interest: none. excellent efficacy and tolerability of inotuzumab ozogamicin in b-cell all relapsed after allo-hsct background: donor lymphocyte infusion (dli) could be used prophylactically to reduce relapse after allogeneic hematopoietic stem cell transplantation for very high-risk leukemia/lymphoma without effective targeted therapy. to compare the safety and efficacy of prophylactic dli for prevention of relapse after allogeneic peripheral blood stem cell transplantation from haploidentical donors (hid-sct) and matched-sibling donors (msd-sct) in patients with very high-risk acute myeloid leukemia (aml), we performed a retrospective, observational cohort study enrolled in hid-sct and msd-sct recipients. methods: the very high-risk features were defined as: (i) in the non-remission (nr) state prior to transplantation, including primary induction failure, relapse untreated or refractory to reinduction chemotherapy, or untreated aml evolution from mds; (ii) achieving complete remission with ≥ cycles of induction of chemotherapy; (iii) carrying tp , dnmt a, tet or flt -itd gene mutation. the scheduled time of the prophylactic dli was + - days after transplantation for msd-sct recipients and + - days for hid-sct recipients. the g-csfmobilized peripheral blood stem cells were infused to the recipient at a dose of × cd + cells/kg. csa was given at mg/kg b.i.d from day - to day + (hid-sct) or to day + (msd-sct), and then tapered at % per month to be discontinued on day + - (hid-sct) or on day + - (msd-sct) unless graft-versus-host disease (gvhd) developed. if the patients received dli before day + (hid-sct) or day + (msd-sct), csa was given weeks after dli in hid group and weeks in msd group at a though concentration of - ng/ml for dliassociated gvhd prophylaxis, and then tapered and discontinued within weeks unless gvhd developed. if gvhd occurred before the scheduled time of prophylactic dli, it would be delayed for weeks when gvhd was well controlled. results: prophylactic dli was administered at a median of ( - ) days for hid-sct recipients and ( - ) days for msd-sct recipients (p= . ), and both groups displayed similar baseline characteristics except for donor's gender distribution (table ) . grade - acute graft-versushost disease (gvhd) at -day post-dli was higher in hid-sct group than that in msd-sct group ( . % vs. . %, p= . ). grade - acute gvhd ( . % vs. . %), -year chronic gvhd ( . % vs. . %) and severe chronic gvhd ( . % vs. . %) were similar between two groups (p> . ). one-year non-relapse mortality was higher in hid-sct group than that in msd-sct group with marginal significance ( . % vs. . %, p= . ). one-year relapse rate was similar between hid-sct group and msd-sct group ( . % vs. . %, p> . ). estimated -year overall survival (os, . % vs. . %) and relapsefree survival (rfs, . % vs. . %) rates were both similar between hid-sct group and msd-sct group (p> . ). in multivariate analyses, non-remission status prior to transplant, poor-risk gene mutations and donor's age ≥ years predicted a higher risk of relapse after dli. nonremission status prior to transplant predicted inferior os and rfs. patient's age ≥ years also predicted an inferior os. conclusions: prophylactic dli after hid-sct demonstrated similar tolerance and efficacy for reducing relapse compared to that after msd-sct for very high-risk aml. disclosure: the authors declare no conflict of interest. prognostic impact of pre-transplant tim levels on transplant outcome in acute leukemia patients background: t cell immunoglobulin and mucin domaincontaining protein- (tim ), a negative regulator of t cells, is expressed on a variety of tumors including hematological malignancies like acute myeloid leukemia (aml) and some lymphoma types in which it was shown to be associated with an adverse prognosis. the aim of this study is to identify the prognostic impact of pre-transplant tim levels on early and late transplant related complications as well as post-transplant relapse and survival methods: a total of hematopoietic stem cell transplantation (hsct) recipients with an initial diagnosis of acute leukemia [median age: ( - ) years; male/ female: / ] were included in the study. aml was the initial diagnosis in patients ( . %), acute lymphoblastic leukemia (all) in patients ( . %), mixed phenotype acute leukemia in patients ( . %) and blastic plasmacytoid dendritic cell neoplasm in patient ( . %). soluble tim- levels in pre-transplant serum samples were measured with enzyme linked immunosorbent assay (elisa). results: median pre-transplant tim level was . ( . - . ) pg/ml in the whole cohort. pre-transplant tim levels were significantly higher in aml patients when compared to all [ . ( . - . ) vs . ( . - . ); p= . ]. tim levels were significantly lower in patients with abnormal cytogenetics when compared to normal karyotype (p= . ). cytogenetic abnormalities, including mainly a complex karyotype or chromosome abnormalities, were more frequent in patients with low tim levels (p= . ). pre-transplant tim levels were significantly higher in patients who developed post-transplant viral hemorrhagic cystitis (p= . ). a positive correlation was demonstrated between tim levels and acute graft versus host disease (gvhd) grade (p= . ; r= . ). at a median follow-up of . ( . - . ) months, overall survival (os) was found to be better in low-tim group when compared to high-tim group, without statistical significance (% . vs % . ; p> . ) ( figure ). probability of os was relatively better in both aml ( . % vs . %; p> . ) and all patients ( . % vs %; p> . ) representing low pretransplant tim levels in the subgroup analysis conclusions: in this study, elevated levels of pretransplant tim levels in aml patients were compatible with the previous reports which had underlined an increased tim expression on aml stem cells. the possible association of tim expression with cytogenetic features should be confirmed with further studies as there is no adequate data except its relationship with flt -itd mutational status. tim- is also expressed on exhausted t cells in patients with viral infections, including human immunodeficiency virus, hepatitis b and hepatitis c virus. it plays an essential role in the regulation of antiviral and antitumor immune responses which may be an explanation for the increased frequency of hemorrhagic cystitis in patients with higher tim- levels. the adverse prognostic impact of tim on gvhd and os was confirmed without statistical significance which may be related to small sample size. as tim has a wide spectrum of action in the tumor microenvironment including stimulatory and inhibitory activities, further clues are required to define the exact role of this molecule in the clinical course of allogeneic hsct in order to develop targeted therapeutic strategies clinical trial registry: n/a disclosure: nothing to declare p homozygous hla-c is associated with increased risk of relapse after hla-matched transplantation in recipients with acute lymphoid leukemia: a japanese national registry study background: after hematopoietic stem cell transplantation (hsct), the role of natural killer (nk) cells which express killer-cells immunoglobulin-like receptors (kirs) and recognize hla-class ligands is important. kir dl recognizes not hla-c asp (c ), but hla-c lys (c ) and has polymorphism based on the th amino acid of the transmembrane domain. low frequency of c and high frequency of strong kir dl are characteristics observed in japanese. by using large transplant database, we reported that homozygous hla-c (c /c ) recipients displayed lower relapse rates than did c /c recipients after hla-matched hsct for acute myeloid leukemia (aml; hr = . , p = . ) or chronic myeloid leukemia (cml; hr = . , p = . ). this effect seemed to be independent of acute graft-versus-host disease (agvhd) or cytomegalovirus reactivation occurrence (arima n et al bbmt ) . methods: relapse rates of japanese recipients who first underwent hla-matched hsct between and for the treatment of acute lymphoid leukemia (all) were compared between c /c pairs and c /c pairs, using data from japanese data center for hematopoietic cell transplantation and adjusting for transplant characteristics. cord blood transplantation was excluded. multivariable competing risk regression analyses were performed to evaluate relapses and relapse-free survival (rfs) was estimated using kaplan-meier method. results: after recipients who did not achieve remission or experienced graft failure and recipients not-expressing c were excluded, resting recipients aged - years (median, . years) were analyzed. the median follow-up period for survivors was . years. there were recipients expressing c /c and recipients expressing c /c , respectively. after hla-matched hsct, c /c recipients had higher relapse rates than c / c recipients (hr = . , p = . ), resulting in worse rfs among c /c recipients (hr = . , p = . ). the frequent relapse in c /c recipients than in c /c was noticeable among recipients with agvhd (hr = . , p = . ), those without cytomegalovirus reactivation (hr = . , p = . ), and those with ph-negative all (hr = . , p = . ). conclusions: kir dl -positive nk cells may promote graft-versus-leukemia (gvl) in c /c recipients with aml or cml but suppress gvl in c /c recipients with all. one interpretation is that transplant-activated nk cells impair antigen-presenting cells or deprive cytotoxic tlymphocytes of their gvl effects on all cells. this hypothesis may be explained by the fact that agvhd was necessary for the recessive relapse in c /c recipients with all. furthermore, ph-positive all cells sometimes mimic aml cells in terms of their frequent myeloid antigen expression and might be directly targeted by nk cells. it would be necessary to further clarify in vitro the character of nk cell-affecting in the transplant immunity against residual leukemia cells. disclosure: authors have nothing to declare. hematopoietic stem cell transplantation with sequential conditioning for children with relapsed/refractory acute leukemia nao yoshida , kazuki matsumoto , daiki yamashita , yiqing zhu , daichi sajiki , ryo maemura , hirotoshi sakaguchi , asahito hama children's medical center, japanese red cross nagoya first hospital, nagoya, japan background: patients with acute leukemia who fail to achieve complete remission show a dismal prognosis even with allogeneic hematopoietic stem cell transplantation (hsct). this study evaluated whether sequential conditioning approach that is cytoreductive chemotherapy applied shortly prior to the main conditioning followed by hsct can improve prognosis in such high-risk patients. methods: we retrospectively analyzed the outcomes of children (median , range - years old) with primary refractory (n = ) or refractory relapsed (n = ) acute leukemia (aml n = , all n = ) who received hsct in our department between and . the stem cell source was related peripheral blood (pb) in patients, related bone marrow in , unrelated bone marrow in , or unrelated cord blood in . the grafts were hla serologically matched (n = ) or mismatched (n = ) with the recipient. in total, patients received the sequential conditioning approach. as cytoreductive chemotherapy, fludarabine/cytarabine/idarubicin/g-csf (flag-ida) was used in patients, mitoxantrone or daunorubicin/cytarabin in , or other regimens in , and of them were combined with gemtuzumab ozogamicin. without waiting for hematological recovery, the patients promptly underwent hsct; therefore, the median interval between cytoreductive chemotherapy and main conditioning was days. the main conditioning regimens were total body irradiation-based myeloablative (n = ), busulfan-based myeloablative (n = ), or reduced intensity (n = ). results: in children with relapsed/refractory acute leukemia, the -year overall survival (os), leukemia-free survival (lfs), cumulative incidence of relapse (ri), and transplantation-related mortality (trm) were %, %, %, and %, respectively. in multivariate analysis, the use of sequential conditioning was identified as the most favorable factor for lfs (hazard ratio [hr] . ; p = . ), although there were no differences in the outcomes according to the types of cytoreductive chemotherapy or the main conditioning regimen. hla-matched donor (hr . ; p = . ) and pb blasts-negative at the beginning of conditioning (hr . ; p = . ) were also independently associated with better lfs. with sequential conditioning, leukemia burden prior to the hsct was significantly reduced; pb blasts became undetectable at the beginning of conditioning in % patients given the approach, while in % patients without the approach (p = . ). notably, the outcomes in the patients without pb blasts at the beginning of conditioning who received sequential conditioning were promising; the -year os and lfs reached % and % and the -year ri and trm were % and %, respectively. conclusions: our study reveals that hsct with sequential conditioning can be an effective and tolerable treatment option for children with relapsed/refractory acute leukemia. the treatment strategies that focus on the reduction of leukemia burden immediately prior to hsct may contribute to the induction of long-term remissions in patients with high-risk acute leukemia. disclosure: this research was funded by japanese red cross, nagoya st. hospital research grant nfrch - . use of blinatumomab to achieve remission and consolidation with haploidentical transplant with cyclophosphamide post for the treatment of children with refractory acute lymphoblastic leukemia (all) background: most of patients with all in relapse or refractory to conventional treatment have only % possibilities to achieve long term remission. this report refers to the therapeutic efficacy and adverse events from the blinatumomab to achieve molecular remission in patients with pre-b cd + which lead to haploidentical with cyclophosphamide post transplant as a consolidation. methods: a pilot study was conducted in children with refractory all preb-cd +. as a strategy to achieved remission blinatumomab was used at a dose μg/m for continous infusion of hours, increasing the dose to μg/m during days, patients with a mrd of < . log, after cycles received an haploidentical bone marrow transplant as a consolidation, the conditioning regimen was with total body irradiation scheme at cgy/day/ days, cyclophosphamide and etoposide. receiving prophylaxis for gvhd with cyclophosphamide. results: a total of patients were included, seven of them achieved complete remission after cycles of blinatumomab, one with partial remission (table ) , these seven patients, six received an haploidentic transplant achieving graft in of the transplanted patients. one patient had a bone marrow relapse in the first months of the follow-up and patients are free of disease with a follow-up to months (figure ). as a acute complication the patients presented cytokine release syndrome, during the infusion of blinatumumab patients presented tachycardia (table ) and the patients presented agvhd after hsct ( grade i-ii and i grade iv). conclusions: allogeneic bone marrow transplant constitutes a treatment option on those patients that relapse or become refractory to treatment, one of the major problem is basically to identify a hla-identical donor, the alternative is an haploidentical donor. the most important factor to get these results is the disease status before transplant. the use of blinatumomab has proven to be effective in achieving remission in relapse acute linfoblastic leukemia pre-b cd + or refractory to treatment. characteristics nº % male % median age at diagnosis, (range), years . ( - ) status of disease o + relapse % refractory to primary or salvage therapy % complete remission after blinatumomab % partial remission after blinatumomab % active disease % [[p table] . table n° . demographic characteristics of patients undergoing blinatumomab (n= )] disclosure: a. olaya-vargas, r. rivera-luna, y. melchor-vidal, h. salazar-rosales, g. lopez-hernandez, n. ramirez-uribe. we wish to confirm that there are no known conflicts of interest associated with this abstact, the only financial support was provided by mexican associations that helping children wiht cancer in a few patients. sequential high-dose chemotherapy reinduction followed by myeloablative allogeneic transplant for active acute myeloid leukemias methods: at our center, relapsed/refractory aml patients were transplanted during chemo-induced neutropenia after high-dose salvage chemotherapy. median age at transplant was years (range - ). patients suffered from de novo (n= / , %) or secondary aml (n= / , %). genetic risk stratification was reported using stardardized groups proposed by the european leukemia net (eln) in . favorable, intermediate i and ii and adverse risk category at diagnosis was observed in / ( %), / ( %), / patients ( %) respectively. all patients had active disease at the time of sequential therapy and median marrow blast count was % (range - %). patients received a high-dose cytarabine based (mec in / , %) regimen as salvage therapy. donors were haploidentical relatives for / ( %) patients, identical siblings and matched-unrelated for / patients ( %) and / ( %), respectively. a myeloablative conditioning was used to further implement anti-leukemic effects. conditioning, thiotepa-busulfan-fludarabine in % patients, was started at a median of days (range [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] after the last day of chemotherapy. bone marrow and peripheral blood stem cells were used as graft source in / ( %) and / ( %) patients. graft-versus-host disease (gvhd) prophylaxis and supportive care were administered accordingly to each hsct platform. results: all patients engrafted. median day of neutrophil recovery was day + (range - ). median follow-up of survivors was months (range - ). non relapse mortality and relapse incidences (nrm, ri) were % and % at year and % and % at years, respectively. overall cumulative incidences of acute and chronic gvhd were % and % at day + and + . one and year overall survival (os) were % and %, while and year event-free survival (efs) were % and %. significant better os and efs were observed in patients with favorable-intermediate i-ii versus adverse risk score ( - years os % and % vs % and % p= . ; - years efs % and % vs % and % p= . ). adverse risk had a significant impact on os (hr . , p= . ) and efs (hr . , p= . ) by univariate analysis and on ri (sdhr . , p= . ) by fine and gray test. conclusions: though small the patient cohort, our findings suggest that sequential therapy with a myeloablative hsct is feasible in treating relapsed/refractory aml. transplant-related toxicity was low ( %) and relapse was the major treatment-failure. however, even with this approach, patients with adverse cytogenetic features have a very dismal prognosis. for these patients, the use of new drugs before hsct and/or maintenance therapy after transplant is highly encouraged to improve outcomes. disclosure: alessandro busca: honoraria from gilead sciences, merck, pfizer pharmaceuticals and jazz background: in spite of satisfactory results of overall survival (os) after allohsct in st and nd cr aml, relapse free survival (rfs) and graft-versus-host-disease free/relapse free survival (grfs) require further improvement. the detection of mrd is one of the factors which influence on the outcome of allohsct in aml is unclear but identification is important to improve risk-adapted relapse prophylactic treatment after allohsct. aim. to evaluate outcomes of allohcst in st and nd cr pediatric aml depending on the level of mrd status before myeloablative (mac) or reduced intensity conditioning regimens (ric). methods: the data of children with aml in st and nd cr underwent allohsct between and were analyzed. median age at the moment of allohcst was years old ( - ). mrd negative status had ( %) patients, ( %) were mrd positive by flow cytometry. mac based on busulfan ( mg/b.w.) received ( %) patients, on treosulfan - ( %) patients. ric based on melphalan received ( %) patients, based on busulfan ( mg/b.w.) - ( %) patients. patients received prophylaxis of agvhd by atg ( %) or ptcy - ( %) patients plus csa - ( %) or tacrolimus ± sirolimus - ( %) patients that depended on source of transplant (related, unrelated or haplo donor) . results: at the median follow up years in the cohort of mrd positive patients os is % vs % in mrd negative (p> , ). rfs is % vs % accordingly (p= , ). graft-versus-host-disease free/relapse free survival (grfs) in mrd positive patients is % vs % in mrd negative (p> , ). os, rfs, grfs in mrd positive patients after mac is %, %, % vs %, %, % after ric accordingly (p> , ). os, rfs, grfs in mrd negative patients after mac is %, %, % vs %, %, % after ric accordingly (p> , ). os, rfs in mrd negative patients with/without ptcy is %, % vs %, % (p> , ); grfs is % vs % accordingly (p= , ). os, rfs, grfs in mrd positive patients with/without ptcy is %, %, % vs %, %, % (p> , ). conclusions: mrd status does not statistically significant affect on os that can be related to different approaches to the treatment of relapse after allohsct. mrd positive status statistically significant decreases rfs that underline the necessity of posttransplant therapy improvement. ric vs mac in all patients in first and second remission do not show statistically significant impact on os, rfs, grfs. ptcy significantly improves grfs in mrd negative patients. disclosure: none of the authors has anything to disclose. background: with increasing overall-survival (os) of lymphoma patients, higher incidences of therapy-related clonal bone marrow diseases, such as acute myeloid leukemia (aml) and myelodysplastic syndrome (mds) are occuring. generally, the outcome is considered poor. allogeneic hematopoietic stem cell transplantation (allo hsct) often remains the only potentially curative treatment option. nonetheless, there is only little data available concerning this patient group. methods: we retrospectively collected data from patients with therapy-related aml (taml) and mds (tmds) after treatment for hodgkin's lymphoma (hl; n= and n= ) or non-hodgkin's lymphoma (nhl; n= and n= ), who received an allo hsct between and . median follow-up of surviving patients was . years (range . months- . years). background: the prognosis of relapsed/refractory acute leukemia (r/r al) is poor and the treatment is challenging. in this setting, allogeneic stem cell transplantation (allo-sct) constitutes the only curative option although the high relapse rate and non-relapse mortality (nrm). the sequential conditioning regimen followed by allo-sct has been used for persistent disease and aims to improve disease control by intensified chemotherapy, thus conceding more time for the presumed graft-versus-leukemia effect to occur. methods: the clinical outcome of r/r al with the sequential conditioning regimen combining a chemotherapy rescue followed by ric allo-sct in our center is described. patients who underwent a sequential allo-sct from to are included. the primary endpoint was progression free survival (pfs) and overall survival (os) that were estimated by the kaplan-meier method. secondary endpoints were non-relapse mortality (nrm). background: recommendations of the european leukemia net (eln) for favorable-risk genetics (frg) acute myeloid leukemia (aml) favor consolidation over transplantation, although reviews suggest advantage of autologous stem cell transplant (asct) in event free survival. our objective was to compare the progression free survival (pfs) and overall survival (os) of normal karyotype npm mutated without flt itd or allelic ratio < . (npm +) aml patients treated with consolidation chemotherapy alone (cc), asct or allogeneic stem cell transplant (allosct). methods: retrospective review of npm + frg-aml patients, treated in one institution ( to ) with the following induction regimens: cytarabine (ara-c) and vp- with daunorubicin (ade) or mitoxantrone (mice). consolidation regimens were ara-c with daunorubicin (ac-d), idarubicin, vp- and ara-c (mini-ice) or highdose ara-c (hidac). in asct, conditioning regimens were bucy or bvac and in allosct were bucy or flubu. pfs and os were calculated from the start of the last consolidation or stem cell infusion. results: a total of patients were evaluated, with a median age of years (y) ( - y), % female, % with ecog performance status (ps) - and % with ageadjusted charlson comorbidity index (aacii) ≥ at diagnosis. patients were treated with cc in % (n= ), asct in % (n= ) and allosct in % (n= ) of cases. there were no differences between groups for age, aacii, ps, leucocytes at diagnosis or extra-medullary disease. flt -itd was more frequent in allosct group ( %) than cc ( %) or asct ( %; p= . ). at induction, ade was used in % and mice in % of patients, with a complete remission (cr) rate of %. there were no differences between groups for induction regimen or cr. in cc group, consolidation regimens were cycle ( %) and cycles ac-d ( %) and cycles mini-ice ( %). asct patients received consolidation with - cycles ac-d ( %) and cycle mini-ice ( %), while allosct patients received - cycles ac-d ( %), cycles hidac ( %) and no consolidation in %. [[p image] . figure . pfs at y in cc, asct and allosct groups.] median follow-up was months, pfs at y was % and os at y was %. pfs at y for asct group was superior then cc and allosct groups ( %, % and %, respectively; figure ), although not statistically significant. os at y was statistically similar between groups, although inferior in allosct comparing to cc and asct ( %, % and %, respectively). conclusions: in this historical cohort review, although there was no advantage in os for asct in npm + frg aml, our data suggests that there might be a pfs improvement in asct over cc, which needs to be further addressed in prospective studies. disclosure: nothing to declare background: acute myeloid leukemia is a hematological malignant disease that motivates the persistent struggle in the scientific world to provide effective cure that can establish acceptable survival rates in this group of patients. autologous stem cell transplantation with myeloablative conditioning is still a powerful weapon that can be used against this entity methods: we have evaluated retrospectively patients with aml where autologous stem cell transplantation was performed in the period from till . our group consisted of patients; male patients ( . %), female patients ( . %). median age at diagnosis was years ( - ). the average period from time of diagnosis to autologous sct was . months. results: in the majority of our group, we used myeloablative conditioning regimen with busulphan-cyclophosphamide, patients ( . %), in patients ( . %) we have added melphalan to bu-cy conditioning, in ( . %) patients we used beam conditioning and in the rest, patients ( . %) we used bam conditioning regimen. as auto graft we used peripheral blood stem cells (pbsc) in patients ( . %), and in patients ( . %) we used bone marrow. the main mobilising regimen for pbsc was g-csf + etoposide and it was performed in patients ( . %), and in the remaining patients ( . %) mobilising of pbsc was performed only with g-csf. the mean number od apheresis procedures done in our group was . , and the mean number of collected mononuclear cells was . x /kg tt. the mean time to engraftment was . days ( - ). the transplant related mortality (trm) was . %. the year overall survival of our patients was . patients. the main reason for death was relapse of the primary disease( %). patients ( %)were treated with salvage chemotherapy regimen (flag-ida) because with the standard induction regimen + there was absence of adequate therapeutic response, or predominantly no complete remission was achieved. all patients were transplanted in complete remission conclusions: autologous stem cell transplantation could be an acceptable therapeutic solution for patients with aml as a consolidation therapy, where neither suitable compatible donor is available nor allogeneic stem cell transplantation could not be performed from various reasons depending on the bone marrow transplant unit disclosure: nothing to declare p prophylaxis dli alone may not prevent relapse of flt -itd positive aml after allogeneic hct background: one of the most potent prognostic factors affecting outcomes in aml is the presence of cytogenetic and molecular markers which can guide the selection of post-remission therapies. recently, favorable outcomes of npm wt /flt -itd neg /non-cebpa dm group after allogeneic hematopoietic cell transplantation (allo-hct) have been reported, that is similar to those of favorable risk by the eln risk classification. however, the role of allo-hct compared to consolidation chemotherapy has not yet been elucidated. methods: the data of patients who were diagnosed with aml and received intensive induction therapy from march to july were included in the current study. to address the time dependence of the allo-hct, the simon and makuch method was used in the graphical representation and the mantel-byar test and andersen and gill methods for identifying risk factors for long-term survival. results: median age of the patients were years (range - ), and patients ( %) were male. npm mutation was detected in patients ( %), and flt -itd were none, low, and high ratio in patients ( %), ( %), and ( %), respectively. the eln risk classification divided the patients into favorable, intermediate, and adverse risk group in patients ( %), ( %), and ( %), respectively. npn and flt -itd both negative group included patients ( %). allo-hct was performed in patients ( %). overall, complete response (cr) after induction therapy achieved in patients ( %), and patients ( %) were primary refractory disease. cr rates did not differ between npm wt /flt -itd negative group (n= / , . %) and other intermediate risk group (n= / , . %; p= . ) . with median follow-up duration of . months (range . - . months), one-year os rate were %, . ± . %, . ± . % in favorable, intermediate, and adverse risk group (p < . ). among intermediate risk group, os rate of npm wt /flt -itd negative group was similar to other intermediate risk (p= . ). allo-hct was performed in patients of npm wt /flt -itd negative group. one-year os rates did not differ between npm wt /flt -itd negative and other for allogenic hematopoietic stem cell transplant (allo-hsct), as a strategy to prolong survival. methods: data from aml pts over years, who underwent ric allo-hsct in our institution between september and september , was retrospectively collected from clinical files to evaluate the overall survival (os) up to november . we calculated the os using kaplan-meyer curves. results: we identified pts, median age y.o. ( - ) and median htc-i score . the median follow-up was months. one patient (pt) had cml blast crisis and was on first major molecular remission. of the remaining aml pts, were in st complete remission (cr), in nd cr and with progressive disease (pd); the other pts could be classified as mds according to who diagnostic criteria and were in cr . donors (d) were: matched unrelated (mud), mismatched unrelated (mmud - / ), matched siblings and haploidentical. thirteen pts were infused with peripheral blood hsc and with bone marrow. conditionings were: flubcnumel in unrelated donor (ud) pts and siblings, flumel in ud pt and sibling, flubu in ud pts and flutbi gy in sibling and in the haploidentical. graft versus host disease (gvhd) prophylaxis was tacrolimus (tac) + mmf in ud pts and sibling, tac + mtx in ud pts and cyclosporine (cya) + mmf in ud pt and siblings. all mmud pts had atg. ptcy was done in the haploidentical setting with tac + mmf. the median time to neutrophil and platelet engraftment for the whole cohort was and days, respectively. one pt with secondary engraftment failure required re-infusion of selected cd + cells. ten pts presented with mild acute skin gvhd. eleven pts had chronic gvhd, classified as severe; required systemic therapy, of those beyond year. the median time on immunosuppressants was days. at years the os was . %. there were deaths: disease-related ( relapses at and months and pd at d+ ), infection complications ( septic shock) and to secondary neoplasia. other relevant complications were hypoxemic pneumonia in pts, urinary sepsis, cmv and ebv reactivation respectively in and pts; pulmonary and renal toxicity either in pts. at end of follow-up, pts were in remission, without negative measurable residual disease (mrd), the other mrd negative pt died of septic shock and severe intestinal gvhd. conclusions: in this small cohort, chronic gvhd and infectious complications were major causes of morbidity but there were no treatment related deaths before d+ . pts maintaining or achieving mrd negativity after transplant had better survival. although with only pts, these results suggest that allo-hsct is feasible as consolidation strategy in selected aml pts over years. [[p image] . overall survival] disclosure: nothing to declare. background: hematopoietic stem cell transplantation (hsct) is the only curative option for fanconi anaemia (fa); an inherited disorder characterized by congenital anomalies, progressive bone marrow failure (bmf) and a predisposition to develop malignancies. methods: we retrospectively analysed the data of consecutive patients that underwent hsct at this centre from till june . the data was analysed for variables affecting the outcome in terms of overall survival (os). results: median age at diagnosis was years ( - years). median age at transplant was . years ( - yrs). all patients at transplant were in aplastic phase. male to female ratio was . : . twenty-four ( . %) patients had congenital anomalies along with bmf while were phenotypically normal. twenty-three ( . %) patients were / hla matched with siblings, with parents and with cousins. eleven ( . %) patients had gender mismatch transplant. three patients had major and had minor abo mismatch. background: paroxysmal nocturnal hemoglobinuria (pnh) is a rare clonal non-neoplastic hematopoietic stem cell disease whose incidence is . - . cases/million of individuals worldwide. disease characteristics and natural history have been mostly analyzed by multicenter, retrospective studies, with the limit of heterogeneous approaches. herein we report the incidence of severe complications and outcome in a real life setting scenario of pnh patients consecutively diagnosed and managed at our pnh referral center between january and june . methods: patients received a homogeneous diagnostic and treatment approach according to the period of observation (availability of diagnostic tests and eculizumab). all patients treated with eculizumab received vaccination with conjugated anti-meningococcus acwyserotypes and, since , conjugated anti-meningococcus b-serotype. in the event of any complication, patients could refer to dedicated hematology emergency rooms (er) hours daily. the occurrence of renal failure and pulmonary hypertension was specifically evaluated. the renal function was studied according to the cockcroft-gault formula and the lung function was prospectively monitored by daytime-on exertion, nocturnal pulsoximetric profiles and complete spirometric tests, with dlco measurement. results: overall, pnh patients, median age years (range - ), were analyzed. at diagnosis, patients had classic pnh, aplastic pnh and an intermediate form. the cumulative incidences (ci) of thrombosis, and clonal hematologic neoplasm were %, and %, respectively. ci of pancytopenia in the patients with classic pnh was %. one patient showed a spontaneous disappearance of the pnh clone. since , eculizumab was administered in patients. after eculizumab treatment % and % of patients reached hemoglobin level > g/dl and > < g/ dl without transfusion, respectively, while % were nonresponsive. during eculizumab treatment no thrombotic event was observed while two severe infectious episodes (respiratory tract and urinary tract infection) were observed in only one of the patients. extravascular hemolysis was demonstrated in % of patients. no patient showed a significant reduction of the renal function.out of patients prospectively monitored for lung function no pathological alteration in any diurnal or nocturnal pulseoximetric test was observed. no patient showed obstructive or restrictive ventilatory deficiency, nor reduced dlco values. -years overall survival (os) was % ( patients who died for non-pnh related reasons were censored at the last follow-up).a better os, even if not statistically significant,was associated to the absence of thrombotic events ( %vs %), and the period of diagnosis ( % in - , % in - , % in - ) . conclusions: our study reports a better os and lower rate of severe complications in pnh compared to previous experiences. although renal failure and lung hypertension have been reported by other groups, we did not observe these complications along a prolonged follow-up. we can assume that the availability of a dedicated er service enabled an early diagnosis and prompt treatment in case of hemoglobinuria crises (reducing the risk or organ damage) or other complications. the use of eculizumab, together with improved supportive approaches, presumably accounts for the trend towards a better survival witnessed over the last decade in the management of pnh patients. disclosure: nothing to declare haploidentical and unrelated allogeneic stem cell transplantation in aplastic anemia:single center experience zafer gulbas , elif birtas atesoglu , meral sengezer , İmran dora , cigdem eren , suat celik , demet cekdemir background: aplastic anemia is a syndrome of bone marrow failure characterized by peripheral pancytopenia and marrow hypoplasia. allogeneic stem cell transplantation from hlamatched sibling is performed in the firstline setting in young aplastic anemia patients and in elderly patients who are refractory to immunosuppressive treatment. but if the patient does not have a hla-matched sibling, allogeneic stem cell transplantation is performed from unrelated and haploidentical donors. in this study, we analyzaed and compared the results of aplastic anemia patients who had undergone allogeneic stem cell transplantation either from matched unrelated or haploidentical donors. methods: we collected and analyzed data of aplastic anemia patients who had undergone allogeneic stem cell transplantation from matched unrelated or haploidentical donor between and . results: there were patients who had received allogeneic stem cell transplantation from unrelated donors and there were patients who had undergone haploidentical transplantation. but in patients who had undergone haploidentical transplantation, engraftment failure had occurred and they were transplanted from different haploidentical donors fort he second time. so a total of unrelated and haploidentical transplants were performed. the median age of patients who had undergone unrelated transplantation was ( - ) and the median age of patients who had undergone unrelated transplantation was ( - ) . the results of the haploidentical and unrelated transplantations are shown in table . the neutrophil and platelet engraftment times were significantly longer in haploidentical transplantations (p= , and p= , , respectively). however, vod, gvhd and day mortality rates were not different in the groups. similarly overall survival (os) of the patients who had undergone haploidentical or unrelated transplantation were not significantly different (p= , ) ( figure ) . conclusions: although the number of patients are low in this study, we can conclude that urelated and haploidentical transplantation in aplastic anemia have comparable toxicity and efficacy. background: autologous stem cells transplantation (ahsct) is an effective treatment for very aggressive autoimmune diseases such as multiple sclerosis (ms). however, toxicity remains the major concern to a wide application of this approach. post transplant viral reactivations may induce severe complications and a rigorous monitoring of peripheral blood viral load for a prompt and effective therapy is required. a higher rate of ebv and cmv reactivation has been observed in patients affected by ms and conditioned with beam plus atg compared with a controlled group of lymphoma patients without atg in the conditioning regimen [ ] . we report here the policy of our center about both monitoring and treatment of such side effect. methods: a series of consecutive patients with ms, transplanted between and is included in this analysis. all patients were mobilized with cyclophosphamide g/sqm + g-csf and conditioned with beam plus rabbit atg (thymoglobulin©, . mg/kg). monitoring of cmv/ebv dna on whole blood by quantitative pcr was performed after the engraftment, weekly for at least one month, then at longer intervals. pre-emptive treatment with valgancyclovir was started in case of cmv viral load ³ x ^ copies/ml. in case of ebv assay between x ^ and x ^ copies/ml further determinations were performed and rituximab-based treatment was started if the viral copies exceeded x copies. patients received treatment in case of symptomatic disease for any value of the pcr of both viruses or ebv titer ³ x ^ copies/ml. results: detectable dna for cmv was observed in / ( , %) patients at a median time from transplant of days (range - ) and / ( %) required pre-emptive treatment. all patients promptly responded to treatment within weeks. ebv viral load was detectable in / patients ( , %) at a median time of days (range - ). one patient out of started the treatment on first determination for high viral load (> x ^ /ml); nine presented an ebv viral load over x ^ copies/ml, three of them were treated thereafter for the persistent increase of the viral load (> /ml). six patients spontaneously recovered the ebv reactivation. previous treatments were not predictive of any higher risk of viral reactivation. no impact on engraftment related to the reactivation was observed. conclusions: this policy shows that, despite a high rate of cmv and ebv reactivation, no grade iii-iv adverse events were observed, suggesting the key role of viral monitoring in these patients and the efficacy of the preemptive treatment. ebv reactivation at low titers should be monitored to identify those cases that could achieve a spontaneous resolution and avoid the induction of further immunosuppression by rituximab. these data confirm that patients diagnosed with ad undergoing autologous hsct need a more intense pattern of care than hematological patients. background: autoimmune diseases are chronic serious conditions that are often refractory to standard therapies. since , autologous haematopoietic stem cell transplantation (hsct) has been a very promising alternative that has shown satisfactory long-term results. the aim of this study is to evaluate immune reconstitution and mortality following hsct in patients with autoimmune disease. methods: a retrospective study was conducted on patients with diagnosis of autoimmune diseases that underwent autologous hsct between july and january at a tertiary referral center in colombia, south america. descriptive statistics were used to analyze patient's demographic and clinic characteristics. results: seven patients were included, with a mean age of years (range - ). five patients were female ( %). the indications for hsct were systemic sclerosis (n= ) , multiple sclerosis (n= ), and myasthenia gravis (n= ). the conditioning regimen administered in patients with systemic sclerosis was cyclophosphamide + human anti-t lymphocyte immunoglobulin, beam (carmustine, etoposide, cytarabine (ara-c), and melphalan) + human anti-t lymphocyte immunoglobulin in patients with multiple sclerosis, and cyclophosphamide + human anti-t lymphocyte immunoglobulin in myasthenia gravis. median time to myeloid engraftment (neutrophils> . × /l) was days post-transplantation, and platelet engraftment, defined as > , platelets/mm untransfused, was days post-hsct. median time of hospitalization was days (range - ); longer in-patient management was due to infectious complications. infectious complications included bacteremia caused by e. coli and pneumocystis pneumonia that resulted in septic shock and acute respiratory failure, respectively. evaluating t-cell immune reconstitution, none of the patients had reached normal cd + cell value after one year of hsct follow-up. four patients ( . %) reached normal cd + cells value at months post-hsct. regarding bcell immune reconstitution, . % of the patients ( / ) had reached both igg and iga normal levels at one-month post-hsct, and four patients ( . %) had achieved normal igm background: multiple sclerosis(ms) is an inflammatory disease caused by autoimmune reactivity of t cells against myelin. there is accumulating evidence of the efficacy of highdose chemotherapy followed by autologous haematopoietic stem cell transplantation(ahsct) in ms patients who failed response to standard immunotherapy, despite a variability in eligibility criteria, conditioning regimens and outcome. methods: we retrospectively reviewed ms patients submitted to ahsct in our centre ( ) ( ) ( ) ( ) ( ) . patient eligibility criteria were active relapsing remitting(rrms) or secondary-progressive ms (spms), with prior failure to treatment with disease-modifying therapies and evidence of disease activity (clinical relapse or new active lesions in magnetic resonance [mr] ). mobilization of cd +cells to peripheral blood was performed with granulocyte colony-stimulating factor(g-csf μg/kg/day) and conditioning regimen according to beam protocol. the severity of ms disability was classified according to the expanded disability-status scale (edss) and ahsct toxicity was evaluated by ctcaev . . results: seven ms patients had undergone ahsct ( female/ male), with a median age at ahsct of . years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . median age at ms diagnosis was . years( - ) and median time from diagnosis until ahsct was . years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . four patients ( . %) had spms and ( . %) had rrms, with ( . %) having mr active lesions. pre-ahsct relapse rate per year was ( ) ( ) ( ) ( ) . median baseline edss was . ( . - . ). median number of previous dmts was ( ) ( ) ( ) ( ) ( ) ( ) ( ) . all patients had been treated with corticosteroids and copaxone, ( . %) received rituximab, ( . %) natalizumab, ( . %) alemtuzumab, ( . %) fampridine and ( . %) fingolimod. all patients collected enough cd + cells in a single apheresis session. median number of cd + cells infused was . ± . x ^ /kg, for a mean dmso volume of . ± . ml. median inpatient stay during ahsct was days( - ). all patients developed febrile neutropenia, one was admitted to intensive care unit due to sepsis. one patient developed an anaphylactic reaction to transfusion and another a self-limited encephalopathy. two ( . %) patients had grade≥ oral mucositis, and all had gastrointestinal toxicity (grade - ). median time until neutrophils> /μl was ( - ) days, to platelets> , /μl was days( - ), and to engraftment was days ( ) ( ) ( ) . patients were transfused with a median of ( - ) unit for erythrocytes and ( - ) for platelets. there was no treatment-related mortality and no long term side effects have been observed so far. for a median post-ahsct follow-up of . months, no patient developed new lesions in mr, but ( . %) experienced symptoms consistent with a clinical relapse, at a median time of . ( - ) months, effectively rescued with corticosteroids. the absence of evidence of disease activity at -months was . %. although there was no variation concerning edss punctuation, ( . %) patients self-reported significant benefits, especially concerning limb strength and sphincter continence improving. conclusions: our real life results claim a stabilization effect of ms patients with highly active/progressive disease after ahsct, with no significant toxicity. the failure in reporting benefits in edss punctuation is probably due to a small sample size and short follow-up. more studies are needed to establish the best patient selection criteria and define the ideal time to include these patients in transplantation programs, as well as to evaluate its long term outcome. disclosure: nothing to declare. elena poponina , elena butina , anna yovdiy , galina zaytseva , natalia minaeva , igor paramonov background: reactivation of epstein-barr virus (ebv) represents a potentially life-threatening condition in approximately % of patients after allogeneic stem cell transplantation, with no specific treatment available. methods: we have previously developed a manufacturing protocol for the expansion of cytomegalovirus (cmv) and ebv-specific t cells by stimulation of g-csfmobilized stem cell grafts with defined peptide pools (gary, ) . this advanced therapeutic medicinal product is currently investigated in an ongoing phase i/iia trial (eudract number: - - ) . however, the expansion of virus-specific t cells relies on a pre-existing virusspecific memory compartment in the stem cell donor. in virus-seronegative donors, no expansion can be achieved. we therefore aim to identify ebv peptide-specific t cell receptors (tcrs) that can be translated into off-the-shelf cell products for the treatment and prophylaxis of ebv infection and ebv-associated malignancies. leftover cells from five allogeneic stem cell grafts were expanded in vitro in the presence of hla-b * -restricted peptides (hpvgeadyfey from ebna , eplpqgql-tay from bzlf ) associated with latent and lytic ebv infection. after expansion, single ebv-specific t cells were facs sorted using peptide-mhc (pmhc) tetramers, and individual tcr αand β-chain pairs were determined with single cell sequencing (han , penter . to confirm peptide specificity, dominant tcr pairs were transfected into a murine αβreporter t hybridoma cell line with nfat-driven gfp expression (siewert, ) . functional tcrαβ candidates were transduced into human peripheral background: lymphoid and myeloid acute leukemia are the most frequent cause of cancer related death in children. interactions between nkg d receptor, expressed in cytotoxic immune cells, and its ligands (nkg dl), that are upregulated in many types of tumor cells including leukemic blasts, are important for anti-tumor immune surveillance. nevertheless, tumor cells may develop immune scape strategies like ligand shedding, which reduces nkg dl expression and may cause nkg d receptor downregulation. engineering t lymphocytes with nkg d car may overcome immune evasion and become an effective therapeutic strategy. methods: cd ra -t cells were obtained by depletion of non-mobilized apheresis with cd ra magnetic beads using clinimacs. nkg d-car t cells were generated by lentiviral (nkg d- bb-cd z) transduction of cd ra -t cells with moi= . the expression of nkg d ligands was analyzed in peripheral blood or bone marrow samples from a total of leukemia patients (aml= , b-all= and t-all= ), at different status of the disease (diagnosis, remission, relapse/refractory), and in different leukemia cell lines by qpcr and flow cytometry. cytotoxicity of nkg d-car t cells against leukemia cells was evaluated by performing conventional- hours europium-tda assays. soluble nkg dl (snkg dl) concentration was measured in the sera of leukemia patients by elisa. to evaluate the effect of snkg dl on nkg d-car t cells, those were cultured in the presence or absence of different concentrations of snkg dl for days. one week later, cell proliferation and car downregulation were measured by flow cytometry using cell trace violet and nkg d labeling, respectively. the production of ifn-g and tnf-a was measured in the supernatants by elisa. the effect on cytotoxicity was evaluated in a hoursdegranulation assay by co-culturing snkg dl pretreated nkg d-car t cells against k cell line. results: nkg d ligands were expressed in leukemia cell lines and leukemic blasts. nkg dl expression changed with disease status with a trend to decrease at diagnosis and relapse/refractory compared to remission. nkg d-car t cells were cytotoxic against / leukemia cell lines with a percentage of specific lysis over %. myeloid and t-all cell lines were more susceptible to nkg d-car t cells (specific lysis ranging from - %) compared to b-all cell lines ( - %). physiological concentrations of snkg dl caused an increase in nkg d-car expression. however, supra-physiological levels of snkg dl decreased nkg d-car expression up to times and increased cell proliferation up to times. cd + subpopulation was more affected by downregulation, while proliferation had more impact on cd + subset. the effects of snkg dl were dose-dependent and attenuated by il- . conclusions: nkg d-car t cells are cytotoxic against leukemia cells, specially aml and t-all, and thus could be a novel therapeutic approach for non-b leukemia, or those b-all that relapse with undetectable cd after cd -car treatment. nkg d-car expression may be downregulated only by supra-physiological levels of snkg dl, although antitumor activity is not affected. il- softens the negative effects of snkg dl inducing nkg d expression, cell proliferation and cytokines production. the changes observed in nkg dl surface expression at the different stages of the disease could be related to ligands release and immune escape. disclosure: nothing to declare denis-claude roy , , ines adassi , , céline leboeuf , , vibhuti p. dave , hôpital maisonneuve-rosemont research center, montréal, canada, university of montréal, montréal, canada background: for patients with high-risk leukaemia, allogeneic haematopoietic stem cell transplantation is the only curative treatment. the presence of alloreactive t cells in the donor graft, however, leads to a high probability of developing graft-versus-host disease (gvhd) . t-cell depletion minimises the presence of gvhd-causing alloreactive cells, but often results in an increased incidence of infections and disease relapse. photodepletion treatment (pdt) can specifically deplete activated alloreactive t cells while conserving resting t cells. pdt-treated cells have been utilised after t-cell-depleted haploidentical transplant to help reduce infection and relapse. the efficacy and safety of such pdt-treated cells is currently under clinical investigation in a phase iii trial (hatcy, nct ; kiadis pharma). here the reactivity of pdt-treated donor t cells was assessed toward tumour-associated and viral antigenic peptides derived from wilm's tumour protein (wt p), preferentially expressed antigen in melanoma (pramep), and from cytomegalovirus and epstein-barr virus (cmv/ ebvp). methods: healthy donor (hla-a* ) peripheral blood mononuclear cells (pbmcs) were co-cultured with irradiated pbmcs from another mismatched donor ( : ) in a -day mixed lymphocyte reaction. th , a photoactive rhodamine derivative, was added and cells were exposed to visible light to deplete the th -containing activated alloreactive cells. elimination of alloreactive cells post-pdt was assessed using cd and hla-dr as activation markers. an ex vivo expansion protocol was exploited to evaluate the impact of pdt on reactivity to tumour and viral antigenic peptides. post-pdt t cells were co-cultured with irradiated autologous monocyte-derived dendritic cells ( : ) pulsed with wt p, pramep or cmv/ebvp. antigen-specific t cells were re-stimulated on days and with wt p-or pramep-pulsed autologous pbmcs or with cmv/ebvp added directly to the culture. mhctetramer staining was performed on days and ; ifn-γ elispot was conducted on day . [[p image] . functional wt -specific and viralspecific t cells can be expanded post-pdt] results: pdt resulted in a drastic decrease of cd and/ or hla-dr activation marker-expressing cd + and cd + t cells. pdt-treated cells showed a significant increase in background: acute lymphoblastic leukemia (all) is the most common childhood cancer and relapsed or refractory all is still difficult to treat. engineered t cells equipped with a synthetic chimeric antigen receptor (car) targeting cd have demonstrated remarkable efficacy to treat all. however natural killer (nk) cells are known for their target-independent cytotoxic potential without induction of cytokine release syndrome (crs) or graft-versus-hostdisease (gvhd), car-nk cells can overcome the persisting problem in the therapy with car t cells. as the use of viral vector generated car nk cells is limited by theire genotoxicity, cost and regulatory demands, we are developing an innovative protocol using non-viral sleeping beauty (sb) transposition of third party nk cells as a source to produce 'off the shelf' car-engineered cell products. methods: nk cells are isolated from peripheral blood mononuclear cells (pbmcs) using cd selection kits. they are successfully expanded ex vivo with il- cytokine stimulation under feeder-cell free conditions. after few days of expansion nk cells are electroporated using pmaxgfp. transfection efficiency and percent of living cells after electroporation is analyzed by flow cytometry. transposition based nucleofection using an sb x mrna and a minicircles (mc) dna vector is performed at different time points after nk cell isolation. the transient mc-venus longtime expansion and the viability after sb x based nucleofection is measured over two weeks. furthermore, α-retroviral (α-rv) cd -car transduction of nk cells with different viral amounts (moi) is conducted and the cytotoxicity of the engineered cd -car-nk cells against the cd positiv cell line supb is addressed. results: for an α-rv cd -car transduction of maximal x nk cells we could show transduction efficiency of , % for moi . the α-rv cd -car modified nk cells had a high killing activity against cd positiv supb cells (e:t ration : , %) compared to cd negativ k cell lines (e:t ration : , %) and the non-transduced nk cells (e:t ratio : , %). in first experiments with pmaxgfp vector based nucleofection, we could show an increasing efficiency of , % h post electroporation with a only slightly decreas of living cells ( , %) comparing to the non-electroporated nk cell viability. using sb x mrna with mc-venus dna we electrotransfected x nk cells after fews days of cultivation and we reached , % of transfected nk cells h post electroporation and a transient expression of mc-venus positive nk cells up to , % efficiency with an increasing rate of live cells over days after electroporation. conclusions: the sleeping beauty based nucleofection of nk cells is a very promising non-viral method to generate more easy, safer and higher amounts of genetically modified third party nk cells for therapy of all and has also a broad range of clinical applications. disclosure: winfried s. wels is an inventor on a patent describing chimeric antigen receptors with an optimized hinge region. axel schambach is an inventor on a patent describing alpharetroviral sin vectors. michael hudecek and zoltan ivics are inventors on patents related to sleeping beaut gene transfer technology. the remaining authors have nothing to disclose. background: mature immune cells from the stem cell graft are essential for the graft-versus-tumor (gvt) effect to eliminate residual malignant cells after hematopoietic stem cell transplantation (hsct), but donor cells are also involved in complications such as graft-versus-host disease (gvhd). methods: we performed a prospective study of the detailed graft composition in recipients of peripheral blood stem cells (pbsc) or bone marrow (bm) in order to identify correlations to clinical outcomes, table . grafts were characterized with concentrations of t cells and nk cells together with a multi-color flow cytometry panel with staining for tcrαβ, tcrγδ, vδ , vδ , cd , cd , cd , hla-dr, cd , cd ro, cd ra, cd , cd , cd and cd for detailed immune phenotyping. cell contents in stem cell grafts were analyzed both as fractions of cd positive lymphocytes and as absolute concentrations converted to transplanted cells/ kg. fractions were evaluated in patients receiving both bm and pbsc (n= ), while concentrations (cells/kg) were only analyzed in patients transplanted with pbsc (n= ). table] . table ] [[p image] . figure ] results: we found, that patients transplanted with graft nk cell doses above the median of x /kg and fractions of nk cells out of lymphocytes above the median of . % had significantly increased relapse-free-survival compared to patients transplanted with grafts containing nk cell doses below these values, figure ; results stayed significant in multivariate analyses. relapse incidence was significantly lower in uni-and multivariate analyses in patients receiving grafts with high nk cell fractions compared with low fractions, p= . , with -year relapse rates of % versus % in patients transplanted with high versus low fractions of nk cells, p= . . peripheral blood concentrations of nk cells obtained from samples from pbsc donors before g-csf mobilization were significantly correlated to graft concentrations-and fractions of nk cells.. analyses of graft contents of nkt cells showed that the incidence of grade ii-iv acute gvhd were significantly lower in patients background: extracorporeal photopheresis (ecp) is an immunomodulatory treatment that has shown efficacy in steroid refractory acute gvhd, but the mechanism of action is only partially understood. there is no clear relationship between the ecp-treated mononuclear cells (mnc) or lymphocyte numbers and response to ecp. the objective of the study was to analyse the relationship between the infused subpopulation cellularity and response. methods: patients from different centers with a total of ecp procedures were retrospectively analized. ecp procedures were performed from january- to june- . all ecp procedures were performed with the off-line system. the response was defined as responder (complete and partial response) and non-responder. infused cell numbers for lymphocytes, monocytes and mononuclear cells (lym+mon, mnc) were calculated. for analytic purposes, the median number of cells infused per procedure until response (or until the median number of procedures until response for non-responding patients) and the cumulative number of cells infused until response (or until the median in non-responders) were calculated for all the subgroups. same procedures were performed with the number cells infused until day of ecp. finally, the response and survival impact of infusing a number of cells above or below the median and in different tertiles was assessed until the median number of procedures needed to achieve a response. [[p image] . results: the median number of procedures until response was . we observed a trend towards a higher median number of monocytes per procedure and cumulative infused monocytes in responding patients (median number infused . vs . x /kg p= . , cumulative infused median number . vs x /kg p= . ) that was lost in the day of treatment. there was also a trend toward higher median infused mnc until response for responders ( vs x /kg p= . ). we observed no differences in the number of lymphocytes infused, but patients who received a number of lymphocytes per procedure over the first tertile ( x /kg) presented higher response rates ( % vs %, p= . ). none of the other analysed parameters showed a significant impact in overall survival. conclusions: patients with acute gvhd who responded to ecp received higher numbers of monocytes and mnc in the early phase of the treatment (a median of the first processes). also the patients who received higher numbers of lymphocytes in the first procedures achieved a higher response rate. these findings suggest the possibility that higher number of treated and infused cells could influence the response to ecp, but specifically designed prospective studies are need to asses this possibility. disclosure: nothing to declare background: the field of kidney transplantation has made enormous progress over the last decades towards being a standard treatment for patients with end-stage renal disease. however, administration of immunosuppressive drugs is still one of the major limitations of long-term allograft survival. therefore, strategies for induction of donorspecific tolerance are highly desirable. to this aim, a clinical phase i study with donor-derived modulated immune cells (mics) was conducted. methods: donor-derived mics were manufactured under gmp conditions. potency of mics was tested by different in vitro bio-assays. mics were administered to patients with an escalation from . x mics/kg on day - (n= , group a), to . x mics/kg on day - (n= , group b) or on day - (n= , group c) before kidney transplantation accompanied by standard immunosuppressive medication post-transplantation. frequency of adverse events (ae) was assessed from day until day post-transplant. dynamic changes of various lymphocyte subsets in patients after mic therapy were detected by multicolor flow cytometry. donor-specific immunosuppression was assessed by measuring anti-donor antibodies and mixed lymphocyte reaction (mlr) against donor and thirdparty cells. results: in all kidney transplant recipients, we observed a median serum creatinine of . mg/dl at day which remained stable until day (median creatinine of . mg/ dl) without significant proteinuria. none of patients experienced rejection episode. aes were observed while three aes being severe. most importantly, none of them was associated with mics transfusion. besides two infectious complications, no post-transplant positive cross match results against the donor or titers of de novo donorspecific antibodies were recorded. notably, immunosuppressive therapy could be reduced without signs of rejection in group c. after infusion, we observed a dramatic increase of cd + b cells up to a median of cells/μl until day , followed by a reduction to cells/μl on day in group c. notably, regulatory b cells significantly increased from a median of % on day to % on day . in parallel, the plasma il- /tnf-α ratio increased from a median of . before cell therapy to . on day . after mic cell therapy recipient lymphocytes showed no or only minimal reactivity against irradiated donor pbmcs in vitro, while reactivity against rd -party-donor pbmcs was not impaired. moreover, in vitro mics product demonstrated their immunomodulatory potency by inducing tolerogenic dendritic cells (tdcs) characterized by low expression of costimulatory (cd , cd ) and maturation (cd ) as well as high expression of inhibitory marker cd . functionally, tdcs could inhibit not only the release of ifn-γ but also the proliferation of cmv specific cd + t cells. moreover, mic-induced tdcs showed the capacity to inhibit donor-specific allo-reactive cd + and cd + t cell proliferation. conclusions: mic cell therapy modulates the immune system of kidney transplant recipients by increasing the ratio of regulatory b cells and facilitates the reduction of conventional immunosuppressive therapy without allograft injury or rejection episodes. therefore, mic cell therapy represents a promising strategy in transplantation medicine. we currently prepare a phase ii trial with mic cell therapy. disclosure: nothing to declare p genome editing of graft-derived t cells for post- background: immunotherapy using car t cells has shown promising results to fight cancer. however, car-t cell production requires specialized infrastructure and operators, which implies high cost and centralized production. automated production of car-t cells in clinimacs prodigy device allows clinical-grade manufacturing of car t cells. methods: million cd ramemory t cells from healthy donors were cultured in texmacs supplemented with iu/ml il- . at day cells were activated with t cell transact for h. at day one, activated cd ramemory t cells were transduced with nkg d-cd tm- bb-cd z lentiviral vector at moi = . then, nkg d-car t cells were expanded for - days. nkg d-car t cell products were next harvested, counted and analyzed for viability, nkg d-car expression and anti-tumor cytotoxicity. different quality tests including sterility, vector copy number, genetic stability, quantification of viral particles in the supernatant, myc/tert expression and endotoxin detection were performed. spare cells were cryopreserved either in autologous plasma and % dmso, m % albumin and %dmso or hypothermosol. after months, cryopreserved nkg d-car t cell products were analyzed for viability, nkg d-car expression and cytotoxicity. results: nkg d-car memory t cells expanded up to ± million with , ± % nkg d-car expression and ± % viability. harvested car t cells showed ± % of specific lysis against jurkat cells and ± % against mii osteosarcoma cell line. no microbiological contamination was observed in final car t cells products. vector copy number was ≤ in all validations except for one. cgh and karyotype showed no genetic alterations. free viral particles were undetectable in the supernatants. no overexpression of myc/tert was found except for one validation. endotoxins were ≤ . eu/ml. all cryopreserved nkg d-car t cell products kept nkg d-car expression one year after freezing. however, viability and cytotoxicity was best preserved using autologous plasma %dmso. conclusions: automated production of large-scale clinical-grade nkg d-car t cells using clinimacs prodigy is feasible and reproducible, allowing a decentralized protocol to generate car t cells for clinical use. background: immune reconstitution (ir) is essential to control severe infections after hematopoietic stem cell transplantation (hsct). reconstitution of adaptive immunity may take up to years to recover t-lymphocytes (lt). delay in early lt recovery increases the risk of relapse, viral infections and transplant related mortality. adoptive transfer of selected t cell subset with low alloreactivity potential is emerging as a strategy to improve ir. methods: depletion of cd ra+ naive t cells, preserving cd ro+ memory t cells could provide functional lymphocytes to protect against infection and leukemia relapse with low risk of graft versus host disease (gvhd). we present our experience with high-dose donor cd ro + memory t cell as donor lymphocyte infusions (dli) to assess safety and outcome. a total of dli of cd ro+ after hsct was performed in cases of cmv/ebv reactivation ( %), mixed chimerism ( %), persistent lymphopenia ( , %), graft rejection ( , %) , relapse ( %) or to boost ir ( %). dli product was obtained performing a cd ra depletion on donor leukapheresis product using the clinimacs® device. results: twenty-two pediatric patients, median age years (range - ), with malignant (n= ) and nonmalignant diseases ( ), received cd ra+ (n= ), tcr alpha/beta (n= ) depleted grafts from haploidentical and cd ra+ depleted grafts from match unrelated (n= ) and match related (n= ) donors. at a median of days (range - ) after transplantation, patients received a total of dli of cd ro+ cells, median (range - ), containing a median of . x /kg (range . x - x /kg), cd +cd ro+ . x /kg (range . x - . x /kg) and cd ra+ cells x /kg (range - . x /kg). all infusions were well-tolerated and did not develop or worsen gvhd. a total of / episodes of cmv/ebv viral reactivations decreased viral load, / cleared viral load and / showed a clinical improvement. a total of / patients with persistent lymphopenia there was a slightly increase in total lymphocyte count, but not to normal levels. prophylactic dli of cd ro+ to boost ir increased lymphocyte count in of cases. none of the dli administered in cases of mixed chimerism, graft failure or relapse were effective in reverting those situations. conclusions: our preliminary data suggest that infusions of high dose cd ro+ memory t cells are a safe adoptive immunotherapy strategy. efficacy has been observed in patients with lymphopenia and cmv/ebv reactivation, with no positive results in patients with mixed chimerism, graft failure and relapse. however, to determine the real efficacy of this strategy, prospective studies are required. disclosure: nothing to declare. background: increasing clinical trials have confirmed that chimeric antigen receptor t cells (car-t) targeting cd antigen (car-t- ) is a promising effective approach for the treatment of relapsed/refractory(r/r) b-cell lineage malignancies. considering cd is frequently expressed in large part of t( ; ) acute myeloid leukemia (aml) cells, we suppose that car-t- may be used as an approach to rescuing r/r t( ; ) aml patients. methods: both patients received lymphodepletion chemotherapy with decitabine mg/m × d, fludarabine mg/m × d and cyclophosphamide mg/m × d (dac +fc). two days after chemotherapy, autologous/allogeneic cart- cells provided by the unicar-therapy biomedicine technology co.(shanghai, china) at a total dose of - × cells per kilogram(kg) were infused dose escalation within to days. the research protocol was approved by the institutional review boards of the first affiliated hospital of soochow university and both patients gave written informed consent. results: both cases responded well with transient and reversible toxicities. case presented with grade cytokine release syndrome (crs), manifested by intermittent fever and chill from day after car-t- infusion for half months associated with neutropenia. car-t cells expansion were observed in blood without obvious increase of cytokines. after infusion, case achieved and maintained molecular complete remission (cr) for more than months. case presented with grade crs manifested by continuous high fever, hypotension and grade liver disfunction from day after car-t- cell infusion for week. obvious cytokines releasing (peak il- serum concentration . pg/ml, peak crp serum concentration pg/ml) were detected which were associated with car-t- cell expansion in blood and no severe off-tumor effect was observed. after infusion, case achieved hematological cr and cytogenetic cr and got months disease free survival. conclusions: our report implicates that car-t- is a safe and promising approach to managing r/r t( ; )aml with cd expression, and may provide a salvage treatment approach for all aml patients with cd expression and benefit a certain population with aml besides b-linage malignancies. clinical trial registry: na disclosure: nothing to declare. this work was supported by research grants from the national key r&d program of china ( yfc ), national natural science foundation of china ( , , , ) background: chimeric antigen receptor engineered t (car-t) cells have emerged as a powerful cellular therapy to treat malignant disease, which is currently revolutionizing field of cancer immunotherapy. a cryopreservation step postmanufacture is not only a logistical necessity for large scale cell manufacturing processes but also a mandatory request by regulatory authorities. in case relapse after st car-t cell transplantation, a second application, maybe at a higher dose constitutes a therapeutical option. however, data concerning clinical grade car-t cell stability and functionality after months of cryopreservation have not been released by companies so far. to investigate the effect of cryopreservation on car-t cells, we performed this study. methods: different batches of cd car-t cells were manufactured according to gmp requirements at our institution. final car-t products were frozen at concentrations of x cells/ml (high batch) and x cells/ml (low batch) by a controlled freezing process with the biofreeze bv device and stored in liquid nitrogen tanks below - °c until release. quality control tests for sterility, endotoxin and mycoplasma were performed for each batch according to european pharmacopoeia and united states pharmacopoeia guidelines. stability of cd car-t cells in terms of viability, recovery, transduction efficiency and functional capacity were determined by microscopy, multi-parametric flow cytometry as well as chromium- release tests following our sops. results: all the results of quality controls fully met the requirements of the regulatory authorities. stability results were highly robust and reproducible over time for all our gmp car-t batches. duration of cryopreservation (up to days) had no negative influence on cell viability, recovery of viable cd car-t cells and transduction efficiency. however, the cell concentration for cryopreservation has a significant impact on the post-thawing viability (low batches vs. high batches: . ± . vs. . ± . , p < . ) and recovery (low batches vs. high batches: . ± . vs. . ± . , p < . ) of cryopreserved cd car-t cells, but not the transduction efficiency. moreover, we observed four transient side-effects of cryopreservation on the amount of cytokines released by car-t cells, the cytokine release on a per-cell basis, the multifunctionality of car-t cells and the killing capacity. of note, functional capacity of cryopreserved car-t cells after overnight resting was comparable or even enhanced for inf-γ and tnf-α release by cd + and cd + cd car-t cells when compared to fresh car-t cells. the multi-functionality of car-t cells could be preserved. furthermore, the killing capacity of cryopreserved cd car-t cells after overnight resting could reach the level of non-cryopreserved/fresh car-t cells. conclusions: cryopreservation up to days has no harmful effect on transduction efficiency and functionalities of car-t cells. however, the cell number per milliliter freezing medium matters. dose over x cells/ml should be avoided. for the conduction of in vitro bio-assays to determine the function of car-t cells, an overnight resting process could mimic the situation after clinical application and eliminate the transient side-effects of cryopreservation to fully regain the functional potency of car-t cells. disclosure: nothing to declare background: dc and specific t-cells are important mediators of ctl-responses. we could already show that allogeneic donor-or autologous t-cells obtained from amlpatients can be stimulated by dc leu , resulting in a very efficient lysis of naive blasts. methods: chemokine-release (cxcl , - , - , ccl , - , and il- ) was analysed by cytometric bead array in serum of aml/mds-pts as well as in supernatants from different dc-generating-methods and correlated with pts' clinical course, dc-and t-cell-interactions as well as specific t-cell-reactions. the lytic activity of dcleu/blast -stimulated t-cells in mlc against naive blasts was quantified in a cytotoxicity assay. results: minimal differences in median chemokine-levels in pts' serum subdivided in subtypes were seen, but higher release of cxcl , - , - and lower release of ccl and - tendentially correlated with more favourable subtypes (< years of age, < % blasts in pb). in persisting disease, a higher serum-release of ccl and at relapse a significantly higher ccl -release were found compared to first diagnosis -pointing to a change of 'disease activity' on a chemokine level. whereas chemokine-levels in dc-culture supernatants compared to serum were variable, clear correlations with lateron (after stimulating t-cells with dcleu in mlc) improved antileukemic t-cell activity were seen: higher values of all chemokines in dc-culture supernatants always correlated with improved t-cells' antileukemic activity (compared to stimulation with blast-containing mnc as control) -whereas with respect to the corresponding serum values higher release of cxcl , - , and - but lower values of ccl and - correlated with higher probabilities to improve antileukemic activity of dcleu-stimulated (vs. blaststimulated) t-cells. predictive significant cut-off-values could be evaluated separating the groups compared. moreover, correlations with lateron achieved response to immunotherapy and occurrence of gvhd were seen: higher serum values of cxcl , - , - and ccl and lower values of ccl correlated with achieved response to immunotherapy. predictive cut-off-values could be evaluated separating the groups compared in 'responders' and 'non-responders'. higher levels of ccl and - but lower levels of cxcl , - , - correlated with occurrence of gvhd. conclusions: we conclude, that in aml-pts' serum higher values of cxcl , - , - and lower values of ccl and in part of ccl correlate with more favorable subtypes and improved antitumor'-reactive function. since in dcculture supernatants higher values of all chemokines correlated with improved antileukemic t-cell reactivity we conclude a change of functionality of ccl and - from an 'inflammatory' or 'tumor-promoting' to an 'antitumor'reactive function. this knowledge can contribute to develop immune-modifying strategies that promote antileukemic adaptive immune-responses. disclosure: nothing to declare background: allogeneic hematopoietic cell transplantation (allo-hct) is a curative treatment option for patients suffering from hematologic malignancies. infusion of donor lymphocytes (dlis) can induce sustained remission in case of minimal residual disease or relapse through potent graftversus-leukemia (gvl) effects, although graft-versus-host disease (gvhd) represents a common dose-limiting toxicity. as invariant natural killer t (inkt) cells are known to prevent gvhd while promoting beneficial anti-tumor effects, we investigated the role of inkt cells for successful dlis. methods: we analyzed dli samples by flow cytometry. inkt cells were identified by staining with pbs -loaded cd d tetramers. culture-expanded and purified dli-inkts were then tested against tumor cell lines and primary leukemia cells in an ex vivo tumor control model. tumor cell viability after coincubation with dli-inkts was measured by flow cytometry using -aad. results: inkt cells represent . % (range . - . %) of donor lymphocytes and can be expanded fold following a two-week protocol with a preferential expansion of cd + inkt cells. tumor cell lines such as jurkat were efficiently lysed after coincubation with dli-inkts. cd a as a marker of degranulation was significantly upregulated on dli-inkts after stimulation by jurkat. in addition, increased concentrations of tnfα, ifn-γ, sfasl and perforin were measured after coincubation of dli-inkts with jurkat. we observed that tumor cell lysis correlated with the expression of the mhc-i-like molecule cd d. consequently, adding a cd d antibody to the coculture abrogated the dli-inktmediated kill of tumor cells. dli-inkts also efficiently lysed primary leukemia cells such as aml blasts: expression of cd d on these aml blasts significantly correlated with dli-inkt-mediated tumor cell lysis (r = . , p= . ). conclusions: ex vivo expansion of dli-inkts and subsequent dli enrichment is an immunotherapeutic approach that could improve leukemia control and thus, prevent relapse after allo-hct without exacerbating gvhd. disclosure: nothing to declare. generation of antigen-specific cytotoxic t lymphocytes targeting wt using activated b cells sun ok yun , kyung won baek , hee young shin , hyoung jin kang seoul national university, seoul, korea, republic of background: the wilms tumor antigen (wt ) is highly expressed in many malignancies including leukemia and targeting wt as a tumor associated antigen (taa) in cancer immunotherapy is attractive. in this study, we generated wt -specific cytotoxic t lymphocytes to confirm if activated b cells can act as a cancer antigen presenting cell and induce ctls. methods: for the induction of ctls against wt , activated b cells were used as an antigen presenting cells. b cells were isolated from pbmcs of normal healthy donors and activated with α-galactosylceramide (α-galcer) and nucleofected with wt -coding plasmid dna. activated b cells were the cultured with pbmcs for days in vitro and harvested for assay. results: cells expanded about times after days of culture. we examined characteristic of wt -specific ctls by their surface markers. wt -specific ctls had more than % cd + marker, and ratio of cd to cd was . - . . we also examined nkt cell markers to see if nkt cells were activated by il- , a cytokine used in the induction of ctls, and the portion of nkt cells was about %. the ctls showed a decrease in naïve cell (cd l+cd ra +) and an increase in effector memory (cd l+cd ra-) and central memory (cd l-cd ra-) compared with non-stimulated pbmcs. subsequently, the ifn-γ elispot (enzyme-linked immunospot) assay was performed to confirm the response of the induced wt -specific ctls to the wt antigen. when wt -specific ctls encounters a target that does not have a wt antigen, it did not produce ifn-γ, but when it encounters a target cells loaded wt antigen, it responded to secrete ifn-γ. killing assays were also performed to determine the immunogenicity of induced ctls. the induced wt ctls was found to be killing more than % when the e:t ratio was : when the autologous pbmc met the target with wt pepmix. in addition, we found that wt ctls has killing activity when it encounters leukemia cell lines that express wt and matched hla-a* . conclusions: in this study, we can induce antigenspecific ctls that specifically react to wt using activated b cells as antigen-presenting cells. these observations confirmed that b cells activated by α-galcer can act as a taa presenting cell to induce taa specific ctls as viral antigen, such as pp and ie , and consequently wt specific ctls could be induced. moreover, ctls induced activated b cells had ability to recognize and kill the target cells expressing wt correctly. our results demonstrate that these in vitro expanded wt -specific ctls using activated b cells can be a promising candidate for adoptive immunotherapy against cancer. disclosure: nothing to declare judith böhringer , michael schumm , christiane braun , marina schmidt , patrick schlegel , christian seitz , murat aktas , georg rauser , sandra karitzky , peter lang , rupert handgretinger university children's hospital tübingen, tübingen, germany, miltenyi biotec gmbh, bergisch gladbach, germany background: t cells with chimeric antigen receptors (cars) on their surface facilitate to target specific surface expressed antigens. research and clinical trials with cd -car t cells show impressive remission induction rates and increased survival in heavily pretreated patients. therefore, car t cells are introduced as new potent cellular therapeutics in the clinical routine. in order to establish the manufacture of cd -car t cells, validation runs with the fully automated clinimacs prodigy t cell transduction process have been performed using the miltenyi anti-cd -car lentiviral vector. methods: unmobilized leukaphereses from donors ( x healthy, x all) were used for the clinimacs prodigy t cell transduction process. leukocytes undergo a cd + / cd + t cell enrichment via magnetic beads, followed by stimulation with macs ® gmp t cell transact™, transduction with an anti-cd -car lentiviral vector, expansion with il and il , and final formulation to the cellular product. during and after the manufacture, facs analyses were performed as well as cytotoxicity assays after cd -car t cell production. results: total volumes of leukaphereses were between and ml with . - . x total mononuclear cells. after enrichment x cd + / cd + t cells were transduced with anti-cd -car lentiviral vector and were further expanded. cells were harvested on day . the final cell counts of the cellular products were . , . and . x mononuclear cells from two healthy volunteers and the all-patient, respectively. the transduction efficiency of the cd -car t cells was . %, . % and . % among viable cd + cells. the final count of car t cells was therefore . , . and . x cells. the final products exerted excellent cytolytic activity against cd + bcp-all cell line nalm- . importantly, cd -car t cells generated from the all patient demonstrated complete eradication of autologous blasts at . to e:t ratio after hours incubation. conclusions: the clinimacs prodigy t cell transduction process has been shown to run a fully-automated manufacturing process over days without any deviations in a clean room environment on a single device. the user interaction was reduced to activities at only days to set up the system and provide fresh medium and reagents. the transduction process yielded a high number of t cells with a high frequency of cd -car t transduced cells. the results were comparable for both unmobilized leukaphereses from healthy donors and showed expected slightly lower results in the patient. finally, these results demonstrate that the clinimacs prodigy t cell transduction process is well suited to provide the clinical mb-cart . r/r cd + bcm study with appropriate investigational medical products. disclosure background: allogeneic hematopoietic stem cell transplantation (allohct) is an effective strategy in the long term control of several hematologic diseases, however, patients could experience complications, as graft versus host disease (gvhd) and disease relapse. recently, the introduction of post-transplant cyclophosphamide (ptcy) allowed to significantly reduce gvhd, but disease relapse remains an important issue. donor-lymphocyte infusion (dli) is an established adoptive cell therapy for disease relapse after allohsct, but, in order to be efficient and safe, patients have to be off immunosuppression treatments and gvdh-free. here we report our data about efficacy and safety of dli infusion as treatment for disease relapse in patients who received peripheral blood stem cell transplantation (allopbsct) from hla-matched unrelated/related plus ptcy as gvdh prophylaxis in our clinical trial (nct ). methods: we collected data from patients, treated with ptcy ( mg/kg/die, days + + ), mofetil mycophenolate (mmf) and tacrolimus (t) as gvhd prophylaxis after allo-pbsct, who received dli infusions. they were treated between january and october . we report data about overall response rate (orr), disease control rate (dcr), and dli-related mortality and morbidity. diagnosis were as follow: had multiple myeloma, had acute myeloid leukemia, had acute lymphoblastic leukemia and had lymphomas. all patients but one, who had chimerism loss, received dli because of disease relapse. results: median time between transplant and dli was (range - ) months. median number of dli infusions was (range - ). patients ( %) received cyclophosphamide mg/m preparative regimen the day before the cryopreserved dli infusions, while in the other cases dli were associated with lenalidomide, ponatinib and -azacitidine. the overall response rate (orr) was %, while disease control rate (dcr) was achieved in %. the patient who received dli because of loss of chimerism converted it in full donor after infusions. after dli treatment the incidence of acute gvhd grade i-iii was %, while was % for grade ii-iii and patients were started on short course of systemic immunosuppression treatments . none of these patients died because of dli adverse events. estimated -year overall survival was % with a limited follow-up length ( months). conclusions: the infusion of non-manipulated lymphocytes from allogeneic donors is a valuable and safe strategy of treatment for patients relapsing after allopbsct with ptcy. ptcy showed high efficacy in gvhd prevention, allowing early discontinuation of immunosuppression drugs. because of this, we can reach the goal to transform transplant in a platform where we could add early dli infusions as a new strategy for disease control. clinical trial registry: nct disclosure: nothing to declare p extracorporeal photopheresis in the treatment of refractory chronic gvhd: analysis of mononuclear cell infusion gillen oarbeascoa , maria luisa lozano , , , luisa maria guerra , cristina amunarriz , nuria revilla , , , pastora iniesta , , , cynthia acosta fleitas , jose luis arroyo , eva martinez revuelta , andrea galego , dolores hernandez-maraver , mi kwon , , aurora viejo , jose maria garcia gala , concepcion andon saavedra , jose luis diez-martin , , background: extracorporeal photopheresis (ecp) is an immunomodulatory treatment that has shown efficacy in steroid refractory chronic gvhd, but the mechanism of action is only partially understood. in some studies, a correlation has been suggested between treated mononuclear cells (mnc) or lymphocytes and response to ecp. the objective of the study was to analyze the relationship between the infused cellularity and response in chronic gvhd. methods: patients from different centers with a total of ecp procedures were retrospectively analyzed. ecp procedures were performed from january- to june- . all ecp procedures were performed with the off-line system. the response was defined as responder (complete and partial response) and non-responder. infused cell numbers for lymphocytes, monocytes and mononuclear cells (lym+mon, mnc) were calculated. for analytic purposes, the median number of cells infused per procedure until response (or until the median number of procedures until response for non-responding patients) and the cumulative number of cells infused until response (or until the median in non-responders) were calculated for all the subgroups. same procedures were performed with the number cells infused until day of ecp. finally, the response and survival impact of infusing a number of cells over or below the median and in different tertiles (t , t and t ) was assessed until the median number of procedures needed to achieve a response. results: the median number of procedures until response was . we observed no differences in the median number of lymphocytes, monocytes or mncs infused until response or until day between responding and non-responding patients. there were no differences in response if patients received lymphocytes or monocytes above or below the median number. nevertheless, patients that received a total absolute number of mncs above the median ( x cells) showed a trend towards a higher response rate ( % vs %, p= . ). the patients that received a cumulative number of lymphocytes in the first ecp procedures above the median showed improved overall survival (os) ( y os % vs %, p= . ). patients that received a number of monocytes above the median showed a trend towards better survival (p= . ), that was significant when the number of monocytes infused surpassed the first tertile ( y os % for t , % for t , % for t , p= . ). finally, the patients that received a cumulative number of mncs above the first tertile also showed improved survival ( y os % for t , % for t , % for t , p= . ). conclusions: there were no differences in the infused cellularity between responding and non-responding patients with chronic gvhd. at the same time, we found that except for a trend toward better response with higher mncs infused, there was no relationship between lymphocytes and monocytes with the response rate as other previous studies have suggested. however, even if there is no relationship with the response rate, the patients receiving the highest numbers of lymphocytes, monocytes and mncs in the cohort showed an improved survival, suggesting that larger quantities of cells could exhibit a protective effect. nevertheless, prospective studies that address this relationship are needed. disclosure: nothing to declare comparative analysis of the cytotoxic potential of cytokine-induced killer and natural killer cells for neuroblastoma therapy annekathrin heinze , beatrice grebe , eva mudry , jochen früh , bushra rais , claudia cappel , sabine hünecke , eva rettinger , thomas klingebiel , peter bader , evelyn ullrich , university hospital frankfurt, frankfurt, germany, german cancer consortium (dktk) partner site:, frankfurt, germany background: neuroblastoma (nb) is the most common solid extracranial tumor in childhood. despite therapeutic progress, prognosis for high-risk nb is poor and innovative therapies are of medical need. therefore, we investigated the cytotoxic potential of interleukin (il)-activated natural killer (nk) cells compared to activated cytokine-induced killer (cik) cells against different human nb cell lines in vitro. methods: nk cells were isolated from peripheral blood mononuclear cells (pbmcs) using cd enrichment or cd /cd depletion kits. they were successfully expanded ex vivo with different cytokine combinations such as il- , il- , il- and/or il- under feeder-cell free conditions. in contrast, cik cells were generated from pbmcs by ex vivo stimulation with interferon-γ, il- , okt- and il- . a comparative analysis of expansion rate, purity, phenotype and cytotoxic activity against different nb cell lines following different culturing protocols was performed. results: cd enriched nk cells showed a median expansion rate of . -fold after to days in culture with a final frequency up to . % nk cells and a median frequency of . % cd + cd -t cells. in contrast, the starting cell product after cd /cd depletion consisted of a median frequency of . % nk cells that expanded significantly faster with . -fold and also reached up to . % purity without any relevant t cell contamination. cik cells expanded with a median rate of . -fold and contained . % nk, . % t and . % nk-like t cells. interestingly, nk cells, particularly after cd /cd , showed a significantly higher median cytotoxic capacity against nb cells depletion ( . % for cd enrichment, . % for cd /cd depletion) compared to cik cells that induced . % killing of nb cells with e:t ratio : in a hours' co-incubation assay. interestingly, prolonging the ex vivo stimulation after cd /cd depletion to days enhanced the median expansion rate to . -fold with a slightly reduced cytotoxic potential ( . % for days' ex vivo expansion, . % for days' ex vivo expansion, comparison of the same donors). the addition of an il boost prior harvesting increased the expansion rate to median . -fold (compared to . -fold for the same donors) with an improved cytotoxicity of . % (compared to . %) . fortunately, all nk cell products showed a high viability and no relevant t or b cell contamination (median < . %). interestingly, further optimization of the culturing procedure with use of another cell culture medium led to an improved median . -fold (compared to . -fold) nk cell expansion rate in days, also resulting in comparable cytotoxicity of . %. conclusions: nk and cik cell products may offer an innovative immune therapeutic option for patients with high-risk nb after allogenic stem cell transplantation. our study revealed that nk cells have a significantly higher cytotoxic potential to combat nb. interestingly, the use of il- expanded and il- activated nk cells developed from a cd / depleted apheresis product is highly promising as additional immunotherapy in combination with haploidentical stem cell transplantation of children with nb. disclosure: nothing to declare. quantitative determination of donor allo-reactive t-cells in haploidentical donor-recipient pairs by enzymelinked immunospot (elispot) and mixed lymphocyte culture (mlc) assays background: t-cell alloreactivity is responsible not only for graft versus host disease and morbidity, associated with hematopoietic stem cell transplantation (hsct) but also for graft-versus-leukemia (gvl) activity. in this regard, monitoring and quantitation of alloreactive t-cells (allo-t) may potentially provide valuable information for individualized clinical management of transplant recipients. the aim of this study was the optimization of allo-Т detection and comparison of the elispot and mlc assays. methods: allo-t were determined in haploidentical donor-recipient pairs before hsct. donor mononuclear cells (mnc) served as effector cells (ec) . patient cd depleted mnc were used as stimulatory cells (sc).the ratio ec:sc were : and : . the frequency of allo-t in donor peripheral blood was tested in elispot assay and mlc. elispot provides the detection and quantitation of activated t-cells on the basis of cytokine secreted by each cell. the co-incubation time was h for ifn-gamma and h for il- detection. in mcl assay donor mnc were labeled with cfse and allo-t, proliferating in response to stimulation with alloantigens, were determined by flow cytometry on day . results: the median number of ifn-gamma producing allo-t per donor mnc was , ( - ; ec:sc ratio - : ) and , ( - ; ec:sc ratio - : ). the median frequency of allo-t was , % ( , - , ; ec:sc ratio - : ) and , % ( , - , ; ec:sc ratio - : ) among lymphocytes. il- -producing allo-t were less frequent in donor mnc in comparison with ifngamma-producing allo-t. the median number per mnc was , ( , - ; ec:sc ratio - : ) and , ( - ; ec:sc ratio - : ). the median frequency of il- -allo-t was , % ( , - , ; ec:sc ratio - : ) and , % ( - , ; ec:sc ratio - : ) among lymphocytes. the ec:sc ratio : is enough for stimulation of il- producing by mnc in elispot assay, but for optimal stimulation of ifn-gamma producing cells ec:sc ratio : is preferable. this suggests that allo-t are predominantly ifn-gamma producing cells. alloreactive proliferating t-clones were detected in mlc in of donor-recipient pairs on day of cocultivation. median percentage of proliferating t-clones were , % ( , - , ; ec:sc ratio - : ) and , % ( , - , ; ec:sc ratio - : ) among lymphocytes. however, mlc assay only permit a qualitative analysis that confirmed the presence of alloreactive t-clones, giving no information on their frequency within the culture. results of elispot and mcl assay directly correlated. conclusions: allo-t were detected in , % of assayed haploidentical donor-recipient pairs by elispot and only in , % by mlc. this difference in detection is due to the fact that elispot allows to detect single cytokine secreting cell whereas mlc can reveal proliferating аllo-t clones. the analysis of allo-t in haploidentical donor-recipient pairs may provide rationale to manipulate the allo-immune response and to exploit the powerful ability of allo-t to control hematologic malignancies. disclosure: nothing to declare allogeneic mesenchymal stromal cell as rescue therapy in an infant with life-threatening respiratory syndrome due to a filamin a mutation background: cell-based therapy has gained attention in the respiratory system diseases and encouraging results are reported following mesenchymal stromal cells (mscs) administration. due to their capacity to produce and secrete a variety of paracrine factors and bioactive macromolecules, mscs became a key player in lung tissue injuries and function, reducing fibrosis, promoting the normal development of alveoli and pulmonary vessels. for the first time we used the msc infusions as rescue therapy in a pediatric patient with flna gene mutation and life-threatening respiratory syndrome. methods: a child with a new pathogenic variant of the flna gene c. _ del; (p.val alafster ) at the age of months, due to the serious and irreversible chronic respiratory failure and dismal prognosis, was treated with intravenous infusions of allogeneic bone marrow (bm)-mscs at the dose of × mscs/kg body weight. bm-mscs were produced at "cell factory", fondazione irccs policlinico s. matteo, pavia,isolated and expanded ex vivo from healthy donor bm, following a previously reported protocol. premedication with antistaminic drug, min before every infusion to avoid any potential reaction was performed. the evolution of the respiratory condition was detected. peripheral blood were collected before each msc treatment for treg and th monitoring. treg, defined as cd + cd neg cd + cells expressing the forkhead box p (foxp ) transcription factor, and th , defined as cd + cells expressing intracellular il- , evaluation was performed by flow cytometry (facscanto; bd biosciences, san diego, ca) as previously reported, following standard procedures. results: no acute adverse events related to mscs infusion was recorded. during follow-up, patient maintained a good general condition and showed a regular growth. no systemic or respiratory infections occurred. after the second infusion, the child experienced a progressive improvement of his clinical respiratory condition, with a good adaptation to mechanical ventilation, in the absence of episodes of respiratory exacerbations. the baby maintains adequate volumes of exchange with substantial reduction of the inspiratory support. a reduction of trigger sensitivity was also obtained. thorax ct scan showed a recovery of the basal parenchyma bilaterally and the improvement of the anatomical-functional alignment and aerial penetration. after the first msc administration, an enrichment of treg and th percentage in peripheral blood, was observed. while, after the second msc infusion a significant increase in treg/th ratio was noted. conclusions: this report suggest that msc serial infusions are a promising therapy in aiding the respiratory failure, even in a pediatric patient with flna mutation. intravenous administrations of allogeneic mscs are feasible and safe without toxicity. our results suggest that to mitigate lung injury, mscs may act as regulators of treg and th balance. further investigations are upcoming to establish the useful of this therapeutic proposal in interstitial lung diseases in children. disclosure: nothig to declare p feasibility of il- stimulated donor nk cells manufacturing for early infusion in patients with high risk acute myeloid leukemia undergoing haploidentical transplantation background: nk cells provide a potent antitumor effect in the setting of manipulated haploidentical hematopoietic stem cell transplant (haplo-hsct). we propose a novel strategy to enhance the antitumor effect of allogeneic transplant through the infusion of nk cells stimulated with il- exvivo in adult high-risk acute myeloid leukemia (aml) patients undergoing unmanipulated haplo-hsct. the objective of this study was to provide efficiency and productivity data obtained in the manufactured cellular products infused. methods: selection criteria included patients with highrisk aml undergoing unmanipulated haplo-hsct. lymphoapheresis of the haploidentical donor was performed using spectra optia (terumo® bct) on days + and + after transplant. from the obtained product a double immunomagnetic cellular selection with clinimacs system (miltenyi biotec®) was performed in two steps: cd + depletion followed by positive cd + selection. the obtained an enriched cellular product of cd -cd + nk cells was incubated with il- ( ng/ml) between and hours at ºc and % co in gmp conditions. quality and microbiological controls were performed at the end of each manufacturing step. dxh cellular counters (beckman coulter®) and multiparametric flow cytometry were used for lymphocyte subpopulations and viability analysis (navios cytometer; beckman coulter®, conjugated monoclonal antibodies; miltenyi biotec®). the final product was infused intravenously to the patient on days + and + if manufacturing conditions were met (range of . - x nk/kg, purity ≥ %, viability≥ % and < x cd + cells/kg). if not, it was discarded. nk cell activation in the product was measured by the expression of cd and cd . results: between november and april , patients were included in this ongoing trial. two products were manufactured for of the patients, and only one for the first patient, due to transplant complications between first and second infusion. one product did not meet minimum viability criteria and was discarded. in the infused final products mean and sem of nk cell purity, recovery and viability were . %± . , . %± and . %± . , respectively. log cd + depletion ranged between - . and - . . median infused doses of nk cells and cd + cells per kg were . x ( . x - . x ) and ( - ). complete manufacturing data of all procedures are shown in table background: cytokine-induced killer (cik) cells are a promising immunotherapeutic approach to combat relapse following allogeneic hematopoietic stem cell transplantation (hsct) for acute leukemia or myelodysplastic syndrome. to show safety and efficacy, a multicenter clinical study with pediatric and adult patients including up to eight cik cell applications with escalating doses is ongoing. methods: we favor single large scale cik cell generation with the aim to apply fresh cik cells and cryopreserve ready-for-use doses according to the study protocol in contrast to recurrent manufacturing. therefore cryopreserved cik cells were tested against freshly generated cik cells to approve equivalence. furthermore, an alternative medium supplement for cik cell culturing was investigated to avoid supply bottlenecks in ab-serum. results: fresh frozen plasma (ffp), platelet lysate (pl) and ab-serum in cik cell culture showed median expansion rates of -fold, whereas cultivation without medium additive resulted in significantly lower proliferation (p< . ). cik cell composition including t cells, nk like t cells and a minor part of nk cells was not significantly influenced by changing the medium additive. moreover, neither cytotoxicity against thp- cells nor cd expression on nk like t cells were significantly influenced by the different medium additives. for cik cell generation either ficollized peripheral blood (pb) or unstimulated leukapheresis (lp) products were utilized. with regard to repeated manufacturing within the clinical study, also cryopreserved lp and pbsc as starting material came into the focus of interest. comparing cik cell expansion rates, no significant differences for the entire cik cells and the subgroup of t cells were detected between the four starting materials. cryopreservation of cik cells had no significant effect on cik cell composition, cytotoxicity and cd expression on nk like t cells. a small, albeit not significant effect of cryopreservation on viability was detected, which was . % before and . % after freezing and thawing. conclusions: the challenge was an efficient time-, personal-and cost saving production of cik cells within the clinical study. introducing ffp enabled cik cell manufacturing for an increased patient cohort by avoiding supply bottlenecks in ab-serum. furthermore, cryopreservation allows the storage of ready-for-use cik cell doses fulfilling the demands of the clinical study. clinical trial registry: eudract number - - disclosure: nothing to declare. automated generation of cd ra depleted donor lymphocyte infusion (dli) with the clinimacs prodigy® cd ra system , methods: the current clinimacs cd ra system was developed for graft engineering. up to x e magnetically labeled cd ra+ cells from leukapheresis products can be depleted from up to x e white blood cells (wbc). we developed a new clinimacs prodigy® process in order to ease the procedure for routine-use, to reduce the specifications according to reported cell numbers for dli applications, and to enable the use of peripheral blood products with high amounts of red blood cells (rbc). the new system was tested by performance runs. an new fluorescent flow analysis protocol was developed. results: the resulting clinimacs prodigy pb- ra system is an automated procedure with integrated labeling and washing steps. the new application software pb- ra depletion enables to deplete up to . x e cd ra + cells from up to x e total wbc from peripheral blood products. a major difference of this process is the rbc removal option based on an integrated camera for cell pellet detection. the final cell product is provided in physiologic saline. verification runs with peripheral blood products (n= in total, n= with whole blood, n= with leukapheresis products) resulted in a mean depletion of . log (range . - . ) for cd ra + t cells in the cd ra depleted product. viability of the target products was always above %, and mean wbc recovery was %. the mean process time was h min (range h to h min) without including the manual steps, i.e. tubing set installation and downstream analysis of blood products by flow cytometry. this data were in line with preceding evaluation runs (n= ), and results obtained in cooperation with an external beta test site. the performance results were furthermore in line with results obtained on clinimacs plus instrument runs. for quality control of cd ra depleted products we developed a flow cytometric analysis strategy for fast, accurate, and convenient analysis of even rare counts of remaining unwanted cells. it allows to determine naïve t cells at two different levels of subset staining. the minimum requirement for the flow cytometric analysis includes colors to define viable cd +cd ra+ cells. for further evaluation of the naïve t cell subsets additional colors are used to define viable cd +cd ro-cd -cd l+cd + cells. conclusions: the automated clinimacs prodigy pb- ra system process is capable to deplete cd ra+ cells efficiently from peripheral blood products within hours. the new process is a fast, convenient, and regulatory compliant method for the preparation of ready-to-use cd ra-depleted cell products for clinical applications. the submission to an european notified body for ce certification is an important next step. myeloablative conditioning regimen was preferred for patients out of . gvhd prophylaxis regimens are csa +mtx: (% ), csa+mmf: (% ), csa only: (% ). atg was given patients. despite been given gvhd prophylaxis (% , ) patients out of transplanted patients had gvhd features. of patients, had experienced steroid resistant gvhd after transplantation, including (% ) grade and (% ) grade . ecp treatment was started mean days after diagnosis of steroid resistant gvhd and (% ) patients had complete response while (% ) patients had partial and (% ) patients had no response to ecp treatment on day . sixteen out of patients had also received mesenchymal stem cell therapy as salvage therapy. only one patient had experienced hypocalcemic tetany, a complication of ecp procedure. thirteen patients had died and were directly related with steroid resistant gvhd. other conditions like relapse of primary disease or pres syndrome also played role in death. conclusions: extracorporeal photopheresis is a reliable and effective second line treatment modality in steroid resistant gvhd. starting ecp sessions as soon as gvhd symptoms occur increases its effectivity. mesenchymal stem cell administration with ecp for (% ) patients limits our study to reach o conclusion for efficacy of ecp itself. need for hemodialysis catheters, the prolonged sessions while adequate flow is not possible and catheter related infections are the lmitations for feasibility of ecp. disclosure: nothing to declare donor lymphocyte infusion administrations after allogeneic stem cell transplantations in pediatrics: a single center experience background: loss of chimerism is one of the major problems after allogeneic stem cell transplantation(sct). donor-lymphocyte infusions(dli) are used as a treatment after taper or stopping immunosuppression. in this study, dli experience in patients with loss of chimerism after sct due to various benign and malign hematological diseases was presented. methods: between july -august , twenty patients, detected chimerism loss and received dli after sct were evaluated retrospectively. patients received myeloablative or reduced intensity conditioning, atg, cyclosporine a and methotrexate for gvhd prophylaxis. chimerism analyses were performed with short tandem repeat(str) method from peripheral blood. results below % were considered as mixed chimeric and below % were nonchimeric. when patients considered as mixed chimeric, immunosuppression therapy was ceased immediately and treated with dli. donor lymphocyte infusions were performed at two-week intervals with chimerism follow-up. student t, mann whitney u, ki kare tests and kaplan-meier analysis were used. results: between - ages (median ), female, male patients were evaluated. the initial diagnoses were thalassemia major( ), aplastic anemia ( ),all( ), aml ( ) . dli initiation time was . +- . days after sct, total number of dli administrations were . +- . . dose of dli was x - . x /kg (mean . x /kg). nine patients' chimerism out of , fell below % at first month after transplant; patients were nonchimeric, of them were complet chimeric and were mixed chimeric. eleven patients´chimerism were below % between - months after sct, patients were nonchimeric and were mixed chimeric. early mixed chimerism was found relevant with graft rejections (p= . ). patients were followed up for - days. eight patients' chimerism increased after dli infusion and continued to decrease in patients. after dli, acute gvhd has been seen in both group.the group with decreased chimerism after dli, dose was mean x ± x /kg while the group with increased chimerism had dli dose mean x ± x /kg. although the difference was not statistically significant, numerical value revealed significantly different. eventually patients out of were mixed chimeric, patients were complete chimeric and were none. in thalassemic patients, patients with thalassemia-trait donor were mixed chimeric, in patients whose donors were normal, of them were complete chimeric and one of them was nonchimeric.the difference was significant (p= . ). the cd infusion doses revealed mean . ± . x /kg in mixed chimeric patients, . ± . x /kg in complete chimeric patients and . ± . x /kg in the patients with loss of chimerism. cd amount was seen high as numerical value in complete chimerics but no statistical significance was found. overall survival was %, disease-free survival was %. conclusions: we evaluated the efficacy of dl for patients with mixed chimerism in our patient group. we concluded that chimerism loss in patients with early decreased chimerism is similar to those in literature in spite if dli practices. dose and application frequency were greater in patients with increased chimerism. the small number and the heterogeneity of the patients limited our study. in this regard, studies with larger series and homogeneous groups are acquired. disclosure: nothing to declare phase i clinical trial of repeated administrations of bone-marrow derived mesenchymal stem cells in steroid-refractory chronic graft-versus-host disease patients nayoun kim , young-woo jeon , jae-deog jang , keon-il im , nak-gyun chung , young-sun nam , yunejin song , jun-seok lee , seok-goo cho (cghvd) is the most common long-term complication of allogenic hematopoietic stem cell transplantation which is associated with poor quality of life and increased risk of morbidity and mortality. currently, there is no standardized treatment available for patients who do not respond to steroids. as an alternative to immunosuppressive drugs, mesenchymal stem cells (mscs) have been used to treat and prevent steroidrefractory acute gvhd patients. these studies and reports have also provided a basis for using mscs in steroid refractory cgvhd patients. methods: to evaluate the safety and efficacy of repeatedinfusions of mscs, we enrolled ten severe steroid-refractory cgvhds patients. steroid refractory was defined as either no response to steroids lasting at least weeks or progression of disease during treatment or tapering lasting at least weeks. patients were intravenously administered with mscs produced from third-party bone marrow donors at a -week interval for a total of four doses. each dose contained x cells per kg body weight and all four doses consisted of mscs from the same donor and same passage. results: we enrolled ten patients ( female/ male, with a median age of . (range - ). median of cgvhd affected organs was (range - ) including the skin (n= ), eyes (n= ), oral cavity (n= ), lung (n= ), liver (n= ) and joints (n= ). all ten patients received their planned four doses of mscs, administering a total of infusions. median time from initial cgvhd diagnosis to first msc treatment was days (range - ). msc infusions were well tolerated with no immediate or delayed toxicities. after weeks of the first msc infusion, all ten patients showed partial response showing alleviation in clinical symptoms and increased quality of life. organ responses were seen in skin (n= ), eyes (n= ), oral cavity (n= ), liver (n= ), and joint(n= ). however, one patient died of progressive gvhd and one patient relapsed from primary disease. conclusions: repeated infusions of mscs was feasible and safe and may be an effective salvage therapy in patients with steroid-refractory cgvhd. further large-scale clinical studies with long-term follow up is needed in the future to determine the role of mscs in cgvhd. background: the majority of pregnant polish women ( %) have heard of cord blood banking. however, most doctors do not have sufficient knowledge about the possibility of using cord blood in order to respond to their potential concerns. only . % of healthcare professionals were aware that cord blood could be used to treat haematological diseases. in order to make doctors aware of this issue and provide patients with the information they expect, we would like to present data on the use of cord blood stored in our blood bank for haematological and nonhaematological therapies. methods: the table presented below has been created using data from the general database of the polish stem cell bank, warsaw, poland. no data regarding umbilical cord blood data have been excluded. all patients were planned to be assessed on day , day , on discharge, days after transplantation and , , , , and years after transplantation, but in some cases, patients were lost from follow-up due to a persistent lack of reports from transplantation centres. results: in cases, the therapeutic use of cb was transplantation (replacement of patients' own tissue); in cases it was administration (infusion without destruction of patients' own tissue). thirty-three were administered as standard therapy and as experimental therapy. conclusions: the survey study cited above, indicated low awareness of cord blood use among healthcare professionals. on the other hand, one study indicated that the expectations placed in cord blood banking may be unreasonable. as a private cord blood bank, we support recommendations which underline the importance of patient education. in poland, cord blood has been approved as standard therapy in approx. diseases; most of them are rare, but polish law allows the use of cord blood for the siblings, parents and grandparents of a donor. additionally, active and planned clinical trials throughout the world evaluate the therapeutic efficacy of cord blood in such areas as haematology, neurology, cardiology, diabetology, congenital paediatric disorders, ophthalmology, dermatology, gastroenterology, hiv infection, and the quality of life during aging. therefore, further indications may be expected in the future. background: cytokine release syndrome (crs) has been identified as a clinically significant, on target, off tumour side effect of the chimeric antigen receptor (car) t-cell therapies. it is clinically increased in interkeukin and elevations in other cytokines, lactate dehydrogenase (ldh), c-reactive protein (crp), and ferritin. these side effects can include fever, fatigue, headache, encephalopathy, hypertension, tachycardia, coagulopathy, nausea, capillary leak and multi organ dysfunction. crs symptoms can appear as early as one day after infusion and can resolve quickly or last for weeks. it´s severity to be related to the disease burden prior to car t-cell therapy. methods: the bristol oncology and haematology centre will be providing car t-cell therapy to patients in early . on collating from the leading consultant on the ward and fellow nursing team members it was apparent that an effective way at managing patients post car t-cell therapy side effects is to provide an educational and informative poster depicting a flow chart that will aid the practitioner to recognise and effectively treat/manage a patient with crs symptoms. results: none as of yet as this is a prospective tool ready for our first patient in early conclusions: through continuing reading and study days prior to the ward receiving its first car t-cell patient it is increasingly important that the entire multi disciplinary team recognise crs and understand the importance of early detection, careful monitoring and early intervention. background: allogeneic stem cell transplantation (allosct) is the only curative procedure for primary and secondary myelofibrosis (pmf, smf). elderly people are mainly affected, limiting the feasibility of intensive myeloablative chemotherapy regimens. the introduction of reduced-intensity conditioning (ric) made allosct feasible and effective for old patients. nevertheless, the incidence of pmf and smf is not negligible in young patients, theoretically able to tolerate also high-intensity therapy. very few data are available about the efficacy of ric-allosct in the particular setting of young-aged mf patients. methods: this study includes myelofibrosis young patients (age < y) who received allosct between and at the university hospital hamburg/germany. four patients were previously splenectomized. patients mostly fall into intermediate risk groups according to dipss. four patients belonged to the high-risk triple-negative category (jak /calr/mpl-). asxl -mut was tested in patients (pos: ). in % graft source was pbsc, patients received bmsc. only % of patients had a / hla-matched sibling, the others were transplanted from fully-matched ( %) or partially-matched ( %) unrelated donor. all transplants were conditioned according the ebmt protocol with busulfan ( mg/kg po or mg/kg iv), fludarabine ( mg/m ), atlg (grafalon® neovii, germany) administered in days at a dose of mg/kg die for mud, mg/kg die for mrd transplants, followed by cylosporina, and mycophenolate in the first days. results: engraftment rate was %, median neutrophil engraftment time days. platelet engraftment was reached by patients ( %, median days). four patients ( %) developed poor graft function, successfully treated with cd + selected pbsc-boost. after a median follow up of . years, estimated y-pfs and os were % and % respectively. dipss-risk and donor hla-matching resulted the only significant impacting factors on os. neither cytogenetic nor molecular abnormalities were significantly related to os. twenty-five patients ( %) experienced agvhd grade > . c-gvhd was observed in patients ( %), mostly ( %) beginning in the first days after transplantation. cumulative incidence of trm was % at year, with a plateau after the first year ( y trm = %). trm was observed only in patients with maximal grade ( ) of marrow fibrosis. furthermore, trm never occurred in previously splenectomized patients (p= . ), but no significant impact from splenectomy on os was observed (p= . ). after transplant, patients ( %) relapsed: died without any treatment because of infection, received dli ( durable cr), patients ( after dli) underwent a second allosct, with long-term survival in cases. conclusions: ric followed by allogeneic sct is a curative treatment approach for younger patients with myelofibrosis with a low nrm. the most important outcome-determining factor is donor hla-matching. interestingly, marrow high grade fibrosis showed to significantly impact trm. biological markers such as asxl mutation and cytogenetics, largely known as highly predictive for poor prognosis in the disease natural course, did not show any impact on survival, suggesting that patients harboring these abnormalities could get the greatest benefit from allosct. further data collection, and a prospective randomized trial are needed to confirm our conclusion. disclosure: nothing to declare p abstract already published. splenectomy as a risk factor for relapse after allogeneic hematopoietic stem cell transplantation in patients with myelofibrosis -retrospective cohort study background: splenectomy is a common procedure in patients (pts) with myelofibrosis (mf) performed to achieve improvement in blood cell counts and reduce b-symptoms. however, it has also been shown that splenectomy may adversely predispose to leukemic transformation in this setting. aim: to evaluate in a single-center retrospective analysis the long-term impact of pre-or post-transplant splenectomy on transplant outcome regarding overall survival and relapse risk. methods: this retrospective analysis comprises the data of pts ( male and female) with primary (n= ) or secondary (n= ) mf after allo-hsct from hla-matched sibling (n= ) or unrelated (n= ) donors in our center between and . the median age was years (range, to years). a myeloablative conditioning regimen was performed in pts, while pts where treated with a reduced intensity conditioning. peripheral blood stem cells (n= ) or bone marrow (n= ) with a median of . x cd + cells/kg bodyweight (bw) (range, . to ) were transplanted. splenectomy was performed in of pts: pts were splenectomized prior to and pts after allo-hsct. relapse was diagnosed in ( %) of pts. the median duration to relapse after transplantion was months (range, - months). results: the median duration of follow-up of this cohort was months (range, - months), the -year overall survival (os) was %. pts died, including pts who relapsed and pts who died of treatment related causes. the observed probability of relapse was significantly higher in splenectomized pts than in non-splenectomized pts: % versus % (relative risk (rr) . , % ci, . - . , p= . ). at years, the os was % in nonsplenectomised and % in splenectomised pts (p= . ) (fig. ) . the relapse rate in splenectomised pts was independent of pre-( of pts, %) or post-transplant ( of pts, %) treatment (rr . , % ci, p= . ) . conclusions: on the basis of our cohort, we could assert that pre-and post-allo-hsct splenectomy was equally and significantly associated with an increased relapse ratio in patients with mf, which also tends to negatively affect overall survival. [[p image] . figure : the overall survival after allo-hsct in patients with myelofibrosis.] background: b-cell prolymphocytic leukemia (b-pll) is a very rare lymphoproliferative disorder. although allogeneic stem cell transplantation (allosct) could be a curative option, patients often do not qualify for this consolidation treatment due to an aggressive course of disease. in this case study, we report on three patients who failed ibrutinib therapy but achieved complete remission and even mrd negativity after treatment with the chimeric cd -antibody rituximab, enabling them to undergo allosct. methods: clinical data and follow-up data were collected by chart review. results: all three patients (pt# : male, years; pt# : female, years; pt# : female, years) were referred with b-pll harboring highly complex aberrant karyotypes, including p abnormalities in pt# and pt# . a tp mutation could be detected in pt# and pt# . all three patients had symptomatic disease with rapidly increasing hyperleukocytosis and massive splenomegaly. two of them were treatment-naive and one relapsed after chemoimmunotherapy. all patients were put on ibrutinib mg. despite initial response to treatment, two patients developed progressive disease after (pt# ) and months (pt# ) on ibrutinib, whereas pt# remained in partial remission with persisting leukocytosis, precluding consolidating allosct as originally intended. in pt# , ibrutinib was replaced by venetoclax, but without response. in order to control rapid lymphoproliferation, rituximab was added to venetoclax. grade infusion reaction / tumor lysis syndrome (tls) (fever, tachycardia and hypotonia requiring intravenous vasopressors) followed each rituximab administration despite fractionating rituximab to small doses. however, continuation of rituximab ( mg/d over d) led to complete and durable clearance of hyperleukocytosis (from /nl to mrd negativity) despite venetoclax cessation. a similar pattern was observed in pt# , who received rituximab while showing rapidly increasing leukocytosis upon ibrutinib. again, complete clearance of b-pll cells in the peripheral blood (from /nl to mrd negativity) occurred after initial grade tls despite only modest cd expression on tumor cells in this patient. also, pt# achieved profound b-pll cell depletion (from /nl to a mrd rate of . %) upon addition of rituximab to ibrutinib (without tls in this case). subsequently, all three patients were able to undergo allosct after conditioning with fludarabine and total body irradiation with gy. pt# received stem cells from a hla-ident sibling donor, whereas pt# and pt# had unrelated donors (hla-ident and hla-matched respectively). with follow-up times of and months post-transplant, pt# and pt# are currently in ongoing mrd-negative remission. pt# developed an acute graft-versus-host disease (gvhd) of the liver (grade ), nevertheless the clinical course was well controlled by immunosuppression. in pt# a chronic gvhd of the skin occurred. pt# , who achieved mrd negativity after allosct, developed acute and chronic steroidrefractory gvhd of the skin and gastrointestinal tract. nine months post-transplant, gvhd deteriorated and after further complications the patient died of pneumonia months post-transplant. conclusions: supplementary treatment with rituximab can induce deep remissions in patients with ibrutinibresistant, genetically poor-risk b-pll, thereby enabling them to undergo successful consolidation with allosct. a high risk of life-threatening infusion reactions / tls associated with the addition of rituximab has to be taken into account. background: there is little experience on the use of the newer targeted therapies in cll patients relapsed after allogeneic stem cell transplantation (allo-sct). against this background, we evaluate the safety and efficacy of the bcr inhibitors (bcri), ibrutinib and idelalisib, administered after allo-sct for the purpose of treating the cll relapse. methods: data from cll pts who relapsed after sct, and were subsequently treated with ibrutinib (n= ), idelalisib (n= ) or both (n= ),were retrospectively collected in collaboration with the spanish group of cll (gellc) and the spanish group of stem cell transplantation (geth). results: transplant characteristics are summarized in table . eight patients received the bcri as the first salvage treatment after sct relapse, whereas patients had received ≥ prior lines of treatment. at the time of the onset of the bcri, patients had rai stage and patients had a lymph node size ≥ cm. del p was present in patients and del q and complex karyotype in patients, respectively. tp gene mutation was detected in patients (all with del p ). median time from sct to bcri therapy was . months, being shorter in patients treated with ibrutinib (n= , median months) than in those treated with idealisib (n= , median months). median time on ibrutinib and on idelalisib was . months ( . - . ) and months ( . - . ), respectively. the best overall response rate (orr) obtained with ibrutinib was % ( cr, pr, pr+l) whereas it was of % for patients receiving idelalisib ( cr, pr+l). among the patients treated with ibrutinib, ( . %) presented an adverse event (ae), being diarrhea (n= ), asthenia (n= ) and infections (n= ) the most frequent. hypertension was seen in patient and none patient developed atrial fibrillation. five patients stopped ibrutinib treatment, due to toxicity (n= ) or progression (n= ). after ibrutinib discontinuation, patients were newly treated with idelalisib (n= ) or venetoclax (n= ). all patients treated with idelalisib developed at least one ae, being diarrhea (n= ), pneumonitis (n= ) and neutropenia (n= ) the most common. four patients discontinued idelalisib because progression (n= ) or toxicity (n= ). venetoclax was given after idelalisib in patients. although acute and/or chronic gvhd before bcri was documented in ( . %) and ( . %) patients, respectively, only one patient (treated with idelalisib) reactivated a mild chronic gvhd. none patient received infusion lymphocyte from donor after bcri and one patient underwent a second sct. with a median follow-up of . months ( . - . ) after the onset of the bcri treatment, patients had died, all of them due to cll progression ( richter´s transformation), whereas patients remained in response ( cr, pr). the overall survival probability of the whole series at months was . % ± . %. conclusions: in our study, ibrutinib and idelalisib, administered in cll patients relapsed after sct did not increase the risk of gvhd reactivation but they show high incidence of adverse events. nevertheless, bcri offers a possibility of disease control in these patients with poor prognosis. further studies are needed to confirm these data. background: prior to the introduction of tyrosine kinase inhibitors (tki), median survival of chronic phase chronic myeloid leukemia (cp-cml) patients was approximately months and the standard treatment with interferon-alpha resulted in complete cytogenetic responses in about % of the patients. autologous stem cell transplantation (auto-sct) was first attempted for patients in transformation in order to restore a second cp and was introduced secondarily in cp to try to prolong the response. the main rational for autografting in cp resides on the reduction of the tumor burden and the number of leukemic cells at risk of developing blastic transformation. nevertheless, auto-sct alone was not able to maintain a long-term remission. nowadays, tkis represent the state-of-the-art therapy for cml and the concept of auto-sct has only little interest while long-term follow-up and outcome in this setting are currently unknown. the aim of our study is to evaluate at a first time the longterm outcome of cml patients who received auto-sct in chronic phase, and to evaluate at a second time in a subgroup analysis, the outcome of those who received tki after having been auto-transplanted, mainly for disease progression/loss of response and/or to enhance disease response. methods: we found a total of patients who received auto-sct for cp-cml in europe between years and , ( %) were males, median age at auto-sct was years (range: - ), the median time between diagnosis and auto-sct was months, stem cells source was peripheral blood in % of patients, most frequent conditioning regimen was busulfan mg/kg/day days + day of melphalan mg/m² one day prior to the cells reinfusion. information about receiving tki post auto-sct was available only for patients, first tki was imatinib for ( %) patients, dasatinib for ( %), nilotinib for ( %) and ponatinib for one ( %) patient. results: after a median follow-up of . years (range: - ) from time of auto-sct for the whole population, the probability of overall survival (os) at years was % ( % ci: - ); there was ( %) patients who relapsed after a median time of months after auto-sct. there was a total of patients transplanted before the tki era and survived until the availability of tkis. when we performed a landmark analysis evaluating the outcome of patients who received auto-sct, survived until the tki era and received tki (n= ), the years os probability of these patients from tki treatment was % ( % ci: - ). additional data requests will be sent to centers querying about prognosis, molecular responses, treatment and disease details. conclusions: we demonstrate here with these preliminary results that the introduction of tki has improved survival of cml patients. in addition, patients who received auto-sct, survived until the tki era and also received tki, had encouraging rates of long-term survival. an extensive analysis will be performed when additional data will be available and the study will be updated with more results. disclosure: nothing to declare a year single center transplant experience in chronic myeloid leukemia background: allogeneic hematopoietic stem cell transplantation (hsct) has been considered for decades the only curative approach for patients with chronic myeloid leukemia (cml). in the tyrosine kinase inhibitors (tkis) era, hsct for cml has been reserved only to patients not achieving a cytogenetic remission or showing progressive disease after multiple tki treatment lines. however, a progressive improvement in the long-term survival has been obtained in the overall hsct population. the present study aimed at evaluating whether in cml patients transplanted at our center over a long time period -from to -the outcome improved over time. methods: consecutive patients who underwent a transplant between and were compared to patients who received the transplant between and . overall survival (os), leukemia-free survival (lfs) and graft-leukemia-free survival (glfs) were estimated using the kaplan-meier method and the log-rank test was used to compare risk factors categories. results: of the patients [median age years (range - )], ( . %) were in st or nd chronic phase, ( . %) in accelerated phase and six ( . %) in blast crisis. matched related donors and alternative donors (matched unrelated donors, cord blood or mismatched related donors) were used in and cases, respectively. as stem cell source, bone marrow was used in patients, peripheral blood in and umbilical cord blood in . tbibased conditioning regimens were used in patients, while in the other cases irradiation-free conditioning regimens were used. both in univariate and multivariate analysis, irradiationfree conditioning regimens (hr . ; %ci . - . , p=. ) and transplants performed in st chronic phase (accelerate phase hr . ; %ci . - . , p=. - nd chronic phase hr . ; %ci . - . , p=. -blast crisis hr . ; %ci . - . , p< . ) were associated with a better os. patients transplanted before had a worse os (hr . ; %ci . - . , p < . ) and dfs (hr . ; %ci . - . , p=. ). a trend for a worse glfs was observed in univariate analysis (hr . ; %ci . - . , p= . ), in the first period of observation. conclusions: our single center experience confirms that higher os, dfs and glfs are observed in cml patients allografted in more recent years. improvement of conditioning regimens, use of tbi-free conditioning regimens and supportive therapy, have presumably contributed to these results, together with the more recent strategy of close monitoring of minimal residual disease, and prompt use of tki or donor lymphocyte infusion in case of relapse. hsct is nowadays a safer therapeutic procedure in cml patients that should be considered timely in tki-resistant patients to avoid progression into a more advanced disease phase. disclosure: the authors declare no conflict of interest. reduced-intensity transplantation (rit) in patients with high-risk or advanced chronic lymphocytic leukemia in last years: improvement of transplant outcomessingle centre experience . hct-ci ≥ was in % of pts. source of stem cells was peripheral blood in % and bone marrow in % of pts. the median of infused cd + cells was , x ^ / kg. the conditioning regimen consisted of fludarabine and melphalan (+atg in unrelated donor). gvhd prophylaxis were cyclosporine and methotrexate. results: all pts engrafted. none of pts in cr before rit progressed at day + after rit and among pts beyond cr before rit all of them achieved at least pr at day + after rit. pts ( %) developed acute gvhd ( pts grade iii-iv) and among evaluable pts ( %) of them developed chronic gvhd ( mild, moderate, severe). with median follow-up months (range - months) pts ( %) are alive in cr. pts ( %) relapsed or progressed , and months after rit and of them died. last relapsed patient achieved next cr after ibrutinib. pts ( %) died due to nrm. nrm till day + after rit was %. the estimated probabilities of -years cgrfs, pfs and os are %, % and %. conclusions: in spite of relatively small number of evaluated pts and retrospective type of analysis our data show that rit in pts with high-risk or advanced cll has achieved promising results ( -and -years pfs and os % and % resp. and %) in recent years and these results are better than outcomes of our historical patient cohort from period - ( -and -years pfs % and % resp. os % and %, p= . ) or ebmt published data of pts transplanted for cll in period - ( and -years pfs % and % resp. os % and %). current results of transplantation should be taken into account in our future decision-making process on indications for transplantation in pts with high-risk cll, of course also in the context of new or updated results of targeted cll treatment and its complications. disclosure methods: retrospective data and treatment outcomes were collected from the singapore childhood cancer registry (sccr). most children with cancer in singapore receive therapy at one of the two public paediatric cancer centers (kkh or nuh). a total of thirty two cases were diagnosed with cml and received treatment in either of these centers over a twenty year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results: the age at diagnosis of the thirty two children ranged from to years (median . years). six patients in the pre-tki era were treated with an upfront hsct. the remainder twenty six patients were initially started on a tki. of these / ( %) had a hsct at a median period of . months from diagnosis (range - months). the reason for hsct in ten out of the twelve children was due to high risk features i.e. accelerated/blastic phase/ no ccr/no cmr. the remaining two patients had a hsct due to parent and patient preference for attempt at upfront cure rather than the use of life-long and expensive tki therapy. non-compliance to tki therapy was a major finding in our teenage cohort. eleven of the eighteen transplants used a matched sibling donor. three patients had cord blood as their stem cell source. one patient had a single antigen mismatched related donor and three patients had a mismatched unrelated donor for their hsct. all patients except one had myeloablative conditioning with busulfan and cyclophosphamide. atg was added according to physician preference. one patient had cy/tbi conditioning because of pre-transplant lymphoid blast crisis. anti gvhd medications included cyclosporine/ methotrexate or tacrolimus and methylprednisolone in the cord transplant patients. six of the eighteen ( %) patients who had a hsct died. four died due to treatment related mortality ( infections, acute gvhd and pulmonary fibrosis). one patient died due to an early relapse and one had a late relapse related mortality. for the pre-tki era, hsct related and year os was % and % respectively. post-tki era and year os was %. for the entire cohort, the year os was %. conclusions: the post-tki era transplant outcomes from our two centers is comparable to leading centers in the world. outcomes for patients with mismatched unrelated donors was poor in our cohort. we recommend a haploidentical related donor transplant or an unrelated cord blood stem cell source for patients when a matched sibling or unrelated donor is not available. clinical trial registry: na disclosure: we have nothing to disclose. fludarabine, busulfan, and thiotepa may be a promising conditioning regimen for myelofibrosis patients undergoing allogeneic stem cell transplantation background: allogeneic stem-cell transplantation (sct) is a curative therapy for patients with myelofibrosis. however, recurrent disease and non-relapse mortality (nrm) are frequent causes of treatment failure. the optimal conditioning regimen for sct in this disease has not been defined. methods: we retrospectively analyzed transplantation outcomes of all adult patients given sct for myelofibrosis between and at a single large academic medical center. patients (n= ) were treated with several conditioning regimens that were grouped according to conditioning intensity. myeloablative conditioning (mac) included busulfan . mg/kg and cyclophosphamide mg/kg (bucy, n= ), fludarabine and busulfan . mg/kg (flu/ bu , n= ) and fludarabine and treosulfan - g/m (flu/ treo, n= ). reduced-intensity conditioning included fludarabine and busulfan . - . mg/kg (flu/bu , n= ). more recently we adopted the tbf regimen including fludarabine, busulfan . - . mg/kg and thiotepa - mg/ m (n= ). all patients were also given anti-thymocyte globulin during conditioning, irrespective of donor source. results: the median age was years (interquartile range [iqr] - ). the majority of patients had documented splenomegaly ( %) and were not previously exposed to ruxolitinib ( %). donor type was an hla-matched sibling ( %), / ( %) or / ( %) matched unrelated donor. the dipps+ score distribution was intermediate- ( %), intermediate- ( %), or high (n= %). the median followup was . years since the success of tyrosine kinase inhibitors (tkis), transplant-related mortality is considered too high to justify allogeneic hematopoietic stem cell transplantation (allohsct) as first-line treatment for chronic myeloid leukemia (cml) patients in chronic phase (cp). allohsct is currently considered for patients failing to at least tkis or with disease in advanced phase. nevertheless, the optimal timing for transplant referral is still not well defined. methods: we performed a retrospective analysis on consecutive patients with cml in cp receiving first transplants from an hla-identical sibling donor with partially t-cell depleted grafts from to at our center. partial t-cell depletion (ptd) consisted of in vitro alemtuzumab incubation of a part of the graft for infusion at day while the rest, containing x cd + cells/kg was given as a t-cell add-back at day . donor lymphocyte infusions (dlis) were provided, in the absence of gvhd, in case of disease relapse or mixed chimerism. molecular monitoring was performed by -month bcr-abl rt-qpcr testing in peripheral blood during at least a -year period after hsct. thereafter, -month testing schedule was maintained where possible, or followed by a -month one. kaplan-meier method was employed to determine the probability of overall survival (os) and leukemia free survival (lfs) since allohsct. results: median age at hsct was years (range, - ). all patients were in first cp but one who was in second cp. twelve patients were tki-naïve at hsct ( hsct ( - , patients had presented suboptimal response or/ and intolerance to imatinib ( - period) , while the last seven patients had presented suboptimal response or/ and intolerance to imatinib, dasatinib and nilotinib ( - period) . the time interval from diagnosis to transplant was < months in / ( %) patients. ( %) patients had an ebmt risk score of - , while ( %) patients of - . the conditioning regimen was myeloablative for all but one patients. the stem cell source was pbsc for patients and bone marrow for one. all patients engrafted. patients presented molecular relapse and one patient hematological relapse with a median interval from transplant to relapse of months (range, - ) . patients received dlis ( for relapse and for mixed chimerism), while patients in relapse also received tki. without prior administration of dli, ( %) patients presented grade ii agvhd and patients moderate cgvhd. after dli, agvhd occurred in and cgvhd in patients. one patient died of disease progression years after hsct and one of myocardial infarction years after hsct. with a median follow-up of . years (range . - . ), -year os and lfs were %. at the time of the analysis / patients were alive and in major molecular response. conclusions: these results of excellent long-term survival and no transplant-related mortality suggest that ptcd improves the outcome of cp-cml patients transplanted from an identical sibling donor and they can be useful for deciding risk-adapted strategies. we believe that ptcd could allow earlier transplant referral of patients failing tkis and having an identical sibling donor. disclosure: nothing to declare single tertiary centre experience in allogeneic haematopoietic stem cell transplantation (allo-hsct) for primary and secondary myelofibrosis (mf) the only curative option for fit patients is allo-hsct. novel therapy is emerging but current recommendation is that eligible patients with life expectancy less than years should be considered for allografting. methods: we retrospectively looked at the clinical features and outcomes of all allo-hsct for mf performed in our centre since . results: patients ( male, female) aged between - years old (median age ) with intermediate- or high-risk mf as per the international prognostic scoring system (ipss) or dynamic ipps (dipps) were transplanted in our centre since . of them ( %) were diagnosed with pmf and the remaining % with secondary mf; post-et and post-pv mf. / of our patient group received a sibling allograft and / a matched unrelated donor allograft ( % received a / human leukocyte antigen (hla)-matched transplant, % a / hlamatched and % a / hla-matched graft). all patients received a reduced intensity conditioning (ric); / patients with fludarabine/ melphalan/ campath (fmc), / fludarabine/ busulphan/ atg (fbatg) and fludarabine/ ara-c/ campath (flag/ campath); all received peripheral blood as source of hsc. engraftment occurred between day - , with a median of d+ . one late graft rejection occurred. all patients were alive at d+ . patients are currently alive; overall survival (os) is %. transplant related mortality (trm) was . % at year, % at years. patient died of graft versus host disease (gvhd) and patients of septicaemia leading to multiorgan failure. acute gvhd grade ii skin occurred in patients, grade iii and above in patients. patients have limited chronic gvhd. / patients received donor lymphocyte infusion (dli) for mixed chimerism (one of which had nd graft failure). out of these patients developed acute grade gvhd and died. response rate: / alive patients i.e . % exhibit no fibrosis in trephine biopsies, / alive patients had residual fibrosis but % donor chimerism, / alive patients had residual fibrosis with mixed donor chimerism, other patient non-assessable. conclusions: allo-hsct remains the only potentially curable option for myelofibrosis. in our centre which serves . million population, with new cases per year, patients were transplanted since . our data suggest that close collaboration between mpn-treating haematologists and transplant physicians is required so that all suitable patients have a transplant assessment early in their disease course. novel molecular prognostic systems are likely to identify those best placed to benefit in future but this series currently supports allo-hsct survival and cure. (range, - ) . dynamic international prognostic scoring system (dipss) score at the time of hct was intermediate- or high risk in patients ( %), intermedate- in patient. molecular evaluation was available in out of : jak v f mutation was detectable in patients, mpl-w k in patient, carl in patient. patients were "triple negative" for driver mutations. cytogenetics information was available for out of ; among which patients had complex karyotype, trisomy and trisomy . patients underwent splenectomy before hct. ruxolitinib was administered in patients before hct. ( %) patients received stem cells from an hla identical sibling, ( %) from a matched unrelated donor and ( %) from an haploidentical sibling. graft source was bone marrow in patients ( %) and peripheral blood in ( %). conditioning was myeloablative in patients ( %), reduced intensity in ( %). all patients engrafted. acute graft versus host disease was absent in patients ( %), grade i-ii in ( %), grade iii-iv in ( %). in evaluable patients chronic graft versus host disease was limited in ( %), extensive in ( %) and absent in ( %). transplantrelated mortality at days was %. main causes of death were: acute gvhd in patients, chronic gvhd in , pancreatitis in , pulmonary aspergillosis in . relapse occurred in patients and was the main cause of death in of them. notably, patients experienced late relapse after . and . years after hct. both of them are living while receiving ruxolitinib therapy. after a median follow up of days (range, - ), out of patients are alive. of them ( %) are disease-free and are living. the kaplan-meyer overall survival and disease-free survival at years was % and %, respectively. conclusions: our experience confirms that hct is a valid option to achieve cure in one third of mf patients. two patients experienced very late (> years) recurrence of mf. the rarity of this condition limits the amount of data and cases available for evaluation and study. life-long follow-up of all mf transplanted patients is warranted to better understand this rare event. disclosure: nothing to declare methods: А -years old female was diagnosed with jak v f-positive pmf, xx, ipss low risk, dipssplus intermediate - risk, subacute budd-chiari syndrome and portal vein thrombosis four years before allohsct. to reduce the splenomegaly and constitutional symptoms we performed pre-transplant ruxolitinib therapy mg daily. after three months of therapy the patient achieved clinical improvement (eln criteria). contrast-enhanced computer tomography and magnetic resonance imaging showed enlarged intrahepatic collateral vessels and signs of portal vein thrombosis with cavernous transformation and multiple dilated collateral veins. gastroscopy documented enlarged esophageal veins. allogeneic stem cell transplantation was performed from / -hla matched unrelated donor with peripheral stem cells ( . x Сd + cells/kg). conditioning regimen consisted of fludarabine ( mg/ m ), busulfan ( mg/kg p.o.). post-transplant cyclophosphamide was administered at mg/kg at day + , + , and ruxolitinib mg was used from d+ till d+ as graft versus host disease prophylaxis. results: starting d+ the patient experienced eight episodes of ebv some of them with severe blood loss. to treat the bleeding episodes blackmore tube was placed six times with temporary effect. to place blackmore tube the patient was two times intubated and required mechanical ventilation. at d+ leukocyte and neutrophil engraftment, full donor chimerism and molecular remission were achieved. platelet engraftment was documented only at d + and poor graft function was present due to cytomegalovirus reactivation (d+ ) and parvovirus b reactivation (d+ ). evb was stopped at d+ only after two esophageal veins ligations, and two procedures of gastric veins sclerotherapy. soon (d+ ) the patient achieved complete platelet recovery (more than x /l) and became red blood cells transfusion independent. at day + complete remission was confirmed by splenomegaly resolution, regression of bone marrow fibrosis, full donor chimerism, jak v f-negative molecular status. cbc showed hb g/l, platelets x /l, leucocytes , x /l. ultrasound examination after transplant documented portal vein thrombosis recanalization. at day + she developed mild (nih) chronic graft versus host disease with eyes and mouth involvement, which was managed with topical steroids. at d+ after transplant the patient is alive in complete remission and has no recurrent bleedings. conclusions: splanchnic vein thrombosis can significantly complicate the course of allohsct in pmf. easy access to surgical, intensive care unit and endoscopic teams is required to make allohsct more feasible in this group of patients. disclosure all patients received treosulfan-based mac regimens, treosulfan(total dose, - gms/m ) was given in combination with different conditioning drugs. the most commonly used regimen was treosulfan, fludarabine ( mgs/m ) and thiotepa( mgs/kg) referred to as ftt that was used in %(n= ). serotherapy was given in % of patients(n= ), as either alemtuzumab or antithymocyte globulin in %(n= ) and %(n= ), respectively. post-transplant graft-versus-host disease (gvhd) prophylaxis was given in all patients, based mostly on ciclosporin. patients( %) received the transplant from identicalrelated donors, patients( %) received the transplant from matched-unrelated donors, and two patients( %) had haploidentical transplants. % of the patients(n= ) were fully hla-matched. all stem cell sources were used as bone marrow in %(n= ), peripheral blood stem cells in %(n= ), and umbilical cord blood in %(n= ). this treosulfan-based conditioning was given as the st transplant in %(n= ), and as the nd transplant after the failure of a first procedure in %(n= ). two patients received treosulfan-based conditioned transplant twice. results: neutrophil engraftment and platelet engraftment occurred at a median of days and days respectively. chimerism was full donor in %(n= ), high donor in %(n= ), and mixed donor in %(n= ). gvhd developed in % of patients(n= ), with acute gvhd grade i/ii and grade iii/iv developed in %(n= ) and %(n= ), respectively. chronic gvhd grade i/ii and grade iii/iv developed in %(n= ) and %(n= ), respectively. all chronic gvhd were mild, limited, non-extensive, and resolved completely. none of our patients had persistent gvhd necessitating long-term systemic immunosuppression. mild vod occurred in %(n= ), and severe vod occurred in %(n= ). one of them died but was believed to be related to the underlying disease (wolman syndrome). viral reactivation occurred in % of patients(n= ), with cmv, ebv, and adenovirus reactivation was found in %, %, and %, respectively. five patients had invasive adenoviraemia that contributed to death in two of them. primary graft failure happened in two patients( %) due to adenoviraemia. seven patients( %) had secondary graft failure with autologous reconstitution. graft failure was significantly lower (p . ) in the ftt group than other conditioning groups. at a median follow-up of months (range, two- months), eleven patients( . %) died, with overall survival of . %, and event-free survival of . %. five patients died due to complications related to their original disease, while six patients died due to transplant-related causes (transplant-related mortality . %). immune reconstitution in alive patients was achieved at a median of eight months. this time was significantly longer (p . ) in ftt group. conclusions: this study demonstrates that treosulfan is a safe and effective conditioning drug that can achieve engraftment, with low rates of graft failure, transplantrelated mortality and morbidity, even if it is used twice in the same patient. disclosure: nothing to declare background: high-dose chemotherapy (hdc) followed by autologous stem cell transplantation (asct) is the treatment of choice for the patients with relapsed or high risk nhl. although the high-dose conditioning regimens commonly used in patients with non-hodgkin lymphoma (nhl) are beam (bcnu, etoposide, cytarabine, and melphalan), beac (bcnu, etoposide, cytarabine, and cyclophosphamide), survival of patients with nhl received above high-dose chemotherapy followed by asct was still unsatisfactory. methods: we prospectively evaluated the efficacy and toxicity of busulfan, etoposide, cytarabine and melphalan (bueam) including iv busulfan instead of bcnu of standard beam as a conditioning for asct in patients with nhl. the high-dose chemotherapy consisted of bu ( . mg/kg i.v. q.d. from day - to day - ), e ( mg/m i.v. b.i.d. on day - and day - ) a ( g/m i.v. q.d. on day - and day - ) and m ( mg/m i.v. q.d. on day - ) at centers in korea. results: two hundred five patients were enrolled onto the study. main subgroup was diffuse large b cell lymphoma (n= , . %), t cell lymphomas (n= , . %), and nk/t cell lymphoma (n= , . %). upfront asct was performed in patients ( . %), and salvage asct in patients ( . %). the disease status of the patients before hdt/asct consisted of patients ( . %) with complete response and patients ( . %) with partial response. treatment related toxicities included nausea in patients ( . %), diarrhea in patients ( . %), anorexia in patients ( . %) and stomatitis in patients ( . %), which were grade i or ii in the majority of cases. the common grade iii toxicities were stomatitis ( . %), diarrhea ( . %), and anorexia ( . %). there were no vod, and transplant-related mortality occurred in patients ( . %), due to infection. one hundred fifty three patients ( . %) achieved a complete response and patients ( . %) after asct, while patients ( . %) showed progressive disease. at a median follow-up duration of . months, the estimated -year overall survival and progression free survival for all patients was . % and . %, respectively. conclusions: the conditioning regimen of bueam for asct was well tolerated and seemed to be effective in patients with relapsed or high risk nhl. disclosure: none of declare background: allogeneic hematopoietic cell transplantation (hct) is potentially curative for high risk acute myeloid leukemia (aml) and myelodysplastic syndrome (mds), however both gvhd and disease relapse remain major challenges. we recently introduced a combination of posttransplant cyclophosphamide (ptcy) and atg ( . mg/kg) as graft-versus-host disease (gvhd) prophylaxis. the purpose of our study was to compare outcomes between ptcy/ atg and other gvhd prophylaxis regimens for high risk aml and mds. methods: we retrospectively investigated outcomes of patients that underwent allogeneic hct between january and july for high risk aml (n= , %) and mds (n= , %). gvhd prophylaxis regimens were compared for overall survival (os), cumulative incidence of relapse (cir) and non-relapse mortality (nrm) in univariate and multivariable analysis. high risk aml was defined as secondary aml, therapy related aml, high risk cytogenetics (eln criteria) in cr , good/ intermediate cytogenetic risk aml in cr and primary induction failure; high risk mds was defined as high/very high risk wpss score. results: median age of patients was years (range - years). donors were matched related in ( %) patients, matched unrelated in ( %) patients and haploidentical in ( %) patients. graft source was peripheral blood stem cells in patients ( %). myeloablative conditioning was used in patients ( %), reduced intensity regimens in ( %) patients. ptcy combined with atg was used in ( %) patients, other gvhd prophylaxis regimens were used in ( %) patients. both donor and recipient were cmv negative in ( %) patients. median follow-up of survivors was months (range - months). univariate analysis demonstrated os of the entire cohort at years was % ( %ci - %), cir at years was % ( %ci - %) and nrm at years was % ( %ci - %). concerning gvhd prophylaxis regimen, -year os for ptcy/atg versus others was % ( %ci - %) versus % ( %ci - %) (p= . , figure) , -year cir for ptcy/atg versus other was % ( %ci - %) versus % ( %ci - %) (p= . ) and -year nrm for ptcy versus other was % ( %ci - %) versus % ( %ci - %) (p= . ). grade ii-iv acute gvhd was seen in % of ptcy/atg patients versus % using other regimens (p< . ). chronic gvhd was observed in % of ptcy/atg patients versus % using other regimens (p= . ). multivariable analysis for os confirmed that the gvhd prophylaxis regimen has no influence (p= . ), while the predominant predictor of survival was age at hct (hr . , %ci . - . , p= . ). for cir, the ptcy/atg combination had no influence compared to other gvhd prophylaxis regimens (p= . ), while ric conditioning was the predominant predictor of relapse (hr . for ric, % p= . ) . for nrm, the atg with ptcy combination demonstrated no significant difference (p= . ), while age at hct was the predominant predictor (hr= . , %ci . - . , p= . ). conclusions: the ptcy/atg combination for gvhd prophylaxis has demonstrated on multivariable analysis similar os, cir and nrm with other previously used regimens at our center. a decrease in atg dose may potentially decrease the relapse rate while retaining the advantage of decreased gvhd. [ background: the combination of fludarabine with myeloablative doses of busulfan (fb ) represents a standard of care conditioning regimen before allogeneic transplantation in patients with myeloid malignancies (giralt, s.: the lancet oncology ). fb has potent antileukemic activity and is associated with low transplantrelated mortality and acute gvhd. however, early after transplantation (days - ), a proportion of patients may not convert to a full donor haemopoietic chimerism, particularly if anti-t lymphocyte globulin (atg) is used as gvhd prophylaxis (rambaldi a, et al.: the lancet oncology ) methods: we retrospective analyzed patients who underwent an allogeneic stem cell transplantation after fb conditioning regimen at our hospital, from november to august . the median age was years (range - ) and diagnoses were aml %, mds % cml % mfi %). the disease status at transplantation was: cr in %, cr in % and active disease in % of patients. the stem cell source was represented by pbsc in more than % of cases and anti-t lymphocyte globulin (atg) was part of the conditioning regimen in more than % of cases at a dose of mg/kg. the donor was a hla identical sibling ( %), a matched unrelated ( %) or mismatched (one allele or one antigen mismatched) unrelated, %. hematopoietic chimerism was molecularly evaluated by variable number of tandem repeats (vntr) on bone marrow (bm) mononuclear cells or peripheral blood (pb) t lymphocytes, purified by immunomagnetic positive selection (miltenyi, biotec). the analysis was performed at day , , , and after transplantation results: after , and days from transplantation, the proportion of patients with a full bm chimerism was %, % and %, respectively. at the same time points, the pb t cell chimerism was %, % and %. before day , patients required the infusion of dli to treat a pending or overt hematologic relapse and patients to convert the lymphoid chimerism from mixed (median %, range - ), to complete (successfully in cases). after day , additional patients required dli to treat disease relapse or progression and patients to improve the chimeric status or the immune reconstitution. at years, the overall survival is %, with a relapse and non-relapse mortality of % and %, respectively ( figure ). by uni and multivariable analysis, aml diagnosis and a mixed bm chimerism before day were associated with relapse and overall survival while age > was the only factor significantly associated with nrm. a mixed pb t-lymphoid chimerism before day does not adversely impact on non-relapse mortality, cumulative incidence of relapse, leukemia-free and overall survival. conclusions: after fb and atg, a progressive increase of pb lymphoid donor chimerism develops gradually after transplantation, in most of cases without the need of dli. early mixed lymphoid chimerism does not compromise the main long-term clinical outcomes and may at least partially explain the low non-relapse mortality. an incomplete bm chimerism within the first months strongly correlates with early disease progression or relapse. background: busulfan (bu) is widely used as a component of myeloablative conditioning regimen before hematopoietic stem cell transplantation (hsct) in children. bu has a narrow cumulative exposure window. the relation of bu exposure with toxicity is well established, but the link between the exposure and efs is not clear due to conflicting reports especially in pediatric patients. obtaining the ratio of bu to its metabolite i.e. metabolic ratio (mr) may serve as an indicator of bu gsh conjugating capacity of an individual, thus cumulative exposure of bu for a particular day that could be used along with auc as a marker to predict efs. the present investigation is aimed at evaluating the utility of bu mr to predict efs in children undergoing allogeneic hsct. methods: two different cohorts with children receiving bu in four times daily (qid, n= ) and once daily doses (qd, n= ) at st. justine's hospital, montreal were studied. bu and su levels were measured on day of the conditioning regimen at the end of infusion (dose in qid or dose in qd dosing). efs was defined from the time of transplant until death, relapse, or rejection, whichever occurred first. a receiver-operator characteristic curve (roc) for bu mrs measured was plotted to show the trade-off in sensitivity vs. -specificity rates for efs, as the cut-off of the test was shifted from low to high. cutoff values were defined based on the youden´s j statistic (i.e. sensitivity+specificty- ). results: twenty-two males and females aged from . to . years (mean±sd: . ± . ) from bu qid cohort had the mean mr of . (sd: . ). a cut off value of . in mr was chosen in roc analysis in this cohort, with better sensitivity ( %) and specificity ( %) for efs prediction (p= . , auc= . ( % ci= . - . ). in qd cohort nine females, and four males aged between . and . years ( . ± . ) had the mean mr of . (sd: . ). in roc analysis, a cut off value of . was chosen with better sensitivity ( %) and specificity ( %) for efs prediction (p= . ; auc= . ). conclusions background: treosulfan is an alkylating agent increasingly used prior to hematopoietic stem cell transplantation (hsct). the main objective of this study was to develop a population pharmacokinetic model of treosulfan in pediatric hsct recipients and to explore the effect of different covariates on treosulfan pharmacokinetics (pk). also, a limited sampling model (lsm) was developed. methods: in this multicentre study, patients, receiving a dose of , or g/m treosulfan a day, administered during consecutive days, were enrolled. a population pharmacokinetic model was developed using nonlinear mixed effect modelling (nonmem version . . , using psn toolkit . . and piraña version . . as modelling environment). demographic factors, as well as laboratory parameters, were included as covariates. results: treosulfan pk was best described by a twocompartment model. a bodyweight-based allometric model improved the model more than a model incorporating body surface area (bsa). clearance (cl) and intercompartmental clearance parameters were . l/h/ . kg ( %ci . - . ) and . l/h ( %ci . - . ). typical volumes of distribution of the central and peripheral compartments were . l/ . kg ( %ci . - . ) and . l ( %ci . - . ). a model-based dosing table based on bodyweight is created to achieve a target exposure of mg*hr/l (table ) , which was the median exposure of our population. estimated glomerular filtration rate (egfr) was shown to be the only parameter that significantly reduced interpatient variability in cl from . % to . %. a limited sampling model with samples (taken at . , and hours after start of infusion) accurately estimated pharmacokinetic parameters of treosulfan. conclusions: to the best of our knowledge, this is the largest cohort of pediatric patients treated with treosulfan used for a population pharmacokinetic study. we developed a two-compartment model with weight and egfr as covariates influencing treosulfan pk. recently we showed a relationship between treosulfan exposure and early toxicity. patients with an exposure > mg*hr/l have an increased risk of developing grade or higher mucositis and skin toxicity. another study in pediatric patients with thalassemia major reported an association between treosulfan clearance (< . l/h/m ) and poor overall survival. our model, together with the limited sampling strategy, can be used to adjust the dose, prior to or during treosulfan administration. ongoing studies conducted in different disease settings will determine if treosulfan exposure can influence patient outcome. subsequently, the optimal target exposure can then be established. background: autologous stem cell transplant (asct) is an effective treatment method for non-hodgkin lymphoma (nhl). until recently, carmustine, etoposide, cytarabine and melphalan (beam) was the most commonly used conditioning regimen. despite acceptable efficacy with beam, carmustine is associated with major pulmonary toxicity. for this reason, the aim of this study was to investigate the safety and efficacy of beb conditioning regimen for asct in nhl. methods: we conducted a prospective, multicenter, phase ii study for beb conditioning regimen for asct in nhl patients. a total of patients were enrolled from centers. they underwent asct with beb conditioning regimen (busulfan . mg/kg for days, etoposide mg/ m for days, bendamustine mg/m for days) between and . [[p image] . two year progression-free survival and overall survival.] results: the median age was years (range - ) and patients ( . %) were men. the most common type was diffuse large b cell lymphoma (n= , . %) and more than half of patients (n= , . %) were classified as ipi score or . eight patients ( . %) had a history of relapse and patients ( . %) received more than lines of chemotherapy before asct. most patients (n= , . %) were complete remission (cr) state at asct. a median number of . x /kg cd cells were infused (range . - . ). all patients engrafted after a median time of days (range - ). twelve patients ( . %) experienced neutropenic fever and patients ( . %) had grade toxicities during asct. however, no one had a documented infection, veno-occlusive disease, or treatment-related death. three months cr rate was . %. during a median follow-up period of . month, patients ( . %) exhibited relapse or progression, while patient ( . %) died of the disease. the estimated -year pfs and os rate were . % and . %, respectively ( figure ). conclusions: the beb conditioning regimens for asct is a feasible with tolerable toxicity in patients with nhl. disclosure: nothing to declare long-term report of total marrow or total lymphoid imrt in advanced leukemia, myeloma and lymphoma background: during the last three decades, total body irradiation (tbi) continues to play an important role in the conditioning regimens for patients undergoing stem-cell transplant (sct) for a wide variety of advanced hematological malignancies. however, tbi showed boundaries in dose limits for toxicity in allogenic and moreover in autologous stem cell transplantation. currently, the choice of conditioning regimen is based on the use of the least-toxic regimen to achieve the optimal therapeutic result. this report aims to assess the feasibility of a conditioning strategy based on high dose chemotherapy and whole-body radiotherapy focused on selective extensive tumor burden irradiation, both in allogeneic and autologous stem cell transplantation. methods: since december , sixty-two patients (pts) have been irradiated by helical tomotherapy (ht) to extensive target before allogeneic or autologous transplantation. selected total marrow irradiation (tmi) schedules were planned to treat patients with high risk acute leukemia (all or aml) or multiple myeloma (mm) as a part of conditioning regimen. total lymphoid irradiation (tli) was planned for patients with refractory or relapsed (r/r) hodgkin (hd) or non-hodgkin lymphomas (nhl). results: tmi and tli allowed delivering therapeutic dose over extensive selected targets with wide reduction of toxicity to all the organs at risk (oars). the higher radiation doses rate to the oars is reduced from % to %. allogenic conditioning regimen was tli ( gy x fx) than fludarabine + endoxan for patients with hd ( pts). tmi ( gy x fx) + fludarabine + melphalan for patients with mm ( pts). tmi ( gy x fx) + thiotepa + fludarabine + busulfan for advanced lam patients ( pts). tmi as the boost ( - gy) after conventional tbi was ( gy in bi-fractionated doses) by cyclophosphamide ( pts). autologous preparation to sct consisted of tli ( gyx fx) followed by high-dose bendamustine and melphalan for patients older than years and conventional feam (fotemustine, etoposide, cytarabine, and melphalan) for younger patients, in hd e nhl ( pts). while tmi ( gy x fx) plus melphalan was delivered for autologous sct in mm and lam ( pts). no unexpected acute toxicity was found. in the allogenic setting, all the patients' engraftment was achieved in all patients. no acute graft versus host disease increasing was detected. within the autologous setting, only % developed grade / mucositis. none experienced grade / extra-hematological toxicity. outcomes of the specific disease will be reported. conclusions: the current report describes the clinical feasibility of using ht to deliver tmi or tli in the setting of autologous transplantation or during allogenic stem cell conditioning regimen, to allow all patients (old, fragile or with high tumor burden) to achieve an ablative regimen before sct. to our knowledge, this single institution experience describes data from one of the largest cohort of patients treated in europe since the development of this irradiation techniques. disclosure induction therapy in both groups of patients was based in polychemotherapy without the use of new drugs. case matching was performed according to age, clinical stage at diagnosis, and response to induction therapy. conditioning regimen consisted of iv bu at a dose of . mg/ kg once a day on days - to - followed by mel at a dose of - mg/m on day - in the bumel group versus mel in the control group. maintenance therapy after transplant consisted of interferon and steroids in the majority of patients. results: the cut-off date for this update was june , . after a median follow-up of and months in the bumel and mel groups respectively, patients had relapsed in the bumel group and patients in the control group. median pfs was ( % ci, . - . ) months in the bumel and ( % ci, . - . ) months in the mel group (p = . ) ( figure ). in this update, patients in the bumel group are in maintained response and of them are in continuous cr (two with negative status for minimal residual disease) between and years after transplantation. ten-year os was not significantly different between both groups, being ( % ci - ) months in the bumel and ( % ci - ) months in the control group.transplant-related mortality was similar in both groups of patients ( % in the bumel and % in the mel group). regarding toxicity, bumel was associated with a higher incidence of mucositis and liver toxicity than the melphalan-only approach but no patient in our series developed sinusoidal occlusive syndrome and the hepatic toxicity observed was only grade i/ii. finally, no long-term side effects have been reported among bumel recipients. conclusions: this long-term follow-up analysis confirms that a therapeutic strategy including bumel as conditioning regimen beforeasct in patients with newly diagnosed mm is highly active and safe in these patients. [[p image] . figure . progression free survival in the bumel (____) and control group (…… frequency of acute gvhd grade iii-iv [cc: %; ct: %; tt: %, p= . ], and transplant-related mortality was higher in tt-carriers (cc: %; ct: %; tt: %, p= . cc&ct vs tt) . ta-tma, cmv infection/reactivation and cgvhd were also not different according to donor genotypes. fungal infections occurred more frequently as causes of death in carriers (cc: . % vs. ct: . % vs tt: . %, p= . ). conclusions: our results suggest that donor tgfb - c>t may exert an adverse influence on the outcome of myeloablative conditioning. our finding might be explained by the combination therapy of calcineurin and mtor inhibition in gvhd prophylaxis in myeloablative conditioning. disclosure: nothing to declare. treosulfan-based reduced intensity conditioning in hla-haploidentical transplantation using ptcy as gvhd prophylaxis in high-risk mds /aml of the elderly background: standard conditioning regimens prior to allogeneic hematopoietic stem cell transplantation (allo-hsct) are often associated with a considerable risk of severe adverse events, especially in elderly patients suffering from high-risk (hr) mds/aml. previous clinical studies have demonstrated feasibility of treosulfan-based reduced-intensity conditioning (ric) by stable engraftment, low non-relapse mortality (nrm), and favorable survival in elderly patients undergoing hla-matched related or unrelated allo-hsct (beelen et al, ash # ). however, data for treosulfan-based conditioning in the t-cell-replete hlahaploidentical (haplo-hsct) setting in high-risk aml/mds patients are rare. here we report on the outcome of eleven patients treated with a treosulfan-based conditioning undergoing haplo-hsct using exclusively post-transplantation cyclophosphamide (ptcy) as gvhd prophylaxis. methods: eleven patients with high-risk (hr) aml (n= )/mds (n= ) who underwent haplo-hsct using treosulfan for reduced intensity conditioning (ric) and ptcy as gvhd prophylaxis were retrospectively analyzed with respect to outcome and toxicity. all patients were > years old and transplanted between january and february at our institution. the majority of the patients ( / ) suffered from active disease at time of treatment initiation, only two patients presented in cr. all but one received sequential conditioning with cytoreductive chemotherapy using flamsa applied shortly prior to treosulfan-based ric ( g/m over days). a bone marrow graft was used in / patients. post-grafting immunosuppression consisted of cyclophosphamide, tacrolimus and mmf. national cancer institute common terminology criteria for adverse events version . were used for nonhematologic toxicity assessment starting from sequential therapy initiation or conditioning until day + . results: median age of the entire cohort was years (range: - ). the hct-ci was ≥ in eight pts (median hct-ci= , range: - ). no graft rejection occurred. neutrophil and platelet engraftment were achieved in % and % of the patients at a median of ( - ) and . ( - ) days, respectively. acute gvhd grade ii-iv occurred in % of the patients, exclusively involving the skin. no one developed severe (°iii-iv) acute gvhd. no patient died prior to haplo-hsct. severe nonhematologic regimen-related toxicities (°iii-iv) occurred in / patients, predominately affecting the gastrointestinal tract. no patient suffered from ≥two iii-iv°toxicities. all patients developed fever during treatment course, four with positive blood cultures. cmv reactivated in / patients at risk. no ebv reactivation or ptld occurred. six patients had clinical and radiological signs of pneumonia (probable invasive aspergillosis) without detection of aspergillus/antigen in the bronchoalveolar lavage. ci of nrm at day + was %. four patients relapsed within the first year after haplo-hsct, with two of them dying due to relapse. at last follow-up (dec ) / patients were alive. with a median follow-up of months ( - ) estimated -year os and dfs were % and %, respectively. conclusions: treosulfan-based unmanipulated hlahaploidentical allo-grafting using ptcy as gvhd prophylaxis in hr mds and aml patients aged over years is safe and well tolerated resulting in stable engraftment and a favorable toxicity profile. our preliminary data further show promising outcome with low nrm, no severe acute gvhd and favorable survival offering an attractive alternative in ric for haplo-hsct of the elderly. disclosure: nothing to declare comparison of outcomes of total body irradiation (tbi) vs non-tbi conditioning regimens in acute lymphoblastic leukemia for allogeneic transplantation background: in adult patients diagnosed acute lymphoblastic leukemia (all) long-term results are poor with intensive chemotherapy. allogeneic stem stem cell transplantation is the potential treatment that provides cure for these patients. myeloablative preparation regimens include total body irradiation (tbİ)+ cyclophosphamide(cy) and busulfan + cyclophosphamide.in adult all patients wbi/cy widely used, but the toxicity rate is higher. the aim of this study is to compare the result and effect of the tbi/cy and busulfan/cy regimens in allogenic bone marrow transplantation in all patients. methods: between - there were all patients who underwent transplantation using myeloablative preparation regimen with or without addition tbi in the adult bone marrow transplantation units of medipol medical faculty, istanbul university istanbul medical faculty, sisli florence nightingale hospital, atakent acıbadem hospital adult bone marrow units . we analyzed overall survival (os), progression free survival (pfs), veno occlusive disease, acute and chronic graft versus disease development rates in these patients. results: demographic characteristics of patients summarized in table - there was no significant difference between groups in donor age, gender, stem cell source. it was observed that the relapse rate was not statistically significant in both group.there was no statistically significant difference between the patients who underwent myeloablative regimen and myeloablative regimen with tbi in relaps,death, os, pfs. (figure- ) [[p image] . figure ] in terms of transplant complications there was also no respectable difference in development of vod and acute and chronic graft versus disease but vod was more common in the group that did not use tbi (p: . ) ( conclusions: although there are contradictory data in the literature, in our multicentre study, it was revealed that the addition of tbi in the myeloablative preparation regimen compared with myeloablative preparation regimen alone did not have a positive or negative effect on overall survival.we think that if we can prepare a good vod prophylaxis approches, we can give up tbi in future. disclosure (n= ) . for gvhd prophylaxis, cyclosporine a was given either alone (n= ), with mmf (n= ) or with methotrexate (n= ). the graft source was bone marrow (bm) in most cases (n= ), pbsc in seven cases, matched sibling cord +bm in two cases and one matched related cord. twentyfive of the donors were family donors and ten were unrelated. twenty-nine of the donors were / hla matched, six were / mismatched and one haploidentical. four patients had engraftment failure and required a second transplant, two of them were re-transplanted with cyclophosphamide and tbi, one with fludarabine, busulfan and campath, and one with no conditioning. thirty of the patients are alive ( %). four patients died of transplant complications and one died of metastatic squamous cell carcinoma. eight survivors are mixed chimeras ( %- % donor) and are all doing well, none of them developed any gvhd. nine patients developed acute gvhd, four of them with grade - . seven of these patients later developed chronic gvhd, two of them have extensive disease. conclusions: our results show a high survival rate of %, with a low rate of engraftment failure and reasonable rates of gvhd. only one of our patients died of late effects of hsct for fa. mixed chimerism does not seem to present a problem. we conclude that reduced intensity fludarabine based conditioning regimens are a good treatment option for patients with fanconi anemia undergoing hsct. disclosure: nothing to declare total marrow irradiation + bendamustine as reducedtoxicity myeloablative conditioning prior to allohsct for younger patients with multiple myeloma background: the prognosis of patients with multiple myeloma (mm) has improved markedly over the last two decades. despite that, allohsct remains the only treatment option with curative potential. however, its use is limited due to high incidence of non-relapse mortality (nrm) after myeloablative conditioning while insufficient efficacy of reduced-intensity regimens. we developed a new protocol characterized by reduced toxicity while preserved myeloablative potential, based on the use of total marrow irradiation (tmi) in combination with bendamustine. the aim of this study was to evaluate its safety and efficacy in a singlecenter experience. methods: between years - , mm patients below years old were offered tandem auto-allohsct as part of first-line therapy. the decision was based on individual patient preferences after detailed description of potential risks. autohsct was preceded by melphalan mg/m iv. the conditioning prior to allohsct consisted of tmi performed using helical tomotherapy at the dose of gy/d on days - , - , - (total gy) and bendamustine - mg/m /d iv. on days - , - (total - mg/m ). the immunosuppressive therapy consisted of cyclosporine + methotrexate +/-atg. peripheral blood was used as a source of stem cells. results: the analysis included patients (women - , men - ). the median follow-up was ( - ) months. the median age at allohsct was ( - ) years. the disease stage before allohsct was as follows: cr- , vgpr- , pr- . patients were treated with hsct from either hlamatched siblings (n= ) or unrelated donors (n= ). the interval between autohsct and allohsct was ( - ) months. all patients engrafted after allohsct with median time of neutrophil and platelet recovery of and days, respectively. one patient ( %) experienced grade acute gvhd, while there were no cases of grade - acute gvhd. the incidence of mild, moderate and severe chronic gvhd was %, % and %, respectively. the rate of grade non-hematological toxicities was %. one patient died of late bacterial infection. the incidence of trm was %. grade adverse events were not reported. disease status months after allohsct was: cr- , vgpr- , pr- . the probability of os and pfs after months was % (+/- %) and % (+/- %), respectively. the incidence of progression and trm was % and %, respectively. conclusions: allohsct using tmi gy + bendamustine conditioning protocol is characterized by good tolerance and low risk of gvhd. it may be used for younger patients with mm as part of tandem auto-allohsct strategy. encouraging results reported in this study should be confirmed in prospective clinical trials. disclosure: nothing to declare p comparison between two reduced intensity conditioning regimens in patients with a myeloid malignancy: a single center experience comparing fb with flumel background: hematopoietic stem cell transplantation (hsct) remains the only curative option for high-risk myeloid neoplasms. the optimal reduced-intensity conditioning (ric) is still debated. methods: a single-center retrospective analysis was conducted at our institution to compare two different ric regimens in adult patients transplanted for myeloid malignancy from to . a total of patients were analysed, of them treated with busulfan-based (fludarabine mg/m , busulfan . mg/kg, fb ) and with melphalan-based conditioning regimen (fludarabine mg/m ,melphalan mg/m , flumel). antithymocyte globulin (atg) was administered in all patients while no one received tbi. partial in vitro t-cell depletion was performed using alemtuzumab for low risk patients. results: the two groups were well balanced with a median age of and years in the fb and flumel group, respectively, and a median follow up of months. the most frequent indication for transplant in both groups was aml ( . and . % for fb group and flumel group, respectively) and the stem cell source was peripheral blood in . and . % of patients. more patients in the first group had near to significant worst karnosfky status (< ) at transplant compared to second ( . vs %, p= . ) and more patients received a t-partial depleted graft ( . vs . %, p= . ). the neutrophil engraftment was significantly shorter after flumel ( vs days, p < . ). the -year overall survival (os) and disease-free survival (dfs) were of . and . %, respectively, after fb and . and . % after flumel, respectively, and were not significantly different (p=. for os and . for dfs), with a karnofsky >= being the only factor significantly associated in univariate analysis with better os and dfs (p=. for both). the cumulative incidence (ci) of grade to acute graft-versus-host disease (agvhd) was . % after fb and . % after flumel (p< . ) and was associated in multivariate analysis with both t depletion and ric type (p< . and . , respectively). the ci of chronic gvhd at years was . % in fb and . % in flumel group (p=. ) . the ci of non-relapse mortality at years was . % after fb and . % after flumel (p=. ). the ci of relapse at years was . % for the first and . % for the second group (p< . ) and was associated with conditioning regimen in multivariate analysis (p=. ). no difference in -years gvhd-free/ relapse-free survival (grfs) was observed between the two group ( . % for fb and . % for flumel, p=. ). conclusions: when comparing two ric regimens for myeloid neoplasms, we observed a higher incidence of agvhd after flumel whereas no statistical difference was noted for the cgvhd occurrence. while the toxicity appears to be higher after flumel, this result is counterbalanced by a higher proportion of relapse after fb , accounting for no difference in os, dfs and grfs between the two groups. these findings could be partially explained by a larger proportion of patients receiving a partial t-depletion after fb ric, but a larger trial is needed to clarify this issue. disclosure: nothing to declare. once-daily vs -times daily intravenous busilvex in conditioning regimen before allogeneic stem cell transplantation for patients with myeloid malignancies: safety and efficacy background: busilvex (bu) is part of standard conditioning regimen before allogeneic stem cell transplantation (asct) for patients with myeloid malignancies and usually administered as an intravenous (iv) infusion -times daily. this study aimed to compare the saftey and efficacy of this schedule to a once-daily iv bu. we conducted a retrospective study in adult patients (≥ years) with myeloid malignancies who received asct from hla-identical sibling donors between january and june following iv bu-based preparative regimens. graft-versus host disease (gvhd) prophylaxis consited of cyclosporine and short course of methotrexate. intravenous bu was administered -times daily ( . mg/kg every hours x to doses) or oncedaily in a -hour infusion ( . mg/kg x to days) since june . results: ninty-nine patients were enrolled ( men and women). median age was years (range, - y). the median time from diagnosis to asct was months (range, days - years). diagnosis were acute myeloid leukemia (n= , %), chronic myeloid leukemia (n= , %), myelodysplasic syndrome (n= , %), primitive myelofibrosis (n= , %) and chronic myelomonocytic leukemia (n= , %). thirty-seven ( . %) patients had ebmt-score ≥ . sixty-five ( . %) patients were transplanted in cr , ( %) beyond cr and ( . %) had active disease. conditioning regimens consisted of bu/cyclophosphamide in patients ( . %), bu/fludarabine in patients ( . %). four-times daily bu was given to patients ( . %, groupe ) and once-daily bu to patients ( . %, groupe ). stem cell source were bm in patients ( . %) and pbsc in patients ( . %). globally, patients characteristics were well balanced between the two groups. the rates of severe complications were similar between the two groups with no statistically significant differences except oral mucositis (table ). non-relapse mortality (nrm) was comparable in the two groups ( % and % in groups and , respectively, p= . ). the relapse rate was % and %, respectively (p= . ). after a median follow-up of years (range, days - years), the os was not significantly different between groups and : % vs % (p= . ). however, the rfs was significantly better in the groupe : % vs % (p= . ). conclusions: once-daily iv bu regimen seems to be an efficient and safe alternative to the -times daily protocol. however, results should be interpreted with caution because the historical comparison and lack of bu pharmacokinetics studies. disclosure background: standard therapy of the most patients with juvenile myelomonocytic leukemia (jmml) is allogeneic hematopoietic stem cell transplantation (ahsct). the choice of optimal conditioning regimen for patients with jmml is crucial as well as long-term observation. we aimed to estimate the long-term follow-up and survival rates of patients with jmml after ahsct with the help of busulfan or treosulfan-based conditioning regimens. methods: thirty eight patients with jmml underwent ahsct in - . we compared equal groups of patients received busulfan (n= ) and treosulfan-based (n= ) conditioning regimen. m:f= : . median of age at hsct was . ( . - ). donor type: hla-related / - % (n= ), hla-related / - . % (n= ), hlaunrelated / - . % (n= ), hla-unrelated / - . % (n= ), and haploidentical - . % (n= ). stem cell source: bm - . % (n= ), pbsc - . % (n= ), ucb - , % (n= ), and ucb+bm - . % (n= ) . disease status on hsct: cr - . % (n= ), refractory - . % (n= ). results: median follow-up . months ( - months) . the estimated -year overall survival (os) probability in patients received busulfan-based conditioning was , ± , % in comparison with , ± , % in patients with treosulfan-based regimen (р= , ). event-free survival (efs) was , ± , % in group with busulfan-based regimen and , ± , % in patients with treosulfanbased conditioning (р= , ). background: post-transplant relapse remains the leading cause of treatment failure in high risk (hr) acute myeloid leukemia (aml), myelodysplastic syndrome (mds), myeloproliferative neoplasia (mpns) receiving allogeneic hematopoietic cell transplantation (allo-hct), especially for patients with relapsed or refractory aml. recently, a sequential transplant approach, as developed by the munich group, comprising of intensive cytoreductive chemotherapy flamsa (fludarabine/amsacrine/cytarabine) to decrease leukemia cell burden shortly prior to conditioning regimen, has been successfully used for high-risk (hr) aml/mds with promising results. methods: we studied patients (median age years, range - ) with hr aml (n= ), as defined by refractory, relapsed disease, secondary leukemia, or high/ very risk disease risk index risk, and hr mds (n= ) according to ipss-r, undergoing allo-hct using the sequential transplant approach in institutions between january and october . the sequential transplant approach combined a cytoreductive chemotherapy, which consisted of either flamsa (n= ), flag +/-ida (fludarabine/cytarabine/granulocyte colony stimulating factor /idarubicin) (n= ), or clo-arac (clofarabine/cytarabine) (n= ), followed by reduced (ric) (n= ) or myeloablative (mac) (n= ) conditioning regimen. all patients received peripheral blood stem cell from matched related donors (n= ) matched unrelated donors (n= ), or mismatched unrelated donors (n= ). post-grafting immunosuppression consisted of calcineurin inhibitor and mycophenolate mofetil in all patients. thymoglobulin was added for gvhd prophylaxis for unrelated donor transplant. results: the median time to neutrophil > /μl was days (range, - ) . with a median follow-up of . months (range, . to . months), the kaplan-meier estimate of leukemia-free (lfs) and overall survival (os) at years were % ( % ci, - ), % ( % ci, - ), respectively. patients receiving flag or clo-arac based sequential regimen showed a trend towards more favourable overall survival (os) as compared to patients given flamsa ( year os: % vs %; p= . ). at years, the cumulative incidences of relapse and non-relapse mortality (nrm) were % ( % ci, - %) and % ( % ci, - %), respectively. in multivariate analysis, the type of sequential conditioning regimen did not show any significant impact on lfs, os, nrm or relapse. conclusions: sequential transplant conditioning with flamsa, flag or clo-arac followed by allo-hct is an effective strategy in overcoming the dismal prognosis of hr aml and mds, and enabling long-term disease free survival. more studies on effective strategies such as posttransplant maintenance therapy of prophylactic donor lymphocyte infusion, are needed to further eliminate the risk of relapse, without increasing risk of treatment related toxicity. disclosure: nothing to declare optimization of the blood sampling procedure for busulfan therapeutic drug monitoring (tdm) to optimize our sampling scheme ( minutes, , , , , , and hours after the end of a -hour infusion), we reduced the number of blood samples collected, reducing nursing and laboratory staff time and increasing patient convenience. this study aims to show the performance of a simplified sampling protocol which includes the first samples from the original protocol. methods: individual pk parameters were retrospectively estimated using samples (simplified protocol) and were compared with those obtained after samples (original protocol). individual pk parameter values for a one compartment model were estimated using a maximum likelihood estimation modelling algorithm (adapt . ) and the statistical analysis of the results was performed (statgraphics centurion xv). results based on the approved dosage recommendations, mean (sd) initial dose was . ( . ) mg. after tdm, mean (sd) calculated dose at day for the remaining days (to achieve the defined target cumulative auc) was , ( , ) mg obtained from the original protocol. according to the simplified protocol the result would be , ( , ) mg. the median and the mean variation of the calculated dose were % and % ( - %) between protocols. a strong relationship between the cl of the day - obtained from the original protocol and the simplified protocol is observed (r = . ). this high correlation is also observed for patients with busulfan t / > h (r = . ), a population were the reduction of sampling could be more problematic. anova test for the log cl with the factors: patient, day of busulfan and type of sampling protocol was performed. sampling protocol was determined as non-statistically significant (p = . ). conclusions: results suggest that both protocols are equivalent concerning to the busulfan cl estimation and calculated auc. variation between protocols regarding the calculated dose at day for the remaining days to achieve the defined target cumulative auc is considered acceptable. we verified a strong relationship between busulfan cl obtained from both protocols and sampling protocol doesn't influence cl statistically. a reduced sampling collection of determinations until h after the end of the infusion is shown to be sufficient for the tdm of busulfan, so this was implemented in our centre in line with published data. disclosure: nothing to declare p impact of anti-thymocyte globulin doses in unrelated hematopoietic stem cell transplantation for patients with myeloid neoplasm background: anti-thymocyte globulin (atg) is widely used for the prophylaxis of graft-versus-host disease (gvhd) in hematopoietic stem cell transplantation (hsct). however, there is still controversy regarding the optimal dose of atg. therefore, we analyzed the impact of atg doses in unrelated hsct for patients with myeloid neoplasm. methods: this was a retrospective multi-center study that assessed the impact of atg doses on clinical outcomes in patients with acute myeloid leukemia (aml) or myelodysplastic syndrome (mds) undergoing an unrelated hsct. the patients who received peripheral blood stem cells (pbsc) transplantation after conditioning regimens containing i.v. busulfan (bu), fludarabine and rabbit atg between and were included in this study. results: a total of patents, median age years, with aml (n= ) or mds (n= ) were included in our analyses. patients ( %) received a myeloablative regimen (i.v. bu> . mg/kg). high-atg (atg mg/kg), intermediate-atg (atg . - mg/kg) and low-atg (atg mg/kg) were given in , and patients, respectively. after a median follow-up of months, the cumulative incidence of extensive chronic gvhd was . % in the high-atg group, . % in the intermediate-atg group and . % in the low-atg group (p= . ). conclusions: our study shows that the incidence of extensive chronic gvhd was similar regardless of the doses of atg after transplantation of pbsc from unrelated donor for patients with aml or mds. however, the rate of relapsefree survival and the rate of a composite end point chronic gvhd-free and relapse-free survival were significantly higher in the intermediate dose ( methods: we retrospectively retrieved data from the electronic medical records for consecutive patients aged and older, who underwent an asct for lymphoma over the last years at our institution. results: forty four patients ≥ years old underwent asct between aug and aug . twenty eight of them received a reduced-dose conditioning (median %, range %- % dose reduction). the dose was reduced for % of patients ≥ years old and for % of patients aged - . the outcomes of the following three groups of patients were compared: a) age ≥ ; without dose reduction, b) age - ; with dose reduction and c) age ≥ ; with dose reduction (table ). only one patient aged received full-dose conditioning. there was no significant difference between the groups in the number of previous chemotherapy cycles (median , range - ). however, significantly more patients at the age of - were in complete remission (cr) pre-transplant in both full and reduced-dose conditioning groups (a and b). no significant intergroup differences were observed in the occurrence of complications (mucositis and infections), day transplantrelated mortality (trm) or engraftment day. similarly, no significant differences were found either in the -year progression-free survival (pfs), which was %, % and %, or -year non-relapse mortality (nrm), which was %, % and %, respectively for groups a, b and c. the -year overall survival (os) tended to be higher in group b ( %), compared to groups a ( %) and c ( %). conclusions: beam/beac conditioning dose reduction was not found to adversely affect -year pfs and os rates. despite the fact that / of the patients in the age group ≥ underwent asct in partial remission and had dose reduction, theier achieved trm, pfs and os rates were similar to those of patients aged - . beam/beac conditioning at a %dose may be a suitable option for patients in their seventh decade requiring asct. this strategy should be further evaluated in prospective clinical trials. background: the transplant related mortality in autologous transplants for lymphoma and multiple myeloma, reported worldwide ranges from - %. from - , the trm at our center for these two diseases was approximately %. we introduced changes in mobilization schedule, conditioning regimens and drug dosages to determine whether these changes affected the transplant related mortality and overall survival. methods: from april -december , we used beam (bcnu: mg/m on day - ; etoposide mg/ m on days - to - , cytarabine mg/m on days - to - and melphalan mg/m on day - as conditioning chemotherapy for patients admitted in transplant unit for autologous transplants in hodgkin's and non-hodgkin's lymphoma. in patients with multiple myeloma high dose melphalan ( mg/m ) was used. the mobilization protocol consisted of cyclophosphamide . gm/m followed by gcsf μgm/kg twice daily till stem cell collection was completed. from january , we changed the beam protocol to bendaeam with dose modifications that included: bendamustine mg/m on days - and - , cytarabine mg/m on days - to - , etoposide mg/m on days - to - and melphalan mg/m on day - . for multiple myeloma melphalan was reduced to mg/m . we used only gcsf for mobilization of stem cells, which was continued till stem cell harvest was complete. response to treatment was evaluated by comparing trm and overall survival for two time periods: - and from till date. results: from april till december , n= autologous transplants were performed. the male:female ratio was . : . fifty seven patients underwent transplant for lymphomas, n= for multiple myeloma and n= for other diagnosis. median age was ± . ( - years). the mean mnc was . × ± . /kg. engraftment was achieved in % of patients. the transplant related mortality was . % and overall survival was % (follow up: months). since january till march we have performed n= autologous transplants of which n= were males. fifteen transplants were performed for lymphomas (nhl: , hd: ) and n= for multiple myeloma. median age was ± ( - years). the mean mononuclear cell count was . x /kg and the mean cd count was . x /kg. engraftment was achieved in all patients. the transplant related mortality was % and the overall survival was % (follow up months). conclusions: we were able to reduce the autologous transplant related mortality to % by decreasing dosages of conditioning chemotherapy and changing the mobilization protocol. long follow-up is needed to determine late mortality and late relapse in comparison to standard chemotherapy dosages disclosure: nothing to declare risk and benefit of thiotepa based conditioning followed by autologous stem cell transplantation in high risk lymphomas years ( - ) . stage (ann-arbor) at diagnosis of hd/dlbcl/pcnsl: stage ie n= / / ( / / %), stage ii n= / / ( / / %), stage iii n= / / ( / / %), stage iv n= / / ( / / %). median time from diagnosis to asct hd/dlbcl/pcnsl: / / month ( - ). induction treatment in hd patients was abvd, in most dlbcl patients r-chop and in pcnsl patients high dose methotrexate and cytosin arabinoside. tumor status at asct hd/dlbcl/pcnsl: complete metabolic remission (cmr) n= / / ( / / %) and from pcnsl patient's n= ( %) were in first complete remission (cr ). type of stem cell graft was periferial blood stem cell in all case. conditioning: thiotepa ( mg/ m on days - to - , busulphan , mg/kg on days - to - and cyclophosphamide mg/kg on days - to - plus rituximab mg/m on day - in dlbcl and pcnsl. median follow up from asct days . tumor stage at asct was defined with computer tomography with positron emission tomography (pet-ct). results: median time of engraftment was days ( - ). thiotepa caused toxicoderma appeared at ( %) patients. cytomegalovirus (cmv) reactivation was seen in ( %) cases with low dna content ( , , copies/ml) and responded completely to oral valgancyclovir therapy. transplantation related mortality hd/dlbcl/pcnsl n= / / ( / / %), in cases bacterial sepsis and one systemic mycoses and one pulmonary fibrosis. incidence of long-lasting grade iii-iv thrombocytopenia and anaemia: n= ( , %) and n= ( %), median time of duration from transplantation days ( - ) and days ( background: this study evaluated the efficacy and toxicity of intravenous busulfan and thiotepa as a conditioning regimen for autologous stem cell transplantation (asct) in patients with multiple myeloma (mm). methods: we retrospectively analyzed the data of patients with mm who received the intravenous busulfan and thiotepa conditioning for asct between november and april in korea. results: the median time to transplant was . months, and patients ( . %) underwent asct within months of the diagnosis. the overall response rate after asct was . %, including . % with complete response, . % with very good partial response, and . % with partial response. the most common severe non-hematologic toxicity (grade - ) was infection ( . %). three patients ( . %) developed venous-occlusive disease. one patient ( . %) died due to severe pneumonia after asct. after a median follow-up of . months, the median progression-free survival (pfs) and overall survival (os) were not reached. conclusions: in conclusion, a conditioning regimen of intravenous busulfan and thiotepa was effective and tolerable. clinical trial registry: not applicable disclosure: the authors have declared no conflicts of interest. myeloablative haploidentical bone marrow transplantation with post-transplant cyclophosphamide in paediatric patients with haematological malignancies santanu sen , sameer tulpule background: haploidentical transplants have been shown to be safe and effective in treating haematological malignancies in the paediatric population. we have previously reported on our experience of using reduced intensity conditioning with post transplant cyclophosphamide in haploidentical patients. we herein report our experience of using a tbi based myeloablative conditioning to treat our first patients with haematological malignancies. methods: patients were enrolled in the study, with relapsed acute lymphoblastic leukemia (all) and with relapsed/resistant acute myeloid leukemia (aml). all aml patients had genetic markers of high risk disease and all all patients had very early relapses (either on therapy or within months of stopping therapy). all patients were conditioned with an identical protocol using tbi-based myeloablative preparative regimen (fludarabine mg/m /d × d and tbi cgy bid on d − to − [total dose cgy]) followed by an infusion of unmanipulated peripheral blood stem cells from a haploidentical family donor. postgraft immunosuppression consisted of cyclophosphamide mg/kg/day on days and , mycophenolate mofetil through day , and tacrolimus through day . results: median time of neutrophil and platelet engraftment was and days, respectively. all patients achieved sustained complete donor chimerism by day + . acute gvhd, grades ii-iv and iii-iv, was seen in % and %, respectively. disease progression occurred in patients: & months after transplant and there was one death due to severe fungal infection. estimated twoyear survival and relapse were % and %, respectively. patients had severe bk viremia and cmv reactivation occurred in patients. all patients were successfully managed with appropriate supportive and antiviral therapy. conclusions: we report good outcome with a myeloablative conditioning in haploidentical transplants with excellent engraftment and hopefully a longer life expectancy. with small number of patients, it is difficult to state whether using a myeloablative conditioning would lead to better long term outcomes in this cohort of patients with very haematological malignancies, but we certainly showed that it is possible to achieve excellent early results. disclosure: nothing to declare fludarabine in combination with melphalan and atg can be the best conditioning for hematopoietic stem cell transplant of children with hemophagocytic lymphohistiocytosis methods: in this prospective study, we analyzed the outcome of two pediatric patients with hlh who had received hsct, using reduced-intensity conditioning (ric) regimen. they received the same ric regimen based on the use of fludarabine ( mg/m /day for days) in combination with melphalan ( mg/m /day for days) and horse antithymocyte globulin (atg mg/kg/d for days). cyclosporine and methotrexate were used as graft-vs.-host disease (gvhd) prophylaxis. results: a months boy with primary hlh (fhl ) was transplanted from his mother and a years girl with secondary hlh was transplanted from her brother. both of donors were hla match with their recipients. they were received x /kg and x /kg cd + cells from the harvested peripheral blood stem cells, respectively. they achieved full neutrophil and platelet recovery. the time to neutrophil recovery was and days, respectively. full chimerism was achieved for both of them. in addition, they was developed grade and of acute gvhd, respectively. gvhd was completely controlled with prednisolone. they are alive and in complete remission without any significant complications after and months, respectively. conclusions: it appears that fludarabine in combination with melphalan and atg may be the best conditioning regimen for hematopoietic stem cell transplant of children with hlh. due to a few number cases of this study, a study with sufficient sample size is required. disclosure background: hematopoietic cell transplant (hct) recipients often report depression and impaired quality of life (qol) before transplant. mixed evidence suggests depression may be a risk factor for greater mortality and worse qol. inconsistent findings may be due to the fact that previous studies have not evaluated antidepressant use. the aim of the study was to compare pre-transplant patientreported physical functioning and post-transplant overall survival (os) between four groups of hct recipients: ) non-depressed/taking antidepressant (treated depression), ) depressed/taking antidepressant (undertreated depression), ) depressed/not taking an antidepressant (untreated depression), and ) not depressed/not taking an antidepressant (control). it was hypothesized that physical functioning and os would be worse among patients with untreated and undertreated depression relative to those with treated depression and controls. methods: this retrospective case-control study included patients completing depression (phq- ) and quality of life (sf- ) questionnaires at pre-transplant. analyses were conducted separately for allogeneic and autologous recipients. results: participants (n= , ) were % men, mean age years ( - ), % allogeneic recipients. regarding depression and antidepressant use, ( %) allogeneic patients were characterized as having treated depression, ( %) as untreated depression, ( %) as undertreated depression, and ( %) as controls. hierarchical linear regression models indicated that after adjusting for significant univariate factors (performance status, disease status, and regimen intensity), allogeneic patients with treated depression (b=- . , % ci=- . , - . ) reported better physical functioning than patients with undertreated depression (b=- . , % ci=- . , - . ) and untreated depression ) but worse physical functioning than controls (p values < . ). cox regression models indicated depression/antidepressant usage was not associated with os among allogeneic patients (p values> . ).among autologous patients, ( . %) were characterized as having treated depression, ( . %) as untreated depression, ( . %) as undertreated depression, and ( . %) as controls. hierarchical linear regression models indicated that after controlling for significant univariate factors (gender, performance status, diagnosis, and disease status), autologous patients with treated depression (b=- . , % ci=- . , - . ) reported better physical functioning than patients with undertreated depression (b=- . , % ci=- . , - . ) and untreated depression (b=- . , % ci= . , - . ), but worse physical functioning than controls (p values < . ). cox regression models showed depression/antidepressant usage was associated with os (p values < . ), with patients with treated depression demonstrating significantly worse os than other groups (p= . ), but this association was no longer significant in multivariate analyses controlling for diagnosis and disease status (p= . ). conclusions: patients with untreated or undertreated depression pre-transplant may benefit from depression screening and treatment to improve physical functioning. disclosure: hslj: consultant for redhill biopharma and janssen scientific affairs p eltrombopag (epag) induces a high percentage of responses in patients with post allo-hsct poor graft function (pgf) and no active gvhd lourdes aguirre , aitziber lizardi , pilar bachiller , brigida esteban , carmen gonzález , nagore argoitia , maría araiz , aranzazu aguirre , anunciación urquía , carlos vallejo background: persistent cytopenia is a life-threating complication after hsct. several causes can lead to this situation (viruses, gvhd, drugs, etc) . a specific entity is the one called "poor graft function (pgf)", which is diagnosed in pts with ≥ cytopenias after day + , in the presence of donor chimerism and the absence of gvhd or relapse. pgf is more frequent after alternative allo-hscts, such a haplo-identical, mismatched, or ucb. several therapeutic approaches for pgf, with poor results, have been tested. recently, epag has been shown to improve platelet counts in the post-allo-hsct setting. in this study, we analysed the efficacy of epag in pts with post-transplant persistent cytopenias. methods: the population analyzed includes all pts who underwent allo-hsct from june through may in our unit. median age was years ( - ). were male ( . %) and female ( . %). baseline diseases were: aml, lpd, all, mds, mpd, mm, and bmf. donor was unrelated in ( . %) and was family in ( . %) (including haplo-identical). conditioning was ric in ( . %) and intensive in ( . %). sc source was pb in ( . %) and bm in ( . %). median followup was months ( - ). epag was initiated at some point during the first -month post-hsct period in pts ( . % of the series) due to thrombocytopenia (< /mcl) plus, at least, one other cytopenia. patients characteristics shown in table . epag was started at mg/day and escalated each weeks to , and mg/day if platelet count was < /mcl. global response was considered when, after epag, the patient needed no transfusions and reached the three of the following: platelets > /mcl, hgb > g/dl, and anc > /mcl. epag was tapered off in responders and discontinued if no response was reached after weeks. results: at epag initiation, all the pts had thrombocytopenia (< /mcl), had anemia (hgb < g/dl), and had neutropenia (anc < /mcl). counts pre and post and response to epag are shown in table . among the responders, all but one (who relapsed from thrombocytopenia and died from bleeding) were alive at analysis close ( . %). among the non-responders, three pts had gvhd-associated cytopenias, and finally died from infectious complications; the other patient relapsed from her aml, reached a new cr after treatment, and is alive and well months afterwards. epag was tapered off and discontinued in / pts who responded; / responders are still on epag. epag was discontinued in the / pts who did not respond. rest of treatment details shown in table . conclusions: ) epag worked striking well in subjects with pgf, an otherwise a life-threatening situation for patients. ) epag induced impressive responses in platelets, but strong bilinear and trilinear responses were also seen. ) epag did not improve gvhd-associated cytopenias. ) to confirm these innovative and transcendent results, we have just initiated a multicenter prospective study on the role of epag for treatment of post-hsct pgf. * five out of the six urdt were mismatched ** the donor was a woman in the six cases: three sisters and three daughters background: hepatic vod/sos with multi-organ dysfunction (mod; typically, renal or pulmonary) may be associated with > % mortality. defibrotide is approved for treating severe hepatic vod/sos post-hsct in patients aged > month in the eu, and for hepatic vod/sos with renal or pulmonary dysfunction post-hsct in the us. this analysis provides an overview of the safety results from studies of patients with vod/sos, with or without mod, who received defibrotide mg/kg/day. methods: safety data were pooled from patients with vod/sos post-hsct treated with defibrotide in a phase trial (n= ) and a phase , randomized dose-finding trial (n= receiving mg/kg/day). safety data for historical controls (hc) from the phase study (n= ) also are provided. reported separately, due to differences in patient population and data monitoring protocol, are aes from the expanded-access program (t-ind) in patients with vod/ sos with and without mod (n= post-hsct). vod/ sos was diagnosed by baltimore criteria/biopsy for the phase / studies; diagnosis by baltimore or modified seattle criteria was permitted in the t-ind. results: median patient age at hsct for the phase / studies was . years, . years for the hc, and . years for the t-ind. in the phase / studies defibrotide-treated group (n= ), ( . %) experienced aes; most common (> %) were hypotension ( . %), diarrhea ( . %), and multi-organ failure ( . %). treatment-related aes were at least possibly related to defibrotide (table) . any hemorrhage (an ae of special interest) occurred in patients ( . %); most commonly epistaxis ( . %), gastrointestinal and pulmonary alveolar hemorrhage and hematuria ( . % each), and conjunctival hemorrhage ( . %). all hc experienced an ae; most common (> %) were hypotension ( . %), tachycardia ( . %), diarrhea ( . %), nausea ( . %), and pyrexia, agitation, and petechiae ( . % each). any hemorrhage occurred in patients ( . %): most common (> %) were petechiae ( . %); hematuria, epistaxis, and pulmonary alveolar hemorrhage ( . % each); and lip hemorrhage ( . %). in the t-ind (n= ), / patients with mod ( . %) and / patients without mod ( . %) had an ae; other than vod/sos and mod, most commonly (> % in either subgroup) hypotension ( . % and . %, respectively). traes occurred in patients ( . %) ( table) . any treatment-emergent hemorrhage occurred in patients with mod ( . %) and patients without mod ( . %); most commonly (> % in either subgroup) pulmonary hemorrhage ( . % and . %, respectively) and gastrointestinal hemorrhage ( . % and . %, respectively). conclusions: the incidence and type of aes were as expected in these critically ill patients. of the pooled patients, % had aes; . % had a hemorrhage. all hcs had an ae, with . % having a hemorrhage. in the t-ind, patients with mod had higher rates of aes. support: jazz pharmaceuticals event, n(%) phase / studies (n= ) disclosure: paul g. richardson has served on advisory committees and as a consultant, and has received research funding from jazz pharmaceuticals. angela r. smith and leslie lehmann have nothing to disclose. nancy a. kernan received grants from gentium during the conduct of the study, and her research was supported by the national cancer institute of the national institutes of health under award number p ca ; the content is solely the responsibility of the author and does not necessarily represent the official views of the national institutes of health. she has a research grant from jazz pharmaceuticals. robert ryan and william tappe are employees of jazz pharmaceuticals and hold stock and/or stock options in jazz pharmaceuticals plc. stephan a. grupp has served on a steering committee and as a consultant to jazz pharmaceuticals. defibrotide for treatment of adults with hepatic vod/ sos with or without multiorgan failure after hematopoietic cell transplantation: results of a systematic review/meta-analysis background: although hematopoietic cell transplantation (hct), autologous or allogeneic, is potentially curable in various hematologic malignancies, the procedure is associated with serious and potentially life-threatening complications, among them veno-occlusive disease/sinusoidal obstructive syndrome (vod/sos) of the liver. several studies, prospective or retrospective, have reported outcomes of defibrotide, when used as prophylaxis or treatment, in a mixed population of adult and pediatric patients. in this systematic review/meta-analysis, we analyze outcomes of defibrotide when specifically used for treatment of adult patients with hepatic vod/sos with or without multiorgan failure. methods: a comprehensive search of large databases (medline/pubmed, cochrane and embase) on november , identified publications. analysis was restricted only to adult patients (defined as median age older than years) who received defibrotide for treatment of vod/sos and were reported in prospective or retrospective (which included ≥ patients) studies published in full manuscript form. there were no limitations based on language. data were extracted in relation to benefits [complete remission (cr) rate and overall survival (os)] and harms (hemorrhage, any site or organ-specific). a total of studies (prospective= ; retrospective= ) with patients met inclusion criteria. results: the median year of publication of prospective studies was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and for retrospective ones ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the prescribed starting dose of defibrotide varied among studies ranging from . mg/kg/day to mg/kg/day, mostly for a -day course. the pooled cr rate was % ( %ci= - %) for prospective and % ( %ci= - %) for retrospective studies. the pooled day + os rates were % ( %ci= - %) and % ( % ci= - %) for prospective and retrospective studies, respectively. the pooled rates of hemorrhage (any site) were % ( %ci= - %) for prospective and % ( % ci= - %) for retrospective studies. when analyzing organ-specific hemorrhage, prospective studies (n= patients) reported pooled rates of pulmonary alveolar (pa) hemorrhage of % ( %ci= - %) and of % ( %ci= - %) for gastrointestinal (gi) hemorrhage. only one retrospective study (n= patients) reported an incidence of pa hemorrhage of % ( %ci= - %) and a different study (n= patients) reported an incidence of gi hemorrhage of % ( %ci= - %). none of the studies reported cerebral hemorrhage as a complication of defibrotide therapy. conclusions: this systematic review/meta-analysis confirms the efficacy of defibrotide for treatment of vod/sos with or without multiorgan failure, yielding cr rates of - % and day + os rates of - %. the purportedly higher pooled cr and os rates observed with retrospective (vs. prospective) studies are likely due to assignment-bias inherent to observational studies. moreover, although the pooled hemorrhage (any site) rates of - % is considered proportionally significant, the pooled rates of pa and gi hemorrhage were ≤ %, in prospective studies. clinical trial registry: not applicable disclosure: m.a.k-d: consultancy for pharmacyclics m.m: received lectures honoraria and research support from jazz pharma efficacy and safety of defibrotide in the treatment of hepatic veno-occlusive disease/sinusoidal obstruction syndrome following hematopoietic stem cell transplantation: interim results from the defifrance study background: hepatic veno-occlusive disease/sinusoidal obstruction syndrome (vod/sos) is a potentially lifethreatening complication of conditioning for hematopoietic stem cell transplant (hsct) but may occur after nontransplant chemotherapy alone. vod/sos with multi-organ dysfunction (mod) may be associated with > % mortality with supportive care alone. diagnosis of vod/sos was traditionally based on baltimore or modified seattle criteria; however, the ebmt recently published separate diagnostic criteria for adults and children. defibrotide is approved for treating severe hepatic vod/sos post-hsct in patients aged > month in the eu, and for hepatic vod/sos with renal or pulmonary dysfunction post-hsct in the usa. the goal of the defifrance study, requested by the french health authorities, is to collect real-world data on safety and efficacy in a broader patient population in france, including all indications. this is the first interim analysis of the largest current evaluation of defibrotide for the treatment of vod/sos in europe. methods: defifrance is an observational, multicenter, post-marketing study that includes any patient treated with defibrotide from hsct centers in france. this interim analysis is based on all patients treated with defibrotide, including those with severe and very severe post-hsct vod/sos. vod/sos was diagnosed using traditional criteria. day+ survival, complete remission (cr; total serum bilirubin < mg/dl and resolution of mod), and safety profile are reported. results: a total of patients treated with defibrotide were included retrospectively and prospectively between july and october from table] disclosure: mohamad mohty: has received honoraria and research funding from jazz pharmaceuticals, delphine lebon: nothing to disclose, ann berceanu: none, charlotte jubert: has received funding from jazz pharmaceuticals, ibrahim yakoub-agha: has received honoraria from jazz pharmaceuticals, stéphane girault: none, marie detrait: has received research funding from jazz pharmaceuticals, cécile pochon: none, fanny rialland: none, virginie gandemer: none, jean-hugues dalle: has received honoraria from jazz pharmaceuticals, régis peffault de latour: has received research grant / honoraria / board from pfizer, novartis, alexion; research grant amgen; and honoraria from jazz pharmaceuticals, david michonneau: has received honoraria from jazz pharmaceuticals, myriam labopin: has received honoraria from jazz pharmaceuticals, floriane delaval: employee of jazz pharmaceuticals and holds stock and/or stock options in jazz pharmaceuticals plc, gerard michel: none, anne sirvent: none, laurence clement: none anne-lise menard: none, anne huynh: has received honoraria from jazz pharmaceuticals, virginie bouvatier: employee of jazz pharmaceuticals and holds stock and/or stock options in jazz pharmaceuticals plc, raj hanvesakul: employee of jazz pharmaceuticals and holds stock and/ or stock options in jazz pharmaceuticals plc, zakaria medeghri: employee of jazz pharmaceuticals and holds stock and/or stock options in jazz pharmaceuticals plc p incidence and predictors of severe cardiotoxicity in patients with severe aplastic anemia after haploidentical hematopoietic stem cell transplantation zheng-li xu , lan-ping xu , yuan-yuan zhang , yi-fei cheng , xiao-dong mo , feng-rong wang , yu-hong chen , wei han , chen-hua yan , yu-qian sun , ting-ting han , yu wang , xiao-hui zhang , xiao-jun huang peking university institute of hematology, peking university people's hospital, beijing, china background: severe cardiotoxicity after hematopoietic stem cell transplantation (hsct) is a rare but fatal complication. the aim of this study was to evaluate the frequency of severe cardiac complications and to assess the ability of various factors to predict these complications in patients with aplastic anemia after haploidentical transplantation., this is the first study evaluating the values of both clinical and imaging factors in the prediction of severe cardiotoxicity among saa patients after haploidentical transplantation. methods: a retrospective study was conducted in consecutive aplastic anemia patients who received haploidentical transplantation from to . all patients received a unified regimen including busulfan, cyclophosphamide (ctx) and antithymocyte globulin at our single center. results: a total of ( . %) patients developed grade iii or iv cardiac toxicity. patients with cardiotoxicity had significantly poorer overall survival (os) than those without cardiotoxicity ( . % vs. . %, p< . ). our multivariable model identified four independent adverse predictors of severe cardiotoxicity, including pre-transplant ecog score (≥ ), abnormal st-t wave on -lead electrocardiogram (ecg), hyperlipemia and recalculated ctx dose (≥ . g/m /d). a predictive risk model was refined as low risk ( - factor), intermediate risk ( factors) and high risk ( - factors) . the respective incidences of severe cardiotoxicity were . %, . %, and . % in the high-, intermediate-and low-risk groups (p< . ). the corresponding os rates were . %, . %, and . % in the three groups (p< . ) at the last follow-up. conclusions: patients with high risk scores had the poorest outcomes and should be monitored closely. a reduced intensity conditioning might be recommended for these patients. disclosure: there are no conflicts of interest to declare. background: allogeneic stem-cell transplantation (allo-sct) is associated with significant transplant-related mortality (trm). acute renal failure (arf) is a frequent complication and usually presents early after the procedure, compromising its feasibility. the aim of this study is to analyse the incidence of arf, its risk factors and its potential impact on trm after allo-sct. methods: patients were included ( males [ %]; median age years, range - ) treated with allo-sct consecutively between january and april in a single institution. patient characteristics are detailed in table . median follow-up was . years (range, . - . ). renal function was evaluated using creatinine and data was collected pre-transplant (baseline) and at the point when arf was developed after allo-sct. arf was evaluated using akin criteria, being akin- an increase . -to . -fold from baseline, akin- an increase . -to . -fold and akin- an increase ≥ -fold. chronic renal disease was evaluated one year after the date of arf using kdigo criteria. results: cumulative incidence of arf at year was % (akin- , %; akin- , %; akin- , %). in the multivariate analysis, arf (akin- / ) was associated with: non-use of antithymocyte globulin in conditioning chemotherapy, p= . (hr . , . to . ) and development of severe agvhd, p= . (hr= . , to . ). in patients with arf akin- , the most important variables in the multivariate analysis were: use of methotrexate (mtx) plus cyclosporine vs mycophenolate mofetil plus cyclosporine as gvhd prophylaxis, p= . (hr= . , . to . ); myeloablative conditioning vs reduced intensity, p= . (hr= . , to . ) and use of total irradiation therapy in conditioning, p= . (hr= . , . to . ). trm at year increased significantly according to akin: akin- , %; akin , %; akin , %; p= , ; hr= . . overall survival at years according to akin was: akin , %, akin , % and akin , %; p= , (figure ). the incidence of chronic renal disease at year after allo-sct according to arf was: no arf ( %), akin- ( %), akin- ( %) and akin- ( %); p= . . conclusions: arf is a frequent complication during the first year after allo-sct and is associated with several factors. arf akin- was associated with more intensive strategies received during conditioning, meanwhile akin- / were related to development of gvhd. there is an association of arf (akin- , or ) with development of chronic renal disease. background: the introduction of cellular therapies such as car-t and modalities of gvhd-prophylaxis with posttransplant/cyclophosphamide (ptcy) that increase the number of admission days have boosted the pressure of available beds in the bm-units. in this sense, our centre started an at-home allogeneic stem cell transplantation (allo-sct) program to follow aplasia from the d+ until independent ambulatory patient. to evaluate the feasibility and safety of allosct, we compared two groups: allohsct/athome (ah-group) vs. allohsct/in-patient (ip-group). methods: we included patients receiving allosct (january -november ) in a single centre: patients, ah-group and , ip-group. all patients received conditioning at the hospital. gvhd-prophylaxis consisted in tacrolimus (tk) plus mycophenolate (mpm) or methotrexate, or ptcy (d+ , d+ ) plus tk (d+ ). all patients received prophylaxis with levofloxacin, fluconazole and acyclovir. besides that, ah-group patients received prophylaxis with ceftriaxone g/ h iv or ertapenem g/ h iv, and aspergillus-prophylaxis with inhaled liposomal amphotericin-b or posaconazole during neutropenia. patients of ah-group since d+ or d+ (in ptcyprophylaxis) received a nurse visit at-home once daily. the visits by the physician were performed at the hospital and only during complication events. first-line therapy of neutropenic fever was meropenem g/ h in both groups, using a portable infusion pump in ah-group. in this group, the absence of focal infection or signs of severe sepsis allowed returning home after the initiation of antibiotics. the platelets support was performed at-home and the red blood support at hospital. results: the median (range) age (years) of the series was . the median follow-up of the series has been not achieved. the source of the sct was peripheral blood in all cases. we didn't find statistical differences between two groups (ah vs ip) in terms of age, diagnosis, type of donor, intensity of conditioning, gvhd-prophylaxis, toxicity (mucositis, acute renal injury, neutropenia and thrombocytopenia), agvhd, aspergilosis and trm. interestingly, a significant reduction of neutropenic fever was observed resulting the lower use of meropenem in the ah-group than ip-group. the admission median days were similar in the both groups and it represented - days the reduction in the total economic cost of the ah-group. the whole analysis of the results are detailed in table: in-patient group, conclusions: in our experience, at home allosct, including ptcy-gvhd prophylaxis, is a feasible and safe procedure reflected in similar trm and aspergillosis incidence. at-home allo-sct is associated with a significant lower risk of neutropenic fever than in-patient group, as well as a very low readmission rate. disclosure: gonzalo gutiérrez-garcía: honoraria from gilead. grant from jazz pharmaceutical and janssen. laura rosiñol: honoraria from takeda, janssen, amgen and celgene. the others author do not have any disclosures to declare. background: renal complications in sickle cell disease (scd) include episodes of acute kidney injury (aki), progressive chronic kidney disease (ckd) and hyperfiltration, defined by abnormally high glomerular filtration rates (gfrs). hematopoietic stem cell transplant (hsct) from an hla identical sibling donor is a well-established curative treatment for scd, but traditional myeloablative conditioning (mac) regimens pose risks of kidney injury due to intensive use of chemotherapeutic agents, infectious risks, and use of calcineurin inhibitors (cnis). aki and subsequent fluid overload (fo) are common in pediatric hsct with reported aki incidence of %- % (kyung-nam koh et. al., ). we report renal outcomes in pediatric patients with scd who received hsct following a non-myeloablative conditioning (nma) regimen without cni exposure. methods: retrospective chart review describing renal outcomes in pediatric patients ( years of age or younger) with scd (hbss) who underwent nma hsct in alberta, canada from july to february . the nma regimen is illustrated in figure . reported renal outcomes: ) measured gfr (dtpa) pre-hsct, ) aki (kdigo definition) post-hsct by reviewing all serum creatinine levels from pre-hsct to one month post-hsct, ) %fo calculated: (max post hsct weight -baseline weight)/ baseline weight x for the two first weeks post-hsct, and ) estimated gfr (egfr) using the pediatric schwartz formula at last follow-up post-hsct, ckd defined as egfr < ml/min/ . m , mildly reduced gfr: - ml/min/ . m , and hyperfiltration: gfr ≥ ml/ min/ . m . [[p image] . results: eighteen patients ( % male, - years old at transplant) were included. most common pre-morbid events: vaso-occlusive crisis (n= ), acute chest syndrome (n= ), splenic sequestration (n= ), and cholelithiasis (n= ). median follow-up time: months (range: - months). all patients engrafted successfully with no acute or chronic gvhd. baseline measured gfrs were all > ml/min/ . m (range: - ) with mildly reduced gfr and hyperfiltration seen in one ( . %) and ( . %) patients respectively. at baseline (pre-hsct), the only aki event was one transplant related aki secondary to delayed hemolytic reaction after exchange transfusion in preparation for transplant. post-hsct, there were no aki events. additionally, no substantial %fo post-hsct was observed. average %fo week one post-hsct: + . % (range: - . % -+ . %) and week two post-hsct: + . % (range: - . % -+ . %). post-hsct egfr remained > ml/min/ . m at last follow-up in all patients. hyperfiltration was present in ( . %) of the patients. conclusions: this is the first study describing stable kidney function in children with scd after the present nma hsct regimen with alemtuzumab/ cgy total body irradiation (tbi) with prolonged post-hsct sirolimus. no episodes of aki or significant fluid overload were observed during the first month post-hsct, and no patient developed ckd during follow-up. further prospective studies are needed to confirm our findings and to determine if stable renal function persists during longer-term followup. disclosure: nothing to declare. lung microbiota in patients with idiopathic pneumonia syndrome (ips) after hct background: idiopathic pneumonia syndrome (ips) is a non-infectious pulmonary complication after hematopoietic cell transplantation (hct) and the etiology remains unknown. recent studies have reported that various diseases are associated with changes of microbiota. the aim of this study was to evaluate the lung microbiota in hct recipients with ips and identify microorganisms potentially associated with ips. methods: frozen bronchoalveolar lavage (bal) samples from hct recipients with ips (n= ) and research bal samples from asymptomatic hct recipients as controls (n= ) were retrospectively analyzed. all samples were negative for common viruses by quantitative pcr. sequencing libraries were made with ng of input dna per sample (nextera xt, illumina). samples were pooled and sequenced by hiseq to obtain -bp paired end data. sequence data analysis and read classification were performed with sunbeam and the quality control and read classification were performed using komplexity and kraken, which classifies bacterial, archeal, and viral genomes. we used sequence data of bronchoscope prewashes from a separate cohort as controls for environmental sources (n= ). bray-curtiss dissimilarity among samples was calculated using the vegan r packages. permanova and a two-sided wilcoxon rank sum test were used to compare between the study groups. results: bal samples started at a median of x raw read pairs per sample and reduced to x reads assignable to microbial taxa following quality control. the bacterial phyla proteobacteria and firmicutes were most abundant followed by bacteroidetes and actinobacteria in both bal and bronchoscope prewash samples. separation of bal and prewash microbiota using bray-curtiss dissimilarity plots showed that bal samples were distinguished by sequences assigned to staphylococcus, acidovorax, and bradyrhizobium species, while prewash samples were distinguished mostly by pseudomonas and elizabethkingia species, consistent with environmental sources (figure) . within bal samples, staphylococcus species were the main drivers of separation between ips cases and the controls (p= . , permanova, figure) . consistent with this, a linear discriminant analysis to identify taxa best distinguishing cases and controls identified staphylococcus, especially s. epidermidis, in ips cases with lactobacillus and streptococcus species in controls. we then compared relative abundances of s. epidermidis between all study groups. ips case samples were significantly enriched in s. epidermidis compared to control (p< . , two-sided wilcoxon rank sum test) and prewash samples (p< . ). viruses were classified by category as human pathogens, non-human pathogens, and bacteriophages. torque teno viruses (ttv) was the most commonly detected virus among viruses that replicate on human cells, and there was a trend towards higher abundance in ips case samples than controls. conclusions: lung microbial sequences in hct recipients predominantly consisted of proteobacteria and firmicutes, and had considerable overlap with environmental background. patients with ips had significantly more staphylococcus sequences detected than asymptomatic hct patients. these results suggest that patients with acute lung injury post-hct show distinct patterns of lung microbiota, although heterogeneity of sample collection and processing cannot be excluded and no singular organism was uniquely associated with ips. a prospective study is required to confirm these findings and define the clinical significance of differences in abundance patterns. disclosure: nothing to declare p abstract withdrawn. romiplostim for the treatment of thrombocytopenia after allogeneic stem cell transplantation background: thrombocytopenia is a common complication after allogeneic stem cell transplantation (allo-hct). with variable possible causes, such as drug side effects, infections, poor graft function, graft vs host disease (gvhd) and immune mediated. the purpose of this study was to evaluate the efficacy of romiplostim, a thrombopoietin receptor agonist, in patients with prolonged thrombocytopenia with no obvious cause after allogeneic transplantation. methods: retrospective analysis of allo-hct patients who received romiplostim at a single bmt unit between november and november . romiplostim was given because of prolonged (> weeks) thrombocytopenia (< , μl) that couldn't be explained by obvious causes such as administration of drugs (antibiotics/antivirals), infection or gvhd. all patients were in complete remission and had complete chimerism. response to romiplostim treatment was considered transfusion independence or plt> . /μl. results: in total, patients (median years, - ) received romiplostim. patients ( male, females) had aml ( pts), all ( ), mds ( ) or hodgkin ( ), received a myeloblative (busiphex-based: , tbi-based: ) or ric ( ) conditioning and were transplanted from a sibling ( ), vud ( ) or haploidentical ( ) donor with pbsc ( ) or bm ( ) . all patients revealed primary neutrophil (median days, range - ) and > . /μl platelet ( days, - ) engraftment. romiplostim was started at median day + (range - ) with a median dose μg/kg ( ) ( ) ( ) ( ) ( ) . the median platelet count before commencement of treatment with romiplostim was . /μl (range . - . ) and them ( %) were transfusion-dependent. in total / ( %) patients responded to romiplostim treatment. eight out of the ( %) transfusion dependent patients responded to the administration of romiplostim. six out of the patients ( %) who were transfusion independent at romiplostin initiation (plt median . /μl, range . - . ) responded. the median duration of treatment was days ( - ) and the median follow up from the commencement of romiplostim was days ( - ). three out of ( %) patients experienced relapse of thrombocytopenia after discontinuation of romiplostim and re-initiation of romiplostim was commenced in all of them, of which responded and didn't. the administration of romiplostim was done on an external basis and was well tolerated by the patients. two patients experienced gvhd during romiplostim treatment (both patients transplanted from / unrelated donor, and days after initiation treatment with romiplostim). / patients interrupted romiplostim due to disease relapse. / patients receiving romiplostim are alive in complete remission and died ( due to relapse, and due to trm). conclusions: we present high response rates to romiplostim in patients with prolonged thrombocytopenia after allogeneic transplantation. in this retrospective study there were no side effects from the administration of romiplostim. however, the administration of romiplostim after allo-hct should be controlled in prospective trials. disclosure we report a single-center analysis of adult patients (median age years, range - , m/f / ), receiving tpo agonists for isolated severe thrombocytopenia (n= ) and spgf (n= ) after allo-hsct. primary diagnoses were aml ( ), all ( ), mds ( ), pmf ( ), mds/mpn ( ), saa ( ), cml ( ), nhl ( ) . severe pgf was defined as cytopenia in ≥ lineages (platelet < × /l, anc < . × /l, hemoglobin < g/l any time after sustained engraftment), full or stable mixed donor chimerism > % and no signs of relapse. median dose of romiplostim was (range, - ) mcg/kg weekly, eltrombopag - (range, - ) mg/day. overall response (or) included cr (platelet ≥ × /l, anc ≥ . × /l, and hemoglobin ≥ g/l) and pr (platelet > × /l, anc ≥ , × /l, hemoglobin > g/l). results: median time from pgf diagnosis to treatment with tpo agonists was days ( - ), median treatment duration was weeks ( - ). tpo agonists were well tolerated with no cases of grade iii-iv toxicity. tpo agonists were combined with rituximab (n= ), rituximab and dli (n= ) and hsc boost (n= ) in ( %) patients. a total of ( %) patients met criteria of response (cr: n= , %; pr: n= , %). combination therapy showed no difference in or compared to tpo agonists alone. or was not depended on the tpo agonist used nor the time to therapy initiation. median increase in anc in responders was . × /l ( . - . ), in platelet count - × /l ( - ). a total of patients died due to relapse (n= ), gvhd iii-iv grade (n= ) and infection (n= ). two-year os from the start of tpo agonist therapy was % ( % ci, - ) with a significant difference between responders and non-responders: % ( % ci, - ) vs. % ( % ci, - ) (p= , ). conclusions: this study showed promising results of tpo agonists for management of spgf. further studies are warranted to specify optimal timing and dosing regimen, predictors of response. [[p image] . two-year os in responders and nonresponders to tpo agonist therapy] disclosure: there are conflicts of interest to disclose p cytomegalovirus reactivation kinetics and peak titers as novel predictors of survival and relapse after allogeneic cell transplantation for hematologic malignancies saskia leserer , evren bayraktar , nikolaos tsachakis-mück , michael koldehoff , lara kasperidus , esteban arrieta-bolanos , mirko trilling , katharina fleischhauer , dietrich w. beelen , amin t. turki university hospital essen, essen, germany, background: after allogeneic hematopoietic cell transplantation (hct), human cytomegalovirus (cmv) reactivation associates with non-relapse mortality (nrm) but also with reduced relapse in patients with leukemia, as shown by numerous studies that evaluated cmv reactivation as a qualitative yes/no parameter in the first months posttransplant. we hypothesized that longitudinal quantitative assessment of cmv reactivation kinetics and virus loads might improve patient-specific clinical outcome associations. methods: this retrospective study included patients with hct for hematologic malignancies treated between / and / at university hospital essen, germany. cmv titers were monitored weekly by quantitative pcr (qpcr); cmv reactivation was defined by a cutoff of > genome copies per ml. patients were included for analysis, if at least measurements were available during the first days after hct. in total, , samples were analyzed. subgroup analyses were performed according to the time of cmv reactivation (before/after + d) or the cmv viremia titer (> , , , - , and - , copies/ml). results: cmv reactivation was detected in (median age years; range - years) out of patients. baseline characteristics (age, gender, underlying disease, transplant) of patients without cmv reactivation were comparable. cmv reactivation kinetics followed a gaussian normal distribution with a median first reactivation at + d and peak titers at + d. all except patient reactivated before d, % before + d. overall survival (os) of the cmv reactivation group as a whole did not significantly differ from the non-reactivation group ( vs. months). however, in subgroup analyses os was significantly reduced in patients with very early (< + d) compared to later reactivation ( vs. months, p= . ). moreover and importantly, os was significantly reduced in patients with cmv reactivation at high titers of > , copies/ml compared to those with lower titers (( vs. months) p< . ).cox regression analyses confirmed significantly reduced os for patients with cmv reactivation > , copies/ml and < day + as compared to the other cohorts (hr . , %ci . - . , p< . and hr . , % ci . - . , p= . ) respectively). the nrm was consistently higher (hr . ; %ci, . - . , p< . ) for patients with cmv copies > , /ml. the risk of hematologic relapse was exclusively reduced in patients with a peak cmv viremia between , and , copies/ml (hr . , % ci . - . ; p= . ) as compared to patients without cmv reactivation. for other levels of cmv reactivation this effect was not observed. conclusions: our data showed that cmv reactivations before + d or with high titers of > , copies/ml associated with significantly reduced os, while cmv reactivations at intermediate titers between , and , copies/ml had a positive impact on relapse incidence. these findings underline the complexity of cmv reactivations after hct outcome, and support longitudinal evaluation of cmv titers and individualized quantitative kinetics models for risk assessment after hct to distinguish the advantageous from the detrimental aspects of cmv reactivation. disclosure: att has received lecture fees from jazz pharmaceuticals and travel subsidies from neovii biotech outside the submitted work. the other authors declare no competing financial interests within the submitted work. association of serum ferritin levels before start of conditioning with mortality after allosct -a prospective, non-interventional study of the ebmt transplant complication working party background: elevated serum ferritin levels occur due to iron overload or during inflammation and macrophage activation. a correlation of high serum ferritin levels with increased mortality after allosct has been suggested by several retrospective analyses as well as by two smaller prospective studies. methods: this international multicentric study aimed to study the association of ferritin serum levels before start of conditioning with allosct outcome. patients with acute leukemia, lymphoma or mds receiving a matched sibling allosct for the first time were considered for inclusion, regardless of conditioning. data were prospectively collected between / and / . a comparison of outcomes between patients with high and low ferritin level was performed using univariate analysis and multivariate analysis using cause-specific cox model. variables included in the multivariate analyses were age, sex mismatch, diagnosis, disease status, karnofsky score, number of cd cells given, intensity of conditioning, type of gvhd prophylaxis, atg use, time from diagnosis to transplant, year of transplant and cmv status. results: twenty centers from european countries reported data on allosct recipients. patient characteristics are given in table . the ferritin cut off point was determined at μg/l (median of measured ferritin levels). overall survival of allosct recipients with ferritin levels above cut off measured before start of conditioning was significantly shorter ( figure a , univariate hr= . ci= . - . p= . ; multivariate hr= . , ci= . - . , p= . ). progression-free survival was also shorter ( figure b , univariate hr= . ci= . - . p= . ; multivariate hr= . , ci= . - . , p< . ). excess mortality in the high ferritin group was due to both higher relapse incidence (univariate hr= . ci= - . p= . ; multivariate hr= . , ci= . - . , p= . ) and increased non-relapse mortality (univariate hr= . ci= . - . p= . ; multivariate hr= . , ci= . - . , p= . ). non-relapse mortality was driven by significantly higher infection-related mortality in the high ferritin group (univariate hr= . ci= . - . p = . ; multivariate hr = . , ci = . - . p = . ). acute and chronic gvhd incidence or severity were not associated to serum ferritin levels. conclusions: ferritin levels before start of conditioning can serve as routine laboratory biomarker to predict mortality after allosct. disclosure: the authors declare no confict of interest related to this study p prediction of reduced lung function and acute gvhd by surfactant protein d in allogeneic stem cell transplantation transplantation (hsct) and may progress to bronchiolitis obliterans that has a high mortality rate. surfactant protein d (sp-d) is an innate defense molecule involved in immune regulation at the epithelial surfaces, particularly in the lungs, and elevated levels have been associated with exacerbation of chronic obstructive pulmonary disease (copd). the aim of this study was to investigate, whether sp-d plasma levels and variants in the gene encoding sp-d may predict the development of reduced lung function after allogenic hsct. methods: we performed a population-based, singlecenter study of children (aged - years) treated with allogeneic hsct. the study consisted of ) a prospective study of serial plasma sp-d levels and rs genotypes in patients during the first months after hsct, and ) a retrospective study of rs genotypes within the sp-d gene in patients transplanted between - . pulmonary function tests were performed regularly as part of the clinical monitoring. results: at the day of graft infusion (day ) sp-d levels were reduced compared to levels before start of treatment with conditioning chemotherapy, defined as baseline ( ng/ml (quartiles - ) at day vs ng/ml ( - ) at baseline, p< . ). from day + sp-d levels increased and remained increased during the whole study period ( ng/ml ( - ) at baseline vs ng/ml ( - ) at months, p< . ). acute gvhd (agvhd) occurred in patients, of those patients with grade - . high sp-d levels at day + were associated with the development of agvhd ( ng/ml ( - ) vs ng/ml ( - ), p< . ) ( fig. ). the c/c genotype was associated with generally low sp-d levels and low fev /fvc at all time intervals compared to the other genotypes, significantly - months post-hsct (p= . ). there was no overall correlation between sp-d levels and lung function, but stratifying for genotype, high baseline sp-d levels were predictive for reduced fev /fvc at - months in cc and tt homozygous individuals. conclusions: patients with a genotype causing low capacity for sp-d production are at increased risk of developing pulmonary impairment after hsct. in addition, our data lend support to other studies indicating that spd production may increase during inflammatory pulmonary disease, acting as a reactive, protective mechanism. further research is warranted to define the role of sp-d levels and genotypes as a prognostic tool for lung function and agvhd. [[p image] . background: allogeneic hematopoietic cell transplantation (allohct) means a long period of restricted mobility and a range of therapy related side effects on muscle function. in this context patients demonstrated a huge decline of physical capacity and muscle mass in particular, accompanied with a decrease of quality of life (qol). resistance training could maintain muscle mass but is limited by patientsb lood values (platelet-count) and well-being. whole body vibration (wbv) was shown to maintain muscle mass during bed rest and has less impact on blood pressure than conventional resistance exercises. furthermore it was also shown to be feasible in patients during high dose chemotherapy. therefore the aim of our study was to examine the effects of wbv during allohct on patients physical and functional performance as well as qol. methods: patients receiving allohct were randomly allocated to either a wbv exercise group (ig) or an active control group (cg) doing stretching and mobilization. both groups exercised during the whole time of hospitalization for times per week and underwent pre-, post-and followup-assessment. physical capacity was determined by maximum oxygen consumption (vo peak ) and maximum power (p max ) during cardiorespiratory exercise test and by maximum strength of the knee extensors and flexors (ex max , flex max ) during isokinetic strength test. functional performance was assessed by jumping height during counter movement jump (cmj) and time of chair rising test (crt) as well as power output during both tests. qol was assessed by questionnaires of the eortc. results: during allohsct vo peak and p max decreased in both groups but till follow-up an increase is seen in the ig (p= . ; p= . ). at day + /follow-up a vo peak group difference is seen (p= . ). ex max (p= . ) and flex max (p= . ) were only reduced in the cg during hospitalization. jumping height and power output decreased in the cg during hospitalization (p= . , p= . ) and a difference between groups were seen in changes of jumping height from pre-to follow-up-assessment (p= . ): increase in the ig and decrease in the cg. the ig showed a decrease in time from baseline to follow-up (p= . ) in the crt and an increase of power output (p= . ). qol decreased only in the cg during hospitalization (p= . ) while during follow-up qol increased in both groups (ig: p= . ; cg: p= . ). in the cg physical functioning decreased during intervention (p= . ) whereas an increase was seen in the ig from pre-to follow-upassessment (p= . ). body image was significant worse in the cg compared to the ig at hospital discharge (p= . ) as well as at follow-up measurement (p= . ) where it got worse over time (p= . ). conclusions: wbv was shown to maintain maximum strength, jumping performance and qol during allohct. although cardiorespiratory fitness could not be maintained by wbv during hospitalization, it seems in the follow up period till day + that recovery of the cardiorespiratory system is enhanced by wbv carried out during allohst. nevertheless reasons for this changes in recovery have to be analyzed in further studies as well as treatment effects of wbv compared to conventional resistance training. disclosure: supported by a grant of the faculty of medicine and comprehensive cancer center freiburg respiratory virus infection within year after of allo-sct is the significant risk factor of obstructive ventilatory disturbance kosei kageyama , michiho ebihara , mitsuhiro yuasa , daisuke kaji , aya nishida , shinsuke takagi , hisashi yamamoto , go yamamoto , yuki asano-mori , naoyuki uchida , atsushi wake , akiko yoneyama , shigeyoshi makino , shuichi taniguchi toranomon hospital, hematology, tokyo, japan, background: obstructive ventilatory disturbance (ovd) is one of the major life-threading complication at the chronic phase of allogeneic stem cell transplantation (allo-sct). bronchiolitis obliterans has been the most established etiology as a part of chronic graft-versus-host disease and major cause of late non-relapse mortality of allo-sct. but other etiologies impact on respiratory function after allo-sct and risk factor of ovd have not been well understood. methods: to address these issues, we retrospectively reviewed the medical record of consecutive patients who first allo-sct at toranomon hospital between and . to detect ovd, forced expiratory volume in second (fev . ) showed less than % of predicted in spirometry test was defined as positive. in the recipients who showed fev . less than % in pre-transplant test, more than % reduction of fev . was regarded as positive. nasopharyngeal swab of those who had upper respiratory tract symptoms were tested for the presence of respiratory viral antigens (adv, piv, and rsv). patients with ecog performance status of , had active infection at transplant were excluded from this analysis. the cases of early death or relapse before days post-transplant, and the cases of graft failure were also excluded. results: the median age was years (range, - ). underlying diseases were aml in , mds/mpd in , cml in , all in , atl in , hl in , nhl in , and others in . five hundred twenty-nine ( %) were not in remission at the time of transplant. five hundred eightythree patients ( %) were conditioned with myeloablative regimens, whereas patients received reduced-intensity regimens. donor sources consisted of related peripheral blood /bone marrow (bm) (n= ), unrelated bm ( ) forty-six developed ovd on median of ( - ) days post-transplant. cumulative incidence of ovd was . % in total population. in recipients those who could spirometry, overall survival at years was . % in patients who developed ovd and was comparable with those who did not develop it ( . %, p= . ). in univariate analysis, disease status (cr/aa or noncr), recipient age (age< or ≥ ), prior autologous stem cell transplantation (yes or no), intensity of conditioning regimen (mac or ric), tbi dose (< gy or ≥ gy), busulfan dose (< . mg/kg or ≥ . mg/kg), donor source (cord blood or non-cord) had no impact on the incidence of ovd. patients who developed respiratory virus infection showed significantly higher incidence of ovd compared to those who did not developed it ( . % vs . %, p< . ). in multivariate analysis, respiratory virus infection was the only significant risk factor for the development of ovd (hr= . , % ci . - . , p< . ). conclusions: respiratory virus infection within year after allo-sct is the significant risk factor of ovd. disclosure: nothing to declare. background: metabolic syndrome (mets) is related to increased risk of cardiovascular disease and type- diabetes (dm- ) and usually seen in overweight individuals in the general population. we investigated mets and clinical risk factors two decades after hsct. methods: all male survivors treated with myeloablative allo-hsct during childhood (< years) between - in denmark were invited to a follow-up study. mets was defined as the presence of at least three ncep atp iii criteria: fasting plasma triglyceride (tg) ≥ . mmol/l, high density lipoprotein (hdl) < . mmol/l or medical treatment of hyperlipidemia; fasting plasma glucose (fpg) ≥ . mmol/l; abdominal circumference (ac) > cm; bp ≥ mmhg (systolic) / ≥ mmhg (diastolic) or medical treatment for hypertension. patients with overt dm- were included into the mets group. furthermore, patients were examined for chronic graft-versus-host disease (cgvhd) by the nih-criteria at the time of follow-up and high sensitivity c-reactive protein (hscrp) was measured. the prevalence of mets was compared to a nordic reference group (hildrum et al. ) . results: we included out of eligible males (participation rate %) aged - years, median years. median (range) follow-up was ( - ) years. of these males, % had a malignant diagnosis and % were treated with tbi-based conditioning. donors were matched siblings (n= ), matched relatives (n= ) or matched unrelated donors (n= ). mets was more prevalent ( %) in the young adult survivors compared to the prevalence reported for - year-olds in the nordic reference ( %). instead the prevalence was comparable to that reported for the - year-olds ( %). of the components of mets, elevated tg ( %), hypertension ( %), and decreased hdl ( %) were frequent, while fpg was elevated in %. importantly, only % of those with mets had increased ac and mean bmi ( . kg/m ) of the hsct survivors was within normal range in contrast to features of mets observed in the background population. having mets was significantly associated with tbi (rr = . , %ci ( . - . ), p= . ) as was the following single components of mets (mean in tbi group vs. mean in non-tbi group): elevated tg ( . mmol/l vs. . mmol/ l, p= . ), lower hdl ( . mmol/l vs. . mmol/l, p= . ) and higher diastolic bp ( mmhg vs. mmhg, p= . ). mets was only demonstrated in one patient who received non-tbi based conditioning. sixteen of patients had cgvhd of which nine were moderate to severe cases, but cgvhd was not associated with mets. however, low-grade inflammation measured by hscrp was related to increased ac (rho= . , p= . ) and tg (rho= . , p= . ). conclusions: our results indicate that male long-term survivors of allo-hsct during childhood have a high risk of mets at an earlier age than the general population. the presence of mets despite normal bmi in several patients suggests unconventional etiologies like the effect of tbi and low-grade inflammation. disclosure: nothing to declare. results: this survey was completed by transplant directors ( %), transplant consultants ( %), nonconsultant grade physicians ( %), hsct clinical nurses specialists (cns) ( %) and other ( %) from centres in countries. % of the centres are adult-only, % paediatric-only and % treat adult and paediatric patients (mixed centres). % are located higher than degrees latitude (northern countries) and % lower than this latitude (southern countries). at the time of the survey % were members of the european union (eu). measurement of serum vd is routinely performed in % of the centres prior and in % after allogeneic hsct. the main clinical indications are known osteopaenia/osteoporosis ( %), previous fracture ( %), treatment with steroids ( %), premature menopause ( %) and established menopause ( %). monitoring occurs every months ( %), every months ( %), once a year ( %) or at other time-points ( %). in this regard, seasonality is not taken into account in the majority of the centres ( %). local and national/international guidelines (nice) are only followed by % and % of the centres, respectively. the most common cut-off value of serum vd for commencing on replacement is nmol/l ( %). northern countries tend to use values of ≥ nmol/l whereas southern countries ≤ nmol/l. % do not use cut-off values. following hsct, % of centres prescribe vd supplements to maintain calcium metabolism and bone health ( %), enhance immune reconstitution post-hsct ( %), gvhd prevention ( %), enhance immune-suppression to treat gvhd ( %), treat depression/fatigue ( %) and reduce relapse risk %. a "loading" dose is administrated in % ( % adult, % mixed and % paediatric), with a mean duration of weeks . the median daily loading dose is , iu ( - , ). the median "maintenance" daily dose is iu ( - , ). there are not remarkable differences between adult and paediatric centres or northern and southern countries. vd replacement is prescribed by transplant physicians ( %), family physicians ( %), endocrinologists ( %), cns ( %), others ( %) and in % of the centres, patients are advised to buy it over-the-counter. vd is prescribed combined with calcium carbonate in % and alone in % of the centres. it is eventually discontinued by % of the centres when therapeutical levels of vd are reached ( %), dexa scan returns to normal ( %) and symptomatic improvement ( %). conclusions: this survey has demonstrated discrepancies in monitoring and replacement of vd across ebmt allogeneic hsct programmes. although awareness has arisen over the last decade, there is still lack of evidence about the optimal levels of vd required for immunemodulation post-hsct. this survey emphasises the need for specific guidelines to harmonise the current management of vd deficiency in adult and paediatric hsct setting. disclosure background: the use of unmanipulated haploidentical sct (haplo-sct) with post-transplant cyclophosphamide (pt-cy) as gvhd prophylaxis has widely extended. primary and secondary graft failure are relatively uncommon complications. however, poor graft function (pgf) after haplo-sct with pt-cy has not been described thoroughly. the objective of this study is to describe characteristics, treatments and outcomes of patients with pgf after haplo-sct with pt-cy. methods: we retrospectively analyzed haplo-sct with pt-cy consecutively performed between and in our centre. pgf was defined as either occurring after initial engraftment: persistent neutropenia (anc < /ul) with the need of at least doses of g-csf and/or thrombocytopenia (platelets < . /ul) with platelet transfusion dependence, with complete donor chimerism and without concurrent severe gvhd or disease relapse. results: nineteen patients were excluded from the analysis due to early mortality (death before day + ), primary graft failure (absence of neutrophil engraftment by day + , with mixed chimerism) or secondary graft failure (development of severe cytopenias and mixed chimerism after initial achievement of neutrophil engraftment). thirty one patients ( , %) were diagnosed with pgf. main characteristics of these patients are summarized in table . twenty six patients ( %) presented with neutropenia and were treated with g-csf, while patients ( %) only developed severe thrombocytopenia without neutropenia, and were treated only with platelet transfusion. twenty four patients ( , %) had at least cmv reactivation, patients ( %) had or more cmv reactivations and patients ( %) received valganciclovir for cmv reactivation treatment. although most patients achieved adequate peripheral blood counts (pbc) with initial salvage therapy, patients ( %) had persistent cytopenias in spite of g-csf, platelet transfusion, cmv reactivation resolution and myelotoxic drugs withdrawal. four of them were treated with a boost of cd + selected peripheral blood donor cells at a median of days after . median cd + cells infused was , x /kg. these patients achieved adequate pbc after salvage therapy and two developed gvhd. the other patients were treated with increasing doses of thrombopoietin (tpo) receptor agonist (tra) eltrombopag. one patient started treatment days after hsct with mg daily and increased dose to mg daily, with complete recovery of pbc months after initiating tra. the second patient started treatment days after hsct with mg daily and increased dose to mg daily, with complete recovery of pbc months after initiating tra. twenty one patients ( %) with pgf diagnosis had long term survival. conclusions: poor graft function is a frequent complication after haplo-sct with cy-post. cmv reactivation and myelotoxic drugs could be the most relevant factors associated with development of this entity. although most patients recover pbc without specific therapies beyond g-csf and platelets transfusion, there is a small group of patients with persistent cytopenias. boost of cd + selected cells is effective in reverting this condition, with gvhd as main complication of this procedure. use of tra seems to be an interesting option for these patients, although more experience is needed to draw definitive conclusions. disclosure: nothing to declare. were also frequently observed. the high risk patients for anxiety (hads-a score ≥ ) and depression (hads-d score ≥ ) was found in . % and . %, respectively. . % of patients was in high distress status (nccn dt score ≥ ). we found that younger age (< years) was significantly associated with poor quality of life score (fact-bmt) (p= . ) and high risk of fatigue (p= . ), anxiety (hads-a) (p= . ), and depression (hads-d) (p= . ). female sex was significantly related to lower physical well-being score and higher distress score (p= . and p= . , respectively). acute lymphoblast leukemia (all) survivors after allo-hct showed significantly worse quality of life score (fact-bmt) (p= . ) and higher depression score (hads-d) (p= . ) compared to those with other disease. chronic graft versus host disease (gvhd) and continuous immunosuppressant usage also have significant adverse impact on lower fact-bmt score (p= . and p= . , respectively) and higher hads-d score (p= . and p= . , respectively). but there was no significant difference in fact bmt, hads-a, hads-d, nccn dt according to donor type, conditioning intensity, anti-thymocyte globulin use, acute gvhd. smoking and alcohol drinking was continued in . % and . % of allo-hct survivors. . % of survivors did not exercise regularly. regular health screening tests have been done only in patients ( . %). conclusions: allo-hct survivors over years following allo-hct still have many physical and psychological symptoms. younger patients (< years), female, all, chronic gvhd, and sustained use of immunosuppressant were significant risk factors for poor quality of life and anxiety. we need to build more active survivorship care plan after allo-hct especially for those patients. disclosure: all authors have nothing to declare. evaluation of the new ebmt criteria for the diagnosis of vod/sos in consecutive transplant patients using an electronic patient record analysis system asha aggarwal , nicola gray , oliver lomas , katalin balassa , nadjoua maouche , robert danby , , andy peniket , grant vallance background: veno-occlusive disease (vod), or sinusoidal obstruction syndrome (sos), is a recognised complication of haematopoietic stem cell transplantation. hepatic vasculature endothelial cells are damaged by conditioning chemotherapy, leading to venous occlusion and centrilobar necrosis. the ebmt criteria for diagnosis of vod are bilirubin >= with two of painful hepatomegaly, > % weight gain and ascites. vod is often under-diagnosed, and as a result, treatment may be delayed. integrated electronic patient record (epr) systems are now widely used, and provide an opportunity to retrospectively audit practice to identify patients in whom vod may have been un-diagnosed or in whom treatment was delayed. in addition these systems have potential for alerting clinicians to the potential diagnosis of vod. methods: we have developed software to analyse the data downloaded from epr to identify patients in whom vod was a possible diagnosis according to the new ebmt criteria. in order to identify patients who may have had vod we first screened for patients with a bilirubin of >= mmol/l (which is an absolute requirement for the clinical diagnosis of vod) within the first days of transplantation. epr data was then used to assess whether patients had > % weight gain. radiology reports were reviewed for patients who had bilirubin >= mmol/l to ascertain if they revealed ascites or painful hepatomegaly. results: patients underwent transplant procedures (january st to july st ). of all transplant patients ( . %) were found to have a bilirubin of >= mmol/l. of ( . %) autograft patients and of ( . %) allograft patients had an elevated bilirubin at this level. these patients were assessed for evidence of % weight gain. this was the case in patients overall- % of autograft patients, . % of allograft patients. seven patients ( autograft and allograft) had radiological evidence of ascites. two patients had a recording of painful hepatomegaly (both post allograft). overall our analysis identified patients ( . % overall) fulfilling the ebmt diagnostic criteria for classic early vod all of whom received defibrotide. all patients had received allogeneic transplants. we failed to identify any cases of late onset vod or any undiagnosed patients over this period. conclusions: this analysis enabled us to efficiently perform a complete audit of our practice to identify patients with vod. we would recommend using electronic patient records to retrospectively audit practice in this way. the tool that we have created for this analysis will be made freely available for public use and the details will be presented at the ebmt meeting. we now plan to extend the function of our epr system to provide alerts to clinicians when vod is a possible diagnosis and may lead to more rapid treatment of these patients. our data suggests that elevation of bilirubin and weight gain of > % will be the most frequently occurring criteria on which to base these alerts. disclosure: g.vallance has performed consultancy work for jazz pharmaceuticals. endothelial activation and stress index in predicting outcome of allogeneic stem cell transplantation-a retrospective cohort analysis zinaida peric , tomislav taborsak , nadira durakovic , lana desnica , alen ostojic , ranka serventi-seiwerth , radovan vrhovac university hospital centre zagreb, zagreb, croatia background: endothelial dysfunction is a common pathophysiology of major complications after allo-sct, such as graft-versus-host disease, veno-occlusive disease, thrombotic microangiopathy and sepsis. endothelial activation and stress index (easix) is a simple score comprised of standard laboratory parameters (creatinine, ldh and thrombocytes) developed as a potential tool to predict allo-sct mortality by luft and colleagues. a recent validation of easix included three retrospective cohorts and showed that easix taken before start of conditioning can be used as an independent predictor of survival after allo-sct. methods: the aim of our study was to retrospectively evaluate pre-transplant easix in our cohort of consecutive patients who underwent allo-sct in the university hospital centre zagreb between and . with the use of a cut-off used in the validation cohorts, we compared two groups of patients for overall survival (os) and transplantrelated mortality (trm). group comparisons were done using the log-rank test or gray test for competing risks outcomes. a multivariate analysis evaluated the association of os with relevant variables by using a cox's proportionalhazard regression model. results: our study group included patients and comprised males ( %) and females ( %, with a median age of years (range, to years) at the time of transplantation. the most frequent malignancies in our population were acute leukemia ( patients, %) and myelodysplastic/myeloproliferative neoplasm ( patients; %). the donor was an identical sibling for patients ( %), matched unrelated donor for patients ( %) and haploidentical for patients ( %). patients ( %) received a myeloablative conditioning regimen while patients ( %) received a reduced-intensity conditioning regimen. with a median follow-up of months (range, - ) for the whole study group, the os at months was %, ( %ci - ) in the group of patients with low easix score and % ( % ci - ) in the group of patients with high easix score (p= . ). this difference was mainly attributed to higher trm in the group with high easix score ( %, %ci - at months) compared to the group with low easix score ( %, %ci - at months) (p= . ). in the multivariate analysis which included easix, patients' age, intensity of conditioning, diagnosis (lymphoid vs myeloid), status of the disease at transplant and type of the donor, worse os was independently associated only with older age of patients (hr . ; % ci, . - . , p= . ) and high easix score (hr . ; % ci, . - . , p= . ). conclusions: our retrospective data support previous data and suggest that easix could potentially serve as a valid tool for prediction of allo-sct outcomes. as a simple biomarker panel, easix could easily be implemented in clinical decision making in the field of allo-sct. these retrospective data need validation in a prospective study which is currently being conducted. clinical background: veno-occlusive disease (vod) is a potentially devastating complication that can occur after hematopoietic stem cell transplant (hsct) and in severe cases can lead to multi-organ failure. (mohty ) defibrotide has been proven to be effective to prevent and treat vod, and it is critical that clinicians are aware of how to diagnose and treat this serious complication of hsct. this study was conducted to determine if an online, simulation-based continuing medical education (cme) intervention could improve performance of hematologists/oncologists (hem/ onc) and advanced practice providers (nurse practitioners and physician assistants, apps) in the diagnosis and treatment of patients with vod. ( methods: a cme certified virtual patient simulation (vps) was made available via a website dedicated to continuous professional development. the vps consisted of cases presented in a platform that allows clinicians to assess the patients and make diagnostic and therapeutic decisions supported by an extensive database of diagnostic and treatment possibilities, matching the scope and depth of actual practice. clinical decisions were analyzed using a sophisticated decision engine, and tailored clinical guidance (cg) employing up-to-date evidence-based and faculty recommendations was provided after each decision. one case was about vod and the other case was about acute myeloid leukemia (aml). decisions were collected post-cg and compared with each user's baseline (pre-cg) decisions using a -tailed paired t-test to determine p-values (p < . indicates significance). data were collected between / / and / / . results: at the time of assessment, hem/oncs and apps had fulfilled the participation criteria for completing the vod case simulation. conclusions: this study demonstrates that vps that immersed and engaged clinicians in an authentic and practical learning experience improved evidence-based clinical decisions related to the management of vod. this vps increased the percentage of clinicians who utilized standardized criteria to diagnose vod and who ordered defibrotide and iv fluids for vod management. however, further education is needed to increase the competence and performance of clinicians, particularly apps, in these areas in order to positively impact patients. disclosure: nothing to declare. a nationwide retrospective study of hematopoietic stem cell transplantation in solid organ transplant recipients: on behalf of jshct, transplant complications working group background: the outcome of hematopoietic stem cell transplantation (hsct) in solid organ transplant remain unclear. to address this issue, we conducted a retrospective survey of the japan society for hematopoietic stem cell transplantation centers. methods: to address this issue, we conducted a nationwide retrospective survey of the japan society for hematopoietic stem cell transplantation (jshct) centers. a first questionnaire was emailed to jshct centers requesting information on cases of hsct in sot recipient. patients' data about sot were collected by sending a second questionnaire to the centers with the patient. based on these reports, patients' data about hsct was identified in the japan transplant outcomes registry database by the transplant registry unified management program (trump), confirmed in . results: of the jshct centers, responded to the survey ( . %). of the responding centers reported a total of patients who had undergone sot from living donor, and subsequent hsct. they consist of three autologous hsct (auto-hsct) and allogeneic hsct (allo-hsct). in auto-hsct, all patients had received liver transplant for hapatoblastoma. they achieved neutrophil engraftment at days after hsct, and two of three patients were alive at one year after hsct. in allo-hsct (n= ), seven patients had received liver transplants, and nine patients had received kidney transplants. five patients received hsct from unrelated donor, and patients received hsct from related donor; two donors were identical in sot. their stem cell sources were seven peripheral blood stem cell, six bone marrow, and three cord blood. all but one patients achieved neutrophil engraftment at days after hsct. five-year overall survival ( yos) was . %. while yos in patients with bone marrow failure (n= ) was %, that in patients with malignant disease (n= ) was . %; all but one patients with malignant disease received allo-hsct in non-remission. seven of nine kidney-transplant recipients experienced dialysis, and three patients experienced renal rejection after hsct. on the contrary, no liver-transplant recipient experienced hepatic rejection. conclusions: in sot recipients, the outcome of allo-hsct for malignant disease was poor, partly due to disease status before allo-hsct. severe renal complications were common in kidney-transplant recipients, suggesting renal care with caution during and after allo-hsct. disclosure: this work was supported in part by the practical research project for allergic diseases and immunology (research technology of medical transplantation) from japan agency for medical research and development, amed. high incidence but low mortality of ebv related ptld after t-cell replete allo-peripheral blood hct with aggressive monitoring and without pre-emptive rituximab background: the aim of the study is to report the incidence and outcome of post-transplant lymphoproliferative disorder (ptld) in the setting of allogeneic peripheral blood hematopoietic stem cell transplantation (allo-hsct) combining post-transplant cyclophosphamide (ptcy) and anti-thymocyte globulin (atg) as graft versus host disease (gvhd) prophylaxis. methods: between october and may , adult patients diagnosed with hematological malignancies underwent a first t-cell replete allo-hsct in our center. all patients received a reduced intensity conditioning regimen with fludarabine, busulfan, and cgy of total body irradiation, combined with rabbit-atg, ptcy and cyclosporine (csa). ebv titres were monitored weekly by quantitative pcr in plasma samples. the cut-off value for test positivity was > copies of ebv dna/ml of plasma. last follow up was november . median follow up for patients known to be alive was months (range - ). results: patient information is summarized in table . ebv reactivation was documented in ( %) patients. median time to ebv reactivation and the diagnosis of presumed/proven (p/p)-ptld were ( - ) days and ( - ) days [ ( - ) months], respectively. median time between first ebv reactivation to p/p-ptld was ( - ) days. seventeen ( %) of the patients developed p/p-ptld. median age was years . two ( %) received mrd, ( %) / mud, ( %) / mud, and ( %) haploidentical donor grafts. twelve ( %) were on therapeutic cyclosporine at diagnosis. pre-emptive therapy was not given to any case and only probable or proven ptld were given rituximab. treatment was based on reduction of the immunosuppression in patients and with the addition of weekly rituximab mg/ m in cases. fifteen ( %) achieved complete clinical responses with pcr negativity. two ( %) patients died secondary to ptld. conclusions: atg based conditioning is associated with increased viral reactivations. frequent ebv monitoring and pre-emptive treatment may lead to rapid disease control. further research is required to optimize monitoring and management strategies in allo-hsct recipients. disclosure: nothing to declare p acoustically enriched extracellular vesicles as potential markers for allogeneic hematopoietic stem cell transplantation complications hooi-ching lim , robert palmason , stig lenhoff , thomas laurell , stefan scheding , background: extracellular vesicles (evs) contain a number of condition-specific proteins, dna and rna types and might therefore be used for the early detection of posttransplant complications. however, traditional ev isolation (ultracentrifugation) is time consuming and requires large sample volumes thus making it difficult to perform longitudinal studies on larger patient cohorts. we therefore investigated whether recently-developed acoustic trapping could be applied to isolate evs from patient plasma for biomarker development. methods: plasma samples were collected from consecutive patients before and up to months after allogeneic hematopoietic stem cell transplantation. patients (age: - years) with high-risk or refractory/relapsed diseases were transplanted with mobilized pbsc from related (n= ) and unrelated donors (n= ) after standard conditioning. gvhd prophylaxis was cyclosporine and methotrexate. plasma samples were frozen and thawed for ev enrichment using a novel acoustofluidic-based technology (acoustic trapping). acoustic trapping uses ultrasound as a local λ/ acoustic standing wave produced by a piezoelectric transducer over a capillary. first, μm polystyrene beads are captured which serve as seeding particles. after washing, target particles (evs) are then captured ("trapped") in the acoustic field. a semi-automatic trapping device (acoutrap) was used to isolate evs from diluted plasma ( : in pbs). the number of evs and size distribution were analyzed by nanoparticle tracking analysis. mirna analysis was performed by qpcr.evs were enriched in duplicate from μl and μl of diluted plasma for nanoparticle tracking analysis and qpcr analysis, respectively. results: evs were successfully isolated from all plasma samples. a total of plasma samples were processed. numbers of trapped evs ranged from . x - . x before conditioning to . x - . x per μl diluted plasma after transplantation. the maximum change in ev numbers in individual patients compared to pretransplantation values ranged from -fold to -fold. most patients showed slight increases in ev size after transplantation. eight of the patients showed signs of infection and received i.v. antibiotics. increased levels of evs (> -fold) were recorded in three patients during these episodes. furthermore, increased ev numbers were observed in a patient who required i.v. antiviral therapy for cmv reactivation. acute grade i gvhd was observed in five patients of which two had increased ev numbers (> -fold). one patient developed grade iv gvhd which was accompanied by a -fold increase in ev numbers. interestingly, progressively increasing ev numbers preceded the detection of early relapse in a pre-b all patient by three weeks. rna isolation from trapped evs yielded sufficient material for mirna profiling. here, first mirna profiling data demonstrated that mirnas were detected in ev samples (mir- a, - a, - c, - and - a) , and that acoustically enriched evs were not affected by hemolysis in contrast to the corresponding whole plasma samples (dcq of mir- a and mir- a). conclusions: acoustic trapping allows for efficient and rapid enrichment of evs from small volume plasma samples. trapped ev samples contain sufficient amounts of mirna for downstream analysis and are thus promising candidates for biomarker development in transplantation. disclosure: laurell and scheding are founders and board members of acousort ab, a lund-based biotech sme that develops particle and cell sorting methods based on ultrasound. the incidence, risk factors and outcomes of primary poor graft function after allogeneic hematopoietic stem cell transplantation fei gao , , jimin shi , , yi luo , , yamin tan , , xiaoyu lai , , jian yu , , he huang , , yanmin zhao , background: allogeneic hematopoietic stem cell transplantation (allo-hsct) is a curative therapy for both hematologic malignancy and many other blood disease. while, primary poor graft function (pgf) is still a severe complication following hsct which lead to poor prognosis. up to now, the incidence and risk factors of pgf have not been totally revealed. methods: from january to december , a total of patients who received allo-hsct in our center were analyzed retrospectively. there were males ( . %) and females ( . %) with a median age of . years ( - years) . pgf was defined as persistent neutropenia (≤ . × /l), thrombocytopenia (platelets≤ × /l), and/ or hemoglobin≤ g/l after engraftment with hypocellular bone marrow and full donor chimerism, without concurrent graft-versus-host disease or disease relapse. incidence was calculated from all patients. of the total patients, nineteen ( . %) developed primary pgf. a : ratio of nested case control study using the good graft function (ggf) subjects transplanted in the same year with the same sex and age of ± years was carried out. results: data was analyzed by univariate and multivariate logistic regression, and univariate analysis identified disease species, the time from diagnosis to transplantation, disease states, myelofibrosis, splenomegaly, serum ferritin (sf) level, cmv infection, mononuclear and cd + cells in graft as potential risk factors (p < . ) for pgf. multivariate analysis identified elements as the independent risk factors (p < . ), including cd + cells < × / background: transplant survivors affected by cgvhd usually take one or more immunosuppressants, as well as prophylactic antimicrobials; use of multiple medication classes concurrently poses a risk for drug-drug interactions or amplified side-effects. the use of medications other than cgvhd-direct immunosuppressive therapies has not been well-characterized. this study aims to evaluate patterns of opioid analgesic use in a cohort of patients severely affected by cgvhd. methods: patients (n= ) with cgvhd were consecutively enrolled in a cross-sectional natural history study (nct ) from / - / at the nih. participants underwent a comprehensive evaluation including a detailed history and physical examination (including current medications), multidisciplinary evaluations, and laboratory and diagnostic testing. for this analysis, respondents were classified as receiving or not receiving an opioid analgesic. following the initial screening by univariate methods (n= ), multivariable logistic regression analysis (mlr) was used to identify a set of factors which could jointly impact opioid use. for mlr data were divided into a training (n= patients) and a validation set (n= ). results: study participants´median age was . years ( - ), % were female, % had severe cgvhd per nih scoring criteria, and % were currently receiving high or moderate levels of systemic immunosuppression. approximately one third ( %) were taking opioid analgesics (oa). based on the univariate screening results (p< = . ), a set of parameters was evaluated by univariate logistic regression in the -patient training set, and the following parameters retained their significance and were included in the mlr model: nih average score per organ, total lss, patient impression of severity, nih cgvhd severity, presence of skin erythema, karnofsky performance score (kps,) clinician's therapeutic intent, nih joint score, and with the presence of several cgvhd symptoms including rashes, mouth sores, avoidance of food, vomiting, weight loss, joint and muscle aches, joint limitation, energy loss, need for naps, fevers, anxiety. multivariable logistic regression identified kps < % as predictive of oa use, or . , % ci . - . . in the training set . % of pts using opioids were correctly identified, . % of those not taking opioids were identified, an overall fraction of correctly identified pts was . % ( % ci . - . %), while in the testing set, . % of those using opioids were correctly identified, and . % of those not taking opioids were correctly identified, with overall . % ( % ci: . - . %) classification accuracy. conclusions: this study showed the burden of oa in this cgvhd cohort. lower kps was significantly associated with oa use, as well as self-reported symptoms and a more severe cgvhd disease, which could be of interest in the development of non-pharmaceutical interventions in this patient population. additional, prospective studies are needed to explore the indications for and effectiveness of oa in this population of survivors. disclosure: no conflict of interest to declare. rcts that tested an internet-based program and patientcentered survivorship care plans for hct survivors. patient and caregiver input is essential to inform the design and features for the mobile app platform so that it is usable and engaging for those it targets. methods: using a qualitative research design, we conducted telephone focus groups of adult patients and caregivers in the united states. adult (age > years at the time of study entry) hct recipients had to be at least oneyear post-hct to participate. participants had to be able to communicate in english, and could have received a hct for any diagnosis, and from any donor source or stem cell type. those who had multiple transplants were included. participants were asked to review printed and online visual presentations of the mobile app before the focus groups so they were prepared to discuss their responses to the materials during the call. focus groups were conducted to saturation, when no new qualitative content was offered. results: three focus groups were conducted with total participants ( patients, two caregivers/patient advocates). all patients received an allogeneic hct; average time since hct was years (range: - years).the majority of participants were female ( . %). participants had differing perspectives on the usefulness of the app to track follow-up appointments, lab values, and other health care plans. there was high interest in having the app tailored to meet specific needs of patients, including tracking information over time (e.g. test results, medications), and having health information available specific to their needs. to minimize duplication of information and data entry, participants recommended syncing the app with their calendars and online patient portals they already use. reasons provided for not using the app included perception that the materials repeated information already received, side effects such as graft-versus-host disease that restricted vision or motor skills, and lack of comfort with apps for some older participants. conclusions: many health technology and mobile apps are being created to improve patients' health and survivorship care. in this study, hct survivors and caregivers identified a variety of features that they would want in an app or website, in particular, features tailored to individual needs. health technologies provide an opportunity to improve survivorship care, but patients and caregivers should be engaged in the process of developing these tools to assure the technology fits their needs and will be used. given the effort required to maintain these technologies, they require testing for health benefits in rigorous clinical trials. clinical background: thanks to allogeneic stem cell transplantation (allo-hsct) patients suffering from hematologic malignancies have seen an increase in there life duration expectancy, but they are many side effets including decreasing in physical performance and in quality of life. the intensity of physical performance decrease is variable between patients, and today we did not know why. the aim of our study was first to characterize the physical performance of subjects less than year following allo-hsct by the use of a cardiopulmonary exercise testing (cpet), and then to determine the predictive factors of exercise performance. methods: we did a retrospective analysis from patients who had an allo-hsct at hematology department of toulouse-oncopole and cpet from / to / . the cpet was performed using a cycle ergometer with o and co analyzer breath by breath, (masterscreen cpx carefusion, san diego, usa), a continuous -lead electrocardiogram, and a blood pressure monitoring. the protocol included a -min rest period, a -min warm-up of w pedaling followed by a w/min incremental phase, up to exhaustion, then a -min active recovery of w pedaling, then a -min passive recovery. three exercise markers were analysed: the peak of oxygen uptake (peak vo ), the ve/vco slope and the first ventilatory threshold (vt ). data relative to conditioning regimen, short-term complications, impairment at cpet day, and physical activity since allo-hsct were gathered. results: after allo-hsct, nearly over patients reported fatigue, a half reported dyspnea, and over or more reported pain, muscular, neurological or psychological impairment. more than % of patients suffer from moderate or severe physical intolerance, particularly when myeloablative conditioning regimen was used. only % of patients followed rehabilitation sessions supervised by a physiotherapist, and non-supervised physical activity has been performed by % of patients. despite normal lung function tests and echocardiography findings in most patients, % had exercise intolerance (ei), % exercise deconditioning, and % had abnormal ventilatory efficiency. patients with moderate and severe impaired exercise capacity were significantly younger at diagnosis and at allo-hsct, such as patients with severe deconditioning conclusions: based on a retrospective study, we reported for the first time complete results from cpet and detailed clinical evaluation concerning deficiency and disability following first year after allo-hsct. these results confirm that exercise impairment is very frequent with more than a half of patients suffering from alterations of one or more of the three performance markers, despite being active. disclosure: nothing to declare demyelinating disorders: a paradigm of immunity disorders after hematopoietic stem cell transplantation background: neurologic complications are a major problem in patients who undergone hematopoietic stem cell transplantation (hsct). given the higher survival of transplanted patients, the burden of neurological complications is increasing in the last years. a significant reduction in overall survival was demonstrated in patients who developed neurological complication after hsct, irrespectively of the hematopoietic stem cell (hsc) source. neurologic disorders in transplanting setting comprise a wide variety of ethiologies including demyelinating disease, which are caused by immune and non-immune mechanisms. here, we analyzed the clinical presentation and the underlie ethiologies of patients developing hsct-related demyelinating disorders in order to give diagnostic and prognostic clues useful to manage these severe but treatable complications in the transplant setting. methods: a total of patients of our department which developed neurological complications after hsct were consecutively collected and ( %) of them, namely those having a diagnosis of a demyelinating disorder, were grouped and described according to the ethiologies of their neurological disorder. results: in / ( %) patients, an immune-mediated process was found, while / ( %) were diagnosed as having an infective etiology and / ( %) were supposed to have a demyelinating disorder caused by toxic exposition. a definitive etiologic diagnosis was not formulated in the remaining / ( %) patients. when patients who developed an immune-mediated demyelinating disorder ( / ) were compared to those in which a clear immune pathogenic mechanism was not detected ( / ), a higher incidence of acute graft-versus-host disease (agvhd) was detected in the former than in the latter ( % vs %). moreover, comparison of these two groups revealed that those with no evidence of immune-mediated process have a slight higher prevalence of t-cell depleted hsct thanthose with an immune-mediated demyelinating disorder ( % vs %). finally, a lymphoproliferative disorder pre-existing the hsct was detected in / ( %) patients with immune-mediated demyelinating disorder but only in / ( %) of those without evidence of immune-mediated processes. conclusions: demyelinating disorders may be responsible of near % of neurologic complications in the posttransplant setting and, among them, an immune-mediated process is likely to be involved in more than % of cases. our results suggest that the immune mechanism that underliesthe agvhd may also be involved in developing demyelinating disease in transplanted patients. it also may be possible that the lymphoproliferative disorder preexisting the hsct is a risk factor able to increase the risk to develop an immune-mediated demyelinating disorder in the post-transplanting setting. using a t-cell depleted hsct can increase the risk of immune-mediated disorders in at least a small fraction of transplanted patients. despite our results should be validated on a larger cohort of patients, we can speculate on the possible connections between the wide range of complex and still poorly defined immunity disorders which can influence the prognosis and course of transplanted patients. disclosure background: injury to the mucosal barrier and subsequent development of oral mucositis (om) is among the most common toxicities of allogeneic stem cell transplantation (sct). despite the high prevalence of om and its debilitating nature, prospective studies evaluating determinants of om are scarce. we therefore prospectively evaluated the occurrence of om following sct. risk factors for om and its implications short and long-term outcomes were assessed. methods: om was prospectively evaluated on a weekly basis in patients undergoing allogeneic hsct. the grade of om was determined based on the national cancer institute common toxicity criteria for adverse events (ctcae) scale (v. . ). severe om was defined as grade ii to iv. conditioning regimens were evaluated individually and according to intensity; myeloablative (mac), reduced intensity (ric) or reduced toxicity (rtc). the latter category included only patients receiving fludarabine and treosulfan at dose of - g/m (flu/treo). risk factors for the development of severe om were initially identified by a univariate analysis and then analyzed in a multivariate logistic regression model. association of om with peritransplant infectious complications, iv morphine consumption, hospitalization length, neutrophil engraftment, acute and chronic graft-versus-host disease (gvhd), non-relapse mortality (nrm) and overall survival were assessed in a univariate analysis. competing events were considered in analyzing engraftment, gvhd, and nrm. results: patients who underwent an allogeneic sct between and were included. median follow-up was days. leading indications for transplantation were acute myeloid leukemia ( %), lymphoma ( %), and myelodysplastic syndrome ( %). the majority of patients received an allograft from a matched sibling or unrelated donor ( %) and methotrexate gvhd prophylaxis ( %). the median time to om onset was (interquartile range [iqr] - ) days. prevalence of grade ii-iv om was %. the median duration om was [ - ] days, and iv morphine was administrated for a median of [ - ] days for patients with grades iii-iv om ( %). in a univariate analysis a younger age (p= . ), lower bmi (p= . ), recent smoking history (p= . ), recent antibiotics exposure (p= . ), mac (p< . ), and use of methotrexate (p= . ) were associated with an increased risk for grade ii-iv om. in a multivariable model the risk for grade ii-iv om was lower with rtc (i.e., flu/treo) vs. mac (odds ratio [or] . ; p< . ) and rtc vs ric (or . ; p= . ), mycophenolate mofetil vs. methotrexate (or . ; p= . ) and recent smoking (or . ; p= . ). compared to lower grades, grade ii-iv om was associated with a longer hospitalization duration (median days vs. days; p= . ), delayed neutrophil engraftment (median vs. days; p=- . ), and more gastrointestinal related infections ( % vs. %; p= . ). grade ii-iv om was not associated with increased risk of bloodstream infections, acute or chronic gvhd, non-relapse mortality, and increased mortality. conclusions: oral mucositis is prevalent among allogeneic-sct recipients. importantly, fludarabine-treosulfan, which is considered a myeloablative is associated with a markedly reduced risk for om. consequences of om include prolongation of hospitalization, delay in neutrophil engraftment, and a tendency for gastrointestinal infections, but does not increase the risk for gvhd and mortality. disclosure: nothing to declare background: the advent of recent diagnostic techniques for the assessment of iron overload (t *-mri) and their systematic use as screening tools in the setting of secondary hemochromatosis have led to an increased awareness that focal nodular hyperplasia (fnh) represents a possible incidental finding after hematopoietic stem cell transplantation (hsct). methods: clinical and radiological features of patients undergoing hsct in a single pediatric institution have been retrospectively reviewed for fnh. in order to provide an estimate of the prevalence of fnh after hsct, we analysed all the t *-mri scans performed during the last years in our centre and recorded the number of patients with fnh (group a). in addition, data about patients incidentally diagnosed with fnh at abdominal imaging performed for different clinical indications have been collected (group b). results: eight out of ( %) transplanted patients who underwent at least one t *-mri scan from september to september were incidentally diagnosed with fnh. group b included subjects with fnh incidentally found at ultrasound or non-t * mri scans performed before . overall, transplanted patients ( males, %), transplanted for al ( cases) or bone marrow failure ( cases) at a median age of . ± . years, were diagnosed with fnh between . and . years after hsct, namely . ± . years in group a and . ± . years in group b. a variable degree of iron overload was demonstrated in all patient (lic: - ± microg/g; baseline serum ferritin: - ng/ml). the potential risk factors for fnh are reported in table . in / patients, the radiological finding was pathognomonic; in / the diagnosis of fnh was confirmed histologically, while / subjects were labelled as "fnhlike", although a potential diagnosis of hepatic adenoma could not be ruled out. in / patients, fnh presented with an isolated lesion, while / had to more than hepatic nodules at diagnosis. the size of nodules at diagnosis ranged from to mm. in unenhanced mri scans, lesions were predominantly hyperintense on both t -and t weighted sequences. in dynamic studies with contrast medium, all lesions strongly enhanced during the arterial phase, with a variable degree of wash-out in the late venous scans. hepatic function tests were normal in all the enrolled patients at diagnosis of fnh. among the / patients for whom at least a follow-up scan was available, presented a complete regression, a reduction and an increase in the size and/or number of lesions, while in patients the nodules remained substantially unchanged after a mean radiological follow-up of . ± . years. no malignant transformations were observed. conclusions: fnh represents a relatively frequent incidental finding after hsct. although a malignant transformation is rare, given the demonstrated variable evolution of the hepatic nodules, a radiological follow-up is highly recommended. disclosure: nothing to disclose. incidence and risk factors for hepatic sinusoidal obstruction syndrome after allogeneic transplantation: retrospective multicenter study of turkish hematology research and education group (threg), updated data methods: ten centers from turkey were enrolled in the study. we retrospectively evaluated the medical records of patients who were treated with allo-sct between january and december . a baltimore criterion was used for assessment of hsos. four hundred twenty six ( . %) of patients who were treated with prophylaxis with defibrotide alone or one or more of the n-acetylcysteine, diuretics and heparin used defibrotide ( - mg/kg/day). results: the study included patients ( males/ females) with median age of ( - ) years. the demographic and clinical characteristics of patients were summarized in table seventy-three ( . %) of patients with hsos were treated with defibrotide after diagnosis. the median time of starting defibrotide in these patients was . ( - ) days. thirty-seven ( %) of patients with hsos recovered completely and forty-nine ( %) of them died as a result of multi organ failure. the incidence of hsos-related mortality in allo-hsct cohort was found to be . %. in univariate analysis, statistically significant associations were not found between hsos incidence and age/sex of recipient, type of conditioning regimen, stem cell source and type of gvhd prophylaxis. on the other hand donor type, engraftment status and prophylaxis for hsos were significantly associated with hsos development. hsos prophylaxis was significantly decreased hsos-associated mortality (p= . ). conclusions: hsos still remains a serious lifethreatening complication of allo-sct. although the incidence is low, hsos is associated with increased -day non-relapse mortality. hsos prophylaxis especially with defibrotide, seems to reduce hsos associated mortality in high risk patients. disclosure: nothing to declare prophylaxis with defibrotide in adults at very high risk of veno-occlusive disease: results in patients background: hepatic sinusoidal obstruction syndrome/ veno-occlusive disease (sos/vod) is a life threatening complication that can occur after hematopoietic stem cell transplantation (hsct). severe sos/vod rapidly evolves in multiple organ dysfunction syndrome (mods), associated with a mortality rate exceding %. precocity of defibrotide (df) treatment is the leading factor for efficacy. prophylactic use of df is recommended in children, but its value has not been validated in the adult population, although factors for individual risk assessment for vod are debated. we here present a real-world experience of df prophylaxis in adult patients at very high risk of sos/vod receiving allogeneic hsct. methods: from to we treated with prophylactic defibrotide and ursodeoxycholic acid (udca) patients, median age years (range - ). nine patients received allogeneic hsct for acute lymphoblastic leukemia ( b-all and t-all), one patient for severe aplastic anemia, one patient for primary myelofibrosis. they were all at high risk for sos/vod because of previous hepatotoxicity ( patients), previous hsct ( patients), double alkylating agent ( patients) or previous treatment with inotuzomab ozogamicin (io; patients). of the patients treated with io, received cycles of io, and received cycle, with the last io dose administered a median . days before hsct (range - d). defibrotide was administered in daily doses for a total dose of mg/ kg per day and udca at the dose of mg twice per day, starting from day - prior transplant. all patients received treosulfan-fludarabine based conditioning. in patients thiotepa was added to the conditioning and in patients a low dose gy tbi. gvhd prophylaxis included posttransplant cyclophosphamide, rapamycin and mycophenolate in all patients, except one patient with aplastic anemia receiving atg, rapamycin and mycophenolate. donor source was pbsc in all cases. seven patients received family haploidentical (mmrd) transplant, patient a mrd transplant and patients a mud transplant. results: the median duration of defibrotide therapy was days (range - days). documented non-severe gastrointestinal bleeding occurred in patients requiring defibrotide temporarily discontinuation, no other significant bleedings were experienced. four patients developed grade ii-iv acute gvhd and no transplant-associated thrombotic microangiopathy were diagnosed. overall, sos/vod occurred in / cases within days after hsct (days , and ) and no late-onset sos/vod were diagnosed. sos/vod was very severe, causing mods and death in all cases. all patients were characterized by a common pattern of very high risk factors for sos/vod by prior hsct and salvage treatment for b-all with cycles of io close to hsct. furthermore, they all received a fully myeloablative conditioning regimen with treosulfan and thiotepa and a mmrd transplant. conclusions: defibrotide prophylaxis was safe and well tolerated with no severe related complications. sos/vod occurred despite continuous df prophylaxis in / patients treated with inotuzomab ozogamicin close before undergoing nd transplant. to reduce the incidence of severe vod, pre allo-hsct treatment with inotuzomab ozogamicin should prompt avoidance of other cumulative risk factors for vod, such as use of double alkylating agents. disclosure background: busulfan is the backbone of many preparative regimens administered to children undergoing allogeneic and autologous hematopoietic stem cell transplantation (hsct). among its many long-term adverse effects, busulfan can cause various degrees of pulmonary injury. although well described in adults, there are few large series exploring pulmonary toxicity of busulfan in children. we describe long-term pulmonary follow-up in a large group of children treated at a single center who had received high-dose busulfan and examine the relationship of systemic drug exposure and lung function over time. methods: all surviving children who had received highdose busulfan between - in the context of hsct at the schneider children´s medical center, were referred for serial pulmonary function monitoring (including spirometry, plethysmography and diffusing capacity for carbon monoxide [dlco] . pre-transplant testing was available for children who were old enough to perform the procedure. spirometry results were adjusted according to the revised global lung initiative formulas for age, gender, and height. pulmonary injury was defined as a z score below - . for spirometry, or < % of predicted for the other parameters. busulfan levels were monitored following the second drug dose. all patients received busulfan in four daily doses. area under the curve (auc) calculations were performed by bayesian calculations. results: between - , patients aged - years were diagnosed with malignant or non-malignant diseases and treated with high-dose busulfan. of shortterm survivors, had at least one post-transplant pulmonary function evaluation. the mean age at treatment with busulfan was . years (range, . - years). of these children, children had undergone autologous transplantation and children had an allogeneic transplant. of these patients eventually relapsed and died. children had one or more pulmonary risk factors before hsct -chest or upper abdomen radiation ( ), chest wall tumors or lung metastasis ( ), chest surgery ( ), prior administration of pulmonary-toxic drug ( ) or asthma ( ). during follow-up (up to years, median . years), fev and fvc spirometry tests both decreased significantly (p= . and . , respectively), while the decrease in dlco was not statistically significant. % of patients had abnormal pulmonary function tests and seven children had symptomatic disease which in two may have been manifestations of gvhd. interestingly, no correlation was found between busulfan auc, busulfan peak levels, the number of busulfan doses administered, the type of transplantation (autologous vs. allogeneic) or primary disease to pulmonary injury. even after censoring of children with pre-transplant pulmonary risk factors we noted a decrease of fev and fvc. conclusions: as in adults, pulmonary injury is observed in children treated with high-dose busulfan prior to hsct. no correlation was observed between busulfan auc and pulmonary injury. follow-up of children who receive this drug should include regular pulmonary monitoring, referral to a pulmonologist when subclinical pulmonary compromise is found, and counseling regarding measures that might prevent or ameliorate pulmonary damage. continued follow-up of this cohort of patients should inform our pretransplant patient information sessions, and the future use of busulfan in children. disclosure: nothing to declare background: transplant-associated thrombotic microangiopathy (ta-tma) is a specific complication of allogeneic hematopoietic stem cell transplantation (hsct). post-hsct tma has been attributed to the vascular endothelial damage caused by high-dose chemotherapy, calcineurin inhibitors (cnis), graft-versus-host disease (gvhd), infections. there is a little evidence published regarding the efficacy and factors influencing the outcome of withdrawal of cnis. methods: the analysis comprised a total of patients, with diagnosed hematologic malignancy (aml ( ), all ( ), mds ( ), hodgkin lymphoma ( ), cml ( ) and neuroblastoma ( ) received allo-sct, from a matched related, unrelated or haploidentical donor between and . patients were diagnosed with ta-tma based on cho criteria. the median age of patients was ( adults, children). gvhd prophylaxis was performed with tacrolimus (tac) in , cyclosporine a(csa) in , combination tacrolimus+sirolimus (sir) in . patients received atg and ptcy. withdrawal of cnis was accompanied by administration of systemic steroids ( patients) or substitution with sir after reaching levels of csa< ng/ml or tac < ng/ml in . the target concentration of sir was - ng/ml. in pediatric patients who received combination tac+sir, the tac was discontinued in one step while sir continued. median time to development tma was , days after allo-sct (range - ). median follow-up of surviving patients was days. the primary outcome was overall survival (os) up to years after development of ta-tma. results: the following significant predictors of -year os were identified: tac replacement with sir (p< , ), ptcy in prophylaxis (p< , ), acute gvhd (agvhd) grade - (p= , ), previous sepsis (p= , ), level of ldh in debut (p= , ), combination sir+tac in prophylaxis (p= , ), major ab -mismatch (p= , ), severity of cns symptoms (p< , ). there was no significant difference in os according to patients' age, sex, "salvage" disease status at transplantation, previous vod, viral (hhv , , , cmv, ebv) reactivations, count of cd + cells transfused, ldh level, shizocytes and creatinine in the debut of ta-tma. in the multivariate analysis replacement of cnis with sir (hr . , %ci . - . , p= . ) and baseline ldh level (hr . , %hr . - . , p= . ) were associated with survival differences. the cut off for ldh was xunl. agvhd grade - (hr . , p= , ) and use of ptcy (hr . , p= . ) were not significant in the multivariate analysis (figure ). ta-tma cases after ptcy were significantly less frequently associated with clinically significant agvhd ( % vs %, p< , ). the survival was higher after ptcy ( % vs %), but not significant due to sample size and other ta-tma factors. leading causes of death were: gvhd progression ( %), bacterial infection ( %), tma ( %) and other ( %) . conclusions: replacing tac by sir is an effective therapeutic strategy in a group of patients with debut of ta-tma at least after ptcy, where it is less likely to be associated with agvhd. there is a significant overlap of populations with ptcy prophylaxis and substitution with sir, thus the study is not powered to provide guidance for patients on conventional prophylaxis with ta-tma. [[p image] . disclosure: none of the authors has anything to disclose. donor-recipient ab mismatch effect on the allogeneic hematopoietic stem cell transplantation outcome: a single-center retrospective study background: because transmission of major histocompatibility complex and blood group system genes is independent from each other, approximately - % of all allogeneic hematopoietic stem cell transplantations (allo-hsct) are realized crosswise the ab -blood group boundary. however, due to the widespread expression of ab antigens on a variety of human tissues other than erythrocytes, ab incompatibility may have an impact on the outcome of allogeneic hsct that goes beyond the wellknown immune-hematological complications such as immediate hemolysis due to the presence of isoagglutinins and delayed hemolysis due to passenger b lymphocytes. here we aimed to assess the donor-recipient ab mismatch effect on the allo-hsct outcome, comprising non-relapse mortality (nrm), overall and relapse-free survival, posttransplant prc transfusion requirement, as well as relapse rate, incidence of graft-failure and acute gvhd. methods: clinical and laboratory data from consecutive patients undergoing allogeneic hsct between / and / at the fondazione irccs ca' granda maggiore policlinico hospital in milan, italy, were retrospectively collected. kaplan meier estimates were used for the analysis of survival outcomes while nrm, relapse and acute gvhd cumulative incidences were investigated by competing risk analysis. results: the patient series included ab -match, major ab -mismatch, minor ab -mismatched and bidirectionally ab -mismatch transplants. indication for allo-hsct were mainly aml/mds ( pts), all ( pts) and t-nhl/ctcl ( pts). mean overall survival for groups of patients undergoing ab -identical, major ab mismatch and minor ab mismatch hsct were months ( % ci [ ; ]), months ( % ci [ ; ) and months ( % ci [ ; ]), respectively. nrm in the three groups were significantly different, with point estimates of %, % and % at years, respectively, whereas no significant differences were observed for relapse rate and graft failure incidence. although not statistically different, incidence of acute grade iii-iv gvhd was twice as high in patients transplanted from minor ab mismatched donors than in the ab identical group ( % vs %). following transplantation, prc transfusion requirement was significantly higher in the major ab mismatch then in the ab -match transplanted patients (median vs , p= . ), with a marginal positive correlation between the anti-donor a/b igg titers measured prior hsct and the total number of prc transfused during the first year following transplantation. we observed only one case of prca occurring in a year-old + woman who was transplanted from a -yearold male a+ hla-identical sibling using peripheral blood as the stem cell source following a myeloablative conditioning for aml in first complete remission. anti-a igg isoagglutinin titers prior to transplantation were : . during the first year post transplantation, the patient required a total of prc transfusions, with gradual resolution occurring only after introduction of danazole treatment. conclusions: in our patient cohort, both major and minor ab mismatch associated to a significantly higher nrm. major ab mismatch associated to a higher prc transfusion requirement. a more frequently occurring severe acute gvhd was also suggested in minor ab -mismatch transplants. altogether, our results suggest that allo-hsct outcome may be significantly affected by ab blood group mismatch. disclosure: nothing to declare background: at-tma is a severe endothelial injury complication and it may involve the intestinal vasculature. intestinal tma could be fatal and missdiagnosed. clinical and pathological criteria to differentiate from intestinal gvhd are needed. the aim of this study was to analyze the incidence and histological characteristics of intestinal tma in patients diagnosed of systemic tma. methods: we analyzed the incidence of tma in patients who underwent allo-hsct in our institution between january -august . tma diagnosis was based on ho criteria. we do a pathological review in biopsies from out of patients in whom an endoscopy have been performed days before and days after the diagnosis of tma for suspicious of gvhd. review was performed by a pathologist expert in gvhd, who examined the biopsies in search of hystopathological features of gvhd, tma or viral infection. diagnosis of gastrointestinal gvhd was stablished according to mcdonald and sales criteria, while intestinal tma diagnosis was stablished by warren et al criteria. results: out of patients ( , %) were diagnosed of tma. transplant characteristics and tma data of patients with systemic tma are shown in image. out of patients with tma ( %) had been diagnosed with prior/ simultaneous acute gvhd, of them grade iii-iv, and % with gastrointestinal gvhd. intestinal tma have been reported only in out of patients ( %) at diagnosis, whereas when review based on warren criteria was performed, in patients ( %) the pathologist found at least of the criteria of endothelial damage and % of the patients or more warren criteria were founded. the most frequent features were endothelial cell swelling (n= , %) and perivascular mucosal hemorrhage (n= , %). review hystological features of biopsies are shown in table of the image. regarding gvhd, it was found in patients ( %) at diagnosis and in ( %) at pathological review. with a median follow-up of months ( - ) patients of the with systemic tma ( %) are dead. of the deaths ( %) were related to tma ( tma, tma +gvhd, and tma+infection). patients with or more warren criteria in pathological review had poor outcome compared with patients less than criteria ( % alive vs % at months, p= . ). conclusions: intestinal tma is a life-threatening underdiagnosed entity. only patients of patients were diagnosed of intestinal tma. we found that most of our patients had endothelial damage in the gastrointestinal biopsy pathological reviews. gvhd histological criteria were present in most of the patients, mainly histological grade i-ii. prognosis of these patients is poor and pathologist effords in diagnosed the entity is guarranted. disclosure: nothing to disclosure p strategies to reduce neutropenic fever and hospital readmission in multiple myeloma patients managed at home after autologous stem cell transplantation background: neutropenic fever (nf) is the most frequent cause of readmission in the outpatient autologous stem cell transplantation (asct) programs. in our at home model for multiple myeloma patients, we added primary prophylaxis with ceftriaxone, decreasing the incidence of fever during aplasia phase from % to . %. the aim of this study was to analyze the addition of two strategies to reduce the non-infectious nf: withdrawal of g-csf and the addition of primary prophylaxis for engraftment syndrome with corticosteroids after asct. methods: between january and august myeloma patients were managed at-home since day + of asct. all were conditioned with mel . all patients received prophylaxis with quinolone, fluconazole, aerolized pentamidine, low-dose acyclovir (hvs+), and ceftriaxone (since day + ). the patients were classified into groups: group a (n= ; g-csf since day + without corticosteroid), group b (n= ; no g-csf and no corticosteroid), group c (n= ; no g-csf with prednisone . mg/kg/day since day + until granulocyte recovery). first-line therapy at home of nf was piperacillin-tazobactam . g/ h i.v. using a portable intermittent infusion pump. fever was an indication of immediate medical consultation and those patients presenting signs of focal infection or severe sepsis were admitted. other indications for readmission were: willingness of the patient or caregiver, uncontrolled nausea, vomiting or diarrhoea, and mucositis requiring total parenteral nutrition or i.v. morphics. results: the main characteristics of the patients and outcomes are shown in table . there were no differences between groups regarding age, gender, immunological subtype, response before asct, hct-ci, and cd cell dose infused. there were more patients with advanced disease (iss iii) in group c compared to group a ( . % vs. . %; p= . ). the duration of neutropenia was longer in those groups that did not receive g-csf (a: days, b: days, c: days; p< . ). comparing group a with group c, we observed that the incidence of nf and the readmissions rates were lower in group c (nf: . % vs. . %; p= . ; relative risk reduction: . , and number needed to treat . ; readmissions: . % vs. . %; p= . , respectively). the -day cumulative incidence of nf were . % in group a, . % in group b, and . % in group c; p= . . the non-administration of g-csf with the addition of prophylactic corticosteroid did not modify the incidence and grade of mucositis, the first day and duration of fever, nor the number of bacterial infections documented. in the multivariate analysis, this combination (no g-csf with corticosteroid) maintained its protective effect for the development of nf and hospital readmission (or . ; p= . and or . ; p= . , respectively). conclusions: the non-use of g-csf and the addition of prophylactic corticosteroid in mm patients managed at home after asct minimize the incidence of non-infectious fever and optimize hospital resources by reducing hospital readmissions. disclosure: nothing to declare. background: antibody titers to vaccine-preventable diseases decline during the - years after allogeneic hematopoietic stem cell transplantation (hsct) if the recipient is not revaccinated. it is therefore considered best practice to try to offer hsct recipients the same level of protection against all vaccine preventable diseases as the general population. few data in the literature are available concerning vaccine-related problems in hsct recipients. we performed a farmacovigilance evaluation in a cohort of allotransplanted patients followed in our clinic during a year period. methods: from october to november we administered a list of recommended vaccines to hsct recipients attending our routine out patient clinic who fulfilled the following criteria: cd t cells> /μl, cd b cells> /μl, anti-cd antibody infusion> months, ivig therapy> months, no active and severe graft-versus-host-disease (gvhd), no chemotherapy or biological therapeutic agents on going. vaccines suggested were influenza, pneumococcal conjugate (pcv ), polio (inactivated polio vaccine), diphteria, tetanus, acellular pertussis, hepatitis b, hepatitis a, haemophilus influenzae type b, meningococcal quadrivalent (mcv ), human papillomavirus, meningococcal b, measles-mumps-rubella (mmr), varicella. live vaccines (mmr and varicella) were not recommended before years after hsct and in patients with chronic gvhd. all the patients were asked to take the list to the local health facilities in order to have the vaccines injected and a vaccination table arranged with the doses already received and those to receive. we checked the vaccination tables at each visit and monitored potential side effects and gvhd status at , , and months after the first vaccine injection. results: twenty-nine out of patients were evaluable (table ), without gvhd and with chronic gvhd ( mild, moderate, severe). median time after hsct was months ( - ). median number of vaccines received was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . as regards patients without chronic gvhd, out of experienced fever after vaccine injections; out of developed transient mild reduction of platelet count; patient reported headache and otalgia after vaccine injection, while another one transient joint pain; out of patients presented signs of mouth chronic gvhd (score nih) and transaminase increase (grade according to world health organization toxicity scale) months after the first vaccine dose, so that cyclosporine dose had to be augmented. as regards patients with chronic gvhd, out of experienced fever after vaccine injections; patients with mild chronic gvhd of the mouth presented hepatic flare two and three months after the first vaccine dose, respectively. in both cases a new increase of cyclosporin and methylprednisolone doses determined progressive normalization of liver enzymes. conclusions: these data show that vaccines were globally well tolerated in hsct recipients, even when they suffered from chronic gvhd. however, close monitoring is warranted in order to better evaluate possible vaccine side effects in this setting of patients. background: allogeneic hsct improves survival for aml patients over the age of years of age when compared to chemotherapy alone. the haematopoietic stem cell transplantation comorbidity index (hct-ci) and ebmt score predict for non-relapse mortality and overall survival, yet little is known about whether qol is preserved in this patient group and whether hct-ci and other performance scores pre-bmt correlate with qol post allo-hsct. methods: we conducted a retrospective analysis of patients years and older who underwent ric allo-hsct at the university hospital of wales, cardiff between september and december (n= ). hct-ci, karnofsky performance score (kps) and ebmt scores were calculated prior to transplant and qol measured using the fact bmt (version ) questionnaire, which was completed at , and months post transplant. patients were grouped at the -, -and -month time points for each of the different performance indices, allowing group comparison against compound sub scores using the mann-whitney u test. results: patients were included in this study, with median age years (range - ). patient characteristics, including conditioning, donor type, pre-transplant hct-ci and kps scores are summarised in table . the year and year overall survival (os) for the patient cohort was . % and . % respectively. hct-ci of ≥ vs was significantly associated with poorer bmt-related qol domains at months (p= . ) and general qol domains at months (p= . ) post-transplant. while ebmt score showed no correlation with qol parameters, patients with kps of vs ≤ showed significant differences in both general (p= . ) and bmt-related qol (p= . ) at months and in all qol domains at months (symptomrelated qol p= . , general qol p= . , bmt-related qol p= . ). importantly neither the hct-ci nor the kps pre-transplant predicted for qol at months post transplant. conclusions: patient selection is key to ensuring maximum benefit from allo-hsct both in terms of overall survival but also with regards to qol and survivorship. we note that while patients with hct-ci ³ or kps ≤ had significantly poorer qol at months post allo-hsct, qol was recovered by months post transplant, with this significant difference no longer seen. our data shows that in selected aml patients over the age of years with good performance status and low comorbidity index, a favourable outcome can be achieved with good qol maintained throughout the post transplant period. background: advances in allosct technology, supportive care, and use of reduced intensity conditioning regimens for older patients have led to significant improvements in longterm survival after transplant. the survivors have an elevated probability of late morbidity and mortality, including abnormalities in phosphocalcic metabolism and bone disease. rapid and progressive bone loss occurs within the first - months after transplant, and this is followed by a slow process of recovery, with bone loss persisting for to months. bone fractures can worsen the quality of life of allosct survivors, but the real burden of the disease is unknown. the objective of the study is to ascertain the prevalence of bone pathology and vertebral fractures early after transplant in our center. methods: this is a retrospective and observational study. forty-nine patients ( male/ female, median age y, range - ) that underwent allosct were included in the study in the period of to months after transplant (may -december ). pre-and post-transplant risk factors associated with bone disease were recorded: age > years, female sex, menopause, hormone replacement therapy, previous treatment with steroids, previous fractures, weight < kg, bmi < - , low physical activity, low calcium intake, smoking, alcohol intake, and history of femoral fractures in parents. in all patients laboratory data (including serum calcium, -hydroxyvitamin d, and pth), lumbar and femoral bmd (dxa), and spinal x-ray were also evaluated. a vertebral fracture was defined as a reduction of > % in the anterior, middle or posterior high of the vertebral body. results: we identified vertebral fractures in ( %) patients. five patients had fractures prior to transplantation, and patients presented "de novo" vertebral fractures following transplantation; therefore, the prevalence of "de novo" postransplant fractures was / ( %). most ( %) of these fractures were asymptomatic at the time of diagnosis. most patients ( %) with vertebral fractures had > pre-sct risk factors (median risk factors pre-sct , range - ), the most frequent being low calcium intake, steroid exposure, presence of previous fractures, and menopause. those patients with fractures and less than risk factors pre-tph, added new risk factors after transplant, mainly steroid treatment. forty-four patients ( %) had vitamin d insufficiency (< ng/ml), ( %) had osteopenia and ( %) had osteoporosis. vitamin d insufficiency and bone disease were more frequent in women than in men ( % vs. % for vitamin d, % vs. % for osteopenia, % vs. % for osteoporosis, and % vs. % for vertebral fractures, respectively). conclusions: the prevalence of post-transplant bone disease and vertebral fractures in our series is high. most fractures appearing "de novo" after allosct were asymptomatic and were diagnosed by x-ray. patients who presented vertebral fractures frequently had more than risk factors identified pre-sct. patients undergoing allosct should have their bone health assessed early in their treatment and, if indicated, should start preventative therapy to avoid bone loss and fractures. other measures such as physical exercise, vitamin d and calcium supplementation, and dxa and spinal x-ray at baseline and following transplantation are also highly recommended. disclosure: maría suárez-lledó received a grant from dkms-spain foundation. other authors have nothing to declare the use of g-csf in selected patients after autologous stem cell transplantation is associated with low incidence of engraftment syndrome background: the use of g-csf after autologous stem cell transplantation (asct) accelerates neutrophil recovery, however it has been related to an increased risk of engraftment syndrome (es) development in some studies. for this reason, we do not routinely prescribe g-csf after asct and we only use it in patients with significant complications (enterocolitis, severe sepsis, atrial fibrillation) after stem cell infusion. the main objective of this study is to evaluate the incidence of es in patients who receive asct for monoclonal gammopathies (mg), non-hodgkin lymphoma (nhl) and hodgkin lymphoma (hl) and receive g-csf only if needed. as secondary objectives we evaluate differences in the engraftment day as well as the length of inpatient stay. methods: we retrospectively analyzed patients with mg or lymphoma, who underwent asct conditioned with high dose melphalan ( - mg/m ) or beam, respectively, between and in our center. specific clinical features for es according to spitzer and maiolino criteria were evaluated between days before and days after the engraftment. statistical analysis was performed with spss v. . . results: thirty-one patients with mg and patients with lymphoma were analyzed. median age at transplant was . years ( . - . ) and patients ( . %) were male. median prior lines of treatment in patients with gm or lymphoma were ( - ) and ( - ), respectively. table shows patients´characteristics. mobilization with g-csf ± plerixafor was performed in patients ( %) and chemotherapy + g-csf ± plerixafor in patients ( %). median cd x /kg cells infused was . ( . - . ). eleven patients ( . %) received g-csf, due to infection ( enterocolitis, listeriosis, acute hepatitis, septic shock) and because of atrial fibrillation or fibrilloflutter. median time from sct to first day of g-csf was days ( - ) and median time on g-csf treatment was days ( - ). patients who received g-csf showed a short time to neutrophil engraftment (≥ . x /l), days vs. days, p< . but longer duration of hospitalization, days vs. days, p = . . non-relapse mortality at day + , + and + was %. es was diagnosed in ( . %) patients, amyloidosis, multiple myeloma and plasmablastic lymphoma. there was not statistical difference in the incidence of es between patients who received g-csf ( . %) and patients who did not ( . %), p= . . analyzed by disease, es appeared in of patients who received g-csf in the lymphoma group ( . %) but none of the patients with mg that received g-csf developed it. we did not find statistical differences between patients who developed es and those who did not in age ( years vs. years, p= . ), length of hospitalization ( days vs. days, p= . ) and the number of cd x /kg cells infused ( . vs. . , p= . ) . conclusions: the use of g-csf in selected patients is associated with low incidence of es. our study confirms that the use of g-csf accelerates neutrophil recovery but it is unclear if it can increase the incidence of es, especially in patients with lymphoma. [[p image] . background: graft failure is one of the top- problems of allo-hsct (after gvhd and relapse). the problem of graft failure becomes more significant due to increasing number of allo-hsct with ric conditioning regimen from haploidentical and hla-mismatched unrelated donors. role of t cells in graft failure is well known. here we report an impact of t-memory cell subsets count before antithymocyte globulin (atg) administration on primary graft failure after allo-hsct. methods: sixteen patients with acute leukemia transplanted in national research center for hematology were included on this prospective study. all patients received horse atg at dose mg/kg/day from day - to - before allo-hsct as gvhd prophylaxis and were balanced by other factors that could affect engraftment. detailed patients characteristics are listed in table . peripheral blood samples were collected on day - before allo-hsct (before atg injection) in edta-tubes. flow cytometry analysis was performed on bd facs canto ii (becton dickinson, usa) to define t-memory subsets: t-naive and t-stem cell memory (tnv+scm) -cd r -ccr +cd +; t-central memory (tcm) -cd r +ccr +cd +; t-transitional memory (ttm) -cd r +ccr -cd +; t-effector memory (tem) -cd r +ccr -cd -; t-terminal effector (tte) -cd r -ccr -cd -, among cd + and cd + t-cells . sysmex xe- was used to calculate absolute count of different t-cell subsets. mann-whitney u test was used for nonparametric data analysis between two groups. fisher's exact test was used for x tables. p-value less than . was considered statistically significant. results: an influence of t-memory cell subsets count before atg administration on primary graft failure is shown in figure . according to our data high absolute number of cd +ttm and cd +tte is associated with primary graft failure. conclusions: based on these findings high absolute number of cd +ttm and cd +tte could be one of the prognostic factors of primary graft failure after allo-hsct. optimizing atg dose due to recipient absolute t-memory cell subsets count before atg administering may prevent graft failure and improve posttransplant results. background: upper gastrointestinal graft-versus-host disease (gi gvhd) has been an increasingly recognised entity following allogeneic stem cell transplantation (sct). budesonide, widely used in inflammatory bowel conditions, has also been found beneficial in gi gvhd. the major benefit of budesonide is attributable to its poor absorption and extensive first-pass metabolism via cytochrome p (cyp) a , which translates to less systemic steroid-related effects. however, transplant patients are often exposed to multiple drugs, among which some agents act as cyp a inhibitors and therefore can increase budesonide bioavailability and might lead to systemic toxicity. azole antifungal drugs are probably the most common concomitantly used cyp a inhibitors in transplant recipients. methods: we reviewed allogeneic sct records for patients treated with oral budesonide for gi gvhd at our transplant centre between and retrospectively. the aim of the work was to assess the development of adrenal suppression with or without clinical features of iatrogenic cushing`s syndrome. the standard dose of budesonide was mg three times a day. patients receiving prednisolone or other glucocorticosteroids and those with no available serum cortisol level measurements were excluded. results: our analyses identified four allogeneic sct patients in whom adrenal suppression was diagnosed with undetectable serum cortisol levels during oral budesonide treatment. of these patients two developed iatrogenic cushing`s syndrome and both patients were treated with cyp a inhibitors concomitantly: . clarithromycin and fluconazole; . clarithomycin and voriconazole. the development was rapid (within and weeks). symptoms included morphological features such as moon face, high blood pressure, weight gain, peripheral oedema and proximal myopathy. symptoms resolved gradually following cessation of azole antifungal agents and on gradual weaning of budesonide. conclusions: although single agent budesonide treatment given for gi gvhd is rarely associated with systemic side effects, patients on azole antifungal drugs and macrolide antibiotics are at higher risk of systemic toxicity due to drug interactions. patients who are allergic to penicillin and receive macrolide-based prophylaxis can be especially vulnerable. to our knowledge the number of cases reported in literature about systemic effects of oral budesonide in transplant recipients is less than . our observation supports previous reports on the potential of oral budesonide to induce systemic effects. we therefore advise careful monitoring of patients treated with budesonide in combination with cyp a inhibitors, including antimicrobial agents routinely used in sct. disclosure: none implemented strategies to overcome barriers in the establishment of a consolidated hematopoietic stem cell transplantation program in a developing country background: the national institute of medical sciences and nutrition "salvador zubiran" is a national health institute located in mexico city. although mexico is considered an upper-middle income country, more than % of the population lives in poverty without health care coverage and patients within this social stratum are referred to our institution. the first hematopoietic stem cell transplantation (hsct) in mexico was performed at our institution in . from this year until , hsct were sporadically performed (n= ), showing a poor overall survival (os) and high non-relapse mortality (nrm). these outcomes resulted from an unstructured hsct program, limitedresources, patient low socioeconomic status, and paucity of population-adapted procedures. in , according to these results, a decision to establish a hsct program was made. therefore, in order to set up a successful hsct program, implementation of financial and medical strategies were necessary. the objectives of this study were to describe the barriers and implemented strategies for the establishment of a hsct program in mexico along with the outcomes of patients undergoing this procedure throughout the reorganization of the program. methods: this study is a health services research. barriers were detected based on the results of the hsct program from - (not shown). table shows the financial, medical, and research strategies that were implemented for each barrier. results: from november to november , hsct have been performed in patients at our institution. most hsct were autologous (n= , %). forty one patients underwent hsct. from the patients, most were males (n= , %) and the median age was . years (range, - ). the most frequent underlying diseases for auto-hsct were lymphomas (n= , %), non-seminomatous germ cell tumors (n= , %), and multiple myeloma (n= , %). acute leukemias (n= , %), aplastic anemia (n= , %), and myelodysplastic syndromes (n= , %) were the most frequent diagnosis for patients undergoing allo-hsct; and acute leukemia was the most frequent diagnosis for patients undergoing haploidentical hsct (n= , %). acute and chronic gvhd were present in % (grades i-ii %) and % (limited %), respectively. for allo-hsct, , day, and -year nrm was . %, %, and %, respectively; and -day nrm in auto-hsct was . %; year os was % and % for auto and allo-hsct, respectively. conclusions: future perspectives of the hsct program include the acquisition of funds for unrelated donors; to improve outcomes of patients undergoing haploidentical hsct, and to increase the number of in-patient rooms. we conclude that despite paucity of resources and other limitations, the implementation of financial, medical, and research strategies have shown that barriers can be effectively overcome in a developing country in order to establish a consolidated and nationally renowned hsct program, providing good outcomes for patients. disclosure: none of the authors have any conflict of interest to disclose. the effect of protective buffering on daily stress and relationship quality in dyads following hematopoietic stem cell transplantation: results from daily process methodology malgorzata sobczyk-kruszelnicka , aleksandra kroemeke , zuzanna kwissa-gajewska , sebastian giebel background: cancer-related support communication (e.g., protective buffering) may impact the risk for psychological and relationship distress in patients following hematopoietic stem cell transplantation (hsct) and their caregivers. previous studies have revealed that protective buffering (i.e., hiding one's concerns and denying one's worries) has mixed effects: is beneficial (for "protected" person), costly (especially for the person using it), or unrelated to dyadic wellbeing. there has been, however, little evidence linking dyadic protective buffering with distress using daily process methodology. we assessed ( ) the relationship between daily protective buffering, and same-and next-day stress and relationship quality in patient-caregiver dyads following hsct and ( ) whether similarity or complementarity in protective buffering between dyads is adaptive. methods: two hundred patients (after first autologous or allogeneic hsct) and their caregivers (spouse or another relative) independently completed measures of daily protective buffering, daily relationship quality, and daily stress for consecutive evenings after patients´hospital discharge. actor-partner-interdependence model (i.e., both partners' and caregivers' reports regarding support communication and distress were studied) was used to test study hypotheses. results: for both patients and caregivers, multilevel structural equation modeling showed a significant positive relationship between daily protective buffering and sameday relationship quality. association of protective buffering with same-day stress level was negative. in next-day analyses, patient-reported protective buffering was related to patient's higher relationship quality, whereas caregiverreported protective buffering increased patient's daily stress. complementarity in protective buffering was related to higher immediate same-day relationship quality for both patients and caregivers, while benefits from similarity have delayed effects, although only in patients. conclusions: contrary to previous studies, protective buffering rather has a beneficial effect in dyads following hsct. protection of the partner and relationship against revealing negative emotions and powerlessness was not related to costs in both parties. the findings suggest that the effect of daily protective buffering in dyads following hsct depends on support timing (same-or next-day effect) and differs for both parties. patients seem to benefit the most from the similarity in protective buffering, while caregivers from complementarity. the "fit" between patient and caregiver in support communication ought to be taken into consideration in the practical approach. disclosure: nothing to declare. virus reactivation and low dose of cd + cell were associatied with secondary poor graft function within the first days after allogeneic stem cell transplantation yuqian sun , xiao-jun huang background: secondary poof graft function (spgf) was defined as the secondary cytopenia after initial engraftment of hsct. it was shown to be associated with poor prognosis, however there are very few reports on the incidence, risk factors and outcomes of spgf. methods: patients who received transplantation from peking university people's hospitial during january, to december, were retrospectively reviewed if they fulfilled the following conditions: ( ) diagnosed with acute leukemia or myelodysplastic syndrome; ( ) received allo-sct from either matched sibling donor (msd) or haploidentical related donor (hid). pgf was defined as persistent neutropenia (≤ . × /l), thrombocytopenia (platelets ≤ × /l), and/or hemoglobin ≤ g/l for at least consecutive days, transfusion-dependence, associated with hypoplastic-aplastic bone marrow (bm), and complete donor chimerism without concurrent graftversus-host disease (gvhd) or disease relapse. primary pgf was defined as the failure to achieve initial engraftment by days after transplantation, while secondary pgf was defined as the fulfillment of the criteria after initial engraftment hsct. results: during january, to december, , patients who received transplantation from peking university people's hospitial were retrospectively reviewed. among the patients who achieved initial engraftment, patients developed spgf. the cumulative incidence of spgf on day was . %. the median time of secondary pgf was . ( - ) days after transplantation. low (< median) cd + cell dose (p= . , hr . ( %ci, . - . )), ebv reactivation (p= . , hr . ( %ci, . - . )) and cmv reactivation (p= . , hr . ( %ci, . - . )) were identified as independent risk factors with spgf. there is no significant difference of pgf incidence in msd group and hid patients (p= . ). the overall survival of patients with spgf at year after transplantation was significantly poor than patients with ggf ( . % versus . %, p< . ). conclusions: in conclusion, spgf develop in . % patients after allo-sct, especially in patients with cmv, ebv reactivation or infused with low dose of cd + cell. the prognosis of spgf is still poor due to lack of standard treatment. disclosure: there is no conflict of interet thiotepa with treosulfan and busulfan based conditioning are significantly more gonadotoxic than treosulfan previous studies suggest that busulfan results in long-term gonadal toxicity. no previous studies have compared gonadal toxicity outcomes after treatment with busulfan with treosulfan, a newer agent with similar marrow toxicity to busulfan but with reduced non-marrow toxcitiy. our aim was to determine whether there are differences in pubertal and fertility outcomes in paediatric patients treated with treosulfan compared with busulfan. methods: inclusion criteria were patients who had received either busulfan or treosulfan or treosulfan with thiotepa, only one hct and were aged years and above in august . eligible patients were reviewed in clinic as part of their routine follow-up, thus research ethical approval was not required. follice stimulating hormone, luteinising hormone, oestradiol, and pubertal history were noted. ovarian reserve was estimated in female patients by measuring serum anti-mullerian hormone (amh). male patients had serum testosterone measured and were also offered semen analysis. results: thirty-five patients met the inclusion criteria, of which twenty-five wanted to be reviewed ( %); seventeen females and eight males. mean age at hct was years, mean age at review was years and mean years since hct was years. female patients treated with busulfan or treosulfan with thiotepa (n= ) had minimal amh and none of these patients were having regular periods. females treated with treosulfan (n= ) had normal amh and regular periods without needing hormone replacement. only four male patients opted for a semen analysis and all had significantly reduced sperm counts. conclusions: our results suggest that females treated with treosulfan have minimal (if any) reduction in ovarian reserve compared to other conditioning regimens which casue significant compromise. although this was a small study, and thus not suitable for statistical analysis, the clinical findings are marked. future studies should further investigate optimal doses of treosulfan that could be used to achieve bone marrow engraftment and limit long-term effects on fertility. disclosure background: autologous and allogenic hematopoietic stem cell transplantation (hsct) are potentially curative treatments for hematological malignancies. patients with related complications may need admission to the intensive care unit (icu) for specific therapy and organ support. mortality risk factors, supportive care and principal causes of admission in icu are described in our cohort of patients (pts). methods: we retrospectively studied pts, male, with a median age of , years (range: - ) who underwent allo-hsct in our center between july and october . two hundred and twenty-seven( , %) pts received autologous hsct (auto-hct) and ( , %) allogenic hsct (allo-hsct); from unrelated donor, from identical sibling, and the remainder, mismatched related donor . twenty-three ( , %) out of pts were admitted in the icu in the transplant procedure admission. results: fifteen ( , %) out of pts were male with a median age of years (range: - ). patients' baseline diseases were: multiple myeloma ( , %), non-hodgkin´s lymphoma ( , %), hodgkin´s lymphoma ( , %), acute lymphoblastic leukemia ( , %), myelodisplasic syndrome ( , %), solid tumor ( , ) and acute myeloblastic leukemia ( , %). fifteen ( , %) pts received auto-hsct, ( , %) allo-hsct from unrelated donor, ( , %) allo-hsct from identical sibling, and the remainder haploidentical hsct ( ) ( , %). so, , % of auto-hsct pts and % of allo-hsct were admitted in the icu. the median stay in the icu was days (range: - ) and reasons for admission were: respiratory insufficiency ( , %), septic shock ( , %), renal insufficiency ( , %) and multi-organic failure ( , %). twenty-one ( . %) pts required respiratory support with: nasal cannula or oxygen mask (c/m) ( %), non-invasive mechanical ventilation (nimv) ( , %) and invasive mechanical ventilation (imv) ( , %). fourteen ( %) pts needed inotropic agents for shock treatment. finally, ( , %) pts required substitutive renal therapy with hemodialysis or haemofiltration (hd/hf). eleven ( , %) out of pts died, ( , %) were male with a median age of years (range: - ). ten of them ( , %) needed imv and were treated with inotropic agents. all patients who required hd/hf (n= ) died. imv and treatment with inotropic agents were associated with icu mortality (or , ; p= , , or ; p= , ; respectively). conclusions: in our series of pts, , % needed admission in the icu, presenting a mortality rate of % approximately. there were no differences in the prevalence of icu admission regarding hsct donor. main reason for admission was respiratory failure with imv requirement in , % of pts. imv and treatment with inotropic agents were associated with icu mortality. an early identification of pts at risk of icu admission could have a beneficial impact on survival improvement disclosure: nothing to declare is there any association between thrombotic risk factors and veno-oclusive disease in childhood allogeneic hematopoietic stem cell transplantation? background: veno-oclusive disease (vod) is a major complication of hematopoietic stem cell transplantation (hsct). in some studies levels of fibrinolytic factors especially plasminogen activator inhibitor- (pai- ) level were found associated with vod. however, little is known about the relationship between thrombophilia risk factors and vod. in this study we aimed to investigate association of major thrombophilic gene mutations on vod in pediatric hsct patients. methods: we reviewed retrospectively patients with vod who underwent hsct between - in ankara pediatrics and pediatric hematology-oncology training and education hospital, bone marrow transplantation unit, turkey. fifty-one patients who did not develop vod and transplanted during the study period were accepted as control group. we evaluated plasma homocysteine and lipoprotein a level, protein s and c activity and antigen levels and factor v g a mutation, prothrombin g a mutation, methylenetetrahydrofolatereductase (mthfr) c t and a c mutations, plasminogen activator inhibitor- - g/ g polymorphism before hsct. we also evaluated the patients' hospital files and noted the demographic values and complications of hsct. statistical investigations were done with spss statistics . for windows and p< . has been accepted as significant. results: there was no difference between control and vod groups as regard to age, sex, diagnosis, donor type, conditioning regimen, hsc source, and hla typing . there was no difference between the groups according to homocysteine, lipoprotein a, protein s and c activity and antigen levels. we did not find any relation between the genetic variations of thrombophilia and vod (table ). in vod group there were patients ( . %) with acute graft versus host disease (agvhd) and in control group there were ( . %) patients with agvhd (p= . ). febrile episodes were more frequent in vod group compared to the controls (respectively; n= , . % vs. n= , . %, p= . ). -year overall survival was % . in vod group and % in control group (p= . ). disease free survival was also different between vod and control groups (respectively; . % vs. . %, p= . ). conclusions: in literature there are recent studies showing higher pai- levels in patients with vod. however, in our study we did not find any relationship between congenital thrombophilia factors and vod. new studies with larger sample groups is necessary to better evaluate the association of congenital thrombophilia factors and vod. disclosure: nothing to declare p different strategies of chemotherapy-induced nausea and vomiting (cinv) prevention in hematological patients receiving an autologous hematopoietic stem cell transplantation: a single center experience ilaria cutini , riccardo boncompagni , chiara nozzoli , antonella gozzini , stefano guidi , chiara innocenti , massimo di gioia , lorenzo tofani , riccardo saccardi background: despite the improvements of pharmacological control, cinv still represents a major problem in patient undergoing hematopoietic stem cell transplantation (hsct). we present here a comparison of two pharmacological strategies for preventing cinv in multiple myeloma (mm), hodgkin (hl), and non-hodgkin lymphoma (nhl) patients who received an autologous hsct in our institution. methods: from january to july , we retrospectively analyzed consecutive patients, median age years ( - yo) , diagnosed with mm, hl, and nhl, who underwent an autologous hsct following a melphalan mg/sqm and beam/feam condition regimens, respectively. the first patients received cinv prophylaxis with palonosetron i.v and dexamethasone mg die (regimen a), whilst the following were administered with fosaprepitant iv, ondansetron iv and dexamethasone mg die (regimen b) both cinv prophylaxis was administered the day of melphalan infusion (day - form transplant). emesis breakthroughs were treated with alizapride and metoclopramide. nausea and vomiting were assessed through the ctcae . score system. categorical variables were compared with pearson chi-square test. results: the overall incidence of nausea was %, ( % grade , % grade , and % grade , respectively). in regimen a was shown to be %, ( % grade , % grade , and % grade , respectively) while in regimen b was % ( % grade , % grade , and % grade , respectively). pearson chi-square test did not show any differences between the groups (p= . ). the overall observed vomit was % ( % grade , % grade , and % grade ). in regimen a it was ( % ( % grade % grade , and % grade ), and % in regimen b ( % grade and % grade ). conditioning regimens didn't' have any significant impact on either nausea or vomit. patientsyounger then median ( yrs), were reported to have higher incidence of both nausea, (p= . ) not related to cinv treatment, and vomit ( % vs %, p= . ). in multivariate analysis the overall incidence of nausea is related to age (younger patients have higher probability to develop nausea (or , ; p= , ) whilst the higher incidence of vomit is related to: regimen a (or . ; p< , ), previously reported nausea (or , ; p< , ), and no smoking habits (or , ; p= , ). conclusions: both regimens are equally effective for nausea control however regimen b evidenced a better vomiting control. this finding is particularly relevant when the center policies include an early discharge program, therefore improving both patient's quality of life and procedure cost-effectiveness. clinical background: patients who underwent an allogeneic hematopoietic cell transplantation (hct) are challenged by medical, psychological and social complications. support groups might help hct-survivors to cope with these challenges. however, the existing literature about post-hct support groups is scarce. moreover, data on professionallyfacilitated support groups do not exist. the aim of this project was ( ) to establish a professionally-facilitated support group and ( ) to assess the discussed topics. methods: from / until / all patients who received an allogeneic hct at the adult stem cell transplantation program of the university clinic mannheim were invited to participate in a professionally-facilitated support group. additionally, spouses and life partners were invited. a theologian who is also a physician served as facilitator. he had no further function within the transplant team. the format of the group was unstructured without any rules regarding regular attendance. the facilitator did not provide topics or a curriculum. during the first year the group met every days followed by a monthly schedule. from the fifth until the th meeting the attendance and the discussed topics were minuted by the facilitator. the content of the minutes was analysed by a combination of an inductive and a deductive approach. all participants provided their informed consent for the study. results: altogether patients (female: n= ; male: n= ) and spouses/life partners (female: n= ; male: n= ) participated. patients ( %) and spouses ( %) attended more than one meeting. among those who participated in ≥ meetings the median time of participation was months. the median count of participations was eight. % of the participants attended the meetings longer than one year, % longer than three years. there was no sex difference with respect to the frequency and the duration of participation. however, the frequency of participation decreased significantly the longer a participant was attending the meetings. during group meetings the facilitator recorded thematically different contributions to the discussions divided in distinct topics. these topics were grouped into main categories [(a) medical topics, (b) private life and environment, (c) human relationships, (d) physical and mental condition and (e) the support group itself] and eight further categories [( ) compliance, ( ) economic issues, ( ) religion, ( ) sexuality, ( ) death and dying, ( ) support and coping, ( ) objectives and needs and ( ) not otherwise specified issues] which could not be grouped in one of the main categories. the most frequent issues were medical topics ( %), human relationships ( %), physical and mental condition ( %), private life and environment ( %), financial issues ( %), the support group itself ( %), support and coping ( %) and objectives and needs ( %). noteworthy, death and dying ( . %) were rare topics and sexuality was never mentioned. conclusions: to our knowledge, this is the first prospective and systematic analysis of a professionallyfacilitated support group for hct-survivors. these data might help to establish support groups and to identify psychosocial needs of patients and targets for specific support. disclosure: nothing to declare background: endothelial damage is associated with inflammatory complications that appear early after hsct, such as sinusoidal obstruction syndrome or acute gvhd. engraftment syndrome (es) is an inflammatory condition diagnosed by maiolino clinical score. potentially, es can exhibit high morbidity and mortality, especially after autologous-hsct in multiple myeloma (mm) patients since the introduction of new drugs such proteasome inhibitors and immunomodulatory drugs (imids). the objective of the present study was to evaluate if es is associated with endothelial dysfunction in patients with mm who underwent auto-hsct. methods: we included six patients with mm who received induction treatment including new drugs and consolidated their response with an autologous-hsct. we analysed comparatively the effect of incubating endothelial cells in vitro with serum samples from patients with es vs. no es. serum samples were collected before (pre), and after , , and days from the transplant. an additional sample was collected at the es onset and at the discharge day (no es group). endothelial cells (hmec) in culture were exposed to media containing % of serum from each patient for h. cell growth was controlled morphologically. expression of the adhesion receptor icam- on the cell surface was analysed by immunofluorescence, and activation of the inflammation related p- mapk signalling pathway was evaluated by sds-page and western blot. results: exposure of hmec monolayers to sera from patients who developed es (onset day, n= ) resulted in an increased icam- expression on the cell surface, higher that the observed with sera from patients who did not develop es (discharge day, n= ) ( . % of labelled area vs. . %, respectively). in addition, in experiments with sera from patients not developing es, icam- expression on cells exposed to sera from day + was reduced with respect to the observed with sera from day + , probably due to the corticosteroid used as a prophylaxis in our centre. this reduction was not observed in es patients. regarding phosphorylation of p- , it was significantly higher in cells exposed to sera from es patients than in response to sera from patients who did not develop es. conclusions: the increase in the expression of the adhesion receptor icam- on the surface and the intracellular activation of p mapk in endothelial cells exposed to sera from patients developing es indicates the existence of endothelial activation in association with es. interestingly, the prophylaxis of es with corticosteroid seems to be less effective in patients who developed es than in patients who did not develop this complication. these results need to be validated in a higher number of patients and modifications in additional markers of endothelial dysfunction should be investigated. disclosure: gonzalo gutiérrez-garcía: honoraria from gilead. grant from jazz pharmaceutical the other authors do not have any disclosure to comment. p association between uric acid levels before and after allogeneic haematopoetic stem cell transplant and transplant outcomes: a single centre experience background: uric acid (ua) is a known endogenous danger signal which activates the nod-like receptor protein (nlrp) inflasome.ua is released from injured cells during conditioning in allogeneic stem cell transplantation (hsct). a pre-clinical study has demonstrated that nlrp inflasome-mediated il- production regulates graft-versushost disease (gvhd). the ua role in inflammation and gvhd is unclear. there are discordant reports in the literature about a potential protective role of ua on gvhd after a hsct. methods: we performed a retrospective study to assess the association between serum ua levels pre-and post- table] . table ] results: the characteristics of the patients are shown in table . median age was years (range - ), and patients ( %) were male. twenty-seven patients ( %) received low doses atg as part of gvhd prophylaxis. allopurinol was from the day before start of conditioning therapy until day . the median levels of ua were , mg/ dl before conditioning, , mg/dl at day , , mg/dl at day + and , mg/dl at day + . there was no impact between the ua levels and os at any time of the hsct. ua levels at day + were associated with a higher ci relapse at years ( % [ % ci, - %] for ua level > , mg/dl, and % [ % ci, %- %] for ua level ≤ , mg/dl [p= , ]). there was a trend for a higher ci of grade ii-iv agvhd for the subgroup of patients not treated with atg with ua < , mg/dl ( % vs %; p= , ) on day - and a higher nrm with ua < , on day ( % vs %; p= , ). conclusions: in our study the ua levels showed no impact on os, and only a tendency for ci of grades ii-iv agvhd grades ii-iv and nrm for the subgroup of patients not treated with atg. surprisingly, high levels of ua at day + of hsct were associated with a significant higher incidence of relapse. disclosure: dkms foundation, pi / (instituto carlos iii) and sgr (grc), generalitat de catalunya. background: veno-occlusive disease (vod) is an early, uncommon but serious complication of stem cell transplantation (sct) that is associated with high morbidity and mortality. defibrotide is the only licensed treatment for vod, and time to start of treatment (tst) affects outcomes. minor differences exist between the seattle, baltimore and classical ebmt ( ) criteria, which may trigger different start points for treatment. late onset vod (> days) is less recognised and we hypothesize, may have worse outcomes with longer time to diagnosis, and more limited treatment options across different healthcare systems. methods: electronic patient records from sept. -oct. at king´s bmt centre and pharmacy databases were reviewed, timepoint to clinical and bio-chemical manifestation of vod, diagnosis, tst, survival and longterm outcomes were analysed. results: of the patients( . %) who underwent an allogeneic sct, developed vod, including paediatric cases. none of the autologous sct patients developed vod. the paediatric and autologous sct patients were not analysed any further. adult patients (male= ; . %) developed vod at a median age of years(range - ), of whom developed < days and patients had late-onset vod as per ebmt criteria(range - days). cases classed as severe and as moderate vod. patients received defibrotide at diagnosis, patients within days, patients between - days, and patients received treatment after days. overall mortality for this cohort was %( / ). / ( . %) of patients with early onset vod and / ( . %) patients with late-onset vod died. of the deaths, died of liver failure and a further patients had vod as a likely contributing factor in their deaths. patient died with subarachnoid haemorrhage and with relapsed disease. patients that received defibrotide after days, / patients( . %) died, as compared to / ( %) for treatments between - days, / ( . %) for treatments within days. the lone surviving patient who received treatment after days has severe chronic liver disease and it's complications. of the patients who fit seattle criteria for early-onset vod, only fit the baltimore or ebmt criteria for classical vod. of these patients met the baltimore criteria later than the seattle criteria were met(range = - days). conclusions: vod carries high morbidity and mortality, and beyond the known risk factors and with the caveat of limited numbers in this study, we strongly suspect this is further increased when time to definitive treatment with defibrotide is delayed, particularly beyond days. nearly a quarter of cases with vod are late-onset as per classical ebmt criteria. however contrary to our hypothesis, their overall outcomes and mortality do not appear worse, with time to treatment again emerging as a strong predictive factor. conditioning treatment related factors, which play a stronger role in endothelial dysfunction in the hepato-portal circulation, may not be as much at play, perhaps for late-onset disease. uniformity in the use of diagnostic criteria, and high degree of vigilance, even beyond days, leading to early treatments may improve outcomes in vod. disclosure: nothing to declare background: hsct-associated thrombotic microangiopathy (ta-tma) affects - % of patients receiving an allogenic sct, with a high mortality up to - % in severe cases. endothelial injury mediated by complement activation has been atribuited a major role in the pathogenesis, and blockade of c with eculizumab offers promising results. methods: we present our experience with pediatric cases of ta-tma treated with eculizumab. the diagnosis of ta-tma was stablished attending to jodele et al criteria. clinical data were collected retrospectively from medical records. results: all cases were diagnosed between august and april , with a median age of years ( . - ) at time of diagnosis. primary disease was acute leukemia in cases ( all and aml), severe aplastic anemia in , and primary immunodeficiency in . they received their first sct in all cases, from mud and from mmrd (cd ra+ depleted haploidentical grafts), with mac regimen in cases, and ric in cases. of them received calcineurin inhibitors (cyclosporine) as gvhd prophylaxis. all patients developed agvhd (grade or higher in cases). and patients presented viral reactivation. hypertension was present in cases at tma diagnosis, requiring or more antihypertensive drugs in of them. all patients had renal injury consisting of less-than-normal glomerular filtration rate (median of ( - )) and proteinuria, with urine protein-to-creatinine ratio higher tan mg/mg in cases (data not available in patients). serum haptoglobin was decreased in just cases at diagnosis, and schistocytes were detected in patients. cutaneos signs were present in all cases, digestive symptoms in , neurological affection in , and notoriously all of them developed polyserositis. c and c were normal in all cases, with sc b higher than ng/ml in patients and lower in (data not available in cases). all patients received defibrotide as treatment, and cases received also rituximab, associated to therapeutical plasma exchange in . all of them received eculizumab, as first line in cases (median of days between diagnosis and eculizumab start). treatment was correctly monitorized with ch levels in cases (not available quick enough in other ). median number of doses needed in induction therapy was , and median interval between doses was days. patients required reduced interval and higher doses to maintain ch supressed. patients did not respond, and died because of tma. patients had hematological response, with chronic renal injury in of them and resolution of acute renal failure in case. nevertheless patient responding to eculizumab died because of tma related complications, and because of an invasive fungal infection. patients are alive, with a median follow up of months from treatment start. conclusions: our experience supports promising results of eculizumab based treatment for ta-tma, highlighting the importance of an early treatment and a careful therapy monitoring by ch supression. prospective studies are needed to achieve a better knowledge of this pathology and its treatment. disclosure: nothing to declare background: approximately - % of allogeneic hematopoietic stem cell transplant (allo-hsct) are made with some sort of abo blood group system incompatibility. an hsct abo donor-recipient incompatibility implies risks of complications during the process of infusion as acute hemolytic anemia (ah), delayed graft and other later complications due to the presence of isohemaglutinins (pure red cell aplasia or passenger lymphocyte syndrome). also, abo incompatibility could impact on graft versus host disease (gvhd) incidence, and could be associated with not relapse mortality (nrm) and overall survival (os). there are not concluded evidence about the abo incompatibility impact, so the aim of this study was to identify complications and response associated with abo incompatibility in patients undergoing allogeneic hematopoietic stem cell transplantation. methods: a retrospective study was performed on patients who receive an allo-hsct between january and august . two groups were performed according to the presences or not of abo incompatibility. demographic and clinical information was collected from physical and electronic medical records, and information was analyzed in spss v results: sixty-eight patients were enrolled in the study, % male, the median age was years ( - ) with the following diagnoses: acute lymphoblastic leukemia %, acute myeloblastic leukemia . %, granulocytic chronic leukemia . %, myelodysplastic syndrome . %, dendritic cell neoplasm . %, aplastic anemia . %. ninety-one percent of the patients received a transplant from an identical hla donor and . % received a haploidentical transplant. fifty-two patients ( %) were abocompatibility (g ) and patients ( %) had aboincompatibility (g ). none patient with aboincompatibility received a haploidentical transplant. the contrast between groups didn't show differences in fever, infections, bacterial isolation, presence and degree of acute or chronic gvhd and relapse of the disease. graft failure was %(g ) vs %(g ) (p= . ), intermediate risk cmv serostatus %(g ) vs (g ) (p= . ). the most relevant characteristics and complications are described in table . contrast analysis between g vs g showed that within the whole group there were deaths ( % vs % respectively) (p= . ), the overall survival -year was % vs % (p= . ) with a median of vs months respectively; mortality associated with relapse was % vs % respectively, and mortality related with transplantation was % vs % respectively. conclusions: abo incompatibility did not show association with complications related with the infusion, but there was a higher tendency of graft failure in the abo incompatibility group. it has no statistical significance, but it is important to expand its study. disclosure: none declared methods: retrospective data for nhl patients who underwent asct between and was analysed. patients were identified using the swbmt database and data on mets was collected using paper and electronic hospital records. forty-eight patients were excluded due to loss of follow-up, inaccessible/incomplete records, or death. cause of death was not determined. the ncep-atpiii definition of mets was used. this requires ≥ of criteria to be met. a bmi of ≥ kg/m and hba c of ≥ mmol/l were used to replace central obesity and impaired fasting glucose, respectively. other criteria include triglycerides (tgs) ≥ . mmol/l or treatment, high density lipoprotein cholesterol (hdl-c) < . mmol/l (male), < . mmol/l (female) or treatment and blood pressure > mmhg systolic or > mmhg diastolic, or treatment. results: the prevalence of mets in the cohort was % (n= ). eighty-two percent of patients (n= ) met one or more criterion for mets. twenty-seven percent (n= ) fulfilled only one criterion, % (n= ) fulfilled two criteria, % (n= ) three criteria, % (n= ) four criteria, and % (n= ) five criteria. the greatest prevalence of mets was in the + age group, accounting for out of ( %) patients with mets. overall prevalence decreased with declining age ( table ). the number of patients aged < years was too small to make any judgement on risk. raised triglycerides was the criterion most frequently met ( / patients), followed by hypertension ( ), raised bmi ( ), low hdl-c ( ) and an increased hba c ( ). conclusions: the prevalence of mets in our cohort ( %) was higher than the estimated worldwide prevalence of %, with the majority in the + age category. this is in keeping with other post-transplant studies, which show an increase in prevalence of mets after transplantation. moreover, the overall prevalence of mets was greater in the older population, which could be associated with the cumulative effect of ageing on the decline of normal metabolic homeostatic mechanisms. background: acute renal failure (arf) is a frequent complication in the early post-allogeneic hematopoietic stem cell transplant (allohsct) period with either myeloablative (ma) or non-myeloablative (nma) conditioning regimens. the aim of this study was to compare the incidence of arf in both types of hsct and to evaluate its impact on overall survival (os) and non-relapse mortality (nrm). methods: all allosct performed in one center between and were included in this study. allohsct from cord blood and from haploidentical donors were excluded. the renal function and the incidence of the main complications after allosct from day to day + were evaluated. arf was defined according to kdigo (kidney disease improving global outcomes) classification; the relative increase of serum creatinine levels was considered a marker of kidney damage. results: seventy-seven patients received a ma allohsct and a nma allohsct. recipients of nma allohsct had a higher median age ( years [range: - ] vs. years , p< . ), higher frequency of arterial hypertension ( % vs. %, p< . ) and showed most frequently active disease at allosct ( % vs. %, p= . ). in both groups the most frequent graft-versushost disease (gvhd) prophylaxis regimen was cyclosporine a and methotrexate. the median follow-up time was . years for the nma group and . years for the ma group. patients from the ma group had higher incidence of grade - mucositis ( % vs. %, p< . ) and acute gvhd of any grade ( % vs. %, p= . ) than patients from the nma allohsct. the incidence of arf was similar in both groups ( % in nma and % in ma). in the nma group arterial hypertension (hr . , p= . ), obesity (hr . , p< . ) and prior pneumonia (hr . , < . ) were predisposing factors for arf by multivariate analysis, whereas any factor was identified in the ma group. arf had no impact on -year os in both groups ( % vs. % p= . for the nma group and % vs. % p= . for the ma group). however, worse os were observed in patients with grade - arf in the nma group ( % vs. %, p= . ) and in patients with grade arf in the ma group ( % vs. %, p= . ). in turn, arf had no influence on nrm in the ma group but was associated with a trend for higher nrm in the nma group ( % vs. %, p= . ). conclusions: arf is a frequent complication in patients receiving allohsct irrespective of the intensity of the conditioning regimen. moderate and severe arf had negative impact on os. disclosure: supported by grants from: asociación española contra el cáncer, aecc (gc biga), instituto carlos iii (pi / fi), -sgr (grc), cerca program from generalitat de catalunya, and "la caixa" foundation. treatment and risk factors of hepatic veno-occlusive disease after pediatric hematopoietic stem cell transplantation: a single-center experience barbaros sahin karagün , ilgen sasmaz , ali bülent antmen background: defibrotide emerged as a promising treatment option for hepatic veno-occlusive disease, a significant cause of mortality in recipients of hsct. as vod diagnosis is quite difficult even with the recently introduced ebmt criteria, studies which report treatment outcomes and response to prophylaxis are required. our aim was to evaluate the efficacy of defibrotide prophylaxis in hsct recipients at our center. methods: a total of transplants in patients from january to july were included in this study. all patients had factors that increased the risk of vod and all received mg/kg/day prophylaxis. patients' coagulation, renal and liver function test were monitored daily and all clinical findings and complaints were recorded. diagnoses were made via the ebmt vod criteria and patients who developed vod received treatment with increased df dose ( mg/kg/day) and supportive interventions. after complete remission of vod findings, patients were returned to the prophylaxis dose. close follow-up of patients was performed until days. results: in total, patients developed vod ( . %), none of the cases were severe ( mild, moderate). median age was . years and the most common clinical findings were weight increase, hepatomegaly, right upper quadrant pain and ascites development. in those with vod, treatment with mg/kg/day df was initiated and average duration of treatment with this dosage was . ( - ) days. no adverse events were reported in any of the patients. conclusions: our findings are consistent with previous studies on this topic, and we believe that the use of df as a prophylactic agent for vod is beneficial for pediatric patients with risk factors. disclosure: the authors report no conflicts of interest in this work. background: several factors might influence outcome of allo-hsct. analysis of the impact of donor-receptor blood group-incompatibility have been performed in different series not always showing the same results. as a consequence, its clinical impact remains controversial. minormismatch is characterized by the ability of donor b lymphocytes to produce anti-recipient antibodies. in majormismatch cases, antibodies against donor antigens are present in the recipient. methods: pts underwent allo-hsct between may and august in our center. median age was years (range: - ). pts were male ( . %) and female ( . %). baseline diseases were: aml, lpd, mds, all, mpd, mm, and bmf. donor was unrelated in , and related in cases (including haplo-identical). donor-recipient abo compatibility was as follows: ( . %) majormismatched (including bidirectional), and ( . %) nonmajor-mismatched (including minormismatched and matched). donor-recipient rh compatibility was as follows: ( . %) major-mismatched, and ( . %) nonmajor-mismatched (including minor-mismatched and matched). the impact of donor-recipient abo and rh compatibility on transfusion needs (prbc and platelet concentrates) and survival by day + was analyzed. results: for the global series the median number transfusions by day + was: ( - ) prbc and ( - ) platelets concentrates. day + overall mortality was . %. rh-incompatible and nonmajor abo incompatible cases showed no different results. however, major abomismatched cases needed more prbc transfusions (median: ; range: - ) and more platelet transfusions (median: ; range: - ), and had higher day + mortality ( . %) (p < . ) (see table) . conclusions: our analysis showed: ) donor-recipient rh-incompatibility, as well as minor aboincompatibility had no impact on prbc and platelet concentrates transfusion needs nor on -day mortality; ) contrarily, donor-recipient major abo-incompatibility had a significant adverse impact on prbc and platelet concentrates transfusion needs and -day mortality. ) donor-recipient rh-incompatibility and minor aboincompatibility.might be considered of marginal importance at the time to choose a potential donor. ) donorrecipient major abo-incompatibility should probably be a factor to be considered, along with other features, to choose the best donor background: survivors of haematopoietic stem cell transplantation (hsct) are at significant risk of developing treatment-related complications, including cardiovascular risk factors such as arterial hypertension, that could eventually lead to cardiovascular disease. the aim of this study is to evaluate the incidence and risk factors of hypertension following hsct in a colombian population. methods: a retrospective cohort study was conducted to assess the incidence and risk factors of hypertension in consecutive adult hsct recipients who underwent transplantation between and at a tertiary referral center in colombia, south america. blood pressure data, from two different measures, were collected at time points: day of mobilization for autologous hsct and day before infusion for allogeneic transplantation, day , and months , , and post-transplantation. hypertension was defined as having a systolic blood pressure >= mmhg and/or a diastolic blood pressure >= mmhg. patients with history of arterial hypertension were excluded. results: one hundred and seventy-five patients were included, with a mean age of years (range - ). ninety-one patients ( %) were male. one hundred and sixteen patients ( . %) underwent autologous hsct and ( . %) allogeneic hsct. the most common indication for hsct was acute leukemia ( . %), followed by non-hodgkin lymphoma ( . %) and multiple myeloma ( . %). twelve patients ( . %) had medical history of type diabetes mellitus (dm), ( . %) dyslipidemia, ( . %) alcohol consumption, and ( . %) tobacco smoking. only two of the patients with history of tobacco smoking were active smokers at time of transplantation. twenty-four patients ( . %) had developed hypertension by the end of the first year post-hsct follow-up. two patients ( . %) had systolic and diastolic, ( %) had only systolic, and ( . %) had only diastolic hypertension. only one patient was hypertensive at more than two time points. the incidences of hypertension at each time point were . % on day post-hsct, . % at first month, . % at three months, . % at months, and . % at one-year post-transplantation. allogeneic hsct (p< . ), therapy with calcineurin inhibitors (p< . ), pre-hsct fasting glucose levels (p< . ), acute gvhd (p< . ), chronic gvhd (p< . ), and media of diastolic blood pressure (p< . ) were significantly associated with the development of arterial hypertension. however, age, history of type dm, history of tobacco consumption, volume of infusion, prophylactic treatment for gvhd with mycophenolate, chronic gvhd, serum creatinine level on day of hsct, and being overweight or obese at time of transplantation were not significantly associated with the development of hypertension. conclusions: arterial hypertension is a fairly common complication in hsct recipients. similar to findings reported in previous studies, association between allogeneic stem cell transplantation, therapy with calcineurin inhibitors, and acute and chronic gvhd, and post-hsct hypertension was found in the present cohort. further studies are needed to assess the link between hsct and developing long-term cardiovascular complications. disclosure: nothing to declare tramadol-based pain management of oral and esophageal mucositis in pediatric hsct recipients background: mucositis is one of the most common early hsct complications seen in about % transplant recipients with % of patients developing gr iii-iv mucositis. mucositis is characterized by painful gastrointestinal mucosa lesions impairing the solid and liquid foods intake and increased risk of infections, bleeding, and intestinal paresis. thus, it greatly decreases the quality of life of a transplant recipient. according to who recommendations, the moderate pain control in pediatric patient is based on the use of low-dose morphine. however, there are some factors such as genetic polymorphisms causing variable morphine pharmacokinetics in children, side effects, and social factors (caregivers' general unwillingness to use narcotic analgesics), which cause the need for alternative pain relief options in pediatric practice. tramadol, which has both opioid and non-opioid mechanisms of action, may be a feasible option in mild to moderate pain. it may be delivered via patient-controlled analgesia (pca), although there is no consensus on its optimal parameters in pediatric practice. methods: a total of pediatric patients with a median age of (range to ) years receiving an autologous or allogeneic hsct in our clinic as part of the treatment regimen for solid tumor (n= ), leukemia (n= ), acquired aplastic anemia (n= ) or inherited condition (n= ) were included. conditioning regimens were myeloablative (mac) in and reduced-intensity (ric) in patients. all patients had oral and/or esophageal mucositis accompanied by moderate pain. the pain severity was assessed using the scales corresponding to patient's age and varied from to points. the pain control was based on intravenous tramadol administration using patientcontrolled analgesia (pca) approach. the following pca parameters were used: loading dose of . mg / kg (not exceeding mg), basal infusion rate of . mg / kg (not exceeding . mg), a bolus of . mg / kg (not exceeding . mg), lockout interval of min. the maximal daily dose was mg/kg/day. the pain control was considered adequate if a patient was satisfied or the basic and breakthrough pain score values were not higher than and, accordingly. in case of inadequate pain control nsaids were added. non-responders were switched to morphine. all patients were divided into groups based on conditioning regimen intensity. results: as a whole, % of patients did not require pain control measures escalation. the tramadol pain control rate was slightly higher for ric (n= , %) compared to mac (n= , %) recipients. in most cases the inadequate pain control was due to progressive mucosal lesions. the pca regimen used was characterized by very few complications. drowsiness was observed in ( %) of patients, in all cases the patients also had anemia. there was only ( %) patients with severe nausea requiring switching to morphine. conclusions: tramadol is an effective pain control option in transplant recipients with mild to moderate pain due to oral and esophageal mucositis without progressive mucosal lesions. the pca allows achieving a very low complication rate. therefore, this option may be considered for both mac and ric recipients. disclosure: no immune reconstitution of lymphocyte subsets after allogenic stem cell transplant (sct) and vaccination background: infectious diseases are a major cause of morbidity and mortality after allogenic stem cell transplant (sct). vaccines constitute an effective strategy to prevent infections but the optimal timing to start vaccinating is not well stablished. in order to individualize the early vaccination schedule, we studied the lymphocyte subsets involved in generating enough response to produce protective serological levels. methods: we studied retrospectively patients that had undergone allogenic sct at our hospital. patient distribution -age range: - years-old; diagnosis: acute leukaemia/myelodysplastic syndrome/ chronic myeloid leukemia ( patients), lymphoma ( patients). analytic parameters: tcd +, tcd +, nk, total b and functional b lymphocyte subsets (naïve igd+cd -, memory igd+cd + and igd-cd +, and effectors cd ++cd ++). immunoglobulin levels (igg, iga, igm) and specific igg for pneumococcus, tetanus, hbv, chickenpox, measles, rubella and mumps. clinical parameters were collected from medical records. results: we distributed patients in two groups, based on the timing of lymphocyte analyses: -less than months since sct ( patients) no patient showed complete immune reconstitution, although had enough t and functional b lymphocytes to generate response to vaccination. in these patients, vaccination for pneumococcus was completed and they generated sufficient protection antibody levels, despite being under immunosuppressive treatment. -more than months since sct ( patients) before the beginning of vaccination, we collected specific antibodies of patients. we compared the serological status before and after sct and observed that protection against tetanus was the most frequently preserved ( patients) and hbv the least frequent ( patients). other than one patient treated with alemtuzumab, all patients in this group had minimum absolute count of tcd + (> cells/microl), tcd + (> cells/microl), nk (> cells/microl) and b cells (> cells/microl). we also observed presence of b effector and b memory cells, with predominance of igd-cd + memory cells. immunoglobulin levels were within the normal range. in this group, we registered vaccination in patients. all of them were vaccinated against flu, and against pneumococcus and hbv. the rest of vaccines administered were heterogeneous in type and timing. patients were under immunosuppressive treatment at the time of vaccination and were able to generate enough specific antibodies for pneumococcus. conclusions: immune reconstitution was not completed months after sct, although minimal immunological reconstitution was observed tcd + and no-switching memory b lymphocytes were the last ones to reach minimum normal values according to patient age. some patients maintain serological protection after allogenic sct. immunoglobulin levels were normal, suggesting no need for immunoglobulin administration to prevent infections. flu, pneumococcus and hbv vaccines were the most frequently administered. pneumococcus vaccination generated a much larger serological response than hbv. this seroconversion occurred in patients under immunosuppressive treatment. the analysis of lymphocyte t, nk, b total and b functional subsets could be useful when programming an early vaccination schedule after sct. completion of the vaccination schedule was heterogeneous despite giving specific indications. therefore a more rigorous supervision of the process may be required. background: the significant advances that have been achieved in the allogeneic transplantation (allohct) field, have resulted in better post-transplant outcome and therefore complications other than the graft vs. host disease (gvhd) or disease recurrence become increasingly important. the post transplant metabolic syndrome (pt-ms), which caused by several factors (i.e. immunosuppressive agents, chemo-radiotherapy, anti-viral, and biologic therapies) is a well known post transplant complication in pediatric allografted long-term survivors however, only few studies have evaluated the prevalence of the pt-ms in adults. in this retrospective study, we sought to evaluate the incidence, the risk factors and the impact of the pt-ms on the allosct outcome. methods: since , patients ( males and females) with adequate clinical and laboratory data and a minimum follow-up of months were included in the study. their median age was . ( - ) years and after a myeloablative (n= ) or a reduced intensity (n= ) regimen they received either mobilized peripheral blood stem cells (n= ) or marrow graft (n= ), originated from full-matched siblings (n= ) or haploidentical donors (n= ). calcineurin inhibitors plus either short-term methotrexate or mycophenolate mofetil were given as gvhd prophylaxis. the diagnosis of pt-ms was based on the ncep-atpiii criteria; for patients with unknown data for abdominal circumference the body mass index (bmi) ≥ kg/m was consider as a criterion for pt-ms diagnosis. the independent t-test, logistic regression analysis and logrank tests were used for the statistical analysis. results: twenty ( . %) patients ( males, females) assessed to have pt-ms within the first months following the allograft. seventeen diagnosed after the st trimester post allosct and additional patients after nd trimester. sixteen out of patients had elevated glucose and bmi> kg/m , / elevated triglycerides levels, / low hdl levels and / hypertension. four ( %) had already known history of ms before allosct (for patients no data were available for ms diagnosis before allosct). interestingly, for / ( %) patients who had diagnosed with pt-ms either in the st or in the nd trimester the syndrome was reversible and did not fulfill the criteria for pt-ms beyond months post allosct. patients' gender, age, bmi, the type of conditioning regimen and gvhd co-existence evaluated as potential predisposing factors for pt-ms diagnosis. in univariate and multivariate analysis only the: bmi> kg/m and age> years were detected as significant risk factors (p< . ). the pt-ms did not affected negatively the survival or the nrm incidence post allosct conclusions: in our study, in agreement with other publications, we demonstrated that the pt-ms is not an uncommon complication post in the early post transplant period however, for a significant number of patients the syndrome was a reversible. for patients with high risk features (bmi> kg/m , age> years, known history of diabetes-mellitus, dyslipidemia, hypertension) apart of close monitoring, specific diet and encouragement for adequate exercise might help to reduce the incidence and the severity of pt-ms. nevertheless, prospective and well design trials are warranted to determine the accurate incidence, severity and the impact of pt-ms on the allosct outcome. disclosure: no conflict ofinterest experience of a single center in the humanization of the hospitalization process: technology and team training impact on the qol of the patient and family maria claudia moreira , marcia rejane , marcia garnica , andrea ribeiro , paulo cesar dias , ilza fellows background: hematopoietic stem cell transplantation (hsct) is one of the most aggressive therapeutic modalities of internal medicine, making it a highly stressful experience for the patient and his family. the duration of hospitalization can be prolonged by several intercurrences, frequently generating anxiety in the patient and their caregiver, which may lead to confinement and reactive depression. interventions in the hospital environment, in addition to the continuous training of the multidisciplinary team, can have a positive impact in this process with improvement in the process of discharge and quality of life of the patient and his / her family. methods: the objective of this research was to evaluate the impact of a reformulation in the unit, completed in may , which modified the facilities with availability of hermetic balconies in each room, with a view of an internal garden. there was also the addition of a screen in the corridor of the floor with images -technology known as videoowall, interconnected to motion sensors (kinects) that allow interaction between patients and families, besides facilitating physiotherapy and physical exercise. there was re-training of the multidisciplinary team with emphasis on the practice of humanization. the methodology consisted in the application of questionnaires of satisfaction to patients and their families during the period of hospitalization in a bone marrow transplant unit in the third quarter of . the items evaluated ranged from the quality of the information provided by the medical team and nursing, to the cordiality and agility with which the patient and his patient were treated by the global team. the results were compared with a similar period of the same unit in the previous year and with the indices collected simultaneously in another unit of the same hospital (cardio-intensive). results: overall and segmental satisfaction scores in the various items surveyed were higher when compared to the previous period of the same unit and were also higher in those obtained in a high complexity unit of the same hospital, composed of patients submitted to mental and psychological stress similar to onco-hematologicos.a reports of "free speech" were also obtained anonymously, in order to guarantee the authenticity and free expression of the subjects analyzed. conclusions: the results obtained allowed the validation of the technical and professional team initiatives, bringing indicators that will allow better monitoring and support of these patients and their relatives in this difficult time of treatment. they served as an initial tool in the continuous process of humanization and stimulated the multidisciplinary team to continuously improve this process. disclosure background: pure red cell anemia (prca) is a rare complication of abo-incopatible hematopoetic stem cell transplantation characterized by anemia, reticulocytopenia and absence of erythroid precursors in patient's bone marrow. most patients with prca resolve spontaneously within months, however a small number of patients requires continued red blood cell (rbc) transfusions. the treatment of this complication is difficult and not standardized. different approaches has been used such as rituximab, donor lymphocytes, plasma exchange with different outcome. recently, a remarkable response to treatment with bortezomib has been described in a case of prca. methods: we reviewed patients who received an allogeneic hematopoetic stem cell transplant (hct) between januar and august at our institution. sixty eight patients received a major abo-mismached hct. prca was defined as a completely absence of erythroid precursors on day + bone marrow puncture, with absence of donor red cells and the recipient requiring rbc transfusion. results: only one patient developed prca ( . %). a years old male received a myeloablative hla-matched abomismatched sibling donor transplant (brother, years) for acute myeloid leukemia (aml), with t( ; ) cr ,mrd positive (runx -runx t ). the donor was blood type a rh positive and the patient rh positive. the patient had no complication after transplant. the day + bone marrow puncture has shown only few erythroid precursors and day + puncture and biopsy no erythroid precursors, he had transfusion dependent anemia requiring a rbc transfusion every two weeks and retukulocytopenia. parvo virus and cytomegalovirus were negative. due to very high ferritin level (> . u/l) and increased luiver enzymes without signs of gvhd, the treatment with deferasirox has been started. the patient has achived cr , mrd negative, and has evidence of complete chimerism. high titers of anti-a and anti-b issohemagglutinin was present.we started the treatment with rituximab mg/m weekly, weeks, however without response. the pathogenesis of the prca is thought to be due to the recipients plasma cells, bortezomib, a proteasome inhibitor inducing apoptosis of plasma cells has been given s. c. , mg/m two times weekly, for two weeks. the patient responded to the treatment two weeks later with increase in hb, which was , g/dl and increase in retikulocyte number. the patient has continued to be well at the last control. conclusions: prca aplasia is a rare but serious complication after abo-incompatible hct. bortezomib is an effective treatment for this complication if mediated by residual host isohemeagglutinins after hct and should be recommended as standard of care. clinical methods: this work is retrospective, observational, cross-sectional and analytical. it included all patients who received hsct at stem cell transplantation unit (utmo, by its spanish acronym) at solca-guayaquil, between the years - .we use the kaplan-meier method to analyze the survival rate between the autologous and allogeneic transplant. the information collected for this study was obtained from the database of the solcay institute and the review of the files of the patients included. results: at least, patients have been undergoing to hsct between - years. according to the type of hsct, . % received an autologous transplant and . % received an allogeneic transplant, from which . % were from a related donor. the main source of transplant was peripheral blood in . %, followed by % obtained from umbilical cord blood and . % by bone marrow aspiration. the most frequently reported pathologies were acute lymphoblastic leukemia (all) ( %), multiple myeloma (mm) ( %) and acute myeloid leukemia (aml) ( . %). the overall survival was % (ic: %). the . % of patients that were undergoing to autologous transplant have survive, meanwhile the patients that were undergoing allogeneic transplant only the . % have survived (p< . ). the highest death rate occurred during the first year after hsct, and decreased considerably after that period. the main cause of mortality related to transplant (mrt) was the graft-versus-host disease (gvhd) ( %); however, the main cause of mortality in the study population (n= ) was relapse in . % of the patients, presented more frequently in all. conclusions: the results showed that % of patients undergoing to hsct have survived. a high rate of deceased patients in this study, have died in the first year before the transplant ( . %%), due to relapse. the main cause of deceased in the study is not related to hsct, and was the relapse in % of patients, in compare the gvhd was the main cause of mrt ( %). we consider that hsct is a technique that is still under development in ecuador, but despite the short time it has been taking and the institutional and medical limitations present in the health field, has presented excellent results comparable to studies conducted in developed countries. [ background: pigmented epithelioid melanocytoma (pem, early known as 'Аnimal type' melanoma) is a rare tumor with unpredictable clinical behavior and metastatic potential. pem generally has favorable prognosis. involvement of regional lymph nodes is not rare. extranodal and distant nodal metastases are extremely rare. we report about patient with fanconi anemia (fa) and pem with developed distant metastases in the early term after allogeneic hematopoietic stem cell transplantation (hsct). methods: -years old boy with fa was hospitalized for hsct. the blue-black painless nodulus х mm was noted on the left cheek. this lesion was observed from early childhood and during life only slightly increased in size. there were no distant and regional metastases on computerized tomography (ct) and scintigraphy with m tc. the nodulus and regional lymph nodes were radically removed before hsct. the resection margin was within the normal tissue. microscopically the derma and subcutaneous fat were infiltrated with epithelioid and spindle cells with total expression of s , melana, mhb , cyclind . ki- expression level was - %. histological structure was specific for pem. hsct with tcrαβ+/cd + graft depletion from match unrelated donor was performed. the conditioning regimen included total lymphoid irradiation gy, fludarabin mg/ m , cyclophosphamide mg/kg, rabbit atg mg/kg and rituximab mg/m . results: at + day after hsct was detected the tumor on the left cheek and parotid region with a histological structure identical to the primary lesion. on ct in s segment of the left lung was detected focus x mm with a cavity. invasive aspergillosis was suspected and empirical antifungal treatment was started. but in days the lung lesion increased in size to x x mm and penetrated in the bronchus. after bronchoscopy with biopsy, pem metastasis was histologically confirmed. moreover, the tumor on the face continued to grow. therapy with cobimetinib and vemurafenib was not effective and patient died from progression of pem on + day after hsct. conclusions: pem was early described as indolent tumor with rare distant metastasis and favorable prognosis. we suspect that pem may acquire an aggressive course in the absence of immunological control, especially in high immunocompromised patients after hsct. disclosure: nothing to declare p abstract withdrawn lidia gartcheva , antoaneta mihova , penka ganeva , margarita guenova , branimir spassov background: the main objective of the study is to assess the dynamics of quantitative and qualitative changes in the parameters of the b cell population and the production of immunoglobulins in patients after autologous transplantation of hematopoietic stem cells in the course of recovery of the immune system. methods: patients with hematological neoplasms undergoing autologous transplantation were included in the study: women and men, with an average age of years. patients were diagnosed with lymphoma (n = ), multiple myeloma (n= ), leukemia (n = ) and solid tumors (n = ). at the time of transplantation, patients were in complete clinical remission or at least with very good partial response, patients were in partial remission and patients -with progression. all patients were evaluated in nine time points through examinations by clinical-laboratory, flow cytometric and immunochemical methods. results: the percentage of cd (+) b cells reached the minimum values one month after transplantation then began to increase in the second month reaching a plateau around the mean values in the period - months after transplantation. the absolute number remained low during the entire period of observation. the amounts of igg and igm serum immunoglobulins gradually increased within the reference range throughout the entire period, while the iga level varied around the lower reference range. conclusions: implementation of an adequate humoral immune response is hampered by the reduction of circulating b cells, suppressed proliferative potential and functional deficits. restoration of b-cell function occurs over a period of months to years after autologous transplantation. clinical trial registry: no clinical trials disclosure: nothing to declare justyna background: allogeneic hematopoietic stem cells transplantation (allo-hsct) is a life-saving and well established therapy for wide range of diseases. however, it is still uncommon treatment for infants less than months of age. the data about indications and outcome of allo-hsct in the youngest group of patients is sparse. the primary objective of this study was to assess the incidence, indications, post-hsct complications and general outcome of allo-hsct among infants not older than months. latter sequelae of hsct such as physical and cognitive development were secondary aim of this study. methods: we retrospectively analyzed data of patients who underwent allo-hsct before year of age in department of pediatric hematology, oncology and bone marrow transplantation in wrocław during years - . clinical and epidemiological features as well as indications for transplantation, early and late complications and general outcome were assessed. results: infants who underwent hsct in our department comprise . % of all patients undergoing hsct in analyzed period of time. thirty-one ( . %) patients received stem cells from matched unrelated donor (mud), ( . %) from mismatched (haploidentical) related donor (mmrd) and ( . %) from a sibling donor (msd). non-malignant disorders were indication for transplant in ( . %) patients and malignant diseases in ( . %) . acute graft versus host disease (agvhd) occurred in ( %) infants, chronic graft versus host disease (cgvhd) in ( %). majority of graft rejections were seen in infants transplanted from mmrd ( . %), whereas the rest ( . %) was associated with mud. median follow-up in study cohort was days, days for alive patients (range days- . yrs) and days for those deceased (range days- days). overall survival (os) in study cohort was . and transplant related mortality (trm) was . . in children with malignancy ( . %) patients died comparing to ( . %) patients in non-malignant group respectively. main cause of death in analyzed group of infants was infection ( %). conclusions: . allo-hsct is rarely performed in children less than months of age. . majority of those patients receive stem cells due to non-malignant disorder. . among youngest hsct recipients, haploidentical transplant are more common than in general pediatric transplant population. . graft rejection is a significant problem in infants transplanted from mmrd. disclosure: nothing to declare unusual non-infectious lung complication after allogeneic haematopoietic stem cell transplantation claudia lucia sossa melo , , manuel rosales , francisco fernando naranjo junoy , , sara inés jiménez , , luis antonio salazar , , angela maría peña , , maría angélica chacón manosalva , maria luna-gonzález , claudia marcela chalela , manuel ardila-báez jirovecii infections, viral infections or nocardia. we describe the case of a patient with acute lymphoblastic leukemia (all) diagnosis with pap associated to a hsct and pulmonary pneumocystis. methods: a -year-old colombian female patient diagnosed with b-precursor all of high-risk in january , positive philadelphia chromosome, positive bcr / abl in february , infiltration to the central nervous system (cns), . % of lymphoblasts, and karyotype without legible metaphases. refractory to induction according to the pethema protocol (vincristine, daunorubicin, prednisone, l-asparaginase) with presence of . % blasts at the end of the induction. re-induction was performed with the flag-ida protocol (idarubicin, fludarabine, cytarabine) achieving complete remission, obtaining minimum residual disease (mrd) < . . dasatinib was initiated by bcr / abl expression and cns involvement at the time of diagnosis. an allogeneic hsct was performed, from a male brother donor, with low intensity conditioning tt buflu and prophylaxis of graft-versus-host disease (gvhd) with tacrolimus and sirolimus. patient showed early posttransplant complications, given the reactivation of cytomegalovirus and hemorrhagic cystitis grade i due to adenovirus. late complications such us gvhd at the cutaneous level and subsequent hepatic and gastrointestinal involvement were seen too, for which immunosuppressive therapy was administered with high doses of systemic corticosteroid. results: patient was hospitalized on day + posttransplantation due to febrile neutropenia and respiratory symptoms, with normal chest ct, and ct of paranasal sinuses with acute pansinusitis, for which she received meropenem gr intravenously every hours plus vancomycin gr intravenously every hours during days with symptom resolution. she remained hospitalized for cytopenias with normal bone marrow and % chimerism. on day + posttransplant she presented fever and leukocytosis, with acute respiratory failure with chest ct that showed bilateral alveolar occupation, "crazy-paving" pattern and frosted glass (see image), so diagnostic fibro-bronchoscopy was performed, reporting postoperatively for pneumocystis jirovecii. she received days of trimethoprim-sulfamethoxazole, with a torpid evolution requiring mechanical ventilation and tracheostomy, persisting with hypoxemia. the report of cultures for fungi, mycobacteria, and respiratory panel of filmarray were negative. a pathology report was obtained with % neutrophils, as well as pas staining with acellular pink material and elevated serum ldh, with a diagnosis of secondary pap. the patient continued with poor general condition, refractory hypoxemia, high ventilatory parameters and hemodynamic instability, due to which she was not able to be a candidate for treatment with total pulmonary lavage; leading to multi-organ failure and later death. [[p image] . high resolution chest ct. sample opacification in frosted glass (a) and pattern ''crazypaving'' (b)] conclusions: the importance of considering the diagnosis of pap as a noninfectious pulmonary complication in patients with allogenic hsct despite its low incidence is recognized. disclosure: nothing to declare methods: once the project was approved by the clinical trials and ethics committee, pairs of blood samples were drawn ( from picc line and from venepuncture) from voluntary allo-hsct recipients who were receiving continuous infusion tacrolimus from february through august . the pts had inserted a double-lumen polyurethane picc. tacrolimus was always administered through the red line, and the blood draw always performed through the purple line. all of the patients signed the informed consent. were male and women. median age was years ( - ). of the venepunctures were carried out in the arm where the picc was set, and the other from the contralateral arm. a limited group of nurses performed the extractions of the samples. results: as shown in the table, tacrolimus trough levels determined in blood from venepuncture were similar to those in blood drawn through the picc (median: . vs . ng/ml). when comparing one by one in the individual patients, the differences were not significant, and changed the dosing prescription in no cases. conclusions: in our experience, there are not significant differences in tacrolimus levels draw from the picc line, compared with a peripheral site. so, in our opinion, if the line for tacrolimus infusion is properly identified and the one used for the sample draw is the alternative one, venepunctures to obtain sample from peripheral sites are not justified for tacrolimus levels measurements. background: patients undergoing a hsct may require icu admission due to transplant-related toxicities. the aim of this study was to analyse a single centre experience with hsct patients requiring icu admission and the factors affecting outcome. methods: we included all adult patients (age >= ) who had an allogeneic or autologous hsct during (d between - - to - - ) at st. george's hospital. data was retrospectively collected from patients' notes. icu outcome and -day survival were analysed. for those patients who were admitted to icu more than once, outcome was analysed from their last icu admission. results: allograft patients were included. were male, with a median age years (range - years). were female, with median age years (range - years). diagnosis n (%) includes all ( %), aml ( %), acml ( %), cmml ( %), hl ( %), mds ( %), mds/mpn ( %), fl ( %), scd ( %). sixteen ( %) patients received their first transplant, ( %) received second transplant. eight ( %) patients had sibling donor, patients ( %) had unrelated donor. sixteen ( %) patients had / matched donor, ( %) patients had / matched donor, ( %) patients had / matched donor. nineteen ( %) received reduced intensity conditioning (ric), one ( %) received myeloablative (ma) conditioning. majority of ric allo-hsct patients were conditioned with fludarabine, mephalan, campath (fmc). a small number were conditioned with busulfan, fludarabine and atg. the ma allo-hsct patient was conditioned with tbi, cyclophosphamide. gvhd prophylaxis was ciclosporin alone starting on day - with a target level of - ug/l for all ric and ciclosporin and methotrexate for the ma patients. two ( %) allograft patients were admitted to icu on three occasions. both patients were male, and years old. one had mmud allograft for mds/mpn. the other had nd mud allograft for relapsed aml. the reasons for icu admission include sepsis, cardiac arrest and respiratory failure. the median duration of icu admission was days (range - ). there were deaths within days of transplant. one patient died on day + during his second icu admission with multi organ failure (mof). one patient died after icu discharge on day + with relapsed disease, bronchopneumonia with disseminated fungal infection. icu mortality rate was %, and -day mortality rate was %. nineteen autologous patients were included (median age (range - years)), ( %) were myeloma patients who were conditioned with melphalan, ( %) were lymphoma patients who were conditioned with beam. the icu admission was %. the -day mortality rate was %. conclusions: our centre's icu admission rate, icu mortality rate, cause of icu admission in allo-hsct patients and autologous patients is comparable to literature reports. autologous transplant is safe with no deaths and icu admissions despite an older age. the mortality rate for allo-hsct patients requiring icu admission remain high. all patients were appropriately referred to icu and there was no one who was denied icu admission. this analysis is being extended to preceding years. disclosure: nothing to declare liposomal doxorubicin for the treatment of iatrogenic kaposi sarcoma following hematopoietic stem cell transplantation background: iatrogenic kaposi's sarcoma (iks) represent a rare complication after hematopoietic stem cell transplantation (hsct), related to hhv- infection in hivnegative immunocompromised patients (pts). methods: we describe a case of iks occurred after an allogeneic hsct and we provide a review of the literature using pub med. results: a -year-old man, hiv-negative, received full hla-matched related hsct after a reduced intensity conditioning regimen for relapsed aml. gvhd prophylaxis was based on atg (fresenius mg/kg), cyclosporine (cya) and methotrexate. no severe complication occurred in the first days after transplant. shortly after cya withdrawal, he developed grade i acute gvhd. gvhd resolved after restarting cya. at fifth month after transplant, the patient developed several red and purple angiomatous plaque and nodules involving the skin of both lower limbs, right arm and the nose (figure ). skin biopsy revealed multiple localizations of iks and positive hhv- viremia was detected in the peripheral blood. a visceral involvement was excluded. patient was treated with cya tapering and nine courses of liposomal doxorubicin mg/m every days, obtaining a negativity of hhv- viremia and partial response of the skin lesions. at last follow up, at months after transplant, the patient was in complete remission (cr) for aml, cya-free without signs of gvhd recurrence and with his single stable residual iks lesion on his left limb, currently waiting for local radiotherapy. we found additional iks published cases after hsct. most of post-hsct iks were secondary to an allogeneic-hsct ( out of , . %) and occurred in adult ( , %) and male ( , %) pts. median age at the time of iks diagnosis was . years (range - ). thirteen pts ( . %) had mediterranean origin. the most frequent underlying disease was aml ( . %). gvhd prophylaxis was primary based on calcineurin inhibitor. half of the pts developed gvhd and were treated with steroid and other immune suppressive drugs. median time between the hsct and the occurrence of iks was . months (range . cutaneous iks was the prevalent form of manifestation, however visceral involvement was reported in pts ( . %). in four cases ( . %) an hhv- associated bm failure was report. immune suppression drugs tapering ( . %) and chemotherapy ( . %) were the most frequent actions taken after the diagnosis of iks. in most cases, liposomal doxorubicin was used as chemotherapy. cr rate was high, . %, whereas progression disease occurred in out pts ( . %), all of which had visceral involvement. in pts ( . %), iks was the cause of death. conclusions: withdrawn of immune suppression drugs and anthracycline based chemotherapy can represent a feasible treatment option for pts with iks after hsct. clinical background: acquired haemophilia a (aha) is an autoimmune disease caused by the spontaneous production of neutralizing immunoglobulin g (igg) autoantibodies (inhibitors) targeting endogenous fviii. treatment of these inhibitors presents additional challenges in a hematopoietic stem cell transplantation (hsct) recipient, because preservation of the graft that restores a normal hematopoiesis is critical. here we describe the management of a case of aha in an acute myeloid leukemia patient following hsct. methods: the clinical, laboratory and molecular aspects of a -year-old italian male who developed aha after allogenic bone marrow transplantation were collected and presented in order to show how we diagnose and manage this severe but rare complication within the special setting of hsct. results: a -years-old man with a flt- itd, npm- , runx -runx t and cbfb-myh negative, not differentiated, chromosomally normal acute myeloid leukemia (aml) in third complete remission (cr) was submitted to a hematopoietic stem cell transplantation (hsct) from his haploidentical son. the conditioning regimen consisted of oncothiotepa, busulfan and fludarabine and was followed by the infusion of a t-cell depleted bone marrow graft. gvhd prophylaxis consisted of cyclosporine a (csa) and mycophenolate mophetyl (mmf). neutrophil engraftment occurred on day + . recipient's autoimmunity was negative. at months post-transplantation the patient received an antipneumococcal vaccination. fifteen days post-vaccination the patient was admitted to our in-patient ward due to general malaise, diffuse muscle and joint pains, cutaneous bleedings, oedemas, hyperchromic urines and constipation. physical examination revealed diffuse ecchymosis, swelling of deep muscles with a progressive functional disability due to hematomas and hemorrhagic suffusions of the tongue frenulum. and anti-factor viii inhibitors . bu/ml (high titers > bu/ml). thus, a diagnosis of acquired autoimmune haemophilia a was made and treatment with feiba combined with prednisone was started. patient's clinical conditions dramatically improved as he referred an improvement of movements and the resolution of joint and muscle pains despite the persistence of deep hematomas just after one day of treatment that had determined an increase of fviii:c value to . % and an improvement of aptt to . seconds. on the following medical checks physical examination showed the progressive disappearance of deep muscle hematomas, and normal values of fviii:c. conclusions: aha is a rare but severe complication following hsct and it could appear years afterengraftment. a prompt diagnosis and an early treatment with feiba and corticosteroid are necessary to avoid life-threatening sequelae. the inclusion of the coagulation panel in the laboratory exams performed during the follow-up is advisable in order to early detect this life-threatening complication. disclosure: nothing to declare background: splanchnic thrombosis is an uncommon complication of myelofibrosis and a controindication to proceed to hematopoietic stem cell transplantation (hsct) due to the risk of additional vascular and endothelial complications. we present a patient with myelofibrosis (mf) that proceeded to hsct from an unrelated donor, despite splanchnic thrombosis unresolved after heparin treatment and unable to proceed to surgical treatment due to severe thrombocytemia. methods: a -year woman with mf secondary to essential thrombocythemia, with intermediate- score according dynamic international prognostic staging system (dipss) and with extreme splenomegaly (maximum diameter cm), refractory to ruxolitinib, showed an extensive thrombosis of the portal and splenic veins, unresolved after -week heparin therapy, at the time of availability of an hla ( / ) and abo matched unrelated donor. she received a conditioning regimen including fludarabine and thiotepa and a gvhd prophylaxis with atg thymoglobuline, cyclosporine and methotrexate, followed by the reinfusion of . x /kg cd + pbsc. at the time of transplant we were aware of an high risk of developing sos, on the basis of the older age of the recipient, the unrelated donor, the advanced stage of myelofibrosis and the ferritin serum level of . ng/mg. results: on day + after hsct sos complicated the aplasia phase, characterized by jaundice, ascites, weight gain, progressive increase in creatinine and bilirubin serum levels. an ultrasound of abdomen confirmed an unchanged thrombosis extension and the development of ascites. on day + the patient was categorized as very severe sos stage, according to ebmt severity criteria, because of doubling of bilirubin serum level in hours and a % increase in comparison with her baseline weight. therefore, defibrotide was promptly started in association with diuretic therapy. the treatment was continued for weeks and allowed gradual restoration of the water balance and normalization of bilirubin serum level. at the last follow-up, months after hsct, the patient shows the persistence of a non-transfusion dependent anemia, platelets . x ^ /ul, palpable spleen cm below the rib, > % allogeneic chimerism in the granulocytic compartment and % in the t lymphocyte compartment. splanchnic thrombosis is partially recanalized and replaced by collateral circles with cavernous aspects. the patient is on treatment with fondaparinux and has shown neither significant infectious episodes or acute or chronic gvhd. conclusions: we conclude that defibrotide treatment allowed to perform a successfull allogeneic transplant in a patient with mf associated with an overt picture of splanchnic thrombosis. background: hematopoietic stem cell transplantation (hsct) is associated with an increased incidence of secondary malignancies including skin cancer. squamous cell carcinoma (scc) is the most common type in patients who are receiving immunosuppressive therapy and chronic graft-versus-host disease (cgvhd) appears to be an important risk factor for its development. recent studies describe voriconazole exposure as an independent factor that may contribute to this increased risk as well. in our best knowledge, no cases of scc have been reported in pediatric allogeneic hsct to date. methods: we present a case report of a year-old boy who developed a scc with high-risk features six years after undergoing hematopopoietic stem cell transplant. results: a year-old boy with acute lymphoblastic leukemia (all) underwent a matched unrelated bone marrow transplant years ago. he developed grade iv agvhd followed by extensive cgvhd with generalized scleroderma. he required intensive and continued immunosuppressive therapy and was on prolonged antifungal prophylaxis with voriconazole. in march , he developed scc involving left temporal region that was completely excised. two months later, more lesions in scalp and nose were noted and intralesion treatment with methotrexate was started. however, an unfavorable evolution was noted and he was put on systemic treatment including cisplatin and cetuximab receiving the whole scheme from january to march and continuing only with cetuximab, ten doses in total, until may, for unaceptable and severe tubulopathy that required admission at the hospital in several ocassions. he achieved a very good partial response but progression was noted shortly in follow up. at this point, non curative therapeutic options were found and he was put on intralesion methotrexate and photodynamic theraphy in a weekly basis with palliative intention. unfortunately, tumor growth was fast and patient passed away in august , fifteen months after squamous cell carcinoma diagnosis, due to tumoral progression. conclusions: ) scc is a rare, non-previously described, secondary malignancy in children undergoing hsct. ) high-risk features scc constitutes an aggresive disease with a median overall survival below year. ) cgvhd appears to be an important risk factor for its development. ) voriconazole induced-photosensitivity might have played a role. ) cisplatin based regimens +/-cetuximab are a therapeutic option in disseminated and/or high risk cases. as outcomes are unsatisfactory in these cases, alternative therapeutic options need to be explored. disclosure background: pregnancy is a rare event after allogeneic stem cell transplantation (sct) for acute leukemia. here we report, to the best of our knowledge, for the first time on a successful pregnancy after treosulfan-based conditioning. methods: a -year old woman was diagnosed with acute myeloid leukemia (aml) secondary to chronic myelomonocytic leukemia in july . ovarian preservation was performed by leuprolide acetate depot injection prior to cytostatic chemotherapy. of note, no cryopreservation of oocytes or ovarian tissue was conducted. she received two cycles of chemotherapy consisting of idarubicine ( mg/m² on day - ) and cytarabine ( mg/m² b.i.d. on days , , and ). due to secondary origin of aml sct was performed in first complete remission of aml after conditioning with treosulfan ( g/ m² days - ) and fludarabine ( mg/m² days - ). she received . × cd -positive cells per kilogram body weight from a hla-matched unrelated donor. results: follow-up bone marrow aspirates showed continuous complete remission of aml. seven months after sct she became pregnant, but decided for induced abortion. in january , months after hsct she became pregnant again and desired the child. medical examinations were performed monthly on an outpatient basis in stringent cooperation with the maternity clinic. the course of pregnancy was unremarkable, although she was hospitalized due to premature labor in the th week of pregnancy. however, gynecological examination showed no clinical significant findings, so that section was planned and she could be discharged again. in the th week of pregnancy she gave birth to a healthy girl ( cm, g) by cesarean section. peripartum she developed hypoethesia of the left body half. neurological examination showed no abnormalities and she recovered immediately. there were no other postpartum complications. breastfeeding was established but additional food was necessary for a sufficient nutrition of the child. conclusions: this case of successful pregnancy following sct demonstrates that fertility can recover after treosulfan-based conditioning. however, detailed studies of ovarian function and fertility are necessary to gain more insight into the risk of premature ovarian failure. disclosure: nothing to declare. experimental stem cell transplantation p cd -cart therapy before allo-hsct in children and adolescents patients who diagnosed r/r b-all with e a-pbx background: b-all with e a-pbx in children and adolescents is described with favourable prognosis. but there are more than % patients with e a-pbx diagnosed as relapsed or refractory. the results of allo-hsct in children and adolescents with this group leukemia in our center was analyzed in order to understand the therapeutic effect of cd -cart on the patients. methods: retrospective analysis, from june st, to july , , all children and adolescents diagnosed relapse or refractory b-all with e a-pbx who received allo-hsct, total cases. all patients was divided into two groups depending on whether or not accepted cd -cart before allo-hsct. according to fcm-mrd and e a-pbx level before allo-hsct, os lfs and cumulative recurrence rate were analyzed. r . . was used as statistical analysis software. results conclusions: . for r/r b-all with e a-pbx in children and adolescents, fcm-mrd pre-transplant hasn't obvious effect on the outcome of allo-hsct, while the level of e a-pbx has obvious effect. the out come of e a-pbx negative group was obviously better than positive group. . cd -cart can obviously improve the os and lfs, it is mainly because of cd -cart can makes more patients fusion to zero. . for r/r b-all with e a-pbx in children and adolescents, if chemotherapy can't make the fusion to zero. it is suggested to accept cd -cart therapy to make the fusion zero. it can improve the outcome of os and lfs. disclosure background: currently, hematopoietic stem cell transplantation (hsct) represents the only curative treatment for numerous hematopoietic malignancies like leukemias, immune deficiencies or metabolic diseases. cd serves a quality marker for stem cell grafts, which is not solely expressed on stem cells but also on a variety of progenitors. the role and the impact of these subpopulations remains unknown. we made use of our genetic barcode system to analyze the influence and contribution during reconstitution on a clonal level. methods: fluorescence activated cell sorting (facs) was used to sort hematopoietic stem and progenitor populations, namely hscs, mpps, cmps and clps, which were lentivirally transduced with our previously established bc barcoding system. after mixing the marked cells with bone marrow support, lethally irradiated recipient animals were and transplanted and monitored over weeks. we focused on bone marrow, blood, spleen and thymus, on chosen endpoints ( w, w, w, w) and samples were used to analyze the contribution of the subpopulations during the reconstitution process based on fluorescent protein (fp) expression. to investigate the clonal contribution in different organs, we performed next generation sequencing (ngs) and frequencies of unique barcodes in a sample were analyzed by bioinformatical approaches. results: a maximum of % of cells expressed the encoded fps, which were mostly derived from the hscs and mpps. cmp-derived cells were only detected week after transplantation in the myeloid compartment. cells derived from the clps were not detected at any time point. we analyzed the barcode content of the differently marked cells after next-generation-sequencing. in accordance with the facs data, the majority of the clones during the weeks of observation are derived from hscs and mpps. cmp-derived clones were only contributing during the first weeks and clp-derived clones are barely detectable. we did not observe any major differences with regard to age of donor or recipient, despite the total number of clones is higher in the group, which received the "aged" graft, independently from the transduced cell population. conclusions: here we show the suitability of our highly complex multi-color barcode system to study the clonal contribution of hscs and three progenitor populations after hsct. our results will contribute to a better understanding how these different populations interact to support the establishment of a new hematopoietic system. emphasized by the variability in data of graft and recipient age, this comprehensive analysis gives rise to an impression to the necessity of personalized graft composition, by which treatment success could be influenced. disclosure: nothing to declare survival and fate of adipose derived mesenchymal stem cells in a rat brain injury model background: mesenchymal stem cells have been identified as promising candidates in the treatment of central nervous system (cns) injury through neurotrophic support and immunomodulation. adipose tissue is an attractive source of mesenchymal stromal/stem cells (ascs) for regenerative therapeutic applications because they can be harvested from autologous donors with minimally invasive methods, can be rapidly expanded ex vivo, show low immunogenicity if allogeneic, and can be used in autologous or heterologous settings. the present study examines the fate and effects of intracerebroventricularly (icv) transplanted ascs in a traumatic brain injury (tbi) model. methods: ascs were isolated from inguinal fat pad of adult wistar rats under sterile conditions and cultured according to standard procedures. ascs at passage ( x cells) were seeded and transfected with sleeping beauty transposase and pt venus-neo r plasmids. selection with g antibiotic resulted in the generation of a homogeneous asc population which expressed fluorescent venus protein for several passages, phenotypic characterization showed that these cells were . % double positive for cd and cd stem cell markers, verifying their mesenchymal origin. tbi was induced by stereotactic surgery under deep anaesthesia and subsequently icv transplantation of venus+ ascs was performed on adult wistar rats. normal ascs-transplanted and tbi-saline transplanted rats were used as controls. the proliferation, migration, survival and fate of transplanted ascs and their effect on injury restoration were examined six weeks post transplantation (pt). results: six weeks pt ascs expressed the fluorescence venus protein and therefore were identified in brain parenchyma. their presence into brain was also confirmed by masson trichrome staining, which revealed their collagen depositions. ascs were found in lesser numbers compared to those transplanted and exhibited no proliferative activity. ascs were found scattered distributed in brain as individual cells, and there were no aggregates of ascs or mass formation into lateral ventricles. extensive migration of ascs was mainly performed through white matter tracks in the corpus callosum and fimbria of hippocampus. six weeks pt ascs retained the characteristics of mesenchymal cells and did not differentiate into cells of neural lineage. ascs exhibited limited long-term survival, which is restricted in perivascular areas probably contributing to vascular formation. homing of ascs into peri-injured area was detected in half of the animals and achieved through the corpus callosum, as revealed by the collagen depositions, in this white matter track. transplanted ascs reduced the area of tbi cavity and did not enhance the astroglial scarring in peri-injured area. in tbi +ascs transplanted animals, the cortical injury site, showed a significantly smaller volume and lower % tissue loss compared to that of tbi+vehicle animals ( . ± . mm and . ± . % respectively, versus . ± . mm and . ± . %, p= . and p= . respectively). conclusions: considering the effects of ascs on inflammation and regeneration, we suggest that their transplantation after brain injury may promote host brain repair mechanisms. ascs transplantation may be beneficial in tbi, however some of its effects need careful and indepth evaluation. disclosure: nothing to declare xie-na cao , yuan kong , zhong-shi lyu , , qi wen , min-min shi , , qian-yu sun , yu-hong chen , yu wang , lan-ping xu , xiao-hui zhang , xiao-jun huang , background: poor graft function (pgf) remains a serious complication after allogeneic hematopoietic stem cell transplantation (allo-hsct). our previous work reported that abnormal bone marrow (bm) endothelial cells (ecs) were involved in the pathogenesis of pgf patients after allo-hsct (bbmt ; bmt ; blood ), but the explicit mechanism requires further clarification. autophagy is a self-degradative process responsible for the elimination of cytosolic components including proteins and damaged organelles. recent findings demonstrated that stimulation of autophagy could reduce oxidative status and angiogenic potential in ecsafter high-glucose exposure, from diabetic patients.however, little is known regarding the autophagy of bm ecs in pgf patients. therefore, the current study was performed to evaluate whether autophagy in bm ecs play a role in the pathogenesis of pgf. moreover, to investigate the effects of autophagic regulation on ecs and thereby regulating hematopoietic stem cell (hscs). methods: in the prospective case-control study, the autophagy levels were compared in bm ecs from pgf patients, and their matched good graft function (ggf) patients.the expression levels of autophagy-related markers (lc , beclin , and p ), and intracellular autophagosomes were detected by immunohistochemical staining, flow cytometry, western blot and transmission electron microscopy. subsequently, rapamycin (the autophagy activators) or hydroxychloroquine (hcq, the autophagy inhibitor) were administrated tothe -day cultivated bm ecs and human umbilical vein endothelial cells (huvecs), respectively.the autophagic vacuoleswere detected by monodansylcadaverine (mdc) staining assay. the bm ecsand huvecs were evaluated by cell counting, dii-ac-ldl and fitc-lectin-uea- double staining, migration, cell proliferation, and levels of reactive oxygen species (ros). to explore whether autophagy would affect the ability of bm ecs to support hscs in vitro, bm cd + cells from healthy donors were co-cultured with cultivated bm ecs and huvecs. colony-forming unit (cfu) and the apoptosis of co-cultured hscs were analyzed. results: the defective autophagy in bm ecs, characterized by decreased intracellular autophagosomes and autophagic vacuoles, decreased expression of lc -ii and beclin , and high level of p , were observed in pgf patients compared with ggf patients. moreover, the coculture of bm cd + cells with bm ecs showed significant deficient cfu plating efficiency, and increased apoptosis of cd + cells in pgf patients. in vitro upregulation of autophagy by rapamycin quantitatively and functionally improved bm ecsand huvecs, which manifested as more dii-ac-ldl and fitc-lectin-uea- double stained cells, increased capacities of migration, lower levels of ros and apoptosis via regulating beclin pathway, whereas inhibition of autophagy by hcq aggravated the huvecs and bm ecs from pgf patients. furthermore, in vitro upregulation of autophagy by rapamycin significant improved cfu plating efficiency, and decreased apoptosis in bm hscs co-cultured with huvecs and bm ecs from pgf patients. conclusions: these findings suggest that defective autophagy in bm ecs may be involved in the pathogenesis of pgf. the effect of rapamycin in pgfpatients is potentially mediated by improving the dysfunctional bm ecsto support hscs. therefore, it would be of value to investigate whether upregulating of cytoprotective autophagy of bm ecs may ameliorate pgf, thereby providing a novel clinical intervention for pgf in the future. clinical background: heparanase (hpse) in an endoβ-glucuronidase that specifically cleaves the saccaride chains of heparan sulphate proteoglycans (hs), leading to a loss of integrity of the extracellular matrix and to release of hs-bound cytokines, chemokines, angiogenic and growth factors. hpse gene is polymorphic and includes approximately snps. the combination of two snps, rs and rs , are involved in the regulation of hpse expression with an inverse correlation between mrna expression and protein levels: gg-cc, gg-ct, gg-tt, ga-cc (low group) expressed high hpse concentration; ga-ct and ga-tt (median group) expressed intermediate hpse levels; aa-tt and aa-ct expressed low hpse concentration (high group). we studied hpse snps in the allogeneic stem cell transplantation (hsct) setting to evaluate a possible association with post-hsct outcomes. methods: we enrolled patients submitted to hsct in our department since to . for each couple recipient-donor, rs snp was genotyped using restriction fragment lenght polymorphism assay, whereas for rs snp an allele-specific polimerase chain reaction was applied. hpse genotype distribution was compared in different groups according to post-hsct outcome: graft-versus-host disease (gvhd), transplantrelated mortality (trm), overall survival (os), infectious complication and disease-free survival (dfs). statistical analysis was performed using ncss . results: distribution of rs snp was as follows: gg . %, ga . % and aa . % among recipients and . %, . % and . % among donors, respectively. hardy-weinberg equilibrium (hwe) was respected. distribution of rs snp was as follows: cc . %, ct . % and tt . % among recipients and . %, % and . % among donors, respectively. rs snp distribution did not respect the hwe. an association was found between recipient rs snp and the cumulative incidence of agvhd among patients submitted to a reduced intensity conditioning (ric): . % for tt genotype and % for ct or cc genotype (p= . ). on the other hand, an association was identified between donor rs /rs snps combination and the cumulative incidence of agvhd: . % for low group donor, % for median group donor and . % for high group donor (p= . ). conversely, aa genotype for donor rs resulted independent risk factor for cgvhd de novo development (p= . , od . ) together to donor-recipient sex mismatch (female donor to male recipient vs. others: p= . , od . ) . considering cmv reactivation rate after hsct, an association was observed according to recipient rs snp: % for cc genotype, . % for ct genotype and . % for tt genotype (p= . ). multivariate analysis confirmed recipient rs snp as independent risk factor for cmv reactivation after hsct (p= . , od . ) together with recipient cmv serostatus at transplant (positive vs. negative: p< . , od . ). conclusions: hpse role was widely studied in the setting of inflammation, autoimmune diseases, hematological disease and tumor. however, it still remains debated the inducing or protective activity of hpse in the setting of gvhd. obviously, our results need to be confirmed in a validation cohort. clinical trial registry: na disclosure: nothing to declare novel protocol for autologous hsct in patients with high risk of complications: ambulatory chemomobilization and transplantation of fresh hematopoietic stem cells with backup storage background: autologous hematopoietic stem cell transplantation (ahsct) is standard of treatment in many patients with high risk of complications: dialysed patients, patients with heart and kidney amyloidosis or patients with systemic sclerosis. we introduced recently a novel protocol for ahsct: combination of ambulatory mobilization with very low doses of ara-c and g-csf connected with direct ahsct with fresh cells. this protocol allowed us to reduce the transplant risk in various patient groups traditionally connected with high risk of complications. in this work we summarize the experience in such high risk patients. methods: the prospectively collected database of patients after ahsct was searched for patients who underwent ahsct after chemomobilization with ara-c and transplantation with fresh cells and who fulfilled at least one study inclusion criteria: a) dependence on dialysis b) amyloidosis c) systemic sclerosis d) disqualification from transplantation at other centre due to the high risk of complications. there were together patients selected for this analysis - with amyloidosis ( with ≥ organs involved), dialysed, with systemic sclerosis, unfit at other centre. the database included prospectively recorded serious adverse events during the mobilization and transplantation. results: there were transplantations performed in this group of patients. mortality was % at days. all patients underwent successful ambulatory mobilization. all patients received mephalan conditioning with single infusion with median dose of mg/m (min , max ). mean engraftment was . days for white blood cells and . days for plt over g/l. the rate of complications was low with cases of neutropenic fewer, single bacterial culture with staphylococcus epidermidis without clinical signs of infection, median mucositis grade of . and without patients on parenteral nutrition. the median time of hospitalization was days (min , max ). conclusions: we present here novel protocol of transplantation combining chemomobilization and ahsct with fresh cells with excellent safety profile among most severely ill patients allowing for safe and efficient transplants. with this protocol we were able to overcome multiple risk factors and perform full intensity transplantation in very fragile patients. disclosure: nothing to declare single umbilical cord blood transplantation provides durable disease remission of advanced hematological malignancies in elderly patients background: although allogeneic hematopoietic stem cell transplantation (allo hsct) is potentially curative therapy in a variety of hematological malignancies, little has been reported of the outcome for elderly patients who are not in remission at transplantation. but it has been pointed out that recipient age alone can not be regarded as contraindication for allo hsct in the literature recently, supported by suitable donor, conditioning regimens and appropriate management of complications. we conducted a retrospective study of elderly patients who had advanced hematologic malignancies to elucidate the outcome of single umbilical cord blood transplantation (sucbt) in toranomon hospital kajigaya, japan. methods: we retrospectively investigated the outcomes of patients aged over who underwent their first ucbt from june to december in our medical center. results: diseases included acute myelogenous leukemia (n= ), myelodysplastic syndrome (n= ), adult t-cell leukemia/lymphoma (n= ), myelofibrosis (n= ) and chronic lymphocytic leukemia (n= ). the median age at transplantation was years (range, - ) and follow-up for survivor post transplantation was day (range, - ). all patients were not in complete remission (cr) at the time of transplantation. reduced intensity conditioning (ric) regimens were used in patients. all patients received tacrolimus and mycophenolate mofetil as graftversus-host disease (gvhd) prophylaxis. all cases except early death achieved neutrophil recovery at median days (range, - ). at year, overall survival (os) rate and disease free survival (dfs) were , % ( % confidence interval (ci), . - . ). we performed univariate analysis to identify the factor that influenced os at year, but no statistical significance was demonstrated at the age of transplantation (aged to vs. ≧ , . % ( % ci, . - . ) vs. . % ( % ci, . - . ), p= . ). the cumulative incidence of non-relapse mortality (nrm) at days was . % ( % ci, . - . %) and relapse at year was . % ( % ci, . - . %). only two patients developed acute gvhd(ii-iv) and one developed severe gvhd at days after transplantation. the main causes of death was infection (n= ), including sepsis (n= ) and viral encephalitis (n= ), followed by idiopathic pneumonia syndrome (n= ) and thrombotic microangiopathy (n= ) during the early phase of transplantation. in contrast, no patients died of recurrence. conclusions: although our report consisted relapsed/ refractory disease of elderly patients at the time of sucbt, durable remission and lower incidence of gvhd could be noteworthy compared with previous reports. further strategies to reduce the rate of nrm and longer duration of follow up would be warranted. disclosure background: pearson syndrome and kearns-sayre syndrome are metabolic disorders caused by a de-novo deletion in the mitochondrial dna (mtdna). allogeneic stem cell transplantation has shown to improve metabolic function in distal organs in several metabolic disorders, but bears significant morbidity and mortality, especially for patients with mitochondrial disorders. novel gene therapies may correct diseases rising from genomic dna mutations, but targeting the mitochondrial dna is complex. mitochondria are able to transfer into cells and between cells, as seen in preclinical models of mitochondrial and other metabolic disorders. here, we introduce a novel concept of mitochondrial augmentation therapy (mat) of autologous cd + cells in children with mitochondrial deletion syndromes. methods: patients were treated under a compassionateuse program, approved by the sheba medical center irb and the israeli ministry of health. briefly, mobilization was performed using gcsf alone (n= ) or in addition to plerixafor (n= ) . cd + cells were isolated via miltenyi clinimacs system and co-cultured with maternal mitochondria, drawn from peripheral blood and confirmed nondeleted, for hours, and re-infused to the patient without any conditioning. patients were followed for clinical and metabolic parameters. results: all four patients presented with different deletions in mitochondrial dna, and different baseline characteristics, and were treated at the age of . , , and years. despite normal cbc, significant bone marrow hypocellularity was seen in evaluated patients ( %, % and % cellularity at age , and ), which correlated with low colony forming unit capacity of patients and low yield of cd + mobilization in the leukapheresis product. patients received on average x enriched cells/kg (range, . - . ), and the median enrichment of cd + cells was % (range, - %). no infusion reactions occurred, and the only severe adverse events of this cellular therapy were leukapheresis-related anemia, hypokalemia, hypocalcemia and alkalosis, all resolved promptly with proper supplementation. follow-up duration is variable, ranging - months. we were able to show improvement in mitochondrial heteroplasmy (proportion of deleted mtdna of total mitochondrial dna) and in normal mtdna content, starting - months from cell therapy, which correlated with improved atp production in peripheral blood derived mononuclear cells. clinically, patients showed improvement in aerobic function and endurance (measured by the half-bruce protocol, sit-to-stand test and -minute walk test), muscle strength (hand-held dynamometry), and in quality of life, measured by the international pediatric metabolic disability scale. no metabolic crises occurred following cell infusion. conclusions: patients with deletion in mtdna have metabolic dysfunction, including poor bone marrow cellularity and function. hematopoietic stem cells in patients with mtdna deletions can be enriched with normal mitochondria, via mat, as first shown in our patients. this novel process is safe and results in increase in the normal mtdna in peripheral blood of patients, and in improved metabolic and clinical function. clinical trial registry: clinicaltrials.gov nct disclosure: moria blumkin, noa sher and natalie yivgi ohana -minovia therapeutics, employment p high cytotoxic efficiency of alpharetrovirally engineered cd -specific chimeric antigen receptor natural killer cells for treatment of acute lymphoblastic leukemia stephan müller , tobias bexte , annekathrin heinze , franziska schenk , axel schambach , winfried s. wels , , ute modlich , evelyn ullrich , background: autologous chimeric antigen receptormodified (car) t cells with specificity for cd showed potent antitumor efficacy in clinical trials regarding relapsed and refractory acute lymphoblastic leukemia (all). natural killer (nk) cells are cytotoxic lymphocytes that are capable to kill their targets in a non-specific manner and additionally do not cause gvhd. therefore, using cd -car-nk cells exhibits several advantages, such as safety in clinical use, possible allogenic settings and the potential to also attack heterologous leukemia cells which lost cd . previous approaches used cd -car-nk cells pre-stimulated by feeder cells, bearing potential risks. thus, we focused on the optimization of generating cd -car-nk cells by viral transduction under feeder-cell free conditions. methods: human nk cells were isolated from healthy donor peripheral blood mononuclear cells via cd negative selection. after a feeder-cell free expansion phase with interleukin , transductions were performed with an egfp or a cd -car encoding vector at different multiplicities of infection (moi). to optimize gene modification different transduction enhancers (retronectin and vectofusin- ) and viral vector systems (lentiviral and alpharetroviral) were compared. finally, generated cd -car-nk cells were tested in their ability to kill cd positive and cd -negative cell lines. results: nk cells transduced with a lentiviral egfp encoding vector or a lentiviral cd -car vector using retronectin and vectofusin- showed similar transduction efficiencies for both transduction enhancers (egfp: retronectin moi : . %; vectofusin- moi : . %; cd -car: retronectin moi : . %, moi : . %; vectofusin- moi : . %, moi : . %). the generated cd -car-nk cells showed increased cytotoxic capacity against cd -positive cells compared to nontransduced (nt) nk cells ( . % vs. . %, effector to target (e:t) ratio : ). both nk cell populations were equally efficient in killing cd -negative cells ( . % vs. . %). alpharetroviral transduction of nk cells with an egfp encoding vector showed higher transduction rates with vectofusin- than with retronectin (retronectin moi : . %, moi : . %; vectofusin- moi : . %, moi : . %). further using vectofusin- , similar transduction efficiencies could be achieved with an alpharetroviral cd -car encoding vector (moi : . %, moi : . %, moi : . %), outperforming the efficiencies of lentivirally generated cd -car-nk cells in the same experiments (moi : . %, moi : . %, moi : . %). additionally, alpharetroviral cd -car-nk cells showed a higher cell killing activity against cd -positive cells than lentiviral cd -car-nk cells or nt-nk cells ( . % vs. . % vs. %, e:t ratio : ). interestingly, similar killing activities were achieved with an e:t ratio of . : ( . % vs. . % vs. . %) and alpharetroviral cd -car-nk cells remained a stable cytotoxicity level at lower cell concentrations down to an e:t ratio of . : . all three nk cell populations were equally efficient in killing cd negative cells ( . % vs. . % vs. . %, e:t ratio : ). conclusions: cd -car-nk cells can be successfully generated under feeder-cell free conditions using different transduction enhancers and viral vector systems. these data suggest the usage of vectofusin- in combination with alpharetroviral vectors to genetically modify nk cells to achieve sufficient amounts of transduced cells. these cd -car-nk cells mediate high cytotoxicity and therefore may offer a new therapeutic option in the treatment of all. disclosure: axel schambach is an inventor on a patent describing alpharetroviral sin vectors. winfried s. wels is an inventor on a patent describing chimeric antigen receptors with an optimized hinge region. the remaining authors have nothing to disclose. graft-versus-host diseaseclinical walter spindelböck , bianca huber-krassnitzer , barbara uhl , gregor gorkiewicz , hildegard greinix , christoph högenauer , peter neumeister background: steroid-refractory acute gastrointestinal (gi) graft-versus-host disease (agvhd) is a severe complication of allogeneic hematopoietic stem cell transplantation (allo-hsct) associated with a high mortality rate. loss of intestinal bacterial diversity is thought to be associated with severity of gi-agvhd and an impaired intestinal microbiota with reduced diversity is an independent predictor of mortality. methods: the fecal microbiota transplantation (fmt) procedures were performed according to a protocol approved by the local ethical committee ( - ex / ) after obtaining informed consent. donors were healthy adult subjects screened for potential infections by serologic and microbiologic tests according to local standards. donor stool was diluted with saline and homogenized to a volume of~ ml fecal solution for instillation into the terminal ileum and caecum via colonoscope. microbiota sequencing analysis of s rdna was performed before fmts and afterwards at predefined timepoints. results: we report the outcome of nine patients refractory to - lines of immunosuppressive therapies with lower gi-stage iii (n= ) or iv (n= ) agvhd following repetitive fmts from a single donor. all patients had received an allo-hsct for mds (n= ) , aml (n= ), pmf (n= ) and mm (n= ) following a reduced intensity (n= ) or mac (n= ) conditioning regimen using pbsc as stem cell source. after an onset of lower gi agvhd between - days after allo-hsct, nine patients refractory to several lines of immunosuppressive therapies received - fmts ( patients were treated with more than fmts, in patients fmt was only administered once or twice) mostly in weekly intervals. five patients achieved a clinical complete response with resolved diarrhea and no gastrointestinal complaints, and four of these could be discharged without gvhd symptoms. two patients (pr, nc) were discontinued after or fmts in pr or nc due to concomitant infections (metapneumoviral pneumonia, cmv gastroenteritis), the other non-responders succumbed to gvhdrelated infectious complications. the establishment of donors' microbiota with the emergence of new taxa, an increase in bacterial richness/diversity, and the disappearance of the "enterococcus signature" were associated with disease control and response to fmt. except the possible transmission of adenovirus by fmt in one patient, no other immediate procedure-related infections or other side effects were observed. conclusions: restoration of dysbiosis by fmt might represent a promising novel therapeutic approach for a subset of patients with refractory lower gi-agvhd. vigorous donor screening for infectious disease is mandatory. clinical background: migration of allo-activated donor effector tcells from lymphoid tissues to target organs is an important step in acute graft versus host disease (gvhd). the sphingosine- -phosphate- (s p ) receptor plays a crucial role in lymphocyte trafficking. data from animal models suggest that pharmacological modulation of the s p receptor reduces gvhd and improves mortality. we investigated this mode of action by using the secondgeneration s p modulator krp for the prophylaxis of gvhd in a pilot clinical trial in patients undergoing allogeneic hsct. methods: a multi-centric, phase b, prospective, open label, two-part study was conducted to evaluate the safety, tolerability and pharmacokinetics of krp in patients undergoing allogeneic hsct for hematological malignancies. primary endpoint was safety. initial efficacy was explored based on the incidence of gvhd, mortality and relapse. part was a single arm open label study to investigate the safety of mg/day krp added to standard of care gvhd prophylaxis (csa/mtx) in patients. part was a randomized two-arm open label study to compare the safety, efficacy and pk of mg/day of krp in combination with tacrolimus/mtx to mg/day of krp in combination with csa/mtx in patients. in both parts, treatment with krp was initiated days before hsct and continued for an additional days. patients were followed up for up to years. results: patients were included in the study. of patients completed the -day treatment with krp at the assigned doses. median duration of follow-up was days (range to days). krp was safe and well tolerated. serious adverse events (saes) suspected to be related to krp were observed. macular edema (n= ) and peripheral edema (n= ) as s p related adverse events occurred and resolved without sequelae. of note, the incidence of macular edema in hsct recipients is unknown. neutrophil engraftment was confirmed in all patients with a median of days (range to days). of patients presented with grade iii or iv acute gvhd (on days , , , and ) . no gvhd or infection related death occurred during the first days. -day survival was %, with no death occurring during krp treatment. death occurred on study day due to lymphoma relapse. a second death occurred on study day due to liver gvhd. four patients died in the follow-up period due to gastrointestinal gvhd (day ), aspiration pneumonia (day ) and relapse (day and day ). the kaplan-meier estimate of overall survival at year was . . when comparing the data from the two dose groups ( and mg krp ), no major differences in safety, engraftment, gvhd rate or mortality were observed. conclusions: this clinical trial was the first to test s p modulation in this population. our data suggest that krp had no negative impact on engraftment and overall, was safe, and well tolerated. based on exploratory data, when comparing to matched historical mortality data, krp may have favorable effects on overall survival ( figure ). background: uric acid is a danger signal contributing to inflammation. relevance to allosct has been demonstrated in preclinical models: the depletion of uric acid led to improved survival and reduced gvhd (j exp med. sep ; ( ): - ). results of a clinical pilot trial suggested that peri-transplant uric acid depletion reduce acute gvhd incidence (bbmt may; ( ): - ). methods: this international multicentric study aimed to study the association of uric acid serum levels before start of conditioning with allosct outcome. patients with acute leukemia, lymphoma or mds receiving a matched sibling allosct for the first time were considered for inclusion, regardless of conditionning. data were prospectively collected between / and / . a comparison of outcomes between patients with high and low uric acid level was performed using univariate analysis and multivariate analysis using cause-specific cox model. variables included in the multivariate analyses were age, sex mismatch, diagnosis, disease status, karnofsky score, number of cd cells given, intensity of conditioning, type of gvhd prophylaxis, atg use, time from diagnosis to transplant, year of transplant and cmv status. results: twenty centers from european countries reported data on allosct recipients. patient characteristics are given in table . the uric acid cut off point was determined at . mg/dl (median of measured uric acid levels). overall survival (os) and progression free survival (pfs) of allosct recipients with uric acid levels above cut off measured before start of conditioning were significantly shorter ( figure a , os univariate hr= . ci= . - . p< . ; multivariate hr= . , ci= . - . , p< . ) ( figure b , pfs univariate hr= ci= . - . p= . ; multivariate hr= . , ci= . - , p= . ). nonrelapse mortality was significantly increased in allosct recipients with high uric acid levels prior to start of conditioning (univariate hr= ci= . - . p= . ; multivariate hr= . , ci= . - . , p= . ). in addition, there was a non-significant trend towards higher acute gvhd incidence (gvhd grades ii-iv univariate hr= . ci= . - . p= . ; multivariate hr= . ci= - . , p= . ) in allosct recipients with uric acid levels above cut off before transplantation. finally, the incidence of relapse after allosct was moderately increased in the cohort with higher uric acid levels (univariate hr= . ci= - . p= . ; multivariate hr= . , ci= . - . , p= . ). conclusions: high uric acid levels before start of conditioning correlate with high mortality after allosct. our results can serve as rationale for clinical trials on depletion of uric acid during allosct. results: we found significant correlation between donors' ctla- + a>g polymorphism and hsct outcome. genotype aa was present in donors, ag in donors and donors was homozygous for g allele. recipients who received graft from g allele carrier donors showed significantly increased cumulative incidence of relapse (at months aa: . %, ag: . % and gg: . %; p= . ). on contrary, the frequency of the acute gvhd grades iii-iv and cytomegalovirus (cmv) reactivation/disease decreased according to the presence of the g allele in the donor ctla- genotype [agvhd: aa: %, ag: %, gg: %; p= . ; cmv: aa: %, ag: %, gg: %; p= . ]. cumulative incidence of agvhd was also markedly decreased among patients with g allele carrier donors (at days aa: . %, ag: . %, gg: . %; p= . ). donor genotype similarly influenced hsct outcome in mud donor and mac conditioning subgroups. overall survival (os) was not different in patient subgroups according to donor genotypes [os at months: aa: . ± . %, ag: . ± . %, gg: . ± . %; p= . ]. we did not find any correlation between recipients' ctla- + a>g polymorphism and hsct outcome. conclusions: several ctla- snps have previously been described to be associated with relapse rate, incidence of agvhd and os, but results are often contradictory in the publications. in our study, ctla- + a>g polymorphism of hsct donors influenced risk of relapse, agvhd, cmv and cause of death, but not overall survival. the genotyping of ctla- + a>g polymorphism in donors may help in the risk assessment process and the choice of personalised therapy. disclosure: nothing to declare. background: although steroids remain first-line therapy for the treatment of acute graft versus host disease (agvhd), response rates in patients with grade iii-iv disease are poor, with no apparent improvement in survival over the past years. we performed a prospective, multicenter trial to assess the efficacy and safety of the combination of ruxolitinib and etanercept as a novel approach to treat grades iii-iv sr-agvhd . methods: forty malignant hematologic disease patients with grades iii-iv sr-agvhd after allo-sct from three centers in east china were enrolled from january to june . ruxolitinib was initiated at a dose of - mg bid for months, and then tapered gradually for another one month. etanercept was administrated at mg biw for - weeks. results: the median age of patients was (range - ) years. at day after the combination treatment, the overall response rate (orr) was % including crs ( %) and prs ( %). the median time to the optimal response was (range - ) days. the incidences of cr per organ were . %, . %, and % for skin, liver, and gut, respectively. the agvhd relapse rate was analyzed for the patients who had achieved cr or pr and survived beyond days. relapses in agvhd occurred in . % ( / ) of responsive patients. the patients who received ruxolitinib within days after agvhd onset have a significant higher cr rate that those with delayed ruxolitinib therapy ( . % vs. . %, p= . ). and the patients without gut infections have a significant higher cr rate than infected cohort ( . % vs. . %, p= . ). by logistic regression analysis, the time from agvhd to ruxolitinib (rr= . , p= . ) and gut infection (rr= . , p= . ) were independent predictors for incomplete response. thirteen patients ( / , . %) suffered from at least infectious episode after the start of the combination therapy, and pulmonary infectious diseases was a frequent complication ( / , . %). iii-iv cytopenia and cmvreactivation were observed in % and . % of patients. the -year overall survival (os) after initiation of the combination therapy were . %. the -year nrm and relapse incidence was . % and . %, respectively. patients with complete response on day had significantly higher os probability than non-cr patients ( -year os: . % vs . %, p= . ). compared with the historical cohort of basiliximab and etanercept for sr-agvhd in our center (n= ), no significant difference was found on the baseline. although the orr in patients treated with ruxolitinib and etanercept is identical with the historical cohort, ruxolitinib group achieved rapider remissions in liver agvhd and gut agvhd than the historical cohort (gut agvhd: days vs. days, p= . ; liver agvhd: days vs. days, p= . ), thus, with regard to hospital stay after agvhd onset, the ruxolitinib cohort stayed shorter (median: days vs. days, p= . ) than basiliximab cohort. conclusions: combined treatment with ruxolitinib and etanercept resulted in a rapid cr to visceral agvhd and meanwhile reserve graft anti-leukemia (gvl) effect as the relapse rate of primary disease is relatively lower. the various infection complications associated with ruxolitinib merit more attention. disclosure: nothing to declare background: graft-versus-host disease (gvhd) remains one of the main life-threatening complications after allo-hsct, especially in patients with non-malignant diseases. the standard gvhd prophylaxis strategy is mostly based on the use of calcineurin inhibitors alone or in combination with other immunosuppressive (is) post-transplant cyclophosphamide (ptcy) is effective gvhd prophylaxis optiont for adult patients (pts), but has limited data in children. methods: the study aim was to evaluate ptcy as gvhd prophylaxis in pediatric pts with inherited disorders undergoing allo-hsct. pts, the most of them are pediatric age (median age - y.o., range month - y.o.) with different types inherited disorders (β-thalassemia - , bone marrow failure syndromes - , storage diseases - , primary immunodeficiencydisorders - ) were inrolled in retrospective study. donor type was: matched/mismatched unrelated (mud/mmud) - , matched related donor (mrd)- , haploidentical (haplo) - . conditioning regimen was: myeloablative (mac) - , reduce-intensity (ric) - . graft sourse was: bone marrow (bm) - , peripheral blood stem cells (pbsc) - , combintions bm +pbsc/bm+cord blood - . ptcy mg/kg days + , + based gvhd prophylaxis recived pts., standart gvhd prophylaxis based on calcineurin inhibitors - pts. results: cumulative incidence (ci) of agvhd was %. grade - , - agvhd were % and % respectively. ptcy based gvhd prophylaxis reduced ci of agvhd ( % vs %, p= , ). another reduce ci of agvhd factors were mac ( % vs % in ric pts group, p= , ), mrd ( % vs % in haplo group vs % in mud/mmud group, p= , ), bm as a transplant source ( % vs % in pbsc group, p= , ). in a multivariate analysis mac (hr , %ci , - ,, p= , ), time from diagnosis to allo-hsct less then month (hr , %ci , - , , p= , ) were predictive for reducing ci agvhd. for agvhd - st. significant factor increase ci was female donor both in univariate ( % vs %, p= , ) and multivariate analysis (hr , %ci , - , , p= , ). years overall survival (os) was %. improving os factors were: transplant age younger then y.o. ( % vs %, p= , ), time from diagnosis to allo-hsct less then month ( % vs %, p= , ), engraftment ( % vs %, p= , ). in a multivariate analysis only transplant age younger then y.o. (hr , %ci , ( ) ( ) ( ) ( ) ( ) p= , ) and engraftment (hr , %ci , - , , p= , ) were predictive for os. conclusions: ptcy-based gvhd prophylaxis can be effective options for reduce risk of acute gvhd. using unrelated donors, bone marrow as transplant source and mac can reduce ci of gvhd. performing allo-hscr earlier from diagnos and in earlier age can improve os patients with inherited disorders background: diarrhea is a frequent complication after allo-sct. at onset it is often difficult to differentiate gi gvhd from other causes of enterocolitis. recently, non-invasive tests, such as fecal calprotectin (fc), have been validated as markers of gut inflammation in patients with inflammatory bowel disease, but only a few studies have been published regarding its use as a diagnostic marker in gi gvhd. methods: our aim in this study was to explore the levels of fc in allo-sct recipients with new-onset diarrhea. so far we have included allo-sct recipients who developed acute diarrhea ≥ stage - at a median of days (range: - ) post allo-sct. stool samples were analyzed as soon as possible after the onset of diarrhea. fc levels were determined in addition to an extensive microbiological panel for infectious enterocolitis (including norovirus pcr and c. difficile associated diarrhea). endoscopies for histologic analysis were performed according to the treating physicians' discretion (n= ). results: patients characteristics are summarized in table . median follow-up for survivors was days (range: - ). twenty-eight patients ( %) were diagnosed of gi-gvhd. the additional causes of diarrhea were: drug-related enterotoxicity (n= ), viral enteritis (n= ), food intolerance (n= ), c.jejuni-enteritis (n= ), and non-specific causes (n= ). the concentration of fc was higher in patients with gi gvhd vs. other causes of diarrhea ( μg/g +/- vs. μg/g +/- , p= . ). patients who did not develop severe enterocolitis had normal to slightly raised calprotectin at the onset of diarrhea [< - in out of ( %) cases], including % ( / ) of patients with enterotoxic drug-related diarrhea. among the patients with gi-gvhd, ( . %) were later found to be steroid-resistant. as shown in figure , we found a significant association between high fc (≥ μg/g) and severe-refractory gvhd (hr . , p= . ). of note, high values of fc were also found in patients with severe infectious enteritis (norovirus, adenovirus and c.jejuni infections), with baseline fc> μg/g, respectively. overall survival was % (ic %: - ) at months. hypoalbuminemia and thrombocytopenia were the only variables linked to -yr os in univariate analysis, regardless of the cause of enterocolitis. conclusions: in the absence of standarized (and expensive) biomarker panels for analyzing and predicting gvhd onset and outcomes, the fc test may be an useful tool in the allo-sct setting. our initial results show that fc is helpful in predicting mild causes of diarrhea and to identify patients with a high probability of developing severe (and potentially steroid-refractory) gi gvhd, although high levels are also found in severe infectious enteritis. background: there is an urgent need for effective therapy for severe acute gvhd. results of gvhd therapies beyond months are rarely reported. we here report a median follow-up of years. we introduced mesenchymal stromal cells as therapy for severe acute gvhd, with a dramatic response in some, but not all patients. the placenta protects the fetus from the mothers haploidentical immune system during pregnancy. we found that maternal stromal cells from the fetal membrane, so called decidua stromal cells (dscs) were more immunosuppressive than other sources of stromal cells. methods: we treated patients, median years of age (range . - ) for severe acute gvhd. all had biopsy proven gastro-intestinal gvhd. all were steroid refractory, after > days or with progression and after > days. we used an improved protocol where dscs were thawed and infused in a buffer with % albumin. dscs were given at a median dose of . ( . - . ) x cells/kg and ( - ) doses, given one week apart. viability of frozen and thawed dscs was % ( - ) and cell passage was ( - ). results: complete resolution of gvhd was seen in patients and had a partial response. the cumulative incidence of chronic gvhd was %. six had mild, moderate and one severe nih overall gvhd severity scoring. nine patients died, from relapse, acute gvhd and septicemia, zygomycetes infection, liver insufficiency, cerebral hemorrhage, multiorgan failure and chronic gvhd with obstructive bronchiolitis. four years transplant related mortalliy was . % and overall survival was %. survival was not significantly worse (p= . ) than % for all patients undergoing allogeneic hematopoietic cell transplantation during the same period - . conclusions: to conclude, dscs seems to be a promising therapy for severe acute gvhd. randomized trials are under way. disclosure: nothing to declare p anti-apoptotic protein bcl- is upregulated in graftversus-host disease stem cell transplantation (allo-hsct) with - % developing either acute or chronic gvhd. recently, bcl- inhibitor venetoclax was approved for treatment of chronic lymphocytic leukemia. induction of apoptosis and depletion of lymphocyte subpopulations e.g. follicular b-cells or cd + and cd + t-cells led to further exploration in autoimmune disease. methods: to establish expression levels of genes in the bcl- pathway, low-input rna sequencing was performed on t cells isolated from non-inflamed skin and peripheral blood of hsct recipients at different time points before until year after transplantation. furthermore, we analyzed blood, lung, gut and skin samples of patients post allo-hsct with and without previously untreated acute or chronic gvhd by rt-pcr, flow cytometry and tissue immunofluorescence. [[p image] . bcl- is up-regulated in t and b lymphocytes of acute and chronic gvhd lesions.] results: rna-sequencing revealed that t cells upregulated bcl- upon conditioning treatment (day ) and cells of patients who later developed gvhd failed to downregulate bcl- after transplantation (day+ , day+ ). bcl- protein levels were elevated in overall leukocytes and pathogenic cell subsets including monocytes, cd + t lymphocytes and nkt cells showed significantly higher expression of bcl- in peripheral blood of gvhd patients as compared to healthy controls. these results could be recapitulated in tissue samples, where disease-promoting lymphocytes (t, b, nk, nkt) were numerically expanded and expressed bcl- in acute and chronic gvhd skin lesions. notably, non-pathogenic cell types such as keratinocytes did not exhibit increased bcl- expression compared to control samples from hsct recipients and healthy donors. while bcl- rna expression did not depend on type of conditioning (mac vs. ric) or gvhd grade, it correlated to disease severity and was significantly elevated in biopsies of patients with steroidrefractory gvhd. conclusions: we could show exclusive upregulation of bcl- in gvhd-mediating cell types in peripheral blood and tissue samples affected by gvhd, correlating to gvhd severity and response to first-line therapy. thus, bcl- inhibition may present a novel and urgently needed targeted therapy in treatment of steroid-refractory acute and chronic gvhd. disclosure: supported by a docmed fellowship od the austrain academy of sciences background: graft-versus-host disease (gvhd) represents a major contributor to morbidity and mortality in recipients of allogeneic hematopoietic cell transplants (hct). several therapeutic strategies exist for gvhd prophylaxis and include post-transplant cyclophosphamide (ptcy) and antithymocyte globulin (atg). while several groups have described the use of ptcy in younger patients, there is a paucity of data about the efficacy of ptcy in older individuals, particularly when combined with atg. we investigated the combined effect of ptcy with atg on transplant outcomes in older patients at princess margaret cancer centre, toronto, canada. methods: this retrospective study included all patients age ≥ who underwent allogeneic hct for any indication at our centre between december and july . overall survival (os) was calculated using kaplan-meier analysis and multivariable cox proportional hazards regression. cumulative incidence of relapse (cir) and non-relapse mortality (nrm) were calculated using competing risk regression (fine and gray method). incidences of acute (agvhd) and chronic (cgvhd) were compared using the fisher's exact test. results: of patients, ( %) were male. median age was (range - ) and median follow-up among survivors was months (range - ). acute myeloid leukaemia (aml) was the most common indication for hct ( patients, %), followed by myelodysplastic syndrome ( patients, %) and myelofibrosis ( patients, %). eightyfour ( %) patients had a matched unrelated donor, ( %) had a matched related donor and ( %) had a haploidentical donor. one hundred twenty-five ( %) patients received reduced intensity conditioning. sixty-two ( %) patients received ptcy combined with atg ( . mg/kg) while ( %) received other forms of gvhd prophylaxis. os at years was % ( % confidence interval (ci) - ) in the entire cohort. patients who received ptcy with atg had a superior -year os compared with other gvhd prophylaxis regimens ( figure a ): % ( % ci - ) vs. % ( % ci - ), respectively (hr= . , % ci . - . , p= . ). the -year nrm for the entire cohort was % ( % ci, - ). patients who received ptcy with atg had a lower -year nrm compared to those who did not ( figure b ): % ( % ci - ) vs. % ( % ci - ), respectively (hr= . , % ci . - . , p= . ). the -year cir in the whole group was % ( % ci - ). use of ptcy with atg was associated with a modest increase in cir at two years ( figure c ): % ( % ci - ) vs. % ( % - ), respectively (hr= . , % ci . - . , p= . ). there was a trend toward lower incidence of grade ii-iv agvhd among patients who received ptcy with atg compared to those who did not: % vs. % (p= . ). the incidence of grade ii-iv cgvhd was lower in individuals who received ptcy with atg compared to those who did not: % vs. % (p= . ). conclusions: in older hct recipients, use of ptcy combined with atg is associated with improved os, lower nrm, decreased risk of both agvhd and cgvhd and a modest increase in relapse risk. therefore the ptcy with atg combination represents an effective strategy for gvhd prophylaxis in older allogeneic hct recipients. disclosure: the authors have no conflict of interest to declare. outcome of severe graft versus host disease in pediatric patients with nonmalignant diseases after allogeneic bone marrow transplantation. a single center experience irina zaidman , sigal grisariu , batia avni , ehud even-or , bella shadur , adeeb nasereddin , polina stepensky background: hematopoietic stem cell transplantation (hsct) remained the only curative option for many nonmalignant diseases in pediatric patients. survival after hsct has improved the last few years due to significant advancement in human leukocyte antigens (hla) typing techniques, less toxic conditioning regimens and better supportive care and resulted to % survival and cure in some non malignant diseases. graft-versus-host disease (gvhd) remains a major complication of hsct and leading cause of morbidity and mortality. prognosis of patients with high grade gvhd is dismal and survival rate varies between % to % in pediatric patients. methods: the retrospective study included patients with non malignant diseases who underwent allogeneic hsct at hadassah medical center from to . the collected data included patient´s clinical data and transplant characteristics. the study was approved by the institutional helsinki committee. results: children with nonmalignant diseases underwent allogeneic bone marrow transplantations in hadassah university hospital during ten years period. fifty seven patients ( %) developed agvhd grade - , twenty five of them ( . %) grade - . median age was . (range . - . ), most patients were males ( males, females). patients underwent bmt from fully matched family members, children were transplanted from matched unrelated donors and from mismatched donors. twenty one of patients with severe gvhd ( %) survived. four patients ( %) died from severe gvhd and complications of immunosuppressive treatment. of deceased patients were transplanted from mismatched donor, in of cases the age of donor was advanced, of patients developed severe gvhd and died after second hsct. all patients were refractory to different treatment modalities. three of patients died in and one in , it was no death from severe gvhd in patients that were transplanted and developed high grade gvhd after . conclusions: the results of this study show a high survival rate of % in pediatric patients with non malignant diseases and severe gvhd. significant risk factors for mortality in our group included mismatched donor, advanced age of donor and second transplant. trend to better survival was observed after . additional multicentral studies analyzed the outcomes of agvhd in pediatric patients with nonmalignant diseases are urgently required. background: chronic graft-versus-host disease (cgvhd) is a serious late complication after allogeneic hematopoietic stem cell transplantation (allohsct) with heterogeneous presentation and still poorly understood pathophysiology including inflammation and endothelial dysfunction. factor viii (fviii) and von willebrand factor (vwf) are coagulation factors but also known indicators of endothelial dysfunction and inflammation in different settings, and therefore could serve as interesting candidate biomarkers of cgvhd. methods: since patients after allohsct were assessed by the multidisciplinary cgvhd team at the university hospital center zagreb, croatia, using established nih cgvhd-related measurements. an extensive history, physical and laboratory evaluations were performed, including fviii, vwf:ag and vwf:ac analysis. descriptive statistic and non-parametric analyses were performed. variables that showed significant univariate correlations were used in multivariate logistic regression (mlr) to identify the most predictive for fviii, vwf:ag and vwf:ac in cgvhd patients. results: cgvhd patients and controls (subjects after allohsct without cgvhd) were analysed. median age of cgvhd patients was ( - ) years, % females, . % underwent allohsct for hematologic malignancies, . % had myeloablative conditioning and . % matched related donor. median time from hsct to study was . days and from cgvhd diagnosis to study days. there were no demographic neither transplant related significant differences between cgvhd patients and controls beside stem cell source (peripheral blood . % vs . %, p= . ) and history of acute gvhd ( . % vs . %, p< . ). majority of patients had moderate ( . %) or severe ( . %) nih global cgvhd score, . % active cgvhd by clinician´s impression. median number of organs involved by cgvhd was ( - ), and the most frequently involved organs were mouth, skin and eyes ( . % each). cgvhd patients compared to controls had higher fviii levels (median ( - )% vs ( - )%, p= . , reference range - %) and higher vwf:ag (median . ( . - )% vs . ( . - )%, p= . , reference range - %), while vwf: ac showed a trend toward higher levels among patients (median . ( - )% vs ( . - )%, p= . , reference range - %). patients had higher ggt (p= . ), lower anticardiolipin igg (p= . ) and igm (p= . ), and lower albumin (p= . ) than controls, without differences between other laboratory parameters. univariate analysis showed that among cgvhd patients higher fviii was associated with worse karnofsky score (ks) (p= . ) and performance score (ps) (p= . ), higher leukocytes (p= . ), cholesterol (p= . ), triglycerides, ast, alt, ggt, ldh, and lower albumin. higher vwf:ag and vwf:ac in cgvhd patients were associated with worse ks and ps (p< . ), with more active cgvhd (p< . ), worse nih cgvhd liver (p= . ; p= . ) and nih cgvhd mouth (p= . ; p= . ), higher total nih score (p= . ; p= . ), higher number organs involved (p= . ; p= . ), higher esr, monocytes, ddimers, ast, alt, ggt, ldh, triglycerides, β- -microglobulin, ferritin, total proteins, iga and lower albumin. mlr analysis showed leukocytes (p= . ) and cholesterol (p= . ) as the strongest predictor of fviii (r = . %; p< . ), while strongest predictor of vwf: ac was number of organs involved by cgvhd (r = . %; p= . ). conclusions: results of this study detected high fviii and vwf levels in cgvhd patients with possible reflections to cgvhd manifestations, what needs to be further confirmed in larger longitudinal studies. disclosure: this work was supported, in part, by the unity through knowledge fund project entitled "clinical and biological factors determining severity and activity of chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation", and also, in part, by the croatian science foundation project entitled "new biomarkers for chronic graft-versus-host disease". antonela samardzic -work financed by the croatian science fondations`"young researchers`career development project -training of doctoral students" background: thrombotic microangiopathy (tma) is a severe complication of allogeneic hematopoietic cell transplantation (hct) with multisystem involvement. a few recent reports have recognized evidence of tma in the intestinal vasculature (intestinal tma/itma) of patients with graft-versus-host disease (gvhd) with or without tma. we aimed to identify patients with itma and describe histological, clinical and prognostic features. methods: we prospectively evaluated available endoscopic samples (stomach and/or colon) from consecutive adult hct recipients for previously described histopathologic signs of itma (january -september ). systemic tma was diagnosed according to the international working group criteria. we compared findings among clinical groups: gvhd/systemic tma, gvhd/no systemic tma and no gvhd/no tma. results: we studied patients, classified as gvhd/ systemic tma, gvhd/no systemic tma and no gvhd/no tma. baseline transplant characteristics (age, donor, hla matching, conditioning) did not differ significantly among groups. histological features of itma, including loss of glands, total denudation of mucosa, apoptosis and detachment of endothelial cells, intraluminal fibrin, intraluminal microthrombi and mucosal hemorrhage were found in patients. previously described features of intraluminal schistocytes were not observed in our patients. interestingly, loss of glands, total denudation of mucosa, apoptosis and detachment of endothelial cells were also found in patients with gvhd and no itma, suggesting that these features are not pathognomonic of itma. among itma patients, two patients were classified in the clinical group of acute gvhd/systemic tma, while the other patients had clinical and histopathological features of itma and severe grade iii-iv steroid-refractory acute gvhd ( patients) or extensive chronic gvhd ( patient) but no evidence of systemic tma. in the majority of patients ( / ), itma occurred during the early posttransplant period at . ( . - ) months. clinical features (gastrointestinal bleeding, diarrhea, pain, nausea) presented no differences between patients with or without itma. prognosis was poor for patients with itma who suffered from a significantly higher mortality rate of % compared to the rest patient population (p= . ). with a median follow-up of . ( . - . ) months, year overall survival probability (os) was . for itma, % for gvhd and % for systemic tma. unfavorable predictive factors for os were itma (p= . ), hla mismatched donors (p= . ) and gastro-intestinal bleeding (p= . ). conclusions: intestinal tma has emerged as a novel distinct entity in patients with gvhd and/or systemic tma. distinct histological features may be useful in differential diagnosis of these severe hct complications. mortality rates higher than those of systemic tma highlight the need of proper recognition of itma that needs to be further studied in terms of diagnostic and therapeutic potential. disclosure: e.g. was supported by the european hematology association clinical research grant. the remaining authors declare no competing financial interest. the beneficial effects of thrombomodulin gene polymorphisms after hematopoietic stem cell transplantation background: chronic graft-versus-host disease (cgvhd) remains the major cause of late morbidity and mortality after allogeneic blood and marrow transplantation. treatment options for cgvhd, particularly its sclerotic forms remain limited. active hedgehog (hh) signaling was shown as a therapeutic target in both mouse and human cgvhd, with limited efficacy and significant toxicities described in a published clinical trial (defilipp, ). methods: adult patients with steroid refractory sclerodermatous cgvhd, defined as requiring > . mg/kg/day of prednisone dose equivalent (pde), or need for second-or third-line therapy beyond corticosteroids and calcineurin inhibitors or sirolimus were eligible for this open label study of vismodegib, a first generation hh pathway inhibitor. primary endpoint was failure free survival, defined as absence of non-relapse mortality, no recurrent malignancy, steroid dose at months =< . mg/kg/day of pde, and no addition of new systemic treatment. vismodegib was administered orally for - months, with dose reductions at development of toxicities. peripheral blood mononuclear cells were isolated from samples collected at treatment initiation and every three months thereafter. the immune profile of circulating b cells was analyzed by flow cytometry and t helper polarization by qrt-pcr of sortpurified cd + t cells. results: at the time of interim analysis, patients were evaluated. patients completed months of treatment and five patients completed months of treatment. therapy was discontinued in patients prior to months due to treatment-related (n= ) and unrelated (n= ) side effects. most patients experienced grade toxicities (muscle cramps and dysgeusia), with only a single grade toxicity (weight loss). patients who completed months of therapy demonstrated partial response, and overall, the primary endpoint was reached in % ( / ) of patients. in patients who discontinued vismodegib, cgvhd worsened acutely after discontinuation. correlative analysis of immune cellular subsets in peripheral blood in paired samples (pre-treatment and month of therapy) documented modulation of b cell subsets pathogenic in cgvhd (pregerminal center and plasmablast-like b cells) and diminished t helper polarization in cd t cells. conclusions: overall, use of vismodegib was associated with potential clinical efficacy in sclerodermatous cgvhd with possible mechanistic evidence arising in correlative studies. while side effects were common, further studies of hh inhibition in cgvhd are warranted. future studies should employ adjusted dosing regimens, along with supportive care interventions to offset side effects, and testing of novel hh inhibitors with enhanced safety profiles. clinical background: graft-versus-host disease (gvhd) results from recognition of host antigens by donor t cells following allogeneic hematopoietic stem cell transplantation (sct). we tested the hypothesis that somatic neomutations occurring after sct from donor and/or recipient dna may trigger gvhd. methods: we longitudinally analyzed both constitutive and somatic mutations by whole exome sequencing (wes) in patients who received sct from a sex-matched hlaidentical sibling for npm mutated acute myeloid leukemia (pt# ) and jak v f mutated primary myelofibrosis (pt# ). both patients were initially refractory to alloreactivity, i.e. not displaying any signs of gvhd, even after several donor lymphocyte infusions. acute gut gvhd finally occurred after a further dli preceded by a lymphodepleting chemotherapy. in pt# , gvhd correlated with a graft-versus-tumor effect. wes was performed on dna from recipient saliva and donor pbmcs (germline samples) and from sequential post-sct pbmcs samples on a hiseq illumina with x bp paired-end reads at a mean depth of coverage of - x. germline and somatic mutations were determined using in-house bioinformatic pipelines (named ewok from the curie institute and smaug from the henri mondor hospital), using briefly gatk as variant caller for germline samples, and a combination of variant callers for matched normaltumor pairs. we adjusted parameters to detect somatic mutations at a minimal variant allelic frequency (vaf) of % compared to recipient and donor germline for all variations (minimal coverage = x for germline and x for tumor sample). results: wes allowed detecting somatic driver mutations explaining aml and pmf for both patients in the initial timepoint and all these driver mutations disappeared at the following timepoints. as expected, the somatic variant rate was x higher in pt# with aml than in pt# with pmf at each timepoint, except for the final gvhd timepoint. indeed, at this final point, the somatic variant rate dramatically decreased by % as compared to previous timepoints. by subtracting variants detected pre-and post-sct from those identified at the ultimate time-point of gvhd occurrence, we created sets of and variants respectively for each patient (keeping only variants with at least reads of mutated dna). these variants can be classified in categories: (i) those with only with a slight increase at time of gvhd, i.e. ≤ -fold compared to highest previous vaf (lrrc , or u , or g , alpp, frg , frg b and lilrb genes), and (ii) those with a significant increase at that time, i.e. > -fold compared to highest previous vaf (phf , smpd , ercc and krtap - genes). none of the variants or genes involved was common between the patients. ontology classification of mutated genes showed the implication of some of them in cell death, regulation of map kinase activity, mrna splicing and immune system process, making them good candidates for further studies. identification of variants appearing pre-gvh and turning off at time of gvhd is ongoing to unveil putative neoantigens that could trigger the alloreactive response. conclusions: using a comprehensive, pre-and post-sct, wes of donor/recipient pairs, we identified several neomutations from donor and/or recipient dna correlating with gvh/gvt effect development. disclosure results: a total of patients experienced cgvhd, and mild, moderate, and severe cgvhd were observed in , , and patients, respectively. the -year cumulative incidence of total cgvhd was . % ( % ci, . - . %), and the -year cumulative incidence of moderate to severe and severe cgvhd was . % ( % ci, . - . %) and . % ( % ci, . - . %), respectively. the patients who had loci mismatched had a higher -year cumulative incidence of total cgvhd ( . % vs. . %, p= . ) and moderate to severe cgvhd ( . % vs. . %, p= . ) compared to those of the patients who had - loci mismatched. the patients who had maternal donors had a higher -year cumulative incidence of moderate to severe cgvhd ( . % vs. . %, p= . ) compared to that of the patients who had other donors. the patients who had grade iii to iv acute graft-versus-host (agvhd) had a higher -year cumulative incidence of total cgvhd ( . % vs. . %, p< . ) and moderate to severe cgvhd ( . % vs. . %, p< . ) compared to those of the patients without agvhd. in multivariate analysis, grade iii to iv agvhd was the only independent risk factor for total cgvhd (hr= . , %ci, . - . ; p< . ) and moderate to severe cgvhd (hr= . , %ci, . - . ; p< . ). in the model excluding agvhd, maternal donor was the risk factor for moderate to severe cgvhd (hr= . , %ci, . - . ; p= . ). conclusions: we observe that severe agvhd was the most important risk factors for cgvhd after haplo-hsct, and further interventions should be considered in these patients to prevent severe cgvhd. disclosure: none of the authors have any potential financial conflict of interest related to this manuscript. background: extracorporeal photopheresis (ecp) has been successfully used for the treatment of graft-versus-host disease (gvhd). ecp therapy might restore the balance between effector and regulatory cells which is severely impaired in gvhd. nk cells are the first lymphocyte subset to be reconstituted after allogeneic hematopoietic stem cell transplantation (allo-hsct). as an important innate immune cell population, nk cells can temporally bridge the transient period of t-cell deficiency post allo-hsct, by protection from opportunistic infections and prevention of leukemic relapse by graft-versus-leukemia (gvl) effect. nk cells not only preserve homeostasis through targeted killing of allo-reactive t cells and thereby control gvhd but also enhance inflammation by secretion of tnf-α and ifn-γ and thereby promote gvhd. therefore, we investigated here the role of nk cells in gvhd patients under ecp therapy. methods: thirty four patients with steroid-refractory/ resistant agvhd ≥ ii°and moderate to severe cgvhd received ecp therapy which performed according to the guidelines. glucksberg and nih criteria were used for clinical staging of agvhd and cgvhd under ecp therapy, respectively. the comprehensive phenotypical analysis of nk cells was evaluated by multicolor flow cytometry. nk activity in terms of killing function, cytokine release capacity and proliferation function was monitored by chromium- release assay, intracellular cytokine staining and cfse staining, respectively. results: five different nk cell subsets were defined based on cd and cd expression. cd bri nk cells displayed an immature and activation profile with high expression of cd l and nkg d. agvhd patients had a higher frequency of cd bri nk cells when compared with hds and cgvhd patients, who were characterized by significant increase of the cd dim cd + and cd -cd + nk cell subsets with high expression of differentiation markers cd b and cd . of note, cd bri cd -nk cells could serve as a novel predictive biomarker for the response of agvhd patients to ecp treatment. in responding agvhd patients, an increase of cd bri nk cells was observed already during the early ecp treatment phase, suggesting immune reconstitution. after priming of the progenitors, ecp could differentiate immature cd bri nk cells into mature cd dim nk cells with reduction of cd l on cd bri nk cells. moreover, cd dim nk cells could further be matured through upregulation of cd expression by ecp. notably, ecp therapy could shift the nk cells from a cytotoxic to a regulatory phenotype within the cd bri nk cells. in spite the immunomodulatory effect of ecp on nk cells, nk activity could be kept intact under ecp therapy. the killing activity of nk cells was stable as confirmed by a cr release assay. ecp therapy had no negative effect on the quantity and quality of cytokine release by nk cells upon k stimulation. especially, the polyfunctionality of nk cells was not altered significantly by the ecp therapy. conclusions: nk cells play an important role in gvhd and could serve as a predictive cell population for the clinical response to ecp therapy. in the current study, ecp influenced the differentiation, maturation and education of nk cells ameliorating gvhd without comprising the antiviral immune defense and gvl effect. disclosure: the authors declare no competing financial interests, except the following: therakos mallinckrodt gave a financial support to as and ms for the documentation of the clinical course and for the analysis of immune cells of the patients, pw has honoraria and membership on advisory boards for sanofi-aventis. abstract withdrawn. cyclosporine levels > µg/l on day post-transplant was associated with significantly reduced acute graftversus-host disease following allogeneic hematopoietic stem cell transplantation monica bianchi , dominik heim , claudia lengerke , martina kleber , dimitrios tsakiris , jakob passweg , alexandar tzankov , michael medinger background: acute graft-versus-host disease (agvhd) remains a major complication of allogeneic hematopoietic stem cell transplantation (allo-hsct). affected patients, especially with steroid-refractory agvhd, have a very poor prognosis. prophylaxis with cyclosporine a (csa) is the backbone of gvhd prevention in most conditioning regimens. methods: in a retrospective analysis of patients treated with allo-hsct, we correlated csa levels at the day of transplantation (day ) and day + with the incidence of acute and chronic gvhd. we postulate that higher target csa levels > μg/l will result in a lower incidence rate especially of agvhd after allo-hsct. results: we assessed patients with either aml n= , lymphoma/myeloma n= , mds/mpn n= , all n= , cll n= , cml n= , or bone marrow failure n= . in patients with clinically relevant agvhd grade ≥ , mean csa levels was lower on day and day + ( ± μg/l; and ± μg/l; respectively) compared to patients without agvhd ( ± μg/l; and ± μg/l; respectively; day : p= . ; day + : p= . x - ). in patients with csa level < μg/l, the incidence of agvhd was significantly more frequent compared to patients with csa levels > μg/l [( / ; %) versus / ( %); p= . x - ]. in patients with cgvhd, there was no significant difference between csa levels < μg/l ( / ) compared to csa levels > μg/l ( / ; p= . ). the optimal csa cut-off level for the prevention (i.e. roughly % incidence reduction) of agvhd was > μg/l at day and > μg/l at day + ( figure ) in a competing risk analysis, time to agvhd grade ≥ (using death of other causes as competing risk) was associated with csa levels > μg/l on day and on day , unrelated donors, myeloablative conditioning (mac), and for the diagnosis lymphoma/myeloma. conclusions: our data support close monitoring with active adjustments of csa dosing to maintain therapeutic csa levels above μg/l in the first days of allo-hcst to reduce agvhd. disclosure: noting to declare. liposomal cyclosporine a for inhalation (l-csa-i) to treat bronchiolitis obliterans syndrome: novel formulation with therapeutic potential for patients with bos following allo-hsct noreen roth henig , emilie hofstetter , dominik kappeler , gerhard boerner background: bronchiolitis obliterans syndrome (bos) is a rapidly progressive lung disease caused by t-cell mediated inflammation that leads to blockage of bronchioles, leading to respiratory failure and death shortly after diagnosis. approximately % to % of patients who undergo allogeneic hematopoietic stem cell transplant (allo-hsct) will develop bos, with - % developing bos as a respiratory form chronic graft-vs-host disease (cgvhd) in addition to other signs of cgvhd. mean time to bos diagnosis ranges from to days post-transplant. the histopathology of bos after allo-hsct and lung transplantation is identical. early studies of l-csa-i for the prevention of bos in lung transplant recipients demonstrated therapeutic benefit. l-csa-i is a novel, liposomal formulation of cyclosporine administered via a pari investigational eflow â nebulizer which delivers a potent immunosuppressant to the site of disease. pharmacokinetics and tolerability of l-csa-i is presented. methods: retrospective review of two clinical studies of l-csa-i (isotonic, mg/ml) for bos associated with lung transplantation. both studies had a control arm and results reported here are for patients who received l-csa-i. subjects received mg (single lung transplant) and mg (double lung transplant) bid via inhalation. blood samples for pharmacokinetic analysis of cyclosporine a concentrations were collected before inhalation, immediately after inhalation, and thereafter in intervals of , , min and , , and hours. local and general tolerability of l-csa-i was investigated. results: between the two studies, subjects received either or mg bid of l-csa-i. pharmacokinetic models predict a constant drug level in the lung. maximum serum cyclosporine a concentration after inhalation was . ± . ng/ml. trough levels for up to -years of daily administration was - ng/ml with no evidence of accumulation following repeated exposure. tolerability data was assessed from patient-month exposure to l-csa-i. reported symptoms were: pharyngeal soreness %; cough %; dyspnoea %; and wheezing %. no subject discontinued due to intolerability. inhalation time is on average - min. conclusions: l-csa-i provides high and constant concentrations to the airways of the lungs and the site of bos. l-csa-i is well tolerated in lung transplant patients. use of l-csa-i instead of augmentation of systemic csa reduces the total drug exposure. a multicentre phase safety and exploratory efficacy trial for the treatment of bos in allo-hsct recipients is underway. disclosure background: there are a number of biomarkers that predict non-relapse mortality (nrm), graft-versus-host disease (gvhd) and relapse incidence (ri) after conventional gvhd prophylaxis based on calcineurin inhibitors with or without antithymocyte globulin. currently there is limited data whether the conventional predictive biomarkers work with posttransplantation cyclophosphamide (ptcy) prophylaxis. methods: prospective single-center study in - enrolled adult patients with acute leukemia in cr ( % with all, % with aml). received matched related bone marrow (bm) graft with single-agent ptcy and received unrelated peripheral blood stem cell graft (pbsc) with ptcy, tacrolimus and mmf. the grafts were studied by flow cytometry (facs aria ii, antibodies by miltenyi biotec). the following populations were analyzed: cd , cd , cd , cd cd , nkt, inkt, treg, double-positive t-cells, double-negative t-cells, tcralpha/beta, tcr v memory cells. the crypreserved plasma from were analysed by elisa (commercial kits by ebioscience and critical diagnostics) for vegf a soluble tnf receptor (stnfr), il- , il- , soluble il- receptor, st , il- and stnfr. the above mentioned biomarkers were tested in logistic regression with roc analysis, assays with auc> . were selected for analysis in fyne-gray regression with competing risks. cut off levels were determined for significant parameters. results: median follow-up was months (range - ). in the whole group overall survival (os) was %, eventfree survival (efs) %, grade ii-iv acute gvhd %, moderate and severe (m&s) chronic gvhd %, nrm %, mortality in patients with gvhd %, ri %. there was no difference between bm/related and pbsc/unrelated grafts in the incidence of gvhd, nrm and ri (p> . ). the only significant predictor of acute gvhd were low levels of il- level on day+ (p= . , % vs % with the cut off pg/ml). m&s chronic gvhd was predicted only by the high percentage of inkt cells in the graft (p= . , % vs % with the cut off . %). there was a correlation between il- levels and number of nk cells in the graft (p= . ). nrm was related to infectious complications, nonetheless high levels of vegf a on day (p= . , % vs % with the cut off ng/ml), st on day+ (p= . , % vs % % with the cut off ng/ml) and low percentage of cd +cd -cells in the graft (p= . , % vs % with the cut off . %). the identified biomarkers of nrm had no association with the pre-transplant crp and ferritin levels (p> . ). the only significant parameter for ri was the level of cd cells in the graft (p= . ). none of the identified biomarkers significantly predicted overall survival (p> . ). conclusions: in the related and unrelated grafts with ptcy the study of biomarkers has low clinical utility due to very low gvhd-related mortality. however st and vegf a can predict infection-related mortality. also the study verified previous observations that high level of il- is associated with reduced gvhd incidence after ptcy and identified the importance of nk and inkt cells in the induction of tolerance with ptcy. references background: hematopoietic cell transplantation (hct) is the only curative approach for many hematological malignancies but life-threatening toxicities, such as graft-versushost disease (gvhd) and infections, still limit its fullpotential impact on the disease. strategies for keeping allohsct more effective and safe are needed in order to reduce morbidity while improving its immunological effect to control disease relapse. post-transplant cyclophosphamide (ptcy) has been demonstrated to improve acute gvhd (agvhd) and chronic gvhd (cgvhd) control in allogeneic bone-marrow hct from identical and haploidentical donor. the use of ptcy, after peripheral blood stem cell transplantation (allopbsct) from hla-matched unrelated/related donors, has been investigated by our group in a clinical trial (nct ) and preliminary results were published last year. here we report updated efficacy and safety data about the expanded cohort of patients treated with ptcy followed by tacrolimus and mycophenolate mofetil (t/mmf). methods: we analysed data about consecutive patients with high-risk hematologic malignancies received allopbsct from hla-matched unrelated/related donors between march and august . gvhd prophylaxis was ptcy mg/kg (days + + ), tacrolimus from day + and mmf from day + to day + . primary objectives were cumulative incidence of agvhd and cgvhd. secondary objectives were event-free survival (efs), cgvhd-efs, overall survival (os) and non-relapse mortality (nrm). results: patients median age at transplant was (range - ) years. ( %) patients were transplanted in first complete response (cr), ( %) patients in second/third cr, the others in disease control. a median dose of . (range - ) x ^ cd /kg was infused. primary graft failure was observed in one patient. all patients were off mmf on day + , the median day of tacrolimus discontinuation was (range - ). eight out of ( %) patients developed agvhd, ( %) of them were grade ii-iii; median day of onset was day (range . no grade iv was observed. no cases of late-onset agvhd were reported. cumulative incidence of cgvhd was % ( / ), median day of onset was (range - ). systemic treatments were required, but all patients were able to discontinue immunosuppression (is). with a median follow-up of (range - ) months, efs was %, cgvhd-efs was % and os was %. non-relapse mortality (nrm) was % ( / ): patients died because of multidrug resistant bacteria septicemia. nowadays patients are alive with no evidence of disease, being continuously off is and completely reintegrated in their normal daily life activities. conclusions: the updated reported results confirm, in a larger cohort of patients with a longer follow-up, that ptcy after pbsc-hct is highly active in agvhd and cgvhd prevention with extremely limited nrm. this strategy, not only allowed earlier discontinuation of immunosuppression, but also reduced the overall time of exposure to is for most of the patients. all these features might contribute, in the future, to transform hct into a safe immunologic platform that may be combined with advanced form of cellular therapies (car-tcells), aiming to increase safely the graftversus-tumor effect. clinical methods: pediatric patients ( - years) with nmd undergoing unrelated hct were eligible for this single center, phase i trial. following reduced intensity conditioning, abatacept ( mg/kg iv on days - , + , + , + ) was added to standard gvhd prophylaxis (cyclosporine, mycophenolate mofetil [mmf]). patients were followed for years for standard hct outcomes. [[p image] . figure results: since june , patients have been enrolled and transplanted (table , excluding # ). donor source was bone marrow in all. with median follow-up of . years, of patients survive without disease. initial engraftment was successful in , at a median of and days, for neutrophils and platelets respectively. one patient ( ) had secondary graft rejection in the setting of viral reactivation (cmv/ebv), with successful engraftment following a nd unrelated hct. in engrafted patients, myeloid (cd ) chimerism was % at all timepoints; t-lymphoid (cd ) chimerism was mixed but reached >/= % (figure ). one patient ( ) with saa had primary graft rejection in the setting of inadequate tnc dose ( . x /kg) and died from marrow aplasia/infection despite nd hct. a second death from wilms' tumor occurred months post successful hct, in a patient ( ) with dba and constitutional chromosome abnormality. except patient , all patients received doses of abatacept, which was well tolerated, with all severe adverse events expected for a hct population. cmv and ebv reactivation occurred in patients each, with resolution using standard anti-viral therapy. one patient ( ) was diagnosed with ebv-driven post-transplant lymphoproliferative disease, which responded to rituximab and immune suppression withdrawal. no patients developed severe acute (grade iii-iv) or chronic gvhd (table ) , and no patients required systemic immune suppression at > year. conclusions: these preliminary data suggest that abatacept can be safely added to cyclosporine and mmf gvhd prophylaxis in pediatric patients with bone marrow failure undergoing unrelated donor hct, with encouraging rates of gvhd despite half of patients having a mismatched ( / ) donor. given the higher risk of graft rejection in this non-malignant cohort, rejection (in addition to gvhd) will be a primary focus in our subsequent multi-center, phase trial. clinical trial registry: clinicaltrials. gvhd and may to have be separated from from toxicity to infectious complications in the early phase after allohsct. methods: from our files we identified patients which had upper gastrointestinal tract endoscopy after allohsct in with biopsies were taken from the esophagus, stomach and duodenum simultaneously. of these patients were excluded because of infection, reflux disease or drug toxity and the remaining patients were included in our study. we evaluated the routine stained esophageal biopsies, applied a grading scheme and compared the histological findings with those within the stomach and duodenum, the endoscopic findings and the clinical course. results: in of biopsy samples of the esophagus, we identified histological features of acute gvhd, ranging from vacuolar degeneration (grade ) and single-cell apoptosis (grade ) to the formation of clefts (grade ) and mucosa denudation in advanced cases (grade ), resembling epithelial lesions in acute gvhd of the skin. these findings correlated with gvhd involving the stomach and duodenum and the clinical manifestations of gvhd in other organs. endoscopically patients with gvhd revealed signs of inflammation, ranging from erythema to ulceration in the more advanced cases, sometimes reminiscent of reflux or infection. clinically these patients had abdominal discomfort ranging from inappetence to nausea, accompanied by emesis or diarrhea and weight loss. conclusions: we have shown that acute esophageal gvhd occurs after allohsct and is correlated with acute gvhd in stomach and duodenum. it could be diagnosed and graded histologically. the endoscopic findings are signs of inflammation. our results may help to establish the histological diagnosis of acute gvhd using endoscopic biopsies from the esophagus and to explain the alterations observed in the esophageal mucosa in patients after allohsct. [ background: intestinal acute graft versus host disease (agvhd) is a major thread after allogenic hematological stem cell transplantation (allohsct), with a high mortality in patients which were refractory to steroid treatment in particular. recent papers point to a correlation of histological grading of intestinal gvhd and prognosis in patient after allohsct. however a comparison with clinical scores has not been performed so far. methods: in this analysis, retrospective data from patients who underwent endoscopy due to clinical signs of agvhd (day + to + after allohsct) were evaluated. of each patient least biopsies from different sites of the colon which were taken simultaneously. of each biopsy series the maximum histological grad of agvhd according to the lerner scheme was obtained and compared with the glucksberg stage of the lower gastro intestinal tract (gslgi) and the overall glucksberg grade (ogg). these three grades were compared for non-relaps related mortality using the log-rank test and for sensitivity to steroid treatment applying the receiver operating characteristic for the patients who received steroid treatment. for these patients the non-relaps related mortality for responder and non-responder were calculated using also log-rank test. results: the histological grade strongly correlated with the survival (p= . ). a statistical significant correlation was also found for the gslgi (p= . ), whereas the ogg revealed no significant correlation (p= . ). non-relaps related mortality was mainly related to infection or sepsis (in / patients who died). -eighty-one of the patients received steroid therapy. the sensitivity to the steroid therapy correlated with each of the three scores (p< . ) but was the strongest for gslgi (area under the curve (auc) . ), compared to ogg (auc . ) and the histological score (auc . ). the survival of the patients, which were sensitive to steroid treatment was significantly better than those of steroid refractory patients (p= . ). conclusions: we found that histological and clinical grading in patients after allohsct with intestinal gvhd was correlated with survival and respond to steroid treatment. histological scoring may predict survival more precisely than ogg and gslgi but did not add substantial information to the prediction of treatment response. [ emerging evidences suggest that regulatory b cells (bregs) play essential roles in inflammation, autoimmune diseases and tumors. few data exist about the role of bregs in the contest of hematopoietic allogeneic stem cell transplantation (hsct). some authors have observed that bregs from patients with chronic graft-versus-host disease (cgvhd) were less frequent and less likely to produce il- than bregs as compared to healthy donors or patients without cgvhd. these findings suggest that bregs may be involved in cgvhd pathogenesis. the purpose of our study was to evaluate a possible role of b cell subsets on gvhd occurrence. methods: lymphocyte subset enumeration was performed by aquios cl flow cytometer (beckman coulter), a quantitative automated analyzer that performs two diagnostic panels: tetra- cd -fitc/cd -rd / cd -ecd/cd -pc and tetra- cd -fitc/cd +cd -rd /cd -ecd/cd -pc . b cell subsets (memory, mature and transitional b cells) on peripheral blood samples were analyzed by aquios designer software, a tool for the creation of user-defined applications. panel- cd -fitc/cd -pe/cd -ecd/cd -pc /cd -pc and panel- cd -fitc/cd -pe/cd -ecd/cd -pc / cd -pc were specifically designed by beckman coulter for our center. the flow cytometric analysis was performed as follows: in donors and patients at basal level; on graft products and in patients at days + , + , + , + after hsct. statistical significance was assessed with prism software (graphpad) by mann withney test. p < . was considered statistically significant. results: actually we enrolled patients submitted to hsct in our center from november . a preliminary statistical analysis was performed on patients. stem cells source was peripheral blood (pb) in cases and bone marrow (bm) in the others . the conditioning regimen was myeloablative in patients and ric in patients. agvhd was diagnosed in patients ( %). no associations were found between b cell subsets in donors and patients at baseline and the occurrence of agvhd. however we found a higher median percentage of transitional b cells in graft products in patients without agvhd ( . %, . - . ) compared to patients with agvhd ( . %, . - . ) (p= . , fig a) . in addition, patients without agvhd showed a lower median percentage of memory b cells ( . %, range . - ) in graft product as compared to patients with agvhd ( . %, range . - . ) (p = . , fig. b ). finally in the subgroup of patients receiving pb as stem cell source we observed a higher percentage of cd + lymphocytes in graft product in patients with agvhd ( %; range - ) compared to patients without agvhd ( %; range - ) (p= . ). in the monitoring of b cells reconstitution we observed that cd + events did not appear before day + after hsct and these were b transitional immature events predominantly. conclusions: our data suggest a possible protective link between transitional b cells and agvhd development. these results data need to be confirmed in a larger cohort of patients. moreover, it will be interesting to evaluate the relationship between transitional b cells at day + and the occurrence of cgvhd. clinical background: agvhd is a major complication of allogeneic hematopoietic stem cell transplant (hsct) and a risk factor for post-hsct mortality. the objective of this analysis is to describe patients with agvhd who had a suboptimal response to corticosteroids. methods: patients who developed ibmtr severity index ii-iv agvhd after first hsct between / / to / / were included in an ongoing chart review at centers in the united states. patients who had ever participated in a gvhd prophylaxis trial or used jak inhibitors were excluded from the study. suboptimal response to corticosteroids was defined as use of additional systemic anti-gvhd therapy, inability to taper high-dose steroids (≥ mg/ kg) by ≥ %, or tapered corticosteroids by ≥ % but not to < mg/day. results: the analysis included patients with suboptimal response to corticosteroids. mean age was years; % were male. median time from transplant to agvhd diagnosis was days. at the time of maximum agvhd grade, % of patients were grade ii and % were grade iii-iv; % had lower gi involvement, and % had ≥ organs involved. from time of diagnosis to maximum agvhd grade, % of patients had new organ involvement or an increase in agvhd grade. median time from diagnosis to maximum grade was . days, and was . days for patients with lower gi involvement. systemic corticosteroids were initiated on the day of diagnosis for % of patients. average starting daily dose was mg ( . mg/kg) for prednisone and mg ( . mg/kg) for methylprednisolone. steroid dose was increased for % of patients during follow-up; % were unable to taper below mg/day. among patients who received additional systemic anti-gvhd therapy (n= ), % increased their corticosteroid dose before initiation of additional anti-gvhd therapy. median time from initiation of corticosteroids to additional therapy was . days. frequently used therapies were mycophenyalate mofetil ( %), atg ( %), extracorporeal photophoresis ( %), tocilizumab ( %), etanercept ( %), and sirolimus ( %). agvhd recurred in % of patients and was managed by increasing corticosteroid dose in % of patients. % had any infection within first days post-hsct. forty patients ( %) required hospital readmission(s); % had ≥ readmissions within days post-hsct, with a mean inpatient lengthof-stay of days. relapse of underlying malignancy was reported for ( %) patients. two-thirds ( %, n= ) patients died at a median of (interquartile range (iqr): - ) days from agvhd diagnosis; a higher proportion ( %) of patients with maximum grade iii-iv agvhd died at a median of (iqr: . - . ) days; majority ( %) of patients with lower gi agvhd died at a median of . (iqr: - ) days. conclusions: a majority of patients with agvhd who had suboptimal response to systemic corticosteroids had severe and rapidly progressing disease and resulted in a high mortality rate ( %); progression was more rapid and mortality increased for patients with lower gi involvement. most patients required readmission to the hospital with extended length-of-stay. an urgent need exists for effective and tolerable therapies that quickly resolve life-threatening agvhd in early stages of disease. disclosure results: median time to onset of bo from allohct was . months (range . - . ). previous acute gvhd in . % (n = ) [grades iii-iv . % (n = )]. in . % (n = ) cgvhd had exclusive lung involvement, while the other patients ( %) had other organs affected. at diagnosis of bo, . % (n = ) were under immunosuppressive treatment. . % (n= ) of patients with bo received ecp as second-line treatment. median duration of treatment was months ( . - . ) and time to response . months ( . - . ). median of sessions was ( - ). evaluation of response was based on the evolution of fev measurement: . % (n = ) complete response; % (n = ) partial response and % (n = ) stable disease. one patient did not get any response and another was not evaluable. . % of patients (n = ) could reduce immunosuppression, and in one case it was completely discontinued. there is a trend for early separation between survival curves in favor of ecp ( figure ). one patient had sepsis secondary to central venous catheter infection as complication related to ecp. conclusions: ecp has emerged as a promising treatment for bo after allohct. in our experience, ecp was effective to stabilize or improve the disease in many patients and allowed to taper esteroids with minimal associated complications. however, prospective studies and longer follow-up are needed to support these findings. disclosure: nothing to declare background: the key role of il- signaling in acute graft vs. host disease (agvhd) and cytokine release syndrome (crs) has evoked growing use of tocilizumab, an anti-il receptor (il -r) antibody, in these settings. apart from regulation of t-and b-cell differentiation, immune cells migration to inflammatory sites and t-cell recruitment, il- complex with il -r through gp upregulates production of fibrinogen (fg) and other acute phase proteins, including c-reactive protein (crp). methods: we retrospectively analyzed data of patients treated with tocilizumab ( mg/kg) due to steroid-refractory (sr) agvhd and patients because of crs. median age was and years, respectively. seven patients were transplanted from unrelated donors (mud/mmud) and from sibling donors. eight patients received myeloablative and reduced intensity conditioning regimen. analyzed data included concentrations of fg, crp, an incidence of infections at tocilizumab administration and in weeks following the infusion. results: stage ii agvhd was diagnosed in patient, stage iii in , and stage iv in patients. involvement of the gastrointestinal tract (gi) was observed in % of cases. the median fg concentration before tocilizumab administration was . g/l (range, . - ) and crp mg/dl (range, - ) and % of patients had an active infection. after infusion of the antibody, we observed a decline of fg and crp levels. the median level of fg was . g/l (range, . - . ) - days after the tocilizumab infusion with no severe bleeding complications. a median crp value was . mg/dl (range, . - ) despite confirmed infectious complications. three weeks after infusion of tocilizumab fg raised to the normal range in % of patients (fig ) . five patients with sr agvhd achieved a complete response, and had a partial response after tocilizumab therapy. [[p image] . fibrinogen levels in gvhd patients following tocilizumab infusion.] a group treated with tocilizumab due to crs had higher initial levels of fg . g/l (range, . - . ) and crp mg/ dl (range, - ) before administration of the drug. reduced fg and crp levels from a baseline value were also observed in this group. however, concentrations were higher than in gvhd patients: fg . g/l (range . - . ) and crp . mg/dl (range . - ). in all patients, a differential diagnosis of disseminated intravascular coagulation was excluded. conclusions: . fibrinogen declines after tocilizumab therapy due to its cytokine-regulated production in the liver. coagulation monitoring should be performed during the first weeks after administration of the antibody to avoid serious bleeding complications. . crp concentrations remain low despite the presence of active infections following infusion of tocilizumab. crp fails as a marker of infection during weeks following the therapy. . tocilizumab is an effective therapy in patients with agvhd, especially with the gi involvement. disclosure: nothing to declare vanishing bile ducts after allogenic hsct: is it really gvhd? antonio grasso , lorenzo d'antiga , aurelio sonzogni , massimo gregori , alessandra maestro , roberto simeone , natalia maximova background: evaluation of liver gvhd was historically based by elevation of bilirubin levels and by reduction and degeneration of small bile ducts on histological samples of post-transplant liver biopsy. however, there is a lack of studies that compared histological finding of ductopenia between post-autologous hsct and post-allogenic hsct. studying severity of ductopenia following allogenic hsct, we aimed to demonstrate lack of correlation between ductopenia and clinical signs of liver gvhd. methods: we retrospectively collected a series of allogeneic hsct performed from to in the institute burlo garofolo. all patients undergo percutaneous liver biopsy in most cases at three months, one year and three or more years after hsct. indications for biopsy were alteration noted at weekly follow-up assessments of at least one clinical or laboratory marker of liver impairment or cholestasis. ductopenia was defined by number of portal tracts with no interlobular bile duct divided by the total number (severe if the ratio was less than . ). clinical gvhd was defined by nih consensus criteria results: our population involved % males and % females with oncological ( %) and non-oncological underlying disease ( %). clinical signs of liver gvhd were present in % of the patients (n= ), % with contextual intestinal involvement, % with cutaneous and intestinal involvement. patients underwent biopsy at a mean time of +/- days after hsct, patients underwent a biopsy at months after hsct and patients after three or more years from hsct. results of biopsies are showed in table . no difference in incidence of ductopenia were found between liver gvhd group and no gvhd. table] . table : incidence of ductopenia - months, months and or more years after hsct in total population, gvhd group and no-gvhd group] the group that not received chemotherapy prior the hsct had an overall incidence of ductopenia of % (severe ductopenia of %) statistically significative in comparison with the oncological underlying disease group ( % of ductopenia and % of severe ductopenia). furthermore, a little sub-group of patients extrapolated from our population received liver biopsy before hsct for diagnostic assessments: of the with an oncological underlying disease % already showed ductopenia, while no signs of ductopenia were found in the others with a nononcological disease. conclusions: there is no correlation between incidence of gvhd and histologically finding of ductopenia on liver biopsy. ductopenia may be caused in the first place by chemotherapy treatment received before hsct and myeloablative conditioning for hsct and it's not related with gvhd. this hypothesis is strengthened by the subgroup analysis of pre-hsct biopsy. background: second and third line therapies for steroid refractory acute graft versus host disease (agvhd) after allogeneic stem cell transplantation (asct) are still lacking. ruxolitinib, a selective januskinase / inhibitor could show high efficacy in agvhd, as well as extracorporeal photopheresis (ecp). here we report a single center experience of combining both therapeutic approaches in severe steroid refractory agvhd with additional analysis of immune status of these patients to elucidate direct effects of this treatment on immune response. methods: from june to february , patients ( . % male, . % female, median age: . years, r: - ) with steroid refractory agvhd of lower gi-tract after asct were treated with ruxolitinib and extracorporeal photopheresis as third, fourth or fifth line therapy. some patients showed additional agvhd of skin (n= ), liver (n= ) or upper gi-tract (n= ). all patients had an overall grade iii ( %) or iv agvhd ( %). steroid refractoriness was defined as no improvement in days or aggravation after days of steroid treatment.median start of ruxolitinib or ecp was day . after asct (r: - ). medianduration of ruxolitinib therapy was . days (r: - ) with a median start dosage of mg per day ( x mg; r: - mg). all patients started with ecp treatments per week with an individual reduction of treatment frequency. median number of ecp treatments was . (r: - ) with a median frequency of ecp therapy once a week (r: . - . ). cytomegalovirus (cmv) status of all patients and immune status of ten patients (lymphocyte count with cd + t helper lymphocyte and regulatory t cell count) were collected previously, after four weeks of starting combined treatment and four weeks after stopping the treatment. results: one-year estimated overall survival (os) of all patients was % with a median estimated os of days. patients died because of relapse of underlying disease, one of severe therapy refractory agvhd of lower gi tract and due to infection complications in agvhd refractory setting. overall response was . % (complete remission rate: . %, partial remission rate: . %). . % (n= ) of the patients had cytopenia ctc i-iii during the treatment, no grade iv cytopenia was reported. cmv reactivation during ruxolitinib occured in . % of cases (n= ). tapering of steroids could be performed rapidly with a medium reduction time of . days for reducing to half of the dosage.remarkably, regulatory t cells significantly increased during combined ruxolitinib/ecp treatment compared to regulatory t cell count before treatment (p= . ) and after stopping treatment, regulatory t cell count decreased again (p= . , see figure) . significant changes in whole lymphocyte count or in cd + t helper cell count were not observed. conclusions: treatment of severe steroid refractory agvhd with ruxolitinib plus ecp could show a high complete remission rate of . % with an one year os of %. detecting increased regulatory t cell count during the treatment underlines its direct effects on immune response and encourages to pursue this promising therapeutic approach. [ background: due to increased immunosuppression infections remain the main cause of death followed by higher risk of relapse in patients treated for acute graft versus host disease (agvhd) after allogeneic stem cell transplant (sct). here we report a single-centre experience with extracorporeal photopheresis (ecp) for acute gvhd that was introduced in order to reduce steroid treatment. comparison of overall survival (os) for patients on ecp and patients that received standard first line therapy for agvhd was performed. methods: we retrospectively analysed patients ( %) with acute gvhd grade ii-iv treated from january to october out of total allogeneic sct in that period. all patients received calcineurin inhibitors or sirolimus while receiving steroid treatment for agvhd. twenty-five patients ( %) received ecp with steroid lowering intent. we defined response as ( ) reduction of steroid dose for at least % from baseline while not adding another immunosuppresive agent and ( ) not repeating second steroid treatment if the ecp was started after lowering of steroids to prevent agvhd flare. we checked separately patient responsive and refractory/dependent to steroids. on average patients received ecp procedure once weekly. results: tapering of immunosuppressive therapy as defined was successful in ( %) out of patients in ecp group. in a group of patients without ecp ( %) patients had steroid refractory or steroid dependent agvhd compared to ( %) patients in ecp group. four ( %) patients with steroid refractory or dependent agvhd showed improvement in ecp group compared to only one ( , %) in non ecp group. twenty ( %) patients died due to infectious complication and ( %) due to relapse in non ecp cohort. in ecp cohort ( %) patients died due to infection and ( %) due to relapse. median os was months in non ecp group (r., - ) compared to months (r., - ) in ecp group and os of % at years in non ecp compared to % in ecp cohort was observed. patients with agvhd treated with ecp and faster steroid tapering had longer os compared to patients without ecp (p= , ). conclusions: ecp enables successful tapering or withdrawal of steroid therapy in many patients, even in those who are steroid refractory or steroid dependent. reduction of immunosuppression leads to reduced incidence of infection and relapse which translates into a better overall survival. background: the curative potential of allogenic stem cell transplantation is hampered by graft-versus-host disease (gvhd). pre-clinical study showed an efficacity of jak / inhibitor, ruxolitinib, in treatment of steroidrefractory gvhd. methods: we reported in this monocentric retrospective study, ruxolitinib response and follow up of cases of chronic gvhd (cgvhd) not improved with standard immunosuppressive therapy. complete organ response (cr) was defined as the resolution of clinical manifestations of cgvhd in a specific organ. very good response partial (vgpr) was defined as an improvement of clinical manifestations of cgvhd with more than % decrease of corticosteroid, while a partial response (pr) was associated with less than % decrease of corticosteroid. treatment failure was defined by the absence of improvement of cgvhd, deterioration of cgvhd in any organ by at least one stage, the development of cgvhd manifestations in a previously unaffected organ, and the use of any additional agents to control the disease. results: median age at transplant was years (range, - ). % of patients presented an acute myeloid leukemia. donor type was sibling (n= ), unrelated (n= ) or haploidentical (n= ).two patients benefited a cord blood transplant. patients received either myeloablative ( %) or reduced intensity ( %) conditioning regimens. stem cell source was peripheral blood for % of patients. patients presented mild (n= ), moderate (n= ) or severe (n= ) cgvhd according to nih score. median number of regimens prior to ruxolitinib was (range, - ), among those corticosteroids (n= ). median follow-up after ruxolitinib was months (range, - ). overall responses rate (orr) at month was % with % cr, % vgpr and % pr ( figure ). % of patients failed at month after introduction of ruxolitinib. the rate of cr increased with time : % at months (n= ), % at months (n= ) and % at months (n= ). but vgpr rate was rather stable at months ( %), at months ( %) and at months ( %) vs % at month. among the patients under steroids, ( %) patients discontinued steroids. the -months overall survival (os) and diseasefree survival (dfs) after ruxolitinib was % ( %- %, % ci) and % ( %- %, % ci), respectively. severe cytopenia (grade and ) was observed in patients. after introduction of ruxolitinib, patients presented bacterial infections, patients presented an invasive pulmonary aspergillosis and patient developped a pneumocystis. cytomegalovirus reactivation requiring preemptive treatment was observed in patients. no toxicities required withdrawal of ruxolitinib. [[p image] . figure and partial response to mesenchymal stem cells (msc), as second-line therapy, varies from % to % in acute gvhd patients. we report our experience using mscs to treat refractory agvhd. methods: the study was a retrospective single center study. all data were collected from patients' files. twenty patients were enrolled (age ranging from months to years) between april and april . results: five of these patients received reduced intensity conditioning and patients received myeloablative regimens before hsct. one haploidentical, autologous, cord blood, mud, msd transplantations were performed. the patients were eligible if they developed grades ii-iv agvhd. all patients were treated with standard first-line treatment with corticosteroids and at least one second-line therapy. the definition of steroid resistant agvhd considered as either no response to steroid treatment lasting at least days or progression during treatment of at least one grade within the first hours. prophylactic treatment with calcineurin inhibitors continued at therapeutic dose level. totally, doses of mscs were infused. the median dose of msc was . × cells per kg body weight. the median duration between the diagnosis of agvhd and initiation of mscs therapy was days (range: - ). the received msc doses ranged from one to seven. none of our patients had severe side-effects during infusions of mscs. overall, complete response (ocr) was obtained in patients, partial response in patients and no response (nr) was documented in patients. in our study group, the complete response rates in liver, gastrointestinal, skin agvhd were %, %, % respectively. four patients ( %) died in days after using mscs from complications of agvhd. eleven of patients ( %) were still alive with a median follow-up of days (range: - days) after first mscs infusion. one year estimated probability of overall survival for patients achieving ocr and partial remission/no remission in th day of mscs were . % and %, respectively. conclusions: in conclusion, mscs appears to be a safe and effective treatment option for pediatric patients with steroid refractory agvhd. disclosure: nothing to declare effect of extracorporeal photopheresis on production of serum elafin in chronic graft versus host disease arun alfred , charlotte burton , kathryn goddard , nichloas matthews background: extracorporeal photopheresis (ecp) is a second line therapy for steroid refractory, dependent or intolerant chronic gvhd (cgvhd). in order to guide ecp there is an unmet need for predictive and diagnostic biomarkers. elafin is a serine-protease inhibitor primarily produced by epithelial cells, particularly keratinocytes in inflammatory skin diseases and plasma and epidermal elafin have been identified as biomarkers of skin gvhd ( , ) . since skin cgvhd is noted for a particularly high response rate to ecp, we conducted a study to investigate whether ecp affects the production of elafin. methods: serum samples were collected from cgvhd patients ( male / female; age range: - ) and age-matched healthy controls ( male / female) before ecp and at month intervals up to year. patients had gvhd affecting skin ( / ), mucosal membranes ( / ), liver ( / ), joints ( / ), gut ( / ), eye ( / ), genital ( / ), and respiratory involvement ( / ). serum elafin was assessed by elisa (r&d systems). data were analysed using graphpad prism . statistical tests performed include -tailed mann-whitney, pearson's correlation test, and -way anova with repeat measures, as appropriate. results: chronic gvhd patients presenting for ecp had significantly elevated serum levels of elafin (p= . ; median of ng/ml, iqr - ng/ml) compared to healthy controls (median of ng/ml, iqr . - ng/ml).while % of patients had skin involvement, only % had elafin levels above the iqr of healthy controls. where disease scores were available (n= ) there were no significant correlations with modified rodnans (r= . ) or nih bsa scores (r= . ).sub-analysis was performed by grouping cgvhd patients according to quartiles of serum elafin at pre-ecp baseline. retrospective analysis of patients after months of ecp (n= ) revealed that those with serum elafin levels in the upper quartile (elafin hi ) pre-ecp (min-max: - ng/ml), showed a significant reduction after months of therapy (p< . ; mean +/-sd : ng/ml +/- ng/ml vs ng/ml +/- ng/ml, respectively), which was sustained up to months of ecp (p< . ; mean +/-sd: ng/ ml +/- ng/ml). in contrast, patients with elafin levels below the upper quartile (elafin lo ) showed no significant change (mean +/-sd: ng/ml +/- ng/ml vs ng/ml +/- ng/ml, respectively). of note, pre-ecp patients with elafin below the median received significantly more corticosteroid (cs) than those above, (p< . ; mean +-sd: +/- mg/d vs +/- mg/d, respectively), which was significantly reduced after months of ecp (p< . ; to +/- mg/d), while cs dose was not significantly changed in elafin hi patients until months (p< . ; mean +/-sd: mg/d +/- mg/d vs mg/d +/- . mg/d, respectively). conclusions: consistent with recent data, we found that serum elafin is significantly elevated in a subset of cgvhd patients compared to healthy controls, but did not correlate with skin disease scores. ecp administration was associated with a reduction in serum elafin in the elafin hi subset. further, elafin lo and elafin hi patients tolerated different rates of ecp-mediated tapering of cs immunosuppression suggests pre-ecp elafin measurements may have predictive value. references : background: allogenic hematopoietic stem cell transplantation (hsct) is a potential curative treatment for many malignant and no malignant hematologic diseases, primary immunodeficiencies and some metabolic and deposit diseases in children. graft versus host disease (gvhd) is a major cause of morbidity and a leading cause of non-relapse mortality. corticosteroids are the standard first-line systemic treatment for both acute and chronic gvhd, whereas no second line option for corticosteroid-refractory patients is standardised. ruxolitinib is a potent inhibitor of jak / showing significant responses in refractory gvhd patients in recent reports. methods: we present two centres experience with ruxolitinib for gvhd treatment in pediatric patients. the study was conducted in two spanish pediatric hsct centres, hospital vall d'hebron (barcelona) and hospital universitario la paz (madrid). all patients receiving ruxolitinib since the drug was available were included for retrospective analysis. results: between march and december pediatric patients with acute or chronic gvhd with refractoriness to corticosteroids were treated with ruxolitinib, in different episodes (one patient received it in different moments, and one patient received it in ). patient's sex at birth was female in and male in cases. median age at hsct was , years ( , - , ). primary disease was malignant in patients and non malignant in . median time of gvhd diagnosis was , days ( - ). all gvhd episodes were treated with corticosteroids as first line, with maximum doses between - mg/kg/day (the main dose used was mg/kg/day, / episodes). patients received a median number of , ( - ) previous lines of treatment including steroids before starting ruxolinib; they were extracorporeal photopheresis ( / episodes), sirolimus ( / ), mesenchymal cells ( / ) ruxolitinib initiation was indicated for acute gut refractory/steroid dependant gvhd in episodes and chronic multisystemic in episodes. other indications were chronic lung ( / episodes), chronic skin ( / ) and acute skin gvhd ( / ) . median post-hsct time of ruxolitinib start was days. doses ranged between , - mg/ h depending on age, weight, and tolerance (hematologic and liver toxicities). average duration of treatment was days ( - ). complete response (cr) rate was , %, global partial response (pr) , %, and no response (nr) % (progression in one patient and recent treatment start in other patient). mean time to maximum response was weeks. treatment stop cause was cr in cases, infection in , liver toxicity in . no severe side effects directly related to ruxolitinib treatment were described. conclusions: ruxolitinib has been recently introduced as second line strategy for rescuing corticosteroid-refractory gvhd in pediatric patients. while results of randomized trials are lacking, we present our experience (two centres). the main indications for starting treatment were acute gut and chronic multisystemic gvhd. most patients achieved some grade of response (partial or complete), allowing stopping or tapering corticosteroids. toxicity profile appears to be acceptable. disclosure: nothing to declare. stability of tacrolimus concentration early after allogeneic hematopoietic stem cell transplantation reduces the risk of acute gvhd background: tacrolimus is used as an immunosuppressive drug after allogeneic hematopoietic stem cell transplantation (allo-hsct). it is well known that early concentration level of tacrolimus is correlated with the risk of acute graft versus host disease (agvhd), however, whether range of standard derivation (sd) of early tacrolimus concentration after allo-hsct also affect to the risk of agvhd still remains unknown. here, we investigate the correlation between the range of sd of early tacrolimus concentration after donor hematopoietic cells engraftment and the development of agvhd. methods: we retrospectively assessed patients who underwent allo-hsct in our hospital from - . all patients received standard gvhd prophylaxis by continuous intravenous (iv) tac with starting dose of . mg/ kg/day from day before allo-hsct (day - ) and iv methotrexate on day , , at dose of mg/m , mg/m , mg/m , respectively. tac dosage was adjusted to target the serum concentration of - ng/ml until at least day and then tapered. to evaluate the sd of weekly tacrolimus concentration, the range of sd of tacrolimus concentration at day - (week- ), day - (week- ), day - (week- ) and day - (week- ) were calculated. the difference of the range of sd between the groups that develop or did not develop agvhd was compared by using mann-whitney u test. multivariate analysis was performed by using multiple logistic regression analysis. patients had given written consent allowing the use of medical records for research, in accordance with the declaration of helsinki, and the institutional review board approved the study. results: there were males and females and the median age was years (range, to years). the risks of disease were low-standard in and high in pts. the number of donors were in hla-identical sibling, in hla-mismatched related donor, in hla-matched unrelated donor and in hla-mismatched unrelated donor. thirty-seven patients developed agvhd (grade i-ii; , gradeiii-iv; patients). as a result, the wide range of sd at week- significantly increased the risk of agvhd (agvhd-group; . ± . ng/ml, agvhd+ group; . ± . ng/ml, p= . ). multivariate analysis demonstrated that narrow range of sd of tacrolimus concentration at week- reduce the risk of agvhd (or= . ; % ci: . - . ; p= . ). there were no correlation between gender, age, disease status, hla with the development of agvhd. conclusions: the range of sd at week- , an engraftment phase of donor hematopoietic cells, was significantly correlated with the development of agvhd. fine tuning of early tacrolimus concentration with narrow range of sd reduces the risk of agvhd, resulting in improvement of the overall survival after allo-hsct. disclosure: nothing to declair p ruxolitinib treatment for steroid-refractory graftversus-host disease han-seung park , je-hwan lee , jung-hee lee , eun-ji choi , miee seol , young-shin lee , young-ah kang , mijin jeon , kyoo-hyung lee background: steroid-refractory graft versus-host disease (gvhd) is one of the most lethal complications after allogeneic hematopoietic cell transplantation. recent studies have shown that ruxolitinib, a janus kinase / inhibitor, is effective in patients suffering from gvhd. here, we report a retrospective result of ruxolitinib treatment for steroid-refractory gvhd. methods: all patients had received cyclosporine and a short course of methotrexate as gvhd prophylaxis. antithymocyte globulin was added for unrelated or mismatched familial donor hct. ruxolitinib mg twice daily was added to immunosuppressive treatment in patients with steroid-refractory gvhd. results: a total of patients with gvhd (acute, , including patients with donor lymphocyte infusion [dli]related; and chronic, ) were included in the analysis. all patients had grade / acute gvhd or severe chronic gvhd at the time of ruxolitinib treatment. six ( . %) of patients with acute gvhd responded to ruxolitinib, including with complete response (cr). the median time to response was . days (range, - ) . nineteen patients received ruxolitinib for severe chronic gvhd, with the median of involved organs (range - ). fourteen patients ( . %) showed response to ruxolitinib, including crs. the median time to response was days (range, - ). five responders discontinued ruxolitinib and patients are still on the agent. after a median follow-up duration of . months, died ( from relapse of disease, from infection). the -year survival probability was . %. eleven of responders discontinued ruxolitinib. gvhd relapsed in of patients at , , and days after ruxolitinib discontinuation. thrombocytopenia ( / , grade / ; ) was the most common adverse event of ruxolitinib. during treatment, with grade / infectious adverse events occurred; pneumonias, brain abscess, and liver abscess. conclusions: ruxolitinib treatment seems to be effective for the treatment of steroid-refractory gvhd including long-standing chronic gvhd. the agent was well tolerated and relatively safe. disclosure: nothing to declare. il -receptor antibody tocilizumab as salvage therapy in the treatment of severe chronic gvhd after stem cell transplantation: a retrospective analysis background: severe chronic graft-versus-host disease (cgvhd) remains the most relevant factor affecting survival and long-term quality of life after allogeneic hematopoietic stem cell transplantation (hct). besides corticosteroids there is no established therapy for cgvhd and many of the used immunosuppressive agents may lead to significant toxicity incl. infectious complications. tocilizumab (an il -receptor antibody) has shown efficacy in acute gvhd and cgvhd. we retrospectively analyzed the efficacy and safety of patients having received tocilizumab for treatment of advanced cgvhd at our center between the years and . methods: patients with severe steroid refractory cgvhd and a median age of years (range: - yrs) having received at least two prior lines of therapy for cgvhd (range: - regimens) were treated with tocilizumab for at least one cycle (q w, dosage: mg/kg iv, maximum: mg) with a median number of cycles (range: . nih consensus criteria grading for cgvhd and the immunosuppressive regimen were noted at the time of the first tocilizumab administration and after , and months of therapy. all patients received additional concomitant immunosuppressive agents already given at least weeks without response before start of tocilizumab. no new immunosuppression (is) was added in parallel to tocilizumab and response assessment was stopped at start of any additional new is. all patients had received peripheral stem cell allografts. gvhd prophylaxis consisted of a calcineurin inhibitor in combination with methotrexate or mycophenolate and in case of unrelated donors atg was added. / patients had quiescent onset of cgvhd, one patient developed de novo cgvhd. the median number of days between hct and onset of cgvhd was ( - ). the median number of days between hct and initiation of tocilizumab therapy was ( - ) days. at cgvhd onset, / patients had mild cgvhd and / patients had moderate cgvhd. the thrombocyte count was < /nl in / patients. organs involved at initiation of tocilizumab therapy were skin ( %, all grade ), eyes ( %), mouth ( %), fascia ( %), lungs ( %) and genitals ( %). / patients are still receiving tocilizumab at the time of analysis. results: as tocilizumab was given fairly recently in most patients, -and -month follow-up was only reached in / patients ( %). at three-month follow-up after initiation of tocilizumab therapy, / patients ( %) showed partial remission, / patients stable disease ( %), and / patients progressive disease ( %) of cgvhd. maximal response was partial remission ( %), stable disease ( %) and progressive disease ( %). patients required subsequent new immunosuppressive treatment. one patient has not yet reached -month follow-up. during tocilizumab therapy none of the patients suffered recurrence of underlying malignancy. two patients developed significant respiratory infection and one patient developed soft tissue infection, all requiring antibiotic treatment and pausing of tocilizumab administration, hospital admission was not required. the os and rfs was % with median follow up of . months (range - months). conclusions: tocilizumab appears to be a promising treatment option in advanced cgvhd but further evaluation within a phase ii trial is required. disclosure: nothing to declare background: allogeneic hematopoietic stem cell transplantation (hsct) is for many patients suffering from aml the only curative treatment option. one major complication is graft versus host disease (gvhd), caused by donor immune cells attacking healthy tissue. regulatory t cells (treg) have been getting huge attention during the past years because of their important role in maintaining immune balance. here we collected peripheral blood samples from patients at different time points after hsct to investigate immune-reconstitution of treg as predictive marker for the development of gvhd. methods: we collected blood samples from patients in the course of allogeneic hsct prospectively once a week from d+ up to d+ . all patients received conditioning regimen with fludarabine and melphalan, combined with alemtuzumab for t cell depletion. patients developed acute gvhd in the later course. after isolation of pbmc`s we performed facs multicolor staining of t cell and nk cells. treg were identified as cd + cd + cd ++ foxp + , nk cells were characterized as cd neg cd + cd + and divided in nk cell subpopulation due to their expression of cd dim or cd high . results: . cd neg t cells: all patients developing acute gvhd in the later course showed significant elevated levels of cd + cd neg t cells, especially cd neg treg at d+ . . cd neg treg / cd + cd + t cells: one patient not developing acute gvhd showed lots of cd neg treg but missed cd + cd + effector t cells. we recently showed that cd + cd neg effector t cells are of impaired effector function. these data suggest that cd neg treg are only of relevance combined with functional cd + cd + effector t cells in the development of agvhd. . t cell marker: patients without agvhd showed elevated expression of garp on treg. garp was significantly higher expressed on cd + treg, indicating a better suppressive capacity of cd + treg. this was detected throughout from d+ until d+ . tigit and ilt showed a heterogeneous expression profile without significant differences between the two groups. . nk cells: we detected a higher ratio of cd ++ /cd dim nk-cell population in patients without. we could also show that tigit is mainly expressed on cd dim nk cells. conclusions: we and others showed reconstitution of cd neg t cell subsets after alemtuzumab mediated t cell depletion -our data on effector t cells showed an impaired effector function for cd neg cd and cd t cells. recently we presented data on impaired suppressive capacity of cd neg treg and the association with acute gvhd retrospectively (wölfinger ebmt , ash ). here we provide prospective data on patients after the use of alemtuzumab in the context of hsct: our preliminary data suggest that the total amount of cd neg-treg and the ratio of cd neg treg to cd + cd + treg on d+ after allogenic hsct could predict agvhd. this data may be a basis for immune monitoring of patients at d+ to evaluate their risk for agvhd and could lead to the use of prophylactic treg dli in the context of alemtuzumab mediated t cell depletion. disclosure: medac -travel support, novartis -consultancy fee, pfizer -consultancy fee, shireconsultancy fee background: multiple factors such as disease activity and severity, therapy and/or dietary habits can cause changes in nutritional status independently or by interacting with each other. presence of malnutrition or significant weight loss in chronic gvhd (cgvhd) patients was reported in literature up to %. the aim of this cross-sectional study was to identify factors that affect nutritional status in cgvhd patients. methods: nutritional status in patients with cgvhd treated at the university hospital center zagreb, croatia from to was assessed. anthropometric measurements (height, body weight (bw), body mass index (bmi)) and clinical validated tool patient-generated subjective global assessment (pg-sga) (where patients were categorized as well-nourished (pg-sga a), moderately malnourished (pg-sga b) or severely malnourished (pg-sga c)) were used. all patients were evaluated according to nih criteria for cgvhd diagnosis. descriptive and correlation analysis were preformed. results: in total, adult cgvhd patients were included in the study, women ( . %), median age ( - ) years, with mild cgvhd in ( . %), moderate in ( . %) and severe in ( . %) patients. according to the pg-sga rating ( . %) patients had pg-sga a, ( . %) pg-sga b and ( . %) had pg-sga c, giving a total malnutrition or risk of malnutrition prevalence of . %. the mean bmi was . ± . kg/m with correlation to pg-sga rating (r= . , p= . ). malnutrition according to the bmi (defined as bmi< kg/m ) was found in patients ( . %). bw changes ( % or more in months) were significant in patients ( . %). according to the pg-sga assessment tool, oral symptoms reported by patient ( . %) and decreased appetite reported by patients ( . %) were associated with oral cgvhd nih score (r= . , p= . ; r= . , p= . ) but not with bw or bmi. gastrointestinal (gi) symptoms assessed with sga, were generally mild with no correlation to gi cgvhd nih score. no significant association was found between nutritional status and other nih cgvhd scores. corticosteroid therapy present in ( . %) correlated with pg-sga rating (r= . , p= . ) but not with bw, bmi or appetite changes. in patients ( . %) with altered pg-sga rating, bmi, appetite and body weight changes, dietary counseling and oral nutritional supplementation were initiated. conclusions: oral symptoms, decreased appetite and corticosteroid therapy in our cgvhd patients were associated with altered nutritional status according to the pg-sga, but not with bmi. therefore, pg-sga might be a more sensitive tool in assessment of changes of the nutritional status and detection of patients at risk of malnutrition than bmi since it includes different factors like physical examination, presence of gi symptoms and corticosteroid therapy in its scoring system. nutritional counseling and support are important in cgvhd patients especially in presence of oral symptoms. disclosure: nothing to declare. background: sclerotic skin changes are common features in chronic graft versus host disease (cgvhd). one of the most challenging aspects in the diagnosis and management of sclerodermoid cgvhd (scgvhd) is the differentiation between reversible symptoms related to active cgvhd and nonreversible symptoms related to residual permanent damage such as long-standing fibrosis. although several candidate biomarkers of cgvhd inflammatory activity have been proposed, none of them are currently validated. therefore, there is a need for the development of more quantifiable and reproducible measurements tools to guide clinical decisions. we report our experience evaluating the usefulness of high-frequency ultrasonography (hfus) plus doppler ultrasound (doppler-us) and serum fibrosis biomarkers to determine the inflammatory activity of scgvhd. methods: we report patients with scgvhd. hfus plus doppler-us were performed at diagnosis of scgvhd and at different time-points after treatment initiation. serum hyaluronic acid and pro-colagen-iii were measured as fibrosis biomarkers simultaneously with hfus and doppler-us. nih cgvhd consensus conference diagnosis criteria, scoring system, and response criteria were used to assess global and organ-specific cgvhd, and to measure overall response to therapy. abnormal ultrasound findings were defined as the presence of ≥ of the following: hypoechogenic dermis, dermo-epidermal junction effacement, hypoechogenicity of septa and/or hyperechogenicity of lobules in hypodermis, hypoechogenic fascia, or myositis, for hfus; and, vessels thicker than mm in dermis and/or hypodermis, systolic pressure > cm/sec, and index of vascular resistance > . , for doppler-us. inflammatory activity was classified as mild, moderate and severe according to the severity of doppler-us findings. results: hfsu showed abnormal findings in all patients at diagnosis with no changes except in two patients along the treatment follow-up. inflammatory activity by doppler-us was observed in / patients at diagnosis ( mild, moderate, severe). four patients responded to treatment ( complete responses, cr, and partial responses, pr), one presented clinical improvement less than pr, and one, progressive disease. all patients with clinical response had also a p-rom improvement or normalization. all patients achieving a response showed normalization (n= ) or improvement (n= ) of doppler-us findings. the patient with clinical improvement less than pr and the patient with progressive disease showed persistence of inflammatory doppler-us findings. most patients had normal or light increase of pro-collagen levels at diagnosis and no significant changes were observed during follow-up. levels of hyaluronic acid tended to be very high in patients with progressive scgvhd (patients and ) and tended to decrease or normalize in those who responded to therapy (patients , , and ). conclusions: in this exploratory study, hfsu was a reliable method for evaluating sclerotic skin changes in scgvhd. doppler-us showed a good correlation with disease activity and response to treatment. serum hyaluronic acid levels might be a biomarker of disease activity that deserves further investigation. hfsu plus doppler-us is a useful, non-invasive, repeatable device in monitoring patients suffering from scgvhd. according to our results, doppler-us may be a more sensitive parameter than hfsu in assessment inflammatory activity of scgvhd. disclosure: maría suárez-lledó received a grant from dkms-spain foundation. other authors have nothing to declare post-transplant cyclophosphamide versus antithymocyte-globulin in hla-matched unrelated and haploidentical transplantation for hematologic malignancies background: post-transplant cyclophosphamide(ptcy) and antithymocyte-globulin(atg) are the most commonly used regimens for the prophylaxis of graft-versus host disease(gvhd). we compared these two regimens in hlamatched unrelated (mud) and haploidentical transplantation for hematologic malignancies. methods: we retrospectively analyzed the consecutive adult patients with hematologic malignancies who received mud and haploidentical transplantation at chungnam national university hospital between january and january . patients who received second transplantation and had refractory disease were excluded. results: this study included patients with median age of (range, - ) years: ( . %) patients received mud transplant ( and patients in ptcy and atg group, respectively), and ( . %) patients received haploidentical transplant ( and patients in ptcy and atg group). graft source was peripheral blood stem cell in all patients. median follow-up duration was . months (range, . - . ). in mud transplant, the estimated -months survival rate were . % in ptcy vs. . % in atg (p= . ), the -months relapse rate were . % in ptcy vs. . % in atg (p= . ), the cumulative incidence of grade to acute gvhd were . % in ptcy vs. . % in atg (p= . ), and the estimated -month extensive chronic gvhd rate were . % in ptcy vs. . % in atg (p= . ). in haploidentical transplant, the estimated -months survival rate were . % in ptcy vs. . % in atg (p= . ), the -months relapse rate were . % in ptcy vs. . % in atg (p= . ), the cumulative incidence of grade to acute gvhd rate were . % in ptcy vs. . % in atg (p= . ), and the estimated month extensive chronic gvhd rate were . % in ptcy vs. . % in atg (p= . ). patients receiving ptcy had significantly longer neutrophil engraftment time than those receiving atg in haploidentical transplant [median(range); . ( . - . ) days vs. . ( . - . ) days, p= . ]. conclusions: ptcy might be a good option for the prophylaxis of gvhd in hla-matched unrelated transplant as well as haplo-identical transplant. disclosure: nothing to declare early fam therapy for post allo-hsct bronchiolitis obliterans syndrome background: bronchiolitis obliterans syndrome (bos) is a potential major complication after allogeneic hematopoietic stem cell transplantation (hsct). attributed to an allo-immune reaction against the small airways, bo is considered a pulmonary manifestation of chronic gvhd. reported incidence of bos ranges from to %, and bos-attributed mortality as high as %- %. a few years ago, a new therapeutic approach with fluticasone, azithromycin, and montelukast (fam) was described (norman bc, et al. bmt ) . our aim was to analyze the outcomes of pts who developed bos and were precociously treated with the fam scheme. methods: all the allo-hsct performed in our center from january and july were included in the analysis. baseline diseases were: aml, lpd, mds, all, mpd, mm, and bmf. day + and day + overall mortality were , % and , %, respectively. rest of characteristics of the series are shown in table. fam therapy was systematically started when any patient was first diagnosed with bo. results: eleven patients ( , %) were diagnosed with bos. at diagnosis of bos, the pts exhibited a fev % of predicted (median fev : %; range; - %) and/or a decline > % from pre-hsct . at day + , pts had already the syndrome. two of them died before the end of the first year: one due to invasive zygomycosis (cns plus pulmonary) and the other to baseline disease progression. at day + , more pts had bos. two more pts with bos died at and months post-hsct due to baseline disease progression. at the close of the analysis, of the pts were alive. so, with a median follow-up of months (range: - ), mortality and bos-attributable mortality of the pts with the complication were , % and , %, respectively. conclusions: ) bos is an infrequent but very severe complication of allo-hsct; ) bos seems to be less frequent in pts with prophylactic pre-transplant ratg or post-transplant cyclophosphamide, as well as in pts undergoing transplantation with bm (compared to pbsc). ) early diagnosis and therapy are critical to minimize the bos-attributable mortality. disclosure background: donor lymphocyte infusion (dli) is an established treatment for patients with hematological malignancies relapsed after allogeneic hematopoietic stem cell transplantation (hsct). however, it is associated with an increased risk of graft-versus-host disease (gvhd) and modest anti-tumor activity. compared to the infusion of nonmobilized lymphocytes, granulocyte colony-stimulating factor (g-csf)-primed dli might induce a stronger anti-tumor effect and reduce the risk of infusion-induced gvhd. due to the limited experience of g-csf primed dli in patients relapsed after haploidentical hsct, we conducted a retrospective study of all patients at our hospital who received dli for the relapsed hematological diseases following related hla-matched or hla-haploidentical hsct. methods: the institutional research board approved the study. we identified patients with hematological malignancies receiving dli following related allo-hsct at national taiwan university hospital between and aug. the infusate was obtained from the cryopreserved specimen, which had been collected and stored at multiple aliquots at the same time as the initial haploidentical peripheral stem cell graft. patients received dli for either hematological relapse, preemptive or prophylactic treatment. univariate and multivariate analysis was performed using cox proportional hazard regression model. results: for the patients following related hlamatched and the patients following hla-haploidentical hsct received and doses of dli, respectively. in comparison, the median cd + cell dosage of haplo-dli is significantly lower (p = . ) than that of dli from sibling donors, with median cell dosage . × /kg (range, . - × /kg) and . × /kg (range, . - . × /kg), respectively. the median time to dli from initial sibling hsct and haplo-hsct was days (range, - days) and days (range, - days), respectively. overall, ( %) of the patients following sibling hsct developed grade - acute gvhd after dli, whereas ( %) of the patients receiving haplo-hsct developed grade - acute gvhd after dli (p= . ). importantly, for patients receiving dli with cd + cell dosage less than × /kg, there is no difference in the risk of developing grade - acute gvhd between patients receiving dli from sibling or haplo donors ( figure a) . interestingly, for patients receiving dli with cd + cell dosage more than or equal to × /kg, ( %) of the patients following haplo-hsct developed grade - acute gvhd after dli, significantly more than ( %) of the patients following sibling hsct developed grade - acute gvhd after dli ( figure b) . the cumulative incidence of grade - acute gvhd at day after haplo-hsct and sibling hsct were % ( % ci: . - . ) and . % ( % ci: . - . ), respectively ( figure b , p = . ). [[p image] . conclusions: our study shows that the administration of g-csf mobilized dli is feasible after haploidentical hsct for relapsed hematological malignancies. however, dli with cd + cell dosage more than or equal to × /kg in patients receiving haplo-hsct is associated with significantly higher risk of developing acute gvhd than dli from the sibling donors. disclosure: the authors declare no competing financial interests. background: the fresenius phelix is a uva irradiation device used to photoactivate mnc collected on the amicus. the system is closed, utilizing a special mnc kit and modified instrument software. the preliminary results of a phase i safety trial involving three patients ( treatments) with chronic graft vs. host disease are presented. methods: reasons for transplantation for the patients ages , and years were: acute myelogenous leukemia, myelodysplastic syndrome, and myelodysplastic syndrome with pnh. stem cell source was peripheral blood with a / match for all. each developed chronic skin gvhd. inclusion criteria included wbc and plt counts > and x /l, gfr > ml/min/bsa, and ast - unit/l. exclusion criteria included active gi bleeding, nyha cardiac disease greater than grade iii, and the presence of light-sensitive diseases. amicus software . and phelix software . were used. settings included: ml/min max draw rate, ml fixed cycle volume, . mg/kg/min citrate infusion rate, and : acd-a ratio. venous access was peripheral or subcutaneous port. target uva dose was . j/cm and -methoxypsoralen dose was . ml. results: the following mean + sd procedure results were obtained: , + ml whole blood with acd-a drawn, + ml acd-a used, + ml saline used, + minutes procedure time, and , + ml total blood volume. minor alarms (n= ) on the amicus and no alarms on the phelix were encountered. all -day aerobic and anaerobic cultures were negative and mean endotoxin levels were . + . eu/ml. mean pre/post cbc and plasma hemoglobin levels were: . / . wbc, . / . neutrophils, . / . basophils, . / . eosinophils, . / . lymphocytes, . / . monocytes, / platelets x /l, / % hct, . / . g/dl hgb, and . / . mg/dl plasma hemoglobin. plasma hemoglobin delta in the product was . + . grams and the subject was - . + . grams. collected product hct. mean . + . %. yields are in the table. adverse events included one each: acute respiratory failure, respiratory failure, muscular weakness, musculoskeletal discomfort, and peripheral swelling. three of four events occurred in one patient two weeks after the study procedure. none of the adverse events were considered related to the procedure or investigational product. the patient who experienced acute respiratory failure was removed from the study because of death due to pneumonia, felt to be unrelated to the procedure. conclusions: results indicate the new closed photopheresis system is capable of collecting sufficient mnc and irradiating the cells producing high lymphocyte apoptosis, with minimal alarms and adverse reactions. ( . %)). ( . %) of the patients also had acute gvhd of the skin or liver. patients ( . %) could be treated and controlled with methyl-prednislone monotherapy, patients had steroid refractory gvhd of whom patients ( . %) could be salvaged with additional drugs (infliximab: ; tacrolimus: ); patients ( . %) had refractory acute gut gvhd and could not be salvaged despite more than three lines of therapy. at the time of reporting, patients ( . %) of the are alive. patients died due to transplant related mortality, while patients developed relapsed disease. on binary logistic regression analysis, no baseline clinical or treatment related predictor (disease indication, disease status at transplant, transplant type, graft source, type of conditioning) could be identified for developing acute gvhd of the gastrointestinal system. conclusions: acute gvhd of the gastro-intestinal system is a significant cause for morbidity in allo-hct patients at our centre. further studies are warranted in our cohort, and a prospective analysis of gut microbiome analysis, faecal multi-drug resistance organism surveillance, conditioning related toxicity and antibiotic usage is ongoing. clinical trial registry: not applicable disclosure: the authors declare no potential conflicts of interest benefits and precautions of ruxolitinib in steroidrefractory acute gvhd background: corticosteroids are the standard first-line treatment option for patients with acute graft-versus host disease (gvhd), but approximately half of patients become refractory to steroids and require second-line treatment. ruxolitinib has the potential to treat gvhd in steroidrefractory (sr) patients based on retrospective clinical data. the ongoing prospective trials are currently enrolling patients to evaluate the therapeutic potential of ruxolitinib for gvhd. methods: we analyzed retrospectively clinical experience with ruxolitinib in patients (n= ) with grade ~ steroid-refractory acute gvhd patients compared with the control group not receiving ruxolitinib. in addition, immune status was evaluated about weeks~ weeks after the administration of ruxolitinib using flow-cytometry. ruxolitinib was used as a third option for sr gvhd, combined with previously used immunosuppressive drugs. and steroids were gradually decreased according to the symptoms and discontinued. patients received ruxolitinib mg twice daily (bid), with increase to mg bid if hematologic parameters are stable and no treatmentrelated toxicities. results: fifteen patients all were assessable for response. seven patients achieved a complete response, had a partial response, and had no response at weeks after the first ruxolitinib dose. overall response rate was %. three were treatment failures. most adverse effects were manageable, except infectious complications. infectious complications were occurred in about % patients (n = ), resulting in two deaths. common cause of infectious events included cytomegalovirus (n = ), herpes-zoster (n= ), epstein-barr virus (n= ), fungal infection (n = ), pneumocystis jiroveci (n = ), bacterial infections (n = ), and pneumonia of unknown origin (n = ). t cell counts tended to decreased in the group with ruxolitinib compared with the control group, especially cd cell counts. conclusions: ruxolitinib is effective in controlling sr gvhd and can lead to clinical benefits. however, we need to be aware of the infectious complications because ruxolitinib may lead to increased risk of opportunistic infections or reactivation of latent infections. in addition, common infectious complications are presumed to involve t cell dysfunction. clinical background: graft versus host disease (gvhd), being one of most common life-threatening complication post hsct, contributes significantly to morbidity and mortality. when affecting gastrointestinal tract (gi) it is the major cause of death in early period post hsct. due to widespread tissue involvement in most patients diagnosed with gi gvhd, surgical treatment is rarely considered. methods: among allo-hsct performed in department of pediatric hematology, oncology and bone marrow transplantation in wroclaw, poland during years - , ( , %) cases were diagnosed with gi gvhd. in this study we present cases ( %) which were referred to and benefit from surgical approach. results: . male, years old underwent hsct from matched unrelated donor (mud) due to chronic myelogenous leukemia (cml) and subsequent molecular relapse succesfully treated with donor lymphocyte infusion, followed by agvhd (skin and gut involvement, grade iv). extensive immunosuppression (steroids, mycofenolate mofetile, atg, okt ) resulted in significant resolution of agvhd symptoms. however aggravating severe abdominal pain and lack of gut movement suggesting bowel obstruction. due to presence of acute abdomen patient was immediately directed for laparotomy. resection of constricted bowel segment followed by subsequent laparotomies for secondary obstruction provided complete resolution of abdominal symptoms. after years of follow-up patient is alive and well. . eleven years old male was diagnosed with skin and gut grade iv agvhd on day + post mud-hsct performed due to acute myelogenous leukemia (aml). he received pronlonged immunosuppressive treatment including steroids, antibodies, msc and ecp which led to resolving of skin leasions and diarhoea. nevertheless patient was suffering from severe paroxysmal abdominal pain and incidentally vomiting. ct enterography showed partial small bowel constriction. after numerous surgical consultations, eventually on day+ patient underwent laparotomy with constricted bowel resection. histopatological examination of resected tissue revealed moderate gvhd. immunosuppersion was tapered to low dose of steroids with ecp. for now, years post hsct patient is alive, rarely experiencing mild abdominal cramps . fourteen years old female developed severe abdominal pain and high volume diarhoea on day + post mud-hsct performed for severe anaplastic anemia (saa). despite extensive immunosuppression (steroids, anti-tnf, anti-il antibodies) patient condition did not improved. through consistent stomach pain, suspected subileus confirmed by ct enterography, laparotomy was performed (day+ ). resection of inflamated and obstructed bowel was made. microscopic evaluation confirmed prior gvhd diagnosis therefore immunosuppression including csa and tapered doses of steroids was continued. complete resolution of abdominal symptoms was almost immediately achieved post-surgery, however months after recurrent abdominal cramps were observed and are now well controlled by pain killers. conclusions: commonly gi gvhd is diffused inflammatory process. however in some cases it may be localized and may lead to partial bowel constriction. in case of severe and prolonged stomach pain, despite of partial resolving of other gvhd symptoms, ileus should be considered. ct enterography may be useful for diagnosis confirmation. in those patients, surgical intervention may improve quality of life or even be a salvage approach. disclosure: nothing to disclose is there any impact of the uric acid levels during the preand early post-graft infusion period, on the gvhd occurence and allotransplant outcome? . ( . - . ) years, who underwent allogeneic stem cell transplantation (allosct) from full-matched sibling donors for acute leukemia (n= ), very severe aplastic anemia/pnh (n= ), lymphoma (n= ), myelodysplastic/ myeloproliferative syndrome (n= ) . thirty-two patients were in remission at the time of allosct (cr : , cr : , beyond cr : ). for a better and more accurate assessment of the ua levels on the agvhd incidence, unlike to the other published studies which evaluated the ua levels only at day , we evaluated the ua levels in different time points during the the peri-transplant period (at the conditioning regimen initiation, and at days , + and + ). because the majority of our patients developed agvhd within the - days post-transplant, we did not incorporated in the study the of ua levels beyond the + day. we also investigated the effect of the ua on survival and the non-relapse mortality (nrm). the vast majority of patients received allopurinol from the st day of conditioning regimen till day - . the independent t-test, kaplan-meir method and logrank test were used in the statistical analysis. results: the median ua levels were . , . , . and . mg/dl at days - , , + and + respectively. for the statistical analysis purposes, we grouped our patients as low-ua if they had values < mg/dl or high-ua if they had > mg/dl. this threshold was chosen based on the ua values from all the collected samples (n= ). finally / ( %) patients developed agvhd; ( %) were assessed as gr ≥ii, while ( %) as gr iii-iv. the incidence of the agvhd gr ≥ii was similar (ranged from - %) in both groups of patients (low-ua and high-ua) and for all the estimated time points (days - , , + , + ). we noticed a better -years overall survival for patients with low-ua ( % vs. %) however without any statistical significance. ten patients succumbed to nrm causes; / deaths attributed to gvhd complications. the nrm was assessed higher in the high-ua group ( % vs. %) but also this difference was not statistically significant. conclusions: though our study bears the limitations of the small number of patients and the retrospective origin, at least to our knowledge is the first which evaluates the impact of ua levels at different time points in the peritransplant period, on the agvhd incidence. in our study the ua levels did not influence the incidence or the severity of agvhd. the higher nrm rates for patients with ua> . mg/dl merits further evaluation. definitely, the role of ua on the allosct outcome will be clarified through well designed prospective trials. disclosure results: five male patients ( %) had genital cgvhd manifestations presented by urethral stricture in / patients and phimosis requiring surgical treatment in one patient. all five patients had simultaneously cutaneous, oral, and/or ocular cgvhd manifestations. the first patient underwent urethroplasty of bulbomembranous part of urethra with termino-terminal anastomosis and urethroplasty of penile part of urethra with buccal mucosa autograft -bmg (dorsal onlay) that resulted in significant improvement of symptoms and normal miction afterwards. biopsy of the urethra showed mononuclear infiltration in lamina propria consistent with cgvhd. biopsy of the buccal mucosa was done prior to surgery and was negative for cgvhd involvement. the second patient underwent urethrotomy due to circular strictures, but symptoms reappeared again and he is now candidate for bmg. in two patients urethral dilatation was done, and the fifth patient presented with phimosis requiring circumcision, resulted in significant improvement of symptoms. conclusions: male genital cgvhd is an underrecognized and under-reported manifestation. patients after allo-hsct need to be actively asked about their genital symptoms and sexual function, especially if they are diagnosed with other mucocutaneous or ocular cgvhd. multidisciplinary approach, early recognition and frequent follow-up is necessary for timely start of treatment. new methods, such as bmg for cgvhd patients with urethral stricture seem promising and should be further investigated. disclosure: nothing to declare. p abstract withdrawn. heracles: a phase ii single-arm prospective study to assess the efficacy of fecal microbiota transfer in the treatment of steroid refractory gastro-intestinal agvhd post allo-hsct background: steroid-refractory acute graft-versus-host disease (sr-agvhd) is associated with an % mortality rate and reduced quality of life (qol). so far, there is no approved standard of care for agvhd second-line treatment. there is an urgent need to identify effective therapy for sr-agvhd to improve patients' outcomes. fecal microbiota transfer (fmt) might be beneficial to substantially improve the prognosis. higher gut microbial diversity is strongly associated with increased survival in gvhd patients. recent studies reported promising results of sr-agvhd patients treated with fmt. further evaluation to confirm the efficacy and safety of fmt for agvhd is warranted. the ongoing phase study (heracles) investigates the efficacy of allogeneic fmt in the treatment of patients with sr-agvhd. heracles was launched after the odyssee study showed promising results in the reconstruction of gut microbiota diversity after induction chemotherapy with fmt in acute myeloid leukemia patients. we expect that fmt-based biotherapeutic drugs could be effective treatments to contain sr-agvhd, and thereby reduce the risk of life-threatening complications after allogeneic hsct. methods: heracles is a single-arm, multicenter prospective trial in european countries. patients aged ≥ years-old, who underwent allogeneic hematopoietic stem cell transplantation (allo-hsct) and developed a first episode of stage or agvhd with gut predominance resistant to a first-line steroid therapy are eligible for inclusion. main exclusion criteria comprise the use of other second-line gvhd therapy, patients with grade iv hyperacute gvhd, late onset agvhd, and overlap chronic gvhd and agvhd after donor lymphocyte infusion. patients receive a first maat enema within days after sr diagnosis (v ) and additional ones week apart (v / v ) from each other. maat is a highly-diverse, microbiome-rich enema formulation obtained from pooled, rigorously screened faeces from healthy donors, manufactured with a standardized process using the signature maat microbiome restoration biotherapeutic (mmrb) platform. at inclusion (v ), before each dosing (v , ), and days post inclusion (v ), patients' faeces and blood are collected. safety monitoring will be performed with corresponding blood analyses. exploratory measures on faeces include characterization of gut microbiota composition and evolution, impact of maat on metabolism, and gut inflammation. immune system phenotyping will be performed by flow cytometry on peripheral blood mononuclear cells, and by elisa assay on plasma. patients' qol will be assessed using a standard, eq- d- l questionnaire. the primary objective is to assess the efficacy of maat by evaluating complete response (cr, according to modified glucksberg criteria) and very good partial response (vgpr, defined by martin et al., bbmt, ) days post-inclusion (primary follow-up). secondary objectives include fmt safety assessment and evaluation of fmt impact on several endpoints, such as overall, relapsefree or gvhd-free survival and chronic gvhd evaluation, as well as multi-drug resistant bacteria carriage. patients will be followed-up until year after inclusion. overall, patients are planned to be enrolled and treated, to assess overall response rates and maat 's safety profile. results background: anti-programmed cell death protein (pd ) monoclonal antibodies can be used as "bridge to" a subsequent allogeneic hematopoietic stem cell transplantation (hsct) in patients with relapsed/refractory hodgkin´s lymphoma (hl). this strategy has been reported to be effective, but a frequent onset of steroid-refractory graft versus host disease (gvhd) was also reported. we report clinical cases of patients affected by hl undergoing allogeneic hsct after having been treated with nivolumab. methods: the patients of , and years respectively had advanced hl and had relapsed after a previous autologous ( ) or allogeneic ( ) hsct. they underwent a rescue therapy with , , nivolumab cycles respectively, depending on the time of partial response achievement and the availability of a donor. two patients received a thiotepa-fludarabinecyclophosphamide conditioning, atg-based prophylaxis and pb cells from unrelated donors. the third patient received bm cells from an haploidentical donor using the "baltimora" nonmieloablative platform. results: at a follow-up of , , months after hsct, respectively, all patients achieved and maintained a complete remission by pet-ct scans. all the patients developed acute gvhd on day + , + and + , respectively. patient progressed to grade iv acute gvhd with hepatic and intestinal involvement unresponsive to first line mg/kg steroid therapy and second line etanercept plus extracorporeal photopheresis (ecp). third line therapy with ruxolitinib partially controlled the gvhd. gvhd onset in patients and was preceeded by a prolonged fever without microbiological findings. patient developed hepatic grade ii gvhd with high transaminase levels, initially responsive to steroid therapy, then it progressed to gut requiring second line therapy with etanercept. patient progressed to severe chronic gvhd with skin involvement and resulted unresponsive to steroids and ecp and it was partially controlled by ruxolitinib. immune reconstitution was delayed in all patients: at months post transplantation cd levels were /μl, / μl and /μl and cd levels were /μl, /μl and / μl respectively. only patient , that underwent haploidentical transplant and received post-trasplant cyclophosphamide (pt-cy), is off of immunosuppressive treatment at months after hsct, without evidence of gvhd and no history of infections. out of the patients receiving pbsc from unrelated donors and atg prophylaxis, patient developed a disseminated fusariosis on day + and died of cns fusarium localization year after hsct, despite targeted antifungal therapy. patient had pulmonary aspergillosis, sepsis by multidrug resistant psuedomonas aeruginosa and otomastoiditis: at + months after hsct, he is on ruxolitinib treatment with skin clinical partial response. conclusions: this case series confirms that nivolumab as "bridge to transplant" is effective in appropriately selected patients. however, risk of acute gvhd and delayed immune reconstitution may require a careful consideration at the moment of planning the transplant. a possible advantage of pt-cy gvhd platform and haploidentical donors should be addressed in larger studies. background: acute graft-versus-host disease (agvhd) is the most important complication after an allogeneic hematopoietic stem cell transplant (hsct). no standard secondline treatment has been established for the corticosteroid refractory agvhd. the anti-tnfα agents are a good option of treatment for these patients, especially when lower gi tract is involved. methods: from april to july we reviewed the outcome of patients with steroid-refractory (sr) agvhd treated with etanercept as at least, second line treatment. etanercept dose was mg twice a week for the first weeks, followed by weekly doses. results: median age was years (range - years), and patients ( %) were male. fourteen patients ( %) had a non-advanced disease status at hstc. eleven patients ( %) received a myeloablative conditioning, and the stem cell source was peripheral blood in patients ( %). sixteen patients ( %) were / hla matched. the characteristics of the patients, their agvhd stage previous to rescue treatment with etanercept and their outcome are shown in table . seventeen patients ( %) had a classic agvhd while had a late-onset agvhd. etanercept was given as a nd , rd and th line in ( %), ( %) and ( %) patients respectively. the median doses of etanercept administered were (range - ), and just patients ( %) completed the doses planned treatment, of whom were alive at , and months from the onset of rescue treatment. complications during etanercept treatment were: infection (n= [ %]: gram negative bacilli [n= ]), grade - neutropenia (n= ) and grade - thrombocytopenia (n= ). etanercept was indicated as a rescue treatment due to: progression after days of agvhd treatment (n= ), no response after days of treatment (n= ), no complete remission after days of treatment (n= ) and relapse due to decrease corticosteroid doses (n= ). at the end of treatment patient achieved a complete response and patients a partial response, all of them are alive. these patients received etanercept as a nd (n= ) and th line (n= ) treatment, all of them had lower gi agvhd without any other organ significantly involved. causes of death were: agvhd with or without infection in patients ( %) and leukemia relapse in patient. conclusions: although if etanercept is an option for treatment of sr agvhd in some patients, their prognostic remains poor and more effective alternative strategies are needed. a prompt initiation of etanercept as a rescue treatment for sr agvhd is crucial to improve the prognosis. ( ) ( ) background: although both cyclosporine (csa) and tacrolimus are calcineurin inhibitors, csa is more widely used in pediatric hematopoetic stem cell transplantation (hsct) as a prophylactic drug for acute graft versus host disease (agvhd). there are some clinical experience but very few data about the clinical efficacy of conversion to tacrolimus. here, we present our single center data on this arguable topic. methods: this study involves the data of pediatric hsct patients in medical park göztepe hospital between - . all patients had prophylactic csa therapy and for various reasons csa was converted to tacrolimus therapy. most of the patients had this conversion due to agvhd. as steroid is the first line therapy for agvhd, conversion to tacrolimus is done concurrently at the start of steroid therapy (within hours after the start of steroid). and also, patients who had any other immunosupressive therapy for agvhd are excluded. response is defined as resolution of symptoms within days after conversion. results: mean age of the study population is months ( - months), male/female ratio is , ( / ), donor types are mud patients ( %), mfd patients ( %), haplo patients ( %) and mean conversion time is days ( - days) . the rationales for conversion are agvhd for patients, unproper csa plasma levels for patients, allergic reaction for patients, nephrotoxicity for patients, hepatotoxicity for patients, severe headache for patients, high arterial blood pressure for patients and one each for refractory vomiting, autoimmune thyroiditis and visual disturbance. the subgroup analysis of agvhd patients reveals that mean conversion time for agvhd is days ( - days) and there are only responders whose agvhd resolve completely (% ) after conversion. all of the patients had proper tacrolimus levels after conversion due to unproper csa levels and also patients in allegic reaction, severe headache, visiual disturbance and refractory vomiting group responded to conversion completely but only one of the patients in nephrotoxicity group responded and also of the patients in hepatoxicity group responded. the only one patient suffered from autoimmune thyroiditis did not respond to conversion. conclusions: in this study, it is obvious that there are response to conversion for some specific adverse effects of csa and tacrolimus is a good alternative for the patients who have unproper csa levels. conversely, the high percentage (% ) of non-responders shows that it is not feasible to make a conversion to tacrolimus for acute gvhd. disclosure: nothing to declare background: capillary leak syndrome is caused by the dysfunction of the vascular endothelial cells,and is characterized by weight gain,generalized edemas,unresponsive to diuretic treatment,and hypotension.it usually develops in the first days post hsct.and it is of great difficuty to distinguish from other complications which are occured post the allo-hsct. to diagnose this complication at the early stage,it is very difficulty. methods: a -year-old man was admitted to ningbo first hospital for its abnormal in the peripheral blood .he was diagnosed with aml-m by the classical morphology and immunophenotype.cytogenetic evaluation showed a normal , xy( ).the patient achieved cr with induction therapy including idarubicin, cytarabine and etoposide. after consolidation therapy,an allo-hsct from hla identical related dornor( -year-old male, donorrecipient matched by high resolution hla typing at hlaa, -b, -c, drb , and dqb , / matches) was performed.the recipient received conditioning with busulfan, mg/kg/day injection for days; cyclophosphamide, mg/kg/day injection for days; cytarabine, g/m /day injection for day; semustine, mg/m /day orally for day; donor peripheral blood stem cells (pbsc:mnc: . × /l, cd +: . × /l) were mobilized, pheresed and administered to the recipient. gvhd prophylaxis consisted of traditional cyclosporine, short-course methotrexate ( mg/ m at day + , mg/m at days + , + , and + ) and cyclosporin a injection mg/kg qer day was mot reduced untill the hematopoietic reconstitute sucessfully . on day + , complete donor chimerism was acheieved. the csa was gradually reduced and tapered.on day + ,the patients was manifested with increasing in the time and volume of the faeces, he was diagnosed with ii°gvhd (gut).the standarded does of immunosuppressive drug including methylprednisolone and cyclosporin a was administrated. the immunosuppressive drug was gradually reduced when the gvhd was controlled.on day+ ,the patient felt distress and the distress was not related to with the exercise,the temperature was normal,and he did not gain weight.there was no edema in the body.laboratory test including routine blood test,c-reactive protein,procalcitonin,blood gas analysis,cmvdna,ebvdna was normal. the ct scan shows that the pleural is filled up with water, and could not be enlarged promptly, there is pericardial effusion in the body.pulmonary function test shows that reduced function in ventilation and diffusion fuction.the laboratory test of the pleural effusion was normal,the blast cell was not detected in the pleural effusion,the cd + cell count was below the dectable level,the next generation sequencing for minimal residual disease shows that there was no gene mutation .thus, post capillary leak syndrome was considered .sirolimus was adopted and taken the place of cyclosporin a,immunoglobulin was adminstrated to reduce the edema. results: taking together comprehensively,the effusion in the pleural and cardiac was absorbed well. conclusions: occurance of capillary leak syndrome is rare,there is limited data about capillary leak syndrome. comprehensively,the mechanism of cls has not been totally identified.and there is no standard treatment to treat the complication.at present,the cls of this patient was absorbed well by administrating sirolimus,closely followup is needed. disclosure: nothing to declare graft-versus-host diseasepreclinical and animal models p short-term krp and posttransplant cyclophosphamide for graft-versus-host disease prophylaxis emi yokoyama , daigo hashimoto , takahide ara , eko hayase , takanori teshima hokkaido university faculty of medicine, hematology, sapporo, japan background: post-transplant high-dose cyclophosphamide (ptcy) in combination with other immunosuppressants such as calcineurin-inhibitors (cis) has been increasingly used as gvhd prophylaxis after hla-haploidentical or matched hematopoietic stem cell transplantation (hsct). however,cis could hamper reconstitution of regulatory t cells (tregs) and tolerance induction after hsct, facilitating us to develop novel ci-free/ptcy-based gvhd prophylaxis. in the current study, we developed a novel gvhd prophylaxis in which ptcy was combined with short-term administration of krp , a selective agonist of sphingosine- -phosphate receptor type (s pr ), using murine models of mhc haploidentical bone marrow transplantation (bmt). methods: b d f (h- b/d ) recipients were lethally irradiated and transplanted with bone marrow cells and splenocytes from allogeneic b (h- b ) donors. cy at a dose of mg/kg was intraperitoneally injected into the recipients on day + , and krp at a dose of . mg/kg was orally administrated daily from day to day + after bmt. donor t cells in the target organs and secondary lymphoid organs were evaluated by flow cytometric analysis. plasma levels of tnf-α were determined using cytometric beads array. to evaluate graft-versus-leukemia (gvl) effects, recipient mice were intravenously injected with luciferase-transduced p cells (p -luc) on day , and in vivo bioluminescence imagingwas conducted weekly after bmt. results: severe gvhd was developed in allogeneic recipients and all mice died by day after bmt.ptcy alone at a dose of mg/kg significantly ameliorated gvhd and % of ptcy-treated allogeneic recipients survived. oral administration of krp alone enhanced contraction of donor t cells in the lymph nodes and also ameliorated gvhd as has been previously shown with multi-s pr agonist, fingolimod. next, we tested if shortterm krp on days to + added to ptcy enhances anti-gvhd effects of ptcy. we found that survivals of ptcy+krp group were significantly prolonged compared to those of ptcy-alone group ( figure a) . plasma levels of tnf-a, clinical gvhd scores ( figure b) , and donor t-cell infiltration into the target organs such as the gut and skin were also significantly reduced in ptcy +krp group compared to ptcy-alone group (figure c and d) . unlike cis, addition of krp to ptcy promoted treg reconstitution after bmt. finally, bioluminescence imaging demonstrated that proliferation of p -luc injected on day was significantly delayed in ptcy +krp -treated allogeneic recipients compared to control mice transplanted only with t-cell depleted bone marrow cells, suggesting that significant gvl effects persisted in ptcy+krp -treated recipients. conclusions: a combination of short-term krp and ptcy is a promising novel calcineurin-free gvhd prophylaxis in mhc-haploidentical sct. we recently showed that donor inkt cells can be expanded ex vivo and that they are able to prevent activation and proliferation of alloreactive donor t cells while promoting efficient graft-versus-leukemia effects (schmid et al. ). however, the underlying mechanisms how human inkt cells induce immune tolerance after allogeneic hct are not fully understood. methods: monocyte-derived dendritic cells (dcs) were cultured in a mixed lymphocyte reaction with mhcmismatched t cells and culture-expanded inkt cells. tcell activation and proliferation was analyzed by multiparametric flow cytometry and released cytokines were measured via multiplex analysis. transwell assays and imaging flow cytometry were performed to elucidate cellcell interactions. bead-controlled flow cytometry-based cytotoxicity assays were used to evaluate dc apoptosis. apoptotic dcs were then purified by fluorescence-activated cell sorting to investigate their tolerogenic potential to prime regulatory t cells (tregs). results: the addition of inkt cells to mixed lymphocyte reactions resulted in a significantly reduced activation and proliferation of mhc-mismatched t cells. transwell assays and imaging flow cytometry revealed a cell contactdependent mechanism between inkt cells and dcs leading to apoptosis with increasing dna fragmentation of dcs over time. interestingly, various fluorescence-activated single cell sorted inkt-cell subsets were all able to induce apoptosis of host dcs. multiplex analysis revealed that dcs triggered inkt-cell release of cytotoxic factors like perforin, granzyme b and granulysin. blocking the inktcell receptor engagement with a cd d antibody prevented inkt-cell degranulation as well as the subsequent induction of host dc apoptosis. inhibition of cytotoxic factors also abrogated apoptosis of dcs. in turn, sorted apoptotic dcs induced tolerogenic dcs characterized by a high expression of pd-l in mixed lymphocyte reactions. such tolerogenic dcs promoted the expansion of cd + cd + foxp + tregs and prevented activation and proliferation of mhcmismatched t cells. conclusions: we propose a novel mechanism how culture-expanded human inkt cells prevent gvhd after allogeneic hct. host dc apoptosis through donor inkt cells induces a tolerogenic immunoenvironment characterized by pd-l high dcs and expanding donor tregs inhibiting activation and expansion of alloreactive donor t cells. our findings pave the avenue for clinical translation of adoptively transferred culture-expanded inkt cells in humans. disclosure: nothing to declare results: vip-ko mice transplanted with allogeneic tcd bm alone had increased graft rejection with lower levels of donor chimerism and % day survival compared with % survival of wt recipients. transplanting tcd bm plus × e donor t cells from b .br or balb/c donors in vip kio mice led to > % donor chimerism and significantly increased gvhd-mortality compared with wt recipients, with % vs % survival in the b .br-->b model (p< . ), and % vs % survival in the balb/c-->b model (p< . ). donor-derived t cells in vip-ko recipients had significantly higher th and th polarization, with higher rorγt in both cd + (p< . ) and cd + (p< . ) t cells, and higher frequencies of ifn-γ (p< . ), tnf-α (p< . ), and il (p< . ) in cd + and cd + t cells compared to wt recipients. b .br-->b second allogeneic transplantation of radiation chimeras caused lethal gvhd mortality in vip-ko-->vip-ko and wt-->vip-ko mice, but not in wt-->wt or vip-ko-->wt b mice, demonstrating the protective effect of vip was due to synthesis by non-hematopoietic recipient cells. immunofluorescent imaging of allo-bmt recipients showed marked up-regulation of vip in lungs post-transplant and high vip production within neurons innervating the lungs. finally, we demonstrated that short-term administration of vip ( mcg/day) from day to day prevented gvhdmortality in vip-ko recipients transplanted with b .br-->b mhc donor bm & t cells. conclusions: the absence of vip in recipient cells led to increased graft rejection in the absence of donor t cells and increased lethal gvhd when donor t cells were transplanted, indicating vip induced post-transplant regulates allo-reactivity of host graft-rejecting lymphocytes and donor gvhd-causing t cells. the protective effect of parenteral vip administration suggests vip-mimetics represent a novel approach to prevent and treat gvhd. these data also suggest a mechanism of action for the mitigation of gvhd by alpha- anti-trypsin (aat) whereby aat inhibits the proteolytic inactivation of endogenous vip. disclosure: dr. waller reports personal fees and other support from cambium medical technologies, grants from celldex, personal fees from kalytera, grants and personal fees from novartis, grants and non-financial support from pharmacyclics, and equity ownership in cerus corporation and chimerix outside the submitted work. in addition, dr. waller has intellectual property related to vip signaling that has been licensed to cambium oncology in which he holds equity. low-density neutrophils expansion is associated with acute graft versus host disease in allogeneic hematopoietic stem cell transplant patients background: low-density neutrophils (ldns) are distinguished from normal-density neutrophils (ndns) by their anomalous sedimentation within the mononuclear cell fraction after density gradient centrifugation of peripheral blood (pb). by analysing ldns and ndns from g-csfstimulated donors or lymphoma patients, we have previously demonstrated that, depending on physiopathological conditions, immature cd b + cd -ldns can promote t cell survival and ifn-γ production, while mature cd b + cd + ldns can exert immunosuppressive proprieties. aim of this study was to establish the frequency of cd b + cd and/or cd b + cd + ldns in pb of allogeneic hematopoietic stem cell transplant (hsct) patients throughout immune reconstitution, and verify their potential correlation with acute graft versus host disease (agvhd). methods: patients undergoing hsct in our institution between december and june were prospectively enrolled in the study upon informed consent and after institutional board approval. criteria of inclusion were age ≥ years and absence of rheumatologic or viral diseases. pb samples were collected at day + , + , + , + and + after hsct and any time within day + in case of gvhd, before first-line therapy. eight healthy donors (hds) were enrolled as control. mononuclear, polymorphonuclear, and whole blood cells were analysed by flow cytometry after cd vioblue, cd apc-cy , cd b pe-cy , cd pe, cd b fitc staining. cd b + ldns were expressed as percentage of cd + pb mononuclear cells (pbmcs) or cd + whole blood cells and were further characterized based on cd expression. cd b + ndns, expressed as percentage of cd + whole blood cells, were also analysed for cd staining. results: patients (m/f / , median age ) were enrolled in the study. patients received hsct from hlaidentical ( ) or haploidentical ( ) related and from hlaidentical unrelated ( ) donors. after a median time of ( - ) days, patients developed grade ii-iv agvhd. no patients were receiving g-csf at agvhd onset. the scheduled assessments were interrupted in agvhd patients at the beginning of first-line treatment and in patients relapsed of their primary malignancy. no patients developed de novo late-acute or chronic gvhd. starting from day + the frequency of ldns within cd + pbmcs was higher in all patients as compared to hds. the patients that did not develop agvhd showed a decreasing frequency of cd b + cd -ldns, with a progressive increase of cd b + cd + ldns, from day + to + . interestingly, patients with agvhd showed a significantly higher frequency of cd b + cd -ldns as compared to patients without agvhd throughout the same time lapse (i.e. from day + to + ) ( . vs . , p= . ). consistently, patients with agvhd had a significantly lower frequency of cd b + cd + ldns ( . vs . , p= . ). the frequency of mature cd b + cd + ndns was normal in all patients since day + . conclusions: ldns are more represented in hsct patients than in hds, with a significant expansion of the cd b + cd subpopulation (with a parallel decrease of the cd b + cd + subpopulation) in patients with agvhd as compared to those without agvhd. according to the previously demonstrated t cell activating function of cd b + cd -ldns, it is tempting to speculate that the expansion of this subpopulation may contribute to agvhd development. disclosure: nothing to declare background: acute graft-versus-host disease (agvhd) is a major complication after allogeneic hematopoietic stem cell transplantation (allo-hsct) which has negative impact on the morbidity and mortality of the patients. accumulating evidences suggest that abnormalities of foxp + regulatory t (treg) cells contributed to the pathogenesis of gvhd, but the underlying molecular mechanisms still remain largely unknown. methods: in this study, we enrolled all the patients treated with allogeneic hsct at the institute of hematology, chinese academy of medical sciences between and ,as well as age-matched healthy adults as control samples. the ratio of tregs in pb and bm of healthy controls (hcs) and patients with and without agvhd was determined by flow cytometry. the transcription profile between tregs from patients with or without acute gvhd was measured,the pathway enrichment analyses were performed by the kyoto encyclopedia of genes and genomes (kegg) pathway database and geneset enrichment analysis (gsea).the expression of lkb at transcript levels and protein levels was measured by realtime pcr and analyzed by the nanopro tm system. a series of functional assays in vitro were performed to assess the function and stability of tregs from patients with and without agvhd.meanwhile, to assume the affect of lkb on gvhd outcome, we established a murine transplant model,which recipient balb/c animals were transplanted with the same amount of mixture made by bm, cd +cd -tcon cells from c bl/ and cd + foxp yfp+ tregs from either foxp crelkb f/f or foxp cre mice. results: in this study, we demonstrated that bm had decreased frequencies of tregs, accompanied with a reversed lower ratio of tregs frequencies between bm and pb in agvhd patients. meanwhile, the number and function of tregs in bone marrow also affected hematopoietic reconstitution. futhermore,to elucidate these mechanisms which regulate tregs homeostasis, we examined the role of lkb on tregs in patients with agvhd and in agvhd murine model. studies demonstrated that lkb deficient tregs lost foxp expression and weaken suppressor function during agvhd. transcriptional profiling and pathway analysis revealed that nf-kb signaling activation and the impairment of a wide spectrum of immunosuppressive genes in agvhd tregs. further mice experiments suggested that cns methylation might lead to the instability of tregs in agvhd group. transplantation with marrow grafts from foxp crelkb f/fmice exacerbates gvhd lethality. conclusions: these studies indicate that lkb is a critical homeostatic regulator for tregs during agvhd. targeting of lkb therefore represents a novel therapeutic strategy that promote immune tolerance to mitigates the severity of agvhd. disclosure: national program on key basic research project ( program) role of aryl hydrocarbon receptor in intestine after allogeneic hsct in mice won-sik lee , soung-min lee , sj-kil seo inje university, busan paik hospital, hemato-oncology, busan, korea, republic of background: aryl hydrocarbon receptor (ahr) is a ligandactivated transcription factor that is activated by various small molecules from the diet, microorganisms, host metabolism, and xenobiotic toxic chemicals. the function of ahr has been demonstrated as a crucial regulator in intestinal homeostasis. here, we investigated the regulatory role of ahr in intestine of recipients after allogeneic hematopoietic cell transplantation in mice. methods: wild-type (wt) b (h- b ), ido -/-(h- b ) and ahr -/-(h- b ) mice were lethally irradiated and transplanted with x tcd-bm plus x t cells from balb/c donor mice. ahr activation in colon tissue of recipients was determined by the ahr target genes cyp a and cyp b expression using real-time pcr. the recipient mice were monitored every other day for survival and clinical score. histopathology and pathogenic effector cytokine levels in colon tissue were analyzed for evaluating ahr function. results: we observed that cyp a was constitutively expressed in the colon tissue of naïve recipient mice. although the expression levels were increased by tbi conditioning, the additive up-regulation of its levels with donor t cell alloreactivity was not observed. in contrast, cyp b expression was markedly induced in the colon tissue by donor t cell alloreactivity. we further observed that the cyp b expression was significantly decreased in the colon of ido-/-recipients with donor t cell alloreactivity, but cyp a was not changed. ido-/-and ahr-/recipient mice showed higher histopathological score for intestinal gvhd and increasing pathogenic cytokine levels in the colon compared with wt mice. conclusions: our results demonstrate that ahr-induced target gene profiles might be differently induced in intestine by ligand dependent manner after hsct, which affect intestinal gvhd. disclosure: nothing to declare. abstract already published. abstract withdrawn. in vitro platelet activation evaluation in allogeneic hematopoetic stem cell transplanted patients in response to haemostatic stimulation and cytomegalovirus stimulation (gvhd), complication of which one of the risk factor is cmv reactivation. the resultant inflammatory platelet response during the high-risk period of gvhd after allogeneic hsct remains unknown. our study aimed to characterize spontaneous platelet activation during the d and d months after allogeneic hsct, and in response to haemostatic stimulation and cmv stimulation. methods: we compared a group of healthy volunteers to a group of allogeneic hsct patients followed between the th and the th days after hsct. platelet activation was determined by the platelet surface expression of cd p and cd using flow cytometer after stimulation by an haemostatic agent, thrombin-receptor activating peptid (trap) and after stimulation by cmv glycoprotein b. the inflammatory response was determined by the detection of immune mediators, rantes, cd ps, pf , cd l and ccl , using the elisa technique in the stimulated platelet supernatants. results: no platelet activation or molecules release were observed after stimulation by cmv glycoprotein b in both groups. rantes and cd ps baseline levels are spontaneously higher in allogeneic hsc patients than in healthy volunteers. platelets from allogeneic hsct patients can be activated after haemostatic stimulation and release cd ps and rantes. in this situation, platelets release more cd ps, rantes and pf than platelets from healthy volunteers. conclusions: although no platelet activation was detected in response to cmv glycoprotein b stimulation, our study revealed a chronic platelet activation condition during the d and d months after allogeneic hsct with an haemostatic inducible hyper-responsiveness. this leads to the release of molecules with immune-modulating properties involved in the pathophysiology of gvhd. as we move further away from the hsct, that phenomenon seems to gradually weaken. clinical trial registry: nct , fipalloc https://clinicaltrials.gov/ct /show/nct disclosure: nothing to declare p efficient process and characteristics of umbilical cordderived mesenchymal stromal cells as a feasible source for anti-inflammatory therapy background: recently, umbilical cord (uc) has become attracted source of mesenchymal stromal cells (msc), because of abundant sources and ease of collection of fetal origin without invasive process for the donor and low immunogenicity with immunosuppressive ability and tissue repair potency. objectives of this study were to explorer the efficient and safe products and to evaluate the antiinflammatory potency of uc-mscs for the application of acute graft versus host disease (gvhd). methods: informed consent was obtained from mothers planning to have cesarean sections. uc tissue was cut and once cryopreserved. the safety assessment including infections and baby's health and development were done after months of birth, and performed small-scale quality test of the frozen uc. then we initiated to isolate master uc-mscs from frozen-thawed uc by an improved explant method, which was passed for quality test. the master uc-mscs were cryopreserved once and thawed and expanded until p . product cells were cryopreserved in original serum-free cryoprotectant dba-d solution. mixed lymphocyte reaction (mlr) assay co-cultured with uc-mscs was carried out using responder mononuclear cells (mnc) stained with cfse, and proliferation and cytokine secretion were analyzed by flowcytometry. results: uc-msc cultured showed significantly higher proliferation ability compared with those from bone marrow-derived mscs, and positive for cd , cd , cd , and negative for cd , hla-dr. cd , and cd were negative even in the high concentration of ifn-γ, while bm-mscs became positive for hla-dr. pd-l was constitutively expressed in uc-msc, while pd-l was induced by the addition of ifn-γ. in mlr, responder t cell proliferation triggered by allogeneic dendritic cells was inhibited efficiently by rd party derived uc-mscs, in which was induced ido, pge , hgf, and tgf-β analyzed by rt-pcr, and inhibited ifn-γ and tnf-α in the supernatant by cytokine beads array. uc-mscs migrated toward the tnf-α treated mnc and increased regulatory t cells incidence in peripheral mononuclear cells by the coculture. conclusions: these results demonstrated that cryopreserved uc are feasible and efficient source of mscs and frozen-thawed uc-mscs have high anti-inflammatory background: a new protocol is under development on the amicus separator that enables the device to perform ecp procedures. the amicus separator is used with a photoactivation device, disposable kit and -mop to provide ecp therapy in a closed system. the objective of this study was to evaluate the safety and performance of the investigational amicus ecp system in healthy human subjects. methods: an irb-approved written informed consent was obtained from subjects ( male, female). the amicus ecp system processed either , or ml whole blood (n ≥ per arm) using double-needle access and acd-a anticoagulation at a : wb:ac ratio. after mnc collection was completed, the subject was disconnected from the device. -mop ( . ml, μg/ml) was injected directly into the collected mnc product and saline (approximately ml total), which was photoactivated with - j/cm uva light. post photoactivation, the amicus separator reinfused the treated mncs into a transfer pack. subject laboratory and safety parameters were evaluated; in vitro evaluations were performed on subject whole blood, collected mncs, treated mncs, and reinfused cells. lymphocyte and monocyte analysis were performed on samples purified using density gradient separation and cultured for up to days post treatment. results: in procedures, median (range) wb processed was . ( - ) ml using . ( - ) ml of acd-a. procedure time was . ( - ) minutes, including photoactivation. no adverse events were reported. subjects' vital signs and hematology values were unremarkable and within expected values. the wbc count of the collected mncs was . ( . - . ) x /μl, comprised of . ( . - . ) % lymphocytes, . ( . - . ) % monocytes and . ( . - . ) % granulocytes and platelet count was . ( - ) background: transfusion of white blood cells (wbc) causes a number of transfusion reactions and complications, for example transfusion-associated graft versus host disease (tagvht), which still does not have effective treatment and is a fatal complication of transfusions. the only effective method of preventing tagvht is irradiation of blood components with ionizing radiation (x-ray or gamma radiation). but the use of ionizing radiation sources has a number of technical and material difficulties. the emergence of pathogen reduction technologies (prt) in blood components targeted by nucleic acids has opened the possibility of using these technologies as an alternative to irradiating of blood components. several prt demonstrated effective inactivation of wbc in platelet concentrates and blood plasma. so, determination of the influence of prt based on the combined effect of riboflavin (rf) and ultraviolet (uv) on the viability and proliferating potential of lymphocytes in whole blood is important. methods: samples of whole blood were obtained in healthy volunteers. each sample was divided into three unequal parts: untreated control, gamma irradiated, and treated by rf and uv prt (mirasol, terumo bct inc.). mononuclear cells (mnc) were cfse stained, viability and proliferating activity were tested at intervals of hours for consecutive days by flow cytometry. statistical analysis was performed with xlstat . . levels of significance were calculated by mann-whitney test, expressed as p-values (p< , ). results: the median viability of mnc after application of both methods of treatment was over , % on day and decreased to day -median percentage of viable mnc were , % (control group), , % (after gamma irradiation) and , % (rf/uv prt). the median of spontaneous proliferative activity on day of untreated and gamma irradiated mnc did not differ ( , % and , % respectively, p< , ). phytohemaglutenin (pha) induced proliferation on day in gamma-irradiated samples was significantly lower in comparison with control group ( , % and , % respectively, p< , ). in samples treated with rf/uv, spontaneous and stimulated proliferating cells was not detected. median percentage of proliferating mnc was less than , %. the use of this prt on whole blood, as well as gamma irradiation, significantly reduces the viability of lymphocytes during storage for days. conclusions: inactivation of wbc using rf/uv prt is a useful and very necessary bonus for a number of reasons. in one procedure two effects are achieved: infectious and immunological safety. the use of prt on whole blood gives the potential for obtaining pathogen-reduced and immunological safety components of blood, which reduces their material cost and staff loading. the use of rf/uv system does not have such complex security requirements and difficulties in servicing as the use of sources of ionizing radiation. the results demonstrate a promising potential for using this technology as an alternative to irradiation disclosure: nothing to declare p influence of patients´serum after allogeneic stem cell transplantation on t cell proliferation and treg function background: acute or chronic graft versus host disease (a/ cgvhd) is one of the major complications after allogeneic hematopoietic stem cell transplantation (ahsct). application of regulatory t cells (treg) as "immunosuppressive dli" to prevent or treat gvhd is investigated in clinical trials. here we ask the question, if there could be clinical conditions (e.g. cytokines or drug effects) limiting the efficacy of this approach. to face this problem we tested the influence of patients´serum on t cell proliferation and treg function. methods: lymphocytes from healthy donors were incubated with t cell medium ( % aim v + % serum + il /okt ) containing serum from healthy donors or serum derived from patients after ahsct with or without gvhd (n= ). next we evaluated the suppressive function of treg by performing treg suppression assays, also comparing serum from patients suffering from gvhd versus serum obtained from healthy donors (n= ). proliferation of cfse stained t cells was measured after days. to test the effect of immunosuppressive drugs on treg we performed treg suppression assays after incubation of treg with corticosteroids or tacrolimus or the combination of both drugs. results: serum of patients with acute or chronic gvhd had a negative effect on t cell proliferation. to avoid bias tests were performed with samples from patients without or only with low levels of immunosuppressive drugs. incubation with serum of patients without gvhd or with serum of healthy individuals showed no differences in t cell proliferation. treg from healthy donors showed a stronger antiproliferative capacity when incubated with serum derived from patients with gvhd. treg previously incubated with immunosuppressive drugs showed no decreased suppressive capacity. conclusions: components of serum from gvhd patients seem to have an antiproliferative effect on t lymphocytes itself. this fact might influence the clinical course of gvhd, but should not be a limiting factor for therapeutic application of treg dli. even the systemic treatment with immunosuppressive drugs e.g. corticosteroids or calcineurin-inhibitors should not diminish the treg application. in a next step we will analyze serum components responsible for this immunosuppressive effect with multi cytokine assays and proteomic analysis. the aim of our project is to develop new strategies to avoid gvhd and to optimize clinical settings for treg dli. disclosure background: hypercalcaemia can be very severe following stem cell transplant (sct) in some osteopetrosis patients. denosumab is a fully human monoclonal antibody that binds the cytokine rankl (receptor activator of nfκb ligand), an essential factor initiating bone turnover. rankl inhibition blocks osteoclast maturation, function and survival, thus reducing bone resorption. we describe the effective management of hypercalcaemia in a patient with rank mutation osteopetrosis who received a haploidentical sct. methods: our patient was diagnosed with osteopetrosis at year of age with a defect in the tnfrsf a gene which codes for rank and received a maternal haploidentical sct aged years. the patients calcium levels were monitored regularly post sct. denosumab was administered for hypercalcaemia as per laboratory reports or clinical symptoms. the drug was diluted with water for injection to make mg/ml solution to facilitate subcutaneous administration. results: significant hypercalcaemia emerged on day + with a level of mmol/l and treated with hyper-hydration and diuretics. this was ineffective in reducing the hypercalcaemia; therefore denosumab was initiated on day + post-transplant. initial dosing was determined using the only available paediatric case report at . mg/kg. a repeated larger dose of . mg/kg was given days later due to an inadequate response (calcium decreased from . mmol/l to . mmol/l). the calcium decreased to . mmol/l after this dose. four weeks later a third dose was required at . mg/kg as the calcium level had increased to . mmol/l. the dose was further increased to . mg/kg for another four doses and then further increased to . mg/kg for another doses and repeated every weeks. normalisation, but not excessive drop in calcium was achieved with these larger doses. over the month follow up post-transplant there were three admissions lasting less than hours for symptoms of hypercalcaemia. these were managed with denosumab administration and hyper-hydration. the remaining doses were given in an outpatient setting. conclusions: denosumab can be safely used as a first line agent in treating post stem cell transplant hypercalcemia in patients with osteopetrosis. a dose of . mg/kg is required as an initial starting dose in order to control hypercalcemia. this is a new higher dose than previously suggested by the original report. denosumab can be effective even after dilution and safely given in children weighing less than kg. disclosure: nothing to declare methods: the clinical, laboratory and molecular aspects of this italian male patient who developed such a complication were collected and presented in order to discuss the origin, clinical outcome and management of this very rare post-transplant event. results: a -years-old man affected by a high-risk chromosomally abnormal, ph -, mll-pro-b (egil b-i) all relapsed during maintenance treatment, nonresponsive to re-induction chemotherapy, in second complete remission (ii cr) after blinatumumab treatment received a female cb transplant. according to sorror's and ebmt scores he was considered a high-risk transplant. the patient and the cb unit were sex-mismatched, shared the same blood groups and were both cmv+/ebv+. he received a tbf conditioning regimen that was followed by the infusion of . x /kg cd + cb cells. gvhd prophylaxis consisted of rabbit atg, cyclosporine a (csa) and mycophenolate mophetyl (mmf). neutrophil engraftment occurred on day + , whereas platelets were never > . /μl. on day + a cm bulged area became apparent on the left parietal region of the skull. an echotomography showed that the lesion adhered to the bone without infiltrating it and lacked blood vessels and suggested that it may be either a site of disease relapse or an area of infection. at the same time a bone marrow (bm) aspiration showed morphological cr confirmed by immune-phenotypic studies and x-y fish a complete chimera. since the patient was still febrile no biopsy was performed, but on day + the axial diameter of the lesion that on a ct scan showed the same appearance revealed by the previous echo-tomography increased to cm. thus, the lesion was surgically removed and histological examination showed cd +, cd +/-, cd +/-, cd /lca+/-, cd -, cd -, cd -, cd -, and s -neoplastic cells whose phenotype suggested a granulocytic sarcoma rather than a histiocytic sarcoma. immuno-chemistry confirmed this suggestion by showing a nuclear npm positivity. fish studies demonstrated that these neoplastic cells were of recipient's origin. a novel bm aspiration showed cr confirmed by immune-phenotypic studies and fish revealed a complete chimera. since the patient was still pancytopenic due to anti-cmv treatment, radiotherapy with gy in nine fractions were given and the lesion completely resolved. conclusions: a granulocytic sarcoma of recipient's origin occurring three months after a cb transplant is a very rare and unusual event. in order to explain such a complication we suggest that granulocytic sarcoma cells were dormant but already present at the time of pro-b all diagnosis and survived not only the initial all treatment but also the cb transplant conditioning regimen. we can't exclude that immune-suppressive treatments given early post-transplant might have promoted the outgrowth of these neoplastic cell population. disclosure: nothing to declare haemoglobinopathy and inborn errors of metabolism p abstract already published. addition of fludarabine on to anti-thymocyte globulin, busulfan and cyclophosphamide conditioning improves outcomes in low-risk matched-related bone marrow transplantation in children with severe thalassaemia flu-atg-bucy. atg dose was mg/kg in all patients except patients with splenomegaly > cm from costal margin and/or sex-mismatched/maternal donor in whom atg was increased to mg/kg. all patients were younger than years and had no hepatomegaly (liver ≤ cm from costal margin) at bmt. results: actuarial overall survival (os) in the atg-bucy and flu-atg-bucy groups is % and %, thalassemia-free survival (tfs) % and %, gvhdfree and thalassaemia-free survival (gtfs) at a median follow up of . and . months was . % and . % months respectively, which is a significantly improved outcome by log-rank statistics (p= . ) in the flu-atg-bucy group. there was no significant difference between the groups in pre-transplant characteristics and posttransplant complications except for the following: median cell dose more in nd group with total nucleated cell dose of . vs . x cell/kg with p< . ; csa taper started later in the new protocol ( day vs. p= . ); median age at bmt ( . vs. . years, p= . ); number of pre-bmt transfusions (p= . ) and ferritin at bmt ( . vs. . ng/ml, p= . ) were higher in the second group; day and chimerisms were also significantly higher in new protocol (p= . and . respectively). there was a trend towards increased incidence of veno-occulsive disease (vod) and posterior reversible encephalopathy syndrome (pres) on the second group but this difference did not reach statistical significance. conclusions: adding fludarabine and targeted dose increase of atg in the standard bucy context seems to significantly improve outcomes of thalassaemia transplants without contributing to excessive gvhd or infectious complications. this protocol can be easily administered in low resource setting without major additional costs. clinical is an acquired clonal disorder of the hemopoietic stem cells for which the only curative treatment is allogeneic hematopoietic stem cell transplantation. however, there are still few reports on the outcomes of allogeneic hematopoietic stem cell transplantation (allo-hsct) in patients with pnh compared to paroxysmal nocturnal hemoglobinuria-aplastic anemia (pnh-aa) syndrome. our study aimed to compare the outcomes of allo-hsct for pnh with pnh-aa syndrome. methods: the clinical data of pnh patients received allo-hsct (pnh = , pnh-aa = ) in our center from july to june were analyzed retrospectively to compare the outcomes of pnh group with pnh-aa group. the clinical data including male patients and female patients, the median age was years (range - ). all patients had received various treatments before transplantation such as steroids, androgens, cyclosporine (csa), antithymocyte globulin, and growth factors. the median interval from pnh diagnosis to hsct was months (range - ). the conditioning regimen was modified bu/cybased regimen in haploidentical donors and unrelated donors, csa, mycophenolate mofetil (mmf) and shortterm methotrexate (mtx) were administered for graftversus host disease (gvhd) prophylaxis. patients with matched sibling donors were treated with the flu/cybased regimen and csa were administered for gvhd prophylaxis. results: there were no differences of baseline between the groups (p> . ) except gender and haploidentical donors. the median values of absolute nucleated cell counts were . ( . - . ) × /kg in the pnh group and . ( . - . ) × /kg in the pnh-aa group (p = . ). the median doses of cd + cells infused were . ( . - . )× /kg and . ( . - . )× /kg (p = . ), respectively. all patients attained complete engraftment, no patient occurred graft failure. the median time for myeloid engraftment were (range, - ) days in the pnh group and (range, - ) days in the pnh-aa group (p = . ). the median time for platelet engraftment were (range, - ) days and (range, - ) days (p = . ), respectively. with a median follow-up of ( - ) months in the pnh group and ( - ) months in the pnh-aa group (p = . ). in pnh and pnh-aa groups the incidences of grade i-iv acute graft-versus-host disease (agvhd) were . % and . % (p = . ), grade ii-iv agvhd were . % and . % (p = . ); chronic gvhd were . % and . % (p = . ), moderatesevere chronic gvhd were . % and . % (p = . ). in haplo-hsct and msd groups the incidences of infection were . % ( / ) and . % ( / ) (p = . ). no patient occurred early death and relapse. -year estimated overall survival (os) of pnh and pnh-aa groups were . % ± . % and . % ± . % (p = . ), gvhd-free and failure-free survival (gffs) were . % ± . %、 . % ± . % (p = . ). conclusions: the preliminary results indicated that allo-hsct is a feasible choice for pnh with favorable outcomes, time for myeloid and platelet engraftment in pnh group were faster than pnh-aa group. there were no differences in os and gffs between pnh group and pnh-aa group. disclosure: no disclosure pattern of calcineurin inhibitor-associated neurotoxicity in sickle cell disease patients receiving a stem cell transplantation background: allogeneic hsct with a msd represents currently the only curative option for sickle cell disease (scd), limited by a donor availability < %. neurotoxicity (nt) contributes significantly to hsct-associated morbidity and mortality. calcineurin-inhibitor (cni) associated nt ranges from . %- . % (severe nt %- %). the elevated incidence of nt in scd (around %) might be triggered by the systemic vasculopathy of scd, with the brain being the primary target. although both cyclosporine a (csa) and tacrolimus (fk ) have a proinflammatory effect, it is more pronounced in csa. infusion modalities also might impact ( . % after bolus injections versus . % after continuous infusion). methods: in a pilot study, we compared t-cell depleted haploidentical hsct (t-haplo hsct) with msd hsct in patients (pts) with advanced stage scd, using almost identical conditioning regimens. pts ( - years; yrs) with homozygous scd or hbs /+ ß-thal were treated between and . nine pts received a msd bone marrow graft, pts received t-haplo-hsct ( second t-haplo due to graft rejection). immunosuppression consisted of either csa ( msd, t-haplo) or fk ( msd, , in combination with mycophenolate mofetil (mmf). fk was administered as a -hours continuous infusion, csa as -hours bolus injections; both target level adjusted (csa: - ng/ml; fk : - ng/ ml). duration of immunosuppression was > months in thaplo-sct and < months in msd, depending on chimerism. results: cni-related nt was observed in . %, severe nt (pres, visual disturbance, aphasia) in . %. nt was more prevalent in msd (n= , . %) than in t-haplo (n= , . %). the incidence of nt was identical under csa ( / ; . %) and fk ( / ; . %), however the majority of severe nt (all pres) occurred with csa. complete recovery of nt was achieved in all pts either spontaneously or after switching to fk /everolimus or withdrawal of fk . moreover, . % of pts with nt were > yrs, and . % > yrs, suggesting an increased risk with age. only . % of pts with pre-existing cerebrovascular disease experienced post-hsct nt. of note, . % of pts with severe nt also developed mild acute gvhd. the overall (os) and disease-free survival (dfs) with a median follow-up of months in t-haplo-hsct and months in msd hsct was % vs. %, respectively. conclusions: our data confirm an elevated nt risk in scd pts following allo-hsct. importantly, the incidence of nt seems to be related to age ( % of pts with nt were > yrs), donor source (msd . % vs. t-haplo . %) and type of cni inhibitor where almost all severe nt ( . %, particularly all pres) was observed under csa. continuous infusion of fk vs. bolus injections of csa might have levelled concentration peaks. the nt observed with csa could be the consequence of predominantly csarelated vascular toxicity inflicting pre-damaged vessels in scd. the mechanism of action could be related to other systemic endotheliopathies such as vod, tam and agvhd, which was observed in . % of pts with severe nt, compared to an overall agvhd rate of %. disclosure: nothing to declare background: matched-related bone marrow transplantation (bmt) may cure over % of low-riskchildren with severe thalassemia (st) defined as a thalassemia syndrome with inability to keep a spontaneous hemoglobin > g/dl. it is well known that patient status at the time of transplant is critical in predicting transplant outcome. liver size > cm is an established adverse prognostic factor in terms of transplant-related mortality and, in our own experience,a spleen size > cm from costal marginis associated with increase rejection rates (blood vol. no. suppl ) . optimising liver and spleen size prior to transplant is likely to improve transplant outcomes. methods: we retrospectively reviewed the effectiveness of our strategy to reduce liver and spleen size pre-transplant using hydroxyurea, super-transfusion and intensive iron chelation. we considered liver size < cm and spleen size less than cm below costal margins as good risk features. liver biopsies were not performed thus pesaro risk classification could not be assigned. all transplant candidates were started on hydroxyurea for a minimum of months and pre-transfusion haemoglobin was maintained > gm/dl while on hydroxyurea. if the child had hepatospenomegaly at enrollmentand no improvement in liver and spleen size after an adequate trial of hydroxyurea (minimum of months of treatment achieving maximum dose of mg/kg day or tolerable haematological toxicity, i.e. neutrophil count between and /μl and/or platelet count between . and . /μl) patients were given a trial of supertransfusion maintaining haemoglobin above g/dl) for a minimum of months prior to declaring the patient as having failed downstaging. results: out of transplants across collaborating centers in india, patients had no hepatosplenomegaly at enrolment and hence were not actively downstaged. twelve patients were excluded due to inadequate information on their records. all of the remaining patients with enlarged liver and/or spleen were downstaged to low-risk features. all patients received adequate hydroxyurea trial among which seven ( %) patients required super transfusion in addition to maximal hydroxyurea. out of the patients ( %) were successfully down-staged with the above strategy and proceeded to transplant as low-risk patients. among the remaining ( %) patients had liver > cm and one had a spleen > cm only. there was significant improvement in liver and spleen size from the time of enrollment to transplant (p value . and . respectively by wilcoxon test for paired samples -two tailed) with median duration of downstaging of months (range - months). there was no significant difference in overall survival (os) and disease-free survival (dfs) by log rank test between the downstaged group and those who did not have hepatosplenomegaly at enrollment (p value . . respectively). conclusions: in the majority of children with thalassaemia and high transplant risk features liver and spleen size can be reduced pre-transplant using hydroxyurea and supertransfusions thereby decreasing transplant risk. disclosure: nothing to declare p abstract already published. abstract withdrawn. longitudinal analysis of the effect of hematopoietic cell transplantation on ocular disease in children with mucopolysaccharidosis i shows ongoing disease progression background: corneal clouding is seen in nearly all patients with mucopolysaccharidosis- (mps- ) causing visual impairment. hematopoietic cell transplantation (hct) is able to stabilize disease in many organs including the brain. however, residual disease in peripheral tissues is often described. therefore, the aim of this study was to determine the long-term effect of hct on ocular disease in mps- patients. methods: corneal clouding (grade - ) and visual acuity (decimal scale) were prospectively collected from all consecutive mps- patients treated with hct between and at the umc utrecht. the primary outcomes of interest, the effect of time on corneal clouding and visual acuity, were analyzed using a linear mixed model. the correlation between corneal clouding and visual acuity was analyzed with pearson's rho. other parameters studied were clinical phenotype, age at time of transplantation and hematological enzyme level after transplantation. other outcomes of interest analyzed included intra-ocular pressure, refraction, and macula and lens abnormalities. [[p image] . results: successfully engrafted mps- patients were included ( % with > % chimerism and normal enzyme levels after hct). corneal clouding stabilized during the first years after hct, but increased rapidly beyond three years (figure ). other predictors for increased corneal clouding were age at time of transplantation ( . , %ci . : . ; p= . ) and clinical phenotype (- . , %ci - . :- . ; p= . ). visual acuity also worsened significantly over time (- . , %ci - . :- . ; p= . ). corneal clouding was strongly negatively correlated with visual acuity (ρ - . , p = . e- ). conclusions: after initial stabilization, ongoing ocular disease is seen in mps- patients despite successful hct. this hallmarks the shortcomings of current standard therapies. new therapies that overcome the weak spots of current therapies are necessary to improve the late outcomes of these patients. clinical trial registry: n.a. disclosure: b.t.a.v.d.b. was supported by a research grant from the sylvia toth charity foundation, the hague, the netherlands, while working on this study. the sponsors of this study are public or nonprofit organizations that support science in general. they had no role in gathering, analyzing, or interpreting the data. all authors would like to thank all parents and patients for participating in this study. all authors state they have no competitive (financial) interests in this study. background: paroxysmal nocturnal hemoglobinuria (pnh) is an acquired clonal disorder of the hemopoietic stem cells for which the only curative treatment is allogeneic hematopoietic stem cell transplantation. haploidentical donor hematopoietic stem cell transplantation (haplo-hsct) is now increasingly applied as a curative therapy for patients with hematologic diseases. however, there are still few reports on the use of haplo-hsct for the treatment of pnh. our study aimed to compare the outcomes of haplo-hsct with matched-sibling donor transplantation (msd-hsct) for pnh. methods: the clinical data of pnh patients received hsct (haplo-hsct = , msd-hsct = ) in our center from july to may were analyzed retrospectively to compare the outcomes of haplo-hsct group with msd-hsct group. the clinical data including male patients and female patients, classical pnh and pnh-aa syndrome, the median age was years (range - ). all patients had received various treatments before transplantation such as steroids, androgens, cyclosporine (csa), antithymocyte globulin, and growth factors. the median interval from pnh diagnosis to sct was months (range - ). the conditioning regimen was modified bucybased regimen in haplo-hsct group, csa, mycophenolate mofetil (mmf) and short-term methotrexate (mtx) were administered for graft-versus host disease (gvhd) prophylaxis. patients with msd-hsct were treated with the flucy-based regimen and csa were administered for gvhd prophylaxis. results: there were no differences of gender, age, patients of pnh-aa and median time from diagnosis to transplantation between the groups (på . ). the median values of absolute nucleated cell counts were . ( . - . ) × /kg in the haplo-hsct group and . ( . - . ) × /kg in the msd-hsct group (p = . ). the median doses of cd + cells infused were . ( . - . ) × /kg and . ( . - . ) × /kg (p = . ), respectively. all patients attained complete engraftment, no patient occurred graft failure. the median time for myeloid engraftment were (range, - ) days in the haplo-hsct group and (range, - ) days in the msd-hsct group (p = . ). the median time for platelet engraftment were (range, - ) days and (range, - ) days (p = . ), respectively. with a median followup of ( - ) months in the haplo-hsct group and ( - ) months in the msd-hsct group (p = . ). in haplo-hsct and msd-hsct groups the incidences of grade i-iv acute graft-versus-host disease (agvhd) were . % and . % (p = . ), grade ii-iv agvhd were . %、 . % (p = . ). chronic gvhd were . % and . % (p = . ), moderate-severe chronic gvhd were . % and . % (p = . ). in haplo-hsct and msd groups the incidences of infection were . % ( / ) and . % ( / ) (p = . ). no patient occurred early death and relapse. -year estimated overall survival (os) of haplo-hsct and msd-hsct groups were . % ± . % and . % ± . % (p = . ), gvhd-free and failure-free survival (gffs) were . % ± . % and . % ± . % (p = . ). conclusions: the preliminary results indicated that haplo-hsct is a feasible choice for pnh with favorable outcomes, haplo-hsct and msd-hsct had similar therapeutic efficacy. disclosure: no disclosure p pres in bmt for thalassemia major in india: lower incidence and limited impact background: posterior reversible encephalopathy syndrome (pres) is a relatively common complication seen after blood or marrow transplantation (bmt) for hemoglobinopathies with a reported frequency of - %. pres has also been associated with poorer survival rates. severe hemoglobinopathies are one of the most frequent indications for bmt in the developing world, particularly in india. given the risk of rejection in multiply transfused patients and the need to minimize gvhd risk, immunosuppression post-bmt for these non-malignant conditions can be particularly intense and prolonged. we sought to measure the incidence and impact of pres in developing countries. methods: we analysed successive transplants for thalassemia using protocol (atg-bucy+csa/mmf or csa/mtx) maintaining cyclosporine a (csa) blood levels - ng/ml for patients and protocol (flu-atg-bucy+csa/mtx) maintaining higher csa levels post, i.e. - ng/ml for patients from fully matched donors with g-csf-primed bone marrow. for patients this was the second transplant from a different matched related donor. pres was confirmed with brain ct/mri for all patients. results: all recipients who had pres had sibling donors, males and females. age median . (iqr . - years). the frequency of pres was . %; disease free survival for patients who had pres was %. pres resolved completely in all. csa was switched to mmf in patients who had received mtx and were on csa only at the time of pres occurrence, while csa was stopped but mmf continued in patients taking csa/mmf combination and csa was continued for patient. three patients with pres had grade acute gvhd, had grade gvhd and none developed chronic gvhd. csa levels at the time of pres were a median of ng/ml (iqr: to ) with patient having ng/ml. three patients had pres while they were thrombocytopenic. hypertension stage was observed in four patients, stage in one patient, one patient was not hypertensive and in one patient blood pressure values were not available. two patients were on methylprednisolone and . mg/kg/day and one was on dexamethasone mg/m /day. one patient was started on csa again after the pres episode and within weeks had another one while on csa (level ng(ml), methylprednisolone . mg/kg/day and ruxolitinib for gvhd. protocol had statistically significant improvement in disease free survival from % to % (p< . ) with probability of occurrence of pres increasing from . % to . % (p = . , see figure ), yet had a benign course in all patients. conclusions: not stopping immunosuppression may have been the key factor which could explain why we have better outcomes with pres than what is reported. intensifying immunosuppression pre-bmt did lead to more pres, albeit not significantly, and yet it was quite manageable. even with addition of fludarabine our pres incidence is lower than previously reported. [[p image] . background: sickle-cell diseases (scd) are a group of genetic hemoglobin disorders marked by brain vasculopathy. allogeneic hematopoietic stem cell transplantation (hsct) is a curative option able to stop vascular disease progression. diffusion-tensor imaging (dti) is a magnetic resonance imaging (mri) technique sensitive to the brownian motion of water molecules and cellular environment. this microscopic quantitative technique is able to detect white matter (wm) alterations before a conventional mri. the aim of this study was to use dti to evaluate axonal damage and structural connectivity in the brain of patients with scd submitted to hla-identical sibling allogeneic hsct. methods: sixteen scd patients with no extensive vasculopathy detected by conventional mri ( male, age range: - years) and age-matched healthy controls ( male, age range: - years) participated in this prospective study. mri acquisitions were performed in a t scanner two times for patients (before and - years after hsct) and at a single moment for controls. from dti acquisitions, fractional anisotropy (fa), mean (md), radial (rd) and axial diffusibility (ad) were calculated in the wm of the whole brain. structural connectivity was also analyzed, based on graph theory, obtaining efficiency, length path and clustering coefficients of the brain network. an anova test was applied to analyze fa differences among controls and patients, before and after hsct. a paired two-tailed t-test was used to determine statistical significance of changes in the fa, diffusivity mean values and network parameters before and after hsct. results: mean fa was lower in patients before hsct than controls (p = , ) and increased after hsct being not statistically different when compared to controls (controls = , ; patients before hsct = , ; patients after hsct = , ; post hoc dunnett's test -error , ; anova test). when patients were compared before and after hsct, md and rd decrease after hsct (p = , and , , respectively). on the other hand, fa increased (p = , ). after hsct, efficiency was higher (p = , ) and path length index was lower (p= , ) than at study entry (table ) . conclusions: this study indicates that, before hsct, patients with scd present axonal damage not detectable by conventional mri, when compared to healthy controls. we also suggest that hsct is able to promote axonal recovery and reorganization. partial diffusivity recovery could be associate to a still unidentified mechanism of myelin regeneration. in the future, longer follow up and comparisons with other forms of treatment are required. background: bmt is a well-established treatment modality for haemoglobinopathies, limited by the availability of related donors. unrelated transplantation has historically shown variable outcomes driven by gvhd and toxicity, and usually restricted to / matches, but the impact of reduced toxicity conditioning regimens is yet to be known. methods: from to twenty-five consecutive unrelated bone marrow transplants were conditioned with fludarabine mg/m , treosulfan g/m , thiotepa mg/ kg and atg (thymoglobulin) . mg/kg if the source of stem cells was marrow (n = ) or ptcy if pbsc (n = ). endogenous haemopoiesis was suppressed pretransplantation for a minimum of weeks. gvhd prophylaxis was provided with ciclosporin/sirolimus and mmf. thirteen patients were transplanted for b thalassaemia major, one of a thalassaemia major and sickle cell disease. the median age was years ( - ). ten patients were / matched ( thalassemia and sickle) and patients had a / match ( thalassaemia and sickle). the median cell dose was . x tnc/kg (range . - . ) and . x cd +/kg (range . - . ). the median survival was . months ( . - . ). patients with thalassaemia were pesaro class i or ii (pesaro class iii patients were intensively chelated pretransplantation to return to class i or ii). patients with sickle cell disease were transplanted for stroke or recurrent vaso-oclusive crises and/or acute chest syndrome not responding to hydroxycarbamide. results: all patients engrafted and achieved evidence of donor haemopoiesis on day + and achieved transfusionindependence and donor haematological values, but subsequently one / patient with thalassaemia suffered secondary graft failure on day + after macrophage activation syndrome. median neutrophil engraftment was days (range to ) and days ( - ) for / and / patients respectively. patient with sickle cell disease had the platelet count maintained > x /l at all times. the median platelet engraftment > x /l was days (range to ) and days (range to ) / and / patients respectively. there were three deaths, all in the / matched group: two with thalassaemia (day + due to idiopathic pneumonia syndrome and day + due to mas) and one with scd (day + due to ips). there were different trends of complications seen by degree of matching that did not segregate otherwise by disease. conclusions: in conclusion, unrelated bmt for haemoglobinopathies with reduced toxicity regimens is feasible. whilst gvhd caused significant morbidity during the transplant period, other alloreactive/endothelial complications (vod, macrophage activation syndrome, idiopathic pneumonia syndrome) were only seen in the / transplants. disease-free survival, dependent on transplantrelated mortality, and lack of long-term toxicity, including chronic gvhd, are determined by the degree of matching. / matched transplants have excellent long-term outcomes with no chronic gvhd > months and can be considered for patients without a related donor; whereas / transplant have significant toxicity and mortality, warranting a haploidentical approach. disclosure: no conflict. long-term safety and efficacy of lentiglobin gene therapy in patients with transfusion-dependent β-thalassemia following completion of the phase / northstar study patients with transfusion-dependent β-thalassemia (tdt) may benefit from gene therapy involving β-globin gene addition to hematopoietic stem cells (hscs) enabling production of functional hemoglobin (hb). lentiglobin gene therapy contains autologous cd + hscs transduced ex vivo with the bb lentiviral vector encoding β-globin with a t q substitution under transcriptional control of the encoding β-globin locus control region. the safety and efficacy of lentiglobin was evaluated in adults and adolescents with tdt in the -year phase / northstar study (hgb- ; nct ). methods: patients with tdt (≥ ml/kg/year of red blood cells [rbcs] or ≥ rbc transfusions/year) received g-csf and plerixafor for hsc mobilization. to generate drug product (dp), cd + hscs were transduced with the bb lentiviral vector. patients underwent single-agent, myeloablative busulfan conditioning, were infused with the dp, and were followed for safety and efficacy. results: eighteen patients have been treated in the completed northstar study. as of september , patients had a median follow-up of . (min -max: . - . ) months. the median age at consent was (min -max: - ) years including patients ≥ years old. patients received a median cell dose of . (min -max: . - . ) cd + cells x /kg with a median dp vector copy number (vcn) of . (min -max: . - . ) vector copies/ diploid genome. the median liver iron content (lic) at baseline was . (min -max: . - . ) mg fe/g dw. outcomes by age and baseline iron status will be presented. the median time to neutrophil and platelet engraftment was . (min -max: - ) and . (min -max: - ) days, respectively. four patients had platelet engraftment ≥ day and four patients had platelet counts of ≤ x /l at month . none of these patients had ≥ grade bleeding events post-lentiglobin infusion. transfusion independence (ti, defined as weighted average hb ≥ g/dl without rbc transfusions for ≥ months) was achieved in / patients with non-β /β genotypes and / patients with β /β genotypes. in patients who achieved ti, total hb at last visit was . - . g/dl. lic increased from baseline in patients who achieved ti by a median of . % and . % at month and then decreased from baseline by a median of . % and . % at month and , respectively. non-hematologic grade ≥ adverse events post-infusion in ≥ patients included stomatitis, febrile neutropenia, pharyngeal inflammation, and irregular menstruation. there was no transplant-related mortality, vector-mediated replication competent lentivirus, or clonal dominance. two patients experienced grade serious veno-occlusive liver disease (table ) . events resolved following treatment with defibrotide and were attributed to myeloablative conditioning. conclusions: in the northstar study, % of patients with tdt and non-β /β genotypes and % of patients with β / β genotypes achieved transfusion independence. the safety profile of lentiglobin remains consistent with myeloablative busulfan conditioning. longer time to platelet engraftment was observed in some patients, but no graft failure was reported. clinical background: sickle cell disease (scd) is an inherited hemoglobin disorder associated with high morbidity and mortality. currently, allogeneic hematopoietic stem cell transplantation (hsct) is the only curative therapy for scd. transplant outcomes with thiotepa, treosulfan and fludarabine (ttf) preparative regimen are encouraging but this regimen has not been directly compared to other preparative regimens in scd. we therefore planned to compare the event free probability for death, rejection and high grade acute graft versus host disease (agvhd) between ttf and busulfan and fludarabine (bf) regimens. methods: in this retrospectively cohort study, we included all patients with scd who received allogeneic hsct at our center or who were transplanted in other centers and referred to ours for follow up before day . patients were transplanted between july and december . we used kaplan-meier curve to estimate the event free probability for death, rejection and high grade agvhd (grades - ). cox regression was used to assess the impact of the preparative regimen on these outcomes. results: a total of patients were included with a median age of years (interquartile range [iqr]: - ) and a median hemoglobin of g/dl (iqr: - ). sixtytwo percent were males. the proportion of patients who had splenectomy, stroke and acute chest syndrome was %, % and % respectively. all patients received peripherally collected hematopoietic stem cells from a matched sibling donor with a median stem cell dose of x /kg (iqr: . - . ). most patients, %, received cyclosporine or tacrolimus based agvhd prophylaxis. most patients received ttf ( %) or bf ( %) preparative regimens. all patients in the bf group received atg. the median follow-up time was months (range: - ). four patients died during the follow-up period with an os of % ( % confidence interval [ci]: %- %) at years. the os was not different (hr . , p = . ) between the ttf ( %) and the bf ( %) regimens. the probability of high grade agvhd free survival at day was % ( % ci: - ) for all patients. this probability was % in the ttf group and % in the bf group and the difference was not statistically significant (hr . , p = . ). the rejection free survival at months was % ( % ci: - ) for all patients. no patients in the ttf group rejected while the rejection free survival at months for the bf group was %. this was not statistically significant (p = . ). conclusions: in patients with scd undergoing allogeneic hsct from a matched sibling donor, the ttf preparative regimen is not associated with improved os, rejection free or high grade free agvhd survival when compared to the bf preparative regimen. larger studies are needed to confirm these findings. disclosure: nothing to declare. novel strategy for haploidentical hematopoietic stem cell transplant in sickle cell disease methods: consecutive patients suffering from scd who underwent hhsct between jan till date were enrolled in the study. all underwent autologous backup (target dose> x /kg) followed by pre-transplant immune suppression (ptis) cycles at weekly intervals using fludarabine @ mg/m /day(d -d ) + cyclophosphami-de@ mg/m /day(d ) + dexamethasone@ mg/m / day(d -d ) along with hypertransfusion (target hb - gm/dl), hydroxyurea ( mg/kg/day) and azathioprine ( mg/kg/day) from day - . the graft was mobilized using gcsf@ mcg/kg/day(d -d ) + plerixafor@ . mg/kg s/ c on d - hours before the pbsch. conditioning included thiotepa mg/kg in two divided doses (d- ), fludarabine mg/m (d- to d- ), cyclophosphamide . mg/kg (d- , d- ), tbi gy with thymic shielding (d- ), ratg (genzyme thymoglobulin . mg/kg (d- to d- ). gvhd prophylaxis included ptcy mg/kg/day on d and , sirolimus (target levels - ng/ml) (till - months post hsct) and mmf (till d ) starting from d . results: the median age of patient's was years (range - years). before transplantation all patients had repeated episodes of one or other complication warranting a transplant, non-responsive to hydroxyurea. six had maternal donors, paternal and sibling. median age of the donor was years (range - years). all were dsa negative with a cutoff mfi of > iu. all patients received x /kg cd cells irrespective of harvested dose which ranged from ( . - . x /kg). median cd dose was . x /kg (range . - . x /kg). all patients engrafted with median time to neutrophil engraftment days (range - days) and median time to platelet engraftment days (range - days). median duration of hospital stay was days (range - days). one patient had cytokine release syndrome needing tocilizumab. five had engraftment syndrome treated with short course of steroids. two had cmv reactivation needing treatment with ganciclovir/valganciclovir. acute gvhd grade ii was seen in one patient. till date of analysis none had features compatible with chronic gvhd. of the patients, are alive without sickle cell disease with lansky/ karnofsky scores of . at median follow up of days (range - ) the probabilities of survival, sca-free survival, and transplant-related mortality after transplant were . %, . %, and . %, respectively. one patient died due to mdr klebsiella sepsis after being discharged initially while he was receiving iv ganciclovir on day care basis. he had full donor chimerism. none of the patient had primary or secondary graft failure. conclusions: pre-transplant immune suppression and upfront use of plerixafor for graft mobilization decreases the risk of graft failure and graft versus host disease leading to overall better survival in hhsct for sickle cell disease. disclosure: none. combined haematopoietic stem cell transplant and enzyme replacement therapy in wolman disease: outcomes and challenges jane kinsella , denise bonney , helen campbell , robert wynn , simon jones background: infantile lysosomal acid lipase deficiencymore commonly known as wolman disease -is an autosomal recessive lysosomal storage disease, characterised by storage of cholesterol esters in the liver, spleen and gastrointestinal tract. these children present under the age of months and traditionally had a poor prognosis, with almost all being dead by the age of months. bone marrow transplant has been used to correct disease manifestations, but limited by high procedure-related mortality with the significant co-morbidities. the survival has changed over the past few years due to pharmacological enzyme replacement therapy but still presents challenges for these patients and their clinicians. in these children haematopoietic stem cell transplant we have offered bmt with enzyme replacement therapy, in certain specific circumstances. methods: four children with wolman disease being treated with enzyme replacement therapy, limited by alloantibody, or poor venous access, received treosulfan-based, myeloablative conditioning with serotherapy followed by a matched haematopoietic stem cell transplant: two family donors, one sibling donor and one unrelated donor. results: three of the four children survived transplant. they have continued to receive enzyme replacement therapy but at reduced dose and frequency with improved tolerability. they have continues to grow and develop. growth and gastrointestinal histology is improved for children having received transplant compared to those receiving enzyme replacement alone. monitoring of peripheral blood chimerism has shown a disease-associated engraftment defect, with mixed chimerism in the surviving patient. conclusions: haemopoietic stem cell transplant is a suitable treatment option in children with wolman disease in whom receiving enzyme replacement therapy is not possible because of venous access, sensitisation or cost reasons. it improves their tolerability of the enzyme treatment and allows for a reduction in enzyme dose and frequency. however, the results of engraftment are not as good as expected for a transplant with myeloablative conditioning and a matched donor. an engraftment defect has been observed in lysosomal acid lipase deficient animal models. a further understanding of this poor engraftment in children with wolman disease is required as to determine whether the risks of transplant is beneficial in these patients and for the consideration of future treatment options including gene therapy. background: thalassemia major is the most common transfusion dependent hemolytic anemia in the world. the absent or reduced production of the β-chain of hemoglobin causes severe ineffective erythropoiesis, massive erythroid hyperplasia in the bone marrow and extramedullary hematopoesis occurs. patients require regular transfusion therapy lifelong. currently, the only proven curative treatment of thalassemia is allogeneic stem cell transplantation (sct). methods: we evaluated the immune reconstitution results of patients at year after hematopoetic stem cell transplantation at our pediatric bone marrow transplantation center between january and december . all patients were not receiving any immunosuppressive treatment at least for months and they have normal lymphocyte counts, immunoglobulin levels and transfusion independent. lymphocyte subtypes and chimerism percentages and the relationship with the donor type were evaluated at year of transplantation. results: ages of transplantation was ranged between - years (median: years). seven ( %) of them was male. matched unrelated donor type was chosen in patients while others ( patients) were transplanted from family matched donor (matched sibling: patients, matched family: patients). all patients received myeloablative conditioning regimen containing busulfan/treosulfan, cyclophosphamide, thiotepa and fludarabine. follow up time was between - months (mean: ± months). in patients, whole bone marrow product was used while peripheral stem cell harvest in remaining patients. cd levels were found low in only patients, in normal patients mean was % ± %. cd levels were severely low in patients while cd in only patient. cd levels were increased in total patients in as compensatory. cd /cd ratios were very low in all patients (range: . - . ). b cells (cd +) were low in patients while immunoglobulin levels were normal. chimerism values between - % (mean: ± %). donor and product types did not differ in cd + lymphocyte reconstitution at year (p= . , p= respectively). all patients were alive and well at year after transplantation. conclusions: after year of transplantation, although patients are in well condition regarding to infection frequency and transfussion dependency, it was seen that their lymphocyte subtypes reconstitution could not be achieved enough as in normal children. we can conclude that low cd + cell levels were an expected finding in almost all patients. so, these patients may have a tendency to suffer serious bacterial and viral infections, and close follow up be required in terms of infections as long as cd levels continue to be low. immunoglobulin replacement therapy did not required even in patients with low b cell levels. disclosure: nothing to declare p phase international, multicentre trial to assess haploidentical aß t-cell depleted stem cell transplantation in patients with sickle cell disease with no available sibling donor background: sickle cell disease (scd) is an inherited disorder with an estimate of , affected newborns per year worldwide. allogeneic hematopoietic stem cell transplantation (hsct) with a matched sibling donor (msd) is currently the curative standard of care for scd patients (pts). however, msd availability is < %. a t-cell depleted haploidentical hsct (t-haplo-hsct) from a relative, mostly a parent, expands the donor availability while exhibiting low gvhd rates and thus could offer cure to the remaining % of scd patients. in a pilot study, comparing t-haplo-hsct with msd hsct in advanced stage scd, using almost identical transplant regimens for both. the overall (os) and disease-free survival (dfs) was % vs. %, respectively. methods: these results led to the design of a clinical trial to assess tcd-haplo-hsct prospectively which aims to demonstrate that a hsct from a haploidentical relative is not inferior to a msd hsct with regard to major outcome parameter. this phase , prospective, stratified, open-label study is targeting enrollment of patients aged - years with homozygous hbs disease or heterozygous hbsc or hbs /+ ß-thal suffering from severe or moderate scd related complications. inclusion criteria are clinically significant scd related complications such as stroke, silent crisis, pathological angio-mri, transcranial doppler (tcd) velocity > cm/s, or more episodes of acute chest syndrome (acs) in a lifetime, chronic transfusion dependency, transfusion-refractory allo-immunization and others. pts fulfilling inclusion criteria will be stratified according to donor availability. pts with a msd will receive a bone marrow graft, pts requiring an alternative donor will be transplanted with an aß/cd depleted graft from a haploidentical family donor. the conditioning regimen for both groups will be identical with the exception that antithymoglobulin (atg-neovii ® ) is given upfront in thaplo-hsct versus day - to - in msd. chemotherapy consists of thiotepa, fludarabine and treosulfan. posttransplant immunosuppression will consist of mofetil mycophenolate and tacrolimus for a duration > months in t-haplo-hsct and < months in msd, depending on chimerism. (eudract number: - - ) results: primary efficacy endpoint: event free survival (efs). event is defined as incidence of acute gvhd, grade iii -iv, chronic gvhd, rejection (graft failure) or death (for any reason). key secondary endpoint(s) are os, dfs, graft failure, hematological and immunological reconstitution, quality of life (qol) assessment and fertility. the primary null hypothesis is: efs of scd patients treated with t-haplo-hsct is non-relevantly inferior to efs in the msd arm. conclusions: results will help to determine if an a/ß depleted t-haplo-hsct can be considered equivalent to msd hsct with regard to dfs, adverse events and safety, in order to offer this form of cure to the majority of patients with scd. disclosure: nothing to declare hit three birds with one stone: successful stem cell transplantation from one family donor to three siblings methods: in august , three thalassemic siblings were admitted to hospital for stem cell transplantation from a full match donor, their years old sister. the patients' general health conditions and specific health issues due to thalassemia were checked extensively. it was decided to perform first transplant to older sister whom the disease and transplant complications are expected more intense due to prolonged transfusion and chelation therapy. the oldest daughter of family, healthy, was planned to accompany her sisters in transplantation unit so parents can take care the others and organize this period for whole family. results: the years old sibling was first admitted to bone marrow transplantation unit in july . the conditioning regimen was busulfan, fludarabine, cyclophosphamide and thiotepa with antithymocyteglobulin(atg) and defibrotide prophylaxis was given. the healthy donor was admitted to hospital and received g-csf for continuous days before harvesting. stem cells were collected peripherally on day and viable cd + cells were /ul. patient received , x e /kg stem cell and the other cell products were divided into parts according to other recipients´weight. no infusion problems were recorded in stem cell transfusion. gvhd prophylaxis was given with cyclosporin and methotrexate. severe sinusoidal obstruction syndrome was observed and successfully managed with supportive therapy. neutrophils were engrafted + . day, and platelets were on day . full blood chimerism results were % in day , % in day and % in day consecutively. after months from first transplant the years old sister was admitted to hospital on october . same conditioning with defibrotide prophylaxis and gvhd prophylaxis were given and , x e /kg peripherally derived and previously frost stem cell was infused without any complications. mild sinusoidal obstruction syndrome was observed and managed with supportive therapy successfully. neutrophils were engrafted + . day, and platelets were on day . full blood chimerism results were % in day , % in day and % in day consecutively. the third transplant was performed on january with the same conditioning and prophylaxis regimen. although defibrotide was used mild sos was observed and treated with supportive therapy with success. neutrophils were engrafted + . day, and platelets were on day . full blood chimerism results were % in day , % in day and % in day consecutively. conclusions: the patients are being followed for over a year after first transplat, neither adverse nor gvhd symptoms were observed. we presented this case for being a unique example for match family donor transplant and the first successful example from one donor to three recipients. disclosure: nothing to declare results: our female patient admitted for anemia at rd month of birth and was transfused every - months from th months to . years of age. since investigations directed towards hemoglobinopathies or membrane defects like hereditary spherocytosis were unremarkable, she was not transfused for years after the age of . -years because hemoglobin level was constant over g/dl. her bm examination showed erythroid hyperplasia and feature of dyserythropoiesis with a few binucleated erythroblasts. it was decided to follow-up the patient with a diagnosis of cda ii. after the age of -years, the need for transfusion started again for every to months which led the parents of our patient to request for bone marrow transplantation, however, the diagnosis was not definite, and because of the insufficient data for the transplantations for cda ii patients, it was decided to go on to follow-up. nevertheless, after years, the frequency of transfusion gradually increased to every - weeks, and bone marrow transplantation was brought into question again. at that time, genetic examination was started and sec b gene was analyzed by direct sequencing. hsct decision from her hla / matched brother, carrying sec b mutation in heterozygous state, was taken. in the preparation regimen, busulfan (bu) at a myeloablative weight adjusted dose ( days), mg/kg cyclophosphamide (cy) ( days), and mg/kg antithymocyte globulin (atg fresenius) were used. graftversus-host disease (gvhd) prophylaxis was with cyclosporin a started on day - and short-term methotrexate on day + ,+ and + . she was transplanted with bm with a dose of total nucleated cells= . x /kg and cd = x / kg. neutrophile and platelet engraftment were achieved at + and + , respectively. indeed, grade hemorrhagic cystitis due to bk virus and a moderate veno-occlusive disease prolonged platelet transfusion days which concealed the exact engraftment day of platelet. the patient was discharged on day with no more need for any transfusion and followed up as a complete chimeric with no type of gvhd since then. now, she is years old, under regular surveillance at our transplant centre without any symptoms. conclusions: hsct data in cda ii patients is still insufficient, however based on data from tm patients with similar treatment approaches in td cda ii patients, it is seen that the hsct is reliable and effective. disclosure: nothing to declare hematopoietic stem cells background: the prognosis after frontline therapy in b-all patients have improved due to monoclonal antibodies (cd , cd , cd ) and approximately % of patients achieve complete remission. in relapsed and refractory (r/ r) b-all and also in mrd + outcomes are relatively poor. disease-free survival (dfs) in this cohort is - %. in this cohort allo-hsct is indicated and complete remission before transplantation is crucial for prognosis. conventional chemotherapy is associated with high failure rate and significant toxicity. immunotherapy with monoclonal antibodies and car-t are more promising approaches. the aim was to evaluate the efficacy (frequency of responses, os, dfs) and toxicity, especially neurotoxicity and cytokinerelease syndrome, of a bispecific monoclonal antibody blinatumomab in patients both children and adults with persistence of minimal residual disease (mrd + ) or r/r b-all as a bridge to allo-hsct. methods: this study included patients with high risk b-all blinatumomab treated in - , among them pts ( %) with t( ; ), ( %) with t( ; ), with mll ( %), pts ( %) who were refractory to previous chemotherapy, ( %) after allo-hsct from deferent type of donors. median age was y.o. (range m- y.o), children - y.o. ( %) and adults > y.o. ( %). r/r all had pts ( %), mrd + - pts ( %), median days of follow up were ( - ). blinatumomab was applied as -day cycles followed by a -day off-period before the start of the following cycle. majority pts received one cycle (n= , %). in r/r all group dose was of mcg/d during the first days and afterwards mcg/d. patients with weight less than kg received mcg/m /d and mkg/m /d accordingly. in mrd group dose was mcg/m /d. results: the frequency of responses to blinatumomab was higher in mrd + pts in comparison r/r all pts ( % vs % p= . ). in mrd + pts cr mrdwas achieved in pts ( . %), pts ( . %) were mrd+ after blinatumomab. two-year os in this group was %. twenty pts ( %) received allo-hsct. in rr all pts cr mrdwas achieved in pts ( %), pts ( %) were mrd+ after blinatumomab, pts ( %) had no hematological response . two-year os in r/r all was %. fifteen pts ( %) received allo-hsct. os in cr mrdpatients who received allo-hsct was not significantly different in comparison with patients who received blinatumomab as a monotherapy ( % vs %, p= . ). no significant differences in dfs were observed at two years in cr mrdpts depending status of the disease before therapy-mrd vs r/r ( % vs %). of the reported adverse events, febrile fever was the most common pts ( %), neutropenia ( %), thrombocytopenia ( %), infection ( %), neurotoxicity ( %), cytokine-release syndrome ( %). all complications were reversible. conclusions: blinatumomab is effective option in patients with high risk b-all especially in the group with mrd persistence after previous chemotherapy and facilitates effective bridging to hsct. blinatumomab therapy is generally well tolerated. disclosure here we address the transcriptional regulation of differentiated cells from human embryonic stem cells (escs) using self-assembling peptide hydrogel without stromal cells, and compare with embryoid body (eb) culture system. methods: esc differentiation was induced in eb culture system or three-dimensional ( d) hydrogel culture system. the engraftment potential of differentiated cells was evaluated by flow cytometry. cd + cells from mobilized peripheral mononuclear blood cells (mpbmcs) or differentiated from escs at different times (day , day , day ) were purified by fluorescent-activated cell sorting. sorted cells were captured on medium-sized microfluidic chips using the fluidigm c single cell auto prep system. sequencing was performed by hiseq x ten. results: self-assembling peptide hydrogel formed a d scaffold for cell culture, the pore diameter of which ranged from to nm. compared to eb culture system, escs in d culture system differentiated more potently. the differentiated cells from d system were short-term engrafted in the nog mice, and myeloid cells, b cells and t cells could all be detected in peripheral blood after transplantation. however, the engraftment was not obtained in differentiated cells from eb culture system. we obtained and analyzed escs, cd + cells from eb culture system, cd + cells from d culture system, and cd + cells from mpbmcs. the cells were divided into cluters ( figure a ). in both differentiation systems, the cd + cells from day were more heterogeneous than cd + cells from day and day ( figure b) . however, cd + cells from mpbmcs were more homogeneous, probably because the differentiated cd + cells contained several cell lineages, including hematopoietic cells, endothelial cells and mesenchymal cells. there is transcriptional overlap between individual cd + cells from eb and d culture systems. however, we found that cluster , which is composed mainly of cd + cells from d at day and day , expressed similar level of several hematopoietic regulator as hsc, such as tal , lmo , erg ( figure c ). the cluster , which is almost the cd + cells from d at day , also expressed the highest gata among the clusters from differentiated cells ( figure c) . conclusions: our study demonstrates that d hydrogel culture system facilitates hematopoietic specification of escs. disclosure: nothing to declare higher cd + cell dose increases overall survival in the setting of dual t-lymphocyte suppression with atg and ptcy in matched related and unrelated donor allosct background: there is no consensus on the cd + donor cell numbers required for optimal outcomes in allogeneic stem cell transplant (allosct). there is controversy on the benefits or harm in higher cell dose for allosct. this study aims to evaluate the impact of cd + cell dose in allosct patients receiving reduced intensity conditioning (ric) combined with anti-thymoglobulin (atg) and posttransplant cyclophosphamide (ptcy) using related (mrd) and / and / matched unrelated donors (mud). methods: this is a single-centre retrospective analysis of adult patients who received allosct for hematologic malignancies between october and may . all received ric using fludarabine ( mg/m /day: day - to - ), busulfan ( . kg/m /day: day - and - ) and total body irradiation ( cgy: day - ). all patients also received rabbit-atg ( . mg/kg: day - to - ), ptcy ( mg/kg/day: day + ,+ ) and cyclosporine (from day + ). unmanipulated peripheral blood stem cells were infused on day . analyses were done using thresholds: ( ) an arbitrary cd + cell dose of x /kg (as this was our target dose) and ( ) cell dose according to quartiles (< . , . - . , . - . and ≥ . x /kg). results: median cd + cell dose was . x /kg. median follow up was months (range - ). median neutrophil engraftment was (range - ) days and platelet engraftment was (range - ) days. a cell dose greater than x /kg was associated with an increased overall survival (os) at year ( . %; % ci, . - . vs . %; % ci . - . ; p= . , figure ). the higher dose was also associated with shorter platelet engraftment time (p= . , figure ). there was no significant difference in neutrophil engraftment, nonrelapse mortality (nrm), relapse free survival (rfs), grade ii-iv acute graft versus host disease (agvhd) and moderate to severe chronic graft versus host disease (cgvhd), (table ) . analyses using quartile cell dose thresholds showed a trend towards decreased os with a cell dose of < . x ^ /kg, however this was not statistically significant ( figure ). higher cd + cell doses were associated with shorter platelet engraftment time (p= . , figure ). there was no significant difference in neutrophil engraftment, nrm, rfs, agvhd and cgvhd (table ) . conclusions: cd + cell dose greater than x /kg significantly increases overall survival in the setting of ric and dual t-lymphocyte suppression with atg and ptcy in mrd and mud allohsct. further studies in a larger number of patients and longer follow up are recommended to validate these findings. disclosure methods: fifty two adult patients were included. median cd + cells requested for infusion were x ^ /kg. all patients received the same ric regimen including fludarabine ( mg/m /day day - to - ), busulfan ( . kg/m /day day - and - ), and total body irradiation ( cgy) (day - ) combined with rabbit-atg ( . mg/kg: day - to - ), ptcy ( mg/kg/day: day + ,+ ), and cyclosporine. unmanipulated peripheral blood stem cells were infused. last followup was november . median follow-up was months (range - ). median cell dose count infused was . cd +/kg. we arbitrarily divided the cohort in two groups with cd + dose of > x ^ cd /kg as cut-off point. results: findings are summarized in figure . the infusion of more than x ^ cd /kg dose had a significant worse impact on overall survival (os) (p= . ), relapse-free survival (rfs) (p= . ) and cumulative incidence of acute gvhd (p= . ). chronic gvhd could not be compared between the two cohorts due to the different median follow-up. conclusions: the infusion of a cd + cell dose count higher than x ^ cells/kg had a significant adverse impact in overall survival and grade ii-iv acute gvhd in the setting of ric and dual t-lymphocyte suppression with atg and ptcy for haplohsct. disclosure: nothing to declare p long-term thymic activity and immune-reconstitution after haplo-identical allografting with post-transplant cyclophosphamide background: the use of post-transplant cyclophosphamide (ptcy) has expanded the application of t repleted haploidentical stem cell transplantation (haplo-hsct). in this setting, to investigate thymus role in longterm clinical outcomes, evaluation of immune reconstitution kinetics was performed. methods: twenty-nine patients (median age ) were enrolled. blood samples were collected before conditioning and at , , , , , months after haplo-hsct. analyses of cd and cd t-cell subsets by flow-cytometry were correlated by generalized linear models with real-time pcr (rt-pcr) quantification of signal joint t-cell receptor excision dna circles (sjtrecs), specific marker of naive t-cells thymopoiesis. a) naive; b) central; c) memory; and d) revertant cd and cd t-cells were defined as follows: a) cd ra+cd l+; b) cd ro +cd l+; c) cd ro+cd -; and d) cd ra+/ ro +, respectively. sjtrecs rt.pcr was performed on genomic dna ( ng) extracted from sorted cd and cd t-cells. results: a gradual increase in absolute numbers of all cd and cd t cell subsets and of sjtrecs copies from the first month up to years post-transplant was observed ( figure ) . however, at years, cd and cd t-cell levels and sjtrecs levels were lower than those observed in healthy donors. sjtrecs kinetics was associated with the increase in cd naive t-cells (overall, p < . ). this correlation suggests that most of cd naive t-cells derives from thymic re-education of donor precursor stem cells, whereas cd naive t-cells undergo peripheral expansion after thymic production. furthermore, an increase in cd revertant memory t-cells was also significantly correlated with sjtrecs kinetic (p , ). central and effector memory t-cells showed a faster thymic-independent expansion in both cd and cd tcells. interestingly, sjtrecs levels and thymic dependent immune-reconstitution were higher in a cohort of patients undergoing hsct from hla identical donors (manuscript in preparation). clinical outcomes and thymic function were correlated starting at months after hsct. lower thymic output was significantly associated by multivariate analysis with low pre-transplant trecs values (p , and p < , in cd and cd , respectively), moderate-severe chronic graft-versus-host disease (gvhd; p < , in cd ), and age (≥ years, p , in cd ). conclusions: the thymus, despite age-dependent involution, substantially contributes to t-cell reconstitution after haplo-hsct. chronic gvhd and older age were significantly correlated with reduced thymic function. overall, lower production of sjtrecs after haplo-hsct as compared after hla identical sibling hsct may partly be due to a higher degree of "mismatching" of mhc molecules during thymic re-education. [[p image] . figure ] background: the use of allogenic hematopoietic stem cell transplantation (hsct) in the treatment of adolescents and young adults (aya) with philadelphia negative all is decreasing with the adoption of pediatric inspired protocols to treat this age group and the incorporation of minimal residual disease assessment in the routine care of all patients. previously, its use was defined mainly by disease risk features at presentation. methods: a study on aya (age - years), who underwent allogenic hsct at our institute for philadelphia negative all, between february and december . all the studied patients received calgb based adult chemotherapy protocol for induction, and underwent a matched related donor (mrd) transplant with cy/tbi conditioning and mtx/csa as gvhd prophylaxis. the patients were eligible for allogeneic hsct, if they have a mrd plus one or more of the following risk factors: ( ) age ˃ years, ( ) high presenting wbc count (> for b-all, > for t-all), ( ) high risk immuno-phenotyping (pro-b, pro-t, early t, and mature t), ( ) bulky splenomegaly or bulky lymphadenopathy, ( ) high risk cytogenetics ( ; , ; , low hypodiploidy/near triploidy, complex), ( ) cns involvement, ( ) relapsed or refractory disease at d of induction. in this study, we investigated the impact of those different risk factors on the long term outcome of allogeneic hsct. results: the median os of our studied patients was not reached at . years, with a median dfs of . years (figure ). in a univariate analysis, relapsed or refractory disease prior to transplant was the only independent risk factor for os and dfs (p-value= . , and . respectively) (figure ). in addition, patients who had or more risk factors ( , . %) prior to transplant had a significantly lower long term outcome compared to patients, who had one ( , . %) or two risk factors ( , . %) with a median os of months, and a median dfs of only months (p-value= . , and . respectively) ( figure ) . conclusions: our results show that the long term outcomes of hsct in aya with philadelphia negative all treated on an adult type chemotherapy regimen, were significantly better in patients who showed a good response to initial therapy and a limited poor prognostic factors at presentation, with worsening of dfs as the number of poor prognostic features increase. we can conclude that, using this risk score can be helpful in predicting the outcome of allogenic hsct in aya with philadelphia negative all treated with adult type chemotherapy protocol. disclosure: no conflict of interest a prospective single center survey on donor-specific anti-hla antibodies and desensitization strategy in patients undergoing an allogeneic stem cell transplant background: in the setting of hematopoietic stem cell transplantation (hsct), considering the risk of poor engraftment or graft failure (gf), the detection of antibodies (ab) directed against donor specific hla loci (dsa) represents a contraindication to proceed with the same donor, suggesting the search of other donors. in many cases, there is not sufficient time to search for alternative donors and it is necessary to plan an immunosuppressive strategy to decrease the dsa level, thus reducing the risk of gf. to date, there is no consensus on desensitization standards to manage dsas in hsct. the aim of this study was to determine the incidence of anti-hla ab and dsas in hematologic patients candidate to an allogeneic hsct, and the efficacy of our desensitization protocol. here, we present an update of the results obtained with our strategy. methods: between august and september , we prospectively screened for dsa consecutive patients candidates to an allogeneic hsct. anti-hla ab research was carried out using the luminex bead assay (lifecode screen and lsa i/ii-immucor). the results were expressed as mean fluorescence intensity (mfi); mfi > was considered positive. in case of a mismatched related donor, a flow cytometric crossmatch test (fcxm) was performed. if the patient had dsas and only one available donor, a desensitization strategy was employed, scheduled with rituximab on day - , single-volume plasmapheresis procedures (pp), usually on day - and - , intravenous immunoglobulins on day - , infusion of hla selected platelets for dsa absorption in case of persistent antibodies directed against class i hla antigens. the aim of this schedule was to avoid interferences with chemotherapy and anti-t-cell globulins, infused during condition regimen results: since august , patients have been prospectively screened. thirty-three patients ( . %) showed anti-hla ab and of them ( . %) had dsas: were treated with the desensitization strategy, applied according to the mfi score and the fcxm result, and all of them obtained an engraftment; in cases, an alternative donor was selected and in case the research for an alternative donor is still underway. dsa detection was performed every days after hsct for the first month and , and days following hsct. neither a dsa rebound nor other complications were observed during the follow-up. conclusions: our prospective analysis underlines the high frequency of anti-hla antibodies detection in hematologic patients, confirming the necessity to routinely evaluate the presence of dsas before an allogeneic mismatched hsct. our desensitization schedules based on the combination of pp, rituximab, ivig and platelet absorption proved successful in reducing dsas. we confirm the necessity of a prospective multicenter collaboration to better define the role of dsas against each hla locus and the critical mfi cut-off level associated with a higher risk of gf. transplant and transfusion specialists should joint to define a consensus for a standard desensitization strategy. disclosure the most frequent technique used for counterbalance partial incompatible hsct is cd + selection that is associated with sustained engraftment and effective reduction of t cells that minimizes gvhd. on the other hand, this approach could delay immune reconstitution and increase risk of viral and fungal infection. in mud setting the use of pbsc is the procedure that most centers have recently adopted. this implies the infusion of a relevant higher number of t cells to times more as compared with bone marrow (bm). since in our centre most part of our patients are primary immunodeficiencies, we applied a procedure to minimize the risk of severe gvhd infusing a controlled number of cd positive cells. methods: we report data about paediatric patients who received mud hsct ( patient received hsct) between and in the bmt unit of the children's hospital of brescia. patients received conditioning, according to the european group for bone marrow transplantation (ebmt) and the european society for immunodeficiencies (esid) guidelines. cd + selection has been realized by a milteny column with an ideal addback of cd positive cells of x /kg. stem cell source was bm in cases and pbsc in cases. results: median patients age at transplant was years (range . months- years). the mean number of infused cells were: x /kg cd + and x /kg cd + in bm product, while x /kg cd + and x /kg cd + in pbsc. mean time for engraftment was day post-hsct. as concerns acute gvhd overall incidence . % ( / ) of the children presented this complication, but only % ( / ) presented gvhd grade iii and none gvhd grade iv, while chronic gvhd presented in . % ( limited, extensive/ ). while acute gvhd incidence and severity weren't significantly different between bm recipients and pbsc recipients, the cases of chronic gvhd were prevalently in the latters. no major infections presented in the post-transplant period and immunological reconstitution both cellular and humoral was completed by months. overall survival at years is % ( / ). the results obtained show how it is possible control severity of gvhd if an addback of a controlled number of cd + lymphocytes. acute gvhd wasn't severe and only few children presented with limited chronic gvhd. the method allows to graft primary immunodeficiencies patients even with pbsc without infusing too many t cells. in fact, especially in very young children, the number could be excessive and risky. nevertheless in case of an oncohaematological patient, gvl effect is preserved. disclosure background: dc is a rare genetic disorder that results from a defective telomere length maintenance and is characterized by mucocutaneous features, bone marrow failure (bmf) and a high predisposition to cancer and pulmonary fibrosis. bmf remains the major cause of mortality and the hsct is the only definitive treatment to restore hematopoiesis but is limited by a high incidence of treatmentrelated mortality. methods: a retrospective analysis of patients (pts) with dc who underwent hsct at the bone marrow transplantation unit in the clinical hospital of federal university of paraná, brazil, between july- and november- . results: boys and girls, with a median age of y ( - y) received a hsct from a mds (n= ), mud (n= ) or mmrd (haploidentical, n= ). pts received bone marrow (bm) and pt received a cord blood unit (cbu). the median of tnc infused was , x /kg (range , - , x /kg) and in the cbu was , x / kg. two pts received a myeloablative preparatory regimen with busulfan (bu) mg/kg + cyclophosphamide (cy) mg/kg or fludarabine (flu) mg/m + antithymocyte globulin (atg). the remaining pts received a ric regimen with cy mg/kg (n= ), flu mg/m + cy mg/kg + atg mg/kg (n= ), and flu mg/m + cy + tbi rads (n= , haplo). graft versus host disease (gvhd) prophylaxis consisted of cyclosporin (csa) and methotrexate or steroids (cbu) and post-transplant cy + csa + mycophenolate mofetil in the haploidentical transplants. of evaluable pts engrafted with a median time to neutrophil recovery of days (range: - days). one patient experienced primary graft failure (haplo) while second graft failure occurred in other pts. all these pts went a second hsct and survived. acute gvhd grade ii-iv occurred in of pts at risk. moderate to severe chronic gvhd occurred in pts with cases occurring in pts who had previously presented acute gvhd. overall survival (os) was , % at a median follow-up of y. the y os was slightly better in msd transplants compared to the others ( , % x , % p= , ). causes of early death include adenovirus sepsis (n= ), toxicity to preparatory regimen and sepsis (n= ), primary graft failure (n= ). pts remain alive between - y after hsct with a median fu of y. among them only pt has developed organ involvement by the underlying disease: hepatopulmonary syndrome (hps). pts died due to pulmonary fibrosis (n= ), liver fibrosis(n= ), gi bleeding(n= ), hps (n= ); cgvhd and sepsis(n= ), infection (n= ), and pts were lost to fu. conclusions: early mortality from bmf can be reduced by hsct, but late outcomes remain a consequence of the underlying disease. long term fu is essential in order to detect late complications related to the hsct procedure or the underlying disease. disclosure: nothing to declare single intra-bone cord-blood transplantation with a treosulfan-based regimen, atg-free and sirolimusbased gvhd prophylaxis: fast hematopoietic engraftment and immune-reconstitution in patients background: cord blood transplants (cbt) require less stringent hla-matching, compared to peripheral blood stem cell or bone marrow. however, cbt has been associated with delayed engraftment and immune reconstitution, especially if in vivo t-cell depletion, such as antithymoglobulin (atg), is used. methods: from to , patients with high-risk diseases received intra-bone infusion of unwashed single cb unit with an atg-free gvhd prophylaxis; were in active disease at cbt and had received prior allogeneic stem cell transplantation. median age was y [range (r) . conditioning regimen was myeloablative, with treosulfan and fludarabine in all, intensified with melphalan in or with gy tbi in . hla matches was / , / , / in , and cases, respectively. gvhd prophylaxis included sirolimus and mycophenolic acid (mmf). results: after thawing, median cd + cells was . x /kg [r . - . ], median cd + cells . x /kg [r . - . ], and median cd + cells . x /kg [r . - . ]. of the evaluable patients all engrafted with a sustained full donor chimerism at day . median time to neutrophils ( / , anc> /μl for consecutive days) and platelet engraftment ( / immune-reconstitution of cbt patients (tables a-b ) was compared with two cohorts of patients transplanted at our center from any adult donor with ( ) or without ( patients, including post-transplant cyclophosphamide cohort) atg in association with sirolimus and mmf. profiles of immune-reconstitution at day - - showed a better cd + recovery at any time-point in both cbt and no-atg versus atg cohort, with no statistic significant difference in the first cohorts. moreover, cd +/cd + ratio at any time point was better in the cbt cohort vs the no-atg cohort. b cell recovery was faster in the cbt cohort; immunoglobulin recovery was superimposable across different platforms. focusing on late events (> days from cbt), / pts experienced ebv reactivation, median time days [ - ] treated with rituximab, and experienced late hhv and cmv reactivation, both solved at last visit. sirolimus was withdrawn after a median of days [r - ]. only patient developed severe chronic gvhd, solved at last visit. overall, after a median follow-up of days [r - ], pts are alive and well. conclusions: our data confirm that intra-bone cbt without in-vivo t-cell depletion is associated with fast hematopoietic engraftment and immune-reconstitution, with very low rate of chronic gvhd and late infective events. background: a promising improvement of hematopoietic stem cell transplantation (hsct) may lie in the transplantation of high numbers of pluripotent stem cells to minimize the time span between transplantation and immunological reconstitution. hence, an ex vivo platform is needed that supports hsc proliferation before application and, at the same time, the maintenance of pluripotency by diminishing hsc differentiation into lineage-specific progenitor cells. methods: to artificially model the natural hsc niche in vitro, we used d bone marrow (bm)-like scaffolds made of polydimethylsiloxane (pdms). these structures are based on a human long bone cross section as a representative of the bm. human cryoconserved hscs were cultured in distinct cultivation systems for days under different conditions. cell counting and facs analyses at day were conducted. for characterization of the cultivated hscs, we used antibodies against cd alone or in combination with antibodies against cd , cd , cd ra and cd f. results: for optimization of culture conditions for human hscs, a commercially available medium was supplemented with a panel of cytokines and valproic acid. we found a significant increase in the number of cd + hscs by simultaneously increasing their vitality using the d system compared with conventional d culturing. a further improvement was achieved by introducing a silicon oxidecovering of the d pdms structures, suggesting that hydrophilic surface properties offer superior attachment for semi-adherent hscs. for a more precise characterization of the cultivated hscs, we introduced a panel of facs markers reflecting the immaturity of the amplified hsc. surprisingly, with increasing immaturity of the cultivated hsc, non-covered d pdms revealed to be best suited for amplification: cell number of vital immature hscs was increased after cultivation on non-covered d pdms compared with silicon oxide-covered d pdms and the d system. conclusions: by establishing a d scaffold according to the human bm, we found a platform mimicking the natural niche of human hsc which is suitable to amplify human hscs in vitro and support their vitality, pluripotency and ability for self-renewal. [[p image] . with the introduction of sion covering of d pdms structures the maintenance of cd + hscs could be further improved. despite the better conservation of cd + hscs by using silicon oxide-covered d pdms, we found that immature human hscs obviously prefer more hydrophobic conditions found on non-covered d pdms. disclosure: nothing to declare. abstract already published. improvements in neutrophil engraftment following changes in freezing method background: in the setting of autologous haematopoietic progenitor cell (hpc) transplants for haematological disorders, peripheral blood stem cells are routinely collected via apheresis and cryopreserved. leicester royal infirmary had been using a controlled rate freezer (crf) to cryopreserve cellular therapy products up until . in a literature review of cryopreservation techniques was undertaken, since the crf required replacement. this review found consistent evidence that cryopreservation using minus o c is comparable to crf, and engraftment times should not be negatively affected by changing to a more simplified method of freezing. there would also be cost saving benefits from switching from a crf to minus o c freezers. methods: as a result two minus o c freezers were purchased following the acceptance of a preparation process dosier (ppd) which was prepared for the human tissue authority. validation was carried out, and from january stem cell laboratory at the lri switched from the crf method to minus o c for cryopreservation of cellular therapy products. briefly, cells are frozen using % dmso (wak-chemie) in g/l human albumin solution (grifols) in cyrobags (origen biomedical, inc). the cells are transferred on cold packs to the minus o c freezer. cells are packaged in between stainless steel heattransfer plates. the plates are placed within a bubble wrap bag, and are placed in a rack within the minus o c freezer, which allows air to circulate freely around each bag. in one plate a el-usb-tc thermocouple data logger (thermosense) is inserted between the bag and stainless steel plate, to record the freezing profile. this data is downloaded after each run. after an overnight freeze at minus o c, the cells are subsequently removed from the bubble wrap and plates, and are transferred to minus o c freezers the following morning. results: a total of patients have had autologous stem cells frozen using this method so far this year. in addition to engraftment data for neutrophils, post-freeze trypan blue viabilities were also compared to the previous year. during a total of patients, who had all their cells cryopreserved, underwent collections. the post freeze median viability was % ( - %). a total of median neutrophil engraftment was . days, with a median cd dose infused of . x /kg. during so far, patients have undergone collections. median viability is . % ( - %). subsequent median neutrophil engraftment is days, with a median cd dose infused of . x /kg. conclusions: ongoing savings of approximately £ per annum have been made by changing our procedure. the benefit of changing to a simplified method of freezing has also resulted in a reduction in staff working overtime. more importantly, this simplified cryopreservation method has resulted in an improvement in neutrophil engraftment times since changing the cryopreservation technique from the previous method using crf to mechanical freezing using a minus o c freezer. disclosure: nothing to declare low doses of granulocytes in the apheresis product predict a better outcome of autologous hematopoietic stem cell transplantation in multiple myeloma patients background: high-dose chemotherapy with autologous stem-cell transplantation (asct) remains the standard consolidation therapy for multiple myeloma (mm). peripheral blood stem cell collection may be contaminated with large quantities of granulocytes and its consequences on the outcome of asct are still unclear. on the other hand, the effect of performing apheresis with high levels of monoclonal component (mc) on outcome is unknown. the objective of this study was to analyze the effect of total nucleated cells (tnc) and granulocytes count (considered as contaminating components of apheresis products) as well as the influence of mc in the apheresis product on outcome of asct in mm. methods: eighty-two patients diagnosed with mm were mobilized with filgrastim μg/kg/day (plus plerixafor if insufficient mobilization of cd + cells on day ). apheresis collection was performed with cmnc program by spectra optia cell separator. cd + count was carried out according to ishage protocol (target: ≥ x e cd +/kg). subsequent cryopreservation were performed according to the local protocol. results: the medians (range) of collected cd +, tnc and granulocytes were . x /kg ( . - . ), . x / kg ( . - . ) and . x /kg ( . - . ), respectively. the medians (range) of infused cd +, tnc and granulocytes were . x /kg ( . - . ), . x /kg ( . - . ) and . x /kg ( . - . ), respectively. a successful collection after first line therapy was performed in % of patients. treatment for mm was continued after carrying out apheresis in % of patients, as per protocol. a significant reduction of mc was observed prior to asct, indicating a further improvement in responses after apheresis (p= . ). an optimal response (cr or vgpr) at the time of apheresis was achieved in % of patients and a suboptimal response (partial or minimal response) was observed in the remaining %. undergoing apheresis in optimal response did not result in lower number of tnc or granulocytes in the harvest. the subtype of mc did not influence on the number of tnc and granulocytes in the product of apheresis. no differences in collected tnc and granulocytes were observed when plerixafor was used as mobilizing agent. the type of chemotherapy given prior the apheresis did not have influence on the characteristics of the apheresis product. a significant improvement in overall survival (os) probability ( %ci) was observed when low tnc (< . x figure a ). lower incidence of relapse (p= . ) ( figure b ) and non-relapse mortality (p= . ) was observed in patients who received low granulocyte count in the graft. no significant correlation was observed between the time of engraftment and the number of tnc or granulocytes infused. similarly, no increase in the frequency of the engraftment syndrome was observed when higher number of tnc or granulocytes were infused. conclusions: in our series, low doses of granulocytes in the product of apheresis predicted a better outcome of asct in mm patients. the amount of mc at the time of apheresis did not have influence in the characteristics of the harvest. efforts for avoiding contamination in grafts are important for its impact on outcome of asct in mm patients. disclosure: dkms foundation, pi / (instituto carlos iii) and sgr (grc), generalitat de catalunya. background: our initial experience (from to years) with hematopoietic stem cell transplantation (hsct) from mud with tcrαβ+/cd + graft depletion in patients with cgd showed high rate of secondary graft dysfunction, the incident of graft rejection was %. to improve the outcome, we hypothesized that the use of plerixafor and g-csf as additional agents in conditioning regimen would offers advantages and better outcomes. this trial was registered at www.clinicaltrials.gov (nct ) methods: between april and september , patients with cgd underwent allogeneic hscts from mached unrelated donors with tcrαβ + / cd + graft. the conditioning regimen included -treosulfan g / m , fludarabine mg / m , thiotepa mg / kg, g-csf mcg / kg and plerixafor mcg / kg. all patients received rabbit atg -timoglobulin® ("genzyme europe b.v.", the netherlands) mg/kg for serotherapy. in all cases, tcrab +/cd + graft depletion was used with the immunemagnetic method (miltenyi biotec, bergisch gladbach, germany) according to the manufacturer's instructions. stem cell source was g-csf mobilized peripheral blood stem cells in all cases. posttransplant gvhd prophylaxis was not performed. minimal follow up was days after hsct. results: neutrophil and platelet engraftment occurred at - days post-hsct in all patients. patients had full donor chimerism in whole blood and in cases we observed predominantly donor mixed chimerism at last follow up. all patients had full donor chimerism in cd + compartment and mixed chimerism in cd + lineage, but it stable without any sign of graft dysfunction. acute gvhd is verified in of cases and was limited to skin grade . all patients are alive for periods from to months post-hsct with good graft function without severe clinical problems. conclusions: we presented first experience of g-csf and plerixafor addition to conditioning regimen before hsct with tcrαβ+/cd + graft depletion in cgd patients . we suppose, the preliminary results are encouraging, as the frequency of primary and secondary graft dysfunction in patients from this group is not observed today, there are no significant toxic complications, as well as clinically severe manifestations of gvhd. currently, the recruitment of patients is continuing, and estimation of the rates of immune reconstitution and a more detail analyses will be evaluated later. background: introduction -it is believed that aboincompatibility is of minor importance in allogeneic stem cell transplantation (allo-sct) and that the clinical outcome is equivalent to abo-compatible sct. therefore, we performed a single center retrospective study to characterize the impact of abo-incompatibility on the outcome of haploidentical stem cell transplantation (haplo-sct). methods: this analysis included consecutive patients who underwent haplo-sct for various hematological malignancies at our center between october and may . we used our institutional database to evaluate details and characteristics of patients and transplant outcomes. results: demographic features of the patients and donors have been summarized in table . all of the patients had advanced hematological disease with a high risk of relapse ( patients with acute leukemia). out of patients, early transplant-related mortality was seen in this cohort of patients. the remaining patients were followed in and months. donor type abo group switch was observed in a median of days ( - days) after transplant. we were not able to show any statistical difference in terms of blood group switch between minor and major abo incompatible transplant. the median red blood cell (rbc) transfusions in the first days for the abo compatible and incompatible transplants were median units (range, - ) and median units (range, - ) (p= . ). no statistical difference was also encountered for the rbc transfusion need for stem cell source, peripheral blood vs bone marrow. a total of patients were followed up for reticulocyte engraftment. the median time for reticulocyte engraftment was days (range, - ) for all patients. reticulocyte engraftment was tended to be faster in minor abo-mismatched group (p= . ) than major or abo-compatible ones. nineteen patients achieved independence from rbc support after a median time of days (range, - days) in abocompatible patients, days (range, - days) in minor abo-incompatibilityand days (range, - days) in major abo-incompatibilitygroup, respectively (p> . ). the engraftman kinetics due to major and minor aboincompatibilitytransplants were presented in table- . pure red cell aplasia was not developed in our cohort. conclusions: the present single center study provides new evidence for the importance of the abo system for erythrocyte recovery in haploidentic stem cell transplantation. it's important to note that, randomize prospective and larger studies are warranted. disclosure: nothing to declare low dose of anti-t lymphocyte globulin protects against severe forms of graft versus host disease in patients undergoing allogenic stem cell transplantation background: graft versus host disease (gvhd) is the most important complication after allogeneic stem cell transplantation (allosct). optimal dose of different anti-tlymphocyte globulin (atg) formulations in this setting has not been established yet. the aim of this study was to analyze the impact of a low dose of atg-fresenius (atg-f) in allosct outcomes. methods: we analyzed adult patients who received an allosct for hematologic malignancies from october to march . the gvhd prophylaxis included a total dose of mg/kg ( mg/kg on day - , - and - ) of atg-f for patients who received a graft from peripheral blood, an unrelated donor; with a mismatch, and/or were older than years; associated to a calcineurin inhibitor and mycophenolate mofetil/short course-methotrexate. statistical analysis was performed using spss v. and r software. results: median age was years ( - ) and . % of patients were males. seventy-four percent of patients underwent myeloablative conditioning. the stem cell source was peripheral blood in patients ( . %), % were from unrelated donors ( % mismatched). seventeen ( . %) patients had high risk cmv status (d-/r+) (see image b). engraftment was observed in patients ( . %). primary graft failure occurred in patients ( myelofibrosis, aml). twenty ( . %) out of evaluable patients developed grade - acute gvhd. the cumulative incidence of severe agvhd and moderatesevere chronic gvhd were . % ( % ci, . - . %) and . % ( % ci . - . %), only ( . %) patients developed severe cgvhd. twenty-nine patients ( . %) discontinued immunosuppression before the first year of transplant. the median duration of immunosuppression for patients with moderate-severe cgvhd was days ( - ). at years non-relapse mortality (nrm) was . % ( % ci, . - . %). thirty-nine ( %) patients developed relevant infectious complications. two ( %) patients died within the first days due to gram negative blood stream infection. eleven ( . %) had at least two episodes of cytomegalovirus (cmv) reactivation between day and . three ( %) patients developed cmv gastrointestinal disease, ( %) had probable invasive fungal infection and ( . %), post-transplant lymphoproliferative disorder associated to epstein barr virus. with a median follow up of months for alive patients , the gvhd and relapse free survival (grfs) at one year, overall survival (os) and progression free survival (pfs) at two years were . % ( % ci, . - . %), % ( % ci, . - . %) and % ( % ci, . - . %), respectively. the relapse incidence at two years was . % ( % ci . - . %). complete remission at transplant was associated with better long term survival ( % at years, p < . ). hla disparity did not affect os (see image a). conclusions: the use of low doses of atg-f is protective against severe forms of acute and chronic gvhd in a cohort with high prevalence of unrelated donors and a high median age. this strategy showed good results in grfs, os and pfs in a population at high risk for developing gvhd or relapse. disclosure: nothing to declare performance parameters of a ngs-product for chimerism monitoring -applicable in patients after hematopoietic stem cell transplantation methods: for this purpose, samples from patients with mixed chimerism (mc) with increasing amounts of recipient dna were analyzed and compared using realtime pcr of insertions/deletions (indels), fragment analysis of short-tandem repeats (str) and ngs of indels. results: whereas real-time pcr displayed excellent sensitivity down to , % mc, but poor precision above %, fragment analysis exhibited good precision with limited sensitivity (> , %). in contrast, ngs chimerism demonstrated good sensitivity, with a limit of detection (lod) of , % mc, and precision throughout the whole spectrum of patient/donor mixed chimerism. the ngs chimerism product (devyser chimerism) exhibited at least three (average eight) and at least two (average ) informative genetic markers (indels), suitable for monitoring mixed chimerism of patients with their corresponding matched unrelated ( ) or related ( ) donor samples. in order to establish the performance of the separate techniques for determination of mixed chimerism on retrospective patient samples, a cohort of patient monitoring samples ( - weeks post-hsct) with low (< %), intermediate or high mixed chimerism (> %) were included and analyzed. dna from all monitoring samples was extracted from sorted cell fractions. the results show that although all evaluated techniques are suitable for monitoring patient/donor chimerism after allogeneic hematopoietic stem cell transplantation (hsct), only the ngs chimerism product exhibits high sensitivity (lod , %) and a broad dynamic range (detection range , - %) with good precision and accuracy throughout the whole spectrum of mixed chimerism (% patient/donor). in addition, the ngs chimerism product employ non-population dependent highly informative genetic markers providing stable resolution power and thus suitable for monitoring mixed chimerism. disclosure: dan hauzenberger is medical adviser at devyser ab and shareholder in devyser holding gender distribution: male - % (n= ), female - % (n= ). age median - , years old ( months - ). stem cell source: bone marrow - % (n= ), peripheral blood stem cells - % (n= ). patients ( %) received / matched unrelated donors hematopoetic stem cells transplantation and patients ( %) - / matched unrelated donors hematopoetic stem cells transplantation. differences in the antigen blood system: single group % (n= ), minor % (n= ), major % (n= ), mixed % (n= ). age of donor: - years old - % (n= ), - - % (n= ), - - % (n= ), and more % (n= ). gender differences in donor/recipient: male/female % (n= ), female/male % (n= ), one sex % (n= ). we also took into account the impact of gender difference and cytomegalovirus serostatus in the donor/recipient pair. results: in / group the estimated probability of overall -years survive was % and in the / group -years survive was %. the increase in donor age of years reduces the -years survive by - % (p= , ), however, the -years survive from donors over years old was %. we have found no difference between -years survive in transplants from donors that are compatible/ incompatible with the antigen blood system, cytomegalovirus serostatus, or the gender differences in donor/ recipient. in the study of donor-related factors, we found the negative impact of an human leucincompatibility ( / ) on the incidence of chronic gvhd - % (p = . ). the combination of cytomegalovirus positive serostatus of the donor and the negative status of the recipient increases the risk of primary graft rejection up to %, in comparison with others (p = . ). conclusions: our study showed the role of genetic matching on the hla system between the patient and the unrelated donor, and the donors age value. / transplants have better outcome and lower incidence of severe a. gvhd and ch. gvhd. younger donor increases -years survive, but there is a significant increase in -years survive if the donor is over years old. disclosure: nothing to declare allogeneic stem cell transplantation in chronic myelomonocytic leukemia. a single center experience nine patients ( %) relapsed with a median of , months ( - ) with different strategies at this point: in all cases we modulated immunosuppression, in cases as the unique strategy, in cases with donor lymphocyte infusion (dli), in cases we employed hypometilating agents (hma) and in cases with intensive chemotherapy, reaching cr only in two patients, one of them after dli and the other one after hma and consolidation with a second asct. eleven patients ( %) died being the relapse the main cause ( %). transplant related mortality (trm) at + were % and global trm were %. in the last follow-up, patients ( %) are still alive, ( %) in cr and ( %) in relapse situation. with a median follow-up of months ( - ), the event free survival (efs) were months ( - ) and the overall survival (os) were months ( - ). we observed advantage in terms of os in those patients that reach cr at + post asct and in those who develop chronic gvchd (p= . and p= . respectively) conclusions: asct is still the only curative option despite the high relapse rates. to reach cr at + post asct and the development of chronic gvhd seems that they confer advantage in terms of os. the importance of knowing the molecular profile of the entities that we consider for asct. disclosure this study documents a first experience of a cell processing lab seeking to integrate process automation technology to wash and volume reduce products which can account for the initial material source volume variability, product characteristics, and number of bags. methods: here we report the pre-clinical assessment of the lab's initial work with the lovo cell processing system for a product experience over days with machine. this study used products intended for destruction. the workflow used parallel and sequential processing schedule. after water-bath thawing, bags were sampled, weighed to determine volume, and subsequently connected to lovo or pooled into a transfer pack and then connected to lovo. the bags were then diluted : at ml/min with lovo at + - c using % hydroxyethylstarch / . (voluven, fresenius kabi) and processed using a cycle procedure. after processing the bags were weighed for volume, sampled, and stored in a - c refrigerator in their lovo final product bags. samples were assessed from t= to t= hours. results: cd + viability and absolute counts were determined using flow cytometry. processing duration and solution volume consumed was determined by the lovo's sensors and confirmed by the operator. data is presented as a percentage relative to the post-thaw values. note, the values presented are not total process yields. the results focus on the lovo processing step. conclusions: the operators easily integrated into the software to drive the machine. the machine demonstrated it's flexibility with a wide-range of volumes, cell-inputs, and number of bags. the lovo produced products which meet our specifications in a quick and reliable manner. further work on this platform will be performed to validate and qualify this system for production use. properties. the aim of this study was to evaluate prospectively the efficacy of a fbm protocol for the prevention of om in patients undergoing a hsct. methods: all patients consecutively who underwent a hsct at our center from x onwards received five weekly fbm sessions with a bidiodic laser (lumix ®, prodent, italy), which simultaneously emitted at nm and nm with a power of mw and energy of j per point. the procedure started the day before the beginning of the conditioning regimen up to the tenth day post-transplant. the laser was applied in a defocused mode on each of the mucosal surfaces ( areas). at each session, the morphine dose, the om level (according to the who scale) and pain through a numerical rating scale (nrs) were recorded. results: consecutive patients ( male/ female) submitted to a hsct were analyzed. the median age was years (range - ). eighteen patients had acute leukemia, myelodysplastic syndromes, lymphoproliferative diseases. the median number of treatment lines before hsct was (range - ). at transplant, patients had advanced disease. the myeloablative conditioning regimen mac (thyotepa, busulphan, fludarabine) was employed in patients; the same conditioning, with a reduced dose of busulphan (ric), was infused in patients. seven patients ( %) had no evidence of om. the incidence of grade ii-iv om was % in the group of patients receiving mac and the median duration days (range - ); grade om was observed, for day, in patient. in the ric group the incidence of om was %, the median duration days (range - ); no patient had evidence of grade iv om. in the whole population, the maximum nrs value was . morphine administration was required in patients, due to the occurrence of non-oral complications. conclusions: in our experience, prophylaxis with fbm to prevent or reduce om was safe and effective, compared to results of previous experiences reported in the literature, which used no prevention against this complication that negatively affects the quality of life of transplanted patients. further studies on a large series of are necessary to confirm our results. disclosure: nothing to declare background: cytogenetic abnormalities are an essential part of prognostic systems in myeloid malignancies before hematopoietic stem cell transplantation (hsct), however, their role in posttransplantation prognosis is unknown. the aim of this study was to assess the prognostic impact of genetic risk stratification of aml and mds patients on posttransplantation course, which could be an additional tool in making decisions regarding preemptive therapy. methods: a retrospective analysis covering patients treated with allo-hsct between and . cytogenetic studies included karyotyping (c-and gbanding) and fluorescence in situ hybridization (fish). the number of analyzed cells exceeded european cytogenetics association guidelines (for each fish at least interphase nuclei were analyzed). cytogenetic risk group in aml was assessed based on the eln criteria. patients with mds were stratified into three groups; favorable (good and very good prognostic score), intermediate, and adverse (poor and very poor) prognostic score according to ipss-r . interestingly, the poorest survival was in patients with monosomy of chromosome , which was present in patients of whom succumbed to refractory disease, while all patients who had deletion of long arm of chromosome (del q)-are alive at the time of writing of this report after a median follow-up of months ( - ). relapse was diagnosed in patients ( %), including; ( %) with adverse, ( %) with intermediate and ( %) with favorable cytogenetic risk. among patients with a complex karyotype and/or cytogenetic evolution prior hct: patients ( %)relapsed, including ( %)-who died. follow-up cytogenetic studies in relapse after transplantation were performed for patients; of them ( %) had clonal evolutions of the original karyotype with additional abnormalities-( % died) and ( %) had new aberrations in cells without primary changes (all died). in patients ( %) ( unfavorable, intermediate group) cytogenetic relapse was diagnosed by fish analysis and they were treated with azacitidine (+/-dli) achieving cr (n= , %), stabilization-(n-= , %), transient response (n= ), while deceased). conclusions: cytogenetic studies in patients after transplantation may facilitate assessment of mortality. karyotype may undergo cytogenetic evolution after allo-hsct. patients with monosomy of chromosome seem to have a particularly poor prognosis. transplanted patients are vulnerable to new cytogenetic alterations. disclosure: nothing to declare methods: the primary end-points were the rate of complete response (cr), defined as no emesis and no nausea without rescue medications, for both acute (cr- ) and delayed (cr - ) cinv and rate of post-transplant complications until discharge. we prospectively analyzed patients undergoing autologous ( %) and allogeneic ( %) stem cell transplantation and receiving cinv prophylaxis with nepa and dexamethasone (schedules shown in fig. ). in our series, patients ( %) were female. patients median age was years ( - ). the most frequent diagnosis were myeloma ( %) and lymphoma ( %), while % of patients were diagnosed with aml or mds. myeloma patients received one day hd-ct with melphalan ( % mel / % mel ). lymphoma patients were conditioned with feam ( , %) or tt_flu_edx ( , %) hd-ct. busulfan-based mds-ct regimen was offered to aml/mds patients. results: the incidence of cr- and cr - observed was % ( / ) and , % ( / ), respectively. more than grade nausea and vomiting (according to ctae- ), was reported in % ( / ) and % ( / ) of patients, respectively. female sex was associated with an increased risk of acute (hr , ; p , % ci . - . ) but not delayed (hr , ; p , % ci - . ) cinv. similar rate of cr and cr - was observed in one-day hd-ct ( % and %) compared to mds-ct ( % and , %) group (pns). median lenght of stay was days ( - ). no case of cardiotoxicity and no exitus was observed. the incidence of febrile neutropenia was % ( % fuo; % sepsis; % pneumonia). only one patient experienced an agvhd on day + . neutrophil (> /mcl) and platelet (> /mcl) recovery occurred in median on day ( - ) and on day ( - ) respectively. conclusions: nepa seems to be safe and effective in preventing acute and delayed cinv in patients receiving both one day hd-ct and mds-ct as conditioning regimen for hsct. more studies are needed to define the better -ht ra and nk- ra combination and the better schedule in transplant setting. disclosure: "nothing to declare background: vod and ta-tma represent two early endothelial complications occurring after allogeneic stem cell transplantation (sct) sharing many pre-transplant risk factors. the aim of our study is to evaluate the impact of donor graft composition, engraftment kinetics and infections on the development of these endothelial complications (ec). methods: we retrospectively reviewed consecutive sct recipients at our institu-tion between january and june . the median age was years (range - ). acute leukemia was diagnosed in patients ( %). complete remission was documented in % of patients at transplant. donor source was from hla mismatched donor in % and from unrelated donor in % of the patients. hbv positive patients were % of the sample. conditioning regimen was busulfan based in % of patients. ursodeoxycholic acid and unfractionated heparin were given to all patients as vod prophylaxis. cyclosporine was used as gvhd prophylaxis. lymphocytic subpopulation analysis (cd +, cd +, cd + and cd +/cd +) and cd + cells count on the donor graft were performed using bd facs cantoll. all patients had routine monitoring for ebv and cmv pcr, hemolysis tests, creatinine and electrolyte panels, proteinuria, complete blood count, blood pressure and schistocytes by direct examination until day + . the fisher's exact test was used to compare categorical variables, while continuous variables were analyzed with anova test. diagnosis of vod and ta-tma were carried out by using ebmt and cho criteria respectively. results: the incidence of very severe vod and tma was % ( / ) and , % ( / ) respectively. cmv reactivations with viral load over . cv/ ml was % and % in patients with and without ec, respectively (p , ; hr , p , %ci , - , ). the median day to neutrophils (ns) engraftment ( /ml and /ml) was vs and , vs in vod/tma group vs control group (p , and , , respectively). more rapid neutrophils engraftment (ns > /ml and ns> /ml within days) was related to a higher risk of ec with a hr of , (p , ; %ci , - , ) and , (p , ; % ci , - , ). patients with ec received a donor graft with a higher median numbers (x e /kg) of cd + and cd + (p> , ) and a lower numbers (x e /kg) of nk cells (p> , ). patients who received a cd + cells count > x e /kg and nk cells count < , x e /kg presented a relative risk of ec of , (p , ; % ci , - , ) and , (p , ; % ci , - , ), respectively. there were no differences with respect to the other analyzed variables between patients who developed vod/tma compared with those who did not. (pic_ ) conclusions: cmv viremia, early neutrophils engraftment and donor nk and cd + cells infused are associated with the risk of vod and tma. very few studies evaluated the link between these variables and the risk of developing such two complications. it could be interesting to investigate these relationships on larger series. clinical trial registry: not applicable disclosure: nothing to declare p when the last hope turns out to be just as good as best: haplosct following tbf conditioning, pt cyclophosphamide and tacrolimus as gvhd prophylaxis background: hematopoietic stem cell transplantation is an effective therapy for a variety of severe hematological diseases. in last decades, haploidentical sct (haplosct) followed by ptcy as gvhd prophylaxis has been reported as a valid alternative for patients who lack an hla matched donor. we therefore analysed outcomes with this. methods: patients without hla-matched donor received a haplosct between / and / . thiotepa mg/kg ( days), fludarabine mg/m ( days) and oral busulfan mg/kg/ h ( days,with pkd dose adjustments) was used as conditioning regiment; in patients > years busulfan administration was limited to two days. gvhd prophylaxis consisted of cyclophosphamide mg/kg on day + and + , and tacrolimus as a continuous iv infusion from day + . all patients received pbsc as the stem cell source. outcomes analysed were overall survival (os), progression free survival (pfs); cumulative incidences (ci) of gvhd, relapse and non-relapsed mortality (nrm). results: median ages was (range - ). % male and % female. diagnoses were: aml ( %), mds ( %), all ( %), hl and nhl ( %), and mm ( %). % (n ) were transplanted in early disease status, while most cases ( %) were in advanced status, including, second/third cr ( %, n ), one ( %) in aplasia without progressive disease and % (n ) had active/progression disease, % (n ) had stable disease; four cases were second alosct. thus, % of patients had a high or very high rdri and % had intermediate. ebmt score was ≤ was in % of patients (n ) . the donor was as son/ daughter in %, % a sibling and % a patient's mother. median time to neutrophil ( . x e /l) and platelet (> x e /l) recoveries were + and + days, respectively (g-csf was not used). only one patient had a primary graft failure attributed to anti-hla donor specific antibodies. median follow up in survivor is months (range - ). overall survival is ± . % (at months) and ± % (at months). pfs is ± % and ± % respectively. the cumulative incidence of relapse was % and %, respectively, while nrm is % at months. day + , grade - acute gvhd were %, while mild/ moderate and severe chronic gvhd were % and % respectively. ebmt ≤ and first alosct were the only variables to clearly impact -months os in univariate analysis. a combined covariate of ebmt ≤ -no prior alosct vs other patients showed a month os ± % vs ± % (p . ), pfs ± % vs ± % (p . ) and nrm % vs % (p . ) but without impact on relapse % vs % (p . ). conclusions: haplosct with an age-adapted tbf conditioning regimen, pbsc and ptcy followed by tacrolimus, led to very encouraging results, mainly in patients with a low ebmt score and as a first alosct. although formerly considered as a last alosct strategy, we now agree that the time has come to compare this strategy with hla mud (and even elderly sibling donors) in ongoing prospective randomized multinational trials. disclosure: nothing to disclosure background: autologous hematopoietic stem cell transplantation (autosct) for acute myeloid leukaemia (aml) is increasing becoming a viable option for an increasing number of patients due to limited availability of matched sibling or unrelated donor for allogeneic hematopoietic stem cell transplantation (allosct). we examined the relevant long-term outcomes in our local patient cohort. methods: we retrospectively reviewed the data for all autosct done for aml in our centre over a -years period between st january until st dec from our electronic record. patients with acute promyelocytic leukaemia (apml) were excluded from this analysis. patients were further stratified based on the number of high risk features present; not achieving complete remission (cr) following induction chemotherapy, high presenting total white cell count (wbc > x /ml, adverse cytogenetics (example: complex cytogenetics) and adverse molecular mutations (example: flt -itd & mll gene arrangement). outcome data including mortality (overall survival (os) and non-relapse mortality (nrm)) and morbidity (leukaemia free survival (lfs)) were recorded and analysed. results: a total of patients were identified. median age at diagnosis is -years old. the cohort comprised of males and females. the overall median os and median lfs is . years and . years respectively. the nrm is . % ( / ). there was no difference in the median os and median lfs for the patients achieving cr following induction chemotherapy and those not in cr following induction chemotherapy; . years versus . years (log-rank, p= . ) and . years versus . years (log-rank, p= . ) respectively. the median os were statistically significant for patients with zero versus one and two and more high risk features present; . years versus . years versus . years (log-rank, p= . ) respectively. however, the median lfs were not statistically significant for these three patient cohorts; . years versus . years versus . years (log-rank, p= . ) respectively. conclusions: in our patient cohort, autosct appeared to be a feasible option for patents with aml without matched sibling or unrelated donor available. disclosure: none to declare methods: between - , thalassemic patientsunderwent hisct. the median age of patients was ( - )years with male preponderance (n= , . %). across the gender and abo mismatch transplants were done in . % and % of patients. stem cell source was bone marrow in ( %) while peripheral blood in ( %) of patients. mean stem cell dose was . ± . x cells / kg and mean volume of product was ± . ml. preparative regimen included anti-thymocyte globulin, busulfan, fludarabine and cyclophosphamide.graft versus host disease (gvhd) prophylaxis comprised of posttransplant cyclophosphamide on day + & + followed by tacrolimus and mycophenolate mofetil. patients were observed for hematopoietic recovery (neutrophil and platelet engraftment) and transplant related mortality including acute and chronic gvhd for skin, gut, liverand lungs, primary and secondary graft failure and infectious complications. results: nine( . %) of sixteenpatients were engrafted with full donor chimerism. twelve ( %) patients belonged to pesaro class i and ( %) toclass ii patients. median time to neutrophil and plateletengraftment were ( - ) and ( - )days respectively. average number of packed red cell and platelet transfusions were . ± . and . ± . respectively.primary graft failure was observed in ( %) and secondary graft failure was observed in ( %) patients. two patients received a second dose of stem cells and they engrafted at and days of infusion respectively. of patients with primary graft failure died, one with sepsis (day + ) and the other because of intracranial bleeding (day + ).acute gvhdof gut and skin (grade ii-iii) was observed in patients each, within first days post-transplant. none of the patients had grade iv gvhd. cytomegalovirus reactivation occurred in % of patients, all of them received pre-emptive therapy with intravenous ganciclovir. none of them developed cmv disease. invasive fungal infection was not observed in any of the patient. culture proven bacterialinfection was documented in % of patients requiring intravenous antibiotics during first days post-transplant.overall survival and relapse free survival were . % and . % over a median follow-up of ( - ) days. conclusions: haploidentical transplant is a suitable modality for thalassemic patients lacking a full matched donor in pakistan. in view of our results, we suggest that thalassemia patients should be offered hisctas an option for cure. clinical background: gemtuzumab ozogamicin (go) is an anti-cd monoclonal antibody with significant activity in de novo and relapsed/refractory (r/r) acute myeloid leukemia (aml). a relevant side effect consists of hepatotoxicity and especially sinusoidal obstruction syndrome (sos). the objective of this study was to analyze tolerability of go during the induction and reinduction therapy in patients with aml, and its possible impact on subsequent hematopoietic stem cell transplantation (hsct). methods: from to , patients who had received go in three hospitals were collected and their medical records were retrospectively reviewed. results: fourteen patients diagnosed with de novo aml received go ( mg/m ) on day + in combination with standard chemotherapy (idarubicin and cytarabine, x schedule) as induction therapy. hyperbilirubinemia (bilirubin > . unl) was detected in patients and increase of aspartate aminotransferase (ast) (> . unl) in . twelve patients achieved complete remission (cr) and one was refractory ( not evaluated). in the r/r setting, patients diagnosed with aml (n= ), biphenotypic acute leukemia (n= ) and acute promyelocytic leukemia (n= ) received go as rd or subsequent rescue therapy either as monotherapy (n= ) or in combination with cytotoxic chemotherapy (n= ). prior hsct was performed in patients (autologous [n= ], allogeneic [n= ] ). rescue therapy was indicated for refractoriness (n= ), relapse (n= ), partial response (n= ) or absence of donor (n= ). four patients received doses of go ( mg/m ) and patients, one dose. hyperbilirubinemia (> . unl) was observed in patient and increase in ast (> . unl) in patients. seven patients achieved cr, was refractory, obtained partial response and died early during induction). thirteen patients received subsequent hsct (autologous [n= ], allogeneic [n= ]) after go therapy ( in the de novo aml and in the r/r group). the reasons for not performing hsct in the remaining patients were: low cytogenetic risk (n= ), active chronic graft versus host disease (gvhd) in previous hsct (n= ), early death during treatment (n= ), relapse (n= ), severe complications in rescue treatments (n= ), and unknown (n= ). the conditioning regimen was myeloablative (n= ), non-myeloablative (n= ) and sequential (n= ), and the donors were matched sibling (n= ) or unrelated (n= ) . cyclosporine, methotrexate and thymoglobulin were administered as gvhd prophylaxis in patients and cyclosporine, mycophenolate and thymoglobulin in . hyperbilirubinemia was observed in patients belonging to the de novo aml group. death after hsct occurred in patients due to infection (n= ), relapse (n= ), gvhd (n= ) and traffic accident (n= ). three patients are currently alive in remission. no sos was observed in any patient. conclusions: in both de novo and r/r aml the administration of low dose go is feasible and does not have impact on subsequent hsct outcome. although some degree of hepatotoxicity was observed, no cases of sos were observed, either before or after hsct. disclosure: supported by grants from: asociación española contra el cáncer, aecc (gc biga), instituto carlos iii (pi / fi), -sgr (grc), cerca program from generalitat de catalunya, and "la caixa" foundation. outcome of allogeneic hematopoietic stem cell transplantation in patients with benign hematological disorders saqib ansari , tahir shamsi , uzma zaidi , saima siddiqui , tasneem farzana background: allogeneic hematopoietic stem cell transplantation is a potentially curative treatment modality for hematological disorders. we evaluated the outcome of patients suffering from benign hematological disorders, including aplastic anemia, fanconi's anemia and thalassemia after matched related allogeneic transplantation. methods: all patients having hematological disorders including aplastic anemia (aa), beta thalassemia (btm), fanconi's anemia (fa) and severe combined immune deficiency disorder (scid) with hla identical related donors who underwent allogeneic transplantation were included. donors were given g-csf at a dose of μg/ kg/day daily for four days prior to harvest. the conditioning regimens for thalassemia included cyclophosphamide (cy) + busulfan (bu) in ( %), bu + cy + thiotepa in ( %) and bu + cy + antithymocyte globulin (atg) in ( %). conditioning regimens for aplastic anemia included, fludarabine (flu) + cy in ( %), flu + atg in ( %) and cy in ( %), cy+ atg in ( %) patients. for fanconi's anemia flu + atg in ( %), flu in ( %), cy + atg in ( %) and flu+ cy + atg in ( %). flu + atg in ( %) and cy given in ( %) and no conditioning regimen was offered to ( %) patients with scid. results: a total of allogeneic transplants were performed for benign hematological disorders including aa (n= ), btm (n= ), fa (n= ) and scid (n= ) from to july . median age was . years (range . - ). across the gender and abo blood group transplants were ( . %) and ( %). the median time to neutrophil and platelet recovery was days (range: - ) and (range: - ). primary and secondary graft failure was observed in ( . %) and ( . %). overall survival in aplastic anemia ( / , %), beta thalassemia ( / , %),fanconi's anemia ( / , %) and severe combined immune deficiency disorder ( / , %). eighty four patients expired ( . %) among them patients expired within days post transplant main cause of deaths included sepsis ( %), multi organ failure ( %) and gut gvhd ( %) conclusions: in developing world scenario where non malignant disorders are leading cause of morbidity and mortality. bone marrow transplantation has been successfully implemented with better long term diseases free survival and quality of life. clinical background: hematopoietic cell transplantation (hct) remains the only curative therapy for many diseases, yet transplant survivors carry an unusually high burden of morbidities, primarily because of exposure to intense chemotherapy, radiation and /or gvhd. this study aimed to evaluate the burden of chronic diseases at the end of life after allogeneic-hct and to identify the disability-adjusted life years (daly). methods: the pubmed, medline, and ovid databases were queried utilizing specific mesh terminology (post, allo stem cell, hematopoietic, bone marrow, transplantation).we collected data on the impact of the hct on the variables affecting survivor's health in all aspects .the rates of late complications were compared to the risks in the general population (united states). results: a total of studies fulfilled the selection criteria totaling to patients (table ) . median os at -year mark varied widely between studies from % to %. majority of the patients at -year mark were found to have new comorbidities thereby indicating a huge burden of late effects at the end of life, though exact dalys could not be calculated due to incomplete data. hct survivors were found to have higher risk of premature arterial disease (pad) at . % compared to the general population, however gvhd or the addition of tbi to the conditioning regimen were not found to be significantly associated with pad. regarding the risk of new cancers, the cumulative incidence of their development at and years was . , and . , respectively. increased risks compared with the general population were seen for some solid cancer including cancers of the lip: p= . , tonsils: p= . , oropharynx: p< . , bone: p< . , soft tissue: p< . , and vulva: p= . . with respect to mental health, depression was prevalent in ( . %) survivors, in whom ( . %) were still on antidepressants at the last follow-up. cognitive impairment and other psychiatric disorders were found in ( . %) and ( . %) survivors, respectively. the most common cause of nrm in the first years was gvhd. however, after years, the leading cause of death in those conditioned with mac regimen was secondary cancer, but in the ric group, new cancers and gvhd contributed equally. conclusions: hct survivors remain at risk of significant complications which lead to premature death and their burden of comorbidities at the end of life is significantly more than that of general population. background: late onset hemorrhagic cystitis (hc) is a common complication of hematopoietic stem cell transplantation (hsct) frequently associated with reactivation of bk virus (bk-hc).there is no consensus as to the best therapy for bk-hc, and many different treatments have been reported. hyper baric oxygen therapy (hbot) is used as primary or adjuvant therapy in diverse clinical situations involving hypoxic injury to tissues and has been explored as a useful tool in treating bk -hc. we report our experience with hbot in combination with non-invasive supportive care in children and adolescents suffering from bk-hc following allogeneic hsct. methods: the computerized database of schneider children´s medical center of israel was reviewed for all patients aged to years who underwent hsct between january and june and developed bk-hc. hbot therapy consisted of hours sessions at atmospheres, with patients breathing oxygen by mask. parents accompanied patients during the treatment. results: fourteen patients with a variety of underlying diseases received (hbot) for treatment of bk-hc following hsct. the initial treatment for children with bk-hc at our center prior to included continuous bladder irrigation and intravesicular instillation of various medications. beginning in , we adopted a non-invasive strategy that included the administration of oral anticholinergics (oxybutinin), systemic pain management, hyperhydration and the administration of weekly cidofovir with probenecid. hbot was administered to patients who failed the above regimen. with this protocol, the average time of starting hbot dropped from (prior to ) to . days. the median onset of hc was days post hsct. all patients were receiving immunosuppressive treatment at the onset of bk-hc. all patients suffered from macrohematuria with blood clots (grade iii cystitis), ( . %) experienced severe dysuria and ( . %) urgency. bk viruria was present in all patients, and concurrent bk viremia was detected in % of those who were tested. patients reported symptomatic improvement at a mean of . days following the initiation of hbot. no patient experienced serious adverse effects due to hbot, but two patients required insertion of tympanic ventilation tubes. eleven of our patients ( . %) experienced complete remission of bk-hc following hbot, with an overall response rate of . % ( / patients).eight of our patients ( . %) eventually succumbed due to either hsct complications or disease relapse. conclusions: hyperbaric oxygen therapy is a safe, effective, non-invasive and well tolerated treatment modality for bk -hc and should be considered for first line therapy for this complication of hsct. clinical background: every year, almost one thousand cases of hematological malignancies in pediatric population are reported in peru. allogeneic hematopoietic stem cell transplantation (allo-hsct) is an alternative strategy in many of these cases. only between - % of the pediatric population that requires a hsct has a compatible human leukocyte antigen (hla) donor. the remaining % have to access international donor registries, extending the awaiting time and conditioning the progress of the disease. allo-hsct has the potential to help children with several hematological disorders with non-compatible hla donor. hla genotypically identical sibling donors are the best option when pursuing an hsct. nevertheless, patients' alternative sources of stem cells could be obtained from an haploidentical donor like one of their parents. the haploidentical transplantation program with macs was implemented in peru in to reduce the risk of graft-versus-host disease (gvhd), support the immune system reconstitution and to expand pool of donors. it allows patients to access a treatment that is efficient and safe, as shown in the depletion of positive tcrα/β+ and b cells procedures for allo-hsct. methods: the mobilized leukapheresis products (n= ) of haploidentical healthy donor was washed to remove platelets and preparations were performed according to miltenyi's clinimacs® manual for tcrα/β+ and cd + cell depletion. analysis of the initial leukapheresis product and tcrα/β + and cd + depleted graft (target and non-target product) was performed using flow cytometer. cells were analyzed for cd +, cd +, -aad, cd +, tcrα/β+, tcrγ/δ +, cd + and cd + with fluorochrome-labeled antibodies from miltenyi biotec using a novocyte cytometer. the results obtained with the ex vivo t-cell depleted allo-hsct procedures show an overall survival (os) over % with an ic % at the end of the first year with low incidence of gvhd. macs of tcrα/β+ and cd + cells are effective (logp . and logp . , respectively) obtaining minimum levels of depleted lymphocytes within clinical established parameters for diverse pathologies. in addition, tcrα/β+ and cd + cell depletion does not significantly affect hematopoietic stem cell populations such as cd + and cd + cells or tcrγ/δ+ cell population. cd + and tcr γ/δ cells are highly recovered ( . % and . , respectively), which contributes with a better engraftment after allo-hsct. conclusions: peruvian results oscillated within european ranges with an os over %. our data suggests that the macs method is an efficient, effective and safe strategy for haploidentical hsct which has a remarkable cost-benefit ratio and makes it viable in countries of the latin american region with peruvian socio-economic characteristics. evaluation of genoresistance for viral reactivation treatment has been implemented as a strategy to improve os. better results are achieved in patients after allo-hsct with the validation of these tests in peru. preliminary pharmacoeconomic evaluations allow us to establish magnetic activated cell sorting (macs) as a promissory strategy compared to other alternatives for haploidentical hsct. it is necessary to increase the number of procedures in order to confirm efficacy and safety of macs in a larger population. disclosure: all authors have no conflicts of interest. abstract already published. micro-costing study of hematopoietic stem cell transplantation in two hospital institutions from southern of brazil background: hematopoietic stem cell transplantation (hsct) is a potentially curative treatment indicated for patients with onco-hematological, hereditary and immunological diseases. considering the increase of patients indicated to the hsct and the lack of knowledge about the costs resulting from this treatment, is important to identify and detail the resources consumed in each phase of hsct and provide knowledge to the public health brazilian system. we aimed measure the total cost of related hsct, based on micro-costing study of patients assisted in two hospitals in the south region of brazil. methods: hsct costs were estimated using the timedriven activity based costing method (tdabc), which measured cost of services / products based on actual consumption of resources. we collected data from medical records of patients submitted to allogeneic hsct in from public and private (philanthropic) hospitals. we interviewed professionals involved in the tcth activities, we performed chrono-analysis and, we consulted financial and administrative systems reports of hospitals. in order to compare costs according to clinical complications observed in patients, we grouped into two ranges of complexity: low/ medium and high. the study was divided into stages: hsct processes mapping; costs measurement; and analysis of results. finally, the costs were compared: by activity, by resource and by hospital. this study was financed by psid-uhs, by an agreement signed between ministry of health and moinhos de vento hospital, through adjustment term number: / , and approved by research ethics committees. results: from the hsct processes mapping, the following steps were defined: (i) hospitalization; (ii) conditioning; (iii) transplantation; (iv) period of aplasia; (v) engraftment; (vi) observation; (vii) pre-and medical discharge. seven patients were classified in low / medium complexity level, with hospitalization median time of days and an median cost of usd , . , whereas the other five patients, classified as high complexity, presented median time of days and median cost of usd , . . the hsct costs evaluation identified that steps ii and iv presented greatest cost in high complexity patients. lower complexity patients presented, in steps ii and iv, median costs of usd , . while in higher complexity usd , . . in addition, median costs of materials and drugs were usd , . and usd , . in lower and higher complexity patients. conclusions: tdabc method allowed the identification of the moment when patients consume the most resources. of all the hsct stages, periods of conditioning and aplasia presented higher costs, representing . % of the total hospitalization value. in these stages, higher complexity patients presented three times higher the median cost. the resources that had the greatest impact were medicines and medical materials, costing times more than lower complexity patients. conclusion: this study allowed a detailed identification of the hsct costs in patients with different complexity ranges in two hospitals from southern brazil. therefore, the identification of service demand regarding the clinical complexity, allows the generation of important information for the management of the best care in the health service. disclosure background: immunodeficiency due to lrba deficiency is characterized by hypogammaglobulinemia and autoimmunity. hemolytic anemia, lymphadenopathy, autoimmune hepatitis and, above all, autoimmune enteropathy are the fundamental characteristics of these patients together with the history of recurrent invasive infections.the therapy includes immunosuppressants, endovenous immunoglobulins. bone marrow transplantation is the final therapy of these patients, especially in the most serious cases and in recent years, also on the light of increasingly targeted conditioning regimes, it is associated with ever better prognosis. methods: we present the case of caterina, an -year-old patient with lrba deficiency, diagnosed at years of age for a history of hypogammaglobulinemia, recurring invasive, bacterial and fungal infections and a picture of autoimmunity represented by ahia, myelitis (c -c ), autoimmune hepatitis and enteropathy in treatment with abatacept and sirolimus. it also presents leptin deficiency lipodystrophy.she presented to our observation for ostemielitis in multiple outbreaks (tibia, femur and left knee) secondary to sepsis from mrsa. broad spectrum antibiotic therapy and curettage surgery were performed during hospitalization.after months of broad-spectrum antibiotic therapy (daptomycin, rifampicin, ceftaroline, cotrimoxazole, levofloxacin, dalbavancin) there was resolution of the infections.because of the seriousness of the disease it is therefore decided to subject catherine to hematopoietic stem cell transplantation. results: therefore were performed bone marrow transplant from mud after conditioning at reduced intensity, delayed in days, with treosulfan, fludarabine and thiotepa. prophylaxis for gvhd was performed with atg ( mg / kg / day), sirolimus (already practiced for enteropathy) and mmf. because of the hepatic picture, we also performed prophylaxis for vod with defibrotide for days. transplantation was performed by peripheral stem cells with x ^ cd / kg and x ^ cd / kg.the patient had always presented good general conditions with engrafment of the pmn to the d + and the plt to the d + . the chimerism at d + was % donor both on pmn and on pbl. prophylaxis for gvhd was changed on d + by replacing the sirolimus with tacrolimus for the appearance of grade i cutaneous gvhd . conclusions: we have successfully performed bone marrow transplantation in patients with lrba deficiency. the new antibiotic molecules, used to induce infectious remission, the new low-intensity regimens, the prevention of the most fearful complications (vod) have been the key to success in such complicated case. the high number of cd cells infused with a controlled number of cd were the key then of rapid engraftment with minimal gvhd readily controlled by the immunosuppressant. disclosure background: in the absence of hla-matched related donor, allogeneic stem cell transplantation from haploidentical donors are potential alternatives for patients with hematological malignencies with an indication to allogeneic stem cell transplantation. herein, we retrospectively assessed the outcome of haplo-sct for patients with refractory hematological malignancies. methods: this analysis included consecutive patients who underwent haplo-sct for various hematological malignancies at our center between october and may . we used our institutional database to evaluate details and characteristics of patients and transplant outcomes. results: demographic features of the patients and donors have been summarized in table . all of the patients had advanced disease with a high risk of relapse. the majority of patients underwent haplo-sct from their parents. out of patients, early transplant-related mortality was seen in this cohort of patients. four patients treated with second haplo-sct and recovered hematopoiesis after second transplant. the remaining patients were followed in a median of months. donor type abo group switch was observed in a median of days ( - days) after transplant. the median time for engraftment was days (range, - ) for all patients. after the first transplant, patients developed acute gvhd ( . %) with patients having grade ii-iii acute gvhd. five ( . %) had chronic gvhd, none of them with extensive manifestation. the prepative regimen was relatively well tolerated with limited regimen-related toxicity. cmv reactivation occurred in patients ( . %) during the follow-up of the study. eight patients ( . %) relapsed after a median of days post transplant (range, - days). cr was achieved in ( %) patients after haplo-sct. mean estimated -year os and pfs are . %± . % and . %± . %, respectively. conclusions: given the growing data on the similarity of outcomes after hla-matched and haploidentical sct, further studies are required to determine whether factors may be more important for donor selection than hlamatching. clinical trial registry: -disclosure: nothing to declare outcome of allogeneic stem cell transplantation for hodgkin and non-hodgkin lymphoma: single center experince from turkey ayşe uysal , hale bülbül , nur akad soyer , mahmut tobu , murat tombuloglu , guray saydam , filiz vural background: allogeneic sct (allosct) is generally optionally treatment choice for young and fit patients with relapsed/refractory lymphoma who were heavily pre-treated and after the failure of autologous stem cell transplantation (asct). relapse after asct is associated with a poor prognosis and allosct is a potentially curative therapy for lymphomas which have relapsed after asct. methods: in this study, we evaluated patients with hl and nhl who had treated with allo-hsct between november and december in ege university adult hematology transplantation unit. results: patients, disease and transplant characteristics were illustrated in table. histologic subtype of nhl was evaluated as t cell lymphoma (n= ; , %), mantle cell (n= ; , %), diffuse large b-cell lymphoma (n= ; , %) and b-cell lymphoma, unclassifiable, with features intermediate between dlbcl and classical hodgkin lymphoma (n= ; , %). all histologic subtype of hl was determined as nodular sclerosing. the median number of prior treatments before allo-hsct was (range, - ). twelve ( , %) patients had refractory disease, ( , %) patients were in complete remission and ( , %) patients were in partial remission before allo-hsct. the median time from diagnosis to allosct was (range, - ) months. peripheral stem cell was used for stem cell source in all of them. total body irritation plus fludarabine plus cyclophosphamide and busulfan plus cyclophosphamide were preferred most frequently for conditioning as non-myeloablative and myeloablative, respectively. neutrophil engraftment was occurred median of (range, - ) days. graft versus host disease (gvhd) prophylaxis was applied all of them and cyclosporine plus methotrexate was preferred most frequently (n= ; , %). gvhd was occurred in , % of them ( , % acute gvhd, , % chronic gvhd and , % both). veno-occlusive disease (vod) was occurred in ( , %) patients. transplant related death was observed in ( , %) patients. overall survival (os) and disease-free-survival (dfs) were evaluated as median (range, - ) and (range, - ) months, respectively. analyze of os and dfs was illustrated in figure. six patients are alive without disease. after a rapid tapering of immunosuopressive therapy was underwent a therapy with ponatinibat dose of mg/die results: afther a month of therapy we observed a rapid decrease in minimal residual disease on molecular assessment with an mmr of p -bcr-abl/abl non detectable confirmed by bone marrow revaluations at days + , + nd + after the salvage therapy. the patient has not had experienced of graft-versus-host disease, ponatinib treatment was well tolerated and considered safe with easily manageable side. conclusions: maybe in the era of tyrosine kinase inhibitors (tkis), philadelphia chromosome positive acute lymphoblastic leukemia (ph+ all) it could benefit from a combined treatment between transpalnt and tkis however more studies are needed to confirm these hypotheses. disclosure: nothing to declare immunodeficiency diseases and macrophage background: although a number of patients with hiv infection and hematological disease have successfully undergone allogeneic hsct together with combination anti-retroviral therapy (cart), short and long-term outcomes remain not well known. we report the largest spanish experience of hiv-infected adult patients with high-risk hematological malignancies with allogeneic hsct. methods: we retrospectively reviewed hiv-positive patients who received allogeneic hsct between and in spanish centers within geth (grupo español de trasplante hematopoyético y terapia celular). results: baseline and transplant characteristics of patients are shown in table . median age was years and % of the patients were men. the most frequent underlying malignancies were non-hodgkin lymphoma ( , %) and aml ( , %). in half of the patients an hlaidentical sibling was the donor; and in the other half, an alternative donor was used. peripheral blood was used as graft source in % of the transplants. at the time of hsct, all patients had been receiving suppressive cart for a median of years and only of them showed detectable plasma hiv rna, one of them because of poor adherence to cart together with the accumulation of multiple resistance mutations; and the other patient had detectable hiv rna at low levels (< copies/ml). all patients received cart throughout the transplant procedure, being temporally stopped in two patients due to significant mucositis. after a median follow-up of months ( - ), -year overall survival (os) and event-free survival (efs) were %. nrm was % at months and relapse was % at months. grade ii-iv agvhd rate was %, and moderate/severe cgvhd rate was % at months. a significant proportion of patients ( %) showed infectious complications with viral infections as the most frequent cause. two patients had invasive aspergillosis and one patient presented disseminated tuberculosis. causes of death included infections ( %), relapse ( %) and toxicity ( %). among the patients who died due to infections, had severe chronic gvhd and were under immunosuppressive therapy. two patients showed severe toxicity related to drug interaction with anti-retroviral therapy. all survivors except one showed undetectable hiv load at last follow-up after hsct. conclusions: allogeneic hsct is an effective therapy for high-risk hematological malignancies in patients with hiv infection, providing long-term disease free survival together to long-term hiv suppression with cart. however, drug interactions with anti-retroviral agents, occurrence of gvhd, and frequent infectious complications account for a complex procedure in this population. selected hiv-infected patients with hematological malignancies should be considered for allo-hsct when indicated, in experienced centers, with a multidisciplinary care. disclosure background: primary immunodeficiencies (pid) are rare diseases often associated with genetic defects in the immune system, predisposing individuals to recurrent infections and increased risk of allergy, autoimmunity and malignancy. allogeneic haematopoietic stem cell transplantation (hsct) has been successfully used as a curative therapy for most severe forms of pid. because pid is a genetic disease, < % of these children will have a healthy, human leukocyte antigen (hla) matched sibling donor available, and umbilical cord blood grafts from unrelated donors are a suitable alternative cell source. we report the results of umbilical cord blood transplantation (ucbt) performed in patients with pid between and at children's hospital of fudan university in china. methods: patients included chronic granulomatous disease (cgd, n= ), severe combined immunodeficiency (scid, n= ), interleukin- receptor-a deficiency (il- rad, n= ), wiskott-aldrich syndrome (was, n= ), leukocyte adhesion deficiency (lad, n= ), severe congenital neutropaenia (scn, n= ) and other immunodeficiencies (n= ). all patients were assessed by clinical immunologist to confirm clinical phenotype and genetic diagnosis. median age of patients was months (range, to months), and median body weight was . kg (range, . to kg). all patients received a ≤ / hla alleles-mismatched cord blood unit, were hla fully matched, were / matched, were / matched and were / matched. median nucleated cells of the cord blood were . x /kg (range, . to . x /kg), and median cd + cells were . x /kg (range, . to . x /kg). results: median follow-up time was months (range, to months), the overall survival rate at year for all patients was . %, and was . %, . % and % for cgd, scid and il- rad, respectively. patients died, most deaths ( / , . %) occurred in + days after transplantation, the main cause of death was infection ( / , . %). / ( . %) patients engrafted, median time of neutrophil engraftment was days (range, to d), and median time of platelet engraftment was days (range, to d). the cumulative incidence of grade - acute gvhd was . %, and that of chronic gvhd was . %. conclusions: unrelated ucbt should be considered for pid patients without an hla -matched sibling donor. effective control of infection before and after transplantation is important for improving survival. disclosure background: dedicator of cytokinesis (dock ) deficiency causes a combined immune deficiency characterised by recurrent bacterial infections, susceptibility to viral infection, eczema, food allergies, vasculitis and increased risk of malignancy. due to the high morbidity and mortality of the disease hsct has been increasingly offered to patients as a potentially curative therapy . methods: we retrospectively reviewed the outcomes of hsct for patients with dock deficiency at great north children's hospital newcastle upon tyne between and ( in published reference). results: ten patients with dock deficiency were treated with hsct (median age . y range . - . y). median duration of follow up was . years (range . - . y). there were a range of donor sources ( msd, mud and tcr ab/cd + depleted haploidentical), conditioning regimens ( treo-flu, treo-flu-thiotepa) and serotherapy ( alemtuzumab, atg+rituximab, none). one patient who received a cd + tcr alpha beta/cd + depleted haploidentical transplant received add back t-cells with caspacide molecular safety switch (bellicum pharmaceuticals). skin only agvhd occurred in / patients ( x stage , x stage ). no patients had cgvhd. overall survival was % ( / ). survival was comparable regardless of donor source. all deaths occurred within months of transplant. the patients who died had significant burden of disease pre-transplant: patient had chronic liver failure secondary to cryptosporidial sclerosing cholangitis, had a cirrhotic liver secondary to cryptosporidium, cerebral vasculitis, an axillary aneurysm and aortic vasculitis requiring grafting of an ascending aortic aneurysm, was pn dependent for failure to thrive with a history of cryptosporidium infection and had candida in a bal pre-transplant. causes of death in these patients were: respiratory failure (n= ), progressive encephalopathy (n= ), multi-organ failure with septic shock and encephalopathy (n= ) and multiorgan failure and septic shock after treatment for tma (n= ). two of these patients had reactivation of cryptosporidium prior to their death. pretransplant cryptosporidium was associated with mortality (graph ). one patient who survived had suffered from stroke pretransplant. one suffered from a basilar artery aneurysm years post-transplant at yo. at the time of latest follow up donor chimerism was % in / survivors and high level mixed in the other( % cd , % cd and % cd ). conclusions: this single centre study of hsct for patients is consistent with literature indicating that hsct is a potentially curative therapy for patients with dock deficiency. the increased morbidity associated with cryptosporidial infection is likely to be a consequence of overall disease burden rather than an infection specific effect. this does however highlight the improved outcomes of transplant prior to development of multiple comorbidities and suggests that hsct should be considered early. it is unclear whether the late occurrence of vascular complications after transplant were caused by a manifestation of disease which is not corrected by transplant or a result of vascular injury sustained pre-transplant. reference methods: referred infants underwent testing for: immune phenotype (ab, gd, naïve and memory t cell, b cell and nk cell numbers); functional activity of t and nk cells; maternal engraftment; adenosine deaminase (ada) and purine nucleoside phosphorylase (pnp) enzyme activity; and genetic testing. those with a confirmed diagnosis of scid underwent either allogeneic hematopoietic stem cell transplant (hct) or (if eligible) gene therapy (gt). infants identified as having ada deficiency as the etiology of their scid received enzyme replacement therapy prior to proceeding to definitive therapy. results: twenty-three ( %) infants were confirmed to have scid. three ( %) of these infants had a family history of scid but would not have been identified without nbs. in addition, one infant, born prematurely at weeks, was diagnosed as having pnp deficiency only after developing infections. this infant was identified by nbs but repeat testing at weeks gestation was normal likely due to support of transient t cell production from exogenous enzyme provided by red cell transfusion. twelve infants with confirmed low trecs had a non-scid diagnosis: with transient lymphopenia of infancy who normalized trec, immune phenotype and function, with prenatal exposure to -mecaptopurine ( -mp), genetically confirmed with digeorge syndrome, and with prolonged lymphopenia. of the three with prolonged lymphopenia, two had recurrent infections: one ultimately diagnosed with ataxia telangiectasia and one with absent trec but near normal number of t cells, normal pha but no specific antigen responses, and absent b cells who will be undergoing transplant in the near future. the third continues with absent trec, short telomeres, low numbers of a/b t cells, presence of g/d t cells, vaccine responses and freedom from infection with no identified genetic etiology. in summary, % of the patients referred to msk with confirmed abnormal nbs for scid have a non-scid diagnosis. there is no uniform collection of data for these infants and the threshold trigger for repeat testing varies from state to state, so the incidence of significant non-scid disorders identified will also likely vary from state to state. although our institution specific experience is biased, as most infants had confirmation of a low number of trec prior to referral, the significant number of disorders in the non-scid cohort emphasizes the importance of full evaluations and follow-up for these infants. disclosure: none of these relate to the work being presented. susan prockop -research funding mesoblast and atara biotherapeutics. nancy kernan -research funding jaz pharmaceuticals. richard o´reilly research funding and royalties atara biotherapeutics. kevin curran consulting juno pharmaceuticals, novartis. j.j. boelens avrobio, magenta, chimerix and bluebird bio background: post-transplant autoimmune cytopenia (aic) is challenging and associated with substantial morbidity and mortality. we aimed to study the cumulative incidence (ci) of post-hct autoimmune cytopenia (aic) and its predictors in a cohort of children with primary immunodeficiency (pid). methods: in this retrospective study, we included children with pid who underwent their first hsct with fludarabine(f)-treosulfan(t)±thiotepa(thio) at great north children's hospital from - . main outcomes of interest were the ci of aic and its predictors. fine-and-grey regression models were used to analyse predictors of aic, considering death as a competing event. variables included were age at transplant (< . years vs > . years), gender, diagnosis (scid vs immune-dysregulatory disorders vs other pids), pre-transplant aic, pre-and posttransplant respiratory virus, donor (mfd vs mud vs mmfd/mmud vs haploidentical donor), abo incompatibility, conditioning (ft vs ftthio), serotherapy (none vs alemtuzumab . - . mg/kg vs alemtuzumab . - . mg/kg vs atg), stem cell source (marrow vs pbsc vs cord vs exvivo t depleted pbsc), infused stem cell doses (tnc, cd and cd ), agvhd (none vs any agvhd), cgvhd (none vs any cgvhd), viral infections (cmv/adenovirus/ ebv/hhv viraemia), chimerism (full vs mixed chimerism (wb < %) within first year post-hct). impact of thymopoiesis using naïve t cell recovery was studied. results: median age at transplant was . years (range, . - . years). primary diagnoses were scid ( %), immune-dysregulatory disorders ( %) and other pids ( %). donors were mfd ( %), mud ( %), mmfd/ mmud ( %) and haploidentical parents ( %). stem cell sources were marrow ( %), unmanipulated pbsc ( %), ex-vivo t-depleted pbsc ( %) and cb ( %). % received additional thiotepa and % had csa/mmf as gvhd prophylaxis. median duration of follow-up of survivors was . years (range . to . years). -year os for the entire cohort was %. -month and -year ci of aic were % and %. of developed aic, ( %) had aiha, ( %) had aiha±itp and ( %) had aiha ±itp±ain. median onset of aic was . months post-hct (range . - . months). patients were treated with a median of treatment modalities (range, - ). one ( %) had steroid, ( %) had steroid+high-dose-ivig, ( %) had steroid+high-dose-ivig+rituximab, ( %) had steroid +high-dose-ivig+sirolimus and ( %) had steroid +high-dose-ivig+rituximab+sirolimus. the median time to resolution in ( %) who achieved remission after first aic was . months (range . - . months). had one relapse and had two relapses. died after development of aic ( aspergillus pneumonia; multi-organ failure). of ( %) surviving patients after aic, had on-going aiha at median of follow-up . years post-hct (range . - . years). on univariate completing-risk analysis, age at transplant > . years (p= . ) and pre-transplant aic (p= . ) were associated with higher incidence of aic (figure a -ic). on fine-and-grey models, only age at transplant (hr . , %ci . - . , p= . ) was independently associated with aic. of with complete immune reconstitution data, naïve t cells > cells/ml at months post-hct was associated lower incidence of aic (hr . , %ci . - . , p= . ) (figure d) conclusions: younger age and thymopoiesis were associated lower incidence of aic in children with pid after hct clinical background: human heme-oxygenase- (ho- ) deficiency has been reported to present with tetrad of anemia, nephritis, inflammation and asplenia and is fatal if not treated. its an auto-inflammatory disorder. macrophages/ monocytes express ho- and are engaged in recycling of red cells. human ho- deficiency results in intravascular hemolysis and severe damage to the endothelial system, kidneys, and other organs. transplantation of either healthy wild type macrophages or new macrophages produced by sct from healthy donor has been proven to be curative for ho- deficiency in mice. in , we had reported first successful allogeneic sct for human ho- deficiency. here we report second successful non-myeloablative msd hsct for a child with ho- deficiency. methods: a -yr-old-girl presented with complaints of fever, anemia and severe hypertension. in the past, at the age of years she was admitted for high fever for month and needed blood transfusion for the first time for severe anemia and had high platelets and high ferritin. she was treated as macrophage activation syndrome with prednisolone alone and later cyclosporine was added. she had short stature, abnormal facies but normal development. hemoglobin g/dl, urine for haemoglobin was positive, platelets , /ul, ferritin mcg/l and urine albumin + and urine rbc - /hpf. ultrasound and ct scan abdomen showed asplenia. a diagnosis of ho- deficiency was suspected. mutation analysis showed homozygous missense mutations in exon (r x) on chromosome q , which would result in the absence of the functional ho- protein. both parents were carriers of this mutation. we managed her over next -years with prednisolone, hydroxyurea and mycophenolate mofetil (mmf). however she remained steroid dependent. hla-typing confirmed her healthy unaffected -year-old brother to be a fully matched donor. at the age of years she was taken up for msd sct after taking informed consent. she weighed just kg. we conditioned her with alemtuzumab- . mg/kg, fludarabine- mg/m , cyclophospamide- mg/kg and total body irradiation gray. we infused million/kg peripheral blood stem cells from her brother. graft-vs.-host disease (gvhd) prophylaxis consisted of tacrolimus & mmf. results: she tolerated procedure very well. her entire hospital stay was uneventful and lowest platelet count recorded was , /ul. her neutrophils engrafted on day + and she was discharged on day+ . his urine albumin was nil by day+ . she had no gvhd. her chimerism on day+ showed % donor cells, on day+ was % and on day+ was % donor. now he is day+ post-sct and doing well. she has no evidence of hemolysis, proteinuria, hypertension, fever. she has normal ferritin and platelets. she has gained cm height and kg weight in last months. she had no viral reactivation and her immune recovery at months post sct is good. conclusions: non-myeoablative allogeneic msd sct is a curative treatment option for human ho- deficiency. disclosure: nil two decades of excellent transplant survival in children with chronic granulomatous disease: a report from a supraregional immunology transplant centre in europe background: haematopoietic stem cell transplantation (hsct) confers life-long curative therapy for chronic granulomatous disease (cgd). the ability of donor-derived neutrophils to replace recipient's defective neutrophils makes hsct a superior therapy compared to conventional standard of care using antimicrobial therapy. methods: we examined the outcome of children with cgd who received a first hsct at great north children's hospital from to . outcomes included overall survival (os), event-free survival (es), toxicity endpoints, autoimmune disease, long-term survival and graft function. cox proportional-hazard models were used to analyse predictors of os and es. variables included for predictor analysis were age at transplant, donor, stem cell source, stem cell doses and conditioning. results: = children were included in this analysis. median age of transplant was . years (range, . - . years). ( %) had x-linked and ( %) autosomal recessive cgd. twenty ( %) had matched family donor, ( %) had unrelated donor and ( %) had parental haploidentical donor. prior to , various conditioning regimens were used, with ( %) patients undergoing conditioning with pharmacokinetic guided intravenous (iv) busulfan (bu) and iv cyclophosphamide with or without serotherapy. from , the conditioning regimen was switched to flu-treosulfan-alemtuzumab with gvhd prophylaxis using ciclosporin (csa) and mycophenolate mofetil (mmf) for family and unrelated donors (n= , %). flu-treosulfan-thiotepa-atg-rituximab was used for cd tcr alpha-beta cd depleted haploidentical grafts (n= , %). ten ( %) patients had grade ii-iv acute gvhd while had ( %) had grade iii-iv acute gvhd. none had chronic gvhd. the -year os for the entire cohort was % ( % ci, - %) (figure ). analysis by age at transplant revealed a -year os of % for children transplanted at < = years of age and % ( %ci, - %) for the children > years of age (p< . ) (figure ) . the os was comparable between match family donor ( %, % ci, - %) and unrelated donor transplant ( %, - %) ( figure ). all four haploidentical transplants were successful. the -year es for the entire cohort was % ( % ci - %). none of the variables was associated with es. all seven patients with slipping chimerism received a successful second transplant. the five deaths were all due to transplantrelated complications ( multi-organ failures; pulmonary haemorrhage; graft iv acute gvhd; post-transplant lymphoproliferative disease). the median age at transplant of deceased patients was . years (range . to years). the -year and -year cumulative incidence of autoimmune diseases were % and % respectively. three ( %) had immune cytopenia while ( %) had autoimmune endocrinopathy ( thyroid dysfunction; type diabetes mellitus). the median age of long-term survivors was years (range, to years) with the median duration of follow-up of . years (range, . to . years). there was no late death in the entire cohort. the median donor myeloid chimerism was % (range to %) conclusions: despite the limitations of a single centre study, our findings confirm that hsct is a safe and longlasting curative therapy for children with cgd disclosure: none non -medical challenges in the diagnosis and transplantation of patients with primary immune deficiency: an experience from a tertiary care center in india sagar bhattad , stalin ramprakash , raghuram cp , chetan ginigeri , fulvio porta , background: primary immune deficiencies (pid) are increasingly being recognized in several parts of india. despite being diagnosed, many patients fail to receive optimal care due to financial and social constraints. methods: case records of patients diagnosed and treated (including hematopoietic stem cell transplants) for pid diseases during feb -nov at aster cmi hospital, bangalore, india were analysed. factors leading to deferred or suboptimal care were assessed in detail. results: patients with various pids were diagnosed during the study period (details in table). of them warranted a hematopoietic stem cell transplant (hsct) as definitive curative treatment. a total of children received hsct. of them died while of them are alive and well. children ( with severe combined immune deficiency) died before a hsct could be carried out. of them were critically ill at presentation, while were stable but deferred further treatment citing financial and social constraints. children needing transplant continue to remain on follow-up and have not been transplanted to date ( of them have significant financial constraints, families are not convinced about the need for transplant and of them are being prepared for transplant). table: (scid -severe combined immune deficiency, vodi-veno-occlusive disease with immunodeficiency, cgd -chronic granulomatous disease, hlh -hemophagolymphohistiocytosis, was -wiskott aldrich syndrome, xlt -x linked thrombocytopenia, lad-leukocyte adhesion deficiency, msmd -mendelian susceptibility to mycobacterial disease, xla -x linked agammaglobulinemia, cvid -common variable immune deficiency, apeced -autoimmune polyendocrinopathy candidiasis ectodermal dystrophy, cmcc -chronic mucocutaneous candidiasis, at -ataxia telangiectasia). conclusions: we present our experience from a developing country and discuss non-medical factors leading to suboptimal care in children with pid. only % children warranting hsct could be transplanted in our cohort. among those where hsct is potentially curative % of children died before hsct could be offered. transplants in developing countries pose unique challenges due to the absence of government funding and/or universal insurance coverage. in addition to delay in diagnosis and critical state of patients at admission, financial and social factors significantly contributed to poor outcome. disclosure: none the outcome of hematopoietic stem cell transplantation (hsct) in pediatric patients with hemophagocytic lymphohistiocytosis (hlh) in korea methods: the korea histiocytosis working party retrospectively collected nation-wide data from the patients diagnosed with hlh and underwent allogeneic hsct between and . the clinical characteristics and treatment outcomes of the patients were analyzed. results: a total of patients were enrolled. there were patients with fhl ( fhl , fhl , and fhl ), infection associated hlh, and secondary hlh of unknown cause. all the patients were treated with hlh- protocol, and patients achieved complete response (cr) after treatment for weeks, while did not. the main reasons for receiving transplantation were fhl in , reactivation in , and refractory disease in . the conditioning regimens were busulfan-based in patients, fludarabine-based in , treosulfan-based in , and busulfan/fludarabine-based in . stem cell sources used for hsct were from peripheral blood in patient, cord blood in , and bone marrow in . the donor types of hsct were unrelated donor in patients and related in ( matched sibling donor, haploidentical donor, partially matched donor). the causes of death of patients were disease reactivation/ progression in , acute gvhd with/without vod in , and graft failure in . five year overall survival rates were . %, respectively. the disease status at the time of hsct was cr in patients, and non-cr in . the -year survival rate of patients who received hsct in cr was % and % for patients transplanted while in non-cr status (p= . ). patients who received hsct using peripheral blood stem cells had a better -year survival rate of % compared to % of patients who received cord blood stem cells, significantly. the presence of neurologic symptoms, disease status after intial week therapy, conditioning regimen, and cd positive cell count did not have statistically significant impact on survival. conclusions: hsct improved the survival of patients who had familial, or relapsed, or refractory hlh in the korean nation-wide hlh registry. these results are similar to other reports in the literature. the disease status at the time of hsct and the stem cell source of the transplant were the important prognostic factors that affected the survivals of the hlh patients who underwent hsct. clinical trial registry: no registry number. disclosure: to the best of our knowledge, the named authors have no conflict of interest, financial or otherwise p hematopoietic cell transplantation with reduced intensity conditioning regimen using fludarabine/ busulfan and fludarabine/melphalan for primary immunodeficiency diseases background: primary immunodeficiency disease (pid) is congenital disorders of innate or acquired immune system. hematopoietic cell transplantation (hct) was a treatment option for pids with life-threatening infections or immune dysregulations. reduced intensity conditioning (ric) was increasingly used to prevent complications in hct, but optimized regimens have not been established. we performed hct for pids with ric using fludarabine and busulfan (flubu) or melphalan (flumel) according to the guidelines of european society for immunodeficiencies (esid) / european society for blood and marrow transplantation (ebmt), and assessed the efficacy and safety of these ric. methods: from april to december , pid patients underwent ric-hct using flubu or flumel in tmdu were analyzed retrospectively. the auc of bu was set to mg*hour/l for severe combined immunodeficiency disease (scid) and mg*hour/l for non-scid. overall survival (os) was analyzed. results: the median age at hct was . ( . - ) years old ( male and female patients). flubu was used for patients ( scid, combined immunodeficiency disease (cid), ectodermal dysplasia (eda), and severe congenital neutropenia (scn)) and flumel was used for patients ( scid, cid, xiap deficiency, and eda). anti-thymocyte globulin was used in patients of flubu group and patients of flumel group. cord blood in and bone marrow in was used for donor sources. matched donor was used for and patients in flubu and flumel groups ( . % and . %), respectively. median follow up period was . years. two years-os of all patients, flubu group patients and flumel group patients was . %, . % and . %, respectively. neutrophil engraftment was . %, . % and . % (all patients, flubu group and flumel group). in scid, all patients in flubu group achieved engraftment and survived. seven out of in flumel group achieved engraftment, but patient had secondary graft failure and patients died. in non-scid, out of in flubu group achieved engraftment, but patients had secondary graft failure. all non-scid patients in flumel group were engrafted and survived. two and patients in flubu group and flumel group suffered from severe acute graft-versus-host disease (grade iii-iv). ten patients had hemophagocytic lymphohistiocytosis (hlh). viral reactivation or infection was observed in patients, and resolved in all but one patient. conclusions: the ric-hct using flubu or flumel was advantagous for neutrophil engraftment, and flubu for scid and flumel for cid with immune dysregulation may be an effective opinion. flubu regimen needs to be improved for secondary graft failure in non-scid. prevention of hlh after transplantation using dexamethasone palmitate will be considered. disclosure: nothing to declare. survival after hematopoietic stem cell transplantation with tcrαβ/cd graft depletion in older children with primary immunodeficiencies background: tcrαβ/cd depletion is a graft engineering method that proved valuable in increasing the survival rate after hematopoietic stem cell transplantation (hsct) in patients with primary immunodeficiencies (pid). decreased survival rate in older patients with pid was previously reported after transplantations with nonmanipulated grafts. methods: patients with various pid (excluding classic scid) who received allogenic hsct with tcrαβ/ cd graft depletion from to september in our center were analyzed. the median age at hsct was , years (range , - , ). patients were divided into age groups: - years - patients, - years - , - years - . patients received hsct from matched unrelated, -haploidentical donors, -siblings. conditioning regimens with - alkylating agents and antithymocyte globulin were used in all patients. patient received short courses of various posttransplant immunosuppressants. median follow up after hsct is , years (range , - , years). results: overall survival (os) in patients was , ( % ci , - , ). we observed similar os in the younger age groups: , ( % ci , - , ) in - years and , ( % ci , - , ) in - years of age. seven of patients in older group ( - years of age) died, the os was only , ( % ci , - , ), p= , . all patients from older age group who died had combined pid: -wiscott-aldrich syndrome, -undefined pid, -il rg deficiency, -dclre c deficiency, -nijmegen breakage syndrome (nbs), -kabuki syndrome, -icf syndrome. the median time of death after hsct was , years (range , - , ). six of those had transplant-related mortality (trm). five patients had hsct-associated viral infections: -cmv pneumonias, -adv infections ( -fulminant hepatitis, -multiorgan). interestingly, of them had prolonged history of disseminated viral infections (adv), with the reduction of viral load in blood and other fluids and tissues upon treatment. one patient with kabuki syndrome after hsct developed hhv associated kaposi sarcoma, was successfully treated. eventually all patients with reduction of viral infection and sarcoma symptoms developed multiorgan failure with some clinical and laboratory evidences of endothelium cell damage syndrome. one patient with nbs died of high grade lymphoma progression. conclusions: hsct with tcrαβ/cd depletion demonstrates high survival rate in patients with various pid. in our group patients' age older than years predisposes to decreased posttransplant survival. patients with combined pid are at higher risks of posttransplant mortality. we conclude that at least in some of our patients with prolonged history of viral infections after hsct the cause of death could be multiorgan failure due to endothelium cell damage syndrome resulting from persistent inflammation and drug toxicity effects. disclosure background: chronic granulomatous disease (cgd) is a primary immunodeficiency (pid) caused by a mutation in of the subunits of the nicotinamide dinucleotide phosphate (nadph) oxidase, which leads to a reduction in the microbicidal activity of phagocytic cell. starting at an early age, cgd patients suffer from severe recurrent infections, as well as inflammatory events. allogeneic hematopoietic stem cell transplantation (hsct) is a curative option for cgd in patients with insufficient benefit from supportive care and prophylactic antibiotics. we reported a series of patients with cgd who underwent unrelated umbilical cord blood transplantation (ucbt) at our center. methods: in this retrospective study, we observed a series of consecutive ucbt performed at our center in children with cgd between and .median age at transplantation was months (range, to months), median body weight was kg (range, to kg). / patients received a myeloablative conditioning regimen consisting of busulfan, fludarabine, cytarabine, cyclophosphamide and g-csf, / patients received another myeloablative conditioning regimen consisting of busulfan, fludarabine, cyclophosphamide and atg. prophylaxis for graft-versus-host disease (gvhd) was tacrolimus. results: engraftment occurred in / ( . %) patients. / ( . %) patients occurred graft failure, all of them received a myeloablative conditioning regimen without atg. median time to neutrophil and platelet engraftment were (rang, - ) and . (rang, - ) days. / ( . %) patients developed acute gvhd, with / ( . %) episodes of grade iii-iv agvhd. chronic gvhd occurred in / patients ( . %). at a median follow-up of months (rang, to months), the overall survival rate was . %, and event-free survival rate was . %. conclusions: unrelated ucbt should be considered as potential curative methods in children with cgd. cgd patients who used myeloablative conditioning regimen with atg shows better graft and survival. disclosure: nothing to declare background: invasive fungal infections (ifi) remain a major cause of treatment-related morbidity and mortality in aml patients. although not uncommon, the presentation of unusually severe clinical features might be indicative for an underlying immunodeficiency. caspase-associated recruitment domain (card ) is recognized to have a crucial role in effective antifungal response, leading to th and th differentiation and to the initiation of the inflammatory cytokine cascade. particularly interferon-gamma (ifng) increases macrophage activity. patients with homozygous card mutations are known to have a significantly increased susceptibility to life-threatening systemic candidiasis. however, some sequence variants may lead to increased ifi-susceptibility even in heterozygosity, e.g. under immunosuppression. ifn-γ has been described as an additive treatment option because of its immune stimulating effect on the leukocyte immune response in a situation of immunological "blindness". methods: here, we report the case of an -year old male with aml m with a severe systemic candida tropicalis infection, unresponsive to triple-antimycotic regimen, leading to multi-organ failure. he was discovered to bear a heterozygous card mutation, and ifn-γ immunotherapy leaded to complete response of all disseminated infections. results: the patient developed septic fever immediately after the first chemotherapy cycle. unexpectedly, candida tropicalis was confirmed in the blood culture within hours. liposomal amphotericin b (ambisome ® ) was started immediately, however candida rapidly disseminated to lungs, liver, spleen, kidneys and cns despite extended antimycotic therapy with caspofungin, voriconazole and fluconazole. the patient was splenectomized due to massive infiltration ( figure ). genetic testing for mycosis predisposition revealed a heterozygous mutation in the card gene, inherited from the father (c. a>t(p.glu val)). ifn-γ treatment was started ( μg subcutaneously, times per week), leading to an almost complete response of disseminated infections. due to the severe infection, chemotherapy had to be interrupted after one course. however, bone marrow remained in complete remission for almost one year. the patient experienced altogether two relapses requiring an unrelated allogeneic and a haploidentical hsct. under combined ifn-γ and ambisome/ fluconazole prophylaxis no further mycosis was observed despite extensive and prolonged immunosuppression. conclusions: ifi in aml patients are common, however an unusual presentation in presumably immune competent individuals should raise the suspicion for immunodeficiencies. in our case, an unexpected early candida-sepsis was completely unresponsive to an adequate multi-agent treatment. while ifn-γ is used in adults as an immune stimulatory cytokine, little data are available for children. to our knowledge, this is the first case of successful ifn-γ treatment of a pediatric aml patient with disseminated candida sepsis, bearing a card mutation. given the elevated mortality risk for ifi, and the apparently safe and well-tolerated application of ifn-γ, an adjuvant immunotherapy might be considered. further studies are needed to define the indication and duration of this kind of adjunctive immunotherapy. moreover, considering the wide heterogeneity of genetic mutations involved in ifi-susceptibility, genome-wide expression profiling might be useful for pediatric cancer patients, as the identification of specific immune pathways might help to identify individual ifisusceptibility in order to improve the outcome of those high-risk patients. [[p image] . background: chronic granulomatous disease (cgd) is curable by allogeneic hematopoetic stem cell transplant (hsct). recent reports of haploidentical donor hsct with with post transplant cyclophosphamide (ptcy) from family donors in pediatric primary immune deficiencies have shown encouraging results. however, it has not been reported in cgd. here we describe successful haploidentical hsct in a child with cgd with myeloablative conditioning and ptcy. a year-old, male child diagnosed with cgd showed oxidative activity . % by dihydrorhodamine (dhr) test. he had no matched related or unrelated donor available so underwent haploidentical hsct after taking informed consent of the parents in may . donor was his / hla matched healthy elder sister (oxidative activity % by dhr). he has had multiple admissions for recurrent pneumonia prior to hsct. the conditioning was with rituximab mg/m iv on day - , thiotepa mg/ kg/dose intravenous (iv) for day (day- ), busulfan . mg/kg/dose daily iv for days (day - to - ) and fludarabine mg/m /dose daily iv for days (day - to - ) and rabbit anti-thymoglubulin (thymoglobulin) . mg/ kg/dose daily for days (day- to - ). peripheral blood stem cells ( million/kg cd + cells) were harvested from his sister and transfused to the patient on day . graft vs. host disease (gvhd) prophylaxis was with ptcy mg/ kg on day+ & , intravenous cyclosporine from day- (targeting levels - ng/ml) and mmf from day+ . results: his neutrophils engrafted on day+ and platelets on day+ . chimerism on day+ , and months was fully donor. he developed no acute or chronic gvhd. at months his lymphocyte counts showed cd - /ul, cd - /ul, cd - /ul and cd / - /ul. his had no viral reactivation. he is disease free and gvhd free on day+ post hsct and is on tapering doses of cyclosporine. his dhr test showed oxidative activity of % on day + . background: primary immune deficiencies (pid) are a functional disorder of inheritance immune system that increase predisposition to infectious disease in number and severity. the incidence is : , birth live; its immunological dysregulation may increase the predisposition of autoimmune diseases and malignancy, the latter being more frequent ( - %). at present, the only curative treatment is hematopoietic stem cells transplant (hsct). methods: we describe all patients transplanted with primary immune deficiencies at instituto nacional de pediatria. the conditioning regimen depended on the type donor and pathology: myeloablative ( . %), reduced intensity ( . %) and non myeloablative ( . %) without modification statistically significantly in overall survival. results: a total of patients were included from to january/ . severe combined immunodeficiency (scid) is the pathology most frequently transplanted ( figure ) . seventy three percent have molecular diagnosis, and . % have cases of family pid. the most used sources were umbilical cord blood (ucb) with . % and peripheral blood ( . %), however the trend of the source of obtaining it has been modified a few years ago (figure ) . the median graft was days for ucb, days for bone marrow (bm) and days for peripheral blood (pb) (figure ) the main complications are infectious (bacterial . % and viral . %) and non-infectious as pre-graft syndrome ( . %). conclusions: the overall survival was . % survival according to pathology was: % chediak higashi syndrome, % scid, . % griselli syndrome, . % hyper igm syndrome, % was, % cgd, % hemophagocytic lymphohistiocytosis. disclosure: ramírez-uribe rosa maria nideshda, salazar-rosales haydeé, olaya-vargas alberto, lópez-hernández gerardo, del campo-martínez maria de los Àngeles we wish to confirm that there are no known conflicts of interest associated with this abstact, the only financial support was provided by mexican associations that helping children wiht cancer in a few patients. long-term outcome following hematopoietic stem cell transplantation of wiskott-aldrich syndrome in a single institute mamoru honda , , yukayo terashita , minako sugiyama , yuko cho , akihiro iguchi background: wiskott-aldrich syndrome (was) is an xlinked disorder of hematopoietic cells, characterized by thrombocytopenia with small platelets, eczema, and immunodeficiency. hematopoietic stem cell transplantation (hsct) is the only curative treatment, and it is recommended to be performed as soon as was is diagnosed. myeloablative conditioning before hsct is recommended because there is a high risk of development of autoimmune disease in patients with mixed chimera after hsct. however, there are few reports about late complications such as pubertal development and eruption of teeth in patients with was receiving hsct. thus, we evaluated late complications in patients with was receiving hsct at hokkaido university hospital. methods: we reviewed medical records of male patients with was who received hsct between and . results: mean age at hsct was . (range, . - . ) years, and median follow-up time after hsct was . (range . - . ) years. conditioning regimen in all patients comprised busulfan at mg/kg for days and cyclophosphamide at mg/kg for days or mg/kg for days. additionally, anti-thymocyte globulin at . mg/kg/day for - days was administered in patients. engraftment, normal platelet count, and complete chimera were confirmed in all patients. no patients showed complications such as severe chronic graft-versus-host disease, autoimmune disease, short stature (≤ - . sd) and second malignancy. however, high ige level was observed in patients. pubertal development has been confirmed in patients. lack of complete eruption of permanent teeth has been observed in patients who received hsct at age of < years. conclusions: although this was a small-cohort study in a single institute, complete chimera has been achieved in all patients who received hsct with busulfan-based myeloablative conditioning. however, late complications such as male infertility and incomplete eruption of permanent teeth remain major problems. disclosure: nothing to declare methods: we performed unrelated umbilical cord blood transplantation (ucbt) in consecutive children with lad-i. median age of children was months (range, to months), and median body weight was kg (range, to . kg). all patients received myeloablative conditioning regimen consisting of busulfan, fludarabine and cytarabine. prophylaxis for graft-versus-host disease (gvhd) was tacrolimus. all patients received a ≤ hla alleles-mismatched cord unit, was hla fully matched, were / matched, was / matched. median nucleated cells of the cord blood were . x /kg (range, . to . x /kg), and median cd + cells were . x / kg (range, . to . x /kg). results: all patients engrafted, median time of neutrophil engraftment was days (range, to d), and median time of platelet engraftment was days (range, to d). median follow-up time was months (range, to months), all patients were alive with continuous completely donor engraftment, and achieved complete clinical remissions. / patients developed grade ii/iii acute graft-versus-host disease (gvhd), and / patients developed chronic gvhd with skin. conclusions: it is the first successful unrelated ubct for lad-i children in china. our data shows ucbt provided excellent outcome for patients with lad-i. disclosure: nothing to declare p excellent outcome using 'nktm' enriched hematopoietic stem cell transplants for patients with inborn errors of immunity results: majority of patients in the cohorts had significant infective co-morbidities at the time of hsct with patients in the later cohort entering hsct earlier. patients in the later cohort were sicker at hsct. final engraftment occurred in all except patient who received a hla mis-matched cord blood hsct. graft failures occurred in patients ( in earlier and in later cohort); of these patients received unmanipulated hscts from hla mis-matched unrelated donors ( cb, bm). second hsct were with same donors in and different donors in patients. no grade ii to iv acute gvhd or extensive gvhd occurred. one patient (cbt) died of infections/ non-engraftment. all patients in the later cohort compared to of patients in earlier cohort are alive, engrafted and cured. performance status were % in all alive patients. of the patients in the later cohort, ( hla mis-matched related and hla matched related donors) received 'nktm' enriched hsct. in the hla mis-matched 'nktm' enriched hscts, patients received high cd +, cd +cd ro+ and nk cell doses, with median of . (range, . - . ), . (range, . - . ) and . (range, - ) x /kg, respectively. no invasive infections occurred in these patients and immune reconstitution in t, b, nk compartments were complete at year after hsct with cd > by months and tcrαb > by year after hsct. background: viral infections contribute to significant morbidity and mortality after allogeneic hematopoietic cell transplantation (allo-hsct), increasing both the human and the financial cost. antiviral agents are often ineffective or/ and associated with toxicity. methods: in view of t-cell anti-viral immunotherapy in greece, we evaluated the actual cost of conventional pharmacotherapy for cmv, ebv and bkv reactivations after allo-hsct, by calculating the costs of (i) the antiviral agents, (ii) the treatment (excluding transfusions) of antiviral drug primary toxicity (e.g. graft failure, cytopenias, renal or hepatic dysfunction) and secondary toxicity (e.g. leukopenia-associated bacterial infections), iii) the treatment (excluding transfusions, ie for bk cystitis) of infectionrelated complications, iv) the transfusions due to treatmentrelated toxicity (ie cytopenias) or infection-related complications (ie, bk cystitis), v) the inpatient or outpatient daily care. notwithstanding that blood and its products, as a common natural good, are provided free in our country, the costs related to blood and platelet collection, processing, storage, laboratory testing and infusions were included in our model. results: the treatment cost of cmv, ebv and bkv reactivations/infections for the first six months post allo-hsct was evaluated in / patients who reactivated viruses and were transplanted between / - / from matched related ( / ), matched unrelated ( / ), mismatched unrelated ( / ), haploidentical ( / ) and mismatched related donors ( / ). we detected cmv, ebv and bkv infections/reactivations in , and patients respectively, with a mean of ± . infection per patient from all three viruses ( - /patient). of note, / patients experienced reactivations from more than one virus, requiring repeated treatments with antiviral agents and/or rituximab. the cost of antiviral agents for all cmv, ebv and bkv reactivations/infections was , €, , € and , € respectively ( , €, , € and , €/patient, respectively). the treatment cost of toxicity related to antiviral drugs and infection-related complications was , € ( , €/patient) excluding transfusions and , € ( , €/patient) including transfusions. in particular, the cost of transfusions for bkv hemorrhagic cystitis reached , €/patient. repeated ( - ) and/or prolonged (Δm d, range - d) hospitalizations were needed, up to a total of and days of inpatient hospitalization and short-term outpatient treatment, respectively. hospitalizations further increased the cost of inpatient and outpatient post-transplant care by , € and , € respectively ( , € and €/patient, respectively), onthe basis of a, rather underestimating the true cost, fixed, unified hospitalization fee ( €/day and €/day). conclusions: overall, in a six-month study period, the treatment of cmv, ebv and bkv infections substantially increased the cost of post-transplant care by , € ( , €/patient). the actual cost is undoubtedly higher as the hospitalization fee for transplant recipients is largely underestimated in greece. considering not only the hematopoietic but also the solid organ transplant recipients, the financial burden of antiviral treatment for national economies is enormous. given that antiviral pharmacotherapy is often associated with suboptimal efficacy, toxicity, development of drug resistance, reactivation recurrences and repeated hospitalizations, it is expected that a one-time treatment with multi-virus-specific t cells, able to expand in vivo and provide a long-lasting protection without significant toxicity, will serve as a powerful and costeffective treatment over conventional pharmacotherapy. disclosure: nothing to declare methods: this is a single-centre retrospective analysis of consecutive patients who underwent tcd allo-hscts for myeloid malignancies between january -june . ebv-dna was monitored frequently on whole blood samples with standardised quantitative real-time pcr. serum protein electrophoresis was routinely tested with immunoglobulin subclasses identified by immunofixation electrophoresis. histological confirmation of ptld was based on standard who diagnostic criteria ('proven'), while those without biopsy were classed as 'probable' based on clinical & radiological criteria as defined by ecil- guidelines. results: majority of patients had aml(n- / ) and mds(n- / ) with a median age of years(range . median follow up of survivors was months(range - ). majority of patients(n- / ; %) developed ebv-r with a median time of days[inter quartile range(iqr) - days] &higher cumulative incidence with atg(n- ) versus alemtuzumab(n- )(p< . ). figure- a shows schematic representation of ebv and ptld events (cumulative incidence of . %( %ci- . %- . %) at months). significantly higher peak ebv dna viral load(evl) were noted in patients with ptld(p-< . ). development of post-hsct mg was observed in %(n- / ). roc curve identified peak blood evl> , copies/ml significantly correlated with risk of developing ptld (sensitivity- . %,specificity- . %;auc- . ,p< . ). based on these estimates, subgroup of patients with no ebv-r(n- / ), peak evl < , (< k)copies/ ml(n- / ) & > , (> k)copies/ml(n- / ) were categorised in groups along patients with/without mg accordingly (groups - ;figure- b). patients with ebv-r had significantly better os [ -year os of % vs %(no ebv-r);log-rank p< . ],with this survival benefit mainly driven by subgroup of patients with lower evl(< k)(p< . ). ptld patients had trend towards inferior -year os( % vs %;p- . ). patients with mg had a significantly better os irrespective of degree of evl (group - ,p< . ).we report a 'sweet spot' of low evl & presence of mg in these patients, with a clear survival advantage compared to those with no ebv-r and/or no mprotein (group- -year os % vs % in group- ; hr- . ; %ci: . - . ;p< . ;figure b). overall cumulative incidence of relapse (cir) was %( %ci: - ) and non-relapse-mortality(nrm) of %( %ci: . - ) at years. multivariate analysis(mva) revealed absence of m-protein,high evl (> k copies/ml) or no ebv-r and absence of any gvhd as significant factors for high cir. similarly, high evl or no ebv-r, absence of m-protein and itu admission were significant predictors of high nrm. conclusions: this study adds to our understanding of role of ebv viraemia & associated mg in tcd-hscts while highlighting its significant impact on risk of ptld, os, nrm & cir. low ebv burden and development of mg is protective with significantly better survival outcomes and we recommend pre-emptive approach of using rituximab for ebv-r /ptld is best employed at higher ebv burden (e.g. > k copies/ml dna) in high risk patients and be prospectively evaluated in future studies. clinical trial registry: n/a disclosure: nothing to declare p impact of early candidemia on the long-term outcome of allogeneic hematopoietic stem cell transplant in non leukemic patients: an outcome analysis on behalf of idwp background: to assess the incidence of, and risk factors for, candida infection in the first days post-allogeneic hematopoietic stem cell transplantation (hsct) and the impact on long-term survival. methods: outcome analysis of , patients, % male, median age years (range - ), with diagnosis of hemoglobinopathies in ( . %), bone marrow failure in ( . %), lymphoma in ( . %) and myelodysplastic/myeloproliferative disesases in ( . %) patients who underwent hsct from to : with candidemia by day + , and , without candidemia. the incidence of -day candidemia was estimated by using the cumulative incidence method. the univariate and multivariate risk factor analysis for -day candidemia was performed with the cause-specific cox regression model. the occurrence of candidemia was analyzed as a timedependent covariate. the overall survival and non-relapse mortality after day + were assessed in a land-mark setting, this analysis was restricted to patients surviving to day + post transplant. [[p image] . figure a - b] results: the incidence of candidemia by day + was . % ( % c.i. . - . ) ( / , ) and occurred at a median of days post-hsct (range - - ). considering the candidemia within -day from hsct as a time dependent covariate, a higher -day non-relapsemortality (nrm) (hr . ( . - . ), p < . ), and a lower -day overall-survival (os) (hr . , % ci . - . ), p< . ) were obtained from the cox model for patients with candidemia. factors significantly associated with candidemia occurrence in the multivariate analysis were: gender female, increased age at hsct, bone marrow failure, lymphoma or myelodysplastic/myeloproliferative diagnosis, bone marrow or cord blood stem cell source, t-cell depletion, less recent year of hsct. among patients alive at day + , the -year nrm and os with and without candidemia were . % vs. . %, p < . , and . % vs. . %, p< . , respectively, after a median follow-up of . years ( % ci . - . ) (figure ). in multivariate analysis, the occurrence of a candidemia episode within day + was an independent risk factor for higher nrm, hr . ( . - . ), p= . , and lower os, hr . ( . - . ), p= . . conclusions: despite the general improvements in prophylaxis and treatment, the occurrence of early post-hsct candidemia had a negative impact on transplant outcome as showed previously in leukemic patients. abstract already published. carbapenem-resistant enterobacteriaceae colonizationimportance in the risk of cre bacteremia and mortality in stem cell transplant (hsct) and acute leukemia patients marcia garnica , , marco a f bellizze , priscila g a de jesus , rafaela r c gomes , filipe m akamine , alan j marçal , luzinete co rangel , andreia assis , marcia rejane valentim , angelo maiolino background: spread of infections due to carbapenemresistant enterobacteriaceae (cre) is a worldwide phenomenon and has been associated with high mortality and clinical complications. gut translocation is the most important portal of entry of bacteria during neutropenia, and cre gut colonization is a possible risk factor for bacteremia during neutropenia. goals: in the present study, we describe the frequencies of cre colonization and analyzed its relationship with development of cre bacteremia and mortality in two different scenarios: stem cell transplant patients (hsct) and leukemia patients. methods: prospective cohorts of hsct (from to ) and leukemia patients (from to ). hsct patients were analyzed from conditioning until discharge (pre-engraphment phase) and leukemia patients from first induction chemotherapy until last intensification. if an hsct was performed in leukemia patient the patient was censored in leukemia cohort and included in hsct cohort. all patients had rectal swabs performed weekly during hospitalization for the identification of cre colonization. patients with at least one positive swab (cre colonization group) were compared to patients with no documentation of colonization (controls). the outcomes analyzed were bacteremia due to cre, and overall mortality. results: there were hsct performed during the study ( [ %] autologous and [ %] allogeneic). multiple myeloma and non-hodgkin lymphoma were the most frequent baseline diseases (n= ; %, and n = ; %), respectively. cre colonization was documented in % (n= ), and it was more frequent among allogeneic hsct and leukemia patients (p< . for both). cre colonized patients had longer hospitalization ( vs. days, p< , ), higher frequency of cre bacteremia ( % vs. . %; p= . ), and mortality ( % vs. . %, p< , ) compared to non-colonized hsct. negative and positive predicted values for cre bacteremia were % and %, respectively. thirty-one patients were analyzed in leukemia cohort, accounting to hospitalizations (median hospitalizations per patient, ranging from to ). the median age was years, and % aml vs. % all. cre colonization was documented in eight ( %), with a median time from leukemia diagnosis and colonization of days ( - days). cre bacteremia was documented only in colonized patients ( % vs. zero; p= , ). all eight colonized patients were submitted to other cycles of chemotherapy after colonization, in one of them cre bacteremia relapsed. conclusions: a routine surveillance of cre colonization showed colonization frequencies from % to % in hsct and leukemia patients respectively and was effective to stratify cre bacteremia risk as the predictive negative value was over %. colonization had association with cre bacteremia and overall mortality. efforts to minimize risks for colonization and mortality are necessary. the information of surveillance can be a tool to improve adequacy in empirical febrile neutropenia therapy in hsct and leukemia patients. disclosure: nothing to declare background: the incidence of hepatitis b virus infection is high to . % in asian population, so there is more and more attention to the risk of hepatitis b virus(hbv) reactivation in the hepatitis b core antibody positive patients during chemotherapy, anti-cd monoclonal antibody, hsct, or other intense immunosuppressive drug therapy (isdt). hepatitis b core antibody is associated with a significant risk of hbv reactivation in patients undergoing hsct. however, there are remain uncertain that the effect of anti-hbsag antibodies in hepatitis b virus reactivation among the hepatitis b core antibody positive patients undergo hsct. we aim to investigate the role of the anti-hbs and the necessity of anti virus in hepatitis b surface antigen(hbsag) negative, hepatitis b core antibody positive patients during hsct. methods: we enrolled hematological malignant patients received hsct in our center from to . we classified hbsag negative and undetectable hbv dna patients into groups as anti-hbc(-)anti-hbs(-) (n= ), anti-hbc(-)anti-hbs(+) (n= ), anti-hbc(+) anti-hbs(-) (n= ), and anti-hbc(+)anti-hbs(+) (n= ). results: hbv reactivation was identified in patients ( . %) after hsct. there was a significant difference in hbv reactivation rate in anti-hbc(+)anti-hbs(-) ( . %) vs anti-hbc(+)anti-hbs(+) ( . %) (p= . ) and anti-hbc (+)anti-hbs(-) ( . %) vs anti-hbc(-)anti-hbs(-) ( . %) (p= . ), anti-hbc(+)anti-hbs(-) ( . %) vs anti-hbc(-) anti-hbs(+) ( . %) (p= . ), but not among anti-hbc(+) anti-hbs(+) ( . %) and anti-hbc(-)anti-hbs(-) ( %) and anti-hbc(-)anti-hbs(+) ( . %). whereas there were no difference according to the donor viral profile(p= . ). the median time of hbv reactivation in hbsag negative patients accepted hsct was ( - ) days after hsct. all of the patients with hbv reactivation have been controlled with nucleos(t)ide analogues drugs, and of them achieved reverse seroconversion which detect persistent anti-hbsag antibodies in their bodies. conclusions: the anti-hbsag antibodies negative and anti-hbc positive patients have the highest risk of hbv reactivation after hsct in resolved hbv patients. the anti-hbsag antibodies play a protective role in resolved hbv patients receiving hsct. we recommend not prophylactic anti hepatitis b virus in hbsag negativity and anti-hbsag antibodies positive patients following hematopoietic stem cell transplantation. disclosure: nothing to declare methods: allo-hscts performed between and for acquired bone marrow failure ( . %) or hemoglobinopathies ( . %), with bm±cb ( . %) or pb±cb+bm ( . %) as a stem cell source were included in this retrospective registry megafile idwp ebmt study. results: demographics: the median age of recipient was . years (range: . - ), and . % were children. . % recipients and . % donors were ebv-seropositive. . % had hsct from a matched family donor, . % from a mismatched family donor, and . % from an unrelated donor. t-cell depletion was performed in vivo in . %, and ex vivo in . % patients. conditioning regimen was myeloablative in . %, ric in . %. median follow-up was . years ( % c.i. . - . ). transplant out-comes: ebv-seropositive recipients in comparison to ebv-seronegative recipients had lower os ( . % vs . %, p= . ), and higher nrm ( . % vs . %, p= . ). no other significant differences were found for: ri, rfs, and acute or chronic gvhd with respect to ebv pretransplant serostatus donor and/or recipient. multi-variate analysis: ebv serostatus as a risk factor did not reach significance, while a trend towards higher risk of development of cgvhd (hr= . ; %ci . - . ; p= . ) and better survival (hr= . ; %ci . - . ; p= . ) in allo-hsct from ebv-seropositive donors. allo-hsct in ebv-seropositive recipients had a trend towards lower risk of development of cgvhd (hr= . ; %ci . - . ; p= . ). when subgroups (r-/d-, r-/ d+, r+/d-, r+/d+ ebv serology) were analyzed, the ebv serostatus had no significant impact on os, rfs, ri, trm and development of acute or chronic gvhd. conclusions: allo-hsct from ebv-seropositive vs ebv-seronegative donors are at % higher risk of chronic gvhd in patients with non-malignant hematological disorders undergoing allo-hsct, however this difference is non-significant in multivariate analysis. disclosure: nothing to declare. results: twenty-eight ( %) pts ( male, female) were tested positive (group ) for subtype a (n= , %), b (n= , %) or a (h n ) (n= , %) while ( %) pts ( male, female) were negative (group ). vaccination rate in group ( %) was significantly lower compared to group ( %, p= . ). the median time after transplantation ( vs days), t-cell counts ( vs / μl), bcell counts ( vs / μl), igg-level ( , vs , g/ l), proportion of immunosuppressed pts ( % vs %), male/ female ratio was not significantly different between groups and . within group influenza subtypes were similarly distributed in vaccinated and not vaccinated pts (a % vs %, b % vs %, a (h n ) % vs %). pts. with subtype b infection had higher levels of t-( vs / μl) and b-cells ( vs / μl) and a longer follow up from sct ( vs days) compared to subtype a / a (h n ) infection but differences were not significant. conclusions: influenza could be proven in one third of all tested pts. dominance of b and a (h n ) pdm e subtype occurrence corresponded to the flu epidemic dissemination in the german population. the most important protective factor for outpatient sct recipients was influenza vaccination. disclosure: nothing to declare background: cmv infection is one of the most frequent complications after haplo. some risk factors are well known but the best strategy (prophylactic or preemptive treatment) to mitigate this complication is not still well defined. the primary endpoint in our study is to describe incidence and risk factors to develop cmv infection or disease in haplo. as secondary objective we analyzed efficacytoxicity of treatment and cmv related mortality. methods: we analyzed patients who underwent haplo in our center between may and may . all of them received ptcy (d+ and d+ ), tacrolimus and mycophenolate as graft versus host disease prophylaxis. a preemptive therapy based on viral load was applied. treatment was started when > ui/ml of cmv were detected in one determination or > ui/ml in two consecutive determinations. cmv analyses were made in plasma using cobas pcr technique® and positive viral load cut-off point was ui/ml. the cmv viremia was determined weekly until d+ and then every two weeks until immune reconstitution. results: the cmv infection and disease incidence at d + was . % ( episodes) and . % ( episodes), respectively. cmv disease was digestive (n= ), pulmonar (n= ), neurologic (n= ) and disseminated (n= ). the median time to first cmv infection was . days ( - ). thirty-six patients had at least one episode of cmv infection: of them ( . %) had one episode, ( . %) had two episodes and ( . %) had or more episodes, respectively. only pre-transplantation cmv status was significantly associated with cmv infection (p< . ). risk factors are shown in image . the median viral load in first cmv infection and disease was ui/ml ( - ) and ui/ml ( - ), respectively (p= . ).the median counts of cd lymphocytes at d+ in cmv infection and disease were /mm and /mm , respectively (p= . ). preemptive therapy for the first episodes of cmv infections (n= ) was valganciclovir ( , %), ganciclovir ( . %) or foscarnet ( . %), reaching a complete viral load clearance in %, with a median time to response of . days ( - ) and a median treatment duration of days ( - ). grade iii-iv toxicity (mainly hematologic) was observed in . % (n= ), % (n= ) and . % (n= ), respectively. three patients had an ul mutation, one of them with clinical and microbiological resistance to the mentioned drugs. three patients ( %) had a graft failure secondary to cmv infections. five patients ( . %) died as consequence of cmv infection: before d+ secondary to cmv disease ( pulmonar, disseminated) and after d+ due to graft failure and infectious complications. with a median follow up of . months, overall survival at months for patients who had cmv infection was . % compared to . % for those who had no infection (p= . ). conclusions: a high incidence of cmv infection in haplo with ptcy was shown in our series and it contributed to mortality in . % of patients. only cmv status (d-/r+ and d+/r+) was significantly associated with higher risk of infection. identification of high risk patients and new prophylactic and treatment strategies may improve these results. disclosure: nothing to declare. methods: consecutive patients admitted at the sct unit between january- to november- were reviewed. only first admission was analysed. screening consisted of rectal and perineal swap on admission and weekly until discharge. in case of detection of mdro, patients were isolated and infection control strategies were applied. results: patients were analysed, median age years ( - ). % were male (n= ). median duration of hospitalization was days( - ). swabs were performed, with a median of swaps/patient ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . patient characteristics are shown in table . patients ( %) spiked fever in a median of days after admission . % (n= ) had previous documented mdro colonization. median neutrophil engraftment was days ( %ci - ), in % patients (n= ) of patients had a positive screen: in ( %) patients at baseline and in ( %) patients were detected for the first time beyond baseline screen. cumulative incidence of colonization at days was . % ( %ci . - . ), at days % ( %ci . - . ), and at days . % ( . - . %) (figure ). mdro identified were: with extended-spectrum beta-lactamases producing e. coli (esbl-ec), multidrug-resistant pseudomonas aeruginosa (mr-ps), vancomycin resistant enterococci (vre) and patient with carbapenemaseproducing (cp) citrobacter freundii. / colonized patients developed mdro infection ( %): patients mr-ps, site of infection was urinary tract infection (uti), urethritis, genital ulcer. two patients were treated with ceftolozane/ tazobactam, with meropenem+amikacin; patients esbl-ec both uti treated with meropenem; patient cpcitrobacter freundii uti treated with ceftazidime/avibactam. in % patients ( / ) antibiotic treatment at febrile episode was guided by positive screening. no mdro related icu admission or mortality was observed. in % patients (n= ) background: hepatitis e virus (hev) can cause chronic infection and liver cirrhosis in immunocompromised individuals. there is limited data on hev infections in patients undergoing allogeneic hematopoietic stem cell transplantation (hsct). the aim of this study was to investigate the frequency and clinical importance of hev in a swedish cohort of hsct recipients. methods: we analyzed serum samples from hsct patients ( adults and children), collected months after hsct. hev igg and igm were detected by elisa (dia.pro®), hev rna by reverse transcriptase pcr, and quantification of hev rna was performed by digital pcr. in all patients, who were positive for hev-rna and/or serology at months, also samples collected at the time of hsct from both the patients and their donors were analyzed. in the hev rna positive patients, additional samples were analyzed to determine the duration of viremia. three hev rna negative controls were selected for each case of hev infection, matched for age, diagnosis, conditioning regimen and donor type. results: hev rna was detected in / ( . %) patients. in three of the patients hev rna was positive during a period of - months, and two of these patients were infected already at the time of hsct. in five patients hev-rna was positive, at a low level, only at months. / ( . %) patients had detectable hev igg and/or igm, whereof eight patients were hev rna negative. in / ( %) patients with hev infection (hev rna positive) alanine aminotransferase (alt) was > upper limit of normal (uln), in / ( . %) patients > . uln, and in / ( . %) patients alt was normal, at months after hsct. bilirubin was elevated > . uln in / ( . %) patients, and > uln in no patient at months after hsct. two patients died with ongoing signs of hepatitis and hev rna detected in blood. one of them developed acute liver failure, at the time interpreted as drug toxicity, and died of multi-organ failure. the other patient died of unrelated causes. the remaining six patients had cleared the infection at - (median . ) months after hsct. active gvhd was present at months after hsct in / ( . %) patients with hev infection, involving the liver in of these patients. corticosteroid treatment was ongoing in / ( %) patients; the mean dose during the preceding days was > . mg/kg in / ( . %) patient, . - . mg/ kg in / ( . %) patients, and < . mg/kg in / ( %) patients. hev infection correlated to elevated alt > . uln, or . p= . ) and > uln, p= . ) at months, but not at months, after hsct, compared to hev rna negative controls. conclusions: hev infection was detected in . % of patients tested at months after hsct and was correlated to abnormal alt. spontaneous clearance was common but one patient died in acute liver failure, where hev may have contributed. hev infection is a differential diagnosis in patients with elevated alt months after hsct. disclosure: nothing to declare monitoring of t-cell responses to viral-coded antigens in pediatric patients receiving tcrαβ-depleted haplo-hsct followed by bpx- cell administration background: αβ t-cell-depleted haplo-hsct is an effective option for children with hematological disorders in need of an allograft. however, recovery of adaptive immunity is impaired in these patients. thus, in order to accelerate immune reconstitution, we developed a novel approach based on post-transplant infusion of a titrated number of donor t cells, transduced with the suicide gene inducible-caspase- , ic (bpx- cells, sponsor bellicum pharmaceuticals®; nct ). we previously reported on immune recovery of children transplanted at our institution, showing that bpx- cells infused after αβ t-cell-depleted haplo-hsct expand in-vivo and persist over time, contributing to fasten adaptive immunity recovery (merli, ash ). here, we report the results of lymphoproliferation assay to viral-encoded antigens to assess tcell function in patients transplanted with this approach. methods: we evaluated children, male and female. median age at transplant was . years (range . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . patients had either malignant ( children) and nonmalignant ( ) disorders. no patient was given any posttransplant graft-versus-host disease prophylaxis. nine children were enrolled in the phase i portion of the trial consisting of cohorts receiving escalating doses of bpx- cells. the remaining patients (phase ii portion) received the recommended dose of x bpx- cells/kg identified in phase i. bpx- cells were infused at a median of days post-hsct (range - ). antigendriven activation of peripheral mononuclear cells was evaluated by lymphoproliferation assay with h-thymidine pulsing at d+ and harvesting at d+ . stimuli included pha or cmv, ebv and adv whole viral lysate. results are given as stimulation indexes (si, cpm stimulated sample/cpm unstimulated control). thresholds for positive response were arbitrarily set at si> for viral-encoded antigens and at si> for mitogenic stimulation with pha. fractions of responders are indicated in the figure. results: patients were analyzed from d+ to d+ post-hsct. pha responders (a) increased to %, while cmv (b), ebv (c) and adv (d) responders were %, % and % at years after haplo-hsct. responses to ebv and adv antigens were slightly delayed but improved over time. responses to pha and to cmv (e,f) were analyzed in the cmv-reactivating and cmv-non reactivating groups (cmv-yes/cmv-no). significant differences in pha response were observed at d+ and d+ . moreover, increased cmv responses were observed in cmvreactivators at d+ , d+ and d+ , with approximately % of responders at d+ , as opposed to cmvnon reactivators which comprised % responders. neither primary disease, age nor tbi during the conditioning regimen influenced proliferative capacity of the two subgroups (not shown). conclusions: we showed a rapid recovery over time of t-cell function after αβ t-cell-depleted haplo-hsct followed by bpx- cells administration. when patients were grouped according to cmv reactivation (previously demonstrated as a strong driver of immune reconstitution), a significant difference in the number of responders among the patients experiencing viral reactivation was observed using the cmv lysate only but not the immunodominant pp protein (not shown), suggesting that other viral antigens account for increased t-cell responses. results of t-cell function after bpx administration complements the phenotypic data we already reported. clinical trial registry: nct disclosure: nothing to declare. background: cytomegalovirus (cmv) is associated with significant morbidity and mortality in allogeneic hematopoietic cell transplantation (allo-hct) patients (pts). cumulative incidence of cmv infection in high-risk patients such as cd -selected or haploidentical hct have been reported as high as . - . % and - %, respectively. letermovir (ltv) was approved in / for prophylaxis (ppx) in cmv-seropositive recipients (r+) of allo-hct. since / , ltv ppx was implemented at our center for both primary and secondary ppx. we report our real-world experience. methods: adult cmv r+ allo-hct pts who initiated ltv as primary and/or secondary prophylaxis were identified between / / and / / . cord blood transplants were excluded. the primary outcome was the incidence of clinically significant cmv infection (cmv viremia requiring preemptive treatment or cmv disease). pts were followed through / . results: pts initiated ltv. . % pts were at high risk for cmv reactivation and disease (primarily ex vivo t-cell depleted hct [n = ; %] or haploidentical t-replete hct [n = ; . %]). the most common indication for hct was acute myeloid leukemia (n = ; . %) and the majority of patients received myeloablative conditioning (n = ; . %). pts ( . %) received ltv as primary ppx after hct, with a median day of ltv initiation of d+ (range d+ ─d+ ). at ltv initiation, pts had an undetectable cmv dna, and had cmv < iu/ml. clinically significant cmv infection requiring preemptive treatment occurred in of pts ( . %). one patient was treated with valganciclovir (vgv) for persistent cmv < iu/ml and received ltv as secondary ppx. a nd patient developed persistently detectable cmv (< iu/ ml) and breakthrough cmv viremia with a mutation in ul at site c yltv successfully treated with vgv. the median duration of primary ltv ppx was days ( - ), with primary ppx continuing beyond weeks post hct in pts. the median additional follow-up in patients who discontinued ltv was days ( - ), without clinically significant cmv infection to date. an additional pts ( pts overall; . %) received ltv as secondary ppx after cmv pre-emptive therapy. the median duration of secondary ltv ppx was days ( - ), with no reactivation. ltv was not discontinued due to toxicity or intolerance in any patient. cmv outcomes are summarized in figure . all-cause mortality for the pts over the observational period was . %. conclusions: primary ltv ppx significantly reduced cmv reactivation, and high-risk patients may benefit from extended prophylaxis. in patients who received preemptive therapy for cmv, use of secondary ppx showed no recurrent cmv reactivation. ltv is well tolerated. additional studies are needed to determine optimal ppx duration and to clarify role of secondary cmv ppx in high-risk allo-hct. the future standard of care will likely include extended primary ppx and secondary ppx and result in decreased morbidity and mortality associated with cmv. disclosure: andrew lin -nothing to declare, molly a. maloy -nothing to declare, valkal bhatt -nothing to declare, lauren derespiris -nothing to declare, meagan griffin -nothing to declare carmen lau -nothing to declare, anthony j. proli -nothing to declare, juliet barker -angiocrine bioscience , letermovir primary prophylaxis (pp) has been shown to reduce clinically significant cmv infection with a favorable safety profile. letermovir pp will improve the outcome of seropositive patients. however, patients who did not benefit from pp and experienced > cmv episode (infection or disease) after hct may be candidate to secondary prophylaxis (sp). indeed half of them will have > recurrent episode after pre-emptive treatment (pet). letermovir is available since november as part of the french early access program for pp and sp. we report the outcome of patients who benefited from letermovir sp in the context of this program. methods: letermovir is granted, in a restrictive manner, by the french drug agency (ansm) on a case-by-case basis for prophylaxis of cmv episode, in cmv-seropositive adult allogeneic hct recipients. sp patients should have a negative baseline cmv pcr, have already experienced > cmv episode, in the context of a potentially harmful pet according to physicians. planned letermovir daily dose was mg in case of concomitant cyclosporine and mg otherwise. all patients were routinely screened by blood or plasma cmv pcr. results: between november -july , patients received letermovir in the early access program, for pp, and for sp. among the sp patients, had previous cmv disease (gut: ; cns: ). mean age was ± years, m/f ratio was / . the sp cohort included one cord blood and haplo-identical hct. main diagnoses were acute leukemia ( %) and myelodysplastic syndrome ( %). the conditioning regimen was myeloablative in % and included atg in %. based on available data ( missing data, md), previous gvhd was present in ( %) patients, and active at letermovir initiation in ( %). thirty two ( %) patients were planned to receive immunosuppressants. donor's cmv serology was negative in / ( %) ( md). at baseline, cmv pcr was detectable in / patients. letermovir was initiated a median of days (iqr: - ) after transplant for a mean duration of ± days. only one ( %) patient developed cmv breakthrough. the median follow-up from letermovir initiation was days. among the patients exposed to letermovir prophylaxis, two patients permanently discontinued because of letermovir-related adverse events (acute gvhd and nephropathy for one, loss of appetite, pruritus, diarrhoea and weight loss for the other); two deaths occurred with no causal relationship to letermovir. data were consistent with the known safety profile of letermovir. conclusions: letermovir is or will be soonly available in most european countries for cmv prophylaxis in hct recipients. pending its routine use, letermovir used as sp was well tolerated and effective, with only / patients developing a breakthrough infection. in this high-risk population for cmv recurrence, letermovir may provide a safe bridge between pet and specific immune reconstitution, pending tapering or discontinuation of immunosuppressants. whether sp may improve survival deserves further studies. disclosure: thierry allavoine is a former employee of msd france, nathalie benard and amir guidoum are employees of msd france, marion masure is an employee of icta pm, sophie alain and catherine cordonnier have participated in advisory boards and have been members of the speaker bureau of msd. ibrahim yacoub-agha has received honoraria from msd, other authors: nothing to declare p real-world data on letermovir prophylaxis for cytomegalovirus reactivation after allogeneic hematopoietic cell transplantation: a single center experience patrick derigs , maria-luisa schubert , paul schnitzler , carsten müller-tidow , peter dreger , michael schmitt heidelberg university hospital, heidelberg, germany, background: reactivation of cytomegalovirus (cmv) still contributes substantially to morbidity and mortality after allogeneic hematopoietic cell transplantation (allohct). recently, letermovir became available as the first drug approved in europe for prophylaxis of cmv reactivation in seropositive patients who have undergone allohct. letermovir is neither myelo-nor nephrotoxic, and significantly reduced the incidence of cmv reactivation in a pivotal phase iii trial (nejm ; : ) . therefore we adopted letermovir prophylaxis according to the label as standard policy in our institution: in seropositive recipients letermovir was initiated after engraftment and continued until day + or cmv reactivation. the aim of the present study was to investigate if the favorable trial results could be reproduced under real-world conditions. methods: the study cohort consisted of the first seropositive patients who received letermovir prophylaxis at our institution (between march and august ). these were compared with a control cohort transplanted between august and march before the advent of letermovir. study and control cohorts were matched for cmv donor/recipient sero-status, underlying disease and donor type source of stem cells and application of atg. cmv viremia was monitored by a quantitative pcr twice a week during the inpatient period and weekly thereafter. patients reactivating cmv prior to engraftment were not considered as event in both groups. results: no major side effects of letermovir intake were observed. with altogether reactivation events, the cumulative rate of cmv reactivation on day + was % ( %ci - %) in the letermovir cohort and thus significantly lower than in the control group ( events, % ( %ci - %); hr . ( . - . ); p= . ). the median time to reactivation was days for the control group and not reached for the letermovir group. the cumulative number of days on valganciclovir before d + was d for the letermovir patients vs d for the control patients. there were no hospitalizations for foscavir administration in the letermovir group compared to hospitalizations in the control group. there were deaths before d + in the letermovir group (one pd, one nrm) and deaths in the control group (all pd). conclusions: this observational study confirms the safety and efficacy of letermovir for the prophylaxis of cmv reactivation in seropositive patients after allohct in a real-world setting. our results are in good concordance with the phase iii trial. although letermovir appeared to reduce the need for therapeutic valganciclovir and foscavir tremendously, larger samples with longer follow-up are needed to assess the impact of letermovir prophylaxis on non-relapse and overall mortality as well as on resource consumption. background: cmv viremia occurs in %- % of cmv r + hct recipients. pet use has reduced the risk of cmv end-organ disease (eod) and associated mortality; however, pet use may lead to substantial antiviral use and healthcare resource utilization. limited real-world data are available on the outcomes of pet. therefore, we aimed to examine cmv outcomes (eod, resistance), cmv-related mortality by day (d) and healthcare resource utilization between pet and no-pet groups among cmv r+ recipients undergoing first hct. methods: we conducted a retrospective cohort study of adults, cmv r+ recipients of first peripheral blood or marrow allograft at mskcc identified from march through december . data was extracted from electronic medical records and hct databases. cmv+ recipients were monitored weekly by quantitative pcr assay starting on d through d post hct. use of antiviral therapy for cmv viremia defined pet. high cmv risk (hr) comprised t-cell depleted (tcd) hct by cd +-selection regardless of donor hla match or conventional hct from mismatched or haploidentical donors; low risk (lr) included conventional hct from matched related donors. cmv eod was scored by standard criteria. cmv resistance mutations were confirmed by sequencing (viracor-eurofins). length of stay (los) for hct admissions and readmissions were identified through d . stratified analyses were performed to examine outcomes by pet use and cmv risk. background: in a phase iii randomized, double-blind, placebo-controlled study of cmv-seropositive post-hsct recipients, letermovir prophylaxis significantly reduced the incidence of clinically significant cmv infection through week . the objective of this research was to assess the impact of cmv prophylaxis on rates of rehospitalization in adult cmv seropositive allogeneic hsct recipients from the letermovir phase clinical trial. methods: rehospitalization was recorded as an exploratory endpoint in the clinical trial at end of treatment (week ), time of primary endpoint (week ) and through an extended follow-up period (week ). cmv-related rehospitalization was assessed in the trial. prespecified analyses describe the observed rates of rehospitalization for the letermovir and placebo groups at the specified times. fine-gray cumulative incidence function(cif) regression models were used to explore the rate of all-cause, and cmv-related rehospitalization accounting for the competing risk of mortality. a multiple linear regression model was used to describe the cumulative length of stay (los) for all-cause rehospitalizations that occurred through week (excluding time of initial transplant stay). results: observed rates of all-cause rehospitalization were lower for the letermovir group compared to placebo at end of treatment ( . %vs. conclusions: letermovir was shown to significantly reduce the rate of clinically significant cmv infection in a placebo-controlled randomized clinical trial. these analyses suggest that there is also a reduction in the rate and cumulative days of rehospitalization. this trial was not sufficiently powered to detect differences in this exploratory endpoint. nonetheless, these data provide valuable insights into the economic burden of cmv. real world data and findings from future clinical trials are needed to better understand the nature of the association between cmv and rehospitalizations. clinical methods: all consecutive patients with hematologic disorders who received hsct at our center between january and august were included. among the evaluable patients, received levofloxacin as antibacterial prophylaxis (group a) while did not receive any fq prophylaxis (group b). baseline characteristics were similar in the two groups, except for the number of patients with advanced disease ( % in group a and % in group b, p , ). median duration of neutropenia was days (range - ) in group a and days (range - ) in group b. a positive rectal swab for carbapenem-resistant enterobacteriaceae (cre) was detected in patients in group a and patients in group b. results: overall, bsi was detected in patients ( , %), ( , %) in group a and ( , %) in group b (p= , ). the median onset of bsi was days post transplant (range - ), without significant differences between the two groups. in univariate analysis, fq prophylaxis (or , ; % ic , - , ) and bone marrow stem cell source (or , ; % ic , - , ) were significant factors associated with the risk of bsi. gramnegative bacteria accounted for , % (n= ) of bsi in group a and , % (n= ) in group b, and gram-positive bacteria for , % (n= ) of bsi in group a versus , % (n= ) in group b, without statistically significant differences (p = , ). polymicrobic bsi were , % (n= ) in group a and , % (n= ) in group b. mdrgram negative bsi were detected in patients ( %) in group a and in patients ( , %) in group b (overall, cre, esbl producing enterobacteriaceae and mdr-pseudomonas). death attributable to bsi occurred in of patients ( , %); of these patients did not receive fq prophylaxis, but of them had both a pre transplant kpc colonization and active disease at transplant. neither antibacterial prophylaxis (p = , ) nor bsi (p = , ) had a significant impact on overall survival (os). conclusions: the preliminary data of our study show that fq prophylaxis is associated with a reduced incidence of bsi, in particular gram-negative infections, with no impact on os. the limitations of our study may be the different group sizes and the retrospective nauture of the study. whether antibacterial prophylaxis should be avoided in the pre-engraftment period in still a matter of debate and needs to be evaluated in larger prospective studies. disclosure: nothing to disclose. gillen oarbeascoa , nieves dorado , , laura solan , , rebeca bailen , , pascual balsalobre , , carolina martinez-laperche , , ismael buño , , javier anguita , , jose luis diez-martin , , , mi kwon , hospital general universitario gregorio marañón, hematology, madrid, spain, instituto de investigación sanitaria gregorio marañón, madrid, spain, universidad complutense de madrid, madrid, spain background: incidence and outcome of invasive fungal infection (ifi) are not well characterized in the setting of peripheral blood, non-manipulated haploidentical stem cell transplantation with postransplant cyclophosphamide (haplosct). the aim of the study was to analyze incidence and risk factors of ifi in patients who underwent haplosct at our institution. methods: consecutive patients who underwent peripheral blood haplosct with postransplant cyclophosphamide between and at our centre were reviewed. ifi was classified according to eortc definitions. proven and probable ifi were included. results: patients´characteristics are shown in table . primary antifungal prophylaxis was performed with micafungin from day - until oral intake, followed by posaconazole until day + . patients on steroid treatment for gvhd received prophylaxis with micafungin or posaconazole. % of patients obtained neutrophil engraftment. twenty-two episodes of ifi were observed in patients: proven and probable, with a cumulative incidence of ifi of % at days. most commonly isolated organism was aspergillus spp (n= ), followed by candida spp (n= : c. kruseii and c. parapsilosis), and fusarium spp (n= ). isolated cases of inonotus spp, mucor spp and trichosporon ashii were observed. pulmonary involvement was the most frequent clinical presentation (n= ), followed by fungemia (n= : candidemia, trichosporon ashii) and skin-pulmonary involvement (n= ). among patients with lung involvement, showed probable ifi: with elevated serum galactomannan and positive galactomannan in bronchoalveolar lavage (bal). there were patients without galactomannan, one with a positive bal culture for penicillum spp and the other with an aspergillus spp. median time to ifi diagnosis was days. thirteen cases were diagnosed in the pre-engraftment period, after engraftment and cases after day + . among patients with late ifi, median time to development was days. all of them were associated with gvhd ( grade iii-iv acute gvhd and moderate/severe chronic gvhd). ifi outcome was favorable in out of the ifi. treatment was liposomal amphotericin b in cases, voriconazole in and combined treatment (amphotericin b and azole) in . there were ifi related deaths, with a cumulative incidence of ifi related death of . %. prior transplant (or . , p< . ), particularly allohsct was associated to ifi development (or . , p< . ). patients with previous allohsct presented ifi mainly from molds: aspergillus, fusarium, inonotus, trichosporon and mucor. there were also candidemia episodes. no other factors were significantly associated to ifi occurrence. conclusions: in our experience, cumulative incidence of ifi in the setting of haplosct with posttransplant cyclophosphamide was similar than observed in previous studies in allosct. having received a previous sct, especially allosct, was the most significant factor related to ifi development. this high risk population should be closely monitored and could benefit from prophylaxis with azoles. disclosure: nothing to declare. methods: rsv infection was diagnosed in nasal wash (nw) or bronchoalveolar fluid (bal) by dfa (millipore, usa) or pcr (seeplex, seegene, kor). urti and lrti were defined according to ecil- guidelines. death from all causes was assessed within days after rsv infection and was attributed to rsv if the patient had persistent or progressive rsv infection with respiratory failure at the time of death. neutropenia and lymphocytopenia were defined as an absolute neutrophil count (anc) < /ul and absolute lymphocyte count (alc) < /ul, respectively. results: median number of confirmed rsv infections per year was , ranging from to . an outbreak of rsv was detected in , possibly due to a lack of compliance with contact precautions in the unit. median patients' age was years and time to rsv infection was day (- to ). twenty-three patients (pts) had received an autologous transplantation ( . %) and were allogeneic hsct recipients ( , %). median time to engraftment was days, ranging from to days. at rsv diagnosis, pts presented with urti ( . %) and with lrti ( . ) . surprisingly, around % of the auto hsct recipients had rsv pneumonia at diagnosis. variables significantly associated with lrti at diagnosis were mud hsct (no/ yes, or . ; ci . - . ); anc < /ul (or . ; ci . - . ); alc < /ul (or . ; ci . - . ); and recent or pre-engraftment hsct (no/yes, or . ci . - . ). among the pts with urti at diagnosis, progressed to lrti ( . %). forty-four of the pts died ( . %) and mortality rate was significantly higher in pts with lrti in comparison with pts with urti ( . % versus . %, p= . ). death was attributed to rsv in of the pts who died ( %). conclusions: autologous hsct recipients are also at risk of lrti caused by rsv. risk of rsv lrti is higher in mud hsct, infection acquired pre-engraftment or early after hsct, and low neutrophil and lymphocyte counts. continued education is necessary to sustain compliance to contact precautions in hsct units. disclosure background: measles is a life-threatening infection after allogeneic hct. due to the decreased coverage of vaccination in many countries, the disease reappears, increasing the risk of outbreaks worldwide. allogeneic hct recipients have been shown to be seropositive for measles in roughly - % of the cases years after transplant. however, these data were obtained before the 's from hct populations mainly conditioned with myeloablative (ma) regimens. our aim was to assess measles immunity before considering vaccination in a cohort of hct survivors including patients conditioned with reduced intensity (ric) or non-ma regimens. methods: allogeneic hct adult recipients who had not been vaccinated for measles since hct were routinely screened for measles immunity. measles igg titers were determined with a chemiluminescence immunoassay (liaison measles igg kit, liaison xl analyser, diasorin, italy). patients were considered to be seropositive if the igg titer was > . ua/ml. risk factors for seropositivity were analyzed. qualitative variables were described as numbers (%) and compared using the chi- test or fisher exact test as appropriate. quantitative variables were described as median or mean (range) and compared using the kruskall-wallis test. ors were estimated separately for factor yielding a p-value < . in the univariate analysis using logistic regression models. results: eighty-six patients, transplanted . to years (mean: , years) ago, were included. the mean age was years (range: - ), the sex ratio m/f: , . the underlying diseases were acute leukemia: ( %), myelodysplastic syndrome: ( %), lymphoproliferative diseases: ( . %), myeloproliferative neoplasms: ( %) and non-malignant diseases : ( . %). the hct was performed from an hla-identical donor in , an unrelated donor in , and a cord-blood in . conditioning regimen were ma in ( %), ric in ( %) and non-ma in ( %) patients no patient had experienced measles or had received measles vaccination since transplant. fifty-seven of the ( %) patients were seropositive for measles. measles seropositivity was not associated with conditioning regimen, patient age at transplant, patient age at time of assessment, donor age at transplant, lymphocyte count or gammaglobulin levels, or type of transplant (hlaid. vs others) measles vaccination before transplant or previous measles before transplant. the only parameters significantly associated to seropositivity were absence of previous gvhd (any type or severity, p= , or , [ , - , ]), and absence of previous extensive chronic gvhd (or , [ , ] p , ). conclusions: sixty-seven percent of allogeneic hct are seropositive for measles at a median of years after hct before vaccination. the only risk factor strongly associated with seronegativity is extensive chronic gvhd. in patients background: cytomegalovirus (cmv) reactivation is a frequent complication after hematopoietic stem cell transplantation (hsct). extracellular vesicles (evs) have emerged as a promising new category of biological biomarkers in different scenarios, including inflammation, tissue damage, cancer and viral infections. we recently reported on the potential use of serum evs as biomarkers of agvhd (lia g. et al. leukemia ( ) , ) . here, we investigated the potential correlation of cmv reactivation with plasma evs in post-transplant cyclophosphamide (ptcy) haploidentical-hsct (haplo-hsct). methods: plasma samples were collected after mononuclear cell separation at given time-points (pre-transplant, on day , , , , , , , , , and after haplo-hsct) and evs were extracted by a protamine-based precipitation method and their concentration and dimension were characterized by nano-tracking particle analysis (nanosight). after extraction, evs were analyzed by flowcytometry (guava easycyte flow cytometer) with a panel of antibodies (cd , cd , cd , krt , cd a, cd , cd , cd , cd , cd , cd , cd , cd , and cd a). results: thirty-two patients with hematological malignancies underwent haplo-hsct between and . cmv reactivation was observed in / ( , %) and occurred at a median of (range: - ) days after transplant. preliminary analysis ( / patients) showed that cd a fluorescence (platelet-derived growth factor receptor-α or pdgfr-α), cd fluorescence (ki- antigen) and cd fluorescence (ve-cadherin) were associated with an increased risk of cmv reactivation (or . p= . ; or . p= . ; or . p= . ), whereas cd (platelet endothelial cell adhesion molecule, pecam- ) concentration level was associated with a decreased risk of cmv reactivation (or . , p= . ). all these biomarkers showed a signal change before cmv reactivation (an increase with cd a, cd and cd , a reduction with cd ). (figure ). conclusions: we observed a potential association of evs membrane proteins with cmv reactivation: cd a, cd , cd and cd . these proteins are crucial for endothelium and immune cells interaction. cmv can infect different cell types including endothelial cells (bentz gl. pnas ( ) ). moreover, cd a (pdgfr-α) has been shown to function as an entry receptor for cmv expressing gh/gl/go complex (wu y. et al. plos pathog ( ) ). we plan to implement our analysis characterizing evs contents (mirnas) and will be applied to investigate other viral reactivations (e.g. epstein barr virus and human herpes virus ). [[p image] . methods: to explore the value of cmv dna extracted from gi tissue for the diagnosis of cmv gastroenteritis, we retrospectively evaluated patients, aged - (median . years) who received allo-hct from sibling( ), matched unrelated( ) or haploidentical donors( ), after receiving myeloablative ( ) or reduced intensity conditioning( ). they all underwent endoscopy for gastrointestinal symptoms between - . cmv dna from tissue samples and parallel blood samples were measured by q-pcr. positive cmv dna on the tissue was considered cmv gi infection.cmv gi disease was proven with the identification of cmv inclusion bodies or positive immunehistochemical staining using anti-cmv antibodies. results: overall, endoscopic tests were performed ( gastro-, colonoscopies) at a median of days (iqr: ) post transplantation. symptoms included nausea, vomiting, diarrhea, abdominal pain and weight loss. cmv dna was positive in / tissue samples: median copies/ml, range: - x ^ . only half patients ( / ) had concurrent cmv viremia (plasma viral load> c/ml). cmv gi infection was not correlated to the type of transplant, acute or chronic gvhd. gi cmv disease was documented by biopsy in patients. cmv dna of the tissue, but not the plasma viral load, was a predictor of biopsy positivity (or: . , %ci: . - . , p= . ). thirty-six out of cmv dna positive patients received specific treatment for at least days. symptoms resolved in / patients ( %) and the gi viral load was not a significant factor to predict cure. gi gvhd was diagnosed in / patients, among which %( / ) with cmv dna positivity. median os was days ( %ci: - ) for patients with cmv infection, similar to those without (median os: , %ci: - days, p=ns). we studied separately endoscopies of the upper ( / ) or lower gi tract ( / ) . there was no significant relationship between cmv gastritis proven by biopsy and cmv dna levels in gastric tissue. however, the viral load of the colon was a predictor of cmv enteritis (or: . , %ci: . - , p= . ). the auroc of the q-pcr was . ( %ci: . to ), the sensitivity was . % and the specificity was . % with a cutoff value of copies/ml dna. conclusions: pathognomonic findings in the biopsy remain the gold standard for the diagnosis, especially for the upper gi tract. however, when the lower gi tract is involved, quantification of cmv viral load in the tissue may be a valuable tool to support the diagnosis. positivity of cmv dna of the gi tissue, in linearity to the cmv viremia, may guide to preemptive treatment for prevention of cmv disease . disclosure: nothing to declare background: clostridium difficile infection (cdi) is caused by cd overgrowth in antibiotic-disturbed intestinal microbiota. antibiotics targeting unselectively beneficial for t-regulatory cell formation strains of clostridiales may increase pro-inflammatory processes in the guts promoting or augmenting the development of graft vs. host disease (gvhd). the efficacy of cdi treatment has impact on the persistence of inflammation which might influence the alloreactive reactions. methods: we retrospectively and, from , prospectively analyzed the data from transplant centers concerning cdi occurrence, treatment efficacy, and gvhd development. the study included patients with hematological malignancies who underwent allogeneic hematopoietic cell transplantation (allohct) between - . results: median time to cdi was days post-allohct with detection of both toxins a and b in % of cases. disturbance of intestinal microbiome was confirmed by a % rate of colonization with multidrug-resistant bacteria (mdrb). the cdi symptoms resolved with the negative toxins after the first line treatment in . % of patients. the median time to remission and therapy duration was and days, respectively. fifteen therapeutic failures were observed after treatment with metronidazole ( ), vancomycin ( ) and a combination therapy ( ) . eleven patients responded to second line treatment. thirty-seven ( %) patients died due to infections ( ), relapses ( ) and gvhd/infections ( ). we noted recurrent cdi in cases. eight patients died with active cdi. we observed occurrence or exacerbation of gvhd in ( %) patients following cdi, including cases with gut involvement (gi-gvhd). treatment with metronidazole and failure of the first line therapy increased the development or escalation of gi-gvhd (p= . and p< . , respectively). the duration of cdi exceeding days also had impact on the gi-gvhd incidence (p= . ). conclusions: . patients colonized with mdrb are at high risk of cdi. . high mortality due to infections and/or gvhd in patients with cdi. . due to lower efficacy and harmful immunomodulatory impact, metronidazole should not be the first line treatment in cdi post-hct. . emphasis must be put on fast cdi resolution to interrupt a vicious circle of the intestinal inflammatory processes. disclosure: nothing to declare establishing optimal preemptive cytomegalovirus therapy threshold post allogeneic hct in a patient population with high prevalence of seropositive status background: preemptive therapy (pet) for cytomegalovirus (cmv) reactivation post allogeneic hematopoietic stem cell transplantation (hct) was shown to decrease the incidence of cmv disease. however, the optimal pet threshold is unknown and there are significant toxicities associated with anti-cmv therapy. at our institution, we initiate pet at cmv dna titer above copies/ml ( iu/ml). our aim was to examine the efficacy of this approach including the incidence of spontaneous clearance in a population with high prevalence of cmv seropositive status. methods: after due irb approval, patients that underwent allogeneic hct were identified and records retrospectively extracted.cmv reactivation was defined as the first detectable viral titer post hct from plasma samples whereas clearance of viremia as the first date of two negative pcr values obtained at least week apart. cmv monitoring was initiated post hct performed at least weekly during the first days and every - weeks thereafter. a high sensitivity assay abbott realtime cmv was used with detection threshold of copies/ml ( . iu/ml). analysis was computed using jmp v. . . results: a. baseline characteristics: a total of patients were identified and included with a median follow up of . ( . - . ) months. median age was ( - ) years and % were male. indication for hct was for a malignant disorder in % of cases. the majority had a matched related donor ( %) and cmv igg was positive in both donor and recipient in % of cases. myeloablative conditioning was given to ( %) and ( %) received tbi. in vivo t-cell depletion was given to ( %); atg in ( %) and alemtuzumab in ( %). b. cmv reactivation and pet: a total of ( %) patients had a positive cmv pcr with median days to reactivation post hct of ; ( %) patients had peak cmv titer < copies/ml (low titer) whereas the remaining ( %) had a peak titer ≥ copies/ml (high titer). patients with high titer were more likely to be older (p = . ), have malignant disease (p = . ), haploidentical or unrelated donor (p < . ) and higher incidence of agvhd grade ii-iv (p = . ) as shown in the table. median peak titers for the low and high groups were vs. , respectively (p < . ). ( %) patients with low titers cleared spontaneously with median time to clearance of days ( - ), ( %) received anti cmv therapy and the remaining died with active viremia (range - copies /ml) with active disease. one patient in the high titer group developed cmv disease. -year os and ci-nrm was . % vs. . % (p = . ) and % vs. . % (p = . ) in the low and high titer groups, respectively. conclusions: cmv reactivation was high in this cohort however of low titer viremia in over %. a pet threshold of copies/ml ( iu/ml) appears desirable as it was associated with spontaneous clearance in almost all patients while minimizing treatment related toxicity. validation of these observations is warranted. background: the risk of pneumocystis pneumonia often warrants antifungal prophylaxis for recipients of blood and marrow or solid organ transplantation. however, complications such as myelosuppression, nephrotoxicity, and intolerance with the existing standard, trimethoprim/sulfamethoxazole (tmp/smx), may hinder or interrupt prophylaxis. rezafungin (rzf) is a novel echinocandin in development for prevention of invasive fungal disease caused by candida, aspergillus, and pneumocystis species in blood and marrow transplant patients. rzf has a favorable safety and tolerability profile and a low risk of drug-drug interactions. furthermore, the stability and pharmacokinetics of rzf allow for once-weekly dosing and broad distribution to the lung and other target organs. rzf was shown to prevent in vitro pneumocystis biofilm formation and to reduce the viability of mature biofilms. a previous prophylactic study was conducted using a broader range of rzf doses. in the current study, the efficacy of rzf was evaluated to better understand the minimum doses necessary to prevent pneumocystis growth in a mouse model. methods: c h/hen mice were immunosuppressed (dexamethasone mg/l in acidified drinking water) and then infected intranasally with p. murina ( x / μl). given the slow growth of p. murina, test agents were administered at the same time mice were inoculated to test for prophylactic efficacy. mice received intraperitoneal injections of either vehicle (control/steroid [c/s]), tmp/ smx / mg/kg/ x/week (wk), caspofungin mg/kg once daily, or rzf mg/kg or . mg/kg once daily, x, or x/wk. after a -week dosing period, mice were sacrificed and lung homogenates were processed for analysis to quantify the nuclei (trophic) and asci (cyst) forms of pneumocystis. prophylaxis efficacy was based on reduction of organism burden compared with c/s. nuclei and asci counts were log transformed and analyzed by anova; individual groups were compared by the student-newman-keuls t test. survival rates were compared using graphpad prism v . results: all mice in the rzf groups had significantly reduced nuclei and asci burdens compared with the c/s group, and all but the lowest doses of rzf ( . mg/kg x or x/wk) worked as well as tmp/smx at reducing nuclei levels. similarly, all rzf groups except for the . mg/kg x/wk group showed reductions in asci levels comparable to that of tmp/smx. the survival rates were not statistically different between treatment groups. conclusions: rzf demonstrated potent in vivo efficacy for prophylaxis against pneumocystis in an in vivo mouse infection model at dose regimens much lower than the human equivalent phase regimen. these data support the development of rzf for the prevention of invasive fungal infections including pneumocystis pneumonia. disclosure: melanie t. cushion: research funding (cidara therapeutics) taylor sandison: employee, stockholder (cidara therapeutics) alan ashbaugh: nothing to declare. yuhua ru , , ziling zhu , , yang xu , , suning chen , , xiaowen tang background: immunocompromising period following allogeneic hematopoietic stem cell transplantation (allo-hsct) may allow opportunistic pathogens to thrive and result in fatal complications. epstein-barr virus (ebv) infects more than % of chinese population, and its reactivation after hsct is one of the major concerns due to the increased risk of ebv diseases and post-transplant lymphoproliferative disease. with the development of infection prophylaxis and supportive care after hsct, demographic data on ebv reactivation post-hsct needs to be updated. methods: we retrospectively analyzed the data of patients who received allo-hsct between july and july in the first affiliated hospital of soochow university. quantitative pcr (q-pcr) was used to monitor ebv-dna load in peripheral blood dynamically. ganciclovir (pre-hsct) followed by acyclovir was given as viral prophylaxis. the treatment protocol for ebv reactivation consisted of tapering of immunosuppressive agents, antiviral agents (including ganciclovir and sodium phosphonatel), and rituximab for persistent positive patients. results: totally cases from most of the provinces in china were enrolled (characterized in table ), among whom ebv reactivation developed in recipients. most reactivation events ( . %) occurred in the first year post-hsct, with a peak of . incidence rates per personyears at the second month. besides, more episodes of lateonset reactivation occurred in patients receiving grafts from haploidientical donors ( figure a ) . multivariate analyses revealed that the major impactors of ebv reactivation included atg as gvhd prophylaxis (p< . ), hlamismatched donor (p= . ) and the appearance of chornic gvhd (p= . ). cumulative incidence of ebv reactivation was low ( . %) among patients with no major risk factors, but increased to . %, . % or . % with , , and major risk factors, respectively ( figure b) . there was no statistical difference of overall survival between people with or without ebv reactivation (p= . ). conclusions: we concluded that there are similar ebv reactivation impactors in chinese population compared to literatures, including atg use, hla-mismatched donor and the appearance of chronic gvhd. additionally, incidences of ebv reactivation increased significantly with the accumulation of risk factors. however, ebv reactivation had no impact on overall survival in current virus management protocol. disclosure: nothing to declare background: several studies have shown loss of diversity of the gut microbiome in association with significant gut injury following hematopoietic stem cell transplantation (hsct). prolonged broad spectrum antibiotic use further promotes loss of microbiome diversity and increases the risk of intestinal colonization by multi-drug-resistant (mdr) bacteria. aims of this study were to prospectively evaluate the overall changes in gut microbiome composition after hsct and differences in patients colonized by mdr bacteria and treated with carbapenems. methods: we performed a prospective observational study evaluating the gut microbiota of hematological patients undergoing hsct, from admission (t ) through day + (t ). fecal microbiota was assessed by s amplicon-based sequencing. clinical, and microbiological data as well as fecal samples were collected every th day from admission. results: one-hundred fecal samples were analyzed. overall, we found a progressive decrease of bacterial richness from t to t , with a significant reduction of blautia, ruminococcus and dorea species, which are strictly associated with the production of short chain fatty acids (sca) (fig. ) . moreover, in the % (no. ) of patients who were colonized by esbl bacteria, we observed a significant reduction of clostridium spp and bifidobacterium species. as for antibiotic therapies, carbapenems were used as second line treatment of febrile neutropenia in % (no ) of cases, usually associated with aminoglycosides. in patients treated with meropenem, a strong decline of blautia and ruminococcus species was observed. this finding suggests a correlation between carbapenem regimens and increase of pro-inflammatory bacterial strains in the gut. conclusions: our data support the hypothesis that loss of intestinal commensals that produce short-chain fatty acids may increase dysbiosis. moreover, for the first time we report significant and progressive alterations in the composition of blautia, ruminococcus and bifidobacterium species in patients treated with meropenem and colonized by esbl bacteria, respectively. our findings offer potential modifiable targets to reduce risk of colonization by mdr bacteria and to promote a carbapenem-sparing approach in the hsct setting. clinical background: cmv is associated with significant morbidity after allogeneic hematopoietic stem cell transplantation. strategies to prevent cmv-related complications include universal prophylaxis and preemptive therapy, more widely spread. antivirals used for cmv reactivation (cmv-r) produces major toxicities and costs. rate and characterization of cmv-r after haploidentical transplantation with post-transplant cyclophosphamide (haplo pt-cy) is scarce. our goal was to analyze cmv-r rate after haplo pt-cy, outcome, complications associated to therapy, and to identify risk factors. methods: one hundred haplo pt-cy transplants using peripheral blood as stem cell source performed between and in our center have been retrospectively reviewed. gvhd prophylaxis consisted of pt-cy mg/ kg/day on days + and + , mmf and csa from day + for all cases. cmv pcr was performed in a biweekly basis during admission for transplant and treatment, and weekly thereafter. cmv-r was considered with any cmv dna level by pcr assay above copies/ml. prior four consecutive negative weekly pcrs were needed to consider a new reactivation episode. preemptive strategy was applied in all cases. data collected in relation to cmv-r included: cmv serostatus of donor/recipient (d/r), number of cmv reactivations, length of each reactivation, antiviral treatment used, need for admission to receive treatment and adverse events related to cmv reactivation and/or antiviral treatment. results: patients characteristics are summarized in table . among patients, of them with positive cmv serology, episodes of cmv-r were detected. seventysix patients ( %) had at least one cmv-r in a median of days after transplant. none of them had cmv disease or die as a consequence of cmv-r. median duration was days ( - ). valganciclovir or ganciclovir was used in episodes ( %). foscarnet was used in episodes ( %). six of the episodes occurred after initial discharge, and required re-admission for treatment, with a median length of hospitalization of days ( - ). cytopenias requiring transfusion or g-csf support occurred in episodes ( %) treated with ganciclovir or valganciclovir. three of them needed further cd + cells booster for graft rescue. mild acute renal failure and genital ulcers were found in ( %) and ( , %) events treated with foscarnet, respectively. no cases of severe renal failure were observed. serological status different than negative/negative (n/n) (p . ) and older age ( vs years, p . ) were significantly associated with cmv-r. no relationship was observed with gender, disease, donor relationship, conditioning, gvhd or cells infused. more than reactivations were more frequent among patients with grade ii-iv acute gvhd (agvhd) and moderate-severe chronic gvhd (cgvhd). conclusions: in our experience, rate of cmv-r after unmanipulated haplo pt-cy, using pbsc as stem cell source, is considerably high. a significant proportion of patients presented complications associated with cmv-r and its treatment. cmv serological status other than n/n and older age are associated with high risk of cmv-r. patients with grade ii-iv agvhd are at higher risk of multiple reactivations. this population could be benefited from primary prophylaxis, in order to decrease treatment´s complications, re-admissions and costs. disclosure: nothing to declare. impact of infectious events occurring during the first hundred days after hsct for hematological malignancy: a monocentric retrospective study over a five-year period marie-pierre ledoux , célestine simand , , karin bilger , annegret laplace , bruno lioure background: patients undergoing hematopoietic stem cells transplantation (hsct) for hematological malignancy often present with infectious events in the early stages of the procedure, some of which having a documented impact on the outcome of the graft. for instance, cytomegalovirus (cmv) has been shown by some authors to have a protecting effect against relapse, whose features remain to be elucidated. we conducted a retrospective monocentric study regarding the outcome in terms of graft versus host (gvhd), relapse and survival of consecutive patients over a period of years, whether they presented or not with an infectious event by day among the following: cmv viremia, epstein-barr virus (ebv) viremia, human herpes virus (hhv ) viremia, bk virus (bkv) viruria, bacterial bloodstream infection (bsi) or invasive fungal infection. results: a high proportion of cmv seropositive recipients underwent a viral reactivation of cmv by day of the hsct: % if the donor is seronegative and % if the donor is seropositive. we observed that cmv wasn't associated with a lower relapse rate in our cohort, and data weren't sufficient to conclude firmly, but showed a trend towards a worse acute gvhd (hazard ratio hr . , pvalue . ). no significant correlation was found for ebv viremia. occurring in % of our patients and mostly with an early timing, hhv strongly correlated with worse acute gvhd (hr . , p-value < . ) but its impact on survival was not significant. bkv ( % of our patients) and bsi ( % of our patients) both correlated with poorer outcome in terms of overall survival (logrank < . and . respectively) although not significantly associated with relapse or acute gvhd. fungal infections were too rare events to draw any conclusion. conclusions: thus, contrary to many studies, we found no protection against relapse induced by cmv, although the trend for worse acute gvhd was obvious. the mechanisms behind this discordance could include early treatment, but remain to be studied. whether hhv is a cause rather than a consequence of acute gvhd or its treatment is debated, but the correlation is strong and the sequence of events suggests hhv might act as a trigger for gvhd. the association between bkv viruria and a higher mortality is in contrast with previous observations, and the lack for association with gvhd and relapse could suggest bkv is a surrogate for poor immune recovery and therefore other causes of non-relapse mortality. in addition to the direct lethal risk of bacteriemia, bsi also are a promoter of late non-relapse mortality through indirect toxicity. through the expansion of immune effectors they promote, one could assume that infectious events play a role in gvhd and gvl, and therefore have an interference with relapse. however, the association between each infectious event and outcome remains to be clarified to guide our prophylactic and therapeutic choices by a better understanding of the bright and dark sides of infectious events. disclosure background: rezafungin (rzf) is a novel echinocandin in phase development for treatment of candidaemia and invasive candidiasis and for antifungal prophylaxis against invasive fungal diseases caused by candida, aspergillus, and pneumocystis in blood and marrow transplant patients. rzf is differentiated by stable, prolonged pharmacokinetics (pk) that allow for once-weekly dosing and a pk-pharmacodynamic (pd) profile correlating with efficacy. clinical in vivo evaluations of drug interaction potential were performed proactively to assess the risk of drug-drug interactions (ddis) with respect to the phase dose of mg once weekly and known pk exposure in healthy individuals. methods: this open-label study of healthy inpatients assessed ddis between rzf (as perpetrator) and drugs known to have interactions with cyp enzymes and transporters (probe drugs): repaglinide (cyp c ), metformin (oct/mate), rosuvastatin (bcrp/oatp), pitavastatin (oatp), caffeine (cyp a ), efavirenz (cyp b ), midazolam (cyp a ), and digoxin (p-gp), as well as tacrolimus, a drug likely to be coadministered with rzf. an initial dose of rzf mg was administered on the first dosing day, to approximate a steady state plasma concentration of multiple once-weekly -mg doses, followed by once-weekly -mg doses on days and . probe drug cocktails containing ≥ drugs were administered, once before and once after rzf administration, on a schedule designed to allow for washout between doses and to limit interactions with other probe and test drugs. samples were analysed to determine respective drug concentrations in plasma (except for tacrolimus which was in whole blood) to characterize the pk profile of each analyte. area under curve (auc) and maximum concentration (c max ) were calculated from the plasma/blood concentration-time profiles by noncompartmental analysis. ln-transformed pk parameters were statistically analysed using an analysis of variance model. the ratio of geometric least squared means between each substrate drug when administered with and without rzf and corresponding % confidence intervals (cis) were calculated for lntransformed c max and auc. results: when rzf was given concomitantly with the probe drugs, six of nine substrates (metformin, pitavastatin, caffeine, efavirenz, midazolam, and digoxin) statistically demonstrated the absence of drug-drug interaction, as their % ci were all included within the default - % noeffect boundary. three substrates had the upper (repaglinide and rosuvastatin) or lower (tacrolimus) bounds of their ci falling just outside of this range (figure ), and these changes are considered unlikely to be clinically significant. conclusions: no meaningful pk interactions were observed between rzf and drugs known to have ddis and/or likely to be coadministered with rzf. these findings provide evidence that no dose adjustment is expected when rzf is co-administered with these commonly used drugs, which stand in contrast with the ddi complications widely associated with azole antifungals. disclosure: voon ong: employee, stockholder (cidara therapeutics), michael boily: employee (altasciences), hong wong: employee (altasciences), taylor sandison: employee, stockholder (cidara therapeutics), shawn flanagan: employee, stockholder (cidara therapeutics) abstract withdrawn. background: cytomegalovirus (cmv) continues to cause morbidity following allogeneic hematopoietic stem cell transplantation (hsct). letermovir is a newly approved drug for cmv prophylaxis in cmv-seropositive allogeneic hsct recipients. however, there is a paucity of data for its efficacy in patients receiving in-vivo t-cell depletion (tcd). at weill cornell medical center, we perform in-vivo tcd with alemtuzumab for related and hla-identical unrelated transplants, and anti-thymocyte globulin for umbilical cord blood transplant supported by third party accessory cells (haplo-cord transplant).although these drugs reduce the frequency of graft-versus-host-disease (gvhd), they significantly delay t-cell immune reconstitution post hsct, and may cause higher rates of cmv reactivation. our historical rate of cmv reactivation in cmv seropositive recipients receiving high dose valacyclovir prophylaxis is approximately %. therefore, we implemented letermovir for cmv prophylaxis in february . the primary aim of this study is to determine the incidence of cmv infection (defined as cmv viremia warranting treatment or development of end-organ disease) in tcd cmv seropositive allogeneic hsct patients who received letermovir prophylaxis. methods: this is a single center, retrospective cohort study to determine the incidence of cmv infection in adult, cmv-seropositive recipients receiving letermovir prophylaxis after in vivo tcd hsct with atg or alemtuzumab for gvhd prophylaxis. all included subjects were at least days post-transplant. results: allogeneic hsct transplant recipients met inclusion criteria. median age was years, iqr [ , ] and % were male. eight ( %) had a matched related donor, six ( %) had a matched unrelated donor, and ( %) were haplo-cord transplants. their underlying malignancy and conditioning regimens are summarized in table . ( %) received atg and ( %) received alemtuzumab for gvhd prophylaxis. median follow up time for survivors is days, iqr [ , ] . the incidence of cmv infection in the first days post-transplant was % as only one patient reactivated with detectable cmv viremia. this same patient developed cmv pneumonitis with documented ul resistance, and was successfully treated with ganciclovir. the incidence of cmv infection within the first days post-transplant was % ( / patients) . six patients ( %) developed acute gvhd in the first days, and one ( %) had relapse of their malignancy. five patients ( %) died within days post-transplant, but none of these deaths were cmv related. background: infectious complications caused by endogenous adenovirus (adv) are common and associated with morbidity and mortality rates in patients after hematopoietic stem cell transplantation (hsct). adv infections occur in about % to % of hsct recipients, with significantly higher rates in pediatric patients. a better understanding of adenoviral-specific t-cells (advt) response in donors can serve as a basis to develop more effective strategies for antiviral therapy. methods: frequencies of cytomegalovirus (cmv)-and adv-specific t cells were determined by enzyme-linked immunospot (elispot) assays with adv hexon and cmvpp respectively in health donors. we used x of mononuclear cells (mnc) per well in elispot assays. all donors were divided into groups according to the number of spots per well (spw) as follows: high responders (hr) (≥ spots; n= ), low responders (lr) (> and < spots; n= ), nonresponders (nr) (≤ spots; n= ). the average spot area of adv-and cmv-specific lymphocytes was calculated by immunospot® multiplate autocount™. cd ra+ and cd ro+ t-cells were generated by immunomagnetic negative selection. hla typing for class i and ii was performed by sequence specific oligonucleotides technology. statistical analysis was performed using graphpad prism v . software. levels of significance were calculated by mann-whitney rank-sum test, expressed as p-values (p< . ). results: the median frequency per well of advts were in hr group, in lr group, in nr group. the median spw of cmv-specific t cells in donors mnc were and didn´t differ between groups. antiviral activity may depend not only on the amount of advt but also on their ability to produce ifnγ. the average spot area for advt did not differ between hr, lr and nr groups and were , , , and , mm respectively. the median of the average spot area for anti-cmv t-lymphocytes was equal to , mm . thus, the frequency of advt was lower than cmv-specific t-cells, but advt have the ability to produce more ifnγ per cell (p< . ). in order to evaluate the distribution of the advt between naive and memory t cell compartments, we evaluated response to adv in preselected cd ra+ and cd ro+ fractions of t-cells in a group of donors. the median frequency of advt in unfractionated mnc was ; the median frequency of advt in cd ra and cd ro fractions were and , respectively. the amounts of cd ra and cd ro tcells were normalized to their amounts in mnc. we evaluated the impact of hla-alleles on the anti-adv response of t-cells in different groups and found association: hla-a* with hr group (p-value= , ; rr= , ; % ci: , to , ) and hla-a* with lr group ; rr= , ; % ci: , to , ) . conclusions: in this study the frequency of donors with advt is , % which corresponds to the reported frequency of adv-seropositive people ( %) in population of russia. advt are exclusively cd ro-positive cells. the analysis of advt in potential hsct donors will allow to determine more accurately the amounts and functional activity of specific antiviral t-lymphocytes administered to patient and optimize antiviral therapy. disclosure: nothing to declare p abstract withdrawn. chemotaxis and exhaustion of γδ t cells in the allografts are associated with cmv reactivation after hematopoietic transplantation background: cytomegalovirus (cmv) reactivation and its related diseases remain the most common and serious complications in patients who underwentallogeneic hematopoietic stem cell transplantation (allohsct). we previously reported that the incidences of total and refractory cmv reactivation reached approximately % and % after haploidentical hsct. while majority of studies in the literatures focused on the adaptive cd + αβ t cellsand nk cells in anti-cmv immunity, increasing evidences highlighted the important role of γδt cells in this context. a progressive and prolonged expansion of vδ + t cells in response to cmv reactivation was observed after allohsct. the effect of vδ + t cells associated with cmv clearance has been reported in vitro and in vivo. in contrast to the reconstituted γδt cells post transplantation, whether the phenotypes of γδt subsets in allografts correlate to cmv reactivation in hsct recipients have not been documented. methods: the proportions and phenotypes of γδ t cells were detected inallografts those were unmanipulated g-csf-mobilized bone marrow (bm) and peripheral blood (pb) harvests from donors for haplohsct. bm grafts were collected by aspiration on the fourth day of g-csf treatment (filgrastim, μg/kg/day), and pb grafts were obtained on the fifth day by leukapheresis. immunophenotyping for γδ t-cell subpopulations, including the expression of cd , cd , cd , tcrγδ, tcrvδ , tcrvδ , hla-dr, nkg d, cxcr , ccr , pd , ki , ifnγ, tnfα, and il- , was performed using flow cytometry. for detection of the intracellular cytokines, bm and pb grafts were pre-stimulated with x cell stimulation cocktail ( x, ebioscience). cmv dna in the peripheral blood of recipients was routinely monitored by quantitative pcr. the association of γδ t-cell contents in allografts with cmv reactivation in haplohsct recipients was analyzed using the mann-whitney u test and spearman test. all calculations were performed using spss . statistical software. results: we found that the proportions of total γδ t cells, and vδ and vδ subsets in both bm and pb grafts for cmv+ and cmv-recipients were comparable. neither the expression of hla-dr nor nkg d in the allografts were significantly different in correlation to cmv reactivation after hsct. the productions of intracellular cytokines of γδ t subsets did not varied in bm and pb grafts for cmv+ and cmv-recipients. interestingly, the proportions of cxcr +vδ and ccr +vδ cells in bm grafts for cmv + recipients were significantly higher than those for cmvrecipients (p = . and . , respectively). meanwhile, pma-stimulated ki +vδ cells in bm grafts for cmv+ recipients were less than those for cmv-recipients (p = . ). in parallel, the concentration of pd +vδ cells in pb grafts for cmv+ recipients were significantly higher than those for cmv-recipients (p = . ). conclusions: this study is the first to connect the chemotaxis and exhaustion of γδ t cells in grafts to the risk of cmv infection after allogeneic hsct. future studies should explore how the expressions of chemokines and exhaustion marker on the effector γδ t cells in allografts facilitate cmv replication and/or dissemination in the setting of hematopoietic transplantation. disclosure: all authors do not have conflicts of interest. this study is supported by the national natural science foundation of china (grants no. and no. ) results: incidence of ic was , %: allo-hsct - % (n= ), auto-hsct - , % (n= ). the etiology: c. parapsilosis %, c. albicans %, c. krusei %, candida tropicalis %, candida dubliniensis %. the most frequent underlying diseases was acute leukemia - % (n= ). the median age was y.o. [ month - years] . the median day of onset of ic after allo-hsct was , auto-hsct - [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . febrile fever was the main clinical symptom; septic syndrome develops in % cases. antifungal therapy was with echinocandins - %, lipid ampho b - %, azoles (fluconazole, voriconazole) - %, without therapy (the early mortality) - %. overall survival (os) at days from diagnosis of invasive candidiasis was %. the central venous catheter (cvc) removal was the only factor significantly improved os ( % vs %, p= , ). conclusions: incidence of invasive candidiasis in children after hematopoietic stem cell transplantation was . %. the main etiology agent was c. parapsilosis. invasive candidiasis infections most often affect leukemia patients, developed later after allo-hsct than auto-hsct. overall survival at days from the diagnosis was %. removing of cvc improved overall survival in children with invasive candida infections after hsct. disclosure: nothing to declare background: graft versus host disease (gvhd) and virusassociated enteropathy in allogeneic hematopoietic stem cell transplantation (allo-hsct) may cause severe quantitative and qualitative composition changes of intestinal microbiota, leading to the development of small intestinal bacterial overgrowth (sibo) on the background of immunodeficiency, which can have a negative impact on treatment effectiveness. the gold standard for diagnosis and the main criterion for sibo is the detection in the jejunum aspirate > /ml bacteria and/or the appearance of colonlike microbiota in small intestine. it is also acceptable to use an alternative non-invasive technique -hydrogen breath test, which could be especially important in patients with severe mucositis, grade iii-iv and thrombocytopenia grade iv. sibo diagnosis in the setting of the gastrointestinal tract damage and dysfunction in patients treated with allo-hsct is insufficiently studied. methods: the study included patients with acute myeloid leukemia (n= ), acute lymphoblastic leukemia (n= ), myelodysplastic syndrome (n= ), non-hodgkin´s lymphoma (n= ), hurler syndrome (n= ), who underwent allo-hsct from an unrelated (n= ) and haploidentical donor (n= ) , and which were complicated by enteropathy development. in cases, the enteropathy reason was a combination of intestinal gvhd and viral colitis (hhv- ), in cases -viral colitis (hhv- ). all patients had esophagogastroduodenoscopy with species aspiration from descending part of the duodenum and feces collection, with further bacteria pcr identification. hydrogen breath test was performed also in which patients were treated with oral lactose g/kg with subsequent hydrogen assessment after and minutes. the study was performed in the period from to days after allo-hsct. results: according to feces analysis data, colon microbiota composition significantly differed from the reference values. at the same time total bacterial mass of the duodenum was less in comparison with colon microbiota: e+ ( e+ / e+ ) and e+ ( e+ / e+ ), respectively (p< . ). quantitative composition of the duodenal microbiota was comparable to that of colon: lactobacillus spp. e+ ( e+ / e+ ) > . e+ ( e+ / e+ ), (p= . ); bifidobacterium spp. e+ ( e+ / e+ ) < . e+ ( e+ / e+ ), (p= . ); escherichia coli e+ ( e+ / e+ ) > e+ ( e+ / e+ ), (p= . ); bacteroides fragilis group e+ ( e+ / e+ ) > e+ ( e+ / e + ), (p= . ); faecalibacterium prausnitzii e+ ( e+ / e+ ) < . e+ ( e+ / e+ ), (p= . ), indicating the presence of sibo. in this case, the hydrogen breath test was completely uninformative: basal values - . ( . / . ) ppm, hydrogen concentration in minutes - . ( . / . ) ppm, in minutes - . ( . / . ) ppm, which is less than in healthy volunteers. conclusions: quantitative composition of the duodenal and colon microbiota is similar in the case of intestinal gvhd and/or virus-associated enteropathy in allo-hsct patients, which may be of diagnostic value for sibo confirmation. the hydrogen breath test is an uninformative method for sibo identification in patients after allo-hsct. disclosure: nothing to declare johannes schulte , patrick hundsdörfer , sebastian voigt background: adenovirus (adv) infections or reactivations frequently occur in the pediatric hematopoietic stem cell transplant (sct) setting and these infections contribute to increased morbidity and mortality. the nucleotide analog cidofovir might be effective in reducing adv load, however, nephrotoxicity is a considerable side effect. the new antiviral compound brincidofovir (bcv, cmx- ), a lipid-conjugate nucleotide analog with broad-spectrum antiviral activity in vitro, has been reported to be effective in cases where cidofovir treatment was unsuccessful. methods: data of eight pediatric patients undergoing sct for malignant and nonmalignant indications were analyzed. all patients were weekly monitored for adv viremia by pcr. in case two consecutive positive adv pcr results indicating a viral copy number > /ml were documented, patients received a weekly dose of cidofovir. if no reduction of adv load was seen within two weeks after the commencement of treatment or side effects demanded cidofovir discontinuation, bcv was obtained through an emergency expanded access programme. results: eight pediatric patients developed adv viremia with maximum viral loads ranging between and copies/ml. six patients had c type adv and two patients had non c type adv infections. five patients had viral co-infections: two had an additional cmv infection, one had an epstein-barr virus (ebv) and herpes simplex virus co-infection, one patient had an ebv co-infection and one patient had a bk virus co-infection. all eight patients initially received cidofovir, however, a substantial decrease in adv load could not be observed in any patient after a two-week administration course. except in one patient who had extensive intestinal graft-versus host disease (gvhd), adv infection was cleared in all patients within three weeks after the beginning of bcv treatment. in addition, all coinfections were cleared. no nephrotoxicity or other side effects were observed. conclusions: bcv was effective in all but one patient. oral bcv might not be effective in advanced upper gut gvhd, especially when applied via a gastric tube, yet this was observed in only one patient. eventually, without nephrotoxic side effects, bcv could be an useful alternative to cidofovir. disclosure: nothing to declare. background: the use of post-transplant high-dose cyclophosphamide (ptcy) has overcome the need for extensive depletion of t lymphocytes from haploidentical donor grafts, which traditionally resulted in severe and prolonged immunosuppression. however, reconstitution of cellular immunity may be delayed even after t cell replete haploidentical stem cell transplantation (haplo-sct) with ptcy. the study of the incidence and severity of viral reactivation is therefore relevant to the outcomes of haplo-sct with ptcy. methods: our study enrolled patients (women/men, / ), who underwent t cell replete haplo-sct from / to / and achieved hematopoietic engraftment. median age at transplant was . years (range, - ) . the underlying disease was aml (n= ), all (n= ), mds (n= ), myelofibrosis (n= ), cml (n= ), or cll (n= ). the conditioning regimen was myeloablative (n= ), reduced-intensity (n= ) or non-myeloablative (n= ). peripheral blood was the graft source in the majority of cases (n= ) and bone marrow in the remaining (n= ). recipient/donor cytomegalovirus (cmv) serostatus was -/-(n= ), -/+ (n= ), +/-(n= ), or +/+ (n= ). the combination of tacrolimus and mycophenolate mofetil was administered in addition to ptcy for prevention of graftversus-host disease. cmv, epstein-barr virus (ebv), and human herpesvirus- (hhv- ) reactivation was monitored by real-time quantitative pcr (rq-pcr) in blood twice weekly post haplo-sct. bk virus (bkv) reactivation was assessed by rq-pcr in urine and/or blood specimens in cases with symptoms suggestive of bkv-associated hemorrhagic cystitis (hc). results: with a median follow-up time of months (range, , the cumulative incidences (cin) of relapse and non-relapse mortality (nrm) were . % ( % ci, . - . %) and . % ( % ci, . - . %) at years, respectively. median disease-free (dfs) and overall survival (os) were . % ( % ci, . - . %) and . % ( % ci, . - . %) at years, respectively. the cin of cmv reactivation/infection (> copies/ml) reached . % ( % ci, . - . %) at months. cmv infection developed in out of patients who were at risk, whereas recurrent cmv reactivation was observed in patients with a median number of episodes (range, - ) per patient. the median total duration of antiviral therapy for cmv infection was days (range, - ) . cmv disease (pneumonia) was documented in patients. the cin of ebv reactivation (> , copies/ml) was . % ( % ci, . - . %) at months. no case of ebv-related post-transplant lymphoproliferative disorder was observed, however preemptive therapy with rituximab was required in patients with rapidly increasing ebv viral load. hhv- reactivation (> , copies/ml) was observed in patients (cin, . % at months; % ci, . - . %), with none of them requiring specific therapy. bkv-related hc occurred at a cin of . % ( % ci, . - . %) at months. cystoscopy for bladder hemostasis was required in / and nephrostomy in / patients with hc. conclusions: despite preservation of non-alloreactive memory t cells, haplo-sct with ptcy is associated with substantial rates of viral reactivation (especially cmv and bkv) resulting in the need for prolonged antiviral therapy and considerable morbidity as well. therefore, strategies to prevent viral reactivation and disease are still warranted in haploidentical stem cell transplantation. disclosure: nothing to declare. background: adenovirus(adv) infections are a wellrecognised cause of morbidity and mortality in children and adults receiving an allogenic stem cell transplant(hsct).the reported incidence of adv infection is higher( %- %) in paediatric hsct than in adults( - %),but we currently lack accurate data of adv infection burden among adults.cidofovir has been extensively used as a pre-emptive anti-adenoviral therapy and is current standard of care.we present our single centre experience of adv incidence and outcomes with pre-emptive approach in adult patients receiving t-cell depleted(tcd) hscts for myeloid disorders. methods: this is a single-centre retrospective analysis of consecutive hsct patients for myeloid disorders including aml, mds, mpn & aplastic anaemia between january -june using atg or alemtuzumab based tcd.adv screening was performed in all patients with standardised real time quantitative pcr on weekly basis during standard risk period. figure a - b] results: baseline characteristics (table ) of patients were similar across both cohorts with or without adv infection. overall . %(n- / ) patients were positive for adv dna on atleast one of the sanctuary sites(upper respiratory airway,blood,faeces,urine) and %(n- / ) of these experienced disseminated infection(defined by adv in ≥ sanctuary sites or rising adv dna copies in blood), while developed typical adenoviral disease (pulmonary). among patients with disseminated infection,majority had adv in gastro-intestinal( %), . % in genitourinary and % as both sanctuary site of infection,in addition to blood viraemia( % of all cases).cumulative incidence of adv infection was . %( %ci: . - . %) at months with median time of days(iqr: - days) to detect adv-dna post hsct.overall survival(os) at years for whole cohort was %( %ci: - ;median os- months) with no statistical difference between patients with disseminated adv infection vs those with none(log rank; p- . ; fig- a ). overall cumulative incidence of non-relapse mortality (nrm) was %( %ci: - %) and relapse(cir) was . %( %ci: - %) at years,but no statistical difference noted between patients with disseminated adv infection & those with none(nrm:p- . ;cir: p- . ;gray test).pre-emptive therapy with cidofovir ( mg/kg weekly iv infusion for weeks and fortnightly thereafter until infection free) was required in %( / ) of symptomatic adv infection patients and %( / ) with disseminated infections.one patient required brincidofovir therapy for refractory disease,but one patient died due to severe sepsis, before adv specific therapy could be given.remaining patients were monitored and all self-recovered on cessation of immunosuppression.all patients treated with cidofovir developed renal impairment(defined by atleast > % increase in baseline creatinine),however majority( %) recovered their renal function near their baseline (fig- b) . conclusions: adv infection remains a significant cause of morbidity in adult hsct patients, however pre-emptive management with cidofovir has improved os and nrm despite use of tcd conditioning.renal toxicity remains common with cidofovir but with use of intermediate doses, majority do recover their renal functions. clinical trial registry: n/a disclosure: nothing to declare background: publications on invasive fungal disease (ifd) in lymphoma patients are limited especially after allo-hsct. there are no data on outcome of allo-hsct in lymphoma patients with prior ifd. this study focuses on epidemiology of ifd before and after allo-hsct in children and adults with hodgkin's lymphoma (hl). methods: single center prospective study included patients with classical r/r hl who received allo-hsct from to . the median age was ( - ) y.o., children (< yo) - %. allo-hsct from mud was performed in , % (n= ), mrd - , % (n= ), mmud - , % (n= ), haplo - , % (n= ), with ric ( %) and predominantly ptcy-based gvhd prophylaxis ( %). primary antifungal prophylaxis was fluconazole in %, secondary -voriconazole ( %). eortc/msg criteria for diagnosis and bronchoscopy before allo-hsct in pts with ct-scan lung lesions were used. "active ifd" means ifd diagnosed just before hsct. median follow-up time was months . results: incidence of ifd before allo-hsct was , % (n= ). ifd prior to hsct were invasive aspergillosis (ia) with lungs involvement. antifungal therapy before allo-hsct was used in , % pts with median duration - months. complete response to antifungal therapy was in , % pts, partial response or stabilization - , %, and , % pts had an "active ifd". after allo-hsct all pts received voriconazole as an antifungal therapy or secondary prophylaxis. cumulative incidence of relapse or progression of ia after allo-hsct was , % with the median day after hsct, which were successfully treated with voriconazole in post hsct period. incidence of ifd after allo-hsct for naïve patients was , % (n= / ). etiology of ifd after allo-hsct was ia - %, invasive candidiasis (ic) - %, mucormycosis - % and % combined ifd caused by aspergillus fumigatus + rhizopus stolonifer. the median day of onset of ifd after allo-hsct was day+ and was associated with post-hsct relapse of hl (p= , ). the main site of infection were lungs ( %), the main clinical symptom -febrile fever ( %). antifungal therapy was used in all patients: voriconazole - %, micafungin - %, posaconazole - %, lipid amphotericin b - % and combination lipid amphotericin b with caspofungin - %. overall survival (os) at weeks from the diagnosis of ifd after allo-hsct was %. the -year os in children and adult with hl after allo-hsct was , %. development of ifd after allo-hsct do not decrease the -year os rate ( , % vs %, p= , ). the impact of prior ifd on -year os in allo-hsct recipients was not statistically significant in all group ( , % vs , %, p= , ) , and separately in children and adults. conclusions: incidence of ifd in children and adults with hodgkin's lymphoma before allo-hsct was , %. incidence of ifd after allo-hsct in patients with hodgkin's lymphoma was , %. the major etiology agents as before as after allo-hsct were aspergillus spp. ifd was a late complication after allo-hsct and associated with post-hsct relapse. despite the high incidence ifd before or after allo-hsct didn't influence the outcome in children and adults with hodgkin lymphoma. disclosure: nothing to declare our community has high cmv positive serostatus, which is a known risk for cmv infection or reactivation. we conducted a study to explore the incidence and outcome of cmv infection among post-hsct children. methods: medical records of pediatric patients (age ≤ years) undergoing single allogeneic hsct from january to december , at king faisal specialist hospital and research centre, riyadh, saudi arabia, were reviewed. all patients with active cmv infection or disease before and during transplant were excluded. a total of patients were included in the study; were female. median age at hsct was years. recipient cmv serostatus was positive in patients before hsct, and donors were cmvpositive. the recipient-donor (r/d) serology was . % r +/d+, . % r+/d-, . % r-/d+, and . % r-/d-. indication for hsct was immune disorders . %, hemoglobinopathies . %, bone marrow failure . %, malignant disorders . %, histiocytic . %, and metabolic disorders . %. source of stem cells was bone marrow in , cord blood in and peripheral blood stem cell in cases. donor was matched related among , unrelated matched/mismatched in , haploidentical , and related with -antigen mismatch in . total body irradiation (tbi) based conditioning was used for patients, while atg was used in patients. results: out of a total of patients, patients developed cmv infection post-hsct ( . %). incidence in female recipients was high ( . % versus . %, p-value . ). both recipient and donor cmv serology positive ( . %) developed cmv infection (p-value < . ). however, no cmv infection in both recipient and donor negative group (r-/d-). the incidence of cmv infection post-hsct was high in patients received tbi based conditioning ( out of , . %, p-value . ), and in haploidentical transplant with . % (p-value . ). source of stem cells, myeloablative versus nonmyeloablative conditioning, atg use in conditioning and agvhd, did not exhibit significant association with cmv infection. in multivariable setting, when adjusted for primary indication for transplant, donor hla type, tbi based conditioning and recipient and donor cmv serology at transplant, haploidentical donor (odds ratio: . , p-value: . ) and donor-recipient cmv sero-positivity (odds ratio: . , p-value: . ) were found to be significant risk factors. cmv infection resolution rate was . % ( ). with a median follow-up time of . ± . months from infusion, five-year overall survival of cmv infected group was lower ( . ± . ) as compared to non-cmv infected ( . ± . , p-value: . ). conclusions: incidence of cmv infection post-hsct in our center is comparable to other centers. our data suggest that donor-recipient cmv positive serostatus, haploidentical donor, and use of tbi based conditioning necessitate close attention and surveillance. background: toxoplasmosis is a rare and underestimated complication following allogeneic stem cell transplantation (allo-sct) with an often fatal course. this is in part due to limited diagnostics relying mainly on imaging and detection of parasite dna by pcr. we present here eleven cases of toxoplasma disease following allo-sct. methods: we retrospectively analyzed consecutive adult patients who received an allo-sct in our bone marrow transplant unit between july and july . eleven ( %) of these patients were diagnosed of toxoplasma disease. the main characteristics of the patients are shown in table . all patients, except two cord blood, have received peripheral blood stem cells. fludarabine-based conditioning regimes were used in all patients. only the two cord blood patients received thymoglobulin in the conditioning. graft-versus-host disease (gvhd) prophylaxis consisted on tacrolimus plus mycophenolate mofetil in ( %) patients and post-transplant cyclophosphamide followed by tacrolimus in ( %). before the allo-sct was performed the igg/igm toxoplasma serology of the recipient and donor. we reviewed the absolute lymphocyte count (alc) and cd + lymphocyte count within four weeks prior to the diagnosis of toxoplasmosis, and if the patients took effective primary prophylaxis for this parasite. toxoplasma disease was defined as the presence of toxoplasma infection plus clinical, radiological or pathological evidence. toxoplasma disease was considered the main cause of death when no other major life-threatening infection or other potential fatal complication occurred immediately before death. results: median (range) age (years) of the eleven patients diagnosed with toxoplasma disease was ( - ). for pancytopenia, no patient received trimethoprimsufmethoxazole (tmp-smz) but pentamidine for pneumocystis jirovecii-pneumonia (pcp) prophylaxis in cases and atovaquone in one. toxoplasma serology pretransplant was positive (igg+/igm-) in ten of the eleven patients. all donors were seronegative (igg-/igm-) except two. toxoplasmosis was diagnosed a median (range) of days ( - ) post allo-stc. the clinical presentations were as cerebral-encephalitis (n= ), chorioretinitis (n= ), pneumonitis (n= ) and disseminated toxoplasmosis (n= ). one case, patient and donor seronegative pre-transplant, was presented as a primary infection in form of chorioretinitis. all three patients with chorioretinitis were diagnosed after day + of allo-sct. at the time of toxoplasma disease, of ( %) of patients had an alc < cells/μl and all of them with immunosuppressive therapy and corticosteroids for acute or chronic gvhd. we had cd + lymphocyte count only in four patients and in three of them was < cells/μl. eight of the eleven ( %) patients died, with a median (range) of days ( - ) since diagnosis of toxoplasmosis, and in of them the toxoplasma disease was the main cause of death. conclusions: in our series, the incidence of toxoplasma disease after allo-sct is low and is related to high mortality, in accordance with what has been reported by other groups. positive pre-transplant serology and gvhd and its treatment were factors strongly related with toxoplasmosis. we encourage the use of tmp-smz instead of pentamidine for pcp-pneumonia prophylaxis in patients seropositive for toxoplasma gondii pre-transplant. clinical trial registry: data about its epidemiology in children are scarce. we retrospectively analyzed the incidence, the severity and the risk factors that contribute to the manifestation of this complication in a pediatric population. methods: during a -year period (january -june ) we performed in our center allogeneic transplantations, for malignant hematological diseases and for non-malignant. the majority of our patients received myeloablative conditioning regimens. diagnostic criteria of hemorrhagic cystitis were the detection of the virus with pcr in urine samples and/or in blood samples, in combination with hematuria and lower urinary tract symptoms (dysuria, urinary frequency, urgency, suprapubic pain) that couldn't be attributed to any other reason. we defined the hemorrhagic cystitis as severe when one of the following factors was present: formation of clots and continuous bladder irrigation, obstructive uropathy with creatinine elevation or need for urological intervention. results: a total of patients with median age , years ( , - ) were studied. children ( %, % ci, , - , ) manifested bk virus associated hemorrhagic cystitis with median age , years ( , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) . onset of cystitis occurred at a median time of days (day +-day + ) after transplantation. in children cystitis was severe. the median duration of symptoms was days ( - ). the median time of hospitalization for children with severe cystitis was days ( - ) whereas for those who didn't manifest cystitis was ( - ) . in of the patients we examined the presence of the virus not only in urine but also in blood samples. in of them the test was positive and almost half of them ( ) manifested severe cystitis. the risk factors that were examined were age, administration of antithymocyte globulin, type of disease, graft source, type of donor and the presence of acute graft versus host disease (agvhd). in multivariable analysis, independent risk factors for the manifestation of hemorrhagic cystitis were age > years old (hr: , , % ci, , - , p< , ), transplantation for malignant disease (hr: , , % ci, , - , , p= , ) and the presence of agvhd (hr: , , % ci, , - , , p< , ). the overall survival of children with hemorrhagic cystitis was , % vs , % of those who didn't manifest this complication, but in multivariable analysis for survival cystitis wasn't a statistically significant risk factor. conclusions: according to our results, stem cell transplantation in children > years old who suffer from a malignant disease and the presence of agvhd consist independent risk factors for the manifestation of bk virus associated hemorrhagic cystitis. the identification of the risk factors of this serious complication will contribute to better management of transplanted patients. further research through prospective trials can contribute to the better understanding of the pathophysiology of hemorrhagic cystitis and to the establishment of appropriate diagnostic and therapeutic guidelines. disclosure: nothing to declare p impact of natural killer cell reconstitution on outcomes in patients with early cytomegalovirus reactivation after allogeneic hematopoietic stem cell transplantation background: cytomegalovirus (cmv) reactivation influences survival after allogeneic hematopoietic stem cell transplantation (sct) and induces natural killer (nk) cell expansion. we evaluated nk cell reconstitution and clinical outcomes following early cmv reactivation after sct. methods: lymphocyte subsets were measured by flow cytometry on day in patients with hematologic malignancies undergoing sct between january and december at kanagawa cancer center, excluding patients with graft failure or death within days. cmv reactivation was defined as initiation of preemptive cmv therapy following pp antigenemia surveillance. results: the subjects were males and females with a median age of years (range: - years). the median follow-up period for survivors was . years (range: . - . years). there were patients with acute myeloid leukemia, with acute lymphoblastic leukemia, with myelodysplastic syndromes, and with other diseases. at transplantation, patients were standard risk and were high risk. myeloablative conditioning and reduced-intensity conditioning were employed in and patients, respectively. bone marrow transplantation, peripheral blood stem cell transplantation, and cord blood transplantation was performed in , , and patients, respectively. cmv reactivation occurred in patients ( %) at a median of days (range: - days) after sct. grade ii-iv acute gvhd and chronic gvhd affected patients ( %) and patients ( %), respectively. among all patients, -year overall survival (os), cumulative nonrelapse mortality (nrm), and cumulative relapse (cir) rates were %, %, and %, respectively. in patients without cmv reactivation (cmvr-) versus patients with cmv reactivation (cmvr+), -year os, nrm, and cir were % vs. % (p < . ), % vs. % (p = . ), and % vs. % (p = . ), respectively. among all patients, the median level of cd -cd + cells, cd +cd cells, and cd +cd + cells on day was /μl (range: - /μl), /μl ( - /μl), and /μl ( - /μl), respectively. nk cell subsets showed no significant differences between cmvr-and cmvr+ patients. when patients were divided into low and high groups at the median level of each nk cell subset, cmvr+ patients with high cd -cd +, cd +cd -, or cd +cd + cells showed significantly better -year os than those with low cells ( % vs. %, p < . ; % vs. %, p < . ; % vs. %, p = . , respectively). high cd -cd + cells were significantly associated with lower nrm ( % vs. %, p = . ), while high cd +cd -cells were significantly associated with lower cir ( % vs. %, p = . ). multivariate analysis confirmed these nk cell subsets as prognostic factors in cmvr+ patients. conclusions: nk cell reconstitution may contribute to improved transplantation outcomes in subgroups of cmvr + patients. disclosure: nothing to declare background: rezafungin (rzf) is a novel echinocandin in development for prevention of invasive fungal infections caused by candida, aspergillus, and pneumocystis spp. in patients at high risk of infection. rzf has demonstrated in vivo prophylaxis efficacy and low risk of drug-drug interactions. furthermore, the stability and pk profile of rzf allow for once-weekly dosing. rzf is also in development for treatment of candidemia and invasive candidiasis using a dosing regimen of rzf mg followed by mg once-weekly, which achieved > % target attainment against candida. while lower doses might be useful to prevent candida and pneumocystis, invasive aspergillosis is a different challenge. we evaluated rzf dosing for prophylaxis against aspergillus fumigatus in blood and marrow transplant (bmt) patients using pk/pd simulations of the treatment dosing regimen. methods: a previous population pk model was refined using data from phase and phase trials of iv rzf (nonmem vers . ). stepwise forward selection (α = . ) and backward elimination (α = . ) were used to assess for relationships between interindividual pk variability and covariates, such as age, sex, bsa, albumin, liver and renal function markers, and infection status. the final model was validated by comparing model-based predictions to observed data. the model and demographic data from bmt recipients at stanford medical center were used for monte carlo simulation (n= , ) of expected rzf concentrationtime profiles in bmt patients receiving iv rzf mg on week followed by mg weekly x . of the patients included in the demographic dataset, were female (mean values at baseline: age, years [ - years]; weight, . kg [ - kg] ). the median (range) bsa in the demographic dataset was . m ( . - . ), and albumin was . g/dl ( . - . g/dl) . free-drug concentration-time profiles were evaluated ( . % human protein-binding) relative to the a. fumigatus minimal effective concentration required to inhibit % of isolates tested (mec ; jmi - sentry international surveillance data). results: the population pk model was a linear, compartment model with zero order iv input. albumin, sex, infection status, and body surface area were statistically significant predictors of interindividual variability; clinical significance of these factors was not determined. the model provided precise, unbiased fits to the observed data (r = . observed vs individual-predicted concentrations). rzf plasma free-drug concentrations at weeks , , and were above the a. fumigatus mec ( . mg/l) for the entire dosing interval in . %, . %, and . % of simulated patients, respectively, and in ≥ . % for all weeks based on the mec ( . mg/l). conclusions: these data modelled from bmt patients support the rzf dosing regimen of mg iv followed by mg once-weekly for prophylaxis against a. fumigatus. current antifungal prophylaxis may be limited by toxicity, ddis, or patient factors such as mucositis. the pk of rzf and its spectrum, safety, tolerability, and lack of ddis may address current unmet needs in ifi prophylaxis for bmt and other immunocompromised patients. disclosure: janice brown: research funding, cidara therapeutics, elizabeth lakota: research funding, cidara therapeutics, shawn flanagan: employment, cidara therapeutics, taylor sandison: employment, cidara therapeutics, voon ong: employment, cidara therapeutics, christopher rubino: research funding, cidara therapeutics p is fungal prophylaxis necessary in non myeloablative peripheral blood stem cell allogeneic transplantation in the pre-engrafment period? julien vaidie , jean-baptiste woillard , stéphane girault , marie-laure dardé , arnaud jaccard , daniel ajzenberg , bernard bouteille , pascal turlure background: non myeloablative peripheral blood stem cell transplantation (pbsc), by limiting toxicity, can be proposed to elderly patients or patients with comorbidities. however, fungal infections remain a key issue that can negatively impact outcome, and increase duration and cost of hospitalization. systematic fungal prophylaxis have demonstrated benefits in outcome in the context of myeloablative conditioning but are not currently in reduced intensity conditioning allograft with pbsc. fluconazole prophylaxis is currently recommended in this situation (ecil). methods: primary objective of this retrospective study was to evaluate fungal infection incidence after allograft procedure in patients who received a non myeloablative allograft with pbsc in limoges university hospital between june and june . patients received fludarabine mg/m /day between d- and d- before allograft and busulfan . mg/kg/day at d- and d- . gvh prophylaxis consisted in rabbit anti-lymphocyte serum at the dose of . mg/kg at d- and d- , and ciclosporin at the beginning dose of mg/kg per os twice a day. mycophenolate mofetil was adding for patients with hla-matched or mismatched unrelated donors. patients did not systematically receive antifungal prophylaxis during the neutropenic pre-engraftment period. when patients had fever during more than hours, an empirical fungal treatment (caspofungine) was added to empirical antibiotics. as soon as neutropenic recovered and in the case of apyrexia without microbiologic documentation, antimicrobial treatments were stopped while in the case of microbiologic documentation, treatments were adjusted to germ in term of dosing and time of administration following recommendations. however, some patients received antifungal azole prophylaxis during the neutropenic pre-engraftment period in case of history of previous invasive aspergillosis (ia), or a nasal colonization by aspergillus. in post-engraftment period, posaconasole prophylaxis was administered for patients with systemic corticotherapy for acute graft-versus-host disease. results: patients were evaluated (median [min-max] age of [ - ] years). % of patients received an hlaidentical related donor, % an hla-matched related donor and % an hla-mismatched unrelated donor. the five years overall survival and survival without relapse or gvhd were % ic [ %- %] and % respectively ic [ %- %]. the median time for neutrophil recovery was days. patients did not receive prophylaxis and only patients received systematic fungal azole prophylaxis in the pre-engraftment period. two patients received an empirical treatment by caspofungine. only ifi was documented during the neutropenic period : candida krusei in blood culture. in the post engraftment period, patients with acute gvhd treated by corticotherapy received an antifungal prophylaxis by posaconazole and only patient had a probable ia at day despite prophylaxis by posaconasole. conclusions: except for patients with previous history of ifi, our results provide additional arguments against systematic fungal prophylaxis after reduced intensity conditioning with pbsc allogenic transplantation in the pre-engraftment period with a very low incidence of invasive fungal infections. in post-engrafment period, posaconazole prophylaxis is required for patient with gvhd treated by corticotherapy. disclosure methods: a simple, rapid and sensitive method using hplc with a diode-array detector (dad) was developed and validated for the quantification of letermovir in human serum using sorafenib as internal standard. after pretreating serum samples by liquid-liquid extraction with tert-butyl methyl ether, separation was achieved on a x-terra rp- column (dimension x . mm, μm) at c using gradient elution with a mobile phase of mm ammonium bicarbonate ph . (mobile phase solvent-a) and acetonitrile: mm ammonium bicarbonate ph . (mobile phase solvent-b). samples were eluted at a flow rate of . ml / min throughout the -minute run. uv wavelength mode was used, detection was at nm. results: the calibration curve was linear (r > . ) in a concentration range of - ng / ml for letermovir. the hplc assay established for letermovir determination showed a high rate of accuracy and precision with an intraday variability of - . to % (accuracy) and . to . % (precision) and an interday variability of - . to . % (accuracy) and . to . % (precision), respectively. letermovir serum concentrations of patients ( male / female, mean age . years) were determined in daily clinical practice. the mean concentration was ng / ml (median ng / ml, standard deviation ng / ml, range - ng / ml). conclusions: the newly developed hplc method is useful for the determination of letermovir concentrations. patient samples analyzed in a routine clinical setting demonstrated considerable interindividual variability. all measured concentrations were above the ec of letermovir. monitoring the concentration of letermovir could help to prevent over-or underexposure, especially in patients with polypharmacy which is frequent in allogeneic hematopoietic stem cell transplant recipients. disclosure background: the use of preemptive strategy (pet) has lowered the incidence of cmv disease in allo-sct to - %. nonetheless the use of this strategy implies that more than % of seropositive patients will replicate cmv. several studies have shown that cmv replication is detrimental for patient survival although the viral load related to this bad outcome variates among studies. objective: to analyse thel impact of cmv replication in overall survival (os) in allo-hct patients. methods: to analyse the impact of cmv replication in os we perform a unicentric, retrospective study on consecutive first allo-hsct patients transplanted between jan- and oct- with a median follow-up of days ( - ). all patients were monitored post-hct with real time pcr cobas-taqman® /cobas ® (rtpcr) in plasma. the cut-off for inception of pet was iu/ml. cmv mutations (ul /ul gene), were studied in plasma samples by sanger sequencing, median cmv viral load iu/ml ( - ). results: patients ( ): women/men ( %/ %), median age was years (range - ). identical allogeneic scts ( %), haploidentical scts ( %). donors were related in cases ( %) and ( %) unrelated. progenitors source was % peripheral blood and % bone marrow. cmv status was (d+/r+) in %(n= ), (d+/r-) in %(n= ), (d-/r+) in % (n= ) and (d-/r-) in % (n= ), unknown cases. positive pcrs were detected in patients: one episode in ( %); episodes in ( %) and to episodes in patients ( %). fifty-five patients ( %) received preemptive therapy. fourteen episodes ( %) were refractory/ probable refractory cmv infections (according to the criteria of chemaly r. cid ). a resistant mutation (ul gene) was detected in one patient with refractory infection patients that developed cmv infection had an inferior non-significant os at years ( , % vs , % log-rank p , ). those patients that received pet for cmv had a significant inferior os compared with those that replicate cmv but didn't receive preemptive therapy ( , % vs %, log rank p= . ). os of patients that received pet was inferior compared with those without pet (with or without infection) ( , % vs , %, logrank p , ). no difference in survival was found for those patients treated pre-emptively that were refractory vs no refractory ( % vs , %, log-rank p , ). conclusions: patients that received preemptive therapy had a significant inferior overall survival compared with those that didn´t replicate and those that replicate cmv but didn't receive preemptive therapy. this reinforce the relevance of prophylactic strategies for cmv with drugs with good safety profile like letermovir that in a randomised trial proved to decrease the need for preemptive therapy. disclosure: rafael, de la camara: has received grants from astellas, gilead, janssen, merck, novartis and pfizer clinical evaluation of stenotrophomonas maltophilia infection in allogeneic hematopoietic stem cell transplant recipients -retrospective single-center data analysis negative bacillus that causes severe infections associated with high morbidity and mortality in immunocompromised patients. the aim of our study was to determine incidence, characteristics and outcome of s. maltophilia infection in patients (pts) who underwent allogeneic hematopoietic stem cell transplantations (allo-hsct) in institute of hematology and transfusion medicine between october and november . methods: we retrospectively evaluated incidence, clinical features and outcome of s. maltophilia infections in consecutive patients with median age- years (range - ), who underwent allo-hsct from unrelated donors - ( . %), matched sibling donors - ( . %) and haploidentical donors - ( . %) in our center. s. maltophilia was detected by culture-based microbiological tests. invasive infection was defined by isolation s. maltophilia from cultures in the presence of both clinical symptoms and signs of infection -blood stream infection (bsi), pneumonia with or without pulmonary haemorrhage. the only colonization status was defined as s. maltophilia culture-positive samples in the absence of infection symptoms. in vitro susceptibility tests to antibiotics were performed. results: pts ( . %) with median age- years (range - ) with s.maltophilia culture positive samples were identified. ( . %) underwent allo-hsct from unrelated donors, -from matched sibling donor and -from haploidentical donor. among them bsi developed in pts ( . %), pneumonia in pts ( %) -with fulminant and fatal pulmonary hemorrhage in pts ( . %). all patients with pneumonia demonstrated bsi. positive sputum cultures were detected in pts, in pts hemoptysis was observed. the rest of isolated strains were identified as colonization (throat -in pts, stool -in pts). all patients with invasive s. maltophilia infection before pathogen identification demonstrated persistent fever despite of the use of broadspectrum antibiotics (carbapenems, glycopeptides, aminoglycosides, colistin), prophylactic antifungals and antivirals. all of them received fluoroquinolone (ciprofloxacin) as a standard antibacterial prophylaxis before neutropenic fever occurred. all patients ( %) with bsi, pneumonia and pulmonary hemorrhage died before engraftment (anc - . g/l) - of them during - hours from the onset of a positive blood culture for s. maltophilia. the c-reactive protein (crp) concentration before identification of s. maltophilia invasive infection was > x- x upper normal limits (unl). susceptibility to antibiotics of isolated strains from blood and sputum was respectively: % and % for ceftazidime, % and % for trimethoprim-sulfamethoxazole, % and % for levofloxacin; while % and % strains were resistant to ciprofloxacin. -year overal survival (os) and -y os for this group was . % and . % respectively compared with . % and . % for group without s. maltophilia infection. conclusions: s. maltophilia invasive infections are associated with high morbidity and mortality in allo-hsct recipients especially in the period from conditioning therapy to engraftment. an exposure to broad-spectrum antibiotics in the treatment of neutropenic fever or confirmed bacteremia of other etiology is one of risk factors of breakthrough s. maltophilia infections. empiric therapy against s. maltophilia in selected patients in risk of such infection before pathogen identification may be lifesaving procedure. disclosure: nothing to declare. role of cmv reactivation following allogeneic stem cell transplantation in preventing relapses in patients with acute myeloid leukemia background: cytomegalovirus(cmv) reactivation is common in patients undergoing allogeneic stem cell transplantation. it has been shown recently that cmv reactivation is associated with reduced risks of relapse in patients undergoing allogeneic stem cell transplantation for aml. however the analysis of cibmtr data did not show any effect of cmv reactivation on relapse. with this background we conducted an analysis of patients suffering from aml who are undergoing allo-sct for their long term disease free survival with respect to cmv reactivation. methods: after obtaining permission from hospital medical records committee, we retrospectively analysed data from electronic medical records of patients undergoing allo-sct for aml at our center between january to august . patients who underwent matched sibling, matched unrelated and partially matched allo sct were included. all patients underwent cmv monitoring with weekly pcr starting from the time of engraftment till d+ following allo sct. value of ≥ copies/mcl was considered as cut off for initiation of treatment in matched sibling donor transplant but in unrelated donor or partially matched donor transplants, ≥ copies/mcl was used as cut off for initiation of pre emptive therapy. results: total of patients were included in study. median age was . ± . years ( - yrs). ( . %), ( . %) and ( . %) patients underwent matched sibling, haplo (partially matched) and mud transplantation respectively. median follow up was months( - months). (table ) acute gvhd (grade - ) was observed in ( . %) of patients. cmv reactivation occurred in ( . %) of patients. overall survival at last follow up was . % ( / patients). ( . %) patients relapsed during follow up. relapse free survival at at last follow up was . %. ( . %) of patients who had cmv reactivation didń t relapse, whereas ( %) of patients who didn´t have cmv reactivation relapsed which was statistically strongly significant p < . . (figure ) similar results were seen in recently published paper from japanese society for hematopoietic cell transplantation (jshct) transplantation-related complication working group. conclusions: . cmv reactivation following allo sct had beneficial effect on preventing relapse in patients with aml. . probable immune activation resulting due to cmv reactivation may result in better graft versus leukemia effect preventing subsequent relapses. [ background: human herpesvirus (hhv- ) causes lifethreating central nervous system disorders such as encephalitis after allogeneic hematopoietic stem cell transplantation (hsct). recent studies showed that cd , a member of the tumor necrosis factor receptor superfamily, has been implicated as a specific receptor of hhv- b, and that its expression levels in cd -positive t cells after hsct could be related to the reactivation of hhv- . real-time quantitative polymerase chain reaction analysis (qpcr) is the most commonly used method for detecting and evaluating hhv- reactivation after hsct, but more sensitive detection method is required. we recently developed a new monitoring method for hhv- reactivation using digital pcr (dpcr) which provides high sensitivity of detecting hhv- dna in clinical samples. in this prospective study, we evaluated the relationship between hhv- reactivation monitored by dpcr and expression of cd on cd + t cells before and after allogeneic hsct. methods: thirty-four patients who underwent allogeneic hsct for hematological diseases at keio university hospital (tokyo, japan) between january and march were consecutively enrolled into this study. peripheral blood samples of the patients were obtained before the conditioning (pre), the day of transplant (day ), and weekly during the first month after transplantation (days , , , and ) . hhv- viral load in plasma was quantitatively measured by dpcr. the primers and a probe of dpcr for hhv- b were selected from immediate-early (ie- ) protein transactivator region (u ). we evaluated the relationship between hhv- reactivation and the serial expression rates of cd in cd + t cells (cd /cd ratio) measured by flow cytometry before and after hsct. results: median age of the patients was . years. onethird of patients received cord blood as a stem cell source. hhv- reactivation was detected in patients ( %) with dpcr. a comparison of cd /cd ratio between the patients with and without hhv- reactivation after hsct revealed that cd /cd ratio was significantly higher in patients with hhv- reactivation than those without before conditioning ( in contrast, there was no such significant difference after transplant (days to ) . in multivariate analysis, higher cd /cd ratio before conditioning (odds ratio (or) = . , % confidence interval (ci): . - . , p = . ) and stem cell source from human leukocyte antigen mismatched donor (including all cord blood transplantation cases) (or = . , %ci: . - . , p = . ) remained to be significantly associated with the incidence of hhv- reactivation. conclusions: higher cd expression rate in cd + t cells before hsct was associated with higher risk of hhv- reactivation, which could be a promising marker for predicting hhv- reactivation after allogeneic hsct. careful observation and monitoring may be needed in cd highly expressed patients. it is a subject of further research to clarify the role of cd + cd + t cell in hhv- reactivation. disclosure: nothing to declare. methods: criteria for the administration of ici (vistide) were grade iii-iv (clinically significant hematuria with clots) bk-related hemorrhagic cystitis after allo-hct which showed no improvement after symptomatic therapy with hyperhydration and bladder irrigation. cidofovir was diluted in ml of normal saline and installed via a foley catheter which was blocked for hour. not knowing the level of absorption of the drug we decided to give probenecid prophylaxis in all patients. ici was repeated weekly according to severity of symptoms. urine and plasma bkv viral loads were quantified by rq-pcr results: six patients (median years, - ) received ici after allo-hct. patients had haematological malignancies (aml , all , mds ), received busilfex-based myeloablative conditioning and a graft (pbsc , bm ) from a / hla-matched ( pts), / ( pt) or haploidentical ( pt) donor. median time for the onset of bkv-hc after allo-hct were . days (range - ). all patients were under standard cyclosporine prophylaxis and none of the patients had any signs of acute gvhd at the time of onset of hc. the median pcr-bkv viral load at the onset of bkv-hc in urine and plasma were . x (range . x - x ) and . (range - ), respectively. the median maximum pcr-bkv viral load in urine and plasma were . x (range . x - x ) and . (range - . ), respectively. five patients had impaired renal function (median egfr ml/min, range - ) at first ici which was probably multifactorial. the median dose of intravesical cidofovir was mg/kg (range . - mg/kg) and a median number of . instillations (range - ) were given. in / cases symptoms of cystitis improved dramatically and hematuria resolved. virological response (at least log reduction) was observed in all cases. two patients experienced relapse of hemorrhagic cystitis and were retreated with ici which resulted in resolution of the symptoms and the hematuria. no deterioration of renal function of other systemic adverse effects were observed. after a median follow up of . days after transplantation (range - ), / patients are alive without cystitis symptomatology and died ( due to relapse and due to trm). conclusions: in this retrospective study we propose that local therapy of bkv-hc with ici is safe and has high clinical and virological response rates. the administration of ici after allo-hct should be controlled in prospective randomized trials. disclosure: nothing to declare background: since cmv-preemptive therapy approach was implemented, cmv disease frequency is very low. however, cmv reactivation and the need of using nephrotoxic plus/less myelotoxic drugs is very frequent. in addition to the toxicity of the medications to avoid cmv disease, other potential adverse effects of cmv have been mentioned in medical literature. in this study, we wanted to estimate how recipient/donor serologic status influences the outcome of allo-hsct in our most recent series of patients. methods: the population analyzed for this report is the all patients who underwent allo-hsct during the -year period from october september in our unit. median age at transplant was years (range: - ). one hundred and thirty were male ( %) and were female ( %). baseline diseases were: aml, lpd, all, mds, mpd, mm, and bmf. donor was unrelated in transplants ( , %) and was family in ( , %) (including haplo-identical). conditioning regimen was ric in procedures ( %) and intensive in ( %). stem cell source was pb in ( , %) and bm in cases ( , %). median follow-up was months (range: - ). patient's and donor's cmv igg were positive in ( , %) and ( , %), respectively. recipient/donor serology was +/-(risk group ) in ( , %), +/+ (risk group ) in ( , %) , -/+ (risk group ) in ( , %) y -/-(risk group ) in ( , %). results: two pts underwent a second transplant before day + due to graft failure. overall mortalities (om) at days + and + of the rest of the series ( pts) are shown in table. the highest risk group (recipient cmv + / donor cmv -) exhibited more than double om at day + and more than four times om at day + , when compared with pts at lowest risk (recipient cmv -). those striking differences were mainly due to nrm. om for risk group ii (recipient cmv + / donor cmv +) was intermediate. conclusions: in our studied population, mainly adult patients, the combination of cmv-seropositive patient with a cmv-seronegative donor had a very clear adverse impact on hsct outcome. as a result, we considered that the election of a cmv-positive donor for a cmv-positive patient continues to be strongly advisable, whenever is possible. on the other hand, once letermovir has proved to be efficient and well-tolerated and has been licensed for prophylaxis of cmv in high risk recipients, this approach appears to be very attractive to try to avoid the adverse impact of recipient cmv-seropositivity, particularly when finally chosen donor is cmv negative. disclosure: nothing to declare an active surveillance and an early and individualized management is critical to avoid mortality from respiratory viral infections in allo-hsct recipients background: respiratory viral infections (rvis) are frequent among the general population. in transplant recipients, rvis are known to cause an important morbidity and potential mortality. for this reason and several others, as the need of preventing other pts from contagious or avoiding misdiagnosis with other infections processes, a high index of suspicion of vris is necessary. during the last few years, we have implemented an active and systematic surveillance policy orientedto early detection and management of rvis in the hsct recipients. methods: the population analyzed for this report is the patients who underwent allo-hsct from january through march in our unit. median age at transplant was years (range: - ). one hundred and four were male ( . %) and were female ( , %). baseline diseases were: aml, lpd, all, mds, mpd, mm, and bmf. donor was unrelated in transplants ( . %) and was family in ( . %) (including haplo-identical). conditioning regimen was reduced in procedures ( %) and intensive in ( %).stem cell source was pb in ( . %) and bm in pts ( . %).median follow-up was months (range: - ); at the close of the analysis, majority of the series ( . %) had a follow-up superior to one year from hsct. a throat swab(ts) was taken from every patient with any, even minor, respiratory symptoms. the respiratorysamples were tested whith a complete pcr panel of human respiratory viruses: rhinovirus (rv), influenza a and b virus (iv-a, iv-b), parainfluenza virus (pivs - ), respiratory syncytial virus (rsv), metapneumovirus (mpv), coronavirus (cov), adenovirus (adv), and bocavirus (bov). results: day + overall mortality of the series was , %. day + overall mortality was , % ( , % nonrelapse mortality -nrm-, and , % progression/relapse mortality). causes of nrm reflected in table . no patients died due to rvis. from st july through th june (a -month period), ts samples were obtained from pts ( , %).the median number of samples/patient was (range: - ).a total of ( - ) rvis episodes were diagnosed in pts ( , %).the median presentation of the first rvi was at the day + ( - ) post-hsct. the viral distribution was: rv ( . %), iv ( . %), piv ( . %), rsv ( . %), mpv ( . %), cov ( . %), adv ( . %), and bov ( . %).there were mixed (two or more viruses) rvi episodes. the temporary distribution of vri episodes is shown in figure . conclusions: ) symptomatic infections due to respiratory viruses are very frequent among the allo-hsct recipients. ) a high level of suspicion, as well as an early and systematic screening and management policy, are critical to avoid potential attributable mortality and the nosocomial spread of rvis among the transplant recipients. ) in our series, rhinovirus, parainfluenza and adenovirus might be detected at any moment of the year; the rest of the viruses showed a clear seasonal pattern (november to april). [[p image] . background: trimethoprim-sulfamethoxazole (tmp-smx) is the most suitable drug for prophylaxis against pneumocystis pneumonia and infections with toxoplasma after allogeneic haematopoietic stem cell transplantation (allo-hsct). allergic reactions or hypersensitivities, mainly exanthemas, occur in about - % of the patients, usually resulting in the use of alternative prophylactic drugs (e.g. pentamidine or atovaquone). it has been hypothesised that allergies might be cured with allo-hsct. methods: we conducted a retrospective chart review of patients with tmp-smx re-exposition after allo-hsct from december to september . follow-up is current as of december . results: six patients (f/m: / , median age: years, range: - years) with a history of tmp-smx hypersensitivity prior to allo-hsct were re-exposed to tmp-smx after engraftment of a matched related (mrd, n= ) or matched unrelated (mud, n= ) donor. median time to re-exposition was . (range: - ) days after allo-hsct with one oral dose of tmp-smx. in four patients, tmp-smx was tolerated without any signs of hypersensitivity reactions and has been continued for a median of days (range - ) until last followup. one patient (mud, re-exposition at d+ ) experienced pruritus and erythema some hours after tablet intake. another patient (mud, re-exposition at d+ ) developed an exanthema one day after re-exposition which was later diagnosed as a cutaneous gvhd. conclusions: re-exposition of tmp-smx in patients with prior hypersensitivity is feasible after allo-hsct. after successful re-exposition, patients can be treated with the best-studied drug for prophylaxis of infections with pneumocystis and toxoplasma. disclosure: nothing to declare brincidofovir for adenoviremia in paediatric hsct for primary immune deficiency background: reactivation of adenovirus is a severe complication of hsct associated with significant morbidity and mortality, particularly for children with primary immune deficiency (pid). the only drug currently licensed to treat adenovirus infection is cidofovir. brincidofovir is a lipidlinked derivative of cidofovir which has been shown to be a safe and effective alternative treatment to cidofovir. there is limited data describing the use of brincidofovir in patients undergoing hsct for primary immune deficiency. we reviewed all patients who received brincidofovir after undergoing hsct for primary immune deficiencies between and at the great north children's hospital, newcastle upon tyne, uk. results: of patients transplanted for pid, developed significant adenoviraemia ( %). all were treated with cidofovir initially but were switched to brincidofovir because of a failure to respond or because of renal toxicity. of these, resolved their adenoviraemia within days of commencing treatment (figure ). donor sources were tcr alpha/beta/cd depleted haplo-identical (n= ), tcr alpha/beta/cd depleted mmud (n= ) and / mud (n= ). patients were conditioned with treosulphan/fludarabine/thiotepa/atg/ rituximab (n= ), treosulphan/fludarabine/atg/rituximab (n= ) or treosulphan/fludarabine/alemtuzumab/ gcsf/plerixafor (n= ). occurrence of agvhd and treatment of agvhd are outlined in table . patient died + days post-transplant of multi-organ failure, severe thrombotic microangiopathy and sepsis. although patient initially responded to brincidofovir, reactivation occurred after cessation of treatment; severe diarrhoea precluded the reintroduction of brincidofovir and the adenoviraemia persisted with poor immune reconstitution. treatment with addback t cells was attempted however the patient died days post-transplant after a cerebral haemorrhage. patient had long-standing chronic diarrhoea which was thought not severe enough to warrant cessation of brincidofovir treatment. conclusions: the complete resolution of adenoviraemia in / patients who had previously failed to respond to prior therapy with cidofovir suggests that brincidofovir may be an effective treatment option for adenoviral reactivation post-hsct for pid. however, resolution of adenoviraemia is influenced by many other factors, including the adequacy of immune reconstitution, the degree of induced immune suppression and the presence of comorbidities such as gvhd. due to the small sample size it was difficult to assess the relative importance of these factors in this cohort. brincidofovir was well tolerated however its effectiveness may have been limited by poor gastrointestinal function in one patient (patient ) and could not be used after a viral reactivation in another for the same reason. further studies of the use of brincidofovir in this specific cohort are needed to clarify the role and effectiveness of this treatment. background: there is a high prevalence of cmv seropositivity in algerian population. because of high morbidity and mortality in pts who underwent allo sct with cmv reactivation, effective surveillance and timely treatment using anti-viral therapy s required. the risk of cmv reactivation depends on the type of stem cell source, immunosuppression (is) and serological status of the donor/ recipient pair. methods: over a months period (from / / to / / ), pts underwent allo-hsct for malignant or non-malignant hematology diseases of which pts are evaluated for this study. cmv reactivation was observed in pts ( . %) (aml: pts, all: pts, cml: pts, multiple myeloma: pt, nhl skin: pt, primary myelofibrosis: pt, aplastic anemia: pts, fanconi anemia: pts, β-thalassemia: pt), with a median age of years ( - ), sex ratio (m/f) of . . allo-hsct done with sibling donors: pts, haplo-identical donors: pts and pheno-identical donor: pt. all pts were treated by chemotherapy alone with myéloablative conditioning (mac) in pts and reduced intensity (ric) in pts. all pts received peripheral blood stem cells with an average rate of cd + cells: , . /kg ( . - . ). additional bone marrow graft was used in pts that received a haploidentical graft without pt-cy. gvh prophylaxis associated cyclosporine (csa) and methotrexate (sibling and phenoidentical); csa-mtx-mmf or csa-mtx-cyclophosphamid (haplo-identical). before transplantation, donor/recipient pair is at high risk reactivation in pts ( . %). detection of cmv reactivation done by antigenaemia pp or by quantitative pcr weekly for the first months and during an is treatment for acute or chronic gvhd. pre-emptive therapy is initiated by ganciclovir as soon as positivity of antigenaemia or increased viral load in pcr. results: a first reactivation occurred on average day ( - ) in pts ( . %) of which pts under corticotherapy for acute gvhd ( pts), thrombotic micro-angiopathy ( pt) and renal failure ( pts) or due to a reinforced is for haplo-identical transplantation ( pts). one pt with chronic gvhd presented a late reactivation months after transplant. twenty pts presented a nd reactivation on average day ( - ) and pts a rd reactivation on average day ( - ). pre-emptive treatment is introduced in the first episode by a viral dna polymerase inhibitor (ganciclovir: pts; valganciclovir: pts, foscarnet: pt). the negativity of antigenaemia is observed on average at days of treatment ( ) ( ) ( ) ( ) ( ) . second line treatment was required in pts ( %) due to resistance ( pts), severe cytopenia ( pt) or renal failure ( pt). the onset of severe cytopenia imposed a dose reduction ( pts) or a therapeutic stop ( pts) before days. two pts received additional maintenance treatment for negativation delay. three pts ( . %) died from cmv infections resistant to antiviral treatment (pneumonia: , colitis: ). conclusions: cmv infection is a serious complication after allo-hsct. in the absence of vaccination, the systematic monitoring for cmv reactivation is strongly recommended for the establishment of a rapid and effective preemptive treatment. disclosure: nothing to declare p abstract withdrawn. results: in transplanted group, episodes of bkv reactivation occurred in patients ( %). in cases only urine colonization (c) found before hsct. in this group in patients ( %) virus was transmitted from urine to the blood (b) . dysuria and/or hc were observed in / ( %) patients . all of them ( %) had urine and serum involvement. in cases bkv replication was found after hsct ( -cases detected in urine, cases-bothserum and urine). dysuric syndromes and/or hc were found in / of cases ( %)-all in patients with serum and urine involvement. urinary tract was always first location of the virus. there was no case of isolated serum reactivation. the incidence of bk infection was higher in patients older than > yrs (p< . ), transplanted from family donor (msd) (p< . ). mud recipients had more often both serum and urine reactivation (p< . ) than isolated urine involvement. sex, day of neutrophil recovery, conditioning regimen, or use of total body irradiation were not significant risk factors for bkv infection, or hc . six patients were treated with cidofovir (range - doses) with good response. there was no death due to evident bkv infection. conclusions: bkv reactivation remains one of the most frequent infectious complication in children undergoing allogeneic hsct. most of patients experienced mild infection and age < years was the positive prognostic factor influencing its incidence. bkv monitoring and prompt treatment of hc resulted in excellent outcome. we observed surprisingly high rate of new bkv replication after hsct. disclosure: nothing to declare background: high-dose chemotherapy (hd-ct) and auto pbsct have been the standard therapy for multiple myeloma (mm) for more than two decades, despite a wide range of new therapeutic options. recurrent/refractory malignant lymphomas and recurrent/metastatic germ cell tumors (gct) also benefit from this intensive therapy. in comparison to allogeneic transplantation, this treatment is known for lower complication rates, e.g. infections. however previous studies have schown that treatment related toxicity may not be underestimated and depending on the conditioning regimen used. methods: we retrospectively analyzed patients ( cases) who underwent hd-ct plus auto pbsct between and in a single-center study. to anlyze the incidence of infections depending on the conditioning regimen, we formed the following categories based on the agiho: no infections, neutropenic fever, sepsis and severe sepsis. results: the median age in this analysis was years; . % were male. the most frequent diagnosis was mm ( . %) receiving high dose melphalan (mel), followed by malignant lymphoma ( . %) receiving beam (bcnu, etoposide cytarabine, melphalan) and relapsed/metastatic germ cell tumours (gct) ( . %) receiving high dose carboplatin/etoposide (ce). % of all patients developed severe sepsis, patients had to be ventilated and patients died. sepsis was documented in . % of all cases ( cases). the majority of patients ( . %, cases) developed neutropenic fever and . % ( cases) didn´t have any infection complications. the beam conditioning regimen showed the highest tendency to result in a septic course ( . %), followed by ce ( . %) and mel ( . %). the most commonly documented pathogen in blood cultures was s. epidermidis ( . %), followed by e. coli ( . %) and s. mitis ( . %). only in one blood culture we detected a multi-resistant pathogen ( mrgn e. coli). p. aeruginosa was detected in blood cultures ( . %), l. monocytogenes in ( . %) and s. aureus in ( %). . % of all patients developed diarrhea, only in . % of these cases we could detect c. difficile. the conditioning regimen shows no significant effect on the incidence of c. difficile. the mean neutropenic period was . days in malignant lymphoma patients, followed by . in mm patients and . days in gct patients. the hospital discharge, calculated from the day of transplantation, was significantly different: for malignant lymphoma the mean was . days, for mm . days and for gct . days. conclusions: our data correspond to former published results by many groups. the beam regimen shows the highest infectious complication rate followed by ce and mel. the duration of neutropenia and hospital stay depends on the conditioning regimen. the type of infectious complication doesn't effect the progression free-and overall survival in our analysis. disclosure: nothing to declare. impact of donor and recipient cytomegalovirus serostatus on outcomes of unrelated allogeneic haematopoietic stem cell transplantation background: cytomegalovirus (cmv) is an important cause of morbidity and mortality in allogeneic haematopoietic stem cell transplant (hsct) patients. the aim of our study is to evaluate the outcomes of our cmv seropositive recipients who received grafts from seropositive unrelated donors (d+r+) compared with grafts from seronegative unrelated donors (d-r+). methods: this is a retrospective single center study on a series of cmv seropositive recipients who underwent hsct from unrelated donors between febuary to july . a total of patients were analyzed. their clinical course and laboratory results were reviewed for evidence of cmv reactivation and/or cmv disease. we defined cmv infection as detection of cmv reactivation or primary infection by antigenaemia or polymerase chain reaction (pcr) assays, but was not accompanied by signs and/or symptoms suggestive of a systemic disease. cmv disease occurred when cmv was isolated from any site in association with organspecific signs and/or symptoms. monitoring for cmv infection commenced upon engraftment (approximately day + ). peripheral blood samples were sent twice a week for cmv antigenaemia or cmv quantitative pcr. the duration of twice weekly monitoring was at least about days. longer monitoring was performed in patients who experienced cmv infection after hsct. results: all patients received graft-versus-host-disease (gvhd) prophylaxis using anti-thymocyte globulin (atg) at . mg/kg in addition to cyclosporin or tacrolimus. among the entire cohort of patients, ( %) had cmv infection, including ( . %) out of patients from the d-r+ group and ( %) out of patients from the d+r + group. patients ( . %) from the d-r+ group and patients ( . %) from the d+r+ group had ≧ cmv reactivation above the threshold for preemptive therapy respectively; p= . . patients developed cmv disease, ( . %) from the d-r+ group and ( . %) from the d +r+ group. cmv resistance to both foscarnet and ganciclovir was detected in patients ( . %) from the d-r+ group but none from the d+r+ group. patients died due to cmv disease, both were from d-r+ group. year overall survival (os) were % versus % for d-r+ group and d+r+ group respectively; p= . . median survival was not reached at years. year non-relapse mortality (nrm) were % for d-r+ group and % for d +r+ group respectively; p= . . conclusions: the incidence of recurrent cmv infection was higher in the d-r+ group compared to the d+r+ group. there were no statistically significant differences between the groups in terms of os and nrm. however, there was a trend towards higher nrm in the d-r+ group compared to d+r+ group. our findings suggest that for matched unrelated hsct, it may still be important to select a seropositive donor for a seropositive recipient. disclosure: none background: it´s known that some patients submitted to allogeneic stem cell transplantation (asct) could present a greater susceptibility to infection even when they are in long term complete remission or potentially cured. this fact is related to the dynamic of immunological recovery that is variable in every single patients and it is dependent from many factors: the haematological disease, the conditioning regimen, the age of patient and donor, the number of stem cell and lymphocytes infused, the anti-gvhd prophylaxis, the use of anti-thimoglobulins and others. in clinical practise we can observe patients who are potentially cured, who tapered and stopped the immunosuppressive treatment months or years ago and who are suddenly graved from opportunistic infections. the largest part of these infections is represented from varicella-zoster virus (vzv) cutaneous eruption. methods: in this report we retrospectively analysed a monocentric cohort of patients submitted to asct for haematological malignancies from a median time of months. all of them were free of disease. they stopped the immuno-suppressive treatment in a median time of days after asct (range: - ) and did not present later chronic gvhd needing treatment neither other moderate or severe chronic post transplant complications nor other diseases. prophylactic treatment with anti viral agents (acyclovir or valacyclovir) has been conducted simultaneously to immuno-suppressive treatment and for a period ranging between to months after its suspension. in this cohort of patients we considered the incidence of vzv eruption occurred after the suspension of the immunosuppressive treatment, and we analysed the immunological recovery in terms of lymphocytes sub-population after , , and months from asct. results: of these patients considered, developed at least one vzv manifestation. all the vzv presentation were cutaneous, we did not observe neurological, ophthalmic or visceral presentation. all the vzv manifestation occurred in patients who ended the anti-viral prophylaxis. median time of presentation was days after asct (range: - ) the remaining patients did not present vzv manifestation nor other kind of opportunistic infection despite the absence of anti-viral prophylaxis. the analysis of lymphocyte sub-population after - - and months did not show a significant difference in b, t, t , t and nk lymphocytes in the different post transplant period. conclusions: vzv reactivation seems not to be correlated with the number of the different lymphocyte subpopulations in the post transplant period. actually it is not possible to distinguish patients more suitable of vzv reactivation on the basis of lymphocyte sub-populations analysis, so anti-viral prophylaxis should be prolonged for a medium period after suspension of immuno-suppressive drugs. in absence of anti viral prophylaxis a careful clinical surveillance should be performed in order to treat early eventual vzv manifestations. disclosure background: infection and disease cytomegalovirus (cmv) are common problems in patients undergoing hematopoietic stem cell transplantation (hsct). cmv infection has a high overall seroprevalence, therefore, during the first days post-hsct, it is important to prevent reactivation of cmv. the international clinical recommendation is the use of ganciclovir as prophylaxis in hsct patients; however, the cost of this treatment is not accessible for our population. in this respect it has been used as an alternative valganciclovir because of its lower cost and oral administration. our study´s aim was to assess the response and safety of valganciclovir in comparison with ganciclovir to prevent viremia and cytomegalovirus disease in patients undergoing allogeneic hsct methods: a retrospective study was performed on patients who receive an hsct-allo between january and august . participants were enrolled in two groups according to prophylaxis treatment: (a) ganciclovir mg/k once daily and (b) valganciclovir mg twice daily for days pretransplant, at day + ; viremia was measured by pcr. demographic and clinical information was collected from medical records and furthermore analyzed in spss v . results: sixty-eight patients were enrolled in the study, % male, the median age was years ( - ) with the following diagnoses: acute lymphoblastic leukemia %, acute myeloblastic leukemia . %, granulocytic chronic leukemia . %, myelodysplastic syndrome . %, dendritic cell neoplasia . %, and aplastic anemia . %. ninety-one percet of the patients received a transplant from an identical hla donor and . % received a haploidentical transplant. thirty-four patients received ganciclovir (g ) and thirtyfour valganciclovir (g ). median age was vs years (p= . ), intermediate risk cmv % vs (p= . ), associated bacterial infections was %vs % (p= . ), and fungal infections % vs % respectively (p= . ). the reactivation by cmv was presented in % vs % respectively (p= . ). there were no significant differences in fever, bacterial isolation, dysfunction or graft failure, presence and degree of acute or chronic gvhd and relapse of the disease. the most relevant characteristics and complications are described in table . within the whole group there were deaths, % in the ganciclovir group and % in valganciclovir group (p= . ), overall survival -year was % vs % (p= . ) respectively; in both groups % was associated with relapse and % associated with transplantation. conclusions: ganciclovir and valganciclovir were effective in preventing the reactivation of cmv, the only statistically significant difference was that the presentation of the disease appeared earlier in the valganciclovir group. no difference in toxicity between the groups was identified. disclosure: none declared background: invasive pulmonary aspergillosis (ipa) is a severe and serious complication that occurs in the immediate post-transplant period due to severe neutropenia or late usually following prolonged corticosteroid therapy during treatment of graft-versus-host disease (gvhd). the objective of this study is to analyze the epidemiological, diagnostic and evolutionary characteristics of this major complication over a period of years. methods: from january to december , patients (pts) received an allogeneic hematopoietic stem cell transplantation (allo hsct) for malignant and nonmalignant haematological diseases. during the transplant procedure, anti-infectious prophylaxis consisted of pts isolation, digestive decontamination, fluconazole and aciclovir. secondary prophylaxis done for pts with prior history aspergillosis. during the follow-up, a standard chest x-ray is performed systematically at each control or in case of clinical signs a thoracic ct scan is requested from suspicion. the diagnosis of ipa is made according to the criteria of the eortc-msg based on the predisposing criteria of the host and clinico-radiological criteria (possible infection). galactomannan antigen and histopathology criteria are not common practice. results: a total of ipa episodes ( %) were identified in pts (aml: , aa: , all , cml , mm ) of median age ( - ) , sex ratio: . . all of them had transplantation from a family donor (geno-identical: , haplo-identical: ) with conditioning by chemotherapy alone and a graft of csp ( pts) and peripheral stem cells-bone marrow ( pts). all pts had at least one predisposing risk factor: antecedent of aspergillosis ( pts), prolonged neutropenia> d ( pts), acute gvhd ( pts), chronic gvhd ( pts), prolonged corticosteroid therapy ≥ , mg /kg/day exceeding days ( pts). the diagnosis of api was possible on average at j ( - ) after appearance of clinical signs (in all cases) and evocative radiological in cases (in cases, the standard chest x-ray was normal). at the time of thoracic ct scan, pts ( %) had characteristic signs: halo sign ( pts), crescent sign ( pt) and cavity ( pts). other minor radiological signs are found in the other pts. empirical first-line antifungal therapy was started as monotherapy in pts (voriconazole: , caspofungin: pts) or in combination in pts. a secondline treatment was required in pts for failure after an average duration of days . three pts presented a second episode after an average delay of months ( ) ( ) ( ) ( ) with a favorable evolution of resumption of thetreatment. fourteen pts ( %) are alive with complete resolution after a median treatment time of months ( - ). twelve pts ( %) died rapidly on average days after diagnosis (ipa , relapse of his disease: ) conclusions: ipa occurring after an allograft of allo-hsct is a severe complication with high mortality. it is essential, in each case, to identify the pts with risk factors, perform a thoracic ct-scan, send serum serology for apergillus galactomannan antigenand start specific treatment as soon as possible while waiting to be able to reinforce the diagnosis by direct examination or sputum or brochoalveolar lavage with aspiration. disclosure: nothing to declare background: cmv (cytomegalovirus) has a prevalence varying between - %. its pathogenicity is relatively low in the general population, usually resulting in a selflimiting viral illness. in an immunosuppressed host, infection can lead to life threatening illness. disseminated cmv infection can manifest in a number of organs and is diagnosed using internationally accepted criteria. in the post solid organ and stem cell transplant (sct) setting, it is postulated that it is viral reactivation, rather than primary reinfection that leads to cmv viraemia. prevention of reactivation requires the presence of a competent immune system, mediated by t-cells. this accounts for the increased incidence in intensive and t-cell depleting sct conditioning regimens. despite improved outcomes following the introduction of cmv monitoring by pcr and pre-emptive treatments (current uk guidance), cmv pneumonitis still carries a high mortality. the use of cmv specific immunoglobulins (cmvig) for the treatment of this complication is generally not recommended post chemotherapy or sct in haematological cancers due to lack of evidence. however, cmvigs are widely used in the setting of cmv reactivation post solid organ transplants. we report the use of cmvig in patients with suspected cmv pneumonitis at a single uk centre. the aims of this retrospective study were to establish safety and review efficacy in this highly immunocompromised group of patients. methods: data was collected retrospectively on the use of cmvig in patients with haematological cancers post sct or chemotherapy alone between and at manchester royal infirmary, uk. all patients included had cmv positive pcr in blood (and or from bronchoscopy), as well as high resolution ct imaging evidence of cmv infection. the data was sourced from pharmacy database and crossreferenced with a departmental list. for each patient identified, case notes and prescriptions were sourced. data collected included patient baseline characteristics, timing of treatment, number of doses of cmvig and outcome. results: eight patients received cmvig for suspected cmv pneumonitis. seven patients were post sct and one patient was severely immunosuppressed with chemotherapy alone. median age was years (range - ). the cmvig regimen used was ml/kg of cytotect ® on days , , and , followed by ml/kg every four days until resolution of symptoms. there were no infusion related reactions observed. patients received a median of doses of cmvig. four out of patients responded to the treatment and showed full recovery but only are alive and well to date. conclusions: this study shows that the use of cmvig is safe in the post-sct setting of acutely unwell patients with multi-organ failure. despite limitations of retrospective studies, there appears to be benefit for the use of cmvig in our patient population, with % of patients showing a full recovery from that episode. allogeneic sct plays a confounding role in the outcome of patients although the numbers in our study are small. there is clearly a need for better treatments of cmv pneumonitis. cmvig is a promising treatment but further studies are needed to identify the optimal dosing regimen and provide evidence of efficacy. disclosure: biotest-honaria p abstract withdrawn. background: the risk of fungal infection related to allogeneic transplantation is a well-known cause of morbidity and mortality. the main agents implicated are yeast during the neutropenic period and filamentous fungi after this period. methods: we decided to evaluate the effectiveness of a prophylactic regimen containing fluconazole since day - . after discharge fluconazole was kept until day or or switched to posaconazole in high-risk patients. patients with gvhd under steroids were kept under prophylaxis.the group of high risk patients was defined by one of the following variables: -non related donors -atg, campath or fludarabine in the conditioning -presence of gvhd with need of steroids above . mg/kg we have analyzed the patients submitted to allobmt during and . all patients were first admitted to an isolation room with hepa filters.patients under secondary prophylaxis were excluded. breakthrough fungal infections during the first year and toxicity leading to discontinuation was evaluated. results: sixty six patients were included with transplants. male/female ratio was / . the age range was . - yo with a median of . malignant ( ) and nonmalignant ( )diagnosis were included. donor type was related ( ) haploidentical ( ) and non-related ( ). the conditioning regimen includes atg in , campath in and fludarabine in . fourteen patients were treated after discharge with fluconazole and with posaconazole. three patients fluconazole were switched to micafungin for hepatic toxicity, two cases to amphotericin due to persistent fever and in one case to caspofungin for a proven fungal infection (candida parapsilosis in blood stream in day + ). after discharge and during the first year of follow-up a single case of possible fungal infection was diagnosed, in a patient with gvhd with a lung nodule. conclusions: during the neutropenic period after transplantation the main risk of fungal infection is associated with candidiasis. the greatest risk of aspergillosis occurs later and have a significant relation with gvhd. except for candida parapsilosis the main source of yeasts are the gi tract. the main source of aspergillus are aerosolized particles retained by hepa filters. in patients without a previous episode of fungal infection the main risk of filamentous fungi occurs only after discharge. we conclude that fluconazole alone or followed by posaconazole in high risk patients is a feasible and effective regimen for primary prophylaxis, in allogeneic transplantation. disclosure background: bk virus-associated hemorrhagic cystitis (bkv-hc) has emerged as a serious infection after hematopoietic stem cell transplantation (hsct). it is characterized by painful hematuria due to hemorrhagic inflammation of the urinary bladder mucosa, this causes significant morbidity, prolonged hospital care with extensive nursing requirements and increases in healthcare costs. the purpose of this study is to determine the incidence, risk factors, and duration of treatment in our center. methods: we performed a retrospective review of hsct patients at luis calvo mackenna children´s hospital in santiago, chile diagnosed with bkv-hc, from st january to th november . we investigated the incidence, risk factors and duration of treatment of bkv-hc in paediatric patients undergoing hsct over a months period. bkv-hc was defined as bk virus (bkv) detection in urine by pcr testing in association with clinical symptoms and hematuria grade or higher. sixty-seven patients were trasplanted during this period. results: eleven patients were diagnosed with bkv-hc at our institution, only one with bk viremia. the cumulative incidence of bkv-hc in our series was %. all of them were treated with cidofovir. the median age at diagnosis was years old (range: - y.o.). the median time from hsct to hemorrhagic cystitis (hc) was days (range: - days), the median length of treatment was weeks (range: - ). all patients received myeloablative conditioning regimens and used cyclophosphamide ( %); ten ( %) were unrelated cord blood transplant recipients and nine ( %) used antithymocyte globulin. a concomitant viral reactivation (cmv/vh ) was demonstrated in six ( %) patients. no patient died due to bkv-hc or its complications, but in the follow up three patients died, one in relapse and two of other post transplant´s complications. conclusions: bkv-hc is the result of a complex interaction between patient characteristics, donor type and conditioning regimen intensity. these patients experienced significant morbidity and prolonged treatment. in our cohort bkv-hc of all patients but one were transplanted with an unrelated umbilical cord blood unit, all of them received myeloablative conditioning regimen with cyclophosphamide and most of them received anti-thymocyte globulin. we also observed frequently co-existence of viral infections from herpes family as cmv and vh . the main limitations of this work are its retrospective nature and it´s from a single center. more studies are necessary to better understand the epidemiology and risk factor associated with bkv-hc and the morbidities associated with its treatment. disclosure: nothing to declare how we manage hhv- reactivation in the posttransplant setting oscar borsani , anna amelia colombo , daniela caldera , paolo bernasconi university of pavia, san matteo hospital, pavia, italy background: hhv- encephalitis is a life-threatening complication in the post-transplant setting and it develops in about % of patients receiving traditional hsct. several risk factors were described. a differential diagnosis between hhv- encephalitis and other neurological complications is extremely important but often not-easy to achieve because of the highly heterogeneous clinical and radiological features and complexity of interpretation, especially in transplanted patients. here we described vignettes that represent and highlight distinct problems in the diagnosis and management of transplanted patients with suspected hhv- reactivation. methods: we collected the clinical, laboratory and radiological (electroencephalogram, brain mri and brain ct) data of transplanted patients who developed a neurological syndrome suspected for hhv- reactivation. hhv- was detected on serum and csf using rt-qpcr. results: ) a -years-old patient developed a diffuse erythema and subsequent encephalitic syndrome following hsct. the brain mri revealed clear signs of limbic encephalitic and searching for hhv- on serum and csf revealed . copies/ml and . copies/ml respectively. an antiviral therapy was started but no clinical benefit was achieved. ) a -years-old patient developed a typical neurological syndrome without brain mri findings of encephalitis and with no evidence of skin involvement. the lumbar puncture and csf analysis showed a total of . hhv- dna copies/ml. antiviral therapy with ganciclovir and foscarnet was promptly started with clinical improvement and a drastically reduction of hhv- dna on both csf and serum. a new brain mri revealed an acute limbic encephalitis. ) a slight neurological syndrome consisting of confusion and amnesia developed in a -years-old-patient. brain mri findings were compatible with a wernicke syndrome, but no improvement of neurologic symptoms were obtained with thiamine supplementation. csf analysis did not revealed hhv- dna, which was detected at low copies number on serum analysis. a second brain mri was conclusive for limbic encephalitis, so an antiviral therapy with foscavir was started and radiological but not clinical improvement was noted. the patient died after few days. ) in the last case we present a -years-old patient who developed a clinical picture of encephalopathy (i.e. amnesia, ataxia, drowsiness, weakness, depression) with rapid progression to coma after seventy-eight days from hsct. a brain mri showed a slight contrast enhancement in parietal-occipital regions. during the recovery phase from conditioning-induced cytopenia, an increasing in serum hhv- dna was detected. searching for hhv- dna on donor's follicles showed a chromosomally integrated hhv- (cihhv- ). cyclosporin a (csa) was interrupted and neurological improvement was observed in the following hours: a diagnosis of pres was made. conclusions: hhv- encephalitis should be suspected in transplanted patients with a clinical syndrome of encephalopathy. pcr detection of hhv- dna in csf associated with either typical brain mri abnormalities or a clinical diagnosis of nonspecific encephalopathy must lead to the urgent initiation of systemic antiviral treatment. if an increase of both serum hhv- dna and wbc is detected, a cihhv- should be confirmed. pres is an important differential diagnosis in transplanted patients which developed an encephalitic syndrome. disclosure: nothing to declare background: cytomegalovirus (cmv) infection is a major cause of morbidity and mortality after hematopoietic stem cell transplantation (hsct). it causes end-organ disease, multi-organ dysfunction syndrome, graft failure, increased susceptibility to infections and gvhd. greatest risk of cmv infection in a seropositive host is the reactivation of latent virus. methods: a prospective descriptive study performed at armed forces bone marrow transplant centre, rawalpindi, pakistan from dec to sep . hundred consecutive patients who underwent hsct were followed with weekly cmv dna quantitative pcr from engraftment till day for cmv reactivation. patients in whom cmv pcr showed more than copies/ml were treated with antiviral therapy. factors associated with cmv reactivation, outcome of antiviral therapy and effect of cmv on transplant outcome is studied. results: out of cases, were hla matched siblings, were matched family donors and were haploidentical transplants there were males and females. mean age was . ± . years. fourty-two transplants were done in thalassemia, in aplasia, in leukemias and in other hematological disorders and immune deficiencies. ninety-eight recipients and all the donors were cmv seropositive before hsct. cmv reactivation was seen in patients and of them had cmv viral load more than copies/ml and patients had cmv viral load less than copies/ml. nineteen patients had no cmv reactivation. mean time to reactivation since transplant was ± days. valganciclovir was given in patients due to ease of administration and six patients were treated with ganciclovir during their hospital stay. only one patient had resistant disease. mean time to clear viremia was ± . days. the patients having viral load less than copies/ml, subsequently cleared cmv without any treatment. antiviral agents; ganciclovir and valganciclovir were equally effective for treating cmv infection with % efficacy, however, more adverse effects were seen with ganciclovir. myelosuppression i-iii was seen in % patients treated with valganciclovir and in % treated with valganciclovir. renal impairment i-ii was seen in % of valganciclovir and % of ganciclovir treated patients. steroid administration was strongly associated with cmv reactivation (p = . ). no statistically significant association was found with the use of atg, gvhd, underlying disease, abo or gender mismatch. os was . % and . % in with and without cmv reactivation (p= . ) and dfs was . % and . % in with and without cmv reactivation (p= . ) conclusions: cmv reactivation was seen in % of the transplant recipients, this is higher compared to the western world due to high cmv seropositivity is this region. steroids administration in post-transplant period significantly increase the risk of cmv reactivation. preemptive therapy with valganciclovir effectively treats cmv reactivation with acceptable side effects. viral threshold for treatment should be decided considering the regional endemicity. cmv adversely affects the transplant outcome in terms of dfs and os. disclosure: no conflict of interest. acute nephritis requiring nephrectomy caused by adenovirus (hadv) and human polyomavirus bk (bkpyv) following allogeneic hematopoietic stem-cell transplantation in a patient with ph+ all background: adenovirus infection represents an important cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (allo-hsct), with no established therapy. although different organs may be affected by disseminated hadv infections, kidney involvement has been rarely reported. co-infection of hadv and bkpyv are common complication in patients undergoing allo-hsct, but recent studies demonstrate that bkpyv may facilitate the replication of hadv and lead to elevated viremia with increased virulence and serious clinical consequences. here we report a case of an adult patient who required a monolateral nephrectomy due to hadv pyelonephritis as an early complication of allo-hsct for philadelphia-positive acute lymphoblastic leukemia (ph+ all). methods: in september , an ethiopian gentleman was diagnosed with ph+ all at the age of years. he was treated with polychemotherapy in association with the tyrosin kinase inhibitor imatinib mesylate achieving a complete remission (cr). one year later, due to disease relapse with cns involvement, he was started on vincristine and dexamethasone plus imatinib treatment and in april he was referred to our bmt center from ethiopia. upon confirmation of the p ph+ b-all diagnosis, therapy with the scr/abl dual inhibitor dasatinib associated to intrathecal chemotherapy was started and a salvage treatment with inotuzumab ozogamicin followed by an allogeneic hsct from a hla-identical brother was planned. having achieved a documented molecular cr disease status, in june the patient underwent allo-hsct following the fludarabine-melphalan reduced-intensity conditioning regimen. graft-versus-host prophylaxis included anti-thymocyte globulin, cyclosporine and mycophenolate mofetil results: on day + post-transplantation the patient developed macro-hematuria due to hemorrhagic cystitis and a ct scan unveiled a left pyelonephritis with marked kidney enlargement. kidney microbial investigations were all negative. at the same time, hadv viremia with very high copy number (> cp/ml) was documented and also elevated bkpyv (> cp/ml) viruria and viremia ( cp/ml). the genotyping of hadv evidenced serotype b mainly involved in infections of the urinary tract. treatment with cidofovir was immediately started; nonetheless, due to rapid clinical worsening despite maximal antibiotic therapy, on day + a left nephrectomy was performed, which led to a subsequent progressive resolution of the clinical symptoms and negativization of hadv and bkpyv viremia and viruria. pcr real time performed on the kidney tissue unveiled very high concentration of hadv copy number. conclusions: acute pyelonephritis due to disseminated hadv infection may represent a possible cause of severe complication following allo-hsct. monitoring of hadv copy number is helpful to evaluate infection severity and response to treatment. co-infection of hadv and bkpyv in immunocompromised patients should be always considered likely to worsen clinical course and outcome. disclosure: nothing to declare background: infection is a major cause of morbidity and mortality in patients (pts) receiving an allo-hsct. its severity is related primarily to the depth and duration of neutropenia. febrile neutropenia (fn) is defined as a neutrophil count below cells/mm and a fever ≥ . °c at a single measurement or≥ °c times at one hour intervals. the objective of our study is to analyze the epidemiological, clinical, biological characteristics of febrile episodes (fe) occurred in pts who benefited an allo-csh over a period of years. methods: from january to december , allo-hsct were performed in pts including sibling-hla identical, haplo-identical and phenoidentical for essentially acute leukemia ( pts, %), acquired and congenital aplasia ( pts, %). the median age is years ( - ) and sex-ratio (m/f): . . prophylaxis consisted on isolation sterile room with laminar flow, digestive decontamination, fluconazole and aciclovir. nine pts ( . %) were infected at the time of hospitalization (cellulitis , pneumoniae , bacterial angina , veinitis , bronchial pneumonia , furuncle cutaneous ) requiring treatment with antibiotics. conditioning regimen is myeloablative in all pts. anti-thymocyte globulin is used in pts ( . %). peripheral blood stem cells (pbsc) are used in pts ( %) with an average level of cd + cells: , . /kg ( . - . ) , bone marrow (bm) in pts with a mean level of nucleated cells: . x /kg ( . - . ) and the association of pbsc-bm in pts (haplo-identical). at each fe, are practiced: chest x-ray, procalcitonin test, blood culture, microbiological study of urine and stool (if diarrhea). results: all pts showed aplasia with an average duration of days ( - ), neutrophil engraftment was observed at day ( - ). one hundred and twenty-nine pts ( . %) presented fe with an average of . per pt. eleven pts ( %) had fe or more. forty nine ( , %) fe are clinically documented (digestive: , skin: , pulmonary: , urinary: , oto-rhino-laryngology: ). the blood cultures are made at fe, fe are microbiologically documented ( %): gram-positive bacteremia in % (mainly coagulase negative staphylococci) and gramnegative bacilli in % of cases. procalcitonin test performed during fe: normal ( cases), probable infection ( cases), probable sepsis ( cases), severe sepsis ( cases) and septic shock (one case). empirical double antibiotic therapy is initiated in pts without waiting for the results of the microbiological study. this association was sufficient in pts ( %). the transition to a second line was needed in pts ( . %) and third line in pts ( %). antifungal is added in cases ( %). eight pts benefited from g-csf. the evolution is favorable in fe ( . %), apyrexia obtained after an average of . days . three pts died ( %) by severe sepsis on a durable aplasia, of which had a cellulitis before the conditioning. conclusions: fe increase morbidity and mortality in allo-hsct so prophylactic measures are essential. empirical antibiotics treatment has to be instituted very quickly in the absence of documentation. disclosure: nothing to declare p abstract withdrawn. atsushi satake , masaaki hotta , ryo saito , akiko konishi , hideaki yoshimura , takahisa nakanishi , shinya fujita , tomoki ito , kazuyoshi ishii , shosaku nomura kansai medical university, osaka, japan background: cytomegalovirus (cmv) infection remains a common complication after allogeneic hematopoietic stem cell transplantation (ahsct), which results in increased morbidity and mortality. letermovir is a novel anti cmv drug that inhibits the cmv-terminase complex. the purpose of this retrospective study is to elucidate the efficacy and safety of cmv prophylaxis with letermovir early after ahsct in clinical practice. methods: we retrospectively analyzed the incidence of cmv infection, cmv disease, preemptive therapy, adverse events through week after ahsct, the rates of engraftment and overall survival. all patients underwent ahsct in our institution for hematopoietic malignancies between may and nov . data collected in this study included patient's characteristics such as age, sex, disease status, donor source and cmv disease risk. cmv infection was evaluated by cmv antigenemia. this study was approved by the research ethics committee of the faculty of medicine, kansai medical university. results: thirteen patients (male , female ) underwent ahsct and received cmv prophylaxis with letermovir. the median age was years (range, - years). overall, of patients ( . %) were considered to be at high risk for cmv, including patients ( . %) with haploidentical donors, and ( . %)with mismatched, unrelated donors. all patients began letermovir from day after ahsct, and achieved engraftment (median , - days). no patient developed cmv disease and required preemptive therapy. one patient died of treatment-related mortality, and patients died of acute gvhd. although one patient discontinued letermovir before day after ahsct because letermovir was suspected to be a cause of persistent nausea, severe adverse events were not observed. conclusions: it is still unknown whether cmv prophylaxis with letermovir improves os and reduces trm; however, our data suggests that cmv infection is considerably inhibited by administration of letermovir early after ahsct. clinical trial registry: not applicable. disclosure: the authors declare noconflicts of interest for this study. background: cytomegalovirus (cmv) is cause of increased morbidity and mortality after transplantation of hematopoietic cells. the pathogenesis of cmv disease or infection is complex with multiple interactions with the immune system, mainly in acute and chronic graft-versus-host disease (gvhd). the aim of this study is to analyze the risk factors for the reactivation of cmv in patients undergoing allogeneic hematopoietic cell transplantation (hct). methods: prospective descriptive study of the risk factors for the reactivation of cmv in the described population. univariate and multivariate analysis of the predisposing factors were performed: donor graft, treatment with corticosteroids, use of antithymoglobin, serologic status, conditioning regimen and the presence of gvhd. results: during the period between august until january , patients were evaluated. . % (n: ) had reactivation of cmv. average reactivation was days post transplant. both (recipient and the donor) had positive cmv igg in . %. in the univariate analysis, the reactivation of cmv was associated with haploidentical transplantation (p: < . ), with the use of corticosteroids (p: < . ) and gvhd (p: < . ). in the multivariate analysis, the haploidentical transplant maintained its statistical significance in comparison with the related allogeneic transplant (p: . , or: . ; ic %: . - . ) as well as the use of corticosteroids (p: . , or: . ; ic %: . - . ). % of patients receiving corticosteroid treatment had grade ii / iii gvhd. the serologicac status, myeloablative conditioning regimen and the use of atg showed no statistically significant association. conclusions: in patients undergoing allogeneic transplantation, were found as risk factor to reactivation, those who received haploidentic transplantation and treatment with corticosteroids. another risk factor that showed greater reactivation was the presence of gvhd. disclosure: nothing to declare methods: a y/o male was referred for allogeneic transplant following cycles of induction therapy for aml with complex karyotype and axsl mutation having achieved complete remission following the first cycle of chemotherapy. his first induction cycle was complicated by a perianal myeloid sarcoma which became infected and required surgical drainage and formation of a defunctioning colostomy. results: following allogeneic transplants, the first complicated by secondary graft failure and the second by primary graft failure he presented with two skin lesions, with a third lesion adjacent to his stoma developing shortly after admission. all lesions were erythematous with central necrosis and progressed rapidly in size over hours. biopsy of the skin and para-stomal lesions revealed fungal mycelia, with culture subsequently identifying rhizopus oryzae. initial treatment was with liposomal amphotericin b mg/kg/day followed by dose escalation to mg/kg/day due to the development of new skin lesions. the patient had been taking posaconazole (tablet) prophylaxis since his first allogeneic transplant and peripheral blood drug levels checked at the time of admission were therapeutic confirming that this was a breakthrough fungal infection. consequently posaconazole was stopped and isavuconazole added to the treatment regimen. surgical assessment was undertaken but surgery was deferred on the basis of high risk due to the extent of the infection and the patient´s profound pancytopenia. the organism was tested for in vitro susceptibilitiy and found to be resistant to posaconazole (mic > mg/l), with borderline resistance to isavuconazole (mic mg/l) and sensitive to amphotericin b (mic . mg/l) (phe mycology reference laboratory, england). isavuconazole was therefore stopped and the patient was managed with liposomal amphotericin b along with daily granulocyte infusions. he underwent a third allogeneic transplant using a different unrelated donor and stable engraftment was achieved. post transplant there was initially an increase in the size of the para-stomal lesion, but no new skin lesions developed. following engraftment he underwent resection of the stomal lesion, with primary closure and re-siting of his stoma. amphotericin b was replaced by isavuconazole prophylaxis on discharge and he continues to make an excellent recovery. conclusions: whilst aspergillus species remain the most common cause of invasive fungal infections in allogeneic transplant patients, other species including the mucorales are seen, and generally associated with poorer outcomes. whilst there are standardised methodologies for susceptibility testing, fungi specific cut offs based on clinical outcomes are only available for a limited number of species/ antifungal agents. in this case, susceptibility testing demonstrated resistance to posaconazole which was consistent with the clinical presentation of invasive infection despite therapeutic levels of posaconazole. it is also worth noting that an estimated % of r. oryzae isolates in the uk are resistant to posaconazole. treatment with high dose amphotericin b resulted in improvement in small skin lesions with stabilisation of the larger stomal lesion until count recovery allowed surgical resection. background: total depletion of innate and adaptive immune cell populations occurs after intensive chemotherapy and hematopoietic stem cell transplantation (hsct). both t and b lymphocyte pools are restored slower that myelomonocytic populations. hsct patients are at high risk for bacterial and viral infections at early terms (< days) post-transplant. the reconstitution of the immune system depends on the time required for stem cell recruitment, differentiation, expansion, maturation and release into the bloodstream. restoration terms for myeloid cells after hsct are usually defined as the st day with neutrophil count of ≥ . x ^ /l with mean recovery terms of to days. high occurrence of cytomegalovirus (cmv) in hsct patients mostly result from reactivation of a latent virus acquired in early childhood. however, delayed immune reconstitution and subsequent infections such as cmv, adenovirus (adv) or herpes (hhv- ) diseases are not unusual and still constitute a major cause of death in peru. methods: peruvian pediatric patients (n= ) diagnosed with aplastic anemia, mds, aml or all underwent a haploidentical hsct performed with the clinimacs device. patients treated were separated in two groups. the group of patients who received viral prophylaxis (ganciclovir) was compared to the group that did not receive any prophylaxis treatment. viral reactivation was confirmed by pcr test twice a week and clinical signs within days after hsct. results: in the group that didn´t received prophylactic treatment, engraftment occurred close to day post haplo-hsct and none of the patients developed gvhd (graft versus host disease). nevertheless, incidences of cmv, hhv- and bkv infections before day post haplo-hsct were still high. an overall survival (os) over % with an ic % was reached at the end of the first year. on the other hand, the group of patients that received prophylaxis with ganciclovir did not developed gvhd and reached the engraftment close to day with a very low viremia incidence after the first month post haplo-hsct. all viral reactivations were caused by cmv and the os was over % with an ic % at the end of the first year. previous prophylaxis to both the donor and the receptor with ganciclovir ( mg/kg) every hours before and during the conditioning regimen has allowed a better control of viral reactivation. conclusions: the attempts to improve immune function and reduce nonrelapse mortality from infectious complications without increasing gvhd have focused on a partial t cell depleted graft, such as t cell depletion (tcr α/β). this graft retains a large numbers of effector cells, such as tcr γ/δ and natural killer cells. however, delayed immune reconstitution and subsequent infections are a big issue. a novel partial t cell depletion strategy such as depleted naïve t cells (cd ra+ t cells) could enhance the recovery of immune function after haplo-hsct because donor pathogen memory t cells from the donor are retained. it is necessary to increase the studies and the database to set the scheme of previous prophylaxis to the recipient to contain the viral reactivation and to help a rapid immune reconstitution. disclosure: no conflict of interest is declared information was recovered from the medical records. results: thirty-four patients were included, of them with the following diagnoses: acute leukemia ( ), granulocytic chronic leukemia ( ), dendritic cell neoplasia ( ), aplastic anemia ( ). % of the patients received a transplant from an identical hla donor and % received a haploidentical transplant. mean age's patients was years ( - ). prophylaxis with posaconazole was performed on % of the patients with identical hla and % on haploidentical group; the rest of the patients received fluconazole. the posaconazole group presented: fever %, mucositis gi-ii %, gastrointestinal toxicity gi-ii % (p= . ), hepatic toxicity %, kidney toxicity %, oral candidiasis %. during this period none of the patients presented invasive fungal infection in any group. there were deceases, one on each group and none related to a fungal infection. the overall survival was of the % versus % on the posaconazole group and the fluconazole group respectively. conclusions: the prophylaxis with posaconazole and fluconazole is effective on the prevention of invasive fungal infection on the first days. the toxicity was similar on both groups. posaconazole can be effective on the prevention of the haploidentical type. is necessary to continue following the patients with infection risk on a long-term period associated with the chronic gvhd. disclosure: none declared lymphoma these results open the question whether allo-sct should still be offered to these patients. methods: we aimed to define the role of allo-sct in refractory or relapsing after two lines de novo or transformed dlbcl patients, and its comparison with zuma- car-t cells trial (neelapu et al nejm ). we analyse long-term allo-sct results in de novo (n= ) or transformed dlbcl (n= ) out of the allo-sct performed in our institution between october to october . results: patients and transplant characteristics are summarized in table . complete response (cr) at days was , % and % of them remain in cr at months. with a median follow-up of months, -year progression-free survival (pfs) was % and -year overall survival (os) %, with a -year transplant-related mortality of %. refractoriness at the time of the transplant was associated with a poorer prognosis, with only out of refractory patients being long term survivors (figure ). similar results were reported for zuma- trial, with a best response of % cr retained in % of them at months. with a median follow-up of months, -months pfs was % and -months os %. patients characteristics did not differ in our series and zuma- , except that all the patients in zuma- were refractory prior to therapy (table ) . conclusions: although very few patients with de novo or transformed dlbcl are offering an allo-sct ( % of all allo-sct), this is a curative option in chemosensitive patients and with more mature data and longer follow-up than with car-t therapy; for these reasons, it should still be offer to these poor prognosis patients. moreover, almost all patients have now available donor, better graft-versus-host disease prophylaxis will decrease trm and morbidity, and new therapies will make more patients in sensitive disease before allo-sct. therefore, allo-sct and car-t cells are strategies to be discussed in every young patient with available donor. disclosure: honoraria as advisor or speaker from gilead ( methods: consecutive patients transplanted for hgbl (excluding burkitts lymphoma) between - in the ebmt database were included. data collected included age, sex, pathology subtype (hgbl (including subtypes), tfl, dhl), disease status at sct, conditioning (ma vs beam cam vs flu-mel-cam/atg), engraftment, day outcome, trm, os and pfs and eligibility for emea licensed indication of car-t therapy. results: fifty patients ( m, f) with a median age of at diagnosis and at sct were included. the subtypes included hgbl (n= ), tfl (n= ) and dhl (n= ). indications for sct were: primary refractory (n= ), relapse < months after primary treatment (n= ), previous autologous-sct (n= ) and dhl (n= ). the median lines of therapy was (range to ). conditioning used was cytbi n= , bu/cy n= , etop/tbi n= , flubucy n= , beamcam n= , fmc/t, n= . all patients engrafted with neutrophil > . /l at median days and platelets > /l at median days. the day mortality was % (progressive disease %, nrm %) with a year os of % and mortality due to progressive disease % and nrm %. disease subtype influenced outcome with an os for primary refractory hgbl, relapsed hgbl, tfl and dhl respectively of %, %, % and %. patients were eligible for a licensed car-t product. conclusions: the outcome of these high risk hgbl patients have an acceptable os of %, with relapsed disease being the commonest cause of mortality. patients with dhl have a particularly good outcome in this series; recent evidence indicates that some of these patients with a non-immunoglobulin gene associated myc translocation could be managed more conservatively (ash sehn). the outcomes achieved with allogeneic-sct in this series will provide a baseline for outcome assessment with a cart program. disclosure: nothing to declare background: immune checkpoint inhibitors (ici) allow to achieve a durable remission in patients with resistant or refractory (r/r) classical hodgkin lymphoma. however, the information about optimal duration of therapy and the prognosis of the patients after ici cessation is limited (manson, blood ). therefore, the optimal role of hematopoietic sct (hsct) in this patient group is not defined. our aim was to determine remission duration in patients who discontinued ici monotherapy after achieving complete remission (cr). methods: this analysis included patients ( male/ female) aged to (median years) with r/r classical hodgkin lymphoma who were treated with nivolumab ( mg/kg every days) and achieved cr. response was assessed by positron-emission tomography/computed tomography (pet/ct) using lyric criteria every month. after nivolumab therapy had been stopped the patients received no other treatment and disease was assessed every months by pet/ct. median follow-up after therapy discontinuation was ( - ) months. results: at the moment of therapy initiation ( %) patients had stage disease, ( %) patients had progressive disease (pd), ( %) patients had stable disease, ( %) patients had partial remission and ( %)complete remission; ( %) patients had b-symptoms and ecog score > . the median number of previous therapy lines was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . before nivolumab initiation high dose chemotherapy with autologous sct was performed in patients ( %) and ( %) received brentuximab vedotin. the median number of nivolumab cycles was ( - ). cr was achieved after median of ( - ) cycles. the median duration of therapy after achievement of cr was ( - ) months. at the time of analysis, all patients were alive, ( %) out of patients relapsed after therapy discontinuation. the median progression-free survival (pfs) for the total group was not achieved. among patients with relapse, the median time before pd was ( - ) months. after relapse all patients were retreated with nivolumab monotherapy or with chemotherapy combination. one patient achieved complete remission; -partial remission; -indeterminate response type . other patients are continuing the therapy and their response has not yet been evaluated. conclusions: while complete response was maintained in some patients at median follow up of months after nivolumab therapy cessation, the pfs plateau was not reached. we report that patients with relapse after nivolumab discontinuation sustained sensitivity to nivolumab and achieved a response during retreatment with nivolumab monotherapy or with chemotherapy combination. in patients with unsatisfactory response to nivolumab retreatment, hsct option should be considered. disclosure: nothing to declare high dose chemotherapy with autologous stem cell transplantation in primary central nervous system lymphoma: data from the japan society for hematopoietic cell transplantation (jshct) registry center hospital, tokyo, japan, national cancer institute, bethesda, md, united states, okayama university hospital, okayama, japan, kanazawa medical university, uchinada, japan, kyoto university, kyoto, japan, aomori prefectural central hospital, aomori, japan, yamagata unversity school of medicine, yamagata, japan, tenri hospital, tenri, japan, hiroshima university, hiroshima, japan, japanese data center for hematopoietic cell transplantation, nagoya, japan, nagoya university graduate school of medicine, nagoya, japan, shimane university hospital, izumo, japan background: high-dose chemotherapy (hdt) with autologous stem cell transplantation (asct) has been shown to improve prognosis of patients with central nervous system (cns) lymphoma. whereas the common regimen of hdt for pcnsl in the europe and the us is thiotepa-based regimen, e.g. bcnu-thiotepa, tbc (thiotepa-busulfan-cyclophosphamide), thiotepa-based regimen was only available before discontinuation of thiotepa in in japan. we report the results of asct for pcnsl from the japan society for hematopoietic cell transplantation (jshct) registry. methods: data from the jshct registry were retrospectively analyzed. patients with pcnsl who received first hdt/asct between and were evaluated. distribution differences of clinical characteristics between groups were analyzed with fisher´s exact or mann-whitney u tests. overall survival (os) and progression free survival (pfs) were calculated using kaplan-meier method. two-group analysis of the cumulative incidence of relapse was conducted using the grey test. factors were analyzed in univariable analysis, and all factors with p≤. were retained in the multivariable model. all p values were sided, and values were regarded statistically significant if p< . . results: median age was months (range - ) with patients over years of age; males and females. ecog-performance status (ps) at diagnosis was better (ps - ) in patients and poor (ps - ) in patients. serum lactate dehydrogenase (ldh) levels at diagnosis were elevated in patients. karnofsky ps and cerebrospinal fluid (csf) protein concentration at diagnosis were not collected in the registry. patients were in complete remission (cr), patients were in partial response (pr), and patients were stable disease (sd) or progressive disease (pd) at the time of hdt/asct. after hdt/asct, additional patients achieved cr. with median follow-up period of months, the -year os and pfs were . % and . %, respectively. the was no significant difference in os and pfs between upfront and salvage hdt/asct. since thiotepa, a key agent in hdt/asct for pcnsl, has been unavailable after the discontinuation in japan, the hdt regimens used were not uniform. thiotepa-containing hdt was received by out of patients before , but by out of patients after . thiotepa-containing hdt showed improved pfs (p=. ), lower relapse (p=. ) and a trend toward a survival benefit. in the multivariate analysis, non-complete remission at hdt/asct was an independent predictor for os (hr= . , %ci: . - . , p=. ) and thiotepacontaining hdt remained significant for pfs (hr= . , %ci: . - . , p=. ). [[p image] . os(a),pfs(b) in all patients (n= ) and cumulative incidence of relapse in cr patients (c; n= )] conclusions: our results confirm the activity of thiotepacontaining regimen for hdt/asct in pcnsl patients. currently a pharmaceutical company re-develops thiotepa for new approval of hdt/asct in pediatric solid cancer and adult lymphoma in japan (japiccti- ). further evaluation with the thiotepa by prospective clinical trials is warranted. disclosure background: t-cell non-hodgkin lymphomas (t-nhl) are rare diseases and they are associated with worse prognosis when compared to their b-cell counterparts. allogeneic stem cell transplantation (allo-sct) may have a curative potential for these patients due to the graft versus lymphoma effect. however, data is limited on the efficacy of allo-sct for these diseases. methods: we identified patients ( % females; median age: y; range, - ) with t-nhl that underwent allo-sct at university hospital eppendorf between and . twenty-one patients (underwent allo-sct from a matched sibling donor (msd) and ( %) from a matched unrelated donor (mud). sixteen patients had ptcl ( %), n= ( %) anaplastic large-cell lymphoma (alcl), n= ( %) angioimmunoblastic large cell lymphoma, n= ( %) adult t-cell leukemia/lymphoma, n= ( %) hepatosplenic gamma/delta t-cell lymphoma, n= ( %) enteropathy associated t-cell lymphoma, n= ( %) tcell-prolymphocytic leukemia, and n= ( %) each extranodal t/nk-cell lymphoma, cutaneous t-cell lymphoma as underlying diagnosis. the median ann arbour stage at diagnosis was (range, - ). ten patients ( %) had bone marrow involvement at diagnosis. all patients were heavily pretreated, ( %) patients relapsed post autologous stem cell transplant (apsct) and one patient post allo-sct. fifteen patients ( %) were transplanted in complete remission (cr) ( in st cr, in nd cr), n= ( %) in partial remission (pr), and n= ( %) with advanced disease. most of the patients received myeloablative conditioning ( %). thirty-eight ( %) patients received total body irradiation based regimens and ( %) received chemotherapy based regimens. twenty patients ( %) received anti-t-lymphocyte globulin (atlg neovii), and most patients ( %) received g-csf mobilized peripheral stem cells. results: overall, patients ( %) had neutrophil engraftment (median days: ; range, - ) . at day , the cumulative incidences of grade ii-iv and grade iii-iv acute gvhd were % and %, respectively. after a median follow up of months (range, - ) the cumulative incidences of chronic gvhd was % distributed evenly between limited and extensive. twenty nine patients ( %) achieved cr after allo-sct. median overall survival (os) and disease free (pfs) survival were months and months respectively. the year os and pfs were % and % respectively. fourteen ( %; % ci [ . - . ]) deaths were due to non relapse mortality (nrm) and patients ( %; % ci [ . - . ]) died due to disease progression. patients with a male donor had improved os compared to those with a female donor ( year os male %, female %; p= . ). patient gender, disease subtype, bone marrow involvement, type of allo-sct, donor, patient cmv status, abo incompatibility, disease stage at diagnosis, previous transplant, disease status at transplant, conditioning regimen, atg and stem cell source had no effect on os, pfs, nrm, and post transplant complications. conclusions: acknowledging the retrospective nature, our study shows that allo-sct induces high rates of complete remission, and may have a curative potential even in diseases relapsing post asct. however our findings need to be confirmed in larger prospective studies. disclosure: no funding, no conflict of interest p abstract already published. at-home autologous stem cell transplantation in lymphoma patients: clinical impact of non-g-csf administration post-transplant background: severe neutropenia remains the main cause of morbidity and mortality after autologous stem cell transplantation (asct). g-csf administration after asct is a common practice, performed to reduce the duration of neutropenia and its complications. in a previous work in patients with multiple myeloma managed at home after asct, we did not observe a deleterious clinical impact in those patients that did not receive g-csf post-transplant (martinez-cibrian n. et al, bmt ) . despite the fact that lymphoma patients receive a more intensive conditioning regimen that multiple myeloma patients, we hypothesized that the use of g-csf in lymphoma patients managed at home during the aplasia phase of asct does not provide a significant clinical benefit. methods: lymphoma patients were managed at-home since day + of asct. between february and july , patients received at-home g-csf μg/kg per day since day + until their anc reached x /l (g-csf group) and, since august , patients did not receive g-csf (non-g-csf group). all patients were conditioned with beam and received prophylaxis with a quinolone, fluconazole, aerosolized pentamidine and low-dose acyclovir (hvs+). in all cases we added primary prophylaxis with piperacillin-tazobactam . g/ h i.v., using a portable intermittent infusion pump (iip), from an absolute neutrophil count (anc) < . x /l until the first day of fever or until attaining an anc of x /l. first-line therapy at home of neutropenic fever (nf) was refrigerated meropenem g/ h i.v using a portable iip. fever was an indication of immediate visit to the hospital, and those patients presenting with focal infection or signs of severe sepsis were admitted. other indications for readmission were: willingness of the patient or caregiver; uncontrolled nausea, vomiting or diarrhea and mucositis requiring total parenteral nutrition or i.v. morphics. results: the main characteristics of the patients are shown in table . there were no differences between groups with respect to gender, diagnosis, stage of disease, comorbidity index (hct-ci), source of stem cells (peripheral blood) and cd + cell dose infused. the median (range) age (years) was ( - ) in g-csf group and in non-g-csf group (p= . ). duration of neutropenia less than . x /l was significantly longer in non-g-csf group, with a median of days (range - ), compared with (range - ) in g-csf group (p < . ). severe neutropenia, less than . x /l, was also longer in the non-g-csf group ( days ( - ) vs. ( - ); p= . ). no differences were observed in the time to platelet engraftment. g-csf post-transplant avoidance did not influence the incidence of neutropenic fever, the first day and duration of fever, the incidence and severity of oral mucositis, bacterial infections documented and number of readmissions. the median duration of the whole procedure at-home was day shorter in the g-csf group ( vs. days; p= . ). conclusions: the policy of not administering g-csf post-asct in our home-based program for lymphoma patients, that include intensive bacterial prophylaxis, did not have a deleterious impact on the main results reviewed, which suggests that elimination of its use can be achieved. disclosure the aim of this study was to analyze the spanish experience with patients diagnosed of nhl who received haplosct with pt-cy. methods: sixty patients who received haplosct with pt-cy in spanish centers from to were analyzed. patients were followed-up until . gvhd prophylaxis consisted in cyclophosphamide mg/kg/d on days + and + , and mmf and a calcineurin inhibitor from day + . results: patients' characteristics are summarized on table . median age of patients was , % male, and diagnosed from t cell lymphoma ( %). most of them didn´t achieve complete response prior to transplant ( %), but only % with active disease. up to % of patients had received previous transplant, from which % was an allogeneic transplantation. source of stem cells was mainly peripheral blood ( %), and reduced intensity conditioning was the preferred ( %) regimen. donors were % siblings ( ), % offspring ( ), and % parents ( ). median neutrophil and platelet engraftment was ( - ) and ( - ) days, respectively. acute gvhd grade ii-iv rate was %, with only patients developing grade iii-iv ( %). chronic gvhd rate was %, and only in ( %) was extensive. median follow-up was months. the -year overall survival and event free survival was % and %, respectively. the -year cumulative incidence of relapse was % and -year cumulative incidence of nrm was %. conclusions: relapsed/refractory nhl are aggressive entities with a fatal course in a short period of time. haplosct with pt-cy permit a new treatment option among these patients, with acceptable outcomes. more studies are needed with a larger cohort of patients and longer follow-up to confirm these results. disclosure: nothing to disclose. higher suv at pre-transplant and day posttransplant pet scan both independently predict inferior survival in patients with diffuse large b cell lymphoma background: autologous stem cell transplant (auto-hct) can cure some patients with relapsed diffuse large b-cell lymphoma (dlbcl) but relapse occurs in about % of patients. while our center and others utilize routine surveillance imaging post-transplant, the utility in this setting is unclear. imaging is costly and exposes patients to radiation. novel interventions are now available for patients relapsing after auto-hct making early disease recognition crucial to intervene prior to clinical progression. hence, we studied impact of post-auto-hct surveillance ( )f-fdg-pet ct at day on transplant outcomes. methods: we analyzed a cohort of consecutive auto-hct recipients with relapsed/refractory dlbcl who then underwent pre-transplant pet/ct and surveillance pet ct at day (interquartile range (iqr): - days) post-hct at the university of minnesota medical center. univariate analysis was performed to analyze pet parameters including deauville score (d), standardized uptake values (suv), total lesion glycolysis (tlg) and total metabolic tumor volume (tmtv) as predictors of relapse and survival after auto-hct. in addition, we assessed outcomes of patients with clinically versus radiographically detected relapsed dlbcl after auto-hct. other pre-hct factors analyzed included age, gender, conditioning regimen, performance status, consolidation radiation therapy, tmtv, suv, tlg. results: five-year cumulative incidence of relapse after auto-hct was % ( %ci to ) and overall survival (os) was % ( % ci to ). twelve ( %) relapsed prior to day . d-score for patients with d pet/ct were d ( %), d ( %), d ( %), d ( %), d ( %) with median survival in years for d , d , d and d of . , . , . , and . , respectively. mean suv varied from . (d ) to . (d ). suv was predictive of relapse and os. risk of relapse increased with doubling of suv; -fold higher suv increased hr by . ( %ci . - . ; p= . ). mortality increased with doubling of suv in both pre-hct ( -fold increase in suv associated with hr . [ % ci . to . ]; p= . ) as well as post-hct pet (hr . [ % ci . to . ]; p= ) irrespective of the bulk of tumor. in addition, risk of death was times higher in d patients relative to d (hr . [ % ci = . to . ]; p≤ . ). patients with d (n= ) had higher tmtv ( cm ) compared to d (n= , tmtv . cm ). the hazard ratio for death following relapse was -fold higher (hr . [ % ci . to . ]; p= . ) if relapse was detected clinically versus only radiographically over a median follow-up time period of . years. other pretransplant patient and disease characteristics did not significantly influenced the outcomes. conclusions: in patients with r/r dlbcl undergoing auto-hct, surveillance pet/ct at day identified patients with poor survival~ year. higher suv in both pre-transplant as well as post-hct pet was predictive of increased mortality. these patients may benefit from novel treatments. [ there are concerns about the risks of nivolumab treatment before and after allo-hsct, due to the risk of heavy gvhd, thus the place of immune checkpoints inhibitors is not yet defined. this report include analysis of our center experience of nivolumab treatment in patients with r/r hl before and after allohsct. methods: we retrospectively evaluated the results of allohsct in patients with r/r chl who had undergone transplant from to . the analysis included patients received the flube conditioning and ptcy gvhd prophylaxis. in group a patients (n= ) received bridge therapy with nivоlumab and in group b patients (n= ) received bridge therapy with brentuximab vedotin or chemotherapy-based bridges. time from the last nivolumab administration to allohsct was at least months. results: at the time of analysis, median follow-up was ( - ) months for group a, and ( - ) months for group b. there was no difference in two-year os (p= , ) with significantly better efs (p= , ) for group a versus group b: % and % vs , % and % respectively. relapse incidence was % for group a versus , % in group b (p= , ). cumulative incidence of non-relapse mortality at years was , % and , % in group a and group b, respectively (p= , ). there was no difference in grade ii-iv ( % vs %, p= . ) and grade iii-iv ( % vs %, p= . ) agvhd, as well as extensive chronic gvhd ( % vs %, p= , ) in groups a and b, respectively. ten patients with relapse after allohsct were treated with different doses ( , - mg/kg) of nivolumab in cic center. at the median follow up of mo ( , - ) all patients remain alive. the objective response to therapy was assessed in patients noted in all patients ( %), disregard the dose of the nivolumab: cr in %, and pr in %. the response was lost in four patients, which required nivolumab retreatment. none of the patients developed gvhd after nivolumab administration. in this analysis, there was also no correlation between dose of nivolumab and incidence and severity of adverse events. conclusions: allohsct in combination with immune checkpoints inhibitors is a good option for patients with r/r chl. consideration for immune-mediated toxicities and the potential for increased graft-versus-host disease remain important. early data suggest that nivolumab may be an efficient therapy in patients with r/r chl relapse after allo-hsct. further research needed. disclosure: the authors declare no conflicts of interest. background: transformation to diffuse large b-cell lymphoma (dlbcl) is considered to be one of the most unfavourable events of lymphoma natural history with poorer outcome as compared to de novo dlbcl (alonso-Álvarez et al, bjh ). in patients suitable for salvage therapy, hematopoietic stem-cell transplantation (sct) could be an option, although its role is not well stablished. we analyse indication and outcome after transplant in transformed dlbcl at a single reference transplant unit. methods: out of total of transplants performed at our unit between and - autologous and allogeneic- were dlbcl transformed from an indolent nhl. of them, received an autologous sct (asct) and an allogeneic sct (allo-sct). results: median age was years old (range - ) and (range - ) for patients receiving asct and allo-sct, respectively. all asct received beam as a conditioning regimen and most of the patients in the allo-sct group received a fludarabine/melphalan combination ( %). gvhd prophylaxis consisted on tacrolimus/sirolimus combination in % and calcioneurin plus methotrexate in %. regarding transplant disease status, ( %) of the asct patients were transplanted in complete response (cr). in the allo-sct group, ( %) patients had received three or more treatment lines before transplant and patients ( %) had received a previous asct, being ( %) in cr, in partial response (pr) and in progressive disease. transplant related mortality (trm) was . % in the asct and % in the allo-sct group. overall survival (os) and progression-free-survival (pfs) at months were % (os), % (pfs) for patients receiving asct and % (os) and % (pfs) for allo-sct. with a median follow up of months for patients receiving an asct, ( %) remain in cr. in the allo-sct group median follow up is months for the whole group and months for alive patients; patients are alive and disease free and have died, due to trm ( %). regarding progression, ( %) have progressed after autologous transplant and after allo-sct. conclusions: indication for hematopoietic sct in transformed dlbcl is stablished in few patients. only % of the patients in our transplant unit receive a transplant due to transformed lymphoma, corresponding to a . % of autologous activity and . % of allogeneic activity. according to our results transplant should be considered a curative option. most of our patients were transplanted in cr, so new agents trying to reach best response before transplant should be considered. [[p image] . eva konirova , antonin vitek , marta krejci , edgar faber , katerina steinerova , david belada , jan novak , juraj duras , petr sedlacek , veronika valkova , andrea janikova , ludek raida , pavel jindra , pavel zak , tomas kozak , marie trnkova , michal karas , marek trneny management. however, differences in patient's characteristics as well as frequency of hsct indication in different lymphoma subtypes have been observed in the last decade. the aim of this study was retrospective analysis of hsct for lymphomas in czech republic. methods: data of adult patients transplanted between years - were retrospectively analyzed using ebmt database. results: between and , autologous hsct (asct) were performed in patients ( men, %) with different lymphoma subtypes. the median age was years (range - ). out of these, ( %) were patients with non-hodgkin lymphoma (nhl), ( %) with hodgkin lymphoma (hl). the nhl group comprised of diffuse large b-cell lymphoma (dlbcl, %), follicular lymphoma (fl, %), mantle cell lymphoma (mcl, %) and t-nhl ( %). the frequency of asct in lymphomas increased from to and has been constant since ( - transplants per year). differences in frequency of asct were observed among lymphoma subtypes -decreasing numbers of dlbcl and fl and increasing numbers of t-nhl and mcl, with asct as part of the induction therapy. between and a total of allogeneic hsct (allosct) were performed in patients ( men, %). median age was years (range - ). out of these ( %) were patients with nhl, ( %) hl. the most common nhl subtypes were fl ( %), mcl ( %), t-nhl ( %) and dlbcl ( %). in the last years the number of allosct for lymphoma is fluctuating around per year. the median age at asct was significantly higher in the years - vs - [ . ( . - . ) vs. . ( . - . ), p < . , fig ] , while the increase at allosct [ . ( . - . ) vs . ( . - . )] did not reach statistical significance (p= . ). with median follow up for allosct, y probability os for patient transplanted in the later period - was in relapsed dlbcl . %, in fl . %, in hl . % and in mcl . %, y os for asct as part of first line therapy in the same period was in mcl . % and in t-nhl . %. os was significantly better in all patients who underwent asct in the years - vs - ( .% vs. . %, p < . ) and there was a trend towards better os in patients after allosct (with . % vs . %, p= . ) (fig ) . conclusions: hsct remains important treatment modality for lymphomas in the era of targeted antibody and molecular therapy and we can transplant older patients due to better supportive treatment. acknowledgment: progress q - uk from the czech ministry of education youth and sports disclosure: nothing to declare background: disease chemosensitivity to salvage treatment has been proven to be a major predictive factor for a favorable outcome after autologous stem cell transplantation (asct) for patients with refractory lymphomas. therefore the importance of effective and safe salvageregimens is indisputable. methods: we retrospectively compared the outcomes in terms of safety and efficacy, in (hl: , nhl: ) patients, with a median age of . ( - ) years, who received as st salvage either dicep [cyclophoshamide ( mg/m ), etoposide ( mg/m ), cisplatin ( mg/ m ), days - , (n= )] or the widely used regimen eshap (n= ). rituximab was additionally given to all cd- positive lymphoma patients. the statistical analysis based on the independent t-test, kaplan meir method and logrank test. results: the reason for salvage treatment was primary induction failure (pif, n= ), early relapse (< months post induction-remission therapy n= ) and late relapsed disease (n= ). more specifically, / patients ( %) in the dicep-group, and / patients ( %) in the eshapgroup were assessed with pif or early relapsed disease, however this difference was not statistically significant. both regimens were well tolerated and no major organ toxicities were noticed. eleven patients ( %) from the dicep-group, while only ( %) from the eshap-group developed febrile infections. all patients were successfully managed with the appropriate treatment and only one, from the eshap-group, required for short period admission to the intensive care unit. after cycle of dicep and cycles of eshap the disease response was re-assessed by pet/ct scan. the overall response rate (> % tumor reduction) was significantly superior for the dicep-regimen, reaching % ( / patients) vs. % ( / patients) for eshapregimen (p= , ). eleven patients ( %) from the dicep-group and ( %) from the eshap-group achieved complete metabolic remission according to pet/ ct criteria (p=ns). the median hospitalization period was ( - ) days for the dicep-group compared to ( - ) days for the eshap-group. however, for the eshapgroup, an additional median of ( - ) hospitalization days were required, since of the non-responders patients received a nd salvage before asct. the mobilization and stem cell collection was successful for both groups, though significant higher number of cd + cells were collected in the dicep-group ( . x /kg vs. . x /kg, p= , ). all but two patients (due to refractory disease) underwent asct. noticeably, the median period from st salvage treatment to asct was significantly shorter for the dicepgroup ( vs. days, p= , ), apparently because non-responders patients from eshap-group treated with a nd salvage. the -years overall and progression free survival were similar for dicep-and eshap-groups ( % vs. % and % vs % respectively). two heavily pretreated patients from the eshap-group developed secondary myelodysplastic syndrome post asct conclusions: in our series of patients both regimens proved to be safe. interestingly, despite the fact that more patients in dicep-group had poor risk disease the dicepregiment was significantly more effective, resulting thus in an earlier asct, less exposure to chemotherapeutic agents, that might led in less long-term toxicity. nevertheless, prospective trials with large series of patients are needed to define the role of dicep in the salvage treatment setting. disclosure: no conflict of interest background: although autologous hematopoietic stem cell transplantation (auto-hsct) is one of the best curative strategies for patients with chemosensitive t-cell lymphoma, major limitation remains a tumor contaminated graft-related relapse or residual disease after chemotherapy. several purging methods were introduced in auto-hsct for these limitations, however there are few studies of ex vivo purging of the autograft in lymphomas, especially t-cell lymphoma. therefore, we retrospectively analyzed consecutive t-cell lymphoma patients receiving auto-hsct with/without ex vivo purging. methods: among them, patients underwent autograft manipulation with ex vivo purging by cd + cells selection using a clinimacs device. results: with median follow-up duration of months (range, - months), -year overall survival (os; . % vs. . %, p= . ) and -year progression-free survival (pfs; . % vs. . %, p= . ) in a purged and unpurged group, respectively. transplant-related mortality was observed in both groups ( patients of a purged group and patient of an unpurged group). neutrophil ( vs. days, p= . ) and platelet ( vs. days, p= . ) recovery were similar in both group and there was no engraftment failure. on subgroup analysis according to upfront and salvage auto-hsct, while survival outcomes were improved by stem cell purging in the upfront auto-hsct (os with p= . and pfs with p= . ), there were no different survival outcomes in salvage auto-hsct. the unmanageable late-infectious complications were few in both groups except for predominantly cytomegalovirus reactivation in a purged group ( vs. patient). conclusions: although cohort was a small number, ex vivo graft-purging method was feasible and safe in t-cell lymphomas. and this purging strategy observed the more favorable survival outcomes in the upfront auto-hsct than salvage setting. therefore, further randomized studies are needed to determine the firm efficacy of cd + purification with the large number of patients in auto-hsct for t cell-lymphomas. disclosure: nothing to declare nivolumab-based regimens in relapsed or refractory non hodgkin lymphomas: the role of hematopoietic stem cells transplantation methods: we analyzed data of patients with r/r nhl, among them n with diffuse large b-cell lymphoma (dlbcl), n with primary mediastinal b-cell lymphoma (pmbcl), n with gray zone lymphoma (gzl) and n with gamma-delta peripheral t-cell lymphoma (ptcl), who received nivolumab-based regimens. the median age was years (range, - years). most of the patients n ( %) had a primary chemoresistant disease, the rest patients n ( %) had a relapse. the median of lines of prior therapy was lines (range, - lines). all sixteen patients with dlbcl and pmbcl received - cycles of nivolumab in combination with bendamustine, gemcitabine and rituximab (begern). the patient with gzl received cycles of nivolumab in combination with brentuximab vedotin and epoch. and the patient with ptcl received cycles of nivolumab monotherapy. results: at median follow up months ( - ) objective response (or) after nivolumab-based regimens was noted in n ( %) patients, complete response (cr) and partial response (pr) in n ( %) and n ( %) patients, respectively. cr observed in n patients with dlbcl, n with pmbcl, n with gzl, n with ptcl. and pr observed in patient with dlbcl. two responding patients with dlbcl underwent auto-hsct. and four responding patients (n dlbcl, n pmbcl, n gzl, n ptcl) received allogeneic hematopoietic stem cells transplantation (allo-hsct). the median duration of response for all n patients with or was (range: - +) months. among n patients who achieved or without hsct, only n remain in cr. two patients who received auto-hsct had a relapse. one patient with dlbcl improved the response after allo-hsct from pr to cr, and all four patients with allo-hsct remain in cr. the probabilities of -year os and pfs rates were % and %, respectively. conclusions: nivolumab-based regimens can lead to an objective response in % patients with r/r nhl. however, the durability of response to therapy is not long. nivolumab-based regimens can be used as bridge to allo-hsct disclosure: there are no conflicts of interest to disclose background: patients with aggressive non-hodgkin lymphoma (nhl) who relapse after autologous stem cell transplantation have a dismal outcome and could benefit from radiotherapy, allogeneic stem cell transplantation or experimental treatments. systemic inflammatory parameters at diagnosis have demonstrated to be useful to predict lymphoma evolution. methods: we conducted a retrospective review of patients with aggressive nhl who underwent autologous stem cell transplantation (astc) to evaluate the relationship between ldh, β -microglobulin, inflammatory parameters (lymphocyte (alc) and monocyte count (amc), ferritin or c-reactive protein) and imaging techniques before and on day + post-astc and progression free survival (pfs), as well as the role of residual disease directed radiotherapy (rt). results: one hundred and sixty patients with aggressive nhl received asct as consolidation treatment in our center between and . the most common diagnosis was diffuse large b-cell lymphoma (dlbcl). one hundred and nine patients received upfront asct for high risk dlbcl (defined as age-adjusted ipi - )(n= ) or for having received two or more lines to obtain first complete remission (n= ), for t-cell lymphoma (n= ) and for mantle cell lymphoma (n= ). the rest was performed in relapsed lymphomas. forty-seven patients ( %) relapsed and pfs was months. pretransplant response was evaluated with ct scan in patients ( of this with partial remission (ct-pr) and patients were evaluated with fdgpet/ct ( were pretransplant positive (pet ); of these, patients maintained positivity at day after astc (pet ). pfs in patients with ct-pr was months, in pet positive ones months and in pet positive ones months. univariate analysis showed pet positivity as the most accurate predictor of relapse (hr , , p= , ) followed by amc at day + (hr , , p= , ), albumin at day + (hr , , p= , ), ldh at day + (hr , , p< , ) and pretransplant alc/amc ratio (hr , p= , ). multivariate analysis only demonstrated an association with pet positivity (hr , ) p< and ldh in day + (hr , ) p= , with pfs. five and ten years overall survival were % and % in pet negative patients vs and % in pet positive ones (p< , ). eight out of patients with pet positivity did not relapse. salvage radiation therapy was used in patients with positive residual mass and of them did not relapse. two patients relapsed: one patient had residual mass and another had remote affectation from primary site and could be considered as progression before day + . conclusions: post asct fdgpet/ ct is superior to conventional ct in predicting outcome in aggressive lymphoma after astc. pre and post asct systemic inflammatory parameters didn't help to improve the relapse risk prediction. addition of consolidative rt after astc has demonstrated improvement in pfs in patients with pet positivity. it would be neccesary to develop randomized trials to assess the role of rt in residual disease in advanced aggressive nhl with insufficient response to systemic treatment with pet response evaluation. disclosure: nothing to declare long term outcome of patients with lymphoid malignancy who underwent high dose chemotherapy followed autologous hematopoietic cell transplantation at a single institution over years joanna romejko-jarosinska , ewa paszkiewicz-kozik , lukasz targonski , lidia popławska , jan walewski background: high dose chemotherapy (hdt) and autologous hematopoietic cell transplantation (auto-hct) is a standard of care for relapsed/refractory lymphoma patients (pts) or it is used as a consolidation for myeloma and high risk lymphoma patients in first line treatment. we retrospectively evaluated long-term outcome including late effects and risk factors in patients with lymphoid malignancy who underwent auto-hct. methods: we collected data from consecutive patients with hodgkin lymphoma (hl) (n= ), aggressive b lymphoma (dlbcl) (n= ), myeloma (n= ), indolent lymphoma (n= ), mantle cell lymphoma (n= ) and peripheral t cell lymphoma (n= ) who underwent auto-hct at our institution between and . at transplant median (range) age was ( - ) years, clinical stage iii/iv was found in of lymphoma pts, complete remission, partial remission and stable/ progressive disease occurred in ( %), ( %), ( %) pts, respectively. beam regimen was used in pts ( %), mel in pts ( %) and other myeloablative regimens in pts ( %). results %) ], respectively. partial remission or stable disease at transplant, clinical stage iii or iv, and age more than , were identified as risk factors associated with inferior os and pfs in univariate and multivariate analysis. histopathologic diagnosis was not a risk factor for os and pfs (p=ns). the outcome of patients who underwent auto-hct between - was inferior to the outcome of patients treated in - or - . - year os was %, %, %(p< . ) and year pfs was %, %, % (p< . ), respectively. we recorded ( %) cases of second primary cancer ( solid tumors and hematologic cancers). acute cardiotoxicity occurred in patients from to years after transplant, and required heart transplant in patients. patients ( %) died. the main causes of death were progressive disease in pts ( %), second primary malignancy in pts ( . %) treatment related mortality was . % ( pts), and mortality within days was ( , %). [[p image] . pfs and os in patients underwent hdt and auto-hct - , - , - conclusions: more than % of patients who underwent hdt and auto-hct had long term survival without progressive disease. older age, non-complete remission at transplant, advanced stage are associated with poor outcome. patients recently transplanted had a better outcome than patients transplanted before . disclosure: nothing to declare outcomes after haploidentical and matched related hsct in lymphoma do not differ significantly: a single center study nadira durakovic , , zinaida perić , , lana desnica , ranka serventi-seiwerth , sandra bašić kinda , ivo radman-livaja , alen ostojić , ante vulić , dražen pulanić , , pavle rončević , zorana grubić , igor aurer , , radovan vrhovac , university of zagreb, school of medicine, internal medicine, zagreb, croatia, uhc zagreb, zagreb, croatia background: allogeneic hsct still offers patients with relapsed/refractory lymphoma the best chance of long-term survival. in most such patients timing of hsct is crucial, therefore a related donor is preferred. we analyzed acute and chronic gvhd incidence, relapse and overall survival, but also time to immunosuppression (is) discontinuation and hematopoietic recovery comparing transplantation using haploidentical (haplo) and matched related donors (mrd) in single center in this indication. methods: in the time period between / and / at uhc zagreb, croatia, mrd and haplo transplantations in lymphoma were done, for hodgkin and for nhl. all patients transplanted from haploidentical donors received ptcy. data were computed using the r package. the probability of gvhd was calculated using the cumulative incidence method and subgroups were compared using the gray test. results: median age was ( - ) years; ( - ) in haplo and ( - ) in mrd group. four patients were in pr and in cr in haplo group, while in mrd group patients were in cr and in pr. in haplo group patients ( %) received bone marrow (bm) and only ( %) peripheral blood stem cells (pbsc). in mrd group all patients received pbsc. all patients in haplo group received nma ("baltimore") conditioning with ptcy while in mrd group patients ( %) received flu-bu atg, and only one received flutbi as conditioning protocol. in haplo group % patients were previously treated with autologus transplantation, % in mrd group. there was no significant difference in time to is discontinuation, and days in haplo and mrd group, respectively. patients after haplo recovered slower, recovering anc after . days ( % ci, . - . ) and . ( % ci, . - ) (p= . ) and recovering platelets after . days ( % ci, . - . ) and . ( % ci, . - . ) (p< . ) in haplo and mrd group. with a median follow up of days, overall survival was % ( % ci, - ) in haplo and % ( % ci, - ) in mrd group. trm was % in haplo and % in mrd group. cumulative incidence of agvhd ii-iv was % ( % ci, - ) and % ( % ci, in haplo and mrd group, respectively (p= . ). cumulative incidence of cgvhd requiring treatment was % ( % ci, and mrd % ( % ci, - ) in haplo and mrd group, respectively (p= . ). all cases of cgvhd developed after dli. cumulative incidence of relapse was % ( % ci, - ) and % ( % ci, - ) for haplo and mrd group, respectively (p= . ). conclusions: we found no significant difference in overall survival, relapse incidence, agvhd and cgvhd incidence between these two groups. hematopoietic recovery was slower after haploidentical transplantation, but it did not influence trm as it was higher after mrd. even though limited in number, this data contribute to the growing body of evidence that use of haploidentical donors, particularly in lymphoma setting, is as worthy as using matched related donors and should be at least second choice in donor selection, and in older patients (with older donors) probably the first one. disclosure: nothing to declare. adjuvant involved field radiotherapy post autologous stem cell transplantation for refractory/relapsed lymphomas results in favorable outcome with low toxicity: a single center experience background: involved field radiotherapy (ifrt) to previous bulky or localized residual disease, is a widely used treatment approach to minimize the risk of relapse post autologous stem cell transplantation (asct). however, the proper time for irradiation treatment remains controversial. adjuvant ifrt (adj-ifrt) in pre-asct period could cause undesirable toxicity which might delays or even cancel the asct resulting in increased risk of relapse, or could affect the marrow environmental and marrow niche resulting thus in impaired engraftment. on the other hand, the ajd-iftr in the early post-asct period, upon marrow recovery, offers a potential advantage by delivering irradiation after sufficient disease response, without affecting the engraftment. in this retrospective study we evaluated the safety and efficacy of the ifrt as adjuvant treatment in patients who had previously treated with asct for relapsed or refractory lymphomas. methods: twenty-three patients (hodgkin= , non-hodgkin= ), aged of ( - ) years, underwent asct, for primary refractory (n= ) or relapsed (n= ) disease. patients who had bulky disease at the time of relapse or those with residual mass post salvage treatment, were considered as candidates for adj-ifrt, early (within - months) after documentation of autologous stem cells engraftment. all patients proceeded to asct with chemosensitive disease after a median of lines of salvage therapy. at the time of asct patients ( %) had residual disease while ( %) evaluated to be in complete remission. the preparative regimens were: single-agent melphalan (n= ), busulfan-etoposide-melphalan (n= ), beam (n= ) and bendamustin-etoposide-cytarabine-melphalan (n= ). filgrastim was given till neutrophills recovery, while prophylaxis against bacteria, fungus, viruses and pcp were administered till the completion of adj-ifrt. results: all patients engrafted promptly and successfully. no patient experienced any severe toxicity or active infection before adj-iftr. though our plan was to proceed with adj-ifrt within months post asct, finally it was delivered after a median of . ( - ) months; the median radiation dose was ( - ) gy. ten patients received radiotherapy in the mediastinum, in the abdomen/pelvis/ inguinal area in the neck, and in the left leg. the adj-ifrt was well tolerated. no patient experienced toxicity grade > and none required hospitalization. currently, after a median follow-up of ( - ) years, / patients are alive and well; the -years overall and progression free survival rates are % and % respectively. four patients died; due to relapsed disease and heavily pretreated patients due to secondary myelodyspalstic syndrome conclusions: in our study, the adj-ifrt in the early post transplant period demonstrated a safe and well-tolerated profile. taking into consideration the poor risk status of our patients (residual disease post salvage regimen or bulky disease at the time of relapse), the promising overall and progression free survival rates suggested that adj-ifrt post asct is also an effective approach. well designed trials are needed to clarify the role and the appropriate time of radiotherapy in the asct setting disclosure: no conflict of interest adverse prognostic impact of pre-transplant neutrophil/ lymphocyte ratio in lymphoproliferative disorders background: brentuximabvedotin(bv) is a chimeric anti cd igg antibody, conjugated to synthetic antitubulinmomomethylauristatin. bv is approved for the treatment of classical hodgkin lymphoma (hl) in relapse either after autologous stem cell transplantation (asct) or after two lines of combination chemotherapy in transplant ineligible patients. the aethera trial revealed increased pfs when bv is used as maintenance therapy for cycles in high risk patients after asct. however, this schedule is associated with a high cost and significant toxicity particularly in term of peripheral neuropathy. our primary objective is to assess the efficacy of cycles brentuximab as consolidation therapy after asct for relapsed/refractory (r/r) hl. secondary objectives include side effects, progression free survival (pfs), and overall survival (os). methods: this is a retrospective single center analysis approved by the irb of the american university of beirut medical center. we included in this study consecutive patients with r/r hl who underwent asct between and , and received bv consolidation post-asct. results: we identified consecutive adult patients with r/r hl treated with bv . mg/kg iv every weeks as consolidation therapy after asct. the indications for bv consolidation was primary refractory disease in patients ( %), early relapse in patients ( %) (after a median time of months; range, - ) andextranodalinvolvement in one patient ( %). the median number of lines of therapy pre-asct was (range, - ). the median time to bv initiation post-asct was days (range, - ). patients received a median of cycles (range, - ) of bv post-asct. after a median follow up of months (range, - ), five ( %) patients relapsed after asct. the median time to relapse was months (range, - ). median pfs and os were not reached. we did not observe any significant toxicities during or after therapy. conclusions: cycles of bv consolidation after asct seem to be safe and effective in preventing relapse, however our findings need to be confirmed with larger prospective studies. chemotherapy or who progress after autohsct is poor. despite introduction of novel agents like brentuximab vedotin (bv) or nivolumab, allohsct appears the most effective treatment option with curative potential. the goal of this study was to evaluate efficacy of allohsct for hl, including patients pre-treated with novel agents. methods: between years - , patients (including males) with hl were treated with allohsct in msc institute of oncology in gliwice, poland. median age was ( - ) years. median lines of preceding chemotherapy was ( - ); ( %) patients had been pre-treated with autohsct, ( %) with radiotherapy, ( %) with bv, ( %) -with nivolumab. disease status at allohsct was as follows: cr- , pr- , nr- . patients were treated with hsct from either hla-matched sibling donor (msd, n= ), unrelated donor (urd, n= ) or haploidentical donor (n= ). conditioning was myeloablative in ( %) cases. peripheral blood was used as a source of stem cells. results: all but one patient engrafted with median time of neutrophil recovery of ( - ) days. the incidence of grade - and grade - acute gvhd was % and %, respectively, while the incidence of chronic gvhd was %. the probabilities of os and pfs at years were % (+/- %) and % (+/- %), respectively. the incidences of progression and transplant-related mortality were % and %, respectively. the y pfs rates were % for msd, % for urd and % for haploidentical donors. in a univariate analysis pfs was affected by recipient gender (female - %, male - %, p= . ) and disease status at allohsct (cr - %, pr - %, nr - %, p= . ). in a multivariate model the disease status other than cr was the only factor associated with increased risk of treatment failure (reverse pfs) -hr= . , %ci . - . , p= . . neither donor type nor conditioning affected long-term outcome. conclusions: results of allohsct for patients with relapsed/refractory hl are determined by disease status at transplantation. efforts should be done to reduce tumour burden before transplantation, optimally to achieve cr. disclosure: nothing to declare background: brentuximab vedotin (bv), nivolumab and pembrolizumab have been assigned to chemorefractory hodgkin lymphoma treatment. impact of these agents on disease-free-survival after autologous stem cell transplantation (asct) remains under investigation. aim of the study is to compare bv-and nivolumab-treated patients with a control group. methods: clinical characteristics and outcomes of chemo refractory hodgkin lymphoma patients who underwent asct during - . results: a total of patients ( men; women, median age years old, - ) were treated with bv: pre-transplant, post-transplant and pre-and posttransplant. pre-transplant bv patients had primary refractory disease or early relapse in the majority ( %). post-transplant treatment occurred in the context of relapsed/refractory disease in patients; ( %) had an allogeneic stem cell transplant. among them, had additional chemotherapy and nivolumab, gaining a complete metabolic response. in the rest of patients, change of treatment due to eventual bv failure occurred. bv was administered as a maintenance treatment in patients. in six of them bv had already been administered pre-transplant as well. out of maintenance treatment patients, relapsed and subsequently received nivolumab. two patients died due to prior chemotherapy complications, whereas are currently on nivolumab treatment. pet-based response was available in patients, having a complete metabolic response (cmr) and a partial metabolic response. stable disease was achieved by ctbased response in the rest patients. no major toxicities were observed. one patient presented with grade asymptomatic hypothyroidism and one with grade anemia attributed to non-inflammatory upper gastrointestinal blood loss. in total, patients received anti-pd treatment, all post bv failure. with a median follow-up of . ( . - . ) months, -year overall survival (os) was . % in patients treated only with bv compared to . % in patients treated with additional anti-pd treatment (p= . , figure) . median os for patients treated only with bv was . months, whereas median os has not been reached for patients that received anti-pd treatment. conclusions: bv pre or post-transplant and anti-pd treatment post-transplant after bv failure have outstanding results in chemo refractory lymphoma patients. treatment sequence in allogeneic transplantation eligible patients remains to be further studied. disclosure: nothing to declare background: allogeneic hematopoietic cell transplantation (allo-hct) with reduced-intensity conditioning (ric) has been used in heavily pretreated lymphoma patients with the promise of decreased treatment-related mortality. despite improvements in outcomes of patients with lymphoid neoplasms, several new agents emerge as potential therapies. therefore, we aimed to describe our long-term experience in patients with hodgkin (hl), non-hodgkin lymphomas (nhl) and chronic lymphocytic leukemia (cll) post allo-hct. methods: in this retrospective study, we enrolled consecutive patients who underwent allo-hct for lymphoid neoplasms in our institution ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results: in total, patients (male:female= : ) aged ( - ) years, underwent allo-hct for hl (n= ), nhl (n= ) and cll (n= ). the majority of patients were diagnosed at stage iv ( %); % had bone marrow involvement and % had undergone autologous hct. most patients were heavily pretreated (median lines= , range - ), of them had received more than treatment lines and at the time of transplantation only had complete response, while had partial response and were refractory. according to disease-risk index (dri), patients were stratified at low (n= , . %), intermediate (n= , . %), high (n= , . %) or very high (n= , . %) category. among patients with hodgkin lymphoma, brentuximab vedotin was administrated in and of them were effectively bridged to allo-hct. all patients received ric, mainly fludarabine ( mg/ m )-cyclophosphamide ( g/ m ) in cll and nhl and thiotepa ( mg/kg)-fludarabine ( mg/m )-cyclophosphamide ( mg/kg) in hl from matched sibling (n= ), matched (n= ) or mismatched unrelated (n= ) donors. graft-versus-host disease (gvhd) prophylaxis consisted of cyclosporine or tacrolimus and mycophenolate mofetil or short-term methotrexate and additional low-dose antithymocyte globulin ( mg/kg) in unrelated donors. peripheral blood was the main cell source ( / ) and median number of cd + cells infused was . x /kg ( . - . ) . two patients succumbed to advanced underlying disease before engraftment; while the other engrafted successfully. median time until neutrophil and platelet engraftment was and days respectively. eighteen patients ( . %) developed acute gvhd (grade iii-iv, n= ), steroid sensitive in ( . %) and relapsed. one-year cumulative incidence (ci) of extensive chronic gvhd was . %, and patients required more than one additional line of immunosuppression (range - ). ten patients presented cmv reactivation successfully treated with antiviral medication and patient died from hsv encephalitis. with a median follow of years ( - years), -year os was . %, -year non-relapse mortality ci . % and year dfs %. there was no difference in survival according to original disease ( -year os for nhl= . %, hl= . %, cll= %%, p= . ). multivariate analysis revealed high and very high dri as the single predicting factor of os (hr . , ci . - . , p= . ), when assessing impact of disease, dri, prior treatment lines, gender and bone marrow infiltration at diagnosis. conclusions: our data suggest that ric allo-hct provides encouraging survival rates, potentially offering the chance of cure, with acceptable long-term mortality in selected high-risk patients with lymphoid neoplasms. dri that is mainly associated with disease stage at transplant independently affects survival. therefore, continued efforts are necessary for clinical application of novel agents aiming to lower disease stage pre-transplant. disclosure: nothing to declare results: six pts were identified, with a median age of years at diagnosis: five with hl nodular sclerosis and with lymphocyte depletion. the median number of therapeutic lines prior to allo-hsct was [ - ]; four pts were previously treated with brentuximaband two pts had been submitted to high dose chemotherapy with autologous bone marrow support. at the time of allo-hsct, pts had progressive disease (dp), was in partial response and in complete response (cr). five allo-hsct were performed with a related donor, of wich were haploidentical ( parents, sibling and descendant) and with an unrelated donor ( / ). prophylaxis for gvhd was performed with tacrolimus and mycophenolate mofetil (with post-transplant cyclophosphamide in haploidentical allo-hsct). on day + evaluations, pts had a cr and patient (pt) had dp. the median time to relapse after allo-hsct was of months. at the time of initiation of nivolumab, pts were under steroid therapy for disease control, without other immunosuppressive therapy. the median time between allo-hsct and the beginning of nivolumab was months. the initial dose was mg / kg (associated with corticosteroid therapy), escalated up to mg/kg biweekly, according to patient's tolerance. after the start of nivolumab, patients, with previous gvhd manifestations, presented a worsening of the cutaneous gvhd, which required an escalation of immunosuppressive therapy. as toxicity, pt had a grade pneumonitis, pt had a grade encephalitis/hypophysitis, pt had a grade pancreatitis, pts had headache (grade and ), pts had a grade - cutaneous reation. with a median follow-up of months since nivolumab treatment, the overall response rate was %: pt obtained cr and pts partial remission. nevertheless, there were deaths after the onset of nivolumab: pt at monts with dp and another one due to acute myocardial infarction at months. at the time of analysis, pts maintained response under nivolumab treatment (median cycles ) and pt had therapy suspended because of toxicity. conclusions: these results demonstrate the high probability of achieving response with nivolumab treatment in patients with rr-hl relapsing after allo-hsct, but adverse events of grade were frequent in this small group, and the treatment toxicity was significant. disclosure: nothing to declare background: intravascular large b-cell lymphoma (ivlbcl) is a rare form of large b-cell lymphoma with pathological findings of intravascular proliferation and/or sinusoidal involvement of lymphoma cells. according to their geographic distribution, ivlbcl could be dichotomized into asian and western variants. compared with the western variant, where skin involvement was common, the asian variant was reported to involve more frequently the liver, spleen and bone marrow, and hemophagocytic lymphohistiocytosis is more common in asian variant. diagnosis of ivlbl is still difficult because of the lack of overt lymphadenopathy and peripheral blood involvement. thus, timely diagnosis and immediate treatment remain as a challenge to improve outcomes for patients with the asian variant. therefore, we analyzed the clinical features and treatment outcomes of patients with the asian variant of ivlbcl. methods: we analyzed patients who were diagnosed with ivlbcl between and . all patients were treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (r-chop). results: forty-six patients were diagnosed with ivlbcl, and their median age at diagnosis was years (range: - years). male patients predominated (n= , %), and b symptoms were present in patients ( %). hepatomegaly and/or splenomegaly were observed in patients ( %), whereas lymphadenopathy was less common (n = , %). bone marrow and liver were the most commonly involved extranodal organs ( %, and %, respectively) and were the most common sites of biopsy for diagnosis in this study. all patients received r-chop as a first-line treatment after diagnosis with a median number of six cycles (range one to eight). at the end of treatment, patients achieved a complete response (cr), whereas eight patients showed progression. six patients died after the first or second cycle of r-chop, and the causes of death were treatment-related adverse events including cytopenia, infectious complications, and pulmonary hemorrhage. upfront asct was done for two patients including one patient with cns involvement at diagnosis, and these patients were still alive at the time of analysis without evidence of relapse. on the other hand, the outcome of six patients undergoing salvage asct after relapse was poor; thus, only one patient was alive. likewise, patients with disease progression at the end of treatment with r-chop showed dismal prognoses even after salvage chemotherapy except for one. at a median follow-up of . months ( % confidence interval, ci . - . ), the median overall survival was . months ( % ci . - . ). the treatment outcome of patients with the asian variant of ivlbcl is still not satisfactory. although upfront autologous stem cell transplantation might be effective for selected patients at high-risk of relapse, its role is still not clear, either. thus, further study should be warranted to develop more effective strategies for diagnosis and treatment. clinical trial registry: not applicable disclosure: nothing to disclare background: peripheral t-cell lymphomas (ptcls) are about % of non-hodgkin´s lymphomas usually with an aggressive clinical course and unfavorable prognosis.given their heterogeneity, consensus on the best first-line treatment and the role of autologous/allogeneic (asct/allosct) stem cell transplantation as consolidation is controversial. methods: we evaluated the overall survival (os), progression-free survival (pfs) and toxicities of a cohort of patients with ptcls submitted to asct/allosct intensification at our institution between january and july . os was calculated from the date of diagnosis until death. pfs was measured from transplant until relapse, progressive disease or last follow-up. os and pfs rates were estimated using the kaplan-meier method and compared with the log-rank test. results: twenty-six patients were identified, female ( %), median age was years (range: to ). ninetytwo percent of patients presented with advanced-stage disease at diagnosis (ann arbor stage iii or iv), % with b symptoms. according to the who classification, histologic ptcl subtypes included angioimmunoblastic tcell lymphoma (n = ); ptcl not otherwise specified (n = ); anaplastic large cell lymphoma, alk-negative (n = ); anaplastic large cell lymphoma, alk-positive (n = ); nodal peripheral t-cell lymphoma with tfh phenotype (n = ). extranodal nk/t-cell lymphoma, nasal type and primary cutaneous subtypes were excluded. the ageadjusted ipi (aaipi) was low/intermediate low in patients ( %) and intermediate high/high in patients ( %). twenty-seven transplants were performed ( asct, allosct); were consolidation in st response ( asct and allosct) with in complete remission (cr) and in partial remission (pr). nine transplants were performed as consolidation of nd response ( asct and allosct) with in cr and pr. in patient allosct was performed after asct, due to early relapse (< months). beam regimen was used in asct as conditioning and flumel in allosct. all patients engrafted, the median time to leukocyte recovery > , /μl was days (range, to ). four of the pts ( %), submitted to allosct had chronic graft versus host disease which was the most relevant complication of this analysis. considering the whole cohort, the median follow-up was . months (range, to ). the estimated -year os and pfs were % and %, respectively. seven patients relapsed ( early) all after asct, there were no relapses after allosct, however, the results were not statistically significant between the allosct and asct groups; the -year os rates were % and % (p = , ) and the year pfs rates were % and % (p = , ) respectively. for the all patients treatment-related mortality (trm) was , %; patients died, with progressive disease (asct) and for hepatic toxicity (allosct) before d+ . conclusions: the results of this retrospective study, taking into account the adverse risk profile of the population, suggest that autologous/allogeneic stem cell transplantation as an effective and safe option for the consolidation of patients with ptcls. these results need to be validated in prospective studies, including a larger number of patients. disclosure background: autologous stem cell transplantation is used as consolidation therapy in relapsed lymphoma patients. however, outcome of lymphoma patients relapsing after autologous stem cell transplantation is poor and allogeneic stem cell transplantation which can be curative is used in the transplant eligible patients in this setting. besides, allogeneic stem cell transplantation can be an option before autologous stem cell transplantation in some high risk patients. in this study, we aimed to compare the survival rates of lymphoma patients older than years of age and patients aged - who had undergone allogeneic transplantation in our center. methods: we collected the data of lymphoma patients older than years of age who had undergone allogeneic transplantation in our center and analyzed the results by grouping them into , namely the ones between - years of age and the ones over years of age. [[p image] . figure results: there were patients over the age of who had undergone allogeneic stem cell trasplantation with the diagnosis of lmphoma between and . of these patients were over years of age. patients had non-hodgkin lymphoma and patients had hodgkin lymphoma. the characteristics of the patients are summarized in table . patients' comorbidity indexes were calculated with augmented hct-ci which includes patients' pretransplant ferritin, albümin and thrombocyte counts as a variable. no difference could be found between groups regarding neutrophil and platelet engraftment times and comorbidity indexes. however, acute graft versus rate and documented bacterial infection rate during the hospitalization period were higher in the - years age group (p= , ). day mortality rate and non-relapse mortality rate were not different between groups. more importantly, progression free survival(pfs) and overall survival(os) of patients in the - years age group and over years of age group were not different (p= , ) (figure ) conclusions: in the present study, although the number of patients is low, we showed that lymphoma patients over years of age have similar outcomes and transplant related toxicity as the patients between to years of age. pfs and os were very close in this study. we think that this may be due to low relapse rate in the patients and high mortality rate in relapsing patients. in conclusion, allogeneic stem cell transplantation which has a curative potential may be employed in transplant eligible elderly lymphoma patients disclosure: nothing to declare background: follicular lymphoma (fl) histologic transformation consist on the development of an aggressive lymphoma, usually a diffuse large b cell lymphoma (dlbcl). histological transformation has been considered to have poor prognosis. in pre-rituximab era median os ranged between and years, however, in recent series of patients treated with chemotherapy plus rituximab, the outcome of transformed fl has improved, especially in those that receive autologous stem cell transplantation (asct), who reach -year os up to % in some series. methods: we have retrospectively studied consecutive patients undergoing asct for transformed fl between and in a tertiary center in the basque country, spain. patients were considered to have a transformed fl if they were diagnosed of a dlbcl and they have previous history of fl or histological evidence of a fl in another location. these patients were compared to a retrospective cohort of dlbcl patients with high ipi or stage that received asct in first remission according to our institution strategy. pfs and os were calculated from the time of the asct. in the case of transformed fl, both relapses of the aggressive or indolent lymphoma were considered. survival analysis was performed with kaplan-meyer estimator results: a total of transformed fl and dlbcl patients were studied, with a median follow up of . and . months respectively. patient characteristics are described in table . -year pfs was % in transformed fl and % in dlbcl, and -year os was % and %, respectively (picture ). there were no significant differences in pfs or os between this two groups (p = . ). in both groups all relapses occurred in the first three years after asct. among the patients with transformed fl relapses were observed. five of them ( %) were aggressive relapses, while only one patient presented relapse as an indolent lymphoma (fl histological grade a with an aggressive clinical course). [[p image] . image : transformed fl and dlbcl pfs after asct] conclusions: in our experience, asct in transformed fl offers good results, similar to those in dlbcl. fl presents a natural course akin to that of dlbcl, with relapses occurring early and survival reaching a plateau. this data suggests that some patients with transformed fl can be cured after asct. disclosure: nothing to declare. safety and efficacy of intensive preconditioning regimen containing cladribine in autologous peripheral blood stem cell transplantation of refractory and relapsed young highly invasive lymphoma background: autologous peripheral blood stem cell transplantation (apbsct) is one of the main treatments for patients with non-hodgkin's lymphoma (nhl). effective and safe conditioning regimens can improve the cure rate of nhl. beam is the most common pretreatment scheme, but for refractory and relapsed young highly invasive lymphoma, especially for dual-expression dlbcl, pretreatment needs to be strengthened. studies have shown that the cladribine (clad)+gemcitabine (gem)+busulfan (bu) combination provides synergistic cytotoxicity in lymphoma cell lines.we evaluated the the safety and short-term efficacy of intensive preconditioning regimen containing cladribine (clad+gem+bu) for refractory and relapsed young highly invasive lymphoma undergoing apbsct. methods: ten patients with nhl received apbsct. ca)ctx+ ara-c) therapy followed by g-csf was used for pbsc mobilization. sevenr patients received conditioning regimens of beam(beam group): bcnu mg/ m ·d - × d (- d), vp mg/m · q h× d (- d-- d), ara-c mg/m ·q h× d (- d-- d), mel mg/m ·d - × d (- d). three patients received intensive preconditioning regimen containing cladribine (clgb group): clad mg/m ·d - × d (- d-- d), gem mg/m ·d - × d (- d, - d), bu . mg/kg q h× d (- d-- d). follow-up date expires on december , . results: the age of patients in clgb group was , and years, respectively. two patients were diagnosed as diffuse large b-cell lymphoma with double expression and one was diffuse large b-cell lymphoma with two recurrences. the patients of beam group were all high-risk, relapsed and refractory nhl.all patients were successfully engrafted after infusing apbsc. the average lowest leukocyte in clgb group and beam group were ( . ± . ) × /l vs ( . ± . )× /l, respectively. the average lowest leukocyte in clgb group was lower than that in beam group. the average time to anc < . × /l in clgb group and beam group were . d ± . d vs . d± . d. the average time to anc≥ . × /l in clgb group and beam group were . d± . d vs . d± . d; the average time to plt≥ × /l of clgb group was not different to that of beam group ( . d± . d vs . d± . d) the average time of neutropenia wasn't significantly different in two groups ( . d± . d vs . d± . d). the adverse reactions of gastrointestinal tract and oral mucosa were close in tow groups.vod, hemorrhagic cystitis, pretreatment-related interstitial pneumonia, liver and kidney dysfunction were not happened in tow groups. the rate of infectious fever was close in two groups ( / vs / ). the median followup period in beam group was ( ~ ) months. in the beam group, a patient died days after transplantation, because he was diagnosed with recurrent nkt cell lymphoma and intracranial infection caused by severe sinus infection. another case of beam group was diagnosed as double-expressed dlbcl, which relapsed months after transplantation. the remaining patients in ebmt group survived disease-free. the follow-up time of patients in clgb group were months, months and months respectively. all patients survived without disease.however, the follow-up time is short and needs long-term follow-up. conclusions: the treatment of intensive preconditioning regimen containing cladribine (clgb) for refractory and relapsed young highly invasive lymphoma undergoing apbsct is safe. the time of hematopoietic reconstruction is short, and the adverse effects is tolerable for patients with refractory and relapsed young highly invasive lymphoma. the current short-term outcome is good, but the long-term effect need a longer time to follow-up. disclosure: this work was supported by national nature sciences found of china ( ). there is no disclosure of conflict of interest.the all authors name: xiang-li chen, yu-zhu zang, wen-hui zhang, yin zhang, zhong-wen liu, ping-chong lei, jing yang, yu-qing chen, kai sun. background: small part of children with hodgkin disease (hd) demonstrate initial resistance to the standard and even "salvage" chemotherapy and need innovative drugs for the treatment. methods: a -year girl was diagnosed with classical hd (nodular sclerosis)corresponding to stage ii e b (fever > °c) in april .after two cycles of oepa (vincristine, etoposide, prednisone and doxorubicin) and next two cycles copp (cyclophosphamide, vincristine, prednisone and procarbazine) the patient again had progressive disease. as the patient achieved a partial response (pr) after "salvage"therapy with two cycles of igev (ifosfamide, gemcitabine, vinorelbine, and prednisone), she received auto-sct in february (patient status before auto-sct was pr). we used ccnu-containing conditioning regimen cem: lomustine (ccnu) mg/m + etoposide mg/m + melphalan mg/m . at day + after auto-sct, the patient again demonstrated progression of the disease: pet/ct-examination showed mediastinal tumor mass enlargement with increased left lung nodule simultaneously to short metabolic activity. patient was under observation. at day + the disease had relapsed and progressed -examination by pet/ct demonstrated multifocal progressive disease with multiple pulmonary lesions and increased metabolism in comparison with the previous pet/ct scan. in july-october , the patient had salvage chemotherapy with a combination of brentuximab vedotin (bv) (bv dhap (dexamethasone, cytarabine, cisplatin) + bv (without chemotherapy due to suspected invasive mycosis) + bv dhap), however, only partial pet-positive remission was achieved. because of many times relapsed and progressed disease pembrolizumab therapy was started in october : mg / kg every three weeks four cycles totally. toxic effects and serious complications during and after therapy by pembrolizumab were not observed. in february , after pembrolizumab # , the patient showed complete metabolic remission of the disease by control pet-ct. in april , the patient received haplo-sct with post-transplant hd-cyclophosphamide. we used conditioning modes with reduced toxicity (fludarabin mg/m + treosulfan g/m ), high doses of cy ( mg / kg) on days + and + . tacrolimus and mycophenolate mofetil started on day + . mmf was terminated on day , tacrolimus -on day . patient did not have acute and chronic gvhd. results: at the moment the patient is alive and still in pet-negative cr with duration more than mo. conclusions: pembrolizumab has demonstrated high activity against resistant hd even after post-auto-sct progression with good tolerability for the sick child. disclosure: nothing to declare p high dose chemotherapy followed by autolougous peripheral blood stem cell transplantation (asct) in diffuse large b cell lymphoma (dlbcl) median age is , years ( to ) and sex ratio (m/f) . ; ann arbor stage iii-iv: pts. before hdt induction chemotherapy (chop, c h opa) was instituted and associated with rituximab in pts ( , %), pts ( , %) received more than treatment lines and pts ( , %) received complementary radiotherapy. transplant disease status before hdt was complete remission (cr) in pts, partial remission in pts (rp) and disease progression in pts. the delay from diagnosis to hdt is , months ( - ). the hdt protocols used are: tutshka : pts, tutshka+vp : pts, bam (busulfan +cytarabine+melphalan) : pts et beam : pts. all pts received, after thawing, mobilized pbsc obtained by g-csf mobilization ( μg/kg/d, days) alone and froze in liquid nitrogen. the median rate cd + cells infused is , x /kg ( . - . ) . the median follow-up at / / is months . results: the median time to graft (pnc > . x /l) was days ( - ). ten early deaths were observed including infection (trm: , %) and in disease progression at months. after months of hdt pts are assessable including pts in cr ( , %) and pts in pr ( , %). relapse was observed in pts ( . %) and it was earlier relapse in a period of months in pts ( %). deaths were among / pts ( %). persistent cr was achieved in / pts ( , %) including / ( , %) mlcl and / ( , %) others dlbcl. the overall survival (os) and event free survival (efs) at years are respectively % and %. the os and efs are better in patients who received rituximab in initial therapy : os ( % vs %; p< , ) et efs ( % vs %; p< , ). herein, we present one patient with refractory mcl, who were insensitive to chemotherapy and then experienced a dramatic improvement with ibrutinib mono-therapy but later developed ibrutinib resistance,ultimately resulting in the deterioration of disease and death. methods: we give the patient several examinations including ultrasound, bone marrow biopsy, lymph node biopsy, exome sequencing, sanger sequencing, and so on. for the treatment of lymphoma, the patient received chemotherapy, including course of chop(cyclophosphamide . g day , doxorubicin mg day ,vinorelbine mg day , and dexamethasone mg from day to ) and course of r-dhap (rituximab mg day , cytarabine g q day , cisplatin mg day ,dexamethasone mg from day to )in succession.because of the failure to control disease progression, ibrutinib mg qd was used until the patient died. results: the -year-old man initially referred to our hospital for complaints of abdominal pain and distention over months. ultrasound showed splenomegaly and multiple enlarged retroperitoneal lymph nodes.excisional biopsy conducted on the right neck lymph node revealed the presence of malignant cells.immunohistochemically, the neoplastic cells were positive for bcl , bcl ,cd , cd , cd a, cd , ki- ( %), sox , cd (fdc) and cyclin d and negative for cd , cd and cd ; fluorescence in situ hybridization(fish) showed igh/ ccnd ,t( ; ) %.thus a diagnosis of mcl was confirmed. course of therapeutic chemotherapy were applied to the patient but he did not respond well.he suffered recurrent fever, thrombocytopenia, left abdominal pain, splenomegaly and multiple enlarged lymph nodes. then he received ibrutinib mono-therapy, and experienced a dramatic improvement as his body temperature was controlled, his hemogram became normal and his spleen and lymph node tapered.after about months response of ibrutinib, the disease deteriorated rapidly and he died very soon. exome sequencing from the patient peripheral blood at this time detected one missense mutation in exon of tp at nucleotide g>a, resulting in an argnine to histidine change at amino acid (p.arg his). but sanger sequencing of the patient bone marrow ffpe sample at the time of original diagnosis did not detect this mutation. conclusions: thus, our study reported a tp r h mutation mcl patient who developed ibrutinib resistance and progressed aggresively, which may open new insight for future effort for alternative therapeutic strategies in ibrutinib-refractory mcl. disclosure: nothing to declare. minimal residual disease, tolerance, chimerism and immune reconstitution peripheral blood samples were obtained for routine analysis at several time points after hsct. all available blood samples between . and years were used in the analysis. to assess changes in the cd +b and cd +cd +memory b cell counts over time while accounting for the correlation between the repeated measurements of each patient, we used linear mixed-effects models. wilcoxon rank test, kruskal-wallis test and linear regression were used for univariate analysis. results: at one year after hsct, univariate analysis showed that patients transplanted with a cb graft compared to bm and pbsc had a significantly higher absolute number of b cells (median bm= , median cb= , median pbsc= cells/μl, p= . e- ) and memory b cells (median bm= , median cb= , median pbsc= cells/μl, . recipients with age under years had significantly higher absolute numbers of b (median= , median= cells/μl, p= . e- ) and memory b cells (median= , median= cells/μl, p= . e- ) than above years. increase in donor age was associated with a decreasing effect on b cell (r = . , p= . e- ) and memory b cell (r = . , p= . e- ) reconstitution as determined in regression analysis. following univariate analysis, we analysed these factors in a mixed effects model to assess the relation with differences in b cell or memory b cell numbers . - years after hsct. in our analysis we found significant decreasing b cell and memory b cell numbers with increasing donor age corrected for recipient age and source (both p< . ). increasing recipient age also showed a significant decrease in b cell and memory b cell numbers (both p< . ) but there was no significant influence of donor source ( figure ) . conclusions: b cell and memory b cell numbers after hsct are influenced by donor and recipient age but not by donor source. older donors and recipients show a decrease in b cells and memory b cells numbers . - years after hsct. [[p image] . figure . b cell development and donor age. green shows cb, red bm, blue pbsc at mean donor age.] copenhagen university hospital rigshospitalet, copenhagen, denmark, leiden university medical center, leiden, netherlands background: the outcome of allogeneic hsct is challenged by a delayed and long-lasting imbalanced t-cell reconstitution increasing the risk of acute gvhd, infections and disease progression. although the role of differentially and functionally distinct t-cell subsets in the development of complications has been addressed, little is known about the factors controlling their recovery. in this study, we investigated the impact of immuneregulating and homeostatic cytokines on the reconstitution of functionally distinct t-cell subsets and associated clinical outcomes. methods: we included children undergoing allogeneic hsct for all (n= ) or aml (n= ) with a median age of . years (range: . - . ). donors were either mrd (n= ), mud (n= ) or mmud (n= ). bm (n= ) or pb (n= ) were used as stem cell source. conditioning regimens were based on tbi (n= ) or highdose chemotherapy alone (n= ) and included atg in patients. thirty age-matched healthy children were included as controls. cytokines (il- , il- , il- , scf, il- , il- and tnfα) and active atg in plasma were longitudinally measured from before conditioning until months after hsct (n= ) along with an extended phenotyping of t-cell maturation and differentiation by flow cytometry (n= ). results: the homeostatic cytokines il- and il- increased from pre-conditioning to peak - weeks post-hsct and gradually declined thereafter. il- levels were shortly elevated, while il- and scf remained relatively stable, and il- and tnf-α levels were below threshold of detection at all time points. the early rise of il- and il- was strongly associated with the degree of t-cell depletion by atg, while il- also correlated with markers of systemic inflammation. il- and il- levels were significantly higher in children treated with atg (p< . ) and correlated with both longer exposure to atg (p< . ) and increased levels of active atg (day + : il- : r= . , p< . ; il- : r= . , p< . ), indicating that high levels of these cytokines reflected more pronounced t-cell depletion during lymphopenia. higher circulating levels of il- and il- were associated with a slow recovery of cd +, cd + and cd + t-cell counts at day + and + post-hsct (p< . ), while the remaining cytokines did not correlate with immune reconstitution. looking into t-cell subpopulations, increased levels of il- and il- during the first month post-transplant were associated with lower numbers of naïve t cells and correlated with an increased proportion of cd + and cd + effector memory cells ( figure) . no differential effect of cytokines on polarization of cd + t cells into th , th , th cells or treg cells was found. in atg-treated patients, il- and il- levels at day + were significantly lower in patients developing acute gvhd grade ii-iv (p= . and p= . , respectively). in the total cohort, increased il- levels were associated with a reactivation of ebv (p= . ). conclusions: these findings suggest that quantification of il- and il- can be indicative for the degree of t-cell depletion during the first weeks after hsct and predictive of complications. overall, these results indicate that the lymphopenia-induced elevation of il- and il- is a major driver of the initial expansion of donor t-cells. background: mathematical kinetic models were adopted to study immune cell reconstitution after allogeneic hematopoietic stem cell transplantation (allo-hsct). the associations between acute graft-versus-host disease (agvhd), relapse and the immune cell reconstitution kinetic models were explored. methods: from june , to may , , sixty-five patients with hematological malignancies after allo-hsct were recruited. peripheral blood was collected on + day, + day, + day and in + month, + month, + month, + month, + month, + month, + month. lymphocyte subsets were determined by flow cytometry, including in total t lymphocytes (cd + ), helper t cells (cd + cd + ), cytotoxic t cells (cd + cd + ), cd /cd ratio, nature killer (nk) cells (cd -cd + ), nkt cells (cd + cd + ), b lymphocyte (cd + ), naive t cells (cd + hla-dr + ), static t cells (cd + hla-dr -), and regulatory t cells (cd + cd high foxp + ). mathematical kinetic models were calculated for immune cell reconstitution with spss. results: after allo-hsct, a logarithmic curve model was observed for cd + t cells. cubic curve models were observed for cd + cd + t cells, cd + cd high+ foxp + t cell, cd + hla-dr -t cells, cd + cd + nkt cells, cd + b cells. cd + cd + t cells, cd + hla-dr + t cells, and cd -cd + nk cells showed s type curve models. considering t cells were the major mediators for agvhd and graft-versusleukemia effect after allo-hsct. with established immune cell kinetic models, we found that different curve models were observed between patients with and without agvhd after allo-hsct. although the kinetic models were almost the same for leukemia-free and relapsed patients in the first months after allo-hsct, significantly different kinetic curves could be observed thereafter. conclusions: the immune cell reconstitution showed different mathematical curve models after allo-hsct. kinetic reconstitution model of certain immune cell was associated with agvhd and relapse. hence, mathematical kinetic models of immune cell reconstitution may be potential indictor for predicting agvhd and relapse after allo-hsct. disclosure: nothing to declare lineage specific chimerism analysis in pediatric patients following allogeneic hematopoietic cell transplantation (hct background: the outcome of allogeneic hct is dependent on several variables that include patient age, disease and stage, cytoreduction, graft, graft manipulation, and graft versus host disease (gvhd) prophylaxis. one aspect of hct that remains poorly defined and studied is the donor/ host (d/h) chimerism post hct. since , we followed patients with d/h lineage specific chimerism post hct. analyses were performed by short tandem repeat (str) polymorphism analysis at the american red cross blood services (philadelphia, pa). studies were performed on blood total leukocytes, myeloid/neutrophil cells, t-cells, bcells, and nk-cells. methods: in this retrospective study, the charts of consecutive patients who underwent allogeneic hct between january to june on the pediatric bone marrow transplant service at mskcc were retrospectively reviewed. lineage specific donor chimerism post hct was studied including d/h chimerism trend, and factors with potential impact on chimerism including: age, disease, graft source, and t-cell depletion (tcd). preliminary analyzes performed on this cohort included wilcoxon rank test and cox proportional hazard analyses. results: patients were selected based on the number of analyses. the median age was . years. patients had hematologic malignancies (n= ) or non-malignant hematologic diseases (n= ), or immune disorders (n= ). cytoreduction included tbi-(n= ), or chemotherapybased regiments (n= ). patients were recipients of t-cell depleted marrow or peripheral blood grafts (n= ), unmodified marrow or peripheral blood grafts (n= ) or cord blood grafts (n= ). full donor chimerism of myeloid cells, b-cells and nkcells, but not t-cells occurred early post-transplant. there was no difference in the percentage of total donor leukocytes at months vs. months post hsct (n= ), while the median of donor t-cell chimerism was % at months and % at months post hsct (p< . , n= ). figure shows the impact of different factors including: (a) the use of tbi-or chemotherapy-based regimens, (b) age (< or > years), and (c) type of graft (t-cell depleted vs unmodified vs cord blood). donor total leukocytes chimerism was significantly lower at months as compared to months for patients < years of age (p= . ). for most grafts, full donor chimerism of t-cells occurred early, while for t-cell depleted transplants, it took up to one year to complete. cord blood grafts were associated with high t-cell donor chimerism throughout the post-transplant period. there was a significant difference in the % donor t-cells at and months post hct when comparing t-cell depleted and unmodified grafts (p= . ). conclusions: this preliminary analysis of lineage specific chimerism post-transplant showed that donor tcells may take one year to fully recover post-transplant, mostly following t-cell depleted grafts, without intervention. cord blood grafts were associated with high donor chimerism throughout the post-transplant period. lastly, factors associated with loss of donor chimerism posttransplant were younger age and non-malignant disorders. more in-depth analyses are being performed including the relation of chimerism and hct outcome. disclosure: eileen nicoletti -employee rocket pharmaceuticals, susan prockop -investigator atara biotherapeutics -research funding, susan prockop -mesoblast -research funding, nancy kernan -gentium -support; jazz pharmaceuticals -support, richard o´reilly -atara biotherapeutics -royalty, consultancy and research, jaap jan boelens -bluebird bio -consultancy, avrobio -consultancy; jaap jan boelens -chimerix -consultancy; magenta -consultancy background: the success of hematopoietic stem cell transplantation (hsct) lies with the ability of the engrafted immune system to remove residual leukemia cells via a graft-versus-leukemia effect. despite this, relapse remains the major cause of mortality among patients receiving hsct. one of the immune evasion mechanisms of leukemic cells to escape from donor t cell recognition in haplo-hsct is the genomic loss of the patient specific hla. it has been described in - % of acute myeloid leukemia (aml) and myelodysplastic syndrome (mds) relapses after haplo-hsct. the aim of this study was to analyze hla loss in a large cohort of patients who relapsed after t-cell replete haploidentical transplantation with posttransplant cyclophosphamide. methods: from december to september , patients with hematological malignancies who received a haplo-hsct were recruited. among them, patients presented a relapse after haplo-hsct. hla typing was performed by real-time pcr using hla-kmr kit (gendx, netherlands).nine patients were excluded from the analysis because the kit employed did not include the recipientspecific hla. thus, a total of relapse cases were analyzed. the analysis of chimerism was carried out using short tandem repeat pcr amplification (ampflstr sgm plus, thermo fisher, usa) with a sensitivity of %. results: genomic loss of the patient hla occurred in / patients ( %) ( table ) . these patients presented different hematological neoplasms. interestingly, patients presented lymphoid neoplasm ( acute lymphoblastic leukemia (all-t), dentritic cell leukemia (dcl) and hodking´s lymphoma (hl)). hla loss relapses occurred later than classical relapses ( vs. days). regarding the treatment received (table ) , four patients were studied retrospectively. three of them were treated with donor lymphocyte infusions (dlis) + chemotherapy or other drugs at the time of the relapse. the other patient did not receive any treatment. in the end, all patients died from disease progression. prospectively, we detected hla loss at relapse in other two patients. at the moment of relapse, the first case received brentuximab + haplo-hsct from alternative donor and the other case received daratumumab + haplo-hsct (pending). both patients are alive, the first one in complete remission (cr) and the second one in partial remission (pr). conclusions: the frequency of hla loss at relapse is similar in our cohort to what is described in the literature. hla loss has been identified in patients with lymphoid neoplasms, while this mechanism has not been previously described in such diseases. the analysis of this immune evasion mechanism should be implemented in the routine screening of patients transplanted from haploidentical donors in order to design effective rescue strategies. these treatments should not be based on dlis or second transplantation with the same donor, instead, alternative donors should be used. background: an adequate immune reconstitution (ir) is crucial to reduce transplant toxicity, relapse rate and mortality after allogeneic stem cell transplantation (allohsct). the aim of this, single center retrospective study was to investigate the correlation between the recovery of different lymphocyte subpopulations with the main transplant outcomes, including overall survival (os), disease free survival (dfs) and non-relapse mortality (nrm). methods: we analyzed the ir of adult patients (aml n= , all n= , mds n= , nhl n= , hd n= , cll n= , cml n= , mm, n= , mpn n= ) who underwent (allohsct) between january and march . median age at transplant was years (range . - . ) with male/female ratio of %. donors were hlaidentical siblings (n= , %), family haploidentical (n= , %), matched unrelated ( , %), mismatched unrelated (n= , %) and cord blood units (n= , %). the stem cell source was the bone marrow (bm) in patients ( %), the cord blood in ( %) and g-csf mobilized peripheral blood in ( %). the conditioning regimen was myeloablative in ( %) transplant, reduced intensity in ( %) and immunosuppressive in ( %). gvhd prophylaxis was based on calcineurin inhibitors in combination with methotrexate or mofetil mycophenolate. antilymphocytes immunoglobulins was used in patients ( %) (anti thymocytes globulin, atg sanofi-genzyme in or anti t-lymphocyte globulin, atlg -neovii biotech, in ). the peripheral blood lymphocyte subsets (cd +, cd +cd +, cd +cd +, cd + (b cells) and cd +cd + (nk) were analyzed by flow cytometry at , , , , and months after hsct. post-transplant engraftment was molecularly determined by vntr analysis. results: as detailed in table the proportion of full donor chimerism analyzed in the peripheral blood t lymphocytes improved progressively after transplantation and the same pattern was observed when the chimeric status was measured in bone marrow mononuclear cells. to favor the achievement of a full donor chimerism, dli were performed in patients starting at the median of days after transplant (range: - ). with a median follow-up observation of months (range - ), the one year os and nrm was % and %, respectively. at months after allohsct, the achievement of values higher than , and /μl for cd +, cd + and nk cells, respectively was significantly associated to a better os (figure ), dfs (p = . ), and to a lower nrm (p< . for cd + and cd +, p= . for nk). a better lymphoid reconstitution was observed after the use of either a sibling or a haplo donor than a matched unrelated or cord blood donors. the use of atg was significantly associated with a delayed cd + recovery but with a faster nk cells reconstitution. conclusions: at six months after allohsct, recovery of cd + and nk cells predicts survival. monitoring of immune recovery may help to guide pre and post-transplant treatment strategies. days infections and disease control. several groups have demonstrated the independent prognostic value of different lymphocyte subpopulations in hsct outcomes. posttransplant cyclophosphamide (pt-cy) effectively prevents gvhd after hla-haploidentical hematopoietic stem cell transplantation (haplo). the use of pt-cy in hla matched related (mrd) or unrelated (mud) donors hsct, although less explored, has also been introduced. the aim of this study was to compare the early immune reconstitution after allogeneic hsct from haploidentical and hla-matched donors using pt-cy. methods: one hundred and sixty-four hsct performed in our center were analyzed: haplo performed between and and hsct from hla-identical donors ( consecutive mrd sct performed with pt-cy between and and mud sct with pt-cy between and ). pt-cy was administered at mg/kg/d in days + and + postransplant, followed by mmf mg/kg/ d and a calcineurin inhibitor (ciclosporina a or tacrolimus) from day + ahead. we retrospectively compared early immune reconstitution at day + and day + among these three populations. early ir was assessed through the analysis of lymphocyte subpopulations including total t lymphocytes cd +, cd + and cd +subpopulations, nk cd -cd + cells, cd + bright immature subpopulation and total b cd + lymphocytes.. lymphocytes subpopulations were determined by multiparametric flow cytometry (fc and navios, beckman coulter®). results: all patients, but mud and haplo, received pb as stem cell source. patients received prior transplant in haplo group. patient´s characteristics are shown in table . patients who received hsct from mrd showed the fastest ir, with statistically significant differences compared to haplo in almost all lymphocyte populations at day + (cd +, cd +, cd + and nk cells), and also in cd +, cd + and b lymphocytes at day + . comparison between haplo and mud hsct showed better ir among haplo, demonstrated by higher counts in cd +,cd +, cd + and nk cell counts at day + . no differences were seen at day + . (figure ). percentage of immature cd bright nk cells was higher in mud hsct at + , with no differences between haplo and mrd hsct. conclusions: in our cohort of patients with pt-cy based gvhd prophylaxis regimen, those who received hsct from mrd showed the earliest immune reconstitution compared to haplo and mud at day + and + . haplo showed better ir compared to mud at day + . nk maturation at day + was a little better among haplo and mrd hsct recipients than mud hsct patients. in our experience, using mostly pbsc as graft source, type of donor influenced early ir in pt-cy based hsct, background: cell-free dna (cfdna) isolated from plasma or serum has received increasing interest for diagnostic applications. however, the reported clinical usefulness of cfdna in patients undergoing allogeneic cell transplantation (hsct) is scarce. methods: the chimeric status both in peripheral blood and in cfdna obtained from plasma was investigated in patients undergoing hsct. dna and rna were isolated from plasma within four hours of blood draw. patients were evaluated for chimerism at day + , + and + post-transplant. a panel of seven microsatellites was amplified by pcr for chimerism detection and pcr products were analysed by capillary electrophoresis. for further cfdna characterization the micro rna (mirna) c was analysed using digital pcr. mutations frequently used for minimal residual disease assessment such as flt -itd, npm and jak were also investigated in cfdna. results: the mean cfdna concentration in transplanted patients was ng/ml, while in healthy donors used as control group (n= ) was ng/ml. the mean cfdna concentration difference between both groups reached statistical significance (p= . ). when analysing cfdna from transplanted patients and in the control group we could not detect dna fragments larger than bp and the size range of the analysed fragments was between and bp. in out of patients a mixture of donor and recipient cfdna (mc) was detected. with the exception of three patients relapsing after transplant in which mc was detected both in peripheral blood and plasma in the rest of the patients (n= ) mc was detected only in plasma. the mean percentage of recipient cfdna in the plasma samples was % (range: - %). all the patients with acute gvhd (agvhd) (grade: i-iv) (n= ) showed mc in plasma at least in one of the time-point tested. no significant difference was found in the mean recipient cfdna percentage in patients with agvhd grade i-ii when compared with grade iii-iv. meanwhile in the group of patients with chronic gvhd (n= ) mc in plasma was detected in patients. in those patients with clinical improvement of agvhd (n= ) a decrease in the percentage of recipient cfdna was observed during treatment. in patients without improvement or even agvhd worsening (n= ) stable or increasing recipient cfdna percentage was detected. since recipient cfdna can be detected in patients without transplant-related complications we analysed the mirna c expression in all patients with recipient cfdna. a significant difference was found in the mirna c expression in patients with agvhd (mean mirna c: . mirna c copies/ u copies) when compared with patients without gvhd (mean mirna c: . mirna copies/ u copies). in those patients with extramedullary aml relapse (n= ) frequent mutations (flt -itd, npm ) were only detected in the cfdna fraction. conclusions: longitudinal analysis of cfdna represents a useful complementary tool in particular for those patients with clinical complications after hsct. disclosure: nothing to declare comparison of the impact of atg/pt-cy-based and tcr αβ-depletion as gvhd prophylaxis regimens on the recovery of memory t-cell compartment background: over recent years haploidentical and hlamismatched donors have been increasingly adopted as a valid donor source. modern graft-versus-host disease (gvhd) prophylaxis regimens such as drug-based (antithymocyte globulin (atg), post-transplant cyclophosphamide (pt-cy)) or graft-manipulated (tcr αβ-depletion) demonstrate effective prevention of gvhd. here we report our data about an influence of different gvhd prophylaxis regimens after allo-hsct with pbsc as a graft source on cd + memory t-cells recovery. methods: our study comprised leukemia patients who underwent allo-hsct with pbsc as a graft source in national research center for hematology, moscow, russia. detailed patients characteristics are presented in table . peripheral blood samples were collected on day + , + and + after allo-hsct. flow cytometry analysis was performed on bd facs canto ii (becton dickinson, usa) to define t-memory subsets: t-naive and t-stem cell memory (tnv+tscm) -cd +cd r -ccr +cd +; t-central memory (tcm) -cd +cd r +ccr +cd +; t-transitional memory (ttm) -cd +cd r +ccr -cd +; t-effector memory (tem) -cd +cd r +ccr -cd -; t-terminal effector (tte) -cd +cd r -ccr -cd -. sysmex xe- was used to calculate absolute count of different t-memory cell subsets. mann-whitney u test was used for nonparametric data analysis. a p-value less than . was considered as significant. results: results of mann-whitney u test (calculated pvalues) to compare absolute number of t-memory cell subsets in terms of different gvhd prophylaxis regimens are presented in figure . during all follow-up period the number of tnv+scm and tcm remains significantly reduced after atg+pt-cy or tcr αβ-depletion compared to atg-based immunosuppressive regimen. on day + we observe no difference in the number of tnv+scm and tcm cells after atg+pt-cy or tcr αβ-depletion. terminally differentiated cd + cells (ttm, tem, tte) count is significantly lowered in tcr αβ-depletion patients group in comparison to atg+pt-cy. nevertheless recovery of tnv+scm and tcm after pt-cy is faster than after tcr αβ-depletion. conclusions: according to our data the mechanism of pt-cy is seems to be more selective compared to tcr αβ-depletion due to its transient impact just on tnv+scm and tcm without affecting on the effector pool. through this it may lead to delayed reconstitution of adaptive immunity after tcr αβ-depletion compared to using pt-cy. clinical relevance of the quantitative characteristics of immune recovery in the context of different approaches to gvhd prevention remains to be established. background: immune effector cells, belonging to either innate or acquired immunity, play a key role on preventing disease relapse after allogeneic haematopoietic stem cell transplantation (hsct). most of known immune effector are cd + cd + t-cells and cd -cd + natural killer lymphocytes, while cd + cd + cells act as modulatory and regulatory cells. the early post-hsct ratio between these cellular subsets may be an indicator of graft vs-tumor (gvt) effect. methods: we retrospectively revised the immune recovery of allogeneic hsct performed at our institution from to , analysed on peripheral blood by multiparametric flow cytometry lymphocyte subpopulations panel. diagnosis were acute leukemias ( %), chronic myeloproliferative neoplasms ( %), lymphomas ( %), myelodysplastic syndromes ( %), multiple myeloma ( %) and severe aplastic anemia ( %). we established early time-points of evaluation, and days from the graft infusion, to analyse the differences in disease free survival (dfs) and overall survival (os) between patients according to the cd + cd + x cd -cd + / cd + cd + ratio. results: median ratio at + days was of , . at this time point, patients who showed the ratio higher than the median had both a better dfs (median dfs time not reached vs months; p = , ) ( figure ) and os (median os time not reached vs months; p = , ). likewise, ratio at + showed an advantage on dfs (p = , ), and not on os (p = , ). other factors possibly affecting both dfs and os were analysed in univariate analysis, such as the use of antithymocyte globulin (atg), conditioning regimen intensity, graft source, hla-matching and disease status at hsct, the latter being the only variable with a significantly detrimental impact on both os and dfs. disease status was confirmed an independent valriable associated with both dfs and os as well as + ratio both on dfs (hazard ratio [hr] - , ; p = , ) and os (hr , ; p = , ). conclusions: our data show that cd + cd + x cd -cd + / cd + cd + ratio assessed at + is and independent predictor of transplant outcome, possibly representing a row indicator of anti-leukemic immune surveillance. the integration of this index with other known outcome predictors may help in improving the management of post-transplant phase. [[p image] . figure background: allogeneic stem cell transplantation (alo-hsct) is a curative treatment but it is associated with lifethreatening complications. most deaths are due to relapse, graft versus host disease (gvhd) and infection. the pattern and quality of the immune reconstitution (ir) after transplantation may affect these outcomes. however, there are limited data on the association of the quality of the ir and either the development of gvhd and survival. methods: eighty-five patients who received a non t-cell depleted alo-hsct in our center from to were prospectively studied. most patients received hla-identical grafts. total cd + and cd + t cells, ccr +cd + and ccr +cd + (which include both naïve and central memory t cells) and naïve ccr +cd l+ t lymphocytes were quantified by flow cytometry. data were collected at days + , + , + , + and + after alo-hsct. the association between ir and the gvhd was studied through an anova. for the multivariate analysis, a logistic regression was performed including those confusing clinical variables that were significant in the univariate analysis (p≤ . ). the study of overall survival (os) versus ir was performed with a cox regression model. results: total cd + t lymphocytes reached normal numbers within the first two months. median t cd + count was cells/ul after one month, which is within the normal range. conversely, it took nearly one year to get normal counts of cd + t cells ( cells/ul). the only two clinical parameters conditioning a worse recovery of the cd + t cells were the previous alosensitization of the donor and the sex, being female donor and male recipient the worst combination for the ir. no parameters influenced the quality of the reconstitution of cd + t cells. of note, the age or the hla status did not influence the quality of the ir. when the patients were divided into gvhd and no gvhd, we found no differences in the recovery of either the proportion or absolute count of every t cell subpopulation, including total t cells as well as naïve/central memory t cells, both cd + and cd +. finally, a multivariant analysis confirmed that the absolute counts of cd +ccr + t cells at day + as well as the absolute counts of both cd +ccr + t cells and naïve cd +ccr +cd l+ at day + were associated with better os. conclusions: in conclusion, neither the development of gvhd nor other relevant parameters seem to play a determinant role in the quality of the ir. to our knowledge this is the first study which demonstrate a clear association between the recovery of naïve cd + t cells measured by flow cytometry and the os. disclosure: nothing to declare p abstract already published. azacitidine (aza) for prophylaxis or pre-emptive therapy for myeloid neoplasms after allogeneic stem cell transplantation whom were treated prophylactically and preemptively. median age was years [range, - ] and all patients had a diagnosis of aml or high-risk mds. prophylactic treatment consisted of aza mg/m for days in cycles of days. in the pre-emptive setting, patients received mg/m for days per cycle and patients mg/m for days per cycle. a median of cycles [range, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] was administered in the prophylactic group and of cycles [range, - ] in the pre-emptive group. ten patients also received at least one dli after the third aza cycle: patients in the prophylactic group and patients in the pre-emptive one. results: during follow-up, patients had significant delays in treatment plan due to transitory mild complications. however, % of patients (n= ) presented infectious complications requiring hospitalisation and % of patients (n= in the prophylaxis group and in the pre-emptive group) presented some form of gvhd. in patients who developed gvhd, had to discontinue treatment (all in the prophylaxis group); also patients discontinued treatment due to disease progression. the overall drop-out rate was . % (n= ). survival was analysed from initiation of treatment with aza and median follow-up was months. one-year efs was % in the prophylaxis group, with only one patient relapsing and no deaths. in the pre-emptive group, the -year efs was % and the median efs was months; -year os was % and median os was months. conclusions: we conclude that post-transplant aza treatment is a well-tolerated therapy, but the incidence of side effects remains discordant in the literature. results in the prophylaxis group are excellent, but patients with positive minimal residual disease treated pre-emptively had a lower outcome with only stabilisation of the disease. randomised prospective trials are needed to define patients who would benefit the most from this treatment and at what timing, dosage and duration of treatment. disclosure: nothing to declare. abstract already published. results: all subjects experienced hematopoietic engraftment at a median of days (range - ) and demonstrated full donor myeloid chimerism. m-mdsc and pmn-mdsc recovery peaked at a median of days posttransplant. the median peak absolute m-mdsc count was , cell/ml (range , - , /ml) representing a range of . % to . % of pbmcs. the pmn-mdsc peak was more robust, with a median absolute peak of , cells/ml (range , - , /ml) representing a median of . % of pbmcs (range . - . %) . of note, the one patient who developed severe, life-threatening gvhd had the lowest absolute and relative pmn-mdsc recovery ( , cells/ml and . % of total pbmcs). recovery of m-and pmn-mdscs occurred at a similar tempo and magnitude in two recipients of standard gvhd prophylaxis (tacrolimus/methotrexate). however, while mdscs isolated from ptcy recipients exhibited clear t-cell suppressive capacity, those from the comparison patients did not (see figure) . conclusions: mdscs recover rapidly and robustly after allohct using ptcy as gvhd prophylaxis, and may play a role in mitigating gvhd risk by mediating t-cell suppression. this may be a mechanism by which ptcy results in donor-recipient tolerance. background: high dose chemotherapy followed by autologous stem cell transplantation (asct) offers a cure in the upfront and relapsed setting in both hodgkin (hl) and non-hodgkin lymphoma (nhl). asct also remains standard of care in previously untreated multiple myeloma (mm) patients after induction therapy, if eligible. the availability of new cellular or other immune therapies that can be used after asct underscores the potential importance of monitoring immune reconstitution after asct. methods: immune reconstitution panels (irp) were evaluated retrospectively in all lymphoma and mm patients over a -year span ( - ) whom underwent asct at our institution. patients were included if they had a pre-asct measured within days of asct and two other irp at any of the following timepoints ( ) day - , ( ) day - , and ( ) at -year post-asct. patients in the lymphoma cohort had their irp excluded if they had additional treatment within the first year post-asct (other than maintenance rituximab). mononuclear cells from peripheral blood were analyzed by flow cytometry for assessment of lymphocyte phenotype and numbers. absolute values were compared using the mann-whitney u test. results: the data on patients were available for analysis ( mm, nhl, hl) . all lymphoma patients were conditioned with beam. all mm patients were conditioned with a standard high dose melphalan regimen. the median pre-asct absolute cd counts in the lymphoma cohort were significantly lower than the mm cohort at cells/μl vs cells/μl, respectively (p= . ). however, the mm cohort exhibited a greater percent reduction in cd cells on day at . % vs . %, respectively which continued through day at . % vs . %, respectively. this led to nonsignificant changes in absolute cd count by day at cells/μl vs cells/μl, respectively (p= . ) (figure ). the median absolute cd count pre-asct for mm and lymphoma cohorts were cells/μl and cells/μl, respectively (p= . ). similarly, a greater percent reduction in cd cells led to comparable absolute counts on day at cells/μl vs cells/μl, respectively (p= . ). the failure of post-asct cd reconstitution to pre-asct levels was driven by lack of cd + cell recovery, namely cd +cd ra+ cells with a median of cells/μl and cells/μl in the mm and lymphoma cohorts, respectively at day (figures and ). this led to markedly diminished cd :cd ratios through day (figure ). [[p image] . conclusions: impaired t-cell reconstitution in both lymphoma and mm continues through -year post-asct. as shown, a larger percent reduction in median cd and cd counts through day was appreciated in mm compared to lymphoma leading to the nonsignificant differences in the post-asct absolute counts despite significantly higher pre-asct counts in the mm cohort. impaired recovery of cd t-cells may increase the risk of opportunistic infections, decrease the response to vaccination and lead to ineffective anti-tumor response. further prospective and larger retrospective studies like this should continue in the modern-era as they may help predict responses to further interventions requiring a robust t-cell repertoire for maximal efficacy such as car-t cell and bite therapies. disclosure: nothing to declare p peri-transplant detection of measurable residual disease by multicolor flow cytometry is highly predictive for relapse in acute myeloid leukemia patients background: presence of measurable residual disease (mrd) prior to allo-sct has been shown to be predictive for survival in patients in hematological cr of aml. in this study we analyzed the impact of mrd in such patients measured by -color multiparameter flow cytometry (mfc) prior to and on day + post-transplant. methods: the bone marrow samples immediately prior to allo-sct and on day + post-transplant were retrospectively analyzed. mrd evaluation was carried out with antibodies against: ( ) results: a number of aml patients (male, n= ) with median age of years ( - ) in hematological cr prior to allo-sct were enrolled in the study. we observed lower survival in patients with mrd by mfc pre-transplant ( y os: % ( - %) vs. % ( - %), p= . ) due to increased relapse incidence ( % ( - %) vs. % ( - %), p= . ). in multivariate analysis, mrd pos prior to allo-sct has strong significant impact on os (hr . ( . - ) , p= . ). of patients, a sample both before and on day + after transplantation was available in patients. of those patients, ( %) were mrd negative prior to transplant and on day + (mrd neg/neg ); ( %) patients were mrd positive prior to transplant and negative at day + (mrd pos/neg ); and ( %) patients were mrd positive at both timepoints (mrd pos/pos ). dfs and os for these three groups were as follow: y dfs: mrd neg/neg : % ( - %), mrd pos/neg : % ( - %); mrd pos/pos : % ( - %, p= . ); y os: mrd neg/neg : %; mrd pos/neg : % ( - %); mrd pos/pos : % ( - %, p< . ). upon multivariate analysis, the mrd status prior to transplant and on day + showed strong significant impact on dfs (hr . ( . - . ), p= . ) and os ), p= . ). we did not observe any significant impact of other factors included in the multivariate analysis (patient's age, patient's sex, and recipient/ donor sex constellation). conclusions: mrd positivity prior to allotransplant and at day + by mfc is highly predictive for survival after allo-sct. disclosure: nothing to declaire background: immune reconstitution is a critical factor for risk assessment of life threatening infections and long-term survival in patients undergoing allogeneic cell transplantation (hsct). methods: immune cell subsets (cd , cd , cd , cd , cd +cd -) were quantified by flow cytometry. trec and krec were quantified simultaneously using droplet digital pcr (dpcr). a total of patients were evaluated. mean age at transplant was years (range: - years) samples were obtained before hsct and at day , and after hsct. results: absolute numbers of cd and cd cells remained below pre-transplant levels until day , increasing further and eventually reaching pre-transplant levels one year after hsct. absolute counts of cd and cd +cd -cells remained below pre-transplant levels beyond one year after hsct. cd cells were characterized by fast reconstitution kinetics, reaching pre-transplant levels already at day . b cells correlated with krec levels at all time-points tested, whereas t cells correlated with trec levels only one year after transplantation. when we compared cell subsets, trec, krec levels and the reconstitution kinetics thereof between patients with reduced intensity conditioning (n= ) or full conditioning (n= ) no significant differences were observed. patients with pre-transplant trec levels above the mean ( trec copies/ml blood) showed higher trec levels and a faster t-cell reconstitution after hsct suggesting that tcell reconstitution can be predicted by analysing thymic functionality before transplantation. indeed, in patients with a pre-transplant trec above trec copies/ml blood, the positive predictive value for an efficient t-cell reconstitution was . (p= . ). we analysed the recovery kinetics of the cell subsets, trec and krec levels in patients with and without transplant-related complications. patients with either acute graft-versus-host disease or severe infections showed a slower trec reconstitution when compared with patients without complications. conclusions: our data suggest that the analysis of immune cell subsets together with trec and krec quantification can be used to evaluate the immune reconstitution process after hsct. pre-transplant trec levels allow t-cell reconstitution efficiency prediction after hsct. disclosure: nothing to declare background: falling donor / mixed chimerism after allogeneic haematopoetic stem cell transplant (sct) is associated with an increased risk of relapse and the potential for graft rejection. donor lymphocyte infusions (dli) are often administered in patients with mixed chimerism to achieve full donor chimerism but there is little data on long term outcomes for dli given for persistent mixed chimerism. methods: a retrospective analysis of all patients administered dli for mixed chimerism between to january was performed. all patients were transplanted at the university hospital of wales within the south wales blood and marrow transplant (swbmt) programme. patients were identified by the swbmt database and additional outcome data gathered by review of patients' medical records. results: patients were treated with donor lymphocyte infusions between and january . thirty one patients treated for relapse (with or without mixed chimerism) were excluded as was a further patient with a mismatched donor. the rest were / match. twenty six patients received a total of donor lymphocyte infusions for mixed chimerism alone. the median age was years (range: - ) with % women. fourteen ( %) of the patients had sibling donor transplants and twelve ( %) from matched unrelated donors. indications for transplant were: for aml or saml (n= ), myelofibrosis (n= ), mds (n= ), hodgkin lymphoma (n= ), non-hodgkin lymphoma (n= ) and all (n= ). escalating doses of donor cd + t cells were administered commencing at × /kg to × /kg then increased at half log increments according to chimerism results until full donor chimerism was achieved. the median number of doses administered was (range - ). the median interval was days (range - ). the median dose was × / kg (range × - × ). seventeen patients ( %) achieved full donor chimerism and remained so until most recent follow up (median months, range - ). one patient continued to receive dli after the study period and later reverted to full donor. two patients had ongoing mixed chimerism with no evidence of relapse. two patients relapsed; one of whom later achieved remission. there were six cases of gvhd; acute gvhd (grade ii n= , grade iii n= ) and cases of chronic extensive gvhd. one patient had gvhd features consistent with overlap syndrome. a total of five patients died, four due to infection (one in a patient with gvhd) and one due to cardiac toxicity from previous treatment (confirmed on post-mortem). conclusions: the results of our single centre study help reinforce the evidence for dli in establishing full donor chimerism when mixed chimerism is detected in the absence of relapse. incremental dli dosing is an effective strategy and associated with a low relapse rate. caution should still be given to the risk of gvhd following dli, however the risk appears to be low in this study. larger prospective studies are ongoing to address the optimal dosing strategy for dli post-transplant. disclosure: nothing to declare hypomethylating agents for the treatment of relapsed acute myeloid leukemia after allogeneic blood stem cell transplantation: a single center experience mariarita sciume , giorgia saporiti , elena tagliaferri , nicola fracchiolla , federica grifoni , giorgia levati , luca baldini , francesco onida the post-transplant period with well-balanced profile of good efficacy and moderate toxicity. we retrospectively evaluated the safety and efficacy of hma +/-dli in a reallife cohort of aml patients relapsing after allo-sct. methods: data from all patients with aml who underwent allo-sct at our institution in the last years and subsequently received hma as a salvage treatment for disease recurrence or preemptively for loss of complete donor chimerism were collected. results: eleven patients with a median age of years (range - ) were identified; median time between allo-sct and time to hma therapy was months (range - ). according to eln genetic risk stratification, patients were classified in the favorable group, in the intermediate-i, in the intermediate-ii and in the adverse one. six patients were treated with aza, whereas the remaining patients with dac. the cycles were repeated every days. ten patients ( %) started hma for morphological aml relapse, while one patient received aza as a sequential treatment after dli administered for loss of complete donor chimerism. median number of cycles was (range - ). treatment strategy included combination with dli in patients ( in the dac cohort, in the aza cohort), while in one case of flt -itd + aml sorafenib was also associated to dac and dli. no grade / toxicities and no acute gvhd occurred. a clinically significant response was observed in four patients ( %), all receiving at least cycles of hma therapy; in particular, a complete remission (cr) was achieved in / patients treated for morphological relapse, including the one who received the dac/dli/sorafenib combination and one (favorable eln risk) who received aza alone (not eligible for dli due to a concomitant lateonset cutaneous grade gvhd). of interest, the latter patient also displayed a resolution of the cutaneous gvhd. full donor chimerism recovery with no gvhd was observed in the patient who received aza for the progressive donor chimerism loss not responding to dli alone. with a median follow-up of months (range - ), the median os from hma treatment in responding patients was months (range - ); at the time of data collection responses were maintained in all four patients. seven patients had died, six from aml progression and one for severe intestinal gvhd occurring after failure of dli+aza and a following salvage induction chemotherapy treatment. conclusions: although arising from a limited number of patients, our real-life experience of treatment with hmas +/-dli in aml patients relapsing after allo-sct showed a general very good safety profile and promising antileukemic activity, altogether suggesting a facilitation of the graftversus-leukemia effect (gvl) associated to a possible suppression of the gvh reaction. disclosure: nothing to declare conclusions: in this study, cd -positive cell count and igg value had recovered about months after sct. in our institute, we have achieved a low incidence of infection by education and medication for patients until recovery of cd -positive cell count and igg. however, we found a higher incidence of infection after recovery of cd -positive cell count and igg. at - months after sct, administration of prophylactic medications such as sulfamethoxazole-trimethoprim were terminated and social comeback such as return to school or work were achieved in most patients. it is possible that the high incidence of community-acquired infection was associated with their comeback. thus, we should consider additional prevention of infection for patients in this period and further evaluation of immunological markers is needed. disclosure: no potential conflicts of interest were disclosed. effect of minimal residual disease before transplantation on the outcome of haplo-identical hematopoietic stem cell transplantation for high-risk acute lymphoblastic leukemia yehui tan , sujun gao , xiaoliang liu , long su , wei han , yu liu , yangzhi zhao background: to analyze the effect of haploid hematopoietic stem cell transplantation (hid-hsct) on high-risk acute lymphoblastic leukemia (all), and to explore the effect of minimal residual disease (mrd) before transplant on the prognosis. methods: a retrospective analysis was made on high risk all patients accepted hid-hsct in our hospital from january to january . the clinical features, stem cell implantation, complications, survival and recurrence were compared between pre-transplant mrd + and mrdpatients. results: all the patients got successfully implanted. the overall survival (os) was . %, the disease free survival (dfs) was . %, the incidence of acute graft versus host disease (agvhd) was . %, including . % ii~iv degree agvhd and . % iii~iv degree agvhd. there was no significant difference in stem cell implantation, gvhd, cytomegalovirus and hemorrhagic cystitis between mrd + and mrdpatients. dfs and os in mrd + patients were significantly lower than those in mrd -patients, and the cumulative rr rate increased significantly, there was no significant difference in cumulative trm. conclusions: hid-hsct was an effective method to treat high risk all, but mrd + patients had high recurrence rate and poor prognosis. strategy adjustment should be considered to reduce tumor residual and the transplantation strategy should be optimized for these kind of high risk patients, so as to improve survival rate. disclosure: nothing to declare background: lymphocytes are responsible for the cellular and humoral immunity and, consequently, its recovery after allo-hsct might be linked with the survival after the procedure. the aim of this study was to analyze this hypothesis in our series of patients. methods: all the allo-hsct performed in our center from january through july were included in the analysis. median age was years (range: - ). pts were male ( , %) and were female ( , %). baseline diseases were: aml, lpd, mds, all, mpd, mm, and bmf. donor was unrelated in ( , %), and was family in cases ( , %) (including haplo-identical). stem cell source was pb in ( , %) and bm in pts ( , %). conditioning regimen was reduced in procedures ( , %) and intensive in ( , %) (including just one non-myeloablative). overall mortalities at days + and + (the latter in patients with follow-up superior to year) were , % and , %, respectively. median follow-up was months (range: - ). evolution of absolute lymphocyte counts (alc) and subpopulations at pre-hsct and during the first year after allo-hsct were analyzed. results: as shown in table , alc and cd + lymphocytes decreased after conditioning therapy, and recovered progressively during the post-hsct period. at day + , majority of patients had > alc/mcl, clearly improved compared to admission values. cd + lymphocytes at day + was still very low, but at day + around half of the series had - /mcl. we found a strong link between alc, cd + lymphocytes, and cd + lymphocytes at days + and day + with overall survival at day + of the series (table ) . conclusions: in our series, immunity recovery was a late event for majority of patients undergoing allo-hsct. in addition, in our experience, the precocity and quality of the alc, cd +, and cd + cells recovery was clearly linked with long-term survival. background: the reconstitution of t and natural killer (nk) cells after hematopoietic stem cell transplantation (hsct) strongly influences the outcome of hsct including viral infection and graft versus-host disease (gvhd). the purpose of this study was to investigate the clinical efficacy of immune reconstitution including t and nk cells after hsct in children. methods: we reviewed the records of patients who undergoing allogeneic hsct in department of pediatrics, pusan national university children's hospital, from january to july . the counts of t lymphocyte subsets and nk cells was monitored in peripheral blood by flow cytometric technique during , , , and months post-hsct. blood samples for cytomegalovirus (cmv) and epstein-barr virus (ebv) monitoring were tested by real-time pcr assay. results: for total of patients, the mean age was . years (range, months- years), of the patients were boys and was girl. out of a total patients without pre-hsct cmv viremia or cmv infection, ( . %) recipients experienced cmv infection. the number of cd + t cells in and months post-hsct was significantly higher in patients with cmv reactivation compared to patients without (median . /μl vs. . /μl, p= . , and . /μl vs. . /μl, p= . ) . in ( %) recipients presented acute gvhd, the number of cd + t cells in and months post-hsct was significantly lower in patients with acute gvhd compared to patients without (median . /μl vs. . /μl, p= . , and . /μl vs. . /μl, p= . ) . the number of nk cells in months post-hsct was significantly lower in patients with cmv reactivation and acute gvhd compared to patients without ( . /μl vs. . /μl, p= . , and . /μl vs. . /μl, p= . , respectively) . in multivariable analysis, acute gvhd was shown to be the decisive factor influencing total t cells (p= . ) and cmv reactivation was independently associated with cd + t cells (p= . ). the cd + t cells counts were associated with prior hsct history and acute gvhd (p= . and p= . ), and the cd + t cells counts were also significantly associated with donor type (p= . ). conclusions: overall, our study documents that immune reconstitution of cd + , cd + t cells and nk cells is strongly associated with cmv reactivation and acute gvhd. additionally, we show that acute gvhd is influenced by lack of sufficient numbers of nk cells as well as cd + t cells early after sct. cd + t cells, on the other hand, significantly increase after cmv-reactivation and most likely play an important role in reactivation. disclosure: nothing to declare background: curative effect of allogeneic hematopoietic stem cell transplantation (allo-hsct) depends on the alloreactive t-cell immune response toward residual malignant cells -graft-versus-leukemia reaction. however, alloreactive population has not been phenotypically defined. recent studies suggest that alloreactive t cells express both costimulatory and inhibitory receptors simultaneously. exhaustion caused by the inhibitory signaling dampens tcell functionality, which could lead to the disease relapse. here we aimed to investigate the expression of costimulatory and inhibitory receptors on antigen-experienced t cells after transplantation, to isolate subpopulation specific for allo-hsct patients and analyze their t-cell receptor (tcr) repertoire. methods: expression of coinhibitory and costimulatory molecules on pbmcs patients at various time points after allo-hsct was analyzed for expression of: cd , cd , cd , cd ra, ccr , cd , cd , cd , klrg , tigit, pd , cd and ox by flow cytometry and compared to healthy donors. cd +cd +cd -cd +cd +pd +tigit+ fraction and cd + cd + control fractions were separated on facs aria ii cell sorter. double barcoded cdna libraries of tcr beta-chains for both fractions were prepared and analyzed by sequencing on illumina platform. sequencing results were processed by migec, mixcr and vdjtools software. enriched clones were identified by fisher's exact test (p> - ). results: we did not find any significant differences between patients after allo-hsct and healthy donors in single marker's expression, but, when considering coexpression of co-stimulatory and inhibitory molecules on t cells we found that cd +cd +cd -cd +cd +pd +tigit+ subpopulation was significantly increased in allo-hsct patients. moreover it increased with the time since the transplantation (fig. ). this population was isolated by cell sorting and alongside with total cd + fraction subjected to tcr beta-chain repertoire sequencing. the population contained clones significantly enriched compared with cd + fraction representing potentially alloreactive cells. this hypothesis is further supported by the notion that the level of expression of cd and cd co-stimulatory molecules is lower in the group of patients who subsequently relapsed, compared with the patients with complete remission, while the expression of inhibitory receptors was high in both groups. conclusions: according to our data patients after allo-hsct have a phenotypically distinct t-cell population characterized by simultaneous expression of costimulatory and inhibitory markers. this population contains specifically enriched clones, which may be specific for alloantigens. further functional assays are needed to confirm the alloreactive potential of this subpopulation. besides low expression of costimulatory molecules combined with high expression of inhibitory receptors on antigen-experienced t-cells of patients after allo-hsct might be associated with a disease relapse. fondazione mbbm, monza, italy, ospedale san gerardo, laboratorio stefano verri, monza, italy background: poor graft function (pgf) is a severe complication after hsct, with a high risk of morbidity and mortality, mainly due to infections. donor cd + scb seems to offer high chances of haematological recovery, not jeopardized by gvhd. however, pediatric reports remain scarce. methods: out of patients undergoing transplantation in our pediatric unit from to have been retrospectively evaluated for at least line persistent cytopenia (hb< . g/dl, plt< /mmc, n< / mmc) and/or transfusion-dependency beyond months after hsct in the presence of full donor chimerism. bone marrow cellularity was evaluated through biopsy as further indicator of pgf. ( / ) to donate or medical decision ( / ). bone marrow cellularity was < % in % of the patients who underwent scb for which the histology was available ( cases), and % in those who have not been treated ( / ). at days after scb / ( %) patients had hematological response, which was complete in % and partial in % of the patients. only patient had no response. the infusion was always well tolerated with no adverse events, and no worsening of gvhd. haematological recovery occurred spontaneously at days after bone marrow biopsy in a significantly lower proportion of patients ( / , %, p< . ) within the non-scb group. in two cases platelets engraftment was significantly delayed, up to one year after bone marrow biopsy and in one case thrombocytopenia persists and the patient is still receiving thrombopoietin agonists and red blood cells transfusions at months after bone marrow biopsy. conclusions: a stem cell boost matched the goal to yield count recovery in our cohort. viral infections and gvhd may be possible risk factors for pgf.bilinear or trilinear cytopenia with transfusion dependency and bom cellularity < % and full donor chimerism are good indications for scb, that can provide a significantly earlier hematological reconstitution, without risks of gvhd. due to the proved early efficacy and safety of cd + stem cell infusion, we suggest that this procedure should be taken in consideration in children with severe bone marrow hypoplasia and persistent cytopenia after hsct. disclosure background: as allogeneic hematopoietic stem cell transplantation (hsct) is sometimes performed despite erythrocyte's antigens incompatibility and mismatch, it is essential to carefully track patients' genotypes after it. methods: for the study we used erythrocytes (n= ) and dna (n= ) from patients undergoing abo-or rhesus-mismatch hsct and their donors. we used posttransplant no transfused patients on the periods according transplant protocol by hemagglutination methods in plate and tube using monoclonal antibodies to abo and rhesus antigens (hematolog, russia). we extracted dna with dna kit (bag, germany) and conducted pcr-ssp with kits abo-type, rh-type (bag, germany). chimerism was assessed by the str-pcr analysis with cordis plus multiplex kit for amplification of polymorphic strmarkers and amelogenin loci. the fragment analysis was performed on a genetic analyzer. informative loci were chosen by comparison of pretransplant patient's and donor's dna. the percentage of donor chimerism was calculated using standard formula. precise rhce and abo genotypes were determined by direct sanger sequencing. we revealed patients with unexpected erythrocyte abo, rhesus phenotypes and genotypes after hsct on + ( patients) and + days (all patients). chimerism analyses on str showed in a.e.kh. and g.l.v. patients % of donor's dna and less than % of recipient's one. b.n.a. patient was relapsed and chimerism analysis revealed % of recipient's dna and % of donor's one. using serological methods and pcr-ssp we revealed genotypes abo * a b ; rhd+; rhce * ccee in patient a. e.kh. before hsct, abo * a o ; rhd+; rhce * ccee in her donor, and abo * a a ; rhd+; rhce * ccee on + d after hsct. genotype a a was no recipient's neither donor's origin. direct sequencing did not prove this genotype, but revealed donor's one.on + d serological methods and pcr-ssp also revealed donor's genotype in this patient. patient b.n.a. had genotypes abo * o /o ; rhd+; rhce * c w cee before hsct, her donor -abo * b o ; rhd +; rhce * ccee. on + d this patient relapsed, but rhesus genotype has been detected as rhd+; rhce * c wcee (lack e gene). direct sequencing revealed gene rhce*ee. abo genotype was recipient's origin -o o . in patient g.l.v. using serological and pcr-ssp methods we determined genotypes abo * o /o ; rhd +; rhce * ccee genotype before hsct, and abo * a / o ; rhd+; rhce * ccee genotype in her hsc donor. on + d patient had unexpected genotype abo * o /o (a lack of a antigen); rhce * ccee (a lack of e antigen). in order to explain unexpected patient's genotypes after hsct we sequenced her rhce and abo genes and found donor's genotype ccee; a o that was in agreement with results of str analysis. to resolve discrepancies between serological, pcr-ssp and sequencing analysis data we sequenced patient's rhce cdna and observed only ce allele. at present time the molecular basis of selective inactivation one of the two rhce alleles is not clear. on + d patient had donor's genotype. conclusions: what kind of mechanisms led to discrepancies between results obtained by different laboratory methods are still not clear. an interesting case of expression of only one rhce allele in patient g.l.v. allows us to suggest involvement of some epigenetic mechanisms like dna methylation or histone modification in this process. clinical background: in relapsed patients with acute b -lymphoblastic leukemia (all-b) who achieved complete remission (cr) after re-induction therapy, minimal residual disease (mrd; ≥ - all-b cells/ul) is often detected. according to available data, such condition varies from % to even % of cases, as assessed by pcr or flow cytometry (fc), while the presence of mrd is the most important risk factor for all recurrence. in this abstract, we describe our experience with bridging therapy using blinatumomab infusion after re-induction regimens and before the planned allogeneic stem cell transplantation (allo-sct). the procedure was performed in three young men suffering from relapsed ph (-) all-b at the age of , and years. in the first case ( yo), relapse with previous mrd accounting for . % occurred months after cr mrd neg . in the next patient ( yo) the second relapse with central nervous system (cns) involvement occurred months after allo-sct performed in cr ( months after cr , mrd neg ), while in the third patient ( yo), recurrence with cns and testis involvement occurred years after cr (mrd neg ). all patients underwent chemotherapy (flam, hypercvad and dnr/vcr/pegasp/dexa regimens respectively) followed by one cycle of blinatumomab (at a dose of mcg/d on days - , followed by mcg/d on days - in a continuous infusion) and allo-sct (using eto/cy/tbi/atg/ conditioning regimen for ist and iiird patient and bucy for iind patient; using matched unrelated donor (mud, ist and iiird patient) or matched related donor (iind patient)). mrd status was assessed after each cycle of blinatumomab by fc. results: all patients achieved cr mrd pos after reinduction therapy followed by clearance of mrd after blinatumomab course (tab. ). the second patient, due to positive mrd months after allo-sct received donor lymphocyte infusions additionally. during the administration of blinatumomab, no adverse events (aes) were observed in grade or . one patient developed cytokine release syndrome in grade . the progression free survival, time to positive mrd and follow up are presented in tab . conclusions: the use of blinatumomab as a bridging therapy between re-induction regimens and allo-sct in patients with all-b and mrd pos appears to be safe and leads to the clearance of mrd which may be crucial in os and pfs prolongation after following allo-sct. future studies on larger groups of patients are necessary to confirm this thesis. background: haploidentical hematopoietic stem cell transplantation (hsct) is considered an alternative treatment for hematologic malignancies in patients who do not have an hla-identical sibling donor [ ] . since infections and disease relapse resulting from delayed immune reconstitution (ir) are the most common causes of mortality among patients undergoing haploidentical-hsct [ ], timely ir is essential in the recovery and survival of these patients. the aim of this study is to describe the evolution of ir after haploidentical-hsct and to estimate survival rates in patients with delayed vs. adequate reconstitution in a single center in colombia, south america. methods: a retrospective cohort study was conducted on consecutive adult haploidentical-hsct recipients at a tertiary referral center. cd +cells, cd +cells, cd +cells, and immunoglobulins levels were monitored before hsct, at first month, and then every three months for the first two years post-transplantation. descriptive statistics were used to analyze patient's clinical characteristics. the kaplan-meier method was used to assess overall survival (os) and relapse-free survival (rfs) rates. results: twenty-six patients were included ( % were male), with a median age of . years (range - ). the most common indication for haploidentical hsct was acute lymphoblastic leukemia (n= , . %), followed by non-hodgkin lymphoma (n= , . %) and myelodysplastic syndrome (n= , . %). all patients received gvhd prophylaxis therapy with cyclophosphamide, tacrolimus, and mycophenolate mofetil. fifteen patients ( . %) presented cytomegalovirus reactivation ( / at risk), patients ( . %) epstein-barr virus reactivation, and patients ( . %) developed adenovirus infection. median time to neutrophil engraftment (neutrophils> . × /l) was days (range - ) for the patients recipients of peripheral blood progenitor cells (pbpcs) and days (range - ) for the three remaining bone marrow recipients. platelet engraftment, defined as > , platelets/ mm background: daratumumab is a human monoclonal antibody directed against the glycoprotein cd that is overexpressed on the surface of plasma cells in multiple myeloma patients. it is approved as second line therapy either as single agent therapy or in combination with lenalidomide or bortezomib for the treatment of patients with relapsed/refractory multiple myeloma. despite the curative potential of an allo-sct, the high relapse rate remains a clinical problem. data addressing the choice of an optimal salvage therapy regime for these heavily pre-treated patients is missing. methods: from april till november a total of patients (male, n= ) with the median age of years ( - ) received daratumumab as a salvage therapy for relapse of multiple myeloma after allo-sct at the university of hamburg. prior to allo-sct all but one patient had received an autograft, patients even ≥ autografts and patients also a . allograft. the median number of salvage lines post-transplant and prior to first daratumumab infusion was ( - ). these salvage regimens included cyclophosphamide, etoposide, bortezomib, lenalidomide, pomalidomide and carfilzomib. daratumumab was started at a median of months ( - ) after relapse/ progress and initiated as single agent therapy in all patients. concomitantly, patients received either an immunomodulatory drug (lenalidomid, n= ; pomalidomid, n= ) or a proteasome inhibitor (bortezomib, n= ) during a later course of daratumumab infusions. combination therapy was initiated when a slow rise of paraprotein and/or free light chains or no response to monotherapy was observed (median at the th infusion). results: the median number of infusions was . twenty adverse reactions were observed in of ( %) patients: dyspnea (n= ), bronchospasm (n= ) shivering (n= ) , cough (n= ), musculoskeletal pain (n= ), acute coronary syndrome (n= ), skin rush (n= ), facial edema (n= ), pressure on eyes (n= ). all adverse reactions appeared during the first infusion and were mostly mild or moderate (ctc - , n= ). tolerance of the following infusions improved and in none of the cases therapy had to be stopped due to adverse events. three patients developed late onset infections (pneumonia, n= ; urinary tract infection, n= ) followed by temporarily therapy interruption. with a median follow-up of months after the first administration of patients remain alive . %). one patient died due to progress of myeloma and another died due to severe infection/sepsis. of patients responded ( %; pr, n= ; vgpr, n= ; cr, n= ) to the therapy with daratumumab. the responses (decrease of paraprotein and/or free light chains ≥ %) occurred at a median of days ( - ) after the first administration and lasted for . months ( . - . ). conclusions: daratumumab shows an encouraging efficacy and acceptable toxicity profile in patients with relapsed/refractory myeloma after allo-sct. further studies are needed to investigate the role of the combination therapy with immunomodulatory drugs or proteasome inhibitors in this setting. disclosure: nothing to declare p clonal plasma cell detection by high sensitive flow cytometry in aphaeresis product is poor prognostic and not increased by use of plerixafor alone background: in an earlier from our center we have demonstrated that residual clonal plasma cells (cpc) decrease both overall survival (os) and disease free survival (dfs) (ash ).plerixafor is a selective antagonist of cxc chemokine receptor (cxcr ) and able to mobilize human peripheral blood stem cell (pbscs) by acting synergistically with g-csf.the purpose of this study was to evaluate the safety and efficacy of plerixafor in myeloma patients who were proven poor mobilizers and specifically to assess the flow cytometric measurement of residual clonal plasma cells in the apheresis products. methods: patients with a diagnosis of mm who underwent auto hsct at our center between january -november were retrospectively analyzed.out of patients, patients received plerixafor as mobilization regimen due to poor mobilization with g-csf.pbsc grafts were tested for the presence of clonal pcs (cpc) and the number of normal pcs (npc) by multi-parameter flow cytometry (fcm).the acquisition of the cells was performed using the navios flow cytometer beckmancoulter) .upon the daily checks of the instrument, x cells for each sample were acquired and the collected data was analyzed using the kaluza software (beckmancoulter,usa). results: patient demographics are shown in table .the majority of patients were male and median age was years in the plerixafor group.the median interval from time of diagnosis to mobilization and follow-up from mobilization were . months and . months in plerixafor group, respectively. cpc contamination in the pbsc grafts was detectable in and patients with counts ranging between - . x - and - . x - in g-csf alone and g-csf+plerixafor groups, respectively (p= . ).there were no significant differences in the proportion of the patients with graft contamination between subtypes of mm in both groups. one hundred (gcsf/plerixafor; / ) patients had pre-asct pet-ct imaging done with (gcsf/plerixafor; / ) have active lesion at the time of mobilization. statistically significant association could not be demonstrated between the disease < cr status at mobilization and the number of apc in the apheresis product in both groups (p> . ).twelve of patients from plerixafor treatment arm proceeded to transplantation within median . months.the best overall response to induction treatment is shown in table .thirtyfour patients from the g-csf alone arm and patients from the g-csf+plerixafor arm died during the follow-up (p= . ).disease progression was seen in patients from g-csf alone group and patients from g-csf+plerixafor group of the study(p= . ).estimated mean os was better among patients w/o apc contamination in plerixafor group, respectively ( . ± . mos vs . mos; p= . ). conclusions: our results on and few plerixafor used patients show that clonal plasma cells are detectable by multiparametric flow more frequently when patients are poor mobilizers and require plerixafor.the clonal pc contamination can be attributed to the myeloma biology as manifested by higher number of lines induction regimens and pet positivity among the plerixafor-required patients. the overall and disease survival was impaired by residual clonal pcs in the graft but not by plerixafor per se. neither was the content of clonal pcs differed from others.thus the cxcr shared by hsc and myeloma cells do not cause a myeloma mobilization. clinical trial registry: -disclosure: nothing to declare prognostic factors for overall survival after allogeneic hematopoietic cell transplantation in multiple myeloma patients all factors with significant influence on pts survival were included multivariate analysis (cox regression model) but only re-admission in the first days demonstrated impact on os (hr , ; p= , ) . conclusions: we analyzed risk factors for survival in mm pts who received allo-hct. our study identified disease-related risk factors like iss and transplantationrelated factors such as hct-ci and pam, hospital readmission, days of hospitalization and cmv reactivation that were associated with worse long-term survival. in our series, the most frequent death and re-admission cause was infection, so focusing the efforts in reduction of infection could have a beneficial impact on improvement of survival in mm undergoing allo-hct. [[p image] . figure ] disclosure: there is no disclosure. novel protocol for autologous hsct in multiple myeloma: ambulatory chemomobilization and transplantation of fresh hematopoietic stem cells with backup storage background: autologous hematopoietic stem cell transplantation (ahsct) after melphalan conditioning is still a part of standard treatment of multiple myeloma patients. traditional transplantation of frozen stem cells poses additional risk for the patients connected with dmso and central venous catheter. the transplantation of fresh cells is an option -however, most mobilization protocols are either low-efficient (g-csf), expensive (g-csf + plerixafor) or toxic (standard dose chemomobilization) to directly proceed to transplantation in this fragile group of patients. we describe here the novel combination of ambulatory mobilization with very low doses of ara-c and g-csf connected with direct ahsct with fresh cells. methods: the prospectively collected database of patients after ahsct was searched for patients who underwent ahsct after chemomobilization with ara-c and transplantation with fresh cells (fc) and compared with control group of consecutive patients transplanted with standard protocol (sp) (transplantation with frozen cells) between july and october . protocol of ambulatory mobilization was: mg/m² of arac on days + and + and g-csf at the dose μg/kg/day from day + and escalated to μg/kg/day split into two doses + to + , apheresis started on day + (or later) and finished when at least . x e cd + positive cells were collected. the collected cells were split in three equal parts: ) for use as fresh transplant ) frozen for possible nd transplant ) frozen as backup. results: there were transplantations with fresh cells and transplantations with frozen cells compared. both groups had same mobilization protocol -ambulatory low dose ara-c. the median age and number of transplanted cells was similar in both groups ( vs , p= . ; . vs . cd +/kg, p= . conclusions: we present novel approach that allows direct ahsct after chemo mobilization in all patients who are treated with melphalan. we show that it is not only feasible to do ahsct directly after chemomobilization but also the results may favour this approach when compared with current standard. disclosure: nothing to declare background: high dose chemotherapy followed by autologous hematopoietic cell transplantation (hsct) is considered, since the nineties, the standard of care for patients aged less than - years old with newly diagnosed multiple myeloma (mm). however, the optimal induction treatment prior to hsct to reduce the tumor burden has changed during the last few years. improved regimens have shown to be able to increase the quality of the pre-hsct response, which might subsequently impact on the post-hsct response, which has been proved to be associated with a longer pfs. we recently changed the induction therapy for pts candidates to hsct. in this analysis, we aimed to check if newer regimens impacted on pretransplant responses, and how auto-hsct changed the pre-hsct status. methods: all the auto-hsct for mm patients performed in our center from january through august were included in the analysis. median age was years (range: - ). pts were male and were female. durie-salmon stage was distributed as follows: i ( . %), ii ( . %) and iii ( %); % had creatinine > mg/dl. iss was: ( %), ( . %), and ( . %). type of monoclonal component was: igg ( . %), light chains ( . %), iga ( . %) , and non-secretory ( . %). . % had bence jones proteinuria. conditioning regimen was melphalan mg/m in ( . %), melphalan - mg/m in ( . %), and other in ( . %). results: pre-transplant therapy was: vcd in (mostly in - ), vtd/vrd/krd in (mostly in - ), and others in cases. status of the disease at transplant was: cr/vgpr in , pr in , and sd in . distribution of pretransplant response based on the type of induction is shown in table . peri-transplant mortality was %. day + mortality was . % ( pts), due to progressive disease. as shown in table , all patients ( / ) who obtained cr pre-hsct, maintained the response at day + post-hsct. among the patients in vgpr at hsct, ( . %) became into cr, and ( . %) maintained the response. the cr rate at post-hsct increased % compared to pre-hsct ( versus pts). altogether, after hsct pts ( . %) improved and ( . %) maintained the pre-hsct response. during the last period of time, pts started on post-hsct maintenance/consolidation, mainly with lenalidomide. conclusions: ) with the new chemotherapeutic schemes, . % of patients underwent hsct in cr or vgpr; ) majority of pts ( . %) consolidated or improved the pre-hsct response; ) cr increased substantially ( . times) after transplant; ) optimized induction regimens, along with auto-hsct followed by the recently licensed use of maintenance therapy with lenalidomide, might result in a better pfs of patients with mm. background: autologous stem cell transplantation (asct) is commonly used in treatment of patients over years with multiple myeloma (mm), however the safety and efficacy of this procedure is debatable. methods: we conducted a retrospective review of mm patients who underwent asct from to at our institution. the purpose of this retrospective study was to compare the -day mortality, time to engraftment, and incidence of grade - toxicities in elderly mm patients with younger patients taking into account comorbidity information. other secondary end points measured were overall survival (os) and progression-free survival (pfs). results: a total of patients were analysed and categorized by age as young patients ( to y; n= ) or elderly ( to y; n= ). the compared groups did not differ in terms of gender, ecog, hct-specific comorbidity index (hct-ci), and disease status at asct. melphalan in a dose of mg/m was used as preparative regimen in % of younger patients, and in % of the elderly (p= . ). the remaining patients received mg/m of melphalan or lower dose (range, - mg/m ) due to hct-ci > or age, on the physician discretion. in the whole study group there were no transplant related deaths within the first days of asct. stratifying by age, there was no statistically significant difference concerning febrile neutropenia (fn) incidence, which was observed in % of younger patients, and % of elderly. in contrast, fn was observed more frequently in patients with hct-ci > ( % vs %, p= . ). grade - infections were more frequent in older patients ( % vs %, p= . ), but no difference was found in grade - infections incidence rate such as pneumonia, uroinfections and neutropenic enterocolitis ( % vs %, p= . ), nor grade - and - noninfectious toxicities ( % vs %, p= . , and % vs %, p= . , respectively) . the median time to granulocyte engraftment was days (range, - days) in elderly and was comparable with younger patients. the time to platelet recovery was also similar. after the median follow-up of months for survivors, os at months was % in both groups. pfs at moths was % for younger patients, and % for elderly (p= . ).however, the association between pfs and the dose of melphalan used in conditioning was observed. pfs probability at months for patients conditioned with the dose of mg/m , mg/m and mg/m was %, % and %, respectively (p= . ). conclusions: our data show that asct in transplant eligible mm patients ≥ years of age is safe and provides similar outcomes as seen in younger patients. disclosure: nothing to declare is mobilization with chemotherapy effect response in the multiple myeloma? background: high dose melphalan therapy with autologous stem cell support is a standart approach in symptomatic multiple myeloma patients. response rates increased with the novel anti myeloma agents and the use of chemotherapy for stem cell mobilization should be questioned. the purpose of this study is to determine the effect of cyclophosphamide used during stem cell collection on disease response and transplantation results. methods: we retrospectively collect data from myeloma patients who underwent autologous stem cell transplantation (asct) in ankara university medicine faculty, blood and bone marrow transplantation unit between january and november . patients who received cyclophosphamide protocol for stem cell mobilization were included in the study. disease response were determined according to international myeloma study group (imwg) criteria before and after the cyclophosphamide. transplant responses and their effects on survival were also indicated. results: after the diagnosis of mm, patients (male/ female: / ; median age: years (between - years)) with median follow-up of . months (between , - , months) underwent asct at a mean of , ± , months.. forty-one patients were evaluated before and after cyclophosphamide (table ). in % of the patients, the disease response was not altered by cyclophosphamide therapy, and % of the patients improved their response status. post-transplant response rates of patients who underwent stem cell mobilization with cyclophosphamide are also shown in table- . the mean survival of the patients was , ± , months. when patients were grouped according to changes in response status before and after cyclophosphamide; there was no statistical difference between mean calculated survival (improved response, disease progression and stable disease; , ± , months, , ± , months and , ± , months respectively, p= . ) (figure- ) . the rates of -year and -year overall survival (os) of the patients with no response to cyclophosphamide treatment were as follows; , %± , % and , %± , % respectively. thirteen patients who were followed up median months after transplantation died at an average of , ± , months; of these deaths were caused by the infection after transplantation. conclusions: in our study, it was observed that the use of cyclophosphamide for cd + stem cell mobilization did not change the disease response rates by %. the posttransplant survival rates of mm patients who had progressive disease after cyclophosphamide use were lower. however, these results warranted confirmed by randomized controlled trials. clinical trial registry: -disclosure: nothing to declare results of a single center experience: an attempt to augment conditioning regimen in first autologous stem cell transplantation treatment of multiple myeloma (mm) continues to evolve in the era of novel agents. the addition of bortezomib to highdose melphalan (bor-hdm) has been reported by several groups, and it has been outcome and toxicity profile is comparable to high dose melphalan (hdm) alone. the aim of this retrospective study was to evaluate the outcome of the bor-hdm conditioning regimen on overall response for patients with mm undergoing first single asct at our institution. methods: this retrospective single center study reviewed consecutive myeloma patients who had received the first asct either with bor-hdm (n= , m/f= / ) or single agent hdm (n= , m/f= / ) conditioning regimen. in the single agent hdm conditioning regimen, melphalan was administered intravenously at a total dose of mg/m on day - and - and stem cells were infused on day . in the bor-hdm group, melphalan mg/m was administered on day - . bortezomib was administered intravenously at a dose of mg/m on day's - , - , + , and + as described in a phase study by intergroupe francophone du myeĺome (ifm). results: all consecutive patients who underwent single asct from january to march using bor-hdm as conditioning or hdm were evaluated. conditioning regimen was hdm in patients and bor-hdm in patients. median age was significantly lower in bor-hdm conditioned asct compared to hdm group ( years vs years, p= ). there was no significant difference for mm subtype, iss stage at diagnosis, prior treatment line among hdm vs bor-hdm cohorts (p> . ). after a median of cycles of induction chemotherapy, patients in the bor-hd exhibited ≥vgpr of . % (n= ) compared to . % (n= ) in the hdm group (p= p> . ). pre-asct immune response (if (-)) was reported in . % of patients treated with hdm, higher than that seen in the bor-hdm group ( . %) (p= . ). nine ( . %) patients achieved post-asct immune response (if (-)) ≥vgpr compared to ( . %) in the hdm group. at the time of this analysis, ten patients in the bor-hdm group and in the hdm group had already died, respectively (p> . ). a total of ( . %) patients in the bor-hdm group and ( . %) patients in hdm group had already progressed (p> . ). estimated mean os and pfs was shorter for group treated with bor-hdm; . ± . mos and . ± . mos vs. . ± . mos and . ± . mos, respectively (p> . ) (figure- ) . we could not demonstrate the impact of pre or post transplant ≥vgpr immune response on survival and disease free survival. there was no engraftment failure observed on either treatment group and no worsening peripheral neuropathy was developed in the bortezomib arm. conclusions: this single center experience on a small patient pool was able to repeat the prospective randomized study results of ifm. further studies are warranted to explore this regimen, especially when induction treatment with novel agents are employed, with special emphasis on the high-risk myeloma patients where response rates are good but sustainability remains an issue. disclosure: nothing to disclosure the efficacy and safety of bortezomib plus busulfan/ melphalan as conditioning regimen in multiple myeloma undergoing autologous stem cell transplantation: phase / study background: bortezomib have a powerful antimyeloma activity and was regarded as backbone of therapy in the past decade but its safety and efficacy as a part of busulfan/ melphalan conditioning regimen of autologous stem cell transplantation is yet to be shown. methods: a phase / trial to explore the safety and activity of a bortezomib on days - , - , and + added to a conditioning regimen with busulfan and melphalan (bumel, . mg/kg/day and busulfan during day - and - , mg/ m /day of melphalan on the day - ), in multiple myeloma (mm) patients who received autologous stem cell transplantation following bortezomib-based induction chemotherapy. in phase , escalating doses ( . , . , and . mg/m ) of bortezomib with bumel were administered in each group with three patients. with determined maximum tolerated dose of bortzomib at a . mg/m /day, cohort with patients were analyzed for phase . results: in phase , no dose limiting toxicity was observed at a . mg/m /day of bortezomib. in phase , overall responses at months was shown as % of very good partial response (vgpr) or better and % of complete response (cr), whereas post-transplant overall best response included % of vgpr or better, and % of cr, respectively. with median follow-up duration of . months, median progression-free survival (pfs) was . months. the probabilities of years-pfs and overall survival (os) were . % and not estimable, respectively. especially, high-risk cytogenetics were associated adverse survival outcome compared to standard-risk cytogenetics, respectively (pfs, . vs. . months, p= . ; os, . vs. . months, p= . ) . with median days and days for neutrophil and platelet engraftments, any graft failure or delayed engraft was not observed. the common grade or severe non-hematological adverse events included neutropenic fever ( . %) and stomatitis ( . %). except three cases with transplant-related mortality due to sepsis, other adverse events were manageable. conclusions: these results demonstrate that bortezomib is safe and can be a part of conditioning regimen in combination with bumel, for patients with transplanteligible multiple myeloma. clinical background: allogeneic stem-cell transplantation (allo-sct) is one of treatment option for patients with multiple myeloma (mm) refractory to novel agents. the reports on allo-sct for mm are limited and it is an important issue to argue appropriate conditioning regimens and stem-cell sources, and patient population who will benefit from allo-sct. methods: we retrospectively analyzed consecutive patients who received allo-sct for relapsed and refractory multiple myeloma (rrmm) between oct and july at japanese red cross medical center. characteristics of patients, progression-free survival (pfs), and overall survival (os) were analyzed. results: median age at allo-sct was (range - ). twelve patients were male and were female. myeloma type were igg: , iga: , igd: , and bence-jones: . stem-cell sources were peripheral blood from hlamatched related donor (rpbsct): , bone mallow from hla-matched unrelated donor (mud): , bone marrow from hla-mismatched donor (mmud): , and cord blood (cb): . twenty-three of patients received flu/mel-base, one patient received bu/mel-based, and one patient received etoposide/cyclophosphamide-based conditioning regimens. twenty-two patients who transplanted after received gy of total body irradiation (tbi). responses before allo-sct were cr: , vgpr: , pr: , sd: . five-year pfs was % ( %ci: - ) and -year os was % ( %ci: - ). ten patients died during observation period and causes of death were primary disease: and treatment-related mortality: . patients with vgpr or better before allo-sct showed significantly better pfs (p= . ) and os (p= . ) as compared with others. female recipients showed significantly better pfs (p= . ) and os (p= . ) as compared with male recipients. recipients of mmud showed significantly better pfs (p= . ). among patients surviving, patients received treatments including maintenance therapy. conclusions: the reason for better pfs and os in female recipients is unknown. it is interesting that recipients of mmud showed better pfs, suggesting graft-versusmyeloma effects. allo-sct can be an effective treatment option if patients and stem-cell sources are appropriately selected. disclosure: authors declare that there are no conflicts of interest. second autologous hematopoietic stem cell tranpslant versus chemoimmunotherapy in relapsed multiple myeloma after first transplantation: single center data background: combination therapy, mostly triple, followed by autologous hematopoietic stem cell transplantation (auto-hct) is widely accepted as the first-line standard therapy for multiple myeloma (mm). despite the availability of agents such as new immunomodulatory drugs (imids), proteasome inhibitors (pis), histone-deacetylase inhibitors and antibodies, it is still possible to achieve longer and deeper responses, however, multiple myeloma is still not cured and relapse is inevitable. the availability of these novel agents has increased questions for determining optimal treatment of patients with relapse after the first auto-hct. methods: we retrospectively analyzed patients who relapsed according to international myeloma working group (imwg) criteria after st auto-hct. first group [salvage chemotherapy(ct)] (n= ) was treated with only chemoimmunotherapy because of early relapse or refractory first auto-sct (within months), ineligible to second transplantation because of co-morbidity, unwillingness to transplant. second group (n= ) (salvage transplantion) was treated with second auto-hct as a salvage therapy. consolidation and long term maintenance treatments were used in both groups. results: there was no difference in sex and age between salvage ct and auto-sct groups [female/male: vs / vs ; ]. the best response after salvage auto-sct was complete remission (cr) in , %, partial remission (pr) in , % patients, while cr in %, pr in , % patients treated with salvage ct. progression free survival (pfs) were significantly better in second transplant group (pfs; % on the first year; , % on the second year after transplant vs % on the first year; % on the second year after the salvage therapy in chemotherapy patients)[p: , ]. overall survival (os) in salvage auto-sct group was longer than salvage ct ( , % . %), although it did not reach a statistical significance (p> . ). time to achieving the best response after salvage auto-sct and salvage ct was ( - ) month versus , ( - ) months [p: , ]. grade or nonhematological toxicities were similar (auto-sct %, salvage ct %) in both groups. conclusions: salvage auto-hct may provides longer progression free survival with similar toxicity profile according to chemoimmunotherapy especially in patients with sensitive to first auto-sct. it is suggested that earlier and better responses, long-term progression free survival can be achieved with salvage auto-sct. we believe that there will be statistical significance in os such as pfs by increasing the number of patients. the authors believe that large scale randomized clinical trials are needed for optimal treatment of relapsing multiple myeloma after first auto-sct. disclosure: nothing to declare background: one of the conditions for successful transplantation of autologous hematopoietic stem cells (auto-hsct) in patients with multiple myeloma (mm) is the timely recovery of hematopoiesis, which is associated with the quantitative and qualitative characteristics of the graft. one of the key indicators is the content of cd + cells in the autograft, which depends on many factors. some of them are due to previous treatment, others are directly related to the patient: age, stage of the disease, features of the hematopoietic stem cells (hsc) microenvironment. the aim of the study was to assess the influence of the immune response genes on the autograft cellularity in patients with mm. methods: А retrospective analysis of the genotyping results was performed. evaluation of loci in genes immune response and harvesting of autologous hsc in patients with mm has been made. hematopoietic stem cell mobilization regimen included cyclophosphamide g/m with granulocyte colony-stimulating factor. genotyping of the immune response genes polymorphic regions was carried out by the polymerase chain reaction with allelespecific primers. the number of cd + cells was counted on a -color facs canto ii flow cytometer. results: according to the results of the autologous transplant harvesting, two groups of patients were identified. first included patients with an autograft cellularity of more than × /kg body weight. the second group consisted of patients examined with the number of cd + cells in the autograft ≤ × /kg of the patient's body weight. comparing the identified haplotypes of the immune response genes with the cellularity of the transplantation material, it was found that the presence of the mutant allele in the homo-and heterozygous haplotypes of the il β gene (t- c) increased the chances of harvesting cellular material with a higher content of cd + cells in times (χ = . , p= . ), and the carriage of the wild type allele in the homo-and heterozygous state of the tlr (arg gln) gene is more than in times (χ = . , p= . ). currently, it has been shown that single nucleotide or amino acid substitutions in genes can lead to changes in the expression pattern of their final products: increased secretion of interleukin β (il- β) or changes in the spatial configuration and functionality of the receptors (tlr ). thus, in the presence of mutations in the il β gene, the enhanced synthesis of il- β influences on fibroblasts, immunocompetent, endothelial, epithelial and other cells, by activating hemopoiesis. in turn, the mutational status of the arg gln locus located within the tir domain of the tlr receptor in the cytosol, determines the spatial configuration of the tlr acting as a co-stimulatory receptor of cd + cells, which ensure the engraftment of the graft. conclusions: identified haplotypical features of the il β and tlr genes in patients with mm may act as predictors of the response effectiveness to mobilization of hscs in their carriers, which may contribute to the mobilization regimen optimization and will contribute to harvesting the optimal cellularity of an autologous graft. clinical trial registry: none. disclosure: authors declare no conflict of interest. differentiating diffuse from focal pattern on computed tomography: added values of a radiomics approach background: focal pattern in multiple myeloma (mm) seems to be related to poorer survival and differentiation from diffuse to focal pattern on computed tomography (ct) has inter-reader variability. therefore the purpose of this study is to assess if a radiomic approach could help radiologists in differentiating diffuse from focal patterns. methods: we retrospectively reviewed imaging data of patients with mm between january and september of whom ( men and women; mean age . ± . ) with ct, pet-ct or mri available before bone marrow transplant. two general radiologist evaluated in consensus only ct images to define a focal (at least one lytic lesion > mm in diameter) or a diffuse (lesions < mm, not osteoporosis) pattern. radiomic analysis on ct thinslice images was then applied with regions of interest (rois) done by one researcher not expert in medical imaging or mm blindly to the condition of the patients. the reference standard to differentiate diffuse from focal pattern was done by radiological evaluation of two expert musculosketal radiologists blinded to the clinical data reviewing ct, mri and pet-ct images. n= radiomics features were extracted and evaluated with an open source software. mann-whitney u test for unpaired data with bootstraps samples was used to compare radiomics features of diffuse and focal patterns and then feature reduction was done to avoid over-fitting. receiver operator characteristic (roc) analysis with area under the curve was done to compare radiologists and radiomics evaluation against reference standard. reading time to perform radiomic analysis was also estimated. results: the pathological group included: diffuse and focal patterns. after feature reduction, features were different (p< . ) in the diffuse and focal patterns (n= / features were shape-based: majoraxislength and sphericity; n= / were gray level run length matrix (glrlm)). mg/kg). a number of eleven patients did not receive any additional immunosuppression except of post-cy. results: after a median follow up of . months (range . - . ) patients were alive. the -year probabilities of pfs and os were % ( - %) and % ( - %).the cumulative incidences (cis) of relapse and nrm at years were % ( - %) and % ( - %), respectively. lower serum albumin level at transplantation (≤ g/dl) was associated with increased relapses (hr . ( . - . ), p= . ) and nrm (hr . ( - ), p= . ) and resulted in poorer pfs ), p= . ) and os ), p= . ). mmud and haploidentical donors were associated with poorer nrm (hr . ( . - . ), p= . ), and resulted in decreased pfs ), p= . ). the high-risk cytogenetic at diagnosis showed no impact on survival. the cis of acute (grade ii-iv) at day + and chronic gvhd at years were % ( - %) and % ( - %), respectively. absence of immunosuppressive medication beside post-cy was associated with poorer os ), p= . ). conclusions: the conditioning with bu, tt and post-cy leads to a favorable pfs and os due to low incidences of relapse and nrm for patients with multiple myeloma relapsing after autografting. disclosure: nothing to declare methods: between january and may , we included patients with mm who underwent asct and received bortezomib/lenalidomide/dexamethasone (vrd) consolidation and maintenance therapy, mainly lenalidomide(r) mg/day for days every days. results: the median age at transplant was years ( - ). forty-six ( %) of patients received r maintenance, patients received vrd maintenance for higher risk features. median duration of r maintenance was months . r dose was changed for toxicity (grade i-ii) in ( %) patients. twenty-nine ( %) patients relapsed: ( %) patients were shifted to different treatment protocols (treatment change). patients ( %) were kept on the same r maintenance (observation group) and ( %) patients had increased lenalidomide dose with dexamethasone (r/ d group). patients ( %) of the last groups required change of treatment later. the median follow up was months . median tnt was months ( - ). at years, the estimated pfs and os were % and . % respectively. the median os and pfs (from change of therapy) were and months for patients in the observation group, versus and months in the r/d group, and and months with treatment change, respectively. no statistically significant difference was noted. conclusions: our small monocentric study is limited by its retrospective design and small sample size. however, it suggests that increasing lenalidomide dose as well as adding dexamethasone in selected patients can postpone change to different lines of treatment without affecting survival. disclosure: nothing to declare can the drugs used before autologous hematopoietic stem cell transplantation have impact on cmv reactivation that results in decreased os in myeloma patients after asct? more intensive treatment regimens, such as proteasome inhibitors (pi) and/or immunomodulatory (imid) agents. we performed a retrospective, single center study to evaluate the incidence, risk factors, and outcomes of cmv infection in patients with mm who underwent asct with a high-dose melphalan-based regimen. methods: this study involved a retrospective review of all patients with who underwent asct between january and november at our stem cell transplantation center. a total of consecutive adult patients with a diagnosis of mm (median age at diagnosis: , range: - ) underwent asct following induction treatment with novel agents (pis and/or imids). all patients received antiviral prophylaxis with acyclovir mg/day (n= ) or valaganciclovir mg/day (n= ). results: baseline patient characteristics, according to induction treatment, are summarized in table- . one hundred-five of the patients ( . %) were cmv iggpositive before asct. overall, . % (n= ) of cmvseropositive patients developed at least one episode of cmv viremia (cmv dna > copies/ml) after a median months (range; - mos) follow-up. persistent cmv viremia (detectable cmv dna load in more than sequential plasma specimens) occurred in . % ( of ) of the seropositive asct recipients and all of them were preventive treated with ganciclovir (n= ) or valganciclovir (n= ). the time from stem cell infusion to the development of cmv viremia ranged from days to days. none of the patients with untreated viremia developed identifiable cmv sequelae. no case of primary infection in seronegative patients at transplant was observed. adding to that none of the patients developed cmv disease post asct. if we analyzed the subgroups of patients according to induction therapy (pi-based, imids, pi+imid), the incidence of post-asct cmv reactivation was higher but not statistically significant, in patients who received only pi vs pi+imid ( ( . %) vs ( . %); p= . ). in univariate analysis, we could not demonstrate the importance of induction therapy with novel agents the occurrence of a post-asct cmv reactivation requiring antiviral treatment. however, statistically significant association found between the disease < vgpr status at asct and cmv reactivation ( . % vs. . %; p= . ). after a median follow-up . months (range; - . months), there was no significant impact on pfs, however there was significant decrease in estimated mean os who had cmv reactivation when compared to those without cmv reactivation ( . ± . vs. . ± . ; p= . ) (figure- ) . conclusions: cmv establishes lifelong latency within host cells and in the setting of impaired cellular immunity; cmv may reactivate from latency, disseminate, and directly cause life-threatening disease. our data suggests that mm patients treated with pi-based induction regimens and immunological response < vgpr at time of asct seem to have higher risk of developing symptomatic cmv reactivation. however, further studies on a large number of patients are warranted to clarify these findings. clinical background: high-dose therapy followed by autologous stem cell transplantation (asct) has been shown to prolong survival in patients with multiple myeloma (mm) in randomized trials. however, these trials only include patients aged < years. data regarding safety and outcomes in this patient population is lacking. methods: the aim of this study was to compare safety profile and outcomes in mm patients younger and older than years-old who underwent asct in our unit from july to october . patient's demographics, clinical characteristics, transplant related variables and probability of admission to the intensive care unit (icu) were analyzed. patients aged < and ≥ years-old would be called m and m , respectively, from now on. sorror index was used to estimate risk of mortality in the two cohorts. results: a hundred and eleven patients with mm underwent asct in the study period. median age was . years-old (range - ) and . % were male. thirtythree ( , %) patients were ≥ years. the probability of having a high risk comorbidity index was similar in both groups (m , vsm , %). the median cells obtained in the apheresis procedure was . x ( , - . ) in m compared to . x ( . - - ) in m . there were no differences in median admission lenght between the cohorts (m : days vs m : days). median days for neutrophil recovery above was days in both groups with a wider range in m ( - ) compared to m ( - ) . no differences were found in platelet recovery above . (m days vs m days). median packed red blood cells and platelets transfusions were ( - ) and ( - ), respectively, in m . in m cohort, they were ( - ) and ( - ), respectively. the incidence of grade - mucositis in m and m was . % and . %, respectively. there were no statistically significant differences in terms of using morphine for pain control between the two cohorts (m , , % vsm , , %). none patient requiered total parenteral nutrition (tpn) in group m and only one in group m . the incidence of icu admission was . times higher in patients aged ≥ than in patients < years-old , % vs , %), but differences were not statistically significant (p = . ). there were no deaths during the transplant procedure in any of the cohorts conclusions: ) in our series, high-dose therapy followed by autologous hematopoietic cell transplantation in mm patients aged ≥ was feasible. ) transplant procedure in older patients was as safe as in patients < years-old. ) no differences were found in terms of graft, transfusion support, transplant related complications and length of admission. ) age should not be a limiting factor in considering the modality of asct in this patient population disclosure: nothing to declare the correlation between the kinetics of peripheral blood counts and the response to treatment after high-dose melphalan with stem cell support in multiple myeloma patients background: the long-term survival of mm patients has dramatically increased in the last years, particularly for younger patients. this is attributable in part to the introduction and development of high dose chemotherapy with melphalan with stem cell support (hdm-asct). currently, frontline asct is still considered the standard of care for all eligible patients. many prognostic factors pre and post transplantation have been identified, e.g.: age, comorbidities, cytogenitcs, response to treatment and disease status prior to and post transplantation. to our knowledge there is no data correlating between kinetics of counts response to melphalan and prognosis. our aim was to assess the prognostic significance of the neutrophil and platelets decaying counts after high dose melphalan. methods -we retrospectively analyzed our cohort of multiple myeloma patients who underwent hdm-asct at the hadassah medical center bone marrow transplant department, between the years - . the kinetics of neutrophil and platelet decay during the first two weeks after melphalan administration was fitted using linear and exponential mathematical models. methods: we retrospectively analyzed our cohort of multiple myeloma patients who underwent hdm-asct at the hadassah medical center bone marrow transplant department, between the years - . the kinetics of neutrophil and platelet decay during the first two weeks after melphalan administration was fitted using linear and exponential mathematical models. results: factors associated with prolonged os in univariate analysis were: iss stage (p= . ), ≤ lines of treatment prior to asct(p< . ), favorable cytogenetics(p= . ), response to treatment (pr or better, p= . ) and rapid linear neutrophil decay (p = . ). in multivariate analysis, only ≤ lines of treatment before hdm-asct and rapid linear neutrophils count decay remained statistically significant for os prolongation. no predictive threshold value of the neutrophil decay incline was found. improved pfs was associated with ≤ lines of treatment prior to asct, and the response status after hdm-asct (p= . , p= . ). additionally, toxicity evaluation showed prolonged neutropenia to be associated with inferior os (hr = . , p= . ) and rapid exponential decay of neutrophil counts to correlate with higher incidence of mucositis (p = . ). fast platelet decay was associated with delayed platelet engraftment (p< . ) conclusions: we have shown that rapid linear decay in neutrophil counts predicts better os without a significant benefit in pfs in mm patients undergoing hdm-asct. this discrepancy might reflect the problematic estimation in a retrospective analysis of pfs. rapid decrease in neutrophils and platelet counts was associated with more toxicity: higher mucositis rate and delayed engraftment, respectively. therefore a rapid decay of blood counts after hdm-asct appears to be an in-vivo phamacodynamic marker of higher efficacy and toxicity of melphalan. disclosure: nothing to declare p do we need to freeze hematopoietic cells for autotransplants in patients with myeloma conditioned with melphalan? daniel garcia belmonte , beatriz aguado bueno , miguel herrero coderch , rafael de la camara background: multiple myeloma (mm) is the most frequent indication of auto-hsct, representing % of all auto-hsct in (passweg jr. bmt ; : - ) . nearly all are performed with peripheral blood progenitor cells (pbpc), and melphalan mg/m is considered the gold standard conditioning regimen. the standard procedure consists in obtaining progenitors, cryopreserved with dimethyl sulfoxide (dmso) and stored and subsequently thawed and re-infused in the patient on day . the procedure of cryopreservation is expensive and has some inherent toxicities (dmso) and loss of cells during the procedure. several groups have used non-cryopreserved progenitors showing some benefits compared with cryopreserved transplants, mainly a faster engraftment and a shorter length of hospitalization. objective: to compare noncryopreserved vs cryopreserved auto-hsct in mm methods: we perform an unicentric, retrospective study on consecutive first auto-hsct mm patients transplanted with pbpc between nov- and oct- , and conditioned with high dose melphalan ( mg/m ). the median follow-up was days (range: - ). patients received non-cryopreserved and cryopreserved auto-hsct. patients characteristics, without differences between non-cryopreserved vs cryopreserved: women/men ( / ); median age was years (range - ); in the majority auto-hsct was done as consolidation after first line therapy ( %); year of transplant ≤ ( %), ≥ ( %). the number of infused cd cells were not different: median . x /kg (range . - . ) in noncryopreserved patients and . x /kg (range . - ) in cryopreserved patients. results: we didn´t observe significant differences in the day of engraftment between non-cryopreserved vs cryopreserved although always was a little bit faster in the noncryopreserved group with a tendency to faster platelet engraftment (> /mm ): > platelets/mm (median day: vs . , p . ), > platelets/mm (median: vs days, p . ); > neutrophils/mm (median: vs . days, p . ). the media of days of hospitalization was shorter in non-cryopreserved patients ( vs days) although not statistically significant (p . ). transplantrelated mortality at day + was % in both groups. overall survival at years was not different: . % in in non-cryopreserved vs . % in cryopreserved patients (kaplan-meier, log-rank p . ). the accumulative incidence of relapse at the median follow up ( days) was similar: . % in non-cryopreserved vs . % in cryopreserved patients. conclusions: in our short experience, auto-hsct with non-cryopreserved pbpc in myeloma patients conditioned with high dose melphalan obtain similar results to those performed with classical cryopreserved pbpc and might has a faster platelet engraftment and shorter length of hospitalization. if no advantages are associated with cryopreservation, the simplicity of using fresh product is appealing. disclosure: nothing to declare p abstract withdrawn. . results: a early death is observed in one pt (group ) and pts(group ). the median delay of aplasia is days ( - ) and days ( - ) respectively. in group , among the evaluable pts, / ( %) are in cr, pts in pr and refractory. in group , cr: / ( %), pr: and refractory. a relapse is observed in pts/ ( , %) in group and pts/ ( %) in group with a frequency of % and % respectively in the first months. at months: pts/ ( %) in group and pts/ ( %) in group are dead. at months: pts ( %) and pts ( %). at months: pts ( , %) and pts ( , %). the overall survival (os) of the group and group pts were % and % at months; . % and . % at months; % and , % at months respectively (without significant difference). the event free survival (efs) of group and pts were % and , % at months, % and % at months and % and % at months respectively (without significant difference). conclusions: these protocols with equivalent toxicity allow obtaining of long-term equivalent results on the response rate early transplant, on the rate of relapse and on the overall survival. these results are identical to those of fermand ( ) . disclosure: nothing to declare background: dimethylsulfoxide (dmso) is a major intracellular cryoprotectant, used for cryopreservation of stem cells. it is toxic to both cells and patients at temperatures above o c. reduction of this effect is achieved by either washing of cells after thawing or by reduction of dmso during freezing and storage. the latter requires addition of extracellular cryoprotectants to the freezing media. we assessed the effect of low dmso concentration and different hematocrits of the frozen cells on cell viability and hematologic recovery in patients, transplanted for multiple myeloma. methods: cells were non-programmed frozen and stored at - o c in a cryoprotectant solution achieving final concentrations of % dmso, . % of hydroxyethyl starch (hes, weight average molecular weight da) and % of human serum albumin. the cell concentration in the frozen product for the first patients ( transplantations) varied between x and x cells/ml. in an attempt to reduce the amount of dmso infused, for the rest of the patients (n= ; transplantations) we further decreased the volume of the freezing suspension by removal of the entire plasma. the average age of the transplanted patients was ( - ). the cells were bedside thawed at o c water bath. the average cell dose was , x /kg ( , - , x /kg). results: viability of the stem cells following thawing assessed by trypan blue exclusion was , % . the hematocrit of the frozen cells had no effect on cell viability ( , %(low) vs , %(high)). the major complaints, if any, during stem cell infusion were coughing and an increase in nausea and vomiting induced by the prior conditioning. the average time for hematological recovery was , days (between and ) for the neutrophils, and , (between and ) days for the platelets. there was no significant difference in viability and hematologic recovery ( , and , vs , and , ) between patients receiving cells frozen with low or high hematocrit. conclusions: dimethylsulfoxide, despite its cryoprotective properties, is toxic for stem cells at temperatures above zero c and induces many side effects (cardiac, neurologic, respiratory, etc.) in the patients. to reduce those side effects we use lower dmso concentration, high hematocrit resulting in lower volume of the frozen cell suspension, thus reducing the final quantity of dmso to be infused to the patients. this does not affect the cell viability or the hematologic recovery of patients after transplantation. our easily performed method for unprogrammed freezing of stem cells with final dmso concentration % at - o c is safe, well tolerated, and provides cryopreservation, which allows high viability and stable cell engraftment, while reducing the undesired side effects of dmso. disclosure: nothing to disclose the conditioning regimen consisted of melphalan for most of the patients. the average age at the time of transplantation was years ( - ). patients were transplanted with an average cell dose of , x /kg ( , - , x /kg) for the first transplantation and , x /kg ( , - , x /kg) for the second one (every patient received the same cell dose as for the first) with average cell viability , % ( - %), with little difference between first and second transplantation. results: the average time for hematological recovery was , (between and ) days for the neutrophils, and . (between and ) days for the platelets. we found no correlation between the cell dose and the hematological recovery. there was no difference in the hematopoietic recovery between the first and the second transplantation in the patients, who underwent tandem or two transplantations. conclusions: recovery time is considered by some to be a function of the effective stem cell number. we did not find such correlation, probably because in the analyzed group all the patients, except four of them, received a dose greater than x /kg cell, which is accepted as a safe dose for autologous stem cell transplantation. disclosure: nothing to disclose p plerixafor-mobilized patients have a high risk of noninfectious fever during engraftment after autologous peripheral blood stem cell transplantation background: plerixafor enables rapid and efficient mobilization of hematopoietic stem cells. however, its impact on adverse clinical events after autologous peripheral blood stem cell transplantation (pbsct) is not fully understood. fever is one of the major complications in the preengraftment phase of pbsct. in this research, we focused on non-infectious fever around the time of bone marrow recovery and investigated whether plerixafor as mobilization therapy plays a role in engraftment fever. methods: we reviewed autologous pbscts for treatment of multiple myeloma at the japanese red cross medical center between - . non-infectious fever was defined as temperature ≥ °c with onset between two days prior to and two days after engraftment without clinical or microbiological documentation of infection. results: patients were mobilized by cyclophosphamide and filgrastim in . % (n = ) and filgrastim and plerixafor in . % (n = ). the median number of transfused cd + cells were . × /kg and . × / kg, respectively (p= . ). patients transfused with plerixafor-mobilized grafts had a higher risk of noninfectious fever ( . % vs . %, p< . ). cd + cell number or cyclophosphamide pretreatment had no relationship to non-infectious fever. the recovery of lymphocytes was more rapid in plerixafor-mobilized patients (p= . ). however, the number of lymphocytes was not associated with non-infectious fever. conclusions: combination of filgrastim and plerixafor as mobilization therapy resulted in an increased risk of noninfectious fever during engraftment comparing to mobilization with cyclophosphamide and filgrastim. while the mechanism remains unclear and requires further studies, plerixafor-mobilized grafts may result in an unintended increase in engraftment fever. clinicians should be aware of this possibility if patients are transplanted with those grafts. disclosure: ks received honorarium outside the submitted work from janssen, novartis, celgene, ono pharmaceuticals, takeda, fujimoto pharmaceuticals and srl. ti received honorarium outside the submitted work from janssen, celgene, ono pharmaceuticals and takeda. we assessed the efficacy of a new conditioning regimen consisted of decitabine (dec), busulfan (bu), cyclophosphamide (cy), fludarabine (flud) and cytarabine (ara-c) for allo-hsct in patients with mds and mds/ mpn. fifty patients were enrolled, including with mds and with cmml. patients received dec mg/m /day on days - to - , combining bu/cy/ flu/ ara-c modified preparative regimen. results: at a median follow-up of ( - ) days, the overall survival (os) was %, disease-free survival (dfs) was %, and relapse incidence was %. the incidence of severe acute (grade iii/iv) graft-versus-host disease (gvhd) was %, and that of (predominantly mild) chronic gvhd was %. os at years was % for mds patients with high risk, % for mds patients with very high risk, respectively. the survival was delightful in patients with poor-risk mutations, such as tp and asxl , ( %) and with three or more gene mutations ( %). among the total patients with poor-risk mutations in our research, only one patient ( %) with tp relapsed and one ( %) with asxl and tet died. result of continuous observation after transplantation, the percentage of nk cells in the peripheral blood of all patients who had received dec/flu/bu/cy/ara-c conditioning increased at day , which may essentially contribute to disease control post-transplantation. conclusions: in summary, the addition of a -day schedule of decitabine to a flu/bu/cy/ara-c conditioning regimen has proven feasible, with a low level of toxicity and promising early disease control especially in patients with high risk mds. disclosure: there are no conflicts of interest. the sfgm-tc mds score at day is associated with post-transplant outcomes in patients with myelodysplastic syndrome who underwent cd + selected allogeneic stem cell transplant conclusions: in patients with mds undergoing tcd-hct, the sfgm-tc score at day is significantly associated with survival. the lower incidence of acute gvhd in recipients of cd -selected transplants and the use of myeloablative condition regimens, with lower relapse, may explain the difference with the original finding that the sfgm-tc was predictive at day in unmodified grafts. disclosure the most frequent grade , toxicities were thromobocytopenia and neutropenia. infections developed in patients ( . %), neutropenic fever in ( . %). five patients ( . %) either developed or experienced exacerbation of acute graft versus host disease (gvhd), nonechronic gvhd. conclusions: azacitidine use is associated with only modest activity in patients who relapse after allo-hsct. however, in patients who respond to treatment it may allow for a durable disease control. disclosure: the authors declare no competing conflicts of interest background: somatic mutations in mds patients are closely related with clinical phenotypes and prognosis in mds patients. but whether mutations are prognostic for outcomes after allogeneic hematopoietic stem-cell transplantation (allo-hsct) remains to be elaborated. methods: targeted mutational analysis were performed on samples obtained before transplantation from patients underwent hsct. we analyzed the relationship of mutations and clinical outcomes. results: all patients carried more than one somatic mutations, most frequently in kmt d( . %), arid b ( . %), ccdc ( . %), pclo( . %), asxl / ( . %), srcap( . %), u af ( . %), dnah ( . %), ush a( . %) and tet ( . %). tp mutations were associated with higher ipss-r risk, complex karyotype and monosomal karyotype. dnah were more frequent in pediatric patients. in univariable analyses, tp mutations were related with decreased disease-free survival (p= . ); dnah mutations were related with increased disease-free survival (dfs) (p= . ). in multivariable analysis including ipss-r stratification, gvhd, hct-ci and candidate genes, dnah mutations were independently associated with better dfs(p= . ). conclusions: dnah mutations is independently associated with better outcomes in mds patients treated with allo-hsct while tp may predict unfavorable outcomes. accounting for these somatic mutations may help better selection of candidates for allo-hsct among mds patients. disclosure background: there is a controversy among experts if and how patients with mds and saml should receive cytoreductive therapy before transplant. while aiming to reduce disease burden in order to lower the risk of relapse after transplant cytoreductive therapy is associated with several drawbacks. besides a considerable risk for toxicity and mortality preventing patients to proceed to transplant cytoreductive therapy may also favour the selection of resistant clones which may be difficult to treat at relapse. methods: to address this hypothesis we retrospectively analysed the response and survival following salvage therapy in patients with mds and saml who had relapsed in median . months ( to months) after allo-sct according to their pre-transplant strategy (upfront transplantation n= %; induction chemotherapy [ctx] n= %; hypomethylating agents [hma] n= %). results: the majority of these patients received salvage therapy with hma (n= , %; aza n= , dac n= ) mostly in combination with dli, while the remaining received other salvage treatments (intensive chemotherapy n= , dli alone n= , nd transplant n= , bsc n= , miscellaneous n= , missing information n= ). when focussing on those patients treated with hma and dli it became apparent that a significantly higher proportion of patients in the upfront group ( %) achieved cr after salvage therapy in comparison to pre-treated patients ( % cr, p= . ; ctx group % cr; hma group % cr). accordingly, overall survival (os) calculated from the time of relapse was significantly longer in patients in the upfront group than in the group of pre-treated patients ( -year os % vs. %, p= . ). conclusions: overall, these findings imply that pretransplant therapy may favour the iatrogenic selection of resistant clones, which poorly respond to salvage therapy with hma and dli in case of relapse after allo-sct. furthermore, the results support the concept that an upfront transplant strategy is a promising alternative for patients with mds and saml that can be augmented by salvage therapy with hma and dli. disclosure: ts and gk received travel support, lecture fees and research funding from celgene gmbh conclusions: in our country, this procedure has shown to be feasible and we hope to improve it, with better infection control and by acquiring more experience related to the management of these patients. background: extramedullar relapse of mds is a rare complication after allogeneic stem cell transplantation. we present the case of a -year-old woman who was admitted into hospital because of insecure walking. paresis of both legs, hypaesthesia of the inner thighs, increased effort at urinating, reduced sphincter tonus, central paresis of the right arm and discreet paresis of the right facial nerve were documented at neurological exam. mri showed a large tumour of the dorsal thorax that immured the adjacent ribs and spine, affected the processus transversus of t - and invaded the spinal canal. the patient had undergone ric allogeneic stem cell transplantation five years ago for mds-eb with complex aberrant karyotype. following an uneventful course and no signs of gvhd, she had been off immunosuppression since , years. at the time of the admission the patient had slightly lowered wbc ( , gpt/l) and plt ( gpt/l) and clearly increased ldh ( u/l). methods: histology of a ct-based biopsy of the paravertebral tumour showed an infiltration of the muscles by blastous cells that were cd -, cd -, pax -positive, tdt and cd a were questionably positive. provisonal diagnosis therefore was lymphoblastic lymphoma, pox tested negative. the bone marrow was hypocellular with increased numbers of mature lymphocytes, but no definite signs of malignancy. cerebrospinal fluid revealed cells/μl with % blasts. immunotype was cd , cd , cd , cd , hla-dr positive, pox and lymphatic markers were negative. because of this we finally suspected meningeosis leucaemica. we completed the diagnostic workup with genetical and chimaerism tests and compared the result to the patients' mds before allogeneic stem cell transplantation. [[p image] . mri scan of the large thoracic tumour] results: cerebrospinal fluid (csf) cells consisted of % recipient cells, whereas peripheral blood cells were % donor. high risk mds at transplant displayed a complex caryotype including trisomy and tetrasomy , now % of the cells in csf showed trisomy and % tetrasomy . chimerism and fish of the solid tumour could not be performed, coexpression of myeloid markers within the tumour is pending. conclusions: in conclusion the patient has meningeosis as a result of exclusively extramedullary relapse of myeloid blasts originating from the initial high risk mds with blast excess and complex aberrant caryotype. the evolution of a trisomy clone to tetrasomy clone in relapse is linked to extramedullar manifestations. whether the solid tumour represents myeloid sarcoma with coexpression of lymphoid markers, extramedullary relapse of mds with lymphoid differentiation or, less likely, a separate lymphobastic lymphoma, is not yet clear. disclosure background: adoptive t cell therapy with genetically engineered t cells is a potent innovative immunotherapeutic approach for cancer treatment. unfortunately, the use of t cells redirected against tumor antigens, is severely limited by ) the difficulty in identifying appropriate cell surface antigens, that could be targeted by car t cells and ) the paucity of tumor-specific t cell receptors (tcrs) against shared, oncogenic antigens. methods: focusing on wilms´tumor (wt ), a tumorassociated antigen overexpressed by acute myeloid leukemia and several solid tumors, we designed and implemented an innovative protocol for the rapid isolation of wt -specific t cells and for the generation and characterization of a library of wt -specific tcrs displaying different human leukocyte antigen (hla) restrictions, to be exploited by tcr gene transfer and tcr gene editing. to this aim, we repetitively stimulated t cells with autologous antigen-presenting cells, including immortalized b cells, pulsed with overlapping peptides spanning the entire wt protein. t cell recognition was assessed by flow cytometry in terms of cd a expression and ifnγ production. recognized peptides were mapped by a deconvoluting grid and t cell clonotypes were longitudinally tracked by tcrαβ sequencing. results: we successfully expanded tumor-specific t cells from consecutive healthy donors, in an average of rounds of in vitro stimulations. the ability of wt specific t cells to recognize naturally processed epitopes and their on-target specificity was demonstrated upon coculture with antigen-expressing targets including primary leukemic blasts. tracking of the tcrαβ repertoire during culture led to the identification of clonotypes that recognize several tumor-associated peptides and are restricted by more than hla alleles, including hla-a* : . tcrs were then expressed via genome editing. briefly, simultaneous editing of endogenous tcr α and β chain genes was achieved using crispr/cas technology (efficiency > %), followed by transduction of t cells with lentiviral vectors encoding wt -specific tcrs (efficiency > % of cd + t cells). phenotypic characterization of edited t lymphocytes showed a major enrichment of cells harboring t stem cell memory properties. functional validation of the edited t cells is currently ongoing. preliminary results of a hours coculture experiment show that tcr edited t cells kill fresh wt + leukemic blasts, harvested from hla-matched patients, with an efficiency up to % at an effector to target ratio of to , while no killing of controls is observed. conclusions: we set up a protocol enabling consistent and efficient hunting for tumor-specific tcrs with no need for labor intensive t cell cloning. tcr genes can be easily and rapidly used to redirect t cell specificity against cancer cells by tcr gene editing. disclosure: chiara bonini: research funding from intellia therapeutics p car t cell therapy targeting relapsed or refractory cd + lymphoid disease with third-generation vector rv-sfg.cd .cd . - bbzeta maria-luisa schubert , anita schmitt , leopold sellner , , brigitte neuber , angela hückelhoven-krauss , kunz alexander , lei wang , gern ulrike , birgit michels , susanne hofmann , carsten mueller-tidow , , dreger peter , , michael schmitt , background: t cells genetically engineered to express chimeric antigen receptors (carts) directed against cd have demonstrated significant efficacy in patients with iymphoid malignancies including relapsed or refractory (r/r) b-lineage acute lymphoblastic leukemia (all) or r/r b-cell non-hodgkin's lymphoma (nhl). access to cart treatment for patients in europe has been limited so far given that the vast majority of cart trials have been performed in the united states and the p. r. of china. here we present the preliminary results of the first investigator-initiated trial (iit) cart trial in germany. hd-car- (eudract no. - - ; nct ) is a phase i/ii trial with in-house cart manufacturing which was initiated in september at the university hospital heidelberg. methods: adult as well as pediatric patients with r/r all and patients with chronic lymphocytic leukemia (cll) or nhl including diffuse large b-cell lymphoma (dlbcl), follicular lymphoma (fl) or mantle cell lymphoma (mcl) are treated with autologous t lymphocytes transduced with a third-generation car retroviral vector (rv-sfg.cd .cd . - bbzeta) targeting cd . the main purpose of hd-car- is to evaluate safety and feasibility of escalating third-generation car t cell doses ( - × transduced cells/m ) after lymphodepletion with fludarabine and cyclophosphamide. patients are monitored for cytokine release syndrome (crs), car-t-cell related encephalopathy syndrome (cres) and/or other toxicities. in vivo function, survival and anti-tumor efficacy of carts are assessed. results: to date, three patients (cll, dlbcl and mcl, respectively) have been enrolled and subjected to leukapheresis. high numbers of transduced carts were harvested on day of culture ( - x carts). transduction efficiency ranged between and %. cart products were sterile and free from mycoplasms and endotoxins. no production failure occurred and all patients received the cart product. no signs of crs or cres > grade have been observed. assessments of clinical responses are pending and will be presented at the conference along with updated technical results. conclusions: for hd-car- , gmp-conform leukapheresis as well as cart manufacturing was effective. administration, patient monitoring and follow-up were performed in-house providing independency from transport or production sites outside the university hospital heidelberg, altogether suggesting that academic cart iits are feasible in germany. clinical background: the prognosis of adult patients (pts) with relapsed/refractory (r/r) precursor b-acute lymphoblastic leukemia (all) is dismal, including with allogeneic hematopoietic stem cell transplantation (allo-hsct). blinatumomab, a bispecific cd -directed cd t-cell engager and inotuzumab ozogamycin (io), a cd -directed antibody-drug conjugate revolutionized the field, improving their outcomes. anti-cd chimeric antigen receptor t (cart) cell therapy has led to further progress and improved outcome (jacoby e; am j hematol, ). nowadays, patients with r/r b-all can be offered both therapies, but there are limited data on the safety and efficacy of cart -cell therapy post antibody treatment. we detailed our single center experience in this regard. methods: this report is a part of a single center, phase b/ study on therapy of b-cell malignancies with locally produced cart-cells (nct ). the approach uses autologous t cells with car construct that is composed of an anti-cd single-chain fv, cd co-stimulatory and cd -zeta intracellular domains. cd expression on the blasts was documented prior treatment in all pts by flow cytometry. all pts received x /kg cart-cells after lymphodepletion with fludarabin and cyclophosphamide. results: six pts ( males and females) with r/r b-all were enrolled, including one with ph-positive b-all. the median age was years ( - ). median number of prior therapy was ( ) ( ) ( ) . five pts had prior allo-hsct. four pts were given antibodies as the last therapy prior to cart cells. two pts received blinatumomab resulting in pr in one of them. two additional pts received io ( after failing blinatumomab) achieving mrdpositive cr. cytokine release syndrome occurred in all pts and was severe in only one patient who required tocilizumab treatment. this patient was also the only patient who experienced neurotoxicity (grade ), and was treated with dexamethasone. this patient eventually died days post infusion of cart cells due to severe pseudomembranous colitis, toxic megacolon and sepsis. all pts had prolonged neutropenia for a median of days ( - ) after the infusion of cart cells. at day after infusion of cart-cells the cr for the entire cohort was %: three pts with mrd-negative and one with mrd-positive response. among the four pts who received antibodies prior the cart-cells, one patient had mrd-positive and two pts had mrd-negative response. the patient with ph positive b-all had progressive disease during the treatment. two pts were referred to second allo-hsct from other donors. one patient with mrd-negative response relapsed after the second transplant and was treated by salvage therapy. the second patient with mrdnegative response demonstrated prolonged remission ( months) even without second transplantation. with a median follow-up of months ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) the median progression-free and overall survival for the entire cohort were . and months, respectively. conclusions: autologous anti-cd car t-cell therapy after debulking treatment with antibodies, including blinatumomab and/or io, is feasible and results in high response rates in pts with r/r b-all. patients may respond to anti-cd car t-cell therapy even after failure to their last salvage therapy with blinatumomab, which demonstrates similar mechanism of action. clinical background: genetically engineered t cells expressing a chimeric antigen receptor (car-t) targeting specific antigens present on acute lymphoblastic leukemia (all) blasts have generated promising results in children and adults with relapsed and refractory disease. the below report provides an insight of lineage switch occuring as a result of intense immunological selection after car-t cell therapy, even with a tumor clone that has no potential for this switch. methods: an eight year old caucasian male with precursor b (pb) cell lymphocytic leukemia was treated with cd directed car-t cell therapy in third remission, and after relapse after previous bone marrow transplantation (bmt) . he was diagnosed with t( ; ) pb cell all at years of age and treated with bfm protocol. he relapsed months after completion of maintenance therapy, and had a / mmud bone marrow transplant after etoposide, tbi and alemtuzumab conditioning therapy. he had cutaneous acute and chronic gvhd but months post-transplant, he relapsed again with pb cell all, with the same cytogenetic and immunophenotypic disease characteristics.. he was treated with lymphodepleting chemotherapy with fludarabine, cyclophosphamide and alemtuzumab followed by infusion of cd directed car t cells. he developed cytokine release syndrome of grade severity manifested as persistent fever, associated with car t cell expansion in the blood. after car-t infusion,there was no detectable b cell all clone in the marrow by pcr and the cytogenetics were negative for t( : ) translocation. months after the car t cell therapy, he was found to have a mrd positive disease which was monitored closely. results: we document clonal evolution from cd negative, mrd positive disease to aml, with the same ig rearrangement (the same clonal disease) but with complete myeloid phenotype mpo, cd , cd positive disease. there was cytogenetic evolution of the underlying clone but the original t( ; ) was retained within the evolved karyotype. sadly, our patient developed fludarabineneurotoxcity during an attempt to induce aml remission, and further curative-intent chemotherapy was not possible. conclusions: there are two case reports of mll rearranged b-all acquiring a clonally related myeloid phenotype associated with cd -negative escape after cd directed car t cell therapy,so far. but, this is the first post car-t cell therapy transformation of all to aml with etv -runx mutation, which is not recognised to have such lineage-switch potential. unlike mll, etv -runx translocation in the pathogenesis of acute myeloid leukemia is not been reported in the literature. the theory behind such transformation is an intense immunological selection of the tumor, driving it to myeloid differentiation with additional clonal cytogenetic events. disclosure: nothing to declare p ivac-all- : interim analysis of a phase i/ii clinical study on personalized peptide vaccination based on patient-individual tumor-specific variants in relapsed pediatric acute lymphoblastic leukemia armin rabsteyn , , christopher mohr , olaf witt , , roland meisel , , cristiane chen-santel , tobias feuchtinger , , christopher schroeder , jakob matthes , background: acute lymphoblastic leukemia (all) is the most common pediatric malignancy. standard chemotherapy is a successful treatment in % of patients, only about % develop a relapse, however these patients have a dismal prognosis. prevention of relapse after firstline chemotherapy or stem cell transplantation (sct) is therefore an urgent clinical need. we established a platform for the design of patient-individual peptide vaccination cocktails by combination of whole exome sequencing of tumor and normal tissue with in silico epitope prediction algorithms for individual patient hla types. we started clinical translation of this approach by starting a phase i/ii clinical trial in (nct ). besides feasibility and toxicity assessments, we aim to assess the capability of the peptide vaccination to induce neoantigen-specific t cell responses in high-risk all patients to target residual tumor cells and prevent leukemic relapses. methods: key inclusion criteria are: pediatric patients with all who suffered from second relapse after standard therapy or first relapse after sct. hematological remission has to be reached prior to vaccination. nonsynonymous mutations are identified by whole exome and transcriptome sequencing of patient leukemic blasts and healthy reference tissue. hla binding peptides harboring the altered amino acids are subsequently predicted in silico by algorithms syfpeithi, netmhc and netmhcpan for the patients' individual hla type. vaccine cocktails consisting of - individual peptides are produced and formulated under gmp conditions. the vaccination schedule is vaccinations over weeks using gm-csf and imiquimod as adjuvants. response to the vaccination is monitored by detection of t cells recognizing the vaccinated peptides occurring over time in peripheral blood of patients by prestimulation and intracellular cytokine staining. results: until now, patients were recruited, for of those, whole exome sequencing was performed to identify all-specific snvs using a comparative bioinformatics pipeline. we found an average of . mutations per patient on dna level. based on these data, an average of hla binders derived from neoantigens could be predicted per patient. an average expression of . % of mutations was assessed by rna sequencing. in all cases validated mutations could be identified and cocktail design was feasible. until now, patients received vaccinations. the vaccine was generally well tolerated and no or only mild side effects were observed. immune monitoring was performed for patients until now. in the first patient, we observed a transient cd + response against one vaccinated mhc class ii ligand and a sustained cd + response against the included wildtype control peptide derived from the antigen survivin. in the second patient, immune monitoring was performed for the first vaccination timepoints, a t cell response was not measurable at this timepoint of vaccination. conclusions: whole exome sequencing of pediatric all patients is feasible and yields small amounts of expressed, tumor-specific mutations. these few mutations are sufficient to predict hla-binding peptides that can be used to formulate individualized peptide vaccine cocktails. we currently conduct a clinical phase i/ii trial in a small cohort of high-risk all patients to assess safety, toxicity and immunogenicity. clinical background: chimeric antigen receptor t cells (cart) are considered as gene therapy medicinal products (gtmp) and genetically modified organisms (gmo). hence, carts manufacturing for clinical application is strictly regulated. appropriate methods assessing car transgene copy number (cn) in a cart product and definition of the frequency of carts in treated cart patient are mandatory. although quantitative real-time pcr-based (qpcr) analysis has been used for this purpose, no standardized procedure to minimize systematic errors and enable comparability has been established yet. here, we report on a single copy genebased (scg) duplex (dp) pcr (scg-dp-pcr) for the determination of the vector copy number (vcn) in cart products as well as patient samples following cart administration. scg-dp-pcr was validated and compared to the broadly used absolute copy number qpcr (acn) approach within the framework of a clinical trial treating patients with good manufacturing practice (gmp)-grade carts (hd-car- ). methods: for conventional acn, primers and probe targeting the car vector rv-sfg.cd .cd . - bbzeta were designed. standard curves were established via serial dilutions of the sfg.car plasmid. amplification of the standard curve as well as target genomic dna for vcndetermination was performed as singleplex (sp) pcr (sp-car) (method a). on the same qpcr plate, duplex (dp) qpcr reactions were carried out. additionally to the components comprised within method a, the experimental setup contained haploid human genomes as well as primers and probe targeting ribonuclease (rnase) p as human scg. the amplifications for the sfg.car plasmid (dp-car) and the rnasep gene (dp-rnasep) were performed simultaneously (scg-dp-pcr; method b). scg-dp-pcr was performed for standard curves and target samples. target-sample dna was extracted from carts prepared from leukapheresis products of three healthy donors (hd). results: for method validation, efficiency and linearity (correlation coefficient) of the qpcr reactions of method a (sp-car) and method b (dp-car, dp-rnasep) were assessed by linear regression of the pcr signal to the reference standard curve. overall, standard curves were only considered valid if a correlation coefficient (r ) of above . and efficiencies of % ± % were achieved. vcns applying method a and b to the same target sample were compared. sp-car pcr reaction displayed efficiency of . ± . %; . % ± . % and . ± . % efficiencies were achieved for dp-car and dp-rnase pcr reaction, respectively (table ) . applying scg-dp-pcr using formula for relative cn assessment ( -Δct (dp-car -dp-rnasep) ) on hd samples resulted in an average of . ± . increased cn when compared to method a (table ) . conclusions: in terms of efficiency and linearity by linear regression qpcr reactions were comparable. validation of scg-dp-pcr was achieved and represents an exact and less error-prone method to fulfil regulatory safety release criteria of cart products. besides of accurately assessing vcn of transduced cells, scg-dp-pcr is also a highly robust method to follow-up carts in treated patients. applying this approach, no standard curve is needed, hence significantly economizing required material as well as time. disclosure: nothing to declare background: t-cells' antileukemic responses in aml-pts need to be improved. dc leu effectively activate t-cells against leukemic blasts, resulting in blast-lysis ex-vivo. factors influencing these activities are not known. methods: we generated dc/dc leu from aml-blastcontaining mononuclear cells (n= ) using standard methods (mcm-mimic/ca-ionophore/picibanil/ifn-α, "mnc-methods") and from blast-containing heparinized whole blood (n= ) using modulatory kits (various combinations of - clinically approved response-modifiers, "wb-kits", patent ) and correlated statistically (t-/u-test, pearsons correlation, # means significant) proportions of dc-/t-cell-subtypes/cytokine-profiles with t-cells' antileukemic cytotoxicity (ctx), achieved after mixed lymphocyte culture (mlc) with/without mncmethod-("t*dc mnc "/"t*bla mnc ") or wb-kit-treated cultures ("t*dc wb "/t*bla wb "). ctx was given as proportions of cases with achieved or "improved" blast-lysis compared to control and as frequencies of viable blasts (bla via ) after effector-cell-influence. pooled data and data obtained with single methods in different cohorts are given. results: . generation of dc/dc leu : with a) mncmethods: Ø ± % dc and Ø ± % dc leu and b) wb-kits: Ø ± % dc and Ø ± % dc leu without induction of blasts' proliferation. t-cell-proliferation increased (vs uncultured t-cells) after mlc with a) mnc-methods: Ø ± % vs Ø ± % and b) wb-kits: Ø ± % vs Ø ± %. . antileukemic reactivity (t-effector-cell-cytotoxicity after mlc): pooling all data: a) mnc-methods ("t*dc mnc " vs "t*bla mnc "): we found a ) blast-cytotoxicity in Ø %(vs %) of cases with Ø %(vs %) bla via , a ) blast-cytotoxicity was improved (vs control) in % with Ø decrease of bla via of %; b) wb-kits ("t*dc wb " vs "t*bla wb "): we found b ) blastcytotoxicity in Ø %(vs %) of cases with Ø %(vs %) bla via , b ) blast-cytotoxicity was improved (vs control) in % of cases with Ø decrease of bla via of %. in general, these results could be confirmed with single methods: best mnc-methods were picibanil and mcm-mimic, best wbkits were kits containing gm-csf+picibanil or prostaglandins. . correlations: pooling all data: cases with "improved" lysis (vs "not improved" lysis) were characterized by a) mnc-methods: increased proportions of mature dc/cells (Ø ± % vs Ø ± %), dc leu /cells (Ø ± % vs Ø ± %) and proliferating t-cells (Ø ± % vs Ø ± %), b) wb-methods: dc/cells (r= . # ), dc leu /cells (r= . # ), dc leu /bla (Ø ± % vs Ø ± %), dc leu /dc (Ø ± % vs Ø ± %), cd + t-cells (Ø ± % vs Ø ± %), ifn-γ (r= . #) , mcp- ( ± vs ± pg/ml). conclusions: blasts are regularly converted to dc leu in the presence of mnc-methods and wb-kits (simulating the in vivo microenvironment). t-cells' coculture with dc/ dc leu after mlc induces and improves antileukemic t-cell activation compared to controls. blast-cytotoxicity correlates with proportions of dc/dc leu -and t-cell subtypes and released cytokines. these data support a role of antigen presentation by leukemic cells (dc leu ) for the stimulation of an immune response in aml in vitro and possibly in vivo. disclosure: nothing to declare evaluation year after the launch of the motion comic immuno-t, explaining patients and their caregivers how immunotherapy strategies work background: one year ago, the first version of immuno-t, a motion comic explaining to patients and caregivers how immunotherapy strategies work, was released. people were informed on and inspired to use the application during (inter)national meetings and events for the general public. meanwhile, the motion comic was further refined and adapted into a second version, based on the evaluations we've collected on the first version. adaptations included a multi-language tool (currently languages), increased user friendliness, and a new supporting musical score. also, a website was launched from which the second version could be downloaded on tablet or smartphone (both android and apple) and a new online evaluation form could be filled in. in months, people have evaluated the motion comic online, and these results are presented here, as well as our future plans within the immuno-t program. methods: through an online questionnaire, participants from belgium (n= ) and the netherlands (n= ) have evaluated the dutch version, and belgian participants evaluated the french version of the motion comic. results: the total group (n= ) consisted of patients (n= ) and their families (n= ), general public (n= ), students (n= ), health care professionals (n= ), researchers (n= ) and kindergarten teachers (n= ). participants' age ranged from to years, with an even distribution amongst the different generations. the majority of the evaluators ( , %, n= ) thought the motion comic is a good way to explain immunotherapy to patients. individuals ( , %) felt mainly interested after watching immuno-t, and a total of participants ( , %) felt hopeful or motivated. focussing on the patient group (n= ), all of the responders think the immuno-t motion comic is a good tool to use in a patient-doctor consultation. patients ( , %) felt hopeful and/or motivated after watching the whole motion comic, while of them ( %) felt combative and ( , %) felt gripped and intrigued. as for the new musical score, participants ( , %) think the music is suitable for the app, while evaluators ( , %) think the new music is not or not at all fitted to support the motion comic. conclusions: the detailed evaluations allow us to further improve immuno-t, and aid us in the development of other motion comics we plan to release under the cancer-t in motion umbrella. with the current version of immuno-t, a single-center pilot study is being set up, to test the efficacy and usability of immuno-t, based on qualitative research during the experience of the tool, and using validated questionnaires. with this study we want to evaluate the impact of immuno-t on patient empowerment, and the decision making process. the study protocol will be presented at ebmt. disclosure: the development of immuno-t was partly financially supported by celyad, calgene, novartis, roche, amgen, bms, but these companies did not by any means influence the contents and development of the motion comic. a therapeutic strategy to trespass the blood brain barrier for adoptive nk cell therapy in glioblastoma multiforme induced rat: a preclinical study background: glioblastoma multiforme (gbm) is among the most common and aggressive primary brain tumors with very poor prognosis. according to the central brain tumor registry of the united states, central nervous system (cns) tumors in pediatric patients (ages between - years old) are the second most common malignancies after blood-born malignancies, and the first amongst solid tumors, and known the most common cause of cancer-related deaths. although hematopoietic stem cell transplantation has been exploited to treat many kinds of malignancies, currently its success rate in gbm is limited. therefore, the gbm treatment paradigm needs shifting towards more effective treatments such as immune cell therapy. natural killer (nk) cells have been recognized as potential anti-cancer effector cells, as they can recognize and target tumor cells. since a small percentage of blood cells are differentiated as nk cells, the number of this group of cells is hardly enough to fight tumors, and so their multiplication and activation would be a potential effective cancer treatment. methods: this preclinical study was focused on setting up an optimal protocol for expansion and activation of naïve nk cells and assessing their efficacy towards induced gbm in rat models. ex-vivo expanded and interlukin- (il- )and heat shock protein- (hsp- )-treated nk cells have been exploited. after in vitro study and confirming the efficacy of treated cells through cytotoxicity assays, we induced gbm in male wistar rats (weighted - gr) using c tumor cells injection in rat brain through stereotactic surgery. the tumor formation was proven by mri imaging. following tumor establishment, we analyzed the effect of single injection of il- -and hsp- -treated nk cells compared with single injection of non-treated nk cells in two groups of rats. results: systemic intravenous delivery of il- -and hsp- -treated nk cells through tail's vein resulted in tumor shrinkage in different time intervals and complete remission in the first group of gbm-induced rat models, whereas in the other group of gbm rats receiving untreated nk cells, the tumor progressed. therapeutic efficacy of the treated nk cells was ascertained compared with non-treated nk cells considering tumor shrinkage observed in mri and survival rates between the two model groups. conclusions: the amelioration of tumor which has been confirmed by mri, proved the migration of activated nk cells through blood brain barrier and homing to cns, and finally targeting gbm tumor cells. our data suggest that nk-cells treated with il /hsp may be a promising immune cell-based therapeutic approach towards treating the fatal gbm. disclosure: nothing to declare p abstract withdrawn. long term sorafenib response for extramedullary flt + aml relapse after allogeneic stem cell transplantation since june , sorafenib dose has been tapered to mg/day, due to mild skin and gi toxicity. after years of treatment, she maintains cr at medullary and extramedulary levels, with no evidence of a disease that had escaped the mechanisms of action of chemo, hsct and dli. conclusions: in our patient, treatment with sorafenib has provided long-term control of this refractory extramedullary disease, even at adjusted doses. further studies are needed to confirm the efficacy of flt inhibitors in the control of relapses after allo-hsct, extramedullary disease and its potential role as maintenance agent. disclosure: nothing to declare background: although chemotherapeutic(ct) agents that used in the treatment of acute lymphoblastic leukemia (all) increase survival, the results are still weak. longterm survival with ct's in relapse all cases is difficult and the prognosis is very weak. inotuzumab ozogamicin is an anti-cd monoclonal antibody and it has the potential to reduce the overall toxicity of intensive regimens for all, as well as to possibly increase the number of patients who may achieve a state of minimal residual disease. methods: -year-old male patient was diagnosed with b-cell all in december .after the hoelzer kt protocol was started, maintenance treatment was continued. in the fifth month of treatment,flag ct protocol was started cause of recurrence was seen on % blast detection in peripheral blood smear. in august , inotuzumab ozogamicin treatment was started and six cures were completed because the patient was not in remission. in september , he had gone haploidentical bone marrow transplantation from his sibling donor( / )with defibrotid prophylaxis for veno-occlusive disease(vod)s. he engrafted succesfully and chimerizm was . % in th days of transplantation. he is th day of transplantation and in a remission. results: bone marrow transplantation cannot be performed since the complete response cannot be achieved in patients with relapse and resistant b-all.in these patients, new therapies targeting malignant lymphoblasts are needed. inotuzumab ozogamicinis a monoclonal antibody drug conjugate that targets cd antigen on malignant lymphoblasts.in many studies, it has been shown that inotuzumab ozogamycin is effective and reliable anti-tumor activity in adults with recurrent and resistant cd positive all. however, monoclonal antibody drug conjugates have been shown to be associated with vod's.for this purpose, we used defibrotid to protect our patient from vod. conclusions: treatment with combination ct regimens in b-all is suboptimal and long-term survival is achieved in only - % of patients.targeted molecular therapy and new regimens are needed in relapse and resistant patients.at this point, inotuzumab ozogamycin is an anti-cd- monoclonal antibody, as in our case, it provides remission in recurrent and resistant b-all patients and allows patients to complete their treatment with an allogeneic transplant from a fully compatible donor. disclosure: nothing to declare background: mesenchymal stem cells (mscs) are an attractive consideration for therapeutic cures of many difficult diseases on the cellular-level. due to the trophic effects of the cytokines and chemokines that they produce, mscs have shown multiple beneficial properties in the field of oncology. in this study, we will be investigating the effect of mscs derived from human bone marrow (bm), adipose tissue (at), and umbilical cord derived mscs (uc-mscs) on ovarian cancer. to differentiate the mscs, we performed a comparative analysis between the various sources for proliferative capacity, surface antigen expression, differentiation ability, tumor marker and paracrine activity, and their influence on ovarian cancer cell proliferation. methods: measurements of ovarian tumor marker proteins were computed by elisa. proliferative effects, immunomodulatory effects, and apoptosis of the mscs were measured by the culture and counting of colony formations. flow cytometry (fcm) was used to measure the variation of the immunophenotyping and cytokine secretions in co-culture, as well as gene expression. results: cells noticeably proliferated without any modifications to their immunophenotype during the third subculture. the colony-forming unit fibroblast (cfu-f) test showed a proliferation of the mscs along with healthy cells and cancer cell lines with no changes in their phenotype. the supernatant of mscs showed an increase in cellular death of the ovcar in ovarian cancer cell lines. a reduction in the level of ca- ( - %; p= . ) with ovcar in co-culture, and a decline of ldh ( - %; p= . ) and beta-hcg ( - %; p= . ) were observed in co-culture in caov , skov and igrov cell lines. a decrease in cd of the cancer cell lines in co-culture with the msc supernatant showed a reduction of the cancer tumorigenicity and aggressiveness, while the rate of the cd and cd asserted their stem state. msc supernatant decreased cell proliferation and mmp- , mmp- , and ca- mrna expression, while increasing timp , , and . this suggests that mscs have a role in cell death and inhibition of ovarian cancer cell proliferation. an increase of anti-inflammatory il- and il- cytokines, and a decrease in growth factor gm-csf along with their proinflammatory inf-a, tnf-a, il- , and il- a cytokines were also noted. conclusions: the gene and cytokine activity indicate a potential therapeutic anti-inflammatory and antiproliferative role of mscs on ovarian cancer despite their sources. the reduction of ca- , ldh, and beta-hcg in co-culture, along with the decrease in cd and amplified cellular apoptosis demonstrate the beneficial effects of stem cells in ovarian cancer cell lines. disclosure background: hematopoietic stem cell transplant (hsct) is the only cure in sickle cell disease (scd) so far. because of the risk of toxicity, its indication in france is restricted to severe patients with match sibling donor. this study compares the incidence of severe acute toxicity after hsct, between children aged less than years and teenagers aged to years old, treated for scd. methods: all patients suffering from scd, aged less than years at transplant, who received hsct in chu robert debré and necker, between / / and / / , were included. severe acute toxicity, defined by onset of severe acute gvhd, organ toxicity or infection, was compared between the two groups of age. results: patients ( children and teenagers) were included. all patients received a myeloablative conditioning regimen. bone marrow from a sibling donor was the main stem cell source (n= ; %). neither death nor rejection was observed with a median follow-up of . months (range, . the incidence of grade iii-iv acute gvhd was . % and was similar between the two groups; no risk factor was identified in univariate analysis. teenagers had more frequently acute skin toxicity ( . % vs %, p= . ). in univariate analysis, patients presenting severe organ toxicity were significantly older than others ( . vs . years old, p= . ). teenagers were more frequently treated for bacterial ( . % vs . %, p= . ) or bk virus ( . % vs . %, p= . ) infections. in univariate analysis, patients who developed infection were also significantly older at time of transplant (respectively . vs . years old, p= . ). no severe sinusoidal obstruction syndrome was observed. regarding long-term toxicity, patients presented an extensive chronic gvhd, they were both aged less than years old. no cut-off of age could have been defined. conclusions: this study confirms the excellent results of hsct in scd, with a -year event-free survival and overall survival of %. an older age at transplant seems to be associated with more frequent severe acute toxicity. these results are consistent with previous studies and suggest that hsct should be performed as soon as possible, without any defined "best age". prospective studies are needed, in order to define the place of each therapeutic in scd, with the aim of reducing treatment-related toxicity and developing alternative strategies for patients without match sibling donor. disclosure: nothing to declare p new insights into risk factors for transplant-associated thrombotic microangiopathy (ta-tma) in paediatric hsct (n= ) was associated with ta-tma in % vs . % vs . % respectively (p= . ). the presence of comorbidities at d (n= ) was significantly associated with an increased risk of ta-tma . % vs . % in absence of co-morbidity (n= ); p= . . use of csa/tac-based gvhd prophylaxis was associated with less ta-tma with an incidence of % vs % if these agents were not included (p= . ). in univariate analysis ta-tma was significantly higher among patients with agvhd grade ii-iv ( / ; . %) vs grade -i ( / ; . %) (p= . ). pres was recorded among cases and % of them developed ta-tma. two out of the patients with ta-tma had pathological gene mutations in their complement pathway. on multivariate analysis the presence of active comorbidity was a risk factor for ta-tma (or: . ; % ci: . - . ; p= . ) while the use of csa/tac-based gvhd prophylaxis did not increase the risk for ta-tma (or: . ; ci: . - . ; p= . ). in the presence of comorbidities the use of defibrotide as prophylaxis or therapy for vod (n= ) was associated with a drop in the incidence of ta-tma from % ( / ) in absence of defibrotide to % ( / ). -year overall survival was significantly lower among ta-tma cases ( %) in comparison to . % in absence of ta-tma (p= . ) (figure ). conclusions: active co-morbidity is a significant risk factor for ta-tma. use of defibrotide prophylaxis in patients with co-morbidities at the time of hsct might offer protection against ta-tma. surprisingly the use of csa/tac based gvhd prophylaxis is not a risk factor for ta-tma probably through limiting the development of high grades agvhd. the association between pres and ta-tma suggests a common pathway of endothelial damage background: gonadal impairment is a severe late effect of myeloablative conditioning regimes with significant impact on quality of life of cancer survivors. the aim of this study was to analyze gonadal function after busulfan (bu) or treosulfan (treo) containing regimens with regard to pubertal stage. methods: this was a retrospective, multicenter study involving patients treated in pediatric ebmt centers between - . patients receiving myeloablative doses of bu or treo as part of hsct conditioning were eligible for inclusion. analysis was conducted in two groups according to pubertal status at time of hsct. results: patients (pts) were treated in pediatric ebmt with bu or treo before allogeneic hsct. the median age at transplant was . years (range - ); / ( %) were males (m), / ( %) were females (f). / ( %) pts were pre-pubertal at hsct (f= ;m= ) and / ( %) were post pubertal (f= ;m= ). / ( %) patients received bu (f= ;m= ), / ( %) were pre-pubertal. / ( %)(f= ;m= ) received treo, / ( %) were pre-pubertal ( figure ). females who received treo in pre-pubertal stage (n= / ) reached more often spontaneous puberty ( % vs %; p= . ) compared to pre-pubertal bu group (n= / ) and occurrence of menarche was higher in treo group (p< . ) hormonal replacement therapy was given in / ( %) females transplanted in pre-pubertal stage and in / ( %) of those transplanted in post-pubertal stage. / ( %) males were pubertal at last follow-up and of them ( %) performed sperm analysis ( oligo-azoospermic, unknown). three pregnancies were reported in the population group, all received bu. regarding the evaluation of hormonal levels in pubertal patients at time of hormonal dosage (median . yrs) ( bu and treo), males treated with treo had significant lower lh levels (p = . ) compared to bu group. females treated with treo had significant lower levels of lh and fsh (p= . and p= . respectively). conclusions: gonadal damage related to treo was significantly lower compared to bu. we observed that: females transplanted during pre-pubertal period had spontaneous puberty more frequently after treo compared to bu and that hypogonadism hypergonadotropic was more frequent after bu than treo. these results must be further confirmed on a larger population. background: viral infections significantly contribute to both morbidity and mortality in patients undergoing hematopoietic stem cell transplantation. traditional antiviral therapy is associated with lack of efficacy, potential toxicity, prolonged hospitalization and increased patient costs. viral specific t cells can be manufactured from donor blood to treat viral infections post-transplant, and are associated with increased clinical efficacy and low toxicity. we postulated that direct costs of vst therapy are lower compared to traditional anti-viral medications methods: vsts were manufactured according to local protocols and fda requirements. total drug cost (as per institutional charges per drug) was calculated for patients who required treatment for viral infections post-hsct. manufacturing costs of vsts are fixed per fda requirements. patients who were treated with investigational antiviral medications (including brincidofovir) were excluded from analysis. patients treated with vsts +/anti-viral medications over a year period were compared to patients treated only using traditional anti-viral medications, including cidofovir, ganciclovir, valganciclovir, foscarnet and rituximab. results: demographics are shown in table . there were no major differences between the two groups treated. the number of anti-viral medications used in the vst group was lower compared to the anti-viral treatment group. median cost of vst treatment was significantly lower compared to those threated with traditional anti-viral therapy ($ , vs $ , , p-value= . ) . conclusions: treatment with vsts post-hsct for viral infections was lower in cost compared to anti-viral medical therapy. it is likely that overall costs are further reduced with vsts due to reduced inpatient hospital time, less monitoring of labs associated with anti-viral medication side-effects and reduced ancillary costs including nursing and pharmacy. more studies are needed to examine these indirect costs further. background: dock deficiency is an autosomal recessive primary immunodeficiency (pid) disease caused by loss-offunction mutations in the dock gene ( ) . patients with dock deficiency present with multiple abnormalities of the immune system, including defective t cell function and impaired production of antigen-specific antibodies. these lead to persistent viral infections of the skin, mucocutaneous candidiasis, recurrent sinopulmonary infections, atopic dermatitis, and other allergic disease, malignancies, and sometimes autoimmunity ( ). hematopoietic stem cell transplantation (hsct) is currently the only curative treatment option available ( ) . methods: we retrospectively evaluated our patients who underwent allogeneic hematopoietic stem cell transplantation due to dock deficiency in ege university pediatric stem cell transplantation unit between and . results: we identified patients transplanted at a median age of . years (range: - . years). of patients; (% ) received hsct from matched sibling, (% ) from unrelated donors and patient from haploidentical donor. we used busulfan-based myeloablative conditioning regimen to patients (% ), reduced toxicity myeloablative regimen with treosulfan to patients (% . ) and nonmyeloablative regimen to patients (% . ). eight of the recipients received bone marrow, of the patients received peripheral blood stem cells, of the recipients received cord blood as stem cell source. fifteen of patients (% ) had achieved engraftment and median follow-up of patients was months ( - ). grade iii-iv acute graft versus host disease (gvhd) occurred in % of patients and chronic graft versus host disease was seen % of patients. one patient received cord blood from unrelated donor did not engraft and died from septic shock. four patients died from transplant related toxicity. our patient's survival was % ; / patients alive. conclusions: hsct is the only curative treatment option for dock deficiency. in particular, patients with high comorbidity scores have a high risk of toxicity and toxic death. therefore, reduced toxicity conditioning regimens should be used for these patients. references : background: eltrombopag, a low-molecular-weight synthetic nonpeptide thrombopoietin receptor agonist (tpo-r), is a second-generation tpo. it is an oral thrombopoietin mimetic licensed in chronic immune thrombocytopenic purpura that induces platelet maturation and release by binding to c-mpl receptors on megakaryocytes. in a recent study; for patients with refractory saa, eltrombopag induced a response (at weeks) in at least one hematologic lineage in % patients and % no longer required platelet transfusions. and also % patients became rbc transfusion independent and % had a neutrophil response. trilineage responses were seen in % of patients; although surprising, this might indicate stimulation of c-mpl receptors on remaining stem cells. delayed recovery from thrombocytopenia is common after stem cell transplantation. in a study including adult patients, eltrombopag was used to enhance platelet recovery for post-hsct thrombocytopenia. it is well tolerated and efficacious offering transfusion independence. methods: in our retrospective study, eltrombopag ( mg/day) was started in pediatric patients (age ranging from to years with a median age . years) for posthematopoietic stem cell transplantation (hsct) thrombocytopenia. all patients fulfilled the following criteria: ( ) undergone hematopoietic stem cell transplantation (hsct), ( ) had improved total leucocyte counts after leucocyte engraftment, ( ) had prolonged thrombocytopenia (< . ) needing platelet transfusion. results: four of the patients have received ric while patients ma conditioning regimens before hsct. two haploidentic, autologous, mud, msd transplantations were performed. et ( mg/day) was started in patients who had thrombocytopenia despite neutrophil engraftment on the + th day of hsct a reduction in platelet transfusions and a platelet count of more than , were the primary endpoints. before et treatment, bone marrow biopsy was checked in / patients, / patients had decreased number of megacocyocytes. none of the patients had active bleeding at the start of eltrombopag but they were all at high risk of bleeding. according to the platelet monitoring, patients had a dose increase starting from the second week. the number of patients in need of platelet transfusions was at the end of the first month; and only at the end of the nd month. all patients had a thrombocyte count of more than . in the third month. in patients, et was discontinued after - months. no dose limiting toxicities have been observed. conclusions: as a conclusion, et was found highly effective for posthsct thrombocytopenia, with no drug related adverse effects. there was a gradual increase in platelet count, and none of the patients had any complication due to thrombocytopenia. disclosure background: isavuconazole (isa) is a new triazole approved for ifi treatment in the adult population. advantages are activity against both moulds and yeasts spp, excellent bioavailability after oral administration without relevant food or gastric ph effect, a water-soluble prodrug developed to facilitate intravenous administration without nephrotoxic excipients such as β-cyclodextrin, potentially poor drug-drug interactions. isa does not currently appear to require tdm. isa safety and efficacy have not been yet established in children and, in particular, no data are available in the pediatric hsct setting. methods: italian association pediatric hematology oncology (aieop) multicentric analysis of a cohort of allogeneic hsct pediatric patients who received isa as ifi treatment or prophylaxis. due to the lack of recommended dosing in pediatric patients and a clear target isa plasma trough-level range, the therapeutic monitoring (tdm) of isa concentrations was applied by a validated liquid chromatography-tandem mass spectrometry (hlpc-ms/ ms) assay technique. isa trough plasma concentrations (c ) and hours after drug intake (c h) were measured. results: a total of allo-hsct recipients were included, (m/f / ); median age: , years, range - , median body-weight , kg (range - ). isa was used as ifi treatment in cases and as prophylaxis in patients. donors were haploidentical in patients, matched-sibling in , allogenic-unrelated in cases. according to eortc criteria, ifi was proven in patients ( penicilum, mucor, aspergillus fumigatus), probable in and possible in patients. lungs were the main localization ( cases), associated with cns involvement in cases and paranasal sinuses in ; patient had possible hepatic candidiasis. all patients, but one, received isa as rescue treatment for previous therapeutic failure ( ambisome, voriconazole, combination therapy, posaconazole). seven patients received only iv isa, received only oral isa whereas patients received both iv and oral isa. patients under kg body weight received half isa dose ( mg tid loading dose on days and , mg/die manteinance). the others received adult schedule; only patients received loading dose. isa was administered for a median of days (range: - ). in patients isa was administered in combination with caspofungin. tdm was applied to patients including patient with severe vod and with renal failure secondary to ta-tma. the median isa concentrations were . ( . - . ) mg/l and . ( . - . ) mg/l for c and c h, respectively. ifi complete remission was achieved in cases, partial remission in ; treatment failure was experienced by patients. in cases fungal lesions remained stable. ctae grade ii-iii toxicity was observed during treatment in patients, with increased transaminase and/or creatinine levels which resolved after temporary isa withdrawal. no drug-drug interactions were observed in patients receiving csa as gvhd prophylaxis and no modification of csa daily dose was needed. conclusions: isavuconazole use may be considered in the pediatric population, even in the hsct setting, for its safety, efficacy, tolerability, no drug-drug interaction. of course these data deserve further evaluation. disclosure: nothing to declare p new treosulfan-based conditioning regimens including epigenetic agents in patients with very high-risk neuroblastoma background: the pts aged mos. or older with disseminated nb involving bone and bone marrow constitute a group of pts with very poor prognosis. although the majority of them are responsive to intensive conventional chemotherapy, most eventually relapse with efs at years of < %. at the beginning of the year we came up with a protocol for this very unfavorable group including epigenetic therapy ( -azacitidine) in the phases of consolidation. methods: seven pts with a median age of ( , - ) years completed the protocol and received hdct with autologous sct as a consolidation. hdct included two different epigenetic agent containing regimes according to tumor response to the induction therapy assessed by i-mibg and mri (ct-scan). three pts revealing large active residual tumor assessed by i-mibg scan or multiple active bone metastases received a conditioning regimen (regimen a) including i-mibg therapy at a dose . - . mbe/kg on d- , treosulfan mg/m /d, on d- ,- and - (total mg/m ), melphalan mg/m /d, on d- ,- (total mg/m ), -azacitidine mg/m /d on d- to d- (total mg/m ). four pts with cr or vgpr received a «split» conditioning regimen (regimen b) including treosulfan mg/m /d, on d and - , and on d- and d- (total mg/m ), melphalan mg/m /d, on d- and - (total mg/m ), and -azacitidine mg/m /d, on d - to d - and on d- to -d- (total mg/m ). a median number of . ( . - ) cd +/kg was infused on d . results: the median recovery times to wbc> . x /l and to an unsupported plt> x /l were ( - ) and ( - ) days, respectively. all pts experienced grade hematological as well as infectious toxicity assessed by nci-ctc score. there were episodes of severe organ toxicity of grade occurring in pts. in cases we observed a severe mucositis, in cases gi toxicity and episode of the erythema multiforme occurred. one pt revealed a lifethreatening episode of hypotension of grade . no transplant-related death occurred. the median number of transfused rbc and plt doses was ( - ) and ( - ), respectively. all pts are alive and well without signs of disease progression in complete hematological recovery with a limited follow-up of . ( - ) mos. from day of hdct. conclusions: although it is rather early to evaluate the efficacy of the epigenetic agent's inclusion in the induction and/or consolidation phases of a very high-risk nb treatment, we can assume that, first, the hdct combining mibg i and/or high dose of treosulfan with epigenetic agent such a -azacitidine was feasible and had an acceptable toxicity. second, the "split" modality of the treosulfan use in conditioning regimen would permit to increase the total dose of the alkylating agent with no inacceptable toxicity. disclosure: nothing to declare pre-and-post magnetic resonance imaging of hips and knees for detecting osteonecrosis in children undergoing hematopoietic cell transplantation: in whom is it necessary? ali y suliman , sue c kaste , ying li , dinesh keerthi , guolian kang , brandon m triplett , ashok srinivasan between april and august at the university medical center hamburg-eppendorf, germany, were included. total and active ratg plasma levels were analyzed by elisa and flow cytometry, respectively. primary endpoint of the study was exposure to ratg. secondary endpoints included transplant-related mortality, incidence of acute and chronic gvhd, immune reconstitution, chimerism, rejection and viral infections. patients were monitored at least days post transplantation. statistical analyses were performed using ibm spss statistics software, or graphpad prism software. results: median total grafalon™ and thymoglobuline™ peak plasma levels were . μg/ml and . μg/ml, respectively; median active grafalon™ and thymoglobu-line™ peak plasma levels (appl) were . μg/ml and . μg/ml, respectively. active thymoglobuline™ plasma levels showed highly variable pharmacokinetics compared to grafalon™. neither grafalon™ nor thymoglobuline™ exposure correlated with lymphocyte count prior to transplantation, cell count in the graft (wbc, mnc, t cells), age, body weight or body surface area (bsa). this is indicative for a saturation effect in both groups. to correlate high or low ratg exposure with clinical outcome parameters, we built two groups within each patient cohort by median appl. the incidence of gvhd was not dependent on high or low ratg exposure. until day post hsct, viral infections or reactivations (ebv, cmv, adv, hhv , bkv) occurred in the patients. interestingly, adv infections affected only children with high ratg exposure. the median time to leukocyte engraftment was not significantly longer in the high ratg groups compared to the low ratg groups ( to days for grafalon™, and to days for thymoglobuline™). there was a decreased and/or delayed recovery of cd + , cd + and cd + t cell reconstitution, but not of b cells and nk cells in the high thymoglobuline™ exposure group compared to the low thymoglobuline™ exposure group. overall survival was not statistically significant with % in the grafalon™ and . % in the thymoglobuline™ group without influence of ratg exposure. conclusions: high and low exposure to grafalon™ or thymoglobuline™ did not result in significant differences in outcome parameters as incidence of survival, agvhd, cgvhd, rejection, or mixed chimerism in this limited cohort. delayed and decreased immune reconstitution in the high ratg exposure groups did not translate into different clinical outcome parameters. adv infections only occurred in the high ratg exposure group. grafalon™ and thymoglobuline™ showed distinct pharmacological and immunological differences in children and larger cohorts are needed to detect clinically significant differences and adjust dosing regimens individually. disclosure: nothing to declare background: the optimal conditioning regimen for allogeneic hematopoietic cell transplantation (allohct) in children with myeloid malignancies remains undefined, particularly when reduced-intensity conditioning (ric) regimens are utilized. methods: we performed a retrospective review of children undergoing allohct for acute myeloid leukemia (aml) and myelodysplasia-related aml (mdr-aml) over a year period ( - ) at our institution, comparing the outcomes of those who received either a busulfan (bu)-or melphalan/thiotepa (mel/thio)-based conditioning regimen. results: a total of patients were analyzed. twentyone received fludarabine/melphalan/thiotepa and received myeloablative busulfan-based conditioning, either in combination with cyclophosphamide (n= ) or fludarabine (n= ). atg was used in patients depending on donor. recipients of mel/thio were selected for ric regimens due to pre-transplant comorbidities (cardiac dysfunction, n= , requiring peri-transplant milrinone), transplant during chemotherapy-induced aplasia (n= ), underlying diagnosis of treatment-related aml (t-aml) and significant pre-allohct chemotherapy exposure (n= ). proportions of patients with de novo aml (mel/ thio, %; bu, %) and mdr-aml ( % and %) were similar between groups; however, recipients of mel/thio were more likely to have t-aml ( % vs %). cytogenetic and molecular risk factors were similar between groups. the majority of patients were transplanted in cr (mel/thio, % vs bu, %) or cr ( % vs %). more recipients of bu conditioning ( % vs %) were mrd-negative at the time of allohct; both groups had comparable proportions of patients with ≥m marrow (~ %). donor types and stem cell sources were similar between groups, except unrelated umbilical cord blood which was more common in bu recipients ( % vs %). there were no graft failures in mel/thio recipients, compared to % (n= ) in those receiving bu-based regimens. engraftment kinetics and immune reconstitution were similar. overall acute and chronic gvhd incidence was higher in recipients of mel/ thio compared to bu ( % vs %, and % vs %, respectively), but rates of grade iii-iv acute or extensive chronic gvhd were comparable. vod requiring treatment was diagnosed in ( %) recipients of bu conditioning and no mel/thio recipients. median duration of follow-up was months (range - ) in the mel/thio group, and months (range - ) in the bu group. transplantrelated mortality (trm) was similar in both groups ( patient), occurring before day . relapse incidence was comparable (mel/thio, % vs bu, %); however, relapse occurred at a later time in mel/thio recipients (median d + vs d+ ). overall survival at and years was superior in mel/thio recipients ( % vs %, and % vs %, respectively). conclusions: in our single institution experience, use of a melphalan/thiotepa-based ric regimen was associated with similar outcomes compared to full-intensity bu-based conditioning, despite higher risk patient and disease characteristics. the majority of recipients of mel/thio conditioning had significant pre-transplant comorbidities, which did not translate into higher trm. while mel/thio recipients had less optimal leukemia control at the time of transplant and high-risk leukemia features (e.g. t-aml), relapse was similar between groups, occurring later in mel/ thio recipients, which may have contributed to better overall survival. disclosure: nothing to disclose methods: pubertal development and biological gonadal parameters were assessed in a retrospective monocentric cohort of pre-pubertal patients who underwent hsct after myeloablative conditioning with total body irradiation (tbi) or busulfan between and . results: seventy-four patients ( girls and boys) were included. no spontaneous pubertal development was found in % of girls and % of boys (p < . ) and delayed puberty or no spontaneous pubertal development was found in % of girls and % of boys (p= . ). hormone replacement therapy was used in % of girls and % of boys (p < . ). in univariate analysis, tbi conditioning (p= . ), female sex (p < . ), acute gvhd (p= . ), extensive chronic gvhd (p= . ), steroid treatment > months (p= . ), and malignant diseases (p= . ) were associated with no spontaneous pubertal development, whereas tbi conditioning (p= . ) and extensive chronic gvhd (p= . ) were associated with delayed puberty. in multivariate analysis, factors independently associated with no spontaneous puberty onset were female sex (p= . ) and age > years (p= . ). factors independently associated with delayed puberty were extensive chronic gvhd (p= . ) and age > years (p= . ). tbi was not an independent risk factor for pubertal complications. conclusions: this study confirms the toxicity of myeloablative conditioning on pubertal development and the role of older age and female sex in increased pubertal issues, and suggests a possible role of gvhd in delayed puberty. disclosure: nothing to declare p abstract already published. neutrophil elastase activity may serve as a marker for neutrophil extracellular traps formation following stem cell transplantation ronit elhasid , sivan berger-achituv , hila rosenfeld-keidar , szilvia baron tel aviv sourasky medical center -tel aviv university, tel aviv, israel background: post-transplant infections rise dramatically in patients with quantitative or qualitative neutrophil defects and constitute a major source of morbidity and mortality following hematopoietic stem cell transplantation (hsct). neutrophils protect the host from microorganisms via multiple processes including phagocytosis and formation of neutrophil extracellular traps (nets). although reactive oxygen species (ros) production seems to be essential for nets formation, the key enzymes of the process are neutrophil elastase (ne) and myeloperoxidase (mpo). methods: ne and mpo activity as well as nets formation were investigated following hsct in patients at week to and after neutrophil engraftment. neutrophils were isolated using easysep direct human neutrophil isolation kit (stemcell technologies inc.) by immunomagnetic negative selection. enzymatic activity of ne and mpo were measured using colorimetric assays. nets formation of phorbol -myristate -acetate (pma)activated neutrophils was investigated by confocal fluorescence microscopy. all results were compared to those of healthy volunteers. statistical significance was calculated using one way-anova with bonferroni post hoc test. results: patients (median age of . years [range - years]) were investigated, following allogeneic hsct ( acute lymphoblastic leukemia, acute myeloblastic leukemia, epidermolysis bullosa, rhabdomyosarcoma) and following autologous hsct ( ewing sarcoma, desmoplastic small round cell tumor). all patients experienced fever and neutropenia. at engraftment, average ne activity was significantly decreased compared to the average value of healthy individuals. ne activity improved week by week in patients, reached the lower reference range at weeks following transplantation (fig. a) and continued to increase. the enzymatic activity of mpo was comparable to the average value of healthy individuals (fig. b) and showed no significant difference between the distinct time points. at neutrophil engraftment, nets formation was absent and comparable to those of non-activated neutrophils (fig. c) . although nets formation increased week by week, it did not reach the average of normal controls during the monitored time period. also linear correlation between ne activity and nets formation (r = . ) was demonstrated. conclusions: impaired ne activity following hsct corresponds to decreased nets formation and could serve as a marker for netosis. strategies to accelerate the recovery of ne function post transplantation might improve nets formation and thereby induce better infection control. a) the average of ne activity (n= ) during weeks following hsct. reference range was measured and calculated from measurements of healthy volunteers using. b) the average of mpo activity (n= ) during weeks following hsct. reference ranges were measured and calculated from measurements of healthy volunteers using the quartile method. c) the average of netosis activity after nm pma activation for h (n= background: to have a better understanding of incidence, treatment, outcome and risk factors of immune cytopenia in children after allogeneic hsct. methods: between january and september , pediatric allogeneic hsct have been performed in patients at the ghent university hospital (ghent, belgium). autoimmune hemolytic anemia was defined by a positive direct agglutinin test (dat). dat was performed at moment of engraftment and in case of hemolysis or unexplained anemia. platelets antibodies were evaluated in case of no otherwise explained thrombocytopenia. results: the cumulative incidence of post allo sct autoimmune cytopenia is . % ( / ). in cases there were positive antibodies against red blood cells, and one patient against had antibodies against platelets. of these cases, only ( . %) were clinically relevant and needed treatment. the median observation period post sct for the whole cohort was months ( - ) . the clinically significant immune cytopenia started at a median time of day+ and day + in the group without symptoms. the patient who presented the autoimmune thrombopenia developed antibodies against anti-gpiib/iiia, this was resolved after days, the treatment consisted intravenous immunoglobulins (ivig). two of the patients with autoimmune hemolytic anemia had igg mediated antibodies, and had complementmediated dat. these patients were treated with ivig, steroids, rapamune and rituximab. one patient has still dat positive after months, but clinical stable. the other two are also dat positive and have some hemolysis, but the follow up is much shorter ( months). treosulfan-contained conditioning regimens were more frequently used in patients with significant immune cytopenia. conclusions: immune cytopenia is an infrequent complication after allogeneic hsct. however, its treatment can be challenging, and the hemolysis can persist for years. the association of rapamune and rituximab was adequate to treat this problem in our patients. background: approaches to the management of refractory and relapsed classical hodgkin´s lymphoma (r-r chl) are changing and become more effective. the role of anti-cd targeted immunochemotherapy with brentuximab vedotin (bv) has been extensively investigated in adults with r-r chl and is only to be elucidated in children. the study included children and adolescents with r-r chl that were sucessfully treated with bv-based therapy prior to hematopoetic stem cell transplantation (hsct). median age of patients was years ( - ), main histological variant -nodular sclerosis ( %, n= ), advanced stage at diagnosis - % (n= ). most were heavily pre-treated (median number of previous therapies - ) and progression after autologous hsct was documented in ( %). refractory disease was diagnosed in ( %) and relapsed in ( %). among relapsed patients ( %) were with multiple episodes, ( . %) -early and ( . %) -late relapse. treatment regimens consisted of bv in monotherapy . mg/kg triweekly (n= ) or combination of bv . mg/kg on day with bendamustine - mg/ m on days and of -week cycles (n= ) or combination of bv . mg/kg on day with dhap (n= ). median number of bv infusions was . ( - ). all selected patients achieved complete (n= , %) or partial remission (n= , %) prior to hsct. consolidation with autologous hsct was performed in ( %) and with allogeneic hsct -in ( %). primary end points were overall (os) and progression free survival (pfs). response to bv was not assessed in the study as only responders to the bv-based treatment were included. results: with median follow-up of days ( - ) os and pfs for all patients are % and %, respectively. pfs after autologous hsct and allogeneic hsct are % and %, respectively (p= . ) at present moment ( %) patients are alive and are in remission. three patients died ( %): disease progression (n= ), postransplant idiopathic pneumonia syndrome (n= ) and posttransplant pneumonia (n= ). bv was generally well tolerated with only mild polyneuropathy in patients ( %) as the main reversable documented adverse event. conclusions: in prognostically unfavourable heavily pretreated children and adolescents with r-r chl achievement of response to bv-based therapy prior to hsct is assosiated with promising rates of os and pfs. disclosure provides a treatment by restoring thymidine phosphorylase function and improving disease manifestations. here we report the outcomes of affected siblings who underwent transplantation using an unaffected sibling donor to highlight important experiences in the transplant of such a rare condition. methods: four siblings of consanguineous pakistani descent aged , , and years underwent myeloablative hsct using fully hla-matched ( / ) peripheral blood stem cells harvested in a single apheresis from an unaffected year old sibling. the oldest sibling, a year old male, first presented in having emigrated from pakistan with a history of growth failure and abnormal movements. biochemical, nerve conduction and imaging studies confirmed a diagnosis of mngie. testing on three other siblings identified similar biochemical abnormalities, though the youngest children had minimal clinical manifestations of the disease. based on the progressive nature of the disease and the availability of a fully matched donor, a decision was made to pursue transplant for all affected siblings. results: due to the severity of their disease, the oldest siblings were transplanted first using a myeloablative conditioning regime of fludarabine, thiotepa and treosulfan with alemtuzumab. neutrophil engraftment occurred on day + for both, with % donor chimerism achieved. there were no significant transplant related complications. the post-transplant course of the year old sibling was complicated by a major stroke-like event characterised by dramatic imaging changes and requiring ventilation, though no cause was identified and the patient's neurologic deficits have since resolved. gastrointestinal symptoms have persisted and both remain tpn dependent, though symptomatically have shown gradual improvement. following the neurologic complications in their older sibling, the younger siblings were conditioned with auc-targeted busulfan and fludarabine plus alemtuzumab. neutrophil engraftment occurred on day + , with full donor chimerism achieved. progression to enteral feeding has been much more rapid, with nutrition now fully enteral for both. there were no significant transplant related complications. conclusions: stem cell transplantation represents the only curative option for mngie. due to its rarity and relative infancy as a condition, little is known of the expected course following transplant or the best approach to transplantation itself. despite previous challenges with graft failure in mngie recipients, we were able to gain rapid and sustained donor engraftment using different myeloablative conditioning regimes with minimal transplant-related morbidity and no mortality. in keeping with previous reports, resolution of established gastrointestinal symptoms has been slow, though the siblings transplanted earlier in their disease course have shown more rapid improvement supporting the role of early recognition and access to transplant. it is essential moving forward that specialised transplantation centres collaborate so as to guide clinicians in the management of such a challenging condition. disclosure: there are no conflicts of interest to disclose. g pc congenital neutropenia -biology of inflammatory colitis associated with gcsf use, and disease response to allogeneic transplant, a report of cases background: an autosomal recessive disease, glucose- phosphatase catalytic subunit (g pc ) deficiency is a relatively recently identified cause of chronic severe neutropenia. there can be a spectrum to the disease and patients may also present with non-haematological features including prominent chest veins, cardiac, endocrine or urogenital abnormalities. we describe in our patient cohort a response to gcsf but an inflammatory, incapacitating, biopsyproven colitis associated with that g-csf response. we have transplanted children with such colitis, and describe a similar colitis with intestinal failure in a fourth. methods: we investigate the biology of the neutropenic colitis, and demonstrate necrosis of the stimulated neutrophils. in vitro studies demonstrated that unstimulated neutrophils from patients with g pc d exhibited significantly increased production of il , reactive oxygen species (ros) and neutrophil extracellular traps (nets) alongside significantly higher expression of cd b, cd b and cd . in contrast, neutrophils from patients with g pc d produced significantly less ros, mmp- , neutrophil elastase and nets upon stimulation. neutrophils from patients with g pc d also exhibited significantly accelerated apoptosis and secondary necrosis which was exaggerated upon stimulation with live escherichia coli bacteria but could only be partially rescued with supplemental exogenous glucose. results: patients have undergone hsct for g pc neutropenic enterocolitis ( unrelated donor and msd) after fludarabine treosulfan and thiotepa conditioning therapy. alemtuzumab was given as as serotherapy. all patients are alive and well, immune suppression has been discotniuned and there is no gvhd with normal organ function, and resolution of colitis. we describe a th patient with no good donor who has continuing intestinal failure with g-csf use. conclusions: we describe the aetiology of intestinal inflammation and failure with an extensive study of neutrophil biology in this metabolic neutropenia. we describe a novel indication for hsct in this "g-csfresponsive neutropenia". disclosure: nothing to declare p does body mass index (bmi) pose a risk to outcome for pediatric non-infantile patients undergoing hematopoietic cell transplantation (hsct)? mona al-saleh , khawar siddiqui , amal al-seraihy , abdullah al-jefri , ali al-ahmari , hawazen al-saedi , awatif al-anazi , mouhab ayas , ibrahim al-ghemlas with no evidence of toxicity. as benefits of stoss therapy in hsct remain unknown, and safety has yet to have been studied extensively in the pediatric population, we hypothesize that stoss therapy is an effective and safe method to reach and attain sufficient levels of vd in pediatric patients undergoing hsct. methods: this is an ongoing prospective, randomized clinical control trial at phoenix children's hospital that commenced december st , . following consent, subjects are randomized to the intervention (stoss) or control arm prior to hsct. stoss therapy consists of a single oral dose of vd (ranging , iu - , iu), given based on baseline -hydroxyvitamin d [ (oh)d] level and age, followed by standard weekly supplementation. subjects enrolled on the control arm receive standard of care based on endocrine society guidelines of weekly vd supplementation. data collection includes demographics, (oh)d levels at baseline, day + , and day + , vd toxicity (hyperphosphatemia, hyperkalemia and renal calculi), as well comorbidities were collected. at each time point and for each trial arm, the mean (oh)d level and changes from baseline were computed with corresponding % confidence intervals (cis) to indicate variability. results: presently, subjects have completed baseline assessment, with day + and day + follow-up completed for and of these, respectively. at baseline, the mean ( % ci) (oh)d was . ng/dl ( . , . ) among stoss patients and . ng/dl ( . results: total hrqol scores of transplanted patients were significantly improved compared to those on supportive care and also compared to healthy siblings (p < . and . respectively), the same was true for physical (p < . and . respectively) and emotional functioning (p < . and . respectively). social and school functioning of transplanted children were not different from healthy siblings (p . and . respectively) while were very significantly improved compared to children with st on supportive care (p < . in both cases). conclusions: bmt in a lower-middle income setting may be even more impactful compared to high-income regions. our analysis clearly indicates normalization of hrqol in all major areas of children transplanted for st. a possible resilience effect was noted for physical and emotional scores which were improved compared to healthy sibling controls. we could not however quantify the effect of longer-term issues like fertility impairment after bmt which may eventually adversely impact hrqol, particularly in the indian culture. disclosure: none allogeneic hematopoietic stem cell transplantation in ataxia telangiectasia patients without malignancy background: ataxia telangiectasia (a-t) is a primary immunodeficiency with mutations in atm-gene. besides a slowly progressive neurodegenerative course, a-t leads to increased susceptibility to malignancies which affects % of patient (median: . years) with a high mortality mainly due tocomplications of conventional radio-chemotherapy. the incidence of cancer correlates with the extent of immunodeficiency. patients often develop severe progressive granulomatous skin disease with evidence of vaccine-strain rubella-virus in the lesions. prolonged survival, neurologic improvement and malignancy prevention was observed in atm-deficient mice after treatment by syngeneic hsct. nevertheless, pre-emptive hsct is not routinely performed in a-t patients due to concerns about neurodegeneration and toxicity. methods: we present three a-t patients with severe immunodeficiency phenotype, undergoing successful hsct as an individual treatment strategy intending to restore immunodeficiency for long-term malignancyprevention (patient- ) and to treat progressive skin/joint granulomas (patients- and - ). results: patient- underwent a reduced intensity conditioning (ric) regimen at years of age including fludarabine ( mg/m ), cyclophosphamide ( mg/kg), and atg-fresenius ( mg/kg/d) which was tolerated well. hematopoietic engraftment occurred by day + . there was an expansion of naïve and memory cd + t-cells and cd + cells. while initially a mixed donor chimerism in patient's pbmcs ( - % donor) was observed, patient's tcells (cd + ) reached over % of donor origin over time. at last follow-up ( years) he is well, without signs of gvhd and organ toxicity, off immunosuppression with normal levels of atm-protein; his granulomas resolved. patient- is a year-old male who was transplanted from his hla-identical sibling, conditioned with fludarabine ( mg/m²), cyclophosphamide ( mg/kg), and atg-fresenius ( mg/kg). hematopoietic engraftment was observed by day + . t-cell reconstitution started by day + with > μl cd + t-cells. his mixed chimerism rapidly turned to donor origin ( % donor cd +) over time. there was no acute toxicity, however, he developed lumbosacral pain episodes with evidence of urine bk-virus with spontaneous remission. an intermittent metapneumovirus associated pulmonary hypertension was observed with pericardial effusion. treatment included sildenafil and oxygen. at last follow-up ( months) patient is well without immunosuppression. patient- suffered from recurrent chest infections, failure to thrive and progressive and debilitating rubella positive progressive granulomas of the skin. she received allohsct from an hla-identical family donor at years of age. conditioning included busulfan ( . mg/kg), fludarabine ( mg/m²), cyclophosphamide ( mg/kg), and alemtuzumab ( x mg/m², x mg/m²). hsct was complicated by intermittent acute renal failure, cmv reactivation and tma. hematopoietic recovery was observed by day + . t-cell chimerism increased rapidly over time (> % donor). at last follow-up ( months) patient is well, off immunosuppression and ivig. her skin granuloma resolved with scarring residues. conclusions: pre-emptive allohsct is feasible in a-t when reduced intensity conditioning is used and can correct the immunodeficiency. it might be a treatment option for some a-t patients at high risk of hematological malignancy and severe granulomatous skin disease. to what extent the restored immune system and the increase of atm-protein in these patients could prevent the development of other malignancies needs to be evaluated further. disclosure: nothing to disclose p abstract withdrawn. hematopoietic stem cell transplantation in diamond blackfan anemia: brazilian experience background: diamond-blackfan anemia (dba) is a rare inherited red cell aplasia caused by an intrinsic defect of erythropoietic progenitors. the main therapeutic approach is based on repeated red blood cell transfusions and/or corticosteroid therapy. hematopoietic stem cell transplantation (hsct), a potentially curative treatment for dba, is indicated for patients that do not respond to first-line therapy. methods: the aim of our retrospective study is to report the outcomes of brazilian dba patients transplanted between and in bmt centers. the median age of the patients was ys (range - ) and % were male. seventeen patients ( %) were transplanted with matched related donors (mrd) and thirteen ( %) from matched and mismatched unrelated donors (mud/mmud). in the mrd group all patients received bone marrow as hsc source, while in the mud/mmud, eight patients received bone marrow and five received cord blood. all patients with incompatibilities (mismatched) were ucb ( / ). nineteen recipients were conditioned with busulfan plus cyclophosphamide, while the remaining received fludarabine and busulfan, which has been the preferred regimen in brazil in the recent years. after transplant, most (n= ) of the mrd and mud recipients received cyclosporine and short course methotrexate as graft versus host disease (gvhd) prophylaxis. results: twenty-two out of the patients were alive and disease-free at a median follow-up of months (range to months). the -year overall survival (os) was % (ci - %) (fig ) . similar results have been demonstrated in studies from europe and from the united states. when analyzed according to donor type, os was % (ci - %) and % (ci - %) in mrd and mud/mmud respectively (fig ) . three out of the patients who were transplanted with ucb died. these results are in agreement with those of previously published data showing worse results in unrelated ucb transplants. twenty-nine out of the patients engrafted successfully. in of the evaluated patients, the median time to neutrophil engraftment was days (range - ). one patient experienced an early death from hemorrhagic shock on day , before neutrophil recovery, and another two patients experienced primary graft failure. post-transplant chimerism was available for patients. sixteen had complete chimera (> % chimerism), while patients presented with mixed chimerism. acute gvhd was observed in patients ( %), of which classified as grade iv. five patients developed chronic gvhd, considered severe in three of them. eight patients died at a mean of days (range - days) after hsct and the main causes of death were infections and hemorrhagic disorders. conclusions: hsct is a potentially curative treatment option for dba. in the present study, we report the outcomes of patients with dba transplanted in brazil with a os of %, with better results in mrd compared to mud, as expected. despite the small numbers, we observed lower survival after mud/mmud ucb transplantation. since dba is a rare disease, international collaborative studies are essential to better understand the benefits of the hsct in the treatment of these patients. disclosure: nothing to declare p treatment of the obliterant bronchiolitis in pediatric allogeneic recipients: two periods compared results: in group , the therapies administered for bo included prolonged treatment with steroids in all patients, anti-tnf in , azatioprine in ; while in the group , all patients received ima, montelukast and azitromicin, and received i.v. mpd. the median duration of imatinib therapy was years ( . - . years). after a median follow-up of . years (range . - . yrs), / patients of group ( %) died with bo in progress for transplant-related causes. while in the group , / ( %) died in presence of worsening bo. the estimated os at year after hsct was % ( % ci; - ) in group and % ( % ci, - ) in group (p= . ) (figure ), while the os after year decreased at % ( % ci; - ) in the group while remained stable in the group . conclusions: this experience shows a relevant improving in prognosis of children with bo with the use of this protocol including ima, since the significant improving of survival obtained, confirming as reported in adult populations. disclosure results: we presented patients with pres, age ranging from months to years with a average of . years. there were ten patients with thalassemia major, two patient with acute lymphoblastic leukemia, three patients with sickle cell disease and one patient with myelodysplastic syndrome, one patient with immune deficiency, two patients with acute miyeloid leukemia, one patient with aplastic anemia. ten patients were males, ten were female. all patients were treated with csa or tacrolimus and metilprednisolone for the prophylasix of gvhd. pres occurred at a median of days (range - ). clinical findings at onset of leukoencephalopathy were hypertension, headache, seizures, visual disturbance, and altered mental function. eighteen patients alive with normal neurological status. mri showed abnormalities in all patients including patchy bilateral cortical and subcortical lesions, especially in parieto-occipital lobes. conclusions: bmt is associated with several neurological complications that may be underlying diseases, bmt procedure, and severe immunosupression. pres is an uncommon but serious complication after bmt. we report cases of pres who received allogeneic bmt for thalassemia major to emphasize the importance of early recognition and institution of appropriate management of pres during bmt. disclosure: nothing to declare p continuous complete molecular remission using three different monoclonal antibodies followed by allogeneic bone marrow transplantation in an infant with chemotherapy-refractory acute lymphoblastic leukemia bernd gruhn , susan wittig , thomas ernst , jana ernst university of jena, jena, germany, background: a -week-old infant was diagnosed with very immature acute lymphoblastic leukemia (all) with myeloid markers in a foreign university hospital. at the end of induction therapy according to the current lal/shop protocol % leukemic cells were detectable in the bone marrow. treatment was changed to fludarabine, cytarabine and granulocyte colony-stimulating factor (flag) in combination with liposomal doxorubicin. after this re-induction still % leukemic cells were detected in bone marrow, so the bispecific t-cell engager antibody blinatumomab was given. due to an increasing portion of leukemic cells during the continuous infusion, antibody therapy was stopped and a cycle of clofarabine, cyclophosphamide and etoposide was administered. unfortunately, still % leukemic cells were detectable afterwards. because of chemotherapy-refractory leukemia a palliative oral treatment with mercaptopurine was started. however, the parents did not accept the palliative situation and searched for alternative therapeutic options in other university hospitals in europe. after plenty of refusals the infant was admitted to our hospital five months after diagnosis. methods: for molecular characterization genomic dna was isolated from leukemic cells. a mll-mllt /af rearrangement as a consequence of the translocation t( ; ) (p ;q ) was detected and used as a marker for minimal residual disease. for further molecular characterization targeted deep next-generation sequencing was performed for a panel of leukemia-associated genes. interestingly, no mutation was found. to allow precise immunophenotyping of the leukemic cells treatment with mercaptopurine was stopped. results: as in the first immunophenotyping the cd antigen was found, we administered the anti-cd monoclonal antibody gemtuzumab ozogamicin twice within two weeks. because of the detection of cd + leukemic cells after infusion of gemtuzumab ozogamicin, the anti-cd antibody daratumumab was given alternating twice within two weeks. unfortunately afterwards, leukemic cells reappeared being negative for cd und cd , but positive for cd . therefore, we administered the third antibody, the anti-cd monoclonal antibody inotuzumab ozogamicin, whereupon our patient developed a tumor lysis syndrome and a severe bone marrow aplasia. shortly after, allogeneic bone marrow transplantation from an unrelated donor using a special conditioning regimen consisting of thymoglobulin, busulfan, fludarabine and clofarabine was conducted. clofarabine was added because an additional antileukemic effect especially in infant all with mll rearrangement was described. after transplantation the patient suffered from a severe hepatic sinusoidal obstruction syndrome with massive ascites, renal and pulmonary dysfunction, but finally the patient recovered completely. the first bone marrow examination days after transplantation revealed a donor chimerism of % and a complete molecular remission using the mll-mllt /af rearrangement as marker for minimal residual disease. in all follow-up bone marrow samples we observed a complete donor chimerism and a complete molecular remission. currently, eight months after transplantation the patient is in a very good physical condition with normal development according to the age. background: paediatric chronic graft versus host disease (cgvhd) is a debilitating condition associated with substantial morbidity and mortality. to date, there are no approved therapies for paediatric patients with cgvhd, and current treatments often lack sufficient efficacy or lead to severe/life-threatening toxicities that limit their effectiveness. ibrutinib, a first-in-class, once-daily inhibitor of bruton's tyrosine kinase (btk), is approved in the us for the treatment of adult patients with cgvhd after failure of ≥ lines of systemic therapy. this phase / study will evaluate the use of ibrutinib in paediatric patients with moderate or severe cgvhd. methods: this open-label, multicenter, international phase / study (pcyc- ) includes patients with moderate or severe cgvhd as defined by the nih consensus development project criteria. it is divided into two parts: part a will determine the recommended paediatric equivalent dose (rped) of ibrutinib in patients aged ≥ to < years, and part b aims to evaluate the safety and efficacy of ibrutinib in patients age ≥ to < years. for part a, patients with cgvhd aged ≥ to < years who have failed ≥ lines of systemic therapy will receive once daily oral ibrutinib at a starting dose of mg/m to be escalated up to mg/m after days, if no grade ≥ toxicities occur, until the rped is determined. for part b, patients aged ≥ to < years with cgvhd who have failed ≥ lines of systemic therapy or have newly diagnosed cgvhd will receive once daily ibrutinib ( mg) until one of the following criteria is met: treatment is no longer required; new systemic treatment for cgvhd is initiated; progression of cgvhd; recurrence of underlying disease; or unacceptable toxicity. patients with newly diagnosed cgvhd will receive ibrutinib in addition to daily corticosteroids ( . - mg/kg prednisone). patients < years of age may be enrolled in part b and treated at the rped after it is determined in part a. key exclusion criteria include uncontrolled active systemic infection or active infection requiring systemic treatment; progressive underlying malignant disease or any post-transplant lymphoproliferative disease; or active hepatitis c/hepatitis b virus. patients must have adequate renal, hepatic, and hematologic function to be enrolled. the primary endpoint of part a is the rped of ibrutinib, as based on pharmacokinetic (pk) data; secondary endpoints include safety and pharmacodynamics (btk occupancy). the primary endpoints of part b are pk and safety of ibrutinib in paediatric patients with cgvhd. secondary endpoints for part b include response rate at weeks as defined by the nih consensus development project criteria; duration of response; overall survival; and late effects on growth, development, and immune reconstitution. results: this global study is currently enrolling. conclusions: this phase / study will explore the use of ibrutinib in paediatric patients with cgvhd to potentially meet the high unmet need for proven effective therapies for this population. disclosure enzyme replacement therapy (ert) is the treatment of choice in non-neuropathic hunter syndrome, but as the recombinant enzyme does not cross the blood brain barrier and neuropathic hunter syndrome is left untreated. hematopoietic stem cell transplantation (hsct) is the standard of care in patients with severe mucopolysaccharidosis (mps) type i (mpsih, hurler syndrome) as early transplantation halts cognitive decline in these patients and significantly improves survival. only few case studies have been published on the potential benefit of hsct in mps ii and mostly used busulfan-based conditioning regimens. in one comparative non-randomised multicenter study, hsct might to be superior compared to ert. here, we present our experience in hsct in three children with hunter syndrome using a treosulfan-based conditioning regimen. methods: a retrospective chart review was carried out in patients, who underwent hsct for hunter syndrome. the conditioning chemotherapy regimen included fludarabine, treosulfan, thiotepa and atg. all patients received bone marrow of either related and or matched unrelated donors. gvhd prophylaxis was performed with csa and methotrexat. results: three patients with hunter syndrome were transplanted in our department in . the age was six months, two years and four years, respectively. bone marrow donors were related in one patient and matched unrelated in two patients. the conditioning therapy was generally well tolerated. major complications were fever of unknown origin with need for antibiotic therapy and a mucositis. one patient developed a cmv reactivation. all patients engrafted successfully and recovered well from the hsct. there was no case of acute or chronic gvhd. in all three patients are alive. donor chimerism is complete in one patient; two patients have a mixed donor chimerism. after application of donor lymphocyte infusions in one patient, donor chimerism is stable at a low level of %. the donor chimerism of the other patient still slowly declines to currently %. after stem cell transplantation, two patients did not show further progression of the disease and even achieved psycho-motor improvements. interestingly, one of these patients is the one with the low donor chimerism of %. one patient suffers from a further progression of the underlying disease with psycho-motoric agitation, aggressive behavior and loss of speech, that occurred within the first year following hsct, but neurocognition stabilized thereafter. conclusions: we found a beneficial effect of hsct on the neuropsychological outcome or at least stabilization of neurocognitive function in our patients with a follow-up of eight years. despite low toxicity of the conditioning regimen, increased donor chimerism may further improve the neurological outcome. disclosure: nothing to declare. tandem sct in pediatric solid tumors, other than brain tumors, has no advantage in terms of efs over single procedure-single center experience , germ-cell tumour (gct), ewing sarcoma (es), nefroblastoma. patients were divided into groups according to the number of procedures: st group-single sct procedure, nd group-multiple procedures. regimens used for stem cell mobilisation were: topo-cy for nbl and epi-tax for gct, followed by g-csf±plerixafor. conditioning regimens: bu-mel and thiotepa-cy for pts with nbl, thio-tax and ice for pts with gct. patients received antibiotic, antiviral and antifungal prophylaxis, parenteral nutrition and supportive treatment. patients received consolidation treatment, followed up monthly in the first year, then yearly. patients were evaluated for residual disease by imaging tests. parents signed informed consent forms. results: we performed sct procedures to patients: . % nbl, . % es, . % gct and . % nefroblastoma. for this study only patients with nbl and gct were considered. in st group were % of pts, % in nd group. patients were diagnosed, staged and treated according to international protocols. sex ratio was f/ m. age distribution was - y % ( pts), - y % ( pts), > y % ( pts). peripheral stem cell (pbsc) mobilisation was more difficult in patients with multiple courses of chemotherapy±radiotherapy. we found no difference in the period of engraftment following a nd or rd procedure. hospitalization and supportive measures increased in nd and rd procedures ( to days). patients with multiple courses of chemotherapy and multiple hospitalizations had increased infectious risk and during the nd or rd procedures developed various infectious complications.incidence of severe oral mucositis after the first hsct was %, after tandem hsct was %. nbl patients : st group- / patients alive and efs, / receives anti g treatment; nd group- / patients-alive, / patients-not reached timepoint for mibg scan; / patients-mibg negative at first, relapsed after mo; / patient deceased due to pulmonary toxicity. gct patients: st group- / patients alive and ef, / high values in afp levels and receives metronomic therapy, / patients deceased due to progressive disease, but only had sct. only / patient had one procedure and died due to progressive disease. conclusions: in our study, tandem hsct in children with solid tumours lead to an increase in survival rates, at least in the first months after sct. most patients ( %) had progressive or relapsed/refractory disease when referred to our department. multiple procedures require a higher number of cd cells, very hard to achieve in patients with multiple courses of chemo± radiotherapy. new approaches have to be considered in these diseases, especially in high risk group. disclosure: nothing to declare background: antimicrobial prophylaxis for prolonged neutropenia occurred during the pre-engraftment period is a common practice in allogeneic hsct recipients. data on its effectiveness are few and generally from cases series and not from randomized clinical trials, especially in children. methods: all clinical records of allo-hsct performed from january st to november th at hsct-unit of istituto g.gaslini, genoa-italy, were retrospectively reviewed. collected data were underlying diseases, type of donor, antibiotic prophylaxis administration and type, development of fever and pathogen isolated from blood culture, if any, during pre-engraftment neutropenia. antibiotic prophylaxis, usually starting together with the conditioning regimen, was categorized in "standard" (with amoxicillin/clavulanate or ampicillin/sulbactam) or "tailored" (when based on previous bacterial isolations or colonizations). results: allo-hscts were performed in pediatric patients ( % males) with a median age at hsct of years (iqr: - ; range: - ). hscts were performed from alternative donor (ad) in % patients, from relative donor (rd) in %, and from haploidentical donor in %. table shows the pre-engraftment febrile neutropenia episodes according to type of antibiotic prophylaxis. ( %) hscts received standard prophylaxis, while ( %) the tailored one; only in ( %) did not receive any prophylaxis. fever occurred in ( %) of episodes in patients receiving standard prophylaxis, in ( %) of those treated with tailored prophylaxis and ( %) in the group without prophylaxis; only % of patients who received prophylaxis did not develop fever.in % of patients, the febrile episodes were diagnosed as bloodstream infections: staphylococcus aureus in %; cons in %; enterococcus spp in %; enterobacteriaceae in %; pseudomonas aeruginosa in %; other non-fermenting gram negatives in % and fungi in %. conclusions: the occurrence of fever in patients who received antibiotic prophylaxis suggested that it could not be effective in prevention of fever related to neutropenia after allo-hsct. the personalization of prophylaxis could be a possible path to follow these patients. disclosure methods: a total of patients with leukemia or neuroblastoma were included in the study. patients' mothers signed an informed consent for participation in the study. six of study participants were boys and girls, all aged to years. the control group consisted of healthy preschool children ( groups of children aged to years), boys and girls. results: in most of games the role of a doctor was played by a child. only one child declined to impersonate both a patient and a doctor. younger children mostly agreed to have for a "patient" a toy (proposed by psychologist or one of child's own), child's mother or a medical psychologist. the game lasted for - minutes. most patients preferred using real medical consumables and instruments (syringes, adhesive tape, winged infusion sets or, more rarely, pills). most often a syringe or an adhesive tape was chosen. as known from their mothers, among medical manipulations most unpleasant for children are injections and changing implanted catheter dressing. also, most healthy preschool children preferred using real medical instruments over toy ones. group more often used a syringe, a winged infusion set, adhesive tape, gauze or pills. group most often chose syringe or gauze. among medical instruments both groups more often chose a phonendoscope or thermometer.one patient refused to cause pain to a "toy patient". other children sympathized with a "toy patient", stroke injection or dressing location sites or used soothing terms ("wait a little", "it's going to be all right"), wished prompt recovery and hugged their "patients". one child was angry over his "patient" wishing him to "get hurt too". first preschool group children were mostly scolding a toy "patient" for "being guilty of getting sick". second group children were mostly compassionate, encouraged a "toy patient" telling that "all the procedures are needed to get healthy". from children's schoolmasters we know that all first group children received vaccination about a week before a test. children from second group had no injections. overall attitude towards toy "patients" was more mild in the second group. conclusions: . during a play children mostly use the medical devices which cause them most discomfort and/or pain. . manipulating the items children illustrate their own impression of medical procedures, which are most unpleasant. . children may express their negative emotions directed towards medical manipulations via their play actions, these negative reactions may be suppressed in different ways by parents or medical staff. . the intensity of child's own traumatic experience and an attitude of nearby adults may influence the child's attitude towards other patients. . the mother's wish for a child to tolerate all medical procedures with ease exceeds real capabilities of a small child. disclosure: nothing to declare. allogeneic stem cell transplantation in patients with mucopolysaccharidosis type iiia (sanfilippo): a case series methods: allogeneic sct was performed at the ages of , and years, respectively. all three patients received intrathecal enzyme replacement therapy within a clinical trial setting prior to hsct. the conditioning regimen consisted of treosulfan, fludarabine, thiotepa and thymoglobuline. gvhd-prophylaxis was carried out with csa and mtx in two patients and csa and mmf in one patient. stem cell source was bone marrow in two patients and peripheral blood stem cells in one patient. results: the conditioning regimen was well tolerated and all three patients successfully engrafted. two of three patients had an uncomplicated course without occurrence of acute or chronic graft-versus-host-disease (gvhd). at last follow-up and months after hsct, both patients are in good condition and show constant progress of psychomotor development. the third patient experienced severe steroid refractory acute gvhd of intestines (stage ) and skin (stage ), which resolved under intensive immunosuppression with cyclosporine, mycophenolate and ruxolitinib. around day after hsct, this patient showed clinical and biochemical signs of transplant-associated microangiopathy (tma) with cerebral seizures and acute renal failure. the cerebral mri showed progressive cerebral atrophy and leukoencephalopathy, also consistent with a progress of the mps iiia. at last follow-up months after hsct, this patient had recovered from tma and was in a stable clinical condition. conclusions: in consideration of the small case number and the short follow-up period in our cohort, allogeneic hsct might be considered as a salvage therapy for patients with mps iiia if other therapeutic options are unavailable for children with this otherwise unfavourable prognosis. however, the early psychoneurological course after transplant seems promising compared to the literature and hsct could become a treatment option for this rare disease. disclosure: nothing to declare methods: for the identification of underlying molecular mechanisms leading to the increased sensibility of rms cells, the activation status of different nf-kb signaling pathways were analyzed using western blot analysis and quantitative real time pcr (qpcr). further, flow cytometry was used to analyze the surface expression of death receptors on either sm treated or untreated rms cells. the overall effect on cell death induction was measured by pi/hoechst staining using a fluorescent microscope. results: treatment with sm led to the suspected degradation of iaps. followed by the activation of both the canonical nf-κb signaling pathway, indicated by the phosphorylation of iκbα and p , and the non-canonical nf-κb signaling pathway, as indicated by the accumulation of nik and the degradation of p to p . determination of selected target gene transcription revealed an upregulation of the inhibitor iκbα, nik, p , il- and at later time points the death receptors trail-r and trail-r . analysis of gene transcription also led to the finding of neither up-nor downregulation of ciap and p . to evaluate the involvement of trail-r and trail-r in the sm induced sensitization towards nk cell-mediated killing, surface expression of both death receptors was analyzed. treatment with sm led not only to an induced transcription of trail-r and trail-r , but also to an increased surface presentation of trail-r . subsequent ligation of trail-r by either wt-trail or a specific agonistic antibody (etr- ) resulted in a significant increase in cell death induction. the aforementioned analysis of gene transcription hints towards a bimodal feedback mechanism regulating both, the canonical and non-canonical nf-κb signaling pathway. on the one side, the canonical pathway is negatively regulated by the induced transcription of the inhibitor iκbα. on the other side, the induced transcription of nik, p and relb points towards a positive feedback loop of the non-canonical pathway. one mechanism of the increased rms cell sensitivity might be the induced transcription and surface presentation of the death receptor trail-r . the involvement of trail receptors is further validated by the cytotoxicity data, illustrating a sm mediated sensitization towards a trail induced cell death induction. this mode of cell death fits to the previous research, were trail transcription could be induced in nk cells by sm treatment. the graphical abstract shows the transcriptional upregulation of target genes leading to a putative bimodal nf-kb regulation and increased surface presentation of trail-r by treatment with smac mimetics. aim: to investigate the outcome of ucb transplantation in pediatric patients with malignant and non malignant diseases methods: data from patients underwent first allogeneic bone marrow transplantation with ucb from / until / were retrospectively analyzed. eighteen had malignant disease (md), of whom in complete hematologic response, and non malignant disease (nmd) (scid , chronic granulomatous disease , severe aplastic anemia , s.kostmann , osteopetrosis , wiskott-aldrich , amegakaryocytic thrombocytopenia ). the majority of the patients were male, for md and nmd, as well (m: /f: , m: /f: , respectively), of median age . years (range . - . years) and . years (range . - . years), respectively results: all patients but one, received ucb unit. hla compatibility in antigen/allele level was at least / and only in patients with md was / . conditioning regimens were myeloablative and tbi gy was given in / . gvhd prophylaxis consisted of cyclosporine and atg was given in all patients pre-transplantation. median value of nucleated cells for md was . χ /kg (range - . χ / kg) and for nmd was . χ /kg (range - . χ /kg). neutrophil and platelet engraftment was achieved in / and / patients with md respectively, in a median time of days (range - ) και days (range - ). in patients with nmd, neutrophil and platelet engraftment was achieved in / and / with median day of engraftment days (range - ) και days (range respectively. acute gvhd grade ΙΙ-Ιv presented in / patients with md and / with nmd, although none had cgvhd. the incidence of viral infections was cases in patients with md and cases in patients with nmd. disease relapse occured in / patients with md. after a median time of years follow up, overall survival (os) and event free survival (efs) for children with md were % and . % respectively, while for nmd, os and efs were %.treatment related mortality at d+ was % for md and % for nmd. among patients with md, are still alive, while the rest died from relapse (n: ), viral infections (n: ), septicemia (n: ) and agvhd(n: ). among patients with nmd, are alive, while the rest died from viral infections (n: ), septicemia (n: ) and multiple organ failure (n= ). the median time of hospitalization for patients with md was days (range - ), whilst for nmd was days (range - ). conclusions: transplantation of unrelated ucb in our unit was combined with high trm in children with nmd and higher probability of relapse for md. disclosure: nothing to declare p serum levels of -s cysteinyldopa is associated with stem cell transplantation related complications yukayo terashita , mamoru honda , minako sugiyama , yuko cho , akihiro iguchi hokkaido university hospital, pediatrics, sapporo, japan background: diffuse hyperpigmentation is common in patients who received chemotherapy or stem cell transplantation (sct). however, there are few reports of the relationship between skin reaction such as pigmentation and the other complications. pigmentation of the skin is thought to be the result of melanin stagnating in the dermic layer due to increased synthesis of melanin and destruction of the basement membrane due to inflammation induced chemoradiotherapy. melanin pigments are classified into two types: brown to black eumelanin and yellow to reddishbrown pheomelanin. -s cysteinyldopa ( scd) is precursors of pheomelanin, and its serum level has been used specific biochemical marker for malignant melanoma. here, we examined serially scd during the course of sct to determine association with sct related complications, because visual evaluation of skin color is difficult, and there have been no reports about scd as sct related biomarker. methods: we prospectively analyzed ( males, females) patients who received sct between may and march in hokkaido university hospital. the median age at transplantation of the patients was . years (range, - ). indication for sct were acute myelogenous leukemia in patients, acute lymphoblastic leukemia in patients, and other disease in patients; juvenile myelomonocytic leukemia( ), malignant solid tumor( ), immunodeficiency( ), anaplastic anemia( ), and diamond blackfan anemia ( ) . patients received allogeneic sct and received autologous sct. myeloablative conditioning (mac) was used for patients and reduced intensity conditioning (ric) was used for patients. sera were obtained from patients before conditioning therapy, on day , + , + , + , + and + . all blood samples were centrifuged at , rpm for min, and stored at - ˚c until used. we also examined sct related complications such as graft-versus-host disease (gvhd), viral infection, and pre-engraft syndrome (pes). statistical analyses were completed using the mann-whitney u test for unpaired samples, and kruskal-wallis test for three samples. each test was performed with a % level of significance. results: the average value of scd reached two peaks, day ( . nmol/l) and day ( . nmol/l), regardless of stem cell source and intensity of conditioning. in all patients, we found that the level of scd on day was associated with viral reactivation (p= . ), scd on day was associated with pes (p= . ), and scd on day was associated with malignant disease (p= . ). similarly, in patient who received allogeneic sct (n= ), the level of scd on day was associated with viral reactivation (p= . ), scd on day was was associated with pes (p= . ), scd on day was associated with malignant disease (p= . ). in addition, the level of scd on day was associated with gvhd of skin (p= . ), the peak level of scd was associated with acute gvhd (p= . ). conclusions: we found that scd can be a biomarker for sct-related complications such as aute gvhd. it is presumed that the production of pheomelanin could be induced by inflammatory procedure in sct. disclosure: nothing to declare p hsct in children with bone marrow failure: outcomes from a single singapore centre prasad iyer , michaela seng , vijayakumari k , ah moy tan , mei yoke chan , rajat bhattacharyya kk women's and children's hospital, paediatric haematology-oncology, singapore, singapore background: children presenting with pancytopenia often present a challenge to the paediatric haematologist. the underlying diagnosis can be hard to establish as many of the inherited bone marrow failure syndromes (ibmfs) can present with protean manifestations. the large majority of patients with bone marrow failure are often diagnosed with idiopathic severe aplastic anaemia (saa) despite extensive testing. we report our experience of hsct in patients treated with primary and acquired bone marrow failure. methods: we reviewed case notes of all the children who underwent hsct for bone marrow failure in our centre. results: a total of fifteen patients underwent eighteen stem cell transplants in our centre between and . three patients were diagnosed with fanconi anaemia, one with hoyeraal-hreidarsson syndrome, one with paroxysmal nocturnal haemoglobinuria and the remaining ten children had idiopathic saa. eight children had matched sibling donor transplant, had a matched related donor, had a matched unrelated donor, had umbilical cord blood transplants and the remainder were haploidentical transplants. four of the haploidentical transplants were t-cell depleted and one was t-cell replete. one child with fanconi anaemia had primary graft rejection with cord blood transplant and was successfully rescued with a haploidentical transplant. one child with saa had primary graft rejection twice (t-cell depleted graft) and then was rescued with an alternate haploidentical donor with a t-cell replete graft. of the two patients who died, one had a fatal fungal infection ten months after transplant, and the other died due to a severe influenza pneumonitis three and a half years after bmt. conclusions: haematopoietic stem cell transplant outcomes from our centre are comparable to leading centres in the world. the understanding of underlying conditions that present with bone marrow failure has improved our approach and the way we treat bone marrow failure syndromes. clinical trial registry: not applicable. disclosure: nothing to declare. methods: a retrospective study was performed in children treated with hsct who received pos or flu during early neutropenic period until engraftment from january to december at siriraj hospital in thailand. the efficacy, safety and tolerability of pos were compared to flu. results: there were hsct recipients (allo-hsct . %, auto-hsct . %) with mean age of . + . years. most of the patients were thalassemia ( . %) followed by hematologic malignancy ( . %) and solid tumor ( . %). seventeen and cases received pos and flu, respectively. all of patients in pos group were allo-hsct whereas . % in flu group were allo-hsct. in pos group, cases were diagnosed with suspected ifi and cases were probable ifi with total cases ( . %). in flu group, cases were diagnosed with suspected ifi and cases were probable ifi with total cases ( . %) which compared groups were not statistically significant (p= . ). no possible and proven ifi in both groups. in flu group patients received empirical antifungal treatment more than pos group but no statistical significance ( . % vs. . %, p= . ). both groups had similar rate of elevated liver function test (p= . ). no early discontinuation of antifungal prophylaxis for intolerance was found in both groups. only . % of patients achieved pos target trough level of . mg/l after days of treatment with started dose mg/kg three times a day. conclusions: pos and flu are comparably effective, safety and tolerability in ifi prophylaxis in neutropenic children treated with hsct. defining dose recommendation of pos in this setting requires larger studies. disclosure background: severe congenital neutropenia (scn) is typically characterized by anc of < /μl, maturation arrest of bone marrow myeloid precursors at the promyelocyte-myelocyte stage, and susceptibility to lethal pyogenic bacterial and fungal infections. scn is a rare group of disorders resulting from intrinsic defects in myeloid cell proliferation and maturation caused by mutations in several genes; elane, hax , gfi , was, and g pc are among the most common ones. almost % of patients are refractory to g-csf, and the only definitive curative approach for such patients is allogeneic hsct. the current absolute indications for hsct is failure to respond to g-csf treatment, or the development of mds/leukemia in patients with scn. here, we present the result of children with scn who received allogeneic hsct . methods: we retrospectively assessed allogeneic hsct in children with severe congenital neutropenia. all patients received busulphan (bu) based myeloablative conditioning regimen. busulphan was used according to weight adjusted dose. in addition, all patients received fludarabine mg/m in five days or cyclophosphamide mg/kg in days and atg mg/kg in days. cyclosporin-a and mtx were used for graft versus host disease (gvhd) prophylaxis. donor chimerism was evaluated in either bone marrow or peripheral blood on days + , + and + . results: the median transplantation age of the patients was months (range - months). six of them are male. two of the donors were matched siblings and were unrelated two of which were ag ag mismatched. stem cell source was bone marrow in patients, peripheral blood in and cord blood in patients. all patients engrafted. the median time of neutrophil and platelet engratment to was ( - ) days and ( - ) days, respectively. graft rejection was experienced in patients, one of them had received unrelated cord blood. all patients are alive, eight of which are with full donor chimerism (between - %) without any complication (no infection, no gvhd) with a median months (range - months) follow up. probability of disease free and overall survival were found % and %, respectively. conclusions: we concluded that hsct is a useful treatment for scn patients, especially those who are unresponsive to gcsf treatment and at high risk for leukemic transformation. however, a larger number of scn patients and longer follow-up are necessary to identify appropriate conditioning regimens and long-term prognosis. disclosure: nothing to declare background: prolonged thrombocytopenia (pt) or secondary failure of platelet recovery (sfpr) are a lifethreatening complications that occurs in - % and - % respectively of the patients following allogeneic hematopoietic stem cell transplantation (allo-hsct). management strategies, including the use of growth factors, cd +-selected stem cell boost, mesenchymal stem cell (msc) transfusion, and second allo-hsct, are not effective or possible for all patients. eltrombopag, is an oral non-peptide thrombopoietin receptor agonist, that leads to signal transduction and results in promoting the proliferation and differentiation of megakaryocytes. some recently studies show that also can promote haematopoiesis along all three lineages. methods: we described our experience in paediatric patients with poor graft function or secondary failure of platelet recovery after allogeneic stem cell transplantation treated with eltrombopag. results: patients characteristics are detailed in table . all the patients received and allo-hst. the median dose of cd + cells infusion was . x e /kg ( . - . ). neutrophils engraftment occurred in + day ( - d) and platelets in + day ( - d). all the patients had an hypoplastic bone marrow with complete chimerism. the median duration from transplantation to spcf diagnosis was months ( . - m) . one of the patients received a stem cell boost prior to eltrombopag, without response. the time onset from spgf/sfpr diagnosis to initiating eltrombopag was days ( - d). eltrombopag was started at a dose of mg/kg/d, requiring an increase dose in all cases. the median dose was mg/d ( - mg). the overall response rate was % ( / ). two patients achieved complete response (cr), as defined by platelet ≥ × /l. both patients already got neutrophil ≥ . × /l without g-csf. the time from eltrombopag initiation to achieving cr was ( - d) days. the treatment was given for a median of days ( - ). it was discontinued after and days respectively in the two responder patients. both patients maintain stable blood counts after discontinuing the treatment. the non-responders patients had to stop the treatment because of other reasons not related to eltrombopag. patient had to be rescued with a cd + cells boost with a good response. two patients that were in treatment with voriconazole for a fungal infection developed hyperbilirubinemia. there were no grade - toxicities related to eltrombopag. conclusions: in our experience, according to recently published studies, eltrombopag is a safe and efficacy drug in the treatment of secondary failure of platelet recovery post-hsct. it may be used successfully in children. sometimes higher doses may be considered if no response is achieved. further prospective trials are needed to increase the level of evidence and to identify predictors of response. disclosure: nothing to declare very slow clearance of busulfan in a child with infant leukemia background: busulfan is a drug with a high interindividual variability between dose and exposition. therefore, it is recommended to perform therapeutic drug monitoring (tdm) in the context of myeloablative conditioning, especially in children. methods: we report on a -month old boy ( . kg, cm) of caucasian decent born to non-consanguine parents with mll-rearranged prob-lymphoblastic leukemia. diagnosis was established one month after birth from peripheral blood and csf tap showed cns involvement. primary chemotherapy was commenced according to the interfant- protocol. however, mrd remained positive two months under treatment, leading to an indication for allogeneic stem cell transplantation. in the interfant- protocol, we opted for a conditioning regimen comprised of fludarabine ( . mg/kg for days), busulfan and thiotepa ( x mg/kg). in our institution, busulfan is applied once daily with a target auc of - h*mg/l in this very high risk situation. according to body weight, busulfan was given with . mg/ kg as a three-hour infusion on the first day. busulfan concentrations in plasma were measured with gas chromatography-mass spectrometry (gc-ms) and auc was calculated using bayesian curve fitting. results: exact busulfan quantification was not possible after the first dose due to technical reasons. as the levels were estimated to be very high, we decided to reduce the second dose of busulfan by %. this resulted in a very high auc of h*mg/l for the second dose, so that busulfan was discontinued after two days, because it was calculated that the patient already received busulfan with a cumulative auc of h*mg/ml. trough levels after the first and second dose were and μg/l, respectively. the patient showed a very slow clearance of . l/h/sqm, while the volume of distribution was in the usual range ( . l/kg). bilirubin and liver transaminases were in the normal range at the time of conditioning, while albumin and quick were decreased on day + after transplantation the patient developed clinical und biochemical signs of venoocclusive disease (vod). vod symptoms completely resolved under therapy with defibrotide. leukocyte engraftment was established on day + . unfortunately, the patients suffered from an early relapse of the leukemia from day + . attempts to induce a second remission with blinatumomab failed. the patient is currently under palliative chemotherapy. conclusions: busulfan tdm is very important especially in infants receiving myeloablative doses of busulfan to prevent under-or over-exposure. there is evidence that high busulfan trough levels contribute to the development of vod, but anti-leukemic activity of busulfan and cns permeability make it a valuable drug for very high risk patients in childhood leukemia. larger patient cohorts are needed to assess the exposure dependent risks of toxicity versus relapse in infants and toddlers. disclosure: nothing to declare blood (ucb) obtained at delivery from three children who received a diagnosis of cerebral palsy. methods: immunophenotyping of the ucb leukocyte fraction was performed using multicolor flow cytometry. the procedure was performed according to the protocol by shatorje and colleagues ( ) . briefly, the ucb samples were labeled with specific antibodies and incubated in the dark for minutes. afterwards, the samples were treated with ml of bd facs lysing solution for minutes to preserve the leukocyte fraction only. the cells were washed using pbs (roche) and then centrifuged twice ( rpm, °c, minutes). the results were analyzed using the facsdiva software (becton dickinson). results: we found an increased white blood cell (wbc) count, lymphocyte count, and cd :cd ratio in all ucb samples. one patient had a low nk cell count and percentage, and another had a low b-cell count and percentage. one sample displayed high t (cd +) and th cell (cd +) counts, but with percentages within the limits of the reference values. conclusions: we detected elevated wbc and lymphocyte counts in all ucb samples, despite a lack of intrauterine infection symptoms. many authors have described the pathogenesis of hypoxic-ischemic encephalopathy. briefly, after an acute hypoxia-ischemia insult, activated resting microglia show macrophage-like activity. this leads to a break-down of the blood-brain barrier, infiltration by peripheral leukocytes, and brain exposure, which further exacerbates inflammation. the role of systemic inflammation is being evaluated in the animal model. it is known that systemic inflammation plays a role in traumatic brain injury (tbi) and is an independent risk factor for poor outcome in isolated tbi patients. on the other hand, m -phenotype microglia inhibit inflammation and protect neurons from secondary damage and death. however, anti-inflammatory mechanisms in neonates are immature and expose them to extremely intensive inflammation. therefore, anti-inflammatory agents, including stem cells, may be beneficial in these patients. disclosure: three of four authors are employees of the polish stem cell bank, warsaw, poland reference: background: under the hypothesis that early natural killer cell infusion (nki) following haploidentical stem cell transplantation (haplo-sct) will reduce relapse in the early post-transplant period, we conducted a pilot study to evaluate the safety and feasibility of nki following haplo-sct in children with recurrent neuroblastoma who failed previous tandem high-dose chemotherapy and autologous sct. methods: we used the high-dose i-metaiodo benzylguanidine and cyclophosphamide/fludarabine/antithymocyte globulin regimen for conditioning and infused × /kg of ex-vivo expanded nk cells derived from a haploidentical parent donor on days , , and posttransplant. results: seven children received a total of nkis, and nki-related acute toxicities were fever (n = ) followed by chills (n = ) and hypertension (n = ); all toxicities were tolerable. grade ≥ii acute gvhd and chronic gvhd developed in two and five patients, respectively. higher amount of nk cell population were detected in peripheral blood until days post-transplant compared with reference cohort. cytomegalovirus and bk virus reactivation occurred in all patients and epstein-barr virus in six patients. six patients died of relapse/progression (n = ) or treatment-related mortality (n = ), and one patient remained alive. conclusions: nki following haplo-sct was relatively safe and feasible in patients with recurrent neuroblastoma. further studies to enhance the graft-versus-tumor effect without increasing gvhd are needed. disclosure: nothing to declare regenerative medicine p repeated administration of g-csf using stem cell mobilization protocol could induce improvement of cognitive functions of children with cerebral palsy: phase ii randomized placebo-controlled study background: we performed phase ii randomized placebocontrolled clinical study to reveal the safety and feasibility of repeated granulocyte colony-stimulating factor (g-csf) administration for improvement of cognitive functions of children with cerebral palsy. methods: forty-four children with non-severe type of cerebral palsy were enrolled, and their age were - years old. g-csf ( μg/kg) was administered for days subcutaneously every months during months. we compared their cognitive functions with the magnetic resonance imaging (mri) findings and the following tools between before and months after treatment; zoo location and picture memory as working memory index (wmi) in wechsler preschool and primary scale of intelligence (wpssi), receptive and expressive vocabulary test (revt), and visual motor integration (vmi)/visual perception (vp) test. mobilized stem cell count and cytokine levels were measured before (d+ ) and after (d+ ) g-csf administration for days every months. results: no significant findings in demography was noticed between g-csf (g-) and placebo (p-) groups. no serious adverse events were observed during the whole study period. the non-severe adverse events such as urticaria (n= ), itching sense (n= ), bone pain (n= ), headache (n= ), fever (n= ), and stomatitis (n= ) were tolerable. the parents felt the clinical improvements of cognition in cases of g-group and cases of p-group (p= . ), of language in cases of g-group and cases of p-group (p= . ). in zoo location test, we can not find out the significant score (expressed as age equivalent) differences between g-and p-groups. however, in picture memory test, there were significant improvement of age equivalent of months ( . ± . → . ± . ) during months of study period in g-group compared to months in p-group (p= . ). in revt, there were significant improvement of months of age equivalent in expressive tests of g-group ( . ± . → . ± . , p= . ) compared to months in p-group. no significant findings were noted in receptive test. vmi test showed the increasing tendency of months of age equivalent in g-group ( . ± . → . ± . , p= . ) compared to p-group. the increment of cd + cell counts in peripheral blood were significant in ggroup compared to p-group. the changed levels of interleukin (il)- , il- , vascular endothelial growth factor (vegf) as well as g-csf were noted in g-group. we also observed the correlation of cognitive function tests and white matter connectoms of several networks using functionally-defined white matter atlases. conclusions: the repeated administration of g-csf using stem cell mobilization protocol is safe and feasible to improve the language and cognitive functions in children with cerebral palsy. further studies for cellular and paracrine effect of g-csf and/or mobilized peripheral blood stem cells would be needed. background: while high-dose chemotherapy (hdct) with autologous hematopoietic stem cell transplantation (auto-hsct) is an integral part of multimodal therapy for highrisk neuroblastoma (hr nb), there are still subgroups, in which the results are extremely poor. for these patients allografting (allo-hsct) may offer some hope. methods: we summarize the experience of consecutive hr nb patients receiving therapy in our pediatric transplant department in - . the median age was years ( months to years). a total of auto-hscts and allo-hscts were performed. all auto-hsct recipients were characterized by one or several high-risk features: age of more than months at disease (onset n= ), primary disseminated disease (n= ), unfavorable biologic variant (n= ), poor st -line therapy response (n= ) or systemic relapse (n= ). most patients (n= ) received bu-mel hdct (in younger patients oral busulfan was replaced by busilvex), in primary resistant cases a d/ d regimen was used. a total of patients with st (n= ) or nd (n= ) chemosensitive relapse, resistant relapse (n= ) or poor mobilizers with locally advanced resistant tumor (n= ) received allo-hsct from haploidentical donor with fludarabine-based ric. in cases the transplant was modified via immunomagnetic positive or negative selection, patients received post-transplant cyclophosphamide (post-cy)-based gvhd prophylaxis. gvhd prophylaxis also consisted of calceneurin inhibitors and sirolimus. thirteen of allo-hsct recipients received posttransplant immunoadoptive (n= ) or targeted (n= ) therapy. results: the -year os and efs in auto-hsct recipients was % and %, accordingly. all but one patient engrafted with a median time of ( - ) days. bu-mel regimen was characterized by acceptable toxicity with most common toxicities being oral mucositis and infectious complications. the vod/sos incidence was only %. four patients dies due to infection (n= ), cns hemorrhage (n= ), and secondary leukemia (n= ). according to multivariate analysis the most important prognostic factors were response to st line therapy and post auto-hsct mibg scan results. the prognosis in initially resistant patients with good response to nd or rd -line therapy was still very poor (all patients relapsed with the median efs of months). all patients receiving a second auto-hsct after relapse died due to disease progression. with a median follow up of ( - ) months allo-hsct recipients are alive, of them with no signs of disease progression. all long-term responders received post-transplant therapy. one patient died due to transplant complications, other deaths were caused by disease progression. there was no obvious difference between outcomes in post-cy based and transplant modification-based transplantations. agvhd more often developed in modified transplant recipients ( patients vs in post-cy group, of these cases gr iii-iv), patients in post-cy group had grade iii-iv hemorrhagic cystitis. the median time to engraftment was longer for ptcm group compared to transplant modification group (d + vs. d+ , accordingly). conclusions: while single hsct with auto-hsct is a golden standard in hr nb patients, the relapse rate is still high and the prognosis in relapsed/refractory patients is dismal. the allografting has some limited effectiveness in these cases and post-transplant therapy has a potential for further improvement. disclosure: nothing to declare p abstract already published. veno-occlusive liver disease (vod) is frequent but well treatable with early defibrotide administration in children with neuroblastoma receiving high-dose busulfan and melphalan background: using high-dose intravenous busulfan and melphalan (bumel) prior to autologous stem cell transplantation (sct) in children with high-risk neuroblastoma, seems to decrease toxicity of the myeloablative regimen, except for vod. in this multicenter retrospective study we aimed to assess the outcome of bumel-associated vod with early defibrotide treatment intervention. methods: we retrospectively analyzed children with high-risk neuroblastoma who underwent autologous sct with i.v. bumel regimen in slovakia and prague, czech republic in the period / - / . busulfan was administered in q hour schedule, with therapeutic drug level monitoring in % of patients. all vod patients except one were treated with defibrotide starting at a standard dose of mg/kg/day, given in doses per day. patient was treated with supportive therapy only. ursodeoxycholic acid was used as prophylaxis in all patients. vod was established using the modified seattle clinical criteria (corbacioglu, lancet ). results: the incidence of vod was % ( / ) in patients treated with intravenous busulfan and melphalan. there was no significant difference in busulfan total dose/kg between patients with ( . mg/kg (sd= , )) and without ( . mg/kg (sd= , )) vod manifestation. vod developed at a median of days after sct (range - days). anicteric forms of vod were documented, although % patients with vod ( / ) presented with increased bilirubin. % patients with vod ( / ) developed ascites but only patients ( %) required ascites drainage. no vod patient received renal replacement therapy and only one needed mechanical ventilation. importantly, we successfully treated vod in all patients. relapse or progression of neuroblastoma was the cause of death in vod patients ( %) who died. conclusions: despite targeting busulfan levels to decrease toxicity of the regimen, vod is common (we observed vod incidence exactly in the range of the siopen hr nbl- multicenter study (ladenstein, ) ). early recognition and early treatment with defibrotide seems to be effective in vod associated with bumel regimen -none of our patients died due to vod. disclosure: nothing to declare results of high-dose chemotherapy (hdct) with autologous hematopoietic stem cell transplantation (auto-hsct) in the treatment of ewing sarcoma family tumors (esft) background: while current dose-intense treatment protocols allow achieving - % survival in localized esft patients, the long-term survival in high-risk cases is still unsatisfactory. although there is a considerable body of data on high-dose consolidation the real effectiveness and optimal indications for this option are still not completely clarified. therefore, a large prospective cohort analysis may still yield useful data. methods: the whole cohort includes consecutive highrisk esft patients with median age of (range - ) years receiving hdct with auto-hsct in to after obtaining st (n= ) or nd (n= ) cr, pr (n= ), or stable disease (n= ). the high-risk features included lung (n= ), bone (n= ) or bone marrow (n= ) involvement, inadequate local control in primary axial tumors (n= ), large lesions volume or poor treatment response (n= ), and chemosensitive relapse (n= ). most patients had several risk factors. disseminated disease patients were also evaluated according to prognostic score by r.ladenstein et al. highdose busulfan-melphalan followed by autologous stem-cell transplantation (hdt/sct) was used. results: the median observation time was (range - ) months. the -year overall (os) and event-free (efs) survival were % and %, accordingly. most important outcome predictors were inadequate local control in chemoresistant cases, a primary tumor volume more than ml, more than one bone metastatic site, bone marrow involvement and additional lung metastases. according to prognostic risk score in disseminated disease esft patients identified three groups with -year os rates of % for score ≤ ( patients), % for score to ( patients), and % for score ≥ ( patients), (p< . ). conclusions: while bu-mel hdct with auto-hsct may still be a feasible option with acceptable toxicity for chemosensitive patients with inadequate local control and some primarily disseminated cases it is ineffective in primary resistant or very high-risk metastatic patients. disclosure: nothing to declare efficacy of tandem high-dose chemotherapy with autologous hematopoietic stem cell transplantation in the treatment of infant embryonal brain tumors day + (range, - ), after the second auto-hsct was day + (range, - ). two-year overall survival (os) was % and disease free survival (dfs) was %. dfs was significantly better among patients with mb ( %) and pnet ( %) in compared to children with etmr ( %), pb ( %) and atrt ( %), (p= , ). dfs in patients who received tandem auto-hsct was % in compare to infants who received only one auto-hsct ( %), (p= , ). complications grade (according to common toxicity criteria ) were observed in % of cases. conclusions: employment of tandem hdct with auto-hsct in primary infant embryonal brain tumors may be a feasible option for patients after induction treatment. both conditioning regimens had acceptable toxicity. all patients who had tandem hdct with auto-hsct had better os ( %) in compare with single hdct ( %). patients with mb and pnet had better prognosis with os % and %, respectively, in compare with other embryonal tumors. disclosure: nothing to declare background: metastatic extra ocular retinoblastoma is carrying a poor prognosis. therapeutic intensification with high-dose, marrow-ablative chemotherapy and autologous hsct has been explored, but its role is not yet clear. this study aimed to evaluate the survival outcome of patients with extraocular retinoblastoma post autologous stem cell transplant, treated at single center methods: this is a retrospective study included all patients with metastatic extraocular retinoblastoma (stages a and b) that underwent autologous hsct at the children cancer hospital egypt (cche) from november to july , the treatment protocol was adopted from cog protocol (aret ) as all patients received cycles induction chemotherapy followed by consolidation myloablative conditioning, cem (vp . mg/m x , melphalan: mg/m x , carboplatin: mg/m x ) and stem cell rescue. patients data including initial disease characteristics, transplant data, and survival outcomes were collected and analyzed results: a total of cases were included with median age of . years, and male to female ratio . . nine patients ( %) were initially presented by extra ocular disease, while patients were presented by intra ocular disease and progressed to metastatic disease. according to cog staging of extra ocular disease, patients had stage a, and were stage b ( of them had trilateral disease). after induction therapy, ( %) showed complete response and ( %) had ≥ partial response. with average cd count of x / kg, the median time to anc and platelet engraftment were days and days respectively, and there was no transplant related mortality. post-transplant radiotherapy was given only to patients. with median duration of follow up of months, the overall and event free survival rates of whole patients were . % and . % respectively conclusions: high dose chemotherapy and stem cell transplantation is a promising potential curative option for patients with metastatic extra ocular only two primary gf ( . %) occurred, both without dsa. patients developed a primary pgf ( %). -years os, years pfs and -year nrm were analyzed according to the presence of dsa in comparison with negative population. no statistically difference was found. no impact of the presence of dsa on the risk of developing gf and pgf was revealed. major outcomes of transplant was analyzed separately in patients with pgf and good graft function (ggf). -years os, -years pfs and year-nrm in ggf and primary pgf populations were % vs % (p< . ); % vs % (p< . ), % vs % (p= . ), respectively. conclusions: the presence of low level of dsa in the absence of desensitization doesn't correlate with the risk of developing gf and pgf. patients who experienced a pgf had worse outcomes in comparison with patients with ggf. disclosure: nothing to declare. the impact of hla-dpb mismatch in t-cell replete unrelated donor allogeneic stem cell transplantation background: high resolution matching of donor-recipient hla improves outcome in allogeneic stem cell transplants. matching for hla-a, -b, -c, -drb and -dq is mandatory in our transplant centre, to identify / or / matched unrelated donors. high resolution matching for dpb has been added over the last - years. however, the role of dpb matching is not yet clearly defined. methods: in this study, we retrospectively analyzed the impact of hla-dpb matching on the outcome of t-cell replete allogeneic hematopoietic stem cell transplants with cya/mtx-and without atg as gvhd prophylaxis in patients with hematological malignancies at oslo university hospital between and . patients with an unrelated donor fully matched ( / ) at hla-a, -b, -c, -drb and -dqb loci were included. further, patientrecipient pairs were also fully matched on dpb ( / ); had permissive and had non-permissive mimatches of one or two dpb alleles. the three groups were comparable with respect to diagnosis, gender, age, cytomegalovirus serostatus and conditioning regimen. results: cumulative incidence of relapse at years were significantly higher in the dpb matched pairs compared with the permissive and non-permissive mimatched ones, at % vs % and % (p< . ) respectively. relpase free survival and overall survival were superior in the nonpermissive and permissive dbp mismatched groups vs the fully matched, at % and % vs % (p= . ) and % and % vs % (p= . ) respectively. no difference in frequency of acute gvhd grade ii-iv between the three groups were found; dp match %, permissive mismatch % and non-permissive mismatched % (p= . ). neither was there a difference seen in gvhd grade iii-iv; % vs % vs %, respectively. finally, there were similar outcomes between the three groups regarding chronic gvhd and trm. in corrected multivariate analysis, only dp matching had significant influence on mortality and survival. conclusions: our results show a favorable relapse free and overall survival following a mud allotransplant with a dpb permissive or non-permissive mismatched donor compared to a fully dpb matched. this is likely due to an increased gvl-effect in dpb mismatched groups without the counterbalance of increased acute gvhd and trm. disclosure: nothing to declare p a haploidentical may be a better choice than a female genoidentical donor to transplant a patient with high risk acute myelogenous leukemia in first remission norbert gorin , myriam labopin , didier blaise , goda choi , gerard socie , jean henri bourhis , fabio ciceri , emmanuelle polge , arnon nagler , mohamad mohty china, the first affiliated hospital of soochow university, hematology, suzhou, china background: despite the incidence of leukemia increases with age, currently the geriatric population is poorly represented in the standards of care concerning that older adults undergoing hematopoietic cell transplant (hct) may experience higher transplant-related mortality (trm). previous studies have demonstrated that donor age is vital for older patients by affecting trm and survival. accordingly a relevant question is whether outcomes can be improved with a younger hla-haploidentical offspring donor rather than an older hla-matched sibling (msd). in our previous multi-center report under atg+g-csf based protocol for haplo hct, offspring donor is correlated with lower trm and higher leukemia free survival (lfs) as compared with older msd in subgroup analysis for recipients > years although it did not reach statistical significance. on the contrary, in a recent report from ebmt and cibmtr under ptcy modality for haplo hct, among patients aged to years, despite lower chronic graft-versus-host-disease (gvhd), graft failure, trm, and overall mortality were higher after transplant from offspring compared with an msd although there were differences in transplant platforms between the groups. methods: we extended our multi-center dataset and a matched pair analysis was performed. outcomes of acute leukemia patients (>= years) transplanted in cr / cr who received hct from offspring (n= ) or msd (n= ) between jan, and june, present in the multi-center database were analyzed. because the patient population was small, a : ratio matched pair analysis was implemented with the following matching factors: underlying disease (acute myeloid leukemia, acute lymphoblastic leukemia), disease status (cr /cr ), age and sex of patients, year of transplant, blood group incompatibilities, and sex of donor. results: we were able to match offspring with msd patients. the two matched groups were comparable in baseline characteristics except for donor age due to the family relationship. all patients achieved myeloid recovery with a median time of d and d for msd cohort and offspring group (p= . ). the d platelet recovery rate was % in both groups. the cumulative incidence of grade ii-iv acute gvhd in msd cohort was significantly lower than in offspring group ( % vs %, p= . ) while the incidence of chronic gvhd in msd cohort was significantly higher than in offspring group ( % vs %, p= . ). the -year trm ( % vs %, p= . ) were significantly lower in offspring-hct compared with in msd-hct and relapse incidence was comparable ( % vs %, p= . ). as a result, the -year overall survival ( % vs %, p= . ) and lfs ( % vs %, p= . ) ( figure ) were significantly higher in offspring-hct compared with in msd-hct. in a multivariate analysis, msd-hct remained a significant factor for decreased overall survival (hr . ( . - . ), p= . ) by increased trm ), p= . ) in comparison with offspring-hct. conclusions: these data favor a young offspring over an older msd in patients > years. the current analyses confirm non-hla donor characteristics, rather than hla disparity, predominantly influence survival in older acute leukemia patients. validation of these findings requires a prospective trial wherein the transplant platforms can be closely matched. [[p image] . figure . lfs in offspring-hct compared with in msd-hct ( % vs %, p= . )] disclosure: nothing to declare. impact of sibling donor-recipient sex combinations on rejection after hla-matched bone marrow transplantation for severe thalassemia cure children foundation, florence, italy, sankalp india foundation, bangalore, india, people tree hospitals, bangalore, india, south east asia institute for thalassemia, jaipur, india, pakistan institute of medical sciences, islamabad, pakistan, central asiri hospital, colombo, sri lanka, nawaloka hospital, colombo, sri lanka, kokilaben dhirubhani ambani hospital, mumbai, india background: severe thalassemia (st), i.e. a thalassemia syndrome with inability to keep spontaneous hemoglobin > g/dl, is a common indication for bone marrow transplantation (bmt) in children in the middle east and south east asia. sex mismatch has been associated with increased risk of solid organ rejection but is not generally considered an important transplant-associated risk factor in the context of fully matched sibling bmt for st. methods: a total of consecutive sibling bone marrow transplants carried out between january and april after conditioning with busulfan ( mg/kg oral, not adjusted to serum levels) and cyclophosphamide ( mg/kg) ( patients) in addition to either thiotepa ( mg/kg) ( patients), or anti-thymocyte globulin (genzyme mg/ kg or fresenius mg/kg on days - to - ) ( patients) and fludarabine mg/m ( patients) were analysed. all cases received cyclosporine and methotrexate or mycophenolate mofetil as gvhd/rejection prophylaxis. in the thiotepa group methylprednisolone at . mg/kg/day was also used during the first days after bmt (lucarelli protocol i). bone marrow was the source of hematopoietic stem cells in all cases, in the atg group it was g-csfprimed ( μg/kg/dose twice daily for to days prior to harvest). all patients were considered low risk based on liver size < cm from costal margin and age less than years (median . years, range . to . ), all sibling pairs where hla-compatible. results: [[p image] . sibling donor-recipient sex combinations.] the lowest rejection rate ( %) was observed in the sister to sister (s s) group of cases, followed by brother to brother (b b) group of cases with %. in the sister to brother (s b) group of cases, rejection rate was %, and % in the brother to sister (b s) group of cases. on univariate analysis the only significant difference at the p . level by log rank test was b s vs. s s groups (rejection proportions of % and % respectively). interestingly, all patients with rejection and persistent pancytopenia were female recipients of male grafts. conclusions: even though several preparative regimens were employed over an -year period, our data suggests that sex mismatch among compatible siblings should be considered as a relevant variable related to bmt decisionmaking. we also recommend to consider autologous back up hematopoietic stem cell collection and storage in sibling sex mismatched transplants, particularly in brother to sister bmts. same-sex fully matched related bmt for severe thalassemia might be the best scenario in which reducedintensity preparation strategies aiming at maximizing fertility preservation might be explored. disclosure: nothing to declare. outcomes of t-cell replete hematopoietic cell transplantation from mismatched related or unrelated donors using high dose post-transplant cyclophosphamide based gvhd prophylaxis background: high dose post-transplant cyclophosphamide (ptcy) based gvhd prophylaxis overcomes immunological barriers in hla mismatched donor transplantation. ptcy has been adopted in many centers as de facto standard for hct from haploidentical donors (haplo hct). it's use in mismatched unrelated donor transplant (mmud hct) is less well established. methods: we analyzed retrospectively outcomes of contemporary cohorts of patients who underwent haplo hct or mmud hct using ptcy + cyclosporine (csa) and mycophenolate mofetil (mmf) at our center. we compared these outcomes with outcomes of cohorts of patients who underwent hct from matched unrelated donors (mud) using atg based gvhd prophylaxis or matched sibling donor (msd) with csa and mmf. patients and donors were considered matched if they background: hla-alloantibodies are a major risk factor for engraftment failure in allogeneic hematopoietic stem cell transplantation (hsct). particularly, complement fixing, donor specific antibodies were shown to be associated with early engraftment failure. prospective antibody-screening, although not currently required for donor search, could permit early identification of high risk patients for positive crossmatch. aim of this study is to set the basis for future applicability of antibody-screening-based definition of acceptable mismatches in donor selection, by creating a large prospective antibody-screening database of patients due to receive an hla-mismatched allogeneic hsct. methods: patients (n= ) diagnosed with mds/mps, nhl, mm, cll, cml, anaemia (aplastic anemia, hemoglobinopathies, pnh) and hl were prospectively screened for hla-antibodies whenever initial donor search indicated that no completely matched donor would be available. screening was performed with an elisa class i +ii screening assay. all positive screening cases were tested for antigen-specific antibody identification with luminex sab, and acceptable mismatches were defined. the results were subsequently considered in donor search and selection. we now report the frequencies of alloimmunization observed in these patients. results: the highest rate of alloimmunization was observed in patients from the anaemia disease group (overall . %) followed by those from the mds/mpn group (overall . %). the lowest immunization rates were observed in cll (overall . %) and hl ( . %) patients. alloimmunization rates for hla-class i antigens (p< . ) were significantly higher compared to hla-class ii antigens. overall hla-class i immunization rates ranged from . % to . %. hla-class ii immunization rates ranged from . % to . % (table ) . conclusions: our findings suggest that patients with high transfusion burden like anaemia and mds/mpn patients have the highest risk of hla-alloimmunization with . % and . % anti-hla prevalence rates, respectively. analysis of follow-up data, will enable us to confirm whether prospective definition and consideration of acceptable mismatches in donor selection may lead to similar engraftment failure rates between immunized and non-immunized patients undergoing hlamismatched hsct. background: mothers displaying a persistent fetal microchimerism (fm) proved to be the most suitable donor in t cell-depleted haploidentical stem cell transplantation (hhsct) in children. we presumed that fetal cells leave an imprint in the mothers' immune system which positively affects recognition and elimination of malignant cells in the child by maternal effector cells. distinct killer cell immunoglobulin-like receptors (kir)/hla constellations are not only associated with reduced relapse rates after hsct in children, but also supposedly influence the establishment of an fm. methods: after approval by the local irb and obtaining informed consent, we initiated a protocol to elucidate the factors that influence the establishment, persistence and effect of fm. we established a digital droplet pcr (ddpcr) protocol to determine the fetal microchimerism. for differentiation between maternal and fetal cells, biallelic short insertion/deletion polymorphisms were used. kir and hla-c genotyping was performed by ssp-pcr. parental nk cell alloreactivity against the respective leukemic blasts and kir phenotyping were analyzed by flow cytometry. results: we analyzed parents, whose children were treated for hematological diseases at the university medical center hamburg-eppendorf. a fetal microchimerism was detected in % of the mothers. the amount of fetal cells varies between individuals ( x - - x - ). we observed a positive correlation between a persisting fm and hla-c homo-and heterozygous mothers along with a maternal cen a/b and cen b/b genotype. additionally, fm positive mothers showed a higher surface expression of the hla-c respective receptors kir dl /s . the percentage of alloreactive maternal nk cells against fetal cells was higher compared to paternal nk cells; while alloreactivity of fm positive maternal nk cells was similar to nk cells from fm negative mothers. conclusions: persistence of fm was more frequent in mothers carrying at least one hla-c allele and a centromeric b/x motif. phenotypically, fm positive mothers had higher expression of kir dl /s indicating a role of these receptors on the persistence of an fm. in vitro, maternal nk cells showed a higher alloreactivity compared to paternal nk cells. there was no difference in alloreactivity whether the mothers were fm positive or negative, suggesting other mechanisms are responsible for the superior outcome in transplantation from fm positive mothers. disclosure: nothing to declare background: although there have been significant improvements with conventional therapies in beta thalassemia major, hematopoietic stem cell transplantation is only curative therapy. related donors are preferred to diminish transplant risks. in lack of identical related donor, identical unrelated donors are second best choice. in this study, thalassemia major patients transplanted from unrelated donors (mud) were compared with thalassemic patients transplanted from relative donor (mrd) retrospectively. methods: patients who were transplanted between june and december in bahçelievler medical park hospital pediatric bone marrow transplantation unit were evaluated retrospectively. all patients were classified according to pesaro risk classification. thirty four of received busulfan, fludarabine, cyclophosphamide, thioteopa for conditioning, patients received myeloablative preparation regimen with treosulfan, fludarabine, thiotepa, cyclophosphamide. all patients were given atg, cyclosporine and methoteraxate for gvhd prophylaxis. the patients were compared in terms of acute complications in first days, engraftment, chimerism, acute and chronic gvhd after transplantation. results were evaluated with ibm spss statistics (ibm spss) program. results: a total of patients, ( . %) male and ( . %) female, aged between and years (median years) were evaluated. patients were evaluated in two groups as "mud" (n = ) and "mrd" (n = ) groups. there was no difference between groups about given stem cells (mud , ± , x /kg and mrd , ± , x / kg). neither significant difference between different pesaro risk groups in terms of developing acute and chronic gvhd and nor decreased chimerism were detected. neutrophil engraftment time ( , days) in mrd group was significantly longer than mud group ( , days) (p = . ) but no difference between platelet engraftments were observed. gvhd ratio was . % in mud donor group and . % in mrd group and no statistically significant difference was found(p> . ). the incidence of engraftment loss in mud group was . % and . % in the mrd group, and there was no statistically significant difference (p> . ). the rate of decreased chimerism was found to be significantly higher in the mrd group ( %) than in the mud group ( . %) (p: . ; p< . ). the survival rate was . % in the mud group and . % in the mrd group. the disease-free survival rate was . % in the mud group and % in the mrd group. the disease-free survival of mud group was significantly higher than mrd group (p: . ). conclusions: in our study, transplant related complications and success of transplantation with both mud and mrds were found to be similar. it is promising for mud transplantations to found lower decreased chimerism and similar os and dfss. based on these results, it was concluded that hsct from non-family donors, especially for patients incompatible with chelation therapy and had organ damage, transplantation from unrelated identical donors can be a good choice. although the results of our study seem promising, larger patient groups and prospective clinical trials are required. disclosure: nothing to declare background: use of g-csf stimulation of bone marrow (bm) donors is beneficial in many aspects; it can enhance tnc yield, but also have an immunomodulatory effect on donor t cell function, particularly invariant natural killer t (inkt) cells expansion as well as apcs. we analyzed outcomes of consecutive patients receiving bone marrow from hla-haploidentical donors that were stimulated with g-csf prior to harvest. methods: in the time period between / and / , patients received bone marrow from donors stimulated with ug/kg bw of g-csf on days - , - and day of bm collection. four patients ( %) received myeloablative (bucy) conditioning, one ( %) received tec ric conditioning while ( %) received nma ("baltimore") conditioning. all patients received posttransplantation cyclophosphamide (ptcy) on days + and + , tacrolimus and mmf were started on day + . for patients donors were fathers, mothers, siblings and children. results: median age was years ( - ), there were female and male patients. twelve patients had aml, hodgkin lymphoma, all, mds, nhl and cml. median number of infused tnc in graft was . x /kg bw ( . - . ) and cd + cells . x /kg bw ( - . ) . after median follow up of days (range - ), overall survival was %, with median survival of months. engraftment was established in ( %) patients, ( %) had primary rejection and patients ( %) died in sepsis prior to engraftment. of patients that engrafted, further ( %) patients had secondary rejection, two of them were transplanted again from a haploidentical donor, both using pbsc as a source of graft. median time to neutrophil recovery (anc> ) was days ( - ), while median time to platelet recovery (plt> x /l) was days ( - ) in evaluable patients. cumulative incidence of agvhd ii-iv was . % ( % ci, - );of note is that of patients that developed agvhd only one had grade iii, while remaining patients had grade ii. cumulative incidence of cgvhd requiring treatment was . % ( % ci, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . cumulative incidence of relapse was . % ( % ci, - ) and trm was . % ( % ci, - ). conclusions: the use of g-csf mobilized bm graft in the hla-haploidentical setting with ptcy has proven to be useful to us, not only in terms of tnc yield which was more than satisfactory and contributed to adequate hematological recovery, but also in the excellent control of both acute and chronic gvhd, with most patients developing agvhd of grade ii and only one grade iii (actually developed only after dli given for decreasing chimerism). comparative studies are of course warranted to prove benefit, but this data contributes to the growing body of evidence that indeed donor stem cell stimulation with g-csf has potentially powerful immunomodulatory effect. disclosure: nothing to disclose p other-relative donors as a reliable bank for allogeneic hsct in countries with culturally accepted cousin-cousin marriages: a two-year report from a pediatric center in iran background: although the optimal donors for patients undergoing allogeneic hematopoietic stem cell transplantation (allo-hsct) are fully-matched siblings, the cousincousin (consanguineous) marriages in some countries have extended the chance to find a matched donor for the hsctrecipient. in this study, an outcome analysis of transplanted patients receiving stem cells from their relatives other than siblings (other-relatives or non-sibling donors) is provided. methods: in this retrospective cross-sectional study, a two-year report of patients who received allo-hsct from their other-relative donors during september to september at the department of stem cell transplantation of children's medical center in tehran, iran is presented. the patients were followed up until st december . results: during this time period, patients underwent hsct (both autologous and allogeneic) at this center, of which cases received allo-hsct. out of allo-hsct recipients, the donors of stem cells for cases ( . %) were their other-relatives. the median (range) age at hsct was ( - ) years and the majority of patients were boys ( / , . %). according to disease class, the patients were most commonly involved with non-malignant hematologic diseases ( / patients, . %) (figure) . the source of hscs for most patients ( cases, . %) was peripheral blood and for only patients the source was bone marrow. the donors for patients were fully matched and only one patient received the hscs from a one-locus mismatched donor. hsct was successful in patients with most of them achieving full chimerism ( patients, . %) followed by those developing mixed chimerism ( patients, . %) and only one patient ( %) experienced graft failure. post-hsct complications included cmv infection in patients ( . %), other infections in ( . %), hemorrhagic cystitis in ( . %) and pres in ( . %). acute gvhd occurred in patients ( . %) and chronic gvhd in ( . %). death occurred in cases and of them were transplant-related, while was due to disease relapse and due to graft failure. the median of overall survival was ( - ) days. conclusions: the likelihood of receiving hscs from an hla-matched other-relative donor in one-thirds of children undergoing allo-hsct, with comparable outcomes to sibling and unrelated donors (as evidenced in this study compared with other studies), introduces family bank as a reliable source for pediatric allo-hsct in countries with culturally accepted cousin-cousin marriages. hence, for transplant physicians, parental consanguinity would be an indication of an extended search for a potential matched donor among the patient's family. [[p image] . distribution of patients according to disease and disease class] disclosure: nothing to declare. abstract already published. update on the hla frequency distribution of the portuguese bone marrow donor registry eduardo espada , dário ligeiro , hélder trindade , joão forjaz de lacerda frequency distribution varied throughout the country, allowing for analyses of molecular variance and generation of relatively geographically accurate graphical representations of genetic distances between regions and districts. conclusions: with the most recent hla analysis of the portuguese bone marrow donor registry we were able to extrapolate high-resolution haplotype frequencies from the most common low-resolution hla-a/-b/-drb haplotypes (corresponding to % of the estimated haplotypes at that level), which will lead to an optimization of its use, hopefully limiting the time between donor search and allogeneic hematopoietic stem cell transplant. disclosure: nothing to declare. abstract already published. abstract already published. unmanipulated haploidentical donor transplantation compared to identical sibling donor had better antileukemia effect for refractory/relapsed acute myeloid leukemia in not remission status background: patients diagnosed with saa with no sibling donors and who are refractory to immunosupression are candidates to hematopoietic stem cell transplant using alternative donors. haploidentical donor transplants has been reported using cyclophosphamide (cy) post stem cell infusion as immunephrophylaxis. the present study has the objective of evaluating overall survival and engraftment rates after haploidentical stem cell transplant for saa in a reference center. methods: saa adult patients (≥ yo) received hsct from haploidentical donors from de january/ to august/ . median age was y ( - ); donor was the father in six, mother in five and a brother in four cases. stem cell source was marrow in cases ( %). conditioning: patients ( %) received cy mg/kg, fludarabine mg/m² e tbi cgy. the remaining received the same drugs but radiotherapy dose varied from - cgy, all them received immunephrophylaxis with post transplant cy mg/kg, cyclosporine and mmf. median of infused cells (tcn) was , x /kg ( , - , ). results: eight patients engrafted ( %). among seven graft failures four received a second haploidentical transplant and one received an unrelated donor transplant as salvage regimen. two patients were successfully rescued after the second haplo and the others died from infectious complications. three years overall survival was %. death causes included: five infections and two lung hemorrhage. median survival was days ( - ). no patient had acute graft-versus-host-disease (gvhd) and one patient had mild c-gvhd. conclusions: haploidentical transplant was feasible as therapy for saa refractory to immunessupression with an overall survival of % in this cohort. graft failure however is still a problem to be addressed in this setting. disclosure: no disclosure stem cell mobilization, collection and engineering p abstract already published. key performance and quality indicators for a successful bone marrow collection marco sampaio , , ana salselas , fátima amado , filipa bordalo , sérgio lopes , catarina pinho , susana roncon and one from ecc (staphylococcus spp.)presented positive microbiological results. conclusions: bm collection is a challenging strategy because it is a one-time procedure and manually operatordependent technique; simultaneously it is more difficult to control the final cellular content of the bm, which is a risk for donor volume depletion. bm collection is feasible even with donor and recipient weight difference. poorer performance may be found when higher tnc are requested. we respond efficaciously when the request is between and * tnc but we fail to accomplish higher tnc values. we must emphasise that icc tnc demanded was generally lower than ecc. deciding the appropriate tnc for each patient remains a dare and an art. disclosure: nothing to declare. impact of adding plerixafor to mobilization protocol in the immune reconstitution of vδt cells after autologous hematopoietic stem cell transplantation efrat luttwak , , yael chava cohen , , odelia amit , , irit avivi , , svetlana trestman , , esti rom , , rinat eshel , , ram ron , tel aviv medical center, tel aviv, israel, sackler faculty of medicine, tel aviv university, tel aviv, israel background: multiple myeloma has remained an incurable disease even in the era of novel therapies. front line treatment typically comprises of induction chemotherapy with - cycles of a bortezomib-based regimen, stem cell mobilization, and harvesting of peripheral blood stem cells (pbsc) by apharesis, followed by high dose melphalan with hct. while brotezomib-based induction regimens have demonstrated no adverse impact on hematopoietic cell harvest number and quality, no study analyzed the impact of timing of the last brotezomib dose prior to collection. in this study we aimed to determine the effect of the timing of the last dose of brotezomib before hematopoietic cell collection and the collection yield. methods: this was a single center historical prospective study, including all sequential newly diagnosed patients with myeloma between and that were given a bortezomib-based induction therapy (≤ cycles) followed by pbsc collection. we excluded patients who either received st line vtd-pace or lenalidomide-containing regimens. peripheral blood cd + cells were measured on the day of collection. patients with cd + levels of > cells/ microliter started collection on the same day, while those with lower levels were given plerixafor. we performed regression analyses to analyze the impact of a variety of precollection factors, including days from last bortezomib therapy on the collection yield. results: we identified patients who fulfilled the inclusion criteria, table. median time from last dose of brotezomib to first leukapheresis was (range, - ) days. a statistically significant correlation was found between the days from last dose of brotezomib and both the first collection day-cd + cells/kg (r= . , p< . ), and the total collected cd + cells/kg(r= . , p= . ), figure. the optimal cutoff point as indicated by the roc curve was . days according to collection success with sensitivity of % and specificity of %, youden´s index . . in multivariate analysis included other factors affecting collection yield (age, gender, status of disease at collection, and prior radiation) -timing of last dose of brotizomib remained significantly associated with the total collected cd + cells/kg (p= . ). increasing age, female gender, and prior radiation were associated with lower collection yield (p= . , . , . , respectively). based on this, we developed a model to predict the total collected cd pos cells = . + . (timing in days of last dose of brotezomib) - . (age) - . (if female) - . (≥pr) - . (if prior radation). conclusions: timing of last dose of brotezomib is an important factor for predicting a successful collection. a washout period of days is associated with a better collection yield. these results should be further validated in a prospective study. age (median, range) ( - ) gender -male (%) ( ) prior radiation treatment (%) ( ) disease status at collection (%) ≥pr - ( disclosure: nothing to declare p mobilization with plerixafor in "poor mobilizer" related and unrelated donors of hpc-a in case of failed mobilization with g-csf background: in the allogeneic hpc transplantation, both from related and unrelated donors, the most commonly used source is peripheral blood after mobilization with g-csf. it is however known that about % of donors are "poor mobilizers"; the rescue strategies are: a third apheretic collection; bone marrow donation. methods: in - in italy a procedure to be adopted in case of failed mobilization of peripheral blood stem cells has been defined and shared between ibmdr, cnt (transplant national center) and cns (blood national center) and the scientific societies simti, sidem and gitmo, using plerixafor, a selective reversible antagonist of the cxcr receptor with its binder (the stromal derived factor sdf- ), in combination with standard g-csf dose. moreover since , in accordance with this protocol, the competent authority (aifa) has extended the registration of plerixafor (law no. / ), also for the mobilization in "poor mobilizer" healthy donors. finally, in the protocol was extended to "poor mobilizer" family donors, making management equivalent in related and unrelated donors. at the time of the donor´s informed consent for the donation of hpc, the hypothesis of the lack of mobilization or inadequate collection was illustrated and the possible actions proposed as "back-up donation" were anticipated. failed mobilization of cse has been defined as the presence of one of the two criteria: a number of cd + circulating on peripheral blood lower than /μl on the th day of stimulation ( d), or the collection of cd + < . x /kg weight of the recipient at first apheresis. in these cases, a single dose of plerixafor is administered subcutaneously by health professionals under medical supervision, . mg/kg of body weight, - hours before the start of apheresis. in case of use plerixafor due to failed mobilization of hpc-a or collection of an inappropriate number of cd +, the notification is made by the collection center to ibmdr (for both family and non-family donors), and to the recipient transplant center : both donor and recipient express their consent; finally once the collection is completed, the collection center informs ibmdr, which in turn notifies cnt/cns/simti/sidem/gitmo. any adverse reactions/events are notified in real time, based on the sop specifications and current regulations. results: since the introduction of the national protocol, donors ( unrelated donors and related donors) were treated, presenting at least one of the two inclusion criteria (cd < /μl at d or cd < x e /kg after first collection)after use of plerixafor in all donors, the required dose of cd was obtained to ensure successful transplantation, with a sufficient increase in the cd + cells. no side effects or adverse reactions related to the administration of plerixafor occurred. conclusions: in cases of failed mobilization in the related and unrelated donor, the use of plerixafor according to the methods described in the shared protocol between ibmdr, cns, cnt, simti, sidem, gitmo, proved to be safe and effective. this protocol emphasizes the great value of the sharing of procedures between the register, institutions and scientific societies, ensuring the supervision of the process and the protection of the donor and recipient. disclosure: nothing to declare background: autologous stem cells transplantation (asct) is an effective treatment option for young patients with multiple myeloma (mm). a minority of patients may still experience untoward toxicity due to delayed engraftment. thus, the current policy in many centers is aimed to increase the target dose of collected cd + cells up to an "optimal" level of x /kg per procedure. therefore, an ideal mobilization, aimed to collect to cd + cells/kg in one apheresis, should achieve a number of circulating cd + cells > /mcl (very good mobilizers). plerixafor may help to maximize the cd + collection but its use is limited by high cost. we carried out a retrospective analysis aimed to predict the quality of mobilization and develop an algorithm to optimize both timing of collection and use of plerixafor. methods: we retrospectively collected data from mobilization procedure performed in our center between and for mm. all received the same mobilization protocol with cyclophosphamide (range - gr/sqm) and g-csf mcg/kg from + . cd + cell count was started when white blood cells (wbc) count exceeded x /l. patients were excluded from this analysis if ) showed a cd + count > /mcl (target achieved at first day count) and/or ) cd + count on second day was missing and/or ) plerixafor was administered on first day according to previous policies. sixty-eight patients were evaluable for the study. univariate and multivariate logistic regression analysis to study ccd + kinetics and assess predictors impact on mobilization was carried out. ratio cd +/wbc in first day count, gender, disease category and time from mobilization chemotherapy were also included results: among the patients included in the analysis, the threshold of cd +/mcl cells on the second day was reached by ( , %) of patients (groupa) whilst the remaining ( , %) failed the target (groupb). median (range) wbc x /l and cd + /mcl counts in group a and b were , ( - , ) and , ( , - , ), , ( ) ( ) ( ) ( ) ( ) ( ) ) and , ( , - , ) respectively, with a statistically significant differences among group (mann-whitney p= , and p= , respectively). only cd + /wbc ratio and cd + /mcl on first day count had an impact on kinetics and optimal mobilization. logistic regression model highlight cd +/mcl (or= , ; % ci: , - , ) on first count as an independent predictor of second day optimal mobilizer, with auc of . % ( , ) in roc analysis. two cd + thresholds were then calculated: < , /mcl (ppv , ; npv , ) that identified poor mobilizer, and ≥ , /mcl (ppv , ; npv , ) that exclude probability to fail on second day. for those with a cd + count between , - , the cd +/wbc ratio (or= , , % ci: , - , ) was a predictor of optimal mobilization (auc , ; , - , ); cut-off value was , (sensibility , ; specificity , ) conclusions: assessment of circulating wbc, cd + and their ratio at wbc recovery in a chemo-based mobilization is a valid tool to manage the collection strategy and the on-demand use of plerixafor. we have developed an algorithm aimed to the use of plerixafor to both rescue poor mobilizers and boost cd + count in intermediate mobilizers. background: successful autologous stem cell transplantation (asct) requires the infusion of a sufficient number of hematopoietic stem cells (hscs). peripheral blood (pb) is the most commonly used source of hscs, therefore, it is important to optimize methods used to mobilize the hscs. the most clinically used chemotherapeutic agents for effective mobilization are cyclophosphamide and etoposide. recent published studies suggest that etoposide has a better mobilization effect than cyclophosphamide even at lower doses, but it is not clear why this difference occurs. in this study, we tried to determine whether there is a difference in the mechanism of mobilization between cyclophosphamide and etoposide. methods: first, in order to confirm the clinical data for efficacy and toxicity of mobilization, we retrospectively analyzed the data of patients who were diagnosed with lymphoma and performed mobilization using cyclophosphamide or etoposide from january to december . second, mesenchymal stem cells (msc) were primarily cultured from the healthy controls, then treated cyclophosphamide or etoposide at a concentration of % inhibition of cell growth, and cytokine analysis was performed to identify cytokines known to be associated with mobilization. third, mobilization mouse model using cyclophosphamide or etoposide was generated, total blood was collected at the time of hscs collection, and cytokine and network analysis (using ingenuity pathway analysis) was performed. results: the mobilization yields for cyclophosphamide or etoposide were analyzed. etoposide miblized a significantly higher median number of cd +cells than cyclophosphamide. the rate of successful or adequate mobilization was also significanctly higher for etoposide in univariate and multivariate analysis (table ). in the analysis of toxicity during mobilization, the incidence of neutropenic fever was higher in the cyclophosphamide group (p = . ). during mobilization, cyclophosphamide maintained lower wbc counts than etoposide and showed a large increase in wbc counts at the start of collection ( figure ). the cumulative dose of cyclophosphamide or etoposide in patients who underwent autologous stem cell transplantation did not affect leukocyte (anc> /microl or platelet (plt > k/microl) engraftment. in msc treated with etoposide at a concentration of % inhibition of cell growth, il- , which is a cytokine that promotes hematopoietic stem cell mobilization, were shown a statistically significant increase (figure ). in the mouse model of mobilization (figure ), the levels of kc, one of the il- homologues in mice, had significantly increased in the etoposide-treated group compared with the levels in the cyclophosphamide-treated group. the levels of other il- homologues, mip- and lix, also showed increases in the etoposide-treated group compared with those in the cyclophosphamide-treated group; these differences, however, were not statistically significant (figure ). network analysis based on in vivo cytokine results identified that etoposide could promote mobilization in association with matrix metalloproteinase as compared to cyclophosphamide ( figure ) . conclusions: etoposide has a higher mobilization efficacy when compared to cyclophosphamide, which could due to the different mechanisms of mobilization through the elevation of il and the activation of matrix metalloproteinase associated therewith. background: high-dose chemotherapy followed by autologous blood stem cell transplantation (asct) is a standard therapy for wide range of hematologic and solid malignancies. although various methods have been introduced to improve the peripheral blood stem cell (pbsc) mobilization, autologous stem cell collection (ascc) is not successful in every patient. furthermore, even if the ascc is complete, not all of them lead to asct. we evaluated the result of ascc and actual use of pbsc grafts in current practical setting. methods: we retrospectively reviewed the all consecutive ascc procedures performed at the department of oncology in asan medical center, seoul, korea, between january and october . the targeted number of background: fanconi anemia (fa) is a rare inherited genetic bone marrow (bm) failure syndrome. while abnormal bm cells production occurs very early in life, the usual age of diagnosis is - years old. gene therapy (gt) might be an alternative to hematopoietic stem cells (hsc) transplantation, but harvest a large number of autologous hsc remains a challenge. we started a mobilization assay, fancomob, to evaluate the safety and the efficacy of fa patients' mobilization with granulocyte-colony stimulating factor (g-csf) and plerixafor. this study is part of the fa's european gt project "eurofancolen". methods: four patients with fanca mutations following the inclusion criteria were selected before pancytopenia. to note, fa was diagnosed before clinical manifestation through family screening. they received subcutaneous injection of g-csf ( μg/kg twice a day) from d- and plerixafor ( . mg/kg/day) from d- . the collection protocol targeted x e /kg of cd + cells, based on a predicted future weight in years. cd + cells and white blood cells (wbc) blood count were monitored tightly along the mobilization. patients with more than cd +/μl or between and cd /μl with a clustered aspect detected by flow cytometry after plerixafor injection underwent apheresis. cd + cells were immunoselected from the collection with clinimacs purification system (miltenyi) and cryopreserved for further gt manipulation. results: the mobilization target was not achieved for the first two included patients (fa years old and fa years old). the minimum value of cd +/μl required wasn't obtained for fa and the flow cytometry cd + aspect was not clustered for fa . cd + cells were mobilized quickly but transitionally after plerixafor injection for the last two patients, fa and fa , and years old respectively. both patients underwent apheresis procedures. no cd + cell rebound was observed after the apheresis was stopped.collection target was not achieved after four days of collection for fa . it was obtained the first day for fa (figure ). back-up for hsc transplantation could not be cryopreserved because of the limited number of cd + cells collected in patients fa and fa . no short-term adverse events were observed. following cd + immunoselection, cd + cell purity and recovery were poor but in the normal range described in the literature for fanconi patients ( - %)( table i) . one month after the collection hemograms were unchanged. conclusions: our clinical study offer new data showing that mobilization of fa patients with g-csf and plerixafor is safe and more efficient for younger patients, especially before clinical manifestations of bm failure. further efforts are required to establish an effective technic to purify the cd + cells after harvesting. basal cd + cell and platelets count are a strong predictor for mobilized peripheral blood stem cells on the th day of g-csf treatment in donors cryopreserved pbscs. this was associated with considerable efforts for the patients and caused additional treatment costs. on the one hand, having the therapeutic option of an autologous transplantation in the future may represent a clinically relevant advantage. however, a huge number of stem cell products are kept in storage for many years without ever been used for transplantation. our study provides cause for a careful reevaluation of the current clinical practice, which may help to focus more precisely on patients who actually benefit from a cryostored autologous stem cell graft. [[p image] . fig. : absolute numbers and relative distribution of stem cell grafts] disclosure: the authors confirm that there are no potential conflicts of interest to disclose, except the following: katharina kriegsmann: research funding from bms, celgene, and sanofi. patrick wuchter: membership in advisory boards for sanofi-aventis. reduction of dimethylsulfoxide (dmso) concentration from % to % in criopreservation of stem cells. influence on the kinetics of engraftment and tolerance to infusion patricia lopez-pereira , beatriz aguado , elena sola , carmen cámara , isabel vicuña , lorena vega , adrian alegre hospital universitario de la princesa, madrid, spain background: dmso is the cryoprotectant most used in the cryopreservation of stem cells. it is associated with adverse effects during the infusion of the product, its toxicity being proportional to the volume infused. the most common concentration used has been %, although recent publications report that reducing it to % leads to lower rate of side effects without impact on the product or the graft. we retrospectively analyzed patients recipients of autologous peripheral blood stem cell transplantation (hct) in our hospital from january to september . they are divided into two groups according to the concentration of dmso used in the freezing ( % until september or % since october ). the baseline characteristics of the patients, the infused product and the graft are shown in table . the cd count was performed by flow cytometry. all freezings were performed with a biological freezer for programmed controlled rate cryopreservation and stored in ultrafreezers at - ºc. results: both population groups are homogeneous. the t-test was used for statistical analysis. regarding the cd + variable, no statistically significant differences were observed (p = . ). neither for the variables leukocyte recovery and platelet recovery (p = . , p = . respectively). the difference in the variable viability is . units (ci %: [ . - . ]) and is statistically significant (p = . ) in favor of dmso %. regarding adverse effects, % (n = ) of the serious adverse reactions occurred in the % dmso group (hypotension and seizures). the mild and moderate ones were similar in both groups, most were mild nausea, vomiting and flushing. overall, no statistically significant differences were observed due to the low rate of adverse effects found. patients starting with until october , total of patients attempted collection of autologous pbscs, and poor mobilizers recieved plerixafor during first mobilization cycle. in total, patients required repeated mobilization cycles ( , %) of which were from the plerixafor group. in total patients recieved pleriksafor; females and males, median age ( - ) with following diagnoses: nhl, mh, multiple myeloma, neuroblastoma, nephroblastoma, sarcoma ewing and seminoma. of repeated mobilizations with plerixafor, patients ( , %) still failed to collect adequate transplant. in this period we had altogether unsuccessful mobilizations ( , % in repeated cycles, , % in total). this group of patients consisted of male and female patients, median age ( - ), diagnosis of nhl and failure to collect after leukapheresis procedures each. median number of leukapheresis needed for adequate collection was with preemtive plerixafor use, and in repeated mobilizations. conclusions: our expirience shows that preemtive use of plerixafor in poor mobilizers is efficient and has enhached success of the pbsc collections. due to drug high cost each institution needs to develop its own algorythm in management of poor mobilizers. the factors contributing to plerixafor mobilization failure still need to be elucidated. disclosure: nothing to declare. platelets recovered from mobilized leukapheresis units obtained from hla-haploidentical donors fulfill the criteria of a conventional hemocomponent and can be used for transfusion background: central venous catheter (cvc) related complications may lead to high morbidity and mortality. unlike cvc, peripheral cannulation offers a quick and inexpensive method for safe and non-traumatic vascular access (va) thus its utilization is strongly recommended whenever possible. the ultrasound (us) guidance for acquiring peripheral va is a useful tool for reduction or elimination of the need of using cvc for stem cells collection. we have made an attempt to introduce us method in our apheresis unit having no previous experience with us devices. the aim of the study was to measure the decrease of cvc insertions after introducing us and evaluate the quality of va by comparing average flow rate and confirming that the desired blood volume could be processed. methods: the theoretical education involved a free elearning course in peripheral ultrasound-guided va (pugva, usabcd, aarhus, denmark). subsequently, the personnel have implemented knowledge in practical training on gelatine and silicone phantoms and healthy volunteers. the practical activities also included a fiveday course in an apheresis centre with us-guided cannulation experience. the details concerning va were recorded, including va site, cannula size, average inlet flow rate, number of inlet pressure alarms reported by the apheresis device. the procedure details where traditional approach was applied i.e. palpable cannulation and cvcs have been collected. similarly, the necessary data for procedures where veins were assessed with ultrasound prior to apheresis were recorded. results: before introducing ultrasonography, stem cell collections have been performed in patients. of all these procedures, were accomplished with cvc ( %) and with peripheral va ( %). median cubital vein was the vessel of choice. out of the peripheral va procedures, ( %) were problematic, with or more inlet pressure alarms during every procedure. after the training stage, collection procedures were performed in patients. after introducing us we have observed a significant reduction of the number of cvc insertion required for successful apheresis from % to % (p= . ; chi-square test with fisher's exact). thirty one procedures were completed with peripheral va ( %). ultrasound device enabled cannulation not only the superficial veins but also for the deeper veins. cannulation sites included upper arm cephalic vein ( %), median cubital vein ( %), upper arm basilic vein ( %), median antebrachial vein ( %). out of the collections, were considered problematic ( %). no difference in an average flow rate was observed between procedures performed peripherally with and without ultrasound usage (p= . ; u mann-whitney test). conclusions: despite no previous experience in us guidance, we have successfully managed to introduce the new method in our apheresis unit. within months, we have reduced cvc usage threefold and as the personnel is gaining more experience, we suppose that the cvc usage may be reduced to episodic cases. despite slightly higher number of pressure alarms, all procedures with ultrasound guidance were completed as planned. ultrasound guidance is the most important tool for significant increase in peripheral va usage and may become the only option for patients with difficult va. disclosure: nothing to declare. abstract already published. donor blood management in healthy bone marrow donors: a retrospective single institution analysis background: over the last two decades mobilized peripheral blood stem cells (pbsc) have been established as the main source of stem cells because of improved engraftment and no necessity for hospitalization for the donors. nevertheless, due to the introduction of promising new transplant regimens, especially in the haploidentical transplantation setting bone marrow (bm) donations are regaining importance. although for both donation methods severe side effects are rarely described, bm collection is associated with considerable blood loss and hence symptoms of acute blood loss are commonly observed. therefore autologous blood are collected routinely in some institutions before donation. since the collected bone marrow amount depends on the target dose, the wbc yield in the product influences the required bone marrow volume. therefore we sought to investigate the relationship between collection volume, rbc volume removal, drop in hb and indications for blood transfusion. furthermore, we assessed wbc and cd +yields in relationship to various donor parameters and to product volume, in order to find prediction tools for collection volumes. methods: allogeneic bone marrow harvests from adult donors were performed at our institution and retrospectively analyzed. complete blood counts, serum iron and ferritin were assessed at work-up and weeks after donation. the bone marrow product quality including wbc, hematocrit (hct) and cd + cells were assessed by automatic hemocytometry and single-platform flow cytometry with ishage gating. results: besides local pain most of the side effects were related to blood loss. none of the donors received blood transfusions. the mean reduction of hemoglobin levels was . g/dl with a minimum hemoglobin level of . g/dl and a persistent anemia according to who criteria after weeks in . % and pathologically low ferritin levels in %. no donor presented symptoms with indication for blood transfusion. the median wbc concentration of the bm product was . /nl ( - % percentile: . - . / nl) the cd +cell concentration . /μl ( - % percentile: . - . /μl). in the linear regression analysis leukocyte counts of the donor before donation correlated significantly with wbc concentration in the product. thus in order to collect with % certainty the mio wbc which are a typical per-kg dose for an allogeneic recipient, . ml of bone marrow must be collected. collection volume did not systematically affect wbc or cd + cell concentration. conclusions: achieving high wbc yields in the bone marrow product allowed for collection of relatively modest bm volumes, thus protecting donors from excessive blood loss. acute adverse events were acceptable. optimization of perioperative management in healthy bone marrow donors may be achieved by good collection technique and reevaluation of wbc yields of each institution to calculate required bone marrow amount. the collection of autologous blood is not indicated. furthermore stringent pre-and postoperative hemoglobin management is predicted to limit adverse effects. disclosure: nothing to declare. donor-recipient weight ratio predicts successful stem cell mobilization on day four of gcsf mobilization results: in group median age of donor was years (range to years). in group median age of donor was years (range to years). table] . table ] elaborates other parameters analyzed between the two groups. one patient in group developed grade ii acute gvhd whereas patients in group developed acute gvhd grade ii-iv. at the last follow up no ( / ) patient in group has any symptoms of chronic gvhd whereas ( / ) patients in group have features of chronic gvhd (one extensive, one limited). conclusions: our observation suggests that upfront use of plerixafor in combination with gcsf modifies the graft favorably decreasing the risk of graft failure and graft versus host disease both acute and chronic. it also helps the donor by decreasing the total volume processed, amount of acd exposure and the duration of harvest. disclosure: none. impact of vitamin d levels on peripheral stem cell mobilization in autologous hematopoietic stem cell transplant recipients ferda can , zeynep arzu yegin , zubeyde nur ozkurt , orhun akdogan , lale aydın kaynar and total product cd + cell count [ . ( . - ) vs . ( . - . ); p= . ] were significantly higher in patients receiving chemotherapy+g-csf than g-csf only. the study group was divided into two groups based on peripheral cd (cut-off level: x /kg) as well as product cd levels (cut-off level: x /kg). vitamin d levels were found to be similar among these groups (p> . ). total product cd + cell count was found to be relatively lower in patients with vitamin d levels below μg/l [ . ( . - ) vs . ( . - . ); p= , ]. (figure ) conclusions: based on its effect on stem cells in in vitro studies, it may be considered that vitamin d may have a favourable impact on stem cell mobilization. statistically insignificant but relatively lower total product cd + cell count in patients who had lower vitamin d levels, which may indicate a role for vitamin d in stem cell mobilization, needs to be confirmed with larger studies. considering the high prevalence of vitamin d deficiency in the general population, the possible role of vitamin d in hematopoietic stem cell mobilization deserves further consideration. disclosure: nothing to declare background: one of the factors, affecting efficiency of autologous hematopoietic stem cell transplantation (autohsct) in hodgkin lymphoma (hl) patients is early recovery of graft, depending on cd + cell count and conditions of cell product cryopreservation and storage. it is well known, that dimethylsulfoxide (dmso), used for cryopreservation, can be cardiotoxic and cause diverse gastrointestinal, pulmonary, kidney, liver side effects and acute hemolysis. lethal for animals dose - mg/kg leads to life threatening arrhythmias and respiratory arrest. in order to improve dmso toxicity different ways of alternative cryoconservation modes are studied -lower dmso concentration ( % vs %), temperature - ˚c instead of ultra-low and washing of cell product. aim of the study is to evaluate the influence of dmso washing on hematopoietic recovery after autohsct. methods: retrospective analysis of hematopoietic recovery of relapse/refractory hl patients after autohsct was performed. mobilization regimen included second line chemotherapy for hl (dhap, begev, igev, ice) with consecutive g-csf administration. cd + cells were assessed, using -colour flow cytometer facs canto ii while cell collection, thawing and washing. cells with % dmso were stored at - ˚and washed in cases of transplantation with human albumin-dextran (reopolyglukin) and centrifugation. statistical data processing was performed by the χ method -pearson criterion; p -the level of significance of differences. results: patient groups had no difference in age, disease stage, gender, time from treatment start to autohsct and cd + cell count (p> , ). time to wbc recovery > х /л was - (median , ) days vs - (median , ) days, time to platelet> х /л recovery was - (median , ) days vs - (median , ) days in groups without and with cell washing respectively (p= , ). no difference in blood component consumption was observed (p= , ). in out of ( %) patients during cell reinfusion without washing nausea, vomiting, arterial hypertension was observed, no reactions were detected after cell washing (p = , ). conclusions: washing autologous mononuclear cells from cryopreservant dmso does not lead to low hematopoietic recovery rate after autohsct and can avoid toxicity, thus making autohsct more safe. disclosure: authors declare no conflict of interests. quality assesment of hematopoietic stem cells autografts after cryostorage, harvested using plerixafor background: the introduction of high-dose chemotherapy followed by transplantation of autologous hemopoietic stem cells (hscs) into the treatment program for multiple myeloma (mm) has significantly increased the frequency of achieving complete remissions and overall survival in patients. to obtain a sufficient amount of hscs, hematopoiesis is stimulated with granulocyte-macrophage factors (gm-csf) both in mono mode and after the administration of cytostatics followed by cytapheresis sessions (alone or after the cytostatics followed by cytapheresis sessions) . cryopreservation protocols are used to preserve cells in a viable state, followed by long-term storage of transplants in liquid nitrogen. however, in some patients it is not possible to obtain the necessary amount of hscs. the inclusion of plerixafor in standard mobilization schemes allows you to prepare the sufficient quantity of hscs in most patients with mm. methods: the study included samples of autografts from patients with mm from to (median . ± . ). hscs mobilization was performed on the background of unstable blood formation after high doses of cyclophosphamide g/m with the subsequent administration of g-csf at a dose of - μg / kg ( samples from patients) and with the addition of plerixaphor at a dose of . μg / kg ( samples from patients). immunophenotype viability of hscs in autotransplants after cryopreservation were determined by flow cytometry using the ishage protocol on a flow cytometer (facs cantoii, becton dickinson) by expressing surface markers of antibodies against cd , cd , cd , cd and staining with aminoactinomycin ( -aad). the colony-forming activity of hscs (cfu-cfu-mix, cfu-gm, cfu-g, cfu-m) was evaluated in methylcellulose (methocult h , stemcell technologies, canada) for x transplanted cells for days. results: the viability of hscs in autografts (cd + / cd + / add-) after cryopreservation in both groups was ± . %. in the group of samples using plerixaphor, a higher content of primitive hemopoiesis precursors (primitive cells) (cd + cd + cd -) was detected compared with the control group ( . ± . % and . ± %, respectively). the cfu count (cfu-cfu-mix, cfu-gm, cfu-g, cfu-m) in the plerixafor group was ± . per x explanted cells, in the control group - ± . ( figure a-d) . conclusions: the use of plerixafor against the background of standard protocols for the mobilization of hscs allows to obtain high-quality graft with a higher content of primitive cells and proliferative activity. disclosure: no conflict of interest. nothing to declare. comparison of effectiveness of plerixafor plus g-csf in poor and very poor-movilizers: efficacy of the combination of plerixafor and g-csf in poor-movilizer background: healthy donors ocassionally show a poor response to mobilization agents. plerixafor+g-csf can be a salvage strategy in poor mobilizers. some series describe the use of plerixafor to collect greater doses of cd + cells in hematopoietic stem cell transplantation (hsct) with tcell depletion. plerixafor use in the mobilization protocol could help collecting higher cd + dose in indirect t-cell depletion (cd + selection) for ex-vivo manipulated haploidentical transplantation, with less number of apheresis and a rapid engraftment. methods: data of fourteen healthy peripheral-blood donors was retrospectively collected. they received days mcg/kg/day g-csf and , mg/kg/day plerixafor on º day as mobilization treatment. fourteen pediatric patients (median age years, range - ) diagnosed with malignant and no malignant hematological diseases received haploidentical hsct with cd + selection and cd ra+ depletion between february and july . results: one leukoapheresis procedure was performed in all cases. median processed volume was liters (range - ). median of cd + cells obtained was , x /kg (range , - , ) . after positive selection, > x /kg cd + cells were infused in all cases (figure ). neutrophil engraftment was achieved after a median of days (range - ). few donors presented only plerixafor mild secondary effects. conclusions: our experience showed that a mobilization protocol using g-csf and standard dose of plerixafor (compasive use) is a safe strategy that allows collecting great cd + dose in one apheresis procedure. this could be useful for haploidentical transplantation with ex-vivo t depletion, especially if there´s a weight disproportion between donor and patient. background: mesenchymal stem cells (mscs) are selfrenewing multipotent progenitor cells with wide differentiation potential. their ease of isolation and expansion in vitro as well as their unique regenerative therapeutic properties suggest the use of msc as an approach for treating several disorders. extra-embryonic tissues as placenta have been proposed as potential sources of mscs due to the absence of ethical problems neither risks for the patients. furthermore, only protocols using fresh placental tissue have been described so far. a protocol for isolating mscs from delayed-manipulated tissue was designed and tested in order to optimize the use of placental mscs (mscs-p) in an advanced therapies context. methods: full term placentas (n= ) were obtained from healthy mothers in hospital universitario central de asturias (spain). informed consent was obtained from each mother prior to delivery. after dissection of gr decidual tissue it was washing with saline (b. braun, germany) and cut into small pieces. these biopsies were conserved hours in dmem media with % antibiotic solution x (gibco, usausa) until processing. the day after, tissue was mechanically minced and then enzimatically digested with a combination of ui/ml dnase i (sigma aldrich, usa) and . % tripsin-edta solution (w/v) (biochrom, germany) at ºc for hour. then, the mixture was filtered with μm cell strainer (bd bioscience, usa) and centrifuge at xg for minutes. finally, cells were resuspended in ml of dmem media suplemented with % fbs and antibiotic, seeded in -cm flask and incubated in forma stericult co incubator (thermo fisher scientific, usa) at ºc, %co . culture-expanded mscs cells were phenotipically characterized by flow cytometry (facs aria iiu, bd) with antibodies against cd , cd , cd , cd , cd , cd , cd , cd , hla-dr cd and cd using mesenchymal cell kit (immunostep, spain). afterwards, these cells were differentiated to adipogenic, osteogenic and chondrogenic lineages using stemmacs adipodiff media, stemmacs osteodiff media and nh chondrodiff medium (miltenyi biotec, germany) respectively. after three weeks of differentiation cells were fixed in % paraformaldehide (merck, usa) and analyzed. adipogenic, osteogenic and chondrogenic differentiation was visualized after staining with oil red o, alkaline phosphatase and hematoxilin-eosin (sigma-aldrich, usa). results: mscs-p isolated cells were characterized according to the isct criteria for mesenchymal stem cells. they were positive for cd , cd , cd , cd and cd and negative for cd , cd , cd and hla-dr, indicative of a typical msc phenotype ( figure ). all the markers showed a high percentage of expression between . and . %, meaning that msc population obtained with the designed method was very homogenous. similarly, staining for the three studied lineages was positive ( figure ). conclusions: the described protocol allows us to obtain mscs from decidual placental tissue stored and processed hours after the biopsy extraction using a unique enzymatic digestion. this circumstance permits to take advantage of placentas that are discarded after delivery giving us the option to obtain mesenchymal cells that could be used in clinical trials. disclosure: nothing to declare outcomes of umbilical cord transplant in high risk relapsed or refractory acute myeloid leukaemia background: high-risk relapsed/refractory acute myeloid leukaemia (aml) is a fatal disease. allogeneic haematopoietic stem cell transplantation represents the only chance of cure. as the transplant relies on the graft-versusleukaemia (gvl) effect, and if different donors exert different gvl effects, then choosing the right donor assumes great importance. in manchester, a large bmt centre in the north of england, our practice in such aml has been to choose unrelated cord blood (ucbt), without serotherapy in the conditioning therapy, as our preferred donor cell source. methods: we report the results of unrelated ucbt in patients (five boys and ten girls) with high-risk aml, defined as relapsed or refractory disease. thirteen patients ( %) received this as a st transplant, two patients ( %) received this as a nd transplant for relapsed aml post matched unrelated donor transplant, and one ( %) received ucbt twice, once in cr and once in cr . nine patients ( %) had mismatched ucbt, and the rest were fully matched at class-i (hla-a, -b, and-c) and class-ii (hla-drb ). conditioning was given as treosulfan, fludarabine and thiotepa in half of the patients (n = ), other treosulfanbased regimens were used in two patients ( %), and busulfan-based regimens were used in six patients ( %). no serotherapy was given. results: the median age at transplant was years (range, months - years). neutrophil and platelet engraftment were achieved in and patients at a median of and days, respectively. patients ( %) had engraftment syndrome. all engrafted patients achieved % donor chimerism, except one patient who had mixed lymphoid chimerism initially, that was corrected spontaneously to % at three months after transplant. acute gvhd grade i-ii developed in six patients ( %), and grade iii-iv developed in three patients ( %). all cases resolved, except two patients where acute gvhd evolved into chronic gvhd (one with grade i skin gvhd which fully resolved, and one with grade iii gvhd gut colitis who was parenteral nutrition dependent till death). two more patients developed chronic grade i skin gvhd and resolved (chronic gvhd developed in % in total). three patients ( %) developed veno-occlusive disease (vod), that completely resolved with defibrotide treatment and necessitated ascitic drainage in one of them. viral reactivations occurred in five patients ( %) and were successfully treated. at a median follow-up of months (range, seven months -four years), eight patients ( %) died at a median of (range, to days), with a transplantrelated mortality of % and relapse-related mortality of %. five patients ( %) relapsed post-ucbt; four died and one had a successful second ucbt (event-free survival was %). immune reconstitution in alive patients was achieved at a median of eight months. conclusions: very high-risk patients treated with ucbt with good overall survival and event-free survival, similar to aml treatment rate with low-risk disease. disclosure: nothing to declare in haploidentical transplants is the incidence of acute and chronic gvhd strictly related to the stem cell source? results: the odds ratio was . with a % confidence interval of . - . (p= . ). conclusions: the risk of infection of the uc is not related to the microbiological status of the ucb. a possible explanation for this is the presence of antibiotics in the medium used for uc, but not ucb, transport. this means that cryopreservation of ucs from which contaminated cord blood has been obtained is justified. comparison of turkish stem cell coordination center (turkok) with istanbul university bone marrow bank (tris); a single center experience in match unrelated donors azize mergen , selime aydoğdu , başak aksoy , yunus emre savcı , gürcan dikme , funda Çipe , ceyhun bozkurt , tunç fışgın older patients are increasingly being transplanted, thanks to improvement in allogeneic hematopoietic stem cell transplantation (allo-hsct) techniques. increasing donor age is associated with greater risk for mortality and graftversus-host disease (gvhd). since sibling donors are of similar age to recipients, we hypothesized that, in older patients, a young matched unrelated donor (mud) would be comparable to an hla-matched sibling donor (msd). methods: we retrospectively compared outcomes of allo-hsct from msd (n= ) and / hla mud (n= ) in patients aged ≥ years with hematological malignancies transplanted between - . all patients received reduced-intensity conditioning and graft source was peripheral blood. the primary outcome was overall survival. msds served as the reference category and were compared to muds split into three age groups (≤ [n= ], - [n= ], > [n= ] years) using univariable analyses and multivariable cox regression models adjusted for patient, disease, and transplantation features. results: the median age of hsct recipients was years and was similar across groups. median donor age for msd was years and , , and for the mud age groups ≤ , - , and > years. acute leukemia was the leading transplant indication ( %) followed by myelodysplastic syndrome, myeloproliferative neoplasms and indolent non-hodgkin lymphoma. disease risk distribution was similar across donor groups (low [ %], intermediate [ %] , and high [ %] in the complete population; p= . ). time from diagnosis to hsct was longer with mud compared to msd and increased with an older age of mud. in a univariate analysis, overall survival was % (msd), % (mud≤ ), % (mud - ), and % (mud≥ , p= . ). corresponding non-relapse mortality (nrm) cumulative incidence was %, %., %, and . % (p< . ) (figure) . gvhd-relapse-free (grfs) was %, %, %, and % (p= . ). in a multivariable cox model, young mud (≤ ) had a similar risk for mortality compared to msd (hr . , p= . ), while a monotonic increase in risk was observed with an older donor age (mud - y: hr . ,p= . ; mud≥ y: hr . , p= . ) (table) . findings were confirmed in a propensity score analysis, matched for key covariates. nrm and grade - acute gvhd were consistently higher with mud, with the greatest risk associated with older muds. the hazard for grfs was higher with mud aged or higher compared to msd; risk was not higher with younger mud. conclusions: in older patients receiving reduced intensity conditioning, msd remain the optimal choice. however, when not available, young mud provide comparable results. disclosure: nothing to declare background: there is growing evidence that community acquired respiratory virus (carv) increase the risk of pulmonary invasive fungal disease (ifd) in recipients of allogeneic hematopoietic stem cell transplantation (allo-hsct). to date, there is a lack of knowledge regarding the rate of ifd, risk factors (rfs) as well as the most critical period for the development of a later ifd after carv infections in allo-hsct recipients. methods: in this prospective observational study, we retrospectively analyzed the effect of carv on the development of a later ifd in a consecutive cohort of allo-hsct adult recipients who developed carv infectious episodes from december to december . respiratory virus in upper and/or lower respiratory tract specimens were tested using multiplex pcr panel assays. results: overall, out of allo-hsct recipients ( %) developed ifd within months after a carv episode at median of days (range - days) from the day of carv detection. all the ifds involved the lungs and in cases ( %) the diagnostic was ia accomplishing criteria of probable (n= ) or proven (n= ). of note, out of ifd ( %) occurred within the first year after transplantation. the overall rate of ifd after carv episodes was % whereas this rate was higher in recipients developing carv during the first year of transplant ( %). ifd was diagnosed in out of with carv lower respiratory tract disease (lrtd) episodes ( %) compared to out of carv upper respiratory tract disease (urtd) ( %) (p= . ). twenty-three out of carv episodes involving the lrtd during the first year after transplant ( %) developed ifd. we did not found differences in ifd rates according to the type of carv identified. multivariate analysis identified rfs for ifd: the use of atg as a part of conditioning [odds ratio (or) . , % confidence interval (c.i.) . - . , p= . ], carv lrtd (or . , % c.i. . - , p= . ), carv infection during the first year of transplant (or . , p natural killer cell alloreactive haploidentical stem cell transplantation for multiple myeloma patients catharina elssen , lotte wieten , peter von dem borne , ellen meijer , gerard bos maastricht university medical center, maastricht, netherlands, leiden university medical center, leiden, netherlands, amsterdam university medical center, location vumc, cancer center, amsterdam, netherlands background: in the past years many new drugs for multiple myeloma (mm) have been developed and are responsible for a increase in survival. notwithstanding such progress, mm remains incurable. results from allogeneic stem cell transplantation (sct), including haploidentical transplantation, in mm has shown clinical results. however, these responses are only observed in a minority of patients. we hypothesize that this observation might be due to differences in natural killer (nk) cell alloreacitvity, since we have shown in in vivo and in vitro models that mismatched alloreactive nk cells hold the capacity to kill mm cells. the aim of this prospective phase study is to evaluate if kir-ligand mismatched haploindentical bone marrow transplantation (bmt) with post-transplant cyclophosphamide will improve progression free survival (pfs) in poor risk mm patients. methods: poor risk mm patients, aged < years were enrolled if they were responsive to their last line of therapy. poor risk was defined as, high-risk cytogenetics, or relapse within a year after autologous sct, or treated with three or more previous lines of therapy. a prerequisite of enrolment was the possibility of an nk cell mismatch and availability of a mismatched family donor. patients were excluded if donor-specific hla-antibodies were present. patients received a haploidentical bmt with a non-myeloablative conditioning regimen and post-transplant cyclophosphamide. primary endpoint is pfs at , years. secondary endpoints are engraftment, bone marrow reconstitution, nk cell reconstitution and repertoire, graft versus host disease (gvhd), infections and non-relapse mortality (nrm) at , years. results: in total poor risk patients were included in the study of which could be evaluated for the primary end point. graft failure and disease progression before transplant rendered the remaining two patients not evaluable. at this interim analysis patients have already reached the , years of follow up, relapsed within , years and died due to treatment related infections, without showing progression of disease ( % nrm). average time of progression is days ( - days). two of the remaining patients at follow up, still show responsive disease (days en ). the average time to neutrophil reconstitution is days ( - days). all evaluated patients ( / ) show nk cell reconstitution with a mature phenotype in the bone marrow and peripheral blood by day . three patients developed acute gvhd ( %) of which / grade i-ii agvhd and / patient showed a grade iv agvhd. treatment related mortality was / ( %), which was in all cases due to infectious disease. conclusions: our interim analysis of mismatched haploidentical bmt in mm showed that the treatment is feasible and forms a possible platform for immunotherapeutic strategies. the majority of patients showed an early disease progression. we predefined that with a pfs of % at , years we would qualify this treatment option successful. with only two patients still in remission this goal will not be achieved and we hypothesize that the late nk cell reconstitution (day ) is responsible for the lack of response. clinical background: mscs are known to have immune modulatory capacity and may be effective in the treatment of patients with acute gvhd. however clinical studies yielded inconclusive results which was in part due to the great heterogeneity of the msc used. the off-the-shelf msc preparation "msc-ffm", generated by a proprietary pooling process, selection by plastic-adherence, expansion for an aggregate four weeks followed by cryopreservation until use, is available in germany through a national marketing authorization. "msc-ffm" is indicated in steroidrefractory agvhd, dosed at - x /kg bw i.v. in four doses one week apart. methods: we report seven consecutive pediatric patients (median age . y), who received "msc-ffm" from unrelated hla disparate donors between december and november in our institution. we gave msc infusions to patients with steroid-refractory grades iii-iv agvhd and one patient who had therapy-refractory background: regulatory t cells (treg) are known for their immunosuppressive function and have proven successful as graft-versus-host disease (gvhd) prophylaxis after allogeneic bone marrow transplantation in a number of preclinical as well as first clinical studies without compromising graft-versus leukemia (gvl) effects. in murine models of acute gvhd lymph node homing capacity via cd l (l-selectin) proved to be essential for disease prevention. yet, treg recruitment from lymph nodes to peripheral sites of ongoing gvhd also seems necessary to achieve maximum protective as well as therapeutic effects. the chemokine receptor ccr directs activated t cells to sites of inflammation, thus high ccr expression should facilitate treg homing to affected gvhd target organs. with this project we lay the foundation for future in vivo studies of treg therapy for gvhd by upregulation of ccr expression. methods: we performed systematic ex vivo analysis of ccr expression on murine naive and memory conventional (tconv) and regulatory t cells isolated from spleen, blood, bone marrow, lymph nodes, liver and lung. cells were stained for characteristic surface and intracellular markers and characterized by multiparametric flowcytometric analysis. ccr expression kinetics following stimulation were analysed in tconv and treg isolated from murine splenocytes by facs and polyclonally activated by anti-cd /cd -coated beads in the presence of exogenous il- . expression was monitored by daily flow cytometric analysis. ccr overexpression was induced by transduction of expanded treg with ccr mrna via electroporation. expression kinetics were monitored by facs, receptor function was tested in transwell migration assays using ccr ligands ccl- and ccl- . results: systematic analyses showed higher ccr expression on memory treg than on their naive counterpart in all examined organs with bone marrow samples displaying the greatest disparity. memory treg showed higher ccr expression than memory tconv in all analysed organs, except for lymph nodes where both memory populations revealed equal expression levels. stimulation of in vitro expanded treg and tconv lead to a strong increase in ccr expression with maximum levels on d and d respectively, whereas restimulation (d ) resulted in no further relevant ccr expression on treg. we performed systematic optimization of stimulation and mrna-electroporation conditions to reliably achieve highlevel short-term ccr expression. transduction of treg on d of in vitro expansion resulted in a strong ccr expression, with maximum levels h after electroporation and strong ccr expression being detectable for at least h. transwell migration assays showed enhanced migrational properties of mrna-electroporated treg towards ccr ligands. analyses performed h and h after electroporation showed persistent migration even though measured ccr surface expression had already declined significantly. conclusions: we showed that high ccr expression can be detected on memory treg in all analysed organs. since in vitro stimulation of murine treg did not reliably induce ccr expression, we established a protocol for ccr mrna-electroporation. electroporated cells showed stable short-term ccr expression and enhanced migrational properties towards ccr ligands in vitro. future studies will show whether the induction of short-term ccr expression will facilitate in vivo homing of adoptively transferred treg to sites of ongoing gvhd and thus mediate long-term inflammation suppression. disclosure: the authors have no conflict to disclose. survival and immune reconstitution of syngeneic, haploidentical and allogeneic hematopoietic stem cell transplantation in atm-deficient mice ruth pia duecker , patrick c. baer , stefan zielen , ralf schubert from allo-hsct. it´s not necessary to do chemotherapy before transplantation for patients with bone marrow blast cells more than % at the time of diagnosis. [[p image] . figure the hci-ct of patients before transplantation and occurance of grade iii-iv agvhd on overall surviv] background: . allogeneic haematopoietic stem cell transplantation (sct) offers the chance of cure for patients with transfusion-dependent thalassemia (tdt). based on the non-neoplastic nature of this condition sct approaches urgently require to prove both efficacious and safe. methods: . we report on children, adolescents and young adults (median age: years; range - years) with tdt receiving sct from an hla-matched donor (mud n= , msd n= , mfd n= ) in our center from - . all patients received the same treosulfan-based conditioning regimen (treosulfan x g/m , fludarabine x mg/m , thiotepa x mg/kg). gvhd prophylaxis was based on atg-fresenius™ ( x mg/kg, if mud or mfd as donor), csa (with taper from day + ) as well as mtx (day , , , ) in / and mmf in / patients with mtx toxicity, respectively. stem cell source was bone marrow in , peripheral blood stem cells in and cord blood in patient. prior to transplantation children received cytoreductive treatment with azathioprine, hydroxycarbamide and intensified erythrocyte transfusion. iron elimination therapy was carried out in / children with deferasirox. among the patients with available ferris-can™ analysis patients showed substantial liver iron overload (liver iron > mg/g) despite intensive chelation prior to sct. results: . all patients achieved leukocyte engraftment at median day + (range - ), however two patients required a cd -selected pbsc boost on day + and day + based on delayed platelet and/or erythrocyte engraftment. nine patients exhibited full donor chimerism in the bm at day + , the other showed mixed chimerism with < % autologous cells. on day + peripheral blood chimerism was complete in / patients with the remaining patient exhibiting stable split chimerism with % donor-derived erythrocytes and - % autologous myeloid cells. acute gvhd was observed in three patients (grade : n= , grade : n= ). however, all patients responded to immunosuppressive therapy with steroids ± ecp and re-initiation of cni (n= ). one patient suffered background: patients with relapsed or refractory acute myeloid leukaemia (aml) have a poor prognosis. allogeneic hematopoietic stem cell transplantation is the only curative option. however, allogeneic transplantation with active leukemia failed to improve significantly the longterm outcome. to improve the outcome of allo-hsct in such high-risk and refractory patients, sequential schedule of cytoreduction therapy followed by nonmyeloablative conditioning has been developed. methods: to evaluate the outcome of sequential intensified conditioning regimen followed by allogeneic hematopoietic stem cell transplantation (allo-hsct) for refractory acute myeloid leukemia (aml). results: a total of patients with primary or secondary refractory aml transplanted between june to july were included. refractoriness was defined as primary induction failure, relapse within months from induction/ consolidation chemotherapy or second relapse. median age is years ( to ). the salvage chemotherapy administered was flag-ida. two patients did not receive intensive chemotherapy because of no recovery after induction chemotherapy. seven days after the end of flag-ida, a reduced intensity conditioning consisting of fludarabine, mg/m , thiotepa, mg/kg and busulfan , mg/kg i.v. (n= ) for haploidentical donors or fludarabine plus busulfan (n= ) for hla identical sibling or unrelated donors was administered. graft-versus-host disease (gvhd) prophylaxis consisted of tacrolimus and mycophenolate mofetil. the mycophenolate was withdrawn at day + post-transplantation and tacrolimus at day + . donor lymphocytes (dli) were infused in patients without agvhd at day + post-transplantation. seventeen patients achieved complete donor chimerism, patients progressed early and patient died before engraftment. one of the patients which recovery was with persistent leukemia reached donor chimerism after immunosupression discontinuation. ten patients are alive in complete remission. median follow-up of survivors is months (range: - ). five patients died of leukemic progression, as result of gvhd and suffered intracranial hemorrhage. five patients received prophylactic dli. the incidence of acute moderate-severe gvhd and moderate-severe chronic gvhd were % (n= ) and % (n= ), respectively. the non-relapse mortality was % (n= ), mainly due to acute gvhd (n= ) . the -year cumulative incidence of relapse posttransplantation was . %. the probability of relapse was %± %. the -year os and dfs were % ± % and % ± % conclusions: the strategy of sequential chemotherapy followed by allohsct ± prophylactic dli has an acceptable toxicity profile and improves both the relapse rate and the survival for refractory aml patients. disclosure: nothing to declare background: the concept of immunological intervention to prevent relapse after hematopoietic stem cell transplantation is associated with the assessment of the chimerism status. distinguishing patient and donor hematopoiesis is usually performed by str-pcr, a powerful method developed for forensic purposes. however, this method shows restrictions with respect to detection limit, preciseness, and the possibility of automated read out. digital pcr could circumvent some of these limitations. methods: recently, validated for the bio-rad droplet digital platforms, the biotype mentype digitalquant assay was released. the assay uses indel polymorphisms on chromosomal dna to distinguish patient and donor hematopoiesis on a fret hydrolysis assay basis ("taqman assays"). thus the assay in principle is applicable on the chamber based d digital pcr system (thermo fisher). due to different reaction chemistry and physical properties of thermal transfer between the digital pcr platforms protocols are reasonably not fully compatible which would lead to lower fluorescence intensities and poor signal resolution on the solid chip based thermo fisher d platform. an adjusted pcr protocol was established and optimized using representative markers, followed by determination of tolerable and optimal amount of input dna. specificity, sensitivity and reproducibility testing with artificial mixed samples preceded the extensive verification by comparative measurement of clinical samples (n= ) and ring-trial samples (n= ). source to allogenic bm or pbsc. ucb units are immediately available for transplantation as they are frozen and banked with defined hla typing and it has an advantage for patients who need urgent transplantation. in addition, a higher degree of hla mismatch appears to be acceptable with a comparatively lower risk of acute and chronic gvhd. meanwhile, a higher incidence of engraftment failure, delayed neutrophil and platelet recovery, and posttransplant immune disorders including pre-engraftment immune reactions (pir) are major problems in unrelated ucbt. methods: in our institute, gvhd prophylaxis in ucbt was changed after march . between january and march , thirty-two patients received tacrolimus plus methylprednisolone (tac/mpsl) and between april and january , thirty-one patients received tac plus methotrexate (tac/mtx) for gvhd prophylaxis. to investigate better gvhd prophylaxis after ucbt, we compared transplant outcomes after ucbt using gvhd prophylaxis with tac/mpsl (n= ) and tac/mtx (n= ) in single-pediatric transplantation center. results: the cumulative incidence of neutrophil engraftment at day in tac/mpsl group was . % and . % in tac/mtx group (p= . ). median time of neutrophil engraftment was days earlier in tac/mtx group ( days) than tac/mpsl group ( days). according to pir, and acute gvhd, tac/mtx group showed superior outcomes; the incidence of pir (p= . ) and the cumulative incidences of acute gvhd at day ( . vs . %, p = . for grade ii-iv, . vs . %, p= . for grade iii-iv) was significantly lower in tac/mtx group than in tac/mpsl. however, the incidences of relapse (p= . ) and cytomegalovirus viremia (p= . ), and estimated overall survival (p= . ) and event-free survival (p= . ) were comparable between two groups. conclusions: our results indicated that gvhd prophylaxis with tac/mtx had favorable effects; reduced incidence of rip and acute gvhd after ucbt without any negative influences. disclosure: nothing to declare transfer of donor regulatory t-cells after atg reconditioning cures severe refractory gvhd and leads to long term persistence of regulatory t-cells in the recipient cells on a clinimacs® plus device (miltenyi biotec). the cell product contained % foxp + t-cells. the patient received , x /kg t reg on day + . subsequently intestinal gvhd decreased and finally resolved. three months after the first t reg transfer the patient got a second t reg transfer ( , x /kg) on day + due to decreasing t reg levels. thereafter t reg persisted and there was no recurrence of gvhd. the patient is well with low dose sirolimus and prednisone as the only immunosuppressants and is particularly recovering intestinal function. conclusions: this case illustrates an unusually severe acute gvhd after matched sibling sct. transfer of donorderived t reg was able to cure severe and refractory gvhd after t-cell ablation by atg. transferred t reg persisted in the recipient for a long period and did not lead to any adverse events. disclosure: no disclosures to declaim allogeneic hsct for patients with transfusion dependent anemia from matched and mismatched donors julia fekadu , andrea jarisch , jan sörensen , emilia salzmann , eva rettinger , andré willasch , shahrzad bakhtiar , thomas klingebiel , peter bader after first asct. the mean harvest for patients receiving dhap was , x cd (+) cells/kg, , x cd (+) cells/kg for cy, . x cd (+) cells/kg for igev, , x cd (+) cells/kg for ice, , x cd (+) cells/kg for choep. the patient mobilized with vtd-pace achieved , x cd (+) cells/kg after apheresis. of the patients achieved the target number of > x /kg cd + cells after apheresis, after two, and after three apheresis. the median time to apheresis was days ( - ) without significant difference between the regimens. the mean wbc count at the time of apheresis was , x /l after dhap, , x /l after cy, , x /l after igev, , x /l after ice, , x /l after choep. there was correlation between wbc and cd harvested cells (p= . ). grate - thrombocytopenia was found in patient ( dhap, ice, igev, vtd-pace). grate - anemia was registered in patients ( dhap and vtd-pace). no correlation was found between the cd + harvest and the age, number of previous lines chemotherapy, the response before mobilization, the type of the lymphoma and the clinical stage. conclusions: our results demonstrate that the chemo-g-csf protocols have comparable effectiveness with accep- background: cytomegalovirus (cmv) may cause severe complications in recipients of allogeneic haematologic stem cell transplantation (allohsct). letermovir (ltv, / mg daily without/with co-administration of cyclosporine) was recently licenced only for cmv prophylaxis in adult allohsct-recipients. paediatric data as well as data on cmv therapy are missing so far. methods: we administered letermovir mg orally once daily (with no co-administration of cyclosporine a) to paediatric patients after allohsct. edta-plasma were occasionally obtained at different time points and frozen for determination of letermovir levels using liquid chromatography/mass spectrometry (lc-ms/ms). results: for details on patients, treatment and cmv load see table . in short periods of letermovir administration, cmv blood levels became negative in both patients. considering the lacking safety data in paediatric patients, we stopped letermovir treatment in both patients, when liver parameters increased. in patient hepatopathy turned out to represent histologically proven graft versus host disease (gvhd). in patient liver parameters further increased despite withdrawal for another weeks, however, hepatopathy was only mild and self-limiting. both patients additionally received other possibly hepatotoxic substances (mycophenolate mofetil and trimethoprim/ sulfamethoxazole). letermovir plasma levels were . ng/ml ( h), . ng/ml ( h), . - . ng/ml (median . ng/ ml, n= , h) and . ng/ml ( h after administration). conclusions: during short letermovir treatment, we observed fast resolution of cmv viraemia as well as rising liver parameters in both patients. while elevated liver parameters represented gvhd in patient, a causal relationship with letermovir might be considered in the other patient. letermovir peak levels after administration of mg were within ranges reported in adults after administration of mg while trough levels were higher indicating differences in pharmacokinetics in terms of delayed clearance. inguinal lymphadenomegaly. after failure to respond to seven conventional treatment lines: methotrexate, cop (cyclophosphamide, vincristin and prednisone); gemcitabine; puva; interferon; acitretin and extracorporeal photopheresis), allogeneic hsct from an identical hla male donor was indicated. the non-myeloablative conditioning consisted of fludarabine ( mg / m ), cyclophosphamide ( mg / kg) and total body irradiation(tbi) ( cgy). prophylaxis of graft versus host disease (gvhd) was performed with cyclosporine ( mg / kg) and mycophenolate mofetil ( mg/kg). after conditioning, there was improvement of pruritus and involution of the skin. bone marrow infusion occurred on / / (d ). on d + he presented recurrence of skin lesions of fmf. donor lymphocyte infusion (dli) was performed ( x cd + cells / kg / recipient). he presented oral lichen and diarrhea respectively as manifestations of gvhd on d + and d + . as infectious intercurrence, hemorrhagic cystitis occurred by bk virus months after the first dli and he received conservative treatment and remained without systemic immunosuppression. nine months after hsct, a second dli ( x cd + cells / kg / receptor) was performed and at this time the patient is without clinical manifestations of fmf or gvhd. conclusions: the clinical response of the presented case confirms what has been reported in the literature. ctcls appear to be particularly susceptible to gvl effect, which makes hsct a potential cure for advanced ctcls in eligible patients. the timing to perform hsct in the clinical course of the disease remains a matter to be settled clinical trial registry: not applicable disclosure: no conflict of interest p abstract already published. methods: we applied next generation sequencing (pgm, ion torrent/ fischer lifetechnologies) to an unselected cohort of patients ( female, male, median age ( - ) years) who had been referred for allogeneic stem cell transplantation due to the presence of a high-risk myeloid disorder dnmt a r h ( . %) . ), cebpa ( . %; ceb-pap s ( . %) vus) kras ( . %; krasr r ( . %) vus), and kit ( . %; kitm l ( . %) . ). patients displayed a median of sequence variants (aml, mpn and cmml patients each ; mds, saa and patients with other, non-malignant hematologic diseases each sequence variants found most frequently in aml were cebpap s ( . % of all sequence variants in patients with aml, p< - , chi² test) in patients suffering cmml, dnmt ar h was particularly frequent ( . % of all sequence variants in cmml, p=. ). asxl e d ( . % of all sequence variants in other, non-malignant hematologic diseases, p=. ), idh r q ( . %, p=. ) and krasr r ( . %, p=. ) were frequent in other, non-malignant hematologic diseases. in saa, nrasg d ( % of all sequence variants in saa patients; p=. ) was frequently found, as were dnmt ak fs* ( %, p=. ), tet l w ( %, p=. ) and tet i v ( %, p=. ). conclusions: taken together, these data show that vus occur with high abundancy in this high-risk cohort of patients, and that they differ in frequency between various myeloid disorders methods: retrospective analysis of patientswho experienced either hematological relapse or progressed to aml after allo-hsct and were treated with azacitidine for this indication at hematological centers in poland. the primary end-point was overall survival (os), the secondary -response rate. results: patients, males ( . %), median age (range, - ), were enrolled. the primary indication for allo-hsct was aml median time from allo-( %ci: . - ); with -year os of . % ( %ci: . - . ). for patients stratified according to ebmt aza relapse prognostic score -year os was: prophylaxis of agvhd: with atg -atgam mg/b.w.- pts( , %), posttransplant cyclophosphomide (ptcy) mg/b.w. on d+ ;d+ - pts ( , %) conclusions: unmanipulated haplo-hsct in st - nd cr in children and adolescents with high risk al allows achieving the long-term survival in , %. the use of g-csf stimulated unmanipulated haplo-bm is associated with a satisfactory rate of engraftment. the main cause of death in our study was relapse after allo-hsct. the frequency of acute and chronic gvhd was acceptable, -years grfs rate of , % in st - nd cr represents good quality of life following unmanipulated haplo-hsct and therefore may be recommended as option for use in children and adolescents with high-risk al. disclosure: nothing to declare background: b -h (cd ) is thought to act as an immune checkpoint and regulates t and nk cell responses. it is highly overexpressed on many solid tumors while on healthy tissue protein expression is limited. this makes b -h an interesting target for cancer immunotherapy. in highrisk neuroblastoma patients, targeting disialoganglioside gd with the recently approved monoclonal antibody (mab) ch . after autologous or allogeneic sct, significantly improves survival. however, gd expression is heterogeneous and ch . causes severe adverse effects. thus, we evaluated b -h as an alternative or additional target antigen. we investigated different anti-b -h mab constructs and mab-cytokine fusions (immunocytokines) for their ability to elicit antibody-dependent cellular cytotoxicity (adcc) using expanded γ/δ t cells of healthy donors, chex lf-il was confirmed to be the most effective mab construct. interestingly, chek -il showed comparable target cell lysis -however, lysis was only transient while chex lf-il mediated permanent target cell lysis. using patient pbmcs after receiving allogeneic sct, chex lf-il and ch . mediated comparable lysis. calculated specific lysis of lan- (after hrs.; in ascending order): targets + effectors w/o mab ( %) conclusions: b -h is a suitable target antigen in case gd expression is low or absent. immunocytokines and fcoptimized mabs targeting b -h might increase the efficacy of immunotherapy in gd -negative tumors and in combinatory approaches. until now, the low-fucose immunocytokine chex lf-il seems to be the most promising anti-b great ormond street hospital, nhs foundation trust petersburg/ raisa gorbacheva memorial institute of children's oncology, hematology and transplantation, rehabilitation medicine, saint petersburg, russian federation, first i. pavlov state medical university of st. petersburg/raisa gorbacheva memorial institute of children's oncology, hematology and transplantation, bone marrow transplantation for pediatric solid tumor petersburg/raisa gorbacheva memorial institute of children's oncology, hematology and transplantation, pediatric hsct outpatients, saint petersburg, russian federation university hospital carl gustav carus james`s hospital diagnosis was aml in %, all in % and mds in % of patients. % of patients received pbsc grafts, % received unmanipulated bone marrow grafts. os at years was % in msd/mud-atg, % in haplo-ptcy, % in mmud-ptcy and % in mmud-atg groups (p= . ). in a multivariate cox model non-relapse mortality was %, %, . % and % in msd/mud-atg, haplo-ptcy, mmud-ptcy and mmud-atg groups, respectively. cumulative incidence of acute gvhd grade or was %, . %, % and % after in msd/mud-atg, haplo-ptcy cumulative incidence of chronic gvhd was % in the msd/mud-atg group uwe platzbecker , verena wais republic of china background: there are two most noteworthy strategies of haploidentical stem cell transplantations (haplo-hsct), the baltimore post-transplantation cyclophosphamide (ptcy) with or without anti-thymoglobulin (atg), and the beijing g-csf primed bone marrow (bm) plus peripheral blood stem cells (pbsc) (giac). however, the comparison of these two modalities is scarce. in this study, we aim to compare these two approaches for hematological malignancies based on the taiwan blood and marrow transplantation registry (tbmtr) with the comparable cd infusion amounts, the neutrophil engraftment time were statistically distinct among these three groups [d+ (group ) vs. d+ (group ) vs. d+ (group ), respectively as to the graft-versus-host disease (gvhd), the patients in group had more grade ii-iv but similar grade iii-iv acute gvhd compared with others (grade ii-iv: . % vs. . % vs. . %, respectively conclusions: haplo-hsct with different strategies is a feasible treatment modality for hematologic malignancies in taiwan. regarding the retrospective nature and limited patient numbers of this study republic of china background: we previously presented a low-resolution hla analysis of cedace, the voluntary portuguese bone marrow donor registry (ebmt , poster p ) and, more recently, its epidemiological characterization (ebmt , poster b ). currently, cedace is one of the largest bone marrow donor registries in the world, including nearly % of the country's population, twice the number of donors present in . the current work is an update on the most common hla haplotypes found in cedace results: of the donors in the cedace registry, . % were typed in at least loci (hla-a/-b/-drb ), . % in (including hla-cw), and . % in (including hla-dqb )the , and most common haplotypes accounted for, respectively, . %, . % and % of the haplotypes found in the entire registry. the five most common haplotypes at the low-resolution at the loci, low-resolution level, out of donors, individual genotypes were identified, leading to an hla matching probability at this level of . % hid-hsct) have a stronger anti-leukemia effect compared to identical sibling donor hsct(isd-hsct) in high-risk features .but in refractory/relapsed(r/r) aml patients who not in remission status, it is unclear whether it also augments the gvl effect antithymocyte globulin was used in haploidentical hsct. unmanipulated bone marrow and peripheral blood stem cells for all patients. cyclosporine, short-term methotrexate were employed for gvhd prophylaxis. mycophenolate mofetil included in hid-hsct. performed multivariate analysis for all patients of pretransplantation variables and developed a predictive scoring system for survival according to adverse factors. results: the total survivor median period of follow up was ( - ) months. hid -cohort had higher -year actuarial of os multivariate analysis showed isd-hsct,standard conditioning regimen and less than % proportional reduction in blast percentage pre-≥ . conclusions: haploidentical donor compared to identical sibling donor had better anti-leukemia effect in allo-hsct for r/r aml in nr status conditioning protocol was melphalan mg/m for mm and beam for nhl. the quantification and characterization of γδt cells in peripheral blood samples were performed by flow cytometry based on the expression of cd /cd /vδ /vδ /vγ /cd at , and days after ahsct. percentage (%) of γδt cells represented the proportion of these cells among all t cells. results: median age at ahsct was ( - ) years, % male. median time from diagnosis to mobilization was ( - ) months, after a median number of therapeutic lines of ( - ); pts ( . %) received radiotherapy. seventeen pts ( . %) were re-mobilized with plerixafor±g-csf ( % mm vs % nhl there was no difference in febrile neutropenia incidence (p= . ), timeto-engraftment (p= . ), time-to-neutrophils> /μl (p= . ) or erythrocyte transfusions (p= . ). however, there was more time-to-platelets> , /μl ( vs days; subpopulations did not affected pfs. conclusions: our results showed that pts mobilized with plerixafor need more collection volume (less cd +cells, higher dmso). plerixafor negatively affected platelet recovery, with similar hematologic and immune recovery for the remaining variables. its use was associated with higher %vδ +, suggesting that it induces an antineoplastic phenotype. more studies with larger samples and follow-up period are needed to evaluate plerixafor results: total ascc procedures were carried out in patients over years, once in patients, twice in patients, three times in patients, and four times in patient. non-hodgkin lymphoma (nhl) comprised . % of all cases (n = ) ), total number of chemotherapy cycles before ascc (or . , % ci . - . , p = . ), failure to achieve at least partial response before ascc (or . , % ci . - . , p = . ), total number of days receiving g-csf for mobilization (or . , % ci . - . , p = . ), and salvage use of plerixafor (or . , % ci . - . , p < . ) were found to be independent factors associated with failure of ascc. at the end of the study period, . % of successful collections (n = / ) were used for asct, . % (n= / ) were in storage awaiting transplantation hôpital necker-enfants malades melf methods: a total ahsct candidates [median age: ( - ) years; male/female: / ] were included in this study. twenty-seven patients ( . %) were diagnosed as non hodgkin's lymphoma, patients ( . %) hodgkin's lymphoma, patients ( . %) multiple myeloma, patients ( . %) acute myeloid leukemia, patients ( . %) plasmocytoma and patient ( %) testis cancer. premobilization serum -hydroxy vitamin d ( -oh d) levels were measured with immunoassay method peripheral cd + cell count background: some published data suggest a positive effect of iron chelators on the risk of post-transplant relapse, with an improvement in overall survival after allogeneic hematopoietic stem cell transplantation (hsct) conditioning regimen consisted to intravenous bu mg/m and, flu mg/m d- to d- . gvhd prophylaxis included atg . mg/kg on d- and d- , ciclosporin and methotrexate. all patients received peripheral blood stem cell transplant from an identical hla-related donor. iron chelation consisted on deferasirox (exjade ® ) - mg/kg/day, started at day , if serum ferritin level ≥ - ug/l and stopped when the level decreased below ug/l or normalized at day after transplant, / patients were evaluable (g = pts), (g = pts). patients were abo compatible ( %), had major incompatibility ( %), and % had minor incompatibility. median serum ferritin level at day , were ug/l ( - ) and ug/l ( - ) in g and g respectively with a median follow-up of months, ( - ), disease relapse incidence was higher in patients who did not received iron chelation treatment (g : . %) versus those who received oral deferasirox (g : . %) (figure ), but the difference was not statistically significant conclusions: these results deserve more investigation choep (n= ), and patient received vtd-pace μg/kg depending on the protocol. the aim was to collect at least x cd (+) cells/kg body weight. results: forty patients all patients were stage iii and iv at diagnosis. of the patients were mobilized after one line of treatment, six after two lines of treatment and five after and more lines of treatment alexandra martínez-roca , gerardo rodriguez-lobato , gonzalo gutierrez-garcia , , maria suárez-lledó background: hematopoietic stem cell transplantation (hsct) is an established procedure in lymphoma background: the role of inflammatory cascade in tumor microenvironment has been demonstrated in several studies. as a part of this issue, elevated neutrophil/lymphocyte ratio (nlr) was shown to be associated with an adverse prognosis, particularly in solid tumors. the aim of this study is to determine the impact of pre-transplant nlr on early transplant complications, as well as post-transplant relapse and survival.methods: a total of lymphoma patients [median age: ( - ) years; male/female: / ] who underwent autologous hematopoietic stem cell transplantation (hsct) were included in this retrospective study.results: the initial diagnosis was hodgkin lymphoma (hl) in ( . %), b-cell non-hodgkin lymphoma (nhl) in ( . %) and t-cell nhl in ( . %) patients. of patients who were evaluated for pretransplant disease status, patients ( . %) were in complete remission, patients ( . %) were in partial remission and ( . %) patients had refractory disease. median pre-transplant nlr was found to be . ( - ) . when the study population was divided into two subgroups as "low-" and "high-nlr", based on median nlr value, number of febrile days were found to be relatively higher in the low-nlr group (p= . ). a positive correlation was demonstrated between nlr and lactate dehydrogenase levels (r= . ; p= . ); and nlr and ferritin levels (r= . ; p= . ). at a median follow-up of ( - ) months, overall survival (os) was found to be better in the low-nlr group without statistical significance [ vs ( - ) months; p= . ]. in univariate analysis, pre-transplant nlr represented a significant impact on os (p= . ). other prognostic factors were age (p= . ), platelet engraftment (p= . ), post-transplant relapse (p= . ) and pre-transplant ferritin level (p< . ). the permanent impact of ferritin on os was confirmed in multivariate analysis (p= . ).conclusions: in this study, an adverse impact of elevated pre-transplant nlr on os was demonstrated in autologous hsct recipients with lymphoma. as a predictor of prognosis, nlr may be considered as a safe and cost-effective parameter. further studies are required in order to use this predictor in routine clinical practice.background: high cure rates in childhood diseases have been achieved by stem cell transplantation (sct). however, there is little knowledge concerning recovery of the immune system and community-acquired infection after sct. here we studied the long-term reconstitution of the immune system and incidences of community-acquired infection after sct.methods: we reviewed medical records for patients (m/f: / , median age: years (range: - years) who were treated in the department of pediatrics, hokkaido university hospital. we analyzed cd -positive cell counts, serum immunoglobulin g (igg) levels, and incidences of community-acquired infection until years after sct. indications for sct were all in patients, aml in , aa in , nb in , rms in , jmml in , nhl in , cgd in , was in , xscid in , apds in , cd ld in , and other solid tumor in patients. stem cell sources were autologous pb/bm in , allogenic bm in ( related and unrelated) and allogenic cb in patients. in this study, we excluded patients who relapsed after sct.results: the duration of cd -positive cell counts < / ml after sct was . ± . months in all patients. the durations were . ± . months in patients with hematologic malignancies, . ± . months in patients with hematologic disorders such as aplastic anemia and pid, . ± . months in patients with solid tumor, . ± . months in patients who received autologous sct, . ± . months in patients who received related bmt/ pbsct, . ± . months in patients who received unrelated bmt, and . ± . months in patients who received cbt. the durations of igg < mg/dl after sct were . ± . months in all patients, . ± . months in patients with hematologic malignancies, . ± . months in patients with hematologic disorders, . ± . months in patients with solid tumor, . ± . months in patients who received autologous sct, . ± . months in patients who received related bmt/pbsct, . ± . months in patients who received unrelated bmt, and . ± . months in patients who received cbt. there was a significantly higher incidence of community-acquired infection from months after sct. there were significant differences in the incidence of community-acquired infections between patients with cd -positive cell counts of < /ml and background: allogeneic hematopoietic cell transplantation (allo-hct) has the potential to cure subgroups of patients with multiple myeloma (mm) but its role is controversial due to high transplant-related mortality. while autologous hct is well established as consolidation after induction therapy using novel agents, allo-hct is still considered experimental due to excessive early toxicity.methods: we retrospectively studied mm patients (pts) ; ( , %) were males with a median age of years (range: - ), who underwent allo-hsct in our center between and .median time between diagnosis and allo-hct was months (range: - ).results: the international staging system (iss) was iss i ( , %), iss ii ( , %), and iss iii ( , %). twentyeight ( , %) pts received cells from unrelated donor and pts from identical siblings. stem cell source were: peripheral blood (n= ) and bone marrow (n= ). grouprisk distribution using hct-ci and pam index can be seen in figure . response was evaluated at day + : cr ( , %), vgpr ( , %), pr ( , %) and sd ( , %); response was not evaluated in pts. regarding hospitalization, ( , %) pts and ( , %) pts needed readmission in the first days and days post-allohct, respectively, and median days of hospitalization was days (range: - ). reasons for first re-admission were: infection ( , %), gvhd ( , %) and renal insufficiency ( , %). twenty-seven ( %) died and death causes were: infection ( , %), progression ( , %), secondary tumor ( , %) and the remainder, gvhd and intracranial hemorrhage. in addition, pts ( , %) suffered cytomegalovirus (cmv) reactivation.median overall survival (os) was months (range: - ). univariate analysis showed that re-admission in first days (hr , ; p= , ) , re-admission in first days (hr , ; p= , ) , cmv reactivation (hr , ; p= , ), iss (iss-i vs iss-ii and iii; hr , ; p= , ), days of hospitalization in the first days and response at + day (cr plus vgpr vs the remainder; hr , ; p= , ) were predictor factors for os. other factors like karyotype, response before allo-hct, hla-mismatch or baseline cmv serostatus, among others, do not impact on os.median os in pts with low hct-ci were months (range: - ) vs months in intermediate-high hct-ci background: allo-sct is a potentially curative therapy for patients with multiple myeloma as it provides a graftversus-myeloma effect and a myeloma-free graft. due to increased nrm and unclear os benefit the recent guidelines suggested allo-sct to be used in context of clinical trials focusing on the high-risk patients and those who relapsed early after autograft. reduced-intensity conditioning regimens may improve rate of nrm; however, optimal conditioning regimen is still to be determined. here we studied conditioning regimen with alkylating agents consisting of thiotepa (tt), busulfan (bu) and gvhd prophylaxis with post-transplant cyclophosphamide (post-cy) in high risk myeloma patients relapsing after autograft.methods: a total of patients (m, n= ) with median age of years (range - ) underwent an allo-sct (mud, n= ; mrd, n= ; mmud, n= , haploidentical, n= ) during a period from to in university of hamburg. the majority of patients had advanced disease (stage iiiab, %) and high-risk cytogenetics ( %). the median response durartion after autograft was . years (range . - . ). the conditioning included tt (cum. dosage mg/kg), bu (median cum. dosage . mg/kg i.v. or . mg/kg in elderly patients) and post-cy (cum. dosage mg/kg, day + and + ). eight patients (all of them received allografts from mmud or haploidentical donors) received additionally fludarabine (flu, cum. dosage of background: the overall incidence of active cmv infection in patients with multiple myeloma (mm) receiving background: several scoring systems have been developed to estimate outcomes in mds patients who undergo allohct. however, none of them have been specifically validated in t cell depleted grafts. the aim of this study is to investigate the prognostic ability of a recently published scoring system (sfgm-tc) in a cohort of patients with mds who underwent tcd transplants.methods: patients underwent a first tcd allohct for mds from to . the sfgm-tc score (caulier et al. curr res transl med. ) is performed at day and ranges from - , discriminating low ( ), intermediate ( ) ( ) ( ) , and high risk ( - ). additional analyses were performed at day and day . a landmark analysis was done at each time point for the day , , and analyses, respectively. background: hematopoietic stem cell transplantation (hsct) is the only curative procedure for the treatment of myelodysplastic syndrome (mds), but among several limiting factors for its accomplishment, such as the patient´s performance status, is a very relevant issue, i.e., the availability of a compatible hla donor and, when available, very often the donor´s age and comorbidities also constitute factors that hinder this medical conduct. considering this scenario, the possibility of a haploidentical transplantation (ht) has emerged as an option. in latin america, ht has been included as a treatment option since . since then, these patients have been included in the latin american registry of transplantation in myelodysplastic syndrome, making it possible to analyze the viability and results of these transplants.methods: from october to october , seventeen ( ) patients were transplanted with a haploidentical donor and included in the latin american registry. none of these patients had an identical hla ( / match) related or unrelated donor. data were obtained from the latin american registry of hsct in mds. the statistical analyses were performed using the software spss, version . and graphpad prism version . , with significance being set at p < . .results: table shows the patients and their characteristics. all donors were haploidentical. there was a predominance of reduced intensity conditioning, which was performed in patients ( . %), whereas the others received the myeloablative conditioning. cell source was peripheral blood in ( . %) and bone marrow in ( . %) of the patients. graft-versus-host disease (gvhd) prophylaxis in post-hsct was carried out with cyclophosphamide mg / kg on d+ and d+ , cyclosporin from d and mycophenolate from d+ . complete hematologic recovery was achieved in ( . %) patients. the incidence of grade ii-iv acute gvhd was . %, whereas chronic gvhd was . %. one death occurred due to graft failure and none of the patients showed autologous recovery. three other patients died. one on d+ due to a fungal infection, the second on d+ due to sinusoidal obstruction syndrome and a third on d+ due to pneumonia caused by pseudomonas. regarding overall complications, there was a predominance of mucositis ( %), overall infections ( . %) and reactivated cmv in . % of cases. of the total number of living patients, ( %) achieved complete remission and ( . %) showed disease relapse. the mean follow-up was months (ranging from to months). the lowest probability of disease-free survival at years was % ( % ci: . - . ).background: relapse is the most important cause of failure after allogeneic hematopoietic stem cell transplantation (hsct) for flt -itd-positive acute myeloid leukemia (aml). treatment with flt tyrosine kinase inhibitors (tki) constitutes a promising clinical approach to induce remission without conventional chemotherapy.methods: a year-old woman diagnosed with aml secondary to myelodisplastic syndrome (mds) with npm mutation and internal tandem duplications of the flt gene (flt -itd) in october . after achieving complete remission (cr) with conventional chemotherapy, she received a hla sibling allogenic-hsct in february , with bucy. four months later, aml relapsed only at medullary level (flt ratio: , %), treated with chemotherapy and donor lymphocytes infusions (dli). she achieved nd cr and developed limited chronic graft-versushost disease (cgvhd). nine months later (april ), she suffered the first extramedullary relapse only, breast and skin. disappearance of the lesions at all levels was achieved with chemo and radiotherapy. she always had full hematologic donor chimerism.in december , she referred atypical precordial pain irradiated to the back. cardiac mri was performed and several masses were visualized in the pericardial sac, up to cm in diameter. bm remained in cr with full donor chimerism.pericardial fluid showed massive infiltration by leukemic-flt positive cells (ratio: , %). she was not considered background: ta-tma is a severe complication that can reduce survival after hsct. risk factors have been variably reported in adults although data on children remains scarce. we aimed to identify a risk profile for development of ta-tma in children undergoing hsct.methods: we retrospectively reviewed clinical charts of children who underwent hscts between - : at great ormond street hospital (gosh) and the great north children's hospital (gnch). ta-tma was defined according to revised criteria (jodele et al. ) . risk factors were categorized into patient derived [age, gender, active co-morbidity at d of hsct (uncontrolled viral/ bacterial or fungal infection, pulmonary, cardiovascular instability, steroid therapy > . mg/kg beyond d , bcgiosis or autoimmune disease), transplant related factors (conditioning intensity, stem cell source, hla-matching, use of ciclosporin a (csa) or tacrolimus (tac), cd + dose, ex-vivo t cell depletion, use of defibrotide) and post-hsct factors (agvhd, post-hsct viral reactivation, venoocclusive disease (vod) and occurrence of posterior reversible leukoencephalopathy (pres).results: at a median of months post-hsct, ta-tma occurred among / transplants ( . %). there was no reported centre variation ( . % vs . % in gosh vs gnch; p= . ). gender, underlying disease -primary immune deficiency (pid) (n= ) vs haematological disease (n= ), use of myeloablative (n= ) vs reducedor minimal intensity conditioning (n= ), use of serotherapy or mega doses of cd ≥ x * /kg did not influence the development of ta-tma. donor type: msd/ mfd(n= ) vs mud (n= ) vs mmud/haplo-hsct background: we evaluated the outcome of haploidentical hct (hhct) using ex vivo αβ t cell-depleted (tcd) grafts after reduced-intensity conditioning (ric) containing low-dose tbi (ld-tbi) in pediatric patients with acute leukemia (al) in complete remission (cr).methods: between may and october , patients with acute leukemia ( all and aml) in cr received haploidentical hematopoietic cell transplantation (hhct) using tcrαβ-depleted graft at asan medical center children's hospital. eighteen patients received hhct between and (earlier time period) and the remaining between and (recent study period). the conditioning regimens, the dose of αβ+ t cells and gvhd prophylaxis are summarized in table. results: all patients achieved a sustained neutrophil engraftment at a median of days (range, - ) . of patients, patients ( all & aml) relapsed at a median of months (range, - ) after transplant. of the patients, patients died of disease. one patient died of disseminated tuberculosis at months after transplant, leading to the trm of % at year. as of december , of the patients survive free of disease at a median follow-up of months (range, . at a median followup of months (range, - ), efs and os at years for all patients were % and %, respectively. outcome of hhct in the recent study cohort was significantly better than that in the earlier study period (efs of % vs efs of %, p= . ). among the patients with all, the efs of patients, who received hhct in early time period after conditioning with tbi of cgy, was significantly worse than that of patients, who received in recent study period after a higher dose of tbi at cgy ( % vs %, p< . ). the efss of aml were similar between the two study groups ( % for earlier cohort vs % for recent study, p> . ).conclusions: in pediatric patients with acute leukemia in cr, our current haploidentical hct using ex vivo αβ tcd graft after ric containing ld-tbi without gvhd prophylaxis is feasible approach with a low trm. the background: anti-hla antibodies (ahab) have been recently recognized as an important risk factor for graft failure (gf), especially in hla-haploidentical stem cell transplantation (haplo-hsct). although, recently, ebmt consensus guidelines have been published [ciurea, bone marrow transplant ] , experience in pediatric t-cell depleted (tcd, another well-known risk factor for gf) haplo-hsct is lacking. in the present study, we report our experience on the use of a desensitization approach based on ebmt guidelines.methods: between june and august , all patients affected by non-malignant diseases and scheduled for a transplant from an hla-haploidentical donor after negative depletion of αβ t and b cells as previously described [li pira, biol blood marrow transplant. ], were tested for ahab with luminex® solid-phase immunoassay (one lambda, thermo fisher scientific) month before the hsct. all patients with a mfi higher than , which is considered a cutoff predicting for gf, were treated with a desensitization protocol based on the use of anti-cd rituximab ( mg/m before and immediately after the end of plasma-exchange cycle) and plasma-exchange (pe) ± infusion of irradiated buffy coat (bc) (if after pe ahab mfi was still > mfi). this latter was obtained by the non-target fraction of the αβ t-cell/b-cell-depletion procedure and consisted of * irradiated nucleated cells/kg of the recipient; this was infused - hours before the infusion of the tcd graft. pe was performed with miltenyi life tm apheresis unit (miltenyi, bergish-gladback) .results: in the study period, patients received αβ tand b-cell depleted haplo-hsct. eighteen ( %) resulted positive for ahab (mfi> ); ( %) of them had an mfi > for either anti-class i or ii ahab. these patients (see table i background: osteonecrosis (on) is a debilitating complication in survivors of allogeneic hematopoietic cell transplantation (hct). limited data is available on its course post-transplantation in children. the purpose of our study was to identify recipients of hct in whom pre-and post-magnetic resonance imaging (mri) is indicated.methods: the retrospective cohort consisted of patients who underwent first allogeneic hct from - , and prospectively underwent a total of pre-and post-transplant mri studies of the hips and knees done annually for years regardless of symptoms. surviving patients were followed for a median time of . (range . - . ) years. cases of on were compared to controls matched for age, sex, transplant type, and follow up in a : ratio for the following variables: ethnicity, underlying disease, on pre-hct, conditioning regimen, graft source, bone mineral density z-scores, body mass index, presence or absence of graft-versus-host disease, steroid use and dosage, and survival status.results: thirty ( . %) patients had mri findings confirming on post-hct. all patients with on except one were more than years of age. twenty ( %) patients were male. on pre-hct (p < . ) was the only factor associated with presence of on post-hct. epiphyseal on was seen in ( %) patients pre-hct, and ( %) post-hct. eighteen ( %) patients had involvement of more than % of articular surface, and were more likely to undergo surgery (p = . ).conclusions: the incidence of on in this large pediatric cohort was %. the only risk factor for on post-hct was pre-existing on. mri evaluation for on pre-hct is indicated in all patients. mri evaluation for on post-hct is only indicated for patients with on pre-hct and symptomatic patients. this will entail cost savings of usd , per surviving allogeneic hct patients per year. patients with more than % involvement of the articular surface need close follow up.clinical trial registry: none disclosure: none impact of rabbit anti thymocyte globulin exposure on immune reconstitution and outcome after stem cell transplantation in children background: rabbit anti thymocyte globulin (ratg) has been frequently used for many years as gvhd prophylaxis in pediatric stem cell transplantation. precise dosing regimens are crucial but remain challenging due to several pharmacological characteristics in children.methods: ratg levels were measured in pediatric patients undergoing allogeneic stem cell transplantation after obtaining approval by the local irb and informed consent by legal guardians. pediatric patients who received either thymoglobuline™ (n= ) or grafalon™ (atg-f) (n= ) as part of their conditioning regimen background: obesity among children is a growing health problem. malnutrition or being over-weight can be of prognostic impact among children who need hsct.scientific literature shows a lot of controversy in terms of effect of bmi at the time of infusion on the outcome of hsct.methods: we reviewed data of patients who underwent hsct at king faisal specialist hospital & research centre between - to correlate bmi with the outcome and complications of hsct. transplant naïve recipients with age at infusion between - years who received hsct from matched related donor or autologous hsct, were included in the dataset for analysis. a total of patients' profiles were reviewed of whom . % were boys. median age at transplant was . years. primary indication of disease was malignancy in . % followed by hemoglobinopathies . %, bone marrow failures . % and immune disorders . %. solid tumors accounted for . % among malignant disorders. myeloablative conditioning was used in . % transplants with . % regimens containing total body irradiation. majority of the patients . % underwent allogeneic transplantation using bm as the source in . % and pbsc in the remaining . % cases. donor was hla-identical sibling in %, parents in . % and others in the remaining . % patients. median tnc dose was . x ^ and cd was . x ^ per kg of the body weight at the time of infusion. age and gender specific bmi percentiles were obtained and classified according to the definition of centers for disease control and prevention (cdc); . % ( ) recipients were categorized as under-weight, . % ( ) normal, . % ( ) over-weight and remaining % ( ) as obese.results: based on chimeric studies at day- , our engraftment rate was . % ( ) out of evaluable cases. median time to neutrophil recovery was -days from infusion and -days for platelets. no statistically significant difference was found for engraftment rate on d- as it was % ( ) among . % ( ) in normal, % ( ) in under-weight and . % ( ) in the obese (p-value: . ). median time to neutrophil recovery from the infusion date was -days in over-weight patients and in the remaining three groups (p-value: . ). acute graft vs. host disease (agvhd) of any grade at day- was recorded in . % ( ). any-grade agvhd was more common in over-weight % ( ), followed by obese with . % ( ), % ( ) in under-weight and . % ( ) in normal bmi-category (p-value: . ). chronic gvhd was more frequent in over-weight ( . %, ), compared to ) background: hematopoietic stem cell transplantation (hsct) is the standard treatment for children with severe aplastic anemia (saa) who have hla-identical related donor. there is no standard conditioning regimen for children with saa secondary to non-fanconi anemia (fa) constitutional bone marrow failure syndromes such as telomeropathies. we report the outcome of a consistent reduced intensity conditioning regimen in patients with idiopathic saa or inherited bone marrow failure syndromes other than fa who underwent hla matched related hsct methods: children with saa underwent hsct using the following conditioning regimen: fludarabine mg/m , cyclophosphamide mg/m , and atg (thymoglobulin) ( mg/kg) . gvhd prophylaxis included cyclosporin and mycophenolate mofetil. donors were all matched related and bone marrow was the stem cell source. all patients had normal chromosomal fragility testresults: a total of children with saa underwent hsct, females and males. average age was . (range . - . years). all nine patients who were tested for telomere length had short telomeres. pathogenic or likely pathogenic mutations were reported in patients ( ercc l , ankrd , tinf , lztfl ). all donors had normal physical examination, normal cbc, and negative genetic testing if patient mutation is known. all patients engrafted successfully, median time to neutrophil engraftment was (range, - days) and platelet engraftment (range, - days). median infused nucleated cell dose was . (range, . - . x /kg) and cd cell dose was . (range, . - . x /kg). none of our patients had acute gvhd and one patient had mild classic chronic gvhd of the skin that was controlled with topical therapy for a short period. three patients had secondary graft failure in the first-year post transplant. first patient had pancytopenia with loss of donor chimerism and underwent successful second transplant using fludarabine, atg, and melphalan. the second patient had a nonfunctioning graft despite full donor chimerism suggesting that the related donor might be affected and had silent phenotype. the third patient had homozygous ercc l mutation and developed progressive cytopenia with myelodysplastic features few months post-transplant and subsequently underwent myeloablative matched unrelated transplant using busulfan, fludarabine, thiotepa and atg. however, the patient progressed to have acute myeloid leukemia six months post hsct. fifteen patients ( %) have normal cbc and stable donor chimerism. median follow-up duration of days (range - days). one patient with lztfl mutation developed chronic renal impairment five years post hsct.conclusions: hsct using lower dose cyclophosphamide ( mg/kg) as part of fludarabine based regimen was safe and effective in saa patients with shorter telomeres and described genetic abnormalities. optimal conditioning regimen in ercc l -associated bone marrow failure needs to be defined. larger study is needed to confirm our results.clinical trial registry: not applicable disclosure: nothing to declare late effects in patients with hemophagocytic lymphohistiocytosis treated with hematopoietic stem cell transplantation: a review of the literature background:hemophagocytic lymphohistiocytosis (hlh) is an inherited or acquired disorder of immunedysregulation. early diagnosis and immunosuppressive treatment can prevent significant organ-failure. the inherited forms, and some acquired cases can only be cured by hematopoietic stem cell transplantation (hsct). with modern transplant practices, a significant number of patients survive. the purpose of this literature review was to collect data on the frequency and type of late effects in hlh patients surviving after hsct and to examine the association with pre-existing hlh conditions (eg. involvement of the central nervous system (cns) before transplant) and with the pre-transplant conditioning regimens.methods: the medline, embase, web of science and pubmed databases were searched, by two librarians at the karolinska institutet, between may and september according to the preferred reporting items for systematic review and meta-analysis (prisma) statement. the search terms included "hlh", "fhl", "mas", multiple terms for "hsct" and late-effect conditions. inclusion criteria were publications in english that included children between january and may . authors of this review screened all the abstracts of studies against the inclusion criteria.results: only nine papers published between and , with information on late effects in hlh patients who had undergone hsct, were identified. three reports include only small numbers of hlh patients. the remaining papers contain data on long-term survivors with a median follow-up of . years. five papers address neurological sequelae with a reported incidence from - %. the highest incidence was found after a thorough neurological assessment of hlh patients compared to matched sibling controls. however, the association with cns disease before transplant and age at transplant was not clear. patients with ebvassociated hlh seem to have fewer long-term neurological problems. non-neurological late effects are described in papers only, with endocrinological problems, namely short stature, being the most frequent. one paper specifically analyzed poor growth, thyroid dysfunction and vitamin d deficiency in a cohort of patients with non-malignant disorders including hlh who had undergone hsct after a reduced intensity conditioning regimen and found significant abnormalities in all groups.conclusions: data on late effects in hlh patients is scarce and is mostly based on the retrospective evaluation of small national cohorts. the available information indicates that a significant number of patients suffers from problems which affect their daily life, but lack of information does not allow to analyze the association between pre-transplant conditions and long-term sequelae. therefore, a retrospective comprehensive analysis of patients registered in the ebmt and cibmtr registries is currently performed. it will be crucial to better define the frequency and type of late effects in a large cohort. this knowledge will aid counselling prior to hsct, provide guidance for long-term monitoring of these patients, and potentially identify specific risk factors for late effects in this rare patient population.disclosure: nothing to declare. allogeneic stem cell transplantation in patients with mucopolysaccharidosis type ii (morbus hunter)bernd hartz , nicole muschol , matthias bleeke , johanna schrum , ingo müller background: the transplantation of hematopoietic stem cells (hsct) is one of the leading methods of treatment in patients with blood system diseases, primary immunodeficiency syndromes and genetic diseases. at the same time, the quality of life in patients in the long-term after hsct significantly differs from the quality of life of healthy people of the same age. deformations in psychosexual development including problems in the gender identity formation cause social isolation of adolescents, which makes their sexual selfrealization impossible and significantly reduces the quality of their life. the purpose of our study was an assessment of the level of gender identity formation of adolescents and psychosexual development correlation to the normal adolescents of the same age.methods: in a prospective single-center study in , on the base of the department of rehabilitation medicine raisa gorbacheva memorial institute of children´s oncology, hematology and transplantation, we conducted a study of families. the respondents were: ) parents / guardians of patients accompanying them in the process of examination; ) adolescents who underwent hsct treatment and undergo planned examinations at the clinic in the posttransplant period (after d + ), (n = , of which girls and boys, age - years, from the date of hsct - years).the following methods were used to assess gender identity: specially developed questionnaires for teenagers and parents; questionnaire by sandra l. bem (sandra l. bem, ) ; projective techniques "the human picture", "the non-existent animal"; max lüscher´s color choices test.results: the traditional type of gender identity, which characterizes high masculinity among male respondents and high female gender indicators in % of cases, was not revealed. both among girls and among boys, the androgynous type prevails with a tendency toward femininity.on average, adolescents see themselves as a bit more courageous than their mothers, with rare exceptions, regardless of gender. this confirms the thesis that we received in a previous study that parents tend to see and encourage complacency of adolescents of both sexes, passivity instead of leadership, dedication and independence. all % of adolescents who participated in the test demonstrate a shift in the theme of aggression, % have some signs of preventing sexual self-determination, abandoning their body, gender, and age. % of patients do not communicate with their peers. in % of them, negative emotions prevail over positive ones. one third of the test participants demonstrate strong support for rest and minimizing their efforts.conclusions: the characteristics of family upbringing of adolescents who have undergone hsct often contribute significantly to limiting their social experience and lead to specific deformities of individuality, including in the sphere of gender identity. we consider advisable to introduce thematic group counseling of parents within the framework of the "patient's school" in psychological treatment support in the clinic. early diagnosis of the personal aspects of the psychosexual development of adolescents after hsct allows for timely identification of individual problems in this area and identification of general trends in the long term after hsct.disclosure: all authors -nothing to disclose. abnormalities in the morphology of the umbilical cord blood obtained at delivery from children who received a diagnosis of cerebral palsy maciej boruczkowski , izabela zdolińska-malinowska , maciej rojek , dariusz boruczkowski background: embryonal brain tumors are the most common malignancies in infants less than months of age. histologically characterized as undifferentiated small round cell tumors, all are similarly aggressive, have a tendency to disseminate throughout central nervous system and very poor prognosis. we tried to assess the effectiveness of tandem highdose chemotherapy (hdct) with autologous hematopoietic stem-cell transplantation (auto-hsct) in this patient group. methods: from to , infants under months with different primary embryonal brain tumors such as medulloblastoma (n= ), different pnet nos (n= ), pineoblastoma (n= ), atypical teratoid rhabdoid tumor (n= ), etmr (n= ) after surgical resection and induction chemotherapy were planned to receive tandem hdct with auto-hsct. nine patients were conducted only single transplantation because of the development of lifethreatening complications after the first hdct (n= ) or the emergence of early disease progression (n= ). at the moment of hdct patients were in complete remission (cr), patients were in partial remission (pr) and patient had stable disease (sd). the conditioning regimen for tandem auto-hsct were: the first hdct was carboplatin and etoposide, the second was thiotepa and cyclophosphamide, both with intraventricular methotrexate.results: the median follow-up is months (range, - ). the median time to engraftment after the first auto-hsct was background: a series of findings suggest that optimizing natural killer (nk) cell reactivity could further improve outcome after allogeneic hematopoietic cell transplantation (allohct). this could be achieved by killer cell immunoglobulin-like receptor (kir) genotype informed donor selection. an enhanced receptor-ligand model which used kir ds and kir dl donor genotype information to augment nk cell activation and minimize inhibition demonstrated improved survival in one large aml study (boudreau et al, jco ) . likewise, a second model built on the classification of centromeric and telomeric kir haplotype motifs, also predicted mortality after allohct for aml (cooley et al, blood ) . this joint ebmt and cibmtr study aimed at validating the two approaches in an independent cohort of patients with mds or secondary aml.methods: donor samples were retrieved from the collaborative biobank (dresden, germany) and mapped to patient outcome data extracted from the ebmt and cibmtr. genotyping of all kir genes by sequencing exons , , , , , and was performed by high resolution amplicon-based next generation sequencing. the impact of the classifiers on time-to-event outcomes was tested in cause-specific cox regression models adjusted for patient age, a modified disease risk index, performance status, donor age, hla-match, sex match, cmv match, conditioning intensity, type of t-cell depletion and graft type.results: clinical data from patients and corresponding donor genotype information were analyzed. the median age at allohct was . years (range, . to . years). the indication for allohct was mds for % and saml for % of patients. disease risk was low/intermediate and high/very high in % and %, respectively. donors were / matched for % of patients. myeloablative, reducedintensity and non-myeloablative conditioning regimens were used in %, %, and % of patients, respectively. peripheral blood stem cells were the predominant graft source ( % of patients). atg was administered in % and alemtuzumab in % of patients. during follow-up after allohct patients died. in univariable and multivariable analyses of the whole cohort, overall survival and the cumulative incidence of relapse of patients with kiradvantageous versus disadvantageous donors were not statistically significantly different. we could not replicate the pattern of outcomes predicted by the kir dl / conclusions: relapse incidence and overall survival after unrelated donor allohct could not be predicted using the kir dl /kir ds -receptor-ligand model and centromeric/telomeric kir-motif model in this large cohort of patients with mds or secondary aml. this points at the possibility of interactions between nk-cell mediated alloreactivity and disease type or procedural variations of allohct. available information on kir-genes, which have been sequenced but not yet analysed, will be investigated in exploratory analyses.disclosure: the authors have nothing to disclose in the absence of an alternative donor, it is recommended that patients undergo desensitization therapy, especially with high dsa levels (> , mfi). the aim of this study is to analyze the impact of dsa on risk of gf and poor graft function (pgf), and on major outcomes in a consecutive cohort of patients who were systematically screened for dsa before haplo-sct. methods: consecutive patients were candidates for unmanipulated haplo-sct with post-transplant cyclophosphamide (pt-cy) at our center from january to january and were analyzed for the presence of hla antibodies.results: patients underwent haplo-sct. hla antibodies were detected in patients, of them were dsa, while were non-dsa (ndsa). patients out of with dsa were transplanted using the same donor; underwent a desensitization program before transplant.background: a recent study from ebmt comparing matched sibling (msd) versus haploidentical donors transplantations, showed better outcome with msd in adult patients with intermediate risk aml in first remission (cr ). however, a female donor to a male recipient transplant combination is a poor prognostic factor and this study did not address the question whether in this situation, a haploidentical donor transplant might do better. the present study compared the outcomes of allografted male patients according to whether they received stem cells from a female msd or a haploidentical donor, in the intermediate and high risk cytogenetics groups (mrc classification).methods: the study included male patients with cytogenetics transplanted between january and june and reported to ebmt. received stem cells from a msd female donor and from a haploidentical donor ( male and female). the follow up was months ( - ). we studied separately intermediate and high risk patients. multivariate analysis was adjusted on factors differing significantly between the groups.results: -intermediate risk group: male patients received a female msd and a haploidentical transplant. the distribution of group characteristics was even except that in the haploidentical transplant group, donors were younger ( y versus ; p< . ), marrow was more frequently used ( % versus %, p< . ) and the interval from diagnosis to transplant was longer ( . versus . months, p< . ). by univariate analysis at two years post transplant, cumulative incidence (ci) of nrm post haplo was higher ( % versus %, p= . ) and ci of extensive chronic gvh lower ( % versus %; p= . ). lfs post msd and post haplo were % and % (p= . ), os % and % (ns), grfs ( % and %). by multivariate analyses the only significant poor risk factors were the haplo-identical transplant for nrm (hr: . ( . - - )) and the patient age for os (hr: . ( . - . ; p= . ). haploidentical transplantation resulted in less chronic gvhd (hr: . ( . - . ); p < - ), but a lower lfs (hr: . ( . - . ); p= . ). -high risk group: male patients received a female msd and a haploidentical transplant. in the haploidentical group, donors were younger ( y versus ; p< . ), marrow was more frequently used ( % versus %, p< . ) and the interval from diagnosis to transplant was longer ( . versus . months, p= . ). by multivariate analysis, haploidentical transplants were associated with a lower relapse incidence (hr: , ( . - . ; p = . ),a better lfs (hr: , ( . - . ; p = . ),os (hr: , ( . - . ; p = . ), and grfs (hr: , ( . - . ; p = . )(see figure) . the only other significant prognostic factor was patient age.conclusions: this study shows that in a male patient with intermediate risk aml, a genoidentical sister donor remains associated with a better lfs. in contrast, in a male patient with high risk aml in cr , a haploidentical donor may be a better choice than an hla genoidentical sister.disclosure: nothing to declare p abstract already published. hematopoietic transplant for older acute leukemia patients: improved survival with offspring donor in comparison with older-aged matched siblingsyu wang , sheng-ye lu , qi-fa liu , de-pei wu , xiao-jun huang background: post-transplant relapse remains the major cause of death of treatment failure. therapeutic options for relapse after first allogeneic stem cell transplant ( st hsct) include chemotherapy followed by donor lymphocyte infusion or second allo-hsct ( nd hsct) from the original donor or change to another donor. however, there is unclear outcome for different treatment approach. in this retrospective cohort study, we aim to compare the clinical outcome after different treatment strategy for relapse after first allo-hsct.methods: between jan and oct, consecutive patients receiving st hsct registered to the bmt database in national taiwan university hospital were analyzed. among them, cases had relapsed after first allo-hsct. one hundred and three patients who received no treatment after relapse or with incomplete data were excluded. their transplant data was collected following the ebmt registry data collection forms and manuals. overall survival rate and progression free survival rate were performed by the kaplan-meier method. univariate and multivariate analysis were performed using cox proportional hazard regression model.results: of the patients who experienced relapse after st hsct, total patients ( %) received chemotherapy followed by dli or nd hsct from the same donor (no change group), patient ( %) received chemotherapy followed by nd hsct from different donors (change group), and ( %) had conventional chemotherapy alone. the patients in "change group" were younger (median age vs , p = . ), and had more patients achieving complete remission (cr) prior to nd hsct ( % vs %, p = < . ) than patients in "no change group". after the nd hsct, the cr was % for "no change group" and % for "change group". the progression-free survival at -year and -year were . % and . % (fig a, p = . %), respectively, for "no change group" and . % and . %, respectively, for "change group". while the overall survival (os) at -year and -year were . % and % (fig b, p = . %), respectively, for "no change group" and . % and %, respectively, for "change group". those who achieved cr prior to nd hsct had a trend of better os than those without cr ( . % vs . % at -year; . % vs . % at year, p =. )( fig c) . there were cases survived for more than years in "change donor group" and cases survived more than years in "no change group". only one had developed relapse after nd hsct but achieved subsequent remission again.conclusions: our study shows that change donor had similar poor outcome comparing to those using the same donor after the st hsct. patients who achieved cr before nd hsct had a trend of better os than those without remission and the long-term survivors were only those who achieved cr prior to nd hsct. novel therapy for cr induction would be warrant for this poor prognostic population.disclosure: nothing to declare functional relevance of fetal microchimerism in nk cell cytotoxicity against leukemic blasts in children: a role for hla-c and kir dl /s ?background: allogeneic stem cell transplantation (allo-sct) remains the most effective curative intent therapy for patients with unfavorable risk acute leukemia. various donor options are available for the patient who lacks an hla-matched sibling donor, such as unrelated donors (urd) and hla-mismatched family (haploidentical) donors. in order to discover the exact role of transplantation type, there are many retrospective analysis, which compared these donor sources, have been reported. recent studies showed some promising results of haploidentical donor transplantation (hidt) using post-transplant cyclophosphamide in comparison with unrelated donor. the goal of this study was to compare the outcome of allo-sct from haploidentical versus matched unrelated (mud / ) or mismatched unrelated donor at a single hla-locus (mmud / ) for patients with acute leukemia in remission.methods: ninety-six adult ( - years) patients with acute leukemia in first or second remission who underwent allogeneic transplantation with a minimum days follow-up at florence nightingale hospital hematopoietic stem cell transplantation center between and were included in this study. patient characteristics and medical records of all patients were reviewed retrospectively. thirty-eight patients who received haploidentical donor transplantation were compared with patients receiving a mud / and receiving a mmud / . patients who completed minimum days post-transplantation follow-up were identified as eligible for survival analysis.results: the characteristics of the patients and transplant donors in this study are summarized in table . median age of patients was . ± years. proportion of male patients was . %, . % and . % for mud / , mmud / and hidt groups, respectively, which is significantly different (p= . ). the other baseline factors were similar, including patient age, donor age, recipient cytomegalovirus (cmv) status, donor cmv status, graft versus host disease incidence, median neutrophil and platelet engraftment times and disease status at post-transplant th day. no significant difference was identified in survival analysis among the mud / , mmud / and hidt groups, even if they were classified according to primary disease (aml vs all) and pre-transplant disease status (cr vs cr ). also, donor cmv status (cmv igg positivity or negativity) was not an important factor on survival analysis when compared between these three groups (p= . ).conclusions: in our study population, clinical outcomes of hidt patients were inferior to mud / and mmud / groups. when choosing an alternative donor for patients without an available hla-matched sibling, urgency of transplantation and host/donor features should be considered. we believe that hidt might be a feasible alternative choice in this subset of patients.disclosure: nothing to declare p g-csf primed bone marrow in hla-haploidentical transplantation using post-transplantation cyclophosphamide (ptcy) could promote tolerance and further reduce risk of gvhd nadira durakovic , , zinaida perić , , lana desnica , ranka serventi-seiwerth , mirta mikulić , brian melamed , alen ostojić , dražen pulanić , , pavle rončević , zorana grubić , radovan vrhovac , implementation, development, and coordination of unique quality management systems with evaluation audits, intrahospital and international accreditation and certification processes. quality of health care is a major focus for providers, patients, and accreditors; so, in this study, we aim to compare the quality of bm harvested at ipo-collection centre (icc) with the quality of bm received from external collection centres (ecc) during these last years.methods: this retrospective evaluation included the number of total nucleated cells (tnc) requested by the transplant centre, the tnc collected, and the results of bm microbiological analysis performed; donor age, weight and infectious disease markers (idm); patient demographics and diagnosis. bm collection technique in use at icc was validated according to jacie standards.we consider successful a collection (sc) with tnc between and % of the requested value, unsuccessful (uc) if lower than % and outstanding (oc) if over %.results: a total of bm was collected, for allogenic ( unrelated) and seven for autologous transplant; unrelated bm were received from ecc (nine from germany, seven from usa and five from portugal). patient main diagnosis were severe aplastic anaemia (n= ), acute myeloblastic leukaemia (n= ), and acute lymphoblastic leukaemia (n= ). donors idm were all negative and nonreactive.mean age (±standard deviation, sd) was (± . ) and (± . ) years for icc and ecc donors, respectively. at icc, we were asked to collect an average (±sd) of . * (± . ) tnc while ecc were asked for . * (± . ). we collected . * (± . ) and received . * (± . ) tnc. correlation between requested and collected tnc was . at icc and . for ecc.we had . % sc and . % oc meaning an accomplishment of . %. we failed to collect required tnc in . %. although % of received bm fulfil tnc requirements, bm processing lowered this value to % due to erythrocyte removal (seven patients with major abo incompatibility) and plasma reduction (two patients with abo minor incompatibility). these steps reduce final tnc available for transplant. weight difference between donor and patient had no significant impact on final tnc collection performance.sixteen bm from icc (seven staphylococcus spp., five propionibacterium acnesand fourcorynebacterium spp.) background: success of peripheral blood stem cell (pbsc) collections depends on patient biological parameters and stable apheresis device performance. peripheral blood cd + cell enumeration is the most reliable predictive factor of apheresis yield however, there are some unexpectedly poor cd + cell harvests despite successful mobilization. the aim of the study was assess total collections cd + yields and factors influencing main apheresis procedure outcomes including collection efficiency (ce).methods: of consecutive donors covering the period - - to - - were analyzed for the following parameters: pre cd count, cd yield per procedure, total cd dose collected per patient, cd collection targets requested by clinical teams. the efficiency of pbsc procedures was determined by calculating the ce and the correlation coefficient between pre cd count and yield per procedure. ce was correlated to preprocedure wbc, platelet count, pre cd count and blood volume processed. all pbsc collections were performed by optia spectra across units in uk.results: of the donors, were autologous and allogeneic. the autologous donors underwent in total procedures. the median cd target dose for these donors was x /kg. ( %) achieved the target dose with procedure and ( %) with procedures. the median pre cd count was /μl. the median cd yield per procedure was . x /kg and the median total cd dose collected per donor was . x /kg. ( . %) of autologous donors collected a total cd dose < x /kg, of those ( . %) had a pre cd count < /μl and ( %) > /μl.the allogeneic donors underwent in total procedures. the median cd target dose for these donors was x / kg. allogeneic donors ( %) achieved the target dose with procedure and ( %) with procedures. the median pre cd count was /μl. the median cd yield per procedure was . x /kg and the median of total cd dose collected per donor was . x /kg. ( . ) % of allogeneic donors collected a total cd dose < x / kg, of those ( . %) had a pre cd count < /μl and ( . %) > /μl. the median ce for autologous donors was % (range - ) and for allogeneic donors was % (range - ). the ce was negatively correlated to wbc (r= - . and - . ) and platelet count (r=- . and - . ) for auto and allogeneic donors respectively, but did not correlate to the pre cd and blood volume processed. the correlation coefficient between pre cd count and cd yield per procedure was r = . for the autologous and r = . for the allogeneic collections.conclusions: the majority of autologous and allogeneic donors achieved the target cd dose with one procedure. . % of autologous and . % allogeneic donors collected a transplantable cd dose of > x /kg. % of autologous and . % of allogeneic donors did not collect a transplantable dose despite a precd count of > /μl indicating suboptimal procedure performance. the ce was variable and was negatively correlated to the preprocedure wbc and platelet count. the ce and correlation coefficient are lower in allogeneic donors compared to autologous donors.disclosure: nothing to declare the outcome of autologous blood stem cell collection and its actual use in real world: the st century experiencekyoungmin lee , jung yong hong , dok hyun yoon , jae-lyun lee , shin kim , kyoung min lee , jung sun park , cheolwon suh background: mobilized peripheral blood stem cells (pbscs) have largely replaced bone marrow as the graft source for allogeneic stem cell transplantation. pbscs mobilization with g-csf is highly effective even on the th day in order to collect enough number of stem cells. a longitudinal, prospective, observational, single-center, cohort study on healthy donors (hds) was designed to identify predictors of cd + cells on the th day. methods: as potential predictors of mobilization, age, sex, body weight, height, blood volume as well as white blood cell count, peripheral blood (pb) mononuclear cells, platelet count, hematocrit, and hemoglobin levels were considered. two different evaluations of cd + cell counts were determined for each donor: baseline (before granulocyte colony-stimulating factor [g-csf] administration) and in pb after g-csf administration on day . a total of consecutive hds with a median age of . years were enrolled.results: the median value of cd + on day was cells/μl (iq - ). basal wbc, plt and basal cd +, are significantly higher for group with cd + on the th day over the median than below. a multivariate quartile regression analysis, adjusted by gender, age, basal cd + and basal plt, shows a, progressively steeper, relationship between baseline cd +, basal plt and cd + on the th day. the basal cd + cut-off for prevision of cd + on the th day was < = cells/μl and >= cells/μl whereas basal platelets count was < = x /l and >= x /l.conclusions: g-csf can be highly effective in hds on the th day in order to collect enough number of stem cells and we have developed a model for predicting the probability to perform pbsc collection after a short course of g-csf.disclosure: nothing to declare p pre-apheresis peripheral blood cd + cell counts highly correlates to actual stem cells collected background: prediction of stem cell yield on the basis of pre-apheresis cd + cell count and the processed blood volume is essential for the planning and executing of the apheresis process.methods: data analyzed included donor weight, complete blood count and cd + count on day of collection, total processed blood volume, cd + cell dose collected in the apheresis product and the number of aphereses performed. using the method described by pierelli et al, predicted cd + yields were calculated: predicted cd + yield x /kg = (benchmark ce x volume of blood to be processed x peripheral cd + count per μl) / (patient's weight in kg x metric conversion factor).results: in we established the method described by pierelli to predict the cd + cell yield. allogenic aphereses were performed in with this approach. mean processed volume was . liters. the mean cd + peripheral count before apheresis was /ul, the mean collected cd +count per kg bodyweight recipient was . . pearson´s correlation coefficient (r) between predicted yield using pre-apheresis cd +count and actually collected cd + cells per kg bodyweight recipient was . . the mean difference between predicted and collected cell dose was + . %.with knowledge of the predicted stem cell count, we were able to adjust apheresis procedure. in case of marginal predicted yield compared to the requested cell dose, we increased the blood volume to be processed. this proceeding led to a significant reduction of second day donations in by % compared to . in only cases we saw more than - % lower cd + doses collected than initially predicted. all donors showed mild iron deficiency with rbc microcytosis, a factor known to affect apheresis procedure.conclusions: pierellis method of calculating the stem cell yield shows a good correlation between pre-apheresis cd + count and actual collected stem cells, making planning and adjusting of the apheresis procedure more feasible and reliable. this proceeding led to significant reduction of second day donations. attention should be paid to iron deficiency anemia, leading to lower than estimated cd + dose.[ background: for more than a decade many transplant centers routinely collect and cryopreserve two or more peripheral blood stem cell (pbsc) grafts for a tandem and/ or salvage autologous blood stem cell transplantation (absct) in patients with hemato-oncological diseases. however, subsequent high-dose chemotherapy (hd-cht) and absct is in many cases not performed for a variety of reasons, specifically in patients with aml, all, mpn and burkitt lymphoma. data about the actual utilization rate of the cryostored stem cell products are lacking.methods: we retrospectively analyzed the collection, storage and disposal practices of pbsc products from a large cohort of patients who were treated at the university hospital heidelberg or at the university medical center mannheim during a -year period. disease entities included acute myeloid leukemia (aml, n= ), acute lymphoblastic leukemia (all, n= ), mpn (n= ; primary myelofibrosis [pmf], n= ; chronic myeloid leukemia [cml], n= ; secondary fibrosis/essential thrombocythemia [et], n= ; not specified, n= ) and burkitt lymphoma (n= ). patients between and were included and followed until .results: an adequate stem cell graft was defined as ≥ . x exp cd + cells /kg body weight. % of the patients were able to collect at least one stem cell graft and the median number of grafts per patient was (range - ). we could demonstrate that only % of all patients who had collected sufficient pbscs for transplant subsequently underwent an absct. among the disease entities the actual use of the stored pbsc grafts varied considerably from % to % (figure ) .conclusions: we could identify striking discrepancies between the collection/storage and actual utilization of background: biosimilars (bio) of granulocyte colony stimulating factors (gcsf) were approved several years ago on the basis of some studies that indicated similar efficacy to the already patented gcsf (neupogen®, neu) both in terms of shortening the neutropenic period after chemotherapy as well as peripheral blood stem cell mobilization in patients with lymphoma and multiple myeloma (mm) treated with autologous stem cell transplantation (auto-hct). however, all these studies are retrospective and there are still concerns about the real efficacy of bio and even more about the real benefit on final costs.methods: we have retrospectively compared the characteristics of the mobilization procedure in both patients with mm and lymphomas, and healthy donors that received either neu or bio (with no chemotherapy) in university hospitals in catalunya from december / to november . bio replaced neu in june in all institutions. primary objectives were the mobilization rate (defined as the percentage of patients that achieved ≥ x /ml cd + cells in peripheral blood on day ) and the use of plerixafor (plex) in each group as pre-emptive strategy. a multivariable analysis of risk factors influencing the use of plex and mobilization failure (defined as collection of < x /kg cd + cells) was also performed.results: we treated patients ( lymphomas and mm) and healthy donors. both groups of patients ( neu and bio) and donors ( neu and bio) were comparable regarding pre-mobilization general characteristics. there was a trend for a lower median cd + peak on day for bio patients ( vs , p value = . ). a total of patients received plex, although of them ( . %) out of strict theoretical indication, cd + cells > x /ml (range . - . ) and were removed for further analysis (n = , in the neu group and in the bio group). median number of cd + cells on day was significantly lower in the group bio who needed plex ( . vs . for neu+plex, p= ), as well as cd + cells finally harvested ( . vs . x /kg, p= . ). mobilization failure rate was higher in bio group ( vs %, p= . ). regarding no plex patients, median number of cd +cells on day was also significantly lower for bio patients ( . vs . , p= . ). risk factors for plex use were age, basal disease (lymphoma) and number of prior mobilization therapies. the use of bio was the only risk factor for mobilization failure patients receiving plex [hr . ( %ci . - . ), p= . ]. with respect to healthy donor mobilization, none of them needed plex but cases from the bio group ( %) needed more than one apheresis procedures ( and , respectively).conclusions: we found a lower efficacy of bio in the setting of stem cell mobilization of patients with only gcsf both in terms of a lower cd + cells peak on day and a lower number of cd + cells in final apheresis product. bio gcsf also seems to be less effective in healthy donors.disclosure: no conflict of interest to be declaredbackground: auto-sct is a common treatment in patients with mm or nhl. the aim of the prospective multicenter goa (graft and outcome in autologous transplantation) study was to investigate the impact of mobilization method used on the cellular composition of collected blood grafts and eventually hematological and immune recovery as well as long-term outcome post-transplant. altogether patients with mm or nhl transplanted between / and / at four university hospitals were included. the long-term goal of the study is to evaluate characteristics of optimal blood grafts in regard to post-transplant recovery and outcome. methods: altogether patients with mm undergoing first auto-sct were compared with patients with nhl. all nhl patients were mobilized with chemotherapy + g-csf, whereas % of mm patients were mobilized with g-csf only (p < . ). mobilization data, graft cellular composition including cd + cell subsets and lymphocyte subsets of the blood grafts, post-transplant hematological recovery and outcome were evaluated. the median followup time was months in mm patients and months in nhl patients.results: mm patients mobilized cd + cells better (median peak blood cd + vs. x /l, p < . ). the median number of aphereses was in both groups (p = . ). altogether % of the nhl patients received plerixafor compared to % in mm patients (p = . ). the median number of cd + cells collected was higher in mm patients ( . vs. . x /kg, p < . ).the median amount of cd + cells (with -aminoactinomycin) in the infused graft was . x /kg in mm group and . x /kg in nhl group (p = . ). the grafts contained more nk cells (median . vs. . x /kg, p = . ) and cd + cells (median . vs. . x /kg, p < . ) in mm patients. neutropenic fever tended to be more common in nhl patients ( % vs. %, p = . ) but mm patients had significantly more bloodstream infections ( % vs. %, p = . ). the median duration of hospitalization was longer in the nhl patients ( d vs. d, p < . ) and the nhl patients had significantly more often icu admissions ( % vs. %, p = . ).post-transplant neutrophil engraftment was faster in the nhl group (median d vs. d, p < . ). the median time to platelet engraftment was days in both groups. platelet count was higher in the mm group from day until year after auto-sct. there were significantly more early deaths (< d from the graft infusion) ( % vs. %, p = . ) and non-relapse deaths ( % vs. %, p = . ) in the nhl group.conclusions: mm and nhl patients differ in terms of cd + cell mobilization, graft cellular composition and post-transplant recovery as well as risk of non-relapse death. thus, the optimal graft may be different in nhl and mm patients.disclosure: the study was supported by vtr fund from north savo hospital district and study grant from sanofi. abstract already published. single-center experience in use of plerixafor for autologous stem cell mobilization: change in practice over years background: plerixafor has been proven to mobilize human periferal blood stem cells (pbscs) alone or acting synergistically with granulocyte-colony stimulating factor (g-csf). it has mainly been used for rescue mobilization after failed regimen of chemotherapy plus g-csf, but lately preemptive use in poor mobilizers has been established as cost-effective. we aim to show ten years of experience and change in practice with plerixafor use in our center.methods: we retrospectively evaluated the outcome of mobilization procedures and leukapheresis collections in our center in the period from january to october . practice from the first years, when plerixafor was mainly used as rescue agent after failed attempt, was compared to period from till present when preemptive use in poor mobilizers (defined as cd + cell counts < x /l blood) was established.results: in the period from to , total of patients underwent collection of autologous pbscs, and patients required repeated mobilization cycles ( , %). g-csf alone was used in patients and patients ( %) recieved combination g-csf with plerixafor. this cohort consisted of males and females with non-hodgkin (nhl) and hodgkin lymphoma (mh); and respectively. we noted unsuccessful mobilizations ( , % in repeated mobilization, , % in total) of which one patient was from plerixafor group ( , %).background: transplantation of hla-haploidentical hematopoietic stem cells (haplo-hsct) is an established procedure for the treatment of several different hematological diseases. one possible strategy to reduce the risk of graft-versus-host disease is represented by the selective depletion of ab t-lymphocytes (coupled with the depletion of cd + b-cells in order to reduce the risk of ptld) using the clinimacs device (miltenyi, bergish-gladback). before depletion, leukapheresis units are washed by lowspeed centrifugation, resulting in a platelet (plt) rich supernatant (prs) as a by-product generally discarded. we studied the possibility of recovering plt from prs of the haplo donor for transfusion to the recipient during the aplasia period occurring after hsct.methods: hsc donors were mobilized with g-csf (plus plerixafor in out of donors) as previously described [locatelli et al, blood ] . leukapheresis units, obtained with a spectra optia device, were washed twice (producing prs bags) at low speed to remove plt before starting the ab t-cell/b-cell depletion. the two prs were leukodepleted by filtration, centrifuged, resuspended and pooled in a total volume ranging from to ml intersol (is-plt) for overnight incubation at °c with agitation ( cycles/min). the is-plt samples were analyzed for the criteria established by the italian transfusion law. is-plt bags were examined for the following parameters: volume > ml, plt after leukodepletion > x , residual leukocytes < x , ph > . at °c at the end of the -day storage period. the sterility was tested using bd bactec culture vials. the evaluation of the residual leukocytes was performed with the bd leucocount kit. the absolute plt counts were determined using hemocytometer sysmex xn .results: prs bags from donors were processed to produce is-plt units. median resuspension volume in intersol was ml (range - ). the absolute mean value of plt counts measured at the end of the storage period was . x (range . - . x ). this value was found below the threshold fixed by italian regulation in cases ( . %). mean value of residual leukocytes was . x (range - x ); the ph value was always > . . sterility was observed in all cases. according to the work of slichter et al. conclusions: we demonstrated that plts recovered from leukapheresis bags can be accepted as a conventional hemocomponent according to the parameters fixed by italian transfusion law and thus can be administered to the haplo-hsct recipients early after transplantation. this strategy carries several advantages. indeed, apart from the obvious advantages in terms of reduced costs, is-plt can be used to desensitize the recipient by absorption of anti-hla class i antibodies, if present in the recipient. moreover, this strategy can avoid the risk of sensitizing the transplanted patients with hla alleles that differ from the donor's ones. finally, the is-plt unit is readily available. a clinical study aimed at testing the use of is-plt units in transplant recipients will be performed to confirm the clinical efficacy of the approach.disclosure: nothing to declare p ultrasound guidance as a powerful tool in increasing background: peripheral blood stem cells are generally the preferred graft source for allogeneic stem cell transplantation for malignant disease. in most centers first apheresis is performed on day after to doses of granulocyte colony stimulating factor (gcsf) up to ug/kg twice daily. the dose of gcsf and the number of apheresis procedures required contribute to symptom, travel and time burden donors are put through during the process. we hypothesized that taking donor-recipient weight differences into consideration may help reduce this burden methods: a total of healthy donors who donated peripheral blood stem cells on day of gcsf mobilization in the period between january and august at the university medical center hamburg-eppendorf were included in this quality control evaluation. the donors were divided into two cohorts. the impact of donorrecipient weight ratio on stem cell harvest was tested in the training cohort ( - ) and validated in the second cohort ( ) ( ) . for the training cohort, donors were grouped according to donor-recipient weight ratio < . vs. . - . vs. > . . for the purpose of this analysis a stem cells dose of x cd +/kg recipient weight was set for successful apheresis.results: in the training cohort including donors, ( %), ( %) and ( %) had a donor-recipient weight ratio of < . , . - . and > . respectively. the target stem cells count of x cd +/kg recipient weight was achieved in of ( %), of ( %) and of ( %) donors with donor:recipient weight ratio < . , . - . and > . respectively. the cut-off for the validation cohort was therefore set at a weight ratio of . .in der validation cohort including donors, ( %) had a weight ratio > . while ( %) had a weight ratio ≤ . . overall in this cohort target cell count of x cd +/kg recipient weight was reached in ( %) cases. this target was reached in of ( %) of donors with weight ratio ≤ . and in of ( %) donors with weight ratio > . , p = . .conclusions: a donor-recipient weight ratio of > . is seen in about % of peripheral blood stem cell donations for allogeneic stem cell transplantation. in these cases apheresis on day after doses of gcsf is reasonable. donors with lower weight ratios should preferentially donate on day after to doses of gcsf.disclosure: all authors declare no conflicts of interest background: the effect of a second mobilization and collection of peripheral blood stem cells (pbsc) on the cell yield is low, as we previously demonstrated. however, donor safety has been poorly addressed with no changes in the clinical practices.methods: second donations of unrelated and related donors performed between and were evaluated (n= ), including pbsc+pbsc (n= ), bone marrow (bm)+pbsc (n= ) and pbsc+bm (n= ). analytical parameters including leukocyte, lymphocyte, hemoglobin and ldh quantification, obtained on the pre-harvest evaluation of first and second donation, were retrospectively analyzed and compared for all donors. the portuguese bone marrow donors registry (cedace) recommends a time between donations no lesser than months. it also states that in very urgent situations like graft failure, donor should be clinical and analytical cleared and its safety ensured.in order to evaluate the impact of time between donations, donor population was divided in groups: < months, - months, > months; to determine the influence of donor age, donors were divided in groups: < and ≥ years.results: among the total of donors, were volunteer donors of cedace and were familiar. fifteen second donations were performed because of recipient graft failure and due to disease progression or relapse. at the time of second collection, median donor age was years (range - ). the median delay between both collections was days ( - ). time between donations did not seem to substantially impact the analytical donor evaluation: leukocytes, lymphocytes, hemoglobin and ldh results are kept within the reference values. however, donors with less than months between donations showed a slight decrease on leukocyte counts ( %) and hemoglobin values ( %), from the first to the second pre-harvest evaluation. donor age showed no significant influence on the analytical evaluation. nevertheless, when considering only the pbsc+pbsc donations, donors with ≥ years showed a small decrease on lymphocyte counts ( %) .conclusions: this study demonstrated that the analytical parameters, chosen based on literature, had no significant changes between first and second donation. however, particular attention should be paid when time between donations is lesser than months or donor age is ≥ years.as we concluded that no significant changes were observed in the group of - months, it is our opinion that the minimum of - months established by the registries can be shortened to months ensuring donor safety. an accurate donor risk assessment with a larger population should be accomplished in order to strengthen this recommendation.disclosure: nothing to declare. gaurav kharya , atish bakane , pratibha dhiman , anil khetrapal , vikrant bhar background: t cell replete haploidentical stem cell transplant (hhsct) is complicated mainly by increased risk of graft failure (gf) and graft versus host disease (gvhd). conventionally gcsf has been used to mobilize hematopoietic stem cells (hsc). in tcr hhsct gcsf mobilized graft with megadose of cd + cells expose the patient to higher doses of alloreactive t cells increasing the risk of gvhd. plerixafor based mobilization gives an advantage of giving high cd cell dose limiting exposure to high alloreactive t cell dose. we share our experience of gcsf + plerixafor based mobilization for tcr hhsct. methods: consecutive patients suffering from scd who underwent hhsct between jan till date along with the respective donors were enrolled in the study (group ). all underwent pre-transplant immune suppression (ptis) cycles at weekly intervals using fludarabine+cyclophosphamide+dexamethasone.the graft was mobilized using gcsf@ mcg/kg/day(d -d )+plerixafor@ . mg/kg(d ) - hours before the pbsch. gvhd prophylaxis included ptcy mg/kg/ day on d and , sirolimus and mmf starting from d . group included historical controls where graft was mobilized using gcsf@ mcg/kg/day(d -d ). various parameters pertaining to mobilization, harvest, engraftment, gf and gvhd were assessed between the two groups.background: poor mobilizers (pm) defined as those with a peripheral blood cd + count ≤ cells/μl on day+ is a significant risk factor for mobilization failure. within these, patients with < cells/μl are considered as very poor mobilizers (vpm). use of plerixafor in vpm patient is controversial. the aim of our study is to compare mobilizing and engraftment between pm and vpm who received plerixafor plus g-csf (p+g-csf).methods: in our center, mobilization with g-csf at dose of μg/kg/day was used in all pts. apheresis were scheduled on day+ . plerixafor ( . mg/kg) was added if the number of cd + cells on day + was < /ul for x cd + /kg requested (or < /ul for x cd + /kg), or if the number of cd + cells collected in the first apheresis was < % of cd + cells requested.between january and september , out of pts ( , %) received plerixafor for mobilization. we retrospectively studied pts who mobilized with p+g-csfdue to the number of cd + cells on day + was < /ul.results: twelve out of pts were pm, were females, median age , years (range: - ). patients' baseline diseases were: non-hodgkin lymphoma (nhl) ( , %), multiple myeloma (mm) and hodgkin lymphoma. median cd + cell count on day + was / ul (range: - ).there was no mobilization failure. eighteen out of pts ( %) were vpm, were females, median age , years (range: - ). patients' baseline diseases were: nhl ( , %), mm and solid tumor. median cd + cell count on day+ was , /ul (range: - ). two out of pts ( , %) were considered mobilization failure, in of them did not realized apheresis due to cd + cell count on day + was /ul. no difference was seen between both groups regarding gender, age, patients baseline disease or median cd + cells count on day + .vpm needed more apheresis sessions, / pts required sessions against / pts in pm (p=not significant (ns). we obtained enough cells to carry asct in % pts, although mean number of cd + cells obtained in vpm was lower than in pm ( , x /kg vs , x /kg, respectively) (p=ns).twenty-six pts underwent asct and mean number of cd + cells infused were , x /kg in vpm vs have been the only route used for chpc administration. the appearance of other catheters types made us to reconsider the exclusive use of the cvc for the infusion of chpc. we analyzed the use of a peripheral iv cannula (pivc) as an alternative to cvc for the infusion of chpc in patients with cardiovascular diseases.methods: medical records of patients who received an asct for hematological malignant diseases at the hospital clínic of barcelona from january to february were reviewed. of those, eight were infused through a pivc due to cardiac impairment related to previous treatments, ischemic cardiomyopathy or amyloid deposition.hpc were obtained from peripheral blood by apheresis after mobilization with g-csf using acd-a as an anticoagulant. cryopreservation was performed with autologous plasma and dmso % by mechanical means and stored in liquid nitrogen. analytical controls were performed including hematocrit, total nucleated cells, total polymorphonuclear neutrophils and platelets using the advia analyzer. the cd + / cd + population was analyzed by flow cytometry following the ishage single-platform protocol. viability of total nucleated cellularity was carried out by vital staining with acridine orange and the specific viability of the cd + population through the technique of -aminoactinomycin d. thawing was performed bag to bag by immersion in a water bath at ºc and transferred to the bedside of the patient for gravity infusion using an infusion set without filter through pivc of gauche. vital sings monitoring performed before, during and the end of the every infusion bag including: blood pressure, heart rate, oxygen saturation, body temperature and central venous pressure. other aspects assessed during the infusion were pain, cold sensation and signs of extravasation in the area of pivc insertion. after the infusion, the recovery time of the granulocyte series and platelet were evaluated.results: median volume and bags administered was ( - ) ml and ( ) ( ) ( ) . the median of total nucleated cells, total nucleated cells / ml and total cd + cells/kg was . x ( . - . ), . x ( . - . ) and . ( . - . ) respectively. vital signs were within the normal range and allowed to perform the infusion in an average of - minutes/bag. no patient required stopping the infusion due to pain in the area of peripheral catheter insertion and no extravasations were detected. all patients referred some cold sensation in the insertion vein and its path. median hematopoietic recovery was ( - ) days for neutrophils and ( - ) days for platelets, similar to the recovery experienced from patients who received chpc through cvc.conclusions: based on our data, we conclude that the administration of chpc, through pivc and by gravity is safe for the product and for the patient, being the preferred choice for patients suffering from some type of cardiovascular disease.disclosure: nothing to declare background: by selective depletion of potentially alloreactive cd ra + cells, t memory cells might be retained in the graft and could mediate pathogen specific immunity. however, cd ra expression is not restricted to naïve t cells, but also available on b cells, nk cells and cd + stem cells to some extent. methods: within this project we aim to analyze cd ra expression on stem-and nk cells by flow cytometric analysis to estimate the eventual loss of these cells during cd ra-depletion. furthermore, clinimacs depletion following a one-step approach of direct cd radepletion and a two-step approach with primary cd selection followed by cd ra-depletion of the negative fraction was investigated.results: cd ra expression on cd + stem cells was in median . %. with a median of . % cd ra expression was measurable on nearly all b cells, which obviates depletion via cd . a comparably high cd ra expression of in median . % was detected on nk cells. unfortunately, the amount of nk cells in the cd ra-depleted product was . %. clinimacs depletion following one-step approach resulted in a stem cell recovery of . %. memory t cell recovery was . % following one-step and . % applying two-step approach. depletion quality measured by log-depletion was . and . for cd ra + t cells and . and . for cd + b cells for one-and two-step approaches, respectively.conclusions: with regard to stem cell recovery, a previous cd -selection before cd ra-depletion is recommendable.background: current clinical practice of routine use of filters for infusion of autologous hematopoietic cell transplantation (ahct) at bone marrow transplant centers across north america and europe is not known. the use of "y" administration tubing without a filter could possibly increase the risk of infusion of macro-aggregates and cellular debris, which may result in increased side effects.methods: we carried out a retrospective chart review of patients (pts) at spectrum health who underwent ahct. group a (gp a) pts received ahct using a "y" administration tubing with -micron filter from / - / . these patients were compared to a control group (gp b) that received ahct without filter administration tubing from / - / .this change in clinical practice occurred due to a change in policy at our transplant center as a result of inorganic particles noticed during cryopreservation. we compared the neutrophil and platelet engraftment duration between these groups. we also studied the length of hospital stay and the effect of filter use on any immediate side effects after infusion. due to the retrospective nature of the study it was not feasible to evaluate the difference in duration of infusion between these groups results: the two groups were similar in their age, gender, primary disease distribution and median number of cd stem cells infused (table) . there was no difference in median neutrophil ( vs days) or platelet engraftment ( vs days) duration for the filter group and the nonfilter group respectively. the median length of hospital stay was also comparable ( days). there was no statistically significant difference in the immediate side effects (fever, cough, dyspnea, fluid overload, flushing, nausea, vomiting, hypertension, hypotension and anaphylaxis) or confirmed post-transplant infections (viral, bacterial, fungal) experienced by these two groups.conclusions: our results show that the routine use of filter does not prolong hospital stay, and neutrophil/ platelet engraftment duration, thereby, suggesting that viable stem cells are not affected. on the other hand, filter use failed to demonstrate any appreciable decline in the immediate side effects experienced after ahct. gp background: allo-hsct from related haplo-identical donors (haplo-hsct) with post-transplant high-dose cyclophosphamide is increasingly employed in patients who lack a matched related or unrelated donor. the current standard is to use bone marrow grafts (bm) as peripheral blood stem cell grafts (pbsc) have been associated with an increased risk of acute and chronic gvhd. thus, the aim of our study was to compare the main transplant outcomes and especially the incidence of acute and chronic gvhd in recipients of bm and pbsc grafts. methods: thirty-five unselected patients with hematologic malignancy who underwent an haploidentical transplant at our unit between and and received bm (n = ) or pbsc (n = ) grafts after the same tbf conditioning regimen were analysed in order to assess differences in transplant outcomes.our gvhd prophylaxis consisted in cyclosporine a (csa) from day - to + , a methotrexate "short course" and mycophenolate mofetil (mmf) from day + to + .results: no statistically-significant differences were observed between patients who received bm grafts and those who received pbsc grafts. at transplant fourteen patients were in first complete remission (cr), twelve in advanced cr and had active disease. according to sorror's risk, nine patients were low-risk, nine intermediate-risk and seventeen high-risk. twenty-eight cmv+ patients received the graft from twenty-three cmv+ and five cmv-donors, seven cmv-patients received the graft from five cmv+ and two cmvdonors. mean age at transplant was years (range - ), mean donor's age years (range - ) and mean follow-up . months (range . - . ). median cd + cell dose was . x /kg (range . - . ), . x /kg (range . - . ) in bm recipients and . x /kg (range . - . ) in pbsc recipients. median time to neutrophil recovery (> /μl) was days (range - ) posttransplant, days (range - ) for bm recipients and (range - ) for pbsc recipients. platelet recovery (> . /μl) occurred in all patients except one at a median of days (range - ) post-transplant, at a median of days ( - ) post-transplant for bm recipients and at a median of days (range ( - ) for pbsc recipients. seven patients never reached platelets > . /μl. three patients developed a poor graft function. acute and chronic gvhd incidence was . % and . % and the risks of acute (hazard ratio [hr], . ; p = . ) and chronic (hr, . ; p = . ) graft-versus-host disease were similar in the two patient groups. in addition, there were no differences in relapse risks post-transplant (hr, . ; p = . ); relapse-free survival was better with pbsc grafts but this difference did not reach any statistical significance. finally, no significant differences were noted in overall mortality by graft type (hr, . ; p = . ).conclusions: despite in haplo-hsct the incidence of acute and chronic gvhd is reported to be higher with pbsc than with bm our small patient series does not confirm this assumption that should be clarified by additional studies. instead, our data suggest that pbsc background: since , cord blood (cbu) has become an alternative source of stem cells for transplantation, with approximately , procedures currently performed. with a -year gs of %.objective: analyze the outcomes from all the patients transplanted with cbu in our hospital unit.methods: retrospective, longitudinal study. all patients transplanted with cbu in our hospital between and were included. we analyzed patients with ages from months to years.results: two of them received doubled cord transplantation the ratio male: female was . : . the transplanted pathologies were: bone marrow failure %, immunodeficiency %, aml %, all . %, osteopetrosis . %. ric regimens were used in patients with bone marrow failure and immunodeficiency and myeloablative conditioning regimens were used in patients with malignant hematology diseases. antithymocyte rabbit globulin (atg) based serotherapy was used. one case received cbu from a related donor (sister), the rest received unrelated cbu obtained from centro nacional de la trasfusión sanguínea. the infusion of cd + was in a range of . to of . x /kg with and average of . x / kg. compatibility was / in %, / in % and / in %. post-thawing cellularity was not measured. the hla-c was not analyzed. forty two point five percent of the patients had a successful engraftment; the average time of engraftment was days. primary graft failure was detected in . % and secondary graft failure in %, for a total success of . %. gvhd was detected in % of patients, of which % was grade i-ii and % grade iii-iv. the overall mortality was . %. causes of death were: infection % relapse %, hemorrhage % and gvhd %. the cbsct continues to be an essential alternative in our patients who required transplantation knowing that this stem cell source allows the procedure to be done with less histocompatibility requirements and it is available immediately, which facilitates the process considering the great diversity that exists within our population. however, in our experience, the cbsct has shown a higher mortality risk, which can be improved by analyzing the hla c, choosing in this way the units with better compatibility, and improving cellular dosage since this is key in success.disclosure: nothing to declare the risk of infection of the umbilical cord is not related to the microbiological status of the umbilical cord blood methods: the statistical analysis was carried out on data obtained from samples taken in poland between -jan- and -dec- . the samples were collected in hospitals by external midwifes and sent to the pbkm in accordance with the requirements of the american association of blood banks. after arrival in the laboratory, the blood samples were cultured and the ucs were assessed immediately for visual signs of infection, such as odor, altered color, or visible bloom. the status of both kinds of samples was introduced into the pbkm general database. for the purpose of this analysis, the ucs were considered as microbiologically pure if stored, destroyed after storage, or handed over to the pbkm. samples marked as infected or disqualified for unknown reasons (other than termination of the contract with the customer, viral infection of the mother, and lack of cell growth) were considered as infected. at the time of the statistical analysis, the samples of unknown ucb microbiological culture status were removed from the generated report. the data was summarized as percentages and the odds ratio was calculated. statistical significance was considered at p˂ . .background: match family donors are the preferable options in allogenic stem cell transplant. however, in the absence of donor relatives match unrelated donors have been an option. in this study, the donor screening, transplant preparation phases of turkish stem cell coordination center (turkok) and the İstanbul university bone marrow bank (tris), were compared.methods: the unrelated donor scanning data between march and november in pediatric stem cell transplantation unit of altınbas university bahcelievler medical park hospital were evaluated. unrelated transplants were performed in total. % of these transplants (n= ) were included from the donors of turkok registration system and , % of these transplants (n= ) were included by means of tris from donors outside of turkey. patients ( tris, turkok) were excluded from the study in consequence of screening update and postpone of transplantation. the statistics were carried out on a total of patients, , % of whom were in turkok (n= ) and , % were transplanted via tris (n= ). the day of application to stem cell transplantation unit, reply dates and the transplantation dates were examined for the transplant patients.results: in the current study, the average response time of turkok was found as , ± , day (median: ), the average transplant time after receiving a reply was found as , ± , (median: ) day, the average number of days from date of application to date of transplantation of patients was found as , ± , (median: ). the average response time of tris was , ± , (median: ) day, the average transplant time after receiving a reply from tris was , ± , (median: ) day, average number of days from date of application of tris to date of transplantation of patients , ± , (median: ) day.the average response time of turkok, the average transplant time after receiving a reply from turkok and the average number of days from date of application of turkok to date of transplantation of patients was shorter than tris. the difference between them was found statistically significant (p< . ).conclusions: in this study, it was determined that the transplantation processes with turkok were progressing more rapidly. the rapid progress of the process was attributed to the fact that all donor hla tissue groups in the turkok database were studied in high resolution. in international scans carried out through tris, it was thought that the examination of the donor castings coming from bone marrow banks and the time differences between the countries prolong the process. it was thought that hla tests of the registered donors in the tris database and some international bone marrow banks were studied in low resolution but not studied the all hla loci, the centers wanted high-resolution hla, and therefore the involvement of social security institutions and payment procedures were among the factors extending this process.disclosure: nothing to declare background: allogeneic hematopoietic stem cell transplantation (ahsct) is being performed for a group of hematologic diseases with a curative intent. outcomes after ahsct are influenced by the type of donor used. haploidentical transplantation is an emerging option when a fullmatched donor is unavailable. methods: we retrospectively analyzed our transplants performed between january and november , investigating outcomes and complications among haploidentical stem cell recipients.results: one hundred and nineteen patients underwent ahsct, of them ( . %) were recipient of a haploidentical stem cell and included in this study. one patient diagnosed with acute lymphoblastic leukemia (all) were performed a haploidentical ahsct for two times due to relapse. among those transplants, of them were diagnosed with acute myeloid leukemia, with all, with chronic lymphocytic leukemia, with myelodysplastic syndrome and with hodgkin lymphoma. the mean age of group was . ± . years. three patients ( aml, all) were in remission at the time of transplantation. patients were given a conditioning regimen based mostly on busulfan, fludarabin and total body irradiation with a myeloablative intent. patients were also given a various combinations of post-transplant cyclophosphamide, calcineurin inhibitors, mycophenolate mofetil and antithymocyte globulin for graft versus host disease (gvhd) prophylaxis; post-transplant cyclophosphamide administered on ( %) of those transplantations. peripheral blood was the source of stem cells in all patients. patients were infused with mean . ± . x /kg of cd + cells. hematological recovery was achieved with neutrophil engraftment at a mean of . ± . days and platelet engraftment at a mean of . ± . days. after a median month ( . - . months) follow up, the cumulative rates of grade - gvhd, relapse and non-relapse mortality were %, % (n= ) and %, respectively. one patient died due to relapse, at the end of the follow up two were still alive with remission. only one patient has died due to chronic gvhd affecting serosa and resulting with a fatal tracheoesophageal fistula. the mean overall survival was . ± . months in our study.conclusions: haploidentical transplant is a feasible option in hematologic malignancies with novel gvhd prophylaxis approaches, especially post-transplantation cyclophosphamide. however, these results need to be supported with further investigations with a larger patient group.disclosure: nothing to declare results: a total of patients between and years (median age: years). transplant was done for following disease: acute leukemia (n= , %), aplastic anemia (n= , %), lymphoma (n= , %), myelofibrosis (n= , %), myelodisplastic syndrome (n= , %), chronic myeloid leukemia (n= , %). ten donors were from turkey and fifteen donors were from different countries of europe and america. two of donors were / and the other was / hla matched. the conditioning regimen was mostly non myeloablative (n= , %) while eight patients were treated with myeloablative regimen. other than two patients who took tacrolimus and mycophenolate mofetile all of them got cyclophosphamide and methotrexate for graft versus host disease (gvhd) prophylaxis. the median time of neutrophil and platelets engrafman were days (range - ) and , days (range - ) respectively. acute gvhd was seen nearly half of the patients ( , %).overall survival was % for all patients and of patiens ( %) died within first month to months (median months). the mortality rate was more higher for the recipients who had donor source from countries other than turkey ( % vs % p= , ). transplant related mortality was the most common reason of mortality (n= / , , %) and other reasons were gvhd ( , %), infections and cirrhosis respectively.conclusions: we found the mortality rate more higher in the patients whose donors were from out of our country. however, we need to further multicentric and prospective investigations to confirm our hypothesis, it would be related with impact of ethnicity.disclosure: nothing to disclose late-breaking abstracts p targeted twice daily busulfan-based ric-conditioning for allogeneic hematopoietic stem cell transplantation in pediatric patients with chronic granulomatous disease: a -year experience with the zurich protocol matthias felber , mathias hauri-hohl , ulrike zeilhofer , federica achini , jana pachlopnik-schmid , janine reichenbach , seraina prader , tayfun güngör background: chronic granulomatous disease (cgd) needs sufficient myeloablation to avoid graft failure. for this purpose the ebmt inborn errors working party currently recommends treosulfan or busulfan-based conditioning regimens for cgd-sct. we analyzed the last years of targeted busulfan-based ric-conditioning including engraftment, gvhd rates, chimerism and late term effects in our pediatric sct center in zurich. methods: between and , n= consecutive pediatric cgd patients (median age years, range - years, n= female, n= autosomal recessive inheritance) have been transplanted. all patients received therapeutic drug monitoring of twice daily administered iv busulfan ( or hour infusions; d- to -d ) to achieve a targeted cumulative auc of - mg/l*h. fludarabine ( mg/ sqm; d- to -d ) and serotherapy (thymoglobuline . mg/ kg total, d- to d- ) or alemtuzumab ( . - . mg/kg total; d- -to d- ) were used for immunoablation. donors were matched unrelated ( / hla; n= ), mismatched unrelated ( / hla; n= ), mismatched unrelated (hla / ; n= ), matched sibling (hla / ; n= ) and haploidentical parental (hla / ; n= ). for patients with haploidentical donor post-transplant cyclophosphamide (d- and d- with mg/kg iv each) and upfront atg-grafalon ( mg/kg - to-d- ) was used. stem cell sources were bm (n= ) and pbsc (n= ). gvhdprophylaxis included iv csa (d- ; continuous infusion) and iv. mmf (d- , in - doses).results: follow-up was to months. good overall engraftment was noted, with n= secondary graft failure followed by successful retransplantation. in one patient a stem cell boost/dli was necessary due to decreasing myeloid donor chimerism during ebv reactivation, resulting in rapid myeloid donor reconstitution after intervention. low rates of gvhd were documented with n= agvhd grade iv and n= mild/limited cgvhd (nih criteria). with exception of one patient, myeloid donor chimerism at last follow-up was over %, mostly over %. overall survival was / ( %). deaths were due to gi-gvhd (n= ), autoimmune hemolytic anemia/sepsis (n= ) and thrombotic microangiopathy (n= ).conclusions: precision dosing of iv busulfan in combination with fludarabine and serotherapy results in excellent outcome of hsct for pediatric cgd-patients with good engraftment, low overall cgvhd rates and stable, mostly excellent donor chimerism. graft failure rate was as low as %. low dose alemtuzumab prevented gvhd in the majority of patients. this analysis demonstrates that targeted busulfan-based conditioning is a valid option for pediatric cgd-patients. serum alemtuzumab or atg monitoring could further improve gf and gvhd rates in the future.disclosure: the authors declare no conflict of interest. abstract already published. young hla-matched unrelated donors are comparable to matched sibling donors in elderly patients receiving reduced-intensity conditioning: an analysis on behalf of the ebmt scientific council % c.i. . - . , p= . ) and voriconazol prophylaxis during carv (or . , % c.i. . - . , p= . ). conclusions: we provide evidence that ifd after carv infection. allo-hsct recipients developing a carv lrtd during the first year after transplant may benefit from an adequate antifungal prophylaxis and a close monitoring for the development of a later ifd.disclosure: jose luis piñana has received both, advisory for preclinical/clinical research and financial support to assist to the spanish society of hematology annual meeting from msd. favorable outcome and engraftment following reducedintensity conditioned allo-hsct in children with primary haemophagocytic lymphohistiocytosis (hlh) and high-risk langerhans cell histiocytosis (lch) laura m. moser, emilia salzmann-manrique, andrea jarisch, jan sörensen, shahrzad bakhtiar, peter bader background: primary haemophagocytic lymphohistiocytosis (hlh) and high-risk langerhans cell histiocytosis (lch) represent two major entities of childhood histiocytoses, which are -although only of rare occurrence -severe in their clinical manifestations. patients present with multisystemic uncontrolled inflammation and multi-organ involvement requiring diverse courses of immunosuppressive and chemotherapy regimens. allogeneic haematopoietic stem cell transplantation (allohsct) is the only available curative option; however, the cumulative treatment toxicity and the underlying inflammatory disease often result in high organ toxicity and inflammatory complications of transplantation, such as graft versus host disease (gvhd) and/or graft failure. especially patients with unrelated donors often deal with high transplant-related mortality (trm) in the setting of conventional intensity conditioning.herein, we present the clinical course of the disease and transplant outcome of children diagnosed with primary hlh (n= ) and high-risk lch (n= ) who underwent allohsct at our centre from / to / .methods: the hlh cohort consisted of cases of familial hlh (fhlh), cases of griscelli syndrome, one xiap-deficient patient and one hlh-patient with inconclusive genetic testing. all hlh patients had developed clinical symptoms prior to transplantation and had been treated according to hlh-protocols , hlh-protocols , or median age at transplantation was months ( to months). stem cells were derived from hla-matched siblings (msd, n= ), matched unrelated donors (mud, n = ) or haploidentical donors (n= ).the majority of patients ( / ) received a ric regimen containing fludarabine, melphalan and thiotepa (n= ) and fludarabine plus cyclophosphamide (n= ). myeloablative treatment ( / ) included a treosulfan-based regimen (n= ) and busulfan-containing treatment (n= ). the entire cohort received serotherapy using either muromonab (n= ), atg-fresenius® (n= ) or alemtuzumab (n= ).results: the overall survival of the entire cohort was . % ( / ) on a median follow-up of . years ( figure a+b) .all lch patients, being treated with fludarabine, melphalan and thiotepa, survived transplantation and showed complete remission ( / ) . within the hlh cohort the overall survival was . % ( / ). fatalities (n= ) included two patients from the myeloablative group and one ric-treated patient. the cause of death were progressive disease activity during the conditioning phase, leading to multi-organ failure on day + despite immunosuppressive treatment (n= ) and complicated cerebral seizures followed by lung haemorrhage, possibly due to aspiration pneumonia with evidence of enterococcus faecium, resulting in septic multi-organ failure on day + (n= ). a third hlh patient developed a sudden cerebral edema and ensuing respiratory insufficiency on day + . whether this was caused by acute neurotoxic damage by fludarabine or a consequence of relapsed hlh could not be conclusively specified. none of our patients suffered from transplant failure or nonengraftment. there was neither severe acute gvhd (iii-iv) nor chronic gvhd observed in this cohort.conclusions: primary hlh and high-risk lch are lifethreatening medical conditions needing rapid allohsct. ric regimens are well-tolerated and sufficient for proper engraftment and disease clearance. disclosure: the authors have no conflicts of interest to disclose. abstract withdrawn. thrombocytopenia following allo-sct concomitant to stem cell boosts. steroid refractoriness was defined as: progression after three days or no response after days of steroid treatment. the median time from sct to the onset of agvhd was . d (range - d), and d (range - d) from the onset of agvhd to the first msc infusion, respectively.the majority of our patients (n= ) suffered from a malignant disease and received a graft from a matched unrelated donor (n= ), while one patient had a haploidentical donor. gvhd prophylaxis was performed in all patients except the patient with the haplo-identical graft. all patients with agvhd were treated with steroids and the patient with thrombocytopenia required regularly transfusions and romiplostin therapy. the median msc dose was . x cells/kg bw (minimum . x ; maximum x ). three patients received msc doses, two patients , one patient and another doses.results: at the time point of agvhd manifestation and msc application, two patients had cmv reactivation, one patient adenovirus infection and one patient ebvreactivation. by day , / agvhd patients responded to msc administration: with complete response and with partial response. at the last follow-up (median: . months, range , - . months), of patients were alive without acute or chronic gvhd. one patient died soon after msc treatment with no obvious response in the course of a systemic hyperinflammation syndrome. the other patient although complete responder to msc-ffm developed fatal adenovirus sepsis. this based on the profound tcell depletion induced by concomitant application of steroids. the overall survival probability at six month was . %. no acute side effects occurred after msc infusions. the previously mentioned patient suffering from thrombocytopenia did not need any further transfusions after receiving doses mscs combined with stem cell boosts while continuing romiplostin application.conclusions: our data confirm excellent tolerability and high efficacy of the licensed off-the-shelf msc preparation "msc-ffm" in pediatric steroid-refractory agvhd. in our center, current treatment algorithms have escalated "msc-ffm" to the second line, i.e. immediately after steroid refractoriness has been established. besides immunoregulatory properties, this product might facilitate hematopoietic stem cell engraftment.disclosure: novartis (consultancy: included expert testimony, speaker bureau, honoraria), medac (research funding, patents and royalties), riemser (research funding), neovii (research funding), amgen (honoraria) expression of ccr modulates migrational properties of in vitro expanded murine regulatory t cells laura m. moser , , ulrike tischler , christin riegel , julia minderjahn , rüdiger eder , jaqueline dirmeier , isabel zimmermann , evelyn röseler , petra hoffmann , , matthias edinger , background: hematopoietic stem cell transplantation (hsct) as it is carried out successfully at other genetic instability syndromes seems to be an encouraging opportunity for a curative therapy to restore immunity and prevent the development of hematologic malignancies in ataxiatelangiectasia (a-t). however, experience in the conditioning regimen is limited and no transplantation strategy for a-t patients exists, especially in an allogeneic setting. conditioning regimen and donor selection are critical factors in the clinical setting of hsct and incur substantial risks, especially in a-t. the aim of this study was ( ) to evaluate whether different approaches of hsct including allogeneic hematopoietic hsct are feasible in regard to graft versus host response (gvhd) and sufficient concerning immune reconstitution ( ) and to de-escalate the toxic effects of the conditioning regimen by reducing the dose of cyclophosphamide (cp).methods: t cells from syngeneic, allogeneic and haploidentical donor mice were used to determine gvhd induced t cell proliferation in a mixed lymphocyte reaction (mlr). atm-deficient mice were treated with cp or reduced cp in combination with fludarabine (flu) and transplanted with x cd . depleted bone marrow donor cells from /svev gfp-transfected wildtype mice (syngeneic) or from mice of the f generation of /svev wildtype mice and c bl/ mice (haploidentical), or from c bl/ mice (allogeneic). tracking of gfp-positive donor derived cells was performed using flow cytometry and atm pcr. oxidative stress and damage were detected by a rt profiler pcr array and -hydroxy- ′deoxyguanosine.results: mlr resulted in an increased proliferation of allogeneic donor t cells compared to syngeneic and haploidentical donor cells. response was lower on dendritic cells isolated from atm-deficient mice compared to wildtype controls. in vivo results showed the restoration of t cells in atm-deficient mice accompanied by a prolonged life span and through reduction of thymic tumors. however, allogeneic stem cell transplantation was accompanied with a higher mortality rate, compared to the haploidentical and syngeneic setting. decreased antioxidative capacity and a higher dna-damage were seen in cp treated atmdeficient mice.conclusions: haploidentical hsct seems to be a feasible strategy for a-t. our data provided further evidence for the high sensitivity against ros-inducing agents in a-t and this fact needs to be taken into consideration in the choice of the host-conditioning strategy.disclosure: nothing to declare this research received funding from action for a-t charity ( gou ) background: prognosis of pediatric patients and young adults suffering from refractory or high-risk soft tissue sarcomas remains poor with limited improvement over the last decades despite multimodal treatment strategies. replacing the immune system by an allogeneic hematopoietic stem cell transplantation (hsct) in refractory solid malignancies has been proposed as a potentially curative therapy due to its presumable graft versus tumor effect. based on this concept we additionally performed consecutive donor-derived lymphocyte infusions in allogeneic hsct-patients with refractory or relapsed solid malignancy to further increase anti-tumor efficacy post-transplant.methods: pediatric patients with relapsed and/or refractory cancers or with delayed responses to the respective induction therapies were offered donorderived cellular therapies after immune system replacement by an allogeneic hsct. cellular immunotherapies comprised of donor lymphocyte infusions (dli), natural killer (nk) cell or cytokine-induced killer (cik) cell infusions generated from the original stem cell donors. allogeneic nk cells were generated from unstimulated leukapheresis by a two-step purification procedure using immunomagnetic cd t cell depletion, followed by nk cell enrichment (cd +) with or without in vitro il- stimulation and expansion for - days. for cik cell generation peripheral blood mononuclear cells were isolated and activated by in vitro cytokine stimulation (inf-γ, anti-cd , il- and il- ) an expanded over - days. expanded cik cells represented a heterogeneous population of polyclonal t cells with in part shared phenotypic and functional properties of nk cells.results: between october st and january st a total of patients (eight patients with rhabdomyosarcoma, one patient with synovial sarcoma, two patients with ewing sarcoma, five patients with neuroblastoma, one patient with hepatoblastoma, and one patient with nasopharynx carcinoma) were enrolled. seven of ( %) patients in this study had achieved complete remission (cr) before hsct while another of ( %) patients had obtained at least very good partial or partial response (vgpr or pr). dli was applied in patients, nk cell treatment was offered to another patients, while cik cell therapy was given to patients. . -year probabilities of overall survival (os) and progression-free survival (pfs) were . % and . % for all patients with a median follow up of . months (range, . - . months). patients in cr at the time of immune cell therapy (it) showed estimated . -year os and pfs of . % and . %, respectively. the majority of patients relapsed and ultimately succumbed to their diseases with two of ( %) patients still being alive . and . years after it. cumulative incidence of relapse was . % at . years. t cell engraftment and immune reconstitution (ir) was improved by it, and correlated with treatment response. however, two of heavily pretreated patients ( %) died due to cumulative treatment-related mortality (trm). furthermore, acute graft-versus-host-disease (agvhd) occurred in of patients ( %) with agvhd grade i-ii observed in ( %) and agvhd grade iii seen in three ( %) patients.conclusions: altogether, the results of this study indicate that allogeneic donor-derived cellular therapy at its current state offers curative benefit in selected refractory childhood cancers but warrants further improvement. background: allogeneic stem cell transplantation (allo-sct) is the only curative treatment option for a variety of nonmalignant diseases. the success of allo-sct is strongly associated with rapid and sustained immune reconstitution (ir). we analyzed the ir in patients who received an allo-sct for nonmalignant diseases.ir was assessed on days + , + , + , + and + after allo-sct analyzing leukocytes, lymphocytes, monocytes, cd + t cells, cd + cd + t helper cells, cd + cd + cytotoxic t cells, cd -cd + natural killer (nk) cells and cd + b cells.methods: we analyzed ir-data of consecutive patients receiving allo-scts between september and november . indications of allo-sct were hereditary anemias (thalassemia, sickle cell disease, diamond blackfan anemia; ha, n= , %), inherited bone marrow failure syndrome (fanconi anemia, severe aplastic anemia, others; bmfs, n= , %), hemophagocytic lymphohistiocytosis (hlh, n= , %), immunodeficiency (id, n= , %) and metabolic disorders (n= , %). the median age at allo-sct was years (range, . - ) and at diagnosis . years (range, - . - . ).patients received st allo-sct from msd/mfd (n= , %), mud (n= , %), haploidentical mismatch family donors (n= , %) and mmud (n= , %). conditioning regimens were busulphan-based (n= , %), treosulphan-based (n= , %), flu-mel-thio (n= , %) or others (n= , %). graft sources were bm (n= , %) and pbsc (n= , %).in order to consider the age-dependency of ir we normalized each absolute cell count with its corresponding age-specific expected mean values. (huenecke et al.; eur j haematol; ) results: the ir pattern was similar between the ha and bmfs groups. the cd + t cells were recovering slightly faster in ha patients compared to the recovery of bmfs patients.monocytes and nk cells proliferate very fast. at day + half of the patients already reached their respective monocytes reference value except for id patients, who reached % of the reference value at the end of the first year.cd + cd + cytotoxic t cells recovered significantly faster in patients with hematologic diseases compared to patients with hlh (p< . ) and id (p= . ). half of the patients reached the reference value of cytotoxic t cells in the hematologic diseases group at day + . by far inferior was the ir for the hlh patients. in this group only % of the patients reached the th percentile of the healthy age-matched reference. in the id group % of all patients reached the th percentile of the age-matched reference group at day + .b cells are profoundly decreased at day + in all groups. however, the longitudinal expansion of b cells was significantly lower both in the id group and hlh group compared to the hematologic diseases group. at day + fifty percent of patients with id, hlh and hematologic diseases reached the th percentile, th percentile and the th percentile, respectively (p< . ; p= . ).conclusions: allo-sct is the only curative option for patients with nonmalignant diseases. ir is dynamic and revealed a complex diversity pattern with regard to the original disease. to investigate factors influencing ir after allo-sct is crucial to improve outcome of these patients.disclosure: nothing to declare. allogeneic hematopoietic stem cell transplantation in patients with myelodysplastic syndrome of relatively high-risk groups: curative effect analysis and optimal timing selection results: among the patients, patients were transplanted successfully. the -year overall survival (os) rate and disease-free survival (dfs) rate was . % ± . % and . %± . % respectively. the -year cumulative relapse rate (rr) and the non-relapse mortality (nrm) rate was . %± . % and . %± . % respectively. the incidence of grade ii-iv acute graft versus host disease (agvhd) was . %± . %. for the patients who survived more than days after allo-hct, the years cumulative incidence of chronic graft versus host disease (cgvhd) was . %± . %. univariate analysis showed that the hematopoietic cell transplantation comorbidity index(hct-ci) and grade iii-iv agvhd are the high risk factors for os( . ± . % vs . ± %, p= . and . ± . % vs . ± . %,p < . ). multivariate analysis demonstrated that grade iii-iv agvhd and hct-ci are independent risk factors for os(hr= . , p < . , % ci: . ~ . and hr= . ,p= . , %ci: . ~ . ). chemotherapy before transplantation did not improve os or dfs for patients with bone marrow blast cells more than % at the time of diagnosis.conclusions: allo-hsct is an effective treatment for mds patients of relatively high-risk groups. the physical condition of the patients and occurrence of agvhd are independent risk factors. for intermediate and high risk ipss-r mds patients, transplantation before the disease progressed into very high risk can achieve better prognosis, high-risk group can still benefit from rebound gvhd after cni tapering which was promptly responsive to treatment steroids, fk and ecp. aa one year after sct / patients were without gvhd and off all immunosuppression while one single patient was still on taper of immunosuppressant after rebound acute gvhd. no chronic gvhd occurred. sctrelated toxicity was common with mucositis in all patients (who grade : n= ), elevated liver enzymes (≥grade : n= ) and impaired renal function (gfr - ml/min: n= ). five patients developed neurologic symptoms (seizures n= , pres n= , pseudotumor cerebri n= ) which all resolved without sequelae. overall survival and transfusion-free survival was % with a median observation time of ( - ) years.conclusions: . treosulfan-based conditioning followed by sct from hla-matched related or unrelated donors represents a highly efficacious treatment approach for children, adolescents and young adults with tdt and exhibits an acceptable but not negligible safety profile. an individual risk-benefit assessment incorporating hazards such as secondary graft failure, gvhd and long-term toxicity including infertility and nd malignancy has to be executed in the informed consent process for every patient and his/her guardians.disclosure: "nothing to declare" p abstract already published. early iron chelation with deferasirox might prevent relapse after busulfan plus fludarabine and atg as a myeloablative conditioning for hla-identical sibling allogeneic hct in aml results: we show an excellent concordance between chimerism assessment on bio-rad and d platforms over the complete range of mixture ratios (r > , ) and proof the lower detection limit ( , %) compared to str-pcr.conclusions: our results promote the transfer of the established mentype assay to a more diverse instrument portfolio. that will allow to implement the analysis of patient and donor hematopoiesis by digital pcr methods in our lab.disclosure background: with the immense progress in therapeutic regimens in pediatric oncology and stem cell transplantation the survivor rates increased up to %. at the same time the field of reproductive medicine has achieved substantial advances to offer potential options for fertility preservation. therefore it is of great importance to implement fertility counseling and fertility preserving (fp) procedures for patients facing gonadotoxic therapy. in the report on the expert meeting of the paediatric diseases working party (pdwp) of the ebmt in counseling related to fp opportunities should be offered to each patient receiving stem cell transplantation (sct), as part of the pre-sct workup by a dedicated and trained team. yet there many medical, ethical, structural and financial issues to consider and overcome. we describe the setting up process to enable fertility counseling for all children with newly diagnosed cancer or those facing stem cell transplantation for malignant and nonmalignant diseases in our department of pediatric oncology and immunology/stem cell transplantation.methods: at our tertiary care center we assembled a multidisciplinary team involved in fertility preservation (pediatric hematology/oncology, pediatric immunology/ stem cell transplantation, reproductive medicine, andrology, psychology and pediatric surgery). we developed an internal grading system for recommendations regarding fertility preservation based on the current recommendations for fertility preservation of leading societies in this field like ebmt, gpoh and dggg. it is important to find a consensus within the team for the counseling to ensure reliable counseling. the third step is to implement structures needed for fertility counseling and performance of invasive procedures including legal aspects (amg). a detailed description of this process is given.results: after setting up structures for the counseling process we counseled oncology and stem cell transplant patients ( - years) between january and may . we analysed data of the patients including age subgroups and disease entities and the results of the counseling process. for those patients undergoing stem cell transplantation the risk of gonadotoxicity is very high, therefore even the very young children underwent fertility preserving procedures in alignment with our recommendations if they suffered from a nonmalignant disease. currently we discourage tissue preserving in malignant systemic disease due to possible contamination with malignant cells. postpubertal female patients were more likely to undergo invasive procedures such as ovarian tissue cryopreservation in the case of oncological diseases, while sperm cryopreservation was recommended in all postpubertal male patients. overall a high percentage of the patients and their family followed our recommendations.conclusions: fertility preservation should be considered as a very important part of the treatment plan for newly diagnosed children and young adults with cancer and those facing stem cell transplantation. unfortunately there is still a great need for setting up structures in institutions taking care of these patients. in addition fertility preservation sadly lacks funding by health insurance in some countries. with the presentation of our experience and data we want to facilitate incorporation of fertility counseling in other pediatric care centers to provide counseling for pediatric patients in need for fertility preservation.disclosure: no conflict of interest regulatory t-cells (t reg ) have been shown to play a role not only in autoimmune diseases and solid organ transplantation but also in gvhd. several mouse models showed a decrease of gvhd incidence after t reg administration. the few clinical trials regarding the application of t reg for the treatment of gvhd are encouraging, however the data is limited. methods: patient: a -year-old boy underwent allogeneic sct for chronic myeloid leukemia refractory to imatinib, dasatinib and nilotinib treatment from his / hla identical brother. freshly derived unmanipulated bone marrow was transplanted after conditioning with of fludarabine ( mg/m²/d, day - to - ), thiotepa ( x mg/ kg, day - ) and melphalan ( mg/m², day - ). cyclosporin a (csa) and mycophenolatmofetil (mmf) were used for gvhd prophylaxis. leukocyte regeneration (> /μl) was seen on day + , granulocyte regeneration (> /μl) on day + and thrombocyte regeneration (> . /μl) on day + . on day + after sct he developed acute intestinal gvhd that exacerbated to grade iv°(bloody diarrhea, ileus) and did neither respond to steroids, nor to different immunosuppressive drugs such as cyclosporin, tacrolimus, sirolimus, mycophenolatemofetil and ruxolitinib. extracorporal photopheresis and the administration of immunmodulatory antibodies (adalimumab and tocilizumab) did not succeed either.results: by administration of low-dose interleukin- (il- ) in vivo induction of t reg was expected but did not succeed. finally antithymocyte globuline (atg, mg/kg/ d) was administered on day + to + to eliminate the gvhd-triggering cells. hence, the gvhd declined to grade iii. finally, a decision was made to manufacture t reg from his stem cell donor. from an unstimulated leukapheresis t reg were selected by magnetic depletion of cd + t-cells and cd + b-cells followed by positive selection of cd + background: treatment of patients with transfusion dependent anemia like thalassemia major (tm), sickle cell disease (scd) and diamond-blackfan anemia (dba) has improved over the last decades. for the vast majority of patients, allogeneic hematopoietic stem cell transplantation (hsct) is the only available curative therapy. for a long time, hsct has only been performed from hla-identical sibling donors (msd) or matched family donors (mfd). however, approximately only - % of affected patients do have a matched sibling donor, therefore hsct from / (mud) and even / (mmud) matched unrelated donors has gained importance in recent years.methods: patients (age range: - years) with scd (n= ), dba (n= ) or tm (n= ), receiving hsct from a msd, mfd, mud or mmud between and were included in our analysis. patients received transplants from msd/mfd, patients from mud/ mmud. patients were identical for hla-a, b, cw, drb and dqb , patients shared only / genes. we analyzed extended haplotypes including drb , drb , drb and dpb for all patients with thalassemia. pairs showed non-permissive dpb mismatch and pair mismatch for dpb and drb .results: median time for granulocyte recovery was days in patients transplanted from msd/mfd and days in patients transplanted from mud/mmud. platelet recovery was reached after days after hsct from msd/mfd and days after hsct from mud/ mmud. / ( %) patients showed complete donor chimerism in all controls. / ( %) patients showed low level mixed chimerism up to % during follow up. patient died shortly after hsct, patient showed slowly increasing mixed chimerism and finally developed autologous recovery and one patient rejected the graft.cumulative incidence of grade ii-iv acute graft-versushost disease (agvhd) of mud/mmud was , %, whereas only cases of agvhd grade i occurred in patients transplanted from msd/mfd. as patient rejected the graft from a hla-identical parent, patient transplanted from a hla-identical grandparent developed autologous recovery after year and patient transplanted from a mud lost the graft due to hemophagocytosis, the probability of event-free survival was , % after hsct from msd/mfd and , % from mud/mmud.altogether / patients ( , %) are alive and transfusion-independent with complete donor chimerism two years after hsct; resulting in an overall survival probability of , %. in contrast, overall survival probability was % in the group of patients transplanted from msd/mfd and , % in patients transplanted from mud/ mmud after years.there were patients with thalassemia ( , %) who died from transplantation-related causes. the first patient died days after hsct from a mmud due to candida sepsis with pulseless electrical activity resulting from cardiac iron overload. the second patient died months after hsct from a mud due to graft failure.conclusions: hsct from mud and mmud is a feasible therapy option for patients with transfusion dependent anemia. nevertheless, it should be noted that iron overload can cause severe complications; therefore, measurement of liver and heart iron concentration through mri prior to hsct as well as phlebotomy after transplantation are advisable.disclosure: novartis (consultancy: included expert testimony, speaker bureau, honoraria), medac (research funding, patents and royalties), riemser (research funding), neovii (research funding), amgen (honoraria) background: the therapeutic options for patients with hodgkin´s disease who relapse after first high-dose chemotherapy with autologous stem cell ( st asct) support are limited. allogeneic stem cell transplantation in this setting is associated with a high level of transplant-dependent mortality rates in excess of - %. new agent, such as brentuximab vedotin, have been approved for the treatment of these patients, however, their efficacy to provide longterm control or cure is still unknown. a second autologous stem cell ( nd asct) has historically been considered as an option only in a small group of patients so the published experience is scarce. we report our institution´s experience with second autologous transplants in this patient population.methods: we evaluated the outcome of adult patients ( ( %) female and ( %) male), who received an nd asct between / and / . planned tandem asct were excluded. the median age at nd asct was years (range - ), ( %) patients had a karnofsky performance score ≥ %. ( %) patients were in complete remission (cr) and ( %) patients were in partial remission (pr) at day after st asct. seven ( %) relapses within months after st asct. patients received a median of ( - ) treatment lines between st asct and nd asct. only ( %) patients received brentuximab vedotin and none of the patients in our series received checkpoint inhibitors as salvage after st asct. the median interval from st asct to relapse/progression was , months (range , - , ). the median interval from relapse/progression to nd asct was , months (range , - , ). all patients received beam as the conditioning regimen for st asct, and beeam as the conditioning regimen for nd asct.results: the median time to neutrophil recovery (> . x /l) after nd asct were days (range - ). best response at day following nd asct included cr in ( %) patients and pr in ( %); ( %) had stable disease. ( %) patients received brentuximab vedotin and none of the patients received checkpoint inhibitors after nd asct. ( , %) patients are currently alive, with a median follow-up , months (range , - , ). patient died after nd asct. causes of death were hl progression. the -year overall survival was %.conclusions: the second asct in patients with a longterm response after the first asct may be the optimal therapeutic option, the effectiveness of which can be enhanced by using new drugs, such as brentuximab vedotin, at all stages of treatment.disclosure: nothing to declare effectiveness of chemo-g-csf protocols for mobilization of peripheral stem cells in patients with non-hodgkin lymphomas and hodgkin disease-single center experienceilina micheva , stela dimitrova , vladimir gerov , trifon chervenkov , liana gercheva , igor reznik background: high-dose chemotherapy and autologous stem cell transplantation (asct) play an important role in achieving long-term remission in patients with non-hodgkin lymphoma (nhl) and hodgkin disease (hd). granulocyte colony stimulating factor (g-csf) combined with high-dose chemotherapy is a frequently used mobilization approach; however, the optimal mobilization strategy has not been determined.the objective of the study was to analyze the mobilizing potential of different regimens used for the collection of peripheral stem cells in patients with relapsed or refractory (r/r) nhl and hd. methods: we retrospectively analyzed patients with r/r nhl and hd undergoing stem cell collection after chemo-mobilization in the transplant unit at the university hospital, varna. patients were mobilized after dhap letermovir is promising, even as a therapeutic agent. more paediatric data are urgently needed.disclosure: nothing to declare p development of paroxysmal nocturnal hemoglobinuria in a patient after mudallohsct due to jak v fpositive myelofibrosis-a case of successful treatment with the second transplantation from another donor agnieszka tomaszewska , barbara nasiłowska-adamska , iwona solarska , kazimierz hałaburda background: paroxysmal nocturnal hemoglobinuria (pnh) is a very rare disease associated with pig-a gene mutations in hematopoietic stem cells. there are only single case reports on evolving myeloproliferative diseases to pnh in the literature. there is no data concerning development of pnh de novo after allogeneic hematopoietic stem cell transplantation. in our report we describe a patient with recurrence of jak v -positive myelofibrosis years after matched unrelated donor allogeneic hematopoietic stem cell transplantation (mudallohsct) with simultaneous development of clinically significant pnh. a year-old-man with a history of mudal-lohsct in may due to jak v -positive myelofibrosis secondary to essential thrombocythemia was admitted to our department years later with mild anemia (hb- . g/dl) and elevated lactate dehydrogenase ( u/l). during last years he remained in complete remission of myelofibrosis with jak v mutation negativisation and % donor chimerism. suspecting disease recurrence we performed trephine biopsy confirming myelofibrosis (mf /mf ) with heterozygous jak v mutation and in flow cytometry analysis of bone marrow we identified cell membrane defect in myeloid line (loss of cd c). we decided to perform detailed diagnostic tests on pnh -multiparametric flow cytometry of peripheral blood revealed % granulocytes and % red blood cells with loss of gpi-anchored proteins -pnh clone. these results corresponded with donor chimerism -it was only % of donor dna in bone marrow and % in blood tests. molecular analysis didn't revealed any mutations in genes: calr, asxl and mpl. finally the diagnosis of myelofibrosis recurrence after mudallohsct with presence of pnh clone was established. the therapy with eculizumab was unreachable. so the second allohsct from another matched unrelated donor after fludarabinemelphalan-thymoglobuline-tbi cgy conditioning was performed on . . . we didn't observe any complications of this procedure, engraftment was slightly delayed: anc> . g/l on the day and plt> g/l on the day.results: at present, more than years after the second mudallopbsct, the patient remains in a very good condition with % of the second donor chimerism and without any features of pnh (clone is undetectable) and myelofibrosis.conclusions: presented case is the first in the literature well documented myelofibrosis recurrence after mudal-lohsct with concurrently development of clinically significant paroxysmal nocturnal hemoglobinuria. the second mudallohsct from another donor was safe and successful treatment strategy in this situation.disclosure: nothing to declare. abstract already published. cutaneous refractory t-cell lymphoma treated with allogeneic hematopoietic stem cell transplantationmarcia silva , ercole orlando , maria claudia moreira , simone lermontov , simone maradei , yung gonzaga , leonardo arcuri , renato araujo , decio lerner instituto nacional de cancer, cemo, rio de janeiro, brazilbackground: folliculotropic mycosis fungoides (fmf) is an aggressive clinical course variant of cutaneous t-cell lymphoma (ctcl) -classic mycosis fungoides (mf) , with distinct clinical and pathological characteristics, and it is less responsive to skin-directed therapies. for diseases in advanced stages, chemotherapy, autologous hematopoietic stem cell transplantation (hsct) or immunomodulator drugs may provide remissions with limited duration and the treatment remains substantially palliative , . these dismal results have induced to explore the therapeutical approach with allogeneic hematopoietic stem cell transplantation (hsct) in such patients. early studies have shown encouraging results also in patients with advanced disease, suggesting a major therapeutical role played by the graft versus lymphoma (gvl) effect , , . methods: this is a case report of the use of allogeneic hsct as a potential cure for cutaneous refractory t-cell lymphoma type folliculotropic mycosis fungoides .results: case presentation : a -year-old male patient with refractory subtype b fmf t-cell lymphoma , diagnosed in , clinically characterized by exfoliative erythroderma, widespread plaques on the trunk and limbs, solitary tumor on the right shoulder, pruritus and bilateral